Management of Common Sports-related Injuries About the Foot and Ankle

Robert B. Anderson, MD Kenneth J. Hunt, MD Jeremy J. McCormick, MD

J Am Acad Orthop Surg 2010;18: 546-556

Stewart MorrisonOrthopaedic RegistrarWestern HealthJune 2011

Management of Common Sports-related Injuries About the Foot and Ankle

Robert B. Anderson, MD Kenneth J. Hunt, MD Jeremy J. McCormick, MD

J Am Acad Orthop Surg 2010;18: 546-556

Stewart MorrisonOrthopaedic RegistrarWestern HealthJune 2011

Outline✚ Incidence

✚ Evaluation

✚ Specific Injuries✚ Turf Toe

✚ Ankle Injuries

✚ Tarsometatarsal Injury

✚ Stress Fracture

✚ Prevention

Incidence✚ NCAA Injury Surveillance System (ISS)✚ Hootman et al. reported on 16 year data for 15 sports:

✚ Ankle ligamentous sprains most common: 14.9% of injuries, 0.83 per 1000 athletes

✚ Anterior cruciate ligament injuries: 2.6% of injuries, 0.28 per 1000 athletes

✚ High school level, ankle and foot constituted 39.7% of athletic injuries

✚ Games of the XXVIII Olympiad Athens, 22% of injuries were ankle sprains

✚ Sport Factors✚ Base Sliding (breakaway bases)

✚ Football (American) has highest injury rate

Evaluation✚ Mechanism of Injury

✚ “return to play” as an important issue

✚ Have injury prevention strategies been followed?

✚ Temporal issues

“the goal is not simply to return to participation, but to perform at a high level while avoiding long-term consequences.”

Turf Toe✚ Hyperextension 1st MTP joint

✚ Tearing of plantar capsuloligamentous structures

✚ Commonly associated valgus component

Hx: 1st MTPJ pain/swelling, push-off / cutting

Ex: 1st MTPJ stability, hallux flexion strength

Ix: AP XR: Excl. sesamoid #, proximal migration

Turf ToeI : attenuation, swelling, minimal ecchymosis

✚ Non Surgical: taping, early rehabilitation

II : partial tear, moderate swelling, restricted ROM

✚ Non Surgical: 2 weeks rest, taping

✚ “turf-toe” or carbon-fibre orthosis to prevent MTP extn.

III : Complete disruption, FH weakness, instability

✚ Non Surgical: Immobilisation 10-16 weeks

✚ Surgical: Open Repair of Capsule case series of 19 athletes, 17 returned to previous level of participation.

Ankle Inversion✚ Inversion most common injury

✚ ATFL, PTFL, FCL

✚ “more extensive evaluation may be indicated when a severe sprain arouses suspicion of a fracture or in cases in which symptoms fail to resolve within 4-6 weeks”

✚ High incidence of peroneal nerve neuropraxia

DDx: ST Dislocation, # Ant. Process Calcaneus, Avulsion base 5th MT

Ankle InversionI : stretched lateral ligament. Able to WBAT without crutches.

II : Partial tear of ligament. Able to walk several steps unassisted.

III : Complete tear. Feeling of instability and difficulty walking.

✚ Most managed non-surgically.

✚ Several treatment algorithms exist, most incorporating RICE, early mobilisation and strengthening, +/- taping.

✚ Return to activity in 6-8 weeks.

✚ MRI Evaluation

✚ Complete treatment of initial injury, peroneal strength, and proprioceptive activities, decrease change of recurrent injury or chronic instability.

Ankle Eversion✚ Risk of injury to the tibiofibular syndesmosis

✚ Predictive of longer recovery and residual symptoms

✚ Valgus, external rotation, eversion

✚ +/- MCL Knee

✚ “Squeeze Test”, External Rotation Test

✚ MRI: Syndesmotic or FHL oedema static evaluation

Ankle EversionStable (No Widening)

✚ CAM Boot until non-tender, graduated return to activity at that point.

✚ ~ 6 weeks recovery time

✚ “15 hops on affected leg” good indicator of appropriate return to sport.

Unstable (Widening)

✚ Sydesmotic Fixation

✚ Open vs. closed vs. suture button

✚ Author’s preferred method is plate, screw, and button, with screw removed at 10-12 weeks.

✚ Plate to protect against fracture through empty screw hole.

TMT (Lisfranc) Injury✚ Axial loading mechanism

✚ Often Missed: often ligamentous, subtle clinical and radiographic findings

Dx: “pop” in midfoot, rapid onset pain. Tender on midfoot compression, pronation, supination, stressing 1st ray into dorsal or plantar deviation relative to second metatarsal head.

XR: B/L WB AP, 30° Oblique, Lateral

✚ > 2mm between 1st and 2nd metatarsal bases, fleck sign

✚ Stress views if plain radiographs equivocal

MRI: not indicated if diastasis seen on plain film

TMT (Lisfranc) InjurySprain : Non-displaced, stable midfoot on stress radiographs

✚ Non-Surgical Management

Rupture/Avulsion : Diastasis > 2mm (compared to other foot) on stress XR

✚ Principle: Obtain and maintain anatomical reduction of the midfoot

✚ Screws: Medial Cuneiform to 2nd MT, 1st/2nd MT-Cuneiform Screws

✚ Dorsal Plating: No disruption of articular surface

✚ Suture Button: little evidence

✚ Recommendation against using K-wires

✚ Strict NWB 6 weeks, early active mobilisation, arch support @ 6/52 , return to sport at 4/12 - 1yr

✚ Removal of hardware controversial

Stress Fracture✚ Most common overuse injuries in athletes, tibia and foot overrepresented

✚ Associated with change in training intensity, program, footwear, running surface

✚ Related to repetitive load

✚ Higher risk with forefoot or hindfoot varus

✚ Dx: Point tenderness, -ve XR

✚ Tc99 Bone Scan vs. MR, then CT

✚ High Risk: 5th MT metaphyseal, medial malleolar, navicular, anterior tibial cortex

✚ Mx: Immobilization, Boot, ProtWB 6-8 weeks. Maintain non-impact activities. Nutrition.

✚ Recent data to suggest surgical management appropriate

Prevention✚ Continued injury surveillance, awareness,

and innovation

✚ Footwear: Insoles, high-top shoes

✚ Playing Surfaces: Artificial Surfaces + Cleats

✚ Performance (high traction coefficient) vs risk (excessive torque)

Reflection✚ Foot and ankle injuries are common

✚ Sport and mechanism specific

✚ Patient demographics, function, comorbidities critical in determining management, as well as critiquing literary evidence