foot and ankle injuries of the athlete

8/11/2019 Foot and Ankle Injuries of the Athlete

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&S trigonum

!urf toe

!ibio-talar spurs and impingement

'etatarsalgia

#reibergs infraction

allu* %algus

allu* rigidus

Sesamoiditis

Short leg-syndrome

!he problem (painful) ankle

$ote+ Important surgical inno%ations include ability to anchor tendons to bone ith bony

anchors and the use of strong suture material such as #iberire.

Foot and Ankle

Introduction

!he evolutionof the human foot has alloed us to stand and mo%e upright so freeing our

hands to e*plore and control our en%ironment. !he foot changed from an arboreal

grasping organto an agent for motion the big toe fell into line ith the little toes

(hich shortened)/ a stiffer subtalar joint/ a medial arch and bigger heel occurred.


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In'uriesin the region occur for the folloing reasons+ !he athletes physical and

personality traits/ training techni1ues, playing en%ironment and e1uipment. !he eekly

running distance has been found to be the critical factor for injury among runners (>?= km

per eek).

@ertain athletes are prone to injury and certain body types confer a biomechanical

ad%antage (#ig. 6).

%tress fractures

Bone pain ith a normal *-ray in an athlete suggests a stress fracture. !here are to

types+ fatigue type(abnormally increased load on a normal bone) or the insufficiency

type($ormal loads on deficient bone (such as osteoporosis). !hey typically occur 9 to 6

eeks into an intensi%e training programme. 3*clude steroid use (decreases trabecular

bone). 'uscles are able to adopt faster than bone and after 5 eeks of ne intensi%e

training the fracture occurs. A small cortical crack occurs and spreads by subcortical

infarction. eriosteal and endosteal ne bone (callus) is seen at 5 to 9 eeks. -rays may

sho the dreaded (black line) of impending complete fracture (#ig. ?). Bone scans are

positi%e early and diagnostic. *ommon sitesare described (#ig. ).

!hee is localised bone pain and tenderness relie%ed by rest. !he athlete limps. 3*amine the

sports shoes for e*cessi%e ear.

!reatment should be comprehensi%e (#ig. C).

%pecial considerations +Fig. ,-.

%tress fractureof the neck of the femur need crutches for 9 to = eeks. If pain persists at

2 to 5 months (groin pain ith rotation f the thigh) seriously consider surgical fi*ation of the

fracture.

avicular fracturesare slo to be diagnosed and to heal. Immobilise for ? to C eeks and

surgically fi* (and bone graft) if symptomatic at 2 to 5 months.

Ankle sprains


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/ateral /igament

Dittle onder ankle sprains are common in sport. e stand perched uponthe

sustentaculum tali ith the calcaneus boed back under the ankle joint and all balanced (in

tension) by the lateral ligament comple* (#ig. 2). In%ersion (ith supination andplantarEdorsi fle*ion) causes injury of the lateral ligament comple*/ usually (5E9 of cases)

the anterior talo-fibular ligament (A0F/ the eakest), sometimes the e*tra-articular

calcaneo-fibular ligament, @#D (seldom the !#D the strongest). !hose at risk are large

athletes, those ith pes ca%us (high medial arches) and a history of similar injury. igh-top

shoes and good splints may protect the ankle.

!here is immediate pain and selling ith resultant anterior and in%ersion instability. !he

se%erity of the injured can be graded (#ig. F). @areful e*amination in the post-acute phasecan delineate the ligament components injured (#igs. 2;, 22, 25).

Figure 1 &rading of /ateral

/igament Ankle In'ury

I ATFL sprain (2/3 cases)

II ATFL, CFL sprains (1/4 cases)

III ATFL, CFL, PTFL tears

Or simply use

Incomplete: end-point to anterior draw

Complete: No end-point to anterior draw

In the acute phase treatith GI@3, $SAI4S, ankle splint(S-Ankle), early

rehabilitationEperoneal e%ersion e*ercises, ater jogging, propriocepti%e obble board

e*ercises) (#ig.29).

3lite athletes may elect for early surgical repair of complete ruptures (contro%ersial).


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-rays are necessary to e*clude fractures ith good talar dome %ies to e*clude

osteochondral fractures (ignore bony a%ulsion of the ligaments). 4o not miss a high fibular

fracture ith syndesmotic injuries ('aisonneu%e H) (#ig. 2=). Stress *-rays are unreliable(

and painful) but possibly helpful in the chronic phase here the patient does not gi%e a clear

history of instability (going o%erJ on the ankle).

/ateral ligamentous la2ity

*hronicunsuccessful treatment of the acute lateral ligament injury may result in chronic

lateral ligament la*ity from stretched-outJ ligaments.

!here is chronic lateral pain (o%er anterior border of the lateral malleolus sinus tarsi)

e*acerbated by repeated in%ersion injuries on irregular terrain. !oo often athletes are left to

persist ith months of unsuccessful physiotherapy instead of a 1uick effecti%e lateral

ligament reconstruction. (I fa%our the #r3strom capsulorrhaphy ith reinforcement from

the inferior e*tensor retinaculum/ e*ceopt in hea%y patient here a peroneal tenodesis is

needed. ((#ig. 26).

Medial ligament in'uries

!hese are rare (usually ith (lat.lig) sprain) or fractures) and need to be differentiated from

lesions of the nearby tibialis posterior or #D tendons and syndesmotic injury.

@areful e*amination (for localised tenderness) ith ultrasKsound e*amination is useful (see

tib post section). It is a strong ligament.

-rays (to e*clude H) ith bone scan and @! maybe necessary to e*clude osteochondral

fractures here there is se%ere, localised pain about the talar dome (#ig. 2?). eight-

bearing *-rays may be useful (#ig. 2=a). @hondral damage (sometimes seen after lateral

ligament injuries ith medial impingement) may re1uire arthroscopic attention (#ig 2).

%ubtalar Instability

ifficult to diagnose as it is really a component of a lateral ligament in'ury +the

*F/ torn- from inversion.


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Special stress *-rays (Broden =68 in rotation and 5;8 caudal tilt) or I>I> may help but

are painful.. !reat as abo%e ith @#D reconstruction (as part of Brostrom operation) from

chronic cases.

%pring ligament sprain

!he mid-foot is prone to tisting injuries ith pain localised to the medial arch from sprain

of the calcaneo-na%icular ligament (spring).

*uboid %yndrome

ain and tenderness o%er the cuboid in the region of the peroneal (e*erting) tendons. S-

ankle the foot.

%yndesmotic ankle in'uries +high ankle sprain-

+distal tibiofibular diastasis-

re%iously unrecogniLed but a probable cause of ongoing painful (ankle sprain).

robably from an e*ternal rotation injury in the professional athlete. !here is marked

selling both sides of the ankle ith tenderness o%er the interosseous membrane. Suspect

here an ankle sprain takes a long time to settle don/ perform the s1ueeLe test or

abductionEe*ternal rotation tests (#ig. 2C) and check a mortise-%ie. -ray (>2 mm

reduction in the medial clear space or M2 mm o%erlap) (#ig. 2F). Date *-rays sho

calcification of the ligaments. !reat in $B art for four eeks or later ith diastasis scre

fi*ation and ligament repair here refractory.

%inus 0arsi %yndrome

!he tunnel beneath the talar neck and upper calcaneus can be a source of pain from

o%eracti%ity and in%ersion injury. It may be related to the strained ligament of the tunnel

(talo-calcaneal ligament). 4istinguish from lateral ligament strain. !reat ith $SAI4,

acti%ities (for hyperpronation) and possible steroid injection and seldom surgical e*cision of

contents.

Peroneal tendon in'uries


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!he peroneal tendons ork hard. !hey e%ert the foot (hich ants to drift into e1uinus) and

maintain the trans%erseElongitudinal arches. !hey are poorly anchored ith a eak holding

retinaculum. #orced dorsifle*ion of the ankle in skiing or football can produce tenosyno%itis

tendinitis tear/ partial or complete (peroneus bre%is) or dislocation of these tendons. !hereis marked tenderness ith reproducible sublu*ation. -rays may sho a rim fracture (#ig.

5;). Strapping may help, otherise decompression, repair, tenodesis to (peroneus longus)

or early stabilisation in the groo%e (because of high recurrence rate). "raduated return to

sport o%er =-? eeks a%oiding cuttingJ procedures or sprinting for ? eeks.

3ndoscopic tenosyno%ectomy is useful for refractory tenosyno%ial selling and pain.

0ibialis Posterior 0endon In'ury

IMPOR0A0 0O PI*5 6P A MAA&7 A*0I87/9.

!hese occur in middle-aged omen ho are unfit as a result of chronic degeneration.

!he pathology is inflammation (tenosyno%itis) or rupture (partial or complete). !hey

e*perience pain and tenderness along the tibialis posterior tendon ith difficulty lifting the

heel off the ground in the single heel raise test (#ig. 52). An ultrasound may secure the

diagnosis. !he arch is flattened and foot pronated. !hey re1uire $SAI4s, (a medial arch

support (for tenosyno%itis and partial ruptures), and debridementEtenosyno%ectomy for

refractory cases. Geconstruct complete tears (use the #4D).

0ibialis Anterior In'ury

Spontaneous rupture may occur but is unusual. !here is localised tenderness, eakened

dorsi fle*ion. Surgical repair is important (either direct repair or tendonEe*tensor transfer).

0endo Achilles In'ury+0A-

Injuries of this region are common and difficult to treat. &%ertraining ill produce an

inflammation around the !A peri$tendinitis), in the tendon (tendinitis) or by the tendon

(retrocalcaneal bursitisand retro$achilles bursitis-. !he painful arc signJ may help to

make the distinction (#ig. 55). @ertain athletes are at risk (e*cessi%e training, poor hindfoot

shoe support, on cambered surfaces).


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A %iolent contraction of the gastrocnemius-soleus unit may rupture (partially or completely)

the !A. atients report ha%ing been hit or kicked in the calf during the push-off phase of

running or rac1uet sports. artial tears are difficult to diagnose/ ultrasound imaging is

helpful.

@omplete tears ill in%ariably ha%e pain, selling, and a palpable gap (prior to selling). 4o

not be fooled by the patient being able to plantar fle* (from intact long fle*ors). Simmonds

test is easy to perform and diagnostic (#ig. 59).

0reatmentof !A problems is outlined (#ig. 5=).

%6R&7R9 :;7 0;7 0A I% 0OR.

A tear of the medial head of the gastrocnemius is common in middle-aged tennis players

(tennis leg.

Rehabilitation

@ross-train (sim) during surgical reco%ery ith slo re-introduction to pre-injury sports

o%er 9 months.

Fractures of the foot and Ankle

#ractures of the ankle are common and re1uire precise treatment to a%oid later

osteoarthritis (2 mm displacement causes =;7 decrease in tibiotalar articulation). !hey are

%ariously classified (#ig. 56) and are usually from a fall ith supination (or pronation) of the

forefoot and e%ersion (or in%ersion) of the hindfoot. ell fitted shoes ith ankle support ill

eliminate such injuries. !he immediate pain, selling and deformity is ob%ious, ne%er

hesitate to *-ray.

A displacedfracture almost alays re1uires open reduction and internal fi*ation (#ig. 5?),

a non$displacedM2 mm), careful follo-up (? eeks in cast) ith *-ray re%ie to detect

early displacement.

A markedly displaced ankle fracture should be reduced in casualty to a%oid skin

problems (blistersEner%osas) (#ig. 5). 3*clude a 'aisonneu%e fracture by careful


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'ost other fractures of the '! shafts and phalanges re1uire reduction and seldom surgical

fi*ation.

4islocated M0P or PIP 'ointsneed prompt reduction otherise they become irreducible

and a source of se%ere pain (#ig. 99).

erve entrapments

!hese are not uncommon about the foot and ankle, difficult to diagnose and treat. 'any are

related to poor (eg ski boot) sports shoe fit or hard surfaces. Se%eral ha%e been described

(#ig. 9=).

All entrapments are diagnosed by localised tenderness o%er entrapped ner%e at le%el of

entrapment. ositi%e !inels test, neuralgic pain (at rest or at night) ner%e conduction

studies are usually unhelpful. !reat ith orthotics, $SAI4s, stretching/ massage. Surgically

release (and e*cise neuroma) at le%el of anatomically located tenderness.

*ompartment %yndrome

Increased pressure ithin a confirmed muscle compartment may lead to ischaemia,

necrosis, contracture and a useless limb. Its early recognition and prompt treatment is

essential. @auses are trauma (ith fracture), post-operati%e and crush injuries (#ig. 96).

!he symptoms and signs of an acute compartmentare ell described (#ig. 9?). It usually

in%ol%es the forearm, the loer leg and foot (hen compartment pressures e*ceed =;

mmg). 'easuring intraKcompartmental pressures is fraught ith problems of accuracy

and should noto%erride clinical judgement. !reatment is to e*ternally split &Ebandages

to skin and if necessary, internally release the compressed compartment

+fasciotomy Fig.


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!reatment is acti%ity modification, massage, e*clude footear or surface problem, $SAI4s,

orthotics (medial edge for posterior compartment), cross-training (cycling) and fasciotomy

(sometimes, C;7 successful).

ere it is useful to carefully measure intra-compartment pressures beforeEduringEaftere*ercise/ (resting pressure >26 mmg or delay in fall after e*ercise of >5; mmgEo%er 9

minutes). !hen consider a careful fasciotomy of the compartment in%ol%ed ith mini skin

incisions and ound closure.

Plantar Fasciitis

@ommon and crippling subcalcaneal (usually medial) heel pain. Gelated to hyperpronation

and pes ca%us (#ig. 9F). !here is localised tenderness/ a positi%e indlass effect

(dorsifle*ing the big toe e*acerbates the pain). -rays may sho a heel spur (ignore it).

72clude@stress fractures, ner%e entrapment (medial branch of the lat plantar nerve) and

Geiters Syndrome.

0reat ?ith %AI" stretching and a soft silicone heel cup. %eldom is surgery

+release- helpful.

Os trigonum

!his ossicle behind the posterior talus (medial tubercle of the posterior process of the talus)

may be the cause of pain ith plantar fle*ion in ballet dancers. It can be asymptomatic,

fused, fractured, absent or big. -rays confirm its presence and e*amination its problem.

!reat ith injection (not steroids) or e*cise. 4o not confuse ith #D tendinitis (#ig. =;).

0urf 0oe

!his is caused by a forceful dorsifle*ion of the 2st'! joint in American football on a hard

surface (artificial turf and fle*ible shoes #ig. =2). -rays may sho a disruption of the

plantar %olar plate comple*. 3*clude stress fracture, sesamoiditis, entrapment of #D. !reat

ith GI@3, taping, custom shoes and sometimes surgical repair of the disruption.

0ibiotalar %purs


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&steophytic spurs may form on the adjoining surfaces of the loer anterior tibia and talar

neck. !here is impingement pain ith dorsifle*ion. Arthroscopic e*cision is useful (#ig.).

Metatarsalgia

#orefoot pain beneath the metatarsal heads (ith callosities) is %ague in nature and related

to impact sports. !here may be cla toes andEor pes ca%us.

3*clude a neuroma, stress fracture, #reiberg s infraction. !reat ith stretching, $SAI4s,

trans%erse arch supports (AA4s) and rarely a closing edge osteotomy (here a single

(usually the second) metatarsal is in%ol%ed).

Freibergs infraction

!his is an osteonecrosis of the second metatarsal head typically in teenage females and ith

e*cruciating pain.

-rays may sho increased density, or collapse of the metatarsal head (#ig. =9).

Symptomatic treatment or debridement syno%ectomy or limited resection of the distal 5nd

'! head.

;allu2 8algus

@ommon in the community fro improper shoe siLe seen in dancers and catchers from acute

injuries (dislocation of 2st'! joint) or chronic repetiti%e injury. Ballet dancers and sprinters

are poor, surgical candidates (post-operati%e stiffness is debilitating here) and all other

a%enues must be e*hausted (delay surgery as long as possible) (#ig. ==).

;allu2 Rigidus

A stiff and painful 2

st

'! joint from micro-trauma, osteonecrosis or &A. Seen in push-offsports here long, narro pronated feet (long 2st'!). Ge1uire stiff sole, AA4 or

cheilectomy (e*cision of painful dorsal osteophytes).

%esamoiditis


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Docalised pain usually belo the 2st'! joint hich may be part of a #D

tendinitisEtethering/ seen in dancers. 3*clude fracture, stress fracture, &A, dislocation,

ner%e entrapment and do not confuse ith bipartite sesamoid. -rays (sesamoid %ies).

!reat ith metatarsal support, $SAI4 and rarely sha%e or e*cise.

%hort /eg %yndrome

A short leg (>5 cm) is prone to injury (stress fractures, '@D knee sprain, patellar

sublu*ation, plantar fasciitis and hyperpronation). !he longer leg is prone to iliotibial

tendinitis. It may be real shortening or apparent (from tilt of tract ith tendon contracture

needs stretching). :se partial heel build-up (andEmid-sole build-up).

Approach to the persistently painful ankle (#ig. =6).AA4 or cheilectomy (e*cision of painful

dorsal osteophytes).

%esamoiditis

Docalised pain usually belo the 2st'! joint hich may be part of a #D

tendinitisEtetAA4 or cheilectomy (e*cision of painful dorsal osteophytes).

%esamoiditis

Fig. B4

Rest, NSAIDs, heel raise, ultrasound, massage

(stretching). Rarely surgery with debridement.

As above but consider surgery. Earlier with excision of

associated retro-calcaneal exostosis.

Rarely surgery for retro-achilles bursitis.


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Postero-superior prominence

of calcaneus

Shoe modification, NSAID gel,

Heel raise or excise.

May require surgical excision of scar and

Grandulation tissue.

Almost invariably surgically repair

(Open technique).

Later repair is difficult and may require

Fascial or tendon augmentation.

Fig. B=

e

s

t

L

o

g

i

c

)

A: at/below joint line

B: at joint line

C: above joint line

supination/adduction

supination/ext. rotation


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a

l

S

I

M

P

L

e

pronation/abduction

pronation/external rotation

lateral malleolus

medial malleolus

posterior malleolus

or combination

Fig.


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Behind the fibula neck from trauma.

Ant-lateral entrapment (12 cm from tip lat mal; distinguish from

compartment syndrome).

Injures in thigh (Hunters canal) or med knee (post-surgical).

Typically pain between 3rd/4

thmetatarsal heads from traumatic

entrapment causing neuroma (runners) of interdigital nerve.

Compression of metatarsal heads reproduces symptoms and patient

aware of mobile peeble.

Fig.


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Popliteal artery

entrapment

Calf claudication with reduced

pulses (when knee extended, foot

dorsiflexed).

Fig.


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Fig.4=

Meniscoid

synovitis ankle

Arthroscopic

Synovectomy

Avulsion tip fibula

excise

Asymptomatic ossicle excise

unrecognised fracture

ant. Process calcaneus

excise

Peroneal or tib

Post/tendon problem

(synovitis, partial tendon,

subluxation)

Surgery; consider

endoscopic

tenosynoectomy

Lat process # talus

fix/excise

Sinus tarsi syndrome

surgery


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Subluxation cuboid

High ankle sprain

(+ fracture Tilbux)

see text

Impingement inferior band

Of tibiotalar ligament

arthroscopic

excision

Nerve entrapment see text

Tarsal coalition (children) excise

Osteochondral

Fracture/dissecans

arthroscopy

RA or occult tumour

refer

* NSAIDs local application * Cross-train

* Water jog * S-Ankle splint

*Gentle PT (low frequency pulsed

ultrasound, TENS, WAX)

Fig. B

Peroneal tendon subluxation

Nerve entrapment

Plantar fasciitis


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Lateral ligament sprains

Stress fractures

Shin splints

Os trigonum

FHL impingement

Sesamoiditis

Stress fracture

Hallux valgus

Turf toe

Ankle and mid-foot fractures

Gastrocnemius

Strains

TA injury

Stress fractures

Ankle sprains

Stress fractures

Lateral ligament sprains

Plantar fasciitis

Jones fracture

Severs disease

Fig. =


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Postural defects

Muscle weakness/inbalance

Lack of flexibility

Mal alignment problems

(pronated feet, LLD with pelvic tilt)

Good for sprinters, tennis and squash

Increased lumbar, lordosis with anterior pelvic

tilt good sprinters, jumpers and gymnasts.

Everted feet good for breastroke

Good for backstroke and butterfly

Ligamentous laxity

gymnasts

Peter Snell (NZ) had body build of sprinter

Rather than middle-distance athlete -

(gold medal 800, 1500 m Rome , Tokyo ,

1960, 1964).


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Fig. ,

Tibia (mid and distal)

Calcaneus

Navicular

Metatarsals (esp 2nd

MT)

Sesamoids (1stMTP)

Med. Malleolus

Cuboid

Calcaneus

Fig. C


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Immediate

Rest

Immobilise

RICE, NSAIDs

Cross-training (swim/cycle to keep fit)

Correct mal-alignment or use orthotics

(hyper pronation, ext. tibial torsion)

Better absorptive impact sports shoes

Hormone treatment female athletes

Alter training schedules

Exclude infection/tumour

Surgery

(at 6 months bone graft/drill

dreaded black-line)

Re-introduce activity at 6 to 12 months

foot and ankle injuries of the athlete

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