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Friday, 23 February 2018 19:45

Compartment Syndrome in Runners

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Any runner who has been running for any decent amount of time will tell you they have been injured. Small injuries like muscle strains, knee pain, sprained ankles, capsulitis, bursitis, toe and toenail injuries are really common, while some runners may have even suffered large injuries like broken bones from missteps or falls. The list could go on, but we’ll keep this to the point. One injury that is starting to get more attention and research is Chronic Exertional Compartment Syndrome (CECS), which is a bit of a mouth full and can be debilitating for some athletes, especially runners.
*Note: this is not to be confused with Acute Compartment Syndrome, which is a surgical emergency, usually following severe trauma.

The classic presentation of CECS is often pain that initially begins as a dull ache in the lower leg (although you can also get this in the arms). As runners continue their training regimen, the pain increases to a level that they have to stop. Usually, stopping for a minute or two relieves the symptoms. The onset and degree of the pain can often become very reproducible and runners can almost predict exactly at which mile the symptoms will start.

CECS3 768x211The pain can be located in different areas of the lower leg (which we’ll define as being anywhere below the knee) or even both legs at the same time. It is usually a full or even cramping feeling in different compartments of the leg (we’ll get to the anatomy in a minute). The pain can also be accompanied by numbness, tingling, or just weakness in the ability to move the foot and ankle. This can even make it feel like the foot has become a numb bag of bones just flapping on the ground with each step.

ANATOMY

In an overly simplistic view of the anatomy of the lower leg, you can think of it as two long bones (your shin bone–the tibia–and another one you can forget) surrounded by muscles with tendons going down to the foot to make it move in all different directions. All of these muscles are enclosed in wrappers called fascia that hold the bundles together. (Think of it as being like tight cellophane around a few chicken breasts.) In the lower leg, there are four compartments. One in the front, one on the side, and two in the back (one deep and one not as deep).

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PHYSIOLOGY

Ok. So everything has its place, and does its job until, well, it doesn’t. That’s when it can go bad.
What exactly is happening with compartment syndrome in runners? We aren’t exactly sure, but we do know some of what is going on. The prevailing idea is that when you exercise, your muscles fill with blood, and when this expands and runs out of room (remember the chicken in the cellophane), it puts pressure on the small arterioles (small arteries) going into the muscle. This causes them to tighten down or even close off, decreasing their nutrient supply. Without oxygen and food, the muscles start “screaming,” and this equals pain. The numbness and tingling may be resultant of pressure on the nerves that run in each of those four compartments. (When you squeeze nerves, they either get numb or start causing pain.) In CECS, it is thought that there is more expansion of the muscles than the fascia wrapper will allow, causing pressure to build to this painful level. Some newer studies not yet published suggest there may be a component of deficiency of one of the major tendons (Tibialis anterior) that could predispose someone to this condition, but this may not account for the whole condition. Research is ongoing.

DIAGNOSIS

The gold standard to get the diagnosis of CECS involves a physician putting tubes into those different compartments and monitoring the pressure both while resting and while exercising. There are other emerging diagnostic imaging studies like MRI and Bone Scans which show promise, but for these, you’d have to rely on radiologists and physicians specialized to recognize the subtle changes that occur with CECS.

TREATMENT

Traditional treatment has been a fasciotomy (essentially cutting that cellophane wrapper). This can be done with large incisions, or with newer techniques that are minimally invasive. These treatments have shown about an 80% success rate. Other non-surgical treatments often tried, but with limited success, include: anti-inflammatory drugs, stretching, prolonged rest, ultrasound, electrical stimulation, orthotics, and massage. But one nonsurgical treatment may have promise.

CECS4 300x227Image from Wikipedia Commons

Changing Gait

There is research out of West Point that showed significant improvement in patients with CECS who transitioned to a forefoot strike gait. This was a small study, but the participants showed a dramatic decrease in pain and increases in their running distance of over 300%.

The thought is that this improved function lies in the difference in foot and knee position at ground contact. Other research has shown that anterior (front) compartment pressures are significantly influenced by running style — and anterior compartment pressures were significantly increased with a hindfoot-striking gait. So picture a full-knee extension combined with full ankle dorsiflexion (landing with your ankle bent and your foot up) at heel strike. Changing to a forefoot strike, like what is pictured below, may reduce the eccentric activity of the front compartment muscles, thereby reducing the pressure on this compartment.

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Chronic Exertional Compartment Syndrome is a condition not often brought up when talking about running injuries or problems, but might start gaining traction with running clubs. There is well documented evidence of improvement with surgery, but changes in gait may be effective in reducing symptoms without surgery. More research will shed light on the exact processes involved with this condition, and more nonsurgical treatments may possibly emerge.

Friday, 16 February 2018 19:40

2018 Winter Olympics: Foot Problems Report

Winter Olympics and Foot Problems

David Collard DPM MHA

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As we are nearing the end of winter in some of the coldest weeks of the year, the 23rd Winter Olympics is in full force…and I’m loving every minute. If you are like me, you live for the Olympics and are captivated by the toughness, skill, passion, and the even the heartbreak of the athletes who put countless hours into their sport. Every two years, I feel like I can’t get enough.

To feed my temporary addiction, I looked a little closer at some of the athletes and their foot problems; in today’s blog post I’ll cover a few highlights of what can happen to the foot during sports and what it means for the future of these athletes.

Figure Skating

Figure Skating can be very hard on the feet and lead to injuries. Much like with other professional sports, some figure skating injuries can even end careers or limit top performance.

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Just before the U.S. Figure Skating Championships last year, Adam Rippon sprained his left ankle and fractured his fifth metatarsal bone in his left foot. The injury occured while hopping up and down to warm up his legs. His foot was immobilized. During his months-long recovery, he stated that he realized that much of the reason for the fracture was his poor diet. Adam admitted to trying to drop much of his weight with drastic dieting measures and eating meals very low in calories. He states he decided to change his diet because he suspected the unhealthy eating regimen had contributed to his injury. “I think I had a stress fracture before I broke my foot, and I think that was absolutely because I was not getting enough nutrients.”
The injury led to his withdrawal from the championships. His winning the US Nationals and now competing in the Olympics is his great return.

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Another well-known skater at the Olympics and a previous European champion, Russia’s Evgenia Medvedeva, had a similar metatarsal stress fracture in her right foot. This happened less than four months ago, leading into the Olympics. Medvedeva was placed into a cast to allow the bone to heal properly. Unfortunately, she was unable to skate for 2 months, missing both the Grand Prix and Russian Nationals. While immobilized, Zagitova, Medvedeva’s 15-year-old training partner and the World Junior champion, has shown to be a new Olympic power.

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Stress fractures are due to several factors, usually from low bone mass, deterioration of bone architecture, and fragile bones. Over time, the bone doesn’t respond well to normal mechanical stresses–like skating routines or simple warm-up exercises–and they crack. While many things can lead to stress fractures, in athletes this is usually tied to poor nutrition.

Snowboarding

Unfortunately, Katie Ormerod is out of the games this year with a fractured right heel. She is part of the Great Britain snowboarding team competing in Slopestyle. She is an upcoming star for Great Britain, having become the first Briton to win a World Cup big air title last year and also coming in third in slopestyle at the 2016 X Games in Aspen.

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She suffered this major injury on February 7th during a training session in Seoul, with only a few days before the opening ceremony. Katie exemplifies the toughness of these athletes, having fractured her wrist the day before while training. She had major foot surgery the following day to put the two pieces of her heel back together, which had been split in half. Healing from this type of injury can take several months with cast immobilization after the surgery and with gradual rehabilitation.

olympics5[Images found on Ormerod’s Facebook Page]

Sports and exercise are great for the body, but can be demanding at the highest levels, and sometimes accidents happen. But it is important to remember to have proper nutrition and eating enough calories and vitamins to build strong muscles and bones to keep you going. Remember to have the proper footwear for the sport! (I couldn’t resist.) Injures can put you down for weeks to even months. Take precautions and wear all safety equipment the sport demands so you can keep being active for many years to come. And, if you need me and I’m not in my office treating people, I’ll be in front of my TV watching the amazing athletes of the 2018 Games.

Hookworm, also know in the medical world as Cutaneous Larva Migrans, has recently been in the news. A couple from Canada, Eddie Zytner and Katie Stephens, recently went on a vacation to Punta Cana, Dominican Republic. It was there that they contracted this parasitic worm in their feet and later posted pictures on Facebook, after which several news outlets picked up their story, putting it back into the public eye.

Eddie and Katie initially noted continuous itching and thought they were being bitten by sand fleas, but later, their symptoms worsened and their feet started to swell, change colors and they noticed tracks through their skin.

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Why have I never heard of this?!

If you live in North America it’s really not a big deal for most people thanks to the sanitation improvements of the 20th century (It’s all about poop control), although hookworm is actually a worldwide problem according to the CDC. It only lives in very warm, moist environments like the tropics, making it rather common among tourists who visit tropical beaches. But there are specialists who do see cases in the warmer parts of the southeast like Florida. The two most common species of hookworm are Ancylostoma duodenale (typically from dog and cat feces) and Necator americanus.

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Symptoms include itching, burning, pain, swelling, blisters, and track marks with wiggling worms (cutaneous larva migrans means: larva that move around in your skin). Nightmarish, I know!

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Life Cycle.

(This diagram is for geeks like me) Eggs are passed in the stool and fall into the nice warm sand/soil and hatch in 1 to 2 days. The released larvae grow in the feces/sand/soil, and after a week they become developed enough to get into your skin. The larvae penetrate the skin and can eventually make their way into the bloodstream, into the lungs, and eventually into the small intestines where they can set up shop and send out more eggs, starting the whole beautiful cycle again.

Treatment.

Hookworm can usually quickly be treated with oral medication with few side effects. (Sigh of relief!) Our friends from Canada were eventually able to get the right diagnosis (three docs later) after they returned home and got started on medication. They have been staying off their feet while they recover and their physician monitors their progress.

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How to Avoid It.

The CDC says the best way to avoid a hookworm infection is not to walk barefoot in areas where hookworm is common and where there may be human and animal fecal contamination of the soil/sand. (Gross.) They also recommend avoiding ingesting soil. (More gross.)
Since we are talking about things that can hurt your feet on the beach, there are also other types of parasites (e.g., strongyloidiasis), or jigger fleas which can burrow into your feet, not to mention all the possible injuries from rocks, metal, glass, and insects. If it is an unfamiliar beach in the tropics, it may be best to protect your feet with water shoes.

If you or someone you know has some strange condition after travel to a tropical area or one of the many injuries which can happen on the beach, we are here to help. Please contact us at one of our locations near you and schedule an appointment.

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