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Foot and Ankle Problems in the Endurance Athlete

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Presentation on theme: "Foot and Ankle Problems in the Endurance Athlete"— Presentation transcript:

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


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

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

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