Foot And Ankle Injuires From Sport

Chapte r 13 Foot and    Ankle  Injuries      

  ‘It is his feet which confer upon man his only real distinction and provide his only valid claim to human status’ •

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Biomechanics ○

Gait

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Biomechanical advantage

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Susceptibility to injury

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Sports specific injury

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Assessing function

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Gait

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Foot

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Sports shoes

Ankle and foot sprains ○

Acute lateral ligament sprains

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Chronic lateral ligament laxity

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Medial ligament sprains

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Subtalar instability

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Syndesmotic ankle injury

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Peroneal tendon injury

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Posterior tibial tendon injury

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Anterior tibial tendon injury

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Achilles fendon injuries

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Gastrocenemius injury

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Spring ligament sprain

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Cuboid syndrome

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Sinus tarsi syndrome

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Fractures

   

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Ankle

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Foot

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Calcaneus

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Talus

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Subtalar dislocations

Mid foot ○

Metatarsal

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Dislocation of the MTP or PIP joint

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Stress fractures

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Nerve entrapment

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Compartment syndrome

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Plantar fasciitis

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Os trigonum

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Turf toe

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Sand toe

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Tibiotalar spurs

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Metatarsalgia

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Freiberg’s infraction

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Hallux valgus

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Hallux rigidus

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Sesamoiditis

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Short leg syndrome

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Persistent painful ankle

Biomechanics The foot has evolved from an arboreal grasping organ to an agent for motion, (probably over last 1.8 million years). The big toe became aligned with the shortened smaller toes, the subtalar joint became stiffer, the medial arch and a higher heel developed. The body is now supported on the sustentaculum tali with the calcaneus bowed under the ankle joint (Fig. 1). It is easily toppled from this ledge where it is balanced in tension by the lateral ligament complex. Little wonder twenty five percent of all sporting injuries involve the ankle and foot. There are 23,000 new ankle sprains in the USA everyday (5,000 per day in the U.K.)

The tibio-talar articulation allows 25° dorsiflexion, 35° plantar flexion and 5° rotation. The instant centre of motion lies on a line along the tips of the malleoli and postero-laterally on the talar dome. Up to 5 times the body weight is transmitted across this joint. Gait has two phases (Fig. 2 ): stance (60% of cycle; foot flat, heel off, toe off) and swing (40% of cycle; toe off/toe clear/heel strike). During walking one foot is always on the ground. In running both feet are off the ground at one point in the stride. The weight is borne from the heel, along the lateral border of the sole then inward across the metatarsal heads from the fifth to the 1st MTP joint. Stability is gained by the talar mortise and ligament support. The subtalar joint functions like a hinge and allows eversion and inversion. The mid-foot permits abduction and adduction. The forefoot provides flexion and extension. Pronation of the foot (5°) involves coupled dorsi flexion, eversion and abduction (sole turned down). Supination (up to 20°) involves coupled plantar flexion, inversion and adduction (sole turned up). The foot transmits 3 times the body weight during running, through 3 arches (medial, lateral, transverse). The second metatarsal is the keystone of the mid-foot in gait; the first metatarsal in the stance phase. Biomechanical advantage in certain sports may result from Pigeon toes (sprinters, tennis, squash; sway-back (increased lumbar lordosis with anterior pelvic tilt) - sprinters, jumpers, gymnasts; duck (everted) feet- breastroke; inverted feet- backstroke, butterfly; double jointedness (ligamentous laxity)- gymnasts. Susceptibility to injury is increased by: postural defects, muscle weakness/imbalance, lack of flexibility, malalignment problems (pronated feet, LLD with pelvic tilt); Training techniques (> 64Km/week of jogging) playing environment and equipment contribute. Pay particular attention t the athlete’s footwear and ankle support. ‘Sexy shoes painful feet the women’s shoe wear problem’1- most of the forefoot problems of women can be traced to undersized, though sexy, fashionable shoes. Make an outline of the patients bare foot standing on a sheet of paper and note that it is often 2 to 3 shoe sizes wider than the sole of their shoe.

1 The title of a very popular Instructional Course lecture at the American Academy of Orthopaedic Surgeons Annual Meeting in Atlanta in 1996. by M. J. Coughlin et al.

Sports specific injury Injuries often associated with particular sports include: skiing- Peroneal tendon subluxation, nerve entrapment, plantar fasciitis; running- lateral ligament sprains, stress fractures, shin splints; ballet- os trigonum/FHL impingement, sesamoiditis, stress fracture, hallux valgus; football- turf toe, ankle and mid-foot fractures; tennis- gastrocnemius strains, TA injury, stress fractures; soccer- ankle sprains, stress fractures; basketball- lateral ligament sprains, plantar fasciitis, Jones' fracture; (diaphyseal fracture base 5th metatarsal) gymnasticsSevers’ disease. (traction apophysitis of the calcaneus)

Assessing function Gait Video analysis of gait on the track or field provides documentation and allows correction of incorrect posture in many sports. Footwear Examine wear patterns on shoes (excessive wear of the outer heel with tibialis posterior problems, blown-out medial shoe with hallux valgus) and /or check the wet footprint. Normal bearing points are centrally under the ball of the foot and postero-laterally at the heel. Note: Orthotics are more effective for planovalgus foot rather than pes cavus. History Collect details of the mechanism of injury (high versus low velocity, spontaneous onset, rolled over on heel), problems shoe wear and athletic performance. Where is the pain localized, and other characteristics, is there stiffness of the ankle/subtalar joint(tarsal coalition) or big toe. Any swelling or instability (of ankle joint). Medical history. Previous injury. Examination Examine the whole patient (exclude other injuries and underlying medical condition e.g. diabetics, cerebral palsy) and the whole limb (alignment, flexion contractive hip, varus/valgus/flexion contracture knee). Review gait (limp present? antalgic/shortlegged/neurological) and whether walk with foot extremely rotated (to avoid pain of roll through). Correlate with examination findings. Test power (heel stand, toe stand, stand on inside/outside foot) Assess medial arch (pes cavus or flat foot). Patient sits on bench, you sit at patient’s foot with small stool between. Note extent and area of swelling. Carefully palpate: ankle joint (note point tenderness) from tip medial malleolus to tip lateral malleolus and behind ankle to TA insertion, mid-foot and forefoot. Document ROM ankle joint, subtalar joint, mid-foot (abduction/adduction) and forefoot (extension / flexion 1st MTP joint) Palpate tibialis anterior (in front medial malleolus) and tibialis post (behind med. malleolus). Assess power of tibialis posterior with single heel rise test: patient stand on small stool, faces wall, lift other foot and note heel raise of foot in question: hesitation /inability = positive test) Fig. 3. Perform Windlass test (dorsi flex big toe, medial arch should rise) (Fig 4). Perform stability tests ankle (anterior draw test, ADT- hold lower tibia, foot plantar flexed, cradle heel in other hand and draw forward; no end-point is positive for ATFL rupture Fig. 5; inversion test - move heel into inversion, 10° greater than other side is positive for CFL rupture) Fig. 6. Palpate pulses, check sensation and perform Tinel's test over posterior tibial nerve. Perform Simmond’s test (patient prone, squeeze calf, no plantar flexion means TA is ruptured).(Fig-). Measure calf and mid-foot diameters. Sports shoes The ideal sports shoe should be comfortable, protect the foot and ankle from injury and possibly enhance performance.

Shoes have caused problems since antiquity and more recently many of the forefoot problems have been related to poor shoe fit. (Sexy shoes / Painful feet). There has been no convincing reduction in the incidence of injury from the use of athletic footwear. Perhaps we should return to barefoot (Zola Budd and Abebe Bikila preferred it and so do most school children) to restore plantar proprioception and reduce stress-related injuries. However sports shoes are here to stay (market-driven forces have seen to that) and its our job to make them work. Current design concerns are: •

Shoe fit - female athletes are stuffing their feet into undersized ‘male designed’ sports shoes (female foot has larger forefoot / heel ratio so they need to use smaller heeled male shoe to get hindfoot fit and so cram their forefoot). Manufacturers are responding with ‘female-designed’ shoes to fix this problem.

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Cushioning - transmitted impact forces may damage red blood cells (haemolysis), cause stress fractures (metatarsals) and alter hyaline articular cartilage. It seems that impact relieving soles will protect the foot and ankle.

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Control - hyperpronation of the forefoot is a factor in injury, but this can be prevented with shoe wear (posterior medial arch support) however the injury location shifts proximally to the knee (or distally to mid-foot). It is related to the hindfoot position with take off supination. Better hindfoot control is gained by high-top lace-up boots, or lateral heel flare. Side-stepping (or cutting) in sports where there is a rapid change in direction results in the lateral ligament complex. This is reduced in the barefoot or with a lateral heel wedge.1

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Flexibility - Turf toe resulted from excessive flexibility of the American football shoe.Foot / shoe / surface interface.

There are two interfaces here: the foot/shoe and the shoe/playing surface. Slip inside the shoe should be kept as small as possible (though not much research here). Interaction with the playing surface is easier to study and has received a lot of attention. Injury occurs when the deceleration forces exceed the breaking strength of bone/ligaments ( a sudden stop in sludgy snow) or from a slide (on icy snow resulting in collision). Playing surfaces have changed from grass, clay, wood concrete, asphalt to synthetic turf (Astroturf). The synthetics are easier to maintain, regulate and probably cause fewer injuries; they are characterized by degree of hardness, ground reaction forces, friction/traction, and energy loss, with loading and compliance. Increased traction (high co-efficient of traction with surfaces) may enhance performance but cause injury (as may slip from low co-efficient-but probably less likely). The cleating design of football shoes is critical to reduce torque and injury rate (change

to soccer-style shoe or Tanel 360 shoe which has a circular cleat for synthetics and a central forefoot cleat for natural grass) 2.

1A. Stacoff et al. Lateral Stability in Sideward Cutting Movements. Med. Sci. Sports Exerc. 1996 28 3 350-358. 2 J.C. Delee D Drez. Orthopaedic Sports Medicare 1994 Saunders 1666-1696.

Sports shoes fall into 6 categories 1 (1)

Running/training/walking

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Court shoes

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Field shoes - soccer/football - cleated/studded/spiked.

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Winter shoes - ski boots

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Outdoor sports - hunting

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Specially sports - golf, cycling.

1 C Frey 1994 Shoe wear and Pedorthotic Devices. In OKU Foot and Ankle AAOS p73-84

Details

1. Hiking boots need to be rugged, water resistant, good traction, firm heel counter. Climbing boots need inflexible soles. Exercise shoes need a light midsole with a firm heel counter, flexible soft upper and good shock absorption. Heel height of 10-15mm. Running shoes for short distances-light heel; torsional stability in longer distances from slight wedge (especially curve running), semi pointed toe-box. Rules for spikes are 6 max for sole, 2 for heel (<2 5mm long and <4 mm wide). Shorter spikes for hurdles, sometimes spikeless or hard surfaces. Training flats (road work) need shock absorption, flexibility and heel counter stability with torsional stability (designated: light, heavy runners, heel strikers, anti pronation, light weight, rugged terrain) Traction variable by variable outsole thickness/tread. Throwing events use good grip leather/suede with spikes. Jumping events may use spikes but need heel cushioning and have ‘jump foot’ shoes (R or L).

2. Court shoes - Subject to heavy use. Tennis requires good lateral support, good tread pattern, ventilation. Basketball needs good ankle support, traction and a pivot point. 3.

Field shoes. Use studs/spikes. Soccer need to feel the ball with soft upper. Football use cleats (but excessive traction may cause knee injuries). Need sturdy toe box and firm heel. Different shoes for different positions in US football (lineman versus backs versus place kickers). Rugby needs firm toe box.

4. Winter shoes: Skaters use leather uppers and firm heel counter. Injection moulded models. Skiing one piece injection moulded plastic foot outer shell. Modified for female foot. Cross-country are soft, low-cut, waterproof and good ventilation.

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Specialty - cycle shoe similar to sprint shoe.

Ankle and foot sprains Acute lateral ligament sprains Inversion, with supination and plantar/dorsi flexion, causes injury of the lateral ligament complex. The most common sporting injury. Usually (2/3 of cases) the anterior talo-fibular ligament (ATFL, the weakest) is involved, sometimes the extra-articular calcaneo fibular ligament (CFL), seldom the posterior talo-fibular ligament (PTFL, the strongest). Those at risk are large athletes, those with pes cavus (high medial arches) and a history of similar injury. Prophylactic (S. Ankle) splints should be worn in high risk sports (basketball, netball, football). High top boots may help (Fig.7). There is immediate pain and (often marked) swelling with resultant anterior and inversion (tilt) instability. To judge the severity of injury, use the anterior draw test (Fig.); (Easier to perform in acute situation then inversion test and will give more information). You may specify as Grade I-ATFL sprain (2/3 cases) (ADT - some laxity); Grade IIATFL and CFL sprains (1/4 cases); (ADT and inversion tests some laxity). Grade III-ATFL, CFL and PTFL tears (both tests positive) or simply distinguish incomplete - with a firm end-point to anterior draw from complete - no end-point to anterior draw. Careful examination in the postacute phase allows identification of the injured ligaments (after ankle RICE for 24 hours). Whether complete or incomplete, treatment is the same-non operative. X-rays are necessary to exclude fractures. Good talar dome views will exclude osteochondral fractures (ignore bony avulsion of the ligaments). Do not miss a high fibular fracture with syndesmotic injuries (Maisonneuve fracture). Stress x-rays are unreliable but possibly helpful in the chronic phase where the patient does not give a clear history of instability (‘going-over’ on the ankle). Treat in the acute stage with RICE, NSAIDs, ankle splint for 6 weeks (s-ankle; outer strap supports in swing phase and boomerang-shaped heel supports in stance phase with valgus and dorsal tilt), early rehabilitation with peroneal eversion exercises, water jogging, proprioceptive wobble board exercises. Some may become chronic. Elite athletes often elect for early surgical repair of complete ruptures (controversial but not unreasonable where ‘wasted’ period of 6 - 9 months conservative rehabilitation). Note: (Downhill) snow boarders may fracture lateral process of talus which maybe confused with lateral ligament sprain (often needs ORIF).1

1 P J Abbott 1997. Personal communication. Vail, Colorado, USA

Chronic lateral ligamentous laxity Unsuccessful treatment of acute lateral ligament injury may result in chronic lateral ligament laxity from ‘stretched-out’ ligaments. There is pain and tenderness over the antero-lateral ankle

joint extending to the sinus tarsi, exacerbated by repeated inversion injuries on irregular terrain. Distinguish mechanical instability (positive ADT/or inversion test) from functional instability (feels unstable but is mechanically stable; a proprioceptive problem). There is anterior instability and excessive tilt. Treatment (Peroneal eversion exercises and wobble board) too often forces athletes to persist with months of unsuccessful physiotherapy. A quick effective lateral ligament reconstruction is better. (The Brostrom capsulorraphy with reinforcement from the inferior extensor retinaculum (Gould modification) is recommended here. lateral ligament complex is tightened-up and reinforced. Immobilized for 6 weeks and back to sport in splint in 3 months.) Medial ligament sprains Sprains of this type are rare. This is a strong ligament. Injury usually accompanies lateral ligament sprain or fractures, and must be differentiated from lesions of the nearby posterior tibial, FHL and FDL, tendons and syndesmotic injury. Carefully check for accentuated localized tenderness and consider ultra-sound examination (see tibialis posterior section). (posterior tibial tendon text invert plantar flexed foot against resistance; FDL test power of loop flexions toes against resistance; FHL test power of resistance of big toe); see diagnostic test syndesmotic injury, page 000. X-rays with bone scan and CT may be necessary to exclude osteochondral fractures when there is severe, localized pain about the talar dome. Weight-bearing (WB) x-rays may be useful. An arthrogram in first week may show tear. Treatment is splinting and sometimes arthroscopic surgery if chondral damage. Subtalar instability Is a difficult entity to diagnose. This is really a component of lateral ligament injury (CFL torn) from inversion. There will be increased inversion compared to the other side. Special stress xrays (Broden- invert heel and 40° caudal tilt) or I.I. may help. Treat either splint or in chronic cases as above with CFL reconstruction (as part of Brostrom operation.)

Syndesmotic ankle injury (high ankle sprain, distal tibiofibular diastasis) Is a previously unrecognized, ongoing and painful ‘ankle sprain’. In the professional athlete the condition probably results from an external rotation injury. There is marked swelling both sides of the ankle with tenderness over the interosseus membrane. Suspect where an ankle sprain takes a long time to settle down. Perform the squeeze test (compress upper tib/fib and distal pain occurs, Fig. 8) or abduction/external rotation tests (hold upper tib/fib and externally rotate/abduct ankle to reproduce pain) and check a mortise view (Fig.9) X-ray (>1mm reduction in the medial clear space AB or <10mm tibio fibular overlap CD). Late x-rays show calcification of the ligaments. Treat in NWB last for 4 weeks. If refractory use diastasis screw fixation and repair ligament (difficult to suture paint-brush to paint brush). Peroneal tendon injuries

The weak perineal tendons work hard, everting the foot (which wants to revert to gestational equinus) and maintaining the transverse / longitudinal arches of the foot. They are poorly anchored with a weak holding retinaculum. Forced dorsi-flexion of the everted ankle in skiing or football can produce tenosynovitis, tendinitis, tear, (partial or complete), subluxation or dislocation of these tendons (especially peroneus brevis which is closer to the bone). There is marked tenderness with reproducible subluxation or dislocation. Turn the foot in and out and note flicking of tendon behind the lateral malleolus. X-rays may show a rim fracture (lateral aspect lateral malleolus) Fig.10. Treatment: Strapping may help, otherwise decompression, repair, tenodesis to peroneus longus or early stabilization in the groove (because of high recurrence rate) is indicated. Must be a graduated return to sport over 4-6 weeks, with ‘cutting’ procedures and sprinting to be avoided for 6 weeks. Posterior tibial tendon injury Typically occurs especially in middle-aged women who are unfit as a result of chronic degeneration and in older athletes. The pathology is inflammation (tenosynovitis) or partial / complete rupture. There is pain and tenderness along the tibialis posterior tendon, with difficulty lifting the heel off the ground in the single heel-raise test pain/hesitation = tenosynovitis; not able to lift heel = complete tear). The arch is flattened and the foot pronated. Ultra-sound examination may secure the diagnosis. Treat with NSAIDs. Recommend a medial arch support with heel up for tenosynovitis and partial ruptures. Perform debridement/tenosynovectomy for refractory cases. Reconstruct complete tears (use the FDL). Anterior tibial tendon injury Spontaneous rupture may occur but is unusual. There is localized tenderness and weakened dorsi flexion. Treatment: surgical repair is important. Use either direct repair or tendon (extensor) transfer. Achilles tendon injury Are common and difficult to treat. Two basic problems of tendinitis and rupture. Overtraining produces an inflammation around the TA (peri-tendinitis), in the tendon (tendinitis) or beside it (in front of TA - retro-calcaneal bursitis, behind TA - retro-achilles bursitis). The ‘painful arc’ sign may help to make the distinction1 Fig 11. With tendinitis the site of tenderness moves with the foot, and does not with peritendinitis. Athletes are at risk through excessive training, poor shoe support of the hindfoot and on cambered surfaces. A violent contraction of the gastrocnemius-soleus unit may cause partial or complete rupture of

the TA. Patients (with complete tear) report having been hit or kicked in the calf during the pushoff phase of running or racket sports. Partial tears are difficult to diagnose; ultra-sound imaging is helpful. Complete tears will invariably lead to pain, swelling, and a palpable gap (prior to swelling). Do not be deceived if the patient is able to plantarflex (through intact long flexors). Simmonds’ test is easy to perform and is diagnostic. Patient prove, squeeze the calf: if the foot does not move, the TA is ruptured. Fig. 12. Treat tendinitis/peritendinitis with rest, NSAIDs, heel raise, low frequency pulsed ultrasound, massage (stretching); rarely by surgery involving debridement. Retro calcaneal bursitis as above but consider surgery earlier with wide excision of retro-calcaneal exostosis. (Haglund’s bump). Retro-achilles bursitis seldom requires excision of the bursa. Partial tendon rupture may require surgical excision of scar and granulation tissue with internal suture splint. Complete tendon rupture almost invariably needs surgical repair (open technique); is easier but percutaneous repair is better; if delayed later repair is difficult and will require fascial or tendon augmentation (with FDL). Expect show post-op recovery and wound healing takes priority. Caution: Avoid steroids. Exclude Reiter’s syndrome, infection, gout, tumour. Gastrocnemius injury A tear of the medial head of the gastrocnemius is common in middle-aged tennis players (tennis leg). Patient feels as if they have been hit behind the heel. Treatment is symptomatic (NSAIDs, stretching, strengthening) and no surgery.

1M.D. Miller, DE Cooper, J.J.P. Warner 1995. Review of Sports Medicine and Arthoscopy, Saunders.

Spring ligament sprain The mid-foot is prone to twisting injuries with pain from sprain of the plantar calcaneo-navicular (spring) ligament. Pain localized to the medial arch (and proximal to the navicular). It may be associated with posterior tibial tendon problems. Cuboid syndrome Involves pain and tenderness over the cuboid in the region of the peroneal (everting) tendons. Treatment: S-ankle splint and NSAIDS/RICE. Sinus tarsi syndrome The tunnel beneath the talar neck and upper calcaneus can be a source of pain from overactivity and inversion injury. It may be related to the strained ligament of tunnel (talocalcaneal ligament). Distinguish from lateral ligament strain by careful point examination. Treat with NSAID, activities for hyperpronation and possibly steroid injection (¼ml celestone). Surgical excision of contents is seldom used. Fractures

Ankle fractures Are common and require precise treatment to avoid later osteoarthritis. Displacement of 1mm causes 40% decrease in tibio-talar articulation. Classification: Fractures of the ankle are best classified for practical purposes by position of the fibular fracture according to Weber’s scheme (AO) - A: below joint line; B: at joint line; C: above joint line. The Launge-Hansen scheme provides a logically based classification according to the direction of the damaging force supination/adduction, supination/external rotation, pronation/abduction or pronation/external rotation. The simple Henderson scheme classifies ankle fracture according to involvement of the lateral, medial, or posterior malleolus, or of a combination of these. Fractures of the ankle usually result from a fall with supination (or pronation) of the forefoot and eversion (or inversion) of the hindfoot. Well fitted shoes with ankle support will eliminate such injuries (seldom seen in skiers with well fitted boots). The immediate pain, swelling and deformity are obvious. Never hesitate to x-ray. Treatment of a displaced or unstable fracture almost always involves open reduction and internal fixation. Markedly displaced ankle fractures should be reduced in A & E to avoid skin problems (blisters/necrosis and vascular compromise). Exclude a Maisonneuve fracture by careful examination (with x-ray) of upper fibula. Support the ankle post-operatively in a plaster splint for 6 weeks (NWB); permit return to sports at 3-5 months. Rehabilitate aggressively with ROM and strengthening exercises. A non-displaced fracture (<2mm) needs 6 weeks in cast with careful follow-up and x-ray review to detect displacement early. An isolated lateral fracture seldom requires ORIF. Residual ankle pain (not uncommon) after bony union may be residual traumatic synovitis (Fergel lesions). Treat with NSAIDs or arthroscopic excision. Look for other causes residual pain (page 000) Foot fractures Tend to be under-appreciated, difficult to detect and sometimes hard to treat. Most can be managed in a below-knee fracture walker orthosis. Displaced and intra-articular fractures often require reduction (usually closed) and fixation (usually percutaneous K-wire). Calcaneus fractures Can be devastating due to a widened painful heel, nerve entrapment, peroneal tendinitis and later sub-talar OA. Treatment Elevate; Start foot pump at the admission (to reduce swelling) and operate when skin wrinkles after light stroke (wrinkle test). Previously most of these fractures were treated with closed reduction and sometimes pin fixation. However better surgical techniques allow a more aggressive approach with ORIF of displaced fractures involving the

sub-talar joint . Restore Bohler’s angle. Extra articular, anterior process calcaneus and tuberosity (without TA attachment) may only require closed reduction and immobilization. Talus fractures May involve the neck (aviator’s astragalus), ORIF when displaced as prone to a vascular necrosis and later OA (above and below), otherwise NWB for 6 weeks), the body /head (accurate reduction to prevent OA) or lateral process (try to leave alone). Navicular fractures Can be avulsions (posterior tibial tendon), hairline, comminuted (reconstitute with ORIF and bone graft) or stress types. Treat by reduction and K-wire fixation. Watch for non-union which is painful and difficult to treat. Stress fractures are slow to heal and need 6-8 weeks in NWB cast or bone grafting at 1 to 2 months if symptomatic. Subtalar dislocations The calcaneus and navicular (talonavicular) are dislocated under the talus either laterally (calcaneus lateral, talar head medially and may be entangled in the posterior tibial or long flexions making open reduction necessary) or medially ( the converse) Plan immediate reduction (open if necessary) to avoid significant soft tissue problems and immobilize for 6 weeks. Total talar dislocation The talus is totally dislocated at the ankle and subtalar joints and in big trouble. Immediate reduction (possibly open) and follow closely for AVN and OA. Mid foot (Lisfrancs) injuries involve the tarsometatarsal joints and in the absence of gross displacement (homolateral, isolated or divergent displacement) can be subtle and easily overlooked with long-term unexplained mid foot pain. Consider both fractures and ligament disruptions. The problem is that the second metatarsal (the keystone of the mid-foot/although recessed between the 1st and third cuneiforms is still only held by one ligament (Lisfrancs ligament) to the 1st cuneiform. Look carefully at WB x-rays to tell whether the medial border of second metatarsal aligns with medial border middle cuneiform, if not, then ORIF is required otherwise NWB for 6 weeks (Fig. 13).. Midfoot Metatarsal fractures In general when these fractures are displaced they must be reduced to prevent mal-union and abnormal weight-bearing over the metatarsal heads (metatarsalgia). The reduction may need to be held with a K-wire or plate. Fractures of the proximal fifth metatarsal are not uncommon from the significant shear forces applied especially in long distance runners. Avulsion fractures

(peroneus brevis/plantar fascia) can be treated in a NWB cast for 4 to 6 weeks (differentiate from accessing ossicle which has smooth margins). At the metaphyseal/diaphyseal junctions (Jones’s fracture) union maybe slow. (Consider ORIF in athlete and definitely when displaced). Dislocation of the MTP or PIP joint Are not uncommonly overlooked. They require prompt reduction to avoid later open reduction and a source of significant pain. Stress fractures Should be suspected when an athlete has bone pain with a normal x-ray. There are two types: fatigue type due to abnormally increased load on a normal bone; insufficiency type resulting from normal loads on deficient bone (as in osteoporosis). ( in ballet dancers/gymnasts who have amenorrhoea). Typically such fractures are seen 3 to 5 weeks into a new and intensive training programme as muscles adapt faster than bone. A small cortical crack occurs and spreads by sub-cortical infarction. Periosteal and endosteal new bone (callus) is seen 2 to 3 weeks later. X-rays may show the ‘dreaded black line’ indicative of impending complete fracture (Fig. 14). Bone scans are positive early and diagnostic. There is typically localized bone pain and tenderness relieved by rest. The athlete limps. Examine the sports shoes for excessive wear. Common sites are the tibia (mid and distal in runners and basketball), calcaneus, navicular (basketball), metatarsals (recruits and runners) (especially 2nd MT and proximal 5th MT) and sesamoids (1st MTP); less commonly the medial or lateral malleolus, (basketball) cuboid, talus and proximal phalanx of big toe. Treatment should be comprehensive. Immediate steps include rest, immobilisation (NWB cast for at least 6 to 8 weeks is critical) RICE, NSAIDs. Recommend cross-training (e.g. swim/cycle) to keep fit. Long term treatment involves correction of malalignment, orthotics (for hyperpronation, external tibial torsion), use of sports shoes with better absorptive impact and alteration of training schedules. Hormone treatment may be necessary for female athletes. Exclude infection / tumour. If the ‘dreaded black line’ of the tibia is still detected at 6 months surgery may be required (bone graft/drill). Reintroduce activity at 6 to 12 months. Navicular stress fractures are difficult: slow to heal and may need surgical fixation and bone graft. Nerve entrapments Are common about the foot and ankle but are difficult to diagnose and treat. Many are related to poor sports shoe fit (e.g. ski boots), to training on hard surfaces and occurs on competition. These include tarsal tunnel: the posterior tibial nerve is trapped behind the medial malleolus under the flexor retinaculum, with pain in the medial foot and sole; anterior tarsal tunnel: deep peroneal nerve trapped under the inferior extensor retinaculum, with pain in the 1st web space; jogger’s foot: medial plantar nerve compressed at the knot of Henry (where FDL crosses FHL) pain over medial toes; sural nerve: pain along the medial border of the foot; common peroneal

nerve: results from trauma, pain behind the fibula neck; superficial peroneal nerve: anterolateral entrapment (12cm from tip of the lateral malleolus where it pierces the deep fascia), distinguish from compartment syndrome; saphenous nerve: injured in thigh (Hunter’s canal) or medial knee (post-surgical the infra-patellar branch); Baxter’s nerve to abductor digiti quinti may be compressed in abductor hallucis and cause....heel pain as part of plantar fascists Morton’s neuroma: typically pain between 3rd and 4th metatarsal heads from traumatic entrapment causing neuroma (runners) of the interdigital nerve. Here compression of the metatarsal heads reproduces the symptoms and the patient is aware of mobile pebble under the ball of the foot. All entrapments are diagnosed by localized tenderness over the affected nerve at the level of entrapment, decreased sensation after activity, positive Tinel’s test and neuralgic pain at rest or at night. Provocative tests may be helpful (s. peroneal nerve: active dorsi flexion and eversion to tighten the peroneal muscles will reproduce the pain). Nerve conduction studies are usually unhelpful. Treat with orthotics (shoe modification), NSAIDs, stretching, massage, celestone injection. If necessary, surgically release nerve (and excise neuroma but bury nerve end in stable bony tissue bed) at the level of the anatomically located tenderness. Compartment syndrome Increased pressure within a confined muscle compartment may lead to ischaemia, necrosis, contracture and a useless limb. Early recognition and prompt treatment are essential (Fig). Causes are trauma (with fracture), post-operative crush injuries and athletic exertion (especially in runners). The clinical features of an acute compartment syndrome are severe pain (early and reliable index not relieved by immobilization or the usual analgesia), exquisite localized tenderness, pain with movement whether active (usually not possible) or passive and paraesthesia. Pallor, paralysis, and pulselessness are late signs where the diagnoses has already been missed. The condition usually involves the lower leg (anterior/extensor/lateral compartments) or the forearm (flexion compartment) when compartmental pressures exceed 30mmHg (or within 10-30mm Hg of the diastolic BP). Compartmental pressures can be measured with a Whiteside or in dwelling catheter (or a commercial electronic monitor e.g. Stryker STIC Device) but such measurements are often fraught with problems of accuracy. Method1 Using back-up non-electronic infusion technique. Equipment: mercury/an aeroid manometer, two plastic IV extension tubes, two 18 g needles (1½’ long), one 20ml. syringe, one three-way stopcock, one vial N. Saline. Set-up: Prep limb to be tested. Put 18 g needle into top sterile bottle saline to break vacuum. Attach 20ml syringe to stopcock, attach IV extension tube to stopcock, attach IV tube with 18g needle to stopcock. Put last needle into top saline bottle (below fluid level). Aspirate (without bubbles) saline into 1/2 of this tubing. Turn off stopcock.

Attach other extensions tubing from stopcock to manometer. Aspirate 15cc air into syringe (with stopcock closed to saline filled tubing). Insert needle into muscle to be tested/measured. Open system to connect both extension tubes (T-system). Make sure top of column saline in tubing is at same level as needle in patient (to avoid artificially wrong reading). Just slightly degrees plunger syringe to clear obstruction . Meniscus of fluid is flat when system is in equilibrium.

1 T E Whiteside MM Heckman Acute Compartment Syndrome J Am Head Orthop. Surgery 4, 4, 1996 p 212-214

Now take readings off mercury column at multiple sites (prox./distal to fracture - highest pressure is critical measurement for decision making) (Fig. 15). Caution: The measurement of compartmental pressures should never over ride clinical judgement (even in unconscious patients who are unable to feel, careful examination of a swollen, tight compartment will provoke some intra-cranial pressure) Treat externally by splitting ↑BP or ↑response such as the POP/bandages to the skin (but not through the skin) and elevate to but not beyond heart level as may decrease already compromised micro-circulation); and internally (if no relieve of symptoms) by surgical release of the compressed compartment (fasciotomy) within 4 hours to avoid irreversible ischaemia. Irreversible nerve injury may occur within 12 hours. Ischaemic/necrotic muscle may need to be debrided. Chronic compartment syndrome (exertional) May be subtle in presentation and results from prolonged training (runners, athletes engaged in court sports). The muscles are overworked, swell and a vicious cycle is triggered (Fig. 16). The anterior/ extensor compartments of the leg are usually involved with crescendo pain and tenderness relieved by rest. There may only be paraesthesia with exercise. Differential diagnosis is essential. Use bone scan to exclude stress fracture. Pain over poster-medial distal tibia may be a compartment problem of posterior tibialis or periostitis of soleus muscle (skin splints see bone scan). Calf claudication with reduced pulses when knee is extended and foot dorsiflexed may result from popliteal artery entrapment. Treat chronic compartment syndrome by activity modification, massage, exclude footwear (try sports shoes with Poron ® impact relieving heels/soles) or surface problems, NSAIDs, orthotics (medial wedge for posterior compartment), use cross-training (cycling). Fasciotomy is sometimes necessary (80% successful). First carefully measure intra-compartment pressures before/during/after exercise; look for resting pressure>15mm Hg or delay in fall after exercise of >20mmHg over 3 minutes.1 Then consider careful fasciotomy of the compartment involved with mini skin incisions and skin closure/drains. Plantar fasciitis (overpull of this fascia) Is a common cause of crippling subcalcaneal (usually medial) heel pain. The condition is

related to hyperpronation and pes cavus. There is localized tenderness with a positive windlass effect (dorsiflexing the big toe exacerbates the pain). X-rays may show a heel spur (ignore it). Exclude stress fractures, nerve entrapment involving the medial branch of the lateral plantar nerve (Baxter’s nerve, with neuralgic component) and Reiter’s syndrome. Treat with NSAIDs, stretching (heel cord), cortisone injection (2mls celestone with 3mls bupivacaine 1/2% plain). and a soft silicone heel cup. Surgery (medial heel incision with release of abductor hallucis fascia and excise 3-4mm of plantar fascia +/- release Baxter’s nerve) is sometimes necessary. Os trigonum This ossicle behind the posterior talus (medial tubercle of the posterior process of the talus) may be the cause of pain with plantar flexion in ballet dancers. It can be asymptomatic, fused, fractured, large or absent. 1 (Fig). X-ray to confirm the presence of os trigonum before finalizing diagnosis. Caution: Do not confuse with FHL tendinitis (where resisted flexion big toe causes medial pain). Treat with injection 2ml cortisone or surgically excise + decompress FHL. Turf toe Is caused by a forceful dorsi flexion of the 1st MTP joint, for instance in American football, on a hard surface (artificial turf and flexible shoes) (Fig. 17). Painful swollen 1st MTP x-rays may show a disruption of the plantar volar plate complex. Exclude stress fracture (proximal phalanx,) sesamoiditis, entrapment of FHL. Treat with RICE, taping, custom shoes. Sometimes surgical repair of the disruption is appropriate. Sand toe Is a hyper plantar flexion injury to the great and lesser toes in beech volleyball players (who play barefoot and land on the hyperflexed forefoot)2 (Fig. 18). There is synovitis and loss of dorsiflexion. Treatment is taping, (in neutral for big toe, buddy tape for lesser toe) exercises, NSAIDs, RICE and rarely surgery.

1 Quirk R. Common foot injuries in dance ortho. Clin North Am 1994 25 127 2 C Frey et al Plantar flexion injury to the metacarpophalangeal joint 1996 Foot and Ankle Int. 17 9 576-581.

Tibiotalar spurs May form as osteophytic outgrowths on the adjoining surfaces of the lower anterior tibia and talar neck. Impingement pain will occur with dorsi flexion. Treatment: Arthroscopic excision is useful (except where OA of ankle joint).

Metatarsalgia Forefoot pain beneath the metatarsal heads (with callosities) is vague in nature and related to impact sports. Hallux valgus claw toes or pes cavus may be present. It maybe a transfer metatarsalgia (from short 1st MT or long 2nd MT). Exclude Morton’s neuroma, stress fracture verruca (wart when trimmed will reveal tell tale pinpoint vessels). Freiberg’s infraction or simply trimming of callosity. Treat with stretching, NSAIDs, transverse arch supports (HAPADs). Rarely a closing wedge osteotomy (or partial plantar metatarsal head condylectomy) is useful where a single (usually the 2nd) metatarsal is involved. Freiberg’s infraction Is an osteonecrosis of the 2nd metatarsal head, typically seen in teenage females. The pain is excruciating. X-rays may show increased density or collapse of the metatarsal head. Treat symptomatically, by debridement, synovectomy or by limited resection of the distal 2nd MT head. Hallux valgus (bunions) Is common in the ballet community (from demi-pointe and rolling in), Fig. 19, results from improper shoe size (and flexibility) in dancers and catchers, as an acute (dislocation of 1st MTP joint) or chronic repetitive injury. Ballet dancers and sprinters are poor surgical candidates due to the debilitating effect of post-operative stiffness. Treat exhaustively by all available avenues (orthotics, toe spread, shoe box enlargement, NSAID gel to inflamed bunion, HV adduction splint) to delay surgery as long as possible. Hallux rigidus Is stiff and painful 1st MTP joint arising from micro-trauma, osteonecrosis or OA. The condition is seen in push-off sports (Fig.) where the feet are long, narrow and pronated (long first MT). Treat by use of stiff sole, HAPAD, or by cheilectomy (excision of painful dorsal osteophytes). Sesamoiditis Localized pain usually below the 1st MTP joint which may be part of an FHL/FDB tendinitis or tethering and is seen in dancers. X-ray (sesamoid views) to exclude fracture, Do not confuse with bipartite sesamoid (usually the tibial and has smooth margins) stress fracture, OA or dislocation and consider nerve entrapment. Treat with metatarsal support, NSAID or, (rarely) shave/excise. Short leg syndrome A short leg (>2cm) is prone to injury involving stress fractures, MCL knee sprain, patellar subluxation, plantar fasciitis and hyperpronation. Other possible problems include equinus foot,

postural scoliosis, low back pain and poor gait. The longer leg is susceptible to iliotibial tendinitis. The shortening may be real or apparent (form tilt of pelvis with tendon contractureneeds stretching). Treatment Use partial heel (and mid-sole) build-up. Persistent painful ankle It is not uncommon to have an athlete with a persistently painful ankle and no ‘apparent’ cause. Pinpoint the precise area of tenderness and then image the area with XR (mortise view), bone scan (to correlate/confirm area of tenderness with increased update), ultra-sound (well performed will define tendon lesion), CT scan (to define bony lesion such as occult fracture) and possibly MRI (expensive but precise for defining soft tissue and bony lesions). Then work through this list:

Problem ‘Meniscoid’ (Fergel lesion) synovitis

Action arthroscopic synovectomy

ankle Avulsion tip of fibula (in children) ‘Asymptomatic’ ossicle Unrecognized fracture of anterior

excise excise excise

process of calcaneus Peroneal or tibialis post. tendon problem surgery (synovitis, partial tendon rupture  

subluxation) Fracture of lateral process of talus fix/excise Sinus tarsi syndrome surgery (debride) ‘High ankle sprain’ (+/- fracture Tillaux) see page 000 Impingement of inferior band of excise band (syndesmosis) tibiotalar ligament Nerve entrapment Tarsal coalition (children) Osteochondral fracture/dissecans RA RSD (painful ankle, sensitive skin)

see page 000 excise/fuse arthroscopy refer nerve block, physical therapy

If no answer then consider NSAIDs by local application, S-Ankle splint, gentle PT, low  

frequency pulsed ultrasound, TENS, WAX., cross-training, water jogging, pain clinic, patience, and don't ignore the problem athlete (be prepared to talk, review and re-assess).