Black Mountain Orthopaedics

Patient Education

Patellofemoral Stress Syndrome
The single most common problem in runners is pain in the front of the knee from abnormal tracking of the patella (knee cap). During normal flexion and extension of the knee, the patella tracks centrally in a grove in the end of the femur (thigh bone). Abnormal alignment of the knee (more common in women) or excessively tight or weak muscles and tendons supporting the patella can lead to abnormal tracking.

Diagnosis: Patellofemoral stress syndrome occurs more commonly in women and low mileage novice runners. It produces pain in the front of the knee, and is aggravated with hill or stair climbing. Prolonged sitting may produce symptoms.

Biomechanics: Obesity, hyperpronation, genu valgum (knock-knee) and certain other structural abnormalities may increase your risk of developing this problem.

Diagnosis: Your orthopedic surgeon or family doctor should be able to make this diagnosis based on your symptoms and with a physical exam. X-rays may be taken to confirm abnormal tracking using a special view called a "sunrise" view.

Treatment: Treatment consists of rest, ice and anti-inflammatory use. Exercises designed to strengthen the anterior thigh muscles without putting stress on the patella are a key component of any rehabilitation process. Avoidance of hill running may also help. Lastly, orthotics to control foot malrotation may be necessary.

Plantar Fasciitis
The most common cause of heel pain is plantar fasciitis. It is an inflammatory reaction due to chronic tension of the plantar fascia on its insertion on the heel bone (calcaneus). A bone spur or heel spur may develop in reaction to this chronic inflammation but the inflammation, not the spur, is the source of the pain.

Overuse: Plantar fasciitis is a classic example of an overuse injury. It is characterized by pain in the sole of the foot in the heel bone which is worse at the beginning of the workout (or the first steps out of bed in the morning). Pain typically improves during the workout only to recur at the end of the workout.

Biomechanics: Plantar fasciitis is associated with the cavus foot type, tight Achilles tendon and obesity.

Treatment: Rest, ice, stretching and anti-inflammatory medications are the first line of treatment for this condition. Your doctor may order heel cups, or shoe wear modification if needed, to address foot structural problems. Rarely, cortisone injections or even surgery may be needed. A few recent reports have shown improvement with ultrasound and lithotripsy (shock wave therapy).

Stress Fractures
Stress fractures are a rare cause of foot and leg pain in the runner.

Overuse: Stress fractures classically occur in someone who either dramatically increases his running mileage, or moves from a soft to a hard running surface (such as a trail runner moving to the city and continuing all his running on concrete).

Biomechanics: Obesity, cavus foot (very high arch) and certain other foot types may have increased risk of stress fractures.

Location: The metatarsals (foot bones) and tibias (shin bones) are the most common locations for stress fractures. Tibial stress fractures are one disease that can produce the symptom classically called "shin splints."

Diagnosis: Ongoing pain, even while walking, and bone tenderness are hallmarks of this disease. X-rays will often miss a stress fracture if the symptoms have been present for less than 3-6 weeks. A bone scan will show a stress fracture in almost all cases even if symptoms have only been present for a very short time.

Treatment: Treatment consists of rest, crutches, and occasionally, casting.

Running Injuries
Most running injuries fall into three basic categories: injuries from overuse, injuries due to body structure abnormalities and injuries from poor and worn footwear. Let's address each of these.

Overuse: The most common mistake amateur athletes make is increasing training mileage faster than their bodies can adapt. If the number of miles run per week or the pace of running is increased too fast, injury rather than increased fitness is often all that is achieved. One rule of thumb is the length of your longest run should not increase more than 10% every two weeks and weekly mileage should not increase by more than 10% every month! Beginning runners (especially those who have been sedentary for long periods of time) should be especially cautious and should have a physician supervise their exercise program. In general, total "couch potatoes" should engage in a regular walking program, comfortably walking 6-10 miles a week before ever contemplating "jogging."

Body Structure Abnormalities: While it is true that many body types can accommodate running, it is also true that certain anatomic differences can predispose to running injuries. Foot type is one of the most common variances than can affect running injuries. Fortunately, today's shoe manufacturers now produce a variety of shoes which can accommodate most foot types and minimize injury potential. The two most common foot types are the flat-footed pronator and the high-arched supinator. When you get fitted for shoes, a qualified shoe expert should be able to tell you if you have these foot types and recommend a shoe that will minimize your injury risk. Another anatomic risk factor for injury is obesity. Increased weight increases joint and tendon loading which increases injury risk. In addition, obesity may have already produced cartilage damage (arthritis) in the weight bearing joints of the hip, knee or ankle. Anyone more than 20-30% over ideal body weight should have their exercise program reviewed by their doctor and strongly consider a walking program (instead of running) until their weight is within 10-20 lbs of ideal. Lastly, mechanical malalignment of the leg, particularly the knee, can predispose to certain injuries and may require custom orthotics.

Worn or Poor Footwear: Fortunately this is the easiest problem to fix! First, anyone who walk or runs should have quality shoes fitted by a trained professional. I recommend you seek the expertise of someone at a dedicated running shoe store who should discourage you from grabbing something off the shelf just to save $10. Running shoes are as important to the runner as tires are to a Nascar driver. And remember that running shoes, like tires, wear out! 300-400 miles is about all you can expect from a pair of running shoes so remember to "change rubber" often.