The Foot
Skin and Nails
14.1 Blisters
Phy Sportsmed 2004;32:36; Curr Sports Med Rep 2002;1:319
Cause: Repeated friction on the skin surface.
Epidem: Common, potentially debilitating injury; often occur early in the season.
Pathophys: Acute response to high-intensity stress, which produces a shear force which separates the skin into 2 layers; the space fills w fluid secondary to hemodynamic forces.
Sx: Pain.
Si: Vessicle, which may be filled w blood or purulent fluid; tender to palpation.
Crs: May rupture w persistent activity.
Cmplc: May become infected.
Rx:
Prevention includes appropriately fitted shoes and socks, padding hot spots, lubricants.
Acute treatment includes possible drainage, use of a blister care product (second skin, sports patch, etc.), antibiotic ointment, and protective padding.
Care must be taken to keep the site clean to avoid infection.
14.2 Subungal Hematoma
Am Fam Phys 2005;71:856; J Am Acad Dermatol 2003;48:58
Cause: Improperly fitted shoes; downhill running; direct trauma.
Epidem: Common in long-distance runners.
Pathophys: Shearing or crushing injury in which there is bleeding under the toenail.
Sx: Pain.
Si: Blood under the nail; may be tender.
Crs: Gradually resolves. The nail may fall off at some future point.
Cmplc: Loss of the nail; subsequent nail abnormality.
X-ray: Rule out fracture in cases of direct trauma.
Rx:
Appropriately fitted shoes may prevent this problem.
If hemorrhage is acute and painful, it can be relieved by drilling a hole in the nail, using a heated 18-g needle or the end of an opened paperclip or a battery-operated cautery (beware of converting a closed fx to an open fx).
A sterile dressing should be applied.
Forefoot Problems
14.3 Hallux Valgus
DeLee and Drez’s Orthopaedic Sports Medicine. Philadelphia: WB Saunders 2003;2483; Textbook of Running Medicine. New York: McGraw-Hill 2001;218
Cause: Previous injury; congenital factors.
Epidem: Congenital and familial factors; previous injury, ie, first MTP dislocation, turf toe, rupture of the joint capsule; overpronation.
Pathophys: Lateral deviation of the proximal phalanx on the first metatarsal; the medial aspect of the head of the first metatarsal enlarges and the overlying bursa becomes inflamed and thickened (bunion).
Sx: Pain; deformity.
Si: Deformity of the first MTP joint; may be tender to palpation.
Crs: Valgus deformity may progress.
X-ray: Valgus deformity of first MTP joint; degenerative joint disease.
Rx:
Shoes with a wide toe box; padding around the metatarsal prominence.
Orthotic devices if overpronation or Morton’s toe are present.
Surgery for persistent pain despite conservative management.
14.4 Turf Toe
DeLee and Drez’s Orthopaedic Sports Medicine. Philadelphia: WB Saunders 2003;2504; Clin Sports Med 2004;23:115
Cause: Hyperextension of the first MTP joint.
Epidem: Flexible shoes and faster playing surfaces increase the incidence of this injury.
Pathophys: Injury to the capsuloligamentous complex of the first MTP joint secondary to hyperextension of the joint.
Sx: Pain, especially w ambulation.
Si: Pain w passive extension of the first MTP joint; swelling and ecchymosis may be present.
Grade 1: pain in plantar and medial aspect of MTP joint, minimal swelling.
Grade 2: increased pain swelling and ecchymosis.
Grade 3: severe pain, marked swelling and ecchymosis.
Crs: Gradual improvement w treatment.
Cmplc: Persistent pain; joint instability.
X-ray: Usually neg; small avulsion fracture may be present.
Rx:
Rest, ice, elevation, NSAIDs:
Grade 1: shoe w stiff sole or orthoses with Morton’s extension; taping.
Grade 2: same as grade 1; return to activity when sxs diminish (1-2 wks).
Grade 3: crutches for several d; orthoses with Morton’s extension; physical therapy modalities; return to activity in 3-6 wks; if sxs of persistent pain, joint instability and swelling, surgery may be required.
14.5 Hallux Rigidus
Clin Sports Med 2000;19:33; Textbook of Running Medicine. New York: McGraw-Hill 2001;217
Cause: Degenerative changes of the first MTP joint.
Epidem: Congenital abnormalities; osteochondritis of the metatarsal head; overpronation; trauma.
Pathophys: Painful restricted motion of the first MTP joint secondary to degenerative changes.
Sx: Pain with walking or running.
Si: Pain and swelling of the first MTP joint; restricted extension; pain w forced extension; palpable bony ridge along the dorsal aspect of the joint.
Crs: Pain w activity may increase as degenerative changes progress.
Cmplc: Tendonitis, plantar fasciitis (see 15.19) or other injury secondary to compensation for altered gait.
X-ray: Bony exostoses and degenerative joint disease.
Rx:
Shoes with wide toe box and rigid sole.
NSAIDs.
Rocker bottom shoe.
Surgery.
14.6 Sesamoid Problems
Clin Sports Med 2000;19:34; DeLee and Drez’s Orthopaedic Sports Medicine. Philadelphia: WB Saunders 2003;2510
Cause: Acute or overuse injury.
Epidem: Repetitive stress or landing on the first MTP joint; increased incidence w pes cavus.
Pathophys: Inflammation or fracture of one of the sesamoids:
Sesamoiditis: tendonitis, bursitis, or chrondromalacia.
Sesamoid stress fracture: similar to sesamoiditis, w persistent pain despite conservative management; pos bone scan.
Acute fracture: usually a transverse compression fracture of the medial sesamoid caused by landing on the ball of the foot.
Sx: Acute or insidious onset of pain; pain w toe-off.
Si: Pain on palpation of one of the sesamoids (typically medial); swelling may be present; painful and possibly restricted extension of the great toe.
Crs: Persistent or worsening symptoms without treatment; often requires prolonged course of treatment.
Cmplc: Persistent pain despite treatment; nonunion of fracture.
X-ray: (Sesamoid view) May demonstrate an acute fracture or stress fracture which has been present for several wks. Bone scan or CT is useful if plain radiographs are neg, but sxs are suggestive of an acute or stress fracture.
Rx:
Sesamoiditis:
Ice.
NSAIDs.
Padding to unload the first metatarsal head.
Semi-rigid orthoses.
Sesamoid stress fracture:
Short leg walking cast for 6 wk.
Use of orthoses to unload the metatarsal head upon return to sports; acute sesamoid fracture: short leg walking cast for 6 wk or taping toe in neutral position, w padding proximal to the sesamoids and use of a wooden soles postoperative shoe. If there is nonunion of a fracture, and/or persistent pain, surgical excision or partial excision may be necessary.Related posts:
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