How Custom Cycling Orthotics Decrease Knee Pain Caused by Forefoot Varus

Knee pain is one of the most common complaints among cyclists. If your knee is aching when you finish the climb over Mt. Tam or a long ride out through Marin, it may be because the foot is slightly out of alignment.

In the simplest of terms, your foot is "locked" in place to the pedal by the cleats. if your forefoot is tilted lightly in relation to the rearfoot (a condition called "forefoot varus" or "forefoot valgus") then your leg may tilt slightly when you pedal.

This tilting of the knee can cause the knee cap (or "patella") to track out of alignment. When the knee cap tracks incorrectly, the cartilage on the inside of the knee cap can become irritated and inflamed. This type of knee pain when biking is called "patellofemoral syndrome."

This short video describes bicycle pedaling biomechanics as it relates to knee pain and conditions such as forefoot varus that can be easily corrected with custom cycling orthotics.

Dr. Christopher Segler is a sports medicine podiatrist, cyclists, and 6-time Ironman triathlon finisher. His practice focuses on cyclists, runners, and triathletes in San Francisco, Marin, and the East Bay. He is currently training for Ironman France. If you have a question about pain while cycling, you can call him directly at 415-308-0833. Learn more about house calls for athletes at www.DocOnThRun.com and learn more about foot and ankle pain at www.AnkleCenter.com .

Sesamoid injury in a runner?

I recently got from a question from a runner who had been ramping up for the California International Marathon in Sacramento and started having pain in the ball of the foot at the big toe joint...

"Hello Dr. Segler, I have been training for my first marathon and read that hills would be a great way to get super strong. I really wanted to do well and finish in under four hours so I started do hill repeats on Fillmore Street in San Francisco. Things were going great and I really felt like all the training was starting to pay off. Then one morning I got up and noticed this little aching pain in the bottom of my big toe joint every time I stepped on my right foot. It seemed to be worse on the hard tile in the kitchen. I have been really ramping up the miles and I am worried that this may be a stress fracture. Can you tell me the best way to tell if this is a stress fracture or something else? It hurts right in the ball of the foot under the big toe joint. Here is a picture of where it seems to hurt the most. Thanks!"


Great question! And thanks for sending the pic.. Here is your answer...

Pain in the ball of the foot can occur under the big toe joint for several reasons. Based on your description and the location of the tenderness, I would be most worried about the following conditions:

1. Sesamoiditis: inflammation of the sesamoid bones under the big toe joint (first metatarsophalangeal joint). You stand on these two little bones. Because they get stressed more when you run uphill, you may develop sesamoiditis when doing lots of hill repeats. If you push right on the hard little bones, and one hurts more than the other, it is probably sesamoiditis.

2. Flexor Hallucis Longus tendinitis (FHL tendonitis): strain, inflammation and/or micro-tearing of the tendon that pulls the big toe down against the ground allowing you to push off when you run. The sesamoid bones are actually embedded within the FHL tendon. If you push right under the big toe joint and the whole area is tender (and doesn't really hurt more on one specific sesamoid bones) it may be FHL tendonitis. If you pull upward on the big toe (away from the ground) you will stretch the FHL tendon. If this hurts, FHL tendonitis is likely.

3. Sesamoid Stress Fracture: a tiny little crack in one of the sesamoid bones from too many hill repeats and or too much running volume. If this is the cause of your foot pain, it will hurt more on one sesamoid than the other, it will also hurt when you pull the big toe upward, and your foot will most likely be swollen and/or bruised. The best way to diagnose a stress fracture of the sesamoid bone is with an MRI. X-rays don't always show stress fractures right away. X-rays will only show a stress fracture in a sesamoid that has fractured or completely cracked. Based on your story, however, this seems unlikely.

Get better as fast as possible and good luck in your marathon!

Learn more about sesamoiditis, FHL tendonitis and sesamoid stress fractures at www.AnkleCenter.com

Dr. Christopher Segler is a nationally recognized expert on running biomechanics and foot surgery. He has been invited to lecture to foot surgeons, sports medicine doctors, podiatrists, triathletes and runners in training all over the United States, as well as Canada, New Zealand, Portugal and Turkey. If you have foot pain caused by a running injury, you can send a picture of where it hurts and a brief description to him. Your picture and answer to your question will then be posted on our blog so others can learn how to deal with running injuries as quickly as possible and keep running pain free. You can email your pic and question to DrSegler@DocOnTheRun.com If you have a quick question about a running injury and you are not in San Francisco, you can actually call him directly as 415-308-0833. He schedules house calls for runners and triathletes in San Francisco, Marin and the East Bay through DocOnTheRun.com.

PRP Injection vs. Cortisone Injection in a runner with Achilles tendinitis?

Today I received a call from a runner who wants to know whether his painful Achilles tendon would get better faster if he had a cortisone shot or the newer Platelet Rich Plasma (PRP) injection.

Cortisone injections are one of the oldest and most common treatments for tendon pain when inflammation arises due to running and over-training. However it is not always the best treatment.

What you need to understand about cortisone injections (also known as corticosteroid injections) and PRP injections is that they are both very effective at reducing Achilles tendon pain, but for very different reasons. They are essentially opposite ends of the same spectrum.

Corticosteroid injections stop the inflammatory process cold. If you're trying to remove pain, swelling and inflammation, cortisone injections are a great tool. The problem is that if you have a small tear in the tissue that needs to heal, you have essentially stopped the healing process. In addition, the corticosteroids are well know for breaking up collagen bonds. Because your Achilles tendon is really a huge cable made of collagen, corticosteroid injections can weaken the tendon and make it more likely to rupture or completely tear.

PRP injections work in the opposite way. The PRP injection takes all of the growth factors that are present in your blood stream (within the platelets) and concentrates them many times. The powerfully concentrated growth factors are then injected directly into the injured tendon tissue in order to stimulate new blood flow, unlock the body's natural healing response and directly stimulate healing of the injured tendon. If there are small micro-tears in the Achilles tendon, a PRP injection will be much more effective than corticosteroid injection.

One injection turns the inflammation off while the other turns the healing on. Each has its place, just make sure you explain all of your running goals with your sports medicine doctor when considering either of these injections for your aching Achilles tendon.

You can learn more about what happens before your Achilles PRP injection by clicking here and what happens after your Achilles PRP injection by clicking here.

Dr. Christopher Segler is a 6-time Ironman Finisher and an award winning foot and ankle surgeon. He even does house calls for busy runners and triathletes in San Francisco, Marin and the East Bay. If you have a question about foot pain related to running, you can call him directly at 415-308-0833. For more information on Achilles running injuries, visit www.anklecenter.com.

What is this new pain in the ball of the foot? Question from a runner in San Francisco

Today I got a question from a runner in San Francisco. She says...

QUESTION:

"I wanted to get in touch about another issue (!) I'm having with my foot. Honestly, always thought it'd be knees that went...not my feet! Basically here is what happened:

*had been running again, but not heavy mileage...like 3-miles a few times a week along with perhaps some slower jogs (1 - 2 miles).

*but, then I participated in a TRX class where we did TONS of plyo stuff. squat jumps, etc. the next day, I noticed this pain.

*the pain is on the same foot as my tendonitis was. not sure if it's relevant. I decided to take a photo to show you where the pain is! hope that's not creepy ;) I did some research online, briefly, and thought maybe it's a bursitis?? I don't know, but the class was 3 weeks ago and I've been icing it, not running and the pain is not decreasing, if anything it's getting worse. I haven't been running, just doing the elliptical at the gym and cycling. Cycling does not exacerbate it at all, thankfully!

Also, do I need to get x-rays and stuff to rule out a stress fracture, etc.?

Anyway, thanks for your time!

Gretchen
San Francisco


MY RUNNING DOC's ANSWER:

Thanks for sending the pic and providing the description of the pain in the ball of your foot!

Based on your story and the location of the pain, it is most likely predislocation syndrome. Predislocation syndrome is capsulitis (inflammation of the joint capsule) in the ball of the foot, most often at the second metatarsal phalangeal joint (the joint at the base of the second toe). The capsulitis is what causes the pain, but the real issue is a strain or even tear in a reinforcing structure of the joint capsule called the plantar plate.

I actually see this all the time in active people who spending a lot of time on eliptical trainers. At the back stroke of the eliptical trainer, your heel comes up and the toes bend way up stressing the plantar plate. The plantar plate is a small ligament that reinforces the bottom of the metatarsal phalangeal joint capsule (the joint at the base of the toe in the ball of the foot).

To get it to calm down you have to avoid stressing the plantar plate. Avoid anything that causes you to bend the toes up, such as an eliptical trainer, running uphill, etc. You can also tape the toe down to decrease stress on the plantar plate. Ice, contrast baths and compression socks can decrease the inflammation.

This of course all assumes that your pain is caused by predislocation syndrome. The other common possibilities include a Morton's neuroma or a metatarsal stress fracture. It is pretty easy for any sports medicine podiatrist to tell on physical exam.

Given that 1) most stress fractures show nothing on x-ray until it has been at least 6 weeks, and 2) any sports medicine doctor who specializes in running injuries could tell you with relative certainly whether this is predislocation syndrome or not without an x-ray, I think a physician should just do a quick check and get you heading in the right direction.

Thanks for the question!

Dr. Christopher Segler
Doc On The Run
Podiatry House Calls for Runners
San Francisco, Marin, East Bay

If you have a question about foot pain caused by running, you can email a picture (pointing to the painful area) directly to DrSegler@DocOnTheRun. Tell me how it happened and I will post a an explanation so you will know what is most likely ruining you run. Your name will be changed, and you will never be identified by your real name, so as to protect your identity and shield you from any possible accusations of making a preventable marathon training mistake. I will also never, ever share your email address with anyone.

Will orthotics help heel pain when running?

This morning I received an inquiry from a runner in Marin who is training for the Dispea. He asked a common question:

"I have severe left heel pain especially after a 5-8 mile run. I am training for the Dipsea. Advice? Should I consider orthotics?"

Answer:
Custom orthotics can certainly help to alleviate many forms of heel pain including the most common type which is plantar fasciitis. Custom orthotics in fact are one of the best ways to slow do pronation and decrease stress to the large ligament on the bottom of the heel called the plantar fascia. If you over-pronate and repeatedly tug on the plantar fascia as your arch height changes, you get inflammation of the plantar fascia... known as plantar fasciitis.

A long run can place a tremendous stress on the plantar fascia and the heel bone. Most people with plantar fascitis will have pain in the bottom of the heel on days following running. Usually the pain is worse with the first couple of steps when they get up out of bed. They can also get a sharp pain in the heel when they start walking after sitting at a desk for a while.

Custom orthotics are one of the best treatments for this type of running-related heel pain. But that doesn't necessarily mean that it is best to get custom orthotics and keep running. You must get an evaluation with a running focused podiatrist first.

The concern is that you might have something worse than plantar fasciitis. In this case, the runner reports heel pain that is "severe" following long runs. Plantar fasciitis would usually be worse (and more annoying) the day after a long run, but not necessarily severe. It would be important to get x-rays and take a look at the heel bone (calcaneus) to be certain that you are not at risk for stress fracture in the heel bone (calcaneal stress fracture).

It is also possible that there is a cyst in the heel bone that is causing the problem. In the simplest of terms, a calcaneal cyst is a hollow or fluid filled pocket that develops within the heel bone. When running, the walls of the cyst can flex slightly causing pain and inflammation in the heel bone itself. In some cases the heel bone can flex so much that it cracks or fractures. This is actually much worse than a calcaneal stress fracture.

With a quick set of x-rays and an exam by an experienced running podiatrist, heel pain can be effectively treated. With all of the conditions that effect the heel, the sooner the best treatment is chosen and starts, the faster you will finish your goal race, wether it is the Dipsea, the Vineman or the San Francisco Marathon.


Dr. Christopher Segler is an Award Winning Foot & Ankle Surgeon, 5-Time Ironman Finisher and a sports medicine podiatrist who makes house calls for busy runners, triathletes and active professionals in San Francisco, Marin, the East Bay and the Peninsula. If you have a question about running related heel pain, you can call him directly at (415) 308-0833. You can also learn more about custom running orthotics at AnkleCenter.com and DocOnTheRun.com.

Stay Fit. Go Long. Run Fast. Be Strong.

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