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

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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 201018 546-556
Stewart Morrison Orthopaedic Registrar Western
Health June 2011
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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 201018 546-556
Stewart Morrison Orthopaedic Registrar Western
Health June 2011
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Outline

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

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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

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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.

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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

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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.

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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

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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.

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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

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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
• Authors preferred method is plate, screw, and
  button, with screw removed at 10-12 weeks.
• Plate to protect against fracture through empty
  screw hole.

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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
• gt 2mm between 1st and 2nd metatarsal bases, fleck
  sign
• Stress views if plain radiographs equivocal
• MRI not indicated if diastasis seen on plain
  film

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TMT (Lisfranc) Injury

• Sprain Non-displaced, stable midfoot on stress
  radiographs
• Non-Surgical Management
• Rupture/Avulsion Diastasis gt 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 _at_ 6/52 , return to sport at 4/12 -
  1yr
• Removal of hardware controversial

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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

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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)

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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