Overuse and Miscellaneous Conditions of the Foot and Ankle

I. ACHILLES TENDINOPATHY encompasses both inflammation and degeneration if present in the peritenon or tendon area.

A. Insertional type may be associated with a Haglund deformity or retrocalcaneal bursitis. This is a typical overuse injury caused by accumulated impact load,¹ which occurs most often in runners and repetitive jumpers. Insertional type occurs more in an older age group than does noninsertional tendinopathy.

Treatment will be conservative in 95% of cases. Rest, analgesics, cross training, physiotherapy, orthotics with a heel lift, and occasionally, casting could all be used. Steroid injections are very seldom indicated.^2,3
Surgery is indicated after 6 to 12 months of failed conservative treatment. It should address the following: excise retrocalcaneal bursa, resect superior calcaneal prominence, and debride the diseased or calcified portion of the tendon. Reattach if necessary. The patient should be nonweightbearing for 6 to 8 weeks. Rehabilitation is resumed but recovery might take up to 1 year. Success rate is 70% to 86%.⁴

B. Noninsertional type is very frequently related to the hypovascular zone of the Achilles tendon 2 to 6 cm proximal to its insertion. The most common profile includes repetitive microtrauma, males, older athletes, tight gastrocsoleus complex and hamstrings, functional overpronation. Extrinsic factors include improper training, improper shoe wear, systemic or injected steroids, and fluoroquinolone antibiotics.⁵ There are various classification systems that can be simplified into peritendonitis (sheath only), tendinosis (tendon only), or pantendinitis (sheath and tendon).⁶ Diagnosis is primarily by history and clinical evaluation and is confirmed by ultrasound (operator dependent) or magnetic resonance imaging (MRI). Typical signs and symptoms are morning stiffness or pain, start-up pain, postexercise pain, and tendon fullness or the presence of a nodule.

Treatment in acute situations includes pain relief, analgesics, ice, and restriction of activities. A heel lift or boot brace can be used until symptoms subside,² followed by a rehabilitation program.⁷ Other measures include stretching and strengthening of the Achilles and gastrocsoleus complex, eccentric muscle-tendon strengthening review, and modification of training regimens (reduce frequency, duration, and intensity and focus on low-impact activities), correction of structural abnormalities (overpronation), and modifications in foot wear. Treatment is 90% to 95% successful, but it usually takes 2 to 6 months to recover from an Achilles tendinopathy.
Treatment of chronic cases (>3 months) depends on severity. Peritendinitis is treated with mechanical “brisement” or surgical debridement followed by an early rehabilitation program.⁷ Chronic pantendinitis is treated with debridement, longitudinal tenotomy,⁸ or tendon transfer depending on the clinical situation. It appears from the literature that surgical treatment of chronic tendinitis may have better outcomes than nonoperative treatment.

II. PLANTAR HEEL PAIN is a common foot problem in the athlete. Running and jumping place repetitive stress on the heel and create an overuse syndrome with chronic inflammation.

A. Differential diagnosis. To differentiate, a thorough history and examination is required. This should include exact location and duration of pain and the relationship to athletic activity. Chronic pain at rest is unusual and might be due to a neoplasm. The differential diagnosis includes the following:

Plantar fasciitis—By far the most common reason for plantar heel pain
Nerve entrapment
Fat pad atrophy
Heel bruise
Tenosynovitis of flexor hallucis longus or flexor digitorum brevis
Stress fracture
Tumor

B. Plantar fasciitis could be at the insertion into the medial calcaneal tuberosity or midsubstance at the midfoot area and may be due to repetitive traction and microtears. Usually, plantar fasciitis has an insidious onset as an overuse condition in long distance runners. Midfoot plantar fasciitis is more common in sprinters who run on their toes. Generally speaking, it has a better prognosis.

Symptoms and signs include pain during the first minutes of walking, especially when first getting out of bed. Pain may subside with low-intensity walking but then recur with prolonged or more vigorous activities.
Always evaluate for leg length discrepancy. Heel pain is more common in the shorter leg and may be treated with an appropriate lift. Also inquire about a functional short-leg syndrome from running on the same slope of the road. Plantar fasciitis is frequently caused by a shortened Achilles tendon because limited ankle dorsiflexion increases the stress on the plantar fascia. Fasciitis at the insertion has localized deep tenderness. It is usually associated with increased pain with passive dorsiflexion of the toes (windlass mechanism). Midfoot fasciitis has tenderness in midfoot and increased pain with passive dorsiflexion of the toes. Passive dorsiflexion of the big toe aggravates both plantar fasciitis and flexor hallucis longus tendinopathy. Pain with resisted flexion of the big toe is painful only with involvement of the tendon.

C. Treatment

Conservative. The cornerstone of treatment is modification in training, for example, reducing mileage, shortening workouts, and alternating activities such as low-resistance cycling and swimming pool running.⁹ There is not a single entity that works for everyone, but conservative measures usually include the following:

a. A shock-absorbing heel cup for heel pain or a full length orthotic or University of California Berkeley Laboratory (UCBL) orthotic for midsubstance pain.

b. Although not proven uniquely effective, analgesics, as they do decrease pain.

c. Physical therapy to include Achilles and plantar fascia stretching, hindfoot taping, contrast baths, and ultrasound treatment.

d. A night dorsiflexion splint might help to keep the fascia under tension to reduce early morning weightbearing pain. It is felt by the authors to be the corner stone of the treatment for plantar fasciitis.

e. Injections may be used in refractory cases. This has historically been done with steroids, although steroids pose a small risk of plantar fascia rupture. Consistent with the fact that this has been noted to be a degenerative rather than an inflammatory process, there are no data demonstrating that the anti-inflammatory component of the steroid is necessary. For these reasons, many physicians are moving away from injections, or injecting, but without the steroid component.

f. Shockwave therapy, which tries to spur on inflammatory response, has proven to be helpful. The economics of health care have put a limitation on the availability of such treatment modality. The heel spur seen on plain radiographs is seldom, if ever, the cause of heel pain.

2. Surgical. Plantar fascia release should be avoided in competitive athletes because it may increase the compressive forces to the dorsal aspect of the midfoot and decrease flexion forces on the metatarsophalangeal (MTP) joint complex.¹⁰ When indicated, the plantar fascia is released from the calcaneus through a medial incision. The patient is allowed to bear weight as tolerated with crutches, and rehabilitation is started after 2 weeks.

D. Calcaneal fat pad trauma. The patient complains of diffuse plantar heel pain that is exacerbated with weight bearing and with activities on hard surfaces.

Examination reveals diffuse tenderness localized to the fat pad. There is no radiation of the pain. The heel pad feels soft and thin, and the underlying calcaneus is palpable.
Treatment is nonsurgical. A cushioned heel cup and shock-absorbing shoes might help. The patient should reduce activities and avoid hard running surfaces. Several months may be required to resolve the constellation of symptoms.

E. Nerve entrapment syndromes

Entrapment of the first branch of the lateral plantar nerve is a common cause of chronic heel pain in athletes.¹¹ The site of compression is between the deep fascia of the abductor hallucis muscle and the medial margin of the quadratus plantae muscle. This injury is more common in athletes who spend a significant amount of time on their toes such as ballet dancers, figure skaters, and sprinters.

a. Diagnosis is made on clinical grounds. Exclude the more common reasons for heel pain. Early morning pain is less problematic; the pain increases as the day goes on. Tenderness is specific over the area of compression and may radiate down toward the toes (the Tinel sign).

b. Treatment is similar to that for other causes of heel pain. If conservative treatment fails, a release of the nerve may be done through a medial incision.

2. Tarsal tunnel syndrome could also be a source of heel pain. Compression of the posterior tibial nerve within the tarsal tunnel results in tenderness over the area that may shoot down toward the toes on the plantar aspect of the foot. Excessive pronation in long-distance runners may place repeated stress on the medial structures of the hindfoot.

a. On examination, there might be burning, pain, or tingling on the plantar aspect of the foot. Pain is more diffuse than with the other causes of heel pain. Electromyography studies along with a Tinel sign (electric shocks down the foot with tapping of the tibial nerve) and a highly suggestive clinical history are critical for the diagnosis of tarsal tunnel syndrome.

b. Treatment. A medial heel wedge or an arch support may decrease the tension on the medial side of the ankle and therefore the nerve. Physical therapy can also improve the biomechanics. Steroid injection into the tarsal tunnel might give short-term pain relief. Tarsal tunnel release is helpful in recalcitrant cases.

3. Metatarsalgia

a. Metatarsalgia or pain over the metatarsal heads is the most common forefoot problem. It typically occurs on the second metatarsal head and can have numerous etiologies.

A tight or shortened Achilles tendon limits ankle dorsiflexion, which, in turn, increases the forces on the forefoot. A person compensates using the long toe extensors to augment dorsiflexion power, but this pulls the plantar fat pad away from the weightbearing surface under the metatarsal heads, further aggravating forefoot pain.
Similarly, idiopathic claw toe deformities could displace the fat pad and cause metatarsalgia.
MTP joint capsulitis may produce pain over the plantar aspect of the joint. This is more common at the second MTP joint and is associated with a long second metatarsal or instability of the first ray.
A Morton (or common digital nerve) neuroma causes pain in the web space as well. It is most common in the third web space (between the third and fourth metatarsals).

b. The differential diagnosis of midfoot to forefoot pain always includes stress fractures (see IV below)

c. Treatment. The goal is to unload the metatarsal area. Orthotics with metatarsal bars/pads, cushioned shoes, analgesics, and Achilles stretching are the cornerstones of initial management. If conservative management does not help, surgical correction of claw toes or excision of neuroma might be indicated.

III. TIBIALIS POSTERIOR DYSFUNCTION SYNDROME. Rupture of the posterior tibialis tendon (PTT) is a cause of a painful, acquired flatfoot deformity in adults. It is more common in women of age 40 and older.^12–14 Numerous reports describing the condition have been published over the past 20 years, but it still remains a condition that is not commonly recognized. This could be due to the insidious nature of the condition, usually without a history of acute trauma.¹²

A. Anatomy. By virtue of its lever arm length and muscle strength, the PTT is the main dynamic stabilizer of the hindfoot against valgus deformity. It also plays a major role in maintaining the medial longitudinal arch. Insufficiency of the PTT results in excessive strain on the static ligament-bone hind- and midfoot constraints. The soft tissue gradually elongates, the arch flattens, and the peroneus longus and brevis tendons have an unopposed abduction force on the forefoot.

B. Etiology of PTT rupture. To understand the etiology of PTT tears, it is important to remember its function. It resists considerable forces in maintaining the medial longitudinal arch. It also helps locking the mid- and hindfoot to allow a solid lever arm during the push-off part of the gait cycle. Approximately 20% of PTT ruptures are associated with rheumatic conditions.¹² An estimated 80% of PTT ruptures develop spontaneously. There are several theories to explain this phenomenon.