Lecture 47 parekh sports f&a

Foot and Ankle Sports

Selene G. Parekh, MD, MBAAssociate Professor of Surgery

Partner, North Carolina Orthopaedic ClinicDepartment of Orthopaedic Surgery

Adjunct Faculty Fuqua Business SchoolDuke University

Durham, NC919.471.9622

http://seleneparekhmd.comTwitter: @seleneparekhmd

http://footdronline.com/

Ankle Problems in the Athlete

Athletic Injuries

• Participation in organized/recreational sports continues to increase

• Injuries can be debilitating

• Recognition, prompt treatment and rehabilitation • Prevent long term disability

Athletic Injuries

• 59% of adults participate in exercise

• 11% jog

• 25% run ≥ 2 miles/day

• 800 footstrikes/mile

• Impact 3-8 x body wt

• Running injuries vary between 37%-57%

Athletic Injuries

• Risk Factors• Intrinsic

• Individual’s physical and personality traits

• Extrinsic• Training techniques

• Weekly running mileage greater than 40 miles

• Playing surfaces• Equipment

• Break-away bases

Athletic Injuries

• Etiologic Factors• Biomechanical abnml

• Flexibility

• Strength

• Footwear & orthoses

• Playing surfaces

Athletic Injuries: Etiology

• Biomechanical abnormalities

• Pelvic obliquity only predictor of injury

• <10% running injuries are due to biomechanical problems

• 70-80% runners treated with orthoses improve

• Need to wean use


• Flexibility• Prevention

• Tight Achilles• Decreased DF

HV, turf toe, midfoot strain, ankle sprain, Achilles tendinitis, calf strain

• Decr. MTP ROM• HR dancers predispose to injury

• Hypermobility• Posterior ankle pain

• Pathologic laxity• Recurrent ankle sprain


• Strength• Weakness injury

• >10% difference in extremity strength puts player at risk

• Soccer & volleyball players risk for injury and recurrence due to weakness

• Restore normal strength ratio though isotonic and isokinetic strengthening


• Footwear and orthoses• Improper fit

• Tight/loose, neurapraxia• Load cushioning

• Reduced calcaneal stress fx in military recruits• Loss of sensory feedback

• Torque• Cleating ankle injuries• Too much, too little traction


• Playing Surfaces• Concrete, synthetic track• Grass vs. artificial turf

• Role not completely defined

Chronic Leg Pain

• Concurrent with foot/ankle complaints• Differential

• Chronic compartment syndrome• Medial tibial stress syndrome• Stress fractures• Muscle strain/tendinitis• Nerve entrapment• Vascular disease• Fascial herniation• Radiculopathy

Chronic Leg Pain

• Incidence• 150 patients

• 33% chronic compartment syndrome• 25% stress fx• 14% muscle strain, 13% medial tibial stress

syndrome• 10% nerve entrapment, 4% venous disease

• Shin splints• Periostitis

• 10-15% all running injuries

Exercise-Induced Compartment Syndrome


• Incidence• Unclear

• 70% runners, 20% ball and puck• Clinical Features

• Pain predictable after certain distance, duration, speed

• Aching, cramping, stabbing, fullness• Neurologic symptoms

• Anterior, deep posterior compartments


• Diagnosis• Clinical

• Rest: Minimal tenderness • Exercise to provoke sx• Muscle herniation 20-60% pts• DPN/SPN

• Radiologic• Stress fx• Occult tumor• Bone scan• MRI


• Criteria for Diagnosis• Pressure measurements

• Resting, post-exercise measurements

• Secondary• Pressure >15mmHg pre-exercise• Pressure >30mmHg 1 min post-exercise• Pressure >15mmHg 5-10 min post-exercise


• Conservative treatment• Dependent on athletes goals• Activity modification• Rest gradual increase in exercise• Ice, NSAID’s• Insoles, orthoses

• Surgical treatment• Fasciotomies


• Results• Good with proper patient and techniques• 80-95% excellent results• 20% decrease in strength

• Complications• Swelling• Hematoma• Infection• Herniation• Nerve entrapment• Recurrence

Stress Fractures: Tibia & Fibula

• Abnormal repetitive loads causing imbalance of resorption over formation

• Running > basketball > soccer > skating > aerobics > ballet

• Athletes with decreased mineral content • Amenorrheic females


• Clinical features• Recent change in routine• Insidious, localized tenderness, swelling

• Diagnosis• X-ray initially negative

• (2-3 weeks) radiodense haze, periosteal rxn• Transverse cortical lucency• Bone scan


• Conservative Treatment• Rest, cessation of activity• NWB PWB to WBAT

• As symptoms allow• Swimming, pool running, cycling

• Resume competition full motion, strength, minimal tenderness

• Surgical Treatment• Excision, bone grafting• PEMF bone stimulation• Intramedullary fixation

Gastrocnemius-Soleus Strain

• Common injury• Racquet sports, basketball, running, skiing• Plantaris tear

• Clinical Features• Sudden knee extension while crouched w/ ankle DF• Sudden sharp pain

• Difficulty with toe-off

Gastrocnemius-Soleus Strain

• Treatment• Casting/immobilization

• RICE

• WBAT• Active dorsiflexion• Gentle passive stretching more functional

recovery

Nerve Entrapment Syndromes

• Superficial Peroneal Nerve• Neuritic pain, burning, tingling, radiation• Tenderness over area of compression• R/o compartment syndrome, double-crush• Tx

• Injections, modalities, thermogesic creams, neuroactive medications, shoe modifications

• Surgical nerve release, fasciotomy

Popliteal Artery Entrapment Syndrome

• Rare, mimics pain chronic compartment syndrome• Recognition important as may lead to amputation


• Clinical• Cramping pain, intermittent claudication

• 67% bilaterality

• Pulses diminished or absent• Knee hyperextended, ankle dorsiflexed

• Knee warm, foot cool• Ischemia, thrombosis; palpable mass


• Diagnostics• Provocative testing (treadmill) absent pulses• Doppler, U/S flow, aneurysm• Biplanar arteriography after exercise

• Deviation, occlusion, dilatation

• Treatment• Release• Bypass grafting

Venous Disease

• Effort thrombosis• Pain, edema, distended veins, discoloration• Venography• Tx: anticoagulation heparin, coumadin

• Thrombophlebitis• Immobilization after injury• Air travel• Dehydration• Oral contraceptives• Alcohol/drug use

Delayed-Onset Muscle Soreness

• Unaccustomed to activity

• Eccentric muscle contraction microinjury, subcellular level• Inability to generate maximal force

• Pain, fatigue• Loss of performance 24-48hrs• Resolve 5-7 days

• Tx• Symptomatic treatment

Medial Ankle Sprains

• Rare, associated with lateral, bony injuries

• 2 portions:• Superficial deltoid• Deep deltoid

DeepSuperficial


• Biomechanics of deltoid• Prohibits abduction

• Secondary restraint against anterior translation ankle

• Deep deltoid • Greatest restraint lateral translation (after fibula)• Highest load to failure

• Valgus tilt superficial & deep rupture


• Clinical Evaluation• Lateral injury, fracture, syndesmotic injury• Abduction, eversion• Other injuries

• Maisonneuve, FDL, PTT, FHL, tibial & saph n

• Radiographs• Assoc fx, AP stress valgus tilt, normal with

incomplete injury• MRI


• Conservative Treatment• Dependent upon associated injuries• Walking cast, boot 6-8wks• Functional treatment

• Surgical treatment• Inability to reduce medial clear space• Direct repair

• Suture, suture anchors

• Stirrup brace 6 months after surgery


Sinus Tarsi Syndrome

• Related to subtalar instability

• Nebulous condition w/ pain in lateral ankle & sinus tarsi

• Pathologic anatomy not clearly defined• Scarring or degenerative changes to soft tissues

within sinus tarsi• Loss of nerve function loss of proprioception


• Diagnosis• Clinical Evaluation

• Pain lateral ankle, sinus tarsi• Prior inversion injury• Instability rare

• Radiologic Evaluation• X-rays- normal• Subtalar arthrography

• Absence of microrecesses, interdigitation• MRI

• Fibrosis, fluid collections


• Conservative treatment• Injection

• Surgical treatment• Exploratory, sx may persist• Resect fibrofatty tissue & extensions from IER• Subtalar arthroscopy

• Results• 96 cases; 69% excellent, 25% good, 6% failures

Os Trigonum/Posterior Impingement

• First Described Rosenmuller

• First Described as Fx Shepherd 1822

• Asymptomatic• Separate

Ossification Center• Age 8-11• Incidence 1.7 - 7%


• No side predominence• Vary in size• Normal anatomic variation

• Mild extension• Thumb shaped projection - 1 cm (Stieda’s

Process)


• Symptoms• Pain with PF• Young Athlete/Dancer

• Spectrum• Acute – Fx• Gradual - FHL Tendinitis


• Conservative• Immobilization• NSAID

• Surgical – Excision

Prone Ankle Scope

Evaluation

• 54% of talar dome

• Os trigonum

• Haglund’s

• Achilles insertion site

Foot Problems in the Athlete

Goals & Objectives

• Specific problems• Midfoot

• Forefoot

Os Peroneum

• Ossification• Complete• Less than complete• Multipartite

• Location• Lateral border calc & plantar lateral cuboid

• Useful marker for ruptured PL

Painful Os Peroneum Syndrome (POS) & PL Disruption

POPS/Peroneus Long. Tendonitis/Tear

• Conservative treatment• Cast immobilization (20% success)• Physical therapy

• Surgical treatment• Os peroneum excision/tendon repair• Peroneal tenodesis

Forefoot Sprains

•First MTP joint/ “turf toe”

•Etiology•Hard artificial surface, flexible shoes•True incidence not defined, but many reports indicate a fairly common entity

•Functional disability•Push-off impaired•Compromised forward drive and running•More missed games & practices than other injuries

Forefoot Sprains

• Mechanisms of injury• Hyperextension of the MTP joint

• Foot dorsiflexed, forefoot fixed, heel raised• Joint capsule tears, compression injury to the dorsal articular

surface with extremes of dorsiflexion

Forefoot Sprains

• Etiologic factors• Shoe-surface interface

• Flexible shoes

• Hardness of surface• Loss of resiliency with time

• Enhanced friction• Fixes foot allows extremes of motion

• Excessive DF• In those with limited DF

Forefoot Sprains

• Radiographs• R/o fx, avulsions, impaction• Other methods usually not necessary

Forefoot Sprains

• Conservative treatment• RICE, NSAID’s• Taping, boot• Increase stiffness in shoe

• Custom molded insert/Morton’s extension

• Rehab once decrease in sx allows

Forefoot Sprains

• Surgical treatment• Rarely necessary

• Instability• Loose bodies, osteochondral injury• Ligamentous disruption• Sesamoid retraction

• Repair plantar plate, FHB, long flexor transfer

Metatarsal Stress Fractures

• Etiology• Injury to opposite limp

increased stress to normal limb

• Muscle fatigue increase in loading

• Hard surfaces, poorly cushioned shoes, heavy heel strike

• Rigid cavus feet decrease shock absorption of the midfoot increase stress on MT’s

• Hypermobile first ray or long 2nd MT

Stress Fractures

• High index of suspicion • Focal tenderness • Min/no swelling• X-rays nl < 3-4 wks • Bone scan, MRI, & CT scans

Treatment

• Activity modifications• Non-impact sports• Avoid casting if possible

Treatment

• Shoe modifications• Rigid cavus foot

• Flexible, cushioned arch support• Hyperpronation/hypermobile 1st ray

• Soft medial arch support• Long 2nd MT

• MT pad

RE ECT

the ankle

the foot

Lecture 47 parekh sports f&a

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