The plantar plate is an important structure of the first metatarsophalangeal joints in the foot. The plantar plate is part of the plantar fascia and is a thickening of the plantar aspect of the joint capsule. Plantar plate dysfunction is a common cause of pain under the first metatarsophalangeal joint. Ultrasound often demonstrates a plantar plate tear that may need surgical repair. The treatment of a plantar plate dysfunction is initially to use something like a metatarsal pad or strapping to plantarflex the toe to allow it to heal. Often a metatarsal pad may need to be used long term.

Sesamoiditis is a common problem in athlete with high loads under the first metatarsophalangeal joint. It is not really a sesamoiditis, as it is an inflammation of the soft tissues around the sesamoid bones at this joint. The pain of sesamoiditis is usually on direct palpation of the area. Imaging is sometimes useful to rule out a fracture of the sesamoid bone. The reason for the higher loads is due to the structure of the foot, most common a higher arched foot with a plantarflexed first ray which when combined with higher levels of activity can create this problem. Sesamoiditis can also be more common in sports that involve pivoting on the first metatarsophalangeal joint such as tennis. The initial treatment if sesamoidtis is the use to offloading techniques in foot orthoses to reduce the load on this structure. Sometimes adding an anti-shear cover to the foot orthoses will help with the pivoting motions. If conservative measures are not successful, then surgical management such as elevating the first metatarsal or the more drastic measure of removing the sesamoid have been tried for sesamoiditis.

This is a common problem in athletes. Sinus tarsi syndrome generally occurs in two situations that are almost opposite to each other. One is that the structures in the sinus tarsi can be damaged during an inversion ankle sprain. Often this problem goes undetected until some of the original ankle sprain settles. The other condition is an excessively flat or pronated foot that pushes the subtalar joint to its end range of motion and compresses the tissues in the sinus tarsi. In both cases there can be a feeling of instability and pain is generally palpated over the sinus tarsi on the lateral side of the ankle joint.

Treatment is mostly done with physical therapy in both situations. Foot orthotics are generally needed if the causes is a flat pronated foot. Occasionally a series of steroid injections into the sinus tarsi will be helpful.

For the latest on sinus tarsi syndrome, see Podiatry Arena:
What actually hurts in sinus tarsi syndrome
Foot orthotics for sinus tarsi syndrome

Exercise for those with diabetes is extremely important. It is important for general health and fitness as well as weight control. There are also some diabetes specific benefits of exercise for those with diabetes such as assisting in glucose controls and also in type two diabetes its also has the affect of increasing insulin sensitivity. Those with diabetes who exercise need to take precautions such as the timing and amounts of insulin injections relative to the timing of exercise. There is one other problem that those exercising need to be conscious of and that is the ‘diabetic foot’. The foot is at increased risk for damage because of the diabetes and that damage may not be detected. Stress fractures are more common in those with diabetes and in the worse case; a Charcot foot problem may develop. Those with diabetes and sign of peripheral neuropathy are at greater risk for diabetic foot problems and are probably better off avoiding weight bearing exercise and take part in activities like cycling and swimming.

The April 2010 edition of  Podiatry Today magazine has a good update of the latest concepts in Medial Tibial Stress Syndrome by Kevin Kirby. Two interesting key concepts that came through in the review is that there is no agreement on exactly what is the pathological process in the condition – is it a soft tissue traction issue or a bone stress reaction due to tibial bending actions?  The tibial bending moments are a recent consideration in the risk factors for this condition. If medial tibial stress syndrome is due to tibial bending moments, then this has implications for the use and prescription of foot orthotics and running shoes to alter these bending moments. There has been some discussion on this concept for medial tibial stress syndrome.

In a recent edition of Radiological Medicine there is a new study that investigated the use of a weightbearing MRI to assess those with plantar fasciitis. They were able to report that the changes in the MRI signal that was associated with plantar fasciitis when compared by blinded examiners in those without plantar fasciitis. Unlike the usual ultrasound finding, the thickness of the plantar fascia was reduced due to stretching in the weightbearing position compared to the supine position. This is an importantt observation given the emphasis  that gets put on the thickness of the plantar fascia with ultrasound measurement which is done non-weightbearing. The important finding in this study was of 15 cases that they looked at, 4 had partial tears of the plantar fascia visible on the weightbearing MRI. This has implications for sports medicine as a number of the cases of plantar fasciitis that are seen, may infact be partial tears.

There has been a lot of recent attention given by the media to barefoot running. Recent publications by Kerrigan et al and Liebermann et al have been widely promoted in the news media and on running barefoot websites. Both studies have been badly interpreted and misrepresented by the media and barefoot running websites as showing something that they did not show. Liebermann even went to the extraordinary step of posting a disclaimer on his website about how his research was being used! See these two analyses on Podiatry Arena: Barefoot Running Debate and The Effect of Running Shoes on Lower Extremity Joint Torques and these two from an anti-barefoot running website: Hook, Line and Sinker and Yet another study they fell for!

Despite claims made by the barefoot running community, there is no evidence that running shoes do any harm. There is also not any evidence yet that running shoes do any good either. There is also no evidence that barefoot running is any better than shod running. Barefoot runners also appear to be somewhat irrational in the way they involve themselves in discussions of barefoot running, having been compared to zealots! For more, see these videos on barefoot running.

Dieting to win or to be thin? A study of dieting and disordered eating among adolescent elite athletes and non-athlete controls
M Martinsen, S Bratland-Sanda, A K Eriksson, J Sundgot-Borgen
Br J Sports Med 2010;44:70-76 doi:10.1136/bjsm.2009.068668

Objective: To examine the prevalence of dieting, reasons for dieting and prevalence of disordered eating among adolescent elite athletes and age-matched controls, and to examine the differences between athletes competing in leanness and non-leanness sports.

Methods: First-year students of 16 different Norwegian Elite Sport High Schools (athlete group, n?=?682) and two randomly selected ordinary high schools from a county representative of the general Norwegian population (control group, n?=?423) were invited to participate in this cross-sectional study. A total of 606 athletes and 355 controls completed the questionnaire, giving a response rate of 89% and 84%, respectively. The questionnaire contained questions regarding training patterns, menstrual status and history, dieting, use of pathogenic weight control methods and the drive for thinness (DT) and body dissatisfaction (BD) subscales from the Eating Disorders Inventory.

Main outcome measure: Disordered eating, defined as meeting one or more of the following criteria: DT score ?15 (girls) and ?10 (boys), BD score ?14 (girls) and ?10 (boys), body mass index <17.9 kg/m2 (girls) and <17.5 kg/m2 (boys), current and/or ?3 previous efforts to lose weight, use of pathogenic weight control methods and self-reported menstrual dysfunction.

Results: A higher prevalence of control subjects were dieting and classified with disordered eating compared with the athletes. An improvement of appearance was a more common reason for dieting among controls compared with athletes. No differences in dieting or disordered eating were found between leanness and non-leanness sports athletes.

Conclusions: Self-reported disordered eating is more prevalent among controls than adolescent elite athletes, and losing weight to enhance performance is an important reason for dieting among adolescent elite athletes.

 

Press Release:

Misuse of non-steroidal anti-inflammatory drugs by athletes
High school winter sports athletes’ need to baby their immune systems

NSAIDs: Take ‘em early and often when competing? Think again. Athletes’ superstitions and rituals can help them get psyched up for contests, but when these rituals involve non-steroidal anti-inflammatory drugs (NSAIDs), which many athletes gobble down before and during events, they could be causing more harm than good. “These agents are treatments for the symptoms of an injury, not the injury itself,” says Stuart Warden, whose research at Indiana University focuses on musculoskeletal health and sports medicine. “They may allow an athlete to exercise or train at a certain level, but pain occurs for a reason. It is basically the body’s mechanism of saying, ‘Hang on, you’ve got some sort of injury that should not be ignored.’” NSAIDs are recommended for use after an injury to reduce swelling or pain. Studies have found that many elite athletes, however, take these over-the-counter drugs — and often several different kinds — before contests and challenging workouts because they think they will reduce anticipated inflammation and soreness that could occur after the event. Warden says there is no scientific evidence for this prophylactic use of NSAIDs. Such misuse, however, can cause a range of problems, from interfering with healing and inhibiting the body’s ability to adapt to challenging workouts, to the development of stomach ulcers and possibly an increased risk for cardiovascular problems, says Warden, assistant professor in the Department of Physical Therapy at Indiana University-Purdue University Indianapolis. The larger the dose and the longer duration of NSAID use, the greater potential for these risks. Warden warned against the misuse of NSAIDs in an editorial published earlier this year in the British Journal of Sports Medicine. “I want people, including recreational athletes, to think about the perceived benefits versus potential risks of taking NSAIDs, and to ask themselves why they are taking these agents,” said Warden. “They need to ask, ‘Do the benefits outweigh the risks?”

• Background. NSAIDs interact with the body’s chemistry at a cellular level by inhibiting the cyclooxygenase (COX) isozymes. The COX isozymes are critical for the synthesis of prostaglandins, which have important functions in the gut and cardiovascular system, as well as during inflammation and the adaptive response of the musculoskeletal system to stress. NSAIDs may reduce pain and inflammation following injury by inhibiting COX isozyme-induced prostaglandin synthesis; however, as they circulate within the body indiscriminately, rather than localizing to the source of an athlete’s specific aches and pains, they may produce undesirable side effects. With regular misuse, athletes face extreme and severe risks, such as the development of ulcers, potentially fatal problems with renal blood flow, and increased risks for cardiovascular problems. On a lesser scale, they could actually increase their risk for injuries because their bodies are less able to adapt to rigorous workouts — and healing could take longer.

Warden said NSAIDs should be taken as directed — in the recommended dosages and for no more than a week after an acute injury that involves swelling and pain. “But to take the drugs before every run and throughout the year is a concern. You need to think of pain not as a hindrance, but as a signal that something is not quite right,” he says, adding that, “NSAIDs should not be used at the expense of a thorough assessment of an injury by a trained professional, such as a physical therapist or physician.”