Case Study July 2017 – Sports Podiatrist and City To Surf

Screening With A Sports Podiatrist

Around this time of year, in Sydney, it is common that some runners request a bio mechanical assessment with a sports podiatrist, prior to their involvement in this annual running event. Patient’s that run regularly tend to increase their frequency and / or distance, and those who rarely or never run, begin to train.

For both of these reasons, some of these runners tend to develop running injuries that often require the intervention of a sports podiatrist.

A 36-year-old female, who rarely runs, presents to the sports podiatrist complaining of pain in the arch of her right foot, which started 6 weeks ago. She informs the podiatrist that she began running twice a week before the pain commenced. She was covering 5K’s to start with and after 2 weeks increased to 7K’s 4 times a week. It was after this increase that she started to feel the arch pain. She hands her running shoes to the podiatrist who notes Nike Free. This patient is approximately 15k overweight and informs the sports podiatrist that she is aware that her body weight is an issue, and that she is struggling to shed some pounds. (Note: At this stage – even before the podiatrist has carried out a physical assessment and bio mechanical assessment, using a Nike free – which is a soft, flexible and non-supportive shoe – it is safe to say that there would be insufficient support for this patient in this particular running shoe).

The patient reports to the sports podiatrist that she feels the pain in her foot every day, even when she is not running. She feels a tight pulling sensation through the sole of her foot when she walks around her house bare foot, and when strolling to the bus stop in a morning. She uses ballet flats for work. The podiatrist immediately advises against this type of shoe, while she is undergoing treatment. A small heel and a thicker mid sole will be required, and bare feet must be avoided. The patient informs the sports podiatrist that she has been rolling her foot on a golf ball, and that this gives temporary relief. She has not been to see her GP or physio therapist and she has no x rays. This is her first ever visit to a podiatrist.

Physical Assessment By Sports Podiatrist

Palpation through the sole of the foot by the podiatrist revealed pain along the line of the peroneus longus tendon. The patient demonstrated rigid calf muscles leading to a limited range of ankle joint dorsiflexion. NOTE: Tight calf muscles causes an early heel lift and leads to over activation and early activation of the peroneal muscles. This is a common cause of peroneal tendonitis.

The podiatrist took foot posture measurements. In a relaxed calcaneal stance position both heels were vertical with minimal eversion. Both arches were above average height: Right 31mm Left 33mm. Length was measured with the patient prone and there was a slight “shortening of the right leg” due to a pelvic rotation. (this would best be addressed by an osteopath or chiropractor). NOTE: An early heel lift is more prominent in the leg with functional shortening, and this would exacerbate the early heel lift that was due to the tight calf muscles.

Bio Mechanical Assessment By Sports Podiatrist

The patient was assessed walking and running on a treadmill while the sports podiatrist recorded her gait using digital software on an iPad. During walking, minimal pronation was observed. During running there was a slight increase in pronation. The overall amount of pronation occurring in this patient’s feet, during gait was deemed appropriate by the podiatrist, and was not of any concern.

Diagnosis

The podiatrist informed the patient that she had signs and symptoms of peroneal tendonitis. The causes were likely: inappropriate running shoes, tight calf muscles and a functional short right leg.

Treatment Recommendation by Sports Podiatrist

This patient understood the likely causes of her condition and was advised by the sports podiatrist to carry out the following if she was to continue training for the city to surf:

1: A visit to a trusted and reliable chiropractor to realign the pelvis and correct the functional right short leg. A referral was given.

2: Calf muscles stretching – the patient was shown how to perform calf stretches and was advised to perform these 3 times a day. Each stretch for 30 seconds and 3 on each leg.

3: Glute muscle stretching, particularly on the right side to assist with the pelvic realignment.

4: The purchase of new running shoes – This patient was advised to purchase a firm neutral shoe. She was asked to try the Saucony Echelon and the Brooks Dyad and to purchase which of the 2 felt better.

5: Rigid sports tape was applied to the affected foot by the sports podiatrist and the patient was shown how to reapply the tape. The tape was to remain in place every day. The tape would elevate the cuboid bone to assist in unloading the peroneal tendon.

6: The podiatrist advised the patient to apply ice packs to the affected foot at least once a day, for 30 minutes. This would reduce the inflammation and assist in recovery, and would also reduce the pain.

The patient also informed the sports podiatrist that she was in possession of a set of generic arch supports which were not seen by the podiatrist. Despite the podiatrist not being able to check the arch supports, she was advised to try using them in her running shoes, removing the existing liner first. If they were comfortable, and did not cause excessive / uncomfortable pressure in any part of her feet (the patient has asymmetrical arch heights from above measurements), then she would be permitted to trial them and use them for training and the main running event.

4 Week Follow Up

The patient reported to the sports podiatrist that she was improving. Her pain levels when not running were close to zero. During the first 5 minutes of her run she felt mild pain but this soon resolved and she was able to complete her runs without pain. For the hour that followed the run there was some foot pain but the patient would recover quicker than usual. On palpation of the affected tendon there was mild pain, which is to be expected as these conditions can generally take up to 8 weeks to recover fully.

The patient was advised to continue with the treatment plan. No changes were necessary.

This patient was eager to recover quickly as the running event was approaching. To this end she was booked in with the sports podiatrist for 4 weekly sessions of shock wave therapy.

8 Week Follow Up

The patient reported to the sports podiatrist that she was free from pain. She was running 4 times a week and was able to complete one 15K run in her weekly training programme.

Please note: The information contained in this case study should not be taken as general advice. If you suffer from foot pain you should seek the advice of a sports podiatrist or other health care practitioner.