Sport

The role of podiatry in sports medicine

2600 Words
19 min. reading time

John is a podiatrist in private practice in Melbourne, PhD candidate at La Trobe University and recently completed the Certified Sports Podiatrist pathway. If he could have an ideal day it would start with a nice coffee, include some reading and finish with a game of golf.

Certified Sports Podiatrist John Osborne facilitates a debrief with three professionals in the sporting world. They open up about their experiences of podiatry and podiatrists, as well as their expectations of the profession.

For most foot and ankle issues that I see, podiatry would play a significant role in the rehabilitation and management of that problem – it would be unusual for podiatry not to be involved in these cases

Meet the panel

Dr Matt Chamberlain

Sports physician

Dr Chamberlain is a fellow of the Australasian College of Sport and Exercise Physicians (ACSEP). He has covered a wide range of sports over the last 15 years, including AFL, A-league, gymnastics, netball and basketball at an elite level. Dr Chamberlain has also worked closely with the Australian swimming team since 2012 and travelled with them to both Commonwealth and Olympics games. He has a special interest in conservative management of degenerative joint, tendon and other musculoskeletal conditions, and particularly enjoys the challenge of foot and ankle pathology. Dr Chamberlain believes strongly in the role of nutritional, lifestyle and exercise approaches for many of these issues, and like a multimodal approach to optimise outcomes. He also has experience using injectable interventions for joint and tendon disorders including the use of prolotherapy, high volume injection techniques, hyaluronic acid, PRP (platelet-rich plasma), ACS (Autologous Conditioned Serum) and stem cells when appropriate.

Megan Tucker

State Female and Melbourne Stars physiotherapist

Megan is a titled sports and exercise physiotherapist who works full time with elite cricketers at Cricket Victoria and previously as the team physiotherapist for the Australian women’s cricket team. She is part-owner of the Cricket & Sports Medicine Centre, a private practice in St Kilda Melbourne, where they specialise in the diagnosis and management of sports-related injuries in particular cricket injuries; from weekend warriors through to elite and professional athletes. Megan has worked in multidisciplinary sports private practice settings over the last 16 years, as well as with various elite teams and professional athletes including the Australian Open Tennis, Tennis Australia/ITF tournaments, AFL (Hawthorn FC), WNBL basketball (Dandenong Rangers), Basketball Victoria and Gymnastics Victoria. She has a keen interest in the unique challenges of working with female athletes.

Jenna O'Hea

Captain of the Australian Opals basketball team

Jenna has proven herself to be one of the most complete players in women’s basketball, with her ability to score, facilitate and defend making her a key cog in the Jayco Australian Opals machine. Jenna cemented her spot in the Opals squad for the 2010 FIBA World Championships before helping the Opals win the bronze medal at the 2012 London Olympic Games and captained the Opals to a silver medal at the 2018 World Championships and a gold medal at the 2018 Commonwealth Games. As well as WNBL honours, Jenna played in the WNBA for the Los Angeles Sparks and the Seattle Storm and in the Basket Lattes-Montpellier Agglomeration (BLMA) in France. Jenna managed to win the title in the French Cup in 2014 with 18 points and five rebounds. More recently, Jenna captained the Southside Flyers (formerly Dandenong Rangers) to their first championship in 2020.

As a sports physician, whilst we have a good working knowledge of these concepts I would say that practical implementation outside the very basics is not in our skillset.

Welcome to today’s discussion! Do you use podiatry in your career?

MC: Yes, of course! I would interact at all my practices on a daily basis with the podiatrists about clinical issues. Bouncing ideas off different practitioners is one aspect that makes this job so enjoyable! For most foot and ankle issues that I see, podiatry would play a significant role in the rehabilitation and management of that problem – it would be unusual for podiatry not to be involved in these cases. I am fortunate to have a network of sports podiatrists I can rely on for excellence in rehabilitation, offloading strategies and load management (and many other things) to help my patients get good results.

There are any number of common lower limb conditions where podiatry plays a pivotal role, especially given most sports medicine/musculoskeletal practice involves complex problems where a team approach is required to optimise the patient’s result. I sometimes view sports medicine practice as a ‘jack-of-all-trades’ job but master of none, meaning that we do need by nature to involve other people often in management plans.

As a sports physician, whilst we have a good working knowledge of these concepts I would say that practical implementation outside the very basics is not in our skillset. So I am heavily reliant on your expertise and practical experience in these areas.

Beyond this, many of the common lower limb conditions we see in young athletes benefit from podiatry input, in terms of resolution as well as injury prevention. Gait mechanics and biomechanical assessments would be another reason for podiatric intervention in the higher-level athlete.

MT: Yes, I have used podiatry, for both myself personally as well as the athletes I work with.

On the personal front, I was an avid gymnast when growing up but I also competed in many varied sports. However, I suffered severely from calcaneal apophysitis and calf cramping pain, largely from high levels of activity and biomechanical issues. Seeing a podiatrist, in conjunction with a physiotherapist, was a huge part of the solution in managing my pain and providing education around the activity levels I was doing while managing growth spurts. Choosing a sport where footwear was not used meant that it became extremely important to build adequate strength to help address some of the biomechanical issues surrounding my pain. The podiatrist really aided me in this area, through their expertise.

Professionally speaking, throughout my career, I have been a strong advocate for the use of podiatry as part of the multidisciplinary team, both when working in private practice as well as within a high performance/elite teams environment.

Early in my career, I was lucky to work in environments where podiatrists have been part of the multidisciplinary team both in private practice clinic settings and within elite teams. As a result, I have seen first hand the positive impact they can have in managing a patient’s return from injury.

I have always considered podiatry just another part of the whole picture for a patient’s diagnosis, management and long term outcome. Just like a doctor, a physio, a dietitian or an exercise physiologist or strength and conditioning coach; they offer their own skillset which should be valued to ensure the best available treatment for my patients.

In team environments where podiatry may not necessarily be part of the day to day staffing of the team, I’ve found it important to make strong positive cross-referral relationships to ensure podiatry services can be offered to the athletes I work with.

JO: Yes I use podiatrists, and for a wide range of issues. Most recently for calluses on my second toe due to my bunion!

What do you think are the strengths of podiatry as a profession in the context of its use in sports medicine?

MC: Podiatrists have an extremely high level of working knowledge of the foot and ankle from an anatomical, functional, and pathological perspective. As I would expect after all that study!

Maybe my view is biased somewhat, but a lot of sports medicine and degenerative lower limb pathology has a strong basis in foot and ankle alignment. So in turn, looking at how that foot interacts with the surface of the earth is equally important. I think this is generally under-recognised in the patient group I see, particularly we see subgroups with a more cavovarus or planovalgus alignment as one example. If this isn’t being managed, then the patient will never get the results they desire. And this is even before we get to functional aspects of management, and it’s only podiatrists who have the skillset and breadth to manage this completely.

Speaking strictly in sports medicine, the subtleties of biomechanics and strength specific issues are incredibly valuable for athletes trying to optimise performance and recovery from injury. From a rehabilitation process, I would find generally podiatrists cover this best.

I am also very grateful I have podiatrists who can answer all those difficult questions about running shoes and shoewear choices that I can no longer keep up with!

MT: Anatomical and physiological knowledge of the foot and ankle are clearly the main strengths of a podiatrist. In particular:

Specific knowledge around strengthening of foot and ankle musculature
Knowledge and referral of imaging and small surgical procedures
Wound/blister advice and management
Sports shoe advice and modifications
Orthotic prescription, and;
Modifications and innersoles.

JO: With how much we run, we need our feet to be tracking and performing correctly, which podiatry plays a big part in. In fact, I don’t know many athletes who don’t use podiatrists.

Note from section editor, John Osborne: My summary here is that we should be, and continue to be, the experts as far as anatomy and its application for this cohort.

In office practice we will very rarely see a case of plantar fasciitis that has been present for two to three months. Instead, 18 months would be the norm and usually after the patient has seen three other practitioners.

What do you think are the weaknesses of podiatry as a profession in the context of its use in sports medicine?

MC: This is a difficult question to answer as a sports physician, because ultimately, we only ever see each other’s failures which biases my perspective. For example, in office practice we will very rarely see a case of plantar fasciitis that has been present for two to three months. Instead, 18 months would be the norm and usually after the patient has seen three other practitioners.

However general themes which seem to recur include:

Repeated use of the same failed strategy by multiple practitioners (e.g orthotics devices in plantar fasciitis, Alfredson Protocol for achilles tendinopathy and so forth). To paraphrase a quote often attributed to Albert Einstein: ‘The definition of insanity is doing the same thing over and over and expecting different results’
Under-recognition of systemic, neural, metabolic and inflammatory contributors to pain
Underuse of strength-based rehabilitation
Inappropriate load management
Recognition of psychological barriers to treatment, and;
‘Treatment fatigue’.

It should be noted, however, that these are common themes amongst all complex referrals and perhaps not specific to any one profession.

MT: I think a weakness is orthotic prescription when it’s perhaps not the only solution or option for management.

To this, I would add the following:

There is a general lack of knowledge within the wider sports medicine teams about the full range of skillsets podiatrists have and can offer
I would like to see more communication back to the referring clinician to work together in a holistic way for the athlete, especially if they are not working all the time in that environment it is important to fully understand the context and nature of the issue and their sport. Then we can get the best outcome by working with those professionals who are seeing the athlete on a daily basis
There is a need for more cross-referrals to other members of the sports medicine team to assist in addressing other areas which may be better managed by them, or it might aid in the overall management of the patient/athlete, and;
Sometimes a poor understanding of the specifics of a sport or the demands required can take place. Treatment needs to be specific to the particular athlete and their sport.

JO: None come to mind.

Note from section editor, John Osborne: I think this is interesting to note the similarity of expectations from the professionals we work with.

When using podiatry as part of a patient’s or your own management, what expectations do you have?

MC: My expectations would be of evidence-guided based practice, with good clinical reasoning and an outlined plan – along with expectations of the treatment, including an approximate timeline. I do value this information, and it helps me set patient expectations as well.

MT: Definitely evidence-based practice (EBP), with the following points in mind.

Good communication with the athlete and myself about the issue, the diagnosis and management and how we can work together to aid the athlete. To ensure an appropriate overlap of expertise and skills that will help to manage the whole picture
Good understanding of the demands of the sport or athlete and their overall goals or outcome
Excellent knowledge of sports-related injuries
Treatment of the specific problem or issues being referred for, and;
Taking on a holistic approach.

JO: To help fix any problems I have to aid in better and more pain-free movements on the court.

Note from section editor, John Osborne: I note the first thing mentioned by the two professionals is ‘EBP’ and being able to apply deeper current knowledge. Perhaps we should be promoting a deeper view of what our strengths are to begin with? Plus the obvious – being communication, communication, communication.

I’d encourage podiatrists to keep in contact with referring practitioners as this helps to foster better team approaches and it helps me learn! This doesn’t happen enough in my opinion – across all allied health as a rule.

Is there anything else you would like to add to help inform Australia’s podiatrists about how they can better function as part of a sports medicine framework?

MC: I’d encourage podiatrists to keep in contact with referring practitioners as this helps to foster better team approaches and it helps me learn! This doesn’t happen enough in my opinion – across all allied health as a rule.

I think most hig- level sporting organisations recognise the value of podiatry, it’s more about establishing the importance and relevance at a community level.

MT: Advocate to specific teams or sports about the unique skillset that you bring and why you are an important and valued team member in an athlete’s care. I feel many disciplines and athletes themselves see podiatrists solely for orthotic prescription; often a podiatrist’s services and skillset can be undervalued.

Get involved with the teams/sports that you work with so you can ensure good understanding and exposure to the specific issues and demands of the athletes and sports you are working with. Watch training, watch footage, attend a training session or game, get to know the athlete and team you are working with to aid buy-in and a positive outcome for all.

Is there anything you would like to know about how podiatry can help inform decision making for lower limb injury?

MC: One of the best aspects of working in sports medicine is that we have a host of people who can contribute to problem-solving in any given clinical situation. Sports medicine, podiatry, physiotherapy, surgeons, exercise physiologists and so forth will all offer a unique insight. Our training lends itself to viewing these problems from a different angle. I find the contribution of podiatry helps me to understand functional and biomechanical aspects of the foot and ankle pathology, which is often valuable. A podiatrist’s insights are useful when making treatment decisions. So don’t be afraid to share your thought process!

MT: I would be interested to hear what podiatrists feel their role is in this area and how they wish for other disciplines to advocate and educate for them to ensure they remain a valued member of the multidisciplinary team.