to open this article in a new window - podiatry management magazine

APRIL/MAY 2013 | PODIATRY MANAGEMENT | 187www.podiatrym.com

Introduction: Where Do We ComeFrom and Where Are We Going?

We’ve previously looked to thefuture in articles such as “All TheSmall Things”1a and examined diffi-cult problems in “Challenging Run-ning Injuries”.1b As we are products of

evolution, our scientific understand-ing also evolves. The future of the sci-ence of sports medicine will includeitems we’ve so far heard little of. Be-sides genomics, we will hear more ofsystems biology, stochastic phenome-na, Markov decision processes in bio-

logical phenomena and mechanobiol-ogy. Today we will take a straightfor-ward look at the current state of themost frequently encountered runninginjuries.

Keep in mind what George BoxContinued on page 188

Continuing

Medical Education

Objectives1) Describe the features of the top

running injuries.

2) Present recent concepts onmuscle imbalance and the relation-ship of core muscles to clinical enti-ties including PFPS and iliotibialband syndrome.

3) Review the significance oftendinopathy and fasciopathy inclinical practice.

4) Review the concept of enthesisand tendinopathy as they pertain toAchilles tendon injuries.

5) Review current theories of thecause of medial tibial stress syndrome.

6) Present current concepts of stressreactions and stress fractures of boneas repetitive stress injuries of bone.

7) Describe an outline of treat-ment recommendations for Achillestendonitis, plantar fasciitis, iliotibialband syndrome, patellofemoral painsyndrome, medial tibial stress andstress reactions of bone.

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin-uing Medical Education by the Council on Podiatric Medical Education.

You may enroll: 1) on a per issue basis (at $22.00 per topic) or 2) per year, for the special rate of $169 (you save $51).You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. You can also takethis and other exams on the Internet at www.podiatrym.com/cme.

If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earnedcredits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake thetest at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 198. Other than those en-tities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be ac-ceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best ef-forts to ensure the widest acceptance of this program possible.

This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of thisprogram is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts bynoted authors and researchers. If you have any questions or comments about this program, you can write or call us at:Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected].

Following this article, an answer sheet and full set of instructions are provided (pg. 198).—Editor

SPORTS PODIATRY

The Top FiveRunning

Injuries Seenin the Office—

Part 1Here’s the current evolution in thought,

literature, and treatmentof these conditions.

BY STEPHEN PRIBUT, DPM

www.podiatrym.com

SPORTS PODIATRY

RUNNING INJURIES

188 | APRIL/MAY 2013 | PODIATRY MANAGEMENT

said: “All models are wrong, butsome are useful.’’ You may couple

that with the following words of wis-dom, a paraphrase of Nobel LaureateJames Black: “Our models are notmerely pathetic descriptions of na-ture; they are accurate descriptions ofour pathetic thinking about nature.”

Long distance running is auniquely human undertaking. Noother primate runs long distances.Considering mammals in general,some cover shorter distances at afaster speed, but only a select few areable to maintain a rapid pace over along distance. The development ofbipedal locomotion and an uprightposture has resulted in structural andfunctional differences in our muscu-loskeletal system and in the biome-chanical function of our locomotorsystems. It is thought that runningmay have been a significant evolu-tionary adaptation permitting easiersurvival by virtue of primitive ho-minids’ enhanced ability to escapefrom predators and to catch prey.

Running is a vitally importantpart of the lives of many people. It isnot only a sport, an integral segmentof the runners’ lives that is often car-ried out with near religious fervor.Running yields health benefits rang-ing from those which impact our psy-chological well being to our physicalhealth. Running has been found tohave a positive impact on depression,cardiovascular health, muscular fit-ness, osteoporosis, diabetes, blood

pressure, obesity, prevention of coloncancer, and a variety of other mea-sures of health.1,2

What Makes Runners DifferentRunners have made their athletic

activity an integral part of their lives.Runners have begun running andcontinue their sport for a variety ofreasons. Runners often participate incharity runs and dedicate their run tocauses or people that are close tothem. They do not do well whentheir sport is interrupted by bad

weather, work, or even worse, an in-jury. Many times runners have inte-grated their exercise into a diet andweight loss program. When the run-ner is forced to stop exercise theirbody image suffers.

Emotional AspectsMost runners are highly motivat-

ed. They suffer physically and emo-tionally when their exercise is inter-rupted. Exercise withdrawal can havea large impact on mental health andmay result in insomnia or depression.Runners have high expectations thattreatment of their injuries will be

speedy and have excel-lent results. Most runnersdo not want to be toldnot to run! In fact, theadvice most often givenby other runners is that“if a doctor tells you notto run, the first thing todo is to run out of theiroffice”. The concepts ofrelative rest, cross-train-ing, and alternative formsof exercise must be care-fully explained to therunner. Clearly spell outthe modifications totraining that must bemade to assist in recov-ery from injury.

Runners often look

for a physician who is a participantand shares their passion for running.While football coaches are not usu-ally chosen for their ability to catchor throw passes, running docs arefrequently sought out if they areknowledgeable and also runnersthemselves.

Physical AspectsMost runners are physically fit,

with the exception of those who arerecent converts to the sport. Theranks of marathoners continue to

swell. Chorley, et al. studied runnersjoining a 25-week marathon trainingprogram and found that 52% hadnever run a marathon before and16% had been sedentary in the threemonths prior to starting training.3 Pre-vious injuries were reported by 38%of runners and 35% of those injurieswere still symptomatic at the incep-tion of the training program. Desiremay oftentimes be greater than readi-ness. No longer do the new runnersslowly work up to a marathon by run-ning for six months to a year beforestarting marathon training.

In looking at the biomechanics ofrunning, it is important to rememberthat running is a one-legged sport.Unlike the walking gait, the runner isonly on one foot and leg at a time,and never on two. Significantly higherforces are encountered while running.The foot gear used for distance run-ning is designed for straight aheadmotion and is not suited for signifi-cant side-to-side motion or suddenchanges in direction.

Risk Factors, Studies on InjuryPrevention

After many years of study we stillcan not accurately predict what fac-tors are responsible for running in-juries.4 While many have conjecturedthat shoe selection plays a role in pre-

In looking at thebiomechanics of running, it is important to remember

that running is a one-legged sport.

Continued on page 189

Continuing

MedicalEducation

MPFL medial patellofemoral ligament

VMO vastus medialis obliquus

PFPS patellofemoral pain syndrome

ITB iliotibial band

ITBS iliotibial band syndrome

MRI magnetic resonance imaging

RSI repetitive stress injury

MTSS medial tibial stress syndrome

VL vastus lateralis

BMU bone multicellular unit

Abbreviations


SPORTS PODIATRY

RUNNING INJURIES

dicting injury, the use of motion con-trol shoes based on foot type was as-sociated with an increased incidenceof injury. The minimalist shoe move-ment has not backed up their claimsof lowering injury rates with any harddata. Clinical observations seem to in-dicate that there is a change in injurypattern among minimalist shoe wear-ers. Clinically those changing to mini-malist shoes and forefoot strike oftenpresent with forefoot stress fracturesor calf and Achilles tendon pain. Run-ners who would like to use minimal-ist shoes should follow the consensusof advice which is to carefully andslowly transition or integrate mini-malist shoe use into their trainingprogram..

Over the years different injurypatterns have been seen. As shoes be-came more cushioned, we saw an in-crease in Achilles and calf injuriescreated by the eccentric forces occur-ring during heel and midfoot strike.We did see a decrease in peripatellarpain while also seeing an increase iniliotibial band syndrome. As the man-ufacturers make shoes lighter and in-corporate a lower heel to forefootdrop, we should expect to see otherchanges in injury trends.

A general agreement exists thatmost running injuries are injuries ofoveruse.3-6 A detailed history must betaken and all aspects of a patient’s ex-ercise program must be evaluated.Look for changes in shoe use such as

a new shoe model, a different shoebrand or old shoes that have becomeexcessively worn. These changes maybe factors in aggravating or creatingan injury. Besides these changes inrunning shoes, a change in the train-ing program may have triggered theproblem. The “terrible too’s” are

often linked to these over-training in-juries. These include “too much, toosoon, too fast, too often, with too lit-tle rest.”

A risk factor that is omitted frommost evaluations of running injuries

is injury from concomitant training.Plyometric exercises often lead to in-jury. Strength training, which is oftensupplemental and helpful, can occa-sionally create an injury. Theseshould be explored while taking thepatient’s history.

The stress loads of exercise mustbe gradually increased. These loadsshould not outpace the body’s physi-cal ability to adapt to the new loads.While some studies have not beensufficiently designed to discern run-ning-related injuries per hours run(RRI/1000 hours), other authors haveposited the significance of the gradualbuild-up although not successfullydemonstrated it in an epidemiologicalstudy.7

In the rush for fitness, many areinjured. As we examine these in-juries, we’ll also note that there hasbeen an evolution in the conceptual-

ization of many of these injuries. Thisevolution has occurred slowly and inthe face of imperfect knowledge. Theconcept of tendinopathy, as the ap-propriate term for tendon pathology,is an evolution of thought as is theconceptual and terminology changessuggested for problems such as plan-

tar fasciitis. Is the iliotibial bandsyndrome a problem of friction orsomething else? Is the Vastus medi-alis the muscle that we need to havethe patient strengthen to improvequadriceps function and treat patello-

femoral pain syndrome? We’ll consid-er these problems below.

Top Five Running InjuriesKnee Pain (PFPS, ITBS)Achilles TendonStress FracturesMedial Tibial Stress SyndromePlantar Fasciitis

Knee Pain: Patellofemoral PainSyndrome (PFPS) and ITBSyndrome

Called by a number of differentterms over the years, patellofemoralpain is one of the top five running in-juries impacting up to 2.5 million run-ners in the United States. Chondroma-lacia patella, runner’s knee, and ante-rior knee pain have all been appliedto this condition. Since the site of ori-gin of pain in this area includes sever-al structures, the appellation “chon-dromalacia” is too limiting. Therefore,the nonspecific term patellofemoralpain syndrome (PFPS) is preferred bymost authors. Pain here is thought toarise from any or all of the followingstructures: the subchondral bone, me-dial and lateral retinaculae, infrapatel-lar fat pad and the anterior synovium.Patellofemoral pain syndrome hasbeen reported to affect up to 30% ofall runners. While many features ofthis very common malady remain tobe detailed, a number of risk factorshave been cited over the years. Thecomplex relationship of anatomicalalignment of the limb, patellar shape,presence of patella alta, and even thefunctional aspects of the peripatellarretinaculum8 have an impact on boththe forces occurring within this sys-

The stress loads of exercise must begradually increased. These loads should not outpace the

body’s physical ability to adapt to the new loads.

A general agreement existsthat most running injuries are injuries of overuse.3-6

A detailed history must be takenand all aspects of a patient’s exercise program

must be evaluated.


Continuing

Medical Education

www.podiatrym.com

SPORTS PODIATRY

RUNNING INJURIES


tem and the development andresolution of symptoms of this con-

dition. A number of risk factors havebeen thought to contribute to PFPS.They are detailed in Table 1.

Changing Concepts in PFPSWe need to keep in mind the

myriad factors that come into playwith this disorder. The stability ofthe patellofemoral joint occurs viathe interplay of soft tissue structures,bone and joint surfaces, and overalllower extremity biomechanics.9

Clearly more than excessive prona-tion of the subtalar joint and a weakvastus medialis muscle contribute tothis problem.

Senavongse and Amis view thestabilizers of the patellofemoralcomplex as 1) active stabilizers—thequadriceps muscles, 2) passive sta-bilizers—the retinaculum and liga-mentous structures, and 3) staticstabil izers—the joint surfaces.9

Structures providing medial stabilityto the patella include the Vastus Me-dialis Oblique (VMO), medialpatellofemoral ligament and, to asmall degree, the medial retinacu-lum.8 The patella itself is found tohave the lowest amount of medialstability at 20 degrees of flexion.9

This is only part of the story butgives a larger picture than we usual-ly consider.

Quadriceps weakness is mostoften addressed in rehabilitative exer-cises. While the VMO is often men-tioned as the weak link within thequadriceps, the VMO cannot be di-rectly and independently strength-

ened using most exercise programs.The only method that has emphasizedthe VMO over the Vastus Lateralis(VL) has been with the use ofbiofeedback. While the VMO10,11 isknown to be the primary muscularstabilizer of the knee, it functionsthroughout the range of flexion and

extension of the knee.Hip abductor weakness is associ-

ated with PFPS and should be ad-dressed in crafting a rehabilitationprogram.12,13 Cichanowski noted sig-nificant differences in hip abductorand external rotator strength be-

tween limbs suffering from PFPS andthe normal limbs. Noehren et. al. ina prospective study of 400 femalerunners, found an increase in thehip adduction angle in those whodeveloped PFPS.13a The study alsonoted this may occur in conjunctionwith compensatory trunk mechanics

such as an ipsilateral lean.Abnormal pronation of the subta-

lar joint was first mentioned as a con-tributing factor to this condition inearly lectures and books of GeorgeSheehan, M.D.14 More recent researchhas confirmed Sheehan’s early feel-ings on this and reaffirmed his sug-gestion that foot orthoses were likelyto be effective.15

The pain of PFPS appears to becaused, in part, by overload of therichly-innervated subchondral bone,the extensor retinaculum, and the in-frapatellar fat pad. Chondromalacia isa surgical observation, and no longera term applied diagnostically to thisclinical condition.

Treatment of PFPS (Table 2)Treatment for this condition in-

cludes a decrease in running via rela-tive or absolute rest. NSAIDs can be

The only method that has emphasized the VMOover the Vastus Lateralis (VL) has been with the use

of biofeedback.


Continuing

MedicalEducation

• Increased Q Angle

• Weak or ineffective Vastus Medialis (VMO)

• Patellar Dysplasia (e.g., small medial pole of patella)

• Trochlear Dysplasia (congenital flattening of the lateralfemoral condyle)

• Patella Alta (Ward et. al. JBJS 2007 Patella Alta: Association withPatellofemoral Alignment….)

• Hypermobility of Patella

• Ligamentous Laxity

• Genu Varum/Valgum

• Female gender (possibly multifactoral, wider hips, higher Q angle, etc.)

• Malalignment of Extensor Mechanism

• Abnormal knee joint moments

• Abnormal pronation of the foot

• Other Lower Extremity Malalignment

• Weak Hip Abductors

• Increased Hip Adduction

• Canted Surface

• Overtraining

TABLE 1

Risk Factors


SPORTS PODIATRY

RUNNING INJURIES

used to reduce pain. It is important tostrengthen the quadriceps by a care-fully instituted program. Straight leglifts result in the least amount offorce occurring at the patello-femoraljoint while strengthening the quadri-ceps. Core body exercises are recom-mended including hip abductor exer-cises and gluteal strengthening exer-cises which may consist of bridgesand single leg bridges. Gentle ham-string and calf stretches are also oftenrecommended.

Lower extremity biomechanicsand foot structure should be assessed.Recommendations for proper shoes,and orthotics, if deemed necessary,should be made. Orthotics have beenfound to be helpful in the treatmentof PFPS.16 Resumption of running

should be gradual with incrementalincreases in at first distance, and laterspeed work.

Other ConsiderationsPatellar tendinopathy is often

found alone or in conjunction with

PFPS. Patellar tendinopathy manyyears ago was called “jumper’sknee”. In runners it may be related tohill running, plyometric exercises or

speed work. We have alreadynoted that running is a one-leggedexercise. Another important factor tobe aware of is that with foot strike,the major muscle activity in the limbis to effect a braking action. Thequadriceps is working after contact to

prevent the knee from bending toorapidly. This creates eccentric forceswithin the tendon. At the same time,the calf muscle is firing to slow theforward motion of the tibia, especial-ly in heel and midfoot contact gait,while the gluteal muscles are firing toslow the forward motion of thefemur. The larger gluteal muscleshave been hypothesized to come intoplay more with faster running andspeed work. Gluteal muscle activityis clearly evident in kicking a soccerball as the forward movement of theleg is braked. Strengthening thegluteal muscles is often used for bas-ketball players with this injury and isequally helpful for runners. Combin-ing the therapy described above withan emphasis on gluteal strengtheningis often successful in rapidly decreas-ing the symptoms of patellartendinopathy.

Iliotibial Band Syndrome (ITBS)Iliotibial band syndrome (ITBS) is

found among the top injuries in re-cent studies.3a The change in trainingmethods and the characteristics ofmany of today’s long distance run-ners, including the “suddenmarathoner syndrome”, is the mostlikely cause of the dramatic increasein this malady. For more than tenyears, it has been clear that ITBS isassociated with weak hip abductormuscles. The gluteus medius workshard to keep the pelvis level. Weakhip abductor muscles result in the re-cruitment of the muscles which insertinto the iliotibial band itself to assistwith hip abduction. This causes an

Another important factor to be aware ofis that with foot strike, the major muscle activity in the

limb is to effect a braking action.


Continuing

Medical Education

Relative or Absolute RestPain reduction with medication (NSAIDs)

For 8-12 Weeks the following exercises:Therapeutic Exercise Program Strengthening the Quadriceps

Straight leg lifts—Start with 3 sets of 10 reps each side,work up to 10 sets of 10 reps.

Hip and Core Muscle Strengthening (Gluteus Medius, Maximus)Bridges 10-15, Planks, After 3 weeks add Single Leg Bridges 8-12

Strengthen Calf Muscles—standing with knee straight

Posterior Stretching—Hamstrings and calf muscles

Additional Therapy:Patellar Tendon and Peripatellar Massage and ManipulationTaping or Bracing

Upon return to running:Easy graded return.Avoid speed workAvoid down hillsProper shoes for biomechanical needs of lower extremityOrthotics, if indicated

Gradual return to speedworkContinue to be wary of downhill running

TABLE 2

Outline of Therapy for PFPS

www.podiatrym.com

SPORTS PODIATRY

RUNNING INJURIES


increase in tension developingwithin the ITB and possibly in-

creased forces in both the tissue ofthe ITB and the adjacent fatty tissue.Most of the historical literature refersto this syndrome as a “friction bandsyndrome” and inflammation wasoften mentioned as contributing tothe pain.17 In spite of this terminolo-gy, no studies documenting inflam-mation within the tendon turned upon a Medline search. The view that itis primarily a “friction”-based syn-drome is fading.

More recently further anatomicalstudies have suggested that pain inthe iliotibial band area is not causedby friction.18,19 Fairclough raises thequestion “Is the iliotibial band syn-drome really a friction syn-drome?”18,19 He contends that the ITBis firmly attached to the femur andis not anatomically capable of mov-ing forward and backwards over thelateral epicondyle of the femur. Re-cent cadaver studies and MRI stud-ies have failed to document the ex-pected evidence for friction or for aprimary anatomical bursa. Insteadan area of compression has beennoted which seems to affect the rich-ly vascularized and thoroughly in-nervated fat below the tendon. OnMRI a zone of signal intensity abnor-mality was found in this area andfelt to be associated with intermit-tent fat compression.19,20

Tension within the iliotibial bandwas cited by Noehren et. al. as a con-tributing factor, with compression oc-curring rather than friction:

“The development of iliotibialband syndrome appears to be relat-ed to increased peak hip adductionand knee internal rotation. Thesecombined motions may increase ili-otibial band strain, causing it tocompress against the lateral femoralcondyle. These data suggest thattreatment interventions should

focus on controlling these secondaryplane movements through strength-ening, stretching and neuromuscu-lar re-education.”21

Muscular and neuromuscular fa-tigue and the resulting kinematicchanges that occur during long dis-tance running may also contribute tothis and other overuse injuries. Im-

pact shock, while more often studied,is not a factor. Instead, increased hipadduction, an increase in knee flexionat heel strike, and maximum knee in-ternal rotation velocity were found tobe higher at the end of a run in indi-viduals with ITBS.22 Miller’s computermodeling system also indicated thattension would be greater in the ITB

for patients throughout the stancephase of the running gait cycle.

Anatomical ConsiderationsThe iliotibial band (ITB) is a con-

tinuation of the tensor fascia lata as athickening of the lateral fascia of theupper leg. A significant portion of thegluteus maximus inserts into the ITB.Along the course of its descent downthe leg there are connections to thelinea aspera of the femur. The ITBfans out distally to insert on the later-al aspect of the patella, the lateralretinaculum and Gerdy’s tibial tuber-cle. Functionally the tensor fascialata, gluteus medius and gluteus min-imus function as hip abductors.

Diagnosis of ITBSIliotibial band syndrome (ITBS) is

a clinical diagnosis which is made inthe presence of lateral knee pain inthe general region of the lateralfemoral epicondyle, with tendernessand pain upon compression of this


Continuing

MedicalEducation

Relative or absolute rest

Strengthening:Hip Abductor Muscle Strengthening—Standing hip tilts on one legto isolate hip abductors.

Stretching:Side bends to stretch tight lateral structures, hip capsule andfibers inserting into the iliotibial band. The latissimus dorsi is alsostretched with this exercise. The latissimus dorsi can alter trunkand hip movements.

Ancillary stretches—adductors and rotators of hip.

Advanced stretches:Stair dipStair Strides

Optional:IceFoam roller

TABLE 3

Treatment Outline for ITBS

The ITBS seems to beprimarily caused by overuse in the presence of

muscular imbalance.


SPORTS PODIATRY

RUNNING INJURIES

area while the knee is flexed and ex-tended. Tenderness in adjacent struc-tures, including the lateral collateralligament of the knee and at the lateraljoint line, should not be present. Inearly stages, the pain might onlymanifest itself while running or fol-lowing a run.

Evolution in Conceptualization ofITBS (Summary)

The ITBS seems to be primarilycaused by overuse in the presence ofmuscular imbalance. Weak hip ab-ductor muscles are the culprit. ITBS,in most cases, is not a friction syn-drome with a “popping” of the ten-don over the femoral epicondyle. In-stead, there is a compression in thisregion that most often affects the fattissue overlying the femoral epi-condyle. Clinically, pain while walk-ing and tenderness is not alwaysfound in the early stages. Tensiondoes develop within the band andearly stage tendinopathic changesmay be present, but no research hasdemonstrated this yet.

The same factors that create ITBScan lead to hip pain which is fre-quently found in conjunction withthis condition. Hip pain associatedwith weak hip muscles and ITBS canbe caused by trochanteric bursitis or

gluteus medius insertional tendinopa-thy. A more serious condition, a tearof the hip labrum, occurs less often.

Treatment of ITBSRelative or absolute rest is an im-

portant component of the treatmentplan for any of these running-relatedoveruse syndromes. Directly address-ing the cause of the ITB syndrome, inmost cases, seems to give significantclinical success. Weak hip abductormuscles have been directly implicatedin this condition. An additional factormay be tendon and capsular tight-ness. A treatment program should in-

clude hip abductor strengthening inconjunction with lateral hip capsuleand soft tissue stretching.

NSAIDs or ice may be used to re-duce discomfort. Foam rollers and tis-sue-mobilizing massage have beenrecommended. Abnormal biomechan-ical functioning of the foot and legshould be addressed, including limblength discrepancy, but there is noevidence that either motion-control

shoes or excessively cushioned shoescontribute to this condition or help toalleviate it. Table 3 outlines a treat-ment program for ITBS.

Achilles Tendinopathy

AnatomyThe Achilles tendon is the contin-

uation of the gastrosoleus complex ofmuscles and is at the terminal aspectof this multijoint system. The gastroc-nemius begins above the knee joint,the soleus below. The joints on which

they have a direct impact include theknee joint, the ankle joint, and thesubtalar joint. The most distal aspectof the insertion becomes contiguouswith the plantar fascia. The complexanatomy of the insertion is describedbelow as an enthesis organ.

PathologyFor years, almost all tendon pain

was lumped into the category of ten-donitis. It was mistakenly believedthat inflammation was the underlyingprocess causing the pain and patholo-gy in what was called Achilles Ten-dinitis. Tendinopathy is now the

lump-all category for tendonpathology. This term includesearly stage tendinitis, paratendinitis,and later stage chronic tendinosis.Histological studies have demonstrat-ed that those with chronic tendonpain do not have inflammatorychanges in the affected tendon, butrather degenerative changes.23

The term tendinosis is used specifi-cally to apply to tendons with known

chronic degenerative changes. Theterm tendinopathy itself does not havethis connotation and is well used toapply to overuse tendon pain andswelling in the absence of ahistopathological diagnosis (Maffulli,Khan, Paddu). In long-standingtendinopathy, at surgery, the tissuedemonstrates the appearance of mu-coid degeneration. The tissue appearsbrown or yellow and shows disorgani-zation, and an apparent lack of well-defined tightly bundled collagen fibers.Microscopic examination reveals de-generative changes and concomitant fi-brosis.24 Ultrasound examination haspreviously demonstrated neovascular-ization in the injured tissue.

Achilles tendon disorders areoften divided into three zones: 1)Noninsertional—the tendon proper(and paratenon), 2) conditions affect-ing the tendon insertion, and 3) proxi-mal—at the muscle tendon interfaceand more structures proximal.25,26 Anoutline based on Puddu, et al., andWerd is seen in Table 4.

Evolution of Thought in InsertionalEnthesopathy

Tendinopathy may occur at theinsertion of the Achilles tendon orwithin the main body of the tendonitself. It is possible that these two dif-fering areas may result from diversepredisposing factors. It has been sug-gested that repeated stresses that arewell within a clinical and functional

Tendinopathy may occurat the insertion of the Achilles tendon or within the

main body of the tendon itself.

Relative or absolute rest is an important componentof the treatment plan for any of these running-related

overuse syndromes.


Continuing

Medical Education

www.podiatrym.com

SPORTS PODIATRY

RUNNING INJURIES


range may create the pathologyin a manner similar to the manner

in which bone stress reactions mayoccur.27 The major contributing caus-es cited include overuse, abnormalbiomechanical factors, fluoro-quinolone antibiotics and corticos-teroid use.

At the insertion of the Achillestendon, a variety of conditions mayoccur. In addition to insertionaltendinopathy of the Achilles tendon,one may find retrocalcaneal bursitis,Haglund’s deformity, and pre-tendi-nous bursitis. When the Haglund’sdeformity is symptomatic, it is usu-ally found as a triad of insertionaltendinopathy of the Achilles tendon,a prominent posterosuperior cal-caneal process, and retrocalcanealbursitis. Insertional tendinopathycan occur in the absence or presenceof calcaneal bursitis. Numerousstudies indicate that insertionaltendinopathy occurs in up to 5%—20% of Achilles tendon overuse in-juries.28 Older individuals appear to

be at higher risk for this injury.28

The insertion of the Achilles ten-don is complex. At the osteotendi-nous junction of the Achilles tendon,histological examination reveals ten-don, fibrocartilage and bone. Thereare three types of cartilage foundhere: sesamoid, periosteal, and enthe-

sial fibrocartilage. The term “articularenthesis organ” has been applied tothe insertion of the Achilles in view ofthe complexity of its insertion (withthe presence of a complex of fibrocar-tilages, a fat pad, and bursae).29 Thesesamoidal fibrocartilage is located atthe deeper portion of the tendon andis termed such since it is within thetendon. The periosteal fibrocartilage

is located on the opposing superiortuberosity of the calcaneus and istermed such since it is a modificationof the periosteum. While rheumatolo-gists began viewing this insertion asfundamentally different, the conceptof enthesis organ is only slowlybreaking ground in the discipline of

sports medicine. What has beentermed an insertional tendinopathymight more correctly be called an in-sertional enthesopathy.

An enthesis is by definition the in-sertion point of a tendon, ligament,fascia or articular capsule into a bone.This area is susceptible to drug-in-duced enthesopathies by fluoro-quinolone antibiotics (which may alsoaffect the tendon prior to its inser-tion). In the case of the Achilles com-plex, the combination of tendon, fi-brocartilage, fat pads, and bursa maybe affected at any of those areas, or inmultiple tissue types, which altersfunction and forces.30

Fibrocartilage functions to resistshear and strains at the enthesis. Thisnew conceptualization has great andsignificant future implications for un-derstanding of forces, function, andtreatment of Achilles tendon inser-tional disorders.

Bone spurs which form at this lo-cation have been noted to not bewithin the substance of the tendon it-self. The relationship of the “spurs”here to the fibrocartilage remains tobe detailed. There are several addi-tional conditions to consider near theinsertion of the Achilles tendon in ad-dition to insertional Achillestendinopathy and enthesopathy.These conditions include retrocal-caneal bursitis alone and Haglund’sdisease which consists of a painfulretrocalcaneal bursa in conjunctionwith a prominent postero-superiorcalcaneal process. Haglund’s deformi-ty itself is often asymptomatic. In the

An enthesis is by definitionthe insertion point of a tendon, ligament, fascia

or articular capsule into a bone.


Continuing

MedicalEducation

Zone 1: Non-insertional Achilles InjuriesAchilles paratendinopathyAchilles tendinopathyAchilles tendinosisAchilles tendon rupture

Zone 2: Insertional Achilles InjuriesAchilles insertional tendinopathyHaglund’s TriadAchilles insertional calific tendinopathyRetrocalcaneal bursitisPre-Achilles tendon bursitisAvulsion fracture of calcaneus

Zone 3:Partial tears/tears of muscle-tendinous junctionStrain of medial head of gastrocnemius musclePlantaris strain/rupture

TABLE 4

Classification of Injuries to theAchilles Tendon and

Surrounding Structures


SPORTS PODIATRY

RUNNING INJURIES

differential diagnosis, be certainto consider Achilles tendinopathycaused by inflammatoryarthropathy.

In Achilles enthesopathy orinsertional Achilles tendinopa-thy, pain is present at the backof the heel. The pain is aggravat-ed by running uphill, and by pro-longed walking, standing, or run-ning. Table 5 offers possible dif-ferential diagnoses of insertionalenthesopathy of the Achilles ten-don.

Non-Insertional AchillesTendinopathy

The Achilles tendon is mostoften affected in non-insertionaltendinopathy at a location 2 to 6cm. proximal to its insertion intothe calcaneus. The paratenonsubstitutes for a true gliding syn-ovial sheath. It is comprised offatty areolar tissue surrounding theAchilles tendon and is organized intoa mesotenon. Werd has pointed out aclinical manner of distinguishingtendinopathy from paratendinopa-thy.25 Upon palpation of the painfularea, if the foot is dorsiflexed andplantarflexed and it is noted that thearea of maximal tenderness does notmove, the presumption is that the siteof tenderness is within the paratenonitself, which is firmly attached to thesurrounding tissues and does notmove. If the tenderness shifts withdorsiflexion and plantarflexion, thetenderness is deemed to be within thetendinous tissue.

Fluoroquinolone use is associatedwith non-insertional Achilles tendoninjuries. The risk is increased with aconcomitant use of oral corticos-teroids, increasing age, magnesiumdeficiency, and HLA B27 associateddisease. The mechanism of injury hasnot been definitively described. Con-tributing factors may include thechelation of Mg2+ by the Fluoro-quinolone which may affect the trans-membrane integrin proteins. A reduc-tion in collagen type I, elastin, fi-bronectin, and Beta1 Integrin whichmimics Magnesium deficiency hasbeen found in dogs given fluoro-quinolones. Athletes should avoid “alluse of fluoroquinolone antibiotics un-

less no alternative is available”.Training should be reduced in vol-ume, intensity, and duration duringthe use of fluoroquinolones with care-ful monitoring and an easy return tofull activity during the month follow-ing treatment completion.25a

Additional Calf and PosteriorCalcaneal Injuries

Injuries to runners are also notedat the myotendinous junction, within

the calf muscle itself, and to theplantaris.

Approach to TreatmentConservative treatment is directed

to decreasing strain on the tendonand allowing the tissue to repair it-self. Relative rest, absolute rest or theuse of a pneumatic walking boot maybe required. NSAIDs are often used,and offer a decrease in symptoms anda more normal gait and motion pat-tern through pain reduction, althoughtheir anti-inflammatory effects are no

longer thought to be ofassistance.

Cross friction massage andice application are often used.The modalities of ultrasound andhigh voltage galvanic stimulationmay also be helpful. Heel liftsand possible custom functionalfoot orthotics may also assist inreducing mechanical strain.

After the pain is reduced, agentle and gradual return to ac-tivity and then speed is helpful.Avoiding hills or inclined tread-mills is advised. Excessivelycushioned shoes, which will in-crease the eccentric forces withinthe tendon, should be avoided.

Alfredson has proposed theuse of eccentric stretching andstrengthening with heavy loads,which when performed as de-scribed, is meant to causepain.31,32 Similar approaches have

been suggested for several othertendinopathies, including patellartendinopathy. Two review articles ex-amining eccentric strengthening astreatment for a number of tendonswere recently published.33 The au-thors thought, in general, that the evi-dence was weak and underpowered.It is important to note that Alfredsonhas recommended that eccentricstretching should not be used to treatinsertional Achilles tendinopathy.32a

The current literature was de-scribed as having a “dearth of highquality research in support of the clin-ical effectiveness of EE (eccentric ex-ercise) over other treatments in themanagement of tendinopathies.”33

Kingma, et al. agreed, that while thetechnique appeared promising “largemethodologically sound studies ….arewarranted.”34

For severe, chronic, and unremit-ting tendinosis, surgery remains anoption. The described surgical proce-


Continuing

Medical Education

Seronegative spondyloarthropathyGoutAvulsion injuryHaglund’s diseaseSever’s disease (found in adolescents)Retrocalcaneal bursitisSystemic steroid induced injuryFluoroquinolone tendinopathyFamilial hyperlipidemiaSarcoidosisDiffuse idiopathic skeletal hyperostosis

TABLE 5

Differential Diagnosisof InsertionalEnthesopathy

For severe, chronic,and unremitting tendinosis, surgery remains

an option.

www.podiatrym.com

SPORTS PODIATRY

RUNNING INJURIES


dures include stripping of theparatenon, linear tenotomies, and

excision of non-viable tissue.28,35

Treatment for Achilles tendinopa-thy is outlined in Table 5. PM

References1a Pribut, S., Overuse Running Injuries

of Bone and Tendon: All The SmallThings. Podiatry Management Magazine.November, 2010.

1b Pribut, S.,Challenging Running In-juries. Podiatry Management Magazine.January, 2010.

1 Presiden-t’s_Council_on_Physical_Fitness. PhysicalFitness Facts/Healthy People 2010. 2007(cited 2008 1/08/2008).

2 Willems, T.M., et al., Gait-relatedrisk factors for exercise-related lower-legpain during shod running. Med Sci SportsExerc, 2007. 39(2): p. 330-9.

3 Chorley, J.N., et al., Baseline injuryrisk factors for runners starting amarathon training program. Clin J SportMed, 2002. 12(1): p. 18-23.

3a Lopes, A.D., et. al., What are themain running-related musculoskeletal in-juries? A systematic review. Sports Med2012; 42 (10): 891-905

4 van Gent, R.N., et al., Incidence anddeterminants of lower extremity runninginjuries in long distance runners: a system-atic review. Br J Sports Med, 2007. 41(8):p. 469-80; discussion 480.

5 Hreljac, A., Etiology, prevention, andearly intervention of overuse injuries inrunners: a biomechanical perspective.Phys Med Rehabil Clin N Am, 2005. 16(3):p. 651-67, vi.

6 Kelsey, J.L., et al., Risk factors forstress fracture among young female cross-country runners. Med Sci Sports Exerc,2007. 39(9): p. 1457-63.

7 Buist, I., et al., No Effect of a GradedTraining Program on the Number of Run-ning-Related Injuries in Novice Runners: ARandomized Controlled Trial. Am J SportsMed, 2008. 36(1): p. 33-39.

8 Powers, C.M., et al., Role of Peri-patellar Retinaculum in Transmission ofForces Within the Extensor Mechanism. JBone Joint Surg Am, 2006. 88(9): p. 2042-2048.

9 Senavongse, W. and A.A. Amis, Theeffects of articular, retinacular, or muscu-lar deficiencies on patellofemoral joint sta-bility. J Bone Joint Surg Br, 2005. 87-B(4):p. 577-582.

10 Goh, J.C., P.Y. Lee, and K. Bose, ACadaver Study of the Function of theOblique Part of Vastus Medialis. J BoneJoint Surg Br, 1995. 77-B: p. 225-231.

11 Merchant, N.D. and C. Bennett, Re-

cent Concepts in patellofemoral instability.Curr Opin Orthop, 2007. 18: p. 153-160.

12 Cichanowski, H., et al., Hip Strengthin Collegiate Female Athletes withPatellofemoral Pain. Med Sci Sports Exerc,2007. 39(8): p. 1227-1232.

13 Tyler, T.F., et al., The role of hipmuscle function in the treatment ofpatellofemoral pain syndrome. Am JSports Med, 2006. 34(4): p. 630-6.

13a Noehren, B., Hamill, J., and Davis,I., Prospective Evidence for a Hip Etiologyin Patellofemoral Pain. Med Sci SportsExerc, 2013. Publish ahead of Print DOI:10.1249/Mss.0b013e31828249d2

14 Sheehan, G., Dr. Sheehan on Run-ning. 1975, Mountain View: World Publi-cations.

15 Powers, C.M., et al., Comparison offoot pronation and lower extremity rota-tion in persons with and withoutpatellofemoral pain. Foot Ankle Int, 2002.23: p. 634-640.

16 Saxena, A. and J. Haddad, The Ef-fect of Foot Orthoses on PatellofemoralPain Syndrome. J Am Podiatr Med Assoc,2003. 93(4): p. 264-271.

17 Fredericson, M. and C. Wolf, Iliotib-ial band syndrome in runners: innovationsin treatment. Sports Med, 2005. 35(5): p.451-9.

18 Fairclough, J., et al., Is iliotibialband syndrome really a friction syndrome?Journal of Science and Medicine in Sport,2007. 10(2): p. 74-76.

19 Fairclough, J., et al., The functionalanatomy of the iliotibial band during flex-ion and extension of the knee: implica-tions for understanding iliotibial band syn-drome. Journal of Anatomy, 2006. 208(3):p. 309-316.

20 Muhle, C., et al., Iliotibial Band Fric-tion Syndrome: MR Imaging Findings in 16Patients and MR Arthrographic Study ofSix Cadaveric Knees. Radiology, 1999.212(1): p. 103-110.

21 Noehren, B., I. Davis, and J. Hamill,ASB Clinical Biomechanics Award Winner2006. Prospective study of the biomechani-cal factors associated with iliotibial bandsyndrome. Clin Biomech (Bristol, Avon),2007. 22(9): p. 951-956.

22 Miller, R.H., et al., Lower extremitymechanics of iliotibial band syndrome dur-ing an exhaustive run. Gait Posture, 2007.26(3): p. 407-13.

23 Movin, T., et al., Tendon pathologyin long-standing achillodynia. Biopsy find-ings in 40 patients. Acta Orthop Scand,1997. 68(2): p. 170-5.

24 Khan, K.M., et al., Histopathology ofcommon tendinopathies. Update and im-plications Sports Med, 1999. 27: p. 393-408.

25 Werd, M., Achilles Tendon Sports

Injuries. J Am Podiatr Med Assoc, 2007.97(1): p. 37-46.

25a Hall, M., et. al. MusculoskeletalComplications of Fluoroqunolones: Guide-lines and Precautions for Usage in the Ath-letic Population. American Academy ofPhysical Medicine and Rehabilitation. Vol.3, 132-142, February 2011

26 Puddu, G., E. Ippolito, and F. Posta-chini, A classification of Achilles TendonDisease. Am J Sports Med, 1976. 4.

27 Rees, J., Wilson, AM, Wolman, RL,Current concepts in the management oftendon disorders. Rheumatology, 2006. 45:p. 508-521.

28 Maffulli, N. and L.C. Almekinders,The Achilles Tendon. 2007, London:Springer-Verlog.

29 Benjamin, M., et al., The “enthesisorgan” concept: Why entesopathies maynot present as focal insertional disorders.Arthritis Rheum, 2004. 50(10): p. 3306-3313.

30 Slobodin, G., et al., Varied Presenta-tions of Enthesopathy. Semin ArthritisRheum, 2007. 37(2): p. 119-126.

31 Alfredson, H., et al., Heavy-load ec-centric calf muscle training for the treat-ment of chronic Achilles tendinosis. Am JSports Med, 1998. 26(3): p. 360-6.

32 Alfredson, H. and J. Cook, A treat-ment algorithm for managing Achillestendinopathy: new treatment options. Br JSports Med, 2007. 41(4): p. 211-216.

32a Ohberg L, Alfredson H. Sclerosingtherapy in chronic Achilles tendon inser-tional pain—results of a pilot study. KneeSurg Sports Traumatol Arthrosc 2003;11(5): 339-43.

33 Woodley, B.L., R.J. Newsham-West,and D.B. Baxter, Chronic tendinopathy: ef-fectiveness of eccentric exercise. Br JSports Med, 2007. 41: p. 188-199.

34 Kingma, J.J., et al., Eccentric over-load training in patients with chronicAchilles tendinopathy. Br J Sports Med,2007. 41:e3(6).

35 Saxena, A., Results of chronicAchilles tendinopathy surgery on elite andnonelite track athletes. Foot Ankle Int,2003. 24.

Dr. Pribut is a ClinicalAssistant Professor ofSurgery at GeorgeWashington UniversityMedical School. Heserves on the Runner’sWorld Board of Advi-sors. He is a past presi-dent of the AmericanAcademy of Podiatric

Sports Medicine. Dr. Pribut is in private practicein Washington, DC.

Continuing

MedicalEducation

CME EXAMINATION

1) Running gait demonstrateswhich of the following features:A) Two feet are in contact withthe ground 25% of the stancephaseB) Two feet are in contact withthe ground 75% of the stancephaseC) The forces of running areless than the forces of walking.D) Two feet are never in con-tact with the ground at thesame time.

2) A viable approach to ITBSyndrome would not include:A) Strengthening hipabductorsB) Decreasing running and“relative rest”C) Soft shock absorbing shoesD) Side bends to stretch tightlateral structures

3) In reference to the impact onthe patellofemoral complex, thevastus medialis oblique is:A) a static stabilizerB) a dynamic stabilizerC) a passive stabilizerD) a destabilizer

4) The patella has the leastamount of medial stability at:A) zero degrees of flexionB) 20 degrees of flexionC) 45 degrees of flexionD) 90 degrees of flexion.

5) Factors considered important tothe development of patellofemoralpain syndrome include:A) abnormal pronation of thefootB) patella altaC) weak hip abductormusclesD) all of the above.

6) Pain that develops after run-ning in the anterior region of a pa-tient’s knee is most likely to be

what is appropriately termed:A) Runner’s KneeB) Patellofemoral painsyndromeC) chondromalacia patellaeD) terrible triad

7) Evidence in studies has indicat-ed that a large contributing factorto iliotibial band syndrome is:A) weak hip abductor musclesB) over pronation of the footC) high archesD) low blood levels of Vitamin D

8) The pain of iliotibial band syn-drome is most often experiencedin the region of the:A) anterior kneeB) posterior aspect of the kneeC) medial aspect of the kneeD) lateral aspect of the knee.

9) The most frequently occurringAchilles tendon injuries in run-ners are best termedA) Achilles tendonitisB) Achilles heelC) Achilles bursitisD) Achilles tendinopathy

10) All of the following types offootgear could aggravate pain inthe Achilles tendon area except:A) zero drop, minimalist shoesand a switch to forefoot con-tact running styleB) firm heel shoe, flexibleat ball, with 1/4” heel liftC) well-cushioned shoesD) shoes with a stiff andhard-to-bend sole.

11) The insertion of the Achillestendon and the plantar fascia aresimilar in that they both:A) insert into the talusB) are both improved withstiff running shoesC) are improved by jumpingjacks and running in sandD) are entheses

12) The histological findings oftendinosis include:A) myxoid degenerationB) parakeratosisC) inflammatory exudatesD) copius lymphocytes

13) Fluoroquinolone use hasbeen associated with:A) Achilles tendinopathyand enthesopathyB) Peri-patellar painsydnromeC) Stress fracturesD) Osteopenia

14) Minimalist shoe gear hasbeen clinically associated with:A) Change to a “paleo” dietB) ITB sydnromeC) Achilles tendinopathyand forefoot stress fracturesD) Osteoarthritis of the hipand knee

15) Hakim Alfredson, theauthor of several studieson eccentric stretching in thetreatment of Achilles tendinopa-thy, does not recommendit for:A) Non-insertional Achillestendinopathy of 4-6 weeksdurationB) Non-insertional Achillestendinopathy of 6-8 weeksdurationC) Non-insertional Achillestendinopathy of 10-14 weeksdurationD) Insertional Achillestendinopathy

16) The following statementabout patellofemoral paindisorder is false:A) the preferred nameof this condition is anteriorknee painB) pronation of the foothas been found in studies to


SEE ANSWER SHEET ON PAGE 199.


Continuing

Medical Education

Continued on page <None>

PM’sCPME Program

Welcome to the innovative Continuing EducationProgram brought to you by Podiatry ManagementMagazine. Our journal has been approved as asponsor of Continuing Medical Education by theCouncil on Podiatric Medical Education.

Now it’s even easier and more convenient toenroll in PM’s CE program!

You can now enroll at any time during the yearand submit eligible exams at any time during yourenrollment period.

PM enrollees are entitled to submit ten examspublished during their consecutive, twelve–monthenrollment period. Your enrollment period beginswith the month payment is received. For example,if your payment is received on September 1, 2006,your enrollment is valid through August 31, 2007.

If you’re not enrolled, you may also submit anyexam(s) published in PM magazine within the pasttwelve months. CME articles and examinationquestions from past issues of Podiatry Manage-ment can be found on the Internet athttp://www.podiatrym.com/cme. Each lesson isapproved for 1.5 hours continuing education con-tact hours. Please read the testing, grading and pay-ment instructions to decide which method of par-ticipation is best for you.

Please call (631) 563-1604 if you have any ques-tions. A personal operator will be happy to assist you.

Each of the 10 lessons will count as 1.5 credits;thus a maximum of 15 CME credits may be earnedduring any 12-month period. You may select any 10in a 24-month period.

The Podiatry Management Magazine CMEprogram is approved by the Council on PodiatricEducation in all states where credits in instructionalmedia are accepted. This article is approved for1.5 Continuing Education Contact Hours (or 0.15CEU’s) for each examination successfully completed.

Home Study CME credits nowaccepted in Pennsylvania

Continuing

MedicalEducation

CME EXAMINATION

www.podiatrym.com198 | APRIL/MAY 2013 | PODIATRY MANAGEMENT

be a risk factorC) studies indicate weak hip abductors to beassociated with PFPSD) the subchondral bone, extensorretinaculum and infrapatellar fat pad arepossible sources of pain in PFPS.

17) All of the following statements about theAchilles tendon insertion are true except:A) Fibrocartilage is found at the insertion ofthe Achilles tendonB) Sesamoidal cartilage is found at theinsertion of the Achilles tendonC) periosteal cartilage is found at theinsertion of the Achilles tendonD) articular cartilage is found at the insertionof the Achilles tendon

18) Surgical treatment of Achilles tendinosismost commonly would likely include any of thefollowing except:A) stripping of the paratenonB) excision of non-viable tissueC) Gastrocnemius recession (e.g., StrayerProcedure)D) linear tenotomy

19) The most specific statement we can makeabout the Gastrosoleus complex and theAchilles tendon is that this complex is:A) Multi-joint functioningB) Primary function is supination of thesubtalar jointC) Primary function is plantar flexion of thegreat toe in ballet dancersD) associated with ITB syndrome

20) Although evidence based proof is weak,overuse running injuries are thought to becontributed to by all of the following except:A) carbohydrate loadingB) overtrainingC) shoes losing shock absorption and wearingdown substantiallyD) starting marathon training never havingrun more than 20 minutes at a time

See answer sheet on page 199.

Please print clearly...Certificate will be issued from information below.

Name _______________________________________________________________________ Soc. Sec. #______________________________Please Print: FIRST MI LAST

Address_____________________________________________________________________________________________________________

City__________________________________________________ State_______________________ Zip________________________________

Charge to: _____Visa _____ MasterCard _____ American Express

Card #________________________________________________Exp. Date____________________

Note: Credit card is the only method of payment. Checks are no longer accepted.

Signature__________________________________ Soc. Sec.#______________________ Daytime Phone_____________________________

State License(s)___________________________ Is this a new address? Yes________ No________

Check one: ______ I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be chargedto your credit card.)

______ I am not enrolled. Enclosed is my credit card information. Please charge my credit card $22.00 for each examsubmitted. (plus $2.50 for each exam if submitting by fax or phone).

______ I am not enrolled and I wish to enroll for 10 courses at $169.00 (thus saving me $51 over the cost of 10 individualexam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone.

Note: If you are mailing your answer sheet, you must complete allinfo. on the front and back of this page and mail with your credit cardinformation to: Podiatry Management, P.O. Box 490, East Islip,NY 11730.

TESTING, GRADING AND PAYMENT INSTRUCTIONS(1) Each participant achieving a passing grade of 70% or higher

on any examination will receive an official computer form stating thenumber of CE credits earned. This form should be safeguarded andmay be used as documentation of credits earned.

(2) Participants receiving a failing grade on any exam will be noti-fied and permitted to take one re-examination at no extra cost.

(3) All answers should be recorded on the answer form below.For each question, decide which choice is the best answer, and circlethe letter representing your choice.

(4) Complete all other information on the front and back of this page.(5) Choose one out of the 3 options for testgrading: mail-in, fax, or

phone. To select the type of service that best suits your needs,please read the following section, “Test Grading Options”.

TEST GRADING OPTIONSMail-In GradingTo receive your CME certificate, complete all information and

mail with your credit card information to:

Podiatry ManagementP.O. Box 490, East Islip, NY 11730

PLEASEDONOTSENDWITH SIGNATURE REQUIRED, ASTHESEWILLNOTBEACCEPTED.

There is no charge for the mail-in service if you have already en-

ENROLLMENT FORM & ANSWER SHEET

� Continuing

Medical Education

rolled in the annual exam CPME program, and we receive this examduring your current enrollment period. If you are not enrolled, pleasesend $22.00 per exam, or $169 to cover all 10 exams (thus saving $51over the cost of 10 individual exam fees).

Facsimile GradingTo receive your CPME certificate, complete all information and fax

24 hours a day to 1-631-563-1907. Your CPME certificate will be datedand mailed within 48 hours. This service is available for $2.50 per examif you are currently enrolled in the annual 10-exam CPME program (andthis exam falls within your enrollment period), and can be charged toyour Visa, MasterCard, or American Express.

If you are not enrolled in the annual 10-exam CPME program, thefee is $22 per exam.

Phone-In GradingYou may also complete your exam by using the toll-free service.

Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday throughFriday. Your CPME certificate will be dated the same day you call andmailed within 48 hours. There is a $2.50 charge for this service if you arecurrently enrolled in the annual 10-examCPME program (and this examfalls within your enrollment period), and this fee can be charged to yourVisa, Mastercard, American Express, or Discover. If you are not current-ly enrolled, the fee is $22 per exam.When you call, please have ready:

1. Program number (Month and Year)2. The answers to the test3. Your social security number4. Credit card information

In the event you require additional CPME information, pleasecontact PMS, Inc., at 1-631-563-1604.

Enrollment/Testing Informationand Answer Sheet

Over, please APRIL/MAY 2013 | PODIATRY MANAGEMENT | 199www.podiatrym.com

�

ENROLLMENT FORM & ANSWER SHEET (continued)Continuing

MedicalEducation

Medical Education Lesson Evaluation

Strongly Stronglyagree Agree Neutral Disagree disagree[5] [4] [3] [2] [1]

1) This CME lesson was helpful to my practice ____

2) The educational objectives were accomplished ____

3) I will apply the knowledge I learned from this lesson ____

4) I will makes changes in my practice behavior based on thislesson ____

5) This lesson presented quality information with adequatecurrent references ____

How long did it take you to complete this lesson?

______hour ______minutes

What topics would you like to see in future CME lessons ?

Please list :

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

EXAM #4/13The Top Five Running Injuries Seen

in the Office—Part 1 (Pribut)

www.podiatrym.com200 | APRIL/MAY 2013 | PODIATRY MANAGEMENT

to open this article in a new window - podiatry management magazine

Documents