Foot and Ankle Injuries in Athletics: Foot and Ankle Injuries in Athletics Brett Haywood M.D. PGY IV


Outline: Outline Incidence Anatomy Ankle Sprains Achilles Tendon Injury Posterior Tibialis Injury Peroneal Tendon Injury Flexor Hallucis Longus Tendon Injury OCD lesions of talus Impingement syndromes Plantar Fasciitis Lis Franc Injuries MTP Injuries


Outline: Outline Fx’s that mimic sprains Stress fx’s Ankle fx’s


Incidence: Incidence Garrick and Requa studied 16,745 sports injuries to Center for Sports Medicine in San Francisco between ’79 and ’87: Ankle sprain most common sports injury. Over half of the injuries at the ankle were sprains Foot and ankle injuries accounted for 25.2% of all injuries. Clinics in Sports Medicine, ‘98


Incidence: Incidence Ankle sprains represent 7-10% of ER cases Most occur in patients under 35 yrs of age Delee. Orthopaedic Sports Medicine, ‘94


Anatomy: Anatomy The ankle is a modified hinge joint consisting of three bones (tibia, fibula, talus) Primary motions are PF, DF, and small amounts of inversion, eversion, and rotation


Anatomy: Anatomy The ankle is stabilized medially by the Deltoid ligament Stabilized laterally by the anterior talofibular ligament, calcaneofibular ligament, and the posterior talofibular ligament


Anatomy: Anatomy Distal articulation of the tibia and fibula or syndesmosis is stabilized by: Anterior inferior tibiofibular ligament Posterior inferior tibiofibular ligament Inferior transverse ligament Interosseous ligament


Anatomy: Anatomy The subtalar joint is made up of three articular facets (ant, medial, and post). Subtalar joint permits inversion and eversion. Talonavicular joint is part of more mobile medial column. The calcaneocuboid joint forms more rigid lateral column The talonavicular and calcaneocuboid joint work with subtalar joint to allow inversion, eversion, and rotation of hindfoot


Anatomy: Anatomy


Lateral Ankle Sprains: Lateral Ankle Sprains Lateral ligamentous complex consists of the ant talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the post talofibular ligament (PTFL)


Lateral Ankle Spains: Lateral Ankle Spains The ATFL is the primary restraint to inversion in plantar flexion. It also resists anterolateral translation of the talus in the mortise. The weakest of the lateral ligaments. The CFL is the primary restraint to inversion when the ankle is in the neutral or dorsiflexed position. The PTFL is the strongest of the collateral ligaments and bridges the posterolateral tubercle of the talus to the posterior aspect of the lateral malleolus


Lateral Ankle Spains: Lateral Ankle Spains Mechanism : the ankle is in a position of instability in PF and inversion as a consequence of the narrow diameter of the talus posteriorly. The anterolateral joint capsule fails first; followed by rupture of the ATFL; finally the CFL fails as the arc of injury progresses. PTFL is usually not disrupted. ATFL is involved in 85% of lateral sprains; CFL is injured concomitantly in 20% - 40%.


Lateral Ankle Sprains: Lateral Ankle Sprains Grading: Grade 1 injuries involve stretching of the ATFL, mild tenderness, no evidence of mechanical stability, ability to bear wt. Grade 2 injuries involve complete tear of the ATFL and usually a partial tear of the CFL and moderate laxity with ant drawer test Grade 3 injuries involve complete rupture of both the ATFL and CFL. Ant drawer and talar tilt test positive


Lateral Ankle Sprains: Lateral Ankle Sprains Treatment - Nonsurgical: tx of choice for all grades; Grades 1 andamp; 2 may be tx’ed with brief immobilization, followed by PT Grade 3 tx’ed with extended immobilization, followed by PT Few indications for acute surgical repair


Sequelae of Lateral Ankle Sprains: Sequelae of Lateral Ankle Sprains Up to 50% of patients will continue to experience sx’s of pain, pain and instability, or instability alone Initial tx is PT If sx’s persist, patient may benefit from arthroscopy and lateral ligamentous repair


Syndesmotic Injuries: Syndesmotic Injuries Also referred to as 'high ankle sprains' Mechanism – external rotation and pronation Estimated to be involve in 1% to 10% of all ankle sprains. OKU: Sports Medicine 3


Sydesmotic Injuries: Sydesmotic Injuries Treatment – Immobilization in NWB cast or splint for 2-3 weeks. Usually take 8-12 weeks to resolve. Functional therapy that uses brace to prevent external rotation. Surgical tx for patients who are refractory to conservative tx, displaying diastasis on plain or stress xrays, and those presenting longer than 3 months after injury.


Achilles Tendon: Achilles Tendon


Achilles Tendon Injury: Achilles Tendon Injury Anatomy – the two heads of the gastrocnemius from the medial and lateral femoral condyles blend with the soleus to form the Achilles tendon. Inserts into the middle 1/3 of the post tuberosity of the calcaneus. Load may reach tensile forces of 1,400 to 2,600N during walking and 3,100N to 5,330N during running Decreased in the number of blood vessels in the midportion of the tendon. This is about 3-4cm prox to insertion and corresponds to weakest area of the tendon.


Achilles Tendon Injury: Achilles Tendon Injury Tendonitis/ tendonosis common. Tx with stretching, shoe modifications, heel lifts, activity modifications. If longstanding or fails conservative tx may require tenolysis or debridement Rupture Typically occurs in 30-40 y.o. 'weekend warrior' Pt’s c/o sudden pain and snapping sensation Absent PF, positive Thompson test Tx surgically Initially splinted in PF, then walking boot with heel lifts


Posterior Tibialis Tendon: Posterior Tibialis Tendon


Posterior Tibial Tendon Injuries: Posterior Tibial Tendon Injuries Associated with pes planus or flat foot deformity Usually seen in sports that require rapid change in direction, including basketball, soccer, football. The tendon is subject to great mechanical stress after heel strike because hindfoot moves from position of loaded eversion to inversion.


Posterior Tibial Tendon Injuries: Posterior Tibial Tendon Injuries The portion of the tendon from the medial malleolus to the navicular tuberosity is relatively avascular. Usually starts as tenosynovitis which can lead to tendonosis and partial tears. Valgus hindfoot late finding Tenosynovitis tx’ed with conservative therapy Acute ruptures and refractory tendinosis surgically tx’ed


Peroneal Tendons: Peroneal Tendons


Peroneal Tendon Injuries: Peroneal Tendon Injuries Can occur from direct trauma, ankle sprains, calcaneal fx’s. Tendonitis Caused by repetitive rubbing against fibula Tendons are relatively avascular from the tip of the fibula to their insertion Partial longitudinal tears are common, may require repair Tx with NSAIDs, lateral heel wedge, rest, casting, physical therapy


Peroneal Tendon Injuries: Peroneal Tendon Injuries Subluxation Caused by rupture of the superior peroneal retinaculum secondary to forceful plantarflexion and inversion from a dorsiflexed position. Tx with NWB and casting has 50% success rate Acute reconstruction of retinaculum is preferred tx with young athletes


Peroneal Tendon Injuries: Peroneal Tendon Injuries Traumatic rupture may occur in association with ankle fx’s and severe sprains. Complete tears can lead to recurrent sprains and ankle instability Tx with primary repair


Flexor Hallicus Longus: Flexor Hallicus Longus


Flexor Hallucis Longus Tendon: Flexor Hallucis Longus Tendon Stenosing tenosynovitis Common in ballet dancers Most common location is medial calcaneus within the fibro-osseous tunnel Resisted active PF of great toe typically reproduces pain Conservative tx first, may need surgical release of fibro-osseous tunnel Complete rupture uncommon – direct repair indicated


Osteochondral Lesions of the Talus: Osteochondral Lesions of the Talus Lesions in talar dome that can range from a small defect in the articular cartliage to subchondral cysts or osteochondral defects. May result from ankle sprains or degenerative changes caused be repetitive microtrauma Present with usually poorly defined pain Tx based on age of pt, size, and location


Osteochondral Defects of Talus: Osteochondral Defects of Talus


Anterolateral Impingement: Anterolateral Impingement Characterized by anterolateral ankle pain with limited and painful dorsiflexion. Soft tissue – Entrapment of thickened synovial Often occurs after sprain or fx Tx with PT, NSAIDS, steroid injections, arthroscopic debridement


Anterolateral Impingement: Anterolateral Impingement Bony – Kissing osteophytes on anterior tibia and talar neck. Often seen with cavus foot Xray appearance may lag behind clinical picture Tx with open debridement


Posterior Impingement: Posterior Impingement Usually the result of the FHL becoming irritated by the os trigonum (ununited lateral tubercle of the post talus). May be associated with fx of the os trigonum. Commonly seen in activities with repetitive jumping and pivoting. Pain between medial malleolus and Achilles Conservative tx, local steriod injection, bracing, excision of os trigonum, debridement of FHL


Plantar Fasciitis: Plantar Fasciitis Presents with acute tenderness at the medial tubercle of the calcaneus over the course of the plantar fascia. Common in runners, accounts for about 10% of running injuries. Microtrauma caused by over pull of the plantar fascia and by tight heel cords. Associated with flatfoot deformities because there is an increased stress on the origin of the plantar fascia


Plantar Fasciitis: Plantar Fasciitis Tx – NSAIDs, activity modification, orthotics, Achilles tendon stretching, steroid injection, night splinting. Operative tx rarely indicated - release


Lisfranc Injuries: Lisfranc Injuries Anatomy – the tarsometatarsal joints are made up of articulations between the bases of the medial three metatarsals and three cuneiforms. The main stabilizer is the 2nd metatarsal base which lies between the medial and lateral cuneiforms Lisfranc ligament is an oblique ligament that extends from the base of the 2nd metatarsal to the medial cuneiform.


Lisfranc Injuries: Lisfranc Injuries Caused by hyperextension of the tarsometatarsal joint Pt’s present with pain, swelling, ecchymosis on dorsum of foot Tx is ORIF, NWB for 6 weeks


MTP Injuries: MTP Injuries Turf toe Caused by hyperextension of the hallux MTP with an applied axial load to the heel of the foot in a fixed equinus position Tx with RICE, NSAIDs, boot or cast for 1 week duration, orthotics (rigid forefoot component) Sand toe Caused by hyperflexion of hallux MTP Tx with RICE


MTP Injuries: MTP Injuries Hallux rigidus – Sequelae of either turf toe or sand toe Leads to loss of MTP extension Osteophytes seen on lateral xray of foot Tx with resection of osteophytes


Fractures that Mimic Sprains: Fractures that Mimic Sprains Lateral process of talus fx’s 'Snowboarder’s fx' Tx in cast after reduction Excise small fragments Fx of anterior process of calcaneus Tenderness distal to the ATFL Tx in cast


Stress Fractures: Stress Fractures Calcaneal Stress fx’s Seen in runners Heel pain, pain with squeeze test If recognized early, tx with heel cushion and restricting inciting activity Later in disease course, tx with walking cast or boot for 6 weeks 2nd, 3rd, 4th Metatarsal Stress fx’s Rarely displace Tx supportively


Stress Fractures: Stress Fractures Navicular Stress Fracture – Seen in sports that require sudden acceleration and deceleration (basketball, football) Long 2nd MT or short 1st MT possible predisposing factors Occur in central portion Nondisplaced fx’s and no evidence of sclerosis, immobilize and NWB for 6-8 weeks Displaced fx’s, fx’s with sclerosis, and those that failed conservative therapy, tx with curettage, drilling, internal fixation


Jones Fracture: Jones Fracture Stress fx within the 5th metatarsal proximal metaphyseal-diaphyseal junction. This is watershed area Noncompetitive athletes tx with short leg cast for 6-8 weeks, followed by protective weightbearing for another 6 weeks Surgical tx for those who have failed conservative therapy and for competitive athletes


Ankle Fractures: Ankle Fractures Are among the most common fractures, with over 250, 000 per year External rotation is the most common mechanism If only the lateral malleolus is minimally displaced and there are no signs of other ligamentous injury, tx with cast and NWB. Otherwise ORIF and NWB