Foot and Ankle: Conservative Management, Operative Management, and Return to Sport

  • Monique C. Chambers
  • Dukens LaBaze
  • Jesse Raszeswki
  • MaCalus V. HoganEmail author


Foot and ankle injuries are one of the most common injuries within the athletic population. For masters athletes, years of repetitive motions inevitably contribute to degeneration of the most dependent structures of the body, the foot and ankle. As a result, competitive activity results in injuries related to stress and fatigue. Particularly, acute rupture of the Achilles tendon and/or chronic tendinopathy can lead to decreased performance and the need for operative intervention. Similarly, the plantar fascia may become irritated and inflamed and require intensive therapy or surgery for the athlete to continue high-level performance. Overuse and persistent load may cause debilitating stress fractures that are difficult to manage. Many of these conditions are managed through conservative measures and an emphasis on maintenance to control the symptoms of the respective condition. However, the masters athlete represents a unique population that may require surgical intervention once all other measures have been exhausted to allow them to continue high-level activity, even in a mature period of life.


Athlete Foot Ankle Injury Degeneration Plantar fasciitis Tendinopathy Insufficiency Stress fracture 


  1. 1.
    Li HY, Hua YH. Achilles tendinopathy: current concepts about the basic science and clinical treatments. Biomed Res Int. 2016;2016:6492597.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Egger AC, Berkowitz MJ. Achilles tendon injuries. Curr Rev Musculoskelet Med. 2017;10(1):72–80.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Saltzman CL, Tearse DS. Achilles tendon injuries. J Am Acad Orthop Surg. 1998;6(5):316–25.CrossRefPubMedGoogle Scholar
  4. 4.
    Pedowitz D, Kirwan G. Achilles tendon ruptures. Curr Rev Musculoskelet Med. 2013;6(4):285–93.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Johnston CA, Taunton JE, Lloyd-Smith DR, McKenzie DC. Preventing running injuries. Practical approach for family doctors. Can Fam Physician. 2003;49:1101–9.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Schepsis AA, Jones H, Haas AL. Achilles tendon disorders in athletes. Am J Sports Med. 2002;30(2):287–305.CrossRefPubMedGoogle Scholar
  7. 7.
    Maffulli N. The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients. Am J Sports Med. 1998;26(2):266–70.CrossRefPubMedGoogle Scholar
  8. 8.
    Reddy SS, Pedowitz DI, Parekh SG, Omar IM, Wapner KL. Surgical treatment for chronic disease and disorders of the Achilles tendon. J Am Acad Orthop Surg. 2009;17(1):3–14.CrossRefPubMedGoogle Scholar
  9. 9.
    Kleinman M, Gross AE. Achilles tendon rupture following steroid injection. Report of three cases. J Bone Joint Surg Am. 1983;65(9):1345–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Verrall G, Schofield S, Brustad T. Chronic Achilles tendinopathy treated with eccentric stretching program. Foot Ankle Int. 2011;32(9):843–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Shalabi A, Kristoffersen-Wilberg M, Svensson L, Aspelin P, Movin T. Eccentric training of the gastrocnemius-soleus complex in chronic Achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by MRI. Am J Sports Med. 2004;32(5):1286–96.CrossRefPubMedGoogle Scholar
  12. 12.
    Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 2004;38(1):8–11; discussion 11.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Beyer R, Kongsgaard M, Hougs Kjaer B, Ohlenschlaeger T, Kjaer M, Magnusson SP. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2015;43(7):1704–11.CrossRefPubMedGoogle Scholar
  14. 14.
    Munteanu SE, Scott LA, Bonanno DR, et al. Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial. Br J Sports Med. 2015;49(15):989–94.CrossRefPubMedGoogle Scholar
  15. 15.
    Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy—a randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004;14(5):286–95.CrossRefPubMedGoogle Scholar
  16. 16.
    Filardo G, Di Matteo B, Kon E, Merli G, Marcacci M. Platelet-rich plasma in tendon-related disorders: results and indications. Knee Surg Sports Traumatol Arthrosc. 2016:1–16.Google Scholar
  17. 17.
    Bhandari M, Guyatt GH, Siddiqui F, et al. Treatment of acute Achilles tendon ruptures: a systematic overview and metaanalysis. Clin Orthop Relat Res. 2002;400:190–200.CrossRefGoogle Scholar
  18. 18.
    Khan RJ, Carey Smith RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev. 2010;(9):CD003674.Google Scholar
  19. 19.
    Gulati V, Jaggard M, Al-Nammari SS, et al. Management of Achilles tendon injury: a current concepts systematic review. World J Orthop. 2015;6(4):380–6.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Zhang YJ, Zhang C, Wang Q, Lin XJ. Augmented versus nonaugmented repair of acute Achilles tendon rupture: a systematic review and meta-analysis. Am J Sports Med. 2017:363546517702872.Google Scholar
  21. 21.
    Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25(5):303–10.CrossRefPubMedGoogle Scholar
  22. 22.
    Kindred J, Trubey C, Simons SM. Foot injuries in runners. Curr Sports Med Rep. 2011;10(5):249–54.CrossRefPubMedGoogle Scholar
  23. 23.
    Digiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am. 2006;88(8):1775–81.CrossRefPubMedGoogle Scholar
  24. 24.
    Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008;16(6):338–46.CrossRefPubMedGoogle Scholar
  25. 25.
    Gill LH, Kiebzak GM. Outcome of nonsurgical treatment for plantar fasciitis. Foot Ankle Int. 1996;17(9):527–32.CrossRefPubMedGoogle Scholar
  26. 26.
    Knobloch K, Grasemann R, Spies M, Vogt PM. Midportion Achilles tendon microcirculation after intermittent combined cryotherapy and compression compared with cryotherapy alone: a randomized trial. Am J Sports Med. 2008;36(11):2128–38.CrossRefPubMedGoogle Scholar
  27. 27.
    Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20(4):214–21.CrossRefPubMedGoogle Scholar
  28. 28.
    Bonanno DR, Landorf KB, Menz HB. Pressure-relieving properties of various shoe inserts in older people with plantar heel pain. Gait Posture. 2011;33(3):385–9.CrossRefPubMedGoogle Scholar
  29. 29.
    Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int. 1998;19(2):91–7.CrossRefPubMedGoogle Scholar
  30. 30.
    Kim C, Cashdollar MR, Mendicino RW, Catanzariti AR, Fuge L. Incidence of plantar fascia ruptures following corticosteroid injection. Foot Ankle Spec. 2010;3(6):335–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Ahmad J, Ahmad SH, Jones K. Treatment of plantar fasciitis with botulinum toxin. Foot Ankle Int. 2017;38(1):1–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Gollwitzer H, Saxena A, DiDomenico LA, et al. Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study. J Bone Joint Surg Am. 2015;97(9):701–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Behrens SB, Deren ME, Matson A, Fadale PD, Monchik KO. Stress fractures of the pelvis and legs in athletes: a review. Sports Health. 2013;5(2):165–74.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Robertson GA, Wood AM. Lower limb stress fractures in sport: optimising their management and outcome. World J Orthop. 2017;8(3):242–55.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000;8(6):344–53.CrossRefPubMedGoogle Scholar
  36. 36.
    Beck BR, Matheson GO, Bergman G, et al. Do capacitively coupled electric fields accelerate tibial stress fracture healing? A randomized controlled trial. Am J Sports Med. 2008;36(3):545–53.CrossRefPubMedGoogle Scholar
  37. 37.
    Mallee WH, Weel H, van Dijk CN, van Tulder MW, Kerkhoffs GM, Lin CW. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med. 2015;49(6):370–6.CrossRefPubMedGoogle Scholar
  38. 38.
    Mann JA, Pedowitz DI. Evaluation and treatment of navicular stress fractures, including nonunions, revision surgery, and persistent pain after treatment. Foot Ankle Clin. 2009;14(2):187–204.CrossRefPubMedGoogle Scholar
  39. 39.
    Greaney RB, Gerber FH, Laughlin RL, et al. Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology. 1983;146(2):339–46.CrossRefPubMedGoogle Scholar
  40. 40.
    Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. J Foot Ankle Surg. 2000;39(2):96–103.CrossRefPubMedGoogle Scholar
  41. 41.
    Shakked RJ, Walters EE, O’Malley MJ. Tarsal navicular stress fractures. Curr Rev Musculoskelet Med. 2017;10(1):122–30.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Monique C. Chambers
    • 1
  • Dukens LaBaze
    • 1
  • Jesse Raszeswki
    • 2
  • MaCalus V. Hogan
    • 3
    Email author
  1. 1.Department of Orthopaedic SurgeryUniversity of Pittsburgh Medical CenterPittsburghUSA
  2. 2.Alabama College of Osteopathic MedicineDothanUSA
  3. 3.Foot and Ankle Division, Department of Orthopedic SurgeryUniversity of Pittsburgh Medical CenterPittsburghUSA

Personalised recommendations