Podiatric Sports Medicine in Focus: Highlights from the APMA 2025 Panel Lectures

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The 2025 American Podiatric Medical Association (APMA) Conference in Grapevine, TX featured a dedicated track on podiatric sports medicine, led by Alicia Canzanese, DPM, ATC. Dr. Canzanese was joined by esteemed colleagues Marlene Reid, DPM, and Karen Langone, DPM, for a comprehensive exploration of injury trends, biomechanics, and treatment strategies across various sports. Their sessions spanned elite athletics to recreational play, emphasizing evidence-based management of common—and increasingly prevalent—injuries in podiatric practice.

Pickleball and Injury Epidemiology: A Rising Challenge

Dr. Langone’s presentation illuminated the rapid rise of pickleball, now the fastest growing sport in the U.S., and its associated injury burden. With over 19 million players and more than 16,000 facilities nationwide, pickleball is drawing in participants of all ages, particularly those aged 25–34 and 65+.¹ 

Injury Trends:

An estimated 17,000 Emergency Room visits annually stem from pickleball-related injuries. The most common injuries are:² 

• Sprains and strains (especially ankle and wrist)
• Fractures (notably wrist and lower extremity)
• Achilles tendon ruptures and tendinopathies
• Plantar fasciitis, neuromas, and 5th metatarsal fractures

Mechanisms:

Dr. Langone stressed that these injuries are frequently caused by falls, quick directional changes, lunges, and overuse, particularly in under-conditioned or older individuals.

Prevention Tips That DPMs Can Share With Patients:

• She encouraged clinicians to emphasize proper technique training, especially for new players.
• Patients may benefit from encouragement of gradual progression of play time and intensity.
• She discussed recommending sport-specific footwear with multi-directional traction.
• Clinicians can promote dynamic warm-ups, static stretching post-play, and routine rest days.
• Patients should use protective equipment (eg, wrist guards, eye wear, ankle braces) and maintain a hazard-free playing surface.

Dr. Langone underscored the need for podiatrists to understand the sport’s biomechanics and to guide patients in injury prevention and safe return-to-play strategies.

The Biomechanics of Golf: Ground Reaction and Gait Nuances

Dr. Reid delivered a compelling lecture on how golf’s complex, multiplanar biomechanics demand more attention to foot structure, function, and orthotic accommodation.

Golf as a Ground-Up Sport:

• The swing relies on ground reaction forces (GRF) that initiate in the feet and transmit upward through the kinetic chain, she shared.
• The lead and trail foot undergo opposite motions: the trail foot supinates in backswing and pronates in downswing, while the lead foot does the inverse, added Dr. Reid. 

Foot Types and Swing Adaptations:

Dr. Reid delved into her experience as to how various biomechanical circumstances can impact one’s golf swing.

• Foot morphology (eg, rigid cavus, metatarsus adductus, tarsal coalition) can restrict range of motion and affect swing consistency.
• First MPJ limitations (arthritis or fusion) can significantly alter balance and torque generation.

Under-Recognized Factors:

• In her observation, Dr. Reid explained that golf instruction often overlooks lower extremity limitations.
• The ability to perform necessary swing mechanics, such as rotation of the feet and hips, must be better understood in context of foot and ankle conditions, she said.

Footwear and Orthotic Considerations:

• Traction, proper fit and stability in golf shoes are crucial, she explained. Cleats help to keep the foot intimately connected to the ground, maximizing GRFs.
• Orthotic demands should match walking versus cart use and individual biomechanical needs. 

Dr. Reid called for more targeted research and collaboration between podiatrists and golf professionals to enhance swing mechanics and reduce injury risk.

An Evidence-Based Approach to First MTP Joint Injuries

Dr. Canzanese tackled the misunderstood and often misdiagnosed realm of first metatarsophalangeal (MTP) joint injuries, particularly turf toe and its variants, with a clinical lens grounded in evidence.

Key Anatomical Insights:

• The first MTPJ is stabilized by a complex of ligaments and tendons, including the plantar plate, collateral ligaments, sesamoidal ligaments, the deep transverse intermetatarsal ligament, and intrinsic/extrinsic musculature.
• The most commonly injured structure is the sesamoid-phalangeal ligaments as they provide peripheral stabilization more plantarly.

Injury Mechanisms:

• The most common mechanism is forced dorsiflexion, and the second most common is hyperdorsiflexion combined with valgus stress. 
• Artificial turf and flexible cleats increase risk.
• Reverse injuries (such as “sand toe”) due to forced plantar flexion also exist, particularly in beach volleyball.

Grading and Imaging:³ 

• Grade 1: Minor strain, minimal swelling. X-rays are usually negative and the case may require magnetic resonance imaging (MRI). 
• Grade 2: Partial ligament tear, moderate symptoms.  X-rays are usually negative, MRI is warranted.
• Grade 3: Severe symptoms, complete tear, instability, and possible sesamoid displacement or avulsion on X-ray.  MRI and surgical consideration is warranted.

Diagnosis Tools:

• ROM, FHL and FHB strength testing, valgus/varus stress tests and comparison of bilateral weight-bearing radiographs are essential, explained Dr. Canzanese.
• MRI should be high-resolution and include <3mm slices for accurate soft tissue visualization.

Treatment Principles:

Dr. Canzanese shared general treatment pathways for each severity of injury.

• Grade 1: Minimal immobilization followed by taping or turf toe plate, and progressive physical therapy and activity modification.
• Grade 2: Period of non-weight-bearing progressing to partial weight-bearing, then taping/turf toe plate, with delayed physical therapy before returning to sport/activity
• Grade 3 (non-displaced): May still be treated conservatively if stable but with longer duration of immobilization.
• Grade 3 (unstable/displaced): Often requires surgical repair.
• Rehabilitation: Avoid dorsiflexion extremes early. Focus on controlled plantarflexion, and gradually reintroduce weightbearing and athletic movement.

She emphasized that early mismanagement often leads to long-term dysfunction, including traumatic hallux valgus or varus or loss of push off strength. Better imaging, classification, and individualized treatment planning can prevent chronic disability.

Closing Thoughts

This trio of lectures spotlighted how sport-specific knowledge and podiatric expertise must intersect to properly diagnose, manage, and prevent injuries in athletes of all levels. From the explosive lateral motion of pickleball to the rotational torque of golf and the power-loading of elite turf toe cases, podiatrists are uniquely positioned to lead in both prevention and recovery.

References
1.        Mackie B. Pickleball statistics – the numbers behind America’s fastest-growing sport. Pickleheads. Updated February 19, 2025. Accessed August 26, 2025. https://www.pickleheads.com/blog/pickleball-statistics
2.        McGowan M. Pickleball injuries more frequent, more severe than you might think. University of Arkansas Research and Economic Development. Published April 4, 2024. Accessed August 26, 2025. https://arkansasresearch.uark.edu/pickleball-injuries-more-frequent-severe-than-you-might-think/#:~:text=The%20researchers%20used%20data%20from,due%20to%20pickleball%2Drelated%20injuries
3.        Poppe T, Reinhardt D, Tarakemeh A, Vopat BG, Mulcahey MK. Turf toe: presentation, diagnosis, and management. J Bone Joint Surg Rev. 2019;7(8):e7.