and cast immobilzation. Physical therapy is begun
once the patient can comfortably bear weight (usu-
ally about 4–6 weeks). An arch support may be
helpful with persistent discomfort associated with
loss of arch height.
•Fat pad insufficiency
- Fat pad insufficiency is often seen in older athletes
or in patients after multiple corticosteroid injec-
tions to the heel. Other causes of heel pain should
be excluded prior to making the diagnosis of fat
pad atrophy. Treatment consists of a viscoelastic
heel cup and well-cushioned shoes (Baxter,
Thigpen, and Pfeffer, 1989; Karr, 1994).
POSTERIORHEELPAIN
- There are several causes of posterior heel pain. In
addition to the entities below, inflammatory condi-
tions such as gout, psoriasis, and Reiter’s disease must
be considered.- Insertional Achilles tendinitis is common in jump-
ing athletes, but may also be precipitated by a
direct blow or poorly fitting shoes. On physical
examination there is tenderness to palpation
directly over the insertion of the Achilles and pain
with resisted plantar flexion. Treatment is conser-
vative with nonsteroidal anti-inflammatory drugs
(NSAIDs), Achilles stretching, and activity modifi-
cation. Felt or silipose pads placed over the poste-
rior heel may also be beneficial. - Retrocalcaneal bursitis can also present as poste-
rior heel pain and direct tenderness to palpation of
the posterior heel. The bursa is a synovial-lined
bursa between the posterior calcaneus and the
Achilles tendon. Treatment is conservative as for
insertional Achilles tendinitis. Rarely, excision of
the bursa may be necessary. - Haglund’s deformity is an abnormal prominence of
the posterosuperior portion of the calcaneus that
can be associated with retrocalcaneal bursitis.
Initial treatment is conservative as for retrocal-
caneal bursitis, but surgical excision of the promi-
nence may be required (Stephens, 1994).
- Insertional Achilles tendinitis is common in jump-
SPRINGLIGAMENTRUPTURE
- Rupture of the plantar calcaneonavicular ligament is
usually seen to fail secondary to rupture of the poste-
rior tibial tendon in the setting of acquired flatfoot.
Rarely, however, acute rupture of the spring ligament
can also be a primary cause of painful acquired flat-
foot. - Presentation is similar to that of posterior tibial
tendon dysfunction with a progressive painful
planovalgus foot. There may be a history of eversion
injury. The patient may have difficulty or be unable to
perform a single toe raise; however, the tibialis poste-
rior will have full strength on testing. Radiographs
may reveal loss of longitudinal arch height.
•Treatment with surgical reconstruction of the spring
ligament complex has been reported to be successful
(Borton and Saxby, 1997).FOREFOOTBONYMETATARSALSTRESSFRACTURE- Stress fractures account for nearly 5% of all sports
injuries. Stress fractures of the metatarsals rank
second after the distal tibia in frequency. Among the
metatarsal fractures, fracture of the diaphysis of the
fifth is most common; however, stress fractures of
the fifth must be distinguished from acute traumatic
fractures.
•Generally presents with pain of insidious onset,
although may present after acute trauma. Patients
often relate a history of increased intensity of activity,
or changes in footwear or activity surface. Ninety per-
cent of metatarsal stress fractures involve the second,
third, or fourth metatarsal. - Presentation of stress fractures of the metatarsals can be
similar to metatarsophalangeal joint(MTPJ) synovitis
or interdigital neuritis. The pain can be reproduced by
pushing the metatarsal upward from below, and is gen-
erally more proximal than the pain from MTP synovi-
tis. Diagnosis is confirmed by radiographs. If stress
fracture is still suspected and routine radiographs are
normal, technetium bone scan may be performed. - Rest and a stiff wooden-soled shoe are usually suffi-
cient treatment. Occasionally, a short-leg walking cast
or walking boot may be required. Symptoms typically
resolve in about 4 weeks and activity is resumed
gradually (Myerson, Haddad, and Weinfeld, 1997).
FRACTURES OF THEPROXIMALFIFTHMETATARSAL- There are at least three distinct fracture patterns in the
proximal fifth metatarsal, each with its own mecha-
nism of injury, treatment options, and prognosis.
1.The most common fractures of the proximal fifth
metatarsal are avulsion fractures of the tuberosity.
The mechanism of injury is thought to be avulsion
of the lateral band of the plantar aponeurosis. These
fractures are generally extra-articular and rarely
displaced. Treatment usually consists of weight-
bearing as tolerated in a walking cast or hard-soled
shoe until pain subsides. If the fracture is markedly
displaced open reduction and internal fixation may
be indicated.
386 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE