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