Overuse and Miscellaneous Conditions of the Foot and Ankle

Ovid: Manual of Orthopaedics

Editors: Swiontkowski, Marc F.; Stovitz, Steven D.
Title: Manual of Orthopaedics, 6th Edition
> Table of Contents > 28 – Overuse and Miscellaneous Conditions of the Foot and Ankle

Overuse and Miscellaneous Conditions of the Foot and Ankle
I. Achilles Tendinopathy
encompasses both inflammation and degeneration if present in the peritenon.
  • 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 should be conservative
      in 95% of cases. Rest, analgesics, cross training, physiotherapy,
      orthotics with a heel lift, and, occasionally, casting should be used.
      Steroid injections are very seldom indicated. (2,3).
    • Surgery is
      indicated after 6 to 12 months of failed conservative treatment.
      Surgery consists of the following: excise retrocalcaneal bursa, resect
      superior prominence, and debride diseased or calcified portion of the
      tendon. Reattach if necessary. The patient should be non–weight bearing
      for 6 to 8 weeks. Rehabilitation is resumed but recovery might take up
      to 1 year. Success rate is 70% to 86%. (4)
  • Noninsertional
    type is associated with typical hypovascular zone 2 to 6 cm proximal to
    insertion. The etiologic profile includes repetitive microtrauma, more
    common in males, older athletes, tight gastrosoleus 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 could be simplified into peritendinitis
    (sheath only), tendinosis (tendon only), or pantendinitis (sheath and
    tendon) (6). Diagnosis is primarily by history
    and clinical evaluation and is confirmed with 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 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
      gastrosoleus, 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 might do
      better 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.
  • Differential diagnosis.
    To differentiate, a thorough history and examination is required. This
    should include exact location and duration of pain and the relationship


    athletic activity. Chronic pain at rest is unusual and might be due to
    a tumor. 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
    • Tendinopathy of flexor hallucis longus or flexor digitorum brevis
    • Stress fracture
    • Tumor
  • Plantar fasciitis
    could be at insertion into medial calcaneal tuberosity or midfoot 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.
    • 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 tilt 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 not
      associated with increased pain or 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. Resisted flexion of the big toe is
      painful only with involvement of the tendon.
  • 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 shock-absorbing heel cup for heel pain
        or a full length orthotic or UCBL (University of California Berkeley
        Laboratory) orthotic for midsubstance pain.
      • Though not proven uniquely effective, analgesics, as they do decrease pain.
      • Physical therapy to include Achilles and plantar fascia stretching, hindfoot taping, contrast baths, and ultrasound treatment.
      • A night dorsiflexion splint might help to keep the fascia under tension to reduce early morning weight-bearing pain.
      • Injections may be used in refractory
        cases. This has historically been done with steroids, although steroids
        pose a risk of plantar fascia rupture. Consistent with the fact that
        this has been noted to be a degenerative rather than an inflammatory
        process, there is 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.
      • Shockwave therapy, which tries to spur on inflammatory response, might prove to be helpful in the future.
        The heel spur seen on roentgenograms is seldom, if ever, the cause of heel pain.
    • 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
      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.
  • P.395

  • 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.
  • 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
      • 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).
      • 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
    • 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.
      • 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 and nerve conduction studies can be helpful but are
        not always sensitive enough.
      • 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.
    • Metatarsalgia
      • 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 by using the long toe extensors to
          augment dorsiflexion power, but this pulls the plantar fat pad away
          from the weight-bearing surface under the metatarsal heads, further
          aggravating forefoot pain.
        • Similarly, idiopathic claw toe deformities could displace the fat pad and cause metatarsalgia.
        • Metatarsophalangeal joint capsulitis
          might cause pain over the plantar aspect of the joint. This is more
          common at the second metatarsophalangeal 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 and is most common in the third web space (between the third and fourth metatarsals).
      • The differential diagnosis of midfoot to forefoot pain always includes stress fractures (see IV below)
      • Treatment.
        The goal is to unload the metatarsal area. Orthotics, metatarsal bars,
        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


III. Tibialis Posterior Dysfunction Syndrome
Rupture of the tibialis posterior (TP) tendon is a cause
of a painful, acquired flatfoot deformity in adults. It is more common
in women 40 years of age and older (12,13,14).
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).
  • Anatomy. By
    virtue of its lever arm length and muscle strength, the TP tendon 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 TP 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.
  • Etiology of TP tendon rupture.
    To understand the etiology of TP tendon tears, it is important to
    remember its function. It resists considerable forces in maintaining
    the medial longitudinal arch. It also helps lock the mid- and hindfoot
    to allow a solid lever arm during the push-off part of the gait cycle.
    Approximately 20% of TP ruptures are associated with rheumatic
    conditions (12). An estimated 80% of TP tendon ruptures develop spontaneously. There are several theories to explain this phenomenon.
    • Mechanical.
      The acute angle around the medial malleolus could lead to excessive
      friction that leads to slow deterioration over many years. This also
      explains the age predilection of this condition.
    • Vascular.
      Laboratory studies have identified an area of poor blood supply to the
      tendon behind the medial malleolus. This could lead to a decrease in
      healing potential after minor trauma.
    • Achilles tendon contracture.
      Either due to gastrocnemius alone or in combination with soleus, a
      contracture or shortness of the Achilles tendon increases the workload
      and force on the TP during the gait cycle.
  • Clinical presentation.
    Contrary to popular belief, TP tendon rupture or insufficiency is
    common in American society. A proper history and thorough physical
    examination is usually all that is needed to make this a
    straightforward diagnosis.
    • History.
      Onset is insidious, with discomfort reported on the medial side of the
      foot without any preceding acute trauma. Women are affected more often
      then men, and persons in their 40s are most often affected. There is
      not necessarily a relation to activity level.
    • Symptoms.
      Initially, patients complain of only mild to moderate pain and of
      swelling and discomfort on the medial side of the foot and ankle. It is
      usually not incapacitating; rather, there is a chronic medial
      weight-bearing ache that limits physical activities. Without treatment,
      the symptoms might increase over a variable length of time. In a late
      stage, the patient might complain of additional weight-bearing pain on
      the lateral aspect of the ankle, a progressive deformity, and an
      abnormal gait.
    • Signs
      • In an early stage, one can see and
        palpate the swelling behind the medial malleolus and over the course of
        the TP tendon to its insertion in the navicular. The tenderness is
        usually over the same area.
      • In a more advanced stage, the hallmark
        deformity becomes apparent. This is a combination of hindfoot valgus,
        forefoot abduction, and flattening of the medial longitudinal arch.
      • Much information can be gathered by
        observing the patient. When viewed from posterior, the amount of heel
        valgus above the normal neutral to 5 degrees in the weight-bearing
        position can be noted. The “too many toes” sign is indicative of
        forefoot abduction. The patient is also asked to raise on the toes. A
        normal TP locks the hindfoot in varus to give a solid lever for
        push-off. With an insufficient TP, the heel does not move into varus,
        and it is impossible to raise oneself on the toes.
      • Frontal and side views confirm the
        forefoot abduction and loss of medial arch. An apropulsive, antalgic
        gait is usually noticed if the patient is asked to walk at a rapid pace.
      • P.397

      • Physical examination further confirms the
        clinical suspicion. Tendon and muscle power around the ankle is tested.
        The TP is evaluated with the foot in plantar flexion, and the patient
        is asked to invert the foot against resistance. Look for recruitment of
        the tibialis anterior to augment this action.
      • The flexibility of the Achilles tendon is
        tested with the knee first extended to determine the role of the
        gastrocnemius in possible tightness, and then with the knee flexed to
        isolate the soleus by eliminating the influence of the gastrocs.
      • Range of movement of the ankle,
        especially the subtalar joint, is evaluated, and any pain is noted. In
        advanced cases, there might be tenderness on the lateral aspect of the
        ankle as a result of impingement of the fibula on the calcaneus.
    • Diagnostic workup. Thorough history and clinical examination is usually all that is needed to make the diagnosis.
      • Plain roentgenographs.
        In most cases beyond stage 1, weight-bearing radiographs show specific
        changes. The most obvious is the change in the talo-first metatarsal
        alignment on the anteroposterior and lateral views. In a normal foot,
        the talo-first metatarsal alignment is in a straight line. In TP tendon
        ruptures, the alignment is altered to varying degrees because of the
        peritalar subluxation.
      • MRI confirms
        a tear or degeneration in the TP tendon and shows the abnormal
        alignment of the bony elements, but it is costly and usually
        unnecessary. It is helpful in early, subtle injuries of the tendon and
        to rule out other causes of medial midfoot pain such as navicular
        stress fractures.
      • Computed tomography
        (CT) is not necessary as a primary diagnostic tool, but it can be
        helpful to determine the integrity of the peritalar joints and,
        therefore, in planning the surgical
        procedure. It is of great value in the continuing study of the changes
        in the foot secondary to TP tendon ruptures.
    • Classification
      • Stage 1a: mild, occult (13%).
        Symptoms last less than 1 year, there is mild swelling and tenderness
        over the TP tendon and slight weakness in inversion power, and there is
        minimal hindfoot valgus on weight bearing.
      • Stage 1b: moderate (44%).
        Symptoms last up to 18 months, and there is definite tenderness,
        swelling, and weakness of the TP tendon. Moderate pes planus and heel
        valgus occur as a result of dorsolateral peritalar subluxation.
      • Stage 2: advanced (17%).
        Symptoms last for 1.5 to 2.5 years. There is more pronounced flatfoot
        deformity caused by peritalar subluxation, and there is considerable
        heel valgus and moderate prominence of the talar head medially. The
        subtalar joint is usually still mobile and the deformities passively
      • Stage 3a: complete (15%).
      • Stage 3b: peritalar dislocation (11%).
        Progressive dorsolateral peritalar subluxation reaches the point of
        dislocation in the neglected case. Symptoms last between 4 and 20
        years. Pain occurs also on the lateral side as a result of impingement
        of the calcaneus on the distal fibula. The fibula takes an increasing
        amount of load on weight bearing. It becomes hypertrophic, and stress
        fractures are not uncommon. The talocalcaneal relation is completely
        distorted, with minimal actual articular contact. The majority of these
        deformities are fixed and not passively correctable.
    • Treatment
      • Nonsurgical. Other than certain grade 1a
        tears, nonsurgical management of TP tendon tears is essentially
        palliative. In most cases, it will neither result in healing of the
        tendon nor correction of the deformity. Noninvasive means are therefore
        only useful if there are factors present that contraindicate surgical
        intervention. This includes advanced age, significant medical problems,
        low activity level, and minimal discomfort. It is still advisable to
        start most patients on conservative treatment before electing to do


        should be directed to control pain, inflammation, and development of
        deformity. Options include the use of crutches, minimal weight bearing,
        or casting in a recent onset case. Nonsteroidal anti-inflammatory drugs
        (NSAIDs) might help relieve pain and swelling. In more advanced cases,
        orthotics come into play. These include heel or sole lifts, inserts,
        UCBL type heel cups, and modified, accommodative shoes. In severe
        deformities, shoe modifications that incorporate calipers could be used.

      • Surgical.
        Surgical treatment options include tendon repair, tendon augmentation,
        and bony stabilization of both nonessential and essential joints.
        • Stage 1. A tendon repair is still
          feasible. The TP tendon is usually augmented with a second tendon. A
          multitude of augmenting techniques have been described (12,14).
          This includes the use of the flexor digitorum longus, flexor hallucis
          longus, or peroneus longus that serve as dynamic stabilizers. Free
          tendon grafts are also used to repair the TP tendon, although the
          results are variable. It is of utmost importance to evaluate for
          tightness of the Achilles tendon and to lengthen it if necessary.
        • Stage 2. In more advanced cases, tendon
          repair and augmentation is usually not sufficient to relieve pain and
          prevent deformity. The surgical option is dependent upon the degree and
          mobility of the deformity. If the peritalar subluxation is still
          correctable, the bony stabilization is done in nonessential joints.
          This includes the lateral column distraction fusion that reduces the
          peritalar subluxation and heel valgus without compromising the
          important subtalar and talonavicular movement. Other options include a
          medial column or a subtalar fusion, with or without an Achilles
        • Stage 3. The surgical treatment of
          subtotal peritalar dislocation with a fixed hindfoot deformity (grade
          3b) usually requires a triple arthrodesis.
IV. Stress Fractures
  • Description.
    The foot and ankle are the most common areas for stress fractures. A
    stress fracture is defined as a partial or complete fracture resulting
    from its inability to withstand repetitive stress applied in a
    repeated, subthreshold manner. It is, therefore, a series of events
    causing stress fractures. Ninety-five percent of stress fractures are
    in the lower extremities, +/- are of the foot and ankle. All the bones
    of the foot and ankle can sustain stress fractures. The metatarsals,
    though, are involved in 55% of cases, whereas the sesamoids and talus
    are involved in less than 1%. Stress fractures occur in all sports but
    especially in running and running-based sports (15).
    Sedentary people starting a fitness program are more prone to stress
    fractures. This is a well-demonstrated phenomenon in new military
    recruits. Stress fractures are more likely to develop in women. Leg
    length discrepancy, malalignment, prior injury, cavus feet that lack
    normal pronation, as well as poor physical condition, predispose to
    stress fracture.
  • Diagnosis
    • The history is fairly typical, with pain
      being intensified by ongoing training. There might be an association
      with a recent increase in duration and intensity of training. It is
      usually insidious with an increase of pain over a period of time.
    • There should always be a high index of
      suspicion for stress fractures with insidious onset of pain. Physical
      examination should localize the involved area.
    • Standard radiographs
      should be the first-line imaging test for evaluation of possible stress
      fractures. However, one must be aware of their lack of sensitivity.
      Callous formation is the abnormality seen on plain films and represents
      the active bone healing the injury. Plain films will thus be normal for
      the first few weeks. Furthermore, a large percentage will always appear
      normal on x-rays. Thus, if one’s clinical evaluation is suspicious for
      stress fracture, further imaging is often necessary (16).
    • Bone scans.
      The gold standard for recognizing a stress reaction in bone used to be
      a technetium bone scan. The bone scan becomes positive after a week of
      ongoing stress reaction in the bone. A negative bone scan effectively
      rules out a stress fracture (16).
    • P.399

    • MRI. It is
      useful to list the indication, as special short time inversion recovery
      (STIR) images may be helpful. It is the most sensitive and specific
      method of diagnosing and grading stress fractures and is especially
      helpful in the feet (17).
    • The combination of a negative
      roentgenogram and positive bone scan represents an early fracture, and
      treatment at this stage may prevent longstanding problems. CT scan has
      a place in diagnosing talus and midfoot fractures because these bones
      are cancellous in structure and stress fractures are difficult to
      identify on plain radiographs.
    • The most critical or at-risk stress fractures of the foot are of the navicular, proximal second metatarsal (18) and intraarticular fractures, and the great toe sesamoids. The navicular is particularly difficult to diagnose (19). Workup should include plain films, MRI bone scan, and CT scan. Significant disability can result from delayed diagnosis.
  • Treatment
    • Treatment greatly depends on the location
      of the stress fracture. Treatment should include 6 weeks of casting
      followed by verification of union by CT. Resumption of leg-based
      athletics is at 12 to 18 weeks after initiation of treatment. Custom
      orthotics should be used when the patient returns to athletics (16).
    • Noncritical fractures include distal metatarsals 2, 3, and 4, the lateral malleolus, and the calcaneus (20).
      Treatment should be aimed at keeping the level of activity below that
      which causes pain. This implies decreasing the level of activity or
      substituting swimming, biking, circuit training, or other low impact
      activities. Orthotics within shoes can limit stress in the involved
      area (19). Activities can progress as long as
      they are not painful. There are reasons to try to limit NSAIDs as their
      anti-inflammatory properties can inhibit bone healing and their pain
      relief properties may give the patients a false level of reassurance (21).
V. Great Toe Metatarsophalangeal Joint Problems
  • Turf toe is
    defined by some as a sprain of the plantar capsuloligamentous complex.
    Others use the term to be more encompassing for a variety of injuries
    around the first metatarsophalangeal joint. Differential diagnosis
    includes injury to the medial or lateral ligamentous structures, the
    phalangeal sesamoid ligament, a fractured sesamoid, osteochondral or
    chondral injury, chondral contusion caused by direct linear impact, and
    dislocations and injury to the interphalangeal joint (22).
    This injury is common in football players but is also seen in
    basketball and track athletes. Careful history and clinical evaluation
    is necessary to localize injury. Anteroposterior, lateral, oblique, and
    sesamoid views should be obtained.
    • Initial conservative treatment
      consists of the general approach: rest, ice, compression, and
      elevation. A postoperative shoe with firm sole to limit movement helps
      in ligamentous injuries. The patient’s foot is immobilized for 3 weeks
      and rehabilitation is started as tolerated. Sesamoid fractures are
      treated with a cast shoe with the great toe in 10 degrees of flexion
      for 8 to 10 weeks.
    • Surgical treatment
      consists of debridement and drilling of articular surface if pain
      persists in a case of chondral fracture. Partial excision or internal
      fixation of sesamoid fracture is undertaken when the fracture does not
  • Hallux rigidus is degenerative arthritis of the first metatarsophalangeal joint. In most cases, there is no specific predisposing factor.
    • Possible etiologies include congenital
      flattening of the metatarsal head, metatarsus primus elevatus,
      osteochondritis of the head, a long hallux, pes planus, and
      osteochondral injuries (turf toe).
    • Hallux rigidus presents a significant
      problem for an athlete. Dorsiflexion of the big toe plays an important
      role in activities such as accelerating and jumping. Compensation by
      rolling onto the lateral aspect of the foot might cause stress and
      strain on the ankle, knee, and hip.
    • Diagnosis.
      Enlargement around the metatarsophalangeal joint is usually obvious.
      This is due to a combination of bony prominences and synovitis.
      Dorsiflexion is limited and reproduces the patient’s pain. Radiographic
      findings might be minimal in early stages. With time, obvious
      degenerative changes and osteophytes within the joint become apparent.
      Sesamoids are generally not involved.
    • P.400

    • Differential diagnosis includes gout or other inflammatory arthritis.
    • Treatment
      • Conservative.
        Pressure against the toe is alleviated by modifying foot wear,
        incorporating a higher and wider toe box, a stiffer shoe, a rigid
        insert, or a rocker bottom sole. NSAIDs or injected steroids might give
        symptomatic relief.
      • Surgical.
        Fusion is a good option in older people but would significantly impair
        athletic performance. In athletes, a cheilectomy with or without a
        dorsiflexion osteotomy of the proximal phalanges (Moberg procedure) is
        preferred (23,24). The
        patient is permitted to ambulate weight bearing as tolerated in a
        postoperative shoe. Rehabilitation starts 7 to 10 days after surgery
        with active and passive range-of-motion exercises. The patient should
        wear a soft shoe to allow motion at the metatarsophalangeal joint with
        walking. Athletes could resume cycling, swimming, and any activity that
        avoids significant impact against the metatarsophalangeal joint, but
        should avoid running, jumping, and similar activities for 10 to 12
        weeks. Metatarsophalangeal joint arthroplasties (excision or prosthetic
        replacement) have very limited application in the young, active
VI. Hallux Valgus (Bunions)
The etiology of hallux valgus is still debated, but
there appears to be a significant hereditary component. Shoe wear has
been suggested as an etiological factor, as a tight toe box and a high
heel will place an increased laterally and distally directed force on
the great toe. Joint laxity is associated with an increased rate of
hallux valgus. Not all hallux valgus deformities are symptomatic.
Typically, patients will describe pain over the medial bunion that
corresponds to bursal inflammation. In more severe deformities the main
complaint is that of second and third ray metatarsalgia.
  • Evaluation
    • History
      • What causes pain?
      • Shoe wear: type and any recent changes?
      • What activities does it affect?
    • Physical exam
      • Compare shoe size to foot size. Any change in shoes due to bunions?
      • Evaluate callus pattern: lesser metatarsal overload, great toe pronation
      • Evaluate gait: excessive pronating, →
        more force on the medial rays, → increased valgus angulation of first
        Metatarsophalangeal (MTP) joint. Evaluate kinetic chain of gait from
        the pelvis down.
    • X-rays
      • Angle of long axis of first and second metatarsals
  • Treatment
    • Conservative
      • Shoe modification is the most important. The shoes should be big enough, have a low heel, and a wide and high toe box.
      • Orthotics to support the medial arch and unload the lesser metatarsal heads might be of benefit.
      • Bunion pads might help for medial eminence pain.
      • Silastic spacers could be used between the toes.
      • Physical therapy if biomechanical factors seem to be resulting in excessive foot pronation
    • Surgical
      • Should never be for cosmetic reasons
      • Refer to an orthopaedic surgeon or
        podiatrist if there is not adequate pain relief after 6 months of
        appropriate conservative care.
VII. Claw and Hammer Toes
The claw toe represents a hyperextension deformity of
the MTP joint and a flexion deformity of the proximal interphalangeal
(PIP) joint. This frequently involves multiple toes and is usually an
indication of a muscle imbalance between the intrinsic or extrinsic
muscles of the toes. The most common complaint is pain and friction
over the dorsum of the PIP joint. With time, the plantar fat pad
dislocates distally and exposes the metatarsal heads. This results in
significant metatarsalgia.


A hammer toe deformity consists of a flexion deformity
of the PIP joint; often with this the MTP joint and the distal
interphalangeal (DIP) joint are spared. The most common cause of a
hammer toe deformity is a result of the toe hitting against the tip of
the shoe resulting in a flexion deformity. These patients typically
will have symptoms as a result of a painful corn at the tip of the toe
or a callus along the dorsum of the toe as indicated in this patient.
  • Evaluation
    • General
      • Neurologic abnormalities
      • Muscle imbalance, specifically gastrosoleus contracture
      • Intrinsic muscle imbalance
      • Diabetes
      • Vascular compromise
    • Local
      • Flexible (correctible) deformity: usually does well with conservative treatment
      • Rigid (impossible to passively correct the PIP or DIP deformity)
  • Conservative treatment
    • Shoe modifications: should be big enough,
      low heel, wide and high toe box. This is especially important for the
      rigid deformities.
    • Orthotics with a metatarsal bar might help to reduce the plantar fat pad and reduce the metatarsal pain.
    • Silatic spaces and claw toe splints might be helpful.
  • Surgical treatment. Only indicated if conservative measures fail
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2. Mohr RN. Achilles tendonitis—rationale for use and application or orthotics. Foot Ankle Clin 1997;2:439–456.
3. Shrier I, Matheson GO, Kohl HW III. Achilles tendonitis: are corticosteroid injections useful or harmful?. Clin J Sport Med 1996;6:245–250.
4. McGarvey
WC, Palumbo RC, Baxter DE, Leibman BD. Insertional Achilles tendinosis:
surgical treatment through a central tendon splitting approach. Foot Ankle Int 2002;23:19–25.
5. McCarvey
WC, Singh D, Trevino SG. Partial Achilles tendon rupture associated
with fluoroquinolone antibiotics: a case report and literature review. Foot Ankle Int 1996;17:496–498.
6. Clement DB, Taunton JE, Smart GW. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med 1984;12:179–184.
7. Johnston E, Scranton P, Pfeffer GB. Chronic disorders of the Achilles tendon: results of conservative and surgical treatments. Foot Ankle Int 1997;18:570–574.
8. Maffulli
N, Testa V, Capasso G, et al. Results of percutaneous longitudinal
tenotomy for Achilles tendinopathy in middle-and long-distance runners.
Am J Sports Med 1997;25:835–840.
9. Pfeffer
G, Bacchetti P, Deland J, et al. Comparison of custom and prefabricated
orthotics in the initial treatment of proximal plantar fasciitis. Foot Ankle Int 1999;20(4):214–221.
10. Daly
PJ, Kitaoka HB, Chao EYS. Plantar fasciotomy for intractable plantar
fasciitis: clinical results and biomechanical evaluation. Foot Ankle 1992;13:188–195.
11. Baxter DE, Pfeffer GB. Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop 1992;279:229–236.
12. Johnson KA. Tibialis posterior tendon rupture. Clin Orthop 1983;177:140–147.
13. Sangeorzan BJ, Smith D, Veith R, et al. Triple arthrodesis using internal fixation in treatment of adult foot disorders. Clin Orthop 1993;294:299–307.
14. Thordarson
DB, Schmotzer H, Chon J. Reconstruction with tenodesis in an adult
flatfoot model. A biomechanical evaluation of four methods. J Bone Joint Surg (Am) 1995;77:1557–1567.


15. Ting A, King W, Yocum L, et al. Stress fractures of the tarsal navicular in long-distance runners. Clin Sports Med 1988;7:89–101.
16. Santi M, Sartoris DJ. Diagnostic imaging approach to stress fractures of the foot. J Foot Surg 1991;30:85–97.
17. Arendt
EA, Griffiths HJ. Use of MR imaging in the assessment and clinical
management of stress reactions of bone in high-performance athletes. Clin Sports Med 1997;16:291–306.
18. Micheli LJ, Sohn RS, Solomon R. Stress fractures of the second metatarsal involving lisfranc’s joint in ballet dancers. J Bone Joint Surg (Am) 1985;67:1372–1375.
19. Schwellnus MP, Jordaan G, Noakes TD. Prevention of common overuse injuries by the use of shock absorbing insoles. Am J Sports Med 1990;18:636–641.
20. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med 1983;11:349–353.
21. Dahners LE, Mullis BH. Effects of nonsteroidal anti-inflammatory drugs on bone formation and soft-tissue healing. J Am Acad Orthop Surg 2004;12(3):139–143.
22. Rodeo
SA, O’Brien S, Warren RF, et al. Turf-toe: an analysis of
metatarsophalangeal joint sprains in professional football players. Am J Sports Med 1990;18:280–285.
23. Mann RA, Clanton TO. Hallux rigidus: treatment by cheilectomy. J Bone Joint Surg (Am) 1988;70:400–406.
24. Mulier T, Steenwerckx A, Thienpont E, et al. Result after cheilectomy in athletes with hallux rigidus. Foot Ankle Int 1999;20(4):232–237.
Selected Historical Readings
Anzel SH, Covey KW, Weiner AD, et al. Disruption of muscle and tendons. An analysis of 1,014 cases. Surgery 1959;45:406–414.
M, Gentz CF, Nilsson P. Imaging in chronic Achilles tendinopathy: a
comparison of ultrasonograpy, magnetic resonance imaging and surgical
findings in 27 histologically verified cases. Skeletal Radiol 1996;25:615–620.
Bennett GL, Graham CE, Mauldin DM. Triple arthrodesis in adults. Foot Ankle 1991;12(3):138–143.
Bonney G, McNab I. Hallux valgus and hallux rigidus. J Bone Joint Surg (Br) 1952;34:366–385.
Dameron TB Jr. Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone Joint Surg (Am) 1975;57:788–792.
Key JA. Partial rupture of the tendon of the posterior tibial muscle. J Bone Joint Surg (Am) 1953;35:1006–1008.
Leach RE, Seavey NS, Salter DK. Results of surgery in athletes with plantar fasciitis. Foot Ankle 1986;7:155–161.
Lehman RC, Torg JS, Pavlov H, et al. Fractures of the base of the fifth metatarsal distal to the tuberosity: a review. Foot Ankle 1987;7:245–252.
Lutter LD. Surgical decisions in athletes’ subcalcaneal pain. Am J Sports Med 1986;14:481–485.
Puddu G, Ippolito E, Postacchini F. A classification of Achilles tendon disease. Am J Sports Med 1976;4:145–150.

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