Foot and Ankle Problems in Foot and Ankle Problems in the Endurance Athletethe Endurance Athlete
Brian A. Weatherby, MDBrian A. Weatherby, MD
Steadman-Hawkins Clinic of the CarolinasSteadman-Hawkins Clinic of the Carolinas
Assistant Professor Clinical Orthopaedic SurgeryAssistant Professor Clinical Orthopaedic Surgery
University of South Carolina School of MedicineUniversity of South Carolina School of Medicine
DISCLOSURESDISCLOSURES
NONENONE
Foot ProblemsFoot Problems
• Lesser MTP DisordersLesser MTP Disorders
• Great Toe DisordersGreat Toe Disorders
• Metatarsal Stress FractureMetatarsal Stress Fracture
Ankle ProblemsAnkle Problems
• TendinopathyTendinopathy AchillesAchilles
Posterior TibialPosterior Tibial
PeronealPeroneal
Not this Endurance Athlete!Not this Endurance Athlete!
This Endurance Athlete!This Endurance Athlete!
Foot ProblemsFoot Problems• Lesser MTP DisordersLesser MTP Disorders
Metatarsalgia/MTP Synovitis/MTP InstabilityMetatarsalgia/MTP Synovitis/MTP Instability Interdigital neuromaInterdigital neuroma
• Great Toe DisordersGreat Toe Disorders SesamoiditisSesamoiditis Hallux RigidusHallux Rigidus
• Metatarsal Stress FractureMetatarsal Stress Fracture
Foot ProblemsFoot Problems
• Lesser MTP DisordersLesser MTP Disorders
Metatarsalgia/MTP Synovitis/MTP Metatarsalgia/MTP Synovitis/MTP InstabilityInstability
Interdigital NeuromaInterdigital Neuroma
Lesser MTP PainLesser MTP Pain
• Differential diagnosis extensive Mechanical Neurologic Idiopathic
MetatarsalgiaMetatarsalgia
• Mechanical Shoewear
• Small toe box• Short shoe
MetatarsalgiaMetatarsalgia
• Mechanical MP instability
• Often associated with long 2nd MT (Morton’s Foot)
– Especially in runner
MetatarsalgiaMetatarsalgia
• Idiopathic Overuse
syndromes (runners)
Fat pad atrophy (aging)
MetatarsalgiaMetatarsalgiaMTP MTP SynovitisSynovitis MTP Instability MTP Instability
• MP Instability Chronic-Volar
plate degeneration • Wide spectrum
of presentation• Can be
progressive
Lesser MTP PainLesser MTP Pain
• Neurologic Morton’s Neuroma
• Mimic or be associated with synovitis
• Almost always 3rd web space
Lesser MTP PainLesser MTP Pain
• Idiopathic Freiberg’s infraction
• 2>3 MT heads
• Occurs in adolescence but symptoms often in adult
MetatarsalgiaMetatarsalgia
• Examination Isolated palpation of
MT head
Plantar keratosis
Fat pad atrophy
MTP synovitis/MTP MTP synovitis/MTP InstabilityInstability
• Examination Deformity
• Hyperextension/Dislocation
Instability
• Lachman’s Synovitis
• Plantarflexion stress
Morton’s NeuromaMorton’s Neuroma
• Examination Palpate Inter-space
(always)
Squeeze Test (majority)
Mulder’s Sign (30%)
BiomechanicsBiomechanics
• Examination• Check for Achilles
contracture Increases forefoot pressures!
Lesser MTP PainLesser MTP Pain
• Diagnostic studies• Radiographs
–Subluxation
–Dislocation
–Degeneration
–MT lengths
TreatmentTreatment• Metatarsalgia
Activity Modification• Cross Train-bike/swim
Shoewear Changes• Rocker bottom
Heel Cord Stretching• 10 minutes/day with body wt
Custom Orthotics• Rx Full length accomodative
orthotic with MT pad to unload __ MT head(s)
Shoewear• Neutral
Stabilitycombines cushioning and support
• Cavus (Supinator) Cushioning shock dispersion
in its midsole and/or outsole design
• Planus (Pronator) Motion control medial
support w/ dual density midsoles, roll bars, or foot bridges, thus
slowing the rate of overpronation
TreatmentTreatment
• Metatarsalgia Activity Modification Shoewear Changes Heel Cord Stretching
• 10 minutes/day with body wt Custom Orthotics
• Rx Full length accomodative orthotic with MT pad to unload __ MT head(s)
TreatmentTreatment• MTP Synovitis/MTP Instability
Activity Mods/Shoe Δ/Achilles Buddy Taping
• Daily 8-10 wks Marble Pick-ups
• 50 x 3 days then 250 for 8-10 weeks
Rx Strength NSAID 6-8 wks Orthotic w/ MT pad
• Temporary felt MT pad (Hapad) 6-8 wks
TreatmentTreatment• MTP Synovitis/MTP
Instability MTP Injection
• Diagnostic &/or Therapeutic• Longstanding/Refractory• Must protect 4 wks in Budin
splint
TreatmentTreatment
• Morton’s Neuroma Activity Mods Shoewear Changes Rx Strength NSAID 6-8 wks Custom Orthotic w/ MT pad
• Temporary Hapad
Webspace Injection• Diagnostic &/or Therapeutic• Longstanding/Refractory• Tape protection 4 wks
SummarySummary
• Consider all possibilities
• Exhaust all non-operative modalities
• Surgical Tx warranted after minimum 16 + weeks conservative care
Great Toe Disorders
• Sesamoiditis
• Hallux Rigidus
First MTP AnatomyFirst MTP Anatomy
• Tibial & Fibular Sesamoids
• FHL & FHB
• Plantar Plate
• Articular Surfaces MTP MT-sesamoid
BiomechanicsBiomechanics
• Importance of great toe Analogous to patella Push-off phase of
gait In athletics:
• Jumping• Sprinting• Spring board diving• Control in ballet, tae
kwon do
BiomechanicsBiomechanics
• Normal gait Up to 50% body weight
transmitted through great toe complex
Great toe 2x lesser toes
• Jogging, running 2-3x body weight
• Running jump 8x body weight
SesamoidtisSesamoidtis• Etiology Spectrum
Acute (fall or forced DF)• Fracture• Sx bipartite sesamoid (tibial)
Chronic (repetitive stress)• Stress Fracture• Sesamoiditis• Osteochondritis• Chondromalacia• Osteonecrosis• Exostosis IPK (tibial)
Sesamoid DisordersSesamoid Disorders• History
Trauma, overuse, idiopathic
Localized plantar 1st MTP pain
Sport/Stairs/High impact worse
Δ in shoes/training/mechanics
Sesamoid DisordersSesamoid Disorders• Clinical Exam
Specific TTP at tibial &/or fibular
Swelling, warmth, erythema
Plantar pain, +/- crepitus w/ motion
IPK over tibial sesamoid
Sesamoid DisordersSesamoid Disorders
• Radiographs Standing AP/bilateral Axial Oblique
Marker over area TTP
Sesamoid DisordersSesamoid Disorders• Bone Scan
Helpful when XR nml High false + Pinhole images to diff
b/w sesamoids
• MRI Bone vs. soft tissue Assess bone viability,
degeneration, tendon continuity
• CT Acute Frx Exostosis
SESAMOIDITISSESAMOIDITIS• Presentation
Swelling and inflammation of peri-tendinous structures
Overuse Pain on WB, TTP directly over Tibial Sesamoid XR normal, +/- ↑ flow TC bone
scan, diffuse edema of sesamoid MRI
Diagnosis of Exclusion
Sesamoid FractureSesamoid Fracture
• Presentation Acute
• Hyperextension injury• Tibial sesamoid• Transverse frx line, mid-waist• Callus formation• Association with MP dislocation• CT to evaluate displacement
Bipartite SesamoidBipartite Sesamoid
Bipartite vs. Acute Fracture (Brown et al. CORR)• Irregular & unequal
fragment diastasis• Callus formation• Presence/absence
on contralateral side
Sesamoid DJDSesamoid DJD
• Post-traumatic
• Iatrogenic s/p bunionectomy
• Chondromalacia
• Osteophytes
• Attritional rupture of abd/adductor H Valgus/Varus
Sesamoid OsteochondritisSesamoid Osteochondritis
• Etiology unknown Crush injury Stress Frx AVN
• Pain, fragmentation, cyst formation, flattening
• XR Δ’s may delay 6-12 mos Bone scan MRI
Bipartite Acute Frx
Stress Frx Osteochondritis
Sesamoid IPKSesamoid IPK
Tibial sesamoid Cavus, PF ray (diffuse) Sesamoid prominence (localized)
Treatment
• Acute Fracture (≤ 2mm diastasis) Heel Touch WB in toe spica
cast x 2 weeks Wedge Shoe x 2-4 weeks Custom Orthotic there after
• Full length accomodative orthotic with area of relief for tibial/fibular sesamoid
PT at 4-6 wks No running 3-4 mos
TreatmentTreatment• Sesamoditis/DJD/Osteochondritis
Activity Mods Shoewear Mods
• Remove cleat under 1st MTP• Rocker bottom shoe (Skecher)
Rx NSAID’s 6-8 wks Custom Orthotic
• Wedge shoe until if ↑ symptoms RTP w/ FPP once asx x 3-4 wks &
w/ orthotics
TreatmentTreatment
• Cortisone Injection Longstanding/Refractory Flouro guided Results Highly Variable
• Surgical Tx Failure appropriate non-op
tx ≥ 16 wks Displaced Frx
Hallux RigidusHallux Rigidus
Hallux RigidusHallux Rigidus• Second most
common condition affecting the hallux MP joint
• Termed coined by Cotterill in 1888, after description by Davies-Colley in 1887
Hallux RigidusHallux Rigidus
• Definition = stiffness of 1st MTPJ
• Multiple names given: Hallux flexus/limitus
• Multiple etiologies considered Degenerative Traumatic (overuse/OCD/injury
sequlae) Dorsal bunion (paralytic) Metatarsus primus elevatus
Hallux RigidusHallux Rigidus• Two groups:
Adolescent• Rigid swollen joint, painful
DF• Chondral lesion
(traumatic) or OCD (atraumatic)
Adult• Degenerative destruction• ? Overuse or traumatic
etiology
Hallux RigidusHallux Rigidus
• Presentation Dorsal
prominenceshoewear irritation
Painful ROM (PF and DF, with push-off)
Hallux RigidusHallux Rigidus• Examination
TTP over dorsal prominence• Keratosis
TTP over sesamoids – poorer prognosis
1st MTP ROM• Pain at extremes• Pain at mid-range
poorer prognosis
Drawer exam
Hallux RigidusHallux Rigidus
• Radiographs Varying Grades
Hallux RigidusHallux Rigidus
• Radiographic worsening does NOT equate to clinical worsening
Hallux RigidusHallux Rigidus
• Treatment Shoewear modifications
• Size• Cushion prominences
Orthotics• Full length orthotic with TPE or
carbon fiber Morton’s extension under 1st ray
Taping Rx NSAID’s
Hallux RigidusHallux Rigidus
• Treatment Steroid injection
• SELECTIVE• Repeated injections will ↑ degenerative process
Hallux RigidusHallux Rigidus
• Surgical Tx Adolescent/Young
Athlete• OCD lesion or chondral
injury Arthroscopic debridement & microfracture
Hallux RigidusHallux Rigidus
• Surgical Tx Adult
• Cheilectomy and Drilling of bare areas
Hallux RigidusHallux Rigidus
• Surgical Tx Lengthy
discussion with athlete
Expectations• Pain relief
(majority)• ? ↓ push-off
power
Metatarsal Stress Metatarsal Stress FractureFracture
Stress FractureStress Fracture
• Definition Partial or complete
fracture of a bone due to its inability to withstand nonviolent, rhythmic, repetitive subthreshold stress
Stress FracturesStress Fractures
• Pathophysiology
“Accumulation of microdamage to bone occurring with multiple subultimate failure strain loads & failure of body to initiate healing response.” AAOS ICL 2004
“Sub-threshold stress exceeds the body’s reparative ability”
Crack Initiation Propogation Final Frx
Stress FracturesStress Fractures
• Etiology Anatomy
• Foot Type & Alignment– Subtle Cavus– Long 2nd MT– Leg Length Discrepancy
• Blood Supply– 5th MT base, middle MT neck
Stress FracturesStress Fractures• Etiology
Footwear Training Surface ↑ in intensity/distance or ∆ in training
method Metabolic
• Hormone abnormality– Menstrual irregularity, oral contraceptives– Female Triad
• Calcium metabolism– Rickets: Vitamin D deficiency, renal tubular
insufficiency, osteodystrophy, hypophosphatasia,
• Hyperparathyroidism
Stress FracturesStress Fractures• History
AWARENESS• Wide spectrum of presentation
↑ pain with activity, ↑ pain with pressure ∆ (airplane)
Vague, deep “throbbing” pain Alteration in stress/training +/- report of an actual single event
• Frx 2° continued loading
Chronic fractures can have very subtle and unimpressive findings
Stress FracturesStress Fractures• Physical Exam
TTP over area Percussion/Tuning Fork Pain with one leg hopping
Assess Foot Stucture
Foot StructureFoot Structure
• Neutral
• Cavus (Supinator)
• Planus (Pronator)
Foot StructureFoot Structure
• CAVUS Subtle Cavus
• Peek-a-boo heel (varus)
• PF 1st ray
Obvious Cavus
Foot StructureFoot Structure
• Cavus Related Conditions
5th MT Stress Fracture
Peroneal Tendon Pathology
Chronic Ankle Instability
OrthoticsOrthotics
• Cavus Foot Pre-fab
• Donjoy Arch Rival
Rx• Full length orthotic w/ lateral forefoot
posting and area of relief for 1st MT head, along w/ MT pad to unload __ MT head(s)
Stress FracturesStress Fractures• Imaging
Supports Clinical Suspicion
Know Your Imaging• XR lag behind or negative in 30-70% cases• MRI & Bone Scan show reaction before
fracture line is visable on CT
Stress FracturesStress Fractures
• XR Frx evident in 30-70%, better for
cortical Pain onset bony ∆ avg.~ 21
days, may take 6 wks
• Tc99 ↑ sensitive w/in 48-72 hrs Poor specificity
• MRI Sensitive & Specific
• CT Complete vs. Incomplete Frx
MT Stress FracturesMT Stress Fractures• Treatment- Stress Reaction
(+ MRI/Bone Scan, - XR) 5th MT NWB in Boot/Cast
until NTTP• When NT place in appropriate
orthotic– Cavus foot Full length orthotic w/
lateral forefoot posting & area of relief for 1st MT head, to include TPE or carbon fiber baselayer
– Nml foot Carbon fiber insert/Turf toe plate
• Modify activity 4-6 wks
MT Stress FracturesMT Stress Fractures
• Treatment- Stress Reaction or Fracture 2/3/4 MT’s WBAT
Boot/Post op shoe 4-6 wks• ∆ to carbon fiber/toe plate
– After minimum 4 wks and NTTP
• Gradual return with FPP
MT Stress FracturesMT Stress Fractures• Treatment-Stress Frx (+ frx line or
periosteal rxn on XR or CT) 5th MT NWB cast 8 wks (+/- bone
stimulator)• If XR healing and NTTP Boot with progressive
wt bearing 2-3 wks• Then ∆ to carbon fiber/toe plate
• Gradual return with FPP
• 15-20 wk Time to Union (bone stim ↓ 8-9 weeks)
• 30-50% RE-FRACTURE/NONUNION
• Mologne et al., AJSM 2005 Cast vs. Screw, Level I Study 18 cast, 19 screw, 25 mos f/u 44% cast Tx Failure 6% screw Tx Failure Time to union/RTP
• Screw 7.5/8 wks• Cast 14.5/15 wks
MT Stress FracturesMT Stress Fractures
MT Stress FracturesMT Stress Fractures• 5th MT Fracture-
Operative Indications Athlete
• Acute/stress fx Nonunion Re-fracture Cavovarus = lateral
overload
MT Stress FracturesMT Stress Fractures
• Operative Goals Expedite healing Quicker recovery;
easier rehab Decrease re-fracture
risk
Ankle ProblemsAnkle Problems
• TendinopathyTendinopathy AchillesAchilles
Posterior TibialPosterior Tibial
PeronealPeroneal
TendinopathyTendinopathy
Tendons: Basic ScienceTendons: Basic Science
*Aging results in increased stiffness due to inc.collagen cross-linking Decrease in tensile strength
Tendons: Basic ScienceTendons: Basic Science
• Blood Supply 3 sources
• Musculotendinous junction• Surrounding connective tissue• Bone-tendon junction
Zones of Hypovascularity Decreases with age and mechanical
loading
Tendinopathy: EtiologyTendinopathy: Etiology• Overuse injury (i.e. Degenerative
Tendinopathy):
Multifactorial:• Repetitive microtrauma (fibril level)• Load induced ischemia oxygen free radicals• Local hypoxia tenocyte death• Hyperthermic cell injury
Most common histiopathologic finding in tendon rupture
• Biomechanics Cavus Peroneal Tendons Planus (Pronation) Achilles Tendon,
Post Tib Tendon
Tendinopathy: EtiologyTendinopathy: Etiology
• Corticosteroids
• Flouroquinolones
• Autoimmune disorders, inflammatory arthropathies, infection
• Trauma
Tendon HealingTendon Healing
• Immobilization Decreases water and proteoglycan content Increases reducible crosslinks Results in tendon atrophy
• Mobilization Controlled stresses in proliferative and
remodeling phases highly organized collagen, increased tenocyte DNA content and protein synthesis
Increased tensile strength, cross-sectional area
Achilles TendonAchilles Tendon
• Zone of hypovascularity 2-6cm proximal to insertion
• Forces 8-10x body wt. in running
Achilles TendonAchilles Tendon
• Insertional Tendinopathy Occurs in older, less athletic, overweight
individuals
• Non-insertional Tendinopathy Occurs in more active athletes as a result
of repetitive stess of jumping, pushing off and cutting activities
Achilles TendonAchilles Tendon
• 1° CLINICAL DIAGNOSIS
• MRI Failure of Non-op Tx or Surgical planning
Achilles TendonAchilles Tendon• Treatment-Non-insertional
Paratenonitis Activity Modification Cross training
• Swimming, Stationary Bike
Rx NSAID’s and/or Medrol Dose Pack 0.25 inch heel lift Ice, Contrast baths Orthotics for overpronators
• Prevent “whipping” action on tendon
Cam boot immobilization (if sx’s > 6 wks)
Achilles TendonAchilles Tendon• Treatment-Non-insertional
Paratenonitis Refractory Brisement injections
Achilles TendonAchilles Tendon• Treatment-Non-insertional Paratenonitis
w/ Tendinosis Cam boot w/ 0.25 in heel lift
• Until no pain w/ ambulation shoe w/ lift
PT Rx Eccentric Exercise Program, Iontophoresis, US, X-friction massage
+/-Night Splint +/-Topical Nitro-Dur Patch
• 0.1mg/hr x 5-7 days
Achilles TendonAchilles Tendon• Treatment-Non-insertional
Paratenonitis w/ Tendinosis Refractory Tx Options
• PRP Injection– Controversial!
Achilles TendonAchilles Tendon• Treatment-Non-insertional
Paratenonitis w/ Tendinosis Surgical Treatment LAST RESORT!!!
• MUST fail 6 mos of non-operative tx
• Plethora of Surgical Procedures– Results 70-75% good to excellent– LESS than traditional orthopaedic procedures
Peroneal TendonsPeroneal Tendons
Peroneal Tendon TearsPeroneal Tendon Tears• Anatomic
Predispositions Peroneus quartus Hypertrophied
peroneal tubercle Os peroneum Low lying peroneus
brevis Convex/Flat groove Cavo-varus foot
Peroneal TendonsPeroneal Tendons• Important Characteristics
Pain Location• Behind or distal to lateral malleolus• PB- Distal to LM Base of 5th • PL- Over lateral calcaneus peroneal tubercle
Pain Elicitation• Passive PF & Inversion• Resisted active DF & Everison
– If pop/click elicited ? Tear or intra-sheath subluxation
Peroneal TendonsPeroneal Tendons
• 1° CLINICAL DIAGNOSIS
• XR Standard foot views
• MRI Difficulty in diagnosis or Surgical planning Sensitivity 17%, Specificity
100% (Kijowski et al.)
Peroneal TendonsPeroneal Tendons• Non-operative Treatment
RICE Cam boot or ASO until pain
subsides Rx NSAID’s or Dose Pack PT Orthotics for Cavus foot
Gradual Return with FPP
Peroneal TendonsPeroneal Tendons
• Surgical Treatment Failure of non-operative treatment
Procedure tailored to pathology• Debridement +/- repair, possible groove
deepening, excision p. quartus or p. brevis muscle belly, excision peroneal tubercle
Posterior Tib TendonPosterior Tib Tendon
• Anatomy Acute
angulation of tendon
• Zone of hypovascularity Frey: starts 1-
1.5 cm distal to MM and extends to navicular insertion
Posterior Tib TendonPosterior Tib Tendon• Important Characteristics
Medial ankle pain• TTP over course PTT
Fullness over PTT Arch collapse “Too many toes” sign Inability to perform DSHR or
SSHR
Posterior Tib TendonPosterior Tib Tendon• AP/lateral weight bearing
films of foot and/or ankle Talo-navicular “sag” Plantar flexion of Talus Collapse of midfoot Collapse of the talo-calcaneal
angle
• MRI Difficulty in diagnosis or Surgical planning
Posterior Tib TendonPosterior Tib Tendon• Non-operative Treatment
RICE PT for Eccentric PTT
program Rx NSAID’s or Dose Pack Protection
• If can do SSHR Orthotic w/ high trim line medially or Aircast Airlift PTTD brace
• If not Cam boot with arch support inside
Posterior Tib TendonPosterior Tib Tendon
• Operative Treatment Failure of 4-6 mos Non-op Tx
Avoidance of bony procedures in athlete• PT debridement +/- FDL t-fer• Medializing calcaneal osteotomy at most