1.
severe inversion ankle sprain causes peroneus brevis tendon to pull away the
base of the 5th metatarsal (Ballerina fracture)ATHLETIC FOOT INJURIES
I. Plantar Fasciitis/Arch Strain
A. Mechanism of Injury
1. strain of plantar fascia-usually at medial insertion into calcaneus
2. middle strip of plantar fascia sometimes involved
3. lateral strip almost never involved
B. Possible Responsible Factors
1. shoes
2. artificial turf
3. severe pronation
4. excessive weight
5. leg length discrepancy
6. tight bed sheets
C. Treatment
1. stretching, Achilles, plantar fascia (night splints)
2. strapping
3. shoe padding - medial heel wedge
-saddle pads
-arch supports
-lift type / padded heel pad
-heel lift for short leg
4. orthotics-rigid (for heavy lineman, need more support & control)
-sports orthotics (lighter in weight with more flexibility for backs and wide receivers)
5. Non Steroidal Anti Inflammatories
6. Steroid Injections - once weekly for 3 weeks
7. Surgical intervention - fasciotomy last resort, after 1 year of conservative treatment
Chronic plantar fasciitis can lead to formation of heel spurs. Plantar Fasciitis is the most common injury seen among long distance runners. It is very painful and can be chronic, extending over several years. The heel spur does not cause the plantar fasciitis, the fasciitis causes the heel spur.
II. Morton's Neuroma
A. Mechanism of Injury
1. direct or microtrauma to an interdigital nerve
2. 90% of neuromas involve the 3rd common digital nerve approximately 10% involve the 2nd common interdigital nerve - 3 & 4 metatarsals
B. Possible Responsible Factors
1. poorly cushioned and or tight shoes, high heels
2. pronation - nerve gets pinched between the heads of the 3rd and 4th metatarsals and the base of the proximal phalanx of the 3rd & 4th toes
3. hard surfaces
4. leg length discrepancy
C. Treatment
1. strapping is ineffective and may increase the symptoms
2. shock absorbent insoles
3. steroid injections - once weekly for 3 weeks
4. shoes with wide toe box and better cushioning
5. orthotics - to reduce pronation and reduce movement of 3rd and 4th metatarsal heads
6. neurectomy - surgical excision of hypertrophied nerve in those not responding to conservative measures
III. Calcaneal Apophysitis (Severs Disease) (pump bumps)
A. Mechanism of Injury
1. direct or microtrauma to the growth center of the posterior calcaneus
2. causes avascularity to the apophysis
3. Usually 8 - 12 year olds
B. Possible Responsible Factors
1. hard playing surfaces
2. shoes - poorly padded
- cleats
- poor support
3. cavus type foot
4. tight Achilles and or plantar fascia
C. Treatment
1. get out of cleats
2. shock absorbent heel pads
3. strapping - to help support plantar fascia
4. orthotic or heel stabilizers
5. in resistant cases immobilization for 4 - 6 weeks may be needed
IV. Sesamoiditis/Sesamoid Fractures
Sesamoid fractures must be differentiated from a normal bipartite sesamoid.
A. Mechanism of Injury
1. direct trauma to tibial (medial) sesamoid - most common
2. direct trauma to fibular (lateral) sesamoid - rare
3. overuse - chronic microtrauma
B. Possible Responsible Factors
1. hard playing surfaces
2. hallux valgus - tibial sesamoid directly under mp joint
3. lack of cushioning in shoes
C. Structures involved
1. sesamoids
2. joint capsule
3. flexor brevis
4. plantar 1st metatarsal head
D. Treatment
Sesamoiditis
1. shoe padding - transfer weight away from sesamoid
2. super cushion inner soles
3. ice, elevation, compression
4. possible post-op shoe
5. steroid injection
Sesamoid fracture
1. cast for 3 weeks - BK
2. post-op shoe
3.surgical excision of affected sesamoid in resistant cases very often will not heal. If hallux valgus present should correct at time of surgery, because weakening of flexor apparatus will increase deformity. This is a last resort in most cases as it changes the bio mechanical forces on the flexor tendons and if a single sesamoid is left in place, the weight bearing mechanics of the foot are greatly altered.
V. Turf Toe
A. Mechanism of Injury
1. hyperextension (most common)
2. hyperflexion
3. valgus injury - usually from sudden acceleration
B. Possible Responsible Factors
1. artificial turf - no give, can be like playing on hard asphalt
2. shoes - too much forefoot flexion (no turf toe plate)
3. combination of turf & shoes
C. Specific Structures Involved
1. capsular & ligamentous structures
2. flexor apparatus
3. possibly sesamoids
D. Treatment
1. rest, ice, elevation, compression
2. possible immobilization and non weight bearing
3. shoe modifications - spring steel splint
4. activity is resumed within the limits of pain
Starting with flat foot walking, then normal gait, then jogging, then straight ahead running at full speed, next running from stance, last performing cutting maneuvers.
5. taping the toe to prevent injury from recurring
6. anti-inflammatories
7. surgery - for capsular repair in non responsive cases
VI. Fracture of Styloid process of 5th metatarsal
A. Mechanism of injury
1.
severe inversion ankle sprain causes peroneus brevis tendon to pull away the
base of the 5th metatarsal (Ballerina fracture)
VII. Direct trauma to base of 5th (Jones fracture)
A. Possible Responsible Factors
1. Cavus foot type
2. chronic ankle sprains
3. poor shoe and/or tape support
B. Specific structures involved
1. peroneus brevis tendon
2. styloid process 5th metatarsal base
C. Treatment
1. ice, elevation, compression and lift under 5th metatarsal base
2. short leg walking brace
3. if severe avulsion of fragment, open reduction screw fixation
VIII. Stress Fractures
A. Mechanism of Injury
1. prolonged, continuous stress on particular weight bearing bone
2. history of particular trauma is lacking
3. insidious onset of pain
B. Possible Responsible Factors
1. Morton's foot-long 2nd metatarsal with short 1st
2. Hallux Valgus-weight transfer to 2nd metatarsal
3. shoes - poor padding and overall support
C. Specific Structures Involved
1. 2nd metatarsal - most common
2. 3rd & 4th metatarsals - less frequent
3. 1st & 5th metatarsals rarely affected
D. Treatment
1. ice, elevation, compression (flexible cast with post-op shoe)
2. short leg walking boot (rarely is open reduction necessary)
X-rays taken shortly after onset of symptoms may be negative. Re-x-ray in 2 - 3 weeks will reveal fracture. If you suspect a stress fracture treat as such until re-x-ray in 2 - 3 weeks, or bone scan.
IX. Shaft Fractures
Distal shaft fractures are often the result of direct trauma. Blunt trauma from a dropped object, having the foot stepped on, etc.
These types of fractures if not displaced tend to respond very well to conservative treatment.
X. Misc. Aggravations
A. Hallux Valgus (bunions)
1. Possible Responsible Factors
a. heredity
b. shoes - irritate but don't cause
c. pronation - accentuates
2. Specific Structures Involved
a. 1st MP - all structures
b. sesamoids
c. lst metatarsal - medial cuneiform joint
3. Treatment
a. accommodate in wider shoes
b. shoe stretching
c. surgical correction in off season if chronically painful (may cause some limitation of joint movement)
B. Hallux Limitus
1. Possible Responsible Factors
a. heredity
b. trauma to joint
c. foot type - plantar flexed 1st digit
2. Specific Structures Involved
a. 1st MP - degeneration of joint cartilage with osteophytic limping of 1st metatarsal head and base of proximal phalanx
b. sesamoids - in advanced cases
3. Treatment
a. rigid soled shoes which limit dorsiflexion
b. taping
c. injection with local and steroid when symptoms acute
d. when condition becomes debilitating & conservative measures fail then surgical intervention is necessary - usually with placement of plastic implant (will weaken push off)
C. Corns (digital clavi)
Calluses (tylomas)
1. Possible Responsible Factors
a. Cavus foot - toes hammer
- plantar flexion of forefoot causes excess pressure on metatarsal heads
b. pronated foot - abnormal weight transfer
c. poor fitting shoes
2. Specific Structures Involved
a. interphalangeal joints of toes
b. extensor & flexor tendons
c. metatarsal heads
3. Treatment
a. deep & wide toe box
b. débride hyperkeratotic tissue regularly
c. Vaseline
d. padding - Spenco 2nd skin
- moleskin
D. Ingrown Nails
1. Possible Responsible Factors
a. improper cutting of nails
b. heredity
c. injury
d. tight shoes
2. Specific Structures Involved
a. tibial & fibular borders, usually hallux nails
b. nail groove
3. Treatment
a. packing cotton under affected border
b. wedge resection of affected border
c. partial radical nail procedure with matrix destruction (phenol method)
E. Black Toe (Subungual Hematoma)
1. Possible Responsible Factors
a. shoes too tight
b. shoes too loose
c. low toe box
d. long 2nd toe
e. cleats
f. kicking
g. direct trauma
2. Specific Structures Involved
a. pedal nails
b. nail bed
c. distal phalanx - possible formation of subungual exostosis
3. Treatment
a. drain hematoma as soon as possible
b. if nail partially avulsed - remove nail completely & débride the nail bed
- start soaks & topical antibiotics
c. if chronic, hypertrophied nail
- keep nail débrided back & thinned as much as possible
- complete avulsion of nail plate with destruction of matrix
F. Plantar Verruca (Warts)
1. Possible Responsible Factors
a. hyperhidrosis
b. abrasions to plantar surface of the foot
c. exposure to verruca virus
- showers- locker rooms - brothers & sisters
d. age - most commonly seen in teen years
2. Specific Structure Involved
a. skin - warts do not penetrate the basement membrane of the skin
b. metatarsal heads and/or calcaneus- areas of most pressure in weight bearing
3. Treatment
a. mechanical debridement prn.
b. topical acids
c. cryotherapy
d. surgical removal - does not leave scar
e. laser
Reference Material:
1. DeVries - Surgery of the foot
2. Subotnick - Podiatric Sports Medicine
3. DePalma - The Management of Fractures & Dislocations Vol. II
4. Yale - Podiatric Medicine
5. Suppan - Podiatric Surgery
6. Giannestras - Foot Disorders
7. Coker, Arnold and Weber - Traumatic Lesions of the Metatarsophalangeal Joint of the Great Toe in Athletes
8. Pagliano - Plantar Fasciitis AMJA Newsletter October 1983
9. Scurran - Pediatric Implications of Podiatric Sports Medicine
Podiatric Sports Medicine Summer 1983
10. Doller, Wilson & Moyles - Intermetatarsal Pain in the Athlete