Foot and Ankle Problems in the Endurance Athlete

1. 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

2. DISCLOSURES NONE

3. Foot Problems • Lesser MTP Disorders • Great Toe Disorders • Metatarsal Stress Fracture

4. Ankle Problems • Tendinopathy • Achilles • Posterior Tibial • Peroneal

5. Not this Endurance Athlete!

6. This Endurance Athlete!

7. Foot Problems • Lesser MTP Disorders • Metatarsalgia/MTP Synovitis/MTP Instability • Interdigital neuroma • Great Toe Disorders • Sesamoiditis • Hallux Rigidus • Metatarsal Stress Fracture

8. Foot Problems • Lesser MTP Disorders • Metatarsalgia/MTP Synovitis/MTP Instability • Interdigital Neuroma

9. Lesser MTP Pain • Differential diagnosis extensive • Mechanical • Neurologic • Idiopathic

10. Metatarsalgia • Mechanical • Shoewear • Small toe box • Short shoe

11. Metatarsalgia • Mechanical • MP instability • Often associated with long 2nd MT (Morton’s Foot) • Especially in runner

12. Metatarsalgia • Idiopathic • Overuse syndromes (runners) • Fat pad atrophy (aging)

13. MetatarsalgiaMTP Synovitis MTP Instability • MP Instability • Chronic-Volar plate degeneration • Wide spectrum of presentation • Can be progressive

14. Lesser MTP Pain • Neurologic • Morton’s Neuroma • Mimic or be associated with synovitis • Almost always 3rd web space

15. Lesser MTP Pain • Idiopathic • Freiberg’s infraction • 2>3 MT heads • Occurs in adolescence but symptoms often in adult

16. Metatarsalgia • Examination • Isolated palpation of MT head • Plantar keratosis • Fat pad atrophy

17. MTP synovitis/MTP Instability • Examination • Deformity • Hyperextension/Dislocation • Instability • Lachman’s • Synovitis • Plantarflexion stress

18. Morton’s Neuroma • Examination • Palpate Inter-space (always) • Squeeze Test (majority) • Mulder’s Sign (30%)

19. Biomechanics • Examination • Check for Achilles contracture Increases forefoot pressures!

20. Lesser MTP Pain • Diagnostic studies • Radiographs • Subluxation • Dislocation • Degeneration • MT lengths

21. 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)

22. Shoewear • Neutral • 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

23. 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)

24. 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

25. Treatment • MTP Synovitis/MTP Instability • MTP Injection • Diagnostic &/or Therapeutic • Longstanding/Refractory • Must protect 4 wks in Budin splint

26. 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

27. Summary • Consider all possibilities • Exhaust all non-operative modalities • Surgical Tx warranted after minimum 16 + weeks conservative care

28. Great Toe Disorders • Sesamoiditis • Hallux Rigidus

29. First MTP Anatomy • Tibial & Fibular Sesamoids • FHL & FHB • Plantar Plate • Articular Surfaces • MTP • MT-sesamoid

30. 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

31. 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

32. 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)

33. Sesamoid Disorders • History • Trauma, overuse, idiopathic • Localized plantar 1st MTP pain • Sport/Stairs/High impact worse • Δin shoes/training/mechanics

34. Sesamoid Disorders • Clinical Exam • Specific TTP at tibial &/or fibular • Swelling, warmth, erythema • Plantar pain, +/- crepitus w/ motion • IPK over tibial sesamoid

35. Sesamoid Disorders • Radiographs • Standing AP/bilateral • Axial • Oblique • Marker over area TTP

36. 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

37. 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

38. Sesamoid Fracture • Presentation • Acute • Hyperextension injury • Tibial sesamoid • Transverse frx line, mid-waist • Callus formation • Association with MP dislocation • CT to evaluate displacement

39. Bipartite Sesamoid • Bipartite vs. Acute Fracture (Brown et al. CORR) • Irregular & unequal fragment diastasis • Callus formation • Presence/absence on contralateral side

40. Sesamoid DJD • Post-traumatic • Iatrogenic • s/p bunionectomy • Chondromalacia • Osteophytes • Attritional rupture of abd/adductor H Valgus/Varus

41. 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

42. Bipartite Acute Frx Stress Frx Osteochondritis

43. Sesamoid IPK • Tibial sesamoid • Cavus, PF ray (diffuse) • Sesamoid prominence (localized)

44. 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

46. 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

47. Treatment • Cortisone Injection • Longstanding/Refractory • Flouro guided • Results Highly Variable • Surgical Tx • Failure appropriate non-op tx ≥ 16 wks • Displaced Frx

48. Hallux Rigidus

49. Hallux Rigidus • Second most common condition affecting the hallux MP joint • Termed coined by Cotterill in 1888, after description by Davies-Colley in 1887

50. 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