Sports Medicine: Just the Facts

CHAPTER 88 • RUNNING 525

• Diagnosis
  
  
  1. Tenderness at myotendinous junction or insertion
  
  
  
  


• Contributing Factors
  
  
  1. Pronation
  
  
  2. Lower extremity varus
  
  
  3. Tight heel cord
  
  
  4. Weak dorsiflexors/plantar flexors(DF/PDF)
     •Treatment
  
  
  5. Heel lifts
  
  
  6. Control pronation
  
  
  7. Flexibility (include gastroc and soleus)
  
  
  8. Strength (particulary eccentric strength)
  
  
  9. Modalities (ionto and cross-friction massage)
  
  
  
  


• Consider if persistent
  
  
  1. Retrocalcaneal bursitis
  
  
  2. MRI (evaluate tears)
  
  
  3. Immobilization
  
  
  4. Lidocaine injections for periotendonitis
  
  
  
  

PLANTAR FASCIITIS

• Definition
  
  
  1. An overload injury including inflammation degen-
     eration, and tearing of the plantar fascia, most
     commonly at its calcaneal insertion.
  
  
  
  


• Contributing factors
  
  
  1. Tight gastroc soleus, plantar fascia
  
  
  2. Rigid rear foot
  
  
  3. Over pronation or supination
  
  
  
  


• Diagnosis
  
  
  1. Pain plantar heel worse in a.m. and with activity
  
  
  2. Tenderness plantar medial heel
  
  
  3. Normal neuro examination
  
  
  4. No bony (calcaneal) tenderness
     •Treatment
  
  
  5. Phase 1:
     a.anti-inflammatories: Nonsteroidal anti-inflamma-
     torydrugs(NSAIDs) and medrol
     b.Device (CTF brace)
     c. Stretch (gastroc-soleus, plantar fascia, hamstring,
     ITB)
     d. Strength (foot intrinsics)
  
  
  6. Phase 2:
     a. P.T. (phono/ionto, massage)
     b.Continue exercise
     c. Different device (heel cushion)
  
  
  7. Phase 3: Night splint
  
  
  8. Phase 4,5: Injections (3 max), orthotics
  
  
  
  


• Consider if persistent
  
  
  1. MRI: r/o calcaneal stress injury
  
  
  2. EMG/NCS: r/o Medial calcaneal, Plantar neuropa-
     thy, and radiculopathy
  
  
  3. Surgery if fail conservative care (6 months)
  
  
  
  

STRESS FRACTURES

• Definition
  
  
  1. Failure of bone to adapt adequately to mechanical
     loads (ground reaction forces and muscle contrac-
     tion) experienced during physical activity.
  
  
  2. Tibial stress fractures predominate in distance run-
     ners. Navicular stress fractures predominate in
     track athletes.
  
  
  
  


• Diagnosis
  
  
  1. Focal tenderness
  
  
  2. Recent transition in training
  
  
  3. X-ray (often neg., esp. early)
  
  
  4. Bone scan (all three phases with increased uptake)
  
  
  5. MRI (periosteal and marrow edema T 2 > T 1 )
  
  
  
  


• Contributing factors
  
  
  1. Rapid transition in training
  
  
  2. Osteopenia/Osteoporosis
  
  
  3. Menstrual irregularities, in particular amennorrhea

     
     

     6 months.

     
     

     
     
  
  
  4. Excessive pes cavus (femoral, tibial) or pes planus
     (metatarsals)
  
  
  5. Poor shoe wear
     •Treatment
     1.Noncritical: Noncritical stress fractures can be
     treated with 6–8 weeks of relative rest and
     include the following: medial tibia, metatarsals 2,
     3, 4, and 5 metatarsal avulsion. Athletes may ben-
     efit from a short period (i.e., 3 weeks) in a walking
     boot.
  
  
  6. Critical stress fractures require more specific atten-
     tion due to slower healing and higher rates of
     nonunion and include the following: femoral neck,
     anterior tibia, medal malleolus, navicular, and base
     5th metatarsal.
     a. Femoral neck
     i. Normal X-ray, no cortical break: Conservative
     RX, partial weight-bearing(PWB) to weight-
     bearing as tolerated(WBAT). Follow clini-
     cally and serial MRI 8–12 weeks.
     ii. Cortical break: ortho. Superior (distraction)
     fractures have a higher incidence of worsen-
     ing and nonunion than inferior (compression)
     fractures.
     b.Anterior tibia
     i. Casting versus relative rest up to 6–8 months.
     ii. If no healing: Ortho (transverse drilling, graft-
     ing, medullary fixation)
     c. Medial malleolus
     i. Nondisplaced: Boot or aircast 6 weeks
     ii. Displaced or nonunion: Ortho
     d. Navicular
     i. Nonweight bearing 6–8 weeks
     ii. Progressive activity over 6 more weeks