Problems affecting the metatarsals, mid-foot or heel account for approximately 15 per cent of all sports-related injuries.
Traumatic and overuse injuries can produce pain in the forefoot known as metatarsalgia.
Excess pressure on the second, third or fourth metatarsals can result in synovitis of the metatarsophalangeal joints. This causes pain in the ball of the foot and toes.
Patients often have a swelling or deformation at the head of the first metatarsal or a stiff first metatarsophalangeal joint.
These patients avoid putting weight on their big toe, causing the smaller toes to be overloaded. The second toe is the most commonly affected. On examination passive plantar flexion of the joint reproduces the pain.
This can be treated with orthotics and NSAIDs as well as foot-flexing stretches. Patients left untreated may develop a hammer toe.
Sudden, forced hyperextension of the big toe can result in a metatarsophalangeal joint sprain, also known as 'turf toe'. Treatment is rest, NSAIDs and keeping weight off the foot for at least 72 hours.
The most common stress fracture site is the neck of second metatarsal. It is most frequently seen in athletes with Morton's foot, where the second metatarsal is longer than the first.
Initial radiographs are often negative and a delayed X-ray, bone scan or MRI may be needed to make the diagnosis.
The first metatarsophalangeal joint contains two sesamoid bones embedded within the tendons of the flexor hallucis brevis muscle, which flexes the big toe.
Landing badly after a jump, sprinting or dancing can cause traumatic or stress fractures to these bones, as can any wrenching upward of the big toe.
Rest, ice, padding and NSAIDs are the usual treatment. Excision is reserved for cases that prove recalcitrant.
Compression or irritation of the nerves, most frequently at the base of the third and fourth toes can cause a thickening of nerve tissue. This produces pain and numbness of the web space between the toes. The pain is felt when wearing shoes but usually absent when barefoot.
Local anaesthetic injection of the intermetatarsal space can be used as a confirmatory test. It can be treated with orthotics, injections, neurolysis or excision.
Swelling of the foot (rather than the ankle) with bruising on the sole of the foot should be referred to a fracture clinic.
Missed mid-foot fracture subluxation or Lisfranc ligament disruption can cause chronic pain and require selective joint fusion.
Mid-foot stress fracture
Sports such as sprinting, jumping and hurdling can result in stress fractures to the mid-foot. The navicular bone is the most commonly affected bone in this area.
A bone scan or MRI may be required for diagnosis. Treatment consists of rest, in an air-cast boot or cast, until symptoms resolve. Surgical treatment might be required if conservative treatment fails.
Overuse of the tendons in the foot can cause tendinopathy of the extensor, flexor or peroneal tendons. This causes local tenderness, pain on stretching passively and pain on active resisted movement.
Extensor tendinopathy can affect the tibialis anterior, extensor hallucis longus and brevis and extensor digitorum longus and brevis.
Tibialis anterior tendinopathy is most common and causes pain on the dorsum of the foot. Peroneal tendinopathy causes pain on the lateral aspect of fibula or the cuboid. Tibialis posterior tendinopathy causes pain over the posteromedial aspect of ankle. Treatment consists of rest, ice, NSAIDs and stretching exercises.
Plantar heel pain is most commonly caused by plantar fasciitis. Patients describe a dull pain that is worst first thing in the morning. The whole heel may be tender, but the medial calcaneal tuberosity is the trigger point.
Steroid injections should be avoided because they cause fat necrosis in the heel pad.
Physiotherapy to stretch the gastrocnemius muscle is usually effective.
If medial and lateral heel compressions are painful to the patient, then a stress fracture of the calcaneus is more likely. A positive squeeze test in children may indicate an underlying infection or a tumour. A positive Tinel test behind the medial malleolus suggests tarsal tunnel syndrome.
Fat in the heel acts as a shock absorber and a fall onto the heels causing contusions of this fat pad is usually very painful. They are treated with rest, ice, silicone gel heel pads and NSAIDs.
Mr Mohan is orthopaedic registrar, and Mr Halliwell and Mr Solan consultant orthopaedic surgeons at the Royal Surrey County Hospital, Guildford.