Athletic Foot Injuries

Question 1

Background

Answer 1

Athletic foot injuries can be difficult to properly diagnose and treat. Bearing the weight of the entire body, the foot is under tremendous stress. In many sports, the foot absorbs tremendous shearing and loading forces, sometimes reaching over 20 times the person’s body weight. Physicians who treat these disorders must have a good understanding of the anatomy and kinesiology of the foot.

Although foot injuries can occur from a variety of causes, the most common cause is trauma. Other etiologies include (1) rapid or improper warm-up, (2) overuse, (3) intense workouts, (4) improper footwear, and (5) playing on hard surfaces.

Physicians who evaluate and treat common foot problems should have a working knowledge of the individual sports and the injuries that are commonly associated with them. An understanding of the basic treatment approaches for these injuries also is imperative.

Question 2

Functional Anatomy Introduction

Answer 2

The foot is composed of 26 major bones, which can be divided into 3 regions: the forefoot, midfoot, and hindfoot.

The forefoot is comprised of the 5 metatarsals and the 14 phalanges.

The 3 cuneiforms (ie, lateral, intermediate, medial), the cuboid, and the navicular represent the midfoot.

The hindfoot is composed of the talus and the calcaneus

Question 3

Anatomy: Bones of the Foot

Answer 3

The talus is oriented to transmit forces from the foot through the ankle to the leg.

The calcaneus is the largest bone in the foot.

The Achilles tendon inserts on the posterior aspect of the calcaneus.

The navicular lies anterior to the talus and medial to the cuboid.

The cuboid articulates with the calcaneus proximally, with the fourth and fifth metatarsals distally, and with the lateral cuneiform medially

Question 4

Anatomy- Tendons of the Foot

Answer 4

The flexor hallucis longus (FHL) tendon is 1 of 3 structures that lie in the tarsal tunnel. Running behind the medial malleolus, the FHL is the most posterolateral. The FHL runs anterior to insert onto the distal phalanx of the great toe. The FHL acts as a flexor of the great toe, elevates the arch, and assists with plantar flexion of the ankle.

The flexor digitorum longus (FDL) tendon passes between the FHL and tibialis posterior tendon. The FDL inserts onto the distal phalanges of the 4 lateral digits and acts to flex the distal phalanges.

The tibialis posterior tendon is the most anteromedial of the tarsal tunnel tendons. This tendon inserts on the navicular tuberosity; the 3 cuneiforms; the cuboid; and the second, third, and fourth metatarsals. The tibialis posterior muscle flexes, inverts, and adducts the foot.

Laterally, the peroneus longus and peroneus brevis tendons share the common peroneal tunnel running behind and around the lateral malleolus. The peroneus longus plantar flexes the first metatarsal, flexes the ankle, and abducts the foot. The peroneus brevis flexes the ankle and everts the foot.

Question 5

Other important structures

Answer 5

The plantar aponeurosis or fascia is a deep span of connective tissue extending from the anteromedial tubercle of the calcaneus to the proximal phalanges of each of the toes. Medial and lateral fibrous septa originate from the medial and lateral borders to attach to the first and fifth metatarsal bones.

Nerve innervation of the foot runs along the medial and lateral metatarsals and phalanges in a neurovascular bundle. These nerves are vulnerable to compressive forces that, in time, can generate the painful Morton neuroma, which most commonly affects the interspace between the third and fourth metatarsals. Four nerves supply the forefoot: the sural nerve (most lateral), branches of the superficial peroneal nerve, the deep peroneal nerve, and the saphenous nerve.

The joint between the forefoot and the midfoot, the tarsometatarsal (TMT) joint or Lisfranc joint, is formed by a mortise of the cuneiform bones surrounding the base of the second metatarsal. This joint is supported by the transverse ligaments, and the Lisfranc ligament joins the medial cuneiform and the base of the second metatarsal. Disruption of this ligament can result in a destabilization of the TMT joint complex of the foot, the result of which can be instability of the arch and the midfoot.

Question 6

Sport-Specific Biomechanics

Answer 6

The 3 planes in which the foot and ankle function are the transverse, sagittal, and frontal. Movement is possible in all 3 planes.

1. Plantar flexion and dorsiflexion occur in the sagittal plane. Plantar flexion involves the foot moving from the anterior leg distally. Dorsiflexion is the opposite motion.
2. Inversion and eversion occur in the frontal plane of motion. Eversion occurs when the bottom of the foot turns away from the midline of the body. Inversion is the opposite action.
3. The 2 transverse plane motions are abduction and adduction. Adduction involves the foot moving toward the midline of the body, whereas abduction is the opposite action.

Question 7

Sesamoiditis

Answer 7

Sesamoiditis is manifested by pain beneath the first metatarsal head with weight bearing on the ball of the foot or with motion at the first metatarsophalangeal (MTP) joint. Common complaints include pain with jumping and with pushing off to run.

Question 8

Turf Toe

Answer 8

Turf toe is an acute injury that involves forced hyperdorsiflexion of the first MTP joint as the classic mechanism of injury. This results in a sprain of the first MTP joint. Symptoms include pain and decreased range of motion (ROM) at the MTP joint and difficulty running or changing directions.

Question 9

Posterior Tibial Tendonitis

Answer 9

Posterior tibial tendinitis occurs most commonly as an idiopathic condition in middle-aged females. Athletes with this condition may present with planovalgus deformity and often play sports with sudden stop-start or push-off activity, such as soccer, football, and basketball. Patients typically complain of pain inferior to the medial malleolus and decreased ROM.

Question 10

Peroneal tendon subluxation/dislocation

Answer 10

Patients with peroneal tendon subluxation/dislocation typically present with acute pain and swelling that is centered behind the lateral malleolus, with extension proximally over the tendons. These symptoms are caused by a dorsiflexion-inversion stress injury that pulls the peroneal retinaculum off the lateral malleolus. Athletes usually complain of snapping and sudden sharp pain when changing directions or pushing off with the foot.

Question 11

Peroneal Tendonitis

Answer 11

Patients with peroneal tendinitis present with pain and swelling on the lateral aspect of the ankle, usually posterior to the lateral malleolus. Patients may also complain of either a “giving way” or “sharp pinching” sensation of the lateral ankle. Long-distance running and any activity that requires repetitive cutting and pushing off can aggravate this condition.

Question 12

Fifth metatarsal fractures

Answer 12

Fifth metatarsal fractures are a common complication with ankle sprains, so physicians must always address this condition when obtaining the patient’s history.

Three types of fractures occur in the fifth metatarsal.
1) Avulsion fractures off the base commonly occur with ankle sprains, particularly the plantar flexion-inversion variety.

2) Proximal diaphyseal fractures result from repetitive cyclical stress to the foot and typically have a prodromal presentation.
3) Transverse fractures occurring within 1.5 cm from the tuberosity at the metaphyseal-diaphyseal junction are the definitive Jones fracture. Contrary to popular belief, true Jones fractures primarily occur traumatically. Pain may be diffuse and difficult to localize, depending on the type and location of the fracture.

Question 13

Stress Fractures

Answer 13

Most athletes with stress fractures complain of progressively increasing pain that correlates with a change in activity, footwear, training, playing surface, or equipment. Trauma is not part of the history. Pain is exacerbated by impact loading and is ameliorated with rest.

Question 14

Ankle Sprain Background

Answer 14

An ankle sprain is usually that of an inversion-type twist of the foot, followed by pain and swelling. The most commonly injured site is the lateral ankle complex, which is composed of the anterior talofibular, calcaneofibular, and posterior talofibular ligaments.

Signs and symptoms of an ankle sprain include the following:
Pain/tenderness
Swelling and/or bruising
Cold foot or paresthesia (possible neurovascular compromise)
Muscle spasm
See Clinical Presentation for more detail.
Diagnosis

The physical examination confirms a diagnosis made on the basis of patient history and differentiates an ankle sprain from a fracture. Examination in patients may include the following tests:

1. Anterior drawer test: To assess for ankle instability
2. Prone anterior drawer test: Also tests for ligamentous instability
3. Talar tilt test (or inversion stress maneuver): To assess integrity of the calcaneofibular ligament
4. External rotation test: To evaluate the integrity of the syndesmotic ligaments
5. Kleiger test: Variation of the external rotation test; to assess the integrity of the deltoid ligament
6. Squeeze test (or fibular compression test): To evaluate for syndesmotic or fibular injury
   Neurovascular evaluation: To assess neurovascular status of the affected limb

Question 15

Imaging studies for Ankle Sprains

Answer 15

The following radiologic studies may be used to evaluate ankle sprains:
1. Plain radiography: Guided by the Ottawa Ankle Rules to diagnose ankle or foot fractures

2. Stress-view radiography: May provide further assessment for ankle stability; accuracy of study increases with use of local anesthesia
3. Computed tomography scanning: May be indicated for imaging of soft tissues or for bone imaging beyond radiography; useful for evaluating osteochondritis dissecans and stress fractures
4. Magnetic resonance imaging: May be useful to assess a suspected syndesmotic or high ankle sprain or if osteochondrosis or meniscoid injury is suspected in patients with a history of recurrent ankle sprains and chronic pain
5. Ankle arthrography: May be useful for determining capsular damage and the number of ankle ligaments damaged
6. Bone scanning: To detect subtle bone abnormalities (eg, stress fracture, osteochondral defects) and syndesmotic disruptions

Question 16

Management of Ankle Sprains

Answer 16

1. Conservative therapy
   Conservative therapy for acute ankle sprains may be described by the acronyms RICE (rest, ice, compression, and elevation) and PRICES (combination of protection, relative rest, ice, compression, elevation, and support). Protective devices include air splints or plastic and Velcro braces. Ankle taping can also increase ankle stability, but its effectiveness is highly dependent on the expertise of the individual who performs the taping.

Physical therapy during the recovery phase is aimed at the patient regaining full range of motion, strength, and proprioceptive abilities, and may include the following:
i. Strengthening exercises: Starts with isometric exercises, then advances to use of elastic bands or surgical tubing
ii. Proprioception rehabilitation: Starts with single-leg-stance exercise in a single plane, then progresses to multiplanar exercises
Other exercises: Uses a balance or tilt board, then advances to functional drills, jogging, sprinting, and cutting, and then progresses to figure-of-eight and carioca drills

2. Pharmacotherapy
   The following medications are used in the management of ankle sprain:
   Analgesics (eg, acetaminophen)
   Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen)
3. Surgery
   In most patients, there is no improved outcome with operative repair of third-degree anterior talofibular ligament tears and medial ankle ligament tears.
   Indications for operative intervention in patients with an ankle sprain include the following:
   Distal talofibular ligament third-degree sprain that causes widening of the ankle mortise
   Deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise
   In selected young patients with high athletic demands who have both anterior talofibular and calcaneofibular complete ruptures
   Surgical procedures for chronic ankle instability and sprains include the Watson-Jones procedure, the Evans procedure, and the Chrisman-Snook procedure.

Question 17

Conservative Therapy for Ankle Sprains

Answer 17

Conservative therapy for acute ankle sprains may be described by the acronyms RICE (rest, ice, compression, and elevation) and PRICES (combination of protection, relative rest, ice, compression, elevation, and support). Protective devices include air splints or plastic and Velcro braces. Ankle taping can also increase ankle stability, but its effectiveness is highly dependent on the expertise of the individual who performs the taping.

Physical therapy during the recovery phase is aimed at the patient regaining full range of motion, strength, and proprioceptive abilities, and may include the following:
i. Strengthening exercises: Starts with isometric exercises, then advances to use of elastic bands or surgical tubing
ii. Proprioception rehabilitation: Starts with single-leg-stance exercise in a single plane, then progresses to multiplanar exercises
Other exercises: Uses a balance or tilt board, then advances to functional drills, jogging, sprinting, and cutting, and then progresses to figure-of-eight and carioca drills

Question 18

Surgery Management for Ankle Sprains

Answer 18

In most patients, there is no improved outcome with operative repair of third-degree anterior talofibular ligament tears and medial ankle ligament tears.
Indications for operative intervention in patients with an ankle sprain include the following:
1. Distal talofibular ligament third-degree sprain that causes widening of the ankle mortise

2. Deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise
3. In selected young patients with high athletic demands who have both anterior talofibular and calcaneofibular complete ruptures

Surgical procedures for chronic ankle instability and sprains include the Watson-Jones procedure, the Evans procedure, and the Chrisman-Snook procedure.

Question 19

Background of Ankle Sprains

Answer 19

The history of an ankle sprain is usually that of an inversion-type twist of the foot followed by pain and swelling. An individual with an ankle sprain can almost always walk on the foot, albeit carefully and with pain.

In an individual with normal local sensation and cerebral function, the ability to walk on the foot usually excludes a fracture. (See Clinical Presentation.) Suspect neurovascular compromise if the patient reports a cold foot or describes paresthesias.

Bone tenderness in the posterior half of the lower 6 cm of the fibula or tibia and the inability to bear weight immediately after the injury and in the emergency department are indications to obtain radiographic imaging. These Ottawa ankle rules have been validated for patients aged 5-55 years.

Drawer and talar tilt examination techniques are used to assess ankle instability; however, the use of these techniques in acute injuries is in question because of pain, edema, and muscle spasm.

Pain reduction is essential, but improvement of any loss of motion, strength, and/or proprioception is equally important. Rest, ice, compression, and elevation (ie, RICE) are the mainstays of acute treatment; more comprehensively, the combination of protection, relative rest, ice, compression, elevation, and support (PRICES) is used.

Physical therapy during the recovery phase is aimed at the patient regaining full range of motion (ROM), strength, and proprioceptive abilities.

For recurrent lateral ankle sprains, treatment should begin with a trial of conservative therapy for approximately 2-3 months. The recurrence rate for lateral ankle sprains has been reported to be as high as 80%.

It is generally accepted that for most patients, operative repair of third-degree anterior talofibular ligament (ATFL) tears and medial ankle ligament tears does not contribute to an improved outcome. One of the few absolute indications for surgery in patients with a sprained ankle is a distal talofibular ligament third-degree sprain that causes widening of the ankle mortise. A second indication is a deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise.

Question 20

Ankle sprains are classified into the following 3 grades:

Answer 20

Grade 1 injuries involve a stretch of the ligament with microscopic tearing but not macroscopic tearing. Generally, little swelling is present, with little or no functional loss and no joint instability. The patient is able to fully or partially bear weight.

Grade 2 injuries stretch the ligament with partial tearing, moderate-to-severe swelling, ecchymosis, moderate functional loss, and mild-to-moderate joint instability. Patients usually have difficulty bearing weight.

Grade 3 injuries involve complete rupture of the ligament, with immediate and severe swelling, ecchymosis, an inability to bear weight, and moderate-to-severe instability of the joint. Typically, patients cannot bear weight without experiencing severe pain.

Question 21

Ankle Anatomy

Answer 21

The ankle joint is a hinged synovial joint with primarily up-and-down movement (plantar flexion and dorsiflexion). The other joints around the ankle are responsible for other movements, giving the ankle a total range of motion (ROM) comparable to that of a ball and socket. The combined movement in the dorsiflexion and plantarflexion directions is greater than 100°; bone-on-bone abutment beyond this range protects the anterior and posterior ankle capsular ligaments from injury. The anterior and posterior ankle capsular ligaments are relatively thin compared with the medial and lateral ankle ligaments.

Question 22

Pathophysiology of Ankle Sprain

Answer 22

The lateral ankle complex, which is composed of the anterior talofibular, calcaneofibular, and posterior talofibular ligaments, is the most commonly injured site.

Approximately 85% of such sprains are inversion sprains of the lateral ligaments, 5% are eversion sprains of the deltoid or medial ligament, and 10% are syndesmotic injuries. *The ATFL (anterior talofibular ligament) is the most likely component of the lateral ankle complex to be injured in a lateral ankle sprain. Osteochondral or chondral injuries of the talar dome should be considered when diagnosing an ankle injury.

During forced dorsiflexion, the PTFL can rupture. With forced internal rotation, ATFL rupture is followed by injury to the PTFL. Extreme external rotation disrupts the deep deltoid ligament on the medial side, and adduction in neutral and dorsiflexed positions can disrupt the CFL. In plantarflexion, the ATFL can be injured.

The strongest ankle capsule-ligament complex is the deltoid ligament, which has 2 parts: the superficial component and the deep component. The superficial component runs the farthest from the medial malleolus to the medial aspect of the calcaneus, posteriorly. The medial malleolus usually fractures before the deltoid ligament fails mechanically.

Question 23

Most likely to be hurt in lateral ankle sprain is..

Answer 23

*The ATFL (anterior talofibular ligament) is the most likely component of the lateral ankle complex to be injured in a lateral ankle sprain. Osteochondral or chondral injuries of the talar dome should be considered when diagnosing an ankle injury.

Question 24

Ankle Spurs

Answer 24

Ankle spurs may occur at any of the bony ligament attachments. On lateral radiographs, it is not uncommon to see an anterior spur at the neck of the talus, where the anterior ankle capsule attaches. This is caused by ossification of the hematoma organization associated with anterior ligament sprains.

Question 25

Syndesmotic Ligament

Answer 25

Because of its great strength, the syndesmotic ligament, which has a deep portion between the bones and superficial, anterior, and posterior portions, is rarely sprained. This distal tibiofibular ligament holds the distal tibia and fibular bones together at the ankle joint and maintains the integrity of the ankle mortise.

It takes a great amount of force to strain this ligament, which normally does not have much excursion. A significant tear of this ligament requires surgical treatment. Severe posttraumatic arthritis of the tibiotalar joint (ankle) can result quickly if a syndesmosis tear remains unrecognized and untreated. A syndesmotic ligament tear is usually a part of an ankle fracture that needs to be treated specifically. This is not generally true of the other ankle ligament tears.

Question 26

Etiology of Ankle Sprains

Answer 26

Mechanical forces exceeding the tensile limits of the ankle joint capsule and supportive ligaments cause ankle sprains.

There are a number of contributing factors, which can be classified as either predisposing or provocative, as follows:
1_ Predisposing factors can result from a lack of physical conditioning; they include poor muscle tone and shortened and/or contracted joint capsule or tendons. Poor proprioception can also be a factor, as can inadequate training or experience with the physical activity being performed.

2) Provocative factors include accidents and other unforeseen circumstances that result in mechanical stresses that exceed the tensile limits of the ankle joint capsule and ligaments. Obesity can contribute to sprains by increasing kinetic energy to a point that exceeds joint-design stress limits.

A cohort study analyzed risk factors in ankle injuries from the Cadet Illness and Injury Tracking System (CIITS) database at the United States Military Academy (USMA) from 2005-2009. The results found higher risk of syndesmotic ankle sprains in males who performed at a higher level of athletic competition; male athletes were 3 times more likely to experience medial ankle sprains than female athletes

Question 27

Prognosis of Ankle Sprain

Answer 27

Acute injuries
The prognosis for isolated and adequately treated ankle sprains is excellent. The prognosis for a patient with ankle sprains and other traumatic injuries is related to the prognosis for the other injuries.

In a systematic literature review, 36-85% of patients with acute ankle sprains reported full recovery at 2 weeks to 36 months, independent of the initial grade of sprain, [28] with most recovery occurring within the first 6 months. After 12 months, the risk of recurrent ankle sprain returns to preinjury levels.

Recurrent Ankle Sprains
If recurrent ankle sprains are treated early and appropriate rehabilitation is initiated, the prognosis is excellent with conservative treatment. The prognosis becomes even more important to consider for patients who require surgical correction. Reconstructive procedures can vary significantly in their ability to correct any persistent instability.

With respect to chronic syndesmotic sprains, long-term outcome studies are few in number. In a study conducted at West Point, all patients who were studied returned to full duty without further problems. One of these patients was surgically treated, and all had full ROM of the ankle.

Question 28

History of Ankle Sprain

Answer 28

The history of an ankle sprain is usually of an inversion-type twist of the foot followed by pain and swelling. Ask the patient about the mechanism of injury, as well as why, when, where, and how it occurred. Often, however, the patient’s account of the mechanism does not correlate with the structures that have been damaged.

An individual with an ankle sprain can almost always walk on the foot, albeit carefully and with pain. In an individual with normal local sensation and cerebral function, the ability to walk on the foot usually excludes a fracture. Sudden, intense pain and rapid onset of swelling and bruising suggest a ruptured ligament. Suspect neurovascular compromise if the patient complains of a cold foot or describes paresthesia.

Question 29

Management/Treatment of Ankle Sprains

Answer 29

Pain reduction is essential, but improvement of any loss of motion, strength, and/or proprioception is equally important. A meta-analysis found that neuromuscular rehabilitation results in more rapid improvements in function. For recurrent lateral ankle sprains, treatment should begin with a trial of conservative therapy for approximately 2-3 months.

It is generally accepted that for most patients, operative repair of third-degree ATFL tears and medial ankle ligament tears does not contribute to an improved outcome. One of the few absolute indications for surgery in patients with sprained ankles is a distal talofibular ligament third-degree sprain that causes widening of the ankle mortise. A second indication is a deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise.

Physical therapy during the recovery phase is aimed at the patient regaining full ROM, strength, and proprioceptive abilities. While a formal physical therapy program is particularly important for athletes and other patients who need a quicker recovery, most low demand patients will do well with a basic home exercise program