A Guide To Common Foot And Ankle Golf Injuries
What About Extensor Tendinitis?
Extensor tendinitis occurs only with the driver of the golf cart and I have seen it occur only in the right foot. I have named this entity “golf cart tendinitis” as it typically will happen after playing rounds on hilly golf courses when the driver uses the parking brake excessively.
The brake pedal on a golf cart is made in two pieces. The top piece is the parking brake and the driver has to depress this downward in order to engage the brake. The motion of depressing the parking brake can cause a strain on the extensor digitorum longus tendons. This repetitive strain causes irritation of those tendons and a tendinitis develops.
Symptoms usually include diffuse dorsal pain. Upon examination, there is typically pain with palpation of the extensor digitorum longus tendons and some forefoot swelling. There is typically no pain with palpation of the lesser metatarsals or metatarsophalangeal joint motion.
Treatment options for this condition are the same as the treatment for any other cause of extensor tendinitis. They consist of elimination of the irritation to the tendon, NSAIDs, corticosteroid injections and immobilization. I have never had to operate for this condition and have not seen a rupture of the tendons.
Discussing the cause of the irritation with the patient is imperative. I encourage patients to alternately use the left and right feet on the brake, and have counseled them to seek flat areas on which to park the golf cart. Using the heel to depress the parking brake can also eliminate strain on the extensor tendons.
When Lateral Ankle Pain Occurs
Lateral ankle pain occurs due to the excessive motion of the rearfoot during the golf swing follow through. The forces applied to the lower extremity during the follow through cause an abduction of the knee of the non-dominant limb and a supination of the foot on that side with eversion of the rearfoot. On longer shots, such as a drive, this force can strain the ankle ligaments and peroneal tendons to the point where they cause pain.
Repetitive strain will cause laxity of the lateral ankle ligaments and predispose that ankle to easier spraining.
Symptoms include lateral ankle pain and lateral midfoot pain. Some swelling may occur. Rarely will bruising occur. The examination usually indicates lateral ankle ligament laxity and diffuse pain on palpation of the lateral ankle ligaments and peroneal tendons. Talar tilt and anterior drawer signs are rare.
Treatment consists of stabilizing the ankle either with a compression ankle brace or a functional stirrup type ankle brace. An orthotic is often useful to control subtalar and midtarsal joint motion. A custom “Richie” type brace may be necessary if there is instability in the ankle. NSAIDs and occasionally corticosteroid injections are helpful to decrease inflammation on the area. Rarely is surgical intervention necessary to stabilize the lateral ankle ligaments. Mechanically, one can reduce the risk of lateral ankle pain by abducting the front foot toward the target and away from the midline of the body in the stance position when the golfer is addressing the ball.
Addressing Hallux Subungual Hematoma
This condition occurs when the golfer applies excessive pressure to the big toe during the golf swing. Typically it will occur at the end of the follow through and will only happen on the dominant foot. In other words, if the golfer swings right-handed, the right hallux will be the involved toe. In a fundamentally sound right-handed golf swing, the right foot will be propelled onto the tip of the hallux at the end of the follow through. This can cause a jamming of the toe into the top of the shoebox. With repetition, the subungual tissue will be injured and blood will form under the nail plate. This can cause pain due to the pressure the blood exerts on the nail bed.
Patient symptoms include pain in the hallux, pain with pressure on the hallux toenail and a discolored hallux toenail. The examination reveals pain with palpation of the hallux nail and usually a dark discoloration beneath the hallux nail.
Treatment options of this condition commonly involve: drainage of the blood under the nail; accommodative padding to decrease the pressure on the nail bed; and possibly avulsion or permanent removal of the nail plate.