Pertinent Pearls On Treating Overuse Injuries In Endurance Athletes

By Kirk M. Herring, DPM, MS
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.

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