On Saturday (bright & early in the morning!) Dr. Chang spoke to Charlottesville Women’s 4 Miler Training Program participants about how to maintain healthy feet & ankles while training for the race coming up this Fall. His main piece of advice for them was to be sure they rest. Their training schedule gives them a ‘day off’ on Fridays and he asked that they stick to that so their body can recover and remain injury free. After their training run, many of the ladies came to Dr. Chang for advice on foot and ankle issues that they are already experiencing. We had a great time meeting so many women who are dedicated to getting fit while helping their community at the same time! If you are planning to run the Charlottesville Women’s 4 Miler next year or just want to get started with running, this training program is a great way to do it!
We gave training program participants a flyer with instructions on how to download our free book- A Runner’s Guide To Maintaining Healthy Feet & Ankles. If you would like a copy, you can download it here: www.brfootandankle.com/book
Inflammation is your body’s response to injuries, trauma, illness or infections, in which your body tries to increase the blood flow to the affected area. The accumulation of fluids, however, can be painful and result in swelling, increased warmth and redness of the skin, and even bruising. Acute inflammation is the immediate response to trauma, injury, irritation or surgery, and will usually occur within two hours of the event of injury. Note that acute inflammation is different from chronic inflammation, which is more regular, does not always follow a traumatic injury, is caused by a virus or bacteria and therefore treated differently.
Acute inflammation treatment should be responded to with “RICE to the D” therapy: the age old Rest, Ice, Compression and Elevation, mixed with a Diagnosis from your podiatrist, since your podiatrist can best determine the cause of your foot and ankle pain and swelling. Remember to R: stay off your foot or ankle since pressure on it may cause further injury. I: Apply an ice pack or bag of ice to intervals of 15 minutes to the injured area, placing a thin towel between the ice and your skin. Wait for 40 minutes before icing again. Repeat as desired – the more the better! C: you can control swelling with an elastic wrap around the inflamed area, and E: raise your foot or ankle slightly above the level of your heart to reduce the swelling. Your podiatrist may also suggest that you take NSAIDs. With RICE, your symptoms will most likely improve within a few days. If your symptoms persist or worsen, be sure to see your podiatrist to receive a proper diagnosis and care.
There are two main kinds of fractures of the foot – traumatic (or impact) injuries and overuse (or repetitive stress) injuries. Stress fractures constitute the latter grouping, and most commonly occur in the metatarsals (bones of the mid-foot), the hallmark of which is swelling on the top of the foot. Stress fractures are also common in the ankles and shins. Regardless of where the stress fracture is located, it will be identifiable by pinpoint (not diffuse) pain. With 26 bones, your foot’s complex structure allows many opportunities for stress fractures!
Stress fractures most commonly occur among athletes and runners who increase their mileage too quickly. In general, stick to the 10% increase in mileage per week rule, and you will more likely avoid getting a stress fracture. However, it is also important to keep an eye on other factors that might lead to a stress fracture. These factors include, but are not limited to, poor nutrition, improper footwear, abnormal foot structures, deformities, osteoporosis, and sudden weight gain. Stress fractures are often diagnosed by pain during activity that goes away with rest, pain when pressure is exerted at the site of the fracture, and swelling without bruising.
Be forewarned that stress fractures are microfractures, so small that x-rays do not show positive signs of them until two weeks after the onset of pain, as the bone calcifies in the healing process. There are, however, other subtle indicators that point to fractures as causing pain, one reason why it is so important to consult seasoned podiatrists to get a correct diagnosis for your injury.
The most important thing to consider when treating stress fractures is the time they take to heal. Do not wait to treat stress fractures, or put off visiting your podiatrist for a diagnosis. If treated improperly or ignored, stress fractures will only worsen with time or reoccur. Untreated, or improperly treated stress fractures can lead to deformities that restrict motion and activity, cause arthritis and make shoes incredibly uncomfortable.
Your podiatrist and you can work together to find the proper treatment plan for your injury, which will likely include a combination of rest, immobilization with a caste or rigid shoe, avoiding the aggravating activity, ice, NSAIDs, physical therapy for rehabilitation, and surgery in extreme cases. In general, remember that it takes time to heal stress fractures. Be patient with your body – you will be a much stronger runner if you are able to give your injury the time it needs to heal!
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A neuroma is a growth or thickening in the nerve tissue due to compression or irritation of the nerve. While neuromas can develop in different parts of the body, they are most commonly found in the feet between the third and fourth metatarsal toes and called Morton’s Neuroma, or intermetatarsal neuromas. Populations who wear restrictive shoes, or have foot abnormalities such as bunions, hammertoes, flat feet, or more flexible feet, are at a higher risk of developing this type of nerve damage. If you suffer from Morton’s neuroma, you probably already know this by the instant relief from the burning and aching toe pain once you take off your shoes. That’s because the width of your shoes often aggravate an already irritated nerve.
Neuromas have a variety of symptoms that vary from pain to tingling, burning or numbness, and even feeling as if something is inside the ball of the foot. Symptoms often have a gradual onset, first only flaming up when wearing shoes with a tight toe box or while engaging in activities that stress the ball of the foot. Initially, symptoms can be relieved by removing a constricting shoe, massaging the tender area, and by avoiding aggravating activities. However, as time passes, symptoms will get progressively worse. If untreated, neuromas can lead to permanent nerve damage, so consult your podiatrist early about your neuroma.
Treatment and prevention vary. First thing first, make sure you have the proper shoes for your feet! Your podiatrist will first suggest using shoe inserts or special padding techniques to relieve the pressure from the affected area. Additionally, icing, using over the counter or custom made orthotics, modifying activities that aggravate the injury, taking NSAIDs, or even cortisone and local anesthetic injections can help. In more severe cases, surgery will be a viable option to remove the neuroma altogether.
Shin splints, also called tibial stress syndrome, are a common complaint of runners who increase their mileage or intensity too quickly. Feeling throbbing or aching in the shins is surprisingly common for athletes and runners. Shin splints, however, aren’t a single medical condition. They can be caused by a number of factors; irritated and swollen muscles, over use, stress fractures, over-pronation or flat feet, and running on hard surfaces, to name a few. With shin splints you will feel a dull and aching pain in the front of the lower leg during exercise, or even after exercise. Shins may be painful to the touch, muscles can swell, and nerves can even be affected causing parts of the feet to go numb.
There are various places where the shin can cause pain. Usually, a flatfoot can cause pain in the tibialis posterior, or the front and outside of your shin. High arches can cause anterior lateral shin splints, on the inside of your shin. Less common is pain deep in the back of the leg, caused by tightness in your inner calf muscles, the soleal complex. No matter what kind, shin splints are a mechanical issue, caused by excessive mileage and a pounding stride.
There is good news for all of you who suffer from shin splints: they are very treatable, with quite high success rates! So have hope as you begin your treatment plan. Treatment for shin splints varies according to the nature of your own individual injury. In general, the very first thing to do is to rest in order for your injury to heal. Additionally, ice, NSAIDs, arch supports, range of motion exercises (as recommended by your podiatrist or physical therapist), a neoprene sleeve to support and warm the leg, and physical therapy will be recommended. If your shin splints are caused by stress fractures, you may be put in a walking boot or even need surgery for severe cases.
Remember that recovering from shin splints can be a frustratingly long process. Many runners need up to six months, or more, to recover. Resist the urge to start running again before you are ready, because your injury could become more severe. To bide time and to stay in shape until you heal, you can take up activities that have little impact on your legs such as swimming or cycling. You will know when you are ready to run again by a number of factors including equal flexibility in your legs, activity does not cause pain, or when x-rays show that your stress fractures have healed. To avoid shin splints wear good shoes with the right amount of support for your foot, warm up and then stretch before working out, run on soft surfaces, and stop working out when you feel pain in your shins.
The posterior tibial tendon attaches the tibialis posterior, a muscle deep in the back of the lower leg, to the metatarsal bones. As one of the major supporting structures of the foot, we could not walk without the tibialis posterior. It goes figure that the onset of posterior tibial tendonitis can be painful and impair walking, running, and other activities.
Posterior tibial tendonitis and tendonosis occur when the tendon undergoes stress, inflames or gets small tears in it, which, in turn, impairs the tendon’s ability to support the arch of the foot. Most commonly this is a result of overuse and inconsistent activity after already having the tendency to pronate excessively or a preexisting flatfoot. Once the posterior tibial tendon tears, PTTD is also referred to as “adult acquired flatfoot,” as the condition usually occurs in adulthood. Posterior tibial tendonitis and tendonosis is a progressive disorder, so catch symptoms early by consulting your local Charlottesville or Waynesboro podiatrist. If you feel pain along the course of the tendon or on the inside of the foot and ankle, notice swelling, redness, a warm sensation, a flattening of the arch or inward rolling (pronation) of the ankle consult your podiatrist for a diagnosis or treatment. In more advanced stages, the arch will begin to flatten, changing the dynamic of the foot and your stride as you walk or run. Your toes will turn outward while your ankle rolls inward, pain will shift to the outside of the ankle, and the injured foot, even the ankle, may develop arthritis.
For advanced cases, surgery will be required. However, early treatment will include NSAIDs, icing, shoe modifications, bracing or orthotic devices, immobilization by a short-leg cast or brace that allows the tendon to heal, and avoiding weight-bearing activities for some time. Physical therapy exercises and treatment will include ultrasound therapy and exercises to strengthen and increase the flexibility in the tendon and attached muscles.
The Achilles tendon connects the calf muscle to the heel bone and is the thickest and strongest tendon in the body in humans. While helping raise the foot off the ground with each step, the Achilles tendon can receive a load stress 3.9 times body weight during walking and 7.7 times body weight when running. Despite its ample strength, the Achilles tendon is prone to injury. The most common Achilles injuries are Achilles tendonitis and tendonosis, the former being inflammation of the Achilles tendon and the latter being degeneration of Achilles tendonitis. The inflammation from Achilles Tendonitis is usually short-lived. Over time, if tendonitis is not treated, it can degenerate into a worse condition called tendonosis, marked by tears in the tendon. In rare cases, chronic degeneration with or without pain may result in rupture of the tendon.
Repeat after me: I will not run through my Achilles injury. The Achilles will not heal if you keep running on it. When you hurt your Achilles, it is time to start cross training and being gentle with it. The most common risks to the Achilles are sudden increases of repetitive activity without giving it enough time to repair itself. Intense activity causes micro-injuries in the tendon fibers, which require time to heal. Additionally, athletes and runners with inconsistent workout schedules, such as weekend warriors and those who increase their workout intensity and volume too quickly, are prone to Achilles injuries. Achilles injuries may also be due to physiological reasons such as excessive pronation and flat feet, which put extra pressure on the tendon while walking or running.
Achilles tendonitis and tendonosis will result in pain, aching and tenderness along the tendon’s path, increasing when the sides of the tendon are squeezed, but with less pain in the back of the tendon. To diagnose Achilles injuries, your podiatrist will examine the foot, its range of motion, and conduct further assessment with imagining techniques such as X-rays. Initial treatment will include rest. Using heal lift inserts on both feet, or wearing high-heeled shoes with an open back, can help relax the tendon and give it the rest it needs.
Treatment plans will focus on reducing force on the Achilles tendon by means of a cast or walking boot, reducing swelling with ice and oral medications, long term preventative strategies such as custom-made orthotics and night splints, and gradually building a physical therapy regimen that includes stretching and strengthening exercises, soft-tissue massage and mobilization, and ultra-sound therapy. Eccentric stretching and strengthening of the Achilles – that is, elongating the Achilles while doing exercises – are key to long-term rehab. Examples include, first, doing calf stretches in a small lunge with your hands pressing against a wall, second, sitting with one leg straight in front of you while flexing and pointing your toe, or, finally, doing toe raises at the edge of a step or stair. You may even want to consult your podiatrist and physical therapist about working on your gait and stride while running, as gait abnormalities can lead to Achilles tendon and other injuries.
Researchers estimate that the front of your foot absorbs three to four times your body weight with each stride as you run. With an average of 1500 strides per mile, runners and athletes can put considerable stress on their feet. Moreover, feet have complex structures, each containing 26 bones, 33 joints , 112 ligaments, not to mention the additional tendons, nerves and blood vessels. Runners and athletes may suffer from a multitude of injuries and conditions in their ankles and feet, which Dr. Kevin Murray and Dr. Stewart Chang have years of experience diagnosing and treating. Glossed below are summaries of the most common podiatric running injuries, including brief explanations, diagnostic techniques, and treatment and rehabilitation strategies.
A common, yet no less painful, injury, plantar fasciitis refers to the inflammation of the plantar fascia, the connective tissue that runs along the bottom of the foot and creates the arch of the foot. The plantar fascia helps to support the arch of the foot, taking pressure off the arch when the foot bears weight. Experts suggest that the plantar fascia supports up to 14% of the pressure exerted on the foot. During activity, the plantar fascia acts like a spring, propelling us forward as we take steps.
Inflammation of the plantar fascia is called plantar fasciitis, and occurs when the plantar fascia is over stretched or over used. Causes include foot arch problems, obesity or sudden weight gain, long-distance running, especially running downhill or on uneven surfaces, a tight Achilles tendon, and shoes with poor arch support or soft soles. Plantar fasciitis is one of the most common injuries treated among the running population.
Plantar fasciitis is frequently diagnosed in men between ages 40 and 70 years, however, it is such a common podiatric injury that it is seen across the board with various age groups and genders. The symptoms of plantar fasciitis include pain and stiffness in the bottom of the heel, which can be either dull or sharp, ache or burn. Patients commonly complain that the worst pain is felt in the morning, but also after standing or sitting for long durations, while climbing stairs or after intense activity.
Here is the unfortunate catch to plantar fasciitis: while it does not hurt during activity, activity is exactly what causes the pain. Plantar fasciitis will hurt during recovery from a workout, or after waking up in the morning. Despite not hurting during running or activity, be aware that running only causes further damage to the plantar fascia. The cold, hard truth of the matter is that you cannot run through plantar fasciitis – running will only make your injury worse.
Diagnosis and treatment for plantar fasciitis vary. You can expect your podiatrist to perform a physical exam to provide clues from your foot’s physiology – flat feet or high arches, for example. Tenderness in the bottom of the foot, mid-foot swelling, redness, and stiffness are indicators of plantar fasciitis. Your podiatrist may also take X-rays to rule out other problems. Treatment regimens include taking non-steroidal anti-inflammatory meds (NSAIDs), such as Ibuprofen, Advil, Motrin, or Aleve, that work by blocking enzymes that stimulate swelling to reduce pain caused by inflammation, heel stretch exercises, mid-foot massage, plenty of rest, and ensuring that you are wearing supportive and cushioned shoes. Applying ice at least twice a day for 15 minutes at a time will help reduce inflammation and pain, and padding such as heel cups, foot pads, shoe inserts and custom made orthotics will help everyday activity. Night splits will enable your plantar fascia to stretch and heal, and let you get up in the morning pain free. In more severe cases, boot castes may be prescribed, and even steroid shots or injections may be given. If pain continues, in very extreme cases, your podiatric surgeon may suggest surgical methods.
In general, to prevent plantar fasciitis, make sure your ankle, Achilles tendon and calf muscles are flexible. Please visit the Heel Pain Center of Virginia on the web for more information on Plantar Fasciitis and other injuries to the heel.