Athletic Foot Injuries Clinical Presentation

Sesamoiditis is manifested by pain beneath the first metatarsal head with weight bearing on the ball of the foot or with motion at the first metatarsophalangeal (MTP) joint. Common complaints include pain with jumping and with pushing off to run.

Turf toe is an acute injury that involves forced hyperdorsiflexion of the first MTP joint as the classic mechanism of injury. This results in a sprain of the first MTP joint. Symptoms include pain and decreased range of motion (ROM) at the MTP joint and difficulty running or changing directions.

Sever disease (eg, calcaneal apophysitis) is a common cause of acute or chronic heel pain in children during early adolescence. Athletes typically complain of heel pain or soreness that improves with rest and worsens with prolonged running.

Posterior tibial tendinitis occurs most commonly as an idiopathic condition in middle-aged females. Athletes with this condition may present with planovalgus deformity and often play sports with sudden stop-start or push-off activity, such as soccer, football, and basketball. Patients typically complain of pain inferior to the medial malleolus and decreased ROM.

Patients with peroneal tendon subluxation/dislocation typically present with acute pain and swelling that is centered behind the lateral malleolus, with extension proximally over the tendons. These symptoms are caused by a dorsiflexion-inversion stress injury that pulls the peroneal retinaculum off the lateral malleolus. Athletes usually complain of snapping and sudden sharp pain when changing directions or pushing off with the foot.

Patients with peroneal tendinitis present with pain and swelling on the lateral aspect of the ankle, usually posterior to the lateral malleolus. Patients may also complain of either a "giving way" or "sharp pinching" sensation of the lateral ankle. Long-distance running and any activity that requires repetitive cutting and pushing off can aggravate this condition.

Patients with FHL tenosynovitis usually present with pain in the posteromedial aspect of the ankle. The pain improves with rest and increases in sports that require push-off and extended running.

Fifth metatarsal fractures are a common complication with ankle sprains, so physicians must always address this condition when obtaining the patient's history. The following three types of fractures occur in the fifth metatarsal:

• Avulsion fractures off the base commonly occur with ankle sprains, particularly the plantar flexion-inversion variety.

• Proximal diaphyseal fractures result from repetitive cyclical stress to the foot and typically have a prodromal presentation.

• Transverse fractures occurring within 1.5 cm from the tuberosity at the metaphyseal-diaphyseal junction are the definitive Jones fracture. Contrary to popular belief, true Jones fractures primarily occur traumatically. Pain may be diffuse and difficult to localize, depending on the type and location of the fracture.

Morton neuroma causes pain over the ball of the foot, followed by radiation of pain to the affected toes. The patient may complain of numbness, tingling, burning, or a sensation similar to an electrical shock. Pain usually eases upon removal of the offending shoes and rubbing the ball of the foot near the affected web space. The information obtained in the history usually reveals the wearing of tight-fitting, high-heeled, or pointed-toed shoes, which are commonly worn by females who are young to middle-aged. Athletes who use a repetitive step-off motion (eg, sprinters, jumpers, those who regularly use stair steppers or treadmill machines) may complain of these symptoms.

Most athletes with stress fractures complain of progressively increasing pain that correlates with a change in activity, footwear, training, playing surface, or equipment. Trauma is not part of the history. Pain is exacerbated by impact loading and is ameliorated with rest.

The TMT fracture dislocation, or Lisfranc fracture dislocation, is named after a field surgeon in Napoleon's army who described amputations through the TMT joint. Injury to the TMT joint was common when a soldier's boot became caught in the stirrup during a fall from horseback. More recently, Lisfranc injuries have been observed in snowboarders and windsurfers, as well as in football and rugby players.

Typically, the Lisfranc fracture dislocation occurs when one player falls onto the heel of another while the foot is plantar flexed and fixed, resulting in axial loading. The clinical presentation depends on the degree of displacement.

Almost universally, patients complain of pain in the midfoot with the inability to bear weight. Edema and ecchymosis are usually present. Gross deformity of the forefoot may be seen in severe cases. Vascular compromise may manifest as absence of the dorsalis pedis pulse.

Sesamoiditis: Pain on dorsiflexion of the hallux, restricted motion of the first MTP joint, or pain on dorsal palpation of a sesamoid bone occurs.

Turf toe: The first MTP joint is red, swollen, tender, and stiff. Pain is usually greatest with end-range dorsiflexion of the foot. The collateral ligaments are stable, but there may be laxity with anterior-posterior translation. Consider gout if a patient presents with this particular clinical picture. If there is no history of repetitive motion or if in doubt, the joint may need to be aspirated. The resultant fluid should be analyzed for the culture and the presence of negative birefringent crystals.

Sever disease: Pain is provoked by palpation along the posterior portion of the heel and the Achilles tendon insertion (refer to image below). Restricted ankle dorsiflexion and knee extension may contribute to symptoms.

Posterior tibial tendinitis: Tenderness is revealed at the posterior tibial insertion, often with a swollen erythematous navicular prominence, or along the distal path around the posterior aspect of the medial malleolus. Patients may have pain and/or weakness with resisted inversion and with a tendency to have a flexible flatfoot, genu valgum, and tibia varum.

Peroneal tendon subluxation/dislocation: Palpation reveals direct tenderness over the peroneal tendons. Subluxation, dislocation, or tear of the peroneal tendon results in weakness of eversion and dorsiflexion. Snapping is palpated through ROM, occasionally only when bearing weight.

Peroneal tendinitis: Examination usually reveals swelling and tenderness along the tendons at the lateral aspect of the ankle. Eversion of the foot against resistance may elicit pain.

FHL tenosynovitis: Usually no palpable tenderness is present due to the deep location of the tendon. Pain and weakness are noted with resistance to plantar flexion of the first MTP joint. Pain may also be present in the tarsal tunnel.

Jones fracture: Tenderness may be difficult to localize specifically, but focal pain on the proximal fifth metatarsal indicates a fracture until proven otherwise. Passive inversion or resisted eversion may also be painful with a fifth metatarsal base fracture.

Morton neuroma: Perform a compression test by squeezing the metatarsal heads together with one hand, while palpating and compressing the involved web space with the other hand. If a Morton neuroma is present, the interspaces between the metatarsals will be tender to palpation.

Stress fractures: The physical examination is usually unremarkable, but it may reveal minor swelling and warmth over the forefoot, and point tenderness may be elicited by applying pressure under the affected metatarsal in a dorsal direction. Maneuvers such as walking on the toes or running in place can reproduce symptoms.

Lisfranc sprain: The physical examination may reveal prominence of the first metatarsal or shortening of the forefoot. The patient complains of pain and may note paresthesias of the forefoot and digits. Passive ROM (PROM) and palpation over the metatarsals, with attention to the base of the second metatarsal, will likely reveal tenderness, which mandates that careful radiographic examination be performed. In a dislocation-fracture, the foot may have more swelling and deformity. Radiographs can demonstrate a fracture, seen most commonly at the base of the second metatarsal.