Robert B. Anderson, MD Kenneth J. Hunt, MD Jeremy J. McCormick, MD
Management of Common Sports-related
Injuries About the Foot and Ankle
J Am Acad Orthop Surg 2010;18: 546-556
Stewart Morrison
Orthopaedic Registrar
Western Health
June 2011
Robert B. Anderson, MD Kenneth J. Hunt, MD Jeremy J. McCormick, MD
Management of Common Sports-related
Injuries About the Foot and Ankle
J Am Acad Orthop Surg 2010;18: 546-556
Stewart Morrison
Orthopaedic Registrar
Western Health
June 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 Toe
I : 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 Inversion
I : 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 Eversion
Stable (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) Injury
Sprain : 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