Transcript Foot and Ankle Problems in the Endurance Athlete

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
DISCLOSURES
NONE
Foot Problems
• Lesser MTP Disorders
• Great Toe Disorders
• Metatarsal Stress Fracture
Ankle Problems
• Tendinopathy
 Achilles
 Posterior Tibial
 Peroneal
Not this Endurance Athlete!
This Endurance Athlete!
Foot Problems
• Lesser MTP Disorders
 Metatarsalgia/MTP Synovitis/MTP Instability
 Interdigital neuroma
• Great Toe Disorders
 Sesamoiditis
 Hallux Rigidus
• Metatarsal Stress Fracture
Foot Problems
• Lesser MTP Disorders
 Metatarsalgia/MTP Synovitis/MTP
Instability
 Interdigital Neuroma
Lesser MTP Pain
• Differential
diagnosis
extensive
 Mechanical
 Neurologic
 Idiopathic
Metatarsalgia
• Mechanical
 Shoewear
• Small toe box
• Short shoe
Metatarsalgia
• Mechanical
 MP instability
• Often associated
with long 2nd MT
(Morton’s Foot)
– Especially in
runner
Metatarsalgia
• Idiopathic
 Overuse
syndromes
(runners)
 Fat pad
atrophy
(aging)
MetatarsalgiaMTP
Synovitis MTP Instability
• MP Instability
 Chronic-Volar
plate
degeneration
• Wide spectrum
of presentation
• Can be
progressive
Lesser MTP Pain
• Neurologic
 Morton’s Neuroma
• Mimic or be
associated with
synovitis
• Almost always 3rd
web space
Lesser MTP Pain
• Idiopathic
 Freiberg’s infraction
• 2>3 MT heads
• Occurs in
adolescence but
symptoms often in
adult
Metatarsalgia
• Examination
 Isolated palpation of
MT head
 Plantar keratosis
 Fat pad atrophy
MTP synovitis/MTP
Instability
• Examination
 Deformity
• Hyperextension/Disloc
ation
 Instability
• Lachman’s
 Synovitis
• Plantarflexion stress
Morton’s Neuroma
• Examination
 Palpate Inter-space
(always)
 Squeeze Test
(majority)
 Mulder’s Sign (30%)
Biomechanics
• Examination
• Check for Achilles
contracture  Increases
forefoot pressures!
Lesser MTP Pain
• Diagnostic studies
• Radiographs
–Subluxation
–Dislocation
–Degeneration
–MT lengths
Treatment
• 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)
• Neutral
Shoewear
 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
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)
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
Treatment
• MTP Synovitis/MTP
Instability
 MTP Injection
• Diagnostic &/or Therapeutic
• Longstanding/Refractory
• Must protect 4 wks in Budin
splint
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
Summary
• 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 Anatomy
• Tibial & Fibular
Sesamoids
• FHL & FHB
• Plantar Plate
• Articular Surfaces
 MTP
 MT-sesamoid
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
Biomechanics
• 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
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)
Sesamoid Disorders
• History
 Trauma, overuse, idiopathic
 Localized plantar 1st MTP pain
 Sport/Stairs/High impact worse
 Δ in shoes/training/mechanics
Sesamoid Disorders
• Clinical Exam
 Specific TTP at tibial &/or fibular
 Swelling, warmth, erythema
 Plantar pain, +/- crepitus w/
motion
 IPK over tibial sesamoid
Sesamoid Disorders
• Radiographs
 Standing AP/bilateral
 Axial
 Oblique
 Marker over area
TTP
Sesamoid 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
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
Sesamoid Fracture
• Presentation
 Acute
• Hyperextension injury
• Tibial sesamoid
• Transverse frx line, mid-waist
• Callus formation
• Association with MP dislocation
• CT to evaluate displacement
Bipartite Sesamoid
 Bipartite vs. Acute
Fracture (Brown et
al. CORR)
• Irregular & unequal
fragment diastasis
• Callus formation
• Presence/absence
on contralateral side
Sesamoid DJD
• Post-traumatic
• Iatrogenic
 s/p bunionectomy
• Chondromalacia
• Osteophytes
• Attritional rupture of
abd/adductor H
Valgus/Varus
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
Bipartite
Acute Frx
Stress Frx
Osteochondritis
Sesamoid 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
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
Treatment
• Cortisone Injection
 Longstanding/Refractory
 Flouro guided
 Results Highly Variable
• Surgical Tx
 Failure appropriate non-op
tx ≥ 16 wks
 Displaced Frx
Hallux Rigidus
Hallux Rigidus
• Second most
common
condition
affecting the
hallux MP joint
• Termed coined
by Cotterill in
1888, after
description by
Davies-Colley
in 1887
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
Hallux Rigidus
• Two groups:
 Adolescent
• Rigid swollen joint, painful
DF
• Chondral lesion
(traumatic) or OCD
(atraumatic)
 Adult
• Degenerative destruction
• ? Overuse or traumatic
etiology
Hallux Rigidus
• Presentation
 Dorsal
prominence
shoewear
irritation
 Painful ROM
(PF and DF,
with push-off)
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
Hallux Rigidus
• Radiographs
 Varying Grades
Hallux Rigidus
• Radiographic
worsening does
NOT equate to
clinical
worsening
Hallux 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 Rigidus
• Treatment
 Steroid injection
• SELECTIVE
• Repeated injections will ↑ degenerative process
Hallux Rigidus
• Surgical Tx
 Adolescent/Young
Athlete
• OCD lesion or chondral
injury  Arthroscopic
debridement &
microfracture
Hallux Rigidus
• Surgical Tx
 Adult
• Cheilectomy and Drilling of bare areas
Hallux Rigidus
•
Surgical Tx

Lengthy
discussion with
athlete
Expectations

•
•
Pain relief
(majority)
? ↓ push-off
power
Metatarsal Stress
Fracture
Stress Fracture
• Definition
 Partial or complete
fracture of a bone
due to its inability to
withstand
nonviolent,
rhythmic, repetitive
subthreshold stress
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
Stress Fractures
• Etiology
 Anatomy
• Foot Type & Alignment
– Subtle Cavus
– Long 2nd MT
– Leg Length Discrepancy
• Blood Supply
– 5th MT base, middle MT neck
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
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
Stress Fractures
• Physical Exam
 TTP over area
 Percussion/Tuning Fork
 Pain with one leg hopping
 Assess Foot Stucture
Foot Structure
• Neutral
• Cavus
(Supinator)
• Planus
(Pronator)
Foot Structure
• CAVUS
 Subtle Cavus
• Peek-a-boo heel
(varus)
• PF 1st ray
 Obvious Cavus
Foot Structure
• Cavus Related Conditions
 5th MT Stress Fracture
 Peroneal Tendon Pathology
 Chronic Ankle Instability
Orthotics
• 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 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 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 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 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 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
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
MT Stress Fractures
• 5th MT FractureOperative
Indications
 Athlete
• Acute/stress fx
 Nonunion
 Re-fracture
 Cavovarus = lateral
overload
MT Stress Fractures
• Operative Goals
 Expedite healing
 Quicker recovery;
easier rehab
 Decrease re-fracture
risk
Ankle Problems
• Tendinopathy
 Achilles
 Posterior Tibial
 Peroneal
Tendinopathy
Tendons: Basic Science
*Aging results in increased stiffness due to inc.
collagen cross-linking Decrease in tensile strength
Tendons: Basic Science
• Blood Supply
 3 sources
• Musculotendinous junction
• Surrounding connective tissue
• Bone-tendon junction
 Zones of Hypovascularity
 Decreases with age and mechanical
loading
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
Tendinopathy: Etiology
• Corticosteroids
• Flouroquinolones
• Autoimmune disorders, inflammatory
arthropathies, infection
• Trauma
Tendon 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 Tendon
• Zone of
hypovascularity 26cm proximal to
insertion
• Forces 8-10x body
wt. in running
Achilles 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 Tendon
• 1° CLINICAL
DIAGNOSIS
• MRI Failure of Non-op
Tx or Surgical planning
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)
Achilles Tendon
• Treatment-Non-insertional
Paratenonitis
 Refractory Brisement injections
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
Achilles Tendon
• Treatment-Non-insertional
Paratenonitis w/ Tendinosis
 Refractory Tx Options
• PRP Injection
– Controversial!
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
Peroneal Tendons
Peroneal Tendon Tears
• Anatomic
Predispositions
 Peroneus quartus
 Hypertrophied
peroneal tubercle
 Os peroneum
 Low lying peroneus
brevis
 Convex/Flat groove
 Cavo-varus foot
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
Peroneal Tendons
• 1° CLINICAL DIAGNOSIS
• XR Standard foot views
• MRI Difficulty in
diagnosis or Surgical
planning
 Sensitivity 17%, Specificity
100% (Kijowski et al.)
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
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
Posterior Tib Tendon
• Anatomy
 Acute
angulation of
tendon
• Zone of
hypovascularity
 Frey: starts 11.5 cm distal to
MM and
extends to
navicular
insertion
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
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
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
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