Athletic Foot Injuries

Sesamoiditis is usually caused by overuse of the foot in a plantar flexed position. Cleats with little insole padding can focus excess stress on the first MTP or sesamoid and thus can trigger this condition. A depressed first ray, forefoot valgus, or pes cavus deformity can lead to sesamoiditis as well.

Turf toe is caused by hyperextension of the first MTP joint beyond the normal 60° of dorsiflexion. The incidence of the injury has increased with the widespread use of artificial surfaces. Lightweight, poorly supported, flexible shoes can predispose the athlete to injury.

Sever disease is caused by excessive traction on the calcaneal apophysis by the Achilles tendon, particularly during running and jumping. Inflexibility of the gastrocnemius, hamstring, quadriceps, and hip flexor muscles can exacerbate this condition.

Posterior tibial tendinitis is caused by repetitive trauma during the pronation phase of cutting, jumping, or running. Pes planus is a risk factor.

Peroneal tendon subluxation/dislocation most commonly occurs with powerful contraction of the peroneal muscles, usually in maximal dorsiflexion. The peroneal tendons are retained in place by the superior and inferior peroneal retinaculum. If enough stress is applied, these may rupture, resulting in subluxation or dislocation of the peroneal tendons.

Peroneal tendinitis may be related to acute inversion injury or chronic overuse secondary to hindfoot varus. Iliotibial band restriction increases force on the peroneal tendons.

FHL tenosynovitis is typically associated with repeated push-off maneuvers, such as those executed by ballet dancers or sprinters.

A Jones fracture usually occurs when a load is applied to the lateral forefoot in the absence of inversion. A Jones fracture can also occur with an acute inversion injury. Jones injuries usually occur in sports involving running and jumping. Fifth metatarsal proximal diaphyseal fractures can occur with chronic overuse and poor biomechanics. Fifth metatarsal base avulsion fractures commonly occur via inversion sprain mechanisms.

Morton (intermetatarsal) neuroma is a biomechanically induced neuropathy of the common digital nerve of the foot. Repetitive microdamage to the nerve fibers produces degeneration and reparative fibrosis, significantly increasing the nerve diameter. Restrictive toe boxes combined with overuse can cause this condition.

Stress fractures

Stress fractures are defined as spontaneous fractures of normal bone that result from the summation of stresses, any of which by themselves would be harmless.[6, 7, 8, 9, 10]  Stress fractures of the foot were first described by Breihaupt in 1855. Serving as a physician in the Prussian army, Breihaupt observed fractures of the metatarsals in otherwise healthy military recruits after long marches. These became know as march fractures.

Of all sports-related injuries, it is estimated that 5-10% involve stress fractures. Nine of the 24 members of the 1994 United States National World Cup Soccer Team were diagnosed with stress fractures. The incidence of stress fractures is increasing for the following reasons: (1) increasing numbers of persons participating in sporting activities, (2) increasing awareness and suspicion of stress fractures, and (3) change in the nature and type of sporting activities (ie, rollerblading). Stress fractures of the second, third, and fourth metatarsals account for 90% of metatarsal injuries

Lisfranc fracture dislocation

The transverse ligaments connect the second, third, fourth, and fifth metatarsal bases. The second metatarsal is recessed and bound to the medial and intermediate cuneiform bones by ligaments. The Lisfranc ligament joins the first (medial) cuneiform bone to the base of the second metatarsal. The base of the second metatarsal, recessed tightly into the mortise formed by the cuneiform bones and attached by multiple ligaments, forms the keystone of the midfoot and, thus, is the primary stabilizing structure of the TMT joint complex.

Lisfranc fracture dislocations are classified as homolateral or divergent. A homolateral dislocation involves displacement of 4 or 5 metatarsals in the same direction. A divergent dislocation involves a split between the first and second metatarsals.

United States statistics

Estimates indicate that 15% of sports-related injuries affect the foot alone.

A study that evaluated rates of severe foot injuries (season- or career-ending injuries, injuries with >30-day time loss, or injuries requiring operative treatment) in US collegiate athletes found that 18.7% of all foot injuries that occurred during a 10-year period were severe. Men’s sports with the highest rates of severe foot injuries were basketball, indoor track, and football, whereas women’s sports with the highest rates were cross-country, gymnastics, and outdoor track.[11]

International statistics

Among professional ballet dancers, the most frequent sites of injury are the foot and ankle, which account for up to 62% of all injuries.[12]

Foot and ankle

The foot is composed of 26 major bones, which can be divided into 3 regions: the forefoot, midfoot, and hindfoot. The forefoot is comprised of the 5 metatarsals and the 14 phalanges. The 3 cuneiforms (ie, lateral, intermediate, medial), the cuboid, and the navicular represent the midfoot. The hindfoot is composed of the talus and the calcaneus (see image below).

The talus is oriented to transmit forces from the foot through the ankle to the leg.

The calcaneus is the largest bone in the foot. The Achilles tendon inserts on the posterior aspect of the calcaneus.

The navicular lies anterior to the talus and medial to the cuboid.

The cuboid articulates with the calcaneus proximally, with the fourth and fifth metatarsals distally, and with the lateral cuneiform medially (see image below).

Each of the cuneiform bones is wedge-shaped. The medial, intermediate, and lateral cuneiform bones articulate with the first 3 metatarsals distally and the navicular proximally. The cuboid articulates with the lateral cuneiform.

The 5 metatarsals articulate with the proximal phalanges.

The great toe is composed of 2 phalanges, with 3 for each lesser toe.

Although variation exists in the number and location of the sesamoid bones, 2 constant sesamoids are present beneath the metatarsal head. The sesamoids are usually present within tendons juxtaposed to articulations.

Select tendons of the foot (see image below)

The flexor hallucis longus (FHL) tendon is 1 of 3 structures that lie in the tarsal tunnel. Running behind the medial malleolus, the FHL is the most posterolateral. The FHL runs anterior to insert onto the distal phalanx of the great toe. The FHL acts as a flexor of the great toe, elevates the arch, and assists with plantar flexion of the ankle.

The flexor digitorum longus (FDL) tendon passes between the FHL and tibialis posterior tendon. The FDL inserts onto the distal phalanges of the 4 lateral digits and acts to flex the distal phalanges.

The tibialis posterior tendon is the most anteromedial of the tarsal tunnel tendons. This tendon inserts on the navicular tuberosity; the 3 cuneiforms; the cuboid; and the second, third, and fourth metatarsals. The tibialis posterior muscle flexes, inverts, and adducts the foot.

Laterally, the peroneus longus and peroneus brevis tendons share the common peroneal tunnel running behind and around the lateral malleolus. The peroneus longus plantar flexes the first metatarsal, flexes the ankle, and abducts the foot. The peroneus brevis flexes the ankle and everts the foot.

Other important structures

The plantar aponeurosis or fascia is a deep span of connective tissue extending from the anteromedial tubercle of the calcaneus to the proximal phalanges of each of the toes. Medial and lateral fibrous septa originate from the medial and lateral borders to attach to the first and fifth metatarsal bones.

Nerve innervation of the foot runs along the medial and lateral metatarsals and phalanges in a neurovascular bundle. These nerves are vulnerable to compressive forces that, in time, can generate the painful Morton neuroma, which most commonly affects the interspace between the third and fourth metatarsals. Four nerves supply the forefoot: the sural nerve (most lateral), branches of the superficial peroneal nerve, the deep peroneal nerve, and the saphenous nerve.

The joint between the forefoot and the midfoot, the tarsometatarsal (TMT) joint or Lisfranc joint, is formed by a mortise of the cuneiform bones surrounding the base of the second metatarsal. This joint is supported by the transverse ligaments, and the Lisfranc ligament joins the medial cuneiform and the base of the second metatarsal. Disruption of this ligament can result in a destabilization of the TMT joint complex of the foot, the result of which can be instability of the arch and the midfoot.

The 3 planes in which the foot and ankle function are the transverse, sagittal, and frontal. Movement is possible in all 3 planes.

• Plantar flexion and dorsiflexion occur in the sagittal plane. Plantar flexion involves the foot moving from the anterior leg distally. Dorsiflexion is the opposite motion.

• Inversion and eversion occur in the frontal plane of motion. Eversion occurs when the bottom of the foot turns away from the midline of the body. Inversion is the opposite action.

• The 2 transverse plane motions are abduction and adduction. Adduction involves the foot moving toward the midline of the body, whereas abduction is the opposite action.

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.

The Ottawa Foot and Ankle Rules are validated clinical decision rules designed to assist the clinician in determining which individuals with foot and ankle pain require radiographic evaluation.[13, 14] The guidelines include: individuals who are unable to bear weight for at least 4 steps immediately following the injury and in the emergency department, or those individuals who demonstrate tenderness over the posterior aspect of the medial and lateral malleoli, over the navicular, or over the base of the fifth metatarsal. Such individuals should have radiographic evaluation performed. The clinical rules have a high sensitivity in adult patients (0.3% false-negative rate) and a 100% sensitivity rate in pediatric patients, although the specificity approaches 30-40%.[13]

• Sesamoiditis: Stress radiographs, axial silhouette views, bone scans, and computed tomography (CT) scans are helpful diagnostic aids. Radiographic examination of the contralateral foot is useful. The radiographs are often normal, although a bipartite sesamoid bone is a common normal variant that can be mistaken for a stress fracture. Additional testing may be needed to help evaluate this possibility further, depending on the patient's symptoms.

• Turf toe: Plain radiographs may reveal a small avulsion fracture from the plantar metatarsal head. If the diagnosis is unclear, MRI may more thoroughly evaluate the integrity of the MTP joint.

• Sever disease: Plain radiographs are often not necessary. However, these imaging studies should be obtained if the patient's symptoms are not alleviated with relative rest or if the clinical picture is somewhat atypical in order to rule out a fracture or tumor.[15]

• Posterior tibial tendinitis: A weight-bearing plain radiograph may help determine the degree and type of flatfoot abnormality. Magnetic resonance imaging (MRI) is the imaging modality of choice for imaging posterior tibial tendon tenosynovitis and degenerative tears. Ultrasound (US) imaging can provide a dynamic picture of the tendon.

• Peroneal tendon subluxation/dislocation: The diagnosis is made on clinical grounds. Most peroneal dislocations reduce spontaneously; therefore, most of these injuries are unrecognized.

• Peroneal tendinitis: Plain radiographs may reveal hindfoot varus. US imaging and MRI are usually not necessary, but these modalities may reveal synovitis, peroneal retinaculum, or tendon tearing.

• FHL tenosynovitis: Plain radiographs of the foot are helpful with the differential diagnosis (see Differentials and Other Problems to Be Considered), and US imaging or MRI can help to rule out a tear.

• Jones fracture: Standard foot radiographs demonstrate most metatarsal base fractures. Note any intra-articular fractures, and determine the percentage of articular surface that is involved, as this percentage is essential to determining clinical management. Avulsion of the fifth metatarsal apophysis should not be confused for a Jones fracture, as the apophyseal avulsion is parallel to the shaft of the fifth metatarsal compared with the perpendicular fracture of the standard Jones fracture.

• Morton neuroma: Radiographic imaging may be employed if the diagnosis is in question. US can help the physician make a reliable estimate of the size of the neuroma.

• Stress fractures

  • Plain radiography is the first imaging study recommended to help confirm the diagnosis of stress fractures. However, radiographic changes may not be evident for 2-3 weeks following the onset of symptoms. Periosteal and endosteal callus formation is typically seen within 2 weeks of injury, whereas callus formation reaches its maximum at 6 weeks. Moreover, only 50% of stress fractures are seen on plain radiographs. Findings of radionuclide bone scanning or MRI help confirm the diagnosis.

  • The criterion standard for the diagnosis of stress fractures is a technetium (Tc) bone scan. The osteoblast incorporates the isotopes in new bone formation and may be positive as early as 48-72 hours following clinical signs of injury. MRI has been found to be just as sensitive and more specific. However, MRI may be cost prohibitive or may not be available, depending on the medical center.

• Lisfranc fracture dislocation

  • Meticulous evaluation of weight-bearing foot radiographs is essential for confirmation of suspected Lisfranc fracture dislocation. A fracture of the base of the second metatarsal is virtually pathognomonic for TMT joint disruption.

  • The medial aspects of the first, second, and third metatarsals should align evenly with the medial borders of the first, second, and third cuneiform bones, respectively. The medial border of the fourth metatarsal should align evenly with the medial border of the cuboid bone. Comparison views of the feet may reveal a widening of the space between the first and second metatarsals or between the second and third metatarsals. Disruption of these anatomic relationships suggests a Lisfranc fracture dislocation.

  • US imaging and MRI can indicate ligamentous disruption by showing fluid in the ligaments and intertarsal joint spaces. Weight-bearing CT is also increasingly used to identify Lisfranc injuries.[16]

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.

• 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.[17]

• 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.[18] 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.

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.[19]

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.[20, 21, 22]

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.[23, 24]

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.[24]

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.[19]

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.

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.

As with all athletic injuries, the athlete's whole being must be considered before he or she returns to action. Athletes should practice before they play and essentially be pain free with all activity. Strength should be at least 90% of the unaffected limb, and proprioception should be restored so that the athlete can avoid recurrence. Mentally, the athlete must feel confident that the foot injury has healed; athletes should be able to compete without conscious awareness of the injury. The mental aspects of the injury are most accurately assessed in practice situations.

Barefoot and minimalist shoe running

Lieberman et al first observed that barefoot endurance runners landed on the forefoot or midfoot with a more plantar-flexed ankle, whereas shod runners landed on the hind foot with significantly higher collision forces. Increased proprioception, coordinative strategy, and improved intrinsic foot muscle strength have supportive evidence to suggest a benefit from barefoot running as well.[25]

Lieberman further explains that barefoot running, from an evolutionary perspective, may be hypothesized to avoid injury, as evidenced by the fact that humans have been running long distances barefoot for millions of years.[26]  In an effort to reproduce the biomechanics of barefoot running with the protection afforded by running shoes, the use of minimalist running footwear has gained popularity among members of the running community. Biomechanical evidence suggests minimalist footwear favors forefoot or midfoot strike and allows for dispersion of impact forces more efficiently. Minimalist runners, moreover, generate smaller collision forces when compared with shod runners.[27]  Proponents of modern running shoes believe that the cushioning and stabilization features are needed to protect the runner from injury.[28]

A study by Mills et al found that the cumulative probability of a successful transition from running in traditional shoes to running barefoot was 70.8%. Factors associated with failure to transition successfully were a rearfoot strike pattern and a higher midfoot width mobility.[29]

Future considerations include research to determine the benefits or barefoot and minimalist running include the appropriate manner with which to transition from shod running to barefoot or minimalist running and the long-term effects of barefoot and minimalist running on foot structure, muscle physiology, and bone and joint health.

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.

Class Summary

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.

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.

Class Summary

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.

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.

Class Summary

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.

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.