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“Mr. Stiff Morning Runner has been trying to get fit again. Working at an office, he spends much time sitting in front of the computer which has resulted in gradual weight gain creep despite the low carb diet. He is also developing knee and hip stiffness as well as a touch of sciatica. So, he decides to take up running as it is one sport that does not require special equipment or preparation. He goes to his local school and decides to run on their track. Just put on your sneakers and run, right? First mile or two go well and he is feeling the breeze and new energy as blood fills his muscles. He is feeling a sense of accomplishment, when all of the sudden his right leg starts to hurt. He has to slow down and calls it a day. He goes running again the following day. Mr. Runner does not have Right leg pain at first, but then his Right shin starts to feel hot and gives a sensation of deep ache. He continues to run through the pain determined to reach his 3 mile goal for the day. He reaches 2.5 miles and must give up because pain in the shin becomes unbearable. He continues with this routine for a week. At that point, he notices that he has developed pain in the left Achilles tendon. Now, both legs hurt when he attempts to run. On top of pain, he sees that his right shin and left Achilles tendons are swollen, with swelling going away only with icing and elevation.
Because of his injuries, Mr. Morning Runner has to abandon running. His spirits are low but he is not ready to give up just yet. He sets on the journey to figure out what happened to make his legs hurt!”
Mr. Morning Runner has sustained at least 3 leg injuries as a result of doing too much, too quick, too soon.
This is called an overuse syndrome and frequently happens to athletes who push their body to work faster than it is able to recover. As we age, the recovery rate is slower and this must be adjusted for in the training routine.
Rehabilitation involves restoration of form and function using a combination of medications, assisting modalities, exercises and therapy.
Because physical and emotional fitness gains obtained by engaging in physical activity will dissipate over time without continuing to exercise, it is essential to concentrate on rehab as soon as injury occurs. It is important to realize that bones take longer to heal than muscle or tendon injuries, especially if there is Vitamin D deficiency.
As important as recovery is, learning how to prevent future injury is what will ultimately help an athlete move beyond current limitations and on to new gains!
Stress Fractures:
Repeat trauma to the same area of the bone leads to tissue overload and breakdown. There is some connection between your foot type and predisposition for developing a fracture in predictable area of the body. Flatfooted people are more likely to develop fibular (long bone on the outside of the leg) stress fractures. Those with high arches are likely to suffer from tibial (shin) stress fractures. This is because these fractures are frequently a result of biomechanical malalignment driving pressure forces to specific areas of the bone, thus increasing bending at those bone segments. This is also why flat-footed people are more likely to develop outside of the knee pain and those with high arches are more likely to develop pain inside of the knee joint pain.
Prevention, of course, requires recognition of the foot type and then addressing the poor alignment either internally or externally. I would also start in with addressing it from external stand point as internal rearrangement and balancing requires surgery, which should always be the last resort.
External rebalancing would include physical therapy by strengthening the weak tendons that move the foot and use of external supportive and bracing devices. Use of well-designed shoes specific to your foot type can be extremely helpful as well. In fact, it is possible to save money on custom orthotics if you are willing to invest into well-built shoes to address the malalignment.
But what about right now? What does Mr. Morning Runner do about his current stress fracture?
Starting point should be to decrease bending of the involved bone with a cast, brace, splint or with the use of offloading modality like crutches, or a walker, or a wheelchair. The modality will depend on your agility level and if you are having issues with the other foot/ankle/leg/knee ect. As now, you will be relying on that other lower extremity to carry all the weight.
The location of leg fracture on a specific bone site as well as runner’s activity level and ability to adhere not recommended offloading regimen will determine treatment. For unstable fractures and runners that are not likely to adhere to non-weight bearing recommendations, a cast may be required for several weeks. For those that can adhere to recommendations and for stable fractures, a removable fracture boot may be used or stabilizing brace may be sufficient.
Mr. Morning Runner may want to speak with his doctor to see if he could speed up recovery with the use of acetaminophen, non-steroidal anti-inflammatory medications, massage, cryotherapy and maybe even physical therapy. All those have a place in treatment of this pathology, but one must be sure there are no contra indications to use of these potent medications as both acetaminophen and non-steroidal anti-inflammatory medications have a long list of potential side effects. Most athletes can and will improve without these albeit recovery may be longer. In fact, recent studies have shown that controlled inflammation is important for healing! Since NSAIDS (non-steroidal anti-inflammatory medications) eliminate or at least significantly decrease inflammation, their use can actually slow down bone healing! Thus, acetaminophen would be a safer choice in treatment of fracture related pain. Unless of course, one is allergic to it or has liver problems. A smart runner would also supplement with vitamin D (at least 2000 units per day) and with calcium. This is particularly important if the fracture occurred due to bone fragility. This can be common in athletes with poor nutrition or hormonal insufficiency resulting in bone weakness.
Some activity like static muscle action can be beneficial to avoid muscle weakening and deconditioning. These are also called isometric muscle contraction exercises and they create muscle contraction without movement at nearby joint. Because form is very important when doing these exercises, one should strongly consider doing these with a certified athletic trainer or under the guidance of physical therapist. These will allow for faster recovery and will avoid additional trauma. As pain improves, need for cast and boot/brace becomes more limited and swelling subsides, an athlete can start to increase activity level and can engage in low impact aerobic exercise like swimming, water running/walking, and cycling.
Once an athlete can do above low impact activities without pain, next phase in recovery can start and activity one participates in can become more difficult in terms of time spent and endurance required to complete. Thus, running on soft surfaces every other day can be started. It is important to establish a baseline which would be the distance or length of time spent before first onset of pain.
As one gains strength and endurance, prevention should come into play with proper selection of exercise shoes and, if needed, corrective orthotics to compensate for biomechanical malalignment.
Shin splints:
Stress fractures can be identified by pain at a particular point along the length of the bone. This point corresponds to the area of the fracture and tends to be closer to the knee area. Shin splints, on the other hand, are more common on posteromedial border of the tibia (long bone in front of the leg). This pain tends to be diffuse and includes its distal and middle portion. Shin splints are associated with sports requiring repetitive lower extremity movements like running and jumping, especially on hard surfaces. The most common cause is inflammation of the bone covering layer called periosteum, because of the rubbing of the muscle against the bone during repetitive activity. This leads to significant pain. The reasons for the onset of this condition can be many. But in all cases, the result is the overuse injury.
Flat feet, worn out shoes with poor cushion, running on hard surfaces, poor training protocols, tight muscles and lack of pre and post exercise stretching can all contribute.
Because this condition is secondary to overuse and inflammation, taking time off, slowing down the pace, use of cryotherapy and occasionally taking all weight off the injured extremity will be helpful.
If you do need to take weight off the leg but want to stay mobile, Iwalk knee crutch device could be a helpful modality.
I only recommend this device for people who have a great sense of balance to avoid falls and other associated injuries
This video explains its design and use.
https://youtube.com/watch?v=9KBXDJRj-XM%3Fautoplay%3D0%26mute%3D0%26controls%3D1%26origin%3Dhttps%253A%252F%252Fwww.prestigefootcare.com%26playsinline%3D1%26showinfo%3D0%26rel%3D0%26iv_load_policy%3D3%26modestbranding%3D1%26enablejsapi%3D1%26widgetid%3D1
Once shin splints resolve, an athlete should start with the regimen of strengthening of inverter and everter leg muscles, especially posterior tibial muscle and peroneus brevis muscles. When ready to restart the activity, it is recommended to start exercises at 50% of pre injury level in terms of duration and intensity of exercise. Then add 10% per week, or slower if pain reoccurs, to build stamina and allow for healing and accommodation in graduated fashion. Again, if the injury happened due to biomechanical malalignment, it will need to be corrected for condition not to reoccur. This can be done with shoes and orthotics in conjunction with strength and balance training.
Achilles tendinitis:
This condition can represent so many different pathologies, all involving pain to the back of the distal leg where the tendon meets the heel bone. This pain can be directly over the back of the heel bone (insertional tendinitis) or just proximal to the bone and along the length of the tendon (non-insertional). This can be further divided into those caused by inflammation because of the heel spur, inflammation due to tearing of the tendon, inflammation of the covering of the tendon (paratenon), inflammation due to scarring or injury to tendon substance (tendinosis) with and without calcium deposits. As you can see, it is very important to diagnose the reason for the Achilles tendon pain to properly direct the treatment. Achilles tendon pain is such a huge topic that it deserves its own blog entry. Acute injury to the tendon usually presents as pain during exercise. Chronic injury and scarring are felt as tightness and chronic pain irrespective of activity but definitely aggravated by stretching of the tendon.
Just like with shin splints, treatment of Achilles tendinitis includes cold therapy, rest, compression therapy, elevation of injured extremity, isometric exercises, and activity modification. Acute condition is slow to heal and may take 3-4 months to achieve full recovery. Recovery takes even longer for chronic Achilles tendinitis. Various bracing and supportive modalities may be beneficial here including the use of heel lifts to decrease stretching of the tendon. Orthotics to correct for flatfeet or excessively high arches. Bracing could be beneficial as well and frequently includes cushion over Achilles tendon as well as heel elevation with limitation of foot/ankle inversion and eversion.
As always, surgery should done as last resort only.
Take away points:
1. Because these conditions are all due to overuse, it is very important to consult with a specialist to ensure proper diagnosis so that correct treatment can be initiated
2. If you suspect that the leg pain may not be due physical activity, it is essential to visit urgent care or your primary care doctor as soon as possible to ensure that you are not suffering from condition like blood clot, blood vessel injury, or nerve compression just to name a few.
3. It is pretty clear that the first resort for the musculoskeletal injuries of the leg should be RICE (rest, ice, compression, elevation) and use of appropriate shoe gear modalities, braces and orthotics.
4. If you are doing everything as recommended and do not see a gradual improvement in symptoms, an alternative diagnosis for leg pain must be investigated as you may be suffering from a condition that is not muscular or skeletal in nature.
5. One must be patient with recovery as most of these conditions requires months to get better and that with adhering to proper treatment protocols.
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Until next time……. Happy Running!
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Author bio:
My name is Dr. Marat Kazak. I have been working as a professional Podiatrist serving Northern California community since 2014. My extensive medical and surgical knowledge combined with an ongoing curiosity to learn about the latest trends define my success in the field of foot, ankle and leg medical and surgical care.
The goal of this website is to give you the tools to better care for yourself, to dispel medical myths, and to empower you with information to save time and money! If you are looking for an answer on foot and ankle pain, this is the place to find it. If you do not see your topic of interest covered, please send me a message and I will do my best to discuss it thoroughly in my next upcoming post.
Visit this blog often to learn about latest developments, treatments, and approaches to healing and recovery!