Pertinent Pearls On Treating Overuse Injuries In Endurance Athletes

By Kirk M. Herring, DPM, MS

Overuse injuries represent the single largest classification of sports-related injuries that require medical attention. All too often, athletes report these injuries to the sports medicine specialist after weeks, if not months, of denial and failed self-treatment. However, with the recent advances in medicine today, injured athletes can recover from injuries that otherwise could end their athletic pursuits. Endurance athletes, especially runners and cyclists, traditionally have a high risk of lower back, hip and lower extremity overuse injury.1-5 During the running boom of the ‘70s and ‘80s, considerable attention and interest were directed to the diagnosis, treatment, classification and causative factors associated with overuse injuries. As the running boom ran its course, interest within the public and general medical community, including podiatry, waned. However, there is a building resurgence of interest. Long-distance running, cycling, swimming and other endurance sports are capturing the attention of the endurance athlete community. Some athletes are attracted to endurance activities as a means to expand their aerobic activities. Some pursue these activities to stay fit and healthy. Others look to endurance activities for cross training to help reduce stress on an aging musculoskeletal system while some have a primal urge to reach new physical limits. Whatever the case, these athletes will, in increasing numbers, develop a wide array of overuse injuries. When these injuries occur, the athletes will turn to the medical community, including podiatrists, for diagnosis and treatment of these injuries, as well as training, biomechanics and equipment recommendations including shoes, pedals, cycling cleats, etc. As was the case with the running boom, podiatry could find itself a key healthcare partner for these athletes. Who are these new-age endurance athletes? Men, women and even youths have become swept up by the challenge to complete a variety of endurance events and adventure races. Most remain close to home and typically focus on local and regional triathlons and duathlons. As athletes gain confidence and experience, they set their sights on larger, more prestigious and even more rigorous events such as an Ironman, Race Across America (RAAM), Badwater or even Primal Quest. Driving this growth are mid-life adults, who are seeking to maintain an active lifestyle in the face of advancing years. However, they often bring to their new athletic pursuits old dominant musculoskeletal injuries hidden during years of relative inactivity. These old and dormant injuries are frequently aggravated by the demands of a rigorous training and/or racing schedule, and frequently intermingle with new overuse injuries. Nicholas DiNubile, MD, has described these injuries collectively as “boomeritis,” an endearing term that clearly defines a generation of aging athletes. Can We Effectively Prevent Overuse Injuries? The exacting etiology of overuse injuries is often shrouded in uncertainty.6 Many have categorized the factors contributing to overuse injuries among endurance athletes with training errors, anatomical/biomechanical factors and equipment failures representing the most frequently cited circumstances associated with overuse injury. The existence of malicious malalignment continues to dominate our suspicions and is frequently described as a cornerstone to overuse injury. However, many more factors play into the development of overuse injuries.7 Contributing factors can be generalized as either intrinsic or extrinsic in nature. One would typically identify these factors via the patient history and physical examination (see “Which Factors May Contribute To Overuse Injuries?” below). The implications for podiatric medicine are to “stay the course” or assume an expanded leadership role in the care of endurance athletes. To accomplish this, podiatric medicine must: pursue randomized investigational/experimental research; reevaluate and revise treatment protocols and recommendations; provide recommendations and preventive measures to the endurance athlete community; strengthen peer education opportunities; promote public awareness; and carefully listen to our patients. Medicine has generally been problem-oriented in its focus on patient care and management. However, we need to help instill preventive behavior within our endurance athletes/patients. We need to encourage more rest and less intense training, and facilitate improved strength and range of motion. New shoes and orthoses alone will not be sufficient to nurture the necessary behavior modifications for the athlete to avoid future disabling overuse injuries. Which Factors May Contribute To Overuse Injuries? Intrinsic factors • Age • Gender • Psychological factors • History of previous overuse injury • History of previous musculoskeletal injury/surgery • Previous long-distance endurance sports experiences • Body height and weight • Muscular imbalance • Restricted range of motion • Biomechanical misalignment of the lower extremity • Chronic musculoskeletal/connective tissue diseases Extrinsic factors • Inadequate warm-up • Inadequate/improper stretching routine • Training intensity/effort • Training frequency • Training speed/cadence • Time of day and year • Previous racing and training efforts • Participation in other sports • Racing and training shoes • Nature of training surfaces (hard, canted, etc) • Foot orthoses • Improper fit and use of equipment • Improper and poor racing/training technique Case Study: When A Triathlon Runner Presents With Neuroma Pain And Gait Abnormalities A 52-year-old male professional who has participated in triathlons for the past five years received an orthopedic referral for treatment. The patient exhibited gait abnormalities and complaints ranging from a chronically painful neuroma on the right foot to chronic patellofemoral pain syndrome involving the right knee and degenerative joint disease of the right hip. His previous treatment has included multiple cortisone injections to the neuroma, over-the-counter (OTC) foot orthoses for training/racing purposes, physical therapy and cortisone injections to the hip. Daily activities, including work and training, cause variable pain, ranging from mild (3/10) to severe (10+/10). The patient describes the most limiting source of pain as from the right hip, which he notes was injured repeatedly during 20-plus years of playing soccer. His hip fatigues and becomes more painful when his neuroma and knee are symptomatic. He will eventually require hip replacement surgery but he has elected upon the recommendation of his orthopedist to put off this surgery for as long as possible. The patient does not intend to abandon his current training/racing calendar. He runs three times per week and accumulates an average of 35 miles per week. He rides six days a week, averaging 275 miles/week and swims 1,000 to 2,000 yards daily. This training routine typically requires him to ride and run two days a week. He only performs all three activities during races or events. The patient does maintain his training regimen and also maintains his racing equipment. He currently uses a stability class running shoe in a wide width, which he replaces every 500 miles. He rides a fit, off-the-shelf road specific bike that has been modified for triathlons. He rides forward in the cockpit area (seat through handlebars) with a tall head tube that places him in a more upright position when he is using his aerobars (aerodynamic handlebars). This has been done in the hopes of relieving hip pain by placing the hip in a more extended position throughout each pedal cycle. His pedal system provides freedom for his foot to float (18 degrees of transverse plain motion) throughout each revolution of the pedal. He rides in a road shoe with a standard sock liner. What The Diagnostic Workup Revealed The patient’s physical examination was generally unremarkable with the exception of findings consistent with a suspected neuroma to the third intermetatarsal space (positive Mulder’s and Tinel’s signs), and moderate pain and mild crepitus to range of motion to the plantar aspect to the second metatarsophalangeal joint (MTPJ). Radiographic imaging detected a mildly elongated and plantarly displaced second metatarsal. Ultrasonography confirmed the presence of a hyperechoic mass in the third intermetatarsal that demonstrated a positive Mulder’s sign to direct manipulation. Treating physicians saw no disruption or displacement to the plantar plate inferior to the second MTPJ. There was also pain in the right lower extremity. Clinicians noted moderate pain to the inferior medial aspect of the patellofemoral joint with crepitus to range of motion. This pain could be accentuated upon extension of the leg with the lower leg internally rotated. Assessment of the patient’s leg strength noted asymmetry between quadriceps with the vastus medialis obliquus (VMO). The patient had noticeable weakness (3+/5) bilaterally. The patient had mild pain throughout the range of motion of the right hip. The patient also had biomechanical abnormalities. The right leg was 8 mm long. He also had excessive internal rotation of the right hip and weakness in the left hip abductors. The patient had a moderate 8-degree forefoot valgus bilaterally, which is fully compensated in resting calcaneal stance position. Treating physicians evaluated the subtalar joint axis of rotation and noted medial deviation with a moderately high pitch, promoting greater transverse plane motion than frontal plane motion. These observable factors all contribute to an abnormal syndrome of midstance and propulsive phase pronation of both feet. The use of F-Scan (Tekscan) imaging confirmed the functional dominance of a long right limb. Digital video (DV) walking and running gait analysis demonstrated a number of abnormalities. These abnormalities included prolonged stance phase pronation of the right foot extending well into the propulsive phase of gait; adduction of the left rear foot at heel off (abductory twist action) secondary to the limb length discrepancy; and a right hip drop secondary to weak left hip abductors. Digital video cycling analysis confirmed the biomechanic details observed during the gait analysis. The analysis demonstrated that the athlete’s relative spinning position in the cockpit was too far forward; the shoe cleat was too anterior to the pedal axial; and there was excessive hip, knee and ankle extension through the power stroke of the right limb. Tracking patellar movements during spinning clearly detected excessive patellar frontal plain motion that was thought to be associated with the patellofemoral pain. A Closer Look At The Treatment Plan The patient’s diagnosis did not significantly change. However, understanding the contributing factors permitted the formulation of a treatment plan that would not significantly detract from the athlete’s immediate goals. Treating physicians proposed a multifaceted treatment plan for this endurance athlete. The plan was successful due to the collaboration of several medical and non-medical specialists, each of whom identified unique problems via the athlete’s medical history, physical examination, and biomechanics assessment. Here were the key elements of the treatment plan. • The athlete had a bike fit done through a local tech shop. • The athlete worked with a physical therapist to improve hip and knee ROM, and balance muscle strength. • A local chiropractor examined the athlete for limb length discrepancy and adjusted the sacroiliac joint. • A local triathlon coach reviewed and revised the athlete’s current training program. • The athlete presented to his orthopedist for follow-up and management of the right hip. • The athlete underwent a series of sclerosing injections on the neuroma on the right foot. • The athlete underwent F-Scan computer assisted gait analysis and received temporary OTC orthoses that were created based upon the results of the F-scan study. • The athlete wore a new training/racing shoe based upon the results of his biomechanic examination. • The athlete wore a new cycling shoe, including a cleat with the addition of a 3 mm shim on the left limb (for the limb length discrepancy) to fit the temporary orthoses. In Conclusion The successful treatment of many endurance athletes requires a coordinated or collaborative approach involving the skills of medical and non-medical specialties. Building a treatment strategy, as with any medical decision, begins with a detailed history, physical examination and laboratory/imaging results. Rarely have I found a circumstance in which I am the sole provider. More importantly, improvement occurs through the integrated efforts of a range of medical and non-medical specialists. Engaging the expertise of non-medical specialists, such as tech shop staff, coaches and trainers, when necessary, benefits both the athlete and the sports medicine podiatrist. The popularity of endurance events is growing. Accordingly, there will be an increasing demand for medical specialists capable of understanding the motivations and the sports, in addition to being able to treat overuse injuries. Similar to the running boom of decades past, podiatric medicine will find itself ideally situated to respond to the complex needs of these new age athletes. Podiatrists provide a unique perspective in that they understand the complex interactions of lower extremity biomechanics, sport and injury. Our ability to respond to the complexities of overuse injuries through the development of a treatment plan that integrates our own expertise with that of other medical and non-medical specialists will endear podiatric medicine with the endurance athlete community. However, only by expanding our experiences via educational opportunities and the pursuit of randomized investigational/experimental research can we maintain our cornerstone role in caring for endurance sports athletes. Will podiatric medicine be capable of continuing to meet the needs of this unique and challenging athletic population? Dr. Herring is a Fellow of the American College of Foot and Ankle Orthopedics and Primary Podiatric Medicine, and the American Academy of Podiatric Sports Medicine. He is a team podiatrist for several college and professional teams, and has a private practice in Spokane, Wash. Dr. Caselli (left) is a staff podiatrist at the VA Hudson Valley Health Care System in Montrose, N.Y. He is also an Adjunct Professor at the New York College of Podiatric Medicine and a Fellow of the American College of Sports Medicine.



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