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Sunday, October 25, 2015

Soft Tissue Injury Treatment and Running Shoe Concepts: A Lecture for the California School of Podiatric Medicine

Soft Tissue Injury Management: 
20 Golden Rules of Foot

                                        by Richard Blake, DPM

1981   We each ran 125 miles during that week
I am the goofy one above the T.

Patients present to your office with various injuries. These injuries have many general principles of treatment that I will call Golden Rules of Foot. These are rules I live by. This particular lecture focuses on soft tissue injuries, including sprains, strains, contusions, bursitis, and nerve injuries.
General Definitions:
  • Sprain is an injury to a ligament
  1. First Degree: overstretching of ligament
  2. 2nd Degree: partial tearing of ligament (will see some ecchymosis/bruising)

  1. 3rd Degree: complete tear of ligament (sudden swelling, impressive bruising seen)

  • Strain is an injury to a muscle or tendon
  1. First Degree: over exertion or over stretch of the muscle or tendon
  2. 2nd Degree: partial tearing of the muscle or tendon
  3. 3rd Degree: complete tear of the muscle or tendon
  • Tendinitis vs Tendonitis: both acceptable spelling
  • Tendinitis vs Tendinosis: Tendinitis is inflammation of the tendon (first degree strain), whereas tendinosis means their is some injury to the tendon (osis means condition of) not inflammatory
  • Tenosynovitis is inflammation of the tendon sheath (peritendon)
  • Stenosis tenosynovitis means that there is scarring along the sheath interferring with normal tendon function

  • Contusion to direct trauma (single blow or multiple blows) to the body causing injury to skin minimally, and as deep as the bone and everything in between

  • Bursitis is inflammation of bursae that protect bony prominences like posterior heel, lateral hip, etc

  • Nerve injuries can be local to the foot or referred from above the foot or systemic like CRPS (complex regional pain syndrome aka RSD).
Patient with left foot CRPS!!

You also have acute injuries (like a sudden fall) and overuse injuries (from chronic repetitive motions) like most tendinitis.

Golden Rule of Foot #1: As you treat patients, listening to their stories, examining their injury, you should develop a checklist of treatments that could help them which include:
My Daughter In Law Clare in the San Francisco Marathon
  1. Activity Level Allowed
  2. Type of Anti-Inflammatory Measures Needed
  3. Appropriate Stretches
  4. Appropriate Strengthening Exercises
  5. Any Bracing Needed
  6. Dietary Help 
  7. Shoegear or other Equipment Changes
  8. Inserts to Purchase
  9. Need for Testing (x rays, etc)
  10. Followup Needed (office visit, email, telephone call)
  11. Logs to Keep (training, stretching routine)
Golden Rule of Foot #2: 98% of all sports medicine lower extremity injuries are non surgical. Therefore, your skill set in non surgical approaches to treatments should be developed.
What are 7 General principles in Stretching?

How do I pad the removable boot for a sesamoid injury?

What is the best shoe for a patient's problem?

Golden Rule of Foot #3: With each office visit, you make changes appropriate to your checklist, based on the patient's response.
  • Activity Level
  • Anti-Inflammatory
  • Stretching
  • Strengthening
  • Bracing
  • Shoe Inserts
  • Diet
  • Shoes and Equipment
  • Testing
  • Followup
  • Logs

Golden Rule of Foot #4: The 3 phases of injury rehabilitation that the patient goes through (sometimes in the wrong direction with 2 steps forward and 3 back) are:
  1. Immobilization/Anti-Inflammatory Phase
  2. Re-Strengthening Phase
  3. Return to Activity Phase
You may have to take an athlete 9 months post injury who keeps hurting him/herself and place them back into the Immobilization Phase. Many times athletes who come into your office seeking 2nd opinions have never been treated appropriately for the phase they were in. 

What are the common ways you strengthen a body part? The various categories of strengthening are:
  • Active Range of Motion (with or against gravity)
  • Isometric (no change in length of muscle)
  • Isotonic (weights--no change in amount of resistance)
  • Progressive Resistive Exercises--variations in resistance (therabands).
  • Functional Exercises--strengthening whole groups at once

Golden Rule of Foot #5: During the treatment of an injury, the athlete will exist within the 3 Phases of Rehabilitation at the same time, although primarily in one phase. The art world I love to dwell within.

Golden Rule of Foot #6: Any time you are treating a superficial soft tissue injury, remember that the true cause of pain can be deeper, or referred from elsewhere. 

This patient's Anterior Tibial Spasm was related to a bone spur in the front of the ankle.

Chronic Ankle Tendinitis (achilles, peroneal, etc) can be related to Cartilage issues
Bunion Pain can be related to arthritic spurs

Neuromas can be related to Low Back Issues
Heel Pain can be related stress fractures

So, always think deep or referred as you work on the soft tissue components. 

Golden Rule of Foot #7: There are 3 sources of pain that patients experience in an injury each with different treatments---mechanical, inflammatory, and neuropathic. Any injury can have all 3 components at one time, with one type primary. The primary source of pain may change during the course of treatment. Typically inflammatory pain is always treated, but mechanical and neuropathic pain ignored completely or inadequately treated. 

What are common treatments for each source of pain?

Golden Rule of Foot #8: For an Acute injury, think PRICE.

  • Protection 
  • Rest
  • Ice
  • Compression 
  • Elevation

PRICE is 5 individual components of treatment that must be changed or at least discussed with each visit.

  • Develop a Pain Free Environment (0-2 pain level)
  • How long is it needed? 
  • What is the best form?
  • Can strengthening be used to take it's place?
  • A 4 Letter Word for most of our patients
  • Develop a Pain Free Environment (0-2 pain level)
  • Activity Modification 
  • Keep up leg tone, core strength, cardio 
  • Typically 96 hours post injury ice alone
  • Then add heat in some form like contrast bathing
  • Continue icing after irritation of injury

  • As long as swelling remains (can be months)
  • Pressure greater towards toes and less as move up leg
  • Patient needs to be able to remove or loosen
  • As long as swelling remains
  • Does not have to be above heart
  • Ankle Pumps and Circles and Toe moving as long as not painful
  • Super Elevation with body on ground and foot up on couch (especially after contrast bathing) once daily

Golden Rule of Foot #9: With any injury whether in the acute phase, subacute phase, or chronic phase, always attempt a pain free environment while rehabing (0-2 pain levels). This is the level of pain that a patient can have and still heal. 

This is how you determine the amount of protection needed, activity levels recommended, the need for icing, NSAIDs, etc. This is crucial in your treatment and the patient may or may not want to follow this. 

Acute Injury: Just happened (PRICE initiated)
Subacute Injury: 2 weeks to 3 months (with active treatment and cause reversal initiation)
Chronic Injury: Over 3 months

Golden Rule fo Foot #10: Rehabilitation is a balance between 0-2 pain levels and a gradual increase in Activity Levels. 80% better is your initial goal in treatment of most injuries. 80% better means you are back to full pre-injury activity level, and you are keeping your pain level between 0-2. It can take 4 times longer to go from 80% to 100% than it took to go from injured to 80% better. 

Golden Rule of Foot #11: With any injury (even if surgically produced), it is crucial to move as much as possible (highest level of activity within 0-2 pain) and begin strengthening the area as soon as possible. Our knee surgeons typically have a muscle stimulation unit on the patient when they wake up in the recovery room. 

Golden Rule of Foot #12: For any injury, seek 3 causes from the obvious to the "I am a great podiatrist" less obvious. This crucial in all overuse injuries, and still very important in some acute injuries. 

Law of Parsimony: The most common cause of an injury is most likely the cause now.
  • Achilles Tendinitis--tight achilles/calf
  • Plantar Fasciitis--tight plantar fascia
  • Posterior Tibial Tendinitis--excessive pronation with arch collapse.
But constantly train yourself to look deeper!!! For example, a patient with a foot stress fracture doing an activity alittle more intense than normal. Initial cause of injury is overuse. You can stop looking. But, why a stress fracture vs tendinitis vs something else? 

Law of "Weakest Link in the Chain": If there is an abnormal overload to the body, the weakest link in the chain will complain first. If a patient who over does an activity breaks a bone, do not just blame it on overuse, look for reasons that they broke their bone vs not strain a tendon, and why that particular bone. I have typically found 4 or 5 reasons that an injury occurred and in helping those reasons can prevent further injuries in the future. 

What are some reasons that a runner who break their heel bone? Think in deeper and deeper layers.

Golden Rule of Foot #13: Podiatrists own the world of preventative sports medicine as we evaluate the causes of injuries, and make decisions to initiate cause reversals. 

Claim it!! But it takes time

How does a tight achilles give you metatarsalgia pain?
How does weak quads give you 4th or 5th metatarsal stress fractures?
How does excessive supination cause medial knee pain?
Which is more likely to cause achilles tendinitis: pronation without heel valgus or pronation with heel valgus?

Golden Rule of Foot #14: With any injury, look at the common mechanics involved for causality or aggravating factors. 
  • Achilles Tendinitis--too tight, too loose, excessive pronation
  • Plantar Fasciitis--too tight, excessive pronation
  • Tibial Stress Fractures--excessive shock, excessive pronation with tibial torque

Golden Rule of Foot #15: The 8 common mechanical causes or contributing factors in lower extremity injuries that can be seen in gait or sport specific evaluations are:
  1. Excessive Pronation
  2. Excessive Supination (also called Underpronation)
  3. Leg Length Discrepancy
  4. Poor Shock Absorption
  5. Tight Muscles
  6. Loose or Weak Muscles
  7. Improper Sport Specific Techniques
  8. Miscellaneous Gait Findings
As we perform gait evaluation, and technique evaluations for specific sports, we look for mechanical problems that may need to be corrected. 

Still working on understanding the mechanics of mud running!!

We need to make sure this ballerina stays in neutral and does not over pronate (winging) or over supinate (sickling)
Cycling is one of those repetitive motion activities that we can greatly influence with subtle mechanical changes.

And then add other causes of stress/overload on that tissue to the mix.

Golden Rule of Foot #16: Besides mechanical causes of injury, there are so many other causes of injury including:
  • Equipment Faults

  • Training Errors

  • Psychological Factors (ie. negative addiction, inability to appreciate correct pain levels, desire not to stop competing, etc)

  • Dietary
This is why it is typically easy to find 3 causes of any particular injury.

Golden Rule of Foot #17: KISS rules!! It is okay to start slow in most cases, but the patient has to be with you on this (and most are). So much depends on the level of pain the patient is experiencing when you see them. 


Golden Rule of Foot #18: For any treatment modality or area, develop expertise in treatments from Simple to Complex. 

Short Leg Treatment: Heel lifts to full length lifts to shoe additions

Orthotic Therapy: OTC to Custom Made to Speciality Orthotics

Anti-Inflammatory: Ice, NSAIDs, Contrast Baths to Physical Therapy, Oral Cortisone, Acupuncture

Golden Rule of Foot #19: Use the mnemonic BRISS for tendinitis treatment.
  • B----Biomechanics
  • R----Relative Rest
  • I-----Ice or Anti-Inflammatory
  • S----Stretching
  • S----Strengthening 
Golden Rule of Foot #20: Treat what you see as directly as possible (and be persistant)!!  
  • Swelling (work on reducing the swelling)
  • Ecchymosis (evaluate for tearing--2nd or 3rd degree injuries--an treat with immobilization and strengthening, along with soft tissue mobilization to reduce scarring
  • Stiffness (work on soft tissue and joint motions)
  • Hypermobility (work on strengthening with protection as needed for activities)
  • Gait Findings (Gait Evaluation is the key to understanding how the patient moves, and if there is problems with that movement)

The 2nd Part of this lecture is on Running and Running Shoes. Let us go to my power point presentations on these subjects.


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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.