Sometimes the conventional wisdom isn't so wise. In running, among the many supposedly ironclad "rules" are three sports medicine matters that merit debunking. First, that cortisone shots are an inherently bad treatment and that you shouldn't receive more than three shots for any injury. Second, that you can't run on a stress fracture, so if you have an injury but can still run, then it can't possibly be a stress fracture. Third, that orthotics can cure every injury. Let's look at each of these and sort fact from fiction.
MYTH: AVOID CORTISONE SHOTS
Cortisone is the commonly used term for all corticosteroid injections. Cortisone and similar types of drugs are known as catabolic steroids. Corticosteroids, of which cortisone is one type, mimic the effects of naturally occurring hormones produced by the pituitary gland and serve to reduce inflammation. The drug can be delivered topically, orally (such as prednisone) or injected. My focus here is on the injectable corticosteroids used to treat running injuries.
Let me start by acknowledging that, like many myths, the one about cortisone shots doing damage has some basis in fact. The contention that you shouldn't receive repeated injections is valid if many injections are performed at the same location in a short amount of time, because in this concentrated delivery corticosteroids can cause breakdown in the tissue. For this reason it's important that injections be performed around a tendon and not directly into the tendon itself. (Because there's so little matter around it, one area that should almost never be injected is the Achilles tendon.)
Getting the Shot?
Nerve, tendon, joint and fascial injuries seem to respond best to a local corticosteroid injection. Some examples include an interdigital neuroma, plantar fasciitis, peroneal or posterior tibial tendinitis and any inflammation in or around a joint. I've found that if there is an acute area of pain about the size of a quarter, then there's a good chance than an injection will be successful.
Steroid injections also work better in the earlier stages of an injury. If an injection has resolved a lot of the pain but there's still some discomfort, then I might recommend a second injection. If, however, there's little to no relief from the first injection, then I typically won't recommend another at the same location.
Corticosteroids are described as banned substances if administered orally, intramuscularly, intravenously or rectally. Steroids injected into a joint or around a tendon are acceptable, but a declaration of use must be filled out by the athlete.
Anabolic steroids are a different class, and serve to build muscle and foster faster recovery from workouts. These are always banned substances in track and field.
MYTH: YOU CAN'T RUN ON A STRESS FRACTURE
It's simply not true that you can't run on a stress fracture. Runners typically have a high pain tolerance, and when endorphins are released during a run this will mask the pain of most injuries, leading to a false sense of security. It's important to pay attention to some of the signs that may indicate a stress fracture, including more pain as a run progresses and a throbbing type of pain after a run is completed and the endorphins are subsided. Metatarsal stress fractures will also be accompanied by swelling; anytime I have a patient with pain and swelling on the top of the foot, then I consider a stress fracture as a possibility.
It's important to note that X-rays often may not show any signs of a stress fracture. If you have the above signs of a stress fracture and an X-ray is normal, follow up with another diagnostic test such as a bone scan, CT scan or MRI.
While you can run on a stress fracture, you shouldn't--doing so simply delays healing and will probably lead to a compensatory injury from altering your running form. The sooner a stress fracture is diagnosed and treated, the faster the athlete can return to activity. Consider the case of Rich Kenah, who won bronze medals at 800m in the 1997 indoor and outdoor world championships. When he resumed training for the 1998 season, he developed pain in the middle of his foot. Kenah was able to run for another month, albeit in pain, and began compensating, which led to pain on the outside of the foot. It turns out that Kenah had a navicular stress fracture (bone in the midfoot) and compensation for this injury led to a stress fracture in the fourth metatarsal bone. A long layoff ensued, which included crutches, a walking cast and a bone stimulator. Kenah had to miss the 1998 season, but was able to return to competition in 1999, and he made the U.S. Olympic team in 2000.
Some stress fractures, such as of the navicular or cuboid bones, require more aggressive treatment, including complete non-weight-bearing and a cast. The most common stress fractures in a runner include the metatarsal and tibia. While treatment varies based on the severity and symptoms, these two areas usually allow the patient to avoid using crutches.
MYTH: ORTHOTICS ARE A CURE-ALL
Orthotic devices aren't a panacea and shouldn't always be considered a first-line treatment. Unfortunately, in some podiatry offices plantar fasciitis automatically equals custom orthotic devices. The reality is that the devices should never be prescribed for a specific injury without considering the biomechanics of the patient. Your physician should provide a good explanation why you should consider a custom orthotic device; typically, the decision should be based more on the shape and function of the foot with consideration also given to the injury being treated.
Be wary of a medical professional who makes the same type of device for every patient or restricts the choice of materials. I can think of a sports medicine "expert" who has stated in a public forum that runners should never run in hard, rigid orthotic devices. In fact, at least three of my patients ran in the 2008 Olympic marathon trials in polyethylene or graphite devices, which would be classified as rigid or semi-rigid.
The fabrication and prescription writing for an orthotic device is a combination of science and art. The fabrication of the device is the most important part. If a device is being made with the intention of correcting a biomechanical flaw, then stepping in a foam box to fabricate the device isn't going to provide as good a device as the use of plaster will.
There are certain injuries that classically respond better to a custom orthotic device, including plantar fasciitis, medial tibial stress syndrome (shin splints) and posterior tibial tendinitis. However, it's extremely important to combine the injury history with a thorough biomechanical and gait examination to determine if the injury is related to how the foot is functioning. If a device is prescribed, it should be only a part of the treatment plan rather than the sole treatment.
There are certain conditions or injuries in which the medical literature recommends custom orthotics, even though there's little to no scientific evidence to support these claims. Two of the conditions that come to mind are iliotibial band syndrome (ITBS) and hallux abducto valgus (bunions). Some physicians may claim that the custom device may help prevent the progression of bunion deformity, but there are no studies to support this assertion.
ITBS may in some cases get worse with use of a custom orthotic device. Michael Fredericson, M.D., at Stanford University has clearly shown in several studies that the most important component to treating this injury is to strengthen the core muscles, in particular the hip abductors. I would seriously question any medical professional who uses a functional custom orthotic device as a first-line treatment for ITBS. The condition is more commonly found in underpronators with a high-arched foot type. If an orthotic device is for this injury, then most times it should be a softer device to aid in shock absorption and possibly promote more pronation.
It's also possible to eliminate the use of custom devices if an injury has resolved and your mechanics are sound. I always ask patients who have used orthotic devices for a long time why they were originally prescribed and if those parameters still apply. Occasionally I'll recommend that a patient stop wearing the devices, but this should be a gradual process, as the feet may need to be strengthened. Unless there's pain throughout the day, I almost always recommend my athletic patients use the devices only when working out because of the weakness that can develop from constant wear.
Sports Med Caveats
One of the most important concepts an injured athlete needs to consider is the choice of medical specialists.
Check out advertising for medical providers and most will list sports medicine as their interest or one of their specialties, particularly podiatrists, orthopedists, chiropractors and physical therapists. Unfortunately, there are no guidelines required to proclaim oneself a sports medicine expert. Fellowship training programs do exist, wherein doctors can train under acknowledged top sports medicine practitioners. For a podiatrist, becoming a fellow of the American Academy of Podiatric Sports Medicine is the top credentialing that can be obtained to show competency in sports medicine.
When trying to find a good sports med doctor, remember that it's the medical professional's duty to provide their patients with a diagnosis and a treatment plan that not only heals the injury but also identifies the cause in order to prevent injuries. That big-picture approach is the essence of sports medicine.
Brian Fullem is a fellow of the American Academy of Podiatric Sports Medicine whose medical practice is located in Tampa, Fla. A longtime runner with a 14:25 5K PR, his website is docfullem.com.