Common Injuries of the Feet
Injuries of the hindfoot
Plantar fasciitis / fasciosis
One of the most common causes of rearfoot pain is plantar fasciitis / fasciosis. It is an overuse condition affecting the thick connective tissue known as the ‘plantar fascia’ at its attachment to the base of the heel. Pain is usually felt on the inside of the heel and is worse when initially weight bearing in the morning. It may ease slightly with activity. Physiotherapy treatment techniques include soft tissue releases, taping, stretching and strengthening exercises and the correction of foot biomechanics through custom orthotics etc.
Fat pad contusion / bruised heel
The bottom of the heel bone (calcaneus) is protected by a small fat pad which provides cushioning during weight bearing. Repeated pounding of the heel or landing heavily on the heel may cause the fat pad to become damaged or displaced leaving less of a protective layer, resulting in heel pain. Treatment consists of assessment of foot biomechanics and the provision of custom orthotics to unload the area while taping may also provide additional support to the heel.
Calcaneal stress fracture
Stress fractures of the calcaneus may present as an insidious onset of heel pain that is aggravated by weight bearing activities. There is often a localised area of tenderness and pain is reproduced when the heel is compressed. Once confirmed through imaging, initial treatment consists of relative reduction in activity and in some cases a period of non-weight bearing. Long term management involves assessment of lower limb biomechanics to identify and treat underlying contributing factors.
Injuries of the Midfoot
Stress fracture of the navicular
Stress fractures of the navicular typically occur as a result of excessive weight bearing activity or a change in training conditions. Symptoms include a poorly localised pain around the inner arch of the foot that is aggravated by weight bearing and eased with rest, pain at night and tenderness on palpation of the navicular bone. Once diagnosis is confirmed by a bone scan, treatment consists of an initial period of rest from weight bearing activity followed by a graded return to physical activity under the direction of a physiotherapist and will vary depending on the severity of the injury.
Midtarsal joint sprain
The midtarsal joint includes the talonavicular and calcaneocuboid joints. Injuries to this area of the foot are rare and often occur in conjunction with acute ankle sprains or fractures. Pain is experienced over the top of midfoot region and may be accompanied by swelling. If no fractures are associated with a midtarsal sprain, treatment may consist of supportive taping, use of a CAM boot, the prescription of orthotics and proprioceptive retraining.
A tendinopathy refers to a painful overuse injury of the tendons. In this case, it affects the tendons which run along the top of the foot and act to extend (‘pull up’) the ankle and toes. These tendons are the tibialis anterior, extensor hallucis longus, extensor hallucis brevis, extensor digitorum longus and extensor digitorum brevis. Symptoms of an extensor tendinopathy include pain which worsens with running and in some cases mild swelling on the top of the foot. As with other tendinopthies, treatment consists of relative rest, soft tissue releases and a graduated strengthening program. Analysis of lower limb biomechanics is also important to identify underlying contributing factors.
Plantar fascia strain
A strain to the plantar fascia may result from a single traumatic incident or occur gradually over time. Depending on the extent of injury, treatment may require relative rest from weight bearing activities, supportive low dye taping of the foot, soft tissue massage and electrotherapeutic modalities.
Injuries of the forefoot
Stress fractures of the metatarsals
Stress fractures of the metatarsals are commonly caused by an increase in the frequency, intensity or volume of activity. Factors that disturb the normal remodeling of bone such as inadequate intake of vitamin D or calcium, or long-term use of corticosteroid medications may also contribute to the development of a metatarsal stress fracture. Once diagnosis is confirmed by a bone scan, treatment consists of rest to allow sufficient healing followed by a graded return to physical activity.
Fracture of the fifth metatarsal
Fractures at the base of the fifth metatarsal often occur as a result of an acute sprain to the foot or ankle. This may cause an avulsion fracture where the force of the ankle sprain causes the tendon of the peroneus brevis muscle to pull away a small piece of bone. This type of fracture is usually managed conservatively with a period of immobilisation in a CAM walker boot.
A fracture which occurs at the junction between the base of the fifth metatarsal and the bone shaft are referred to as a ‘Jones fracture’. This area of bone has a poor blood supply and the healing period associated with these fractures may be prolonged. If a Jones fracture is not displaced significantly, treatment involves immobilisation in a cast or CAM walker boot.
Metatarsophalangeal joint synovitis / Metatarsalgia
Metatarsalgia refers to an inflammatory condition affecting the metatarsophalangeal joints (MTPJs). Symptoms include pain in the forefoot which is worse when weight bearing and mild swelling may also be present. Treatment usually consists of NSAID's (non steroidal anti inflammatory drugs), and use of padding or customised orthotics to protect and re-distribute weight on the forefoot.
urf toe is the term commonly used to describe a sprain to the joint capsule and ligament of the first metatarsophalangeal joint (base of the big toe), which frequently occurs in sports played on artificial turf. Treatment consists of rest, ice, electrotherapeutic modalities, supportive taping and assessment of lower limb biomechanics.
Morton’s interdigital neuroma
Morton’s neuroma refers to the swelling and scarring of the nerve that runs between the third and fourth metatarsals. Symptoms include pain, pins and needles &/or numbness which radiates into the toes and worsens with weight bearing. Treatment consists of unloading the forefoot through padding (met dome) or customised orthotics, strengthening exercises to maintain the transverse arch of the foot and sometimes a corticosteroid injection may be indicated. If conservative treatment fails to offer relief, surgical excision of the nerve may be required.
Hallux limitus describes a restriction of dorsiflexion (extension) which occurs at the first metatarsophalangeal joint (base of the big toe) as a result of osteoarthritis. Restriction in range of movement in this joint often results in problems with gait and may require the prescription of customised orthotics for biomechanical correction.
Hallux valgus is the subluxation of the first metatarsophalangeal joint causing the big toe to deviate towards the other toes. Treatment consists of biomechanical correction with customised orthotics, advice regarding appropriate footwear and biomechanical assessment to identify factors which may be contributing to the condition. When severe deformity occurs, surgery may be the only option.
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