Overuse injuries are described as tissue damage 2ry to repetitive microtrauma, which results in both cellular and extracellular degeneration.1 Some of the common overuse injures of the foot and ankle are tendinopathies and stress fractures.
The etiology of overuse injuries is multifactorial and involves increased exposure to repetitive activity in susceptible individuals with biomechanical abnormalities, which may be genetic or acquired.1,2
Epidemiology including risk factors and primary prevention
The foot, ankle and lower leg make up almost 40% of injuries experienced by recreational and competitive distance runners during any one-year time.1 Stress fractures account for 0.7%-20% of all injuries at sports medicine clinics. Risk factors for ankle and foot overuse injuries involve intrinsic and extrinsic factors. Intrinsic factors include muscle deficits, inflexibility, weakness, instability, anatomic variations (e.g., high arches and pes planus), and history of previous injures (e.g., previous stress fracture). Extrinsic factors include poor technique, drastic changes in training patterns (intensity, frequency and duration), running surface (e.g., asphalt, natural/synthetic grass, sand), and improper equipment (e.g., shoes). 2
Overuse injuries result from repeat microtrauma, which leads to cellular and extracellular degeneration, eventually causing tissue damage. A disparity in overload and recovery can lead to breakdown on a cellular, extracellular or systemic level.1 As for stress fractures, they develop when bone fails to adapt adequately to the mechanical load experienced during physical activity. Excess loading leads to microdamage and bone remodeling cannot maintain the integrity of the bone, leading to the formation of a stress fracture.4
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Tendinopathies: The response to tendon injury often involves a deficient, incomplete and disordered repair mechanism, which results in defective repair. This often leads to tendon lacking in extracellular tissue organization with lessened resistive strength and increased vulnerability for further injury.1
Stress fractures: The initial stage is a stress reaction where there is an increase in osteoblast activity, resulting in increased focal bone formation. Fracture occurs when these stresses continue over time without adequate parallel osteoblast activity.5
Specific secondary or associated conditions and complications
In tendinopathies, over time, the tendon thickens 2ry to scar tissue formation, creating a weakened, degenerative tendon. This usually causes partial or complete tears of the tendon, most commonly in the Achilles and peroneus brevis tendon. Stress fractures are divided in two main categories, low (e.g., calcaneus and cuboid) and high (e.g., navicular, fifth metatarsal, and sesamoids) risk, either of which may progress to complete fractures or nonunion. Nonunion is the primary complication of metatarsal stress fractures, with a 35-50% mal union risk in fifth-metatarsal stress fractures.1, 2
2. ESSENTIALS OF ASSESSMENT
The patient’s history should include the mechanism of injury, onset of pain, its duration, and aggravating factors. Documentation of any past ankle injuries, patient’s goals regarding functional results, the level and intensity of their sports and activity, and their medical history should be included. Achilles tendon injuries usually involve an insidious and gradual increase in pain. Pain may be present after physical activity and improved with rest. A patient with a stress fracture typically presents with a history of insidious onset of activity-related pain that progressively worsens over time. The patient with peroneal tendon pathology typically complains of laterally based ankle or hindfoot pain. The pain usually worsens with activity. However, presentation and diagnosis often are delayed.1,4
An effective exam includes inspection of both lower extremities starting at the hip in standing, supine and prone positions; noting any local deformity, edema, erythema, tendon asymmetry, localized thickening, or previous scars. It is important to assess flexibility, lower limb alignment, foot structure, and motor function.1
Achilles tendon disorders: Palpate the entire gastrocsoleus complex for tenderness, nodules, swelling, warmth, atrophy, or defects, and note whether ecchymosis is present. Evaluate ROM and strength at the level of the knee, ankle, and subtalar joints. Special test may be performed to better evaluate the integrity of the tendon, such as the hyperdorsiflexion sign and Thompson test.6
Peroneal tendinopathies: Tenderness to palpation along the course of the peroneal tendons with associated localized edema may be evident. A provocative test has been described (foot in a relaxed position with knee flexed 90º, slight pressure is applied to the peroneal tendons posterior to the fibula and the patient is asked to forcibly dorsiflex and evert the foot) in which pain may be reproduced with such maneuver.7
Stress fractures: Evaluate for localized bony tenderness upon palpation or percussion of affected area and for evidence of localized swelling or erythema. Use of therapeutic ultrasound and tuning forks may reproduce or increase pain when used directly over the site of the suspected lesion 4
Include observational evaluation of the hip-knee and foot kinetic chain during single leg stance or squat. Also, analysis of the gait during ambulation, running or jumping technique for identification of risk factors such as over-striding, heavy foot plant, excessive pronation/supination,5 as well as forces during push-off.8
Laboratories are usually not necessary for ankle overuse disorders, except in those who present with stress fractures. Work up should be directed towards other medical conditions, such as infection, malignancy or rheumatologic conditions. These include C-reactive protein, erythrocyte sedimentation rate, complete blood count, metabolic panel, vitamin D and calcium levels.9
X-rays are useful to supplement the clinical history and physical examination in case of uncertainty of a stress fracture,5 malignancy or infection. For stress fractures, X-rays may initially be negative, for which they may be repeated after 2-3 weeks. Bone scan and MRI can be used to confirm the presence of stress fractures, however MRI has shown slightly higher sensitivity and higher specificity and has become the study of choice.2 A four-stage grading system has been developed to classify stress fractures depending on MRI findings: grade 1 injuries show periosteal edema on fat-suppressed images, grade 2 injuries demonstrate abnormal increased signal intensity on fat-suppressed T-2 weighted images, grade 3 injuries show decreased signal intensity on T-1 weighted images, and grade 4 injuries demonstrate a fracture line on both T-1 and T-2 weighted images.1 Both ultrasound and MRI are utilized in the diagnosis of tendon disorders. Ultrasonography provides an inexpensive, sensitive evaluation of the tendon width, water content, collagen integrity, and helps evaluate the presence of retrocalcaneal bursitis and insertional tendinitis. MRI provides information on the internal morphology of the tendon and the surrounding structures, usually used for evaluation before surgical intervention.1 CT scan can play a role for the assessment of complex fractures or tumors.10
Supplemental assessment tools
Supplemental assessment tools include the use of goniometers for objective measurement of ROM and application of ultrasound or vibrating tuning fork for evaluation of stress fractures. Quantitative gait analysis and evaluation of running and jumping technique can be helpful in order to identify biomechanical deficiencies. Nerve conduction and electromyography studies are helpful in evaluating nerve involvement.
Early predictions of outcomes
Predictors of poor outcomes include progression of the pain (previously painful at activity only, vs now present on non-athletic activities). 11 Pain at rest or during daily activities can have slower response than those with pain upon rigorous sport activity.
Some environmental factors include footwear, running surfaces, lap direction and training quantity and quality.5 Running with worn-out shoes or on harder surfaces may produce greater stresses on the body.12-14 Also, excess cushioning creates a stiff counter, increasing torque and resultant stress with push-off.15
Social role and social support system
Treatment outcomes involve the cooperation of the patient, the parents (in young athletes), the athletic trainers and the coaches. Sport psychologists can address coping with the natural process of the disease, the timing of recovery, and the treatment expectations.
The return to premorbid activities, such as the return to play in athletes and return to work in professional individuals are important aspects in the management of overuse foot and ankle injuries. There should be a multidisciplinary approach, with discussion of the natural process of the injury in order to make an informed decision.
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
There are no specific treatment guidelines for ankle and foot overuse injuries. However, treatment is based on clinical reports, expert clinical opinion and revision of current scientific literature. A proactive approach involving education about proper fitting, selection of shoes and adequate training would be ideal, along with a medical screening to identify individuals at risk of overuse injuries.8 Initial conservative management aims to relieve symptoms and correct factors causing load imbalance and repetitive strain.
At different disease stages
The goals of treatment for tendinopathies are to minimize pain, prevent further degeneration, and allow return to baseline activity. Rest (complete or modified), cryotherapy, anti-inflammatory therapy and/or steroid pain relievers, and orthotic treatment (heel lift, change of shoes, corrections of malalignments) may help to diminish pain and facilitate rehabilitation. Appropriate and progressive exercises using eccentric exercise programs for 6 weeks and improving flexibility, represent the gold standard for rehabilitation. Operative treatment is recommended for patients who do not respond adequately to a 3-to 6-month trial of appropriate conservative treatment.1, 16
Treatment of noncritical stress fractures requires relative rest with progression to activity modification on a pain free level within 4-8 weeks. Critical stress fractures, depending on the exact site and grade of the fracture, treatment may require absolute rest (4-12 weeks) or surgery (internal fixation). 1,17 Arendt and Griffiths proposed a classification (grade 1-4) for stress fractures with the aim to define the length of resting time (e.g., stage 1; 3.3 weeks and stage 4; 14.3 weeks). Rehabilitation should include a program of muscle strengthening and generalized conditioning, which may include cross-training and aquatic exercise.4, 17
Coordination of care
Coordination of care should include a multidisciplinary team involving multiple healthcare disciplines such as physiatrists, orthopedic surgeons, family physicians, and physical therapists, as well as the patient, athletic trainers, coaches and parents, in case of pediatric patients. In case of stress fractures, nutrition and sports psychologists should be included as well.
Patient & family education
The patients and their families, as well as their coaches and trainers, should be fully involved in care. They should be educated about the findings, expectations and recommendations, if consent to discuss these findings has been obtained from the patient.
Some of the short-term outcomes include reduction in pain (at rest versus during activities) and reduction of inflammation. Long-term outcomes will include correction of biomechanical deficiencies, as well as improvement in flexibility, range of motion and strength using goniometers and isokinetic testing, respectively.
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
The etiology of ankle and foot overuse injuries is multifactorial, involving intrinsic and extrinsic risk factors. Identification and education concerning these risk factors is necessary to avoid chronicity of the symptoms.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
Some of the cutting-edge therapies include ultrasound guided injection of polidocanol (a sclerosing agent) to decrease the neovascularization and symptomatology of chronic midportion Achilles tendinopathy. 18 Another potential treatment for Achilles or peroneal tendinopathy is platelet-rich plasma, which has shown mixed results in the medical literature.19 Application of topical glyceryl trinitrate to the Achilles tendon in adjunct to an eccentric exercise program has shown decrease in pain level and improved outcomes.16
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
Treatment for tendon injuries is currently of high interest as tissue engineering and regenerative medicine concepts continue to evolve, but refers that further research is needed in order to identify precise conditions required to assure adequate repair and treatment success before such therapies can be safely introduced into clinical trials.20 As for stress fractures, few studies using growth factors have reported that when used during surgical treatment of high-risk fractures, they may accelerate and improve recovery.17
- Wilder, P. and Sethi, S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 2004;23:55-81.
- Patel, D., Matt, R., and Kapil, N. Stress Fractures: Diagnosis, Treatment, and Prevention. American Family Physician. 2011; 83(1).
- Khoury, V., Guillin, R., Dhanju, J., and Cardinal, E. Ultrasound of Ankle and Foot: Overuse and Sports Injuries. Seminars in Musculoskeletal Radiology. 2007;11(2).
- Mayer, S., Joyner, P. Almekinders, L., and Parekh, G. Stress Fractures of the Foot and Ankle in Athletes. Sports Health. 2013;6(6);481-491.
- Strakowski J, Jamil T. Management of common running injuries. Phys Med Rehabil Clin N Am.2006;17(3):537-552.
- Saglimbeni, A. (2016, August 18). Achilles Tendon Injuries Clinical Presentation. Retrieved from https://emedicine.medscape.com/article/309393-clinical.
- Malhotra, R. (2016, May 10). Peroneal Tendon Pathology Clinical Presentation. Retrived from https://emedicine.medscape.com/article/1236405-clinical.
- Hreljac A. Etiology, prevention, and early intervention of overuse injuries in runners: a biomechanical perspective. Phys Med Rehab Clin North Am.2005;16(3):651-667.
- Brukner P, Bennell K. Stress fractures. In: O’Connor F, Wilder R, eds. The Textbook of Running Medicine. New York,NY:McGraw-Hill; 2001:227-256.
- Balint GP. Best Practice and Research Clinical Rheumathology. 2003;17(1):87-111.
- Harrast MA, Colonno D. Stress fractures in runners.Clin Sports Med. 2010:29:339-416.
- Nigg BM. Biomechanical aspects of running. In: Nigg BM, ed. Biomechanics of Running Shoes. Champaign,IL (IL): Human Kinetics; 1986:1-25.
- Frederick EC, Hagy JL. Factors affecting peak vertical ground reaction forces in running.Int J Sports Biomech. 1986;2:41-49.
- Stacoff A, Denoth J, Kaelin X, et al. Running injuries and shoe construction: some possible relationships. Int J Sports Biomech. 1988;4:342-357.
- Cavanagh PR, Lafortune MA. Ground reaction forces in distance running. J Biomech. 1980;13:397-406.
- Alfredson, H., and Cook, J.A treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med. 2007;41:211–216.
- Astur, D., Zanatta, F. , Goncalves, G., Moraes, E., De Castro, A., and Ejnisman, B. Stress fractures: definition, diagnosis and treatment. Rev Bras Ortop. 2016;52(1):3-10.
- Wilder RP, Sethi S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clinics in Sports Medicine.2004;23(1), 55-81.
- Vannini F, DiMatteo B, Filardo G, Kon E, Marcacci M, Giannini S. Platelet-rich plasma for foot and ankle pathologies: a systemic review. Foot Ankle Surg. 2014;20(1):2-9.
- Ho, J., Sawadkar, P., and Mudera, V. A review on the use of cell therapy in the treatment of tendon disease and injuries.J Tissue Eng.2014.5:1-18.
Original Version of the Topic
Alexandra Rivera-Vega, MD, Stephanie P. Joseph, MD, William F. Micheo, MD. Ankle and foot overuse disorders. 09/20/2014.
William Micheo, MD
Nothing to Disclose
Brenda Castillo, MD
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Alexandra Rivera, MD
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Odrick Rosas, MD
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