April is National Foot Health Awareness Month. For obvious reasons the foot health is important as the foot is a vital structure which provides a platform for walking and running. What you may not realize is how intricate the foot is. Each foot is comprised of 28 bones and 33 ligaments! That’s is a whole lot of stuff packed in one place! In addition to how many structures are in each foot, the overall shape, location, and pressure put on the foot make it vulnerable to injury. With all those bones and ligaments and exposure on the body, no wonder the foot gets injured.
While it is important for everyone to have healthy feet, athletes are exquisitely prone to foot related issues and injuries. Athletes require excessive demand and function from their bodies. The athlete’s foot is not immune from the stress put on them from the requisite requirements of sport. It is estimated that 20% of all injuries involve the foot. Running, jumping, cutting, pushing off, and kicking all put the foot at risk for injury. While some foot injuries in athletics are inevitable as they are an unfortunate byproduct secondary to sport participation, most athletic foot injuries are secondary to overuse. Therefore, prevention and risk mitigation of foot injuries must be a top concern for athletes. Prevention of injury and re-injury is the key to foot health for athletes.
Common Injuries with Athletes
So, what foot injuries do we see in athletes? In a 2020 article in the Journal of Athletic Training, injury-surveillance data was obtained for NCAA athletes concerning foot injuries. Of importance, the study looked at injury risk, which is a combination of injury occurrence rates and severity of the injury. The most common foot injuries encountered in the study were foot/toe contusions, midfoot injuries, plantar fascia injuries, turf-toe, and metatarsal fractures with metatarsal fractures and plantar fascia injuries having the highest risk. So not only do metatarsal fractures and plantar fascia injuries happen a lot, these injuries also have extended healing and recover times. Therefore, the goal is to prevent such injuries from happening in the first place if possible.
Outside of not participating in sport, how do we prevent injuries of the foot? The answer is understanding the factors which contribute to injuries of the foot. These factors are categorized into 2 groups, things specific to the athlete themselves (intrinsic factors), and outside influences such as athletic facilities and equipment or environmental conditions (extrinsic factors). There are many ways athletes can prevent the risk of foot injuries based on these factors.
Examples of intrinsic factors which can lead to injury include bodyweight, foot shape, and inflexibility. Maintaining a healthy weight will place less stress on the feet decreasing the risk of injury. Athletes should eat properly and hydrate accordingly. Foot structure is inherent to each athlete. The foot can be flat without an arch [pes planus], have a normal arch [neutral], or have a high arch [pes cavus]. It is extremely important to wear the category of athletic shoe [especially with running] which correlates to the athlete’s foot type. Flatfoot athletes require a stability shoe, normal arch athletes a neutral shoe, and high arch athletes a cushion shoe. Inflexibility is a major contributor to overuse foot injuries in the athlete. The inflexible athlete does not evenly disperse forces across the foot creating excessive stress on the many bone, ligaments, and tendon structures of the foot. Stretching of the body from the back and hips all the way to the feet several times per week along with before and after athletic activity is of utmost importance to decrease the risk of injury. There should be an emphasis on whole body work-outs, especially core work. Particular attention should be directed to stretching and maintain flexibility of the hips, quads, hamstrings, and calves. Running is not just with the feet!
Causes of Foot Injuries
There is a broad array of extrinsic factors which can lead to injury. In general, these extrinsic factors can be considered “errors in training”. The use of worn out or improper shoe gear will set the athlete up for injury. Running shoes should be replaced every 350-500 miles or 6 months of use. They should be purchased at a reputable athletic/running shoe store where the athlete is placed through a fit process for the shoes. Not following a sport specific training program may also lead to injury. Athletes should avoid sudden increases in load or intensity of training with a gradual introduction of things such as speedwork of hill running. A slow ramp up of intensity will decrease the risk of injury. Do not run or train too hard immediately. More specifically, running over 40 miles per week significantly increases the risk of injury as noted in a 2007 study out of Stanford University. The athlete should also always allow the body to recover after athletic participation to prevent injury.
Concerning these most common athletic foot injuries, what are they specifically and how are they treated when they occur. Let’s take them one at a time.
-Foot/toe contusions: These are direct injuries to the foot from either stubbing the foot or getting the foot stepped on. They are extremely common, however are usually minor and heal quickly. The length of symptoms determines the time needed away from athletics. These injuries respond well to RICE treatment; Rest, Ice, Compression, and Elevation.
-Midfoot injuries: The midfoot is the region of the foot between the toes and the heel. This area is vulnerable to injury as it accepts forces across it with cutting, stopping, and changing directions during sport. Most often athletes encounter a midfoot sprain, or a stretching of the ligaments to this midfoot region. Midfoot injuries are most often treated with the use of immobilization with a walking boot for several weeks, however there is a vital structure called the Lisfranc ligament which if injured is a more detrimental condition which often requires surgery.
-Plantar fascia injuries: The plantar fascia is a ligamentous structure that runs along the bottom of the foot. Plantar fascia injuries are extremely common. The hallmark of the condition is pain first step in the morning or after extended inactivity such as getting out of a chair, and/or pain after long periods of time of the feet. Initial treatment includes not going barefoot or wearing shoes that are flat without a heel, icing of the area 2 times a day for 15 minutes, use of oral over the counter anti-inflammatory medication 2-3 times per day with meals, use of a supportive athletic shoe with an over the counter running/athletic insert, and stretching of your calf muscles 2 times per day. Should the condition persist, a cortisone injection may be performed or formal physical therapy initiated.
-Turf-toe: This is a traumatic sport related injury to the knuckle joint of the big toe. It occurs when the big toe is forcefully hyperextended. While the injury includes the term “turf”, it is not an injury isolated to playing on a turf field surface. There are Grade 1 (mild), Grade 2 (moderate), and Grade 3 (severe) injuries. Grade 3 injuries require surgery; however, these are rare injuries. For the more common Grade 1 & 2 injuries, the treatment is rest and immobilization with the Grade 2 injuries requiring more time off from sport.
-Metatarsal fractures: These occur in the long bones in the middle of the foot. Think of these bones like pencils, which can break with repetitive force (stress fracture), or can break from a singular excessive force (acute fracture). A metatarsal stress fracture is usually the result of excessive pressure over a long distance, running more than normal, repetitive injuries to the same bone, constant pressure of a bone for a period of time, or repetitive vertical forces. Acute fractures result from stepping with an associated twisting motion of the foot. Most often these fractures require immobilization, rest, and time to heal. There is a specific subset of these fractures that involve a specific portion of the 5th metatarsal called Jones Fractures, which occur in a region of bone with limited blood supply. These fractures take a long time to heal and have a risk of not healing at all. Because of this, surgery is recommended for Athletes who suffer a 5th metatarsal Jones fracture.
Athletes, get out there and do your thing. Keep up the hard work and dedication to your sport. But remember, it is important to think of your feet at all times and protect them from injuries that could send you to the sidelines. Protection is the key. Wear the right shoe for your foot and replace your shoes when worn-out, stretch on a regular basis including before and after athletic activity, warm-up before activity, and maintain a strong core. Keeping your feet healthy and protected can limit your chances of a foot injury, however, if you should injure your foot, prompt evaluation with a foot and ankle surgeon will help to quickly get you back on your feet and competing again in your chosen sport.