Foot bone contusion

 Getting a collision of the foot isn't a great thing to have. This chap limped in to see me with a slight swelling on his left foot. He thought it was fine as he was able to jog 6km in his sports shoes. However, he was concerned that he wasn't able to play football. His initial X-rays ruled out a fracture and the ultrasound scan ruled out tendon involvement. (One may resort to do an MRI if there is a high index of suspicion of a stress fracture especially if he has prodromal pain). We resorted to focal shockwave to sort out any bone oedema. He felt much better and was hopeful to play soon. Whatever it is, he would still need to have full pain-free function to execute all the football skills when he goes back to sports specific rehabilitation next week. 

Plantar fasciitis in 2025

Patients (even athletes) often come with heel pain (see photo), getting out of bed just as they start walking or after getting up from prolonged sitting. Walking barefoot makes things worse and going into a pair of comfortable shoes 👟 with a heel cushion or heel lift helps. I've had this on several occasions myself, but got better after doing frequent calf raises.

 

Sports medicine physicians have started to diagnose this both with physical examination and imaging (X-ray and Ultrasound scan) for better clarity. 

Clinically, the patient may have palpation pain at the bottom of the heel (inner part more common), and occasionally also at the back of the heel (Achilles tendon). The doctor would often examine the whole plantar fascia and calf for other signs of stiffness and pain. 

A quick prescription of silicone heel cup and taping by your physiotherapist would work wonders along with calf stretching and strengthening exercises. If pain persists, you could see your doctor who could prescribe further exercises, shockwave therapy or a local Platelet rich plasma or corticosteroid injection. You may seek further evaluation with your foot and ankle surgeon if 6-12 weeks of supervised physiotherapy does not resolve the pain. 

Plantar Fascia Rupture

This gentleman suddenly felt a snap followed by sharp pain in the hindfoot (medial tubercle of calcaneus) while playing badminton. He could only place his weight on his forefoot and had to use a pair of crutches to walk.

He was diagnosed with a partially ruptured plantar aponeurosis and told to use a pair of running shoes with a silicone gel pad. However, he was not allowed to bear weight due to the severe pain. His X-rays did not indicate any signs of fracture of the calcaneus.

After vigourous RICE treatment over the next few days and the use of oral Cox-2 inhibitor, the pain reduced significantly and he was able to walk with less pain. He was treated with ultrasound for several sessions and started with toe and foot exercises. We encouraged him to go into the swimming pool for hydrotherapy to maintain his aerobic fitness. He would require at least another 2 to 4 weeks before he can return to training.

Right 1st metatarsalgia in Ballet dancer

A young lady in her (28 yrs old) came to see me with chronic pain (3 yrs) in the Right big toe. The pain would worsen with repetitive jumping and landing during ballet and modern contemporary dance. Despite getting better shoes, she still seemed to suffer from the pain. Her toes was also 'crowding' in her shoes with the big toe moving towards the 2nd toe (Hallux valgus).

She had tenderness at the base of the right 1st metatarsal bone and moreso adjacent to the 2nd toe. Upon treatment with ultrasound she felt better and we taught her some strengthening exercises and taping. She should be feeling much better if she takes adequate precaution and implements RICE treatment when she feels sore after training.

Foot Contusion and bruise from bike fall

A young lady in her 20s came in with a swollen and bruised right forefoot and toes from a fall off her bike. I sent her for an X-ray which did not show any signs of fracture. She was treated with RICE Treatment, topical Anti-Inflammatory gel and some Cox-2 Selective NSAIDS. The swelling and bruising should subside within 1 week but she will be reviewed in a week.

Hip-hop Dance and Fracture in the foot

An 11 yrs old girl came yesterday complaining of a swollen and painful left foot after hearing something snap in her foot while doing hip-hop barefoot. She had been training barefoot for 1 year but it did not cause any pain. Now, she could not walk or put pressure on the side of her foot or even tip-toe.

I examined her left foot and found that she had some bruising and swelling around outer part of her midfoot (lateral aspect adjacent to the base of 5th metatarsal). There was severe tenderness at the base of the the 5th metatarsal.

Her X-rays shown that her left foot had a non-displaced transverse fracture of the base of 5th metatarsal (Jones Fracture). She was treated non-surgically with non-weight bearing posterior slab crutches to allow the swelling to subsides. She would benefit from a daily dose of low frequency ultrasound (Exogen) to promote healing. Once the swelling subsides we may consider placing her foot in a functional walking brace but she would not be allowed to walk until after 6 weeks later.

Interesting links:
Diagram of metatarsal fractures

Toe abrasions from cycling without proper footwear

I took these 2 photos of the right forefoot of a young cyclist who decided to ride to a grocery shop in slippers instead of cycling shoes. It would be prudent for cyclists to wear suitable footwear even if they are making short trips as abrasions like these are quite common otherwise.

Foot contusion from soccer

A recreational soccer player came to me showing off his bruised left foot 2 weeks ago. He told me he was kicked by an opponent and had difficulty sprinting fully although he was a forward.

I examined him and found that he only had slight difficulty toeing-off while running and was able to do resisted ankle dorsiflexion. Besides the RICE treatment, he was given an anti-inflammatory gel e.g. Reparil and 5 days of Cox-2 selective NSAIDS as he has previous history of gastric pain. He was advised him to avoid full sprints and jumps for the next week. If he was to play, he needs to tape his ankle and foot to avoid the full plantarflexion (to allow pain-free range of motion). I expect him to be better within 1 to 2 weeks.

Extensor Retinaculum Injury and Extensor Digitorum Longus tenosynovitis

A male artistic gymnast was seen a few days ago with complaints of pain in the dorsum of the left foot after intensive training involving runs and jumps since 2 weeks earlier. He had difficulty standing on-toes, taking-off from jumps and landing.

After examining his ankle, I found that he had slightly reduced range of plantarflexion in the left ankle due to pain. There was tenderness and mild oedema of the extensor retinaculum and mild tenosynovitis of the Extensor Digitorum Longus tendons. However, resisted extension was pain free.






I did a simple taping to prevent extreme plantarflexion while enabling him to point his toes during his routine(Two figure of 6, and a double medial and lateral ankle locks and closed up the 'holes'). That seemed to do the trick and he should be back doing some training. However, he was told to refrain from sprinting or jumping to his maximal height as it may aggravate the injury. He was advised to undergo physiotherapy to reduce the symptoms and strengthen his lower limb.

Hallux Valgus

A fencing athlete was seen with her big toes (hallux) turned outwards (valgus), hence crowding into her second toe. She was lucky as she did not have any symptoms of pain usually seen in the prominent bunions. Gymnasts and dance athletes often suffered from painful bunions. She could consider using nights splints for the big toe, taping during training and some icing after training to assist her. If she wanted something off-training, she could buy a broad forefoot footwear and use a silicone gel spacing device between the toes.

Just don't wear the toe spreader to run or play badminton or table-tennis. You might get really bad blisters.

Right forefoot contusion

Dave played soccer 2 days ago and had slight right forefoot pain during the match but completed the game despite the pain. The pain worsened in the evening and he was given a hot ointment (Methyl Salicylate) by his mother. He faithfully massaged his right foot with the ointment and found that the foot was swollen (the light shade in the picture). He limped into my clinic yesterday and I thought that he had had a fall and or suffered from a stress fracture of one of his metatarsal bones.


He had oedema and tenderness of the softhis 5th metatarsophalangeal joint and both 4th and 5th metatarsal bones.

He was given some RICE treatment, Arnica Comp gel and 5 days of NSAIDS to reduce the swelling and pain. He is expected to get much better and I will review his injury once the swelling subsides over the next 48 hours.



Interesting links:-
Jones Fracture

Tinea Pedis (Athlete's Foot) and Onychomycosis

Tinea pedis (athlete's foot) is a common fungal condition occuring in the feet of athletes or workers who routinely wear their shoes without drying and cleaning them properly. Although it is more common to find the itchy, scaly (not always) and smelly skin lesion in between the toes, they can also infect the sole of the foot. Athletes who have the habit of wearing shoes belonging to their team mates may transmit the disease to others. This condition is easy to treat with foot hygiene, topical anti-fungal creams and occasionally require oral anti-fungal medication.

The nails may also be infected (see 2nd photo) causing Onychomycosis. This condition is more difficult to treat often requiring oral anti-fungal medication, topical anti-fungal lotion after filing the infected nail.

Links of interest:-
Athlete's Foot: MayoClinic.com
Nail Fungus

Morton's Neuroma (Interdigital Neuroma) and Ankle Instability

My ex-colleague referred a housewife in her forties with complaints of left forefoot pain since 4 months duration. The excruciating pain is worse while taking the first few steps after sitting or lying down. She got herself a pair of soft Japanese slippers at home to help her walk at home. Hence, she places her weight on her right lower limb and just drags the left lower limb (painful gait). Her back started to hurt when she needed to walk a while longer. She told me she had seen multiple surgeons (received 2 Corticosteroid injections with pain-relief lasting for 2 months), traditional medicine practitioners, massage therapists and general practitioners but the pain relief was inadequate and short-lived.

After probing a little more, she told me that it first started when she twisted her left ankle 4 months ago. She then visited a traditional chinese medicine practitioner who massaged her foot and ankle. Apparently her foot started hurting after the treatment.

Upon examination of her posture and gait, I found that she had overpronation and unstable ankle. Her anterotalofibular ligament was torn and she had poor muscle tone in her left lower limb due to disuse atrophy. She had tenderness between the 4th and 5th metatarsal heads (uncommon for Morton's Neuroma) and a positive squeeze test. She would probably need an Ultrasound scan (more economical than MRI) for definitive diagnoses.

Taping her medial longitudinal arch seem to reduce her pain. A further double ankle lock and lateral stirrups seemed to complete eliminate the pain. I was concerned that she had lost muscle power and tone since she was placing her weight on the opposite side. I left her with some NSAIDS and athletic tape after teaching her the technique but she would need at least 4 - 8 weeks rehabilitation to return her normal function.
We will look into getting her a suitable orthoses for her feet. She may not require Corticosteroid or Alcohol injections if symptoms subside with the use of corrective insoles. If conservative treatment fails after 3-6 months, surgical excision could be done.


Articles of interest:
Morton's Neuroma
Alcohol Injections under Ultrasound guidance
Investigations for Morton's Neuroma
Interventions for the treatment of Morton's neuroma (Cochrane Review)

Extensor Digitorum Brevis Ganglion Cyst

Mr Chin is an ardent 45 yrs old runner who plays badminton occasionally. Since 2 years ago he noticed a swelling on his right midfoot when he runs marathons or plays badminton more frequently. The swelling goes of after several weeks. I examined the swelling and found it to be non-tender, like a fluid-filled sac (cystic) and seem to arise from the fascia covering the Extensor Digitorum Brevis muscle (Inferior Extensor Retinaculum). This chap also has Hallux Valgus.

I told him that he could do an Ultrasound to confirm the diagnoses and a possible X-ray to rule out any bony anomaly which could cause the swelling. He was quite content as the swelling was usually painfree and decided to leave it alone for the time being.

24 hour Walk Swollen and Bruised Toes

Mr Singh is an ex-athlete and junior walking coach who participated in the 4th Malaysia International 24-hour walk at Dataran Merdeka on the 11th August. He came back with a pair of swollen feet with both big toe badly bruise when I saw him on the next day.

It is common for marathon runners to have such lesion after competition. I advised him to keep his feet elevated, have them iced, use the lysozyme tablets (for swelling) and NSAIDS (for pain and swelling). He would need to have the subungual hematoma (blood accumulation under the nailbed) relieved by the doctor using a sterile needle. Surprisingly he only a few small blisters.

He told me today that his feet were perfectly fine after doing the RICE treatment.

Extensor Digitorum Brevis Hematoma

Ms Lee is a 40 year old lady who was brought to my clinic in a wheelchair after she slipped a step on the stairs last Saturday afternoon. There was an immediate bluish swelling (the size of a Mc Donald's chicken McNugget) on the side of her midfoot. It didn't look good as she looked like she had fractured her 5th metatarsal as she could not place her foot on her ground*.

I did a simple examination and was surprised that the 5th metatarsal bone was non-tender. The swelling seemed to come from the Extensor Digitorum Brevis (Peroneus Tertius, if present). Her plain X-rays did not show any fracture.





I advised her to use RICE treatment and gave her a Tubigrip sleeve to compress the site. She was also given analgesics and ARNICA Comp gel to reduce the swelling and inflammation. Her review will be in a week's time.

*AAFP article on Fractures of the Proximal Fifth Metatarsal

Tibialis Posterior Tendinopathy (Traction apophysitis)

Ms Chia is an 11 years old child who played basketball barefooted last week. She came with Right midfoot pain since a few days duration. She particularly mentioned that she had pain jumping and doing brisk walking. Her mother was worried as she thought it could be cancerous.

I examined her feet and found out that she was flat footed and had a prominent navicular tuberosity(insertion of Tibialis Posterior tendon) on both feet. She had tenderness at that spot but there were no obvious signs except that she had pain standing on her toes and resisting inversion (pushing her forefoot inward against my hand).

I explained to her mother that she would benefit by having good medial longitudinal arch support with orthoses. She could have taping of her foot to provide additional arch support. If symptoms persisted, an X-ray could be done to rule out avulsion fracture (tendon pulls off the tubercle from the bone) or other pathology.

She should recover swiftly with proper footwear, modified activity, isometric and theraband resistance exercises within 2-4 weeks.

Navicular Stress Fracture

Crystal is an elite basketball player who landed on her right foot after doing a jump shoot and suffered from severe foot pain a week ago. She was taken off the court as she could not continue weight-bearing. Subsequently, she was seen by another colleague and found to be having tenderness and fullness (oedema) over the inner portion of the dorsum of her right foot. Her X-rays showed a Type III Navicular Fracture.

Anatomy:

The navicular bone, located in the midfoot, articulates with the head of the talus, cuboid, and the three cuneiform bones that are involved in the acetabulum pedis. It gives attachment to the spring ligament (superomedial and inferior calcaneonavicular ligament)that can be injured in a failure of the posterior tibialis tendon and cause an adult acquired flatfoot deformity. The navicular bone provides insertion for the posterior tibialis tendon. Some pathologies can be related to the presence of an accessory navicular bone.Osteonecrosis or stress fractures can affect the navicular bone because of its poor vascularization, especially in its central portion.

Radiological classification of Navicular Fracture: dorsal cortical break (type I), fracture propagation into the navicular body (type II), and fracture propagation into another cortex (type III). It includes modifiers "A" (avascular necrosis of a portion of the navicular); "C" (cystic changes of the fracture), and "S" (sclerosis of the margins of the fracture).


She was placed in a non-weight bearing cast for 4 weeks (as she wanted play if there was no pain!). I saw her at 4 weeks post-injury and her repeat X-ray did not show much callous formation. She was placed in a functional walking brace (Donjoy) and advised minimal weight bearing for another 2-4 weeks. She was told that such fractures may take a longer period to heal and some studies suggest that surgery (ORIF) may be an option. I prescribed her low frequency ultrasound treatment (Exogen) to encourage bone healing. Most studies suggest that conservative (non-surgical) management provide good results for non-displaced navicular fracture but a few small studies suggest that elite athletes may benefit from surgery in type II or III fractures. Return to sporting activity varies from 3.0 months (Type I), 3.6 months (Type II) and 6.8 months (Type III) according to Saxena et al*.

*J Foot Ankle Surg. 2000;39(2):96-103

Rt Big Toe Gouty Arthritis

Mr Lim came in walking on his heel with a painful and swollen base of the right big toe (see photo) yesterday. He could not remember having any falls or trauma to the toe but had a little too much beer, seafood and peanuts for the past week.

I was keen to find out whether he had any insect bites or previous injury but he had none. I took a blood sample for his uric acid levels and sent him off with an NSAIDS for 5 days. Had to give him some gastric preventive medication i.e. Proton-Pump Inhibitors to prevent any gastric side-effects. Also warned him not to take NSAIDS on his own as it could cause hypertension or heart problems if given indiscriminately.

True enough his serum uric acid levels came back elevated. He was advised to avoid excessive intake of protein and beer. If he had recurrence in his condition, he may have to be on medication to lower the uric acid levels e.g. cholchicine or allupurinol.

Forefoot contusion after supper!

The local council is going to get a complaint from this patient. He was walking back from 'Mamak' (a spicy, not so fancy, local fast-food) when he accidentally stepped into a pothole in Subang Jaya last Saturday.

He had a painful swelling on the dorsum of his right foot (see photo) and could only walk on his inner side of his foot. He had a painful gait when he walked into my clinic yesterday. I was getting a bit worried as he could not put weight on the side of the foot. After examination, I felt that he could be spared from an X-ray as most of the pain came from the superficial swelling and not the 5th metatarsal (common site of injury for such falls). I once had a 50 year old colleague who fractured her 5th metatarsal in the same manner walking along the pavement! Her risk was higher as she was having Osteoporosis.

Told him to do the RICE treatment (see first-aid) and gave him some Arnica gel and oral NSAIDS. He was advised to avoid excessive walking for another 5 days and return for a review if pain and swelling persisted.