Essential Insights On Developing Expertise In Podiatric Sports Medicine
- Volume 21 - Issue 12 - December 2008
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Also bear in mind that other aspects of treatment can help or hurt a situation. A classic example is someone who continuously gets physical therapy modalities or various adjustments (orthoses or manipulation) for lateral or medial foot pain when it turns out he or she has a tendon tear or a stress fracture. In these situations, surgery is often indicated because as mentioned earlier, faster is better. In fact, treating some injuries such as Achilles ruptures and Jones fractures non-surgically could be construed as “aggressive,” even though it is also considered “conservative.” For the sports medicine patient, surgery for these types of injuries is generally accepted as routine treatment and “conservative” treatment would not be ideal.
With the U.S. population aging and realizing the need to continue to exercise, physicians are recognizing more degenerative conditions. Often runners with knee pain receive foot orthoses, usually with medial rearfoot posting. With our long-term patients, what Brian Fullem, DPM, and I have personally noticed is that patients with genu or tibial varum can develop medial meniscal wear and degenerative joint disease. Rearfoot valgus posting has proven to be beneficial for patients with this condition.
We assume orthoses really do help in the treatment of knee pain. However, in the age of evidence-based medicine, we need more proof. Dr. Fullem and I have documented the healing time of other sports injuries such as plantar fascia rupture and navicular stress fractures in major orthopedic journals, and we look forward to a longitudinal study on orthoses for knee pain.
In speaking with two other well-known podiatric sports medicine specialists, Richard Bouché, DPM, and Marque Allen, DPM, they feel what sets podiatric sports medicine apart is the ability to make a rapid and accurate diagnosis, and then offer a full spectrum of up-to-date, efficient treatment options including non-surgical and surgical approaches. The margin of error is small and timeliness is paramount. Athletes appreciate the one-stop shopping aspect of their care and the sports medicine podiatrist of the present era is someone who can help them.
Balancing Urgency With Caution In Returning Athletes To Play
This could not be more apparent than my cohort of patients at this year’s Olympic track and field trials. Thirty athletes/patients competed. Ten of these patients used custom foot orthoses, eight had surgery and five utilized extracorporeal shockwave therapy.
Fourteen of these patients made the Olympic team. Five other patients could not compete because their injuries (such as ankle osteochondral defects and having had retrocalcaneal surgery less than 10 months prior). Three patients who did compete did so with navicular “stress reactions” that were diagnosed via magnetic resonance imaging (MRI). Follow-up computer tomography (CT) scanning revealed that all three had actual stress fractures.
This is a common pattern, particularly with high-level athletes. They get MRIs very rapidly and if no fracture is apparent, they continue to participate. Unfortunately, a doctor may tell them, “Let pain be your guide,” but high-level athletes usually have a high pain threshold. The CT scan shows bone alignment and fractures more accurately. Therefore, with elite athletes, it is not uncommon to order both, again on the same day, to get a rapid and accurate diagnosis. This is paramount to facilitate ideal treatment.
Urgency and speed are part of sports medicine. One needs to be available to these patients not only daily (including weekends) but sports medicine physicians also need to be willing to see them pro bono sometimes, such as on the field or at hotels.
It is not only important to order tests and get accurate results quickly, but it is also important to do surgery and get custom devices as well. During a season, a one- to two-week delay can make the difference between athletes getting back to their sport this season as opposed to the following year.