Partially due to our work in treating athletes, podiatry has become extremely well respected in North America in recent years. Very often it has been the podiatrists (and other foot specialists) who have been able to get the athletes back into their sports activity quickly, rather than restricting them to “no sports for six months”.
So, what are the considerations for treating athletes that have foot problems? This will be discussed over several areas.
Athletes needs differ considerably from non-athletic patients. In order to attain cardiovascular and pulmonary effects, the athlete (including recreational athletes) must participate for at least 20 minutes, three to four times per week, with an increased heart rate during that activity of approximately 220 beats/minute minus their age. The level of heart activity can be achieved through various exercises, so if a particular exercise is causing a problem, the practitioner can suggest alternatives. For example, a runner with a foot injury may participate in swimming or cycling and maintain the aerobic conditioning.
Athletes are also determined to correct their problem and usually willing to work at it. Thus it can be beneficial to outline remedial exercises that can be done at home. For example, an athlete with pronated feet and chondromalacia may benefit by doing some quadriceps exercises at home to improve the tracking of the patella. Also because they are dedicated to their sports, athletes will usually be quite willing to come to your office three time or so per week for physiotherapy treatments.
Athletes will often carry on with their sports activities regardless of their problem, so we can be of considerable help with our knowledge of accommodative padding, taping techniques, and, of course, orthoses. Frequently, the athlete will have already diagnosed the problem and taken corrective steps. A long distance runner, for example, may come in and indicate that he has a particular problem for which he has already used padding, orthotics, taping, ultrasound, ice, and rest. It is often necessary for the practitioner treating patients such as this to go a step further in assessing their patient’s problems.
Because of the athlete’s strong desire to get back into their activity as soon as possible, it is often helpful for us to use a “shotgun” approach rather than waiting to see if one therapy works versus another. As an example, for the patient that present with heel pain, some podiatrists may try a heel cup one day, a foam pad the next, some low dye taping the next, perhaps an injection the following week, and then eventually orthotics. It is not unusual for a month of treatments to go by before the podiatrist resorts to the use of orthotic devices after these multiple therapeutic modalities. While everyone has their own philosophy of treatment, using all the modalities in one or two visits including casting for orthotic devices (when indicated) would be of benefit to the athlete in the long run.
An area in sports medicine that is a concern is the nature of the athlete’s training and sport. Obviously, the more knowledge one has with respect to the nature of the particular sport an athlete is involved with, the better the treatment approach can be.
- Is the athlete doing any sprinting?
- Are they doing any speed work?
These factors can affect Achilles/calf muscle problems or forefoot problems. Surprisingly enough, sometimes simply deterring an athlete from doing speed work will take care of the particular problem.
- Is this athlete running up any hill?
Up-hill running will increase the stretching of the Achilles/calf muscle complex, perhaps leading to problems. On the other hand, downhill running can create jarring. The anterior tibial muscle/tendon complex decelerates the body with downhill running and this can become a factor in the case of shin splints or lateral knee pain, iliotibial band syndromes and lower back pain.
- What type of surfaces is the athlete running on?
Asphalt is softer than concrete, and grass, although soft, is not always the most ideal surface. A somewhat irregular grassy surface can increase transverse plane motion of the foot and enhance ankle of shin splint problems.
Obviously, shoes are important and a thorough understanding of shoes is necessary when dealing with athletes. I’m sure most practitioners are familiar with the construction difference between running shoes and tennis shoes. The Canadian Podiatric Sports Medicine Academy has available a list of tips for your patients on what to look for when buying different athletic shoes.
Another important factor with runners: how many miles are the running per week now, and how many miles were they running previous to the injury? Often an athlete has to be told to cut their mileage by 50%. Sometimes they have to be told to cease running altogether. This would apply for example, in the case of longstanding Achilles tendonitis problems. With most patient histories we are concerned about whether or not the problem was of a sudden onset or gradual onset. Most of the problems that we see in sports are the overuse syndromes with a gradual onset; problems that are in fact an active ongoing process even though they may come and go. Unless you treat them, they’ll likely persist over the long run.
Most practitioners will perform a biomechanical evaluation of their patients when a biomechanical etiology is suspected. Range of motion studies, muscle strength and function determinations, as well as stance and gait analysis should be performed thoroughly.
With athletes there are certain other things to bear in mind with respect to their injuries: is their muscle strength equal? Check the anterior tibial and posterior tibial strength and compare their right to their left. This holds true for the flexors, extensors and the peronei as well. Be on the lookout for limb length discrepancies which can multiply with long distance runners (a one quarter inch leg length discrepancy can be more like a one half to three quarters of an inch in someone doing thirty plus miles per week). Often measurements for muscle atrophy are of benefit (for example, in calf muscle girth).
Treatment of athletic type foot injuries are well within the scope of the podiatrist, but in all phases of treatment it must be kept in mind that athletes will tend to be on their feel more than non-athletes, creating increased stress. A good general principle to begin with is the “R.I.C.E.” approach.
“R.I.C.E.” stands for rest, ice, compression, and elevation. Ice can be used directly on the skin and often a Styrofoam cup filled with water and frozen, serves as a good applicator. Ice should be used for 10 to 15 minutes three or four times per day on the affected areas.
If using orthotic devices, be sure to keep the athlete’s particular sports in mind. For example, tennis requires a lot of side-to-side motions to a deep heel cup and either intrinsic or long rearfoot posts are helpful. Someone with a rigid pes cavus foot type playing tennis who happens to have a measured rearfoot varus of 4 degrees should be kept in a zero post, otherwise an ankle sprain is very possible.
Knees and Legs
Athletes will often require help with problems they are having with lower legs, knees, and sometimes their hips or back. Although these areas are not, in themselves, treated by foot specialists, the relationship between foot malfunctions and symptoms elsewhere in the body has been well demonstrated. It is extremely helpful therefore for practitioners interested in treating athletes to have an awareness of problems affecting the lower legs and knees.
The classical case of shin splints would results in pain along the lower one third to two thirds of the tibia and along the anterior. Myositis, tendonitis, and periostitus is usually present. Palpation of the area reveals pain, and supination against resistance may evoke moderate discomfort. Percussion of the tibia and subsequent pain may indicate periostitis and or a pre-stress fracture.
While we are not expected to treat this problem nor render physiotherapy, there are certain things to bear in mind as far as the feet are concerned. First of all, a rigid pes cavus foot type or a rigid plantarflexed first ray will result in significant jarring forces transmitted up the leg. Advising patients about well cushioned shoes and recommending swimming or cycling, and the use of insoles such shock absorbing materials would be helpful. Frequently and orthotic device is also of considerable help.
Dr. Lloyd Nesbitt, DPM
Paragon’s Sport and Pro Sport devices are specially designed to withstand the unique forces and stresses applied during higher intensity activities. Get in touch to learn more.