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Running a marathon with MTSS

Discussion in 'Biomechanics, Sports and Foot orthoses' started by cheryl, Apr 2, 2008.

  1. cheryl

    cheryl Active Member


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    Hi

    I have had a 42 year old chap in this morning who has a hisory of tibial sterss syndrome. It started when his running shoes began to wear out. He bought new trainers and improved, then when they wore out he bought the wrong trainers by mistake which made it worse. He is now back to his nrmal good neutral trainers but hasnt been able to run.

    He is due to take part in the london marathon in less than 2 weeks and is going to carry on due to rasing so much money for a charity close to him and the trouble he took to get in to the race.

    He has tight posterior leg muscles and hamstrings, tibial varum with too much internal tibial rotation. His knees will even knock together after tiring during a run.

    I have issued him with some prosteps with the kirby skive encorporated but have not added any posting as this alone seemed to improve foot position and hubscher.

    I have also advised on gastoc/soleal and hamstring stretching.

    Obviously the marathon is so close i dont have much time to help him. Is there anything I or he can do to reduce pain and injury during the marathon or before. (apart from not running).

    I would appreciate your advice and i can forward it to him.

    Thanks
     
  2. Given that the marathon is less than 2 weeks away, he should be near the point of easing right down on his mileage now anyway. In my experience with this type of patient, if you can get them to the start line, they'll get through it when the adrenaline kicks in on the day. Advise running on softer surfaces e.g. track or treadmill, anti-inflammatory medication, iceing etc. If it's not a compartment syndrome, I often use a spiral strapping up the shin. I've also had reasonable results with neoprene compression sleeves used in conjunction with the above.

    I'm sure Kevin will chip in more here (if you provide your name it would help).

    Interesting that you think he needs neutral trainers and yet have issued medial heel skive devices. What is your rationale for this?
     
  3. BTW, when did you issue him with the preforms? Some might argue that to get a runner habituated to a pair of preforms and ready to run a marathon in them will take longer than 11 days. Personally, I think it is a pretty ambitious time-scale, given that he's not likely to be doing that much mileage in this last week or so. What advice did you give re: habituation and break in?

    Vaseline anyone? He may well need it.
     
  4. Admin2

    Admin2 Administrator Staff Member

  5. I suppose I am a rather strange man, expecting someone to provide me their real name in order for me to decide whether I am going to take more time away from my family to contribute more posts to Podiatry Arena than I already have. Sometimes, I ask myself....is all this time I spend contributing to Podiatry Arena worth it??
     
    Last edited: Apr 3, 2008
  6. Kevin, I know where you are coming from which is why I recently took a couple of weeks off from Podiatry Arena. I've said before anonymity negates accountability. I'm in the "lets know who we are talking to" camp.

    P.S. you are a rather strange man, but I suspect you've known that for some time.:drinks
     
  7. cheryl

    cheryl Active Member

    Dear all

    Please do not see me as ignorant in not supplying my real name, it was not my intention to remain anonymous, unfortunately it was a bit of a side effect of running a bit of a hectic nhs biomechanics clinic. My name is Cheryl Clark and i work for Torbay PCT.

    Firstly, i will explain my rationale for the continuation of neutral trainers. He first developed this condition as a pair of old trainers began to wear out, he then bought a new pair of neutral trainers which releived his symptoms (at the time), when these wore out he tells me the symptoms returned and began wearing antipronatory trainers by mistake, he says that these made matters worse and since then hasnt been able to recover. Im sure all this coincided with a running distance increase, all road running.
    I dont quite have an explanation for this other than maybe too much too soon???? What do you think?

    Secondly i realise i am a bit ambitious in issueing the preforms at such a late date, i did explain about the building up time, which we normally suggest is structured over at least a week and to do this before running in them. But I dont have this time, i dont expect he will be able to run in them yet but maybe some releif during day to day activities will help, im clutching at straws here.

    I will see him again early wednesday morning but if there is anything he can do before then, i will contact him.

    Thanks for your help, and all time taken to reply to me is appreciated, honest, now be nice!

    Cheryl
     
  8. Cheryl:

    First thing to consider is the proper diagnosis in your runner-patient. Are you certain this patient has medial tibial stress syndrome (MTSS) and not a medial tibial stress fracture? Clinically, if the only time that patients with medial tibial border pain experience pain is when they attempt to run, but not when they walk, then this generally means they have MTSS and not a medial tibial stress fracture. However, this clinical scenario is not always 100%. Therefore, I would suggest a bone scan or MRI scan be performed before you send him out to run the marathon with a medial tibial stress fracture and it becomes a frank fracture of the tibia. Remember that intense pain is meant to be the body's signal to stop activities and is a very useful indicator of potentially serious tissue damage.

    If you have determined that the pain is caused by MTSS, then here is what I would do with the patient. Have him discontinue running completely until the day of the marathon. He may bike ride and/or do elliptical trainer 1 hours a day without pain to maintain his cardiovascular fitness. Have him do no aerobic exercise for the day before the event and no more than 15 minutes of aerobic exercise for 2-3 days before event, along with carbohydrate loading to optimize the glycogen storage in his liver and muscles. Have him also ice the medial tibial borders 20 minutes twice daily until the day of the event.

    As far as foot orthosis modifications, I would try adding a varus forefoot wedge of 3-5 degrees to the symptomatic side(s) under the 1st-4th metatarsal heads in order to increase the ground reaction force on the medial forefoot earlier in the running gait cycle. This orthosis modification along with further inversion of the foot orthosis will help decrease the valgus bending moment on the tibia and/or decrease the tensile forces on the medial tibial border that are the causes of the pain your patient is experieincing. In addition, I would review the lecture on MTSS and medial tibial stress fracture that I gave in 2005 in Melbourne to better acquaint yourself with this common running injury.
     
  9. cheryl

    cheryl Active Member

    Kevin

    Thank you for your informative reply. I steared away from a stress fracture as he has the pain quite continual lately even in walking, the pain can also radiate up and down the area. I will read up on your lecture more this evening when i get home to refamiliarise myself.

    I had advised some non weight bearing cardio vascular exercise for now to keep up his fitness, but i will forward all your advice to him straight away.

    I ll keep you informed
    Thanks again

    Regards

    Cheryl
     
  10. cheryl

    cheryl Active Member

    Sorry i forgot to say that the pain was mainly during running before but very recently has been during walking.

    Cheryl :)
     
  11. Cheryl:

    If the pain is also occurring during walking then do not allow him to run the marathon since this is likely to be a tibial stress fracture until proven otherwise with MRI or bone scan.
     
    Last edited: Apr 4, 2008
  12. Kevin, I was once told by an "expert" that a bone scan cannot differentiate effectively as it just shows a "hot spot" in both cases, is this your experience?

    Cheryl, I'm not too hot on NHS waiting times these days, but what are the chances of getting either of these imaging studies done in the next week?

    So Cheryl, do you think you can talk him out of it? Or, do you think he'll run /walk around the 26 miles anyway? I've seen cases of avulsion fractures of the styloid process at the finish line in London that occurred during the first mile!! Marathon runners are very strange;)
     
  13. Dean Hartley

    Dean Hartley Active Member

    To put my 'two cents' in here in regards to bone scans and MTSS. I have suffered from this condition for several years on and off. In regards to the bone scan and tibial stress# I have noticed it to be a localised, very specific hot spot (focal uptake), where as the bone scan which demonstrates MTSS has hot spots diffusely spread along the medial border of the tibia (or everywhere in my case). This is my limited knowledge on the subject.

    Actually I will post my bone scan here, may help the discussion slightly.

    I think the attachment worked, let me know if you can not view it.
     

    Attached Files:

    Last edited: Apr 4, 2008
  14. Triple phase radionuclide imaging of medial tibial stress fractures will demonstrate a more focal-higher intensity pattern of uptake on the medial tibial border on the delayed image. On the other hand, triple phase imageing of medial tibial stress syndrome (MTSS) will demonstrate more of a linear-lower intensity pattern of uptake along the medial tibial border on the delayed image. Unfortunately the bone scan may be equivocal when the pattern is moderately focal and of moderate intensity. See attached images which show a medial tibial stress fracture in the distal 3rd of the tibia (left) and a patient with the more diffuse pattern of MTSS (right).

    MRI scans are less invasive and more specific than bone scans. However, MRI scans are 3 times more expensive than bone scans here in the States. Here is the grading system for MTSS and tibial stress fracture proposed by Fredrickson et al using MRI scan:

    Grade 1: mild to moderate periosteal edema on T2 images only
    Grade 2: more severe periosteal edema with bone marrow edema on T2 only
    Grade 3: moderate to severe edema of both periosteum and marrow on both T1 and T2 images
    Grade 4: low signal fracture line with severe marrow edema on both T1 and T2 images

     
    Last edited: Apr 4, 2008
  15. cheryl

    cheryl Active Member

    Thank you all for your replies.

    Simon, as ever NHS waiting times are not the quickest, so the liklihood of me getting an imaging study done this week is slim, but i shall see what i can do.

    Also I have about the same chances of talking him out of running.

    I ll make a few phone calls today and keep you posted

    Thank you

    Cheryl
     

  16. Cheryl:

    In your chart notes make sure that you document that you told him not to run the marathon and that if he did choose to do so against your medical advise and suffered a tibial fracture, that he could end up with a non-union, leg surgery and not be able to run for over a year after the marathon. Good documentation is the key to keeping patients from successfully using the legal system to place blame on you for their stupid mistakes.
     
  17. cheryl

    cheryl Active Member

    Thank you Kevin, good advice about documentation. Its paramount these days.

    Ive had a good ring around various health professionals that i work with and the wait for imaging is a good 5-8 weeks in the nhs and no one is any wiser of methods to fast track urgent cases apart from suggesting private treatment, which is still unlikely to be quick enough in this case.

    I will see this patient the day after tomorrow and see how things are. I have already sent lots of advice to him in the mail that he can try.

    Cheryl :rolleyes:
     
  18. Thus demonstrating the gulf between health care provision in this country with the USA (and probably the rest of the western world).

    To be honest, I'm pretty amazed that this guy was seen by NHS podiatry services in the first place, is he diabetic?:rolleyes: How long was he on the waiting list?

    Ultimately, you are not his mother, and he'll do what he wants to do with the information you offer. Seen half a dozen like this today including a female nurse with chondromalacia who "couldn't possibly give up/ reduce her 6 high impact/ loading exercise sessions per week"- joy :bash:
     
  19. cheryl

    cheryl Active Member

    Hi Simon.

    Yes what a divide between britain and the U.S., what we could do with a system like that!
    No this chap is not diabetic, we will see most patients with a biomechanical need despite there medical history, usually for a short course of treatment.

    And you're right, I must stop mothering my patients, i think being 6 months pregnant has something to do with it!

    Cheryl :morning:
     
  20. cheryl

    cheryl Active Member

    Well, he came back this morning with not a great deal of change. He doesnt have pain when walking now and only feels it when running and the day after.

    He feels like he needs to run to see how he is rather than wait for Sunday, but I expect this is a common anxiety for first time marathoners who are advised to ease off for the week leading up to the run.

    He is stretching and icing etc and will try the neoprene compression sleeve. I think he will make it and I have more peice of mind that there is no fracture. Although we have discussed all points.

    Thanks for all you help, greatly appreciated.

    Cheryl
     
  21. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    Wasn't it the late George Sheehan who coined the phrase that runners are like farmers who want to pull up the carrots to see if they are growing?
     
  22. cheryl

    cheryl Active Member

    What a great analogy, he felt just like that.

    Cheryl
     
  23. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    But the problem is that after you have pulled the carrot up, you can not put it back in the ground.
     
  24. I always enjoy the ones who come in the week before the Plymouth 1/2 marathon or the Great West Run, who have picked up an injury the weekend before when they have "had" to run the whole course "to see if they can do it and give themselves a target to beat during the actual race" -Idiots.:bash:

    If he runs and decides he can't make it, that's not such a bad thing, right? The reallity is that he'll run, find that it hurts and still run the marathon anyway.:bash: So wouldn't it just be better to limit the damage??????

    At London, he won't be able to run for the first few miles anyway: way too many people to get into stride. He'll probably walk & run intermittently the whole way round and be sore as hell for the next week or so, but feel great in the same way that a masochist does after a good hiding. He'll then start thinking about doing another one :deadhorse:

    You've done your job, sleep well.

    Athletes: you need to be 50% podiatrist & 50% psychologist. AND, too many undergrads want to be "biomechanics specialists" but at the same time skip/ hate psychology lectures and "don't see the relevance". Dream on.:cool:
     
  25. Yes you can. Might not grow though...;)
     
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