1. Common foot problems in sport Trevor D Prior Consultant Podiatric Surgeon Homerton University Hospital © TD Prior 2013

2. Foot & Ankle Injuries Athens 2004 Badekas et al, JFAR 2009 © TD Prior 2013

3. Sports injuries of the foot and ankle © TD Prior 2013

4. Injuries per discipline © TD Prior 2013

5. Soft tissue injuries © TD Prior 2013

6. Bone injuries © TD Prior 2013

7. Evaluation and management of the athlete History History Mechanism Mechanism Onset of symptoms Onset of symptoms Examination Examination Clinical Clinical Investigations Investigations Investigations X-ray US MRI CT Bone Scan Choose the investigation for the suspected pathology © TD Prior 2013

8. Clinical assessment Direct palpation Direct palpation Passive motion Passive motion Joint Joint ROM, Ligamentous stability, capsular stability ROM, Ligamentous stability, capsular stability Muscle / Tendon Muscle / Tendon Stretch / flexibility Stretch / flexibility Resisted motion Resisted motion © TD Prior 2013

9. Clinical assessment Functional movement Functional movement Dynamic weakness Dynamic weakness Protection Protection Spasm Spasm Neurological Neurological Compression Compression Percussion Percussion Stretch Stretch Vascular Vascular © TD Prior 2013

10. Evaluation and management of the athlete History History Mechanism Mechanism Onset of symptoms Onset of symptoms Examination Examination Clinical Clinical Investigations Investigations Diagnosis Diagnosis Management Management Mechanical Mechanical Symptoms Symptoms Pathology Pathology © TD Prior 2013

11. Management of the athlete Mechanical Mechanical Strapping / immobilisation Strapping / immobilisation Rehab Rehab Mobilisation Mobilisation Footwear Footwear Orthoses Orthoses © TD Prior 2013

12. Management of the athlete Mechanical Mechanical Strapping / immobilisation Strapping / immobilisation Rehab Rehab Mobilisation Mobilisation Footwear Footwear Orthoses Orthoses Symptoms Symptoms Medication Medication Injection therapy Injection therapy Steroid, HA, sclerosant Steroid, HA, sclerosant Shockwave therapy Shockwave therapy Pathology Pathology Surgery Surgery © TD Prior 2013

13. You find what you look for You look for what you know Lawrence Harkless DPM © TD Prior 2013

14. Examining for pathology Skin Skin Subcutaneous layer (superficial fascia) Subcutaneous layer (superficial fascia) Nerve, blood vessels, fat, tumours Nerve, blood vessels, fat, tumours Muscle / tendon Muscle / tendon Overuse, tenosynovitis, tear, rupture Overuse, tenosynovitis, tear, rupture Ligament Ligament Stretch, tear Stretch, tear © TD Prior 2013

15. Examining for pathology Joint Joint Capsular damage, synovitis/capsulitis Capsular damage, synovitis/capsulitis OA, AVN OA, AVN Inflammatory disease Inflammatory disease Bone Bone Oedema, Stress lesion, fracture, tumour Oedema, Stress lesion, fracture, tumour © TD Prior 2013

16. 1 st Ray IGTN (8.3%) IGTN (8.3%) HAV (2.9%) HAV (2.9%) Palpation Palpation Joint line, sesamoids, medial eminence, EHL, MCJ Joint line, sesamoids, medial eminence, EHL, MCJ Passive motion Passive motion ROM, 1 st ray (sagittal & transverse) ROM, 1 st ray (sagittal & transverse) Tracking Tracking Resisted motion Resisted motion FHL strength FHL strength © TD Prior 2013

17. 1 st ray HAV HAV Weightbearing Weightbearing Rotation, Angle, width (load / fhl) Rotation, Angle, width (load / fhl) Management Management Mechanical: Mechanical: shoes / orthoses / strapping / protection shoes / orthoses / strapping / protection Symptoms: Injections Symptoms: Injections Surgery: Correction Surgery: Correction © TD Prior 2013

18. 1 st ray OA: HL / HR (3.4%) OA: HL / HR (3.4%) Palpation Palpation Joint line, thickening, sesamoids Joint line, thickening, sesamoids Passive motion Passive motion ROM, compression ROM, compression Resisted Resisted FHL, EHL FHL, EHL Weightbearing Weightbearing Hallux Hallux © TD Prior 2013

19. 1 st ray OA: HL / HR OA: HL / HR Management Management Mechanical Mechanical Footwear / orthoses / Strapping Footwear / orthoses / Strapping Symptoms Symptoms Injections Injections Surgery Surgery Disease specific Disease specific © TD Prior 2013

20. 1 st ray Sesamoid complex Sesamoid complex Sesamoidits Sesamoidits Fracture (0.5%) Fracture (0.5%) Turf toe (1.3%) Turf toe (1.3%) Fhl / ligament Fhl / ligament © TD Prior 2013

21. 1 st ray Sesamoid complex Sesamoid complex Palpation Palpation Sesamoids, FHL, ligament Sesamoids, FHL, ligament Passive motion Passive motion Stretch, compression Stretch, compression © TD Prior 2013

22. 1 st ray Sesamoid complex Sesamoid complex Resisted motion Resisted motion FHL FHL Weightbearing Weightbearing Load Load Management Management Mechanical Mechanical Boot, Footwear, orthoses Boot, Footwear, orthoses Symptom Symptom Injection Injection Surgery Surgery Removal, repair Removal, repair © TD Prior 2013

23. 1 st ray Miscellaneous Miscellaneous Synovitis / plica Synovitis / plica Bone bruising Bone bruising Osteochondral lesion Osteochondral lesion Fracture / stress fracture Fracture / stress fracture Digital Digital Metatarsal Metatarsal © TD Prior 2013

24. Central forefoot Lesser MTPJs Lesser MTPJs Synovitis / capsulitis Synovitis / capsulitis Plantar plate (0.3%) Plantar plate (0.3%) Freiberg’s (0.3%) Freiberg’s (0.3%) Tendon (FDL) Tendon (FDL) Deformity Deformity © TD Prior 2013

25. Central forefoot Lesser MTPJs Lesser MTPJs Palpation Palpation MTPJ / IM, digital MTPJ / IM, digital Irregularity Irregularity Metatarsal parabola Metatarsal parabola Passive motion Passive motion FHL, EHL FHL, EHL Capsular stress Capsular stress Resisted motion Resisted motion FDL, FDB, EDL FDL, FDB, EDL © TD Prior 2013

26. Central forefoot Lesser MTPJs Lesser MTPJs Weightbearing Weightbearing Digital position, FDB Digital position, FDB Management Management Mechanical Mechanical Boot, strapping, Footwear, orthoses Boot, strapping, Footwear, orthoses Symptom Symptom Injection Injection Surgery Surgery Correction, debridement, repair Correction, debridement, repair © TD Prior 2013

27. Central forefoot Neuroma (1%) Neuroma (1%) Palpation Palpation IM IM Passive motion Passive motion Compression, Moulders click, ? Slump test Compression, Moulders click, ? Slump test Resisted motion Resisted motion FDL, FDB, EDL FDL, FDB, EDL © TD Prior 2013

28. Central forefoot Neuroma Neuroma Weightbearing Weightbearing Soft tissue mass, splaying, pain Soft tissue mass, splaying, pain Management Management Mechanical Mechanical Footwear, orthoses Footwear, orthoses Symptom Symptom Injection Injection Surgery Surgery Excision, release Excision, release © TD Prior 2013

29. Metatarsal fractures Fracture Fracture Stress Stress Jones Jones Styloid process (0.5%) Styloid process (0.5%) © TD Prior 2013

30. Metatarsal fractures Palpation Palpation Metatarsal shaft, styloid process Metatarsal shaft, styloid process Passive motion Passive motion Stress metatarsal, PB Stress metatarsal, PB Resisted motion Resisted motion PB PB © TD Prior 2013

31. Metatarsal fractures Weightbearing Weightbearing Deformity, swelling Deformity, swelling Management Management Mechanical Mechanical Boot, orthoses, footwear Boot, orthoses, footwear Symptom Symptom Nil Nil Surgery Surgery Fixation for Jones, displaced, non union Fixation for Jones, displaced, non union © TD Prior 2013

32. Lisfrancs joint Palpation Palpation Joint line, osteophytes Joint line, osteophytes Passive motion Passive motion Stress, rotation Stress, rotation Resisted motion Resisted motion Extensors Extensors Weightbearing Weightbearing Position Position Management Management Surgery Surgery © TD Prior 2013

33. Cuboid syndrome Palpation Palpation Articulations, peroneals Articulations, peroneals Passive motion Passive motion Peroneals, articulations Peroneals, articulations Resisted motion Resisted motion Peroneals Peroneals © TD Prior 2013

34. Cuboid syndrome Weightbearing Weightbearing Heel lift, forefoot abduction Heel lift, forefoot abduction Management Management Mechanical Mechanical Boot, strapping, footwear, orthoses, stretching, mobilisation Boot, strapping, footwear, orthoses, stretching, mobilisation Symptom Symptom Injection Injection Surgery rare Surgery rare Possible fusion or arthroplasty Possible fusion or arthroplasty © TD Prior 2013

35. Midfoot pain Differential diagnosis Differential diagnosis Tendonopathy Tendonopathy OA OA Bone bruising Bone bruising Stress fracture Stress fracture AVN AVN Accessory ossicle Accessory ossicle Tarsal coalition Tarsal coalition Nerve entrapment Nerve entrapment © TD Prior 2013

36. Midfoot pain Palpation Palpation Joint lines Joint lines Hot spots Hot spots Tendon / insertion Tendon / insertion Nerves Nerves Accessory ossicles (1.4%) Accessory ossicles (1.4%) Os peroneum / versalianum Os peroneum / versalianum Os naviculare Os naviculare Passive motion Passive motion ROM, rotation, stress, tendon ROM, rotation, stress, tendon © TD Prior 2013

37. Midfoot pain Resisted motion Resisted motion Tendons Tendons Weightbearing Weightbearing Position Position Axial loading Axial loading Management Management Mechanical Mechanical Boot, orthoses, strapping Boot, orthoses, strapping Symptom Symptom Injection Injection Surgery Surgery Repair, fusion Repair, fusion © TD Prior 2013

38. Plantar heel pain Differential diagnosis Differential diagnosis Plantar fasciitis Plantar fasciitis Fascial tear Fascial tear Bone marrow oedema Bone marrow oedema Spur Spur Nerve entrapment Nerve entrapment Fibroma Fibroma Bursitis Bursitis © TD Prior 2013

39. Plantar heel pain Palpation Palpation Plantar calc., central band / distal slips, medial calcaneal nerve, tarsal tunnel Plantar calc., central band / distal slips, medial calcaneal nerve, tarsal tunnel Passive motion Passive motion Passive stretch, slump test Passive stretch, slump test © TD Prior 2013

40. Plantar heel pain Resisted motion Resisted motion Plantarflexion Plantarflexion Weightbearing Weightbearing Digital position, fat pad Digital position, fat pad Management Management Mechanical Mechanical Strapping, stretching, footwear, orthoses, night splint Strapping, stretching, footwear, orthoses, night splint Symptom Symptom Cortisone, ESWT Cortisone, ESWT Surgery ??? Surgery ??? © TD Prior 2013

41. Conclusions Good history Good history Functional Anatomy Functional Anatomy Assessment skills Assessment skills Appropriate investigation Appropriate investigation Knowledge of conditions Knowledge of conditions Targeted management plan Targeted management plan © TD Prior 2013

42. Thank You © TD Prior 2013

43. Rearfoot Soft tissue Soft tissue Tendonopathy: Tendonopathy: Peroneals (10.3%) Peroneals (10.3%) Tib ant. (4.5%) Tib ant. (4.5%) Tib post, flexors, Tib post, flexors, Peroneal subluxation Peroneal subluxation Nerve Nerve Tarsal tunnel syndrome Tarsal tunnel syndrome Medial calcaneal nerve Medial calcaneal nerve Sural nerve Sural nerve © TD Prior 2013

44. Rearfoot Joint Joint Ligament (22%) Ligament (22%) Lateral ligament complex Lateral ligament complex Deltoid Deltoid Impingement / synovitis Impingement / synovitis Sinus tarsi Sinus tarsi Anterior ankle Anterior ankle Posterior medial / lateral Posterior medial / lateral Osteochondral defect Osteochondral defect © TD Prior 2013

45. Achilles (24.5%) Soft tissue Soft tissue Bursitis Bursitis Tendonopathy Tendonopathy Partial/ complete rupture Partial/ complete rupture Bone Bone Pump bump Pump bump Haglunds Haglunds Insertional tendonopthy Insertional tendonopthy © TD Prior 2013

46. Rearfoot Bone Bone Accessory ossicle Accessory ossicle – Os trigonum – Os trigonum Bone oedema Bone oedema Fracture / stress fracture Fracture / stress fracture Malleoli: medial, lateral Malleoli: medial, lateral Calcaneus Calcaneus © TD Prior 2013