New User Special Price Expires in

Let's log you in.

Sign in with Facebook


Don't have a StudySoup account? Create one here!


Create a StudySoup account

Be part of our community, it's free to join!

Sign up with Facebook


Create your account
By creating an account you agree to StudySoup's terms and conditions and privacy policy

Already have a StudySoup account? Login here

Math week 1

by: Monicaa Notetaker

Math week 1 MTH 113

Monicaa Notetaker
GPA 3.3

Preview These Notes for FREE

Get a free preview of these Notes, just enter your email below.

Unlock Preview
Unlock Preview

Preview these materials now for free

Why put in your email? Get access to more of this material and other relevant free materials for your school

View Preview

About this Document

Finite Math
Sergio Hernandez
Class Notes
25 ?




Popular in Finite Math

Popular in Mathmatics

This 18 page Class Notes was uploaded by Monicaa Notetaker on Monday August 8, 2016. The Class Notes belongs to MTH 113 at University of Miami taught by Sergio Hernandez in Fall 2016. Since its upload, it has received 10 views. For similar materials see Finite Math in Mathmatics at University of Miami.


Reviews for Math week 1


Report this Material


What is Karma?


Karma is the currency of StudySoup.

You can buy or earn more Karma at anytime and redeem it for class notes, study guides, flashcards, and more!

Date Created: 08/08/16
FULL TEXT ARTICLE Foot and Ankle Injuries in Runners Adam S. Tenforde MD, Amy Yin MD and Kenneth J. Hunt MD Physical Medicine and Rehabilitation Clinics of North America, 2016-02-01, Volume 27, Issue 1, Pages 121-137, Copyright © 2016 Elsevier Inc. Foot and ankle injuries account for nearly one-third of running injuries. Achilles tendinopathy, plantar fasciopathy, and ankle sprains are 3 of the most common types of injuries sustained during training. Other common injuries include other tendinopathies of the foot and ankle, bone stress injuries, nerve conditions including neuromas, and joint disease including osteoarthritis. This review provides an evidence-based framework for the evaluation and optimal management of these conditions to ensure safe return to running participation and reduce risk for future injury. Key points • Achilles tendinopathy is common and may require comprehensive assessment and management. A similar approach is required for most foot and ankle tendon-related diseases. • Plantar fasciopathy is the most common cause of plantar foot pain in runners; interdigital neuromas, tarsal tunnel syndrome, and jogger’s foot should also be considered. • Although lateral ankle sprains are a common cause of ligament injury and ankle dysfunction, other joint conditions must be considered in chronic cases with refractory pain and dysfunction. • Most foot and ankle conditions respond favorably to conservative management, including activity modification along with corrective exercises to restore strength and function. • Preventive measures may reduce the risk for injury and are an emerging area for future investigation and research. Introduction Foot and ankle injuries are estimated to compose 31% of total running injuries sustained. A1 systematic review of running injuries by Lopes 2 in 2012 revealed that Achilles tendinopathy, plantar fasciopathy, and ankle sprains are 3 of the top 5 most common running injuries. The complex anatomy and biomechanics of the foot and ankle underscore the importance of a careful and thorough history, examination, and workup to confirm a diagnosis and rule out concomitant conditions. The running athlete requires special consideration during rehabilitation and return to participation. This review encompasses common foot and ankle injuries in running athletes, including evaluation and management of these conditions. Although the majority of our focus is on the most common injuries, this comprehensive discussion covers the full spectrum of pathology from tendinopathies to bone, joint, and nerve disorders ( Table 1(tbl1)). Table 1 Categories of running injuries Category Diagnosis Tendinopathies Achilles tendinopathy Posterior tibial tendon dysfunction Peroneal tendinopathy Flexor hallucis longus tendinopathy Anterior tibial tendinopathy Ligament and fascia conditions Plantar fasciopathy Inversion ankle sprain High ankle sprain (syndesmosis injury) Bone conditions Bone stress injuries Joint disorders Hallux rigidus Osteochondral defect of the talus Osteoarthritis Nerve disorders Interdigital neuralgia/Morton’s neuroma Tarsal tunnel syndrome Superficial peroneal neuropathy Jogger’s foot Achilles tendinopathy The Achilles tendon is the largest tendon of the body and connects the soleus, and medial and calcaneus. Insertional fibers of the Achilles tendon are in continuity with the plantar aponeurosis. This musculotendinous group serves as the primary plantar flexor of the foot and ankle. The Achilles tendon is a common site of pain in runners and may be the second most common 2 musculoskeletal injury, after medial tibial stress syndrome, with an incidence of 9.1% to 10.9%. The lifetime risk in former elite male distance runners is 52%. 3In addition to overuse from running, multiple intrinsic and extrinsic risk factors have been outlined that may contribute, 4 including systemic disease, older age, sex, body composition, and biomechanics. Terminology becomes important in the assessment and management of Achilles tendon disorders. In the acute phase, Achilles tendinitis refers to inflammatory changes at the tendon level and may include the paratenon that surrounds the tendon. In the chronic phase, Achilles tendinosis represents a more chronic and degenerative process. Achilles tendinopathy is our preferred term to use for Achilles tendon pain, with recent proposed definition for tendon pathology on a continuum of 3 stages: “reactive tendinopathy, tendon disrepair (failed healing), and degenerative tendinopathy.” 5 Clinical Evaluation The 2 most common sites of injury in runners include midportion Achilles tendinopathy (2–6 cm 6 distal to the calcaneal insertion, a region of reduced vascularity ) and insertional Achilles tendinopathy (injury localized to the insertion of the Achilles tendon with calcaneus), although injuries to other regions including the myotendinous junction can occur. Developing a systemic clinical evaluation is recommended to evaluate this injury and differentiate from other causes of heel pain. First, the runner should be asked to localize the site of maximal pain. Examination should include inspection of the tendon for differences in the general appearance of the Achilles tendon, including thickening or overlying erythema. The calcaneus should be evaluated for difference in size or prominence of the posterior aspect that may suggest presence of Haglund’s deformity. On palpation, patients with unilateral Achilles tendinopathy may have differences in the quality of the tendon, such as thickening. Presence of crepitus, swelling, and tenderness localized to a fixed position with ankle range of motion (ROM) suggests active inflammation in the paratenon surrounding the Achilles tendon. Dorsiflexion ROM may be limited on the affected side. Dorsiflexion ROM assessment should include evaluation of ROM with knee in full extension and 90° of knee flexion to determine differences in ROM (the Silfverskiold test), with decreased ROM with full knee extension suggesting the presence of gastrocnemius tightness or contracture that may place the Achilles tendon in increased tension. Evaluation of strength should include requesting the patient perform a series of single leg calf raises and evaluating for pain during this maneuver, differences in heel height from side-to-side, and fatigue. If there is concern for Achilles tendon rupture (based on patient history or presence of palpable gap of the tendon), the Thompson’s test should be performed. To perform this maneuver, the patient lies prone and examiner squeezes the triceps surae distal to the knee. Passive foot plantar flexion suggests that the Achilles tendon is contiguous with the calcaneus and unlikely to have a full- thickness tear. If there is no foot plantarflexion with calf squeeze (be sure to compare with the contralateral side), there is concern for Achilles rupture. Extensor lag and a palpable gap at the rupture site are also signs of rupture. The calcaneal squeeze test is helpful to exclude the presence of a calcaneal BSI. This test is performed with the clinician pressing both medially and laterally onto the calcaneus and evaluates for pain localized to the calcaneus. With regard to imaging, weight-bearing radiographs (lateral and axial views of the heel), may be helpful to evaluate for Haglund’s deformity, calcific tendinopathy, or if the diagnosis is unclear. MRI is indicated primarily if there is concern for significant tear or rupture of the Achilles tendon or to evaluate for a BSI. Ultrasonography is a useful modality that can be helpful to qualify Achilles tendon injury. 7 Differential Diagnosis The differential diagnosis for heel pain in a runner includes Achilles tendinopathy, posterior ankle impingement, retrocalcaneal bursitis, symptomatic Haglund’s deformity, BSI to the distal tibia, fibula, or calcaneus, peroneal tendinopathy, and hindfoot arthrosis. Management In the acute phase, initial management includes rest, activity modification, trial of heel lifts, and stretching the triceps surae. If the patient has significant pain with weight bearing, a brief period of immobilization in a boot can help to alleviate this, but long periods of time in a boot should be avoided owing to the risk of increased muscle atrophy. Local modalities including ice, massage, and ultrasound may reduce pain. Iontophoresis may also be considered to reduce local inflammation for acute presentation. Nonsteroidal antiinflammatory medications (NSAIDs) are commonly prescribed for a short course of treatment, although the degree of true inflammation is questionable in more chronic conditions. Topical nitroglycerine does not have clear evidence to support its use. 9 After achieving pain control, treatment should focus on strengthening the integrity of the Achilles tendon and triceps surae. Alfredson and colleagues 10 demonstrated efficacy of eccentric loading protocol for addressing pain and strength in patients with Achilles tendinopathy. In this landmark study, 15 subjects with unilateral midportion Achilles tendinopathy completed a 12-week session of single leg eccentric loading program with progressive weight loading. Subjects who completed this protocol of 3 sets of 15 repetitions with both knees bent and straight twice per day had normalization of strength, reduction of pain, and all returned to running over 12 weeks. 10A larger study using Alfredson’s protocol in athletes with a 5-year follow-up reported that most individuals experienced gains in function, although nearly one-half of subjects pursued other therapies and most reported mild pain. 11 For insertional Achilles tendinopathy, the authors recommend a modified version of Alfredson’s protocol with eccentric load calf raises that do not include heel drop. 12 Additionally, rehabilitation exercises that address function of the full kinetic chain are important given studies that suggest biomechanical factors may contribute to Achilles tendinopathy including reduced activity of tibialis anterior, rectus femoris,3 gluteus medius, and gluteus maximus. 14 Foot intrinsic strengthening and restoring proprioception is important for this condition, as with any foot and ankle disorder. Treatment for chronic refractory Achilles tendinopathy may include injection of platelet-rich plasma (PRP) at the affected site. PRP injection has shown benefit for Achilles tendinopathy in symptomatic patients based on published case series. 15 16However, 1 randomized control trial in chronic patients who were treated with eccentric exercise, a PRP compared with a saline injection did not result in improved management of this condition. 17 18 Operative management for this condition may include debridement of degenerative tendon and repair of remaining healthy tendon. In cases of recalcitrant insertional Achilles tendinopathy, removal of an associated Haglund’s deformity and retrocalcaneal bursectomy can be beneficial. In individuals over 50 years of age or with severe tendon degeneration, the augmenting the repair with ipsilateral flexor hallucis longus (FHL) transfer may provide additional benefit. 19 20 Plantar fasciopathy The plantar fascia serves as both a static and dynamic stabilizer for the medial longitudinal arch of 21 the foot and consists of lateral, medial, and central bands. The central band spans the medial tubercle of the calcaneus to the 5 toes of the foot. The term plantar fasciopathy reflects that this condition may include acute inflammation or chronic degenerative changes, both of which result in significant pain and limitations during running activity. Clinical Evaluation A runner typically reports a sensation of pain over the plantar aspect of the foot, typically worse with initial morning ambulation and improved during the course of a run, with worsening pain after discontinuation of activity. Duration of symptoms helps to classify the phase of injury and 22 guide management. The runner commonly exhibits tenderness to palpation over the medial calcaneal tubercle and along the plantar fascia. Thus, the plantar fascia should be palpated for presence of crepitus, thickening, or swelling. The Achilles tendon contributes fibers in continuity with the plantar fascia and should also be evaluated by palpation for presence of pain. Ankle ROM is important to assess, as described, using the Silfverskiold test. Passive extension of the toes places the plantar fascia and medial longitudinal arch on stretch and may elicit pain (Windlass test). Tinel’s sign, or shooting pains elicited by tapping over the tarsal tunnel, may help to identify tarsal tunnel syndrome as a contributor to pain. The calcaneal squeeze test should be performed to evaluate for signs of a calcaneal BSI. The calcaneal fat pad should be examined for evidence of atrophy or tenderness to palpation, because this may suggest fat pad atrophy. Weight-bearing radiograph of the foot and ankle is valuable to assess for presence of tension esophytes or calcifications, and can help exclude fracture or stress injury of the calcaneus. In a runner with acute onset of plantar foot pain with suspicion for significant tearing, MRI can be helpful to further evaluate for plantar fascia tear or rupture. New ultrasound techniques are emerging as a tool for dynamic evaluation of hindfoot structures including evaluating the plantar fascia. 23 Differential Diagnosis Personal and family history of rheumatologic conditions, including seronegative spondyloarthropathies, should be queried, because enthesopathy of the foot may mimic plantar fasciopathy. Additionally, a history of low back pain or radicular symptoms is important to elicit and consider as lumbosacral referred pain patterns can result in plantar foot pain. Other conditions on the differential diagnosis for plantar foot pain include sesamoiditis (inflammation and irritation of the sesamoid bones that lie on the plantar aspect of the hallux) and metatarsalgia, or pain localized to the metatarsal heads. These conditions are usually differentiated from plantar fasciopathy by its more forefoot location. Further discussion is beyond the scope of this article, but 24 can be found elsewhere in the literature. Management The vast majority of cases of plantar fasciopathy respond to conservative treatment. A passive plantar foot stretching program has been shown to improve pain compared with active Achilles tendon stretching exercises for chronic plantar fasciopathy with good long-term effects. 25 26In this stretching protocol, the runner should be instructed to use 1 hand to passively extend the toes toward the shin until a stretching sensation is achieved, with the other hand palpating the medial longitudinal arch to ensure the plantar fascia structure is being stretched, held for 10 seconds for 10 25 26 total repetitions and performed 3 times daily. A recent, randomized, controlled trial demonstrated high load strength training resulted in less pain at 3 months and similar outcomes at 1 year compared with the passive plantar foot stretching program. 27The high load strength training program consisted of performing single leg calf raises with the toes supported under a towel to aid in Windlass mechanism. The program started with 3 sets of 12 repetitions and advanced to added weight with 5 sets of 8 repetitions, performed every other day. The strength training program has added advantage of being performed less frequently than passive plantar stretching and may be reasonable initial therapy for most runners. Foot orthosis can also be beneficial. 28 Other treatment may include use of low-dye or calcaneal taping, accommodative foot orthosis, acupuncture, manual therapy, night splints, iontophoresis, and extracorporeal shockwave therapy. Treatment may also include injections, including corticosteroid medication, PRP, or botulinum 29 30 toxin. Corticosteroid injections have been shown to provide pain relief for 1 month and may be more effective under ultrasound guidance. 31However, complications for corticosteroid injection include heel fat pad atrophy, nerve damage, and risk for rupture of the plantar fascia that result in biomechanical changes in the Windlass mechanism. Thus, corticosteroid injections should be used with caution, and the number limited. PRP and botulinum toxin injections may provide greater duration of benefits. PRP has been shown to provide durable benefits up to 24 months when compared with corticosteroids. 32Botulinum toxin has been shown to provide pain relief at 33 3 months after treatment. Because studies on management of plantar fasciopathy have been primarily performed in nonathlete populations, the effectiveness of these treatments in runners is unknown. Ankle sprains Acute ankle sprains are a common injury in runners, especially those who run on uneven terrain. One study found that nearly one-third of female and one-quarter of male high school-aged runners 34 have a history of ankle sprain. Lateral (ie, inversion) ankle sprains are most common and result from damage a combination of the anterior talofibular ligament, calcaneofibular ligament, and posterior tibiofibular ligament. High ankle sprains (ie, eversion or external rotation) are less common and result in injury to the syndesmotic ligaments and/or deltoid. Clinical Evaluation A careful history should be obtained regarding injury mechanism, history of ankle sprain, or feelings of instability and prior rehabilitation completed. Physical findings from a comprehensive examination allow for grading of ankle sprain severity, and may be used to guide appropriate 35 36 37 management and return to play (Table 2(tbl2). Table 2 Severity of ankle sprain Grade Signs and Symptoms First degree (mild) Ligament strain with or without some ligament fibers torn Mild tenderness and swelling No laxity or residual instability Full function Full strength Second degree (moderate) Incomplete ligament tear Moderate pain and swelling Mild laxity and instability Slight reduction in function Possible decrease in strength Potential loss of proprioception Third degree (severe) Complete ligament tear Severe pain and swelling Gross instability and laxity Potential complete loss of function Potential complete loss of strength Potential complete loss of proprioception Grading criteria modified from Wolfe (2001)original reference.5 The clinician should evaluate for the presence of swelling, discoloration, and pain with ambulation. The clinician should systematically palpate the full length of the tibia, fibula, and over the anterior inferior tibiofibular ligament to evaluate for evidence of syndesmotic injury or high ankle sprain. The anterior talofibular ligament, calcaneofibular ligament, and posterior tibiofibular ligament should each be palpated for tenderness. Additionally, the fifth metatarsal, and the cuboid and tarsal navicular should be assessed for bony tenderness. Single leg balance can be assessed for general proprioception and neuromuscular control of the lower extremity. The peroneal tendons should be evaluated for subluxation, tendinosis, and/or weakness. Anterior drawer test and talar tilt tests are compared with the asymptomatic side for differences in total translation and laxity to assess for the integrity of the anterior talofibular and calcaneofibular ligaments, respectively. A weight-bearing radiograph of the ankle should be obtained based on the Ottawa Ankle Rules for acute presentation 38or based on concern for high ankle sprain, syndesmotic injury, or associated fracture. Differential Diagnosis Differential diagnosis for acute low lateral ankle sprain should include consideration for high ankle sprain involving the syndesmosis and associated fracture, such as a Maisonneuve fracture, because this would urgently change management decision making. There are 5 concomitant injuries that should be considered in patients who have not made expected progress during their course of injury rehabilitation after an inversion sprain. These include (1) peroneal tendinopathy or tear, (2) osteochondral lesion of the talar dome, (3) fracture of the anterior process of the calcaneus, (4) neuritis of the superficial peroneal nerve or sural nerve, and (5) lateral malleolar fracture. Management Initial management for inversion ankle sprain begins with PRICE: protection, rest, icing, compression, and elevation. This can be accomplished with use of a walking boot for runners with painful ambulation, or a stirrup ankle brace. The authors advocate a short period in a walking boot until pain free (usually 7–10 days) followed by transition to functional bracing. NSAIDs can be initiated 24 hours after the injury. Initial rehabilitation goals include resolution of edema and restoring painless ROM of the ankle. Postural control is impaired after both acute and chronic lateral ankle trauma, and balance exercises have been shown to help address this impairment. 39 Additionally, reduced muscle activity of the hip, knee, and ankle has been observed in patients with chronic ankle instability. 40 Therefore, advanced ankle rehabilitation protocols should include strengthening both intrinsic and extrinsic muscles of the foot and ankle along with addressing neuromuscular control and evaluation of the full kinetic chain. Although an optimal protocol for injury rehabilitation and prevention has not been defined, we recommend applying concepts of foot 41 core paradigm for management of this injury. For patients with recurrent ankle sprains (≥3 total), or persistent anatomic and functional instability despite appropriate conservative care, referral to an orthopedist for evaluation and surgical reconstruction of the lateral ligaments may be considered. Bone stress injuries Bone stress injuries (BSI) are a common form of overuse injury in runners, developing when the bone fails to respond to submaximal forces from running and resulting in structural damage and pain. 42The biological and biomechanical risk factors are discussed elsewhere. 43 44Most anatomic locations for injury in the foot are considered high risk owing to biomechanical forces that increase likelihood of malunion, nonunion, or progression to full fracture. 42 Clinical Evaluation The runner should be queried for risk factors, including history of prior fracture or BSI; changes in training volume, intensity, or technique; and screening for female athlete triad risk factors, including disordered eating, low energy availability, late menarche (defined as first menstrual period at age ≥15 years), menstrual dysfunction (including periods >35 days apart or <10 periods in 12 months), and a history of low bone mineral density. 45 Physical examination helps to localize bone pain and differentiate from other soft tissue etiologies of pain. On examination, evaluate general alignment of the foot, because cavovarus foot type may 46 increase the risk of injury. Assess for presence of pain with weight bearing, including the single leg hop test. Focal swelling or erythema, tenderness to palpation, and pain with indirect percussion can also be clinical signs of BSI. Radiographs can demonstrate evidence of cortical hypertrophy to suggest healing response or radiolucency may be visible in the setting of a high grade BSI. When clinical suspicion is high and radiographs are equivocal or when determining a specific timeline for recovery is needed, the authors recommend use of MRI to further evaluate for presence of a BSI and value in grading 47 severity of the injury to help with guide return to play. Other forms of advanced imaging may be required to evaluate BSI depending on clinical context. For example, computed tomography scans may be helpful to assess navicular BSI because surgical decision making is based in large part on whether the fracture is complete or incomplete. Differential Diagnosis Differential diagnosis of BSI varies by location and must be differentiated from other forms of injury, including soft tissue injuries such as chronic tendinopathy, arthropathy, joint instability, rheumatologic, or even oncologic pathology. Management BSI can occur in virtually any bone of the foot (although they are rare in the phalanges). Locations considered high risk include the tarsal navicular, base of the fifth metatarsal (Jones fracture), talus, 48 base of the second metatarsal, sesamoids, and medial malleolus. Common low-risk factures in the foot and ankle include the calcaneus, and the second through fifth metatarsals (excluding the 49 base of the second metatarsal and metaphysis of the fifth metatarsal). Initial management for all BSI includes immobilization or shoe modifications to achieve pain free ambulation. High-risk fracture sites typically require surgical decision making or use of immobilizer boot or cast with crutches to maintain a non–weight-bearing status, often for 6 or more weeks to facilitate bony healing. Repeat clinical evaluation is needed to ensure the patient is pain free before advancing weight bearing and initiation of cross-training and aerobic activity. It is appropriate to refer the runner to a foot and ankle orthopedic surgeon when managing injuries in high-risk locations to optimize management decisions. In female runners, current evaluation for female athlete triad risk factors and management of this condition is critical to ensure the overall health of female runners. 45 Both males and females must meet Institute of Medicine calcium and vitamin D guidelines to assist in fracture healing and prevention, including calcium targets of 1300 mg for ages 9 to 18 years old (both sexes) and 1000 mg ages 19 to 50 in females and ages 19 to 70 in males and vitamin D targets of 600 IU daily for ages 9 to 70. 50Footwear and training regimens must be evaluated for possible contribution as well. Posterior tibial tendon dysfunction Although not as common as Achilles tendinopathy, posterior tibial tendon dysfunction is another potential cause of posteromedial ankle pain in runners. The posterior tibial tendon runs from the deep posterior compartment of the leg down to insert extensively on multiple areas of the foot, including the navicular tuberosity, middle cuneiform, and second through fourth metatarsals, 51 although variants have been described. The posterior tibial tendon acts as a shock absorber during heel strike, stabilizes the foot during midstance, and aids in force generation in heel lift and toe off. Thus, dysfunction of the posterior tibial tendon can cause significant changes in biomechanics and, thus, runner performance and health. 52 Posterior tibial tendon dysfunction was classically discussed in 3 stages by Johnson and Strom, and later refined into a 4-stage classification system.53 The acute phase may include significant synovial inflammation within the tibialis posterior tendon sheath and/or paratenon. In later stages, this may progress to involve degenerative changes manifesting as thickening of the tendon, adhesion formation, and stenosing of the tendon. With progression of posterior tibial tendon dysfunction, a painful flatfoot deformity may develop. Clinical Evaluation A runner usually presents with slow progressive onset of swelling and pain along the path of the posterior tibial tendon, and possibly extends more proximally to the myotendinous junction. The pain is initially aggravated by running and progresses to include normal ambulation. Clinical examination should involve inspection and palpation of the entire path of the tendon, both distally to the navicular tuberosity and proximally to the posterior tibial muscle. Swelling and tenderness are commonly present in injured runners. Functional testing may include evaluating ability to perform heel raises both in single and double stance, and pain and/or weakness with resisted inversion of a plantarflexed foot. The double-limb heel rise test can also be useful to evaluate posterior tibial tendon function. For this test, the asymptomatic side goes into ankle plantarflexion and the other foot is lifted off the floor. The normal foot remains inverted whereas the affected side stays in hindfoot valgus in the setting of posterior tibial tendon dysfunction. Resisted inversion should be tested for weakness or reproduction of pain. Radiographs may be helpful to evaluate for bony abnormalities including presence of os trigonum. Ultrasonography is useful in evaluation of the posterior tibial tendon and may be helpful to demonstrate inflammation of the tendon and/or paratenon as well as heterogenicity or disruption of the tendon fiber, indicating degenerative changes or tears. Neovascularization may be evaluated with use of Doppler imaging with ultrasonography. MRI may also be considered, especially to evaluate abnormalities in the surrounding structures, such as in the spring and deltoid ligament complex. Differential Diagnosis Differential diagnosis for posterior tibial tendon dysfunction is similar to Achilles tendinopathy, and includes bone stress injuries of the distal tibia, fibula, or calcaneus, retrocalcaneal bursitis, posterior ankle impingement, and tendinopathies of the toe flexors. Rheumatologic disease may also contribute and should be considered with presentation of significant posterior tibial tendon inflammation or an unusual presentation. Os trigonum can cause posterior ankle pain and may be visualized on lateral radiographs of the ankle. Management Treatment for acute posterior tibial tendinitis includes activity modification, including immobilization with a walking boot and/or relative rest from repetitive loading activities, ice, 54 NSAIDs, and iontophoresis. Use of an arch support orthotic to decrease pronation may be helpful as well. In a study of 47 patients with posterior tibial tendon dysfunction, Alvarez and colleagues 55 (2006) used a structured nonoperative protocol in patients with stage I and II posterior tibial tendon dysfunction including use of a foot orthosis or short articulated ankle foot orthosis, and a rehabilitation consisting of aggressive high repetition plantarflexion exercises and heel cord stretches. After 10 physical therapy visits over 4 months, 39 (83%) had successful subjective and functional outcome. 55Thus, functional restoration should then be the focus of treatment, to include addressing both muscle weakness and imbalance as well as tightness of the triceps surae. Historical treatment for posterior tibial dysfunction include corticosteroid injections, which carry significant risk of complications, with tendon rupture a significant concern with steroid exposure. 56These authors do not recommend the use of steroid injections for posterior tibial tendinopathy and Achilles tendinopathy given that these are high weight-bearing tendons and are at increased risk of rupture with injection. In contrast with Achilles tendinopathy, we are unaware of published studies evaluating the use of PRP in posterior tibial tendon dysfunction. Surgical management may be considered in severe and refractory cases. Peroneal tendinopathy The peroneus longus and brevis tendons course from the lateral compartment of the leg, then via a common synovial sheath runs posterior to the lateral malleolus, and finally insert onto the base of the first metatarsal and the tuberosity of the fifth metatarsal, respectively. The peroneal muscles serve as primary everters of the foot. Peroneal tendinopathy is often seen in runners and may be 57 especially common for those with chronic ankle instability. Clinical Evaluation Runners with peroneal tendinopathy most often present with chronic lateral ankle pain posterior or distal to the lateral malleoli, which may be accompanied by radiating pain proximally along the lateral aspect of the leg. If there is associated peroneal subluxation or dislocation, there may be a sensation of snapping or popping when bringing the foot into plantar flexion. Although some runners may report a history of sharp and acute pop in the setting of an ankle sprain, often this is not the case. Evaluation should begin with inspection, which may note swelling and warmth along the peroneal tendon. Alignment of the foot should also be assessed given the association of a cavovarus foot with increased rates of peroneal tendon disorder. 58Palpation of the tendon may note pain and palpable tendon thickening. The peroneus longus may be differentiated from brevis when asking the runner to plantarflex the great toe given the insertion of peroneus longus. The examiner should also palpate for the presence of subluxation of the peroneal tendon over the lateral malleolus. Provocative maneuvers that may reproduce symptoms include passive inversion of a plantarflexed foot or resisted eversion of a dorsiflexed foot. With regard to radiographic studies, radiographs are helpful to evaluate for the presence of fracture or anatomic variants including os perineum. Ultrasound may be useful to elucidate signs of inflammation along the tendon and tendon sheath. Irregularity and tears of the tendon could also be evaluated, with reported accuracy of 90% (sensitivity, 100%; specificity, 85%) for diagnosis of peroneal tendon tear. 59 Dynamic testing under ultrasound guidance to visualize tendon subluxation and dislocation can also be performed. MRI may also be helpful to characterize extent of peroneal tendinopathy and/or tear. Differential Diagnosis The differential diagnosis of peroneal tendinopathy includes lateral ankle sprain and fibular fracture in the acute setting, whereas in chronic cases clinicians should consider peroneal subluxation or dislocation and os perineum syndrome. Management Peroneal tendinopathy usually responds well to conservative management, including a short period of immobilization, relative rest, lateral heel wedge, and physical therapy. Given the role of hindfoot cavovarus in peroneal tendinopathy, an accommodative custom foot orthotic should be considered. 60The role of injection of biological agents in peroneal tendinopathy is unclear, given there has only been 1 published pilot study investigating ultrasound guided PRP injection as a treatment for peroneal (among others) tendinopathy. 61Surgical debridement with tenosynovectomy and repair 62 may be considered after a period of at least 3 to 6 months of nonoperative management. Other tendinopathies Flexor Hallucis Longus Tendinopathy FHL tendinopathy is more common in classical ballet dancers, 63 although this injury may occur with running athletes performing repetitive forceful push off. Pain from FHL tendinopathy can occur anywhere along the course of the FHL, from the posterior aspect of the fibula down to the base of the distal phalanx of the hallux, although the pain may localize to the posteromedial ankle. Clinical examination may also note swelling, tenderness, and crepitus, with pain elicited by resisted plantar flexion of the hallux. Conservative management of FHL tendinopathy should include assessment of training errors and biomechanical deficits along the kinetic chain that contribute to increased FHL stress during push-off while running. Anterior Tibial Tendinopathy Anterior tibial tendinopathy may cause anterior leg or ankle pain in a runner. Weakness and pain with dorsiflexion is the primary clinical finding, and pain along the anterior tibial tendon with resisted dorsiflexion can be helpful to distinguish this condition from pain originating from the tibiotalar joint. There is no consensus on the management of anterior tibial tendinopathy and/or tear. Conservative management is reasonable for tendinopathy without significant tear, although surgical management seems to provide good outcomes for many patients with anterior tibial 64 tendon rupture. Joint pathologies There are a variety of joint pathologies that may contribute to pain in a runner. Given the prevalence of osteoarthritis, degenerative joint conditions should be considered for older runners. Hallux rigidus or osteoarthritis of the first metatarsalphalangeal joint is a common cause of forefoot pain. Runners may present with pain, crepitus, and stiffness with running and/or walking. Clinicians should start with evaluating for swelling and/or bony deformity over the dorsum of the first metatarsalphalangeal joint. ROM may be limited for both dorsiflexion and plantar flexion, whereas pain with plantar flexion may be associated with bone spur over the dorsum of the first metatarsophalangeal joint. Pain with palpation and with the “grind test,” where the examiner applies axial compression onto the phalanx into the metatarsal head, are strongly supportive of this diagnosis. Radiographic evaluation can demonstrate characteristic findings of osteoarthritis changes, including joint space narrowing, osteophyte formation, and subchondral sclerosis and cyst formation. Initial conservative management includes PRICE as well as shoe modifications. Although injection of corticosteroids may provide temporary relief, the role of injectable viscosupplementation and biological agents have not been demonstrated in the literature for management of hallux rigidus. Wide toe-box shoes can help to alleviate pressure on the toe, and use of a rigid Morton extension or full-length carbon fiber orthosis can provide support to the medial column of the foot and symptom relief. 65Surgical options include cheilectomy or arthrodesis. 24 66 Osteochondral Lesions Osteochondral lesions and defects of the foot and ankle are a potential cause of joint pain. A history of trauma is noted in 80% of medial and 100% of lateral talar osteochondral lesions 67 68and should be suspected in those with history of ankle sprain with delayed healing and/or with a history of ankle instability or injury. Patients may present with pain and swelling of the ankle, and symptoms may be aggravated by weight bearing. Physical examination may demonstrate evidence of joint effusion and pain with palpation over the talus. Although radiographs may visualize a talus fracture, MRI may be useful with negative plain films. Nonoperative treatment with non–weight- bearing status and immobilization with a walking boot may be tried, although operative treatment is often required. Excision, curettage, and drilling was reported to be effective in management of osteochondral lesions of the talus by systemic review. 69 Others have proposed a role for use of regenerative techniques, such as autologous chondrocytes implantation or bone marrow–derived stem cell transplantation, in the treatment of osteochondral lesions of the talus. 70 Nerve conditions Disorders affecting the nerves that innervate the foot also affect runners. Nerve disorders should be included in the differential for most of the injuries discussed so far, particularly in cases that do not improve as anticipated. A prevalent nerve disorder is interdigital neuralgia/neuroma, which is classically described as irritation and inflammation of the interdigital nerve to the toes as it passes below the transverse ligament of the metatarsal heads. Interdigital neuromas most commonly occur between the third and fourth metatarsals (referred to as a Morton’s neuroma), although they can occur in other locations. This condition is common in the sixth decade of life and has a greater prevalence in 71 women. Patients typically present with pain or paresthesias in the metatarsal heads and/or the neighboring toes, which is aggravated by weight bearing and wearing heels or shoes with narrow toe boxes. In contrast, metatarsalgia tends to be worse when barefoot. Often, patients may describe this as a sensation of having “pebble” in their shoe. Radiographs are usually normal, but help to identify any other abnormalities. Although MRI is the primary diagnostic imaging tool, ultrasonography in the hands of an experienced provider can yield high sensitivity (100%) and 72 specificity (83.3%) for the evaluation of a Morton’s neuroma. Management of an interdigital neuroma usually include offloading strategies, such as avoiding high heels, wearing shoes with a larger toe box, prefabricated metatarsal relief pads/bar, and/or use of custom foot orthoses. Injection with anesthetic and steroids can be both diagnostic and therapeutic. Sclerosing alcohol therapy under ultrasound guidance is highly controversial and lacks sufficient evidence to be recommended. 73If symptoms do not improve with conservative management, surgical excision may be considered. Additional neuropathies relevant for runners include tarsal tunnel syndrome, superficial peroneal neuropathy, and jogger’s foot. Injury to the posterior tibial nerve as it courses beneath the flexor retinaculum on the medial side of the ankle is termed tarsal tunnel syndrome and may result in pain and paresthesias into the medial foot. The superficial peroneal nerve courses over the lateral aspect of the foot and can be injured with lateral foot and ankle injuries, including lateral ankle sprains. Jogger’s foot is caused by irritation of the medial plantar nerve causing pain and 74 paresthesias along the medial arch of the foot. Tinel’s sign along the tarsal tunnel, superficial peroneal nerve, or over the medial plantar nerve, may help with clinical evaluation. Additionally, nerve conduction studies and electromyography may help to localize the lesion and grade severity, 75 although false negatives may occur in tarsal tunnel syndrome. Although tarsal tunnel syndrome may ultimately require decompression surgery in certain patients, 75superficial peroneal neuropathy and Jogger’s foot usually can usually be managed conservatively with rehabilitation protocol, including anti-inflammatory medications, a running biomechanics evaluation, and assessment for proper footwear. 74 Injury prevention and management Many of the foot and ankle overuse running injury conditions are likely to recur without appropriate rehabilitation efforts to reduce risk for future injury. A foot–core paradigm was recently proposed that discusses the role of intrinsic, extrinsic, and neuromuscular training to address foot conditions. 41Although custom foot orthotics or other shoe modifications may have a role for initial management of running injuries by changing the biomechanical forces through the foot, we acknowledge that compensatory changes may occur and result in unintended loading of other tissues and joints by altering the kinetic chain with continued use. Modifying foot function through rehabilitative exercises is an exciting and largely unexplored area for future research and advancement in management and prevention of overuse injuries in runners. Summary Foot and ankle conditions are common causes of overuse injuries in runners. Similar to most overuse injuries, activity modification with corrective physical therapy program to restore strength and function are key to the management of most conditions. The role of prevention specifically optimizing foot and ankle function along with full kinetic chain assessment to optimize biomechanics of running form and foot strike patterns may be an effective strategy for injury prevention and requires further investigation given the high cumulative prevalence of overuse injuries in the running population. Authors have no conflicts of interest to disclose, and no funding was received in preparation of this review. References 1. Epperly T., and Fields K.B.: Running epidemiology. New York: McGraw-Hill, 2014. 2. Lopes A.D., Hespanhol Junior L.C., Yeung S.S., et al: What are the main running-related musculoskeletal injuries? A systematic review. Sports Med 2012; 42: pp. 891-905 Cross Ref ( 3. Zafar M.S., Mahmood A., and Maffulli N.: Basic science and clinical aspects of Achilles tendinopathy. Sports Med Arthrosc 2009; 17: pp. 190-197 Cross Ref ( 4. Magnan B., Bondi M., Pierantoni S., et al: The pathogenesis of Achilles tendinopathy: a systematic review. Foot Ankle Surg 2014; 20: pp. 154-159 Cross Ref ( 5. Cook J.L., and Purdam C.R.: Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 2009; 43: pp. 409-416 Cross Ref ( 6. Carr A.J., and Norris S.H.: The blood supply of the calcaneal tendon. J Bone Joint Surg Br 1989; 71: pp. 100-101 7. Paavola M., Paakkala T., Kannus P., et al: Ultrasonography in the differential diagnosis of Achilles tendon injuries and related disorders. A comparison between pre-operative ultrasonography and surgical findings. Acta Radiol 1998; 39: pp. 612-619 Cross Ref ( 8. Neeter C., Thomee R., Silbernagel K.G., et al: Iontophoresis with or without dexamethazone in the treatment of acute Achilles tendon pain. Scand J Med Sci Sports 2003; 13: pp. 376-382 Cross Ref ( 9. Kane T.P., Ismail M., and Calder J.D.: Topical glyceryl trinitrate and noninsertional Achilles tendinopathy: a clinical and cellular investigation. Am J Sports Med 2008; 36: pp. 1160-1163 Cross Ref ( 10. Alfredson H., Pietila T., Jonsson P., et al: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998; 26: pp. 360-366 11. van der Plas A., de Jonge S., de Vos R.J., et al: A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med 2012; 46: pp. 214-218 Cross Ref ( 12. Jonsson P., Alfredson H., Sunding K., et al: New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. Br J Sports Med 2008; 42: pp. 746-749 Cross Ref ( 13. Azevedo L.B., Lambert M.I., Vaughan C.L., et al: Biomechanical variables associated with Achilles tendinopathy in runners. Br J Sports Med 2009; 43: pp. 288-292 Cross Ref ( 14. Franettovich Smith M.M., Honeywill C., Wyndow N., et al: Neuromotor control of gluteal muscles in runners with Achilles tendinopathy. Med Sci Sports Exerc 2014; 46: pp. 594-599 15. Gaweda K., Tarczynska M., and Krzyzanowski W.: Treatment of Achilles tendinopathy with platelet-rich plasma. Int J Sports Med 2010; 31: pp. 577-583 Cross Ref ( 16. Owens R.F., Ginnetti J., Conti S.F., et al: Clinical and magnetic resonance imaging outcomes following platelet rich plasma injection for chronic midsubstance Achilles tendinopathy. Foot Ankle Int 2011; 32: pp. 1032-1039 Cross Ref ( 17. de Vos R.J., Weir A., van Schie H.T., et al: Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA 2010; 303: pp. 144-149 Cross Ref ( 18. de Jonge S., de Vos R.J., Weir A., et al: One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med 2011; 39: pp. 1623-1629 Cross Ref ( 19. Schon L.C., Shores J.L., Faro F.D., et al: Flexor hallucis longus tendon transfer in treatment of Achilles tendinosis. J Bone Joint Surg Am 2013; 95: pp. 54-60 Cross Ref ( 20. Hunt K.J., Cohen B.E., Davis W.H., et al: Surgical treatment of insertional Achilles tendinopathy with or without flexor hallucis longus tendon transfer: a prospective, randomized study. Foot Ankle Int 2015; 36: pp. 998-1005 Cross Ref ( Copyright © 2016 Elsevier, Inc. All rights reserved.


Buy Material

Are you sure you want to buy this material for

25 Karma

Buy Material

BOOM! Enjoy Your Free Notes!

We've added these Notes to your profile, click here to view them now.


You're already Subscribed!

Looks like you've already subscribed to StudySoup, you won't need to purchase another subscription to get this material. To access this material simply click 'View Full Document'

Why people love StudySoup

Steve Martinelli UC Los Angeles

"There's no way I would have passed my Organic Chemistry class this semester without the notes and study guides I got from StudySoup."

Jennifer McGill UCSF Med School

"Selling my MCAT study guides and notes has been a great source of side revenue while I'm in school. Some months I'm making over $500! Plus, it makes me happy knowing that I'm helping future med students with their MCAT."

Steve Martinelli UC Los Angeles

"There's no way I would have passed my Organic Chemistry class this semester without the notes and study guides I got from StudySoup."

Parker Thompson 500 Startups

"It's a great way for students to improve their educational experience and it seemed like a product that everybody wants, so all the people participating are winning."

Become an Elite Notetaker and start selling your notes online!

Refund Policy


All subscriptions to StudySoup are paid in full at the time of subscribing. To change your credit card information or to cancel your subscription, go to "Edit Settings". All credit card information will be available there. If you should decide to cancel your subscription, it will continue to be valid until the next payment period, as all payments for the current period were made in advance. For special circumstances, please email


StudySoup has more than 1 million course-specific study resources to help students study smarter. If you’re having trouble finding what you’re looking for, our customer support team can help you find what you need! Feel free to contact them here:

Recurring Subscriptions: If you have canceled your recurring subscription on the day of renewal and have not downloaded any documents, you may request a refund by submitting an email to

Satisfaction Guarantee: If you’re not satisfied with your subscription, you can contact us for further help. Contact must be made within 3 business days of your subscription purchase and your refund request will be subject for review.

Please Note: Refunds can never be provided more than 30 days after the initial purchase date regardless of your activity on the site.