Author name: Stephen Pinney

As the weather gets warmer, more people will be heading to the golf course. Golf has often been called “a good walk, spoiled.” It can be frustrating and challenging—but also rewarding and a great form of exercise. That said, golf can also cause injuries. While many golf injuries involve the upper body due to the swinging motion, the sport also leads to many lower body issues—especially foot problems. The main cause of golf foot injuries is the repetitive stress on the feet from walking 4 to 6 miles during a typical round. This kind of movement puts extra pressure on the soft tissues like tendons and ligaments, as well as on joints and bones—especially if someone is more active on the course than usual. Let’s take a look at some common golf-related foot issues. Plantar Fasciitis It’s not uncommon to feel sharp or aching heel pain after a round of golf. A common cause of this pain is plantar fasciitis. This happens when the thick band of tissue on the bottom of the foot (the plantar fascia) gets overstretched or torn where it connects to the heel bone. Each step puts stress on this area, and the body responds by creating inflammation, which leads to heel pain—often the day after playing. Treatment usually includes rest, stretching the plantar fascia and calf muscles, using orthotics (shoe inserts), wearing supportive shoes, and taking anti-inflammatory medication.For more information on plantar fasciitis click here. Metatarsalgia Metatarsalgia is a medical term for pain in the forefoot—the area near the base of your toes. This pain happens when one area under the foot is repeatedly loaded during walking or standing, causing discomfort, swelling, or a burning feeling. People sometimes confuse metatarsalgia with Morton’s neuroma, a condition where a nerve between the third and fourth toes becomes irritated. But most of the time, metatarsalgia is not due to a nerve issue—it’s due to inflamed tissue from all the walking and standing golf involves. Treatment includes resting the foot, wearing shoes with a stiff sole and a soft insert (especially one with a pad under the ball of the foot), and taking anti-inflammatory medication if needed.For more information on metatarsalgia click here. Tendonitis Tendons are the rope-like structures that connect muscles to bones and help us move. In the foot, different tendons help with walking and swinging a golf club. Tendonitis happens when these tendons become inflamed from too much repetitive use. It usually occurs when a tendon is overloaded—meaning it has to handle more strain than it’s used to. For example: Treatment typically involves rest, bracing or using a heel lift, physical therapy to keep the tendon flexible and strong, and short-term use of anti-inflammatory medication.Click on the links below for more information on tendonitis: Stress Fractures Though less common than other foot injuries, stress fractures can sideline a golfer for weeks or even months. These fractures happen when a bone is exposed to more stress than it can handle, leading to small cracks. At first, this might only cause some pain—known as a stress reaction. But if the pressure continues, the bone may fully break. Stress fractures might not show up on early x-rays. However, pain in a specific spot in the foot may be a clue. After a few weeks, signs of healing might appear on follow-up x-rays. MRIs can help detect early signs too. Common causes include suddenly increasing activity—like playing 36 holes in one day when you’re used to doing less. People with weaker bones (like those with osteoporosis) are also more at risk. The location of the fracture often depends on your foot shape: Treatment includes rest to let the bone heal, rehabilitation, and identifying and fixing the cause to prevent future injuries.For more information on specific types of stress fractures click below: While there’s no guarantee of a completely injury-free golf season, there are steps you can take to reduce your risk By understanding these common foot injuries and taking some basic precautions, you’ll be better prepared for a safe and enjoyable season on the course—though lowering your score is another story! Good luck! Stephen Pinney MD, April 9th, 2025

If you’re like most people, you’ve probably twisted your ankle at some point (Figure 1). Maybe you were walking on uneven ground or playing a sport, and suddenly your ankle rolled inward. You felt a sharp pain on the outside of the ankle, and the area swelled up quickly. Walking might have been difficult or even impossible. That sharp pain often turns into a steady, throbbing ache—classic signs of an ankle sprain, where some of the ligaments that stabilize the outside of the ankle have torn. But what if your “ankle sprain” isn’t just a sprain? What if it’s something more serious or even an additional injury on top of the sprain? Most of the time, an ankle sprain really is just that—a sprained ankle. But in about 2-5% of cases, there can be other injuries that happen instead of or alongside the sprain. These less common but important injuries include fractures or tendon issues that require different treatments (Figure 2). Let’s break down some of these possible injuries and their treatments: Fracture of the Anterior Process of the Calcaneus A fracture of the anterior process of the calcaneus is a break in a small bony part at the front of the heel bone (calcaneus) near where it connects to other foot bones. This injury usually happens when the foot twists suddenly or during a hard landing after a jump. Sports involving quick direction changes or jumping, like basketball or gymnastics, are common culprits. Athletes and active people are more prone to this injury, but it can also occur from accidents like slipping and twisting the foot. Treatment: Mild cases typically heal with rest, ice, wearing a protective boot, and avoiding putting weight on the foot. Severe fractures may require surgery to repair the bone. Avulsion Fracture of the Fifth Metatarsal Base An avulsion fracture of the fifth metatarsal base happens when a small piece of bone is pulled off the base of the fifth metatarsal, the long bone on the outer side of the foot that connects to the little toe. This injury usually occurs when the foot twists inward or during sudden, sharp movements, such as rolling an ankle. It often happens to athletes, but older people with weaker bones due to osteoporosis are also at risk. Treatment: Rest, ice, and wearing a supportive boot or cast are common treatments. In rare cases, surgery may be needed if the bone doesn’t heal properly. Acute Peroneal Tendon Subluxation with Disruption of the Superior Peroneal Retinaculum An acute peroneal tendon subluxation injury occurs when the tendons on the outer side of the ankle (peroneal tendons) slip out of their normal position because a supportive tissue called the superior peroneal retinaculum is torn. It often happens during sudden twisting or rolling of the ankle, especially in sports like soccer, basketball, or skiing. Treatment: Mild cases can heal with rest, ice, a supportive boot, and physical therapy. Severe cases often require surgery to repair the torn tissue and stabilize the tendons. Fracture of the Lateral Process of the Talus (Snowboarder’s Fracture) A fracture of the lateral process of the talus is a break in a small bony part on the outer side of the talus, a key bone in the ankle that helps connect the foot to the leg. This type of fracture often occurs during high-impact activities or accidents, such as snowboarding, where the ankle twists forcefully or lands awkwardly. Treatment: Minor fractures can heal with rest, ice, wearing a protective boot, and avoiding weight on the foot. Severe fractures may require surgery to realign the bone and ensure proper healing. Acute Osteochondral Injury to the Lateral Talar Dome An acute osteochondral injury to the lateral talar dome involves damage to the smooth cartilage and the underlying bone on the outer part of the talus. This injury often happens during sudden twists, falls, or ankle sprains, which can cause the cartilage to crack or break. Athletes who play sports requiring sharp turns or jumping, like basketball or soccer, are at higher risk. Treatment: Mild cases may heal with rest, ice, physical therapy, and wearing a brace or boot. More severe injuries, where the cartilage and bone are loose or damaged, may require surgery to repair or remove the damaged tissue. In Conclusion: If your “ankle sprain” seems unusually painful, swollen, or doesn’t improve with time, it’s important to get it checked by a healthcare professional. These less common injuries may only happen in a small number of cases, but catching them early can make a big difference in recovery time and long-term joint health. So next time you twist an ankle, remember—it might be more than just a sprain! Edited by Stephen Pinney MD February 5th, 2025

NFL stars Russell Wilson (calf muscle tear), Aaron Rodgers (Achilles tendon rupture), Christian McCaffrey (Achilles tendonitis), and Justin Herbert (plantar fasciitis) have all suffered from major orthopedic issues in the last 12 months. On the surface these are all very different orthopedic diagnoses. However, the mechanism by which these injuries occurred is actually quite similar! Furthermore, it’s related to their elite athleticism and the dynamic moves required in a sport like football. To understand how these various injuries develop, and how they’re interrelated, it is necessary to understand the mechanism by which the forces needed to stand, walk, run, and changed direction are generated in the lower extremity. A review of lower extremity anatomy illustrates that the calf muscle, Achilles tendon, and plantar fascia are all distinctly different structures. However, practically, they function as a unit and can be envisioned as an interconnected whole (Figure 1). A sling of sorts running from behind the knee to the base of the toes. When pushing off during walking or running the calf muscle contracts applying force to the Achilles tendon, which in turn applies force to the heel bone and indirectly to the plantar fascia with the foot acting as a lever to magnify these forces. The forces going through these interconnected elements are even greater when an elite athlete makes a sudden explosive move to change direction. In this situation the calf muscle is not only contracting to apply force through the other elements, but additionally, the foot is moving upwards immediately prior to changing motion. This means the calf muscle is also lengthening. This is known as an eccentric contraction and the effect of this type of movement is that the internal forces created within all of these structures is many times body weights. The point of all this is that each of these individual anatomical structures (calf muscle, Achilles tendon, and plantar fascia) are subject to considerable force with isolated dynamic movements –and through repetitive action. What determines which specific orthopaedic condition each individual suffers is determined by the location of their particular “anatomic weak link.” An Achilles tendon rupture occurs when the internal forces generated are greater than the tendon can handle. The Achilles weakens and stiffens with age. When the Achilles tendon ruptures it does so in the same explosive way that an excessively stretched rubber band breaks –a sudden catastrophic failure! This is contrasted with Achilles tendonitis, a condition where individual fibers of the Achilles are microscopically injured, but the overall tendon remains intact. The forces leading to the development of Achilles tendonitis occur from the same mechanism as an Achilles rupture! However, rather than a single catastrophic failure of the tendon repetitive microscopic injuries occur. Imagine a rope swing that is repetitively used over for many years. The rope will tend to develop some fraying while still remaining intact. The body responds to these microscopic injuries to the tendon fibers by sending increased blood and inflammatory mediators to the Achilles. This creates pain, swelling, and dysfunction that is seen in Achilles tendonitis. Alternatively, when an individual suffers a calf muscle tear the site of anatomical failure is the calf muscle –usually the inside lower part (Figure 2). The extensive forces the calf muscle is subject to combined with stiffening and weakening with age predisposes an older athlete to suffer a calf tear. This injury is not as catastrophic as an Achilles tendon rupture because much of the calf muscle and it associated fascia usually remains intact. However, a calf tear is very painful, and recovery often takes many weeks before dynamic sporting activities can be resumed. Plantar fasciitis develops from repetitive loading similar to an Achilles tendonitis, albeit with the weak link being the point where the strong plantar fascia inserts into the heel bone (Figure 3). The dynamic forces creating the microscopic injuries in this area are the same force through the anatomical sling that also create the other injuries. The plantar fascia can rupture from this mechanism. However, more commonly the plantar fascia remains intact but suffers microscopic injuries from the repetitive loading. With the plantar fascia remaining intact recovery from plantar fasciitis is usually quicker.  Many athletes can play through the condition, although pain symptoms form plantar fasciitis can be quite debilitating. This interconnected sling of calf muscle – Achilles tendon – heel bone – plantar fasciitis combined with the dynamic forces created by sprinting and sudden change of direction movements in athletes leads to all these different injuries. Same force mechanisms! Different injuries! Furthermore, having a tight calf muscle and explosive muscle strength often allows elite athletes to run faster and make quicker changes in direction –but the price they pay for this athletic advantage is probably an increased risk of suffering one of these injuries -especially as they age. November 17th, 2024

With the NBA playoffs in full force, college star Caitlyn Clark beginning her WNBA career: and the Paris Olympics on the horizon basketball is taking center stage in the sports world. Unfortunately, foot and ankle injuries such as ankle sprains, calf tears, plantar fasciitis, Achilles tendonitis, and stress fractures are an all too common occurrence among basketball players. These injuries can, and often do, impact the results of games and fundamentally affect the outcome of a series or tournament. As a recent example, Milwaukee Bucks star Giannis Antetokounmpo’s calf muscle injury knocked him out of the NBA playoffs and doomed his team to an early exit.  The dynamic nature of basketball; the size of the players; and the intensity of many games means that foot and ankle injuries are likely to always be a risk. Injuries can be acute from a single event, or chronic due to the large repetitive loads placed through the lower extremity. So, what are the most common basketball injuries affecting the foot and ankle (and the lower leg)? Some injuries are minor and a recovery can be expected in short order. Whereas other injuries are debilitating and may cause the loss of the season or even a career. Here is a review of some of the more common foot and ankle injuries that basketball players suffer: Ankle Sprains An acute ankle sprain is perhaps one of the most common basketball injuries. There are two types of ankle sprains. An inversion ankle sprain where the ankle rolls inwards tearing the ligaments on the outside of the ankle, and a high ankle sprain where the planted foot rotates outwards tearing some or all the ligaments connecting the two bones of the lower leg (the tibia and fibula) together. Of these two ankle injuries the inversion ankle sprain is by far the most common. In basketball this injury commonly occurs when a player changes direction suddenly or the player lands on someone’s foot after jumping. In both cases, the ankle rolls inward and ligaments on the outside of the ankle are stretched or torn. The severity of the ligament tearing dictates the extent of the injury. For many players, particularly those with loose ankles, some of the restraining ankle ligament fibers are torn, but they’re able to continue playing. Whereas for in more severe ankle sprains an extensive recovery might be required. Patient who have suffered previous ankle sprains, or have a higher arch foot are more likely to suffer sprain. Almost all ankle sprains can be treated conservatively without surgery. However, for patient that have repetitive ankle sprains due to looseness of the lateral ankle ligaments their ankle instability may need to be addressed surgically. Calf Muscle Strain A Calf tear or calf strain is another relatively common basketball injury. This injury often occurs following at dynamic movement such as suddenly changing direction. These activities cause the calf muscles to contract and lengthen at the same time creating considerable force within the muscle which can leads to tearing off some of the muscle fibers. This muscle injury can be debilitating. It is often a number of weeks before players who have suffered a calf muscle tear can return to competition. The muscle injury needs to heal with scar that is strong enough to withstand the large forces that occur during the running, jumping, and change of direction activities that commonly occur in a basketball game.  Plantar Fasciitis Chronic heel pain due to plantar fasciitis is another common problem among basketball players. The plantar fascia is a strong fibrous tissue that runs through the length of the sole of the foot. In basketball players repetitive loading of the feet due to running and sudden changes of directions can create microscopic tearing at the origin of the plantar fascia where it attaches to the heel bone. The body responds to these microscopic injuries by sending inflammatory mediators to this area leading to notable pain in the heel area. Basketball is a dynamic game, and players are often tall and heavy. This combination creates tremendous loads through the fascia increasing the likelihood that basketball players will develop plantar fasciitis over time. Also, a tight calf muscle can help a basketball player jump high, but it also increases the force through the plantar fascia predisposing to the development of painful plantar fasciitis. Fortunately, with a consistent calf and plantar fascia specific stretching program as well as other treatment strategies most cases of plantar fasciitis can be resolved or controlled. Achilles Tendonitis Similar to the plantar fascia, the Achilles tendon can be subject to extraordinary repetitive loading forces in the course of a basketball game. Microscopic injury to the Achilles tendon can lead to tendonitis. This can create pain and swelling around the tendon and which can make playing basketball difficult or impossible. Dynamic activities, such as jumping and sudden changes of directions combined with the size of many basketball players, all serve to increase the forces going through the Achilles and the potential for Achilles tendonitis. A coordinated Achilles tendon stretching program, local soft tissue massage and mobilization, and backing off activities in the short term will usually lead to an improvement or resolution and symptoms — although Achilles tendonitis can become a chronic issue. Achilles Tendon Rupture A ruptured Achilles tendon is a devastating injury for a basketball player! Dynamic forces can create loads through the Achilles that are 4-7 times bodyweight. These forces combined with wear and tear of the tendon with age can lead to a catastrophic rupture of the entire tendon. A ruptured Achilles tendon is an all too common basketball injury with many elite NBA stars having suffered the injury including: Patrick Ewing, Kobe Bryant, and Kevin Durant. Recovery following an Achilles rupture is prolonged and it is often a year or more before players are fully recovered. The Achilles tendon itself not only needs to heal, but it must heel strong enough to be able to withstand many times bodyweight. Also, the Achilles and

Almost everyone has suffered a stub toe at some point. You inadvertently smash your foot into a solid object -often at night when you’re half asleep. A swear word may be uttered! Almost immediately searing pain emanates from the stubbed toe or toes that have been injured. A marked limp ensues. So, what actually happens when you stub your toe? There’s no such thing as a “good stubbed toe“. However, some stubbed toes are more manageable than others. So, let’s think of the extent of the injury, in terms of those that are manageable; those that are bad; and those that are ugly! Anatomy of the Toes To understand a stubbed toe it is important to understand a bit about the anatomy of the toes -and the physiology of an injury. The four smaller toes are called the “lesser toes“. They are each made up of three bones, the phalanges -and there are three associated joints (Figure 1). The joints are held together by strong soft tissues called ligaments. All the lesser toes are fairly mobile, although they tend to mostly move up-and-down rather than side to side. The toes move during walking due to ground reactive forces or when pulled by one of the tendons that acts on the toes. The types of injuries that often occur with a stubbed toe include: bruising; tearing of one of the joint ligaments, or a fracture of one of the toe bones. All of these injuries will elicit a physiological response with the body sending increased blood flow to the area as part of the healing response. This is both good and bad. You need the increased blood flow to bring the healing elements to the injured area. However, toes are relatively confined structures and don’t tolerate too much swelling. So, the blood flow causes swelling, which unfortunately exacerbates the pain. It is helpful to think about a stubbed toe in terms of the severity of the injury. The Manageable Stubbed Toe Fortunately, most toes are in the manageable category. They are essentially a bad bruise to the involved toe or toes. Sometimes some partial tearing of one of the joint ligaments may occur, but not enough to destabilize the joint. Patients will need to deal with pain and swelling for a day or two or even up to a week. However, with no major injury, and no associated deformity, the toe will settle –usually with no residual symptoms. Initial treatment would include limiting activities, using a stiff shoe with a wide toebox, and possibly icing the toe. If there are no contra-indications an anti-inflammatory medication may be taken to help reduce the pain. The Bad Stubbed Toe A bad stubbed toe can be more challenging with a longer recovery. This type of injury usually involves a fracture of one of the phalangeal bones and/or notable tearing of one or more of the joint ligaments. The swelling and pain can be intense and symptoms can persist for many weeks. However, without a significant deformity of the bones or joints conservative treatment will be successful. Helpful treatment includes limiting weight-bearing activities, elevating the foot to decrease swelling, using a stiff shoe with a wide toebox, icing as needed, and possibly taking anti-inflammatory medication to help the discomfort. Recovery can take many weeks and some residual stiffness of one or more of the joints is not uncommon. The Ugly Stubbed Toe The “ugly” stubbed toe is problematic! Fortunately, this level of severity is not that common. The vast majority of stubbed toes are just painful, but will not require intervention. However, if the injury is such that a displaced or significantly angulated fracture has occurred and/or there is a dislocation of one of the joints of the toe then more involved intervention may be required. In addition, any “open injury” where a fractured bone has poked through the skin and is exposed to the outside world would also create a “ugly” stubbed toe. If there is an obvious angular or rotational deformity to the toe this will usually need to be treated. Sometimes, a doctor will be able to freeze up the toe and gently pull on it to straighten it. The straightened toe is then “buddy taped” to the toe beside it. In rare instances, surgery may be required to formally straighten the toe and stabilize it in the appropriate position. In patients where a fractured bone has poked through the skin surgery may be required, as well as a course of antibiotics in order to minimize the risk of infection. Needless to say an “ugly” stubbed toe is a frustrating injury that has a prolong recovery time and often leads to residual stiffness. Fortunately, these types of more extensive toe injuries are relatively uncommon. It’s always best to prevent an injury. So, give some thought about structures in your home that could be a stubbed toe hazard! Hopefully, you can avoid this type of injury, but, if you’re unfortunate enough to be a victim of a stubbed toe, hopefully this overview will help. April 4th, 2024

An ankle sprain is one of the most common orthopedic injuries. So, what are the ankle sprain risk factors? Most people will suffer a sprained ankle at some point in their life. Often, you’re doing something active when suddenly your ankle rolls inward. You experience a marked pain on the outside of your ankle follow by noticeable swelling. The ligaments supporting the outside of your ankle are torn. If you’re lucky, you’ll be able to limp home and recovery in a week or two. However, for more severe ankle sprains the recovery time can be much longer –and chronic symptoms including ankle looseness is common. So, who sprains their ankle? The chance of suffering an ankle sprain is not random. Some people are at high risk for ankle sprains. While the majority of people have suffered an ankle sprain at some point in their life, a small minority (~10–20%) will suffer numerous ankle sprains during their lifetime. What is it about these people that makes them more likely to sprain their ankle? It turns out there are predictable risk factors. These include: Ankle Sprains Increase in High Risk Activities Participation in activities that are more likely to lead to an ankle sprain is a big risk factor. Sporting activities, where athletes are jumping and landing (basketball, volleyball, etc.), or suddenly changing direction (soccer, pickleball, etc) are associated with increased rates of ankle sprains. It’s common for athletes in these sports to tape their ankle or use an ankle brace for extra support. However, other activities, such as hiking on uneven terrain may also increase the risk of suffering an ankle sprain. Increased Ankle Inversion Increased ankle inversion is also a risk factor for an ankle sprain. An ankle with increased inward motion (inversion) will also considerably increase the chance of that person suffering an ankle sprain. The type of ankle that has increased inversion is often seen in association with a higher arched foot shape. When the foot lands during walking or following a jump, it may roll inwards initially. Individuals who have excessive inversion will often not realize their foot is in a “at risk” position until it’s too late. The foot continues to roll inwards. There is marked force through the ligaments on the outside of the ankle, and these lateral ankle ligaments tear. Loose Ankle Ligaments make an Ankle Sprain more likely Ligamentous laxity is another risk factor for suffering an ankle sprain. Some individuals are just more flexible than others. This includes younger athletes who tend to have more flexibility than older individuals. There is also a condition called ligamentous laxity where individuals have excessively loose ligaments supporting their joints. These individuals can often bend their fingers backwards more than 90 degrees and can noticeable hyperextend their elbows. Due to their lax ankle ligaments their foot can roll excessively inwards before their brain realizes the ankle is in a position from which it cannot recover. The end result is tearing of the lateral ankle ligaments, which may heal in a further lengthened position. This may exacerbates the looseness in their ankle potentially leading to chronic ankle instability. A History of Multiple Ankle Sprains Not surprisingly, if a person has had multiple ankle sprains they are much more likely to suffer an ankle sprain in the future. Often, they have one or more of the above risk factors. In addition, previous ankle sprains often lead to further stretching out of the ligaments on the outside of the ankle. This can lead to ankle laxity and predisposes patient to recurrent ankle sprains. Physical therapy can be helpful. Treatment includes strengthening the protective muscles on the outside of the lower leg (the peroneal muscles) as well as improving the inherent balance from muscular control (proprioception). However, some patients with recurrent ankle instability will require surgery to stabilize the stretched-out ankle ligaments. If someone is at high risk for suffering an ankle sprain there are a variety of things they can do to minimize the possibility of an ankle sprain. These include appropriate muscle strengthening and balance exercises; activity modification to avoid “at risk” sports; and ankle taping or bracing. When an ankle sprain does occur, early icing, elevation, and immobilization can help with symptoms. During the recovery period there is a critical need for optimal rehabilitation as failing to completely regain baseline lower leg strength and balance (proprioception) can also increase the risk of another ankle sprain. For more information on ankle sprains and rehabilitation strategies check out our webpage on ankle sprains. March 3rd 2024

Recovery and Rehabilitation Following a Calf Muscle Tear Imagine you are playing pickleball (or tennis, basketball, soccer, etc.). You race for the ball, suddenly changed direction –and immediately feel a sharp intense searing pain in your calf muscle. You have suffered a calf muscle tear -also known as a calf strain! You gingerly limp to the sidelines. Your game is over, and you now have weeks (or months) of calf muscle rehabilitation ahead of you. The good news is it is not an Achilles tendon rupture! The calf muscle has two primary muscles, the soleus and gastrocnemius These muscles joint together to form the Achilles tendon which in turn attaches to the heel bone (the calcaneus). A calf muscle tear results in local disruption of some of these muscle fibers. The muscle injury is often in the lower inside part of the calf muscle. However, tearing the calf muscle fibers can occur anywhere. Bleeding at the injury site where the muscle fibers are torn will result in bruising, although sometimes it can take a few days for this bruising to appear. To obtain optimal recovery following a calf muscle injury require three goals to be achieved. These are competing goals. Healing often requires immobilization, limiting activities, and protection of the injured area. However, inactivity and limited functioning of the calf muscle very quickly results in atrophy and stiffness. So, how do we balance these goals to achieve an optimal recovery and rehabilitation following a calf muscle tear? Function of the Calf Muscle To understand the optimal recovery strategy following a calf muscle tear it is helpful to understand how the calf muscle functions. The calf muscle contracts repetitively with each step we take. Specifically, this contraction controls our bodyweight as it passes over our foot during walking or running. This means the calf muscle is contracting eccentrically – the muscle contracts while at the same time lengthening. This eccentric muscle contraction generates considerable internal force within the muscle. This force is even greater when the activity is dynamic, such as during running or suddenly changing direction. This is why it is often a sudden change of direction maneuver that causes a calf tear or an Achilles tendon rupture. It’s also why the calf muscle needs to be very strong. In addition, the calf muscle is contracting with each step. We take for granted that our calf muscles will be able to contract thousands of times each day -once for every step we take. This muscle function requires stamina and resiliency. Healing a Muscle Tear The healing process following a calf strain initially involves local bleeding around the torn muscle tissue. This bleeding clots, forming a strawberry jam like confluence around the torn muscle fibers. Over time, bruising resorbs and the healing blood clot transforms into scar tissue. Initially, the scar tissue may be rubbery and lumpy. As it gets stronger, it will tend to smooth out. However, excessive force at any time during this recovery period can cause a re-tearing or breakdown of the forming scar tissue causing a slowing of the recovery process –or even requiring the healing process to start again. Therefore, protection of healing scar tissue with relative immobilization is critical. It may mean markedly limiting activities, or using a cast or walker boot if the muscle tear is significant enough. Balancing the Rehabilitation Process Following a Calf Strain The recovery challenge following a calf muscle tear occurs once the acute pain of the injury has settled somewhat. This can be a few days to a few weeks after the injury. At this point, patients can begin to mobilize more and the rehabilitation process can start in a formal way. A good recovery requires patients to balance their rehabilitation between doing too little –and doing too much. Doing too little means the calf muscle will continue to atrophy. Doing too much means the calf muscle can re-tear, aggravating the injury and slowing the recovery. The hallmark of a good rehabilitation following a calf strain is a graduated approach – and a continuation of the exercises until full strength and function of the calf muscle has been achieved. Optimal rehabilitation of a calf muscle tear often takes many months. Rehabilitation of a calf muscle tear can be thought of in terms of regaining: 1) muscle strength; 2) flexibility, and 3) dynamic functioning. Calf Muscle Strengthening Muscle strength can be built with graduated resistance. Initially, this may simply be firing the calf muscle by pointing the toes. Progressively more resistance can be added with resistance bands, leading to double leg heel rises, and eventually to single leg heal rises. The calf muscle needs to contract thousands of times a day, so it’s important to do this strengthening program employing high repetition strengthening exercises (ex. 3-5 sets of 20-40 repetitions). The key is gradual progression using the opposite leg as a comparison. Calf Muscle Stretching The healing calf muscle tissue must also be stretched and made more resilient. A graduated stretching program should be undertaken on a daily basis. While the calf can be stretched both with the knee bent and the knee straight. It’s important to emphasize stretching the calf with the knee straight as this stretches the outer calf muscle, the gastrocnemius (Figure 1). The gastrocnemius muscle is usually the tighter of the two muscle and is often the part of the calf muscle that is injured. Stretching can be augmented by local massage or percussive therapy (Figure 2) to help loosen up the muscle tissue. Again, this stretching and massage of the muscle tissue needs to be done in a graduated manner often over many weeks. Increasing Dynamic Loading The last phase of recovery is the addition of dynamic loading. In addition to being used thousands of times a day while we walk or run our calf muscles also needs to be able to function dynamically –particularly in sporting activities that require a sudden change of direction. These motions place an enormous stress through the calf

With lots of snow during the winter months, many people are flocking to the mountains to snowboard. While carving turns and fresh powder brings joy to snowboarders the sport is not without its risks. A lateral talar process fracture is an unusual fracture affecting the ankle area that is surprisingly common in snowboarders. This “snowboarder’s fracture” results from a sudden jarring stop combined with a rotation of the foot on the lower leg. The sudden jamming creates a fracture affecting the lower bone of the ankle (the talus). Pain and swelling is experienced on the lateral, or outside, of the ankle. Sometimes the fracture is relatively undisplaced, like the way a hard-boiled egg cracks. However, displacement of the fracture and involvement of the joint below the ankle, the subtalar joint, will often necessitate surgery. Signs and Symptoms   This injury usually occurs after a fall or sudden jamming stop while snowboarding. Symptoms of a talar lateral process fracture include immediate pain in the outside of the ankle. Local ankle swelling on the outside of the ankle is also common. Weight-bearing may be difficult and cause considerable pain. Symptoms are often quite similar to a bad ankle sprain, and for many patients this is the initial diagnosis. Imaging Studies of Lateral Talar Process Fractures Standard complete x-ray series of the ankle includes three views. It is often only on one of these x-ray views that the talar lateral process fracture can be seen (Figure 1). As a result, the fracture is often missed or not seen on plain x-rays.  The fracture pattern can vary from an undisplaced crack in the bone, to a series of small fragments of bone, to a relatively large fracture fragment, that is displaced. More advanced imaging studies such as a CT scan or MRI are sometimes. This is the case if the diagnosis of a lateral talar process fracture or the size and displacement of the fracture is in question. Treatment One key to effectively treating a snowboarder’s fracture of the ankle is to make the actual diagnosis as this injury is often initially thought to be “just an ankle sprain”. Once a snowboarder’s fracture has been identified the amount of displacement will often dictate the treatment. If the lateral talar process fracture is essentially undisplaced it can be treated conservatively. Conservative treatment requires relative immobilization in a CAM boot, or cast, with limited or no weight-bearing while the fracture heals. It often takes 6–8 weeks before the fracture is adequately healed. At that time patients can more aggressively increase their weight-bearing activities and mobilization. After the fracture is adequately, healed therapy to regain motion and strength can be beneficial. Needless to say, this fracture often causes the snowboarder to miss a large chunk, or all, of the snowboarding season.  🙁  In addition, if the fracture involves a large part of the subtalar joint it may lead to chronic painful subtalar arthritis. Surgical Treatment of Lateral Talar Process Fracture If the snowboarder’s fracture is displaced or interferes with the function of the joint below the ankle (the subtalar joint) surgery is often required. If the fracture fragment is small or in multiple small pieces, surgically removing the fracture fragments is often all that is required. However, if the fracture fragment is relatively large, repositioning it back where it belongs and stabilizing it with a screw is usually the surgical procedure of choice. Following surgery to address a lateral talar process fracture healing is required. This is longer if the fracture fragment has been retained and fixed with a screw. Usually it is six weeks before patients can be aggressively mobilized. Similar to patients who are treated nonsurgically physical therapy is often beneficial to improve motion and strength that has been lost as a result of the injury. Overall, it can take a number of months or even up to a year before patients reach their point of maximum improvement. Edited January 29th, 2024

If you are starting a new athletic activity or recommitting to an old sport your choice of shoe wear is often critical. Choosing the right athletic shoe to optimize both comfort and performance is not easy. However, understanding the role of four components of an athletic shoe will help you make the right shoe choice. These shoe elements are: the size, the sole, the insert, and the uppers. 1. Shoe Size When thinking about getting an appropriate fitting shoe it is natural to think about shoe size. The listed shoe size is important, but there are other elements to having a well fitted shoe. There is a Chinese proverb that says: “if you want to forget, your troubles, wear tight shoes.“ Most people have experienced the discomfort associated with wearing shoes that are too small. However, shoes that are too large can also cause problems. Larger shoes may not be uncomfortable, but they often negatively impact performance, and the excess foot motion within a shoe that is too big can lead to blisters and other problems. Getting a good fitting shoe is so much more than just choosing the right “shoe size”. Shoe width is critical. The width of a shoe can vary widely between shoes that are the same “size”. For example, two size 11 shoes can be very different in their width, just as two individuals with “size 11 feet” may have very different widths to their respective feet. Making sure the length AND the width of the shoe fits your foot is essential. To do this often requires testing many brands, or in some cases seeking out specific shoe brands that make shoes in multiple widths. The “forefoot width to heel width” ratio is also important. Getting a shoe which is perfectly fitted for length and forefoot width can still create major issues if the heel is too loose, or too tight. It is fairly common for individuals to have a wide forefoot and a narrow heel. In this scenario, achieving a well fitted shoe may require some extra work. Sometimes adding heel cushioning can help. Alternatively, a snug fitting heel with a tight forefoot may be addressed by attempting to further stretching out the forefoot width. This can often be done professional via shoemaker or by purchasing a commercial shoe stretcher. 2. Optimizing the Sole Finding a well fitted shoe for your sport of choice is just the starting point. Ensuring that the sole functions optimum is the next step. When considering the sole of a shoe there are three elements to consider: stiffness, shock absorption, and heel height. A soul that is stiffer will generally be more comfortable. In some sports, such as running, a high-end stiff sole will absorb force and then return energy during the gait cycle helping to improve performance. However, in many sports there is a trade-off between having a stiff soled shoe that is more comfortable versus a shoe with a flexible sole that may improve performance and control. Sorting out this balance between comfort and performance is something that each individual will need to determine based on the sport they are performing, and their own personal preference. The shock absorbing capacity of a shoe’s sole can vary widely. Increased shock absorption provided by the sole of the shoe can improve comfort, but for some sports too much shock absorption in the sole can decrease performance. Additionally, consideration needs to be given to the longevity of the sole with respect to shock absorption. For sports that involve considerable walking or running the shock absorbing component of the shoe’s sole can be lost fairly quickly. It can be frustrating when you need to buy another pair of running shoes eight weeks after you made a purchase because the sole has lost its shock absorbing capacity. Finally, the heel height can be very important. The “heel rise“ is the difference between the height of the sole at the heel, and the height of the sole at the forefoot. For many sporting activities, a slight heel rise of 4–12 mm can help offload the Achilles and decrease the likelihood of developing Achilles tendinitis or other overuse injuries in this area. However, for other sports, there may be a loss of performance if the heel rise is too high. 3. Orthotic Insert The orthotic insert is another critical element when looking to purchase an athletic shoe. Inserts can be prefabricated or custom. A softer insert may be beneficial from a comfort point of view, especially if the sole of the shoe is fairly stiff. Many athletic shoes and hiking boots come with high-quality pre-fabricated orthotics. However, if the orthotic insert is flimsy consideration may be given to buying a shock absorbing over-the-counter orthotic. In some instances, individuals may benefit from a custom orthotic. Although it should be noted that many, if not most, custom orthotics are a high-priced version of a well-made over-the-counter orthotic. If the goal is dispersing force widely across the sole of the foot, a good over-the-counter orthotic will likely do the trick. Shoe Uppers The “upper” of a shoe is the part of the shoe above the sole that covers the foot. Choosing an athletic shoe with the right upper is often a matter of balancing comfort –versus protection and support. Many athletic shoes have flexible mesh-type shoe uppers which will provide considerable comfort. However, for some activities such as hiking, or sports such as tennis that require a sudden change of direction a more supportive, durable upper will be preferable. Additionally, it can take a while to “break in” a new shoe with a stiffer upper. Doing this in a graduated manner can make this process easier. Choosing the optimal shoe for your athletic or fitness endeavor can be a challenge. However, by thinking about the the four elements of 1) size, 2) sole, 3) orthotic, and 4) upper; you will be well on your way to getting an athletic shoe that is not only comfortable, but also

There have been some high profile Achilles tendon ruptures recently, including NFL quarterbacks Aaron Rodgers and Kirk Cousins both suffering season ending Achilles tears. This has focused a spotlight on this fairly common injury. There are three important things to know about Achilles ruptures that will allow you to understand the injury –and why treatment of Achilles tendon ruptures can be challenging and prolonged: Role of the Achilles Tendon The calf muscle runs into the Achilles tendon (Figure 1). The tendon then attaches to the back of the heel bone. Effective functioning of this muscle-tendon unit is important for propelling the body forward, whether it be walking, running, or jumping to dunk basketball. When the calf muscle contracts it pulls through the Achilles tendon applying force on the heel bone which can move the foot downwards (plantar flexion). The calf muscle working through the Achilles tendon allows the foot to generate a strong push-off. However, “pushing off” is actually NOT the primary function of the calf muscle and the Achilles tendon. Its main function is to slow the upward movement of the foot immediately prior to pushing off (Figure 2). Think about suddenly changing direction like a running back might do in football. The calf muscle working through the Achilles tendon needs to generate a lot of force to limit, and then stop, the upward motion of the foot. This resistance to upward motion of the foot is essential so that the foot stops moving upwards and then begin the push-off motion -allowing the athlete to change direction. It is almost like a rubber band in that the Achilles lengthens with increased loading, and then recoils during push-off. This concept is critical to understand because it’s this phase when the calf muscle is contracting and the calf and Achilles are actually LENGTHENING when the most force goes through the Achilles tendon. This is known as an eccentric contraction. It’s during this phase just prior to push-off that the Achilles tendon ruptures. Requirements for optimal Achilles function To function optimally the Achilles tendon must be strong. Additionally, the calf muscle must not only be strong, but also contract in a coordinated manner. The forces generated by the previously mentioned eccentric contractions can be enormous –many times bodyweight in the case of certain athletic maneuvers. This is why the Achilles is the largest tendon in the body. It has to withstand the most force of any tendon. The need for the Achilles tendon and calf muscle to have optimal strength is problematic with respect to recovering from an Achilles tendon ruptures. Inherent challenges in recovery from an Achilles tendon rupture To function athletically we need a strong Achilles and a strong coordinated calf muscle. An Achilles tendon rupture affects both of these adversely for an extended period of time. A ruptured tendon will have no strength immediately after it has ruptured. It will remain weaker than needed for many months after the injury. This is because optimal tendon healing is a slow process. It takes time! Additionally, because the calf muscle is not used normally while the tendon is healing this muscle becomes considerably atrophied. This calf atrophy and loss of muscle coordination is exacerbated if the calf is not allowed to contract at all. So the inherent challenge of recovering from an Achilles rupture is that not only does the tendon need to heal to the point where it can withstand maximal force (many times bodyweight weight), but the associated calf muscle ALSO needs to be strengthened. It invariably loses considerable strength and coordination during the extend time when the Achilles tendon is healing. This is why modern rehabilitation strategies for Achilles tendon recovery focus on keeping the calf muscle firing while still allowing the tendon to heal without stretching out. It is an inherent challenge. Even with a strong surgical repair it is often six months before the Achilles tendon has regained enough strength to think about beginning intense athletic activity. Unfortunately, during this extended recovery period the calf muscle invariably loses a marked amount of strength and coordination –even with an optimal rehab program. In addition to subpar athletic performance re-rupture of the Achilles is a distinct possibility. Re-rupture of the tendon can occur if an athlete returns to sports prior to regaining BOTH Achilles tendon strength, and calf strength and function. Following an Achilles rupture the best outcomes occur when the patient and their medical team work diligently to balance allowing the Achilles tendon to heal strongly without lengthening, while still finding ways to fire the calf muscles so that calf atrophy is minimized -and then calf strength is ultimately regained. Good results can be achieved with both non-surgical and surgical repair. A strong surgical repair may allow patients to be using their calf muscle and Achilles a little earlier in the recovery process. However, this advantage needs to be balanced against the very real possibility of developing a devastating wound healing problem or infection. Working collaboratively with a skilled medical and rehabilitation team can greatly improve the chance of having a full recovery –although it won’t be quick! Published December 29th, 2023