Baseball has been a popular choice of sport for youth and high school athletes for over a century. It is a relatively safe sport, with general low rates of injury compared to other sports. Injuries can occur, however, and foot and ankle injuries are among them. This article will discuss common foot and ankle injuries associated with baseball and how these injuries are often treated.
Cleat-Related Issues: Toenail Pain, Blisters, and Nerve Injuries
Like many sports, baseball uses cleated shoes to help with traction when running in the outfield and the infield. Like any other pair of shoes, cleats can fit well or fit poorly. In youth sports, cleats may be worn secondhand or as hand-me-downs from one sibling to another, and may not fit properly or be too structurally worn down to be supportive. Some players also choose to wear tighter cleats for a ‘better’ feel. Under these circumstances, cleats can actually cause problems in the feet. Among these various problems, toenail issues seem to develop most frequently. Bruised nails are very common and can occur when the toe is jammed into a tight shoe while running or sliding, or simply as the poorly fitting shoe causes gradual pressure damage to the nail and the skin below it. As blood pools under the nail plate, it will turn the color of the nail blue, purple, or eventually black. This color will stay in the nail until the new nail grows outward, where the discolored area will be pushed slowly towards the toe tip. The blood will be liquid initially, and then will eventually dry up into a powder.
Bruised toenails may often be painless, but they also can very painful, limiting performance. Small bruises involving a quarter or less of the nail’s
total size are often left alone, and allowed to grow outward. Larger bruises may require removal of the nail to help drain the blood and prevent infection, and allow for inspection of the skin underneath the nail for any cuts that need to be repaired. The nail will eventually grow back, although sometimes the injury that caused the bleeding in the first place may be severe enough to damage the nail root cells, leading to a permanently thick or strangely shaped nail. Nail bruises that are painful must be evaluated by a podiatrist or other physician to ensure that a fracture or significant skin injury has not occurred, and any nail discoloration that does not grow out with the nail needs a similar evaluation to rule out nail fungus or a more serious condition.
Ingrown toenails can also be a problem in poorly fitting cleats. Those that are present from birth can become agitated by a tight fitting shoe, and ingrown toenails can also develop on their own over time from shoe pressure and gradual toe injuries playing baseball or other sports. As damage occurs to nail root cells, the nail growth becomes deformed and the nail plate itself can curl in towards the skin. This does not lead to pain in and of itself, unless skin next to the nail becomes inflamed from minor injury or shoe pressure. Once inflamed, the skin is sensitive, and the nail growing into it can cause pain at that point. Bacteria can also become trapped, leading to infection and drainage. Because of the shape of the nail, persistent issues of the ingrown nail is to be expected over the years, and it is often not enough to simply treat with antibiotics, soaking, and even partially removing the side of the nail. Permanent removal of the side of the nail by chemically destroying the nail root cells is the best way to get permanent relief. The results are excellent, the procedure is quick and easy to perform in the office. Most players can return to the field within a few days after this procedure.
Blisters are a common problem in any sport. Blisters form when there is too much friction across the skin, causing it to separate its top layer from the bottom layer and fill the space in between with fluid. Tight shoes can rub on the skin, and loose shoes can allow the foot itself to move excessively in the shoe, leading to rubbing of the skin. Excessive moisture, such as from sweating and a moist sock, can also contribute to blisters developing. The use of properly fitted shoes and cleats can help reduce the chance of blisters, and the use of synthetic blend socks designed to wick away moisture off the skin (as opposed to pure cotton which retains moisture on the skin) can help. Some people simply have overactive sweat glands, and may need topical treatment to reduce sweat production all together.
Tight shoes can also cause compression injuries to nerves in the feet. In particular, a bundle of nerves on the top of the foot near the arch and ankle can become compressed by a tight fitting shoe or poorly positioned shoe tongue, and this can lead to sharp pain, tingling, or burning to the top of the foot or to shooting to the toes. The use of a properly fitting shoe and perhaps adjustments in the lacing pattern of the shoe can help relive this pressure. Another set of nerves in the ball of the foot near the bottom of the toe bases can become compressed by shoes that are too narrow, leading to pain in the ball of the foot, a sensation one is walking on something (sometimes described as a hot marble), and possibly numbness and tingling to either the 2nd and 3rd toes or the 3rd and 4th toes. Called a neuroma, this condition can become chronic over time as swelling and tissue thickness around the nerve expands. Wider shoes and inserts to reduce pressure to the bottom of the foot can help relieve this nerve irritation, although in many cases anti-inflammatory medication and possibly a steroid injection may be needed to reduce the nerve inflammation.
In older players, (such as collegiate or professional) or youth who have early foot deformities, tight shoes can also agitate conditions like bunions, hammertoes, and early great toe joint arthritis. Wider and deeper shoes may be needed to accommodate these deformities.
Ankle Sprains
Ankle sprains are common injuries in sports. In baseball, these can occur in many situations including when running the bases, sliding, or even when playing in the outfield. Divots and uneven surfacing of the outfield can cause the ankle to roll in, and since most fielders will be tracking the ball such imperfections in the field will not be seen in advance to avoid.
On the outside of the ankle, there are three separate ligaments: one towards the front of the ankle, one along the side, and one towards the back. These ligaments connect the outermost bone prominence of the ankle to one of the bones of the back of the foot. Most athletes roll their ankle inward during an injury. This motion stretches and tears the ligaments on the outside of the ankle. Usually the first one or two ligaments are injured in a sprain, although severe sprains can involve the final ligament near the back. Sprains in which the ankle rolls outward are uncommon. The inside of the ankle is held by a very strong ligament structure that acts as a single unit. It is difficult to sprain this side of the ankle due to the strength of the ligament, and therefore sprains on this side do not occur with great frequency.
Ankle sprain symptoms include swelling, warmth, bruising, and of course pain following the injury. These symptoms do not necessarily show up at the exact time of the injury. In some cases, the symptoms can be delayed by a few hours. Additionally, a feeling of ankle weakness is also common, due to extra laxity of the ankle joint developing from the ligament tearing. Pain with standing or walking is to be expected. Severe pain in which one cannot even place the foot down without excruciating pain possibly indicates a major fracture in the ankle or foot. The same is true for any sprain in which the ankle looks deformed or is angled off to one side. Several smaller foot fractures have been associated with ankle sprains, which do not necessarily add to the pain of a typical sprain directly. These often go untreated as people assume the pain was solely due to the sprain itself. In essence, a medical evaluation with foot and ankle x-rays is needed for all severe sprains, and most moderate sprains as well.
‘High’ ankle sprains are a somewhat different and more serious variation of the traditional ‘lateral’ ankle sprain, and involve damage to the tissue (syndesmosis) that binds the end of the leg bones that comprise the top part of the ankle joint. The pain is felt primarily above the ankle, and x-rays may indicate separation of these bones.
Treatment of any sprain begins with the usual formula of rest, ice, compression, and elevation, primarily to reduce inflammation and improve comfort. The ankle will need support in order to heal, even if pain is minimal. The use of an ACE bandage or a stretchable ankle sleeve is helpful for very low grade sprains in non-athletes, but is probably of little use in an athlete trying to decrease recovery time. More substantial bracing is often recommended, along with physical therapy as soon as the pain will allow. Sprains that are moderate to severe (or high ankle sprains) may require more aggressive treatment, including a period of immobilization prior to advancement to physical therapy. These injuries obviously take much longer to heal. All sprains should have a medical evaluation, including x-rays, to identify any significant instability, as well as any small fractures that may involve the bones surrounding the injury site. Further tests may need to be done if a full ligament tear is suspected, including the use of an MRI scan. Surgery is sometimes indicated to repair ligament tears that remain chronically unstable, or to immediately repair fractures that occur with the injury. Surgery is also sometimes needed in high ankle sprains.
The long term complications that can occur with an untreated or under treated ankle sprain include instability, pain or stiffness in the ankle joint, ankle arthritis, and frequent spraining due to the inherent weakness of the injured ankle tissue. These symptoms can last a lifetime, and can make even simple walking difficult, especially on uneven surfaces. Proper initial treatment guided by a foot and ankle specialist can help prevent these complications, and lead to a lifetime of healthy ankle function.
Turf Toe and Sesamoiditis
Turf toe is a common sports injury that involves a sprain to the great toe joint. It is called turf toe as it is commonly experienced by those who play on artificial turf surfaces, but it can occur on grass as well. This injury can have two different causes. More commonly, the toe is injured when it is pulled upward on a hard surface, causing tearing of the tissue on the bottom of the joint. Less commonly, the toe is injured when it is flexed downward and tissue on the top of the toe is torn. The injury may be minor enough that it is not really noticed at first, and the pain may be dull enough that the athlete continues to play on it. This eventually leads to a worsening of the injury, and can make healing time far more extended. Baseball players are at risk for this injury when running in the outfield or when sliding as the toe can catch on the base if improper technique is used.
Common symptoms include pain, and swelling of the big toe joint, especially when the toe is pushing off of the ground. The motion of the joint can eventually become restricted due to the pain, and the skin around the joint can appear black and blue due to bleeding incurred from tissue tearing. The toe will be more painful while barefoot or in lighter, more flexible shoes, and up to half of the people who develop this injury will have long term pain issues.
Treatment is centered around a combination of icing, rest, anti-inflammatory medications, and stiff shoes. Strapping or taping the toe can help an athlete return to activity quicker, and the use of a prescription orthotic insert can provide support for the great toe joint from underneath. The time away from the sport varies by the severity of the injury. Minor cases may only need a few days of rest, while more significant cases may need one to two months of rest. Physical therapy is sometime necessary. Severe cases may need cast immobilization or surgery outside of rest from sports to allow for full healing.
Sesamoiditis is a condition somewhat related to turf toe, in which there is inflammation and possibly even fracturing of the sesamoid bones. The sesamoids are two small egg-shaped bones found under the big toe joint, just behind where the toe meets the foot. Chronic, stressful activities such as high impact jumping or running (and even impact on the bases) can lead to inflammation and bruising of one or both of these bones. Eventually this damage may lead to stress cracks of the bone. Immediate injuries can even occur, causing outright fracturing of the bone if the injury force is severe enough, and this can also be seen with long term stress damage if the bone is weakened without relief. The pain of this condition is felt just underneath the big toe joint, usually in a very specific location. Pressure on the inside ball of the foot becomes painful, and running or jumping will become difficult. Unless a fracture has occurred, swelling and bruising are usually not seen. Treatment centers on reducing the inflammation by reducing the stress to this site, using special pads or prescription inserts which direct pressure away from the sesamoids, as well as icing, rest, and anti-inflammatory medications is also used. More serious injuries may need to be immobilized in a walking boot for a few weeks to months depending on the severity, and fractured sesamoids that wont heal may need to be removed surgically.
Plantar Fascia Injuries
One of the most common structures injured in the foot, the plantar fascia is a ligament that passes on the bottom of the foot from the heel bone forward to the base of the toes. In sports that involve sustained running like soccer or cross country, injury to this tissue is more subtle and involves inflammation and microscopic tearing the tissue tissue (plantar fasciitis). In other sports that require shorter, more explosive movement, the plantar fascia can also rupture, or tear. In baseball, a mix of these two injuries is seen. Catchers are particularly prone to injure the plantar fascia due to the constant squatting position and the need to forcefully rise up from this position. The pain of either a plantar fascia rupture or simply plantar fasciitis is usually felt on the inner side of the bottom of the heel where it meets the arch, or more closely to the middle of the arch. While ruptures can eventually heal, if untreated they can eventually lead to chronic plantar fasciitis which can persist for years. Plantar fascia rupture treatment involves a short period of rest and immobilization in a walking boot to allow the tissue to heal, followed by arch support or taping and gradual return to the field. Treatment of fasciitis is fairly simple, and involves gentile stretching, inflammation reduction, and orthotics ( specialized shoe inserts) to provide greater foot support. Surgery is uncommon.
Heel Pain
Heel pain is common in children ages 9-15, and is typically caused by inflammation in a growth plate in the heel bone. Growth plates are soft parts of developing bone that help to produce bone growth, and can be susceptible to injury until their job is done and the plates harden into bone once the body stops growing. In the heel bone, this condition is also known as Sever’s disease, and is often seen in athletic children. Those that participate in year-round sports seem to be the most likely to get it, as this condition typically represents overuse in a child’s musculoskeletal system that is not fully developed yet. Frequent impact force on the heel can agitate the growth plate. The Achilles tendon is often part of the problem, as it can pull directly on the growth plate in the heel bone. Tightness of the Achilles tendon can worsen this pull, and lead to bone inflammation. Symptoms typically include pain with sports (running and jumping), while daily activity such as walking are usually not painful in most cases. The pain can be felt anywhere in the heel, but is typically worse on the bottom back of the heel pad. Inflammation and warmth at this site is rare, and may indicate an uncommon but more problematic growth plate injury or even rare tumor.
Treatment usually involves only support, as this condition may come and go until the growth plate fuses, after which the condition resolves. Rest from athletics is important. Support measures often require stretching exercises, possible stretching help with a night splint, anti-inflammatory medications like ibuprofen, icing, and structural support with arch inserts to reduce heel rotation.
Foot Fractures
The foot has a number of different bones that can be fractured in baseball, and each type of fracture can have differing causes and differing treatment needs based on the severity of the fracture. Common baseball related fractures include toe fractures and metatarsal fractures. There are three bones in each toe, except for the big toe which only has two. Toe bones can fracture when toes strike the ground forcefully if one trips while running, when striking the base in an improper sliding technique, or even when hit by the ball or stepped on by another player. Symptoms include toe pain, swelling, and bruising. Toe fractures typically are treated with splinting to help assist healing, however some fractures have enough movement (or displacement) that surgery is required to put the pieces back together and keep them stable as they heal.
The metatarsal are the long bones in the foot, running from the middle of the foot to the toe bases. There are five of them, each corresponding with a toe. Metatarsals can be fractured from twisting injuries, impact forces like being stepped on or being struck by the ball, or when striking the base in an improper sliding technique. The symptoms of a metatarsal fracture usually include pain, swelling, bruising, and warmth in the foot. The middle or front part of the foot will be painful to walk or stand on, and may be painful to move. In some cases, the symptoms may be minimal and difficult to notice initially, with more pain in the weeks following the actual injury. Treating metatarsal fractures varies by which metatarsal is fractured, whether the fracture has moved the bone out of alignment, or how stable the bone is during the healing process. Many metatarsal fractures can be easily healed by limiting weight bearing pressure using a walking fracture boot. The healing process is usually six weeks, especially in healthy athletes. More unstable fractures or multiple metatarsal fractures require the use of a cast and crutches for support and complete limitation of weight bearing. If the fracture has moved out of place, it must be returned to a proper position by either externally manipulating the fracture back to a proper position, or by surgically repairing the fracture and securing the bone with medical hardware. Surgery is often necessary for Jones fractures in athletes (the base of the 5th metatarsal bone on the outside of the foot), as this area is often unstable.
A fracture particularly unique to baseball players occurs when the foot is struck by a ball fouled off of a pitch. A comma-shaped bone called the navicular, located on the inner side of the foot, is typically fractured in this scenario, although other bones can be struck. Navicular fractures can be treated for 4-8weeks with immobilization in a cast or walking boot depending on severity, although some people with higher grade fractures require surgery to complete the healing.
A final, but serious fracture that occurs in baseball players (although it is seen more often in football players) involves the bases of the metatarsal bones and their attachment to the bones in the middle of the foot at the arch. This series of joints, called collectively the Lis Franc joint, can either be sprained with ligament tearing, or fractured with separation of the metatarsal bones from their bases. Twisting motions and direct impact on the middle of the foot can cause this significant injury. These injuries often go under-treated even by medical professionals, as the x-ray findings can be subtle, and this condition is often missed in the emergency rooms if a significant fracture has not occurred. In some cases, if the bones have remained in place, the injury can be treated with immobilization in a cast. However, most cases of either sprain or fracture at the Lis Franc joint are unstable, and surgery is needed to stabilize the region to allow for full healing.
Achilles Tendonitis and Ruptures
Achilles tendon injuries and ruptures are common, can be quite disabling to an athlete Full recovery of this injury is often lengthy.
The Achilles tendon is a strong, large, strap-like tissue that connects the two calf muscles to the heel bone, allowing the leg to flex the foot downward. Without this tendon, the foot would uncontrollably flop upward during the walking cycle. The tendon can become damaged and inflamed from repetitive running and motion which gradually leads to tendon degeneration, and the potential for rupturing. Ruptures can also occur when the foot is flexed upward forcibly while one is pushing downward, or rarely when the back of the heel is forcibly kicked or struck by a ball. The typical area of rupture occurs at a place above the heel bone where there is poor blood flow to the tendon tissue. A rupture will feel sharp and stabbing, and often a pop or snap is heard. The calf can feel like it has been hit from behind. Walking is extremely difficult, and after the rupture the ability to rise up on the toes is lost. The back of the heel can become swollen and bruised, and there may be a indentation in the heel where the Achilles tendon rupture has formed a gap. Simpler tendon injuries, such as overuse inflammation, or tendonitis, have less pain severity, and while athletes typically play through the pain, the damage of untreated tendonitis can worsen and eventually lead to a hight chance for rupturing.
Treatment of Achilles ruptures in athletes usually requires surgery to repair the severed ends of the tendon together. The sooner the repair can take place, the easier the tendon ends will heal together. Lengthy delays in repair, especially those months in duration, will often lead to scar tissue, tendon degeneration, and a widening of the gap between the severed tendon ends. This makes repair very difficult. Once the ends are stitched together, the foot is held in place within a cast for four to six weeks as the tendon heals. Physical therapy is usually started soon afterwards to restore strength and flexibility. Tendonitis is often treated with stretching, bracing, and physical therapy. Surgery is performed in cases that do not improve to repair and strength the tendon tissue.
Final Note: Other Various Foot and Ankle Injuries
There are many kinds of foot and ankle injuries baseball players endure beyond the major injuries list above. These include common nuisance injuries like contusions, in which there is bleeding under the skin or within deep tissue from being stepped on by another player or being struck by the ball. Contusions are painful, but generally heal well with a simple treatment course of ice, elevation, compression, and time. Most players can play through the discomfort of all but the most severe contusions.
Another injury found in catchers is due to compression on the front of the ankle while in a squatting position. As the ankle is bent upward, the tissue that covers the front of the ankle joint can impinge into the joint, leading to inflammation and pain. This can also irritate the bone in the ankle joint, causing bruising or even microscopic compression injury. Treatment options can be varied, and may include steroid injections, bracing, and physical therapy.
Finally, another tendon in the ankle region besides the Achilles tendon can become injured through play. The peroneal tendons are a group of two tendons that start from muscle in the outer side of the leg and run underneath the outer ankle bone to attach either on the outer side or underneath the foot. These tendons help stabilize the foot and rotate it outward. They can be injured during ankle sprains, but can also become strained on their own with repetitive running on uneven surfaces like a grass field. Sometimes, the tendons can become strained or even tear during sliding if the foot catches the base at an improper angle, forcing the foot inward. Treatment of peroneal tendonitis involves reduction of the inflammation and support of the foot and ankle to allow for complete healing. Anti-inflammatory medication, elevation, rest, and icing all contribute to the reduction of the inflammation. Bracing is used to stabilize the tendon. Often, physical therapy can be employed to reduce inflammation and strengthen the tendon integrity. If these measures are not helping, or if a more severe injury is suspected, and MRI will be taken to evaluate the tendon substance. Reparative surgery is performed when the damage is severe, or if the tendon is not healing with the above measures.
Scott R. Kilberg DPM 