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Athletic Foot Injuries Treatment & Management

  • Author: Timothy J Rupp, MD, MBA, FACEP, FAAEM; Chief Editor: Craig C Young, MD  more...
 
Updated: Oct 07, 2015
 

Acute Phase

Rehabilitation Program

Physical Therapy

Physical therapy is effective in treating inversion injuries and tendinitis of the foot, particularly in athletes who are continuing competition. Most athletes with fractures rehabilitate around the injury to minimize joint restriction and to maintain fitness levels. Acute phase treatment includes relative rest, ice, electrical stimulation, phonophoresis, and iontophoresis.

  • Sesamoiditis: Treatment consists of wearing cushioned-soled shoes with total-contact inserts to relieve stress on the first metatarsal head; taking nonsteroidal anti-inflammatory drugs (NSAIDs); and implementing rest, ice, compression, and elevation (RICE). An orthotic device should be worn for at least 6 months.
  • Turf toe: The management of turf toe injuries is determined by the grade of injury. Acute treatment consists of a period of RICE, taping, and strapping the toe in a plantar-flexed position to avoid further hyperextension. Rigid turf-toe orthotics may be helpful as well. Ambulation is well tolerated in a hard-soled shoe. Mild-to-moderate sprains may require rest from the activity from days to weeks. Severe sprains may necessitate relative rest for up to 6 weeks.
  • Sever disease: Treatment consists of implementing RICE, wearing protective heel inserts or prefabricated arch supports, performing stretching and strengthening exercises, and, occasionally, taking NSAIDs (see image below).
    Select tendons of the foot. Select tendons of the foot.
  • Posterior tibial tendinitis: Treatment depends on the degree of symptoms. Initially RICE, NSAIDs, and analgesics are used as needed. Cast immobilization may be helpful during the early stages of the disease.
  • Peroneal tendon subluxation/dislocation: If reduction is necessary, it is accomplished by directing pressure posteriorly and then casting the ankle in slight pronation and flexion.
  • Peroneal tendinitis: For acute tenosynovitis, rest or immobilization and NSAIDs are initial measures. Wearing a cast for 2-3 weeks and then implementing extensive rehabilitation is appropriate for severe symptoms. An injection of a corticosteroid should be considered for patients with resistant symptoms.
  • FHL tenosynovitis: Treatment consists of immobilization, activity restrictions, and NSAIDs.
  • Jones fracture: The management of fifth metatarsal base fractures depends on the type of fracture. Extra-articular tuberosity fractures heal well and are managed symptomatically with either a walking cast or a hard-soled shoe for 2-3 weeks. Nondisplaced diaphyseal fractures are usually treated with non–weight-bearing casting for up to 8 weeks, followed by radiographic assessment. Diaphyseal fractures of the fifth metatarsal are often complicated by nonunion, delayed union, or recurrence secondary to compromised vascular supply. Intra-articular fractures often lead to posttraumatic arthritis.
  • Morton neuroma: Initially, treatment is conservative and is designed to relieve pain while permitting the athlete to continue activity. This treatment involves rest, ice, NSAIDs, and US. The application of a felt pad under the heads of the affected metatarsals may spread the metatarsal heads and relieve pain and inflammation. Injection of a corticosteroid may be effective in reducing the diameter of the impinged nerve branch. Podiatric consultation may be considered for proper shoe fitting.
  • Metatarsal stress fractures (not fractures of the fifth metatarsal): Conservative therapy, including rest, anti-inflammatory medications, application of ice, and cessation of the offending activity, is implemented. Athletes should maintain their aerobic capacity throughout recuperation by beginning a training program that involves non–weight-bearing activity such as swimming or stationary cycling.
  • Lisfranc fracture dislocation: Because TMT fracture dislocations are associated with complications such as loss of arch, degenerative arthritis, chronic pain, and impaired circulation to the distal foot, it is imperative that an orthopedic surgeon determine the most appropriate course of action for the patient.

Medical Issues/Complications

Although the Ottawa Foot and Ankle Rules are validated clinical decision rules, it is recommended that individuals with persistent pain or pain out of proportion to the physical examination findings undergo radiography to rule out a fracture or a bony abnormality. Plain radiographs are often sufficient for the acute evaluation of foot injuries. More detailed radiographic evaluation (ie, stress radiographs, CT scans, MRIs, and bone scans) may be required if plain radiographs fails to reveal a cause of the athlete's pain.

Surgical Intervention

See the list below:

  • Sesamoiditis: Surgical excision is a last option that is rarely indicated.
  • Turf toe: Surgical treatment may be necessary to treat sesamoid injuries and repair capsular tears.
  • Sever disease: Surgery is usually not indicated in patients with Sever disease.
  • Posterior tibial tendinitis: Severe disease may require surgical debridement or repair.
  • Peroneal tendon subluxation/dislocation: Surgery is reserved for those in whom conservative therapy has failed or for those who are high-level athletes.
  • FHL tenosynovitis: Surgical release is occasionally necessary.
  • Jones fracture: Surgery to internally fixate the fracture is often performed to speed up recovery and to minimize the length of time before the athlete can return to play.
  • Fifth metatarsal fractures: Intra-articular tuberosity fractures involving more than 30% of the articular surface may require surgical fixation; therefore, orthopedic consultation is advised. Nondisplaced diaphyseal fractures in athletes may require immediate surgical fixation. Displaced diaphyseal fractures are usually managed operatively.
  • Morton neuroma: Surgical therapy may be recommended for patients or athletes in whom conservative management techniques fail. Surgical resection of the offending neuroma can provide rapid relief from pain and inflammation. [13] A short course of rehabilitative therapy following surgery is generally recommended.
  • Stress fractures: Surgery is considered for athletes with stress fractures if conservative therapy fails. Furthermore, surgery for stress fractures should only be considered if the fracture is in a bone in which a complete fracture would result in serious complications (ie, tarsal navicular bone, fifth metatarsals).
  • Lisfranc fracture dislocation: The orthopedist may elect to perform closed reduction under general anesthesia with the use of finger traps and countertraction at the ankle. The patient may require open reduction and internal fixation for more definitive stabilization. The patient will likely require a short leg cast from 6-12 weeks following surgery. At first, the patient will have a non – weight-bearing restriction and then gradually will progress his or her weight bearing in a walking cast. A custom arch support may be used for up to 1 year.

Consultations

Consultation by an orthopedist or podiatrist is recommended for those individuals with pain out of proportion to the physical examination findings, persistent pain, pain associated with stress fractures, or any of the fractures mentioned herein that typically require operative management.

Other Treatment

Manipulation can be used to reintroduce motion and joint play into the foot, especially after prolonged immobilization, which often occurs during the postsurgical period or during fracture care. This manipulation can speed up return to play, which is the essential issue in athletic injuries.

Injections are controversial in such problems as plantar fasciitis because corticosteroids can increase the risk of tissue failure and rupture. Never use corticosteroids in a suspected or known fracture or directly in a tendon. A steroid agent can be injected into a tendon sheath to treat recurrent inflammation, but such an agent is rarely used as a first-line treatment. A diagnostic injection with lidocaine or bupivacaine may be used only as a means of localizing pathology.

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Recovery Phase

Rehabilitation Program

Physical Therapy

After the acute phase, focus moves to ROM. PROM and active ROM (AROM) exercises are used; muscle energy can be applied to restore the muscle set points. Therapy then shifts to improving strength and proprioception. Balance exercises are vital before returning an athlete to competition to prevent further injury.

Medical Issues/Complications

NSAIDS are prescribed for the acute management of inflammation and pain associated with a number of athletic foot injuries, including sesamoiditis, apophysitis, plantar fasciitis, and stress fractures. Although these agents are efficacious, there is evidence in the literature to suggest that NSAIDS prescribed for the acute management of stress fractures have demonstrated impaired bone healing. The concern about masking painful symptoms, prompting premature return to activity and exacerbating a stress fracture, has resulted in some clinicians avoiding the use of NSAIDS in the management of stress fractures.[14]

Surgical Intervention

Because of the importance of the Lisfranc joint, nearly all fracture dislocations through the TMT joint are aggressively treated with open reduction/internal fixation or percutaneous pinning.[15, 16, 17]

Calcaneal fractures almost universally require operative management, although repair is often delayed to allow for resolution of the marked soft-tissue swelling that accompanies fractures of the calcaneous.[18, 19]

A multi-center, assessor blinded, randomized controlled trial of 151 patients reported that standard operative treatment by open reduction and internal fixation for patients with typical displaced intra-articular fractures of the calcaneus (Sanders classifications 2-4) showed no difference in symptoms or function after two years compared to non-operative care. Since the risk of complications was higher in the operative group, the authors concluded that operative treatment was not recommended for these fractures.[19]

Jones fractures of the fifth metatarsal may be treated with a short leg cast for 6-8 weeks, although the high incidence of delayed union has resulted in more aggressive operative management of these fractures.[14]

Other Treatment (Injection, manipulation, etc.)

Taping or bracing may be considered when preparing to return the athlete to play. For example, an athlete with turf toe may have steel-toe inserts in his/her shoes and taping on the first MTP joint.

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Maintenance Phase

Rehabilitation Program

Physical Therapy

The athlete needs to continue implementing a proprioception and strength program to maintain function. Bracing, taping, or other prophylactic measures are taken into account with each individual injury and athlete. The long-term use of braces on the foot or ankle are discouraged.

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Contributor Information and Disclosures
Author

Timothy J Rupp, MD, MBA, FACEP, FAAEM Staff Physician, Emergency Medicine Consultants; Staff Physician, Innovative Emergency Medicine; Staff Physician, Emergency Service Partners

Timothy J Rupp, MD, MBA, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Texas Medical Association, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Steven J Karageanes, DO, FAOASM Director of Sports Medicine, St Mary Mercy Hospital Livonia; Regional Assistant Dean, Kansas City University of Medicine and Biosciences; Clinical Assistant Professor, Michigan State University College of Osteopathic Medicine

Steven J Karageanes, DO, FAOASM is a member of the following medical societies: American Medical Association, American Osteopathic Academy of Sports Medicine, American Osteopathic Association, Michigan State Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

David T Bernhardt, MD Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics/Ortho and Rehab, Division of Sports Medicine, University of Wisconsin School of Medicine and Public Health

David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

References
  1. Malanga GA, Ramirez-Del Toro JA. Common injuries of the foot and ankle in the child and adolescent athlete. Phys Med Rehabil Clin N Am. 2008 May. 19(2):347-71, ix. [Medline].

  2. Birrer RB, Dellacorte MP, Grisafi PJ. Common Foot Problems in Primary Care. 2nd ed. Philadelphia, Pa: Hanley & Belfus Inc; 1998.

  3. Sammarco GJ, Cooper PS. Foot and Ankle Manual. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998.

  4. Scurran BL. Foot and Ankle Trauma. 2nd ed. New York, NY: Churchill Livingstone; 1996.

  5. Cailliet R. Foot and Ankle Pain. 3rd ed. Philadelphia, Pa: FA Davis Co; 1997.

  6. Weinfeld SB, Haddad SL, Myerson MS. Metatarsal stress fractures. Clin Sports Med. 1997 Apr. 16(2):319-38. [Medline].

  7. Knapp TP, Garrett WE Jr. Stress fractures: general concepts. Clin Sports Med. 1997 Apr. 16(2):339-56. [Medline].

  8. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. 1983 Sep-Oct. 11(5):349-53. [Medline].

  9. Maitra RS, Johnson DL. Stress fractures. Clinical history and physical examination. Clin Sports Med. 1997 Apr. 16(2):259-74. [Medline].

  10. Ebell MH. Evaluating the patient with an ankle or foot injury. Am Fam Physician. 2004 Oct 15. 70(8):1535-6. [Medline]. [Full Text].

  11. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993 Mar 3. 269(9):1127-32. [Medline].

  12. Rachel JN, Williams JB, Sawyer JR, Warner WC, Kelly DM. Is radiographic evaluation necessary in children with a clinical diagnosis of calcaneal apophysitis (sever disease)?. J Pediatr Orthop. 2011 Jul-Aug. 31 (5):548-50. [Medline].

  13. Richardson DR, Dean EM. The recurrent Morton neuroma: what now?. Foot Ankle Clin. 2014 Sep. 19 (3):437-49. [Medline].

  14. Rupp T, Hancock R. Evaluation and management of foot pain in the emergency department. Emerg Med Rep. Jan 22 2007. 28(3):

  15. Simon RR, Koenigsknecht SJ. Tarsometatarsal fracture-dislocations. Emergency Orthopedics: The Extremities. 3rd ed. Norwalk, Conn: Appleton & Lange; 1995. 331-2.

  16. Hesp WL, van der Werken C, Goris RJ. Lisfranc dislocations: fractures and/or dislocations through the tarso-metatarsal joints. Injury. 1984 Jan. 15(4):261-6. [Medline].

  17. Lenczner EM, Waddell JP, Graham JD. Tarsal-metatarsal (Lisfranc) dislocation. J Trauma. 1974 Dec. 14(12):1012-20. [Medline].

  18. Germann CA, Perron AD, Miller MD, Powell SM, Brady WJ. Orthopedic pitfalls in the ED: calcaneal fractures. Am J Emerg Med. 2004 Nov. 22(7):607-11. [Medline].

  19. Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M, et al. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. BMJ. 2014 Jul 24. 349:g4483. [Medline].

  20. Hsu AR. Topical review: barefoot running. Foot Ankle Int. 2012 Sep. 33(9):787-94. [Medline].

  21. Lieberman DE. What we can learn about running from barefoot running: an evolutionary medical perspective. Exerc Sport Sci Rev. 2012 Apr. 40(2):63-72. [Medline].

  22. Rixe JA, Gallo RA, Silvis ML. The barefoot debate: can minimalist shoes reduce running-related injuries?. Curr Sports Med Rep. 2012 May-Jun. 11(3):160-5. [Medline].

  23. Altman AR, Davis IS. Barefoot running: biomechanics and implications for running injuries. Curr Sports Med Rep. 2012 Sep-Oct. 11(5):244-50. [Medline].

  24. Conti SF. Posterior tibial tendon problems in athletes. Orthop Clin North Am. 1994 Jan. 25(1):109-21. [Medline].

  25. Gellman R, Burns S. Walking aches and running pains. Injuries of the foot and ankle. Prim Care. 1996 Jun. 23(2):263-80. [Medline].

  26. Gilman AG, Rall TW, Nies AS, Taylor P, eds. Goodman and Gilman's the Pharmacological Basis of Therapeutics. 8th ed. New York, NY: McGraw Hill Inc; 1993. 489-500, 664-667.

  27. Haverstock BD. Foot and ankle imaging in the athlete. Clin Podiatr Med Surg. 2008 Apr. 25(2):249-62, vi-vii. [Medline].

  28. Jenkins WL, Raedeke SG, Williams DS 3rd. The relationship between the use of foot orthoses and knee ligament injury in female collegiate basketball players. J Am Podiatr Med Assoc. 2008 May-Jun. 98(3):207-11. [Medline].

  29. Nunan PJ, Giesy BD. Management of Morton's neuroma in athletes. Clin Podiatr Med Surg. 1997 Jul. 14(3):489-501. [Medline].

  30. Sherman KP. The foot in sport. Br J Sports Med. 1999 Feb. 33(1):6-13. [Medline]. [Full Text].

  31. Sims EL, Hardaker WM, Queen RM. Gender differences in plantar loading during three soccer-specific tasks. Br J Sports Med. 2008 Apr. 42(4):272-7. [Medline].

  32. Wedmore IS, Charette J. Emergency department evaluation and treatment of ankle and foot injuries. Emerg Med Clin North Am. 2000 Feb. 18(1):85-113, vi. [Medline].

  33. Wu KK. Morton neuroma and metatarsalgia. Curr Opin Rheumatol. 2000 Mar. 12(2):131-42. [Medline].

 
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The hindfoot is composed of the talus and the calcaneus.
Select tendons of the foot.
Select bones of the foot (dorsal and plantar views).
Select bones of the foot (medial and lateral views).
Select bones of the foot (superolateral view).
 
 
 
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