Entry By: Eric Folmar, MPT, OCS, PT
I am looking for some commentary on stress reactions of the lower extremity in recreational endurance athletes. In the spirit of the Boston Marathon this past Monday, I think this is an appropriate topic. I have had the privilege of treating 4 patients with stress related injuries directly related to training for Boston. As we all know stress reactions/fractures are very delicate to work with, for many reasons.
First, and probably foremost, is personality associated with the injury. To me these fall into 2 categories: the crazy, insane, stop-at-nothing endurance athlete type and the highly motivated, new to training, have to meet my goals type. Both can be difficult to reel in and get on board with the appropriate treatment plan.
Second issue is what exactly are we dealing with. A stress fracture or a stress reaction. Just like any other diagnosis…. if we catch it early and correct the abnormal stresses we can get the patient back to sport much quicker. If it has progressed to a fracture, we obviously have to respect the fracture healing in additional to identifying the abnormal stress.
The final issue is the actual treatment plan. What is right??? Often times the plan goes something like this: immobilize, rest, rehab, and return to activity. What often is missing is the correction of biomechanical faults? These patients did not develop stress related injuries randomly….. at least not typically. There is often an underlying, unidentified biomechanical issue…. or perhaps it was simply a change thatoccurred in what the patient had been doing. For instance…. one of the patients training for Boston came to me with a diagnosis of a cuboid stress reaction. She was 10 weeks before marathon monday and had been told that she was out of the race. Easy to say for a doctor that hadn’t trained for a year and raised the required $3800 or so for running on a charity exemption. She is well known to my clinic. On evaluation she reported that she had rested for 2 weeks and was pain free for all activity except running. Pain was isolated over the cuboid. She had not strayed from her previously outlined training program. Her only change was her shoeware. She had changed 4 weeks prior from stability plus sneakers to Asics Gel Nimbus (neutral) shoes on a recommendation from a friend. Her mechanics are such that she is a severe overpronator and that was the final straw. A few weeks with no support and increasing mileage left her destined for trouble. Upon identifying this we decided to change her to Asics 2150 series sneakers (stability plus) and go with an OTC Vasyli orthotic with some varus FF and RF posting. We began a slow, gradual return to running program (100% painfree). Within 5 weeks she was back on track for her marathon training, albeit at a slowere, more controlled pace. She completed her marathon on Monday painfree.
So after a drawn out entry what is my point. Identifying underlying mechanics and the stage of injury can lead to much greater success in treating an otherwise frustrating and frustrated patient population. 2 of the stress injuries we worked with were able to complete their marathons. The other 2 were full stress fractures and were unable to run. We are working on making sure they make good on their goals next year.
Matt,
Great post and great point. It is very difficult to do this without video. I have an interesting and conflicting patient right now that we are working through and I will likely post on once we’ve done video. As far as your patient’s shoe change. You are right on with the Mizuno. Mizuno sneakers in general have a much “harder” ride. The outsole is a harder than most other shoes, equalling increased force potential, primarily into pronation. I spoke with a Mizuno rep a while back at a marathon expo. I explained to her that I loved the weight and feel of the Mizuno but the surface impact was much harder. She informed me that a material change was something they were playing with for that reason but they had not come up with a good solution that would give them the lightweight shoe they were looking for. I appreciate the post Matt.
Eric
Eric,
Thank you so much for that feedback. Please keep posting any interesting cases you see. I’m always looking to improve as a clinician who specializes in this area.
I recently had a 15 year old female runner in the clinic with a diagnosis of stress reaction in both her tibias. She began running cross-country in the fall and winter track in Asics Trainer DS (lightweight stability shoes) which happened to be several years old. At the beginning of the spring track season the coach recommended that everyone purchase new running shoes. She had selected Mizuno Inspire (mid-range stability shoe) and began having the problems about 3 weeks later. After taking a careful history I was able to exclude any issues with her training routine and the surfaces as being a possible cause. She also had a complete evaluation by a non-surgical pediatric sports medicine specialist who had referred her to me. After doing my initial examination I was somewhat confused why she developed this injury. She presented with bilat low arches and mod hypermobility bilat with a mild rearfoot and mod forefoot varus deformity L>R.
Also significant was that her mid-foot was somewhat hypermobile in subtalar joint pronation but did not significantly improve in subtalar joint supination. Hardly to patient you would expect to develop a stress injury especially after switching to a more stable shoe. Given the situation of having hypermobility with overpronation why would she experience this type of injury once she switched from her old and worn out asics to a new shoe with improved stability? I decided to do a video analysis of her running and the answer became quite clear. In her old asics DS trainer the lateral gel crash pad allowed for her to absorb more shock at initial heel strike and give her a smoother transition into pronation especially since she did have a mild rearfoot varus causing her to land more lateral. When analyzed in the Mizuno Inspire, with the more rigid heel, it demonstrated a catapult affect which caused her to move much quicker into pronation allowing less time for shock absorbtion to occur. Due to this experience it would be difficult for me to imagine any clinician who treats running injuries on a regular basis to not utilize video analysis as a tool.
So glad to hear the increased understanding of how important it is to keep atheletes active by correcting simple deviated mechanics.