Running Foot Pain or Stress Fracture?

Running Foot Pain or Stress Fracture?

Pain is often a runner’s most loyal training partner, free from the busy social calendars or alarm clock failures that leave you pounding the pavement solo during those early-morning 5 milers.

Differentiating “normal” pain from one that merits a visit to your local sports medicine specialist is the tricky part of that relationship.  Let me help you address this problem to keep you healthy and happy…and running pain-free.

The Inside Scoop on Foot Stress Fractures

Stress fractures located in the foot are usually characterized as an overuse injury to weight-bearing bones.  High-impact sports that involve running and jumping contribute to simple foot pain and, if left untreated, can lead to a more serious problem like stress fractures.

Bones generally respond to stress by hardening along their outer margins.  When suddenly exposed to strong forces or ongoing stress, there is little time for bones to adapt. Meanwhile, muscles associated with the feet lose their shock-absorbing capacities when fatigued. These uncontrolled forces inadvertently transfer to nearby bones, possibly resulting in small cracks that are better known as stress fractures.

Stress fractures commonly occur in distance runners along the outer ridge of the forefoot over the fifth metatarsal bone. This is often referred to as either a Jones fracture or a Dancer’s fracture, depending on location.

Statistically, women are more prone to stress fractures than men due to biomechanics, nutrition and possibly menstrual cycles. Running an excessive amount of miles in a short time span with insufficient rest increases the risk of generalized foot pain, plantar fasciitis, turf toe, metatarsalgia and stress fractures.

Obviously, any underlying bone disease or disorder will drastically increase one’s risk for these conditions. Outlined below are key characteristics and recommendations with respect to these aches and pains:

Signs & Symptoms of Stress Fractures in the Foot

  • Localized foot bone pain that is dull, aching or sharp and occurs during activity (especially running) and/or periods of rest
  • Mild widespread foot swelling and tenderness
  • Pain that worsens with prolonged exposure to ice and during sleep
  • An initial sensation of sharp pain followed by intensifying aching
  • Related lower-extremity symptoms such as lateral thigh/knee pain, low back tightness and/or Achilles tendonitis due to altered foot mechanics sometimes observed in runners

Professional Treatment for Foot Pain in Runners

  • Get plenty of rest and apply ice.
  • Avoid placing excessive weight on the affected foot.
  • Wear shock-absorbing footwear, and if symptoms worsen, use a walking boot to help mitigate stress on the injury site.   
  • Eat healthy and ingest the Recommended Daily Allowance (RDA) of calcium and vitamin D to help restore bone integrity.
  • Engage in strength training for the arch, toe flexors and weak muscles, which may have contributed to the initial injury.
  • Maintain an ideal range of motion for surrounding muscles and joints, specifically the Achilles, calf, plantar fascia, great toe and ankle joint.

Ask the Right Questions Like a Pro

Here’s what smart pro athletes would ask a sports medicine specialist to ensure a fast and safe return to their beloved game or sport:

1. What do you believe is the main reason(s) why this injury occurred?

2. How can I best manage this pain and safely return to running?

3. Do I need orthotics and if so, which foot doctor(s) do you recommend I discuss treatment with, specifically as a runner?

4. Should I concern myself with any potential long-term issues associated with this pain?

Elite Sports Medicine Tips from Mike Ryan

  • Time is of the Essence – Visit a sports medicine specialist as soon as symptoms appear to best manage foot pain from the onset.
  • Rest Rocks – It’s boring, but REST is the #1 tool to tame a stress fracture.  For how long, you ask?  Prepare yourself for 2 to 6 weeks of inactivity if symptoms persist.
  • Be a Turtle, Not a Hare – Resume your running regimen slooooowly. Include pool running, run/walk routines and off-road routes while increasing your miles by no more than 10% per week.
  • Mix It Up – Cross training is king. Add varied activities such as biking, swimming, yoga, strength training and elliptical training to stay in shape and save your “marriage” during this break from running.
  • Smooth and Steady – Wear stable and proper-fitting shoes to protect your feet.
  • No Big Break – Stress fractures can easily develop into typical bone fractures if left untreated.  Setting limitations from the get go can help you avoid the “big break.”

Managing a Foot Stress Fracture the Right Way

Managing a Foot Stress Fracture the Right Way

A stress fracture in the foot is usually associated with an overuse injury to weight-bearing bones. Most athletes affected are involved in high-impact sports that involve running and jumping such as distance running, basketball, tennis, and football.

Bones generally respond to stress by hardening along their outer margins. When suddenly exposed to strong forces or ongoing stress, there is little time for bones to adapt.  Meanwhile, muscles associated with the feet lose their shock-absorbing capacities when fatigued. These uncontrolled forces inadvertently transfer to nearby bones, possibly resulting in small cracks that are better known as stress fractures.

Foot pain caused by stress fractures generally occurs on the top portion of the foot but can also radiate along the heel, side of the foot, and within the ankle joint itself.  Stress fractures commonly occur along the outer ridge of the forefoot over the fifth metatarsal bone. This is often referred to as either a Jones fracture or a Dancer’s fracture, depending on location.

Individuals with a stress fracture usually experience increased pain with movement and, as the condition worsens, even while resting.

Sources of Sore Feet

High-impact activities that result in overuse and put frequent pressure on the lower extremities can lead to stress fractures, such as running, soccer, football, basketball, gymnastics, etc. 

Wearing footwear with little to no shock-absorbing capacities is another contributing factor. Women are more likely to be affected than men, possibly due to poor eating habits/eating disorders and disruptions in their menstrual cycle. Among both genders, excessive aerobic exercise with insufficient rest periods can also increase the chance of getting a stress fracture.

Notably, the presence of underlying bone diseases or disorders can drastically increase the risk for these painful foot conditions.

Signs & Symptoms of Stress Fractures in the Foot

  • Localized foot pain that is dull, aching or sharp and occurs during activity (especially running) and/or periods of rest
  • Mild-to-severe foot swelling and tenderness
  • Pain that worsens with prolonged exposure to ice and during sleep
  • An initial sensation of sharp pain followed by intensifying aching  
  • Localized discoloration and possible stiffness in surrounding joints

Professional Treatment for Stress Fractures

  • Get plenty of rest and apply ice.
  • Consult a physician early on to obtain an exam, X-rays and special testing, if necessary.
  • Avoid placing excessive weight on the affected foot.
  • Wear shock-absorbing footwear, and if symptoms worsen, use a walking boot to help mitigate stress on the injury site.
  • Use a non-weight bearing cast and crutches, if necessary.
  • Eat healthy and ingest the Recommended Daily Allowance (RDA) amounts of calcium and Vitamin D to help restore bone integrity.
  • When symptoms improve, engage in strength training for the arch, toe flexors and weak muscles in the lower extremity.
  • Maintain an ideal range of motion for the surrounding muscles and joints, specifically the Achilles, calf, plantar fascia, great toe and ankle joint.

Ask the Right Questions like a Pro

Here’s what smart pro athletes would ask a sports medicine specialist to ensure a fast and safe return to their beloved game or sport:

1. What do you believe is the main reason(s) why this injury occurred?

2. Are diagnostic tests necessary to further assess the injury?

3. How can I best manage this pain and get back to my sport?

4. What non-surgical treatment options are available, if any?

5. Do I have any leg length disparities or other biomechanical abnormalities that require orthotics or other treatment to avoid long-term foot pain issues?

Elite Sports Medicine Tips from Mike Ryan

  • Time is of the Essence –  Visit a sports medicine specialist as soon as symptoms appear to best manage foot pain from the onset.
  • Rest Rocks –  It’s boring, but REST is the #1 tool to tame a stress fracture.  For how long, you ask?  Prepare yourself for 2 to 6 weeks of inactivity if symptoms persist. 
  • Proceed with Caution – Resume your pre-injury activities at a slow pace, adding strengthening and stretching exercises to your routine.
  • Mix it Up –  Cross Training is king. Add varied activities such as biking, swimming, yoga, and elliptical training to stay in shape and save your “marriage” during this break from activity.
  • Accessorize Appropriately – Ensure all footwear and exercise equipment meet the required standards to prevent re-injury.
  • No Big Break – Stress fractures can easily develop into typical bone fractures if left untreated.  Setting limitations from the get go can help you avoid the “big break.”

Tame Heel Pain Flareups From Plantar Fasciitis

Tame Heel Pain Flareups From Plantar Fasciitis

Understanding Plantar Fascia Strains

Plantar fasciitis causes localized pain in the backside portion of the arch that attaches to the underside of the heel bone, or calcaneus.  It often results from overstretching, overloading or tearing in the arch origin that runs from the heel to the front portion of the foot, under the toes.

This band of tissue helps stabilize and propel the foot forward during movement and stretches each time weight is applied when standing or walking. Plantar fascia strains occur when the band experiences excessive trauma or if the arch is exposed to persistent stress. A plantar fascia strain usually gives rise to sustained inflammation in the front of the heel and back portion of the arch. This creates a high level of localized pain, particularly after a prolonged period of rest during non-weight bearing activities such as sleeping and sitting.  The band simply tightens when not in use, and if left untreated, a plantar fascia strain can become a chronic and troubling ailment.

Causes: The most common cause of plantar fasciitis is wearing inadequate footwear while running, walking and/or jumping. Additionally, beginners who go overboard doing new physical activities may inadvertently overstretch the band.   Additional factors include obesity, sudden weight gain, flat feet, and excessive exercise with insufficient levels of progression.  Heel bone spurs may also result as the band continues to pull on the heel bone, causing chronic arch pain.

Signs & Symptoms of Heel Pain From Plantar Fasciitis

  • Burning, stabbing, or dull aching pain in the front of the heel and along the tissue band in the backside of the arch
  • Difficulty placing weight on the foot while barefoot
  • Arch pain that occurs with heel raises or flat-footed squatting
  • Localized swelling and tenderness under the heel and arch

Professional Treatment for Plantar Fasciitis

Plantar fascia strains usually respond well to conservative treatment methods. However, recovery time does vary from individual to individual. Be sure to:

  • Rest and avoid weight-bearing activities to lessen heel pain.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Ice the arch and toe flexor tendons in a stretched position on a consistent basis to reduce inflammation and pain while elongating the sore plantar fascia tendon. 
  • Always wear the proper footwear for your sport(s).
  • Tape the foot to assist in arch support, reduce inflammation and decrease the risk of further injury.
  • Massage the posterior arch with progressive, aggressive transverse-friction, applying more moderate pressure to the ankle and lower shin.
  • Perform strengthening and stretching exercises for the neighboring arch and calf muscle.
  • Buy arch support shoe inserts.
  • Properly tape the arch to provide effective support and reduce heel pain when performing weight-bearing activities.
  • Minimize weight-bearing activities.
  • Work to shed excess pounds, if overweight or obese.

Ask the Right Questions like a Pro

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to their beloved game or sport:

1)   Is this heel pain related in any way to my pelvis, lower extremity or foot alignment?

2)   Which types of physical therapy are best to quickly resolve this problem so I can get back to my sport(s), pain-free?

3)   Are non-surgical treatment options available?

4)   Can this problem cause any long-term complications?

5)   Will anti-inflammatory medicines provide relief?

6)   Is my painful heel a result of some other biomechanical abnormality that must be addressed?

Elite Sports Medicine Tips from Mike Ryan

  • Fast Treatment=Fast Recovery: The sooner you address plantar fascia strains, the sooner they resolve.  Seek treatment quickly to avoid a chronic problem.
  • Defy Sir Isaac Newton: Aggressive weight-bearing activities prolong recovery time and increase the risk of long-term complications.
  • Embrace that Après Workout Life: Immediately following your workout (or related treatment):
    • Elevate your foot for 3 minutes
    • Stretch for 5 minutes
    • Ice your arch and heel for 7 minutes
  • Unleash Your Inner Gumby: Aggressively stretching your calves, arches, big toe and toe flexor tendons will go a long way toward maintaining healthy tissue in the entire foot.
  • Eat and Drink Right: It’s easier and safer to control inflammation and promote healing by staying well hydrated and maintaining a healthy diet rather than popping pills to manage the problem.

Solving the Stop and Go Issue of Sinus Tarsi Syndrome

Sinus Tarsi Syndrome is a rather common foot injury for stop-and-go type sports, which can leads to pain in the sinus tarsi region of the foot. Some refer to this area in front and slightly below the lateral malleolus as “the eye of the foot”. The sinus tarsus is a bony canal located on the outer (lateral) surface of the foot between the talus bone and midfoot.

Understanding Sinus Tarsi Syndrome

Sinus Tarsi Syndrome is a rather common foot injury for stop-and-go type sports, which can leads to pain in the sinus tarsi region of the foot.  Some refer to this area in front and slightly below the lateral malleolus as “the eye of the foot”. The sinus tarsus is a bony canal located on the outer (lateral) surface of the foot between the talus bone and midfoot.

The sinus tarsus contains the talo-calcaneal ligament, which spans between the talus and clacaneus bones. Injury to this ligament is commonly a result of an inversion mechanism, as with a lateral ankle sprain.

In 1957, Denis O’Connor was the first to use the term “sinus tarsi syndrome” to describe an injury which is characterized by pain, limitation of movement and instability in the hind portion of the foot. At the time, O’Connor treated the injury with a local injection of anesthetic agents into the sinus tarsus.

Common causes of sinus tarsus are inversion ankle sprains, chronic ligament instability and poor foot biomechanics.

The diagnosing of this injury is typically based on the mechanism of injury, the location of the symptoms, palpation findings in this area and the MRI findings.

Signs & Symptoms of Sinus Tarsi Syndrome

  • Pain just anterior to the lateral malleolus, which is the bony prominence on the outer border of the ankle. Prolonged standing usually aggravates the pain.
  • Point tenderness anterior to the lateral malleolus, which is typically aggravated by excessive ankle inversion and/or excessive eversion of the forefoot.
  • Instability and looseness of the lateral ankle and/or midfoot joints.

Professional Treatment for Sinus Tarsi Syndrome

  • Immediately ice the entire ankle and forefoot to help reduce inflammation and control pain.  Ice bags are good but an ice bucket is much better.
  • Mild anti-inflammatory medicines are sometimes prescribed by the treating physician to minimize the pain.
  • Immobilization of the ankle joint, the sub-talar joint and forefoot is a key early step to promote healing. This is best accomplished with a walking boot or a removable splint.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Assess and correct biomechanical problems related to the entire lower extremities if necessary with orthotics and postings.
  • Utilize a physical therapist to assist you with range of motion, manual strengthening and proprioceptive strengthening ankle exercises with tools such as a wobbles board.
  • Surgery is quite unusual and should only be considered for sinus tarsi syndrome cases that fail to respond to all other conservative forms of treatment.

Asking the Right Questions like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Have I developed sinus tarsi syndrome and what structures have been injured?
  2. Do I need to have an MRI or any other special test to confirm this diagnosis?
  3. Do I have any biomechanical concerns or previous injuries contributing to this injury?
  4. Will I need orthotics and if so, where can I have them made correctly with free adjustments for less than $300?

Elite Sports Medicine Tips from Mike Ryan

  • Bottom Line – The bottom line of your standing body is your foot.  Gravity is going to bring fluids to that foot.  Early and aggressive ice therapy and elevation is key.
  • Contol Your Weight – Rest is needed.  If the doctor gives you crutches, use them.
  • Proper Footwear – Check with the people that know and make sure you are wearing the proper shoes with the right fit for your sport.
  • Trust the Experts – If this is a chronic issue, the reasons can be many.  Take the time with the best physical therapist or certified athletic trainer available to learn from the best how to put this injury in the rearview mirror.

Metatarsalgia: Foot Pain’s Evil Brother

Metatarsalgia is a general term relating to forefoot pain secondary to inflammation in the area of the distal foot and toes.

Metatarsalgia: Foot Pain’s Evil Brother

Metatarsalgia is a general term relating to forefoot pain, secondary to inflammation in the distal foot and toe area.  Joints that connect metatarsal foot and toe bones become swollen, and the second, third, and fourth MTP joints are most often affected.  Additionally, Metatarsalgia is commonly found within the second, third, and fourth joints between the toes.

Morton’s Neuroma is a similar condition that presents with forefoot pain.  Unlike Metatarsalgia, Morton’s Neuroma pain is located between the distal metatarsal bones as opposed to within the forefoot and toe joints themselves.

Morton’s Neuroma is caused by pinched nerves located between the second, third, and fourth metatarsal bones, resulting in nerve inflammation.

Pain in the ball of the foot is not typically linked to either of these conditions, although it is not surprising to develop this symptom by compensating for lower extremity dysfunction.

Signs and Symptoms of Metatarsalgia

  • Forefoot and toe pain that increases with weight-bearing activities
  • Symptoms that worsen when wearing tight-fitting shoes or high heels
  • Point tenderness pain in the distal foot area and proximal toes
  • An excessive pattern of blisters, calluses and wear and tear in the forefoot and toes
  • Increased pain from passive toe bending and rotating
  • Pain in the ball of the foot (related to compensation mechanics that sometimes present with chronic foot pain)
  • A contributing factor of long-term abnormal toe alignment, such as claw toes or bunions 
  • Excessive skin or calluses underneath the foot due to excess pressure

Signs and Symptoms of Morton’s Neuroma

  • Localized pain between the third and fourth distal metatarsal bones and toes
  • An increase in weight-bearing symptoms, such as feeling as if you are  “standing on pebbles”
  • Increased pain with weight-bearing activities
  • Sharp pain, burning, numbness and/or tingling in the distal foot and toes
  • Increased symptoms between the metatarsal bones when squeezing the forefoot
  • Excessive callus and wear patterns under the distal forefoot and great toe
  • Pain in the ball of the foot (related to compensation mechanics that sometimes present with chronic foot pain)

Treatment for Metatarsalgia and Morton’s Neuroma

  • Aggressively ice the arch, foot and toes with ice bags, ice massage or (ideally) an ice bucket, for 10 to 15 minutes.
  • Wear the proper footwear for specific activities.
  • Minimize weight-bearing activities.
  • Massage and apply soft-tissue treatments to the arch, great toe, ankle joint and calf.
  • Perform a biomechanical evaluation to assess contributing factors such as a leg length discrepancy, hyper pronation/supination, tight ankles, restricted toe extensor tendons, hypomobile toes, or knee, hip or low back conditions.
  • Stretch your calves on a consistent basis.
  • Wear orthotics, ideally with a rigid steel insert, when experiencing pain in the ball of the foot.

Questions a Pro Athlete Would Ask

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to their beloved game or sport:

1. Are you concerned that I may have a stress fracture in my foot or toes?

2. Could my foot symptoms be related to nerves in my back or leg?

3. Will orthotics help, and if so, where can I find them at a reasonable price?

4. If faced with this same problem, where would you go for therapy?

Sports Medicine Tips

If the Shoe Doesn’t Fit, Don’t Wear It – It’s a fact that women’s shoe designs help keep foot doctors in business.  They may look sexy and stylish but are absolute killers for the health of your feet.  Ladies (and gentlemen) – rid your closet of any ill-fitting shoes ASAP!

Do Some Sole Searching – Assess the overall health of your shoes in addition to your feet. Wearing old, “expired” shoes with worn soles is a common factor that leads to foot and arch pain.

(Yet Another) Test with a #2 Pencil – Using the eraser end, apply pressure between the metatarsal bones of the foot to help pinpoint the location of the pain and lead to a diagnosis.

Ice is Your Friend – I’m sorry, but it’s true – the bitter chill of ice is necessary to treat this injury.  The pros will tell you that ice is their best teammate.  Stop complaining and stock your freezer accordingly!

Sprained Ankle Management

Sprained Ankle Management

Year over year, ankle sprains are the most common lower extremity injury in all of sports.  From a minor “tweak” to a high ankle sprain, the range of symptoms and corresponding limitations vary greatly.  Ankle sprains are challenging due to the ankle joint’s inherent vulnerability years after the sprain and ligament instability that is common after a significant injury.

The term “sprain” refers to an injury that involves ligament damage.  Ligaments connect bones to bones, while tendons connect muscles to bones.  Ligaments help stabilize joints and are embedded within capsules surrounding most joints in the body.  The ligaments in a “normal” ankle provide static stability to lower leg and hindfoot bones.

A ligament sprain can be as simple as a minor stretch or as complex as a complete disruption or tearing of the ligament fibers that provide joint stability.

Lateral Ankle Sprain

When a lateral ankle sprain, commonly referred to as an inversion sprain, occurs, the majority of the ligament damage occurs along the lateral or outside part of the ankle joint.  This includes the following ligaments:

1.  Anterior Talofibular Ligament (ATF) – located in front of the outer distal Fibula (shin) bone

2.  Calcaneofibular Ligament – connects the fibula (shin) to the heel bone

3.  Posterior Talofibular Ligament (PTF) – located behind the outer distal Fibula (shin) bone

High Ankle Sprain

We often read about elite athletes who have an ankle sprain that sidelines them for 2-6 weeks.  This sparks immediate questions about why anyone would miss so much time with “just” a sprain (rather a more serious-sounding injury, like a break).  In most cases, this athlete has suffered a high ankle sprain, one of the most frustrating and difficult injuries to overcome.  Recovery is even more difficult when the athlete plays (what I refer to as) a “stop-and-go sport” that involves quick changes in direction.

With a high ankle sprain or interosseous ankle sprain, most damage is found in the anterior ankle and distal shin area.  These structures include:

1. Interosseous Membrane – located between the two distal shin bones

2. Anterior Distal Tibiofibular Ligament – located at the front of the two distal shin bones, just above the ankle joint

Ankle sprains cause damage to surrounding bones, tendons, capsules and joint surfaces, but the most serious ones can lead to a rupture of lateral and anterior ankle ligamentous structures, including the capsule.  Ankle joint dislocations and fractures can also occur, which I personally suffered as a collegiate athlete and had to endure two surgeries and four months of rehabilitation.

Signs and Symptoms of a Lateral Ankle Sprain

The signs and symptoms of a lateral ankle sprain vary based upon the grade or significance of the ligament damage.  Sprained ankles are graded from one to three depending on their laxity, or looseness of the ligaments.

Grade 1 Lateral Ankle Sprain:

  • Mild pain
  • Mild joint stiffness when walking or running
  • Minor stretching of the lateral ankle ligaments
  • Minimal joint instability with a firm end-feel or tautness of the ligaments when stressed
  • Minimal swelling around the bone on the outside of the ankle

Grade 2 Lateral Ankle Sprain:

  • Moderate stretching and tearing of the lateral ankle ligaments
  • Moderate joint instability with a firm end-feel or tautness of the ligaments when stressed
  • Moderate swelling on the outside, front and back of the ankle
  • Moderate bruising of the lateral ankle and mid-foot
  • Moderate-to-severe pain and difficulty walking
  • Significant stiffness of the ankle and mid-foot

Grade 3 Lateral Ankle Sprain:

  • Complete tearing of the lateral ankle ligaments
  • Significant joint instability with a soft end-feel or tautness of the ligaments when stressed
  • Significant pain
  • Significant swelling throughout the outside, front and back of the ankle and mid-foot
  • Significant bruising of the lateral ankle and mid-foot

Treating a Lateral Ankle Sprain

  • Rest the distal leg with Ice, Compression and Elevation (RICE).
  • Leverage the power of ice as a valuable tool for a fast recovery.  Placing ice bags on the outside and inside of the ankle joint for 15 minutes each day is a good way to reduce pain and swelling.  The best way to aggressively treat the entire ankle/foot/distal shin area is to immerse it in an ice bucket for 10 minutes.  Placing a rubber glove or insulated sock over only the toes will make this significantly more tolerable.
  • Depending on the grade of the sprain, adhere to weight-bearing limitations.  Utilize a walking boot and/or crutches to help gradually reduce symptoms while still allowing for normal activities of daily living (ADLs).
  • Gradually perform range-of-motion (ROM) activities with elevation.  Use only upward (dorsi flexion) and downward (plantar flexion) directions to avoid stretching any damaged ligaments located on the outer ankle joint.
  • Use compression to control swelling and pain in the ankle joint and surrounding tissue when performing weight-bearing activities.  Mixing compression with rest is also helpful for acute sprains.
  • Massage the arch, ankle joint, Achilles and calf to help reduce swelling and enhance blood flow to the injured tissue.
  • Ride a bike using compression, which can be started early on.
  • When the swelling is 50% improved, perform strengthening exercises with manual resistance.  Start with upward (dorsi flexion) and outward (eversion) movements while avoiding inward (inversion) stretches, as inversion motion is the typical injury mechanism that causes ligament damage in the outer ankle.
  • Use a slant board to aid in stretching the calf and posterior ankle joint as it becomes more comfortable.  Include calf-strengthening heel raises when tolerable.
  • As you prepare for your return to sport, perform balance activities, which are great exercises during the final stages of treatment. 
  • Begin sport-specific activities when back to 75% strength and if swelling does not significantly increase with activity.
  • Call on a certified athletic trainer to tape your ankle joint, a smart way to minimize the chance of re-injury.

Questions a Pro Athlete Would Ask

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to their beloved game or sport:

1. Is my ankle sprain classified as Grade 1, 2 or 3?

2. Is an X-ray required to rule out a fracture?

3. What do I need to accomplish in rehab to safely return to my sport?

4. Should I have my ankle joints taped or braced when I return to my sport?

Sports Medicine Tips for a Sprained Ankle

Avoid a Bum Ankle – Trust me: A chronically loose ankle can ruin your confidence and your game.  Without proper treatment, ankle sprains can result in a “bum ankle” that rolls over while performing simple actions such as walking across the yard or stepping off a curb.  Prioritize treatment to tighten affected ligaments and prevent becoming a “bum” down the road.

Flexible Calves and Achilles Are Key – Partnered with loose calves and Achilles, your ankle will enjoy great range of motion and function normally.

Compression is Your Friend – Employing compression on the ankle joint and distal calves will help maintain congruity of the lower leg long after the sprain has healed.

Get Back to Basics – Other than Michael Jordon, none of us were born with sneakers on our feet.  Bust out of those tight shoes and spend more time barefoot to strengthen your arches, foot muscles and ankle ligaments.

Turf Toe Management

Turf toe is an injury with a short name but a long history of pain in the NFL. With large men rapidly changing directions on varying surfaces, the forces originating at the ground level are extremely high. Simply stated, every football player move that you see on your plasma screen during Sunday’s game start at the foot and big toe.

Turf Toe Caused By Hyperextension

Turf toe is an injury with a short name but a long history of pain in the NFL.  With large men rapidly changing directions on varying surfaces, the forces originating at the ground level are extremely high.  Simply stated, every football player move that you see on your plasma screen during Sunday’s game start at the foot and big toe.

Turf toe is the medical term related to a sprain of that 1st metatarsophalangeal (MTP) joint or, as it is commonly referred to as, the “big toe”. The name turf toe originated in the mid-1970’s when certified athletic trainers and physicians reported an increase in 1st MTP joint injuries with a large number of games being played on artificial turf.  The combination of harder playing surfaces, increased shoe traction and lighter less rigid shoes proved to be the main contributing factors to injuries related to the big toe.

Big toe pain originates at the 1st metatarsophalangeal (MTP) joint and usually includes surrounding soft tissue.  The most common mechanism of injury is joint compression with hyperextension of the 1st MTP joint.  In reality, turf toe can occur with any combination of compression with excessive extension, flexion, rotation, adduction (moving away from the 2nd toe) or abduction (moving towards from the 2nd toe) of the 1st MTP joint.

An example of this injury in football is when a player lands on the back of another player’s ankle while athlete’s big toe is planted in the ground and extended.  With the extra weight applying pressure into the arch and the player’s inability to unload the front of the foot, the 1st MTP joint is forcefully hyperextended and the joint surfaces are compressed.  It’s easy to see how this mechanism of injury can create considerable damage to the joint itself and all the structures on the plantar (undersurface) of the distal arch and big toe.

With the example noted above, the muscles that flex or bend the 1st MTP joint can be stretched or torn.  The capsule that surrounds the joint is vulnerable along with the ligaments and plantar plate complex, which is the stabilizing structure on the underside of the big toe.

Lastly, the two small sesamoid bones that rest under the 1st MTP joint, or “ball of the foot”, are potential sources of pain with turf toe and any injury that affect this area of the distal arch.  With direct trauma or hyperextension of the big toe, the sesamoids can become inflamed or fracture.

Signs & Symptoms of Big Toe Pain

  • A sudden or slow onset of pain anywhere encompassing the base of the big toe.
  • With an abnormal motion of the 1st MTP joint, a “pop” or a “shifting” sensation is noted.
  • Point tenderness and swelling at the base of the big toe.
  • Passive and active movements of the toe upward (extension) are painful and the amount of motion is significantly limited when compared to the other foot.
  • When moving the big toe into the direction of the injury, the symptoms increase and the strength in that position is significantly reduced.
  • Pressure while weight bearing, twisting and pushing off the front of the foot will increase symptoms in the big toe.

Treating Turf Toe Pain

  • Icing, elevate and rest the foot is the best start to controlling the swelling and pain.
  • Icing techniques include a 15 minute ice bag (good), a 10 minute ice massage (better) or the Granddaddy of them all, the 12 minute ice bucket (the best).
  • Walking boots are valuable tools in the NFL and a wonderful ways to protect the toes, forefoot and ankles while allowing an athlete to walk.
  • When you’re able to comfortably wear a shoe, utilizing a steel shoe insert or rigid orthotic in all of your shoes will stabilize the forefoot and minimize extension at the big toe.
  • Avoid barefoot walking or any activities in flimsy and unsupported shoes.
  • Massage of the arch, gentle painfree range of motion (ROM) of the toes, stretching of the ankles and calves will enable better blood flow to the injured tissue while maximizing the drainage from the areas with excess swelling.
  • When the warmth in the joint has subsided and at least 75% of your painfree motion had returned, picking up marbles/rocks/peanuts with your toes will increase the strength and mobility of your toes.
  • Towel curls, to be started with the same criteria as the marbles, will effectively strengthen your arches and intrinsic muscles of your forefoot.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Do I have turf toe and exactly what structures did I damage with my injury?
  2. Do I need an x-ray, MRI or CT Scan to determine the extent of my injury?
  3. Will orthotics help me and if so, where do you suggest that I purchase them at a reasonable price?
  4. Did my shoe wear contribute to my injury and if so, what changes do you suggest?
  5. Are my non-athletic shoes contributing to my problem?
  6. Do you think that I need surgery on this injury now or in the future?

Elite Sports Medicine Tips from Mike Ryan

  • Swelling Control – Your toes are located at the end of very long network of blood vessels, which are assisted by both contracting blood vessels and gravity.  Help control your swelling by minimizing your standing time, maximizing your elevation time, aggressive icing, wearing stiff shoes and being consistent with your physical therapy.
  • Gout? – I have pro football players fight me on this every year.  Sometimes Gout really is the source of the pain if the mechanism “just doesn’t fit”.  If your unsure, check with your doctor because Gout is more common than you think.  “If the Gout shoe fits, wear it.”
  • Joint Surface Status – Degenerative joint disease (DJD) in the big toe is common with high level “stop and go” athletes as are…(are you ready for this?)….women who commonly wear crowded, pointed-toed high heeled shoes. If your toe angles are changing and your toe ROM is decreasing, your joint surface is probably less then ideal.
  • Don’t Forget About Your Calves – Ankle ROM is an important factor related to toe pain.  Keeping your calves loose and limber will help.  Massage and stretching of the calves will immediately increase ankle ROM and decrease the need for excessive 1st MTP extension.  Flexible calves and loose ankle can reduce your turf toe pain by 25%!
  • Little Piggy’s #2, 3, 4 & 5 – Don’t forget about the little guys in the neighborhood.  Your other toes need to be stretched and cared for as well.  I see many bad looking toes and toenails in my business and I can tell you that your foot will function allot better with all five Little Piggy’s doing their part.

How To Eliminate Heel Pain

How To Eliminate Heel Pain

In order to eliminate heel pain, it is important to understand its underlying cause(s). Although the term “heel pain” is somewhat generic, you can testify to its significance if you suffer from this condition.  Sources of the pain, which is located in the arch area on the underside of the foot, can vary.

Heel pain may be caused by trauma such as a forceful strike of the heel against a hard surface, but an overuse injury such as plantar fasciitis is also a potential culprit.

The underside of the heel, or calcaneus, bone has a thick layer of fat and protective fascia that provides padding as the heel makes contact with the ground.  Excessive forces or repetitive pounding can cause this fat pad to move or become inflamed.  When the protective layer under the heel bone loses efficiency in this manner, heel pain and burning feet are painful side effects.

Common Sources of Heel Pain

  • Plantar Fasciitis – A common source of arch pain, this inflammatory condition involves the plantar fascia in the back of the arch.
  • Heel Bone Spur – This problem occurs when excessive bone forms underneath the calcaneus (heel).
  • Heel Contusion – Simply put, this is a bruised heel bone.
  • Calcaneal Stress Fracture – This represents either a preliminary or significant fracture of the calcaneus bone.
  • Tarsal Tunnel Syndrome – This painful condition occurs when nerves encroach upon the back of the foot and arch.
  • Calcaneal Bursitis – This manifests itself as inflammation that occurs within the sack of fluid that sits under the heel.

Heel Pain Signs & Symptoms

  • Tenderness associated with the surface of the heel bone
  • Increased warmth and potential swelling of the underside of the heel bone
  • Arch pain that originates on the heel and can extend into the underside of the foot, towards the toes
  • Posterior heel pain trigged by bearing weight on the foot, which may worsen with active toe flexion

Professional Treatment for Heel Pain

  • Ice the entire heel bone with an ice bag, ice massage or, ideally, with an ice bucket.
  • Rest the area to minimize pressure on the calcaneus.
  • Gently massage the arch and toes.
  • Wear appropriate shoes that bolster padding for the heel bone and help absorb shocks.
  • Stretch the calf to foster pain-free movement of the ankle joint.
  • Consider utilizing orthotics or arch supports, depending on the anatomical alignment and biomechanics of your lower extremities.

The treatments noted above may improve heel bone spur symptoms and help avoid surgery.

Ask The Best Questions to Receive the Best Care

To ensure you receive the best possible care for your injured foot, ask questions like smart professional athletes would as they seek a quick, safe return to the sport they love. Specifically, here’s what a pro athlete would ask his or her sports medicine specialist:

1. Are you 100% certain of the diagnosis provided?

2. Do I need an X-ray to determine the extent of this injury?

3. What are my injury treatment options?

4. What can I expect when dealing with this injury over the next 2-6 weeks?

5. Can you recommend any expert heel pain rehab specialists in this area?

6. Will you provide me and my therapist with a detailed protocol to direct my rehab regimen?

Tips for a Speedy Recovery

  • Act Fast – Arch pain and heel pain are not injuries to ignore.  By prioritizing treatment, it is possible to resolve this injury quickly with minimal downtime.
  • Do Some Sole Searching – Shoes are typically the source of the problem.  Old, improper shoes and worn shoe soles are common factors that lead to arch pain and burning feet.
  • Remember That Ice is Your Friend – Yes, it’s a reality check:  Ice hurts, but it’s exactly what you need for this injury.  Professional athletes will tell you that ice is their best teammate.  Stop complaining and do what is needed….ICE, and lots of it.
  • Know What to Expect – Heel pain typically dictates minimal recovery time.  Provided there is no stress fracture, large bone spur or significant plantar fasciitis, the downtime required for this injury can range from a couple of days to a few weeks.  Quickly determine the source(s) of the problem and seek the appropriate treatment, and you’ll be back in the game before anyone even knew you were cooling your heels!

How To Recognize And Treat Achilles Tendon Ruptures

How To Recognize And Treat Achilles Tendon Ruptures

Your Achilles tendon is remarkably strong. It connects the calf muscles (comprised of the gastrocnemius and soleus) located in the back of the lower leg to the back of the heel. Unfortunately, the Achilles tendon can partially tear or completely rupture under the right circumstances. Complete ruptures are more commonly seen in individuals over the age of 35 than in younger athletes.

Achilles tendon ruptures are frequently associated with history of inflammation. Additionally, significant Achilles tendon injuries commonly result from aggressive acceleration movements in the lower leg and/or rapid change-of-direction activities. Let’s learn more to help mitigate complications from this injury and avoid it becoming your Achilles heel moving forward.

Signs & Symptoms of an Achilles Tendon Rupture

  • Sudden, sharp pain, as if struck in the back of the leg
  • A sudden snapping sound accompanied by intense, but short-lived, pain
  • An inability to push the foot downward or rise up on the toes while walking
  • A divot or gap where the tendon is located, felt by palpation
  • A significant amount of swelling and surprisingly, minimal pain, in the back of the lower leg
  • A positive Thompson’s test result

How to Treat a Torn Achilles Tendon

  • Apply ice to the area with an ice bag, ice massage or, ideally, an ice bucket.
  • Avoid walking.  Until the severity of the injury is determined, walking with this injury may result in additional damage that can significantly prolong recovery time.
  • Elevate the ankle and lower leg to limit swelling and decrease pain.
  • Immediately seek a sports medicine consultation. Early diagnosis is crucial when treating this injury.

Questions to Ask About Your Torn Achilles Tendon

Even if you’re not a professional athlete, be sure to seek safe, efficient treatment for your torn Achilles tendon. To emulate smart professional athletes with this injury who want to safely return to their sport, ask your sports medicine specialist the following questions:

1. Are you 100% certain of the diagnosis, and is an MRI needed to determine the extent of the injury?

2. What are my rehab options from both a conservative (non-surgical) and more aggressive (surgical) standpoint?

3. Given both rehab options above, what can I expect over the next 3, 6 and 9 months?

4. If your son or daughter were in my situation with the same exact injury, what treatment plan would you recommend?

5. If surgery is my best option, how many of these types of surgeries do you perform per year?  Who do you consider expert Achilles surgeon(s) in this area?

6. Which expert Achilles rehab specialists do you recommend in this area?

7. Will you provide me and my therapist with a detailed rehabilitation protocol?

Apply These Elite Sports Medicine Tips To Foster a Speedy Recovery

  • Know What You’re Dealing With – Seek immediate help from an orthopedic medical specialist (rather than a general practitioner) to obtain a clear diagnosis and treatment plan.
  • Act Quickly Varied treatment options such as walking boots, surgery and early weight-bearing plans must be considered in the immediate aftermath of the injury to promote a full recovery.
  • Listen to Nike – Think realistically about your short and long-term activities and act accordingly.  Utilizing crutches for a month or two is never ideal, but if doing so improves your prognosis to remain a happy and active athlete over the course of your lifetime, JUST DO IT!
  • Think Like a Pro – Most high-level athletes with a complete Achilles tendon rupture choose surgical repair for their tendon.  The outcome is usually better than employing conservative treatment options, which typically see longer healing times and a slower rehabilitation schedule.
  • Expect a Marathon Recuperation Period – Recovery time is considerable for this type of injury.  Generally speaking, surgical repair dictates a recovery timeframe of approximately 6 months.  This timing extends closer to 9 months with conservative, non-surgical approaches.

Achilles Tendonitis

Achilles Tendonitis

Understanding Achilles Tendonitis

Achilles tendonitis is a common injury associated with the presence of inflammation and scar tissue in the largest tendon in the body. The Achilles tendon is located above the ankle in the back of the lower leg. It connects the large calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). Its main function is to transfer power to the ankle during the push-off phase of the gait cycle while either walking and running.

Achilles tendonitis is commonly described in medical literature as “Achilles tendinopathy.” The presence of scar tissue and degenerative changes in the tissue often accompanies inflammation. Athletes older than 30 years of age with Achilles tendonitis often present with decreased elasticity and fiber strength in the tendon.

Achilles tendonitis is either of an acute variety, occurring over only a few days, or chronic, spanning a longer period of time.

With this condition, inflamed tissue is located anywhere along the tendon from the calf muscle or where it attaches to the heel, or calcaneus, bone. The healing period is often lengthy due to daily stress placed on the area when walking and performing normal activities, alongside a less-than-adequate blood supply.

The calf muscles described above merge together to form the Achilles tendon before it anchors or inserts into the calcaneus. The gastrocnemius is the larger and more superficial muscle, originating above the knee. Conversely, the deeper, shorter soleus does not cross over the knee joint.

Therefore, both calf muscles must be involved to obtain long-term pain control in Achilles heel pain treatment.

Signs & Symptoms of Achilles Tendon Pain

  • With milder cases of Achilles heel pain, localized pain that presents at the onset of exercise will decrease as the athlete warms up.
  • Pain and symptom onset can occur either quickly (within minutes) or build up gradually over days or weeks.
  • Symptoms such as pain, stiffness and calf weakness typically decrease with rest.
  • Tenderness may be noted anywhere along the tendon with palpation and during activities.
  • Prolonged periods of inactivity such as in the morning or after sitting for a long span of time can result in significant Achilles tendon pain and stiffness.
  • Palpable knots or lumps in the Achilles tendon are common.
  • Tendon “squeaking” is sometimes experienced with ankle motion.
  • Performing a one-legged toe raise with a completely straight knee may summon pain in the tendon, weakness in the calf and a limited range of motion in the ankle.
  • Swelling or thickening within the tendinous sheath is common.

Causes of Achilles Heel Pain

Achilles tendonitis is typically an overuse injury. The basic cause of these ailments is “doing too much too soon.” With that said, other factors can contribute to inflammation in the largest tendon in the human body:

  • Altered or improper footwear worn in physical activity or work environments
  • Inconsistency in training surface firmness and inclines, such as hills
  • A rapid increase in activity volume and/or intensity
  • Insufficient recovery time between workouts
  • Various arch and foot pathologies such as fallen arches, excessive pronation, hyper-supination or poor toe alignment
  • Weak calf muscles
  • Tight calves and Achilles tendons
  • Stiff ankles due to arthritic changes

Professional Treatment for Achilles Tendon Pain

  • Avoid activities and footwear, two classic factors, that are linked to symptoms.
  • Place a ¼ – ½ inch heel lift in both shoes when walking more than 50 yards.
  • Avoid prolonged barefoot walking.
  • Massage the calves, arches and front of ankles to promote a decrease in Achilles tendon and ankle stress with motion.
  • Improve arch and toe flexor strength with activities such as marble or rock pickups and towel curls in a seated position.
  • Perform daily calf rolling treatments for the calf and peroneal tendons (lower outside of the shin), but not on the Achilles tendon itself, to promote healing. Increase efficacy by warming up the tissue prior to treatment, and while slowly rolling the areas noted above, breath comfortably while consistently moving the foot in a wide circular pattern.
  • When at least 75% of the pain is gone when walking, initiate toe raises to strengthen the calf muscles. Start with double legs on a flat surface and progress to single legs on an uphill incline. Between strengthening sets, perform a 20-second “duck walk,” a straight-legged heel walking technique with the front of the foot off the ground. This (crazy looking) exercise is an effective drill to both enhance strength in the front of the ankle and prolong stretching of the Achilles tendon and calf.
  • Stretch both calf muscles to reduce Achilles tendon pain on a long-term basis. Perform wall pushes or slant-board stretches with both straight and bent legs to address both muscles and the Achilles tendon. Key Tip – Adjust the angle of your foot to keep the stretch pain-free while performing five slow breaths to promote relaxed tissue elongation.
  • Utilize calf compression during activities to maintain warmth and improve blood flow.
  • Ice your Achilles tendon and calf muscles in a moderately stretched position using ice bags/frozen veggies, an ice cup or (ideally) an ice bucket.

Questions a Pro Athlete Would Ask

Smart professional athletes with Achilles tendonitis who want to safely return to their sport will ask their sports medicine specialist the following questions:

1. What are the main factors causing my Achilles tendon pain?

2. Do I have abnormal foot/arch/subtalar joint biomechanics that must be addressed with an orthotic device?

3. Do I have a leg length difference of greater than 1/4 inch?

4. Am I a candidate for cross-friction massage on my Achilles tendon, or is that form of treatment too aggressive?

5. Who is the best physical therapist in the area to rehab with for my Achilles heel pain?

Elite Sports Medicine Tips

  • Look Around – Achilles tendon pain is likely related to a bigger issue than just isolated inflammation in your tendon. Examine everything from your shoulder levels, to your core strength, to your ugly toes for clues.
  • Break Out Your Magnifying Glass – What triggered this flare up right now, detective? List all activities and new routines from the past month – you may find the reason(s) staring right back at you!
  • Embrace Your Inner Gumby – I watch my young son stretch and bend every day like Stretch Armstrong. Unless you’re a former (or current) gymnast, flexibility generally wanes at our more mature age. Perform exercises every day to stretch your shoulder, back and legs.
  • Do Some Sole Searching – Compare the wear pattern on your favorite shoes. Do the soles look different from one side to the other?
  • DON’T Run for the Hills – Upon a return to activity, avoid hills for the first couple of weeks. Whether running, walking or biking, hills exert excess stress on the calves and Achilles tendon.