MONICA L. OMEY and LYLE 1. MICHELI

Divi.si{}n {}f Sp{Jr/.s Medicine, Children'.f Hospi/al, Bo,s/on, MA 02//5; and Hi/I,'ard Medical Schnol, B{J.s/{JIJ, MA

ABSTRACTOMEY. M. L.. and LYLE J. MICHELI. Fu<)t and ankle problems in the young athlete Med. Sc;. ,"'J'iJrt.' l:.~r('r£.. Vol 31. No 7(SuppIJ.

pp. S470-S486. 1999. In the US.. greater than half of boys and one quarter of girls in the 8- to 16-yr-old age range are engaged in

~ome type of competitive. :\cholastic. organizedspon during the school year. Children and adole~cent~ are becoming more involved

in sports at earlier age~ and wilh higher levels of intensity. Foot and ankle problem~. in particular. are the ~econd mo~t common

musculoskeletal problem facing primary care physicians in children under 10 yr of age neXI to acute injury. Thi~ report f(lCu~e~ on foot

and ankle problems. trauma. and overuse in the young athletic population. Guidelines are given for both conservative and surgical

managemenl. Specific problem~ addressed include pes planus. tarsal coalition. adolescent bunion. os Irigonum. acces~ory navicular.

physeal fracture~. sprain~. peroneal tendon subluxation. metalarsal fractures. sesamoid fraclures. turf toe. stress fractures. tendonitis.

osteochondritis dissecans. ankle impingement. bursitis. Haglund's deformity. sesamoiditi~. plantar fa~ciiti~. apophysitis. osteochon-

droses, cuboid syndrome, and reflex sympathetic dystrophy. An extensive review of the literature i" performed and presented in

combination with the extensive experience of a well-established sports medicine clinic at the Boston Children's Hospital.

n the U.S., greater than half of boys and one quarter ofgirls in the 8- to 16-yr-old age range are engaged insome type of competitive, scholastic, organized sport

during the school year (118). In a study of Massachusettsemergency rooms over the course of I yr, I of every 14teens seen for an acute injury sustained that injury from asports accident (38). Children and adolescents are becomingmore involved in sports at earlier ages and with higher levelsof intensity. Also, during periods of rapid growth, alter-ations in strength or flexibility may contribute to the risk of

injury (79).Foot and ankle problems are the second most common

musculoskeletal problem facing primary care physicians inchildren under 10 yr of age next to acute injury (117). Acutetrauma and overuse injuries are two common mechanismsof foot and ankle disorders in the sports-active child. Earlydiagnosis and intervention can prevent negative sequelae orpersistent pain (43,80,131). The young athlete can be achallenging patient. An understanding of the developing footand ankle, combined with the knowledge of certain sports-specific mechanisms of injury, can be instrumental in makingthe correct diagnosis and instituting appropriate treatment.

This review is for the physician who deals with injuries toyoung athletes. General guidelines will be given for bothconservative and surgical management of common foot and

.mkle problems.

DEVELOPMENTAL PROBLEMS

Congenital skeletal variations of the lower extremity maybe undetected until a child puts high demands on the ex-

tremities through sports participation (58).

Pes Planus

A patient with little or no longitudinal arch while standingis said to have a flatfoot or pes planus. At birth, mostchildren have a foot that has a minimal longitudinal arch.Staheli et al. (116) confirmed that flatfeet are standard ininfants and common in children up to the age of 6. A flatfootis said to be flexible if the arch can be recreated with the

patient standing up on their toes.Flexible pes planus has been reported to occur in 15% of

the general population (6), with the majority being asymp-tomatic (44). If a flatfoot is painful, other causes must besought out, such as tarsal coalition, vertical talus, or acces-

sory navicular (125).Most flexible flatfeet require no treatment (51-53,125).

although an arch support may be prescribed. In young ath-

letes involved in running or field sports, excessive pronatiollmay be a risk factor for the onset of overall injury to thclower extremity, particularly the knee. Correcting the pr-onated foot with an orthotic may prevent future injury.

Tarsal Coalition

T..lrsal <:o..llitilll1 is ..1 fihrllus. <:..lrtilagil1ous, or hollY <:1111

l1e<:tiol1 of two or morl: hl)f1I:S in the miJfl)()t or hind!!),'

(34,125). It usu..lIly prl:sl:nts Juring adolcs<:l:n<:l:. at ..111 a\

erage ..Igl: Ilf 13 yr I 1111). whl:n the <:o..lIili()f1 is ossifying ..IIi,

01 ').'i-'1 I "'I/'J'J/"I 107-()470/0

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("opyrighl ~) 1'1')') hy Iho: 1\lllo:ri.:all «(lllo:go: III Sp,'rl' \\c",li.:i'Ic'

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l\l"':O:Plo:,II"r puhli.:ali"n ro:hruar) I'}'}'}

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signillcant risk factl)r In thl: dancl:r. onl: possihle explana-

tion for hallux valgus may he I:xcessivl: rearl()ot varus with

increased pronation and incrl:ased ahduction forcl: on the

first metatarsophalangeal joint. causing a hallux valgus (71 ).Initial treatment of thl: adolescent bunion includes wider

shoes. bunion pads. orthotics. and physic.,1 ther.,py

(26.40.85). If pain persists. however. structur.,1 re.llignment

of the first met.'t.lrs.1I v.lrus is usu.llly necessary. We prefer

a distal first metatars.1l osteotomy with medi.,1 capsulorra-

phy, as do others (2.3.~0). Simple bunionectomy is rarely

successful in this age group. Recurrence after metatarsal

osteotomy has been reported to be as high as 20-60o/c

(3,10,40,85.111). Approxim.'tely one third of these patients

will not return to a complete r.mge of shoewe.,r and activity

level may decrease (85).

Figure 1- Talocalcanl!al cllalilic,n \\ilh lalar heaking.

f:

ACCESSORY OSSICLES

Os Trigonum

The posterior aspect of the talus often exhibits a separateossification center. appearing at 8-10 yr of age in girls and11-13 yr of age in boys. Fusion usually occurs I yr after itsappearance (12.86). When fusion does not occur. an ostrigonum is formed (Fig. 4). It has been reported to bepresent in approximately IOo/c of the general population andis often unilateral (12.68.69.81). The origin of this ossiclemay be congenital or acquired. Congenitally. it can be apersistent separation of the secondary center of the lateraltubercle from the remainder of the posterior talus secondaryto repeated microtrauma during development (12.81). Theacquired form may be secondary to an actual fracture thathas not united (12.61.81). With either form. the os trigonumis asymptomatic in most. However. it can become symp-tomatic in those young athletes who actively plantarflextheir ankle. such as the ballet dancer. gymnast. ice skater. or.on occasion. soccer players (12.55.68.81.139). An os trig-onum can cause mechanical impingement of the posteriortalus between the posterior tibia and the calcaneus. Repet-itive impingement of the soft tissues in this interval can also

result in hypertrophic capsulitis (12.69).The young athlete with a painful os trigonum will usually

present with pain in the posterolateral ankle ( 12.32.49.134).

subtalar motion becomes more limited. Most tarsal coali-

tions are.bilateral (34.60) and have been reported to occur in

less than I % of the general population (34). Calcaneona-

vicular and talocalcaneal are the most common coalitions

seen (34.93.101.122.125).

The young athlete with a tarsal coalition will usually

present with pain that is vague and insidious in onset. They

may present with a history of trequent "ankle sprains" or

generalized hindfoot or midfoot pain ( 101). Symptoms often

begin or are exacerbated by athletic training: thus. a rela-

tively high occurrence is encountered in a sports-active

population. Exam will show limited or no subtalar motion

compared with the other foot and occasional tight peroneal

muscles (52). Spastic peroneals have been reported to occur

in less than I % of these patients. however (122).

Plain radiographs should include AP. lateral. and oblique

views of the foot (34.125). Lateral x-ray may show second-

ary signs of a decrease in subtalar motion (i.~.. talar beaking;

Fig. I). The oblique view is usually diagnostic with calca-

neonavicular coalitions. whereas an axial view may reveal a

talocalcaneal bar (34.125). CT scanning. though. is usually

necessary when the diagnosis is in question (Fig. 2).

The goal of conservative treatment of tarsal coalition is to

reduce stress in the foot, relax the peroneal muscles, and

support the foot. This can usually be accomplished with

orthotics and physical therapy, although temporary casting

may be necessary (34,125). If conservative treatment fails,

however, a resection may be necessary in order to restore

mobility and decrease pain. allowing for a complete return

to athletics {34,1 0 I). If indicated. resection should be done

early and not delayed until skeletal maturity. as is some-

times advised.

Adolescent bunion. Hallux valgus has been reported

to affect 22-36% of adolescents (15.24.26.27.40.85.111).

thouoh we tend to find that pe rcentage to be lower in our1: -

practice. With hallux valgus. the first metatarsal deviates

medially and the great toe laterally with a resultant medial

bulging of the first mctatars(lphalangeal joint (Fig. 3). There

can be paill over this pr(lmillence. exacerbated with

shoewear. The cause is unclear. but various factors are cited

such as tight shoes. metatarsus primus varus. pes planus.

forefoot pronation. .joint hyperlaxity. and heredity (40.H5).

Hallux val!!us is seen more c()mm()nly in female subjects.

particularl; th()se involved ill athletics (Ir dance training.

such as ballet. This athletic inv(»vl:ment alone may hI: a fi!:ur" 2-Tal"l',.ll':lnl'al l'..aliti.,n,

5471Medicine & Science In Sports & ExerciseBIOMECHANICS OF THE VNSTABLE ANKLE JOINT

,

(125). The incidence in the general population has beenreported to be 4-14% (18.125). but few actually becomesymptomatic. A histologic study by Grogan et al. in 1989(45) suggested that tensile failure in the cartilaginous syn-chondrosis was the cause of pain.

In the adolescent athletic population, symptoms may arisesecondary to pressure over the bony prominence. a tear inthe actual synchondrosis. or tibialis posterior tendonitis( 18). The athlete will present with pain and a prominenceover the navicular in a pronated foot. There is local tender-ness to palpation and pain with foot inversion against resis-tance (125). It has been hypothesized that the tibialis pos-terior tendon inserts into the accessory navicular, a weakerinsertion point, thereby causing a drop in the medial arch ofthe foot. resulting in a pes planus (72). However, Sullivanand Miller (126) found that there was no difference in thelongitudinal arches of those with an accessory navicular andthose without.

Physical examination is supplemented by radiographicassessment. The AP view or a 450 eversion oblique view is

usually diagnostic (125).We treat our young athletes with orthotics, trial of casting,

physical therapy, and eventual removal if symptoms con-tinue (7,18,45,60,125,126,135). Conservative treatment isusually quite successful; however, we will excise the acces-sory navicular more often in the adolescent athlete becauseof persistence of symptoms with sports.

1-1

Figure 3-Juvenile hallux valgus.

IIposterior to the peroneal tendons. Pain is reproduced withplantarflexion. Associated posteromedial pain (12,49,55)may indicate a concurrent flexor hallucis longus tendonitis.

Plain x-rays should include a lateral of the ankle, as wellas a lateral view in plantarflexion. A bone scan may be usedto determine the reactivity of the os trigonum (12,14), butabsence of uptake does not exclude impingement.

Differential diagnosis includes posterior ankle impinge-ment, Achilles tendonitis, peronea11endonitis, and flexorhallucis longus (FHL) tendonitis (12). Conservative treat-ment begins with rest, anti-inflammatories, avoidance ofplantarflexion, physical therapy, casting, and injection(12,55). The pain, however, usually returns once the youngathlete resumes their sport, particularly the ballet dancer.

We feel a resection is necessary in the competitive youngathlete. We prefer a lateral approach (103), unless there is aconcomitant flexor hallucis longus tendonitis when a medialapproach is necessary. Some authors prefer the medial ap-

proach only (55).

.Accessory Navicular'

The accessory navicular is the most common accessorybone in the foot. It occurs on the medial, plantar border of

the navil:ular at the site of tibialis posterior tendon insertion I-'i\:ure 4-<)s tri\:unum.

http://wwwwwilkins.com/MSSEOfficial Journal of the American College of Sports MedicineS472

Figure 5-Salter II di~tal tibia fracture re-quiring ORIF.

Medial Malleolus Ossification Center

The medial malleolus ossification center (MMOC) ap-pears between I and 2 yr of age and usually fuses by age IIor 12. Persistence into adulthood is uncommon. When itdoes persist, however, the source of pain is thought to berelated to repetitive microtrauma at the chondro-osseusjunction with the main body of the medial malleolus. Thistends to be more evident in our young athletes.

In a study by Stanitski and Micheli in 1993 (119), IIcases of symptomatic MMOC were examined. All patientswere involved in some type of vigorous athletic activities.All complained of isolated medial ankle pain without ahistory of direct trauma. The ossification center was wellvisualized on AP ankle x-ray. There was swelling and pointtenderness over the medial malleolus. Treatment includedeliminating athletics for 3 wk. If the patient was still symp-tomatic, a short leg cast was tried for another 3 wk. Ifsymptoms still persisted, the cast was continued another10 d. In this particular study, every single patient improvedwith this treatment plan. However. if symptoms still persist,arthroscopic removal of the fragment is indicated.

mentous sprain. Childhood fractures also rarely disturb the

talotibial relationship itself (28,88).

Fractures of the distal tibial and fibular physes constitute

4% of all ankle injuries (28). However, the degree of dis-

placement does not always correlate with premature physeal

fusion. Goldberg and Aadalen (42) reported on 53 fractures

of the distal tibial physes; 3 I of 53 occurred while patients

were participating in athletic events. When examining the

skeletally immature athlete, AP, lateral, and mortise view

x-rays are necessary. A comparison view is often needed for

clarification.Physeal fractures can be divided into the Salter Harris

classificatioJl system: (28)

I: fracture through the physis without a metaphyseal frag-

ment;II: fracture through physis and exiting out through the

metaphysis with a fragment;III: fracture through the physis and exiting out through the

epiphysis with a fragment;IV: vertical fracture through the epiphysis and out

through the metaphysis with a fragment; andV: axial compression crush injury to the physis. not

evident on initial plain x-rays.

In general. the higher the class of fracture. the greater the

likelihood of significant disruption of growth.Physe..tl ankle injuries involve different mech..lnisms. Su-

pin..lti(ll1/external rotation, pronatiol1/eversion/external rota-

ti(ll1, al1tl supinatiol1/pl..tl1t..lr flexion all can cause v..lryingstag.:s (If ..ll1kl.: ligal11.:ntous and bony in.jury with S..llter

H..lrris I and II fr..lctures of the distal tibul..t ..Ind tihia (Fig. 5).S..llt.:r I ..and II fr..lctures (If th.: dist..11 fibul..1 ..Ir.: al11(mg the

Medicine & Science in Sports & Exercise 5473

INJURIES

Ankle Injuries: Acute-Fractures

Physeal. In Ihc t:hild or udolcst:CI!I. Ihc dislullihial uno

fihulilr grl\\\'lh plutcs liwm u plunc llf wc.lkncss. rcsullillg in

ill.jury pattl.'rlls m..rkcdly diffcrcllt from those seen ill auult\.

l.igUIII~lIts ill thc skclct.llly immuturc m.lY hc str<mgl:r th.11I

Ihl.' physi\. illt:rc.lsillg thc risk <If physL'.11 injury O\'l:r lig;J-

BIOMECHANICS OF THE UNSTABLE ANKLE JOINT

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ankle stirrup to be helpful in promoting early weightbearing.Physical therapy can also be helpful with particular empha-sis on active motion, peroneal strengthening, and proprio-ception. The management of most sprains of the ankleshould be conservative for at least 6 months before operativeintervention is considered. Chronic problems after anklesprains usually fall into three categories: instability, im-pingement, and articular lesions (98) (Fig. 6). These will allbe discussed later. .

most common fractures seen in the athletic child (60). A

supination/inversion mechanism usually causes a SalterHarris ill or IV fracture of the distal tibia and has a greaterchance for growth arrest. It is necessary to reduce displacedfractures and follow the athlete closely and long-term forpossible physeal arrest (28).

Juvenile tillaux fracture. The juvenile tillaux fractureis an isolated fracture of the lateral portion of the distal tibialphysis that occurs with external rotation (28). As the medialaspect of the distal tibial physis closes at the end of adoles-cence, external rotation athletic injuries may result in afracture of the anterolateral quadrant of the tibial physis,resulting in a Salter ill injury (60). This fracture can be seenon plain x-rays of the ankle and usually needs internalfixation with greater than 2 mm of displacement (28,60),because it involves the articular surface.

Triplane ankle fracture. As the distal tibial physisbegins closing, the anteromedial portion begins flfSt, fol-lowed by the posteromedial physis. This whole processtakes about 18 months. A fracture occurring during this timeperiod usually takes the form of a triplane fracture. Threefragments are included: the anterolateral. distal tibia physis(SH 111), the remainder of the anterolateral physis and aposterolateral spike of the distal tibia metaphysis (SH Ill),and the remainder of the distal tibia metaphysis. Thesefractures can be seen in the young athlete and usuallyrequire internal fIXation (28). .

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Peroneal Tendon Subluxation

Subluxation of the peroneal tendons is an uncommon butpotentially disabling condition that can affect young athletes(92). It is a frequently overlooked cause of persistent lateralankle pain after trauma (22). Among the cases of acutedislocation reported in the literature, more than 90% werethe result of athletic injuries from snow skiing, ice skating,running, basketball, soccer, or football (21).

The peroneal tendons lie behind the lateral malleolus in afibro-osseous tunnel formed by a groove in the fibula andthe superficial peroneal retinaculum. The peroneal retinac-ulum and the posterior calcaneofibular ligament form theposterior wall of this tunnel. The peroneal muscles serve asboth plantarflexors and evertors of the foot (11,22).

In some young athletes, there may be an anatomic pre-disposition to peroneal tendon subluxation, which wouldinclude an absent or shallow fibula groove (22,36,88,96),possibly combined with pes planus, hindfoot valgus, orlax/absent peroneal retinaculum (11,22,36,107,123). Theretinaculum can also traumatically rupture from a violentforced dorsiflexion of the ankle with reflex contraction ofthe peroneal muscles and dislocation (1,11,22,33,68,88,123).

Peroneal tendon subluxation can be an acute episode thatturns into a chronic problem due to misdiagnosis. Many ofthese are incorrectly diagnosed at the acute stage as simpleankle sprains (113). The young athlete may present acutelyafter a supposed ankle sprain with pain and swelling overthe posterolateral aspect of the ankle. More commonly,though, the initial presentation may be weeks to monthsafter the injury (68). The adolescent may complain of re-current inversion ankle sprains and lateral ankle instabilitywith a painful snapping across the ankle (115). Chronicankle instability can also contribute to chronic peronealtendon subluxation with the development of an incompetentsuperficial peroneal retinaculum (22,115).

On physical exam, subluxation may be provoked withforceful ankle dorsiflexion and eversion. There may be painposterior to the lateral malleolus in an acute situation, aswell as a negative anterior drawer test. This can also beconfused with the rare isolated injury to the posterior talo-fibular ligament (11,22,96,123).

Plain ankle x-rays are useful to rule out other fractures butmay show a bony, shell- like avulsion fracture off theposterolateral border of the lateral malleolus, a so-called"rim fracture," indicating an avulsion of the superior pero-neal retinaculum (96,107) that occurs with dislocation of the

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Sprains ' '.,'

Ankle sprains have been reported to make up 10-28% ofall athletic injuries (4,66). In dealing with the adolescentathlete, be reminded that serious ankle sprains are unusual inthe skeletally immature because the ligaments are usuallystronger than the bone (28,60,88). Think of a physeal frac-ture until proven otherwise.

The most common mechanism of an ankle sprain is oneof inversion and plantar flexion, injuring both the anteriortalofibular and calcaneofibular ligaments. The young athletewill commonly have tenderness over the anterolateral ankle,as opposed to the ~ista1 fibular physis, which can be repro-duced with an inversion stress. With eversion and externalrotation, the deltoid and/or syndesmosis ligaments can beinjured. Tucker recommends treating these medial and cen-tral injuries more aggressively with a nonweightbearing castfor 10-14 d (132).

Ankle sprains can be graded. Grade I sprains are painful,but do not have swelling or instability. The adolescentathlete can usually return to sports in 1-2 wk. Grade IIsprains have marked swelling, pain, and slight laxity. Theseathletes usually require 8-12 wk to return to their sport.Grade III sprains have gross instability, marked swelling,and significant pain. These athletes are at greater risk forchronic instability or osteochondral lesions (28,137), requir-ing future surgery.

Treatment of an ankle sprain usually begins with rest, ice,compression, and elevation (RICE). The athlete usually canadvance their weightbearing as tolerated. We find an Aircast

5474 Official Journal of the American College of Sports Medicine

Figure 6-Ankle stress views demonstratingchronic instability.

peroneal tendons. This may be seen in up to 50% of acuteperoneal tendon dislocations (22,31). .

If the diagnosis is made acutely, casting in mild p1antar-flexion and inversion for 6 wk (22,33,97) may be sufficientfor healing. However, it has been our experience and hasbeen documented in the literature, that high-demand youngathletes usually come to surgery because of persistent symp-toms with sports (22,33,68,81,87,92,113,123). However, afelt pad may be taped over the tendons temporarily if theathlete wishes to complete their season (68).

Many different surgical procedures have been describedfor chronic peroneal tendon subluxation (22,33,59,65,70,83,92,113,114,120,123,140); however, we prefer advancinga shelf of bone distally off the fibula (92). This can becombined with reconstructing the peroneal retinaculum. Thepatient must be skeletally mature to do the bony part of theprocedure, so that injury to the growth plate will not occur.In the skeletally immature athletes who have disablingsymptoms, we will commonly do a Chrisman-Snook anklereconstruction procedure instead, which works quite well.

t. ..~:.~:':::'~ "':",of the children greater than 10 yr of age. Knowledge of theanatomy here is important The fifth metatarsal has itsepiphysis distally and its apophysis located proximally. Aninversion stress can cause the peroneus brevis to avulse thebase of the metatarsal, resulting in a transverse fracture. Thisis usually treated with a short leg walking cast for 3-6 wk.The normal apophysis is diagonal in nature, aiding in its

distinction from a fracture.A Jones fracture occurs at the junction of the metaphysis and

diaphysis. This is less common in the skeletally immatureathlete, though. The average age of occurrence is 15-21 yr, andthe subjects are usually involved in athletics. The usual mech-anism is a vertical ground force on a weightbearing foot Thisfracture is notorious for nonunion due to the vicarious bloodsupply of this area; hence, it should be treated in a nonweight-bearing cast for 6 wk (47,60,102) ORIF with bone graft may benecessary in the competitive young athlete (60) (Fig. 7). Theyoung athlete with a simple metatarsal fracture can usually waitto return to sports until the fracture has healed. because the

healing time is relatively quick.Sesamoid fracture. Acute sesamoid fractures are rare

in the young athlete. Sports at risk include those requiringrapid acceleration and deceleration, jumping, and running.

The usual clinical presentation is a several-week historyof pain about the MP joint of the great toe. Swelling isusually present An acute event of MP hyperextension is

sometimes remembered (104).X-rays include AP, lateral, oblique and sesamoid views of

the foot. Bone scan or CT scan may be necessary when the

diagnosis is in question.The usual treatment is a short leg cast for 4-6 wk.

However, because this is a fracture under distraction, de-

S475Medicine & Science in Sports & Exercise

Foot Injuries: Acute-Fractures

Metatarsal fractures. Metatarsal fractures are com-mon in children participating in sports (60). These usuallyoccur indirectly as a result of torsional forces and avulsionsor from direct trauma (102).

The incidence of first metatarsal fractures is highest withchildren under 5 yr of age. This has been called the "bunkbed fracture" because of its common mechanism (47). Thefifth metatarsal, however, is the most common metatarsalfracture in children, occurring 45% of the time and in 90%

BIOMECHANICS OF THE UNSTABLE ANKLE JOINT

are being seen with increa.~ing frequency by the pcp. as wellas the sports medicine specialist. The physician treating theseinjuries must be acquainted with the biomechanics of theparticular sport as well as the tendency these young athleteshave to continue activities that are painful (128). An analysis ofthe six S's will allow one to pinpoint the overuse source: shoes.

surfaces. speed. structure. strength. and stretching (I 18).In the adolescent athlete. bones may grow quicker than

muscle-tendon units. resulting in poor flexibility and overuseinjuries (90). Stress fractures. tendonitis. muscle strains. andapophysitis all have a common denominator: the structureinvolved is stressed beyond the limits of its ability to repair.

Ankle Injuries: Overuse

Stress fractures. Stress fractures represent the ulti-mate overuse injury (57). They have also been referred to inthe literature as "fatigue fractures" and "insufficiency frac-tures" (94). Stress fractures in young athletes present as a

Conservative treatment can proceed if displacement ofthe metatarsals on x-ray is less than 2 mm. This wouldinclude an orthotic or a fracture boot if the patient is unableto bear weight comfortably. Physical therapy is institutedwhen the foot is comfortable. A stiff shoe is recommendedfor return to athletics (20).

Sinus tarsi syndrome. Sinus tarsi syndrome is a sprainof the subtalar joint. This usually occurs after an ankleinjury and is sometimes difficult to distinguish from a rou-tine ankle sprain. The adolescent athlete will usually presentwith swelling in the dorsaVanteriorllateral portion of thefoot, just anterior to the lateral malleolus. There will be painwith palpation and pronation (88), usually due to scarring inthe soft tissue elements of the sinus tarsi (20). Treatmentmay include an orthotic to limit pronation (88). Selectivecortisone injection into the subtalar joint can also be diag-nostic and therapeutic (20).

OVERUSE INJURIES

Repetitive, unrepaired microtrauma in the young athleteresults in manifestations of "overuse injury:' Overuse injuries

BIOMECHANICS OF THE UNSTABLE ANKLE JOINT 5477

Figure 9-Normal oblique foot view.

Medicine & Science in Sports & Exercise

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fI

mechanical pain, increasing with activity and decreasingwith rest. This is the hallmark of a stress fracture (118).

Specific risk factors in young athletes include femalegender (13,39,63), white race (13,39), sudden increase intraining level (63), menstrual irregularity (5), and certainanatomic factors (41), such as tibia vara and decreased hipinternal and external rotation.

Distal fibular stress fracture. Stress fractures of thedistal fibula are rare because it is a nonweightbearing bonebut do occur in young athletes, particularly ballet dancers.The patient will complain of lateral leg or ankle pain, andexam will often show tenderness over the distal fibula(75,94). Differential diagnosis includes exertional compart-ment syndrome and peroneal tendonitis (57). X-rays mayshow medial bowing of the fibula, a break in the normaltrabecular pattern, or even periosteal reaction w-ith healing(75). A bone scan may aid in the diagnosis as well (75,94).(Fig. 10) Treatment is conservative with a decrease in theoffending activity, and fracture boot or ankle stirrup, if thereis pain with walking. Fibular stress fractures usually healwithin 6 wk (94).

Tendonitis

Overuse tendonitis in the tendons spanning the ankle canbe seen with training errors, muscle-tendon imbalance, an-atomic malalignment, improper footwear, or a. suddengrowth spurt (88). Tendonitis can also be seen in 'the ado-lescent that resumes play after a period of decreased training

(107).Flexor hallucis longus tendonitis. FHL tendonitis

will usually present itself in the young athlete as pain withresisted great toe flexion, as well as pain posterior andinferior to the medial malleolus. We have also seen painalong the tendon's course distal to the medial malleolus,Ballet dancers who assume the repeated plantar flexion

posture of demipointe or pointe are panicularly susceptibleto FHL tendonitis. It can also be seen in runners, gymnasts.and field sport players.

Treatment involves correcting improper techniques. icing,stretching, and strengthening (128). We have good successwith tenosynovectomy after failed conservative treatment.

Peroneal tendon tendonitis. The young athlete withperoneal tendonitis will usually present with pain behindand distal to the lateral malleolus (107). There may beassociated swelling in the acute phase. There will also bepain with resisted foot eversion. Peroneal tendonitis is par-ticularly common in young dancers and ice skaters but canbe seen in any running athlete.

Treatment for peroneal tendonitis includes a program of

stretching, strengthening, icing, and sometimes, ankle brac-ing (107) during contact sports. We do not recommendcorticosteroid injection as pan of our treatment plan, how-ever (107). Tenosynovectomy is sometimes necessary inrecalcitrant cases (107).

Achilles tendonitis. Achilles tendonitis is most fre-quently encountered in young athletes who have had asudden increase in training quantity or intensity(23,54,79,112). Additional contributory risk factors may bea rapid growth spurt with a tighter gastrocnemius-soleus

complex, hyperpronation of the foot, or inadequate foot-wear. The patient will present with pain along the Achillestendon, sometimes with associated swelling.

Sporting activities that tend to put undo stress across theAchilles tendon are those that involve running, jumping, orstanding up while cycling. Young gymnasts and dancers are atrisk with sudden deceleration from jumps or vaults. Dancerswho use pointe technique are also prone to Achilles stress

(128).Treatment for Achilles tendonitis includes Achilles

stretching, strengthening, orthotics, and the addition of a

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M.B.Figure to-Positive bone scan of fibula stress fracture.

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Osteochondritis Dissecans

Osteochondritis dissecans (OCD) of the talus may resultfrom an inversion stress to the ankle. This is actually a "tran-schondral fracture" secondary to trauma (88). More com-monly, onset of pain is insidious, and some prior macrotraumais evident. Young athletes may present with pain over theanterolateral or posteromedial talus. They often report recur-rent ankle effusions or weakness. Plain x-rays of the ankle willusually show the lesion (Fig. II), but sometimes bone scan orMRI is necessary for diagnosis (124). The Bemdt/Harty (8)classification of talus OCD is as follows:

Type I: small ar.ea of compression of subchondral bone;Type II: partially detached osteochondral fragment;Type III: completely detached osteochondral fragment

but remaining in its crater;Type IV: displaced osteochondral fragment.Berndt and Harty (8) reported that 43% of OCD lesions

involve the middle third of the lateral talus, with 57%involving the posterior third of the medial talus (88). A!itudy by Canale and Belding (16) concluded that acutetrauma caused all of the lateral lesions and half of the medialIc!iion!i. The re!it of the medial lesions were thought to bc

I

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S479Medicine & Science in Sports & ExerciseBIOMECHANICS OF THE UNSTABLE ANKLE JOINT

Yet another form of impingement seen in the youngathlete is a hypertrophied anterior talofibular ligament. Thisis not usually due to acute trauma, but rather repetitivemicrotrauma in the young active patient. The athlete willhave point- tenderness over the A TF ligament with a dra-matic increase in their pain with ankle dorsiflexion. Allstudies will be negative for an OCD lesion. We treat thisproblem with debridement of the A TF ligament through an

arthroscopy.

Posterior Ankle Impingement

Posterior ankle impingement or talar compression syn-drome (12) is seen most often in young female dancers, iceskaters, or gymnasts. These sports require excessive plan-tarflexion of the ankle, compressing the posterior structuresof the ankle (12,49).

On physical exam, the athlete will have pain on palpationof the posterior ankle, dramatically increased with forcedplantarflexion. Plain x-rays of the ankle can be taken to ruleout a bony etiology (i.e., os trigonum) (12). Soft tissueetiology includes FHL irritation, thickel)ed or invaginatedposterior capsule, synovitis, and calcific debris (49,58,62).

FHL tendonitis. Our young athletes with FHL tendon-itis will usually present with pain along the posteromedialankle. With chronic inflammation and hypertrophy, the ten-don gets compressed in plantarflexion over the. posteriortalar tubercle (49). With dorsiflexion, however, the FHL isstretched between the posterior talar tubercle and the sus-tentaculum tali. We see this condition most often in theyoung dancers. The tendon can actually lock in dernipointeand become unable to release in plie (71). FHL tendonitis,with pain posterior to the medial malleolus, is most oftenconfused with posterior tibialis tendonitis (49).

Koleitis et al. (73) reported incidences of stenosing FHLtenosynovitis in a study involving ballet dancers. They allhad crepitus and triggering exacerbated by the en pointeposition. Nonoperative treatment included decreased activ-ity, physical therapy, and NSAID. Operative interventionincluded releasing the tendon sheath. All of their dancerswent back to their previous levels of dancing.

Figure II-Medial talus OCD lesion.

Anterior ankle bursitis. Anterior ankle bursitis iscommonly seen in the young figure skater and ice hockeyplayer in our practice and is affectionately known as a "skatebite." This condition can present with swelling over theanterior ankle or over the malleoli. A doughnut pad insidethe skate over the irritable area will usually decrease thepressure at this point. Sometimes, however, we will aspirateor surgically remove the bursa.

Haglund's Deformity

Haglund's deformity is an abnormal prominence of theposterosuperior surface of the calcaneus, also known as a"pump bump" (29,56,121,127). This can be commonly seenin adolescent females because of shoewear (77) but is alsoseen in young male and female ice skaters, soccer players,and runners.

On physical exam, the bump is usually located more tothe lateral side of the heel. The young athlete will sometimeshave an associated retrocalcaneal bursitis or Achilles ten-donitis, as well, with the appropriate tenderness. There will

11

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Bursitis

Retrocalcaneal bursitis. Retrocalcaneal bursitis is adistinct entity denoted by pain that is anterior to the Achillestendon, just superior to its insertion on the os calc is (64).The bursa becomes inflamed, hypertrophied, and adherentto the underlying tendon (35). The young athlete with thiscondition will have pain with a two-finger squeeze justsuperior and anterior to the Achilles insertion. Retrocalca-neal bursitis should be distinguished from Achilles tendon-itis or bursitis, where pain would be posterior to the tendonand beneath the skin occurring from shoewear ( 110).

We see retrocalcaneal bursitis most often in our youngfigure skaters. We treat them with physical therapy andrarely bursectomy with associated resection of the posteriorsuperior margin of the os calcis.

5480 Official Journal of the American College of Sports Medicine

TABLE 1. Differential diagnosis of lateral ankle pain.usually be an accompanying thickening of the overlyingskin. Sometimes a varus hindfoot is found.

Treatment of Haglund's deformity involves relieving thefriction imposed by the shoe counter by increasing shoe sizeby one half, padding the prominence, or using a heel lift toactually raise the heel out of the shoe (121,127). We pre-scribe physical therapy as well for Achilles stretching and

strengthening. Quite often, with persistent symptoms in theyoung athlete, we will surgically excise the deformity(29,67,121) (see Tables I and 2, and Algorithm on posteriorankle pain).

1-Resumesports

fa

resection

ANKLE PAINf

Focused physical exam

"" Jra ys- ~

Os olgonum Haglund's defonnitY.,.. / --:;- / -,.. ~Rest -~ Confinn Heel padAvoid excessive plantarflexion pain locaioo Heel liftPhysical ~y I 1 "'" Physical therapy) !.._~ . ,.. onbn~ ~\ Postenor Posteromedial Posterolatloral

Surgical Resume /" sp.;-/

Inc=scd pain Pain with,.. ,/With plan~exion =isted big toe fiexion\r subluxation and/or ~

Posterior impingement Paiiterior or J. tendonitis Pain with Peroneal=isted inve"ion teIKlonitis

~ialiS posten(orteIKlonitis

-k

Phys,caI ~py.,QIthotics

Physicallherapy - \ Oxrect techniques Avoid plantarflexion Pbysieallherapy

Injection! AcrulJesbuBitis IendonitiJ

Continued pain I J

,aL -\ Pbytcallherapy PTOrthotics

S rgical Resume Hcelliftdebride~nt sportS .

Tenosynovectomy

Algorithm Cor the young athlete presenting with posterior ankle pain.

may be induration, swelling, and palpable mass (47,94). Abone scan can be very helpful in early diagnosis when plainx-rays are negative. If the fracture is only painful withsports, then the treatment should include refraining from thesport until the symptoms resolve. If it is painful with weight-bearing, then a short leg cast or hard-soled shoe for 2,-4 wkis used (47,94). Most young athletes will return to their sportby 4-6 wk.

Proximal second metatarsal. The proximal secondmetatarsal stress fracture differs from other metatarsal stressfractures in so far as it can be difficult to heal, and may resultin chronic nonunion. The anatomy in this area is such that thebase of the shaft is countersunk into the bony arch of the footand is therefore rigid (Lis Franc's joint). This tends to place anabnormal amount of stress across this area, particularly inyoung ballet dancers (50). Stress fractures are a frequent injury

Medicine & Science in Sports & Exercise S481

FOOT INJURIES: OVERUSE

Most pediatric foot problems in sports are related toabnormal biomechanics of the foot and lower extremity(88,108). -

Stress Fractures

Calcaneus. Calcaneal stress fracture can be a frequentand often misdiagnosed cause of heel pain (76). We do notsee this condition in the young athlete very often, but itshould be included in the list of differential diagnoses ofheel pain. Because most heel pain resolves with conserva-tive treatment, we may not know the actual incidence of thisentity. For persistent heel pain in the adolescent athlete,consider a bone scan to rule out calcaneus stress fracture.

Navicular. Navicular stress fractures are uncommon butwhen present deserve specific attention. The young athletewith a navicular stress fracture will present with the insid-ious onset of vague pain on the dorsum of the foot and/ormedial aspect of the longitudinal arch. Tenderness to pal-pation of the midfoot may be the only physical sign (94).This condition is most commonly seen in basketball playersand runners (68). Hurdlers seem particularly prone to thisstress fracture, as well.

Increased stress across the navicular may be secondary toa short first metatarsal, metatarsus adductus, or limiteddorsiflexion or subtalar motion. Microangiographic studieshave shown the central portion of the navicular to actuallybe avascular (130).

To confirm the diagnosis, bone scan or CT scan may benecessary, as plain films are rarely diagnostic. In a study of21 navicular stress fractures, Torg et al. (130) found that in12 cases (57%), the standard x-ray did not show the fracture.

Treatment begins with nonweightbearing for 6-8 wk(88,130) If the fracture fails to heal or is displaced, thenfixation with compression screw must be considered. Ad-ditional bone grafting may sometimes be needed (88,130).Return to sport may take as long as 16-20 wk (94) Theyoung athletes' symptoms guide their return to activity.

Metatarsal. Metatarsal stress fractures are seen withincreasing frequency in children and adolescents. They usu-ally occur with an increase in activity level or change insport. The second and third metatarsals are the most fre-

quently injured (94).The young athlete will present with point tenderness

directly over the appropriate metatarsal. Occasionally. there

BIOMECHANICS OF THE UNSTABLE ANKLE JOINT

.

ture as differential (100). (Fig. 12) An MRI may be neces-sary if the diagnosis is unclear (50).

Treatment of the second metatarsal stress fracture usuallyconsists of6-8 wk of rest in a hard shoe or ca.o;t (50,100), withgradual return to dance when the tenderness resolves. Fol-low-up cr scan in 8-12 wk is necessary to ensure healing.

An unusual type of second metatarsal stress fracture thatwe have seen in our young ballet dancers is one that caninvolve Lisfranc's joint, consisting of an oblique fracture atthe base of the metatarsal. A study by Micheli et al. (91)showed that the dancer will present with pain in the middlepart of the foot, particularly en pointe. Plain x-rays areusually negative as well. An oblique x-ray, tomogram, orbone scan can aid in the diagnosis. A short-leg cast is theinitial successful conservative treatment; however, non-union was found in one of his patients, requiring surgicaldebridement.

Sesamoid stress fracture. The young athlete with asesamoid stress fracture will present with the insidious onsetof pain and swelling over the plantar aspect of the firstmetatarsophalangeal joint (9,68). This is usually aggravatedby activity and relieved with rest. Differential diagnosisincludes metatarsalgia, bursitis, sesamoiditis, and bipartitesesamoid (9).

Initial evaluation should include plain x-rays with a ses-amoid view. Keene and Lange (68) showed in his study that5-30% of people have bipartite sesamoids with 75% occur-

ring unilaterally.If the diagnosis is still in question, a bone scan or CT scan

should be obtained. The intensity of uptake could helpdistinguish between bipartite sesamoids and actual fractures.

We begin initial treatment with a short leg cast and a crscan at 8 wk to detect signs of avascular necrosis. If avascularnecrosis is present and the young athlete has persistent symp-toms, resection may be necessary (104). If resection is done, amicrosurgical dissection with plantar approach is used, and theresultant defect in the flexor tendon must be carefully closed to

prevent subluxation of the opposite sesamoid.

Strains

First metatarsophalangeal joint. The first metatar-sophalangeal joint is most often strained with young balletdancers who engage in pointe work. On exam, normal firstMTP joint range of motion in dorsiflexion is 60°. Balletdancers need at least 80-100° of dorsiflexion to permit fullreleve onto demipointe (71). Treatment includes avoidingpointe work, physical therapy. and taping.

This injury can also be encountered in field sports (turftoe). A rigid orthotic or stiffened forefoot of the shoe mayhelp resolve symptoms, but this can be a course of per~istentsymptoms, and early hallux rigidus may result.

Sesamoiditis

Sesamoiditis can usually be seen in those young athleteswho push off the ball of their foot, to include jumpingsports, tennis, or ballet. On physical exam, there will oftenbe swelling and pain on palpation under the first metatarsal

in ballet companies and the most common location is at thebase of the second metatarsal (48,50,91,99). With ballet, mostof the body weight is placed on the fIrSt two metatarsals withdemipointe and pointe work. One study (48) showed that 6 of8 ballet dancers with a second metatarsal stress fracture eitherhad a short fIrSt metatarsal or a long second metatarsal (Mor-ton's foot). Other predisposing factors can include amenorrhea,anorexia nervosa. cavus foot, and anterior ankle impingementwith resulting hyperpronation (50). The young dancer willreport an insidious onset of pain worse in releve, en pointe. andwith jumps, a.., well. On physical exam, there will be pain in thefirst web space usually accompanied by proximal second meta-

tarsal pain (100).Initial foot x-rays will most often be negative; hence. a

bone scan is usually necessary. The bone scan may benonspecific. with synovitis, stress reaction, and stress frac-

5482 Official Journal of the American College of Sports Medicine httP://Www.wwilkins.com/MSSE

Figure 12-Positive bone scan of proximal second metatarsal stressfracture in a ballet dancer.

head (60), mostly localized to the tibial sesamoid. They mayhave a pronated or cavus foot. Occasionally, a hypermobileplantarflexed first metatarsal is found, as well (88). We treatsesamoiditis with ice massage, orthotics with or without acut-out for the sesamoids, foam pad, rest, or NSAID. Steroidinjections should be avoided.

the heel cord and heel cups or heel wedges and avoidingbarefoot walking until becoming asymptomatic (88).

Iselin's disease. Iselin's disease is a traction apophy-sitis of the tuberosity of the fifth metatarsal. It is morecommonly seen in athletically active older children andadolescents. The secondary center of ossification appears asa small, shell-shaped fleck of bone oriented slightly obliqueto the metatarsal shaft and is located on the lateral plantaraspect of the tuberosity of the fifth metatarsal. This apoph-ysis is located within the insenion site of the peroneus brevistendon. The center appears in girls at an average of 9 yr andin boys at 12 yr and usually fuses to the shaft by II and 14

yr, respectively. This apophysis is best viewed on theoblique x-ray of the foot.

The patient will usual\y be a young athlete involved insports with running, cutting, and jumping, resulting in aninversion stress to this area. They will have pain over thearea and usual\y no specific history of trauma. Resistedeversion should reproduce the pain. A bone scan will usuallybe positive. Iselin's disease can be differentiated from an avul-sion fracture of the base of the fifth metatarsal because theapophysis is located parallel to the long axis of the shaft and anavulsion fracture is usually transverse in nature.

Treatment for Iselin's disease includes immobilization foracute pain and physical therapy for strengthening of theperoneal tendons. Bony union will then occur (17).

Plantar Fasciitis

Plantar fasciitis in the young athlete usually coincideswith calcaneal apophysitis and rarely exists by itself. In theadolescent athlete with closed physes, the presentation willbe one of medial arch or heel pain (109,128). Pain typicallyoccurs during weightbearing and may be exacerbated byclimbing stairs or going up on the toes. Morning pain andstiffness are common as well. This inflammation is usuallysecondary to repetitive stretching of the plantar fascia be-tween its origin at the anterior plantar rim of the calcaneusand its insertion into the metatarsal heads. There will betenderness to palpation along the medial edge of the fasciaor at its origin on the anterior edge of the calcaneus. Youngathletes involved with jumping, hill running, or speed workare at a higher risk for getting plantar fasciitis (109,128).Certain anatomic factors including pes cavus or a rigid varushindfoot may also put the athlete at risk (109).

X-rays usually do not contribute to the diagnosis, and thoughheel spurs may be a result of this condition, they are not thesource of the pain (128). Treatment of plantar fasci:itis in theyoung athlete includes rest (with alternative conditioning pro-grams (136», ice, Achilles stretching, heel cups, NSAID, cor-recting training ecrors, orthotics, and occasional steroid injec-tion (109). Plantar fascia release (37) is reserved for extremelyrecalcitrant cases.

Osteochondroses

Kohler's disease. Kohler's disease is an idiopathicischemic necrosis of the tarsal navicular. This is usuallycaused by repetitive microtrauma to the maturing epiphysis.It is largely found in male, active children age 4-7 yr. Painwill be aggravated by activity, and x-ray will show a nar-rowed, radiodense navicular with occasional fragmentation.This condition is self-limiting and should not require anytype of surgery. Initial treatment involves decreased activityor a short leg cast for 3-6 wk (80) Orthotics may benecessary .to maintain the longitudinal arch.

Freiberg's infraction. Freiberg's infraction is avascu-lar necrosis of the second metatarsal epiphysis. The epiph-ysis is located at the distal end of the metatar~al. Etiologycan be secondary to the repetitive trauma of athletics or footpronation with a hypermobile first metatarsal, resulting intransfer of pressure to the second metatarsal (88). The av-erage age of presentation is 13 yr and 75% are female.Physical exam of the young athlete will usually show uni-lateral pain over the second metatarsal head. Less com-monly, this can also occur at the third, fourth, or fifthmetatarsal heads as well. An x-ray will show osteosclerosisprogressing to osteolysis (46). This condition is usuallyself-limiting and requires only conservative treatment in theform of an orthosis to correct pronation (53) or a short legcast for more severe acute pain. Physical therapy is used torestore motion to the joint. Surgical debridement or meta-tarsal head resection are used only in refractory cases (46) orin cases where loose bodies have formed.

Apophysitis

Sever's disease (calcaneal apophysitis). The cal-caneal apophysis serves as the attachment for the Achillestendon superiorly and for the plantar fascia and the shortmuscles of the sole of the foot inferiorly (79). This os calcissecondary center of ossification appears at age 9 and usuallyfuses at 16 yr of age.

Sever's disease \s the preadolescent equivalent of Os-good-Schlatter's and is a common cause of heel pain in theathletically active child; 61 % occur bilaterally (90). Theaverage age of onset for this condition is 8-13 yr (118).

Factors involved in the etiology of Sever's disease in-clude beginning a new sport or season, foot pronation, anda tight gastrocnemius-soleus complex (89). There usually isa history of an increase in running activity, beginning a newsport, or the beginning of a new season. The tight Achillestendon is usually associated with a recent growth spurt andis not related to a specific injury.

On physical exam, there can be swelling and indurationover the calcaneal apophysis, and/or tenderness with medialand lateral heel compression. The young athlete may alsohave an associated Achilles tendonitis. X-rays are not rec-ommended unless symptoms continue for a greater length oftime. Treatment of Sever's disease begins with stretching

BIOMECHANICS OF THE UNSTABLE ANKLE JOINT S483Medicine & Science in Sports & Exercise

Osteochondritis dissecans of the first metatar-sal. OCD of the metatarsal head is part of the differentialdiagnosis of fIrSt metatarsophalangeal joint pain. Plain filmsmay show the lesion. but cr or MRI will often be diagnostic.

sary. After reduction in their dancers, the abducted positionof the foot in releve must be corrected to prevent recurrence.

II

:

REFLEX SYMPATHETIC DYSTROPHY

Reflex sympathetic dystrophy (RSD) is "a complex dis-order of pain, sensory abnormalities, abnormal blood flow.sweating, and trophic changes in superficial and deep tis-sues" (78). The disease is underdiagnosed in children be-cause the pattern of presentation can be different fromadults. Adults usually present after a fracture or trauma withimmobilization. With children, it is seen most often inathletic girls (1:6 boys to girls) with an average age of 12 yr(74). Most of the cases are in the lower extremity, to includethe foot and ankle, and usually have a history of minortrauma. The more classic patient will present with severe

regional pain, swelling, dysesthesia to light touch (allo-dynia), and vasomotor instability (30).

RSD, in effect, is a pain cycle that has the potential to spinout of control if not diagnosed and treated promptly. Thephysical exam will be one of pain out of proportion to thedegree of injury. Early physical therapy is important as wellas referral to a pediatric pain clinic for possible sympatheticnerve blocks or neurosuppressive medications.

Cuboid Syndrome

Marshall and Hamilton (82) report that cuboid subluxa-tion is common but poorly recognized. We do not tend to seemany cases in our young athletes, however. The etiology hasbeen proposed to be secondary to overuse or an ankle orlateral foot sprain (82).

The young athlete with cuboid syndrome will usuallypresent with lateral mid foot pain and pain with plantarpressure on the cuboid (82). A subtle forefoot valgus mayalso be present, as well as a tight peroneus lo~gus tendon.This tightness can produce torsion around the cuboid, caus-ing a rotatory subluxation (71,95). Marshall and Hamilton

(82), however, rarely found a cuboid in this position. Theydo believe, though, that the peroneals are tight. Newell andWoodie (95) found 80% of cuboid subluxation in athletesoccurred in pronated feet. Marshall and Hamilton (82),however, did not feel this to be true in dancers. Dancers withthis condition will usually experience pain when going fromflat to demipointe.

The diagnosis of cuboid syndrome in young athletes isprimarily subjective, and x-rays usually are not he,lpful (82).Treatment for this condition includes stretching the peronealtendons and strapping or plantar padding (7 I). Marshall andHamilton (82) largely feel that manual reduction is neces-

Address for correspondence: Monica L. Orney, M.D., Fellow,Division of Sports Medicine, Children's Hospital, 300 LongwoodAvenue, Boston, MA 02115.

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