Pertinent Pearls On Treating Overuse Injuries In Endurance Athletes

By Kirk M. Herring, DPM, MS

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.

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