Athletic Foot Injuries Treatment & Management

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).

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• 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.