Sports Med - Foot Injuries

Talus fracture - Etiology

• Laterally: Severe inversion and dorsiflexion force

• Medially: Inversion and plantarflexion force with tibial external rotation

Talus fracture - Signs and symptoms

• History of repeated ankle trauma

• Pain with weight bearing

• Intermittent swelling

• Catching and snapping

• Talar dome is tender upon palpation

Talus fracture - Management

• Rehab focusing on strength and gaining full ROM

• If conservative treatment isunsuccessfully: Surgery may be required (return to play in 6-8 months following surgery)

Calcaneus fracture - Etiology

• Jump or fall from heigh, often results in avolusion fracture anteriorly or posteriorly

  • Anterior avulsion fractures can be misdiagnosed as tendinitis of the posterior tibialis

Calcaneus fracture - Signs and symptoms

• Immediate pain, swelling, and inability to bear weight

• Minimal deformity unless comminuted fracture occurs

Calcaneus fracture - Management

• Refer for x-ray for diagnosis

• For nondisplaced fracture: Immobilization and early ROM exercises when pain and swelling subsides

Calcaneal stress fracture - Etiology

• Repetitive trauma

• Characterized by sudden or gradual onset in plantar-calcaneal area

Calcaneal stress fracture - Signs and symptoms

• Pain with weight bearing, particularly at heel strike

• Complaints of pain continue following exercise

• May require bone scan for diagnosis

Calcaneal stress fracture - Management

• Conservative for 2-3 weeks, including rest and active ROM exercises

• Non-weight-bearing cardio training should continue

• As pain subsides, activity can be returned gradually

Apophystis of the calcaneus (Sever’s Disease) - Etiology

Traction injury at apophysis of calcaneus where the Achilles attaches

Apophystis of the calcaneus (Sever’s Disease) - Signs and symptoms

• Pain occurs at posterior heel below Achilles attachment in children and adolescent athletes

• Pain occurs during vigorous activity and ceases following activity

Apophystis of the calcaneus (Sever’s Disease) - Management

• Best treated with ice, rest, and NSAIDs

• Heel lift could also relieve some stress

Retrocalcaneal bursitis - Etiology

• Inflammation of bursa beneath Achilles tendon

• Result of pressure and rubbing of shoe heel counter

• Chronic condition: Develops over time and may take extensive time to resolve

• Exostosis may develop (Haglund’s Derformity)

Retrocalcaneal bursitis - Signs and symptoms

• Pain with palpation above and anterior to Achilles insertion

• Swelling on both sides of the heel cord

Retrocalcaneal bursitis - Management

• NSAID used as needed

• Ultrasound can reduce inflammation

• Routine stretching of Achilles and use of heel lifts to reduce stress

• Donut pad to reduce pressure

• Possibly invest in larger shoes with wider heel contours

Heel contusion - Etiology

• Sudden starts, stops, or changes in direction and irritation of fat pad

• Pain on the lateral aspect due to heel strike pattern

Heel contusion - Signs and symptoms

• Severe pain in heel and is unable to withstand stress and weight bearing

• Often warmth and redness over the tender area

Heel contusion - Management

• Reducing weight bearing for 24 hours and NSAIDs should be administered

• Resume activity with heel cup or doughnut pad after pain has subsided (be sure to wear shock-absorbent shoes)

Tarsometatarsal fracture/dislocation (Lisfranc injury) - Etiology

Foot hyper-plantarflexed with foot already plantarflexed and rearfoot locked, resulting in dorsal displacement of the proximal end of the metatarsals

Tarsometatarsal fracture/dislocation (Lisfranc injury) - Signs and symptoms

• Pain and inability to bear weight, swelling, and tenderness localized on dorsum of foot

• Possible metatarsal fractures and sprains of fourth and fifth proximal metatarsals

• May cause severe disruptions of ligaments

Tarsometatarsal fracture/dislocation (Lisfranc injury) - Management

• Key to treatment is recognition (refer to physician), realignment, and maintaining stability

• Generally requires open reduction with fixation

• Complications include metatarsalgia, decreased metatarsophalangeal joint ROM, and long-term disability

Morton’s Toe - Etiology

• Abnormally short first metatarsal, making the second toe look longer

• More weight-bearing occurs on second toe and can impact gait

• Stress fracture could develop

Morton’s Toe - Signs and symptoms

• Pain during and after activity, with possible point tenderness

• Bone scan would be positive

• Callus develops under second metatarsal head

Morton’s Toe - Management

If no symptoms: Nothing should be done

Plantar fasciitis - Etiology

• Attributed to heel spurs, plantar fascia irritation, and bursitis

• Catchall term used for pain in proximal arch and heel

• Increased tension and stress on the fascia (particularly during the push-off or running phase) 

• Change from rigid supportive footwear to flexible footwear

• Poor running technique

• Cause due to running on soft surfaces with shoes that have poor support

• Plantar fascia is a dense, broad band of connective tissue attaching proximally to the medial surface of the calcaneus and fans out over the plantar aspect of the foot

• Works in maintaining stability of the foot and bracing the longitudinal arch

• Common in athletes and non-athletes

Plantar fasciitis - Signs and symptoms

• Pain in anterior medial heel

• Increased pain in morning, lessens after first few steps

• Increased pain with forefoot dorsiflexion

Plantar fasciitis - Management

• Extended treatment (8-12 weeks)

• Orthotic therapy very useful (soft orthotic with deep heel cup)

• Simple arch taping and using night splint to maintain a position of static stretch

• Vigorous Achilles tendon stretching and exercises that increase great toe dorsiflexion

• NSAIDs and occasionally steroidal injection

Jones fracture - Etiology

• Fracture of metatarsal

• Can be caused by:

  • Inversion and plantarflexion

  • Direct force (stepped on)

  • Repetitive stress

• Base of fifth metatarsal most common

Jones fracture - Signs and symptoms

• Immediate swelling and pain over fifth metatarsal

• High nonunion rate and course of healing is unpredictable

Jones fracture - Management

• Controversial treatment

• Crutches with no immobilization, gradually progressing to weight-bearing as pain subsides

  • May allow athlete to return in 6 weeks

• If nonunion occurs: Internal fixation may be required

• Bone-growth stimulators have also been suggested

Metatarsal stress fractures - Etiology

• Second metatarsal fractures (March fracture)

• Change in running pattern (increased mileage, running hills, or running on a harder surface)

• Forefoot varus, hallus valgus, flatfoot, or short first metatarsal

• Fifth metatarsal fracture at insertion of peroneus brevis

Metatarsal stress fractures - Signs and symptoms

• Over 2-3 weeks of dull ache during exercise, progressing to pain at rest

• Progresses from diffused to localized pain

• Patient often reports in increase in duration/intensity of training

Metatarsal stress fractures - Management

• Bone scan may be necessary

• 2-4 days of partial weight-bearing followed by two weeks of rest

• Return to running should be gradual and orthotics should be used to correct excessive pronation

Sprained toe(s) - Etiology

Sprained toe(s) - Signs and symptoms

Sprained toe(s) - Management

Great toe hyperextension (Turf Toe) - Etiology

Great toe hyperextension (Turf Toe) - Signs and symptoms

Great toe hyperextension (Turf Toe) - Management

Fractures/dislocations of the phalanges - Etiology

Fractures/dislocations of the phalanges - Signs and symptoms

Fractures/dislocations of the phalanges - Management

Subungual hematoma - Etiology

Subungual hematoma - Signs and symptoms

Subungual hematoma - Management