Although SFF is a clinical diagnosis, x-rays—including 3-view plain films of the foot, with the area of concern clearly noted on the order—are recommended. Magnetic resonance imaging may be used for secondary imaging if doubt about the source of the pain remains.35
Of note: Occasionally, a metatarsal stress fracture progresses to a frank fracture, specifically of the metaphyseal-diaphyseal junction of the fifth metatarsal—known as a Jones fracture. This type of fracture has a high rate of malunion or nonunion.36 If there is any suspicion of a fracture in this area, consider a referral to a sports medicine specialist or orthopedic surgeon.
Treatment: Icing, analgesics, and a boot. Standard treatment for SFF includes icing for 15 to 20 minutes up to 3 times a day for a minimum of 72 hours after injury, but may be continued throughout the healing period. Analgesics such as acetaminophen and a walking boot for 3 to 4 weeks, with follow-up at 3 weeks, should also be implemented. Recent evidence suggests that NSAIDs may hinder the bone healing process, and their use in treating SFF is controversial.10-12
Weaning from the boot can begin when the patient is pain free with the boot on, usually by 3 to 4 weeks. Patients often progress quickly from wearing the boot at all times to wearing it only outside of the house, to not wearing it at all. Advise patients who need to walk long distances for a good portion of the day to keep the boot nearby and to put it on if the pain returns.
Once weaning from the boot begins, physical therapy (PT) should be considered to help the patient regain foot and ankle range of motion (ROM), proprioception, and strength. Once he or she learns the exercises, rehabilitation can be accomplished with a home exercise program. Foot deformities, such as pes planus or pes cavus, may indicate a need for orthotics. A well-structured athletic shoe may help to prevent future injury.7,8
Return to running. Once adequate ROM and strength in the foot and ankle are recovered, the patient can begin to resume activity, starting with a low-impact cross-training exercise, such as a stationary bike or elliptical, for a week or 2. A patient who remains pain free can progress from cross-training to running on a treadmill for another week or 2, then gradually switch to outdoor running.
Plantar fasciitis: Heel pain with an insidious onset
Plantar fasciitis is one of the most common causes of heel pain in athletes (primarily runners) and nonathletes alike. Plantar fasciitis may be associated with acute trauma, but is more commonly insidious in onset. The diagnosis is clinical and rarely requires imaging.
Pain associated with plantar fasciitis may be described as sharp and stabbing or dull and aching. It is on the plantar surface of the heel, sometimes radiating to the arch, and may localize to the insertion of the plantar fascia on the medial calcaneal tubercle (FIGURE 2). The pain is typically most severe with the first few steps in the morning or after other periods of prolonged rest. It usually improves after a few steps, but may return later in the day. Plantar fasciitis does not cause paresthesias or other neurologic symptoms, so their presence is suggestive of a different diagnosis, such as nerve entrapment, compartment syndrome, or tarsal tunnel syndrome.3,5
Treatment: It’s multifactorial. NSAIDs are commonly used. Relative rest is recommended, but cross training may be considered to maintain fitness.37 Short-term PT is also recommended to teach the patient proper stretching and strengthening techniques in the form of a home exercise plan. Modalities such as iontophoresis (a system of transdermal delivery of medication with the use of electrical currents), Graston (a form of instrument-assisted soft tissue mobilization), and taping may be incorporated into PT, as well.13
Night splinting may also be used to keep the foot in a dorsiflexed position. A splint can be purchased without a prescription and prevents the plantar fascia from shortening overnight by providing a continuous passive stretch, thus reducing pain with first steps.14
Orthotics may also help to reduce symptom severity and duration, and studies have found no difference in outcomes with prefabricated vs custom-made devices.15 Another treatment to consider, particularly for recalcitrant cases of plantar fasciitis, is extracorporeal shock wave therapy, which has been studied for more than a decade with conflicting results.16 Corticosteroid injection may also be used for treatment-refractory plantar fasciitis, but caution is required, as the injection may increase the risk of rupture of the plantar fascia.17,18
Return to running. There are no set guidelines for when an athlete with plantar fasciitis can return to running. Typically, after 2 to 4 weeks of relative rest and other treatments, the runner can begin to transition from cross-training to treadmill running.
FIGURE 2
Severe pain with first steps of the day
The pain of plantar fasciitis—often most severe first thing in the morning—may localize to the insertion of the plantar fascia on the medial calcaneal tubercle, as shown above.