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(electronic music) – [Edward] What we’re do is we’re gonna talk about a couple of things tonight. Mark is gonna demonstrate a couple of things for us, and this is a nice enough, small enough group that I think what we’ll do then is we’re gonna split up and, so we’re not gonna try and make this too lengthy, but we’ll split up and if you have any individual questions, you can either talk to Dr Sauer, or to Mark, or to myself about any issues you have, so does that sound good to everybody? Good. All right. Running’s a unique sport, you all know that. I don’t have to cover a lot of the basic stuff here because of the history that all you folks have here. But during running the feet are hitting the ground sometimes up to 2,000 times per mile. The force at impact is two to four times body weight, so picture a 150 pound person, and the amount of impact that that structure, the foot, and the ankle, and the lower leg, and the knee, have to take up that pressure, and so as a result there’s a lot of things that can go wrong and just from listening to the different things that everybody talked about here tonight, and the different problems you’ve had, there are a lot of things that go on. The biggest problems that we see with individuals, or where people end up having problems, is because of training errors, running surfaces, running shoes, and the bio-mechanical or structural abnormalities, and we’re gonna address some of these. Training errors, what are some of the biggest training errors that people have? Anybody? Too much too soon, that’s the big one, too much too soon. The golden rule has always been, and still is, you should not increase, whether it’s your mileage, or your frequency, or the duration of your running, more than 20% per week. In fact, some people think that’s a lot. If you’re gonna get into… a lot of people are couch potatoes, they get into a walking program, before you know it, they’re getting into a running program, and they just take things too quickly, and their body just doesn’t have the ability to adapt that quickly to that type of stress, and that’s where certain problems come in. Running surface. You know there are some people that can run on sidewalks for 20 years and never have a problem, and there are other people that can’t do that. We’re all different, and that’s probably the one big thing. Just look at the people in this room, and the different body structures we’re looking at, different height, different weights, mechanics, age groups, there’s so many different things when it comes into each individual runner. The problem we see a lot of times is, especially in the high school and college runners, is they’re comparing themselves to the person next to them, and you can’t. You know, “My friend Dave can run five days a week. “He’s putting in 40 miles a week, “why can’t I do that?” Well you’re not Dave. Your body is different. That becomes just an acceptance thing that we have to realize about our own self. Running shoes. The running shoes that are out there today, as you all know, are fabulous for the most part. What I get a kick out of is, I have individuals who wear the best running shoes when they’re running, but the other 12 hours of the day, they’re wearing flip-flops, or really non-supportive type shoes, and it just doesn’t make sense. Uggs, it’s been the best thing for business. Uggs are the winter version of flip-flops. There’s no support, so the type of shoe that you’re wearing not just for running, but the type of shoe you’re wearing during the course of your day makes a huge difference. We know that after about 300 miles, about 60 to 70% of the shock absorption of a running shoe is gone, so keep track of the type of mileage that you’re putting on your shoes. You cannot look at the bottom of a shoe, you know, turn a shoe over, look at the bottom, and look at the wear pattern, and say, “Oh, now I know it’s time to get new running shoes, “because my shoe’s worn down.” Well believe me, that material on the bottom of the shoe, the sole, is like a car tire. The midsole material, the shock absorbing properties of those shoes has been shot, or wasted, a lot sooner than the sole has worn down. So really try and keep a mental note of how much mileage that you have on your shoes. Here in the Lehigh Valley, we are extremely fortunate. We have the Aardvark Shop and The Finish Line, two great places here. Most communities don’t have that type of resource. Go to those places, support those places, the people there know what they’re talking about. You’re not gonna buy a bad show there. Yes? (audience question) After about 300 miles, as much as…anywhere from 60 to 70% of the shock absorption of the midsole. The difference between a $40 pair of running shoes, and a $90 pair of running shoes, a lot of times is that midsole material, the part of the shoe that you really can’t see. If you can take your shoe, and bend it very easily, that’s not a shoe you want to be in. If you take that shoe by the heel and by the toe, and if you’re having a hard time bending it, that’s gonna be a better shoe. For those of us in the crowd that are 50 or above, when we were young, all our shoes had, the good shoes had steel shanks in them. Well you can’t buy a shoe with a steel shank in today, hard to find, but that’s what made that shoe supportive, it made it good. Well the running shoes that have a real stiff midsole material make that a better shoe. And the biomechanical or structural abnormalities again, huge difference in terms of one runner to the next. If a person has a flat foot, that’s gonna, they’re gonna have a certain mechanics when they run. If they’re gonna have a certain hip structure, or tightness of their hip, or tightness of their hamstrings, all those different little mechanical or structural problems come into play when we’re talking about running. One person could have one leg that’s a little bit longer than another, that’s gonna come into play and cause certain stresses on individuals. We kind of, just to make things simple, we kind of break the foot structure into two different types. You have the low-arch foot, or the pronated foot, everybody’s heard the term pronation. And then you have the high-arch foot, or the cavus foot. We’re gonna see 90 of these for every 10 of these that we see. So you have more people with a flexible pronated foot than you do with a high-arch foot. The high-arch foot, this one down here, tends to be a very poor shock absorber. These are the people that can’t sneak up on you. You can hear them coming, you know in the house, those are the kids that are boom, boom, boom. People like that are prone to certain problems because of the lack of shock absorption, so their Achilles tendon is gonna have to absorb a lot of shock, so some individuals with rigid feet, or pronated feet are gonna be more susceptible to Achilles problems maybe, than some other individuals. The pronated foot, this is that arch, and here in this picture you see this arch that’s really flat, well you can have an arch that’s flat when you sit, and when you stand, but there are some individuals that have a really nice arch when they sit, but when they stand the arch comes down. So there’s a lot of torque, there’s a lot of motion occurring in that type of a foot structure, and that’s a really unstable type of foot, and we see a lot of problems with that, we see structural problems like toe deformities, hammer toes, bunion deformities. People like that are real susceptible to plantar fasciitis, neuroma problems, nerve problems, so we’re gonna talk about some of those tonight. What’s pronation? Everybody’s heard that term. It’s a lowering of the arch which causes strain to tibialis posterior. Tibialis posterior is that muscle up here in our leg that gets sore, that’s the one that causes shin splints. Increases the amount of tibial tortion. One of things Dr Sauer’s gonna talk about is some knee issues, and people who have a lot of knee issues with running sometimes have too much internal rotation because of what their arch is doing. Structural problems, hammer toe. Genetic for the most part, it’s not caused by shoes. Aggravated by shoes, but not caused by it, but if you have a hammer toe deformity, it could not only get sore here, but it could get sore on the ball of the foot underneath that hammer toe. Nail issues. Everybody that’s a runner has bad toenails. It’s the price we pay for running, right? You can get a fungus problem on top of that. You can get more susceptible to ingrown toenails, that’s a common issue with runners. For the most part, if you’re a runner, you’re not gonna have pretty toenails. Bunion deformities, another genetic problem, but you try and get a running shoe on that, not gonna work real easily, and bunions unfortunately don’t respond to a lot of conservative treatment, and most of the time we’re talking about a surgical procedure to address a bunion deformity. But what happens is, with a bunion, is this does not bear the weight that it should, and a lot of times, people with bunions don’t necessarily come in because of the bunion, they come in because of pain around the second or third toe, and sometimes people with bunions are more susceptible to stress fractures of some of the other metatarsal bones. People that have a real pronated foot will use an orthotic. Now, there are different types of arch supports, and there are different types of orthotic. What’s an orthotic, or what’s the difference between an over-the-counter arch support, and a prescription orthotic? A prescription orthotic is molded to the person’s foot. So it’s a custom-made type of device. Does everybody need one of these? No. Think of it this way, the more mild your problem, the chances are you can get away with probably an over-the-counter type of support, if you needed support. The more significant the type of foot, or ankle, or knee problem you have, then the more likely you’re gonna need a prescription orthotic. Prescription orthotics are made out of different types of materials, they’re made… some are very rigid, some are soft, it all depends on the type of person, and the problem that they have. Plantar fasciitis, we’re gonna talk a little bit about that. Heel pain, we’re gonna get in a little more in depth with that. Basically we’re talking about pain right here in the heel. This structure is called the plantar fascia. If you picture the foot like a triangle, that would be the bottom strut to the triangle. That’s a very thick ligament-type structure, and what happens is that gets over-strained in some individuals, and the most common denominator among people with plantar fasciitis is a tight Achilles Tendon. When the Achilles gets tight, it makes the foot strain a certain way and that aggravates the plantar fascia. We’ll get into that a little bit more. Pain around the great toe joint. There are too little bones underneath the great toe, underneath the first metatarsal, right in through here. Those two little bones are called sesamoids. We see a lot of sesamoid problems with runners. Picture a sesamoid bone like a kneecap. It’s almost like the kneecap for the big toe. They’re two small little bones, they’re enveloped within a tendon, and they’re subject to a lot of pressure, and those little bones, once they get irritated, they can take a long time to develop. A person with sesamoid…a long time to settle down I mean. A person with sesamoid problems, or sesamoid pain is gonna have pain underneath the great toe joint, right on the ball of the foot, and it’s gonna feel like they’re stepping on a lump, or stepping on a sore spot, and sometimes the bone will just get inflamed, sometimes they actually get a stress fracture in the little bone. When you get a crack in that bone, a lot of times they don’t heal. The longer bones in our body tend to heal quicker than some of these smaller bones because a lot of it’s because of the type of blood supply that these little bones don’t have, and sesamoid problems can be dealt with sometimes with injections, sometimes they can be dealt with with an orthotic. In some real chronic sesamoid problems, we actually have to take the sesamoid bone out. Patello-femoral stress. This is an issue that we’ll get into a little later with Dr Sauer in terms of some knee pain. I’ll let him address that. – We can quickly go through some of the stuff on stress fractures. We talk about two to 70% of athletes, I mean that’s a pretty wide range, can develop a stress fracture. I think a lot of people, in any walk of life, can develop a stress fracture. It doesn’t just have to be a runner, or any type of athlete. People doing daily walking, or just on their feet constantly can get a stress fracture, and this percentage covers a wide range of athletes as well as a wide range of people, so you can see a couple of these studies which I won’t bore you with, they basically out of a thousand training hours, people developed stress fractures. And then some studies show that once you have a stress fracture, you’re more likely to get another stress fracture and the data on that is a little incomplete, but it has to do with biomechanics. It has to do with just the way your genetic makeup is. Maybe the bone quality that you have, or just the way your foot is positioned when you’re stepping down or walking, that could lead you to having a stress fracture. Some concepts or stress and strain. Basically stress is what you think it is, it’s the load that’s applied to the area, and strain is basically how that load affects the bone, or how it deforms it, and that over time, you think about athletics, two to five times body weight on a foot when you’re doing any kind of activity, a lot of that stress and strain can be really magnified on certain parts of the body. Jumping itself can exceed 12 times body weight. So that’s a huge amount, just on one part of the body, foot, or ankle, leg, so stress fractures can definitely develop. And the direction of stress, depending on the way your foot hits the ground, the angle, particularly if, let’s say if you miss a curb, or step into a hole or something, now you’re not planning on that stress and it’s magnified even more. Some of the bone remodeling, that occurs as things are healing. I think that’s all important. We have to think about hormones and nutrition, and other chemical factors in order to maximize healing. It’s a little bit more detailed, but those are all things that are very important to getting these stress fractures to heal. Things that the normal activity levels for the athlete, what pushes them over the edge? You get a sudden change in weight, if your bone density changes, any kind of training errors or muscle fatigue. If you’re having a rough day, or rough week and you’re really busy and you go out and try and do the same activity that you normally do, it may not be the best, and then that’s when your muscles are fatigued and what Mark talked a little bit about. If your hip flexors or your hips aren’t as strong as they should be, and I would be willing to bet a lot of us in the room don’t have, we don’t focus on that when we’re worried about our ankles or feet, that comes into play when you’re running or doing any athletic activity. But running in particular just because of the repetitive nature of it, you fatigue very quickly, and if you’re already fatigued from work, or stress, or whatever, that just puts extra stress on the bones, so that’s something to pay attention to. Certainly the terrain, various different terrains, pavement, gravel, grass, sand, those are totally different animals when it comes to running terrain and that can affect muscles and bones differently. We diagnose these, as you would suspect. Clinical suspicion is probably the most, is the easiest way to diagnose a stress fracture. But that’s, you’re never gonna get a definitive answer. Palpating over the bone, you’re gonna feel pain, and based on history, you’re gonna get a story of a stress fracture, but you never really know until you get that X-ray, even a bone scan, or an MRI is more detailed, and you’re gonna actually see…on an X-ray you might see a little crack in the bone, or you may not see anything on an X-ray, that’s another thing. People come in go, “Well how do you know I have a stress fracture? “I have an X-ray and it’s normal.” Or they get the X-ray from their primary doctor, or at an urgent care center, and they come in and they’re like, “But my X-ray’s normal.” Well we’ve seen enough stress fractures that we kind of know you’re tender right over this bone here, even though the X-ray’s normal, that’s when you consider getting an MRI or a bone scan, cause that just gives you a little more detailed analysis of that particular bone in general. If people come in after multiple stress fractures, you certainly worry. It really depends on what your activity is like. If you’re somebody that is running constantly, and you’re running every day and you have stress fractures in the past, it may just be you won the bad lottery, and you’re gonna get another stress fracture. It could have something to do with the way your foot is shaped. If the metatarsals are more prominent on the bottom of your foot, that constant pounding of the foot is gonna cause weakness in the bone, you’ll get a stress fracture. But it also could have to do with some of these other things i mean these are chemical issues. Vitamin D deficiency, parathyroid hormone, other hormonal levels like estrogen and testosterone, other amino acid levels. These are things that you wouldn’t know about, and we may know a little bit about them, but chances are we’re gonna get blood tests, and check them, and make sure that those things are at the appropriate levels, and obviously if they need to be treated, then that’s what we would have your primary doctor do, or somebody like that. How do we manage them? It really depends on the bone involved, the fracture site, how bad it is, and what other things we’re dealing with. Some people can’t be in a walking boot, or they can’t be in a cast. The facts of life are that you gotta live your life, you gotta work, you gotta do things, so there are various ways to manage stress fractures that may be convenient, or we try to make them as convenient as possible, as long as it’s safe. Conservatively, it’s typically immobilization and cross-training if possible. A lot of times, especially if it’s minimal, or it’s not as painful, or it seems to be improving, that’s the key. Then in phase two we’ll slowly increase the stress. You could even go into a brace, try to return to a normal range of motion and strength, and then the phase three is pretty much ready to go. Is that a fair analysis Mark? You’re talking about 12 weeks, it sounds long, but realistically by the time the fracture’s healing over a four to six or eight week period, now you gotta deal with what happened while the fracture is healing which, you get atrophy of muscles, you get weakness of all of, not just the foot or the ankle, or wherever the fracture was but if you haven’t been doing normal activity, and especially if you’re in a boot, or a shoe, or something to keep that bone from moving a lot, now you’re walking differently for that period of time, this side gets a little bit stronger, that side gets weaker, now you’re all out of balance, so there’s a lot of stuff that needs to be worked on. Surgically there are some surgical considerations for stress fractures. Typically though that’s when things aren’t healing, and we would know that unfortunately after a long period of time, usually it’s about a 12 week period of time. This is some pictures here. Don’t have a pointer, but this is a little bit harder to see here, but this says, “Second metatarsal stress fracture.” There’s a little area of density here. That’s a very common metatarsal fracture to get. Again, here’s another, here’s an MRI. This is showing a third metatarsal here. basically a white line, so first, second, third, fourth, fifth. Third metatarsal’s lit up here, whereas if this is the same X-ray to this foot, I can’t really appreciate any fracture on this X-ray right here OK? And that’s not unusual. When you come in with your X-ray, and you say, “But there’s not fracture,” well that’s not necessarily the case. Problematic stress fractures. So not only in the foot, but also in other bones, like the tibia, anterior tibial cortex. So anterior just means the front, that’s in the front of the tibia, like in the shins. So when you’re talking about like a shin splint, at that point you just have inflamed bone, or inflamed muscle, and where the muscle connects to the bone, if you ignore that and try to run through it, it can often push into the bone and you’ll get a weakening of the bone, and you can get a crack in the bone, and that’s that’s what we’re talking about with this anterior tibial cortex. And the calcaneal stress fracture, I mean the calcaneus is the heal bone. You can get a heal stress fracture, and that is often confused with plantar fasciitis, Achilles tendonitis, and other things. This is a heal bone, so a calcaneal stress fracture. Again it’s not obvious on this X-ray. Now this is a skeletally immature person, so there’s a growth-plate here, that’s normal, but when you get the MRI, there’s all this white here. Normally bone should like like gray like this, gray or black, but here there’s this white inflammation here that’s not normal, and that’s a calcaneal, or a heal bone stress fracture. There are other foot bones, the navicular, that’s a bone in the foot, right in the middle part of the arch. The fifth metatarsal, that’s on the outside of your foot. We might have some X-rays of that. Again, here’s the fifth metatarsal on this side here. There’s a crack right in the bone here, and that’s in a spot that very typically can get a stress fracture, right in the metatarsal shaft so in the middle of the metatarsal. So again, it’s kind of hard to see, but there’s the crack line right there. That’s a little bit harder to manage just because that’s sort of your typical basketball player, runner, a highly competitive athlete that will get a stress fracture there, and oftentimes you’ll have to do something like this, where you put a screw across it, because that area in particular, doesn’t heal very well. I don’t think we have any stress fracture, sesamoid stress fractures, so stress fractures you just can’t ignore. And you never know if you have one. If you have foot pain, and it’s minimal, and it seems to be going away, that’s fine, but stress fractures typically they’ll start hurting early it’ll be minimal, you won’t even think about it, and then it just gradually gets worse, and I’ve seen it gradually get worse in one run. Somebody said, “I was fine, mile number two, “started having a little bit of pain, “and then mile number six it was worse, “and then I felt the pop and then I couldn’t run anymore.” And I’ve had other people that say, “Yeah I was doing fine, I was starting to train, “I was increasing my training, “I was running two or three miles, “I felt a little bit of pain at the end, “then it starts to get worse with every run, “and now it hurts when I walk.” It’s worse with activity, it gets worse and worse. So just don’t ignore that. You have anything that you want to add? – [Edward] All right, the next thing we’re gonna talk about is something that everybody’s heard about, that’s plantar fasciitis. Touched on this a little bit before, the plantar fascia is this thick supportive structure on the bottom of the foot. It goes from the heal, goes all the way up to the ball of the foot, up to the metatarsal and toe area. If you look, here’s that person’s Achilles tendon. This is a structure which is very much in relationship with the Achilles tendon, and the two work off each other. Person’s gonna come in, and they’re gonna say, “You know, the first couple of steps “out of bed in the morning are murder. “Then I walk around for a couple minutes, “it loosens up, doesn’t feel quite as bad. “But if I get in my car and I have a 20 minute ride to work, “when I get outta the car, again, “the first couple steps really hurt. “Or sometimes even just working “the gas pedal can hurt in the car. “Or if I’m sitting at my desk for a half hour, “and I get up, that initial getting up is gonna be sore.” Those are the most common symptoms with plantar fasciitis. Runners who have plantar fasciitis will sometimes notice it that first mile or so into their run, but then after they run and loosen up for a while, it doesn’t feel quite as bad, but when the run is over, and they take a break, and then they get back up, oh then that’s that intense heel pain. These are all signs of plantar fasciitis. You see up here it says, “Plantar fasciitis heel spur syndrome.” Years ago, we would collectively call it heel spur syndrome, but we don’t do that anymore because you do not have to have a heel spur, you don’t have to have that ledge of bone on the calcaneus in order to have the same symptoms. The spur does not cause the pain, the pain is caused by a strain of that plantar fascia. Now, why does it get strained? Well, your first name? – [Gordon] Gordon. – Gordon, Gordon’s arm is the plantar fascia, and when he is at rest, when he’s sleeping or when he’s at rest, that plantar fascia is kinda contracted. During the course of the day, by him doing certain things it gets strained. Now when he gets off it, it contracts. When he’s on it again, it gets strained. Well if I kept doing this to Gordon all day long, eventually his shoulder would get sore. Well picture it the same way in the foot. Eventually it gets sore where that attaches, and that attaches at the heel bone, and sometimes there’s actually little microfibers, thank you by the way Gordon, I hope you’re not sore. Sometimes there’re little microtears in the fibers of that plantar fascia where it attaches itself to the calcaneus, or the heel bone. Again here’s that structure, and there’re two main components, there’s this big band of the fascia, and there’s also a part of the fascia that goes on the little toe side of the foot. But typically when people get plantar fasciitis, they’re gonna have symptoms right around here. They could also have symptoms up into the arch. Sometimes they’ll even get lumps that will form in the arch. Anybody know what a Dupuytren’s contracture is of the hand? When you get that real thick scarring of the hand, and sometimes it’ll even pull the finger down? Well there’s a similar component that some people can actually get on the foot, in the plantar fascia. They’ll get a lump-type of structure that’ll form in the plantar fascia. But anyway, again, the plantar fascia attaches to the heel, some people will develop this ledge of bone, this calcaneal spur. What that tells us is that fascia has been strained or stretched for a long time. It takes years to develop a spur that big. Sometimes people can also have spurs in the back of their heel where their Achilles tendon comes down. And those can be a real difficult thing to manage. Some statistics. About 25 to 30% of people with fasciitis are overweight. As much as 1% of the population, that doesn’t sound like a lot, but when you think of the number of people, on an average day we’ll see anywhere from three to 10 people with plantar fasciitis. it can be that common. Again the most common denominator though, is that tight Achilles tendon, because when that Achilles gets tight, the foot has to compensate. The way it compensates is by pronating, and by pronating, you strain that plantar fascia. What else can cause heel pain? Is it always…if you have heel pain, is it always plantar fasciitis? Well no, Dr Sauer’s just talked about calcaneal stress fractures, it could be a stress fracture sometimes. It could be a tarsal tunnel, what’s tarsal tunnel? That’s kinda like the carpal tunnel version of the foot and ankle. It’s an entrapment of a nerve. Posterior tibial tendonitis. That muscle that comes down that causes the shin splints, sometimes that can get sore as it comes down into the foot, and that could mimic heel pain, or give you heel pain. You could have atrophy of the fat pad. What does that mean? That means that that cushion which is normally there underneath our heel bone can get thin. Females tend to be a little bit more susceptible to that than some males, but that can be a cause of heel pain. A lot of people with rheumatoid arthritis have heel pain related to their rheumatoid arthritis. You could have a fracture of the heel spur, and again you could have tears of the plantar fascia. What do we do? First thing we always talk about when people come in with plantar fasciitis is what kind of shoe you’re wearing? Again, goes back to what we talked about. Are you wearing a good shoe throughout the day? Is it a stiff, supportive shoe? Is a backless shoe OK? Well, if it’s a real rigid, supportive shoe like a Dansko, that can be OK, but most backless shoes just don’t give you the amount of support you need. If you’re the type of person that comes home from work, you throw your shoes off, and for the next three or four hours you’re walking around bare-foot, or in non-supportive slippers, that’s just as bad. I have a lot of high school and college cross-country and track coaches. If they see one of their athletes wearing flip-flops on campus during the running season, they won’t let them practice that day. So be smart about the type of shoe you’re wearing, not only when you’re running. Stretching, we’ll have our patients see people like Mark, we’ll get them into a stretching program. We want you to stretch before you run, we want you to stretch when you come out of bed in the morning, we want you to stretch as much as you possibly can throughout the day, and we’re gonna show you some stretches for this. An arch support, a lot of the times an over-the-counter arch support at first can be very effective for this. In some individuals they need a more prescription orthotic. Non-steroidal anti-inflammatories, your Motrin’s, your Advils, your Aleve’s. Tylenol is a painkiller, it does not reduce inflammation so Tylenol’s not typically a medication you’re gonna use when you have this type of a problem. Sometimes a steroid injection into the heel is needed to calm down the inflammation. Again, just a cortisone injections, and the therapy. Night splints, what’s a night splint? A night splint is basically a contraption that holds your foot up like this while you’re sleeping. It doesn’t let your foot relax. The idea here is that while it is stretched, you’re gonna keep a certain stretched sensation on the plantar fascia, you’re not gonna let that plantar fascia contract and get real tight. We use this on some individuals, especially the ones that have really bad pain in the morning when they first get up. The problem with night splints is, they’re not comfortable and most people end up taking them off during the middle of the night. So that’s one of the problems with that. Surgery, is surgery ever needed for plantar fasciitis? Yes, but not very often. I’d say 90, 95% of people we see with plantar fasciitis do not need surgery for this condition. Now between the anti-inflammatories, the stretches, and all the things we just talked about, how long does it take you to get over plantar fasciitis? That’s a bell-shaped curve. There are some people that get over it in a matter of a couple weeks. Your average person might take a couple months, and there are some individuals that could take a whole year till it gets over. – I’ll see if you’re interested in doing a stretching program on your own, cause sometimes it’s hard to get the therapy, and I’ll give you a few weeks. if you can’t do it, or it’s just not working, then we talk to Mark, we get the therapy going, cause then it’s more of a hands-on, somebody else doing the stretching for you. But usually it can take a good two months on average for some relief to occur. But some people, it takes longer, it really does. – One other thing I’m gonna talk about before Dr Sauer gets into knee pain, is you have a patient that comes in and they’re complaining of pain in the ball of the foot, kind of right behind the toes. They typically feel it on the bottom. Sometimes they’ll say, “Sometimes it feels “like I’m walking on a lump. “Other times it feels like my sock is bunched up, “and I’ll take my shoe off and it’s not.” Sometimes the pain is hard to pinpoint, but htey know it’s up there somewhere. Sometimes people will talk about numbness, or tingling that goes into the toes. Anybody know what I’m talking about? What? Moreton’s neuroma. Right. Moreton’s neuroma, very common problem in the ball of the foot. See a couple people a day with it, and it’s an inflammation, or a thickening of the covering around the nerve. I always use this example. You see this extension cord? Picture this as a nerve. What we see is this black plastic coating on the outside of the nerve, which we would be visually seeing the nerve. On the inside of this black plastic is a copper wire. Well picture the copper wire like the nerve, and this black plastic coating as the covering around the nerve. When people get neuromas, the copper wire’s fine. It’s the black plastic that gets thick, and it gets thick because of irritation or pressure. And it can give you a variety of symptoms like I just talked about, pain, numbness, feeling like a lump, but it’s a very common problem. Again we recommend more of a stiffer-soled shoe for that problem. Sometimes we’ll have to put a little pad inside the shoe called a metatarsal pad. Sometimes we have to inject those areas with cortisone, and sometimes, maybe about 30% of the time, 35% of the time we have to end up taking that piece of nerve out if it doesn’t respond. So that’s another real common problem with runners. – [Dr Sauer] I’ll touch a little bit on this patello-femoral stress syndrome. I think knee pain in runners is a whole other topic. I even gave a talk on it at the Lehigh Valley Half Marathon last year. But basically, this in particular just has to do with the way the kneecap is riding in the groove, and typically the kneecap is being forced outward and because of weakness and various other things that we could talk about, the kneecap itself doesn’t often want to ride in the groove efficiently, and it’ll get pulled outwards, and generally if there’s any underlying arthritic change, or any scar tissue or inflammation in the knee, you’ll get pain in the knee from that. There are plenty of other reasons to have knee pain as everybody’s aware here as a runner, so I don’t want to get too bogged down with that. – [Edward] Everybody stand up, cause we’re gonna have you mimic what Mark’s doing here. – [Mark] I’m gonna take my shoes… I’m not gonna dare take my socks off. – [Edward] Andrea come on up here. – [Mark] I can show you on Andrea. – Yeah we’ll show you on Andrea. – [Mark] So I usually have people stand… can you stand on this towel for me? We’re gonna put the corner of your heel on there, and then what I tell people, is turn, if your other foot’s forward, we’ll do that classic runners’ stretch style, I tell people, turn your foot, if you turn your toes toward the instep of the other foot, and so you’re rotating the foot inward, and basically putting a little posting on the inside of the heel, so that the heel is tipped outward like that OK? Just slightly, and then turning it in about 30 degrees, 25 or 30 degrees, and what that does, is that helps unwind that tendon to allow it to safely stretch the tendon, and then she can, then Andrea can perceive to gently begin to take up the slack and I think the most important thing to do is to keep in mind low load, long duration. Very ballistic things, like going into it, coming out of it, going into it, coming out of it, probably not real good. You want to take up the slack, feel that stretch, and then you can kinda creep along through it. I tell people 20, 30 seconds, longer if you’d like, but your first few, don’t worry about how much you’re doing. Just kinda take up the slack and let your body speak to you. So that’s a think a nice way to stretch the Achilles. Now that would be the gastroc, because that’s the long muscle, it crosses the knee so we’d want to have the knee straight. Now the soleus is the shorter muscle, so we’d want to bend the knee, and then do the same thing. You just post that heel, keep that towel under the inside corner of the heel, have that foot turned in, toes toward the arch of the other foot, and then Andrea can begin, with her knee bent, to lean forward, and those are those classic standing runner’s stretches. If you’re doing it on your bed per se, in the morning, or on your floor, and you want to…that’s good, did everybody catch that? You know you can do it if you’re long sitting on the floor, same kinda deal, you just wanna turn your heel in a little bit, and then kinda turn your toes in and pulling back. And again, you don’t have to be super aggressive on your first few, OK? There’s some more advanced things that I learned from a gentleman that are kinda neat. You’re getting involved with some leg pumping, front to back and side to side of the other limb, while you’re maintaining those stretch positions. He was doing that…he’s a very good foot and ankle therapist that I’ve had the luxury of, I worked with and took his course, and he does that with a lot of the collegiate athletes that he sees, and so there’s some variations to that. (electronic music)