1. Foot and Ankle Problems in the Endurance Athlete
Brian A. Weatherby, MD
Steadman-Hawkins Clinic of the Carolinas
Assistant Professor Clinical Orthopaedic Surgery
University of South Carolina School of Medicine

2. DISCLOSURES
NONE

3. Foot Problems Lesser MTP Disorders Great Toe Disorders
Metatarsal Stress Fracture

4. Ankle Problems
Tendinopathy
Achilles
Posterior Tibial
Peroneal

5. Not this Endurance Athlete!

6. This Endurance Athlete!

7. Foot Problems Lesser MTP Disorders Great Toe Disorders
Metatarsalgia/MTP Synovitis/MTP Instability
Interdigital neuroma
Great Toe Disorders
Sesamoiditis
Hallux Rigidus
Metatarsal Stress Fracture

8. Foot Problems Lesser MTP Disorders
Metatarsalgia/MTP Synovitis/MTP Instability
Interdigital Neuroma

9. Lesser MTP Pain Differential diagnosis extensive Mechanical Neurologic
Idiopathic

10. Metatarsalgia
Mechanical
Shoewear
Small toe box
Short shoe

11. Metatarsalgia Mechanical MP instability
Often associated with long 2nd MT (Morton’s Foot)
Especially in runner

12. Metatarsalgia Idiopathic Overuse syndromes (runners)
Fat pad atrophy (aging)

13. MetatarsalgiaMTP Synovitis MTP Instability
MP Instability
Chronic-Volar plate degeneration
Wide spectrum of presentation
Can be progressive

14. Lesser MTP Pain Neurologic Morton’s Neuroma
Mimic or be associated with synovitis
Almost always 3rd web space

15. Lesser MTP Pain Idiopathic Freiberg’s infraction 2>3 MT heads
Occurs in adolescence but symptoms often in adult

16. Metatarsalgia Examination Isolated palpation of MT head
Plantar keratosis
Fat pad atrophy

17. MTP synovitis/MTP Instability
Examination
Deformity
Hyperextension/Dislocation
Instability
Lachman’s
Synovitis
Plantarflexion stress

18. Morton’s Neuroma Examination Palpate Inter-space (always)
Squeeze Test (majority)
Mulder’s Sign (30%)

19. Biomechanics Examination
Check for Achilles contracture  Increases forefoot pressures!

20. Lesser MTP Pain Diagnostic studies Radiographs Subluxation Dislocation
Degeneration
MT lengths

21. Treatment Metatarsalgia Activity Modification Shoewear Changes
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)

22. Shoewear Neutral Cavus (Supinator) Planus (Pronator)
Stabilitycombines 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

23. Treatment 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)

24. Treatment 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

25. Treatment MTP Synovitis/MTP Instability MTP Injection
Diagnostic &/or Therapeutic
Longstanding/Refractory
Must protect 4 wks in Budin splint

26. Treatment 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

27. Summary Consider all possibilities
Exhaust all non-operative modalities
Surgical Tx warranted after minimum 16 + weeks conservative care

28. Great Toe Disorders
Sesamoiditis
Hallux Rigidus

29. First MTP Anatomy Tibial & Fibular Sesamoids FHL & FHB Plantar Plate
Articular Surfaces
MTP
MT-sesamoid

30. Biomechanics 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

31. Biomechanics Normal gait Jogging, running Running jump
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

32. Sesamoidtis Etiology Spectrum Acute (fall or forced DF)
Fracture
Sx bipartite sesamoid (tibial)
Chronic (repetitive stress)
Stress Fracture
Sesamoiditis
Osteochondritis
Chondromalacia
Osteonecrosis
Exostosis IPK (tibial)

33. Sesamoid Disorders History Δ in shoes/training/mechanics
Trauma, overuse, idiopathic
Localized plantar 1st MTP pain
Sport/Stairs/High impact worse
Δ in shoes/training/mechanics

34. Sesamoid Disorders Clinical Exam Specific TTP at tibial &/or fibular
Swelling, warmth, erythema
Plantar pain, +/- crepitus w/ motion
IPK over tibial sesamoid

35. Sesamoid Disorders Radiographs Standing AP/bilateral Axial Oblique
Marker over area TTP

36. Sesamoid Disorders Bone Scan MRI CT 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

37. SESAMOIDITIS 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

38. Sesamoid Fracture Presentation Acute Hyperextension injury
Tibial sesamoid
Transverse frx line, mid-waist
Callus formation
Association with MP dislocation
CT to evaluate displacement

39. Bipartite Sesamoid Bipartite vs. Acute Fracture (Brown et al. CORR)
Irregular & unequal fragment diastasis
Callus formation
Presence/absence on contralateral side

40. Sesamoid DJD Post-traumatic Iatrogenic Chondromalacia Osteophytes
s/p bunionectomy
Chondromalacia
Osteophytes
Attritional rupture of abd/adductor H Valgus/Varus

41. Sesamoid Osteochondritis
Etiology unknown
Crush injury
Stress Frx
AVN
Pain, fragmentation, cyst formation, flattening
XR Δ’s may delay 6-12 mos
Bone scan
MRI

42. Bipartite
Acute Frx
Stress Frx
Osteochondritis

43. Sesamoid IPK Tibial sesamoid Cavus, PF ray (diffuse)
Sesamoid prominence (localized)

44. 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

46. Treatment 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

47. Treatment Cortisone Injection Surgical Tx Longstanding/Refractory
Flouro guided
Results Highly Variable
Surgical Tx
Failure appropriate non-op tx ≥ 16 wks
Displaced Frx

48. Hallux Rigidus

49. Hallux Rigidus
Second most common condition affecting the hallux MP joint
Termed coined by Cotterill in 1888, after description by Davies-Colley in 1887

50. Hallux 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

51. Hallux Rigidus Two groups: Adolescent Adult
Rigid swollen joint, painful DF
Chondral lesion (traumatic) or OCD (atraumatic)
Adult
Degenerative destruction
? Overuse or traumatic etiology

52. Hallux Rigidus Presentation Dorsal prominenceshoewear irritation
Painful ROM (PF and DF, with push-off)

53. Hallux 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

54. Hallux Rigidus
Radiographs
Varying Grades

55. Hallux Rigidus
Radiographic worsening does NOT equate to clinical worsening

56. Hallux Rigidus Treatment Shoewear modifications Orthotics Taping
Size
Cushion prominences
Orthotics
Full length orthotic with TPE or carbon fiber Morton’s extension under 1st ray
Taping
Rx NSAID’s

57. Hallux Rigidus Treatment Steroid injection SELECTIVE
Repeated injections will ↑ degenerative process

58. Hallux Rigidus Surgical Tx Adolescent/Young Athlete
OCD lesion or chondral injury  Arthroscopic debridement & microfracture

59. Hallux Rigidus Surgical Tx Adult
Cheilectomy and Drilling of bare areas

60. Hallux Rigidus Surgical Tx Lengthy discussion with athlete
Expectations
Pain relief (majority)
? ↓ push-off power

61. Metatarsal Stress Fracture

62. Stress Fracture Definition
Partial or complete fracture of a bone due to its inability to withstand nonviolent, rhythmic, repetitive subthreshold stress

63. Stress 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

64. Stress Fractures Etiology Anatomy Foot Type & Alignment Blood Supply
Subtle Cavus
Long 2nd MT
Leg Length Discrepancy
Blood Supply
5th MT base, middle MT neck

65. Stress 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

66. Stress 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

67. Stress Fractures Physical Exam TTP over area Percussion/Tuning Fork
Pain with one leg hopping
Assess Foot Stucture

68. Foot Structure
Neutral
Cavus (Supinator)
Planus (Pronator)

69. Foot Structure CAVUS Subtle Cavus Obvious Cavus
Peek-a-boo heel (varus)
PF 1st ray
Obvious Cavus

70. Foot Structure Cavus Related Conditions 5th MT Stress Fracture
Peroneal Tendon Pathology
Chronic Ankle Instability

71. Orthotics Cavus Foot Pre-fab Rx Donjoy Arch Rival
Full length orthotic w/ lateral forefoot posting and area of relief for 1st MT head, along w/ MT pad to unload __ MT head(s)

72. Stress 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

73. Stress Fractures XR Tc99 MRI CT
Frx evident in 30-70%, better for cortical
Pain onset  bony ∆ avg.~ 21 days, may take 6 wks
Tc99
↑ sensitive w/in hrs
Poor specificity
MRI
Sensitive & Specific CT
Complete vs. Incomplete Frx

74. MT 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

75. MT 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

76. MT 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

77. MT Stress Fractures 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

78. MT Stress Fractures 5th MT Fracture-Operative Indications Athlete
Acute/stress fx
Nonunion
Re-fracture
Cavovarus = lateral overload

79. MT Stress Fractures Operative Goals Expedite healing
Quicker recovery; easier rehab
Decrease re-fracture risk

80. Ankle Problems
Tendinopathy
Achilles
Posterior Tibial
Peroneal

82. Tendinopathy

83. Tendons: Basic Science
*Aging results in increased stiffness due to inc.
collagen cross-linking Decrease in tensile strength

84. Tendons: Basic Science
Blood Supply
3 sources
Musculotendinous junction
Surrounding connective tissue
Bone-tendon junction
Zones of Hypovascularity
Decreases with age and mechanical loading

85. Tendinopathy: 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

86. Tendinopathy: Etiology
Corticosteroids
Flouroquinolones
Autoimmune disorders, inflammatory arthropathies, infection
Trauma

87. Tendon Healing Immobilization Mobilization
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

88. Achilles Tendon Zone of hypovascularity 2-6cm proximal to insertion
Forces 8-10x body wt. in running

89. Achilles Tendon Insertional Tendinopathy Non-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

90. Achilles Tendon 1° CLINICAL DIAGNOSIS
MRI Failure of Non-op Tx or Surgical planning

92. Achilles 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)

93. Achilles Tendon Treatment-Non-insertional Paratenonitis
Refractory Brisement injections

94. Achilles 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

95. Achilles Tendon Treatment-Non-insertional Paratenonitis w/ Tendinosis
Refractory Tx Options
PRP Injection
Controversial!

96. Achilles 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

97. Peroneal Tendons

98. Peroneal Tendon Tears Anatomic Predispositions Peroneus quartus
Hypertrophied peroneal tubercle
Os peroneum
Low lying peroneus brevis
Convex/Flat groove
Cavo-varus foot

99. Peroneal 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

100. Peroneal Tendons 1° CLINICAL DIAGNOSIS XR Standard foot views
MRI Difficulty in diagnosis or Surgical planning
Sensitivity 17%, Specificity 100% (Kijowski et al.)

101. Peroneal 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

102. Peroneal 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

103. Posterior Tib Tendon Anatomy Zone of hypovascularity
Acute angulation of tendon
Zone of hypovascularity
Frey: starts cm distal to MM and extends to navicular insertion

104. Posterior 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

105. Posterior 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

106. Posterior 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

107. Posterior 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

108. Thank You