Sports Medicine: Just the Facts

CHAPTER 65 • FOOT INJURIES 385

of nonweightbearing immobilization (Arntz, Veith,

and Hansen, Jr, 1988; Myerson, 1989; Kuo et al,

2000).

SOFT TISSUE

COMPRESSIONNEUROPATHY(JOGGER’SFOOT)

• Entrapment of the medial plantar nerve distal to the
  tarsal tunnel can cause a neuropathy known as
  jogger’s foot. The medial plantar nerve courses plan-
  tarward after it exits the tarsal tunnel where it may be
  compressed by osteophytes from the talonavicular
  joint or a fibrotic master knot of Henry.
  •Patient’s complain of pain or numbness of the medial
  sole of the foot and medial toes.


• Conservative treatment consists of rest, nonsteroidal
  anti-inflammatories, or soft orthoses. Patients with a
  planovalgus foot may benefit from a University of
  California Biomechanics Laboratory (UCBL) orthosis.
  Injection of corticosteroid with local anesthetic can be
  diagnostic as well as therapeutic. Surgical release of
  the medial plantar nerve may be indicated with failure
  of nonoperative management (DiGiovanni and Gould,
  1998).

TARSALTUNNELSYNDROME
•Tarsal tunnel syndrome is the most common compres-
sion neuropathy of the foot and ankle. Etiology is
entrapment neuropathy of the posterior tibial nerve in
the tarsal tunnel or one of its terminal branches after
leaving the tarsal tunnel. Tarsal tunnel syndrome may
be posttraumatic, as result of a space-occupying
lesion, accessory muscle, or idiopathic (Schon, 1994).

• The tarsal tunnel is a fibro-osseous tunnel. The osseous
  boundaries are the medial surface of the talus, the
  medial surface of the os calcis, the sustentaculum tali,
  and inferomedial navicular. The fibrous portion of the
  canal consists of the flexor retinaculum as the roof and
  the abductor hallucis with its investing fascia.
  •Patients complain of burning, tingling, or numbness
  on plantar aspect of foot and may have night pain, or
  discomfort with even light bedcovers.


• The physical examination is characterized by a posi-
  tive Tinel’s sign at the tarsal tunnel or reproduction of
  symptoms with compression for 60 s.


• Other causes of peripheral neuropathy should be con-
  sidered such as diabetes, hypothyroidism, and alco-
  holism. Radiographs are obtained to rule out extrinsic
  bony abnormality. Electrodiagnostic studies are help-
  ful in differentiating from peripheral neuropathy or
  lumbosacral radiculopathy.


• Conservative treatment consists of avoidance of
  aggravating activities, control of generalized edema,

if present, with medications or compressive stockings

as indicated. Arch supports or medial heel wedges

may helpful. Nonsteroidals or injection of corticos-

teroid into the tarsal tunnel may benefit patients with

tenosynovitis. Surgical management consists of com-

plete release of the tibial nerve and all its branches,

and has been shown to result in improved outcome

measures after failure of conservative management

(Lau and Daniels, 1999).

PLANTARHEELPAIN

• Plantar heel pain is a common complaint among ath-
  letes and military recruits. There are several etiologies
  for chronic plantar heel pain.
  •Plantar fasciitis
  
  
  1. Plantar Fasciitis is probably the most common
     cause of plantar heel pain. Repetitive or acute
     trauma leads to microtears at the calcaneal inser-
     tion of the plantar fascia. The patient typically
     presents with pain localized to the plantar medial
     heel. The pain is often worse with the first few
     steps in the morning or after rest, also with jump-
     ing or pushing off.
  
  
  2. Radiographs may show a plantar heel spur in 50%
     of patients with plantar fasciitis and 15% of
     asymptomatic patients. Bone scan can help differ-
     entiate plantar fasciitis from calcanael stress frac-
     ture.
  
  
  3. Primary treatment of plantar fasciitis is nonopera-
     tive, conisisting of Achilles stretching and activity
     modification. Hand massage, ice massage, or anti-
     inflammatories may also be helpful. Cushioned
     heel cups are often prescribed. Injection of corti-
     costeroids with local anesthetic may be considered
     after failure of other methods. Repeated steroid
     injection may cause atrophy of the heel fat pad and
     should be avoided.
  
  
  4. Ninety-five percent of patients with plantar fasci-
     itis will have resolution of their symptoms within
     12–18 months. For the 5% of patients who fail
     conservative treatment, surgical release of the
     plantar fascia may be considered. Although sur-
     gery generally results in improvement in symp-
     toms patients should be counseled that recovery
     can be prolonged, and that exercises to maintain
     Achilles length must be continued (Pfeffer, 2003).
  
  
  
  


• Acute posterior fourchette(PF) tear
  
  
  1. A variation of insertional plantar fasciitis is acute
     tear of the plantar fascia. Patients present with
     acute pain or swelling of the plantar foot. A defect
     in the plantar fascia may be palpable, and loss of
     arch height may be noted with complete rupture.
  
  
  2. Treatment varies with symptoms, ranging from
     weightbearing as tolerated to nonweightbearing