A 12-Year-Old Tear Returns to Haunt

I am 42 and have been running for about four years. I set a PR in a half-marathon three weeks ago (1:19:36), as part of training for an upcoming marathon. My race is in 10 days, so I started tapering down from 95 miles a week to 60 miles a week. I was doing an easy recovery run when I heard a pop-and-tear as I landed. I had immediate pain in my knee area and had to hobble home. I had an ACL repair about 12 years ago but have never had any knee problems since then. I have a friend who is a radiologist, so I had an MRI done that very day, and it showed a contusion of the posterolateral tibial plateau along with an effusion, but no torn ligaments or meniscus. I can’t find any information about running causing this type of injury. Besides rest and NSAIDs, how do I treat it and what can I do to prevent it from happening again?

Silas Donnelly
Mobile, AL

It would certainly be very unusual to suffer a bone contusion in the manner in which you describe. However, it is well known that bone contusions commonly occur at the time of an anterior cruciate ligament tear, and this itself is not uncommon with a simple twisting type injury. In any event, although there are no hard and fast rules, bone contusions typically take four to six months to resolve on MRI, with some most likely never resolving. It is possible that this is residual signal uptake from your original injury 12 years ago. There is really nothing you can do from a treatment standpoint for a bone contusion except time, activity modification, and analgesics. Be as active as comfort allows.

However, you must avoid impact activities such as running; substitute with swimming or bicycling. I would also like to note that MRIs are not perfect. It’s been shown that MRIs miss up to 20% of cartilage tears. If your tenderness is not directly over the area of the bone contusion on the MRI, I would question whether the MRI abnormality is in fact causing your pain. Perhaps you have a torn posterolateral meniscus that has gone unidentified on the MRI.

G. Klaud Miller, MD
Evanston, IL

It sounds like you may have had a microscopic fracture of your plateau. This is a variant of a stress fracture and really is the result of too much, too often, too long, and too hard. If this is in fact what we are dealing with here, you must learn to scale back your training to more moderate levels and incorporate more low-impact crosstraining. Ninety-five miles a week may have been too much.

Immediate treatment involves no running for several weeks, followed by one or two days at most, and then working into increased distance and intensity slowly. I had a patient who tried to keep running and had loss of joint surface cartilage in the area, and consequent long-term problems. Swim, row, bike, or use a glider-type crosstraining machine to substitute impact activity. If you are running some in three months, consider that very good progress and don’t become impatient. I am not a great fan of NSAIDs just to keep people going, as inflammation is part of the healing process, so use these with caution.

Larry Hull, MD
Centralia, WA

A Lump on the Bottom of My Foot

I have a pea-sized lump on the bottom of the arch of my left foot, which my doctor believes may be a ganglion cyst in the plantar fascia. It swells to a larger size after I walk or run on it. I’ve had it for about six weeks, and it’s tender to the touch; it gets irritated and painful when I run or take long walks on it. I’ve tried conservative treatments like ice, stretching, a night splint, and I’m in the process of getting new orthotics. My doctor is now considering cortisone injections or surgery. I’ve been a regular runner for over 20 years and a marathoner for the past 10. I’ve been told that ganglion cysts often recur, and I am very troubled by the thought that I may not be able to run consistently again, or for long distances. What are the various treatments and procedures for this injury, and what are the success rates? I would
also like to know what the recovery times are like.

Sam Brownstein
Mystic, CT

I’ve been in practice for multiple decades, including two years as a foot and ankle surgery resident, and I have never seen a ganglion on the ligament in the arch. While it is possible, it is very unlikely. What I believe this is, most likely, is a fibroma. The only treatment is excision and you never perform that unless they hurt consistently. First, ask your doctor if (s)he was using the term cyst as a term you would understand, even though it is really a fibroma. If the answer is still a cyst on the ligament, get an MRI to confirm that it really is a cyst, get it drained, and you may do very well. If it is a fibroma (as I suspect), get your orthotics modified to fit the lump without pressing into it. Otherwise, leave it alone until it drives you nuts; surgery is the only way to get rid of it and recurrence is indeed high.

Gene S. Mirkin, DPM, FACFAS
Kensington, MD

A fibroma is indeed the more likely diagnosis, as a fluid-filled cyst (ganglion) is rarely painful. You ought to have a diagnostic ultrasound to identify for certain which type of lesion it is, how big it is, and where it is attached before you can begin to assess treatment options or get discouraged about time before a return to running. If the growth is solid and painful, surgical removal is usually very successful and has minimal disability.

David M. Davidson, DPM
Williamsville, NY

When Military Presses Cause Shoulder Pain

I am a 46-year-old male who has been lifting weights since about the age of 13. As I have gotten older I have had to reduce the amount of weight I lift, as well as the number of sets, due to pain in my shoulders while lifting. The pain is usually only present when I do military presses. If I am unable to lift due to work or other scheduling conflicts, I notice I can lift pain free for a while when I return.

I have had one of my shoulders arthroscoped twice due to a torn rotator cuff from playing softball 15 years ago. I take glucosamine/chondroitin daily to help my joints. I realize the easy answer is to cease doing this particular lift. I wonder, is there anything I can do to correct this problem, or barring that, another lift that will strengthen the same muscle group without stressing this area?

Jason Gurion
Palmdale, CA

This sounds like shoulder impingement syndrome. People who raise their arms over their heads, as with the military press, often irritate their rotator cuff muscles and tendons. The two previous surgeries have complicated your situation. Even successful surgeries will leave scar tissue in the shoulder joint. There are several things which should help your condition:

1. Pay strict attention to your posture. Try to keep your shoulders from drooping forward throughout the day.

2. If you haven’t been doing so already, start performing scapular retraction exercises. Examples include seated rows and reverse flies.

3. Eliminate movements that aggravate your shoulders.

4. For the time being replace the bench press with incline bench or DB incline bench.

5. Do front, lateral, and posterior raises instead of the military press, at least for the time being.

6. Perform shoulder and chest stretches on a daily basis—but only stretch to a point that does not aggravate your symptoms.

If these measures do not help over the next six to eight weeks, I suggest scheduling a visit with a sports medicine specialist. You may need more intensive therapeutic treatment.

Doug Lentz, CSCS
Chambersburg, PA

The rotator cuff muscles provide the stability your shoulder needs to perform the movements created by the prime movers of the joint. As you engage in a strengthening program that includes shoulder presses, your larger shoulder muscles become stronger and create a greater imbalance of strength between them and the rotator cuff muscles. To continue with shoulder presses, you could try altering your range of motion, the angle at which you press, and your hand position, any one of which may take the burden off the shoulder that had the surgeries. You can accomplish this using dumbbells instead of a machine, which has a fixed path of movement. As noted above, a regimen of rotator cuff strengthening exercises should be added to your program. A visit to an orthopedist would help you both receive a proper diagnosis and get more details on which exercises to add.

Greg Tymon, MEd, CSCS
East Stroudsburg, PA

Persistent Achilles Pain

I’m 56 years old, 5’ 9”, 174 lbs, and I have a sore left Achilles tendon. My weekly mileage and speed have decreased with age since I began running in 1976, but I am still addicted to running. I am willing to do whatever it takes to get back to it.

I have not run regularly for about eight months. Prior to that I ran 5 to 6 miles every other day, at around 8:00 pace. On the odd days I played racquetball, bicycled or used a crosstrainer. I also do weight training two to three times a week. I received ultrasound therapy for the Achilles for two months, and iced it every night, but the pain persisted. I now only use the crosstrainer and bicycle, though I do Achilles stretches every day, and wear a heel pad in my left shoe at all times. In the past, I’ve had problems with my right Achilles and right hamstring. The same physical therapist helped me with these problems, but this new, left Achilles pain seems difficult to treat. Any suggestions would be greatly appreciated.

Tony Wolny
Bloomington, IN

Without more info on the area of the tendon involved, it’s difficult to say, however it seems there may be structural changes such as calcification within the tendon. I say this because the situation has not improved over time and with physical therapy. Do see a podiatrist or an orthopedist and discuss the advantages of an MRI exam.

Jeff Carrel, DPM
Williamsville, NY

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