The lower extremity, from the toes to the hip, is subject to harmful forces from every angle. Whether you’re a weekend warrior or a trained athlete, time spent injured is time lost from competition and having fun. The best way to avoid getting hurt is to understand how it happens and then take precautions, if possible.
Long-distance runners, skiers, ballet dancers and anyone who engages in a sport that applies a lot of pressure or repetitive pressure to the toes is familiar with the black- and-blue toenail. Bleeding under the nail, or subungual hematoma, is caused by trauma to the nail bed. When the toe is repetitively jammed into the end of a boot or shoe, the blood supply to the nail is compromised, whether through shearing or crushing forces. Blood collects under the nail plate and appears reddish blue initially and then turns black or purple. If pressure from the volume of blood is not released (surgically, by making a small hole in the nail, or losing the nail completely), the toe can become inflamed, swollen, and very painful. It can even get infected if the skin has been cut by the nail, since bacteria then have a nice portal of entry into the body.
Once the nail plate has lifted off the nail bed, it dies and falls off. A new nail will grow in over the next six months. If the nail is loose, but still attached at the base, keep it trimmed short so it doesn’t get snagged on socks. After the nail falls off, it’s a good idea to keep the toe moisturized (with a foot cream or even antifungal cream, if you suffer from athlete’s foot) so the new nail grows across a flat, healthy surface.
The best way to avoid a subungual hematoma is to prevent toes from hitting the end of the shoes. Some athletes prefer to buy their shoes a half size bigger or they wear thicker socks. The best guarantee to lose a nail is to wear shoes that are too tight and run downhill.
The most commonly fractured bone in the foot is the fifth metatarsal, on the lateral part of the foot.(1,2) When the foot is plantarflexed and the person is trying to pivot or forcefully invert the foot, the fifth metatarsal can experience an avulsion fracture of the base (where a piece of bone is torn off by the tendon that attaches there) or the bone breaks 1.5 to 3cm distal to the tuberosity or distal to the articulation of the fourth and fifth mets (aka Jones fracture).(1,3) It happens in soccer players, dancers, gymnasts and basketball players, both as a result of chronic overuse and also as an acute injury. But it can also occur in runners or anyone who just lands wrong on the outside edge of the foot.
There are many studies on what treatment options have the best results, but the general consensus is that if the blood supply to the base of the bone is not compromised, it will heal in a weight-bearing soft cast. This is especially true of avulsion fractures. For Jones fractures occurring more distally in the bone, the options are nonweight-bearing immobilization or surgery, depending on the severity of the fracture. Surgical fixation is recommended if nonweight-bearing casting results in a nonunion. In athletes, surgery is the first line of treatment.(1-4)
Preventive measures are difficult to take, since these fractures mainly occur with quick, high-energy movement during athletic activity. However, some studies have shown that weak ankles and overuse/overtraining may predispose to fifth met injuries.(5) Ankle support and shoes with good lateral support, or shoes and orthotics designed for supinated feet are therefore recommended. In the case of dancers who cannot wear sneakers, external bracing of the ankle in addition to exercises may be the only option. Strengthening the peroneal muscles and increasing subtalar range of motion may offer possible benefits, since the peroneals are responsible for eversion of the foot, which counterbalances hypersupination.
Achilles Heel Is Real
The typical Achilles rupture feels like someone hit the back of the leg or the calf with a baseball bat. There is often an accompanying “pop” sound, pain and gradual—but definite—inability to plantarflex the foot at the ankle, depending on the degree of the tear and the amount of swelling. In athletes, this is a debilitating injury that may take up to a year from which to recover.
The mechanism of injury usually involves changing direction while running or jumping. Forceful dorsiflexion of an ankle that’s in a plantarflexed position while the knee is extended puts a contracted muscle under further strain. For example, this can occur while pushing off of the weight-bearing foot with the knee in extension. Many studies have shown that the injured tendon was already compromised by poor circulation or calcification, which caused the tendon to degenerate.(6-8) The exact cause of this is unknown, but may be linked to chronic injury and/or overuse. There is no strong correlation between age of the patient or extreme athleticism: Rupture occurs in the recreational and the pro athlete alike. Seventy-five percent of the ruptures occur while people are engaged in sports.(8)
Treatment of a ruptured Achilles is determined by whether the person is an athlete or not (doctors are usually more aggressive in their treatment of athletes and likely to do invasive repair sooner). But a complete rupture always requires surgery. This is ascertained via ultrasound or MRI, along with manual testing. Sometimes a physical defect can be seen. Recovery from surgical repair is a time-consuming process due to the necessity of progressive nonweight-bearing casting and regaining range of motion slowly without reinjuring the tendon.(1) Partial tears are treated with posterior splinting or casting up to eight weeks, or a hinged orthosis, followed by progressive range-of-motion exercises.(8) In both complete and partial tears, heel lifts may be worn and gradually diminished in height over time as therapy increases the patient’s ability to dorsiflex at the ankle.
Prevention of tendo Achilles rupture may lie in avoiding overuse injuries that weaken the tendon and making sure the ankle joint does not overpronate.(7) Also, in sports that require repetitive jumping or quick acceleration, strengthening the accessory plantar flexion muscles may help take some of the load off of the Achilles.