This case report describes a cross country runner who developed planus clavi (corns) on the plantar surface of his right foot that persisted for 18 months. Due to avoiding pressure on the corns, he developed an abnormal gait pattern that caused patellofemoral pain in his knee. The corns were removed by a podiatrist trimming the thickened skin. A gait retraining program using exercises to improve balance and weight distribution helped return his gait to normal. Proper prevention and early treatment of foot issues in runners can help avoid abnormal gait development and injuries.

1. Planus Clavus on Plantar Surface of Foot in Cross Country Runner: A Case Report of
Abnormal Gait Rehabilitation
Wind LA*, Renkiewicz R*:*Weber State University, Ogden, UT.
Background: This case report views evaluation of dermatological healing and gait training of a
patient with several clavi on the plantar surface of the right foot persisting for a time period of
approximately 18 months, which have caused noticeable issues in gait in a cross country and
track athlete causing patellofemoral pain. An 18 year old, male, cross country and track athlete
(body mass=72.12 kg, height=175.89 cm) reported to ATC for pre-participation physicals where
gait abnormalities were observed by ATC and student ATs. After further observation, the
presence of 3 plantar clavi was noticed on patient’s right foot, which he estimated to have lasted
around 18 months at the point of evaluation. He had attempted self-removal multiple times via
salicylic acid pads and drops, in addition to soaking in Epsom salts, prior to successful excision
occurring after initial examination by ATC. He denied any additional past medical conditions,
illnesses, injuries, medications, or supplementations. Differential Diagnosis: Other possible
conditions include callus, verruca, myrmecia, and verruca plantaris. Treatment: After
conservative self-treatment through changing footwear and additional padding over affected
areas was not effective. The ATCs initial action for this condition was to remove the planus clavi
through paring down or trimming, by a podiatrist, of the thickened skin in order to reduce the
localized pressure on the tissues. Following the removal of these dermatological problems, the
course of action was to provide the maximal healing environment in order to decrease the pain in
the area. This was done by keeping activity to a minimum for the first week following surgery.
Athlete also kept the affected area covered, sterile and moisturized for 2 weeks following
surgery. After these 2 weeks, we began a gait training program with him in order to decrease
pain in the unaffected limb due to abnormal gait. Gait training exercises used include single-
legged balancing of each side beginning with eyes closed on the ground for 3 sets of 30 seconds
and progressing to single-legged balancing of each side on a Bosu ball for 3 sets of 45 seconds.
Hip stabilization using a chair was used with the progression from 2 sets of 20 seconds to 3 sets
of 30 seconds through the course of the rehabilitation program. This exercise is also repeated on
both limbs with the focus of all exercises being to have weight distributed equally on each
separate limb. The final exercise used in this rehabilitation plan was the heel to toe walk in order
to retrain his weight distribution when walking. This exercise was performed by walking 3 laps
of 20 feet with focus on looking forward, not at the feet. In conjunction to these exercises, we
have had him ice after his rehabilitation every day for 15-20 minutes. After completing the
healing and rehabilitation program, his patellofemoral pain has decreased and he has no more
gait abnormalities. Uniqueness: The condition of plantar clavi is not uncommon among runners,
but the persistence of this particular condition, leading to an abnormal gait, is how this
individual’s case may be considered unique. Conclusion: In conclusion, this injury, while
nothing severe, caused a progression of gait abnormality over time due to its severity. This is a
condition that should have been monitored early to prevent this. However, gait retraining came
easy to this patient, and he returned to normal, painless gait in about a week after healing and
rehabilitation. Word Count: 586.

2. Laura Wind
MSAT 6451
11/13/15
Planus Clavus on Plantar Surface of Foot in Cross Country Runner: A Case Report of
Abnormal Gait Rehabilitation
This case reviews the occurrence of planus cavus in a cross country runner, but, in this
particular case, an abnormal gait was observed due to the length of prevalence in the athlete.
During running, pressure on an athlete’s foot is at high levels. Due to this, athletes are more at
risk for fore foot deformities than those who participate in cardiovascular exercises which are not
on tough surfaces such as biking, climbing, and using an elliptical machine. Peak pressures in the
forefoot of athletes are highest during running and walking.1 Information in determining the
location of increased forefoot or plantar stress can be observed in physical examination based on
regions calluses or blisters form, the quality of soft tissue, painful regions present, and additional
deformities.2 These conditions can be categorized into a variety of skin disorders including
inflammatory conditions, traumatic conditions, infections, and environmental injuries.3 The
increase in pressure on the foot during running can lead to conditions known as hyperkeratotic
lesions or calluses and corns which are considered traumatic conditions due to the constant
pressure on the plantar surface of the foot. They are usually a result of mechanical stresses which
cause stimulation of the keratinization process. This process leads to an increased thickness in
the stratum cornuem. The buildup of this can cause pain and tissue damage.4Although, this may
seem like a minor condition, improper care of these types of conditions can cause further
developing issues such as bursitis and ulceration depending on the area or severity.5Fortunately,
several case studies have ruled out cancer as a risk factor from this particular condition.6 With

3. this information, it is important that patients, and especially athletes, that show signs of theses
dermatological conditions take the right precautions early.
The key to dermatological conditions of the foot is proper prevention or management of
lower-limb issues as they occur, which is the biggest problem this runner had. Prevention of
these pathologies begins in the footwear chosen by athletes. Since the foot has to be able to adapt
too many stresses, the footwear is an important aspect of sports, especially those sports with
increased pavement pounding such as in running.7 It is important to acknowledge the pressure
distribution between the plantar region of the foot and the insole of shoes. The repetitive loads on
feet during pounding types of activities is one of the main causes for these conditions because of
the changes made biomechanically to the structures of the feet. Studies have examined this in
detail, but visual inspection of shoe insoles may also be helpful when examining where a
particular athlete’s major area of pressure is.8 Another form of prevention, which is not always
an easy choice for athletes, is choosing an event where less excessive pressure is placed on the
plantar surface of the feet.6 However, long term distance running and training may be a reason to
explore alternate solutions such as managing one’s running mechanics throughout the entirety of
a long distance race. Based on a study by Nagel et al., about the pressures during long distance
runs, the higher peak pressures can be observed under the forefoot area especially noticed during
a post-race cool-down type run.9ue to these types of findings, it is apparent that fatigue plays a
large role in the biomechanical stresses placed on athlete’s feet.
If these skin issues have already developed, there are also ways the athlete should
manage the problem, sooner rather than later. An initial accurate diagnosis can help long-
distance runners, and other athletes, continue with their training and competing with little
limitation from these dermatological problems. This early accurate diagnosis can help get the

4. athlete proper education to avoid these problems in the future.10 As apparent in our case study,
timing of diagnosis and management or treatment can play a large role in an athlete’s condition
and competitive improvement.3
In this case, patient was an 18 year old, Caucasian, male, cross country and track runner
who presented with multiple plantar clavi on the right foot. He presented to us during pre-
participation physicals with these plantar clavi, which, by then, had persisted approximately 18
months and multiplied during the course of their presence. Patient’s chief complaint was intense
pain on the plantar surface of the right foot. He began to notice potential hot spots initially, but
thought nothing of them due to the minority at the beginning. As he continued running during his
cross country and track seasons, the spots began to get more painful. This was when he began
self-treatment with Epsom salt soaking then, after no improvement, progressing to salicylic acid
pads and drops in order to remove pathology. Patient described that spots on foot began to
multiply from 1 to 3 after about a year of initial presentation. After further examination, the
athletic training staff present, determined the pain coming from the plantar clavi or corns on the
plantar surface of his foot. The differential diagnosis for these corns included potential verruca,
myrmecia, calluses, or verruca plantaris. After further research, along with dermatological and
podiatrist consults, it was determined that they were, in fact, plantar clavus spots or corns in 3
places that had spread from 1 spots. However, this was not the reason the sports medicine staff
went into further investigation. In the pre-participation exam, he complained of knee pain which
was thought to be derived from an antalgic gait that had developed from avoiding placing too
much pressure on the corns while continuing to fully train and move day to day normally. The
first goal for this athlete was to remove the initial cause of his issues, the plantar clavi. Then,
after the recovery from this, we would begin to work on returning his antalgic gait back to a

5. normal gait, and, hopefully, rid him of the knee pain that had started to persist through his
summer season of training.
Taking care of the corns was done by a podiatrist through a method called paring down
the area. This method trims down the thickened skin to reduce some localized pressure on the
involved tissues. These means were taking after following more conservative treatments
including Epsom salts which are used to smooth the skin in the area in hopes of decreasing
friction of involved area. The other type of self-treatment used by our patient was the use of
multiple types of Salicylic acid treatments. This type of treatment is usually the first choice
because it is an over the counter option for patients. Salicylic acid therapy is a method which
slowly destroys the infected area from the virus present in order to potentially create an immune
response.11 Following the paring procedure, our patient kept the area covered and rested in order
to let the tissues properly heal before causing more pressure. However, when he returned to
running fully, it was important to educate him on the proper means of managing the area. This
was done by the correct footwear with more support along with some extra padding which we
provided with second skin and donut padding initially. To really ensure the protection of his feet
and knees, a pair of orthodics was suggested.12
After full recovery from his corns being parred down, we wanted to begin with a gait
reeducation program so that relief in his knees could be had. To begin the process, as gait
analysis in walking and running was done to determine the root of the problem. It was
determined that his knee pain was probably attributed to his gait favoring the heel on the affected
side. This has apparently caused trouble up the kinetic chain causing additional stress on his
knee. In order to correct this, proper mechanics were demonstrated and weight-distribution
retrained through a variety of exercises.13 The exercises used were to focus on improving

6. posture, increasing balance, and ensuring proper weight distribution. The exercises used in this
program were single legged balance of each side beginning with eyes closed on the ground for 3
sets of 30 seconds and progressing to single-legged balancing of each side on a Bosu ball for 3
sets of 45 seconds. Hip stabilization using a chair was used with the progression from 2 sets of
20 seconds to 3 sets of 30 seconds through the course of the rehabilitation program. This exercise
is also repeated on both limbs with the focus of all exercises being to have weight distributed
equally on each separate limb. The final exercise used in this rehabilitation plan was the heel to
toe walk in order to retrain his weight distribution when walking. This exercise was performed
by walking 3 laps of 20 feet with focus on looking forward, not at the feet. From this last
exercise, we had him run a mile at the track for us to observe in order for him to transfer these
mechanics back to his running form.14 In conjunction to these exercises, we had him use an ice
bag after his rehabilitation every day for 15-20 minutes. After final evaluation, the athlete had
returned to a normal gait, and had no pain in his feet or knees. Once we did a final gait
evaluation with the athlete pain free, we were able to clear him to return to cross country practice
as normal.
Even though the final treatment and gait rehabilitation program was successful, if we had
taken other means of prevention or correction prior, this would not have been even needed. Some
early means of prevention include new running shoes, experimenting with new insoles, covering
the area for protection from spreading, using taping techniques to alleviate plantar pressures of
the foot, and removal at an earlier time. Some taping techniques studied and used in the past with
success include the low dye taping technique and other arch taping variations. However,
considerations must be taken because, while the low dye taping technique decreases pressure in
the medial forefoot and rearfoot regions, it increases midfoot pressures.15 This case study

7. provides a review of why dermatological conditions in the foot may be cause for more attention
in an athlete’s physical examination. While these conditions seem minor initially, they can easily
lead to further mechanical issues up the kinetic chain because the pain and discomfort they may
cause.

8. References
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