The following essays are extracts of monthly articles written for the Syracuse Track Club newsletter by Dr. Dan Wnorowski.
Click on a topic below.
| Achilles Tendon Problems | Metatarsal Stress Fractures |
| Ankle Problems | Morton’s Neuroma |
| Ankle Sprains | Plantar Fasciitis |
| Big Toe | Foot Alignment |
| Purple Toes | Shin Splints |
Achilles Tendon Problems
Achilles and the Mountain Goat…
With the Mountain Goat Race on the horizon, I thought it appropriate to write a bit about Achilles tendonitis. Due to the relative cold weather and the steep hills encountered early in the race, it is a virtual certainty that a number of runners will develop a new Achilles tendonitis or aggravate an underlying problem with this sensitive tendon during this year’s race. Here’s hope for prevention.
Three muscles originating from behind and below the knee come together several inches above the heel bone (calcaneus) to form the belt-like Achilles tendon. The dual gastrocnemius muscles and their deeper counterpart, the soleus, are all “plantar flexors” of the foot. They enable “pushing off” with the forefoot. This means that they help push the toe-end of the foot down, enabling one to push on the gas pedal, stand on one’s toes, and ascend stairs and hills. There is considerable strain on the Achilles tendon during normal walking. Force plate studies have shown forces 125% of body weight during the toe-off phase of normal gait for walking, and forces increase drastically over this amount for running, proportional to speed. In addition to increased force, running necessitates greater range of motion of the joints of the lower extremity, again proportional to speed. For instance, the total range of ankle motion required for walking is 30 degrees, versus 45 for running on level ground. Add to this the increased demand for more dorsiflexion (extension) for the 10-12 degree inclines in the first four miles of the Mountain Goat course, and it is easy to appreciate the strain on this tendon.
Many runners will be training on this course in early mornings to prepare adequately for the race, in temperatures often ranging from 0-40 degrees F. The Achilles tendon is not well insulated from the environment, as it is close to the surface. The importance of adequate stretching before hill training runs and before the race itself cannot be overstated. Two types of stretches for the calf muscles are especially useful, and every runner should know how to do them. With the heel on the ground, and the foot positioned two to four feet from a wall, lean into the wall until you feel a good stretching sensation in the calf. Keeping the knee bent will concentrate the stretch down low in the Achilles tendon, and keeping the knee straight will concentrate stretching forces higher in the calf muscle. Avoid bouncing stretches, and try to hold these stretches for 6-10 seconds. Variations include stretching with the heel lower on a slant board, with the heel off of a step, pulling on the balls of the feet with a towel while seated, and using rocker devices sold commercially.
Symptoms of Achilles tendonitis include pain and soreness in the tendon, tenderness, swelling, and difficulty walking up stairs or running up hills. The troubles may resolve during a run, at least initially, but this is not a signal that things are improving. Often things are worse early in the morning, or at the end of the day.
Once Achilles tendonitis is underway, this problem can be difficult to resolve with continued training, especially if running hills. Stretching now becomes as important as breathing, both before and after running. Icing for twenty minute sessions after runs and intermittently during the day may help to “put out the fire”, along with aspirin, ibuprofen, and naproxen, if there are no stomach problems, such as gastritis and ulcers. Another useful tip is using a heel lift of 1/8” to ¼” placed beneath the insole of the shoe. A heel cup or felt pad works well for this purpose, and serves to reduce the strain on the tendon by lifting the heel, simulating a minimal downhill grade. New shoes or a cushioned insole may help reduce forces on the injured tendon. If you have symptomatic tendonitis going into the race, suffice it to say that the Mountain Goat course, run at a racing pace, will not make the condition better.
Long-standing symptoms (greater than 3-6 months) usually necessitate avoidance of uphill running, a trial of cross-training, pool running, or some other distraction while waiting for the condition to improve. Danger signs include palpable nodules in or about the tendon, and persistent appreciable swelling and/or thickening of the tendon. The worst case scenario is a tendon rupture, fortunately a rare event, typically associated with jumping and push-off sports such as racquetball, basketball, and volleyball. I have seen cases of ruptured Achilles tendons following a protracted course of tendonitis.
Now is the time to avoid or minimize this problem by religious stretching, breaking in a new pairof shock absorbing shoes, and preparing your Achilles’ for the Goat by training on hills in a slowly progressive fashion. Gradually increase the length and grade of your hills during training to prepare adequately, and try to avoid running up hills until midway into training sessions. Good luck with the Goat!
Dan Wnorowski, M.D.
Ankle Problems
Evaluation of Lateral Ankle Pain in Runners- Part 1 of 2
Ankle problems often occur in runners, and a review of the more common conditions that produce lateral, or outside, ankle pain is relevant. These include fibular stress fracture, lateral ankle sprain and its possible sequelae, synovial impingement, and peroneal tendinitis, among others. Although all of these can cause lateral pain, tenderness, swelling, weakness and/or instability, the causes and management of these problems varies greatly, and thus the determination of the precise diagnosis is extremely important.
The discussion will be presented from the standpoint of a clinician’s thought process during the presentation of a runner complaining of ankle pain. Knowing how a clinician thinks helps the patient prepare for an office visit and anticipate the question and answer “give and take” of the history-taking process.
The first, and most important, part of a medical evaluation is the history, or the story of the patient’s problem. In 90+% of situations, a good history will reveal the diagnosis, or at least serve to eliminate possibilities and whittle the list of potential diagnoses to just a few: the “differential diagnosis”. The best history taking technique is open-ended, that is, it allows the patient to ramble along at their own pace, telling their story in their own way. This requires a very patient clinician in some instances, and the process is facilitated by a well-prepared, organized, concise story, not always the case. Once the patient is finished, the relevant blanks can be filled in and more directed questions can be asked to complete the job.
With regard to lateral ankle pain, a history of injury or overuse is important. Inversion injury, such as rolling the ankle in the turf, can produce a sprain or initiate tendinitis. A history of training errors indicating rapid progression of mileage or intensity may suggest stress fracture. A story of a more remote sprain accompanied by persistent pain, swelling, and possibly catching sensation suggests impingement of the lining synovial tissues or scar tissue left over from the old sprain. With regard to pain, we need to know the precise location (on the bone, or in the soft tissue), any radiation (up the leg, or into the foot), chronology (timecourse), aggravating factors (footware, surface conditions), alleviating factors (mileage, medications, orthotics), associated symptoms and their relation to the pain (back pain, numbness, swelling, catching, locking, etc.).
The focus of the exam is on physical findings, so-called signs. These include swelling, range of motion, bruising, tenderness, weakness, and instability. Synovial impingement is usually accompanied by swelling and tenderness in the front of the ankle, as well as pain and limitation of upward motion (extension=dorsiflexion) of the foot at the ankle joint. Tendinitis of the lateral peroneal tendons usually is accompanied by boggy swelling and tenderness at the outside of the ankle just behind and beyond the lateral ankle “bump”, or malleolus, as well as weakness of eversion of the foot (motion of the foot outward). A stress fracture of the fibula may have no findings whatsoever, or perhaps produce swelling or tenderness directly over the bone laterally.
Next time, a common sense and practical approach to the management of lateral ankle problems will be presented.
Lateral Ankle Pain in Runners- Part 2 of 2
Ankle problems often occur in runners, and last month we reviewed the more common conditions that produce lateral, or “outside”, ankle pain. These included fibular stress fracture, lateral ankle sprain and its possible sequelae, synovial impingement, and peroneal tendinitis. The determination of the precise diagnosis is extremely important, and the subtle differences in history and physical findings were discussed, to give the runner an appreciation of the mechanics, and complexity, of the diagnostic process.
A common sense and practical approach to the management of lateral ankle problems will now be presented. To select a reasonable treatment plan, one needs to have a sense of the probable diagnosis, or likely alternative diagnoses. These ankle problems differ greatly in their management options, and therefore illustrate the supreme importance in knowing the likelihood of what one is dealing with when the ankle is painful and running is a problem.
For the runner, probably the worst of these possibilities is the fibular stress fracture, as the usual recommendation is the cessation, or at least significant restraint, of running activity, substituting non or low impact activities, such as cycling or pool running. Other alternatives include using a treadmill or stair climber, both of which are more forgiving. It is extremely difficult for a stress fracture to heal and hence, for pain to resolve, when running continues at levels which initiated the problem in the first place. On the other hand, there is often no reason to completely cease running when one is reasonably sure a stress fracture does not exist. Peroneal tendinitis can be treated with inversion stretching (such as walking the toes up the opposite shin), peroneal strengthening, lateral heal wedges, medication, an ankle sleeve, and ice. Usually running can continue, at least initially, while these conservative measures are undertaken. One may want to avoid running on a banked surface, especially on the right side of the road with involvement of the right ankle, and vice versa.
Similarly, the runner can often continue running with modifications if synovial ankle impingement is considered. Uphill runs may be painful with this condition, but flat surfaces may be tolerable. Even the slight incline of a treadmill may be a problem. Again, conservative measures, such as ice, medication, and plantar flexion stretches (pointing the toes downward) also are advisable with this problem, which usually resolves with time.
Finally, once a sprained ankle has begun to settle down, and straight-ahead, level walking is no longer painful, light jogging can be initiated. Again however, cambered, banked roadsides may aggravate the pain for awhile, and flat, soft surfaces are preferable. Medication to control swelling, post run ice massages, and an ankle sleeve can all alleviate pain and swelling following runs. Stretching, especially into dorsiflexion, or extension (typical calf stretches) are essential following a sprained ankle, and will usually facilitate uphill running. Peroneal strengthening exercises, such as with stretch tubing or a forefoot weight, are also necessary to compensate and reinforce the damaged lateral ligaments while they are healing. A lace up brace may prevent reinjury as running resumes, especially if off-road trail runs are selected.
Warning signs of a serious problem that merits immediate evaluation include the following: pain, which increases during the run, locking or catching sensations in the ankle, especially after an injury, recurrent sprains or instability of the ankle, swelling across the front of the ankle joint, and localized bone tenderness, among others. When in doubt, have it checked out!
Dan Wnorowski, M.D.
More on ankle sprains: Ankle Sprains
Ankle Sprains
Running and Ankle Sprains:
What about the common “ankle sprain”? Ankle sprains typically occur following a rollover type injury, such as when the runner steps into a rut or pothole, which causes the foot to roll with the sole inwards, called “inversion”. Depending upon the degree of inversion, and the reflexive and protective pull of the outside muscles and tendons (peroneals), the resultant damage to the outside ligaments of the ankle can be highly variable.
As usual, first we need some background anatomy (figure 1). Three ligaments connect the bones and stabilize the outside of the ankle: the anterior talofibular (ATF), the calcaneal fibular (CF), and the posterior talofibular (PTF). These can be thought of as passive leashes or restraints to inversion type motions of the ankle joint. The typical inversion sprain most commonly produces damage to the ATF +/- CF ligaments, and more rarely the PTF. The peroneal tendons pass over this area. Muscles and tendons are active restraints. As muscles contract, they provide forces countering inversion proportional to the intensity of contraction. It is important to recognize that these tendons are very important stabilizers as well. It is only when these muscles and tendons are overpowered or caught off guard that they fail in their mission, and the underlying ligaments are tested. Stronger muscles can mean milder sprains!
When a sprain occurs, the ligaments may be injured, but not stretched (grade 1), stretched, but not torn (grade 2), or completely torn or ruptured (grade 3). In the ankle, the actual grade of the sprain is almost never of consequence, as virtually all initial first-time sprains are treated the same. Acutely, during the first 2-7 days, it is recommended that one use “R.I.C.E.”, a mnemonic that means rest, ice, compression and elevation. The intent is to prevent further injury, control inflammation (swelling), and reduce pain. Ice is useful for as long as 72 hours (20 minutes on, 20 minutes off, etc.), and elevation (as often as possible) should continue until swelling has peaked and is decreasing. Compression with an elastic wrap or sleeve should continue until swelling is gone.
Rest does depend upon the degree of injury. Some mild sprains may necessitate only a few seconds of rest, such as during a run. Obviously, if one can keep running after a rollover during training or a race, the sprain is quite mild. However, it would be wise to elevate, ice, and wrap immediately afterwards. On the other hand, a severe “blowout”, that causes intense pain with difficulty with even standing characterizes a grade 3 injury, and needs a longer period of rest for healing to occur. These “bad sprains” typically produce bruising, marked swelling, and a prominent limp.
A good rule of thumb is that when one can stand without pain, try walking. When one can walk without pain, try jogging. When one can jog pain-free, advance to running, etc. Let pain be the guide.
What is the role of medical evaluation and physiotherapy in the sprained ankle? Many studies have tried to define the need for x-rays following a sprain: based upon the location of pain and tenderness, presence of instability, etc. It is my opinion that it is reasonable to get x-rays of the ankle after a sprain, especially if there is pain with weight-bearing. It is very difficult to determine by physical exam alone whether a fractured fibula exists or not without an x-ray. Furthermore, when the ankle bone (talus) rolls over during inversion, small pieces of the dome of the talus can be sheared off. The treatment for fractures is markedly different from the treatment of a sprain.
There is no doubt that physiotherapy or physical therapy (P.T.) can make a big difference in recovery. Although ligaments require a given time to recover from injury, P.T. offers distinct advantages over benign neglect: reduction in pain and swelling, faster restoration of motion, and better strength preservation during healing. Most importantly, it facilitates retraining, reeducation, and strengthening of the injured ankle to allow earlier and safer return to activity, with a lower risk of reinjury.
For more information go to: Ankle Problems
and: FAQs: Ankle Sprains
Dan Wnorowski, M.D.
Big Toe
Big Problems With the Big Toe
Two relatively common problems involving the “hallux”, or “great toe” (big toe), can plague a runner. Both can cause pain and stiffness in the area called the “metatarsalphalangeal joint (MTPJ)”. This is the first knuckle of the big toe, where the toe joins the foot. This joint is very important structurally and functionally. Most of the body weight is transferred to the ground during the “toe off” phase of gait through this area, and faster pace running requires greater range of motion at this joint. Therefore, problems with this joint and the surrounding structures can seriously hinder running ability. Three derangements of the hallux MTPJ account for much of the troubles seen in this anatomical location. These include “hallux rigidus”, or arthritis, sesamoiditis, and “hallux valgus”, or bunion. Bunions are a symposium in their own right, and may provide fuel for a future topic. We will look at hallux rigidus and sesamoiditis this time.
Hallux rigidus literally means “rigid big toe”. This condition is caused by arthritis of this joint, which can come on insidiously, or follow an injury to the joint which occurred some time in the past. Arthritis of any joint includes thinning and loss of the low friction cartilage surfaces of the bones, formation of peripheral spurs, and thickening and inflammation of the surrounding soft tissues or joint lining. These changes contribute to the symptoms of pain and tenderness, stiffness and loss of motion, and warmth and swelling. Loss of motion at the first MTPJ limits the ability to extend or raise the great toe, as spurs on the top of the joint block movement of the toe. This is a devastating problem for any athlete, since the speed of running correlates with upward range of motion of the toe. In other words, limited extension equals limited speed, with pain as the spurs impinge.
Diagnosis is based on the findings of swelling, tenderness, palpable spurs, and reduced motion in extension (upward motion). An X-ray is confirmatory. Prior to considering surgery, treatment for the runner includes avoiding hills and inclines (uphill running demands increased toe extension), and decreasing speedwork. These modifications may be permanent. A stiffer sole shoe helps to splint the toe and reduce painful extension, and a roomy toe box keeps the pressure off this tender area. Gentle stretching can help maintain available range of motion. Ice and anti-inflammatory medication may be helpful as well. Unfortunately, as the disease progresses, running will become more limited, and surgery to remove spurs (“cheilectomy”) may be necessary to allow running to continue.
There are two tiny bones, about the size of coffee beans, that rest beneath the great toe MTPJ, embedded in the tendons that flex the toe (pull the toe down). These bones are like miniature kneecaps, serving to increase the mechanical advantage of the tendons, and gliding on the overlying joint surfaces. The can become a source of irritation, called “sesamoiditis”, due to overuse, injury, or arthritis. The pain is on the bottom of the MTPJ, and is typically aggravated by weight-bearing activity. As most of the body’s weight is born at the great toe MTPJ with toe-off, pain beneath this joint can be very disabling.
Sesamoiditis is usually present if there is tenderness beneath the MTPJ, and pain with direct pressure on the sesamoid bones. Extension of the toe may increase the pain. X-rays may be normal, may show a two-part bone, or even arthritis. Treatment includes reduction of mileage and intensity, or even cross-training (biking or swimming). As with hallux rigidus, uphill running usually makes things worse. I have noticed that stair climbing equipment or Nordic skiing type equipment can also aggravate this condition, and probably should also be avoided if it is to improve. Orthotic treatment can also be helpful. Cutting a depression or hole in the insole, directly beneath the tender sesamoid, can help relieve the pain while running. If ice and medication are unsuccessful, occasionally a steroid injection and/or a rest period with casting may be necessary. Surgical excision is a last resort.
Dan Wnorowski, M.D.
Purple Toes
The Dreaded Purple Toe
Many runners will at some time develop a purple toenail, usually after long runs or races, particularly marathons, or after extensive downhill running. The medical term for this condition is a “subungual hematoma”. A hematoma is a collection of blood, and subungual means beneath the nail. It comes from trauma to the nailbed, fragile tissue beneath the nail. With repeated blunt injury, such as frequent loading against the front end of the shoe, the nailbed begins to bleed. The area beneath the nail is a closed space, and any bleeding is contained within, and usually stops quickly as pressure builds. (Remember the rule of first aid, control bleeding with pressure.)
There is usually minimal, or no pain, at least initially, and the uninitiated runner will often be surprised at the sudden onset of color change. There is no rule that only one toe will be involved. I once saw a runner with nine purple toes after the NYC Marathon! The typical course is an increase in pain for 24-48 hours, of a variable degree, followed by resolution of pain, and probable loss of the nail from the affected toe in several weeks. Typically, the nail gradually grows back. In rare cases, the pain can be severe and incapacitating, and even necessitate a visit to the emergency room. Pain relief is easy to achieve, by draining the blood from beneath the nail and thereby relieving the pressure. The usual method is by heating a paper clip to “red hot” and burning a hole in the center of the nail. Stand back, the pressure can be so great as to create a bloody geyser! Pain relief is abrupt and dramatic. Secondary infections of these hematomas are very unusual, but drainage can increase the risk slightly. Signs of infection include progressive pain, redness, and swelling, all well beyond the local nail area.
The usual subungual hematoma needs little or no treatment. A brief rest period is helpful, during which twenty-minute soaks may be undertaken, accompanied by anti-inflammatory medications. Running can be resumed when pain and tenderness has resolved. If the nail falls off, a band-aid is helpful to protect the underlying sensitive nailbed. Avoid downhill running until pain is absent. If the nail does not fall off, the area of discoloration will tend to grow outward toward the tip of the toe. A word of caution, pigmented spots beneath a nail without prior trauma that enlarge and/or do not move must be evaluated by a doctor, as these may represent a melanoma, a form of cancer,
Like most other running injuries, training factors and footware are often partly responsible for the development of this condition. As noted previously, high mileage and downhill running contribute. However, tight shoes are the most common predisposing problem. A roomy toebox is one of the most important attributes of a proper fitting shoe. This is especially true in the runner with the so-called Morton’s foot. This type of foot has a long second ray, and hence second toe, which may extend beyond the first (great) toe. Many shoes are designed with the greatest depth built into the area for the great toe. A long second toe will impact the end of the shoe, particularly when going downhill. A thicker than normal sock can produce a similar effect.
Happy and healthy running!
Dan Wnorowski, M.D.
Metatarsal Stress Fractures
Perhaps the most common stress fracture in the runner is that of the metatarsal, the long, slender bone that connects the midfoot to the toes. There are actually five metatarsals, the first one being that of the first ray, or great toe, with the fifth being that of the small toe. Stress fractures most commonly occur within the fourth metatarsal.
A stress fracture of a bone happens because of excessive force, usually of a repetitive or cyclical nature. Each individual force is of little or no consequence to the bone, but sometime numerous “cycles” of such force are more than the microscopic architecture of the bone can bear. Tiny layers of bone fail in a serial fashion, one by one. Early, healing may be able to keep pace, but if repetitive forces continue, cracks propagate, and a true fracture occurs. The entire process is analogous to breaking a paper clip by bending it over and over again. With time, after a certain number of bending cycles, the structure fatigues.
Diagnosis is usually easy to make, as the injured runner typically has pain well-localized to the midfoot during and after running activities, especially on the top, or “dorsum”, of the midfoot. The foot may feel “stiff” or “full”, and other descriptions I have heard include “burning” or “numbness”. There is almost always pin-point tenderness along the bone, and not in between the bones. Swelling is common, although often subtle. A limp might be present, more prominent after running. Usually the pain is minimal during rest or walking, and may even be absent early in the run, coming on only later. If neglected, the pain will typically get worse, occurring earlier and earlier during runs, and usually affecting performance in a progressive fashion.
X-rays can be, and often are, negative, especially within the first three weeks after onset of symptoms. Since the fracture is usually microscopic early, it is likely too small of a crack for the resolution of an X-ray study to detect. Often we might see healing on the film before a fracture line. A bone scan or MRI test may be helpful to make a definitive diagnosis in this “acute” stage. However, these expensive tests are not always necessary. A doctor with experience with these injuries can usually make the diagnosis by clinical suspicion alone. The history provided by the patient is often one of increasing or high running mileage or intensity, high-mileage old footware lacking residual cushioning, running on hard surfaces, etc., and physical findings are very specific.
The treatment of choice, of course, is rest. Oral and topical medicines, ice, orthotics, stretching, and the like will not solve the problem, but rather only minimize the symptoms. Without rest, healing cannot take place. Early in the course of the injury, successful healing may occur merely by restricting mileage and intensity, or by switching to softer running surfaces or a treadmill. However, as the fracture worsens, it will become necessary to avoid running all together, in favor of cycling, swimming, or pool running. Casts and crutches can almost always be avoided, as the symptoms quickly respond to rest and normal walking, unless the injury is neglected and running continues for a prolonged period.
Dan Wnorowski, M.D.
Morton’s Neuroma
What is a Morton’s Neuroma?
We have reviewed Achilles tendonitis before the Mountain Goat, and three issues ago, plantar fasciitis, two of the most common foot-related causes of running ailments. Another troublesome condition is Morton’s neuroma.
This problem is due to irritation of one of the nerves that retrieves sensory information from the toes. These nerves begin as a trunk called the posterior tibial nerve, which begins in the lower leg , courses down the calf, curving around the inner bony prominence of the ankle, called the medial malleolus. Below the medial malleolus, the nerve gives off some branches to the heel, and then traverses a tunnel called the tarsal tunnel, analogous to the carpal tunnel in the wrist. The nerve subdivides within the sole of the foot, with branches that connect the intrinsic foot muscles to the central nervous system. Between the slender metatarsal bones, the nerves subdivide for the last time, and at this great distance from the brain, carry only sensory fibers from the toes. It is in this remote location that a Morton’s neuroma may form.
This condition arises when there is pressure on the nerve, usually secondary to pressure between the metatarsals. At this site, the nerves are a “Y” shape, with the stem formed by the last main trunk, and each arm of the “Y” a branch to the side of each toe. It is important to appreciate the fact that the stem portion is in the base of the web space between each toe, such that the arms go to the sides of adjacent toes. Thus with pressure to each stem segment near the web space between the toes, the more distal sides of two adjacent toes will be affected. Since these are sensory nerves, pain and numbness are characteristic.
The most common location is the third web space, i.e.- between the 3rd and 4th toes, where toe #1 is the big toe, or hallux. Usually the process begins as inflammation of the nerve, and as such there may be swelling or fullness within the web space. As the process continues, one can often feel the swollen nerve segment, referred to as a “cocktail onion” sensation. With chronicity, the nerve begins to form scar tissue, and a mass. But early on there may be no palpable lump.
There is usually pain under the ball of the foot, which may radiate to the involved toes. There may be a sensation of something “rolling or sliding around” under the foot, or of a catching sensation. Pain is typically worse with weight-bearing activity, and running may be progressively difficult. The most common causes of this problem stem from inadequate footwear, and chiefly from inadequate room for the toes, or a tight toe box. Thus this problem is most often seen in women runners who wear tight, high-heeled shoes by day. Runners do not have an increased incidence of this condition relative to sedentary individuals, but there may be more disability in a runner with a neuroma.
Treatment is logically aimed at reducing pressure on the nerve, by changing to footwear that has a roomy toe box with a low heal. A soft metatarsal pad placed just behind the the ball of the foot can help a great deal; its purpose being to relieve direct pressure on the nerve, and to help the metatarsals spread out. Some running shoes have forefoot pads to cushion this portion of the foot. In my experience, they are a mixed blessing. I have seen both initiation of this problem, as well as relief from it, after switching to this design. Anti-inflammatory medications may help in the acute stage, as well as the application of ice. If chronic however, these symptoms are not likely to recede so easily, and rest, injections and surgery may be necessary.
Dan Wnorowski, M.D.
Plantar Fasciitis
A Few Agonizing Steps in the Morning…
One of the easiest diagnoses one can make is plantar fasciitis (PF). Unfortunately, the condition is not as easy to treat as it is to diagnose, especially in active people, like runners. Like almost all running injuries, PF, is an inflammatory condition that usually results from overuse: doing too much, too soon, too fast. Inadequate footware is nearly always the rule; shoes with too many miles, and with little cushion remaining. A good rule of thumb is shoes with 300 miles have probably lost 50% of their shock absorption capability.
The sole of the foot, especially the heel, is well-designed for energy storage and shock absorption.
The bottom of the heel is compartmentalized, with fatty “chambers” separated by tiny walls called septae. This arrangement helps to absorb impact, and reduce loads transmitted up the leg. The plantar fascia, on the other hand, is a thick, tough band of tissue that runs from the ball of the foot to the heel. It serves as a spring to store energy during the flattening of the arch that normally occurs during the stance phase of gait.
The weak link of this system seems to be the attachment of the PF to the bottom, inside edge of the heel bone. Following sudden or repetitive overuse involving this sheet of tissue, inflammation develops at the attachment point, causing pain and stiffness, especially with weight-bearing activities, and classically, during the first few steps in the morning. There is inevitably point tenderness at the attachment site, and Achilles tendon type stretches, as well as upward stretches of the toes typically reproduces one’s pain. The pain may disappear entirely during the day and during running, only to come back in the morning.
Like almost any other running overuse injury, the key to recovery is relative or complete rest, cross-training with low impact sports, such as swimming or cycling, use of ice, anti-inflammatory medications, and most importantly, PF stretches. The latter include Achilles stretches, toe and shin curls, and upward toe stretches. Heel cups, or heel “cut-out” orthotics, can also provide relief, especially if running continues. Lay off the hills, as uphill running can aggravate the condition. Rarely, complete rest is necessary, with casting and/or steroid injections reserved of resistant cases. Surgery is almost never needed.
Dan Wnorowski, M.D.
Foot Alignment
Running Injuries and the Shape of the Foot- Pronation
A very interesting aspect of orthopedics is the predictability of injury. Patterns exist in nature, and a correlation is often seen between the shape of one’s foot and the injuries one may encounter. “Experience” then becomes nothing more than pattern recognition: the realization that certain types of foot alignment predispose to specific types of problems. Of course there are exceptions, and the following examples represent generalizations only.
Most runners are familiar with the term “pronation”. This describes a foot that is flat. In other words, the arch is minimal, or even absent. A pronated, or flat, foot, can be rigid or flexible. Rigid means that the deformity is fixed or constant, and independent of weight-bearing. A flexible flat foot presents only with weight bearing, and the arch is restored when weight is off the limb. The function of the arch is two fold: shock-absorption and energy-storage, and it acts similarly to the leaf spring of a car. The arch is supported by many small ligaments and by the posterior tibial tendon, which serve to maintain and control the arch.
The only other fact that is essential to understand is that a relationship exists between the normal “controlled collapse” of the arch with weight-bearing and rotation of the lower leg. This occurs through the complex series of joints between the leg and foot. In short, the greater the tendency toward pronation (the greater the flexibility and flattening of the arch), the greater the rotation of the lower leg. This is the basis for many of the overuse injuries that correlate with the pronated foot.
Thus, rotation of the leg that occurs with each and every step, can produce torsional, or twisting, forces on the soft tissues that attach to various parts of the leg. If excessive, one may develop patellar tendinitis, or shin splints, for example. Furthermore, rotation of the lower leg also affects the alignment and motion of the patella, which can produce pain in and around the patella, called “patellofemoral syndrome”. The focus therefore, is controlling pronation by supporting the arch of the foot, in addition to treating the symptoms and problems above the foot. Often, simply using a more supportive shoe, one which incorporates some type of “motion control”, or arch buttress, will do the trick. Another option is a supportive insert (“arch support”), i.e.- an orthotic. It is useful to check the shoe first, as it is easy to buy the wrong type. Custom orthotics can be expensive. Over-the-counter varieties are much cheaper, and can be useful as a short-term trial.
Running Injuries and the Shape of the Foot- Supination
Several issues ago, the concept of foot shape and injury correlation was introduced. The pronated foot is a “flat foot”, one with a diminished, arch. Recall that the function of the arch is two fold: shock-absorption and energy-storage. The arch is supported by many small ligaments and by the posterior tibial tendon, which serve to maintain and control the arch. Furthermore, the greater the tendency toward pronation (the greater the flexibility and flattening of the arch), the greater the rotation of the lower leg. This is the basis for many of the leg overuse injuries that correlate with the pronated foot.
The opposite of the pronated or flat foot is the supinated, or high-arched foot. The chief characteristic of the high arch is its rigidity. It lacks the controlled collapse characteristics of the normal arch. Without this flexibility and collapse, there is reduced capacity for shock-absorption and cushioning. In addition, there is decreased energy-storage without the controlled arch collapse of the supinated foot. It has been shown that more than 50% of the energy absorbed with arch collapse is retransmitted to the limb with toe-off. Hence, the supinated foot is a less-efficient, stiffer, less cushioned foot, relative to its opposite.
Remember that the pronated foot transmits torsional (twisting) forces upwards within the limb secondary to the complex biomechanics of the ankle and other joints of the hindfoot. The supinated foot then, by virtue of its stiffness, confers little rotation, as there is minimal arch collapse, but rather transmits direct impact forces up the leg. Unfortunately, just as the twisting forces of the pronated foot can contribute to injury, so too can the direct waves of concussion transmitted by the supinated, high-arched foot. However, these forces are more likely to produce high impact type injuries.
Injuries most likely to occur because of impact transmission most commonly include stress fractures. These may include sites such as the tibia (lower leg), and neck of the femur (hip). These pounding forces may even effect more distant locations such as the sacroiliac joints of the lowest portion of the back and pelvis, and the lumbar spine (low back). Symptoms may include running related leg, knee, groin, and low back pain. Whether these forces can actually contribute to arthritis of the knee, hip and spine is debatable. Evidence is controversial (see below web site for archived discussion of running and arthritis).
Just as orthotics may be helpful to the injured pronator, they may also benefit the supinator. Extra cushioning is essential in this type of foot. Usually, this involves the use of shock-absorbing inserts, for example, viscoelastic substances, commercially available at most running stores. Certain shoes are designed with extra padded soles for the same function. These shoes utilize a variety of substances including closed-cell midsoles, air chambers, and gel pads within the heel. The effectiveness of these substances is variable.
In summary, it is useful to know the type of foot architecture one must live and run with, in order to select the correct shoe type, and to avoid and recover from injuries. The pronated foot needs arch support to control excessive arch collapse and limit the rotational forces transmitted upwards within the leg. The supinated foot needs cushioning to compensate for the lack of arch collapse and shock-absorption, with excessive axial forces passed upstream.
Finally, excessive pronation and supination represent the extreme ends of the spectrum, the “toe regions”, or small ends of the population curve. Most feet are in between, with average, or relatively “normal” arches.
Dan Wnorowski, M.D.
Shin Splints
Shin splints, shoes, and the posterior tibial tendon
One of the most common troublesome conditions that can plague the runner is “shin splints”. This entity classically presents as pain on the inside of the shin bone (tibia), usually in a longitudinal distribution (up and down the leg), typically in the lower third. It is often bilateral. I most commonly see this problem in runners with a history of sudden increases in training mileage or intensity, those that run on the same side of the slanted shoulder of the road, or those with a change in footware.
Every runner has a unique foot, and the arch of the foot is especially variable. The arch of the foot can be high and rigid (the “cavus” foot), or low and flexible (the “flat foot”). Furthermore, the flat foot, though most often flexible, can be fixed, or rigid. It is the flexible flat foot (“pes planus”, or “pronation”), that contributes to the shin splint problem.
The arch of the foot is made up of a column of bones much like the architectural “Roman arch”. These bones are arranged apex upward, and tethered together by a series of ligaments that bind and support the bones. But like any structure, the arch may be prone to fatigue and collapse. Therefore, the muscles and tendons that help support the arch are extremely important. The main muscle-tendon unit that supports the arch is the posterior tibial tendon. As it’s name implies, it originates from the back (posterior) of the tibia, traverses behind the medial malleolus (bump on the inside of the ankle), and attaches near the apex of the arch to help support it.
Shoes are also very important and will be the focus of this discussion, as they relate to the shin splint problem. We all have heard the importance of “supportive shoes”, but what does this really mean? For the runner with flatfoot tendency, or with a “tired arch”, support means a cushion in the shoe, or some sort of “motion control” component engineered into the shoe design which serves to prop up the arch. The motion the shoe is supposed to control is pronation, or simply, collapse of the arch during stance phase (with weight-bearing). This usually means stiffening the area directly adjacent to ad beneath the arch (tough plastic buttresses are common, or a different material in the outer sole beneath the arch). Sometimes special insoles will do. This can make a big difference in avoiding arch overuse, strain, and collapse.
So what does this have to do with shin splints? A supportive shoe is very important in the feet of those with flexible flatfoot, i.e.- pronators, to prevent fatigue of the arch, and hence, stretching and fatigue of the posterior tibial tendon. Overuse of the posterior tendon can present as either a tendinitis, or shin splints. The symptoms vary from pain in the arch, pain behind or below the medial malleolus, or along the inner shin. Swelling may sometimes be present. Treatment is aimed at reducing inflammation (ice, medication, etc.), resting the inflamed tissue (decreased mileage, avoiding the cambered side of the roads, etc.), and supporting the arch, and secondarily, the posterior tibial tendon (shoe modifications).
A word of warning. If pain persists despite these conservative modifications, one must consider the possibility of more serious injury, such as tibial stress fracture, or posterior tibial tendon tear. Also, numbness in the foot is not typical, and suggests other problems, as well. If in doubt, get it checked out!
Dan Wnorowski, M.D.
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