Foot Pain - Baseball

Abstract

HISTORY: A 38-year-old Major League Baseball player presented after feeling a pop in the plantar aspect of his left foot. Four days prior to injury, he noticed tightness in the arch of his foot medially and laterally. He experienced a pop through the center of his foot after batting when rolling his ankle while planting foot to run out of batter’s box. After diving back to the base on a pick-off attempt, he experienced pain on the lateral side of his foot going up his lateral leg. PHYSICAL EXAMINATION: Left lower extremity neurovascularly intact with no atrophy or deformity. Exam demonstrated peroneal longus tendon weakness with weakness of eversion and weakness of plantarflexion of the 1st metatarsal bone. Peroneal brevis tendon was palpable upon eversion and intact. No instability. The left heel strike is 5 to 10 degrees of varus with splinting secondary to pain without correction to neutral with ambulation. Contralateral side neutrally aligned and achieves 5 degrees of valgus with ambulation. Increased abduction and more lateral heel strike of the left heel. Foot progression angle on the left side is about 10 degrees, compared to zero. DIFFERENTIAL DIAGNOSIS: 1. Peroneal longus tear 2. Peroneal brevis tear 3. Peroneal tenosynovitis 4. Fracture/diastasis of os peroneum 5. Peroneal subluxation 6. Stress fracture 7. Sural neuritis TEST AND RESULTS: 1. Foot radiographs demonstrate no abnormalities 2. MRI: rupture of peroneus longus tendon with retraction to lateral margin of calcaneus. FINAL WORKING DIAGNOSIS: Peroneal longus rupture TREATMENT AND OUTCOMES: 1. Left peroneal longus tendon debridement with re-attachment to fifth metatarsal with iliac bone marrow aspiration and injection. 2. 10 days post-operatively removed from posterior splint and permitted to invert against resistance to midline but not to cross midline. Eversion allowed but not against resistance. Ambulation in plantarflexion permitted. 3. Return to jogging at two months, progressively increasing exercises of figure-of-8s, A-skips, and agility. 4. Return to full baseball activity at 3 months including baserunning, cutting, and sliding. Minor League rehabilitation delayed due to unrelated baseball injury following hit-by-pitch. 5. Return to Major League Baseball at 4 months at pre-injury activity level prior to conclusion of the season.