November 24, 2009

Plantar Fasciitis…or not

“I started getting a pain on the bottom of my foot near the heal but I’m not sure if it’s actually Plantar Fasciitis. I’ve been doing a lot of trail running (at night)and my feet (and ankles) take some abuse. I’ve twisted them, banged them, over-flexed them, etc..My problem foot is weak, especially when I rotate inward or point my toes. Kicking a soccer ball would hurt, for instance. This pain would be more towards the top of my foot, right where it attaches to the leg. I can walk, even run with it with hardly any pain…until I twist my ankle or land on a rock on the bottom of my foot.

I don’t want to panic and think it’s PF, but I’m not sure what to do for treatment. Any ideas would be helpful.”

Steve

Steve, it seems like you are describing two different problems – on one hand, the pain under the foot near the heel sounds a lot like plantar fasciitis to me and then the pain on the top of the foot, like the pain you describe while kicking a ball sounds like it could be related to your ankle or the talo-crural joint or possibly an old high ankle sprain.

plantar fascia irritated

If it is your ankle joint, then you can have a qualified physical therapist perform a distraction manipulation of the ankle which would allow the Talus to re-seat and that in turn should resolve the pain on the top of your foot that occurs when you load the foot in to plantar flexion.

x-ray talocrural joint

OK? Good luck!

November 21, 2009

Curious Shoulder Pain

Neil,
I read your blogs on the shoulder. Fantastic work. I used to play professional baseball 15 years ago. I tore my rotator cuff in college and spent six months rehabbing it back to form. I designed my own regimen complete with tubing, weights, stretches etc and it worked fantastically.

I’ve recently injured (have pain in the front of my left shoulder- feels like the front-side) and am having trouble defining what the issue is. I will try to diagnose and rehab first before xray, mri, cortisone etc.

The pain occurs when when I extend my left arm across my body and slowly move it upwards in that position (not right against my body as in the typical stretch you would do with that motion) but just slightly off my body. In the same position and turn my hand inwards (supinate) (the shoulder area is painful). The other painful movement is the golf swing. When my left arm is dead straight (as in when the club is parallel to the ground) is when it seems to be aggravated.

I can’t tell whether it’s my AC joint, Glenoid Labrum, or Subscapulerous tendon, or possibly something else.

It’s been around for a while, I don’t think it’s tendinitis as I don’t use it all that often. I’ve stretched, ice’d, tubed, painkillers etc but it doesn’t seem to go away.

From my definition, does something stand out?

Any feedback would be appreciated.

Dave Doherty

Dave, the most incriminating thing you note is that the shoulder hurts more when you bring your arm across your body (as in your golf swing). This, it turns out, is an incrimination test for the AC joint. My guess is that based on the data you provide, you seem to have an inflamed AC joint. I would suggest you see an orthopedic surgeon who can more closely examine it and possibly treat it with a cortisone shot. You might (repeat, might) be a surgical candidate too. Often there is a relationship between the Acromion, the AC joint and the distal third of the Clavicle that a surgeon can treat by excising much of the bone to give more vertical dimension. Nevertheless, I think your best bet is to see a doc and perhaps look at an MRI to get the full picture.

Thanks for your kind words about the blog!

Neil

November 13, 2009

Working Though A Stress Fracture

Lets face it, dealing with a stress fracture is frustrating. First of all, stress fractures occur because of over use. The first consideration is biomechanical. Do your orthotics actually accommodate and correct for your dysfunction? Do you have orthotics? Do you need them?

Second, stress fractures occur because of excessive training. I often see people who can run 50 to 70 miles a week without any trouble sustain a stress fracture when they push to more than 80 miles a week.

Third, if you are a high mileage runner, then you need to pay attention to the health of your shoes. Old shoes, less cushion, more stress in the skeleton.

Fourth, diet is important. A diet rich in fruits and vegetables is important in the absorption of soluble calcium important in building the skeleton.

Speaking of diet, especially in young female athletes, we are concerned about the Female Athlete Triad, a condition where disordered eating (as opposed to an eating disorder) with insufficient protein in the diet, leads to stress fractures as well as other symptoms like amenorea as warning signs along with shin splints. You can read more about the Female Athlete Triad here.

Evaluating a stress fracture is a challenge sometimes, because the fracture might be a tiny crack in the surface of the bone that is invisible to an x-ray. For this reason, that an x-ray requires a 50% change in bone density, I prefer to have the stress fracture confirmed by a bone scan, a technology that requires only a 2% change in bone density to pick up. Clinically, we try to confirm the stress fracture with a tuning fork vibrating the bone. When a stress fracture is present, the bone vibrating really irritates the periostium and the stress fracture is confirmed.

Here is a picture of a bone scan illustrating a stress fractre:

stress fracture by bone scan

So a stress fracture is a fracture. This means that the normal healing time for a fracture is important to respect. So you will need to go non-weight bearing for 6 weeks, and then take 6 more weeks to strengthen before you return to normal training schedules.

For me, this means time in the pool swimming and running in the deep end is the best form of therapy. Beyond that, upper body weight training is OK but you need to protect against weight bearing. Once you hit the 6 week mark, then you can start building your loading times on the leg so that on a gradient you can get back to running. You should not run significant miles before 12 weeks is passed. It takes the fracture a few weeks to harden up. So be cautious once the fracture is healed.