Coordinated Health

VideoApril 21, 2015

Runners Seminar Part I – Scott Sauer, MD


(upbeat music) – We’ll get started. We have a couple of topics tonight. So I’ve met everyone here, hopefully. And my name is Dr. Scott Sauer. I’m an orthopedic surgeon, board certified. I’m also foot and ankle fellowship trained. So my main area of expertise is in the foot and ankle. Although if you did come to see me, I would obviously be able to evaluate the entire body, be able to determine if some of your problem is coming from back, hip, knee, things like that. And you’re going to hear from Jim Sunday after this talk about common knee problems in runners. And we’ll sort of proceed from there. Now is a very popular time. Thank goodness that the weather is hopefully changing for the better. There’s good weather on the horizon from what I hear. So there’s going to be a lot of opportunity to go out and run, if you haven’t been running all winter as it is. So this is about the time when we start seeing a lot of patients in the office that have various running issues. And a lot of people don’t even know what the problem is, so that’s why they come to see us. So I was hoping with this, in this sort of venue, to discuss some of the common foot and ankle problems that may account for some of the pain that people have when they’re running, and just in general. But this is a very common topic for runners. What I hope to cover tonight, there are many different foot and ankle problems that I can cover. So this is just a list of some of the things that we’ll cover. Jim’s going to touch on the iliotibial band and the patellofemoral pain, which is more in the knee. But ankle sprains, Achilles tendon problems, shin splints, stress fractures, plantar fasciitis, that’s probably the top five, you know, problems in foot and ankle when it comes to running. So we’ll touch on a little bit of each. Ankle sprains, probably the most common injury in orthopedics across the board. But this usually occurs when you step in a hole or you step off a curb wrong or something that causes the ankle to turn in like this picture in the upper right. There would be a lot of swelling, maybe some redness on the outside part of your ankle. And what a sprained defined is is basically any type of injury to the ligaments. Now, ligaments by definition hold bones together. So they’re the things that keep your joints together. In this particular case, the arrow’s pointing to the most common ligament that’s torn, which is called the anterior talofibular ligament, which really doesn’t mean much to you. It’s just the ligament on the outside that’s commonly torn when the ankle inverts. There’s a lot of pain on the outside of the ankle when this occurs. Again, just another artistic rendering of an ankle sprain. Clearly you’re turning your ankle in. You get a lot of swelling and bruising. The ligaments are torn by definition. They may partially torn. They may be completely torn. They could tear in the middle of the ligament. They could tear a piece of bone off the ligament. That’s why sometimes when you see x-rays after a sprain, you might see a little piece of the bone next to the larger bone. That really is more indicative of a sprain, when the ligament pulls a piece of the bone off. There are different types of sprains when we diagnose them. The grade one, which is sort of a lesser number, so that’s obviously a very minimal sprain, versus a large or a high energy sprain. We go all the way up to grade three. The definition is the good, the bad, and the ugly. Well, the intact ligaments typically occur with the grade one where you just might have a little tiny sprain or a tweak. The ligaments don’t tear completely. And then it goes all the way to a complete tear which can often sometimes be as bad as a fracture in terms of pain and swelling that you would feel in that area, very difficult to walk with a grade three sprain. Your typical treatment is initially hued. As you can imagine, we call it the RICE method, rest, ice, compression, and elevation, just what you probably learned in grade school and in high school. I mean, how do you deal with a sprain? Because you’re going to get a lot of swelling. You want to stay off of it. You’re going to ice it to get that swelling down. Compression, like either a compressive stocking or an ACE wrap can help to get some of the swelling down. Elevation above the heart level will then allow everything to run downhill. There’s really not a lot of problems with that. Crutches may be needed. Typically the prognosis is good for the grade one sprain, maybe seven to 10 days, all the way up to even a month, six weeks sometimes for these grade three sprains. So a lot of people don’t realize that it can take as long as a fracture to heal. Usually when you get past the initial stage of the injury, that’s when you would start to do the rehab process. So depending on the grade, you’d look at some physical therapy options and bracing, if needed, to prevent any further injuries. Surgical treatment is pretty unusual for an acute ankle sprain. But if you’ve had multiple sprains throughout your life, you may have something called instability. That means that the ligaments just haven’t healed fully or they haven’t healed in the nice, tight position that they used to be. And now the ankle moves a little bit more than it should. And you can get some chronic inflammation in the ankle joint. Things that occur, you know, with simple activities, normal walking, your ankle gives out. So that might be indicative that you’ve had some issues with the ligaments in the past, and they’re not just as strong as they used to be. In those cases you would consider something surgically to tighten up the ligaments if you can’t respond to conservative treatment, like bracing, therapy, different modalities like that. So sprains are pretty straightforward. I think everybody’s probably had a sprain in the room. You kind of figured out how to treat it on your own. And if you can’t, that’s when you come to see me or one of the orthopedists here at Coordinated Health. We’d kind of help take care of that. And again, it’s pretty much always conservative. But it can take some time. And a lot of people are impatient, understandably, want to get back to running activity, and it’s difficult sometimes with some of these severe sprains. We’ll talk a little bit about the Achilles tendon. Achilles tendinitis and Achilles tendon tear. So first start off with tendinitis. This is, in terms of definition, when you have some type of change around the tendon. Now, the Achilles tendon is probably the largest tendon in the body. It connects the calf muscle to the heel bone right in the back of your ankle. And it helps you when you push off or you’re walking steps, things like that, to get up and down. Tendinitis by definition is inflammation around the tendon. In the Achilles region it can occur around the tendon or directly in the tendon. So in this middle portion, the inflammation is around the tendon, where here there’s actual changes in the tendon. And this is just the definition of this area. Typically in the mid tendon area where you’d have some change in the tendon, sometimes you get a bulbous appearance. You’ll get pain, inflammation, swelling in the back of the ankle and difficulty in walking and pushing off. Again, pain and swelling in the back of the ankle. Usually the pain gets worse with activity and better with rest. The Achilles is often tight. So some people have tight hamstrings, tight Achilles, tight calves. That way there’s a lot of difficulty with that kind of movement. On physical exam there’s tenderness over the tendon or at its insertion on the bone. There may be a bony prominence. And decreased ankle flexion upward, it can contribute to this type of pain. At the insertion point, this is a little bit different than in the tendon itself, but right where it attaches, sometimes you can get a little bony spur. There’s oftentimes some calcification in the tendon. This is more indicative of a chronic tendinitis. And that’s something you might have had for a while. You might feel some swelling in the back, often called a pump bump. Just by definition, some of the women’s shoes, the pumps, where the straps go around the back of the ankle there, that often would push right on this area. And that can be difficult or painful. That being said, you know, shoes in themselves can wrap around that area too. It really doesn’t matter what type of shoe. But it can affect if there is a strap there. This is just an x-ray that shows that. We’ll often get x-rays, even though it’s a tendon problem, because we’re looking for calcification. These little areas in the bone where there’s been some chronic inflammation, where this area should be flat, but there’s some spurring here, also in this region, the circle is not where it should be, but… Again, treatment typically for this is nonsurgical. So you can do things to try to make this feel better. Oftentimes it’s some kind of modification of your running routine, going into a no cross training scenario. Anti-inflammatories, non-steroidals can help. Sometimes a little heel lift. The concept of that is you put a heel lift in the shoe. It allows the Achilles tendon to become shorter, and it takes some of the pressure off so it’s not going through the longer range of motion that it normally would where it pulls in that area. A walking boot sometimes is necessary which is kind of like a cast but it’s removable. It immobilizes, taking the muscle and the tendon out of the working phase altogether, helping it to decrease the inflammation. Usually when it dies down and it’s not as painful we talk about stretching. A little pad in the area can help. Physical therapy will also be very important at this point. Injections aren’t recommended only because it has been shown to be detrimental to the tendon over time and actually can cause a tendon to rupture if done repeatedly. So we tend to avoid injections around the Achilles tendon. Sometimes surgical treatment is necessary. Basically going in and just repairing the tendon, you remove the bad part of the tendon. You might take away some of the bone spurs. This is just a picture of an MRI that shows an inflamed tendon here at the heel area. And if you had to have surgery for this, it’s not the worst thing in the world. Most people recover fully. They do pretty well after about six weeks. You’re usually walking, doing things with a boot on, starting therapy. And usually at about five to six months which is pretty common for most tendon injuries or even ligament injuries, you’re back to like a normal activity. Achilles tendon rupture is very similar kind of scenario. But this is where you have an acute injury where you may have stretched out the tendon to the point of breaking. And then you try to forcefully do something through that elongated tendon, and it ruptures or tears. A lot of people will describe this feeling of getting hit or kicked in the back of the leg, almost like a snapping. Oftentimes it might feel painful initially, but then it doesn’t feel painful. I’ve had patients that walk into the office or they limp into the office, but it’s not that painful. And they just can’t push off very well because they don’t have that tendon connected. And then you’ll feel some swelling and sometimes you can even feel a gap in the back of the leg in that portion where the tendon’s torn. This is just one way that we test it. But I put it up here just to demonstrate like what it’s like to have, you know, a torn tendon. When you’re squeezing the calf or the calf’s trying to contract, the foot itself won’t even move. And that’s why it’s difficult to walk. Because normally when the tendon’s connected, obviously you’re able to push off and go up and down stairs and hills and things like that. But if there’s no tendon working, then it’s very difficult to do that. There’s still some strength there because some of the other muscles in the back. But it’s significantly less. Again, just a picture of feeling a defect there you could actually feel. Sometimes it’s a little swollen so you can’t feel it entirely. And then the test that you do, squeezing the calf, doesn’t move at all. For the most part, if you have an Achilles tendon rupture, it depends on your activity level, your medical history, determining if you’re a candidate for surgery or not. There is a role for conservative treatment in some patients or some people that have this. Typically it’s a low demand, older person with maybe multiple medical problems or just for whatever reason is against having surgery. I mean, that’s always an option. I’ve treated many Achilles tendon ruptures conservatively. They’ve done well. There is a little bit higher risk that the tendon can tear while you’re treating it again just because there’s nothing holding it together. For the most part we do repair Achilles tendons. Usually at the six-month point is when they’re strong enough to tolerate normal activity. And that goes for both nonoperative and operative treatment. So if you had to go through any kind of treatment for the Achilles, you can sort of bank on the fact that at six months you should be doing pretty well and often can return to normal activity. And again, the postoperative protocol, I used to have pictures of Achilles tendon tears. And I’ve found that people didn’t really appreciate the graphic nature. So I did take them out. But they’re basically, it’s as simple as that. There’s minimal, you know, it’s not very difficult to get to the tendon. You repair it directly, and then you just close it up. It takes about 25 minutes to do. And people do, you know, it’s an in and out surgery. So postoperatively, though, really the mainstay is you’re in a cast for about four to six weeks. You get into a boot, start walking in therapy. And usually at the three to four month point you’re in a shoe. And then about six months is when you’re pretty much ready to go. Okay, so that finishes the fairly common Achilles problems. Then we’ll talk about shin splints. And a lot of times, you know, you don’t really know you have a shin splint. You’ll kind of come in and you’ll say, well, my legs have been hurting. Typically it’s in the front of the leg more towards the inner part of your calf muscle along the bone or it can be on the outer portion in the front of your leg. And really what it is is there’s a connection of the muscle to the bone. And a lot of times when the muscle’s overused or utilized a lot, like when we first start running or if we’re running longer distance or if we increase our distance or try to run at a quicker pace, the muscles themselves can get irritated. The connection to the bone can get irritated as well. And that actual pulling from the bone is what kind of causes some of the pain from a shin splint. Again, with some of the causes, as I talked about, the biomechanics are also important. And Kat’s going to talk about that. The running surface can have something to do with it. But for the most part it’s an overuse type injury or a moving forward too quickly kind of thing. And again, these are just two areas. The picture’s a little small. But in the front part of your leg, usually the muscles that are in that front part pulling your ankle upward are what are pulling against the tibia. And then on the back portion of your leg when you’re pushing off, some of the muscles in that area can give you more pain in the back. And this is just a drawing of that kind of problem where I’m trying to indicate or show here this muscle that’s irritating, getting irritated at the bone junction. And that’s sort of what a shin splint is. And it’s important to kind of see this in the sense as it affects the bone somewhat. It’s causing pain in the bone because for the most part, treatment is pretty straightforward. It’s virtually never surgical. It’s something that involves rest, stretching, some therapy can help. Cross training’s important. The pounding nature of running can cause this to just kind of stay inflamed. And you don’t, unless you treat it, it can often progress to something worse that I’ll show you a picture of. But the taping, physical therapy, Graston or deep kind of tissue massage can help kind of break up the scarring in that area, try to make the muscle excursion a little bit better and take some of the inflammation away. Therapy is often shown that the type tight Achilles and some weak muscles in the front of the leg, in the leg can cause shin splints. So it can make the leg a poor shock absorber. And you’ll get an injury because of this, the muscle contracting so forcefully can pull off the bone. Basically that’s what therapy will address, tightness and strengthening, kind of important, particularly in running. Shoewear definitely can have something to do with it in terms of that shock absorption. There’s a lot of, we can talk about this after the talk, but different types of shoes are helpful, important. You know, people ask me about these barefoot running type of shoes or the five fingers. I think, you know, if you don’t have an underlying problem with your foot or you don’t have any pain with your foot, you can run and do fine with those. A lot of times people have some underlying problem. And they try to run in a barefoot shoe, and it may, you know, not be the best thing for them. So I don’t really have an opinion on the shoe itself. I think they’re fine. It just comes down to your underlying biomechanics and whether or not, you know, you’re running appropriately or you have a good gait or you have full function, like in the hips, in the knees, in the feet, for all that to work. Other shoes that have different support, I mean, systems, like, you know, these, the shoes in the middle have a better, you know, cushion or the gel padding versus like a support or a stabilizing shoe for somebody that has like a flatter foot or pronates more. And that overpronation or like a flatter foot kind of run can affect the inner parts of the ankles and go all the way up the tibia to have some type of a shin splint scenario. Cross training is very important when it comes to something like this. I mean, you’re developing your other muscle groups. You’re trying to prevent an overuse. But at the same time you’re trying to stay in shape somewhat. So these other activities, like yoga, biking, elliptical, can help to stay in shape but also avoid any kind of boredom or deconditioning. And this is really what we try to prevent. It’s important not to ignore these problems. In general, any, you know, pain that you’re having that’s getting worse or not getting better, particularly in shin splits because that picture I showed you where the bone is affected can get worse and worse if you ignore it. And you’ll have pain that just progresses to the point where, you know, normal daily walking or standing affects things. And it could be developing into a stress fracture of the tibia, which is something that is a little bit, it’s not a surgical problem typically, but it takes a lot longer to treat. You’re talking now immobilization followed by therapy. It could take anywhere from six to eight weeks to really get over, as opposed to maybe a couple of weeks. Stress fractures are very common in runners. This is a very common cause. It starts with minimal pain and will often worsen with activity. And then people say, oh, I’ll take a week or two off, and they do, and then they try to go back to running, and boom it recurs. It’s because the bone is weakened to the point where it’s going to crack. And it will often start healing immediately but then gets worse when you try to go back to your activity. That’s something that obviously shouldn’t be ignored. And often that’s kind of what we do. We treat ourselves. It gets worse. Then, you know, take some time off, gets better, try to go back too soon, and then it happens again. So this is very common in runners to get a stress fracture, typically in the metatarsal, one of these metatarsals can happen. This is a little bit harder to see. But this would be more of a stress fracture in the fifth metatarsal, which is on your pinky toe. And then in some cases we might put a screw in it. This is just to indicate where the fracture was. In most cases stress fractures can be treated conservatively. Again, a lot of times they don’t even show up on x-ray. You might see a normal x-ray. And if necessary, we can get an MRI. And this is just kind of like we sliced your foot like a loaf of bread and we’re looking at the metatarsals on end. And this metatarsal in particular has this white appearance around it. And that’s more indicative of an inflamed bone or some type of fracture in that area. That’s a nice picture. I’ll just keep looking at it, right. Heel, you can get a stress fracture in your heel. Sometimes in younger people we see that they may have heel pain. In this case it’s just indicating, I have an MRI kind of supporting the fact that here’s the heel bone. And normally the heel bone should look nice and dark and black. In this case there’s a lot of white here around, which is more inflammatory response. And you might even appreciate a small crack in the bone here whereas in the x-ray it looks fairly normal. So those are things that we kind of look for, particularly with the pounding nature of running, especially if you’re a heel-to-toe, that can definitely occur with an overuse type picture. Again, sort of the, as you can see from this talk, I mean, these conditions can almost all be treated conservatively. So treatment is conservative. We modify your activity. We might need immobilization in a boot or a cast, depending on the location of the fracture and how significant it is. Oftentimes therapy would be helpful to maintain some level of conditioning in the leg and then getting back quicker to a normal gait and running for that scenario. In rare cases surgery is required. If the bone would fracture completely and displace, it might need surgery. If it’s something that keeps recurring over time, then you might consider that. But for the most part it can be treated conservatively. So the last probably the number five or the last of the top five, you know, foot conditions, would be plantar fasciitis. Now, the plantar fascia is this thick strap of tissue on the bottom of your foot. And if you look at this kind of drawing here, this is what the plantar fascia is. And it really acts as almost like a rubber band type device in the foot and helps contract the foot as you’re running or walking, for that matter. When the foot is flexing, when you’re trying to extend the toe and push off, the plantar fascia will actually contract or it’ll help the foot contract to basically biomechanically make you walk normally. And because of that, because of the movement there, you can sustain injuries there. You can have a chronic injury or micro tears in that fascia, particularly where it attaches to the heel bone, and you’ll get what we call plantar fasciitis. This is an inflamed area, usually right at the bottom of the heel, that is pretty painful. It’s probably the most common cause of heel pain in athletes and in anyone in general. There’s other things that can cause heel pain, Achilles tendinitis, which we talked about, stress fractures of the heel, tarsal tunnel is kind of like carpal tunnel in your ankle, but it’s in your ankle, obviously. Carpal tunnel is in your wrist. But the nerve gets irritated. You can get some pain in the heel. Usually it’s pain in the morning or after periods of rest because the foot is relaxed and everything gets stiff and contracts. And then you step on it or you get up in the morning, step on it, everything pulls and stretches, and it’s really painful. And oftentimes it might get a little bit better with activity because it’s now loosened up a little bit. There may or may not be a spur there. I don’t pay too much attention to that because it’s not usually located in the plantar fascia area. Just another drawing of the plantar fascia in this area here. Treatment, again, mostly conservative. Appropriate shoe gear, stretching exercises. Arch supports sometimes are needed. Non-steroidal anti-inflammatories can help. But for the most part, stretching is the most important. If it’s recurring or doesn’t get better, we’ll consider a cortisone injection. I think part of the injection healing process is actually passing the needle into that area kind of creates a little bit of an injury there and it can help it heal. The cortisone helps with anti-inflammatory because you’re putting it directly in the area. Therapy can help. Night splints or things that stretch you out when you’re sleeping, it actually is something you put on your leg that helps to kind of stretch the bottom of your foot and your Achilles. Orthotics can help. And surgery is usually reserved for the last resort, where you go in, remove the chronically inflamed portion and then recover after that. (upbeat music)