CHAPTER 15
Foot and Toe Injuries
Christopher E. Hubbard, MD, and William G. Hamilton, MD
The foot is made up of 26 bones plus the soft tissues. The soft tissues are the skin, blood vessels, nerves, and connective tissues that include tendons, which connect muscles to bones, and ligaments, which hold bones together and allow joints to move in only certain directions. The hindfoot is the heel bone (also called the calcaneus). The midfoot or midtarsal bones are solidly packed together like the stones of a Roman arch, and the forefoot contains the long bones—the metatarsals—that lead to the toes.
The feet each of us ends up with are the ones we were genetically programmed to have. In terms of the arch of the foot, there are three types (see figure 15.1):
- The normal-arched foot—with the arch moderately high off the ground—is the ideal foot to absorb energy; it is neither too rigid nor too flexible.
- The flat foot—low arch—is hypermobile and does not transmit energy well. It is a weak foot that is easily overstrained and tends to tire.
- The cavus foot—high arch—is rigid and does not absorb energy well. It is prone to stress fractures and ankle sprains.
In terms of the shape of the foot, there are several types (see figure 15.2):
- The Grecian foot is sometimes called the Morton’s foot, on which the second toe is the longest.
- The Egyptian foot is one on which the great toe is the longest.
- The Simian foot is a wide foot that forms a bunion.
- The peasant’s foot is broad and square with metatarsals of almost equal length; it is very stable and absorbs energy quite well. It is an ideal foot for sports.
- The model’s foot is narrow and tapered. Because of the unequal length of the metatarsals, it absorbs energy poorly and is not a good foot for impact sports.
FIGURE 15.1 The three arch types include (a) the normal-arched foot, (b) the flat foot, and (c) the cavus foot.
FIGURE 15.2 The foot shapes include (a) the Grecian foot, (b) the Egyptian foot, (c) the Simian foot, (d) the peasant’s foot, and (e) the model’s foot.
Injury | Page |
Plantar Fasciitis | |
Stone Bruise | |
Painful Accessory Navicular Bone | |
Navicular Bone Stress Fracture | |
Lisfranc’s Sprain | |
Metatarsal Stress Fractures | |
Fifth Metatarsal Fractures | |
Hallux Rigidus | |
Turf Toe | |
Bunions | |
Sesamoid Injury | |
Tennis Toe | |
Freiberg’s Disease | |
Forefoot Neuromas | |
Second Metatarsophalangeal Joint Instability | |
Tarsal Coalition | |
Corns | |
Fungal Infections | |
Tarsal Tunnel Syndrome | |
Shoelace Pressure Syndrome | |
Purple Toe | |
Talon Noir |
PLANTAR FASCIITIS
Common Causes
The plantar fascia is a strong, tough band of tissue on the sole of the foot that begins at the ball of the foot and attaches to the bottom of the heel. It can be strained either acutely or chronically, but chronic conditions appear to be more common. Plantar fasciitis is often the result of overuse, either from running too long without rest or jumping on the heel too much. Strains sometimes occur in the midportion of the arch but are more often seen at the attachment to the heel, usually on the inner side of the heel. Occasionally, the plantar fascia is torn, either partly or completely, during physical activity.
It was once thought that a heel bone spur, often seen on X-ray, was the cause of plantar fasciitis—however, the spur is located above the insertion of the fascia rather than in the fascia itself. The spur is likely not the cause of the pain.
Plantar fasciitis must be differentiated from plantar fibromatosis. Although plantar fibromatosis also involves the plantar fascia and causes pain, this problem arises from fibrous lumps that form in the plantar fascia rather than from inflammation. Plantar fibromatosis tends to run in families and is sometimes associated with a similar condition in the palmer fascia of the hand. The condition can be identified by soft, mobile lumps on the sole of the foot that can be painful to the touch and symptomatic during standing or playing sports. These lesions can increase in size over time but typically are not fast-growing tumors. Plantar fibromatosis tumors are benign tumors and are best left alone because they have a very high recurrence rate following surgical removal. The athlete with plantar fibromatosis may participate in sports as tolerated.
Identification
Plantar fasciitis is characterized by localized tenderness on the bottom of the heel that often is worse in the morning when one first places the foot onto the ground after getting out of bed. The first few steps are quite painful, but then the pain lessens somewhat. The discomfort during the first few steps occurs because during sleep the foot is held in a plantar-flexed position (toes pointing down). Thus, during the first steps, the toes and foot extend upward (dorsiflexion). This action causes tension on the plantar fascia and irritates the inflamed tissue. Athletes will also feel this pain with increased activity and impact.
Treatment
Treatment of plantar fasciitis is somewhat controversial because there are dozens of different items available on the market for this common problem. A study done by the American Orthopaedic Foot & Ankle Society showed that there is a 90 percent healing rate in nine months regardless of treatment. Athletes might try using heel cups, physical therapy, and a night splint worn to hold the foot extended upward toward the shin while lying down. This splint usually decreases the morning pain, and once this pain begins to get better, the condition usually resolves itself. Healing can be slow and frustrating, but the best treatment for plantar fasciitis is rest and avoidance of irritating factors. There are a few cases that fail to get better, and these might need to be treated with plasma-rich platelet injections, shockwave therapy, or surgical release.
Return to Action
The athlete should return to sports only when completely pain free. The timetable for return to sports is variable; it can be as brief as a few weeks or may be an entire year. Postoperatively, athletes can expect several months of downtime before returning to competition.
STONE BRUISE
Common Causes
There are many causes of heel pain; the heel has many nerve endings and is quite sensitive to injury. A stone bruise is caused by a stone or other object that bruises the bottom of the heel. This injury might sound minor, but it can produce severe pain depending on the number of cells that get bruised. Stone bruises are seen most often in athletes and other active people. Often, these bruises are accompanied by a hairline fracture that will not show on an early X-ray but might show up later when the injury begins to heal (by the appearance of callus formation at the fracture site on X-rays). In running and other repetitive-type sports, this pain can also be caused by a navicular bone stress fracture (see p. 310).
Identification
When the bottom of the heel is bruised it is often extremely painful and tends to heal slowly. Pain might be accompanied by swelling and tenderness. The athlete might have difficulty putting weight on the foot.
Treatment
The best treatment for a stone bruise is to curtail walking as much as possible until the injury heals. The foot should be immobilized and placed in a walking boot until symptoms subside, which might take anywhere from two to eight weeks.
Return to Action
A stone bruise heals slowly. The athlete should return to sports only when completely pain free. This might take as long as eight weeks, and longer if not treated with care.
PAINFUL ACCESSORY NAVICULAR BONE
Common Causes
Roughly 5 to 10 percent of people are born with an extra bone on the inside of the arch of the foot adjacent to the navicular bone. Athletes who have an accessory navicular in one foot have a 50 percent chance of having it in the other foot as well. It is present from birth and frequently causes no trouble other than an abnormal prominence in the arch of the foot. Its presence can render the appearance that the arch is flat, when in actuality it is not.
Identification
Many people with an accessory bone go through their whole lives without difficulty, whereas others have symptoms from an early age. Some experience pain following a sprain or direct blow to the area. Once the area begins to hurt it may eventually stop hurting but often progresses to cause pain or a flat-foot deformity.
Treatment
Initial treatment is immobilization in a boot or cast, with the use of crutches. If these measures fail, the bone can be removed surgically, but recovery time can be long, taking from three to nine months. The younger the athlete is when surgery is done, the faster the recovery.
Return to Action
Athletes with a symptomatic accessory navicular should immobilize it until symptoms subside. They should return to sports only when completely pain free and might need to wear a medial arch support or orthotic inside the tennis shoe or cleat.
NAVICULAR BONE STRESS FRACTURE
Common Causes
The navicular is a boat-shaped bone directly in front of the medial (inner side) ankle that runs across the midfoot. In athletes with a high-arched foot that absorbs energy poorly, this bone is prone to stress fractures.
Identification
The athlete with a navicular stress fracture will typically experience severe midfoot pain without an injury. Like all stress fractures, a navicular stress fracture might not show up on an X-ray, but it is a dangerous fracture because if it is not recognized and treated, the fracture line can propagate, and bone fragments will separate. If a navicular stress fracture is suspected, a computed tomography (CT) scan is best used to see the fracture line.
Treatment
This injury is potentially serious and needs to be treated aggressively, usually with surgery including screw fixation to promote healing and prevent recurrence.
Return to Action
Following surgery, the athlete will be unable to bear weight on the foot for two months. Expected return to sports is anywhere from six months to one year after surgery.
Common Causes
The middle of the foot is normally quite rigid because it is bound together by a series of strong ligaments. In the forefoot (just beyond the midfoot), there are five rays, each of which has a metatarsal and toe bone (phalange). The ray running to the great toe is the first ray, and the rest follow suit, two through five. At the base of the first ray is a strong ligament (Lisfranc’s ligament) that binds the first ray to the other rays. When this ligament is torn, the connection is disrupted, leaving the foot weak and unstable. This sprain is particularly common in American football, soccer, and any sport in which the foot may twist severely.
Identification
This injury comes in several different types and degrees of severity. It is important not to miss it because it can lead to chronic pain and posttraumatic osteoarthritis. The sprain will sometimes show up on a weight-bearing X-ray of both feet, but both magnetic resonance imaging (MRI) and a CT scan might be required to make the diagnosis and to determine if there is any separation or diastasis between the bones of the midfoot.
Treatment
Surgery is often needed to stabilize the midfoot and prevent chronic pain. If the alignment is anatomic, however, then a period of non-weight bearing on the foot, followed by an orthotic, can successfully treat the condition.
Return to Action
The recovery from this injury is prolonged. Following surgery, the athlete is unable to bear weight on the foot for two months. Expect a full return to take anywhere from six months to one year after surgery.
METATARSAL STRESS FRACTURES
Common Causes
Stress fractures of the metatarsals are quite common. The “march fracture” got its name because it was common in army recruits after a long march. This injury usually occurs in the middle of the second or third metatarsal bone in the forefoot. It is very common in runners who begin training for a marathon. Female ballet dancers, probably because they dance on their toes, get the same fracture, but they sustain it not in the shaft of the bone but at the base of the second metatarsal. Metatarsal neck fractures are most common at the second and third metatarsals.
Identification
The pain and tenderness are typically localized over the shaft of the bone, in the middle of the midfoot. As with all stress fractures, this one rarely shows up on the initial X-ray but can be seen several weeks later as it begins to heal and lays down new bone (callus). The most reliable way to diagnose a stress fracture early is with MRI.
Treatment
Athletes should avoid activity until the bone heals. Dancers who develop this fracture should be screened for the female athlete triad, which includes amenorrhea, disordered eating, and osteopenia or osteoporosis. Treatment is usually a walking boot until healing has occurred. Surgery is very rarely needed for these conditions.
Return to Action
Return to weight-bearing exercises typically begins about six weeks from the time of diagnosis. Running can be initiated at three months.
FIFTH METATARSAL FRACTURES
Common Causes
The fifth metatarsal is the small bone on the outside of the forefoot just below the ankle. Injuries to this bone are very common and are usually caused by abrupt twists of the foot during a fall.
Identification
The athlete might feel a pop and have immediate pain, discoloration, and swelling of the area. Fractures occur in four different locations of the bone.
The tubercle fracture occurs at the base of the bone nearest the ankle, at which there is normally a bump where a tendon attaches to the bone. This fracture is the most common of the fifth metatarsal fractures and the least serious. The Jones fracture is very near the tubercle but occurs in an area with a poor blood supply and heals poorly. It is the most serious of these injuries. The spiral oblique fracture (also called the dancer’s acute fracture) occurs further down the shaft of the bone in the distal third. This fracture occurs frequently when dancers who dance up on the ball of the foot roll the foot over. A boxer’s fracture involves a break at the distal end of the bone, just near the knuckle of the fifth toe joint.
Treatment
Tubercle fractures are usually treated in a walking boot until they heal. They rarely require surgery. Jones fractures tend to not heal, proceed to a nonunion, and result in chronic pain and disability—especially if the athlete is allowed to walk on the foot. For this reason, many orthopedists favor putting a screw in the bone to secure healing and prevent recurrence. The alternative is to avoid weight bearing and use crutches for six to eight weeks until the fracture has healed, which has only a 75 percent success rate. The spiral oblique fracture will usually heal without surgery, although some displacement might occur. Boxer’s fractures rarely require treatment aside from PRICE (protection, rest, ice, compression, and elevation) and activity restrictions.
Return to Action
Nonsurgical fifth metatarsal fractures are stable injuries. Athletes typically return to full activity within two months from the time of injury. Athletes with a surgically repaired Jones fracture return to sport after a few months, when cleared by the surgeon.
HALLUX RIGIDUS
Common Causes
Hallux rigidus is a condition in which the big-toe joint begins to wear out and becomes painful, stiff, and arthritic. This can occur in one foot or both and is hardly ever caused by a specific injury. Women often have more trouble with hallux rigidus because the use of high-heeled shoes is painful with this condition.
Identification
Athletes who are bothered by hallux rigidus experience pain and stiffness in the big toe. A bump usually forms on the top of the joint and is frequently mistaken for a bunion (see p. 315). Hallux rigidus is easy to differentiate from a bunion by the painful loss of motion that occurs. Bunions do not usually become stiff, whereas loss of motion is the hallmark of hallux rigidus.
Treatment
Once the condition begins, it usually progresses slowly despite treatment. The nonsurgical approach involves footwear that prevents the big-toe joint from being forced to move beyond its limited range of motion. This usually means wearing a modified shoe with a stiff sole and a rocker mechanism that allows one to walk or run without forcing the big toe upward.
If conservative measures fail, surgery for hallux rigidus depends on the severity of the arthritis and pain. In the early stages, osteoarthritis begins in the uppermost part of the joint and over time destroys the whole surface. Procedures that clean out the arthritis and remove the bone spurs work best in the early stages of the condition; but when all or most of the joint has deteriorated, these measures are less successful. Surgical treatment of advanced hallux rigidus presents a difficult problem. The traditional treatment is to fuse the two bones on either side of the toe so the joint no longer exists, but this requires up to three months to fuse and might cause some limitations later. For example, cross-country skiing is very difficult, if not impossible, after fusion surgery because the toe joint will not move upward. Additionally, high heels cannot be worn after fusion surgery. A newer approach is a surgical implant composed of isopropyl alcohol (same as contact lens material). This procedure has shown some greater success than previous implants for the great toe.
Return to Action
Athletes with this condition can be as active as their discomfort allows. They will often be limited in sports requiring jumping (basketball) or explosive bursts of sprinting (tennis). Following surgery athletes can return to play when cleared by the surgeon.
TURF TOE
Common Causes
Turf toe is a violent injury that happens most often in contact sports such as American football, basketball, and soccer when a player falls on another player’s foot and the first metatarsal phalangeal joint is driven upward to an extreme degree, tearing the attachment of the sesamoids under the base of the big toe. The collateral ligaments of the toe can also be injured, along with the cartilage inside the joint.
Identification
Like so many injuries in orthopedics, turf toe is graded I, II, or III, depending on the extent of the damage. Symptoms include pain, swelling, bruising, and difficulty bearing weight on the ball of the foot.
Treatment
Turf toe is a serious injury with potential for long-term disability. Frequently, surgery is required to restore the normal anatomy. Conservative treatments include taping the toe and wearing solid-sole shoes to reduce motion and encourage healing.
Return to Action
Turf toe injuries require a minimum of one month out of sports. Depending on the severity, return to action can take as long as a year from the time of injury.
BUNIONS
Common Causes
Bunions arise from an inherited disorder that causes a bump to form on the inside of the foot at the base of the big toe. This causes the big toe to drift laterally, sometimes causing its distal end to cross under the second toe. Bunions are much more common in women than men. Narrow footwear, tight-fitting cleats, or training sneakers might exacerbate this condition, but they do not cause it. A traumatic bunion is an increasingly common injury in which the big toe is bent upward similarly to turf toe injury, but also with a valgus or forcing of the big toe inward.
Identification
Many people have bunions and are symptom free all their lives. Others experience pain with footwear and forefoot pain with exercise. Pain is typically present on the bump itself or on the sole of the foot of the second metatarsal, where a callus might have formed. There is a misconception that the deformity is often caused by osteoarthritis; this is usually not the case.
Treatment
An athlete with a bunion should wear shoes that accommodate the shape of the feet because most of the pain that occurs is caused by shoe pressure against the bump. Women with bunions often find relief by buying wider sneakers or even men’s shoes, which are wider than those made for women. Commercially available toe spacers can be placed between the first and second toes to alleviate pain when wearing shoes. Many people with bunions choose to have them surgically corrected. The results are usually quite good, and the complication rate is low.
Return to Action
There is no required downtime in most cases. The athlete can be as active as discomfort or pain allows. Return time to sports after surgery is at least three months.
SESAMOID INJURY
Common Causes
Two small bones that lie beneath the big-toe joint are shaped like sesame seeds; these are the sesamoid bones. They lie inside one of the flexor tendons of the toe much as the kneecap lies within the quadriceps muscles. When these bones are injured and painful, the condition is called sesamoiditis. Many factors can make the sesamoids hurt, including a fracture or stress fracture, a separation of the bone, avascular necrosis, and osteoarthritis.
Identification
With sesamoiditis, the athlete experiences progressively increasing pain beneath the great (big) toe. The onset is typically spontaneous and not caused by an injury. The condition is relatively easy to diagnose because of the characteristic symptoms and the specific location of the tenderness on physical exam. However, determining whether the problem was caused by fracture, separation, or sprain of a two-piece sesamoid (many people are born with the sesamoid in two pieces instead of one) or avascular necrosis of the sesamoid can be difficult. In avascular necrosis, for reasons that are poorly understood, the sesamoid dies and can be painful for months before the problem shows on X-ray. Avascular necrosis often follows a stress fracture when the bone, rather than healing, disintegrates. Osteoarthritis of the sesamoids can be painful in older athletes. Exact diagnosis frequently requires a bone scan or MRI.
Treatment
Treatment depends on the diagnosis and can involve anything from an orthosis, which limits the motion in the joint and takes weight off the painful area so it can heal, to a walking boot, crutches, or a bone stimulator. Surgery should be a last resort, but removal of one of the two sesamoids can be safely performed when nonsurgical options have failed.
Return to Action
There is no required downtime in most cases. The athlete with a sesamoid injury can be as active as discomfort or pain allows. Return time to sports after surgery is at least a month.
TENNIS TOE
Common Causes
Tennis toe is a black toenail that forms as the result of a contusion or bruise under the toenail, usually of the second toe or whichever toe is longest. The condition is really a blood clot caused by wearing shoes that are too small or by not lacing the shoe up tightly enough to hold the foot back in the shoe. As a result, the toe slips forward and hits the tip of the toe box.
Identification
Diagnosis is made on inspection of the foot once the toenail turns black. The athlete experiences pain, but the injury is not serious.
Treatment
The best treatment is to leave the toe alone. The nail will come off once a new nail has grown in beneath it.
Return to Action
There is no required downtime with tennis toe. The athlete can be as active as discomfort allows.
FREIBERG’S DISEASE
Common Causes
In Freiberg’s disease, the head of the second metatarsal dies. This condition is most commonly seen in female athletes in their 20s. The precise cause is unknown, but the disease is an example of avascular necrosis—death of bone caused by lack of blood supply. You sometimes see this occur in other bones in the body, including the foot, ankle, knee, or wrist.
Identification
Freiberg’s disease is characterized by chronic pain and stiffness in the middle of the forefoot. Weight bearing and sports activity can be painful. Initial X-rays might be normal, but repeat X-rays taken several months later because of persistence of symptoms might show the disease with flattening of the metatarsal head. When Freiberg occurs in the foot, it is not associated with problems elsewhere.
Treatment
If orthotic management is unsuccessful, surgery might be required to correct the condition.
Return to Action
There is no required downtime in most cases. Athletes may be as active as their pain or discomfort allows. Return to sport after surgery takes at least two months.
FOREFOOT NEUROMAS
Common Causes
A neuroma is caused by a pinched or irritated nerve. Several different types of neuromas can occur throughout the body. Morton’s neuroma is common in women. It usually occurs in the third web space of the foot between the third and fourth toes (80 percent), and less frequently (20 percent) in the second web space between the second and third toes. Morton’s neuroma is usually caused by wearing shoes that are too tight, but also can be hereditary. Joplin’s neuroma occurs adjacent to the medial sesamoid below the inside of the big toe; it is commonly seen in runners who pronate or roll in with their stride.
Identification
Neuromas cause distinctive and localized pain, often described as numbness, tingling, stinging, or pain radiating either up or down the foot. In the case of Morton’s neuroma, the pain radiates into the toes and is characteristically relieved by removing shoes and massaging the foot. Joplin’s neuroma is often confused with sesamoid pain (see p. 316); the pain in this case tends to radiate up and down the medial side of the foot.
Treatment
Initial treatment consists of wearing shoes with a wide toe box or orthoses. If this fails, cortisone injections are recommended. If these measures fail, surgical removal is recommended. Treatment for Joplin’s neuroma includes wearing shoes with a wider toe box to prevent rubbing of the shoe against the irritated nerve.
Return to Action
There is no required downtime with this condition. Athletes may be as active as pain or discomfort allows. Recovery time after surgery is at least a month.
SECOND METATARSOPHALANGEAL JOINT INSTABILITY
Common Causes
Second metatarsophalangeal (MTP) joint instability refers to a laxity of the MTP joint. This is caused by stretching of the ligaments of the joint, especially the plantar plate ligament, which connects the metatarsal to the phalanx bones on the undersurface of the joint. Causes can include repetitive athletic activities such as running, foot deformities such as a bunion, and other inflammatory conditions.
Identification
Pain is typically under the ball of the foot, most often near the second toe. The drawer test—stabilizing the metatarsal and pushing the toe upward—elicits pain with this condition. On weight bearing, the athlete can have some elevation or sideways drift to the toe compared to the opposite foot. This condition often is misdiagnosed as a neuroma.
Treatment
Treatment starts with a cross-taping of the toe to provide stability, as well as use of an orthotic with a metatarsal pad. Rocker sole shoes can unload the forefoot, but ultimately there are surgical ways to repair the plantar plate if pain and instability persist.
Return to Action
Taping and use of an orthotic with a metatarsal pad typically allow a quicker return to sports. If surgical intervention is required, return to sporting activity can take 10 to 12 weeks.
Common Causes
Tarsal coalition is a congenital anomaly in which the bones of the hindfoot and midfoot are not free to move but rather are fused together. Coalitions are thought to occur in 1 to 2 percent of the population, but only 25 percent of these people have symptoms. The common coalitions in the foot are the calcaneonavicular (CN), and the talocalcaneal (TC).
Identification
The athlete will present with pain, spasm, limited range of motion, and frequent foot and ankle injuries. Often in adults with coalition, the position of the hindfoot is normal when compared to a younger patient, where the hindfoot is in a more valgus, or flattened, position.
Treatment
In the short term, a walking cast or boot can help decrease the pain. Orthotics, physical therapy, and nonsteroidal anti-inflammatory drugs (NSAIDs) can be beneficial. If these measures fail, then surgically resetting the coalition or fusing the subtalar joint if the coalition is very large can resolve the pain.
Return to Action
Usually orthotics and NSAIDs can allow the athlete to return to activities after four to six weeks. Surgery to excise a smaller coalition provides a better chance of returning to athletics compared with the need for fusion surgery.
CORNS
Common Causes
Among the several types of corns are hard corns, soft corns, and seed corns. Hard corns form on the top surface of the toes where friction occurs between the skin and the shoe. They tend to build up with time. Soft corns occur in the web spaces in between the toes, usually between the fourth and fifth toes. They are caused by wearing shoes that squeeze the toes together. Seed corns, which are related to cholesterol plaques, are a kind of corn typically found on the sole of the foot.
Identification
All corns tend to cause significant pain and discomfort. Hard and soft corns usually build up in layers like onion skin. A seed corn, however, dives inward and forms a little white nidus that acts much like a splinter. Seed corns are easily identified by the presence of a little white dot in the center of the corn.
Treatment
Hard corns can be controlled by wearing corn pads and rubbing the corns down occasionally with a pumice stone. Soft corns usually will need to be trimmed and can often be controlled by wearing lamb’s wool or cotton between the toes. In chronic conditions, surgery might be required. Immediate relief is obtained for seed corns when the little white nidus is removed by a professional in the office setting.
Return to Action
There is no required downtime with this condition. Athletes may be as active as pain or discomfort allows.
FUNGAL INFECTIONS
Common Causes
Athlete’s foot and onychomycosis are both caused by fungal infections. Athlete’s foot is usually spread in moist areas such as locker rooms and showers. Onychomycosis is a specific type of athlete’s foot that grows under the toenails and is very resistant to treatment. It is typically not a serious problem, but it is an unsightly one.
Identification
Athlete’s foot causes dry, itchy, and flaking skin in between the toes. More severe cases may include scaling, blistering, pain, or swelling. If untreated, the symptoms may spread to the sole and top of the foot and the toenails. Scratching the feet and then touching other parts of the body can spread the infection to these areas (e.g., groin, knees, elbows, or underarms). Athletes with onychomycosis typically have deformed, discolored, and rigid toenails that resist normal grooming.
Treatment
Good foot hygiene should be maintained. Keep the feet clean and dry, change socks daily, allow shoes to air out before wearing again, and do not walk barefoot (wear sandals or flip-flops) when walking in potentially contagious areas such as the locker room. Topical antifungal medications are often required. Depending on how chronic and severe the symptoms are, an oral antifungal medication may be prescribed.
Many varieties of local medications have been tried for the problem of onychomycosis, but all have failed. The only effective way to get rid of this infection is to take an oral antifungal medication regularly for at least three to six months. However, these drugs are potentially damaging to the liver, so people taking this medicine need to have their liver function tested every six weeks to ensure they are not harming the liver. Because of this potential side effect, many people feel the cure is worse than the problem.
Return to Action
During treatment, athletes with athlete’s foot or onychomycosis should avoid walking barefoot in locker rooms to prevent spreading the infections. Otherwise, they may be as active as pain or discomfort allows.
TARSAL TUNNEL SYNDROME
Common Causes
There are two bumps (malleoli) on the ankle, one on the inner side and one on the outer side. Behind the inner bump, there is a tunnel through which several structures pass, including the posterior tibial nerve. Tarsal tunnel syndrome occurs when this tunnel is compressed and the posterior tibial nerve becomes irritated. Common causes of tarsal tunnel syndrome are altered biomechanics and trauma. Contributing factors include excessive pronation, posterior tibial tendon deficiency, and space-occupying lesions such as cysts or varicosities.
Identification
Athletes with tarsal tunnel syndrome typically experience vague pain on the inner side of the ankle. Numbness, tingling, burning, and a “funny” sensation on the inner side of the ankle may also be present. These symptoms may radiate into the arch of the foot. Symptoms usually improve with rest and worsen when one is running or engaged in other weight-bearing activities.
Treatment
Orthotics can be helpful to correct symptoms stemming from a biomechanical problem such as hyperpronation or flat feet. Sometimes an injection of steroid into the tunnel helps calm the inflammation. If conservative treatment is not effective, surgical decompression of the tunnel may be necessary.
Return to Action
Return to sport following tarsal tunnel syndrome depends on the underlying cause. Return to sport may occur once the athlete has full, pain-free range of motion and an activity challenge that does not reproduce the symptoms. Conservative treatment allows the athlete to return to sports in as little as two to three weeks, as symptoms abate. Depending on the type of procedure, surgical treatment may require that the athlete be out for two to three months.
SHOELACE PRESSURE SYNDROME
Common Causes
Shoelace pressure syndrome occurs when the athlete ties shoelaces too tightly or when the tongue and top of the footwear is too snug.
Identification
Shoelace pressure syndrome causes pain, numbness, or tingling at the top of the foot where the shoelaces are tied. The symptoms may radiate toward the toes.
Treatment
Once other causes of the symptoms are ruled out by appropriate diagnostic studies, simply tying the shoelaces less tightly may relieve the symptoms. Remember, the feet swell during the day. Athletes should try on and purchase running or athletic shoes late in the day and wear socks that are similar to those that will be worn during running or participation in their sports.
Return to Action
If no other problems exist, the athlete may return to sport with shoes that fit properly.
PURPLE TOE
Common Causes
Purple toe, similar to tennis toe (see p. 317) but affecting the entire toe rather than just the nail, results from repetitive banging of the nail into the front of the shoe. This repetitive trauma results in minimal bleeding beneath the nail bed. It is seen in long-distance runners and in those who wear shoes with rigid toe boxes.
Identification
Purple toe causes a purple discoloration of the toe and throbbing pain in the toe. The toe may also be somewhat swollen. The first and second toes are most often affected.
Treatment
For this condition, PRICE is helpful. Appropriate modification of footwear is often necessary to provide more support and take pressure off the toe. The toe box should not be too rigid. An orthotic may also be required. Often, this condition is solely related to overuse (i.e., too many strides).
Return to Action
Once the athlete has full, pain-free range of motion and the underlying cause has been addressed (e.g., footwear, biomechanics), it is permissible to return to sport.
TALON NOIR
Common Causes
Repetitive jumping, cutting, twisting, or turning can lead to shear stresses on the small blood vessels within the skin of the heel. When these blood vessels bleed, they cause a darkening in the heel, which is known as talon noir, or black heel. It is most commonly seen in young athletes and in runners, weightlifters, tennis players, and mountain climbers.
Identification
Talon noir typically causes painless blue or black dots or discolorations on the back or bottom of the heel. Although they may not feel them, athletes may notice them and be worried about them.
Treatment
No treatment is generally required for these asymptomatic discolorations, but a heel pad may help the lesion disappear more quickly. Athletes should consult a physician if the lesion persists for more than a week to make sure that it is not something more serious such as a malignant skin cancer.
Return to Action
The athlete may continue to participate in sports with this asymptomatic lesion.
*The authors would like to acknowledge the contribution of Andrew A. Brief to this chapter.
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