Heel Pain in the Young Athlete

Heel pain is one of the most common symptoms I see in young athletes.  Often, the pain is so bad that it keeps kids from being able to practice and compete.  Occasionally, the heels become so severely painful that it is difficult for the athlete to even walk without limping.

So what is the cause of this scourge of the active young athlete?  Chances are someone on your team or in your league, or even an older sibling has suffered from it—Sever’s Disease.

Sever’s Disease is an inflammation of a small growth plate at the back of the heel.  It’s not a growth plate that is active to make a child taller.  Rather, this growth plate, called the calcaneal apophysis, is where the Achilles tendon attaches to the heel.  As the bones of the leg grow longer, the muscles and tendons don’t lengthen at the same speed, causing them to get tighter.  The job of the calcaneal apophysis is to allow for some wiggle room so the tendon doesn’t just pull off the bone as the bone grows.  Unfortunately, when an athlete is growing quickly, the tension of the Achilles on the apophysis can become too much, causing it to inflame.

In addition to the inflammation, athletes are constantly banging on the bottom of the heel in their cleats and shoes.  Cleats in any sport, from soccer to baseball, are usually less cushioned and cause more stress on the heel—and the growth plate.  This causes more pain.

Athletes with Sever’s Disease are usually between ages 8 and 13 and usually report pain with running, jumping, and landing.  They describe the pain as starting slowly, without any obvious injury, and feeling like the heel is “bruised.”

Once the diagnosis is made, the treatment is pretty simple. The first and most important treatment is rest.  But the athlete doesn’t have to just stick to the couch.  He or she can participate in activities that do not cause pain, like cycling or swimming, to keep their fitness up while they rest the foot.  Parents can provide ice and anti-inflammatory medicines.  I recommend a silicone heel cup to provide some cushion and pain relief.  The athlete can perform one of the most important treatments him or herself—and that’s stretch, stretch, stretch, stretch, stretch that Achilles.  The more flexible it is, the less it will pull on the growth plate.

Other problems can cause heel pain, as well.  Diagnoses like stress fractures and bone cysts can also be to blame, and the differences are subtle.  If pain persists despite rest and stretching for more than a week or so, the athlete should consult his or her physician.

What To Eat and When To Eat It

Athletes focus much of their effort on physical training and honing their skills on the field.  Countless hours of thought and practice are put in to improve and master their sport.  However, most don’t put the same energy into their nutrition routine.  I see an awful lot of candy wrappers and empty chip bags on the sidelines and in the gyms.  Obviously, these choices aren’t ideal for optimizing health and performance.  By following basic nutrition guidelines, athletes can ensure that they are at their best before, during, and after activity.

                                                                                            Before Exercise

The amount of energy, or calories, an athlete should consume is dependent on his or her gender, height, weight, and activity level.  So making broad recommendations is difficult. Most teenagers and adults burn about 1400 calories a day just going about their routine at school and work.  So athletes need more than that to cover the energy used during practices and games. Consult with your doctor or a sports dietician to determine your proper calorie needs.

Carbohydrates are essential for peak athletic performance, as the body uses this nutrient more efficiently during exercise than fats and protein.  The best recommendation is to eat 1 to 4 grams of carbohydrate per Kg of body weight one to four hours before exercise (1 Kg = 2.2 pounds).  A longer-lasting carbohydrate combined with a protein is a good choice.  This could be something like peanut butter on whole-wheat toast.  For endurance training (7-10g/kg/day) and high intensity activities (5-8 g/kg/day), the recommendations change a bit.

For protein, the advice again depends on the individual athlete.  More protein is required for athletes in critical growth periods or around puberty.  But a good rule of thumb for daily dietary protein intake is 1.2 to 1.7 g/kg/day.

Fat has a bad reputation among athletes, but it serves several important functions.  It’s a source of more energy when the carbohydrate stores run low.  Fats provide essential fatty acids the body can’t make on its own and helps to absorb certain vitamins.  So fat isn’t evil—it’s helpful!  20 to 35% of total calories should come from fat, with less than 10% from saturated fat sources.

During Exercise

Carbohydrates are key during exercise, especially glucose and electrolytes.  For longer lasting activities (more than one hour), try to consume an additional 30-60 grams of carbohydrates.

After Exercise

Recovery requires carbs, ideally within 15-30 minutes after the activity.  The body’s cells are especially receptive to glucose absorption during this period.  1-1.5 g/kg of rapid-acting carbohydrate is recommended immediately after exercise.  Or, take in a ratio of 4 g or carbohydrate to 1 g of protein.  Lowfat chocolate milk is a tasty choice that fits the bill.  After 30 minutes, focus on a good balance of the three nutrients (carbs, protein, and fat) for your next meal.

As you can see, a little bit of planning can go a long way toward making sure an athlete is making healthy choices and performing at his or her best with enough of the right kind of gas in the tank.  Good nutrition can help keep you performing at your best and keep you from running out of energy at the wrong time.

Preventing ACL Injuires

The ACL, or anterior cruciate ligament, is a very important structure for knee stability.  It has many functions in the knee, but the most important are to prevent abnormal shifting and rotation of the joint.  Many of us know someone who has torn an ACL, and the injury in young athletes can often kill a season.  When I make the diagnosis in my patients, it is often met with tears and many, many questions.

Fortunately, most people who suffer an ACL tear will do well with a surgery to reconstruct the ligament.  It takes several months to return from the injury, but athletes are usually able to return to their sport at the same level after rehabilitation.

ACL injuries most commonly occur from “noncontact” events.  These include quick changes of direction combined with sudden stopping, landing awkwardly from a jump, or pivoting with the knee nearly fully extended when the foot is planted on the ground.  Sometimes, player-to-player contact causes a tear, as well.

Research shows that female athletes may be at higher risk than males for ACL injuries.  This seems to be because females may perform actions like cutting, landing, and pivoting in a more knock-kneed position.  Other issues may be tightness of the hip and knee joints or weaker hamstrings.  All of these findings in the legs of athletes combine to increase risk for injury.

The best treatment for the ACL is to prevent injury to it.  Studies show that targeting weak muscles in the hips can help decrease the knock-kneed landing position.  We often use specific types of training, like jump routines and learning to pivot properly, to help prevent ACL injuries.  Programs like these are more effective when they start young.  

It may be optimal to start prevention programs during early adolescence, prior to the development of habits that increase the risk of injury.  I recommend preseason screening of athletes to identify young athletes who are at high risk and who would therefore benefit from targeted training.  There is no way to completely avoid risk of ACL injuries, but strengthening may be the best way we know to decrease it.

Shin Splints or Stress Fracture?

This is a common question that comes up with athletes who are training in any sport.  Shin splints can affect anyone who does a lot of running, from marathoners to soccer players, and it is one of the most common ailments I see in my office.

Shin splints are known by many names, but the correct terminology is medial tibial stress syndrome, or MTSS.  As the name implies, the condition involves stress or overload of the inner, or medial, border of the shin bone—the tibia.

We usually see MTSS when someone abruptly changes their training routine.  The bone is overstressed and begins to remodel.  It also develops a tiny amount of fluid between the main layer of bone and the outer jacket, called the periosteum.

On examination, the inside of the leg is very tender, especially along the bone.  X-rays usually don’t show any abnormalities. And bone scans and MRIs, while helpful to confirm the diagnosis, are usually unnecessary and expensive.

So what do you do about shin splints if you have them?  The answer is simple, but is one that athletes don’t like to hear.  REST!!  That doesn’t mean sitting on the couch all day and resting, but rather changing the exercise to a cross-training activity like swimming or biking to maintain cardiovascular fitness while allowing the bone to heal.

Other things that may help include anti-inflammatory medicines, ice, compression sleeves, and arch supports.  However, there is no clear evidence that any of these things work.  Generally, rest is key!

It’s usually just better to avoid getting shin splints.  The most important way to do that is to increase training gradually, allowing for plenty of time to reach your goals.  A high quality shoe and limiting running on really hard surfaces also helps.

If you suspect you have shin splints, try giving it some time to rest.  But if there is one small area on the shin that is a lot more tender than the surrounding bone or if your pain is not improving over time, it may indicate a stress fracture, and you should have your doctor take a look.

"I Just Got My Bell Rung."

I recently had the opportunity to speak with the coaches of the Tony Glavin Soccer Club about concussions.  The coaches are very interested in the health of their athletes and how best to take care of them if such an injury does occur.   Stories of head injuries have dotted the sports pages and often the front pages quite a bit lately, as more and more athletes, parents, and coaches attempt to understand the injury.  We are figuring out that getting “dinged” or ‘rung” may actually be a more serious injury.

A concussion is a traumatic injury to the brain.  It can occur from a blow to the head or even to the body if that hit causes movement of the brain inside the skull.  It results in any number of symptoms because of a change in how the brain is working.  It does not cause a structural injury, so you can’t see a concussion on a CT scan or MRI.  And you don’t have to get knocked out to have a concussion.  In fact, a brief loss of consciousness doesn’t even mean an athlete has suffered a more severe injury.

Evaluating head injuries can be tricky, as symptoms are often explained away as another illness or injury.  Coaches are often the first responders to an injured athlete, and they should be conservative when it comes to head injuries.  They are taught, “when in doubt, sit them out,” even if they aren’t sure of the diagnosis.  A medical professional, such as a doctor or athletic trainer, should evaluate an injured athlete as soon as possible after a head injury.  The risk of much more serious injury is very high if an athlete suffering from the effects of a concussion is allowed to continue playing and endures another hit.

Not every injury causes the same issues.  The signs and symptoms of concussion vary between individuals.  These can include balance problems, dizziness, concentration and memory issues, drowsiness, mental fogginess, headache, feeling emotional, nausea, irritability, light or noise sensitivity, trouble falling asleep, and vision problems.  If your athlete is describing any of these symptoms after a head injury, get them to the doctor.  Be careful not to judge the severity of the injury yourself.

When a concussed athlete comes into my office, I perform a very thorough evaluation.  I talk with both the athlete and his or her parents about how the athlete is acting.  I examine the nervous system from head to toe.  I include memory and concentration tests, as well as balance and visual tests as part of the visit.  Then we spend a great deal of time discussing the injury and how to minimize the time the athlete is suffering.  Often I have to recommend shorter school days or make changes to the work the student does at school while having symptoms.

Once an athlete is feeling back to normal at rest and then at school, they move through a progression of physical activity to test their readiness to return to sports.  If he or she is successful and does not have a return of their symptoms, I allow them to return to play fully.

Concussion is often an uncertain situation for athletes, parents, and coaches.  A little understanding of the injury helps to decrease the anxiety if you or your athlete gets hurt.  I will be talking more about concussions at the Tony Glavin Soccer Club Parents Meeting on Sunday, September 14^th.  I’ll be able to arm you with more knowledge and answer any questions you have.  Hope to see you there!

Preventing Soccer Injuries

I see a significant number of injuries from soccer in my office.  Most of them involve the lower extremities.  They may be from a traumatic injury like a kick to the leg or a twist to the knee, or may result from overuse.  Sprains of joints and strains of muscles and tendons are the most common injuries, but cartilage tears, fractures and contusions do occur.  Shin splints, patella tendinitis and Achilles tendinitis are the most common overuse injuries.  In these cases, there is no one event that causes the pain.  Instead, the pain builds up over time.  I also see several stress fractures every year.  These occur when the bone becomes weak from overuse.  It’s often pretty tough to distinguish between soft tissue injuries and injury to the bone, so if leg pain does not improve after a few days of rest, you should consult your physician.

Treating soccer injuries can be tricky.  I strive to limit the time lost from training while ensuring a safe return to play.  For most acute injuries, a short period of rest with ice and elevation will do the trick.  For some of the longer term injuries, especially overuse injuries, relative rest is possible.  This means that the athlete can continue to do some modified training while avoiding painful activities.  For example, I will often have players work on drills, but avoid scrimmaging.  Sometimes I have to put them on a bike or in the pool to maintain cardiovascular stamina while avoiding a lot of weightbearing on an injured leg.  Rarely are players completely restricted from activity for a long-term basis.

Prevention of soccer injuries often involves just using common sense.  Use well-fitting cleats and shin guards.  Watch out for mobile goals that can fall on players.  Remember to hydrate adequately.  Maintain proper fitness—we know that athletes who are stronger and more prepared physically have lower risk of injury.  If an injury does occur, returning to play after a player is healed needs to be gradual, progressing through aerobic conditioning, strength training, and then agility training.

Staying fit for the field is easy with proper preparation, but injuries do occur.  Playing through pain is often not the answer.  Never hesitate to consult your physician if you are unsure. 

Arthritis Foundation's Jingle Bell Run Hits the Airwaves

The 2013 edition of the Arthritis Foundation's St. Louis Jingle Bell Run takes place in November at Hollywood Casino in Maryland Heights.  I've been named a medical honoree for the last two years, and part of the job includes a media blitz to help publicize all of our Jingle in July activities.  So I've been visiting the local news stations to talk about arthritis and how fundraising efforts like these help us to conduct research that will help us decrease pain in current arthritis sufferers and decrease risk in those who are yet to develop the disease.

We've visited Show Me St. Louis on KSDK and Fox2News in the Morning to talk about the events.  We even got to cuddle with some mice in a warm-up to this weekend's mouse races in St. Peters.

The Arthritis Foundation is an integral part of fundraising for research that helps us battle all types of arthritis, from Juvenile Idiopathic Arthritis to Osteoarthritis.  These conditions affect millions of Americans.  Consider donating or better yet, consider joining the Advanced Bone & Joint team at the Jingle Bell 5K run/walk this fall.  It's a lot of fun.  Costumes abound, and there is an all you can eat pancake breakfast that's pretty incredible.  Bring the family and help us win the fight against arthritis!