Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA

Treating Athletes

In light of this past weekend’s Superbowl XLV, I was thinking about athletes. Many podiatrists treat athletes of one sort or another, whether it’s the high school long distance runner, the college basketball player, the amateur triathlete, or the professional footballer.

I’m not an expert in treating athletes. I did not do a sports medicine fellowship and my practice doesn't focus on athletes. However, like many podiatrists, I have had the opportunity to treat many athletes of varying levels. So, I don’t write this issue with national expertise but rather as a fellow colleague with experiences like many other podiatric physicians.

The idea of treating an athlete calls up several interesting and important questions for podiatric physicians. Let’s take a look at a few of these issues.

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A Different Patient Population

Athletes are not your average patient. First, these are not your 60 year-old sedentary diabetic patient. Instead, you have a healthy, physiologically younger patient with a different body chemistry. Their healing rates are different. Their motivations are different. The biggest problem I have with my high level athletes is keeping them inactive for the time necessary to heal their injuries. I suggest cross-training, but that never replaces the adrenaline addiction, whether its running, biking, hiking, or bungee jumping, among others. One of my residency attendings once told me, if you want your high level runner with plantar fasciitis to see another doctor, tell her to stop running and rest.

" The biggest problem I have with my high level athletes is keeping them inactive for the time necessary to heal their injuries. "

A couple of years ago, I had a new patient complaining of plantar heel pain. She was absolutely addicted to physical activities. While obtaining her history, I discovered she ran 15 miles per day, bicycled everywhere (she almost never drove), and took vacations to places like the Grand Canyon in Arizona, where she actually ran the entire way to bottom! It turned out her MRI clarified the issue: she had a cuboid stress fracture. Unfortunately for me, I had to curtail her activities. Did she listen? Well…kinda. Her version of diminished activities was stopping her running, while continuing to hike 20 mile mountain trips. When I suggested at one point she wear a cast or cam walker, she almost jumped over the table and strangled me.

The other issue is the different disease manifestations these patients suffer from in comparison to the average patient. I’m not sure about other podiatrists, but I have very few long distance runners with plantar fasciitis. More commonly, I see on MRI stress responses and stress fractures. I’m not saying I never see plantar fasciitis in athletes, just that I more commonly see this in my obese, middle age patients, so much so that when I see one of these patients, I’m often correct in diagnosing them with plantar fasciitis – before I even see them!

These patients also differ in the history necessary to treat them. My history for the athletic patient always includes things such as training regimen (intensity, duration, location, running surfaces, stretches, competition, etc.), shoes (they often have several pairs for different activities), socks (same thing), and diet. My female athletes are always questioned to find out about amenorrhea. A very detailed biomechanical examination is additionally necessary to fully understand all of the pathological forces passing through these limbs. My treatment methods invariably include recommendations for changes in training regimes, shoes, etc. in addition to other more aggressive treatments.

Of course, each sport has its own quirks. One can become a super-subspecialist in one athletic activity. I’ve heard of doctors who, for example, primarily treat runners. Shoes differ with every sport: cleats, tennis shoes, running shoes, ballet slippers, or no shoes. Treating each sport’s athletes requires an often different and challenging approach.

During my first year in practice, I had a 22 year-old professional modern dancer with posterior tibial tendon dysfunction, confirmed with degenerative changes of her PT tendon on MRI. We had more than one serious conversation about how much longer she was going to be capable of high level dancing. She wanted desperately to stay out of the operating room, and it was a monumental effort on my part to biomechanically control her foot while she danced barefoot. I kept her out of the operating room, but to this day I don’t think I was especially effective with her.

There are, of course, limitations to the level of cost effectiveness any single specialty can achieve as long as healthcare reform remains unfinished. If, for example, insurance companies ran lower operating costs and a less complex system for providers to handle, money would be saved while providers would spend less time, effort, and staff dealing with these complexities. Imagine how easy practice would be if all insurances had one simple standard system for reimbursements. Wasted staff, time, and money is just part of doing business as a modern day doctor until this aspect changes. What other methods will improve the cost effectiveness of podiatric practice?

More Aggressive Care – Is It Appropriate?

Another issue that always has me debating with myself is whether athletes should have more aggressive care than the average patient. We’ve all heard of the professional football player who sprains his ankle and has an MRI completed before the end of the game. Could you even imagine one of your office patients having their MRI done in a 2 to 3 hour period? The team is probably paying for the study from their very deep pockets, while your office patient has to wait for insurance approval and then scheduling with the MRI center. Why the disparity?

One part of me argues, “Why do these million dollar prima donnas receive better care than my patients?” The other part of me replies, “Because no one has invested millions of dollars in you.” Maybe if my multimillion dollar investment rode on an intact anterior talofibular ligament, I wouldn’t hesitate to order that MRI.
I’m still not settled with the answer but can live with the reality…for now.

As with all patients, our athletes have their own peculiarities, challenges, and rewards. What are your thoughts and concerns when it comes to athletes? Do you enjoy treating athletes? What practices have made you more successful with your athletes? Let us know.