General Principles
Overview: Injuries and disorders of the foot can impose considerable dysfunction in an athlete. While most foot problems will improve with appropriate care, a clear understanding of normal anatomy and physical examination findings is vital to recognize injuries and abnormal processes to prevent worsening and long-term damage.
Anatomy and Physiology of the Foot
Bones: Normal bony architecture includes 28 bones (7 tarsals, 5 metatarsals, 14 phalanges, and 2 hallux sesamoids) ( Fig. 60.1A ).
Figure 60.1
Bones, muscles, and vessels of the foot.
Accessory bones: Common accessory bones that can create symptoms in athletes are the accessory navicular ( Fig. 60.1B ), os trigonum, and os peroneum.
Muscular anatomy: Most lower leg extrinsic muscles have tendinous attachments on the foot. Foot intrinsic muscles are important for normal function ( Fig. 60.1C ).
Neurovascular structures: Three primary arteries/veins provide blood supply and five primary nerves provide innervation to the foot ( Fig. 60.1C ).
Sport- and Athlete-Specific Issues
Overview: Most foot injuries in athletes are caused by acute or repetitive trauma. Several intrinsic and extrinsic factors can increase the risk of injury.
Intrinsic factors: Foot position, joint laxity and stiffness, nutrition, fitness level, training regimen, biochemical deficiencies, age, and body mass index
Extrinsic factors: Coaching, technique, environmental factors, footwear and equipment, and safety hazards
Running and jumping sports: Increased risk of bone stress injuries, tendinopathies, and fasciopathies
Impact/collision sports: Increased risk of acute fractures, tendon ruptures, and joint injuries
History
Overview: An athlete’s recollection of injury onset, mechanism, and location is an important part of the diagnostic process.
Mechanism: Acute, chronic, or acute on chronic; position of the foot during injury; was a pop felt or heard?
Severity: Was the athlete able to ambulate on his/her own after the injury? Was there an obvious deformity, swelling, or discoloration?
Location: Ask the athlete to indicate “with one finger” the location of the injury, pain, or symptoms.
Previous injury: Has the athlete experienced a similar injury in the past? Tendinopathies can flare up or rupture or bone stress injury can lead to fracture.
Physical Examination
Observation and Measurement
Standing Examination
Alignment of the lower extremities: View the patient from the front and back. Check for limb length inequality, pelvic tilt, genu varum, genu valgum, flexion, extension, and rotational abnormalities of both lower extremities.
Foot alignment and mechanics: Evaluate the medial longitudinal arch for pes planus, pes planovalgus, pes cavus, forefoot abduction, and forefoot varus ( Fig. 60.2A ). Check single- and double-leg heel rise to confirm that the heels invert and arches increase. Evaluate the forefoot for hallux valgus (or varus) and pronation; toe cross-over, cock-up, hammering or clawing of lesser toes ( Fig. 60.2B ); and metatarsus adductus.
Figure 60.2
Physical examination of the toe and deformities.
Gait Analysis
Inspect ambulation: Assess all phases of gait for asymmetric movement on either side of the body, degree of toeing in or out, inversion of the heel, and supination of the foot. Observe the medial longitudinal arch during the stance phase. Assess for antalgic, neuropathic (e.g., steppage), and myopathic (e.g., Trendelenburg) gait and symmetric strength during push-off.
Seated Examination
Visible abnormalities: Note varicosities, erythema, ecchymosis, edema, and muscle wasting.
Vascular: Palpate posterior tibial and dorsalis pedis pulses. Assess capillary refill time. Absence of hair distally may indicate peripheral vascular disease.
Skin: Note the location of callus formation, scars, wounds, blisters, ulcerations, and discoloration. Visualize toenails and nail beds.
Range of motion: Check active and passive ankle, subtalar, and transverse tarsal and first metatarsophalangeal joint (MTPJ) motion; compare them to the uninjured side. Notable crepitus during range-of-motion examination indicates degenerative changes, fracture, or tissue thickening.
Strength testing: Test muscle groups against resistance—dorsiflexion, plantarflexion, inversion, and eversion; compare with the contralateral side.
Palpable Anatomic Structures
Bones: Fifth metatarsal base, peroneal tubercle, first tarsometatarsal joint, navicular tuberosity, head of talus, sustentaculum tali, lateral malleolus, medial malleolus, and metatarsal heads (see Fig. 60.1A )
Ligament attachments: Calcaneofibular ligament, anterior talofibular ligament, superficial deltoid ligament, spring ligament, and plantar fascia (see Fig. 60.1C )
Tendons: Posterior tibialis, flexor hallucis longus (FHL), anterior tibialis, peroneal brevis and longus, extensor hallucis longus, and Achilles (see Fig. 60.1C )
Bursae: Calcaneal, retrocalcaneal
Special Tests/Signs
Thompson test: Patient prone with affected leg extended; squeeze calf muscles to indirectly plantar flex the foot; failure of the foot to plantarflex (a positive test)
Abduction stress test: Manual abduction of the forefoot while stabilizing the hindfoot; assess for pain clinically and widening of Lisfranc joint on radiographs
Calcaneal compression text: Squeeze the posterior heel simultaneously from medial and lateral sides. Pain is a positive test and suggests stress fracture.
Too many toes sign: View the patient from behind, three or more toes visible lateral to the heel suggests forefoot abduction, often seen with posterior tibial tendon or spring ligament dysfunction (see Fig. 60.2A )
Peek-a-boo heel sign: Viewed from the front, indicates hindfoot varus alignment ( Fig. 60.3 )
Figure 60.3
Peekaboo heel sign in hindfoot varus.
Common Injuries and Disorders of the Foot
Skin and Nail Problems
For details, see Table 60.1 , Fig. 60.4 , and Chapter 40 , Skin Problems in the Athlete.
| Type | Cause | Signs and Symptoms | Treatment |
|---|---|---|---|
| Calluses and corns | Excessive localized friction or pressure from tight shoes or structural abnormalities of feet, such as hammer toes | Pain; thickening and hardening of skin (soft corns between toes due to moisture) | Appropriate shoe fitting, padding (e.g., doughnut pad), pumice stone, resection of bony prominences, metatarsal pad, Budin splint |
| Blisters | Friction, pressure Epidermal/dermal separation by serous fluid | Painful vesicles | Unruptured: sterile dressing, pressure relief Ruptured: sterile cleansing, dressing (consider antibiotics for diabetic patients or signs of infection in any patient) |
| Warts | Virus (papilloma) | Pain at site; skin thickening with central core; flat or raised | Trichloracetic acid or salicylic acid, liquid nitrogen |
| Tinea pedis (athlete’s foot) | Fungus | Dry or vesicular lesions; scaling, peeling, and cracking fissures in skin; deformed nails, hyphae, and buds on KOH wet mount | Dry: miconazole, clotrimazole, terbinafine, salicylic acid Vesicular: wet dressings with Burrow’s solution Erythema or other signs of infection: consider antibiotics |
| Paronychia | Soft tissue infection around the nail | Inflamed nail margin with or without drainage | Warm water soaks, antibiotics; partial nail resection; appropriate nail-cutting techniques |
| Subungual hematoma | Trauma | Dark blood under nail; pain/pressure at site | Drainage (insert no. 18 needle or drill sterilely through nail) Note: ensure traumatic history to distinguish from subungual melanoma |
Tendinopathies ( Table 60.2 )
Etiology: Repetitive or abnormal stress on a tendon causes macrotears (acute trauma) or microtears (chronic overuse) with resulting inflammation (tendinitis) and ultimately tendon degeneration (tendinosis).
Common tendinopathies: Posterior tibial, Achilles, peroneal, anterior tibial, and FHL tendinopathy
Diagnostic considerations: Plain radiographs show alignment, mechanical risk factors, bony avulsions, and bony contributions (e.g., Haglunds and/or calcification at Achilles tendon insertion). Magnetic resonance imaging (MRI) and ultrasound best to assess tendon status and confirm partial or complete ruptures
Treatment: Most tendinopathies will resolve with rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and addressing the risk factors. Acute tendon ruptures should typically be repaired in athletes (i.e., Achilles, posterior tibial, anterior tibial); peroneal tendon transfer can be considered in attritional peroneal ruptures; surgery for tendinopathy only if conservative treatments fail
| Type | Signs and Symptoms | Treatment |
|---|---|---|
| Posterior tibial tendinitis | Medial arch pain, swelling, pain with resisted inversion, painful or inability to perform single heel rise, medial arch collapse, “too many toes sign”: when viewed from behind, abducted forefoot allows more toes to be seen on the affected side |
|
| Peroneal tendinitis | Lateral pain, particularly with active and resisted eversion; swelling; may complain of snapping sensation in cases of peroneal tendon subluxation; may be due to underlying tendon tear |
|
| Anterior tibial tendinitis | Pain in anterior medial foot, worse with active dorsiflexion; swelling and crepitation; seen in runners, hikers, and racquet sports |
|
| Achilles tendinitis | Decreased gastrocnemius flexibility; pain, tenderness, swelling, and crepitation; pain with active plantarflexion; radiographs to look for Haglund’s deformity or insertional calcifications |
|
| Retrocalcaneal bursitis | Posterior heel/ankle pain; tenderness and swelling in bursa located between the Achilles tendon and the calcaneus |
|
| Sesamoiditis | Generic term; local tenderness (tibial side most common); pain worse with weight bearing; rule out avascular necrosis, sesamoid fracture. Bipartite sesamoid reported 10% tibial, rare fibular |
|
| Metatarsophalangeal joint synovitis | Pain at metatarsophalangeal joint (second most common), positive Lachman test (increased anterior-posterior translation), and joint crepitus; distinguish from interdigital neuroma |
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