Wednesday, February 15, 2006


The body's foundation originates with the feet, which support the body weight in a myriad of positions and function over a multitude of surfaces and contours. Most athletic activity begins with and is dependent on the feet. As such, the feet continually bear the brunt of physical stresses and rapidly changing forces thrust on them from all directions.
Injuries involving an athlete's feet are often magnified in severity because the feet are weight bearing structures. A relatively minor injury of the foot can impair an athlete's performance as dramatically as a major injury to another body area. Proper and adequate care should be given all injuries and athletic related conditions of the feet, no matter how minor they appear. 


Bunion (Hallux Valgus) 
A bunion is an inflammation and thickening of the bursa of the metatarsophalangeal joint of the big toe, usually associated with abnormal enlargement of the joint and lateral displacement of the toe. The normal cause is chronic irritation and pressure from poorly fitted shoes or structural anomalies. A bunion-like enlargement of the metatarsophalangeal joint of the fifth tore is called a bunionette or tailor's bunion. 

A hammertoe is an extension deformity of the metatarsophalangeal joint and flexion deformity of the proximal interphalangeal joint of the lesser toes. Occasionally this condition involves flexion of the distal interphalangeal joint as well. 
A hard corn is a localized hardening and thickening of the skin produced by friction and pressure. The most common location is over the dorsum of the toes, especially the dorsal aspect of the proximal interphalangeal joint of the fifth toe. A corn has a conical shaped core that extends into the dermis, and causes pain and irritation. A soft corn is a thickening of the epidermis between the toes caused by pressure between the prominent phalangeal condyles. This type of corn is kept softened by moisture and maceration, and often leads to painful inflammation beneath the corn.
Ingrown Toenails
An ingrown toenail occurs when the skin of the nail fold receives pressure from the nail edge, causing inflammation and pain. It can be caused by improperly trimming of the toenail or poor fitting shoes. Ingrown toenails occur most often in the big toe. In a competitive athlete this condition can be aggravating and even disabling
Contusions about the foot resulting from various types of direct impacts are common occurrences in athletics. The skin over the dorsum (top) of the foot is thin and only loosely attached to the underlying structures. Further, subcutaneous placement and exposed nature of most structures near the dorsum of the foot make them susceptible to contusion injuries. Injuries in this area tend to be painful even if actual tissue damage is minor. However, all direct trauma to the dorsum of the foot should be evaluated for the presence of significant damage to underlying structures such as bones, tendons, or nerves. 
Contusions to the plantar, or weight-bearing, surface of the foot can be particularly bothersome and handicapping. These injuries, common to the plantar aspect of the heel and ball of the foot, are normally caused by direct trauma such as repeated pounding on a hard surface, a faulty spike or cleat, stepping on an object, or even a wrinkle in the athlete's sock. The subcutaneous tissue between the bones of the foot and the thick plantar skin becomes bruised and inflamed. This injury, often called a stone bruise, or heel bruise, may become quite painful and disabling during weight bearing and athletic competition. Localized tenderness at the site of trauma may persist until weight bearing is relieved. Contusions of this type may develop into a chronic inflammatory process and reoccur throughout the athletic season.
Stress fractures may involve any bone in the foot, but more commonly involve the second, third, or fourth metatarsal. These fractures, occasionally called march fractures, occur with repetitive trauma. Excessive foot pronation or a high and rigid arched foot may contribute to the incidence of stress fractures. Symptomatically, stress fractures often exhibit a gradual increase in forefoot pain that is aggravated by activity and relieved by rest. X-ray films may be negative initially. If symptoms persist, the foot should be reexamined by radiography in a few weeks. At that time callus formation may indicate the presence of a stress fracture. 
Fractures involving the midfoot and hindfoot during athletic activity are not nearly as common as those in the forefoot. When fractures do occur in these areas of the foot, they are usually associated with severe torsion or compression forces and result in major foot injuries. 
Strains involving the foot are common occurrences in athletics. These injuries may involve the intrinsic muscles, the tendons, and tendinous attachments of the extrinsic muscles, and the plantar aponeurosis (plantar fascia). Strains may occur to any of the intrinsic muscles of the foot as a result of excessive overuse or violent stresses applied to muscles during athletic activity. Symptomatically, these injuries usually cause cramping or fatigue of the involved muscles and are painful during resistive movements. Symptoms normally subside when activity is reduced or discontinued. Strains of the extrinsic tendons cause tenderness at the site of the injury and increased pain on active and resistive contractions of the muscle or muscles involved. 
Plantar Fascittis
Is a common strain of the foot involving the plantar aponeurosis or fascia. These strong bands of fibrous connective tissue originate on the calcaneal tuberosities and inserts into the sides of the metatarsal heads and into the flexor digital tendon sheaths. This tough fascia surrounds the soft tissue structures of the sole of the foot and acts as one of the primary supports for the longitudinal arch. It is often described as a "tie rod" for the longitudinal arch because it serves to connect its end and prevent their spread. The plantar fascia is subjected to many stresses and forces during athletic activity, which may result in a strain injury that often becomes chronic. The pain associated with this type of an injury can be acute and handicapping. In many cases is most severe when the athlete first puts weight on the foot, for example, when getting out of bed in the morning or at the beginning of activity. The pain generally diminishes during activity, only to increase when activity stops or when the athlete is "cooling down." Point tenderness is usually located toward the calcaneal end of the aponeurosis and very often over the anterior medial tuberosity of the calcaneus. Occasionally the pain can be reproduced by having the athlete stand on the toes. Plantar fasciitis is often aggravated by excessive pronation of the foot, obesity, or an abnormally high arch (pes cavus).
Injuries involving the ligaments or ligamentous capsules surrounding the various joints of the foot are common in athletic activity. Sprains frequently result from forced motion at the joint, especially torsion movements, which can stress any of the supporting ligaments and cause various degrees of damage. Although it must be remembered that the human body is a chain-linkage system, sprains will be discussed in three segments that correspond to divisions of the foot: (1) Fore-foot, (2) Mid-foot, and (3) Hind-foot, which also includes the ankle joint. An injury in any one of these segments can cause problems or affect the others.
The forefoot is composed of the metatarsals and phalanges. This part of the foot is used in the pushing off of the foot and is subjected to stresses that may result in various types of sprains. The interphalangeal and metatarsophalangeal joints are most often injured by extreme dorsiflexion or plantar flexion forces.
Great Toe Sprain -- the metatarsophalangeal joint of the great toe is a common site for a sprain type of an injury, which is often referred to as a turf toe. A sprain of this joint can be debilitating n that the great toe is very important in weight bearing and must bear the brunt of every step. Symptomatically, sprains about the toes will be tender at the site of injury with an increase in pain on reproduction of the stress that caused the injury. In addition, there are normally varying amounts of swelling, stiffness, and soreness surrounding the articulations. Depending on the amount ligamentous damage, there may be varying amounts of instability associated with the injury. If instability is recognized, the athlete should be referred for medical assistance. 
Transverse Arch Sprain -- the metatarsal bones are joined by a complex mechanism of ligaments. Occasionally the ligaments and supporting tissues of the metatarsal head will be injured. The mechanism is varied but usually is associated with prolonged activity on hard surfaces or with overuse. Physical findings normally include tenderness and swelling under the heads of the metatarsals and pain upon weight bearing. Sprains involving the tarsometatarsal joints sometimes occur as a result of a twisting mechanism or direct stress, such as the athlete stepping on someone or something. This type of forefoot sprain can be very disabling because of the increased tenderness and pain upon weight bearing. Return to full activity may take up to 4 weeks or longer with this type of injury. 
Fractures -- are by the most common area for fractures in the foot. These fractures can result from a direct blow to the area or by indirect trauma produced when harmful forces are transmitted along the shaft of the bones. Symptomatically these fractures demonstrate point tenderness over the injured site and increased pain during longitudinal stress. Swelling, discoloration, crepitation, and deformity may also be present.
The midfoot is composed of the navicular, cuboid, and three cuneiform bones. The mid-tarsal and tarsometatarsal joints are supported by a strong ligamentous system that is not injured often. Midfoot sprains can result from severe twisting mechanisms or forceful direct trauma that causes a subluxation of the involved tarsals or metatarsals. These sprains produce tenderness at the site of the injury, and often weight bearing is extremely painful. Tenderness may be elicited at the involved joint by gentle passive pronation and abduction of the forefoot. Midfoot sprains can prevent an athlete from normal activity for a considerable length of time. If recovery is slow, it is often beneficial to place the foot in a firm-soled shoe or firm orthotic to decrease the stress across the midfoot and promote healing.
Longitudinal Arch Sprains -- the ligaments that support the longitudinal arch are also subjected to many stresses during athletic activity and can become inflamed, stretched, or torn. The mechanism of injury and symptoms are very similar to plantar fasciitis that was previously discussed. 
The hindfoot is composed of the calcaneus and talus. These bones serve as attachments for the medial and lateral ligaments that support the ankle joint; therefore injuries to the hindfoot are included in the segment with injuries to the ankle.
Information obtained from Booher & Thibodeau, Athletic Injury Assessment, 3rd Ed., Chapter 17

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