Freiberg's Disease

Freiberg’s Disease is caused by avascular necrosis of the head of the 2^nd metatarsal. This condition is more common in patients who have a longer 2^nd metatarsal bone relative to the 1^st metatarsal. This leads to the transfer of excessive loads onto the 2^nd metatarsal, which may interfere with the blood supply. This disease tends to occur more commonly in young females during growth spurts.

Freiberg’s Disease usually presents itself as pain and swelling at the 2^nd metatarsophalangeal joint that is related to activities and walking in high heels. There may be point tenderness and swelling over the head of the 2^nd metatarsal. There may also be limited range of motion in the 2^nd metatarsophalangeal joint. Early in the disease, x-rays may only show minimal changes. Radiological evidence of the condition may only be clearly visible on an MRI and bone scan. In more severe cases, sclerosis, fragmentation, collapse of the metatarsal head, and severe arthritis, may make the condition easily visible on an x-ray.

Treatment

Conservative treatment consists of nonsteroidal anti-inflammatory medications, activity modification, orthotics, and immobilization with a short leg cast. Surgical intervention involving a joint debridement is indicated only after the failure of all conservative measures. Other procedures may be indicated depending on the complexity and severity of the case.

Heel Pain & The Baxter's Nerve

Pain located at the heel can have several different causes. It is important to make the correct diagnosis for the cause of the heel pain, so that appropriate treatment can be given to the patient. Common causes of heel pain include:

1. Baxter’s Nerve Compression
2. Plantar Fasciitis
3. Fat Pad Atrophy
4. Achilles Tendonitis
5. Stress Fractures of the Calcaneus
6. Lumbar Spine Radiculopathy

The sites and locations from different causes of the pain are all very close to each other, making it difficult to determine the source of the pain and to diagnose injuries.

In plantar fasciitis, irritation and swelling will occur at the thick tissue on the bottom of the foot. This fascia can become inflamed and painful, making walking more difficult. Plantar fasciitis is most severe in the morning when patients first stand on their feet. Stretching exercises or walking, often helps in relieving the painful tightening associated with plantar fasciitis. Pain symptoms will intensify with prolonged exercise or standing.  Plantar fasciitis is usually associated with a tight heel cord.

During fat pad atrophy, the fat that cushions the calcaneus is thinned. This condition is common in elderly people and can cause significant pain while walking. It also commonly occurs in patients with a history of steroid injections.

Achilles Tendonitis is a chronic injury to the tendon that joins the heel to the muscles of the lower leg, primarily occurring from overuse. The Achilles tendon gives us the ability to rise up on our toes, allowing for the act of walking. If a patient has Achilles tendonitis, walking can be painful and difficult.

Stress fractures of the calcaneus can occur due to overuse injuries. The patient will experience weight bearing pain. Stress fracture injuries of the heel are typical in patients who engage in running sports, due to the repetitive shock being placed on the heel. Side to side compression of the calcaneus is painful.

Pain on the lateral side of the foot may be a result of L5-S1 radiculopathy.

The Baxter’s nerve is the first branch of the lateral plantar nerve. It also contributes to 20% of all heel pain causes. The Baxter’s nerve provides motor innervation to the abductor digiti minimi muscle. When the nerve is affected by compression, the symptoms are similar to planter fasciitis. Entrapment of the Baxter’s nerve may cause up to 20% of heel pain, but is still overlooked. The first branch of the lateral planter nerve is the inferior calcaneal nerve (Baxter’s Nerve).

The nerve courses vertically between the abductor hallucis and the quadratus plantae muscles, then makes a 90° horizontal turn, coursing laterally beneath the calcaneus to innervate the abductor digiti minimi muscle. The Baxter’s nerve can become entrapped within the medial heel. The entrapment will result in heel pain, paresthesia, abnormal sensations on the plantar aspect (bottom) of the heel, and medial heel tenderness. There are two sites of entrapment that are typical with Baxter’s nerve impingements. The first site is located between the fascia of the abductor hallucis and quadratus plantae muscles. The second site is where the nerve passes along the anterior aspect of the medial calcaneal tuberosity.

Treatment

Management is usually conservative and consists of heel stretching exercises, rest, NSAIDs, and Orthotics. Surgery is done as a last resort with neurolysis of the nerve after release of the deep fascia of the abductor hallucis muscle. There is a good-excellent result in about 90% of patients after decompression of the nerve. Involvement of the Baxter’s nerve may affect running athletes causing pain on the medial plantar aspect of the foot.

 Stress Fractures:

Common for Athletes and Those with

 

Active Lifestyles



Figure 1

Fractures are typically caused by a single traumatic event such as a car accident or fall. Here, bones are exposed to forces so extreme they are unable to support energy that is placed upon them. In contrast, there are fractures caused by a repetitive application of force. These fractures, called stress fractures, occur when muscles become so fatigued they lose their ability to absorb additional shock. These fractures are categorized as overuse injuries and are characterized by tiny cracks in the bone.

Bone is incredibly resilient. Each day, bone broken down by daily living is replaced by the body in a necessary balancing act. However, this balance is disturbed with excessive physical training.

Stress fractures often present in athletes such as tennis players, basketball players, gymnasts and track and field participants. Typical stress fracture causes include improper equipment, increased physical stress, increasing the amount or intensity of an activity too rapidly and the impact of an unfamiliar surface.

Figure 2

Stress fractures are usually categorized one of two ways: a fatigue fracture or an insufficiency fracture. Fatigue fractures are the result of bone being overused or being exposed to repetitive stress beyond its ability to repair itself. In contrast, insufficiency fractures are the result of bone being deficient in minerals or vitamins.

 

A typical cause of an insufficiency fracture is if a bone has been weakened by osteoporosis.

Figure 3

 While stress fractures can occur anywhere on the body, more than 50 percent occur in the lower leg. (Figure 1) (Figure 2). Stress fractures rarely occur in the upper extremities because they are not weight bearing bones, like the tibia and bones that run from the mid-foot to the toes. (Figure 3).

There are certain red flags that may signal stress fractures. These red flags include: pain that increases over time, pain that increases with activity and decreases with rest, pain that persists

Figure 5

Figure 4

even at rest, pain that occurs earlier in each successive workout and swelling. A runner with groin pain and a negative x-ray must have a back scan or an MRI to rule out hip stress fractures.

Early diagnosis of hip fractures is necessary to avoid displacement of the fracture.

The best treatment for stress fractures is rest. After about 6 to 8

weeks, patients should be able to return to their regular activities.
It’s important to do your best to safeguard against stress fractures.
This includes implementing a prevention plan that includes the following:
alternating activities that accomplish the same fitness goals (crosstraining); setting incremental goals when participating in a new sports activity; and maintaining a healthy diet(Figure 4) with
bone strengthening vitamins and minerals such as calcium and vitamin D (Figure 5).
In some situatoins, however, surgery is needed to treat stress fractues.(Figure 6)

Figure 6