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

1. 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 Morrison Orthopaedic Registrar Western Health June 2011

2. 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 Morrison Orthopaedic Registrar Western Health June 2011

3. Outline • Incidence • Evaluation • Specific Injuries • Turf Toe • Ankle Injuries • Tarsometatarsal Injury • Stress Fracture • Prevention

4. 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

5. 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.”

6. 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

7. 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.

8. 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

9. 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.

10. 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

12. 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.

13. 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

14. 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

15. 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

17. 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)

18. 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