The Foot: coddle tendons and bones

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SPECIAL FITNESS ISSUE: THE FOOT

.... coddle tendons and bones

Whether you run marathons or walk, injuries are just a step away.

Knowing what -- and what not -- to do can help avoid them.

By Jeannine Stein, Times Staff Writer

http://www.latimes.com/features/health/la-he-

mechanical1jan01,1,1842185.story?coll=la-headlines-health

From the pickup basketball player to the motivated marathoner, all

who exercise can suffer the agony of the feet.

During the simple act of walking, the foot absorbs one-and-a-half

times the body's weight. In running, it bears two to three times the

body's weight. One giant leap to dunk a basketball can ratchet that

force up even higher. Because one stress fracture can seriously

derail an entire sports career, researchers are continually studying

athletes to determine the optimum methods of training and treatment,

to both prevent and care for these injuries.

The most common athletics-related injuries, say sports medicine

orthopedists and podiatrists, are plantar fasciitis, Achilles

tendinitis, neuromas, capsulitis and stress fractures.

Plantar fasciitis

Any activity that involves jumping, plus sudden stops and starts,

can lead to plantar fasciitis. And apparently plenty of activities

do. This overstretching of the ligament that runs from the heel to

the ball of the foot, straight through the arch, affects about 14%

of men and women ages 18 to 60, according to the American Podiatric

Medical Assn.

" It comes on slowly, " says Dr. Doug Richie, a Seal Beach-based

podiatrist and past president of the American Academy of Podiatric

Sports Medicine. " It's not a sudden event. But it's always worst

first thing in the morning, and it can be worse while playing the

sport. "

Cause: The repeated stress of propelling the foot upward strains the

ligament, sometimes creating small tears and possibly also causing

pain at the arch. Being overweight can exacerbate the condition for

the additional load it puts on the foot. The injury is especially

common this time of year, when resolution-makers start exercising

with a little too much gusto.

Although the pain can be felt in the arch, it's usually felt in the

heel in part because that's where the ligament is weakest, says Dr.

Pagliano, a Long Beach-based podiatrist and fellow of the

American College of Sports Medicine. " The fascia is nice and broad

in the arch, but narrows as it comes into the heel. " The heel is

also where the foot bears the brunt of impacts.

" It's supposed to be a nice, soft, pliable material, " Pagliano says,

but after taking a pounding, it can form adhesions and scar tissue,

becoming " gristly and hard. "

Prevention: Warm up before an exercise routine, and gradually

increase your workout intensity over time. Wear shoes with adequate

arch support.

Treatment: First, try rest, plus orthotics that lift the arch and

take the pressure off the ligament. If that doesn't do it, try a leg

splint worn at night to keep the foot at a 90-degree angle, so the

plantar fascia is prevented from tightening up. For those prone to

plantar fasciitis, physical therapists often recommend exercises to

stretch the ligament. For instance, while seated, roll the foot on a

tennis ball for about five minutes twice a day. But do the move only

when warmed up — never first thing in the morning when the foot is

stiff — and only on the fleshy bottom of the foot under the arch. A

study published last year also showed good results, finding that

curling the toes backward while flexing the ankle resulted in less

pain and more improvement than those who did an Achilles stretch.

Another therapy could be on the horizon: In a pilot study presented

at a meeting last year of the American College of Sports Medicine,

29 men and women recently diagnosed with the injury were given eight

weeks of standard care — ibuprofen, rest and stretching exercises.

Half were given glucosamine supplements, and half a placebo.

Although all started off with the same severity of pain, six of the

15 who took glucosamine were pain-free after about a month, compared

with only one of 14 in the placebo group.

Achilles tendinitis

The tendon that brought down the mythic hero Achilles also fells

numerous runners, dancers and gymnasts. Some 6.5% of people suffer

from general tendinitis, according to the American Podiatric Medical

Assn. In 2002, Washington, D.C.-based sports medicine podiatrist Dr.

Pribut surveyed nearly 10,000 runners via the Internet and

found that 7% reported that Achilles tendinitis pain prevented them

from running for more than a week.

The Achilles tendon connects the calf muscle to the back of the heel

bone. But it's the action of the foot that can cause injury, says

Richie — specifically too much bounding, jumping or fast-paced

running.

" The more you get up on the toes, the more that uses the Achilles, "

he says, " since it's the propulsive tendon of the foot, lifting the

heel and driving the body forward over the foot. " The less flexible

the Achilles, the more strain it endures.

Cause: All that stress can eventually lead to inflammation, strains

and micro-tears in the tendon, forming scar tissue that results in

even more inflexibility, says Pagliano. That can cause severe pain

that shoots like a thunderbolt from the back of the ankle with every

step. In extreme cases, the Achilles can completely rupture.

Saying goodbye to weekend basketball games or five-mile daily runs

is usually the first call to action for Achilles tendinitis

sufferers, although sometimes people can substitute an activity with

less impact such as an elliptical trainer or bike workout, Richie

says. They should also make sure their shoes have proper cushioning

for greater shock absorption.

Prevention: Do stretching exercises, three times a day when warmed

up, to increase the tendon's flexibility.

Begin with a classic calf stretch, leaning against a wall, one foot

in front of the other, gradually pushing the back heel down, then

slightly bending that leg.

The tendon can also be stretched using a large, rubbery band. While

sitting on the floor, extend one leg and wrap the band under the

arch of the foot. Hold the ends of the bands in both hands while

pointing and stretching the foot.

Treatment: Shoes that offer a slight heel raise (about 1 1/2 inches)

can take stress off the tendon while it heals. Ultrasound can help

break up scar tissue, as can massage therapy.

In a promising new development, low-level laser therapy is being

tested to treat Achilles tendinitis. The treatment has been used to

reduce inflammation in other areas of the body, because the laser

light can activate changes in the cells, such as stimulating wound

healing.

In a study published last year in the British Journal of Sports

Medicine, seven people who had Achilles tendinitis in both legs were

given laser treatment and a placebo treatment on each. The laser

treatment proved to significantly reduce inflammation and pain

compared with the placebo treatment.

Neuromas

The front of the foot has its own set of sports-related problems.

Neuromas are nerves that are squeezed between tissue and metatarsal

bones, those long bones behind the toes. They're especially common

among cyclists, whose forefeet are under constant pressure while

pedaling and who frequently squeeze into tight cycling shoes. Almost

15% of people complain of pain in the ball of the feet, says the

American Podiatric Medical Assn.

Pain is usually felt on the ball of the foot, between the third and

fourth metatarsal bones, behind the toes. It's often sharp, but can

sometimes feel like a burning or tingling sensation, causing

sufferers to doff their shoes and massage their feet the first

chance they get, possibly discovering a little bump — a sign of an

inflamed nerve. But trying to rub away the pain isn't the best thing

to do since putting additional pressure on the area can exacerbate

the injury, says Judy Seto, a physical therapist with HealthSouth in

Los Angeles.

Cause: The area is thought to be a prime target for problems, says

Richie, since " the nerve has an extra branch, making it more likely

to be pinched. " Also, some feet may have metatarsal bones that are

naturally closer together, leaving even less space for the nerve.

Prevention: The first line of defense is simple: change shoes. If

they're on the worn side, opt for ones with more cushioning, Richie

says. If you're feeling a squeeze in the forefoot, try another brand

that has a wider toe box. Orthotics may help too, especially ones

that distribute pressure more evenly throughout the bottom of the

foot.

Treatment: Cortisone shots can shrink the nerve and reduce pain.

Some doctors inject an alcohol solution into the foot to kill the

nerve. Surgery, used in a few cases, removes the nerve, usually

causing no serious side effects.

Capsulitis

Basketball and tennis players — and those with unusually high

arches — know the feeling well: a bruised sensation in the ball of

the foot that can bring pain with every step.

Known as capsulitis and caused by inflammation around the joint

capsule, the condition usually occurs under the second or third

metatarsal bone. Distinguishing between a neuroma and capsulitis is

important in terms of treatment, but MRIs might help.

In a study presented earlier last year at the annual meeting of the

American College of Foot and Ankle Surgeons, the scans altered the

treatment for several, leading some to skip surgery and others to

have more precisely targeted surgery. MRIs are helpful in detecting

these injuries that usually can't be seen on X-rays.

Cause: Pounding on the ground on a hard surface can bring it on.

Wearing hard-soled shoes can intensify the condition.

Prevention: Choose well-padded athletic shoes. " You must have

adequate cushioning and your shoes shouldn't be abnormally worn.

That focused, unrelenting pressure compacts the foam [in the shoe], "

Richie says. Another option is to wear two pairs of socks for more

padding, a trick Seto says many pro basketball players use.

Treatment: Cortisone shots can reduce inflammation and orthotics can

help redistribute the body's weight more evenly.

Stress fractures

For these micro-cracks within the bone, a casual walker could be as

much at risk as an ultra-marathoner — if both are overdoing the

activity and overtaxing the feet.

Excessive running, stair-climbing or other cardio activity can leave

the bone unable to adapt and repair quickly enough by building up

more calcium and becoming stronger. " In a stress fracture, the body

doesn't have time to adapt to the stress, and it fails by breaking

down internally, " Richie says. Pain intensifies over several days,

he says, but without the dreaded " pop " that's usually associated

with a break.

Cause: The metatarsal bones, those skinny, long bones that connect

the toes to the mid-foot, are the most common spots for stress

fractures because they bear much of the body's weight. Other

conditions also contribute, such as high arches, which can put even

greater pressure on that area.

Stress fractures can also occur in the shins. If the feet don't do a

good enough job absorbing the shock from workouts, sometimes due to

over-pronation, supination or plantar fasciitis, " the shockwave goes

up the leg and it's now straining the bone, " says Dr. Kwong,

an orthopedic surgeon at the Kerlan-Jobe Orthopaedic clinics in Los

Angeles and Anaheim. The heel bone is another hot spot for stress

fractures. The clue is pain that radiates all through the heel that

doesn't get better with time.

Prevention: Gradually increase activities, even in pursuit of a

shape-up for the new year. Says Richie: " The body needs more time to

adapt and recover. " Those training for a marathon, for instance,

should take one or two days off after long runs.

Treatment: Rest alone usually doesn't fix the problem since even a

minimal amount of walking can put stress on the foot, Richie says.

More drastic measures are required to give the bone time to heal, so

often the foot is immobilized in a cast for several weeks.