Athletic Foot Injuries

Background

Athletic foot injuries can be difficult to properly diagnose and treat. Bearing the weight of the entire body, the foot is under tremendous stress. In many sports, the foot absorbs tremendous shearing and loading forces, sometimes reaching over 20 times the person's body weight. Physicians who treat these disorders must have a good understanding of the anatomy and kinesiology of the foot.

Although foot injuries can occur from a variety of causes, the most common cause is trauma. Other etiologies include (1) rapid or improper warm-up, (2) overuse, (3) intense workouts, (4) improper footwear, and (5) playing on hard surfaces.

Physicians who evaluate and treat common foot problems should have a working knowledge of the individual sports and the injuries that are commonly associated with them. An understanding of the basic treatment approaches for these injuries also is imperative.

Frequency

United States

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

Functional Anatomy

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 1).

• The talus is oriented so as 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.

• 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 sesamoid bones, 2 constant sesamoids are present beneath the metatarsal head. The sesamoids usually are present within tendons juxtaposed to articulations.

Select tendons of the foot (see Image 2)

• The flexor hallucis longus (FHL) tendon is one 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.

Sport Specific Biomechanics

The 3 planes in which the foot and ankle function are the transverse plane, the sagittal plane, and the frontal plane. 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, while abduction is the opposite action.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

Physical therapy is effective in treating inversion injuries and tendonitis 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 first metatarsal head stress; taking 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. Ambulating 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 tendonitis: 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 tendonitis: 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 usually are treated with non–weight-bearing casting for up to 8 weeks, followed by radiographic assessment. Diaphyseal fractures of the fifth metatarsal often are 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.

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 usually is not indicated in patients with Sever disease.

• Posterior tibial tendonitis: 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 often is 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 usually are 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 generally is 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, a fifth metatarsals).

• Lisfranc fracture-dislocation: The orthopedist may elect to perform closed reduction under general anesthesia using 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.

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, as 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 rarely is 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 range of motion (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.

Other Treatment (Injection, manipulation, etc.)

Taping or braces 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. 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.

Drug Category: Nonsteroidal anti-inflammatory drugs

Used to suppress manifestations of inflammation. Inhibition of cyclo-oxygenase, the enzyme responsible for biosynthesis of prostaglandins, generally is thought to be a major facet of the mechanism of action of NSAIDs.

Drug Name	Ibuprofen (Motrin, Ibuprin)
Description	Classified as a propionic acid derivative. All drugs in this class are effective inhibitors of cyclo-oxygenase, though the potency varies.
Adult Dose	400-600 mg PO q6h prn
Pediatric Dose	5-10 mg/kg PO q6-8h prn
Contraindications	Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Drug Name	Naproxen (Naprelan, Naprosyn, Anaprox)
Description	Classified as a propionic acid derivative. All the drugs in this class are effective inhibitors of cyclo-oxygenase, though the potency varies.
Adult Dose	250-500 mg PO q12h
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Drug Category: Cyclo-oxygenase-2 inhibitors

COX-2 inhibitors are a new class of NSAIDs. COX-2 inhibitors appear to be as effective as nonselective NSAIDs in treating pain and inflammation. Their theoretical advantage over nonselective NSAIDs involves significantly less toxicity, particularly in the 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 recent literature questioning the safety of COX-2 inhibitors. Rofecoxib (Vioxx) has been withdrawn from the worldwide market because of its association with and increased rate of cardiovascular events (including heart attack and stroke) compared to placebo. Valdecoxib (Bextra) has been recalled for similar concerns. It is not clear whether these safety concerns are specific to Valdecoxib and Vioxx. The cardiovascular issues may be a class effect of all COX-2 inhibitors. Further study should help to answer questions concerning the safety of COX-2 inhibitors.

Drug Name	Celecoxib (Celebrex)
Description	Primarily inhibits COX-2. COX-2 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 lowest dose of celecoxib for each patient. Celecoxib has the same general class labeling as conventional NSAIDs.
Adult Dose	100 mg PO qd/bid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, and conditions predisposing to fluid retention; severe heart failure and hyponatremia may occur because celecoxib may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction

Drug Category: 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.

Drug Name	Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)
Description	Has analgesic and antipyretic effects that do not differ significantly from aspirin. However, acetaminophen has only weak anti-inflammatory effects. Exact mechanism of action is not clear.
Adult Dose	325-650 mg PO/PR q4-6h prn
Pediatric Dose	10-15 mg/kg PO q4-6h prn
Contraindications	Documented hypersensitivity
Interactions	Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, and conditions predisposing to fluid retention; severe heart failure and hyponatremia may occur because acetaminophen may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction

Drug Name	Hydrocodone and acetaminophen (Vicodin, Norcet, Lortab)
Description	Drug combination indicated for moderate to severe pain for pain refractory to NSAIDs.
Adult Dose	1-2 tab or cap PO q4-6h prn pain
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; high-altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Interactions	Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Drug Name	Codeine and acetaminophen (Tylenol #3)
Description	Indicated for the treatment of mild to moderate pain. Elixir has 12 mg of codeine combined with 120 mg of acetaminophen in 5 mL.
Adult Dose	1-2 tab PO q4h prn
Pediatric Dose	3-6 years: 5 mL PO q4h prn 7-12 years: 10 mL PO q4h prn >12 years: 15 mL PO q4h
Contraindications	Documented hypersensitivity
Interactions	Toxicity of codeine increases with administration of CNS depressants, tricyclic antidepressants, MAO inhibitors, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics; rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity of acetaminophen
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction; hepatotoxicity with acetaminophen is possible following various dose levels in those with chronic alcoholism; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses that exceed recommended maximum dose