eMedicine Specialties > Sports Medicine > Foot and Ankle

Athletic Foot Injuries

Timothy J Rupp, MD, FACEP, Associate Medical Director, Physicians Emergency Care Associates, Methodist Health System, Dallas, Texas; Staff Physician, Innovative Emergency Medicine, Frisco, Texas; Staff Physician, Department of Emergency Medicine, Children's Medical Center of Dallas, Dallas, Texas
Steven Karageanes, DO, Director, Primary Care Sports Medicine Fellowship, Director, Sports Medicine Education, Center for Orthopedics and Neuroscience; Department of Medical Education, Oakwood Healthcare System
Contributor Information and Disclosures

Updated: Jun 18, 2008

Introduction

Background

Athletic foot injuries can be difficult to properly diagnose and treat. Bearing the weight of the entire body, the foot is under tremendous stress. In many sports, the foot absorbs tremendous shearing and loading forces, sometimes reaching over 20 times the person's body weight. Physicians who treat these disorders must have a good understanding of the anatomy and kinesiology of the foot.

Although foot injuries can occur from a variety of causes, the most common cause is trauma. Other etiologies include (1) rapid or improper warm-up, (2) overuse, (3) intense workouts, (4) improper footwear, and (5) playing on hard surfaces.^{1, 2, 3, 4, 5}

Physicians who evaluate and treat common foot problems should have a working knowledge of the individual sports and the injuries that are commonly associated with them. An understanding of the basic treatment approaches for these injuries also is imperative.

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center and Sports Injury Center. Also, see eMedicine's patient education articles Broken Foot and Broken Toe.

Frequency

United States

Estimates indicate that 15% of sports-related injuries affect the foot alone.

Functional Anatomy

Foot and ankle

The foot is composed of 26 major bones, which can be divided into 3 regions: the forefoot, midfoot, and hindfoot. The forefoot is comprised of the 5 metatarsals and the 14 phalanges. The 3 cuneiforms (ie, lateral, intermediate, medial), the cuboid, and the navicular represent the midfoot. The hindfoot is composed of the talus and the calcaneus (see Image 1).

• The talus is oriented to transmit forces from the foot through the ankle to the leg.
• The calcaneus is the largest bone in the foot. The Achilles tendon inserts on the posterior aspect of the calcaneus.
• The navicular lies anterior to the talus and medial to the cuboid.
• The cuboid articulates with the calcaneus proximally, with the fourth and fifth metatarsals distally, and with the lateral cuneiform medially.
• Each of the cuneiform bones is wedge-shaped. The medial, intermediate, and lateral cuneiform bones articulate with the first 3 metatarsals distally and the navicular proximally. The cuboid articulates with the lateral cuneiform.
• The 5 metatarsals articulate with the proximal phalanges.
• The great toe is composed of 2 phalanges, with 3 for each lesser toe.
• Although variation exists in the number and location of the sesamoid bones, 2 constant sesamoids are present beneath the metatarsal head. The sesamoids are usually present within tendons juxtaposed to articulations.

Select tendons of the foot (see Image 2)

• The flexor hallucis longus (FHL) tendon is 1 of 3 structures that lie in the tarsal tunnel. Running behind the medial malleolus, the FHL is the most posterolateral. The FHL runs anterior to insert onto the distal phalanx of the great toe. The FHL acts as a flexor of the great toe, elevates the arch, and assists with plantar flexion of the ankle.
• The flexor digitorum longus (FDL) tendon passes between the FHL and tibialis posterior tendon. The FDL inserts onto the distal phalanges of the 4 lateral digits and acts to flex the distal phalanges.
• The tibialis posterior tendon is the most anteromedial of the tarsal tunnel tendons. This tendon inserts on the navicular tuberosity; the 3 cuneiforms; the cuboid; and the second, third, and fourth metatarsals. The tibialis posterior muscle flexes, inverts, and adducts the foot.
• Laterally, the peroneus longus and peroneus brevis tendons share the common peroneal tunnel running behind and around the lateral malleolus. The peroneus longus plantar flexes the first metatarsal, flexes the ankle, and abducts the foot. The peroneus brevis flexes the ankle and everts the foot.

Other important structures

• The plantar aponeurosis or fascia is a deep span of connective tissue extending from the anteromedial tubercle of the calcaneus to the proximal phalanges of each of the toes. Medial and lateral fibrous septa originate from the medial and lateral borders to attach to the first and fifth metatarsal bones.
• Nerve innervation of the foot runs along the medial and lateral metatarsals and phalanges in a neurovascular bundle. These nerves are vulnerable to compressive forces that, in time, can generate the painful Lisfranc fracture dislocation
  Nerve Entrapment Syndromes [in the Neurology section]
  Nerve Entrapment Syndromes of the Lower Extremity [in the Orthopedic Surgery section]
  
  Related Medscape topics:
  Resource Center Exercise and Sports Medicine
  Resource Center Fracture
  Resource Center Trauma
  Specialty Site Neurology & Neurosurgery
  Specialty Site Orthopaedics

  Sport-Specific Biomechanics

  The 3 planes in which the foot and ankle function are the transverse, sagittal, and frontal. Movement is possible in all 3 planes.
  
  

  • Plantar flexion and dorsiflexion occur in the sagittal plane. Plantar flexion involves the foot moving from the anterior leg distally. Dorsiflexion is the opposite motion.
  • Inversion and eversion occur in the frontal plane of motion. Eversion occurs when the bottom of the foot turns away from the midline of the body. Inversion is the opposite action.
  • The 2 transverse plane motions are abduction and adduction. Adduction involves the foot moving toward the midline of the body, whereas abduction is the opposite action.

  Clinical

  History

  • Sesamoiditis is manifested by pain beneath the first metatarsal head with weight bearing on the ball of the foot or with motion at the first metatarsophalangeal (MTP) joint. Common complaints include pain with jumping and with pushing off to run.
  • adolescence. Athletes typically complain of heel pain or soreness that improves with rest and worsens with prolonged running.
  • Posterior tibial tendinitis occurs most commonly as an idiopathic condition in middle-aged females. Athletes with this condition may present with planovalgus deformity and often play sports with sudden stop-start or push-off activity, such as soccer, football, and basketball. Patients typically complain of pain inferior to the medial malleolus and decreased ROM.
  • Patients with peroneal tendon subluxation/dislocation typically present with acute pain and swelling that is centered behind the lateral malleolus, with extension proximally over the tendons. These symptoms are caused by a dorsiflexion-inversion stress injury that pulls the peroneal retinaculum off the lateral malleolus. Athletes usually complain of snapping and sudden sharp pain when changing directions or pushing off with the foot.
  • Patients with peroneal tendinitis present with pain and swelling on the lateral aspect of the ankle, usually posterior to the lateral malleolus. Patients may also complain of either a "giving way" or "sharp pinching" sensation of the lateral ankle. Long-distance running and any activity that requires repetitive cutting and pushing off can aggravate this condition.
  • Patients with FHL tenosynovitis usually present with pain in the posteromedial aspect of the ankle. The pain improves with rest and increases in sports that require push-off and extended running.
  • Fifth metatarsal fractures are a common complication with ankle sprains, so physicians must always address this condition when obtaining the patient's history. Three types of fractures occur in the fifth metatarsal.
    • Avulsion fractures off the base commonly occur with ankle sprains, particularly the plantar flexion-inversion variety.
    • Proximal diaphyseal fractures result from repetitive cyclical stress to the foot and typically have a prodromal presentation.
    • Transverse fractures occurring within 1.5 cm from the tuberosity at the metaphyseal-diaphyseal junction are the definitive Jones fracture. Contrary to popular belief, true Jones fractures primarily occur traumatically. Pain may be diffuse and difficult to localize, depending on the type and location of the fracture.
  • Morton neuroma causes pain over the ball of the foot, followed by radiation of pain to the affected toes. The patient may complain of numbness, tingling, burning, or a sensation similar to an electrical shock. Pain usually eases upon removal of the offending shoes and rubbing the ball of the foot near the affected web space. The information obtained in the history usually reveals the wearing of tight-fitting, high-heeled, or pointed-toed shoes, which are commonly worn by females who are young to middle-aged. Athletes who use a repetitive step-off motion (eg, sprinters, jumpers, those who regularly use stair steppers or treadmill machines) may complain of these symptoms.
  • Most athletes with stress fractures complain of progressively increasing pain that correlates with a change in activity, footwear, training, playing surface, or equipment. Trauma is not part of the history. Pain is exacerbated by impact loading and is ameliorated with rest.
  • The TMT fracture dislocation, or Lisfranc fracture dislocation, is named after a field surgeon in Napoleon's army who described amputations through the TMT joint. Injury to the TMT joint was common when a soldier's boot became caught in the stirrup during a fall from horseback. More recently, Lisfranc injuries have been observed in snowboarders and windsurfers, as well as in football and rugby players. Typically, the Lisfranc fracture dislocation occurs when one player falls onto the heel of another while the foot is plantar flexed and fixed, resulting in axial loading. The clinical presentation depends on the degree of displacement. Almost universally, patients complain of pain in the midfoot with the inability to bear weight. Edema and ecchymosis are usually present. Gross deformity of the forefoot may be seen in severe cases. Vascular compromise may manifest as absence of the dorsalis pedis pulse.

  Related Medscape topics:
  Resource Center Exercise and Sports Medicine
  Specialty Site Neurology & Neurosurgery
  Specialty Site Orthopaedics

  Physical

  • Sesamoiditis: Pain on dorsiflexion of the hallux, restricted motion of the first MTP joint, or pain on dorsal palpation of a sesamoid bone occurs.
  • Turf toe: The first MTP joint is red, swollen, tender, and stiff. Pain is usually greatest with end-range dorsiflexion of the foot. The collateral ligaments are stable, but there may be laxity with anterior-posterior translation. Consider gout if a patient presents with this particular clinical picture. If there is no history of repetitive motion or if in doubt, the joint may need to be aspirated. The resultant fluid should be analyzed for the culture and the presence of negative birefringent crystals.
  • Sever disease: Pain is provoked by palpation along the posterior portion of the heel and the Achilles tendon insertion (see Image 3). Restricted ankle dorsiflexion and knee extension may contribute to symptoms.
  • Posterior tibial tendinitis: Tenderness is revealed at the posterior tibial insertion, often with a swollen erythematous navicular prominence, or along the distal path around the posterior aspect of the medial malleolus. Patients may have pain and/or weakness with resisted inversion and with a tendency to have a flexible flatfoot, genu valgum, and tibia varum.
  • Peroneal tendon subluxation/dislocation: Palpation reveals direct tenderness over the peroneal tendons. Subluxation, dislocation, or tear of the peroneal tendon results in weakness of eversion and dorsiflexion. Snapping is palpated through ROM, occasionally only when bearing weight.
  • Peroneal tendinitis: Examination usually reveals swelling and tenderness along the tendons at the lateral aspect of the ankle. Eversion of the foot against resistance may elicit pain.
  • FHL tenosynovitis: Usually no palpable tenderness is present due to the deep location of the tendon. Pain and weakness are noted with resistance to plantar flexion of the first MTP joint. Pain may also be present in the tarsal tunnel.
  • Jones fracture: Tenderness may be difficult to localize specifically, but focal pain on the proximal fifth metatarsal indicates a fracture until proven otherwise. Passive inversion or resisted eversion may also be painful with a fifth metatarsal base fracture.
  • Morton neuroma: Perform a compression test by squeezing the metatarsal heads together with one hand, while palpating and compressing the involved web space with the other hand. If a Morton neuroma is present, the interspaces between the metatarsals will be tender to palpation.
  • Stress fractures: The physical examination is usually unremarkable, but it may reveal minor swelling and warmth over the forefoot, and point tenderness may be elicited by applying pressure under the affected metatarsal in a dorsal direction. Maneuvers such as walking on the toes or running in place can reproduce symptoms.
  • Lisfranc sprain: The physical examination may reveal prominence of the first metatarsal or shortening of the forefoot. The patient complains of pain and may note paresthesias of the forefoot and digits. Passive ROM (PROM) and palpation over the metatarsals, with attention to the base of the second metatarsal, will likely reveal tenderness, which mandates that careful radiographic examination be performed. In a dislocation-fracture, the foot may have more swelling and deformity. Radiographs can demonstrate a fracture, seen most commonly at the base of the second metatarsal.

  Causes

  • Sesamoiditis is usually caused by overuse of the foot in a plantar flexed position. Cleats with little insole padding can focus excess stress on the first MTP or sesamoid and thus can trigger this condition. A depressed first ray, forefoot valgus, or pes cavus deformity can lead to sesamoiditis as well.
  • Turf toe is caused by hyperextension of the first MTP joint beyond the normal 60° of dorsiflexion. The incidence of the injury has increased with the widespread use of artificial surfaces. Lightweight, poorly supported, flexible shoes can predispose the athlete to injury.
  • Sever disease is caused by excessive traction on the calcaneal apophysis by the Achilles tendon, particularly during running and jumping. Inflexibility of the gastrocnemius, hamstring, quadriceps, and hip flexor muscles can exacerbate this condition.
  • Posterior tibial tendinitis is caused by repetitive trauma during the pronation phase of cutting, jumping, or running. Pes planus is a risk factor.
  • Peroneal tendon subluxation/dislocation most commonly occurs with powerful contraction of the peroneal muscles, usually in maximal dorsiflexion. The peroneal tendons are retained in place by the superior and inferior peroneal retinaculum. If enough stress is applied, these may rupture, resulting in subluxation or dislocation of the peroneal tendons.
  • Peroneal tendinitis may be related to acute inversion injury or chronic overuse secondary to hindfoot varus. Iliotibial band restriction increases force on the peroneal tendons.
  • FHL tenosynovitis is typically associated with repeated push-off maneuvers, such as those executed by ballet dancers or sprinters.
  • A Jones fracture usually occurs when a load is applied to the lateral forefoot in the absence of inversion. A Jones fracture can also occur with an acute inversion injury. Jones injuries usually occur in sports involving running and jumping. Fifth metatarsal proximal diaphyseal fractures can occur with chronic overuse and poor biomechanics. Fifth metatarsal base avulsion fractures commonly occur via inversion sprain mechanisms.
  • Morton (intermetatarsal) neuroma is a biomechanically induced neuropathy of the common digital nerve of the foot. Repetitive microdamage to the nerve fibers produces degeneration and reparative fibrosis, significantly increasing the nerve diameter. Restrictive toe boxes combined with overuse can cause this condition.
  • Stress fractures
    • Stress fractures are defined as spontaneous fractures of normal bone that result from the summation of stresses, any of which by themselves would be harmless.^{6, 7, 8, 9} Stress fractures of the foot were first described by Breihaupt in 1855. Serving as a physician in the Prussian army, Breihaupt observed fractures of the metatarsals in otherwise healthy military recruits after long marches. These became know as march fractures.
    • Of all sports-related injuries, it is estimated that 5-10% involve stress fractures. Nine of the 24 members of the 1994 United States National World Cup Soccer Team were diagnosed with stress fractures. The incidence of stress fractures is increasing for the following reasons: (1) increasing numbers of persons participating in sporting activities, (2) increasing awareness and suspicion of stress fractures, and (3) change in the nature and type of sporting activities (ie, rollerblading). Stress fractures of the second, third, and fourth metatarsals account for 90% of metatarsal injuries
  • Lisfranc fracture dislocation
    • The transverse ligaments connect the second, third, fourth, and fifth metatarsal bases. The second metatarsal is recessed and bound to the medial and intermediate cuneiform bones by ligaments. The Lisfranc ligament joins the first (medial) cuneiform bone to the base of the second metatarsal. The base of the second metatarsal, recessed tightly into the mortise formed by the cuneiform bones and attached by multiple ligaments, forms the keystone of the midfoot and, thus, is the primary stabilizing structure of the TMT joint complex.
    • Lisfranc fracture dislocations are classified as homolateral or divergent. A homolateral dislocation involves displacement of 4 or 5 metatarsals in the same direction. A divergent dislocation involves a split between the first and second metatarsals.

  References

• Achilles Tendonitis
• Ankle Sprain
• Contusions
• Plantar Fasciitis

• Breaks, Fractures, and Dislocations Center
• Sports Injury Center
• Broken Foot Overview
• Broken Foot Causes
• Broken Foot Symptoms
• Broken Foot Treatment