Time Wounds All Heels

The foot is divided into three regions: rearfoot, midfoot and forefoot. The top of the foot is referred to as the dorsum or dorsal surface; the sole of the foot is referred to as the plantar surface. There is a fair amount of overlap among the regions, with some structures originating proximal and traversing distal. As a result, injury to a proximal (close) structure may result in distal (distant) symptoms.

The rearfoot consists of the topmost bone of the foot (the talus), which connects with the bones of the lower leg (tibia and fibula) to help form the ankle. The talus also connects with the calcaneus, the bone that forms the heel. The Achilles tendon originates at the muscles of the calf and inserts on the back of the calcaneus. Several tendons course down from the muscles of the lower leg and insert onto bones of the foot, allowing for complex motion. Injury to these tendons may result in injury to the bone where they attach. The tarsal tunnel is a connective-tissue canal located below the medial ankle. It contains tendons and nerves that can become painfully entrapped.

The midfoot contains the tarsal bones, small bones that mirror the carpal bones of the wrist. The plantar aponeurosis is a thick band of connective tissue that originates at the calcaneus and inserts into the proximal phalanges, the bones of the toes.

The forefoot contains the metatarsals (the long bones of the foot) and the phalanges. Sensation in the plantar aspect of the foot is provided by branches of the medial plantar nerve. These branches run between the metatarsal bones, where they can become compressed, with resultant injury and pain.

For an in-depth look at foot anatomy (including muscle origin, insertion and action), as well as exercises to strengthen your feet, see the Fine Anatomy column in the April 2003 issue of IDEA Personal Trainer, pp. 46–51.

Biomechanics

To close the kinetic chain most efficiently, the feet need to have solid contact with the ground. They must support the forces applied by the body in motion above them, while absorbing the impact of the hard surface below.

In most sports we use our feet for walking, running or jumping. Forces exerted on the foot during each step of light running equal about two to three times body weight; during sprinting, forces equal four times body weight and may be much greater during push-off.

Impact is most often on the heel, but may be flat or on the ball of the foot during a sprint. Over the course of time, minor errors in biomechanics can cause cumulative damage. A small amount of excess pounding on the heel or arch is no big deal when walking to get the mail; but after an hour of high-impact exercise, it is a very different story.

Some degree of pronation (medial rotation) of the planted foot is normal and helps absorb impact forces. Watch your bare foot as you step and you can see the arch roll downward. Problems can result from excessive pronation or excessive rigidity of the foot at the arch or at the articulation of the foot and ankle.

When a client complains to you about a painful foot, take a close look. Have him or her stand barefoot, feet pointing straight ahead. Observe from the front and rear, and look carefully for differences between the two feet. Look for “flat feet” (pes planus), which can result from excess pronation or an incompetent arch. Look for a high, rigid arch that does not allow for rotational mobility (pes cavus). Successful relief from foot pain and prevention of recurrence are enhanced when biomechanical issues are addressed.

Common Foot Injuries

Retrocalcaneal Bursitis. Bursae are small, fluid-filled sacs that act as bumpers between bone and tendon or bone and surface tissues. Prominent and frequently injured locations on the body include the olecranon bursa of the elbow and the subacromial bursa of the shoulder. Retrocalcaneal bursitis occurs when the bursae between the skin and the Achilles tendon or between the tendon and the calcaneus become irritated.

This most often occurs due to friction from tight-fitting shoes and is frequently seen in runners or in step class participants. Clients will complain of pain on the posterior heel. A positive two-finger squeeze test (pain with pressure on the bursa, just anterior and superior to the tendon insertion) helps confirm the likelihood of the problem. This entity should be differentiated from Haglund’s deformity, or “pump bump,” in which friction from tight-fitting women’s shoes causes pathologic bone growth over the posterior calcaneus. Ask your female clients what type of shoes they wear when not training.

Treatment consists of friction reduction, using either open-back shoes or padding, which should be placed behind the heel, between skin and shoe, to prevent abrasion. A number of over-the-counter products can be used, including moleskin, lamb’s wool or preshaped adhesive pads. Ensure that your clients are wearing quality shoes that are not too tight over the heel and yet do not allow excessive foot sliding. Recalcitrant cases should be referred to a physician, who may place the clients on anti-inflammatories, recommend a period of relative rest and ensure proper shoe fit. Steroid injections are usually avoided because of the risks of injecting into the tendon, which could potentially rupture. Haglund’s deformity will respond to the same treatments, although referral to a podiatrist or orthopedic surgeon for excision of the abnormal bone growth may be required.

Plantar Fasciitis. Also referred to as subcalcaneal pain or, more generally, heel pain syndrome, this is a common problem among athletes and nonathletes alike. Individuals may complain of gradual-onset heel pain that is worse upon arising in the morning or after a period of inactivity. Examination reveals maximal tenderness at the plantar-medial aspect of the calcaneus. Those who have had radiographs of the foot may claim to have a “heel spur.” While often present in chronic or recurrent cases, spurring of the calcaneus is not the cause of pain but rather a result of ongoing irritation of the bone.

A closer look at clients with heel pain syndrome often reveals hyperpronation and a tight Achilles tendon, both of which increase tensile forces on the plantar fascia. Other risk factors include a change in sporting activity or intensity, poorly fitting footwear and obesity.

Finding solutions can be challenging, and symptoms may persist for months. Have your clients limit barefoot walking, and be sure they are wearing well-padded athletic shoes that protect the heel and support the arch. Over-the-counter or custom-made arch supports may be helpful. Instruct your clients on proper Achilles tendon stretching and toe curls to strengthen muscles of the foot. Oral anti-inflammatory medications and ice massage (rolling a can of frozen juice under the foot) can help ease pain. Night splints are available from a number of manufacturers. The theory is that during sleep with the foot in dorsiflexion (cocked up toward the body), injured fascia heals under tension. Therefore, the first few steps in the morning will not stretch and reinjure tissue crosslinking formed overnight. Night splints have not proven effective, however, and compliance is low owing to bulk and discomfort.

Fat Pad Syndrome. This condition presents with heel pain similar to that of plantar fasciitis. Clients may have tenderness directly under the weight-bearing portion of the calcaneus. Injury may occur acutely from a fall or jump (basketball, track and field) or may be cumulative (running, high-impact aerobics). Protective padding or a heavily cushioned insole may alleviate the problem. Plastic heel cups are available and help compress the fat pad medially and laterally, allowing it to be a more effective cushion over the center of the calcaneus.

Posterior Tibial Tendinopathy. The posterior tibial tendon runs posterior and inferior to the medial malleolus of the ankle, from rearfoot to midfoot. It allows for inversion and plantar flexion of the foot and can easily be irritated through overuse in almost any athletic activity. Pain is usually present with palpation of the tendon posterior and/or distal to the medial malleolus. To stress the tendon, place resistance against an inverted and plantarflexed foot (point the foot down and roll the ankle in); this maneuver causes pain when injury is present.

Acute tendon rupture may occur in association with a twisting injury to the foot or ankle and is associated with unilateral loss of the medial arch. If you suspect such a rupture in a client, have him or her face away from you, feet pointed forward. Look at the medial arch. A flat foot in combination with an acute injury in the medial foot or ankle is a concerning find and requires urgent referral to a physician for possible surgical repair.

A physician might prescribe a treatment course that consists of relative rest, ice and analgesics. Please note, I avoid the term tendonitis. The suffix “-itis” implies inflammation, which may or may not be present in an injured tendon. Tendinopathy is a more proper term for the many findings in an injured tendon, including inflammation, degeneration and tears. Support of the medial arch with orthotics can alleviate stress on the tendon.

Tarsal Navicular Stress Fracture. This injury is difficult to spot. It would not be unusual for a frustrated client who has already been seen by a physician to complain of a weeks- or even months-long history of ongoing pain in the dorsum of the foot. Radiographs already obtained may have read as normal.

This is an overuse injury most often seen in running sports such as distance running, soccer and basketball. Stress fractures occur over the course of weeks, in parts of the body where bones either absorb direct shock or are repeatedly stressed by attached contracting muscle. If damage accumulates faster than the body’s ability to heal, a fracture develops. Thorough questioning will usually elicit a typical scenario for stress fracture: A recent increase in activity has precipitated gradually worsening pain that, after a number of weeks, now impedes athletic activities and may be impeding daily activities. Early in stress fracture, clients may complain of pain at night following their training; eventually the pain appears during activity.

Physical exam reveals tenderness over the navicular tuberosity, and there may be overlying soft-tissue swelling. Radiographs are often normal until late in the disease process. Navicular stress fractures have a high risk for nonunion of the fracture fragments. If you suspect this injury in a client, immediately refer the person to an experienced sports medicine physician or orthopedic surgeon. Definitive diagnosis is made by radio-nuclide bone scan, CAT scan or MRI. Treatment consists of prolonged casting or surgery.

Metatarsal Fractures. The metatarsals are commonly injured bones. Their vulnerability is due to their role in shock absorption as well as their tendinous attachments.

Metatarsal stress fractures are also known as “march fractures” owing to their prevalence among military recruits. In fact, much of the early and current research in stress fracture prevention looks at this population.

A history of increased high-impact activity is coupled with complaints of aching pain in the forefoot. Examination reveals tenderness over the affected bone, most often the second or third metatarsal. Soft-tissue swelling about the affected bone may be present.

Early on, it can be difficult to differentiate between this injury and metatarsalgia, a benign irritation of a metatarsal (often at the metatarsal “head” where it joins with the toe). If you have clients complaining of gradual forefoot discomfort, conservative action is reasonable. Give them a rest from high-impact activities (cross-training with low-impact swimming or cycling is suggested) and ensure that they are using quality footwear in good condition. Address issues such as excess pronation with properly fitted shoes or inserts. When pain is resolved, gradually increase the intensity of the clients’ activity. Refer those with recurring, persistent or worsening pain to an experienced physician.

Fracture of the proximal fifth metatarsal most often occurs in association with ankle inversion injury. The base of the bone may be avulsed off at the insertion of the peroneous brevis tendon. When a client sprains an ankle and it is significantly swollen, unable to bear weight or tender over the bones of the ankle or at the base of the fifth metatarsal, refer the client to a physician. The majority of avulsion fractures will heal without operative intervention, but they do need to be watched.

There is an area of the fifth metatarsal approximately 2 centimeters from its base that has extremely poor blood flow. Fractures in this zone, called Jones fractures, are prone to slow healing and nonunion. An acute Jones fracture requires cast immobilization and sometimes surgery. Refer anyone with bone tenderness to a sports medicine physician.

Intermetatarsal (Morton’s) Neuroma. Morton’s neuroma develops when the intermetatarsal nerve becomes entrapped or compressed in the space between the metatarsal bones. The resulting nerve injury causes burning pain, numbness and tingling that worsen with activity, most often in the third web space. This injury is also of gradual onset, developing over weeks to months. When you feel along the bottom of the foot, soreness should be in the space between the bones, not on the bones themselves. You may be able to duplicate the symptoms by compressing the metatarsal heads together. Occasionally, the thickened nerve may actually be felt between the heads, in the web space.

Diagnosis and treatment can be challenging. Other injuries, such as stress fracture, must be excluded. Refer clients to a sports medicine specialist or podiatrist for follow-up. Treatment is aimed at easing nerve irritation. Ensure that clients’ shoes have an adequately wide toe box. Submetatarsal orthotics (such as commercially available metatarsal pads) may help lift and separate the metatarsal heads. A physician may try a corticosteroid injection into the affected area to reduce inflammation.

In your role as the fitness professional, you are often the first one to see an injured client. It is critical that you make swift referrals for diagnosis and treatment. Remember to get a thorough history of any injury in the screening process and keep ongoing records of injury. Develop a network of sports medicine physicians and orthopedists with whom you can discuss injuries and to whom you can refer clients when needed. Rapid diagnosis and treatment lead to rapid recovery, and your clients will appreciate your ability to get them back to the activities that enrich their lives and keep them healthy. n