M C e o d n i t ca in l u SPORTS PODIATRY Ed in u g c at io n

Objectives After reading this continuing education article, Challenging the podiatric physician should be able to: 1) Understand and list the possible causes of hallux rigidus. Running 2) Describe the major staging systems for hal - lux rigidus. 3) Describe surgical and conservative treat - Injuries: Be ment for hallux rigidus by stage of deformity. 4) Define and classify turf toe. Knowledg eable, 5) List predisposing factors for the turf toe injury. 6) Describe conservative treatment of turf toe. 7) Discuss differential diagnoses for sesa- Be Prepared moidopathy and describe causes of pain in the region of the sesamoid bones. 8) Describe the features healthy tendon and tendon affected by tendinopathy. Here’s the current 9) Be able to discern structures injured in what evolution in thought, this article terms the “zone of confusion.” In par - ticular clinically distinguish between plantar fas - literature, and ciopathy, peroneus longus tendinopathy and flexor hallucis longus tendinopathy. treatment of these 10) Be able to describe treatment plans for conditions. the midfoot tendon injuries described in this arti - cle including peroneus longus tendinopathy and flexor hallucis longus tendinopathy.

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By Stephen Pribut, DPM nomic characteristics of basic and Genetics has been found to play a clinical phenomena that can pre - role in motivation to exercise 1 and revolution is in the making dict and alter the mechanisms of can be responsible for a lack of re - for the prediction of and health and disease. Progress is sponse to exercise training. Specific therapy for sports injuries. being made on linking the genome genes have been associated with A 2 The next advances will come with the metabolic characteristics leisure time activity. Prediction is through genetics and genomic of tissues and cells. 3 Recent studies critical for groups as diverse as pro - analysis. Functional genomics has have hinted at the relationship be - fessional sports teams to the mili - led to a surge in research on the ge - tween tendinopathy and genetics. Continued on page 158 www.podiatrym.com JANUARY 2010 • PODIATRY MANAGEMENT 157 n g o in ti u a n c Hallux Rigidus, Turf Toe, came obligate bipeds and were able ti u Injuries... n d o E Sesamoid Injury to run. C al ic tary. Susceptibility to injuries The first metatarsophalangeal d e such as stress fractures and Anatomy joint includes four bones. The most M Achilles tendinopathy will alter A properly functioning first readily apparent portion of the joint training regimens as risk assess - metatarsophalangeal joint is critical is the articulation between the con - ment and prevention strategies for running. In evolution, the ab - cave-shaped base of the proximal improve. duction of the first ray, disappear - phalanx and the convex, rounded ance of an opposable hallux, and head of the first metatarsal. The Genetics and Athletic realignment of the first metatar - plantar surface includes the two Injuries sophalangeal joint and first sesamoid bones (fibular or lateral, Genetics may play a specific metatarsocuneiform joint marked a and tibial or medial) and the joint role in the pathogene - capsule. The joint cap - sis of many athletic sule is reinforced on its injuries. Studies of TABLE 1 plantar aspect by both Achilles tendinopathy a fibrocartilagenous suggest a genetic com - Modified Hybrid plate and the plantar ponent. This was first Grading System accessory ligament. hypothesized when a The flexor hallucis study revealed an ap - for Hallux Rigidus longus and flexor hal - parent association of lucis brevis attach on the O blood group Stage I: Functional limitus the plantar aspect, and Achilles tendon Metatarsus primus elevatus along with the abduc - injuries in the Hun - Hallux equinus or flexus tor hallucis muscle and garian and Finnish Plantar subluxation of the hallucal proximal phalanx the adductor hallucis populations. Chromo - Periarticular subchondral sclerosis muscle. Dorsally, the some 9 was then Minimal dorsal exostosis (first metatarsal head and base of tendons of the exten - thought to be the proximal phalanx) sor hallucis longus and Minimal flattening of first metatarsal head locus of a change to the extensor hallucis this gene or a closely Stage II: Early joint adaptation brevis muscles insert. linked gene. Other Moderate dorsal exostosis (first metatarsal head and base of Turf toe, sesamoidi - studies did not proximal phalanx) tis, and hallux rigidus demonstrate this asso - Moderate flattening of first metatarsal head are a functionally in - ciation. Minimal joint space narrowing terconnected set of in - More recently, ge - Subchondral joint sclerosis juries. These problems nomic studies have Lateral first metatarsal head erosion, and/or joint flare/exostosis can impair the ability shown that individu - Sesamoid hypertrophy ± Subchondral cyst formation/loose body to run. In severe cases, als with variants of the formation a runner may consider 4 tenascin-C gene or Stage III: Established Arthrosis giving up the sport alterations in the Severe dorsal exostosis (first metatarsal head and base of permanently. We’ll ex - COL5A1 gene, 5 espe - proximal phalanx) amine these entities cially a BstUI restric - Irregular joint space narrowing individually and re - tion fragment length Traction enthesiopathic sesamoid hypertrophy with view treatment. polymorphism, are immobilization induced osteopenia more prone to develop Definite subchondral cyst formation and presence of loose bodies Hallux Rigidus Achilles tendinopathy. Future genomic re - Stage IV: Ankylosis Description and search is likely to yield Exuberant exostosis proliferation, trumpeting of the first metatarsal Definition head, base of the proximal phalanx, and sesamoid apparatus much more informa - Minimal/absent joint space Hallux rigidus tion about susceptibil - Sesamoid fusion refers to an absence of ity to injury. Hallucal interphalangeal and/or first metatarsal-medial dorsiflexion at the first In this article, cuneiform osteoarthritic changes metatarsophalangeal we’ll be taking a prac - joint. The term hallux tical approach as we limitus has been used wait for the new research to blos - complete change from arboreal liv - to describe the condition in which som. Our topics include injuries ing to obligate bipedalism. Ardip - the dorsiflexion is not absolutely that are frequently encountered, ithecus ramidus, the oldest known limited. Functional hallux limitus, those that are not common, those hominid, had an adducted first first described by Laird, 7 refers to difficult to treat, and some not metatarsal, opposable hallux, and biomechanical features of the joint readily identified. We’ll begin with was able to walk in a bipedal man - which limit dorsiflexion. Function - the first metatarsophalangeal joint ner. 6 When Australopithecus al hallux limitus is a condition in and then move to the plantar sur - evolved with a more modern align - which no degenerative changes are face of the foot. ment of the great toe, hominids be - Continued on page 159

158 PODIATRY MANAGEMENT • JANUARY 2010 www.podiatrym.com M C e o d n i t disorder of the first metatarsopha - Clinical ca in Injuries... l u Ed in langeal joint. Starting with a mild Presentation u g c present. It is thought to be one of limitation of dorsiflexion and little Patients usually first com - at io many possible etiological causes of to no discomfort, it can progress to a plain of pain at the dorsal aspect n hallux rigidus. condition that causes marked limita - of the joint. The limited motion is The term hallux limitus has tion of motion at the joint, pain not often noticed at this stage. Later, been useful to describe limited during athletic the head of the range of dorsiflexion, but the cur - participation, and metatarsal en - rent trend is to use only the term ultimately pain larges dorsally, hallux rigidus. Hallux rigidus was while walking. Steroid injections flattens, and dor - first described in 1887 by Davies- Shoes can im - at the joint will not sal osteophytes de - Colley, who used the term hallux pinge on the dor - velop. At this flexus in referring to a plantar- sal aspect of the offer a long-term stage, the available flexed posture of the phalanx rela - joint and cause benefit for athletes. dorsiflexion de - tive to the metatarsal head. 8 The pain. Open-back creases. Compen - term hallux rigidus was first used shoes and sandals If a steroid satory gait changes by Cotterill in 1888. 9 can create discom - follow, which in - Grading systems which delin - fort because of the injection is used, clude increased eate the biomechanical features increased motion the athlete should dorsiflexion at the and x-ray criteria are helpful to required to walk ankle and in - stage hallux rigidus. The most use - in such shoes. not participate in creased knee flex - ful classification system for hallux Pain associated ion. Athletes rigidus was suggested by Roukis 10 with hallux sports for 48 hours. change their run - and combines criteria from the sys - rigidus is caused ning gait so that tems of Drago, 11 Hanft, 12 and by the degenera - they run more to - Kravitz. 13 Table 1 describes a modifi - tive arthrosis of the joint. Prolifera - ward the outside of their foot. These cation of these approaches. tion of bone and cartilage at the dor - compensatory gait changes can lead Hallux rigidus is a progressive sal aspect of the joint contribute to to other injuries. Central metatarsal - the limita - gia is often found as weight-bearing tion of forces shift laterally. A large dorsal TABLE 2 move - exostosis can cause pain from the ment. Car - pressure of rubbing against footwear. Possible Hallux Rigidus tilage de - Pain and occasionally hyperkeratoses Etiologies generation sometimes develop at the interpha - and osteo - langeal joint in association with Biomechanical phyte for - compensatory dorsiflexion. Functional hallux limitus mation are Functional hypermobility of first ray caused by Etiology Gastrocnemius-soleus equinus abnormal, Metatarsus primus elevatus is Compensated forefoot valgus repetitive believed to be a prime cause of hal - Excessive rearfoot pronation contact of lux rigidus (Table 2). Restriction of Post-traumatic the joint plantar flexion of the first Osteochondral first MTP joint injury surfaces. Continued on page 160 Intra-articular fracture at first MTP Hallucal sesamoid fracture with resulting sesamoid dysfunction TABLE 3 Structural Metatarsus primus elevatus Functional Orthoses Long first metatarsal Long proximal phalanx of hallux Modifications for Hallux Rigidus Iatrogenic Post-surgical excessive elevation of the first metatarsal Inverted cast correction Post-surgical excessive lengthening of the first metatarsal Medial heel skive Post-surgical malalignment of the first metatarsophalangeal joint Deep heel cup Excessive fibrosis Minimal arch fill on cast Hallucal sesamoid dysfunction Prolonged immobilization Forefoot modifications: Other Reverse Morton’s padding Gouty arthritis Sesamoid Accommodation Septic arthritis Kinetic wedge ® Neuromuscular derived muscle imbalance affecting first ray Other techniques to off-load the first ray.

www.podiatrym.com JANUARY 2010 • PODIATRY MANAGEMENT 159 n g o in ti u a n c shape, short first metatarsal, long ti u Injuries... n d o E proximal phalanx, or a tight medial C al ic metatarsal could also play a slip of the plantar fascia could each d e role. If the first metatarsal head contribute to a limitation of plantar M does not functionally contact the flexion of the first metatarsal. 10,14 supporting sur - face, the first ray Treatment (See will become ele - Flow Chart) vated or dorsiflex Turf toe refers during gait. Con - to a condition Stage 1, 2— ditions which Functional may contribute to that is commonly Orthotics metatarsus Most patients primus elevatus termed a “sprain” with early stage include gastrocne - of the first hallux rigidus mius-soleus equi - complain of pain nus, functional metatarsophalangeal in and around the hypermobility of first MTP. Dorsal the first ray, com - (MTP) joint. pain at the joint pensated forefoot is often the pri - valgus, and an ex - mary complaint. Figure 1: X-ray demonstrating stage-3 cessively long first metatarsal. The patient doesn’t usually report hallux rigidus. Sesamoid dyscrasias, flexor plate in - “stiffness”, but the range of motion jury or immobility, intrinsic muscle will usually be limited. Further ex - ness in one or both hallucal contracture, altered metatarsal head amination will often find tender - sesamoids. X-ray changes are mini - mal. Patients with severe symptoms should try a brief course of immo - CHART 1 bilization, followed with off-load - ing the joint using functional or - thotics with forefoot modification. NSAIDs can be useful in the ini - Hallux Rigidus tial stages. Ice is a useful adjunctive therapy. Activity level should be decreased as needed. Steroid injec - History tions at the joint will not offer a Painful 1st MTP Stiffness 1st MTP long-term benefit for athletes. If a Pain with activity steroid injection is used, the athlete Insidious onset should not participate in sports for 48 hours. Stages 1 and 2 can often be suc - Clinic Examination cessfully treated with functional or - Other Findings Dorsal prominence thotic therapy (Table 3). The goal Central Metatarsalgia Hallux equinus Radiographic Findings of the functional orthotic is to im - IPJ Plantar callous IPJ Hyperentension prove first ray function by enhanc - +/- Abnormal ROM 1st MTP ing stability and limiting dorsiflex - ion of the ray. The design of the or - thotic should allow the first Initial Treatment Orthoses Medial skive metatarsal to maximally plantar- NSAIDS/Ice Deep heel cup flex. This allows the first MTP to be Reduce activity Inverted cast correction Immobilization Reverse Mortons in a more relative dorsiflexed posi - Orthoses Kinetic wedge tion towards the latter stages of Shoe modifications Off load first ray stance. Less abnormal motion will take place at the first metatarsopha - CLINICAL langeal joint and there will be a less RESPONSE sudden abutment at the dorsal as - NOT IMPROVED IMPROVED pect of the joint. Consider surgery Monitor progress Chielectomy Deteriorates Stages 3, 4—Surgical Dorsiflexory Osteotomy Re-evaluate Intervention Arthrodesis Joint Replacement Surgical solutions may be need - ed at Stages 3 (Figure 1) and 4 if conservative care fails to relieve Continued on page 161

160 PODIATRY MANAGEMENT • JANUARY 2010 www.podiatrym.com M C e o d n i t first metatar - ca in Injuries... l u Ed in sophalangeal u g TABLE 4 c pain. The most popular joint (MTP). On ex - at io surgical solution for Stage Turf Toe Grading System amination, carefully as - n 3 is chielectomy. In stage sess the sesamoid bones. 4, arthrodesis of the joint Classification systems for 1st MTP Sprains/Turf Toe As the toe moves up, the or joint replacement may sesamoids are forced into be required (Chart 1). A. Jahas in 1980 classified sprains of the 1st MTP the first metatarsal bone. joint as follows: They are then subject to Turf Toe: From the severe and sudden forces Ground Up Type I which injure the cartilage Inter-sesamoid ligament and sesamoids remain intact. Turf toe refers to a of the sesamoids and the condition that is com - Type II plantar surface of the monly termed a “sprain” Sprain disruption of the intersesamoid ligament and an metatarsal head. Some - of the first metatarsopha - associated transverse fracture of the sesamoids. times, the sesamoids may langeal (MTP) joint. Ini - fracture from these forces. tially, it was applied only B. Clanton and Ford 15 devised a useful classification Often the soft tissue at - to injuries incurred by system for 1st MTP sprains or Turf Toe in 1993: tachments are also in - those participating in jured. The flexor hallucis American-style football, Grade 1 brevis, abductor hallucis and it occurred on artifi - Stretch injury or slight tearing of the capsule and and adductor hallucis ligaments of the first MPJ. Findings include local plantar cial turf. In reality, it oc - or plantar medial tenderness, mild swelling, minimal loss muscles all have an inti - curs in many other sports of range of motion, ability to bear weight with only mild mate attachment with the including soccer, basket - symptoms some pain on continuation of play. sesamoid bones. ball, volleyball, among If the plantar portion dancers and occasionally Grade 2 of the joint is injured runners. While this injury Partial tear of the capsule and ligaments of the first MP Joint. (which in reality, it always can range in severity from Findings include moderate swelling, bruising, and moderate seems to be) there will be a mild soft tissue sprain to restriction of first MPJ range of motion. Limp noted. a limitation of motion. complete dislocation of Attempts to increase the the first MTP joint, in Grade 3 range of motion while the Complete tear of the capsule and ligaments. Possible tear runners it does not often of the plantar plate. plantar structures are in - extend to the more seri - jured, and the dorsal ous grade injury (Table 4). structures are not in much Turf toe is a complex injury dorsal aspect of the first metatarsal. better condition, are not recom - (Table 5). It is caused by a sudden There is usually an injury to the mended. Instead, support, stabilize, dorsiflexion (bending upwards) of cartilage on the dorsum of the first and limit motion while the problem the great toe on the first metatarsal metatarsal head, and almost always is in an acute stage. head. Pain is often found at the a limitation of motion in dorsiflex - ion after the Treatment of Turf Toe/1st MTP injury. Joint Sprain (Table 6) TABLE 5 Much of Do not force the injured toe to the injury oc - move, since it is going to cause Turf Toe Predisposing Factors curs below the Continued on page 162 • Artificial turf and playing surfaces • Athlete’s experience and years of sports participation TABLE 6 • Flattened 1st MTP Joint Turf Toe Treatment • Cavus foot type Summary • Football players (defensive and offensive running backs, wide receivers, linemen) Careful assessment followed by the appropriate • Foot pronation treatment: • Hallux degenerative joint disease Acute Care: • Increased ankle dorsiflexion PRICE: Protection, Rest, Ice, Compression, Elevation. Off-loading shoe • Increased friction between athletic shoe and turf Rocker sole • Excessive toe box flexibility Pneumatic walker • Prior 1st MTP joint injury Long Term: • Sesamoiditis Off-loading orthotic with sesamoid accommodation

www.podiatrym.com JANUARY 2010 • PODIATRY MANAGEMENT 161 n g o in ti u a n c tures attached to the sesamoid ti u Injuries... n d o E bones. Off-load it with a sesamoid C al ic pain and reinjure the dam - accommodation pad (or a d e aged area. Rather, immobilize a “dancers” pad) designed to shift M high grade, painful injury that weight and forces proximally and causes an antalgic gait. A CAM laterally. If this is successful, use an walker or pneumatic walker works orthotic of a semi-rigid or some - well for this purpose. Immobiliza - what softer material with an ac - tion will prevent or limit the load - commodation pad. On occasion, ing of the fore - the injury needs foot and will also to be evaluated limit the dorsi - For long-term for sesamoid frac - flexion of the ture and avascular great toe at this follow-up, treat necrosis. Long- early stage of term x-rays on healing. These de - turf toe primarily as fractured vices limit the an injury to the sesamoids do not movement far usually demon - better than a sesamoid apparatus strate healing as “post-operative and structures they do in the shoe.” By limiting long bones. It just the forward mo - attached to stays split, but fi - tion of the tibia brous connective the sesamoid bones. Figure 2: Orthotic with tapered over the foot and tissue can make a sesamoid accommodation. stopping the rela - firm union of the tive dorsiflexion parts. An accom - functional position, and eliminat - of the foot, forces at the first modation built into an orthotic ing the early, rapid change in posi - metatarsophalangeal joint and con - usually helps, if well designed. tion of the great toe that takes comitantly, the sesamoid bones, Orthotics must be used for at place as the gait cycle passes will be lessened. least 12 months. The orthotic func - through heel-off. Shoes with a stiff For long-term follow-up, treat tions by directly removing pressure forefoot or a rocker forefoot sole turf toe primarily as an injury to from the sesamoidal apparatus, can be adjunctive therapy when the sesamoid apparatus and struc - placing the great toe in a good used with orthotics. Bone stimulators may be effective. TABLE 7 TABLE 8 Splints have been suggested and are Differential Diagnosis Differential Diagnosis placed below the first of Sesamoidopathy of FHL Tendinopathy metatarsophalangeal joint. and Causes of Pain • Symptomatic os trigonum Sesamoidopathy Differential Diagnosis • Posterior impingement syndrome The hallucal • Steida’s process fracture (Shepherd’s sesamoid bones are Stress Fracture fracture) associated as a por - AVN tion of the first Diastasis • Posteriomedial talar osteochondral injury metatarsophalangeal Overt Fx joint complex, along Chondral injury • Subtalar joint coalition Osteomyelitis with the big toe and Neoplasm • Posterior tibial tendinopathy the first metatar - • Flexor digitorum longus tendinopathy sophalangeal joint. Causes of Pain in Sesamoid Region They function as a • Peroneus longus tendinopathy fulcrum, although Intra-articular: • Partial tear of the plantar fascia some describe the Chondral injury • Plantar fasciopathy function as being Plica more like a pulley. Cyst • Hypertrophy of the FHL muscle and The primary effect of Capsulitis compression within the fibro-osseus the sesamoids is to tunnel Extra-articular: increase the mechan - Tendinopathy • Sesamoiditis ical advantage of the Neural trauma • Neoplasm muscles that plantar- Bursitis flex the big toe. Continued on page 163

162 PODIATRY MANAGEMENT • JANUARY 2010 www.podiatrym.com M C e o d n i t of tendon are not dependent upon dons such as the Achilles ca in Injuries... l u Ed in metabolic activity. tendon, which do not have u g c Sesamoid pathology is more The tensile strength of tendon a true synovial sheath, may at io complex than the term “sesamoidi - at 5.0 kN/cm2 to 10 kN/cm2 is be covered with tissue that n tis” would imply (Table 7). Method - higher than that of bone. With the serves a similar function. ical analysis will allow one to dis - strength of tendons at times ex - 5) Tendon bursa—The tendon tinguish among the myriad entities ceeding the strength of bone, in - bursae reduce friction. The retrocal - that may occur in this location. juries such as fifth metatarsal sty - caneal bursa and pes anserinus Richard Bouché, DPM has lectured loid process avul - bursa are well often on the “sick sesamoid”, and sion fractures known examples. has coined the term sesamoidopa - may occur. Ten - In this article thy. That is the term we will use to dons may become Repetitive overload we’ll be looking apply to sesamoid injuries in which injured when re - and microtrauma at tendons that the diagnosis has not been further peated loads are often injured refined. exceed their can occur in but not consid - strength capacity. ered in the diag - Treatment of The elastic modu - conjunction with nostic process. Sesamoidopathy lus of an injured non-uniform stress Here, we will pay Treatment of sesamoidopathy tendon is less - special attention may include padding, orthotics ened while its within a tendon. to the peroneus (Figure 2), or surgery. Immobiliza - stiffness is in - longus tendon tion is used in severe cases. In the creased. and the flexor long term, orthotics with a The structures hallucis longus sesamoid accommodation are often which surround tendons consist of tendon, which along with the in - helpful. Surgical procedures that five types of tissue 16 : sertion of the posterior tibial ten - have been used include relocation, 1) Fibrous sheaths—These are don and the mid-portion of the complete or partial excision, channels through which usually plantar fascia, sit in what I call the sesamoidal planing, longer tendons glide. “zone of confusion.” In this zone, metatarsophalangeal Friction is reduced too many injuries are often called joint fusion. through their course. “plantar fasciitis.” A high level of The grooves and suspicion and careful examination The Rise of notches through should lead to the proper diagno - Tendinopathy which tendons must sis. Treatment failure often follows Healthy tendons pass are almost al - a failure to make the correct diag - are white, firm, have ways lined with fi - nosis. Diligence in creating a rea - a fibroelastic texture, brocartilage just sonable set of differential diag - and are able to han - below the fibrous noses should be done for each pa - dle heavy loads. sheath. Overlying tient. Careful examination, con - Shapes of tendons the notches and sideration, and imaging (when vary from short and channels, above the necessary) will minimize diagnos - broad, such as the tendons, are often tic errors. quadriceps tendon, retinacula such as Tendinopathy is now the term to long and round - the superior and in - of choice for the clinical condition ed, such as the per - ferior extensor reti - following overuse injury. The terms oneal tendons. Ten - nacula at the ankle tendinosis and tendinitis are histo- dons transfer the and the superior and pathological descriptions and forces generated by inferior peroneal should not be used without micro - muscles to bone. retinacula. scopic confirmation. Overuse ten - This force transfer 2) Reflection pul - don injuries cause pain, reduce results in move - leys—The cuboid strength and function, and decrease ment. The elasticity groove is an exam - tolerance and length of exercise. of tendons allow for Figure 3: Zone of confusion key ple of a reflection The Achilles tendon and posterior improved muscle structures P.T.—Insertion of poste - pulley. Reflection tibial tendon are among the most rior tibial tendon. P.L.—peroneus function through pulleys are areas in common areas affected by longus tendon. F.H.L.—flexor hal - the force-length-ten - lucis longus tendon). which the tendon tendinopathy in runners. sion relationship. must make a dra - Surgical specimens, taken from This improved function also results matic change in direction. patients with well-established from the ability of the tendon to 3) Synovial sheaths—Where tendinopathy, show little to no store mechanical potential strain friction may occur, tendons are signs of inflammation. Instead, the energy. The storage and recovery of often covered with synovial sheaths specimens show hypercellularity, energy is a passive process that does which usually secrete a friction-re - an increase in proteoglycan con - not need to be turned on and off. ducing peritendinous fluid. tent, vascularization, and a loss of In fact, the mechanical properties 4) Peritendinous sheaths—Ten - Continued on page 164 www.podiatrym.com JANUARY 2010 • PODIATRY MANAGEMENT 163 n g o in ti u a n c are all compatible with the current important component of the evalu - ti u Injuries... n d o E major theories of tendinopathy. ative process. Bains and Porter C al ic the usual tightly bundled col - The theory of incomplete healing (2006) state that “clinical evalua - d e lagen appearance. Tendinopath - views the injured tendon as being tion remains the main criterion M ic tissue is usually grey or brown in in a healing phase, with active cel - measure” for evaluation of poten - color. Physically, the tissue is soft lular activity and increased protein tial areas of tendinopathy. 22 and fragile. Animal preparations do production occurring in the midst not demonstrate inflammation as a of a disorganized matrix and neo - Zone of Confusion: component of long-standing ten - vascularization. This has also been Re-evaluating Intractable don injury. Inflammation is only termed “failed healing.” 19 Plantar Fasciitis seen in cases of acute and extreme Overuse tendon injuries have The plantar mid-foot can be an tendon loading. The microscopic also been viewed area of consterna - pathology of both mid-tendon and as degenerative tion. Classically, enthesis injuries is histologically processes. The the mid-foot in - similar. terms hypoxic de - Longitudinal tears cludes the navicu - Repetitive overload and micro - generation, mu - of the peroneus lar, cuboid, and the trauma can occur in conjunction coid degeneration three cuneiform with non-uniform stress within a or hyaline degen - longus tendon at bones. It lies anteri - tendon. The result is local fiber eration are often or to Choparts degeneration. A single abnormal applied. This sug - or proximal to the joint which in - loading cycle (e.g., a misstep) gests an end stage cuboid tunnel can cludes the calca - could be enough to create isolated and difficult-to- neocuboid and fibril damage. The patient would reverse process. 20 often be treated with talonavicular not likely recall a specific injury. It is possible that immobilization. joints. Our zone Neer believed impingement could a continuum may of confusion ex - be a cause of tendinopathy in the exist with incom - tends within the supraspinatus tendon below the plete healing soft tissue a bit anterior margin of the acromi - leading ultimately to a degenerative distal to this (Figure 3). Many times, um. 17 An analogous process may process. Cook and Purdam have de - pain in this area is mistakenly as - contribute to peroneus longus scribed this hypothesis. 21 cribed to plantar fasciitis or plantar tendinopathy adjacent to the fasciopathy. cuboid bone. Diagnostic Approaches Perform a painstakingly careful Tendon overload creates matrix Magnetic resonance imaging evaluation of this area while keep - changes in the collagen structure. (MRI) and diagnostic ultrasound ing in mind the structures you are There is an increase in proteogly - (US) are the most frequently em - palpating (Figure 3). Specifically, cans and cellular protein, and en - ployed diagnostic procedures. In trace and palpate the peroneus zyme production is altered. Produc - contrast to tenography, both of longus tendon, flexor hallucis tion of prostaglandin E2 and these procedures are non-invasive longus tendon, and the insertion leukotriene B4 are increased. These and cause no further damage to the point of the posterior tibial tendon. compounds likely tissues. US is a Any of these tendons could cause contribute to the fast and inexpen - symptoms that mimic plantar fas - development of sive technique ciopathy. tendinopathy. The accessory which can be per - We’ll focus on these clinical en - Apoptosis may navicular bone is formed in an of - tities, but you should keep in mind also play a role. fice setting. Ten - more dorsal structures that could An increase in cy - reported to occur don thickening, contribute to pain in this area, in - tochrome-c relat - echogenic cluding: Lisfranc ligament or joint ed caspace activa - in up to 21% changes around injury, metatarsal stress fracture, tion is a potential of the population. the tendon, and cuboid stress fracture, navicular inductive path - adhesions are stress fracture, and plantar fascia way for apoptosis. readily seen. Ten - tear. Heat shock pro - dons affected by tein (HSP-25) is also found in ani - tendinosis, on US examination, Structures Affected in the mal models of tendinopathy with show low reflectivity peripherally. Zone of Confusion apoptosis. 18 In chronic tendinosis, peritendi - nous adhesions are seen as a hypoe - Posterior Tibial Tendon/ Theories of Tendon choic paratenon with poorly de - Spring Ligament Pathology fined borders. MRI, using relatively The posterior tibial tendon We need to look at other possi - small spaced images, provides (PTT) runs behind the medial ble mechanisms for overuse greater detail, but takes longer to malleolus in a fibro-osseous groove tendinopathy, as inflammation is perform and is considerably more and inserts primarily into the nav - no longer believed to be the major expensive. icular tuberosity, but also into the cause. The features described above Clinical examination is still an Continued on page 165

164 PODIATRY MANAGEMENT • JANUARY 2010 www.podiatrym.com M C e o d n i t In conjunction with an inver - pair is not possible, one ca in Injuries... l u Ed in sion injury and tenderness at the may either perform a ten - u g c cuneiform bones. In the athletic cuboid, the os peroneum is often a odesis to the peroneus brevis at io population, overtraining and exces - contributing factor in lateral foot or alternatively attach the n sive pronation of the foot are risk pain. This bone can traumatically longus to the cuboid. factors. MRI can be an adjunct to fracture. In the presence of a Physical examination of the diagnosis and to recognition of painful os perineum, the MRI often plantar aspect of the foot must be tears in the tendon. shows signs of tendinopathy of the meticulous. Often an injury to the The spring ligament (plantar peroneus longus tendon, along peroneus longus tendon in this lo - calcaneonavicular ligament) is a with peritendinopathy, and bone cation is missed. Avulsion from the static structure, but functions in marrow edema of the cuboid. 24 Scle - tendon’s insertion into the base of tandem with the posterior tibial rosis and fragmentation of the os the first metatarsal or medial tendon. An injury to the spring lig - peroneum after chronic pain have cuneiform is possible. Usually, sur - ament would usually be found only also been found. gical repair is not necessary for in conjunction with an injury to Clinically, always examine pa - tears of the peroneus longus ten - the PTT. The MRI would show the tients with lateral foot or plantar don in this region. Diagnosis, fol - ligament to be abnormally thick - mid-foot pain for tenderness along lowed by immobilization and ade - ened and would demonstrate in - the plantar course of the peroneus quate time for healing, is vital. If creased signal intensity. Previous longus tendon. It appears to be a pain and swelling persist, consider articles have discussed posterior tib - structure that is often injured. The removing non-viable tissue and ial tendon dysfunction in detail. first step in diagnosis of a distally perform a tenodesis to the peroneus injured peroneus longus tendon is brevis. 25 Accessory Navicular suspicion of the injury. After deter - Bone Flexor Hallucis Longus The accessory navicular bone is Tendinopathy reported to occur in up to 21% of The flexor hallucis longus is a the population. This bone may FHL tendinopathy multi-joint muscle which plantar- slightly increase the risk for PTT flexes the hallux, contributes to re - pathology. Type-I accessory navicu - has been found sisting pronatory forces, and is a lar bones are small, round, and can in conjunction with weak plantar-flexor at the ankle, al - be located considerably proximally. though in the ballet dancer, it is They have the appearance of a plantar fasciitis. the important force transfer link in sesamoid bone and are not likely to attaining the point position. Flexor create any dysfunction in the PTT. hallucis longus (FHL) tendinopathy Type-II accessory navicular is is known to be a frequently en - larger and sits immediately adja - mining that there is a likely per - countered injury among ballet cent to the main body of the navic - oneus longus injury, direct your at - dancers. In ballet dancers, FHL ular bone. Type-II accessory navicu - tention to the lateral ankle. Tender - tendinopathy can be found in asso - lar bones are what most clinicians ness of the lateral ligaments is a ciation with a symptomatic os readily observe. Type-III navicular confirmatory sign of inversion in - trigonum. Scattered reports exist of bone is cornuate shaped and incor - jury. Often, the inversion injury injuries to this tendon in runners. 26 porates the accessory navicular into does not appear major and tender - Olaff, in a study of non-athletes, the body of the navicular. An in - ness is only seen at the anterior noted that this is likely an under- jured accessory navicular bone talofibular ligament. An MRI can be reported injury. 27 Most authors (Type-II) will show bone marrow of assistance and prevent a mistak - have found that the majority of the edema and possibly cyst formation. en diagnosis of “cuboid syndrome”. injuries to this tendon take place PTT pathology can often be seen in Longitudinal tears of the per - proximally, with some tears occur - conjunction with the injury to the oneus longus tendon at or proximal ring at the level of the hallucal accessory navicular bone. 23 to the cuboid tunnel can often be sesamoid bones. treated with immobilization. If Our concern here is with Os Peroneum/Peroneus Longus these tears fail to heal, excision of tendinopathy within the “zone of Tendinopathy non-viable tissue and suturing may confusion.” Most clinicians do not The os peroneum is a sesamoid be performed. An enlarged peroneal have injuries to this tendon high bone found within the peroneus tubercle should also be removed. on their list of suspected causes of longus tendon. It is usually located Look to see if a peroneus quartus plantar and medial foot pain. In just proximal to the cuboid tunnel. inserts into the tubercle. Complete addition to the widely described This bone is thought to be present peroneus longus tendon tears occur common areas of injury, be certain in the majority of people, and a most often at the cuboid tunnel, to examine the plantar mid-foot corresponding facet is found in the sometimes in conjunction with an carefully and palpate this tendon. cuboid 93% of the time. The os per - os peroneum. The os peroneum can The term flexor hallucis longus oneum is often only partly ossified retract proximal to the calca - dysfunction appears most appro - or fibrocartilagenous. It is visible on neocuboid joint when the distal priate and should be included in a x-ray only 5% of the time. tendon is torn. If an end-to-end re - Continued on page 166 www.podiatrym.com JANUARY 2010 • PODIATRY MANAGEMENT 165 n g o in ti u a n c Summary dons: Anatomy, Physiology, and Patholo - ti u Injuries... n d gy. 1997: Human Kinetics. o l E We have reviewed several trou - C a 17 ic differential diagnosis for pain bling injuries. Diagnosis is the key Neer, C., Impingement lesions. Clin d e in the medial foot or plantar to successful treatment of injuries. Orthop Relat Res, 1983. 173: p. 70-77. M 18 medial foot (Table 8). The symp - Careful assessment and review of Xu, Y. and G.A. Murrell, The basic science of tendinopathy. Clin Orthop toms may overlap with that of differential diagnoses should lead Relat Res, 2008. 466(7): p. 1528-38. plantar fasciitis, tarsal tunnel syn - to the proper diagnosis. Regular 19 Iglehart, J.K., The new era of medi - drome, and insertional posterior critical review of the available liter - cal imaging--progress and pitfalls. N Engl J tibial tendinopathy. 28 ature will keep your knowledge up- Med, 2006. 354(26): p. 2822-8. Tenography may be an accurate to-date. Successful diagnosis and 20 Jozsa, L. and P. Kannus, Histopatho - indicator of injury to this tendon, treatment of your patients is the logical findings in spontaneous tendon but is no longer widely used. Physi - first step towards overall success. I ruptures. Scand J Med Sci Sports, 1997. cal examination, MRI, and diagnos - 7(2): p. 113-8. 21 tic ultrasound could be useful in References Cook, J.L. and C.R. Purdam, Is ten - the diagnosis of this clinical entity. 1 Eisenmann, J.C. and E.E. Wickel, don pathology a continuum? A pathology model to explain the clinical presentation Physical examination will reveal The biological basis of physical activity in of load-induced tendinopathy. Br J Sports tenderness along the course of the children: revisited. Pediatr Exerc Sci, 2009. 21(3): p. 257-72. Med, 2009. 43(6): p. 409-16. FHL tendon. Limitation of dorsi - 22 2 De Moor, M., et al., Genome-Wide Bains, S., Porter, K, Lower limb flexion of the hallux may be found. Association Study of Exercise Behavior in tendinopathy in athletes. Trauma, 2006. 8: Pain may be elicited by dorsiflexion Dutch and American Adults. Med Sci p. 213–224. 23 of the hallux or dorsiflexion at the Sports Exerc, 2009. Ting, A.Y., W.B. Morrison, and E.C. ankle. 3 Beloqui, A., Guazzaroni, M., Pazos, Kavanagh, MR imaging of midfoot injury. FHL tendinopathy has been F., Vieites, J., Reactome Array: Forging a Magn Reson Imaging Clin N Am, 2008. found in conjunction with plantar Link Between Metabolome and Genome. 16(1): p. 105-15, vi. 24 Sobel M, P.H., Geppert MJ, Thomp - fasciitis. 29 Upon questioning, the Science, 2009. 326(October 9): p. 252-257. 4 son FM, DiCarlo EF, Davis WH, Painful os patient will often reveal having per - Mokone, G.G., et al., The guanine- peroneum syndrome: a spectrum of condi - formed vigorous dorsiflexion exer - thymine dinucleotide repeat polymor - phism within the tenascin-C gene is asso - tions responsible for plantar lateral foot cises of the toes and hallux in at - ciated with achilles tendon injuries. Am J pain. Foot Ankle Int, 1994. 15((3) March): tempting to “stretch” the plantar Sports Med, 2005. 33(7): p. 1016-21. p. 112-24. 25 fascia. 5 Mokone, G.G., et al., The COL5A1 Slater, H.K., Acute peroneal tendon gene and Achilles tendon pathology. tears. Foot Ankle Clin, 2007. 12(4): p. 659- Treatment Scand J Med Sci Sports, 2006. 16(1): p. 19- 74, vii. 26 Conservative treatment is often 26. Coghlan, B.A. and N.M. Clarke, useful and yields excellent results 6 Lovejoy, C.O., et al., Combining pre - Traumatic rupture of the flexor hallucis in the plantar mid-foot. Dorsiflex - hension and propulsion: the foot of Ardip - longus tendon in a marathon runner. Am J Sports Med, 1993. 21(4): p. 617-8. ion exercises of the great toe and ithecus ramidus. Science, 2009. 326(5949): 27 Oloff, L.M. and S.D. Schulhofer, vigorous over-stretching of the p. 72e1-8. 7 Laird, P.O., Functional hallux limi - Flexor hallucis longus dysfunction. J Foot Achilles tendon should be discon - tus. Illinois Podiatrists, 1972. 9(4). Ankle Surg, 1998. 37(2): p. 101-9. 28 tinued. Short-term immobilization 8 Davies-Colley, M., Contraction of Schulhofer, S.D. and L.M. Oloff, may be necessary. Eliminate over- the metatarsophalangeal joint of the great Flexor hallucis longus dysfunction: an cushioned and excessively flexible toe. Br Med J, 1887. 1: p. 728. overview. Clin Podiatr Med Surg, 2002. shoes. Following weaning from a 9 Cotterill, J., Stiffness of the great toe 19(3): p. 411-8, vi. 29 CAM walker or pneumatic walker, in adolescents. Br Med J, 1888. 1: p. 1158. Michelson, J. and L. Dunn, begin soleus and gastrocnemius 10 Roukis, T.S., et al., A prospective Tenosynovitis of the flexor hallucis stretching and strengthening. Rec - comparison of clinical, radiographic, and longus: a clinical study of the spectrum of presentation and treatment. Foot Ankle ommend a running shoe that is a intraoperative features of hallux rigidus. J Foot Ankle Surg, 2002. 41(2): p. 76-95. Int, 2005. 26(4): p. 291-303. good match for the patient’s indi - 30 11 Drago, J.J., L. Oloff, and A.M. Ja - Hamilton, W.G., Posterior ankle vidual biomechanics. cobs, A comprehensive review of hallux pain in dancers. Clin Sports Med, 2008. The surgical treatment de - limitus. J Foot Surg, 1984. 23(3): p. 213-20. 27(2): p. 263-77. scribed includes debridement, 12 Hanft, J.R., et al., A new radiograph - tenolysis, decompression, and exci - ic classification for hallux limitus. J Foot sion of a symptomatic os trigonum. Ankle Surg, 1993. 32(4): p. 397-404. Dr. Pribut is a The reported surgical results for 13 Kravitz, S.R., LaPorta, G. A., Lawton, Clinical Assis - proximal injuries have been excel - J., Progressive staging classification of hal - tant Professor of lent. 29,30 The patient should be kept lux limitus and hallux rigidus. Lower Ex - Surgery at non-weight-bearing for two to tremity, 1994. 1(1): p. 55-66. George Wash - 14 three weeks. Begin gentle hallux Vanore, J.V., et al., Diagnosis and ington Universi - treatment of first metatarsophalangeal ty Medical range of motion exercises at seven joint disorders. Section 2: Hallux rigidus. J School. He is a days. Following the non-weight Foot Ankle Surg, 2003. 42(3): p. 124-36. past president of bearing time period, transition to a 15 Clanton, T.O. and J.J. Ford, Turf toe the American pneumatic walking boot for two injury. Clin Sports Med, 1994. 13(4): p. Academy of Po - weeks, then wean the patient from 731-41. diatric Sports Medicine. He is in private the pneumatic walking boot. 16 Jozsa, L., Kannus, P, Human Ten - practice in Washington, DC.

166 PODIATRY MANAGEMENT • JANUARY 2010 www.podiatrym.com M C e o d n i t ca in l u Ed in EXAMINATION u g c at io n See answer sheet on page 169 .

1) A painful stage 3 hallux known as turf toe, include which B) Bursitis rigidus is likely to be treated by of the following? C) Injury to the regional all of the following, except: A) Mild stretching of the nerves A) Orthotic therapy capsule of the first MTP D) Chondral injury B) Chielectomy B) Partial tear of the capsule C) First metatarsophalangeal of the first MTP 11) Treatment of painful joint fusion C) Complete tear of the cap - sesamoidopathy is least likely to D) Achilles tendon sule of the first MTP include: lengthening D) Intact and uninjured cap - A) Cole procedure sule of the first MTP B) Excision of the sesamoid 2) The most likely surgical proce - bone dure for a Stage 4 hallux rigidus 7) The most important area of C) Orthotic with a is: those listed below to evaluate in sesamoidal accommodation A) First metatarsophalangeal turf toe injury is: D) Immobilization joint fusion A) Base of the fifth B) Chielectomy metatarsal 12) Tendons assist in making C) Achilles tendon B) The sesamoid bones muscles more efficient, in part, lengthening C) The medial cuneiform by their ability to store: D) Lapidus procedure bone A) Kinetic energy D) The Achilles tendon B) Potential strain energy 3) The most likely etiology of C) Chemical energy hallux rigidus is which of the 8) Useful initial treatment of turf D) Nuclear energy following? toe does not include which of A) Tailor’s bunion the following? 13) The mechanical features and B) Metatarsus primus varus A) Excision of both sesamoid properties of tendon result from C) Metatarsus primus elevatus bones all of the following except: D) Metatarsus adductus B) Pneumatic or CAM walker A) active metabolism of C) PRICE (protection, rest, tendons 4) Turf toe is caused by: ice, gentle compression, B) fibroelastic texture A) Sudden stop or change of elevation) C) their force-tension rela - direction D) Off-loading shoe tionship B) Sudden dorsiflexion of the D) decreased friction and im - hallux 9) The sesamoid bones function proved function from the C) Tight shoes to: surrounding tissues around D) Haglund’s deformity A) Increase the mechanical tendon. advantage of the flexor hal - 5) Risk factors that may con - lucis longus 14) Plantar fasciopathy or par - tribute to turf toe include all of B) Decrease the efficiency of tial tears of the fascia may be the following, except: the flexor hallucis longus confused with which of the A) Prior first metatarsopha - C) Increase the ability of the following? langeal joint injury hallux to dorsiflex A) Extensor digitorum B) Sesamoiditis D) Increase pronation of the longus tendinopathy C) Playing football on artifi - midtarsal joint B) Achilles tendinopathy cial grass C) Peroneus longus D) Diabetic neuropathy 10) Intra-articular causes of pain tendinopathy in the sesamoid region include D) Peroneus brevis 6) Grade-3 first metatarsopha - which of the following? tendinopathy langeal (MTP) joint sprains, also A) Tendinopathy Continued on page 168 www.podiatrym.com JANUARY 2010 • PODIATRY MANAGEMENT 167 n g o in ti u a n c ti u n d o E EXAMINATION PM ’s C al ic ed (cont’d) M CPME Program Welcome to the innovative Continuing Education 15) The structures which most frequently surround tendon include all of the following, Program brought to you by Podiatry Management except: Magazine . Our journal has been approved as a A) Glial cells sponsor of Continuing Medical Education by the B) Synovial sheaths Council on Podiatric Medical Education. C) Peritendinous sheaths D) Reflection pulleys Now it’s even easier and more convenient to enroll in PM’s CE program! 16) Structures in the “zone of confusion” include You can now enroll at any time during the year all of the following, except: and submit eligible exams at any time during your A) Peroneus longus tendon enrollment period. B) Flexor hallucis longus tendon PM enrollees are entitled to submit ten exams C) Extensor hallucis longus tendon published during their consecutive, twelve–month D) Insertion of the posterior tibial tendon enrollment period. Your enrollment period begins 17) Injured tendon without histological examina - with the month payment is received. For example, tion is properly termed: if your payment is received on September 1, 2006, A) Tendinitis your enrollment is valid through August 31, 2007. B) Tendinopathy If you’re not enrolled, you may also submit any C) Tendinosis exam(s) published in PM magazine within the past D) Stenosing tenovaginitis twelve months. CME articles and examination questions from past issues of Podiatry Man - 18) The major theories of the causes of agement can be found on the Internet at tendinopathy include all of the following, except: http://www.podiatrym.com/cme. Each lesson A) Incomplete healing is approved for 1.5 hours continuing education con - B) Tendon degeneration tact hours. Please read the testing, grading and pay - C) Apoptosis, enzyme activation, and heat ment instructions to decide which method of partici - shock protein production pation is best for you. D) Vitamin D deficiency Please call (631) 563-1604 if you have any ques - 19) Useful procedures for the diagnosis of tions. A personal operator will be happy to assist you. tendinopathy include all of the following, except: Each of the 10 lessons will count as 1.5 credits; A) Tenography thus a maximum of 15 CME credits may be B) MRI earned during any 12-month period. You may se - C) Plain Film lect any 10 in a 24-month period. D) Ultrasonography The Podiatry Management Magazine CME 20) Likely causes of lateral foot pain within the program is approved by the Council on Podiatric “zone of confusion” include which of the Education in all states where credits in instruction - following? al media are accepted. This article is approved for A) Injury to os peroneum 1.5 Continuing Education Contact Hours (or 0.15 B) Injury to the proximal phalanx of the CEU’s) for each examination successfully completed. fifth toe C) Calcaneus D) Fracture of the neck of the fifth metatarsal Home Study CME credits now See answer sheet on page 169 . accepted in Pennsylvania

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