By Barry Mulshine, M.D.
Whether you are a serious athlete or a weekend warrior, injuries to the foot and ankle are common with participation in many types of sports. Acute injuries, such as ankle sprains or fractures will cause problems suddenly, but other overuse injuries such as tendinitis and stress fractures, can have a more gradual onset. This article will review some of the more common sports-related foot and ankle problems typically seen in our clinic.
The Achilles tendon is the largest, strongest tendon in the body. It connects two large muscles in the calf, the gastrocnemius and the soleus, to the back of the heel, so that when these muscles contract the ankle plantar flexes, or pushes downward. This is necessary to generate the push-off power needed for running and jumping. Because of the high stresses transmitted through this tendon, and its rather unprotected location behind the ankle, the Achilles tendon is somewhat prone to injury in athletes.
Achilles tendinosis (sometimes referred to as tendinitis) commonly occurs as an overuse injury among athletes. This is typically caused by prolonged running or jumping. Inflammation along the lining of the tendon will result in visible swelling of the tendon, pain, and sometimes a scratching feeling with motion. Initially this will present as pain after strenuous activities, and may then progress to pain with everyday activities and even at rest.
Non-operative treatment is successful in 70-75% of patients and is directed at relieving symptoms. It is important to correct any training errors and alignment problems. Physical therapy to improve flexibility and strength may be beneficial.
In acute tendinopathy controlling inflammation is recommended. Modified rest, cross-training, and icing the affected area is important. Anti-inflammatory medications may have a role for acute tendinitis, but are less helpful for chronic tendinopathy. There is controversy regarding the effectiveness and safety of various types of injections. Studies investigating injections of cortisone, sclerosing agents, and platelet-rich plasma (PRP) have not demonstrated convincing benefits.
For the approximately 25% of patients that continue to have pain despite conservative treatment surgery may be considered. In most cases the tendon can be debrided through a small incision or even percutaneously. This involves removing adhesions and scarring around the tendon, jumpstarting the blood supply to the weakened area. This is successful 75-100% of the time. If there is an area of significant damage to the tendon, more invasive surgery may be needed to reconstruct the damaged tissue.
Achilles Tendon Rupture
A complete tear of the Achilles tendon can occur if the calf muscles quickly contract while the ankle is being forced into dorsiflexion. This is most common in middle aged men, the so-called “weekend warriors.” Sometimes this can occur when trying to jump, or during a slip or stumble. Sometimes an audible crack or pop can be heard. The pain is usually more severe in the calf than by the ankle. Patients will often report that they thought someone had kicked or struck them in the calf. Initially, walking is difficult and painful, although the pain does gradually improve with time.
It is very important that treatment begin immediately after an Achilles rupture, so early evaluation by an orthopedic surgeon is critical. Patients that wait 4-6 weeks to seek treatment because they self-diagnosed an ankle sprain will have poorer outcomes. Acutely, the diagnosis can usually be made without an MRI except in some equivocal cases.
The proper treatment for acute tendon ruptures is somewhat controversial. Traditionally, non-operative treatment was recommended for ruptures in older and less active patients, and open surgical repair of the tendon recommended for younger, more active patients. Non-operative treatment consisting of casting and crutches for 6 weeks had pretty good results, but with a higher rate of repeat ruptures compared to surgical repair. Newer non-operative protocols involving early motion and earlier weight-bearing have – somewhat counterintuitively – yielded better outcomes. In fact, some studies have shown very similar outcomes compared with surgical treatment, without the risk of wound-healing problems.
For more athletic patients desiring surgical treatment, there are newer less invasive techniques that reduce the risk of wound problems, and allow for earlier weight-bearing than traditional open surgical repair. Sutures can be placed into the tendon through puncture holes in the skin and brought together using a special instrument inserted through a small incision over the torn tendon. The sutures can either be tied together to repair the tendon, or can be attached directly to the heel bone with bone anchors.
The key to obtaining good outcomes with Achilles tendon ruptures is prompt diagnosis, and quickly initiating treatment, be it operative or non-operative.
In the same way that tendinitis is often an overuse injury of a tendon, a stress fracture is an overuse injury of a bone. Since the bone is a living tissue, it continuously responds to the stresses that are applied to it during activities. In response to repeated stress, such as from exercise, the bone will gradually get stronger. Unfortunately, bone cannot strengthen itself very quickly – this is a gradual process. If someone begins a new exercise program or rather suddenly increases the length or duration of workouts, this repetitive trauma could cause a localized weakening of a particular bone. Common locations for stress fractures are the 2nd metatarsal, 5th metatarsal, tibia, and the navicular.
The first sign of a stress fracture is pain and swelling during or after exercise. There is usually tenderness directly over the affected area of the bone itself. X-rays may not show the fracture for the first 3-4 weeks after the onset of symptoms.
The key to treatment for stress fractures is relative rest. The key is to reduce activities enough to prevent the pain. Sometimes using a stiff-soled shoe or boot is necessary. The recovery will become more prolonged if an athlete tries to “play through the pain.” In certain instances surgery may become necessary.
Peroneal Tendon Problems
There are two peroneal tendons, peroneus brevis and peroneus longus, that are located along the outside part of the ankle. The function of these tendons is to stabilize the ankle and prevent inversion. Sometimes they can be damaged during a twisting injury to the ankle, or tendinitis may occur with overuse, such as running on uneven surfaces.
Peroneal tendinitis may resolve with rest and icing the affected area. A brace, heel wedge, or certain shoe modifications is sometimes necessary. If the problems persist an MRI may be indicated to evaluate for a tear of one of the peroneal tendons. If the symptoms persist, surgery may be needed.