Best Practice Case Studies-Case 112 Ankle - "SUPER SHOES CAUSING SUPER PROBLEMS"

Pdf Summary

A 16-year-old male cross-country runner developed a month of insidious, atraumatic right posterolateral heel and hindfoot pain shortly after returning to training in new carbon-plated “super shoes” (Nike Vaporfly) following one week off after his season. Pain was sharp and worsened with weight-bearing, toe walking, direct pressure, and faster or longer runs, but he could heel-walk without pain and had no mechanical or radicular symptoms. Exam showed an antalgic gait, tenderness posterior to the lateral malleolus and near the lateral Achilles insertion, pain with resisted ankle eversion, and pain with calcaneal and midfoot compression; strength, sensation, and range of motion were otherwise normal.<br /><br />Initial differential included bone stress injury, peroneal tendinopathy, Achilles tendinopathy, sinus tarsi syndrome, and chronic lateral ankle instability. X-rays suggested a density near the anterior calcaneal process possibly representing a mildly displaced fracture. MRI clarified the diagnosis, demonstrating moderate peroneal longus tendinopathy with tenosynovitis and an ossified body at the anterior calcaneal process (likely an ossicle or remote trauma).<br /><br />The working diagnosis was peroneal tenosynovitis likely induced by abrupt adoption of carbon-plated footwear. Experts noted that carbon plates increase longitudinal bending stiffness, shifting forces toward the forefoot, reducing energy loss at the metatarsophalangeal joints, and enhancing ankle plantarflexion/Achilles energy return—changes that may improve running economy but can overload tissues if introduced too quickly, especially in runners with biomechanical risk factors (e.g., varus hindfoot, forefoot strike, over-supination) or uneven-terrain training.<br /><br />Recommended conservative management included stopping/reducing carbon-plated shoe use, switching to a flexible cushioned neutral shoe, RICE/NSAIDs as needed, bracing, orthotic modifications (e.g., lateral heel post/wedge, deep heel cup), and physical therapy emphasizing early motion plus progressive isometric/eccentric tendon loading and proprioception. The athlete completed 6 weeks of PT with complete symptom resolution and returned gradually to running, reserving super shoes for select high-intensity workouts/races.

Meta Tag

Edition 4th Edition

Related Case 4th Edition, Case 2

Topic Ankle

Keywords

peroneal longus tendinopathy

peroneal tenosynovitis

posterolateral heel pain

carbon-plated running shoes

Nike Vaporfly

cross-country runner injury

hindfoot overuse injury

anterior calcaneal process ossicle

MRI diagnosis

conservative treatment physical therapy

4th Edition

4th Edition, Case 2

Ankle