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Examination of the injured runner includes assessment not only of the
injured area but of all related structures (ie, the runner’s entire “
kinetic chain”), noting any imbalances or deficits in structure (eg, leg
length discrepancy), strength, flexibility, or motion. Discrepancies may
exist between legs or between muscle groups of the same leg (eg, quadriceps
disproportionately stronger than hamstrings). One way to organize each
element (eg, observation, strength testing) of the physical examination is
to begin with proximal structures (eg, spine and pelvis) and work distally.
Careful observation of the patient’s walking and running gaits helps to
confirm that the anatomic problems identified during a stationary
examination affect biomechanical performance.
Begin your assessment by asking the injured runner to stand in front of you,
noting their posture and lower extremity alignment. Observe the legs from
hip-to-foot looking for symmetry. Note the structure of the knee, especially
genu varum (which may be associated with iliotibial band syndrome or medial
meniscal pathology) or valgus (often seen in women with patellofemoral pain
). Note the position of the patella and any apparent muscular asymmetry. Ask
the patient to stand on one foot and then the other, watching for balance,
control, and posture. Does the unsupported hip sag (ie, a positive
Trendelenberg test)? A positive Trendelenberg test suggests weakness of the
gluteus medius, a common finding in runners with hip and knee pain. Make
note of foot structure and position. Does the runner have a normal, high, or
flat arch? Ask the patient to walk and to squat. Watch for a limp,
stiffness of one limb, and a tendency to shift weight off one limb.
Screen for tenderness and altered mobility of the spine, pelvis (including
sacroiliac joints), hips, knees, ankles, and feet before turning your
attention to the area of complaint. Be sure to assess muscle strength and
neurovascular status throughout the lower extremity. Weakness of the hip
musculature (particularly hip abductors) is common among novice runners,
frequently contributing to lower extremity pain, especially patellofemoral
pain syndrome. (See "Patellofemoral pain syndrome".)
The following findings may be noted during the examination:
Hip flexion, rotation, or abduction weakness is present with many lower
extremity injuries, particularly those affecting the hip or knee.
Increased lumbar lordosis suggests weak anterior core muscles, a common
condition in runners with hip weakness.
Vastus medialis atrophy or asymmetry can occur with patellofemoral pain
syndrome (PFPS), or in athletes who have had knee surgery.
Tenderness along the medial tibial border bilaterally is often present
with medial tibial stress syndrome (MTSS), or “shin splints.”
Loss of normal lumbar lordosis (with or without back pain) is often
present with tight hamstrings.
Loss of internal rotation of the hip occurs with femoral neck stress
fracture.
Asymmetry of the quadriceps muscles is common in runners with
osteoarthritis of the hip.
Pain and/or a sense of “catching” in the groin with the knee flexed to
90 degrees suggests a labral tear, but also may be seen with iliopsoas
tendinopathy.
Localized tenderness and a positive hop test suggest a tibial stress
fracture.
Achilles tendon thickening or nodules suggests Achilles tendinopathy.
Tenderness at the medial insertion of the plantar fascia into the
calcaneus suggests plantar fasciitis.
Hallux limitus or hallux rigidus and reduced ankle dorsiflexion can
develop with plantar fasciitis or calf muscle injuries.
Splayed toe sign and forefoot widening can occur with metatarsalgia.
Leg length inequality may be present with stress fractures, and possibly
with iliotibial band syndrome and lower back and pelvic injuries.
Diagnostic imaging, including plain radiographs, ultrasound, magnetic
resonance imaging (MRI), computed tomography (CT), and bone scan may be
necessary in some cases to make a definitive diagnosis. However, the
clinician should have a clear differential diagnosis in mind before ordering
such studies.
Once a diagnosis is made and a treatment plan established, the clinician and
athlete should work together to uncover and eliminate potential
contributing factors, as many running injuries appear to be multifactorial.
The mainstay of treatment for the vast majority of running injuries is “
relative rest,” which means stopping running, or at a minimum significantly
reducing mileage, while the injury heals. Depending upon the injury, most
runners can maintain reasonable conditioning by performing non-impact
exercises in a pool or on a bike, or by using other equipment (eg, rowing
machine).
SPECIFIC INJURIES
Hip injuries
Overview and approach — Hip injuries are less common in runners than
injuries to the lower extremity and they can be difficult to diagnose.
Nevertheless, during jogging, the hip joint is subjected to loads up to
eight times body weight and both acute and chronic injuries can occur [55].
In runners, the differential diagnosis of hip pain includes gluteus medius
tendinopathy, piriformis syndrome, stress fracture of the femoral neck,
labral tear, and, less often, radicular pain from the lumbar spine. Better
understanding of the functional anatomy of the hip suggests a correlation
between hip muscle weakness and injury to the low back or lower extremity in
athletes, including runners [56-58].
Gluteus medius weakness and tendinopathy and piriformis syndrome — The
gluteus medius originates along the external surface of the ilium and runs
distally and laterally to its attachment on the greater trochanter of the
femur (picture 1). The gluteus medius abducts the hip and assists with
pelvic stability during running. Weakness of the muscle typically causes
pain with hip abduction and rotation. Pain generally increases when the
muscle is stretched and there may be focal tenderness at the muscle’s
insertion, just medial and superior to the greater trochanter. Difficulty
maintaining a level pelvis while standing on one leg (positive Trendelenburg
sign) may be noted.
The piriformis muscle is a small but important external rotator of the hip
that crosses the sciatic nerve and is believed by some to cause sciatica-
type pain when it compresses the nerve [59,60]. However, the existence of
this so-called “piriformis syndrome” remains controversial and diagnosis
is difficult [61-63]. Piriformis syndrome in the runner may be associated
with foot overpronation, weakness of the gluteal muscles and other hip
abductors, and tightness of the hip adductors.
The mainstay of treatment for both gluteus medius tendinopathy and
piriformis syndrome is physical therapy and correction of biomechanical
abnormalities. Orthotics and massage therapy may be useful; acetaminophen
and nonsteroidal antiinflammatory drugs may be used for analgesia. There are
reports of using injections of local anesthetics, glucocorticoids, and
botulinum toxin (Botox) to treat piriformis syndrome [64].
Femoral neck stress fracture — Stress fractures of the femoral neck are an
uncommon but important cause of hip or groin pain in the adult runner
because of the relatively high risk of nonunion. (See 'Stress fractures'
below.)
Labral tear — The acetabular labrum is a ring of fibrocartilage and dense
connective tissue attached to the bony rim of the acetabulum. It is thought
to be largely avascular. Although the labrum’s function is not fully
understood, it is thought to provide stability and decrease the stress
placed on the hip joint. Therefore, a significant tear in the labrum can
increase stress on the hip joint, decrease stability, and ultimately lead to
damage of the articular cartilage.
Labral tears are reported in sports that require frequent hip rotation, such
as soccer and hockey, and in runners, especially female runners. Runners
with a labral tear typically complain of pain in the anterior hip or groin.
They may have mechanical symptoms, including clicking, locking, catching, or
giving way (so-called “snapping hip”). Other hip injuries that may
produce such mechanical symptoms include iliopsoas tendinopathy.
Labral tears are complex and often frustrating to treat. Physical therapy
has mixed results. Arthroscopic surgery is often helpful, but the recovery
can be prolonged. Runners diagnosed with labral tears should be counseled
carefully regarding the paucity of evidence for determining the best
treatment and the benefits and risks of each approach.
Iliopsoas tendinopathy — Iliopsoas tendinopathy produces symptoms similar
to a labral tear but presents more often as anterior hip pain in younger
athletes, especially after a rapid growth spurt, and is more easily treated.
Athletes who repeatedly engage in forceful flexion of the hip, including
track and field athletes (eg, hurdlers, jumpers), are at greatest risk.
Examination usually reveals tight, painful hip flexors (picture 2).
Iliopsoas tendinopathy typically responds within a few weeks to activity
modification, acetaminophen and nonsteroidal antiinflammatory drugs, and
physical therapy.
Knee and thigh injuries
Knee pain (patellofemoral pain syndrome) — Knee pain is among the most
common complaints from runners. Most such runners are diagnosed with
patellofemoral pain syndrome (PFPS) [5,65]. Despite the prevalence of this
diagnosis, no consensus exists about its etiology or the factors most
responsible for causing pain. Overuse and malalignment are commonly cited
causative factors. In addition, runners (especially females) with PFPS often
have decreased strength in hip abduction, external rotation, and extension
compared to healthy controls [66,67]. Patients with PFPS typically complain
of anterior knee pain that worsens with squatting, running, prolonged
sitting, or when ascending or descending steps. Pain is often poorly
localized "under" or "around" the patella. Details about the diagnosis and
management of PFPS are provided separately. (See "Patellofemoral pain
syndrome".)
Iliotibial band syndrome — The iliotibial band (ITB) consists of connective
tissue that runs from the ilium to the anterolateral aspect of the proximal
tibia (picture 3). It is involved in hip abduction and internal rotation,
knee extension and flexion, and helps to stabilize the knee during running.
The iliotibial band syndrome (ITBS), which occurs primarily in runners, is
characterized by an aching or burning pain at the site where the ITB courses
over the lateral femoral condyle; occasionally the pain radiates up the
thigh toward the hip. Runners often complain of such lateral knee pain while
running, but pain may persist after training, especially with activity that
requires repetitive flexion and extension of the knee, such as ascending or
descending stairs or standing from a seated position. The diagnosis of ITBS
is clinical; no imaging is typically needed.
The ITB does not attach to bone between the hip and knee, and for years many
clinicians believed that repeated flexion and extension of the knee caused
the band to rub back and forth over the lateral femoral condyle, creating
friction and inflaming the tissue beneath the band. However, subsequent
investigations suggest that the ITB moves very little and that the pain of
ITBS results from compression of a layer of innervated fat and connective
tissue between the ITB and lateral femoral epicondyle [68].
Biomechanical studies and our clinical experience suggest that the
underlying causes of ITBS are multifactorial but that patients often fall
into two major categories [69-71]. One group (usually less experienced or
female runners) demonstrates weak hip abduction, increased hip adduction,
and internal rotation of the knee (genu valgum); the other group (often
advanced runners) manifests decreased hip adduction and external rotation of
the knee (genu varum). Physical therapy for the first group should
emphasize strengthening the hip abductors; therapy for the latter group
should include stretching exercises to improve hip adduction. Other risk
factors for ITBS include excessive running mileage, worn shoes, repetitive
running on uneven terrain, and continually running in only one direction on
a track [72].
Ice, analgesics (eg, acetaminophen and nonsteroidal antiinflammatory drugs),
and a short period of rest are usually effective at reducing acute
discomfort. Glucocorticoid injections may be helpful for symptomatic relief
in refractory or severe cases, or when there is associated bursitis, but
there is little evidence supporting such treatment [73]. Once inflammation
is reduced, the patient begins stretching and strengthening exercises to
correct identified deficits [74,75]. A study comparing three common
stretches for the ITB found all to be effective [76]. In one limited
randomized trial, deep transverse friction massage was not beneficial [77].
Hamstring injuries — Hamstring injuries are typically acute; the injured
runner complains of developing a sudden, sharp pain in the posterior thigh
while running at high speed or up hills. Examination findings depend upon
the severity of injury and may include a limping gait (due to the inability
to fully extend the knee); ecchymosis; a visible or palpable defect in the
hamstring muscle; focal tenderness; and pain or weakness with muscle
contraction. Details about the diagnosis and management of hamstring muscle
injuries are provided separately. (See "Hamstring injuries".)
Knee OA — Exercise is recommended for most patients with OA of the hip or
knee. Although water-based exercise is often suggested, multiple studies
confirm the value of regimens involving full weightbearing exercise. (See "
Nonpharmacologic therapy of osteoarthritis", section on 'Exercise'.)
Despite this evidence, many clinicians subscribe to the traditional teaching
that patients with osteoarthritis (OA) of the knee should not run because
it exacerbates the condition. The medical literature, however, does not
support the contention that running contributes to the degeneration of
articular cartilage in the knee [78]. Examples of such studies include:
A prospective cohort study followed 45 runners and 53 controls over 18
years and, using a validated score to assess for OA, found no difference
between the two groups in the progression or the number of severe cases of
knee OA [79].
Another prospective study of 16 runners and 13 nonrunners found no
evidence that running predisposes to OA of the lower extremities [80].
Multiple retrospective studies have found no evidence of premature
damage of articular cartilage or increased risk for OA among long-distance
runners [81-83].
Small clinical and laboratory studies using MRI to evaluate the knees of
long-distance runners report no significant damage to articular cartilage
following a race and no major differences when images were compared to those
of active nonrunners [84-86].
Stress fractures — Stress fractures in runners occur most often in the
tibia, but can develop in any bone of the lower extremity, including the
metatarsals, navicular, and femoral neck [87]. Detailed discussions of
stress fractures, including a description of those at high risk for nonunion
, appear separately; a brief description and information of particular
importance for runners is provided here. (See "Overview of stress fractures"
and "Stress fractures of the tibia and fibula" and "Stress fractures of the
metatarsal shaft".)
When evaluating the runner with a suspected stress fracture, the clinician
should ask for a description of the pain, running patterns and recent
changes in training, shoe and orthotic wear, and prior injuries. Information
about the patient’s nutrition and menstrual history, and any family
history of metabolic bone disease, are also important.
Typically, the runner with a stress fracture complains of focal pain that is
insidious in onset, increases as a run progresses, and improves with rest.
Over time, if the athlete persists in running despite such symptoms, pain
occurs with less strenuous activity and ultimately at rest. Some runners
present with acute onset of severe pain, which may result from a complete
fracture at the site of a preexisting stress fracture.
Important risk factors for developing stress fractures include a history of
prior stress fracture, increasing volume and intensity of training, poor
running biomechanics, female gender and menstrual irregularity, a diet poor
in calcium, and poor bone health. The management of stress fractures in
runners is discussed separately. (See "Overview of stress fractures",
section on 'Treatment concepts'.)
The clinician should be aware that stress fractures at high risk for
nonunion (eg, femoral neck and navicular) are more common in runners than in
other athletes. If a high-risk stress fracture is suspected, an aggressive
work-up is warranted and immediate orthopedic consultation should be
obtained if the diagnosis is confirmed. A history of recurrent stress
fracture or a fracture in cancellous bone suggests that the runner’s bone
mineral density may be low and should be measured.
Femoral neck stress fractures should be suspected in any distance runner
with groin pain of insidious onset, especially female distance runners at
risk for the “female athlete triad” (eating disorder, amenorrhea, and
osteoporosis). The female athlete triad is reviewed separately. (See "
Amenorrhea and infertility associated with exercise".)
Navicular stress fractures occur more often in male athletes participating
in track and field events (eg, hurdlers, jumpers, sprinters) and middle
distance runners [87]. The athlete with a navicular stress fracture often
presents with insidious pain in the midfoot or arch that increases with
jumping.
Medial tibial stress syndrome (shin splints) and tibial stress fractures —
Clinicians confronted by runners with shin pain must distinguish between
stress fractures of the tibia and medial tibial stress syndrome (MTSS),
often referred to as “shin splints.” Although the history may be similar,
a focal, palpable area of tenderness is present in most patients with stress
fractures, whereas tenderness is much more diffuse and there are no
discrete palpable lesions in those with MTSS. Imaging may be necessary in
some cases to rule out a stress fracture. Plain radiographs are normal in
patients with shin splints, but may also be unrevealing early in the course
of a stress fracture. (See "Stress fractures of the tibia and fibula",
section on 'Clinical presentation and examination' and "Stress fractures of
the tibia and fibula", section on 'Radiographic findings'.)
Distinguishing between the two diagnoses affects treatment: a runner with a
stress fracture should avoid running and pursue non-impact activities like
swimming or cycling while the stress fracture heals, while the runner with
MTSS can continue running but should reduce the total mileage. A systematic
review found that shock-absorbing insoles may reduce symptoms and prevent
recurrence of MTSS [88].
Chronic exertional compartment syndrome — Chronic exertional compartment
syndrome (CECS) occurs when increased pressure within a muscle compartment
reduces blood flow, leading to muscle ischemia and pain when metabolic
demands cannot be met. The patient with CECS is often a young runner who
describes gradually increasing pain in a specific muscle region (usually the
lower leg) during exertion. The pain may be described as aching, squeezing,
cramping, or tightness. Pain generally begins within several minutes of
starting a run, often at a specific point in training. Runners can often
describe the time or distance required for symptoms to develop. Pain
resolves completely with rest, although not immediately upon stopping
exercise. The diagnosis and management of CECS is discussed in detail
separately. (See "Chronic exertional compartment syndrome".)
Foot and ankle injuries — Foot and ankle injuries account for up to 20
percent of running injuries, and are the most common injury reported by
distance runners and marathoners [89]. This is not surprising given that the
ground reaction forces the foot must absorb with each stride are several
times body weight. The most common foot injuries in runners are overuse
injuries of soft tissues, including tendons and fascia.
Plantar fasciitis — Plantar fasciitis (PF) is the most common cause of
rearfoot pain in runners. The predominant symptom of PF is pain in the
plantar region of the foot that increases when initiating push-off while
walking or running. The hallmark for diagnosis is focal point tenderness.
The etiology of PF remains unclear but the condition is often attributed to
training errors, biomechanical problems, and excessive foot pronation or
supination, and is more common in older and heavier runners [89-91]. The
biomechanical abnormality most often associated with PF is decreased
dorsiflexion of the foot and toes and thus stretching is an important part
of treatment. Another common biomechanical problem is weakness of the
plantar flexors, which some clinicians believe is best treated with
eccentric strengthening exercises. The diagnosis and management of PF is
reviewed separately. (See "Plantar fasciitis and other causes of heel and
sole pain", section on 'Plantar fasciitis'.)
Tendon injuries — Runners are susceptible to tendon injuries at a number of
sites, the Achilles being most common. Others include the peroneal,
posterior tibial, and anterior tibial tendons (picture 4).
Achilles tendinopathy occurs in up to 10 percent of elite runners annually [
92]; runners with more than 10 years of experience are at higher risk [93].
Among former elite male distance runners, the lifetime risk is reported to
be as high as 52 percent [94]. The biomechanical factors that predispose
runners to Achilles tendinopathy remain unclear but are the subject of
research [95-97]. Poor flexibility of the Achilles tendon, overpronation,
and valgus or varus deformity of the calcaneus all affect rear-foot
mechanics, possibly increasing torque on the Achilles. Some clinicians
advocate using a heel pad or orthotic in runners to counteract this effect.
Patients with Achilles tendinopathy typically complain of pain or stiffness
2 to 6 cm above the posterior calcaneus. The pain is frequently described as
burning, increases with activity, and is relieved by rest. Runners with the
condition often have recently increased their training intensity or have
been training rigorously for a long time. A history of excessive foot
supination, increased speed work or hill training, or improper (eg, poorly
fitting shoes, tennis instead of running shoes) or worn out footwear may be
found. The diagnosis and management of Achilles tendinopathy is discussed
separately. (See "Achilles tendinopathy and tendon rupture".)
Peroneal tendon injury may be traumatic, usually from a lateral ankle sprain
, or related to overuse and associated with excessive foot pronation and
weak foot plantar flexors [98]. Examination reveals tenderness along the
course of the tendon posterior or inferior to the lateral malleolus, which
increases with resisted eversion.
Posterior tibial tendinopathy is typically an overuse injury that develops
following an abrupt increase in training intensity, and is associated with
poor foot and calf flexibility and excessive foot pronation. Examination
findings include tenderness along the course of the posterior tibial tendon
posterior or inferior to the medial malleolus, which increases with resisted
inversion.
Anterior tibial tendinopathy is a common cause of anterior ankle pain in
runners, and often develops following abrupt increases in training,
particularly hill running. Examination often reveals tenderness, and
possibly swelling, of the tendon as it crosses the ankle joint. Pain
increases with resisted dorsiflexion.
The treatment of overuse tendinopathies is discussed separately. (See "
Overview of the management of overuse (chronic) tendinopathy".)
First metatarsal phalangeal joint — Running generates substantial forces
across the forefoot and thus can aggravate hallux rigidus or hallux valgus (
bunion) of the metatarsal phalangeal (MTP) joint of the great toe (ie, first
MTP joint). The sesamoid bones located on the plantar surface of the MTP
joint can become inflamed from running and may cause discomfort.
Hallux rigidus and hallux valgus (bunion) — There is little high-quality
evidence to provide insight into the causes and guide the management of
hallux rigidus. Hallux rigidus is presumed to be a degenerative condition of
the first MTP joint associated with either an acute injury (eg, forced
hypertension of the great toe, so-called “turf toe”) or repetitive
microtrauma, as would occur with running [99,100]. Genetic predisposition
may play a role. The result is limited dorsiflexion of the first MTP joint;
approximately 60 degrees of dorsiflexion is needed for normal gait.
Runners with hallux rigidus are typically older than 30 and complain of pain
at the dorsum of the great toe. However, some runners may present with
vague lateral forefoot pain. This presentation is likely due to runners
shifting their body weight to the lateral foot during the foot-strike phase
of running to reduce the load on the great toe. It remains unclear whether
running is a cause of hallux rigidus or aggravates symptoms elicited by
other factors. Shoes with a toe box that is too small or pointed may
contribute.
Hallux valgus (ie, bunion) deformity is defined as a lateral deviation of
the hallux (great toe) on the first metatarsal. The etiology of hallux
valgus is multifactorial and likely involves abnormal mechanics and anatomy.
Patients generally complain of a deformed and painful great toe. (See "
Hallux valgus deformity (bunion)".)
In runners with either of these conditions, mechanically limiting first MTP
joint motion by using appropriate shoes and unloading techniques can be
helpful. We suggest walking shoes with a wide toe box, stiff soles, rocker
bottoms, and low heels. Comfortable running shoes with a wide toe box
combined with techniques to reduce the impact on the first MTP joint, such
as custom orthotics or cushioned insoles, reduce symptoms in many runners.
Acetaminophen or nonsteroidal antiinflammatory drugs may be used for short-
term pain relief. Ice can be applied following running. Glucocorticoid
injections may provide short-term pain relief for those with mild hallux
rigidus [101]. Consultation with a foot surgeon should be obtained for
severe or recalcitrant cases, although there is little high-quality evidence
to guide decisions about surgery or conservative care.
Sesamoiditis — The sesamoids are pea-sized bones that function as pulleys
for tendons (just as the patella does for the knee extensors) and assist
with weightbearing. Inflammation or injury of the sesamoid bones located on
the plantar surface of the first MTP joint can cause focal pain in runners,
particularly sprinters (picture 5 and figure 1). The runner with
sesamoiditis typically complains of pain at the area of the MTP joint with
weightbearing that is exacerbated by walking, and even more so by running.
Exquisite tenderness of the sesamoids is present, and is exacerbated by
dorsiflexion of the great toe. Imaging is required to differentiate between
sesamoiditis and a stress fracture.
Both sesamoiditis and sesamoid stress fractures are notoriously difficult to
treat and may require a short period of immobilization followed by
prolonged rest from running. Runners can use alternative, nonweightbearing
forms of exercise to maintain fitness. Treatment with custom orthotics, soft
pads cut to relieve pressure on the sesamoids, and in severe cases
glucocorticoid injections may be helpful, but there is little evidence to
guide treatment. Women runners should avoid wearing high heels; shoes with a
stiff sole (eg, clog) are often helpful. Consultation with a foot surgeon
is reasonable in recalcitrant cases.
Treatment of sesamoiditis does not differ significantly from that for
sesamoid fractures. The evaluation and management of sesamoid fractures is
discussed separately. (See "Sesamoid fractures of the foot".)
Metatarsalgia — Pain in a runner’s forefoot that is not due to a
metatarsal stress fracture is likely due to metatarsalgia or an interdigital
neuroma. (See 'Stress fractures' above.)
Metatarsalgia is a general term for pain that occurs along the ball of the
foot. Most runners with metatarsalgia complain of pain in the forefoot
during running; the examiner will find tenderness along the plantar surface
just proximal to the metatarsal heads. The condition is often associated
with overpronation and/or collapse of the transverse arch. A metatarsal pad
placed proximal to the area of tenderness often relieves symptoms; in more
severe cases, a custom orthotic may be needed.
(Mortons) neuroma — Interdigital neuromas (often referred to as Mortons
neuroma) are thought to be due to swelling and scar tissue formation on the
small interdigital nerves. They most commonly involve the third webspace,
but may also be seen in the second and fourth.
The runner with a neuroma may complain of numbness of the involved toes or
pain that increases with activity and is usually felt in the interspace
between the third and fourth toes (figure 2) [102]. The diagnosis can be
confirmed by noting a clicking sensation (Mulders sign) when palpating this
interspace while simultaneously squeezing the metatarsal joints.
Overpronation and tight shoes are often associated with the condition.
An intermetatarsal bursitis can cause a similar pain. The use of magnetic
resonance imaging (MRI) to diagnose Morton's neuroma is problematic because
features consistent with neuroma may appear in as many as one-third of
asymptomatic individuals [103,104].
Conservative treatment should precede expensive diagnostic procedures. This
approach involves decreasing pressure on the metatarsal heads by using a
metatarsal support or bar or padded shoe insert. Several studies have
measured the loading pressures placed on metatarsals before and after use of
metatarsal pads, bars, orthotics, and specialized orthopedic shoes [105-110
]. In all reports, pain relief correlated with reduction in pressure. Proper
placement of the inserts just proximal to the metatarsal head is important.
Strength exercises for the intrinsic foot muscles are often part of
conservative treatment. No randomized controlled studies have been performed
to assess these interventions.
Treatment inserts are often placed in both shoes, even when symptoms are
unilateral, to ensure that the patient walks evenly, but bilateral pads are
not always needed. Symptomatic relief often begins within a few days of
insert use and pain may completely subside over several weeks.
A broad-toed shoe that allows spreading of the metatarsal heads may be
helpful. Proper shoe width should be determined while standing, using a
professional shoe fitting device. If width has changed, older shoes should
be discarded.
If conservative measures fail to relieve symptoms, a single injection of a
local anesthetic and glucocorticoid into the site of tenderness can be
performed using a dorsal, not plantar, approach [111,112]. A plantar
approach is more likely to cause complications. A combination of
methylprednisolone (20 mg, or 0.5 mL) and one percent lidocaine (0.5 mL) may
be used.
Ultrasound guided injection is preferred by many practitioners although
studies are limited. Ultrasound can distinguish neuroma from adjacent joint
synovitis or bursitis. The majority of patients experience some relief with
ultrasound-guided injection according to three case series involving a total
of 113 patients [113-115]. Complications are rare; metatarsal fat pad
atrophy can be debilitating but may occur less often if a dorsal injection
is used. No randomized controlled trials of ultrasound guided injection have
been published.
Surgical removal of the neuroma and nerve may be necessary in patients who
remain symptomatic after 9 to 12 months of nonoperative therapy. Surgical
success rates of up to 80 to 90 percent have been reported in uncontrolled
studies [111,116-118]. Surgery performed using a dorsal approach resulted in
more timely weightbearing, return to work, and less painful scarring [119].
No randomized trials of surgery for plantar neuroma have been reported.
Rarely, a neuroma may recur following surgery. Experience with injections of
alcohol, phenol, and other substances and with nerve transplants is limited.
Tarsal tunnel syndrome — Tarsal tunnel syndrome (TTS) is an uncommon source
of foot pain in runners due to entrapment of the posterior tibial nerve (
PTN) or one of its branches as it courses behind the medial malleolus. The
most common causes include an acute injury and its sequelae (eg, scar tissue
) or repetitive microtrauma, as occurs with running, particularly in runners
who overpronate. Runners with TTS complain of numbness or burning pain,
usually along the plantar surface of the foot, although complaints may be
localized to the medial plantar surface of the heel, mimicking plantar
fasciitis. TTS typically worsens with running or at night. Findings are
almost always sensory; muscle weakness is uncommon. A positive Tinel sign
may be present. As in carpal tunnel syndrome, a positive sign occurs when
symptoms are elicited by tapping over the path of the nerve. TTS is
discussed in detail separately. (See "Overview of lower extremity peripheral
nerve syndromes", section on 'Tarsal tunnel syndrome'.)
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Beyond the Basics patient education pieces are longer, more sophisticated,
and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can
also locate patient education articles on a variety of subjects by searching
on “patient info” and the keyword(s) of interest.)
Basics topic (see "Patient information: Achilles tendinopathy (The
Basics)") |
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发表于 2012-4-18 08:02:14
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