• Newsletter Winter 2017

     

    Sport Doctors Australia Newsletter No: 11


    Winter 2017

    Greetings to SDrA members for winter 2017, with spring rapidly approaching. I recently returned from a 3 week driving holiday through far western NSW, rural South Australia and Victoria. My sporting involvement was regular running through the Clare and Barossa Valleys, Great Ocean Road, and central Victoria, which helped insulate me from the current professional sport issues (Cricket pay wars, Rugby Union team sackings and CEO resignations, the Tour de France, underperformance at the swimming World Championships). I reflected on the existential nature of sport and confirmed to myself that it is all about the positive physical and mental health benefits for the individual rather than the tribal warfare that appeals. This is only a personal reflection, with the majority of doctors working in the sports medicine field enjoying high level sports involvement.

    “Pro football is like nuclear warfare. There are no winners, only survivors”. Frank Gifford, USA NFL player.

    Much of my work involves “patching up” athletes who have “survived” high level sport, but remain scarred from their sports involvement, usually through osteoarthrosis. I continue to find it distressing when people who have scaled the sporting heights suffer from chronic pain, and are reduced to semi-sedentary activities. I am also unimpressed by the intrusion of gambling into sport, and find the spectacle of multimillionaire sports people and institutions fighting for even more money, when many grass roots level clubs struggle.
    Against this is the joy I feel in helping a couch potato become active, losing weight, improving diabetic control, running their first City to Surf, or a vast array of other simple but meaningful sporting achievements.


    Plantar Fasciosis/ Fasciitis/ Fasciopathy
    Another condition with nomenclature issues. For a number of reasons (principally working closely with a foot and ankle surgeon, and have one of 2 Extracorporeal Shockwave (ESWT) Units in Central West NSW), I treat a considerable number of patients with plantar fasciosis (PF). I am unaware of many conditions with so many treatment options, but find it difficult to access any good research on any of them. Possibly this is because PF is considered a “self-limiting” as well as benign condition, therefore not worthy of research dollars. Possibly it is due to the generally miserable success rate with each.

    My standard patient is a middle-aged female, who has had symptoms 6-12 months, severe in nature, and had 2 or 3 unsuccessful steroid injection, months of physiotherapy, taping, orthotics, heel raises, NSAID’s, dry needling, and a host of other conservative modalities.
    Some have been referred to a surgeon, who rules out surgery. Others are self-referred, or referred by physiotherapist or podiatrist.

    Experience and numerous data base searches suggest the duration of the condition is unpredictable, ranging from months to years. No single treatment modality has a monopoly, and no consistent evidence exists as to the most appropriate treatment for each patient. Investigations are helpful but inconsistent, with mild changes on U/S or MRI in severely incapacitated patients, and severe changes in asymptomatic heels. Although the condition is self-limiting, I have seen a number of people severely incapacitated and with quite severe depression as a result of living with pain.

    My general approach is based on a number of factors- severity of symptoms, duration, cost, access to treatment, and what has already been tried (usually a plethora of conservative modalities as mentioned). My first line treatment is usually ESWT which, in my experience, leads to “some” improvement in 60-65% of patients, though this is often suboptimal. BJSM published a good review of ESWT recently:

    Cathy Speed; “A Systematic Review of Shockwave Therapies in Soft Tissue Conditions: Focusing on the Evidence”; British Journal of Sports Medicine Nov 2014, 48 (21) 1538-1542; DOI: 10.1136/bjsports-2012-091961

    According to this, ESWT is useful in treating PF, though of limited use for other conditions. My experience echoes these findings. My usual regime is 2000 shocks, once weekly for 6 weeks, at maximal tolerated pressure.

    If this fails to produce significant improvement, I often add platelet rich plasma (PRP) injections, usually 3 over 12 weeks under U/S control. I standardly review patients 6-8 weeks following the final injection, and my own data indicates 80-85% of patients have had significant improvement by this stage.

    A Pubmed search on injectable treatments yield very limited data, though some studies (small or of limited quality) indicate a benefit for PRP over other injectables. Although botulinum, dehydrated amniotic membrane, autologous whole blood and PRP have all been used, my access to PRP guides my treatment choice in this respect.

    Adv Biomed Res. 2016 Nov 28;5:179. doi: 10.4103/2277-9175.192731. eCollection 2016. Beneficial effects of platelet-rich plasma on improvement of pain severity and physical disability in patients with plantar fasciitis: A randomized trial. Vahdatpour B1, Kianimehr L2, Moradi A1, Haghighat S1.

    With no scientific rationale whatsoever, I also recommend Hoka shoes- anecdotally these are effective in easing pain (I also use these personally and effectively for marathon running). Patients whose work involves standing on hard floors for long hours, particularly those with a high BMI, I suggest having an extended period off work, often 2-3 months if possible. I find this further enhances the efficacy of the other failed treatment. Again there seems to be no data on this, but common sense suggests it to be a reasonable option.


    Conferences
    2017 Asics SMA Conference; 25-28 October; The Westin Langkawi, Malaysia.
    https://members.sma.org.au/QuickEventWebsitePortal/2017-asics-sma-conference/2017confwebsite

    The Running Symposium: Keeping Athletes On Track; Saturday September 2, 2017; Western Sydney University, Parramatta.
    https://members.sma.org.au/QuickEventWebsitePortal/nsw-running-symposium/runningsymposium

    Adolescent Athletes: Treating tweens and teens not mini adults; Waurn Ponds Estate, Deakin University Waurn Ponds Campus, Geelong; Sunday August 27, 2017.
    https://members.sma.org.au/QuickEventWebsitePortal/adolescent-sport-medicine/asmwebsite




    Back

Website Global