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Foot Injuries of the Recreational Athlete

Stephen M. Simons, MD

The Recreational Athlete Series
Editor: James L. Moeller, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 1 - JANUARY 1999


In Brief: Adult recreational athletes, or 'weekend warriors,' are vulnerable to foot injuries such as Achilles tendon ruptures, plantar fasciitis, retrocalcaneal bursitis, midfoot tendinitis, metatarsal stress fractures, and interdigital neuroma. Physicians also need to be alert for less common injuries such as Jones fractures and tarsal navicular stress fractures because of the risk of delayed healing or nonunion. Many foot injuries can be treated conservatively, but some Achilles tendon ruptures, Jones fractures, and tarsal navicular stress fractures may require surgery.

The scenario is a common one: The "weekend warrior" hobbles into the workplace on a Monday morning, injured in the pursuit of recreation or, ironically, health—only to endure gentle ridicule from sedentary colleagues. Such adult recreational athletes contribute to the 3% to 15% of all athletic injuries that involve the foot. This incidence varies by sport, but whether the activity is recreational or professional, organized or spontaneous, the level of play makes little difference in the type or severity of foot injury (1).

The foot is a complex structure that provides the principal interface with the playing surface. Though the foot is highly adaptable, vertical reaction forces—from 0.6 times body weight during walking to 7.9 times body weight for a running jump—place it at risk for acute traumatic and chronic overuse injuries (2). The weekend warrior typically lacks the conditioning that would prepare the musculoskeletal structures for occasional heavy demand. Without proper conditioning, aging tissues lack the flexibility, strength, and resilience to withstand high stresses that are applied only sporadically. These factors pave the way for both acute and overuse injuries of the foot.

Some of the injuries discussed here are fairly common in unconditioned recreational athletes. Others are less common but need to be kept in mind because they are easily missed or heal poorly.

Traumatic Injuries

Achilles tendon ruptures. The middle-aged recreational athlete who continues a youthful passion for basketball, racquetball, soccer, or some other vigorous sport becomes a prime candidate for Achilles tendon rupture. The older, occasional athlete may have had repeated episodes of subclinical or overt Achilles tendinitis. This scarred tissue that has become less flexible with age becomes vulnerable to rupture.

Rapid eccentric loading of the Achilles tendon can occur with an abrupt stop, landing from a jump, running the bases, or other quick movements. A recent instance in my practice, for example, occurred when the patient was playing badminton and landed from a jump.

Patients may report a "pop" at the back of the leg or may say they were struck from behind. On examination, a palpable defect may be found in the tendon 2 to 6 cm from the calcaneus. With the Thompson test, done with the patient prone, the absence of passive plantar flexion when the calf is squeezed indicates total Achilles rupture. Inability to perform a weight-bearing single-leg toe raise can also indicate total rupture. Active plantar flexion is possible using only the long flexor, peroneal, and tibialis posterior muscles, but these muscles alone are generally too weak to allow full weight bearing on the toes of one foot (3).

The decision regarding conservative vs surgical treatment for Achilles tendon rupture is a case-by-case judgment that requires consideration of the patient's occupation and social circumstances as well as expectations about future sports activity.

A recent report (4) reviewed 19 studies examining operative vs nonoperative management of patients who had Achilles tendon ruptures. The average patient was 37.9 years old, and 83% of the patients were male. The surgically treated patients more often returned to sport at the same level, and 2.8% experienced reruptures, as compared with 11.7% of the conservatively treated patients. But the average sick leave was 8.2 weeks for patients treated nonsurgically vs 10.5 weeks for those treated surgically, and fewer minor complications occurred in patients who were treated nonsurgically (5).

Conservative treatment involves cast immobilization for 3 months, followed by use of crutches and wearing of shoes that have a built-up heel.

Acute fractures. Acute fractures of the foot occur infrequently in nonmotor sports. However, physicians should be alert for fractures of the proximal fifth metatarsal, including avulsion fractures and Jones fractures.

Fifth metatarsal avulsion fractures. Because avulsion of the proximal tip of the fifth metatarsal (figure 1) occurs occasionally as a complication of a lateral ankle sprain, palpating the base of the metatarsal should be a routine part of the ankle sprain evaluation. Tenderness at the site should prompt x-rays. In the setting of an acute injury, a vertical fracture to the proximal 1.0 to 1.5 cm of the fifth metatarsal is most likely an avulsion at the insertion of the peroneus brevis.

[Figure 1]

This fracture generally heals without complication. Acute care with ice, elevation, and compression should be followed by wearing a stiff-soled shoe such as a hiking boot or briefly using a short leg cast. A minimum of 3 to 4 weeks of rest from sports activity can be followed by gradual pain-guided return to sport. The patient should be warned about returning to sports activity too early. The risk includes not only reinjury at the fracture site, but also secondary overuse injuries due to new stresses resulting from incomplete rehabilitation.

Jones fractures. A Jones fracture is an acute fracture of the base of the fifth metatarsal at the metaphyseal-diaphyseal junction (figure 1). In my experience these injuries have occurred as a result of a pivot in the direction opposite the planted foot. A Jones fracture is sometimes associated with antecedent lateral foot pain that indicates a preexisting stress fracture. These fractures are prone to delayed healing and also to nonunion.

Torg (6) proposed a classification system for Jones fractures to assist management decisions: Type 1 fractures are acute without prior pain; x-rays reveal a clean fracture line without sclerosis or cortex hypertrophy. Type 2 fractures involve prior symptoms or a known prior stress fracture; x-rays show some medullary sclerosis and a widened fracture line. In type 3 fractures, x-rays demonstrate repeated trauma, a wide fracture line, and exuberant sclerosis that suggests fracture nonunion.

Because of their poorer healing rate, Jones fractures need to be distinguished from simple metaphyseal avulsion fractures. Type 1 fractures in nonathletes may heal in 6 to 8 weeks with a non-weight-bearing cast, but most authors recommend surgical management for active patients. Type 2 and type 3 fractures are best treated with surgical fixation.

Rearfoot Overuse Injuries

Overuse injuries are more common than traumatic injuries and are caused by the repetition of loading forces that, if applied singly, would not cause damage. Overuse injuries affecting the foot can be grouped by their location in the rearfoot, midfoot, or forefoot. Rearfoot injuries that can befall the weekend warrior include plantar fasciitis, fat pad syndrome, and calcaneal bursitis.

Plantar fasciitis. Plantar fasciitis, or subcalcaneal pain, is a common reason for physician office visits. Pain is located distal and medial to the base of the calcaneus at the tuberosity. The condition is characterized by an insidious onset of heel pain, which is worse on arising in the morning or after a brief period of inactivity.

A change of sports activity, training regimen, shoes, or other biomechanical factors may precipitate plantar fasciitis. Weekend warriors are particularly at risk for plantar fasciitis when tremendous repetitive stress is applied to a plantar fascia otherwise accustomed only to the strain of a flight or two of stairs.

Once the condition is established, it may resist many different treatments. Pain of a few days' to a few weeks' duration may be eased by simply providing more supportive athletic shoes, minimizing barefoot walking, and taking oral nonsteroidal anti-inflammatory drugs (NSAIDs).

Heel cups may help some patients. These work by providing direct shock absorption or by minimizing fat pad splay under the calcaneus. Heel cups force more fat to remain below the heel (figure 2), which helps if the pain is from swelling around the plantar fascia.

[Figure 2]

However, the pain may be due to tensile forces on the plantar fascia or calcaneal periosteum. Controlling arch collapse or excessive pronation with off-the-shelf or custom orthoses can provide some relief of this tension. I also find that advising people to lace their shoes as tightly as tolerable assists medial support by the shoe's heel counter, reducing pronation. Attention to Achilles flexibility will also relieve some of the arch-collapsing forces.

Another helpful measure is the use of a tension night splint (see "Making a Tension Night Splint for Plantar Fasciitis," June 192021, page 113). The splint holds the foot in a slightly dorsiflexed position, providing a gentle stretch and reducing the swelling that accumulates in the relaxed plantar fascia.

Corticosteroid injections can provide dramatic, though often temporary, relief. The possibility of fat pad injury should be discussed with the patient before injecting this area. Surgical plantar fascia release is rarely necessary.

Fat pad syndrome. A direct blow to the bottom of the heel that results in a bruise, such as a forceful heel-first landing on a rock by a swimmer, can also injure the fat pad, causing symptoms similar to plantar fasciitis. Examination of the heel usually reveals tenderness directly under the weight-bearing part of the calcaneus rather than on the anterior distal tuberosity.

A well-fitted heel cup cushions the heel and prevents the fat pad from splaying, thereby improving the intrinsic cushioning of the calcaneus (figure 2) (7). Also helpful are shoes with softer midsoles, which provide more cushioning for the fat pad.

Retrocalcaneal bursitis. The bursae between the skin and the Achilles tendon and between the Achilles tendon and the calcaneus are subject to friction from tight shoes or a calcaneal protuberance. This differs from Achilles tendinitis in that, with retrocalcaneal bursitis, tenderness is present at the Achilles tendon insertion rather than at the narrowest part of the tendon, 2 to 3 cm proximal to the insertion.

Treatment for retrocalcaneal bursitis is directed at reducing the friction. The simplest solution is to rest the area by wearing a shoe with an open back. But if conventional shoes are a must, a well-padded heel counter is necessary. The fit of the shoe is also very important. A shoe that is too loose at the heel allows the heel to rise first in the shoe and the shoe to follow, causing rubbing and friction. Minimizing this slippage will minimize heel irritation. If a shoe is too tight, compression of the bursa will also cause irritation. Accommodative donut padding around the inflamed tissue can provide pain relief.

Midfoot Overuse Injuries

Tendinitis. Tendinitis of the posterior tibial tendon on the medial side and the peroneus longus tendon on the lateral side (figure 3) can easily occur in the adult recreational athlete unaccustomed to hours of stress.

[Figure 3]

With inflammation of these tendons, pain and tenderness are usually present along the tendon inferior and distal to the malleolus. This tendinitis does not usually cause pain until weight is placed on the foot. Eccentrically stressing the suspect tendon by applying resistance force with the hand on the actively contracting muscle of the patient's inverted or everted foot can help identify the tendon as the source of pain. If this test is negative, pain could be originating from injury to ligaments, tissue, bone, or the ankle joint. Weight-bearing stress as with a standing toe raise is used to assess tendon integrity. A newly collapsed arch suggests the rarely occurring posterior tibial tendon rupture.

Tendinitis usually responds to rest, NSAIDs, ice, and, occasionally, brief immobilization. Supporting the medial arch with motion-control shoes and orthoses will reduce eccentric forces to the posterior tibial tendon, and supporting the medial longitudinal arch may help peroneus longus tendinitis simply by reducing late-phase pronation. A gradual return to activity and some weekday conditioning will help the weekend warrior resume his or her previous routine. Posterior tibial tendon rupture requires more aggressive management, such as casting.

Tarsal navicular stress fractures. Tarsal navicular stress fractures are rare, but unfortunately many go undiagnosed for months (8). Chronic dorsal medial midfoot pain that is mainly activity-related suggests the possibility of this stress fracture, which mostly occurs in repetitive activities such as running, soccer, and basketball. In my practice, two patients who presented with ankle pain were diagnosed as having tarsal navicular stress fractures.

The navicular tuberosity is easily palpated about 3 to 4 cm inferior and distal to the malleolus. The fracture site is usually at the apex of the bone, or "N" spot (figure 4) (9), and tenderness usually is present just under the anterior tibial tendon. X-rays are often normal. A bone scan or computed tomography (CT) scan is necessary to make a definitive diagnosis.

[Figure 4]

Like carpal navicular (scaphoid) fractures, fractures of the tarsal navicular are notorious for poor healing. Nonsurgical treatment is the use of a non-weight-bearing cast for 6 to 8 weeks. If the fracture is managed nonsurgically, the patient should be warned that it will take a long time to heal. Return to sport may take 6 months. Following immobilization, the patient should focus on gastrocnemius and Achilles flexibility, wear good shoes, and use care in sports activity.

Painful fracture nonunion requires internal fixation.

Forefoot Overuse Injuries

Metatarsal stress fractures. These injuries were originally called march fractures. The second, third, and fourth metatarsals account for 90% of these fractures (10). Second metatarsal fractures are most common, followed by fractures of the third and fourth metatarsals. These fractures can occur in sports that involve running, such as soccer, basketball, or tennis.

Metatarsal stress fractures often cause a diffuse swelling of the forefoot, disguising the focused nature of the injury. Careful palpation of each metatarsal helps identify one of the bones as the source of pain. Calluses on the plantar skin can provide clues to a pattern of inordinate stress on the metatarsal heads.

Chronic pain at the proximal metaphysis should alert the examiner to the possibility of a stress fracture. Prompt conservative treatment for a stress fracture at this site may prevent the eventual occurrence of an acute (Jones) fracture.

With metatarsal stress fractures, x-rays are normal for the first 2 to 3 weeks, but obvious bone callus usually appears subsequently. The diagnosis can be made earlier with a bone scan.

Avoiding weight-bearing while cross-training for approximately 4 weeks will allow adequate healing for most metatarsal stress fractures. Accommodative orthotic devices, which incorporate a depression that reduces pressure at the fracture site, may help prevent recurrence if signs of excessive stress to the fractured metatarsal are present.

Interdigital neuroma. The classic Morton's neuroma (figure 5) is an interdigital lesion involving the digital nerve common to the third and fourth metatarsal heads. This is not a true neuroma, but rather a perineural fibrosis where the nerve passes underneath the transverse metatarsal ligament. Repetitive irritation at this location causes distal plantar pain and often numbness in the interdigital web space supplied by this nerve. The condition can occur in runners, and shoes with a tight toe box may contribute to the problem. Palpating the distal plantar area while squeezing the metatarsal heads together can elicit the patient's symptoms.

[Figure 5]

A shoe with a wide toe box and a soft metatarsal pad can gently spread the metatarsals and may provide symptomatic relief. For weekend exercisers, NSAIDs and rest during the week may control the symptoms and forestall the need for further intervention. If these measures do not suffice, corticosteroid injection with a dorsal approach just proximal to the metatarsal heads also can produce clinical improvement.

Patients whose symptoms do not improve with these conservative measures require surgical management (11).

Other Problems

Black toe. Subungual hematoma develops from tight-fitting shoes, repeated sliding of the foot into the front of the toe box, or direct trauma. Pain can be relieved by draining the blood that is under pressure. This is accomplished with cautery or the heated tip of a paper clip. Attention to shoe fit and movement in the shoe prevents recurrence of subungual hematoma (12).

Blisters. Blisters are probably the most common foot injury in weekend athletes. Infrequently stressed skin that is not conditioned is subject to injury just as muscle, tendon, and bone are. Shoes that are new, improperly fitted, or wet contribute to blister development.

Skin that is red but not yet blistered may be protected with 2nd Skin dressing (Spenco Medical Corporation, Waco, Texas) or an adhesive bandage, allowing the athlete to continue sports activity.

An established blister should be drained and covered and further skin injury should be avoided until epidermal recovery (13). I have found that layering first antibiotic ointment, then 2nd Skin dressing, next an adhesive bandage, and sometimes donut padding around the blister allows sports participation with reduced pain. The patient should watch closely for signs of infection.

Stress Conditioning

Physicians who inquire about the activity patterns of their foot-injured patients may discover a weekend warrior. Such patients may need to be reminded to train during the week. This will help them avoid some of the overuse foot injuries that could become chronic or even debilitating.

References

  1. Clanton TO: Etiology of injury to the foot and ankle, in DeLee JC, Drez D, Stanitski CL (eds): Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, WB Saunders, 1994, pp 1642-1704
  2. Nigg BM: Biomechanics of Running Shoes. Champaign, IL, Human Kinetics, 120216, p 21
  3. Soma CA, Mandelbaum BR: Achilles tendon disorders. Clin Sports Med 1994;13(4):811-823
  4. Lo IK, Kirkley A, Nonweiler B, et al: Operative versus nonoperative treatment of acute Achilles tendon ruptures: a quantitative review. Clin J Sport Med 1997;7(3):207-211
  5. Cetti R, Christensen SE, Ejsted R, et al: Operative versus nonoperative treatment of Achilles tendon rupture: a prospective randomized study and review of the literature. Am J Sports Med 1993;21(6):
    791-799
  6. Torg JS, Balduini FC, Zelko RR, et al: Fractures of the base of the fifth metatarsal distal to the tuberosity: classification and guidelines for non-surgical and surgical management. J Bone Joint Surg (Am) 120214;
    66(2):209-214
  7. Wargon C: Common foot injuries, in Sallis RE, Massimino F: Essentials of Sports Medicine. St Louis, Mosby-Year Book, 1997, pp 463-478
  8. Bojanic I, Pecina MM: Conservative treatment of stress fractures of the tarsal navicular in athletes. Rev Chir Orthop Reparatice Appar Mot, 1997;83(2):
    133-138
  9. Khan KM, Brukner PD, Kearney C, et al: Tarsal navicular stress fracture in athletes. Sports Med 1994;
    17(1):65-76
  10. Weinfeld SB, Haddad SL, Myerson MS: Metatarsal stress fractures. Clin Sports Med 1997;16(2):319-338
  11. Mann RA: Entrapment neuropathies of the foot, in DeLee JC, Drez D, Stanitski CL (eds): Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, WB Saunders, 1994, pp 1838-1841
  12. Petrizzi MJ: Foot injuries, in Birrer RB (ed): Sports Medicine for the Primary Care Physician, ed 2. Ann Arbor, MI, CRC Press, 1994, p 580
  13. Garrick JG, Webb DR: Sports Injuries: Diagnosis and Management. Philadelphia, WB Saunders, 1990, p 320

Dr Simons is associate director of the family practice residency at St Joseph's Medical Center in South Bend, Indiana, a fellow of the American College of Sports Medicine (ACSM), and a charter member of the American Medical Society for Sports Medicine (AMSSM). Dr Moeller is an assistant residency director and director of sports medicine at the William Beaumont Hospital Family Practice Residency Program in Troy, Michigan, a member of the ACSM and the AMSSM, and a member of the editorial board of The Physician and Sportsmedicine. Address correspondence to Stephen M. Simons, MD, 837 E Cedar, Ste 125, South Bend, IN 46637; address e-mail to [email protected].


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