Editorial The 1970’s were a pivotal time for Sports Medicine. For reasons that are still unclear, long distance, especially marathon running suddenly developed as a popular recreational activity for many thirtysome- thing’s who had not previously considered themselves to be particularly athletic. The result was that the numbers o f entrants in road races such as the New York and London marathons and our own Comrades Marathon, suddenly jumped from a few hundred to tens o f thousands. Whilst this passion for marathon running has dissipated somewhat in the last 5 years, its influence is still felt with the growth in participation in diverse recreational activities including aerobics and other gymnasium activities, cycling, walking and hiking, and water sports. But perhaps the greater contribution ol the 1970’s to Sports Medicine was the acceptance o f podiatry as a crucial component in injury treatment and prevention especially in mechanically repetitive sports like running. Prior to the 1970’s, the management o f these injuries followed a traditional approach that focused exclusively on the site o f injury. No attention was given to an understanding o f why the injury hap­ pened in the first place. As a result, the majority o f injured runners in those years soon became ex­ runners. Fortunately the skills o f an evolving profession in North America soon began to seek answers in an unusual direction. These podiatrists spearheaded by D r Richard Schuster in New York and Drs John Pagliano and Steve Subotnick in California, inspired a revolution in our understanding o f how these injuries occurred. Their genius was to suggest that identifiable and correctable abnormalities in the lower limb could explain why these injuries were resistant to our conventional treatments which failed to acknowledge their importance. In this edition o f the Journal, guest editor Dennis Rehbock and his colleagues address these issues in the first edition o f our Journal ever to be dedicated exclusively to podiatry. We are also privileged to include a paper from one o f these inspirational podiatrists D r John Pagliano who describes his with management o f the iliotibial band friction syndrome, perhaps one o f the running injuries that is most resistant to therapy. His ideas will be o f value to all who struggle with this injury. Recently a local Cape newspaper carried the interesting opinion o f a leading politician who was dissatisfied with what he saw as the fragmentation o f medical services. His specific complaint was that prior to and following major hip surgery, he had not been referred for a programme o f exercise rehabilitation. Yet when, on his own initiative, he had availed himself o f this treatment, he had experienced substantial benefit. Whv, he wanted to know, was such referral not routine? Sports Medicine is leading the way in showing that sportsmen and women, regardless o f their ability, benefit most from a multi disciplinary approach, involving experts from a wide range o f fields. It is a pleasure for this multidisciplinary Journal, to provide our podiatric colleagues with the appropriate forum to display their expertise. Professor Tim Noakes Editor SPORTS MEDICINE JUNE 1997 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Guest Editorial Dennis Rehbock - Guest Editor T h is issue o f the Jo u rn a l is d evoted to podiatrie s p o ils m edicine. It gives me g reat pleasure to be the guest editor o f th is issue o f the Sou th African Jo iu n a l o f S p o rts M edicine. In So u th A frica we are a very sm all group o f p o d iatrists w ith an interest in sports m edicine and podiatrie sports m edicine. CXu- field o f interest h as developed over many years, based 011 A m erican podiatrie sports m edicine and our own experiences. Throu gh personal contacts, increasing involvement in treating sports injuries, and more recently the presentation o f podiatrie p ap ers at So u th African S p o rts M edicine Association ( S A S M A ) C o n gresses, we arc being recognised for oiu- role in the m anagem ent o f injured sportsm en and women. With the m odern m u lti-d isciplinary approach to the managem ent o f sportsm en and women, the importance o f biom echanical an alysis and treatm ent o f the feet and lower limb becom es vital for im proved perform ance and injury prevention and treatm ent. Mr B ernhard Zip fcl d escrib e s how forefoot varus, a common foot type, can influence su b talar joint pronation. T h is foot type c a u se s com pensatory ovcrpronation in the foot and may need b io m cchanical correction. B ernhard Z ip fcl is program m e le a d e r o f the Podiatry departm en t o f the T cch n ikon W itw atcrsran d and a p ractisin g p odiatrist in the West Rand. Mi- Mike E ls p ro vid es us with a review o f sc sa m o id itis o f the first m etatarsal. A11 increase in the w eight b earing b allistic types o f sport h as resulted in this injury becom ing more common. Mike E ls is a lecturer at the P o d iatry d ep artm en t o f the T cchnikon W itw atcrsran d and a practisin g p o d iatrist in Albcrton. Ah’ Darryl Coh en d e sc rib e s the effect o f excessive pronation o f the foot 011 patcllofcm oral pain syndrom e. T h is h ig h ligh ts the role o f the podiatrist in the treatm ent o f patcllofcm oral pain syndrom e bv m eans o f biom cch anical an alysis and the prescription o fo rth o tic therapy. Darryl Cohen is a practisin g p o diatrist in Jo h a n n e sb in g . In this Jo u rn a l I have included som e work by Dr Jo h n Pagliano. D r Pagliano is a very old friend and colleague from Long B each California in the United S ta te s o f Am erica. H e is a practisin g podiatrist in A m e rica with a great interest in podiatrie s p o ils m edicine. Dr Pagliano p resented a paper and a clinical workshop at the 1995 S A S M A C on gress in D iubau. Mr P h ilip C a rste n s looks at a podiatrie approach to sonic cycling injm ies. T h is is a sport that is not often associated with foot and lower limb injiuies. Philip C arsten s is a p ractisin g p odiatrist in C ap e Town. A s sp o rts p o d ia trists we are being called upon to take otu place in the field o f sp orts m edicine. Oiu- recognition by the sports m edicine fraternity and the South African S p o rts M edicine A ssociation will urge 11s to new h eig h ts o f excellence in our field o f podiatrie sports m edicine. q ReoprilvGel on-the spot-pain relief 2 SPORTS MEDICINE JUNE 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) THE S O I’TII AFRICAN JOl'RYYE OF SPORTS MEDICINE VO L I TVER 4 NUMBER 2 JIHVE 1997 Editors I’rof TD Noakes CONTENTS J)r M P Scliwellniis Editorial 1 Editorial Board TD Noakes D r M E Mnnlla D r P de Jayer Guest Editorial 2 Dr ,J Skotvno D Rehbock Dr P Schwartz P ro f K Stretch D r ( ' de Iiidder Pro/ 1 > ( ' Andrews Forefoot varus and it’s influence on 4 subtalar joint pronation Dr E IT Derman B Zipfel Mr R I I Farman A review of sesamoiditis of the firstI)r R II Mars 6 Dr ( ' A Noble metatarsal M Els International Advisory Board L ijle ,! Micheli Associate Clinical Professor o f Orthopacd ic Sn rgc ry Excessive pronation as an etiology in patellofemoral pain syndrome 7 Boston, USA D Cohen Chester R Kyle Research Director, Sports Equipment Research Associates Iliotibial band svndrome (ITBS) in 9 California, USA * lon£ distance runners Pro/’I K ' Wildor Hollmann Prasident dcs Deutschcn J W Pagliano Sportarztcbundcs Kohl, West Germany A podiatric approach to common lower 12 Howard J Green Professor, Department o f extremity injuries in cycling Kinesiology Ontario, Canada PA Carstens George /I Brooks Professor, Department o f Physical Education California, USA Neil F Gordon Director, Exercise Physiology Texas, USA Edmund K Burke Associate Professor, Biology Department, University of Colorado Colorado, USA Graham X Smith Physiologist Glasgow, Scotland T h e E d ito r T h e So u th African Jo u rn a l o f S p o rts M edicine P O B o x 115. New latuls 7725 PRODUCTION Andrew Thomas PU B LISH IN G G len barr Publishers cc Private Bug X14 Parkliinds 21iK) Tel: ( O i l ) 442-9759 Fax: (0 1 1 ) 880-7898 AD VERTISING Marika de Waal/Andivw Thomas REPRODUCTION ( ) n ( i> n I R e ] i r o d i H ’ t i o n PR IN TIN G 1 Iortors Rep^riJcGel on-the-spot-paln relief The views expressed in individual articles arc the personal views of the Authors and are not necessarily shared by the Editors, the Advertisers or the Publishers. No articles may be reproduced without the written consent of the Publishers. SPORTS MEDICINE JUNE 1997 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Forefoot varus and it’s influence on subtalar joint pronation Bernhard Zipfel NHD Pod(SA), NHD PS Ed(SA) INTRODUCTION Forefoot vams is a well recognised loot type and the measurement o f the forefoot angle eonipared Lo tire rearfoot is commonly referred to in podiatrie literature. Different disciplines appear to have differing opinions on the definition o f forefoot varus and its role in caus­ ing lower limb pathology which may lead to a lack o f understanding o f the etiology o f many lower limb injuries especially in long distance runners. Forefoot varus was first defined by Root et al.' as an inverted position o f the forefoot in relationship to the rearfoot. This is a frontal plane deformity and can be readily seen from the posterior view o f the foot by creating a line perpendicular to the bisection of the calcaneus which represents the transverse plane o f the rearfoot. This line is then compared to the plantar surface o f the metatarsals and any angulation between the two lines determines the degree o f forefoot varus present .- This comparison is made with the subtalar joint in neutral and the forefoot (midtarsal joint) fully pronated. The etiology of forefoot varus is thought to be a delayed derotation o f the head and neck o f the talus and decreases from 5 degrees (below 5 years) to 2 degrees in the adult according to Tax (1965).;U Excessive angu­ lation o f the forefoot in relation to the rearfoot com­ monly results in compensatory subtalar joint overpro- nation and may result in lower limb injuries especially in long distance runners.’ Neutral position and the recognition o f forefoot varus During the stance phase o f the gait cycle, the subtalar joint moves through the motions o f pronation and supination in order that the foot may act as a mobile adapter (pronation) dining the contact and midstance phase and a rigid lever (supination) dining the propid- sive phase. The primary reasons for these motions is to make the foot function more efficiently and thereby reduce the incidence o f injury’.*'’ The foot strikes the ground in a supinatcd position, moves into a pronated position in order Lo absorb shock and resupinates in order to propel the body forward.' In order for the sub­ talar joint to move from a supinatcd position into a pronated position it must go through a neutral position in which the joint is neither pronated nor supinatcd. This occurs shortly after heel strike and just before heel lift. At the point before heel lift the foot is still flat on the groimd with the body weight peqiendicular to the foot. The groimd reaction forces load the lateral side o f the forefoot, dorsiflexing the fifth metatarsal head and fully pronating the midtarsal joint1'" into a position perpendicular with the posterior bisection of the calcaneus. This occurs because the natural noil- weightbearing position o f the forefoot is slightly invert­ ed and the evcrsion range o f motion is usually available to a llo w th e fo refo o t Lo a d ap t to th e w eigliL b ea rin g position . At th is c ritic a l point d u rin g the stance ph ase the su b talar joint, is n eutral and the m id ta rsa l jo in t fid lv p ron a ted so that the foot is n e ith e r p ron a ted nor su pin atcd. Root ct al.' stated that the foot, at Lliis p oin t in the g a it cy c le is in it ’s m ost functional p o sition and th at th e tim in g o f th is neutral p o sitio n is essen tia l in d e te rm in in g th e c o n e d am ount o f supination for e f f i ­ cien t prop u lsion and to e -o fl.’ ' W ern iek an d I.anger'* d e fin e d su b talar joint n eu tral as th e p alp ation of th e h e a d o f th e ta in s a tta in in g o s s e o u s co n g ru e n c y b e tw e e n th e h ead o f th e talus and th e n avicu lar bone. The la tera l s id e o f th e fo o t is lo a d ed to resista n ce so Llial Lhe m id ta rsa l jo in t is fully p ro n a te d .' By m an ip u ­ lating th e fo o t in to th is p o sition (Figiue 1), th e critica l point just b e fo re h eel lift can be s im u la ted and any b io ­ m ech a n ica l a b n o rm a litie s seen. Observations are best don e w ith Lhe patient pron e (Figiue 2). Figure 1. Neutral position. Note position o f hands. Figure 2. The classic position for observing forefoot varus. StricLly speaking, forefoot varus is an osseous frontal plane deformity,'1 but an element o f soft tissue involve­ ment may be present,' especially in children’ "’ which 4 SPORTS MEDICINE JUNE 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) is indicated by reduced niidtarsal joint range o f motion. This is difficult to determine, as niidtarsal joint range o f motion lias 110 fixed parameters. The soft tissue component o f forefoot invert us is referred to as forefoot supinatus. The use o f these terms is purely academic, as the resulting compensa­ tion is the same regardless o f the etiology causing the forefoot to be inverted. The compensatory mechanisms o f forefoot varus Forefoot varus compensates by subtalar joint prona­ t i o n . J o n e s and Todd'- slated that a greater than 4- degree forefoot varus will cause niaximiun evcrsion o f the calcaneus provided that the evcrsion range o f motion is available at the subtalar joint (Figiue 3). The residting compensatory pronation has been recognised in the beginning walker4" and Subotnicks identified that forefoot compensatory pronation results in many problems o f the medial aspect o f the foot, ankle and leg and may result in lumbar lordoses caus­ ing back pain. I11 short, compensatory ovcrpronation may be responsible for almost any common running injiu v o f the lower extremity. Figure 3. Forefoot varus in neutral non-weightbearing position and compensated weightbearing position. Should t he evcrsion range o f motion not be avai lable in the subtalar joint, the joint will maximally evert and this is known as part ial compensation.” An example of this could be that there is a forefoot varus o f 10 degrees, but the eversion range o f motion at the subta­ lar joint is only 5 degrees and the joint can thus only compensate 5 degrees for the 10 degree forefoot varus. In the rare event o f there being no evcrsion range o f motion available in the subtalar joint, then the forefoot varus wotdd remain lmconipensatcd and the foot would function in a snpinated position. When full compensa­ tion takes place and the foot remains pronated before and after heel lift, the foot does not adequately resupinate for propulsion and toe off. This residts in instability o f the foot and that is transferred into the leg with the potential for causing a number o f foot and lower limb injuries. Should partial or no compensation take place, then the subtalar joint will attempt to evert at the calcaneus, and unable to do so adequately, result in unnatural stresses being applied to the joint and surrounding tissue. The measurement o f forefoot varus Philips'1' put emphasis on the measurement o f forefoot varus in orthotie manufacture. Yale” referred to the forefoot measuring device. Spencer'’ and SeibcF described the use o f both the forefoot measuring device and the tractograph in measuring forefoot varus. These measurements are difficult and poor residts are obtained."’ C)MJcjn 1 ic 11 (199o)" suggested that there is poor inter-examiner reliability using the forefoot measuring device and it can be presumed that similar devices currently in use do not consistently pro­ duce the same results as they work 011 the same prin­ ciple. Much has been said about the degree o f forefoot varus producing compensatory pronation41' " and sur­ gical evaluation was described by McGlamry et al" but there has been a failiue to determine the repeatability' and reproducibility o f forefoot varus measurements. The classical instruments used for the measure­ ment o f forefoot varus are the forefoot measuring device, which is difficult to use and gives poor mea- siuenicnt"’ and the tractograph or goniometer which is easier to use than the forefoot measuring device.1 Both methods require the forefoot to be compared to the posterior calcaneal bisection, which is technically to achieve consistently.17 Literature quantifies forefool varus in terms o f degrees, but fails to explain exactly how these measurements were taken nor does it con­ sider the accuracy o f standard methods o f measure­ ment. Conclusion Forefoot varus is an extremely common foot-type and is responsible for compensatory overpronation in a large percentage o f distance nmncrs resulting in many o f the common running injuries. By understanding the bio- mechanics o f forefoot van is, the etiology o f pronation and subsequently the resulting injury can be diagnosed and treated. Although this foot type is difficult, if not impossible to measure, the most common method of ‘measurement’ is to subjectively estimate the degree of deformity, which appears to be adequate in the author’s opinion for clinical purposes. The harmful effects o f subtalar compensation can be reduced by modifying the socldiner innersole o f the running shoe with a forefoot medial wedge made o f EVA or similar material. In some cases it may be necessary' to make a neutral orthosis with forefoot medial postmg depend­ ing 011 the amount o f control required. In both cases the ground is in effect brought up to the forefoot, instead o f the forefoot rolling down onto the ground forcing the subtalar joint to compensate by pronating. Many common running injuries can be adequately man­ aged by limiting the compensatory effects o f forefoot varus. References 1. Root ML. Orien \VP, Weed J II. Normal and Abnormal Function o f the Foot. Los Angeles: Clinical Biomechanics Corporation. 1997:46. 80. 173. 297. 329. 2. Grumbine NA . The varus components o f the forefoot in flat- foot deformities. J.A.P.M .A. 1987: 77(1): 14 - 20. 3. Seibel MO. Foot function, a programmed text. Baltimore: continued on page 11 SPORTS MEDICINE JUNE 1997 5 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) A review of Sesamoiditis of the first metatarsal Michael Els N H D P O D (SA) INTR OD UCTION Sesamoids can become tender and painful and so too the associated structures and joint complex can be affected, this is loosely termed as sesamoiditis. Commonly known as the tibial and fibial sesamoids they lie in the tendon slips o f the flexor hallucis brevis tendon and underlie the first metatarsal head. These two bones have the function o f elevating the first metatarsal head, to disperse impact forces, protect the flexor hallucis longus tendon, reducing friction and allowing the first metatarsal to glide posteriorly during the propulsive phase o f gait.7 Sesamoiditis is a pain syndrome becoming more common due to the increase in popularity o f sports.2 Though the condition can be found in patients of any age or activity level and may present with symptoms of sudden onset, acute or chronic duration and with or without a history o f associated trauma or systemic disease. The condition can be classified as either congenital, anatomical, arthritic, infectious, systemic or ischaemic. Etiology The most common cause o f sesamoiditis is repetitive microtrauma from jumping sports,2,4 such as basket­ ball, netball and in cricket bowlers, where as much as fifty percent o f the individuals weight is transmitted through the first metatarsalphalangeal apparatus. Sesamoiditis is also seen in women due to wearing o f high heeled shoes which force the first metatarsal to be vertical, placing the hallux in extension which in turn fixes the medial and lateral sesamoid bases under the metatarsal.7 Biomechanical derangement o f the lower limb, such as rigid planterflexed first raj’, a forefoot valgus or a foot wit h a marked talar declination angle seem to be pre­ disposed to sesamoiditis. Typically a sesamoidal fracture is transverse or com­ municated and one or both sesamoids are involved." It is more common for the tibial sesamoids to be frac­ tured because o f the increased load in closed kinetic chain o f gait. These injuries should be differentiated from congenital bipartite, tripartite sesamoids which result from the incomplete coalition o f the primary ossification centres.4 '1 Clinical features A localized pain on the affected sesamoid is usually’ described, aggravated by weightbearing and isolated on deep and firm palpation.3 Pain could be either post traumatic or o f insidious onset. Active or passive dor- siflexion and planteflexion elicit pain. Localized signs o f inflammation may or may not occur in the surround­ ing first metatarsaphalangeal joint. In insidious sesamoiditis the appearance o f adventitious bursitis and or hyperkeratosis underneath the first metatar- sophal angeal joint.'1 There are many’ conditions which cause a simdar metatarsalgia and may be local or systemic in nature. Osteochondritis or Treve’s disease is avascular necro­ sis o f sesamoids showing both lytic and scleritic changes with fragmentation occurring.14 Radiographic changes are not always seen with sesamoiditis and requires observation for differential diagnosis. Occasionally’ sesamoiditis can produce a positive bone scan. Differential diagnosis from osteo­ chondritis, fracture, infection, neuritis o f the medial plantar nerve, or bursitis. Management Initial treatment involves the need to relive the pressure o ff the sesamoid bone. A cushion pad with an aperture over the sesamoids and strapping o f the hallux in a planter flexed position in order to relax the tendons containing the sesamoids.3 Icing, prescription o f analgesics and advice on rest and appropriate footwear. The injection o f local anaesthetic and anti­ inflammatory cortisone derivatives are o f help.4 The prescription o f a custom made innersole with a single wing plantar metatarsal pad or where required for more biomechanical correction a “ u” out Slieaffer plate ortliotic to compensate for a first metatarsal equi- nus.47 A plaster cast may be used to immobilize and decrease weightbearing o f the first metatarsopha­ langeal joint i f initial padding fads to reduce the symp­ toms. I f conscientious conservative treatment does not help, surgical removal may' be required. This is accom­ plished by an incision at the medial planter aspect of the metatarsal head with care taken to avoid the planter m edial nerve, a dorsal intermetatarsal approach to reach the lateral sesamoid may also be taken.s Removal however results in a change o f biome­ chanics to a certain degree and the risks invalidating the function o f the short flexors which may lead to subsequent deformities. References 1. Burquist TH. Im aging o f sport injuries. Aspen 1992. 113. 2. Ellis J. Feet first, Runners world. Vol 5:2 (F eb ru a ry ): 26 1997. 3. Ilela l B, Wilson D. The foot. Vol 2 Churchill Livingston 1988: 166-182. 4. Jahss M. Disorders o f the foot. Vol 2 WB Saunders 1991:134-151. 5. Levy A L , Iletherington JV. Principals and practice of podiatrie medicine. Mosby 1991,88-93. 6. Noble C. The pfizer manual o f sports injuries. Vol 1 Medical Tribune 28. 7. Yale I. Podiatrie medicine. 2nd ed. Williams and Wilkins 1974:112-115. □ 6 SPORTS MEDICINE JUNE 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Excessive pronation as an etiology in patellofemoral pain syndrome Darryl Cohen N H D Pod(SA ) Patellofemoral pain is a common condition facing prac­ titioners. Whilst the condition is common, it is a d iffi­ cult condition to treat, and there is no clearly defined management protocol. There are many beliefs about the cause o f patellofemoral pain, and generally it is accepted to be a condition occurring due to maltrack- ing o f d ie patella. Anatomy o f die patellofemoral join t In order to have a good understanding o f patellofemoral syndrome, it is vital that the anatomy o f the joint is well understood. The patellofemoral joint comprises the articulation between the femur and the patella. The patella surface o f the femur (Fig 1) is situated at the anterior aspect o f the condyles o f d ie femur. It extends proximally more on the lateral side, the prox­ imal border being oblique, runs distally and medially, and is separated by the tibial surfaces by two faint grooves crossing the condyles obliquely. Where d ie medial groove ceases, the patella surface continues to die lateral part o f the medial condyle as a semdunar area adjoining the anterior region o f the intercondylar fossa, this area articulates with the medial vertical facet o f the patella in lull flexion.4 surface sub-cutaneously is separated from the skin by a prepatella bursa, and is covered by an expansion from d ie tendon o f quadriceps femoris, which blends superficially with fibres o f the patella ligament.4 The posterior surface o f the patella has a proximal smooth, oval, articular area, crossed by a smooth ver­ tical ridge which fits the groove on the femoral patella surface and divides the patella into a medial and larg­ er lateral facet. Both the ridge and flanking are natu­ rally protected by articular cartilage. A narrow strip, proximally broader, is marked o ff medially from the medial facet, which makes contact with the femoral condyle in extreme flexion. Distal to the apex is a roughened area at the attachment o f the infrapatella tendon and proximal to this the area between the roughened apex and t he articular surface is covered bv an infrapetella fat pad. Th e thick superior border as an attacliment for the rectus femoris and vastus inter- medius slopes down and forward, except near the pos­ terior margin. The medial and lateral borders are thin­ ner and converge distally forming the attachments for the expansions o f the tendons o f vastus medialis and lateralis. Near the superolateral angle is a shallow, cir­ cular depression for a distinct attachment o f the ten­ don o f vastus lateralis.4 P a te lla r s u rfa c e Figure 1. The Knee joint showing the patella surface:' (Coetzee 1987) The patella is the largest sesamoid bone in the body, and its main biomechanical function is to increase the effective lever arm o f the quadriceps. This bone also centralizes die divergent forces o f the quadriceps into one tendon, namely the patella tendon, thus helping to provide stabdity to d ie knee joint." The patella is shaped like an inverted triangle (Fig 2), with rounded sides. The base (proximal end) gives attachment to die quadriceps femoris muscles, and its apex (distal end) gives attachment to d ie patella liga­ ment and in turn to d ie tibial tuberosity." The anterior Figure 2. A nterior and Posterior views o f the Patella ( Gray 1989) Gait as an etiology in patellofemoral pain A long distance runner's feet make contact with the groimd approximately five thousand times in an hour’s run, and thus it is vital that both their feet and lower extremities are functioning at their best.1 Gait can be divided into two phases; the stance phase and the swing phase. The stance phase is fur­ ther divided into heel strike, and mid-stance and toe- off. As the foot strikes the ground on its lateral aspect, d ie knee is in frill extension (Fig 3), the femur and dbia SPORTS MEDICINE JUNE 1997 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) are externally rotated but in the process o f internally rotating through to a quarter of die midstance phase, and the knee join t begins to move into flexion. Thereafter the femur and tibia begin to externally rotate for die rest o f the stance phase.*’ As the knee joint flex­ es the compressive force o f the patellofenioral joint increases; diis may help to understand why the pain is often present when a patient rises from sitting, climbs stairs or is sitting with the knee flexed ( ‘cinema sign’).7 With the above in mind, it becomes easy to understand that if the foot pronates excessively beyond 25% o f stance phase, the tibia and femur are still internally rotated when they should be externally rotating. Thus with the excessive pronation comes excessive internal rotation o f the tibia and femur, an increase in the ent­ angle. and therefore maltracking o f the patella1 (Fig 4). This excessive internal rotation also causes an abnormal pull o f the quadriceps on the patella. This usually occurs as the knee flexes and the patellofemoral joint is expe­ riencing increasing compression forces. Since with excessive pronation, the origin and insertion o f the quadriceps are situated lateral to the patella, the quadri­ ceps tend to pull the patella in a lateral direction.1 Figure 4. The change in the Q-angle in relation to the position o f the foot. Illustrative Case study to indicate the typical patient with this condition and the response to therapy. Subject: 23 year old female presented with bilater­ al patellofemoral pain, brought on by aer­ obics. Th e Clarke’s test was positive and crepitus was evident and the patient was experiencing the ‘cinema sign’ . There was a quadriceps imbalance between Vastus lateralis and Vastus medialis. She was not responding to the McComiel taping and exercise programme, a usually successful therapy. Foot biomechanics showed a fore­ foot invertus and hyperniobility in both feet. Gait examination revealed excessive sub-talar joint pronation, beyond 25% of the stance phase.The weightbearing foot as view ed on a podiascope was very planoid. Treatm ent: Semi-flexible moulded sports orthotics were manufactured. Th ese comprised 2mm polypropylene vacume moulded to a plaster cast for specificity, with forefoot and rearfoot medial posting o f a firm EVA, and an arch filler o f low density EVA for cushioning. Th e patient was advised on easing into the orthotics. Result: Within three weeks the patient was completely asymptomatic. When trying without the orthotics, the symptoms ini mediately returned. Conclusion Th e exact cause o f patellofemoral pain may not have been accurately identified, perhaps because there is no single cause. It is therefore vital Unit, all possible eti­ ologies are considered, including quadriceps imbal­ ance which has proven to be quite successful when treated, using taping and exercise therapy by a quali­ fied physiotherapist. From the above it is also clear that in the complete treatment o f patellofemoral pain it is important to ensure that patients have had a frdl biomechanical gait assessment, and any gait abnor­ malities corrected. RcfcrcncGS 1. Burchbinder MR, Napora NJ, Biggs EW. (1 9 7 9 ) The Relationship o f Abnorm al Pronation to Chonromalacia o f the patella in Distance Runners. Journal o f the American Podiatry Association 1979 Vol. 69 No. 2. 2. Coetzee T (1 9 8 7 ). Drennan’s Numan Osteology Qth erf. Maskew M iller Longman. 3. Donatelli R (1 9 9 0 ). Biomechanics o f the Foot and Ankle. Philadelphia. F A Davis. 4. Gray’s Anatomy. Edited by Williams PL, Warwick R, Dyson M, and Bannister LH . Thirty Seventh Edition (1 9 8 9 ). Churchill Livingston. 5. Inman VT, Ralston H J and Todd F. (1 9 8 1 ). Human Walking. Baltim ore Williams and Williams. 6. Ilungerford D S and Barry M. (1 9 7 9 ). Biomechanics o f the Patellofemoral Joint. Clinical Orthopaedics and Related Research N o .244 O ct 1979. 7. Noakes T. (1 9 9 2 ) Lore o f Running. 3rd Edition. Oxford University Press. 8. Whittle MW. (1 9 9 1 ). G ait Analysis. Oxford Butterworth- Heinemann. D Figure 3. Position o f the knee throughout the gait cycle (W h ittle 1991) 8 SPORTS MEDICINE JUNE 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Iliotibial band syndrome (ITBS) in long distance runners John W Pagliano DPM, MS AB S TR A C T T h is painful condition on the lateral side o f the knee was diagnosed in 4.9% o f 4,198 long distance run­ ners treated for lower extrem ity musculoskeletal complaints. Many o f these runners related a sign ifi­ cant change in th eir running habits, i.e., changes in distance, speed, terrain, surface and/or training shoes prior to the onset o f their symptoms. Th e mean age for athletes examined was 34.5 years for m ales and 32.6 years for females. Females were found to be disproportionately high in ITB S when compared to other running injuries. Surprisingly, ITB S cases are reliably ligh ter than other categories treated for lower extrem ity injuries. D espite the la t­ eral knee pain m ost runners were able to continue running but had their workouts and distance com ­ promised. T h ere did not appear to be any relation between ITB S and valgus or varus foot types. Our original study showed a correla tion between varus knee alignment and ITBS. I t was rarely seen in a valgus position. Once present, the symptoms often persisted from two to six months. A ll o f the runners in our series w ere treated by non-surgical measures including rest, reduction in running, anti-inflammatory m ed­ ication, local steroid injections, new shoe gear and/or orthoses. Shoes did not seem to be a contributing factor but we feel the use of a well-cushioned training fla t with a good heel counter is essential for controlling this problem. Iliotib ial band syndrome (IT B S ) is one o f the more common injuries among long distance runners. W ith the advent o f jogging and com petitive running over the past several years this syndrome has becom e more w idely recognized. 1-340-7-8!) Ilio tib ia l band syndrome has been classified as an overuse injury developed by rep etitive movement o f the ili­ otibial band as it slides over the prominent margin o f the lateral femoral condyle as the knee flexes and extends.27 It occurs in approximately 5% o f all run­ ners treated for musculoskeletal complaints. T h e iliotib ial band its e lf is a thickened strip o f fascia lata that extends from the iliac crest to the lateral tib ia l tu b ercle (G e rd y ’s tu b ercle ) and receives part o f the insertion o f the tensor fascia lata and gluteus maxitnus. With flexion the tensor facia lata pulls the band anteriorly and with extension the gluteus maximus shifts the band posteriorly.2 A t the ltnee join t the band acts as a stabilizing ligam ent between the femoral condyle and the tibia. Evans believes that because it crosses two joints its effect on the knee varies according to the position o f the hip. To achieve maximum stability in standing the IT B locks the ltnee into extension and con­ tributes to pelvic slouch by its action on the hip. Evans also believes the IT B enables us to rest w hile standing and that it appeared phylogenetically with the developm ent o f upright posture. As the knee flexes and extends during athletic activity, the iliotibial band rubs over the lateral fem oral condyle and an inflammatory condition is produced. T h e pain is usually localized above the knee join t but can extend up the lateral side o f the leg. Orava,4 in cadaver dissection, has found a reddish brown bursal thickening under th e ITB in the vicin­ ity o f the fem oral condyle. H e states that this con­ dition is the result o f the iliotib ial band rubbing over the femoral condyle. I f one we re to walk s tiff legged, the condition would not be as pronounced as th e band no longer rubs over th e epicondvle. Running, clim bing stairs and deep squats aggravates the condition. Our original study o f 84 patients with iliotibial band syndrome showed that the age ranges from 15 to 63 years o f age with a m edian age o f 33.9. O f those, 56% were men and 44% w ere women. Th is contrasts with our original prediction o f 70% male and 30% female. We feel that there is a greater than expected number o f women with ITBS and is th ere­ fore a gender-related running injury. O f those 83 patients seen with ITBS, 32 (33%) had right knee involvement, 38 (46%) had left knee involvement, 13 (16%) had bilateral involvement and one case was not recorded. Th is shows a higher than predicted value for the left knee. We had expected only 32% to have left knee involvement and 31% to have bilateral involve­ ment. I t is difficu lt to draw a conclusion on this ev i­ dence. A ll o f the runners examined wore shoes that were designed for running. Ten differen t brands were worn and 90% wore one pair o f socks. Clinical histories revealed that the majority o f the patients with ITB S ran less than 62 Ion per w eek (Table 1) and had running between one and five years with an equal number over five years. (Table 2) M ore injured runners w ith ITBS than control run­ ners with other injuries ran between 32-621tm. Table 1 Proportions o f runners with ITBS or with after injuries who ran different distances km % Control group per week with ITBS with (%) other running injuries 1-32 38 45 32-62 48 34 63-94 14 14 95-126 4 5 127+ 1 2 SPORTS MEDICINE JUNE 1997 9 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Table 2 Running experience o f runners with ITBS Experience level Proportion o f runners (%) Less than 3 months 3-6 months 6 months to 1 year 1-5 years 5 years+ Most limners failed to seek medical care until the severity^ o f the pain had reached levels where their workouts would be compromised or terminated due to increased pain levels. (Table 3) Symptoms often persisted two to six months but some runners ran with the condition for more than two years. Usually, once the condition was corrected, it very rarely returned under careful athletic guidelines. Examination o f training records indicated that the pain was aggravated by repetitive movements such as running, climbing stairs and squatting. The patients could generally walk for long distances but were lim it­ ed in their running activities. Diagnosis was somewhat complicated but usually confirmed by tenderness elicited by palpation o f the area o f the lateral femoral epicondjle. Usually the popliteal tendon, lateral collateral ligament, anterior lateral fat pad, lateral joint line and patellar tendon were not tender to palpation. Joint masses and cystic masses were ruled out. Clinical examination revealed that the patient could jog in place and hop without significant discomfort. There was no ligamentous laxity and anterior drawer, pivot shift or jerk tests, and McMurray’s test were also negative. Renee’s “ creak” sign was also absent while palpating the lateral aspect o f the knee. In most cases tliere was a neutral knee alignment or varus knee alignment. Very few had a genu valgum deformity'. In our initial study’ we found that the longitudinal arch structure was normal in the majority o f runners while nine had pes planus deformities and 11 had high arches. Seven o f the 48 original study patients were wearing orthoses, four rigid and three flexible, before the onset o f symptoms. X-rays usually showed no degenerative changes or prominent ridges. In examining training programs9 we found that most patients had made a significant change in their run­ ning schedule, either in time or distance. The addition o f interval work was also reported. The addition of hilly terrain was also implicated and a lew patients stated that they had changed from a soft running surface to a hard running surface when the symptoms appeared. Treatment included reduction o f distance and speed. We wished to treat most oi our athletes I>y noil- surgical methods and rest was our treatment, o f choice. We advocated the application o f moist heat on a daily basis. The use o f a Pro Knee Sleeve appeared to stabi­ lize the outer knee area and to provide heat to the knee area. This also limited the athlete in squatting and stair climbing activity. A local steroid injection was o f help in some cases. Th e patients were allowed to return to running on an asymptomatic basis with the addition o f proper training shoes and a softer running surface such as packed grass or dirt. No single treatment seemed better than others. We used a “ mixed bag” o f treatments to m eet the patients’ desires and patience. Orava recommends the use ol topical vasodilatory agents but these were not used in our population. Noble, described a surgical technique used in nine o f his 220 patients who did not respond to conservative treatment." H e transversely split the posterior 2.0 cm o f the iliotibial band at d ie area o f the lateral femoral epicondyle so that a portion.of the band was not taut at 30 degrees o f flexion. H e did not believe in excision o f the prominent ridge. Only two runners in our series did not respond to conservative treatment but surgery' was not elected in these patients. The higher degree o f left knee injury may indicate tli at. running on a sloped terrain or on the crown o f the road mav cause some friction on the knee rather than on a flat surface. The syndrome was usually seen in ectomorphs and mesomorphs and was generally absent in endomorphic populations. This may be due to the higher percentage o f fat deposited around the knee area. It was more common in those running between 20 and 40 miles per week and in those who had increased their mileage and speed prior to onset o f symptoms. Increasing the mileage was the most often noted change. Obviously, one has to run a certain distance in order to incite and sustain an inflammation reaction o f the lateral femoral epicondyle. Most could run with pain, but they usually ran fewer hills and reduced both mileage and speed. As in most studies, there are probably a great number o f subclinical cases in which the patients adjust their own schedule without seeldng medical advice, and the condition may spontaneously improve. A specific brand o f shoes could not be implicated in causing symptoms. But three patients did note a recent change in shoes and an additional three described running on vvom-out shoes. One patient did not experi­ ence symptoms until he began adding glue to the bottom o f his shoes. (The role o f footwear may be a contributing factor in certain cases but in our sampling this was not apparent.) It does not appear that foot structure is a significant contributing factor. A cavus foot may result in a more varus stress on the knee but this is speculative. Some patients could participate asymptomatically in other 4 2 16 38 40 Table 3 Severity o f pain at time o f seeking medical care in runners with ITBS Severity' o f pain Proportion o f runners (%) Pain only after running Pain before, during and after run­ 8 ning 23 Workout compromised by pain 52 Unable to work out 17 10 SPORTS MEDICINE JUNE 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) sports, i.e., racquetball, softball and basketball without pain. The}- experienced pain only with sus­ tained running and constant repetitive knee move­ ment. The differential diagnoses should include tom lateral meniscus, capsular and ligamentous tears and avulsions, discoid meniscus, pseudogout and chondromalacia patella or popliteal tendinitis. Synovial plications in our experience have not been symptomatic on the lateral side o f the knee with running. Th e long-term prognosis for iliotibial band syndrome appears to be good, although some patients had recurrent symptoms i f they did not follow proper guidelines. Although there are many types o f treatment for ITBS, we have broken our treatment regime into the following: 1) Rest 2) Physical therapy modalities 3) Anti-inflammatory medications 4) Local steroid injections 5) Foot orthoses 6) Knee stabilizer 7) Topical vasodilatory' agents (ORVA) 8) Training flats 9) Asymptomatic exercise 10) Surgical Physical therapy modalities were prescribed on an every-other-day basis or three times weekly. Moist heat was applied on a daily basis either at the physical therapy facility or at home. This was applied with a moist pack or whirlpool, 110 degrees for 20 minutes. Th e purpose o f the moist heat is to reduce pain, reduce spasm, increase blood flow, reduce joint stiffness and to increase collagen extensibility. Electrical stimulation or H-wave is used to reduce muscle atrophy, reduce spasm, reduce edema and reduce pain. Therapeutic measures also include soft tissue mobilization to include massage or musculofascial release. Stretching may include proprioceptive neurofacilita- tion and passive massage. Perhaps the most effective is ultrasound, applied directly at 7.5 watts/cm2 for seven minutes. The use o f a good, stable training shoe on a level surface is recommended. Shoe selection w ill be discussed in the oral presentation. I recommend the use o f a good warmup prior to the running workout. This may include a one-half mile walk. Ice may be applied briefly after the workout. References 1. Renne J. The Iliotibia l band friction syndrome. J Bone Join t Surg 57:1110-1111, December 1975. 2. Kaplan FB. The iliotibial tract: Clinical and morphological significance. J. Bone Joint Surg. 40:817-832, July 1958. 3. Evans R The postural-function o f the iliotibial tract. Ann Coll Surg Engl 61:271-280. July 1979. 4. Orava S. The Iliotibia l tract friction syndrome in athletes- an uncommon exertion syndrome on the lateral side o f the knee. Br. J Sports Med 12:69-73, June 1978. 5. Smillie IS: Injuries o f the Knee Joint, ed 4 London, Churchill Livingstone, 1973, pp. 357. 6. Noble CA. The treatment o f iliotibial hand friction syndrome. Br. J Sports Med: 13:51-54, June 1979. 7. Pagliano JW. A Clinical Study o f 3000 Long Distance Runners, American College o f Sports Medicine, Annual Meeting, San Diego, CA, 1984. Colloquin Presentation. 8. Brody D. C IB A , Volume 32, November 1980. 9. Sutker A N . Jackson DW, Pagliano JW: Iliotibial Band Syndrome in Distance Runners. Physician and Sports medicine 9:69-73, October 1981, McGraw-Hill, Inc.ends □ continued from page 5 Williams and Wilkins, 1988: 166 - 179, 226 - 227. 4. Tax IIR . Podopediatrics. Baltimore, Williams and Wilkins, 1988: 166- 179, 226 - 227. 5. Subotnick SI. Sports Medicine o f the Lower Extremity. New York, Churchill Livingston, 1989: 167 - 168. 6. McGlamry ED, Banks A S. Downey MS. Comprehensive textbook o f fo o t surgery. Vol. 1 2nd ed., Baltim ore, Williams and Wilkins, 1992: 776, 821. 7. R oot ML, Orien WF, Weed J II. Biomechanical examination o f the fo ot. Los Angeles, Clinical Biom echanics Corporation. 1971: 72. 8. Werniclc J, Langer S. A practical manual fo r a basic approach to biomechanics. New York, Langer acrylic labo­ ratory. 1971: 10-20. 9. Jahss M il. Disorders o f the fo ot. Vol. 1. 2nd ed. Philadelphia, WB Saunders Company. 1991: 472 - 474. 10. Thomson P. Introduction to Podopaediatrics. London, WB Saunders Company. 1993: 56, 206. 11. Boyed PM , Neale D, Rendall G. The adult foot. In: Neale D. Ed. Common fo o t disorders. 4th ed. London, Churchill Livingston. 1994: 54, 58. 12. Jones U , Todd WF. Abnormal biomechanics o f flatfoot deformities and related theories o f biomechanical develop­ ment. Clinics in podiatrie medicine and surgery. Vol. 6 .(3 ). 1989: 517. 13. Philps JW. The functional foot orthosis. 2nd. ed. Singapore, Churchill Livingston. 1995: 8, 9. 14. Yale I. Podiatrie medicine. 2nd ed. Baltimore, Williams and Wilkins. 1980: 280. 15. Spencer A M . Practical podiatrie orthopedic procedures. Ohio, Ohio college o f podiatrie medicine. 1978: 54. 16. O ’Donnell M A. A prevalence study of f orefoot varus, fore­ foot valgus, rearfoot varus and rearfoot valgus in six to eight year old children. FV International congress o f podia­ try, London, May 1995. 17. Menz H B . Clinical hindfoot measurement: a critical review o f the literature. The Foot. Vol. 5 (1 ). 1995:59,62. □ SPORTS MEDICINE JUNE 1997 11 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) A Podiatric approach to common lower extremity injuries in cycling Philip A Carstens (ND. P O D S.A.) The modem day Podiatrists importance and input to cycling is not a superficial interest, but it becomes a sci­ ence to improve performance, prevention and treat injuries, correct techniques and to give a vital service to research and data on this neglected but growing field of sports medicine, especially in tiiis current competitive and professional sports era. The most important feature o f a bicycle is how it fits the rider.” Performance, comfort and the risk of injury can be affected by variations, some­ times as little as 5mm in the riding position. The gener­ al belief is that cycling is a harmless, innocuous and low impact activity. Bicycliug is actually a very popular aero­ bic exercise that can be harmful i f not done properly with the correct equipment, settings and under supervision. Cycling is a favourite prescription for the rehabilitation o f certain post-surgical conditions when the patient is not able to do other exercises. It can however lead to overuse injuries o f the lower extremities (including the lower back) due to improper settings, biomechanical malalign­ ments and wrong riding techniques. When treating a patient with an injury caused by cycling, it is important to determine whether it is the patient’s primary sport and what type o f cycling is exer­ cised, e.g. mountain biking, racing, track, touring, train- er(rehab.) or triathlete biking. Some key questions are: 1. What type o f cycling is exercised? (to determine equipment and terrain) 2. A t what rate do you pedal? (ideally between 70-110 r.p.m.) 3. What type o f shoe is used? (cycling shoes are cur- rentiy categorised into cleated, clip’s, mountain bike and touring, although several o f the categories may overlap.) 4. Do you use cleats, toe clips or clipless pedals and what type? (this determines what position the foot is kept in) 5. Do you know your knee position on your bicycle at 3/6’0 clock respectively? (it shows quicldv i f the seat height or position must be adjusted) Before you can proceed to making any diagnosis and pre­ scribe treatment you must have knowledge of the follow- ing:- 1. The anatomy o f cycling - A general description of the anatomy involved is a basis for understanding the general injuries and the prevention o f these injuries. The anatomy mainly involved is the muscles and joints o f the neck, back, arms, pelvis,legs and feet. This varies in degree from regions during specific move­ ments. The quadricep and gastroc-soleus muscles are o f the main power suppliers and the knee and subta­ lar joints are o f the most importance, their strength and flexibility can prevent knee and lower leg injuries.5 (Fig 1) aspect. 2. Cycling biomechanics - During a pedal cycle, the foot moves from top dead centre (TDC=0) to bottom dead centre (BDC=180) and proximally back to TDC. As with the closed kinetic chain gait cycle, a change in a joint angle gene rally affects the joints distal and proximal to it because o f the ground- foot-leg-thigh linkage. Cycling has the same chain, except the foot is fixed on the pedal, and there is no heel contact. Minimal metatarsophalangeal joint motion is allowed because the rigid cycling shoe is fixed to the pedal. A remarkabfe difference between gait and cycling occurs in the phase where maxi­ mum pronation corresponds respectively to a dorsi- flexed and plantarflexed ankle. As the foot enters the power phase o f the pedalling stroke, the ankle plantarflexes, the knee extends and the tibia medially rotates. This everts the calcaneus, pronates the subtalar joint and unlocks the mid- tarsal joint. 3. Proper settings o f a bicycle - Machines such as the elite (Fig 2), the fit kit, and Serotta size cycle, and specialised computer programmes such as probike fit can be used. In practise it is mainly done manually The vital factors in sizing are saddle height (Fig 3), the length o f the top tube, amount of seat post exposed when saddle height is correct, the clearance between your crotch and the top tube. Relative to height, women generally have shorter torsos than do men. Sizing a woman’s bike by inseam length and seat tube size can often result in too long a top tube. The best is to have a longer seat post and smaller bike frame. Childrens fit­ ting is done by wheel sizing. These factors will vary slightly depending on the cycling activity and the patient’s physique. PHYSICAL EXAMINATION 1. Standard biomechanical assessment, checking head, shoulders, torso, pelvis, hips, knees and feet positions, 12 SPORTS MEDICINE JUNE 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) motions, lengths and alignments.'4 Doing measure­ ments to determine any degree o f abnormality, in particular Genu Varum or Valgum, external or internal tibial torsion.(Fig 4a & 4b) 2. On bilte, riding assessment It is advisable to use a video camera for playback i f you are not familial- with cycling bio- mechanics and also to compare alter settings and adjust­ ments have been made. Place the patient on a trainer using his own bicycle and marking die tibial tubercle clearly with a blight coloured koki pen. Video shooting must be done from the front, sides and rear. The patient should cycle ± 2min. at between 70-110 rpm pedal cadence oil a high gear. From the front the ftnees should move straight up and down." As die foot pronates, the knee often moves medi­ ally towards the top tube during die power phase, and lat­ erally during pull up. From the rear the legs should move straight up and down with both feet fixed on the jjedals with minimal in-out toe movement and die buttocks must stay in the same seat position with no rocking of die hips.7 From the side with the foot in die top dead centre posi­ tion, die ltnee ideally is flexed approximately 100 to 110 degrees and the ankle is slightly dorsiflexed or 0 degrees. The ball o f the foot should be on the axis o f die pedal when the loot is in the 3 o’clock position with the ltnee in a plum line position to it (Fig 5). Once die foot reaches bot­ tom dead centre die knee ideally is extended to about 160- 165 degrees, the ankle is maximally plantarilexed and the foot in supination. Determine i f any abnormality can be detected and if; adjust die settings accordingly. COMMON INJURIES Many biomechanical problems can lead to injuries, even with the bicycle properly positioned. Most lower extremi­ ty injuries occur during the powder phase when die foot moves from top dead centre to 120 degrees, vvidi the peak­ ing o f force at 90 degrees. Simple strains o f the dioracic paravertebral muscles or lumbosacral paravertebral muscles can often be alleviated by shifting position, moving the seat forward (or back­ ward) on its mount or varying the lengdi o f the handlebar stem. The lower back is also at risk o f pain due to the bent over position. Knee pain is the most common injury in cyclists.'1 I t is usually caused by chondromalacia patellae, but can include patellar tendinitis, bursitis, and nivotendinitis quadriceps (where it inserts into die superior aspect o f the patella.)8 (Fig 6) The quadriceps provides die power in cycling and also the area most often injured in a bicycle crash usually with contusions. These injuries should be treated with ice, massage and immobilisation o f muscle action to prevent myositis ossificans. Often the rider is to blame for the ltnee pain in that the seat is too high or low. I f too low7, the ltnee flexed too much at die area o f most force in the down stroke, generating excessive pressure across die patellofemoral joint.' From lull extension to lull flexion o f the knee the patella glides caudally ± 7cm on the femoral conchies. Both die medial and lateral lascets of the femur articulate with the patella from full extension to 90 degrees o f flexion. Beyond 90 degrees o f flexion die patella rotates externally, and onlv medial femoral facet articulates with the patella. A t full flexion the patella sinks into the intercondylar groove.(Fig 7a & 7b) Sizing Frame: Adjustable for p r o p o r t io n a l tu b e le n g th s .# Figure 2>. Example of the E lite size cycle. SPORTS MEDICINE JUNE 1997 13 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Cleat placement can also put cxcess strain 011 the knee. Cleats lha( are adjusted too far outwards cause prcssiu'c placement on the outside o f the knee and loo much inwards 011 the inside o f the knee. Shoes should be adjusted such that the metatarsal heads (wider part o f the loot) are placed directly over the pedal spindle, (women need a little more inward tilt to account for wider hips.) Knee pain can also be caused by pushing gears that are high. When cranking along slowly in a high gear, at low cadence the rider is getting more force across the patellar femoral joint. Pronation can lead to pain, mostly in elite riders or riders cycling in sneakers or running type shoes, allowing more subtalar joint motion because of the lack o f rigidity. This can lead to knee and other pronatorv type injuries like posterior tib- ial tendinitis, plantar fascitis, bursitis neuroma type and soft tissue pressure injuries, including toenail problems. Orthotics can be used to correct these problems," but arc different to running type orthotics because they do not fit well in the shoes and there is no heclstrike or stance phase in cycling. Riuining type orthotics arc designed to work during heel strike and toc-off. Good results can be achieved with a variation o f forefoot wedging or cleat adjustment in cyclists. Some canting can be done lmdcrncath the cleat, although with some newer pedal systems it becomes impossible. Orthotie control must be applied to the forefoot, even in the absence o f a measurable forefoot deformity. Orlhotics must be very specific for sports that require no or little metatarsophalangeal motion such as cycling, skiing or skating.7 Preferably the forefoot posting must be placed cxtrinsically and is extended beyond the metatarsal heads to the sulcus o f the toes. This will give good forefoot control. A dense rubber material can be used for (he posting and the orthot.ie must fit prop­ erly in the shoe. I f the shoe becomes too narrow the patient might have to change to a different shoe. It is important that the amoiml o f forefoot posting equals the amount o f posting that would normally have been used in the rearfoot, plus the ainoiuit that is required in the forefoot. A biopedal can also be used to correct various discrepancies.7 The gastrocnemius solcus muscle is another power source. Tears will result in pain upon plantar flexion o f the foot. (Fig 8) Cyclists with achilles tendonitis must avoid [lulling up dm ing the passive phase. II severe, apply R.I.C.E. and physical therapy. To prevent one can wedge the heel; stretching exercises; strapping and the use o f anti inflammatorics." Complete rupture rarely occms during cycling. Traumatic injuries - knowledge o f first aid is required and proper woimd cleaning techniques must be applied. Numbness is a common complaint affecting the hands, feet, genitals and buttocks area. Numbness to the genitals and hands is very common and is referred to as cyclist’s palsy. The cause for affecting the genitals is compression o f the pudenal nerve. The saddle type; height; position and tilt must be checked and correct­ ed. Padded cycling pants must be worn. Numbness in hands and feet can be due to cold and exposure or too narrow and tightly fitting shoes; toe clips; gloves or too light a grip. Treatment involves changing to the right shoe size, gloves, and keeping the hands and feet warm. Regular movement o f the lingers and toes will allow for increased circulation. c o n tin u e d on p a g e 10 Figure 5. K n e e p o s itio n o v e r ped a l spindle, w ith cra n k a t 3 o ’ clock. Figure 6. Types o f e x tra -a rtic u la r in/luinm ation sites o f the knee. Figure 8. In/lamed A c h ille s tendon. 14 SPORTS MEDICINE JUNE 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) GLENBARR PECIALIST PUBLICATION SO U T H A FR IC A N J O U R N A L OF SP O R T S MEDICINE VdI 3 No 2 July 1996 o P ^ t t Q J GLENBARR PUBLISHERS Private Bag X14, Parklands 2121. Tel: (011) 442-9759 Fax: (011) 880-7898 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) ENROLLMENT FORM I am interested in attending the FIRST South African Podiatry Congress on October 4, 1997, at the Volkswagen Conference Centre, Midrand. FIRST NAME: SURNAME: ... TITLE: ......... ADDRESS:.... CODE: .. FAX: .TEL: .................... If you wish to present a paper, please send your resume and presentation to the S.A.P.A. Executive P.O. Box 1011 Rosettenville 2130 to arrive not later than September 1, 1997. Assisted travel for accepted papers. COST S.A.P.A. member Non-S.A.P.A. members Receipt given on request. Only cheques or postal orders. All payments to be made to Podiatry Association. I enclose my cheque of R ........................... Post to. Mckenzie Dickerson Int. P.O. Box 53101 Troyeville 2139 Tel: (011) 402-3240 • Fax: (011) 402-0164 Final programme will be posted to all dele­ gates August/September. R100,00 R140,00 the S.A. continued from page 14 REFERENCES , 1. Ronald L. Valmassy. Clinical biomechamcs o f the lower extremities. Mosby, 1996: 453-454. 2 Margareta Nordin, Victor H. Frankcl. Basic Biomeehanics of Lhe musculoskeletal system. 2nd Edition: Lea & Felnger, 3 J e ffi-e ^ M . Robbins. Clinical handbook o f podiatrie medicine. Volume 1. Ohio College o f Podiatnc Medicine, 1983: 16-37. , , , 4. Sheldon Langer, Justin Wernick. A practical manual fo r a basic approach to foot biomechanics. The Langer Foundation for biomechanics and Sports Medicine Research, 1990: 6-8. THE SOUTH AFRICAN PODIATRY ASSOCIATION The FIRST South African Podiatry Congress O ctober 4, 1997 Volkswagen Conference Centre M idrand 08:00 - 18:00 O v e r 20 S u pplier Exhibits fo r the P odiatry Profession Refreshments & 4 -course lu n c h BEST PAPER AWARD Congress organized by Mckenzie Dickerson International 6. 8. 9. Stanley Hoppenfeld. Physical examination o f the spine and extremities. Appleton-Century-Crofts, 1976:176. Steven I Sidyotnick. Sports medicine o f the lower extremity. Churchill Livingstone, 1989: 314. 638-639, 643-644. Ayne Furman. Lower Extremity Overuse Injuries in cyclists. Foot & leg fiinction. Volume 2 No. 2, June 1990: 1-4. Sandra Adams Eisele. A precise approach to anterior knee pain. The Physician and Sportsmedicine. Volume 1J, J\o.b, June 1991:128-137. Richard Bailantine, Richard Grant. Richard s ultimate bicy­ cle book. Dorling Kindersley, 1992 :20-21,116,162-163. David. M.Brody. Running Injuries. Clinical Symposia. Ciba. Volume 32, No. 4. 1980. 21. , 11. Bob Prichard. Screen Test. Bicycling. 136-13J. U 10 16 SPORTS MEDICINE JUNE 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. )