Stress Fractures of the Foot: Prevention and Treatment

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Dr. Kamran Hamid from Midwest Orthopaedics at Rush talks with Dr. Cole and Steve Kashul about stress fractures of the 5th metatarsal and Jones fractures; prevention and recovery.

Dr. Kamran HamidDr. Kamran S. Hamid has a special interest in ankle replacement surgery, foot deformity correction, sports injuries, and arthritis and trauma of the foot and ankle. He earned his medical degree from the Texas A&M College of Medicine. Dr. Hamid went on to complete his Master of Public Health degree in Quantitative Methods at the Harvard School of Public Health. He completed his fellowship in orthopedic foot and ankle surgery at Duke University School of Medicine.

Dr. Hamid is a member of the American Academy of Orthopaedic Surgeons (AAOS) and American Orthopaedic Foot & Ankle Society (AOFAS). He has authored numerous peer-reviewed publications on the topics of ankle replacements and is a national expert on providing high value care to patients.

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Ask the Doctor!

This regular segment of ‘Ask the Doctor’ addresses questions sent in by Sports Medicine Weekly followers.

In this segment Dr. Cole answers questions about:

  • Recovery from a Broken Toe: Recommended Rehab Routine.
  • Fluid on the Knee: Description, causes and treatment.
  • Discussion with Steve Kashul on family workouts.

Click here to have your question addressed live by Dr. Brian Cole on an upcoming show.

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Is Toe-Walking an Early Sign of a Health Condition?

By Brian Rog with Contributions by: Annie Kender, PT, DPT, C/NDT of the ATI Grand Blanc, Mich., Clinic

Is Toe-Walking an Early Sign of a Health Condition?

When a child learns to walk, instinctively, he or she will begin walking with their feet flat on the ground. But because this is a skill that takes much practice, it’s not uncommon for them to transition on and off their tip toes as their walking abilities develop.

Some children begin walking on their toes for stability, others walk on their toes for sensory reasons – these children sometimes have difficulty tolerating pressure through their heels or they prefer the sensations (or proprioceptive input) they received from their joints locking out. Children may also walk on their toes due to range of motion restrictions in their calf muscles (gastrocs).

As your child’s coordination and muscles develop, they will begin walking with a heel-toe pattern; on average around 18 months of age. However, should those heels remain ascended beyond age 2-3 as your child’s only means of getting around, this may be an early sign of a neurological condition (Cerebral Palsy, Spina Bifida, Tethered cord, etc.). Conversely research reports 7-24 percent of children who walk on their tip-toes are idiopathic toe walkers, meaning they do not have a correlated disgnosis such as Cerebral Palsy.

When to see a specialist

Research supports the idea that heel strike in children begins around 22 weeks following initial onset of walking independently. For the majority of children, this occurs around 18 months of age. Toe walking is not considered a normal part of this early independent gait. As we mentioned, if by age 2, your child hasn’t outgrown toe walking, this may be an indication of neurological immaturity or muscle weakness.

To that, ATI Physical Therapy experts suggest consulting with your pediatrician, because if left untreated, toe-walking can put your child at further risk for contractures, foot deformities and balance deficits. And in severe cases, your child may require surgical interventions if deformities or contractures are advanced. Fortunately, physical therapy interventions are an effective way to help your child overcome this.

Long-term effects of toe walking, if left untreated

As you can imagine, toe-walking places a great load on the muscles and tendons. Many children who consistently walk on their tip-toes since establishing independent ambulation, may develop foot deformities as early as the age of four. These children may demonstrate ankle range of motion restrictions, impaired balance and poor postural alignment.

Physical therapy for toe walking

Therapeutic treatment such as physical therapy can assist your child in achieving a heel-toe gait pattern as well as correcting any range of motion restrictions, muscle imbalances and postural deformities.  After identifying the child’s origin for toe-walking, a plan of care is established to address the child’s deficits. Treatment methods typically include stretching, strengthening of lower extremities and core, balance retraining, sensory integration techniques, serial casting, orthotic training and a home exercise program.

After completing physical therapy, what’s next?

Once your child has successfully completed their PT treatment, you will receive a home exercise program to further continue their treatment plan at home.

For children with an established heel-to-toe pattern, who no longer demonstrate weakness or range of motion restrictions, their home program is minimal. For children with neurological conditions as an underlying source of their toe-walking, they may require intermittent services over their lifetime to maintain gains, usually around growth spurts.

Is your child toe-walking? ATI may be able to help

If you are concerned about your child’s toe-walking tendencies, we first suggest connecting with your pediatrician to determine the next course of action. Should physical therapy be required, please don’t hesitate to contact your your nearest ATI physical therapy clinic to see what pediatric therapy options are available for your child.

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When Turf Toe Strikes, You’ll Know What To Do

Turf toe is not a term you want to use when talking to a ballerina before her diva debut or a head football coach about his star running back.

“Turf toe” is the common term used to describe a sprain of the ligaments around the big toe joint. Although associated with athletes who play sports on artificial turf or hard surfaces, such as soccer, basketball, wrestling, gymnastics, and dance, it can happen to anyone! It’s a condition that’s caused by jamming the big toe or repeatedly pushing off the big toe forcefully as in running and jumping.

What Causes Turf Toe?

Turf toe is a sprain to the ligaments around the big toe joint, which works primarily as a hinge to permit up and down motion.

Just behind the big toe joint in the ball of your foot are two pea-shaped bones embedded in the tendon that moves your big toe called sesamoids. These bones work like a pulley for the tendon and provide leverage when you walk or run. They also absorb the weight that presses on the ball of the foot.

When you are walking or running, you start each subsequent step by raising your heel and letting your body weight come forward onto the ball of your foot. At a certain point you propel yourself forward by “pushing off” of your big toe and allowing your weight to shift to the other foot. If the toe for some reason stays flat on the ground and doesn’t lift to push off, you run the risk of suddenly injuring the area around the joint. Or if you are tackled or fall forward and the toe stays flat, the effect is the same as if you were sitting and bending your big toe back by hand beyond its normal limit, causing hyperextension of the toe. That hyperextension, repeated over time or with enough sudden force, can — cause a sprain in the ligaments that surround the joint.

What Are the Symptoms of Turf Toe?

The most common symptoms of turf toe include pain, swelling, and limited joint movement at the base of one big toe. The symptoms develop slowly and gradually get worse over time if it’s caused by repetitive injury. If it’s caused by a sudden forceful motion, the injury can be painful immediately and worsen within 24 hours. Sometimes when the injury occurs, a “pop” can be felt. Usually the entire joint is involved, and toe movement is limited.

How Is Turf Toe Diagnosed?

To diagnose turf toe, the doctor will ask you to explain as much as you can about how you injured your foot and may ask you about your occupation, your participation in sports, the type of shoes you wear, and your history of foot problems.

The doctor will then examine your foot, noting the pattern and location of any swelling and comparing the injured foot to the uninjured one. The doctor will likely ask for an X-ray to rule out any other damage or fracture. In certain circumstances, the doctor may ask for other imaging tests such as a bone scanCT scan, or MRI.

How Is Turf Toe Treated?

The basic treatment for treating turf toe, initially, is a combination of rest, ice, compression, and elevation (remember the acronym R.I.C.E).This basic treatment approach is to give the injury ample time to heal, which means the foot will need to be rested and the joint protected from further injury. The doctor may recommend an over-the-counter oral medication such as ibuprofen to control pain and reduce inflammation. To rest the toe, the doctor may tape or strap it to the toe next to it to relieve the stress on it. Another way to protect the joint is to immobilize the foot in a cast or special walking boot that keeps it from moving. The doctor may also ask you to use crutches so that no weight is placed on the injured joint. In severe cases, an orthopaedic surgeon may suggest a surgical intervention.

It typically takes two to three weeks for the pain to subside. After the immobilization of the joint ends, some patients require physical therapy in order to re-establish range of motion, strength, and conditioning of the injured toe.

Can Turf Toe Be Prevented?

One goal of treatment should be to evaluate why the injury occurred and to take steps to keep it from reoccurring. One way to prevent turf toe is to wear shoes with better support to help keep the toe joint from excessive bending and force with pushing off. You may also want to consider using specially designed inserts that your doctor or physical therapist can prescribe for you.

A physical therapist or a specialist in sports medicine can also work with you on correcting any problems in your gait that can lead to injury and on developing training techniques to help reduce the chance of injury.

 Contributed by Aetrex

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