eMedicine Specialties > Sports Medicine > Foot and Ankle

Athletic Foot Injuries: Treatment & Medication

Author: Timothy J Rupp, MD, FACEP, Associate Medical Director, Physicians Emergency Care Associates, Methodist Health System, Dallas, Texas; Staff Physician, Innovative Emergency Medicine, Frisco, Texas; Staff Physician, Department of Emergency Medicine, Children's Medical Center of Dallas, Dallas, Texas
Coauthor(s): Steven Karageanes, DO, Director, Primary Care Sports Medicine Fellowship, Director, Sports Medicine Education, Center for Orthopedics and Neuroscience; Department of Medical Education, Oakwood Healthcare System
Contributor Information and Disclosures

Updated: Jun 18, 2008

Treatment

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: 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 2).
• 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

• 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. 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.

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.¹²

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.^13,14,15

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.¹⁶

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.¹²

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.

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.

Medication

NSAIDs remain the mainstays of medical therapy for athletic foot injuries. For moderate to severe pain, the addition of an opioid analgesic may be necessary as well.

Nonsteroidal Anti-inflammatory Drugs

NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well; these may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Related eMedicine topic:
Toxicity, Nonsteroidal Anti-inflammatory Agents

Ibuprofen (Motrin, Ibuprin)

Classified as a propionic acid derivative. All drugs in this class are effective inhibitors of cyclooxygenase, although the potency varies.

Naproxen (Naprelan, Naprosyn, Anaprox)

Classified as a propionic acid derivative. All the drugs in this class are effective inhibitors of cyclooxygenase, though the potency varies.

Cyclooxygenase-2 Inhibitors

COX-2 inhibitors promote control of moderate pain and anti-inflammatory effects, especially in patients who have sensitivity to the traditional NSAIDs. These agents appear to be as effective as nonselective NSAIDs in treating pain and inflammation, and their theoretic advantage over nonselective NSAIDs involves significantly less toxicity, particularly in the gastrointestinal (GI) tract. This class of drug generally is indicated for patients at risk for GI hemorrhage. These patients include those with peptic ulcer disease, patients on warfarin therapy or on concomitant steroids, and elderly persons.

There has been literature questioning the safety of COX-2 inhibitors. Rofecoxib (Vioxx) was withdrawn from the worldwide market because of its association with and increased rate of cardiovascular events (including heart attack and stroke) compared with placebo. Valdecoxib (Bextra) was recalled for similar concerns. It is not clear whether these safety concerns are specific to rofecoxib and valdecoxib.

Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeding is clearly less with COX-2 inhibitors than with the traditional NSAIDs. The cardiovascular issues may be a class effect of all COX-2 inhibitors. Ongoing analysis of the cost avoidance of GI bleeding and further study of the cardiovascular issues should further define the populations that will benefit from the use of and help to answer questions concerning the safety of COX-2 inhibitors.

Related eMedicine topic:
Cyclooxygenase Deficiency

Related Medscape topic:
Resource Center Adverse Drug Events Reporting

Celecoxib (Celebrex)

Primarily inhibits COX-2, which is considered an inducible isoenzyme, induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient. Celecoxib has the same general class labeling as conventional NSAIDs.

Analgesic, Miscellaneous

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who are in pain. Opioids produce their major effects by acting as agonists on specific opioid receptors. The effects are diverse and include analgesia, drowsiness, respiratory depression, decreased GI motility, nausea, and vomiting.

Related eMedicine topics:
Opioid Abuse
Toxicity, Acetaminophen
Toxicity, Narcotics

Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches

Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)

Has analgesic and antipyretic effects that do not differ significantly from aspirin. However, acetaminophen has only weak anti-inflammatory effects. The exact mechanism of action is not clear.

Hydrocodone and acetaminophen (Vicodin, Norcet, Lortab)

Drug combination indicated for moderate to severe pain for pain that is refractory to NSAIDs.

Codeine and acetaminophen (Tylenol #3, Tylenol Elixir with Codeine)

Indicated for the treatment of mild to moderate pain. The elixir formulation has 12 mg of codeine combined with 120 mg of acetaminophen in 5 mL. Tylenol #3 has 300 mg acetaminophen and codeine phosphate 30 mg.

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