Following a three month break, I finally return to my job as a Podiatrist this week. Admittedly, upon my return the majority of my caseload will involve routine management of painful corns, hard skin, long toenails and an influx of fungal skin and nail infections which generally come hand in glove with the recent warm weather conditions that we have recently experienced.
But will this be all? The latest issue of our professional monthly Podiatry Now features an article which questions whether exercise habits during the Covid-19 pandemic lockdown could instigate a spike in overuse running injuries.
Thinking back to last summer, I remind myself of a lady in her 40s who limped into clinic with a ‘shooting’ pain in her right heel. It was the first time I’d seen this lady and while taking the usual medical and social history, she reveals that she had recently completed a couch to 5k programme. This in itself is a fantastic achievement. However, what this lady had done was complete the 9 week programme in just 2 weeks. So what had happened is she had gone from a fairly sedentary lifestyle to increased training volume in a relatively small space of time. The result of her enthusiasm was a sharp increase in stress on the soft tissues of the foot and consequent inflammation and degeneration.
Fast forward to March 2020. Concurrent with UK Government guidelines to close gyms, health clubs and any other means of indoor activity, the public were encouraged to take 1 hour of exercise once a day. The most obvious and accessible means of getting a workout without the need for masses of equipment is probably to go for a run.
From my own observation while out running, there was a notable increase of runners and joggers. It may be fair to hypothesise that many of these had never indulged in running outside, if ever at all. Perhaps they were regular gym attendees and accustomed exercise in some form, but not to the comparatively harsh impact that running can place on the body?
Further to this, with running events cancelled or postponed, social media has been flooded with running related distance and time achievements thanks to virtual running challenges. Even I signed up to do 200km in June via Virtual Runner UK to satisfy the running bling urge that would otherwise remain unmet at least until a new variation of normality resumes. Bling aside, virtual running events are fantastic for maintaining focus and motivation especially when the world around you has been plunged into complete weirdness. But could the closure of gyms, disruption of normality and increased enthusiasm for physical exertion actually provide ‘the perfect storm’ for inciting an increase in running related overuse injuries?
Some running injuries can be acute in their nature. Typically these are the injuries that arise with a sudden onset and are usually caused by trauma. For example running down off a kerb or treading on a hidden stone or tree root and rolling your ankle. This type of ‘inversion’ injury (whereby the foot inverts or rolls in suddenly) is accompanied by sudden pain and probable inflammation, heat, swelling and bruising. However, it’s the more chronic injuries that I want to focus on. Chronic injuries are those that are insidious in their onset and there’s probably no specific ‘pinpointable’ event that you can identify as a cause. In fact, it probably started as a niggling pain that you could manageably run through, which has gradually worsened until running becomes impossible.
Studies have shown that overuse injuries of the foot and leg affect between 27 - 70% of runners within a 12 month period. Generally speaking, the cause of these types of injury can largely be blamed on frequent strain and inadequate recovery time but there are other more specific causes that should be considered, depending on the site of injury.
Before going on to discuss the most frequent of these, I MUST emphasise that a correct and explicit diagnosis and identification of the causative factor are ESSENTIAL in seeking the right treatment and achieving the best possible outcomes. Don’t rely on google, and certainly don’t post “what’s this?” type questions on forums.
· Plantar Fasciopathy.
o This also gets called plantar fasciitis amongst a myriad of other pronunciations. This is feasibly the most common overuse injury that I see in clinic, probably because it’s not strictly running specific. Those who indulge in other forms of physical exercise as well as those who spend a lot of time on their feet, and especially in flat shoes, are particularly prone to this. The plantar fascia is a band of fibrous tissue that contributes to the arch of your foot. It starts at the bottom of the heel bone (the calcaneus) and fans up approximately to the metatarsal heads. So what causes the pain? Due to overuse, poor footwear or poor ‘gait’ (amongst other reasons), the plantar fascia becomes strained, most commonly at its point of attachment on the heel. If you imagine it as an elastic band across the arch of your foot that’s constantly being pulled and stretched, you can soon see why this becomes problematic. Structural changes actually occur through degeneration rather than through inflammation as was previously thought, and as a result the tissue becomes thickened and collagen depletes so that the fascia loses its elasticity. Those who suffer will note a sharp pain normally during the first few steps of a morning or after they’ve been sat down for a while as the tissue contracts during non-weight bearing. This, along with physical examination and questions relating to your exercise, social and employment history are normally enough to indicate the condition. However, the use of diagnostic ultrasound may also be used to image the plantar fascia and, if present will show thickening, tearing and general tattiness like an old frayed rope. If your heel pain is found to be plantar fasciopathy, treatments are usually non-invasive and include taping or strapping the affected foot to offload some of the strain, physiotherapy, stretching exercises, extracorporeal shock wave therapy, shoe inserts or orthoses and footwear advice. If the patient shows compliance with their treatment programme, outcomes are generally very good and the condition resolves.
· Achilles Tendinopathy
o The role of the Achilles tendon is to attach the calf muscles to the back of the heel. In doing so, it is responsible for flexion and extension of the ankle joint therefore allowing for ‘plantarflexion’ (when your toes point down) and dorsiflexion (when the toes point up). Achilles tendinopathy presents as pain and swelling along usually but not always along the mid portion of the Achilles tendon. It can affect both elite and recreational athletes alike and can either be of gradual onset or it can suddenly flare following an intense training session. However, this condition does not only affect the active community and those with sedentary lifestyles are also at risk. Just like with plantar fasciopathy, high and repetitive training loads and increases in volume and intensity to those who are unaccustomed to exercise can play a contributory role. Systemic problems such as Type 2 diabetes, autoimmune diseases and inflammatory conditions will also place you into a higher risk category for suffering from Achilles Tendinopathy. Diagnosis of the condition can be through clinical presentation and/or diagnostic ultrasound which will show thickening of the tendon. Ultrasound or MRI might also be useful in ruling out other conditions such as posterior ankle impingement. So what’s the best treatment? Well if it’s a sudden onset, the RICE (rest, ice, compression & elevation) is essential for reducing inflammation and preventing tissue damage. That aside, treatments go from least to most invasive and include activity modification, changing footwear, foot orthoses, extracorporeal shock wave therapy, eccentric loading programming, cortisone injections and possibly surgery as a last resort. I must reiterate, the most important thing is to obtain a proper diagnosis through professional examination. This will allow the cause to be identified and the correct treatment path taken so that the best possible outcome can be achieved.
· Iliotibial Band Friction Syndrome (ITBFS).
o The iliotibial band (IT Band) is a thick band of fascia that runs from the outside of the knee to the iliac crest (the top of the hip bone). The purpose of this structure is to assist the adjacent muscles to allow for flexion and extension at the knee joint, flexion and extension, abduction and rotation at the hip. It is essential for locomotion and is a common site of overuse injury across all sports. In runners, it accounts for 12% of running related injuries and results in a sharp pain at the lateral aspect (outside) of the knee as the foot hits the floor. It is thought that the act of the IT band ‘flicking’ over a bony landmark on the femur (called the epicondyle) through knee flexion and extension causes irritation through friction. Diagnosis can be made through clinical presentation and examination and if a positive diagnosis is made, will require cessation of the activity causing the pain. Again, depending on the cause, treatment will include stretching, strengthening and mobilisation of the surrounding structures. If the cause is due to abnormal loading of the foot through the gait cycle, a Podiatrist can prescribe foot orthoses and offer footwear advice.
· Peroneal Tendinitis
o The peroneal muscles and their respective tendons run along the outside of the lower leg and the outside border of the foot to connect at the base of the fifth metatarsal (the little toe). The job of these muscles is to evert the foot, imagine trying to turn the sole of your foot outwards. Increased training load in weight bearing activities such as running and walking coupled with improper training techniques and incorrect footwear predispose this muscle group to work harder than they should leading to inflammation and degeneration. If you are suffering from peroneal tendinitis, pain is felt along the outside edge of the foot and it may even span as far as the little toe. In some cases may refer under the plantar aspect of the foot. Diagnosis once more is the key to successfully treating the condition and this can be done in clinic through a thorough examination and patient history taking. Treatment will depend on the suspected cause and severity and can include RICE (Rest Ice Compression Elevation) protocol, footwear advice, orthoses, stretching and strengthening exercises and activity modification. The possibility that the pain could also be caused by a metatarsal stress fracture should also be ruled out.
End Points
All of the above conditions have a common theme that might be affecting you as a runner; that being a sudden increase in training load or volume of activity. Following a training programme and listening to your body whilst doing so is essential. If you find that you are affected by niggles, don’t try and run through them; reduce the activity that is causing the pain and it’ll pay dividends in the long run. If your niggles worsen, book an appointment with a clinician (social distancing allowing) who can take a look at your gait and biomechanics and advise accordingly. Although the internet has a wealth of information for runners and their injuries, you can do far more damage treating a condition incorrectly that’s been misdiagnosed. The correct treatment path can only be taken if the correct diagnosis is made.
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