Taken from Podiatry Today:
How To Evaluate Figure Skating Injuries
VOLUME: 19 ISSUE: 4
PUBLICATION DATE: Apr 01 2006
By Rachel A. Janowicz, DPM
Skate boots can cause and exacerbate soft tissue conditions. For instance, when skaters use a new or excessively stiff boot, there may be insufficient ankle dorsiflexion, which causes forward leaning and an eccentric load on the back leg in an attempt to maintain the center of gravity over the skate rocker. With continuous forward canting, the skater must maintain excessive knee flexion and ankle dorsiflexion to maintain balance. This can strain the posterior elements and contribute to Achilles injury or tendonitis. These are common in skaters, especially those who are predisposed to these conditions. Over-training, poor technique and the mechanical pressure and rubbing of a stiff posterior upper against the Achilles can also cause tendonitis.
Contrarily, if the boot is too loose and the heel is allowed to move up and down excessively (more than 1/2 inch), Haglund’s deformity or retrocalcaneal bursitis may occur. If the boots are relatively new, advise the skater of the etiology of the condition so the manufacturer can perform any necessary posterior upper modifications such as stretching, molding or the addition of extra padding.
Another posterior ankle/leg soft tissue injury caused by boot fit is irritation or dermal thickening of the lower posterior leg due to repeated plantarflexion. However, one can easily remedy this by adding a modification called a dance back. To do so, one would remove a portion of the posterior-superior upper and insert a soft, closed-cell foam material. The manufacturer can do this during or after boot fabrication. The manufacturer can also “punch out” other areas of boot irritation such as those over bony prominences. Padding can also be used for such problems. Clinicians can recommend moleskin, felt and silicone devices such as Bunga Pads (Absolute Athletics) to the skater. The boot manufacturer and ice arena pro shops usually carry these materials.
Skate boots can also cause abrasions, blisters and ganglion cysts. As an example, a 13-year-old female skater presented in my office with a large ankle joint ganglion cyst just anterior to the lateral malleolus. The skate boot was secondhand and excessively stiff. There was no bend to the upper with forceful effort. There had been no modifications for malleoli or bony prominences. I proceeded to aspirate the ganglion and used a corticosteroid injection followed by compression. I advised the skater that she needed new boots or, at the very least, her current pair would have to be molded to accommodate pressure points. The skater missed her follow-up but related that she felt “fine” during a phone conversation two months after treatment. She had obtained new boots.
Bursitis, hammertoes, Sever’s disease and plantar fasciitis (especially in skaters with tight posterior leg muscles or increased longitudinal arches) are other chronic pedal conditions that have been linked to figure skating. It is not currently known whether hallux valgus, limitus or rigidus are directly correlated to skating or its equipment. However, painful bursa and neuritis can form over deformities due to the rigidity of the boot. Again, heat-molding of the boot by the manufacturer and/or padding is appropriate.
Other common tendinitis conditions related to skate boots are that of the extensor hallucis, tibialis anterior and posterior tibial tendons. Extensor tendonitis or lace bite results from lateral slipping and compression of the tongue across the top of the foot and ankle with dorsiflexion. One can add midline lace hooks or alternate lacing, or supplement the skate tongue with porous rubber, felt or lamb’s wool in order to treat this problem in conjunction with antiinflammatory medication and ice.
Skating can exacerbate or even cause posterior tibial tendinitis because the standard boot construct lacks intrinsic arch support. Custom orthoses are certainly indicated in this case.
Overuse injuries occur when a repetitive motion irritates nerves, bones, a muscle, or other connective tissue in the body. An overuse injury typically becomes a "chronic" injury, which develops over time and can be long term, vs. an "acute" injury, which is a sudden injury usually related to some sort of accident (i.e. a broken bone or ankle sprain). Because overuse injuries are a result of repetitive stress on a body part, they can often be avoided by listening to the body's warning signals. The problem is that many active and/or athletic people don't want to listen to those warnings because it usually means stopping what they are doing for a while until the early signals go away.
Some overuse injuries which can affect skaters include: plantar fasciitis, tendonitis, neuroma, and low back strain. Causes of these injuries include poor body mechanics/posture, inadequate flexibility, improper equipment (i.e. skates), and increasing skating mileage or intensity too rapidly.
Plantar fasciitis is intense inflammation of the plantar fascia, a band of fibrous connective tissue that spans the bottom of the foot from heel to toe. Heel spurs may also develop, causing further pain and discomfort. Plantar fasciitis is characterized by severe pain under the heel and arch of the foot. Lack of adequate arch support can be a contributing factor to developing this as can intense gripping (with toes) or poor calf muscle flexibility.
Common treatments include ice and anti-inflammatory medicine. Many people find relief by wearing supportive shoes, good arch support, foot massage and stretching, and stretching the calf muscles. In severe cases, the foot may have to be immobilized by a brace or walking cast.
Tendonitis is the inflammation of a tendon and/or the tendon sheath (a tendon connects muscle to bone). In general, this is a very common overuse injury in different parts of the body for many different sports-related activities. Tendonitis is characterized by pain and stiffness with movement and localized swelling. If left to worsen over a long period of time, mineral deposits can even accumulate in the tendon tissue. In some cases, it is more noticeable in the morning and improves slightly when the tendon is warmed up through mild exercise.
Skaters could potentially develop tendonitis in the foot (from excessive edging or heel-brake stopping), below the knee cap (patellar), or even in the achilles tendon (lower calf). If skating is not a direct cause of these problems, it certainly can exacerbate them. The achilles tendon is the largest tendon in the human body and can withstand forces up to 1000 pounds or more. Overuse of this tendon is often directly related to a lack of proper flexibility in the calf muscles.
Treatment of tendonitis is to stop the activity that is irritating the tendon. Antiinflammatories, ice, and elevation are prescribed. Some people find relief with a combination of ice and heat or liniment (i.e. Tiger Balm). Doctors might use ultrasound treatments, cortisone injections (should not use in the Achilles Tendon), taping or restrictive bandages, insoles or, as a last resort, surgery. The important thing to note is that nothing is an instantaneous cure. Tendonitis can take a while to go away, according to some people, even up to one year or more. Any of the previously mentioned treatments must be coupled with rest for the injured area! The hardest thing to do is to stop doing the activity that is causing the discomfort.
A neuroma is another potential overuse injury that could affect skaters. It is a pinched nerve in the ball of the foot that causes pain. Actually, the nerve becomes enlarged due to too much pressure on the ball of the foot, usually as a result of overpronation or other technique flaws. Neuroma often manifests itself initially as a feeling of numbness or dull ache between toes 2-4. Eventually, this condition becomes painful.
In the early stages, treatment can be as simple as addressing the technique (i.e. correct the overpronation), wear shoes that provide stability, orthotics, and eventually antiinflammatories and ice. Worst-case scenario is surgery.
The other most likely over-use injury or problem to afflict skaters is low-back strain. It is estimated that 60-80% of the population has low back pain at some time. This is almost inherent with the different degrees of forward flexion that skaters adopt. Most people don't have adequate core strength to support their low backs and that can be the source of a lot of the problems. Another cause is tightness in the low back and/or hamstrings and even hip flexors. Low back strain manifests itself as a dull ache and tightness in the muscles of that area (erector spinae muscles).
Massage, ice, heat, and anti-inflammatories can be used for more serious low-back strain, while treatment of mild low back strain generally includes stretching the muscles of the hip, trunk, spine, and hamstrings. This should be coupled with strengthening of the core musculature, especially the abdominals. Ease gently into strengthening the back muscles, but these should ultimately be included in any fitness program. A good stretch for the low back is the "cat/cow" stretch, which can be done from a standing position by resting your hands on your knees or a hands and knees position on the floor, and alternating rounding the back and flattening it. When you round the back, pull the abdominal muscles up toward the spine.