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Orthotics Q&A

When Treadmill Running Causes Foot Pain

At this time of year, many people begin to run on treadmills after receiving them as holiday presents and some seek to lose weight during the winter months. However, treadmill use increases the amount of repetition, possibly leading to biomechanical injury and potentially complicating common conditions like plantar fasciitis. With that in mind, our expert panelists take a look at the finer points of diagnosing and treating injuries sustained by patients while using treadmills. Q: What are the most important biomechanical considerations? A: Exercising on treadmills exacerbates the incidence of biomechanical injury since repetitions increase dramatically, notes Nicholas Sol, DPM, CPed. As he points out, the normal human cadence is 90 to 120 steps per walking minute or 5,400 to 7,200 steps an hour, which can see a substantial spike during treadmill use. “While their daily routine continues despite the purchase of a treadmill, the addition of treadmill exercise can add a significant number of repetitive biomechanical injuries,” says Dr. Sol. “Treadmill use often includes the use of incline and/or interval training. This also causes greater mechanical strain and biomechanical injury.” Stanley Beekman, DPM, says the most important biomechanical considerations he has seen are related to equinus, which the incline of a treadmill can aggravate. In the realm of biomechanics, for Marc Borovoy, DPM, it is most important to identify the functional mechanics that have led to the symptomatology and address them appropriately via stretching, mechanical control and educating the patient. Q: What is the most common diagnosis you make in patients complaining of foot pain associated with treadmill use? A: All three panelists say plantar fasciitis is a common finding in patients who have run on treadmills. Dr. Sol says intermetatarsal neuroma is the second most common diagnosis next to plantar fasciitis. Dr. Borovoy adds the exacerbation of neuroma pain, knee impingement and lateral hip pain to his list of commonly seen injuries. For Dr. Beekman, the most prevalent diagnoses he encounters are related to the incline and he sees Achilles tendonitis in addition to plantar fasciitis. Q: What are the characteristic findings? A: As far as plantar fasciitis goes, all three panelists say their findings are similar whether or not the patient uses a treadmill. “I have found the insertion of the medial and/or middle band of the plantar fascia is painful to palpation,” notes Dr. Beekman. “I have found the Achilles tendon is painful at either the insertion or along its course. I have yet to see focal degeneration of the Achilles tendon but I am sure that this exists also.” While plantar fasciitis often presents the same with treadmill use as without, Dr. Sol notes that you may detect pain with palpation at the midfoot level. Dr. Borovoy adds that with plantar fasciitis, he sees tight plantar fascia at the insertion site, pain with palpation of the plantar medial tubercule and a tight gastroc soleus. As for intermetatarsal neuromas, most of Dr. Sol’s patients present with a similar clinical picture regardless of treadmill use albeit with one unique difference. Dr. Sol notes that he sees a faster progression of neuromas in patients who use treadmills. Q: What diagnostic tools do you use? A: Dr. Sol uses radiographs, F-Scan and started using diagnostic ultrasound imaging about a year and a half ago. “Since a significant proportion of the complaints seen in my practice are related to soft tissue, I have found it to be a very valuable diagnostic tool,” he says of the imaging. “It has enhanced timely diagnosis of soft tissue pathology and contributed to a decline in the use of MRI. When it comes to biomechanics, the gold standard is in-shoe testing.” Dr. Sol uses the F-Scan system (Tekscan, Inc.) for “accuracy, ease of use and multi-format output of data.” In addition to radiographs, Dr. Borovoy uses a biomechanical evaluation. He also takes a thorough history of the patient’s use of the treadmill and his or her functional and athletic activity. Dr. Beekman says he tends to emphasize the history and palpation rather than special diagnostics. Q: How do you treat conditions associated with treadmill use? A: For plantar fasciitis, Dr. Borovoy emphasizes stretching of the gastro-soleus and maintains biomechanical control with orthotics. He uses ice and NSAIDs to combat inflammation. He also discusses proper training techniques with the patient and the importance of decreasing inclines when using a treadmill. When it comes to hip pain, Dr. Borovoy usually notes a tight iliotibial (IT) band and pain with palpation of the superior attachment. His treatment for this is the same as for plantar fasciitis and he recommends specific stretching for stretching the IT band. Since most knee pain is secondary to a shortened stride with treadmill use and pronatory forces, Dr. Borovoy recommends counseling the patient on appropriate training, decreasing the use of inclines and adjusting one’s speed appropriately in addition to orthotic control. In all cases, Dr. Beekman advises his patients to lower the incline of the treadmill. For the plantar fasciitis, he tapes the affected feet and fabricates orthotics if the taping does not lead to permanent relief. If equinus is an aggravating factor, depending on the situation, Dr. Beekman emphasizes stretching after pre-fatiguing with electrical stimulation, heel lifts and/or night splints. When treating Achilles tendonitis, Dr. Beekman institutes treatment in three phases: rest, transition and rehabilitation. The transition stage consists of Achilles taping, stretching after pre-fatiguing with electrical stimulation, ultrasound and heel lifts. The rehabilitation stage entails stretching after pre-fatiguing with electrical stimulation, ultrasound, heel lifts and night splints. Dr. Beekman adjusts his treatment depending on the severity of the patient’s condition, starting treatment at the appropriate phase. His more severe patients start at the rest phase while the least severe patients will start at the rehabilitation phase. He adds that he will use a CAM walker during the rest phase in severe cases. In Dr. Sol’s experience, orthotic management alone is often insufficient to treat treadmill related plantar fasciitis and intermetatarsal neuroma. In addition to custom orthotic management, he often uses steroid infiltration. He combines this with a prescription for new athletic shoes and emphasizes changing the exercise routine by decreasing exercise time and incline, and increasing rest. As for intermetatarsal neuromas, Dr. Sol has discovered, like many of his colleagues, that sclerosing injections are a “very useful therapy.” Dr. Beekman is a Diplomate of the American Board of Podiatric Surgery and the American Board of Podiatric Orthopedics and Primary Podiatric Medicine. He is also a Fellow of the American Academy of Podiatric Sports Medicine. Dr. Borovoy practices in Novi, Mich. and is Chief of Podiatric Surgery at Providence Hospital in Southfield, Mich. Dr. Sol (shown here) founded the Walking Clinic, PC and practices in Colorado Springs, Colo. He is a consultant to Tekscan.

Orthotics Q&A
Clinical Editor: Nicholas Sol, DPM, CPed
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