Essential Insights On Developing Expertise In Podiatric Sports Medicine

   Over the decades, the concept of podiatric sports medicine has evolved. In years past, educators at podiatry schools directly and indirectly implied that it was primarily making orthoses for runners. Certainly, this was the case in the early 1970s running boom as George Sheehan, MD, a cardiologist, urged runners to seek the biomechanical benefit of foot orthoses.

   However, as more patients from other sports gravitated to podiatrists for biomechanical help, the knowledge base of the practitioner had to expand. One of my mentors, John Durkin Jr., DPM, advised me, “Do not just get good at treating runners.” Furthermore, when athletic patients had to undergo surgery, they often wanted a doctor with an understanding of their ability to return to sport. A current podiatric sports medicine practitioner has to be a “triple threat” in that he or she needs to know when and how to incorporate rehabilitation, orthoses/shoes and surgery into the treatment regimen.

   In my opinion, the current training programs in undergraduate podiatry school have minimal exposure and lectures in sports medicine. Most schools do not have formalized lectures. In this case, students should try to attend meetings conducted by sports medicine groups such as the American Academy of Podiatric Sports Medicine, be involved in the sports medicine clubs, and read journals such as the Journal of Sports Medicine (British and American versions), Medicine and Science in Sports and Exercise, and the Journal of Orthopedic and Sports Physical Therapy. In addition, the student should try to shadow sports medicine practitioners including orthopedists, physical therapists and athletic trainers. This is exactly what I did and still do.

   Doctors can always have the excuse they are too busy but there is no time like the present, even for established practitioners who want to learn. Residencies also have minimal exposure to sports medicine unless you are fortunate enough to train under a residency director who has strong knowledge of these issues. I did my residency training under John Grady, DPM, who is truly one of the few podiatrists to be a specialist in all aspects of podiatry.

   Post-residency, there are a few certified sports medicine programs such as the one I direct. Even without formal rotations, one can get training. There are two great sayings: “Never let your education get in the way of your learning” and “What you learn after you know it all is what counts.”

Keys To Being A Successful Sports Medicine Podiatrist

   One should know when an orthosis will treat or actually cure something. Unfortunately, orthoses for sports injuries have not been studied with rigid criteria. For instance, I know I can modify an insert or orthosis to take the pressure off a toe joint or metatarsal. However, we have not studied cohorts with and without this modification to see if one group gets better faster or not. The reality is, in sports medicine, faster is better.

   As a podiatrist who specializes in sports medicine, the most common injuries I see are ankle sprains, Achilles tendon ruptures and tendonosis, stress fractures, ankle osteochondral and transchondral defects, Lisfranc injuries, hallux rigidus and peroneal tendon pathology. Other than hallux rigidus, very little in the formalized educational process has traditionally concentrated on these pathologies.

   Physicians should spend time with practitioners who treat these conditions. If one cannot treat them surgically, you can at least recognize them and facilitate a possible referral. I can honestly say one can stay busy full-time just treating these entities as a podiatrist.

   One also has to know if the shoe gear is helping or hurting the situation. A sports medicine podiatrist should be as familiar with shoe gear as he or she is with medication.

   Also bear in mind that other aspects of treatment can help or hurt a situation. A classic example is someone who continuously gets physical therapy modalities or various adjustments (orthoses or manipulation) for lateral or medial foot pain when it turns out he or she has a tendon tear or a stress fracture. In these situations, surgery is often indicated because as mentioned earlier, faster is better. In fact, treating some injuries such as Achilles ruptures and Jones fractures non-surgically could be construed as “aggressive,” even though it is also considered “conservative.” For the sports medicine patient, surgery for these types of injuries is generally accepted as routine treatment and “conservative” treatment would not be ideal.

   With the U.S. population aging and realizing the need to continue to exercise, physicians are recognizing more degenerative conditions. Often runners with knee pain receive foot orthoses, usually with medial rearfoot posting. With our long-term patients, what Brian Fullem, DPM, and I have personally noticed is that patients with genu or tibial varum can develop medial meniscal wear and degenerative joint disease. Rearfoot valgus posting has proven to be beneficial for patients with this condition.

   We assume orthoses really do help in the treatment of knee pain. However, in the age of evidence-based medicine, we need more proof. Dr. Fullem and I have documented the healing time of other sports injuries such as plantar fascia rupture and navicular stress fractures in major orthopedic journals, and we look forward to a longitudinal study on orthoses for knee pain.

   In speaking with two other well-known podiatric sports medicine specialists, Richard Bouché, DPM, and Marque Allen, DPM, they feel what sets podiatric sports medicine apart is the ability to make a rapid and accurate diagnosis, and then offer a full spectrum of up-to-date, efficient treatment options including non-surgical and surgical approaches. The margin of error is small and timeliness is paramount. Athletes appreciate the one-stop shopping aspect of their care and the sports medicine podiatrist of the present era is someone who can help them.

Balancing Urgency With Caution In Returning Athletes To Play

   This could not be more apparent than my cohort of patients at this year’s Olympic track and field trials. Thirty athletes/patients competed. Ten of these patients used custom foot orthoses, eight had surgery and five utilized extracorporeal shockwave therapy.

   Fourteen of these patients made the Olympic team. Five other patients could not compete because their injuries (such as ankle osteochondral defects and having had retrocalcaneal surgery less than 10 months prior). Three patients who did compete did so with navicular “stress reactions” that were diagnosed via magnetic resonance imaging (MRI). Follow-up computer tomography (CT) scanning revealed that all three had actual stress fractures.

   This is a common pattern, particularly with high-level athletes. They get MRIs very rapidly and if no fracture is apparent, they continue to participate. Unfortunately, a doctor may tell them, “Let pain be your guide,” but high-level athletes usually have a high pain threshold. The CT scan shows bone alignment and fractures more accurately. Therefore, with elite athletes, it is not uncommon to order both, again on the same day, to get a rapid and accurate diagnosis. This is paramount to facilitate ideal treatment.

   Urgency and speed are part of sports medicine. One needs to be available to these patients not only daily (including weekends) but sports medicine physicians also need to be willing to see them pro bono sometimes, such as on the field or at hotels.

   It is not only important to order tests and get accurate results quickly, but it is also important to do surgery and get custom devices as well. During a season, a one- to two-week delay can make the difference between athletes getting back to their sport this season as opposed to the following year.

   When it comes to orthoses, it is important to use an orthotic lab that has quick turnaround. Plus Labs, the lab I use, has a one-day turnaround. With one day express shipping, I can cast a patient for orthoses on Monday and have the patient back in the office by Thursday. The lab can also mill devices thin and light enough (less than 1 ounce) to fit into all types of sports shoes and match the insoles exactly. Patients appreciate this speed and efficiency. This is true not only for professional athletes but high school students and those trying to make it to their first marathon.

When An Athlete Comes To You For Another Opinion

   When it comes to surgery for athletes, I do an even more thorough workup than usual. It may be construed as flattering that patients are seeing you as the “nth number” opinion with various studies and diagnoses, but you need to come up with your diagnosis from “scratch.”

   This was the case with Nike’s top distance runner, who had seen eight different types of doctors but none had looked at the imaging studies in combination or taken a weightbearing X-ray. Granted, she did have an unusual ossicle that I have never seen associated with the posterior tibial tendon at its distal insertion to the first cuneiform. However, it was apparent on both the CT and MR scans.

   After we excised the ossicle and repaired the tendon, the patient started an aggressive rehabilitation program. This included the use of a “G-trainer” at seven weeks post-op. The G-trainer is a special treadmill that reduces body weight so even an injured athlete can run sooner. She went on to break American records in distances from 3K to 10K and win an Olympic medal in Beijing.

   In addition to knowing about the availability of these devices that can facilitate rehabilitation, sports medicine podiatrists must have an ability to converse with the patient, coach, agent and rehabilitation specialists. One learns how to communicate with them through experience and exposure. Then collectively, this team draws up a timeline for the athlete’s return to activity.

Final Notes

   It also helps if you are a competitive athlete yourself. Patients will realize that you are trying to help them get better as soon as possible, and appreciate it. In fact, using this philosophy with all of your patients — facilitating a rapid return to their activities — gives credence to treating all of your patients like athletes. Who would not want to get better faster? As the astute Dr. Sheehan opined, “Everybody is an athlete. Some just do not know it yet.”

Dr. Saxena is the Fellowship Director in the Sports Medicine Department of the Palo Alto Medical Foundation in Palo Alto, Calif. He is also a consultant to Alter-G and Plus Labs, as well as a podiatrist for the Nike Oregon Project.

Editor’s note: For related articles, see “How To Develop A Thriving Sports Medicine Practice” in the September 2007 issue of Podiatry Today, “Can Foot Orthoses Help Improve Postural Control?” in the May 2007 issue and “Are Orthoses Effective Against Plantar Fasciitis In The Long Run?” in the September 2006 issue.

References:

1. Toda Y, Segal N, Kato A, Yamamoto S, Irie M. Effect of a novel insole on the subtalar joint of patients with medial compartment osteoarthritis of the knee. J Rheumatol. 28(12):2705-10, 2001. 2. Saxena A, Fullem B. Plantar Fascia ruptures in athletes. Am J Sports Med 32(3): 662-65, 2004. 3. Saxena A, Fullem B. Navicular stress fractures: a prospective study in athletes. Foot Ankle Int. 27(11): 917-21, 2006.