Here is the latest copy of the APMA Newsletter “Footprints”. Focus on Foot Injury: Identification, management and protection tips from future injury.
Blue Ridge Foot and Ankle Clinic’s employee, Mark Smith, had a strong showing at the Shenandoah Mountain 100 mountain bike race this past Sunday (watch). This was Mark’s first attempt at a 100 mile mountain bike race. Racing for the Charlottesville Racing club/Blue Ridge Cyclery p/b Reynolds GM Subaru, he completed the course in 8 hours and 39 minutes, placing him 35th out of over 500 competitors.
“I’ve been wanting to compete in this race for a couple years now, but injuries kept me from participating”, says Mark. Finally injury free, Mark was able to get a last minute entry to the race. Mark admits, “I have not been this nervous about an event in a very long time. All my friends and fellow competitors were giving me advice and it was making me more and more nervous.” Once on the starting line, the familiarity of racing calmed his nerves and the race was on. “100 miles of fun!” Yeah um, maybe for you Mark.
“All joking aside, this was a very hard race that tested every aspect of my biking skills. I didn’t want to get stuck in traffic, so I went out fast, too fast. 45 miles in, I had a hard time communicating with the volunteers at aid station 3. Luckily the volunteers were on the top of their game and just took care of me: food, drink, and a shove off in the right direction.”
Mark ran into hard times before reaching aid station 4 around 60 miles. A bad headache caused him to slow and have a hard time keeping his bike on the trail. Disappointment set in as he sat at aid station 4 with a cold wet cloth dripping water over his head and watching other racers ride by. “I was dizzy and in a lot of pain. I even contemplated dropping out.” After 10-15 minutes, Mark decided to just get on his bike and pedal slowly to the finish, well at least try to.
Approximately, 10 miles later Mark’s headache started to dissipate and he started to feel much better. “I couldn’t believe it. I couldn’t explain it. It was like my body did a complete 180.” For the last 30 miles, Mark, “put the hammer down”. Fellow riders warned him about the difficult climbs still remaining, but why slow down when you feel this good. “I felt great and was climbing stronger than I had all day. Maybe it’s the strength I developed on my back to back 100 miles to Georgia or with my teammate Barry Pugh.”
First 100 mile mountain bike race completed. When asked if he will do it again next year, Mark had this to say. “YES! I not only learned a lesson about staying in the race and finishing, I also had a blast. The whole weekend was fantastic. Chris Scott of Shenandoah Mountain Touring and all of the really helpful volunteers made this event one of my all time favorites. The trails were so much fun and at times extremely challenging. The climbs were long and hard. The competition was crazy good. Yes, these are the things I enjoy about racing. I love pushing myself and can’t wait till next year. Oh, tell Dr. Chang the custom carbon orthotics he made for my cycling shoes did great. I had no foot pain whatsoever.”
Great job Mark. See race results here, SM100.Follow up note: Mark’s calves became very sore and tight a couple days after this race. Dr. Stewart Chang treated his calves with Extracorporeal pulse activation treatment (EPAT) Wednesday. We are happy to report, Mark’s calves were immediately better and he is back on the bike. Athletes who need to stay consistent with their training should consider EPAT. Read about EPAT on this site or call us today.
Blue Ridge Foot and Ankle Clinic 887 A Rio East Court Charlottesville, VA 22901 434-979-8116 417 South Magnolia AveWaynesboro, VA 22980 540-949-5150 Blue Ridge Foot and Ankle Clinic has been a part of the Waynesboro and Charlottesville communities for over 20 years. Podiatrists Dr. Kevin Murray and Dr. Stewart Chang offer services in sports podiatry, foot and ankle problems and diabetic foot care. Our friendly, accommodating team of Certified Podiatric Medical Assistants look forward to welcoming you to our practice.
Links to upcoming events:
If you have foot or ankle pain, come see us. If you need advice on training, I’m sure the folks at Ragged Mountain Running Shop and Crozet Running Store can help you out. Most importantly, get out there and enjoy yourself.
Plantar Fasciitis: Treatment Pearls
by Douglas Richie, Jr. D.P.M., President Elect AAPSM (2003 – 2004)
Epidemic Of Heel Pain:
Heel pain is the most common musculoskeletal complaint of patients presenting to podiatric practitioners throughout the country. It is well-recognized that subcalcaneal pain syndrome, commonly attributed to plantar fascitis, is a disease entity that is increasing in its incidence, owing partly to the fact that it has a predilection for people between the age of 40 and 60, the largest age segment in our population.
The orthopedic and podiatric literature have been filled with original scientific investigations and anecdotal reports about the appropriate surgical and non-surgical approach to plantar fascitis. The vast majority of these scientific articles deal with the general patient population presenting with heel pain. There is a growing consensus of opinion that plantar fascitis is best treated non-surgically with the vast majority of patients becoming asymptomatic within twelve months of the onset of symptoms.
While patience, rest and tolerance of pain are virtues recommended to the patient presenting with plantar fascitis, different treatment strategies must be employed when dealing with the athlete.This article will focus on the differences in treating plantar fascitis in athletes vs. the general, sedentary population.
Subcalcaneal pain syndrome in athletes is thought to be brought on by an overload of the plantar fascia.However, the mechanism of this overload is debated.Overload causes micro-tears at the fascia-bone interface of the calcaneus or within the substance of the plantar fascia alone.The central band of the plantar fascia is primarily affected where a hypercellular, inflammatory response occurs within the fibers of the fascia, leading to degenerative changes.
A spur may result from further inflammation but is not implicated as the primary source of heel pain.Many studies have shown the presence of spurs on the heels of asymptomatic patients.One study found that only 10% of all calcaneal spurs visible on x-ray were actually symptomatic.
Other authors have attributed “painful heel syndrome” to an entrapment of either the medial calcaneal nerve or the first branch of the lateral plantar nerve.However, the mechanism of entrapment proposed by these authors is still related to overload of the soft tissue and fascial structures on the plantar and medial aspect of the calcaneus.
Although heel pain is common, there is no commonality of opinion of the biomechanical etiology of this syndrome.Contributing factors reported in the literature include leg length inequality, pronation of the subtalar joint, restricted ankle joint dorsiflexion, weakness of plantar flexion, high arched feet, low arched feet and heel strike shock.Studies have shown that decreased arch height has shown no correlation to the development of plantar fascitis in runners.In fact, it is well accepted that the common athlete presenting with heel pain has a medium to high-arched foot.
Scherer and coworkers have given the best insight into the pathomechanics of plantar fascitis.Their study proposed that supination around the longitudinal axis of the midtarsal joint is a common feature in over 100 feet presenting with heel pain.Supination about the longitudinal axis of the midtarsal joint can occur in two primary situations:when the heel everts past perpendicular (heel valgus) or when a forefoot valgus deformity is present (sometimes accompanied by rearfoot varus).
TREATMENT STRATEGIES FOR THE ATHLETE
In most cases, the goal of the athlete is to quickly return to activities to minimize loss of fitness and performance.This will put pressure on the treating practitioner to be more aggressive than treating cases of more sedentary patients.
A survey was conducted by this author of the board members of the American Academy of Podiatric Sports Medicine two years ago to compare treatment protocols for athletes vs. standard population.The following treatment pearls were elicited:
1) Assignment to alternative activity
The athlete must be encouraged to maintain cardiovascular fitness during rest from damaging activities that may delay healing.For the runner, dancer or volleyball player, this means a complete cessation from running and jumping activities until acute symptoms subside.On the other hand, the athlete should be assigned to alternative cardiovascular fitness activities that minimize impact and loading on the plantar fascia including stationary cycling, swimming, upper body weight machines, and low resistance flat-footed stair master machines.
2) Change and modulation of footwear
Footwear analysis is critical for evaluating athletes with subcalcaneal pain.The footwear may be a contributory factor and can be utilized as a powerful treatment modality.Athletesshould be placed into shoes that have a minimal 1″ heel height with a strong stable midfoot shank and relative uninhibited forefoot flexibility.The American Academy of Podiatric Sports Medicine has a list of recommended footwear for the athlete that can be obtained on their web site:www.aapsm.org.It is well recognized that recent trends in athletic footwear have actually predisposed to greater frequency of plantar fascitis due to the fact that athletic shoes have weaker midsoles with newer designs.The popular “two-piece” outsoles with an exposed midsole cause a hinge effect across the midfoot placing excessive strain on the plantar fascia in the running and jumping athlete.These shoes must be eliminated if the injured athlete is wearing them.Careful attention must be paid to having the athlete keep shoes on in the house and during all standing and walking activities.Barefoot and sandal-wearing activities are prohibited.
3) Home therapy
Athletes are accustomed to designing and participating in their own training programs.They are willing participants in their own treatment programs. Heel cord stretching is central to the rehabilitation process to decrease load on the plantar fascia and encourage healing.The use of plantar fascia night splints has been well proven to be a treatment adjunct for plantar fascitis by placing the heel cord and the plantar fascia on a sustained static stretch during sleeping hours while preventing the normal contractures that occur in the relaxed foot position during sleep.Having the athlete roll or massage their foot on a golf ball or tennis ball is helpful to improve blood flow and break down adhesions in the injury site.
4) Custom foot orthoses
Intervention with semi-rigid custom foot orthoses has been well proven in many prospective and retrospective studies showing successful outcomes in patients with plantar fascitis.In the athlete, the use of foot orthoses should be considered earlier than in the average sedentary patient because of the fact that the athlete will be subjecting their feet to greater stresses during treatment and certainly after return to activity.Athletic footwear is more amenable to semi-rigid and rigid orthotic therapy than are casual shoes worn by sedentary patients.Sports podiatrists are more likely to employ arch taping procedures as a precursor to or adjunct to orthotic therapy.Athletes respond very favorably to the immediate intervention and relief obtained by expertly applied arch taping procedures.
5) Physical therapy
Athletes are amenable to referral for physical therapy because they are willing to invest the extra time to expedite recovery.Many athletes are used to going to the training room for hands on rehabilitation.Athletes appreciate a partnership between the sports podiatrist and the physical rehabilitation specialist.
6) Anti-inflammatory medication
Sports podiatrists should be cautioned against over-aggressive use of anti-inflammatories in treating the athlete.While it is tempting to utilize corticosteroid injections to expedite healing, athletes are often skeptical of receiving this treatment and are certainly at greater risk for sequela of over-ambitious use of steroid injections.There are reports in the literature of athletes undergoing spontaneous rupture of the plantar fascia after even single injections of their plantar fascia with corticosteroid.The conservative, biomechanical interventions outlined above should be implemented before considering injection therapy.
Athletes presenting with plantar fascitis must be treated aggressively because they have immediate needs and long-range goals that are different than those seen in the average sedentary patient with heel pain.It is important to be aggressive and employ a variety of modalities and treatments when formulating a treatment plan for the athlete.At the same time, caution should be made about the overzealous use of quick fixes, including corticosteroid injections because of the potential deleterious effect on athlete.
The cornerstone of plantar fascitis treatment for the athlete is biomechanical.Podiatric practitioners possess the greatest skill set and knowledge available in medicine today to adequately address the pathomechanics of plantar fascia overload.The use of properly casted and designed custom foot orthoses should be the cornerstone of non-surgical treatment of subcalcaneal pain in the athlete.
Resistant Plantar Fasciitis Treatment Program (Initial)
Contributed by Richard Bouche D.P.M. , William Olson, D.P.M., Stephen Pribut, D.P.M., Douglas Richie, Jr,. D.P.M.
PHASE 1- Acute Phase:
- Goal decrease acute pain and inflammation:
- absolute or relative rest- Decrease sports activity to avoid rebound pain
- ICE: 2 appliations of 20 minutes per day
PHASE 2- Rehabilitation Phase:
- Further decrease pain and inflammation:
- contrast baths
- Maintain/increase flexibility of injured (and surrounding) tissue:
- gentle stretching exercises: calf, hamstring, posterior muscle groups
PHASE 3- Functional Phase:
- Functionally strengthen intrinsic muscles of the foot
- closed chain therapeutic exercise
- Doming of Arch (towel toe curl)
- closed chain therapeutic exercise
- Protect injured area during functional activity
- stability running or other appropriate athletic shoes
- orthoses as needed
Note: this is probably the most important phase because it prepares the patient for their return to activity. Care needs to be taken at this stage not to allow the patient to overdo these exercises and stay within their limits as re-injury can easily occur.
PHASE 4- Return To Activity
Return to desired sport activity: gradual, systematic, “to tolerance”
Initiate preventive strategies:
appropriate athletic shoewear
functional exercises (i.e., pilates, plyometrics)
revise training program
Note: Be careful in the first months return to exercise to avoid recurrence of pain.
Consider shock wave therapy if there is a 6 month failure and a failure after repeated modification and remaking of orthotics.
- Posted in Athletic Injury, Cycling, Dr. Kevin Murray, Dr. Stewart Chang, EPAT, Extracorpeal Pulse Activation Treatment, Foot Doctor, Foot Pain, Heel Pain, Orthotics, Plantar Fasciitis, Podiatrist, Podiatry, Running, Shockwave Therapy, Shoes, Shoes and Socks, Uncategorized
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Common cycling injuries are often due to trying to do, “too much, too soon”, but may also be due to improper equipment, biomechanics, technique, or bike fit. As with all athletic injuries, pain that is persistent indicates a need to seek treatment from a sports medicine specialist familiar with cycling injuries.
1. “Hot foot” (numbness and burning in the ball of the foot)
Impingement of small nerve branches between the second and third or third and fourth toes can cause swelling which results in numbness, tingling, or burning, or sharp shooting pains into the toes. Loosening shoe toe straps, wearing wider shoes with a stiffer sole and using anatomical footbed with a metarsal pad will help alleviate the problem.
Besides tight shoes, another risk factor is small pedals, especially if you have large feet. Small pedal surfaces concentrate pressure on the ball of the foot. Switching to larger pedals may be the cure. Re-focus the pressure on the ball of the foot by moving the cleats towards the rear of the shoe. If your cycling shoes have flexible soles like most mountain bike shoes, they’ll be less able to diffuse pressure.
Physician-designed custom orthotics provide biomechanical benefits and can be made with built-in “neuroma pads”. Cycling orthotics are different than those for runners, as cycling is a forefoot activity, not a heel-strike activity.
Cortisone injections occasionally may be helpful for symptomatic relief, but they do not address the cause of the pain.
The sesamoids are two small “seed-like” bones found beneath the big toe joint. Injury to these tiny bones can result in inflammation or even fracture, leading to debilitating pain and inactivity. Sesamoiditis can be relieved with proper shoe selection, accommodative padding, and foot orthoses.
1. Achilles tendonitis
Irritation and inflammation of the tendon that attaches to the back of the heel done can be caused by improper pedaling, seat height, lack of a proper warm-up, or overtraining. This condition is usually seen in more experienced riders and can be treated with ice, rest, aspirin, or other anti-inflammatory medications. Chronic pain or any swelling should be professionally evaluated. Floating pedals which allow excessive foot pronation may also worsen this condition.
2. Shin splints
Pain to either side of the leg bone, caused by muscle or tendon inflammation, which may be related to a muscle imbalance between opposing muscle groups in the leg. It is commonly related to excessive foot pronation (collapsing arch). Proper stretching, changing pedals, and corrective orthoses that limit pronation can help.
Some intrinsic knee problems like swelling, clicking, or popping should be immediately evaluated by a sports medicine specialist. Cartilage irritation or deterioration, usually under the knee-cap, can be caused by biomechanical imbalance, improper saddle height, or faulty foot positioning on the pedals. Riding in too high a gear “mashing”, excessive uphill climbing, or standing on the pedals all may aggravate the problem. Cleated shoes or touring shoes with ribbed soles that limit side-to-side motion can cause knee pain if the knees, feet, and pedals are misaligned.
Pain under the kneecap. Most chondromalacia sufferers can ride at some level no matter how sever the degeneration.
2. Patellar Tendonitis
Strain of the tendon which attaches the kneecap to the leg, this injury often occurs in the novice cyclist or early in the cycling season. The first sign of a problem may be an ominous twinge after cycling in too hard a gear.
Bike fit is key; have a professional check your fit and make bike modifications as needed.
Carefully choose the shoes you will wear in cycling.
Train properly using adequate warm-up and cool-down. If you are doing “too much, too soon” and start having pain, reduce training frequency, intensity, and time.
Pain is not normal and may indicate a medical condition. Seek medical attention from a sports medicine specialist.
Before beginning any exercise program, be sure to check with your physician.
-The American Academy of Podiatric Sports Medicine (AAPSM)
Comment on this post to share your thoughts or contact Blue Ridge Foot and Ankle Clinic. We’d love to hear from you!
Blue Ridge Foot and Ankle Clinic
Charlottesville Podiatrist Location: 887 A Rio E Ct., Charlottesville VA, 22911 (434) 979-8116
Waynesboro Podiatrist Location: 417 S. Magnolia Waynesboro, VA 22980 540-949-5150
Blue Ridge Foot and Ankle Clinic has been a part of the Waynesboro and Charlottesville communities for over 20 years. Podiatrists Dr. Kevin Murray and Dr. Stewart Chang offer services in sports podiatry, foot and ankle problems and diabetic foot care. Our friendly, accommodating team of Certified Podiatric Medical Assistants look forward to welcoming
you to our practice.
- Posted in Achilles Tendon, Athletic Injury, Blisters, Bunions, Cycling, Dr. Kevin Murray, Dr. Stewart Chang, EPAT, Foot Doctor, Foot Pain, Heel Pain, Ingrown Toenails, Leg pain, Neuroma, Orthotics, Our Community, Plantar Fasciitis, Podiatrist, Podiatry, Shockwave Therapy, Shoes, Shoes and Socks, Triathlons
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- Tags: Athletics, charlottesville cycling, charlottesville podiatrist, Custom Orthotics, Exercise Related Pain, foot inflammation, foot surgery, mortons neuroma, Overuse Injury, Plantar Fasciitis, Sports Related Injuries, Tendonitis
Are you sick and tired of chronic pain and injuries that won’t go away? Don’t lose hope! Blue Ridge Foot and Ankle is now offering Extracorpeal Pulse Activation Treatment (EPAT), a cutting edge technology proven to increase the rate of healing for soft tissue injuries.
EPAT, also called Shockwave Therapy, was developed in Europe by the company CuraMedix, but is now being used by doctors world wide. EPAT is an FDA approved emerging technology that delivers non-invasive low frequency (8-11 Hz) acoustic sound waves into a localized area. The sound waves act as pressure, and penetrate deep through your soft tissue. The energy emitted causes the cells in your soft tissue to release certain biochemicals that intensify the body’s natural healing process. These biochemicals allow for the building of an array of new microscopic blood vessels in your soft tissue. Overall, EPAT increases the nutrient flow to the chronically injured tissue, stimulating your cell metabolic rate, and giving hope for those who are considering surgery as their only option.
EPAT studies promise that, with EPAT treatments, you will have your cake and eat it too: first off, you can continue the activities that you love through treatment. Secondly you will not need surgery. Finally, you will still reap positive results – many times, more positive results than any other available treatment. In fact, the results of other treatments such cortisteroidal injections, orthoses, e-stim, and even surgery, seem to be significantly less effective in research studies than EPAT. Moreover, more than 80% of patients who have failed to respond to anything other treatment are relieved of their pain after being treated with EPAT. Furthermore, While studies on ultrasound methods have been conflicting (Alexander, L.D. et al 2009), EPAT therapy studies, even when conducted by skeptics of EPAT, have seen resounding success in EPAT effectiveness to cure soft tissue maladies (Saxena 2011; Gerdesmeyer, L. 2008; Ibrahim, I. M. in press; Rompe, J.D. 2009; Rompe, J. D. 2008; Rompe, J. D. 2007; Rompe, J. D. 2009; Rompe, J. D. 2009; Furia, J. P. 2009). These studies, with high standards of wellness and success rates, show between 75% – 95% success with EPAT.
After trying other types of treatment (cortisone injections, stretching, anti-inflammatories, night splints, physical therapy, and orthotic devices), you might be disheartened to start considering surgery for your injury. However, consult Dr. Murray and Dr. Chang about EPAT, since it might be a viable option instead of invasive surgery. EPAT is a small machine with a trigger end that looks like an ultrasound. It is administered once a week for a series of three weeks (up to five weeks), each taking approximately fifteen minutes (depending on the area of injury). Dr. Murray and Dr. Chang will apply coupling gel and use the EPAT on the area, in essence, breaking the soft tissue down and providing an opportunity for your cell responses to quickly get rid of dead cells and regenerate new ones. In essence, this is the most rapid stimulation of cell generation, known to have the most rapid healing rate of any technology out there.
EPAT can be used for acute and chronic musculo-skeletal pain – even knots, dysfunction, plantar fasciitis, Achilles Tendonitis and tendonosis, chronic heel pain, tendonal insertional pain, acute and chronic muscle pain, myofascial trigger points, and the list goes on. There have been very few side effects reported – in few cases, skin bruising may occur, and patients may feel sore afterward, as though they have worked out. Patients who choose EPAT treatment should not take NSAIDs (including ibuprofen, Motrin, Advil, Naproxen, Aleve, and Aspirin) for two weeks prior to and one month after the administration of EPAT, as they interfere with the hormones that regenerate your cells.
EPAT is available for a wide range of patients. Research suggests to postpone EPAT treatment for pregnant women, for deep venous thrombosis or malignancy cases, or if you are taking blood thinners. These studies suggest that women should wait until four months after pregnancy to receive EPAT treatment, waiting for regular swelling in the feet to go down, and for the hormones that act as muscle relaxants during pregnancy to level out.
While the initial fees for EPAT are expensive, you can rest assured that they are cost-effective in the long run. EPAT is not covered by insurance. You can expect to pay $500 for a series of three treatments, not including the fee of a co-pay for your initial office visit and evaluation charge, (after which there will be no co-pay). Inquire with your qualified health savings account or your employer’s flexible payment medical savings account, as these can usually be used to pay for the treatment. If a 4th and 5th treatment is necessary, you can expect to pay $150 per treatment. Despite these initial costs, remember that surgery is much pricier, and that EPAT is proven to be much more effective than other treatments. Additionally, patients treated with EPAT are immediately fully weight bearing, have no incision, no risk of infection or scar tissue, experience very few (if any) side effects, and do not need to be put under anesthesia. Overall, EPAT is sure to save money and time, and to accelerate your road back to having healthy feet!
So inquire with Dr. Murray and Dr. Chang to see if EPAT is the right treatment for you. Blue Ridge Foot and Ankle is excited to bring such an effective and preeminent technology to the office, in order to serve you with top quality and cutting edge medical care!
Comment on this post to share your sesamoid injury story or contact Blue Ridge Foot and Ankle Clinic. We’d love to hear from you!
Blue Ridge Foot and Ankle Clinic
Charlottesville Podiatrist Location: 887 A Rio E Ct., Charlottesville VA, 22911 (434) 979-8116
Waynesboro Podiatrist Location: 417 S. Magnolia Waynesboro,VA 22980 540-949-5150
Blue Ridge Foot and Ankle Clinic has been a part of the Waynesboro and Charlottesville communities for over 20 years. Podiatrists Dr. Kevin Murray and Dr. Stewart Chang offer services in sports podiatry, foot and ankle problems and diabetic foot care. Our friendly, accommodating team of Certified Podiatric Medical Assistants look forward to welcoming you to our practice.