THIRD EDITION

Baxter’s
THE FOOT AND ANKLE
IN SPORT
David A. Porter, MD, PhD
Sports Foot and Ankle
Orthopedic Sports Medicine
Methodist Sports Medicine/TOS
Indianapolis
Director of Foot and Ankle Rotation
Orthopedics
Indiana University
Indianapolis, Indiana

Lew C. Schon, MD, FACS

Director of Foot and Ankle Fellowship and Service
Department of Orthopedics
MedStar Union Memorial Hospital
Baltimore
Associate Professor
Department of Orthopedics and Biomedical Engineering
Johns Hopkins University
Baltimore, Maryland
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 CONTRIBUTORS

Mostafa M. Abousayed, MD, MSc Don Baxter, MD

Resident Former Clinical Professor and Fellowship Director Orthopedic
Orthopedic Surgery Department, U of Texas Medical School and Baylor College of Medicine
Albany Medical Center, Houston Texas
Wynantskill, New York
Associate Lecturer Karim Boukhemi, MD
Orthopaedic Surgery UC Davis Dept of Orthopedics
Kasr Al-Ainy Hospitals, Cairo University College of Medicine University of California, Davis
Cairo, Egypt Sacramento, California

Annunciato Amendola, MD Nathaly Caicido Cruz

Professor Foot and Ankle Fellow
Orthopedic Surgery Foot and Ankle Unit Orthopaedics and Traumatology Department
Duke University Clínica Alemana
Durham, North Carolina Santiago
Orthopaedic Surgery Universidad del Rosario
Robert B. Anderson, MD Bogotá Colombia
Founder Foot and Ankle Surgery Universidad del Desarrollo
Foot and Ankle Santiago, Chile
OrthoCarolina,
Charlotte, North Carolina Debbie Carroll, DA MPT
Director, Foot and Ankle Physical Therapist
Titletown Sports Medicine and Orthopedics Rehabilitation
Bellin Hospital Methodist Sports Medicine
Green Bay, Wisconsin Indianapolis, Indiana

Gustavo Goncalves Arliano Sr, MD Rebecca Cerato, MD

Professor Orthopaedic Surgeon
Departamento de Ortopedia e T­ raumatologia Mercy Medical Center
Universidade Federal de São Paulo The Institute for Foot and Ankle ­Reconstruction
São Paulo, Brazil Baltimore, Maryland

Lara Atwater, MD, BA Felipe Andres Chaparro, MD

Fellow Foot & Ankle Surgeon
Institute for Foot and Ankle Reconstruction Foot & Ankle Center, Orthopaedic Surgery
Mercy Medical Center Clinica Universidad de los Andes
Baltimore, Maryland Santiago
Foot & Ankle Surgeon
Erin Richard Barill, BSc, PT/ATC Foot & Ankle Division, Orthopaedic Surgery
Director of Sports Medicine Hospital San José
Athletic Training Santiago, Chile
Indianapolis Colts
Indianapolis, Indiana Apisan Chinanuvathana, MD
Lerdsin Hospital
Gonzalo F. Bastias, MD Foot and Ankle Service
Foot and Ankle Unit Institute of Orthopedic Surgery
Department of Orthopedic Surgery Bangkok, Thailand
Clinica Indisa
Santiago, Foot and Ankle Unit Thomas O. Clanton, MD
Instituto Traumatologico “Dr. Teodoro Gebauer” Director Foot and Ankle Sports Medicine
Santiago, Chile Orthopedic Surgery
The Steadman Clinic
Vail, Colorado

v
vi CONTRIBUTORS

J. Chris Coetzee, MD Eric Giza, MD

Orthopedic Foot and Ankle Surgeon Chief, Foot & Ankle Surgery
Orthopedics Department of Orthopedics
Twin Cities Orthopedics University of California, Davis
Minneapolis, Minnesota Sacramento, California

Cesar de Cesar Netto, MD Joaquim Grava

Assistant Professor Sport Club Corinthians Paulista (SCCP)
Orthopedics and Rehabilitation Team Physician of Sport Club Corinthians Paulista
University of Iowa Instituto Grava
Iowa City, Iowa
Clinical Fellow Michael C. Greaser, MD
Foot and Ankle Surgery Assistant Professor
Medstar Union Memorial Hospital Department of Orthopedic Surgery
Baltimore, Maryland UT Health Science Center at Houston
McGovern Medical School,
Peter A. de Leeuw, MD PhD Houston, Texas
Orthopedic Surgery
Academic Medical Center Gregory P. Guyton, MD
University of Amsterdam Attending
Amsterdam, The Netherlands Orthopedic Surgery
MedStar Union Memorial Hospital
Peter Edwards, MD Baltimore, Maryland
Senior Attending
Orthopedic Surgery Amgad M. Haleem, MD, PhD
Ohio Orthopedic Center of Excellence Assistant Professor
Columbus, Ohio Orthopedic Surgery
Oklahoma University,
Richard D. Ferkel, MD Oklahoma City, Oklahoma
Program Director Lecturer
Sports Medicine Fellowship Orthopaedic Surgery
Southern California Orthopedic Institute Cairo University
Van Nuys, Los Angeles Cairo, Egypt
Assistant Clinical Professor
Orthopedic Surgery Mary Hastings, PT DP MSCI APT
UCLA Program in Physical Therapy
Los Angeles, California Washington University School of Medicine
St. Louis, Missouri
Lucas Fonseca, MD
Unifesp Elias Hermida
Orthopedic Department Orthopaedic and Traumatology Surgeon
Federal University of São Paulo Member of the Mexican Orthopaedic and Traumatology College
São Paulo, Brazil Certified by Mexican Orthopaedic and Traumatology Council -Inter-
national AAOS member -International NASS member -Director of
LCDR Apiporn Garnjanagoonchorn, MD PM&R Hospital de Ortopedia para Niños “German Díaz Lombardo” Mexico
Research Fellow City -Director of Spine Surgery Fellowship, Universidad La Salle
Orthopedic and Rehabilitation Director of Trauma Service at Hipódromo de las Americas, Mexico City
MedStar Union Memorial Hospital
John Hopkins Hospital Luis Felipe Hermida, MD
Baltimore, Maryland Orthopaedic Surgeon
Staff Physician Orthopaedics and Traumatology
Rehabilitation Centro Medico ABC
Somdech Phra Pinklao Hospital Mexico City, Mexico
Bangkok, Thailand
Foot and Ankle ­Consultant Adam M. Huff, MD
Indianapolis Colts, Community Physician Network
Indianapolis Indianapolls, Indiana
Foot and Ankle Consultant
Indiana University, Purdue University, ­
University Indianapolis
Indiana
 CONTRIBUTORS vii

Kenneth J. Hunt, MD Rover Krips, MD PhD

Associate Professor and Chief, Foot and Ankle Surgery Orthopedic Surgery
Department of Orthopedic Surgery Academic Medical Center
University of Colorado, School of Medicine Amsterdam
Aurora, Colorado Afdelind Orthopaedie
Diaconessenhuis Leiden
Jim Jastifer, MD Leiden, The Netherland
Foot and Ankle Orthopedic Surgeon
Surgery R. Jay Lee, MD
Borgess Medical Center Assistant Professor
Kalamazoo, Michigan Orthopedics
Johns Hopkins
Juan Pedro Kalb, MD Baltimore, Maryland
Department of Orthopedic Surgery
Clinica del Campestre, Shuyuan Li, MD PhD
Medellin, Research Coordinator
Antioquia, Colombia Steps2Walk
Miami, Florida
David C. Karli, MD, MBA
Steadman Clinic-Physician Partner Gustavo Damasio Magliocca, MD
Greyledge Technologies, LLC Medical Department
Vail, CO Sociedade Esportiva Palmeiras
São Paulo, Brazil
Moosa Kazim, MD FRCS(C)
Medical Director Dave Himanshu Malhar, MBBS, MS Ortho
Orthopedics and Sports Medicine Orthopaedics
Orthosports Medical Center, Abhishek Hospital
Dubai, United Arab Emirates Vaddodara
Gujarat, India
Cesar Khazen
Foot and Ankle Department Peter Maurus, MD
Hospital de Clinicas Caracas Orthopedic Surgeon, Foot and Ankle ­Surgery
Caracas, Venezuela Mercy Hospital
Steindler Orthopedic Clinic
Garbriel E. Khazen, MD Iowa City, Iowa
Foot and Ankle Department
Hospital de Clinicas Caracas, Jeremy McCormick, MD
Caracas, Venezuela Associate Professor
Orthopedic Surgery
Amed Khedr, MD MSc PhD Washington University School of Medicine
Lecturer St. Louis, Missouri
Orthopedic Surgery
Cairo University William C. McGravey, MD
Cairo, Egypt Associate Professor of Orthopedic Surgery
Clinical Fellow Orthopedic Surgery
Orthopedic Surgery Orthopedic Residency Program Director
University of Pittsburgh Orthopedic Surgery
Pittsburgh, Pennsylvania University of Texas Health Science Center-Houston
Houston, Texas
Walter Klyce, MD
Poggi Research Fellow Alireza Mousavian, MD
Pediatric Orthopedics Assistant Professor
Johns Hopkins University Orthopedic Surgery
Baltimore, Maryland Mashhad University of Medical Sciences
Mashhad
Christopher Kreulen, MD MS Khorasan Razavi, Iran
Assistant Professor
Orthopedics
University of California, Davis Medical Center
Sacramento, California
viii CONTRIBUTORS

Mark S. Myerson, MD Carlos Enrique Ramirez, MD

Executive Director and Founder Foot and Ankle Surgeon
Steps2Walk Orthopedic
Baltimore, Maryland Centro Médico Imbanaco
Cali
Devon Nixon, MD Professor
Resident Orthopedic Surgery
Department of Orthopedic Surgery Universidad del Valle
Washington University in St. Louis Cali
St. Louis, Missouri Valle Del Cauca, Colombia

James A. Nunley, MD Andrew Roney, BA

J Leonard Goldner Endowed Professor Foot and Ankle
Orthopaedic Surgery Hospital for Special Surgery
Duke University New York, New York
Durham, North Carolina
Gregory Y. Rowdon, MD
Martin O’Malley, MD Team Physician
Attending Orthopedic Surgeon Athletics
Foot and Ankle Surgery Purdue University
Hospital for Special Surgery (HSS) W Lafayette, Indiana
New York
Associate Professor Lew Schon, MD, FACS
Orthopedics Director of Foot and Ankle Fellowship and Service
Weill Medical College of Cornell University Department of Orthopedics
New York, New York MedStar Union Memorial Hospital
Baltimore
Jakrapong Orapin, MD Associate Professor
Orthopaedic Surgeon Department of Orthopedics and Biomedical Engineering
Orthopaedic Surgery Johns Hopkins University
Ramathibodi Hospital, Mahidol University Baltimore, Maryland
Bangkok, Thailand
Elliot N. Schwartz, MD
Christian A. Ortiz Sr, MD Medical Director
Chief Clark Miller Center for the Evaluation and Treatment of Stress
Foot Ankle Surgery Fractures
Clinica Alemana Northern California Institute for Bone Health, Inc. Orinda
Santiago, Chile Institute Director
Northern California Institute for Bone Health, Inc.
Pedro Augusto Pontin Orinda, California
Care Club and Sociedade Esportiva Palmeiras (SEP)
Department of Orthopedic Surgery Nikesh Shah, MS (Ortho)
University of Sao Paulo Director
Orthopaedics
David A. Porter, MD PhD Indrapuri Hospital
Sports Foot and Ankle Vadodara
Orthopedic Sports Medicine Gujrat, India
Methodist Sports Medicine/TOS
Indianapolis Rajiv Sumanlal Shah, MS (Ortho)
Director of Foot and Ankle Rotation Foot & Ankle Orthopaedics
Orthopedics Sunshine Global Hospital
Indiana University Vadodara, India
Indianapolis, Indiana
Scott B. Shawen, MD
Orthopedic Foot & Ankle Surgeon
Foot and Ankle Institute
OrthoCarolina
Charlotte, North Carolina
 CONTRIBUTORS ix

Jonathan P. Smerek, MS MD Adriaan van Zyl, MBChB MMed

Associate Professor Visiting Consultant Orthopaedics
Department of Orthopedics Orthopaedics
Indiana University School of Medicine University of Stellenbosch
Indianapolis, Indiana Cape Town
Orthopedic Surgeon
Kenneth Smith, BA MD Louis Leipoldt Mediclinic
Resident Physician Cape Town
Orthopedics Western Cape, South Africa
University of Alabama at Birmingham
Birmingham, Alabama Emilio Wagner, MD
Staff Foot and Ankle Unit
Yasuhito Tanaka, MD Orthopedic and Traumatology
Professor and Chair Clinica Alemana
Department of Orthopaedic Surgery Santiago, Head Foot and Ankle Unit
Nara Medical University Orthopedic and Traumatology
Kashihara, Japan Hospital Padre Hurtado,
Santiago, Chile
Michel A. Taylor, MD MSc FRCSC
Orthopedic Surgery Norman E. Waldrop III, MD
University of Arizona Attending Physician
Tucson, Arizona Department of Orthopedic Surgery
Andrews Sports Medicine and Orthopedic Center
David Taylor, MD Birmingham, Alabama
Sports Medicine Fellow
Methodist Sports Medicine Xu Xiangyang, MD
Indianapolis, Indiana Professor
Department of Orthopaedics
Wisutthinee Thueakthong, MD PM&R Shanghai Jiaotong University Medical College
Physical Medicine&Rehabilitation Ruijin Hospital
Bhumibol Adulyadej Hospital Shanghai, China
Bangkok, Thailand
Zijun Zhang, MD PhD
Andrew M. Tucker, MD Director
Medical Director Orthobiologic Lab
MedStar Sports Medicine MedStar Union Memorial Hospital
MedStar Union Memorial Hospital Baltimore, Maryland
Baltimore, Maryland
Yuan Zhu, MD
Pim A.D. van Dijk, BSc Orthopedic Surgeon
PhD Student Orthopedic Department
Department of Orthopaedic Surgery Foot & Ankle Center
Academic Medical Center Shanghai Ruijin Hospital
Amsterdam, The Netherlands Shanghai Jiaotong University School Of Medicine
Shanghai, China
C. Niek van Dijk, MD PhD
Head
Department of Orthopaedic Surgery
Academic Medical Center
Amsterdam, The Netherlands
 P R E FA C E

The third edition of “Baxter’s The Foot and Ankle in Sport” is ground-breaking videos educate more about our approach and
finally here! We are excited to enhance your knowledge and the anatomy.
skills with this unique updated textbook. So, “What’s new?” The chapter on Medical and Metabolic Considerations in the
We have created five fresh chapters and have done major revi- Athlete is the most up-to-date and authoritive treatise on the
sion on over 50% of the chapters. More than 50% of the authors subject. The full extensive chapter is available online, but a more
are new to this edition and reflect diversity in experience and streamlined version is in the written text. We recommend you
perspective. We have included new, younger authors, as well as avail yourself of the whole chapter. We have also included the
retained some of the best names in orthopedic athletic foot and chapter, The Team in the Care of the Athlete, to help with assess-
ankle care. To further enhance the reader’s experience, we have ing this critical area within the care of the athlete. The chapter
incorporated a video section highlighting radiographic and specifically discusses how the healthcare provider and specialist
ultrasonographic techniques as well as physical assessment of can interact with all the other providers, caregivers, patient rep-
the dancer. resentatives, and team administrators. We have taken an inter-
This text focuses on the evaluation, decision making, treat- view and key word approach and think it delivers at every level
ment algorithms, and rehabilitation of the athlete at all levels. from perspective of the athlete, athletic trainer, general man-
Often, the technical surgical approaches to athletes are similar ager, parent, and specialist. Tendonoscopy and Arthroscopy of
to the nonathlete, but the decision making, impact on return other Foot and Ankle Joints looks at the ever-expanding role of
to play, interplay with other healthcare providers and caregivers, arthroscopy and endoscopy in the evaluation and treatment of
as well as the rehabilitation of the athlete take more specific the foot and ankle. The Military Athlete is a unique new chapter
detailed education. We have attempted to elucidate this aspect that delineates and addresses needs, circumstances, and con-
of care well. siderations in this special population of athletes. We are not
We start the book off in this edition with a thorough outline aware of another foot and ankle text that addresses this. Lastly,
and explanation of a good, standard foot and ankle examina- we have also added a chapter on the ever-expanding Orthobio-
tion that we use on most all our athletes, Evaluation of the Ath- logics in Foot and Ankle Surgery. This chapter gives up-to-date
lete. This is a complete rework of the 2nd edition chapter and information on biological additives, subchondroplasty, cartilage
takes a totally different approach. To augment the chapter, we substitution, and other bone and cartilage options for operative
have included extensive videos on examination to better help and nonoperative treatment. We think it is a must-read for all
the reader incorporate the exam into their practice. We have those caring for the athlete.
also integrated unique ultrasound examination of common foot We hope you enjoy the book. We welcome any feedback you
and ankle ailments and dynamic radiographic examination of would like to give us. As always, we hope all your foot and ankle
other foot and ankle injuries. A series of videos on assessment of patients get better.
the dancer is presented to enlighten our readers. We hope these David A. Porter, MD, PhD, and Lew Schon, MD, FACS

xi
 1
The Basic Foot and Ankle Physical Exam
David A. Porter

OUTLINE
1. Neurologic Exam, 2 4. F
 urther Investigation When Indicated by Patient History
2. Pulses and Edema, 2 and Physical Exam, 4
3. Musculoskeletal Exam, 3
 

The physical examination is essential to properly diagnose ail- d. Nerves Examined

ments of the foot and ankle. Subsequent to obtaining a patient’s i. Deep peroneal nerve
history and noting the patient’s overall well-being, the medical ii. Superficial peroneal nerve
professional conducting a routine exam of a new patient should iii. Medial plantar nerve—found over great toe
investigate the following on the involved and uninvolved foot iv. Lateral plantar nerve—felt over fifth metatarsal
and ankle: e. If further investigation is indicated, the Semmes Wein-
**Please view the following videos that accompany this stein test is performed. This assesses the patient’s ability to
chapter, especially the primary video of the foot and ankle exam: feel pressure and examines altered sensations indicative of
Examination of the Foot and Ankle in the Athlete (Video 1.1) different neuropathies.
Other mini C-arm X-ray evaluations are useful to the exam- 2. Pulses and Edema
ination of the Foot and Ankle. (Videos 1.2‒1.5) a. At least one pulse on each foot must be felt in order to be
Ultrasound videos also presented for review. Ultrasound has considered as having sufficient blood flow to the foot. Good
become more prevalent in musculoskeletal evaluation. We have blood flow to the foot and ankle is important for proper
provided 11 narrated ultrasound videos of common foot and healing, especially in patients with preexisting conditions
ankle pathology. We recommend you avail yourselves of these that could impede the return of function, e.g., diabetes and
videos to learn how to use ultrasound to evaluate foot and ankle peripheral vascular disease in the older athlete.
pathology from the Achilles, to the peroneals, to the Anterior b.  While palpating for pulses, the medical professional
tibial tendon, to the posterior tibial tendon, to neuromas, and should place the patient’s feet on his or her knees so the
even muscle injury. (See Videos 1.6‒1.16) patient’s legs are completely relaxed. In a non-relaxed
Please note, from the standpoint of billing and thoroughness, position, the lower limb will begin to shake, making it
there may be more things you want to include in your exam, such hard to feel the pulses.
as constitution, skin, lymphatic, psychiatric, etc., but it may not be i. The following arteries are examined bilaterally:
specific to this exam. I. Pedal posterior tibial artery—palpated just poste-
1. Neurologic Exam rior to medial malleolus
a. The purpose of this exam is to look for light touch sensa- II. Dorsalis pedis artery—palpated laterally to exten-
tion in different nerve distributions. Underlying conditions, sor hallucis longus muscle over the Lisfranc
such as prior surgeries, diabetes, neuropathies, or prior region of the bigfoo5t
back ailments, may cause decreased light touch sensation. ii. Pulses are reported in reference to their rhythm and
b. While the patient is seated, the medical provider should quality.
be at the patient’s level, if not slightly below. Place the I. “No Pulse (NP)” is reported if no pulse is felt. If
patient’s legs in a straight position onto the provider’s lap/ no pulse is felt, the medical provider checks to
upper thighs. This makes it easy to examine the foot and make sure the foot is at least warm to the touch.
ankle while the patient is relaxed. II. If either pulse is felt, it is reported as regular or
c. The nerves should be simultaneously examined bilaterally irregular, noting bradycardia or tachycardia. A
in order for the patient to differentiate the sensations he “+1” or “+2” is additionally added to describe the
or she may feel. This allows the patient to better assess ease of finding the pulse; “+2” means the pulse
subtle differences in light touch. was found quickly.

2
 CHAPTER 1  The Basic Foot and Ankle Physical Exam 3

c.  Edema is reported on a scale of 0–2, with 2 being a sub- ii. Decreased calf tone tells us that the use of the foot
stantial amount of edema. Fullness (“puffiness”) and and/or ankle has been limited within the last few
swelling (noticeable edema) should be described along months, indicating an injury may have occurred.
with the location of the edema. Toe Raise
f. 
3. Musculoskeletal Exam i. Bilateral toe raise is used to observe the quality of calf
a.  Gait is observed and reported as normal or antalgic, tone. It also aids in the understanding of the function-
which means that it has changed in order to avoid pain. ing of the posterior tibial tendon. By the nature of the
This is a good indication that a patient may have problems heel, and the posterior tibial tendon mechanics, as the
bearing weight on the involved foot and/or ankle. patient goes up onto his or her toes, alignment of neu-
b.  Knee Alignment tral, varus, or valgus can be determined and the func-
i. It is essential to always look at knee alignment with the tion of the posterior tibial tendon (PTT) is assessed.
patient/athlete fully standing in a weight-bearing posi- That is, normally, the heel should go from slight valgus
tion, as some ailments are related to malalignment. in stance to significant varus with heel rise. Pathologic
ii. Knee alignment is not measured in degrees. It is function of the PTT or if the athlete has a subtalar coa-
reported as varus (angled medially toward midline), lition will result in the heel staying in valgus or only
valgus (angled laterally from midline), or neutral. The getting to neutral. The medical provider should note
patient’s feet are placed together to get the best read- any pain associated with this maneuver also.
ing of varus and valgus alignment. I. While in a bilateral toe raise, the patient should
c.  Deformity notes the different types of deformities present walk to assess for pain and strength.
and the impact they have on the function of the foot and/ II.  Additional walking tests include having the
or ankle. One example would be a pronation deformity. All patient walk on his or her heels. This will demon-
deformities should be reported as mild, moderate, or severe. strate any extensor lag of the foot that patient may
Another is femoral ante version that can be associated with be experiencing due to a radiculopathy, or weak-
patellofemoral malalignment and pronation deformity. ness/tear of the anterior tibial tendon.
d. Hindfoot Angle ii. Single toe raise is used to diagnose and assess specific
i. This angle is measured by aligning the goniometer injuries. The provider should note if the patient is
from the center of the calf, through the center of the unable to perform the maneuver or if it is considered
Achilles tendon, to the center of the plantar heel as the good or poor. The alignment of varus, valgus, and
patient is standing with his or her feet shoulder width neutral should also be reported. It is common to see
apart facing away from the medical provider so the patients limp if they are unable to perform a single toe
provider sees the back of the patient. raise because they cannot push off while walking.
ii. The hindfoot angle is reported as varus, valgus, or I. A single toe raise can be used to observe the func-
neutral. If in varus or valgus, the angle measurement tional status of the posterior tibial tendon.
is reported with it. II. During the healing process of an Achilles tendon
iii. The deltoid ligament is crucial to medial instability. rupture, a single toe raise can assess calf size to
Like the lateral collateral ligament of the knee for varus see if there has been an increase in the use of the
stability, it is under tremendous tension during stance. foot and/or ankle.
The knee often is in varus, while the hindfoot is often Range of Motion
g. 
seen in valgus, thus the medial tension on the deltoid.  Throughout range-of-motion testing, the provider should sit
iv. Common measurements for males in our experience at the same level of the patient’s lower extremities, if not
are 2–3 degrees of valgus, while for females they are slightly below the patient. This allows the patient to relax his
3–4 degrees of valgus, but the variance can be as great or her foot and ankle.
as 3 degrees of varus up to 6–8 degrees of valgus. i. Straight Leg Raise
Dancers often have more of a neutral or sometimes I. Straight leg raise with the patient still seated, is
varus hindfoot angle. used as a screening exam to determine if pain in
v. Hindfoot angle, type of alignment, and type of injury the lower limb involves the back. This is a good
are all considered when deciding on the proper treat- maneuver to test for herniated disc pain/sciatica/
ment. For example, if a patient has a hindfoot varus radiculopathy.
malalignment (walking more on the lateral heel) with II. The medical provider lifts the straight leg while
chronic ankle instability, alignment must be con- the patient is seated to test for shooting pain down
sidered and possibly fixed because a reconstruction the leg. If there is abnormality reported with this
could fail due to continued stress of malalignment. maneuver, the patient is then asked to lay supine
e.  Calf Tone and perform the leg raise again in order to exe-
i. Observed during a bilateral toe raise, calf tone reports cute a more thorough examination to assess if
the size of the calf while looking at the contour of the the pain is coming from the back instead of tight
muscle. It is reported as good or decreased. hamstrings.
4 SECTION 1  An Introduction to Athletic Evaluation

ii. Dorsiflexion II. It is reported as good stability or increased liga-

I. Maximal dorsiflexion is measured with a goniome- mentous laxity. If increased, it is reported as mild,
ter to assess flexibility in degrees. The angle is created moderate, or severe.
with the anterior edge of the tibia and a line parallel III. While performing an anterior drawer, the medical
to the plantar sole while the foot is passively posi- provider should look for a positive “suction sign.”
tioned into dorsiflexion. We measure dorsiflexion When a torn ligament is present, there is negative
from the medial foot/ankle for proper placement of pressure in the ankle with this maneuver, pulling
the goniometer just for the convenience of not having the skin into the space. These are often accompa-
to move our position or the patients (see video 1.1). nied with poor endpoints.
II. If a patient presents with a severe pronation iii. Endpoints
deformity, the medical provider must first correct I. Both the talar tilt and anterior drawer are reported
the hindfoot alignment before passively moving with an endpoint, which is where the movement
the foot into dorsiflexion. from the test is halted. It is determined based on
III. Pain during dorsiflexion should be noted. laxity during the exam by feeling a firm endpoint,
IV. The average dorsiflexion angle is 10 degrees to 15 mild softness, or no endpoint, with other soft-
degrees; however, the goal is to get patients to 20 tissue structures possibly limiting excursion.
degrees. II. An endpoint is reported as good, poor, soft, or no
V. Good dorsiflexion is an important part of treat- endpoint.
ment because it can relieve general pain caused by 4. Further Investigation When Indicated by Patient History
tightness. and Physical Exam
iii. Plantarflexion(PF) a. Special Tests
I. PF is primarily assessed postoperatively to ensure i. External Rotation (ER) Test (see also Video 1.3 Eval-
full range of motion has returned. uation of Syndesmosis)
II. It is measured with a goniometer by passively put- I. External rotation test is used to check for syndes-
ting the foot into PF. mosis (high ankle sprain) injuries.
iv. Subtalar Motion II. The medical provider rotates the foot and ankle
I. The quality of subtalar range of motion is tested externally while keeping the lower leg straight.
by passively inverting and everting the foot to We believe this test is more sensitive, specific, and
check lateral and medial range of motion. definitive than the Squeeze test.
II. It is reported as good or restricted, noting if ii. Squeeze Test
inversion or eversion is impeded. If restricted, it I. The squeeze test is also used for syndesmosis
is reported as mild, moderate, or severe. Pain with injuries; however, the ER test is often considered
the maneuver should also be reported. more sensitive, specific, and definitive.
v. Great Toe Extension (GTE)—Is assessed by measuring II. The provider is looking for reported ankle pain
the angle between the dorsal border of the first meta- while squeezing the proximal leg around the
tarsal and the axis of the distal toe itself (see video 1.1). proximal tibiofibular joint.
Normal GTE is 70—90 degrees and is decreased with iii. Thompson Test
Hallux Rigidus. I. It is used to assess the integrity of the Achilles’ tendon.
h. Stability (see Video 1.1) II. The patient lies in the prone position, and the
i. Talar Tilt (Assesses the Calcaneofibular ligament—CFL): examiner passively bends the knee to a 90-degree
I. Talar tilt is assessed with the ankle maximally angle. As the medical provider squeezes the calf,
dorsiflexed and the whole foot and hindfoot tilted the foot should plantarflex, showing the Achilles is
into varus through the ankle joint. This is because intact. If there is no PF, the Achilles tendon is rup-
the CFL is under maximal tension in DF. tured. This is called a positive Thompson Test.
II. It tests the stability of the calcaneofibular liga- III. To avoid the confusion regarding what is a pos-
ment by inverting the ankle joint. itive (+) Thompson test and what is a nega-
III. It is reported as good stability or increased lax- tive (–) Thompson test, we recommend stating
ity, meaning that there is no or positive ligamen- whether there is “+ Plantarflexion with Thompson
tous laxity present, respectively. If increased, it is test” (Achilles intact) or “no plantarflexion with
reported as mild, moderate, or severe. Thompson test” (torn Achilles tendon). We believe
ii. Anterior Drawer (Assesses the Anterior Talofibular this approach is simpler and clearer (don’t have to
Ligament—ATFL). remember, or expect those reading your report to
I. It tests the stability of the anterior talofibular lig- remember, when the Thompson test is positive or
ament by holding the tibia stable and then grab- negative, with or without PF).
bing the whole foot and hindfoot with the other IV. It is reported as “+ PF” for positive plantarflexion
hand and pulling the complex forward to 10–15 or “No PF” if there is no plantarflexion. The pres-
degrees of PF. ence of a palpable defect should be noted.
 CHAPTER 1  The Basic Foot and Ankle Physical Exam 5

iv. Abduction Stress Test II. The provider applies a lateral force while the
I. This test is used to examine Lisfranc ligamentous patient everts the foot against the force.
injuries. iii. Extension of Knee Strength—While the knee is fully
II. To perform the test, the lateral foot is held while extended, the provider applies force to try to move
a valgus stress is applied to the medial foot to test knee into flexed position.
for ligamentous instability of the Lisfranc. iv. Flexion of Knee Strength—The provider tries to dis-
III. The presence of pain while performing the test rupt flexion of the knee by applying an anterior force
should be reported. to the calf in order to extend the knee.
b. Posterior Ankle Impingement (PAI) (See also Video 1.4 v. Abductor Strength—With a patient in a neutral posi-
Evaluation of Os Trigonum) tion, the provider pushes the lateral thigh toward the
i. The provider is assessing the amount of pain with pas- midline while the athlete tries to move the leg away
sive plantarflexion or hyperplantarflexion and palpa- from the midline (Abduction).
tion of the posterior process of the talus (Os trigonum vi.  Adductor Strength—With the athlete in a slightly
or Stieda process). It is important to ask the athlete if abducted position, the provider tries to move the ath-
the pain he/she reports is actually in the anterior or lete’s leg away from the midline (abduct) the leg while the
posterior ankle; posterior pain implies posterior ankle athlete tries to move the leg toward the midline (adduct).
impingement, while anterior pain with PF implies vii. Hip Flexor Strength—With the athlete in a seated
only stretching of the anterior capsule and does not position with the knees in flexion, the athlete should
imply PAI. lift one knee at a time against downward resistance
ii. The medical provider moves the foot into plantar- force applied by the provider.
flexion while pushing the heel up so the posterior e. Palpation of Nerve Pain
talus is impinged by the posterior distal tibia and i. Deep peroneal nerve (DPN)
calcaneus. I. Located lateral to first metatarsal and medial to
c. Reflexes second metatarsal (the soft space interval between
 Reflex examinations should be performed on athletic these two metatarsals), it can be palpated in the
patients reporting athletically associated lower leg pain. soft space distal to the Lisfranc ligament.
If there is difficulty assessing the following reflexes, have II. Pain in this area is characteristic of deep peroneal
the patient interlock his or her fingers and forcefully pull nerve entrapment.
against them to block any resistance. III. The athlete does not always have numbness, tin-
i. Achilles (S1 reflex) gling, or light touch deficits with DPN entrapment.
I. It is a neurologic exam used to look at the Achilles ii. Superficial peroneal nerve (SPN)
jerk reflex. I. It can be palpated approximately four finger-
II. The Achilles tendon is tapped while the foot is breadths above the distal tip of the fibula, just
dorsiflexed. A positive test results in the foot jerk- anterior to the fibula (can be coming out of the
ing toward the plantar surface. anterior or lateral compartment). Typically seen
ii. Patellar (L4 reflex) traversing the ankle over the anterorlateral ankle
I. It is a neurologic exam used to look at the patellar joint with the ankle PF and inverted.
stretch reflex. II. Localized pain can occasionally radiate to the top
II. The test is performed by striking the patellar ten- of the foot.
don just below the patella while the knee is bent III. Pain to palpation that reproduces the athletes
and relaxed. A positive test will cause the leg discomfort is the most common manifestation of
to extend (a goniometer itself can be used as a SPN entrapment.
“reflex hammer,” since it is readily available). iii. Medial plantar nerve (MPN)—Palpate the nerve just
d. Strength inferior to the abductor hallicus muscles at the level of
 Strength should also be assessed in athletes who report the medial navicular
lower leg pain. 5/5 (normal) strength is reported if the med- iv. Lateral plantar nerve (LPN)—This nerve is hard to
ical provider cannot change direction of foot/ankle or lower palpate, but with isolated LPN entrapment, one notes
limb with resistance while the athlete actively moves the pain with palpation of the PT (posterior tibial) nerve
foot/ankle during each of the provocative tests. posterior to the medial malleolus. (This entrapment
i. Inversion strength can occur with an accessory flexor tendon in the tar-
I. The purpose of this test is to examine the strength sal tunnel—it can abut the LPN only and cause lateral
of the posterior tibialis. plantar foot pain.) See Chapter 11 section on Tarsal
II. The provider applies medial force while the tunnel.
patient inverts the foot against the force. v. Posterior tibial nerve
ii. Eversion strength I. Palpated posterior to posterior tibial tendon
I. This test examines the strength of the peroneus and flexor digitorum longus tendon in the tarsal
longus and brevis. ­tunnel.
6 SECTION 1  An Introduction to Athletic Evaluation

II. Pain with or without palpation in this area h. Great Toe Pain (see also Video 1.2 Evaluation of Turf Toe)
can be indicative of neuralgia or tarsal tunnel i. If the athlete reports plantar great toe pain, both sesa-
syndrome. Further testing is required to deter- moids should be examined. If the pain is acute with a
mine cause. See Chapter 11 section on Tarsal history of GTE injury and swelling, then turf toe must
tunnel. be considered and evaluated.
vi. Sural nerve ii. The provider can often palpate well between the tibial
I. It is located posterior to the fibula, and it is often sesamoid and fibular sesamoid, and the plantar plate
palpated along the lateral malleolus, or just poste- (turf toe injury) is just distal to the sesamoids.
rior to it and anterior to the Achilles. i. Lower Leg Pain
II. Though uncommon, sural nerve entrapment can i. Palpation for Musculoskeletal Pain—Stress Fracture
occur with pain in this localized area. I. Anterior crest of the tibia—anterior tibial stress
III. Also, sural nerve can be associated in rare cases fracture
after chronic calf strains with excessive scarring. II. Proximal tibial stress fracture—posteromedial
In this scenario, the pain is in the central calf tibial metaphysis
between the medial and lateral heads of the gas- III. Distal tibial stress fracture—posterormedial tibial
trocnemius where the sural nerve runs at the level metaphysis and distal tibial diaphysis (medial tib-
of the musculoskeletal junction. ial stress syndrome [MTSS] will have pain over
f. Suspicion of Neuroma larger area, stress fracture has focal pain)
i. If nerve pain is suspected, the provider should sepa- IV. Distal fibula
rately palpate each individual web space on the dorsal a. The fibula is subcutaneous over the distal 8‒10 centime-
and plantar surface of each foot noting any difference ters. The SPN can be confused with the distal fibula stress
in sensation, radiation into the toes, or pain. fracture. The SPN exits its fascial compartment 3‒4 finger
ii. The Mulder Click, noted with medial and lateral com- breadths above the ankle. The SPN is usually more anterior
pression of the forefoot while simultaneously palpat- to the fibula at this level, and to differentiate between SPN
ing the webspace. We have noted this is a common entrapment and fibula stress fracture, the provider pal-
finding due to movement of local tissues (tendons and pates the posterior border of the fibula, which will be pain
bursae) even in those without any other evidence of a free in SPN but still painful with fibular stress fracture.
neuroma. Therefore, we do not put a lot of weight on ii. MTSS (pain at soleus bridge and soleus/gastroc soft
this finding. tissue attachment to medial tibia)
iii. It is important to palpate each space and not just the I. We want to differentiate the pain from a distal tib-
symptomatic interspace. If a patient is symptomatic ial stress fracture and this soft-tissue attachment
in all web spaces, it could be indicative of neuralgia that is akin to a “tennis elbow of the leg.”
or tarsal tunnel syndrome. Pain, primarily localized II. Starting at the distal posterior tibial tendon on the
to one interspace (2-3 or 3-4 interspace) is suggestive medial side, the provider palpates up the medial
of a symptomatic neuroma. Doing this discriminat- tibia, marking where pain is felt. The provider
ing exam can help differentiate nerve pain caused by then starts proximally and moves distally along
a neuroma or nerve pain caused by neuralgia or tarsal the medial tibia noting the location of pain.
tunnel. III. To ensure accurate location of pain, it is recom-
g. Dorsal Foot Pain mended that a mark with a pen be made at the
i. The medial provider should specifically examine the two extents of pain. Typically, the pain is over a
deep peroneal nerve found between the first and 8‒15-cm segment of the posteromedial tibia. We
second metatarsals. The first and second metatar- measure and document how far each mark is
sals along with the soft space in between should be from the distal tip of the medial malleolus.
­palpated. IV. MTSS has a much larger area of pain (8‒15 cm),
ii.  The metatarsophalangeal joints (MTP), especially and distal tibial stress fracture has a very focal
the second MTP joint and occasionally the third and small area of pain (3‒6 cm).
MTP, should be moved passively into plantarflexion In addition, the medical provider should note any bruising,
to assess for MTP synovitis. Passive PF of the joint abrasions, varicosities, or masses that are seen throughout the
tightens the capsule and, with synovitis, can result in physical examination. Pain and tenderness with palpation and
severe pain. movement should be described by their location and severity.
Video Legends - https://www.kollaborate.tv/link?id=5c9d1f8590f70 Video 1.9  Title: Ultrasound Evaluation for Achilles Tendon Partial
Tear. Legend: Ultrasound over the Achilles shows the partial tear. Note
Video 1.1  Title: General Complete Physical Exam of the Foot and there is partial tear but not a full-thickness tear.
Ankle Legend: This video demonstrates a complete and detailed physi-
cal examination of the foot and ankle. Video 1.10  Title: Ultrasound Evaluation for Dislocating Peroneal
Tendon. Legend: Ultrasound over the lateral ankle demonstrates sub-
Video 1.2  Title: Mini C-arm Evaluation for Turf Toe Legend: Mini luxation/dislocation of the peroneus longus over the posterolateral fibula.
C-arm of the great toe with hyperextension to assess if the sesamoids
move with movement of the toe itself. Video 1.11  Title: Ultrasound Evaluation for Intrasheath Peroneal
Tendon. Legend: Ultrasound over the lateral ankle demonstrates sub-
Video 1.3  Title: Mini C-arm Evaluation of the Syndesmosis Legend: luxation of the peroneal tendon side-to-side on each other within the
Mini C-arm of ankle syndesmosis with abduction stress demonstrating expanded sheath.
widening of the medial clear space and the syndesmosis. External rota-
tion stress shows more subtle rotational instability. Video 1.12  Title: Ultrasound Evaluation of Posterior Tibial Tendon
Tear. Legend: Ultrasound over the medial ankle shows an abnormal
Video 1.4  Title: Mini C-arm Evaluation of the Os Trigonum. Legend: posterior tibial tendon consistent with a degenerative posterior tibial
Mini C-arm of the Os trigonum shows movement of the Os-trigonum tendon tear.
with plantarflexion and dorsiflexion, and with needle injection, the bone
moves also. Video 1.13  Title: Ultrasound Evaluation of the Plantar Fascia. Leg-
end: Ultrasound over the plantar medial heel demonstrates chronic
Video 1.5  Title: Mini C-arm Evaluation of an Apophyseal Nonunion plantar fasciitis. This can be used diagnostically and also to direct nee-
of the 5th Metatarsal Legend: Mini C-arm of the lateral foot with a ster- dle injection.
ile needle demonstrates that the apophyseal nonunion is actually loose
and will likely remain symptomatic without removal. Video 1.14  Title: Ultrasound Evaluation of the Peroneal Tendons.
Legend: Ultrasound over the lateral ankle demonstrates a longitudinal
Video 1.6  Title: Ultrasound Evaluation for Base 5th Metatarsal Frac- split tear of the peroneus brevis tendon. The peroneus longus tendon is
ture. Legend: Ultrasound over lateral foot to demonstrate a 5th metatar- found to be free of tears.
sal Jones stress fracture.
Video 1.15  Title: Ultrasound Evaluation of the Peroneal Muscles
Video 1.7  Title: Ultrasound Evaluation for Anterior Tibial Tendon Legend: Ultrasound over the lateral ankle demonstrates degeneration
Pathology. Legend: Ultrasound over the anterior ankle is utilized to of the peroneus brevis muscle belly with a normal-appearing gastrocne-
assess the anterior tibial tendon. It can evaluate for tendinopathy or tear. mius and soleus muscle.

Video 1.8  Title: Ultrasound Evaluation for Achilles Tendon Ten- Video 1.16  Title: Ultrasound Evaluation of the Plantar Foot for Neu-
dinopathy. Legend: Ultrasound over the Achilles shows the thicken- roma. Legend: Ultrasound over the plantar foot demonstrating a 3-4
ing of the midsubstance consistent with tendinopathy. interdigital neuroma, showing the subluxating neuroma between the
3-4 metatarsal with squeezing of the foot.

6.e1
 2
Impingement Syndromes of the Ankle
Michel A. Taylor, Annunziato Amendola

OUTLINE
Introduction, 8 Open Medial Approach—FHL Tenolysis and Excision Os
General Technique Tips for Osteophyte Removal, 8 Trigonum, 16
The Ankle, 8 Posterior Ankle and Hindfoot Arthroscopy, 16
Anterior (Medial, Central, Lateral) Impingement, 8 Medial Ankle Impingement, 19
Lateral Ankle Impingement, 11 Sinus Tarsi Impingement, 19
Posterior Ankle Impingement, 12 Conclusion, 20

INTRODUCTION Studies have shown that preoperative computed tomography

Impingement is derived from the Latin verb impingere, mean- (CT) scan may improve the characterization of the osteophytes
ing “to force against,” where an anatomic structure becomes and lead to more complete removal at the time of surgery.5
entrapped causing pain, bony and soft tissue injury, decreased
range of motion, and dysfunction.1–3 When impingement The Ankle
occurs, one bone repetitively strikes another, which over time In order to understand and appropriately manage ankle
can stimulate the deep layer of the periosteum to form osteo- impingement conditions, one must first understand the anat-
phytes that further exacerbate the impingement and alter the omy of the ankle joint. The talus articulates inferiorly with the
normal mechanics of the ankle joint. Osseous or bony impinge- os calcis, and the talar axis is in line with the first web space of
ment most commonly occurs following spur formation along the foot, while the axis of the os calcis is in line with the fourth
the anterior margin of the distal tibia and talus or as a result of a web space (Fig. 2.1). In dorsiflexion, bony impingement occurs
prominent posterolateral talar process—the os trigonum (OT). anteromedially between the neck of the talus and the anterior
Soft tissue impingement usually results from scarring and fibro- lip of the tibia. In plantarflexion, bony impingement occurs pos-
sis associated with synovial, capsular, or ligamentous injury and terolaterally between the os calcis and the posterior lip of the
most often occurs in the anterolateral gutter, the medial ankle, tibia. Therefore, anteromedial and posterolateral impingement
or in the region of the syndesmosis.4 Conservative treatment is usually bony in nature while anterolateral and posteromedial
such as activity modification and retraining should be aimed impingement is usually a soft tissue condition. Impingement
at breaking this repetitive cycle in order to decrease the inflam- conditions are most commonly seen in the anterior ankle; how-
mation and provide relief. However, the sporting limitations are ever, they can also occur in all quadrants of the ankle joint,
often limiting, and if conservative management fails, surgery is including anterior, lateral, posterior, and medial.
usually indicated.
Anterior (Medial, Central, Lateral) Impingement
GENERAL TECHNIQUE TIPS FOR OSTEOPHYTE Anteromedial Impingement
Anterior ankle impingement is relatively common in the ath-
REMOVAL lete. Repetitive forced dorsiflexion can lead to frequent impac-
1. Obtain adequate exposure and visualization prior to attempt- tion injuries as the talar neck and hypertrophied synovial
ing removal, to ensure complete excision tissue impinge on the anterior lip of the tibia leading to the
2. Careful placement of skin incisions in order to avoid painful formation of osteophytes over time.6 Recurrent supination
neuromas and hypersensitive scars. injuries in the form of inversion ankle sprains, seen in chronic
3. The surgeon should be meticulous with osteophyte removal. ankle instability, can also cause inflammation and hypertro-
Care should be taken to remove all of the impinging osteo- phic changes of the synovium between the talus and tibia.7 If
phyte. Intraoperative fluoroscopy can be utilized to confirm the instability is not addressed, synovitis and scar tissue will
complete removal. accumulate most commonly in the anterolateral gutter leading

8
 CHAPTER 2  Impingement Syndromes of the Ankle 9

Fig. 2.1  Axis of talus versus axis of os calcis.

Fig. 2.3  Oblique stress fracture.

lateral talar neck and body and anterolateral tibia.8 An oblique

anteromedial impingement view (AMI) can be obtained by
plantar-flexing the foot and externally rotating the leg to 30
degrees with the x-ray beam tilted 45 degrees cranial. This view
has been shown to be especially useful in detecting anterome-
dial bone spurs.8 During arthroscopy, the anteromedial ankle
should be adequately visualized and inspected for the presence
Fig. 2.2  Lateral impingement and stress fracture. of an impingement spur, which should be debrided when pres-
ent. Holding the ankle in dorsiflexion will help with visualiza-
to pain, swelling, continued impingement and lateral column tion and any required debridement.
overload, and stress fractures (Figs 2.2, 2.3). Anteromedial Another form of anterior impingement was described by
ankle impingement occurs when the anterior portion of the Amendola et al., as cam-type impingement of the ankle, sim-
medial malleolus impinges against a spur on the medial shoul- ilar to the impingement that has previously been described in
der of the talus. The medial joint spurs form following injuries the femoral neck. This form of impingement occurs when the
to the deltoid ligamentous complex. In addition, the anterior sagittal contour of the talar dome forms a non-circular arc with
tibiotalar ligament becomes thickened and can impinge on the anterior talar flattening and creates pathologic contact with the
anteromedial corner of the talus. Patients typically complain anterior aspect of the tibial plafond with the ankle in dorsiflex-
of anteromedial joint line pain, which is aggravated by walking ion (Fig. 2.4). On lateral weight-bearing foot x-rays, the cam
and running as well as planting and pivoting during sporting ratio is measured by drawing a line under the lateral process of
activities. They also report medial clicking and limited, pain- the talus parallel to a line drawn along the navicular, cuneiform,
ful dorsiflexion. Patients often have anteromedial ankle swell- and metatarsal bones. From this line, the widest and narrowest
ing and pain over the anterior aspect of the deltoid ligament, portions of the talus are measured distal to the apex of the talar
and the spur can often be palpated on physical exam. Anterior dome (Fig. 2.5). The cam ratio is then determined by dividing
osteophytes are often seen on standard lateral weight-bearing the narrowest point by the widest. The α-angle is determined
plain x-rays. The “plié view,” which is a lateral weight-bearing for both the medial and lateral talar domes. A circle is drawn
view in maximal dorsiflexion, can be useful to demonstrate to match the curvature of the tibial plafond. This circle is then
anterior impingement. With regards to the anteromedial talar overlayed with the curvature of the talar domes. The α-angle is
and tibial bone spurs, plain anteroposterior and lateral radio- positive when the radius of the talar dome exceeds the radius
graphs can often miss these osteophytes. Studies have shown of the circle anteriorly. The authors found that the medial dome
that spurs over 7 mm in size can be missed in these locations was most prominent and anterior in cases of impingement.
due to projectional issues and the relative positions of the The authors also found that cam-type ankles were associated
10 SECTION 2  Sport Syndromes

Fig. 2.4 CAM lesion. From Amendola N, Drew N, Vaseenon T, Fem-

ino J, Tochigi Y, Phisitkul P. CAM-type impingement in the ankle. Iowa
Orthop J. 2012;32:1-8. Fig. 2.6 Basset’s ligament. (Arthroscopic view seen from the medial
portal.)

2. Spurs found primarily on the talus. This pattern of impinge-

ment is more difficult to treat with only an arthroscopic
technique. The osteophytes are typically found within the
capsular insertion on the talar neck, and it becomes nec-
essary to strip the capsule distally in order to visualize the
pathology. In addition, the osteophytes are easily missed, and
therefore intraoperative imaging may be needed to ensure
W adequate removal.
3. Spurs are present on both the lip of the tibia and the talar
N
neck. This pattern is also associated with loose bodies that
have broken off the osteophytes. This pattern is common and
the most technically challenging. Surgical management often
involves arthroscopy with an associated mini arthrotomy.
4. Multiple anterior osteophytes are present secondary to
advanced ankle osteoarthritis. The benefit of arthroscopic
Fig. 2.5  CAM measurement. From Amendola N, Drew N, Vaseenon T, debridement in these cases is questionable and should prob-
Femino J, Tochigi Y, Phisitkul P. CAM-type impingement in the ankle. ably not be performed.
Iowa Orthop J. 2012;32:1-8.
Anterolateral Ankle Impingement
with higher cam ratios and positive α sign when compared Anterolateral ankle impingement is usually secondary to soft
to control ankles. The authors suggest that if unrecognized tissue impingement, as the tibia and talus do not come together
and untreated, cam-type impingement, like femoroacetabular in this location. Impingement in this location is usually a result
impingement, can lead to recurrence as well as degenerative of one of two pathological conditions: Bassett’s Ligament and
arthritic changes.9 synovial impingement.
Bassett’s Ligament. Bassett’s ligament is an abnormal
Anterocentral Impingement thickened distal fascicle of the anterior tibiofibular ligament
Anterocentral impingement is the classic location when describ- (AITFL). Rather than being a distal component of the AITFL,
ing anterior ankle impingement. The locations of the spurs have Bassett’s ligament represents a separate ligament that is separated
been described in four typical patterns: by a fibrofatty septum11 and extends distally on the lateral
1. Spurs found primarily on the lip of the tibia. This type is malleolus. It can lead to impingement of the lateral shoulder
ideal for arthroscopic management. Under direct vision, the of the talus when the ankle is plantarflexed (Fig. 2.6).12 Patients
impinging lip of the distal tibia can be easily removed with typically present with anterior ankle pain and a remote history
a burr or thin osteotome. The osteophyte is removed while of an ankle sprain. Physical exam findings include anterolateral
holding the ankle in maximal dorsiflexion while using an talar dome and AITFL point tenderness exacerbated with
osteotome with blunt edges to avoid damaging the dome of ankle eversion and dorsiflexion. The ankle is usually found to
the talus.10 be stable on physical exam. Treatment is usually nonoperative
 CHAPTER 2  Impingement Syndromes of the Ankle 11

and should be attempted for approximately 6 months prior and appear inconsequential at first, such as a first-degree ankle
to considering any kind of surgical intervention. The surgical sprain with no residual lateral instability. Other conditions to
management of this condition involves the surgical excision of consider in the evaluation of lateral ankle impingement and
the ligament and has been associated with good to excellent pain are:
results. 1. The “meniscoid” of the ankle – Thought to be soft tissue
Synovial Impingement. Synovial impingement or Ferkel’s trapped between the lateral shoulder of the talus and the lat-
disease is the chronic accumulation and entrapment of scar eral malleolus. This lesion was described in four soccer play-
tissue and synovitis in the anterolateral gutter of the ankle, ers with a history of frequent ankle sprains who underwent
which is usually preceded by trauma in the form of an inversion arthroscopic debridement after failing nonoperative treat-
injury.13 The patient typically presents with symptoms similar ment.26 After appropriate rehabilitation, all four had com-
to Bassett’s ligament impingement. Pain with palpation over plete resolution of symptoms and returned to competition.
the anterolateral gutter with the ankle plantarflexed typically 2. Fracture of the lateral process of the talus27 – Can be a source
reproduces the symptoms. Plain films are usually normal of impingement beneath the lateral malleolus. The frac-
but can be used to rule out other bony pathology. Advanced ture is also known as a “snow-boarder’s fracture” due to the
imaging modalities such as CT scan and conventional magnetic increased incidence in this particular athletic population. It
resonance imaging (MRI) have shown moderate sensitivity is often misdiagnosed as an ankle sprain, therefore a high
and specificity but often rely on the experience level of the index of suspicion is required. Routine plain radiographs of
reader.14–18 Magnetic resonance (MR) arthrogram, however, the foot and ankle can often miss the subtle fracture, and a
has been associated with a sensitivity of 96%, specificity of CT scan is the study of choice. Surgical treatment options
100%, and accuracy of 100% in the assessment of anterolateral range from bony excision to open reduction internal fixation
impingement when clinical signs are present.19 Like Bassett’s (ORIF), depending on the size of the fragment.28
ligament, arthroscopic debridement is the surgical treatment 3. The symptomatic os subfibulare – An accessory ossicle that
of choice after a trial of nonoperative management has failed, was previously asymptomatic can loosen or fracture follow-
with good to excellent results in approximately 94%–96% of ing an injury and become symptomatic.
patients.20,21 4. Distal fibula avulsion fractures – The tip of the fibula can often
Anterolateral ankle pain can also be caused by anterior syn- become trapped at the insertion site of the calcaneofibular
desmosis pathology. Although this is not as a result of true ligament (CFL) and become symptomatic. If the fragment
impingement, it can be exacerbated by ankle dorsiflexion as the is small, it can be excised and the stump of the ligament can
widened anterior aspect of the talus engages the malleoli and be sutured to the tip of the lateral malleolus. If it is large, it
places tension on the anterior tibiofibular ligament. There are often can be reattached with a screw or K-wire. Infrequently
three types of anterolateral syndesmosis pathology: a sprain of a similar fracture can occur at the anterior edge of the lateral
the syndesmotic ligaments and interosseous membrane, also malleolus at the insertion of the anterior talofibular ligament
known as a high ankle sprain; the Tillaux fracture, which is an (ATFL) (Fig. 2.7).
avulsion fracture of the insertion of the AITFL usually on the 5. Os Calcis fractures – Previously healed or malunited fractures
distal tibia; and the herniation of synovium into rents in the of the os calcis can present with lateral ankle pain and sub-
tibiofibular ligament. fibular impingement, which is often difficult to differentiate
Results of arthroscopic anterior ankle debridement have been from subtalar joint pain and dysfunction. A small injection
reported as good to excellent by numerous authors, with success of local anesthetic beneath the tip of the lateral malleolus,
rates of approximately 67%–88%.2,13,22,23 A systematic review but not into the subtalar joint, can help elucidate the cause. If
looking at the results of anterior ankle arthroscopy found good there is significant pain relief with local anesthetic, fragment
or excellent results in 64%–100% of patients while most studies excision may be considered prior to recommending subtalar
had outcomes greater than 80%. Improved postoperative out- arthrodesis.
comes were seen in patients with mostly soft tissue impinge- 6. An avulsion fracture of the anterior process of the os calcis29 –
ment compared to bony impingement.24 Studies comparing an avulsion fracture of the origin of the EDB and EHB and
open and arthroscopic debridement for anterior ankle impinge- not a true impingement syndrome. It can usually be seen
ment found significant postoperative clinical improvements in on x-ray (Fig. 2.8) and suspected on physical examination
both groups with shorter hospital stays seen in the arthroscopic by point tenderness over the site exacerbated by pronation-­
group and earlier return to sports.10 Multiple studies have con- supination of the forefoot. If symptoms persist despite
sistently found that patients undergoing arthroscopic or open nonoperative treatment, excision of the fragment is war-
debridement in the presence of arthritic changes have inferior ranted (see Fig. 2.8).
clinical outcomes.10,23–25 7. Accessory anterolateral talar facet – The accessory antero-
lateral talar facet was first described by Sewell in 1904 who
Lateral Ankle Impingement found it to be present in 10.2% of cadaveric tali.30 A case
The lateral ankle is complex and the causes of pain and dis- series by Martus et al. described the association between an
comfort are varied, therefore obtaining an accurate diagnosis accessory talar facet and the anterior process of the calca-
can often be difficult. Symptoms in this area are also often pre- neus leading to talocalcaneal impingement and symptomatic
ceded by ankle sprains. The original trauma can often be mild rigid flatfoot. Patients typically presented around the age of
12 SECTION 2  Sport Syndromes

out the presence of a tarsal coalition, confirm the presence of

the accessory talar facet, dorsal talar beaking was frequently
present, and MRI showed bone marrow edema localized
to the anterolateral talar facet and adjacent calcaneus. The
authors stipulate that symptoms are caused by the combined
effect of increased body mass, subtalar joint eversion in the
presence of an accessory talar facet leading to impingement
and associated painful flatfoot deformity. In the absence of
subtalar arthrosis or an associated coalition, treatment con-
sists of isolated resection of the accessory facet through a
sinus tarsi incision with or without gastrocnemius recession,
peroneal lengthening and medial displacement calcaneal
osteotomy.31
8. Peroneal tendon dysfunction – although not true impinge-
ment, can also cause lateral ankle pain and should always
be considered in the differential diagnosis. This can include
peroneal tendon subluxation, longitudinal tears,32 and frac-
tures of the os perineum with retraction of the peroneal ten-
don (Fig. 2.9).33

Posterior Ankle Impingement

Posterior ankle impingement, also known as talar compression
syndrome, os trigonum syndrome, posterior triangle pain, and
posterior tibiofibular impingement,34 is relatively common in
athletes such as dancers, gymnasts, soccer players, and skat-
ers who engage in repetitive and forceful ankle plantarflexion.
A working knowledge of the anatomy of the posterior ankle
and its key structures is important in order to understand and
appropriately manage the impingement syndromes found in
this area (Tables 2.1 and 2.2). The posterior talar anatomy is the
Fig. 2.7  Fracture of the tip of the fibula trapped under the lateral mal- main determining factor underlying posterior ankle impinge-
leolus. ment. The posterior aspect of the talus has two tubercles: the
medial and the lateral tubercles (Fig. 2.10). The lateral tuber-
cle is the origin of the posterior talofibular ligament (PTFL).
When the lateral tubercle is large, it is referred to as the poste-
rior process of the talus or Stieda’s process. In 7% to 11% of the
population, this posterior process is separate from the talus and
connected by a fibrous synostosis; in these cases, it is referred to
as an OT. The OT is the second most common accessory bone
in the foot, behind the accessory navicular or os navicularum.
Anatomical variants like these ones in combination with a trau-
matic injury such as an ankle sprain or repetitive microtraumas
as is seen with certain sports can lead to posterior impingement
syndrome.
There are also important soft tissue structures of the poste-
rior ankle that can contribute to posterior ankle impingement
such as the flexor hallucis longus (FHL) tendon, the posterior
Fig. 2.8  Fracture of the anterior process of the os calcis. ankle ligaments, the joint capsule, and synovium. The FHL
tendon passes in a groove on the posterior tibial plafond and
through a fibro-osseous tunnel between the medial and lateral
15 with lateral sided ankle and hindfoot pain and symptoms posterior tibial tubercles (Fig 2.11). It runs from its proximal
consistent with a rigid flatfoot deformity. The patients were origin on the fibula to its insertion on the distal phalanx of the
overweight with an average body mass index (BMI) of 34.6, hallux. Chronic tendinitis and dysfunction within this tunnel
and symptoms had been ongoing for almost 2 years. Lateral can produce posterior medial pain.34–36 The most common
radiographs typically showed a broadening of the anterioin- sources of posterior ankle impingement pain in the athletic
ferior lateral talar process suggestive of an accessory antero- population is trigonal impingement laterally and FHL tendini-
lateral facet. CT scan and MRI were performed and ruled tis medially.
 CHAPTER 2  Impingement Syndromes of the Ankle 13

Fig. 2.9  Retraction of the os peroneum (arrow), following rupture of the peroneus longus tendon.

TABLE 2.1  Flexor Hallucis Longus (FHL)

Tendonitis Versus Posterior Impingement
of the Ankle
FHL tendonitis Posterior impingement
Posteromedial Posterolateral
Tenderness over FHL tendon Tenderness behind fibula
Pain or triggering with motion of
the hallux Pain with plantar flexion of the ankle
±Thomasen’s sign 28 Plantar flexion sign
Mistaken for PT tendonitis Mistaken for peroneal tendonitis
FHL, flexor hallucis longus; PT, posterior tibial.

TABLE 2.2  Medial Versus Lateral Posterior

Ankle Pain in Athletes and Dancers
Posteromedial Posterolateral
FHL tendinitis Posterior impingement (OT syndrome) Fig. 2.10  Anatomy of the posterior talus.
Fx. trigonal process (Shepherd’s
Soleus syndrome fracture) Posterolateral Ankle Impingement
PT tendonitis Peroneal tendonitis A common cause of posterolateral ankle impingement is from
Posteromedial fibrous tarsal coalition Pseudomeniscus syndrome the natural consequence of full weight bearing in maximal
FHL, flexor hallucis longus; Fx., fracture; OT, os trigonum; PT, posterior plantarflexion of the ankle in the demi-pointe or full pointe
tibial. position, especially when an OT is present. In these cases, the
14 SECTION 2  Sport Syndromes

Fig. 2.11  Flexor hallucis longus (FHL) posteromedial scope.

OT is compressed between the posterior lip of the tibia and

the superior portion of the os calcis (Fig. 2.12) causing pos-
terolateral ankle impingement and pain. The chronic repetitive
impingement events can lead to inflammation of the OT. It can
be confirmed on physical examination with patients experienc-
ing point tenderness posterior to the peroneal tendons behind
the lateral malleolus, which is exacerbated with forced passive
plantarflexion of the ankle known as the “plantar flexion sign.”
Fig. 2.12  Posterior impingement on the os trigonum.
This pattern of impingement can often be mistaken for pero-
neal tendinitis, which can also occur in association. It is best
seen on a lateral view of the ankle en pointe or in full plantar
flexion (see Fig. 2.12). MRI findings often include bone marrow
edema in the posterior talus (Fig. 2.13) or within the OT and/
or a prominent posterior calcaneal process or a downward slope
to the posterior tibia. It can also be associated with traumatic
osteochondral defects of the talus (Fig. 2.14, 2.15). If necessary,
the diagnosis can be confirmed by injecting 0.5 ml of a local
anesthetic into the posterior soft tissues behind the peroneal
tendons. It is important to keep in mind that most people who
have an OT are asymptomatic and that posterior impingement
syndrome is uncommon in most athletes. Unfortunately, due to
the often dramatic appearance of the OT on x-ray, the condition
is frequently overdiagnosed by practitioners, who may then rec-
ommend surgery unnecessarily.
Treatment of posterolateral impingement syndrome begins
with conservative management options such as activity mod-
ification, avoiding exacerbating plantarflexed ankle positions,
nonsteroidal antiinflammatory drugs (NSAIDs), and physical
therapy. In addition, an injection of 0.25 to 0.5 ml of a mixture
of a long-acting and a short-acting corticosteroid may provide
Fig. 2.13  Edema OT.
significant relief of symptoms, and the accuracy of the injection
can be improved with sonography.
Although uncommon, if nonoperative treatment has failed posterolaterally in the interval between the FHL and the
and the OT remains symptomatic, surgical excision becomes peroneal tendons while protecting the sural nerve. However,
indicated. If the pathology is isolated to a symptomatic OT posterolateral impingement is often associated with FHL ten-
with no medial symptomatology, it can be approached dinitis (Video 2.1 “Os Trigonum and FHL”), and in this case,
 CHAPTER 2  Impingement Syndromes of the Ankle 15

Posterolateral impingement can also occur following an

ankle sprain where the lateral ligamentous structures are dis-
rupted. The resulting instability causes the talus to slide for-
ward and the posterior lip of the tibia to comes to rest on the
os calcis. In this case, the treatment is to correct the anterior
drawer by reconstructing the lateral ligamentous complex (ex:
Brostrum-Gould).34,39
A posterior pseudomeniscus or plica in the posterior ankle,
with or without an OT, can cause posterior impingement syn-
drome in the absence of an OT or ligament laxity. Bucket-handle
like tears in this structure can cause locking and other mechan-
ical symptoms similar to what is typically seen in the knee.34
The differential diagnosis of posterolateral ankle pain can
also include acute trauma including fractures of the posterior
process of the talus, avulsions of the PTFL, fracture of the trigo-
nal process also known as a Shepherd’s fracture or of the os tri-
gonium synchondrosis.

Posteromedial Ankle Impingement

Bony impingement does not typically occur in the posterome-
dial ankle as the tibia and talus do not come together. Therefore,
Fig. 2.14  MRI osteochondral defect (OCD) sag.
posteromedial impingement is mainly due to soft tissue causes.
The posteromedial flexor tendons, joint capsule, and tibiotalar
ligament are the main contributors of posteromedial impinge-
ment. The FHL passes through a fibro-osseous tunnel behind
the talus between the medial and lateral tubercles to the level of
the sustentaculum tali like a rope through a pulley. As it passes
through this pulley, it is easily strained. When this occurs,
rather than moving smoothly in the pulley, it begins to bind.
This binding causes irritation and swelling. Chronic inflamma-
tion and hypertrophy of the musculotendinous unit within this
tunnel can lead to a painful stenosing tenosynovitis, analogous
to de Quervain disease in the wrist. Tendinitis of the FHL ten-
don behind the medial malleolus of the ankle is also known as
dancer’s tendonitis but can also occur in other athletes as well.
If a nodule or partial tear is present, triggering of the big toe
may occur; this is known as hallux saltans (Fig 2.16). In extreme
cases, the tendon may become completely frozen in the sheath,
causing pseudo hallux rigidus. Physical exam findings include
localized tenderness and swelling over the FHL sheath behind
and lateral to the medial malleolus. Palpation of the sheath with
active and passive motion of the hallux will mimic the patient’s
symptoms. Dorsiflexion of the first metatarsophalangeal (MP)
joint can be reduced or absent when the ankle is in maximum
dorsiflexion and the muscle fibers of the FHL are drawn into the
Fig. 2.15  MRI sag axial. FHL tunnel, producing a functional hallux rigidus (Thomasen’s
sign). This finding is not always pathological, as it may be pres-
the posteromedial approach is utilized in order to adequately ent in asymptomatic patients. Usually there is no pain with
develop and protect the neurovascular bundle and perform a forced plantarflexion of the ankle. FHL tendinitis is often mis-
tenolysis of the FHL after excising the adjacent OT. Results diagnosed as posterior tibial or Achilles tendonitis, and it typ-
of OT resection using a posterolateral approach have shown ically responds to the usual conservative measures such as rest
significant improvement in APFAS scores, with a complica- (no pointe work), activity modification, and NSAIDs. Steroid
tion rate of approximately 20% including sural nerve injury, injections should be avoided in this location. In refractory cases
superficial wound infection, and reflex sympathetic dystro- that have failed conservative management, surgical release of
phy.37 Ankle arthroscopy using two posterior portals can also the fibro-osseous is indicated.
provide excellent visualization of the posterior structures of FHL tendinitis usually occurs behind the medial malleolus,
the ankle and good access to the OT, loose bodies, and FHL but occasionally it can be isolated to the knot of Henry where
tendon sheath.38 the flexor digitorum longus (FDL) crosses over the FHL, and
16 SECTION 2  Sport Syndromes

the posterior aspect of the neurovascular bundle, therefore the

interval between the medial malleolus and the anterior aspect
of the neurovascular bundle should be developed at this point.
The bundle can then be taken down off the malleolus by blunt
dissection. In this region, there are several small vessels that will
need to be ligated and the bundle can then be mobilized and
held with a blunt retractor. The surgeon should examine the
tibial nerve and artery and note the location where they divide
into medial and lateral plantar branches as they leave the tar-
sal canal. It is not unusual for either the artery or the nerve, or
both, to divide above this area, leading to reduplication within
the tunnel. There also may be reduplication of the FHL tendon.
With the neurovascular bundle retracted posteriorly, the FHL
is identified by moving the hallux. The thin fascia overlying the
FHL is opened proximally and tenolysed from proximal to dis-
tal. Usually the fascial sheath is stenotic and rigid, and the FHL
can be seen entering at an acute angle. Care should be taken dis-
tally, as the FHL tunnel and the nerve are in close proximity. As
the tendon approaches the sustentaculum tali, the fascial sheath
becomes exceedingly thin. At this point, the tendon should be
inspected for nodules or longitudinal tears and, if such are pres-
ent, should be carefully debrided or repaired. Following this,
the FHL and neurovascular bundle can be retracted posteriorly
allowing access to the OT or trigonal process on the lateral side
Fig. 2.16  A nodule in the flexor hallucis longus (FHL) tendon causing of the FHL tunnel. If the posterior aspect of the talus cannot
triggering of the great toe; “hallux saltans.” be visualized, a capsulotomy should be performed. If there is
difficulty in visualizing the OT, it helps to identify the superior
under the head of the first metatarsal where it passes between border of the os calcis and the subtalar joint (by moving the
the sesamoids. A fibrous subtalar coalition may be present in os calcis into adduction and abduction). The subtalar joint is
the posteromedial ankle, mimicking FHL tendinitis or tarsal then dissected from medial to lateral, and this will take the sur-
tunnel syndrome. This condition should be suspected when geon underneath the OT. Once identified, it can be removed
limited subtalar motion is seen on physical examination. by circumferential dissection. Care should be taken to stay on
In the management of posteromedial ankle impingement, the bone when performing this part of the procedure. This can
operative treatment is indicated when conservative therapy be somewhat difficult, especially if the OT is large. Once it is
has failed. A posterior-based approach can be made on either removed, the posterior ankle joint should be inspected for bone
the medial or lateral side of the Achilles tendon. The lateral fragments, loose bodies, soft tissue entrapment, or the large
approach should be utilized if the patient has isolated posterior articular facet on the upper surface of the os calcis that often
impingement without a history of FHL tendinitis or medial- articulates with the OT. If this articulation is large, it may need
based pathology. However, if the patient presents with posterior to be removed with a thin osteotome. The FHL sheath should
impingement and FHL tendinitis with or without an incidental not be closed. The wound is then irrigated and the ankle is put
OT, a medial incision should be performed. The medial incision in plantarflexion to check for any residual impingement. The
is preferred as it avoids the sural nerve and provides access to wound is closed in layers with the ankle in neutral flexion. Full
the lateral structures while allowing direct access to the postero- weight bearing with crutches can begin immediately with swim-
medial neurovascular bundle. ming and physical therapy started at approximately two weeks
once the wound has healed. Ankle range of motion is started as
Open Medial Approach—FHL Tenolysis and early as possible to prevent residual stiffness. If only the tenoly-
Excision Os Trigonum sis is performed without excision of the OT, the recovery period
This procedure can be performed with the patient prone or is approximately 6 weeks. When the tenolysis is performed with
supine with a bump under the contralateral hip in order to OT excision, the recovery time is approximately 8 to 12 weeks.
provide external rotation of the hip and knee. A well-padded
tourniquet is placed around the thigh. A curvilinear incision is Posterior Ankle and Hindfoot Arthroscopy38,40,41
made following the neurovascular bundle beginning just above This is our preferred technique to deal with posterior ankle
the superior border of the os calcis and ending just posterior impingement and pathology. The patient is positioned prone
to the tip of the medial malleolus (Fig. 2.17A). Blunt dissec- and a well-padded tourniquet is placed around the thigh.
tion is performed and the deep fascia is then divided carefully Although used infrequently, ankle distraction is achieved with
to avoid damage to the posteromedial neurovascular bundle. a tensioned wired can be placed transversely in the calcaneus,
The tibial motor branches to the os calcis are more variable in the operative knee is cephalad to the break in the operating
 CHAPTER 2  Impingement Syndromes of the Ankle 17

A B

C D

E
Fig. 2.17  (A) Posteromedial incision. (B) Neurovascular bundle beneath a thin layer of fascia. (C) Neurovas-
cular bundle taken down from the posterior medial malleolus. (D) Posterior tibial nerve protected with a blunt
retractor. Underneath lies the flexor hallucis longus (FHL) sheath. (E) FHL sheath opened.

table and the contralateral knee is bent to 90 degrees and exchanged for a 4.0 mm or 2.7 mm 30 degree arthroscope. At
secured to a padded post. The foot of the operating table is then the same level using a similar technique, the working portal is
lowered allowing access for the mini c-arm. In cases where dis- the made just medial to the Achilles tendon. In this case, the
traction is not applied, the operative leg is elevated by means blunt trocar is advanced in line with the third web space and
of two sterile towel bumps. For intra-articular posterior ankle aimed medial to the midline.
procedures, the posterolateral portal is first made lateral to the To gain access to the hindfoot or for extra-articular pro-
Achilles tendon at the level of the tip of the lateral malleolus cedures, blunt dissection is performed through the medial
(Fig. 2.18). A shallow skin incision is made and blunt dissec- portal in line with the third web space toward the posterior
tion is then performed with a straight clamp to avoid injuring process of the talus. Once the clamp is felt to be resting on
the sural nerve. Using fluoroscopic guidance, a blunt trocar is bone, it can be exchanged for a 4.0 mm arthroscope, which is
advanced in line with the first web space and toward the pos- directed laterally. A mosquito is then advanced from the lat-
terior process of the talus. Once inside the joint, the trocar is eral portal dissecting toward the tip of the arthroscope. Once
18 SECTION 2  Sport Syndromes

Fig. 2.18  Dissection with the shaver.

Fig. 2.20  Post ankle scope.

Fig. 2.19  Os Trigonum and flexor hallucis longus (FHL) adjacent.

the mosquito can be seen in the arthroscopic field, it can be

exchanged for a 3.5-mm shaver. At this point, careful dissec- Fig. 2.21 OCD larger posterior approach.
tion with the shaver is performed to remove adipose tissue
and expand the viewing field (Fig 2.18). Careful debridement
can be continued from lateral to medial exposing the poste- tenolysis is to be performed, the sheath can be released to the
rior tibiofibular ligament, the posterior tibiotalar and subtalar level of the sustentaculum staying in the lateral side of the
joint capsule, the os trigonum, and finally the flexor hallu- tendon. If any associated osteochondral lesions are present,
cis longus tendon (Fig 2.19). Once the impinging lesion or they can be visualized, debrided (Figs 2.20–2.22), and treated
OT is identified, the debridement is made as close to bone (i.e., microfracture) at this point. Prior to closing, 20 cc of
as possible (Video 2.2 “Os Trigonum”). The position of the 0.5% Marcaine with epinephrine is injected into each portal
FHL should be confirmed throughout the debridement by and the portals are loosely closed with 3-0 monocryl suture.
moving the great toe. Once the OT has been circumferen- Postoperatively, patients are placed in a well-padded dressing.
tially debrided, it can be broken down with a 4-mm burr or Protected weight bearing and range-of-motion exercises are
detached from the posterior process of the talus and retrieved started immediately. At 4–6 weeks, physical therapy should
en bloc with arthroscopic grasper. The adequacy of resection focus on strengthening and proprioceptive exercise, and the
can be confirmed by noting the position of the FHL and by patient is permitted to return to sport when full range of
direct observation while plantarflexing the ankle. If an FHL motion and strength have returned.
 CHAPTER 2  Impingement Syndromes of the Ankle 19

force was applied. With the foot in equinus, the anterior deltoid
will be most affected; with the foot plantigrade, it will be the
middle deltoid; and although rare, the posterior portion of the
deltoid is most commonly affected when the foot is in a dorsi-
flexed position. Following a sprain, medial osteophytes can then
form and cause bony impingement. Persistent symptoms on the
medial side may also be due to an unrecognized fracture of the
sustentaculum tali, which can often be seen on a bone scan,
or can be due to a fibrous tarsal coalition. An accessory bone,
the os subtibiale, may be present in the deep layer of the del-
toid and can become symptomatic following a sprain. An x-ray
should be taken to rule out bony pathology, including a physeal
injury in the appropriate age group. In the acute phase, treat-
ment consists of RICE (rest, ice, compression, and elevation),
an aircast stirrup brace, and crutches if necessary, as well as
physical therapy. Recovery usually is uneventful. Occasionally,
persistent pain over the deltoid ligament is reported, and this
is usually from an avulsion fracture or accessory ossicle. These
often respond to conservative therapy, and only rarely is surgi-
cal excision necessary.

Fig. 2.22 OCD larger. Sinus Tarsi Impingement

Sinus tarsi syndrome is a controversial topic and an uncom-
A retrospective study that looked at the results of poste- mon source of ankle impingement, which was first described
rior ankle and hindfoot arthroscopy in 189 ankles found a low by Denis O’Connor.45 It is an impingement condition affecting
complication rate of 8.5%, which included plantar skin numb- the subtalar joint that produces lateral foot and ankle pain deep
ness, sural nerve injuries, Achilles tendon contracture, complex in the sinus tarsi, which is exacerbated by impact (jumping and
regional pain syndrome, infection, and superficial synovial por- running) activities as well as pronation. Patients will present
tal cyst.40 A separate study found the average time to return to with discrete lateral subtalar pain located within the sinus tarsi,
sport was 5.8 months, and 14 of 15 patients were able to return which will often, but not always, be preceded by an ankle sprain.
to pre-injury level of play.38 A study by Carreira et al., looking On physical examination, pain is located deep in the sinus tarsi,
at the results of posterior arthroscopy for impingement, found and can be exacerbated with forceful abduction-pronation of
an increase in American Orthopaedic Foot & Ankle society the heel and midfoot. The diagnosis can usually be confirmed
(AOFAS) score from 75 preoperatively to 94.9 postoperatively, with an injection of 0.5 ml of lidocaine into the sinus tarsi. If
a decrease of visual analog scale (VAS) from 5.4 to 0.85, equal the pain is relieved by the local anesthetic, a second injection
range of motion to the contralateral ankle at 1 year, and all of 0.15 ml of corticosteroid is often effective. Other diagnostic
patients were able to return to their pre-injury level of play.42 and imaging techniques used to assess for sinus tarsi syndrome
have included arthrography, MRI, and more recently SPECT/
Medial Ankle Impingement CT.46–48 Although there is currently no clear etiology underly-
Medial sprains of the ankle are rare because the medial bony ing sinus tarsi syndrome, several theories have been proposed
and ligamentous structures are strong and rigid in comparison such as soft tissue entrapment or partial tear and scarring of the
with the lateral side of the ankle. In the athletic patient who interosseous talocalcaneal ligament (ITCL), synovial inflam-
presents with medial ankle pain, posterior tibial tendonitis is mation and impingement, osteophyte impingement (Fig. 2.23),
the most common cause. When dancers present with medial neural entrapment (motor nerve to the extensor digitorum bre-
ankle pain, this is often caused by repetitive pronation of the vis [EDB]), sensory nerve traction injury, arthrofibrosis, and
ankle known as “rolling in,” which causes a chronic strain of degenerative arthrosis.46,47
the deltoid ligament. Scar tissue forms along the joint line and Due to their anatomical proximity, it can be difficult to dif-
becomes trapped between the posterior talus and medial mal- ferentiate sinus tarsi syndrome from general subtalar dysfunc-
leolus, causing pain. This type of impingement is often associ- tion. Subtalar osteophytes incidentally found on imaging are not
ated with lateral ligamentous instability and if unidentified, the uncommon,49 and changes in subtalar motion on physical exam
patient will continue to be symptomatic following lateral liga- can be an effective method to differentiate the two conditions.
mentous reconstruction.43,44 First-line management includes nonoperative treatment
This presentation must also be distinguished from postero- consisting of antiinflammatory medication, physical therapy,
medial ankle pain in dancers, which is usually caused by FHL orthotic support such as a medial heel wedge or arch support
tendonitis. Medial ankle sprains usually occur from landing off that functions to open the sinus tarsi, and local injections. If
balance with sudden pronation. The part of the ligament that is the diagnosis is clear and symptoms persist despite nonopera-
injured depends on which portion was under tension when the tive modalities, surgical management is indicated. Arthroscopic
20 SECTION 2  Sport Syndromes

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ic treatment for anterior impingement exostosis of the ankle:
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11. Nikolopoulos CE, Tsirikos AI, Sourmelis S, Papachristou G.
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high incidence of associated conditions suggesting an alterna- 2004;32(2):389–395.
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3. van den Bekerom MP, Raven EE. The distal fascicle of the anteri- 22. Ogilvie-Harris DJ, Mahomed N, Demaziere A. Anterior impinge-
or inferior tibiofibular ligament as a cause of tibiotalar impinge- ment of the ankle treated by arthroscopic removal of bony spurs. J
ment syndrome: a current concepts review. Knee Surg Sports Bone Joint Surg Br. 1993;75(3):437–440.
Traumatol Arthrosc. 2007;15(4):465–471. 23. Amendola A, Petrik J, Webster-Bogaert S. Ankle arthroscopy:
4. Watson AD. Ankle instability and impingement. Foot Ankle Clin. outcome in 79 consecutive patients. Arthroscopy. 1996;12(5):565–
2007;12(1):177–195. 573.
 CHAPTER 2  Impingement Syndromes of the Ankle 21

24. Glazebrook MA, Ganapathy V, Bridge MA, Stone JW, Allard JP. 39. Hamilton WG, Thompson FM, Snow SW. The modified
Evidence-based indications for ankle arthroscopy. Arthroscopy. Brostrom procedure for lateral ankle instability. Foot Ankle.
2009;25(12):1478–1490. 1993;14(1):1–7.
25. van Dijk CN, Tol JL, Verheyen CC. A prospective study of prog- 40. Nickisch F, Barg A, Saltzman CL, Beals TC, Bonasia DE, Phisitkul
nostic factors concerning the outcome of arthroscopic surgery for P, et al. Postoperative complications of posterior ankle and hind-
anterior ankle impingement. Am J Sports Med. 1997;25(6):737–745. foot arthroscopy. J Bone Joint Surg Am. 2012;94(5):439–446.
26. Mccarroll JR, Schrader JW, Shelbourne KD, Rettig AC, Bisesi 41. van Dijk CN, de Leeuw PA, Scholten PE. Hindfoot endoscopy
MA. Meniscoid lesions of the ankle in soccer players. Am J Sport for posterior ankle impingement. Surgical technique. J Bone Joint
Med. 1987;15(3):255–257. Surg Am. 2009;91(suppl 2):287–298.
27. Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg 42. Carreira DS, Vora AM, Hearne KL, Kozy J. Outcome of ar-
Am. 1970;52(5):991–1002. throscopic treatment of posterior impingement of the ankle. Foot
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Snowboarder’s talus fracture: treatment outcome of 20 cases after 43. Liu SH, Mirzayan R. Posteromedial ankle impingement. Arthros-
3.5 years. Am J Sports Med. 2005;33(6):871–880. copy. 1993;9(6):709–711.
29. Harburn TE, Ross HE. Avulsion fracture of the anterior calcaneal 44. Paterson RS, Brown JN. The posteromedial impingement lesion of
process. Phys Sportsmed. 1987;15(4):73–80. the ankle. A series of six cases. Am J Sports Med. 2001;29(5):550–
30. Sewell RB. A study of the astragalus. J Anat Physiol. 1904;38(Pt 557.
3):233–247. 45. Smith JW. The ligamentous structures in the canalis and sinus
31. Martus JE, Femino JE, Caird MS, Kuhns LR, Craig CL, Farley tarsi. J Anat. 1958;92(4):616–620.
FA. Accessory anterolateral talar facet as an etiology of painful 46. Klein MA, Spreitzer AM. MR imaging of the tarsal sinus and
talocalcaneal impingement in the rigid flatfoot: a new diagnosis. canal: normal anatomy, pathologic findings, and features of the
Iowa Orthop J. 2008;28:1–8. sinus tarsi syndrome. Radiology. 1993;186(1):233–240.
32. Sammarco GJ, DiRaimondo CV. Chronic peroneus brevis tendon 47. Taillard W, Meyer JM, Garcia J, Blanc Y. The sinus tarsi syn-
lesions. Foot Ankle. 1989;9(4):163–170. drome. Int Orthop. 1981;5(2):117–130.
33. Thompson FM, Patterson AH. Rupture of the peroneus lon- 48. Chicklore S, Gnanasegaran G, Vijayanathan S, Fogelman I. Poten-
gus tendon. Report of three cases. J Bone Joint Surg Am. tial role of multislice SPECT/CT in impingement syndrome and
1989;71(2):293–295. soft–tissue pathology of the ankle and foot. Nucl Med Commun.
34. Hamilton WG. Foot and ankle injuries in dancers. Clin Sports 2013;34(2):130–139.
Med. 1988;7(1):143–173. 49. Meyer JM, Garcia J, Hoffmeyer P, Fritschy D. The subtalar sprain.
35. Hamilton WG. Tendonitis about the ankle joint in classical ballet A roentgenographic study. Clin Orthop Relat Res. 1988;(226):169–
dancers. Am J Sports Med. 1977;5(2):84–88. 173.
36. Hamilton WG. Stenosing tenosynovitis of the flexor hallucis 50. Frey C, Feder KS, DiGiovanni C. Arthroscopic evaluation of the
longus tendon and posterior impingement upon the os trigonum subtalar joint: does sinus tarsi syndrome exist? Foot Ankle Int.
in ballet dancers. Foot Ankle. 1982;3(2):74–80. 1999;20(3):185–191.
37. Abramowitz Y, Wollstein R, Barzilay Y, London E, Matan Y, Sha- 51. Lee KB, Bai LB, Song EK, Jung ST, Kong IK. Subtalar arthrosco-
bat S, et al. Outcome of resection of a symptomatic os trigonum. J py for sinus Tarsi syndrome: arthroscopic findings and clinical
Bone Joint Surg Am. 2003;85-A(6):1051–1057. outcomes of 33 consecutive cases. Arthroscopy. 2008;24(10):1130–
38. Willits K, Sonneveld H, Amendola A, Giffin JR, Griffin S, Fowler 1134.
PJ. Outcome of posterior ankle arthroscopy for hindfoot impinge-
ment. Arthroscopy. 2008;24(2):196–202.
Video Legends - https://www.kollaborate.tv/link?id=5c9d1e192  Video 2.2  Title: Posterior ankle arthroscopy for resection of
b4c3 posterior process talus Legend: Posteior ankle arthrocopy video
depicting resection of posterior process talus and arthroscopic
 Video 2.1  Title: Posterior ankle arthroscopy for evaluation of
evaluation of posterior ankle and posterior subtalar joint.
Flexor Hallucis Longus tendon and Os trigonum Legend: Poste-
rior ankle arthroscopy video demonstrating tear in FHL tendon and
loose Os trigonum.

21.e1
 3
Stress Fractures: Their Causes
and Principles of Treatment
Christopher D. Kreulen, Karim Boukhemis, Eric Giza

OUTLINE
Introduction, 22 Differential Diagnosis, 25
Historical Perspective, 22 Treatment, 25
Etiology of Stress Fractures, 22 Bone Stimulators, 26
Epidemiology, 23 Surgical Intervention, 26
Risk Factors for Stress Fractures, 23 Common Stress Fractures, 26
Evaluation, 25 Conclusion, 28
Diagnostic Studies, 25

INTRODUCTION physical activity, typically that which is repetitive. Ground reac-

tion forces and muscular contraction result in bone strain. It is
Historical Perspective these repetitive strains that are thought to cause a stress frac-
Stress fractures were first described in 1855 by Briethaupt, a ture. Bone normally responds to strain by increasing the rate of
Prussian military physician who observed foot pain and swell- remodeling. In this process, lamellar bone is resorbed by osteo-
ing in young military recruits unaccustomed to the rigors of clasts, thereby creating resorption cavities that subsequently are
training. He considered it to be an inflammatory reaction in the replaced with more dense bone by osteoblasts. Because there is a
tendon sheaths resulting from trauma and called the condition lag between increased activity of the osteoclasts and osteoblasts,
Fussgeschwulst. It was not until the advent of radiographs that bone is weakened during this time. If sufficient recovery time
the signs and symptoms were attributed to fractures in the meta- is allowed, bone mass eventually increases. However, if load-
tarsals.1 The condition then became known as a march fracture ing continues, microdamage may accumulate at the weakened
because of the close association between marching and the onset region. Remodeling is thought to repair normally occurring
of symptoms. Stress fractures were first noticed in civilians in 1921 microdamage. The processes of microdamage accumulation
by Deutschlander,2 who reported six cases in women. However, it and bone remodeling, both resulting from bone strain, play an
was not until 1956, more than a century following their identifi- important part in the development of a stress fracture. Running,
cation in military recruits, that they were recognized in athletes.3 for example, produces ground reaction forces approximately
A variety of terms have been used over time to describe stress five times greater than walking. The result of excess strain is an
fractures. These include march fractures, Deutschlander frac- accumulation of microdamage leading to fatigue reaction or
tures, fatigue fractures, or crack fractures.2 Virtually all of these fatigue failure.
terms have been intended to describe some etiologic attribute of If microdamage accumulates, repetitive loading contin-
the stress injuries of bone. In recent years the most commonly ues, and remodeling cannot maintain the integrity of the
used term has been stress fracture. bone; a stress fracture may result. This may occur because the
Following the radiographic description of metatarsal stress microdamage is too extensive to be repaired by normal remod-
fractures, many theories were set forth to explain the etiology eling, because depressed remodeling processes cannot ade-
of this injury. Most of the reports were based on series that quately repair normally occurring microdamage, or because of
were small, and the theories proposed were concerned with some combination of these factors. Another special consider-
either mechanical factors, such as spasm of the interossei, or flat ation in the pathophysiology of stress fractures is the influence
feet, or with inflammatory reactions, such as nonsuppurative of skeletal muscle. For example, muscles may protect the tibia
osteomyelitis. during activity by producing shear forces that counteract the
joint reaction forces and result in reduced net shear stresses in
the lower extremity.4,5 It has been hypothesized that reduced
ETIOLOGY OF STRESS FRACTURES lower leg muscle strength increases the risk of stress fracture
It is now recognized that the development of a stress frac- through this mechanism. There is another theory that brings in
ture represents the end product of the failure of bone to the possibility of repeated oxygen deprivation during activity.
adapt adequately to the mechanical loads experienced during In this theory, the repeated load of an activity such as running
22
 CHAPTER 3  Stress Fractures: Their Causes and Principles of Treatment 23

TABLE 3.1  Distribution of Multiple Stress Fractures According to Anatomic Location in Both
Sexes
WOMEN MEN TOTAL

Location N % N % N %
Metatarsal 15 34.1 13 18.6 28 24.6
Calcaneus 2 4.5 0 0.0 2 1.8
Tarsal 5 11.4 3 4.3 8 7.0

Tibia
Distal third 7 15.9 13 18.6 20 17.5
Middle third 4 9.1 11 15.7 15 13.2
Proximal third 4 9.1 16 22.9 20 17.5

Fibula
Distal third 2 4.5 5 7.1 7 6.1
Middle third 1 2.3 3 4.3 4 3.5
Proximal third 0 0.0 1 1.4 1 0.9

Femur
Distal third 1 2.3 0 0.0 1 0.9
Middle third 0 0.0 0 0.0 0 0.0
Proximal third 1 2.3 3 4.3 4 3.5
Pubic bones 2 4.5 2 2.9 4 3.5
Total 44 100.0 70 100.0 114 100.0
From Korpelain R, Orava S, Karpakka J et al. Risk factors for recurrent stress fractures in athletes. J Sports Med. 2001, 29(3):304-310.

is thought to cause decreased oxygen delivery and brief isch- athletes and found runners with a high weekly training mileage
emia in weight-bearing bones. This ischemic environment is are at a high risk of recurrent stress fractures of the foot and
thought to stimulate the bone-remodeling process, specifically shin. Leg-length inequality, a high longitudinal arch of the foot,
by increasing osteoclastogenesis.6 The end result is a weakened forefoot varus, and menstrual irregularities may also be etio-
bone that is susceptible to stress fractures. logic factors for recurrent stress fractures (Tables 3.1 and 3.2).15

EPIDEMIOLOGY RISK FACTORS FOR STRESS FRACTURES

Stress fractures have been reported to occur in association with Repetitive mechanical loading arising from athletic training
a variety of sports and physical activities. Clinical impression contributes to stress fracture development. However, the con-
suggests that stress fractures are more common in weight-bear- tribution of each training component (volume, intensity, fre-
ing activities, particularly those with a running or jumping com- quency, surface, and footwear) to the risk of stress fracture
ponent. Numerous case series have reported that stress fractures has not been elucidated. Training also may influence bone
comprise between 0.7% and 15.6% of all injuries sustained by indirectly through changes in levels of circulating hormones,
athletic populations.7 through effects on soft tissue composition, and through associ-
It often is suggested that women sustain a disproportionately ations with menstrual disturbances.16
higher number of stress fractures than men.8 A gender difference Training surface has long been hypothesized to contribute
in stress fracture rates is, however, not as evident in athletic pop- to stress fracture development. Anatomic and biomechanical
ulations.9 Studies either show no difference between male and problems can be accentuated by cambered or uneven surfaces,
female athletes or a slightly increased risk for women, up to 3.5 whereas ground reaction forces are increased by less compliant
times that of men. Bennell et al. found no significant difference surfaces. Researchers also have implicated training surface or
between gender incidence rates even when expressed in terms change in surface as a risk factor but do not provide substantial
of exposure.10 Women sustained 0.86 stress fractures per 1000 evidence in support.
training hours, compared with 0.54 in men. Reported increased Biomechanical abnormalities may predispose athletes and
incidence of stress fractures in women has been attributed to active individuals to stress fractures by creating areas of stress
decreased bone density/size, hormonal aberrations, and bio- concentration in bone or by promoting muscle fatigue. Both
mechanical/anatomical differences.11–14 Korpelainen and col- excessively supinated and excessively pronated feet can be con-
leagues looked into risk factors for recurrent stress fractures in tributing factors in the development of stress fractures. Pes
24 SECTION 2  Sport Syndromes

TABLE 3.2  Distribution of Multiple Stress Fractures by Sports Event According to Anatomic
Location
SPORTS EVENT TOTAL

Long-Distance Power Ball

Bone Running Sprinting Jumping Orienteering Skiing Events Games N %
Metatarsal 20 3 2 0 0 1 2 28 24.6
Calcaneus 2 0 0 0 0 0 0 2 1.8
Tarsal 5 2 1 0 0 0 0 8 7.0

Tibia
Distal third 11 1 0 0 3 2 3 20 17.5
Middle third 7 1 4 0 0 0 3 15 13.2
Proximal third 12 0 2 6 0 0 0 20 17.5

Fibula
Distal third 5 1 0 1 0 0 0 7 6.1
Middle third 2 0 1 0 0 0 1 4 3.5
Proximal third 1 0 0 0 0 0 0 1 0.9

Femur
Distal third 1 0 0 0 0 0 0 1 0.9
Middle third 0 0 0 0 0 0 0 0 0.0
Proximal third 4 0 0 0 0 0 0 4 3.5
Pubic bones 3 0 0 0 0 0 1 4 3.5
Total 73 8 10 7 3 3 10 114 100.0
From Korpelain R, Orava S, Karpakka J et al. Risk factors for recurrent stress fractures in athletes. J Sports Med. 2001, 29(3):304-310.

TABLE 3.3  Grouping of Intrinsic and Dietary behaviors and eating patterns may differ in those
Extrinsic Factors with stress fractures. Low calcium intake may contribute to
Intrinsic Factors Extrinsic Factors
stress fracture development by directly influencing the pro-
cesses of bone remodeling and bone mineralization or by indi-
Cavus feet Type of activity
rectly affecting soft tissue composition and ovarian function.
Leg length discrepancies Excessive/new training regimen
Other dietary factors, such as fiber, protein, and caffeine intake,
Excessive forefoot varus Poor equipment/footwear may play a role. Scores on a validated test relating to dieting,
Tarsal coalitions Improper technique bulimia and food preoccupation, and oral control (EAT-26) did
Prominent posterior calcaneal process Type of training surface not differ between ballet dancers or track and field athletes with
Tight heel cords Sleep deprivation and without stress fracture.9
Osteopenia/osteoporosis Theoretically, low bone mineral density (BMD) could con-
Poor vascular supply tribute to the development of a stress fracture by decreasing the
Abnormal hormonal levels fatigue resistance of bone to loading and by increasing the accu-
From Parekh et al. Stress fractures of the foot and ankle in athletes.
mulation of microdamage. The findings of a 12-month prospec-
FAI. 2013, 6(6):481-491. tive study using dual energy x-ray absorptiometry (DEXA) to
measure bone mass indicate that low bone density is a risk factor
planus (pronated) was initially implicated as a common foot type for stress fractures in women and possibly in men.9 Female ath-
in athletes who presented to sports clinics with stress fractures; letes who sustained tibial stress fractures had 8.1% lower tibia/
however, athletes with pes planus that did not sustain an injury fibula BMD than athletes without stress fractures (p<0.01). In
were not assessed.17,18 Therefore, this cannot be solely implicated the men, the tibial stress fracture group had 4.0% less tibia/fib-
as a risk. Parekh and colleagues developed a chart representing ula BMD than the non-stress fracture group, although this was
intrinsic and extrinsic factors that can be used to rule out other not significant (p = .17). However, it is important to note that in
causes (Table 3.3).19 A prospective study that examined a number this study the athletes with stress fractures still had bone den-
of clinical biomechanical measurements in athletes, including sity levels that were similar to or greater than less active control
range of hip rotation and ankle dorsiflexion, calf and hamstring subjects. This implies that the level of bone density required by
flexibility, lower limb alignment, and static foot posture, did not athletes for short-term bone health is greater than that required
find any to be useful predictors of stress fracture occurrence.9 by the general population.9
 CHAPTER 3  Stress Fractures: Their Causes and Principles of Treatment 25

from a suspected bone tumor or infectious process.22 CT scan-

EVALUATION ning will enable the clinician to differentiate between a stress
A detailed history and physical exam of the patient with a fracture, which will be visible on CT scan, and a stress reaction.
stress fracture is essential for an accurate and timely diag- Particularly in the elite athlete, this may help in the rehabilita-
nosis. In addition to obtaining a history of the patient’s pain tion program and forthcoming competition program.23
and its relation to exercise, it is important to determine the
presence of predisposing factors. In particular, note should
be taken of recent changes in activity level, such as increased
DIFFERENTIAL DIAGNOSIS
quantity of training, increased intensity of training, and The differential diagnosis of stress fracture can be divided into
changes in surface, footwear, and technique. A full dietary nonbony or bony causes. Nonbony causes, in particular, relate
history should be taken; particular attention should be paid to muscle or tendon injury; either muscle strain, hematoma
to the possible presence of eating disorders. In females, a or delayed-onset muscle soreness, or tendon inflammation or
menstrual history should be taken as well. degenerative change.
Typically, the pain is one of insidious onset of activity-related Bony pathologies that can mimic stress fracture include
pain. Usually the pain will be described initially as a mild ache tumor and infection. Osteoid osteoma commonly is mistaken
occurring after a specific amount of exercise. If the patient con- for a stress fracture because it presents with pain and a discrete
tinues to exercise, the pain may well become more severe or occur focal area of increased uptake on isotope bone scan. Two distin-
at an earlier stage of exercise. The pain eventually may increase guishing features of osteoid osteoma are the presence of night
to the point that it limits the quality or quantity of the exercise pain and the relief of pain with the use of aspirin.24 In addition,
performed or, occasionally, forces cessation of all activity. In the a CT scan or MRI can clearly distinguish the nidus of an osteoid
early stages, pain usually will cease soon after exercise is termi- osteoma from the cortical abnormality of a stress fracture.
nated. However, with continued exercise and increased severity
of symptoms, the pain may persist after exercise cessation. Night
pain occasionally may occur.
TREATMENT
On physical examination the most obvious feature is local- The basis of treatment of stress fractures involves rest from
ized bony tenderness. Stress fractures typically have a more the aggravating activity, a concept known as relative rest. The
point-specific tenderness, and in comparison, stress reactions amount of time from a diagnosis of a stress fracture to full
will have a more generalized region of tenderness. The physi- return to sport depends on a number of factors, including the
cal examination also must take into account the potential pre- site of the fracture, the length of the symptoms, and the stage
disposing factors; and in all stress fractures involving the lower in the spectrum of bone strain. Most stress fractures with a rel-
limb, a full biomechanical examination must be performed. Any atively brief history of symptoms will heal in a straightforward
evidence of leg-length discrepancy, malalignment (especially manner, and return to sport should occur within 6 to 8 weeks.
excessive subtalar pronation), muscle imbalance, weakness, or However, there is a group of stress fractures that require addi-
lack of flexibility should be noted. tional treatment to relative rest, and these are considered later.
The primary aim of initial management of stress fracture
is pain relief. This may involve the use of mild analgesics or
DIAGNOSTIC STUDIES nonsteroidal antiinflammatory drugs (NSAIDs). In some
Radiography has poor sensitivity but high specificity in the cases, in which activities of daily living are painful, it may
diagnosis of stress fractures. The classic radiographic abnormal- be necessary for the patient with a stress fracture to be non–
ities seen in a stress fracture are new periosteal bone formation, weight bearing or partial weight bearing on crutches for a
a visible area of sclerosis, the presence of callus, or a visible frac- period of up to 7 to 10 days.25 In the majority of cases this is
ture line. Unfortunately, in the majority of stress fractures there not necessary, and mere avoidance of the aggravating activity
is no obvious radiographic abnormality. The abnormalities on will be sufficient.
radiography are unlikely to be seen unless symptoms have been When activities of daily living are pain free and there is no
present for at least 2 to 3 weeks. In certain cases, they may not focal tenderness, then resumption of the aggravating activity
become evident for up to 3 months, and in a percentage of cases can occur on a graduated basis. Progress should be monitored
never become abnormal. clinically by the presence or absence of symptoms and local
If plain radiography demonstrates the presence of a stress signs. It usually is not necessary to monitor progress by radiog-
fracture, then there seldom is any need to perform further inves- raphy, scintigraphy, CT, or MRI. Radiologic healing often lags
tigations. However, in cases in which there is a high index of behind clinical healing.
suspicion of stress fracture, magnetic resonance imaging (MRI) It is important that the athlete with a stress fracture be able
is the recommended advanced imaging study to be used. MRI to maintain strength and cardiovascular fitness while undergo-
visualizes marrow hemorrhage and edema well, a characteristi- ing the appropriate rehabilitation program. The most common
cally difficult finding with the other advanced imaging comput- ways are biking, swimming, water running, and using upper
erized tomography (CT).20,21 Although CT scan visualizes bone body weights. These workouts should mimic the athlete’s nor-
detail, MR imaging does better at distinguishing stress fractures mal training program as much as possible in both duration and
26 SECTION 2  Sport Syndromes

intensity. Water running is particularly attractive to runners it can vary from the placement of screws across the fracture
for this reason. Water running involves the use of a buoyancy site to the placement of plate constructs to stabilize the frac-
vest as a flotation device. Stretching should be performed to ture. Calcium phosphate cement has also been used in some
maintain flexibility during the rehabilitation process. Muscle stress fractures where typical screws and/or plates are difficult
strengthening also is an important component of the rehabil- to place. Biologic augmentation is also being utilized at this
itation phase. In addition to maintaining these parameters of time, bone marrow aspirate concentrate, platelet-rich plasma,
physiologic fitness, it is possible in most cases for the athlete to and synthetic orthobiologic proteins can also be used to aug-
maintain specific sports skills. In ball sports these can involve ment fixation and the healing response. Overall, the gold stan-
activities either seated or standing still. This active rest approach dard with all fractures that have healing concerns is autograft.
also greatly assists the athlete psychologically. Typically, this is taken from the calcaneus or the tibia on the
As with any overuse injury, it is not sufficient merely to treat ipsilateral side of the lower extremity. Surgical options will be
the stress fracture itself. An essential component of the manage- discussed further below.
ment of an athlete with an overuse injury involves identifica-
tion of the factors that have contributed to the injury and, when
possible, correction or modification of some of these factors to
COMMON STRESS FRACTURES
reduce the risk of the injury recurring. The fact that stress frac- Certain bones of the foot and ankle are more at risk for stress
tures have a high rate of recurrence is an indication that this fractures. There are different reasons for why each bone has
part of the management program often is neglected. an increased risk, but many of these can be treated conserva-
tively. Some examples of activities and professions that are at
Bone Stimulators increased risk for stress fractures are long-distance runners,
If healing potential is diminished secondary to physiologic military recruits, and explosive sports.28–30 The following will
factors or patient wishes to promote a healing response, bone review some of the more common stress fractures and discuss
stimulators are an additional option. Electromagnetic fields their onset, diagnosis, and treatment plan.
and their uses in bone healing have been well studied, with Medial malleolus stress fractures are not very common but
most results showing improvement in healing of both bone do need to be closely watched to check for displacement. They
and cartilage. There are three different methods for bone stim- are also notorious for having limited healing ability. Pain is
ulation; direct current (DC), capacitive coupling (CC), and commonly ill defined in the medial ankle region. There is no
pulsed electromagnetic field (PEMF). Most supportive data significant history of trauma that the patient can recall. This
are found in relation to the spine, femur, and tibia, but there is injury is commonly misdiagnosed as posterior tibial tendon-
increasing evidence for its use in the foot and ankle for treat- itis or deltoid ligament injury. X-ray is initially obtained but if
ment of nonunions and as an adjunctive device in arthrodesis. inconclusive, MRI is recommended. There is some controversy
Scott and King performed a level I prospective double-blind with treatment. Most individuals will recommend conservative
trial with CC on 21 patients with nonunions of femoral and care with immobilization in cast or cam boot and slow return to
tibial shaft nonunions.26 They did report a significant benefit activity. If the fracture is easily visible on MRI and is more of a
with bone stimulation between the two groups. Reports/stud- vertical orientation, ORIF is recommended to prevent proximal
ies have demonstrated that electric bone stimulation with DC, displacement of the fragment.
CC, and PEMF devices maybe a useful adjunct in the treatment Lateral Malleolus fractures occur more often than medial
of delayed unions and nonunions. For high-level athletes, a malleolus fractures. There is a stress fracture of the distal fib-
return to sport as soon as possible is paramount; therefore the ula called “Runner’s Fracture,” and is believed to be caused by
use of a bone stimulator can be added to the treatment plan to repetitive eccentric contractions of the plantar and long toe
enhance the possibility of an earlier return. Exogen (Bioventis, flexors with axial load.31 This is because when the foot is plan-
Durham, NC) is another device that can be used to stimulate tar flexed, the fibula is anatomically closer in relationship to the
bone healing. It is a pulsed low-intensity ultrasound device. tibia and may impart undue stress at the distal end. Either way,
Gold and Wasserman27 did find benefit while using Exogen in the presentation is almost identical to all stress fractures with an
their patients with large tibial segmental defects. Other studies insidious onset and increased pain with activity that progresses
have found similar findings. to pain at rest. Standard weight bearing radiographs are the
initial standard, and in medial and lateral malleolus fractures,
oblique images of the ankle at 45 degrees can also be considered.
SURGICAL INTERVENTION In the absence of any pathologic findings an MRI is considered
If conservative treatment fails to heal the stress fracture and cre- a viable next step. Nonoperative treatment is recommended as
ate a solid union, then surgical intervention is recommended. initial treatment. Rarely is operative treatment necessary for lat-
It is also important to note that with high-level athletes that eral malleolus fractures. A cam boot or immobilization device
surgical intervention is commonly the first line of treatment for is used, and a slow progressive return to non-painful activity is
many stress fractures of the foot and ankle. The type of surgery recommended.
required varies depending on the location of the stress frac- Calcaneal stress fractures are the most common in military
ture and the type of bone that is requiring treatment. Briefly, recruits, and many papers have reviewed this phenomenon.32
 CHAPTER 3  Stress Fractures: Their Causes and Principles of Treatment 27

C
A

D E F G
Fig. 3.1  A-G, 27-year-old professional soccer player with left anterior ankle pain. Pain was slow in presenta-
tion, then chronically all the time. No obvious fracture on plain films. MRI and CT scan reveal a stress fracture
of the navicular. Given the fact the patient is an elite athlete, he underwent operative fixation.

Clinically this type of stress fracture presents with a prodro- Intrinsic and extrinsic factors have been implemented in the
mal period and then worsening swelling and plantar heel pain. cause. These injuries can be confused with possible neuromas.
Typically, a calcaneal compression test can elicit pain and aid It is important to remember that typically neuromas are more
in the diagnosis. Commonly, lateral radiographs of the calca- painful plantarly and are not associated with swelling/edema.
neus can reveal a fracture line between 10–14 days after onset. Usually these injuries are diagnosed after callus or bony reac-
Ideally, standard of care is an MRI to verify the diagnosis.33 tion is noted on initial radiographs (Fig. 3.2). Treatment is
Treatment is always initially conservative with immobiliza- commonly nonoperative/conservative with a hard-soled shoe
tion and refraining from high-intensity activity. Symptoms or cam boot walker for these injuries. Soreness can usually
largely direct treatment modalities after an initial period of continue for upward of 3–4 months while these fractures
immobilization. heal. Treatment duration is tailored to symptom duration and
Another common tarsal bone that sustains stress fractures is activity.
the navicular. It is not as common as calcaneal stress fractures Fifth metatarsal stress fractures are another stress fracture
in military recruits but can occur in the same type of popula- that usually occurs secondary to lateral overload or avul-
tion, as well as explosive athletics such as sprinters. It commonly sion of the peroneus brevis. The fifth metatarsal fracture can
presents with an indistinct vague achy pain with activity that have a prevalence to injury in a cavovarus foot. Surgery may
improves with rest, and pain at the dorsum of the midfoot or be recommended in athletes or a recurrent base of the fifth
along the medial longitudinal arch with activity. It can easily go metatarsal fracture. There are certain distinctions with fifth
undiagnosed for quite some time given the difficulty in visualiz- metatarsal stress fractures regarding location and healing
ing the navicular with plain radiographs. Clinically, it is difficult rates that need to be taken into account.35,36 Occasionally,
to make the diagnosis, and therefore advanced imaging is nec- the cavovarus deformity will need to be corrected as well to
essary (Fig. 3.1). MRI and CT scan can be used to understand reduce the risk of recurrence or non-union. Surgical fixation
the extent of the injury. In non-displaced stress fractures, con- consists of a single screw placed in an antegrade fashion.
servative nonoperative treatment is the appropriate treatment Patients have returned to competitive sports within 6 weeks,
modality.34 When displacement is noted or there is a delay in but it should be noted that causes of failure were linked to
diagnosis, then operative treatment is recommended. Operative early return. This fracture still has an appropriate healing rate
treatment is also considered in elite athletes. in the layperson using conservative measures with immobi-
Metatarsal stress fractures occur via a similar mechanism lization and time.
as stated above. More specifically the second and third meta- These areas are the more common locations in the foot
tarsals sustain stress fractures more commonly than the other and ankle that sustain stress fractures. As stated throughout
three metatarsals. Clinically, a prodromal period is noted prior this text, initial treatment is conservative with immobiliza-
to diagnosis of these injuries. Typically, the individual has tion. Occasionally, nutritional lab values can be obtained to
increased their activity in some way. Radiographs and possibly possibly determine a physiologic cause in conjunction with
MRI are imaging modalities routinely recommended as above. immobilization.
28 SECTION 2  Sport Syndromes

A C D
Fig. 3.2  A-D, Stress fracture in a ballerina with chronic changes on CT. Healed with conservative treatment
and immobilization.

PEARLS 3. Devas MB, Sweetnam R. Stress fractures of the fibula: a review of

50 cases in athletes. J Bone Joint Surg. 1956;38B:818.
Stress fractures are fatigue fractures and result from repeated overuse, and 4. Haris PA, Schache AG, Crossley KM, Wrigley TV, Creaby MW.
they are common in the athlete. Sagittal plane bending moments acting on the lower leg during
MRI is helpful to diagnose a stress fracture early in its presentation and running. Gait Posture. 2010;31(2):218–222.
should be ordered immediately for any patient participating in sport. Stress 5. Sasimontonkul S, Bay BK, Pavol MJ. Bone contact forces on
fractures of the second, third, or fourth metatarsals swell and the pain is dor- the distal tibia during the stance phase of running. J Biomech.
sal, whereas neuromas of the forefoot do not swell and the pain typically is 2007;40(15):3503–3509.
plantar. 6. Romani WA, Gieck JH, Perrin DH, Saliba EN, Kahler DM. Mech-
Most stress fractures of the foot and ankle heal with relative rest. Navicu- anisms and management of stress fractures in physically active
lar, fifth metatarsal, base of second, and medial malleolus may require more persons. J Athl Train. 2002;37(3):306–314.
involved care for healing. 7. Dixon M, Fricker P. Injuries to elite gymnasts over 10 yr. Med Sci
Sport Exerc. 1993;25:1322.
8. Brukner P, et al. Stress fractures: a series of 180 cases. Clin J Sport
Med. 1996;6:85.
CONCLUSION 9. Bennell KL, et al. Risk factors for stress fractures in track and
Stress fractures are a common injury, particularly in runners field athletes: a 12 month prospective study. Am J Sports Med.
1996;24:810.
and in sports that involve a large amount of running. Various
10. Bennell KL, et al. The incidence and distribution of stress frac-
risk factors for the development of stress fractures have been tures in competitive track and field athletes. Am J Sports Med.
proposed; however, the relative importance of these is still 1996;26:211.
uncertain. The diagnosis is primarily on clinical grounds, and 11. Queen RM, Abbey AN, Chuckpaiwong B, Nunley JA. Plantar
imaging can be used to confirm the diagnosis or to assess the loading comparisons between women with a history of second
extent of the injury. The treatment is straightforward in most metatarsal stress fractures and normal controls. Am J Sports Med.
cases, but there is a small group of stress fractures that require 2009;37(2):390–395.
more specific management. 12. Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors
for stress fractures. Sports Med. 1999;28(2):91–122.
13. Bennell KL, Malcolm SA, Thomas SA, et al. Risk factors for stress
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1. Stechow AW. Fussoedem und roentgenstrahlen. Dtsch Mil-Aerztl study. Am J Sports Med. 1996;24(6):810–818.
Zeitg. 1897;26:465. 14. Callahan LR. Stress fractures in women. Clin Sports Med.
2. Deutschlander C. Ueber eine eigenartige mittelfuszerkrankung. 2000;19(2):303–314.
Zentralbl f Chir. 1921;48:1422. 15. Korpelainen, et al. Risk factors for recurrent stress fractures in
athletes. Am J Sports Med. 2001;29(3):304–310.
 CHAPTER 3  Stress Fractures: Their Causes and Principles of Treatment 29

16. Stanitski CL, McMaster JH, Scranton PE. On the nature of stress 28. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S,
fractures. Am J Sports Med. 1978;6(6):391–396. et al. Determinants of stress fracture risk in United States Military
17. Taunton JE, Clement DB, Webber D. Lower extremity stress frac- Academy cadets. Bone. 2013;55(2):359–366. PMID 23624291.
tures in athletes. Phys Sportsmed. 1981;9:77. 29. Tenforde AS, Sayres LC, McCurdy ML, Sainani KL, Fredericson
18. D Sullivan, et al. Stress fractures in 51 runners. Clin Orthop Rel M. Identifying sex-specific risk factors for stress fractures in
Res. 1984;187:188. adolescent runners. Med Sci Sports Exerc. 2013;45(10). 1843-51
19. Parekh, et al. Stress fractures of the foot and ankle in athletes. FAI. 23584402.
2013;6(6):481–491. 30. Abrams GD, Renstrom PA, Safran MR. Epidemiology of
20. Monteleone G. Stress fractures in the athlete. Orthop Clin North musculoskeletal injury in the tennis player. Br J Sports Med.
Am. 1995;26:423. 2012;46(7):492–498. PMID 22554841.
21. Fredericson M, et al. Tibial stress reaction in runners. Correla- 31. Sherbondy PS, Sebastianelli WJ. Stress fractures of the medial
tion of clinical symptoms and scintigraphy with a new magnetic malleolus and distal fibula. Clin Sports Med. 2006;25:129–137.
resonance imaging grading system. Am J Sports Med. 1995;23:472. 32. Sormaala MJ, Niva MH, Kiuru MJ, Mattila VM, Pihlajamaki HK.
22. Swischuk LE, Jadhav SP. Emerg Radiol. 2014;21(2):173–177. Stress injuries of the calcaneus detected with magnetic resonance
https://doi.org.10.1007/s10140-013-1181-1. Epub 2013 Nov 30. imaging in mili- tary recruits. J Bone Joint Surg Am. 2006;88(10):
23. Gaeta M, Minutoli F, Scribano E, et al. CT and MR imaging find- 2237–2242.
ings in athletes with early tibial stress injuries: comparison with 33. Dodson NB, Dodson EE, Shromoff PJ. Imaging strategies for di-
bone scintigraphy findings and emphasis on cortical abnormali- agnosing calcaneal and cuboid stress fractures. Clin Podiatr Med
ties. Radiology. 2005;235:553–561. Surg. 2008;25(2):183–201, vi.
24. Zhang, Y et al. Bone-forming tumors. Surg Pathol Clin. 34. Torg J, Moyer J, Gaughan J, Boden B. Management of tarsal
2017;10(3):513–535. https://doi.org/10.1016/j.path.2017.04.006. navicular stress fractures: conservative versus surgical treatment:
Epub 2017 Jun 29. a meta-analysis. Am J Sports Med. 2010;38(5):1048–1053.
25. Tuan K, Wu S, Sennett B. Stress fractures in athletes: risk factors, 35. Lee KT, Park YU, Young KW, Kim JS, Kim JB. The plantar gap:
diagnosis, and management. Orthopedics. 2004;27(6):583–591; another prognostic factor for fifth metatarsal stress fracture. Am J
quiz 92-3; PubMed PMID: 15237898. eng. Sports Med. 2011;39(10):2206–2211.
26. Scott G, King JB. A prospective, double-blind trial of electrical 36. Torg JS. Fractures of the base of the fifth metatarsal distal to the
capacitive coupling in the treatment of non-union of long bones. tuberosity. Orthopedics. 1990;13:731–737.
J Bone Joint Surg. 1994;76-A:820–826.
27. Gold Wasserman. Preliminary results of tibial bone transports
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2005;19(1):10–16.
 4
Medical and Metabolic Considerations
in Athletes With Stress Fractures
Elliott N. Schwartz, Clinten P. Edmondson

OUTLINE
Introduction, 30 Case 1, 61
Definition of BSI, 30 Case 2, 62
Classification Systems of Bone Stress Injuries, 31 Case 3, 64
Epidemiology of Bone Stress Injuries, 33 Abaloparatide (Tymlos) PTHrP (1-34), 64
Pathophysiology, 33 Bisphosphonates, 66
Genetic Predisposition, 37 Bone Marrow Edema Syndrome, 67
Risk Factors, 39 Bone Growth Stimulators, 69
History and Physical Exam, 39 Platelet-Rich Plasma Therapies, 70
Bone Densitometry, 42 Stem Cells, 70
Bone Quality, 45 Romosozumab, 72
Trabecular Bone Score (TBS), 46 Diet and Nutrition, 72
Osteoprobe, 48 Rest and Physical Therapy, 74
Laboratory Workup and Btom In Stress Fractures, 49 Return to Play (See Online Chapter to View this Assessment
Therapy-Calcium, Vitamin D, Anabolics, Bisphosphonates, and Recommendations), 74
and Bone Growth Stimulators, 55 Prevention, 78
Calcium, 55 Clinical Application, 81
Vitamin D, 55 Conclusion: Stress Fractures, 81
Anabolic Agents for Bone, 57 Lessons Learned After 20 Years of Treating Stress Fractures,
Teriparatide (Forteo) rh PTH (1-34), 57 Delayed Unions, and Nonunions, 81

INTRODUCTION DEFINITION OF BSI

Bone stress injuries (BSI) are common injuries of athletes. BSI represent a “presumed” spectrum of bone damage that occurs
Much of the work in this chapter is based on our work as the result of repetitive trauma that is not handled correctly by
with elite athletes over the last 13 years (Box 4.1). the bone repair mechanisms. For management purposes, BSI may
For the purpose of this chapter, we will define elite be considered as a “bone stress–failure continuum” in which “shin
athlete as one who is participating in athletics at the high splints” (more properly, medial tibial stress syndrome) is a relatively
school, college, or professional level. While some of the infor- mild expression of the damage at the low end of the spectrum and
mation may pertain to recreational athletes, we have made no stress fracture is a severe example of the damage at the other end of
attempt to collect our information on this group of individuals. the spectrum (Tables 4.1 and 4.2).
There are numerous articles on stress fractures in military These conditions do not necessarily occur concurrently or in
populations and settings, beginning with the original reference temporal sequence.3 In fact, we are unaware of someone with
in 1855 of “march fractures” by Breithaupt.1 However, “The medial tibial stress syndrome who has progressed to a stress
findings from military recruits (many of whom are under- fracture or a stress reaction.
trained) may not generalize to athletes (many of whom are well- Numerous articles have defined the components of this
or overtrained) as they may represent different populations.”2 spectrum (medial tibial stress syndrome, stress reaction, and
Therefore, we did not complete a full review on the military lit- stress fracture) (see Chapter 23), but there are no official diag-
erature, but selected certain information from that body of work noses of any of these entities from the American Academy of
that is appropriate to our work. Orthopaedic Surgeons (AAOS), the American Society for Bone

30
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 31

BOX 4.1  Elite Teams and Number of TABLE 4.1  Low-Risk Stress Fracture
Athletes Seen in the Last 13 Years as of Treatment Guide
October 5, 2018 Symptoms Goal Treatment Suggestions
• S an Diego Chargers – 3 Any level of pain Heal injury Titrate activity to a pain-free
• Houston Texans – 1 level for 4–8 weeks depend-
• Oakland Raiders – 5 ing on the grade of injury
• NY Football Giants – 2a Braces/crutches
• University of Georgia – 1a Modify risk factors
• UC Davis – 1 Pain with no functional Continue Titrate activity to a stable or
• Los Angeles Lakers – 1 limitations participation decreasing level of pain
• Milwaukee Bucks – 1b Closely follow
• Golden State Warriors – 4 Modify risk factors
• Philadelphia 76ers – 2 & 1a
Pain with functional Continue Decrease activity level to
• Brooklyn Nets – 1
limitation participation point at which pain level
• New Orleans Pelicans – 1
is decreasing and until a
• Dallas Mavericks – 1
functional level of pain has
• Houston Rockets – 1a
been achieved, then titrate
• Charlotte Bobcats – 1a
activity to stable or continued
• OKC Thunder – 2a
decrease level of pain
• Washington Wizards – 1
Modify risk factors
• U of Portland male cross-country runner – 1
• Minnesota Timberwolves – 1a Limiting pain intensifies Heal injury Complete rest
• Oakland Athletics – 10 despite functional activity Immobilization
• Colorado Rockies – 2 modification (i.e., unable Surgery
• Los Angeles Dodgers – 1 to continue to perform at Modify risk factors
• Los Angeles Angels – 1 any reasonable functional
• Detroit Tigers – 1 level despite activity
• Arizona Diamondbacks – 1 modification)
• Cleveland Indians – 1 & 1a From Diehl JJ, Best TM, Kaeding CC. Classification and return-to-play
• US Olympic Skating – 1b considerations for stress fractures. Clin Sports Med [Internet]. 2006
• Harvard female cross-country runner – 1 Jan [cited 2018 Jul 6];25(1):17–28, Table 1.
• UC Berkeley Basketball – 2
• San Diego State Basketball – 2a
• Wesleyan softball player – 1 a more diffuse lesion spreading several centimeters over the
• Sacramento Kings – 1 bony surface.3
• Valparaiso basketball player – 1a As a specific entity, stress reactions are studied much less
• St. Louis Cardinals – 1a than MTSS or lower extremity stress fractures. Although the
• Minnesota Timberwolves – 1a causation of stress reactions, the complaints by which they
• New York Knicks – 1a present, the history, the physical findings, and the imaging by
• New York Jets – 3a which they are diagnosed are the same as stress fractures, the
aConsulted but not seen in office term “stress reaction” means there is no fracture line or break
bNot seen yet but referred in the continuity of the bone. X-ray images are usually negative
in an initial stress reaction. A bone scan will be positive, but
and Mineral Research (ASBMR), or the American College of this cannot help tell whether there is or is not a fracture line.
Sports Medicine (ACSM).4–6 Therefore, the diagnosis is made by either magnetic resonance
“Shin splints” is a nonspecific lay term associated with a imaging (MRI) or computed tomography (CT) scan.7
large number of fundamentally different tibial exercise-in- Stress fractures result from the repeated application of a stress
duced leg injuries where there is repeated foot-to-ground lower than that required to fracture bone in a single loading
impact. Such distinct leg injuries as tibial and fibular stress situation.8
fractures, tibial periostitis, anterior and deep posterior com-
partment syndromes, popliteal artery entrapment, and tibia- CLASSIFICATION SYSTEMS OF BONE STRESS
lis posterior and anterior muscle strain, or tendinitis have all
been referred to under the rubric of shin splints. As part of the INJURIES
push to make a more specific medical evidence-based diag- The classification of stress fractures has become more com-
nosis of these different entities, medial tibial stress syndrome plex since the initial description by Breithaupt in 18551 and
(MTSS) has been separated from the other conditions. MTSS Stechow’s subsequent observation that on early radiographs,
is a condition comprising periostitis or symptomatic perios- clinical findings in the feet were due to fractures.9 Garbuz et al.
teal modeling occurring in the vicinity of the junction of the reviewed the value and role of orthopedic classification systems
middle and distal thirds of the medial border of the tibia. It is used to characterize the nature of a problem to guide treatment
32 SECTION 2  Sport Syndromes

TABLE 4.2  Management of and Return-to-Play Strategies for High-Risk Stress Fractures
Anatomic Site Complications Suggested Treatment Level of Data
Femoral neck Displacement Tension: Strict NWB or bed rest Level C (expert opinion)
Nonunion Surgical fixation Level D (case series)
Avascular necrosis RTP when healed
Compression: NWB until pain-free with radiographic evidence of healing,
then slow activity progression
RTP after no pain on examination or with any activities
Surgical fixation (optional)
Anterior tibia Nonunion Nonoperative: NWB until pain-free with ADL; pneumatic leg splints Level A (RCT)
Delayed union RTP with slow progression after nontender and pain-free with ADL (9 mo) Level B (nonrandomized)
Fracture progression Operative: Intramedullary nailing Levels C and D
RTP is usually faster (2–4 mo)
Medial malleolus Fracture progression Nonoperative: (No fracture line) Levels C and D
Nonunion 4–6 wk pneumatic casting
Avoid impact; rehabilitation
RTP when nontender, no pain with ADL
Operative: (Fracture line, nonunion, or progression)
ORIF with bone graft
Tarsal navicular Nonunion Nonoperative: NWB cast 6–8 wk, then WB cast 6–8 wk Levels C and D
Delayed union RTP is gradual after pain-free with ADL
Displacement Orthotics and rehabilitation suggested
Operative: (Complete, nonunion)
RTP only when healed
Talus Nonunion Nonoperative: NWB cast 6–8 wk Level C
Delayed union RTP is gradual after pain-free with ADL
Orthotics and rehabilitation suggested
Operative: Reserved for nonunion
Patella Displacement Nonoperative: (Nondisplaced) Level C
Fracture completion Long-leg NWB cast 4–6 wk
Rehabilitation following RTP is gradual after pain-free with ADL
Operative: Horizonal—ORIF
Vertical—lateral fragment excision
RTP when healed
Sesamoids Nonunion Nonoperative: NWB 6–8 wk Level C
Delayed union RTO is gradual after pain-free with ADL
Refracture Operative: Excision if fail nonoperative
Fifth metatarsal Nonunion Nonoperative: (No fracture line) Levels C and D
Delayed union NWB cast 4–6 wk followed by WB cast until healed
Refracture RTP after nontender and pain-free
Operative: (Fracture line, nonunion, or individual at high risk for refracture)
Intramedullary screw fixation
RTP 6–8 wk, early ROM/rehabilitation

ADL, Activities of daily living; NWB, nonweight bearing; ORF, open reduction with internal fixation; RCT, randomized controlled trial; ROM, range of
motion; RTP, return to play; WB, weight bearing; wk, week.
From Diehl JJ, Best TM, Kaeding CC. Classification and return-to-play considerations for stress fractures. Clin Sports Med [Internet]. 2006 Jan
[cited 2018 Jul 6];25(1):17–28. Table 2.

decision-making and establish an expected outcome for the these aspects of fractures. Arendt and Griffiths developed a classifi-
natural history of a condition. This formed a basis for uniform cation based on x-ray, scintigraphy, and MRI findings.25
reporting of results for surgical and nonsurgical treatments and The most intensive and thorough review of this issue comes
for comparison of results from different centers.10 from Kaeding and his group in a series of articles starting in
Various classification systems have been proposed on the basis 2005.26–29 In their initial paper,26 they reviewed the patho-
of clinical findings (e.g., client history and physical examination)11; physiology, diagnosis, and classification of stress fractures
radiographic results,12 including scintigraphy,13,14 ultrasound,15 on the basis of the separation of low-risk stress fractures and
CT,16; MRI17,18 and dynamic contrast-enhanced MRI19; fatigue high-risk stress fractures.23,24 High-risk stress fractures (see
versus insufficiency (pathogenesis)20–22; high- versus low-risk frac- also Chapters 3 and 5) occur at the femoral neck, the patella,
tures23,24; and on practices that involve multiple components of the anterior tibial diaphysis, the medial malleolus, the talus,
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 33

TABLE 4.3  Stress Fracture Classification TABLE 4.4  Proposed Stress Fracture
High-Risk Fractures Low-Risk Fractures
Classification System
Occur on tension side Occur on compression side Radiographic Findings
(CT, MRI, Bone Scan,
Natural history poor Natural history favorable
Grade Pain or Radiograph) Description
Often require aggressive Often require nonsurgical treatment with
I No Imaging evidence of stress Asymptomatic
treatment, including surgery rest and gradual return to weight-
fracture, no fracture line stress reaction
or strict nonweightbearing bearing
II Yes Imaging evidence of stress Symptomatic stress
From Kaeding CC, Najarian RG. Stress fractures: classification and fracture, no fracture line reaction
management. Phys Sportsmed [Internet]. 2010 Oct 13 [cited 2018 Jul
6];38(3):45–54. Table 2 Available from: http://www.tandfonline.com/ III Yes Nondisplaced fracture line Nondisplaced fracture
doi/full/10.3810/psm.2010.10.1807. IV Yes Displaced fracture (≥2 mm) Displaced fracture
V Yes Nonunion Nonunion
the tarsal navicular, the proximal fifth metatarsal and the first
From Kaeding CC, Miller T. The comprehensive description of stress
metatarsal phalangeal sesamoids. Low-risk stress fractures fractures: a new classification system. J Bone Jt Surg - Ser A [Internet].
include the femoral shaft, medial tibia, ribs, ulna shaft, and 2013 Jul 3 [cited 2018 Jul 6];95(13):1214–20. Table 1. Available from:
first through fourth metatarsals. Previous studies showed that https://insights.ovid.com/crossref?an=00004623-201307030-00010.
high-grade injuries (grade 3 and 4) took longer to heal than
low-grade injuries (grade 1 and 2). stress fractures incorporating x-ray, bone scan, and MRI findings
The management of each fracture should be individualized. graded from 1 to 4. Five other systems used multiple imaging
“The key difference between a low-grade stress fracture at a modalities. Four of the less frequently cited systems did use clin-
high-risk versus low-risk location is that an individual who has ical parameters, and pain was the most common symptom men-
a low-grade fracture at a low-risk site can be allowed to con- tioned. None of the studies incorporated an assessment of the
tinue to compete but an individual who has a low-grade fracture healing capacity of the fracture combined with a notation of the
at a high-risk site needs to heal before full return to activity”27 extent of structural damage. The authors were able to determine
(Table 4.3). High-risk stress fractures have more frequent com- from their systematic review of the literature that the ideal stress
plications like delayed union, nonunion, and refracture. fracture classification system they hoped to find did not exist.
Kaeding and Najarian27 continued the development of their Subsequent to the that analysis, Kaeding and Miller sought
classification system in 2010, stressing the important distinction to develop a system that incorporated their belief that the clas-
between a high-risk and a low-risk fracture. sification describe not only the extent of the structural damage
High-risk fractures occur on the tension side, have a poor nat- but also the healing potential of the lesion.29 This is complicated
ural history, and require aggressive treatment, whereas low-risk by the tremendous variability of the stress fracture lesion. Their
fractures occur on the compression side, have a favorable natural classification system employs three descriptors: 1) fracture grade;
history, and frequently can be handled by nonsurgical treatment. 2) fracture location; and 3) imaging modality used (Table 4.4).
A complete classification system of a stress injury (reaction or The system they developed had the reproducibility they
fracture) requires knowledge of the anatomic location and the desired, was simple, easy to use, and formed the basis for treat-
grade of injury. Arendt and Griffiths25 and Fredericson18 have ment. When reporting the stress fracture, “a CT scan revealing a
developed grades of increasing severity of these stress fractures, nondisplaced fracture line in a tarsal navicular in a healthy col-
from 1 to 4, with the latter representing a complete fracture. At legiate basketball player would be reported as a Grade-III tarsal
that time, they felt that the management of stress injuries should navicular stress fracture on CT scan.”29 We have adopted this
be determined by the location and grade of the injury. system for use at our center.
Subsequently, Miller, Kaeding, and Flanigan conducted a sys-
tematic review of the literature of Classification Systems of Stress
Fractures.28 They wanted to determine if there was a system that
EPIDEMIOLOGY OF BONE STRESS INJURIES
was “reproducible, inexpensive, safe, broadly applicable, widely For further details, see Chapters 3 and 5.
accessible, and clinically relevant to prognosis and treatment
considerations.” According to their review, 27 previous systems
were found and analyzed for strengths and weaknesses. Of the
PATHOPHYSIOLOGY
most commonly cited systems in their review, none included a The understanding of the pathogenesis of stress fractures has
clinical parameter or parameters. None of the classification sys- advanced since Breithaupt’s original description,1 advancing
tems tested for inter- or intra-observer agreement; therefore, their beyond the concept that they are due to performing repetitive
reproducibility of use by single or multiple observers is unknown. tasks resulting in overuse with accumulation of microdamage.
Of the 27 systems evaluated, 16 were applicable to the entire skel- Recent advances in our understanding of bone biology enable
eton, whereas 11 were applicable only to a specific bone or loca- us to have a deeper insight into the actual events29 (Fig. 4.1).
tion. The more modern classification systems included MRI as There are numerous beautiful descriptions of the pathogenesis
an imaging technique. Arendt and Griffiths’ system is most often of stress fractures on a macroscopic level but very few on a micro-
cited since 1990, and provides a system of radiologic grading of scopic or nano-structural level because most of these cellular and
34 SECTION 2  Sport Syndromes

Mechanical loading

Intrinsic factors (skeletal,

muscle, joint, and
biomechanical factors)

Bone strain
Feedback to Feedback to
positively Strain magnitude and rate, positively
influence and number of loading cycles influence
skeletal skeletal
factors factors
Bone damage No damage

Damage-related Strain-related modeling

remodeling and/or remodeling

Extrinsic (training) and

intrinsic (gender) factors

Damage repair Imbalance between

damage and remodeling

Altered skeletal
properties (bone geometry Accumulation of damage
and/or material properties)

Stress reaction
Asymptomatic Pathology
continuum
Stress fracture

Complete bone fracture

Fig. 4.1  Proposed pathophysiology of stress fractures. (From Warden SJ, Burr DB, Brukner PD. Stress frac-
tures: pathophysiology, epidemiology, and risk factors. Curr Osteoporos Rep. 2006 Sep;4(3):103–109. Fig 1.)

subcellular evaluations are new and the findings are just being rebounds to its original position. The force that a bone can endure
incorporated into the overall picture as our knowledge develops. and still rebound back to its original state without damage is within
In 1998, Harold M. Frost, one of the clearest thinkers about the elastic range. Forces that exceed a critical level above the elastic
bone physiology, histomorphometry, and bone pathology, range are in the plastic range. Once forces reach the plastic range, a
stated, “Bone is a fatigue-prone material.”30 lower load causes greater deformation; it is at this level that forces
In 2001, Boden et al. stated that the “exact mechanical phenom- summate to permanently damage the bone.”31
enon responsible for initiating stress fractures remains unclear.”24 Warden and his colleagues stated in 2006 that the “precise
But it is clear that an increase in the duration, intensity, or fre- pathophysiology of stress fractures is unknown, and current mod-
quency of physical activity, either military basic training or athlet- els are based on theory.”32 Although the pathogenesis of stress frac-
ics, without sufficient rest intervals may lead to increased osteoclast tures in these models is usually discussed at the macroscopic level,
activation and bone resorption. Muscle fatigue may also result in damage really initiates at the level of the collagen fiber or below.33
excessive forces being transmitted to the bone. In 2002, Romani Fatigue is the loss of strength and stiffness that occurs in materials
et al. added that “stress fractures are not the result of one specific subjected to repeated cyclic loads.34 Bone fatigue fractures (now
insult. Instead, they arise as the result of repetitive applications of known as stress fractures) are a complex in  vivo phenomena in
stresses that are lower than the stress required to fracture the bone which mechanical damage and biological repair have major roles.35
in a single loading.”31 Whenever a low level of force is directed on If microdamage from bone fatigue activity accumulates at a slow
to the bone, whether due to contact with the ground or muscle rate, normal biological remodeling may be able to repair the dam-
activity, it causes the bone to deform, which is known as a strain. age and retain the structural integrity of the bone. However, the
The bone’s stress–strain response depends on the load’s direction; creation of microcracks initiates osteoclastic bone resorption and
the bone’s geometry, microarchitecture, and density; and the role the microdamage removal in a bone that continues to be exces-
of attached muscle and its contractions. “In most activities of daily sively loaded with high cyclic stresses may accelerate the accumu-
living (ADLs), when the force is removed, the bone elastically lation of fatigue damage.
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 35

With every bone movement, and especially repetitive epi- Hughes et  al. reviewed the role of adaptive bone forma-
sodes of mechanical loading, bone strain occurs, producing tion in the etiology and prevention of stress fractures. The typ-
microdamage. Strain is defined as the change in length per unit ical model of stress fracture development does not account for
length of a bone and is frequently expressed as microstrain (μƐ). the actual clinical occurrence of a stress fracture. In the previ-
Usual strains (400–1500 μƐ) are far below the single load-failure ous calculation by Schaffler,36 the basic training recruits are
threshold (10,000 μƐ). But strains below the single load-failure exposed to less than 1/400th the duration of loading required to
level can have a cumulative effect on the bone structure. Carter develop a fatigue-induced stress fracture under in vitro loading
et  al. studied the fatigue behavior of adult cortical bone. The conditions. This may be due to differences between the exper-
bone fatigue microdamage accumulates at a slow but unknown imental loading conditions, where bones may be repetitively
rate, and how much is too much is also unknown. Cortical bone strained in one plane, and the live loading conditions, in which
fails in fatigue within 10³ to 105 loading cycles when strains are the soldier or the athlete is subjected to multidirectional load-
between 5000 and 10,000 μƐ.35 According to Schaffler and col- ing. This may result in more abnormal loading and strain, pro-
leagues, strains in the physiologic range of 1000 to 1500 μƐ in ducing more microdamage than the experimental model does.
ex vivo studies have been shown to cause fatigue and microdam- Additionally, in the experimental model, a small portion of bone
age but not to result in complete fracture of cortical bone even is utilized, and the human bone is larger and is more likely to
after 37 million loading cycles.36 have weaker regions than the laboratory specimen, and in vivo
The repetition of sub-maximal strains produces microdam- bones are undergoing remodeling in response to increased
age in the bone. Much effort has been undertaken to decide mechanical loading, which can transiently weaken the bone.39
how much strain can produce microdamage and how much Remodeling directed at removing microdamage is referred to
microdamage can produce fatigue failure of bone. Schaffler et as targeted remodeling. This repair activity causes a temporary
al. summarized some other work by noting that “strains in the porosity that may contribute to stress fracture risk, although the
range of 1200–1500 microstrain and strain rate of 0.03 s-1 are authors say, “the link between increased porosity and stress frac-
typical of the strain environment measured on tensile surfaces ture risk remains to be demonstrated experimentally. In principle,
of long bone diaphysis during running. If one assumes (con- the process of bone remodeling in response to physical training
servatively) a stride length of three feet for a runner. Each [sic] is paradoxical in that it may promote stress fracture development
limb would be loaded every six feet, and each million cycles by introducing an acute increase in porosity, but may also pre-
would correspond to about 1136 miles of running. Ten million vent stress fracture development by replacing fatigue-damaged
load cycles correspond to more than 11,000 miles of continu- bone.”39 The porosity that develops represents a temporary neg-
ous loading without the advantages of remodeling or repair.”35 ative bone balance that exists until the resorption cavity is filled
This implies a much greater fatigue resistance for compact bone with new bone that becomes fully mineralized. However, deposi-
at physiological strains than would be calculated from earlier tion of osteoid, newly formed unmineralized bone, by osteoblasts
studies.34 The military recruit experience suggests that stress does not immediately restore normal bone stiffness and other
fractures occur within 6 weeks after the start of basic training, or characteristics. What is needed is mineralization, which occurs
at about 100 to 1000 miles of vigorous exercise, or an estimated in two phases: primary mineralization, which occurs during the
100,000 to 1,000,000 loading cycles by the previous calculations. first few weeks and results in 65%–70% of the final mineraliza-
This “suggests that other mechanisms may be involved in fatigue tion; and secondary mineralization, which occurs slowly over
failure.”36 They hypothesized that “brief stress or strain loading the next 8–12 months.40 “As stress fractures may occur within
would lead to complete fracture.”36 weeks of onset of physical training, newly activated remodeling
The excessive strains produce microcracks in the bone and cycles remain in early stages when a negative bone balance can
microdamage resulting in collagen fiber-matrix debonding, dis- theoretically contribute to a cycle of increased strain and accu-
ruption of the mineral–collagen aggregate, and collagen fiber mulation of microdamage upon continued loading until stress
failure.33 fracture ensues.” 40 Targeted remodeling is a key process for
There are three distinct types of microdamage based on dif- replacing fatigue damage. Bone remodeling is a process charac-
ferences in staining properties in bone. These different staining terized by four phases: the activation phase, when the osteoclasts
characteristics also allow for the demonstration of microcracks are recruited; the resorption phase, when the osteoclasts resorb
in the bone. “Fatigue loading and the extent of microdamage bone; the reversal phase, when the osteoclasts undergo apopto-
are associated.”37 Microdamage is difficult to demonstrate in sis and the osteoblasts are recruited; and the formation phase,
bone specimens and takes special staining procedures, devel- where the osteoblasts lay down new organic bone matrix that
oped initially by Frost. It is considered impossible to apply subsequently mineralizes. By definition, remodeling is a process
these techniques to in  vivo situations. The specific interac- where osteoclasts and osteoblasts work sequentially. Bone mod-
tion between mineral and collagen is poorly understood. To eling is the process in which bones are shaped or reshaped by the
understand microdamage in  vivo is going to take the devel- independent (noncoupled anatomically or temporally) action
opment and use of new imaging tools, like Trabecular Bone of osteoblasts and osteoclasts. Skeletal development and growth
Score (TBS) and Texture Research Investigation Platform take place by the process of bone modeling.41
(TRIP) (Medimaps Group SA, Geneva, Switzerland), μCT, Adaptive bone formation deposits bone, via bone model-
finite element analysis (FEA), and high-resolution peripheral ing (as opposed to remodeling), on the periosteal, endocorti-
CT (HRpQCT).38 cal, or trabecular surfaces in response to mechanical loading.
36 SECTION 2  Sport Syndromes

Bone modeling is the process of bone growth that takes place the questionnaire was revised to subdivide the type of ball sports
in infants, children, and adolescents where bone is forming into soccer, basketball, volleyball, tennis, and handball. Of the
and involves the independent action of osteoblasts without 1118 soldiers who completed basic training, stress fractures in
prior osteoclastic bone resorption. Modeling involves osteo- the group that did not play ball ranged between 28.9%, 27%,
cyte activation where the osteocytes act as mechanotransduc- and 18.8% in the individuals in each group, respectively, who
ers. Osteocytes are important regulators of bone function (and did not participate in ball sports and 13.2%, 16.7%, and 16.3%
will be discussed more thoroughly below). The mechanosens- in the individuals in each group who did play ball sports. They
ing and mechanotranducing osteocytes transform an induced also inserted strain gauges into the tibias of three volunteers
deformation of the bone matrix from some external force into and found that the tension, compression, and shear strain rates
biochemical and flow signals that lead to new bone formation.39 during rebounding were higher than those during running and
The mechanism for stimulation of osteocytes is thought to be were 2.16 to 4.60 times higher during rebounding and running
electric streaming potential created by ionic fluid movement than during walking.45 In Scandinavian46 and Israeli47 studies,
through the lacuna-canalicular system and cellular shear stress a history of long-distance running or jogging did not affect the
generated by fluid flow along the osteocyte cell body and den- incidence of stress fractures in military recruits. Previous activ-
dritic processes. Apparently, the cell body, the primary cilia, and ities such as weightlifting, swimming, and martial arts did not
the dendritic processes are responsible for mechanosensation. lower the incidence of stress fractures, and a history of swimming
Changes in the osteocytes and their dendrites lead to increased increased the risk for stress fractures. In the paper presenting
intra-osteocyte calcium signaling, and formation of pro-osteo- three separate studies,45 those recruits who played ball sports for
blastic molecules such as prostaglandin E2 (PGEƨ), insulin-like more than two years before their military training, in the first two
growth factor (IGF-I), nitric oxide, and adenosine triphosphate of the three studies, had only 50% of the stress fractures; in the
(ATP) that positively affect bone formation and suppress osteo- third study, where the recruits were specifically asked what sport
cyte production of negative regulators of the Wnt/ß-catenin they played and what ball sport they played, 90% of the recruits
pathway, such as sclerostin and dickkopf-1 (DKK1).42 played basketball, and in those who played ball sports, the stress
Deposition of bone along the diaphysis of long bones on fracture rate was 20% (80% decrease) compared to those who did
the periosteal surface provides great mechanical advantage.39 not play ball sports. To explain this phenomenon, in vivo human
Long bones with mass distributed furthest from the neutral tibial bone strain measurements were obtained in a number of
axis, i.e., wide bones, are stronger in relation to bones with different studies including the above-cited one.45 The principal
similar masses that are narrower.43 Stress fracture risk is compression strain was 48% higher, the principal tension strain
affected directly by the properties of the skeleton, like wider 15% higher, and the shear strain 64% higher during basketball,
bones or denser bones, and thus it is thought that modification rebounding than during running. The compression strain rate
of these properties via the adaptive ability of bone may be used was 20% higher, the tension strain rate 6% higher, and the shear
as a way of reducing an individual’s risk. Warden et al. looked strain rate 28% higher during basketball rebounding than during
at bone adaptation to a site-specific mechanical loading pro- running. The amount of strain and strain rate change are major
gram using a rat ulna axial loading model that compared determinants of adaptive bone formation to loading. The authors
the loaded right forearm (ulna) to the control, an unloaded felt that the high strains and strain rates that occur during play-
left forearm (ulna). The mechanical loading induced bone ing basketball can cause maximum adaptive bone formation. This
changes that resulted in a significant increase in ulna fatigue resulted in stiffer bone in the basketball players who played for
resistance. The authors found that by improving the structural 2 years before entering the military and, thus, less bone strain
properties of a bone through a mechanical loading program, during basic training than the recruits who did not play basket-
the bone’s fatigue resistance could be significantly improved. ball, and therefore fewer stress fractures in the basketball play-
They suggested that an exercise program directed at changing ers. Milgrom et  al. concluded that, “On the basis of this study,
the structural properties of the skeleton can be employed as a logical strategy for lowering the incidence of stress fractures
a possible prevention strategy for stress fractures. When the in military recruits and athletes would be to adapt their bones
fatigue life of the trained and untrained limbs was compared, before they begin formal training. This would involve a pretrain-
the untrained limb fractured after 15,000 cycles whereas the ing program, over a course of at least 2 years, of properly applied
trained limb failed after an average of 1.5 million cycles. This high-strain- and high-strain-rate-generating exercises that mimic
100-fold increase in fatigue resistance after a 5-week loading the strain and strain rates that occur during basketball. Such a
regimen shows the potential impact of adaptive bone forma- program would ideally stiffen the bone and not lead to stress frac-
tion with physical training.39,44 tures during this adaptation period.”45 In our opinion, a modern
Milgrom and his group performed three prospective studies understanding of the pathophysiology of stress fractures requires
of military recruits in different basic training classes to evaluate an understanding of the role of osteocytes in bone physiology and
bone’s adaptation ability to lower the incidence of stress fractures. pathophysiology.
Different groups of 452, 433, and 404 elite infantry recruits had Osteocytes were first described by Carl Gegenbaur (also
their physical fitness assessed by a timed 2-km run, the maxi- Gegenbauer), a German physician, anatomist, zoologist, and
mum number of chinups they could perform, and the number physiologist,48 in 1864,49 only 9 years after Breithaupt1 described
of situps they could perform in 1 minute. The pre-­induction “march” fractures. It would take over 150 years for stress frac-
participation in sports activity was assessed. In the third study, tures and osteocytes to come together.
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 37

In the last few years, there have been multiple reviews of the between osteocytes and muscle cells, which also play a role in
etiology, evolution, and function of osteocytes. It is clear from response to mechanical stimuli.
these studies that the matrix-producing osteoblasts can become Microcracks develop as a result of daily cyclic loading,
an osteocyte, a lining cell, or can undergo programmed cell which is repaired by a balanced process between resorbing
death.50,51 and forming cells.52 Microcracks can damage the osteocyte
Hazenberg and colleagues state that human that bone con- and its processes, inducing the osteocyte to send signals to
tains between 13,900 and 19,400 osteocytes per mm³.52 Buenzli initiate bone resorption and formation. Microdamage and
and Sims give slightly different numbers of 20,000 to 30,000 bone fatigue are both associated with loss of osteocyte integ-
osteocytes per mm³, but since it is estimated that 5% of osteocyte rity.55 The role of osteocytes is being increasingly recognized
lacunae are empty, this suggests an average osteocyte density of in a wide variety of metabolic bone diseases. Lower osteocyte
19,000 to 30,000 osteocytes per mm³. This results in an estimate density has been shown to play a role in some patients who
of 42 billion osteocytes in the human skeleton.53 The osteocytes are destined to sustain a vertebral compression fracture.56
form an interconnected network through their dendritic pro- Apoptosis of osteocytes has been recognized as a factor in glu-
cesses, creating communication between individual osteocytes cocorticoid-induced osteonecrosis of the hip.57 Parathyroid
and the surface bone lining cells. The number of osteocytic den- hormone (PTH) and the PTH Type 1 Receptor (PTH1R) play
dritic processes varies per species. Osteocytes contain between a role in osteocyte survival as well as in the mechanosensory
40 and 60 cell processes per osteocyte with a cell-to-cell distance process.58
of 20–30 μm per Hazenberg, and 18–106 processes per Buenzli, Although no real research has been performed on stress frac-
making a total of 3.7 trillion projecting from the osteocyte cell ture patients, the increasing understanding of the role of fatigue
bodies. This results in a cumulative length of all osteocytic and microdamage in disrupting canalicular flow and creating
dendritic processed in the human skeleton to be 175,000 km apoptosis of osteocytes, which initiates bone resorption and
(108,740 miles). One cell process may form up to 12.7 termini remodeling, are all steps in the pathogenesis of stress fractures.
on average, so that a single osteocyte may possess up to 1128 In 2016, we formulated the hypothesis that stress fractures may
termini connecting with other cells. Extrapolated to the whole be due to disordered, dysfunctional, or diseased osteocytes
skeleton, this calculates to 23.4 trillion osteocytic connections.53 where fluid mechanics, shear/strain forces, mechanosensory
Transmission of mechanical signals to the osteocytes can occur forces, mechanotransducer forces, and production and release
directly via cell surface receptors through the solid matrix of of bone growth inhibitors (Dkk1, sclerostin) and bone growth
the tissue due to load-induced fluid flow or indirectly via fluid stimulation (activation of the Wnt/ß-catenin pathway) may
pressure and shear stresses.52 result in abnormal bone remodeling, including the necessary
Osteocytes have numerous functions in bone. They can bone resorption and, perhaps, the lesser or delayed bone for-
serve as orchestrators of bone remodeling including formation mation that allows bone failure to occur with subsequent devel-
and resorption; inducers of osteoclast activation; modulators opment of a stress fracture. It is increasingly clear that the effect
of mechanical loading via mechanosensation and transduc- of many anti-osteoporotic drugs, like PTH, may be mediated
tion; sources of factors and regulators of mineral metabolism; by their direct or indirect effect on osteocytes.59–61 (The role of
remodelers of the perilacunar matrix; and other functions, such PTH and other anabolic drugs for bone is discussed under the
as regulators of mineralization. Osteocyte cell death leads to section on Treatment)
skeletal fragility via the recruitment of osteoclasts to the site.
Viable osteocytes secrete an as yet unknown factor or factors
that inhibit osteoclast activity, and when they die, osteoclasts
GENETIC PREDISPOSITION
are released from inhibition to start the process of bone resorp- The ease with which it is possible to study the human genome
tion.54 They perform these functions via the release of signal- has improved tremendously in the last several years, and the
ing molecules such as nitric oxide, prostaglandin E2, and ATP cost of doing so has markedly decreased, putting these indi-
from the osteocytes in response to external stimuli, such as vidual analyses within reach of the general public. We now can
mechanical strain. Fluid fluxes in the canaliculi and, perhaps, both perform genome-wide association studies (GWAS) and
electromechanical signals induced by the mechanical load- study single nucleotide polymorphisms (SNPs).
ing also participate. The osteocytes are multifunctional cells, Many studies have looked at the genetics of osteoporosis,62
and they undertake some of these functions via an endocrine the genetics of low bone mineral density (BMD),63,64 and the
role. Osteocytes are known to produce fibroblast growth fac- genetics of fragility fracture.65,66
tor 23 (FGF 23), one of the most important osteocyte-secreted It has been increasingly shown that many sports injuries
endocrine factors, which plays a role in phosphate metabo- have a genetic basis. Some of this pioneering work has been
lism, is a marker of early kidney failure, and can down-regu- done by Stuart K. Kim and colleagues at Stanford. Among
late1-α hydroxylase, which is required for the conversion of other injuries, a genetic predisposition has been shown for
25-hydroxyvitamin D to the active 1,25-dihydroxyvitamin D. medical collateral ligament (MCL) rupture,67 shoulder dis-
They also produce sclerostin, which is an inhibitor of bone location,68 rotator cuff injury,69 ankle sprains and strains,70
formation in the Wnt-ß catenin system. In addition, other fac- De Quervain’s tenosynovitis,71 and plantar fasciitis.72 There
tors involved in phosphate metabolism, such as DMP1, PHEX, is increasing evidence that, to some degree, there is a genetic
and MEPE, are expressed by the osteocyte. There is crosstalk predisposition to stress fractures.
38 SECTION 2  Sport Syndromes

One of the early interesting occurrences in this regard was SNPs within the P2RX7 gene. Some SNPs seemed to be gain-
reported by Singer et al. in 1990. Two 18-year-old identical twin of-function polymorphisms and were associated with higher
brothers, who were in the same basic training program in the BMD, whereas others were loss-of-function polymorphisms
Israel Defense Force (IDF), were seen with pain in the proximal and were associated with lower BMD.79 Husted et  al. studied
part of the left thigh starting 4 weeks before examination in the SNPs of the P2X7R gene in a population of 462 osteoporotic
sixth week of their training class. Both brothers were in good women and men with a T-score less than –2.5 or one low trauma
physical health and exercised regularly prior to their induc- vertebral compression fracture referred to the Department of
tion. They both underwent nuclear medicine bone scans with Endocrinology at Aarhus University Hospital. The effect of var-
Technesium-99m diphosphonate, which showed significant ious genotypes on fracture risk was examined and factors asso-
uptake in both the left and right proximal femurs along with ciated with fracture risk and BMD and/or body weight were
some uptake in the tarsal bones of their right feet. Although found. Again, these findings were in accord with the phenotype
the authors listed numerous potential clinical risk factors, they of the knockout mouse described by Ke.75,80
stated that genetic factors had never been considered to play a The vitamin D system includes 25 vitamin D, its active form
role in predisposition to stress fractures, but the finding in this 1,25 dihydroxyvitamin D, a variety of enzymes involved in its
monozygotic twin set suggested that genetic factors might need formation, and a specific receptor, the Vitamin D Receptor
to be considered in the future.73 (VDR), which mediates its actions.81 Mutations in the VDR
In 1997, Burnstock summarized work being performed to gene are known to cause disorders such as 1,25 dihydroxyvita-
elucidate the role of purine nucleotides as signaling molecules.74 min D–resistant rickets, a rare monogenetic disease. Apparently,
Subsequent experimental studies showed that osteoclasts and, polymorphisms (more subtle sequence variations) in the VDR
perhaps, a subpopulation of osteoblasts contain cell surface gene happen more frequently in the population than the severe
nucleotide receptors and established a role for the P2X nucle- deleterious mutations.82 In a study of 32 young (age range
otide receptor in bone formation and resorption. P2X7 recep- 19–30 years) stress fracture patients and 32 healthy volunteers,
tor-deficient mice have smaller bone diameter and lower cortical Chazipapas and colleagues genotyped the study subjects for
mass and a reduction in periosteal bone formation. Deletion of four different polymorphisms of the VDR: Fokl in exon 2, BsmI
the P2X7 receptor resulted in decrease in periosteal mineraliz- and ApaI in intron 8, and Taql in exon 9. For example, the Fokl
ing surface, mineral apposition rate, and bone formation rate polymorphism contained FF, Ff, and ff genotypes; stress frac-
consistent with reduced periosteal osteoblast number and activ- tures were found to be eight times more likely in subjects with
ity. Nucleotides released from many cell types in response to the ff and Ff genotypes compared to the FF genotype. Similar
mechanical stimulation are felt to mediate mechanotransduc- data were produced for the other polymorphisms. Fokl and
tion in bone.75 This has now been confirmed in work by Li and Bsml polymorphisms were found to be independent risk factors
Turner, where it was shown that the P2X7 nucleotide receptor for stress fractures.81
mediates skeletal mechanotransduction.76 Subsequently, the Korvala et al. looked at the genetic predisposition for femoral
occurrence of mutations in the cytoplasmic domain of the P2X7 neck stress fractures in a group of Finnish soldiers. All military
receptor has been reported.75 conscripts who had suffered a femoral neck stress fracture between
Advancing from these murine studies to human studies, 1970 and 1995 were invited to a follow-up study in 2002 to 2003;
numerous (and increasing) functional SNPs have been iden- 72 subjects participated. The diagnosis of stress fracture had been
tified, which result in either gain or loss of function of the made based on standard X-ray, nuclear medicine, or MRI criteria.
P2X7 receptor protein (P2X7R) and have been associated with A group of 120 soldiers without stress fractures served as a control
important clinical bone alterations. Jørgenson and colleagues population. Clinically, the cases were shorter and had lower body
conducted a 10-year genetic analysis of SNPs of the P2X7R gene weight and BMI than the controls. A total of 15 SNPs in six genes
in the Danish Osteoporosis Prevention Study (DOPS) popu- (COL1A1, COL1A2, CTR, IL-6, VDR, and LRP5) were genotyped.
lation. They were able to show that several of the uncommon The COLA1A RS2586488 and COL1a2 rs3216902 SNPs were asso-
loss-of-function variants induced a predisposition to accel- ciated with stress fractures in a recessive model, and the risk was
erated loss of BMD in postmenopausal women similar to the increased in carriers of the LRP5 rs2277268 SNP minor allele in
loss produced in knockout mice in the previously cited studies. comparison with noncarriers. The authors felt that genetic factors
The small number of individuals in each of three different risk might play a role in the development of stress fractures in individ-
groups prevented them from showing a relationship to osteo- uals subjected to heavy exercise and mechanical loading who were
porotic fracture.77 Gartland and colleagues, using the Aberdeen lighter weight, and thus the heavy loads they were subjected to were
Prospective Osteoporosis Screening Study, showed that poly- responsible for the relatively higher numbers of neck stress fracture
morphisms in the P2X7R gene were also associated with low than in larger individuals.83
lumbar spine BMD in addition to confirming accelerated bone Yanovich et al. studied candidate genes in Israeli soldiers with
loss in their postmenopausal women.78 Wesselius and his group, stress fractures. The study population consisted of 203 soldiers
which included some of the aforementioned researchers, stud- (162 males and 41 females) with no findings of stress fractures
ied men and women ≥50 years of age who had presented to the and 182 soldiers (165 males and 17 females) with known stress
osteoporosis clinic at the Maastricht University Medical Centre fractures. Of interest, 10 participants from the stress fracture
(MUMC), the Netherlands, following a traumatic or fragility group had a family history of bone disorders or stress fractures;
fracture. The subjects were genotyped for 15 nonsynonymous 5 reported that their fathers had suffered stress fractures during
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 39

their military service. A total of 268 candidate SNPs from 17 fragility, the sensitivity to mechanical loading and the expres-
genes spanning 12 chromosomes were selected for study. sion of mechanotransduction by osteocytes may be at the basis
Sequence variants in a total of eight genes were associated with of the pathophysiology.86
an increased risk for the development of stress fractures. Of In 2017, further studies by Varley et al. offered newer data
note, variants in six genes were associated with decreased risk from the previously discussed SFEA cohort. They investigated
of stress fractures. One of the limitations of this study was that it 11 SNPs in the vicinity of Wnt signaling pathway, especially the
may have been underpowered to detect significant differences, SOST gene, which have a role in bone formation and mecha-
because correcting for multiple comparisons resulted in the fact notransduction. By this point in time, 125 stress fractures were
that none of the comparisons remained significant.84 reported in the SFEA cohort. Three SNPs in the SOST gene and
Varley and coworkers undertook an evaluation of the role of the VDR gene studied were reported as being associated with
the RANK/RANKL/OPG pathway, which is important in osteo- increased incidence of stress fracture. Again, at this point in
clastogenesis controlling osteoclast activation, formation, and time, the mechanisms by which these SNPs increase the stress
differentiation, working with a convenience sample of 518 elite fracture risk is not known, but since the SOST gene is involved
athletes (449 males and 69 females) to form the Stress Fracture in with regulating bone formation, it is possible that the rare allele
Elite Athletes (SFEA) cohort who participated in a variety of sports of rs1877632 down-regulates sclerostin expression, via its role
including soccer, cricket, track and field, running events, rowing, in inhibiting Wnt signaling, which could result in a reduction in
boxing, tennis, hockey, and gymnastics. Each sport produced bone formation, thus impairing the response to accumulation of
both stress fracture and nonstress fracture subjects. Genomic stress fracture microdamage.87
DNA came from saliva samples. A SNP of RANKL rs1021188 was
shown to be associated with stress fractures in the whole group,
the male group, and the multiple stress fracture group. A SNP
RISK FACTORS
of RANK rs3018362 was also shown to be associated with stress In perhaps the largest study of stress fractures, Bulathsinhala
fracture occurrence in different groups. A rare allele of rs4355801 et  al. looked at racial and ethnic differences in 1.3 million
had a greater association with stress fractures in the OPG group. US Army soldiers using the Total Army Injury and Health
They concluded that SNPs of the RANK/RANKL/OPG signaling Outcomes Database (TAIHOD), a large repository of admin-
pathway were associated with stress fractures. Although the spe- istrative (medical and demographic) data on the entire Active
cific function of the genotyped SNPs was not known, this path- Duty Army (ADA) population. Race origin was Non-Hispanic
way is associated with osteoclast differentiation and activation black, Non-Hispanic white, Hispanic, American Indian/
that could decrease bone resorption, thus, perhaps, affecting the Alaskan Native, Native Hawaiian/Pacific Islander, and mixed
ability to respond to or repair microdamage.85 races. Race was categorized as Black, White, American Indian,
Additionally, in another study, Varley and colleagues pos- Asian, and More than one race. Ethnicity was also expressed,
tulated that the P2X7 receptor gene, now recognized as a key e.g., Asian consisted of Chinese, Japanese, Korean, Vietnamese,
regulator of bone remodeling, might play a role in the develop- Filipino, Indian, and other Asian. They identified 21,549 inci-
ment of stress fractures both in military recruits and elite ath- dent stress fractures among 1,299,332 soldiers during 5,228,525
letes. They studied a group of 210 Israeli Defense Force (IDF) person-years. The overall incidence of stress fractures was 4.12
military recruits and 518 elite athletes. The elite athletes (449 per 1000 person-years from 2001 to 2011. Female soldiers had
men and 69 women) formed the SFEA cohort. This cohort a 3.6-fold higher incidence of stress fractures than did male sol-
was recruited from the United Kingdom and North America diers. Non-Hispanic white and Hispanic groups had a higher
and were predominantly white Caucasian (83.2% in the stress risk of stress fractures than non-Hispanic blacks. Non-Hispanic
fracture cases and 79.9% in the nonstress fracture controls). white men and women had the highest risk of stress fracture.
Both groups had had stress fractures diagnosed in standard There was further breakdown of the racial and ethnic groups.
ways by complaints, physical examination, and appropriate The youngest soldiers (<20 years) were more susceptible to stress
imaging. From the military participants, DNA was extracted fractures than older groups, and those with lower weight were at
from peripheral blood leukocytes, and from the SFEA cohort, higher risk than those of normal weight. The reasons for these
genomic DNA was derived from saliva. Analyses of five P2X7R race and ethnic-related risks for stress fractures are unknown,
SNPs in the SFEA cohort showed that specific SNP (designated but probably they are related to issues of bone mineral density
rs1718119) was associated with multiple stress fractures. Thus, and bone quality including issues like bone size, bone architec-
the findings in these two distinct populations (military cohort ture, and microdamage handling—all issues we now know are
data not presented) are the first to demonstrate an independent probably related to underlying genetics.88
association between stress fracture incidence and specific SNPs For further details of issues about Risk Factors, see Chapters
(rs1718119 and rs3751143). As described previously, in multi- 3, 5 and 28 as well as below.
ple Scandinavian studies, these SNPs have been shown to affect
various bone parameters, e.g., bone loss rate, vertebral compres-
sion fracture, etc. The mechanisms by which these SNPs in the
HISTORY AND PHYSICAL EXAM
P2X7R gene are involved in the production of stress fractures is The clinical history should make the health care professional (phy-
unknown. However, since it is hypothesized that stress fractures sician, nurse practitioner, and/or physician’s assistant) suspect the
are related to repetitive loading causing microdamage and bone presence of a stress fracture. The most important diagnostic tool
40 SECTION 2  Sport Syndromes

TABLE 4.5  Intrinsic and Extrinsic Factors in fractures in a prospective study of 372 male infantry recruits.
the Causation of Stress Fractures If the response to the stress fracture history was positive, a
complete physical examination was performed; each bone in
Intrinsic Risk Factors Extrinsic Risk Factors
the lower extremity was examined by palpation to determine
• Gender • Training errors if tenderness was present. “The femurs, because they lie within
• Age • Training surfaces a large cuff of muscles were examined for tenderness by a ‘Fist
• Ethnicity • Worn-out/inappropriate
Test. That is, pressure was applied simultaneously to the anterior
• Body Mass Index footwear
aspect of both thighs, directly over the femurs, beginning distally
• Bone characteristics • Excessive training intensity
• Muscle strength • Environment
and progressing stepwise proximally. This was done with the
• Pretraining fitness level clenched fists of the examiner applying the weight of his upper
• Lower extremity morphology body. An area of specific tenderness difference in sensitivity
• Nutrition factors between femurs using the Fist Test was considered suggestive of
• Genetics a femoral stress fracture.” By using this expanded stress fracture
• Menstrual dysfunctions clinical assessment (SFCA) and employing the full upper-body
• Muscle fatigue weight of the examiner, they uncovered more previously asymp-
• Flexibility tomatic femoral stress fractures to more appropriately classify
• Previous injury and inadequate them as symptomatic.90 Giladi and their group also looked at
rehabilitation
external rotation of the hip as a predictor for stress fractures.
Adapted from Rosenthal and McMilan, Recruit Medicine, Chapter 11, Each of the group of 295 new male infantry recruits between 18
2006 , ed, Bernard L. DeKoning, Office of the Surgeon General, pp and 20 years of age who were evaluated in this study underwent
175–202. a pre–basic training screening that included an extensive ortho-
pedic examination with measurements of joint motion includ-
is a detailed clinical history supported by a complete (for the non- ing the range of internal and external rotation of the hip with the
surgeon) and/or a focused physical examination (for the ortho- hip flexed to 90°, among other measurements and assessments
pedist). Most athletes relate an insidious onset of pain over 2–4 for ligamentous laxity. External rotation of the hip was found
weeks. This is usually associated with the initiation of a training to have a significant relationship to all types of stress fractures
program (e.g., I thought I would run a 5K, a half-marathon, or a (p = 0.0163), and specifically tibial stress fractures ( p = 0.0345),
marathon), an increase in training regimen (e.g., getting in shape but not for femoral stress fractures. They divided the external
for the start of a season), or a change in equipment (e.g., new run- rotation into two categories—external rotation ≥65° and <65°—
ning shoes). Utilization of a list or a preset questionnaire (Table and found that the recruits with an external rotation ≥65° had
4.5) will help the history-taker be complete and cover more of the a 1.8 times higher incidence of stress fractures than the <65°
important issues. The pain is focal and local as opposed to medial group. They hypothesized that the ≥65° group might represent
tibial stress syndrome where the pain is more generalized along those with retroverted hips, increased joint laxity, a different
the anterior medial surface of the tibia. gait pattern, or different collagen characteristics of their bone.91
Initially, the pain occurs only during the offending activity, Matheson and colleagues found alignment and biome-
such as running. At this point, suspicion must be high to make chanics of the lower extremities are significant factors in the
the diagnosis. Usually, the athlete notices pain at the end of causation of stress fractures. The frequency of varus alignment
an event but typically the pain subsides quickly with cessation was reviewed: genu varum 29%, tibial varum 18.9%, subtalar
of the activity; then, over the next several days to weeks, the varus 71.9%, and forefoot varus 72.6%. Pronated feet were most
pain progresses to occur earlier in the event and becomes more common in tibial and tarsal stress fractures and least com-
severe, although frequently the athlete is trying to play through mon in metatarsal stress fractures. Cavus feet were found most
the pain. The pain then increases to the point where it persists commonly in metatarsal and femoral stress fractures.89 All of
for a prolonged period of time after the event and, eventually, these alignment and biomechanical abnormalities create gait
starts to occur between events, then extends to occur between difficulties, and some are quite subtle. Therefore, sometimes an
events without an obvious precipitating activity, and ultimately individual with a stress fracture or, more likely, multiple stress
to pain at rest. Throughout this progression, there is a decrease fractures or stress reactions or a combination of the two may
in mileage or in time spent playing the activity, like basketball. be well served to have an evaluation at a human performance
At this point, when the athlete is finally unable to perform, he laboratory, including gait analysis.
or she may complain to the trainer, other staff members, or Three-dimensional instrumented gait analysis (3D-GA)
another health care professional.11 results in information on normal and pathological gait to
Physical examination, at this point, is usually focused on provide comprehensive data about joint motions (kinemat-
the site of pain. Often the patient can point to the site of the ics), time-distance variables (spatio-temporal data), and joint
pain, especially in the lower extremity, and one can find local movements and powers (kinetics). 3D-GA can be helpful for
tenderness to palpation or possibly slight nodular swelling. In obtaining objective information for analysis of functional lim-
Matheson et al.’s series of 320 athletes, localized tenderness was itation or for follow-up over time. A number of indices have
found in 65.9% of cases and swelling in 24.6%.89 Milgrom and been developed including: normalcy index (NI), hip flexor
their group conducted a clinical assessment of femoral stress index (HFI), gait deviation index (GDI), gait profile score
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 41

(GPS), and movement analysis profile (MAP). The NI is the lengths (preferred and –10% preferred) and three running regi-
most extensively validated and used measurement in clinical mens (3, 5, and 7 miles) in 10 experienced male runners free of
gait research and practice.92 Napier and colleagues conducted any lower extremity injuries. A 10% reduction in stride length
a systematic review of gait modifications that have been under- resulted in a corresponding reduction in peak resultant contact
taken to change lower extremity gait biomechanics in runners. force. Increasing running mileage from 3 to 5 miles resulted in
Several measures including rearfoot eversion, vertical loading an increase in stress fracture probability of 4% to 5%. Increasing
rate, and foot strike index have shown an association with run- running mileage from 3 to 7 miles increased stress fracture
ning-related injuries. Some of the biomechanical issues, such probability from 7% to 10%. Their results suggested that a 10%
as cadence and foot strike, may be modifiable. They found 27 reduction in preferred stride length reduces the risk for a tibial
articles that investigated different gait-retraining interventions. stress fracture, and that if this were done, it would allow runners
Foot strike manipulation was the most common intervention; to run an additional 2 miles per day and maintain the same low
step frequency and step length were also common interven- risk of fracture. They also felt that the benefits of reduced stride
tions. Some studies looked at other manipulations. They cov- length are noticed more at higher weekly running mileages. The
ered changes in hip kinematics, changes in knee kinematics, authors stated that the “difficulty for the clinician is in identify-
changes in ankle kinematics, vertical, and leg/lower extremity ing those runners ‘at risk’ for stress fracture that would benefit
stiffness, spatiotemporal variables, step frequency, step length, from a 10% stride length reduction. Presumably, these would be
and ground contact time. Impact loading (the sudden force inexperienced runners beginning a weekly running routine or
applied to the skeleton at initial contact) has demonstrated the runners with a history of stress fracture. Poor physical fitness
greatest relationship with lower extremity overuse injuries from and low physical activity before physical training and a previous
any of the biomechanical variables.93 history of stress fracture are both associated with a higher risk
Zadpoor and Nikoyan94 conducted a metanalysis of 13 arti- of stress fracture development.”96
cles of the relationship between lower extremity stress fractures Crowell and Davis studied gait retraining to reduce lower
and the ground reaction force (GRF). The GRF is an approximate extremity loading in runners. They performed a pretraining
measure of the loading of the lower extremity musculoskeletal instrumental gait analysis. They then began a retraining pro-
system, is fairly easy to measure, and is an important feature to gram, which included eight sessions over a 2-week period in
measure in the study of the kinetics of the lower extremity during which an accelerometer was taped to the distal tibia and subjects
running. The vertical loading rate (VLR) is defined as the slope of ran on a treadmill, during which time they were instructed to
the initial part of the vertical-GFR time curve (between the foot “run softer”: make their footfalls quieter and to keep their accel-
strike and the vertical impact peak). According to the authors’ eration peaks below a given line. The monitor depicting the peak
analysis of the included literature, the studies do not agree on line was placed in front of the treadmill for the runners to view.
whether or not the vertical GFR and/or loading rate are signifi- Run time was gradually increased from 15 to 30 minutes over the
cantly different between the stress fracture groups and the control eight sessions. Feedback was provided continuously for the first
groups. However, the average VLR and the instantaneous VLR four sessions and then removed. A comparison of the pretrain-
are significantly higher in the stress fracture group (p < 0.05). ing and posttraining results revealed significant reductions in
One of the limitations the authors state of the cited studies was peak positive acceleration (PPA), vertical instantaneous (VILR),
that they were only short-term studies, and many individuals and vertical average loading rates (VALR), and a vertical impact
with lower extremity injuries are running for a long time, and peak (VIP) of about 20–30%. These reductions were maintained
consequently, muscle fatigue may play a role in their injuries. at the 1-month follow-up. The reductions in PPA, VILR, VALR,
When muscles fatigue, the amount of energy transmitted to the and VIP achieved in the current study were at least two times
surrounding bones increases. Grimston and colleagues from the greater than those achieved through the use of cushioning shoes,
Human Performance Laboratory at the University of Calgary foot orthoses, or shock-attenuating insoles, indicating that
showed, in a study of a 45-minute run in subjects with a history an individual’s ability to alter their own running mechanics is
of a tibial stress fracture (n = 5) and no stress fracture history (n = greater than the ability of any of these external devices to assist
5), maximum lateral forces were significantly greater for the stress them. So, lower extremity impact loading can be reduced with a
fracture subjects during both early and late stages of the run com- gait retraining program that uses real-time visual feedback.97 But
pared to nonstress fracture subjects. “This finding of increased most of the gait retraining studies have taken place in the labora-
loads during the course of a 45 min run in SF, and constant or tory and not in the natural setting, like a track or cross-country
decreased loads in NSF, may be indicative of differences in fatigue course, a marathon course, or a basketball court.98
adaptation and warrants further study.”95 Napier and his colleagues concluded, from their meta-anal-
Of the different measurements used to test impact loading, ysis, that gait retraining works in the short term to produce
average vertical loading rate (AVLR) is the most serious run- small to large effects on kinetic, kinematic, and spatiotempo-
ning-related injury risk factor. There is a link between step fre- ral results during running. Foot strike changes had the great-
quency, step length, and ground contact time. Typically, a greater est effect on kinematic measures, and real-time feedback also
step length and ground contact time has been associated with a had its largest change on kinetic measures, whereas combined
higher incidence of stress fracture. Edwards and his group cre- training protocols had the biggest alteration on spatiotemporal
ated a probabilistic stress fracture model based on the effects of measures. Further research on these and other interventions is
stride length and running mileage. They investigated two stride still needed.93
42 SECTION 2  Sport Syndromes

In 1990, Myburgh and colleagues showed that low bone

BONE DENSITOMETRY density was an etiologic factor for stress fractures in athletes.
Bone density testing, in its present form, has been available for In their study, 25 athletes with stress fractures were recruited
about 30 years.99 Initially developed in 1961 by Cameron, and from the University of Cape Town Sports Injury Clinic during
improved upon by Cameron and Sorensen,100 this early device a 1-year time interval. They were compared with a group of
measured cortical bone in the forearm by single photon absorp- control subjects who matched the injured athletes closely.
tiometry (SPA). The first commercial devices were manufac- Bone mineral density was measured by DXA (Hologic QDR
tured by Norland Corporation (now Norland at Swissray, Fort 1000) at the lumbar spine (L2–L4) and the left hip (including
Atkinson, WI, USA). Subsequently, Mazess and others devel- the left total femur, Ward [sic] triangle, femoral neck, greater
oped dual photon absorptiometry (DPA) in the early 1970s. The trochanter, and the intertrochanteric space), although now,
modern era of bone densitometry was ushered in by the devel- per ISCD Official Positions the Ward’s triangle, greater tro-
opment of dual-energy X-ray absorptiometry (initially DEXA; chanter and intertrochanteric space are not “official” ISCD
now, DXA) in 1986 by Hologic, Inc., (Waltham, MA, USA) and ROIs. In subjects with a history of a left femoral neck or shaft
subsequently again by Mazess at Lunar Radiation Corporation stress fracture, the contralateral side was measured, and vice
(now GE Healthcare, Madison, WI, USA). Over the last 30 years, versa. All measurements were made at least 6 months after
DXA has emerged as the primary clinical device for fracture risk the diagnosis of stress fracture was made and when all pre-
assessment, for monitoring changes in bone health or for diag- viously injured subjects were exercising regularly. Of the 25
nosing osteoporosis before or after a fracture has occurred. The injured athletes and 25 control athletes, 32 participated in
International Society for Clinical Densitometry (ISCD), through road running, 2 in track, 4 in aerobics, and 12 in both aerobics
its Consensus Development Conferences, has expanded on the and running. Of the 50 subjects, 38 were women. They were
criteria for the diagnosis of osteoporosis and developed positions matched for age (32 ± 8 years), body mass, and height. Injured
of official ROIs for diagnosis and monitoring and principles of runners and their controls were matched for average training
clinical monitoring changes in bone density over time.101–104 distance (53 ± 27 and 45 ± 17 km/wk). Nonrunners and their
Although the vast majority of clinical DXA centers perform controls had similar training times (6 ± 4 and 5 ± 2 h/wk). In
a minimum study of AP Spine (L1–L4), and one hip (mea- the 25 athletes with stress fractures, 7 fractures occurred in
suring regions of interest [ROIs] that are known as the Total the foot, 6 in the femoral neck, 3 in the pubic rami, 3 on other
Hip and the Femoral Neck), the densitometers have developed areas of the femur, 4 in the tibia, and 2 in the fibula. Of the
into sophisticated tools that can measure multiple parameters 25 injured subjects, 7 had previous shin splints and 5 had a
of musculoskeletal health.99 Many of the early papers on bone history of one or more previous stress fractures. Focusing on
densitometry in the area of stress fractures dealt with female the bone density results only, for the purposes of this chap-
athletes, including those with the Female Athlete Triad. ter, bone mineral density was lower in injured subjects than
Perhaps one of the first uses of bone densitometry in ath- in control subjects in the lumbar and the proximal femur (p
letes was the report by Drinkwater et  al. in 1984 on the bone < 0.02, each, respectively). The six subjects with femoral neck
mineral content (BMC) of amenorrheic (age 24.9 ± 1.3 years) stress fractures had significantly lower femoral neck bone den-
and eumenorrheic athletes (25.5 ± 1.4 years).105 Twenty-eight sity than the matched controls. Other clinical risk factors were
women athletes, 14 of them amenorrheic, were studied, and the also studied but are not reported here. The authors felt that the
14 eumenorrheic controls were selected from a larger pool of most important finding was that athletes with stress fractures
potential subjects. SPA and DPA were used to measure fore- had lower bone mineral densities than did well-matched con-
arm bone mineral density (BMD) at two sites at the one-tenth trol athletes. They also showed that the lower bone mineral
and one-fifth forearm sites and lumbar spine BMD of L1–L4, density occurred in both the axial and appendicular skeleton.
respectively. Although the forearm bone density did not differ The authors concluded that “evidence suggests the etiology of
at either site between the two groups, the BMD of the lumbar stress fractures in athletes is more complex than traditionally
vertebrae was significantly lower in the amenorrheic group of believed.”109
athletes. Before the World Health Organization classification Giladi, Milgrom, and their colleagues reviewed identifiable
was developed,106 the BMD of the amenorrheic athletes was risk factors for stress fractures in the Israeli Defense Force.
said to be equivalent to that of women 51.2 years of age; two of They studied a group of 312 male military recruits during
these athletes had a vertebral mineral density below the “fracture 14 weeks of basic training; after dropouts, 289 soldiers were
threshold” as defined by Riggs et al., which is 0.965 g/cm2.107 studied. As part of the pretraining evaluation, foot and tibial
In a follow-up study, Drinkwater and her group reported on radiographs were obtained to measure tibial bone width, BMC
seven of the original amenorrheic women who regained their was measured by SPA at 8 cm above the ankle mortise, and
menses within 1–10 months after 40.4 months (range 11–86 BMD was measured by a Compton bone densitometer, which
months) of amenorrhea. Even though the miles run per week was a precursor of quantitative computed tomography (QCT),
by the amenorrheic group was higher than the eumenorrheic measuring the bone density (in grams per cubic centimeter)
group, their mileage had decreased by 10%, their weight had for a cancellous window in the center of the tibia. The main
increased by 1.9 kg in the women who regained their menses, bone-related risk factor found was: soldiers with wider tibia
and they had an increase in calcium intake. The bone density sustained less tibial, femoral, and total stress fractures than
increase was 6.2% in 14.4 months.108 those with narrow tibia.110
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 43

Lauder et  al. performed an early study on the relationship With further technologic development of DXA and sophis-
between stress fractures and bone mineral density in active- tication of our understanding of the use of the tool, additional
duty US Army women at Fort Lewis, WA, with a total of 423 ROIs are available for study, like the forearm (usually, the
subjects of which 190 women were available for the BMD evalu- nondominant forearm 1/3 radius site, which is an Official ISCD
ation study; 30 of these women qualified by having one or more site)104, vertebral fracture assessment (VFA), and whole body
stress fractures in the last 2 years. Five women were excluded bone mass (also known as total body bone mass [TBBM])114
for a variety of invalid entries on some data items, producing from which body composition measurements can be deter-
a study population of 185 women. Of the 185 women, 27 had mined with percent body fat and lean and fat mass.101,102
stress fractures, and 158 women without stress fractures were This newer understanding of DXA and the ISCD definitions
used as controls. An extensive evaluation of demographics and of an abnormal DXA for children, adolescents, and premeno-
risk factors for stress was undertaken. BMD of the PA lumbar pausal women has been incorporated into the latest 2014 Female
spine (L2–L4) and femoral neck was measured on all subjects Athlete Triad Coalition Consensus Statement on Treatment and
by DXA using a Lunar DPX (now GE Healthcare) by a trained Return to Play of the Female Athlete Triad.113,115 That panel uti-
technician. Their multivariate analysis revealed a strong inverse lized the definitions published by the ISCD as well as the ACSM
relationship between femoral neck BMD and the probability criteria for female athletes involved in regular weight-bearing
of a stress fracture as their most significant finding, indicating sports116 (Box 4.2).
that lower levels of femoral neck BMD were associated with an Looking at another role for bone densitometry in the ath-
increased likelihood of stress fracture. BMD of the lumbar spine letic population, Gustavsson and her colleagues studied rapid
was not found to be a significant predictor of stress fractures.111 bone loss of the femoral neck after cessation of ice hockey
Marx and colleagues from the Hospital for Special Surgery training over 6 years in young males. They assessed the effects
looked at stress fracture sites as they are related to underlying of training and detraining on the BMD of the total body, spine,
bone health in athletic females.112 They noted that the most and femoral neck in a cohort of adolescent male hockey play-
commonly described sites for stress fractures are cortical ones, ers in Sweden. The study group initially consisted of 65 ice
including the tibia, the metatarsals, and the femoral shaft, hockey players and 30 controls with a mean age of 16.7 ± 0.6
whereas fractures are less common at sites of trabecular (or years and 16.8 ± 0.3 years, respectively. After a mean period of
cancellous) bone, such as the femoral neck, pelvis, and sacrum. 2.5 years, 59 hockey players and 30 controls agreed to partic-
They felt that patients who had stress fractures of trabecular ipate in a first follow-up session; 12 of the ice hockey players
bone sites had lower bone mineral density than those who had had stopped training and were excluded; one of the controls
cortical bone stress fractures at their Women’s Sports Medicine was excluded for a variety of extraneous medical reasons.
Center. They conducted a retrospective chart review of 65 After a mean period of 5 years and 10 months, 22 active and
patients diagnosed with stress fractures over a 4-year period. 21 retired hockey players and 25 controls participated in a
Patients underwent DXA scanning. They did not describe the second follow-up examination. At baseline, the average train-
type of DXA machine or software versions used in their study. ing per week for the hockey players was 9.4 ± 2.6 hours. The
They did state that 15 of the DXA scans were performed at training consisted of ice hockey training or games, with addi-
their institution and 5 at other locations, so presumably they tional weight and aerobic training. The control group’s physi-
were different machines from different manufacturers. (At cal activity was playing soccer and football, distance running,
that time, some of the individual machine differences were not and some weight training. At the start of the study, all boys
understood as clearly as they are today).101–104 They utilized participated in 2 hours of physical education in school each
the World Health Organization definition of osteopenia, which week. The subjects were divided into different pubertal Tanner
had been recently formulated.109 This definition has also been stages; all were judged to be at least Tanner stage 4. Using a
refined.101,102 Because of study patients eliminated for a variety Lunar DPX-L (now GE Healthcare) bone densitometer, they
of reasons, they had DXA scans of 9 patients with stress frac- measured the total body and spine BMD and BMC and area of
tures of trabecular bone sites and 11 with stress fractures of the right femoral neck at baseline and the two follow-up exam-
cortical bone sites. Using this small population, they found that inations. The authors felt their most important finding was the
stress fractures of trabecular bone sites were associated with effect of detraining on the femoral neck BMC in the retired
“early onset osteopenia (p = 0.01).” Eight of the nine patients players. These retired players lost significantly more bone at
with stress fractures at trabecular sites had DXA scans that indi- the femoral neck ROI between 19 and 22 years of age than the
cated osteopenia, while only three of the patients with cortical ice hockey players who continued their training. Thus, the gain
bone site stress fractures had osteopenia. They concluded a tra- in BMD from training effect is not sustained after cessation of
becular bone site stress fracture in a young female might be a training.117
warning sign of “early onset osteopenia.” They recommended Studies by Davey et  al. carried the differences in axial
that females under age 40 who have documented stress fractures and appendicular bone density in stress-fractured and unin-
of either trabecular or cortical bone sites (with risk factors for jured royal marine (RM) recruits even further. According
osteopenia) undergo bone density evaluation. (Current ISCD to the authors, RM training is widely acknowledged as one
Official Positions would refer to these DXA measurements as of the most arduous and longest (32 weeks) military train-
“below the expected range for age” if the Z-score is ≤ –2.0 and ing programs in the world. In their study, they measured
“within the expected range for age” if the Z-score is > –2.0.113) BMD by DXA, by ultrasound, and by peripheral quantitative
44 SECTION 2  Sport Syndromes

BOX 4.2  Low Bone Mineral Density (BMD) Diagnosis

How is Low BMD Diagnosed? (3) In addition, an athlete with a history of ≥1 nonperipheral or ≥2 peripheral
The Panel has utilized the definitions published by the International Society of long bone traumatic fractures (nonstress), should be considered for DXA
Clinical Densitometry (ISCD) for low BMD and osteoporosis in children and ado- testing if there are 1 or more moderate- or high-risk Triad risk factors. This
lescents and for premenopausal women and adolescents and for premenopausal will depend on the likelihood of fracture given the magnitude of the trauma
women, as well as ACSM-suggested criteria for female athletes involved in reg- (low or high impact) and age at which the fracture occurred. Athletes on
ular weight-bearing sports. Criteria are described below for who and what site medications for 6 months or greater that may impact bone (such as depot
should be considered for a DXA scan and how often DXA should be performed. medroxyprogesterone acetate, oral prednisone, and others) should also be
considered for DXA testing.
Who Should Get DXA Scans for BMD Testing?
The Panel agreed that indications for obtaining a DXA scan for BMD testing in an How Often Should Athletes Get DXA Testing?
athlete should follow Triad risk stratification (see Clearance and Return to Play The Panel agreed that the frequency of BMD assessment by DXA will depend
section) and include the following: on the initial BMD and ongoing clinical status of the athlete. We agree with
(1) ≥1 “High risk” Triad Risk Factors: the ISCD 2013 guidelines that repeat DXA screening should be obtained when
History of a DSM-V-diagnosed eating disorder the expected change in BMD Z-scores equals or exceeds the least significant
BMI ≤17.5 kg/m2, <85% estimated weight, OR recent weight loss of ≥10% change. Those with definitive indications for DXA testing may require BMD test-
in 1 month ing every 1 to 2 years to determine if there is ongoing bone loss, and to evaluate
Menarche ≥16 years of age treatment.
Current or history of <6 menses over 12 months
Two prior stress fractures, 1 high risk stress fracture, or a low-energy Which Sites Should be Screened with a DXA Scan?
nontraumatic fracture Bone mineral density Z-scores (and not T-scores) should be reported for all chil-
Prior Z-score of < –2.0 (after at least 1 year from baseline DXA) dren, adolescents, and premenopausal women.
OR (1) Adult women ≥20 years
(2) ≥1 “Moderate risk” Triad Risk Factors: Weight-bearing sites (posteroanterior spine, total hip, femoral neck)
Current or history of DE for 6 months or greater Nonweight-bearing sites, namely the radius (33%) if weight-bearing sites
BMI between 17.5 and 18.5, <90% estimated weight, OR recent weight loss cannot be assessed for any reason.
of 5% to 10% in 1 month (2) Children, adolescents, and young women <20 years
Menarche between 15 and 16 years of age Posteroanterior lumbar spine bone mineral content (BMC) and areal BMD
Current or history of 6 to 8 menses over 12 months Whole body less head if possible (otherwise whole body) BMC and areal BMD
One prior stress reaction/fracture Adjust for growth delay (with height or height age) or maturational delay
Prior Z-score between –1.0 and –2.0 (after at least 1-year interval from base- (with bone age)
line DXA) Use pediatric reference data, and when possible, report height-adjusted
Z-scores.

Data from De Souza MJ, Nattiv A, Joy E, et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the
Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapo-
lis, Indiana, May 2013. British Journal of Sports Medicine 2014;48:289.

computed tomography (pQCT). In their cohort of 1090 There were structural differences between stress fractured
recruits, 78 (7%) developed one or more stress fractures; 62 recruits and controls at all slices of the tibia, with the 38%
pairs of stress-fractured recruits and controls were assessed slice the most marked difference between the groups; there
with DXA; the 62 fractured recruits had 79 stress fractures; 7 was also a strong negative correlation between cross-sec-
recruits had 2 fractures, 3 had 3 fractures, and 1 had 4 frac- tional area of the tibia and BMD at this site. There were no
tures. The most common sites of fracture were the metatar- differences in the serum C-Telopeptide (s-CTx), a marker of
sals (n = 41) and tibia (n = 26). Areal BMD assessed with bone resorption, between the stress fracture cases and con-
DXA (two-dimensional projection) was lower at all sites in trols. They concluded that stress–fractured young RM male
the stress fracture group compared with the control group recruits undergoing specialized prolonged military train-
(p < 0.01) Although they used T-scores (the group of males ing had a lower BMD of the spine and hip, narrower tibiae,
were aged 16–32 and Z-scores should have been utilized), and reduced tibial strength indices compared with the study
they did state that 28 of the 62 had T-scores “below the nor- controls.118
mal range (T-score < –1.0)” but, if Z-scores had been appro- Edmondson and Schwartz reviewed non-BMD DXA mea-
priately used, per ISCD, these would have been classified as surements of the hip.119 These included hip axis length (HAL),
“normal for age” since we do not know if any had Z-scores hip structural analysis (HSA), and finite element analysis
< –2.0, which would have been classified as “below normal (FEA), among other techniques. Beck and colleagues utilized
for age.” There was no difference in ultrasound measured by an additional DXA technique that involved scanning at both
broadband ultrasound attenuation (BUA) of the dominant or the midthigh (midfemur length) and distal third of the lower
nondominant foot at baseline (week 2) between stress frac- leg (one-third tibial length from the medial malleolus). With
tures and control recruits. In the recruits measured by pQCT, this DXA technique, they prospectively followed 626 US Marine
there were 51 pairs for the first three slices of the tibia (4%, Corps recruits for 12 weeks of basic training to study cross-sec-
14%, and 33%) and 43 pairs for the 66% slice of the tibia. tional geometric properties of the midshaft femur and middistal
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 45

tibia. Previous studies had shown that the most important geo- BONE QUALITY
metric properties of a long bone are the cross-sectional area
(CSA) and, for bending and torsion, the cross-sectional moment Since the NIH Consensus Development Panel on Osteoporosis
of inertia (CSMI). Within a bone under a given load, the stress Prevention, Diagnosis and Therapy was formed in 2000,124 the
forces are determined by the bone structural geometry, while concept that osteoporosis is a result of compromised bone
the bone’s ability to resist these forces is defined by the bone strength has evolved. Both low BMD and micro-architec-
material properties. The CSA is an index of axial strength and is tural deterioration of bone tissue (bone quality) combine to
related to shear strength, while the CSMI is an index of bending lead to increased bone fragility and consequent increase in
rigidity. The section modulus (Z), an index of bending strength, fracture risk. It seems the same principles must apply to the
was also calculated as the CSMI divided by half bone width. pathophysiology of stress fractures and increased fracture risk
Twenty-three of the 626 recruits (3.7%) presented with 27 lower in other metabolic bone diseases, that is, they result from a
extremity stress fractures. The most common site was the tibia combination of bone mass and bone quality issues. Sorting out
(n = 11), metatarsals (n = 7), femur (n = 5), and tarsals (n = 4); the role of these issues in the individual patient is increasingly
two recruits had fractures at two sites and one had fractures at possible.
three sites. Most anthropometric dimensions were significantly Interest in bone quality has grown significantly in the last
smaller in the stress-fractured recruits than in normal individ- several decades as investigators have realized some of the lim-
uals. Small body size and narrow long bone diaphysis relative to itations of DXA: 1) many fractures occur among patients with
body size were risk factors for the development of lower limb normal bone density; 2) fluoride treatment did not reduce frac-
stress fractures during the 12-week basic training program. tures despite large increases in spinal BMD; 3) small changes in
CSA, CSMI, Z, and pelvic and knee width were significantly areal BMD in patients treated with antiresorptive therapy result
smaller than normal in the tibia and femur. After correcting for in greater than expected decreases in future fracture risk; 4)
body weight differences, CSA, CSMI, Z, and pelvic and knee the measured changes in BMD in patients treated with antire-
width as well as BMD were all significantly smaller in the frac- sorptive drugs explain only a small part of the variance in the
tured recruits. The authors stated that “bone structural data reduction of future fracture risk; 5) reductions in future fracture
derived from DXA provides important new information that risk are evident long before early maximal changes in BMD are
may be useful in the identification of subjects at higher risk for expected or can occur; and 6) patients receiving glucocorticoid
stress fractures under intense physical training conditions.”120 therapy for a variety of illnesses have more fractures than indi-
Nattiv and colleagues studied the correlation of MRI grading of viduals of the same BMD who have not received glucocorticoid
bone stress injuries with clinical risk factors and return to play in therapy. Contributors to bone quality include, among others,
a 5-year prospective study in collegiate track and field athletes. In trabecular architecture, the rate and extent of bone turnover, the
their study, DXA exams were performed at baseline and annually. organic and inorganic composition of the bone matrix, the type
Athletes with a higher MRI grade injury exhibited a lower BMD at and amount of collagen crosslinks, the degree of matrix min-
the total hip (p < 0.050) and radius (p < 0.047). Those athletes with eralization, microdamage accumulation, and cell viability.125,126
bone stress injuries at trabecular sites had significantly lower bone Issues of bone quality have been well studied in the bone fra-
mass at the lumbar spine, femoral neck, and total hip (p < 0.001).17 gility of osteoporosis127,128 (Fig. 4.2). Tommasini et  al. looked
Other imaging modalities, such as ultrasound measurements at the relationship between bone morphology and bone qual-
of the calcaneus, have also been employed in studying the bone ity in male tibias and their implications for stress fracture risk.
of athletes.121 Having a narrow (i.e., slenderer) tibia relative to body mass, an
We utilize bone densitometry on every patient we see at our aspect of bone geometry, is a predictor of stress fracture risk and
center, not to make the diagnosis of stress fracture, but to help bone fragility in male military recruits and male athletes. This
us differentiate between those individuals with fatigue fractures was assessed by testing the biomechanical properties of tibias
and those with insufficiency fractures. Thus, at the Northern
California Institute for Bone Health, Inc., which has both
Lunar Prodigy Advance (GE Healthcare, Madison WI, USA) The Goal: Increased Bone Strength
and Hologic Discovery A (Hologic, Inc., Waltham, MA, USA) NIH Consensus Statement 20001

bone densitometers, we perform a comprehensive DXA study

Bone Bone Bone
including the following ROIs: PA Spine (L1–L4), both hips (for Strength
=
Quality
and
Mineral Density
total hip and femoral neck), nondominant forearm (1/3 fore-
arm [radius]), VFA, a screening of the PA and lateral spine from aBMD = g/cm2
T4 to L4, TBBM, which allows analysis of lean body mass, fat Architecture vBMD = g/cm3
Bone Remodeling
mass, and percent body fat. We particularly, use TBBM in ath- Damage Accumulation
letes less than 30 years old because they may not have achieved Mineralization
peak bone mass and in female athlete triad and individuals Bone Size and Shape
Matrix Quality
with eating disorders, even if they are older than 30 years of
Fig. 4.2  Increased Bone Strength (From NIH Consensus Development
age. There is increasing interest in the use of TBBM in National Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteopo-
Football League (NFL, USA) players122,123 and in other athletic rosis prevention, diagnosis, and therapy. JAMA. 2001;285(6):785-795.
settings.114 https://doi.org/10.1001/jama.285.6.785)
46 SECTION 2  Sport Syndromes

from young adult males. Tibias of 17 male donors (15 white, 1 TABLE 4.6  Trabecular Bone Score (TBS)
Hispanic, 1 black, 32.9 ± 10.4 years of age; range 17–46 years) Interpretation
were acquired from the Musculoskeletal Transplant Foundation
HOW IS THE NUMBER INTERPRETED?
(Edison, NJ, USA). Extensive whole bone morphology was
studied; CSMI, CSA, and Z were assessed. A slenderness index BMD TBS
(S) was calculated; an inverse ratio was created so that a tibia Normal Normal
with a large S was thinner for weight and height of the indi- T-score > –1 TBS > 1.350
vidual; and a small S reflected a heavier or larger tibia. Cortical Low bone mass Partially degraded
bone samples were prepared from the diaphysis of each tibia for –1 < T-score < –2.5 1.200 < TBS < 1.350
biomechanical testing. Tissue-level mechanical properties and Osteoporosis Degraded
damageability were assessed. There were significant correlations T-score < –2.5 TBS < 1.200
between tibia morphology and mechanical properties in tissue
BMD, bone mineral density; TBS, trabecular bone score.
brittleness and damageability. Narrower bone was made up of
From http://www.medimaps.fr/tbs-insight
tissue that failed in a more brittle way and accumulated more
damage. Positive correlations were observed between measures
of bone size and measures of tissue ductility, and negative cor- Analogous to the World Health Organization (WHO) clas-
relations were observed between bone size (CSMI and Z) and sification of osteoporosis of normal, low bone mass (osteope-
tissue modulus. “The correlation between tissue ductility and nia), and osteoporosis,106 the TBS values for postmenopausal
bone size may help explain why male military recruits and male Caucasian women was initially established with the advent of
athletes with narrow bones show a higher incidence of stress the software: TBS ≥1.350 is “normal;” TBS between 1.200 and
fractures compared with individuals with wide bones.” “The 1.350 is considered to be associated with “partially degraded”
data provide a new paradigm that may explain how variation in microarchitecture; and TBS ≤1.200 is classified as “degraded”
bone slenderness contributes to stress fracture risk.” Narrower microarchitecture (Table 4.6).
tibias were composed of tissue that was more brittle and prone These cutoff thresholds were established by a working group of
to accumulate more damage compared with tissue from wider TBS users from different countries.134 McCloskey et al. conducted a
tibias. “Having tissue that is more or less damageable may be meta-analysis of TBS in fracture risk prediction. This study resulted
inconsequential during day-to-day activities. However, tis- in a change of the classification thresholds so that a TBS value <1.23
sue-level mechanical properties like total energy and ductility is “degraded;” between 1.23 and 1.31 is “partially degraded;” and
become particularly important in defining the response of bone >1.31 is “normal.” There was no difference between sexes.135 At
to an extreme loading condition, such as that expected during this point in time, the FDA has approved only a postmenopausal
military training….” From this study, it is now clearer as to why Caucasian database, although other gender- and race-specific
bone size is a risk factor for stress fractures.129 databases are available: female and male, White; male and female,
The search for how to measure bone quality clinically has been Black; and male and female Mexican American (personal commu-
like the search for the Holy Grail (or the Holy Chalice).130–132 nication). We use these additional databases in our research.
But in the last several years new tools (e.g., Trabecular Bone Score Most of the studies reported have dealt with older popula-
[TBS] [Medimaps Group, Geneva, Switzerland] and Osteoprobe tions, as the primary use of TBS has been in establishing frac-
[ActiveLife Scientific, Santa Barbara, CA, USA]) have become ture risk in the osteoporotic population.136,137
available to enable insights into bone quality. In 2015, Silva et al. reviewed the literature on fracture risk
prediction by TBS for the International Society for Clinical
Trabecular Bone Score (TBS) Densitometry (ISCD) and established its official positions: 1)
TBS is a software program that is an add-on to the DXA soft- TBS is associated with vertebral, hip, and major osteoporotic
ware in the densitometer database. It measures the texture fracture risk in postmenopausal women; 2) TBS is associated
parameter that evaluates the pixel gray-scale variations in the with hip fracture risk in men greater than the age of 50 years;
DXA images of the lumbar spine. The TBS variations may and 3) TBS is associated with major osteoporotic fracture risk
reflect bone microarchitecture, and thus TBS has become a in men older than the age of 50 years. Thus, the official positions
surrogate for aspects of bone quality. It uses the experimen- applied to an older population.138
tal variogram of 2D projection images. The TBS is calculated Over the last several years, there have been reports of the
from unprocessed raw computer data from the DXA acqui- responses of TBS to various osteoporosis antiresorptive and ana-
sition. TBS is based on X-ray absorption by tissues, similar bolic medications and other disease states. Sean et al. reported
to BMD computation. Calculation of TBS and BMD is done on the results of teriparatide (Forteo) and ibandronate (Boniva)
separately and by different methods. TBS is derived after the on spine BMD and TBS in 210 postmenopausal women with
BMD measurement is made and at the same region of interest osteoporosis (70 treated with teriparatide 20 μg self-injected
(PA spine). TBS is a unitless measurement. A high TBS value subcutaneously daily versus 140 treated with intravenous iban-
indicates “good” microarchitecture associated with “good” dronate 3 mg every 3 months) who were 68.9 ± 9.0 years of age
mechanical strength and a reduced fracture risk; a low TBS versus 67.4 ± 6.5 years of age, respectively. Only women with
value indicates poor-quality microarchitecture and, therefore, evaluable DXA scans for both LS BMD and TBS at baseline and
increased fracture risk.133 after 2 years were included in the analysis; this made the final
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 47

numbers 65 (93%) and 122 (87%) in the teriparatide and iband- on 57 adolescent girls age 11–18 years with anorexia nervosa
ronate groups evaluable, respectively. Both groups started with recruited from an urban eating disorders clinic where they had
TBS of 1.206 ± 0.100 versus 1.209 ± 0.100, respectively, both in undergone DXA examinations and peripheral QCT studies. The
the “degraded” class. After 24 months of therapy, lumbar spine TBS of 6 (11%) of the participants were degraded and of 19 (33%)
BMD and TBS increased significantly more with teriparatide were partially degraded, according to adult normative values.152
compared with ibandronate (+7.6 ± 6.3% versus +2.9 ± 3.3% Heiniö et  al. looked at the association between long-term
and +4.3 ± 6.6% versus +0.3 ±4.1%, respectively; p < 0.0001 exercise loading and TBS in different exercise loading groups.
for both). Compared to baseline, increases in BMD were sig- Eighty-eight Finnish female athletes competing at a national
nificant for both teriparatide and ibandronate, while increases or international level and 19 habitually physically active non-
in TBS were significant only for those treated with teriparatide athletes with a mean age of 24.3 years (range 17–40 years) who
(p < 0.0001), suggesting a stronger positive effect on bone were all postpubertal and premenopausal were analyzed. The
microarchitecture with teriparatide.139 Saag et  al. reviewed athletes represented seven different sports and five different
the results for TBS obtained from archived DXA reports from loading regimens based on their sport-specific training history.
a randomized clinical trial of patients with chronic glucocor- Triple jumpers and high jumpers comprised the high-impact
ticoid therapy-induced (median 7.5 mg/d prednisone for ≥90 group, soccer and squash players made up an odd-impact load-
days) osteoporosis treated with alendronate or teriparatide. ing group, power lifters made up the high-magnitude group,
In patients treated with teriparatide, TBS was significantly endurance runners a repetitive-impact group, and swimmers a
increased from baseline at 18 and 24 months and increased repetitive nonimpact group. Several parameters of training and
by 3.7% at 36 months; in patients treated with alendronate fitness status were employed, including maximal isometric force
(Fosamax), TBS did not change significantly at any time from and dynamic performance of the lower extremities. Endurance
baseline to 36 months.140 Bilezikian et al. analyzed the effects of runners’ mean TBS was about 6% lower than controls. Power
subcutaneous abaloparatide on TBS in a post hoc retrospective lifters had about 3% higher TBS compared with the reference
analysis of 138 subjects from a phase II 24-week double-blind group. In the high-impact group, the correlation between max-
randomized clinical trial. In the 80 μg abaloparatide subcutane- imal isometric leg press force, peak jumping force, and TBS was
ous self-injection group (which would prove to be the clinically significantly positive. The authors “found that athletes experi-
approved dosage), the TBS measured 1.181 ± 0.078 versus 1.201 encing a large number of monotonous impacts (repetitive, mod-
± 0.068 in the 20 μg teriparatide group (which is the approved erate impact loading represented by endurance runners) in their
dose); both these measurements are in the “degraded” group. In training and competition had significantly lower TBS compared
the 80 μg abaloparatide subcutaneous self-injection group, TBS with all other groups including the reference group, whereas
increased by 2.37% in the abaloparatide group (n = 24) versus the athletes experiencing extreme axial loading (high-magni-
1.16% in the teriparatide group (n = 31) at 12 weeks and TBS tude loading represented by power lifters had somewhat higher
increased by 5.23% in the abaloparatide group and by 3.27% in crude TBS values compared with the reference group).” These
the teriparatide group at 24 weeks. Therefore, the effect of aba- TBS values were independent of lumbar spine BMD.153
loparatide on TBS was greater than in the placebo group and the Thus, with increasing interest in the TBS of relatively young
teriparatide group. An increase in TBS greater than the least sig- elite athletes, we undertook a study of our athlete population,
nificant change (LSC) was attained by 52.2% of subjects treated most of whom had been referred for recurrent bone stress inju-
by abaloparatide versus 30.0% of the teriparatide group. The ries, including traumatic fractures, stress fractures, stress reac-
authors conclude that the increase in TBS values in the context tions, and various degrees of delayed healing or nonunions.
of anabolic treatment is associated with a reduction in fracture Prospectively, studying the athletes referred to us, we noticed
risk, over and above what an increase in BMD would indicate some athletes with degraded or partially degraded TBS values.
(although this remains to be demonstrated), and the results Therefore, we undertook a retrospective study of the TBS values
help to differentiate abaloparatide from teriparatide in terms of in our athletic population in whom DXA studies had been per-
potential effects on bone microarchitecture as determined by its formed. We evaluated 10 Major League Baseball (MLB) players,
surrogate measurement, TBS.141 The exact implications of these 5 minor league players, 7 NBA players, 2 collegiate basketball
differences and their significance in the treatment of stress frac- players, 5 active and 1 retired NFL players, and 4 amenorrheic
tures and fracture healing, if any, remains to be determined. intercollegiate female runners (n = 34). All TBS databases
The effects of denosumab on TBS,142 the effects of other employed were gender and ethnic specific. One MLB player
antiresorptive agents,143 and the effects of various disease (Black) and one minor league player (White) had degraded TBS;
states, such as Crohn’s disease144 and end-stage renal disease in one minor league player (White) had partially degraded TBS;
patients on hemodialysis,145 primary aldosteronism,146 ankylos- two NBA players (Black) had degraded and one NBA player
ing spondylitis,147 and in so-called causes of secondary osteo- (White) had partially degraded TBS; one NFL player (Black)
porosis148 have also been studied, but are beyond the scope of had partially degraded TBA (n = 7), indicating 20% of the pop-
this text. ulation we deal with had an abnormally low TBS (Fig. 4.3).
The normative database extends down to 20 years of age (and All of the individuals had normal or “high” BMD based on
up to 80 years of age). However, only a few studies have looked their Z-scores, and therefore, BMD and TBS were discordant in
at younger individuals149–151 and at young women with anorexia these individuals.154 Although the role that an abnormally low
nervosa. In this later study, Donaldson and colleagues reported TBS plays in the pathogenesis of bone stress injuries or fracture
48 SECTION 2  Sport Syndromes

TBS in Patients A and B

MALE, MEXICAN
FEMALES WHITE MALE BLACK AMERICAN
1,8 1,8 1,8
1,7 1,7 1,7
1,6 1,6 1,6
1,5
1,5 1,5
B B

TBS L1-L4

TBS L1-L4

TBS L1-L4
1,4
1,4 1,4
1,3
1,3 1,3
1,2
A 1,2 1,2
1,1 A
1,0 1,1 1,1
0,9 1,0 1,0
0,8 0,9 0,9
20 25 30 35 40 20 25 30 35 40 20 25 30 35 40
Fig. 4.3  Trabecular bone score (TBS) in 2 NBA centers: A = “degraded;” B = “normal;” 1st panel utilizing
FDA-approved normal female Caucasian database; utilizing gender and ethnic specific-databases: 2nd panel
utilizing male Black database; 3rd panel utilizing male Mexican American database; for gender- and ethnic-
specific databases.

healing is not certain at this time, it probably indicates some

underlying microstructural abnormality for which it is a surro-
gate, and therefore might be able to serve as a screening tool for
athletes at greater risk of bone problems during their careers.
What to do about this structural abnormality remains to be seen.
New approaches are constantly being developed for further
evaluation of bone. A new software product, Texture Research
Investigation Platform (TRIP) (Medimaps Group SA, Geneva, Impact
Mechanism
Switzerland), for the analysis of individual bone TBS is now avail-
able and will be utilized going forward. This new product will
enable us to take the image from various modalities including
x-ray, DXA, CT, pQCT, HRpQCT, and micro CT or MRI and ana- Displacement
lyze it for bone quality and microarchitecture. It displays images Transducer
with several formats (e.g., Dicom, JPG, PNG, TIFF, BMP) and var-
ious sizes (personal communication). We hope that TRIP will be
able to further help evaluation of the patient with a stress fracture Probe
because it can be localized to the bone in question and not applied
to a bone that may not be involved in the local process as is lumbar
spine TBS.

Osteoprobe Fig. 4.4  Osteoprobe (Courtesy of Davis Brimer, ActiveLife Scientific,

In 2006, Hansma and colleagues discussed the development of 2014).
a prototype bone diagnostic instrument that took advantage
of work being done on indentation to assess deteriorating bio- that both BMD and FRAX* underestimate fracture risk in type
materials and was applied to alterations in bone microarchi- 2 diabetes, other factors, such as bone quality, have been evalu-
tecture.155 Zysset subsequently reviewed the development of ated. Therefore, Farr et  al. conducted a study of indentation in
depth-sensing technologies allowing for better measurement of the nondominant anterior tibia site. Type 2 diabetes patients had
the tip displacement during the indentation process.156 significantly lower BMSI by 10.5% (p<0.001), implying that fra-
Osteoprobe is now a handheld medical device that creates gility fractures in these patients may be due to reduced BMSI158
an indentation in the anterior surface of the tibia to measure the (Fig. 4.4).
material properties of the bone in vivo. The device uses reference
point indentation (RPI) technology to perform precise micro-in-
*FRAX (Fracture Risk Assessment Score), a tool to assess personal
dentations in the bone and quantify a patient’s bone score or bone
fracture risk, in use since 2008. FRAX uses demographic information
material strength index (BMSI), a measure that may be related to (age, sex, weight, height, and ethnicity) and clinical risk factors (previ-
bone quality.157 In the last several years, significant literature has ous fracture after 50 years of age, parental hip fracture, current smok-
appeared utilizing Osteoprobe. Farr and colleagues from Mayo ing, current glucocorticoid use [≥5 mg/d for >3 months, rheumatoid
Clinic discussed their in vivo assessment of bone quality in post- arthitis, secondary osteoporosis, three or more alcoholic drinks/day,
menopausal women with type 2 diabetes). Because it now seems femoral neck [FN], BMD, and, after 2015, TBS).
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 49

Patients with stress fx. exhibit

impaired bone material properties
LABORATORY WORKUP AND BTOM IN STRESS
100
FRACTURES
p=0.002
In the evaluation of patients with osteoporosis, the initial evaluation
Bone Material Strength

of the patient must include history and physical examination, and

80 a workup for so-called causes of secondary osteoporosis167(Table
4.7, Box 4.3). The tabular list of diseases described may vary167–169
depending on the time when the list was originally compiled, as
new diseases are constantly being added, e.g., aromatase inhibi-
60
tor-induced bone loss, androgen deprivation therapy, and chronic
use of proton pump inhibitors. In addition, the laboratory workup
recommended varies in different references and guidelines.167,170
40 The workup may also change depending on whether the workup
Controls SF
is undertaken by a primary care physician or by a specialty center
Fig. 4.5  Patients with stress fractures exhibit impaired bone material
properties. fx, fractures; SF, stress fracture. (From Sosa and Eriksen, looking for unusual occult causes of secondary osteoporosis.171,172
ASBMR, Abstract MO 0028, Sept, 2014. S350) Davsi Duarte Sosa and Most of the laboratory tests have been established as independent
Erik Fink Eriksen, Patients with stress fractures exhibit impaired bone risk factors in older adults, and some of their value in the stress
mineral properties by microindentation. Journal of Bone and Mineral fracture population remains to be determined. Over the years, we
Research (JBMR), 2014, 29(S1):S359. Abs #MO0028.
have refined our laboratory workup to consist of the evaluation as
Over the last several years, the utilization of micro-indenta- shown in Box 4.4.
tion has increased in an effort to further understand the role of Bone metabolism consists of two processes: bone formation
BMSI in various settings.159–164 Sosa and Eriksen utilized the and bone resorption, which together result in bone modeling in
Osteoprobe device to study micro-indentation measurements children and adolescents and bone remodeling in adults after bone
in a retrospective case–control population of 30 pre- and post- growth has stopped. There are two groups of bone turnover mark-
menopausal women with a history of previous stress fracture. ers, assessed using blood or urine tests, that measure the function
A control population of 30 subjects free of bone disease was of the osteoclasts and osteoblasts. For bone formation, we utilize
also recruited. BMD was measured at the hip and lumbar three blood tests to look for: bone-specific alkaline phosphatase
spine, and body composition was also obtained. Bone turnover (BSAP), osteocalcin (OC), and P1NP. For bone resorption, we uti-
markers (BTOM), procollagen type 1 N-terminal propeptide lize one blood test, the C-terminal cross-linking telopeptide of type
(P1NP), a product of the osteoblast, and serum C-telopeptide I collagen (s-CTx), and one urine test, the N-terminal cross-link-
(s-CTx), a product of osteoclast function, were also measured. ing telopeptide of type I collagen (u-NTx).173,174 Other markers of
Bone micro-indentation was performed by a described proto- importance that we don’t utilize are for formation, C-terminal pro-
col where the average of eight measurements was taken and peptide of type I procollagen (P1CP) and for resorption,: isoform
converted to BMSI. All micro-indentation measurements were 5b tartrate resistant acid phosphatase (TRACP5b). There is a great
made a median time of 4 (2–6) months after fracture (Fig. 4.5). deal of individual and systematic variability in all these tests. They
Compared with the controls, the stress fracture patients had are affected by food intake, by menses, by seasonal variation, by
significantly lower BMSI values-unadjusted (–6.7%; p = 0.01), exercise and physical activity, by various diseases, and by time of
age-adjusted (–5.2%; p=0.02), and following adjustment (–6.3% day. It has been shown that there is a strong circadian variation in
p = 0.01) The stress fracture patients had a mean BMSI value of the serum concentration of CTx. Qvist and colleagues studied 100
70.5 ± 8.7 versus control subjects’ BMSI of 77.1 ± 7.2. Mean BMSI individuals with blood samples drawn every 3 hours over 27 hours
was similar in the 6 postmenopausal women and in the 24 post- and showed that the highest level of CTx occurred at 5:00 AM, with
menopausal women with stress fractures (69.1 versus 71.8; p = a low level at 2:00 PM with a variation of ±40% and was similar in
0.9). Femoral neck and lumbar spine BMD were both statistically premenopausal and postmenopausal women with normal and low
lower in the stress fracture group than in the control group. Mean bone mass; the circadian cycling was not affected by 5 days of bed
s-CTx levels were similar in the two groups; however, subjects rest.175
with stress fractures had higher serum P1NP levels than controls. Ben-Sasson et al. looked at whether sleep disturbances might
The authors concluded that “the lower values of BMSI in patients increase the risk of stress fracture and showed that there was
with stress fracture combined with a lower BMD may contribute evidence of increased urinary calcium and hydroxyproline in
to the increased fracture propensity in these patients.” They added the two groups that did not sleep horizontally (63 hours of
that “the technique might possibly help identify subjects who are sleeplessness [Group A] and vertical sleep in a seated position
at increased risk of developing stress fractures in the future—after [Group B]); fasting urinary calcium increased by 170% and
further validation in a prospective setting.”165 fasting urinary hydroxyproline (a marker of bone resorption)
Contraindications to this procedure might include a signifi- increased by about 100%. About 40% of individuals in Groups
cant skin disorder, bruising, local edema or infection, history of A and B were classified as “responders” and the remainder as
lower extremity clotting disorders, undergoing treatment for a “nonresponders.” Following this study, a mandatory sleep of
clotting disorder, or severe coagulation defects.158 At the pres- 6 hours a day was instituted. “Preliminary results” from two
ent time, the Osteoprobe has received approval for clinical use cycles of basic training indicated a drop of more than 50% in
in Europe and is awaiting approval by the FDA in the US.159,166 the incidence of stress fractures among major combat units.176
50 SECTION 2  Sport Syndromes

TABLE 4.7  Conditions, Diseases, and Medications That Cause or Contribute to Osteoporosis
and Fractures
Lifestyle Factors
Alcohol abuse Excessive thinness Excess vitamin A
Frequent falling High salt intake Immobilization
Inadequate physical activity Low calcium intake Smoking (active or passive)
Vitamin D insufficiency

Genetic Diseases
Cystic fibrosis Ehlers-Danlos Gaucher disease
Glycogen storage diseases Hemochromatosis Homocystinuria
Hypophosphatasia Marfan syndrome Menkes steely hair syndrome
Osteogenesis imperfecta Parental history of hip fracture Porphyria
Riley-Day syndrome

Hypogonadal States
Androgen insensitivity Anorexia nervosa Athletic amenorrhea
Hyperprolactinemia Panhypopituitarism Premature menopause (<40 years)
Turner and Klinefelter syndromes

Endocrine Disorders
Central obesity Cushing syndrome Diabetes mellitus (types 1 and 2)
Hyperparathyroidism Thyrotoxicosis

Gastroinestinal Disorders
Celiac disease Gastric bypass Gastrointestinal surgery
Inflammatory bowel disease Malabsorption Pancreatic disease
Primary biliary cirrhosis

Hematologic Disorders
Hemophilia Leukemia and lymphomas Monoclonal gammopathies
Multiple myeloma Sickle cell disease Systemic mastocytosis
Thalassemia

Rheumatologic and Autoimmune Diseases

Ankylosing spondylitis Other rheumatic and autoimmune diseases
Rheumatoid arthritis Systemic lupus

Neurological and Autoimmune Diseases

Epilepsy Multiple sclerosis Muscular dystrophy
Parkinson disease Spinal cord injury Stroke

Miscellaneous Conditions and Diseases

AIDS/HIV Amyloidosis Chronic metabolic acidosis
Chronic obstructive lung disease Congestive heart failure Depression
End-stage renal disease Hypercalciuria Idiopathic scoliosis
Posttransplant bone disease Sarcoidosis Weight loss

Medications
Aluminum (in antacids) Anticoagulants (heparin) Anticonvulsants
Aromatase inhibitors Barbiturates Cancer chemotherapeutic drugs
Depo-medroxyprogesterone Glucocorticoids (≥5 mg/day prednisone GnRH (gonadotropin-releasing hormone)
(premenopausal contraception) or equivalent for ≥3 months) agonists
Lithium cyclosporine A and tacrolimus Methotrexate Parental nutrition
Proton pump inhibitors Selective serotonin reuptake inhibitors
Tamoxifen (premenopausal use) Thiazolidinediones (such as Actos and Avandia) Thyroid hormones (in excess)

From: The Surgeon General’s Report [1], with modification

From Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int [Inter-
net]. 2014 Oct 15 [cited 2018 Jul 11];25(10):2359–81. Table 1 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25182228
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 51

for almost 30 years. Oni and colleagues measured serum OC and

BOX 4.3  Exclusion of Secondary Causes of total alkaline phosphatase levels as prognostic indicators in tibial
Osteoporosis shaft fractures. Serum was obtained from 50 adults with closed
Consider the following diagnostic studies for secondary causes of osteopo- unilateral fractures of the tibia treated nonoperatively in a larger
rosis study of delayed union (100 consecutive patients) of these frac-
Blood or serum tures. Total alkaline phosphatase levels were obtained immedi-
Complete blood count (CBC) ately after fracture and every two weeks thereafter for 20 weeks,
Chemistry levels (calcium, renal function, phosphorus, and magnesium) and OC levels were measured at 0, 4, 8, 12, and 16 weeks after
Liver function tests
fracture. The interesting findings were in the OC tests. OC was
Thyroid-stimulating hormone (TSH) +/– free T4
lower in high-trauma fractures as compared with low-trauma
25(OH)D
Parathyroid hormone (PTH)
fractures throughout the study. The differences were statistically
Total testosterone and gonadotropin in younger men significant at 12 weeks. Additionally, the OC levels were higher
Bone turnover markers from the fracture occurrence in the normal union group, com-
Consider in selected patients pared with the delayed union group. The authors suggested that
Serum protein electrophoresis (SPEP), serum immunofixation, serum-free this “indicates that patients who develop delayed union may have
light chains a depressed osteoblastic function very early on…Thus, [OC]
Tissue transglutaminase entibodies (IgA and IgG) activity following a fracture may prove a useful indicator of the
Iron and ferritin levels ability of a fracture to heal…”177,178
Homocysteine Ivaska and coauthors updated the earlier information on bone
Prolactin
turnover markers before and after fracture. Most of the previous
Tryptase
studies took samples after the fractures had already occurred.177 In
Urine
24-h urinary calcium
order to avoid that problem, Ivaska’s group utilized data from the
Consider in selected patients Malmo Osteoporosis Prospective Risk Assessment (the Malmo
Protein electrophoresis (UPEP) OPRA) study, a population-based prospective, longitudinal study
Urinary free cortisol level of 1044 women 75 years of age at inclusion selected at random
Urinary histamine from the city files of Malmo, Sweden. Specimens for blood and
urine were obtained at entry and stored. Eventually, 113 women
From Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B,
Randall S, et al. Clinician’s guide to prevention and treatment of had low-trauma fractures and were available for the study after
osteoporosis. Osteoporos Int [Internet]. 2014 Oct 15 [cited 2018 Jul various exclusions. They had both serum and urine samples
11];25(10):2359-81. Table 4 Available from: http://www.ncbi.nlm.nih. available at baseline, immediately after injury, at 4 months after
gov/pubmed/25182228
injury and at about 12 months after injury. For bone resorption,
they measured: s-TRACP5b, s-CTx, urinary total deoxypyridin-
BOX 4.4  Biochemical Risk Factors for oline (u-DPD); for bone formation, they measured serum total
Fracturea OC (s-totalOC), serum intact OC (s-OC), urinary osteocalcin
• Homocysteine-Van Meurs, N Eng J Med, 2004;350:2033-41 (u-OC) and urinary midOC (u-midOC [referring to the middle
• Ferritin-Lipovetzki, Immunol Res, 2016;Aug 9 [Epub ahead of print] of the OC molecule]), and s-P1NP. There were 30 hip fractures,
• Vitamin B 12-Clemens, N Eng J Med, 2014;371:963-4 27 wrist fractures, 4 clinical symptomatic vertebral fractures, and
• Carotene-Accessed at http://mayomedicallaboratories.com/test-catalog 24 other fractures. Within 1 day after the occurrence of the frac-
• Hemoglobin A1c-Schwartz, AV, Curr Osteoporos Rep, 2007;5:105-11 ture, there was no significant change in any of the markers. At
• Hs CRP-Eriksson, J Bone Miner Res, 2014;29:418-423 4 months after fracture (18/30 hip fracture patients and 22/27
• Magnesium-Orchard, Am J Clin Nutr, 2014;99:926-33 wrist fracture patients sampled), the bone turnover markers were
• Phosphorus (Phosphate)-Wigner, J Bone Miner Res, 2010;25:724-33
significantly elevated: 67% for s-OC, 55% for s-totalOC, 51% for
• Total and free testosterone-Eberling, N Eng J Med, 2008;358:1474-82
s-P1NP, and 60% for u-midOC. The levels of all the bone turn-
• Serum and urine calcium-Bauer, N Eng J Med, 2013;369:1537-43
• 25 vitamin D level-Miller, JR, J Foot ankle Surg, 2016;55:117-120
over (except u-totalDPD) remained above prefracture level at 1
• Estradiol-Reginster, Calcif Tissue Int, 2000;346:180-8 year. At the 4-month-after-fracture point, all bone formation and
• TSH, free T4-Bauer, Ann Int Med, 2001;134:561-8 bone resorption markers were significantly elevated; formation
• SPEP, MGUS-Melton, J Bone Miner Res, 2004;19:25-30 more than resorption, especially after hip fracture. Analyzing the
• Vitamin A-Feskanich, JAMA, 2002;287:47-54 changes in the markers over time allowed researchers to moni-
• Vitamin K-Pearson, Nutr Clin Pract, 2007;22:517-44 tor the different stages, processes, and patterns of osteoblast and
osteoclast activity in the bone remodeling of fracture healing.
• C ollagen Diagnostic Lab (Peter Byers, M.D., Univ of Washington) - When
There was an early increase in resorption markers and a latter
appropriate.
increase in formation markers. Although all the markers were
aMostly in older men and postmenopausal women above baseline at the 1-year point, most of the increase occurred
There are an extensive number of studies that review changes within 6 months of the fracture. Thus, although the fracture may
in the bone turnover markers due to exercise, i.e., low-trauma be clinically healed or biomechanically healed, there is still some
and high-trauma fractures, and stress fractures. Research on bone remodeling going on at the fracture site for at least 1 year. Because
turnover markers in the response to fractures has been going on the bone turnover markers “sampled within a few hours after a
52 SECTION 2  Sport Syndromes

fracture are not significantly altered from preinjury levels, imme- training intervention on bone resorption was less consistent
diate postfracture sampling may…provide information on the than the effects on bone formation.182
baseline state of bone turnover of a fractured patient [and] this Banfi et al. concluded the following: bone formation markers
information will be a prerequisite if, in the future, we would by change in sedentary subjects engaged in a physical activity program;
means of BTMs, be able to monitor the effects of pharmacological professional athletes show changes in bone formation depending
interventions promoting fracture healing.”179 on program intensity whereas bone resorption appears to be sta-
Coulibaly et  al. studied the use of bone formation mark- ble; during prolonged training, the characteristics of exercise (e.g.,
ers to monitor callus development and fracture healing. They weight-bearing, impact) are crucial; and different training baseline
reviewed a great deal of the literature (some of it cited already) levels due to prestudy training history may partly explain different
and concluded “that PINP is the best candidate for use as a sero- results between athletes and sedentary controls. The type of sport
logical marker of bone healing.”180 is more important than gender and whether the sports are high
It has been thought that monitoring of bone metabolism by impact and weightbearing or nonweightbearing, e.g., male cyclists
bone turnover markers in athletes would be instructive on the usually have lower BMD than male runners. They concluded that,
state of the responses and their bone health. Banfi et al. reviewed given the lack of homogeneous behavior of bone markers in ath-
this topic in depth in 2010. There was tremendous variability letes, specific studies are needed that take into account the different
in the results of individual studies depending on the gender of effects a certain sport will have on bone metabolism.177
the athlete, the age of the athlete, the type and intensity of the Other studies have also looked at the response of bone turn-
exercise (high-impact versus low-impact), the markers studied over markers (and cytokines) to a single episode of high-intensity
(formation versus resorption), and whether or not the exer- exercise in order to define the earliest changes due to exercise.
cise was acute or chronic (training). The authors drew a num- Earlier studies have shown that single episodes of 60-minute stren-
ber of conclusions: short exercise is insufficient for modifying uous exercises such as treadmill running and cycling stimulate
serum concentrations of bone metabolism markers; variations a bone turnover response, with increased bone resorption over
in serum concentrations of bone metabolism markers are more bone formation. Mezil et al. performed research on short bouts of
evident during various hours or days after the exercise; bone high-intensity interval exercise (HIE) (or training–HIIT), which
metabolism markers show variable patterns depending on the has become popular to produce results similar to more conven-
type of exercise and the study design; acute changes may be due tional long-term exercise. They designed a trial of 23 male uni-
to changes in plasma volume and renal function; stimulation of versity students who undertook a course of exercise that involved
osteoblast and osteoclast functions are exercise-dependent but 12 minutes of intermittent cycling of six 1-minute high-intensity
immediate, and delayed effects need to be distinguished; and cycling intervals at 90% of maximum workload separated by six
changes in osteocalcin may be partly due to changes in energy 1-minute active rest periods. Markers studied included bone-spe-
metabolism and increased osteoclast activity.181 cific alkaline phosphatase (BSAP), the receptor activator of NF-ĸß
For example, Eliakim and colleagues performed a study (RANK), the ligand of RANK (RANKL), osteoprotegerin (OPG),
with two components: 1) a cross-sectional investigation of which acts as a decoy receptor for RANKL, and NTx. Blood was
the correlation between fitness and bone turnover mark- drawn at baseline, at 5 minutes after exercise, 1 hour after exercise,
ers and 2) a prospective, controlled, endurance exercise and 24 hours after exercise. Also, selected cytokines were studied.
training intervention. Forty-four high school males, 71% There was a significant time effect for all markers: at 5 minutes
Asian, 20% Caucasian, and 9% Hispanic, 15–17 years old, after exercise, BSAP, OPG, and RANKL increased from baseline
at different Tanner stages, who were enrolled in a sum- by 10.9%, 13.5%, and 34.2%, respectively; at 1 hour after exercise,
mer school program of two classes per day, were recruited only BSAP was significantly higher than baseline by 9.5%; at 24
and randomized to a control (n = 22) and training group hours after baseline BSAP was still 10.9% higher than baseline,
(n = 22). All subjects took part in the 2-hour teaching pro- whereas NTX was 14.6% lower than baseline. There were signif-
gram. The training group undertook an endurance-type train- icant correlations between the percent exercise-induced changes
ing consisting of running, aerobic dance, competitive sports in bone turnover markers and cytokines. Since this study had a
(e.g., basketball), and weightlifting. Bone formation was high level of exercise, as opposed to lower levels of exercise in
measured by osteocalcin, bone-specific alkaline phosphatase, some other studies, it may be more like the level of exercise in elite
and the C-terminal procollagen peptide (P1CP), and bone athletes, and if there is a decrease over time in bone resorption,
resorption was measured by urinary free deoxypyridinoline then, maybe after HIIT, bone resorption cannot keep up with the
cross-links (dPYR), urine C-Telopeptide (u-CTx), and urine degree of microdamage developed by the exercise program and
N-terminal peptide (u-NTx). Blood and urine specimens were eventually, failure of bone occurs.183
collected early in the morning during the week before and the Starting in 1988, the question of whether bone turnover markers
week after the exercise program was concluded. All three bone could be used to select a population of at-risk individuals in either
formation markers showed a significant increase in the train- the military or athlete populations has been actively researched.
ing group but not in the control group. In the training group, Murguia and coauthors measured basal plasma hydroxyproline, a
two of the three urinary bone resorption markers did not product of collagen degradation in 104 male Navy Seal candidates
change but u-NTx decreased significantly. None of the urinary 1 week into their basic underwater demolition (BUD/S) training
markers changed in the control group. The positive changes in program to see if it correlated to the incidence of connective tis-
bone formation were in the range of 15–30%. The effect of the sue injuries, that occurred later in the training program. Eleven
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 53

subjects (10.6%) were diagnosed as having connective tissue inju- = 199) entered a gender-integrated basic recruit training program
ries, and they had a significantly higher mean hydroxyproline level in the IDF and blood for bone turnover markers was collected
(4.02 μg/mL) than trainees without injury (3.10 mcg/mL). They before training (baseline), at the midpoint of training (about 2
concluded that there was a relationship between baseline elevated months), and the day before graduation from training (about 4
hydroxyproline levels and subsequent connective tissue injuries, months). Bone formation was measured by BSAP and P1NP, and
which may indicate an increased risk of connective tissue injuries bone resorption was measured by TRAP5b and s-CTx. All mark-
including stress fractures in individuals with the highest level of ers of bone turnover were significantly higher in men than women
hydroxyproline at baseline.184 at baseline and remained higher at all three time points. The bone
Bennell and colleagues, in a three-part series of studies on formation markers increased significantly over time (p<0.001) in
track and field athletes, looked at the relationship between stress both genders. For BSAP, the increase was evident from baseline to
fractures and bone turnover in these individuals. Eventually, after 2 months (p<0.001) with no change from 2 to 4 months. Women
exclusions, 95 athletes (46 women, 49 men) were available for anal- had a nonsignificant 20.6% increase in PINP, while men had an
ysis. Of these athletes, 5 women and 11 men competed in sprints, increase of 5.2% from baseline to 2 months, which declined sig-
17 women and 18 men in middle-distance running, 9 women and nificantly from 2 months to 4 months (p < 0.01). Bone resorp-
10 men in distance running, 6 women and 5 men in hurdles, 5 tion markers changed with the same trend in both genders: CTx
women and 5 men in jumps, and 4 women and 0 men in multi- increased in both men and women between 0 and 2 months
events. During the 12-month study period, 10 women (21.7%) and (p < 0.001) and declined to baseline at 4 months (p = 0.003), and
10 men (20.4%) had at least one stress fracture. One man and one TRAP5b increased from 0 to 2 months only (p < 0.001). Thus,
woman had multiple stress fractures. Of the 26 fractures in the 20 a strenuous 4-month period of military recruit training resulted
athletes, 45% occurred in the tibia, 15% in the navicular, 12% in in similar increases in serum markers of bone formation and
the fibula, and 8% in the metatarsal bones. OC was measured as resorption in both men and women primarily during the first 2
a marker of bone formation, and urinary pyridinium cross-links months of training, implying that the initial response to exercise
(u-Pyr) and deoxypyridinoline (D-Pyr) and u-NTx were collected is an acceleration of bone turnover that does not differ between
appropriately. Samples were collected at baseline and monthly over men and women.187
the course of the study. There was no difference between stress Hetland et al. studied bone turnover in 120 male medium-
fracture and nonstress fracture groups. After adjusting for age and and long-distance runners selected randomly from a population
sex, integrated monthly values of u-Pyr, D-Pyr, and OC were 5%, of 1520 men who were respondents to a questionnaire sent to
4%, and 35% higher, respectively, in those athletes who developed 2467 participants in various running events in Denmark. They
a stress fracture, although these were not statistically significant. In measured bone density by DXA of the lumbar spine and hips
the hydroxyproline study, where there was elevation of that value and SPA of the forearm. u-Pyr and u-Dpd, serum total alka-
in the sailors with connective tissue injuries, these authors point line phosphatase, and osteocalcin were also studied along with
out the differences in the markers, including the main fact that testosterone, progesterone, estradiol, leuteinizing hormone,
hydroxyproline is not specific to bone, so some of the elevation follicle-stimulating hormone, and sex-hormone binding glob-
may have been from nonskeletal sources, whereas the markers in ulin. All the bone turnover markers were significantly and pos-
this study were more specific for osteoblast function and collagen itively correlated to the weekly distance run. The bone turnover
breakdown. Several issues, including the high variability of their markers were within the normal laboratory range in all of the
markers and the size of the study group, may have contributed to elite runners, but the markers of the elite runners were 20–30%
these differences between the Bennell and Murguia studies. They higher than the controls. Of interest, their “principal finding”
concluded that single and serial measurements of bone turnover was a significant negative correlation between running distance
are not useful in predicting the tendency to stress fractures in indi- and BMD. The male long-distance runners had a significantly
vidual athletes.185 lower bone mineral content (BMC) at the lumbar spine, proxi-
Etherington et al. studied the effects of 10 weeks of military mal femur, distal forearm, and total body than the controls. The
training on heel ultrasound and bone turnover in 40 male military difference between runners and nonrunners increased as the
recruits entering their basic training in the United Kingdom; 10 weekly distance run increased. For those who ran more than
(25%) of the recruits sustained an injury. Subjects were assessed 100 km a week, the lumbar spine BMC was, on the average,
at the start and end of training. They measured bone formation 19% lower than controls. Thus, the long-distance runners had
via OC and BSAP, and bone resorption by TRAP. There were two lower BMC and higher bone turnover. There were no significant
clinically diagnosed stress fractures: one in the tibia and one in a changes in the hormonal studies. Thus, the BMC and bone turn-
metatarsal. OC declined 11.6% significantly, and there was a non- over studies suggest long-distance running causes bone loss.188
significant decrease in BSAP 13.3% and TRAP of 9.5%. Baseline Ruohola and colleagues studied randomly selected healthy
concentrations of all bone markers were not significantly higher individuals (796 men and 24 women) with a mean age of 19.8
in those recruits subsequently injured compared with those not (range 18–28) years entering military service. Baseline blood
injured. These changes suggest there is a decrease in bone turn- samples were obtained for TRACP5b, a marker of bone resorp-
over in response to the level of strenuous exercise to which these tion. Subsequent TRACP5b samples were drawn on the day the
recruits were subjected.186 Evans and colleagues looked at the stress fracture was diagnosed or suspected (Sample I), and then
effects of a 4-month recruit training program on markers of bone drawn every 3 to 4 days for three more samples (Samples II, III,
metabolism. In this study, 257 healthy men (n = 58) and women (n IV). Previous studies had shown 85% of stress fractures occurred
54 SECTION 2  Sport Syndromes

in the first 8 weeks of basic military training for all conscripts in TRAP5b levels were 409 ± 209.3 and 318.6 ± 81.6 mU/dL (p
Finland. Twenty of the 820 (2.4%) individuals developed stress < 0.05) in the stress fracture and control groups, respectively.
fractures; 6 were lost to follow-up. Therefore, 21 stress fractures They concluded “that TRAP5b may be a useful bone metab-
were diagnosed in 14 individuals; 3 conscripts had bilateral olism marker for monitoring bone status in female lacrosse
stress fractures; 1 had two unilateral tibial fractures; 1 had frac- players.”191 Harada and colleagues looked at bone metabo-
tures in the first and second metatarsals; 12 (57%) were in the lism markers in 21 male college artistic gymnasts who were
tibia, 6 (29%) were in the metatarsals, and 3 (14%) were in the at an Olympic level of competition. They measured BSAP,
calcaneus. A comparison of the ratio of Sample IV results and PINP, and PICP (cleaved C-terminal propeptide), s-NTx,
baseline values between the fracture and control groups indi- u-NTx, and TRACP5b. The study was conducted to clarify
cated that the odds of a stress fracture were eight-fold greater in bone turnover in periods of different training intensity based
the soldiers with greater serum TRACP5b results, but this value on the annual schedule. Measurements were performed in
was not significant (p = 0.17) The difference in TRACP5b activ- three periods: the preseason, the competition period, and
ity levels between baseline and Sample III was statistically sig- the training period. BSAP was significantly higher during
nificant (p = 0.039), but although the TRAPC5b was increased the competition period than during the preseason or train-
and increased over time from the diagnosis of a stress fracture, ing periods; no significant difference was found between the
the overall increase remained statistically nonsignificant when preseason and competition periods. PINP was significantly
the point of significance was set at p < 0.05. Therefore, “the use- higher during the competition period than during the train-
fulness of serum TRACP5b measurement for early diagnosis of ing period; no significant difference was found between the
bone stress injuries could not be confirmed,” although the ele- preseason and the competition periods or between the pre-
vated level probably indicates a high bone turnover rate in these season period and the training period. s-NTx was signifi-
individuals.189 cantly higher during the preseason period and the training
Yanovich and coauthors recruited 85 male members of a period than the competition period. No significant difference
combat unit of the IDF; 69 of them completed an 18-week was found between any period for u-NTx. TRACP5b was sig-
training course, 22 of whom developed a stress fracture. nificantly higher during the preseason and training period
They measured BSAP, PINP, TRAP5b, and s-CTx. At base- than the competition period and significantly higher during
line, none of the bone turnover markers differed between the training period than the preseason period. They decided
soldiers who did and did not have stress fractures. During that PINP and TRACP5b sensitively reflect bone turnover.
basic training, starting at baseline, none of the bone turn- Bone formation–dominant bone turnover occurred when
over markers tested differently between subjects who sub- training intensity was high and significant mechanical stress
sequently did and did not have stress fractures, although all was applied to the gymnasts’ bones, and training intensity
marker levels decreased by week 18: in the stress fracture bone resorption–dominant bone turnover occurred when
group, BSAP decreased by 13.3%, PINP decreased by 22.3%, the training intensity was lower and less mechanical stress
TRAP5b decreased by 2.6%, and CTx decreased by 19.4%; was applied to the bones.192
in the nonstress fracture group, BSAP decreased by 19.7%, Beyond the effect of exercise on bone turnover markers (and
PINP by 40.5%, TRAP did not change, and s-CTx decreased cytokines), there has been an interest in the effect of stress frac-
by 21.5%. There were multiple limitations to this study, most tures on these tests. Fujita and colleagues looked at the evolu-
importantly the small sample size. So, neither the bone for- tion of urine NTx bone resorption marker prospectively over a
mation markers or the bone resorption markers could iden- 3-year time interval to attempt to capture any changes in bone
tify soldiers who had stress fractures and those who did turnover markers if a stress fracture developed. To undertake
not, so they could not be used as diagnostic or predictive this study, they recruited 25 female long-distance runners, ages
tools for stress fracture evaluation in soldiers during basic 19–34 years (avg 23.99 ± 4.11). In order to have baseline mea-
training.190 surements, they took u-NTx 11 times during a period from
A series of recent articles from Japanese sports medicine 2011 to 2014. Six participants ended up with less than three
programs looked at bone turnover markers, various athletic specimens and were excluded, so the study ended up with 19
programs, and stress fractures in athletes as opposed to mil- participants. The onset date was when the participants experi-
itary recruits. Wakamatsu et  al. studied 84 elite university enced pain at the injury site. The mean u-NTx before a stress
lacrosse players (male = 35 with control group = 30; female = fracture in the whole group was 40.16 ± 9.10 nmol BCE/mmol
49 with control group = 42). There were 5 male athletes and creatinine; the mean u-NTx after a stress fracture was 64.08 ±
7 female athletes with stress fractures. They measured blood 16.07 nmol BCE/mmol creatinine (p < 0.01). This indicated
BSAP, NTx, and TRAP5b as well as homocysteine and pento- increased bone resorption, which they ascribed to the accumu-
sidine as bone quality markers. There were no significant dif- lation of excessive microdamage.193
ferences in the levels of BSAP, NTx, and TRAP5b as observed In order to more precisely define the role of bone turnover
between the stress fracture and control groups for all subjects. markers in the prediction of stress fracture risk, the patho-
In male players, no significant differences in BSAP, NTx, and physiology of stress fractures, or the healing of stress fractures,
TRAP5b were observed between the stress fracture and con- additional larger series that are adequately powered to pres-
trol groups. Similarly, in female players, no significant dif- ent the results in statistically significant numbers need to be
ferences were seen in the levels of BSAP or NTx; however, conducted.
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 55

How We Use Calcium

THERAPY-CALCIUM, VITAMIN D, ANABOLICS,
Most of our patients have 24-hour urine collections for creati-
BISPHOSPHONATES, AND BONE GROWTH nine clearance and total urinary calcium. If the calcium is low,
STIMULATORS we give calcium by adding dairy sources to the diet (each dairy
source is about 300 mg). If they are not able to take dairy or
Calcium additional dairy, we add CitraCal with vitamin D, one to two
It goes without saying that calcium is important for bone stabil- tablets per day in divided doses.
ity and building. We have criteria from the Institute of Medicine
(IoM) in 2011 to set guidelines for calcium intake. The Committee Vitamin D
concluded that available scientific evidence supports a key role A complete review of vitamin D synthesis, action, and metabo-
of calcium and vitamin D in skeletal health194,195 in community- lism is beyond the scope of this chapter. However, vitamin D defi-
living, ambulatory, noninstitutionalized individuals. The question ciency or insufficiency can cause or exacerbate low bone mass
is whether elite athletes have different requirements (Table 4.8). (osteopenia) or osteoporosis, can cause osteomalacia and mus-
Increased activity in and of itself does not increase the need cle weakness, and can increase the risk of fracture.199 Although
for calcium.196 There may be some excess calcium loss in the there is no consensus on optimal levels of 25-hydroxyvitamin
sweat, but this has not been shown to be irreplaceable with a D (25 [OH]D) as measured in the serum, and there are meth-
normal to high-calcium diet,197 but this is not true for all stud- odological differences and lack of standardization in the mea-
ies.198 So if an athlete is in hot, humid climate or profusely surement of 25 hydroxyvitamin D levels that result in significant
sweating, a diet adequate in calcium should be consumed or interlaboratory variability,200 the 25 hydroxyvitamin D defi-
some additional calcium intake and/ or supplementation may ciency level, as defined by most experts, is below 20 ng/mL (50
be necessary. Certainly, athletes restricting calories to reduce or nmol/L).199 Data exist that suggest that a 25 hydroxyvitamin D
control weight may be reducing their intake of many minerals level of 21–29 ng/mL (50–80 nmol/L) indicates an insufficiency
and may require supplementation.196 state of 25 hydroxyvitamin D, and a level of 25 hydroxyvitamin
D equal to or above 30 ng/mL indicates a sufficient level of 25
hydroxyvitamin D,199 but the IoM report indicated that a level
of 20 ng/mL (50 nmol/L) meets the vitamin D needs of 97.5%
TABLE 4.8  New Recommended Daily of the population.194 The IoM report also set guidelines for vita-
Amounts of Calcium and Vitamin D min D intake, but did state that individuals with bone disease
Calcium Vitamin D might need more intake or higher levels.
Recommended Recommended Without vitamin D, only 10%–15% of dietary calcium and
Dietary Dietary 60% of phosphorus is absorbed. When 1, 25-dihydroxyvitamin
Allowance Allowance (IU/ D interacts with the vitamin D receptor (VDR) at the intestinal
Life Stage Group (mg/day) day) lumen, it increases the efficiency of intestinal calcium absorp-
Infants 0 to 6 months * ** tion to 30%–40% and phosphorus absorption to approximately
Infants 6 to 12 months * ** 80%. Bischoff-Ferrari et  al. reviewed numerous studies in an
1–3 years old 700 ** attempt to estimate optimal levels of 25 hydroxyvitamin D for
4–8 years old 1000 600
multiple different health outcomes.201 One cited study showed
that maximal bone density was obtained in both sexes and mul-
9–13 years old 1300 600
tiple ethnicities when a 25 hydroxyvitamin D level of 40 ng/mL
14–18 years old 1300 600 was reached.202 In addition, it was shown that optimal fracture
19–30 years old 1000 600 prevention occurred at a 25 hydroxyvitamin D concentration of
31–50 years old 1000 600 40 ng/mL (100 nmol/L).203
51–70 years old 1000 600 There is an extensive body of literature that documents an
51–70 years old females 1200 600 apparent worldwide deficiency or insufficiency in vitamin D;
by some estimates, this number may be as high as 1 billion peo-
71+ years old 1200 600
ple.199 The athletic population is not immune to this phenome-
14–18 years old, pregnant/ 1300 600
non. Numerous studies have looked at convenience samples of
lactating
athletes. Villacis et al. evaluated 223 (40%) of 559 NCAA Division
19–50 years old, pregnant/ 1000 600 I athletes at the University of Southern California in 2012. One
lactating
resting venous blood sample was taken from each study partic-
*For infants, adequate intake is 200 mg/day for 0 to 6 months of age ipant between June and August 2012. Measurement of serum
and 260 mg/day for 6 to 12 months of age. 25(OH)D was done using liquid chromatography tandem mass
**For infants, adequate intake is 400 IU/day for 0 to 6 months of age spectrometry (LC-MS/MS) that had an analytical sensitivity of
and 400 IU/day for 6 to 12 months of age.
New recommended Daily Amounts of Calcium and Vitamin D NIH
4 ng/mL for 25(OH)D2 and 25(OH)D3. Vitamin D “sufficiency”
MedlinePlus, 2018 was defined as a serum 25(OH)D level greater than 32 ng/mL; a
From MedlinePlus The Magazine, Winter 2011, Page 12 level between 20 and 32 ng/mL was defined as “insufficient,” and a
https://magazine.medlineplus.gov/pdf/MLP_Winter_2011.pdf level less than 20ng/mL was defined as “deficient.” Results showed
56 SECTION 2  Sport Syndromes

148 (66.4%) of the athletes had sufficient levels and 75 (33.6%) non-VDP fraction (bioavailable 25(OH)D) consists of albu-
had abnormal levels, of which 68 (30.5%) were insufficient and 7 min-bound 25(OH)D (10%–15% of total 25(OH)D), with less
(3.1%) were deficient. Male athletes had a 2.8-fold higher chance than 1% of total 25(OH)D in the free form. Common genetic
of having an abnormal vitamin D level than female athletes did. polymorphisms in VDP gene produce variant VDP that differ
Dark-skinned athletes had a 15.2-fold chance of having an abnor- in their affinity for vitamin D. The prevalence of these polymor-
mal vitamin D level than did light-skinned athletes. Winter sports phisms differs between racial groups.
athletes had a greater chance of having a low vitamin D level than Clinical assays measure the level of 25(OH)D without mea-
did spring sports athletes. Indoor sports athletes had lower levels suring fractions bound to carrier proteins. Powe et al. studied
of vitamin D than did outdoor sports levels. Athletes with muscle 3720 participants from the Healthy Aging in Neighborhoods of
injuries have significantly lower vitamin D levels compared with Diversity across the Life Span (HANDLS) and measured levels of
uninjured patients. Those with higher 25(OH)D levels have sta- total 25(OH)D2 and 25(OH)D3 via LC-MS/MS, levels of VDP
tistically significant higher jump velocities, jump heights, and fit- using a commercial enzyme-linked immunosorbent assay that
ness indices. The authors concluded that vitamin D insufficiency uses two monoclonal antibodies in a sandwich format, levels of
was common in elite athletes, and dark skin tone was the only parathyroid hormone (PTH), and calcium levels corrected for
statistically significant risk factor.204 A recent study examined the albumin. BMD was also measured. DNA samples of the subjects
vitamin D levels of 89 players on a single NFL team and found were genotyped for two common SNPs at the coding region of
that 30% of the players were deficient while 51% had insufficient the VDP gene (rs4588 and rs7041). Bioavailable 25(OH)D was
levels.205 Vitamin D levels of an NBA team, performed at pre- defined as circulating 25(OH)D not bound to VDP. Subjects
season physicals in 2007, 2008, and 2009, showed that between were divided into quintiles to examine relationships between
9 and 12 out of 16 individuals per year were deficient or insuf- 25(OH)D and markers of vitamin D status (PTH level, calcium
ficient, and of an MLB team in 2011 found 90% of players were level, and BMD). Racial differences in total 25(OH)D levels per-
low, defined as less than 30 ng/mL. In these two studies, 25(OH) sisted after multivariable adjustment (17.3 ± 0.3 ng/mL in Blacks
D levels were measured by the LC-MS/MS methodology.206 versus 25.5 ± 0.4 ng/mL in Whites (p < 000.1) Race explained
Ruohola and colleagues looked at the association between 22.7% of the variation in total 25(OH)D. Adjusted mean BMD
serum 25(OH)D levels and stress fractures in young Finnish men. at the femoral neck, the calcium levels, and the PTH levels were
In this prospective study, 800 young Finnish men undergoing mil- higher in Blacks than Whites. Blacks were more likely than
itary training were randomly selected. Blood samples for serum Whites to have the T allele at rs7041, whereas Whites were more
25(OH)D levels were drawn from these 800 recruits; because of likely to have the G allele, and Blacks were less likely to have the
failed samples, incomplete follow-up data, and other issues, the A allele. These genetic differences explained 79.4% of the vari-
total final study population consisted of 756 subjects. During the ation in VDP levels and 9.9% of the variation in total 25(OH)D
3-month follow-up of the 756 recruits, 30 stress fractures were levels. Thus, the concentration of VDP and the genotype of VDP
identified in 22 recruits. The median 25(OH)D level was lower appeared to explain about 31.2% of the variation. Researchers
in the stress fractured group (25.7 ng/mL) than the nonfractured concluded that low vitamin D levels in Blacks did not neces-
group (30.5 ng/mL), and 81.8% of the fracture patients were below sarily indicate vitamin D deficiency; that bioavailable 25(OH)
the median. Thus, this study showed that a lower level of 25(OH) D may be a more appropriate cross-racial marker of vitamin D
D was a risk factor for developing stress fractures.207 In a pro- sufficiency; that levels of total 25(OH)D are, in part, genetically
spective double-blind, placebo-controlled, randomized clinical determined; and that to improve the determination of vitamin
trial of female US Navy recruits during the 8-week basic training D status in different populations, the measurement and level
program, Lappe et al. treated 5201 volunteers. The study groups of VDP needs to be incorporated into the assessment.216 In an
were given treatment of 2000 mg calcium and 800 IU of vitamin accompanying editorial, Holick noted that “vitamin D defi-
D or identical control placebo. Three hundred nine recruits were ciency may need to be redefined to consider not only total but
diagnosed with 496 stress fractures in the tibia, fibula, femur, or also bioavailable 25-hydroxyvitamin D levels.”217
pelvis. There was a 21% lower incidence of stress fractures in the This potentially exciting new insight into vitamin D lev-
supplemented group than in the control group.208 els and metabolism drew a great deal of interest. In a series of
There is a large body of literature on the topic of vitamin D’s letters to the editor of the New England Journal of Medicine,
effect on athletic performance, but that is beyond the scope of numerous issues were raised, including whether or not the
this chapter.209–211 Magnesium, phosphorus, and other nutri- vitamin D levels were correctly measured, whether or not the
ents play a role in athletic performance but do not have a known two monoclonal antibodies in the VDP assay had equal affinity
role in the prevention or causation of stress fractures or in frac- for all genotypes, and a variety of other technical issues.218 In a
ture healing.212–215 subsequent letter to the editor, Nielson et al. stated that it was
One issue with regard to vitamin D needs to be touched unclear whether circulating free or bioavailable 25(OH)D is a
upon: it has been known for many years that community-dwell- better test of vitamin D status than is total 25(OH)D, especially
ing Black Americans have lower levels of total 25(OH)D than in racially diverse populations. They “presented evidence that
whites, and thus they are frequently given a diagnosis of vitamin the use of a monoclonal ELISA to measure vitamin D-binding
D deficiency. Because of this, Powe and her colleagues consid- protein in persons of African ancestry introduces a critical flaw
ered whether vitamin D–binding protein (VDP) might play a into the calculation of free or bioavailable 25-hydroxyvitamin
role in this phenomenon. VDP is the primary vitamin D carrier D, a limitation that influenced the conclusions of Powe et al. (see
protein, binding 85%–90% of total circulating 25(OH)D. The earlier section) and other investigators.” And “in conclusion,
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 57

median levels of free 25(OH)D were significantly lower in D level by the LC-MS/MS technique at baseline and then give
black men than in white men in the United States when the lev- the athlete five sample tablets of a vitamin D3 50,000 IU prepa-
els were measured directly or calculated on the basis of poly- ration to take daily. Then we usually will have the vitamin D
clonal antibodies against vitamin D-binding protein.” “These level result from the laboratory, and follow up as before, fre-
results contradict previous reports of similar levels of free or quently continuing vitamin D3 50,000 IU weekly in this popu-
bioavailable 25-hydroxyvitamin D between races.” Their results lation. There are two phases of vitamin D treatment: restoration
emphasize “the importance of the choice of assay for vitamin and maintenance. Each of these has its own issues, techniques,
D-binding protein in the calculation of free 25-hydroxyvitamin and tricks for correction and preservation. It is important to
D in diverse populations and support the measurement of total become familiar with these steps in practice.
25-hydroxyvitamin D in the general population as a marker of
vitamin D status, regardless of race or GC genotype.”219 Denberg Anabolic Agents for Bone
et al. reported the first study that compared the measurement In early 2002, the clinical use of teriparatide (PTH 1-34) began
of VDP by three assays: two widely used commercially avail- the era of anabolic drugs for the treatment of osteoporosis. This
able immunoassays, a monoclonal and polyclonal ELISA; and required that attention be paid to further defining the nature and
an LC-MS/MS and estimates of free and bioavailable 25(OH) role of medications that are anabolic for bone. All previously
D concentrations. Combinations of two SNPs produce three available medications (etidronate, calcitonin, estrogen, alendro-
major VDP isoforms (Gc1f, Gcs, and Gc2). The authors felt nate, risedronate, and subsequently ibandronate) had antire-
their results confirmed the differential and biased performance sorptive mechanisms of action. Anabolic drugs can increase
of the monoclonal ELISA according to genotype and, therefore, bone mass and reduce fracture risk.223 These medications act by
race. “Inferences from studies that have used this assay should increasing bone remodeling and formation more than resorption,
be made cautiously, especially when interpreting reported race whereas the other type of bone-active medications, classified as
differences in vitamin D status. Future studies of DBP and free antiresorptive or anticatabolic, act by reducing bone remodeling.
or bioavailable vitamin D metabolites should employ DBP In the adult skeleton, virtually all the bone-forming units, called
[VDP] assays that are not biased by DBP [VDP] genotype.”220 basic multicellular units (BMUs), participate in bone remodel-
Bouillon, in a commentary on laboratory implications in the ing. During the growth phase of the skeleton, many BMUs are
Journal of Bone and Mineral Research, stated that “monoclonal committed to a different process called bone modeling, in which
R&D [one of the manufacturers of one of the assays] DBP assay bone formation occurs without a preceding resorption phase and
displays a bias in the measurement of DBP/GC1f and cannot be can produce large increases in bone mass (growth from fetus to
considered a reliable method for genetically mixed populations. adolescence). Teriparatide affects both remodeling and model-
Polyclonal antibodies do not display this bias, but the abso- ing, and newer anabolic medications also stimulate both bone
lute concentration of DBP differs very widely according to the remodeling and modeling; however, the effectiveness of the ana-
assay technique. Therefore, assay standardization is needed….” bolic agent, especially with regard to the off-label use of fracture
In a section on clinical implications, he wrote that in the con- healing, may well depend on the proportions of remodeling or
clusions of the Powe study (see earlier section) there are racial modeling that a specific drug produces. Intermittent PTH does
and genetic differences in free 25(OH)D that cannot be revealed this by increasing the number of osteoblasts and their function
by total 25(OH)D, and suggested that there is a need for a new and life expectancy.224,225
evaluation of measured vitamin D status and health outcomes. Experimental studies looking at the effects of various PTH
This conclusion “was based on a wrong DBP assay resulting in extracts on the bones of growing rats and the histological changes
marked overestimation of free 25(OH)D in African Americans.” that occurred from those extracts date back to the 1930s.226,227
Thus, the studies of directly measured free 25(OH)D studies are By the 1990s, it was clear that the intermittent administration
contradictory at this point in time.221 In addition, experience of PTH had a greater anabolic effect on bone than the contin-
with direct measurements of free levels is limited at the present uous infusion of PTH. In these early studies, intermittent PTH
time, but it is likely that free vitamin D levels will play an import- increased bone mass by approximately 30%, whereas continu-
ant role in the assessment of vitamin D status in the future.222 ous PTH had a smaller and less consistent effect on bone mass.
However, “the final answer about racial or genetic differences in In a prelude to a potential future use, researchers found that
measured free 25(OH)D is, therefore, still unsettled.”221 both continuous and intermittent PTH reversed the decrease in
bone formation by diphosphonates (now bisphosphonates).228
Clinical Application
How we use vitamin D. Presuming there is no previous or recent Teriparatide (Forteo) rh PTH (1-34)
vitamin D level, when we see a light-skinned athlete, we obtain In 2001, Neer and colleagues reported on the effect of parathy-
a 25 vitamin D level by LC-MS/MS technique and wait for the roid hormone (1-34) on fractures and BMD in postmenopausal
results before deciding on the vitamin D prescription that may women with osteoporosis. Native PTH is a 1-84 amino-acid
consist of vitamin D3 at 1000 IU, 2000 IU, or 5000 IU per day or peptide. Its biologic effect is concentrated in the first 1-34 amino
50,000 IU per week. Depending on the initial value and the pre- acids. They screened almost 10,000 women more than 5 years
scription, we repeat the 25 vitamin D level test in 1- to 3-month postmenopause and selected 1637 who were randomized to pla-
intervals. When we see a dark-skinned athlete, where the likeli- cebo (544 women) or to parathyroid hormone (1-34) at a dose
hood of a low vitamin D level is high, presuming there is no pre- of 20 μg per day (541) or 40 μg per day (552). PTH (1-34) at the
vious or recent vitamin D level, we will determine a 25 vitamin 20 μg or 40 μg per day dose reduced the risk of one or more new
58 SECTION 2  Sport Syndromes

vertebral fractures by 65% or 69%, respectively; the risk of two 18-month treatment period, 6 monkeys from each group were
or more fractures was reduced by 77% and 86%, respectively; sacrificed to perform an interim analysis. The remaining ani-
and the risk of at least one moderate or severe vertebral frac- mals were sacrificed 4–5 years after the initiation of the study.
ture was reduced by 90% and 78%, respectively. Nonvertebral All monkeys underwent necropsies. There was no evidence of
fractures were reduced by 35% and 40%, respectively. BMD of bone neoplasia in either the control or PTH(1-34) groups after
the spine increased 9.7% and 13.7%, respectively; BMD of the 18 months of treatment or 36 months of follow-up.231
femoral neck increased 2.8% and 5.1%, respectively; BMD of The PTH (1-34) used in a rat toxicology study was negative
the total hip increased 2.6% and 3.6%, respectively; shaft of the in a battery of in  vitro and in  vivo genotoxicity tests; all tests
radius (a cortical bone site) declined 2.1% and 3.2%, respec- were negative, supporting the conclusion that the bone prolifer-
tively. These BMD changes may have relevance to the issue of ative lesions in the rat toxicology study were produced through
fracture healing (see below). Side effects included nausea, head- a nongenotoxic, receptor mediated mechanism.230
ache, dizziness, and leg cramps, with less severity in the 20 μg The relevance of the bone proliferative changes observed in
group. Injections of PTH (1-34) raised the serum calcium 4–6 the 2-year rat toxicology study is uncertain, but there are sev-
hours postinjection, and levels came down to normal at 16–24 eral issues to consider: 1) rats were treated for 2 years, which
hours after the injection. The urinary calcium increased by is approximately 80%–90% of their expected normal life span;
about 30 mg per day but the incidence of hypercalciuria did in comparison, the anticipated duration of therapy for humans
not. Serum 25-hydroxyvitamin D did not change although 1,25 is approximately 24 months, which represents only 2%–3% of
di-hydroxyvitamin D declined slightly. Serum magnesium also their life span; 2) in terms of bone growth, rats were treated
declined slightly. Serum uric acid rose 13%–20% in the 20 μg for about 25–30 bone-turnover cycles; again, in comparison,
group and 20%–25% in the 40 μg dose group. Within an average the expected treatment duration in osteoporotic women is 1–3
of 5 weeks after cessation of treatment, serum calcium, magne- bone-turnover cycles; 3) there are fundamental differences in
sium, and uric acid concentrations returned to or approached bone physiology between rats and humans, including longi-
pretreatment levels. Serum creatinine and creatinine clearance tudinal growth of bones throughout much of the rat’s life and
were unaffected by PTH (1-34) treatment. Circulating antibod- the near absence of osteonal remodeling in rats; and 4) the pro-
ies were rare and did not have any discernible adverse effects.229 longed duration of treatment combined with the considerable
As that clinical trial was being conducted, a 2-year study in sensitivity of the rat skeleton to the pharmacologic effects of
rats was simultaneously conducted to assess the near-lifetime PTH resulted in chronic hormonal stimulation of the osteoblast
exposure to PTH (1-34). The high dose used in this study (75 and highly exaggerated increases in bone mass that were in con-
μg/kg) was over 200 times greater than the therapeutic human siderable excess of the effects observed in nonhuman primates
dose. The Fischer 344 rats (60/sex/group) used in this study had and humans.230 Therefore, Vahle and his numerous coauthors
a spontaneous rate of developing osteosarcoma. Doses of 5 and concluded that in adult humans (with mature skeletons), in
30 μg/kg were also given; all rats were treated for up to 2 years whom such exaggerated pharmacologic effects do not occur, it
or to their spontaneous death; any rats alive at the end of 2 years is unlikely that the risk of bone neoplasia would be increased by
were sacrificed. A necropsy was conducted on each rat. Bone daily treatment with PTH (1-34) for a relatively small fraction
mass markedly increased as measured by quantitative computed of the normal life span.230
tomography and histomorphometry. Substantial new bone for- PTH (1-34), teriparatide, a recombinant human parathy-
mation resulted in a large decrease in marrow space accompa- roid hormone analog (1-34), [(rhPTH (1-34)], as brand name
nied by altered bone formation. Osteosarcoma occurred in 3, Forteo, was approved by the FDA on November 26, 2002 with
21, and 31 male rats and in 4, 12, and 23 female rats in the 5-, an indication for treatment of postmenopausal osteoporosis
30-, and 75-μg/kg treatment groups, respectively. Focal osteo- in women at high risk of fracture. Because of a higher inci-
blast hyperplasia, osteomas, and osteoblastomas were also seen dence of side effects in the 40-μg dose, the 20-μg dose became
but less frequently. It was felt that the exaggerated effects of the approved dose. Because of the advent of the rat toxicology
chronic stimulation of osteoblasts by PTH (1-34) resulted in the study results, the Neer study229 was terminated at 19 months
bone neoplasms. At that point in time, the authors felt that other (longest subject treated 21 months; personal communication).
related compounds that produce a similarly profound bone Subsequently, after further analysis of those data and their rela-
anabolic response in the rodent would also result in bone pro- tion to human skeletal physiology, in a boxed warning, in which
liferative lesions following near-lifetime treatment. Thus, this the rat osteosarcoma data was presented, it was decided that the
issue would be expected with other PTH and PTH-related pep- use of the drug for more than 2 years “is not recommended.”
tides, including PTH (1-84), PTH (1-38), PTH (1-31), PTHrP Also, because of the uncertain relevance of the rat osteosarcoma
(1-34), and PTHrP (1-36), which have anabolic activity on the finding to humans, it is advised to only use Forteo for patients
rat skeleton through interactions with the PTH/PTHrP recep- for whom potential benefits outweigh potential risk. In addi-
tor.230 An additional study was performed in 60 purpose-bred, tion, Forteo should not be prescribed for patients at increased
mature herpes B- and simian retrovirus-free female cynomol- baseline risk for osteosarcoma, e.g., those with Paget disease
gus monkeys who were estimated to be at least 9 years of age of bone or unexplained elevations of alkaline phosphatase, as
and skeletally mature, based on closed physes. The monkeys well as pediatric and young adult patients with open epiphyses
were injected with PTH(1-34) 0 or 5 μg/kg/d for 18 months, and or prior external beam or implant radiation therapy involving
then followed for up to an additional 36 months. At the end of the skeleton.232 Subsequently, Forteo received approval for two
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 59

other indications: increase of bone mass in men with primary or practice, of which over 500 have been for the off-label uses, pre-
hypogonadal osteoporosis at high risk of fracture; and treatment viously described.
of men and women with osteoporosis associated with sustained In 2007, Schwartz reported on the first use of teriparatide in
systemic glucocorticoid therapy at high risk of fracture.232 speeding fracture healing and initiating healing of nonunions
While the clinical trial was bringing Forteo to FDA approval, in humans.236 A further report by the same group followed in
there was great preclinical interest in fracture healing by the use 2008 that looked at teriparatide-induced stimulation of osteo-
of intermittent PTH (1-34) in rat and other fracture models. blast function to stimulate stress fracture healing.237
Among these studies, Andreassen and colleagues used 3-month- Since that time, there have been several reports of different
old female Wistar rats, given appropriate doses of hPTH (1-34) forms of PTH in fracture healing. Aspenberg et al. studied the
in a fracture model. External callus volume was increased 77% use of teriparatide for acceleration of fracture repair in humans
in the high-dose hPTH (1-34) group versus the lower-dose in a prospective, randomized, double-blind study of 102 post-
group and by 99% versus the vehicle group. The callus forma- menopausal women with distal radial fractures that were
tion and the mechanical strength improvements were measured treated with closed reduction. The primary objective of the
at 20 and 40 days after the fractures were created. A variety of study was to compare the effect of 8 weeks of once-daily subcu-
mechanical strength tests were also increased in the high-dose taneous treatment with teriparatide 20 or 40 μg versus placebo
treatment group. In conclusion, this early experiment showed on time to radiographic healing in postmenopausal women
that intermittent administration of high dose PTH (1-34) was with a unilateral dorsally angulated distal radius (Colles) frac-
able to improve fracture healing.233 ture. Radiographic healing was defined by cortical bridging in
Nakijima et al., with a different fracture model of the right three of four cortices. A few other secondary endpoints were
femur in 2-month-old male Sprague-Dawley rats treated with chosen for further evaluation. The estimated median time from
PTH (1-34) of 10 μg/kg/day versus vehicle, showed at day 14 fracture to first radiographic evidence of complete cortical
that bony callus, ultimate load to failure, BMC, and BMD were bridging in at least three of four cortices was 9.1, 7.4, and 8.8
increased in the PTH group. Likewise, serum osteocalcin, a weeks in the placebo, teriparatide 20 μg, and teriparatide 40 μg
bone formation marker, was significantly higher in the PTH- groups, respectively. In actual fact, the time to healing was not
treated group compared with controls, and the mRNA expres- shorter in the 40 μg group compared to placebo, but the time
sion of bone matrix proteins was markedly increased. They were to healing was shorter in the 20 μg group compared to placebo
able to show that the anabolic effects of PTH on bone formation (p < 0.001) and in the 20 μg teriparatide group as compared
are mediated by IGF-I early in the healing process. In the later with the teriparatide 40 μg group (p < 0.03). Although the
stages of fracture healing, the PTH effect was IGF-I indepen- primary hypothesis that teriparatide 40 μg would shorten the
dent. They concluded that “intermittent low-dose treatment time to cortical bridging was not supported, post hoc analyses
with human PTH (1-34) may represent an effective strategy for suggested that the clinically approved teriparatide 20-μg dose
the enhancement of fracture healing and could become the first significantly shortened median time to healing in three of four
systemic intervention for the repair of skeletal injuries.”234 cortices compared with placebo. It was felt that the reason for
Additionally, in 2003, Jiang et al. reported the results of the this unexpected finding might be that, in the Neer trial, 40 μg
bone biopsies from the Fracture Prevention Trial.229,235 A total was associated with a decreased BMD in the cortex of the radius
of 102 subjects participated in the biopsy study and yielded a shaft due to increased bone remodeling (what we would now
total of 51 paired iliac crest biopsy specimens. Static parameters call “cortical porosity”). They felt that teriparatide increased the
from the 2D histomorphometry and 3D trabecular structural number of early healers: at 7 weeks, approximately 10% of the
parameters were measured, creating one of the iconic images of placebo group had healed compared with 20% and 40%, respec-
osteoporosis treatment. Increased trabecular and cortical thick- tively, for the teriparatide 40 μg and 20 μg groups. They also
ness was observed in most posttreatment biopsies. Thus, teri- felt that teriparatide might reduce the risk of nonunion and that
paratide was able to improve both cancellous and cortical bone a reduction in healing time could also have “economic impor-
structure. The micro-CT images suggested that the increased tance for the young, active patient.” Also, of importance, the
cortical thickness resulted from increased bone formation at 8-week treatment time resulted in the discontinuation of teri-
both the periosteal and endosteal surfaces. paratide before radiographic healing occurred in all patients.
Because of the preclinical work, clinical study, and the They concluded that the shortened time to healing with 20 μg
approval of teriparatide for postmenopausal fracture reduction, of teriparatide compared with placebo suggested that fracture
during the MLB season of 2004, it was used to treat a lefty- hit- repair could be accelerated but that this might need to be shown
ting baseball player who was hit by a pitch, fracturing the fourth with other types of fractures.238
metacarpal bone in his right hand. Team orthopedists predicted Another key study was performed by Peichl and associates
it would take 6–8 weeks to heal. He was started on 20 μg per using PTH (1-84), the “complete” PTH molecule, to acceler-
day of teriparatide; his fracture was healed according to x-ray ate fracture healing in pubic bones and/or ischial rami of the
and CT scan in 3 weeks and he returned to play in 4 weeks. pelvis of elderly osteoporotic women. Performed in Vienna,
Thus began our experience in treating acute fractures, stress Austria, this was a randomized blinded study of 100 μg PTH
fractures, stress reactions, and delayed and nonunion fractures (1-84) (which was not available in the United States at that
to speed and improve fracture healing. All of these uses are time but is now approved as of January 23, 2015, in the United
off-label. We have used teriparatide in over 2700 cases in our States, for the treatment of hypoparathyroidism) once-daily
60 SECTION 2  Sport Syndromes

as a subcutaneous injection. Older patients with pelvic pain because the latent period of 7 years is characteristic of a radia-
were admitted to the hospital and underwent evaluation with tion-induced osteosarcoma, the tumor occurred in the radiation
DXA, X-ray of the pelvis, CT scan of the pelvis, and bone turn- field, and the short duration of Forteo treatment.243 An additional
over markers, PTH level, and 25 hydroxyvitamin D level. For case was reported at the ASBMR 31st annual meeting as a poster
patients with pelvic fractures, the CT scan was repeated and (SU 0354),244 but upon consultative review, this was determined to
functional progression was assessed every 4 weeks. All patients be a neural sheath tumor and not an osteosarcoma (personal com-
received 1000 mg of calcium and 800 IU of vitamin D. Twenty- munication). Forslund et al. reported a unique case of a complex
one patients were treated with PTH (1-84) and 44 patients patient with malignant (multiple) myeloma after a course of teri-
served as controls. Fracture healing was assessed on CT scans at paratide 20 μg daily from June 2005 to January 2007. In September
weeks 0 (at least 2 days after the fracture) and at 4, 8, 12 weeks 2004, an MRI demonstrated multiple vertebral compression frac-
and later until evidence of fracture healing (defined as cortical tures with subsequent vertebroplasty. No evaluation of her serum
bridging) was confirmed. The percentage of fractures that had protein (e.g., SPEP) was done at that time (although many would
healed at week 8 was considered to be the primary endpoint. consider a presentation with multiple new vertebral compression
Assessment of the CT scans was blinded to treatment arm. The fractures to be an indication for a thorough myeloma workup).
median time from the fracture to the first signs of complete cor- In September 2006, her renal function was said to be normal, and
tical bridging of the pelvic fracture on CT scan was 7.8 weeks in May 2007, she was found to have significant renal failure and
for the treatment group, compared with 12.6 weeks for the con- proteinuria with a kappa M-spike with very high serum free kappa
trol group (p<0.001). At week 8, the primary endpoint, all frac- light chain level; the beta-2-microglobulin level was also very high.
tures in the treatment group and four fractures in the control There was a question raised by the authors as to whether or not the
group had healed (healing rate 100% compared with 9.1%). The gammopathy could have predated the course of teriparatide, but
treatment group also demonstrated significant improvement in no conclusion about this status was made.245 Clinically, it seems
functional outcome compared with the control group. At week certainly probable that myeloma predated the initiation of Forteo
12, all fractures in the treatment group and 30 fractures (30/44) treatment. Please see the full online chapter for more information
in the control group were healed (68.2%). The mean time to regarding potential side effects and risk for Forteo.
healing for the fourteen fractures that had not healed by week As part of the safety surveillance program, the FDA required the
12 was 14.9 weeks (range 13–18 weeks). Laboratory monitoring manufacturer to perform several postmarketing studies. In 2012,
was followed during the study. PTH was continued for a total of Cipriani et al. reported on the safety of osteoanabolic therapy after
24 months as the patients were being treated for osteoporosis.239 the first decade of use. They reviewed PTH mechanisms of action,
Thus, the Peichl study239 differed from the Aspenberg PTH efficacy, PTH in men, PTH in glucocorticoid-induced oste-
study238 in that in the former study, treatment was continued oporosis, and PTH (1-84) use in hypoparathyroidism, its role in
for 24 months, and in the latter study, treatment was arbitrarily accelerated fracture healing, and, most importantly, safety. These
given for only 8 weeks. relatively rare cases of osteosarcoma would appear to be consistent
Since the time of these reports, additional studies have with the epidemiology of osteosarcoma in adults. The incidence
been reported by Ohtori et al. on other uses of teriparatide in of osteosarcoma was felt to be similar to unselected populations
orthopedic applications that show that teriparatide accelerates of adult humans who develop osteosarcoma and are not receiving
lumbar posterolateral fusion in women with postmenopausal PTH. The incidence of hypercalcemia with teriparatide was 11%
osteoporosis and reduced pedicle screw loosening after lum- and was observed 4–6 hours after the injection.246 Andrews and
bar spinal fusion surgery from a bone quality perspective in the colleagues reported on the first 7 years of a 15-year mandated FDA
same population.240,241 postmarketing surveillance study. From June 2004 to September
As part of the development of the Forteo program, there has 30, 2011, 1448 cases of osteosarcoma (diagnosed 2003 to 2009)
been monitoring of the potential occurrence of osteosarcoma from were reported to the 15 involved cancer registries in the United
the beginning. In a letter to the editor of the Journal of Bone and States. A subset of patients was interviewed. There were no valid
Mineral Research, published online on November 13, 2006, Harper reports of teriparatide use before the diagnosis of osteosarcoma
et al. reported one case of osteosarcoma at a time when >250,000 was made. These authors emphasized the importance of under-
patients in the United States and >300,000 patients worldwide had standing the potential latency period between the exposure to an
been treated with an estimated background incidence of osteosar- inciting exposure and the appearance of an increase in the number
coma in the general population of men and women ≥60 years of of clinically observed cancer patients. In cancers where the time of
age of 1 in 250,000 per year. “The identification of this case does not the exposure is known, e.g., radiation-induced, the latency period
change the risk/benefit profile for Forteo.”242 In 2010, Subbiak and has ranged from less than a year to more than a decade. The authors
colleagues reported a second case of osteosarcoma that occurred presumed that a study period of 15 years would be adequate to take
within a year of the previous reported case. This case, of note, was any potential latency into effect. They stated that among the 16,000
in a man with prostate cancer who received proton beam therapy to patients who received teriparatide in controlled clinical trials and
the bed of the prostate 9 years after the original diagnosis for local observational studies in the previous 15 years, the largest of which
recurrence; he had taken Forteo for 2 months for osteoporosis when was 4000 patients treated for 2 years and followed for up to 2 years,
a 6 x 5.7 x 5.5 cm high-grade chondroblastic osteosarcoma was dis- no cases of osteosarcoma were reported. As of June 2012, over 1 mil-
covered. The authors felt, for a variety of stated reasons, that the lion patients worldwide had received treatment with teriparatide
osteosarcoma was probably due to the previous radiation therapy, with approximately 4 million patient-years. From that experience,
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 61

there were the three previously described cases of osteosarcoma of fracture) or control treatment. The primary outcome was blinded
which one turned out to not be osteosarcoma and one occurred 2 radiographic findings of fracture healing and callus formation at 7
months after initiating teriparatide (and this would be an unusually weeks. This study did not show any positive effect of teriparatide on
short latency period, making the previous radiation therapy a more the treatment of proximal humerus fractures, either radiographi-
likely etiologic factor; whether the teriparatide incited malignant cally or on pain and/or function. The author admitted that his study
change in a previous damaged tissue is unclear).247 had several limitations: it may have been underpowered; the time
There was also a similar study started a year later in five of treatment may have been too short; it was not known if the opti-
Nordic countries (Denmark, Finland, Iceland, Norway, and mal dose of teriparatide for fracture healing is 20 μg or 40 μg; and,
Sweden). Kellier-Steele reported the results of the first 12 years finally, the study was not blinded because of lack of placebo pens.257
of the United States study through September 30, 2015, in which Bhandari et al. studied whether or not teriparatide would improve
939 osteosarcoma patients (or their proxies) were interviewed, femoral neck fracture healing after internal fixation as measured by
and the results of the Nordic study that concluded in 2014 in frequency of revision surgery, radiographic fracture healing, and
which 112 cases were reviewed. In the United States study, one other safety outcomes including pain control, gait speed, and safety.
patient was identified who reported the use of Forteo prior to Two separate but identically designed double-blind placebo-con-
the diagnosis of osteosarcoma. No further details of this case are trolled Phase III clinical trials to meet FDA criteria to gain a new
available. In the Nordic study, no patients were identified with indication were initiated to evaluate the effect of teriparatide 20 μg
a history of Forteo use prior to the diagnosis of osteosarcoma. for 6 months subcutaneously versus placebo. The effect was to be
The authors concluded, “Although there is a single case of prior evaluated at 24 months. The trials were conducted concurrently
FOR(S)TEO exposure in the US, evidence of a causal relation- with a planned enrollment of 1220 patients per trial. However, the
ship between FOR(S)TEO treatment and OS [osteosarcoma] in trials were stopped due to poor patient recruitment and enroll-
humans has not been identified.”248 As far as we know, no case of ment, and only a total of 159 patients were randomized: 81 placebo
osteosarcoma has been reported after the use of PTH (1-84).249 and 78 teriparatide. The combined program had very low power to
In yet another study, Gilsenan et  al. reported on a patient detect the originally expected treatment effect. There was no dif-
registry linkage to multiple state cancer registries. This Forteo ference between the groups in the proportion of patients achieving
Patient Registry (FPR) was established in 2009 to estimate the radiographic healing at 12 months (75% [61 of 81] placebo versus
incidence of osteosarcoma in US patients treated with teri- 73% [57 of 78] teriparatide). One of the comments by the authors
paratide. This prospective registry was designed to link partici- was that plain radiographs obtained at various intervals may be too
pants annually with state cancer registries. Patient enrollment is crude for evaluation of femoral neck fracture healing.258
planned for 10 years (2009–2019) and annual linkage data col- Several of our cases illustrate our approach to the problems
lection for 15 years (2010–2024). For the eighth annual linkage of these studies.
in 2017, 63,270 patients contributed 242,782 person-years of
follow-up. A total of 5268 adult osteosarcoma cases diagnosed Case 1
since January 1, 2009 were available for linkage from partici- Thirty-seven-year-old black male, 6’3 3⁄4”, 292 lbs, previous stress
pating state cancer registries. Projecting current enrollment rate fracture right navicular healed in past. Complaining of left foot
to study end, it is anticipated that the completed study will be pain; 6/04, given cortisone injection; 7/13/04, NMBS & MRI left
able to detect a four fold increase in the risk of osteosarcoma if navicular fracture; low-intensity pulsed ultrasound bone growth
one exists. To date, no incident cases of osteosarcoma have been stimulator initiated at 20 min/d; 9/10/04, CT: stress fracture mid
identified among patients registered in the FPR.250 portions left navicular bone; nonunion navicular fracture;10/6/04,
In the last 5–10 years, beyond the studies by Aspenberg238 ORIF: take down cystic nonunion of navicular fracture; internal
and Peichl,239 there has developed a significant literature of fixation w/2 cannulated screws; insert Osteogenic Protein – 1 (OP
anecdotal cases and review articles about utilizing the available No1) and BMP – 7; 10/22/04, postop x-ray 2 screws across navic-
anabolic agents off-label for various aspects of fracture healing, ular non union; EBI bone stimulator 10 hrs/d; 12/16/04, post op
including acute fractures, delayed healing, and nonunions.251–254 CT “appears to be healing;” disuse osteoporosis; 3/15/05, CT still
In addition, several articles have approached the topic of how to fracture lucency; 4/2/05, recurrent pain in foot; inject 1 cc beta-
evaluate the various products in order to create future adequate methasone (Celestone Soluspan); 7/05, 4–5 shock wave treatments;
studies that might actually help achieve an indication for frac- 7/26/05, new horizontal fracture through navicular bone; 8/18/05,
ture healing.255,256 A full discussion of these issues is beyond the short leg cast; using restart bone growth stim; 9/15/05, CT scan 2
scope of this chapter. There has also been use of the available navicular fractures (Fig. 4.6).
anabolic agents for resolution of stress reactions and treatment 11/3/05, CT scan subtle progressive healing along the dorsal
of stress fractures (again, off-label usage). In addition, in cer- aspect of the vertical navicular fracture; osseous bridging over
tain situations, we have utilized 40 μg of teriparatide per day for prior cleft; 1/27/06, referral from orthopedist for consideration of
increased anabolic effect (also off-label usage; see below). teriparatide treatment for fracture healing; office visit: informed
However, several of small studies deserve some comment. consent obtained and Black Box Warning discussed; Citracal +D
Johansson reported a series of 40 postmenopausal women with one BID started; a diagnosis of nonunion navicular fractures was
a proximal humerus fracture not suitable for operative treatment made; teriparatide injection training was conducted; Lab drawn
who were randomized to either daily subcutaneous injections with and obtained: Ca 10.0 mg/dL; 25 hydroxy vitamin D 35 ng/mL;
20 μg of teriparatide for 4 weeks (starting within 10 days of the osteocalcin 13.5 ng/mL (11.3–35.4); total alkaline phosphatase 108
62 SECTION 2  Sport Syndromes

inadvisable. A “secondary” osteoporosis laboratory workup

showed prediabetes and hypogonadism. A DXA showed normal
FT
bone density. He was started on a low-dose pulsed ultrasound.
A month later, he was started on teriparatide 20 μg subcutane-
ously daily. A month later, he was started on a heart-healthy
diet and testosterone gel. He was followed with appropriate
laboratory monitoring and serial CT scans at appropriate inter-
vals. The CT scan performed at 1 year showed an incompletely
healed medial malleolar fracture. A CT scan of the ankle per-
formed 23 months after initiation of osteoanabolic treatment
showed complete healing of the medial malleolar fracture.

History and Clinical Course

The patient, a 66-year-old, right-handed married white male, a
Fig. 4.6  CT navicular, Case 1. medically disabled butcher, was seen for the first time on 9-2-11
for evaluation of nonunion of a right medial malleolar fracture. He
U/L (30–115); BSAP 19.5 ug/L (7.7–21.3); Serum CTx 249 pg/mL stated that he didn’t know what happened to his ankle. He had been
(70–780); DXA (GE Prodigy Advance): LS 1.500 gm/cm2, Z-score in a COPD exercise class for 7 weeks when his ankle “started to
+1.7; Left Total Hip 1.447 gm/cm2, Z-score +2.2; 1/3 Left Forearm hurt.” He taped it up, but 1 week later, he saw his orthopedist. An
(Radius) 0.874 gm/cm2, Z-score +0.2; TBBM 1.607 gm/cm2, x-ray in late April 2011 showed a fracture. No trauma. When he
Z-score +2.8; vertebral fracture assessment (VFA) no compression started the exercise program, “couldn’t hardly walk,” when done (7
fractures. Trabecular Bone Score (TBS) 1.134; this value is less than weeks), “could walk for 1 hour without stopping.” Multiple previous
1.200 and is classified as “degraded” compared to a normal female fractures due to motorcycle accidents. Spinal fusion, 1983. Smoked
Caucasian database; (now, less than 1.23; and, is, also, “degraded” 3 packs per day for 30 years, stopping 12–14 years ago. Intermittent
compared to a normal male Black database [not officially approved prednisone for COPD. NSAID for 2–3 years; none for 6 months.
by the FDA; used in research only, at this time]; retrospectively “Probable” alcoholic; none for 15 years. Taking a multivitamin for
analyzed on 2-18-16); 1/30/06, teriparatide start date; dose 20 μg/ years and vitamin D3 1000 IU “for a couple of months.” Tallest
day; continue bone growth stimulator (low-intensity pulsed ultra- remembered height: 6’1’’; height measured on wall-mounted stadi-
sound - LIPUS) but change to 20 minutes every 12 hours; 2/22/06, ometer 5’9¼”. Weight 298lbs. BMI 43.7. Swollen right ankle. Testes
CT navicular bone: lucency with partial union distally; 2/22/06, small, soft, DRE negative. 9-3-11 Start Exogen low-dose pulsed
increase teriparatide to 40 μg/day (2 consecutive injections from ultrasound one treatment per day; 9-23-14 Start Heart-Healthy
same pen with same needle); 5/6/06, Lab: PTH 59 pg/mL; 25 vita- Diet; 9-24-11 Start teriparatide (Forteo) 20 μg subq daily; Increase
min D 34 ng/mL; s-CTx 535 pg/mL; total alkaline phosphatase vitamin D3 from 1000 IU to 2000 IU per day; 10-20-11 Start
158 u/L; BSAP 46.0 ng/L; 6/16/06, XR Left heel: fractures healed; Androgel 1% 5 g pkt, apply one per day; 5-12-12 Increase vitamin
6/27/06 decrease teriparatide to 20 μg/d 8/8/06 total alkaline phos- D3 to 5000 IU per day; 8-26-13 Weight 266 lbs, down 32 lbs; 9-24-
phatase 137 u/L; PTH 43 pg/mL; 25 vitamin D 20 ng/mL; osteo- 13 Stop teriparatide (Forteo), fracture healed; 8-21-14 Weight 261
calcin 37.5 ng/mL; s-CTx 772 pg/mL; BSAP 52.4 ug/L 10/20/06 lbs, down 37 lbs; Height measured on wall-mounted stadiometer
discontinue teriparatide. Teriparatide restarted in 2-07 until 10-07. 5’9½”, BMI 38; 1-year post-fracture healing follow-up.

Case 2 DXA
Abstract These studies were performed on a Hologic Discovery A densi-
Nonunion of a fracture is defined as permanent failure of heal- tometer utilizing software version 13.3 (Table 4.9).
ing following a fracture, usually by 6 months. The FDA defines Imaging: 5-3-11; RT ankle XR: medial malleolar fracture,
nonunion for investigative purposes as a fracture 9 months old SAD type 9-8-11; CT RT ankle with reconstructions: non-
that has shown no signs of healing for 3 months. Nonunions union of medial malleolar fracture which extends into the
occur in 10%–20% of the 6,000,000 annual fractures in the trabecular articulation; 12-13-11; CT RT ankle with recon-
United States. The morbidity of nonunions is extensive and structions: interval healing of the vertically oriented fracture
expensive. The treatment of nonunions is usually surgical, but involving the medial malleolus without evidence for complete
the development of osteoanabolic agents suggests there may be union; persistent nonunited fracture involving anterior caudal
another approach. However, the duration of time of treatment portion of the medial malleolus fracture with persistent artic-
to “heal” a nonunion is unknown. Numerous individuals sug- ular extension; 2-13-12; CT RT ankle: Partially healed medial
gest that this treatment may take weeks to a few months. We malleolar fracture with osseous bridging. Improved from 9-8-
evaluated a 66-year-old morbidly obese white male who frac- 11 although appears similar to 12-13-11; 4-19-12; CT RT ankle
tured his right medial malleolus after 7 weeks in an exercise with reconstructions: persistent incomplete union of the cortex
class without obvious trauma; presumably, a stress fracture due of the articular surface of the medial malleolus. 6-18-12; CT RT
to increased activity. A CT scan of the ankle 5 months later ankle with reconstructions. partially healed medial malleolar
showed a nonunion. Because of morbid obesity and chronic fracture with osseous bridging noted. This has improved from
obstructive pulmonary disease, surgical repair was deemed 9-8-11 with persistent cortical break; 9-6-12; CT RT ankle with
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 63

reconstructions. Incompletely healed medial malleolar fracture; Laboratory Results

no interval change from prior CT of 6-18-12; 1-20-13; CT RT
9-8-11: Initial blood and laboratory workup; 12-18-11, 2-4-12,
ankle with reconstructions. Incompletely healed medial mal-
4-31-12, 6-19-12, 9-7-12, 9-27-13, 8-5-14: Follow-up laboratory
leolar fracture: no significant interval change since prior study
studies notes particularly the increasing and decreasing response
from 9-6-12; 8-27-13; CT RT ankle. Healed medial malleolar
of the anabolic BTOM, P1NP (Tables 4.10 and 4.11).
fracture; no new fracture (Fig. 4.7).

TABLE 4.9  Dual-Energy X-ray Absorptiometry (DXA)

EXAM DATE: 9/2/11 9/13/2012 9/24/2013A 8/25/2014
BMD g/cm2 T-Score Z-Score BMD g/cm2 T-Score Z-Score
AP Spine (L1–L4) 1.506 3.8 4.6 1.624 1.801 1.766
Femoral Neck (FN) (right) 0.954 0.2 1.2 0.899 0.990 1.067
Total Hip (TH) (right) 1.087 0.4 0.9 1.108 1.077 1.237
1/3 Forearm (FA) (right) 0.780 –0.7 0.4 0.787 0.799 0.799
VFA No VCF No VCF No VCF No VCF
TBSb 1.127 1.019 1.166
aPerformed on an outside Hologic Discovery A densitometer utilizing software version 12.7.3.2.
bScore>1.350 = “normal”; >1.200, <1.350 =”partially degraded”; <1.200 = “degraded”
AP, anterior-posterior; BMD, bone mineral density; TBS, trabecular bone score (Medimaps, Geneva, Switzerland).; VCF, vertebral compression
fracture; VFA, vertebral fracture assessment

TABLE 4.10  Laboratory Results for Case Study 2

9/8/11 12/18/11 2/4/12 4/31/12 6/19/12 9/7/12 8/27/13 8/5/14
CBC Hgb 13.1: Hct 38.9 Hgb 13.1: Hct 38.9
CMP Glu 90: Creat 0.86 Glu 159
HgbA1c 6.0% 6.3% 5.7% 5.7% 5.6% 5.8%
25 VD 31 38 33 26 37 40 46 54.4
1.25 VD 37 (15.75)
SPEP No M Protein
Estradiol < 20 (0.47) 27
TSH 0.89 0.64 1.010
fT4 0.7 0.7 1.16
Ttestost 90 (175–781) 857 683 >1500 1163 860 (348–1197)
Ftestost 14 (47.244) 229 283 19.0 (6.6–18.0)
PTH 42 (14.0–72.0) 35.4 43 36.9 26.7 24
TTG Ab, IgG < 1 (< 6)
TTG Ab, IgG < 1 (< 6)
Gliadin Ab, IgA 3 (< 19)
Gliadin Ab, IgG 9 (< 19)
Homocysteine 9 (< 19) 9 8.7
Carotene 8 (4–13) 18
Osteocalcin 90 (60–200) 38 44 52 58 41 7.4
P1NP 54 (22–105) 136 175 143 111 138 62 29
BSAP 14.4 (6.5–20.0) 17.3 21.9 20.8 16 21.5 12.0 8.0
sCTx 183 (87–345) 415 437 560 765 534 302 240
uNTx 28 38 39 57 45 44 20
Creat Ckear 113 102
U Calcium 133 147 213 285 192
PSA 0.43 0.66 0.7
Ca 94 9.5 8.8 9.4
P 3.0 3.7 2.9 3.2 2.5
Ferritin 88
64 SECTION 2  Sport Syndromes

TABLE 4.11  Laboratory Results for Case Study 2

9/8/11 12/18/11 2/4/12 4/31/12 6/19/12 9/7/12 8/27/13 8/5/14
Osteocalcin 19 (11–50) 38 44 52 58 41 7.4
P1NP 54 (22–105) 136 175 143 111 138 62 29
BSAP 14.4 (6.5–20.0) 17.3 21.9 20.8 16 21.5 12.0 8.0
sCTx 183 (87–345) 415 437 560 765 534 302 240
uNTx 28 38 39 57 45 44 20

A B C
Fig. 4.7  CT case 2. (A) Initial stress fracture (arrow) and showing nonunion at 5 months postinjury. (B) CT
showing incompletely healed medial malleolar fracture at 1 year post-initiation of teriparatide. (C) CT showing
completely healed medial malleolar fracture at 2 years post-initiation of teraparatide. CT, computed tomography.

Conclusions injection with another scheduled for a week after his first office
Current osteoanabolic therapy can heal fracture nonunions, but visit. He had a vitamin D level performed 3 years previously,
the length of time to do so may be prolonged. which he was told was “below average,” but he was not told to take
vitamin D, nor was the level ever repeated. He was taking dairy
Case 3 products in his diet but no supplemental calcium. PMH, FH, SH,
Professional basketball center; Seen in original consultation on and ROS were otherwise unremarkable.
5-19-15; The last time his foot was entirely well was early in the His DXA showed an AP Spine (L1–L4) Z-score +1.6; Right
2011/2012 season; it began to be “sore;” it was evaluated with Femoral Neck Z-score +2.5. TBS = 1.458 “normal.” 25 vitamin D
imaging, and he was told there was “a fracture;” (Jones fracture); level was 25 ng/mL (normal: 30–100). He was treated with high-
he underwent surgery with placement of a screw. He played 3–5 dose vitamin D3. His laboratory workup for causes of secondary
games in 2011/2012 season starting after the All-Star Game but metabolic bone disease was normal or negative. His bone turnover
the foot “didn’t feel right;” imaging was performed and he was markers to measure bone resorption and bone formation were
told his fracture “was not healed” and he was shut down for the normal. A specimen to the Collagen Diagnostic Laboratory at the
rest of the season. He played the 2012/2013 season with his foot University of Washington showed no abnormality in bone genes
“pain free;” at the end of the season, an x-ray showed the screw analyzed. He was restarted on teriparatide 20 μg subcutaneously
was bent, and so a bigger screw was placed during the off-season, daily, one bone growth stimulator 20 minutes twice a day, and fol-
but he was told there was “still a tiny line.” He played 20 games of lowed with appropriate lab and imaging. Imaging showed com-
the 2013/2014 season but he had recurrent foot pain; a new screw plete healing of the right fifth metatarsal fracture after 15 months.
was placed and a first metatarsal osteotomy was performed along Teriparatide was continued through the end of the next season
with an iliac crest bone graft; he didn’t play again that season. He (Figs. 4.8 and 4.9).
was given teriparatide for 2 months, from January to mid-March
2014; he was given a bone growth stimulator, which he used for a Abaloparatide (Tymlos) PTHrP (1-34)
“period of time.” He played throughout the 2014/2015 season, but In April 2017 (4-28-17), the third anabolic drug, abaloparatide,
at the end of the season an x-ray showed “a line.” He was given a which is indicated for treatment of postmenopausal women at
new, different bone growth stimulator to use along with the pre- high risk of fracture, was approved for patient use by the FDA
vious bone growth stimulator, which was restarted; he was also as Tymlos. Abaloparatide is a novel synthetic analog of human
restarted on teriparatide; and he was given a PRP or stem cell parathyroid hormone related peptide (PTHrP [1-34]). PTHrP
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 65

Stress Fracture NBA Center

5-7-15

A B C
Fig. 4.8  Case 3,1 (A) 5th metatarsal fracture, S/P 3rd ORIF, nonunion, AP View. (B) 5th metatarsal fracture, SP
3rd ORIF, nonunion, Lateral View. (C) X-ray of right foot.

Stress Fracture NBA Center

Patient B

A B C

X-ray August 2016

Fig. 4.9  Case 3,2 (A) 5th metatarsal fracture, healed after 15 months of teriparatide. (B) 5th metatarsal frac-
ture, higher power view. (C) 5th metatarsal, lateral view.

is a paracrine-acting morphogenic factor that regulates cell of abaloparatide or 30 μg/kg of PTH (1-34) as a positive control
proliferation and differentiation in developing bone and other for up to 2 years. This study resulted in a dose-and time-depen-
tissues. It works through its action on the parathyroid hormone dent formation of osteosarcomas with a comparable response to
receptor type 1 (PTHR1), which mediates the actions of both PTH (1-34) at similar exposure.260
PTH and PTHrP. Abaloparatide has 76% homology to human The registration trial, known as the Abaloparatide
PTHrP (1-34) and 41% homology to human PTH (1-34) due Comparator Trial in Vertebral Endpoints (ACTIVE), was a
to substituted amino acid residues in the peptide.259 Similar to Phase III, double-blind, placebo-controlled trial in which 2463
teriparatide, a study to determine the carcinogenic potential of postmenopausal women with low bone density and a significant
abaloparatide performed in Fisher F344 rats administered sub- percentage of prevalent vertebral and nonvertebral fractures
cutaneous daily abaloparatide at doses of 0, 10, 25, and 50 μg/kg were randomized to daily subcutaneous injections of placebo
66 SECTION 2  Sport Syndromes

(n = 821), abaloparatide 80 μg (n = 824), or open-label teriparatide bridging and significantly greater callus area in the high-dose
20 μg (n = 818) for 18 months. Both abaloparatide and teriparatide group compared with vehicle. Three-point bending tests at
reduced both vertebral and nonvertebral fractures. Of importance week 4 showed that callus stiffness was 60% and 96% higher
for this chapter are some of the details of the study. Daily admin- in the abaloparatide groups and 112% higher at 12 weeks. The
istration of abaloparatide resulted in a 93% increase in the bone authors concluded that abaloparatide enhanced fracture heal-
formation marker, P1NP, that was maximum at 1 month with ing in the model of femur fracture utilized in this study.262 In
a decline over the next 17 months so that at conclusion of this the second abstract, Chandler et  al., the results were inter-
study, the P1NP was 45% above baseline. The bone resorption preted as showing early increases in callus stability, perhaps
marker, s-CTx, was 43% above baseline at 3 months and was 20% related to the augmentation of chondrogenesis and osteogen-
above baseline at 18 months. This time course of bone remodel- esis representing a potential pharmacodynamic profile for
ing from abaloparatide is somewhat different than that of teri- improving fracture healing.263
paratide. Teriparatide reached its maximum bone formation at 6 At the time of writing, there are no human fracture healing
months which plateaued until 12 months and then declined to 18 data available for abaloparatide. Whether there will be a human
months at the conclusion of the study. The teriparatide curve of fracture healing study undertaken by the company has not been
the bone resorption marker exceeded the respective curve of the announced at this time. Thus, any use of Tymlos in fracture
abaloparatide bone resorption marker and was much higher than healing at this time would be off-label.
abaloparatide at the conclusion of the study. The BMD changes of
abaloparatide at the LS spine were 5.9% at 6 months, 8.2% at 12 Bisphosphonates
months, and 9.2% at 18 months; for teriparatide, the changes were Bisphosphonates were discovered about 50 years ago and were
4.8% at 6 months, 7.4% at 12 months, and 9.1% at 18 months. At found to have extensive effects on bone metabolism. They have
the total hip, the BMD in the abaloparatide patients increased by been used clinically for 40 years for the treatment of a variety
2.1% at 6 months, 2.9% at 12 months, and 3.4% at 18 months; the of metabolic bone diseases associated with excess resorption
corresponding changes in the teriparatide subjects were 1.3% at 6 since the FDA approval of etidronate (Didronel) on September
months, 2.0% at 12 months, and 2.8% at 18 months, respectively. 1, 1977.264,265 Over the subsequent time period, the mechanism
At the femoral neck, the abaloparatide increases were 1.5% at 6 of action has been delineated that bisphosphonates inhibit bone
months, 2.2% at 12 months, and 2.9% at 18 months, whereas the resorption by selective adsorption to mineral surfaces and sub-
corresponding changes in the teriparatide arm were 0.8%, 1.4%, sequent internalization by bone-resorbing osteoclasts where
and 2.2%, respectively. There is a suggestion, but one that is not they interfere with various intracellular processes. There are less
evidenced-based at this time, that fracture reduction might begin potent nonnitrogen-containing bisphosphonates (clodronate
earlier with abaloparatide than with teriparatide. Adverse events [not approved in the US] and etidronate). Most of the clinical
of each arm were similar. Of importance, adverse reactions due experience has been with the more potent nitrogen-containing
to hypercalcemia (albumin-corrected >10.7 mg/dL) were 0.4% bisphosphonates (pamidronate [approval date: 9-22-98]; alen-
for placebo, 3.4% for abaloparatide, and 6.4% for teriparatide.261 dronate [approval date: 9-29-95]; risedronate [approval date:
However, because the Tymlos arm used its specific pen and the 3-27-98]; oral ibandronate [approval date: 5-16-03] and intra-
teriparatide arm used its specific pen, the study was not blinded venous ibandronate [1-9-06]; and zoledronic acid [approval
for the anabolic agent with which the subjects were treated. Also, date as Zometa: 8-20-01 and as Reclast: 8-17-07]). These nitro-
because of the size of the population in each arm, it is not possible gen-containing bisphosphates inhibit a key enzyme, farnesyl
to draw some of the conclusions we might like to draw about the pyrophosphate synthase, in the mevalonate pathway, thereby
efficacy of one anabolic versus the other. preventing the biosynthesis of isoprenoid compounds that are
In a post hoc analysis of a Phase II trial, abaloparatide given at essential for the posttranslational modification of small gua-
multiple doses was evaluated for its effect on TBS. After 24 weeks, nosine triphosphate (GTP)-binding proteins (which are also
TBS increased significantly by 4.21% in the 80 μg per day group. GTPases) such as Rab, Rho, and Rac, the inhibition of protein
In the teriparatide 20 μg daily group, TBS increased by 2.21%.141 prenylation, and the disruption of the function of these key reg-
Saag et  al. reported on the TBS changes in a study of patients ulatory proteins, explaining the loss of osteoclast function.266,267
treated with chronic glucocorticoid therapy-induced osteoporo- The clinical pharmacology of these drugs is characterized by
sis. In the teriparatide-treated patients, the TBS increased signifi- poor oral absorption from the intestine (<1%–4%) but highly
cantly by about 2% at 18 months and by 3.7% at 36 months. There selective localization and long-term retention in bone. Side effects,
was no increase in TBS in the alendronate-treated group.140 when properly used, are minimal, but in the last 10–12 years, the
At the present time, the preclinical fracture healing data appearance of rare side effects (osteonecrosis of the jaw and atypi-
are limited to two reports. In the first abstract, 96 12-week-old cal femoral fractures) has somewhat dampened the enthusiasm of
male Sprague-Dawley rats underwent creation of a right femur their use, at least by the public if not physicians.268–270
closed internally stabilized fracture. Rats were treated with 5 These drugs have numerous FDA-approved indications,
or 25 μg/kg/day or vehicle. Micro-CT of the fracture calluses including prevention and treatment of postmenopausal osteo-
showed that the abaloparatide-treated rats had greater callus porosis, male osteoporosis, glucocorticoid-induced osteoporosis,
bone volume, bone volume fraction, and BMC at weeks 4 and Paget disease of bone, hypercalcemia of malignancy, and numer-
6 than vehicle. Semiquantitative histologic scoring of cortical ous other oncologic indications. They have many off-label uses.
bridging across the fracture gap showed significantly greater They were originally given orally every 3 months (etidronate); to
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 67

orally daily (alendronate) to weekly (alendronate); to orally daily, Participants were given either 30 mg of risedronate or pla-
weekly, and monthly (risedronate); to orally monthly and intra- cebo daily for 10 days during the first 2 weeks of basic train-
venously every 3 months (ibandronate); to monthly and yearly ing before any significant training. After the 10-day loading
(zoledronic acid). The oral drugs have fastidious dosing recom- period, treatment-arm subjects received a 30-mg maintenance
mendations: fasting (alendronate and risedronate) and postpran- dose weekly for 12 weeks. Side effects of medication were
dial (risedronate); and the intravenous drugs can be given as a charted. Those with a suspicion of stress fracture were eval-
bolus (ibandronate) or as a slow infusion (zoledronic acid). uated by the standardized IDF stress fracture protocol. For a
Shima and colleagues reviewed the literature on the use of variety of reasons, there were a lot of dropouts in the study.
bisphosphonates for the treatment of stress fractures in ath- However, the results of the intention-to-treat analysis showed
letes.2 Controversy has existed over the years about whether or that prophylactic treatment with risedronate did not lower the
not bisphosphonates interfere with fracture healing, resulting in incidence, time of onset, or severity of stress fractures.275
delayed healing or fracture nonunions. Little et al. suggested in In 2009, Shima concluded his review with the statement:
a rat model that zoledronic acid could improve fracture heal- “…there is still no conclusive evidence to prove any effect of
ing by optimizing the amount and mineral content of the callus bisphosphonates on stress fracture healing in humans. Until the
produced, which might prove to be of clinical benefit in obtain- results of well-designed clinical trials are available, it is prudent
ing fracture healing.271 to limit the use of bisphosphonates in the treatment of stress
In 2005, five female intercollegiate athletes with bone scan fractures.”2 Despite the newer report by Eriksen,274 this conclu-
positive lesions consistent with stress fractures were treated sion still holds.
with intravenous pamidronate. Each patient received an initial
test dose of pamidronate 30 mg intravenously over 2 hours; sub- Bone Marrow Edema Syndrome
sequently, the first three patients received 90 mg intravenously In the study by Eriksen, it is said that the subjects exhibited bone
and the final two patients received 60 mg intravenously. They marrow (edema) lesions (BMLs) with and without fracture lines
were given weekly infusions for a total of five treatments. The on MRI.274 Whether or not these lesions should be considered
authors described marked improvement in pain within 48 to stress-related is not clear. Ringe et  al., in their description in
72 hours during clinical evaluation and sport-specific partici- 2005, stated that BMLs constitute a rare disorder of localized
pation beginning after the 30-mg test dose.272 In another case high bone turnover of unknown etiology, self-limited; and that
series, Chambers reported the treatment of five lumbar pars the lesion was characterized by the onset of disabling bone pain,
interarticularis stress fractures in athletes with intravenous bis- usually at a single skeletal site, generally in the lower limbs,
phosphonates. One received two infusions of pamidronate of and especially the hips, in the absence of trauma. The entity
60 mg and four received 3 mg of ibandronate and three further has also been termed locally transient osteoporosis (LTO). The
infusions at 4-week intervals. They resumed play at 1–6 months lesion is now diagnosed by MRI.276 The pathology of LTO has
after their final infusions. The longest follow-up was 45 months been evaluated in patients who underwent core decompression
at which time that patient remained symptom free.273 for the lesion. The specimens showed changes in the marrow
In 2016, Eriksen reported the use of intravenous zoledronic and the bone. They showed marrow edema,277,278 thin seams of
acid to heal complicated stress fractures in the foot with delayed woven bone278,279 with active osteoblasts, thinning of the tra-
healing. Seven females and two males, aged 30–72, with non- beculae, and osteoclastic bone resorption. There was no fat or
union of stress fractures for more than 12 months were studied. bone necrosis.279 The lesion has been reported in the hip,280
Intravenous zoledronic acid (5 mg) was given in two infusions 3 the knee,281 the ankle,282 and foot,277 and has been treated with
months apart. Pain was monitored and MRI was performed in six intravenous ibandronate276 and intravenous zoledronic acid278
patients at baseline, 3, 6, and 12 months after the first infusion. to turn down what is essentially increased bone resorption and
All patients received calcium and vitamin D. They reported that high turnover osteoporosis.276
all patients experienced clinical healing with significant reduc- In 1996, Schweitzer and White noted that altered biome-
tion of pain at the fracture site with improvement of ambulation chanics in weight bearing could produce marrow edema on
within 1–3 months after the first infusion. Four patients experi- MRI. They studied the hips, knees, and ankles of 12 asymptom-
enced further pain relief after the second infusion. At 6 months, atic volunteers (6 women, 6 men), age range 19–41, mean age
all patients had normal ambulatory function and significant pain 30 years, who, unilaterally, underwent the creation of a walking
relief. He concluded that treatment with intravenous zoledronic alteration by the placing of an extra-large, 9/16-inch longitu-
acid represents a safe and effective treatment of delayed union of dinal metatarsal pad underneath the lateral aspect of one foot
stress fractures of the foot, thus avoiding surgical intervention.274 to increase pronation. Images were obtained on a 1.5 T MRI
In an iconic study, Milgrom, his team, and Burr looked system before (baseline), after 2 weeks of altered weight bear-
at prophylactic treatment with risedronate on stress fracture ing, and 2 weeks after removal of the pad and return to normal
incidence among infantry recruits in the IDF. Four hundred ambulation. The MR images of 11 of the 12 volunteers showed
seventy-three new male infantry recruits, training on the changes of marrow edema in multiple bones consisting of a
same base between December 2002 and March 2003, were diffuse increase in marrow that varied between “subtle” and
approached to participate in the study, and 324, median age “intense.” Occasionally, the lesions appeared similar to stress
18.8 years, (range 18–28), agreed to do so. Subjects were fractures. At follow-up, the MR images returned completely to
randomly assigned to receive either risedronate or placebo. normal, although one subject demonstrated minimal persistent
68 SECTION 2  Sport Syndromes

marrow edema.283 Subsequently, in 1997, Lazzarini et al. asked, two 75-mg doses of diclofenac sodium per day for 3 weeks
“Can running cause the appearance of marrow edema on MR and nonweight-bearing status for 3 weeks, and then partial
images of the foot and ankle?” To determine this outcome, weight-bearing for 3 weeks. Standardized functional and pain
they imaged the feet and ankles of all runners of a university scales were employed to evaluate the patients’ responses. MRIs
cross-country team. They found edema in 16 of 20 runners and of the affected regions were also obtained. Intravenous iband-
in 4 of 12 nonrunners, but all subjects were asymptomatic. The ronate produced “rapid and effective pain relief ” based on the
total edema score and the number of bones with edema was pain scores at 1 month, 6 months, and 12 months, with similar
significantly higher in the runners than in the nonrunners. improvements in functional scores and improvements in MRIs
Thus, running itself can account for marrow edema lesions. The compared with the pain medication arm. They concluded that
authors concluded that the edema detected in these lesions on intravenous ibandronate was an “effective treatment option
MRI might represent a continuum with stress fractures. Today, for BMES [bone marrow edema syndrome] of the knee and
we would probably refer to these lesions as stress reactions.284 ankle.”291
Another lesion in the spectrum of these bone marrow Beckmann et  al. studied 24 hips in 23 patients of which
edema lesions is a “bone bruise” or “bone contusion,” which is 12 were treated with off-label iloprost infusions coupled with
an occult posttraumatic bone injury that may cause substantial core decompression, versus core decompression alone in bone
clinical problems, since it is associated with acute and subacute marrow edema lesions. Iloprost is a synthetic analogue of
pain and some degree of loss of function in a limb. These lesions prostacyclin PGI2, which is a systemic and pulmonary arte-
are easily detected on MRI scans with decreased signal intensity rial vasodilator. Iloprost was administered over 5–6 hours on 5
on T1-weighted and increased signal intensity on T2-weighted consecutive days with a starting dose of 20 μg on the first day,
images.285 The early time course286 and the later time course287 30 μg on the second day, and 40 μg on the following 3 days.
have been described. In 2012, Ucar et  al. stated, “Currently, Core decompression and iloprost infusion decreased pain on
there is no definite consensus on the natural history of bone the first postoperative day. The combination therapy was sta-
injuries secondary to minor knee traumas.”287 While it is gener- tistically significant over the monotherapies. There were fewer
ally thought that these lesions resolve in a short time, some per- cases of persistent BMEL in the combined group as opposed to
sist for 6–24 months or longer.288 After trauma to the hip, knee, the monotherapy group radiologically.292
or ankle, individuals are sometimes left with persistent “bone Baier and his group compared infusions of iloprost versus
bruise” (bone [marrow] edema) beyond the usual expected ibandronate. The investigators used the off-label iloprost infu-
healing of the injury. These injuries produce persistent and/or sion protocol of Beckmann versus the off-label ibandronate
lingering residual pain and discomfort that correlates with the protocol of Bartl. It was felt that iloprost had certain advantages
bone edema seen on MRI, which does not resolve at the same to the bisphosphonate, including rapid pain relief and a shorter
pace as other symptoms or signs of inflammation. This entity time to complete the infusion protocol. Both medications helped
reduces athletic performance and delays return to play. In these the BMEL to resolve, and the differences from either were not
situations, an intravenous bisphosphonate (ibandronate or zole- significant.293 Fabbriciani et al. reported a case of a 62-year-old
dronic acid) has been shown to reduce pain and disability and man with a 2-month history of increasing pain in the left hip.
speed return to play. The ability to reduce bone pain in these MRI showed bone marrow edema. After further workup, which
benign disorders of increased bone turnover may be a property included finding significant vitamin D deficiency (9 ng/mL),
unique to intravenous ibandronate.289 and DXA of the proximal left femur that showed osteopenia, the
From 2009 to the present, we have treated four professional patient was treated with teriparatide 20 μg subcutaneously daily.
basketball players and two intercollegiate basketball players After 4 weeks, the patient was asymptomatic with no physical
with such a scenario as described previously, allowing earlier disability. An MRI showed almost normal signal intensity and
return to play. All were given 3 mg of intravenous ibandronate DXA showed an 8% BMD increase in the left hip. From this
(the US FDA–approved dose) “push,” with one player receiving one case, the improvement in the time course to resolution with
a second dose (3 mg) at 1 month after the first infusion. Pain an osteoanabolic drug as opposed to the previous antiresorp-
began to subside within 7–10 days of the infusion. All returned tive or vasodilatory drugs seems impressive.294 Rolvien and his
to play after 1–8 weeks with reduction in pain and improvement colleagues retrospectively studied 14 patients with atraumatic
in athletic performance based on clinical symptom and sign res- bone marrow edema syndrome who underwent a metabolic
olution. The MRI may or may not show improvement in the bone disease evaluation with 25 vitamin D levels, bone turnover
short term but will improve over the long term.290 markers, DXAs, and MRIs. Mean time from onset of pain and
Since our work on the use of intravenous ibandronate infu- treatment with subcutaneous 60 mg of denosumab (Prolia) was
sions in the treatment of elite athletes with bone marrow edema 5.2 +/- 4.3 months (155 days). One patient had had a previous
syndrome following a bone bruise, a number of further studies ibandronate infusion and two patients had had previous core
have been published. decompression. Six to 12 weeks after injection, the bone mar-
Bartl and colleagues performed a prospective, observa- row edema had resolved in 50% (7/14) of the patients and had
tional, off-label study of intravenous ibandronate with a pain improved in 6 other patients, thus demonstrating that denos-
medication and partial weight-bearing group. The treatment umab is also an effective treatment for this syndrome.295
group received three intravenous infusions of 6 mg of iban- Simon and colleagues looked at the use of intravenous bis-
dronate monthly for 3 months versus a group that received phosphonates and vitamin D in the treatment of bone marrow
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 69

edema in 25 professional athletes (3 women and 22 men). In five those in the placebo-treatment group. At 150 days, 94% of the
of the cases, a stress fracture was also present on the MRI in the fractures in the active-treatment group were healed compared
region of interest. The time between the onset of pain and cor- with 62% of the placebo-treated group. There was variance
rect diagnosis was 106 +/- 104 days. Sixty percent of the patients for a number of other parameters: time needed for bridging
were considered vitamin D deficient; 44% had vitamin D levels of three cortices, time to complete cortical bridging, and time
between 20–31 ng/mL (insufficient), and 16% had vitamin D to complete endosteal healing, but all significantly favored
levels less than 20 ng/mL (deficient). All vitamin D abnormal- the active-treatment group rather than the placebo-treatment
ities were corrected with high-dose vitamin D. After that was group. Adverse reactions were minimal. However, in their
accomplished, all individuals were given 600 mg of calcium and discussion, the authors stated that the specific mechanism by
400 IU of vitamin D daily in tablets once a day. The treatment which low-intensity pulsed ultrasound accelerated the fracture
regimen consisted of an intravenous infusion of 3 mg of iband- repair process was not known.299
ronate. If there was no improvement, a second or third infusion Kristiansen and colleagues reported a study of healing of
was given after 4–6 weeks of the preceding infusion. Sixteen of closed, dorsally angulated metaphyseal fractures of the distal
the athletes (64%) noted pain reduction and improved mobility aspect of the radius within 4 cm of the tip of the radial styloid
in the first 2 weeks after the first infusion; nine athletes got a using low-dose pulsed ultrasound where the fracture was initially
second infusion, and two received a third infusion. All athletes treated by closed reduction and immobilization in a below-the-
returned to play at the previous level of function, but the group elbow cast. Eighty-three patients with 85 fractures were enrolled
that only required one infusion returned to play at 78 +/- 61 at 10 sites. Forty patients with 40 fractures were randomized to
days; two infusions at 141+/- 47 days; and, three infusions at the active-treatment group and 45 fractures in 45 patients were
164 +/- 33 days.296 randomized to the placebo-treatment group. Two patients had
bilateral fractures, and one fracture was treated with an active
Bone Growth Stimulators device and one with a placebo device. Sixty patients fulfilled all
There is extensive literature on the development and use of aspects of the protocol. For both groups, the time from fracture
bone growth stimulators. In the interest of full disclosure, I was to the start of treatment averaged 3 days. Time to a healed frac-
involved in the development of a low-dose, pulsed ultrasound ture was 61 ± 3.4 days for the active-treatment group compared
device and have used that device since it became clinically avail- with 98 ± 5.2 days for the placebo-treatment group; a significant
able about 1 month after its approval on October 5, 1994. acceleration of healing by 37 days (a 38% acceleration of heal-
In a series of articles in Spanish (in 1983) and English (in ing). The percentage of organized trabecular healing at 5–16
1987), Xavier and Duarte reported the acceleration of the normal weeks was significantly greater in the group treated with active
fracture repair process and healing of ununited diaphyseal frac- ultrasound, and loss of reduction was significantly greater in the
tures in humans with the use of low-intensity ultrasound.297,298 group treated with placebo device. Use of the active ultrasound
In 1997, Heckman and colleagues reported on a multi-institu- device significantly reduced the time to healing in the group of
tional, prospective, randomized, double-blind, placebo-con- smokers.300
trolled study of the acceleration of tibial fracture healing by a In 2001, Rubin et  al. conducted an extensive review of the
noninvasive, low-intensity pulsed ultrasound device. Ninety- literature. Numbers of studies pointed to the role of ultrasound
six patients were recruited for the study but 13 were lost to on the biological processes of fracture healing, including its role
follow-up for a variety of reasons, leaving 84 patients with 85 on influx and efflux of ions into cells, increasing calcium incor-
fractures. Another 17 subjects were excluded because of a vari- poration in cartilage and bone cell cultures, and modulation of
ety of protocol violations, leaving 64 closed fractures (31 in the adenyl cyclase activity and transforming growth factor-ß syn-
active-treatment group and 33 in the placebo group), and 3 thesis in osteoblastic cells, the increased release of platelet-de-
open grade I fractures (2 in the active-treatment group and 1 in rived growth factor, and the upregulation of aggrecan gene
the placebo-treatment group). The fractures were treated with expression, all of which augment the processes of callus forma-
closed reduction and immobilization in an above-the-knee cast. tion. These data suggest that besides moderating gene expres-
Ultrasound treatment was started within 7 days after the frac- sion, ultrasound may increase blood flow through the dilatation
ture and consisted of one 20-minute period daily. Treatment was of capillaries and increase angiogenesis to optimize fracture
continued for 20 weeks or until the clinical investigator believed healing.301 Rubin also reviewed Frankel and Lane’s review of
that the fracture was healed enough to discontinue the active the patient registry of Exogen (Piscataway, New Jersey), which
or placebo treatment. The endpoint for the study was a healed in June 2000 contained data on 22,300 patients; 10,500 patients
fracture, as judged by clinical examination and on radiographic had a 91% rate of healing; between 80% and 90% of the patients
examination (three out of four cortices bridged). Also defined only had ultrasound as the new treatment, and 83% of the non-
were several stages of intermittent healing, e.g., time to discon- unions healed.301
tinuation of the cast, time to cortical bridging, and periosteal Over the last several years, there have been a number of
and endosteal healing. Mean time to a healed fracture clinically meta-analyses of the last several decades of low-intensity pulsed
and radiographically was 96 ± 4.9 days for the active-treatment ultrasound. These studies showed that LIPUS is effective for
group compared with 154 ± 13.7 days for the placebo-treatment surgically managed, fresh, type C comminuted diaphyseal
group. At 120 days after the fracture, 88% of the fractures in fractures of the lower limbs when there is appropriate stability
the active-treatment group were healed compared with 44% of at the fracture site.302 In 2014, a National Institute for Health
70 SECTION 2  Sport Syndromes

and Care Excellence medical technologies guidance stated that growth factor (bFGF of FGF2), fibronectin, insulin-like growth
the clinical evidence supports the use of Exogen bone-healing factor-I (IGF-I), osteocalcin, P-selectin (also called GMP-140),
system in nonunion long bone fractures that have not healed platelet-derived endothelial growth factor (PDECGF or thymi-
after 9 months303; another study looked at treatment of chronic dine phosphorylase), platelet-derived growth factor (PDGF),
nonunion in a cohort of 767 patients where the heal rate was serotonin, transforming growth factor-ß1 (TGF-ß1), thrombo-
86.2% with nonunion >1 year, 82.7% with nonunion >5 years, spondin-1, vascular endothelial growth factor (VEGF), and von
and 63.2% with nonunion >10 years304; in a systematic review, Willebrand factor (vWF).56 A discussion of the production of
Rutten et  al. evaluated 24 randomized trials in which time to PRP is beyond the scope of this chapter, but the concentration
radiographic fracture union was the most common primary of platelets in PRP may vary according to the procedure used
outcome; their patient population (n = 429) had a mean reduc- and the amount of plasma used to resuspend the platelets. Thus,
tion in healing time of 39.8 days, and the most reduction time the guidelines for PRP use need to be adhered to.313
was seen in fractures with a long natural healing time, but they The Cochrane Collaboration has reviewed the topic on a
could not show a beneficial effect of accelerated functional number of occasions.314,315 In their 2012 review, Griffin and co
recovery or prevention of delayed union or nonunion305; in a authors found only one eligible study that met their selection
retrospective, observational cohort of a convenience sample of criteria. Dallari and colleagues conducted a prospective, ran-
patients with metatarsal fractures less than 1 year old enrolled in domized, controlled study to evaluate enhanced tibial osteotomy
a registry, they found a heal rate of 97.4% for those treated with healing. Thirty-three patients who had undergone a unilateral
ultrasound, which was significantly better than for those treated opening-wedge high tibial osteotomy for genu varum and osteo-
without ultrasound (94.2%)306; Leighton et al. performed a sys- arthritis, with an opening defect of >1 cm on the medial side,
tematic review and meta-analysis of 1441 nonunions treated were enrolled and randomly assigned to three groups: lyophilized
with low-intensity pulsed ultrasound, which produced a heal bone chips with platelet gel were used to fill the defect in Group
rate of 82%, comparable to the heal rate of surgical treatment of A; lyophilized bone chips with platelet gel and bone marrow stro-
noninfected nonunions.307 mal cells were used in Group B; and lyophilized bone chips alone
Schandelmaier and co authors, as part of the BMJ Rapid were used in Group C. At 6 weeks, 12 weeks, 6 months, and 1 year
Recommendations process, created a systematic review of after surgery, the patients underwent a clinical and radiographic
low-intensity pulsed ultrasound for bone healing. Their conclu- evaluation. Histology and histomorphometry were also studied.
sions differed from other such studies; they felt that, based on The “final clinical outcome of lyophilized bone chips with added
moderate-to high-quality evidence from studies in patients with platelet gel or platelet gel and bone marrow stromal cells did not
fresh fractures, LIPUS did not improve outcomes important to differ from that obtained with the use of bone chips alone.”316
patients and probably had no effect on radiographic bone heal- Their report concluded “that there remains insufficient clinical
ing. However, they did state the applicability to other types of evidence to recommend the use of PRT [platelet rich therapies]
fractures is open to debate.308 in treatment of long bone fractures.”314
Interestingly, there have been a number of studies over the However, in the Cochrane Collaboration report, the authors
last several years that looked at the effects of both low-inten- mention that one other study is currently under way involving
sity pulsed ultrasound and parathyroid hormone. Warden and hip fracture patients and “will provide further evidence concern-
colleagues,309 Naruse et al.,310 and Mansjur et al.311 all reported ing the use of PRT in the future.”314 The study they were referring
data utilizing a rat model, which showed the combined treat- to was undertaken by three of the four authors of the Cochrane
ment of PTH and LIPUS may accelerate fracture healing and Collaboration report. This study, the Warwick Hip Trauma Study
enhance bone mechanical properties better than either single (The WHiT Study), was a randomized clinical trial comparing
agent alone.311 We have been using the combination of a LIPUS interventions to improve outcomes in internally fixed intracapsu-
unit and teriparatide for our patients with acute or chronic frac- lar fractures of the proximal femur. The protocol was reported in
tures or delayed union or nonunions. a first paper.317 The design planned was a three-arm, single-cen-
ter, standard-of-care controlled, double-blind, pragmatic, ran-
Platelet-Rich Plasma Therapies domized clinical trial comparison between platelet-rich plasma
Please see the full online chapter for this information and and standard-of-care fixation versus standard-of-care fixation
Chapter 29 for information on use of platelet-rich plasma. alone. The results of the study were reported in a second paper by
Platelet-rich plasma (PRP) therapies are autologous blood the same authors and showed no evidence of a difference in the
products in which the platelets have been concentrated to a level risk of revision surgery within 1 year in participants treated with
greater than normal blood, and they have been used since the PRT compared with those not treated with PRT.318
1990s to promote bone and soft tissue healing.312 PRP can be Although the majority of studies are underpowered and con-
manufactured at the bedside by centrifugation or filtering of a sist of small case series or anecdotal studies, the role of PRT in
patient’s whole blood to produce a small volume of fluid with soft tissue injuries may be completely different than its role in
a supraphysiologic concentration of platelets. Upon activation, bone problems.319
the platelets contained in PRP release the following factors:
ADP and ATP, angiopoietin-2 (Ang-2), connective tissue-acti- Stem Cells
vating peptide III (CATP III), epidermal growth factor (EGF), Many of the stress fracture patients we see are referred for
factor V, factor XI, factor XIII, fibrinogen, basic fibroblast delayed union or nonunion. Therefore, any advances in fracture
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 71

healing are to be noticed, evaluated, and applied, if appropriate, (average), 20 of the 34 stage IV hips required total hip replace-
to the problem of bone repair. Initial enthusiasm for repair by ment; 14 of the lesser stage hips required replacement; most of
human embryonic stem cells has been stalled by many scien- these replacements occurred in the first 3 years after the initial
tific, technical, political, and legal issues, whereas the search has procedure. They developed a procedure to count the stem cells
developed for an “ideal” stem cell for clinical applications. Thus, injected, and there was a significant difference in the number
the present approach has focused on mesenchymal stem cells of colony-forming units obtained from the iliac crest according
(MSCs), which arise from blood, adipose tissue, skin, trabecular to the etiologic factors of the osteonecrosis. Hips that received
bone, and fetal blood, liver, and lung; they have also been identi- a low number of transplanted stem cells had a more significant
fied in umbilical cord blood and placenta. Adult stem cells from risk of failure at the latest follow-up than hips that received a
the bone marrow are considered to have the highest multilineage high number of transplanted cells.321 Hendrich et al. also looked
potential. MSCs were able to differentiate into osteoblasts, chon- at a series of 101 patients of which 37 had osteonecrosis of the
drocytes, and adipocytes. These cells have been well character- head of the femur, 32 avascular necrosis/bone marrow edema
ized biochemically via cell surface markers. Autologous MSCs of other bones, 12 nonunions, and 20 other defects. In the non-
ease the accessibility of these cells for therapeutic needs. The use union, healing of the fracture could be achieved with injection
of stem cell–based therapies for the stimulation of fracture heal- of transplanted cells.322
ing in nonunion has been an area of a great deal of research.320 In a review of studies on the role of stem cells in fracture heal-
Hernigou and Beaujean reported on the treatment of osteo- ing and nonunion, Fayaz and associates put together a series of
necrosis of the femoral head with core decompression followed 208 nonunion cases of which 195 cases were tibial nonunions.
by an injection into the femoral head of aspirated anterior iliac They were treated with concentrated bone marrow aspirates
crest marrow. The etiology of the osteonecrosis in 116 patients prepared by a variety of different methodologies. Eighty-eight
was steroids (n = 18), alcohol (n = 32), sickle cell disease (n = of 100 cases discussed had reported healing323 (Table 4.12).
38), organ transplantation (n = 12), idiopathic (n = 10), and Steinert et al. reviewed 1279 patients from 31 different studies
“others” (n = 6); a total of 189 hips were treated. They were fol- with nonunion, avascular necrosis, distraction osteogenesis of
lowed up for more than 5 years. Marrow was aspirated from the long bones, bone cysts, cartilage, and tendon lesions. They con-
anterior iliac crests with the patient under general anesthesia. cluded that “delivery of MSCs for the repair of bone, cartilage,
The aspirated marrow was pooled in plastic bags containing cell and tendon cells has shown safety and efficacy in several phase
culture medium and anticoagulation solution. The aspirated I clinical trials but large comparative prospective randomized
material was reduced in volume to increase its cell count by clinical trials are required for adequate comparison of the MSC-
removing red cells and plasma to leave the mononuclear cells; based therapies to standard treatment modalities,” and “the
this resulted in a 150-mL marrow aspirate being reduced to a ideal combinations of cell preparation, bioactive factor(s), and
30-mL suspension for injection. At the 7-year follow-up material(s) for each application have to be identified that also

TABLE 4.12  Clinical Evidence for Use of Mesenchymal Stem Cells (MSC) in Nonunion
Study and Year Bone Area of Level of No. of Mode of Administration Healing
Marrow Aspirate Treatment Evidence Patients and Carrier Times Outcomes
Connolly and Tibial nonunion III 100 100–150 mL marrow 6 to 10 Better outcome com-
Schindell osteoprogenitor cells months pared with standard
19867 open iliac crest
grafting.
Healey et al. Patients with III 8 50 mL marrow 4 to 36 Good clinical outcomes
199021 primary sarcomas osteoprogenitor cell weeks. achieved under
that developed delayed difficult clinical
unions or nonunions circumstances
Giarg et al. 15 tibia, 3 humerus, III 20 cases Percutaneous autogenous bone 5 months In 17/20 cases, non-
199314 and 2 ulna nonunions marrow grafting (15–20 mL of union healed
bone marrow)
Goel et al. Tibial nonunion III 20 cases Percutaneous autogenous bone 14 weeks In 15 cases, clinical
200518 marrow grafting (15 mL of bone and radiological bone
marrow union was achieved;
4 cases showed no
sign of union
Concentrated bone marrow Tibial nonunion III 60 cases An average total of 51×103 12 weeks Bony union was
aspirate Hernigou et al. fibroblast colony-forming units was achieved in 53/60
200522 inoculated into each nonunion site patients.

From Fayaz HC, Giannoudis PV, Vrahas MS, et al. The role of stem cells in fracture healing and nonunion. International Orthopaedics (SICOT)
2011;35:1587-1597, Table 2.
72 SECTION 2  Sport Syndromes

meet the desired safety and cost requirements in a satisfactory in ovariectomized rats that also showed enhanced bone mass,
manner.”324 Gomez-Barrena et al. also reviewed the role of cell bone strength, bone formation at the fracture site, and fracture
therapy in bone fracture healing of delayed union and non- healing. These studies suggested that sclerostin-antibody might
union. They concluded, “A major criticism on the available trials have a role in healing osteoporotic fractures.335 Its role in heal-
are the underreported results, which may reflect lack of protocol ing stress reactions, stress fractures, delayed unions, and non-
adherence, patient heterogeneity in small unicentric trials, con- union is at present unknown but, as in the case of other anabolic
founding efficacy results in part due to patient or to protocol agents, might result in off-label use in these settings.
variability, or other issues. Many of these trials do not offer suf-
ficient information about the cell product to correlate with the Clinical Application
results in other trials and many are also impossible to reproduce 1. We would like our athletes to have a calcium intake of 1000–
in other centers due to lack of transparency. However, reliability 1200 mg through diet and/or supplementation; usually, we
is particularly challenged by the size and design of the currently use calcium citrate (usually CitraCal w/D) as opposed to cal-
available trials. Unless large, comparative trials, with well-de- cium carbonate, usually one tablet per day.
fined cell products are published, evidence on this therapy will 2. We would like our athletes to have a vitamin D 3 intake of
remain controversial or even negative.”325 Abou-El-Enein and 2000–4000 IU per day or vitamin D3 50,000 IU (Replesta),
others concluded in their paper that “cell therapies, especially one tablet per week.
autologous therapies, pose significant challenges to researchers 3. We would obtain a 25 vitamin D level by LC-MS/MS (e.g.,
who wish to move from small, probably academic methods of QUEST Diagnostics, #92888) at baseline; probably, >30 ng/
manufacture to full commercial scale. There is a dearth of reli- mL for prevention; probably, 40–60 ng/mL for fracture heal-
able information about the costs of operation, and this makes ing; probably, about 50 ng/mL for optimal athletic perfor-
it difficult to predict with confidence the investment needed to mance (based on studies that we have at this time).
translate the innovations to the clinic, other than as small-scale, 4. Teriparatide (Forteo/Forsteo), rh PTH (1-34), a medication
clinician-led prescriptions…. This evaluation illustrated the that stimulates bone growth, has been used off label to heal
need for cooperative and collective action by the research com- stress reactions, stress fractures, acute fractures, delayed
munity in pre-competitive research to generate the operational unions, and nonunion.
models that are much needed to increase confidence in process 5. Other anabolic drugs, such as abaloparatide (Tymlos) and
development for these advanced products.”326 Thus, although romosozumab (if approved), need adequate further evalua-
frequently utilized as a procedure of last resort, the role of stem tion beyond preclinical studies to find their respective roles
cell transplantation in the healing of stress fractures, especially in fracture healing.
those with delayed union or nonunion, is unclear. 6. It is well established that bone growth stimulators, espe-
cially the Bioventus Exogen bone growth stimulator, using
Romosozumab low-intensity pulsed ultrasound (LIPUS), are useful in help-
(The following is a brief review, as the drug is undergoing eval- ing acute fractures, stress fractures, delayed unions, and non-
uation by the FDA for registration at this time.) unions to heal.
Romosozumab is an antisclerostin monoclonal antibody.
Sclerostin is a product of the osteocyte that inhibits osteoblast
activity. The origin of the agent resulted initially from the rec-
DIET AND NUTRITION
ognition of van Buchem disease in South Africa and scleroste- It goes without saying that diet and nutrition are important for
osis, both of which affect the skeleton in that progressive bone bone health. Over the last 20–30 years, there has been increased
overgrowth leads to gigantism, cranial nerve entrapment, and attention to diet and nutrition at all levels of athletics, including
raised intracranial pressure, but these bone overgrowths also individuals or teams. The issue is: Do we have general principles
seem resistant to fracture.327,328 The genetic defect that pro- that we can bring to patients, and specifically to athletes, espe-
duces these syndromes is identical and has been discovered as a cially those deemed to be at high risk for stress fractures? There
deletion mutation downstream of the SOST gene.329 The mech- is some controversy as to whether individual components of a
anism of action for romosozumab is to bind to sclerostin, which diet or the dietary pattern are more important in the epidemiol-
results in an increase in bone formation. Li and colleagues ogy of general health and bone health.336
showed that sclerostin antibody treatment increases bone for- To review healthy dietary patterns and their effect on frac-
mation, bone mass, and bone strength in a rat model.330 There tures in postmenopausal women, the Women’s Health Initiative
have been a Phase 2 clinical trial and two Phase 3 clinical trials (WHI) conducted an observational study (WHI-OS) that
reported.331–333 All the studies showed a significant reduction examined the indicators and natural history of important causes
in vertebral and nonvertebral fractures and increase in BMD of morbidity and mortality in postmenopausal women. In its
when compared with alendronate or teriparatide. Of interest, entirety, the WHI, initiated by the National Institutes of Health
there has been preclinical work in rats and nonhuman primates. in 1991, consisted of three clinical trials and the WHI-OS; it
In a study by Ominsky et  al., the sclerostin-antibody–treated enrolled over 160,000 postmenopausal women aged 50–79
animals showed increased bone formation without increases years (at the time of enrollment). Women were recruited from
in bone resorption and showed enhanced fracture healing.334 October 1, 1993 to December 31, 1998, and the final study pop-
Liu and colleagues reported on another closed fracture model ulation included 90,014 women who were monitored through
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 73

August 29, 2014, with a median follow-up time of 15.9 years. The first step in the therapy of female eating disorders is to
Nutrient and food intake was derived from self-report through restore normal menstrual cycling and increase BMD by modify-
a WHI food frequency questionnaire (WHI-FFQ), and dietary ing their diet and exercise behavior to increase energy availabil-
quality was assessed using the alternate Mediterranean diet ity by increasing energy intake, reducing energy expenditure,
(aMED) score, the healthy eating index 2010, (HEI-2010), the or both. Menstrual cycles may be restored by increasing energy
alternate healthy eating index 2010 (AHEI-2010), or the dietary availability to more than 30 kcal/kg FFM/day, but increases in
approaches to stop hypertension (DASH) score. These indices BMD may require more than 45 kcal/kg FFM/day.116
were used to assess the extent of adherence to the dietary pat- Rosenbloom reviewed the role of nutrition in the preven-
terns. Incident hip fractures and total fractures (except toe, fin- tion and treatment of stress fractures, making the point that
ger, sternum, and clavicle fractures, which were all excluded) the dietary guidelines for Americans identify four nutrients “of
were assessed. During a median follow-up period of 15.9 years, concern” for Americans, and three of the four—calcium, vita-
2121 hip fractures and 28,718 cases of self-reported total frac- min D, and potassium—are elements related to bone health.
tures were counted. The data supported an association between She looked at specific nutrients and emphasized the need for
the extent of adherence to a healthy diet (and also a high-qual- increased intake of protein because, beyond muscle building,
ity diet), Mediterranean diet, and lower hip fracture risk. it is an important component of bone. She states that protein
Confounding issues of falls and low muscle mass did not change foods popular with athletes include chicken, turkey, egg whites,
the analysis.337 cheese, nuts, dairy foods, and soy.344 She suggested the follow-
There are studies of individual dietary components that ing strategies that she uses as a consulting sports dietitian:
might be of interest to the high-fracture-risk patient. Byberg • “Deliver nutrition seminars to teams on the importance of
et al. studied the intake of fruit and vegetables and their effect on bone health, targeting incoming freshmen, female athletes,
the risk of hip fracture in a cohort of Swedish men and women. and those involved in sports with high risk for stress frac-
Men and women with a zero intake of fruit and vegetables had tures (cross-country, track and field, basketball).
an 88% higher risk of hip fractures than those who took five • Encourage athletes to keep 3-day food [diaries] at the begin-
portions per day, and taking more (eight) portions per day did ning of each season…. Nutrition education materials, forms
not reduce the hip fracture rate further.338 Onion powder has and videos are available….
been reported to reduce bone resorption in rats.339 Dried plums • When analyzing food records and counseling athletes, show
have also been shown to reduce bone resorption in osteopenic them where they could add an additional food or snack to
postmenopausal women.340,341 increase any shortfall nutrients.
The role of diet and nutrition in the prevention, causation, • Use social media (Twitter or Facebook) to educate athletes
and healing of stress fractures is an issue that has been perco- with quick nutrition tips or easy-to-fix recipes.
lating for about 20 years. These studies have been undertaken • Review all vitamin-mineral supplements taken by athletes:
in both soldiers and nonmilitary athletes. Much of this infor- encourage athletes to bring the bottle of supplements they
mation concerns amenorrheic female runners or athletes with use as a teaching tool and to review for any possible banned
the female athlete triad (see also Chapter 28 on the Female substances (although banned substances are unlikely to be
Athlete). In 2014, Mountjoy and co authors published the IOC found in vitamin and mineral supplements, supplements
(International Olympic Committee) consensus statement, that claim to be ‘fat-burning’ vitamins or ‘testosterone boost-
Beyond the Female Athlete Triad on Relative Energy Deficiency ing’ could contain banned substances).
in Sport (RED-S), to delineate the adverse effects of RED-S • Spend time with athletes in the dining hall to educate at the
on the health of athletes. The syndrome of RED-S refers to point of selection or to steer them to more nutrient-rich
impaired physiological function including, but not limited to, choices”344 (Tables 4.13 and 4.14).
metabolic rate, menstrual function, bone health, immunity, Nieves et  al. recruited 125 runners from intercollegiate
protein synthesis, and cardiovascular health caused by relative cross-country teams (n = 55), postcollegiate running clubs
energy deficiency.342 Energy availability is calculated as dietary (n = 70), and road race participants who ran at least 40 miles per
energy intake minus the energy cost of exercise relative to fat- week during peak training times and had to compete in races.
free mass (FFM), and in healthy adults a value of 45 kcal/kg Eligible women were randomly assigned to receive an oral con-
FFM/day equals energy balance.116 To quantitate this problem traceptive or no intervention for 2 years. Extensive questionnaires
in amenorrheic athletes, energy deficits have ranged from -148 were completed, including a modified version of the 97-item
to -652 kcal/day, and amenorrheic athletes have lower energy National Cancer Institute health habits, and a history food fre-
intakes (200–900 kcal/day) than their eumenorrheic colleagues quency questionnaire was used to estimate nutrient intake during
despite similar body weight, body composition, and training the previous 6 months. A customized automated computer anal-
status. Kopp-Woodroffe et al. organized a study of four active ysis program was used to calculate nutrient intake from the ques-
amenorrheic females (age 18–35) who participated in a 20-week tionnaire. They estimated the relationship between the specific
intensive comprehensive evaluation and intervention program. dietary factors and annual rates of change of BMD and BMC.
Exercise was reduced by adding a rest day each week. Each study The 125 runners were followed for stress fracture occurrence for
case is reported in extensive detail. There was improvement in a total of 2792 months (avg. 1.86 years per woman). Seventeen of
the participants’ dietary intakes and energy balance, and in their the 125 participants had at least one stress fracture; 9 occurred in
intake of macronutrients and micronutrients.343 the tibia, 6 in the foot, and 2 in the femur; 4 had a second stress
74 SECTION 2  Sport Syndromes

TABLE 4.13  Nutrients Associated With day were each related to a reduced rate of stress fracture, with the
Bone Health, Food Sources, and Recommended strongest protection coming from higher skim milk consump-
Intakes for Male and Female Athletes tion. Every additional cup of skim milk consumed per day was
associated with a 62% reduced fracture risk (p<0.05); every addi-
Recommended
tional serving of dairy products consumed per day conferred a
Intakesa (per
40% reduction in risk. The authors divined four patterns of nutri-
Nutrient Food Sources Day)
ents: pattern 1: higher consumption of dairy, lower consumption
Protein Eggs 1.2–1.7 g/kg/body
of fat; pattern 2: higher fruits and vegetable consumption, higher
Lean meat weight
fiber and lower fat consumption; pattern 3: higher animal pro-
Poultry
Nuts
tein, higher fat, lower fruits and vegetable, lower fiber consump-
Low-fat milk (dairy or fortified tion; and pattern 4: higher protein (both animal and vegetable).
soy or rice milk) They found that runners with a high-dairy and low-fat intake
Low-fat yogurt (pattern 1) had a significantly reduced risk of a stress fracture
Low-fat cheese (p < 0.05). Calcium intake, skim milk, total milk intake, and num-
Calcium Low-fat milk (dairy or fortified 1000–1300 mg ber of dairy servings per day predicted significant gains in hip
soy, rice, or almond milk) BMD and whole-body BMC; vitamin D intake predicted gains in
Calcium-fortified orange juice spine and hip BMD; and animal protein predicted gains in whole-
Hard cheese such as Parmesan body BMD and BMC. There was a positive relationship between
cheese increased potassium and significant increases in BMD of the hip
Cabbage and whole body and in whole-body BMC. The authors felt that
Broccoli increasing dairy consumption might constitute a simple interven-
Canned salmon
tion that women runners could implement to reduce their risk of
Calcium-set Tofu
stress fracture.345 Examples of forms to assist in taking a nutri-
Vitamin D Wild salmon 600 IU tional history in an athlete are presented in Figs. 4.10 and 4.11.
Egg yolks
Fortified milk, margarine, and
cereal REST AND PHYSICAL THERAPY
Potassium Bananas 4700 mg
A discussion of the role of physical therapy and rehabilitation is
Low-fat milk
White and lima beans
beyond the scope of this chapter. For details, see Rosenthal and
Spinach McMillan.346 See also Chapter 30 and 31.
Lentils
Vitamin K Cooked greens (kale, spinach, 60–75 μg
RETURN TO PLAY (SEE ONLINE CHAPTER
collards) TO VIEW THIS ASSESSMENT AND
Broccoli RECOMMENDATIONS)
Asparagus
Magnesium Whole grains 310–410 mg The decision to return to play is a complex one and has to be
Almonds individualized to the underlying lesion, e.g., high-risk versus
Cashews low-risk stress fractures, the progression to recovery, and the
Spinach state of recovery. Every clinician dealing with sports medi-
Raisin bran cine has had to make or will have to make this decision. In the
Legumes (dried beans and peas) absence of clear-cut evidence-based scientific data or protocols,
Boron Fruit-based beverages No recommendation the return-to-play decisions lack standardization and can be a
Avocado for intake source of confusion for clinicians, athletes, coaches, and admin-
Legumes istrators.347 Therefore, we have to gather what information we
Peanut Butter can from studies that try to review the stress fracture data.
Peanuts Return-to-play considerations are more difficult for athletes
Silicon Grains No recommendation with high-risk stress fractures versus those with low-risk frac-
Vegetables for intake tures (see Tables 4.1 and 4.2). The discussion of the rehabilitation
aRecommended intakes are from the Institute of Medicine, Food, and of the athlete with a stress fracture is beyond the scope of this
Nutrition Board,22 Institute of Medicine, Food and Nutrition Board,29 chapter, but for those interested in developing their own reha-
National Academy of Sciences,32 and Burd and Philips.33 bilitation program, Rosenthal and McMillan supply an excellent
From Rosenbloom, C. Stress fractures in athletes: what is the role of discussion.346
nutrition in prevention and treatment? Nutrition Today: March/April
2013;48(2):81-87. Table 2.
In 2002, the American College of Sports Medicine issued a
consensus statement on the team physician and return-to-play
fracture: 2 in the tibia, 1 in the foot, and 1 in the femur. The second issues. The statement reviewed establishing a return-to-play
stress fractures were not considered in the analysis. Higher intakes process including addressing the safety of the athlete, potential
of calcium, skim milk, milk, and servings of dairy products per risk to the safety of other participants, functional capabilities of
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 75

TABLE 4.14  Bone-Building Snacks for Athletes

Snack Bone-Building Nutrients in Snack
Raisin bran with fat-free milk and banana Calcium, vitamin D, magnesium, potassium, protein, silicon
Almonds and strawberries in vitamin D fortified low-fat yogurt Calcium, vitamin D, magnesium, potassium, protein
Lentil soup with whole grain crackers Protein, potassium, magnesium, silicon
White bean chicken chili with whole-grain bread Protein, potassium, magnesium
Peanut butter sandwich on whole grain sandwich thin with cranberry juice Protein, magnesium, boron
Sports drink with string cheese and whole grain crackers Protein, calcium, potassium, magnesium
Broccoli and carrots with Greek yogurt-based dip Calcium, protein, potassium, silicon
6-in. sub on whole grain roll with sliced turkey topped with spinach and Calcium, protein, vitamin D, potassium, magnesium, vitamin K, silicon
tomato with low-fat milk
Low-fat chocolate milk Calcium, protein, vitamin D, potassium
Scrambled egg with spinach and cheese in a whole wheat tortilla Protein, vitamin D, potassium, vitamin K, magnesium, silicon
Yogurt parfait with mixed fruit and granola Calcium, protein, vitamin D, potassium
Bean burrito with avocado slices Potassium, magnesium
Calcium-fortified orange juice and wheat bran cereal with fat-free milk Calcium, protein, potassium, vitamin D, magnesium, silicon
Trail mix with almonds, cashews, and dried fruit & grape juice Protein, magnesium, calcium, boron
Air popped popcorn with melted margarine and Parmesan cheese Calcium, vitamin D

From Rosenbloom, C. Stress fractures in athletes: what is the role of nutrition in prevention and treatment? Nutrition Today: March/April
2013;48(2):81-87. Table 3.

the athlete, functional requirements of the athlete’s sport, and Creighton and co workers created a three-step decision-based
federal, state, local, school, and governing body regulations model to help a physician resolve issues in return to play. In the
related to returning an injured or ill athlete to practice or com- risk evaluation process, step 1 is evaluation of the health sta-
petition. They also discuss evaluating, treating, and rehabilitat- tus: this considers patient demographics, symptoms, personal
ing injured or ill athletes, and returning an injured or ill athlete medical history, signs (physical examination), laboratory tests
to play. The later phase should confirm the following criteria: (including imaging and, in our evaluation, blood and urine tests,
the status of the anatomical and functional healing; the status especially for bone turnover markers), functional tests, psycho-
of recovery from acute illness and associated sequelae; the sta- logical state, and potential seriousness. Step 2 is evaluation of
tus of chronic injury or illness; the athlete must pose no undue participation risk, which involves type of sport, position played,
risk to the safety of other participants; restoration of sport-spe- limb dominance, competitive level, and ability to protect. Step
cific skills; psychosocial readiness; ability to perform safely with 3 is decision modification, which involves timing and season,
equipment modification, bracing, and orthoses; and compliance pressure from athlete, external pressure, masking the injury, and
with applicable federal, state, local, school, and governing body fear of litigation. The authors felt that the decision-based return-
regulations.348 to-play model would provide a basis for research into the indi-
Beyond the general consensus statement, one must deal vidual factors and components that, when integrated, provide
with the issues of return to play specifically revolving around clinicians with an evidence-based rationale for return-to-play
the issue of stress fractures. Diehl and colleagues, in their series decision making.347 The ethical issues involved in these return-
of articles developing the classification system, also dealt with to-play decisions have been addressed and are of tremendous
issues of return to play.26 They divided treatment into that importance.349,350
of low-risk stress fractures and high-risk stress fractures (see In 2015, the Swiss Sport Physiotherapy Association along
Tables 4.1 and 4.2). They felt that most low-risk fractures could with the International Federation of Sports Physical Therapy
be successfully treated with rest for 2–6 weeks followed by a and the British Journal of Sports Medicine organized a world
gradual increase in activity level of limited weight bearing, pro- congress to issue an updated statement on return-to-sport
gressing to full weight bearing performing low-impact activities (which they considered a more generic term that was intended
such as biking, swimming, or pool walking or running, and use to apply to all sports and all athletes rather than to only team
of an Alter-G machine. After the patient can perform low-im- sports and athletes). Although previous statements had focused
pact exercises without pain for prolonged periods of time, high- on the team physician as the central figure in the decision-mak-
impact activities can be started; usually a program of increas- ing process, this document was more athlete-centered and
ing jogging followed by sport-specific activities. In the high- placed the athlete in the position of an active decision maker.351
risk stress fracture patient, surgical intervention may be Utilizing the Kaeding-Miller stress fracture classification sys-
advisable, or even necessary, including open reduction and tem (discussed in detail in the Classification section29), Miller
internal fixation with or without bone grafting, PRP, stem cell and colleagues looked at the expected time to return to ath-
injection, or anabolic drugs.24 letic participation after stress fracture in Division I collegiate
76 SECTION 2  Sport Syndromes

Wendy Sterling, MS, RD, CSSD

1150 University Drive, Suite 105, Menlo Park, CA 94025
919 Fremont Avenue, Suite 105, Los Altos, CA 94024
www.sterlingnutrition.com
[email protected]
917-568-9695
Nutrition Initial Note

Patient’s Name:
DOB:
DOS:

S:

History of Present Illness:

Weight History:
Max Weight: Date:
Min Weight: Date:
CBW: Height:
UBW:
Goal Weight:
Social:

ED Behaviors: Denies binging,purging, laxatives, diuretics, diet pills, chewing/spitting

DIETARY:

24 hour recall:

7 Day Food Record Notes:

Food Groups Description of foods consumed in each food category

DAIRY
PROTEIN
CARB
FRUIT
VEGETABLE
FAT
SNACKS

Fluids: Water: Soda: Shakes:

Juices: Coffee/Tea: Smoothies:

Alcohol:
Drugs:

Food Allergies:

LMP: PMP: Menarche: Diagnosis:

Body Image:
Preoccupied with food, weight, shape:
Percentage of time thinking about it:
Fear of gaining weight:
Fig. 4.10  Example of forms to assist in taking a nutritional history in an athlete. (Courtesy of Wendy Sterling,
MS, RD, CSSD) Courtesy of Wendy Sterling, MS, RD, CSSD, CEDRD-S.

athletes. They evaluated 57 stress fractures in 38 athletes over the classification system was a reliable prognostic tool for com-
a 3-year period with mean age 20.48 years (range 18–23 years) municating injury severity between clinicians.352
with 10 athletes who sustained recurrent or multiple stress frac- Nattiv and colleagues studied the correlation of MRI grading
tures. The mean time to return to unrestricted sport participa- of bone stress injuries with clinical risk factors and return to
tion was 12.9 ± 5.2 weeks (range 6–27 weeks). A trend toward play in a 5-year prospective study of collegiate track and field
increased time to return to sport was noted in women (13.9 ± athletes. Two hundred eleven male and female Division I cross-
5.7 weeks) compared with men (11.3 ± 3.8 weeks). They felt that country and track and field participants enrolled in the study at
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 77

Wendy Sterling, MS, RD, CSSD

1150 University Drive, Suite 105, Menlo Park, CA 94025
919 Fremont Avenue, Suite 105, Los Altos, CA 94024
www.sterlingnutrition.com
[email protected]
Nutrition Initial Note 917-568-9695

Patient’s Name:
DOB:
DOS:

Distorted body weight:

Exercise Currently:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Exercise History:
Cramper? Yes No

Supplements:

Sleep:

Mood:

Self-harm:

Family History:
Mom:
Dad:

Past Medical History: Past Surgeries:

Bowel Function: GI Symptoms:
Medications:
Calcium:
Multivitamin:
Other:

TEAM:
Therapist: MD: Coach/Trainer:

Anthropometrics: WEIGHT GOAL:

Height: % Height
Weight: % Weight
BMI: % BMI
MBW (@ 50th percentile for BMI): % MBW:

ASSESSMENT:

PLAN:
1.
x Wendy Meyer Sterling, MS, RD, CSSD
#859803
Fig. 4.11  Example of forms to assist in taking a nutritional history in an athlete. (Courtesy of Wendy Sterling,
MS, RD, CSSD) Courtesy of Wendy Sterling, MS, RD, CSSD, CEDRD-S.

the time of the preparticipation at the start of their seasons and a modified MRI grading system described by Fredericson18
were followed prospectively to the end of the study at 5 years for and Arendt.25 Thirty-four (12 males, 22 females) sustained 61
bone stress injuries. When a bone stress injury developed, the bone stress injuries during the 5-year study period. The most
athlete was seen first by an athletic trainer with regard to their frequent sites of injury were the tibia (51%) and metatarsals
injury and then a team physician. If a bone stress injury was (21%). Weeks to full return to sport for grade 4 bone stress inju-
suspected, a radiograph was ordered; if negative, an MRI was ries (31.7 ± 3.7 weeks) were significantly higher compared with
obtained; sometimes an MRI was the initial study. They utilized grade 3 (18.8 ± 2.9 weeks, p = 0.055), grade 2 (13.5 ± 2.1 weeks,
78 SECTION 2  Sport Syndromes

p = 0.001), and grade 1 (11.4 ± 4.5 weeks, p = 0.008) injuries. Umemura and colleagues looked at the effect of different
Weeks for return to sport for grades 3 and 4 bone stress injuries jumping regimens in 5-week-old rats who were divided into a
were significantly higher than grades 1 and 2 injuries (23.6 ± 2.4 control group and five jump-trained groups who performed 5,
weeks versus 13.1 ± 2.0 weeks, respectively, p = 0.002). Among 10, 20, 40, and 100 jumps per day. They jumped 5 days per week
grade 3 and 4 injuries, time to return to play was significantly for 8 weeks. Each jump took about 3 seconds. After the 8-week
longer for those at bone sites high in trabecular bone versus sites trial, the rats were sacrificed and the right femur and tibia were
high in cortical bone (38.1 ± 6.4 versus 18.8 ± 2.1 weeks, p = dissected and subjected to a number of tests, including bone
0.005). In those with grade 1 and 2 injuries, there was no differ- mass and bone morphometry. Measuring the fat-free femur and
ence in time to return to play between injuries at bone sites high tibia weights, it became apparent that there was a significant dif-
in trabecular bone versus cortical bone (17.1 ± 9.1 versus 12.7 ference between controls and the 5-jump threshold. There was
± 1.6, p = 0.75). In addition to MRI grade, total body BMD and not much difference between the 5-jump group and the other
bone stress injuries of trabecular bone regions of interest in the jump groups, although the 100-jump group weight was slightly
femoral neck, pubic bone, and sacrum were the most important greater (21.9% increase). The cortical area and periosteal perim-
independent predictors of return to play. While many studies eter were markedly increased by the jump training. For these
have found that a lower BMD is predictive of increased risk for and other reasons, jump training (which took a few seconds to 5
stress fracture, this study found that a lower BMD is predictive minutes in the 100-jump group) is more effective in producing
of return to play (longer recovery time). Clinically, the authors bone hypertrophy than running (which in these experiments
concluded that trabecular bone stress injuries were associated usually takes 30–60 minutes).354
with a significantly longer time to return to play than cortical Robling, Burr, and Turner, in a further attempt to iden-
bone stress injuries, which should help physicians and training tify the exact mechanical signal to which bone adapts, stud-
staff to utilize a more gradual progression of return to play with ied the effect of partitioning a daily mechanical stimulus into
activities like Alter G machines or endless pools. discrete loading bouts and showed this improved the osteo-
genic response to loading. As stated previously, the osteogenic
response to dynamic loading desensitizes after relatively few
PREVENTION cycles.355,356 These authors studied whether the bone formation
In 1987, Giladi, Milgrom, and their cohorts, from their studies response to mechanical loading could be increased by applying
on the IDF, showed a statistically significant difference in the multiple bouts of four-point bending within a 24-hour period
mean mediolateral width of the tibia at different measurement as opposed to one continuous loading event. Sixty-three adult
levels in recruits with and without stress fractures. Standard female Sprague-Dawley rats were randomly divided into 7 groups
radiographs were taken using a magnification ruler of total tibial (n = 9) including four bending groups, two sham bending groups,
width and cortical width in both anteroposterior and mediolat- and one nonloaded control group. A standardized limb-bending
eral planes at three levels in each bone: at 8 cm above the ankle device was employed. Load cycles (360 per day) were applied
joint, at the point of the narrowest mediolateral width, and at to the rat right tibia on days 1, 3, and 5 of the experiment. The
the point of the narrowest anteroposterior width. During the groups differed from each other only in the distribution of the
basic training, 91 of the 295 recruits (31%) were found to have delivered cycles over the course of the day. On each loading day,
one or more stress fractures. Of the total of 184 stress fractures, one group of rats received 60 cycles of bending in each of six
51% were in the tibial diaphysis, 5% in the tibial plateau, 21% in discrete loading bouts (60 x 6), each bout separated by 2 hours;
the femoral diaphysis, 9% in the supracondylar region, and 4% another group received 90 bending cycles in four discrete loading
in the femoral condyles. All of the tibial and femoral diaphyseal bouts (90 x 4), each bout separated by 3 hours; the next group was
fractures were in the medial cortex. For example, at the nar- given 180 cycles of bending twice a day (180 x 2), with the bouts
rowest mediolateral measurement, those with stress fractures separated by 6 hours; and the last bending group received all 360
measured 23.8 ± 2.1 mm (n = 86) and those without stress frac- bends in one bout (360 x 1). The left tibia served as a control, and
tures measured 24.6 ± 1.8 mm (p = 0.001). It was felt that wider there were also sham bending groups. All bending groups exhib-
tibias should have greater resistance to bending, and resistance ited significantly greater mineralizing surface, mineral apposition
to compression and tension would also be greater, since a larger rate, and bone formation rate in the loaded tibias than in the
cross-sectional area results in better distribution of the strain unloaded tibias. By applying the 360 bending cycles in four dis-
forces created by activity over a greater area. The authors stated crete bouts (90 x 4) rather than one bout (360 x 1), the following
that the decreased tibial width was “the first physical parameter increases occurred: 71% increase in relative mineral apposition
of the bone to be identified as a risk factor” for stress fractures.43 rate, 80% increase in relative bone formation, and 94% increase
Thus, the concept arose of preventing stress fractures by build- in mineralizing surface. The 180 x 2 and the 60 x 6 groups had
ing wider bones39 and, therefore, stronger bones. lesser changes. Thus, the results show that 360 cycles per day
The role of prevention of stress fractures and the mecha- cause a much greater bone formation response if those cycles
nisms underlying the attempt to do so has been reviewed in a are divided into different bouts with an interruption. By adding
variety of preclinical trials. Bone desensitizes rapidly to a load- a rest period between bouts, the bone cells appear to lose some of
ing (dynamic strain stimulus) regimen where bone cells accom- their desensitization and regain some of their mechanosensitiv-
modate to routine loading and the exerciser develops a situation ity. For the same number of cycles, providing more “rest” periods
that Turner calls “diminishing returns.”353 result in more bone formation due to an increase in mineralizing
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 79

surface and mineral apposition rate. In conclusion, the authors Continuing the development of this line of research, Robling
remark, “These data support the concept of a saturation curve for and colleagues studied bone structure and strength after long-
bone cell mechanosensitivity and suggest that physical activity term loading and found it was improved the most if loading was
programs aimed at maintaining or improving bone mass can be separated into short bursts. With a similar study protocol, they
optimized by scheduling mechanical loading bouts (exercise ses- studied ex vivo strain gauging, peripheral QCT, micro-CT, and
sions) so that most of the load cycles occur during a time when mechanical testing to the rat ulna diaphysis curvature after their
the bone cell network is highly mechanosensitive. This probably dynamic loading of 360 cycles delivered in one single bout and
would entail several shorter intervals of daily exercise, rather than 90 cycles delivered in four bouts with 3 hours between each bout.
a single sustained session.”357 Three-dimensional reconstructions of the micro-CT whole ulna
The same authors extended their work on desensitization slices showed that the right (loaded) limb was significantly dif-
(or adaption), recovery periods, and the restoration of mech- ferent from the left (nonloaded) limb. The loaded bones had
anosensitivity to dynamically loaded bone. As they showed significant mediolateral thickening of the diaphysis near the
previously, recovery periods, as marked by intervals between midshaft and the distal shaft. The 90 x 4 group had significantly
bending cycles, are necessary to restore mechanosensitivity to greater improvement in the measurement of geometric prop-
mechanodesensitized cells, but they questioned how much time erties, e.g., the maximum and minimum second moments of
cells require in vivo to become fully resensitized after a loading area (Imax and Imin), than the 360 x 1 group. Percent differ-
bout. They took another group of rats and exposed them to the ence (right versus left) in ultimate force and energy to failure
same 360 loading cycles with the same loading device. Then, was also significantly different, by 35% and 75%, respectively, in
they introduced recovery periods of 0.5 seconds, 3.5 seconds, 7 the 90 x 4 group. So, biomechanical properties were increased
seconds, or 14 seconds. The 0.5 second group was loaded for 18 by loading. The loaded ulnas exhibited 5.4% and 8.6% greater
seconds; the 3.5 second group was loaded for two minutes; the 7 areal BMD (DXA) in the 360 x 1 and 90 x 4 groups, respec-
second group was loaded for 4 minutes; and the 14 second group tively. These “small” gains in aBMD and BMC resulted in “very
was loaded for 8 minutes. Each bout consisted of 90 load cycles. large” increases in ultimate force (64%–87%) and energy to fail-
Among the bending groups, the four daily loading bouts were ure (64%–165%). The authors summarized their work by stat-
separated by 0, 0.5, 1, 2, 4, or 8 hours of recovery. There were ing that “it might be possible to significantly enhance fracture
both short-term and long-term recovery experiments. Longer resistance through mechanical loading (e.g., exercise) even if
recovery periods resulted in higher bone formation rates. In some of the noninvasive measurements of bone mass or den-
tibias allowed 8 hours of recovery between each of the loading sity (e.g., DXA) reveal only slight changes. For example, most
bouts, bone formation rates were 125% greater than the rates exercise intervention studies yield differences in aBMD of only
found in rats that had received four bouts with no recovery time a few percent at most, but it is not known how such interven-
between bouts (0-hour group) and 102% greater than the rates tion affects fracture susceptibility. [Their] data suggest that bone
found in animals who had received four loading bouts with 0.5- strength can be enhanced substantially from small changes in
hour recovery time between bouts. Calculation of the recovery BMD or BMC if bone is added to the mechanically appropriate
curve beyond 8 hours revealed almost no further increase in (high strain) sites.”359
sensitivity with increasing recovery duration. “Thus, a recovery Hughes and her group also dealt with clinical issues for pre-
period of approximately 8 h[ours] is sufficient to restore full vention of stress fractures. They reviewed the data on building
mechanosensitivity to the cells.” Mineralizing surface and bone wider bones. The only modifiable, nonpharmacological way
formation rate were significantly higher (66%–190%) in the 14 to increase the width of long bones is via physical training.
second group than in any of the other three bending groups. Thus, the hypothesis was proposed that before beginning either
The results in the short-term experiment suggested the exis- basic training in the military or formal training as an athlete,
tence of a short-term recovery threshold somewhere between 7 pretraining might be instituted to stimulate adaptive bone for-
and 14 seconds. By increasing the duration of recovery between mation.39 Two early studies seemed to indicate this was not so:
loading bouts, a greater degree of sensitivity is restored to the Mustajoki et  al. in 1983 felt their prospectively obtained data
cells. Approximately 8 hours of recovery is adequate to restore on 103 men from the Parachute Ranger School of the Finnish
full sensitivity. Although suboptimal, shorter recovery peri- Defense Forces suggested that previous physical activity (not
ods (0.5–1 hour) allow more bone formation than no recovery specifically stated as to what activity they were referring) did
period at all (0-hour group). The 2001 paper stated that the cel- not affect the risk of stress fractures in military recruits.46 Swissa
lular mechanisms involved in mechanosensory loss and recov- and colleagues conducted an early IDF study of 295 new male
ery and those involved in short-term recovery phenomenon are infantry recruits, where 79 (28%) out of 279 recruits who were
unclear.358 But in the context of newer information discussed interviewed did not participate in any sport activity prior to
elsewhere in this chapter, it is possible that osteocytes, known basic training, 160 recruits (57%) participated in running and
mechanosensors and mechanotransducers of the skeleton, play jogging, and the remaining 58 recruits (21%) participated in
a role. The authors conclude: “Physical activity programs used various sports, usually basketball or soccer. In their analysis, no
as prophylaxis for bone loss might be met with greater success if correlation was found between pretraining sport activity and
appropriate recovery periods were structured into exercise pro- stress fractures.47 Newer studies and reviews contradict these
grams.”358 The same might be said for programs developed to findings and support the original hypothesis: Milgrom and
prevent stress fracture occurrence. Shaffer360 and Milgrom et al.45 in further carefully documented
80 SECTION 2  Sport Syndromes

studies of IDF recruits found, as previously discussed, that the component and a “forced desynchronization” component in which
incidence of stress fractures was 28.9% among those who did the sleep-wake cycle was separated from the internal circadian
not play ball sports and 13.2% among those who played ball cycle. This was accomplished by scheduling recurring 28-hour
sports for at least 2 years before induction in a first epidemio- sleep–wake cycles with a 21.47-hour wake episode and a 6.53-hour
logic study (1988 induction group); 27% among those who did sleep opportunity (equivalent to 5.6 hours of sleep opportunity
not play ball sports and 16.7% among those who played ball per 24 hours) over approximately 3 weeks. Therefore, participants
sports in a second epidemiologic study (1990 induction group); experienced circadian disruption (i.e., a mismatch between the
and 18.8% among those who did not play ball sports and 3.6% internal clock and the external environment). Serum for this study
among those who played ball sports for at least 2 years in a was obtained hourly from the participants who were admitted to
third epidemiologic study (1995 induction group). Playing ball individual suites in the Intensive Physiological Monitoring Unit
sports for less than 2 years had no protective effect; swimming of the Center for Clinical Investigation at Brigham and Women’s
provided no protective effect; the number of kilometers run Hospital between 2007 and 2010 over a 24-hour period on days
per week was also not protective. The major ball sport that was 5 and 6, at the baseline and at the end of the forced desynchrony
protective was playing basketball three times per week. In the period, referred to as postintervention. They measured four bone
chapter by Milgrom and Shaffer, they state that over the three biomarkers, including serum C-telopeptide (s-CTx) as a marker of
periods of time involved in these studies, the sport of basketball bone resorption, the N-terminal propeptide of type I procollagen
replaced soccer as the primary ball sport in the country, and this (P1NP) as a marker of bone formation, and sclerostin and fibro-
resulted in a significantly lower incidence of stress fractures.360 blast growth factor 23 (FGF 23) as measures of osteocyte function.
The only two papers that try to deal with the application of Without going into further description of the details of the sleep
the principles of prevention to reduction in stress fractures both studies, the authors found a lower P1NP and no change in s-CTx
apply to the IDF.45,355 I have been unable to find any papers that after 3 weeks of circadian disruption and sleep restriction creating
apply this basic science information to an athlete population, a “bone loss window.” Their study suggests that the changes were
but we can make some inferences to help from the basic science greater in the six younger individuals (20–27 years, mean 23.5) than
information so far developed. In 2008, Finestone and Milgrom the four older (55–65 years, mean 58.75) individuals. “If sustained,
reviewed their 25-year effort to lower the stress fracture inci- these alterations in bone metabolism induced by sleep/circadian
dence in the IDF. The first step toward lowering the incidence disruption could result in suboptimal peak bone mass, bone loss,
of possible stress fractures is to develop as comprehensive a osteoporosis, and fracture.”362 The decrease in P1NP is “of similar
list of risk factors for stress fractures as possible. Narrow tibias magnitude to the expected increase in P1NP seen with responders
were found to be a risk factor for both tibial and femoral stress to teriparatide treatment,”362 indicating that bone formation may be
fractures. The reason the narrower tibia is a risk factor is that preferentially affected by sleep and circadian disturbances. Perhaps
increasing the diameter of the bone from 2 to 2.5 cm increases an important reason for microdamage accumulation is that, while
the bending and rotational strength by 126% and the compres- bone resorption cannot clear all the microdamage that occurs, the
sion strength by 51%. External rotation of the hip greater than defect may be that bone formation cannot repair the deficit left by
65° was found to be a risk factor. The narrow tibia and hip rota- the bone resorption. In the IDF studies, not all soldiers responded
tion are independent risk factors, and combining them allowed equally; 40% of the recruits in the sleep-deprivation and verti-
profiling of those at high risk for stress fractures. As previously cal-sleep groups had increased bone markers (“responders”) while
discussed, basketball was found to be a deterrent and long-dis- 60% did not have increased bone turnover measurements (“nonre-
tance running was not. They found a discrepancy between the sponders”).176 While the increased occurrence of stress fractures in
laboratory bench studies as reported and the in  vivo human basic training is likely due to multiple different factors, “these data
bone strain recordings, so this led them to the hypothesis that may explain part of the pathophysiology underlying these injuries,
tibial and femoral stress fractures are mediated by bone remod- and the incidence of stress fractures during basic training may be
eling.45 The authors then took a look at the amount of sleep the partially mitigated by sleep extension or at least minimizing the
recruits had and its effect on stress fracture incidence. Among interval during which recruits are exposed to sleep/circadian dis-
the sleep-deprived recruits, bone turnover markers increased turbance.”356 Therefore, the IDF decided to strictly enforce a mini-
by 170%, and in those who slept in a vertical position they mum 6-hour sleep requirement during basic training.356 Qvist and
increased by 68%. Because this study was performed in the early colleagues, in their study of the circadian variation in the serum
1990s, urinary hydroxyproline was measured as a bone turn- concentration of s-CTx and the effects of gender, age, menopausal
over marker.356 status, posture, daylight, serum cortisol, and fasting, found that
The understanding of the importance of sleep and bone metab- s-CTx should be obtained in the fasting state.175
olism is increasingly recognized.176,361,362 Studies suggest that there The effect of sleep deprivation on athletic performance
is a diurnal circadian rhythm for serum C-telopeptide (s-CTx), has definitely been shown in multiple settings.363 Mah and
indicating sleep is essential for normal bone function and that coauthors from the Stanford Sleep Disorders Clinic and
sleep or circadian disturbance could directly affect bone physiology Research Laboratory studied 11 healthy students from the
and metabolism.175 Swanson et al. studied bone turnover markers Stanford University men’s varsity basketball team. The ath-
after sleep restriction and circadian disruption as a mechanism for letes maintained their habitual sleep–wake schedule for a 2- to
sleep-related bone loss. They recruited 11 healthy men, aged 20–65 4-week baseline period followed by a 5–7-week sleep exten-
years, to a complex sleep study that included both a “sleep satiation” sion period, with a minimum goal of 10 hours in bed each
 CHAPTER 4  Medical and Metabolic Considerations in Athletes With Stress Fractures 81

night. Total objective nightly sleep time increased during sleep prospectively, it was thought this would help. Second, there was a
extension compared with baseline by 110.9 ± 79.7minutes (p change in the infantry boot. Third, they added a physical therapist
< 0.001). Subjects demonstrated a faster timed sprint following to the unit.
sleep extension (16.2 ± 0.61 seconds at baseline versus 15.5 ± Again, some of these changes would be of value to the elite
0.54 seconds at the end of sleep extension, p < 0.001). Shooting athlete but others might not be applicable. In addition, in an IDF
accuracy improved, with free throw percentage increased study, infantry recruits whose march distance was increased more
by 9% and 3-point field goal percentage increased by 9.2% gradually during basic training than a control group sustained
(p < 0.001). The Psychomotor Vigilance Task and the Epworth the same incidence of stress fractures but over a more extended
Sleepiness Scale both decreased following sleep extension (p < period of training.356 Although the role of some of the rat stud-
0.001), and the Profile of Mood States improved with increased ies is unclear, the study that shows an interval in the training
vigor and decreased fatigue subscales (p < 0.001). The players regimen for 3 hours probably has some relevance to the human
also reported improved overall ratings of physical and mental condition. But whether a variation of a high-intensity interval
well-being during practice and games. The authors concluded training (HIIT) is better than the usual training programs cur-
that “optimal sleep habits and obtaining adequate sleep will play rently employed for the prevention of stress fractures is unclear.
an important role in peak performance in all levels of sports.”363
There is, as yet, no reference that shows that poor sleep habits Clinical Application
in athletes leads to an increased incidence of stress fractures; 1. The preclinical science studies delineate some information
this is an area that needs research. If we look at the IDF find- about ways to exercise, such as breaking up a session into
ings, it certainly seems like poor sleep hygiene could potentially multiple shorter exercise periods per day with several-hour
contribute to poorer bone health and stress fractures. What it intervals between sessions (recovery periods).
means is that physicians and health care professionals taking 2. Very modest changes in aBMD or BMC can translate into
care of stress fracture patients need to ask about sleep habits. large changes in mechanical properties because mechanical
Sleep health should be incorporated into training programs, loading tends to add bone to the most structurally relevant
based on the individual needs of the athletes, and if there is a sites. This does not necessarily happen with pharmaceutically
recognized or perceived problem, the athlete may need to be induced bone formation. For example, teriparatide (Forteo)
referred to a sleep health professional. adds bone primarily to the endocortical and trabecular sur-
In 2017, Milgrom and Finestone summarized all their work, faces where it contributes little resistance to bending.362
again, on stress fracture interventions aimed at prevention of stress 3. Warden et al. set forth steps for targeting exercise toward the
fractures as it applied to a single elite infantry unit.356 Of course, skeleton to increase bone strength. They made some sugges-
the concept of prevention is based upon not exceeding the loading tions: Step 1: start young; Step 2: select dynamic, high-impact
or repair potential of bone. It is easier to deal with these issues in a exercises; Step 3: exercise the bones you want to strengthen; Step
military unit, whereas it is impossible to know, at our present state 4: exercise briefly but often; and Step 5: continue exercising as
of knowledge, what these thresholds are in an individual athlete, you age.364
but there may be more variability of body type, body composi- Burr (personal communication), in response to a question
tion, and bone density in a NFL team than in an IDF elite infantry about designing the ideal exercise program to reduce stress
unit.123 Studies were undertaken during the 14-week basic train- fractures, felt that “a small amount of exercise, several times
ing of the same elite IDF infantry unit in 1983, 1988, 2002, 2006, per day (with 4–6 hrs between bouts) is the most beneficial for
2007, 2011, 2012, 2013, and 2015. In all of the studies, the basic building bone because bone cells have a refractory period after
training was done in the winter (daily January temperature about a fairly small amount of loading. Therefore, to build bone spe-
60–70° F). In 1983 and 1988, the training was performed on a topo- cifically, requires perhaps a few hundred cycles of jogging/run-
graphically very hilly base; but, starting in 2002, the training was ning, repeated 3–4 times per day with 4–6 hr intervals between
moved to a topographically flatter base—a significant first change. [bouts]”. This would also prevent the muscle fatigue–related
The cumulative formal march distance in 1983 and 1988 during negative effects of longer periods of exercise that cause increased
the 14 weeks of basic training was 548 km (340.5 miles); beginning strain and strain rate on bone, and can cause bone damage.
in 2002, the march distance was decreased by one-third to 348 km
(216.2 miles). So the second change that was made in the IDF train- CONCLUSION: STRESS FRACTURES
ing was a decrease in the recruits’ cumulative marching and run-
ning.356 These two changes had a statistically significant association Lessons Learned After 20 Years of Treating Stress
with a decreased incidence of stress fractures.356 Another change Fractures, Delayed Unions, and Nonunions
introduced was the development of an authorized training protocol 1. In cases of acute fracture, a modest metabolic/endocrine
to be followed by the units. By multivariate analysis, the only stress workup is indicated, including 25 hydroxy-vitamin D, para-
fracture training intervention that had a statistically significant thyroid hormone, calcium, and phosphorus that should be
association with lowering the occurrence of stress fracture during obtained in addition to appropriate imaging.
the observation period of 1983 to 2015 was restricting training to 2. In cases of delayed union or nonunion, a comprehensive
the “authorized training protocol.” In 2011, three changes were metabolic/endocrine workup is indicated, as proposed,
made to the training regimen. First, a mandatory 7-hours-a-night and includes bone turnover markers, at least P1NP and
sleep regimen was enforced; even though this had not been studied sCTx.
82 SECTION 2  Sport Syndromes

3. Teriparatide should be initiated as 20 μg subcutaneously 7. Skarda LE. Stress Reactions of Division-I Track Athletes. Diss
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4. LIPUS should be used twice a day (every 12 hours) until
9. Stechow A. Fussoedem und roentgenstrahlen. Disch Mil-Aerzil
fracture is healed.
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mechanosensitivity to dynamically loaded bone. J Exp Biol [In- 364. Warden SJ, Fuchs RK, Turner CH. Steps for targeting exercise
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structure and strength after long-term mechanical loading is
 5
Problematic Stress Fractures
of the Foot and Ankle
Christopher E. Gross, James A. Nunley

OUTLINE
Introduction, 95 Stress Fracture of the Hallucal Sesamoids, 100
Stress Fracture of the Tarsal Navicular, 95 Anatomy and Presentation, 100
Anatomy and Presentation, 95 Imaging, 101
Imaging, 96 Treatment, 101
Treatment, 97 Stress Fracture of the Fifth Metatarsal, 101
Stress Fracture of the Base of Second Metatarsal, 97 Anatomy and Presentation, 102
Anatomy and Presentation, 97 Imaging, 102
Imaging, 97 Treatment, 102
Treatment, 97 Conclusion, 103
Stress Fracture of the Medial Malleolus, 98
Anatomy and Presentation, 98
Imaging, 99
Treatment, 99

PEARLS athletes with these injuries.4 (See also Chapter 3—Stress Fractures:
Their Causes and Principles of Treatment; Chapter 4—Metabolic
1. Subtle, unexplained pain in the foot or ankle in an athlete can be a stress
fracture.
Assessment and Treatment in the Athlete; and Chapter 28—Unique
2. Stress fractures of the medial malleolus may be associated with pathologic Considerations for Foot and Ankle Injuries in the Female Athlete.)
varus coming from the knee, ankle, or hindfoot. If surgery is warranted, the The insidious onset of ill-defined foot and ankle pain is the
underlying biomechanics leading to the stress fracture need to be addressed. main culprit in the delay of diagnosis. Understanding the bio-
3. Navicular stress fractures can occur in both the competitive and recre- mechanics leading to such injuries, the means of diagnosis, and
ational athlete. the execution of treatment should be requisite in the armamen-
4. Metatarsal base stress fractures in elite athletes must be treated aggres- tarium of physicians treating athletes.
sively because they can place one’s career at risk.

STRESS FRACTURE OF THE TARSAL NAVICULAR

INTRODUCTION Tarsal navicular stress fractures account for one-third of all
A stress fracture is a complete or incomplete fracture of bone stress fractures.2,5 However, navicular stress fractures remain an
secondary to failure over a prolonged period due to repetitive elusive and poorly understood facet of dorsal midfoot pain in
microtrauma and submaximal stresses. While these fractures sports. Primarily diagnosed in running athletes,2 its incidence
are relatively rare, they can pose a significant barrier to perfor- has risen from 0.7%–2.4% in the 1980s6,7 to more recently1,2,5 at
mance and function in the athlete and non-athlete alike if not 14% to 35% of all foot an ankle stress fractures. It is unclear why
properly diagnosed and managed in a timely fashion.1 such the rapid rise in the incidence; it may be due an increase
Stress fractures differ from acute fractures in that their course in better imaging modalities and a higher index of suspicion.8
generally is more gradual with oftentimes an elusive radiographic Navicular stress fractures are not to be taken lightly. In an epide-
appearance. Stress fractures of the foot and ankle are common in miological NFL Combine study, players with these injuries had a
running athletes, especially those who jump. For example, track greater probability of not being drafted and not competing in at
athletes, ballet dancers, and basketball players have a high inci- least two NFL seasons when compared with matched controls.9
dence of stress injury.2,3 Many studies have implicated biomechani-
cal factors, such as leg-length discrepancies, cavus foot deformities, Anatomy and Presentation
and limb malalignment. Women have a higher incidence of stress The tarsal navicular serves as a keystone in the medial longitu-
fractures, and amenorrhea often is a concomitant finding in female dinal arch and consequently is subjected to tremendous forces
95
96 SECTION 2  Sport Syndromes

through the foot. Moreover, nutrient arteries arising from both onset of pain during activity occurs sooner and rest does not
the anterior and posterior tibial arteries create a generous sup- offer a respite. Eventually, the dorsomedial pain (over the “N”
ply of blood to the medial and lateral thirds of the navicular. spot) limits sports and as activities of daily living. (Fig. 5.1)
The result is a poorly vascularized zone in the middle third of
the bone as described by Waugh in 1958.10 Recently, this arte- Imaging
rial anatomy has been called into question, as a recent study Stress fracture of the tarsal navicular is often overlooked due
demonstrated a robust intraosseous vascular supply in 59% of to radiograph’s poor sensitivity (33%).5 An anteroposterior
adult cadaveric specimens.11 Factors other than vascularity may view of the foot can show: sclerosis of the proximal border of
predispose the navicular to a stress injury, such as the location the navicular; a short first metatarsal; metatarsus adductus and
of the navicular, sandwiched between the talar head and the hyperostosis; and stress fracture of the second, third, and fourth
cuneiforms. Lateral shear forces are generated during running, metatarsals. Most fractures are linear, lie in the middle third of
as the medial aspect of the navicular has its stress shared by the the navicular, and can be complete or partial.17 Oblique or supi-
talar head.12 nated radiographs can be useful (Fig. 5.2).
Misdiagnosis of stress fracture of the tarsal navicular generally Radionuclide bone scanning has 100% sensitivity and high
is the rule rather than the exception, as the average time to diag- positive predictive value.13,18–20 Uptake generally will appear in
nosis is 6–8.8 months.13,14 There are several sources of midfoot the shape of the navicular on the plantar view. Although radio-
pain that are more common, including anterior tibial and poste- nuclide scanning can assist in localizing the area of concern to
rior tibial tendinitis, spring ligament injury, Lisfranc sprain, and the navicular, definitive diagnosis and definition of the fracture
degenerative joint disease.15 Therefore, unrelenting symptoms in pattern require magnetic resonance imaging (MRI) or a com-
the seemingly normal midfoot merit further diagnostic workup. puted tomography (CT) scan.
Towne et  al. first reported stress fracture of the navicular The typical fracture is an incomplete fracture in the central
in humans in 1970.16 In this series of two patients, each was a one-third with the fracture line extending obliquely from dorsal
distance runner who had experienced midfoot pain with swell- lateral to plantar medial on CT scan.17 A useful CT classifica-
ing and failure to respond to conservative therapy. Plain radio- tion,21 based on coronal cuts is as follows:
graphs were negative, and only specialized studies were able to Type I: Dorsal cortex fracture
reveal the occult fracture. Type II: Extension into the body
Clinically, an athlete complains of a slow but progressive Type III: Extension from dorsal to plantar cortex
onset of medial dorsal foot pain that radiates along the medial While MRI scans have a high sensitivity, CT scans can more
arch. Initially, this is experienced only during sports and is accurately diagnose a navicular stress fracture.14,18 However,
relieved by rest. Certain activities can increase the pain, such MRI is better able to show edema patterns and a medullary
as cutting, sprinting, pushing-off, and jumping. After time, the extension of the fracture.

Fig. 5.2  An oblique radiograph of the tarsal navicular demonstrates a

Fig. 5.1  Examination of a foot for the “N” spot. stress fracture.
 CHAPTER 5  Problematic Stress Fractures of the Foot and Ankle 97

Treatment The nature of this injury is due primarily to the unique biome-
Treatment at our respective institution is based on CT findings, chanics of ballet and specifically to the incredible stresses placed
athletic participation level, and the patient’s functional status.8 on the midfoot when the dancer is in the en pointe position. When
Complete elucidation of the fracture pattern is important in dic- en pointe, the ballerina (male dancers dance only on demi-pointe)
tating management of the athlete. Patients with incomplete and stands on the tips of her toes with the foot in maximal plantar-
nondisplaced/incomplete fractures (Type I) typically respond flexion.13 Consequently the mechanical axis of the lower extrem-
well to conservative management. We typically treat patients in ity is directed straight through the plantarflexed foot. The middle
a nonweight-bearing cast for at least 6 weeks, followed by a pro- cuneiform serves as a keystone in an arch-type configuration. The
tected weight bearing in a cam boot for 2–4 more weeks until base of the second metatarsal is countersunk into this keystone.
pain is no longer present. Furthermore, the plantar ligaments create tensile forces about the
Athletes with Type II or any patient with Type III fractures, second metatarsal at push-off during normal gait. This anchor of
patients with displaced fractures, or those who have failed non- the proximal second metatarsal generates a substantial stress riser
operative management benefit from bone grafting with open at the junction of the metaphysis and diaphysis when the dancer
reduction and internal fixation (ORIF). We prefer to use either is en pointe. Treatment can be as simple as restricted dance with a
two 4.0-mm cannulated screws or two cannulated headless com- moratorium on en pointe maneuvers until union is achieved.
pression variable pitched screws to provide fixation after gently
debriding and reducing the fracture. Most of these athletes will Imaging
return to sport within 5 to 7 months. High-performance career The evaluation of the painful foot in a ballerina must include
athletes and the treating surgeon may elect a more aggressive weight-bearing views of the foot and ankle. O’Malley et al.23 rec-
approach to nondisplaced fractures. In a recent study by Saxena ommended a specialized view called the posteroanterior danc-
et al.14 patients who underwent ORIF had a return to activity 4.6 er’s view. The dancer’s foot is placed with the dorsum on the
months compared with those who had undergone nonoperative cassette to eliminate overlap of metatarsals. Approximately 30%
treatment, who had an average return to activity of 4.0 months. of plain films will demonstrate a stress fracture. Bone scintigra-
phy is positive in 100% of second metatarsal stress fractures; yet
STRESS FRACTURE OF THE BASE OF SECOND Harrington et al.26 reported positive bone scans in two of their
patients diagnosed with synovitis of the second tarsometatarsal
METATARSAL joint. The role of MRI has not been clearly defined, but it is used
A base of the second metatarsal stress fracture is an often mis- routinely in our practices, as it can show edema as early as 2–8
diagnosed condition that seemingly is exclusive to elite-level days following the onset of symptoms.24 CT with fine cuts also is
ballet dancers. However, fractures of the other metatarsals also an effective method to demonstrate a stress fracture of the base
are seen in new military recruits and running athletes.22 The of the second metatarsal. Differentiation can help to direct a less
unique biomechanics of ballet dancing, coupled with the high disruptive management routine for professional dancers. For
incidence of hypoestrogenism among female performers (see example, nonsteroidal treatment and dance modifications for
Chapter 28 on unique considerations for foot and ankle injuries traumatic synovitis may seem more attractive to a professional
in the female athlete), generates an environment conducive to dancer than 6 weeks of rest. A large cohort of patients experi-
stress fracture of the base of the second metatarsal. High-level enced good results following external shockwave therapy.24
ballerinas generally have a narrow window of opportunity and
short-lived careers; therefore, rapid diagnosis and treatment are Treatment
essential. Outcomes from treatment of second metatarsal frac- The timing of this injury, in concert with the goals and aspi-
tures are excellent, and this injury usually is not considered to rations of the dancer, should lead the clinician in treatment.
be a career-threatening disability. Patients usually can expect a full recovery in approximately 6
to 8 weeks. Initial management should include cessation of all
Anatomy and Presentation dance activity and application of a hard-soled shoe. Pain at the
The most common presentation of stress fracture of the second base of the second metatarsal then serves as a barometer for
metatarsal is the insidious onset of midfoot pain. However, bal- return to activity. The dancer may begin working out but should
lerinas will report intermittent sudden onset of pain after an delay return to jumping and en pointe maneuvers. The rate of
increase in training or after a jumping maneuver. Many perform- recurrence can be as high as 12%. Ballerinas should be reas-
ers will be able to “dance through” the pain and often do not pres- sured that this is rarely, if ever, a career-ending injury.
ent until 2 to 6 weeks after the onset of symptoms.23,24 Hamilton25 If a patient fails nonoperative management, we prefer to per-
reported five risk factors for stress fracture in the ballet dancer. form an open reduction internal fixation of the metatarsal shaft.
They include amenorrhea, anorexia nervosa, cavus foot, anterior We use a minifragment plate with 2.0-mm screws. After fixa-
ankle impingement, and a Morton’s foot (short first metatarsal). tion, the patient is placed into protected weight bearing for 6
Examination of the foot can be confusing rather than reveal- weeks. The patient can return to dance at 8 weeks.
ing because patients will exhibit generalized tenderness of the
midfoot with palpation and motion. It is oftentimes hard to Case Example
distinguish pain localized to the base of the second metatarsal An 18-year-old, college-level, female basketball player presented
versus the Lisfranc joint.26 to the sports medicine clinic with a long-standing history of left
98 SECTION 2  Sport Syndromes

midfoot pain that had gotten acutely worse. The pain was exac- and a rigid shank for her shoe to wear during play. The boot was
erbated by play and persisted the majority of the season. She worn during off times, and the shank was worn during games.
had a history of a similar injury that was treated successfully in She successfully completed the season without limitations.
high school. Follow-up images showed a nonunion of the second metatarsal
Examination demonstrated bilateral pes planovalgus deformi- and a healed third metatarsal fracture. At last follow-up, she con-
ties with tenderness over the base of the second metatarsal. Pain tinued to play at the collegiate level asymptomatically.
was reproduced with motion of the second, third, and fourth tar-
sometatarsal joints. Plain radiographs and a CT scan (Figs. 5.3, STRESS FRACTURE OF THE MEDIAL
5.4, and 5.5) showed a chronic stress fracture at the base of the
second metatarsal. She was given a walker boot for daily activity
MALLEOLUS
There is a paucity of literature regarding this unusual injury as
this was only first described in 1958. Medial malleolar fractures
represent a rare stress fracture injury, as they account for only
0.6% to 4.0% of all lower extremity stress fractures.2,27

Anatomy and Presentation

The majority of patients with stress fracture of the medial malle-
olus are running and jumping athletes who present with gradual
onset of pain over the medial ankle. Pain is exacerbated by activ-
ity and is localized to the medial malleolus.28 In 2002, Shabat
and colleagues performed a review of the 23 cases reported in
literature.29 Males were affected disproportionately higher than
females (78%). The average age of the affected patients was 24
(range, 15–60).
Shelbourne et al. identified three criteria for the evaluation
of medial malleolar stress fracture.30 They include tenderness
over the medial malleolus with an ankle effusion, pain during
activity preceding an acute episode, and a vertical line from the
tibial plafond proximally.
Physical examination often demonstrates edema of the
medial malleolus with bony tenderness. Patients often will have
normal motion in the ankle and subtalar joints and should not
Fig. 5.3 An anteroposterior (AP) oblique radiograph shows a chronic have tenderness of the lateral ankle or posterior tibial tendon.
stress fracture of the base of the second metatarsal.
Analysis of hindfoot alignment is critical to assess any varus
deformity that may exacerbate stresses on the medial malleolus.
The ankle is exposed to repetitive dorsiflexion and external
rotation of the tibia during running. During heel strike, and as
the hindfoot dorsiflexes, the forefoot pronates; the navicular
becomes abducted relative to the talar head.30 The talus is thus
forced to internally rotate into the medial malleolus causing the

Fig. 5.4  An oblique radiograph shows a chronic stress fracture of the Fig. 5.5 A sagittal computed tomogram (CT) shows a chronic stress
base of the second metatarsal. fracture of the base of the second metatarsal.
 CHAPTER 5  Problematic Stress Fractures of the Foot and Ankle 99

tibia to externally rotate. Consequently, the fracture line usually CASE STUDY 5.1 
starts anteriorly at the medial tibial plafond and extends super-
omedially into the metaphysis. This vertical type of fracture pat- An elite-level, male, college basketball player began to note pain in the antero-
tern is also seen in Lauge-Hansen adduction injuries. medial distal ankle early in the season. As the season progressed, he had to stop
playing because of recalcitrant pain. Physical examination demonstrated tender-
Theoretically, a varus malalignment at the ankle biomechan-
ness along the anteromedial aspect of the tibia and pain with dorsiflexion. Plain
ically places more sheer and rotational stress along the medial
films (Figs. 5.6 and 5.7) showed a small lucency in the anteromedial plafond that
malleolus,31,32 though most case reports note that a major- may have been consistent with an osteochondral defect. An MRI (Figs. 5.8 and 5.9)
ity of their patients did not have any mechanical alignment did not show a definitive chondral lesion; however, there was high signal in the
abnormalities.28,33 anterior and medial tibial plafond, suggesting a stress fracture of the medial mal-
Shelbourne et  al. used strict criteria to diagnose a medial leolus. The patient was treated conservatively, and he sat out the remainder of the
malleolus stress fracture.30 The patient must have: tenderness season. He returned the following year and played successfully without incident.
over the medial malleolus and a joint effusion; pain during
activities before an acute medial sided ankle pain; and a vertical
fracture propagating from the medial tibial plafond.

Imaging
Plain film radiography is requisite in the diagnosis of medial
malleolar stress fractures and can be more useful with other
problematic stress fractures of the foot. There may be a small area
of fissuring along with cysts at the junction of the tibial plafond
and the medial malleolus.12 When one has normal radiographs,
a triple phase bone scan, CT, or MRI can be useful. We routinely
use MRI in our diagnosis, as it can be used to accurately identify
stress reactions and subtle fractures lines (high-intensity sig-
nal on T2-weighted and decreased T1-weighted images at the
plafond-medial malleolus junction).34 MRI use was supported
in the case series27 in which medial malleolar stress fractures
picked up all edema patterns while initial radiographs were
negative.

Treatment
Initial management of stress fracture of the medial malleolus
should include cessation of sport, with nutritional and endo-
Fig. 5.6  An anteroposterior (AP) radiograph in an elite college athlete
crine interventions when appropriate. Recreational athletes does not show obvious fracture of the medial malleolus.
with small fracture lines can be treated nonoperatively in a
short-leg cast or removable boot. Patients treated conservatively
should not return to sport until they are asymptomatic, a period
of time that averages 6 weeks.
Conversely, many authors prefer operative management of
this injury, citing the possibility of nonunion and faster return
to sport as incentives.
The objective of operative management is to create a con-
struct that counters the tensile forces of the medial malleolus
and allows quick rehabilitation. Standard AO technique should
be used with either cancellous or cortical lag screws positioned
perpendicular to the fracture line. Some surgeons advocate
the use of lag screws through a buttress plate. Patients treated
with internal fixation return to sport on average at 4.5 weeks
and have evidence of union by 4.2 months.29 The elite or profes-
sional athlete may prefer this option because it portends a faster
return to activity and theoretically reduces the risk of nonunion
or complete fracture.
A malleolar nonunion can lead to significant lost playing
time and potentially can be career ending. Isolated medial ankle
pain with normal radiographs merits further workup with either
bone scintigraphy or MRI, followed by an appropriate scheme Fig. 5.7  A lateral radiograph in an elite college athlete does not show
of management tailored to the athlete’s goals and aspirations. obvious fracture of the medial malleolus.
100 SECTION 2  Sport Syndromes

Fig. 5.10  Axial computed tomography (CT) scan showing stress frac-
ture of the anteromedial tibial plafond.

Fig. 5.8 T2 coronal images show increased signal in the anterior medial
malleolus. Note that this area appears normal on the initial plain radiographs.

Fig. 5.11  Internal repair of vertical stress fracture of the medial malleolus.

Anatomy and Presentation

Fig. 5.9  T2 sagittal images show increased signal in the anterior medial Rarely will a patient report focal pain of his sesamoid bones.
malleolus. Note that this area appears normal on the initial plain radiographs. Rather, he or she often describes a gradual onset of pain about
the plantar surface of the great toe. This pain often is exacer-
CASE STUDY 5.2  bated by dorsiflexion of the hallux. In some instances, pain
may be replaced by paresthesia of the great toe. Conversely, the
An elite-level, male athlete experienced debilitating pain in the ankle. Exam-
ination and imaging were consistent with a stress fracture of the medial
patient may recall a specific incident in which he or she experi-
malleolus. Axial CT images clearly demonstrated involvement of the antero- enced a loud pop or snap on toe-off. Key features of the history
medial tibial plafond (Fig. 5.10). The player was not able to return to preinjury should include changes in activity level, adequacy of footwear,
performance after nonoperative management. Therefore he was treated with and other important risk factors for stress fracture previously
internal repair of the vertical fracture fragment (Fig. 5.11). described.35
Physical examination should include a detailed, segmental
STRESS FRACTURE OF THE HALLUCAL analysis of the hindfoot, midfoot, and forefoot. Cavus are predis-
posed to sesamoid injury because of the increased load placed
SESAMOIDS on the first metatarsal head. Direct palpation of the sesamoid
Located on the plantar surface of the great toe metatarsophalan- will elicit pain. The tibial (medial) sesamoid is most commonly
geal (MTP) joint, the hallucal sesamoids are an often neglected involved. Furthermore, one may note decreased dorsiflexion of
and inadequately respected pair of tiny bones that reside in the the first MTP joint and pain with range of motion. The corollary
flexor hallucis brevis. They are capable of causing an enormous to this finding may be decreased strength of plantarflexion of
amount of pain, discomfort, and disability in the running and the first toe.36
jumping athlete. Stress fractures of the sesamoid is an unusual The hallucal sesamoids increase the mechanical advantage of
and rare diagnosis that requires clinical and radiographic perse- the flexor hallucis brevis. The sesamoid location subjects them
verance on the part of the treating clinician. to enormous amounts of force when the phalanx is dorsiflexed
 CHAPTER 5  Problematic Stress Fractures of the Foot and Ankle 101

and planted. The medial sesamoid is injured more often, owing A study of six patients reported good or excellent outcomes in
to its larger size and more demanding role in weight bearing. dancers and in a long jumper treated with a partial excision of
the medial sesamoid.36 Athletes should expect a full recovery
Imaging but should remain nonweight bearing for 4 to 6 weeks in the
Plain radiographs of the foot are not often helpful in the diag- postoperative setting, followed by protection of the first MTP
nosis of sesamoid stress fracture. The clinician first must under- joint for another 4 to 6 weeks and a gradual return to activity
stand that a standard lateral view is essentially useless, and by 3 to 4 months. A recent meta-analysis38 demonstrated that
an anteroposterior (AP) of the foot is infrequently revealing. internal fixation shows the best return to full-level sport rates
Medial and lateral oblique views of the sesamoids will more with low rates of complications.
clearly visualize the tibial and fibular sesamoids, respectively. Surgeons and patients will find that diligent treatment of
Several patients will have normal radiographs or the appearance these seemingly diminutive and insignificant bones can lead to
of a bipartite sesamoid. The role of scintigraphy, CT, and MRI a full recovery and return to competitive sport.
continues to evolve.
Many authors have recommended the use of bone scintig- CASE STUDY 5.3 
raphy (or now SPECT/CT scan) in the evaluation of sesamoid
pain. However, the ordering physician must communicate the A 30-year-old, recreational athlete presented to a foot and ankle surgeon
need to perform oblique scans because a traditional anteropos- after a several-day history of right forefoot pain. The pain was associated
with a long walk and progressed significantly in the week before the office
terior bone scan of the foot can reveal first MTP activity that can
visit. Examination demonstrated edema of the first MTP joint and pain with
obscure the sesamoids. A study of army recruits37 found no dif- dorsiflexion. The patient was exquisitely tender over the tibial sesamoid. Plain
ference in sesamoid bone scan activity between soldiers in basic x-rays showed a fracture of the tibial sesamoid (Fig. 5.12). This was confirmed
training for several weeks in comparison with sedentary adults. with CT. She was placed in a compressive boot with no weight bearing on
They cautioned readers about the interpretation of increased the forefoot for 6 weeks. She was progressively weaned out of the boot and
uptake in the sesamoid, warning that this may be normal phys- back to full weight bearing. At last follow-up she had full return to activity and
iologic activity for this bone. radiographic evidence of callous formation.
Perhaps axial imaging serves a more important role to the
surgeon who potentially will treat the patient with excision of
one of the sesamoid fragments. CT is an excellent modality for
detection of sesamoid stress fractures. However, obtaining only
STRESS FRACTURE OF THE FIFTH METATARSAL
axial images of the sesamoid can result in a false negative by A constant stream of dialogue exists in the literature regarding
“skipping” the fracture line. This error can be prevented by sup- the history and treatment of fracture disorders of the proximal
plementing axial CT images with longitudinal cuts through the fifth metatarsal. Accordingly, misuse of the eponym “Jones frac-
sesamoid.36 ture” is both propagated and defied. True stress fractures in this
Improved availability of high-quality MRI may supplant anatomic location in fact represent an entirely different injury,
the use of CT and bone scan because it enables the treating with its own mechanism and behavior, and should not be con-
physician to obtain axial and longitudinal images, as well as fused with the traditional Jones fracture or an avulsion fracture
indicators of stress fracture such as edema. Imaging facilities
must use the appropriately sized coil for imaging of the sesa-
moids to ensure the proper resolution. High-resolution MRI of
the sesamoid will show fragmentation and marrow changes in
the face of acute stress fracture. Although MRI may not clearly
define stress fracture versus avascular necrosis or chronic non-
union, this point is moot because treatment ultimately will be
the same.

Treatment
In our practices, we favor a conservative approach consisting
of a nonweight-bearing, short-leg cast for 6 to 8 weeks. Return
to jumping and running activity should be graded on the basis
of symptomatology. Furthermore, custom orthoses designed to
unload the first MTP joint, such as a dancer’s pad or a metatar-
sal bar, can be instituted after completing a course of casting.
Unfortunately, nonunion and delayed union of the hallucal ses-
amoids is a common occurrence.
Management of the recalcitrant sesamoid fracture is surgeon
specific and may include bone grafting and ORIF or excision
of the sesamoid. Authors have reported excellent results for all
types of procedures. Potential pitfalls of operative intervention Fig. 5.12  A plain radiograph demonstrates stress fracture of the hallu-
include digital nerve injury and weakness of the great toe flexor. cal sesamoid.
102 SECTION 2  Sport Syndromes

of the tuberosity (Fig. 5.13). Cavus feet have been radiographi- medullary canal may be sclerotic. The type III fracture (non-
cally implicated in increasing the risk for developing fifth meta- union) differs in that the bone ends will appear to be entirely
tarsal stress fractures.39 sclerotic, as though the medullary canal were nonexistent.
The clinical and plain radiograph diagnosis of fifth metatar-
Anatomy and Presentation sal stress fractures rarely requires the use of bone scan or MRI.
The history and presentation of this injury are useful in dis­ Scintigraphy will demonstrate increased uptake within 72 hours
cerning the diagnosis of stress fracture over an acute Jones frac- of acute injury but is less specific. As in other stress fractures,
ture. DeLee et al.40 described three criteria for a fifth metatarsal MRI will clearly demonstrate a fracture line with surrounding
stress fracture: prodrome of pain in the lateral foot, ultimately edema and signal change.
leading to debilitating pain; radiographic evidence of stress
fracture; and no history of previous fracture and treatment of Treatment
the fifth metatarsal. Consequently, patients often report a pro- Management of fifth metatarsal stress fractures is determined on
longed period of pain on the lateral border of the foot that may the basis of the needs and goals of the athlete, as well as the radio-
be exacerbated by a jumping or running maneuver. graphic classification of the injury. Surgeons may opt to be more
Variations in the anatomy of the proximal fifth metatarsal are aggressive in professional athletes, who are dependent on a rapid
described and can be misleading clues for diagnosing fracture of return to play. Conversely, patients may advocate a less invasive
the tuberosity. These variations include the os peroneus, the os approach to initial management. All athletes with this injury
vesalianum, and the secondary ossification center of the tuberos- should be counseled on the pitfalls that may be encountered,
ity. The os peroneum is a sesamoid bone located in the tendon of including nonunion and temporary disability. Authors favoring
the peroneus longus that may occur in up to 15% of normal feet. conservative management have reported lackluster results.40,43
The os vesalianum is a similar sesamoid, with a less regular shape, Specifically, patients are prone to prolonged immobilization and
occurring only 0.1% of the time. The secondary ossification cen- nonunion. Improved results have been demonstrated with sur-
ter or apophysis of the fifth metatarsal does not appear until after gical intervention. As such, this modality is advocated in most
age 8 in females and age 11 in males. The apophysis may be pres- athletes who desire early definitive treatment.45
ent only in up to 50% of feet. This structure can be differentiated Torg et al.44 have demonstrated that acute, nondisplaced stress
from a fracture because the physeal line runs parallel to the shaft fractures of the fifth metatarsal can be treated successfully with
of the bone. Conversely, a fracture in this anatomic location gen- nonweight-bearing immobilization. The importance of compli-
erally is in a plane orthogonal to the diaphysis of the bone.41 ance with nonweight-bearing status should be emphasized for the
Fractures of the base of the fifth metatarsal are subdivided first 6 to 8 weeks, as weight bearing has been shown to diminish
into three types. They include type I tuberosity avulsion frac- healing. The management of type II delayed unions is less clear.
tures, type II Jones fractures, and type III stress fractures of the Nonweight-bearing immobilization is effective but prolonged, and
diaphysis.42 Stress fractures are subdivided further into types the specter of nonunion is not unreal. We tend to be more surgi-
A, B, and C, which corresponds to early stress fracture, delayed cally aggressive with athletes and opt for intramedullary fixation.46
union, and nonunion. This classification scheme is useful Nonunions demand intramedullary fixation (or tension
because it is anatomically based and describes separate fractures band wiring47) with or without biologic supplementation.48
with differing mechanisms. Nonunions have also been treated with pulse electromagnetic
fields and bone grafting. However, patients should be aware that
Imaging persistent nonunion is a potential complication and possibly is
Radiographic diagnosis of fifth metatarsal stress fracture typi- related to screw diameter.49
cally is not as elusive as the other bones of the foot and ankle. Stress fracture of the base of the fifth metatarsal is a debil-
Patients who present early in the course of their lateral foot pain itating injury that requires expertise in diagnosis on behalf of
may have normal radiographs. The first feature to appear is the treating surgeon. Mistaking this injury for a less benign
thickening of the cortex and a small periosteal reaction.43 Type fracture, such as a tuberosity avulsion, can result in painful
I fractures44 (acute/chronic) are characterized by a straight line nonunion and significant loss of playing time. Therefore com-
at the junction of the proximal and middle third of the diaph- mensurate management demands a thorough understanding
ysis. The bone ends are sclerotic, there is minimal periosteal of the anatomy of the fifth metatarsal and the variable fracture
reaction, and there is no widening. Type II fractures (delayed patterns existing in this location. Athletes treated correctly can
unions) will demonstrate widening with hypertrophic perios- often expect an excellent prognosis.
teum and a wide band of radiolucency across the diaphysis. The
CASE STUDY 5.4 
2 3 Shaft
A 22-year-old, college-level, female soccer goalie noted lateral border of the
foot pain after kicking a soccer ball. Physical examination was consistent with
1
fifth and fourth metatarsal tenderness. Plain films demonstrated a fracture at
the base of the fifth metatarsal (Fig. 5.14). She underwent percutaneous screw
Fig. 5.13  The three zones of injury at the base of the fifth metatarsal. fixation with a 4.5-mm shaft screw (Figs. 5.15 and 5.16) and had full return to
Modified from: Lawrence SJ, Botte MJ. Jones’ fractures and related sport 6 weeks postoperatively.
fractures of the proximal fifth metatarsal. Foot Ankle. 1993;14:358-65.
 CHAPTER 5  Problematic Stress Fractures of the Foot and Ankle 103

CONCLUSION
Poorly defined foot and ankle pain in the athlete can be a frus-
trating condition for athletes and physicians. Stress fractures
represent a subset of maladies of the foot and ankle that require
diligence on behalf of the diagnostician. Careful history and
physical examination will illuminate mechanisms of injury spe-
cific to each fracture type and risk factor, such as weight loss,
amenorrhea, and eating disorders. Moreover, stress fractures
often require advanced imaging modalities, such as CT, bone
scintigraphy, and MRI. Therefore a global approach to care of
the athlete is advised. This should involve activity modifica-
tion, improvements in training, nutritional and psychological
counseling, as indicated, and definitive orthopedic intervention.
Accurate diagnosis and successful treatment of problematic
stress fractures of the foot and ankle is a rewarding and attain-
able goal for all physicians.

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 6
Ankle and Midfoot Fractures
and Dislocations
William C. McGarvey, Michael C. Greaser

OUTLINE
Introduction, 105 Bimalleolar/Trimalleolar Fractures, 112
Clinical Evaluation, 105 Arthroscopic Evaluation of Acute Ankle Fractures, 115
Radiographic Evaluation, 105 Pediatric Ankle Fractures, 116
Treatment, 106 Ankle Rehabilitation, 116
Ankle Fractures, 107 Lateral Process Talar Fractures, 119
Medial Fractures, 107 Anterior Process Calcaneal Fracture, 120
Posterior Malleolus Fracture, 108 References, 122
Lateral Fractures, 110

INTRODUCTION axial views of the heel, Broden’s view of the subtalar joint, and
stress views of the foot, also are helpful in certain circumstances.
Fractures and dislocations of the foot are among the most com- Because of the complexity of the anatomy and lack of uniform
mon injuries in the musculoskeletal system. Sports-related lower appreciation or interpretation of the foot and ankle radiographs,
limb fractures and dislocation are less frequent than those of adjunctive studies, such as computed tomography (CT), bone
the upper limb, but they are particularly problematic for athletes scan, and magnetic resonance imaging (MRI), can be of tre-
because they often result in significant periods of non-weight mendous value. These also are particularly useful because of the
rehabilitation. The disability and time away from sports result- subtle nature of many foot and ankle injuries.
ing from these injuries warrant close attention to diagnosis and
management.
RADIOGRAPHIC EVALUATION
Standard radiographic examination of the ankle includes three
CLINICAL EVALUATION views: AP, lateral, and mortise. These radiographs allow the
In evaluating patients with trauma to the ankle, it is essential to clinician a clear view of the relationship of the three bones that
obtain a thorough, detailed history to direct the physical and comprise the ankle mortise—tibia, fibula, and talus. The use of
radiographic examination. measurements of mortise width; medial or tibiofibular clear
Physical examination should be meticulous and systematic. space; talocrural angle; “Shenton’s” line of the ankle (that space
Because of the high incidence of coexisting injuries or fracture/ that demonstrates a mirrored congruity between the lateral
dislocations in the injured limb, careful examination and pal- talar wall and the corresponding curvature of the distal medial
pation of points of tenderness should be performed to detect fibula); and talar tilt all are helpful in determining the subtle
evidence of occult injury. Evaluation of range of motion of the abnormalities of the ankle mortise (Fig. 6.1). When in doubt,
ankle, subtalar, mid-tarsal, and metatarsophalangeal joints is the clinician also may obtain contralateral views to determine
incorporated into every routine examination. A careful motor that which constitutes normal anatomy for that particular
examination, both intrinsic and extrinsic, as well as a sensory patient, because there tends to be a high degree of variability
examination are performed. Vascular examination, including in what is considered normal from patient to patient.
Doppler studies, is essential. Radiographs are guided by the Mortise views should demonstrate relative congruity of the
examiner’s history and physical examinations. Oftentimes, the joint space circumferentially—medial tibiotalar, dorsal tibiota-
injured athlete is unable to localize the injured part, so a more lar, and lateral fibulotalar. The distance between these subchon-
global radiographic survey is performed. Standard views of the dral bone margins should be equivalent. In addition, a congruous
foot include anteroposterior (AP), lateral, and oblique views. relationship should exist between lateral talus and medial fibula,
The oblique view, for example, is particularly useful for evaluat- the so-called Shenton’s line of the ankle. Abnormalities, as evi-
ing joints, such as the calcaneal cuboid joint, that typically are denced by incongruity, provide clues to malalignment resulting
hidden or poorly examined in AP view. Specialty views, such as from bony or soft tissue injury.

105
106 SECTION 2  Sport Syndromes

account for the space existing between the medial edge of the
fibula and the lateral edge of the tibial incisura, determined at 1
cm proximal to the joint line to ensure reproducibility. Average
distance should be less than 5 mm but may vary up to 6 mm in
larger individuals. Another measure of syndesmotic integrity is
the tibiofibular overlap. The distance between the medial fibula
and the lateral edge of the anterior tibia should be 10 mm (see
A B C Fig. 6.1).
Ancillary studies, such as CT scanning and MRI, are used
liberally to provide more information regarding ankle relation-
ships and stability.

TREATMENT
Generic goals in the treatment of fractures and dislocations of
the ankle are as follows:
D E • Avoiding stiffness and loss of mobility.
Fig. 6.1  A to F, Schematic representation of radiographic parameters. • Removing bony prominences, which may result in pressure
(A) Medial clear space should equal the articular distance at any point phenomena.
around the mortise. (B) Talo-crural angle. (C) Talar tilt. (D) “Shenton’s • Restoring the articular surfaces.
line” of the ankle. (E) Tibio-fibular clear space. (F) Tibio-fibular overlap. Any fracture or dislocation of the foot or ankle that results
(From Myerson MS: Foot and ankle disorders, St Louis, 1999, Mosby.)
in focal skin pressure or evidence of neurovascular compro-
mise must be addressed immediately. Manipulation or even
open reduction must be carried out to reduce the potential
The medial clear space of the ankle as viewed on AP or sequelae, including skin necrosis, neuropraxia, ischemia, and/
mortise radiographs is the distance between the medial talar or pressure-induced necrosis of articular surfaces, because of
wall and lateral portion of medial malleolus. The measurement abnormal loading secondary to malpositioning after fracture or
of the medial clear space continues to play a significant role in dislocation.
determining the stability of ankle fractures, and thus the need Even anatomic restoration does not guarantee optimal
for operative interventions. Although this is a linear mea- functional outcome, but it certainly provides the athlete with
sure, it reflects a rotational (external) abnormality of the talus a significantly reduced risk of morbidity associated with
with respect to the tibia. Injury leading to abnormality of this sequelae of delayed or untreated injury. However, injuries
relationship with measurements of less than 1 mm or greater that present without gross distortion of anatomy or immi-
than 4 mm has been shown to correlate with poor outcomes, nent threat to the viability of the limb may be treated better
including chronic pain, instability, and arthrosis.1-3 There after an appropriate “cooling down” period. This is not to say
remains significant variability in the literature with respect to that they should be splinted and ignored, but a short period
the correct method of measuring the medial clear space. It is should be devoted to rest, ice, compression, and elevation
our practice to measure the medial clear space on a weight (RICE) to allow the soft tissue integrity and oxygenation to
bearing or external rotation stress mortise view at a level 5 mm reestablish itself, particularly before the clinician embarks on
below the medial talar dome. It is imperative that the ankle is any invasive procedures.
not plantar flexed in radiographs in which the medial clear The evolution of treatment of the traumatized ankle of the
space is evaluated, as the narrower posterior talar dome will athlete has directed more attention to aggressive intervention
often produce a falsely elevated measurement of medial clear than to “benign neglect.” Recognition of the fact that long
space widening. periods of immobilization after trauma may lead to muscu-
The talocrural angle helps to define the appropriate fibular lar atrophy, myostatic contracture, reduction of joint mobility,
length. This is measured as the angle between the line parallel associated connective tissue proliferation leading to scarring,
to the distal tibial joint surface and another line drawn between synovial adhesion, and cartilage degeneration has prompted a
tips of the medial and lateral malleoli. Normal values average 83 more aggressive approach to ankle injuries, using appropriate
± 4 degrees. Differences of more than 2 degrees to the contralat- surgical intervention to stabilize injuries and institute earlier
eral normal side suggest fibular shortening. range of motion and weight bearing when possible. These tenets
Talar tilt is measured by determining the angle between provide for the ability to institute potential prevention against
articular surface lines drawn parallel to the distal tibia and prox- previously disabling factors such as disuse osteopenia, limb
imal talus. Although uniform agreement on what is considered atrophy, proprioceptive losses, and chronic, persistent pain.4-8
normal does not exist, a side-to-side difference of more than 5 Introduction of early range of motion, physical therapy modal-
degrees (or 2 mm) is considered pathologic. ities, appropriate splinting, and bracing, as opposed to casting,
Syndesmotic space probably is the most confounding of all allows for the earlier restoration of function and avoidance of
radiologic measures. Measurements should be performed to complications. The static accumulation of hematoma, fluid
 CHAPTER 6  Ankle and Midfoot Fractures and Dislocations 107

A B
Fig. 6.2  (A and B) Medial malleolar fracture in a 16-year-old basketball player. The athlete elected to undergo
nonoperative treatment and healed uneventfully in 6 weeks.

extravasation, and resultant articular and tendinous adhesions range of motion, lack of immobilization, and potentially early
is far less with treatment that promotes earlier rehabilitation.4 return to activity.
This type of treatment also helps to prevent disabling sequelae, As evidenced by Ramsey and Hamilton,10 as well as Yablon,11
such as arthrofibrosis and regional pain syndromes.7 ankle stability is dependent on medial integrity. Michelson and
Although the realm of athletically related ankle injuries others2,12-21 have shown that the talus will not shift abnormally
is too vast to be encompassed in this chapter, the more com- with integrity of medial structures. Therefore, attention should
mon injury patterns encountered are addressed. Diagnostic be directed to anatomic restoration of the medial ankle if it
and management controversies are discussed and elucidated is disrupted. Repair may be performed percutaneously with
for the reader. Rather than a trauma compendium, this is cannulated screw fixation but should be reserved for abso-
meant to be a guide for the treatment of frequently occurring lutely anatomic reductions. Any incongruity, as evidenced by
sports and athletic injuries to the ankle for one’s reference articular irregularity, necessitates open repair with restitution
and perusal. of the articular surfaces. The author prefers open techniques
because radiographs often may disguise an occult malreduc-
ANKLE FRACTURES tion. Often, anterior/posterior reduction appears anatomic,
but evaluation via live fluoroscopy will demonstrate some
Medial Fractures degree of articular step-off with internal rotation toward a
Isolated medial fractures are unusual but not rare. Fracture pat- mortise view. The author prefers an open reversed J incision
terns may vary from vertical, oblique, or horizontal, depend- with attention to interposed periosteum and unrecognized
ing on the mechanism of injury. Isolated, minimally displaced comminution at the fracture site. Additionally, open reduction
medial malleolar fractures may be treated with 6 weeks of non- affords the opportunity to inspect the articular surface, which
weight bearing cast immobilization. Good functional outcomes provides useful prognostic information. Fixation is dictated
and less than 5% rate of non-union have been demonstrated in by fracture pattern. Most often, one or two partially threaded
studies of a general population (Fig. 6.2, A and B).9 However, cancellous screws are sufficient; however, with a more vertical
radiographs demonstrating talar tilt or subluxation in associa- fracture pattern, several screws with washers or even a small
tion with a medial malleolus fracture should raise suspicion for one-third tubular anti-glide plate will be indicated (Fig. 6.3).
a “bimalleolar variant” in which lateral ligamentous injury has Recent attention has promoted the development of fracture-
occurred in deference to bony injury. Patients with radiographic specific implants, and a variety of medial malleolar hook plates
signs of instability of the ankle should be treated operatively. In now exist as well to provide more options to the surgeon for
the athlete, even in the absence of clear signs of instability given better fixation in an effort to secure the fragment(s) and gain
the risk of sequelae and potential for instability and abnormal earlier mobility.
mechanics with medial malleolar fractures, it is the author’s Once wound healing is stable, range of motion and resis-
practice to repair all but those that are non-displaced. Even tance exercises are instituted. Weight bearing is restricted until
those demonstrating minimal (<2 mm) displacement carry 4 weeks and is advanced on the basis of symptoms. Results gen-
some advantage to stabilization, such as reliable fixation, early erally are good.
108 SECTION 2  Sport Syndromes

A B
Fig. 6.3  (A and B) Vertical shear type medial malleolus fracture. Anti-glide plating provides excellent stability
allowing early range of motion and weight bearing.

Posterior Malleolus Fracture studies suggested that degeneration after posterior malleolus
The posterior malleolus encompasses the posterior projection fracture malunion may result from decreased contact area
of the distal tibia plafond. It is bordered medially by the groove and increased contact pressures at the tibiotalar joint.26,28,33
for the posterior tibial tendon and laterally it includes the pos- However, more recently, these results have been called into
terior aspect of the tibial incisura. The lateral tubercle of the a question by a number of studies that suggest that poste-
posterior malleolus serves as the origin of the posterior inferior rior malleolus fracture malunion effects force transmission
tibiofibular ligament (PITFL), which plays an important role by changing the area of contact without a decrease in contact
in the stability of the distal tibia-fibular syndesmosis. Ogilvie- area or change in peak contact pressures at the joint.34,35 It has
Harris and colleagues22 showed in a cadaveric study that the also been noted that, in addition to changing the contact area,
PITFL was responsible for 42% of the stability of the syndes- larger PMF place increased stress on the lateral ligamentous
motic ligament complex. Thus, any posterior malleolar frac- structures including the anterior tibiofibular ligament (ATFL)
ture (PMF) involving the posterior tubercle has the potential and anterior inferior tibiofibular ligament (AITFL), particu-
to result in an unstable syndesmotic injury. It is also important larly with ankle dorsiflexion.34 It is postulated that posttrau-
to recognize that large triangular posterior malleolar fragments matic arthritis following posterior malleolus fractures, rather
may involve a significant portion of the tibial incisura, and asso- than resulting from increased contact pressures, may result
ciated malreduction of this fragment has the potential to result from a change in the pattern of force distribution resulting in
in malreduction and altered biomechanics of the syndesmosis forces in areas of the joint that may not typically be subjected
(Fig. 6.4A).23,24 Despite these anatomic considerations, the role to loading.
of anatomic reduction and fixation of PMFs continues to be a While our understanding of the biomechanics of posterior
topic of considerable debate. malleolus fractures continues to progress, the current cadaveric
Large PMFs have been implicated in posttraumatic arthri- studies may oversimplify the biomechanics of the ankle, par-
tis, and thus fractures involving greater than 25%–33% of the ticularly when the posterior malleolus fracture is a component
posterior tibial articular surface have traditionally been recom- of a more complex injury pattern including adjacent bony and
mended for operative reduction and fixation.25-29 More recently, ligamentous injuries. Thus, when making treatment decisions
many authors have advocated a more aggressive approach, rec- for posterior malleolus fracture, it is important for the clinician
ommending fixation of even small fractures of the posterior to take into account the totality of the ankle injury. Below we
malleolus based on a potential for syndesmotic malreduction outline our treatment algorithm for PMFs.
and posterior micro-instability of the tibiotalar joint.27,30-32 Posterior malleolar fractures are typically easily identified on
Some surgeons have suggested this is conceptually akin to a a lateral radiograph, but their characteristics are best evaluated
bony Bankart lesion in the shoulder. with computed tomography. Computed tomography allows for
Several cadaveric biomechanical studies have attempted a more accurate determination of fracture size, articular impac-
to elucidate the importance of the posterior malleolus frac- tion, comminution, syndesmotic disruption, and medial exten-
ture size to ankle stability and force transmission. Initial sion, in many cases changing the decision to treat as well as the
 CHAPTER 6  Ankle and Midfoot Fractures and Dislocations 109

A B C

D E
Fig. 6.4  (A through E) (A) Displaced posterior malleolus fracture resulting in malalignment of the tibial incisura
and syndesmosis. (B and C) Intraoperative radiographs showing a displaced trimalleolar ankle fracture. (D and
E) Postoperative radiographs with buttress anti-glide plating of the posterior malleolus. Note the syndesmosis
is stable after fixation of the fracture.

operative approach.36-38 It is our practice to obtain CT scans of the degree of displacement and evaluate for syndesmosis injury
nearly all fractures involving the posterior malleolus. as well as to look for occult concomitant injuries. Isolated
Isolated fractures of the posterior malleolus are rare, with an PMFs are often fairly large, and if any degree of displacement
estimated incidence of 0.5% to 1% in the general population.39,40 or instability is present, we advocate for open reduction and
Non-displaced, isolated PMFs may be considered for nonop- internal fixation. This approach ensures anatomic reduction of
erative treatment, with 6 weeks of non-weight-bearing cast the joint surface and restores the anatomy of the syndesmosis,
immobilization. Our experience would indicate that these frac- while allowing for early range of motion and protected weight
tures are exceedingly rare in the athletic population, and when bearing. Patients with large isolated posterior malleolus frac-
encountered, we recommend CT evaluation to better quantify tures with stable fixation may initiate weight bearing as soon
110 SECTION 2  Sport Syndromes

as 2 weeks postoperatively and advance as symptoms allow. preventing abnormal ankle mechanics. Several studies sup-
Immobilization may be discontinued at 6 weeks and return to port displacement, lateral or posterior, of up to 5 mm without
play is allowed after completion of a proper ankle rehabilitation significant compromise in clinical outcomes.42-46 Physiologic
program, as soon as 8–12 weeks postoperatively. loading studies of the normal and compromised ankle suggest
More commonly, posterior malleolus fractures are treated that the medial structures are, in fact, most important for stabil-
as a component of bimalleolar or trimalleolar fracture variants. ity.2,11-20,46,47 It also has been shown by CT analysis that fibular
Treatment of posterior malleolus fractures in this scenario is displacement occurring as a result of an external rotation force
often more complex and is dependent on the overall stability of with intact medial structures (Lauge-Hansen SER2) is the result
the ankle joint. As mentioned above, fractures involving greater of internal rotation of the proximal fragment.19 This implies that
than 25%–33% of the articular surface were traditionally rec- the distal fibula maintains its relationship with the mortise and
ommended for surgical reduction and fixation, based on early that no functional incongruity is present (Fig. 6.5, A through
biomechanical studies in which larger fracture fragments were D). Clinical studies have supported this notion, demonstrat-
thought to result in greater instability and increased joint con- ing good results with up to 30-year follow-up on nonoperative
tact pressures. The concept of fracture size is likely less import- treatment of isolated lateral malleolar fractures.43,44,48,49
ant in making treatment decision as is the requirement to restore Alternatively, an argument may be made for repairing all
structural integrity to the ankle joint. As noted by Bartonicek,23 but nondisplaced fibular fractures, the rationale being that even
restoration of the anatomy of the fibular incisura and the distal small increments of displacement may lead to fibular shorten-
tibia-fibular syndesmosis may be more clinically significant in ing or mortise widening.4,11 Early mechanical testing suggested
restoring function and limiting arthritis. We continue to treat that the lateral talar displacement of as little as 1 mm would sig-
these fractures aggressively. Our indication for surgery include nificantly increase contact pressures in the tibiotalar joint, thus
a PMF involving greater than 25% of the articular surface, dis- creating a potential predisposition to early arthritic changes. 10
ruption of the distal tibia-fibular syndesmosis, and we tend to In addition, it was shown that the talus would routinely follow
fix fractures of any size in the presence of a posterior dislocation. the displacement of the fibula, thus lending itself to anatomic
We prefer to approach these fractures through a posterior malpositioning and subsequent abnormal loading stresses (Fig.
lateral approach to the ankle. This approach allows for easy 6.6, A through F).11
visualization of the PMF for reduction and fixation. In cases in However, these studies10,11 are some of the most often mis-
which an intercalary fragment must be reduced, the PMF can be quoted or misinterpreted in the literature. These analyses were
hinged on the PITFL or the piece can be pushed inferiorly with performed in vitro and, as such, focused specifically on the rela-
a tamp or freer. We prefer to use a buttress plate due to the better tionship between the fibula and talus after eliminating all other
biomechanical strength of this construct (Fig. 6.4, A through attachments. There was no medial restraint to motion; thus,
E). Alternatively, cannulated screws with washers may be used. even though the results can be viewed as reliable and truthful,
It is still debatable as to whether screw placement is better from they bear limited clinical applicability because the contribution
either the front or back. of the medial osseous and ligamentous structures was ignored.
Postoperatively patients are immobilized in a splint for 7–10 Appropriate interpretation of these studies suggests that abnor-
days. Patients in which the posterior lateral approach is utilized mal ankle mechanics may be encountered when a fibular
may develop significant stiffness, and we prefer to place these fracture exists in the face of medial deficiency. In these cases,
patients into some form of removable immobilization and ini- operative treatment should be used.18 However, these studies
tiate physical therapy as soon as 1 week after surgery. Weight fail to speak to the long-term, clinical consequences of a truly
bearing may be initiated as soon as 4 weeks postoperatively for isolated lateral malleolar fracture.
solidly fixed fractures, but is typically delayed until 6 weeks. More practical arguments for operative fixation in the athlete
Return to play typically commences between 10–14 weeks if are more reliable reduction in the face of unclear medial injury;
aggressive rehabilitation is undertaken. anatomic bone-to-bone contact, facilitating primary bone heal-
ing, faster recovery times, and earlier return to weight bearing;
Lateral Fractures stabilizing weight bearing; rehabilitation; and shorter duration
Isolated lateral malleolar fractures present one of the most chal- of pain. All are anecdotal, and none have been demonstrated in
lenging management dilemmas in the realm of sports injuries. a prospective comparison study of operative versus nonopera-
Associated syndesmosis widening or medial injury, bony or tive treatment specific to this injury pattern.
ligamentous, make the choice of treatment fairly simple and Controversy persists surrounding the process of decision
obvious.18,41-43 However, fibular fractures at any level without making. Despite evidence to the contrary, many surgeons per-
concomitant injury or significant radiographic displacement form, and athletes elect to undergo, repair of the injured lateral
generate varied and controversial opinions as to what is consid- malleolus, presumably for fear of abnormal and untoward results
ered appropriate intervention. of pathologic mechanics and to resume activity as quickly as pos-
On one hand, arguments may be made that surgery is sible. A large body of clinical evidence favoring this faction is
unnecessary because, even though the lateral stability is com- the demonstrated lack of reliability of reproducible medial ten-
promised, it is not completely diminished. Intact medial struc- derness on clinical examination in disclosing the presence or
tures, specifically the malleolus and deltoid ligament, provide absence of deltoid ligament injury.50 It is unclear as to what degree
primary resistance to lateral talar translation, thus limiting or of deltoid injury in the face of the fibular fracture will allow for
 CHAPTER 6  Ankle and Midfoot Fractures and Dislocations 111

A B

C D
Fig. 6.5  (A and B) Nondisplaced distal fibula fracture that this athlete elected to treat without surgery. (C and
D) Note that, despite clinical healing, radiographs still disclose a fracture line at 4 months. The athlete was
asymptomatic and back to full activity.

clinical instability.11 Therefore many surgeons ascribe to the phi- Sports-specific activities are resumed with protective taping or
losophy that it is better to be aggressive, especially in someone bracing as necessary. Radiographs are monitored frequently in
whose livelihood may depend on the anatomic function of an the first month to ensure no displacement, but after 4 weeks
ankle or lower extremity. Again, the perspective is anecdotal but these typically are not helpful as long as no changes are noted,
reasonable. Surgical treatment often is pursued, as detailed later. specifically no mortise widening.
Nonoperative management consists of immobilization until Should one embark on the surgical management of the iso-
swelling and pain allow motion, usually about 10 to 14 days. lated lateral malleolus fracture, operative principles of anatomic
Subsequent weight bearing ensues in a walking boot, again, restoration and rigid fixation apply. The goal is to allow early
when symptoms abate. In most instances, athletes are back to mobilization and quick recovery. Debate still exists regarding
protected weight bearing somewhere between 3 and 4 weeks. the use of interfragmentary fixation combined with lateral
The walking boot is maintained until full weight bearing and buttress plating versus posteriorly placed, anti-glide fixation.
nearly normal range of motion are restored. Physical therapy Lateral plating is technically easier, whereas posterior plating
focuses on maintaining muscle tone, joint mobility, and pro- theoretically provides greater mechanical stability.51,52 Both
prioception during the healing phase. Return to activity is seem to perform well clinically. No current consensus exists,
dictated by relief of pain, normal symmetric joint range, and and the method remains the preference and comfort level of the
strength equal to 80% of that in the normal, unaffected side. surgeon.
112 SECTION 2  Sport Syndromes

A B C

D E F
Fig. 6.6  (A and B) Displaced fractures of the fibula with mortise widening require open reduction and internal
fixation, with possible attention to the deltoid ligament if the mortise remains widened. (C and D) Even after
anatomy is restored through closed reduction, stability is in question. (E and F) Open reduction and internal
fixation (ORIF) ensures anatomic restoration of the joint and allows early institution of joint motion and therapy.

Weber A variant lateral malleolus fractures present another Bimalleolar/Trimalleolar Fractures

clinical dilemma. The majority of these fractures represent Little debate exists regarding treatment of bimalleolar/trimalle-
stable injuries, and may be treated with a short period of non- olar ankle fractures. In an athletic population, uniform agree-
weight bearing immobilization. Early range of motion is initi- ment exists regarding the need for operative intervention (Fig.
ated once swelling and tenderness has diminished, and weight 6.7, A through D).41,42
bearing is usually possible within 10–14 days of the injury in a Some caveats do exist, however. Particular attention should
fracture boot. In cases with significant displacement at the frac- be paid to the fibular length and rotation. Any degree of malre-
ture site or athletes requiring a more expedited return to play, duction may lead to abnormal mechanics and possibly could
surgical stabilization may be permissible. Depending on the size hasten the advance of degenerative arthritis.
of the fracture, a single 4-mm or larger intramedullary screw High fibular fractures associated with bimalleolar fracture
or a hook plate provides stable fixation. Postoperative recovery patterns should be stabilized rigidly and anatomically. All inju-
commences with a short period of non-weight-bearing immo- ries should be tested for syndesmotic stability, but especially
bilization. Weight bearing is allowed at 10–14 days in a fracture those demonstrating a medial soft tissue injury. This test can
boot, and an ankle rehabilitation program is initiated. Return to be done by directly visualizing the syndesmotic ligaments while
play is allowed as early as 6–8 weeks postop if managed aggres- applying a laterally directed pull on the fibula with a towel
sively in the postoperative period. clamp, reduction tool, or other grasping object. Any laxity in
 CHAPTER 6  Ankle and Midfoot Fractures and Dislocations 113

A B

C D
Fig. 6.7  (A through D) Bimalleolar and trimalleolar fractures require open treatment.

tibiofibular stability associated with a fibular fracture more than the basis of biomechanical evidence of abnormal ankle mechan-
3.5 to 4.0 cm from the joint should be stabilized with syndes- ics in the face of restricted talofibular motion.53 This reduces the
motic fixation (Fig. 6.8, A through D).12 risk of a free-standing screw hole as a stress riser and theoreti-
Syndesmosis fixation remains a topic of debate and is dis- cally allows quicker, safer, and more reliable return to activity.
cussed in more detail in the syndesmosis chapter (see Chapter Trimalleolar fractures at least should have the medial and
15). In the athletic population, the author prefers to use one or lateral components repaired. Fixation of the posterior fragment
two suture-buttons to secure the syndesmosis. Suture-button of tibia as discussed above remains controversial, and stabili-
fixation of the syndesmosis allows for stable fixation with the zation should be considered in patients with large fragments,
advantage of allowing some rotational motion at the syndesmo- significant displacement, syndesmosis injury, and intercalary
sis (see Fig. 6.9, D). In addition, the use of a dynamic implant fragments.
obviates the need for hardware removal in the case of pain or It is also important to discuss the controversies surround-
screw failure. Alternatively, a 3.5-mm screw with three cortex ing deltoid ligament repair in trimalleolar equivalent fractures.
fixation and a plate long enough to incorporate the screw prox- Traditionally, these injuries have been treated indirectly with
imally to the distal-most hole (see Fig. 6.8, D). If screws are restoration of the ankle stability by way of anatomic stabili-
removed, routine screw removal is performed after 12 weeks on zation of the lateral malleolus fracture and syndesmosis. This
114 SECTION 2  Sport Syndromes

A B

C D
Fig. 6.8  (A through D) Syndesmosis repairs should be performed at the level of injury occurrence and be
based on the stability of the joint after malleolar repair. (A and B) Displaced bimalleolar fracture in an adoles-
cent wrestler. Note the avulsion of the anterior inferior tibiofibular (AITF) ligament from the distal tibia. (C)
Malleolar repair with a screw in the syndesmotic fragment. (D) More traditional fixation for a higher-level fibula
fracture and persistent tibio-fibular widening.

approach has resulted in satisfactory clinical outcomes in many screw and neutralization plate or a posterior anti-glide plate
studies.45,54-56 Nonetheless, many of the level IV studies pub- (Fig. 6.9, A through D). The syndesmosis is then evaluated and
lished on this matter do not clearly define what a satisfactory stabilized in patients with clinical or radiographic evidence of
outcome is, and also do not elaborate on the clinical findings in syndesmotic instability. Valgus and rotational stress testing is
those patients with unsatisfactory outcomes. Stromsoe et  al.55 again performed to determine if any persistent instability of the
published the only high-quality study on the subject in which deltoid exists. If stress testing produces either increased talar
50 patients with ankle fractures were randomized to direct pri- tilt or medial clear space, then the deltoid is primarily repaired,
mary repair of the deltoid or in situ healing. They found no clin- restoring the stability of the ankle mortise. We typically repair
ical difference in outcomes between the direct repair group or only the superficial deltoid, which is commonly avulsed from
non-repair group, and recommended against primary repair of the medial malleolus. Deltoid, repair is typically carried out
the deltoid. When analyzing this body of evidence, one must be through drill tunnels or with a suture anchor device. End-to-end
cognizant that the population described in these studies may repair may be carried out in cases of midsubstance rupture. The
not reflect the same athletic population that many of us are deep deltoid is not typically repaired but may be repaired with
charged to treat. In many athletes, the goals and expectations anchor to post reinforcement if desired.57
regarding level of activity, early return to play, and need for an Postoperative rehabilitation after bimalleolar and trimal-
elite level of function exist, and thus a more aggressive approach leolar ankle fractures typically includes a 7–10-day period
to stabilizing the ankle maybe necessary. of immobilization followed by transition to a fracture boot
In treating athletes with a trimalleolar equivalent fracture we with initiation of early range of motion. Early mobilization
recommend the following algorithm. We begin with anatomic is particularly important in patients with fixation through
reduction and fixation of the fibula fracture with either a lag a posterior lateral approach, as this approach may result in
 CHAPTER 6  Ankle and Midfoot Fractures and Dislocations 115

A B

C D
Fig. 6.9  (A through D) (A) Preoperative radiograph of a trimalleolar equivalent ankle facture in a collegiate
football player. (B) External rotation stress after fibula fixation reveals medial clear space and syndesmosis
widening. (C) Valgus stress after reduction and fixation of the syndesmosis reveals valgus tilt and medial clear
space widening. Deltoid repair is performed to stabilize the medial ankle. (D) Final radiograph at 3 months
postop reveals restoration of the ankle mortise and syndesmosis alignment.

significant stiffness at the ankle and contracture if the FHL chondral lesion in the setting of acute ankle fractures has been
tendon is immobilized for prolonged periods. Weight bear- reported to be as high as 88%, with most series documenting
ing is typically delayed until 6 weeks in patients requiring lesion in at least 60% of ankle fractures.60-64 Several studies have
fixation for unstable syndesmosis injuries. In the absence of shown that intra-articular lesions are more common in patients
significant syndesmosis instability and with stable bony fix- with ankle fracture dislocation and higher-energy variants such
ation, the patient may be allowed to weight bear at 3 weeks as Lauge-Hansen SER IV and PER IV fractures.61,62,65
postoperatively. Traditional means of open reduction and internal fixation
(ORIF) allows for a limited evaluation of the ankle joint, espe-
Arthroscopic Evaluation of Acute Ankle Fractures cially in presence of an intact medial malleolus. Ankle arthros-
Despite anatomic reduction, many patients with operatively copy has been proposed as an adjunct allowing the surgeon to
treated ankle fractures report residual pain, stiffness, and dys- fully evaluate the joint for intra-articular lesion, assist in reduc-
function at intermediate- to long-term follow-up.58,59 Several tion, and examine the deep deltoid ligament and syndesmosis
authors have suggested that these poor results may be due to ligaments. Intra-articular findings may help to guide treatment,
unrecognized ligamentous or intra-articular injuries result- but also assist the physician in setting patient expectations and
ing from the initial trauma. The incidence of intra-articular provide potential prognostic information.
116 SECTION 2  Sport Syndromes

Despite the numerous theoretical advantages of arthroscop- Tillaux and triplane fractures are considered adult, and
ically assisted treatment of ankle fractures, high-quality studies issues regarding treatment should be viewed as such (Fig. 6.14).
are lacking to support its use. As mentioned earlier, numerous The focus of treatment should be based on congruity of articular
case series have documented the high incidence of pathology reduction, because the complications surrounding these inju-
identified with arthroscopically assisted ankle fracture ORIF, ries arise from nonanatomic incongruous relationships, lead-
but to date no studies have shown that this practice results in a ing to early degenerative changes rather than the more popular
significant improvement in patient outcomes.65,66 Nonetheless, but erroneous presumption of growth arrest. Abnormalities or
the practice of using arthroscopy to assist in treating acute ankle asymmetry in growth actually are rare and not terribly conse-
fractures has been shown to be safe, and results in a nominal quential in these scenarios.
increase in operative time, typically between 10–15 minutes.65 Any question of articular irregularity should be settled by
The author uses arthroscopy liberally in treatment of ankle obtaining advanced imaging studies, specifically CT scanning,
fractures, and finds it to be particularly useful in treating ankle to eliminate the possibility of articular step-off. Separations of
fractures in athletes. Missed intra-articular lesion and inade- more than 2 mm in distance along the joint surface, regardless
quately treated syndesmosis and deltoid injuries may result in of congruity, should be repaired. No compromise should be
a delayed postoperative rehabilitation or potentially require accepted at the articular surface for fear of early degenerative
reoperation. This can have serious consequences in an athlete changes.
attempting to return to play or in those that make a living off Percutaneous techniques using large reduction clamps or
their sport. devices and cannulated screw fixation are acceptable, but the sur-
Patients undergoing ankle arthroscopy at the time of their geon must be certain of anatomic restoration and no interposed
ankle fracture fixation are positioned supine (Fig. 6.10, A tissue. If there is any question regarding adequacy of reduction,
through D). The author typically uses a noninvasive distrac- open treatment is required. Alternatively, arthroscopic assis-
tor to gain access to the joint, but alternatively the procedure tance is an increasingly attractive adjunct for this purpose, to
can be done with manual traction. The anterior medial portal avoid larger open procedures. Once stability is ensured, motion
is established and a spinal needle is used to provide outflow may be introduced; however, weight bearing should be withheld
and guide placement of the anterior lateral portal. Hematoma for 6 to 8 weeks until healing is confirmed.
is always present in the joint in the acute setting, and can
be easily cleared with an arthroscopic shaver. After clearing Ankle Rehabilitation
the hematoma, the tibiotalar joint surfaces are inspected for The primary focus of rehabilitation following ankle fractures
chondral injuries. Unstable articular lesions are debrided, and is prevention of stiffness, muscle atrophy, and loss of range of
microfracture may be performed if subchondral bone is intact. motion. In the immediate postoperative period, patients are
Small PMFs and PITFL injuries not identified on radiographs typically immobilized in a short leg splint to allow for stabiliza-
are easily identified with arthroscopy and provide clues to tion of the wounds. At 1–2 weeks following surgery patients are
potential instability of the syndesmosis. Injuries to the deep transitioned to a fracture boot and are allowed to initiate early
deltoid are easily identified, while the superficial deltoid is range of motion. Early weight bearing in a fracture boot is typ-
more difficult to visualize. ically allowed for stable fracture patterns after the first postop
visit, while weight bearing for more unstable fracture patterns
Pediatric Ankle Fractures commences between 4 to 6 weeks postoperatively or when
Pediatric ankle fractures constitute a wide variety of patterns radiographic healing is noted. In the presence of stable fixation
and complexity. However, these often are encountered in the and progressive healing, most patients can be transitioned to
growing population of high school, junior high, and primary a lace-up style ankle brace at 6 weeks postop or after they are
school athletes. walking comfortably in a boot. Regardless of weight-bearing
Salter-Harris (S-H) fractures not involving the joint adhere status, it is our practice to initiate physical therapy as soon as the
to principles of all generic, pediatric fracture management patient transitions to a fracture boot. Again, the primary focus
protocols (Fig. 6.11). Closed anatomic reduction often is suc- of the physical therapy is on early range of motion, strengthen-
cessful simply by reversing the mechanism of injury. Cast ing, and edema control. Patients most prone to stiffness, such as
immobilization typically is effective for management, and bony those with a posterior lateral ankle approach, often require more
remodeling usually compensates for any minor malalignments. intensive therapy to regain range of motion. Aquatic therapy or
Immobilization usually is required for 6 to 8 weeks, at which mobilization on an anti-gravity treadmill such as the AlterG
point gradual weight bearing and range of motion may be may be helpful to normalizing gait and strength. Evidence-based
advanced as tolerated. Any articular incongruity necessitates measures for return to play are lacking for patients undergoing
open management (Fig. 6.12, A and B). ankle surgery. It is our practice to allow patients to return to
Complexity increases in the diagnosis and management of play when strength and range of motion are 80% of the contra-
the adolescent variants of the Tillaux (S-H III) and triplane lateral side. Physical therapist and athletic trainers are often uti-
(S-H IV) fractures. These typically occur in the 12- to 14-year lized to help make decision regarding return to play, employing
age range as the medial tibial physis begins to close, creating test such as the Y balance test and single-limb hop test, which
an irregular stress distribution and resistance to forces applied provide an objective measure of the strength, proprioception,
across the ankle (Fig. 6.13). and coordination of the affected extremity.
 A

B C

D E
Fig. 6.10  (A through E) (A) Typical positioning for arthroscopic assisted treatment of ankle fractures. The well
leg holder is removed after completion of the arthroscopy and ORIF commences. (B) Arthroscopic image
showing the deltoid ligament flipped into the joint in a patient with a trimalleolar equivalent ankle fracture. (C
through E) Unstable medial talus osteochondral lesion associated with an acute Weber C distal fibula fracture.
Debridement and microfracture were performed.
118 SECTION 2  Sport Syndromes

C
D
Fig. 6.11  Dias, Tachdjian modification of Salter-Harris’ classification of ankle fractures in the immature skel-
eton. (From Green NE, Swiontkowski MF: Skeletal trauma in children, Philadelphia, 2002, WB Saunders.)

A B
Fig. 6.12  (A and B) Supination-inversion injury of the ankle. (B) With repair. Care is taken to avoid the tibial
physis and articular surface. The fibular pin is removed after 4 to 6 weeks.
 CHAPTER 6  Ankle and Midfoot Fractures and Dislocations 119

Epiphyseal plate
LATERAL PROCESS TALAR FRACTURES
Anterior Fractures of the lateral process of the talus previously have been
Lateral considered an uncommon injury. Historically, this injury was
thought to occur as the result of high-energy trauma and would
result from a peritalar dislocation that caused avulsion of the
Posterior
subtalar ligamentous attachments on loading. More recently,
Medial
however, this injury has gained notoriety because of its strong
predilection for presentation after snowboarding injuries.
Before the advent of this relatively new winter sport, reports
were infrequent. However, with the explosion of attention to
this activity by a predominantly young, risk-taking popula-
12.5 yr. 13 yr.
tion, the incidence and recognition have risen dramatically—so
much so that this injury has been deemed by some as the “snow-
boarder’s ankle.”67,68 One review demonstrates 74 lateral process
fractures of the talus that occurred as the result specifically of
snowboarding, accounting for 2.3% of all snowboarding inju-
ries. This is, to date, the largest series reported.68
Lateral process fractures often are missed, commonly mas-
querading as chronic ankle sprains. It is easy to understand why
this happens because of the relative anatomic proximity of this
injury to the anterior talofibular ligament, as well as the lack
of reliability of reproducible evidence of fracture on standard
13.5 yr. 14 yr. radiographic studies. Early diagnosis and treatment, however,
Fig. 6.13  Demonstrating the unusual closure of the distal tibial physis. are important, because studies have suggested that late recog-
First, it starts in the middle of the growth plate, then moves anterome- nition and failure to implement treatment routinely lead to
dially, and finally laterally. (From Green NE, Swiontkowski MF: Skeletal
trauma in children, Philadelphia, 2002, WB Saunders.)
poor outcomes such as chronic pain, stiffness, instability, and
arthritis.69-76
Traditionally, lateral process fractures were purported to
arise from a sudden dorsiflexion inversion force on a fixed foot.
However, mechanical loading studies have demonstrated that
an acute external rotation or shear force is a key element in
reproducing this fracture pattern in a cadaveric model. 67
Hawkins71 has classified these fractures into three subcatego-
ries (Fig. 6.15). Type I is a simple fracture of the lateral process
extending from the tibiofibular articulation down to the poste-
rior talocalcaneal articular surface of the subtalar joint, with or
without displacement of the fragment. Type II fractures involve
comminution of the fibular and posterior calcaneal articular
surfaces, as well as the lateral process. Type III is an avulsion
or chip fracture off the anterior and inferior part of the poste-
rior articular processes of the talus. Another classification sys-
tem has been proposed by Fjeldborg,70 who described stages of
injury with type I fissuring, type II lateral process fracture with
displacement, and type III lateral process fracture with subta-
lar dislocation. Diagnostically, this fracture pattern presents a
dilemma, and a high index of suspicion is needed by the clini-
cian. Injury pattern reports by the patient often are unreliable
and inaccurate. Physical examination findings often are similar
to those found with an acute, severe ankle sprain with tender-
ness just anterior and inferior to the tip of the fibula, along with
swelling and ecchymosis.
Radiographs sometimes are helpful when large fragments
B or significant comminution are present but, again, are not
Fig. 6.14  (A and B) Tillaux and triplane ankle fracture variants in the ado- reproducibly diagnostic because of the irregular anatomy and
lescent athlete. (From Green NE, Swiontkowski MF: Skeletal trauma in overlap of joints in this area.69,77 Special radiographic views
children, Philadelphia, 2002, WB Saunders.) have been proposed to help elucidate these fractures, including
120 SECTION 2  Sport Syndromes

Superior Sequelae of untreated or missed fractures are well docu-

mented. Malunion, non-union, instability, overgrowth, and/or
arthritis of the subtalar joint can be debilitating. Missed frac-
tures that present late often are refractory to repair or remove
fragments and will necessitate subtalar arthrodesis.69,79,83
Therefore it is critical that awareness of this injury pattern
remain prevalent and a high index of suspicion be maintained
Anterior Posterior for any patient presenting with atypical or persistently painful
A ankle sprains.7,68,79

ANTERIOR PROCESS CALCANEAL FRACTURE

Anterior process calcaneal fractures often are missed in the
B acute setting. This fracture must be sought in anyone with recal-
citrant lateral foot pain or ankle sprain; if untreated, it will lead
to problematic sequelae. There are two types of anterior process
fractures, and they occur by opposing mechanisms of injury:
avulsion and compression.82,86
Avulsion injuries occur as a result of a plantarflexion, inver-
sion force (Fig. 6.17A). As such, these often are misrepresented as
lateral ankle sprains.87-89 The overall presentation is similar with
C respect to mechanism in the onset of lateral foot or ankle pain,
Fig. 6.15  (A through C) Hawkins classification of lateral talar process ecchymosis, and swelling. However, tenderness typically occurs 1
fractures. (From Boon AJ, Smith J, Zobitz ME, Amrami KM, et al: Am J to 2 cm more distally in the region of the sinus tarsi. The fracture
Sports Med, 29(3):333, 2001.) fragment often is small and extra-articular, occurring as a plan-
tarflexion and inversion force tensions the bifurcate ligament,
a 20-degree internal rotation view with the foot in neutral dor- which overcomes the attachment of the distal-most calcaneus.
siflexion.78 Alternatively, Dimon69 has suggested that the ankle Alternatively, compressive injuries occur with sudden abduc-
be placed in 45-degree internal rotation and the foot plantar- tion forces across the foot and are much more ominous (Fig.
flexed at 30 degrees to show the posterior facet in profile. If 6.17B). These often will be intra-articular and involve variably
the diagnosis is entertained, the best and most reliable study sized fragments of joint surface, as well as causing displacement
remains CT scanning. This not only provides the examiner of the fragments posterior, dorsal, or lateral, sometimes leading to
with diagnostic evidence but also demonstrates the degree substantial incongruity. Because of the similarity in presentation
of displacement and comminution of fragments. Because of to lateral ankle sprain, a high index of suspicion should be main-
the poor outcomes obtained, all fractures must be sought tained and careful clinical inspection performed. Radiographs
and treated aggressively. Nondisplaced fractures should not are helpful, but a clear and obvious fragment is not always visi-
be ignored but immobilized in a cast for 6 to 8 weeks with ble. Because these often are confused with ankle sprains, it is not
no weight bearing and then reevaluated at that time for bony uncommon that only ankle x-rays are obtained. Suspicion should
union. Failure to aggressively treat larger displaced fracture prompt the clinician to obtain foot radiographs, particularly
fragments or comminuted fractures may and often does result obliques, to verify the diagnosis. 90 Occasionally, a small fragment
in malunion, nonunion, heterotopic overgrowth, subtalar or ossicle, the calcaneus secondarium, will be noted on a lateral
instability, and, ultimately, disabling arthritis.71,72,74,75,79-85 ankle or oblique foot radiograph. This is smooth and regular in its
Late symptoms have been shown often to not respond to exci- contours and should be differentiated from the rough, irregular
sion of the offending fragments.69,79,83 edges of an acute anterior process fracture. Computed tomogra-
Treatment is fracture type dependent. Large displaced frac- phy may be helpful to determine specific characteristics of acute
tures are managed with anatomic restoration of the articular fracture versus ossicle presence.82,90 Additionally, this is recom-
surface with internal fixation (Fig. 6.16, A through E). These mended for those patients presenting with compressive injuries
often are large enough to accept at least one small fragment to determine the degree of articular involvement.
screw for fixation (2.7 or 3.0 mm usually will suffice). This most Early diagnosis aids in the quality of treatment for this injury.
often can be done through a typical Ollier approach to the sinus Healing, particularly of the avulsion type of fracture, is reliable
tarsi and subtalar joint region. Comminuted fracture patterns if identified early. Typically, immobilization in a walking boot
are more ominous and carry a more unpredictable outcome. or a cast for 4 weeks is sufficient. Delay in diagnosis and lack
These often are refractory to repair and necessitate excision for of immobilization can lead to persistent symptoms and affect
all fragments. This at least removes any potentially abrasive sur- the ultimate outcome. Occasionally, excision will be required to
faces and areas of future impingement. If repaired, early range remove a non-united fragment after delayed or missed diagno-
of motion, focusing on inversion/eversion, will promote resto- sis. Compressive injuries, especially those with displacement,
ration of subtalar mechanics. are more complex and carry less-predictable outcomes because
 CHAPTER 6  Ankle and Midfoot Fractures and Dislocations 121

B C

D E
Fig. 6.16  (A) Schematic of a lateral process talus fracture. (B and C) Direct visualization of the lateral process
fragment before (B) and after (C) reduction. (D and E) Fixation is achieved with a posteromedially directed screw. A
talar neck fracture is fixed here, as well. ((A) from Myerson MS: Foot and ankle disorders, St Louis, 1999, Mosby.)
122 SECTION 2  Sport Syndromes

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70. Fjeldborg O. Fracture of the lateral process of the talus. Supina- 85. Tucker DJ, Feder JM, Boylan JP. Fractures of the lateral process of
tion-dorsal flexion fracture. Acta Orthop Scand. 1968;39(3):407– the talus: two case reports and a comprehensive literature review.
412. Foot Ankle Int. 1998;19(9):641–646.
71. Hawkins LG. Fracture of the lateral process of the talus. J Bone 86. Hansen ST. Foot Injuries. In: Browner JBJ Bruce D, Levine Alan
Joint Surg Am. 1965;47:1170–1175. M, Trafton Peter G, eds. Skeletal Trauma. Fractures, Dislocations,
72. Heckman JD, McLean MR. Fractures of the lateral process of the Ligamentous Injuries. Philidelphia: WB Saunders; 1992.
talus. Clin Orthop Relat Res. 1985;199:108–113. 87. Hodge JC. Anterior process fracture or calcaneus secundarius: a
73. Mills HHG. Fractures of the lateral process of the talus. Australia case report. J Emerg Med. 1999;17(2):305–309.
New Zeland Journal of Surgery. 1987;57:643. 88. Judd DB, Kim DH. Foot fractures frequently misdiagnosed as
74. Motto SG. Stress fracture of the lateral process of the talus—a case ankle sprains. Am Fam Physician. 2002;66(5):785–794.
report. Br J Sports Med. 1993;27(4):275–276. 89. Trnka HJ, Zettl R, Ritschl P. Fracture of the anterior superior
75. Noble J, Royle SG. Fracture of the lateral process of the ta- process of the calcaneus: an often misdiagnosed fracture. Arch
lus: computed tomographic scan diagnosis. Br J Sports Med. Orthop Trauma Surg. 1998;117(4-5):300–302.
1992;26(4):245–246. 90. Norfray JF, Rogers LF, Adamo GP, Groves HC, Heiser WJ.
76. Sneppen O, Christensen SB, Krogsoe O, Lorentzen J. Fracture of Common calcaneal avulsion fracture. AJR Am J Roentgenol.
the body of the talus. Acta Orthop Scand. 1977;48(3):317–324. 1980;134(1):119–123.
77. Giannestras N, Sammarco GJ. Fractures of the foot. In: Rock- 91. Degan TJ, Morrey BF, Braun DP. Surgical excision for ante-
wood CA, Green David P, eds. Rockwood and Green’s Fractures in rior-process fractures of the calcaneus. J Bone Joint Surg Am.
Adults. Vol. 2. Philidelphia: JP Lippincott; 1975. 1982;64(4):519–524.
 7
Midfoot Fractures and Dislocations
William C. McGarvey, J. Chris Coetzee

OUTLINE
Introduction, 125 Tarsometatarsal Dislocations, 126
Clinical Diagnosis, 125 Tarsal Bone Fractures, 133
Treatment, 126 Fractures of the Fifth Metatarsal, 133

tomography (CT), especially weight bearing CT, bone scan,

INTRODUCTION and magnetic resonance imaging (MRI), can be of tremendous
Injuries to the foot are common in the athletic population, value. These also are particularly useful because of the subtle
accounting for approximately 16% of all sports injuries.1 Trauma nature of many foot and ankle injuries.
to the tarsometatarsal (TMT) joints is the second most com- Weight-bearing anteroposterior (AP), 30-degree oblique,
mon injury pattern, second only to metatarsophalangeal (MTP) and lateral radiographs are the first and typically most valuable
joint injuries. The Lisfranc joint complex is the most commonly imaging studies obtained for a patient with a foot injury. If the
involved in injuries to the midfoot due to the limited static and patient is too painful for a standing radiograph, an ankle block,
dynamic stability of this region. Stress fractures, especially of or intra-articular local anesthetic, could be performed to obtain
the fifth metatarsal, continue to be a common reason for loss of adequate weight-bearing radiographs. It will also allow stress
time in athletes. x-rays to be performed (Video 7.2). A comparison weight-bear-
Misdiagnosis or maltreatment of these potentially career-end- ing AP radiograph of the contralateral foot should be obtained
ing injuries may not only prolong return to competitive play but to identify subtle subluxation or translation at the Lisfranc joint
can also lead to post-traumatic degenerative changes and pain complex, which appears asymmetric in the injured foot. This is
that limit activity and quality of life in the future.2 particularly useful for cases with less than 2 mm of instability,
as this amount of displacement is often difficult to assess on a
plain radiograph.2
CLINICAL DIAGNOSIS The oblique view, for example, is particularly useful for eval-
In evaluating patients with trauma to the foot, it is essential to uating joints, such as the calcaneal cuboid joint and the 4-5
obtain a thorough, detailed history to direct the examiner in TMT joints, that typically are hidden or poorly examined in AP
physical and radiographic examination. In addition, it will pro- view. Specialty views, such as axial views of the heel, Broden’s
vide a clue to the associated degree of soft tissue injury. view of the subtalar joint, and stress views of the foot, also are
Physical examination should be meticulous and systematic helpful in certain circumstances.
(Video 7.1). It is recognized that although most forefoot inju- Advanced imaging studies are utilized to identify or con-
ries are easily diagnosed, midfoot injuries often go undetected. firm a subtle injury, especially as up to 20% of Lisfranc complex
Because of the high incidence of multiple fractures or fracture/ injuries are missed on initial radiographs. Thin-cut CT imaging
dislocations in the injured foot, careful examination and pal- with reconstruction views will identify small fractures or possi-
pation of points of tenderness should be performed to detect bly subluxation at the TMT joints, and may be particularly help-
evidence of occult injury. Evaluation of range of motion of ful if the foot can be loaded with a simulated weight-bearing
the ankle, subtalar midtarsal, and MTP joints is incorporated study. MRI is both sensitive and specific in identifying partial
into every routine examination. A careful motor examination, and complete ligamentous injuries at the Lisfranc joint com-
both intrinsic and extrinsic, as well as a sensory examination plex, but it is unnecessary for evaluation of injuries with obvi-
are performed. Vascular examination, including Doppler stud- ous subluxation or dislocation.3 A normal appearance of the
ies, is essential. Radiographs are guided by the examiner’s his- plantar Lisfranc ligament on MRI is highly suggestive of a stable
tory and physical examinations. Because of the complexity of midfoot whereas the best predictor for instability is a rupture
the anatomy and lack of uniform appreciation or interpretation or a grade-2 sprain of this ligament. MRI has demonstrated a
of the foot radiographs, adjunctive studies, such as computed sensitivity, specificity, and positive predictive value for detecting
125
126 SECTION 2  Sport Syndromes

injury to the plantar Lisfranc ligament of 95%, 75%, and 94%, and athletic injuries to the foot and ankle for one’s reference and
respectively.4 perusal.

TREATMENT TARSOMETATARSAL DISLOCATIONS

Generic goals in the treatment of fractures and dislocations of The TMT joint, consisting of the bases of the five metatar-
the foot are as follows: sals and their articulation with the three cuneiforms and the
• Avoiding stiffness and loss of mobility. cuboid, is named after Lisfranc, a French surgeon in the army
• Removing bony prominences, which may result in pressure of Napoleon, who originally described an amputation through
phenomena. that joint.5,6 These are recognized more commonly in a poly-
• Restoring the articular surfaces. trauma patient because of the severity,2,7,8 but also are increas-
Any fracture or dislocation of the foot or ankle that results ingly recognized to occur in the athletic population.2,5
in focal skin pressure or evidence of neurovascular compro- Faciszewski et  al.9 have reported on patients with “subtle”
mise must be addressed immediately. Manipulation or even injuries to the Lisfranc joint, defined as diastasis of 2 to 5 mm
open reduction must be carried out to reduce the potential between the bases of the first two metatarsals. A third of their
sequelae, including skin necrosis, neuropraxia, ischemia, and/ patients’ injuries were sports related. Other reports support the
or pressure-induced necrosis of articular surfaces, because of increasing frequency of occurrence of Lisfranc injuries in ath-
abnormal loading secondary to malpositioning after fracture or letic events.10-15 Any patient diagnosed with a midfoot sprain
dislocation. should arouse suspicion for an undiagnosed TMT ligament
Even anatomic restoration does not guarantee optimal func- disruption.
tional outcome, but it certainly provides the athlete with a sig- In the athletic population, the occurrence and severity vary
nificantly reduced risk of morbidity associated with sequelae by sport. Lisfranc injuries are reported to be the second most
of delayed or untreated injury. However, injuries that present common athletic injury to the foot, after MTP joint injuries,
without gross distortion of anatomy or imminent threat to the presenting in 4% of football players per year, with a prepon-
viability of the limb may be treated better after an appropriate derance occurring in linemen (29.2%).11 Although complete
“cooling down” period. This is not to say that they should be injuries resulting in diastasis of more than 5 mm are easier
splinted and ignored, but a short period should be devoted to diagnostically and more dogmatic in treatment plan, more sub-
rest, ice, compression, and elevation (RICE) to allow the soft tle injuries (1 to 5 mm) often are overlooked and, even when
tissue integrity and oxygenation to reestablish itself, particularly diagnosed, may lead to therapeutic dilemmas for the surgeon,
before the clinician embarks on any invasive procedures. as well as frustration for the injured athlete. Partial capsule tears
The evolution of treatment of the traumatized foot and ankle with no diastasis, for instance, can be a compounding problem
of the athlete has directed more attention to aggressive interven- resulting in prolonged disability for the elite performer.
tion than to “benign neglect.” Recognition of the fact that long The TMT joint really is more of an articulating complex pro-
periods of immobilization after trauma may lead to muscular viding both motion and stability—much more so the latter. The
atrophy, myostatic contracture, reduction of joint mobility, osseous anatomy reveals multiple, wedge-shaped bones coalesc-
associated connective tissue proliferation leading to scarring, ing to form an arch in the transverse plane. The second metatar-
synovial adhesion, and cartilage degeneration has prompted sal often has been referred to as the keystone of this Roman arch
a more aggressive approach to foot and ankle injuries, using analogy, reflecting its overall importance to the integrity of the
appropriate surgical intervention to stabilize injuries and insti- maintenance of this structure. Structural rigidity of the shape of
tute earlier range of motion and weight bearing when possible. the foot is dependent on the stability of this relationship of the
These tenets provide for the ability to institute potential preven- midfoot bones. Because the bases of the metatarsals are wider
tion against previously disabling factors such as disuse osteope- dorsally, collapse of the arch in any plane is prevented in the face
nia, limb atrophy, proprioceptive losses, and chronic, persistent of weight-bearing load.
pain. Introduction of early range of motion, physical therapy The second through fifth metatarsals are interconnected
modalities, appropriate splinting, and bracing, as opposed to by a dense weave of short, broad-based ligaments and capsu-
casting, allows for the earlier restoration of function and avoid- lar ligamentous structures. These tend to be bundled together
ance of complications. The static accumulation of hematoma, and often will move as one unit. However, there is a notorious
fluid extravasation, and resultant articular and tendinous adhe- absence of ligamentous connection between the bases of the
sions is far less with treatment that promotes earlier rehabili- first and second metatarsals. This is thought to account for
tation. This type of treatment also helps to prevent disabling the predominance of diastasis in this interval. Instead, there
sequelae, such as arthrofibrosis and regional pain syndromes. exists a dense, plantar-based, oblique ligament extending from
Although the realm of athletically related foot and ankle the base of the second metatarsal to the lateral portion of the
injuries is too vast to be encompassed in this chapter, the more medial cuneiform—Lisfranc’s ligament. This ligament anchors
common injury patterns encountered are addressed. Diagnostic the lesser metatarsal complex to the medial column of the foot.
and management controversies are discussed and elucidated for The anatomy of the Lisfranc ligament complex has been
the reader. Rather than a trauma compendium, this is meant studied in detail in recent orthopedic and radiology literature,
to be a guide for the treatment of frequently occurring sports with an emphasis on clarifying the anatomy and determining
 CHAPTER 7  Midfoot Fractures and Dislocations 127

the amount of ligamentous disruption that leads to an unsta- medial column is disrupted, followed by the lateral dislocation of
ble injury pattern. The dorsal ligaments are the weakest of the the lesser metatarsal and associated tarsal cuneiforms.23 A third
complex and are the first to fail in the typical indirect injury type of injury occurs when the fixed plantarflexed foot is forced
mechanism associated with subtle Lisfranc injuries. The next into extreme equinus as a result of being struck from behind.9,13
ligament, the C1-M2 interosseous ligament, is the largest and This is more common in turf sports such as football. Elements
strongest ligament in the complex, and is referred to as “The” of torque, rotation, and compression are all present and cumula-
Lisfranc ligament. The plantar ligament attaches C1 to M2 and tively lead to a dorsal capsule ligamentous disruption.
the third metatarsal (M3). This C1-M2/M3 ligament is consid- Many classification systems have been proposed to describe
ered by some to be the primary stabilizer of the Lisfranc joint.16 the multitude of injury patterns that may occur.2,7,10,24,25
The tibialis anterior, with its insertion on the medial aspect Because of the tremendous variation, no one system has been
of the proximal first metatarsal and the peroneus longus, which universally accepted. These classification systems usually apply
inserts into the lateral proximal first metatarsal, also contributes to high-energy injuries and are based on segmental patterns of
to the stability of the Lisfranc articulation. In certain phases of metatarsal-tarsal bone displacement.
gait, these two tendons provide dynamic restraint. Plantar fas- Recently a useful classification has been proposed specif-
cia, intrinsic musculature, and plantar TMT ligaments provide ically for the athletic midfoot injury, including undisplaced
additional structural support against arch collapse and plan- sprains, and is based on clinical findings, weight bearing, x-rays,
tarward dislocation. The midfoot articulation may be divided and bone scan results (Fig. 7.1).12 Stage I patients were found
mechanically by columns. The medial column includes the first to have pain at the midfoot and were unable to play sports but
metatarsal and medial cuneiform. The middle column consists had no radiographically visible changes. Bone scan results did
of the second and third metatarsals, as well as the middle and demonstrate increased uptake in the area of Lisfranc joint.
lateral cuneiforms. The lateral column is formed with the fourth Pathoanatomy is thought to include dorsal capsular tear without
and fifth metatarsals, along with the cuboid bone. This column elongation of Lisfranc’s ligament. Stage II is described as clinical
provides the greatest motion throughout the TMT joint. findings similar to those in stage I, but with diastasis of 1 to 5
Vascular structures in this region deserve mention because of mm between the bases of the medial two metatarsals present on
their proximity to the area of potential injury. The dorsalis pedis plain AP radiographs. Most important, no loss of longitudinal
artery and the plantar arterial arch are structures at risk, partic- arch was noted on weight-bearing lateral x-rays. Pathoanatomy
ularly when the dorsalis pedis dives down between the bases of here differs from stage I in that the Lisfranc ligament is elon-
first and second metatarsals. Disruptions here, especially with gated, but the plantar structures remain stable and prevent arch
a tethered vessel, can result in kinking, vasospasm, and, ulti- collapse. Stage III was defined as diastasis greater than 5 mm
mately, ischemia. Lisfranc dislocation derives its name, in fact, and loss of lateral arch height, defined by loss of space between
as previously stated, from the Napoleonic surgeon who so defi- the fifth metatarsal and the medial cuneiform on lateral radio-
nitely amputated cavalrymen after midfoot injuries resulting in graph.12,25 All capsuloligamentous structures are thought to be
vascular catastrophes.2,5,7,8 Although less common compared injured in stage III. Other forms of injury, such as gross dis-
with the high-energy version of this injury, anecdotal reports ruption with fracture and/or dislocation, were defined by these
of associated vascular injuries abound and should be sought for authors in the method originally proposed by Myerson,26 which
fear of missing an ischemic sequela. was based on segmental instability (Fig. 7.2). The advantage of
Patterns of injury to the TMT joint have been described as such a classification is that treatment may be predicated on the
a result of both direct trauma to the foot and indirect violence. level of injury.
The majority of nonathletic traumatic midfoot injuries can Up to one in five Lisfranc injuries are missed or improperly
occur as a result of significant direct force, usually applied to diagnosed on initial screening, whether it be in the emergency
a foot in plantarflexion or abduction, and typically will accom- department or at practitioner’s office. This often can be ascribed
pany high-velocity or high-energy trauma, such as motor vehi- to the presentation of these injuries as part of a polytrauma,
cle accidents or falls from heights.2,7,16-18 These can result in with other, more severe and more obvious injuries demanding
significant soft tissue compromise, neurovascular injury, and the bulk of attention.2,3,5
compartment syndrome.8 In the athlete, however, it is the subtle or complete absence of
Indirect injury is more relevant to this discussion. Athletes radiographic diastasis that may occur that confounds the exam-
may sustain direct violence to the foot as the result of an awk- iner.9,10,12-14,27 A high index of suspicion must be maintained
ward collision or in the melee of a collision in certain sports. for athletes presenting with midfoot pain after athletic con-
However, more commonly the athlete is injured because of tact or activity, even without radiographic evidence of injury.
low-velocity, indirect energy imparted to the foot. Most will Consideration should be given to stress radiographs as a means
describe some sort of axial longitudinal force while the foot is of furthering diagnostic abilities.
plantarflexed and, often, slightly rotated.12 Two specific patterns Physical examination is especially important with subtle
have been described. Simple lateral dislocations result from injury. Gross distortion of the bony architecture of the foot is
eversion of the hind foot on a fixed plantarflexed foot, as may be readily identified. Clinical and radiographic findings of frac-
seen in ballet dancers en pointe.16,19-22 Alternatively, supination tures and dislocations are relatively simple to determine. The
or inversion of the hindfoot on a fixed plantarflexed forefoot patient presenting with no overt disruption or equivocal radio-
will result in a more dissociative pattern of injury because the graphic divergence becomes a diagnostic dilemma.
128 SECTION 2  Sport Syndromes

Lisfranc Ruptured 2–5 mm

ligament Lisfranc diastasis
sprain ligament

No diastasis

Stage I Stage II

Ruptured 2–5 mm
Lisfranc diastasis
ligament

Diastasis and
loss of longitudinal
arch height

Stage III
Fig. 7.1  Nunley classification of athletic Lisfranc injuries. (From Nunley JA, Vertullo CJ: Am J Sports Med,
2002;30(6):872, Fig. 7.1.)

Examination typically demonstrates tenderness at the midfoot 10. A small compression fracture at the lateral edge of the
that is worsened by provocative maneuvers such as pronation or cuboid.10,24-30
abduction of the foot. Swelling is often significant, and ecchymosis Even after perusing the radiographs with these parameters
is variably present. Neurovascular injuries are unusual in the in mind, the clinician may find it difficult to make a diagnosis.
lower-energy traumas, but the possibility of impending compart- Weight-bearing, contralateral radiographs often are helpful in
ment syndrome always should be considered, because there discerning any asymmetry.
often is tremendous edema accompanying these injuries. In more subtle and problematic cases, multiple advanced
Classic radiograph findings and markers have been well imaging studies have been suggested, including CT, MRI,
established. A minimum of three radiographic views of the static stress radiographs, and stress fluoroscopy under anesthe-
foot (AP, lateral, and oblique) should be obtained. Assessment sia.2,5,10,29-33 However, the best and most reliable studies seem
in suspicious injuries should be made of all of the following to be a set of standing radiographs (Fig. 7.3, A through E) and
relationships: bone scan, if necessary, in the completely undisplaced metatar-
1. Diastasis of metatarsals one and two. sal that manifests persistent pain.12,13 There are two advantages
2. Cuneiform diastasis, especially medial and middle. to weight-bearing radiographs. First, the dynamic nature of the
3. Widening between the second and third metatarsals. injury can be determined in a more appropriate physiologic
4. Widening between middle and lateral cuneiforms. and mechanical state, thus determining the need for treatment.
5. Small fracture, “fleck sign” at the medial base of the second Second, prognostic value exists in determining the presence of
metatarsal or medial cuneiform, representing an avulsion collapse or instability.9,14,15
of Lisfranc’s ligament. Principles of treatment of Lisfranc injuries are universal and
6. Horizontal plane malalignment of metatarsals on lateral include providing an anatomic reduction in stabilization. Care
x-ray. must be taken to observe and manage the soft tissue and neuro-
7. Relationship of medial border of the second metatarsal vascular consequences, as well.
should be parallel to the medial edge of the middle cunei- Debate still exists as to how much diastasis is acceptable in
form. the injured athlete. The literature is heavily weighted toward
8. Relationship of the medial fourth metatarsal should be par- high-energy trauma management, and little has been pro-
allel to the medial edge of the cuboid. posed regarding management of the athletic midfoot sprain.
9. General loss of parallelism of metatarsal bases with respect Most recent literature suggests that residual diastasis may
to one another. result in a poor outcome, such as persistent pain, deformity,
 CHAPTER 7  Midfoot Fractures and Dislocations 129

A B C

D E F
Fig. 7.2  Myerson classification of Lisfranc injuries. (From Myerson MS: Foot and ankle disorders, St. Louis,
MO: Mosby; 1999.)

and arthrosis.10,12-18,26,32-35 Nonanatomic reductions have been reviewed 19 athletes with varying degrees of TMT injury, citing
shown to be inferior with respect to outcome and the need for poor functional results despite “relatively nondisplaced injuries”
secondary procedures, such as revision repairs or fusions. in patients with delays in diagnosis and those not treated ade-
Athletic injuries are sparsely documented, but the evidence quately, with three failing to return to sport. Lewis in one paper
that is available seems to support the conclusion that injuries and DeOrio in another showed excellent results with treatment of
resulting in diastasis will lead to poor outcomes. Curtis et  al.10 Lisfranc injuries in athletic populations. A high level of return to
130 SECTION 2  Sport Syndromes

A B

C D

E
Fig. 7.3  (A) Radiograph of a 34-year-old professional waterski jumper with acute midfoot pain after a fall.
There is a suggestion of subtle intermetatarsal diastasis. (B through D) Various advanced imaging studies
confirm the Lisfranc ligament disruption by avulsion of the base of the second metatarsal. (B) Bone scan
shows increased uptake about the midfoot. (C) Computed tomography demonstrates the avulsed fragment.
(D) Magnetic resonance imaging reveals edema in the region of the ligament with suggestion of bony injury.
(E) Plain anteroposterior weight-bearing x-rays of the injured and comparative contralateral side clearly dis-
close the diastasis.
 CHAPTER 7  Midfoot Fractures and Dislocations 131

Fig. 7.4  Incision placement for exposure to the diastasis of Lisfranc’s Fig. 7.5  Percutaneous reduction technique with a large Weber clamp.
joint. Surgeons must be aware of the tendency for dorsal plane malalignment
as a result of overtightening or improper clamp placement. Lateral fluo-
play was achieved.14,18 Nunley and Vertullo12 showed that 14 of 15 roscopy should always be employed to verify anatomic reduction.
patients had good results when treated within the algorithm based
on a classification, they proposed that guided treatment on the reduction. In addition, especially in unstable injuries, the
basis of displacement. Patients were assessed on the basis of plain motion at the joint surfaces will induce pin loosening and
x-rays and bone–scan-documented injury. Only completely non- migration with predictable loss of stability, thus requiring con-
displaced injuries (seven patients) were treated nonoperatively. All current cast immobilization, which prevents early rehabilita-
others were treated by open reduction with internal fixation. The tion. Conversely, screw fixation is reliable and allows for early
only patient with residual pain was one treated by open reduction mobilization of the foot and ankle, as well as edema control after
and internal fixation (ORIF) after 10 months of failed conservative wound healing has been achieved.
treatment. Return to sport in the operative group averaged 14.4 Screw configuration is dependent on injury pattern and
weeks, which was comparable to nonoperative results. extent of ligamentous disruption. My preference is to use fully
Only one study demonstrates reasonable results with nonan- threaded, 4.0-mm or larger screws. Partially threaded screws
atomic reductions. Shapiro et  al.13 reported on nine athletes are acceptable, but because this is a “position screw” to maintain
with diastasis between 2 to 5 mm. Eight elected for nonopera- reduction, the surgeon must guard against the tendency to com-
tive treatment and returned to sport within 3 months, with good press across the TMT joints. Typically, the first screw is placed
results reported in an average of 33 months after the injury. on the orientation of the disrupted Lisfranc’s ligament, that is,
On the basis of these reports and personal experience, my from medial cuneiform to second metatarsal base. Additional
recommendation is for operative treatment in all but nondis- screws are placed as needed (Fig. 7.6, A through F). Should the
placed injuries of the TMT joint. Although percutaneous tech- injury extend through the medial and middle cuneiforms, an
niques have been proposed, an open approach is more reliable intercuneiform screw should be placed first.
and eliminates the possibility of retained or interposed tissue, as The patient is kept non–weight bearing for 6 to 8 weeks. Early
well as allowing direct visualization of the joint for an anatomic motion and therapy modalities such as muscle stimulation can
reduction (Fig. 7.4). Closed or percutaneous techniques using begin as soon as soft tissue healing allows. Partial weight bear-
the large Weber reduction clamp carry the risk of malreduction, ing in a boot begins at 6 to 8 weeks and is advanced until 12
especially in a horizontal plane, even in the face of an anatomic weeks. Screws are maintained for no fewer than 16 weeks and
appearing anterior/posterior image (Fig. 7.5). often, but not routinely, are removed. The athlete is returned to
Open treatment affords the surgeon the opportunity to extri- athletic activity with a molded, semirigid insole and a semirigid
cate any incarcerated bony fragments or soft tissue that may extended steel shank device.
have been interposed, including the Lisfranc’s ligament itself or, There is a movement away from transarticular screw fixation
in high-energy injuries, the tibialis anterior tendon. Anatomic for ORIF of Lisfranc injuries. The premise is that if you want to
restoration of the arch is achieved and verified, as well as pro- maintain/preserve the joints, it is best not to violate a substantial
viding direct visualization for hardware placement. cross-section of the articular surface with a screw. A secondary
Screw fixation is preferable because K-wire fixation is ten- issue is that if the screws break in the joint, it could significantly
uous, at best, and not as reliable in maintaining an anatomic compromise the joint.
132 SECTION 2  Sport Syndromes

A B

C D

E F
Fig. 7.6  (A through D) Running back with Lisfranc injury that was treated with a Bridge plate and home run
screw. (E and F) The hardware was removed at 4 months and examination showed the joints stable.
 CHAPTER 7  Midfoot Fractures and Dislocations 133

Bridge plating has become increasingly popular, as it does regarding the description, the understanding, and thus the
not violate the joint, even if the screw breaks, and is easy to treatment of these injuries throughout the literature. The classic
remove. Hu and coworkers showed in their study that the bridge Jones fracture was named after Sir Robert Jones,41 who originally
plate patients did better than screw fixation.2,29 described the fracture in his own foot in 1902. He sustained the
Frank disruptions and intra-articular fractures are treated in fracture “Whilst dancing, I trod on the outer side of my foot, my
the way that trauma guidelines dictate and are managed ORIF heel at the moment being off the ground. Something gave way
or primary arthrodesis.14,18 midway down my foot...the fifth metatarsal was found fractured
Postoperative protocols are similar to those described pre- about 3/4 inch from its base.” Jones originally described the
viously, but usually require larger periods of rehabilitation, and fracture of the metaphyseal diaphyseal junction without exten-
return to activity is less predictable in these patients. sion distal to the anterior metatarsal (4–5 intermetatarsal) junc-
tion. Currently, a Jones fracture is recognized as any fracture
involving the fifth metatarsal metaphyseal-diaphyseal junction.
TARSAL BONE FRACTURES This fracture often is confused with, although less commonly
Anatomic variants of Lisfranc’s injuries do exist. There have encountered than, its cohort, the avulsion of the tuberosity
been reports citing evidence of bipartite cuneiforms and ana- encountered more proximally. The significance of the true Jones
tomic variations in anatomy throughout the midfoot bones fracture is that it can develop delayed or non-union. Zelko
(Fig. 7.7, A through F). Should these be encountered, pursue et al.,42 Kavanaugh et al.,43 and DeLee44 have reported difficulty
and treat aggressively, with the same guidelines as those for the treating the fractures of this region in which diagnoses initially
previously described injuries.36-38 were missed or that, in reality, were stress fractures.
Fractures or dislocations exclusive to the cuneiforms or cuboid Stewart45 originally introduced a classification to help clar-
area are unusual. These often are present in conjunction with a ify fractures in this region. Type I fractures are at the junc-
TMT joint injury, in which the force of the injury has disrupted tion of the base and shaft of the metatarsal. Subgroups include
further proximally through the navicula, cuneiform, or talonavic- noncomminuted (IA) and comminuted (IB) variants. Type
ular joints, or even through the body of the cuboid. Although rare, II fractures involve only the styloid process. Again, these are
these injuries have been identified.39,40 Because cuneiform frac- subdivided into extra-articular (IIA) and intra-articular (IIB).
tures and dislocations often occur as part of a midfoot dislocation, Stewart established a treatment plan that is based on his classi-
treatment principles should follow those of the injured TMT joint. fication system.
Isolated cuboid injuries most often present as insignificant Zelko et  al.42 tried to define fractures on the basis of clin-
“chip” fractures along the lateral side. Typically, these occur as ical history and initial radiographic findings. Group 1
a result of an inversion injury and often are seen secondarily patients reported an acute injury with no previous symptoms.
after the patient has been diagnosed with “sprain.” Treatment Radiographs demonstrated what appeared to be acute fracture
requires supportive immobilization in either a walking cast or line and no evidence of any chronic change, defined as perios-
hard-soled shoe for approximately 4 weeks or until symptoms teal reaction or intramedullary sclerosis. Group 2 demonstrated
allow resumption of activity. A rigid orthosis may allow earlier an acute injury but also reported a prodrome of mild lateral foot
return to sport. Fracture instability is not usually a concern. pain. Radiographs in these patients evidenced a clear fracture
Compressive cuboid injuries can occur with a sudden abduc- pattern. However, there also was demonstration of some peri-
tion force. So-called nutcracker injuries are far more severe. osteal reaction. Group 3 patients were categorized as a rein-
Again, this is considered a variant of the mechanism for Lisfranc jury after one or more previous injuries. Radiographs of these
injuries, and the same principles are applied. Early anatomic patients demonstrate lucent fracture line, periosteal reaction,
reduction is necessary (Fig. 7.8, A through F). Manipulation and intramedullary sclerosis, and this group presented with
alone is often unsuccessful in restoring the length of the lateral chronic pain or multiple recurrent injuries with sclerotic mar-
column. Open treatment frequently is required. Placing a small gins bordering a lucent fracture line.
plate to span the collapsed intercalary segment is necessary on DeLee and colleagues44 attempted to combine classifications
occasion. If there is poor-quality bone fixation in the subartic- and divided these into multiple fracture types. Type I fractures
ular cuboid, a spanning plate to the distal calcaneus represents are those at the junction of the base of the shaft and the base and
a good alternative. For severe comminution, the author prefers are subcategorized into type A for nondisplaced and type B for
structural tricortical graft to reestablish the length. This may be comminuted fractures in this area. Type II fractures occurred
interposed between subchondral bone proximally and distally, again at the junction of the shaft and the base but carried clin-
because the articular surfaces often are not severely commi- ical and radiographic evidence of prior injury. To fall into this
nuted. If necessary, fixation can be applied as previously stated, category, patients had to report prior lateral foot pain and/or an
or a spanning external fixator from distal calcaneus to proximal established radiographic periosteal stress reaction or frank frac-
metatarsals may be used to distract the lateral column. ture line. Type III fractures included those of the styloid process
or tuberosity and again were classified into subcategories A,
nonarticular, and B, articular.
FRACTURES OF THE FIFTH METATARSAL The recommended current classification includes a com-
Fractures of the base of the fifth metatarsal are the most common bination of all the classifications discussed and divides the
metatarsal fracture. However, there are many misconceptions metatarsal injuries into classification that correlates to zones of
134 SECTION 2  Sport Syndromes

A B

C D

E F
Fig. 7.7  (A) Weight-bearing anteroposterior radiograph, with comparison, of a high school quarterback with
acute midfoot injury. (B) Close-up suggests unusual arrangement in the area of medial cuneiform. (C) Lateral
radiograph demonstrates separation of dorsal and plantar halves of medial cuneiform. (D) Computed tomog-
raphy confirms bipartite tarsal bone. (E and F) Open repair requires attention to both the separated bipartite
cuneiform with removal of synchondrosis and closure of the intermetatarsal diastasis, as well.
 CHAPTER 7  Midfoot Fractures and Dislocations 135

vascular anatomy (Fig. 7.9). Currently, preferred classification proximally are secure both dorsally and plantarly and provide
uses three separate zones. Zone 1, or the most proximal zone, tremendous stability. Finally, zone 3 injuries are fractures of
includes the cancellous fifth metatarsal, the so-called tuberosity the fifth metatarsal shaft. This zone begins just distal to the
fragment. It includes the insertion of the peroneus brevis ten- fourth and fifth intermetatarsal ligaments and extends distally
don and calcaneometatarsal ligamentous branch of the plantar into the tubular portion of the diaphysis approximately 1.5 to
fascia. Fractures in this zone typically extend into the fifth meta- 2.0 cm. Most current management protocols use some form of
tarsal cuboid joint but may be extra-articular. Zone 2 injuries zone concept in classifying and reporting fractures. Therefore,
involve the metaphyseal-diaphyseal junction. This encompasses the bulk of the discussion regarding treatment will reflect this
the articulation of the proximal fourth and fifth metatarsals. trend and be focused on management of fractures by type and
The ligaments holding the fourth and fifth metatarsals together location.46-48

A B

C D
Fig. 7.8 (A and B) Shows a severely comminuted fracture dislocation of the talonavicular (TN), calca-
neo-cuboid, and cuboid/metatarsal joints. Also fracture dislocations of the second, third, and fourth meta-
tarsophalangeal joints. This patient was involved in a high-speed bicycle crash. (C and D) shows initial
open reduction and internal fixation of the fractures and a primary talo-navicular arthrodesis. (E and F) Four
months after with the fractures and TN arthrodesis healed. The TN arthrodesis did not limit her as a cyclist,
and she was able to return to her sport.
136 SECTION 2  Sport Syndromes

E F
Fig. 7.8, cont’d

Peroneus
tertius tendon
III
II

A Peroneus
brevis tendon

Lateral band
of the plantar
fascia
Fig. 7.10  Anatomy of tendon attachments at the base of the fifth meta-
tarsal. (From Lawrence SJ, Botte M: Foot Ankle 1993;14:360.)

The proximal end of the fifth metatarsal not only articulates

with the cuboid at the TMT joint but also has an intermetatar-
sal articulation with the base of the fourth metatarsal. This is a
Tuberosity avulsion fracture true joint. The bases of the fourth and fifth metatarsals are bound
Jones’ fracture closely to the cuboid by dense, ligamentous structures on every
Diaphyseal stress fracture side. The stability of the TMT complex is provided by capsular
ligamentous structures, the dorsal and plantar cubometatarsal lig-
B aments, the lateral band of the plantar aponeurosis, and the broad
Fig. 7.9  Fracture zone classification at the base of the fifth metatarsal. insertion of the peroneus brevis tendon (Fig. 7.10). It is believed
(From Lawrence SJ, Botte M: Foot Ankle 1993;14:360.)
that these capsular ligamentous structures contribute greatly to
The fifth metatarsal itself has been subdivided into main seg- the genesis of a true Jones fracture,3,43 because the proximal por-
ments, including the head, neck, shaft, base, and tuberosity or tion of the fifth metatarsal and its articulation with the cuboid
styloid process. The metaphyseal portion of the bone tapers into is held fast while torsional forces produce stress that is relieved
a tubular diaphyseal segment. The size and the shape of this bone through the fracture line just distal to these structures, approxi-
vary somewhat but typically demonstrate that a larger, wider, mately 0.5 cm distal to the insertion of the peroneus brevis and
more triangular proximal portion becomes a fairly narrow just distal to the joint between the fifth and fourth metatarsals.
tubular structure that has a slightly lateral curve as it traverses The base of the fifth metatarsal proceeds laterally and inferiorly
distally. The radius of curvature as the bone proceeds distally is beneath the inferior edge of the cuboid on the lateral radiograph.
highly variable and can lead to tremendous distortions in the There is a tremendous variability in size and shape of this promi-
shape and stress applied to the distal end of this structure.46 nence, accounting for its variable susceptibility to injury.
 CHAPTER 7  Midfoot Fractures and Dislocations 137

Nutrient
artery

Metaphyseal
Metaphyseal arteries
arteries

Periosteal
blood supply

Fig. 7.11  Vascularity of the fifth metatarsal. (From Smith J, Arnoczky SP, Hersh A: Foot Ankle 1992;13:144.)

The vascular anatomy in this region also is relatively import- shape. Individuals with more cavus foot alignment have been
ant (Fig. 7.11). This has been thought to be a fairly tenuous vas- shown to be more likely to develop this injury pattern because
cular supply, particularly at the proximal diaphysis. The arterial of the increased rigidity of the foot, as well as the propensity
plexus at this level has been well established by Shereff et al.47 to have a stress transfer to the lateral foot.3,42-44,47-49 Individuals
and Smith et al.,48 demonstrating only a small nutrient vessel in with planovalgus foot also have been suggested to be predis-
the so-called watershed area. This is unique contradistinction to posed to this injury because of increased loads forced along the
the fairly abundant blood supply more proximal to this water- lateral border of the foot during the latter part of stance, phase,
shed area. and gait. These relationships have not been demonstrated in any
Direct and indirect mechanisms have been implicated in the formal mechanical studies.
genesis of the fifth metatarsal fracture. Certainly, the promi- Clinical diagnosis of the Jones fracture is dependent on
nence of the tuberosity makes it particularly at risk for a more making an appropriate diagnosis and localizing the specific
direct mechanism of injury when discussing this version of the type of injury with respect to zone as well as acuity. History
fracture.46 Jones himself alluded to the indirect nature of inju- may be vague but typically involves an aching sensation on
ries, describing a “cross-breaking strain directed anteriorly to the lateral aspect of the foot related to some sort of push-off
the metatarsal base and caused by body pressure on an inverted or inversion-type injury. Prodromal symptoms may be reported
foot while the heel is raised.”41 Presumably, he is describing the for up to several weeks before any evidence of the actual doc-
commonly accepted foot in fixed equinus sustaining rotatory umented injury suggestive of a prefracture state or impending
and/or tensile forces overcoming the thinning cortical bone in fracture.42,44,46
the proximal metaphyseal-diaphyseal junction. Physical examination findings are fairly reproducible and
Fractures of the tuberosity occurring indirectly are more include an improved tenderness, specifically over the base of
common because of the number of structures that attach to the the fifth metatarsal. Ecchymosis and swelling are present to
prominence.46 These structures have been identified previously. variable degrees and, again, depend on the acuity of the injury.
The importance of the pull of the peroneus brevis has been There is typically an accentuation of pain by inversion of the
emphasized in the creation of a separation stress that forces foot. However, there is little motion at the fracture site, and
the proximal fragment of the metatarsal away from the shaft. therefore no crepitus or palpable mobility of the fracture site on
Because of the strong peroneus brevis contraction in stance manipulation.
phase, the tendon already is contracted when an inversion stress Radiographs often will confirm the diagnosis, although
is applied to a weight-bearing, plantarflexed foot. This tendon in some instances some fractures may present as occult or
holds fast while the force causes the shaft to be pulled away incomplete. Careful radiographic assessment is important to
from it. Avulsion of the base away from the shaft is the result.3 determine the presence of a fracture line because this may be
Kavanaugh et al.43 used high-speed cinematography and force particularly subtle. If the diagnosis is in question, studies such
platform analysis in an attempt to recreate the position of the as MRI or bone scintigraphy tend to be particularly helpful.43-45
foot at the time of the index injury. Conclusions of this study Diagnosis of fractures can be especially confounding in the
suggested either an axial or mediolateral force or a combina- adolescent athlete because secondary centers of ossification at
tion of these acting on the fixed base of the fifth metatarsal. This the base of the fifth metatarsal are present and sometimes are
would bring the patient up on the metatarsal heads, concentrat- confused with acute fractures. The ossification center typically
ing the axial and mediolateral forces on the lateral metatarsal. occurs between 8 and 12 years of age and usually is united
It was postulated that failure to invert the foot would produce by 12 years in girls and by 15 years in boys. A secondary
a tremendous axial and mediolateral ground force culminating ossification center occurs in approximately one-fourth of all
in fracture. children.46
Other factors also have been implicated in the genesis of the Distinction between these secondary centers of ossification
injury here, including repetitive use, such as prolonged running and acute fracture is relatively straightforward. Distinguishing
or jumping activities; vascular contribution, particularly at the characteristics include the orientation of the apophyseal line,
avascular or watershed zone; and certain morphologies of foot which reproducibly traverses the tubercle parallel to the long
138 SECTION 2  Sport Syndromes

axis of the shaft. Additionally, the apophysis occurs lateral to the patient is placed in a splint for approximately 1 week, and a
and does not extend into the TMT joint.46 Ossification centers short leg, non-weight-bearing cast is applied for an additional 2
also tend to have smooth, regular edges, as opposed to a more to 3 weeks. At 3 weeks, stationary bicycling, swimming, and stair
irregular appearance of fracture. climbing are allowed in a protective boot, with weight bearing
Two other ossicles often will occur in this region. The os progressed as tolerated, depending on pain. Running is encour-
peroneum is present in approximately 10% to 15% of all radio- aged only when evidence of significant fracture healing is pres-
graphs. The os vesalianum is variably present as well. Again, ent radiographically, and typically this takes 5 to 7 weeks. Return
a smooth, sclerotic, appositional surface often is present and to sports-specific activity is prohibited until the patient can run
differentiates this from fracture. These ossicles, which are inde- and cut painlessly. Caveats with respect to this procedure involve
pendent, sesamoidal-type bones, should be distinguished easily injury to the sural nerve, which is as close as 2 to 3 mm from the
from acute fracture situations. position of the screw head.54
Treatment is injury specific and fracture type dependent. Lastly, a combination of the previous two procedures men-
Treatments vary and range from weight bearing in a protective tioned has been applied.5 The technique for screw placement is
shoe as soon as pain allows to various forms of ORIF and, some- as previously stated. However, this is done with a larger incision,
times, bone grafting. The literature is replete with information to and access is gained through the canal before placement of the
support just about any stance one may want to take. It is crucial screw. Bone graft should be placed dorsally, medially, and plan-
that a clear understanding of the injury pattern, the outcomes of tarly before insertion of the screw. Once bone graft is placed,
nonoperative versus operative treatment, and the potential com- the screw is inserted and the wound is closed. An alternative to
plications be understood by the surgeon before embarking on this method is a so-called strain-relieving cancellous bone graft,
a treatment plan.50,51 Various forms of surgical treatment have which can be placed in similar fashion but specifically in a dor-
been described and are addressed independently by procedure. somedial trough spanning the fracture site. Once the screw has
First, the technique of medullary curettage and inlay bone been placed, additional bone graft can be packed in and around
grafting has been well established.49,52 At present this method is the fracture site. Return to activity is similar to that as previ-
essentially of historical value and is seldom used. The base of the ously stated for screw fixation alone.
fifth is approached via a curvilinear dorsolateral incision. The As previously stated, literature abounds regarding multiple
fracture site is exposed subperiosteally. A rectangular section forms of fractures. It is somewhat confusing because, in some of
of bone measuring 0.7 × 2.0 cm centered over the fracture is the earlier literature, either specific type of fracture is not spec-
outlined by four drill holes and removed with a sharp osteo- ified or uniform treatment is applied to all fracture types. An
tome. The medullary canal is curetted free of all sclerotic bone, attempt will be made to dissect the literature and apply it in a
and the continuity of this cavity is reestablished. The original relatively simple yet appropriate fashion.5,42,49,50,51,54-59
description includes a tibial corticocancellous graft that is fash- Extra-articular tuberosity fractures typically require no more
ioned and replaced into the fracture defect. No fixation typically than supportive therapy and weight bearing as tolerated as soon
is applied because the graft often is slightly oversized, yielding a as the patient is able to manage pain and swelling appropri-
tight fit. The postoperative protocol includes non-weight-bearing ately. Multiple forms of “benign neglect” have been described,
cast applied for 6 weeks, with gradual resumption of activities including suggestions for compressive dressings, adhesive tap-
determined on the basis of pain tolerance after that. ing, supportive footwear with padding around the prominence,
Percutaneous intramedullary screw fixation also has been des and even short leg casting.45,50,51 There has been no consensus
cribed.3,5,42,44,50,52-58 This is performed through a small incision on the type of protective device necessary. However, it has been
initially at the base of the fifth metatarsal between the peroneus reported that even short leg walking casts probably are overpro-
brevis tendon and the lateral band of the plantar fascia. The tective in the management of this fracture.3,29 The pain usually
interval is developed, and a guidewire for a cannulated screw is has subsided significantly by the second week to allow reason-
inserted under fluoroscopic guidance. The key point to remember ably functional walking and transition into a more sports-spe-
about placement of the screw is that, on the basis of the anatomy, cific shoe and resumption of activity, again, as pain would allow.
the wire should be initiated “high and inside.” This suggests that It also is important to note that radiographic union may not
the guidepin should be started on the dorsal and medial aspect be present for a minimum of 4 to 6 weeks, and often longer.
of the bone just inside and superior to the edge of the tuberos- However, this should not preclude an athlete’s returning to
ity. Once the guidepin is positioned appropriately and verified sport should symptoms subside appropriately. It also has been
under fluoroscopic guidance, a canal is drilled and an appro- suggested that, on occasion, the fracture will heal with fibrous
priate- length screw is placed. Choices for the size of the screw union, and that typically this also is not symptomatic and, again,
typically are based on the size of the bone, and it is well accepted will allow the athlete to return to activity appropriately.50
that the largest screw that the canal can accommodate should Indications for surgery in this region are reserved for those
be placed. One technique tip is to overdrill using the cannulated patients that have either significantly displaced tuberosity frac-
guidepin system and then to remove the guidepin and place a tures or intra-articular involvement with displacement.45,60 Open
solid screw to provide greater tensile strength to the bone. It is reduction need not require an intramedullary screw as previously
crucial to avoid fracturing the metatarsal, and thus maintenance described, but only a small interfragmentary screw. Recognition
of the intramedullary position is of utmost importance. No cor- and treatment after delayed presentation may require that exci-
tex should be violated on passage of the screw. Postoperatively, sion of the fragment be performed, as opposed to standard open
 CHAPTER 7  Midfoot Fractures and Dislocations 139

reduction. The author’s experience with this fracture, even with required subsequent surgical treatment. Review of the literature
intra-articular, nondisplaced varieties, suggests that the non- demonstrates a rate of delayed union as high as 38% and a definite
operative treatment is and continues to be the standard of care. non-union rate of 14% with nonoperative treatment of these frac-
However, if there is any question regarding management, a more tures.51 It was additionally noted by Zelko et al. that, even after
aggressive approach should be instituted. Poor results with tuber- an extended period of non-weight-bearing, short leg casting for
osity fractures are largely anecdotal60 and may be a result of a a period of 10 to 12 weeks, refracture was possible, and surgi-
painful fibrous union, because lack of bony consolidation can cal treatment would be indicated for these patients.42 Still, there
approach 19%.61 Other factors involved in poor outcomes would exists a fairly large and reputable group of surgeons who suggest
be articular incongruity or sural nerve entrapment in the fracture that only in circumstances in which previous conservative treat-
after healing ensues, necessitating surgical management. ment has failed should surgical treatment be implemented. These
Treatment of the true acute Jones fracture has evolved. Initially, authors suggest that fractures that occur with no intramedullary
universal treatment was considered to be the application of short- sclerosis or no prior attempts at treatment not only will heal, but
leg walking cast.3,51 However, even in reports advocating this form will allow athletes to return to weight bearing within 6 weeks and
of treatment, there were found to be non-unions occurring that to activity by 12 weeks (Fig. 7.12, A through D).51,61-63

A B

C D
Fig. 7.12  (A and B) Acute fifth metatarsal or “Jones fracture.” (C and D) The patient elected for conservative
treatment and healed uneventfully after 6 weeks of non-weight-bearing casting.
140 SECTION 2  Sport Syndromes

A B
Fig. 7.13  (A and B) Percutaneous fracture reduction and treatment with intramedullary screw fixation.

A B

D
Fig. 7.14  (A and B) Shows a well-healed fifth metatarsal fracture in a professional soccer player. Six months
after return to full activities he came back with acute increase in pain and swelling. (C) Shows refracture as
well as fracture of the screw. (D) Three months after removal of the screw and plantar plate fixation with bone
marrow aspirate. Complete healing, and athlete returned to play.
 CHAPTER 7  Midfoot Fractures and Dislocations 141

In general, however, most authors agree that because of the A zone 3 injury, a true shaft fracture, usually involves a
potential for refracture, the cited delayed union rate, and the distraction-type force and typically behaves differently from
incapacitation required from nonweight bearing and immobi- a Jones fracture. These injuries often will present in a delayed
lization as a result of casting, high-performance athletes and fashion and may in fact even be stress fractures. An acute frac-
high-demand individuals be given the option for and be treated ture in this region typically will heal with a non-weight-bearing
with some form of surgical management.42,44,55,58,64,65 cast in a lower-demand individual, but again, operative treat-
Paired comparisons of operative versus nonoperative treat- ment as described for the Jones fracture should be offered to a
ments have been analyzed. Josefsson et  al.50 described 63 high-demand or high-performance athlete.
patients in which one-third of the patients were treated oper- In a more delayed or recurrent injury at this level with pro-
atively and two-thirds conservatively. Average follow-up was 5 dromal symptoms, these patients should be treated with sur-
years, and, on the basis of delayed union or refracture, in almost gical management with intramedullary screw, with or without
25% of the nonsurgically treated patients, subsequent surgical application of bone graft. Due to the variable curvature of the
treatment was required. Late surgery was required in 12% of bone more distally, these injuries may not be as amenable to
the acute fractures and 50% of chronic fractures. Clapper indi- intramedullary screw stabilization and plate fixation, should
rectly supported operative intervention, based on a review of be considered a viable and more reasonable alternative. Either
100 patients treated for acute Jones fractures with 8 weeks of plantar or dorsolateral plating has been effective and does not
non-weight-bearing casting. Results demonstrated only a 72% seem to provide much irritation despite the relatively thin soft
success rate with this form of treatment and average time to tissue envelope here.
union of 21 weeks.59 Frank non-unions and chronic injuries should be treated with
On the basis of the historical literature and currently available internal fixation and bone grafting. The author leans towards
techniques and prevailing opinions, a protocol has been estab- plantar plate fixation and bone grafting in these situations.66
lished that is my preference for the approach to the fifth meta-
tarsal-based fracture. This should be fractures of zone 1, acute
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36. Azurza K, Sakellariou A. ‘Osteosynthesis’ of a symptomatic bipar- 1995;315:238–241.
tite medial cuneiform. Foot Ankle Int. 2001;22(6):499–501. 60. Gould N, Trevino S. Sural nerve entrapment by avulsion fracture
37. Dellacorte MP, Lin PJ, Grisafi PJ. Bilateral bipartite medial cunei- of the base of the fifth metatarsal bone. Foot Ankle. 1981;2(3):153–
form. A case report. J Am Podiatr Med Assoc. 1992;82(9):475–478. 155.
38. O’Neal ML, Ganey TM, Ogden JA. Fracture of a bipartite medial 61. Pearson JB. Fractures of base of fifth metatarsal. Br Med J.
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39. Compson JP. An irreducible medial cuneiform fracture-disloca- 62. Drez Jr D, Young JC, Johnston RD, et al. Metatarsal stress frac-
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 CHAPTER 7  Midfoot Fractures and Dislocations 143

63. Lehman RC, Torg JS, Pavlov H, DeLee JC. Fractures of the base of retrospective case series and literature review. Foot Ankle Spec.
the fifth metatarsal distal to the tuberosity: a review. Foot Ankle. 2015;8(6):454–459. Epub 2015 Jun 30.
1987;7(4):245–252. 66. Varner KE, Harris JD. The proximal fifth metatarsal metadiaph-
64. Solan M, Davies M. Nonunion of fifth metatarsal fractures. Foot yseal Jones fracture: intramedullary screw vs plantar plate. Oper
Ankle Clin. 2014;19(3):499–519. Epub 2014 Jul 19. Tech Sports Med: Foot and Ankle Injuries in the Athlete: Foot and
65. Granata JD, Berlet GC, Philbin TM, et al. Failed surgical man- Ankle Injuries in the Athlete. 2017;25(2):59–66.
agement of acute proximal fifth metatarsal (Jones) fractures: a
Video Legends - https://www.kollaborate.tv/link?id=5c925  Video 7.2  Title: Radiographic demonstration of midfoot insta-
cadde934 bility. Legend: Abduction stress is placed across the midfoot while
examining the foot radiographically with a physician controlled min-
iature C-arm x-ray machine. Instability of the Lisfranc midfoot liga-
 Video 7.1  Title: Clinical evaluation for midfoot and Lisfranc
ments is demonstrated on this radiographic video.
instability. Legend: This video demonstrates clinical evaluation for
Lisfranc midfoot instability. The hindfoot is stabilized by the right
hand and the left hand pushes the foot into abduction.

143.e1
 8
Rupture of the Anterior Tibial
and Peroneal Tendons
Mark S. Myerson, Shuyuan Li, David A. Porter

OUTLINE
Rupture of the Anterior Tibial Tendon, 144 Peroneal Tendon Dislocation and Subluxation, 156
Anatomy, 144 Introduction, 156
Diagnosis, 144 Historical Perspective, 156
Methods of Repair, 144 The Anatomy of the Tissue (Peroneals, Retinaculum, and
Skin Incision and Approach to the Posterior Fibula), 156
Tendon, 145 The Nature of the Problem, 157
Tendon Graft, 146 History and Exam, 157
Extensor Hallucis Longus Tendon Transfer, 147 Treatment, 158
Outcomes of Treatment, 147 The Author’s Preferred Approach, 158
Rupture of the Peroneal Tendons, 148 Direct Groove Deepening Approaches, 158
Introduction and Tenosynovitis, 148 Indirect Groove-Deepening Approaches, 158
Tears of the Peroneus Longus, 151 Intrasheath Peroneal Dislocation Without SPR Avulsion, 159
Tears of the Brevis Tendon, 152 Rehabilitation Principles and Approaches, 159
Tears of Both Tendons, 155 Complications and Potential Pitfalls, 160

RUPTURE OF THE ANTERIOR TIBIAL TENDON

imaging studies necessary. Occasionally if there is focal pain,
Anatomy and one suspects inflammation or early degeneration, then
The anatomy of the tendon makes it susceptible to degenerative either ultrasound or magnetic resonance imaging (MRI) are
rupture due to attrition under the extensor retinaculum.1,2 The useful to delineate the extent of disease.3-5 In the presence of
healthy tendon passes under the medial compartment of the trans- complete rupture, MRI of the tendon rupture does not add any-
verse and cruciate crural ligament, and inserts onto the medial thing to planning treatment, since it is impossible to determine
cuneiform dorsally and medially, with an extension of the attach- the quality of the ruptured tendon, although some surgeons
ment to the more inferomedial aspect of the first tarsometatarsal may still use MRI to determine the extent of tendon retraction
joint and first metatarsal. The tendon frequently divides into two into the leg. Ultrasound may be used as a more dynamic evalu-
slips, equal in size, one on the medial cuneiform and the other on ation of the tendon to determine the excursion of the ruptured
the medial base of the first metatarsal, and only occasionally does tendon, which may have some impact on planning treatment.
the tendon attach only onto the medial cuneiform. If the tendon has retracted and one is faced with a chronic
Rupture of the anterior tibial tendon (ATT) usually occurs in rupture, then an MRI has a role, but here we do not focus on
older individuals due to degeneration and friction underneath the the ankle, but rather on the leg. This is relevant particularly in
extensor retinaculum.1,3-6 There is always a retraction of the prox- chronic ruptures where the tendon repair will require a graft,
imal stump of the tendon ranging from 1 cm to 10 cm, and not but this treatment cannot work if the muscle is not healthy. We
infrequently there is only a small stump left distally at its attach- therefore look for atrophy or fatty infiltration into the muscle
ment. Because the rupture rarely occurs as an acute precipitous prior to surgery to determine if a graft is possible or a tendon
episode, most patients do not present for some time, and a delay transfer is necessary.
in diagnosis with further retraction of the tendon is common.
Methods of Repair
Diagnosis We have three methods of repair available: an end-to-end repair,
The diagnosis of rupture of the ATT is made clinically by vir- the use of an adjacent tendon such as the extensor hallucis lon-
tue of weakness of dorsiflexion and a foot drop, and rarely are gus (EHL), or a tendon graft.6-10 The repair chosen depends on
144
 CHAPTER 8  Rupture of the Anterior Tibial and Peroneal Tendons 145

the size of the defect and the quality of the anterior tibial mus- cuneiform. It is important to insert or attach the ATT to the
cle noted on MRI. It does not help with treatment planning to navicular in the correct position under fluoroscopy over the
obtain an MRI of the ankle, since this does not demonstrate the dorsomedial navicular using a drill hole, and passing the ten-
quality of the muscle, i.e., with fatty infiltration or muscle atro- don through the hole and securing it with either an interference
phy, which would contraindicate the use of a tendon graft. If a screw or a suture anchor (Fig. 8.1A−C).
graft is not available or if the quality of the muscle is poor, then
a tendon transfer with either the EHL or the EHL and the exten- Skin Incision and Approach to the Tendon
sor digitorum longus (EDL) combined is used. For a rupture Regardless of the type of repair or reconstruction used, the
with a small gap less than 1cm with good quality of the tendon skin incision must always be more lateral than the under-
stumps on both sides, an end-to-end repair is appropriate and lying repair so that with skin closure, it is not directly over
easy to perform.11 the repair, thus reducing the pressure from the tendon on the
A patient rarely presents early enough such that an end- actual incision. This is less likely to occur if the tendon repair,
to-end repair or reattachment of the tendon can be easily per- transfer, or graft is passed under the retinaculum, but the latter
formed. An equinus contracture or fixed claw toe deformities is frequently scarred and this passing under the retinaculum
will often present as a result of the rupture of the ATT and the is difficult to do. Always therefore make the incision along the
attempt to compensate by using additional muscles to extend central aspect of the foot at least 1 cm lateral to the position of
the foot. In these cases, a transfer of the EHL and/or the EDL is the ATT. The skin is retracted medially, the extensor retinacu-
indicated in combination with an arthrodesis of the interpha- lum is incised longitudinally, and the tendon ends are visual-
langeal (IP) joints of the toes. ized. Before incising the retinaculum, pass a clamp under the
If the ATT is short but has enough length to be attached to retinaculum to see if passage of the tendon will occur to avoid
the navicular, this can be considered. This repair is very effec- cutting the retinaculum. Frequently, however, the extensor ret-
tive in cases in which retraction of the tendon is minimal but inaculum has to be incised distally to be able to identify the
not enough length is available to reattach it distally into the stump of the tendon. The proximal tendon is sutured with a

A B

C
Fig. 8.1  This patient sustained a rupture 8 weeks prior to diagnosis. (A) Note the slight hemorrhage in the
distal tendon with fraying of the tendon margins distally. One can see that the tendon has been avulsed under
the retinaculum; minor splits are still present in the distal tendon. (B) This is commonly associated with early
ruptures. One can attempt to pull on the tendon for 10 minutes to determine if any relaxation of the scarring,
fibrosis, and contracture occurs. (C) In this case, no further mobility of the tendon was noted and it was
secured into the navicular shown here with an anchor inserted under fluoroscopy.
146 SECTION 2  Sport Syndromes

No. 2 suture, and the tendon is then pulled distally. Maximal Tendon Graft
tension is applied to the tendon for 10 minutes to determine If the tendon is chronically ruptured and retraction of the ten-
the mobility of the muscle and then obtain some relaxation don is greater than 3 cm, a tendon graft is useful and a ham-
with elongation of the tendon at the musculotendinous junc- string allograft or autograft is used (Fig. 8.2A−G). A tunnel is
tion. The biggest challenge with this repair is to obtain the created under the retinaculum with a large clamp and exits at
correct tension; unless constant tension is applied at this time, the medial cuneiform where a small incision is made. We find
elongation of the muscle develops later on, along with dorsi- that it is easier to attach the graft to the proximal ATT first
flexion weakness and a partial foot drop. before the distal attachment, which is far more difficult to gain
The other problem that occurs with all repairs is slight the correct tension if done the other way around. The tendon
over-supination of the foot—an inevitable consequence of graft is attached to the ATT using a weave through and through
tightening the repair. This should not be of concern initially, the ATT, which means that the graft has to be tapered to half
although the foot position must be monitored during the recov- its diameter to facilitate passage of the tendon weave. It is then
ery and rehabilitation phase. An Achilles tendon lengthening passed under the retinaculum and attached to the cuneiform.
may be necessary to regain adequate dorsiflexion and to cor- The graft is always long enough to be able to secure it to the
rect the position of the foot during the repair. The repair should cuneiform using a double drill hole technique. This will give
be performed with minimal tension on the tendon, and the maximum bone tendon bone healing and more importantly
position of the foot must be passively correctable to at least 10 allow one to tension the tendon adequately. This is more diffi-
degrees of dorsiflexion without much resistance. Immediately cult when using a suture anchor technique. Here, with the latter
postoperatively, use of a cast, rather than a splint, is preferable technique, we recommend starting with the distal attachment,
to hold the foot in dorsiflexion. creating a soft tissue flap, suturing the tendon graft using the

A B

C D
Fig. 8.2  A chronic rupture was present in this patient who presented 6 months following the initial rupture
episode. (A,B) The skin incisions are marked out. Note that the proximal incision is anterolateral, lateral to the
passage of the anterior tibial tendon. (C) The allograft is now attached to the medial cuneiform with a double
drill hole technique supplemented by a suture anchor. (D) The distal stump of the anterior tibial tendon is now
indentified and pulled with a hemostat clamp until it is quite free in the incision.
 CHAPTER 8  Rupture of the Anterior Tibial and Peroneal Tendons 147

E F

G
Fig. 8.2, cont’d  (E) The allograft is passed deep to the retinaculum and the distal anterior tibial tendon cut sharply
proximal to the zone of tendon injury. The allograft is now slightly thinned to facilitate passage through the ante-
rior tibial tendon using a weave type attachment. (F) It is important to maintain the tension at each passage of the
tendon. (G) The tendon graft is finally sutured into the anterior tibial tendon using a 2-0 slowly resorbable suture.

anchor and then overlapping the flap over the tendon for fur- prevent anurey equinus. Patients can start weight bearing in the
ther fixation (Fig. 8.3A−E). cast at approximately 2 weeks once wound healing is apparent.
Any plantar flexion beyond neutral must be avoided during the
Extensor Hallucis Longus Tendon Transfer recovery process for the first 8 weeks. Aggressive physical ther-
If an EHL tendon transfer is to be performed in conjunction apy with rehabilitation is important once the cast is removed,
with an IP joint arthrodesis, the arthrodesis is performed first. for the muscle to regain strength.
The EHL tendon is then cut distally and pulled proximally to
lie adjacent to the insertion point of the ruptured tendon. The Outcomes of Treatment
length usually is sufficient for a double strand of the EHL ten- The outcomes of both nonoperative and operative treatment
don. The tendon is pulled distally and then secured over the of ruptures of the ATT are quite satisfying, provided that the
distal stump or the medial cuneiform with a suture or suture treatment meets the expectations of the patient.1,7,12,13 Many
anchor. Alternatively, one can drill two perpendicular 4.5-mm elderly patients do not object to the use of an ankle foot ortho-
holes into the dorsal and medial cuneiform and pass the EHL sis (AFO), and this can be supplemented with a dorsiflexion
tendon through the tunnel. There will be sufficient tendon assist on the AFO, if the foot is catching on the ground in the
length to pass the distal portion of the EHL tendon proximally swing phase of gait. The problem with the AFO is that it is
as a second strand and sutured down onto the proximal ATT not universally accepted, and if it is not worn regularly, the
under tension (Fig. 8.4A−D). foot will catch as a result of the foot drop as it lags behind in
Regardless of the type of suture repair, the foot must be the final swing phase of gait. Surgery will always restore the
immobilized in dorsiflexion of at least 10 degrees and prefera- ability to dorsiflex the foot to at least minus 5 degrees, and
bly 20 degrees during recovery. As noted above, a percutaneous although in the worst-case scenario full active dorsiflexion is
Achilles tendon lengthening is the rule rather than not for these not achieved, these patients function well. Once the skin has
cases. We use a cast that is split immediately postoperatively to healed, we commence with rehabilitation as noted above. This
148 SECTION 2  Sport Syndromes

A B

C D

E
Fig. 8.3  This is a complex chronic rupture with scar and multiple strands of apparent tendon that are actually
only tendon scar. (A) The healthy extensor hallucis longus (EHL) tendon can be noted deep in the incision. (D)
The scarred and ruptured anterior tibial tendon (ATT) is now mobilized under tension with a hemostat. (E) At
the completion of the graft interposition, the remaining scar tissue is used to reinforce the tendon, and the
retinaculum repaired.

is very important, particularly in this age group who are prone RUPTURE OF THE PERONEAL TENDONS
to develop muscle atrophy that at times cannot be recovered.
We have not identified any patients in our experience with a Introduction and Tenosynovitis
recurrent rupture following treatment, but weakness in active Rupture of the peroneal leads to unpredictable results even
dorsiflexion most definitely does persist in about 15% of with what appears to be optimal surgical treatment. We used
patients. to believe that a rupture that involved more than 50% of the
 CHAPTER 8  Rupture of the Anterior Tibial and Peroneal Tendons 149

A B

C D
Fig. 8.4  In this case, the anterior tibial tendon (ATT) was so severely scarred and associated with fatty infil-
tration of the proximal muscle on magnetic resonance imaging (MRI) that we went directly to the extensor
hallucis longus (EHL) transfer without opening the ATT sheath. (A) The EHL is cut in the midfoot leaving suffi-
cient length to pass through a drill hole in the middle cuneiform. (B) A tunnel is made in the middle cuneiform
using a hand reamer that removes a 7-mm diameter of bone. (C) A needle is attached to the suture on the
EHL and passed through the cored hole, into which a suture anchor has been inserted prior to passing the
EHL tendon. (D) The tendon is then pulled into the hole and tensioned with the foot in 10 degrees of dorsi-
flexion and sutured.

tendon, a repair would not be successful, but it is apparent clinical condition. As the tearing worsens, deformity begins
that this is not the case in recent studies where as little as 30% to occur (in particular, varus deformity of the heel). A com-
of a viable tendon may be sufficient for tendon function.14-16 mon example of early disease occurs with stenosis at the level
Perhaps the greater issue is that we do not understand what is of the peroneal tubercle, which enlarges when associated with
the capacity for tendon healing to occur. The issue has to do heel varus deformity, and as the peroneal tubercle enlarges,
with chronic fibrillation of the tendon during rupture, and it it will lead to a complete rupture.15,22 Although the tubercle
is rare that one has a clean tear of the tendon. More likely with may enlarge for no particular reason, enlargement is more
both tendons, but more commonly with the brevis, multiple common in patients with heel varus or a cavus foot deformity.
longitudinal splits of the tendon are present, and it is difficult This leads to chronic friction and pressure of the tendons on
to know what the potential is for one or the other strand to heal the tubercle, causing what appears to be an hourglass shape
with suture repair.16-18 deformity under the retinaculum over the tubercle, and this
We are not certain if a true form of tenosynovitis actually will cause thinning and narrowing of the tendons. The tendon
occurs, or whether these are all prerupture conditions, since changes will in turn be worsened by the increased stress on
progression to more extensive tears seems to be common.19-23 the tendons if the heel is in varus. If a patient presents there-
Regardless of the pathology, it is our opinion that the earlier fore with chronic pain directly over the tubercle, one has to
these conditions are treated, the better (whether tensosynovi- consider stenosis of the tendon(s) (Fig. 8.5A−D). The tubercle
tis, tendon fibrillation, or complete tendon tears), given we see presses from below and the retinaculum from above, leading
that pathologic changes will progress, leading to a far worse to the stenosis. If treated early enough, simple arthroscopic
150 SECTION 2  Sport Syndromes

A B

C D
Fig. 8.5  This patient had experienced 1 year of pain over the mid-lateral calcaneus, and the pain was directly
over the peroneal tuberble. (A) When opened, a normal brevis tendon was present, but the longus was
severely hypertrophied and partly torn. (B) Both tendons were retracted and the tubercle removed with a
sharp chisel. (C) Bone wax was then applied to the surface of the bone. One must always inspect both ten-
dons carefully, since this tear of the longus was not initially apparent. (D) The tear was excised and the tendon
left open without a tubular repair of the tendon.

decompression and debridement of the tubercle, or an open Another common cause of retro-fibula pain that is worsened
release of the tendon sheaths and removal of the tubercle, is by passive dorsiflexion of the ankle is a low-lying peroneus bre-
a very effective early treatment.21,24 Left untreated, however, vis muscle.25-28 This is not associated with a tear of the tendon,
the stenosis will cause rupture of one or both tendons. The but the patient presents with the same symptoms. Generally, at
longus and brevis tendons distal to the fibula have a separate the level of the distal fibula, there is no muscle present, so that
sheath, and both tendons should be opened and the split in gliding of the tendons is present with passive plantar and dor-
the tendon(s) identified under the separate retinaculum, and siflexion of the ankle. When there is a low-lying brevis muscle
the peroneal tubercle is debrided if it is seen to be enlarged. I the tendons do not subluxate, although the patient will report
use bone wax on the raw abraded surface under the peroneal that it feels as if the tendon is going to pop, but is more associ-
tubercle once the repair is done. MRI might be expected to ated with pain than a feeling of subluxation. The pain is caused
be a useful diagnostic modality in the management of acute by the volume effect of the increased mass of the tendons and
tears or inflammation, but we have found that there is not a muscle under the retinaculum. As the foot dorsiflexes, the ten-
good correlation between the clinical and pathologic findings dons are sucked into the fibula groove, and if the muscle volume
and MRI (Fig. 8.6). This is not, however, the case with chronic is increased, pain will develop from impingement. This is very
ruptures, where an MRI of the leg will yield useful informa- simple to treat. Usually, we have not made the diagnosis preop-
tion, particularly if one is considering whether or not a tendon eratively unless an MRI had been obtained, but the diagnosis
transfer or a tendon graft is required for treatment. If there is becomes immediately obvious when opening the retinaculum.
muscle atrophy, or fatty infiltration of the peroneal muscles, The muscle is peeled off the tendon, and it is rare to find an
then it is not possible to use these tendons for reconstruction, associated tear of the tendon present. A simple repair of the ret-
and one has to rely on a tendon transfer.14 inaculum is enough to contain the tendons.
 CHAPTER 8  Rupture of the Anterior Tibial and Peroneal Tendons 151

Tears of the Peroneus Longus

Tears of the peroneus longus occur more commonly at the level
of either the peroneal tubercle or in association with a patho-
logic os peroneum as the tendon winds under the cuboid.20
Rarely, the os peroneum is visible radiographically but not
under the cuboid in its normal location, but more proximally
along the margin of the calcaneal tuberosity. This is not always
easy to see because of the shadows of the calcaneus, but efforts
to observe should be made (Fig. 8.7A−C). A common X-ray
finding of rupture of the peroneus longus is the position of the
os peroneum on an oblique view of the foot. The os peroneum
normally lies under the cuboid, and if it is more proximally
located, particularly if one has prior radiographs for compari­
son, then an acute rupture is suspected. Acute ruptures of
the longus occur under the cuboid, and one has to decide how the
repair is performed. If the os peroneum is still present, and the
tendon is fibrillated and torn at both ends of the os, then
one can still try to perform an end-to-end repair with excision
of the os peroneum. Excision of the os peroneum may create
a defect, and if this is greater than 1 cm, it becomes difficult
to repair end-to-end. Often, however, with careful excision of
Fig. 8.6  The magnetic resonance imaging (MRI) of the tendons demon- the os peroneum, the shell of the remaining longus tendon can
strates edema around the longus tendon, but it is not possible to deter-
be repaired with multiple running weave sutures as the tendon
mine with any accuracy the extent of the tear. In our experience, there
is no correlation between the MRI and the pathologic findings intraop- passes under the cuboid. If one attempts this kind of repair
eratively. under the cuboid, it is necessary to extend the skin incision

B C
Fig. 8.7  (A) The normal appearance of the os peroneum is demonstrated here. (B,C) In contrast to the normal
os, note the pathologic changes in the next illustration associated with hypertrophy and irregularity of the
bone against the cuboid.
152 SECTION 2  Sport Syndromes

A
B

C
Fig. 8.8  (A) This rupture of the longus tendon occurred 8 weeks previously and the tendon has organized the
stump and retracted almost to the level of the tip of the fibula. The scar has been excised and is lying free on
the side of the foot, and the longus sutured and placed on tension. (B) Now one can appreciate the extent of
proximal retraction. (C) As an alternative to suture of the ruptured tendon into the brevis, it was inserted into
the calcaneus with an interference screw. This prevents potential scarring of the tenodesis.

along the base of the fifth metatarsal so as to gain more visual- or torn tendon, such that wherever possible, it should be avoided.
ization under the cuboid by reflecting the abductor digiti min- Generally, therefore, unless we specifically want to rebalance the
imi muscle dorsally. hindfoot in a cavovarus deformity, a ruptured peroneus longus is
If the tear is more chronic, it cannot be repaired in an end- inserted into the cuboid or calcaneus with an interference screw.
to-end fashion because the retracted portion of the tendon is Regardless of the treatment, unless one is able to repair the longus
impossible to reattach distally under the cuboid (Fig. 8.8A−C). tendon underneath the cuboid, its function on the first metatarsal
In this case, one has to decide what to do with the torn tendon. will be lost, but not its eversion function.
There are two options, one to transfer it into the peroneus bre-
vis, and the other using a drill and interference screw into either Tears of the Brevis Tendon
the cuboid or calcaneus depending on the length of the tendon. For repair of isolated tears of the peroneus brevis, an incision
We are not generally in favor of a tenodesis of the longus to the is made along the length of the posterolateral ankle extending
brevis, particularly in the athlete. The side-to-side tenodesis of along the course of the tendon behind the fibula. The proximal
the peroneus longus or peroneus brevis tendon is an acceptable and distal extent of the incision is determined once the disease
procedure; however, insertion of the peroneus longus into the is identified after the retinaculum is opened. It may not be pos-
cuboid is preferable (Fig. 8.9A−B). Although transfer of the lon- sible to preserve the extensor retinaculum by leaving a slip of
gus to the brevis is commonly performed to realign a cavovarus the retinaculum intact, but make sure that there is a good cuff of
foot deformity, we worry that scarring of the tendon may cause tissue for repair at the completion of the repair, particularly at
symptoms in what was otherwise a normal brevis tendon. We the distal fibula. The brevis tendon usually has multiple longitu-
have seen too many recurrent peroneal tendon problems with dinal splits or tears. It is important to check the ankle for insta-
aggravated tears following side-to-side tenodesis of the abnormal bility, since there is a high incidence of tears of the peroneus
 CHAPTER 8  Rupture of the Anterior Tibial and Peroneal Tendons 153

brevis associated with ankle instability.29 There are a few ways to If ankle instability and peroneal splits are associated with
consider the repair. Either one excises the split tendon leaving varus deformity of the heel, then all three components of the
the larger portion behind, or attempts a repair. Then one has to deformity can be addressed simultaneously.15,30 We prefer to
decide what to do with the remaining piece of the tendon that is use one and not two incisions for this procedure, through which
left behind. We used to use a running slowly resorbable suture the tendon repair, the ankle ligament reconstruction, and the
for repair of the remaining tendon, but found that this was not peroneal debridement or repair can be performed. As for the
always successful in our hands or in those patients we treated type of ankle ligament reconstruction, one can perform an ana-
who had already undergone debridement with repair (Fig. tomic procedure, i.e., a Brostrum type procedure, supplemented
8.10). A few years ago, we began to debride the major splits, by fiber tape or fiber wire sutures, but this depends on the qual-
leaving behind as much of one section of the tendon as possible ity of the anterior talofibular ligament. One cannot augment the
and then just left it alone without a tubular repair of the ten- repair with fiber tape unless there is sufficient ligament beneath
don (Fig. 8.11). This treatment was far easier, quicker to recover it, since the fiber wire or tape will eventually fail unless there is
from, since there was no tendon healing to recover from, and biologically viable tissue beneath it. If there is any question as
rehabilitation could begin earlier. The midterm (2−5 years) to the viability of the ligament or if the tear of the brevis ten-
results with this technique seemed to be better than those ten- don is extensive, reaching both proximal and distal to the fib-
dons that we had repaired, but we never performed a definitive ula, a portion of the tendon may still be excised or even used as
comparison of the two patient groups. We will leave the tendon part of a nonanatomic ankle ligament reconstruction. The latter
behind even if the largest of the split pieces is about 30%−40% procedure is very useful when there is marked ankle instabil-
of the diameter of the normal tendon. Considerations in this ity and an anatomic repair cannot be performed, or where the
decision include the size, length, and extent of the split. patient is a heavy athlete for whom the Brostrom type repair will

A B
Fig. 8.9  (A,B) The rupture of the longus occurred more distally at the level of the os peroneum, but could not
be repaired, and a drill hole was made into the cuboid and the tendon inserted with an interference screw.

Fig. 8.10  This isolated rupture of the brevis tendon included 30% of Fig. 8.11  The rupture of the brevis tendon included 50% of its diame-
the tendon diameter, and the 70% remnant was then sutured by tubu- ter, and the torn tendon was excised and not repaired. Once the tear
larizing the tendon. was excised, no suture repair was performed.
154 SECTION 2  Sport Syndromes

not be sufficient. For these cases, in addition to the attempted a tendon graft to a nonfunctioning muscle does not make sense.
Brostrum procedure, any number of different types of nonan- In patients in whom both tendons are torn, but the muscle is
atomic procedures can be considered such as the Evans or the healthy, with good excursion elicited by pulling on the mus-
Chrisman Snook procedure. In this type of case, a portion of culotendinous junction, a tendon graft can be performed. The
one of the splits of the tendon may be used to reinforce the ankle free graft is first attached proximally to the healthy tendon or
ligament reconstruction to perform a Brostrum-Evans proce- at the musculotendinous junction. When it is attached distally,
dure. In cases where there is more deformity or severe insta- the correct tension on the graft must be applied. The optimal
bility, which may include the subtalar joint, a Chrisman Snook degree of tension may be difficult to determine because no ret-
procedure should be considered. Any chronic isolated tear of inaculum is present, and the tendon graft may have a tendency
the peroneus brevis may be associated with a varus deformity to sublux from behind the fibula. Once the suture attachment is
of the calcaneus. This is quite a common scenario in a cavus performed distally, the retinaculum must be repaired anatomi-
foot with heel varus, which is often associated with a tear of the cally to prevent dislocation
peroneal tendons (Fig. 8.12A−G). If a tendon graft is not available, nor possible because of
If the brevis tendon is irreparable, then one has to consider the quality of the peroneal muscle or significant scarring of
either a tendon transfer or a tendon graft.31 If a graft is used, the the proximal tendon, then a transfer of either the flexor digi-
brevis muscle must be healthy on MRI and also demonstrate torum longus (FDL) or the flexor hallucis longus (FHL) ten-
good excursion proximally. We note that an MRI of the leg is don is performed. There are advantages and disadvantages
obtained in contrast to the usual technique of MRI of the ankle of using either the FDL or the FHL tendon. All patients are
to evaluate the tendons only. The latter is of no value in manag- aware of weakness following the use of the FHL, and it would
ing a chronic rupture, since we are more interested in the quality be incorrect to assume that removal of the FHL does not cause
of the muscle in order to perform a tendon graft. If the musculo- functional losses. If one uses a short FHL tendon for transfer,
tendinous junction is scarred and has no mobility, then adding then a limited length of the tendon is available, but there are

A B

C D
Fig. 8.12  This patient suffered from chronic retrofibular pain associated with ankle instability. (A) There was a
massive osteophyte on the distal fibula and a tear of the brevis tendon noted. (B through D) The osteophyte
was first removed with an osteotome from the distal fibula.
 CHAPTER 8  Rupture of the Anterior Tibial and Peroneal Tendons 155

E F

G
Fig. 8.12, cont’d  (E through F) The split tear of the peroneus brevis was then extended more distally and the
anterior half of the tendon used to perform a modified Chrisman Snook procedure.

cross connections between the FHL and the FDL just distal released proximally so that it can be pulled out of the incision
to the master knot of Henry, and if the FHL is cut proximal just behind the posteromedial ankle.
to this, there may still be adequate function of the hallux IP
joint. The length of the tendon harvested in this manner is not Tears of Both Tendons
very long, and is sufficient to pass around the back of the ankle When both tendons are ruptured, one should try to deter-
and into the stump of the peroneus brevis. If, however, there mine if the remaining strand of either one is viable to use,
is no peroneus brevis stump or if one desires better bone fix- since one of the tendons (the longus) can be transferred to
ation, then the entire FHL tendon should be harvested with the distal stump of the brevis.16,32 This obviously depends
a tenotomy under the hallux IP flexion crease, and this will on the percentage of the torn tendon that is still healthy.
provide a very long strip of tendon to pass through a drill hole Alternatively, repair of one of the two tendons can be
in the base of the fifth metatarsal and then sutured back on attempted, if the other is not salvageable. If both tendons
itself for a very secure fixation that permits early weight bear- are torn, there are generally only two options, either a ten-
ing. For the approach to harvest the FHL, we use an incision don transfer or a tendon graft (Fig. 8.13). The gracilis/sem-
along the medial arch of the foot just between the plantar fas- itendinosus graft is indicated provided it is available as an
cia and the abductor hallucis muscle. We then palpate the FHL allograft or if the surgeon has the necessary skill to harvest
by manipulating the hallux. Deeper dissection is performed an autograft hamstring tendon.33 It can only be performed
until both the FHL and FDL tendons are visible. It can then if the muscle remains healthy, with good excursion elicited
be cut at the level proximal to the master knot of Henry or by pulling on the tendon and noting mobility at the muscu-
at the IP joint of the hallux depending on the length of the lotendinous junction. The free graft is first attached prox-
tendon required. Once the tendon is cut, there are cross con- imally to the healthy tendon and then distally where it is
nections between the tendon and adjacent tissue including the easier to apply the correct tension to the graft. It is always
retinaculum, and the tendon often has to be more completely very important to have the correct tension maintained, since
156 SECTION 2  Sport Syndromes

PERONEAL TENDON DISLOCATION AND

SUBLUXATION
Introduction
Peroneal tendon dislocation is often associated with athletic
activity. It was first popularized as a diagnosis in the sport of
downhill skiing.34 It was surmised that the tip of the ski itself
could get caught in the snow causing the athlete to dorsiflex
and evert the ankle while the momentum carried the athlete
down the hill. The tip of the ski would remain lodged in the
Fig. 8.13 Multiple tears of both tendons were present in this young
snow while the peroneal tendon would seek a more direct path
patient who had undergone two prior attempts at repair. There are mul- from the lateral foot to the retro-fibular area and dislocate ante-
tiple splits in the brevis tendon, and the clamp is holding the longus rior and laterally around the tip fibula. This dislocation has now
tendon. The remnant of the longus tendon is severely scarred under the been noted in most all sports and can be associated with similar
hemostat clamp. activity to an ankle sprain. The association between lateral ankle
instability and peroneal tendon dislocation is actually some-
there may be inevitable stretching out of the graft or the what uncommon, and is probably around 10% (personal obser-
suture margins. The optimal degree of tension may be diffi- vation). It is speculated that a smooth or convex posterior fibula
cult to determine because no retinaculum is present, and the contribute to instability of the peroneal tendons. Nonoperative
tendon graft may have a tendency to sublux from behind the treatment for peroneal tendon dislocation has historically
fibula. Once the suture attachment is performed distally, the proven unsuccessful. However, surgical procedures for stabili-
retinaculum must be repaired to prevent dislocation of the zation have historically shown excellent outcomes. With appro-
tendon. We do not perform a tendon graft for the peroneus priate rehabilitation and avoidance of some common pitfalls,
longus, only for the brevis tendon. such as extensive immobilization that leads to scarring, a suc-
Peroneal muscle weakness often is associated with a cavo- cessful return to recreational or competitive athletics is typically
varus foot, and injury to both tendons in a varus hindfoot is attainable.
therefore common.14,15 A tear of both tendons leads to net
inversion of the hindfoot by the tibialis posterior muscle, and Historical Perspective
this results in a fixed varus hindfoot deformity, which must be Peroneal tendon injury is a common problem in both the ath-
corrected in addition to the correction of the dynamic balance letic and nonathletic population. Most peroneal tendon injuries
of the muscle imbalance. Ankle ligament instability needs to occurr in the middle-aged patient. Peroneal tendon tear and
be corrected, and if a varus heel is present, a calcaneal osteot- tendinopathy is the most common injury to the peroneal ten-
omy (Dwyer or lateral slide osteotomy) should be performed to don complex. The degenerative tearing of the peroneal tendon
decrease the force on the heel and protect the repair. It does not again occurs in the older population, while the younger athletic
make any sense to perform a repair of the peroneal tendon in population has a much less common incidence of peroneal ten-
the setting of heel varus, which could lead to recurrent hindfoot don injury. However, in the younger population, and especially
instability and recurrent tearing of the tendon. the athletic population, peroneal tendon dislocation is much
If a tendon transfer is indicated, we perform either an FDL or more common.35,36 In fact, peroneal tendon dislocation may be
FHL tendon transfer to the stump of the peroneus brevis tendon the most common presentation for peroneal tendon complex
or the base of the fifth metatarsal. This transfer is preferable if injury in the teenage and young adult athlete.37 A great deal of
there is no proximal muscle function or excursion. If, however, attention has been given to instability of the peroneal tendons,
excursion of the proximal muscle is present, use of a tendon but true dislocation remains uncommon. Pseudo-subluxation
graft (with a hamstring graft) seems more logical, but tendon or intrasheath peroneal tendon instability is also another cause
grafting is contraindicated in the presence of muscle fibrosis or of peroneal tendon pain.38-40 This involves the peroneal tendons
scarring of the tendons to the lateral compartment of the distal subluxing within the sheath around one another. Intrasheath
leg. With either repair, it is important to determine the condi- subluxation involves the peroneus longus tendon displacing
tion of the tissue bed. If active inflammation or fibrosis exists, lateral to the brevis within a stretched-out sheath and “loose”
then a nonfunctional result is likely as a consequence of scarring superior peroneal retinaculum.
and limited tendon excursion (Fig. 8.14A−D).
Correcting any deformity of the hindfoot or ankle that The Anatomy of the Tissue (Peroneals, Retinaculum,
could lead to recurrent tendon injury is important. Repair of an and Posterior Fibula)41
unstable ankle must be performed as a planned procedure that The posterior sulcus of the fibula has a variable contour, thus
is based on preoperative symptoms of instability of the ankle it is considered a predisposition to contribute to dislocation
confirmed with stress radiographs. If present, associated hind- in some athletes/patients.42,43 The two tendons are in a fibro-
foot varus is corrected with a closing wedge biplanar calcaneal osseous tunnel bordered anteriorly by the posterior fibular
osteotomy, and the same incision is used for the peroneal ten- fibro-cartilaginous sulcus (distal 4 cm), posteriorly and later-
don repair as for the calcaneal osteotomy. ally by the superior peroneal retinaculum (primary constraint
 CHAPTER 8  Rupture of the Anterior Tibial and Peroneal Tendons 157

A B

C D
Fig. 8.14  This patient had undergone two prior surgeries with a tenodesis of the longus to the brevis as the
last procedure. (A) Note the markedly thickened tendon. (B) The tendon was noted to be torn at the level of
the prior attempted tenodesis. There was no good muscle noted on magnetic resonance imaging (MRI) of
the leg, and a transfer of the flexor hallucis longus FHL was performed. (C) Note the length of the tendon that
can be obtained by cutting the tendon under the interphalangeal (IP) joint of the hallux. (D) The FHL tendon
is passed through a drill hole in the base of the fifth metatarsal and then sutured back on itself for excellent
fixation, which will facilitate immediate bearing of weight.

to dislocation) and medially primarily by the calcaneal fibular posterior fibula is typically enough to prevent redislocation after
ligament (CFL; a though the posterior talofibular ligament and appropriate superior peroneal repair in acute settings, but it
posterior-inferior tibio-fibular ligament form part of the medial could still need deepening in chronic cases that require retinac-
border). There is also a posterolateral fibocartilaginous meniscal– ula reconstruction. The earliest approach to groove deepening
like structure that adds depth and lateral constraint to the ret- was by Kelly46 and involved a true rotational fibular osteotomy.
romalleolar groove/sulcus.42,43 This is the structure that is often We should note here that another approach taken by several
avulsed with acute tendon dislocations and degenerated in authors involved rerouting the peroneal under the CFL by oste-
chronic dislocations. The posterior fibular anatomy has a varied otomizing the CFL attachment to the distal fibula.47-50
surface contour. Eighty-two percent are concave, 11% are “flat,”
and 7% are actually convex.41,44 The flat and convex anatomy in History and Exam
association with peroneal dislocation requires a formal fibular The injury history can be very similar to a common lateral ankle
osteotomy for groove deepening in addition to reconstruction sprain. It is commonly seen during sport and as mentioned, was
of the superior peroneal retinaculum, regardless of the acuity first reported commonly in downhill skiers.34 However, it can
of the dislocation. It should be noted, however, that Adachi and occur with any sport or active lifestyle activity. There is often a
coworkers42 did not find a difference in the inherent anatomy sensation of a “pop” and occasionally a feeling “like something
between subjects treated for peroneal dislocation and a simi- came out of place.” The athlete notes pain in the lateral ankle
lar population of subjects that did not have a peroneal tendon and swelling in the posterior lateral ankle. Tenderness is more
instability history. Schon’s lab has demonstrated that a peroneal specific to the posterior lateral fibula than the anterior lateral
groove-deepening procedure can reduce the pressure within the ankle seen with lateral ankle sprains. In the acute setting, it is
peroneal sheath.45 difficult to get the peroneals to dislocate on exam in the office.
Two to three weeks after the injury, or in the chronic setting,
The Nature of the Problem the peroneals can be dislocated by plantarflexing the ankle,
A shallow, flat or convex posterior fibula is thought to lead to placing it in eversion and displacing the tendon over the pos-
poor bony stability of the peroneal tendons. After a dislocation terolateral fibula to confirm the diagnosis (Video 8.1 and Video
of the peroneal, lack of inherent bony stability puts a significant 1.11). A thorough ankle exam also needs to be performed to
strain on the repaired or reconstructed superior peroneal reti- rule out concomitant lateral ankle ligament instability/injury.
naculum. It has been concluded that groove deepening of the Routine ankle series x-rays are helpful and required. For the
posterior fibula is not only helpful but necessary in situations peroneal dislocation, assessment for a small posterolateral fib-
where there is no deep bony stability. Even mild concavity to the ular avulsion or other associated bony/osteochondral lesion
158 SECTION 2  Sport Syndromes

(OCL) injuries is needed. In the acute setting, any type of bony Direct Groove Deepening Approaches
fractures is evaluated well in with plain x-rays. Advanced imag- RE Kelly in 1920, reporting from Liverpool England in the British
ing is reserved for chronic setting to assess for a concomitant Journal of Surgery,46 first proposed groove deepening for a recur-
peroneal tendon tear (most commonly a peroneus longus tear rent peroneal tendon dislocation. He described a sagittal “veneer”-
if present).51 Also, the superior peroneal retinaculum can be type osteotomy of the distal 2 inches above the distal fibular tip and
assessed in the acute setting and is seen best on the axial imag- then rotated the lateral bony “veneer” of bone posterior to create a
ing. Thomas has described using ultrasound to evaluate the dis- deepened groove.46 Zoellner and Clancy71 proposed a hinged pos-
locating peroneals.40 terior flap of the retromalleolar groove that produced a more direct
posterior deepening. Their technique involved the following: “the
Treatment36,52 groove for the tendons is deepened by removal of some inner fibu-
Nonoperative treatment has not been shown to be effective for lar substance, while the smooth tenosynovial channel is maintained
stabilizing the tendons. We have used a “J” or “U” pad around as an intact periosteal flap on the fibula.”71 Slatis and co-workers65
the lateral fibula to allow some athletes to complete a season. modified the Zoellner and Clancy71 report of direct deepening by
Operative stabilization is the mainstay of treatment. removing the cartilaginous gliding layer of bone from the retro-
malleolar fibular groove, removing further cancellous bone using
The Author’s Preferred Approach53 a curved chisel and replacing the cartilaginous gliding bone by
We first determine if there is an acute dislocation. That is, are we impacting it into the deepened groove.65 Porter, McCarroll, and
seeing the athlete/patient within the first 1–2 weeks of injury, or co-workers53 also modified the Zoellner and Clancy approach by
is this a chronic recurring dislocation that has been re-occur- removing the posterior cortical cancellous retromalleolar groove
ring greater than 4 weeks from the time of initial injury? with the intact serosa surface, deepened the distal posterior groove
For the acute dislocation, we still believe that operative treat- by removing cancellous bone with a motorized 4.0 egg burr, and
ment is the treatment of choice. In some situations, the pos- then replaced the gliding surface by reattaching it with sutures in
terior lateral cartilaginous rim is still intact and the posterior the depth of the deepened groove.53 This detailed groove deepen­
fibular anatomy has a reasonable concave contour. In this situ- ing and standard retinacula reconstruction allowed the authors to
ation, with a good underlying groove, we will initially try acute offer a more accelerated protocol in their rehabilitation. The authors
repair of the superior peroneal retinaculum(SPR).54,55 We have reported on 13 athletes (14 ankles) who were allowed early weight
had good success when there is a naturally good deep groove in bearing (1–2 weeks PO); these only used intermittent immobiliza-
the acute setting. However, we do not take this acute repair only tion with a walking boot (4 weeks total and then 2 weeks wean into
approach in the chronic setting.55 a stirrup brace) and reported earlier return to sports (3 months).
For the chronic recurring dislocation, there are numerous No dislocations and near-normal ROM were achieved (Fig. 8.15).
approaches described.38,46-49,53-74 We always perform a groove- Zhenbo and collegues70 report in 2014 an approach rem-
deepening procedure. In this chronic setting, the posterior lat- iniscent of the Kelly procedure. Their approach also involved
eral cartilaginous rim is almost always absent, and we have not a sagittal osteotomy in the fibular with a posterior slide of the
found the posterior fibula to have enough concavity to support osteotomy fixed with absorbable screws.70
the peroneal tendons and their position.
An oblique 20-degree (toward the sagittal plane) osteot-
Surgeons have described several operative approaches to
omy was made anteromedially with a small oscillating saw
groove deepening of the fibula. We have categorized the osteot-
extending from about 3 cm above the lateral malleolus to
omies into direct groove deepening and indirect groove deep-
the fibular apex. When the saw nearly reached the posterior
ening. However, the general principles we believe are universal.
edge, the osteotomy exit(s) posterolaterally without damag-
We think the following principles are crucial to an optimal
ing the cartilaginous ridge. The graft (3 × 2 × 0.5 cm) (is)
outcome:
slid 20 to 30 degrees (3–5 mm) posteriorly to ensure an ade-
1. A fibular osteotomy is necessary to give adequate groove
quate block to dislocation. The graft was secured to the dis-
deepening if not inherently present.
tal fibula with 2 or 3 absorbable self-reinforced polylactide
2. The fibular osteotomy must be deepened to a point that the
(SR-PLLA) screws (Conmed Biofix SmartScrew, Conmed
posterior border of the peroneal tendons, when replaced
Linvatec, Espoo, Finland). The SPR and sheath are attached
within the deepened groove, is flush with, or anterior to, the
to the graft, using the modified Das De technique.68
posterior border of the resultant groove.
3. Tightening and imbrication of the superior peroneal retinac-
ulum must be undertaken also to give appropriate soft tissue Indirect Groove-Deepening Approaches
constraint to dislocation. Reattachment of the SPR must be Shawen and Anderson first described the indirect approach.64
undertaken in instances of true dislocation (intrasheath dis- The tip of the fibula is exposed and a “suitable sized” reamer
locations do not require reattachment of SPR, just imbrica- from the Arthrex biotenodeses screw set is used to “thin” the
tion). posterior cortex of the groove. A moderate, wide bone impac-
4. Rehabilitation must include early range of motion (ROM) to tor is used to deepen the posterior surface in an indirect man-
prevent scarring and subsequent pain from tendon restric- ner, recreating the concavity needed to insure stability. Walters
tion. We believe early weight bearing is advantageous for and co-workers describe using a 3.5-mm drill to make multi-
accelerated recovery. ple passes under the posterior; a “small” osteotome is utilized
 CHAPTER 8  Rupture of the Anterior Tibial and Peroneal Tendons 159

Retinaculum

Peroneus
longus tendon
(dislocated)

A B
Peroneus
brevis tendon

C D

Fig. 8.15  A-D Porter and associates approach to direct fibular osteotomy for groove deepening. A modified
approach to the Zoellner and Clancy43 approach involves removing the posterior cortical cancellous sulcus
(rather than hinging), deepening the cancellous groove, and replacing the posterior sulcus in the deepened
cancellous bed with reattachment of the superior peroneal retinaculum. (From Porter D, McCarroll J, Knapp
E, Torma J. Peroneal tendon subluxation in athletes: fibular groove deepening and retinacular reconstruction.
Foot Ankle Int. 2005;26:436-441.)

to perforate the medial and lateral border of the retromalleolar rightful position (longus posterior to the brevis) requires a deep
groove; and the posterior cortical serosal surface can then be groove to provide both bony and soft tissue constrains to sub-
impacted/“compacted” to “deepen” the groove to a depth of at luxation. We have not attempted to treat these athletes/patients
least 5 mm utilizing a wide blunt bone tamp/impactor. The pos- with a soft tissue correction only. Vega, Guelfi and co-work-
terior cartilage rim is retained if it is present. ers75,76 from Barcelona have reported experience with tendono-
scopic treatment with six of the eight patients not requiring a
Intrasheath Peroneal Dislocation Without SPR fibular osteotomy but resection of a peroneus quartrus and/or
Avulsion resection of low-lying peroneus brevis muscle with good results.
Intrasheath dislocations typically present as “snapping tendon” Our rehabilitation of these subluxations post-surgery is the
(see Video 1.11).38-40 There may or may not be a definable history same as the rehabilitation of a chronic condition, and is discussed
of a lateral ankle injury. It is proposed that the SPR has been either below.
torn or stretched but not avulsed, and thus there is added redun-
dancy to the superior peroneal retinaculum. Thus, the peroneus Rehabilitation Principles and Approaches
longus subluxes laterally around the brevis but still stays within We advocate an early weight bearing and early ROM approach to
the peroneal sheath, creating this “snapping” sensation that can, alleviate some of the risk of scarring and stiffness than can come
at times, be audible. with prolonged immobilization. We utilize cold and compression
Our approach is the same as the chronic dislocation. We sur- therapy and a walking boot immobilization to allow the athlete
mise that to adequately return the tendons permanently to their to come out of the boot after week 2 to begin active ROM in
160 SECTION 2  Sport Syndromes

dorsiflexion, plantarflexion, and inversion. We do not allow ever- 4. Huh J, Boyette DM, Parekh SG, Nunley 2nd JA. Allograft recon-
sion until 6 weeks PO to protect the SPR repair/reconstruction. struction of chronic tibialis anterior tendon ruptures. Foot Ankle
We utilize biking with the walking boot at 2 weeks, we transition Int. 2015;36(10):1180–1189.
to a stirrup brace between weeks 6 and 8 and allow StairStepper- 5. Khoury NJ, el-Khoury GY, Saltzman CL, Brandser EA. Rupture
of the anterior tibial tendon: diagnosis by MR imaging. AJR Am J
like exercises. Running is allowed after 10–12 weeks, functional
Roentgenol. 1996;167(2):351–354.
progression is initiated after the athlete can run in a straight line
6. Lee WC, Moon JS, Kim JY, Ko HT. Fracture of an ossified tibialis
with no pain, and full sports are allowed when the athlete can anterior tendon. Orthopedics. 2009;32(2):132.
pass the functional progression test, typically 3–4 months postop. 7. Sammarco VJ, Sammarco GJ, Henning C, Chaim S. Surgical re-
pair of acute and chronic tibialis anterior tendon ruptures. J Bone
Complications and Potential Pitfalls Joint Surg Am. 2009;91(2):325–332.
Recurrent dislocation is uncommon, especially with groove- 8. Yamazaki S, Majima T, Yasui K, Kikumoto T, Minami A. Recon-
deepening procedures. We have only had one re-dislocation and struction of chronic anterior tibial tendon defect using hamstring
it was in a female with Ehlers-Danlos on whom we tried using tendon graft: a case report. Foot Ankle Int. 2007;28(11):1190–1193.
her native tissues. She did well with revision and use of allograft 9. Kopp FJ, Backus S, Deland JT, O’Malley MJ. Anterior tibial
tissue. Infection should be rare, reported in less than 0.5% of tendon rupture: results of operative treatment. Foot Ankle Int.
2007;28(10):1045–1047.
cases. Wound healing problems are rare in the athlete but can
10. Frigg AM, Valderrabano V, Kundert HP, Hintermann B.
be common if the patient is a smoker or a diabetic. Even with
Combined anterior tibial tendon rupture and posterior tibial
early ROM, we did not see a high propensity for wound healing tendon dysfunction in advanced flatfoot. J Foot Ankle Surg.
issues. Peroneal tendon tear is common at the time of surgery 2006;45(6):431–435.
in chronic, recurring dislocation cases, but is otherwise rare. We 11. Otte S, Klinger HM, Lorenz F, Haerer T. Operative treatment in
have found direct repair and/or tabularization has a high success case of a closed rupture of the anterior tibial tendon. Arch Orthop
rate. Non-union should be uncommon, and is not commonly Trauma Surg. 2002;122(3):188–190.
reported. The osteotomy is performed in well-vascularized can- 12. Forst R, Forst J, Heller KD. Ipsilateral peroneus brevis tendon
cellous bone. If secured, we have found no non-unions even with grafting in a complicated case of traumatic rupture of tibialis
early weight bearing and early ROM. There is a higher risk with anterior tendon. Foot Ankle Int. 1995;16(7):440–444.
the earlier rotational osteotomies in theory, but none had been 13. Crosby LA, Fitzgibbons TC. Unrecognized laceration of tibial-
isanteriortendon: a case report. Foot Ankle. 1988;9(3):143–145.
reported. Stiffness can be a real potential for disability if the ankle
14. Squires N, Myerson MS, Gamba C. Surgical treatment of peroneal
is immobilized for a prolonged period of time. To counteract this
tendon tears. Foot Ankle Clin. 2007;12(4):675–695.
potential complication/risk, we chose to secure the bone flap in 15. Cerrato RA, Myerson MS. Peroneal tendon tears, surgical manage-
the deepened groove, fully place the posterior bone flap in the ment and its complications. Foot Ankle Clin. 2009;14(2):299–312.
groove, maintain the serosa surface on the posterior flap, and 16. Redfern D, Myerson M. The management of concomitant tears
encourage early ROM. This necessitated boot/splint immobiliza- of the peroneus longus and brevis tendons. Foot Ankle Int.
tion, rather than casting, and has now shown to be both reliable 2004;25(10):695–707.
and near complication free.53 Fibula fractures with large fragment 17. Seybold JD, Campbell JT, Jeng CL, Myerson MS. Anatomic
fractures requiring open reduction and internal fixation are rare. comparison of lateral transfer of the long flexors for concomitant
Small fracturing of the posterior lateral lip of the lateral deepened peroneal tears. Foot Ankle Int. 2013;34(12):1718–1723.
groove can and has occurred in our series, but it responds well to 18. Seybold JD, Campbell JT, Jeng CL, Short KW, Myerson MS.
Outcome of lateral transfer of the FHL or FDL for concomitant
boot immobilization for 3–4 weeks and then back into a stirrup
peroneal tendon tears. Foot Ankle Int. 2016;37(6):576–581.
brace with rare long-term difficulty and no requirements for fur-
19. Stamatis ED, Karaoglanis GC. Salvage options for peroneal ten-
ther surgery. Sural nerve injury or neuritis is potentially debilitat- don ruptures. Foot Ankle Clin. 2014;19(1):87–95.
ing complication because the nerve can be in the operative field 20. Stockton KG, Brodsky JW. Peroneus longus tears associated with
for all peroneal tendon surgery approaches. If the surgeon stays pathology of the os peroneum. Foot Ankle Int. 2014;35(4):346–352.
close to the posterior border of the fibula, this takes the surgical 21. Bare A, Ferkel RD. Peroneal tendon tears: associated arthroscopic
field anterior to the sural nerve. Drifting the incision or dissection findings and results after repair. Arthroscopy. 2009;25(11):1288–1297.
more posterior certainly puts the nerve at risk. 22. Tiwari M, Singh V, Bhargava R. Peroneus brevis attrition and
longitudinal split tear without subluxation and associated hyper-
trophy of peronal tubercle”—treatment of an uncommon lesion. J
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Video Legend - https://www.kollaborate.tv/link?id=5c925f43c5078

Video 8.1  Title: Clinical Evaluation for Peroneal Tendon Dislocation

Legend: This video demonstrates evaluation of an athlete with chronic
or subacute peroneal tendon dislocation. It demonstrates dislocation of
the peroneus longus tendon across the fibula with manipulation. Typi-
cally, it is the peroneus longus that dislocates.

162.e1
 9
Achilles Tendon Disorders Including
Tendinopathies and Ruptures
Thomas O. Clanton, Jess H. Mullens, Lew C. Schon,
Jason P. Tartaglione

OUTLINE
Introduction, 163 Postoperative Management, 178
Achilles Tendinopathy, 164 Expected Success Rates and Return to Sport, 182
Noninsertional Tendinopathy, 164 Acute Achilles Tendon Rupture, 182
Insertional Achilles Tendinopathy, 165 Introduction, 182
Haglund’s Deformity, 166 Nonsurgical Treatment, 186
Retrocalcaneal Bursitis, 166 Surgical Treatment, 187
Treatment of Achilles Tendinopathy, 167 Chronic Achilles Tendon Rupture, 192
Nonsurgical Treatment, 167 Primary Repair, 193
Extracorpeal Shock Wave Therapy, 167 V-Y Advancement, 197
Autologous Platelet-Rich Plasma, Bone Marrow Concentrate, Tendon Transfer, 198
Allogenic Factor Injection, and Other Biologics, 169 Autograft/Allograft Reconstruction, 200
Surgical Treatment, 169 Conclusion, 200
Noninsertional Tendinopathy, 170

tendon. The pre-Achilles bursa lies superficial to the Achilles

between the Achilles and the skin. These bursae, composed
INTRODUCTION of synovium, provide lubrication to assist with tendon gliding
The Achilles tendon is formed by a coalescence of fibers from the and to minimize tendon irritation. A large, sometimes abnor-
gastrocnemius and soleus muscles. This complex spans both the mal prominence of the posterior superior calcaneus, Haglund’s
knee and ankle joints, making it more susceptible to injury than deformity,2 may create repetitive frictional irritation on the
muscles that span a single joint. The Achilles tendon is nota- Achilles tendon that can lead to tendinopathy (Fig. 9.1A–B).
bly susceptible to injury with concomitant knee extension and The Achilles tendon is the strongest and longest tendon in the
ankle dorsiflexion. The medial and lateral heads of the gastroc- body, measuring approximately 12 to 15 cm in length. Although
nemius originate from the medial and lateral femoral condyles, it is the main plantarflexor of the ankle, it also functions to
respectively. The soleus muscle originates from the posterior invert the heel during late stance phase and thereby locks the
proximal tibia and fibula. More distally, the medial and lateral transverse tarsal joint for push-off along with the posterior tibial
gastrocnemius and soleus tendons coalesce to form the triceps tendon. It is subject to forces up to 10 times body weight during
surae complex. The Achilles tendon then rotates 90 degrees running, experiencing up to 7000 N of force.1,3,4
such that the medial gastrocnemius position is more posterior The blood supply to the Achilles tendon is segmental and
and superficial. This rotation may result in torque stresses that is predominantly derived from anterior branches of the para-
can increase the risk of tendinopathy.1 After passing distal to tenon. Additional sources include intratendinous vessels,
the posterior superior calcaneal tuberosity, the Achilles tendon the posterior tibial artery, and distal osseous and periosteal
inserts into the posterior and plantar calcaneal tuberosity about branches. A relative zone of hypovascularity exists within 2
halfway between the dorsal and plantar aspects of the calcaneus. to 6 cm proximal to the calcaneal insertion, corresponding to
The retrocalcaneal bursa lies between the distal Achilles the site of most Achilles tendon ruptures and noninsertional
tendon and the posterior superior calcaneal tuberosity. It is tendinopathy.5,6
horseshoe shaped and sits around the insertion of the Achilles, Similar to other tendons, the Achilles is composed of pre-
which has more fibers centrally and proximally. Anteriorly it is dominantly type I collagen. Collagen fibrils are bundled into
composed of fibrocartilage, whereas posteriorly it blends with fascicles, which contain elastin, lymphatics, and neurovascular
the paratenon and commonly connects to the posterior Achilles structures and are held together by the endotenon. The epitenon

163
164 SECTION 2  Sport Syndromes

Achilles Tendinopathy
Achilles tendinopathy is common among athletes, affecting
nearly 18% of runners.15–17 Repetitive impact-loading activities
(overuse) such as jumping are responsible for the majority of
cases.1 Other predisposing extrinsic risk factors include over-
use, training errors, environmental conditions, poor footwear,
and improper training techniques (excessive running, sudden
increase in intensity, uphill running). Other intrinsic predis-
posing factors include poor extremity biomechanics (foot pro-
nation, cavus foot, genu varum), increased age, increased body
mass index, gender, prior history of tendon disorders, medical
comorbidities, and genetics.16,18 Another risk factor includes
A the previous use of fluoroquinolone antibiotics. Athletes com-
monly affected by tendinopathy are involved in running, jump-
ing, dancing, tennis, racquetball, basketball, and soccer

ACHILLES TENDINOPATHY RISK FACTORS

Repetitive impact-loading activities
Abnormal lower-extremity biomechanics (foot pronation/supination, stiff
joints, genu varum)
Improper training techniques (intensity, frequency, duration, speed, terrain)
Poor footwear selection
Fluoroquinolone antibiotics

B Puddu et al.19 classified Achilles tendinopathy into three clin-

ical categories. Peritendinitis is characterized by inflammation
Fig. 9.1 (A) Lateral radiograph of calcaneus demonstrating Haglund’s
deformity. (B) Sagittal magnetic resonance imaging of the same patient affecting the paratenon. Peritendinitis with tendinosis refers to
showing changes at Achilles tendon from bony prominence and its both inflammation involving the paratenon and degeneration of
effect on Achilles tendon, with thickening and fibrosis as it passes by the Achilles tendon. Tendinosis reflects Achilles degeneration.
the bone and more proximally. Clain and Baxter1 later created an anatomic classification, sepa-
rating tendinopathy into insertional disorders, affecting the area
surrounds the group of fascicles, forming the structural unit of of the enthesis, and noninsertional disorders, commonly affect-
the tendon. The paratenon further surrounds the epitenon and ing the tendon 2 to 6 cm proximal to the calcaneus.
consists of an inner parietal layer, lying directly on the epitenon, Whereas noninsertional tendinopathy occurs more often in
and an outer, visceral layer. The paratenon, containing a small younger, more active athletes, insertional Achilles tendinopathy
amount of fluid between its layers, facilitates glide and mini- develops more often in those athletes who are older, less active,
mizes posterior adhesion formation. and sometimes overweight. Although bilateral insertional ten-
The nomenclature used to describe tendon disorders has dinopathy will most likely be due to mechanical overuse, it may
been confusing, as multiple terms are used to describe the same be associated with inflammatory disorders, including seronega-
disease process. Tendinitis is the term that has traditionally been tive spondyloarthopathies.20,21
used to mean chronic pain and dysfunction of tendons with
inflammation as the main underlying etiologic factor. However, Noninsertional Tendinopathy
histologic examination has demonstrated the absence of an Noninsertional tendinopathy can present with peritendinitis.
acute inflammatory process or minimal inflammation as com- The Achilles tendon itself is less involved. In chronic cases,
pared to what was originally anticipated.7-12 On the contrary, adhesions may form between the paratenon and tendon, lead-
several other studies have demonstrated that in the early stages ing to more profound pain and tenderness. Pain is noted most
of tendon damage, there is an acute phase of tendon injury that often at the initiation of activity (start-up pain) and improves
involves inflammatory cells.13,14 Tendinosis describes a chronic with continued exercise. Acute pain typically resolves with rest.
degenerative process within tendons that lacks an inflammatory In chronic cases, however, the pain may persist and significantly
process. The term tendinopathy encompasses a broad spectrum impair further athletic participation. On examination, a local-
of acute and chronic disease processes affecting tendons. It is ized, increased diameter that more commonly affects the medial
most likely that inflammatory and chronic degenerative pro- side is appreciated with palpation of the tendon. Tenderness,
cesses both play integral roles during tendon pathology. For and at times crepitus, is noted throughout all ankle range of
the purpose of this chapter, the term tendinopathy will be used motion (Fig. 9.2). Radiographs generally are unremarkable.
to encompass acute and chronic degenerative stages of tendon Peritendinitis with tendinopathy represents further inflam-
pathology. mation with associated intratendinous degeneration. Pain is
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 165

Fig. 9.2  Tenderness with squeezing the Achilles and crepitance with range of motion are hallmarks of peritendi-
nitis. The discomfort related to peritendinitis will be constant in location as the ankle is brought through a range
of motion. With Achilles tendinosis, the tenderness moves with the thickened tendon during range of motion.

more marked and constant. The tendon is thickened and infre- Insertional Achilles Tendinopathy
quently has palpable intrasubstance calcifications (Fig. 9.3). The Insertional tendinopathy is an inflammatory reaction within
painful arc sign may help to distinguish between tenderness the Achilles tendon affecting the enthesis, or tendon insertion
associated with peritendinitis and that associated with ten- onto the calcaneus. This disorder more commonly affects older,
don degeneration. Tenderness related to peritendinitis will be heavier, and less active athletes but can be seen in competitive
constant in location as the ankle is brought through a range of athletes as well.21 An abnormally enlarged, bony prominence
motion, whereas tenderness associated with tendinopathy will may aggravate this condition. There is a high association with
change position with ankle motion.22 Haglund’s deformity and retrocalcaneal bursitis, but unlike these
Isolated tendinopathy, or noninflammatory atrophic degen- disorders, insertional tendinopathy involves the tendon itself.
eration, is associated with normal aging and typically is accel- This most often results from chronic overuse and poor train-
erated by overuse. Most affected are middle-aged, recreational ing habits. Improper techniques include inadequate stretching,
athletes. With repetitive trauma, microtears develop within rapid increase in training, running on harder surfaces, and heel
the tendon, mostly in the hypovascular zone, leading to fur- running. Although pain initially follows exercise, particularly
ther fibrosis and degeneration.23 These athletes complain of uphill running, symptoms may become more persistent despite
weakness in push-off, with pain and swelling localized to the activity modification.
area approximately 2 to 5 cm proximal to calcaneus. Whereas Pain, swelling, and warmth are noted specifically at the
ankle dorsiflexion commonly is limited, tendon elongation may enthesis. In athletes, there often is a localized area of pain with
develop with an associated increase in passive ankle dorsiflex- a small spur. Ankle range of motion is painful, with dorsiflexion
ion. Pathologic examination reveals fatty degeneration with dis- typically limited because of a tight or painful Achilles tendon.
organized collagen. Calcific deposits may be present External irritation from a shoe’s heel counter plays less of a role
in provoking symptoms in athletes with Achilles tendinopathy
than in retrocalcaneal bursitis and Haglund’s deformity. This is
SURGICAL ALTERNATIVES because the insertion lies within the center of the heel cup and
Paratendinitis: release paratenon tends not to get rubbed unless the tendinopathy extends more
Tendinopathy: degree of width involved <50%, ellipse and repair; >80%, proximally near where the edge hits the shoe. Radiographs
ellipse and augment generally reveal calcifications or a bony spur at the most distal
1–3 cm gap after debridement:V-Y aspect of the Achilles insertion (Fig. 9.4A). Magnetic resonance
3–5 cm gap after debridement: turndown imaging (MRI) will show thickening of the tendon with longi-
>5 cm gap after debridement: turndown with consideration for FDL or FHL tudinal striations of fibrosis or splits where the tendon attaches
tendon transfer
to the calcaneus. Often there will be localized bony edema in the
FDL, flexor digitorum longus; FHL, flexor hallucis longus calcaneus at this junction (Fig. 9.4B).
166 SECTION 2  Sport Syndromes

B C
Fig. 9.3  (A) Noninsertional Achilles tendinopathy with characteristic swelling 2 to 5 cm above dorsal aspect
of calcaneus. (B) Magnetic resonance imaging shows thickened Achilles tendon. A Haglund’s deformity also
is noted. (C) Technetium bone scan demonstrating increased uptake in the Achilles tendon; the third phase of
the scan, indicative of advanced intrasubstance degeneration.

result in bone overgrowth. Most affected are young women who

Haglund’s Deformity wear fashionable high-heeled shoes. In the athletic population,
Haglund is credited with first describing the presence of a we have observed this condition more commonly in males who
prominent posterolateral superior calcaneal tuberosity in 1927.2 participate in running sports. Long-distance runners are sus-
This enlarged superolateral tuberosity predisposes the precalca- ceptible to this condition and the other Achilles tendon disor-
neal bursa to be compressed between it and any tightly fitting ders (see Figs. 9.1 and 9.5).
shoe heel counter, possibly leading to skin irritation and inflam- On examination, the affected heel has a swollen, red, and ten-
mation. Because of the association of footwear, this disorder der posterior prominence, predominantly on the lateral side of
also has been referred to as a “pump bump” and “winter heel.” the calcaneus. The Achilles tendon itself is not tender. Numerous
Although there is a frequent association with retrocalcaneal radiographic measurements have been used to quantify the size
bursitis and insertional Achilles tendinopathy, Haglund’s defor- of the posterosuperior prominence. These techniques generally
mity initially generally does not involve the Achilles tendon. are not used by orthopaedists as they do not always correlate
Poorly fitting shoes in conjunction with this genetic bony with the clinical findings.
prominence generally are responsible for the development of
symptoms of Haglund disorder. Other predisposing risk fac- Retrocalcaneal Bursitis
tors include the presence of a cavus foot and hindfoot varus. Retrocalcaneal bursitis refers to inflammation affecting the
In rare cases, childhood apophyseal trauma may be a cause. bursa immediately anterior to the Achilles tendon. As with
In the nonathletic population, repetitive injury or trauma may Haglund’s deformity and Achilles tendinopathy, this condition
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 167

is common in running athletes. In the general population, as addition, it may be critical to temporarily or permanently
with insertional tendinopathy, those most commonly affected eliminate provocative, more rigid, and less compliant surfaces
are older, less active recreational athletes. As the disorder and terrain.
becomes chronic, the bursa enlarges and may become adherent Reported results of nonoperative treatment of insertional
to the Achilles tendon. A prominent posterosuperior bony pro- and noninsertional Achilles tendinopathy have been generally
jection may be present. successful. Studies have found that 70% to 90% of patients have
Athletes typically complain of pain with activities that force found symptomatic improvement after corrections in their foot-
the ankle into dorsiflexion, particularly uphill running, and wear, training habits, and mechanics.16,27–31 There are, however,
thereby compress the inflamed bursa between the postero- fewer predictable results with nonsurgical management in those
superior calcaneus and the Achilles tendon. Schepsis et  al.23 with chronic tendinopathy and in the older athlete, as a result of
described the two-finger squeeze test, in which pain is noted greater degenerative tendon involvement.30
when two fingers compress medially and laterally immedi- In our experience, athletes with isolated Haglund’s deformity
ately superior and anterior to Achilles insertion. This area will can be managed with footwear modification about 50% of the
be warm with a notable soft-tissue bulge. Pain is elicited with time. The presence of a prominence does not mandate surgery.
passive dorsiflexion. Radiographs may show a subtle soft tissue We have seen improvement in about 30% of patients with ret-
fullness and loss of the retrocalcaneal soft-tissue shadow, as well rocalcaneal bursitis and in about 25% of those with insertional
as the presence of a posterosuperior bony prominence. MRI tendinopathy.
demonstrates the bursal enlargement anterior to the Achilles
tendon above its insertion in the retrocalcaneal region (Fig. 9.6). Extracorpeal Shock Wave Therapy
The use of extracorporeal shock wave therapy (ESWT) for the
TREATMENT OF ACHILLES TENDINOPATHY treatment of Achilles tendinopathy has not been conclusively
studied. The most information on shock wave therapy comes
Nonsurgical Treatment from upper extremity tendinopathy (e.g., tennis elbow) and
The treatment for Achilles tendinopathy is nonoperative at first plantar fasciitis. Shock wave therapy works by creating a pres-
with surgical intervention for recalcitrant cases. Initial treatment sure change that propagates rapidly through a medium. When
should include anti-inflammatory medications, gentle Achilles transmitted through a water medium, it can either directly
stretching and activity modification. Relative rest with limita- create high tension at a given structure or indirectly create
tions on intensity, duration, or frequency of training and con-
comitant institution of nonstressful cross training (exercise bike,
pool running, elliptical trainer) should be helpful. An open-back
shoe may benefit those with no heel counter pressure (Fig. 9.7).
A padded heel sleeve can be comfortable. If there is no response,
a heel lift (one-fourth to three-eighths inch), night splint, or tem-
porary immobilization in neutral or slight plantarflexion with a
removable walking boot or cast may be required. If the athlete
has notable foot pronation, a semirigid orthotic may improve
overall foot biomechanics by supporting the medial arch.
Intratendinous corticosteroid injections should be avoided
because local use of these injections has been associated with
tendon attrition and potential rupture. Although there is no
strong evidence of similar deleterious effects after paratendi-
nous corticosteroid injections, there are similar worries with an
injection in the bursa. It would be advisable to immobilize the
ankle temporarily after a retrocalcaneal injection because the
retrocalcaneal bursa has a direct communication to the Achilles
and may make it structurally vulnerable.21,24–26 In general, we
advise against corticosteroid injections.
For refractory peritendinosis we have found that brisement
may provide symptomatic relief in a third to half of total cases.27
Brisement consists of injecting 5 to 10 ml of sterile saline or local
anesthetic agents into the Achilles tendon sheath; this may forc-
ibly disrupt any adhesions between the paratenon and Achilles
tendon. Repeating the injections two to three times over several A
weeks may be necessary to achieve success.23,27
Fig. 9.4 (A) A lateral x-ray and (B) a series of sagittal magnetic reso-
After initial symptoms resolve, it is imperative to correct nance images of the same patient with insertional degeneration of the
predisposing factors, including improper technique, exces- Achilles tendon with tendon thickening and fibrosis from about 2 cm
sive training, inappropriate footwear, and poor flexibility. In proximal to its insertion on the calcaneus.
168 SECTION 2  Sport Syndromes

B
Fig. 9.4, cont’d.

microcavitations. Theories behind its analgesic effect in ortho- 30%–40%.34,35 A systematic review by Al-Abbad et al.36 demon-
pedic applications include an alteration of the permeability of strated evidence for the effectiveness of ESWT in the treatment
neuron cell membranes and induction of an inflammatory-me- of chronic insertional and noninsertional Achilles tendinop-
diated healing response by increasing local blood flow.32 Studies athies with a minimum of 3 months follow-up before under-
have also shown that ESWT decreases tenocytes expression of going surgery. Furthermore, they demonstrated that ESWT in
matrix metalloproteases and interleukins.33 Studies on ESWT on conjunction with eccentric loading shows superior results. In
Achilles tendinosis have shown a success rate of approximately our experience, we have found a success rate of approximately
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 169

Achilles tendinopathy. Several later studies reported prom-

ising results after ESWT with those affected with chronic
Achilles tendinopathy.38–40 The cost of shock wave treatment
can be an important consideration because the therapy may
not be covered by insurance. With lower-energy shock wave
machines, three treatments are used, at a total cost of $500 to
$1500. The higher-energy machines usually require one treat-
ment ($1000 to $3000) but this typically involves a regional or
general anesthesia given the magnitude of the pain. Authors
(LCS and JPT) do not generally recommend ESWT for those
patients with bony prominences (e.g., Haglund’s or large
insertional spurs).
Autologous Platelet-Rich Plasma, Bone Marrow
Concentrate, Allogenic Factor Injection, and Other
Biologics
Injection of autologous platelet-rich plasma (PRP), bone mar-
row concentrate or allogenic factors—derived from decellular-
ized placental/chorion/amniotic tissue—can also be considered
for resistant cases (See Chapter 29). For the PRP, patients need
Fig. 9.5  Clinical photograph of Haglund’s deformity. to have their blood drawn and equipment is needed to process
the blood and harvest the platelets via centrifugation or filtra-
tion. Costs can be between $500 and $2000. The techniques of
the platelet isolation and the subsequent quantity of platelets
and white blood cells (WBCs) vary. Clinical studies have not
been able to demonstrate a clinically significant improvement of
tendon healing with PRP injection.41,42 However, platelet-rich
plasma has been shown to stimulate cell proliferation, enhance
the activity of growth factors like vascular endothelial growth
factor (VEGF) and platelet-derived growth factor (PDGF), and
increase total collagen production in a controlled laboratory
study.43
For the bone marrow concentration, the patients require
some pre-medication and may benefit from sedation in the
operating room or procedure room. The bone marrow is har-
vested in 5ml aliquots via multiple trajectories from the iliac
crest. Typically a specialized chamber is used to perform cen-
trifugation to separate the red blood cells (RBCs) from the
plasma and the platelet rich cellular buffy coat. Unlike in PRP,
the concentrate contains endothelial progenitor cells, mesen-
Fig. 9.6 Magnetic resonance imaging demonstrates Haglund’s defor- chymal signaling cells, hematopoietic stem cells, and other
mity with enlarged posterior superior aspect of the calcaneus. progenitor cells in addition to the platelets. For the allogenic
factor injections, the materials and methods also are diverse.
50% in athletes. Even with this lower success rate, we try ESWT For both, the method of injection and post injection rehabil-
and then wait 3 months before surgery given the minimal side itation vary as do the results in the literature. When there is a
effects. Depending on the immediate results, we may allow bony element that causes a mechanical prominence (e.g., large
sports play with only 1 or 2 weeks off. If the athlete is in midsea- Haglund’s or spurring in the insertional Achilles tendinopathy)
son, then this modality is his or her best chance to resume play. the results can be less than 30% successful. If there is only the
If the athlete is at the end of the season, then we may try shock bursitis or tendinopathy, the results can be up to 75% for PRP
wave therapy and a boot brace for 2 to 6 weeks and then allow or growth factors or 90% for bone marrow concentrate in the
the athlete to resume impact activities. After the season, when authors’ (LCS and JPT) experience.
there is more time for recovery, decisions regarding further
treatment can be made. Contraindications to ESWT quoted in Surgical Treatment
the literature include pregnancy, coagulopathies, bone tumors, Surgical intervention is considered after approximately 3
bone infection, and skeletal immaturity.32 months of nonoperative treatment measures. The surgical
Saggini et al.37 noted successful outcomes after two treat- technique is chosen on the basis of location of pathology. For
ments with no complications using shock wave therapy on a symptomatic athlete with a normal tendon, determined by
170 SECTION 2  Sport Syndromes

A B

C D
Fig. 9.7  Shoe Alternatives and Modifications for Patients with Achilles Tendinopathy. Clockwise from
the top left: (A) A higher-heeled, backless shoe, “a mule.”(B) A completely removed heel counter. (C) A partial
heel counter cut to relieve external pressure. (D) A backless sneaker.

physical examination and possibly by MRI, we generally try to

avoid a procedure that may irritate or traumatize the tendon. A
medial or lateral approach 5 to 10 mm anterior to the Achilles
tendon and paralleling its course is best in these cases because it
runs through thicker skin and subcutaneous tissues. If the ten-
don is involved, this approach also provides excellent access to
the tendon with the creation of full thickness flaps down to the
level of the paratenon. Debridement of the tendon depends on
the location of the clinical and radiographic findings – above,
at, or below the insertion of the tendon. In general, the points of
tenderness dictate where the exposure must occur. Thus, if there
is more medial and central Achilles tendinopathy, the tendon in
the medial and central aspect must be elevated off the calcaneus,
the tendon must be debrided there, and the underlying bone
must be resected and recontoured.
Fig. 9.8  Release of the Paratenon. Note that the incision is made 1 cm
Noninsertional Tendinopathy anterior to the margin of the Achilles tendon. The incision can be made
For noninsertional tendinopathy, the choice of procedure is much smaller than shown in this case.
based on whether the disease involves the paratenon, tendon,
or both. In peritendinitis, all adhesions are excised, and the sur-
geon also performs a limited resection of any thickened para-
tenon. The extremity is immobilized for 3 to 5 days, followed
by a range-of-motion program to limit the recurrence of scar
formation (Fig. 9.8).
When there is tendinopathy and peritendinitis, elliptical
excision of the tendon and longitudinal paratenon release is per-
formed. Maffulli et al.44 have reported a success rate of approx-
imately 70% after percutaneous longitudinal tenotomy of the
middle third of the Achilles tendon. In this technique a no. 11 or
no. 15 blade is introduced posteriorly through the skin and ten-
don. With the blade held stationary, the ankle is dorsiflexed, and
the tendon moves, allowing it to be cut longitudinally. Next the
blade direction is reversed 180 degrees and the ankle is plantar- Fig. 9.9  The Maffulli Technique. An incision is made with a no. 11 or
no. 15 blade. The blade is held stationary and the ankle is dorsiflexed
flexed. The process is repeated through four additional incisions creating a longitudinal cut in the tendon. The blade then is turned 180
in the zone of the degenerative tendon (Fig. 9.9). This creates a degrees, and the ankle is plantarflexed. The process is repeated until
controlled tendon trauma and triggers a healing response. there are five longitudinal cuts.
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 171

Fig. 9.10  Magnetic resonance imaging cross section of the Achilles tendon demonstrating more than 80%
tendon involvement. This would indicate the need for tendon augmentation or transfer following debridement.

The type of procedure chosen for treatment of tendinop- the degenerative fibers and the thickened tendon (Fig. 9.11).
athy depends on many factors, the largest, in our experience, The tendon then is repaired with internally placed, nonabsorb-
being the extent of tendon involvement, determined by clinical able sutures with buried knots. The subcutaneous tissues are
findings, ultrasound, or MRI. When less than 50% of the ten- apposed, followed by closure of the skin. The leg is immobilized
don is involved, we longitudinally ellipse the diseased tendon; for 3 to 5 days in a splint, followed by range-of-motion exer-
when more than 80% of the tendon is involved, a debridement cises, strengthening, and nonimpact activities. A boot brace is
and tendon augmentation (e.g., turndown) or transfer is rec- worn for 6 to 12 weeks during ambulation to unload the healing
ommended (Fig. 9.10). When there is between 50% and 80% tendon. Jogging and running may be introduced at 3 months,
involvement, the decision is determined by the patient, the depending on the extent of involvement and the nature of the
sport, and the surgeon’s preference. patient’s athletics.
Debridement of tendon. For tendinopathy, typically the Tendon transfer. If more than 50% of the tendon width
degenerative portion of the Achilles tendon is debrided and is involved, then one must consider the risks and benefits of
the paratenon is released. If less than 50% of the tendon width either longitudinal tenotomy, debridement, or tendon transfer.
is debrided, then the remaining section of intact longitudinal The decision to consider tendon transfer is determined by the
tendon should be strong enough to withstand stresses. structural weakening of the tendon that may result from a large
Typically, a medial incision is made just anterior and paral- debridement.
lel to the border of the tendon that is thickened, and the para- Because most athletes use all their tendons for ultimate, low-
tenon is entered. On the basis of maximal tenderness, MRI, or er-extremity performance, it is difficult to justify harvesting a
ultrasound localization of the degenerative zone of the tendon, working structure to improve the function of the Achilles. Thus,
an elliptical longitudinal excision of the diseased tendon is per- depending on the demands of the athlete and nature of his or
formed, leaving intact the anterior and posterior surfaces of the her skills, we must balance the pros and cons of using the tendon
tendon. Essentially the zone of ellipsed tissue should include transfer. If 50% to 80% of the width of the tendon is resected, we
172 SECTION 2  Sport Syndromes

consider these factors. However, if 80% or more of the tendon Achilles debridement and FDL transfer. Patients are placed
is involved, our experience has been that the transfer becomes in a semi-lateral position, with the operative side down, to allow
more critical to restore function. Alternative procedures in this access to both the posterior and medial aspects of the foot and
latter scenario include a turndown procedure, tendon allograft, ankle. Patients who have had prior surgery on the Achilles
and V-Y advancement. tendon through a posterior incision were placed in the prone
The flexor hallucis longus (FHL), flexor digitorum longus position. Surgeries are performed under regional block with
(FDL), or, less commonly, the peroneal tendons can be trans- general sedation. The surgeons (LCS and JPT) caution not to
ferred. Authors (LCS and JPT) prefer to use the FDL tendon in use the tourniquet.
a nonsprinting athlete, nondancer, or rock climber.45 Exposure of the diseased Achilles tendon is done via a pos-
Transferring the FHL or any other tendon in a sprinting teromedial approach, except in patients who had prior midline
athlete or ballet dancer could lead to loss of agility, power, or posterior approach. Dissection is carried out sharply down to
balance. In these athletes, it is better to consider performing a the Achilles tendon with minimal undermining distally to pre-
turndown procedure, a V-Y advancement, or an allograft if a serve a full-thickness flap for closure. The Achilles is debrided.
wide area of tendon is involved. If indicated, the insertion of the Achilles and/or the posterior
The patient can be positioned prone or supine and both legs superior prominence of the calcaneus is resected.
are prepped for any tendon transfer, turndown procedure, or A 1–3-cm separate incision is made longitudinally over the
V-Y advancement because it usually is necessary to compare medial aspect of the hindfoot just over the proximal medial neck
resting tensions with those of the contralateral side. of the talus. After the posterior tibialis tendon (PTT) sheath is
identified, the dissection is carried down inferior to the PTT
to identify the FDL tendon. The right-angle clamp is used to
tension the FDL tendon to confirm that the appropriate tendon
is found. (Fig. 9.12.)
Another small separate incision is made 6–10 cm above the
tip of the medial malleolus at the posterior edge of the tibia.
After the posterior compartment sheath is open, the FDL ten-
don and muscle are identified and freed. By pulling on the FDL
distally, the FDL proximally can be found. (Fig. 9.13.) Then the
FDL tendon is transected under direct visualization with the
toes in maximum plantarflexion at the medial hindfoot inci-
sion. The FDL stump is carefully retracted through proximal
tibial incision leaving the FDL muscle belly on the tendon. (Fig.
9.14) Tunneling is created from the tibia incision through the
subcutaneous tissue above the superior retinaculum down to
the Achilles tendon insertion. (Fig. 9.15) Finally, the end of the
FDL tendon is fixed to the calcaneus using a 5.0 mm anchor and
Fig. 9.11  Intraoperative photo of debridement of the Achilles tendon. the Achilles tendon is repaired with a nonabsorbable suture and
Once the degenerative tissue is ellipsed from within the substance of
the tendon, buried sutures are used to close the defect.
a 5.0 mm anchor under appropriate tension with 20 degrees of
ankle plantarflexion.

Fig. 9.12  After debriding the distal Achilles tendon, an incision is made
distal to the medial malleolus over the neck of the talus. The flexor Fig. 9.13  Just posterior to the medial tibia, the flexor digitorum longus
digitorum tendon is identified just inferior to the posterior tibial tendon. is found 6-10 cm proximal to the medial malleolus.
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 173

The wounds are closed in a layered fashion, and the leg is Follow and release the FHL tendon from the sheath (fibro-os-
placed in a bulky plaster-reinforced splint with the foot in rest- seous tunnel) as it travels between the medial and lateral tuber-
ing plantarflexion for 2 weeks. Postoperatively, patients are kept cles of the posterior talus. Continue to release the tendon for
nonweight-bearing in a boot for 2 to 6 weeks and then advanced as much length as possible from the posterior approach, dis-
to weight bearing in the boot as tolerated until 8 to 12 weeks. secting toward the underside of the sustentaculum tali. Cut the
Achilles debridement and FHL transfer. In the FHL tendon tendon as distally as possible, again avoiding the tibial nerve.
transfer, our preferred technique is prone with a medial Alternatively, the FHL can be harvested with the patient prone
approach to the Achilles tendon, typically staying 1 cm anterior or supine from the medial midfoot with a small longitudinal
to the medial edge of the tendon. The incision is extended incision just inferior to the naviculocuneiform joint in order to
more inferiorly and centrally over the posterior calcaneus. The obtain more length for transfer. Once the FHL tendon is har-
paratenon is opened, the degenerative tendon is excised, and the vested, it can be sewn to the Achilles repair or inserted into the
deep fascia between the superficial and deep compartment is calcaneus or its periosteum, depending on tendon length. A
released. It is felt that, by opening the fascia and exposing the useful technique involves drilling a hole the width of the tendon
deeper FHL muscle belly, there is an improved vascular bed for (typically 5 mm) through the calcaneus from dorsal to plantar
the Achilles. Ranging the big toe should facilitate identification (Fig. 9.17). A small incision made over a K-wire passed through
of the moving FHL muscle belly and tendon. The FHL tendon this tunnel can facilitate placement of a small-bore suction tip
may have a more distal origin and may not be viewed readily over the wire from plantar to dorsal and out the planned entry
in the wound. Care should be taken while dissecting along the point for the tendon. The whip suture in the FHL tendon then
course of the muscle because the tibial nerve runs immediately can be passed through the suction tip and pulled plantarly to per-
medial to the tendon (Fig. 9.16A–E). mit tensioning. An interference screw can be inserted through
the tunnel. Alternatively, an anchor can be placed obliquely in
the tunnel wall just distal to the opening but not obscuring the
passageway. After the proper tension has been determined, the
tendon is secured. Occasionally there is a need to resect the pos-
terior superior calcaneus; this procedure is determined by the
presence of Haglund deformity and bursitis. We do not close the
deep fascia between the compartments because the FHL muscle
belly may provide for improved healing following the Achilles
repair.
V-Y advancement. A V-Y advancement may be required if
more than 80% of the tendon width and 2 to 3 cm in length
is involved. With this large amount of tendon involvement, the
remaining normal tendon may not be thick or wide enough to
safely flap. The V-Y advancement is accomplished by extending
the initial posterior incision more proximally toward the
musculotendinous junction (Fig. 9.18A–C). A V-shaped fascial
incision is made with the apex proximal. With traction on the
Fig. 9.14  The flexor digitorum is found proximally with the assistance tendon distally, an advancement of 2 to 3 cm then can be achieved;
of pulling on the tendon distally. this should close the distal gap sufficiently. The distal repair can

A B
Fig. 9.15  A. The flexor digitorum longus is delivered proximally. B. The flexor digitorum longus is passed
deep to the subcutaneous fat but superficial to the tarsal tunnel and secured to the dorsal medial calcaneus.
174 SECTION 2  Sport Syndromes

A B

C D

E
Fig. 9.16  (A) A medial approach 1 cm anterior to the medial edge of the Achilles tendon. (B) The deep fascia
between the superficial and deep compartment is released. Ranging the big toe should allow palpation and
identification of the moving flexor hallucis longus (FHL) (two black arrows). The tibial nerve runs immediately
medial to the tendon; therefore dissection of the tendon must be carefully performed. (C) The tendon is
released distally and secured with a whipstitch. The degenerative Achilles tendon is excised. (D) 4-0 or 2-0
nonabsorbable suture is buried within the tendon. (E) The defect is closed and the FHL tendon is sewn to an
anchor into the calcaneus. This area of the calcaneus is prepared by locally elevating the periosteum. In this
case the Achilles tendon length was normal, so the FHL was tensioned to permit full dorsiflexion.
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 175

A B

C D
Fig. 9.17  (A) Following debridement of the Achilles and harvest of the flexor hallucis longus (FHL),the thick-
ness of the FHL is determined to properly select the drill size. (B) A guidewire is passed through the calcaneus
and then is advanced to pierce the plantar soft tissues. The exit point plantarly is just anterior to the fat pad
of the heel. (C) A drill matching the width of the FHL is used to create a channel in the calcaneus but should
not penetrate the soft tissues. (D) A small incision is made and a small-bore suction tip is placed over the wire
from plantar to dorsal and out the planned entry point for the tendon.

be performed with a modified Krackow or whipstitch, and then the end of the proximal tendon is mobilized, then grasped with
balancing of the tendon tension is performed by checking for Alice clamps and gently distracted by pulling distally on the Alice
the resting posture of the foot and testing the “springiness” of clamps for 5 to 10 minutes (Fig. 9.19A).
the foot as it sits in the normal, slightly plantarflexed position. The size of the gap is measured while the foot is maintained in
The V-Y advancement can be performed in the supine or prone a neutral position (Fig. 9.19B). An additional 4 cm then is added
position. Because it usually is necessary to compare resting ten- to the tendon defect (a 2-cm distal hinge that is overlapped by
sions with those of the contralateral side, both legs are prepped the turned-down flap, or 2 cm plus 2 cm). Another 1 cm is added
as for any tendon transfer or turndown procedure. However, the to account for the intended 1-cm overlap of the tendon ends dis-
tendon may begin to tear and pull off the muscle base beyond an tally (Fig. 9.19C). Thus, the flap begins proximally at a point 5
advancement of 3 to 5 cm. If it appears that there is not enough cm more than the size of the gap. For example, if the gap is 6 cm,
fascia/tendon substrate or if too large a defect exists for advance- then a flap is initiated 11 cm proximal to the gap (Fig. 9.19D).
ment, then a turndown or an allograft tendon transfer such as with A strip of tendon approximately 1 cm wide and 1 cm thick is
a semitendinosus tendon may be used as a connecting bridge. harvested centrally. The tendon graft now can be turned distally
Turndown procedure. A turndown procedure provides to span the void (Fig. 9.19E–F). At approximately 2 cm proxi-
substrate for healing and may limit the possibility of rerupture mal to the defect, two no. 1 Ethibond sutures are used to anchor
when there is between 50% and 80% of tendon width involvement. the corner of the turned-down graft, reinforcing the high stress
The patient is positioned prone with both legs prepped to compare junction so there is no propagation of the split between the strip
the two and recreate normal resting tension. A medial incision is and the main body of the tendon (Fig. 9.19G). To decrease the
used, with care taken on deeper exposure to avoid branches of bulk created by this method, the tendon then is passed anteriorly
the sural nerve. After the rupture or degeneration site is exposed, deep to the tendon instead of posteriorly.
176 SECTION 2  Sport Syndromes

E F

G
Fig. 9.17, cont’d.  (E) The whip suture in the FHL tendon then can be passed through the suction tip and
pulled plantarly to permit tensioning. (F) An interference screw is inserted through the tunnel. As an alter-
native, an anchor can be placed obliquely in the tunnel wall just distal to the opening but not obscuring the
passageway. (G) A corkscrew anchor is inserted to repair the Achilles tendon onto bone.

The distal tendon end then is secured to the remaining via-

ble Achilles or to the bone. Tensioning of the graft requires Insertional Tendinopathy
checking the range of motion and the springiness of the oper- Insertional tendinopathy is surgically treated by excising the
ative side versus the normal side. Usually, the foot should have retrocalcaneal bursa and any prominent posterosuperior bone.
a resting position of 15 degrees of plantarflexion. The graft and Additionally, the Achilles tendon is debrided of any intratendi-
the turned-down flap are held in place by hand or by suture. nous calcifications and degenerated tissue, including detachment
Once the appropriate tension and position are established, of part of the tendon’s insertion. Achilles tendon reattachment
whipstitches are used for final anastomosis. The resting ten- through calcaneal bone tunnels or with suture anchor is advised. A
sion and springiness are checked once again at the end of the central splitting, paralateral, and paramedian Achilles approaches
procedure. have been advocated.21 Our preference is a paramedian approach
with full thickness flaps down to the paratenon which facilitates
excellent visualization while avoiding a wound directly over the
NONINSERTIONAL TENDINITIS SURGICAL Achilles tendon and the relatively thin skin in this location (Fig.
ALTERNATIVES 9.20A–H). The direct posterior central approach affords optimal
• P aratendinitis: release paratenon visualization, but risks putting the incision under tension and
• Tendinosis: degree of width involved through thinner skin found proximal to the calcaneus that is
• <50% ellipse and repair potentially more problematic with delayed healing of a wound.
• >80% ellipse and augment Through the paramedian incision, we debride both the bone
• Tendinosis: degree of length involved and the tendon at the junction and resect the posterior superior
• 1–3 cm V-Y
process. Tendon augmentation may be required, depending on
• 3–5 cm turndown
the extent of debridement. When more than 80% of the tendon
• >5 cm turndown with consideration for FHL or FDL tendon transfer
is involved or when the Achilles is degenerative at the insertion
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 177

to the bone through a tunnel or into a trough, the Achilles ten-

don is reattached with one or two suture anchors.
A biomechanical study by Kolodziej et  al.46 demonstrated
that as much as 50% of the Achilles tendon may be safely
resected. Despite this study, we still recommend placing suture
anchors to optimize tendon bone contact and healing. When
reattaching the tendon, it is important to restore normal resting
tension, using the remaining intact portions of medial and lat-
eral slips of tendon as a guide. Inadvertent overtensioning of the
repair when using anchors could cause an equinus contracture
or difficulty squatting or lunging.
A
Haglund’s Deformity
Surgical treatment for Haglund deformity and retrocalcaneal
bursitis focuses on resecting the enlarged posterior bony prom-
inence, including the attached precalcaneal bursal projection.
Any inflamed retrocalcaneal bursa also is excised. Because the
lateral side is more commonly affected, it is easier to approach
through a lateral incision (Fig. 9.22A). A medial approach is
warranted when the bony prominence is found medially (Fig.
9.22B). When the tendon is not involved, the insertion can be
avoided through the lateral or medial approaches. Either way,
it is critical to resect a sufficient amount of bone to prevent
impingement on the tendon and avoid creating a sharp edge
after resection that may irritate the tendon (Fig. 9.22C–D). Too
B
much resection can weaken the tendon insertion, and the sub-
talar joint may be penetrated if the surgeon is not careful. Jones
and James47 advocated a combined medial and lateral approach
to ensure a thorough bony resection (Fig. 9.22E). This exposure
helps to avoid inadvertent creation of a sharp, bony edge.
We recommend a lateral approach or the combined medial
and lateral exposure. The central posterior approach for
Haglund deformity should not be used because it is better to
avoid disrupting the insertion of the tendon unless there is a
clinically relevant component of insertional tendinopathy (Fig.
9.23A–D). Bone resection should be performed just proximal to
the insertion of the tendon (Fig. 9.23E). A power reciprocating
rasp should be used to help contour the cut edges beside the
tendon (Fig. 9.23F). A mini-C arm should be used to help iden-
tify any remaining prominences (Fig. 9.23G).
Endoscopic Haglund resection as presented by Niek van
Dijk (see Chapter 16) has gained popularity. In this technique,
the patient is placed in a prone position, and a lateral incision is
made just dorsal to the calcaneus and anterior to the tendon (Fig.
C 9.24). A 4.5-mm, 30-degree arthroscope is introduced. A spinal
Fig. 9.18  The V-Y advancement. (A) The section of the diseased Achilles needle then is introduced medially just dorsal to the calcaneus,
is debrided, and the new edges are sutured with a whipstitch for anasto- and the 5.0-mm full-radius resector is inserted. With the shaver
mosis. (B) A V-shaped fascial incision is made with the apex proximal. With on the superior surface of the bone, the periosteum is removed. In
traction on the tendon distally, an advancement of 2 to 3 cm can then be
plantarflexion the Haglund’s prominence can be resected with the
achieved. (C) The final tendon tensioning is performed by checking the
resting posture of the ankle and testing the “springiness” of the foot as shaver. A burr may be needed to remove bone at and near the inser-
it sits in the normal slightly plantarflexed position. A comparison with the tion point of the tendon. The site of the burr placement should be
other side is helpful. The V-Y is then sutured. If it appears that there is too confirmed with fluoroscopy. Adequate decompression is achieved
large a gap to close, a turndown or a tendon transfer may span the defect. at the posterior medial and lateral edges by alternating portals. The
portals are sutured after the bursa and Haglund prominence have
and proximally, an FDL or FHL graft should be considered (Fig. been removed with fluoroscopic assistance. This technique avoids
9.21A–C). The FHL or FDL can be harvested in the arch of the the creation of tender scars in this region, has low morbidity, and
foot or, as we prefer, behind the ankle. After the FHL is attached may shorten recovery relative to the open procedures.
178 SECTION 2  Sport Syndromes

A B

C
Fig. 9.19  The Turndown Procedure. (A) After the rupture or degeneration site is exposed, the end of the
proximal tendon is mobilized and then grasped with Alice clamps, and tension is pulled. (B) The size of the
gap is measured while the foot is maintained in a neutral position. (C) An additional 4 cm then are added to
the tendon defect (a 2-cm distal hinge that is overlapped by the turned-down flap, or 2 cm plus 2 cm). Another
1 cm is added to account for the intended 1-cm overlap of the tendon ends distally. Thus, the flap begins
proximally at a point 5 cm more than the size of the gap. (D) A strip of tendon 1 cm wide is harvested centrally.

Alternatively, some authors have advocated a dorsal closing

wedge osteotomy of the posterior tuberosity of the calcaneus. It is Postoperative Management
rarely used in athletes because of inherent complications with this Our postoperative management for the athlete is determined on
procedure, including nonunion or malunion, potentially longer the basis of the extent of tendon involvement. If there is no ten-
recovery times, difficult fixation, painful prominent hardware, don repair or reconstruction, a nonweight-bearing posterior and
broken hardware, and altered mechanics. This procedure may U-splint is applied in mild plantarflexion for the first 10 days. The
have a role if an athlete has a noticeably deformed posterior and sutures then are removed, and progressive, full weight bearing is
superior calcaneal prominence, which we call the “pregnant heel” permitted with a boot brace in neutral position. Between 6 and
(Fig. 9.25). It should be reserved for atypical cases. 12 weeks, the athlete is weaned out of the boot as tolerated. Early
range-of-motion and strengthening exercises are encouraged.
SYMPTOMS AND SURGERY Impact activities are avoided for about 8 to 12 weeks. Swimming
and exercise bicycling are encouraged by 3 weeks, followed by the
Haglund’s/retrocalcaneal bursitis
elliptical trainer by 4 weeks. Beyond 12 weeks, the athlete may
• Tender over posterior superior bony prominence and/or anteromedial
and anterolateral Achilles
progress to sports-specific activities. Our average time for athletes
• Surgery: resect bone through medial and/or lateral incision over prominence to return to sports has been 3 to 6 months.
If the tendon was repaired or reconstructed or if a tendon
Insertional Achilles tendinitis was transferred, a postoperative splint is applied in a relaxed
• Tender at the insertion of the Achilles halfway between the dorsal and resting position (25 to 45 degrees of equinus). At 10 days, the
plantar aspect of the calcaneus
sutures are removed, and a boot brace is applied in 20 degrees of
• Surgery: central posterior Achilles splitting incision, debride tendon and bone
plantarflexion. We permit active dorsiflexion progressively up
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 179

G
Fig. 9.19, cont’d.  (E and F) The tendon graft now can be turned distally to span the void. (G) Two no. 1
Ethibond sutures are used to anchor the corner of the turned-down graft (arrows) reinforcing the high stress
junction. The central slip typically is passed anteriorly deep to the tendon to decrease the bulk. The distal
tendon end then is secured to the remaining viable Achilles or to the bone. Comparison with the nonoperative
side facilitates tensioning of the graft.

toward the neutral point but recommend reaching the neutral With the ankle in plantarflexion and the ipsilateral leg remaining
point at 6 weeks. Exercises are encouraged with the knee flexed anterior to the body at all times, the patient leads with that leg in
to eliminate extra pulling of the gastrocnemius muscle during gait and keeps the sole of the foot in contact with the ground by
dorsiflexion. Ankle inversion and eversion strengthening may flexing the knee and hip, similar to a fencer’s advance. Although
be performed. Flexing the toes against resistance is avoided if the appearance is awkward, this method permits ambulation
a tendon transfer was performed but encouraged if no transfer without crutches.
was done. Ankle neutral position is achieved by 6 weeks, permitting
Partial weight bearing in a boot is allowed while maintain- full weight bearing with the boot adjusted at a right angle to
ing the “triple flex walk” (flexion of hip, knee, ankle) (Fig. 9.26). the leg. Then progressive dorsiflexion exercises beyond neutral
180 SECTION 2  Sport Syndromes

B C
Fig. 9.20  Insertional Achilles Tendinopathy. (A) Sagittal magnetic resonance imaging of a patient with
insertional Achilles tendinopathy and retrocalcaneal bursitis. Note the bony prominence, the fluid in the bursa
anterior to the tendon, and the abnormal signal at the insertion consistent with degeneration at the interface.
(B) A central incision is made through the site of maximal tenderness through the tendon down to the bone.
(C) The tendon is released from its insertion posteriorly and the posterior superior calcaneus is exposed.
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 181

D E

H
Fig. 9.20, cont’d.  (D) Two human retractors are placed, and the chisel is used to resect the insertion site and
the posterior superior bony prominence. (E) A side view of the chisel angle to resect the bony prominence.
Care is taken not to inadvertently penetrate too anteriorly and end up in the subtalar joint. The medial lateral
and dorsal edges are checked for remaining bone. (F) The bone has been resected and the suture anchor is
placed centrally into the calcaneus about 5 to 8 mm proximal to the previous insertion site. (G) An intraopera-
tive image demonstrating the anchor placement. (H) The sutures are placed close to the midline, penetrating
the tendon directly over the anchor with very minimal divergence to maximize tendon apposition to the bone.
The knots should be buried so that postoperative irritation is avoided.
182 SECTION 2  Sport Syndromes

or perhaps more than 9 months, depending on the extent of the

tendon disease and the integrity of the repair.
Surgical results typically correspond to the athlete’s age, with
patients younger than 50 years generally having less tendon
involvement, more rapid return to work and sports, and fewer
postoperative problems. Patients older than 50 years typically
have more tendon involvement, require greater debridement,
and have longer postoperative recovery.27,30

Expected Success Rates and Return to Sport

Success rates have ranged from 50%–90%, depending on the extent
and location of tendon involvement. Surgical debridement for
Haglund syndrome and chronic tendinosis generally has less favor-
able results.48,49 Watson et al.50 reported that those with insertional
A tendinosis are older athletes, have greater tendon involvement, take
a longer time to recover, and often do not achieve results as sat-
isfying as those with isolated retrocalcaneal bursitis. Leach et al.51
reported in a small series of athletes that the long-term success rate
was 85% following surgical treatment. However, the authors noted
that symptoms recurred in two patients and required reoperation.
A study by Schepsis et  al.48 also demonstrated initially high sat-
isfactory results, mostly in athletes with paratendinitis, although
long-term results deteriorated with time. In a recent study by
Saxena,52 return to activity was fastest in elite athletes requiring
only soft tissue procedures, particularly peritenolysis. Return to
competition was approximately 6 months. Although many studies
in the literature have quoted high success rates, this optimism for
surgical treatment must be tempered by the fact that these were
retrospective analyses that often did not differentiate among the
B
various Achilles tendon disorders.23,27,30,47-49,51,53,54

ACUTE ACHILLES TENDON RUPTURE

Introduction
Although once believed to have a lower incidence than other
lower extremity tendon ruptures (i.e., patellar tendon, quad-
riceps tendon), the incidence of Achilles tendon ruptures has
been increasing over the past few decades to become the most
common tendon rupture in the lower extremity.55-61 Most
Achilles tendon ruptures occur in males in the fourth or fifth
decade of life with nearly 70% of injuries occurring from sport-
ing activity. Thus, the increased incidence of Achilles tendon
C ruptures seems related to the higher number of middle-aged
males who participate in high-demand sports only on occasion;
Fig. 9.21  When the Achilles is degenerative at the insertion and prox- the so-called “weekend warriors.”56
imally or when more than 80% of the tendon is involved, a flexor hal-
lucis longus (FHL) graft should be considered. (A) The central approach
In the United States, in decreasing order of incidence, bas-
is used to detach the Achilles posteriorly, and the prominent bone is ketball, tennis, and football, have been the most commonly
resected. (B) The degenerative tendon is debrided. (C) The FHL tendon involved sports, accounting for 73% of all sports-related
is harvested from behind the ankle and will be reattached through a Achilles tendon ruptures.56 However, with the increasing pop-
tunnel or into a trough before repairing the Achilles tendon. ularity of professional and amateur soccer within the United
States, the incidence may increase further since soccer is the
are performed, with caution not to overstretch. Dorsiflexion most common sport involved in acute Achilles tendon ruptures
is progressed slowly, depending on the integrity of the repair. in European and Canadian studies.57-60
Swimming, bicycling, and other nonimpact activities are com- Although direct injuries to the Achilles tendon can occur
menced at 6 weeks. At 12 weeks, the boot is discontinued, and from a laceration or a direct blow, most athletes experience
lower-impact activities such as the elliptical trainer are insti- an indirect mechanism with the foot in a dorsiflexed position
tuted and increased. The patient then is progressed to jogging with an extended knee. The tensioned tendon experiences a
and then running. It may take 4 to 6 months to return to play, rapid eccentric load seen in explosive accelerations or jumps
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 183

A B

C
Fig. 9.22  The Incisions for Treatment of Haglund’s Deformity. (A) A lateral incision is more common
because the prominence is usually more pronounced on this side. (B) A medial approach is warranted for
a medial bony prominence. (C and D) Radiographs preoperatively and postoperatively show sufficient bone
resection without impingement at the tendon insertion.

that place athletes at an increased risk for an Achilles tendon without an audible pop or snap during a jumping or push-
rupture.62 A 2 to 6 cm hypovascular region of the tendon off maneuver.70 The player will not return to play and walks
located superior to the calcaneal tuberosity has been found with a limp from weak plantarflexion and pain. On a side-
to be susceptible to degenerative changes and can predis- line examination, increased passive dorsiflexion along with a
pose an athlete to an indirect injury.63 Risk factors for ten- palpable gap in the tendon are found in most circumstances
don disruption include chronic tendon degeneration,64 use other than the most distal tears and avulsions . In late-pre-
of fluoroquinolone antibiotics,65 oral or local injection of cor- senting Achilles tendon ruptures, significant swelling can
ticosteroids, gout, systemic lupus erythematous, rheumatoid obscure the gap between the tendon ends making the diag-
arthritis, ankylosing spondylitis,66 renal failure, hyperthyroid- nosis less obvious. The Thompson test, or calf squeeze test, is
ism, infection, and tumor.67,68 A recent study reported that the most commonly used and most sensitive physical exam
there was no difference in injury rate related to game play on test to assess an Achilles tendon injury. The athlete kneels on
grass versus artificial turf.69 a chair with the foot extending beyond the chair edge. The calf
A focused history and physical examination is usually suf- is squeezed and an intact tendon will briskly plantarflex the
ficient to diagnose acute Achilles tendon ruptures. An ath- foot. On the injured side, plantarflexion of the foot is absent
lete may report a feeling of a “gunshot to the heel” with or (a positive test).71 The knee flexion test can also be performed
184 SECTION 2  Sport Syndromes

D E
Fig. 9.22,  cont’d.  (E) A combined medial and lateral approach ensures a thorough bony resection and edge
contouring.

with the patient prone with the knees flexed to 90 degrees in an area of relative hypovascularity of the Achilles tendon,
(Fig. 9.27). The uninjured ankle will rest in plantarflexion, 2 to 4 cm proximal to the superior aspect of the calcaneus.68
while the injured ankle falls into neutral or dorsiflexion (see Additional risk factors include intratendinous degeneration,
Fig. 9.28).72 vascular impairment, corticosteroid or fluoroquinolone use,
In equivocal or late presentations of Achilles tendon rup- mechanical malalignment, and systemic disorders such as
tures, diagnostic studies are useful. A lateral radiograph may gout, hyperthyroidism, and renal insufficiency.67,68
reveal an avulsion of the tendon from the calcaneus, intraten- An athlete typically reports an audible snap and a sensation
dinous calcifications, or a loss of the Kager triangle (a lucency of being struck or shot from behind following a misstep or
created by the anterior border of the Achilles tendon, poste- sudden jump. The player will note significant loss of push-off
rior border of the deep flexors, and posterosuperior border strength and normally will be unable to continue sports par-
of the calcaneus). MRI is useful to provide information on ticipation. Diffuse swelling, ecchymosis, and residual strength
chronic tendon degeneration and to distinguish between a par- from remaining ankle plantarflexors can make diagnosing an
tial or complete tear in equivocal situations (see Fig. 9.29).73 initial injury difficult. However, findings consistent with an
Ultrasound is an effective imaging method and is becoming acute Achilles tendon rupture include a palpable tendon gap
more widely used due to its low cost, convenience, and ability (Fig. 9.30), positive Thompson test (absence of passive ankle
to dynamically determine where the two ends of the Achilles plantarflexion with calf squeeze in prone position; see Fig.
tendon are located. The use of ultrasound has been expanded 9.27 and Video 9.1), loss of the normal plantarflexion rest-
to help predict the risk of rerupture and poorer outcomes in ing tone while prone in comparison with the unaffected side,
patients with Achilles tendon ruptures.74 Sports-related inju- inability to perform a single toe heel rise, and weak active
ries are most often the result of a rapid eccentric load that is plantarflexion. Although imaging generally is unnecessary in
applied to a tensioned tendon with ankle dorsiflexion and acute cases, lateral radiographs may show an avulsion frac-
simultaneous knee extension. This occurs during the loading ture (Fig. 9.31). MRI and ultrasound are useful in equivocal
phase of a rapid push-off or sudden jump. Most ruptures occur or late cases (Fig. 9.29).
CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 185

B
Fig. 9.23  (A) through (C) This athlete’s x-rays and sagittal magnetic resonance images demonstrate a Haglund
deformity, retrocalcaneal bursitis, posterior calcaneal bony edema, and some insertional Achilles tendon
changes. (D and E) Because all the tenderness and prominence were lateral and there was no tenderness as
the Achilles insertion, a lateral approach was chosen, with the intraoperative option of an additional medial
incision to contour the sides. (F) Bone resection should be performed just proximal to the insertion of the
tendon. A power reciprocating rasp should be used to help contour all edges by the tendon. (G) A mini-C arm
should be used to help identify any remaining prominences.
186 SECTION 2  Sport Syndromes

C
Fig. 9.23, cont’d.

Nonsurgical Treatment Nonoperative management generally is better than operative

Although treatment of choice for most athletes with an acute management in those with systemic disorders, such as diabetes,
Achilles tendon rupture is surgical repair followed by early, peripheral vascular disease, lower-extremity edema, or overly-
protected range of motion and weight bearing, nonoperative ing skin conditions. However, these comorbidities are not often
treatment of Achilles ruptures using cast or boot immobiliza- found in the athletic population. Following nonoperative man-
tion followed by functional rehabilitation has some advocates. agement, a short-leg, nonweight-bearing cast or a controlled
The ill effects of “cast disease”75,76 include calf atrophy and ankle motion (CAM) walking boot in slight equinus is used for
resultant muscle weakness, and the consequences of immo- 6 weeks. This is followed by a weight-bearing cast or walking
bilizing joints, ligaments, and uninvolved muscles and ten- boot with progressively increased dorsiflexion.
dons. Additionally, tendon elongation, loss of muscle strength, Results similar to those of operative management have been
extended rehabilitation, additional time-loss from sport, and reported for nonoperative treatment with a functional boot
decreased function are persistent concerns in Achilles tendon brace guided by ultrasound.84 Ultrasound is used to ensure
ruptures treated nonoperatively in the high-level athlete.77,78 that the ends of the torn tendon remain apposed as the ankle is
Although operative management is associated with inher- progressively dorsiflexed during the first 6 weeks. Additionally,
ently potential surgical risks, including poor wound healing, a successful nonoperative protocol has been reported using a
infection, and nerve injury, the risks are balanced by a lower functional brace to minimize the ill effects of immobilization
incidence of tendon rerupture rates, less than 2%, compared and to shorten the time needed for rehabilitation and return
with 13% to 35% after nonoperative care.75,77,79,80 Newer less to activities.85 A more recent study found similar success with
invasive, mini-open techniques and knotless repairs have operative and nonoperative treatment in the athlete.86
lessened the risk of these complications. 81,82 Further, studies More recent postoperative trends have focused on a func-
have demonstrated improved strength and ankle motion with tional rehabilitation program with early controlled range-of-
a greater potential of sports resumption following surgical motion and strengthening exercises.87-89 Early mobilization
repair.75,83 limits the dystrophic effects of prolonged cast use and has been
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 187

D E

F G
Fig. 9.23, cont’d.

shown to reduce tendon adhesion, improve healing, and max- medial approach 1 cm anterior to the Achilles tendon border
imize tendon strength without increasing the risk of rerupture avoids injury to the sural nerve and is located in relatively thick
or infection. We favor operative repair unless contraindicated. tissues, which are biomechanically better suited to provide a
healthy closure farther away from the tendon (Fig. 9.32). Care
Surgical Treatment is taken to minimize soft-tissue handling. Meticulous soft tis-
Surgical treatment is the mainstay of treatment for the athlete sue handling is used to protect the incision and reduce the risk
with an acute rupture of the Achilles tendon. Level 1 literature of wound breakdown. A Krackow-type stitch technique with
suggests that operative repair increases strength and improves nonabsorbable, no. 2 sutures is used to reapproximate the “mop
clinical outcomes compared with nonoperative treatment at 6 end” rupture Fig. 9.33 The hematoma is evacuated, and the ten-
and 18 months.90 Athletes with well-controlled systemic dis- don ends are found. The suturing begins in the proximal end so
orders, such as diabetes, should be considered for operative that tension can be progressively applied to the tendon, allowing
treatment. This higher-risk situation requires close attention the contracted muscle proximally to relax. Next, the distal end is
to wound closure and postoperative management, including sutured, and the tendon ends can be anatomically reduced. The
meticulous and frequent follow-up. sutures are then tied.
Whenever possible, the paratenon is reapproximated to min-
Standard Technique imize scar formation and improve tendon glide. Additionally,
Acute Achilles tendon ruptures in an athlete should be treated reapproximation of the fat pad anterior to the tendon can be
operatively with the goal of recreating normal tendon length performed. Initially, we immobilize the leg for 10 days until the
and tension. The patient can be positioned in the supine or wounds have healed. The same postoperative protocol described
prone position. Additionally, it is helpful to prep and drape the above for tendon reconstructions is used. Return to sport for
contralateral extremity to help match resting ankle tension. A the athlete after repair is 4 to 6 months.
188 SECTION 2  Sport Syndromes

A C
Fig. 9.24  Endoscopic Portal Landmarks With the patient in a prone position, the lateral incision is made
just dorsal to the calcaneus and anterior to the tendon. (A) The posterior view demonstrating the lateral portal
(black arrow) and the medial portal (white arrow). The area of pain is marked on the patient’s skin. A dotted
line is marked at the superior site of the Achilles insertion below the area of pain. (B) The lateral perspective
of the portal site. (C) The medial perspective of the portal. A 4.5-mm, 30-degree arthroscope is introduced
laterally. A spinal needle is introduced medially just dorsal to the calcaneus. The 5.0-mm full-radius resector
then is inserted.

The method of suturing and the suture material have been Krackow stitch.94 Several modifications such as the “Gift Box”
a source of research. Since both early weightbearing and early or the “triple bundle” technique have shown greater strength as
motion are essential to improving clinical outcomes,91,92 the compared with standard Krackow sutures95-97, though strangu-
technique used must be strong enough to withstand the forces lation of the tissue should always be a concern in these types of
applied during rehabilitation. Traditionally, a Krackow-type suture constructs. Typically, the strength of a tendon repair is
stitch technique was used with nonabsorbable No.2 sutures directly related to the number of core strands of suture and the
to repair the tendon.93 However, studies have focused on the strength of the suture itself. For example, a biomechanical study
specifics of suture constructs, suture caliber, and number of using a modified Kessler technique found that a construct con-
core strands crossing the repair in an effort to strengthen the sisting of four strands of No. 2 sutures and two strands of 2-mm
construct. tapes and a construct with 12 No. 2 suture strands were able to
In terms of suture repair constructs, no difference in strength survive the later stages of a simulated rehabilitation protocol.
was seen between a double Bunnell, double Kessler, and double Substituting suture tape for two core strands or doubling the
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 189

Fig. 9.25  Top left corner shows the preoperative appearance of this large posterior prominence. It is unchar-
acteristically inferior, although the patient did not have insertional tendinopathy. The senior author LCS calls
this the “pregnant heel.” This is a rare exception to consider, a dorsal closing wedge osteotomy of the pos-
terior tuberosity of the calcaneus. Top left shows the lateral approach anterior to the Achilles tendon. Bottom
left shows the preoperative radiograph. The bottom right demonstrates the calcaneus following the resection
of the dorsally based closing wedge and fixation with a screw. The technique is used rarely because of inher-
ent complications with this procedure, including nonunion or malunion, potentially longer recovery times,
difficult fixation, painful prominent hardware, broken hardware, and altered mechanics.

core strands with a smaller-caliber suture both created a biome- Percutaneous Technique
chanically stronger repair in a cadaver model.98 The true percutaneous technique was introduced as a minimally
TOC and JHM’s preference for open repair has been a 6 core invasive procedure to reduce the morbidity and complications
strand technique with 2-0 FiberWire (Arthrex Inc., Naples, associated with open surgery. The original percutaneous tech-
Florida) placing one set of sutures central posterior, one set nique for repair of Achilles tendon ruptures was described by
anteromedial and a final set anterolateral. This is followed by an Ma and Griffith and used six stab incisions, a proximal Bunnell
epitenon repair with 3-0 Monocryl (Ethicon Inc., Somerville, suture and a box suture in the distal tendon stump.102 Reduced
New Jersey) and standard wound closure. Whenever possi- surgical complications were noted in meta-analyses of this
ble, the epitenon is repaired to minimize scar formation and procedure,103-105 but sural nerve entrapment was as high as
improve tendon glide. It also improves the strength to failure 16.7%.103,106 In order to reduce this risk of injury to the sural
by 53-–119%.99-101 The leg is immobilized in a splint in rest- nerve,107 techniques and devices used through a mini-open
ing equinus for 7 to 14 days until the incision has healed. We approach have been developed.108,109
use a specific postoperative protocol to guide patients through
their surgery and postoperative rehabilitation, including pro- Mini-Open Technique
gressive dorsiflexion and weightbearing (Table 9.1A–B). The Recently, the mini-open approach has been used more widely
athlete is allowed to return to sports activity in 4 to 6 months at in order to minimize surgical complications. The Achillon
the earliest, but this is guided by objective testing. It can occa- device (Integra Life Sciences Corp., Plainsboro, New Jersey)
sionally require a full year for the athlete to return to full sport was designed to be used through a mini-open approach.108
participation. Early results of this technique compared with an open repair
190 SECTION 2  Sport Syndromes

A B
Fig. 9.26  Partial weight bearing in a boot in plantarflexion is allowed while maintaining the “triple flex walk”
(flexion of hip, knee, ankle). (A) With the ankle and the ipsilateral leg remaining anterior to the body at all
times, the patient leads with that leg in gait and keeps the sole of the foot in contact with the ground by
flexing the knee and hip, similar to a fencer’s advance. (B) The back leg is now brought forward but does
not advance beyond the front healing leg so that the Achilles can be kept unloaded. Next the braced leg is
advanced again as in A. This method permits ambulation without crutches.

showed lower complication rates and improved cosmetic device and the suture ends are pulled out from under the para-
appearance.110 A similar device by Giannini (Citieffe, Calderara tenon and incision such that the ends of the sutures grasping the
di Reno, Bologna, Italy) is also effective. Another device, the tendon now rest entirely within the paratenon. The tendon ends
Percutaneous Achilles Repair System (PARS) (Arthrex, Inc., are reapproximated, and the sutures are tied.
Naples, Florida), has been available since 2010 and uses non- Assal et al.108 reported their experience using the Achillon
locking and locking sutures to gain greater purchase within the device in 82 patients, noting that all patients who were elite
tendon stumps. A biomechanical study showed greater con- athletes were able to return to their same level of competition.
struct strength under cyclic and ultimate loads with the PARS Maffulli et  al. 112 found that the average time to full return
repair as compared with the Achillon system.111 to sport participation after percutaneous fixation of Achilles
To minimize the possibility of injury to the sural nerve inher- tendon ruptures in elite athletes was 4.8 ± 0.9 months. In a sin-
ent in a purely percutaneous suture technique, a mini-open gle-center, retrospective cohort study, Hsu et al. compared 101
approach can be used. A small stab incision is made, and then PARS Achilles repairs with 169 open repairs. For PARS cases,
the subcutaneous soft tissue is spread bluntly before passing the a reusable metal PARS jig was used to pass sutures through
suture/wire. These mini-open techniques permit the advantage the Achilles proximal and distal stumps in a way that pulls
of direct visual repair while minimizing potential complications the sutures within the paratenon and reduces the risk of sural
of wound and nerve problems. A small skin incision is made, nerve injury. The PARS jig is used to place sutures in the prox-
and the Achillon, Giannini’s device, or PARS is introduced imal and distal Achilles tendon stumps and has the ability to
under the paratenon. A needle with suture is passed from the lock one or two of the three to five sutures used through the
external guide through the skin into the tendon and out the device. With the foot in a plantarflexed position, the sutures
opposite side. Three sutures are passed through the proximal in each end are tied under maximum tension nearest to far-
tendon end, and three are used in the distal tendon end. The thest from the rupture site to avoid tendon bunching in the
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 191

to physical activity at 5 months with 98% of PARS patients

returning, compared with 82% of open repairs.88
A knotless modification of the above mini-open technique
was reported by McWilliam and MacKay and has become our
preferred method. It uses the PARS device for placement of the
proximal sutures and then anchors these sutures to each side
of the calcaneus with bone anchors.89 Based on biomechanical
research,113 TOC and JHM have modified this technique slightly
to include a FiberTape suture (Arthrex, Inc., Naples, Florida).114
In McWilliam and MacKay’s preliminary report on 34 patients
with follow-up of 2 to 36 months, there were no wound compli-
cations, reruptures, or nerve injuries, and all patients reported
satisfaction with their outcomes (Fig. 9.34).89

Expected Results of Acute Surgical Repair

Though most high-level athletes have near limitless rehabil-
itation, an Achilles tendon rupture can be a career-ending
injury. Significant delay in return to play, and reduced playing
time and performance have been shown in National Basketball
Association (NBA) and National Football League (NFL) play-
ers who sustain an Achilles tendon rupture requiring surgical
repair. Overall, a return to play rate of 66% to 78% was noted in
these studies.63,115-120 In a study of 62 athletes, which included
NBA, NFL, and Major League Baseball players, functional
Fig. 9.27 A positive Thompson test in the near leg with the Achilles
tendon rupture. The calf muscles are squeezed and there is an absence deficits were seen only at 1 year after surgery compared with
of passive ankle plantarflexion in the prone position. matched controls. The players showed performance at a level
comparable to uninjured controls at 2 years postoperatively.120
In another study examining outcomes in recreational athletes at
an average of 32 months following acute Achilles tendon repair,
Porter et  al. showed that while there were objective plantar-
flexion strength deficits in the operative extremity, subjective
results indicated near normal pain level and function.121 Due to
the various methods of obtaining and analyzing available infor-
mation on professional athletes and their injuries, critical eval-
uation of scientific method and careful interpretation should
always be applied to these outcomes studies of professional
sports athletes.122
One may expect return to sports generally at 4 to 6 months
after acute repair and a program of early protected weight bear-
ing.23,77,123,124 Cetti et al.75 previously showed less calf atrophy
and improved ability to resume preinjury level of athletic play
after surgical repair as compared with nonoperative treat-
ment.75,77,81-83,123 However, Heikkinen et  al. 125 demonstrated
that surgically repaired Achilles tendons are longer, more atro-
phied, and have less strength when compared with the unin-
jured leg. In a meta-analysis of acute Achilles tendon treatment,
Bhandari et al.105 confirmed a statistically significant reduction
in rerupture rates after surgical repair (3.1%) as compared with
Fig. 9.28  Loss of plantarflexion angle after Achilles rupture. nonoperative treatment (13%). However, infections occurred
only in the surgically treated group (infection rates ranging
center. The overall complication rate was 8.5% with no rerup- from 4% to 20%). The proportion of patients who regained
tures in either group. Of the 101 patients treated with PARS, normal function was similar in the operative and nonoperative
3 had superficial wound dehiscence treated with local wound treatment groups.
care without antibiotics. Two other patients in the PARS In another meta-analysis, Khan et al.104 identified 12 suitable
group underwent reoperation for a foreign-body reaction to papers for inclusion. They found that the relative risk of rerup-
FiberWire suture that developed 4 months after the initial ture was 0.27 with operative versus nonoperative treatment.
surgery. The study showed a significant difference in return Complications including infection, adhesions, and altered skin
192 SECTION 2  Sport Syndromes

Fig. 9.29  Sagittal magnetic resonance image showing a long, complex Achilles tear (white arrows).

sensitivity had a relative risk of 10.6 (operative versus nonopera- uncommon to diagnose a late injury. Chronic Achilles tendon
tive). Functional bracing postoperatively had lower complications ruptures generally present for delayed diagnosis or after a failed
than casting postoperatively (relative risk 1.88). They concluded acute repair. Chronic ruptures typically are defined as those
that operative treatment significantly reduced the risk of rerup- diagnosed more than 4 to 6 weeks after initial injury.124,128 After
ture but significantly increased the risk of complications overall. this period, the gap between the separated tendon ends fills with
In a multicenter randomized trial, Willits et  al.,126 exam- fibrinous material. This scar tissue contains disorganized fibro-
ined the outcomes of 144 patients with acute Achilles tendon blasts and does not possess the same biomechanical strength as
ruptures treated operatively vs nonoperatively for which both normal tendon. Over time, the tissue will elongate and lead to
groups were treated with an accelerated functional rehabilita- further functional weakness.23Those patients treated with non-
tion protocol including early weight bearing and early range operative modalities or those with a failed acute repair can also
of motion. The authors did not find a significant difference in fall into this group and can develop pain, weakness, and dys-
rerupture rates between operative and nonoperative treatments. function due to the elongation of the tendon.129
However, similar to findings presented in previous studies, they Typically, a patient will complain of loss in push-off strength
found an increased risk of complications in the operatively and be unable to perform toe walking and repetitive heel rise.
treated group. Despite these findings, a recent analysis of 12,570 When the patient lies prone, the injured extremity will demon-
patients treated for an acute Achilles tendon rupture demon- strate less resting plantarflexion tone as compared with the
strated that the rate of surgically treated acute Achilles tendon contralateral ankle. The involved ankle will display a relative
ruptures is increasing in the United States.127 increase in passive dorsiflexion and significantly less plantar-
flexion with calf squeeze. A palpable tendon gap is not typi-
cally evident, but the contour of the tissues will be altered, with
CHRONIC ACHILLES TENDON RUPTURE thickening and loss of defined margins. The appearance of the
More than 20% of patients with an Achilles tendon rupture affected calf muscle can be different from the contralateral side.
are missed on initial examination,23 and it therefore is not Often the muscle belly is more proximally situated (“balled up”)
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 193

Fig. 9.31  A lateral radiograph shows an avulsion fracture in a patient

with a history of retrocalcaneal bursitis. There was no history of steroid
injection.

B Since the improved results seen with nonoperative treatment

using functional rehabilitation and early weight-bearing are
based on diagnosing and treating the Achilles tendon rupture
acutely, nonoperative treatment has little place in the manage-
ment of athletic individuals with this injury.

Surgical Treatment
The goals of operative reconstruction are to restore anatomic
musculotendinous length and restore strength and endurance.
Regardless of the specific procedure used, pharmaceutical
anticoagulation should be used for repair or reconstruction of
chronic ruptures, as a significantly higher rate of venous throm-
boembolism has been shown to occur following surgical inter-
vention for chronic versus acute Achilles tendon ruptures.130
Due to the scarring, muscle retraction, and atrophy, direct
repair is not always possible for the chronic Achilles tendon tear.
C
The type of tendon reconstruction will depend on the size of the
Fig. 9.30  (A) The side with the Achilles rupture has a visible indentation residual gap after debridement of scar tissue. Myerson described
(arrow). (B) The normal side. (C) The ruptured side has a palpable defect.
a scheme for surgical treatment of chronic Achilles tendon rup-
tures on the basis of defect size (Table 9.2).124 Outcomes for sur-
as a result of its detachment distally. MRI and possibly ultra- gical treatment options for chronic ruptures are limited mostly
sound evaluation are useful in evaluating the size of the tendon to small case series and case reports.
gap and assist in surgical planning.
Primary Repair
Nonsurgical Treatment Primary repair is an option in cases of chronic ruptures with
Nonoperative management may be considered in those patients less than 2 cm of retraction or in cases where the tendon has
without functional deficits or high-risk patients, but surgical healed in an elongated position. Porter et al. published a report
management is certainly the treatment of choice for the athlete. of 11 patients with neglected Achilles ruptures (between
194 SECTION 2  Sport Syndromes

D
Fig. 9.32  (A) An acute Achilles tendon rupture repair is performed with the patient in a prone position. (B) A
medial approach made 1 cm anterior to the Achilles tendon avoids injury to the sural nerve. (C) The approach
is with the scalpel, avoiding blunt dissection. (D) The exposure is through relatively thick tissues, which are
biomechanically better suited to provide a closure that provides a barrier to the tendon, which is 1 to 1.5 cm
away from the incision. (E) The exposed mop ends of the tendon.
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 195

TABLE 9.1A  General Guidelines for Postoperative Achilles Tendon Rehabilitation Following
Surgery
POSTOPERATIVE REHABILITATION PROTOCOL
Time Therapy
Weeks 1–2 Nonweight bearing in a postoperative splint
Weeks 3–6 Walking boot with 4 heel wedges, start 4-week weight bearing progression, removal of 1 wedge per week, allowed to start active plantarflexion
and dorsiflexion up to 5–10 degrees short of neutral. Formal PT can start at this time for range of motion (active and active-assisted, not passive)
Week 7 Wean from boot to shoe with 2 wedges, remove 1 wedge per week
Week 8 Start functional PT with sports progression
Weeks 12–16 Limit activities in athletes to practice. Risk of rerupture persists up to 4 months
Week 16 Start controlled practice with pain as guide
Months 6–12 Athletes able to return to full preinjury level of activity as symptoms allow
PT, physiotherapy

TABLE 9.1B  Achilles Tendon Rupture Postoperative Protocola

General Instructions
• The goal of this surgery is to return you to full strength, power, function, and comfort in the shortest amount of time. This time will vary from person to person.
Following the guidelines outlined here give you the best chance for a full recovery.
• You will need to use crutches and a walking boot for 2–6 weeks. You will receive crutches (if you don’t already have them) after surgery. You will receive a walking
boot brace at your first postoperative visit. This boot brace will be worn when walking for up to 8 weeks. The boot may be one that allows for the ankle to move in a
downward direction (plantarflexion) but will limit its ability to go in an upward direction (dorsiflexion) or you will be in a fixed-position boot with heel lifts that will be
removed weekly and you will be able to remove the boot and work on moving the ankle within specific ranges using your muscles as described below.
• Avoid squatting, lunging, rising up on toes, bouncing, or jumping motions. Do not roll through the foot when walking for approximately 8–12 weeks. Reruptures of
the repaired Achilles tendon are rare, but can occur between 6 weeks and 4 months after surgery. Wear your boot, brace, or heel lifts as prescribed.
• Weight bearing progression in the boot will begin following the first postoperative visit and you will receive a written protocol for guidance along with instruc-
tions by your physical therapist or athletic trainer.
• Do not force upward motion of the ankle. The tendon is repaired with tension applied which will limit your ankle’s upward motion initially. This will gradually
improve and allow more upward motion with time and therapy. If you overstretch the tendon before adequate healing has occurred, you increase your risk of
losing strength, power, and function. It is better for it to be too tight rather than too loose.
• Compression socks that are at or near medical grade are beneficial for 3–6 months following surgery, especially when active during the day, at work, or exercis-
ing.
• Achilles tendons take considerable time to heal whether you are an elite athlete or nonathletic. The general rate of healing is 75% healed by 3 months and 90%
healed by 6 months. Attempts to push for early return to high stress activities risk re-injury or stretching of the surgical repair. Some individuals take as long as
1–2 years to reach maximum improvement.
• Postoperative rehabilitation is best done under the direction of a physical therapist or athletic trainer knowledgeable in Achilles rehab. The advancement of
exercises introduced over time is partly related to the standard time necessary for certain tissues to heal and gain strength, and in later stages of rehabilitation,
this becomes more dependent on reaching specific goals for motion, strength, power, agility, and balance. Different individuals reach these goals in varying time.
Rehabilitation involves retraining and conditioning the entire body, not just the Achilles tendon or foot and leg.

Postoperative Course
Day 1–4
• The foot will be wrapped in a plaster splint with lots of padding and a removable bandage. If for any reason your splint is uncomfortable or too tight, remove the
ace wrap, loosen padding, and re-apply to your comfort level.
• It is important to ice and elevate the foot, take pain medication, and rest as needed.
• Expect numbness in the ankle for 4–12 hours and then anticipate the onset of pain. Your strongest pain will be the first 3–4 days after surgery.
• No weight bearing on injured foot.
• Do not get the foot or splint wet.
• Moving toes and moving the ankle to the degree allowed within the splint and trying to tighten your muscles (isometric contractions) in the leg, foot, and ankle
help reduce swelling.
• As you feel better, you may perform exercises such as leg lifts and core exercise.

Day 4–10
• Pain should improve after the third day. If your pain has worsened since day 3 or you have a fever and/or chills, please call the doctor’s office.
• Continue exercises as guided by the doctor’s office, but with no weight on the surgical leg.

Continued
196 SECTION 2  Sport Syndromes

TABLE 9.1B  Achilles Tendon Rupture Postoperative Protocola—cont’d

• Showers are possible if you can sit in the shower with the splinted leg in a water-impenetrable bag. Commercially available bags can come from the hospital,
outpatient surgery center, or doctor’s office. An alternative is the use of 2 plastic medium-size trash bags with each one sealed at the top with Duct Tape (one bag
will usually leak).

Day 10 –to 3 weeks

• First postoperative visit in the office.
• Your sutures will be removed and the dressing will be changed.
• You will be placed in a walking boot brace with your ankle fixed in the position of slight tension on the tendon repair. This may be anywhere from 10–20 degrees
of downward positioning (plantarflexion), but it should not be painful.
• You can remove the boot and begin movement exercises with your muscles. Begin drawing the alphabet with the foot and ankle and move the ankle up and down.
The ankle should not move above a right angle to the leg (neutral position) during this time.
• Using a towel, do inversion, eversion, and toe crunch exercises.
• Your physical therapist/athletic trainer will work with you on these exercises and others.
• If the incision is healing well, you may get the foot wet in the shower 2 days after your first postoperative visit.

3–6 weeks
• Once the incision is fully healed, you may submerge the ankle in water in a bath or pool.
• Gentle exercise for conditioning on a stationary bike is permitted in the boot. Start with no resistance.
• Exercising in the pool is permitted (primarily deep-water exercise) with buoyancy conditions (e.g., pull buoys); however, swimming, pushing off, and kicking are not
permitted.
• Walking in boot without crutches is permitted if stable and nonpainful.

6–8 weeks
• Boot brace comes up into neutral position or fixed boot should now have no heel lifts.
• Biking without boot is permitted in shoe with heel lift or pedal positioned toward heel.
• Swimming is permitted. No wall push-offs.
• Pool program can include gait retraining and heel raises in shoulder depth water for buoyancy. Start with double leg heel raises and progress to single leg as
tolerated.

8–12 weeks
• May begin to wean out of boot brace gradually.
• Avoid lunging, squatting, jumping, or single heel raises.
• Walk progressively more as tolerated.
• Biking with resistance as tolerated.
• Treadmill on level surface.
• Balance retraining program.
• Pool therapy: walking, heel raises, gentle hopping, and jumping starting in shoulder depth and progressing to waist deep water.

12–16 weeks
• Treadmill walking on increased incline, gradual progression to jogging if symptom free.
• Road biking permitted.
• Pool therapy: pushing off as tolerated. Avoid diving and especially diving board.
• Progressive submaximal dorsiflexion and plantarflexion for endurance.
• Closed chain strength program. Start double leg heel raises.
• Continue balance on dynamic surfaces.

16–20 weeks
• Individualized strength and flexibility program.
• Progress to running but not sprinting.
• Progress resistive exercises to body weight exercises such as repeated heel raises.
• Progress proprioceptive and balance training.

20–24 weeks
• Sport-specific training with careful monitoring in accordance to pain and swelling.
• Running, jumping, and squatting are introduced and advanced.
aThe detailed postoperative course and rehabilitation protocol used for patient education by the authors.
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 197

TABLE 9.2  Guideline for Treatment of

Chronic Achilles Tendon Tears Based on Defect
Size
Defect Size Surgical Procedure
1–2 cm End-to-end anastomosis and posterior compartment
fasciotomy
2–5 cm V-Y lengthening, augmented with tendon transfer, if
needed
>5 cm Tendon transfer alone or in combination with V-Y
advancement or turndown

Myerson, M. Achilles tendon ruptures. Instr Course Lect 1999;48:219-

30. Reproduced with permission and adapted from Myerson M: Achil-
les tendon ruptures. AAOS Instr Course Lect. 1999;48:219–30.

A
months (range, 2.8 to 9 months).131 In a more recent study,
Yasuda et al. performed a similar procedure in 30 patients with
chronic ruptures ≥4 weeks old by utilizing resection of scar
tissue (15 to 50 mm in length) between the healed stumps of
the tendon prior to a direct repair of the tendon with No. 2
nonabsorbable polyfilament Krackow stitches. Mean AOFAS
scores increased from 82.8 preoperatively to 98.1 postopera-
tively. At latest follow-up, no patients experienced reruptures
or difficulty walking or climbing stairs. All 14 athletes (includ-
ing three competitive) returned to their preinjury levels of
participation.132

V-Y Advancement
V-Y advancement is typically performed in cases of 2 to 5 cm
defects.133 An inverted V is incised on the proximal stump of
B
the Achilles tendon with the apex of the V at the tendinous
portion of the myotendinous junction. The arms of the V are
made with a length that is 1.5 times that of the defect size.
With larger defects (>5 cm), the arms of the V should be twice
the defect size. (see Fig. 9.18).The proximal Achilles tendon
is pulled carefully and slowly so that the myotendinous junc-
tion is stretched and not torn to allow suture repair of the two
segments.134
While studies of V-Y advancement alone are lacking, several
studies combine the procedure with further reinforcement.134,135
Guclu et al. performed V-Y advancement with fascia turndown
in 17 patients with chronic Achilles tendon ruptures at an aver-
age of 7 months postinjury (range 4 to 12 months). There is no
mention of the number of athletes. Mean defect size was 6 cm fol-
lowing debridement but ranged from 4.5 to 8 cm. AOFAS scores
C improved from a mean of 64 preoperatively to 95 postoperatively
Fig. 9.33  (A) Another acute Achilles repair with exposure of the frayed with no reruptures at an average follow-up of 16 years (range 13 to
tendon ends. (B) Care is taken to minimize soft-tissue handling. A Krac- 19 years).135 In another case series, Elias et al. described improved
kow-type stitch technique with nonabsorable, no. 2 sutures is used to outcomes in 15 patients undergoing V-Y advancement and flexor
reapproximate the “mop end” rupture. (C) The edges of the anastomo-
halluces longus (FHL) tendon transfer for gaps larger than 5 cm
sis should be made neat with a 2-0 or 4-0 absorbable suture. The resting
tension should be restored. with an average of 2-year follow-up (range 1 to 4.5 years). While
no patients in the follow-up portion of the study were reported
4- and 12-weeks postinjury) treated with proximal release of to be athletes, one surgical patient did not attend follow-up and
the gastrocnemius–soleus complex, imbrication of the early was dropped from the study because he was playing professional
fibrous scar without excision of local tissue, and direct pri- basketball in Europe.134
mary repair of the tendon. All patients were reported to have For more chronic cases seen more than 12 weeks after a
returned to their preinjury level of activity at a mean of 5.8 missed rupture or after a previous completely failed repair, a
198 SECTION 2  Sport Syndromes

A B

C D
Fig. 9.34  (A) Acute rupture showing preoperative loss of carrying angle. (B) Transverse incision at rupture
site for mini-open technique. (C) Percutaneous Achilles Repair System (PARS) jig in place for suture passage
through proximal stump. (D) Sutures passed through Achilles’ proximal stump within paratenon and brought
out of transverse incision.

V-Y advancement or turndown likely will be required, depend- gastrocnemius/soleus muscle, an FHL or FDL tendon transfer
ing on the size of the defect after repair. For defects between 2 may be considered (see Figs. 9.16 and 9.17). An FHL tendon
and 3 cm, a V-Y advancement is possible, as mentioned previ- transfer is most commonly used,137 though a peroneus brevis
ously. For defects longer than 3 to 5 cm, a turndown procedure tendon transfer can also be effective.136 In addition to mechan-
with possible tendon augmentation is required, as discussed ical support, the FHL transfer provides additional blood supply
earlier (see Fig. 9.19). to the ruptured tendon.137 However, there are arguments that
FHL harvesting eventually reduces push-off during the stance
Tendon Transfer phase.138 Wapner et al. were the first to report on a technique
Chronic Achilles tendon ruptures are typically more diffi- for harvesting the FHL tendon through an additional medial
cult to repair than acute ruptures due to retraction of the ten- midfoot incision at the knot of Henry and transferring the
don ends.136 For those cases with preoperative atrophy of the tendon through the calcaneus.139 This approach can put the
E F

G
Fig. 9.34 cont’d. (E) Drill hole in lateral calcaneus for anchoring sutures in the knotless technique. (F)
Restored carrying angle postrepair with anchors in medial and lateral calcaneus. (G) Position of slight tension
on repair for postoperative splint.

A B C
Fig. 9.35  Single incision FHL Transfer technique from a medially base “J” approach. (A) Exposure of flexor
hallucis longus (FHL) tendon. (B) Harvested FHL tendon from deep within medial tunnel in single incision
technique. (C) FHL tendon fixed in calcaneal tunnel with interference fit screw.
200 SECTION 2  Sport Syndromes

medial plantar nerve at risk with dissection. Newer technolo-

gies such as interference fit screw fixation, bone suture anchors,
and endobuttons have allowed surgeons to achieve strong bony
fixation with less tendon harvest length through a one-incision
technique (Fig. 9.35).140,141
The FHL can be harvested from the posterior ankle in the
depths of the posterior approach (Fig. 9.36A) to the Achilles,
or, if a longer graft is felt to be advantageous, from the arch of
the foot. The graft harvest can be performed through a medial
approach just plantar to the posterior tibial tendon and the
talonavicular joint (Fig. 9.36B) or through the plantar aspect
through the plantar fascia (Fig. 9.36C). For the latter approach,
once the incision is made through the plantar fascia, care is
taken to avoid the medial plantar nerve. The FHL and FDL
A tendons can be found in the depth of the wound next to the
first metatarsal and medial cuneiform. Once the tendons have
been identified, the FHL is sutured to the FDL distal to the point
at which the tendon will be transected (at or near the knot of
Henry). A suture placed in the FHL proximal to the transec-
tion is helpful in case the tendon does not pull through into the
proximal wound.
Den Hartog142 described a technique of harvesting the FHL
tendon near the tip of the medial malleolus for chronic Achilles
tendinosis. Good to excellent results were reported in 23 of
26 treated patients without any deficit to first-toe function. A
recent biomechanical study showed little pressure change under
the first or second metatarsophalangeal (MTP) joint and no
clinical functional deficit after FHL harvesting.138 Prior studies
also showed promising clinical results.139,143
B
Autograft/Allograft Reconstruction
Chronic Achilles tears can also be managed by free autologous
gracilis tendon grafts. In one study, this technique was reported
as a safe but technically demanding procedure, and it was noted
that plantarflexion strength could be significantly reduced com-
pared with the contralateral side.144 Donor site complications
should be kept in mind when considering reconstruction with
allologous tendon grafts (Fig. 9.37)
Synthetic augmentation has been reported to result in a strong
reactive immune response after undergoing revision Achilles ten-
don surgery. Adverse immune reactions may lead to catastrophic
complications that may eventually require removal of the graft.145

CONCLUSION
Achilles tendon disorders are common in the athlete. If diag-
nosed early, the process usually is a tendinopathy and is amenable
to nonoperative treatment such as intermittent immobilization,
C stretching, modalities such as ultrasound and iontophoresis,
Fig. 9.36 (A) The flexor hallucis longus (FHL) can be harvested from and use of anti-inflammatory medication. More chronic cases
the posterior ankle in the depths of the posterior approach to the Achil- take longer to treat and have a higher risk of requiring more
les. (B) The graft harvest through a medial approach just plantar to the invasive intervention such as the shockwave, PRP, bone marrow
posterior tibial tendon and the talonavicular joint. (C) The graft harvest
through the plantar aspect of the foot. After incising the plantar fas-
concentrate, growth factors or operative intervention. Operative
cia and reflecting the medial plantar nerve, the FHL and flexor digito- treatment typically is 70% to 90% successful but requires 3 to 6
rum longus (FDL) tendons can be found next to the bones. The FHL months for return to athletic participation.
is sutured to the FDL distal to where the tendon will be transected. Achilles rupture typically will require operative treatment in
Next, the FHL is cut proximal to the tenodesis and withdrawn out the the athlete, and 6 to 9 months can be a typical recovery period.
proximal ankle incision.
 CHAPTER 9  Achilles Tendon Disorders Including Tendinopathies and Ruptures 201

A B

C D E
Fig. 9.37 (A) Achilles tendon reconstruction of chronic injury with large gap utilizing an Achilles tendon
allograft with bone block. (B) Allograft tendon fixated to calcaneus with cancellous screws and attached to
proximal stump with Pulvertaft weave. (C) Completed reconstruction. (D) Incision closure. (E) Lateral radio-
graph showing bone block fixation.

A wide variety of options are available for treatment of chronic 3. Burdett RG. Forces predicted at the ankle during running. Med
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an autograft reconstruction have the most support.129 Careful
Bone Joint Surg Br. 1989;71(1):100–101.
consideration of individual patient circumstances together with
6. Langergren C, Lindholm A. Vascular distribution in the Achilles
the experience of the surgeon are critical factors in surgical tendon: an angiographic and microangiographic study. Acta
management of chronic Achilles tendon ruptures since these Chir Scand. 1959;116:491–495.
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1995;316:151–164.
8. Hashimoto T, Nobuhara K, Hamada T. Pathologic evidence of
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 Video 9.1  https://www.kollaborate.tv/link?id=5c9d1b2b536f4
The Thompson Test for Evaluation of Acute Achilles Rupture The
Thompson Test assessing for plantarflexion to evaluate the Achilles
tendon. Good plantarflexion in the right lower leg indicates an intact
Achilles, while lack of plantarflexion on the left indicates a positive
Achilles rupture

205.e1
 10
Posterior Tibialis Tendon
Injury in the Athlete
Kenneth J. Hunt

OUTLINE
Introduction, 206 Treatment, 213
Anatomy and Biomechanics, 206 Conservative, 213
Diagnosis, 207 Surgical Treatment, 213
History and Questions to Be Answered, 208 Stage I—Tendon Length Normal, 213
Physical Examination and Questions to Be Answered, 208 Stage II—Tendon Elongated, Deformity Mild and Flexible, 214
Radiographic Imaging, 209 Stage III—Tendon Elongated, Flexible or Rigid Moderate to
Ankle and Foot Radiographs, 209 Severe Deformity, 221
Magnetic Resonance Imaging, 211 Perils and Pitfalls, 222
Disease Staging, 212 Summary, 222

INTRODUCTION long flexors prevents the tendon from subluxing over the medial
The tibialis posterior muscle and its tendon (PTT) play a vital malleolus.11 Because the posterior tibialis tendon lacks a meso-
role in most athletic activities. The tibialis posterior is the stron- tenon, there is an area of relative hypovascularity from this acute
gest inverter of the foot, it locks the triple joint during gait turn at the medial malleolus to the medial navicular insertion.
progression facilitating a rigid lever of push-off, and provides These factors of hypovascularity and the mechanical stress of a rel-
both power for acceleration and control for deceleration. Due atively acute turn of the tendon as part of a strong, weight-bearing
to these important and repetitive roles, acute and chronic injury leg muscle (second only to the gastrocnemius), make the tendon
to the PTT are commonplace in athletes. A knowledge of dis- predisposed to acute and overuse injury in this area.
ease progression, risk factors, and treatment measures is vital Because the posterior tibial tendon travels posterior to the
for treating physicians. axis of the ankle and medial to the axis of the subtalar joint, it
Acute posterior tibialis tendon injury in the athlete is rare1,2,3 functions as a strong ankle plantarflexor and foot invertor via
but must always be considered in the differential diagnosis when the transverse tarsal joint (talonavicular and calcaneocuboid
an athlete presents primarily with tenderness, swelling, and pain joints).12 The tendon also has multiple slip attachments to the
over the medial ankle or plantar medial midfoot. Antecedent to the capsule of the naviculocuneiform joint, all three of the cunei-
acute presentation, there often is a history of less severe prodromal forms, the cuboid, and their respective metatarsal bases in the
symptoms more consistent with a chronic tendinopathy or tendi- plantar arch.5,13 The posterior tibialis tendon therefore is pri-
nosis. In most cases, there are identifiable mechanical or physio- marily a midfoot invertor and dynamically supports and ele-
logic risk factors that contribute to this development. The chronic vates the medial longitudinal arch. It also indirectly supports
picture is seen more often in the middle-aged to elderly athlete.4-6 the hindfoot because of its medial malleolar pulley action and
While most of the literature on the topic focuses on chronic PTT intimate relationship to the deep deltoid ligament, plantar
dysfunction, 1,2,7–10 it is important to identify acute injuries and medial talonavicular joint capsule, and spring ligament (calca-
understand them in the context of the individual athlete. neonavicular ligament).14 The dynamic role of the PTT places it
at risk of elongation and degenerative tearing or even rupture.
The resulting loss of dynamic function can lead to progres-
ANATOMY AND BIOMECHANICS sive loss of static support structures, such as the ligaments and
The tibialis posterior muscle occupies the deep posterior compart- plantar capsules of the midfoot joints, and ultimately a pes pla-
ment of the leg, originating along the proximal one third of the novalgus deformity (Fig. 10.1). As the deformity progresses over
tibia and intraosseous membrane. Distally, its tendon travels poste- time, other structures are affected, including the talonavicular
rior, then inferior, through the medial malleolar groove, changing joint capsule, deltoid ligament, and spring ligament. The stretch-
direction abruptly almost 90 degrees. The stout retinaculum of the ing out or even frank rupture of these structures eventually leads
206
 CHAPTER 10  Posterior Tibialis Tendon Injury in the Athlete 207

A B
Fig. 10.1  Dorsal-plantar view demonstrating the normal foot (A) and the posterior tibialis tendon incompetent
foot (B). With external rotation or abduction of the forefoot, the medial talar head becomes more uncovered
by the navicular as it rotates externally. The calcaneus also secondarily rotates externally and tilts into more
valgus.

A B
Fig. 10.2  Posterior-anterior view of the normal (A) and posterior tibialis tendon incompetent ankle and hind-
foot (B). With external calcaneal rotation, the talar head translates plantarward. This also leads to increased
valgus tilting of the calcaneus and subfibular or sinus tarsi impingement.

to a more severe valgus inclination of the hindfoot and external

rotation of the calcaneus, also associated with contracture of the
DIAGNOSIS
triceps surae as it transitions into a hindfoot everter (Fig. 10.2).12 Usually, a detailed history, careful physical examination, and
Clinically, this may result in impinging pain and swelling in the weight-bearing radiographs will establish the diagnosis of a
subfibular or sinus tarsi area as the calcaneus abuts against the posterior tibialis tendon injury. Additional imaging can help
lateral malleolus. In very severe or neglected cases, a valgus tilt of to further elucidate the structures involved and extent of dis-
the ankle may be seen as the deltoid ligament becomes incompe- ease, but is usually not necessary to reach a diagnosis and
tent, and asymmetric valgus arthritis can result. classification.
208 SECTION 2  Sport Syndromes

Predisposing Factors
• Does the patient have a preexisting and/or progressive pes
planus deformity?
• Is there a history of oral steroid use, injected steroids in the
area of the tendon?
• Does the patient have a history of, or risk factors for, diabetes
mellitus?
• Does the patient have vasculopathy, obesity, or active tobacco
use?

Physical Examination and Questions to Be

Answered
For comparison, both unclothed and unshod lower extremi-
ties from the midthigh distally to the toes should be carefully
examined.
• Is there a valgus knee deformity (genu valgus) of the symp-
Fig. 10.3  Usual area of maximal tenderness and swelling along the ter- tomatic side? (This may precipitate or exacerbate posterior
minal course of the posterior tibialis tendon between the medial malle- tibialis tendon dysfunction, especially if chronic.)
olus and medial navicular insertion. Occasionally, this can extend to the • Is there tenderness and swelling along the PTT, particularly
area posterior to the medial malleolus. as it courses between the medial malleolus and the navicu-
lar insertion, or the posterior aspect of the medial malleolus
(Fig. 10.3A−B)?
History and Questions to Be Answered • In viewing the weight-bearing patient from front and behind,
Sometimes the history alone will provide the physician with is there increased forefoot abduction or pronation (the
enough information to suggest the diagnosis. Athletes will “too many toes sign”) (Fig. 10.4)? In addition, is the symp-
complain of pain on the medial aspect of the hindfoot, below tomatic hindfoot in valgus compared to the contralateral
the medial malleolus. While the chief complaint is often “ankle side?
pain,” a careful history can isolate the pain to the medial sub- • Does the patient have difficulty heel rising with all of his
malleolar region. Since conditions of the PTT can occur insid- or her weight on the injured side (“single foot heel rise”
iously, acutely, or a combination of the two, it is important to test), or if he or she is able to heel rise, does the hind-
explore common etiologies. foot fail to invert or invert less than the normal side (Fig.
10.5)? It is important to determine the contributors of
pain and weakness.
Acute Pain or Injury • Is there tenderness and swelling laterally in the sinus tarsi
• What was the mechanism of injury? or subfibular area, suggesting subfibular impingement, espe-
• Did the foot sustain an eversion twisting injury, especially cially in the patient with deformity (Fig. 10.6)?
on impact from tripping or a fall? • Is there pain and/or weakness with resisted inversion com-
• Conversely, was there a sudden increase in the level of pared to the asymptomatic side?
athletic activity temporally related to the onset of symp- • Is the Achilles tendon and/or gastrocnemius contracted?
toms? This can be determined with Silfverskiold’s test (passive
• Were there prodromal symptoms suggesting possible tendon ankle dorsiflexion with the knee extended, tests gastroc-
degeneration before the acute injury? nemius tightness, passive ankle dorsiflexion with the knee
bent relaxes the gastrocnemius and tests Soleus/Achilles
tightness).
Chronic or Acute on Chronic • Are there abnormal sensory findings that might suggest
• Has the athlete noticed that the arch on the involved side peripheral neuropathy, especially in the diabetic patient?
is “flatter,” the foot is “turned out,” the ankle “turned in,” or • Is there a positive Tinel’s sign over the tibial nerve in the
complained that the injured foot is “weaker”? medial ankle or plantar foot sensory deficits that might sug-
• When barefoot on a hard, wet floor surface, such as at bath gest a tarsal tunnel syndrome?
time, does the patient notice a wider footprint or a “sucking • Is there a tender and swollen bony prominence in the area
sound” because of a vacuum effect of the collapsed arch on of the medial navicular, suggesting an accessory navicular or
the symptomatic side? bone stress injury?
• Has the athlete noticed more medial shoe sole wear or “run- • Is the medial malleolus itself tender or painful with percus-
ning over” the medial vamp? sion, suggesting a stress fracture?
• Does the athlete have any history of gout, pseudogout, or • Are there any dysvascular findings (absent posterior tibial
autoimmune disease? or dorsalis pedis pulses, delayed capillary refill, cyanosis, toe
• Are there sensory (dysesthesias or paresthesias) complaints? hair loss, and dystrophic nail changes)?
 CHAPTER 10  Posterior Tibialis Tendon Injury in the Athlete 209

A B
Fig. 10.4  View from (A) Posterior and (B) Anterior. The positive “too many toes” sign in the posterior tibialis
dysfunctional right foot is appreciated when examining the weight-bearing patient from behind. The forefoot
is abducted/pronated and the hindfoot is in greater valgus, resulting in more toes seen laterally in the right
foot when compared with the left.

A B
Fig. 10.5 Notice hindfoot inversion in the normal left foot. Although
patients with posterior tibialis tendon dysfunction may be able to per-
form the single-foot heel-rise test, notice that the hindfoot does not
invert, or inverts less, than the normal foot. This may be due to some
residual function of the posterior tibialis muscle-tendon unit with assis-
tive recruitment of the long toe flexors. Fig. 10.6  Zone of tenderness and swelling indicative of impingement in
the subfibular or sinus tarsi area, often seen with more severe posterior
tibialis tendon dysfunction with hindfoot valgus deformity.
Radiographic Imaging
Ideally, weight-bearing x-rays of the symptomatic foot and ankle • Calcaneal pitch angle: angle measured on a weight-bearing
should be taken. Also, comparison views of the other foot and lateral foot radiograph between the supporting surface and
ankle often are helpful diagnostically. This includes, at a mini- a line drawn along the most inferior portion of the calca-
mum, the following five views: anteroposterior (AP) foot, lateral neal tuberosity and the most distal and inferior point of the
foot, oblique foot, AP ankle, and hindfoot alignment (Saltzman) calcaneus at the calcaneocuboid joint. Normal value range
view. If there are concerns about the global alignment of the is commonly considered 17 degrees to 32 degrees.
extremities, a standing x-ray of both legs can be helpful. • Meary’s angle: angle measured on a weight-bearing lateral
foot radiograph between the midline axis of the talus and
Ankle and Foot Radiographs the midline axis of the first metatarsal. Normally Meary’s
• Is there flattening of the medial longitudinal arch as mea- angle is 0 degrees.
sured by calcaneal pitch angle, Meary’s angle, and medial • Do films demonstrate a medial or valgus tilt at the ankle (Fig.
arch sag angle (MASA) angle? 10.7A)?
A B

D
Fig. 10.7  Radiographs of patients with medial ankle or midfoot pain and swelling demonstrating medial talar
tilt because of primary deltoid ligament incompetency (A) accessory navicular (B) medial talar dome osteo-
chondritis dissecans with a coronal magnetic resonance imaging (MRI) view (C) and medial column arthritis.
(D) All of which can mimic to varying degrees the clinical presentation of posterior tibialis tendon dysfunction.
 CHAPTER 10  Posterior Tibialis Tendon Injury in the Athlete 211

• Are there arthritic changes with joint space narrowing,

osteophytes, or loose bodies medially? Look at the ankle and
all hindfoot and midfoot joints.
• Is there any evidence of a medial malleolar stress fracture or
medial talar dome osteochondral lesion (Fig. 10.7C)?
• Is there significant arterial (anterior and posterior tibial) cal-
cification?
• Is an accessory navicular or avulsion fracture visible on the
medial navicular (see Fig. 10.7B)?
• Do the films of the foot reveal arthritic changes of the medial
subtalar, talonavicular, naviculocuneiform, or medial tar-
sometatarsal joints (Fig. 10.7D)?
• Is there any evidence of a tarsal coalition, especially in the
peri-adolescent athlete?
• On the lateral view, is the talo-first metatarsal angle negative
(particularly if different than the contralateral film) (Fig. 10.8)?
• On the AP foot view, is there an increased talo-first meta-
Fig. 10.8  Lateral weight-bearing views demonstrating the midfoot sag tarsal angle or increased “uncovering” of medial talar head
of the posterior tibialis incompetent right foot. I prefer this more sim-
at the talonavicular joint, thus indicating forefoot abduction
plistic measurement of the angle between the long axis of the talus (A)
and the I metatarsal (B). The resultant angle (C) is greater in the involved (compare again with the contralateral foot, Fig. 10.9)?
foot. In this case in the normal left foot, these lines are virtually parallel.
Also, notice that the subtalar joint is less clearly seen in the symptom- Magnetic Resonance Imaging
atic right foot because of superimposition of the talus and calcaneus Although not always necessary, if the history, physical exam-
from a hindfoot valgus deformity.
ination, and x-rays fail to conclusively determine the diagnosis

Fig. 10.9  Anteroposterior (AP) weight-bearing views demonstrating abduction deformity resulting from pos-
terior tibialis tendon incompetency in the right foot. Again, I prefer this more simplistic measurement of the
ankle between the long axis of the talus (A) and the I metatarsal (B). The resultant angle (C) is great in the
involved right foot. Also, notice that the medial talar head is more uncovered by the navicular in the involved
foot (D).
212 SECTION 2  Sport Syndromes

of a posterior tibialis tendon injury, or to confirm the diagnos- tenography8 or ultrasound,19 but their sensitivity is signifi-
tician’s impression, then a magnetic resonance image (MRI) cantly less than that of a high-quality MRI.
may be indicated.15,16 An MRI can also help determine the Generally, the MRI will reveal fibrous tendinopathtic lon-
extent of acute injury or chronic tendinosis, arthritic changes, gitudinal hypertrophy or bulbous enlargement of the tendon,
and guiding treatment, especially if surgery is planned, and sometimes with cystic or longitudinal voids (Fig. 10.10A).
may predict the postoperative clinical outcome.15 Finally, Also, there is typically evidence of degenerative tendinosis and
the MRI may help to determine other conditions that may increased tenosynovial fluid within the sheath surrounding the
mimic, be concomitant with, or even contribute to posterior tendon (Fig. 10.10B).19,20 These findings are most commonly
tibialis tendon disease (Table 10.1).9,11,14,17,18 Perhaps of his- seen in the inframalleolar region, but also can extend proxi-
torical interest, others have proposed the diagnostic use of mally into the posterior medial malleolar area.

DISEASE STAGING
TABLE 10.1  Differential Diagnosis Once the diagnosis is firmly established, the stage of posterior
tibialis tendon disease, as popularized by Kenneth A. Johnson’s
Medial ankle arthritis Medial subtalar joint or medial column
arthritis
seminal work, is important to determine the proper course of
treatment. Johnson initially described stages I to III,6 and a
Medial ankle instability with Symptomatic accessory navicular with
stage IV was subsequently added12,21 to include degenerative
deltoid ligament rupture/laxity synchondrosis disruption
arthritis of the ankle joint (Box 10.1). Stage IV deformities are
Medial malleolar or talar stress Medial navicular bony avulsion or stress
exceedingly rare in the active athlete, and further discussion is
fracture fracture
beyond the scope of this chapter. Bluman and Myerson elabo-
Medial talar dome osteochondri- Acute injury or tendinosis of the flexor
rated on the original classification by subclassifying the stage II
tis dissecans hallucis longus or flexor digitorum longus
tendons
deformity, as described below.22
Stage I is essentially peritendinitis and/or tendon degener-
Tarsal tunnel syndrome Peri-insertional anterior tibialis tendon
rupture or tendinosis
ation (tendinosis) with a normal tendon length and no defor-
mity. Stage II is characterized by an incompetent or lengthened
Tarsal coalition, especially in Medial ankle or hindfoot/midfoot crystalline
periadolescent athletes or autoimmune arthritis
tendon with a flexible pes planovalgus deformity, meaning
that the foot can be manually restored to a corrected neutral

A B
Fig. 10.10  Magnetic resonance imaging (MRI) findings of posterior tibialis tendon dysfunction. (A) Sagittal
view at the level of the medial malleolus (MM) demonstrating longitudinal void within the tendon. (B) Trans-
verse view at the level of the talus also demonstrating degenerative tearing and thickening of the PTT with
intratendinous voids and increased fluid around the tendon.
 CHAPTER 10  Posterior Tibialis Tendon Injury in the Athlete 213

BOX 10.1  Disease Stages allowed as tolerated. The benefit of a boot, in a compliant ath-
lete, is removal for passive range of motion and application of
Stage I Peritendinitis and/or tendon degeneration (tendinosis) modalities to reduce swelling. Nonsteroidal antiinflammatory
No deformity medications also are helpful, but chronic oral steroids should be
Stage II Tendon elongated/incompetent
Mild flexible deformity
avoided. Steroid injections also should be avoided, since these
Stage III Findings of Stage I and II can lead to complete rupture8,23 or exacerbate a tendinosis.
Moderate-to-severe deformity that may be rigid with possible subfibular or Support of abnormal alignment. Upon symptom improve-
sinus tarsi impingement ment following immobilization, custom-molded arch supports
Radiographic arthritic changes of triple joint complex and/or naviculocunei- with medial wedging incorporated either in the orthotic and/or
form joints on a supportive shoe on the symptomatic side are advised for sev-
(Stage IV, which involves a valgus talar tilt and early ankle joint degeneration, eral months as the athlete integrates back to sport. This can help
also has been described but probably is not applicable to this discussion, to support the joints of the medial longitudinal arch, preventing
given its extreme rarity in the active athlete.)
abnormal forces on a healing PTT. Optimal long-term manage-
ment includes supportive and often-replaced, high-quality ath-
letic shoes. The injured athlete also should avoid any repetitive
alignment on examination. Bluman et al.22 further subclassified impact-loading sports or conditioning for several weeks during
stage II to include stage IIA (flexible hindfoot valgus), stage IIB treatment until symptoms have improved. Cross training (e.g.,
(flexible hindfoot valgus with forefoot abduction), and stage bicycling, swimming, open-chain weight training, antigravity
IIC (flexible hindfoot valgus with fixed forefoot varus). Stage treadmills, pool running, etc.) can help maintain muscular and
III encompasses the findings of the preceding stages but with cardiovascular fitness during treatment and recovery.
a greater degree of deformity that also may be rigid. X-rays of Address the deforming forces. In the athlete with a tight gas-
the stage III foot may further reveal significant arthritic changes trocnemius/Achilles tendon, stretching is helpful,24 especially
in any or all of the triple joint complex (subtalar, talonavicular, to avoid reinjury, once he or she has been successfully treated
and/or calcaneocuboid joints) or naviculo-cuneiform joints, as conservatively and returns to the preinjury level of activity.
well as clinical signs and symptoms of subfibular or sinus tarsi Alvarez25 described a protocol for conservative management of
impingement. PTT dysfunction and pes planovalgus. In addition, if the athlete
is overweight, weight loss is recommended. Other comorbid
TREATMENT conditions also should be addressed when applicable, such as
smoking cessation, good control of diabetes and autoimmune
Conservative disease, and management of vasculopathy.
In general, conservative treatment is recommended initially,
especially for the stage I and II presentation in the otherwise Surgical Treatment
healthy athlete. In the older athlete who has significant comor- Athletes who fail to improve with appropriate conservative
bid conditions (e.g., diabetes, smoking, vasculopathy, obesity, management should undergo an informed discussion about
etc.) that may contraindicate surgical treatment, conservative surgical options (Table 10.2). In general, the focus of surgery
treatment may be the definitive treatment. In the young, com- for the athlete should be to address the same factors outlined for
petitive athlete, these comorbidities are uncommon. In gen- conservative treatment: 1) the dysfunctional or ruptured PTT;
eral, the focus of treatment for the athlete should be to address: 2) progressive deformity; and 3) the deforming force of the tri-
1) the primary issue of a painful, inflamed and/or dysfunc- ceps surae. It is critical to be mindful of, and address, all planes
tional PTT; 2) alignment abnormalities that may contribute of deformity. As a hindfoot deformity progresses, the midfoot
to attrition of ligaments and PTT; and 3) the deforming force and forefoot must accommodate, which can alter anatomy and
of the triceps surae. If these can be addressed and mitigated, joint stability. Failure to recognize all deformities can lead to
return to sport is feasible for most athletes with stage I and undercorrection and persistent symptoms or even failure of the
for many with stage II. Stage III deformities are compatible corrective procedure.26
with few sports, but conservative treatment is an appropriate
first step in treatment. Stage I—Tendon Length Normal
Reduction of inflammation. As with any inflammatory Intraoperative findings include tenosynovitis, often with gran-
condition or injury, rigid immobilization can be therapeutic. ulation tissue, increased tenosynovial fluid, and an interstitial
Either casting or a rigid boot is recommended for 1–2 weeks longitudinal rupture, usually between the medial malleolar tip
to reduce acute inflammatory symptoms. The length of immo- and the navicular insertion of the tendon.4,10 Fusiform hyper-
bilization can vary based on the response to such treatment trophy with tendinotic “crabmeat” tissue often is encountered,
with reduction of swelling or tenderness. The cast that is well as well as possible cystic degeneration, especially in a more
molded to support the arch or the incorporation of an arch chronic presentation.
support and/or medial wedge if a boot is chosen is further rec- Surgical treatment involves removal of inflammation (teno-
ommended. Prolonged immobilization can be problematic in synovitis) and removal of degenerative sections of the PTT. The
athletes, since calf atrophy and gait abnormalities can develop. first can be accomplished arthroscopically and is associated
Weight bearing during the immobilization treatment period is with good outcomes.27,28 The latter typically requires an open
214 SECTION 2  Sport Syndromes

TABLE 10.2  Surgical management

Technique Postoperative regimen Return to sports postoperative
Stage I
Tenosynovectomy Cast: 3 weeks 3 months
Repair of interstitial rupture Rigid brace: 3 weeks
Possible medial shift calcaneal osteotomy for severe cases? Supportive shoes with custom-molded arch supports:
until 3 months postoperative

Stage II
Repair and advance/shorten tendon Cast: 6 weeks 6 months
Imbricate talonavicular joint plantar medial capsule Rigid brace: 6 weeks
Flexor digitorum longus tendon transfer Supportive shoes with custom-molded arch supports:
until 6 months postoperative
Medial shift calcaneal osteotomy with flexible deformity
Possible Achilles tendon lengthening or gastrocnemius recession

Stage III
Repair/reconstruction of tendon may not be necessary? Cast: 9–12 weeks 9–12 months
Medial shift calcaneal osteotomy and/or lateral column Rigid brace: 6–9 weeks
lengthening if deformity is flexible
Arthrodesis if deformity rigid and/or arthritic changes present Supportive shoes with custom-molded arch supports?
Possible Achilles tendon lengthening or gastrocnemius recession

procedure to address degenerative sections of the tendon. If dis- excursion in the healthy tendon rarely exceeds 1 to 2 cm.) There
ease is noted proximal to the medial malleolus, then it is import- is a progressive pes planus deformity noted on physical exam-
ant to preserve, if possible, an approximately 1-cm section of the ination and radiographs, but the deformity is passively correct-
sheath at the medial malleolar level to prevent subluxation of able. The association of a significant gastrocnemius equinus
the tendon. (If this is not possible because of extensive proximal with stage II disease entails that manual passive compression
disease, then that portion of the tendon should be repaired after of the supple hindfoot deformity results in a rigid plantarflexed
the tendon itself is addressed.) Tenosynovitis and granulation ankle. As described in for conservative management above, the
tissue are debrided with a small rongeur. The hypertrophied surgical approach to stage II requires addressing 1) the painful,
portion with tendinosis within the tendon then is debrided inflamed and/or degenerative PTT; 2) correction of bony align-
and debulked sharply via a longitudinal incision in the tendon ment abnormalities that contribute to attrition of ligaments and
itself. The incision then is repaired with absorbable, interrupted PTT; and 3) the deforming force of the gastrocnemius or triceps
suture with inverted knots. surae.
Postoperatively, splint immobilization is recommended for The attenuated, degenerative posterior tibial tendon.
2 weeks, followed by rigid bracing, stirrup bracing, or a short The PTT is debrided and repaired as described for stage I.
articulating ankle foot orthosis (AFO) for another 3 weeks. After Shortening of the tendon is advised by removing degenerative
immobilization, supportive shoewear with a custom-made arch tissue and advancing the healthy tendon to its plantar medial
support is recommended for 3 months. In the athlete, repetitive insertion on the navicular. It usually is necessary to detach
impact-loading sports or conditioning endeavors are avoided the medial insertion and excise excess peri-insertional tendon
until at least 3 months postoperatively. Good results have been before securing it to the decorticated plantar medial aspect of
noted with both the arthroscopic and open approaches.27,29 the navicular with nonabsorbable sutures incorporated in bone
anchors10 or through drill holes (Fig. 10.11F−I).5,6,10,12,14,30,31
Stage II—Tendon Elongated, Deformity Mild and Other options include excising a transverse segment and imbri-
Flexible cating the attenuated plantar medial capsule of the talonavicular
Similar but more severe pathologic findings as seen in stage I joint torn (Fig. 10.11B, D, and G).12,30
are encountered in stage II disease. There usually is a longer area In more severe stage II cases, and especially if the tendon is
of interstitial rupture with accompanying bulbous enlargement ruptures or extensively degenerated, a flexor digitorum longus
of the tendon that may even extend proximal to the medial mal- tendon transfer is recommended (Fig. 10.11A).4-6,8,10-12,14,20,30,31
leolus. The tendon is found to be elongated, and thus incom- The flexor digitorum longus (FDL) is in close proximity to the
petent, resulting in excessive pronation and abduction of the posterior tibialis tendon (Fig. 10.11C and E). Within the same
forefoot. (The function of the posterior tibialis is easily compro- surgical incision, the flexor digitorum longus is tenotomized
mised with even a small increase in length because the normal sharply as distally as possible and is secured to the navicular or
 CHAPTER 10  Posterior Tibialis Tendon Injury in the Athlete 215

B
Fig. 10.11  Intraoperative photographs and corresponding schematic drawings demonstrating my preferred
method of reconstruction of a complete rupture of the posterior tibialis tendon. This patient had a flexible
deformity without degenerative triple joint arthritis. A medial shift calcaneal osteotomy was added to the
medial soft tissue reconstruction. (A) Complete rupture of the posterior tibialis tendon. The two ends could
not be approximated because of proximal migration of the proximal end. (B) Subsequent to debridement of
the distal end of the posterior tibialis tendon, the plantar medial talonavicular joint capsule was incised and an
elliptical segment removed to later imbricate it.
216 SECTION 2  Sport Syndromes

D
Fig. 10.11, cont’d  (C) The flexor digitorum longus tendon is harvested as distally as possible. It is not neces-
sary to tenodese the distal end of the flexor digitorum longus of the flexor hallucis longus tendon to maintain
adequate lesser toe flexor function. (D) Heavy absorbable stay sutures are placed and tagged in the plantar
medial talonavicular joint capsule.
 CHAPTER 10  Posterior Tibialis Tendon Injury in the Athlete 217

F
Fig. 10.11, cont’d  (E) The flexor digitorum longus tendon is passed through and tenodesed with maximal
tension to the proximal end of the posterior tibialis tendon. (F) A bone anchor is placed in the decorticated
medial aspect of the navicular.
218 SECTION 2  Sport Syndromes

H
Fig. 10.11, cont’d  (G) The plantar medial talonavicular joint capsular stay sutures are tied. (H) The flexor dig-
itorum longus tendon is secured to the medial navicular under tension with the nonabsorbable sutures from
the bone anchor.
 CHAPTER 10  Posterior Tibialis Tendon Injury in the Athlete 219

J K
Fig. 10.11, cont’d  (I) Final appearance of the reconstruction. Heavy absorbable sutures also are used to fur-
ther secure the flexor digitorum longus tendon transfer to the fibrous tissue of posterior tibialis tendon sheath
and the surrounding periosteum. (J) Posterior tibial tendon stump at proximal extent of incision, (K) tenodesis
of PTT to transferred FDL with distal tenodesis of FDL to navicular.

as a side-to-side transfer to the repaired and advanced posterior the subtalar joint and the posterior plantar edge of the calca-
tibialis tendon. Other tendons have been suggested for transfer if neal body, thereby avoiding the insertion of the Achilles ten-
the flexor digitorum longus is not health or available. Although don and the plantar fascia origin.12,20,30,31 An oblique, slightly
the flexor hallucis longus has a stronger muscle than the flexor curved incision is made, and great care is taken to protect the
digitorum longus, its transfer is not recommended because the sural nerve in the lateral approach to the calcaneal wall (Fig.
dissection associated with its harvesting is technically challenging 10.12A). The periosteum is incised and preserved for later clo-
and risky, since Flexor Hallucis Longus (FHL) transfer requires sure. A power saw can be used until the surgeon approaches
crossing the neurovascular bundle. Also, the resultant weakness the medial calcaneal wall, but an osteotome is recommended to
of great toe flexion may be a significant problem for a high-per- complete the osteotomy medially to prevent injury to the neu-
formance athlete. rovascular bundle (Fig. 10.12B−C). A medial shift of approx-
Correction of bony alignment. Since the early 1990s, a stan- imately 8–10 mm is recommended depending on the extent
dard component of the surgical correction of stage II deformity of deformity.12,20,30,31 Provisional fixation is achieved with two
includes osteotomies to correct mechanics and alignment, and percutaneous pins in the sinus tarsi area until definitive inter-
support the soft tissue repair. A medial displacement calcaneal nal fixation is placed (Fig. 10.12D). A partially threaded can-
slide osteotomy (MDCO) was popularized by Myerson,12,30 and nulated cancellous screw via a separate plantar posterior heel
described by others,11,20,24,32 for stage II disease. The effect of this incision can be used for internal fixation. The proper placement
osteotomy is to correct the hindfoot valgus deformity, translate of this screw should be guided fluoroscopically to avoid pene-
the pull of the gastrocsoleus muscle via the Achilles tendon more tration of the subtalar joint and medial or lateral calcaneal wall.
medial to the axis of the subtalar joint, thus enhancing varus force Countersinking the screw head is advised to prevent symptom-
on the hindfoot, and partially reestablish the medial longitudinal atic hardware.
arch. The long-term benefit includes a reduction in load stress on Several fixation methods are available. Dynamic compression
the reconstructed posterior tibialis tendon or FDL transfer. nitinol step staples or contoured plates can be used for definitive
The MDCO is a straight cut from the lateral hindfoot at internal fixation (Fig. 10.13A−C). This eliminates the need for
an angle of approximately 45 degrees to the plantar surface a second incision associated with screw placement, is techni-
of the heel roughly equidistant between the posterior facet of cally less challenging, and theoretically reduces the likelihood
220 SECTION 2  Sport Syndromes

A B

C D
Fig. 10.12  Medial shift calcaneal osteotomy. (A) Recommended location of lateral incision. (B) Power saw used ini-
tially for osteotomy. Multiple retractors are recommended to protect the surrounding soft tissues. (C) Osteotomy
completed through the medial calcaneal wall using an osteotome to minimize any potential damage to the neuro-
vascular bundle. (D) Temporary percutaneous smooth pin internal fixation until definitive internal fixation is placed.

A B C
Fig. 10.13  Intraoperative photograph (A) and lateral (B) and axial (C) heel views demonstrating nitinol step sta-
ple internal fixation of the medial shift calcaneal osteotomy of approximately 10 mm for patients with primarily
stage II and III posterior tibialis tendon dysfunction.

of symptomatic hardware. Alternatively, a single compression In most cases of stage II deformity, there is a residual equinus
screw can be placed through a percutaneous incision on the contracture which prevents the foot from passive dorsiflexion
heel achieving compression across the osteotomy site (Fig. to at least 10 degrees with the knee fully extended. In this event,
10.14A−C). The size and number of screws are a matter of some a percutaneous Achilles tendon lengthening or gastrocnemius
debate and is at the discretion of the surgeon.33 recession is indicated.24 This procedure serves to allow sufficient
 CHAPTER 10  Posterior Tibialis Tendon Injury in the Athlete 221

A B C
Fig. 10.14 Radiographs of double calcaneal osteotomy to correct flatfoot, including medializing calcaneal
osteotomy with compression screw fixation and lateral column lengthening procedure. (A) Pre- and postoper-
ative anteroposterior views, (B) pre- and postoperative lateral views, and (C) postoperative axial view.

ankle range-of-motion for normal gait, and to diminish the combined with a lateral column lengthening, with either a cal-
stress on the reconstruction and may help to prevent recurrent caneocuboid joint distraction arthrodesis or anterior calcaneal
rupture and deformity postoperatively. lateral column lengthening with bone graft can be effective to
Postoperative care. Postoperatively, non–weight bearing and correct the deformity (Fig. 10.14).21,24 A calcaneocuboid dis-
casting is advised for 6 weeks, initially with the foot in plantar- traction arthrodesis is suboptimal for the athlete, as this will
flexion and inversion for the first 2 weeks. The foot is brought to limit hindfoot motion significantly and unduly stress the artic-
a neutral position gradually by the end of the fourth week, when ulations of the synchronous function of the talonavicular and
partial weight bearing is permitted. If a medial shift calcaneal subtalar joints, possibly leading to early degenerative arthritis,
osteotomy is performed, then serial axial and lateral x-rays of which may be the result of diminution of circulating synovial
the heel are taken to monitor healing. Following casting, rigid fluid delivery of nutrition to the cartilage of these unfused, but
bracing with an arch support is recommended for 6 weeks, with now stiffer, joints. Theoretically, a lateral column lengthening
progression to full weight bearing as tolerated. The patient may with opening wedge osteotomy has the advantage of preserving
remove the brace for bathing, sleeping, and active ankle range more motion and thus preventing long-term arthritic disease.24
of motion exercises. Supportive shoewear with a custom-made An opening wedge plantarflexion osteotomy with bone graft of
arch support is worn until 6 months postoperatively. Return to the dorsal medial cuneiform also has been described21 to fur-
repetitive impact-loading sports or conditioning is ill advised ther correct residual forefoot varus deformity with restoration
before 6 months postoperatively. The majority of athletes are of a more balanced, “tripod,” weight-bearing foot. In addition,
able to return to their previous sport and activity level following step-cut osteotomies of the anterior process of the calcaneus
this procedure.34 may improve bone contact area and improve outcomes.35 These
procedures are technically challenging, and overcorrection can
Stage III—Tendon Elongated, Flexible or Rigid be a problem. Also, if autogenous iliac tricortical bone graft is
Moderate to Severe Deformity chosen, the surgeon must consider the associated morbidity. In
Stage III presentation is rare, especially in the younger athlete. cases with stage III deformity and degenerative arthrodesis is
Intraoperative pathologic findings often eclipse those of stage indicated. This can be limiting for an elite field or court ath-
II, and the tendon is grossly incompetent even if still intact or lete. There is evidence of success with arthrodesis of the sub-
may be completely ruptured with retraction of the proximal end talar6,21,36 or talonavicular joint alone, calcaneocuboid and
of the tendon in the distal medial leg. Surgical repair or recon- talonavicular joint arthrodesis (double arthrodesis),10 or triple
struction of the tendon as described in stage II disease may not arthrodesis.32 Perhaps it may not make much difference which
be necessary when a bony stabilization procedure (fusion or type of arthrodesis is chosen, because, again, the fusion of even
opening wedge osteotomy) is performed in stage III disease. A one of these joints severely limits the motion of the other two,
soft tissue reconstruction alone, even with a medial shift calca- thus maintaining the desired correction. However, long-term
neal osteotomy, is likely inadequate to prevent recurrent defor- pain and eventual arthritis may develop because of the limited
mity and associated symptoms, especially in the heavier athlete. motion in the remaining unfused joints for the same reason as
If the deformity, although moderate to severe, is still flexible an isolated calcaneocuboid distraction arthrodesis as previously
and there are no significant degenerative arthritic changes, then described. A triple arthrodesis with deformity correction would,
the surgeon may consider a medial shift calcaneal osteotomy of course, prevent this, but over time it may lead to usually
222 SECTION 2  Sport Syndromes

valgus ankle instability and arthritis.12,24 This is the result of the development of fixed deformity or degenerative arthritis and
long-term attenuation of the deltoid ligament usually resulting the potential need for an arthrodesis, which is highly problematic
from undercorrection of hindfoot valgus that is rigid and there- for repetitive, impact-loading conditioning and sports.
fore incapable of inversion/eversion torque conversion, thus
translating those forces to the medial ankle. On rare occasions,
especially if the hindfoot is overcorrected to varus, or in the pre- REFERENCES
existing cavovarus foot that is undercorrected, just the opposite 1. Kettelkamp DB, Alexander HH. Spontaneous rupture of the pos-
can occur, with lateral talar tilt, instability, and arthritis. It is terior tibialis tendon. J Bone Joint Surg. 1969;51A:759.
generally wise to limit the arthrodesis to joints that absolutely 2. Mueller TJ. Ruptures and lacerations of the tibialis posterior
need it due to arthrosis or significant deformity. It is not uncom- tendon. J Am Podiatr Med Assoc. 1984;3:109.
mon to fuse just the subtalar joint to correct hindfoot valgus, 3. Porter DA, Baxter DE, Clanton TO. Posterior tibial tendon tears
or just the talonavicular joint (if arthritic) to correct abduction. in young competitiveathletes: two case reports. Foot and Ankle.
Fusions can be augmented with osteotomies to correct a defor- 1998;19(9):627–630.
mity. As is the case with stage II, a percutaneous Achilles tendon 4. Funk DA, Cass JR, Johnson KA. Acquired adult flatfoot secondary
lengthening or gastrocnemius resection24 is further indicated if to posterior tibial-tendon pathology. J Bone Joint Surg. 1986;68A:95.
5. Johnson KA. Tibialis posterior tendon rupture. Clin Orthop.
the foot cannot be passively dorsiflexed beyond 10 degrees with
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the knee fully extended. 6. Johnson KA, DE Strom. Tibialis posterior tendon dysfunction.
Postoperatively, cast immobilization generally is in the 6- Clin Orthop. 1989;239:196.
to 12-week range, depending on the progress of healing of the 7. Goldner JL, Keats PK, Bassett FH 3rd, Clippinger FW. Progres-
osteotomy or arthrodesis. Some limited weight bearing usually sive talipes equinovalgus due to trauma or degeneration of the
is allowed at 6 weeks postoperatively, depending on the level of posterior tibial tendon and medial plantar ligaments. Orthop Clin
healing on serial x-rays. Rigid bracing after casting is advised for North Am. 1974;5:39.
6 to 12 weeks. Supportive shoes with custom-molded arch sup- 8. Jahss MH. Spontaneous rupture of the tibialis posterior tendon:
ports may not be necessary, especially if a fusion is performed. clinical findings tenographic studies, and a new technique of
Return to athletic activity is allowed 9 to 12 months postopera- repair. Foot Ankle. 1982;31:158.
tively, pending complete bony and clinical healing. 9. Leach RE, DiIorio E. Pathologic hindfoot condition in the athlete.
Clinic Orthop. 1983;177:116.
10. Mann RA, Thompson FM. Rupture of the posterior tibialis ten-
PERILS AND PITFALLS don causing flatfoot. J Bone Joint Surg. 1985;67A:556.
11. Pomeroy GC, Pike RH, Beals TC, Manoli A 2nd. Acquired flatfoot
Underdiagnosis or misdiagnosis of posterior tibialis tendon in adults due to dysfunction of the posterior tibialis tendon. J
injury in the athlete can be avoided with a conscientious history, Bone Joint Surg. 1999;81A:1173.
physical examination, and weight-bearing x-rays. The differen- 12. Myerson MS. Adult acquired flatfoot deformity. J Bone Joint Surg.
tial diagnostic possibilities (see Table 10.1) also should be kept in 1996;78A:780.
mind when encountering the athlete with a suspected posterior 13. Bloome DM, Marymont JV, Varner KE. Variations in the inser-
tibialis tendon injury to prevent the perils and pitfalls of misdi- tion of the posterior tibialis tendon: a cadaveric study. Foot Ankle
agnosis and to aid selection of the proper treatment. If the pre- Int. 2003;24:780.
senting patient’s diagnosis then is still in question, then an MRI 14. Gazdag AR, Cracchiolo A. Rupture of the posterior tibialis ten-
don. J Bone Joint Surg. 1997;79A:675.
is recommended. However, even the most astute diagnostician
15. Alexander IJ, Johnson KA, Berquist TH. Magnetic resonance im-
can fail to determine the proper diagnosis. MRI can also help the aging in the diagnosis of disruption of the posterior tibial tendon.
clinician identify other contributing or masking injuries, such as Foot Ankle. 1987;8:144.
spring ligament tear, accessory navicular, stress fracture, etc. It is 16. Conti S, Michelson J, Jahss M. Clinical significance of magnetic
important to remove all degenerative PTT tissue, but tenodesis of resonance imaging in pre-operative planning for reconstruction
healthy PTT to FDL proximally can contribute additional muscle of posterior tibialis tendon ruptures. Foot Ankle. 1992;13:208.
to the tendon repair (Figs. 10 and 11J−K). 17. Koff FJ, Marcus RE. Clinical outcome of surgical treatment of the
symptomatic accessory navicular. Foot Ankle Int. 2004;25:27.
18. Yeap JS, Singh D, Birch R. Tibialis posterior tendon dysfunction: a
SUMMARY primary or secondary problem? Foot Ankle Int. 2001;22:51.
Injury to the tibialis posterior tendon is not uncommon in 19. Perry MB, Premkumar A, Venzon DJ, Shawker TH, Gerber LH.
Ultrasound magnetic resonance imaging, and posterior tibialis
athletes. Acute ruptures are rare, but tendinopathy can occur,
dysfunction. Clin Orthop. 2003;408:225.
impacting athlete performance, and creating risk of progressive 20. Trnka HJ. Dysfunction of the tendon of tibialis posterior. J Bone
deformity. Prompt diagnosis and identification of injury and clas- Joint Surg. 2004;86B:939.
sification of foot alignment is critical to managing this problem 21. Johnson JE, Yu JR. Arthrodesis techniques in the management of
in athletes. Most cases will respond to conservative treatment, stage II and III acquired adult flatfoot deformity. J Bone Joint Surg.
particularly in the patient without deformity (stage I). Surgical 2005;87A:1866.
treatment is advised if conservative treatment fails in any stage, 22. Bluman and Myerson Posterior tibial tendon rupture: a refined
but especially if there is significant deformity (stages II and III). classification system. Bluman EM, Title CI, Myerson MS. Foot
Prompt treatment, whether conservative or surgical, may prevent Ankle Clin. 2007;12(2):233–249, v. Review.
 CHAPTER 10  Posterior Tibialis Tendon Injury in the Athlete 223

23. Ford LT, DeBender J. Tendon rupture after local steroid injection. 31. Wacker JT, Hennessy MS, Saxby TS. Calcaneal osteotomy and
South Med J. 1979;7:827. transfer of the tendon of flexor digitorum longus for stage-II
24. Coetzee JC, Castro MD. The indications and biomechanical dysfunction of tibialis posterior. J Bone Joint Surg. 2002;84B:54.
rationale for various hindfoot procedures in the treatment of 32. Coetzee JC, Hansen ST. Surgical management of severe deformity
posterior tibialis tendon dysfunction. Foot Ankle Clin North Am. resulting from posterior tibialis tendon dysfunction. Foot Ankle
2003;8:453. Int. 2001;22:944.
25. Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and 33. Lucas DE1, Simpson GA2, Berlet GC3, Philbin TM4, Smith JL5.
II posterior tibial tendon dysfunction treated by a structured Screw size and insertion technique compared with removal rates for
nonoperative management protocol: an orthosis and exercise calcaneal displacement osteotomies. Foot Ankle Int. 2015;36(4):395–
program. Foot Ankle Int. 2006;27(1):2–8. 399. https://doi.org/10.1177/1071100714559073. Epub 2014 Nov 20.
26. Hunt KJ, Farmer RP. The undercorrected flatfoot reconstruction. 34. Usuelli FG, Di Silvestri CA, D’Ambrosi R, Maccario C, Tan EW.
Foot Ankle Clin. 2017;22(3):613–624. Return to sport activities after medial displacement calcaneal
27. Gianakos AL, Ross KA, Hannon CP, Duke GL, Prado MP, Ken- osteotomy and flexor digitorum longus transfer. Knee Surg Sports
nedy JG. Functional outcomes of tibialis posterior tendoscopy Traumatol Arthrosc. 2018;26(3):892–896.
with comparison to magnetic resonance imaging. Foot Ankle Int. 35. Saunders SM, Ellis SJ, Demetracopoulos CA, Marinescu A,
2015;36(7):812–819. https://doi.org/10.1177/1071100715576485. Burkett J, Deland JT. Comparative outcomes between step-cut
Epub 2015 Mar 10. lengthening calcaneal osteotomy vs traditional evans osteotomy
28. Hua Y, Chen S, Li Y, Wu Z. Arthroscopic treatment for posterior for stage IIB adult-acquired flatfoot deformity. Foot Ankle Int.
tibial tendon lesions with a posterior approach. Knee Surg Sports Foot Ankle Int. 2018;39(1):18–27.
Traumatol Arthrosc. 2015;23(3):879–883. https://doi.org/10.1007/ 36. Russotti GM, Cass JR, Johnson KA. 1988 Isolated talocalcaneal
s00167-013-2629-2. Epub 2013 Aug 24. arthrodesis. J Bone Joint. Surg. 1988;70A:1472.
29. McCormack AP1, Varner KE, Marymont JV. Surgical treatment
for posterior tibial tendonitis in young competitive athletes. Foot
Ankle Int. 2003;24(7):535–538. FURTHER READING
30. Myerson MS, Corrigan J, Thompson F, Schon LC. Tendon transfer 1. Marks M, Schon LC. Post-traumatic posterior tibialis tendon
combined with calcaneal osteotomy for treatment of posterior insertional elongation with functional incompetency: a case report.
tibialis tendon insufficiency: a radiological investigation. Foot Foot Ankle Int. 1998;19:180–183.
Ankle Int. 1995;16:712.
 11
Functional Nerve Disorders
and Plantar Heel Pain
David A. Porter

OUTLINE
Introduction, 224 Anterior Tarsal Tunnel Syndrome, 228
Author’s Approach Tarsal Tunnel Syndrome, 226 Conclusion, 228
Medial Plantar Nerve Entrapment “Jogger’s Foot”, 227

and 2002, 2.7 patients were treated annually with TTS. While
INTRODUCTION this number is small, the percentage of sports-related cases
Tarsal tunnel syndrome (TTS) is classified as a focal compres- among them is relatively high (39.1%).6 As mentioned above,
sive neuropathy of the posterior tibial nerve (PTN) or one of TTS typically due to a secondary pathology. The increased fre-
its associated branches individually or collectively within the quency in athletes could be related to direct contusion, ill-­fitting
tarsal tunnel.1,2 The tarsal tunnel is a fibro-osseous space that shoe wear, space occupying pathology (e.g., venous stasis,
is defined by the medial malleolus (superiorly), tibia (anterior varicosities, accessory muscles, and ganglion cysts), or lower
border), posterior process of the talus (posterior border), cal- limb malalignment.8 Specific examples include tenosynovi-
caneus (lateral border), abductor hallucis (inferior border), and tis, accessory muscle (accessory soleus, accessory flexor ten-
flexor retinaculum (laciniate ligament), which lies over the tib- dons), fracture, or, more rarely, ligament fibrosis from chronic
ial nerve to create an enclosed space.2 Within the tarsal tun- medial/deltoid ankle sprains.4 Repetitive trauma in the set-
nel lies the long flexor tendons and posterior tibial artery and ting of predisposing malalignments is commonly seen in ath-
vein along with the tibial nerve and its branches.3 Because of letes.7 Researchers believe that injury to the PTN, because
the inelasticity of the tunnel, any enlargement of the structures of its location and vulnerability at the tarsal tunnel, is due to
inside the tunnel can increase pressure leading to nerve com- the repetitive nature of running accompanied with abnormal
pression.4 In general, nerve injury in this area is secondary to or excessive pronation.9 Valgus deformity or flat feet can also
another pathology.4 The intrinsic and extrinsic etiologies of TTS exacerbate the problem.4,6,10,11 Additionally, sports that require
primarily stem from posttraumatic, biomechanical, inflamma- repetitive hyper dorsiflexion may predispose athletes to TTS
tory, and morphological conditions; however, it can also be clas- because dorsiflexion increases the overall pressure within the
sified as an idiopathic and iatrogenic syndrome.1 Characteristic tarsal tunnel.8
clinical manifestations of TTS include paresthesia, dysesthesia, Athletes with TTS will experience symptoms similar to non-
and hyperesthesia radiating from the retro-malleolar region to athletes. Individuals with TTS may report medial ankle pain
either the sole, heel, digits of the forefoot, or any combination with cramping, burning, and tingling that radiates into the plan-
of these areas.1,5,6 In some cases, pain has been shown to radiate tar arch of the foot and is exacerbated by activity, such as run-
proximally up the calf.4 The patient may report foot weakness ning, jumping, and prolonged standing.8 The pain can be sharp,
as well.4 In addition to the symptoms described above, swelling shooting, or dull.4 Swelling, as mentioned previously, may also
over the tibial nerve may be palpable.4 Symptoms are typically be present. Individuals may get relief from symptoms with rest,
made worse with increased activity such as standing, walking, elevation, and removal of tight shoe wear.8
or running.2 The varying location and degree of symptoms Medical causes of leg/ankle-pain have many similar pre-
depends on the location and the degree of compression of the senting features, which makes TTS frequently misdiagnosed or
tibial nerve or nerve branches.4 underdiagnosed. Underdiagnoses is one possible reason why
While rare in the general population, TTS has become the incidence of tarsal tunnel in the general population and
increasingly more common in athletes. Neurologic conditions athletes seems low. Clinical presentations may appear similar,
account for 10% to 15% of all exercise-induced leg pain among but in fact have a different pathophysiology relating to separate
running athletes.7 Although the exact incidence of TTS in ath- vascular abnormalities, compartment syndrome or neurologi-
letes is unknown, a study conducted by Kinoshita et al. identified cal dysfunction.12 For example, Sanger et al. reviewed the case
surgically treated TTS patients, and found that between 1986 of a 19-year-old female collegiate soccer player complaining of
224
 CHAPTER 11  Functional Nerve Disorders and Plantar Heel Pain 225

unilateral foot pain that later transformed into bilateral foot

pain with numbness, tingling, and cramping. This led to the
diagnosis of TTS; however, the initial diagnosis was plantar
fasciitis because of the location of pain and the description of
symptoms. The misdiagnosis subsequently delayed her return to
sport.13 Early diagnosis is key because a delay in diagnosis can
lead to worsening of symptoms, inferior athletic performance,
missed competition, and delayed return to sport.8 Clinicians
should consider several general principles to facilitate the
diagnosis and management of neurologic symptom: (1) main-
tain high level of index of suspicion for neurologic syndromes;
(2) recognize common presentations of neuropathic pain; (3)
perform a meticulous physical examination with detailed pal-
pation of individual anatomic structures; (4) consider a broad
differential diagnosis (neurologic and non-neurologic); (5)
use diagnostic testing appropriately—electromyography/nerve
conduction velocity test (EMG/NCV) and magnetic resonance
imaging (MRI); and (6) make rational clinical decisions, includ-
ing referral for second opinion when indicated.7
Tarsal tunnel syndrome diagnosis greatly relies on an in-depth
history and physical examination because of the many possible Fig.11.1 Axial T1 MRI scan of left ankle showing accessory muscle
causes of leg/ankle-pain. The aim of the history in a patient with tarsal tunnel. Arrow points to accessory flexor muscle in tarsal tunnel
possible neurologic leg/ankle pain is to gather occupational and against lateral planter nerve of posterior tibial nerve. Can be source of
sporting history, to determine the location and timing of the plantar lateral foot pain with tarsal tunnel variant involving only the lat-
eral plantar nerve.
pain, its mechanism of onset, degree of irritability, aggravating
and relieving factors, presence of other joint pain or swelling,
previous local trauma, and presence of neurological signs focal changes in the tarsal tunnel cross-section area.7 Diagnostic
or symptoms.12 The physical exam combines the use of many evaluation should also include weight-bearing foot and ankle
investigations to properly diagnosis TTS. The Hoffmann-Tinel radiographs to evaluate for deformity, talocalcaneal coalition,
sign is the most commonly used clinical test of TTS.1 A positive fracture malunions, and osteophytes.6,8,10,11
Tinel sign or nerve percussion/compression test will cause par- We have noted an increasing occurrence of an accessory
esthesia either locally or radiating along the course of the nerve muscle that acts to compress the PTN in the tarsal tunnel in the
when the suspected site of compression is percussed.1 It is sug- athlete. This can present as either an accessory soleus, which is
gested that greater than 50% of patients with compression neu- outside the tarsal tunnel but still causes pressure on the PTN, or
ropathy of the tarsal tunnel will demonstrate a positive Tinel’s an accessory flexor tendon within the tarsal tunnel. The acces-
sign of the PTN.1 Patients may also exhibit loss of two-point dis- sory flexor tendon is unnamed but is thought to be an accessory
crimination4 or occasionally, an abnormal Semmes-Weinstein flexor hallucis tendon (Fig. 11.1).
test for pressure. Dorsiflexion-eversion test has been shown to In some circumstances, the accessory flexor tendon in the
increase strain on the tibial nerve and illicit symptoms also.4 tarsal tunnel will only affect the lateral plantar nerve. In this
Kinoshita et al. report that the dorsiflexion-eversion test repro- isolated lateral plantar nerve compression, the athlete com-
duces or aggravates symptoms in 36 out of 44 feet in their study, plains only of pain in the lateral plantar foot (see case study).
with no replication evident in the control group.6 However, it is This presentation can be more confounding, and we have seen
this author’s opinion that local pain with palpation specific to athletes misdiagnosed as fifth MT stress fractures, peroneal ten-
the PTN nerve and the medial plantar nerve (MPN) is still the don injury, and cuboid stress fracture. Failure to improve with
hallmark of TTS and its diagnosis. nonweight bearing (NWB) or immobilization is often a clue to
Radiological imaging modalities such as isotope bone scan- nerve pain in the athlete.
ning, ultrasound, and magnetic resonance imaging (MRI) relate In addition, electrodiagnostic investigations, which include
to the detection of bone and soft tissue lesions rather than neu- nerve conduction studies and EMG, can assist in the diagno-
rological disease for the etiology of TTS.12 MRI, the gold stan- sis of TTS.1,6 While it has been concluded that sensory nerve
dard in identifying suspected compression of the tarsal tunnel conduction is more sensitive, yet less specific in identifying
caused by obstructive masses, can be used to confirm space-­ nerve injury than motor nerve conduction, it is recommended
occupying pathology.1,14 MRI has been shown to be effective that both motor and sensory nerve conductions are evaluated.9
in 88% of patients with a firm clinical diagnosis of TTS.7 Not Unfortunately, these studies often yield an unacceptable level of
only does it confirm a suspected lesion, but it defines the depth, false-negative results with inexperienced electromyographers,
extent, and margins of the lesion for accurate characterization.1 and should be utilized as an adjunctive assessment to confirm
Ultrasounds can also effectively visualize structures within the physical examination findings.1 Because of the poor sensitivity
tarsal tunnel and accurately identify compressive lesions and/or and specificity for TTS, these investigations may be most useful
226 SECTION 2  Sport Syndromes

in ruling out proximal nerve pathology.8 We do believe, how- failure is described to be less than 5%, initial releases often fail
ever, that with experience, detection of TTS with EMG/NCV because of failure to control hemostasis, which leads to scarring
can be more sensitive and specific. We therefore recommend and neuritis or nerve damage.2 Therefore, we advise meticulous
developing a relationship with an interested lower extremity hemostasis after tourniquet release before definitive skin clo-
electromyographer to enhance their capabilities diagnosing the sure. Failures of surgical intervention often result from incor-
condition with the technique. rect initial diagnosis, incomplete release of the tarsal tunnel
Researchers have recently recommended that a firm diagno- (releasing the PTN, without releasing the MPN in the abductor
sis of TTS be made only when the following triad exists: (1) foot canal), adhesive neuritis following initial decompression mea-
pain and paresthesia, (2) positive nerve percussion sign/Tinel sures, intraneural damage associated with direct neural trauma
sign, and (3) positive electrodiagnostic studies. If only two exist, or systemic disease, presence of space-occupying lesion, or dou-
then the term probable TTS is recommended, and if only one ble crush syndrome.1, 15
exists, the diagnosis should be reconsidered.7
Nonoperative, conservative treatments are the preferred CASE STUDY 11.1 
initial treatments even though they are often unsuccessful.8
Treatment includes activity modification, immobilization, The athlete was a 21-year-old white female senior basketball player who
oral or topical nonsteroid antiinflammatory drugs (NSAIDs), plays the 4-5 position on a Division I program majoring in Sports Management,
neuromodulator medications (e.g., Gabapentin, Pregabalin), who was originally from Serbia. She was evaluated for right lateral foot pain.
She presented with a chronic 3-year history of right foot pain that was inter-
physical therapy, biomechanical management, and steroid
mittent, achy, throbbing, sharp, and burning in nature. She states that she does
injections.2,7,12 Physical therapy includes strengthening the foot
not remember a specific injury but has a history of “recurrent stress fractures/
intrinsic and medial arch supporting muscles, Achilles stretch- stress reactions in the right foot” that never improved with immobilization,
ing in subtalar neutral, lower limb kinetic chain rehabilitation, rest, even NWB status. Because of her lateral foot pain we were concerned
and proprioception-enriched rehabilitation in cases of ankle or for a peroneal tendon or abductor digitii quniti minimi (ADQM) injury. An MRI
subtalar joint instability.7 Special attention should be paid to was normal and particularly showed no stress fractures and normal peroneal
Achilles tendon flexibility and foot intrinsic and ankle support tendons. We tried an injection in the ADQM with no relief. We then ordered an
muscle strength and coordination.8 Biomechanical manage- EMG/NCV test, and it showed changes in the lateral plantar mixed nerve only
ment varies with clinical presentation and can be assisted with with decreased amplitudes (essentially absent) but near-normal medial plantar
the use of motion control shoe, medial heel wedge, medial sole mixed nerve amplitudes. There were severe changes on the needle exam to
wedge/medial buttress, ankle stirrup brace, heel lift, or fixed the ADQM with severe motor unit drop-out and severe loss of recruitment con-
sistent with lateral plantar nerve involvement. The needle exam to the MPN
ankle walking brace.7 In severe cases, medial wedges and arch
was essentially normal.
supports may exacerbate symptoms, and more rigid immobi-
The exam was consistent with pain over the PTN in the tarsal tunnel. There
lization via molded hindfoot orthosis, ankle-foot orthosis, or was some sharp tenderness locally and radiation into the lateral plantar foot
walking boot/cast may be needed.7 Tarsal tunnel injections may that reproduced her symptoms. The plain x-rays were normal.
assist with treatment by reducing swelling in the tarsal tunnel We performed an injection into the right tarsal tunnel placing some local
providing relief of symptomatic nerve compression.12 However, anesthetic with steroid around the PTN and the MPN. We were able to confirm
for those infrequently injecting the tarsal tunnel or if there is a we were near the nerve by some mild radiation into the distal nerve distribu-
poor pulse to palpate, ultrasound guidance should be consid- tion with the injection. It took 10 days to 2 weeks to get relief (a little longer
ered when doing steroid injections to minimize risk of neuro- than typical), but the athlete reported near-complete relief with her lateral foot
vascular injury.8 pain. Since we were still in the off-season, she elected to proceed with a com-
In the result of failed conservative treatments, surgery should plete tarsal tunnel release. We followed a typical postoperative protocol that
included cold compression therapy intermittently; boot immobilization for 2–4
be considered. Surgical procedures involve decompressing
weeks; then gradual return to biking, Stairmaster, and elliptical; and then run-
the tibial nerve or involved branches, while also repairing the
ning with a lace-up and velcro ankle brace. A functional progression program
pathology responsible for increased tunnel pressure.4 This may followed after she could run comfortably for 30–40 minutes on a treadmill.
involve dissection of the flexor retinaculum, neurolysis of the She returned to practice at 3 months and led the team in scoring and rebound-
affected nerve, tenosynovectomy, excision of bony fragments, ing her senior year. She returned overseas after the season and pursued pro-
stretching of the neurovascular bundle around foot deformi- fessional basketball. She obtained complete relief of her preoperative pain.
ties, or removal of space-occupying masses.4 While pain relief
can be immediate with surgery, neuropathic symptoms gen-
erally improve 6 weeks postoperatively, but maximal recovery AUTHOR’S APPROACH TARSAL TUNNEL
time may take 6 months or more.7 Kinoshita and colleagues
reported a complete return to sports in 12 of 18 athletes post-
SYNDROME
surgery.4 Many studies have revealed that surgical release may We have taken a conservative approach to evaluation and treat-
improve or resolve the overall symptoms of TTS in 85%–90% ment of TTS in the athlete. Many athletes can have nerve pain
of cases.1 Alternatively, several studies have also reported little that is not amenable to surgical release. We are careful and cau-
to no improvement of symptoms from surgical intervention.1 tious regarding our indications for surgical release of the pos-
Researchers believe that this could be due to continual clinical terior tibial and MPN. We have seen the effects of operative
dichotomy between objective and subjective surgical outcome treatment of nerve pain that is not entrapment, and often noted
parameters, making definitive results highly variable.1 While that the patient can be worse.
 CHAPTER 11  Functional Nerve Disorders and Plantar Heel Pain 227

Therefore, we have taken the following approach. If other

injuries and ailments have been ruled out—e.g., posterior ankle
impingement, anteromedial ankle impingement, posterior tib-
ial tendon problems, medial dome osteschondrial lesion (OCL),
etc., and the athlete has pain over the posterior tibial and/or the
MPN suggesting TTS (radiation into the tarsal tunnel nerves
with local palpation, reproduction of their symptoms with local
palpation of the nerves, +/- burning pain)—we will obtain an
EMG/NCV test with a skilled and experienced electromyogra-
pher (often many neurologist or physical medicine specialists
are competent in the upper extremity but not experienced in
tarsal tunnel evaluation). If the test is positive for “tarsal tunnel,”
we then proceed with a tarsal tunnel injection in the office to
see if these electromyography changes are indeed reversible and
specific to the athlete’s pain. We also like to see if the injection
in fact alleviates the athlete’s symptoms at least temporarily. We
inject both the traditional tarsal tunnel area around the PTN
and around the MPN in the medial midfoot. We ensure we are
around the appropriate nerves by confirming with the athlete
that they experience some radiating symptoms corresponding to
the nerves being injected. Others may want to do the injection with Fig.11.2 Well-healed tarsal tunnel release incision left ankle. Note
the aid of an ultrasound (as mentioned above) to navigate the extension of incision into medial midfoot for good release of medial
location of the needle injection. We mix 0.5 cc of 1% lidocaine nerve.
without epinephrine, 0.5cc of 0.25% Marcaine without epineph-
rine, and 3–6 cc of betamethasone all in one syringe so we know muscle.” In an isolated entrapment, a minimal incision releases
if the patient gets good relief in the office, the steroid injection is the MPN; because it is relatively deep, care must be taken to
in the proper location. We ask the athlete to report the percent avoid damage to other nearby structure. We also routinely
of relief in the office and then have the athlete call and report release this area with our TTR unless there are no symptoms
their pain relief 7–10 days after the injection. Relief in the office referring to the MPN.
indicates relief from the local anesthetic and confirms at least
that the nerve is the source of pain. Relief 7–10 days later indi-
cates the nerve changes are reversible and surgical release may CASE STUDY 11.2 
be beneficial. We believe the relief with the steroid must be 75%
A 16-year-old female elite middle distance runner from New Mexico was seen
relief of pain or greater and be for greater than 1–2 weeks to be
in consultation for chronic left foot pain. She complained of mainly sharp pain
a positive result. with running in the left midfoot just below the navicular. She had mild pro-
We have noted 75%–90% chance of good results with a com- nation deformity restricted to the left foot and normal midfoot and hindfoot
plete TTR if there is a positive EMG/NCV test for tarsal tunnel alignment on the right. She had seen several other health care providers who
and there is greater than 75% pain relief with the steroid injec- had diagnosed her with left hindfoot collapse. She had reported a moderate
tion for greater than 2 weeks (Fig. 11.2). left foot injury 3–4 years ago but had not sought out treatment for that injury.
Some of our most satisfied athletes are those that have She had recovered but had this mild collapse in her left foot ever since. She
been misdiagnosed and found to have TTS and have had had been told she would not run competitively again and would need involved
good relief with surgical decompression. We also still cau- hindfoot and midfoot reconstruction.
tion: some of our most unhappy athletes can be those who However, her symptoms seemed much more localized to the MPN just
underneath the navicular. She reported some radiation into the left forefoot
have had poor results from nerve releases and likely did not
with palpation of the MPN. An EMG/NCV test was undertaken and was
have entrapment, or had some form of iatrogenic worsening
suggestive of distal TTS with primary involvement of the MPN. An in-office
of their nerve pain. injection of the MPN and distal PTN gave 100% relief for several weeks. She
returned for an attempt at distal TTR. At the time of surgery, she had promi-
MEDIAL PLANTAR NERVE ENTRAPMENT nent scarring of the adductor canal around the MPN and the distal PTN. The
distal PTN and the MPN were released with the open procedure and complete
“JOGGER’S FOOT” release of the MPN was undertaken down to the bifurcation of the MPN into
The “Jogger’s foot” can be more common that treating physicians the common digital nerves.
realize. Don Baxter, who has treated numerous elite runners, She underwent a traditional TTR rehab protocol with a full-length soft
commented on this entity in Chapter 1 of our second edition. orthotic to support but not overly pressure the MPN under the midfoot. She
He noted that the MPN gets entrapped at the knot of Henry and returned to win the state championship in her primary race. She received a
Presidential scholarship to an Ivy League school and ran track for 2 years in
mentioned that is can be an isolated entrapment irrespective of
college before deciding to discontinue her competitive career. She remained
any more proximal TTS. Abnormal range of motion may lead
pain free at last contact.
to a “squeezing effect by the hypertrophied abductor halluces
228 SECTION 2  Sport Syndromes

intervention. If the symptoms persist and become debilitating,

surgery should be considered. There is still much debate on
the positive outcomes of surgery because of the objective and
subjective parameters used. More research needs to be done in
this area to determine the true effectiveness of surgical inter-
vention. Also, further evaluation needs to be directed toward
the incidence of accessory muscle involvement with TTS in the
athlete. Jogger’s foot is a focal MPN entrapment that is in
the continuum of TTS.

ACKNOWLEDGMENT
Fig. 11.3 Lateral radiograph of a dorsal osteophyte on naviculum
caused a deep peroneal neuralgia. Dr. Porter would like to acknowledge the assistance in man-
uscript preparation from Anoka Padubidri, MD, orthopedic
resident, Indiana University; and Madison Walrod and Nicole
ANTERIOR TARSAL TUNNEL SYNDROME Heffern, students, Butler University.
Anterior tarsal tunnel is a compression neuropathy of the
deep peroneal nerve under the extensor retinaculum, dorsal
talonavicular joint, or more distally over the Lisfranc liga- REFERENCES
ments and underneath the extensor halluces brevis muscle 1. McSweeney SC, Cichero. Tarsal tunnel syndrome—a narrative
and tendon. Symptoms include anterior ankle or dorsal foot literature review. Foot. 2015;25(4):244–250.
pain with radiation to the first webspace that worsens with 2. Ferkel E, Davis WH, Ellington JK. Entrapment neuropathies of
plantar flexion.16 the foot and ankle. Clin Sports Med. 2015;34(4):791–801.
The hallmark is pain to palpation over the affected nerve. 3. Kennedy JG, Baxter DE. Nerve disorders in dancers. Clin Sports
Treatment includes release of the inferior aspect of the exten- Med. 2008;27(2):329–334.
sor retinaculum and debridement of any dorsal talonavicu- 4. McKean KA. Neurologic running injuries. Neurol Clin.
2008;26:281–296.
lar spurs (Fig. 11.3). The lateral branch of the deep peroneal
5. Kopell HP, Thompson WAL. Peripheral entrapment neuropathies
nerve supplies motor innervation to the extensor digitorum of the lower extremity. N Engl J Med. 1960;262(2):56–60.
brevis (EDB), and entrapment can cause sinus tarsi–like symp- 6. Kinoshita M, Okuda R, Yasuda T, Abe M. Tarsal tunnel syndrome
toms. We avoid transecting the nerve as a treatment, especially in athletes. Am J Sports Med. 2006;34(8):1307–1312.
proximal to the lateral branch to the EDB. This will denervate 7. Peck E, Finnoff JT, Smith J. Neuropathies in runners. Clin Sports
the EDB and lead to its atrophy. In dancers, hypertrophy of Med. 2010;29:437–457.
the extensor hallucis brevis has been shown to cause bilateral 8. Meadows JR, Finnoff JT. Lower extremity nerve entrapments in
anterior TTS.16 athletes. Curr Sports Med Rep. 2014;13(5):299–306.
9. Jackson DL, Haglund B. Tarsal tunnel syndrome in athletes—case
reports and literature review. Am J Sports Med. 1991;19(1):61–65.
CONCLUSION 10. Carrington SC, Stone P, Kruse D. Accessory soleus: a case
report of exertional compartment and tarsal tunnel syndrome
In conclusion, TTS is an entrapment of the tibial nerve within
associated with an accessory soleus muscle. J Foot Ankle Surg.
the tarsal tunnel due to increased pressure typically second- 2016;55(5):1076–1078. https://doi.org/10.1053/j.jfas.2015.07.011.
ary to another pathology. Local or radiating numbness, tin- 11. Sweed TA, Ali SA, Choudhary S. Tarsal tunnel syndrome
gling, and pain over the medial heel, arch, medial sole, or sole secondary to an unreported ossicle of the talus: a case report. J
of the foot can be described by patients with TTS. A sensory Foot Ankle Surg. 2016;55(1):173–175. https://doi.org/10.1053/j.
deficiency may also be observed or reported. These symptoms jfas.2014.09.029.
have much overlap with other causes of leg pain, so a broad 12. McCrory P, Bell S, Bradshaw C. Nerve entrapment of lower leg,
differential diagnosis is crucial. Tarsal tunnel syndrome is ankle, and foot in sports. Sports Med. 2002;32(6):371–391.
increasing in frequency among the athletic population. Because 13. Sanger R, Lopez RM, Dann C, Mozerolle SM. Bilateral tarsal
of this, it is important that sports medicine physicians have a tunnel syndrome in a collegiate female soccer player. University
high index of suspicion of lower extremity neuropathy when of Connecticut Storrs, CT.
14. Frey C, Kerr R, D M. Magnetic Resonance Imaging and the Evalua-
dealing with exercise-induced leg pain. A detailed patient
tion of Tarsal Tunnel Syndrome; 1993.
history and meticulous physical exam is of great importance 15. Gould JS. The failed tarsal tunnel release. Foot Ankle Clin.
when diagnosing TTS. Together, the physical exam, radio- 2011;16(2):287–293. https://doi.org/10.1016/j.fcl.2011.03.002.
graphic imaging, and nerve conduction studies in conjunction 16. Tennant JN, Rungprai C, Phisitkul P. Bilateral anterior tar-
with selected tarsal tunnel injections create a reliable method sal tunnel syndrome variant secondary to extensor hallucis
of diagnosis for TTS. A quick diagnosis will aid in appropri- brevis muscle hypertrophy in a ballet dancer: a case report.
ate treatment and a more rapid return to sport. Generally, an Foot Ankle Surg. 2014;20(4):e56–e58. https://doi.org/10.1016/j.
initial conservative treatment is recommended over surgical fas.2014.07.003.
 CHAPTER 11  Functional Nerve Disorders and Plantar Heel Pain 229

BIBLIOGRAPHY Neurologiche S, La U. Tarsal tunnel syndrome in skiers. Case Report.

1993:391–392.
David L, Haglund B. Tarsal tunnel syndrome in athletes. Am J Sports Romani W, Perrin DH, Whiteley T. Tarsal tunnel syndrome: case
Med. 1991;19(1):61–65. study of a male collegiate athlete. J Sport Rehabil. 1997;6(4).
Fujita I, Matsumoto K, Minami T, Kizaki T, Akisue T, Yamamoto Willis AR, Samad AA, Prado GT, Gabisan GG. Heterotopic ossifica-
T. Tarsal tunnel syndrome caused by epineural ganglion of the tion and entrapment of the tibial nerve within the tarsal tunnel. J
posterior tibial nerve: report of 2 cases and review of the literature. Foot Ankle Surg. 2016;55:1106–1109.
J Foot Ankle Surg. 2004;43(3):185–190.
 12
Arthritic, Metabolic, and
Vascular Disorders
Gregory Rowdon, David Taylor

OUTLINE
Introduction, 230 Other, 233
Inflammatory/ Rheumatologic, 230 Lyme Disease, 233
Still’s Disease (Adult Onset), 230 Sarcoidosis, 233
Ankylosing Spondylitis, 231 Metabolic Disease, 233
Reiter’s Syndrome, 231 Diabetes Mellitus, 233
Psoriatic Arthritis, 231 Metabolic Bone Disease, 234
Enteropathic Arthritis, 231 Medications/Supplements/Deficiency States, 235
Rheumatoid Arthritis, 232 Vascular/ Lymphatic Disorders, 235
Systemic Lupus Erythematosus, 232 Arterial Disease, 235
Gout, 232 Venous Disease, 236
Pseudogout/Calcium Pyrophosphate Dihydrate Crystal Lymphatic Disease, 236
Deposition (CPPD), 232 Conclusion, 237

musculoskeletal problem in both the competitive and recre-

INTRODUCTION ational athlete. Knowledge of these conditions is essential to the
Foot and ankle problems are common complaints to the phy- physician caring for athletes.
sician who cares for athletes. Most of these complaints can be
attributed directly to the athlete’s training and competition INFLAMMATORY/ RHEUMATOLOGIC
with their sport. However, athletes are not immune from dis-
ease. Most of these athletes will present to the sports medi- Still’s Disease (Adult Onset)
cine physician assuming their complaints are related to their Still’s disease is a seronegative polyarthritis that usually affects
participation, and many will try to explain their complaints as young adults. It is characterized in its initial manifestation as a
being secondary to some aspect of their training. Although the spiking fever and a red/salmon-colored rash, usually over the
vast number of complaints evaluated by the sports medicine trunk and extremities. The rash is transient and appears at the
physician is directly attributable to a primary musculoskeletal time of the fever spikes. The inflammatory arthritis is a poly-
source, the physician must maintain an appropriate differen- arthritis or oligoarthritis. It commonly affects the proximal
tial diagnosis to include those disease states that also can affect interphalangeal (PIP) and metacarpophalangeal (MCP) joints,
the musculoskeletal system. The foot and ankle are common as well as the wrists, knees, hips, and shoulders. Occasionally,
sites for these disease states to present as they mimic sports the cervical spine, intertarsal joints, temporomandibular
injuries. joints (TMJ), and the distal interphalangeal (DIP) joints are
Many of the individuals who present to a sports medicine affected. It may lead to fusion of the carpal-metacarpal and
clinic are not “highly competitive” athletes but are athletes the intercarpal joints. Laboratory evaluation commonly shows
nonetheless. These individuals are commonly referred to as an elevated white blood cell count as well as an elevated eryth-
“recreational athletes” and generally are older. They strive rocyte sedimentation rate (ESR). Anemia of chronic disease
to maximize their abilities in their own chosen activity while is commonly present. Secondary nonmusculoskeletal findings
attempting to reap the myriad of benefits of a healthy lifestyle. include lymphadenopathy, hepatosplenomegaly, pericarditis,
This group of athletes may have concurrent disease states that and carditis. The disease is treated with nonsteroidal antiin-
must be taken into account as they attempt to maintain their flammatory medications (mild disease). Often, oral cortico-
healthy, active lifestyle. Diseases such as diabetes, gout, thy- steroids are required to control moderate disease along with
roid conditions, osteoporosis, and so forth can present with biologic/nonbiologic disease modifying antirheumatic drugs
musculoskeletal complaints. The purpose of this chapter is (DMARDs) for severe disease. Overall, Still’s disease has a
to review those disease states, which may mimic a primary good prognosis.
230
 CHAPTER 12  Arthritic, Metabolic, and Vascular Disorders 231

Ankylosing Spondylitis syndrome is generally good, with typical duration of 3–5 months
Ankylosing spondylitis is an insidious-onset seronegative with either complete remission or little active disease after 6–12
inflammatory condition affecting young individuals, that is, months. However, 15%–20% of patients may develop a chronic
generally younger than 40 years old. It has a uniform sex dis- persistent arthritis.
tribution, but the disease seems to be milder in females. Also,
females have more peripheral involvement rather than spine Psoriatic Arthritis
involvement. Ankylosing spondylitis affects the sacroiliac (SI) Psoriatic arthritis is the combination of psoriasis and inflam-
joints, followed by the spine and peripheral joints. There usu- matory arthritis. To make a definitive diagnosis of psoriatic
ally is symmetric loss of spine movement. The peripheral joint arthritis, skin or nail changes of psoriasis must be present at
involvement occurs in 20% to 30% of ankylosing spondyli- some point in the course of the disease. The arthritic changes
tis patients and has a predilection for the lower extremities. can be present before skin changes develop. The joint pattern
Achilles’ tendinitis, plantar fascitis, and costochondritis also are in psoriatic arthritis is variable but commonly includes a pau-
associated with the disease process. It is common to have fatigue, ciarticular asymmetric arthritis involving the peripheral joints.
weight loss, low-grade fever, and, in more severe cases, uveitis, It is common to have the spine involved in combination with
pulmonary fibrosis, and cardiac abnormalities. Laboratory find- peripheral joints as well as inflammation of tendon and inser-
ings include an elevated ESR. The natural history of ankylosing tion points of tendons, that is, enthesitis. Digits may become
spondylitis is poorly defined, with some patients experiencing sausage like. There often are associated eye changes, includ-
minimal disease and some patients experiencing severe disease. ing conjunctivitis, iritis, and episcleritis. Psoriatic arthritis has
Treatment usually involves physical therapy and antiinflamma- an equal sex distribution and usually has onset in the 30- to
tories. Refractory cases may respond to antitumor necrosis fac- 40-year-old age group. Laboratory results are often normal, but
tor (TNF) agents. some athletes will present with an elevated ESR and/or a nor-
mocytic normochromic anemia. Synovial fluid evaluation typ-
Reiter’s Syndrome ically reveals a mild inflammatory process. Radiographs often
Reiter’s syndrome involves the triad of arthritis, uveitis, and reveal DIP erosive disease, sacroiliitis, and enthesopathy and/
conjunctivitis. It commonly occurs following an episode of or periostitis. Treatment of psoriatic arthritis involves the use of
either genitourinary or gastrointestinal (GI) infection. It has antiinflammatory medications (mild disease), physical therapy,
associated features of inflammatory eye lesions, balanitis, oral and intra-articular corticosteroids to treat the inflammatory
ulcers, and keratodermatitis. Reiter’s syndrome has a male-to- arthritis. Oral glucocorticoids are generally avoided due to the
female occurrence of 5:1. The arthritis experienced in Reiter’s increased risk of developing erythroderma or pustular psoria-
syndrome is a reactive arthritis rather than an infectious arthri- sis. The focus of treatment, however, involves treating the ath-
tis. It usually occurs 2 to 6 weeks following the onset of an infec- lete’s skin lesions. Oral methotrexate (a nonbiologic DMARD)
tious episode. It is asymmetric and mainly affects knees and is a common therapeutic choice because it treats both the skin
ankles. It is usually of acute onset. There may be diffuse swelling lesions and the arthritis. Severe disease may require a biologic
of fingers and toes, that is, sausage digits. There is commonly DMARD or TNF agent. Psoriatic arthritis was once considered
inflammatory change at both the Achilles’ tendon insertion and a mild disease with a good prognosis. Now, however, it is con-
the plantar fascial origin. There also may be associated low-back sidered a more severe disease, and early referral to rheumatol-
pain with involvement of the SI joints, making it difficult to dis- ogy is recommended.
tinguish it at times from ankylosing spondylitis. The conjuncti-
vitis in Reiter’s syndrome may be either unilateral or bilateral. Enteropathic Arthritis
It usually is mild and transient and is a noninfectious source Enteropathic arthritis is arthritis associated with inflammatory
like the arthritis. Common skin lesions in Reiter’s syndrome are GI conditions including ulcerative colitis and Crohn’s disease,
small, shallow, painless penile ulcers called balanitis circinata. and infectious GI conditions, including Shigella, Salmonella,
Another associated skin lesion is keratoderma blenorrhagica, Campylobacter, Yersinia, and Whipple’s disease. The arthri-
which represents hyperkeratotic skin lesions mainly involving tis, when associated with ulcerative colitis or Crohn’s disease,
the soles of the feet, but they also can be found on the palms and usually is one of a peripheral arthritis with associated sacroi-
the scrotum. Radiographic findings may demonstrate erosions liitis and less often enthesopathies. It often is a transient, oli-
or periosteal changes, particularly at the Achilles’ tendon inser- goarticular, migratory, nondestructive arthritis associated with
tion or plantar fascial origin. Also, an asymmetric sacroiliitis the bowel disease activity. The knees and ankles are most often
may be present that is in contrast to the symmetric involvement involved. Synovial fluid from the affected joints contains mild
of ankylosing spondylitis. Reiter’s syndrome also is seronega- to severe inflammation. There are a variety of associated cuta-
tive but usually demonstrates an elevated ESR and white blood neous lesions with the disease, and mucosal, serosal, and ocu-
count. Treatment for Reiter’s syndrome involves antiinflamma- lar lesions may occur. The arthritis with ulcerative colitis and
tory medications and intra-articular steroid injections as well Crohn’s disease often resolves with medical (glucocorticoids or
as physical therapy. Systemic oral steroids have been shown to TNF agents) or surgical treatment of the intestinal disease.
be of minimal benefit except in refractory cases. Nonbiologic The arthritis associated with enteropathic infection often
DMARDs may be necessary. Topical steroids are used for the comes on a few weeks following the bowel symptoms. The
skin lesions and for the conjunctivitis. The prognosis for Reiter’s arthritis, in this case, is a reactive arthritis and, again, affects
232 SECTION 2  Sport Syndromes

mainly knees and ankles. There also may be axial joint involve- of the disease, treatment is highly individualized. In general,
ment. Enthesopathies, although not common in association antiinflammatories, topical/oral corticosteroids, antimalarials,
with ulcerative colitis and Crohn’s disease, are common in asso- and immunosuppressive agents are used.
ciation with infectious GI conditions and typically involve the
plantar fascia and Achilles’ tendon insertions. The arthritis is Gout
usually self-limited, resolving weeks to months after the bowel The pathogenesis of gouty arthropathy involves tissue depo-
infection. Treatment is symptomatic, involving the use of anti- sition of uric acid crystals from a supersaturated extracellu-
inflammatory medications, physical therapy, and intra-articular lar fluid. Gout involves recurrent attacks of severe articular or
corticosteroid injections. periarticular inflammation. Late involvement of the disease
involves crystal deposition of uric acid within articular, osse-
Rheumatoid Arthritis ous, soft tissue, and cartilaginous structures. These tophi occur
Rheumatoid arthritis is a chronic, systemic inflammatory late (>10 years) in the disease. There may be renal impairment
disease characterized by significant joint involvement. It with or without uric acid urinary calculi. Hyperuricemia may
affects multiple systems extensively, and thus a full detailed be demonstrated in individuals without gout and uric acid
description of the disease is beyond the scope of this chapter. levels may be within the normal range in individuals showing
It involves symmetric upper extremity, knee, and foot destruc- clinical gouty arthropathy. Gout is a disease of middle-aged
tive changes, sparing the DIP joints of the hands and feet. It men and postmenopausal women. It increases in frequency
results in progressive joint destruction and deformity. Again, with age.
there are multiple extra-articular features, including rheu- An acute, gouty, arthritic flare most commonly involves
matoid nodules, arteritis, neuropathies, scleritis, and peri- the great toe metatarsophalangeal (MTP) joint but also com-
carditis. Lymphadenopathy and splenomegaly are common. monly involves the ankle. It usually involves a single joint with
The incidence in females is two to three times greater than an acute onset, often during the evening hours. The joint often
in males. It may occur at any age and increases in frequency appears warm, red, and swollen and usually is exquisitely ten-
with increasing age. Hand, wrist, knee, and foot are most com- der. The flare may subside spontaneously 3 to 10 days follow-
monly involved, but any diarthrodial joint can be affected. The ing onset without treatment. Individuals often are symptom
elbows, shoulders, sternoclavicular (SC) joints, hips, ankles, free following an acute attack, but over time, if untreated, the
and TMJ are less commonly involved. Spine involvement is attacks may increase in frequency, in the number of joints
limited to the upper cervical spine. affected, and in duration of symptoms when flared. The flares
Feet and ankle changes are similar to those seen in the may be triggered by trauma, alcohol, drugs, stress, or medical
hands. Cocking up of the toes may occur secondary to sub- illness. Tophi when present occur most commonly in the syno-
luxation of the metatarsal heads. This gives the digits a claw- vial tissue, subchondral bone, olecranon bursa, patellar and
like appearance. Fibular deviation of the first through fourth Achilles’ tendons, subcutaneous tissue on the extensor surface
toes may occur. Bursal inflammation about the foot/ankle of the forearms, and overlying joints. Radiographic findings
also occurs with the retrocalcaneal bursa being most com- in gout usually are negative. Often they are obtained to rule
mon. Laboratory evaluation usually shows a normocytic, out other joint processes, such as a septic joint, or to evaluate
normochromic, or hyperchromic anemia. There often is an for the presence of chondrocalcinosis. More chronic cases can
elevated ESR and positive rheumatoid factor. Joint fluid eval- show periarticular erosions and frank degenerative changes,
uation reveals mild inflammation. Treatment involves refer- especially in the great toe MTP joint. The gold standard for
ral to a rheumatologist and the use of DMARDs in all patients diagnosis is monosodium uric crystals demonstrated in joint
diagnosed with rheumatoid arthritis. The use of antiinflam- fluid. The white blood cell count from a symptomatic joint
matory medications, physical therapy, and intra-articular usually reveals moderate inflammation. Treatment in the acute
corticosteroid injections for symptomatic joints are adjuncts setting may involve antiinflammatory medications, oral corti-
to treatment. costeroids, or colchicine. Treatment in the chronic setting may
also involve the use of colchicine the most commonly involves
Systemic Lupus Erythematosus the use of allopurinol or probenecid.
Systemic lupus erythematosus (SLE) is a chronic, multisystem
inflammatory disease affecting bone, joints, tendons, skin, kid- Pseudogout/Calcium Pyrophosphate Dihydrate
ney, heart, lungs, GI tract, and central nervous system (CNS). Crystal Deposition (CPPD)
Again, a full and detailed description of the disease process Pseudogout involves acute, gout-like, inflammatory attacks that
is beyond the scope of this text. SLE has a 9:1 female-to-male occur secondary to calcium pyrophosphate dihydrate crystal
ratio. The arthralgias and arthritis are a common presenting deposition (CPPD) within joints. The incidence of clinically
complaint. The arthralgia/arthritis often is symmetric. Joint symptomatic pseudogout is one-half that of true gout. Calcium
capsule, ligamentous, and tendon involvement can be promi- pyrophosphate dihydrate crystal deposition may occur as an
nent in the disease, and hand or foot deformities may develop. incidental finding in a symptom-free joint with radiographic
There often are marked laboratory abnormalities, including a evaluation. The term “chondrocalcinosis” is used to describe
normocytic, normochromic anemia, leukopenia, thrombocyto- this x-ray appearance. The male-to-female ratio of pseudogout
penia, elevated ESR, and positive antinuclear antibody (ANA) is 1.4:1 and is in marked contrast to the distribution in gout.
and double-stranded DNA. Because of the great heterogeneity The pseudogout flare usually involves one or more joints lasting
 CHAPTER 12  Arthritic, Metabolic, and Vascular Disorders 233

for several days. It usually is abrupt in onset but self-limited. in the disease course, there often is migratory pain without spe-
Findings may be as severe as in true gout, but typically the cific inflammation to the joints. Tendon, bursal, and muscular
attacks of pseudogout are less painful. The knee is the most inflammation is common. The reactive arthritis usually occurs
commonly affected joint, but all joints are susceptible, including in intermittent attacks. It can be monoarticular to oligoarticular
the first MTP joint. The flare may be triggered by trauma, sur- and has a preference for large joints, especially the knees. It can
gery, stress, or medical illness. Individuals usually are symptom last for months, with chronic flares over several years. The treat-
free between flares. Treatment is with antiinflammatory medi- ment for Lyme disease early in its course is tetracycline, amoxi-
cations and intra-articular steroid injections. Recurrent disease cillin, or cefuroxime. With disseminated or late course disease,
may be treated with prophylactic colchicine. intravenous penicillin usually is the treatment of choice.

Sarcoidosis
PEARL Sarcoidosis is a multisystem illness characterized by noncaseat-
Suspect inflammatory disease in a joint that has no history of trauma and that ing epithelioid granulomas in affected tissues. It has a tendency
is swollen and warmer than expected for the history. to affect young adults of either sex. It most often begins as bilat-
eral hilar lymphadenopathy, pulmonary infiltrates, and skin and
eye lesions. However, there may be bone lesions, localized mus-
PEARL cular granulomas, and acute inflammatory arthritis. The arthri-
tis is the most common rheumatologic manifestation and can be
Suspect inflammatory disease if there is a history of multiple joint involvement
the initial complaint. The arthritis most commonly affects the
or other systemic complaints that is, skin, GI, constitutional, and so forth.
ankles and knees. The most severe attacks usually occur during
active disease. These flares usually last for 2 to 3 weeks. Chronic
arthritic changes are much less common. The prognosis in sar-
CASE STUDY 12.1  Gout coidosis is favorable. Treatment usually is antiinflammatory
A 46-year-old, male runner awakens with a swollen, warm, red right ankle, medication or a short course of oral corticosteroids.
which is exquisitely painful. He denies injury but did go for his usual 3-mile run
1 day ago. The rest of his history is noncontributory. On physical examination
he demonstrates an effusion to the ankle with the joint erythemic and warm.
METABOLIC DISEASE
The ankle is diffusely and significantly tender. The rest of the examination is Metabolic diseases are an uncommon cause of concern in the
noncontributory. X-rays are normal. Laboratory studies show a normal com- athletic foot and ankle. The most common metabolic disease
plete blood count (CBC), ESR, renal function, and uric acid. Joint aspiration that may present with foot and ankle issues is diabetes mellitus.
demonstrates a mild to moderate inflammatory response and is positive for The neuropathy and microvasculopathy in the extremities, espe-
monosodium urate crystals. The patient was treated with indomethacin and
cially the foot and ankle, can result in a wide range of sequelae.
demonstrated a complete response over the next few days.
Metabolic bone disease is another common metabolic disease that
uncommonly affects an athlete’s foot and ankle. In cases of recur-
rent stress fractures, metabolic bone disease such as osteoporosis
CASE STUDY 12.2  Reiter’s Syndrome may be the underlying cause. Medications and/or supplements
A 24-year-old, professional basketball player presents with a left ankle that is can cause metabolic bone disease or can cause other condi-
painful, swollen, red, and warm. He also notes several toes that are swollen tions that are risk factors for metabolic bone disease. Examples
and right heel pain. His past medical history and family history are noncon- include steroid use (or abuse), which causes drug-induced
tributory, except that he was treated for a Chlamydia infection 1 month osteopenia, or vitamin B12 deficiency, which can cause a neu-
ago. He is on no medications except for Visine for “irritated” eyes. Physical ropathy that may present with diabetes-like complications.
examination demonstrates an erythemic, warm left ankle with mild effusion.
Several sausage digits are noted. The right plantar fascia origin is tender. Diabetes Mellitus
Both conjunctiva are injected. The rest of the examination is noncontributory.
X-rays are normal. Laboratory studies are negative, including an inflamma- Diabetes mellitus is a common disorder. Younger athletes are
tory workup, except that the ESR is elevated and the white blood cell count more likely to be type I, but many type II diabetics are involved
is at the upper limits of normal. The athlete was treated with nonsteroidal with athletics, especially on a recreational or fitness level. The
­antiinflammatory drugs (NSAIDs) and physical therapy. The athlete returned to most important factor is achieving optimal control of the
baseline and there were no recurrences. athlete’s diabetes. Tighter control usually equates with fewer
complications. In the setting of the foot and ankle, the most
important complication is peripheral neuropathy, which usually
OTHER occurs in a long-standing diabetic. Peripheral neuropathy leads
to the possibility of skin breakdown and subsequent ulceration
Lyme Disease and infection. In an athlete’s foot and ankle, skin integrity can
Lyme disease is a multisystem illness caused by the tick-borne be a concern, regardless of diabetes. Callus formation, blisters,
spirochete Borrelia burgdorferi. The disease is characterized by abrasion, and fungal infections are very common in athletes. In
a rash at the bite site (erythema chronicum migrans), consti- the setting of diabetes, these conditions can lead to ulceration
tutional symptoms, neurologic abnormalities, cardiac involve- and bacterial infection and potentially may develop a serious
ment, musculoskeletal complaints, and a reactive arthritis. Early complication faster than in a nondiabetic athlete.
234 SECTION 2  Sport Syndromes

Skin ulceration is a significant concern for all diabetic athletes. treatment is prevention. Calcium intake should be at least 1000
Cellulitis can develop quickly. Even worse is the possibility of mg/day in an adult, and vitamin D (800 IU per day) is needed
osteomyelitis. Left untreated, these complications could be career to aid in the absorption of the calcium. Weight-bearing resis-
altering or even career ending. Most plantar wounds or ulcers in a tance exercise also is important in building and maintaining
diabetic are polymicrobial. Superficial skin infections on the dor- strong bones. Once osteoporosis has been diagnosed, several
sum of the foot or around the ankle may be less likely to be polymi- treatment options exist. Calcium and vitamin D need to be
crobial, but if empiric treatment is warranted, standard regimens taken, but they will not adequately increase bone density. At
to cover typical pathogens for diabetic ulcerations should be used. this time bisphosphonates (e.g., alendronate and risedronate)
Proper wound care is essential, and weight-bearing activities may are a first-line treatment for increasing bone density. Estrogen
have to be restricted temporarily. One special note is that deep foot increases bone density in postmenopausal osteoporosis but has
ulcers with signs of cellulitis may be infected with Pseudomonas other significant tissue effects that need to be taken into account
because athletic shoes may harbor these bacteria. Lastly, deep before use. Selective estrogen-receptor modulators (raloxifene
ulcers need debridement and/or other investigation to search for and tamoxifen) can prevent bone density loss and decrease frac-
osteomyelitis, although this would be unusual in the athlete. tures. Parathyroid hormone actually can stimulate osteoblastic
Diagnosis and testing of diabetes is beyond the scope of activity if the concentration is not too high. Follow-up DEXA
this chapter, but it is important to note that monofilament tac- scanning is important to monitor therapy.
tile and vascular examinations are essential for the evaluation Most cases of osteoporosis are idiopathic, age-related, or post-
and monitoring of diabetic neuropathy. Routine diabetic care menopausal. There are many secondary causes that are not as
is essential for tight control of glucose levels and prevention of common but need to be kept in mind. Please see Box 12.1 for a list
complications. It also is important to note that sports participa- of these secondary causes. The majority of patients with osteopo-
tion should be encouraged in the diabetic population because rosis will be older recreational athletes, but bone loss can occur in
physical activity can have beneficial effects on the disease as a a younger athlete. The classic scenario in a younger patient would
whole. Simply keep in mind that more attention must be paid be a college-age, female runner with recurrent stress fractures
to lower-extremity skin care in the athlete. In individuals with and an eating disorder and who is anovulatory. This is the classic
foot alignment prone to callus formation, such as a cavus foot, female athletic triad (see Chapter 28). The results of the female
professional callus shaving may be warranted. Orthotics may be athletic triad syndrome include metabolic bone disease and can
useful in spreading out load-bearing surface of the foot and may lead to an increased rate of stress fractures. Any patient with
help to alleviate pressure spots before they can ulcerate. recurrent stress fractures or problems healing existing fractures
Diabetics have other complications that can affect the ath- must be evaluated for possible metabolic bone disease. Clinical
lete’s performance and general health, but one that can have judgment is needed to determine when to test an athlete for met-
specific foot and ankle relevance is the fact that diabetics have a abolic bone disease in the setting of recurrent stress fractures.
higher incidence of osteoporosis and may have an increased rate There are no established guidelines for the number or frequency
of stress fractures. The key is focusing on the foot and ankle but of fractures that necessitate further investigation. In our opinion,
remembering to see the athlete as a whole person.

Metabolic Bone Disease

Metabolic bone disease encompasses any disorder that changes BOX 12.1  Secondary Causes of
the mineralization of the normal skeleton. Osteoporosis is the Osteoporosis
most common metabolic bone disease that could affect the foot or Nutritional Marfan’s syndrome
ankle. This is a concern primarily in the mature or elderly athlete. Inadequate calcium intake Ehlers-Danlos syndrome
Osteoporosis and osteopenia are common disorders, espe- Malabsorption Osteogenesis imperfecta
cially in postmenopausal women. However, they do not usually Bulimia or anorexia nervosa Endocrine Disease
affect the foot and ankle. The most common sites of fracture in Exogenous Substances Diabetes mellitus
osteoporosis are the spine, wrist, ribs, pelvis, hip, and humerus. Glucocorticoids Hyperparathyroidism
Some chemotherapeutic agents Hyperthyroidism
Osteoporosis is a concern in mature or elderly athletes because
Excessive alcohol Cushing’s syndrome
weaker bones may lead to an increased fracture rate or recur- Some anticonvulsants Vitamin D deficiency (rickets/osteo-
rent fractures. Osteoporosis and osteopenia are abnormalities of Cyclosporine malacia)
the bony matrix, where bone is less dense but of normal archi- Tacrolimus Hypogonadism
tecture. Other metabolic bone diseases may not have normal Thyroxine Growth hormone deficiency
bony architecture, such as osteomalacia. Bone Marrow Disease Functional
Bone densitometry (dual energy x-ray absorptiometry Leukemia Prolonged immobilization or disuse
[DEXA] scan) is the test of choice for diagnosis of osteoporosis. Lymphoma Miscellaneous
Standard radiographs are unreliable. DEXA scanning will dif- Myeloma Postsurgical
ferentiate osteoporosis from osteopenia. A DEXA score of 2.5 Metastatic carcinoma Subtotal gastrectomy
standard deviations below the mean is diagnostic of osteoporo- Bone cysts Celiac disease
Rheumatologic/Connective Tissue Renal
sis. Scores of 1.0 to 2.5 are diagnostic of osteopenia.
Disease Renal tubular acidosis
Treatment of osteoporosis is beyond the scope of this chap- Rheumatoid arthritis Hypercalciuria
ter (see also Chapter 4), but a brief summary follows. The best
 CHAPTER 12  Arthritic, Metabolic, and Vascular Disorders 235

there is no specific number of fractures needed to prompt workup VASCULAR/ LYMPHATIC DISORDERS
for metabolic bone disease, but if there is enough clinical evi-
dence to suggest metabolic bone disease, a workup is warranted Arterial Disease
(i.e., two to three stress fractures within a 2-year period). Arterial disease represents decreased blood flow to the lower extrem-
Workup for metabolic bone disease is directed toward the ity. The most common cause is occlusive disease secondary to ath-
suspected cause. For example, in a mature fitness athlete with erosclerosis and associated embolic phenomenon. It is uncommon
recurrent stress fractures the cause is most likely to be a result in young healthy athletes unless there is a genetic predisposition or
of idiopathic or primary osteoporosis, and initial workup would severe risk factors. It is most common in middle-aged to older-aged
start with a DEXA scan. A significantly different approach recreational athletes, especially those who have concurrent disease,
would be the case for a teenage girl with recurrent stress frac- that is, diabetes or elevated triglycerides or cholesterol. It presents
tures and would include a more detailed dietary and menstrual as claudication of the lower extremities, which is defined as exer-
history, as well as laboratory workup. cise-related pain. Evaluation at rest, unless late in the disease, may
be entirely normal, although decreased lower-extremity pulses may
Medications/Supplements/Deficiency States be present. The disease usually is progressive, causing increased
Several medications, supplements, or deficiencies can result in pain at lesser workloads. Evaluation may include arteriography, and
disease-like states that can result in foot and ankle issues in an definitive treatment may require vascular surgery.
athlete. Most cases concern medications or supplements that Claudication in a young athlete may be caused by popliteal artery
result in metabolic bone disease. Table 12.1 has several examples entrapment (see Chapter 23). Its cause is either an entrapment of
of medications that can cause osteoporosis. Also, deficiencies can the popliteal artery in the popliteal fossa secondary to an anatomic
result in metabolic bone disease. The obvious is calcium defi- variation of the popliteal artery and surrounding myofascial struc-
ciency, but other states can lead to osteoporosis as well. Examples tures or a functional entrapment compressing the artery by the
include growth hormone deficiency, thyroid hormone deficiency, exercising muscles and surrounding bone. It has an 85% male pre-
and hypogonadism. Please see Table 12.1 for more examples. ponderance and usually occurs in the second or third decade. It is
In some cases, excess states can lead to metabolic bone disease. bilateral in 25% of cases. The athlete usually complains of cramping
Hyperparathyroidism and Cushing’s disease would be exam- to the calf and foot with associated numbness or paresthesias. In
ples. In addition, medications, supplements, or deficiency states 10% of patients, there are acute or chronic ischemic changes of the
can lead to other conditions that can affect the foot and ankle. lower extremity, including skin and temperature changes as well as
Vitamin B12 or folate deficiency can lead to a peripheral neurop- rest pain and possible tissue necrosis. Physical examination usually
athy, which in turn could lead to some of the same concerns that is normal, but the diagnosis may be suspected if pulses diminish
a diabetic athlete may have. The bottom line is to search for clues in the affected extremity with maximal ankle dorsiflexion or with
to the underlying cause and, if possible, correct the disorder, dis- active plantarflexion with the knee fully extended. However, these
continue the medicine or replete the deficiency. examination findings also are found in normal individuals who
have no lower-extremity complaints. Evaluation usually includes
noninvasive vascular studies, including lower-extremity Doppler,
CASE STUDY 12.3  Female Athlete Triad preexercise and postexercise ankle/brachial blood pressure indices,
continuous wave Doppler ultrasound with provocative maneuvers,
A 19-year-old, female, college freshman, cross-country/track athlete presents
with a 2-week history of gradually worsening left foot pain. The pain initially mentioned previously, and a duplex ultrasound that combines
was present at the start of her runs and became worse as she tried to run anatomic evaluation with quantitative and qualitative analysis of
through the pain. Now the pain is present with activities of daily living (ADLs). arterial blood flow. The gold standard for evaluation, however, is
Over the last 24 hours, her pain has worsened significantly. She has noted arteriography. Treatment involves surgical release of the entrapped
some mild swelling in the area of her dorsal midfoot/forefoot. About 1 month artery. Although few long-term studies exist regarding the progno-
ago she added some runs outside of her usual training runs/practices. She sis of popliteal artery entrapment syndrome, studies suggest that
has concern for a possible stress fracture as she has a history of prior stress the prognosis is most favorable if no arterial damage has occurred
fractures (three fractures during her senior and junior years of high school). at the time of diagnosis and treatment.
The rest of her history of present illness is noncontributory. She is on no med- Raynaud’s phenomenon is manifested by pallor and cyanosis
ications but admits to the use of over-the-counter (OTC) diet pills. She has a
of the digits in response to some type of stressor, usually expo-
history of “spotty” periods and has not had a period since she was a sopho-
sure to the cold but also possibly secondary to an emotional dis-
more in high school. The rest of her past medical history is noncontributory.
Physical examination demonstrates a height of 5 feet 6 inches and a weight tress. It can present at any age but is most common in women
of 105 lb (BMI = 17), minimal erosions of the enamel of the teeth and fine hair between the ages of 20 and 40 years. It has an unknown etiology.
on the arms but is otherwise noncontributory. X-rays show a completed fourth Patients usually have no findings at the time of physical exam-
metatarsal stress fracture. Laboratory studies including CBC, electrolytes, ination. Occasionally, some bluish discoloration of the tips of the
thyroid, and hormonal status tests are noncontributory. DEXA testing shows digits may be present between attacks. A typical attack causes
bone mineral density 2.5 standard deviations below the mean of young adults. the digits to become pale and cyanotic with a sharp demarca-
A multi-team approach was used to treat the athlete and involved the team tion of these findings with the skin more proximally. Raynaud’s
internist, a dietician, and a sports psychologist. Treatment included a walking may be associated with other diseases such as scleroderma, and
boot for the stress fracture with activity modification, increased caloric intake when this occurs, it is referred to as Raynaud’s phenomenon.
and calcium supplementation to 1500 mg per day, hormonal supplementation,
When just the Raynaud’s findings are present without concur-
counseling, and involvement of the athlete’s family for emotional support.
rent other disease, then it is called Raynaud’s disease.
236 SECTION 2  Sport Syndromes

The prognosis for Raynaud’s patients generally is good. For to pump the blood back up the venous gradient. Intact/compe-
athletes who are exposed to cold weather conditions, protective tent venous valves prevent back flow. When the valves are incom-
clothing is usually sufficient. More severe cases may require a petent or absent, pooling blood distends the veins, leading to
pharmacologic treatment, which may include calcium channel further obstruction that causes worsened flow from the lower
blockers, alpha-adrenergic blockers, or vasodilators. extremities. An exercising athlete with varicose veins further
Another condition that may affect the foot during cold worsens this condition because of increased arterial flow into the
weather outdoor activities is chilblain or pernio. Chilblain is an exercising lower extremities. Usually this worsening of the venous
inflammatory disorder of the skin induced by cold temperature. return during exercise has little effect on exercise tolerance. Some
It often affects women in the second or third decade of life. The athletes, however, may complain of a nonspecific heavy sensation
etiology of chilblain is unknown. It presents as bluish red edem- to the extremities with exercise. This vague, exercise-related dis-
atous areas of the skin overlying the lower extremities. Patients comfort is known as “venous claudication.”
may complain of itching/burning to the areas of skin change. If venous congestion of the superficial system progresses, it
Repeated exposure may cause the lesions to become chronic may lead to involvement of the deep venous return. This may
and ulcerative. The lesions generally resolve with avoidance then result in chronic edema, venous dermatitis, and/or stasis
of the cold. Often, however, there will be a permanent area of ulcers. Treatment is initially symptomatic using elevation and
hyperpigmentation at the prior site of the lesions. support stockings. Surgical vein stripping also may be an option
for persistent problems, which do not respond to a more con-
Venous Disease servative approach. Proper skin care to treat the chronic derma-
Thrombophlebitis is uncommon in a young, healthy athlete. It titis and any ulcers that may develop also is necessary.
may occur from direct trauma from a contact sport, especially
in association with postgame travel in an away team returning to Lymphatic Disease
the home location or following limited activity after a significant Other sources of edema of the lower extremities, but usually not
injury or elective surgery. A previous history of thrombophlebitis associated with pain, are abnormalities of the lymphatic sys-
may predispose an individual to a second episode. Three factors tem. Lymph vessels serve to transport lymph fluid back to the
as part of Virchow’s triad may lead to the formation of a throm- venous system through the thoracic duct at the left jugular vein.
bosis, and these include venous stasis, injury to the venous wall, At lymph node junctions along the lymph system, immunologic
and a hypercoagulable state. Any unexplained swelling associ- and filtering is done to the lymph fluid. Lymphatic channels,
ated with lower-extremity erythema and increased temperature which normally follow the venous tree, are susceptible to many
should raise the suspicion of a venous thrombus. of the same forces that affect the venous system and include
The main concern in detecting a venous thrombus is to deter- trauma, mechanical obstruction, and surgical removal of lymph
mine whether the lesion occurs within the superficial venous nodes as well as venous hypertension.
system or the deep venous system. Superficial lesions are treated Primary lymphedema is a disease of the lymph systems with
symptomatically and may present as tender, erythemic, palpable an unknown cause. It is most common in females and often is
cords within the subcutaneous tissue. However, because of the unilateral. It usually has onset before the age of 40. The diag-
potential serious complications of a deep venous thrombus, defin- nosis may be confirmed with either lymphogram or contrast
itive study should be obtained to rule out any deep system involve- lymphangiography. Treatment is symptomatic and aimed at
ment if there is any question regarding the presentation. Testing reducing the lower-extremity edema with elevation, support
involves noninvasive, lower-extremity Doppler examination that stockings, and, occasionally, diuretics. Chronic lymphedema
provides an approximate 90% accuracy. If deep venous thrombosis may cause recurrent skin infections, which in turn lead to an
is discovered, treatment involves rest and initiation of anticoagu- overload of the lymph system, causing further edema. Rarely,
lation therapy. Anticoagulation therapy usually is instituted for 3 surgical intervention may be necessary.
to 6 months for the first episode and may require chronic antico-
agulation therapy for repeated episodes. Anticoagulation reduces CASE STUDY 12.4  Popliteal Artery Entrapment
the likelihood of further formation of the thrombus and lessens A 17-year-old, high school senior cross-country runner presents with a
the potential complications of embolic phenomenon. Measures ­several-month history of exercise-related left calf and foot pain. The pain is
aimed at correcting any underlying risk factors such as minimiz- described as cramp-like in quality and has become progressively worse with
ing immobilization and treating any cause for the hypercoagulable time. The pain has become more intense and has onset earlier in his runs. There
state also are recommended. are no associated paresthesias, increased tension to the calf musculature, or
Varicose veins are prominent, abnormally distended, tortuous, loss of foot or ankle control during the runs. The pain will resolve after several
superficial veins of the lower extremities that occur in approxi- minutes of rest, but with return to running after resolution, the pain will return
mately 20% of adults. The cause is usually one of defective valves almost immediately. There are no symptoms noted on the right or symptoms
outside of activity. Past medical history and family history are noncontributory.
within the veins or congenitally absent valves. They are more com-
Physical examination is noncontributory except that with the knee in full exten-
mon in females and often are associated with a family history of
sion and forced dorsiflexion or active plantarflexion, the dorsalis pedis and pos-
varicosities. Any condition that decreases venous outflow from the terior tibialis pulses diminish. X-rays are negative. Superficial and deep posterior
lower extremities, that is, pregnancy, also may cause varicosities. chronic exertional compartment testing is negative. Arteriography demonstrates
Normal venous return from the lower extremities usually is entrapment of the artery at the knee. The athlete is treated surgically with
accomplished by contraction of the lower-extremity musculature release of the artery and makes a gradual return to running.
 CHAPTER 12  Arthritic, Metabolic, and Vascular Disorders 237

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Endocrinol Diabetes. 2015;123(7):419–422. https://doi.org/10.1055 Wigley FM, Flavahan NA. Raynaud’s phenomenon. N Engl J Med.
/s-0035-1545344. 2016;375:556.
Ritchlin CT, Kavanaugh A, Gladman DD, et al. Treatment recom- Zhang W, Doherty M, Pascual E, et al. EULAR evidence based rec-
mendations for psoriatic arthritis. Ann Rheum Dis. 2009;68:1387. ommendations for gout. part I: diagnosis. report of a task force of
Rizzato G, Palmieri G, Agrati AM, Zanussi C. The organ-specific the standing committee for international clinical studies including
extrapulmonary presentation of sarcoidosis: a frequent oc- therapeutics (ESCISIT). Ann Rheum Dis. 2006;65:1301.
 13
Dermatologic, Infectious,
and Nail Disorders
Andrew M. Tucker

OUTLINE
Introduction, 239 Nail Conditions Caused by Trauma, 241
Skin Conditions Caused by Mechanical Stresses/Trauma, 239 Onychocryptosis (Ingrown Toenail), 241
Blisters, 239 Infections of the Skin and Nails, 242
Calluses, 240 Fungal Infection of the Skin, 242
Corns, 240 Fungal Infections of the Nail, 242
Nodules, 240 Bacterial Infections of the Skin, 243
Black Heel, 241 Summary, 244
Piezogenic Pedal Papules, 241

untreated. Also, identification and education to the athlete can

INTRODUCTION help alleviate fear of a more ominous disorder.
The majority of sports and fitness activities place extraordi-
nary stresses on the feet. In addition to the potential for mus- Blisters
culoskeletal injury, the sport participant’s foot is at risk for a Blisters are caused by repetitive friction between skin and
number of dermatologic and infectious conditions that range shoe and/or sock. Moisture from perspiration, increased heat,
from incidental to potentially disabling. Direct pressure from and poorly fitting shoes increases the risk of blister formation.
shoe or surface, sheer stresses from running/jumping/cutting Underlying bony abnormalities of the foot may also increase the
activity, and the increase in moisture from perspiration are risk of formation. Blisters are formed from a split between the
predisposing factors to these commonly seen conditions. The epidermis layers that fills with transudate. Blisters are among
increase in moisture at the outer layer of skin (stratum cor- the most common complaints in surveys of runners and other
neum) can enhance the passage of microorganisms through athletes and typically appear in toes, plantar surfaces of the
the skin. Certain anatomical issues of the foot or lower leg, and metatarsals heads, and heels.1,2
extreme participant size in some sports, increase the stressors Blisters appear as areas of erythema followed by formation
on the skin structure. Cuts and abrasions are less common in of the vesicle or bullae (Fig. 13.1). Formation is often accompa-
the feet than other sites on the athlete, but can occur in certain nied by sensation of burning or stinging. The fluid filled lesions
settings and also increase the risk of infection. In addition, the may appear dark when blood fills the blister cavity. Data has
athlete’s environment, including playing surfaces, locker rooms demonstrated that blisters are best treated with sterile drainage
and shower areas, may contribute to risk of certain types of using a blade or needle without disturbing the roof. The roof of
infection. the blister can adhere to the base of the lesion, providing protec-
This chapter will review the most common dermatologic and tion and decreasing risk of infection.3 After drainage, petroleum
infectious issues that present to the medical staff in the train- jelly and occlusive dressings may be used to protect the healing
ing room and clinic setting, and focuses on the presentation, lesion. Commercially available products, such as hydrocolloid
examination findings, and treatment strategies with the goal of pads, are available that can be applied daily to promote healing
maintaining optimum health and performance. (2nd Skin). Athlete and clinician should continue to monitor
the affected area for secondary infection.
SKIN CONDITIONS CAUSED BY MECHANICAL Prevention of blisters includes properly fitted shoeware,
moisture wicking socks, and consideration of extra padding
STRESSES/TRAUMA over bony prominences. Athletes have often used two pairs of
A myriad of trauma-related skin conditions occur commonly in socks to help distribute the frictional forces to the foot. Drying
athletes, and the foot is a common site for these typically benign powders, such as aluminum chloride, may be used to decrease
findings that usually do not interfere with participation and moisture around the foot. Agents such as 10% tannic acid soaks
training, but can be problematic in certain circumstances if left may assist in hardening the skin.4
239
240 SECTION 2  Sport Syndromes

Fig. 13.1  Blister formation on plantar surface of toe.

B
Fig. 13.3 (A) Hard corn characterized by well-demarcated hyperkera-
totic skin. (B) Soft corn located in interdigital space.

and are often painful.5,6 Diagnosis is confirmed by paring of the

lesion. Corns are characterized by a central core, while calluses
show normal skin lines and plantar warts the characteristic
black dots. Paring will provide pain relief, and pads may help
redistribute and minimize pressure. In addition to mechanical
or sharp debridement, electrosurgery has been used successfully
as an alternative treatmemt.7 Nonsurgical treatment options
Fig. 13.2 Callus on plantar aspect of foot, with hyperkeratosis and
include warm water soaks and keratolytics (salicylic acid pads),
prominence of skin lines.
topical or intralesional steroids, or topical retinoids.4 Preventive
measures are similar to those for calluses and blisters.
Calluses
Calluses are defined as hyperkeratotic plaques created by repeated Nodules
friction and pressure on the skin (Fig.13.2).5 Most calluses are Athlete’s nodules have been classically described as small, flesh-
painless, but can become symptomatic when extremely thick and colored lesions, usually occurring at the dorsum of the toes,
place excessive pressure on underlying structures. The differential foot, or anterior ankle and lower leg due to repetitive pressure
diagnosis includes plantar warts and corns. The diagnosis can be and friction of tight fitting shoes, skates, or boots. Comparable
confirmed with paring of the lesion. Warts contain the characteris- lesions have been described on the hands of boxers and labor-
tic black dots of tiny thrombosed vessels, while corns contain a cen- ers.8 The lesions typically present insidiously and are often pain-
tral core. When treatment is required, gentle paring with a blade or less. Occasionally, the lesion may reach a critical size and cause
pumice stone will debulk the lesion and provide relief. Prevention some pressure-related discomfort that may require attention.
of calluses can include synthetic socks, lubricant jelly, and properly The histology of these lesions often will show increase in colla-
fitting shoes in order to minimize friction and pressure across the gen density in the dermis with relatively normal epidermis.8 The
skin. In symptomatic cases, where underlying anatomical abnor- differential diagnosis can include ganglion, granuloma annulare,
malities are causative, surgical treatment may be indicated. rheumatoid nodule, gout, foreign body reaction, and elastoma.6
Treatment is often not necessary but, when symptoms dictate,
Corns can include medical treatment with topical keratolytics (salicylic
Corns, similarly as calluses, may present in two ways. Hard acid), or intralesional injection of corticosteroid to address the
corns (clavus durus) are typically found on the sole or dorsum thickened collagen in the dermis.4 Surgical removal is an option
of the toes (Fig.13.3). Soft corns (clavus mollis) are often found for recalcitrant cases, and would be reserved for the athlete’s off
in the interdigital area due to pressure from one toe on another season if possible.
 CHAPTER 13  Dermatologic, Infectious, and Nail Disorders 241

Fig. 13.4  Black heel (talon noire) – painless black macule on heel, can
resemble melanoma. (From Williams JD, et al. Dermatoses Resulting
From Physical Factors. In: Williams JD, Andrews’ Diseases of the Skin
13th edition. 2020, Elsevier. 18-45.e3. Fig. 3.36)

Fig. 13.6 Repetitive trauma of the second toe resulting in subun-

gual hematoma (“tennis toe”). (From Smith, ML. Environmental and
Sports-Related Skin Diseases. In: Bolognia, J ed: Dermatology 4th edi-
tion. Philadelphia, Elsevier. 1569-1594. Fig. 88.16)

in runners and other sports.10 When symptomatic, multi-

ple treatments have been tried with limited success including
injectable corticosteroids, compression, and heel cups and pad-
ding.11 However, in most athletes, benign neglect after educat-
ing the athlete is the treatment of choice.

NAIL CONDITIONS CAUSED BY TRAUMA

Fig. 13.5 Flesh colored painless papules of the medial heel consis- A number of conditions have been described that share a
tent with piezogenic papules. (From Smith, ML. Environmental and common mechanism of acute or repetitive trauma to the nail,
Sports-Related Skin Diseases. In: Bolognia, J ed: Dermatology 4th edi-
including “tennis toe” or “jogger’s toe” (Fig. 13.6).12 The longest
tion. Philadelphia, Elsevier. 1569-1594. Fig. 88.17)
toes (first or second) are usually affected. Acute stress from a
sudden stop/start or repetitive stresses from long distance walk-
Black Heel ing or running can be causative as the affected nail is pushed
Black heel, also called “talon noire”, has been described in mul- against by the toe box. The nail may become acutely painful due
tiple sports including basketball, football, lacrosse, soccer, and to subungual hemorrhage, or may be asymptomatic. The differ-
tennis.9 Sheering force caused by the athlete’s rapid stops and ential diagnosis includes fungal infection, melanoma, or psori-
starts is the cause, resulting in tiny blood vessels rupturing in asis. Fungal infections tend to cause yellowish, hyperkeratotic
the papillary dermis. The presentation is a painless black macule changes to the nail. Culture may be needed to confirm the diag-
that is well defined, usually less than 1 cm, on the posterior heel nosis. Melanoma may be difficult to distinguish and requires a
or plantar aspects of the toes (Fig. 13.4). The differential diag- biopsy. Hutchinson’s sign, pigmentation of the nail and the nail
nosis includes melanoma, melanocytic nevus, and tinea nigra. fold, suggests melanoma (Fig. 13.7).13
Paring of the superficial layers of the stratum corneum removes Treatment may include simple observation, and the traumatic
the hemorrhage, though no specific treatment is necessary for nail changes resolve with rest from the offending activity. For
this asymptomatic lesion. Hemoccult testing of the material can acute subungual hematomas, drainage with a heated paper clip
confirm blood and give reassurance. Punch biopsy is appropri- or needle boring through the nail will provide quick relief. The
ate if melanoma is suspected. nail should be covered with sterile dressing until the nail heals.
Prevention relies on properly fitted footwear and trimming of the
Piezogenic Pedal Papules nails. Toe caps can provide protection inside the shoes.
This entity is characterized by multiple small flesh or yellow
appearing papules that are painless and found in the poste- Onychocryptosis (Ingrown Toenail)
rior, medial, or lateral surface of the calcaneus (Fig. 13.5). The Onychocryptosis typically occurs when a curved great toenail
cause is subdermal fat herniation and their appearance is most causes excessive force and stresses on the adjacent soft tissue,
noticed with prolonged weight-bearing and has been observed producing pain and inflammation. Predisposing factors include
242 SECTION 2  Sport Syndromes

Fig. 13.8  Diffuse scaling of tinea pedis (moccasin type). (From Vega-Lo-
pez F. Dermatological Problems. In: Farrar J, et al. Manson’s Tropical
Diseases. Philadelphia, Elsevier. 2014. 995-1026.e1. Figure 68.22)
Fig. 13.7  Pigmentation of the nail and nail fold suspicious for melanoma
(Hutchinson’s sign).
Treatment for mild to moderate fungal infection of the feet
trimming the nail excessively short and curving the edges of usually involves a topical antifungal cream for 2 to 4 weeks. The
the nail.6 Treatment can include removal of the offending por- allylamine creams are fungicidal and are preferred.15 Ciclopirox
tion of the nail versus nonoperative treatment of frequent soaks is both fungicidal and antibacterial. For severe fungal infec-
and modification of footwear.14 The area should be monitored tions, oral therapy with terbenafine or itraconazole may be used
for development of more serious secondary bacterial infection. for 2 weeks, in addition to the topical treatment. These oral anti-
Prevention includes trimming the nail straight across without fungals may be contraindicated if the athlete is taking a number
rounded edges, properly fitted footwear, and foam toe caps. In of common medications, including quinidine, benzodiazepines,
rare circumstance, repeated oncychocryptosis recalcitrant to par- and statin drugs. Blood counts and liver function tests are rec-
tial nail excision, can require partial or complete nail bed ablation. ommended for athletes taking oral antifungals for a month or
more.6
Additional treatment may include drying agents (Domeboro
INFECTIONS OF THE SKIN AND NAILS solution, aluminum chloride) to assist in the treatment of weep-
Infections of the feet are common in athletes and fitness partic- ing lesions. Extreme pruritis may require use of mild to mod-
ipants due to increased moisture from perspiration that facili- erate-potency corticosteroids, in addition to the appropriate
tates growth and entry of microorganisms through the skin, and antifungal medication.
to the athlete’s environments that may harbor increased concen- Prevention of these common infections includes use of
trations of bacteria and fungi. moisture-wicking socks, the immediate removal of wet socks
after activity, thorough cleaning and drying of feet, and proper
Fungal Infection of the Skin cleaning of locker room, showers, and pool decks to minimize
Tinea infections are caused by the dermatophytes trichophy- the growth of common fungi. Studies have shown that regular
ton, microsporum, and epidermophyton.15 Tinea pedis, fungal use of topical or oral antifungal medication can reduce the inci-
infection involving the foot, may present in three ways. The most dence of infection in susceptible athletes.16
common, caused by Tinea rubrum, presents as mild to moder-
ate erythematous scaly plaques in a moccasin distribution (Fig. Fungal Infections of the Nail
13.8). The interdigital type, also caused by Tinea rubrum, is Tinea unguium, also called onychomycosis, is common
characterized by macerated plaques between the toes. A third among athletes, as the predisposing factors for fungal skin
presentation causes pruritic erythematous vesicles and plaques infections translate to increased risk for infection of the nail.
on the instep, and is caused by Tinea mentagrophytes.6 Dermatophytes from the genus Trichophyton are the most
The differential diagnosis of tinea pedis includes contact common causes, specifically Tinea mentagrophytes and Tinea
dermatitis, psoriasis, and pitted keratolysis. The diagnosis can rubrum.6
often be successfully made on clinical grounds. However, potas- The clinical presentation is that of a thickened distal nail,
sium hydroxide slide exam or culture may be used to confirm usually yellowish in color (Fig. 13.9). The patient usually com-
the diagnosis. The clinician must be aware that secondary infec- plains of the cosmetic appearance of the nail rather than pain;
tions with bacteria, such as staphylococcus or pseudomonas, however, the nail may be thickened to the point of causing
commonly accompany fungal infections, complicating both discomfort. The differential diagnosis includes the previously
diagnosis and treatment. Culture may be helpful to confirm described traumatic nail conditions (subungual hematoma) and
co-infection. psoriasis.
 CHAPTER 13  Dermatologic, Infectious, and Nail Disorders 243

Fig. 13.9 Onychomycosis of the great toe with yellow, thickened

nail. Fig. 13.10  Evolving staphyloccal infection with redness, swelling, and
purulent drainage.

Diagnosis is usually made on clinical grounds, but may be

confirmed by KOH slide test or culture. Treatment resulting Impetigo
in cure is difficult. Oral terbenafine or itraconazole is recom- Impetigo is a common infection of the superficial epidermis
mended for 12 weeks, but resolution is difficult to attain.17 and is usually caused by staphylococcus aureus and group A
Alternative treatments include laser therapy. Extended use of beta-hemolytic streptococcus pyogenes.20 Infections most
oral antifungal medication necessitates monitoring of blood commonly affect young children, though may occur at any age.
counts and liver function tests before and after drug regimen. Face and upper extremities are more commonly involved than
Prevention involves the same measures as those for skin fungal the feet and lower extremities. The classic lesions are char-
infections acterized by erythematous plaques and papules with honey-
colored crust. Pustules may or may not be present. Diagnosis
Bacterial Infections of the Skin is typically made clinically and can be confirmed by culture.
Bacterial skin infections are common in athletes, though per- Treatment includes warm water soaks and topical mupiro-
haps more likely at sites where abrasions and minor lacerations cin twice daily for 10 days is as effective as oral antibiotics for
occur in the exposed skin of the head, neck, and extremities. limited disease. Oral antibiotics are necessary for more wide-
Bacterial skin infections likewise can occur in the feet as a result spread disease, and selection is based on culture results and
of the same predisposing factors as fungal infections, including patient tolerance. Systemic antibiotic choices include beta-lac-
excess moisture from perspiration facilitating microorganism tamase resistant penicillins (cloxacillin, dicloxacillin), broad
entry through the skin. Skin breakdown from blisters or trauma spectrum penicillins, cephaloporins, or macrolides. Treatment
from ingrown toenails may predispose to infection. Secondary duration is typically 10–14 days.20
bacterial infections can occur at the site of fungal infections,
and require specific treatment. Folliculitis
Bacterial skin infections may be caused by a number of Folliculitis may affect the lower legs and generally is caused by
gram positive or gram negative bacteria. Streptococcus and staphylocccus aureus, streptococcus, or pseudomonas, though
staphylococcus species are common causes of skin infections. mechanical or chemical causes are also possible.15 Association
Outbreaks of bacterial skin infections, including methacil- with exposure to water or hot tubs has led to the common ref-
lin resistant staphycoccus aureus (MRSA), have been docu- erence of “hot tub folliculitis.”21 Fungal etiology is uncommon
mented in several team sports in recent years (Fig. 13.10).18 but should be considered in resistant cases. These discreet ery-
MRSA infections have become more prevalent in the out- thematous pustules are seen in association with hair follicles,
patient setting and account for over half of skin and soft and are most common on the back and extremities (Fig. 13.11).
tissue infections (SSTIs) in U.S. emergency departments.19 Diagnosis is generally made clinically, but culture may be nec-
Clinicians are encouraged to consider MRSA as a cause for essary in certain resistant cases. Treatment of limited lesions is
any purulent soft tissue infection, including those of the foot. with mupirocin topical twice a day. More severe disease requires
In general, treatment for localized infection without systemic treatment with cephalexin, dicloxacillin, or flucloxacillin.
signs or symptoms is usually incision and drainage, with or
without oral antibiotics.15 In the sports medicine setting, Cellulitis
mild to moderate MRSA infections are most typically treated Cellulitis is a bacterial infection of the subcutaneous tissue and
with clindamycin, trimethoprim-sulfamethoxazole, or doxy- presents as a rapidly expanding, painful, indurated area with
cycline, though local variations in microbial sensitivity may overlying erythema and warmth (Fig.13.12).15 In addition, sys-
drive antibiotic choice. temic symptoms of fever, chills, and malaise may be present.
244 SECTION 2  Sport Syndromes

Fig. 13.11 Folliculitis with small erythematous pustules associated Fig. 13.13 Characteristic pits of keratolysis are caused by enzymatic
with hair follicles. breakdown of the stratum corneum.

days.15 The lesion may become fluctuant and drain. Any drain-
ing or fluctuant lesion should be cultured. Antibiotic selection
depends on culture, but empiric treatment covers MRSA and
trimethoprim-sulfamethoxasole, doxycycline, or clindamycin
can be used until culture results are available.

Pitted Keratolysis
This infection is typically seen in adolescent and young adult
basketball players, tennis players, and runners. Excessive per-
spiration and occlusive footwear are risk factors. A number
of bacteria have been implicated, including corynebacterium,
actinomyces, and streptomyces.23,24 The well-defined crater-
like pits on the sole of the foot are due to enzymes that break
down the stratum corneum, and a distinct foul odor is charac-
teristic (Fig. 13.13). Topical therapies including clindamycin,
mupirocin, and erythromycin topical solutions are effective
treatment. Drying agents can also be helpful for treatment and
prevention.

Fig. 13.12 Cellulitis of the leg characterized by expanding erythema- SUMMARY

tous border, tenderness, and warmth of the skin.
The active patient and sports participant is at risk for a num-
ber of dermatologic and infectious conditions of the foot due
Group A beta-hemolytic streptoccocus and staphylo- to a number of predictable and modifiable factors. This chapter
coccus aureus are the most common causes and methacil- provides the sports medicine provider with an overview of the
lin resistant staphylococcus aureus must be considered.22 most common diagnoses, their presentation, clinical findings,
Diagnosis is clinical, and Gram stains and cultures from and treatment options, with the goals of maintaining health and
infected material may assist in identification. Blood cultures limiting interference with performance.
are obtained when the patient presents with systemic symp-
toms. Treatment should not be delayed. If MRSA is con- REFERENCES
sidered, sulfamethoxasole-trimethoprim, clindamycin, or
doxycycline is recommended. Patients with systemic symp- 1. Mailler EA, Adams BB. The wear and tear of 26.2: dermato-
toms or unstable vital signs require immediate hospitaliza- logical injuries reported on marathon day. Br J Sport Med.
2004;38(4):498–501. PMID 15273194.
tion and parenteral antibiotics.15
2. De Luca JF, Adams BB, Yosipovitch G. Skin manifestations of ath-
letes competing in the Summer Olympics; what a sports medicine
Furunculosis (Boils)
physician should know. Sports Med. 2012;42(5):399–413. PMID
Furunculoses are uncommon in the lower legs and feet and 22512412.
present as tender erythematous lesions that can progress from 3. Cortese TA, Fukuyama K, Epstein W, et al. Treatment of friction
small (1 cm) to several centimeters over the course of 1 to 2 blisters. Arch Dermatol. 1968;97:717–721. PMID 5652977.
 CHAPTER 13  Dermatologic, Infectious, and Nail Disorders 245

4. Emer J, Sivek R, Marciniak B. Sports dermatology: part 1 of 2 14. Gera SK, PG Zaini DKH, Wang S, et al. Ingrowing toenails in
traumatic or mechanical injuries, inflammatory conditions, and children and adolescents: is nail avulsion superior to nonopera-
exacerbations of pre-existing conditions. J Clin Aesthet Dermatol. tive treatment? Singapore Med J. 2018. Epub. PMID 30182130.
2015;8(4):31–43. PMID 26060516. 15. Clebak KT, Malone MA. Skin infections. Primary Care.
5. Phillips S, Seiverling E, Silvis M. Pressure and friction injuries in 2018;45(3):433–454. PMID 30115333.
primary care. Prim Care. 2015;42(4):631–644. PMID 26612376. 16. Jaworski CA, Donahue B, Kluetz J. Infectious disease. Clin Sports
6. Adams BB. Sports Dermatology. New York, NY: Springer; 2006. Med. 2011;30(3):575–590. PMID 21658549.
7. Bevans JS, Bosson G. A comparison of electrosurgery and sharp 17. Piraccini BM, Alessandrini A. Oncychomycosis: a review. J Fungi.
debridement in the treatment of chronic neurovascular, neurofi- 2015;1(1):30–43. PMID 2937689729.
brous and hard corns. A pragmatic randomized controlled trial. 18. Garza D, Sungar G, Johnston T, et al. Ineffectiveness of sur-
Foot. 2010;20(1):12–17. PMID 20434674. veillance to control community-acquired methicillin resistant
8. Cohen PR, Eliezri YD, Silvers DN. Athlete’s nodules: sports-re- staphylococcus aureus in a professional football team. Clin J Sport
lated connective tissue nevi of the collagen type. Cutis. Med. 2009;19(6):498–501. PMID 19898079.
1992;50(2):131–135. PMID 1511619. 19. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resis-
9. Wilkinson DS. Black heel: a minor hazard of sport. Cutis. tant S.aureus infections among patients in the emergency depart-
1977;20(3):393–396. PMID 891256. ment. N Engl J Med. 2006;355(7):666–674.
10. Redbord KP, Adams BB. Piezogenic pedal papules in a marathon 20. Brown J, Shriner DL, Schwatz RA, et al. Impetigo: an update. Int J
runner. Clin J Sport Med. 2006;16(1):81–83. PMID 16377984. Dermatol. 2003;42(4):251–255. PMID 12694487.
11. Doukas DJ, Holmes J, Leonard JA. A nonsurgical approach to 21. Luelmo-Aguilar J, Santandreu MS. Folliculitis: recognition and man-
painful piezogenic pedal papules. Cutis. 2004;73(5):339–340, 346 agement. Am J Clin Dermatol. 2004;5(5):301–310. PMID 15554731.
PMID 15186050. 22. Swartz MN. Clinical practice: cellulitis. N Engl J Med.
12. Burkhart CG. Skin disorders of the foot in active patients. Phys 2004;250(9):904–912. PMID 14985488.
Sportsmed. 1999;27(2):88–101. PMID 20086699. 23. Bristow IR, Lee YL. Pitted keratolysis: a clinical review. J Am
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 14
Nonsurgical Treatment of Acute and
Chronic Ankle Instability
Mary Hastings, Devon Nixon, Jeremy McCormick

OUTLINE
Introduction, 247 Chronic Ankle Instability, 251
Acute Ligament Injuries, 247 Authors’ Preferred Treatment Approach for Chronic Ankle
Diagnosis, 247 Instability, 252
Acute-Phase Treatment, 247 Prevention, 252
Progressive-Phase Treatment, 249 Conclusion, 253
Authors’ Preferred Treatment Approach for an Acute Ankle
Injury, 250

literature, and grading may be difficult to assess in the acute

INTRODUCTION setting, as specialized tests are poorly tolerated by patients.
Ankle sprains are common injuries in the athletic population, Fractures need to be identified when evaluating a painful foot
with an estimated 85% involving the lateral ligament complex.1 or ankle. Ottawa ankle rules guide when radiographs are nec-
The lateral ligament complex consists of the anterior talofibu- essary, including when the patient is unable to tolerate weight
lar ligament (ATFL), posterior talofibular ligament (PTFL), bearing on the injured extremity or when there is tenderness at
and the calcaneofibular ligament (CFL).2 Cumulative data the medial malleolus, lateral malleolus, base of the fifth meta-
from a systematic review and meta-analysis estimated the inci- tarsal, or navicular.6 Furthermore, the role for stress imaging in
dence of ankle sprains at 12 per 1000 exposures based on the the acute setting to assess for excessive radiographic talar tilt
highest-quality studies reviewed, with athletes participating in has been debated. We do not routinely employ them in clinical
indoor and court sports at greatest risk of injury.3,4 Moreover, practice.1
a recent study of collegiate athletes found that at least 1 in 28
collegiate athletes sustains a lateral ankle sprain during each aca- Acute-Phase Treatment
demic year, with the highest incidence in basketball and soccer.5 The hallmark of treatment for an acute ankle injury involves
Duration of symptoms (acute versus chronic) helps treatment early mobilization7 and a protocol of rest, ice, compression,
decision making; broadly, ankle instability can be managed non- and elevation (RICE).8,9 Rehabilitation after injury to the lat-
surgically (through short-term immobilization with bracing or eral ankle ligaments and surrounding tissues follows a contin-
casting and then early functional rehabilitation) or with surgery. uum of care that is sensitive to the severity of injury and the
This chapter will focus exclusively on the nonsurgical manage- injured tissues’ ability to tolerate stress.10 During the early phase
ment of both acute and chronic ankle instability. of rehabilitation, injured tissues poorly tolerate stress. The goal
of acute ankle sprain treatment is to optimize tissue healing by
ACUTE LIGAMENT INJURIES protecting injured tissues and providing an environment that
promotes tissue healing.
Diagnosis
Acute lateral ankle injuries most commonly occur following an Role for Immobilization
excessive inversion and internal rotation of the hindfoot while Ankle sprain severity helps to determine the type and dura-
the leg is in external rotation.1 Accurate diagnosis is achieved tion of immobilization and weight-bearing limitations.11
through careful history and physical examination including Short-leg casts and nonweight-bearing restrictions are typi-
anterior drawer and talar tilt ankle ligament testing (with com- cally reserved for severe sprains or sprains that have impacted
parison to the uninjured side) (Fig. 14.1 and Video 14.1). Acute the integrity of the weight-bearing joint. Injuries that may
ankle injuries are commonly graded I to III, with higher grades require strict immobilization and nonweight bearing include
indicating more injury to the lateral ankle ligament complex. grade III ankle sprains or perhaps more mild sprains in less
However, there are multiple grading schemes offered in the compliant patients. In general, cast immobilization and/or

247
248 SECTION 3  Anatomic Disorders in Sports

A B
Fig. 14.1  (A) Anterior drawer test. The foot is translated anteriorly with a grasp of the heel with the foot in
slight plantarflexion. Counterpressure is applied to the anterior leg with the opposite hand. (B) Talar tilt test.
The foot is inverted with a grasp of the hindfoot with the foot in neutral dorsiflexion. By placing a finger
on the lateral talar process one can more clearly discern ankle motion from subtalar motion. (From Irwin
TA, Anderson RB, Davis WH. Principles of the physical examination of the foot and ankle. In: Coughlin MJ,
Saltzman CL, Anderson RB eds. Mann’s Surgery of the Foot and Ankle. 9th ed. Philadelphia, PA: Saunders;
2014:37-60, [Fig 2.29])

Fig. 14.2  Lace-up ankle brace for ankle sprain. (From Bret C. Jacobs, Justin A. Lee, Durable medical equip-
ment: types and indications, Medical Clinics of North America 2014;98(4):881-893, Fig. 10.)

protected weight bearing should be brief for acute ligamen- As patients move to the next phase of rehabilitation, they may
tous injuries—some authorities even recommend that it not choose to maintain use of a supportive ankle brace or use ankle
exceed 10 days.12 However, immobilization duration differs taping as they work through recovery.13 Taping has been shown
in the presence of a fracture. Use of a walker boot and full in normal subjects with below-average proprioceptive scores
weight bearing may be a reasonable consideration for patients to add proprioceptive feedback to ankles.14 Extrapolating this
with less severe ligament injuries and who might benefit from might suggest that a patient may feel better early in the recov-
boot removal for range of motion (ROM) and active edema ery period after an acute ankle sprain when some of their pro-
management. Rigid ankle braces are also suitable alternatives prioceptive feedback has been slowed relative to normal. Taping
for immobilization (Fig. 14.2). Assistive devices (i.e., crutches, and bracing, however, should not be used as a substitute for the
walker, and knee scooters) might be indicated if patients can- phases of rehabilitation reviewed below. These supportive tools
not ambulate without a limp. Once patients can ambulate can be used in conjunction with the rehabilitation protocol and
without a limp in either a walker boot or ankle brace,11 they should be weaned as a patient progresses through recovery and
then proceed to the next phase of rehabilitation. demonstrates return of proprioception and balance.
 CHAPTER 14  Nonsurgical Treatment of Acute and Chronic Ankle Instability 249

Edema Management
Edema management is critically important during the early
phase of rehabilitation and is best managed with a multi-modal
approach that includes:
• Rest (immobilization and weight-bearing restrictions as dis-
cussed above)11
• Ice (potential regimen may include icing for 10 minutes
on, 10 minutes off, 10 minutes on and then waiting 2 hours
before repeating)15
• Compression (with compression garments and/or pneu-
matic compression devices)
• Elevation16
• Antiinflammatory medications
Educating patients to avoid gravity-dependent positions
is crucial for maintaining edema reduction. Research demon-
strates that ankle edema can return after only 5 minutes in the
gravity-dependent positon.17

Mobility
For uncomplicated ankle sprains, a randomized control trial
demonstrated that mobility exercises initiated during the first Fig. 14.3  Patient performing a single leg stance, eyes closed. Occlud-
week after injury can improve function and activity level with- ing visual input challenges postural control and is an important compo-
out increasing pain, swelling, or risk of reinjury.18 The accel- nent of rehabilitation after an ankle ligament injury.
erated rehabilitation protocol proposed by Bleakley et  al.18
was completed twice daily and included: 1) active ankle dor- also progress from solid, predictable surfaces to softer, less pre-
siflexion/plantarflexion (20 repetitions); 2) active ankle clock- dictable surfaces. Finally, the exercises should also incorporate
wise and counter clockwise circumduction (20 repetitions); 3) external perturbations (e.g., being bumped) and unexpected
active, combined hip, knee, and ankle flexion followed by full challenges (e.g., responding to sport-specific needs). Treatment
extension (30 repetitions); 4) resisted isometric dorsiflexion, progression should also consider sport-specific environments.
plantarflexion, inversion, and eversion contractions (5 repe- For example, soccer players may have ball-specific drills intro-
titions of each exercise, held for 10 seconds); and 5) standing duced into their rehabilitation protocol to assess their functional
gastrocnemius ankle stretching (3 repetitions, held 20 seconds recovery and to identify deficits to be addressed in treatment.
each). Avoiding extremes and forced motions replicating the The Star Excursion Balance Test, a measure of targeted reach
direction of injury (which is typically plantarflexion and inver- distance while balancing on the involved leg, can be a sensitive
sion) will help to reduce tissue disturbances during the healing marker for identifying postural control deficits and tracking
process. For more severe ankle sprains, foot and ankle ROM progression with rehabilitation (Fig. 14.4).21,22
may need to begin following a brief period of immobilization.
Strengthening
Progressive-Phase Treatment Ankle strengthening should progress from isometric exercises to
As patients advance through the acute treatment phase, addi- resistance band exercises. If the targeted muscle is not fatigued
tional exercises should be instituted to gradually increase stress during resistance, resistance should be increased. Both concen-
on the injured tissues in a controlled manner. The use of activity tric and eccentric phases should be observed. Often eccentric
monitors (with step goals and limits) as well as patient journals motion has poorer control with a cogwheel appearance, so exer-
(to detail the type of new activities performed) help to guide cises should be tailored to address these impairments. If there
the patient and therapist during treatment progression. Minor, is an ankle plantarflexion strength deficit, functional activities
transient increases in symptoms are expected during this reha- should progress to unilateral heel rises as well as bilateral and
bilitation phase; however, symptom exacerbation should not unilateral hopping. Careful attention should also be paid to
persist for more than a day and should not exceed a level that eversion strength, as peroneal deficits can exacerbate feelings
results in new restrictions on function. of ankle instability.23 A complete rehabilitation plan should
address strength of the uninjured limb and any hip abductor or
Postural Control external rotator strength deficits to improve poor lower extrem-
Perhaps the most important component of rehabilitation fol- ity positional control noted during weight-bearing activities
lowing an ankle sprain is postural control (Fig. 14.3).19,20 These (i.e., single leg stance, jumping, or hopping).24
exercises will challenge the musculoskeletal, somatosensory,
and cardiovascular systems, particularly as exercises increase in Loading Tolerance
difficulty. The visual system can compensate for limitations in The overall volume and intensity of weight-bearing activities
the somatosensory system – therefore, postural control exercises can be gradually increased as symptoms abate. Activity moni-
should progress from eyes open to eyes closed. Exercises should tors and patient journals should be continued to aid in the safe
250 SECTION 3  Anatomic Disorders in Sports

Fig. 14.4 The modified star excursion test (Y-balance test). The patient stands on the involved side and
reaches as far forward, postero-laterai, or postero-medial as they can. The toe gently touches down and the
patient returns to the upright single leg standing position. Distance reached is recorded.

progression of rehabilitation. Running can be slowly introduced distance.28 Poor performance on these tests has been associated
and gradually increased using a run/walk ratio. An example with incomplete functional recovery and residual symptoms;
walk/run rehabilitation protocol can be found in Table 14.1. however, these tests are not uniformly used in the clearance of
Rehabilitation protocols should be tailored to the individual athletes back to sport.
needs of the athlete: for example, baseball players need to exe-
cute short sprints over straight or curved distances on uneven Authors’ Preferred Treatment Approach for an
surfaces, whereas volleyball players need to jump, pivot, and cut Acute Ankle Injury
quickly. For patients presenting with an acute ankle sprain, we obtain
a thorough history and perform a detailed physical examina-
Return to Sport Testing tion. For less severe injuries and patients able to tolerate weight
To assess an athletes’ readiness to return to sport, several tests bearing, we initiate the above-mentioned protocol early in the
can be used to quantify function, including the Star Excursion rehabilitation to aid in patients’ functional recovery. For more
Balance Test,22,25 shuttle run test,26,27 single leg hop for distance severe injuries requiring immobilization and protected weight
test,28 triple hop test for distance,28 and crossover hop test for bearing, we typically limit immobilization to approximately
 CHAPTER 14  Nonsurgical Treatment of Acute and Chronic Ankle Instability 251

TABLE 14.1  Run/Walk Rehabilitation sprains, and repeated giving-way episodes.29,30 Further, 20% of
Protocol patients continue to report symptoms of instability and pain at
even 5 years following an acute ankle sprain.31 In general, symp-
Run/Walk Ratio Number of Cycles toms are categorized as chronic if they persist beyond 6 months
15 seconds/45 seconds 4 from index injury and have failed appropriate nonoperative
30 seconds/60 seconds 4 management.32
1 minute/1-2 minutes 4 (building up to 4-10 minutes of Like acute ankle sprains, a careful history is fundamental to
total running)
an accurate diagnosis for those patients presenting with chronic
2 minutes/1 minute 5 (building up to 10-24 minutes
symptoms. For patients presenting with long-standing com-
of total running)
3 minutes/1 minute 8 (24 minutes of total running)
plaints, it is important to carefully understand the chief com-
4 minutes/1 minute 6 (24 minutes of total running) plaint, mechanisms of injury (in particular those that cause
6 minutes/1 minute 4 (24 minutes of total running) continued instability), current level of activity and disability, and
8 minutes/1 minute 3 (24 minutes of total running) the presence or absence or mechanical symptoms. In addition, it
12 minutes/1 minute 2 (24 minutes of total running) is imperative to understand what treatments patients have pre-
15-20 minutes continuous   viously received: specific note should be made to the duration of
running* rehabilitation and the types of modalities and exercises employed
*Increase 1-3 minutes per run until at goal distance during therapy. Studies indicate that, for many patients, chronic
ankle instability is likely the result of poor initial rehabilitation
following an acute injury.1 Physical examination, again, should
1 week. Patients requiring this are then reevaluated, and if there is be systematic and detailed. Ligamentous laxity—as assessed
no improvement in symptoms, we explore alternative diagnoses by the anterior drawer and talar tilt tests—can be more readily
(i.e., high ankle sprain, lateral process of the talus fractures). If no identified in patients with chronic instability given the lack of
other diagnosis is identified, immobilization will continue until ecchymosis and swelling seen in acute injuries. Furthermore,
the patient is able to tolerate weight bearing in a protective boot. the exam should note deformities33,34 including hindfoot varus,
For those patients that are able to enter into a rehabilitation proto- plantar-flexion of the first ray, and midfoot cavus as well as
col (either initially after the injury or after a period of immobiliza- those patients with generalized ligamentous laxity as calculated
tion and protected weight bearing), we reassess their rehabilitation by the Beighton score (Fig. 14.5).35 Weight-bearing radiographs
progression at approximately 4 weeks from injury. If there has not should be obtained, with attention paid to alignment to assess
been sufficient progression, we consider advanced imaging such for the presence of a radiographic cavovarus posture that may
as magnetic resonance imaging (MRI) to identify other pathology predispose to lateral ankle instability. MRI can be informative
that may be limiting recovery (i.e., osteochondral lesions of the to identify alternative sources of ankle pain including chondral
talus). A comprehensive list of potential diagnoses for the contin- lesions, peri-articular tendon tears, degeneration, sinus tarsi
ually painful ankle is beyond the scope of this chapter. injury, and impingement syndromes. Characteristic findings
of chronic ankle instability on MRI include abnormal ligament
thickness and ligament discontinuity, with wavy, attenuated lig-
CHRONIC ANKLE INSTABILITY
aments being the most common appearance.36
Approximately 40%–55% of patients with an ankle injury suf- Traditionally, chronic ankle instability has been attributed
fer from residual symptoms including persistent pain, recurrent to either mechanical or functional instability.37 Functional

A B C
Fig. 14.5  Patient with bilateral subtle cavus deformity. (A) The peek-a-boo heels and the prominent extensor
digitorum brevis muscle on the dorsolateral aspect of the foot seen on the frontal view (△). (B) varus posture
of the heel on the rear view. (C) Correction of the varus on the Coleman block. (From Ali Abbasian, Greg-
ory Pomeroy. The idiopathic cavus foot—not so subtle after all, Foot and Ankle Clinics 2013;18(4):629-642,
Fig. 2.)
252 SECTION 3  Anatomic Disorders in Sports

instability is viewed as the patient-reported sensation of insta- sprains wear prophylactic ankle support (tape or brace) for
bility that can be due to a variety of causes including impaired all practices and games.8,26,47,48 They also suggest that lace-up
proprioception and sensation,38 impaired neuromuscular firing braces, semi-rigid ankle braces, and traditional ankle taping are
patterns,39,40 or impaired postural control. Mechanical instabil- all effective in reducing the rate of recurrent ankle sprains in
ity, conversely, may be the result of pathologic ligament laxity, athletes.8,47,49,50
impaired arthrokinematics, synovial inflammation, and degen- For those patients who fail nonsurgical management, oper-
erative changes.37 While chronic instability, historically, has ative interventions can then be considered. Consensus opin-
been viewed as a dichotomous process (mechanical versus func- ion on the definition of failure of nonsurgical management for
tional), it is likely more a spectrum of disease with a subset of chronic ankle instability is not clearly defined in the literature.
patients displaying features of both mechanical and functional
instability. Tools like the Star Excursion Balance Test may aid Authors’ Preferred Treatment Approach for Chronic
in the assessment of patients with multidimensional instability. Ankle Instability
In general, chronic ankle instability due to predominantly Patients who present with long-standing ankle instability require
functional instability can be best managed initially through a detailed history, as discussed previously, to better understand
nonoperative measures.41 Patients with functional instability are what treatments they have undergone prior to presentation for
more likely to benefit from a structured program of rehabilitation care. Physical examination is fundamental to understand if there
than patients with mechanical instability. Such conservative man- is evidence of mechanical instability versus functional insta-
agement includes similar principles to those outlined previously bility (or a combination of both). Alignment evaluation is key
for acute ankle injuries; immobilization is typically not required, to uncovering underlying deformity that may be exacerbating
though. Evidence even suggests that through a structured func- instability. Advanced imaging is most helpful in understanding
tional rehabilitation program, 50% of patients with chronic ankle associated pathologies. For those patients with predominantly
instability can achieve satisfactory functional stability.42 functionally based instability without deformity or associated
As an adjunct to a rehabilitation protocol for ankle insta- pathologies, we recommend initially a rehabilitation program
bility, many patients will benefit from the use of an orthotic.43 as described above to target areas of deficit. If, after a reason-
While orthotics are frequently referred to as “arch supports,” an able course of therapy and consideration of other nonoperative
orthotic best suited to help a patient with chronic lateral ankle adjuncts such as orthotics, taping, or bracing, patients continued
instability will have more lateral hindfoot support and less “arch to report ankle complaints, we then discuss surgery. For those
support” so as to reduce varus force through the hindfoot and chronic patients with predominantly mechanically based insta-
ankle. Ideally the orthotic will provide more of a pronation bility, we may be more inclined to discuss the role for surgery
effect to the foot and resist excessive supination. There may earlier in the treatment algorithm. While a trial of nonoperative
need to be a cutout for the first metatarsal head to allow the treatment is a reasonable consideration, patients with significant
pronation from the lateral heel wedge. This type of orthotic will mechanical instability should be educated on the potential for
be most helpful in a patient with underlying hindfoot varus. The surgery. An informed discussion is key to these evaluations to
orthotic should not be used as a stand-alone method of treat- devise a treatment plan that follows the patients’ preferences.
ment for ankle instability but in combination with the estab-
lished rehabilitation protocol. Prevention
Patients with chronic lateral ankle instability may also con- Given how common ankle sprains are, injury prevention con-
sider taping or bracing as an additional mode of treatment. tinues to be a topic of great interest. Ankle injury prevention is
Taping has been shown to improve proprioception in normal of particular concern with the increase in sport specialization
subjects with baseline decreased proprioception,14 and bracing among adolescent athletes. Recent data from McGuine et  al.
has been shown to reduce the incidence of acute ankle injuries revealed that high school athletes with moderate and high sport
in high school football and basketball athletes.44,45 However, a specialization were more likely to sustain a lower extremity
meta-analysis by Raymond et al. suggested that in patients with injury than athletes with low sport specialization; ankle injuries
chronic lateral ankle instability, taping and bracing provided were the most common injury in this cohort.51 Further, ongoing
no benefit to proprioception. While studies are not in complete prospective trials are assessing the impact of preventive inter-
agreement regarding the efficacy of taping or bracing, patients ventions on musculoskeletal injuries including ankle sprains.52
often like it as an adjunct to treatment as they progress through The role of ankle taping in managing ankle instability has long
their rehabilitation protocol. There is often concern that reliance been a feature of treatment and injury prevention. While there
on taping or brace wear over time can weaken an ankle, leaving is data to suggest that ankle-taping programs may restrict
it more prone to injury. Corodova et al., however, suggested that extremes in ROM and improve muscle reaction time,53 there
the concern is not well founded when they demonstrated that is mixed evidence regarding its efficacy in ankle injury preven-
consistent use of a brace did not change the latency to inversion tion.54 However, there is reasonable evidence to suggest that
of the peroneus longus.46 ankle bracing55 and postural control exercises56 can decrease
As with use of an orthotic, taping and bracing should not be ankle sprain recurrence. More recently, the use of mobile appli-
used as a stand-alone treatment for chronic lateral ankle insta- cations to aid in ankle injury prevention have been proposed,57
bility. The National Athletic Trainers’ Association do, though, but clearly further work is necessary to determine how to best
recommend that athletes with a history of previous ankle reduce the burden of ankle injuries.
 CHAPTER 14  Nonsurgical Treatment of Acute and Chronic Ankle Instability 253

CONCLUSION 13. Johnson GB. Appendix 2. Athletic taping and bandaging. In:
Marc R, Safran DBM, Steven P, Van Camp, eds. Manual of Sports
Acute lateral ankle injuries are common and best treated ini- Medicine. Philadelphia, PA: Lippincott-Raven; 1998:635–641.
tially with an early rehabilitation program. A brief period of 14. Long Z, Wang R, Han J, Waddington G, Adams R, Anson J. Opti-
immobilization may be necessary in the initial treatment phase. mizing ankle performance when taped: effects of kinesiology and
This is followed by a regimented program of physical therapy athletic taping on proprioception in full weight-bearing stance. J
geared toward efficient recovery and return to sport. For those Sci Med Sport. 2017;20(3):236–240.
15. Bleakley CM, McDonough SM, MacAuley DC, Bjordal J. Cryo-
patients with continued ankle instability and chronic symptoms,
therapy for acute ankle sprains: a randomised controlled study
understanding how much of the instability is functional versus
of two different icing protocols. Br J Sports Med. 2006;40(8):700–
mechanical may help predict the likely effectiveness of further 705; discussion 5.
rehabilitation. However, this can be challenging, as some patients 16. Rucinkski TJ, Hooker DN, Prentice WE, Shields EW,
may present with features of both functional and mechanical Cote-Murray DJ. The effects of intermittent compression on
instability. Fortunately, most patients improve nonoperatively edema in postacute ankle sprains. J Orthop Sports Phys Ther.
after acute and chronic ankle sprains, and if they do not, there 1991;14(2):65–69.
are surgical procedures that can be helpful for these patients. 17. Tsang KK, Hertel J, Denegar CR. Volume decreases after eleva-
tion and intermittent compression of postacute ankle sprains
are negated by gravity-dependent positioning. J Athl Train.
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  Video 14.1 https://www.kollaborate.tv/link?id=5c9d1c7f4da0c Title: the anterior drawer and talar tilt exam. Radiographic evaluation of
Clinical and Radiographic Evaluation of Lateral Ankle Instability. chronic lateral ankle instability showing instability on anterior drawer
Legend: Clinical evaluation of the right ankle lateral ligaments utilizing and talar tilt test.

254.e1
 15
Ankle Sprains, Ankle Instability,
and Syndesmosis Injuries
Thomas O. Clanton, Jess Mullens, Jonathan Backus, Norman
Waldrop, III, Ana Robinson

OUTLINE
Introduction, 255 Medial Ankle Sprains, 261
Epidemiology, 255 Acute Medial Ankle Sprain, 261
Combination Injuries, 255 Chronic Medial Instability, 265
Lateral Ankle Sprains, 255 Syndesmosis Sprains, 266
Acute Lateral Ankle Sprain, 255 Acute Syndesmosis Sprain, 266
Chronic Lateral Ankle Instability, 257 Chronic Syndesmosis Sprain and Instability, 268
Failed Prior Surgery, 261 Rehabilitation, 269

INTRODUCTION Combination Injuries

Ankle sprains include those to the lateral ligament complex, the
Epidemiology deltoid complex, and the syndesmosis. Sprains of the lateral ankle
Despite attempts to reduce the incidence of ankle sprain inju- ligament complex generally comprise up to 85% of all sprains to
ries worldwide, ankle sprains continue to account for a large the ankle.8 It is important to realize that while this chapter is sep-
proportion of sport-related injuries as reported consistently in arated for discussion of these specific areas of injury, combina-
epidemiological studies.1–6 In the US population in general, the tion injuries occur and include multiple sprains, as well as other
incidence of ankle sprains was reported to be 2.15 per 1000 per- injuries including fractures, contusions, strains, tendon tears, car-
son-years with the peak incidence in ages 15–19 (7.2 per 1000 tilage injury, and tendon dislocations. Clearly, this requires a thor-
person-years). Almost 50% of those ankle sprains happened in ough evaluation of each patient to understand the mechanism of
athletic endeavors, with basketball, football, and soccer having injury, the severity and nature of the symptoms, and any history
the highest percentage of ankle sprain injuries among sports in of ankle problems. Coupling this with a detailed physical exam-
the United States.6 Hootman et al. reported that ankle sprains ination and appropriate imaging allows determination of the best
accounted for 15% of all injuries in 15 sports analyzed using treatment for the individual patient. Postinjury follow-up is also
National Collegiate Athletic Association (NCAA) injury sur- important, since persistent symptoms can exist in 32%‒74% of
veillance data from 1988–2004. They found ankle sprains to individuals with a history of lateral ankle sprain, and these symp-
have an incidence of 0.83 per 1000 athlete exposures (AEs) toms may continue beyond 10 years.9,10 A checklist of potential
compared with 0.15 per 1000 AEs for anterior cruciate ligament sources of continuing symptoms is valuable (Table 15.1).
(ACL) injury and 0.28 per 1000 AEs for concussions.7 Thus, an
ankle sprain is approximately five and a half and three times as
common in occurrence as an ACL or concussion, respectively!
LATERAL ANKLE SPRAINS
In an epidemiological study of ankle injuries in 255 coun- Acute Lateral Ankle Sprain
tries, Fong et  al. reported on 70 sports, with aeroball, wall Assessment
climbing, and indoor volleyball having the highest prevalence Approximately 70% of all lateral ankle sprains involve isolated ante-
of ankle injury, with ankle sprains accounting for over 50% of rior talofibular ligament (ATFL) injury.2 The ATFL is the weakest
the ankle injuries in 30 of the 43 studies where injury type was of the lateral ligament structures and is put under increased stress
defined.2 A systematic review and meta-analysis of prospective in the most common mechanism of injury, which is foot supina-
epidemiological studies was reported by Doherty et al. and con- tion with heel inversion while the ankle is plantarflexed. Pain and
cluded that higher risk for ankle sprain occurred in (1) females swelling are present followed by bruising, loss of motion, and diffi-
over males, (2) children over adolescents and adults, (3) court culty walking in more serious cases. The anterior drawer and talar
sports and indoor sports, and (4) lateral sprains over syndesmo- tilt tests signify instability when positive, and this may vary from
sis and medial sprains.1 mild to severe. A classification of lateral ankle sprains related to the

255
256 SECTION 3  Anatomic Disorders in Sports

severity of injury and magnitude of the above findings has been Nonoperative Treatment (see Chapter 14)
published and validated for time to recovery (Table 15.2). When nonoperative treatment is the chosen course, a comprehen-
Acute lateral ankle sprains are typically treated nonop- sive plan needs to be drafted that includes evidence-based inter-
eratively (see Chapter 14) in almost all circumstances.11 ventions. This includes functional rehabilitation with a supportive
Exceptions to this would include open injuries, large avul- ankle brace in Grade I and II injuries, while Grade III injuries are
sion fractures, or other associated pathology such as dislo- more controversial regarding functional treatment versus a short
cating peroneal tendons, an osteochondral fracture or loose period of immobilization in a walking boot or short-leg cast for
body, or a bimalleolar fracture equivalent, which would 10–14 days.15–17 Additional treatment includes rest, ice, compres-
essentially be a dislocated ankle that tears both medial and sion, and elevation method (RICE), antiinflammatory medication
lateral ligaments. Among the remaining controversies related (if there are no contraindications), physical therapy with supervised
to acute lateral ankle sprains is whether to operate when early exercise when possible, and crutches, but only when weight
faced with an athlete who clearly has a severe injury with bearing is not possible. In this latter situation, it is important to
major instability. Varying opinions can still be heard on this immobilize the ankle in neutral to slight dorsiflexion, or the ankle
topic.8,12–14 Another situation that stimulates discussion over will naturally assume a plantarflexed position and heal with the lig-
whether to operate is the athlete who has a history of signif- aments in an elongated state.18 Improvement in ankle dorsiflexion,
icant prior ankle sprains and then presents with a recurrent increased strength in the kinetic chain, manual therapy techniques,
severe sprain. This is the situation that requires a thorough and balance training have all been shown to have evidence-based
discussion with the patient to determine the best course of gains in ankle function and pain.16,19 Other treatments with less
action, and extenuating circumstances often play a role. In evidence include laser therapy, dry needling, vascular restriction,
other words, is this the correct time to repair what is clearly electrotherapy, vascular restriction, diathermy, and ultrasound.16
chronic lateral ankle instability? The majority of patients treated with evidence-supported methods
improve relatively quickly. According to the classification of acute
TABLE 15.1  Sources of Chronic Pain or lateral ankle sprains as Grade I, II, IIIA, or IIIB, full recovery aver-
Instability After Ankle Sprain ages 8, 16, 25, and 39 days, respectively.20 However, when this is not
Articular injury Impingement the case, further evaluation is warranted, particularly in the high-
  Chondral fractures Anterior tibial osteophyte level athlete where time loss is critical.
  Osteochondral fractures Anterior inferior tibiofibular ligament
Nerve injury Miscellaneous conditions
Operative Treatment
  Superficial peroneal Failure to regain normal motion (tight In the situation where surgical repair of the torn ligaments is
Achilles) necessary, it is important to define the tissues and repair them
  Posterior tibial Proprioceptive deficits anatomically whenever possible (Figs. 15.1 and 15.2).21 In the
 Sural Tarsal coalition acute situation, the injured tissues typically become immedi-
  Tendon injury Meniscoid lesions ately evident on opening the skin incision. It is important to
  Peroneal tendon (tear or Accessory soleus muscle assess all local structures including the articular cartilage of the
dislocation)
ankle joint, the anterior capsule, the deltoid ligament, the pero-
  Posterior tibial tendon Unrelated ongoing pathology masked
neal tendons, and superior peroneal retinaculum. At the same
by routine sprain
time, the surgeon should be protective of the superficial nerves.
Other ligamentous injury Unsuspected rheumatologic condition In severe sprains, which are essentially dislocations of the
 Syndesmosis Occult tumor ankle joint, one or more of these structures may be injured
 Subtalar Chronic ligamentous laxity (collagen and need repair. Ligaments torn in midsubstance are repaired
disease)
with sutures, while tears off bone or with a bony avulsion are
 Bifurcate Neuromuscular disease (Charcot-Ma-
rie-Tooth disease)
repaired with suture anchors. Newer methods of augmentation
 Calcaneocuboid Neurologic disorders (L5 radiculopathy, of repairs have been introduced and proven to be effective.22,23
poststroke) In cases of acute on chronic tears, tissue quality may be lacking
and repair with augmentation may be more critical to obtain

TABLE 15.2  Classification System of Lateral Ankle Sprains

Grade Clinical Tests Decreased ROM Edema Stress Radiographs Return to Sport (days)
I <5° <0.5 cm Normal 7.24 ±1.63
II + anterior drawer 5–10° 0.5–2 cm Normal 14.95 ± 2.1
IIIA + anterior drawer & talar tilt >10° >2 cm Normal 30.65 ± 3.07
IIIB + anterior drawer & talar tilt >10° >2 cm Joint laxity >3 mm 55.41 ± 4.92

ROM, Range of motion.

Modified from Malliaropoulos N, Papacostas E, Papalada A, Maffulli N. Acute lateral ankle sprains in track and field athletes: an expanded classifica-
tion. Foot Ankle Clin. 2006;11(3):497-507, Tables 3 and 4.
 CHAPTER 15  Ankle Sprains, Ankle Instability, and Syndesmosis Injuries 257

mm
mm 5.3
Inferior Tip Lateral 13.8 Inferior Tip Lateral
Malleolus Malleolus

mm
.8
17

Apex Lateral Talar Process

16
.3
m
4.4 mm m
Posterior Point
14.1 mm Peroneal Tubercle

Fig. 15.2  Position of the Calcaneofibular Ligament. Origin located

at an average of 5.3 mm from the inferior tip of the lateral malleolus
and insertion located 14.1 mm posterior to the posterior point of the
Fig. 15.1  Position of Single Band Anterior Talofibular Ligament. peroneal tubercle of the calcaneus and 4.4 mm superior. (From Clanton
Origin located at average distance from inferior tip of the lateral mal- TO, Campbell KJ, Wilson KJ, et al. Qualitative and quantitative anatomic
leolus of 13.8 mm (50% of the distance from the inferior tip to the investigation of the lateral ankle ligaments for surgical reconstruction
fibular anterior tubercle [anterior-most point of the fibula near the tibial procedures. J Bone Joint Surg Am. 2014 Jun 18;96(12):e98, with per-
plafond]). Insertion is located at average distance of 17.8 mm from apex mission “Courtesy of Thomas O. Clanton, MD”)
of the lateral talar process (61% of the distance from the apex of the lat-
eral talar process to the anterolateral corner of the talar trochlea). (From
Clanton TO, Campbell KJ, Wilson KJ, et al. Qualitative and quantitative BOX 15.1  Criteria for Progression—Phase
anatomic investigation of the lateral ankle ligaments for surgical recon-
struction procedures. J Bone Joint Surg Am. 2014 Jun 18;96(12):e98,
I—Range of Motion
with permission “Courtesy of Thomas O. Clanton, MD”) Clinical Finding or Test
1. Use objective outcome measures throughout recovery. Recommend
adequate stability versus reconstruction with a tendon auto- FAAM, FAOS, SANE, VAS scores.
graft or allograft or a tendon transfer (see next section).24–28 2. Little to no edema, recommend Figure of Eight method, ICC = 0.99 (Tatras–
Adams)
The rehabilitation program in these cases is very important
3. Symmetrical AROM and PROM
and is outlined in the section on rehabilitation (Boxes 15.1 to
4. Weight Bearing Lunge Test, achieve at least 50% as compared with unin-
15.3 and Tables 15.3 to 15.5). volved side. Measure distance of foot from wall in cm and tibial angle with
inclinometer. ICC = 0.96 to 0.99 (Konor et al.).
Chronic Lateral Ankle Instability 5. Demonstrate proper open chain muscle recruitment for all lower extrem-
Assessment ity musculature through full available range of motion. Patient can resist
Most patients with chronic lateral ankle sprains and instability increasingly difficult resistance bands × 15 reps through full ROM without
present with either recurrent ankle sprains or with the feeling of pain.
looseness in the ankle and the sensation of “giving way.” Patients 6. Demonstrate ability to perform short arch exercise in seated position, and
may complain of ankle pain, but it is not a requirement for this intrinsic flexion exercises (McKeon et al.)
diagnosis. The examination typically confirms the presence of a 7. Patient can ambulate with safe and appropriate gait pattern in boot with-
out crutches.
positive anterior drawer test and/or a positive inversion stress test.
Tenderness may be present, but often is more indicative of associ- AROM, active range of motion; FAAM, Foot and Ankle Ability Measure;
ated pathology, such as synovitis, an osteochondral injury, or ten- FAOS, Foot and Ankle Outcome Score; ICC, intraclass correlation
coefficient; PROM, patient reported outcome measure; SANE, single
donitis. The examiner must be thorough enough to rule out other assessment numeric evaluation; VAS, visual analog scale (for pain).
sources of symptoms (Table 15.1), because the clinical diagnosis Tatros-Adams D, McGann SF, Carbone W. Reliability of the fig-
of chronic lateral ankle instability has been associated with the ure-of-8 method of ankle measurement. J Orthop Sports Phys Ther.
intraoperative findings of peroneal tendon pathology (tenosyno- 1995;22(4):161–163.
Konor MM, Morton S, Eckerson JM, Grindstaff TL. Reliability of three
vitis, tears, dislocation), anterolateral impingement lesions, ankle measures of ankle dorsiflexion range of motion. Int J Sports Phys Ther.
synovitis, intra-articular loose bodies, talar osteochondral lesions, 2012;7(3):279–287.
and medial ankle tenosynovitis.29 A comprehensive physical ther- McKeon PO, Hertel J, Bramble D, Davis I. The foot core system: a new
apy program should be initiated first. Symptoms often will resolve paradigm for understanding intrinsic foot. Br J Sports Med. 2015;49(5):290.
258 SECTION 3  Anatomic Disorders in Sports

with correction of the deficits in proprioception, strength, and results in patients who ultimately require surgery. Nonoperative
flexibility. This is specifically the case in patients with functional treatment also includes activity and/or shoe modification (e.g.,
instability.30,31 Regardless, preoperative therapy can improve the lateral heel wedge), an ankle-foot orthosis, and/or orthotic devices
incorporating a lateral heel wedge. Brostrӧm found that symptoms
BOX 15.2  Criteria for Progression—Phase of instability remained in 20% of his patients who were treated in a
II—Endurance conservative fashion, and this has been a consistent finding.18,32,33
Clinical Finding or Test Athletes may use a nonoperative approach to get through a season
1. Objective outcome measures score reassessed. but rarely consider this an acceptable long-term solution unless
2. Normal Gait pattern demonstrated at varied cadence on flat surface. their symptoms are minimal.
3. Foot Lift Test, demonstrate <5 errors during testing period (Linens et al.) Indications for surgical treatment include instability symptoms
4. Weight-Bearing Lunge Test, within 75% of uninvolved leg. and signs found in young to middle-aged, active individuals who
5. Standing Double-Leg Heel Raise, can demonstrate equal heel height. have not responded to a well-designed, nonoperative treatment
6. Double-Leg Squat, demonstrate proper technique. program. Radiographic criteria for surgical consideration include
7. Isotonic Single-Leg Leg Press: Achieve 50–60% of body weight × 15 reps an anterior drawer greater than 1 cm (or a side-to-side difference of
8. Demonstrate ability to perform seated towel curls with added weight,
>3 mm), and a talar tilt greater than 15 degrees (or a side-to-side dif-
pulling weight equal to capability of uninvolved side
ference of >10 degrees) as guidelines, but in general, the symptoms
Linens S, Ross S, Arnold B, Gayle R, Pidcoe P. Postural-Stability tests and signs are most critical.34 An in-office mini C-arm is a conve-
that identify individuals with chronic ankle instability. J Athl Train. nient tool to confirm radiographic instability. Contraindications to
2014;49(1):15–23. https://doi.org/10.4085/1062-6050-48.6.09. surgery include other causes of instability (collagen diseases, tarsal
coalitions, neuromuscular diseases, neurologic disorders, or func-
BOX 15.3  Return-to-Sport Criteria tional instability), older patients with sedentary lifestyles, patients
1. Criteria for progression met. If any goals are not achieved, this is reviewed with serious medical conditions that would preclude anesthesia
and discussed with rehabilitation team and physician. and major surgery, circulatory impairment, presence of ongoing
2. Subjective outcome measure reassessed; progress suggests return-to-sport infection, lateral ankle pain without documented lateral instability,
readiness. SANE score >93%. history of complex regional pain syndrome, or degenerative arthri-
3. Athlete reports he/she has resumed preinjury training volume. tis. A relative contraindication is failure of the patient to participate
Return to practice noncontact × 1 week
in a preoperative rehabilitation program.
Return to practice contact × 1 week
Ankle arthroscopy is warranted before ankle stabilization.
Return to game play, progressively working up to preinjury position time of
play. Chondral injury is the most common problem discovered at
arthroscopy, with almost 30% of acute ankle injuries and 95%
SANE, single assessment numeric evaluation. of chronic ankles having this lesion in one study of an athletic

TABLE 15.3  Overview of Rehabilitation Orders: Ankle Stabilization Procedures

Syndesmosis Repair,
ATFL and CFL Syndesmosis Deltoid Repair and
Brostrӧm Repair + Reconstruction With Repair of AITFL Fibular ORIF (no
Procedure(s) Brostrӧm Repair InternalBrace Allograft and Tight Rope cartilage injury)
Range-of-Motion No inversion or plantarflexion • Full active, pain free • Full active, pain-free range None No eversion × 6 weeks
Precautions × 6 weeks range of motion of motion
• No passive inversion • No passive inversion × 6
× 6 weeks weeks
Weight-Bearing • Splint × 7–10 days • Splint × 7–10 days • Splint × 7–10 days
Orders • When out of splint, • When out of splint, PWB → FWB over 2-week period • NWB × 4 weeks
PWB → FWB over 4-week • Walk in boot without crutches, no pain or swelling for 5–7 days, then: unless specified by
period • Wean out of boot as tolerated surgeon
• Walk in boot without • After 4 weeks, PWB
crutches, pain, or swelling to FWB over 2–4 week
for 5–7 days , then: period as tolerated
• Wean out of boot over • Once FWB in boot
2-week period × 5–7 days without
crutches, no pain or
swelling then:
• Wean out of boot × 2
weeks
Return to Sport • Must pass all criteria for progression (Boxes 15.1-15.3 and Tables 15.4-15.5)
• Outcomes measures match clinical findings
• MD clearance for noncontact practice granted (Table 15.3)
AITFL, Anterior inferior tibiofibular ligament; ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; FWB, full weight bearing; NWB,
Non-weight bearing; PWB, partial weight bearing; ORIF, open reduction internal fixation.
 CHAPTER 15  Ankle Sprains, Ankle Instability, and Syndesmosis Injuries 259

TABLE 15.4  Criteria for Progression—Phase III—Strength

Clinical Finding or Test
Subjective outcome measure reassessed.
Patient can demonstrate ability to maintain proper arch posture in single leg tasks.

Test Passing Score Notes

Weight Bearing Lunge Test Symmetry to uninvolved side, within 5* or 1.5 cm ICC = 0.96 to 0.99 (Konor et al.)
Heel Raise Endurance Test Within 90% of uninvolved side, recorded in successful ICC = 0.97 (Sman et al.)
repetitions
Single Leg Squat Endurance Test Within 90% of uninvolved side, recorded in repetitions ICC = 0.95–1.0 (Garrison et al.)
Y Balance Test Composite score above 90% ICC= 0.85–0.93 (Shaffer et al.)
Anterior reach within 4 cm of uninvolved side
Isotonic Leg Press Within 90% of uninvolved 3 × 5 reps

ICC, intraclass correlation coefficient.

Konor MM, Morton S, Eckerson JM, Grindstaff TL. Reliability of three measures of ankle dorsiflexion range of motion. Int J Sports Phys Ther.
2012;7(3):279–287.
Sman AD, Hiller CE, Imer A, Ocsing A, Burns J, Refshauge KM. Design and reliability of a novel heel rise test measuring device for plantarflexion
endurance. Biomed Res Int. 2014;2014:391646. https://doi.org/101155/2014/391646.
Garrison JC, Shanley E, Thigpen C, Geary R, Osler M, DelGiorno J. The reliability of the vail sport test™ as a measure of physical performance
following anterior cruciate ligament reconstruction. Int J Sports Phys Ther. 2012;7(1):20–30.
Shaffer SW, Teyhen DS, Lorenson CL, et al. Y-balance test: a reliability study involving multiple raters. Mil Med. 2013;178(11):1264–1270.

TABLE 15.5  Criteria for Progression—Phase IV—Power and Agility

Clinical Finding or Test
Pick Appropriate Test(s) from each category related to patient’s sport. Not all tests need to be performed.
Subjective outcome measure reassessed. Progress suggests return to sport readiness. SANE score >93%.

Test Passing Score Notes

Single hop for distance Within 90% of uninvolved side ICC = 0.92–0.97 (Ross et al.)
Triple hop for distance ICC = 0.84–0.98 (Kockum et al.)
Square Hop Within 90% of uninvolved side, measured in seconds Square Hop: ICC = 0.90
Figure of 8 Hop SEM 1.40 sec MDC 3.88 sec
Side Hop Side Hop: ICC = 0.84 SEM 2.10 sec MDC 5.82 sec
Cross-Over Hop 6 Meter Cross Over Hop: ICC = 0.6
SEM 0.37 sec MDC 1.03 sec (Caffrey et al.)
MAT Test Within 90% of uninvolved side, measured in seconds ICC = 0.825 (Hickey et al.)
Modified T Test

ICC, intraclass correlation coefficient; SANE, single assessment numeric evaluation; SEM, standard error of the mean; MDC, minimal detectable
change, MAT, modified agility T Test.
Ross MD, Langford B, Whelan PJ. Test-retest reliability of 4 single-leg horizontal hop tests. J Strength Cond Res. 2002;16(4):617–622.
Sman AD, Hiller CE, Imer A, Ocsing A, Burns J, Refshauge KM. Design and reliability of a novel heel rise test measuring device for plantarflexion
endurance. “https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4022004/“. Biomed Res Int. 2014;2014:391646. https://doi.org/101155/2014/391646.
Caffrey E, Docherty CL, Schrader J, Klossner J. The ability of 4 single–limb hopping tests to detect functional performance deficits in individuals
with functional ankle instability. J Orthop Sports Phys Ther. 2009;11:799–806.
Hickey KC, Quatman CE, Myer GD, Ford KE, Brosky JA, Hewett TE. Methodological report: dynamic field tests in an NFL combine setting to iden-
tify lower extremity functional asymmetries. J Strength Cond Res. 2009;23(9):2500–2506.

population.35 The value of ankle arthroscopy in discovering and in 1966.40 It has taken almost five decades for the accumulation
treating chondral injury, loose bodies, osteophytes, and soft- of scientific evidence to cast doubt on the tenodesis procedures
tissue impingement has been confirmed in several studies.36–39 described by Evans, Watson-Jones, Larsen, and Chrisman and
Not only is this important for recognizing and treating additional Snook.41–45 The following discussion focuses on the anatomic
pathology, but it is also helpful in discussing prognosis with the procedures, whether by direct repair in the tradition of Brostrӧm
patient following surgery. or by using tissue transfer or tissue grafts placed anatomically.
Brostrӧm described his anatomic repair as a delayed procedure
Operative Treatment for chronic lateral ankle instability. The procedure is a straightfor-
Similar to the surgical history of shoulder and knee instabil- ward division and imbrication of the anterior talofibular ligament.
ity, more anatomic reconstructions have gained popularity for The calcaneofibular ligament was not addressed in his original
ankle instability. This began with secondary repair of the previ- description, and others have since indicated that ATFL second-
ously injured anterior talofibular ligament by Lennart Brostrӧm ary repair alone is adequate.46,47 Various modifications have been
260 SECTION 3  Anatomic Disorders in Sports

Fig. 15.5  Drawing depicting the position of an InternalBrace over the

top of an anterior talofibular ligament secondary repair with suture
anchors in the fibula. (From Arthrex Inc. with permission)
Fig. 15.3 Stretched anterior lateral ligaments found in typical chronic
ankle sprains. (Courtesy Matthew Morrey, MD)

Fig. 15.6  Intraoperative picture of an InternalBrace (IB) anchored into

talus (T) and fibula (F) over the top of a repaired anterior talofibular liga-
Fig. 15.4  Imbrication of stretched ligaments in anatomical reconstruc- ment. The IB acts as a checkrein over the repaired ligament and not as
tive procedure. (Courtesy Matthew Morrey, MD) an artificial ligament. (Courtesy Thomas O. Clanton, MD)

described, the most popular being a reinsertion into a bony trough, tissue (Figs. 15.5 and 15.6) The calcaneofibular ligament (CFL)
imbrication of the calcaneofibular ligament, reinforcement with is also imbricated when it is loose. This is performed most fre-
the inferior extensor retinaculum, and, more recently, the use of quently by reattaching the CFL to the distal fibula 5 mm anterior
suture tape augmentation.25,48,49 Other authors have described the to the inferior tip of the fibula with a suture anchor. The CFL can
use of different graft sources to rebuild the lateral ankle ligaments often be intact visually as well as on magnetic resonance imaging
while emphasizing the anatomic placement of bone tunnels. Graft (MRI) but on direct inspection can be confirmed to be stretched
sources have included the plantaris tendon, the split peroneus bre- or attached to periosteum of the distal fibula that has become
vis tendon, hamstring tendons, and allograft tendons. disengaged from the distal fibula. The authors feel that including
Our preferred method when adequate tissue is available is the secondary repair of the CFL ensures that talar tilt ankle stability
Brostrӧm-Gould procedure repairing the ATFL with sutures or will be restored along with subtalar stability when that pattern of
suture anchors (Figs. 15.3 and 15.4) followed by placement of instability is present. Tightening the inferior extensor retinacu-
an InternalBrace that acts as a checkrein to protect the healing lum adds an extra degree of stability to the repair (Fig. 15.7).50,51
 CHAPTER 15  Ankle Sprains, Ankle Instability, and Syndesmosis Injuries 261

ATFL arm of allograft tendon

anchored with interference
fit screws in talus and fibula.

Graft passed through fibular tunnel

to origin site for CFL, marked for
length in calcaneal tunnel prior to
cutting excess and passing into
calcaneus with Beath pin and fixing
with interference fit screw.

Fig. 15.9  Intraoperative picture showing the graft in the talar and fibu-
lar tunnels prior to suturing with Krakow stitch, cutting excess tendon
length, and passing graft into calcaneal tunnel and fixing with interfer-
ence screw. (Courtesy Thomas O. Clanton, MD)

Fig. 15.7  Imbrication of inferior extensor retinaculum to periosteum of

distal fibula. (Courtesy Matthew Morrey, MD)

Fig. 15.8  Drawing depicting the position of the tendon allograft passing
through tunnels in the talus, fibula (2 fibular bone tunnels denoted by
dashed lines), and calcaneus with fixation using bioabsorbable interfer-
ence fit screws. (From Arthrex Inc. with permission)
Fig. 15.10  Anterior-posterior x-ray of suture-button used to fix revision
In the circumstance where no adequate tissue is available for allograft into fibula of small patient with prior secondary repair with
repair, a tendon graft (autograft or allograft) or tendon transfer bone anchors. (Courtesy Thomas O. Clanton, MD)
can be effective (Figs. 15.8 and 15.9).24,26,28
have been used, it is critical to evaluate their location and size
Failed Prior Surgery to determine the best method to address placement and fixa-
The results of surgical treatment of chronic lateral ankle tion of the graft or tendon transfer. Understanding anatomical
instability are generally above 90% regardless of the method. landmarks from a radiographic standpoint can be helpful, along
However, there are isolated cases where the surgery fails either with computed tomography (CT) imaging.52
due to reinjury or mechanical breakdown of the previous fix-
ation. Nonanatomic reconstructions will typically stretch out MEDIAL ANKLE SPRAINS
over time or will over-constrain the joint, leading to stiffness,
which may be unacceptable to the patient. These are the situ- Acute Medial Ankle Sprain
ations most suited to reconstruction with a tendon graft or a The deltoid ligament is injured in up to 15% of all ankle
tendon transfer, and the authors prefer the former. The graft is sprains.53,54,55 Injuries to the medial ankle ligamentous complex
placed into an anatomically oriented tunnel(s) in the fibula and rarely occur in isolation. Broström’s original study reported on
fixed with an interference fit screw(s) or suture button (Figs. 105 ankle sprains and showed only three cases of isolated medial
15.10 and 15.11). Since previous hardware or bone tunnels may ankle sprains.56 The majority of deltoid ligament injuries occur in
262 SECTION 3  Anatomic Disorders in Sports

Tibiocalcaneal Ligament

Posterior Superficial
Tibiotalar Ligament
Tibiospring Ligament
Deep Posterior
Tibionavicular Ligament
Tibiotalar Ligament

Fig. 15.12  Drawing of medial left ankle depicting the superficial com-
ponents of the deltoid ligament. (From Campbell KJ, Michalski MP,
Wilson KJ, et al. The ligament anatomy of the deltoid complex of the
ankle: a qualitative and quantitative anatomical study. J Bone Jt Surg.
Fig. 15.11  Lateral x-ray of endobutton used to fix revision allograft into 2014;96(8):e62-e62.)
fibula of small patient with prior secondary repair with bone anchors.
(Courtesy Thomas O. Clanton, MD)

association with lateral malleolus fractures, syndesmosis injuries,

injuries to the lateral ligament complex, and/or damage to the
articular cartilage surfaces of the tibiotalar joint.57 In a study of
1206 West Point cadets, isolated medial ankle sprains accounted
for 5.1% of injuries. Males had a three times greater risk of medial
ankle sprains than females.55 Diagnosis of deltoid ligament tears
in complex ankle injuries have increased due to use of arthros-
copy and advanced imaging studies. These injuries can be missed
with history and physical examination alone.55,58,59 A study of
NCAA collegiate athletes reported 380 deltoid ligament injuries
over a 6-year period.60 In their study, men’s football and men’s and
women’s soccer had the highest rates of deltoid ligament sprains.
Player contact was the most common mechanism of injury,
occurring in nearly 50% of athletes.
Fig. 15.13  Photograph of cadaveric dissection depicting the superficial
Assessment components of the deltoid ligament. (From Campbell KJ, Michalski MP,
Wilson KJ, et al. The ligament anatomy of the deltoid complex of the
As stated previously, concurrent injuries are common with inju- ankle: a qualitative and quantitative anatomical study. J Bone Jt Surg.
ries to the deltoid ligament. The history and mechanism of injury 2014;96(8):e62-e62.)
can lead the clinician to an accurate differential diagnosis, but an
examination of the entire leg is essential to rule out associated can reveal an increasingly flat foot or pronated foot deformity
injuries. The entire length of the fibula should be palpated to rule that is actively correctable with contraction of the posterior tibial
out a high fibula fracture or proximal tibiofibular injury as seen muscle. A sensory examination, with a Tinel’s test, can identify
in a Maisonneuve-type injury. A squeeze or external rotation test traction injuries to the saphenous or posterior tibial nerve.
can be performed to help rule out an acute syndesmosis injury. Radiographs are important in the evaluation of an injury to
The lateral ligaments should each be examined carefully with the deltoid ligament, especially in the setting of a fibular frac-
an anterior drawer and talar tilt test, keeping in mind that ante- ture and/or a syndesmotic injury. A small avulsion fracture of
rior instability relies on the secondary restraints of the deltoid the tip of the medial malleolus can be seen on standard ante-
ligament. A thorough understanding of the anatomical location rior-posterior (AP), oblique, and/or lateral radiographs (Figs.
of the medial ankle structures is necessary to locate the point of 15.16 and 15.17). If the history and physical examination are
maximum tenderness (Figs. 15.12 to 15.15).61 Individual palpa- suggestive of a more proximal injury to the lower leg, supple-
tion, range of motion, and excursion of the posterior tibial, flexor mental radiographic views of the leg should be obtained to rule
digitorum longus, and flexor hallucis longus tendons should out any pathology proximal to the ankle.
be performed along with assessment of the spring ligament. A While a weight-bearing AP ankle radiograph can reveal
standing examination with assessment of the longitudinal arch valgus tilt of the talus in a complete deltoid rupture, manual
 CHAPTER 15  Ankle Sprains, Ankle Instability, and Syndesmosis Injuries 263

Deep Anterior Tibiotalar Ligament

Deep Posterior Tibiotalar Ligament

Fig. 15.14  Drawing of medial left ankle depicting the deep components of
the deltoid ligament. (From Campbell KJ, Michalski MP, Wilson KJ, et al.
The ligament anatomy of the deltoid complex of the ankle: a qualitative and
Fig. 15.16  Radiographic example of small avulsion of deltoid ligament
quantitative anatomical study. J Bone Jt Surg. 2014;96(8):e62-e62.)
with widened medial clear space. Arrow denotes the small bony avul-
sion. (Courtesy Thomas O. Clanton, MD)

Fig. 15.17  Radiograph of larger medial malleolar avulsion injury in elite

snowboarder. (Courtesy Thomas O. Clanton, MD)

Fig. 15.15  Photograph of cadaveric dissection depicting the deep com-

ponents of the deltoid ligament. (From Campbell KJ, Michalski MP, in patients without an associated fibular fracture.62 The exact
Wilson KJ, et al. The ligament anatomy of the deltoid complex of the amount of medial joint space widening on stress radiographs is
ankle: a qualitative and quantitative anatomical study. J Bone Jt Surg. a controversial topic, but most authors accept that greater than
2014;96(8):e62)
4 mm (or 1 mm greater than the superior tibiotalar joint space)
indicates an injury to the deltoid ligament.63,64
stress radiographs remain the gold standard for evaluating MRI has become more widely used for diagnosis of deltoid
medial ankle instability especially if an incomplete injury is ligament and associated soft-tissue injury. In the athlete with
present. The stress can be applied as manual external rotation signs and symptoms of a deltoid ligament sprain but with equiva-
stress or as a gravity stress. If the athlete has significant pain lent stress radiographs, an MRI can be useful to obtain an objec-
and guarding with external rotation stress, the gravity stress is tive confirmation of the diagnosis. However, MRI findings must
useful, though the validity of the test has not been confirmed be used cautiously, as MRI is highly sensitive and can demonstrate
264 SECTION 3  Anatomic Disorders in Sports

clinically insignificant changes in the medial ligamentous com-

plex.65 In a series of 36 patients with acute deltoid ligament inju-
ries evaluated with MRI, Jeong et al. showed that 58% of patients
had complex tears of the superficial and deep components of the
deltoid ligament after rotational ankle fractures. The tibionavicu-
lar ligament was the most commonly disrupted, occurring most
often at the anterior colliculus of the medial malleolus.66
Ankle arthroscopy is another alternative for diagnosis when
nonoperative treatment fails in the setting of possible deltoid
ligament injuries.59 Hintermann et  al. found that at least 40%
of 288 ankle fractures had deltoid ligament damage upon
arthroscopic assessment.67

Nonoperative Treatment
In general, isolated acute deltoid ligament ruptures are treated
nonoperatively. Treatment of athletes with isolated grade 1 Fig. 15.18  Clinical photograph of a torn and entrapped posterior tibial
and most grade 2 deltoid sprains is similar to the nonoperative tendon in a patient with a Weber C ankle fracture. (Courtesy Thomas
treatment of acute lateral ankle sprains, but return to play can be O. Clanton, MD)
more prolonged.55,68 Cold therapy and the use of a pneumatic
brace, walking boot, or rarely a walking cast is started as soon as a suture anchor 6 mm proximal to the inferior tip of the medial
possible. The athlete can be weight bearing as tolerated with the use malleolus.72 Jackson et al. used a Kessler-type suture tied over
of crutches, advancing weight as pain allows. Return to play can drill holes in the medial malleolus to repair an isolated, com-
be expected in 3 to 6 weeks depending on functional progression. plete rupture of the anterior deltoid in a football player.73
More severe grade 2 and grade 3 deltoid sprains can be Before an open deltoid repair, ankle arthroscopy is performed to
treated nonoperatively in a walking boot or cast if the mortise diagnose any associated injuries and evaluate the articular surface.
reduction is maintained on radiographs. Similar weight-bearing Once this is completed, the surgical repair of the deltoid ligament
progression can be used, but immobilization may be necessary begins with an incision made from 3–4 cm above the posterior
for 6 to 8 weeks to prevent external rotation or medial collapse edge of the medial malleolus paralleling the posterior tibial tendon
of the foot and allow healing of the deltoid complex, which can and extending to the talonavicular joint. The superficial and deep
include injury to the spring ligament. The foot and ankle are bands of the deltoid are inspected as well as the posterior tibial ten-
supported with a custom orthotic device upon return to sport. don. The deltoid is repaired anatomically using nonabsorbable or
slowly absorbable sutures. The deep deltoid is approximated before
Operative Treatment repairing the superficial structures. In the setting of an avulsion of
Proponents of surgical repair of the deltoid ligament in the ath- the ligament, or a short stump at the distal or proximal end, reat-
lete believe that nonanatomic healing may lead to persistent tachment with a suture anchor is preferable. The neurovascular
medial gutter pain, instability, and functional loss over the long bundle should be protected throughout the procedure.
term, with the potential for early arthritis.69 In a prospective, Postoperative care may be dictated by the associated injuries
randomized controlled study of 41 patients with supination- (fibular fracture, syndesmosis tear, etc.) rather than the deltoid
external rotation type 4 equivalent injuries, Rungprai showed repair. For the deltoid, the ankle is splinted for 7 to 10 days and the
that while there were no differences in functional outcome athlete is kept nonweight bearing. The athlete is then transitioned to
between casting and repair of deltoid ligament injuries, deltoid a boot or cast and remains nonweight bearing for another 3 weeks.
repair resulted in less medial-sided ankle pain and decreased At 4 to 6 weeks from surgery, the athlete starts a weight-bearing
medial clear space widening.70 Woo et al. showed in their retro- progression over 2 to 4 weeks based on radiographic evidence of
spective, comparative case series that patients undergoing syn- healing of any associated fracture. An ankle brace with a medial
desmotic fixation with deltoid repair had a significantly smaller arch support is advised for the first 6 months after surgery.
medial clear space and better outcome scores as compared with Limited research is available regarding treatment of deltoid
conservative treatment of the deltoid ligament at an average of ligament injury in the athlete. Such injury is usually reported in
17 months postoperatively.71 While there is controversy regard- studies of other injuries to the ankle. In a level 4 case series, Hsu
ing treatment of the deltoid ligament injury in well-reduced et al. reported on 14 NFL players treated with ankle arthroscopy
mortises, an entrapped deltoid ligament or posterior tibial with debridement, followed by fibular fracture fixation with plate
tendon (Fig. 15.18) preventing reduction of the ankle mortise and screws, syndesmotic fixation with suture-button devices,
requires an open medial ankle arthrotomy and repair of the del- and open deltoid complex repair with suture anchors. Offensive
toid ligament and/or the posterior tibial tendon. lineman was the most common position sustaining this injury
Numerous descriptions of deltoid ligament repair and recon- (9/14). All players returned to running and cutting maneuvers by
struction techniques can be found in the literature. These vary 6 months after surgery. Return to play was 86% for all players.69 In
based on the severity of the injury and surgical indications. another series of 61 deltoid ligament reconstructions performed
Hintermann et al. described approximation of the avulsed tibi- in the acute setting, Aljabi et al. reported that 100% of patients
onavicular and tibiospring portions of the deltoid ligament with returned to sports within 3.5 months postoperatively.70a In
 CHAPTER 15  Ankle Sprains, Ankle Instability, and Syndesmosis Injuries 265

general, athletes are unique in their ability to return to play, and

that may not always be the case among the general population, as
shown in the study by Hong et al., in which only 27% of patients
from the general population with rotational ankle fractures were
able to return to their preinjury athletic activity.74
Currently, it is unclear whether surgical repair of a com-
plete deltoid rupture offers the athlete a quicker return to sport
when compared with conservative treatment. Further research
is needed to compare the long-term outcomes of nonoperative
treatment versus operative repair of deltoid ligament injuries,
particularly in the absence of fibular fracture and/or syndesmo-
sis injury. With the small numbers of isolated deltoid ligament
injuries and the confounding effects of associated injuries, it is
difficult to predict whether repair of the deltoid ligament leads to
decreased rates of chronic medial instability and posttraumatic
arthritis in the athlete. Nevertheless, it seems intuitive that if there
is clear injury to the deltoid ligament and instability is present,
repairing the deltoid and restoring stability offers the athlete a Fig. 15.19  Drawing depicting allograft tendon reconstruction of the del-
better chance of returning to their preinjury level of performance. toid ligament using a TightRope through a tibial tunnel with suture-but-
ton and/or interference screw fixation through talar and calcaneal
Chronic Medial Instability tunnels. (From Arthrex Inc. with permission)
Very few series of chronic deltoid injuries have been reported,
and none have specifically addressed the athletic situation.75,76 varying degrees of success. If these measures fail to achieve satis-
Hintermann et  al. arthroscoped 148 ankles for chronic instabil- factory results, surgical reconstruction is the next step.
ity and found a 40% incidence of deltoid lesions.76 All were asso-
ciated with a lateral ligament injury. The addition of arthroscopy Operative Treatment
contributed to a 10% higher diagnosis of medial instability than Two approaches may be used depending on the availability and
that determined by clinical diagnosis alone. Almost 100% of ankles quality of tissue apparent at surgery. If the tissues are of good
with deltoid ligament injuries had evidence of cartilage damage in quality, direct imbrication may be performed.77–79 A suture
contrast with 66% of the ankles with lateral ligament injury alone. anchor can be used to tighten the tibionavicular component of
the superficial deltoid and/or the deep deltoid ligament. In con-
Assessment trast, if the tissues are inadequate, an autograft or allograft tendon
Patients with medial instability usually have pain and tenderness can be used to reconstruct the deficient deltoid (Fig. 15.19).80–83
at the medial ankle. They generally exhibit increased heel valgus Hindfoot valgus is an indication to perform a medial dis-
when examined during weight bearing. Their ability to actively placement calcaneal osteotomy combined with the use of an
correct their heel valgus by contracting the tibialis posterior mus- allograft reconstruction technique to protect the reconstructed
cle is indicative of a deltoid injury.77 Valgus stress radiographs ligament and other medial structures. According to a finite ele-
usually show valgus instability of the ankle or medial clear space ment analysis of deltoid reconstructive techniques, no method
widening, but the AP and oblique weight-bearing views of the can fully restore the kinematics of the normal ankle with
ankle may show a decreased medial or lateral joint space. MRI is regard to flexibility and stresses on the ligament components.84
helpful in identifying deltoid pathology and visualizes the separate Evaluating the procedures used to date for chronic deltoid insta-
components of the superficial and deep deltoid. An arthroscopic bility reconstruction reveals no satisfactory long-term results,
method for grading medial ankle joint stability using probes or indicating a need for more work in this area.
shavers of varying size has been proposed by Hintermann et al.75 Two series of surgically treated chronic medial ankle insta-
The joint is considered stable if only a 2-mm probe or shaver bility include younger, more athletic patient populations.
can be passed into the medial gutter, moderately unstable with a Hintermann et al. reported on 51 patients with 52 ankles treated
5-mm arthroscope or probe, and severely unstable with opening for medial ankle instability. Patients had an average age of 36
greater than 5 mm and visualization of the posterior ankle joint. years (range, 16−60) and their average follow-up was 4.43 years
(range 2−6.5 years).77 In 49 of the 52 cases the deltoid was reat-
Nonoperative Treatment tached and imbricated utilizing sutures and suture anchors.
Conservative treatment of chronic deltoid instability includes Three patients were treated with reconstruction using a plan-
various methods for specific goals: (1) reduction of inflam- taris tendon autograft. A calcaneal osteotomy was performed
mation through oral or topical medications, physical therapy in the 14 patients with more severe deformity. Results were
modalities, and immobilization; (2) stabilization of the ankle good to excellent in 46 cases (90%). In the only other series of
with taping or bracing; (3) improving the foot and ankle posi- younger individuals with chronic deltoid instability, Buckhorn
tion through use of inserts or orthoses; and (4) strengthening the et al. reported a series of combined medial and lateral ankle lig-
surrounding musculature to help stabilize and protect the ankle ament reconstructions in 81 patients. There was no indication
joint. Normally, a combination of these methods is utilized with of the exact number and level of athletes, but the mean age was
266 SECTION 3  Anatomic Disorders in Sports

32 years (range, 14−44) with 1 year follow-up.79 The authors BOX 15.4  Classification of Traumatic
commented that they felt that professional athletes, in particu- Syndesmotic Disorders
lar, needed medial side stabilization along with lateral ligament
reconstruction in cases of rotational instability. Acquired: Traumatic
Not only is there a deficiency in level 1 and 2 studies on A. Acute
1. Sprain without diastasis
chronic deltoid instability; there are no long-term studies of
2. Latent diastasis
this condition and its surgical or nonsurgical treatment in
a. Stable, no deltoid injury, negative squeeze test
an athletic population. What is known is that it can occur in b. Unstable, deltoid injury and/or positive squeeze test, ± PITFL injury
association with lateral ankle instability and that medial imbri- 3. Frank diastasis (per Edwards and DeLee)
cation can be effective when there is good tissue and a well- Type I. Lateral subluxation without fracture
aligned foot. In other cases, there is no evidence-based answer. Type II. Lateral subluxation with plastic deformation of fibula
Considering that, the authors recommend reconstruction with Type III. Posterior subluxation/dislocation of fibula
an autograft or allograft tendon and a realigning calcaneal oste- Type IV. Superior subluxation/dislocation of talus into mortise
otomy. Potentially, there will be a role for augmentation using B. Subacute (3 weeks to 3 months)
an InternalBrace. When reconstruction is performed, resto- C. Chronic (longer than 3 months)
ration of the anatomic footprint of the deltoid ligament complex 1. Without tibiotalar arthritis
a. Without synostosis
is essential. A clear understanding of the anatomic locations of
b. With synostosis
the components of the superficial and deep components of the
2. With tibiotalar arthritis
deltoid, as well as their radiographic locations, can be valu-
able.61,85 If the deltoid heals in a nonanatomic fashion, this may Modified from Edwards GS Jr, DeLee JC. Ankle diastasis without
lead to worse clinical and functional outcomes in the short and fracture. Foot Ankle 1984;4:305-312; Clanton TO, Schon LC. Ath-
letic injuries to the soft tissues of the foot and ankle. In: Mann RA,
long term.86–89 Regardless, it should be recognized that this can Coughlin MJ, eds. Surgery of the Foot and Ankle, 6th ed, vol 2, St.
be a career-ending injury in a high-level athlete. Louis, Mosby; 1993, p. 1149, Table 27.6; Calder JD, Bamford R, Petrie
A, McCollum GA. Stable versus unstable grade II high ankle sprains:
a prospective study predicting the need for surgical stabilization and
SYNDESMOSIS SPRAINS time to return to sports. Arthrosc2016;32(4):634-642.

Acute Syndesmosis Sprain It can be useful when the radiographic signs from a weight-
Acute injuries to the syndesmosis continue to be challenging both bearing set of ankle radiographs are positive. Unfortunately, the
for diagnosis and treatment. Unlike a lateral ankle sprain, distal tendency toward self-reduction makes reliance on radiographic
tibiofibular joint injury, or a “high ankle sprain,” results in signifi- views and measurements unreliable for diagnosis unless they are
cantly increased disability and often requires surgical manage- very clearly positive.98 Even stress radiography and intraopera-
ment.90–94 Further confounding the subject is the frequent presence tive stress fluoroscopic imaging are often inaccurate. Diagnostic
of concurrent injuries such as fractures and deltoid injury. This sec- ultrasound is helpful but very dependent on the experience of the
tion will specifically deal with syndesmosis injury alone, although examiner.99 CT and MRI have emerged as the most accurate imag-
some of the principles of diagnosis, treatment, and return to sport ing methods, with MRI having 97% accuracy and the ability to
can apply to the other situations. Injury can occur both without a visualize individual ligaments.100,101 In the care of high-level ath-
fracture and without obvious diastasis.90,95 Due to the configura- letes, examination under anesthesia and ankle arthroscopy have
tion of the joint and elasticity of the tissues, spontaneous reduction become more commonplace for diagnosis and treatment.102–104
is common in less severe cases, and diastasis will not be apparent
initially. Advanced imaging technology and increased focus on this Nonoperative Treatment
topic in research journals and medical conferences has led to an In the acute injury, initial management includes rest, ice, com-
increased ability to diagnose this injury. However, treatment is con- pression, and elevation (RICE). The affected extremity should
troversial and evolving in terms of when to treat, how to treat, and be immobilized in a splint or CAM boot, the patient should
when to allow weight bearing and return to play. remain nonweight bearing, and the appropriate diagnostic
tests should be ordered. Treatment is based on a modified clas-
Assessment sification system of syndesmosis injuries (Box 15.4).34,105,106
An understanding of the mechanism of injury in syndesmosis Within the acute traumatic injuries are type 1—stable, which
sprains has become clearer due to high-grade videos of the injury can be treated nonsurgically. Patients are made weight bearing
in professional athletes, with most injuries demonstrating external as tolerated in a CAM boot or brace. Crutches are used if pain
rotation of the body and leg over the foot that is fixed on a surface. prevents weight bearing. Physical therapy can start when pain
Varying degrees of ankle dorsiflexion and load are contributing fac- subsides and weight bearing becomes easier. Expected time to
tors.90,96,97 If the athlete presents shortly after the injury, localized recovery for these patients in one of the West Point studies was 43
tenderness and swelling at the syndesmosis can be clearly defined. days, barring reinjury. Type 2—latent diastasis injuries have nor-
The physical examination is notable for being difficult without mal routine weight-bearing x-rays but are diagnosed by positive
using multiple parameters. These include an inability to hop, ante- stress x-rays. These are typically the most troubling to diagnose
rior inferior tibiofibular ligament (AITFL)-specific tenderness, a and treat, leading to a subdivision of type 2a which are stable,
positive dorsiflexion–external rotation stress test, along with pain have a normal deltoid, and a negative squeeze test. If confirmed
out of proportion to the injury and a positive squeeze test. by imaging to have an anatomically reduced syndesmosis, this
 CHAPTER 15  Ankle Sprains, Ankle Instability, and Syndesmosis Injuries 267

group of patients can be treated nonoperatively with cast or CAM BOX 15.5  Research Supporting Use of
boot immobilization for 2 to 4 weeks, careful weight-bearing Suture-Button Fixation of the Syndesmosis
progression, and gradual rehabilitation. Average return to play
(RTP) in this group is 6 weeks. Subtype 2b patients are unstable, 1. Suture-buttons allow triplanar motion.155
with a deltoid injury and/or a positive squeeze test, and may have 2. Suture-button system promotes self-reduction of the joint.156
3. Suture-buttons have faster rehabilitation and quicker return to work than
injury to the posterior inferior tibiofibular ligament (PITFL).106
screw fixation.157–162
This group typically takes longer to recover (average RTP is 9
4. Biomechanics studies and clinical studies show that suture-buttons provide
weeks). The authors have a low threshold for performing an the same stability as syndesmotic screws.163–166
examination under anesthesia and arthroscopy in athletes in this 5. Cost-effective solution because these implants rarely require removal.167–168
subtype, since we believe that there is more assurance that they 6. Syndesmotic screws experience improvement in symptoms and function
will heal with stability and earlier return to play, with less chance following removal.169
of time loss from a reinjury. Type 3 frank diastasis patients were
subcategorized by Edwards and DeLee into four different sub-
types of frank diastasis injuries: type I, lateral subluxation without clinical significance of this finding is still unknown.109–113 It is
fracture; type II, lateral subluxation with plastic deformation of critical to correct any external rotation deformity and confirm
the fibula; type III, posterior subluxation/dislocation of the fib- an anatomic reduction visually and radiographically, since this
ula; and type IV, transsyndesmotic dislocation of the talus—also correlates directly with improved outcomes.114,115 The only
called the “Logsplitter” injury.105,107 other reliable method to confirm reduction is the use of CT in
the operating room, with an O-ring system.116 We have used
Operative Treatment this technology, and believe it is accurate, but widespread uti-
Patients with latent (type 2b) or frank diastasis (type 3) are consid- lization is doubtful because of cost and radiation exposure to
ered unstable and are treated surgically if their medical comorbid- the patient and operating room personnel.
ities do not preclude surgery. The patient is taken to the operating If anatomical reduction cannot be obtained, a medial inci-
room as soon as the soft-tissue envelope allows. We prefer to sion is made over the deltoid ligament to remove any inter-
operate as soon as possible following the injury before the ankle posed tissue blocking reduction. In some cases, this tissue can
becomes massively swollen. If significant swelling is already pres- be identified arthroscopically and removed. Sutures or suture
ent when the patient is evaluated, it is best to wait until the swell- anchors are placed in the ruptured deltoid ligament but not
ing resolves (5 to 10 days) before operating. In the surgical care of tied. A second attempt at reduction is performed. If the fib-
acute syndesmosis injuries, we always utilize ankle arthroscopy ula still cannot be reduced in the incisura, the preoperative
to assist in the diagnosis and treatment. Using both anteromedial x-ray films and fluoroscopic views are reevaluated in younger
and anterolateral portals, the articular surfaces are inspected, and patients to see whether plastic deformation of the fibula might
a 3-mm probe or 2.9-shaver is used to confirm injury to the syn- have been missed. When present, this deformation requires
desmosis. Additionally, one can use a Freer elevator to actively that an osteotomy of the fibula be performed before stabilizing
stress the distal tibiofibular joint. Injury to the deltoid ligament the distal tibiofibular joint with a syndesmotic screw. Edwards
and the AITFL can be visualized and probed to confirm a tear. and DeLee recommend that the osteotomy of the fibula be
We place the lateral portal so that it can be incorporated into the performed proximally because of the instability of a distal
subsequent exposure of the anterior syndesmosis. This can then osteotomy with damage to the interosseous membrane.105
be used to place sutures or suture anchors for the torn AITFL Once anatomic reduction is achieved and held, a drill hole
and confirm an anatomical reduction of the syndesmosis. Since is made in the anatomic plane 1.5 to 2.5 cm proximal to the
the lateral branch of the superficial peroneal nerve is within mil- tibiotalar joint.117 Biomechanically, a screw or suture-button
limeters of this incision, careful dissection and gentle retraction placed 1.5 to 2.5 cm above the joint line results in less widening
are essential to avoid nerve injury. The distal tibiofibular joint is (compared with fixation placed more proximally) and will not
inspected after exposing the tear in the AITFL. Any ligamentous violate the synovial capsule or articular cartilage of the distal
tissue or debris in the tibiofibular space is removed. If there is an tibiofibular joint.118,119 It is our preference to use endobuttons
avulsed bone fragment from the anterior tubercle, it is evaluated for fixation in lieu of screws for several reasons (Box 15.5).
to determine whether it is large enough to take a screw without An additional suture-button is often placed 1 cm or one plate
fragmenting. If it is, a small screw, with or without a soft-tissue hole superior to the first in a divergent fashion aiming 15 degrees
washer, is used to reattach the fragment. If it is too small, the frag- posterior to the first implant when it is considered to be necessary
ment is excised, and the ligament is repaired with a suture anchor. for additional stability. Once the screws or suture buttons are in
An additional incision is made at the posterior edge of the place, any previously placed deltoid sutures are tied (if a medial
fibula just above the plafond to accommodate fixation and aid incision was necessary), and absorbable sutures are placed and
in reduction. The authors now perform the reduction manu- tied in the AITFL, as it contributes at least 24% of syndesmotic
ally, since this has been shown to be more likely to produce stability.120 When the tissue for the AITFL repair is of poor qual-
anatomic reduction than with clamp fixation.108,109 A syndes- ity and will not hold sutures, an InternalBrace is placed over the
mosis clamp is applied to hold that reduction while fixation anatomical location of the AITFL (Fig. 15.20).121,122
is secured; however, only one or two clicks are used with the If one chooses to use a screw, a fully threaded cortical screw
clamp, because multiple studies suggest that a syndesmo- that crosses four cortices is our recommendation, since this will
sis clamp overcompresses the tibiofibular joint, although the allow easier removal of a broken screw. Otherwise, based on
 268 SECTION 3  Anatomic Disorders in Sports

is based on the presence or absence of tibiotalar arthritis (Box

15.4). In many cases, these injuries have been treated conserva-
Anterior tubercle of fibula tively and the athlete is now complaining of residual pain from
at tibiofibular joint the prior injury. Sometimes this is from malreduction, while in
Anterolateral others the injury was missed altogether. Treatment depends
tibial tubercle on the findings and degree of pain and disability, but typically
requires surgical intervention.

Assessment
In patients who complain of symptoms from a syndesmosis sprain
for more than 3 months, it is important for the physician to have
a high index of suspicion. Advanced imaging, in addition to stan-
dard radiographs, is warranted. Both CT scan and MRI have a role
in the diagnosis and treatment of these patients. CT scan allows
better visualization of the position of the fibula within the distal
tibiofibular joint. It also allows the physician to better visualize the
presence of synostosis and the amount of heterotopic bone present.
CT scan has been shown to be more effective at finding patients
who have subtle diastasis, in particular when the widening was
3 mm or less above the normal upper limit of the tibiofibular
Fig. 15.20 Intraoperative image of anterior inferior tibiofibular liga- clear space of 6 mm.128,129 These cases of subtle diastasis are often
ment (AITFL) InternalBrace placed over repair of torn AITFL. (Courtesy missed on plain radiographs.129 Both angular and area measure-
Thomas O. Clanton, MD) ments taken with CT scan are reliable measurements and make
chronic malreduction of the fibula easier to identify.130 MRI also
available literature, there is no major difference in functional out- aids diagnosis and assessment of intraarticular pathology and has
comes between tricortical and quadricortical screws at 1 year, nor been proven to be a sensitive, specific, and accurate tool for the
is there a difference between titanium and stainless steel, one or diagnosis of chronic syndesmotic injury.131 One of the MRI find-
two screws, metal or bioabsorbable screws, or transsyndesmotic ings that can be useful in a chronic situation where the patient
and suprasyndesmotic fixation.123,124 The screw(s) may be placed has clinical findings indicative of injury to the syndesmosis is the
through a 3- or 4-hole plate with unicortical screws at the top and “Lamda sign” described by Ryan et al.132 Their study found this to
bottom, thus allowing removal of the syndesmosis screw(s) while be both sensitive (75%) and specific (85%) when judged by 2 mm
keeping the plate to protect the screw hole(s) during return to ath- diastasis seen on subsequent arthroscopy (Fig. 15.21). MRI is also
letics.125 Alternatively, an endobutton can be placed through one effective at determining the amount of inflammation present and
of the screw holes and can be left in place when the syndesmosis determining the amount of cartilage damage.
screw is removed. Fixation with the ankle in dorsiflexion has been
advocated to prevent overtightening of the syndesmosis, but this Operative Treatment
does not appear necessary with screws or suture-buttons.110,126,127 Ankle arthroscopy is the standard for visualizing the condition
Rehabilitation is covered in a later section for this con- of the entire ankle joint. Significant synovitis is expected in the
dition, but in general, patient care is individualized based on chronic setting and a “meniscoid-type” lesion is often seen with
the severity of the injury, the stability of the fixation, and the hypertrophic scar tissue filling the lateral gutter and syndesmosis
progress of the patient in reaching specific goals with therapy. from the initial injury. A probe or a shaver can be used to deter-
Most patients with syndesmosis injuries alone can be well stabi- mine if there is diastasis present. In many cases where the joint
lized, which can allow splinting until wound healing (typically is salvageable, debridement and reconstruction of the syndes-
7 to 14 days). Once the splint is removed, the patient can be mosis can be performed. In cases of chronic injuries with asso-
placed in a CAM boot and removed intermittently for range ciated cartilage pathology, the extent of damage becomes crucial
of motion. Progressive weight bearing can begin over a 2- to in determining whether microfracture (with or without use of
6-week period, guided by pain and function. A more aggressive biologics), autologous osteochondral transplantation, or fresh
alternative in a well-stabilized syndesmosis can be early use of a allograft transplantation may be needed. In more severe cases,
cold compression system (e.g., Game Ready) along with weight arthroplasty or arthrodesis may be necessary to relieve symptoms.
bearing as tolerated in a CAM boot with earlier return to sport Arthroscopic debridement of the joint has been used previ-
using taping, bracing, and potentially spatting the shoe. ously for treatment of chronic syndesmosis injuries. In one of the
original studies of this method, Ogilvie-Harris and Reed reported
Chronic Syndesmosis Sprain and Instability significant improvement in patients’ symptoms with debride-
Chronic syndesmosis injuries are classified as persistent widen- ment of the hypertrophied synovitic tissues within the joint.133
ing of the distal tibiofibular joint greater than 3 months old. These In a more recent prospective randomized trial of 20 patients, Han
chronic injuries can be sources of chronic pain and dysfunction. et  al. showed no difference in outcome scores in patients with
Such injuries can lead to poor outcomes and significant disability chronic syndesmosis injuries with arthroscopic debridement
for the patient. The classification of chronic syndesmotic injuries alone versus those with debridement and screw fixation.131
 CHAPTER 15  Ankle Sprains, Ankle Instability, and Syndesmosis Injuries 269

average follow-up of 41 months, mean American Orthopaedic

Foot and Ankle Society (AOFAS) scores increased from 37±15
Upside down
to 87±11. All associated deformities, such as fibular malunions
Lambda sign γ
and equinus contractures, were corrected at the time of the
index procedure.138 This study supported earlier findings by
Pena and Coetzee who also recommended arthrodesis for
patients with an injury older than 6 months, severe incongru-
ity, or a recurrence of diastasis after removal of fixation.139 The
authors thought this procedure should be reserved for low-de-
mand patients. Overcompression of the syndesmosis should
be avoided, as this creates a nonanatomic mortise, increasing
the risk of tibiotalar arthritis.
Chronic syndesmosis injuries are challenging injuries, and
a high index of suspicion is often necessary to discover the
correct diagnosis; advanced imaging is necessary for the cor-
rect diagnosis. Surgical options range from simple arthros-
copy and debridement to ligamentous reconstruction of the
entire complex. The degree of instability, the amount of dis-
placement, and the extent of the arthritis all play a role in the
decision-making process. Ultimately, restoration of normal
Fig. 15.21 Example of a magnetic resonance image with lambda sign anatomy with a stable, congruent joint is the goal. However, in
indicative of latent syndesmotic injury. (Courtesy Thomas O. Clanton, MD) some scenarios, this is unattainable, and viable salvage options
through arthrodesis or arthroplasty must be considered.
In many cases, reconstruction of the joint is necessary. The
goal remains restoration of the normal relationship between
the distal tibia and the distal fibula while stabilizing the
REHABILITATION
ankle mortise. Various techniques have been described. In Rehabilitation after surgical treatment of acute or chronic ankle
most cases, simple stabilization of the mortise after debride- instability related to ligamentous injury has evolved due to
ment of the medial gutter and the syndesmosis with either a changing surgical techniques described earlier in this chapter.
suture-button construct or screws is enough. In some cases, Physical therapy can be ordered earlier (as soon as the post-
however, more extensive reconstructive efforts are needed. operative dressing is removed), with a shorter time of limited
In cases where the previously ruptured AITFL is not use- weight bearing and less restriction on allowable range of motion
ful, autograft or allograft reconstruction is the best alter- (ROM) (Table 15.3).140–142 The benefits of early rehabilitation
native. Multiple techniques have been described. Grass are largely due to the process of mechanotransduction where
and colleagues described a peroneus longus ligmentoplasty cellular stress stimulates healing in bone, tendon, muscle, and
reconstructing the entire ligamentous complex with excel- cartilage, whereas longer periods of immobilization have been
lent outcomes in 16 patients who had resolution of symptoms shown to be detrimental to tendon-to-bone healing.143,144
1 year out from surgery.134 The technique was complicated, Communication between the therapist and surgeon should
and as a result, simpler techniques were devised. Morris et al. address any ROM restrictions to protect the repair, as well as any
described reconstruction with a hamstring autograft using other notable findings, such as quality of cartilage or concurrent
a two-tunnel technique with interference screw fixation. injuries noted during the arthroscopy. Manual techniques are
Excellent outcomes were achieved in this small cohort of recommended to improve joint mobility and reduce swelling and
patients.135 Lui described a minimally invasive technique uti- pain. Compression stockings are useful at least until the patient
lizing three tunnels and the peroneus longus tendon. There is fully weight bearing, if not through the endurance phase.
were no long-term outcomes reported for this technique.136 Rehabilitation after surgery has shifted to a criteria-based
Finally, Moravek and Kadakia used a double-limbed ham- progression (Boxes 15.1 and 15.2, and Tables 15.4 and 15.5) in
string allograft reconstruction of the syndesmosis in six lieu of earlier protocols driven by tissue-healing timelines. This
patients. In contrast to the previously described methods, gives the therapist the opportunity to treat the patient based on
this technique primarily reconstructs the interosseous liga- their own rate of recovery. The criteria have been generated from
ment (IOL) and is augmented with suture-button fixation. the available body of evidence related to lower extremity injury
No long-term follow-up was available.137 risk factors,145–148 tests that are effective in identifying deficits in
A final option for patients with chronic syndesmosis mal- those with foot/ankle dysfunction,149–154 and tests that are clini-
union or instability is arthrodesis of the distal tibiofibular joint. cally relevant, reliable, valid, and simple to perform.
While arthrodesis of this joint can be challenging to obtain, the The therapist is instrumental in recommending and man-
stability of the joint long term has been shown to be effective. aging load progression from initial weight-bearing phase
Olson and colleagues described debriding the distal tibiofibu- through to their preinjury training schedule. In the authors’
lar joint and fixating the arthrodesis with two 3.5-mm corti- experience, loading the patient too quickly can increase joint
cal screws placed in a lag fashion through four cortices. At an signs such as pain and swelling, but in the later phases are
270 SECTION 3  Anatomic Disorders in Sports

often reflected only in functional ROM loss (functional plan- 13. Renström PA, Konradsen L. Ankle ligament injuries. Br J Sports
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14. Malliaropoulos N, Papacostas E, Papalada A, Maffulli N. Acute
progression should be adjusted. Objective outcome measures
lateral ankle sprains in track and field athletes: an expanded
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 16
Osteochondral Lesions of the
Ankle and Occult Fractures
of the Foot and Ankle
Petros Frousiakis, Eric Ferkel, Richard Ferkel

OUTLINE
Introduction, 275 Chronic Injury Treatment, 296
Occult Fractures of the Hindfoot, 275 Authors Preferred Treatment, 297
Clinical Anatomy, 275 Acute, 297
Occult Fractures of the Calcaneus, 280 Chronic, 298
Sustantaculum Tali Fractures, 280 Osteochondral Lesions of the Talus Alternative Treatments,
Anterolateral Process of the Calcaneus Fractures, 282 298
Os Peroneum Avulsion Fractures , 283 Cartilage Replacement Strategies, 300
Occult Fractures of the Cuboid, 284 Future Cell Strategies, 305
Occult Fractures of the Talus, 285 The MIAMI Cell, 305
Talonavicular Avulsion Injures, 285 Metallic Cap Implant, 306
Posterior Talus Fractures/Posterior Impingement Osteochondral Lesions of the Tibial Plafond, 306
Syndrome , 286 Technique, 306
Lateral Process of the Talus Fracture , 288 Biologic Adjuvants to Cartilage Repair , 307
History and Incidence, 291 Platelet-Rich Plasma (PRP), 307
Mechanism, 292 Hyaluronic Acid, 307
Diagnosis and Evaluation, 293 Bone Marrow Aspirate Concentrate (BMAC), 307
Examination, 293 Bone Marrow–Derived Cell Transplantation, 307
Imaging, 294 International Consensus Meeting on Cartilage Repair of the
Classification, 294 Ankle, 308
Treatment, 296
Acute Injury Treatment, 296

INTRODUCTION the clinician in an accurate diagnosis. Often, further diagnostic

Fractures of the foot and ankle are a common occurrence in the testing, such magnetic resonance imaging (MRI) or computed
athletic population. Sometimes fractures may not be obvious tomography (CT) scans, can confirm a diagnosis.
on x-rays, and one must be on the lookout for occult fractures. Occult fractures of the hindfoot include anterior process of
Ankle fractures are approximately 7% of all sport-related frac- the calcaneus, talonavicular avulsion injuries, cuboid fractures,
tures,1 and as high as 11% in National Football League (NFL) navicular stress fractures, distal tibia or fibular stress fracture,
players evaluated at the combine.2 Disability due to foot and and calcaneal or talar stress fractures.
ankle stress fractures is a major source of injuries in athletes,
and is seen to be as high as 15% in the running population.1–3 Clinical Anatomy
The foot and ankle are comprised of 28 bones, multiple joints,
and connecting ligaments. The foot and ankle are vulnerable
OCCULT FRACTURES OF THE HINDFOOT to compression and avulsion injuries with many complex and
Occult fractures of the hindfoot are a significant and common diverse movements during competitive sports. The hindfoot
cause of injury and can often be misdiagnosed as a soft-tissue is made up of the tibia, fibula, talus, calcaneus, navicular, and
injury without having a high level of suspicion. In-depth knowl- cuboid. Often, the talus is prone to injury during athletics as it
edge of the anatomy, coupled with a thorough history and phys- moves through both dorsiflexion/plantarflexion and inversion/
ical examination, and a keen differential diagnosis will assist eversion motions. The talus is connected at the ankle joint to
275
276 SECTION 3  Anatomic Disorders in Sports

Deltoid ligament Fibula

Post. talofibular Ant. talofibular
ligament ligament

Talus

Calcaneus

Calcaneofibular
A B ligament
Fig. 16.1  Hindfoot anatomy of the ankle. Note the (A) medial attachment of the talus the tibia with the deltoid
and (B) laterally to the fibula with the anterior and posterior talofibular ligaments.

Cuboid
Navicular

Dorsal
talonavicular Plantar
ligament calcaneonavicular
“spring”
Interosseous Talus ligament Plantar
talocalcaneal
talonavicular
ligament
ligament
Calcaneus

Calcaneus
Cervical
ligament

A B
Fig. 16.2  Hindfoot anatomy of the subtalar joint. Note the attachment of the talus to the calcaneus via the
(A) talocalcaneal and cervical ligaments and the talus to the navicular via the (A) dorsal and (B) plantar talona-
vicular ligaments.

the tibia medially through the deltoid ligament (Fig. 16.1A) and ligaments connect the talus and navicular. Approximately 60%
to the fibula laterally through the anterior talofibular ligament to 70% of the talar surface is articular, with the ankle joint supe-
(ATFL) and posterior talofibular ligament (Fig. 16.1B). The pos- riorly, the talonavicular joint anteriorly, and the subtalar joint
terior talofibular ligament attaches at the posterior talus, on the inferiorly.4,5 Blood supply to the talus therefore is limited, com-
Stieda process (posterolateral) or os trigonum. ing from its ligamentous attachments and a leash of vessels sur-
The talus is connected to the calcaneus by the talocalcaneal rounding the talar neck that receive contributions from the artery
interosseous ligament and the cervical ligament (Fig. 16.2A). to the tarsal canal medially, the dorsalis pedis artery anteriorly,
The dorsal (see Fig. 16.2A) and plantar (Fig. 16.2B) talonavicular and the artery to the sinus tarsi laterally (Fig. 16.3A-C).4,6 The
 CHAPTER 16  Osteochondral Lesions of the Ankle 277

Dorsalis pedis artery

Artery to the sinus tarsi branches
Dorsalis pedis
artery

Peroneal
artery

Artery to the
tarsal canal

Artery to the sinus tarsi Artery to the tarsal canal

branches
Fig. 16.4  Internal vasculature anatomy of the talus.
Post. tibial
artery
A
Dorsalis pedis
artery

Lateral talar
process
Peroneal
Artery to the artery
sinus tarsi

B Ant. talofibular
Dorsalis pedis ligament
artery
Calcaneofibular
ligment
Post. tibial
artery Peroneal
artery

Talocalcaneal
ligament

Artery to the
C sinus tarsi B
Fig. 16.3  Vasculature supply anatomy for the talus. Note contributions Fig. 16.5  Anatomy of the talus. Note the (A) predominance of articular
from the (A-C) dorsal pedis artery, (A-C) peroneal (artery to the sinus surface and (B) laterally the attachment of the talocalcaneal ligament to
tarsi), (A) artery to the tarsal canal, and (A and C) posterior tibial artery. the lateral process.

internal vasculature of the talus varies considerably (Fig. 16.4).7 two processes: posterior and lateral. The lateral process of the
External athletic injuries to the talus that involve disruption of talus is a wide, triangular-shaped process that slopes down to
the vascular leash or the ligamentous attachments often produce meet the lateral calcaneus (see Fig. 16.5A). On the lateral view
vascular insult to the talar body or neck and may produce talar it is wedge-shaped and articulates superiorly with the fibular
fractures or compression injuries that have delayed healing. The surface and inferiorly with the calcaneus, forming the lateral
talus is unique in that it has no direct muscular attachments. It portion of the subtalar joint (see Fig. 16.5A). The lateral talocal-
has seven articular surfaces along with the head, neck, body, and caneal ligament attaches to the lateral process (Fig. 16.5B).
278 SECTION 3  Anatomic Disorders in Sports

FHL
Post. inferior
A tibiofibular
ligament
Transverse
ligament
B
Posterolateral Posteromedial
tubercle tubercle
Post. deltoid
ligament

Post. talofibular
ligament
Posteromedial
tubercle

Posterolateral
tubercle

FHL C
Fig. 16.6  Posterior anatomy of the talus. Note the (A) posterior process of the talus, the (B) flexor hallucis
longus between the two tubercles of the posterior talus, and (C) the posterior ligamentous anatomy.

The posterior process of the talus originates from the con- The saddle-shaped anterior surface articulates with the cuboid
vex-curved posterior half of the talar dome and slopes down anteriorly, and the superior tip articulates to a varying degree
and back to form the posterior talar ‘‘beak’’ or the Stieda process. with the lateral navicular. The extensor digitorum brevis also
Saraffian calls it the trigonal process.8 Inferiorly, it is concave and originates from this calcaneal process. The blood supply to the
articulates with the posterior subtalar facet of the calcaneus. The calcaneus is quite robust, and fractures of the calcaneus tend to
posterior process has both a posteromedial tubercle and postero- heal more easily than other fractures. The ligamentous attach-
lateral tubercle. In between lies the flexor hallucis longus, which ments at the calcaneus are the talocalcaneal interosseous liga-
is commonly involved in posterior talar injuries (Fig. 16.6). ment, lateral talocalcaneal ligament, and cervical ligament to
This posterior process is widely variable in shape, from a short, the talus and the calcaneofibular ligament laterally (Fig. 16.9).
rounded end to a long ‘‘beak’’ that is prone to injury. The posterior, lateral, and anterior calcaneocuboid ligaments
The posterolateral tubercle (Stieda’s process) is larger than and the plantar calcaneonavicular (spring ligament) and lateral
the posteromedial tubercle. In approximately 7% to 10% of calcaneonavicular ligaments connect the calcaneus anteriorly
humans a separate os trigonum may exist, connected to the to the cuboid and navicular, respectively. The strong plantar
posterolateral tubercle by a fibrous cartilaginous synchondrosis calcaneonavicular or ‘‘spring’’ ligament acts as a ‘‘sling’’ to hold
(Fig. 16.7A and B).9 The posterior talofibular ligament attaches the talar head in place. The bifurcate ligament (Y-ligament) is
the fibula, to the posterolateral tubercle, or the os trigonum (see composed of the anterior and lateral calcaneocuboid ligament
Fig. 16.7B). The posterior third of the deltoid or posterior talo- (Fig. 16.10A and B) and is commonly injured during ‘‘sprain-
tibial ligament attaches the posterior tibia to the posteromedial type’’ inversion injuries, producing an avulsion fracture at the
tubercle of the talus. The Y-shaped transverse or bifurcate talo- anterolateral process of the calcaneus. Inversion/adduction
calcaneal ligament is a thickening in the posterior ankle capsule injuries of the midfoot also may produce avulsion fractures at
that holds the two tubercles together and restrains the flexor the base of the cuboid.
hallucis longus (Fig. 16.8). Hallux saltans can develop at this The saddle-shaped cuboid forms the base of the lateral col-
site due to a stenosing tenosynovitis of the flexor hallucis longus umn and articulates with the anterior process of the calcaneus
that creates pain and triggering. and may be involved in either compression or avulsion ten-
The calcaneus is a complex, bony structure, the largest in the sion-type injuries. The peroneus longus tendon courses along
foot, providing attachment for the Achilles posteriorly and the the lateral border of the cuboid.
plantar fascia and plantar intrinsic muscles of the foot inferiorly. The tarsal navicular is a ‘‘C’’ or saucer-shaped bone articu-
It articulates with the talus superiorly, as well as with the cuboid lating with the talus posteriorly and the cuboid laterally. The
and navicular anteriorly. The peroneal tubercle is prominent dorsal talonavicular ligament and capsule can be injured in
laterally and serves as a point at which the peroneal longus and avulsion-type injuries of the navicular from plantarflexion-type
brevis tendon sheath separate. The anterolateral process of the injuries. Compression-type injuries also may be produced by
calcaneus extends forward to form the calcaneocuboid joint. the impact of the talar head on the navicular. The blood supply
 CHAPTER 16  Osteochondral Lesions of the Ankle 279

Synchondrosis

Flexor
hallucis
longus
Os trigonum
Os trigonum
A B
Fig. 16.7  (A) Lateral view. Anatomy of the os trigonum. Note that the os trigonum is the posterior process that
is attached to the talus via a synchondrosis and (B) is attached to the posterior talofibular ligament (axial view).

Fibula (B)
Tibia (A)
Posterior
Talofibular
Ligament (J)

(D) Talus

Posterior
Calcaneofibular Tibiotalar
Ligament (K) Ligament (H)

Lateral Medial
Talar Talar
Process (F) Process (E)

Posterior
Talocacaneal
Ligament (I)
Fibroosseus
tunnel for the flexor
hallucis longus tendon (L) Calcaneus (C)

Fig. 16.8  Anatomy of the posterior hindfoot, including the ankle and subtalar joint. a = tibia; b = fibula; C =
calcaneus; d = talus; e = medial talar process; f = lateral talar process; g = posterior tibiotalar ligament; h =
posterior talofibular ligament; i = calcaneofibular ligament; j = fibrous tunnel for passage of the flexor hallucis
longus tendon. (From Foot and Ankle Arthroscopy, 3e, Guhl, Boyden & Parissien, eds; Springer, 2004.)
280 SECTION 3  Anatomic Disorders in Sports

Fibula
Fibula Lateral
Talus calcaneonavicular
ligament
Talus
Navicular

Bifurcate Anterior
Calcaneofibular calcaneocuboid
ligament Calcaneus ligament
ligament

Interosseous Cuboid
Calcaneus talocalcaneal Cervical Long calcaneocuboid lig. Lateral
ligament ligament calcaneocuboid
Deep calcaneocuboid
ligament
A ligament

Fig. 16.9  Calcaneal ligaments. Note laterally the calcaneofibular, cervi-

cal, and lateral talocalcaneal ligaments.

Calcaneus
to the midportion of the navicular is poor (Fig. 16.11) and may
contribute to delayed healing or nonunion of such fractures.10
The articulation between the cuboid and the navicular varies Talus
from a true articulating joint to a fibrous connection to a bony
Long
bridge (tarsal coalition). Various important and powerful ten- CC
dons attach to the hindfoot; these produce considerable forces ligament
during athletic activities and can create injuries. The posterior
tibial tendon attaches to the navicular (Fig. 16.12A and B), pro- Deep
ducing inversion/supination and adduction while elevating the CC
ligament
arch. It fires twice during each gait cycle or step—both eccen- Lateral
trically as a shock absorber and concentrically during push-off. Spring CC
ligament ligament
The anterior tibial tendon, with attachments to the cuneiform
and first metatarsal, is the primary dorsiflexor for the ankle and
also inverts the foot. It also fires eccentrically during heel strike
to decelerate and cushion the landing foot. The peroneus brevis
and longus tendons (Fig. 16.13) both evert the foot and ankle
and resist inversion injuries. The peroneus brevis attaches to the Navicular
base of the fifth metatarsal. The peroneus longus wraps around Cuboid
the cuboid at the trochlea to insert broadly underneath the foot
near the base of the first metatarsal, which allows the longus
also to help plantarflex and stabilize the medial foot.
B
Fig. 16.10  Lateral plantar transverse tarsal ligaments.
OCCULT FRACTURES OF THE CALCANEUS Anterior
The majority of fractures of the calcaneus occur from high-
energy trauma, such as a motor vehicle accident or a fall from
height, but there are many commonly missed calcaneal frac-
tures and related injuries seen in the sporting population.

Sustantaculum Tali Fractures Lateral

Medial

Mechanism of Injury
Sustantaculum tali fractures are rare, extra-articular fractures
of the calcaneus. The sustantaculum tali is a medial projection
of the calcaneus that serves as an attachment of the plantar cal-
Posterior
caneonavicular ligament (spring ligament) and for the deltoid
ligament. It is also important in that the flexor hallucis lon- Fig. 16.11  Vasculature anatomy of the tarsal navicular. Note the cen-
gus tendon runs in a plantar groove of the sustantaculum tali. tral area of decreased blood supply corresponding to areas of navicular
Fractures of this can lead to subtalar joint discordance that can stress fractures.
 CHAPTER 16  Osteochondral Lesions of the Ankle 281

Long Peroneus
Post. plantar longus
tibial ligament tendon
tendon

Peroneus
brevis
Posterior tibial tendon
Tibia tendon

Talus

Navicular

Calcaneus

A B
Fig. 16.12  Posterior tibial tendon anatomy. Note the attachment to the medial navicular, medial cuneiform,
and lateral cuneiform that produces inversion, supination, and adduction.

Presentation and Physical Exam

The patient will often present with medial sided ankle pain,
swelling, and ecchymosis. One should assess the flexor hallucis
longus for direct trauma to the tendon or entrapment.

Imaging
Fibula Plain foot and ankle radiographs may show a normal Bohler’s
angle; however, a Harris axial x-ray can often assist with the
Peroneus diagnosis and show the fracture. CT is most useful to identify
Talus brevis the fracture displacement and determine the need for surgical
Navicular tendon
management.
Calcaneus
Cuboid
Treatment
Operative management of these fractures should be considered
5th met. in cases of any displacement.12 Open reduction internal fixation
of these fractures is best done with a direct medial approach and
Peroneus lag screw construct with a cannulated partially threaded screw
longus
tendon
fixation while protecting the FHL and neurovascular bundle.
Fig. 16.13  Anatomy lateral ankle depicting peroneus longus and brevis
tendons.
Rehabilitation and Return to Sports
Rehabilitation will usually consist of nonweight bearing in
possibly lead to subtalar joint and hindfoot stiffness, flexor hal- a splint or cast for the first month, followed by a boot and
lucis longus (FHL) entrapment, and medial sided ankle pain. nonweight bearing until 6 weeks postop. Thorough follow-up
Isolated fractures are rare but can occur with a direct trauma with axial Harris x-rays will allow one to determine union
or a fall onto an axial loaded, rotated foot and can be associated (or a CT scan if the plain imaging is inconclusive) and the
with a talus fracture.11 Misdiagnosis of this fracture can lead to a beginning of weight bearing. The athlete should focus on
nonunion, tarsal tunnel syndrome, chronic FHL impingement, joint mobilization and specifically focus on the FHL tendon
and progressive pes planovaglus deformity.12 to prevent adhesions.
282 SECTION 3  Anatomic Disorders in Sports

Fig. 16.15  Clinical photograph of right foot demonstrating area of hind-

foot that is tender with underlying anterior process fracture of calca-
neus.

Fig. 16.14 Diagram of right foot demonstrating supination and inver-

sion of hindfoot causing avulsion of anterior process of calcaneus with
tension on bifurcate ligament.

Anterolateral Process of the Calcaneus Fractures

Mechanism of Injury
The anterior process of the calcaneus makes up 23% of frac-
tures of the calcaneus.13 The injury occurs via an inversion
injury mechanism with the ankle in plantarflexion, which
can lead to an avulsion injury at the tip of the anterolateral
process through tension of the bifurcate ligament that con-
nects the anterior process to the cuboid and navicular (Fig.
16.14). A
A second injury mechanism is forced dorsiflexion, eversion,
abduction injury leading to a compression fracture of the ante-
rior process between the cuboid and talus.14

Presentation and Physical Exam

When an athlete presents with pain over the hindfoot following
a mechanism of injury as stated above, it is crucial to have a high
level of suspicion to avoid delayed diagnosis of the fracture.
Typically, the patient will present with ecchymosis and swelling
with tenderness 2 cm anterior and 1 cm inferior to the ATFL
(Fig. 16.15).14 Often pain may be produced by inversion stress
through the subtalar joint (distracting the fragment). There may
be instability of the transverse tarsal joint, which is tested by
holding the heel stable with one hand and pronating and supi-
nating the midfoot with the other hand (Fig. 16.16A and B). B
Fig. 16.16  Clinical photograph of right foot demonstrating assessment
Imaging of transverse tarsal instability by stressing the hindfoot in (A) supination
X-rays may present as negative if the fracture is nondisplaced. and (B) pronation.
If displaced, the fracture through the tip of the anterolateral
process of the calcaneus is best seen with the bean directed 20 A CT scan is useful to evaluate displacement of the fracture,
degrees superior and posterior to the midportion of the foot and in severe cases, the advanced imaging is necessary to plan
(Fig.16.17).15 for surgical management. (Fig. 16.18A-C)
 CHAPTER 16  Osteochondral Lesions of the Ankle 283

range of motion (AROM) of the foot and protected weight bear-

ing in the boot for an additional 4 weeks. General ankle rehabili-
tation then is begun, followed by sports-specific exercises.
Athletes with anterolateral process fractures treated by open
reduction internal fixation (ORIF) or excision and ligament
repair are placed in a nonweight-bearing boot for 6 weeks until
healed. They then begin general ankle rehabilitation followed by
sports-specific exercises. Return to sports usually occurs within
8 to 12 weeks.

OS PERONEUM AVULSION FRACTURES

(SEE ALSO CHAPTER 8)

Mechanism of Injury
Fig. 16.17  Lateral radiograph of hindfoot demonstrating small anterior Os perineum fractures are a rare but often overlooked diagnosis
process fracture (arrows) of calcaneus. in athletes that can be associated with complete rupture of the
peroneus longus tendon and requires a high index of suspicion.
The os peroneum is a sesamoid bone that can be found in the
Classification peroneus longus tendon, often found adjacent to the plantar-
Degan et al. proposed the following classification for fractures lateral aspect of the cuboid. It has been reported in 5% to 26% of
of the anterior lateral process of the calcaneus, which is useful in the population.17 It is important to recognize this injury early to
the diagnosis and treatment (Table 16.1).14 plan for management of an associated tendon injury.

Treatment Presentation and Physical Exam

Small nondisplaced fractures and those less than 2 mm can be Patients will often present after an inversion ankle injury with
treated in a cast and boot for 6 weeks of nonweight-bearing a swollen, painful, and occasionally ecchymotic foot and ankle.
management until the fracture has fully healed. Clinicians will observe point tenderness plantar-laterally along
In cases of chronic nonunion of the anterolateral process of the inferior lateral cuboid area and pain with inversion and
the calcaneus, asymptomatic athletes are treated with obser- eversion of the hindfoot.
vation only. For large fragments, greater than 1 cm or involv-
ing a significant portion of the articular surface, the fracture Imaging
site is debrided and internal fixation is applied. For smaller Plain x-rays will reveal a proximally migrated bony fragment
fragments, the fragment is excised. The calcaneocuboid joint that may be misread as a “benign” avulsion, or different acces-
is inspected and debrided if necessary. The bifurcate ligament sory ossicles. Radiographic features of an acute fracture of the
may be repaired back to the calcaneal process if any insta- os peroneum will demonstrate the presence of “cortical discon-
bility of the transverse tarsal joint exists (though this is not tinuity with nonsclerotic margins” and a “pieces of a puzzle”
common). appearance.18 A normal-appearing os perineum will appear as
For cases of malunited fractures, arthritic changes in the an oval, well-corticated ossicle near the calcanealcuboid joint.
superior portion of the calcaneocuboid joint and/or the junction MRI imaging is essential to evaluate the appearance and pos-
between the process of the calcaneus and navicular may exist. In sible retraction of the peroneus longus tendon and rule out any
these cases, a trial injection of cortisone in the calcaneocuboid other surrounding soft tissue injury. A retracted os peroneum is
joint and calcaneonavicular space may provide relief or help to highly suggestive of a complete peroneus longus rupture.
establish the diagnosis of arthritic changes. Surgical treatment
involves open resection of a portion of the anterolateral pro- Treatment
cess of the calcaneus, trimming it back to a point at which a Treatment for an os peroneum fracture can include nonopera-
healthy calcaneocuboid joint is present. Recently, arthroscopic tive management when the os perineum fracture is minimally
resection through a subtalar approach has been described.16 We displaced.17 Excision of the ossicle with primary repair of the
prefer a limited debridement of the area and arthroscopic exci- peroneal longus or tenodesis of the peroneus longus to the
sion of the nonunion. If the fracture is quite large, a small open brevis is most often the preferred method for managing this
incision is made rather than arthroscopically removing a large injury in the athlete. Repair or tenodeses helps the athlete to
amount of soft tissue to gain access to the anterior subtalar joint. avoid loss of eversion strength, and first metatarsal plantarflex-
ion strength. Postoperatively, the ankle is immobilized in a cast
Rehabilitation and Return to Sports nonweight bearing for 3 weeks in slight eversion, followed by a
In cases in which excision is required, boot immobilization and boot or cast for another 3 weeks. Therapy will begin at 6 weeks
nonweight bearing are used for 2 weeks, followed by gentle active with the focus on ankle and subtalar mobilization.
284 SECTION 3  Anatomic Disorders in Sports

A B

C
Fig. 16.18  (A) Sagittal reconstruction, (B) coronal, and (C) axial computed tomography view of occult anterior
process fracture (arrows) of calcaneus. Plain radiographs did not reveal fracture, but athlete had tenderness
over anterior process.

TABLE 16.1  Classification of Fractures of OCCULT FRACTURES OF THE CUBOID

the Anterior Process of the Calcaneus14
Mechanism of Injury
Type I Nondisplaced tip avulsion
Type II Displaced avulsion fracture not involving the calcaneocuboid
Midfoot injuries, specifically of the cuboid, are rare in the ath-
articulation lete, but can often be overlooked as a midfoot sprain. They can
be observed in two different variants in athletes: as either a cap-
Type III Displaced, larger fragments involving the calcaneocuboid joint
sular avulsion injury or a compression cuboid injury. Capsular
 CHAPTER 16  Osteochondral Lesions of the Ankle 285

avulsion injuries are seen during an adduction/inversion injury

when the patient lands in plantarflexion. This is common in
sports like basketball, volleyball, and dancing.19 In an avul-
sion cuboid injury, the calcaneocuboid capsule and plantar
calcaneocuboid ligament are torn producing a small avulsion
fragment off the plantar posterior cuboid. Alternatively, a com-
pression injury can occur, creating a nutcracker mechanism of
acute compression of the cuboid between the anterior process
of the calcaneus and the base of the fourth and fifth metatarsal,
accompanied by medial column distraction injury of the mid-
foot. It is important to rule out injuries to the Chopart joint in
this situation, which can be seen by widening of the talonavic-
ular joint.19,20

Presentation and Physical Exam

The patient will typically present with lateral foot pain (just
proximal to the insertion of the peroneus brevis), ecchymosis,
and swelling with difficulty walking, especially with plantar-
flexion.

Imaging
X-rays can show a small lateral cuboid avulsion injury or will
reveal compression fractures (Fig. 16.19). CT scan imaging is
best used to more clearly visualize the fracture, its pattern and
its extent. CT imaging can help establish the extent of fracture
and the amount of joint depression that can be involved with the
impaction injury.
Fig. 16.19  Oblique radiograph of foot demonstrating small fracture of
Treatment cuboid.
Surgery will be required when there is significant shortening
of the cuboid in an impaction injury. Surgery is also required
if displacement results in destabilization of the lateral col-
umn. This can be performed with mini-fragment screws by the opposing force of the bifurcate ligament attachment on
with or without bone graft and plating to restore the lateral the lateral navicular and the posterior tibial tendon attachment
column.21 to the medial navicular. This injury occurs commonly in sports
Conservative management is typically used to treat most in which a sudden change of direction is followed by the athlete
types of painful cuboid injuries. Cast and boot treatment are planting his foot, decelerating, and twisting a plantarflexed foot
preferred with pain and a return to sports is advised when the to reaccelerate and push off. The force of the posterior tibial ten-
patient is pain free. don on the navicular may produce an avulsion at its insertion
(Fig. 16.21).
OCCULT FRACTURES OF THE TALUS Presentation and Physical Exam
Frequently missed or misdiagnosed fractures after an ankle The patient will often complain of pain dorsally at the navic-
sprain comprise a large number of occult talus fractures. ular just lateral to the tibialis anterior insertion. Dorsal mid-
These can be classified into dorsal talar injuries, lateral foot swelling and ecchymosis can be seen along with pain with
process fractures, posterior process fractures, and compres- resisted dorsiflexion and active inversion/passive eversion
sion injuries of the talus and osteochondral fractures of the (Fig. 16.22).22–24 Frequently a bony firmness can be noted over
talus. the dorsal navicular or talar head.

Talonavicular Avulsion Injures Imaging

Mechanism of Injury Plain radiographs will show an avulsion fracture of the dorsum
Talonavicular avulsion injuries are a commonly missed diagno- of the navicular or talar head on the lateral view (Fig. 16.23).
sis in patients presenting with an acute ankle sprain. The dorsal CT and MRI can be useful in chronic cases of nonunion or to
talonavicular capsule ligament will pull off with a forced plan- rule out a concomitant navicular stress fracture (Figs. 16.24 and
tarflexion moment (Fig. 16.20). The dorsal force can be created 16.25).
286 SECTION 3  Anatomic Disorders in Sports

Fig. 16.21  Anterior-posterior radiograph of athlete’s foot depicting pain-

ful medial accessory navicular attached by synchondrosis.

Fig. 16.20 Fracture of navicular caused by plantarflexion of foot and

ankle with avulsion of dorsal fragment.

It is important to differentiate this injury from os supranavic-

ulare, which represents a normal variant.

Treatment
Management of a talonaviclar avulsion fracture is typically
treated conservatively in a short-leg cast for 3-4 weeks non-
weight bearing, followed by a boot. If there a painful nonunion,
excision of the fragment can be considered or ORIF if the frag-
ment is greater than 5 mm.
Fig. 16.22  Clinical examination of athlete’s foot depicting area of pain
noted on foot with dorsal avulsion fracture of navicular.
Rehabilitation and Return to Sports
Rehabilitation will usually begin at 4–6 weeks after the injury
with a focus on edema control, range of motion (ROM), pro-
Posterior Talus Fractures/Posterior Impingement
prioception, and progressive resisted exercises (PREs) (espe- Syndrome (see also Chapters 2 and 24)
cially the posterior tibial tendon). Running is done first, initially Mechanism of Injury
on an underwater treadmill or AlterG, and jumping activities Posterior impingement syndrome can result from trauma,
are added next, followed by sports-specific exercises. The ath- overuse or abnormal anatomy and is seen with chronic force-
lete may return to practice/play on successful completion of the ful plantarflexion leading to pain at the os trigonum, espe-
program (6 to 10 weeks post injury). cially when the os trigonum is large. However, other causes of
 CHAPTER 16  Osteochondral Lesions of the Ankle 287

posterior impingement can be caused by prominent Stieda pro-

cess, laxity in the ATFL after an ankle sprain (due to excessive
anterior sliding of the talus when performing a toe rise), poor-
fitting dance shoes or bad technique in the demi-pointe or
en pointe positions. These injuries are most often seen in sports
involving repetitive plantarflexion such as ballet, soccer, or
jumping and landing sports like gymnastics, volleyball, and
basketball. Occasionally a large Stieda process can be fractured
during a plantarflexion inversion injury (sometimes referred to
as a Shepherd’s fracture) (Fig. 16.26).
A forced ankle dorsiflexion and pronation injury such as forced
planting of the foot backward with force applied (Fig. 16.27, A) or
weight applied to the back of a dorsiflexed ankle at the bottom of
a scrum or pileup (Fig. 16.28) may produce an avulsion fracture
of the posteromedial tubercle by traction on the posterior deltoid
Fig. 16.23 Radiographic findings of dorsal, wafer-like fracture with ligament (see Fig. 16.27B).9,25
acute injury.
Presentation and Physical Exam
Athletes will complain of posterior ankle pain that is often pro-
voked by forced plantarflexion or pain with push-off, jumping,
and landing. Dancers will often note that going into the demi-
pointe or en pointe position is very painful and limiting. It is
important to differentiate this pain from tenosynovitis of the
flexor hallucis longus, although they can exist in concert with
each other.
The posterior talar process can be best palpated between the
Achilles and peroneal tendon. The “pinch test” posteromedially
or posterolaterally just posterior to the ankle (Fig. 16.29) will
produce pain. The posterior impingement test (Fig. 16.30A and
B) will produce pain and possibly clicking. Manipulation of the
great toe, producing stretch on the flexor hallucis longus, also
may produce posterior ankle pain. A diagnostic injection into
the posterior capsule or posterior process can be helpful in dif-
ferentiating symptoms.

Fig. 16.24  Computed tomography (coronal view) demonstrating more

Imaging
involved navicular body fracture with comminution. Radiographs will often be normal except to demonstrate a
large os trigoum. CT scans can be helpful to demonstrate the
bony fragments or multiple os trigonum fragments. MRI is
the best imaging to evaluate the soft tissue and show edema
at the synchondrosis and possible disruption. It is also helpful
to asses any FHL pathology as well as concomitant ankle or
subtalar joint pathology that may need to be addressed at the
time of surgery.

Treatment
The authors feel an arthroscopic approach is the best way to
treat posterior impingement. The arthroscopic technique can be
performed supine or prone. The supine position technique was
first described by R. Ferkel and Marumoto, with excision of the
os trigonum through subtalar arthroscopy. The AOFAS scores
improved from 45 to 86.26 Since that time, several hundred os
trigona have been removed with similar results at Southern
California Orthopedic Institute. van Dijk has shown the success
Fig. 16.25  Computed tomography (axial view) demonstrating navicular of the prone arthroscopic excision as well with AOFAS score
body fracture with displacement. improvement from 75 to 90 at 36 months.27–29
288 SECTION 3  Anatomic Disorders in Sports

Fig. 16.26 Common mechanism for posterior process fracture with compression of posterior process
between calcaneus and posterior tibia in severe plantarflexion of ankle.

For acute nondisplaced fractures of the Stieda process or os applied to a dorsiflexed inverted foot (Fig. 16.31) may pro-
trigonum, immobilization in a boot/cast and limited weight duce a force to the lateral process and result in a fracture.36,37
bearing may lead to healing in 4 to 6 weeks. Both the body and the snowboard act as a lever arm on the
For large displaced fractures that extend into the talar body ankle and talus, with the skier’s leading foot injured most
region, internal fixation through a posterolateral or posterome- frequently.38
dial approach with cannulated 4.5 screws or headless screws
is indicated. An unusual cause of posterior impingement is a Presentation and Physical Exam
bipartite talus.30,31 The athlete will typically present with history of a rotational
injury to the ankle with the complaint of lateral ankle pain, most
Rehabilitation and Return to Sports often localized 1 cm distal to the tip of the lateral malleolus that
After internal fixation of talus fracture, the patient should be in is increased with weight bearing.39 Often swelling and ecchy-
cast followed by a boot and remain nonweight bearing for 6 weeks. mosis will be exhibited.
When the fracture is healed, progressive weight bearing and ankle
rehabilitation is begun, followed by sports-specific exercises. Range Imaging
of motion and strengthening of the FHL is emphasized. Obtaining anterior-posterior (AP), lateral, and oblique
After os trigonum excision, the authors will typically keep ankle x-rays may show an avulsion-type fragment laterally
the patient in a splint the first week followed by boot or cast (Fig. 16.32A) or be negative if the fracture is nondisplaced
with the progression to weight bearing by weeks 2 to 3. The with (Fig. 16.32B and C). The mortise or Broden’s view are felt to
gentle ROM of the ankle and subtalar joint is allowed out of be best to visualize these fractures.
the boot and physical therapy is commenced. A typical time to The authors believe that CT scan imaging should be ordered
return to sports after excision is 6–8 weeks. if there is a suspicion of a lateral process fracture. This study
can aid in identification of lateral talar process fractures, aiding
Lateral Process of the Talus Fracture in sizing and surgical planning (Fig. 16.33). MRIs can also be
(see also Chapter 6) ordered to rule out chondral pathology in the talus.
Lateral processes of the talus fractures are commonly misdiag-
nosed and often mimic the clinical symptoms of ankle sprains Classification
with up to 59% missed initially.32,33 It is estimated that they are Two commonly used classifications for lateral talus process frac-
present in 0.86% of all lateral ankle sprains.34 tures exist: the Hawkins classification:16 type 1—simple two-part
fracture, type 2—comminuted fracture, and type 3—avulsion
Mechanism of Injury fracture of the anterior inferior process; and the McCrory and
Lateral processes of the talus fractures are most commonly Bladin classification, recently modified by Tinner and Sommer
seen in the snowboarder, accounting for 2.5%–6.3% of all (Fig. 16.34):40,41 Type I—small, minimally displaced, extra-
snowboarding injuries.35 Typically “snowboarder’s frac- articular chip fracture, type II— simple large fragment fractures,
ture” will occur with a dorsiflexed and inverted force on the and type III—comminuted fractures. It is also important to
ankle and talus. Recent studies suggest that external rotation assess the fracture displacement: minimal displacement, <1 mm
 CHAPTER 16  Osteochondral Lesions of the Ankle 289

Post.
deltoid
ligament

Posteromedial
tubercle
of the talus

B
Fig. 16.27 (A) Lateral view of posterior talus process fracture caused by forced dorsiflexion of the ankle
against a planted foot. (B) Posterior view, showing avulsion forces produced by the posterior deltoid ligament
on the posterior medial tubercle of the talus.
290 SECTION 3  Anatomic Disorders in Sports

Tibia

Talus

Fig. 16.28  Posterior talus process fracture caused by force on the back of the ankle, causing avulsion of the
posterior talar process through tension on the posterior deltoid ligament.

immobilization with immediate, gentle AROM until healing is

accomplished.
For chronic cases (previously undetected) or cases of
nonunion after immobilization, treatment of large frag-
ments (greater than 1 cm) or fragments involving the artic-
ular surfaces require debridement and/or internal fixation
and can be addressed either open or through a combination
of ankle and subtalar arthroscopy.

Rehabilitation and Return to Sports

Athletes with intra-articular lateral talus fractures requir-
ing internal fixation should start gentle AROM exercises
of the ankle and subtalar joints during this healing and
nonweight-bearing phase to maintain joint mobility (typi-
cally around 3 weeks post-op). Full weight bearing can begin
Fig. 16.29  Clinical demonstration of “pinch test.” Compression of pos- around 6 weeks post op with progression out of the boot by 8
terior process fracture of talus (os trigonum) in athlete just behind ankle weeks. When all fractures are healed, more aggressive ankle
from medial and lateral sides cause pain. rehabilitation begins, followed by sports-specific exercises and
return to sports. Initially, pool therapy can be very helpful as
articular step off and <2 mm gap and distinguish it from dis- well.
placed fractures, >1 mm articular step off and 2 mm or greater
gap.
OSTEOCHONDRAL LESIONS OF THE ANKLE
Treatment
Acute, nondisplaced talar lateral process fractures can be treated
INTRODUCTION
with immobilization in a splint followed by a boot, nonweight Chondral and osteochondral lesions of the ankle continue to
bearing for 4 to 6 weeks. pose a challenge to orthopedic surgeons due to the anatomi-
For smaller displaced fractures conservative treatment with cally limited joint surface, high degree of joint contact forces,
boot or cast immobilization and nonweight bearing also is indi- difficulties of easily accessing the tibiotalar joint, and prob-
cated. Early excision of displaced small fragments and progres- lems with cartilage healing. Osteochondral lesions of the talus
sive weight bearing can be considered. (OLT) remain one of the most common lesions of the ankle and
For larger displaced fractures (> 2 mm) and/or with joint are often sequelae of ankle sprains and fractures. Despite sig-
surface irregularity greater than 1 mm, open reduction inter- nificant advances in cartilage restoration therapy over the last
nal fixation with headless screws through a curvilinear sub- two decades, the heterogeneity of injury patterns and location,
fibular approach is preferred. Ankle arthroscopy should be depth, and acuity of treatment make development of a rational
considered prior to the open approach to evaluate the cartilage and evidence-based treatment algorithm difficult. This review
of the talus and address any chondral pathology. Some clini- will attempt to briefly summarize the historical treatment
cians have proposed performing an arthroscopic reduction options for sport-related OLT and osteochondral lesions of the
and internal fixation for this type of fracture using cannu- tibial plafond (OLTP), and outline newer options for cartilage
lated screws.42 Postoperative involves nonweight-bearing boot restoration.
 CHAPTER 16  Osteochondral Lesions of the Ankle 291

A B
Fig. 16.30  Clinical demonstration of “posterior compression test.” Forced maximal plantarflexion (A and B)
of ankle produces pain in athlete with posterior process fracture (os trigonum).

Lateral
talar
process
Fig. 16.31  Diagram noting mechanism for lateral process fractures of talus. Forced external rotation with the
ankle in dorsiflexion and inversion results in a lateral process fracture.

HISTORY AND INCIDENCE Given the tenuous blood supply of the talus, the genetic
The description of OLT originated in a discussion of trauma- predisposition for OLTs, the 10% incidence of nontraumatic
related loose bodies in the ankle by Alexander Monro in 1856.43 bilateral OLTs, and the association of OLTs with systemic
The term osteochondritis desiccans was first termed by König inflammatory conditions, thrombotic conditions, and chronic
when describing osteochondral lesions in the knee.44 At that steroid use, the pathogenesis of OLTs is clearly multifactorial.49
time, König proposed a theory of spontaneous necrosis as the It is estimated that there are over 1 million sports-related ankle
cause of these lesions. In an effort to describe the etiology of sprains annually in the United States, and the estimated inci-
the lesion, Barth proposed that the lesion was secondary to a dence of articular cartilage injury and OLT associated with
fracture of the intra-articular surface in 1898.45 Shortly there- ankle sprains are found to be between 6.5% and 50%.48,50,51 In
after, Kappis first applied the term osteochondritis dissecans to an active military population, incidence was estimated to be 27
the ankle joint.46 In 1959, Berndt and Harty suggested that the per 100,000 person-years.52 In a separate study, the mean age of
lesion had a traumatic etiology and coined the term transchon- patients with OLT was between 20 and 30 years old, with a slight
dral fracture of the talus.47 Since that time, nomenclature and predilection for men.53
discourse have centered on the role of trauma, subchondral Medial OLTs are seen most frequently and are associated with
bony vascular insult, and cartilage genetics in the development trauma in 61% to 70% of cases. These lesions are also observed
of OLT.48 to have greater depth in comparison to lateral lesions. Lateral
292 SECTION 3  Anatomic Disorders in Sports

A B

C
Fig. 16.32 Lateral process fracture of talus. (A) Anterior-posterior (AP) radiograph of ankle demonstrating
lateral process fracture (arrows) noted just inferior to the tip of the fibula. (B) Lateral and AP radiographs of
athlete with lateral process fracture that was not able to be visualized on x-rays.

lesions are associated with trauma in up to 98% of cases.50 In of congruence, and a thinner cartilage relative to that of the
contrast to the relatively high incidence of OLT, OLTP are rare. knee.50 While these characteristics lend a low risk (2%) of pri-
In one cohort of more than 880 consecutive ankle arthrosco- mary osteoarthritis when compared to the hip or knee, they do
pies, OLTP represented less than 3% of articular cartilage inju- predispose the talus to significant acute chondral injuries and
ries, with less than 1% having a bipolar lesion of both the tibia progression to posttraumatic arthritis.55
and talus.54 Multiple studies have examined the application of both com-
pressive and shear force to the joint and its relation to osteo-
chondral lesion location. Berndt and Harty reproduced lateral
MECHANISM talar dome lesions via an inversion force applied to a dorsiflexed
The talus is anatomically remarkable in that it demonstrates a foot with the tibia internally rotated. Similarly, medial dome
high percentage of articular cartilage surface area, a high-level lesions were reproduced by applying an inversion force to a
 CHAPTER 16  Osteochondral Lesions of the Ankle 293

A B

C D
Fig. 16.33 Axial computed tomography scan of talus demonstrating lateral process fracture that was not
identified on ankle radiographs in athlete.

In contrast, posteromedial lesions are seen in the setting of ankle

Dorsal
plantarflexion, while anterolateral lesions occur with inversion
and ankle dorsiflexion. Yao and Weiss deduced that lateral OLTs
Posterior Posterior were secondary to eversion dorsiflexion ankle injuries with the
tibia in an internally rotated position.57
Advanced imaging modalities may demonstrate subchon-
dral cyst formation, a known sequela of OLT. Subchondral cysts
are believed to develop as a result of a crack in the articular car-
tilage that allows synovial fluid to leak into the underlying bone.
The increased hydrostatic pressure with continued walking
Type A
forces synovial fluid into the potential space of the talus fissure
and creates a cystic cavity. Egress of fluid from the joint space
and enlargement of the developing cyst may be aided by dam-
aged cartilage functioning as a one-way valve. The cartilaginous
Type B Type C
“valve” allows the flow of fluid from the joint space into the sub-
Fig. 16.34  Funk classification for lateral process fracture talus. Type A chondral bone but not in the opposite direction (Fig. 16.35).58
involves only a small avulsion fragment, type B involves only the talocal-
caneal joint, and type C involves both the talocalcaneal and talofibular
articulations. DIAGNOSIS AND EVALUATION
plantarflexed foot with tibial external rotation. Other investiga- Examination
tors have postulated that significant inversion of a plantarflexed Distinguishing patients with osteochondral lesions from those
foot would result in the application of distracting forces to the with uncomplicated ankle sprains can be challenging, and the
lateral talus, as well as compressive forces to the medial talus.56 diagnosis is often delayed by the tendency to treat routine ankle
294 SECTION 3  Anatomic Disorders in Sports

A B
Fig. 16.35  Cystic osteochondral lesion of the right talus. (A) Coronal CT scan showing an oval shaped subchon-
dral cystic lesion in the talar body. Note the line of communication from the cyst within the joint. (B) Accompany-
ing diagram showing presumed mechanism of cyst formation that occurs with the synovial fluid leaking through
the crack in the articular cartilage and forming a cyst in the bone. (Reprinted with permission from Ferkel RD:
Foot and Ankle Arthroscopy, 2nd edition, Wolters Kluwer, 2017. Illustration by Susan Brust, MS.)

sprains conservatively. Many patients will describe a history of found CT scans to be superior to x-rays for both diagnosis and
a sports-related injury with failure to improve after conservative follow-up.60 Although there remains debate regarding selection
management. Furthermore, patients are often unable to return of follow-up imaging, either CT or MRI should be considered
to sports-related activities, and may report a history of an ach- for diagnosis of OLT. In cases of known OLT, we favor a thin-
ing pain, ongoing edema, and prolonged stiffness after an oth- slice CT scan with low-dose radiation protocol, as this modality
erwise uncomplicated injury. Given the variable presentation of allows for improved definition of the lesion and has been shown
ankle sprains, identifying OLTs requires a high index of suspi- to correspond more accurately to the size of the lesion at the
cion in patients who fail to improve with standard conservative time of arthroscopy.61 In cases of ongoing pain without a clear
treatment. While physical exam findings are generally nonspe- diagnosis, MRI should be considered in order to evaluate bone
cific, the most common exam finding may be anterior joint line marrow edema and to more accurately characterize overlying
tenderness with the foot plantarflexed. Mechanical symptoms, cartilage. MRI also reveals other soft-tissue abnormalities that
such as locking or catching, can occur in the setting of a loose can be associated with an OLT. However, it should be noted that
or displaced osteochondral fragment. Given the association of MRI can overestimate the size of the OLT in a significant number
OLTs with ankle sprains, ankle instability should be routinely of cases.48 Novel imaging techniques, including T2rho cartilage
evaluated with anterior drawer and inversion and eversion test- mapping, show promise but are currently used experimentally
ing. In addition, subtalar motion should be evaluated to assess and are not considered standard of care.
for bony coalition as a possible cause of recurrent instability.
Moreover, the patient’s alignment needs to be carefully assessed. Classification
The diagnosis and evaluation of OLT have improved dramatically
Imaging with advances in diagnostic imaging and operative arthroscopy.
Despite the routine necessity of advanced imaging for diagnosis, To further characterize and specify imaging findings, several
all patients should always undergo standard weight-bearing AP, classification and staging systems have been devised. In 1959,
mortise, and lateral plain radiographs with optional stress radio- Berndt and Harty used x-ray analysis and specimen dissection
graphs for those with possible ankle instability. Weight-bearing to help develop a radiographic-based classification, which has
views can be helpful in evaluating ankle alignment and joint space been appended to include six stages of lesions visualized on x-ray
collapse. Roughly 50% of lesions will be noted on radiographic imaging.47 Stage 0 describes a lesion that is not seen on x-ray
examination.59 Most patients with an OLT will require advanced imaging but is visualized on MRI. Stage I denotes a nondisplaced
imaging, either an MRI and/or CT scan. CT and/or MRI should compression fracture. Stage II is a partially detached osteochon-
be considered for patients with continued pain after ankle dral fracture. Stage III is a completely detached but nondisplaced
trauma or any mechanical symptoms. Zinman et al. reported on fragment. Stage IV is a completely detached and displaced frag-
32 patients with osteochondritis dissecans of the talar dome and ment. Lastly, stage V describes lesions with deep cystic change.62
 CHAPTER 16  Osteochondral Lesions of the Ankle 295

Fig. 16.36  Ferkel-Sgaglione CT classification for osteochondral lesions of the talus. (Reprinted with permis-
sion from Ferkel RD: Foot and Ankle Arthroscopy, 2nd edition, Wolters Kluwer, 2017. Illustration by Susan
Brust, MS.)

MRI staging has been described by several different authors. correlate more accurately with arthroscopic findings and treat-
Beginning in 1999, Hepple developed an MRI-based classifica- ment outcome (Fig.16.36).
tion system wherein stage I described articular cartilage damage Drawing on arthroscopic findings, Pritsch described a classi-
alone, stage IIA described cartilage injury with underlying frac- fication system based on the graded appearance of the overlying
ture and surrounding bony edema, stage IIB described carti- cartilage.66 In this system, arthroscopic findings were stratified
lage injury with underlying fracture without surrounding bony into three surgical grades: I) intact, firm, and shiny articular
edema, stage III described detached and nondisplaced osteo- cartilage; II) intact but soft cartilage; and III) frayed cartilage.
chondral fragment, stage IV described a detached and displaced Citing poor correlation between x-ray imaging and arthroscopic
osteochondral fragment, and stage V described an osteochon- findings, investigators asserted that arthroscopic evaluation and
dral lesion with subchondral cyst formation.63 Anderson and the intraoperative appearance of lesions in cases of OLT were
colleagues applied MRI to modify the radiographic classifica- the most valuable determinants of treatment.
tion established by Berndt and Harty, allowing for further char- Using data derived from 80 subjects treated for OLT at the
acterization of fragment separation, underlying bone marrow Southern California Orthopedic Institute between 1985 and 1994,
edema, and subchondral cyst formation.64 Cheng, Ferkel and Applegate developed a more detailed classifi-
Ferkel and Sgaglione developed a four-stage classification cation system based on the arthroscopic appearance of articular
system based on two-plane CT imaging.65 Stage I describes cartilage. In this study, investigators compared preoperative x-ray
a cystic lesion within the intact dome of the talus seen in all imaging and CT or MRI with intraoperative findings.67 Using this
views, stage IIA describes a cystic lesion communicating with classification, grade A describes articular cartilage that is smooth,
the talar dome surface, stage IIB describes an open articular intact, but soft or ballotable; grade B describes a rough surface; grade
surface lesion with an overlying nondisplaced fragment, stage C describes fibrillations or fissures; grade D describes the presence
III describes a nondisplaced lesion with lucency, and stage IV of a flap or exposed bone; grade E describes a loose, nondisplaced
describes a displaced fragment. This classification appeared to fragment; and grade F describes a displaced fragment (Fig. 16.37).
296 SECTION 3  Anatomic Disorders in Sports

All of the above-mentioned staging systems are helpful in the specific evidence-based recommendations has been detailed by
diagnosis and treatment of OLT (Table 16.2). However, each of Kraeutler et al.59 In addition, there are a number of risk factors
these staging systems must be used together with the patient’s for failed cartilage repair that are listed in Table 16.3.
symptoms and accurate sizing measurements to determine
appropriate treatment. Acute Injury Treatment
In the setting of acute OLT, identification of the lesion with x-ray
imaging may be possible. CT or MRI may be used, if needed, to
TREATMENT further characterize the lesion and determine radiologic stag-
Treatment of an OLT must be customized to each unique ing. Although there is a paucity of evidence-based data regard-
patient. Treatment options are determined based on the patient’s ing the role of weight-bearing or nonweight-bearing ambulation
symptoms and activity level, stage and size of the lesion, and in the treatment of OLT, nonoperative treatment with immo-
whether it is an acute or chronic cartilage injury. A summary of bilization and nonweight bearing is commonly employed in
cases of acute nondisplaced OLTs.6,68–71 To assess evolution of
the acute lesion, serial imaging, including x-ray, CT, or MRI, is
routinely performed. If the acute lesion is displaced and purely
chondral in nature, the lesion should be treated by arthroscopy
and excision with subsequent debridement, drilling, and pos-
sible microfracture to stimulate angiogenesis and formation of
fibrocartilage.69 If the displaced chondral piece has adequate
underlying bone, the fragment should be reattached with bio-
absorbable pins, K-wires, or headless screws. Cases that do not
heal should be treated as chronic cases.

Chronic Injury Treatment

Numerous operative techniques have been described to treat
OLT. These treatment strategies can be classified as cartilage
repair, cartilage regeneration, cartilage replacement, or pros-
thetic replacement (Table 16.4).72 Full-thickness loss of artic-
ular cartilage presents a significant therapeutic challenge, as
Fig. 16.37  Palpation of an arthroscopic grade D osteochondral lesion of
only 50% of patients report “good” or “excellent” results with
the talus in a right ankle. The probe is brought in from the anteromedial conservative treatment.4,6,73 A combination of x-ray, CT scan,
portal while visualizing through the anterolateral portal. and/or MRI evaluation along with arthroscopic assessment

TABLE 16.2  Classification of Osteochondral Lesions Based on Radiographs, MRI, CT, and
Arthroscopy
Radiographic Classification MRI Revised Classification CT Classification Arthroscopic Grade Based on Articular Cartilage
Berndt and Harty47 Anderson64 Ferkel & Sgaglione65 Ferkel et al.67
Stage 0 Stage I Stage I Grade A
Not visible on radiographs Subchondral trabecular compression—plain Cystic lesion within dome of Smooth, intact cartilage, but soft and bal-
radiograph normal, positive bone scan; talus, intact roof on all views lotable
marrow edema on MRI
Stage 1 Stage IIA Stage IIA Grade B
Trabecular compression of Formation of subchondral cyst Cystic lesion with communication Rough articular cartilage surface
subchondral bone to talar dome surface
Stage 2 Stage II Stage IIB Grade C
Partially detached Incomplete separation of fragment Open articular surface lesion with Articular cartilage has fibrillations and fissures
osteochondral fragment overlying nondisplaced fragment
Stage 3 Stage III Stage III Grade D
Detached and nondisplaced Unattached, nondisplaced fragment with Nondisplaced lesion with lucency Articular cartilage flap present or bone
osteochondral fragment presence of synovial fluid around fragment exposed
Stage 4 Stage IV Stage IV Grade E
Detached and displaced Displaced fragment Displaced fragment Loose, un-displaced fragment
osteochondral fragment
Grade F
Loose, displaced fragment
 CHAPTER 16  Osteochondral Lesions of the Ankle 297

of the cartilage surface allows accurate staging. Furthermore, Once excised, curettage, antegrade or retrograde drilling, and/
arthroscopic evaluation may aid in identifying appropriate sur- or microfracture are performed. In large lesions, the entire cys-
gical management. While excision alone has demonstrated only tic region, including the deformed loose cartilage, should be
moderate patient satisfaction outcomes (40% good to excel- curetted out and the area debrided, drilled, and microfractured.
lent result), excision and curettage yield 78% good to excellent While some asymptomatic lesions can be followed over time
results.6 Satisfaction outcomes were further improved with the without intervention, bone graft with autograft or demineral-
addition of drilling or microfracture to excision and curettage, ized bone matrix (DBM) allograft should be used on cysts >5
yielding 86% good to excellent results.4,73–76 mm.78,79
Several techniques have been used for penetrating sub-
chondral bone, including resecting sclerotic subchondral bone, AUTHORS PREFERRED TREATMENT
drilling through the subchondral bone, abrading the articular
surface, and creating small-diameter defects with microfrac- Acute
ture pics. These techniques are called bone marrow stimulation Principles of treating acute osteochondral lesions are different
(BMS) and are reparative procedures that are the most common than those for chronic lesions. In an acute OLT, the first priority
operative treatment choice for an OLT. The procedure is done is to characterize the lesion as soon as possible. X-ray, MRI, and/
arthroscopically in the following steps: (1) debridement of the or CT are helpful to further visualize the exact size and location
unstable cartilage and necrotic bone; (2) debridement of the cal- and amount of bone that may or may not be associated with the
cified layer; and (3) penetration of the subchondral bone plate chondral fragment. Overall steps for treatment of an acute OLT
(SBP) using a thin microfracture pick or small diameter K-wire. are summarized in Box 16.1.
Penetration of the subchondral bone disrupts subchondral Acute anterolateral osteochondral lesions are usually dis-
blood vessels, leading to the formation of a fibrin clot, and ulti- placed and oftentimes upside-down in the joint. We have coined
mately to fibrocartilage tissue forming on the surface. Studies the term for these lesions: “Lateral Inverted Osteochondral
have demonstrated that undifferentiated mesenchymal cells are Fractures of the Talus (LIFT).”80 These lesions must be debrided
released from the underlying marrow. These cells then differen- as soon as possible and are relative surgical emergencies. Often,
tiate into chondrocytes and chondroblasts that ultimately form these patients are very swollen after a severe ankle sprain, and
the fibrocartilage cells that infiltrate the articular surface.77 clinical exam and MRI will reveal a complete tear of the ante-
In the chronic setting, the lesion should be carefully probed. rior talofibular and calcaneofibular ligaments. Initially these
If the lesion is intact, antegrade or retrograde drilling through patients are treated in a bulky dressing and posterior splint, and
the talus can be done. Fixation techniques with absorbable elevated for 1–2 weeks until the swelling is diminished enough
pins, K-wires, or screws can be used in loose fragments with to proceed with surgery.
healthy-appearing articular cartilage. Superficial displaced frag- LIFT lesions are best approached arthroscopically in the
ments with unhealthy articular cartilage are typically excised. supine position, with the arthroscope in the anteromedial por-
tal, inflow posterolaterally, and instrumentation anterolaterally.
TABLE 16.3  Risk Factors for Failed Loose lesions need to be flipped back to the proper position
Cartilage Repair and then reduced and fixated if enough bone is attached to
Age Chondrocyte function decreases as patients get
the cartilage. If there is minimal or no bone, the lesions need
older to be excised. With maximum plantarflexion, sometimes these
Obesity Inferior functional outcomes associated with
lesions can be fixated with absorbable pins or headless screws
elevated BMI arthroscopically, if the abnormality is anterior enough to clear
Smoking Overall negative influence on cartilage repair
the tibial plafond. An absorbable pin made of polyglycolic acid
can be inserted in a triangular fashion, so that three pins are
Activity level After a certain threshold, an increase can have
negative effect on articular cartilage
usually used to stabilize the displaced fragment.
More often, acute anterolateral osteochondral lesions are
Inflammatory disease Current treatments could affect cartilage health
not amenable to arthroscopic fixation alone. In this situation,

TABLE 16.4  Treatment Strategies for Osteochondral Lesions of the Talus: Repair, Replace or
Regenerate
Repair Regeneration Replacement
Marrow stimulation (microfracture) Autologous chondrocyte implantation (ACI) Osteochondral allograft transfer (OAT)
Retrograde drilling Matrix-induced chondrocyte implantation (MACI) Osteochondral allografting
Bone marro-derived cell transplantation Particulated juvenile cartilage allograft transplantation
Micronized cartilage matrix
Metallic cap implant
(Modified from Dekker TJ, Dekker PK, Tainter DM et al.: Treatment of osteochondral lesions of the talus a critical analysis review. JBJS Reviews
2017;5:e4-e13.)
298 SECTION 3  Anatomic Disorders in Sports

BOX 16.1  Treatment of Acute OLT as previously described. Chen et  al. found that drilling 6 mm
deep produced better fill and quality of cartilage than 2 mm
1. Palpate the lesion with a small joint probe deep.87 They used a nano-fracture device of 1-mm diameter to
2. Excise chondral fragments with little or no bone and drill/microfracture the stimulate a better healing response. They also found that microf-
base
racture results were similar to drilling to the 2-mm depth.
3. Reattach loose osteochondral fragments with absorbable pins, K-wire, or
The technique we prefer is with the patient in the supine
screws
4. If lesion is displaced, reduce with probe or grasper gently and temporarily
position, using a nonsterile thigh support and lateral post,
fixate with K-wire, then firmly fixate with absorbable pins, screws or K-wire with the pad at the foot of the bed removed. This gives excel-
lent access to the anterior and posterior aspects of the ankle.
The patient is paralyzed by the anesthesiologist after a popli-
a Broström approach is performed with a longitudinal incision teal block has also been performed. The tourniquet is inflated
to expose the torn lateral ankle ligaments, and then the foot is at the surgeon’s discretion and soft-tissue distraction is applied.
plantarflexed with inversion and an anterior drawer to display Standard anteromedial, anterolateral, and posterolateral portals
the lesion site more clearly. It is critical to remove the displaced are established, as previously described (Fig. 16.40).48 The entire
fragment and keep it in sterile saline on the back table in the ankle is debrided and then the osteochondral lesion is palpated.
operating room (OR) until it is ready to be reattached. The If it is unstable, which is frequently the case in chronic situa-
osteochondral lesion bed needs to be debrided, with good sharp tions, it is excised using different-angled cup and ring curettes,
margins. Rarely is a bone graft necessary. The acute OLT is then shaver, and a grasper. Good, 90-degree vertical walls are estab-
reduced and secured with pins or screws (Fig. 16.38) lished to hold the clot. Drilling of the lesion is accomplished
using a 0.045 or, in some cases, a 0.035 wire throughout the
osteochondral lesion. The wire should be irrigated at all times
PEARL to prevent heat necrosis. Small-diameter microfracture picks
Pearls: can also be selectively used on a limited basis, to penetrate the
1. The osteochondral fragment absorbs water and is always bigger than the subchondral bone. If the lesions are more central or posterior, a
area from where it came. The fragment needs to be carefully trimmed and MicroVectorTM aiming device can be used to assist with accu-
sized to fit into the osteochondral bed flush and not be proud. rate drilling of the lesion (Fig. 16.41).
2. A small burr is used to remove a little bit of bone to help with resection and Van Bergen et al. described 50 patients followed for a mean
anatomic reduction of the OLT fragment. of 141 months and reported overall functional scores were
3. Place two guide pins or K-wires into the fragment on the back table to use 88/100.88 Numerous other investigators have also showed good
as joysticks to help with reduction and fixation, so that the fragment can be
functional outcomes following BMS, with short to mid-term
anatomically reduced and not fall to the floor accidentally.
evaluations of athletic populations.51,89
Although successful outcomes have been attained with
BMS, deterioration of the regenerated fibrocartilage can occur.
Chronic Ferkel et  al. found 35% of patients had deterioration in their
Most chronic OLT are unstable and require excision. However, result within 5 years after BMS.75 Lee et  al. showed only 30%
more recently, a technique termed “lift and fill” has been devel- of patients who had BMS had good graft integration on sec-
oped to reattach these fragments, if the osteochondral fragment ond-look arthroscopy.90 Although van Bergen et  al. showed
is felt to be viable and not avascular.81 Other techniques have good long-term results, one-third of their patients progressed
also been used, such as ORIF, with insertion of pins or cortical by one grade of arthritis severity on regular x-rays.88 It is
bone pegs. Kumai et al. showed good clinical outcomes in 24/27 unclear why the joint deteriorates, but it may be due to the result
patients at a follow-up of 7 years.82 of a combination of mechanical and biologic factors. Biologic
Principles of treatment of chronic OLT are described in agents that can reduce inflammation and give a good chondro-
Box 16.2. The choice of treatment for an osteochondral lesion is genic biologic response would be a big advantage to patients
multifactorial and is determined by factors such as size, depth, with BMS, and will be discussed later in the chapter. Hurley
location, containment, number, and age of defects, subchondral conducted a literature review of 57 studies with 3072 ankles for
bone quality, and prior surgery. The primary indicator of suc- patients who had marrow stimulation technique for an OLT.91
cess with marrow-stimulating techniques is determined by the The review found a high rate of return to sports of 87%, and the
size of the lesion. In the past, studies have indicated poor results mean time to return to play was 4.5 months. However, there was
in lesions that measure >150 mm2 in size, or 15 mm in diam- a significant deficiency in the reported rehabilitation protocols,
eter.83,84 However, more recently, Ramponi et  al. have shown as well as poor documentation in returning back to play criteria.
that the optimal size should not exceed 107.4 mm2.85 Another
important factor that determines prognosis is containment, and OSTEOCHONDRAL LESIONS OF THE TALUS
Choi et al. have shown worse results with uncontained lesions
than when the lesions are contained.86 Treatment decisions can
ALTERNATIVE TREATMENTS
be developed through an algorithm or diagram (Fig. 16.39). When BMS fails after a good treatment technique or when
In general, BMS is still the treatment of choice, using the OLT is greater than 107.4 mm2 (particularly with cystic
small-diameter microfracture picks or small-diameter K-wires, lesions >6 mm), alternative treatment modalities need to be
 CHAPTER 16  Osteochondral Lesions of the Ankle 299

D
C

E
Fig. 16.38  Treatment of an acute osteochondral lesion of the talus (LIFT lesion). (A) A Broström incision is
made and the torn lateral ligaments are identified. The foot is then inverted and plantarflexed, and an anterior
drawer is applied to access the lateral OLT. (B) Lateral view showing the lateral OLT brought out anteriorly.
(C) Oblique view demonstrating the lateral OLT is reduced with a grasper and temporarily fixated with K-wires.
(D) Absorbable pins are sequentially inserted to reattach the lateral OLT. (E) Cross-sectional diagram shows
the position of the global pin stabilizing the OLT while a second pin is inserted. (Reprinted with permis-
sion from Ferkel RD: Foot and Ankle Arthroscopy, 2nd edition, Wolters Kluwer, 2017. Illustration by Susan
Brust, MS.)
300 SECTION 3  Anatomic Disorders in Sports

BOX 16.2  Treatment of Chronic OLT

1. Probe with small joint probe
2. Evaluate with palpation whether lesion is loose; if there is any question,
use dilute methylene blue to detect staining around the lesion that would
suggest whether it is loose or not
3. Drill the lesion if it is not loose
4. Fixate the lesion if loose and if articular cartilage and underlying bone
are healthy, with or without inserting bone graft, using absorbable pins,
K-wires, or screws
5. Excise the lesion if loose or displaced, and then drill/microfracture the
base
6. Bone-graft large cystic areas if cartilage is intact; otherwise, curette the
cyst out and drill or abrade the bone (bone grafting of open defects can
be considered)

A
Treatment Options for Cartilage Defects

< 1 cm2 1 - 2.5 cm2 2.5 - 4 cm2

Debridement Debridement Debridement
Drilling Drilling Drilling
MicroFracture MicroFracture MicroFracture
Osteochondral Osteochondral
Transplants Transplants
MACI MACI
Allografts Allografts
Juvenile Juvenile Allografts
Micronized Cartilage
Allografts
Matrix
Micronized Focal Resurfacing
Cartilage Matrix Implant
Fig. 16.39  Treatment options for cartilage defects based on the size of B
the osteochondral lesion.
Fig. 16.41  Use of the MicroVectorTM drill guide. (A) The MicroVectorTM
drill guide has two articulating arms with different sized K-wire cannu-
las. In addition, an offset guide allows a precisely patterned series of
drill holes to be made. (B) Transmalleolar drilling with the arthroscope
posteromedially into an osteochondral lesion of the medial talar dome.
The probe is retracted as the K-wire enters through the distal tibia
before going into the talus.

Cartilage Replacement Strategies

Osteochondral Autograft Transplantation (OAT)
Hangody first introduced his clinical technique of mosaicplasty
in 1992, to transplant healthy osteochondral plugs from rela-
tively nonweight-bearing areas of the knee to treat osteochon-
dral lesions of the knee.92 Over the years, this concept has been
carried forth to treat OLT. Osteochondral autograft transplanta-
tion (OAT) is a single-stage replacement rather than a repara-
Fig. 16.40  Standard setup for ankle arthroscopy in a right ankle. Note
tive treatment option that transfers intact hyaline cartilage with
the arthroscope is in the anteromedial portal, the shaver is in the antero- subchondral bone to relatively large defects of the ankle. These
lateral portal, and dedicated inflow is placed through the posterolateral osteochondral plugs can be removed from the sulcus terminalis
portal, with soft-tissue distraction applied via a strap. of the knee intercondylar notch, anterior talar head, or medial
and lateral nonarticulating portions of the talus. This tech-
considered, such as osteochondral transplants, membrane/ nique has the advantage of graft availability, absence of disease
matrix autologous chondrocyte implantation (MACI), juvenile transmission, lower cost, and ability to use multiple plugs (Fig.
allografts, micronized cartilage matrix, or, rarely, a focal resur- 16.42A-D). Disadvantages of the technique include graft avail-
facing implant. These alternatives will be discussed in the fol- ability, nonunion of the osteotomy, donor site morbidity, poor
lowing sections. integration of the graft surface with native tissue, cyst formation
 CHAPTER 16  Osteochondral Lesions of the Ankle 301

A B

C D
Fig. 16.42 Osteochondral autograft transplantation. (A) The osteochondral autograft is obtained from the
lateral femoral condyle in this arthroscopic picture. (B) Note the use of multiple autografts obtained from
the lateral knee. (C) After the osteochondral lesion is removed and the holes drilled appropriately, the osteo-
chondral autograft is inserted until it is flush with the remaining articular cartilage. (D) The final result after
osteochondral autograft insertion. The medial malleolar osteotomy is then reattached with internal fixation.

around the graft site, and nonunion or deterioration of the graft compared chondroplasty and microfracture and OATs in 33
cartilage.93–97 More anterior lesions can be accessed through ankles.100 Although postoperative scores showed significant
plantarflexion and ankle distraction, but more central or pos- improvement at 12 months, the ankle-hindfoot scale showed no
terior lesions, medially and laterally, require an osteotomy with difference in the rest of the group at 24 months, and the subjec-
subsequent screw and/or plate fixation. If the graft protrudes or tive assessment numeric evaluation ratings at 53 months also
sinks below the margin of the normal articular cartilage, contact did not show significant differences in groups. Valderrabano
pressures on the graft surface increase significantly. In addition, et  al. studied 12 patients with OATs and reported significant
biomechanical and structural differences are present between pain relief and improvement at 72 months, but half the patients
talar and knee articular cartilage that may produce problems subsequently noted knee pain and most patients had developed
long-term. recurrent ankle lesions with associated joint degeneration.96
Sammarco and Makwana treated 12 patients with grafting Flynn et al. reported on autologous osteochondral transplan-
from the medial or lateral talar facet and reported improve- tation in 85 consecutive patients.101 The mean FAOS improved
ment in AOFAS score from 65 to 91 at 25 months, follow-up.98 from 50 to 81, and the MOCART score was 86. Lesion size was
Scranton et al. performed 50 OAT procedures for OLT, utiliz- negatively correlated with the MOCART score, and a quanti-
ing plugs from the intercondylar notch.99 Sixty-four percent tative T2 mapping suggested that graft tissue may not always
of these patients failed one or more surgeries prior to the pro- mirror native hyaline cartilage. Hannon et  al. did a prospec-
cedure. These patients achieved 90% good-excellent results, tive randomized study comparing osteochondral autograft
although 15 patients required a second operation. Gobbi et al. transfer, chondroplasty, and microfracture.102 Although the
302 SECTION 3  Anatomic Disorders in Sports

A B

C D
Fig. 16.43  Insertion of osteochondral allograft. (A) Through an anterior approach and distraction, the medial
portion of the talus is removed. (B) This shows the size of the lesion that is removed and measurements done
to replicate the exact anatomy and size on the allograft. (C) The graft of the talus appears to match nicely the
excised portion of the autograft talus removed. (D) Appearance of the allograft after insertion and fixation into
the right ankle.

numbers were small, the pain and functional scores improved grafts for very large lesions. The allograft can be taken from the
in all groups, but there was no significant differences in the exact location on the donor talus as the lesion on the patient’s
Ankle-Hindfoot Scale at 12 and 24 months, or the Subjective own anatomy. A CT scan of the patient’s uninjured talus can be
Assessment Numeric Evaluation. used as a template (Fig. 16.43A-D).
A number of studies suggest that between 63% and 95% of Because of safety concerns over potential infection, allografts
athletes return to their previous level of activity following OAT. are hypothermically stored for a minimum of 14 days to allow
Paul et al. examined sports activity postoperatively in a group for extensive seriologic and biologic testing. Since chondro-
of 31 patients after OATs.103 Although the patients’ time doing cyte viability decreases after 28 days post-mortem, fresh osteo-
sporting activity did not change after surgery, their Tegner chondral allografts should be utilized between 15 and 28 days
scores decreased and the patients did less high-impact and con- post-mortem. Osteochondral allografts, however, also have
tact sports. Paul et al. also reported on 112 patients with mini- some concerns, including difficult graft availability, chondro-
mum 2-year follow-up.104 Only 55% were happy with their knee cyte viability, disease transmission, and cost.
postoperatively. The WOMAC score was 5.5% and the Lysholm Hahn et al. showed improved activity and pain levels in 13
Score was 89. The number of grafts, size of the transplant cylin- patients who underwent allograft transplantation with inter-
ders, and patient age did not influence either the WOMAC or nal fixation.105 Raikin inserted allografts in 15 patients with an
the Lysholm Score. average follow-up of 54 months, and 11 of 15 patients graded
the result as excellent or good.106 El-Rashidy et  al. used fresh
Osteochondral Allograft Transplantation allografts in 38 patients, with a mean age of 44 and a mean
Osteochondral allograft transplantation is similar to OATs lesion size of 1.5 cm2.107 At a follow-up of 38 months, the graft
but avoids some of the disadvantages of the latter procedures. survival was 89% and the AOFAS score went from 52 to 79.
Indications are for failed previous surgery, large lesions, particu- More recently, Gortz, DeYoung, and Bugbee did a follow-up
larly with cysts, and lesions with significant bone loss. Allograft report on 11 allograft patients with 12 ankles.108 All involved
transplantation can use plugs of bone and cartilage or do en bloc partial unipolar grafts inserted through an anterior approach
 CHAPTER 16  Osteochondral Lesions of the Ankle 303

without osteotomy. Mean age was 36 and the follow-up was for OLT.117 AOFAS scores improved from 70 to 95 at 64 month
38 months. The mean OMAS improved from 28 to 71. Graft follow-up. Magnan et al. treated 30 patients with MACI, with a
survival rate was 83%, but only 5 of 12 patients achieved good- mean OLT size of 2.36 cm2.118 The mean AOFAS score improved
excellent results. Shimozono et al. compared 25 nonrandomized from 37 to 84 at a follow-up of 45 months. However, only 50%
autograft patients to 16 allograft patients who had an osteo- of the patients returned to previous sports activity. Kreulen
chondral transplantation for an OLT.109 The autograft group et al. prospectively studied MACI on 10 patients with an OLT
provided better clinical and MRI outcomes than the allograft who had failed previous surgery.119 Nine patients were avail-
patients. The rate of chondral wear on MRI was higher with able at 7-year follow-up and compared with their preoperative
allograft than with autograft, and the allograft-treated patients scores. The SF-36 at 7 years showed significant improvements
had a higher rate of clinical failure. in physical functioning, lack of bodily pain, and social func-
tioning. The mean AOFAS Hindfoot Score improved from 61 to
Autologous Matrix-Induced Chondrogenesis 78. Giannini et al. used a hyaluronic acid-based membrane for
Autologous matrix-induced chondrogenesis (AMIC) is a one- MACI on 46 patients, with mean lesion size of 1.6 cm2.120 Mean
step scaffold-based therapy and is done by performing microf- AOFAS scores improved from 57 to 87 at 12 months, and 89
racture and/or drilling of the lesion, then inserting a type I/III at 36 months. Forty patients were able to resume their normal
collagen membrane to cover the defect. Theoretically, this offers level of sports; only four were forced to give up athletic activity.
a barrier for the clot to be held, and provide an environment for More recently, MACI has been cleared by the FDA to be used
cell differentiation and new cartilage formation. Valderabano in the United States since 2017. The technique we currently use
showed 26 patients with good clinical results on AOFAS and VAS involves usually a medial or lateral malleolar osteotomy with
scores.110 However, MRIs showed complete filling in only 35% of excision of the OLT. If a cyst is present, it is excised and bone
the defects, and 50% of the patients had a hypertrophic cartilage grafted, then covered with fibrin, and the membrane impreg-
layer. Thermann in 2012 did AMIC with microfracture and plate- nated with the patient’s cells is placed over the defect. If no
let-rich plasma (PRP) in 64 patients for an OLT.111 The microf- cyst is involved, the membrane is placed over the defect with
racture holes were filled with PRP and the collagen matrix was fibrin glue and, in some cases, suture augmentation (Fig. 16.44).
soaked in PRP and then glued over the defect. Postoperatively, Currently, studies are underway to assess its efficacy and results
their Hospital for Special Surgery (HSS) results improved from using open surgery in several U.S. centers.
55 to 81 and their VAS scores also significantly improved.
Particulated Juvenile Cartilage
Autologous Chondrocyte Implantation (ACI) Particulated juvenile cartilage (DeNovoTM, Zimmer Biomet) is
In 1965, Smith et al. were the first to isolate and grow chondro- a relatively new technique that involves the use of allograft carti-
cytes in a culture medium. Subsequently, Grande, Peterson, and lage obtained from donors under the age of 13 years. Immature
others were the first to introduce a biologic cell-based technique articular cartilage has a much higher cellular density.121 In addi-
to treat full-thickness cartilage defects with cultured expanded tion, there is an increased proliferation rate and improved ability
chondrocytes.112 They termed this process “autologous chon- to produce extracellular matrix and retain cartilage phenotype.
drocyte implantation,” and it was first introduced in humans The use of particulated juvenile cartilage is a single-stage
in 1987. The indications for this procedure included patients procedure and involves arthroscopic excision of the osteochon-
who failed previous surgery for osteochondral lesions and for dral lesion, drilling or microfracture (this is under debate), and
larger defects, including cystic lesions. Peterson developed the placement of fibrin glue on top of the osteochondral lesion, then
“sandwich technique” to treat large cystic lesions with bone insertion of the particulated cartilage, followed by another layer
grafting and insertion of chondrocytes between two biologic of fibrin glue. This procedure can be done either completely
membranes. Nam and Ferkel reviewed the results of their first arthroscopically or through an open approach (Figs 16.45A-C).
11 patients who failed previous surgery, and excellent results If there is an underlying cyst below the osteochondral lesion,
were seen in 82% of the patients.113 Kwak, Ferkel et  al. pub- this is curetted, removed, and filled with bone graft, then cov-
lished a second report on 29 patients undergoing autologous ered with a layer of fibrin glue prior to inserting the particulated
chondrocyte implantation (ACI) for OLT using a periosteal juvenile cartilage. Coetzee et  al. reported the first large series
graft cover.114 Patients demonstrated significant improvement results in 2013.122 More recently, they have updated their results
in Tegner scores at a follow-up of 70 months. Giannini et  al. with 2-to 7-year follow-up on 77 patients and showed 90% had
studied 46 patients undergoing ACI for large osteochondral over 70% improvement compared with preoperative scores, and
lesions.115 Patients with lateral lesions had better AOFAS scores 92% were satisfied without any or minor reservations.123 There
compared with medial lesions. They operated on 29 athletes, were five revisions in this group of patients. Dekker et al. fol-
and 20 resumed sports at the same level, while 4 could not go lowed 15 patients for a mean follow-up of 35 months and had a
back to their sport. 40% failure rate, with the risk factors of failure including preop-
erative MRI area, intraoperative OLT size, and male patients.124
Membrane/Matrix Autologous Chondrocyte Implantation They found that lesions greater than 125 mm2 had significantly
In 1998, Behrens et al. implanted a type I, III collagen membrane increased risk of clinical failure. Karnovsky et  al. studied 50
impregnated with harvested cultured chondrocytes (MACI).116 patients: 30 with microfracture and 20 with particulated juve-
Since that time, Anders et al. performed MACI on 22 patients nile cartilage.125 Both patient groups showed significant clinical
304 SECTION 3  Anatomic Disorders in Sports

A B C

D E
Fig. 16.44  MACI case study. (A) Cystic osteochondral lesion of the talus that has failed previous surgery
in a left ankle. (B) Guidepins are used to cut along the medial malleolus to ensure that an accurate osteot-
omy is performed lateral to the osteochondral lesion. (C) After excision of the osteochondral lesion, careful
measurement is made of the exact size of the lesion. (D) Placement of the MACI scaffold onto the medial
osteochondral lesion and securing with fibrin glue. (E) Reattachment of the medial malleolar osteotomy in a
left ankle with a hook plate device.

improvements, but no differences were seen in patient-reported utilizing the anteromedial, anterolateral, and posterolateral
outcomes between the groups. However, the average OLT size portals. The OLT is excised and drilled and/or microfractured,
was seen to be larger for the particulated juvenile cartilage then the micronized cartilage is inserted (Fig. 16.46). Fortier
patients than the microfracture patients. At SCOI, we recently et  al. treated 10-mm cartilage defects in horses with microf-
looked at our results with particulated juvenile cartilage in the racture alone or microfracture plus micronized cartilage and
first 18 patients with a prospective study and a mean follow-up PRP.126 The micronized cartilage group safely improved carti-
of 25 months. Scores from the FAOS, FAAM, and SF-36 mark- lage repair compared with microfracture alone up to 13 months
edly improved in every subscale category. We continue to moni- after implantation. The micronized cartilage is mixed with
tor this group with longer follow-up. Further Level 1 studies are bone marrow aspirate into a syringe, which is then injected
necessary to determine the long-term effects of its use. through an open or arthroscopic technique into the ankle. Its
cost is significantly less than particulated juvenile cartilage or
Micronized Cartilage MACI, and it has a shelf life of 5 years. Fansa et  al. studied
More recently, micronized cartilage matrix (BioCartilageTM, 31 patients with micronized cartilage matrix and bone mar-
Arthrex) has been introduced as another cartilage transplant row aspirate concentrate (BMAC), with a mean age of 38 and
alternative. Micronized cartilage matrix is an allograft carti- mean follow-up of 16 months.127 The average lesion size was 86
lage extracellular matrix that contains the key components mm2. The PROMIS scores improved, and the mean postopera-
of cartilage, including type II collagen, proteoglycans, and tive MRI and MOCART were 69. Dekker and Patel studied 12
additional cartilaginous growth factors. It is dehydrated, then patients who had micronized cartilage and BMAC for OLT.128
micronized into small particles and aseptically packaged. Its The PROMIS pain and function were assessed at different
intended use is to provide a scaffold over the microfracture intervals. No significant differences were seen in the PROMIS
defect and hopefully improve the quality of cartilage tissue pain and function scores at 6 and 12 months or preop scores.
that has formed over the osteochondral lesion defect. The The MOCART score was 53. Much more research needs to be
technique is done arthroscopically or through a small mini- done on micronized cartilage to determine its effectiveness in
arthrotomy. Currently, we do all these arthroscopically, the ankle.
 CHAPTER 16  Osteochondral Lesions of the Ankle 305

C
Fig. 16.46 Micronized cartilage matrix. (A) The loose flap of articular
cartilage in a right ankle medial talar dome. (B) Percutaneous drilling
with a thin wire of the OLT. (C) Insertion of the micronized cartilage
matrix through the anteromedial portal in the right ankle, while visualiz-
C ing from the posterolateral portal.
Fig. 16.45 Particulated juvenile cartilage. (A) After the osteochondral
lesion is excised in this right ankle, fibrin glue is applied over the osteo-
chondral lesion bed and then the juvenile particulated cells are inserted FUTURE CELL STRATEGIES
through the anteromedial portal. Visualization through the posterolateral
portal. (B) The entire lesion is carefully filled with the particulated juve- The MIAMI Cell
nile cartilage and impacted with a freer elevator. Visualization through The MIAMI (marrow isolated adult multilineage inducible) cell
the posterolateral portal. (C) A small amount of fibrin glue is placed is a primitive mesenchymal stem cell that expresses many of the
over the juvenile particulated cartilage to ensure stability. Visualization
genes expressed by embryonal cells but follows a script. Under
through the posterolateral portal.
appropriate experimental conditions, these cells can be induced
306 SECTION 3  Anatomic Disorders in Sports

to become bone forming or cartilage forming. Tom Temple and

his colleagues have done a great deal of work on this, but no
results are available at this time.

Metallic Cap Implant

A metallic cap implant has been developed for use in cases of failed
OLT surgery. It has a cobalt chrome component and many of the
original biomechanical studies were done at the University of Iowa.
It is intended to be used for osteochondral lesions of the medial talar
dome, and it is hoped that it will redistribute the contact stresses
toward normal. Van Bergen et al. reported using a metallic resur-
facing implant in 20 patients with an average follow-up of 3 years.76
They found the FAOS scores improved and there was decreased
pain on rest, walking, stair climbing, and running. More recently,
Vuurberg et al. reported on the metallic cap implant on 38 patients
with a mean follow-up of 5.1 years.129 AOFAS scores increased
from 57 to 80 and most of the FAOS scores improved. Return to
sport occurred at a mean of 4.1 months, and 77% resumed some
sports activity. There were 2 failures and 21 reoperations.
In the future, cartilage transplant material must be implanted
easily and quickly, preferably through the arthroscope. It must
have reduced surgical morbidity and not require harvesting
other tissue. In addition, it must exhibit an enhanced cellular A
proliferation and maturation, easier phenotype maintenance,
and allow for efficient and complete integration with surround-
ing articular cartilage.
Hopefully in the future, techniques will be developed that allow
athletes to return back to their sporting activity with a high per-
centage of excellent results that hold up after a long time period.

OSTEOCHONDRAL LESIONS OF THE TIBIAL

PLAFOND
OLTP or osteochondral lesions of the distal tibia are much less
common than OLT. In the past, we looked up our own num-
bers at the Southern California Orthopedic Institute and found
approximately 30% of all ankle arthroscopies involved OLT,
B
while only 3% of our ankle arthroscopies involved OLTP. The
etiology can be trauma, spontaneous osteonecrosis, vascu-
lar supply problems, and others. Elias et  al. used 38 MRIs to
determine the most common location and size of OLTPs.130 The
medial central plafond was most common and the posterome-
dial plafond was the second most frequent. In our own experi-
ence, most of these occur in the central posterior aspect of the
distal tibia. Some occur in the medial malleolus.

Technique
The technique for treating an OLTP is the same as an OLT. We
use small joint 2.7-mm 30- and 70-degree arthroscopes and
use small instrumentation with multiple portals. Occasionally,
lesions of the distal tibia will occur with a lesion of the talus, and
are called “bipolar” lesions. C
The technique for treatment includes unroofing and removing
Fig. 16.47 Osteochondral lesion of the tibial plafond. (A) Sagittal CT
the loose articular cartilage and bone with curettes and a shaver. scan showing the posterior location of the osteochondral lesion of
We then use a thin wire to drill the lesions, either retrograde or the tibial plafond. (B) Excision of the osteochondral lesion of the tib-
antegrade, and may also put a few small microfracture holes in the ial plafond with curettes to good bleeding bone and healthy cartilage.
lesion as well. The MicroVectorTM is very helpful to drill these par- (C) Insertion of the MicroVectorTM to drill holes into the osteochondral
lesion of the tibial plafond.
ticular lesions retrograde (Fig. 16.47). If there are cysts, these cysts
 CHAPTER 16  Osteochondral Lesions of the Ankle 307

need to be removed and the area bone grafted as well. Mologne three intraarticular hyaluronic injections performed weekly
and Ferkel published the first paper on treatment of these lesions beginning in the third postoperative week after an arthroscopic
in 17 patients and found the AOFAS scores improved from 52 debridement and microfracture significantly improved clinical
to 87.54 Fourteen of 17 patients (82%) had good and excellent scores, compared with microfracture only control.133 Mei-Dan
results. Cuttica et al. reported on 13 patients who were treated for et  al. compared the use of PRP or hyaluronic acid to treat an
an osteochondral lesion of the tibial plafond.131 Nine patients had OLT.135 Both groups improved postoperatively, but the PRP
an isolated lesion and four had a bipolar lesion. Eleven of the 13 group significantly had a better outcome than the hyaluronic
patients were available for follow-up, and their AOFAS score went acid group.
from 35 to 50. Four patients had a poor outcome.
If there is an underlying cyst below the osteochondral lesion, Bone Marrow Aspirate Concentrate (BMAC)
this is curetted, removed and filled with bone graft, then cov- BMAC is a great source of mesenchymal stem cells, growth
ered with a layer of fibrin glue prior to inserting the particulated factors, and cytokines that may improve the quality of carti-
juvenile cartilage. lage repair tissue. BMAC is obtained intraoperatively from
the iliac crest, proximal or distal aspects of the tibia, or calca-
neus. Fortier et al. graded an osteochondral lesion in 12 horses
BIOLOGIC ADJUVANTS TO CARTILAGE REPAIR and compared the use of BMAC with microfracture versus
(SEE ALSO CHAPTER 30) microfracture alone.136 The group with BMAC plus microf-
racture resulted in superior healing of cartilage defects than
Platelet-Rich Plasma (PRP) the microfracture alone. Goodrich et  al. studied the effect of
PRP is an autologous blood product that contains at least twice BMAC on PRP-enhanced fibrin scaffolds and chondral defects
the concentration of platelets compared with baseline values. in horses.137 He found PRP resulted in thicker repair tissue that
These platelets contain cytokines and growth factors that par- was not improved by adding BMAC. We usually obtain the
ticipate in tissue healing and can also potentially attract mes- BMAC from the iliac crest through a separate setup, then repo-
enchymal stem cells to the osteochondral lesion. Smyth et  al. sition, re-prep, and drape the patient for the arthroscopic ankle
showed in a literature review that there was a positive effect of procedure. After the osteochondral lesion is excised and mar-
PRP on cartilage repair.132 A number of the authors showed that row stimulation is performed, the joint is suctioned dry and the
PRP increased chondrocyte and mesenchymal stem cell prolif- thickened BMAC is then inserted over the osteochondral lesion
eration, type II collagen deposition, proteoglycan deposition, (Fig. 16.48).
and inhibited the effects of catabolic cytokines.
Bone Marrow–Derived Cell Transplantation
Hyaluronic Acid Bone marrow–derived cell transplantation (BMDCT) uses
Hyaluronic acid is a carbohydrate component contained within a combination of BMAC and a scaffolding material to fill the
synovial fluid that enhances the viscoelastic properties and osteochondral defect after excision and marrow stimulation.
experimentally increases the proliferation of cultured chon- Postoperative scores have been shown with this technique to
drocytes in vitro.133,134 More recently, Doral et al. showed that significantly improve the clinical results.138

A B
Fig. 16.48  Bone marrow aspirate concentrate. (A) A small incision is made in the iliac crest and a Jamshidi
needle is inserted between the inner and outer tables of the iliac crest to obtain 60 ccs bone marrow aspirate.
(B) Bone marrow aspirate is then spun down to approximately 5 ccs and injected onto the osteochondral
lesion after a bone marrow stimulation procedure has been performed. Visualization from the anterolateral
portal in an osteochondral lesion of the left ankle medial talus.
308 SECTION 3  Anatomic Disorders in Sports

INTERNATIONAL CONSENSUS MEETING ON on a yearly basis. In November 2017, the first International
Consensus Meeting on Cartilage Repair of the Ankle occurred
CARTILAGE REPAIR OF THE ANKLE in Pittsburgh, Pennsylvania. Ninety-five participants from 26
In 2011, Drs. John Kennedy, Niek van Dijk, and Richard Ferkel countries around the world convened, using the Delphi Process
formed the International Society on Cartilage Repair of the to answer questions on all aspects of cartilage repair of the
Ankle (ISCRA) to study osteochondral lesions. The first meet- ankle. These proceedings have been published in a supplement
ing was called the International Congress on Cartilage Repair to the Foot and Ankle International journal and are available for
of the Ankle (ICCRA) and was held in Dublin, Ireland, in all to read and review.139 Very specific guidelines are presented
March 2012. Subsequently, there were five other meetings in this monograph to help guide treatment of OLT.

S U M M A R Y
Osteochondral lesions of the talus and tibial plafond pose sig- is very exciting, but much work needs to be done to develop a
nificant challenges for treatment. There are many factors that technique that will produce true type II articular cartilage, hold
influence results, including the size of the lesion, location of up for a lifetime, that will be safe, cheap, and easy to perform,
the lesion, containment of the OLT, subchondral cysts, status preferably arthroscopically. At this time, we have options for our
of the cartilage cap, as well as other associated pathology. Great athletes with osteochondral lesions of the tibia and/or talus, but
research is occurring throughout the world to try to find bet- significant questions still exist as to the best technique to return
ter techniques and materials to treat these lesions. The future athletes long term to their desired sport.

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 17
Disorders of the Subtalar Joint, Including
Subtalar Sprains and Tarsal Coalitions
Gregory P. Guyton

OUTLINE
Introduction, 312 Physical Examination, 317
Anatomy, 312 Radiographic Evaluation, 318
Subtalar Instability, 313 Nonoperative Treatment, 318
Clinical Presentation, 313 Surgical Treatment, 318
Physical Examination, 313 Tarsal Coalition, 318
Radiographic Evaluation, 313 Clinical Presentation, 319
Nonoperative Treatment, 315 Physical Examination, 319
Surgical Treatment, 315 Radiographic Evaluation, 319
Sinus Tarsi Syndrome, 315 Nonoperative Treatment, 320
Clinical Presentation, 315 Surgical Treatment, 320
Physical Examination, 315 Calcaneonavicular Coalitions, 321
Radiographic Evaluation, 316 Technique of Resection of Calcaneonavicular
Nonoperative Treatment, 317 Coalition, 321
Surgical Treatment, 317 Talocalcaneal Coalitions, 321
Subtalar Dislocation, 317 Technique of Resection of Talocalcaneal Coalition, 322
Clinical Presentation, 317

(Fig. 17.1). Confluence of the anterior and middle facets is

INTRODUCTION present in over 40% of cases.1 The bony articulations provide
Pathology in the subtalar joint can be debilitating, is challenging inherent stability and soft tissues provide additional stabili-
to diagnose, and can lead to significant lost time for the athlete. zation. The lateral soft-tissue stabilizers have been classified
In addition to acute bony or cartilage injuries, instability, liga- into three separate layers.1 The superficial layer is composed
mentous strain, and congenital coalition may all play a role in of the lateral root of the inferior extensor retinaculum, the lat-
generating subtalar pain. Subtalar instability as an isolated phe- eral talocalcaneal ligament, and the calcaneofibular ligament
nomenon or in conjunction with lateral ankle ligament insta- (CFL). The intermediate layer consists of the intermediate root
bility is often subtle and is frequently overlooked. Sinus tarsi of the inferior extensor retinaculum and the cervical ligament.
syndrome remains a nebulous diagnosis that can typically be The deep layer consists of the medial root of the inferior exten-
correlated with distinct intraarticular pathology. Additionally, sor retinaculum and the interosseous talocalcaneal ligament
pain along the lateral aspect of the subtalar joint may result from (Fig. 17.2).
a severe planovalgus position of the foot leading to impinge- The joints move in a triaxial plane, which allows for
ment of the calcaneus against the fibula. Subfibular impinge- the motions of flexion/extension, inversion/eversion, and
ment must be distinguished from true pathology of the subtalar adduction/abduction.
joint. Tarsal coalition, although found in up to 2% of the popu- The sinus tarsi is a broadly conical space on the lateral
lation as a whole, is commonly symptomatic in the running or aspect of the foot that lies anterior to the posterior facet
jumping athlete/dancer. between the talus and the calcaneus. It is in continuity with
the tarsal canal. The tarsal canal is a narrow opening within
the medial subtalar joint and is situated in a posteromedial-
ANATOMY to-anterolateral direction. Soft tissues within the sinus tarsi
The subtalar joint is comprised of three articulating surfaces: include the artery of the tarsal canal, bursae, nerve endings,
the posterior facet, the middle facet, and the anterior facet and multiple ligaments.
312
 CHAPTER 17  Disorders of the Subtalar Joint 313

the hindfoot. This results in a progressive injury to the talona-

vicular ligament and talonavicular capsule, followed by injury
to the calcaneofibular and lateral talocalcaneal ligaments.8 The
presenting complaint often is a sensation of giving way of the
ankle. The patient may report pain localized to the region of
the sinus tarsi. Athletic activities can exacerbate the symptoms,
resulting in a dependence on bracing or taping. Uneven surfaces
may cause pain and a feeling of instability.
It is difficult to differentiate lateral ankle instability from sub-
talar instability on the basis of patient history. A thorough clin-
ical and radiographic workup can help define the source of the
athlete’s complaints, but the differentiation still can be elusive.
Fig. 17.1  Variations in the anterior and middle facets of the calcaneus.
Conjoined, transitional, and distinct facets are all seen in the population. Physical Examination
(From Ragab AA, Stewart SL, Cooperman DR. Implications of subtalar The most notable finding on physical examination is increased
joint anatomic variation in calcaneal lengthening osteotomy. J Pediatr inversion of the subtalar joint. This should be compared with
Orthop 2003; 23:79-83.)
the presumably uninjured opposite limb. The increased inver-
sion can result from subtalar instability or a combination of
subtalar and ankle instability.4,8 It is not possible to detect the
SUBTALAR INSTABILITY location of increased inversion by examination. In addition to
The role that instability of the subtalar joint plays in the patient increased inversion of the hindfoot, an increased translation
with lateral ankle instability has been elucidated only recently. of the calcaneus in the medial direction has been noted by
Some authors have estimated that 10% to 30% of patients with Thermann et al.10 In their test, a valgus stress was applied to the
functional ankle instability marked by a sense of “giving way” calcaneus, followed by an abrupt internal rotation stress. Stress
of the ankle have evidence of instability of the subtalar joint.2,3 radiographs showed a medial shift of the calcaneus in relation
It has been suggested that consideration should be given to the to the talus or an opening of the talocalcaneal angle in patients
concept of global hindfoot instability rather than simply func- with subtalar instability.
tional instability about the ankle joint.4 Following an acute injury, there may be swelling, bruising,
Instability of the subtalar joint was first proposed in 1962 and tenderness laterally. In the more chronic setting, increased
by Rubin and Whitten.5 They proposed a series of stress radio- inversion and lateral tenderness are more likely. It is easier to
graphs to further evaluate this disorder. Brantigan et al.6 were detect instability clinically in the chronic setting because the
the first to detect radiographic evidence of subtalar instability in athlete will be less apt to guard because of pain.
their series of three patients. Chrisman and Snook7 in 1969 were
able to document clinical subtalar instability in three of seven Radiographic Evaluation
patients who were undergoing their tendon transfer procedure The initial radiographic workup of the patient with subta-
for lateral instability. Clanton and Berson8 described subtalar lar instability involves a weight-bearing anterior-posterior
injuries as a continuum of other injuries in athletes, particularly (AP), lateral, and mortise view of the affected ankle, as well
sprains of the lateral ankle ligaments. as weight-bearing AP, lateral, and oblique radiographs of the
While most cases of subtalar instability are associated with a affected foot to rule out evidence of bony pathology.
more global pattern of injury to the lateral ankle ligament com- Plain radiographs often are negative, and further investigation
plex including the anterior talofibular and calcacaneofibular must be carried out to arrive at the diagnosis. There have been
ligaments, cases of isolated subtalar instability do occasionally multiple investigations into the use of stress radiographs in the
present without associated tibiotalar pathology. It is difficult if not workup of subtalar instability (Fig. 17.3).6,11-13 In a series of three
impossible to distinguish excess motion on physical examination patients, Brantigan et al.6 were able to radiographically demon-
from the subtalar joint alone from that emanating from the tibio- strate subtalar instability. They attributed the instability to an
talar joint or a combination of the two. While stress radiographs injured CFL. Heilman et al.13 sequentially sectioned ligaments in
have a very limited role in the diagnosis of ankle instability, they cadaver limbs and then obtained lateral and Broden’s radiographs.
may be of utility in diagnosing isolated subtalar instability pat- They found that sectioning of the calcaneofibular joint caused a
terns. Lateral gapping of the subtalar joint on a Broden’s view is 5-mm opening of the subtalar joint. With subsequent sectioning
typically seen in these cases, although the results must be inter- of the interosseous ligament, the joint opened up to 7 mm.
preted with caution. The diagnosis is based upon a combination The utility of stress radiographs has been called into question
of radiographic and clinical factors; lateral gapping on stress view by multiple authors.14-16 Harper14 reported a wide range of sub-
may be seen in asymptomatic patients as well.9 talar tilt with stress radiographs in his group of asymptomatic
patients. Louwerens et al.15 examined 33 patients with chronic
Clinical Presentation ankle instability and 10 control patients who were asymptom-
The typical injury that leads to instability of the subtalar joint atic. Broden’s views were checked under fluoroscopy and they
is a severe supination or supination-inversion force applied to detected no difference between symptomatic and asymptomatic
314 SECTION 3  Anatomic Disorders in Sports

DORSAL

Fibula
Tibia Inferior extensor
MEDIAL
Talus retinaculum
Interosseous
Calcaneus talocalcaneal Lateral
Intermediate Roots
Talus ligament
Medial

Cervical

Lateral talocalcaneal
Calcaneofibular
Calcaneus LATERAL

Cervical ligament

PLANTAR
Fig. 17.2  The anatomy of the subtalar joint. (From Mann RA, Coughlin MJ, edis: Surgery of the foot and ankle,
7th ed. St Louis: CV Mosby; 1999: p1147, Figure 26-57.)

A B
Fig. 17.3  Stress radiographs. (A) Stress anterior-posterior (AP) radiograph with subtalar tilt. (B) Stress Broden
view showing subtalar instability.

feet with regard to subtalar tilt or medial shift. Van Hellemondt tilt and anterior drawer stress radiographs for ankle instability
et al.16 examined both stress radiographs and stress computed and found no normative values and little agreement between
tomography (CT) scans in 15 patients with unilateral chronic studies. Nevertheless, a markedly positive stress radiograph
ankle instability with suspected subtalar instability. Although remains the only definitive means to demonstrate the presence
three of the symptomatic feet and one of the asymptomatic feet of subtalar instability.
had increased subtalar tilt on plain films, there was no signif- It is most accurate to state that a positive stress radiograph,
icant difference between the symptomatic and asymptomatic either in a clinic or operating room setting, is a necessary but
sides. None of the patients had increased subtalar tilt on the not sufficient condition to clearly make the diagnosis of isolated
stress CT scans. The authors therefore doubted that a Broden’s subtalar instability. The false-positive rate is high, and the radio-
stress examination reveals the true amount of subtalar tilt. Frost graphic findings must be correlated with the physical examina-
and Amendola17 reviewed the collective literature on both talar tion and history.18
 CHAPTER 17  Disorders of the Subtalar Joint 315

Nonoperative Treatment The use of the braided suture anchored with interference
In an acute injury, the standard treatment regimen for lateral screws has also recently been described for lateral ankle ligament
ankle sprains will suffice for subtalar ligamentous injuries as reconstruction.31 The primary utility of the suture construct is
well. Rest, ice, compression, and elevation (RICE) are part of a immediate strength of the ATFL portion of the reconstruction
good protocol, as well as immobilization and physical therapy, to allow early mobilization. That same rigidity can create the
when needed. The same can be said for management of chronic hazard of limited subtalar motion if it is used across the path
subtalar instability. The routine nonoperative regimen used for of the CFL. While routine use of the suture construct across
chronic lateral ankle instability is initiated. This may include the ATFL reconstruction may have significant benefit for early
proprioceptive training, peroneal strengthening, and bracing or mobilization, extension across the subtalar joint is not neces-
strapping.8,19 With bracing, it is important to understand the sary in most cases.
delicate balance in providing an athlete with enough support
without impeding his or her performance. Taping by an athletic
trainer before participation can be effective. Wilkerson20 exam-
SINUS TARSI SYNDROME
ined a modification of the standard method of ankle taping with Symptoms of sinus tarsi syndrome may overlap with those
the incorporation of a “subtalar sling.” He found that addition associated with subtalar instability. Some authors consider this
of the sling enhances the protective function of taping but cau- syndrome simply a variant of subtalar instability.32 Sinus tarsi
tioned that it may impede performance of certain activities. syndrome simply describes pain localized to the region of the
sinus tarsi. Characteristic findings on clinical and radiographic
Surgical Treatment examination have not been well defined. Likewise, the patho-
Patients with residual symptomatic instability despite an ade- logic changes found at the time of surgery are unclear. The most
quate program of nonoperative management will require a widely reported description of the pathologic anatomy asso-
surgical stabilization of their subtalar joint. If both ankle and ciated with this condition is degenerative changes to the soft
subtalar instability exist and require surgery, both problems tissues of the sinus tarsi.33,34 The majority of cases are posttrau-
should be corrected at the time of surgery.4 Surgical stabiliza- matic but also may be related to inflammatory arthropathies,
tion involves direct ligament repair or lateral tendinosis proce- gout, ganglion cysts, and structural foot abnormalities.35,36
dures to substitute for the irreparable ligaments. The term sinus tarsi syndrome is typically used to refer to
Many techniques have been described to concurrently stabi- pathology emanating from the subtalar joint. It must be dis-
lize the ankle and subtalar joint (Fig. 17.4, A through C).2,7,10,19-27 tinguished from extraarticular impingement of the fibula
Many require some form of extraarticular tendon transfer to against the lateral calcaneus in a fixed or dynamic planovalgus
provide stability. Kato28 and Pisani29 described techniques deformity. The pain in the case of subfibular impingement is
focused on the subtalar joint involving intraarticular ligament more typically located underneath the fibula and may only be
reconstruction of the interosseous ligament between the calca- present with weight bearing. The condition typically does not
neus and talus. respond even transiently to injection of the subtalar joint, as
A less invasive technique that, according to Clanton and the impingement is extraarticular. Magnetic resonance imag-
Berson8 and Gould et al.,25 provides a good treatment for subta- ing (MRI) may be helpful in making the diagnosis in subtle
lar instability is the Brostrom-Gould reconstruction technique cases; edema in the lateral talus, distal fibula, or lateral calca-
for lateral ankle instability (Fig. 17.4, D and E). With the recon- neus is often present.37
struction of the CFL and anterior talofibular ligament (ATFL)
buttressed by the inferior extensor retinaculum, subtalar stabil- Clinical Presentation
ity is effectively restored.8,25 There is no significant drawback to The typical complaint is pain over the lateral and anterolateral
its routine inclusion in lateral ankle ligament reconstruction; ankle and hindfoot centered in the region of the sinus tarsi.
doing so may obviate any concern over subtle subtalar insta- The patient may report a sensation of mild hindfoot instabil-
bility in many cases. When the extensor retinaculum and the ity. It has been estimated that as many as 70% of patients with
fibular periosteum are sufficient to hold suture, the Gould mod- sinus tarsi syndrome have had a previous inversion injury to the
ification of the Brostrom procedure should be performed. hindfoot.38
No clear criteria exist to guide the use of allograft or autograft Excessive motion of the subtalar joint may result in tem-
reconstruction of the lateral ankle ligaments. In patients with a porary impingement against the fibula in the athlete partici-
previous failed reconstruction, documented history of Ehlers- pating in a cutting activity. The symptoms in these cases are
Danlos syndrome, or failed contralateral reconstruction, aug- transient and localized to the sinus tarsi or lateral calcaneus.
mentation of the repair is warranted. The technique originally The diagnosis of this entity is based primarily upon the same
described by Colville utilizes a split peroneus brevis tendon to criteria as for subtalar instability. As in subfibular impinge-
recapitulate the ATFL and CFL in an anatomic fashion.30 Rather ment, edema in the distal fibula or lateral calcaneus may be
than split a normal native tendon, O’Neil and Guyton recently present on MRI.37
described a method of reconstruction utilizing a combination of
semitendinosis allograft and a braided suture construct to pro- Physical Examination
vide both new tissue and early strength to difficult cases with Tenderness over the lateral ankle and hindfoot overlying the
poor soft-tissue envelopes.18 sinus tarsi is the most common finding on clinical examination.
316 SECTION 3  Anatomic Disorders in Sports

1/2 Peroneus Peroneus brevis

brevis

Sutured

A B Sutures C
Anterior talofibular ligament Lateral
Lateral malleolus
malleolus

Extensor Extensor
retinaculum retinaculum

Peroneal
tendons

Calcaneofibular
ligament
Calcaneofibular Peroneal
ligament tendons
D E
Fig. 17.4  (A) Chrisman-Snook modification of Elmslie procedure. (B) Triligamentous reconstruction. (C) Larsen
procedure. (D) Lateral ankle ligament reconstruction. (E) Reinforcing repair with inferior extensor retinaculum.
(From Mann RA, Coughlin MJ, eds: Surgery of the foot and ankle, 7th ed. St Louis: CV Mosby; 1999, A from
p1128, Figure 26-35; B from p1153, Figure 26-64; C from p1127, Figure 26-34; D and E from p1128, Figure
26-36.)

Patients may have findings of mild subtalar instability; however, Radiographic Evaluation
this is difficult to elicit and often absent. Swelling overlying the Plain films are negative in this condition. Stress views may reveal
sinus tarsi is variably present. mild subtalar instability, but, as noted in the previous section,
To distinguish sinus tarsi syndrome from subfibular impinge- these are of uncertain value. Subtalar arthrograms have been
ment, examination of the foot while standing and walking described in the evaluation of this condition. The normal sub-
should be performed to assess hindfoot valgus. In more subtle talar joint will accept 3 ml of contrast dye and will demonstrate
cases, intraarticular injection of the subtalar joint may be per- multiple recesses and interdigitations within the joint capsule.21
formed to help distinguish the two entities. Subtalar injection is Under normal circumstances there is a small recess that projects
less reliable, however, at distinguishing pathology of the subta- anteriorly from the subtalar joint. The absence of this synovial
lar joint from that of the ankle and peroneal tendons; Kirk et al. recess has been associated with sinus tarsi syndrome.35,38
demonstrated that communication on injection of the subtalar MRI has also been used in the evaluation of sinus tarsi syn-
joint into these structures is remarkably common even in nor- drome. The key MRI features include replacement of the normal
mal specimens.39 fat signal intensity in the sinus tarsi with fluid, inflammatory
 CHAPTER 17  Disorders of the Subtalar Joint 317

A B
Fig. 17.5  (A) Arthroscopic examination of the subtalar joint with anterior working portal. (B) Posterior working
portal.

tissues, or fibrosis.36,38 The inflammatory changes often will was first described separately by DuFaurest41 and Judcy42 in
obscure the ligaments that are normally visualized in the sinus 1811. Broca43 later classified these injuries as medial, lateral, and
tarsi. Additional findings may include ganglion cysts and chon- posterior. Dislocations are named by the direction in which the
dral changes.40 foot moves relative to the talus. In 1856, Malgaigne44 revised
MRI is not typically useful in the setting of acute injury, as this classification and added anterior subtalar dislocations as a
it typically shows dramatic postinjury bony edema and is less specific entity. Frequency of the different subtypes of subtalar
reliable than CT for demonstrating small bony fragments that dislocations has been reported as 80% medial, 17% lateral, 2%
may become incarcerated in the joint. posterior, and 1% anterior.45

Nonoperative Treatment Clinical Presentation

Injections of local anesthetic and steroid into the sinus tarsi may These injuries may result from high-energy mechanisms such as
be both diagnostic and therapeutic. If the patient does not report motor vehicle accidents or falls from a height, but they also can
even temporary relief following injection, then skepticism must result from a twisting athletic injury. In 1964, Grantham46 coined
be directed at a diagnosis of sinus tarsi syndrome. In the case of the term “basketball foot” to describe medial dislocations because
suspected subtalar intraarticular pathology, accurate placement of four of the five patients in his series injured their foot playing bas-
a diagnostic injection into the capsule of the subtalar joint is pos- ketball. Low- and high-energy mechanisms create two subtypes
sible on a consistent basis.39 Some patients may report permanent of subtalar dislocations. High-energy injuries are more likely to
resolution of their symptoms after a series of injections.21 Surgery be open, more likely to be lateral, have a higher incidence of asso-
is indicated if pain recurs after a series of one to three injections. ciated fracture, and have a worse long-term prognosis.47
Forced inversion of the foot results in a medial subtalar
Surgical Treatment dislocation, whereas eversion causes a lateral dislocation.
Open and arthroscopic techniques are available. Open excision During medial dislocations, the sustentaculum tali serves as
of the tissue filling the sinus tarsi has been reported to have good the fulcrum around which the foot rotates. With lateral dis-
results.21,34,35 Typically a lateral oblique incision is made over locations, the foot rotates around the anterior process of the
the region of the sinus tarsi. The lateral branch of the superficial calcaneus.
peroneal nerve is avoided. The inferior extensor retinaculum Significant foot deformity is found in all patients with sub-
and the origin of the extensor digitorum brevis are reflected dis- talar dislocation, although this may be somewhat obscured by
tally. The sinus tarsi is entered, and debridement is performed. swelling. Approximately 20% of subtalar dislocations involve
Arthroscopic exploration (Fig. 17.5) of the sinus tarsi for open injuries.48-50 However, open injuries are unusual in the
diagnosis and treatment has been described and is preferred. athlete.
Typically, a tear of the interosseous ligament and associated
fibrosis is encountered. Complete decompression and wide Physical Examination
exposure of the posterior and middle facet is required.27 The deformity is usually clinically obvious. With medial dislo-
cations, the skin is tented over the lateral malleolus and the dor-
solateral talar head. With lateral dislocations, the skin is tented
SUBTALAR DISLOCATION over the prominent medial talar head and the medial malleolus.
A subtalar dislocation involves the dislocation of the talocalca- A thorough neurovascular examination should be performed,
neal and talonavicular joints. With this injury there is no asso- although ischemia of the foot is uncommon with these injuries,
ciated dislocation of the calcaneocuboid or tibiotalar joints. It especially in the athlete. There is a risk of local ischemia to the
318 SECTION 3  Anatomic Disorders in Sports

soft tissues in the region of the tented skin if reduction is not methods. Lateral dislocations are more likely to require open
prompt. Medial dislocations may reduce prior to presentation reduction than medial dislocations.50,55 In their series of 25
in the emergency department. patients, Bibbo et  al.50 reported that closed reduction was
unsuccessful in eight patients (32%). Four of these cases had
Radiographic Evaluation identifiable soft-tissue interposition that blocked reduction.
The relationship of the talar head to the concave proximal side None of the patients with a low-energy mechanism of injury
of the navicular is normally is congruent. On the lateral radio- required an open reduction.
graph, the talar head lies superior to the navicular with medial Blocks to reduction with medial dislocations may include
subtalar dislocations. With lateral subtalar dislocations the buttonholing of the talar head through the extensor retinaculum
opposite is true, and the talar head appears inferiorly displaced. or capsule of the talonavicular joint.56,57 There have been reports
Associated fractures about the foot and ankle are common. of the deep peroneal nerve interposition blocking reduction as
These are better identified on postreduction radiographs. DeLee well.56 Finally, the lateral edge of the navicular may impact into
and Curtis51 reported a 47% incidence of associated osteochon- the medial talar head and thereby block reduction.57 With lat-
dral fractures of the talonavicular or talocalcaneal joints in their eral dislocations, reduction may be blocked by impingement of
series of 17 patients. Osteochondral fractures were more com- the posterior tibial or flexor digitorum longus (FDL) tendons
mon with lateral subtalar dislocations in this series. Other series and by impaction of the medial edge of the navicular onto the
have reported an incidence of associated foot and ankle injuries lateral talar head.57-59
of 64% to 88%.49,50 For open reduction of medial dislocations, a longitudinal
Because of the difficulty in identifying associated fractures anteromedial incision is made along the talar neck extending
on plain radiographs, postreduction CT scans have been recom- to the talar head. This allows access to the structures that have
mended as a means of identifying associated injuries.51 Bohay entrapped the talar head. At the same time, inspection of impac-
and Manoli52 reported four cases of patients who had normal tion fractures of the articular surfaces can be carried out. For
films following reduction of subtalar dislocations. CT scans lateral dislocations, a more medial longitudinal incision is made
revealed intraarticular fractures in all four cases. The authors over the prominent talar head. Interposed tendons are released
recommended CT scanning in all patients with normal radio- and joint surfaces are inspected. Any tears found in the tendons
graphs following reduction of subtalar dislocations. Diagnosis is should be repaired.
important because associated intraarticular fractures have been
associated with a poor prognosis.50,51,53
TARSAL COALITION
Nonoperative Treatment Tarsal coalition involves a congenital developmental failure of
The majority of subtalar dislocations can be reduced using separation between two or more tarsal bones. This coalition
closed methods. Depending on the time from injury, reduction may be bony or fibrous. The two most common locations for
can be achieved with minimal sedation. The reduction process coalition are at the talocalcaneal and calcaneonavicular joints.
involves bending the knee to relax the gastrocnemius. Traction These locations account for approximately 90% of all coali-
is applied to the heel and countertraction is applied to the thigh. tions.60 Less commonly, coalitions have been described at the
As traction is being applied, the deformity is accentuated by talonavicular, calcaneocuboid, navicular cuneiform, and cuboid
inverting the foot for medial dislocations and everting it for lat- navicular articulations.
eral dislocations. The deformity then is reversed as direct pres- Previously it had been suggested that the etiology of
sure is placed over the prominent talar head to aid in reduction, tarsal coalition involved the incorporation of accessory
particularly those with entrapped fragments within the subtalar ossicles into adjacent tarsal bones.61 In 1955, Harris62 per-
joint. formed microscopic dissection of fetal hindfeet and demon-
Following reduction, the foot is placed into a bulky splint. strated a failure of mesenchymal separation. This failure of
Slight eversion of the hindfoot in the splint will help to stabi- segmentation has become the most widely accepted the-
lize medial dislocations, and inversion will hold lateral disloca- ory regarding the etiology of this disorder. It generally is
tions. Plain radiographs then are obtained to verify reduction. described as an autosomally dominant disorder with incom-
A CT scan is recommended to rule out associated fractures. plete penetrance.63,64
Early mobilization of the uncomplicated medial subtalar dis- The incidence of tarsal coalition has been estimated to
location with a 2-week progression to weight bearing has been be less than 1%.65 The incidence was likely underestimated
supported.54 Injuries with associated fractures will require a before the use of CT scans. Further confounding the inci-
longer period of immobilization, typically in the range of 6 to dence is the asymptomatic nature of a large percentage of
8 weeks. Following casting, a program of strengthening and coalitions. In 1974, Leonard66 studied the first-degree rela-
range-of-motion exercises is initiated. tives of 31 patients with tarsal coalition. He found that 39%
of the first-degree relatives had coalitions on radiographs,
Surgical Treatment but all were asymptomatic. Approximately 50% of coalitions
The indications for operative intervention are open injuries are bilateral, with calcaneonavicular coalitions more likely to
and inability to achieve a congruent reduction using closed occur bilaterally.65,67
 CHAPTER 17  Disorders of the Subtalar Joint 319

Clinical Presentation
PEARL
Children with hindfoot coalition are often asymptomatic until
ossification of the fibrous or cartilaginous coalition occurs. This should be differentiated from an asymptomatic flexible flatfoot, in which
Before this time, some degree of motion is preserved at the heel varus and medial arch is restored with single-foot and double-foot heel rise.
affected joint. Once the coalition ossifies, the motion at the The degree of the deformity can be quite variable. Talocalcaneal coalitions are
associated with a more severe hindfoot valgus deformity than coalitions at other
affected joint is lost and symptoms may arise. The timing of this
sites.72 Talocalcaneal coalitions typically eliminate motion of the subtalar joint.
ossification may vary, depending on the location of the coali-
tion. Patients with calcaneonavicular coalitions may become
symptomatic earlier (age 8–12 years) than patients with talocal-
caneal coalitions (age 12–16 years).68 PEARL
Patients with tarsal coalition can present with pain, stiff- Calcaneonavicular coalitions may cause only a partial reduction of hindfoot
ness, and/or a deterioration of athletic performance. Increased motion.
stresses are placed on surrounding structures as motion in the The patient may be tender about the hindfoot/midfoot, depending on the
hindfoot is restricted, and this may lead to pain. Although a pla- location of the coalition. Calcaneonavicular coalitions often cause anterolat-
novalgus position of the foot has been classically described, feet eral tenderness directly over the joint. Talocalcaneal coalitions may cause lat-
with normal arches or even a cavovarus deformity may contain eral tenderness over the sinus tarsi and peroneal tendons, as well as medially
over the sustentaculum. A bony eminence from talocalcaneal coalitions has
a coalition.69 The symptoms are often low grade and not severe
been described as a cause of tarsal tunnel symptoms. In one series, 30% of
enough to prompt a visit to the doctor until a traumatic event
patients with tarsal tunnel syndrome were found to have an eminence from a
causes a flare-up of pain. talocalcaneal coalition as a source of the symptoms.73
Recurrent ankle sprains often are described in athletes with Peroneal spasm may or may not be present. This finding has been suggested
tarsal coalitions.70 Forced motion beyond that which can be as part of the classic presentation of this disorder; however, it is found only in
accommodated by the abnormal joints may lead to partial or the minority of cases.65,74
complete ligamentous injuries. The abnormal joints are unable
to dissipate the forces generated by athletic activities, and there-
fore the increased stresses are transferred to the ligamentous Radiographic Evaluation
structures. Initial evaluation of the patient should include weight-bearing
Persistent medial sustentacular pain in the presence of AP, lateral, and oblique radiographs of the affected foot. An
ankle instability may represent a low-grade coalition identi- axial heel view should be added to these three views of the
fiable only as arthrofibrosis of the middle facet with a positive foot so that the talocalcaneal joint can be inspected. These may
bone scan.71 identify the presence of a coalition and degenerative changes
The age of the patient is an important consideration in in the surrounding joints. A calcaneonavicular bar is best seen
determining treatment. All isolated calcaneonavicular coali- on the 45-degree medial oblique view. A lateral x-ray may
tions should undergo resection regardless of age, but the talo- show the “anteater nose,” a projection from the anterior pro-
calcaneal coalition often fails with simple resection in patients cess of the calcaneus to the navicular (Fig. 17.6, A) that is a
beyond early adulthood. It is likely that these older patients did sign of the calcaneonavicular coalition.75 The axial heel view is
not develop symptoms early because they had more extensive the best plain radiograph for diagnosing coalitions of the mid-
or stiffer coalitions to begin with until a later mechanical distur- dle facet of the subtalar joint, but a CT is required to exclude
bance occurred. The return of subtalar motion following talo- the diagnosis. Secondary signs of a talocalcaneal coalition also
calcaneal resection in the adult is typically poor; subtalar fusion may be detected on the lateral view. These include narrowing
is a more reliable option in these cases. of the posterior facet of the subtalar joint, blurriness of the
Whether or not a patient participates in athletics should not middle facet of the subtalar joint, beaking of the dorsal head
be a consideration in surgical decision making if a talocalcaneal of the talus, and rounding of the lateral process of the talus.76
coalition is complete. No alternative guidelines for resection CT has been established as the gold standard study for the iden-
versus fusion exist in athletes, and the patient who has already tification of talocalcaneal coalitions.77,78 A CT scan (Fig. 17.6, B)
become a successful athlete with a stiff subtalar joint will be no allows one to identify the coalition, determine the extent of joint
less successful if that joint remains stiff but becomes painless as involvement, and assess any areas of surrounding degenerative
a result of a fusion procedure. changes. It can be particularly useful for preoperative planning
A dorsal talar beak is often present in cases of a congenitally and determining whether a coalition is resectable. It also may be
stiff hindfoot including coalition. There is no evidence that used postoperatively to assess the completeness of resection, pro-
resection of the talar exostosis improves motion or reduces gressive degenerative changes, and recurrence of the coalition.
pain from the coalition site itself; however, the prominence Less commonly, MRI has been used in the workup of tarsal
may itself be painful with shoewear and can be resected if this coalitions (Fig. 17.6, C). It may better identify nonosseous coa-
is the case. litions.79 The surrounding joints and soft tissues can be evalu­
ated as well. A radionuclide bone scan also may be useful in
Physical Examination the diagnosis of the symptomatic patient with suspected tarsal
Patients tend to have a rigid flatfoot involving heel valgus, loss coalition, particularly as a screening procedure.80 This test can
of the midfoot arch, and abduction of the forefoot. be positive when the patient is symptomatic. Accumulation of
320 SECTION 3  Anatomic Disorders in Sports

B C
Fig. 17.6  (A) Radiograph of calcaneonavicular coalition, with “anteater nose” projection from anterior process
of calcaneus to navicular. (B) Computed tomography scan. (C) Magnetic resonance imaging of middle facet
coalition.

the radionuclide most likely is the result of increased stresses at period of 6 weeks. If the patient responds favorably to immo-
the surrounding joints or within the coalition itself. bilization, then orthoses are used. The patient is considered to
have failed nonoperative treatment if pain persists after two
Nonoperative Treatment cast applications.
Typically, a trial of nonoperative management is indicated in the
treatment of tarsal coalitions. A study by Jayakumar and Cowell81 Surgical Treatment
in 1977 found that one-third of their patients responded favor- The most common procedures performed for tarsal coalition
ably to conservative treatment. When the diagnosis is made in include resection of the coalition, selected arthrodesis, and triple
the adolescent who is a competitive athlete, definitive treatment arthrodesis. Previous reports have examined resection of tarsal
on a more expedient basis may be appropriate. In this manner, coalitions in adolescent athletes. In Morgan and Crawford’s82
the time off from competition may be reduced. Morgan and review of 12 adolescent athletes, they reported their results in
Crawford82 looked at 12 adolescent athletes with coalitions 8 athletes who underwent resection of tarsal coalitions. They
(8 calcaneonavicular and 4 talocalcaneal). Nonoperative treat- found that five out of six athletes who had calcaneonavicular
ment was successful in none of the patients, and 8 of the 12 bars were able to return to play. Both athletes with talocalca-
elected to undergo surgery. neal bars were also able to return to play following resection.
The usual regimen of nonoperative management for Elkus83 examined 15 feet with calcaneonavicular coalitions and
patients with mild symptoms includes antiinflammatory 8 with talocalcaneal coalitions in a population of young ath-
medications and orthotics. For more severe symptoms, letes. All patients underwent resection of their coalitions with
patients may undergo a trial of a short-leg walking cast for a or without soft-tissue interposition. The majority of the patients
 CHAPTER 17  Disorders of the Subtalar Joint 321

Calcaneus navicular
coalition
Area of resection

Fig. 17.7  Drawing demonstrating excision of calcaneonavicular coalition and interposition of extensor brevis.
(A) Skin incision. (B) Exposure of the extensor brevis. (C) Reflection of the extensor brevis forward demon-
strates the area of coalition. (D) Demonstration of the area of coalition to be resected. (E) Interposition of the
extensor brevis muscles. (From Mann RA, Coughlin MJ, eds: Surgery of the foot and ankle, 6th ed. St Louis:
CV Mosby;1992.)

had relief from pain (no numbers reported) with variable return Technique of Resection of Calcaneonavicular
of subtalar motion. The author did note that all eight cases of Coalition
talocalcaneal bar resection had improvement in motion, had A 4-cm incision is made over the calcaneonavicular interval,
decreased pain, and were able to return to athletic activity. exposing the fascia overlying the extensor digitorum brevis.
One should avoid branches of the superficial peroneal and
sural nerves. The extensor digitorum brevis is reflected distally,
CALCANEONAVICULAR COALITIONS exposing the calcaneocuboid joint, sinus tarsi, and calcaneona-
The primary treatment for calcaneonavicular coalitions is resec- vicular coalition. The coalition is resected in parallel cuts from
tion unless degenerative changes are present in the subtalar or each surface, avoiding convergence. K-wires can be used to plan
midtarsal joints. Although talar beaking previously was thought the cuts. A total resection of at least 1 cm is desirable. The hind-
to be evidence of degenerative changes, it is not a contraindi- foot is mobilized to test for adequate subtalar motion. Bone wax
cation to resection.84 One contraindication to resection is the is generously packed into the bony surfaces. Closure is done in
presence of a concomitant talocalcaneal coalition. Generally, layers (Figs. 17.7 and 17.8).
the bar should be resected during adolescence, but resection of
bars in the adult population has been shown to be beneficial as
well.85 There is evidence that results are better after resection of
TALOCALCANEAL COALITIONS
fibrous coalitions rather than bony bars.86 Resection of the coalition also is the treatment of choice in
The reported outcomes following surgical excision of the patients with symptomatic talocalcaneal coalitions. Skeletally
coalition have been variable. Cohen et  al.85 in 1996 reviewed immature patients with smaller bars and no evidence of degen-
their results when resecting coalitions in adults. They exam- erative changes in the subtalar joint are most likely to bene-
ined 12 patients, 77% of whom displayed degenerative changes fit from resection.78 Contraindications to resection include
before resection. All but two of the patients reported subjective patients with rigid flatfeet or degenerative changes of the
relief of the preoperative symptoms. Gonzalez and Kumar86 subtalar and transverse tarsal joints. These patients are better
reported on 75 feet in 48 patients with calcaneonavicular coa- served with a subtalar or triple arthrodesis. In carefully selected
litions. Their results with resection and interposition with the patients, generally 80% to 90% will report satisfactory results
extensor digitorum brevis muscle was good or excellent in 77% following a resection.88-90
of the patients. The authors noted that their best results were The decision whether to resect the coalition or perform a
in patients who had a fibrous coalition and who were younger fusion may be influenced by the size of the bar. Some feel that
than 16 years. In contrast, Andreasen87 reported results of 31 involvement of more than one-half of the joint will preclude
bar resections that were examined 10 to 22 years following sur- a successful resection.90 Wilde et  al.91 reported unsatisfactory
gery. He found 30% of the patients had mild pain and 26% had outcomes with middle coalition resection and fat interposition
severe pain. A recurrence of the bar was seen in 67% of patients, in the presence of middle facet coalition area greater than 50%
and 96% of feet had osteoarthritic changes. Six patients required of the area of the posterior facet. On the other hand, Kumar
triple arthrodesis. et al.89 did not find a correlation between the extent of middle
No material for interposition into the resection site has been facet coalition and the postoperative results in 18 feet on which
demonstrated to be superior to any other or to simple resection. resection was performed. In general, the quality of the residual
322 SECTION 3  Anatomic Disorders in Sports

A B
Fig. 17.8  Calcaneonavicular coalition. (A) A 45-degree oblique view of the foot demonstrates the calcaneo-
navicular coalition. (B) Postoperative 45-degree oblique view of the foot demonstrates adequate excision of
the calcaneonavicular coalition.

Flexor
Tibialis posterior hallucis
Flexor longus
digitorum
Flexor digitorum longus longus

Neuro-vascular
Neurovascular bundle
bundle

Head of tarsal
B coalition

A
Periosteum over
coalition Talus

Coalition outlined by
Keith needles

Bony
bridge
Coalition
excised

C Calcaneus D
Fig. 17.9  Excision of talocalcaneal coalition. (A) Skin incision. (B) Reflection of structures dorsally and plan-
tarward to expose the area of coalition. (C) Outlining the coalition with needles. (D) Postexcision appearance
of the coalition. (From Mann RA, Coughlin MJ, eds: Surgery of the foot and ankle, 6th ed. St Louis: CV
Mosby;1992.)

posterior facet of the subtalar joint is likely more important posterior tibial tendon, FDL, and tibial neurovascular bundle.
than the extent of the area involved with the coalition. The middle facet lies just under the FDL, often covered by min-
Mosca and Bevan92 reported the concurrent correction of imal periosteum. The middle facet with coalition is identified
pes planus deformity using a calcaneal lengthening osteotomy and dissected, showing the extent of the coalition (Figs. 17.9,
in eight patients. They emphasized the importance of concur- C and 17.10, B). The tarsal tunnel can be entered with a wire or
rent deformity correction, but no comparative group undergo- probe anteriorly to assist with orientation. Once the corners of
ing resection alone was reported. the coalition are identified, excision is done using small straight
osteotomes and rongeurs. The excised surfaces should be paral-
Technique of Resection of Talocalcaneal Coalition lel to prevent contact and potential osseous fusion (Figs. 17.9,
A 6- to 7-cm linear incision is made just below the medial D and 17.10, C). Bone wax may be packed on the bony resec-
malleolus, just above the sustentaculum tali (Figs. 17.9, A and tion surfaces to reduce bleeding. Closure of the FDL sheath is
17.10, A). Tenotomy scissors are used to dissect and identify the included in the layered closure.
 CHAPTER 17  Disorders of the Subtalar Joint 323

A B

C
Fig. 17.10  (A) Incision marked on medial hindfoot. (B) Middle facet coalition with corners defined, flexor digi-
torum longus retracted inferiorly. (C) Coalition excised, flexor digitorum longus retracted superiorly.

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 18
Diagnostic and Operative Ankle
and Subtalar Joint Arthroscopy
C. Niek van Dijk, Peter A. de Leeuw, Rover Krips, Pim A.D. van Dijk

OUTLINE
History of the Technique, 326 Loose Bodies and Ossicles, 336
Indications and Contraindications, 326 Surgical Technique, 336
Surgical Technique—Preparation, 327 Surgical Techniques and Conciderations Per Specific
Operative Setup, 327 Indication—Posterior Ankle, 337
Arthroscopic equipment, 327 Os Trigonum Syndrome, 337
Instrumentation, 328 Posttraumatic Calcifications, Loose Bodies, and Bony
Irrigation, 328 Avulsions, 338
Surgical Technique—Portals, 328 Osteochondral Lesions, 339
Anterior Portals, 328 Surgical Techniques and Conciderations Per Specific
Posterior Portals, 329 Indication—Pathology of the Tendons and Talar Joint, 339
Transtibial and Tansmalleolar Portals, 330 FHL Tendon Pathology, 339
Surgical Technique—Arthroscopic Anatomy, 330 Posterior Tibial Tendon Pathology, 341
The Anterior Ankle, 330 Peroneal Tendon Pathology, 342
The Posterior Ankle, 331 Achilles Tendon Pathology—Paratendinitis and
Diagnostics, Considerations, and Surgical Techniques Per Tendinosis, 343
Specific Indication—Anterior Ankle, 333 Achilles Tendon Pathology—Insertional Tendonitis and
Anterior Ankle Impingement, 333 Retrocalcaneal Bursitis, 344
Surgical Technique, 333 Subtalar Joint Arthroscopy and Intraosseous
Synovitis, 334 Talar Cysts, 344
Osteochondral Lesions, 334 Combined Anterior and Posterior Ankle Arthroscopy, 345
Surgical Technique, 335 Rehabilitation, 346

HISTORY OF THE TECHNIQUE tendoscopic surgery, and the introduction of a two-portal tech-
Arthroscopy has revolutionized the practice of orthopedic nique for posterior ankle problems, ankle arthroscopy further
surgery since the mid-1970s. After a long history of sporadic developed to the current state.
attempts at arthroscopy, technologic breakthroughs in Japan Nowadays, arthroscopy of the ankle joint has become the
and several surgical pioneers in North America launched wide- most important diagnostic and therapeutic procedure for
spread interest in percutaneous joint surgery. In 1939, Tagaki chronic and posttraumatic complaints of the ankle joint and
was the first to introduce systematic arthroscopic assessment of became an integral part of modern orthopedic surgery. The
the ankle in the literature.1 More than 30 years later, Watanabe dynamic nature of arthroscopy, moreover, necessitates constant
published a series of 28 ankle arthroscopies in 1972,2 followed improvements that will continue to allow this field to grow. In
by Chen in 1976 and several publications in the 1980s.3,4 The order to optimize the practice of arthroscopic procedures, a
rapid rise of the popularity of foot and ankle arthroscopy over firm understanding of their subtle refinements, limitations, and
the last 20 years is partly because other noninvasive techniques risks is fundamental.
cannot adequately diagnose disorders in these joints. To oper-
ate in the central and posterior ankle, some type of distraction
device is needed. Invasive external distraction was tried in the
INDICATIONS AND CONTRAINDICATIONS
early 1980s. The first noninvasive technique was described by The key in assessment of ankle joint pathology is clinical assess-
Yates and Grana in 1988.5 With the advent of better small-joint ment of the patient. By means of a clinical diagnosis, an indi-
arthroscopes and instrumentation, the production of more cation is set for an arthroscopic intervention and the clinical
efficient noninvasive distraction devices, the development of diagnosis is essential for preoperative planning.6 The clinical
326
 CHAPTER 18  Diagnostic and Operative Ankle and Subtalar Joint Arthroscopy 327

diagnosis is based on history, symptoms and signs, and radio-

graphic examination. Anterior problems of the ankle include
soft-tissue or bony impingement, synovitis, loose bodies, or
ossicles. More centrally located complaints can originate from
an osteochondral lesion or arthrosis, whereas posterior prob-
lems can be caused by intra-articular pathology, such as pos-
terior impingement syndrome (os trigonum); posttraumatic
calcifications; loose bodies or synovitis; or by periarticular pos-
terior ankle pathology, such as peroneal tendon, posterior tibial
tendon, or flexor hallucis longus (FHL) pathology. In posterior
ankle disorders, especially, differentiation from subtalar pathol-
ogy is sometimes difficult.
The relative contraindications for ankle arthroscopy include
moderate degenerative joint disease with restricted range of
motion, a significantly reduced joint space, severe edema, and
tenuous vascular status.7 The absolute contraindications for Fig. 18.1  For posterior ankle arthroscopy, the patient is placed in prone
ankle arthroscopy include absence of a clinical diagnosis, severe position. A tourniquet is applied and a small support is placed under the
degenerative joint disease, and localized soft-tissue infection. lower leg, making it possible to move the ankle freely.
However, if septic arthritis is present, ankle arthroscopy is indi-
cated, since it is a useful tool for drainage, debridement, and anterior osteophytes, ossicles, loose bodies, and soft-tissue
lavage of the joint.8 impediments. Furthermore, when portals are created and
instruments are introduced in the distracted position, this may
SURGICAL TECHNIQUE—PREPARATION result in iatrogenic cartilage damage at the talar dome.6
The main reason for inspection of the talar dome and tibial
Operative Setup plafond is for treatment of an osteochondral lesion. A clinical
In general, the procedure is carried out as outpatient surgery diagnosis must be established preoperatively using history, phys-
under general anesthesia or epidural anesthesia. Patients can be ical examination, and standard x-rays. In case of doubt about
placed in various positions according to the surgeon’s prefer- the existence or the exact location and size of a defect, a pre-
ence, with a supine position with slight elevation of the ipsi- operative spiral computed tomography (CT) scan or magnetic
lateral buttock being mostly used. The heel of the affected foot resonance imaging (MRI) can be performed. Knowing the exact
rests on the very end of the operating table in order to make it location of a defect makes it possible to decide preoperatively
possible for the surgeon to fully dorsiflex the ankle by leaning whether distraction will be necessary or whether the osteochon-
against the sole of the patient’s foot. For the treatment of poste- dral lesion can be approached in a forced plantarflexed position
rior ankle problems, the patient is placed in prone position and of the foot. In our experience, more than 90% of medial and
a small support is placed under the lower leg, making it possible lateral talar dome lesions can be treated in a hyperplantarflexed
to move the ankle freely (Fig. 18.1). In both settings, a tourni- position.6 Distraction may be beneficial when an osteochondral
quet is placed around the upper thigh. lesion is located in the posterior part of the medial or lateral
There are some important considerations in deciding talar dome, the tibial plafond, or when a soft-tissue impediment,
whether to use dorsiflexion or traction for routine anterior ossicles, or an impregnated loose body is located in the joint
ankle arthroscopy. When saline is introduced in the dorsiflex- space between fibula and tibia (intrinsic syndesmotic area).10,11
ion position, the anterior working area and any bony or soft-tis- For posterior ankle problems, for example an osteochondral
sue impediment in front of the medial malleolus, in front of the lesion in the posterior quarter of the talar dome or in the pos-
lateral malleolus, at the talar neck, or at the distal tibia can be terior part of the tibial plafond, two-portal posterior ankle
adequately visualized and treated. For the treatment of anterior arthroscopy is an important alternative (Fig. 18.2).12
impingement lesions, synovitis, ossicles, and loose bodies, it
therefore is beneficial to perform the procedure without dis- Arthroscopic equipment
traction. In this dorsiflexed position, the talus is concealed in Both a 4.0-mm and a 2.7-mm arthroscope with 30-degrees
the joint, thereby protecting the cartilage from potential iatro- obliquity can be used for ankle arthroscopy, depending on the
genic damage. Moreover, loose bodies usually are located in the indication. Small-diameter, short arthroscopes yield an excel-
anterior compartment of the ankle joint and with dorsiflexion lent picture that is difficult to distinguish from a standard 4.0-
creating an anterior working area, removal is facilitated.9 On the mm scope. The small-diameter arthroscope sheet, however,
other hand, distracting the joint makes it possible for the loose cannot deliver the same amount of irrigation fluid per time
body to fall into the posterior aspect of the joint, thus making as the standard sheet, causing an important drawback when
removal more difficult or impossible by an anterior approach. motorized instruments are used, since these cases must ben-
The same is true for the removal of ossicles and bony spurs by efit from an adequate amount of irrigation fluid. For routine
a chisel or burr. Distraction of the joint results in tightening of arthroscopic procedures such as anterior impingement syn-
the anterior capsule, thus making it more difficult to identify drome, loose body removal, treatment of synovitis, and the vast
328 SECTION 3  Anatomic Disorders in Sports

Fig. 18.2  Two-portal posterior ankle arthroscopy is an important alterna- Fig. 18.3  Left ankle. The anteromedial portal is placed just medial to the
tive for the treatment of posterior ankle problems. anterior tibial tendon at the joint line. Care must be taken not to injure
the saphenous vein and nerve transversing the ankle joint along the
majority of osteochondral defects, it is beneficial to use the 4.0- anterior edge of the medial malleolus.
mm arthroscope. A 2.7-mm arthroscope should be reserved for
the treatment of osteochondral lesions of the posterior third common because it is physiologically compatible with articu-
of the talar dome (when not approached by a posterior ankle lar cartilage and is rapidly reabsorbed if extravasated from the
arthroscopy), pathology of the articular part of the tibiofibu- joint. Other options include glycine and normal saline. When a
lar joint, such as a soft-tissue impediment or impregnated ossi- 4-mm arthroscope is used, gravity inflow usually is adequate if
cles or loose bodies, or other posterior ankle problems that are the fluid is introduced through the arthroscope sheet. When a
treated by an anterior approach. Use of a 2.7-mm scope usually 2.7-mm arthroscope is used, the gravity inflow should be intro-
necessitates the creation of a third posterolateral portal to main- duced through a separate (posterolateral) cannula. An alterna-
tain adequate flow in the joint. tive is to use an arthroscopic pumping device.

Instrumentation
An 18-gauge spinal needle is used to distend the joint and to
SURGICAL TECHNIQUE—PORTALS
locate the anterolateral portal by allowing precise positioning Portals provide an entry to visualize the structures of the ankle
under direct vision of the portals. The probes used in ankle and foot. In order to perform adequate diagnostic and therapeu-
arthroscopy should be about 1.5 mm in diameter to reach the tic arthroscopy, proper portal placement is critical.13 Numerous
small recesses of the gutters and to lift up under loose articu- portals for arthroscopy of the ankle have been described in lit-
lar cartilage. An angled tip is desirable to touch over the dome- erature. In general, these portals can be grouped into a) anterior,
shaped talus and flat tibia. Another important instrument is the b) posterior, c) transmalleolar, and d) transtalar.
grasper. For the removal of small, loose bodies in soft tissue, In routine ankle arthroscopy, two primary portals are used:
a flat-tipped grasping forceps with fine teeth can be used. For the anteromedial and the anterolateral portal. Some authors,
larger loose bodies and soft-tissue fragments, a cup-shaped, however, recommend routine placement of posterior portals in
jaw-grasping forceps with serrated edges is better. Small-joint ankle arthroscopy. In these cases, a posterolateral portal is rec-
basket forceps with different tip designs help to remove soft-tis- ommended. Because of the potential for serious complications,
sue and chondral fragments. Various small-joint curettes, either most authors feel that the posteromedial portal is contraindi-
straight or curved, are particularly valuable for removing osteo- cated when performing anterior ankle arthroscopy.14
chondral lesions and trimming of articular cartilage edges.
Small-joint osteotomes and chisels are available to remove Anterior Portals
osteophytes and ossicles and can facilitate tissue elevation. Anteromedial Portal
Sometimes a small periosteal elevator can be useful. Motorized The anteromedial portal should be made first, since it is easy
instruments can excise larger volumes of tissue than conven- to access. This is especially true with the ankle in hyperdorsi-
tional hand instruments and suction it quickly out of the joint. flexion. The exact point of entry in this position is easily repro-
They also can be used for debridement of large osteochondral ducible, and the risk of neurovascular damage is minimal. The
lesions. A power burr is useful for abrading or excising hard anteromedial portal is placed just medial to the anterior tibial
bone fragments. tendon at the joint line (Fig. 18.3). In the hyperdorsiflexed posi-
tion, a local depression can be palpated. In the horizontal plane,
Irrigation this depression is located between the anterior tibial rim and
Different fluids can be used for arthroscopic irrigation during the talus. During palpation the thumb first detects the interval
ankle and foot arthroscopy. Lactated Ringer is used most in the horizontal plane and subsequently locates the vertical
 CHAPTER 18  Diagnostic and Operative Ankle and Subtalar Joint Arthroscopy 329

position. In the vertical position, the anterior tibial tendon

is the landmark. One should palpate the anterior tibial in the
dorsiflexed position. In this dorsiflexed position the anterior
tibial tendon moves 1 cm lateral. The location of the anterome-
dial portal now can be marked onto the skin just medial from
the anterior tibial tendon. Care must be taken not to injure the
saphenous vein and nerve traversing the ankle joint along the
anterior edge of the medial malleolus. By moving the ankle joint
from the plantarflexed position to the dorsiflexed position, the
talus can be felt to move in relation to the distal tibia. The thumb
gets locked into the soft spot in the hyperdorsiflexed position.
A small longitudinal incision is made through the skin only just
medial from the anterior tibial tendon. Blunt dissection is per-
formed with a mosquito clamp through the subcutaneous layer
and through the capsule into the ankle joint. With the ankle in
the forced dorsiflexed position, cartilage damage is avoided. In
this forced dorsiflexed position, the arthroscope shaft with the
blunt trocar is introduced. When the trocar is felt to contact the
underlying bony joint line, the shaft with the blunt trocar is gen-
tly pushed further into the anterior working area in front of the
ankle joint toward the lateral side. The anterior compartment is Fig. 18.4  Left ankle. The anterolateral portal is placed just lateral to the
irrigated and inspected. The next portal to make is the antero- tendon of the peroneus tertius at or slightly above the joint line.
lateral portal.
minimizing the risk of necrosis. The lateral accessory portal is
Anterolateral Portal placed just below the anterior talofibular ligament. After intro-
The anterolateral portal is the second standard anterior portal. duction of a spinal needle, a skin incision is made under direct
In general, it is placed just lateral to the tendon of the peroneus vision in line with the anterior talofibular ligament. The medial
tertius at or slightly proximal to the joint line (Fig. 18.4) and accessory portal is placed in. On the medial side, after locating
is made under direct vision by introducing a spinal needle. In the portal with the spinal needle, the incision is made in line
the horizontal plane, it is situated at the level of the joint line. with the fibers of the deltoid ligament. The knife can be intro-
In the vertical plane, the anterolateral portal is located lateral duced directly into the joint under direct vision.
to the common extensor tendons and the peroneus tertius
tendon. Care must be taken to avoid the superficial peroneal Posterior Portals
nerve because it runs subcutaneously. This subcutaneous nerve Posterolateral Portal
often can be palpated or visualized by placing the foot in forced The posterolateral portal is made 1.2–2.5 cm proximal to the tip
hyperplantarflexion and supination. The intermediate dorsal of the lateral malleolus, just lateral to the Achilles tendon (Fig.
cutaneous branch of the superficial peroneal nerve crosses the 18.5, A). Both the small saphenous vein and the sural nerve are
anterior aspect of the ankle joint superficial to the common in close proximity and therefore may be at risk for damage.14
extensor tendons. Damage to this branch can be avoided by After making a vertical stab incision, the subcutaneous layer
staying lateral to the extensor tendons. Once the lateral branch is split by a mosquito clamp. The mosquito clamp is directed
is identified, its position can be marked with a marking pen on anteriorly, pointing in the direction of the interdigital webspace
the skin. between the first and second toe (Fig. 18.5, B). When the tip
It should be noted that the location of the anterolateral portal of the clamp touches the bone, it is exchanged for a 4.5-mm
may vary depending on the location of the lesion in the ankle arthroscope shaft with a blunt trocar pointing in the same direc-
joint. For the treatment of anteromedial ankle pathology, the tion. By palpating the bone in the sagittal plane, the level of the
anterolateral portal can be placed slightly above the level of the ankle joint and subtalar joint most often can be distinguished
ankle joint and as close to the peroneal tertius tendon as possi- because the prominent posterior talar process can be felt as a
ble. For the treatment of lateral pathology, the anterolateral por- posterior prominence between both joints. It is not necessary
tal is placed at the level of the joint line and more laterally. After to enter either joint capsule. The blunt trocar is situated extra-­
a small skin incision has been made, the subcutaneous layer and articular at the level of the ankle joint. Next, the blunt trocar
capsule are divided bluntly with a mosquito clamp. is exchanged for a 30-degree, 4.0-mm arthroscope. In order to
prevent damage to the lens system, the direction of view should
Accessory Inferior Anteromedial and Anterolateral Portals be lateral.
Accessory portals can facilitate instrumentation or the intro-
duction of fluid in specific indications. Separation between the Posteromedial Portal
main portal and the accessory portal should be at least 5 mm in This portal is made second, just medial to the Achilles tendon.
order to allow proper instrumentation and triangulation while In the horizontal plane, it is located at the same level as the
330 SECTION 3  Anatomic Disorders in Sports

A B
Fig. 18.5  (A) Right ankle. The posterolateral portal is made level to or slightly above the tip of the lateral
malleolus just anteriorly to the Achilles tendon. (B) Left ankle. The mosquito clamp is directed toward the first
interdigital webspace.

the placement of the portal and the Kirschner wires that are used
to drill the defect. Transtibial or transmalleolar drilling with a
guiding system is especially useful for tibial plafond lesions. For
the treatment of talar dome lesions, the transmalleolar portal
has the disadvantage of causing damage to the cartilage of the
medial malleolus opposite the osteochondral talar defect and
therefore is not recommended to perform on a routine basis.

SURGICAL TECHNIQUE—ARTHROSCOPIC
ANATOMY
The ankle joint can be divided into anterior and posterior cavi-
ties, each of which can then be subdivided into three compart-
ments for methodologic inspection of the ankle joint. Ferkel14
Fig. 18.6  Right ankle. The posteromedial portal is made just medial to developed a 21-point systematic examination of the anterior,
the Achilles tendon. In the horizontal plane, it is located at the same central, and posterior ankle joint to increase the accuracy and
level as the posterolateral portal. reproducibility of the arthroscopic examination (Box 18.1).
For posterior ankle problems, Van Dijk et al.12 reported on a
posterolateral portal (Fig. 18.6). Care should be taken, since the two-portal approach with the patient in the prone position,
neurovascular bundle and its branches are at risk.13,14 After the specifically for close visualization of the posterior compart-
skin incision has been made, a mosquito clamp is introduced ment of the ankle and subtalar joint. He developed a 14-point
and directed toward the arthroscope shaft, which already was systematic examination for the hindfoot and posterior ankle
introduced through the posterolateral portal. When the mos- joint (Box 18.2).
quito clamp touches the shaft of the arthroscope, the shaft is
used as a guide to travel anterior in the direction of the ankle The Anterior Ankle
joint. All the way, the mosquito clamp must touch the shaft of The anterior arthroscopic examination is initially performed
the arthroscope until the mosquito clamp touches the bone. The through the anteromedial portal, followed by evaluation through
arthroscope is pulled slightly backward and slides over the tip of the anterolateral portal. From medial to lateral, several structures
the mosquito clamp until the tip of the mosquito clamp comes that can be visualized. First examined is the deep portion of the
to view. The clamp is used to spread the extra-articular soft tis- deltoid ligament as it arises from the tip of the medial malleolus.
sue in front of the tip of the camera and, when present, scar Its fibers run vertically down to the medial trochlear surface of
tissue or adhesions; the mosquito clamp is then exchanged for a the talus, an area where ossicles may be hidden and that should
5-mm, full-radius shaver. be evaluated carefully for pathology. Next, the articular surface
of the tip of the medial malleolus as it corresponds and articu-
Transtibial and Tansmalleolar Portals lates with the medial talar dome, the posterior recess and poste-
A transmalleolar portal may be used for debridement and drill- rior ligaments can be evaluated. The medial gutter includes the
ing of lesions of the talar dome and is used most often in com- area from the deltoid ligament to below the medial dome of the
bination with distraction of the ankle. A special guide facilitates talus. Areas of articular damage here should be carefully noted.
 CHAPTER 18  Diagnostic and Operative Ankle and Subtalar Joint Arthroscopy 331

BOX 18.1  The 21-Point Arthroscopic The distal portion of the tibial lip directs slightly anteri-
Examination of the Ankle orly in the sagittal plane. This portion of the tibia articulates
within a depression in the talar surface and is called the sagittal
Anterior: groove. The groove lies between the medial and lateral shoul-
Deltoid ligament ders of the talus and projects from anterior to posterior. At the
Medial gutter
area between the anterior tibial lip and the capsule is a peri-
Medial talus
osteum-covered subchondral bone, the synovial recess, which
Central talus and overhang
Lateral talus
extends from medial all the way to the lateral portion of the
Trifurcation of the talus, tibia, and fibula ankle. This is where tibial osteophytes develop and synovium
Lateral gutter and capsule become adherent at the margins of the osteophyte.
Anterior gutter More laterally, the trifurcation includes the distal lateral tibial
plafond, the lateral dome, and the fibula and is bounded by the
Central: anterior inferior tibiofibular ligament superiorly. This relation is
Medial tibia and talus important in the ankle because it is often the site of soft-­tissue
Central tibia and talus
pathology. The syndesmotic or anterior inferior tibiofibular lig-
Lateral tibiofibular or talofibular articulation
ament runs at approximately a 45-degree angle from the lateral
Posterior inferior tibiofibular ligament
Transverse ligament
portion of the distal tibia to the fibula, just below the level of
Reflection of the flexor hallucis longus the lateral talus. The anterolateral talar dome also is the site of
osteochondral lesions of the talus, and access into ankle joint
Posterior: usually is easy in this region. The lateral gutter is the space
Posteromedial gutter between the medial border of the fibular articulation and the
Posteromedial talus lateral border of the talar articulation. It extends from below the
Posterocentral talus anterior inferior tibiofibular ligament to the anterior talofibular
Posterolateral talus
ligament. This often is the site of chondromalacia and ossicles at
Posterior talofibular articulation
the tip of the fibula within the ligament substance. The anterior
Posterolateral gutter
Posterior gutter
talofibular ligament lies intracapsular and runs from the tip of
the fibula to the inferior lateral portion of the talus. It can be
From Ferkel RD. Arthroscopic surgery. The foot and ankle. Philadel- easily reached for a shrinkage procedure in case of laxity. The
phia, PA: Lippincott-Raven; 1996.
anterior gutter represents the capsular reflection anteriorly of
the ankle as it inserts along the talar neck. There is a normal
BOX 18.2  The 14-Point Hindfoot bare area proximal to the capsular insertion, similar to the area
Endoscopic Examination on the central portion of the distal tibia. A synovial recess also
1. Lateral talocalcaneal articulation
can be found at the anterior inferior aspect of the talar dome.
2. Flexor hallucislongus retinaculum In this area, anterior talar osteophytes may articulate or butt
3. Flexor hallucis longus tendon against osteophytes of the anterior tibial lip.9
4. Posterior talar process
5. Posterior talofibular ligament The Posterior Ankle
6. Posterior tibiofibular ligament Using a posterolateral and posteromedial portal with the patient
7. Transverse tibiofibular ligament in the prone position, one first approaches the fatty tissue over-
8. Tip of the medial malleolus/medial malleolus lying the joint capsule (Fig. 18.7). This tissue can be partially
9. Posteromedial gutter removed. At the level of the ankle joint, the posterior tibiofibular
10. Posteromedial talus/tibia
ligaments and the posterior talofibular ligament can be recog-
11. Posterocentral talus/tibia
nized. After removal of the very thin joint capsule of the subtalar
12. Posterolateral talus/tibia
13. Posterolateral gutter
joint, the posterior compartment of the subtalar joint can be visu-
14. Tip of lateral malleolus alized. The posterior talar process can be freed of scar tissue and
the FHL tendon can be identified. The FHL tendon is an import-
Additional (when indicated): Posterior tibial tendon, Flexor digitorum ant landmark to prevent damage to the more medially located
tendon, Peroneal tendons.
From Van Dijk CN, Scholten PE, Krips R. Arthroscopy. 2000;16:871- neurovascular bundle (Fig. 18.8). When manual distraction is
876. applied to the os calcaneus, the posterior compartment of the
ankle joint opens up and can be visualized. The arthroscope and
The tibia articulates with the medial dome of the talus, forming instruments can be introduced into the posterior ankle compart-
the medial corner of the ankle. In this region, the anterior artic- ment. Procedures such as a synovectomy and/or capsulectomy of
ular margin of the tibia deviates from its more horizontal config- both ankle and subtalar joint can be performed. On the medial
uration centrally and laterally to a more convex configuration in side, the tip of the medial malleolus, as well as the deep portion of
the coronal plane. At this medial articular notch, the arthroscope the deltoid ligament, can be visualized. Opening the joint capsule
may be maneuvered most easily into the central and posterior from inside out at the level of the medial malleolus permits the
aspects of the joint without damaging the articular surfaces. tendon sheath of the posterior tibial tendon to be opened and the
332 SECTION 3  Anatomic Disorders in Sports

Fig. 18.7  Right ankle. Using a posterolateral and posteromedial portal

with the patient in the prone position, one first approaches the fatty
tissue overlying the joint capsule. This tissue can be partially removed.

Fig. 18.9  Right ankle. By opening the joint capsule from inside out at
the level of the medial malleolus, the tendon sheath of the posterior
tibial tendon can be opened and the scope can be introduced into the
tendon sheath of the posterior tibial tendon. This patient has a tendinitis
of the posterior tibial tendon, recognized by the increased vascularity on
and around the tendon. Higher up, a vincula is identified. The direction
of the view is from distal to proximal.

Fig. 18.8  Left ankle. After removal of the thin joint capsule, the poste-
rior ankle and subtalar joint can be visualized. The posterior talar process
can be freed of scar tissue and the flexor hallucis longus tendon can be
identified. This is an important landmark to prevent damage to the more
medially located neurovascular bundle.

arthroscope to be introduced into the tendon sheath to inspect

the posterior tibial tendon (Fig. 18.9). The same procedure can
be followed for the flexor digitorum longus (FDL). Next, the talar Fig. 18.10  Left ankle. Removal of a symptomatic os trigonum or a non-
dome and nearly the entire surface of the complete tibial plafond union of fracture of the posterior talar process involves partial detach-
can be inspected. An osteochondral lesion or subchondral cystic ment of the posterior talofibular ligament and release of the flexor
retinaculum, both of which attach to the posterior talar prominence.
lesion can be identified, debrided, and drilled. The posterior syn-
desmotic ligaments can be inspected and, if hypertrophic, par-
tially resected. Moreover, the intrinsic syndesmotic area and the flexor retinaculum from the posterior talar process (Fig. 18.12).
posterior talofibular ligament can be examined (Figs. 18.10 and Adhesions surrounding the flexor tendon can be removed. On the
18.11). Removal of a symptomatic os trigonum or a nonunion lateral side, the peroneal tendons can be inspected (Fig. 18.13). A
of fracture of the posterior talar process involves partial detach- tight and thickened crural fascia can hinder the free movement of
ment of the posterior talofibular ligament and release of the flexor instruments; it can be helpful to enlarge the defect in the fascia by
retinaculum, both of which attach to the posterior talar prom- means of a punch or shaver. Bleeding is controlled by electrocau-
inence. Release of the FHL tendon involves detachment of the tery at the end of the procedure.
 CHAPTER 18  Diagnostic and Operative Ankle and Subtalar Joint Arthroscopy 333

Fig. 18.11  Left ankle. Removal of a symptomatic os trigonum involves

partial detachment of the posterior talofibular ligament (PTFL) and
release of the flexor retinaculum, both of which attach to the posterior
talar prominence (see also Fig. 18.12). Fig. 18.13  Left ankle. During posterior ankle arthroscopy, the peroneal
tendons can be inspected on the lateral side

BOX 18.3  Classification System for

Degenerative Changes of the Ankle

Grade X-ray Finding

1 Normal joint or subchondral sclerosis
2 Osteophytes without joint space narrowing
3 Joint space narrowing with or without osteophytes
4 (Sub)total disappearance or deformation of the joint space

From Van Dijk CN, Tol JL, Verheyen CC. Am J Sports Med.
1997;25:737-745.

the ankle. They demonstrated that the treatment and recov-

ery correlated with the grade, with all grades being able to be
resected arthroscopically. The reproducibility of this classifica-
tion system may be doubtful, however, because the correlation
was assessed with outcomes at short-term follow-up (10 weeks
postoperatively).
Other studies determined that the degree of osteoarthritic
Fig. 18.12  Left ankle. Release of the flexor hallucis longus retinaculum
changes also influences the outcome of treatment.9 Osteophytes
from the posterior talar process to remove a symptomatic os trigonum
(see also Figs. 18.11 and 18.13). without joint space narrowing are not a manifestation of osteo-
arthritis; subsequently a normal joint remains after removal
of these spurs. A classification for anterior ankle impinge-
DIAGNOSTICS, CONSIDERATIONS, AND ment based on the degree of degeneration was developed (Box
SURGICAL TECHNIQUES PER SPECIFIC 18.3).9 The results at long-term follow-up show that the use of
INDICATION—ANTERIOR ANKLE this osteoarthritic classification is more discriminating than
the impingement classification of Scranton and McDermott as
Anterior Ankle Impingement a predicting value for the outcome of arthroscopic surgery for
Arthroscopic scoring systems for anterior impingement use the anterior ankle impingement.9,15
location (tibia or talus) and size of osteophytes as prognostic
factors for postoperative success. A study by Scranton et  al.15 Surgical Technique
compared open resection with arthroscopic resection of pain- The patient is placed in a supine position with slight elevation
ful anterior impingement spurs, ranging from grade I through of the ipsilateral buttock. The heel of the affected ankle rests
IV according to the size of spurs and degree of involvement of on the very end of the operating table, thus making it possible
334 SECTION 3  Anatomic Disorders in Sports

After an arthroscopic intervention, a hematoma will be

formed postoperatively that subsequently will develop into scar
tissue. The scar tissue that fills the defect will act instantly as
a new anterior soft-tissue impediment. It therefore is import-
ant to remove the osteophytes to enhance more anterior and
anteromedial space and diminish the chance for a recurrence
of symptoms.16-18

Synovitis
Synovitis can be a noninflammatory, inflammatory, or septic
process of the synovium, which is most characterized by joint
swelling and tenderness. A generalized or localized synovitis can
occur, most often with fibrous bands and adhesions. Synovitis
of the ankle may be a difficult diagnostic problem. Even after
careful history, physical examination, and diagnostic testing,
the diagnosis may not be readily apparent. During arthroscopy,
localized or generalized inflammation of the synovia can be
present. It may contain hemosiderin or fibrin debris. Scarring,
fibrosis, and adhesions often are seen in relation to the synovitis.
In 1997, Cheng and Ferkel19 proposed the following classifi-
cation system for synovial disorders:
• Congenital: plicae or congenital bands within the ankle; pli-
cae, or shelves, have been demonstrated in the knee but are
difficult to find in the ankle. Congenital bands are seen as an
incidental finding when examining the ankle for other types
of pathology.
• Traumatic: sprains, fractures, and previous surgery
Fig. 18.14  The heel of the affected ankle rests on the end of the oper- • Rheumatic: rheumatoid arthritis, pigmented villonodular
ating table, thus making it possible for the surgeon to dorsiflex the ankle synovitis, crystal synovitis, hemophilia, and synovial chon-
joint fully by leaning against the sole of the patient’s foot.
dromatosis
• Infectious: bacterial and fungal
for the surgeon to fully dorsiflex the ankle joint by leaning • Degenerative: primary and secondary
against the sole of the patient’s foot (Fig. 18.14). After mak- • Neuropathic: Charcot joint
ing an anteromedial skin incision, the surgeon bluntly divides • Miscellaneous: ganglions, arthrofibrosis
the subcutaneous layer with a hemostat. A 4-mm, 30-degree
arthroscope routinely is used. The anterolateral portal is made Osteochondral Lesions (see also Chapter 16)
under arthroscopic control. Additional portals just anterior An important cause of residual pain after an ankle sprain is an
to the tip of the lateral or medial malleolus are used only osteochondral lesion of the talus. It is defined as the separation
when indicated. Osteophytes are removed by a 4-mm chisel of a fragment of articular cartilage, with or without subchon-
and burr. These spurs can be identified easily when the ankle dral bone. The incidence of an osteochondral lesion after an
is in a fully dorsiflexed position to prevent the anterior joint ankle sprain probably is underestimated because these lesions
capsule from covering the osteophytes. Another advantage often remain undetected and has been reported to be as high
of the forced dorsiflexion position is the fact that the talus is as 6.5% after ankle sprains. In the acute situation, symptoms
concealed in the joint, thereby protecting the weight-bearing depend on the amount of damage to the periarticular tissues
cartilage of the talus from potential iatrogenic damage. The and the involvement of afferent pain fibers in the subchondral
contour of the anterior tibia is first identified by shaving away bone. Usually the lesion is located in the anterolateral or pos-
the tissue just superior to the osteophyte. An overcorrection of teromedial aspect of the talar dome. Histologically the medial
the medial malleolus generally is pursued by shaving some of and lateral lesions are identical, but morphologically they differ;
it away after resection of the osteophyte. the lateral lesions are shallow and more wafer shaped, indicating
Visualization of the anterior ankle joint can be improved by a shear mechanism of injury. In contrast, medial lesions gener-
bringing the ankle into a forced dorsiflexion position because ally are deep, cup shaped, and located posteriorly, indicating a
in this position the anterior working area opens up. Distraction mechanism of torsional impact. From an etiologic point of view,
makes the anterior capsule more tense over the osteophyte, and trauma is the most common cause of osteochondral lesions
its use therefore is not recommended.9 It is important to iden- of the talus, but idiopathic osteonecrosis often may be the
tify the anterior and superior borders of the osteophyte, and this underlying pathologic process. In the literature, the latter has
often requires careful elevation or peeling of soft tissues from been associated with alcohol abuse, use of steroids, endocrine
the confines of the osteophyte. disorders, and some hereditary conditions. Although initial
 CHAPTER 18  Diagnostic and Operative Ankle and Subtalar Joint Arthroscopy 335

Fig. 18.15  A heel-rise view (left) demonstrates a posteromedially located osteochondral defect. Because of
the relative posterior location of the defect, a plain anterior-posterior view (right) is not able to demonstrate
this lesion.

symptoms may be absent, in chronic cases most patients pres-

ent with intermittent pain located deep in the ankle joint that
increases on weight bearing. On physical examination, signs are
often absent. A discrete limitation of range of motion with some
synovitis may be present. Local tenderness on palpation with
recognition is absent in most cases. Since there are no specific
pathognomonic signs or symptoms, it is essential for the exam-
ining physician to be aware that an osteochondral lesion can be
present. The frequent absence of radiographic changes on con-
ventional radiographs has led to the use of more sensitive meth-
ods for detection. A heel-rise view doubles the change to detect Fig. 18.16  From anterior to posterior the talar dome can be divided into
four equal parts. When an osteochondral defect is located in one of the
an osteochondral lesion (Fig. 18.15).20 Furthermore, both CT three anterior parts, it can be reached by a routine anterior ankle arthros-
scan and MRI can be helpful for the diagnosis and preoperative copy. Soft-tissue distraction might be necessary. When the lesion is
planning with a lack of significant difference between the sensi- located in the most posterior quarter, it can be reached only by posterior
tivity and specificity of both modalities.20 ankle arthroscopy.
Pritsch et  al. developed an arthroscopic staging system
that correlated well with the CT classification of Ferkel and osteochondral lesions is to determine whether they are symp-
Sgaglione21-23 and the MRI classification of Anderson et al.21-26 tomatic or asymptomatic.
In 1999, a new arthroscopic staging system was developed by
Taranow et  al.,27 who classified cartilage as viable and intact Surgical Technique
(stage A) or breached and nonviable (stage B). The bone com- From anterior to posterior the talar dome can be divided into
ponent was determined as follows: (1) stage 1 is a subchondral four equal parts (Fig. 18.16). When the osteochondral lesion is
compression or bone bruise, (2) stage 2 lesions are subchon- located in one of the three anterior parts of the talar dome, it
dral cysts and are not seen acutely (these develop from stage 1 can be treated by a routine anterior ankle arthroscopy. When
lesions), (3) stage 3 lesions are partially separated or detached it is located in the most posterior quarter of the talar dome,
fragments in situ, and (4) stage 4 represents displaced frag- the defect should be approached by a posterior ankle arthros-
ments. The condition of the cartilage and bone together deter- copy (see “Osteochondral lesions” under 18.6) or by means of
mines the type of surgical treatment. a medial malleolar osteotomy. The current routine treatment
Despite the existence of classification systems, few authors consists of removal of dead bone and overlying cartilage.28 After
base their treatment decision on these systems. A meta-analysis debridement, the subchondral sclerotic zone is perforated with
of Tol et  al.28 showed that the value of preoperative radiologic a burr or K-wire or by microfracture. Preoperatively, it is desir-
staging systems was of minor value in the preoperative planning able to decide whether to use mechanical distraction in combi-
because they hardly correlate with the perioperative findings. This nation with a 2.7-mm arthroscope or to use a standard 4-mm
demonstrates the shortcoming of preoperative radiologic staging arthroscope and to treat the osteochondral lesion in the ante-
systems as a guide for the treatment strategy. Perioperative stag- rior working area by forcing the ankle into full plantarflexion.
ing of osteochondral lesions therefore seems more appropriate. The osteochondral lesion in the posterior quarter of the talar
Eventually, the most rational way of preoperative assessment of dome is difficult to reach in the hyperplantarflexed position in
336 SECTION 3  Anatomic Disorders in Sports

perform a precise and complete debridement, with removal

of all loose fragments. Introduction of the instruments and
the arthroscope is performed with the ankle in the fully dor-
siflexed position, thus preventing iatrogenic cartilage dam-
age. After full debridement, the sclerotic zone is approached
with a microfracturing technique, or multiple drill holes are
made with a 2-mm burr or a 1.6-mm K-wire. A K-wire has the
advantage of flexibility, whereas a 2-mm drill can break more
easily if the position of the ankle is changed during drilling.
When a 2-mm drill is used, a drill sleeve is necessary to protect
the tissue.
In posteriorly located lesions for which an anterior approach
is chosen, a noninvasive traction device that allows the surgeon
to change quickly from the fully dorsiflexed position (introduc-
tion of the instruments) to the distraction position offers obvi-
ous advantages. The distraction device consists of a belt around
the waist of the surgeon that is connected to a noninvasive dis-
traction loop placed around the ankle. The amount of distrac-
tion can be adjusted by leaning more or less backward (see Fig.
18.18, B).
Fig. 18.17  An anterolateral located osteochondral defect of the talus. By
bringing the ankle in full plantarflexion, the defect can be fully debrided.
Completeness of the debridement can be checked by switching portals.
Loose Bodies and Ossicles
Loose bodies can be either bony, chondral, or osteochondral
and can arise from osteophytes or defects in the talus or tibia.
patients having a diminished plantarflexion or in case of ante- Sometimes, a loose body is attached to the capsule or other
rior osteophytes.27,29 structures with scar tissue, better known as a corpus liberum
Routinely the procedure is performed without distrac- pendulans.14 A small, loose body may cause catching symptoms
tion. The standard anteromedial and anterolateral approaches along with pain, swelling, and limitation of motion. Symptoms
are created as described earlier. In an osteochondral lesion of internal derangement may resolve if a small loose body
located medially, the 4-mm arthroscope is moved over to becomes fixed to the synovial lining, ceasing to cause joint
the anterolateral portal and the instruments are introduced irritation. A loose body may grow by proliferation of chond-
through the anteromedial portal. For an anterolateral defect, roblasts/osteoblasts or may shrink because of the action of
the arthroscope remains in the anteromedial portal and the chondroblasts/osteoclasts.
instruments are introduced through the anterolateral portal. If Physical examination may not be very revealing, with vague
osteophytes are present, they are removed first by chisel and/ areas of tenderness, possible limitation of motion, and catching.
or burr. Synovitis located anterolaterally (in case of an antero- Rarely is a loose body palpable. As with all ankle problems, a
lateral defect) or anteromedially (in case of an anteromedial careful physical examination must rule out extra-articular enti-
defect) is removed by a 4.5- or 5.5-mm synovator. The extent ties that can cause symptoms similar to intra-articular lesions.
of removal of osteophytes and synovitis is checked by bring- Peroneal subluxation, posterior tibial tendon attrition or rup-
ing the ankle into plantarflexion. It now should be possible to ture, tarsal tunnel syndrome, sinus tarsi syndrome, stress frac-
palpate and visualize the osteochondral lesions (Fig. 18.17). ture, and tendinitis must be carefully excluded by both physical
If this is not the case, then a further synovectomy should be examination and ancillary studies. Plain radiographs usually
performed in the dorsiflexed position. After sufficient syn- reveal an osseous loose body, but chondral loose bodies are
ovectomy, it is possible to identify the lesion in the forced not visible on routine studies. A CT or MRI study is best suited
plantarflexed position by palpating the cartilage with a probe. to make the distinction between an intra-articular versus an
Not only can the lesion be palpated with a probe, but it also extra-articular or intracapsular abnormality.
should be possible to visualize at least the most anterior part
of the lesion. It can be helpful to add a soft-tissue distraction Surgical Technique
(Fig. 18.18, A and B).18 If possible, a 3.5- or 4.5-mm synovator The arthroscopic approach to loose bodies is straightforward.
is now introduced into the lesion. After it has been debrided Loose bodies localized to the anterior compartment, particu-
by the synovator or curette, the arthroscope is moved over to larly in patients with ligamentous laxity, can be approached with
the portal opposite the defect to check the completeness of the a routine setup using anteromedial and anterolateral portals.
debridement. The scope then is brought back to the opposite However, the posterior joint also should be examined for the
portal and further debridement is performed. It is import- presence of loose bodies, which can hide in the posterior recess
ant to remove all dead bone and overlying, unsupported, of the joint.12,29 A posterolateral portal can be made for inspec-
unstable cartilage. Every step in the debridement procedure tion and posteriorly located loose bodies can be removed best
should be checked by regularly switching portals in order to by means of a two-portal posterior approach.
 CHAPTER 18  Diagnostic and Operative Ankle and Subtalar Joint Arthroscopy 337

A B
Fig. 18.18  (A) A resterilizable soft-tissue distractor can be helpful to visualize lesions that are located more
posteriorly in the ankle joint. (B) The amount of soft-tissue distraction can be adjusted by leaning more or less
backward.

SURGICAL TECHNIQUES AND cause an overload posttraumatic syndrome of the os trigonum.

CONCIDERATIONS PER SPECIFIC In this condition, the os trigonum becomes painful but appears
undisrupted on the lateral x-rays (Fig. 18.19). On the other
INDICATION—POSTERIOR ANKLE hand, chronic impingement of the posterior process of the talus
Posterior ankle syndrome involves pain syndrome. It presents against the tibia caused by chronic microtrauma or overuse by
mainly on forced plantarflexion. Posterior ankle impingement repeated hyperplantarflexion movements can lead to an inflam-
is caused by overuse or trauma, mainly found in ballet dancers matory process of the os trigonum. It also can result in degener-
and runners.12 Distinction between these two disorders seems ative changes in the posterior capsule of the ankle joint, adjacent
important because posterior impingement through overuse has ligaments, tendon, and chondrosynovial surface.
a better prognosis. Clinically, the patient complains of pain during push-off
There are at least 10 specific causes for posterior ankle pain: while running. The pain often is absent during walking on level
os trigonum syndrome; posttraumatic calcifications, loose bod- ground but appears on uneven terrain. Usually pain is com-
ies, and bony avulsions; osteochondral defects; tendinitis of the plained of posterolaterally in the ankle joint, but sometimes it
FHL tendon; tendinitis of the posterior tibial tendon; tendini- may be located in the posteromedial region. Physical examina-
tis the peroneal tendons; tendinitis of the Achilles tendon; and tion can reveal the presence of moderate swelling on only the
ankle and subtalar arthrosis.12,29 medial or on both sides of the Achilles tendon, with tenderness
on palpation.
Os Trigonum Syndrome A forced passive plantarflexion of ankle and foot will repro-
The os trigonum is an inconsistently present accessory bone duce the recognizable symptoms. With this test the examiner
of the foot situated at the posterolateral aspect of the talus. It performs repetitive, quick, passive forced plantarhyperflexion
appears between the ages of 8 and 11 as a secondary center of movements. The test can be repeated in slight external rotation
ossification and usually fuses to the talus within 1 year after or internal rotation of the foot relative to the tibia. The investiga-
its appearance. When this ossification center remains separate tor should apply this rotation movement on the point of maxi-
from the talus it is referred to as the os trigonum. According mal plantarflexion, thereby grinding the posterior talar process/
to Sarrafian, the prevalence of this ossicle ranges from 1.7% os trigonum in between the posterior tibial rim and calcaneus
to 7.7%.30 A recent study by Zwiers et  al. found a prevalence (Fig. 18.20). A negative test rules out a posterior impingement
of 23.7% on CT-scans of non-affected ankles.31 When fusion syndrome. A positive test in combination with pain on postero-
does occur and there is a large, intact posterolateral process, it lateral palpation can be followed by a diagnostic infiltration.
is referred to as a fused os trigonum. Since Rosenmuller first The infiltration is performed from the posterolateral position
described the os trigonum in 1804, there has been controversy between the prominent posterior talar process and the posterior
concerning its origin.32 McDougall33 believed it to be a sec- edge of the tibia. If the pain disappears on forced plantarflexion,
ondary ossification center of the talus, whereas other authors the diagnosis is confirmed. After clinical examination, a routine
state that it is a non-united fracture of the posterolateral talar lateral radiograph of the ankle should reveal an os trigonum.
process. The os trigonum usually remains asymptomatic, but Bone scanning can effectively localize osseous injuries in and
an otherwise normal os trigonum can become symptomatic around the talus by demonstrating increased uptake in the pos-
during or after strenuous physical activities or following an terior talar region but is not very specific. A CT scan enables the
injury to the ankle. Sometimes an acute trauma in plantarflex- surgeon to determine the exact location, size, and shape of the
ion may result in contusion, compression, or fracture of the os ossicle and therefore is valuable for preoperative planning (Fig.
trigonum or posterior process of the talus. These injuries may 18.21, A and B).
338 SECTION 3  Anatomic Disorders in Sports

Fig. 18.19  Posttraumatic syndrome of the os trigonum of the right ankle. Plain lateral x-rays (left) reveal an
undisrupted os trigonum. Additional posteromedial impingement views (PIM) with the foot in 25-degrees
external rotation in the same patient show that the os trigonum is disrupted.

FHL tendinitis is often present in patients with a symptom- an unsuspected chondral or osteochondral lesion may occur
atic os trigonum and pain located posteromedially. The FHL and result in a loose body floating in the posterior compartment
tendon can be palpated behind the medial malleolus. By asking of the ankle or subtalar joint.
the patient to flex the toes repetitively with the ankle in 10- to Osteophytes of the posterior tibial rim, an os trigonum, and
20-degree plantarflexion, the FHL tendon can be palpated in its even part of the posterior talar process may break off during
gliding channel behind the medial malleolus. During palpation a hyperplantarflexion trauma and act as a loose body. After a
there may be crepitus and recognizable pain. severe inversion trauma, the posterior talofibular ligament may
avulse a bony fragment from the posterior talar process, possi-
Surgical Technique ble causing posterior ankle impingement. Multiple loose carti-
A two-portal (posterolateral and posteromedial) approach with laginous or osteocartilaginous bodies also may form in synovial
the patient in the prone position gives excellent access to the chondromatosis.
posterior ankle compartment of the ankle joint. The posterior A small, loose body may cause catching symptoms with
compartment of the ankle joint thus can be visualized, and the joint motion along with pain. Plantarflexion may be limited
subtalar joint, os trigonum, and FHL can be inspected. After and painful during the hyperplantarflexion test. Plain lat-
inspection, the posterior talofibular ligament must be detached eral radiographs usually reveal an osseous loose body, but
from the posterior talar process. The superior border of the pos- when located posteromedially it may over-project. An addi-
terior talar process is cleaned with the shaver, after which the tional posteromedial impingement view (PIM) with the foot
FHL tendon can be inspected (Fig. 18.22). The flexor retinac- in 25-degree external rotation relative to the tibia is helpful
ulum can be cut. After this has been performed, the posterior when there is suspicion for bony pathology in posterome-
talocalcaneal ligament must be cut. Finally, the os trigonum can dial compartment of the ankle joint (see Fig. 18.19). Lesions
be detached with a chisel or small osteotome and subsequently that appear to be loose bodies on routine radiographs may
removed (Fig. 18.23). actually be intra-articular, intracapsular, or extra-articular
in location, particularly in the posterior ankle joint com-
Posttraumatic Calcifications, Loose Bodies, and partment. The location of the lesions should be determined
Bony Avulsions preoperatively to avoid embarrassment of performing an
Calcifications, bony avulsions, and loose chondral- or osteo- arthroscopic examination for loose body removal only to find
chondral fragments may result from major trauma to the ankle the joint free of any abnormality. A CT scan is best suited to
joint.14 When the fragments are located in the posterior com- make the distinction between an intra-articular abnormality
partment of the ankle, they are most likely the result of a hyper- versus an extra-articular or intracapsular abnormality and
plantarflexion trauma or a combination of strong inversion, to determine the exact location in the posterior ankle joint
plantarflexion, and external rotation of the tibia. In either case, compartment.
 CHAPTER 18  Diagnostic and Operative Ankle and Subtalar Joint Arthroscopy 339

Fig. 18.20  Forced passive plantarflexion test. This test will reproduce
the recognizable symptoms. The examiner performs repetitive, quick,
forced passive plantarhyperflexion movements. The investigator should
apply rotational movements on the point of maximal plantarflexion;
thereby, the posterior talar process/os trigonum is pinched between the
posterior tibial rim and calcaneus.

Osteochondral Lesions B
On the sagittal plane, the talar dome can be divided into four Fig. 18.21 (A and B) A computed tomography scan enables the sur-
equal quarters. When an osteochondral lesion is located in geon to determine the exact location, size, and shape of loose ossicles
one of the anterior three quarters of the talar dome, which and is therefore valuable for preoperative planning. (A) A loose fragment
posterolateral in the ankle joint on a sagittal reconstruction. (B) Loose
included the majority of the lesions, the pathology should be fragments between the distal fibula and talus of the left ankle.
approached by routine anterior ankle arthroscopy. In case the
lesion is located in the most posterior quarter, however, the
lesion is better treated by posterior ankle arthroscopy. A preop- microfracturing are best be approached by retrograde drilling
erative CT scan with sagittal image reconstructions is import- using a retrograde aiming device. Cysts larger than 1-cm diam-
ant to determine the exact location of the lesion (Fig. 18.24). In eter demand filling with bone graft.
case of a posteromedially located osteochondral defect, the FHL
tendon also should be inspected routinely. The tendon can be
affected because of shredding of the tendon against the defect SURGICAL TECHNIQUES AND CONCIDERATIONS
during flexion of the great toe while walking. When the ten- PER SPECIFIC INDICATION—PATHOLOGY OF
don is affected, the flexor retinaculum should be cut and thus THE TENDONS AND TALAR JOINT
the tendon released and debrided. Osteochondral lesions of the
tibial plafond can best be treated by means of posterior ankle FHL Tendon Pathology
arthroscopy, since the joint opens up quite well with soft tis- Tendinitis of the FHL tendon is caused most often by poste-
sue distraction. Treatment includes debridement and microf- rior overuse and posttraumatic injuries.34 It is typically found in
racturing. A 90-degree microfracture probe is very well suited athletes performing repetitive, forceful push-offs such as gym-
for this purpose. Cystic lesions that are too large to reach by nasts, skaters, long-distance runners and swimmers,35-38 and in
340 SECTION 3  Anatomic Disorders in Sports

Fig. 18.24  A preoperative computed tomography (CT) scan with sagittal

image reconstructions is important to determine the size and location of
posterior located osteochondral defects. A sagittal CT reconstruction of
a left ankle with an osteochondral defect that is located at the posterior
Fig. 18.22  Right ankle. Inspection of the flexor hallucis longus tendon end of the talar dome.
in its channel. The view is from proximal to distal. (See also Figs. 18.6
and 18.12.)

Fig. 18.23 Removal of an os trigonum with a chisel. On the left the

flexor hallucis longus tendon is located. Fig. 18.25 In a cadaver specimen it is shown that the flexor hallucis
longus tendon shreds against the posterior part of the talus (often the
place where osteochondral defects are located) during dorsiflexion (see
ballet dancers.35,36 Moreover, it is a concomitant finding with text).
other pathology, such as an os trigonum, loose bodies, bony
avulsions, ankle and subtalar arthrosis, or a combination. An contact with the tendon. The tendon, meanwhile, is moving in
unexpected but consequent finding that may cause FHL ten- the opposite direction because the toes are actively flexed to start
dinitis is a posteriorly located osteochondral lesion, with the with the push-off phase. Here, the tendon may shred against the
defect being located in the posterior quarter of the talar dome osteochondral lesion, leading to irritation and inflammation
on the medial side. In a case series reporting on 50 patients with (Fig. 18.25). In this way a posteriorly located osteochondral
FHL tendinitis, only three patients had an isolated tendinitis. A lesion can cause tendinitis of the FHL.
concomitant posteromedial osteochondral defect was found in The pain of an FHL tendinitis is located posteromedially. The
seven patients, and in 40 patients the tendinitis was accompa- tendon can be palpated behind the medial malleolus. By asking
nied by os trigonum syndrome, bony avulsions, calcifications, the patient to flex the toes repetitively with the ankle in 10- to
and localized synovitis.39 The tendinitis is maintained during 20-degrees plantarflexion, the FHL tendon can be palpated in
the stance phase when walking. During this phase, the ankle its gliding channel behind the medial malleolus. The tendon
joint is in dorsiflexion and the posterior talar dome is in closest glides up and down under the palpating finger of the examiner.
 CHAPTER 18  Diagnostic and Operative Ankle and Subtalar Joint Arthroscopy 341

Fig. 18.27  Right ankle. The distal portal for posterior tibial tendoscopy
is located directly over the tendon 2 cm distal to the posterior edge of
Fig. 18.26  Release of the flexor retinaculum in a left ankle. Adhesions the medial malleolus. A 2.7-mm arthroscope is introduced.
surrounding the flexor hallucis longus tendon are removed.
Posttraumatic calcification in the posteromedial joint capsule
In case of stenosing tendinitis or chronic inflammation, there can produce symptoms of posterior tibial tendinitis because
may be crepitus and recognizable pain. Sometimes a nodule in of the close connection of joint capsule and posterior tibial
the tendon can be felt to move up and down under the palpating tendon sheath in this region. In a cadaveric study, a consis-
finger.39 tent membranous mesotendineal structure was found between
tendon and tendon sheath.34 This thin, vincula-like structure
Surgical Technique runs between the posterior tibial tendon and tendon sheath
The routine two-portal approach with the patient in the prone and attaches to the tendon sheath of the flexor digitorum ten-
position is used when evaluating and treating flexor hallucis don. It runs from the proximal end all the way with a free edge
longus pathology. In general, during posterior ankle arthros- approximately 4 to 5 cm above the level of the posteromedial
copy the FHL tendon is an important landmark to prevent tip of the malleolus. After traumatic injury to the ankle, these
damage to the more medially located neurovascular bundle.12,29 mesotendineal structures may have clinical implications.
When a tendinitis is present, it is treated by performing a release
of the flexor retinaculum (Fig. 18.26). The tendon sheath can Surgical Technique
be opened distally all the way up to the level of the sustentac- The main portal for posterior tibial tendoscopy is located
ulum tali. Here, the arthroscope may enter the tendon sheath directly over the tendon, 2 cm distal to the posterior edge of the
in order to inspect the tendon tissue. Adhesions surrounding medial malleolus. The distal portal is made first, with an inci-
the FHL tendon, nodules, and scar tissue can be removed and sion through the skin. The tendon sheath is penetrated by the
inflammation, tears, and thickness can be debrided. In case of arthroscope shaft with a blunt trocar. A 2.7-mm arthroscope
a FHL tendon tear, treatment includes reduction of any nodule with an inclination angle of 30 degrees is introduced (Fig.
and debridement of the tendon with removal of irregularities by 18.27). After a spinal needle is introduced under direct vision,
means of radiofrequency. In our experience, converting to an an incision is made through the skin into the tendon sheath to
open procedure is not necessary. create a proximal portal. Instruments such as shaver system can
be introduced. Through the distal portal a complete overview
Posterior Tibial Tendon Pathology can be obtained of the posterior tibial tendon, from its insertion
The posterior tibial tendon plays an important role in normal (navicular bone) to approximately 6 cm above the level of the tip
hindfoot function. It plantarflexes and supinates the foot and of the medial malleolus.
thus prevents valgus deformity. Different stages of posterior The complete tendon sheath can be inspected by rotating
tibial tendon dysfunction have been described as the disease the scope over the tendon. Special attention should be given
progresses from peritendinitis to elongation and degenera- to inspect the tendon sheath covering the deltoid ligament, the
tion of the tendon.34 Tenosynovitis is often seen in association posterior medial malleolus surface, and the posterior joint cap-
with flatfoot deformity or a prominent navicular tubercle and, sule. More proximal, the free edge of the vincula is inspected.
to a lesser extent, in association with psoriatic and rheuma- The posterior joint capsule can be palpated and removed with
toid arthritis. In the early stage of posterior tibial tendinitis, a shaver system. The arthroscope is placed from the distal por-
tenosynovectomy can be performed if conservative treatment tal between tendon and medial malleolus. The shaver comes
fails. Postsurgical and post-fracture adhesions and irregularity down from the proximal portal. Once the arthrotomy is made,
in the contour of the posterior aspect of the tibia/medial mal- the arthroscope and instruments can be manipulated into the
leolus can account for a symptomatic posterior tibial tendon. posteromedial compartment of the ankle joint. Synovectomy or
342 SECTION 3  Anatomic Disorders in Sports

Fig. 18.28 Left ankle. The main portal for peroneal tendoscopy is

located directly over the tendons 2 cm distal to the posterior edge of
the lateral malleolus. The distal portal is made first. A 2.7-mm scope can
be introduced. The proximal portal is created under direct vision.

loose body removal thus can be performed. In case of a pos-

terior tibial tendon tear, after arthroscopic debridement, the
procedure must be converted to a mini open procedure for
tubularization of the tendon

Peroneal Tendon Pathology

Tenosynovitis of the peroneal tendons, (recurrent) dislocation,
Fig. 18.29 Through the distal portal a complete overview can be
rupture, and snapping of one of the peroneal tendons account
obtained of both peroneal tendons. The inspection starts approximately
for most of the symptoms at the posterolateral side of the ankle 6 cm proximal from the posterior tip of the lateral malleolus where a thin
joint.34,39 This disorder must be differentiated from fatigue frac- membrane splits the tendon compartment into two chambers (1). More
tures of the fibula, lesions of the lateral ligament complex, and distally (2, 3) both tendons lie in one compartment.
posterolateral impingement (os trigonum syndrome). Peroneal
tendon disorders often are associated and secondary to chronic needle is introduced under direct vision, an incision is made
lateral ankle instability.40 Because the peroneal muscles act as through the skin into the tendon sheath to create a proximal
lateral ankle stabilizers, more strain is placed on their tendons portal. Instruments such as shaver system can be introduced.
in the presence of chronic lateral instability, resulting in hyper- Through the distal portal on the lateral side, a complete overview
trophic tendinopathy, tenosynovitis, and ultimately in (partial) can be obtained of both peroneal tendons. The inspection starts
tendon tears. The diagnosis may be difficult in patients with approximately 6 cm proximal from the posterior tip of the lat-
lateral ankle pain. Recurrent peroneal tendon dislocation and eral malleolus, where the tendon compartment is split into two
tenosynovitis can be established by clinical examination. In chambers by a thin membrane (Fig. 18.29). More distally, both
the case of tears or ruptures of the peroneus brevis or longus tendons share one compartment. The complete compartment
tendon, supplemental investigations such as MRI or ultraso- can be inspected by rotating the endoscope over and between
nography can be helpful to establish the diagnosis. Postsurgical the two tendons. A vincula-like membrane by which both ten-
and post–fracture adhesions and irregularities in the posterior dons are attached to the tendon sheath allows the arthroscope
aspect of the fibula where the gliding channel of the tendon is to rotate freely all around each tendon. The muscle fibers of
located can be responsible for symptoms in this region. the peroneus brevis can be recognized in the thin membrane
The primary indication for peroneal tendoscopy is postero- up to the tip of the fibula. At this location both tendons cross
lateral ankle pain with a high clinical suspicion for tenosynovitis the calcaneofibular ligament, which usually gives some fibers
of the peroneal tendons, subluxation or dislocation, a tear or to the anterior talofibular ligament. Approximately 3 to 5 cm
postoperative adhesion,41,42 independently of whether or not distal from the fibula the tendons cross each other and again get
positive MRI findings are present.43 divided by a membrane and a bony prominence. Here, a patho-
logic thickened vincula or tendon sheath can be released, adhe-
Surgical Technique sions can be removed, and a symptomatic prominent tubercle
The main portal for peroneal tendoscopy is located directly over can be removed. When a total synovectomy of the tendon sheath
the tendons, 2 cm distal to the posterior edge of the lateral mal- is to be performed, it is advisable to create a third portal more
leolus. The distal portal is made first, with an incision through distal or more proximal from the previously described portals.
the skin. The tendon sheath is penetrated by the arthroscope In case of treatment for recurrent peroneal tendon dislocation,
shaft with a blunt trocar. A 2.7-mm arthroscope with an inclina- it is possible to deepen the groove of the peroneal tendons with
tion angle of 30 degrees is introduced (Fig. 18.28). After a spinal a burr.41 In case of a peroneal tendon tear, the tendon can be
 CHAPTER 18  Diagnostic and Operative Ankle and Subtalar Joint Arthroscopy 343

Fig. 18.30 Left ankle. In patients with paratendinitis and tendinosis

there is localized swelling approximately 4 to 7 cm above the insertion
of the Achilles tendon.

arthroscopically debrided followed by a mini open procedure

for tubularization of tendon. Several authors suggest that when
>50% of the cross-sectional area of the tendon is involved in
the tear, the tendon is considered irreparable requiring more Fig. 18.31  For peritendinitis of the Achilles tendon, the portals are cre-
advanced surgical treatment. A recent international consensus ated 2 cm distal and proximal of the lesion. After a spinal needle is
introduced under direct vision, an incision is made at the location of the
statement, however, concluded that this threshold remains quite
proximal portal.
arbitrary and a surgeon should always try to repair the tear in
case some reasonable native tendon is present.44 In case one or
both tendons are nonreconstructable, grafting of the tendon(s) When treating Achilles tendinopathy, several treatment
is favoured.44 options are proposed in literature. Heavy-load eccentric
calf-muscle training has been demonstrated to be an effective
Achilles Tendon Pathology—Paratendinitis and treatment for chronic Achilles paratendinitis. When treating
Tendinosis (see also Chapter 9) paratendinitis surgically, the diseased and thickened paratenon
Overuse injuries of the Achilles tendon can be divided into is excised. Operative treatment of chronic tendinosis con-
insertional and noninsertional pathology.45,46 Noninsertional sists of debridement of the paratenon and removal of degen-
tendinopathy can be divided into three subgroups: erative necrotic tissue. The thickened degenerative portion
• Paratendinitis, characterized by inflammation on the lining of the tendon is excised, and the defect is closed primarily.
of the tendon. In case of acute paratendinitis, there is diffuse Revascularization is stimulated by making multiple longitudi-
swelling around the tendon. Most cases of isolated paraten- nal incisions into the tendon. Open surgery, however, produces
dinitis respond well to conservative treatment. a guarded prognosis. In fact, Maffulli et  al.48 reported poor
• Paratendinitis combined with tendinosis, most often pre- results in more than 60% of patients. Therefore, an arthroscopic
senting with localized swelling 4 to 7 cm above the insertion approach is recommended.
of the Achilles tendon (Fig. 18.30). On examination there is
pain, particularly when the tendon is squeezed. Most often Surgical Technique
the pain is localized predominantly on the medial side. MRI For peritendinitis of the Achilles tendon, the portals are created
demonstrates marked thickening of the tendon. 2 cm proximal and 2 cm distal of the lesion (Fig. 18.31). The dis-
• Tendinosis, where fields of local degeneration in the ten- tal portal is made first: an incision is made through to the skin
don are present. Since no evidence is available showing only. The crural fascia is penetrated by the arthroscope shaft
inflammation in these patients, the term tendinitis has been with a blunt trocar, and a 2.7-mm arthroscope with an inclina-
exchanged for tendinosis.34,47 With advanced tendinosis, the tion angle of 30 degrees is introduced. After a spinal needle is
tendon elongates because of chronic degeneration and is no introduced under direct vision, an incision is made at the loca-
longer in functional continuity. There often is an increase in tion of the proximal portal. An instrument such as a probe is
passive range of dorsiflexion. then introduced and the pathologic paratenon is removed by a
344 SECTION 3  Anatomic Disorders in Sports

A B
Fig. 18.32  (A) Achillotendoscopy: retrocalcaneal bursitis. (B) After removal of the bursa and inflamed soft
tissue, the calcaneal prominence is removed with a full-radius resector and small acromionizer.

small shaver. The Achilles tendon can be inspected by rotation healing. Angermann and Hovgaard49 reported a cure rate of
of the scope over the tendon. The plantaris tendon can be recog- only 50% after open surgery for chronic retrocalcaneal bursi-
nized and released, or resected when indicated. tis. Endoscopic treatment offers the advantage of less morbidity,
reduced postoperative pain, and outpatient treatment. It pro-
Achilles Tendon Pathology—Insertional Tendonitis vides easy access to the narrow anatomical space around the
and Retrocalcaneal Bursitis Achilles tendon and is associated with a lower rate of complica-
Insertional tendonitis can be subdivided into three categories: tions and requires a shorter rehabilitation period.50
• (Chronic) retrocalcaneal bursitis, accompanied by deep pain
and swelling of the posterior soft tissue just in front of the Surgical Technique
Achilles tendon (Fig. 18.32). The prominent bursa can be Achilles tendinoscopy for retrocalcaneal bursitis is performed
palpated medially and laterally from the tendon at its inser- with the patient in the prone position. Two portals are created,
tion. The lateral radiograph demonstrates the characteristic medial and lateral to the Achilles tendon, at the level of the
prominent superior calcaneal deformity. Operative treat- superior border of the os calcis. A 4-mm arthroscope with an
ment involves removal of the bursa and resection of the lat- inclination angle of 30 degrees is introduced through the pos-
eral and medial posterosuperior aspect of the calcaneus. terolateral portal. A probe and subsequently a 5-mm, full-radius
• Retrocalcaneal bursitis, frequently combined with midpor- shaver are introduced through the posteromedial portal. After
tion insertional tendinosis. Often a partial rupture of the removing of the bursa and inflamed soft tissue, the surgeon uses
midportion of the tendon is present at its insertion. When a full-radius shaver and small acromionizer to remove the cal-
operative treatment for retrocalcaneal bursitis is indicated, caneal prominence.
debridement of the midportion of the Achilles insertion
should be considered in case of a partial rupture.34 Subtalar Joint Arthroscopy and Intraosseous
• Isolated insertional tendinosis, leading to pain at the Talar Cysts
bone-tendon junction that worsens after exercise. The ten- Subtalar arthroscopy was first described in 1985,51 and may be
derness is specifically located directly posterior to the junc- applied as both a diagnostic and therapeutic tool. As with any
tion. Radiographic signs of ossification at the most distal other joint, the subtalar joint should be compartmentalized and
extent of the insertion of the tendon (bone spur) are typical examined. Indications for subtalar arthroscopy include the evalu-
signs of insertional Achilles tendinosis. Most patients can be ation of subtalar instability, debridement of osteochondral lesions,
managed with nonoperative measures, such as widening and and excision of avulsion fragments or loose bodies. The anterior
deepening of the heel counter of the shoe. When operative subtalar joint consists of the anterior facet, middle facet, talona-
treatment is indicated, the pathologic ossifications and spurs vicular joint, and spring ligament. The dividing axis through the
can best be approached by a central heel-splitting incision. subtalar joint consists of the sinus tarsi, tarsal canal, cervical liga-
Open surgery for insertional tendinitis with removal of the ment, talocalcaneal interosseous ligament, inferior extensor reti-
chronically inflamed bursa and the posterosuperior promi- naculum, and fat pad. The posterior subtalar joint consists of the
nence of the calcaneus can be associated with a poor outcome. posterior facet that is 40 to 45 degrees lateral to the longitudinal
Moreover, open surgical treatment requires plaster immobiliza- axis of the foot, the capsule, the posterior recess, the lateral recess
tion to prevent equines malformation and to stimulate wound (thickened by the calcaneofibular ligament), and calcaneus.
 CHAPTER 18  Diagnostic and Operative Ankle and Subtalar Joint Arthroscopy 345

the lateral ankle gutter. For this reason, fluoroscopic confirma-

tion of position can be useful.
Assessment of the posterior articulation of the subtalar
joint can best be performed by means of a two-portal endo-
scopic approach of the hindfoot with the patient in the prone
position.13 The therapeutic indications include debridement
of chondromalacia, excision of osteophytes, the removal of a
loose body, lysis of adhesions with posttraumatic arthrofibrosis,
and synovectomy. Intraosseous talar cysts can be approached
through the subtalar joint.52 Retrograde curettage of these
lesions with destruction of the surrounding zone of sclerosis,
along with bone grafting, is the treatment of choice. Lesions
with a communication to the subtalar joint can be treated with
the patient in the prone position. For proper preoperative plan-
ning, a CT scan is indispensable.
Fig. 18.33  Subtalar joint arthroscopy: the posterior lateral portal is made A shaver is introduced through the posteromedial portal.
approximately 1 cm posterior and 1 cm proximal to the tip of the fibula. After identification of the FHL tendon, the posterior talar pro-
cess is freed from its capsular attachments. The joint capsule of
the subtalar joint is resected, and the opening of the cyst in the
Surgical Technique subtalar joint is identified by direct vision and palpation by means
The patient may be positioned supine or laterally with a bol- of a small probe (Fig. 18.34, A and B). With the endoscope in the
ster under the foot at the edge of the table. A 1.9- to 2.7-mm posteromedial portal and the probe in place through the same
arthroscope with 30-degree wide angle is used. Small joint shav- posterolateral portal, the drill guide is introduced. The drill guide
ers and burrs can be introduced. When needed, soft-tissue dis- is parallel to the probe of which the curved tip is in place in the
traction can be performed. Four portals have been described.51 opening of the cyst in the subtalar joint. The drill guide is posi-
The anterior lateral portal is made in the sinus tarsi 2 cm ante- tioned onto the posterior talar process and a hole is drilled into
rior and 1 cm inferior to the tip of the lateral malleolus. Caution the cystic lesion with a 4.5-mm drill (Figs. 18.35 and 18.36). The
should be taken not to injure the superficial peroneal nerve. The lesion is curetted and debrided with a closed-cup curette. The
inframalleolar portal is made anterior to the calcaneofibular opening of the cyst is enlarged to 6.5 mm, and a 6.5-mm blunt tro-
ligament. Caution should be taken not to injure the peroneal car is introduced. Multiple drill holes are made through the cystic
tendons. The posterior lateral portal is made 1 cm posterior wall from inside the lesion with a K-wire (Fig. 18.36). Cancellous
and 1 cm proximal to the tip of the fibula (Fig. 18.33). Caution bone obtained from the iliac crest is packed into the cystic lesion
should be taken not to injure the sural nerve, lesser saphenous through the trocar (Fig. 18.37). This two-portal endoscopic
vein, and peroneal tendons. The medial portal is made in the approach offers an excellent alternative to open techniques, with
sinus tarsi approximately 2 cm anterior to the tip of the lateral obvious advantages. An arthrotomy or malleolar osteotomy is
malleolus. A blunt trocar is introduced through the deep fascia prevented. The articular origin of a cyst can be identified under
and guided gently through the tarsal canal to the medial skin direct arthroscopic vision. A second portal makes it possible to
surface. The foot is placed in equinus to relax the neurovascular probe and subsequently treat the lesion by debridement, drilling,
structures. An incision is made over the trocar. A blunt trocar is and transtrocar bone grafting. Excellent results at follow-up have
introduced from the medial portal. The joint is insufflated and been reported by using this technique.12,52
the arthroscope is introduced to view the anterior lateral and
posterior medial subtalar joint. Caution is taken to avoid the Combined Anterior and Posterior Ankle
neurovascular structures, which are approximately 2.5 cm dis- Arthroscopy
tal to the tip of the medial malleolus. A systematic examination In case of combined anterior and posterior ankle pathology,
of the subtalar joint is performed by varying the portal place- anterior arthroscopy can be combined with posterior arthros-
ment of the scope. An arthroscope in the anterior lateral por- copy of ankle in the same operative setting. Indications include
tal enables evaluation of the sinus tarsi, interosseous ligament, rheumatoid arthritis, pigmented villonodular synovitis, chon-
cervical ligament, and lateral and posterior gutters. Placing the dromatosis, or ankylosis.
arthroscope in the posterior lateral portal enables evaluation
of the lateral gutter and lateral compartment. An arthroscope Surgical Technique
in the medial portal enables evaluation of the anterior lateral First, the patient is placed in the prone position for the posterior
and posterior medial compartments. The major complications approach. A tourniquet is applied and a small support is placed
specific to this procedure are sural nerve injury at the posterior under the lower leg. A two-portal endoscopic approach of the
lateral portal, superficial peroneal nerve injury at the anterior hindfoot is performed and the pathology can be treated. When
lateral portal, and peroneal tendon disruption at the inframalle- the procedure has been finished, the portals are closed and the
olar portal. The arthroscope may be placed inadvertently in the wounded is draped, a strap is placed around the foot, the knee is
ankle joint or may penetrate the capsule of the ankle and enter flexed approximately 90 degrees, and the strap is attached with
346 SECTION 3  Anatomic Disorders in Sports

A B
Fig. 18.34  (A and B) A computed tomography (CT) scan is indispensable for proper preoperative planning.
This CT scan shows an intraosseous cyst of the right talus that has communication with the subtalar joint.

Fig. 18.35  The opening of the cyst (see Fig. 18.36, A and B and text)
in the subtalar joint is identified by direct vision and palpation by means Fig. 18.36  The drill guide is positioned, parallel to the probe, onto the
of a small probe. posterior talar process. With a 4.5-mm drill, a hole is drilled into the
cystic lesion.

a string to the ceiling of the operating room. The foot is now is instructed to actively dorsiflex his or her ankle and foot on
hanging upside down (Fig. 18.38). Next, the portals for the ante- awakening and to continue this exercise a few times every hour
rior ankle arthroscopy are made and synovectomy or capsulec- for the first 2 to 3 days after surgery. In cases where a retinac-
tomy is performed in the anterior ankle compartment ulum or tendon tear repair is performed, it is recommended to
apply a lower leg splint for 2 days followed by 12 days of a non-
weightbearing lower leg cast. Next, patients are allowed weight
REHABILITATION bearing for an additional 4 weeks in either a Walker boot or in
In general, postoperative rehabilitation consists of a compressive a lower leg cast, followed by physical therapy to regain strength
bandage and partial weight bearing for 3 to 5 days. The patient and range of motion.
 CHAPTER 18  Diagnostic and Operative Ankle and Subtalar Joint Arthroscopy 347

8. Myerson MS, Quill G. Ankle arthrodesis: a comparison of an

arthroscopic and an open method of treatment. Clin Orthop.
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9. Van Dijk CN, Tol JL, Verheyen CC. A prospective study of prog-
nostic factors concerning the outcome of arthroscopic surgery for
anterior ankle impingement. Am J Sports Med. 1997;25:737–745.
10. Cameron SE. Noninvasive distraction for ankle arthroscopy.
Arthroscopy. 1997;13:366.
11. Van Dijk CN, Verhagen RAW, Tol JL. Technical note. Resteriliz-
able non-invasive ankle distraction device. Arthroscopy. 2001;17:1.
12. Van Dijk CN, Scholten PE, Krips R. Technical note. A 2-portal
endoscopic approach for diagnosis and treatment of posterior
ankle pathology. Arthroscopy. 2000;16:871.
13. Ferkel RD, Guhl J, van Buecken K. Complications in ankle arthros-
copy: analysis of the first 518 cases. Orthop Trans. 1993;16:727.
14. Ferkel RD. Arthroscopic surgery. The Foot and Ankle. Philadel-
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15. Scranton Jr PE, McDermott JE, Rogers JV. The relationship be-
tween chronic ankle instability and variations in mortise anatomy
and impingement spurs. Foot Ankle Int. 2000;21:657.
16. Tol JL, Verhagen RA, Krips R, et al. The anterior ankle impinge-
Fig. 18.37  Cancellous bone obtained from the iliac crest is packed into ment syndrome: diagnostic value of oblique radiographs. Foot
the cystic lesion through a trocar. Ankle Int. 2004;25:63.
17. Tol JL, van Dijk CN. Etiology of the anterior ankle impinge-
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terior impingement in the ankle. J Bone Joint Surg Br. 2001;83:9.
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20. Verhagen RAW. Diagnostic Guidelines for Chronic Ankle Pain.
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Joint Surg Am. 1980;62:97–102.
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Fig. 18.38  Combined anterior and posterior ankle arthroscopy. Poste-
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35. Hamilton WG. Tendonitis about the ankle joint in classical ballet 1992;13(8):482–487.
dancers. The Am J Sports Med. 1977;5(2):84–88. 46. Saltzman CL, Tearse DS. Achilles tendon injuries. J Am Acad
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 19
Foot and Ankle Endoscopy
Cristian Ortiz, Emilio Wagner, Nathaly Caicedo

OUTLINE
Introduction, 349 Biomechanics, 356
Achilles Tendoscopy, 349 Indications, 357
Anatomy, 349 Evidence-Based Recommendations, 358
Biomechanics, 350 Other Tendoscopies, 359
Indications, 350 Flexor Hallucis Longus Tendonoscopy, 359
Evidence-Based Recommendations, 354 Tibialis Anterior Tendonoscopy, 360
Posterior Tibial Tendoscopy, 354 Extensor Tendonoscopy, 360
Anatomy, 354 Other Arthroscopies, 361
Biomechanics, 354 Metatarsophalangeal Joint of the Lesser Toes, 361
Indications, 354 Indications, 361
Trauma, 354 Lisfranc (Tarsometatarsal) Joint, 362
Evidence-Based Recommendations, 356 Indications, 362
Peroneal Tendoscopy, 356 Chopart (Transverse Tarsal) Joint, 363
Anatomy, 356 Conclusions, 364

INTRODUCTION the Achilles tendon, including non-insertional Achilles tend-

In the last decade, minimal invasive management of mul- inopathy, Haglund’s deformity, equinus contracture, and even
tiple foot and ankle pathologies has been proposed, seek- Achilles ruptures.
ing to reduce the postoperative complications that occur in Tendoscopic surgery minimizes some of the risks present
patients classically treated with open surgical management. in some open procedures by reducing the complications asso-
Arthroscopy and endoscopy has emerged as a powerful min- ciated with open surgery, such as scarring, perioperative pain,
imally invasive tool for intra- and extra-articular pathologies and wound complications, and it may also provide a faster
in foot and ankle. As a diagnostic tool, it has been utilized to recovery.1
evaluate articular osteochondral lesions, impingement lesions,
syndesmotic instability, and lesser metatarsophalangeal insta- Anatomy
bility, among others. In fracture cases, arthroscopic assistance The Achilles tendon, or calcaneal tendon, is the thickest and
has been reported to be very useful too, as in pilon, tillaux, strongest tendon in the human body. It measures approximately
talus, and calcaneus fractures, to mention some. For tendinous 12 to 15 cm in length and is formed by the junction of the apo-
pathology, increasing indications for diagnostic and treatment neurosis of the gastrocnemius (attaches on the distal femur, has
alternatives have been reported for the Achilles tendon, poste- two muscle heads, one medial and other lateral, crosses the knee,
rior tibial, and peroneal tendon, among others. In this review, ankle, and subtalar joints) and soleus muscle (originates poste-
we will summarize arthroscopic or endoscopic alternatives for riorly off the proximal tibia and fibula, and crosses the ankle
foot and ankle pathologies excluding the ankle, subtalar, and and subtalar joints). Structurally, the Achilles tendon is formed
metatarsophalangeal joints. by fascicles separated by endotenon. Each fascicle is composed
of a mature type of fibroblasts denominated tenocytes; these are
located in a matrix made of glycoproteins, mucopolysaccha-
ACHILLES TENDOSCOPY rides, elastin, and collagen.
Achilles endoscopic surgery is a minimally invasive option that Throughout the tendon trajectory, there is a lateral 90-degree
has been described to manage different pathologies related to twist, finally inserting itself between 13 and 30 mm distal to the

349
350 SECTION 3  Anatomic Disorders in Sports

superior portion of the posterior tuberosity of the calcaneus.2 It can be divided in three different entities: tendinopathy, para-
The previous twist explains the fact that the fibers provided by tendinopathy, and a combination of both.7
the gastrocnemius muscle insert at the lateral aspect of the pos- Overuse is commonly associated with this condition, but
terior process of the calcaneus and the fibers of the soleus mus- other factors have been described, such as poor training tech-
cle insert at the medial aspect. Some of the insertional fibers are nique, improper training surface, strength imbalance, compres-
in continuity with the plantar aponeurosis.3 sion and friction of the tendon, shoe-related factors, rheumatoid
The Achilles tendon does not have a sheath, is surrounded arthritis, and endocrine disorders.
by a paratenon that is divided into an outer parietal and inner
visceral layer, with a mesotenon layer in the space between both, Diagnosis
to provide the blood supply. At the Achilles insertion, the blood The Achilles tendon is easily palpable even in obese patients,
supply is limited and is provided by periosteal and osseous ves- and local tenderness and swelling should be assessed. If the
sels. For this reason, it is believed that degenerative changes focal tenderness or swelling moves up and down with pas-
are often seen in this area and may explain prolonged recovery sive dorsiflexion and plantarflexion, it suggests that the
times for tendinopathic tendons. patient suffers from a tendinopathy. This condition can pres-
Just before its insertion on the calcaneus between the ventral ent three different patterns: local degeneration of the tendon
side of the distal part of the Achilles tendon and the calcaneus, but mechanically intact, diffuse thickening of the tendon, or
the retrocalcaneal bursa is found,1 which can be inflamed and insufficiency of the tendon with a rupture. In paratendinopa-
produce pain. This chronic inflammation can occasionally be thy, the swelling does not move and its pathology is exclusively
detected on plain films because it can disturb Kager’s triangle.4 in the paratenon, clinically and also on magnetic resonance
imaging (MRI). Often, pain is more severe on the medial
Biomechanics side of the achilles.11 Some investigators have theorized that
In the gait cycle, the Achilles tendon is placed in maximum the degeneration of the soleus tendon and a relatively fixed
tension during the late-stance phase. The gastrocnemius limits plantaris tendon is a possible explanation for this medial pain.
the degree of ankle’s dorsiflexion while the knee is in extension, Medially, the soleus and plantaris tendons are separated by the
whereas the triceps limits dorsiflexion with the knee in flexion. paratenon and with the simultaneous movement of the knee
The late-stance phase dorsiflexion beyond 10 degree of dorsi- and ankle both tendons are pulled at the same level and may
flexion is dependent on the flexibility of the gastrocnemius generate pain.1
muscle.5 Imaging in Achilles tendinopathy demonstrates intra-
The soleus and gastrocnemius muscles account for almost substance or intrinsic inflammatory changes of the tendon,
90% of energy in plantarflexion, and the Achilles tendon sup- with MRI findings including fusiform thickening and linear or
ports the body weight 12.5 times during running activities.3,6 diffuse low to intermediate signal intensity on T2-weighted or
STIR images. On the sagittal MRI view, an anterior convexity
Indications or a focal enlargement of the Achilles tendon can be observed.
Chronic achilles tendinopathy has a high prevalence in older When paratendinopathy is present, where the inflammation is
athletes. Most of the injuries are caused by overuse during run- seen in the paratenon, adhesion can be found between the para-
ning activities (33%).7 Clement and colleagues theorized that tenon and the Achilles tendon.1
the injuries are caused by microtrauma produced by fatigued Some other diagnoses should be ruled out when evaluating
muscles, eccentric loading, or excess tendon loading.8 Achilles tendinopathic patients, like tendinitis of the tibialis
In 1999, Alfredson and colleagues found there were no sig- posterior or flexor hallucis longus tendon; peroneal tendinop-
nificant differences in the mean concentrations of prostaglan- athy; posterior subtalar arthritis; ankle arthritis; tarsal tunnel
din E2 between tendons with the diagnosis of “tendinosis” and syndrome; posterior ankle impingement; seronegative arthri-
normal tendons.9 For this reason, the term “tendinitis” is an tis; and systemic diseases, including seropositive arthritis
inaccurate diagnosis, because the inflammatory reaction rarely (Rheumatoid arthritis, lupus).7
is found in the tendon. Instead, degenerative changes have been
found as intraoperative findings in patients with overuse inju- Treatment
ries, such as calcifications; fibrocartilaginous metaplasia; and Conservative management (nonsteroidal antiinflammatory
fatty, hyaline, and myxoid degeneration.7 Chronic Achilles drugs, activity modifications, shoe modifications, insoles,
tendinopathy can be divided into non-insertional, which can immobilization, and eccentric stretching)1,12 is the first-line
present as a local degeneration of the tendon combined with of treatment. The use of steroid injections in any presen-
paratendinopathy, or insertional where tendinopathic changes tation is controversial, and injections around or inside the
are found at the insertion, including the retrocalcaneal bursa Achilles tendon can promote degeneration and increase the
and the posterior process of the calcaneus.10 risk for a subsequent rupture of the tendon.13 In refractory
cases, shock wave therapy could be considered as second-line
Non-insertional Achilles Tendinopathy intervention because of its similar effectiveness to tendon
Non-insertional pathology of the Achilles tendon is frequently eccentric strengthening.14 In patients with combined para-
found in athletes and runners, who present clinically with pain- tendinopathy and tendinopathy, it can be difficult to deter-
ful swelling 4 to 6 cm proximal to the insertion in the calcaneus. mine which pathology needs to be treated, because the role
 CHAPTER 19  Foot and Ankle Endoscopy 351

of the focal tendinopathy on clinical pain is not clear.15 In the

majority of the cases, management is focused on treatment
of the paratendinopathy, because Alfredson and colleagues
in 1999 described as a possible cause of pain the neovascu-
larization around the tendinopathic nodule in patients with
a combined pathology.16
Up to 25% to 45% of patients do not respond to conservative
treatment after 6 months, and may require surgical interven-
tion.4,13 Open Achilles tendon surgical management for tendi-
nopathy consists in a decompression of the tendon by incision/
excision of the degenerative tissue. Releasing the plantaris ten-
don at the level of the nodule and removing the focal thickened
paratenon is the classic procedure in cases of paratendinopa-
thy.1 Great attention should be paid to the anterior aspect of the
tendinopathic area, which presents greater neovascularization
changes and neural ingrowth.17 To obtain optimal results from
surgery, some surgeons have tried to achieve all of these goals
during surgery. The results of open surgery have been reported
to be satisfactory in 50% to 96%18 of patients, but complications
such as prolonged recovery, skin edge necrosis, deep vein throm- Fig. 19.1  Endoscopic achilles tendon portals for non-insertional Achilles
disease.
bosis, superficial wound infection, seroma, hematoma, scarring,
and sural nerve irritation have been described.19 No clear guide-
line exists relative to how to treat surgically this condition, as we arthroscope is introduced, looking ventrally over the
do not even know the pathophysiology of the disease. edge of the tendon on the craniolateral side. The cranial
Based on these previous factors, an endoscopic option has portal is located 2–4 cm above the pathologic nodule on
been developed, trying to achieve the same goals as open sur- the medial border, and is made in the same manner, after
gery but hopefully avoiding its drawbacks. The endoscopic tech- localizing the correct site under direct visualization, and
nique has been able to achieve decompression of the tendon the use of a needle (Fig. 19.1).
by excision of degenerative tissue, excision of thickened para- The Achilles tendon is easy to identify on the healthy part.
tenon, lysis of adhesions, and stimulation of healing response. With the portals previously mentioned, it is possible
One aspect not obtainable with tendonoscopy is the removal of to visualize and work around the whole surface of the
degenerative tissue from the substance of the tendon.1,20 tendon over 10 cm of length approximately. To avoid
and minimize the risk of damage to neurovascular
Operative Technique structures always keep the arthroscope on the tendon.
As described by van Dijk and colleagues,21 the patient is on the The plantaris tendon is identified medial to the Achil-
operating table in prone position, with a pneumatic tourniquet les tendon.
placed around the upper thigh. The foot is placed at the end • Procedure:
of the table to allow the surgeon to move it in full dorsiflexion With the shaver, all fibrotic tissue binding the sheath or
and plantarflexion. Before inflating the tourniquet, the surgeon retrocalcaneal bursa to the tendon on the deep tendon
should mark the short saphenous vein on the lateral side of the surface can be removed (Fig. 19.2). Also, Kager’s fat pad
Achilles tendon. can be debrided if necessary. In paratendinopathy the
• Instruments required: plantaris tendon is released from the Achilles tendon,
A small-diameter short arthroscope (2.7 mm with a and the thickened paratenon is resected on the anterior
30-degree angle) or a standard 4-mm arthroscope. The aspect of the tendon at the level of the pathologic nod-
first one yields an excellent picture but cannot deliver ule. The neovascularization, which is accompanied by
the same amount of irrigation fluid per time than the small nerve fibers, can be found in this area, and it also
standard one. With a 4-mm arthroscope the gravity can be removed. Changing portals can be helpful. At
inflow of the irrigation is usually sufficient, but for the the end of the tendoscopy it must be possible to move
2.7-mm arthroscope a pump device or a pressurized bag the arthroscope over and around the symptomatic area
sometimes is used.22 Additionally, a probed endoscopic of the tendon. To prevent a postoperative draining
shaver system is used. sinus, skin incisions must be sutured, and a compres-
• Portals: sive dressing is applied.
The distal portal is first made and is located 2–3 cm dis-
tal to the pathologic nodule on the lateral border of
the Achilles tendon. Once the skin incision is made, a After Care
mosquito clamp is introduced, followed by the cannula In our experience, patients can bear weight as tolerated, using a
in a craniolateral direction. In the same direction, the CAM walker boot for 2 weeks. During this period of time the foot
352 SECTION 3  Anatomic Disorders in Sports

Fig. 19.2  Debridment of Kager’s fat pad and retrocalcaneal bursa adhe-
sions on the deep tendon surface.

must be elevated when not walking. After 2 weeks, aerobic exer-

cises and concentric strengthening exercises are initiated as toler- B
ated.1,4,20 At the fourth week the patient is able to walk uphill, and
at this point jogging or light impact activities can be initiated.20

Results
Steenstra and van Dijk1 in 2006 published successful results
with no complications in 20 patients with non-insertional tend- Fig. 19.3  Lateral x-ray view of the hindfoot. Enlarged posterosuperior
inopathy treated endoscopically. The Foot and Ankle Outcome aspect of the os calcis (A); calcaneal spurring at the insertion of the
and SF-36 scores were comparable to a cohort of people with- Achilles tendon (B).
out Achilles tendon complains after 6 years of follow-up.
Maquirriain23 reported in 96% of patients that were treated with Haglund’s deformity), with or without retrocalcaneal bursitis
endoscopic debridement of peritendinous tissue and percuta- and insertional tendinopathy. Most commonly, these character-
neous longitudinal tenotomies a complete resolution of symp- istics are all present with varying degree of severity.26,27
toms at 7 years postoperatively. Lui24 also described an Achilles
endoscopic debridement associated with a flexor hallucis longus Diagnosis
transfer in five patients with Achilles tendinopathy obtaining On physical examination, patients with insertional Achilles
good results. tendinopathy have pain and tendon thickening at its calcaneus
In our own experience, we have performed endoscopic insertion, and can also present tenderness to palpation on the
debridement and release of the ventral aspect of the Achilles superolateral aspect of the calcaneus.12 On clinical inspection,
tendon, which is, in the author’s opinion, the most important it is possible to see the deformity secondary to the bony promi-
location where to remove diseased tissue, obtaining excellent nence at the Achilles insertion.
functional results in 10 of 11 patients (full pain relief at rest Imaging the lateral x-ray view of the hindfoot allows the
observed at a median of 9 weeks, achieving full sports activities treating physician to evaluate the posterosuperior calcaneal
at 4 months of average) with a median postoperative VISA-A border, the calcaneal spurring at the insertion of the Achilles
score of 100 (30–100) points at final follow-up (2 years).20 tendon, and the obliteration of Kager’s triangle provoked by the
Similar results have been obtained by Thermann et al.25 in his retrocalcaneal bursitis (Fig. 19.3). In addition, the MRI can be
series of eight patients who underwent an endoscopic debride- useful to rule out intrasubstance tendon degeneration.27
ment of the ventral and dorsal aspect of the tendon. With these
results, we suggest that it is not necessary to excise the tendino- Treatment
pathic tissue putting at risk the tendon or consider additional The nonoperative management consists of shoe wear modifi-
procedures like tendon transfers20,25 and it would suffice in cations, nonsteroidal antiinflammatory drugs, night splinting,
order to obtain successful results to ventraly remove the dis- heel inserts, rest, and eccentric strengthening. In refractory
eased area and any adhesions including the neovascularization cases, as well as in non-insertional Achilles tendinopathy, shock
normally present. wave therapy can be used. However, 50% to 56% of patients may
not respond to nonsurgical treatment after 6 months.28
Insertional Achilles Tendinopathy The classic open surgical approach consists in a debridement
Insertional Achilles tendon pathology can present with an of the Achilles tendon, retrocalcaneal bursectomy, and resection
enlarged posterosuperior aspect of the os calcis (also called of the posterosuperior aspect of the calcaneus.29 Depending on
 CHAPTER 19  Foot and Ankle Endoscopy 353

the extension of the Achilles lesion distally and the resulting

debridement, in some cases a reinforcement of the insertion is
recommended. Some complications have been described with
the open technique, including skin breakdown, Achilles avul-
sion, scar hypersensitivity, altered skin sensation about the heel,
inadequate resection, and postoperative stiffness, although they
are rare.30 The endoscopic approach first described by van Djik
and colleagues21 in 2001 may be used, particularly in younger
patients who have mild to no Achilles tendinopathy, and where
the main findings are retrocalcaneal bursitis and a Haglund
deformity. In some cases, an impingement tendinopathy can
be found, with bone edema and focal tendinopathy localized to
the point where contact happens between the tendon and the
calcaneus.31 In these cases, no real Haglund deformity is found;
rather, a posterior prominence of the calcaneus may exert more
pressure on the tendon and therefore explain the focal tendi-
nopathy. This situation, in the author’s opinion, is the best indi-
cation for an endoscopic approach.

Operative Technique
As described by van Dijk and colleagues,21 the patient can be Fig. 19.4 Endoscopic Achilles tendon portals for insertional Achilles
placed on the operating table in prone or supine position, with disease.
a pneumatic tourniquet placed around the upper thigh. In
the prone position, the patient’s feet are positioned just over the can be identified, and all the disease area is removed with
edge of the operating table, while in the supine position, the the shaver. In the tendinopathic areas, as arthroscopi-
arthroscopic leg holder is needed to hold the leg around the calf, cally the debridement is very limited, is possible to tre-
the end of the table is dropped down, and the other leg is placed phine these areas with a needle, looking for a vascular
out the operative field. In both positions, the surgeon is allowed response.21
to move the foot in full dorsiflexion and plantarflexion.
• Instruments required: After Care
A small-diameter short arthroscope (2.7 mm with a 30-degree The patient should remain nonweight bearing for 2 weeks,
angle) or a standard 4-mm arthroscope. The setting is sim- depending on local edema and pain. The following 2 weeks the
ilar to the one already described for the non-insertional patient is allowed to perform range-of-motion exercises and
tendinopathy. weight bearing in a CAM walker boot. Return to normal foot-
• Portals: wear may be initiated as early as 4 weeks.21
The lateral portal is made first, at the level of the superior
aspect of the calcaneus; the incision should be made Results
immediately adjacent to the Achilles tendon. The retro- Only small series can be found in the literature reporting
calcaneal space is penetrated by a trocar, followed by the endoscopic treatment for insertional Achilles tendinopathy.
arthroscope; the medial portal is located at the same level In endoscopic calcaneoplasty van Dijk et  al.21 in their ini-
but on the medial edge of the Achilles tendon. The medial tial series obtained good to excellent results after treating 20
portal is similarly established under direct vision, utiliz- patients who had a painful prominence of the posterosuperior
ing a needle (Fig. 19.4).4,21 aspect of the calcaneus associated with a retrocalcaneal bur-
• Procedure: sitis. Nineteen of these 20 patients returned to sports after 12
The inflamed retrocalcaneal bursa is removed through the weeks. Ortmann and Mcbryd30 reported on 28 patients after a
medial portal, allowing the surgeon to see the posterior similar intervention with an average follow-up of 35 months,
calcaneus and the Achilles attachment. With the foot in good clinical results with an American Orthopaedic Foot &
full dorsiflexion, the impingement site is easily identi- Ankle Society score improvement from 62 to 97. No wound
fied. Then, the foot is placed in full plantarflexion and the complications or infections were reported, but two patients
posterosuperior calcaneal prominence is resected with needed an open reintervention, due to a rupture of the Achilles
a synovial resector or arthroscopic burr, taking care not tendon during the third week postoperatively. Jerosch and col-
to injure the tendon, which is protected by keeping the leagues32 in 2007 studied 81 patients with an average follow
closed end of the shaver against the Achilles tendon.4,21 up of 35.3 months after endoscopic treatment obtaining excel-
Adequacy of the resection is confirmed with lateral flu- lent Ogilvie-Harris score in 41 cases, good in 34, fair in 3, and
oroscopy images with the ankle in full dorsiflexion, and poor in 3 patients. The poor results underwent revision with
confirms the absence of impingement. In fully plantar an open approach and ossification of the Achilles tendon was
flexed foot position, the insertion of the achilles tendon found.
354 SECTION 3  Anatomic Disorders in Sports

Evidence-Based Recommendations Biomechanics

It is important to have a thorough understanding of the sur- The PTT rotates the tibia externally and induces foot supination. In
gical anatomy and endoscopic technique to minimize surgical the gait cycle the PTT is stretched during the first rocker to allow
complications and obtain good results. No clear guidelines subtalar pronation.41 On the second rocker of gait, the PTT helps to
have been established related to the efficacy of the endoscopic center the talus over the navicular. Finally, during the third rocker,
technique in Achilles tendinopathy. Only small series have the foot behaves like a second-class lever, balanced by the peroneal
been reported, and over different populations with varying tendons and the PTT, with this last one blocking the medial col-
degrees of tendinopathic compromise, which makes it even umn by locking the calcaneocuboid and talonavicular joints.40
harder to give recommendations for its use. We believe that The PTT strength is more than twice that of the peroneus
tendonoscopy has a role for Achilles tendinopathy, as it rep- brevis (PB), its primary antagonist. Inactivity of the PTT pro-
resents a minimally invasive option that can deliver successful duces midtarsal instability, and the propulsive force of the
results with minimal morbidity. The indication for tendonos- Achilles acts at the mid-foot instead of at the metatarsal heads.
copy in non-insertional Achilles tendinopathy is becoming Excessive and persistent pronation of the subtalar joint may
more accepted, with good results and good outcomes consis- render PTT insufficient.
tently reported with few or no complications. As already said,
these studies are limited by its low number of patients and Indications
retrospective nature, and therefore on a review of the litera- Symptomatic Adult Flatfoot
ture performed in 2014 by Cychosz et al.,33 a grade C recom- The PTT dysfunction ranges from tenosynovitis to a flatfoot
mendation34 (for intervention) to the Achilles tendoscopy was deformity. Johnson and Strom42 classified PTT dysfunction in
given. No evidence-based recommendation has been given to three different stages, and later Myerson43 refined it, adding a
tendonoscopy for insertional Achilles tendinopathy, and more fourth stage.
information with well-designed studies are needed to further
elucidate the role of impingement against the calcaneus. The Diagnosis
authors believe that this is a promising area for further research Patients in stage I, as defined by Johnson and Strom,42 present
where limited surgical approaches will have an important role with tenosynovitis or tendinitis, with a normal tendon length,
in the future. without foot deformity associated. Usual findings include
medial perimalleolar pain, swelling, and tenderness.40
On physical examination, patient can perform a single heel
POSTERIOR TIBIAL TENDOSCOPY rise, sometimes with slight discomfort over medial ligamen-
Posterior tibial tendon (PTT) endoscopic surgery is the tous structures, often resulting in a misleading diagnosis of an
minimal invasive option described to diagnose and treat ankle sprain, delaying the correct diagnosis and adequate early
PTT disorders, such as tenosynovitis, degenerative and treatment.44,45
post-traumatic tears, dislocation of the PTT, enthesopa- In stage II, the PTT has become permanently elongated and
thies, and chronic tendinopathy with symptomatic flatfoot usually presents signs of tendinopathy and a flexible flatfoot
deformity.35 deformity.46 These patients have a too-many-toes sign positive
Tendonoscopy procedure allows functional after treatment, with forefoot abduction during the physical examination, and
quick recovery, and offers the advantage of less morbidity mini- when performing a single heel rise, mild to moderate weakness
mizing neurovascular damage risk, reduction of the postopera- is noted. Plain foot radiographs with weight-bearing lateral and
tive pain, and easier outpatient treatment.36 dorsoplantar views may allow for the evaluation of PTT disor-
der in flatfoot deformity cases.40
Anatomy
The PTT is the most anterior and largest tendon in the deep Trauma
posterior compartment of the leg and have a synovial sheath Direct or indirect trauma could develop tendinopathy and
that is 7–9 cm in length, starting 6 cm proximal to the tip of partial tears of the PTT.40 Partial ruptures frequently occur in
the medial malleolus. The PTT is originated on the proximal middle-aged and low sports active people,47 but also some cases
tibia, fibula, and interosseous membrane; descends into the ret- have been reported in the literature in athletes, secondary to
romalleolar medial groove; and inserts close to the tuberosity of overuse disorders, though its incidence is underestimated.48,49
the navicular.3,37 When entering the foot, it flattens and presents Masterson et  al.50 reported that complete PTT tears in young
an increased amount of fibrocartilage, showing also hypovas- people were most often caused by penetrating trauma.
cularized area in the retromalleolar region.38,39 This portion of The retromalleolar region of the PTT is more vulnerable to
the tendon rubs back and forth between the malleolus and the repetitive microtrauma, and where most ruptures occur, because
flexor digitorum longus.40 of the poor repair response of the hypovascular fibrocartilagi-
This tendon has no mesotendon, but it has a vinculum, nous tissue. The longitudinal friction and changes in the gliding
between the posterior side of the PTT and the sheath,2 that runs resistance of the tendon make PTT more susceptible to suffering
proximally to end with a free edge at around 4.3 cm above the longitudinal tears.51 This rubbing may be affected by an irregu-
posteromedial tip of the medial malleolus. It is irrigated by ves- larity of the posterior aspect of the tibia after ankle fracture and
sels from the posterior tibial artery collaterals. postfracture adhesions producing initially synovitis and pain.40
 CHAPTER 19  Foot and Ankle Endoscopy 355

Dislocation and instability are uncommon but can be found

in athletes after suffering injuries with inversion and dorsiflex-
ion of the foot. In these cases, tendonoscopy is useful to confirm
it.40

Diagnosis
Usually, patients present with posteromedial ankle pain associ-
ated to a trauma story or an excessive sport activity increase. On
physical examination, it is possible to find swelling around the
medial malleolus and tenderness on palpation from the tip of
the malleolus to the navicular. Also, weakness with supination
of the foot on manual testing can be found.40
Plain x-rays of the ankle can reveal post-traumatic changes
around the medial malleolus. Ultrasound permits an assess-
ment of the PTT integrity, diagnosing partial or total ruptures
of the tendon. Also, increased vascularization on doppler and
thickening of the peritendinous tissues may suggest tendinopa-
thy. Even dynamic assessment of the PTT in the retromalleolar
groove is useful, permitting diagnosed subluxation or disloca-
tion of the tendon.52
Finally, MRI is the gold standard study for PTT disorders, and Fig. 19.5  Endoscopic posterior tibial tendon portals.
it helps to assess other abnormalities in surrounding tissues.53
leg around the upper thigh. The references points are marked on
Systemic Inflammatory and Autoimmune Disorders the skin to identify the PPT (asking the patient before the anes-
Tenosynovitis is the most common extra-articular manifesta- thesia to actively invert the foot), the navicular, and the medial
tion of autoimmune disorders and rheumatoid arthritis, and it malleolus.
can eventually lead to a rupture of the tendon.54 Michelson and • Instruments required:
colleagues55 found alteration of the PTT in patients with rheu- A small-diameter short arthroscope (2.7 mm with an inclination
matoid arthritis in 13% to 64%. The criteria used were loss of angle of 30 degrees) or a standard 4-mm arthroscope may be
the longitudinal arch, lack of a palpable PTT, and inability to used. The setting is similar to the one already described for
perform a heel-rise. the Achilles tendoscopy.
• Portals:
Treatment The distal portal is created first, located halfway between the
Initially treatment is conservative, including rest, immobiliza- navicular and medial malleolus following the PTT. Once the
tion, nonsteroidal antiinflammatory drugs, cryotherapy, and sheath is exposed, it is opened perpendicular to the axis of
local ultrasound, for 3 to 6 months.40,45 If nonsurgical treatment the PTT to avoid enlarging the entry to the tendon with the
fails, then surgical management can be indicated. The purpose moving during the procedure. The tendon sheath is pene-
of surgical treatment is to achieve a pain-free ankle through trated by a trocar, followed by the arthroscope, and filled
debridement, synovectomy, and tendon release. These previous with saline, inspecting the PTT up to the vinculum.54
goals can be achieved through an open or endoscopic approach, Under direct visualization, the proximal portal is made around
and most commonly surgical indications have been found in 3 cm proximally to the tip of the medial malleolus. With a
stage I flatfeet patients, post-traumatic tenosynovitis, or second- blue probe and a shaver through this portal it is possible to
ary to an inflammatory disease.40 In patients with stage II flatfoot inspect the complete tendon sheath (Fig. 19.5).36,40,54
and persistent symptoms after conservative management, surgi- A third portal more proximal, around 7 cm from the medial
cal treatment remains controversial. Within the most common malleolus, can be used in cases of severe synovitis.40
options, a medial sliding calcaneal osteotomy, in association • Procedure:
with a debridement of the PTT and flexor digitorum transfer Once the first portal is made, inversion of the foot allows the
is the most common one.40 Lui and colleagues46 reported the arthroscope to advance and get a complete overview of the PTT
transfer combined to an arthroreisis endoscopic-assisted with a until near 4–7 cm above the tip of the medial malleolus. The
reconstruction of a torn PTT. tendon sheath can be completely inspected rotating the scope,
When a direct trauma causes a complete rupture of the PTT, and the vinculum can be also visualized; if it has an abnormal
surgical management and repair can be indicated. thickening, it can be debrided or resected if necessary (Fig. 19.6).
Adherensiolysis and synovectomy can be performed using a
Operative Technique probe to free the tendon and a conventional shaver.36,40,54
PTT tendoscopy was first performed by Wertheimer56 in 1994, Partial ruptures can also be treated and reconstructed with a
but it was van Dijk who described the technique in detail,36 with mini-open approach, while frayed edges or peripheral tears
the patient in supine position, and a tourniquet on the affected can be resected endoscopically.54
356 SECTION 3  Anatomic Disorders in Sports

Some authors have also reported it as a diagnostic procedure.

Because of the low number of studies available for PTT ten-
donoscopy, on a review of the literature performed in 2014 by
Cychosz and colleagues33 they concluded that it is not possible
to make a recommendation for or against this intervention, and
assigned a grade I recommendation.34

PERONEAL TENDOSCOPY
The endoscopic approach for peroneal disorders is a technique that
has been slowly gaining acceptance, importance, and popularity to
be used as a diagnostic procedure and also to treat peroneal tendon
pathologies such as tendinopathy, tenosynovitis, peroneal sublux-
ations, and dislocation associated or not associated with ruptures
of the peroneal tendons. This minimally invasive approach enjoys
the advantages of minimally invasive surgeries, such as small scars,
less postoperative pain, and higher patient satisfaction.57

Anatomy
Fig. 19.6  Posterior tibial tendonoscopy assessment.
The peroneus longus (PL) originates over the proximal two-
thirds of the fibula and is completely tendinous 3–4 cm prox-
After Care imal to the tip of the fibula, enters into the fibro-osseous
A compression bandage is used for the first 24 hours and then reticular system, and finally inserts at the base of the first
just an adhe­sive bandage. Partial weight bearing is allowed for 2 metatarsal. The PB originates more distally on the fibular shaft
to 3 days. After the third day post-op, weight bearing is allowed and interosseus membrane, usually has some muscle fibers
as tolerated. Immediately after surgery, active movements like that extend into the superior peroneal retinaculum, also enters
inversion and eversion are encouraged.31,40,54 into the fibro-osseous reticular system, and inserts at the base
of the fifth metatarsal.58
Results Brandes and Smith59 described the zones of peroneal ten-
Posterior tibial tendon tendoscopy offers advantages over open don pathology, and later Sammarco and Sammarco60 added
procedures, namely smaller wounds and reduced risk of infec­tion. a fourth zone. Zone A is delimited by the distal fibula ante-
Likewise, there is less morbidity and blood loss, quicker recovery, riorly and the superior peroneal retinaculum posteriorly. At
and reduced postoperative pain with early mobilization and func- this level, the fibula has an has an osseous groove that adds
tional activity.40 van Dijk and colleagues36 reported the outcome in stability to the tendons. However, there has been described
16 patients with pain over the PTT secondary to different causes anatomic variations with the presence or absence of groove
(rheumatoid arthritis, post-traumatic), with a focus on the patho- deepening structure formed by a periosteal cushion of
logical thickening of the vinculum; most of them were free of pain fibrocartilage that deepens the bony groove. Here the PB is
and did not show complications after the tendoscopy. flattened and sits anterior to the PL. Both tendons lie in a
Bulstra et al. in 2006 published a study involving a series of common synodal sheath that extends from approximately 4
33 patients who underwent PTT tendoscopy with good results cm proximal to the tip of the lateral malleolus, to 1 cm distal
in rheumatoid arthritis and pathologic vincula, but poor results to it.58,61 Zone B corresponds to the location of the inferior
for adherensiolysis, with low complication rate.54 At the same peroneal retinaculum. This inferior retinaculum at the level
time, Chow and colleagues treated endoscopically six patients of peroneal tubercle on the lateral wall of the calcaneus. The
with symptomatic flatfoot in stage I, with no complications and PL sits inferior to the PB at this location and the tendons
no progression to stage II.44 Similar results were obtained by are separated and enclosed in two distinct syno­vial sheaths
Khazen and Khazen in 2012.45 divided by the peroneal tubercle. Zone C is the groove in the
The most recent publication by Hua et  al. in 2015 showed plantar and lateral cuboid where the PL curves. At this level
the results of a retrospective review of 15 patients with PTT dis- 20% of the individuals present an os peroneus. Zone D cor-
orders treated with a posterior arthroscopic approach with no responds to the level of the tendon insertion for PL and PB.
neuromuscular complications.46 Finally, both tendons have a 1–2-mm-thick vinculum-like
membrane in between, dorsally attached to the dorsal aspect of
Evidence-Based Recommendations the fibula.57
There are few quality evidence-based data in the current lit-
erature to support the use of PTT tendoscopy. Only levels IV Biomechanics
and V studies are available and reported for tibialis posterior The PB provides 63% of total eversion, as well as assisting in
tendoscopy, with dislocation, tenosynovitis, tendinopathy, and ankle plantarflexion. Peroneus longus acts to plantarflex the first
post-traumatic adhesions as the most frequent indications. ray and evert the foot, and also acts as a secondary plantarflexor
 CHAPTER 19  Foot and Ankle Endoscopy 357

of the ankle, stabilizing the medial column in stance phase. or tearing of the superior peroneal retinaculum, so the PB gets
When the PL contracts, the first ray locks at the first tarsometa- injured with the posterolateral edge of the fibula. The second
tarsal joint (TMTJ). mechanism theorizes a compression of the PB between the fib-
The first muscles to contract in response to a sudden ankle ula and PL tendon causing a split during an inversion injury.65
inversion stress are the peroneal, and thus are vital to control the
dynamic stability of the lateral ankle complex. Diagnosis
The clinical presentation in these patients is similar to that
Indications with tendonitis, except the symptoms are usually prolonged,
Peroneal Tendinitis and Tenosynovitis and patients may complain of frequent episodes of weak-
Typically, patients present with posterolateral ankle pain that ness. Magnetic resonance imaging is the most used diagnostic
worsens with activity and improves with rest. On clinical assess- method to confirm the diagnosis because it permits visualiza-
ment, there is tenderness over the peroneal tendons, and some- tion of intrasubstance tears and identification of anatomical
times a palpable mass moves within the tendon. variants such as the peroneus quarts muscle.66
More commonly tenosynovitis presents in the infra-malleo-
lar portion, and is characterized by thickening and focal tendon Treatment
degeneration and swelling. Often, associated with splits, tears of The initial treatment is nonsurgical and consists in nonsteroidal
the tendon or nodular thickening can be found. antiinflammatory medication, activity modification, rest, and
orthoses with lateral forefoot posting in mild cases. In patients
Diagnosis with refractory symptoms, immobilization or controlled ankle
In zone A the pathology may be limited to impingement caused movement in a walker for 6 weeks may be helpful. The use of
by excessive or inflamed synovium, and some patients, espe- corticosteroid injection is controversial, due to the risk of iat-
cially the athletic ones, may suffer from hypertrophy of the PB. rogenic rupture.
Even accessory peroneal muscles can produce symptoms. At If conservative treatment fails, open surgery is indicated and
zone B it may present tenosynovitis or degenerative tearing of usually consists in an open synovectomy or resection of the dis-
the peroneals in the area of the peroneal tubercle and the infe- tal muscle fibers when symptoms are caused by a hypertrophied
rior extensor retinaculum.60 The diagnosis is possible to confirm PB muscle.
with ultrasound or MRI, even when the MRI can be misleading Symptomatic subluxation or dislocation of the peroneals
in these cases and can erroneously be interpreted as degener- should be repaired surgically. Reconstructive procedures are of
ative tendinopathy principally at zone A, although sometimes three types: (1) rerouting of tendons, involving substituting the
this condition is assumed to be a MRI artefact.62 calcaneofibular ligament for the incompetent peroneal retinac-
ulum; (2) soft-tissue repair or reconstruction, which could be
Peroneal Subluxation and Dislocation a direct repair of the superior peroneal retinaculum or using
The principal mechanism is forceful dorsiflexion of the ankle, grafts to reconstruct it; and (3) bony procedures including the
hindfoot inversion with contraction of the peroneals causing groove-deepening while preserving the fibro-osseous tunnel to
disruption of the superior peroneal retinaculum. The presence prevent scarring.63,66,67
of a varus heel and/or a convex retromalleolar groove is a risk Management of peroneal tears starts with nonsurgical
factor causing instability.61 management as previously discussed for peroneal tenosy-
novitis. If symptoms persist, surgical treatment is indicated,
Diagnosis including debridement and repair of the tendon split.66 In
In general, patients present pain that is localized to the poste- one biomechanical study performed by the authors, we sug-
rior aspect of the fibula. They may report hearing a “snap” or gest that it is safe to leave up to 33% of remaining tendon
“pop” at the time of the injury or still hear it after the injury with without risking spontaneous rupture of it, and therefore not
walking, associated to instability sensation when they walk on needing a tenodesis that is the current indication. For higher-
uneven surfaces. In acute injuries it is possible to identify swell- demand patients, we strongly recommend repairing the rup-
ing, tenderness, and posterolateral ankle ecchymosis, with pain ture, either to itself (in case of a split rupture) or to a tendon
produced at the activation of the peroneals muscles. auto/allograft.66
The ones with chronic injuries usually complain of retromal-
leolar pain and may refer a snapping sensation along the tip of Operative Technique
the fibula or ankle instability. Dorsiflexion and eversion against The peroneal tendoscopy technique was first described in detail
resistance can reproduce the subluxation.63 Safran and colleagues by van Dijk;68 the patient may be placed in lateral position,
described a provocative test in which, with the patient’s knee with the affected leg slightly elevated, to allow free movement
flexed, the ankle is actively dorsiflexed and plantarflexed with of the ankle joint, and a tourniquet around the upper thigh.
resisted eversion to assess the dynamic stability of the tendons.64 Also, patients could be placed prone or supine depending on
any concomitant procedure that is planned to be performed.69
Peroneal Tendon Rupture Anatomic landmarks are palpated and highlighted. The distal
There are two possible mechanisms for split lesions of the PB. part of the fibula, peroneal tubercle, and the fifth metatarsal
The first suggests subluxation of the PB, secondary to a laxity tuberosity are marked.57,68,70
358 SECTION 3  Anatomic Disorders in Sports

• Instruments required:
A small-diameter short scope (2.7 mm with an inclination
angle of 30 degrees) or a standard 4-mm to 4.5-mm scope
may be used. The setting is similar to the one already
described for the Achilles tendoscopy.
• Portals:
The distal portal is made first, around 1.5 to 2.5 cm distal to
the apex of the fibula. The tendon sheath is penetrated with
blunt trocar, and the scope is introduced. Under direct
vision, the proximal portal is created 2 to 3 cm proximal
to the posterior edge of the lateral malleolus. Accessory
portals can also be performed throughout the complete
tendon excursion, according to the pathology that has to
be treated.57,68,70,71 A plantarlateral portal is developed 1
to 1.5 cm proximal to the tip of the fifth metatarsal tuber-
cle and 1 cm plantar to the tubercle. The plantarmedial
portal is developed next to the first TMTJ, at the plantar-
lateral base of the first metatarsal (Fig. 19.7).69
• Procedure:
The peroneal tendon sheaths are divided into three zones.
Zone 1 extends from the retrofibular groove to the pero-
neal tubercle, where the PL and PB share a common ten-
don sheath. Zone 2 tendon sheath runs from the peroneal
tubercle to the cuboid tunnel, here the PL and PB have
separate sheaths. Zone 3 tendon sheath refers to the PL Fig. 19.7  Endoscopic peroneal tendons portals.
sheath at the sole (Fig. 19.8).69
Once the portals are made, the surgeon has to adopt a tri- Weight bearing is allowed as tolerated, usually after 3 weeks.72
angulation technique positioning the instruments at an At the fourth week, patients can return to nonimpact sports,
angle of nearly 180 degree.71 The inspection of the ten- and impact sports are allowed at 6 to 8 weeks after surgery.67
dons is realized with the aim to look for synovitis, tears,
or subluxation/dislocation (Fig. 19.9). Also, the superior Results
peroneal retinaculum can be assessed. The two standard Peroneal tendoscopy allows anatomic evaluation of the tendons
portals permit zone 1 examination, while zone 2 needs and a dynamic assessment. It can be used as a diagnostic pro-
a separately approach for each tendon, as well as zone 3, cedure and to treat the pathologies previously described. In the
with the help of accessory portals.69 literature, the available studies are level IV and V of evidence.
Depending on the diagnosis, it is possible to realize an endo- Panchbhavi and Trevino in 2003 performed tendoscopy as a
scopic synovectomy, resection of the hypertrophic PB diagnostic procedure, finding as a cause of pain a peroneus quar-
muscle, and superior peroneal retinaculum reconstruc- tus tendon and a low-lying muscle belly attached to PB, which
tion. In cases of longitudinal tears, resection of the scar were treated by a mini-open procedure, after which patient’s
tissue or the injured area is carried out. Tendon repair symptoms resolved.72 Scholten and van Dijk treated 23 patients
is an option at the retromalleolar area, with the help of with a minimum follow-up of 2 years, with diverse diagnoses
an arthroscopic grasper and pusher; if the rupture is too (recurrent peroneal tendon dislocation, tenosynovitis, and lon-
long or too distal, it could be repaired through a mini- gitudinal tears of the PB). None of the patients had complica-
open approach.69 After the repair, a direct or indirect tions or recurrence of the symptoms.57 Vega et  al. treated 52
groove-deepening procedure is performed. In our experi- patients with a follow-up of 1 year, with different indications
ence, the indirect groove deepening described by Shawen for tendoscopy, such as peroneal adhesions, tendon rupture,
and Anderson is the most reliable and effective, which tenosynovitis, and recurrent peroneal tendon subluxation. They
involves hollowing the bone beneath the posterior cortex reported a complete relief of symptoms in patients with tendon
of the fibula by inserting a drill in the apex of the fibula, tears in 62.5%, partial relief in 25%, and the final 12.5% had no
then collapsing the floor of the fibular groove.67 change. Additionally, excellent results have been reported in
patients who were treated with endoscopic groove deepening.70
Aftercare
The postoperative management is dictated by the intraoperative Evidence-Based Recommendations
diagnosis. In general, a compression bandage is recommended The levels IV and V studies on peroneal tendoscopy have
for the first 24 hours, then an adhesive bandage in a removable reported good to excellent outcomes in most patients, with
brace to allow early passive range of motion and preventing few complications. The indications accepted in the literature
adhesions.69,67 for peroneal tendoscopy include subluxation or dislocation
 CHAPTER 19  Foot and Ankle Endoscopy 359

A B C
Fig. 19.8  Peroneal tendoscopy (A). Zone 1 (B). Zone 2 (C). Zone 3.

lower part of the interosseous membrane. It extends to the

posterior part of the ankle and courses from the fibro-os-
seous tunnel posterior to the talus, under the roof of the
sustentaculum tali. The tendon is bound to the flexor digital
longus at the Knot of Henry. Distally, FHL passes between
the sesamoid bones and inserts into the plantar surface of
base of distal phalanx of hallux.3,73
Lui in 2009 described the surgical technique for the FHL
tendonoscopy.73 The course of the tendon is divided in three
zones:
• Zone 1: Behind the ankle joint, from the musculotendi-
nous junction to the entrance of the tunnel underneath
the sustentaculum tali. Usually, the FHL at this zone is
assessed with a posterior ankle endoscopy, described by
van Dijk.74
-  Portals: The posteromedial portal is ubicated at the
intersection point between a line joining the sustentac-
ulum tali and the inferior border of the medial cune-
iform and first metatarsal joint with the medial edge
of the Achilles tendon. The posterolateral portal is
Fig. 19.9  Peroneal Brevis Rupture. located at the same level in the lateral edge of the achil-
les tendon.
-  Procedure: The fatty tissue on the Kager’s triangle over
of the peroneal tendons, tenosynovitis, snapping, and partial the FHL tendon is resected with a shaver. Here it is pos-
tears that require debridement. Because of the level of evi- sible to examine the musculotendinous junction of the
dence of the studies available for the peroneal tendonoscopy, FHL (Fig. 19.10).
on a review of the literature performed in 2014 by Cychosz • Zone 2: Is located between the tunnel underneath the suste-
and colleagues,33 they assigned a grade C recommendation for ntaculum tali to the Knot of Henry.
the intervention.34 -  Portals: Once the posteromedial portal is made. Under
In our experience, peroneal tendoscopy is a powerful tool to direct vision, a Wissenger rod is introduced to the tendon
assess and diagnose patients with unclear diagnosis of peroneal sheath through the tunnel. The plantar fascia is penetrated
pathology. This is particularly true when some other procedures distal to the level of the navicular tubercle for the plantar
are going to be performed at the same time, such as ankle insta- portal. It may reduce the risk of injury to the medial plan-
bility reconstruction, cavus foot surgery, etc., in order to plan tar nerve.
incisions the best way. -  Procedure: The FHL tendon in zone 2 can be assessed
during his trajectory through the tunnel until the Knot
OTHER TENDOSCOPIES of Henry. The portals can be interchanged to do a better
examination of the tendon.
Flexor Hallucis Longus Tendonoscopy • Zone 3: It starts at the Henry’s Knot and ends at the inser-
The flexor hallucis longus (FHL) tendon originates at the tion of the tendon at the base of the distal phalanx of the
inferior two-thirds of the posterior surface of the fibula and big toe.
360 SECTION 3  Anatomic Disorders in Sports

Fig. 19.10  Flexor hallucis longus Zone 1 tendonoscopy.

Fig. 19.11  Flexor hallucis longus Zone 3 tendonoscopy.
-  Portals: Using the plantar portal previously described for
the assessment of zone 2, the plantar toe portal is created
close to the insertion of the FHL at the base of the distal as described by Maquirriain et al.77 Lui in 2007 described a
phalanx of hallux. different distal portal for the TA tendoscopy, located close to
-  Procedure: The tendon can be assessed with a 2.7-mm the insertion of anterior tibial tendon.46
30-degree arthroscope (Fig. 19.11).
The FHL tendon is susceptible to ruptures, laceration, longi- Evidence-Based Recommendations
tudinal splits, stenosing tenosynovitis, and pigmented villonod- In the literature the two studies that described the TA tendos-
ular synovitis.75 copy are case reports, corresponding to a level V of evidence.
With only these studies available in the review of the literature
Evidence-Based Recommendations performed by Cychosz and colleagues,33 they assigned a grade I
The evidence-based data in the current literature to support recommendation, because there is a paucity of evidence-based
the use of FHL tendoscopy are level of evidence IV and V. literature.34
Most of the authors reported good to excellent outcomes,
with complications rates from 0% to 25%. The indications Extensor Tendonoscopy
found in the literature available include stenosing tenosyno- The extensor hallucis longus (EHL) muscle arises from the mid-
vitis, tenosynovitis, and also harvesting the FHL for use in dle two-thirds of the anterior surface of the fibula, adjacent to the
the augmentation of the Achilles tendon.76 On the review of interosseous membrane. It is deep and lateral to the TA tendon
the literature performed by Cychosz et al.33 they assigned a and extends distally, reaching the inferior extensor retinacu­
grade C recommendation for the endoscopic release of the lum. The EHL tendon passes through its own fibrous tunnel and
FHL.34 inserts on the dorsum of the base of the distal hallucal phalanx.
The extensor digitorum longus (EDL) muscle originates from
Tibialis Anterior Tendonoscopy the upper three-fourths of the anterior surface of the fibula, the
The tibialis anterior (TA) muscle originates in the upper two- upper part of the interosseous membrane, and the anterior
thirds of the outside surface of the tibia and inserts into the intermuscular septum. It splits in four tendons over the lower
first metatarsal and the medial cuneiform.3 Tibialis anterior part of the tibia, beneath the superior extensor retinaculum,
tenosynovitis is not frequent, and the majority of cases allevi- which are restrained by the inferior extensor retinaculum and
ate with conservative management. For that reason in the liter- finally insert on dorsum of middle and distal phalanges of the
ature, only two studies exist that describe TA tendoscopy: the lesser toes.3,78
first one is a case report for the endoscopic technique debride- - Portals: The patient is placed in a supine position. The prox-
ment of the TA tendon, by Maquirriain and colleagues;77 the imal portal is made 3–4 cm proximal to the anterior ankle
other is the one used for stage II flatfoot patients where TA joint line on the lateral edge of the EDL tendon, and the
tendoscopy was used to transfer the medial half of the TA distal portal is located 3–4 cm distal to the ankle joint, also
tendon.46 on the lateral edge of the EDL tendon. These portals vary
- Portals: The patient is placed in a supine position. The prox- according of the location of the pathology. It is important to
imal portal is the first made, and is located 8 cm above the be extra careful with the superficial peroneal nerve, which
ankle joint line, following the TA tendon. Under direct can be easily damaged. To avoid iatrogenic damage, Lui78
vision, the distal portal close to the joint line can be made, suggested that the subcutaneous tissue should be bluntly
 CHAPTER 19  Foot and Ankle Endoscopy 361

spread with a hemostat after the skin incision is made until

the EDL tendon is seen. Then, the scope can be introduced to
assess the EDL and EHL tendons.

Evidence-Based Recommendations
The evidence-based data in the literature to support the exten-
sor tendoscopy are level of evidence V. There were four studies
describing the surgical technique for the tendoscopy and used
in patients with tenosynovitis, tendinopathy, fibrous adhe-
sions, ganglions, and to assist in the repair of delayed tendon
ruptures.78,79,80,81 Given the lack of evidence-based literature
for extensor tendonoscopy, in the review of the literature per-
formed by Cychosz and colleagues33 they could not make a rec-
ommendation on extensor tendonoscopy (EHL and EDL), and
assigned a grade I recommendation.34

OTHER ARTHROSCOPIES
Metatarsophalangeal Joint of the Lesser Toes
The metatarsophalangeal joint (MTP) of the lesser toe is stabi-
lized by the plantar plate that arises from proximal to the artic-
ular surface of the metatarsal head and inserts on the base of Fig. 19.12  Metatarsophalangeal lesser toe joint arthroscopic portals.
the proximal phalanx; collaterals ligaments (medial and lateral),
composed of two bands: the phalangeal collateral ligament and
the accessory collateral ligament; and the joint capsule and tra- The management of this patient is initially conservative; the
versing tendons.82,83 goal of the treatment is to alleviate the symptoms and min-
imize bone deformity. If nonsurgical management fails and
Indications symptoms persist or the disease advances, surgical treatment
Metatarsophalangeal Synovitis is indicated.93 It varies depending on the stage. Carro and col-
This pathology is commonly caused by metabolic diseases, leagues proposed a pattern of arthroscopic management: the
such as arthritis, gout; inflammatory diseases, such as rheu- arthroscopic removal of loose body and debridement are rec-
matoid arthritis; and abnormal mechanical stress. They pres- ommended in early stages, and an arthroscopic Keller proce-
ent with pain and swelling, in general treated conservatively, dure is reserved as salvage procedure in the later stages (stages
but in cases with persistent symptoms, a synovectomy can be IV and V).94 el-Tayeby described in 1998 an interposition
indicated. 84 arthroplasty, using the tendon of the extensor digitorum bre-
vis (EDB) to resurface and act as a joint spacer.95,96
Metatarsophalangeal Instability
In claw toe deformities, the key deformity is the hyperextension Operative Technique
of the MTP joint. The plantar plate is attenuated on the meta- The patient may be placed in a supine position, with a tourni-
tarsal neck, leading to dorso-distal subluxation. The synovium quet around the upper thigh.
ruptures at its proximal attach­ment resulting in the MTP joint • Instruments required:
dislocation.85,86 When nonsurgical management fails, surgi- A small-diameter short scope (1.9 mm with an inclination
cal correction with soft tissues (e.g., flexor to extensor tendon angle of 30 degrees) is used. The gravity-driven inflow is
transfer)87 and bony procedures (e.g., Weil osteotomy, excision always adequate. Instrumented traction is not used rou-
arthroplasty and arthrodesis) have been described, but second- tinely.
ary stiffness is also frequent. • Portals :
The plantar plate repair should decrease toe stiff- The dorsomedial and dorsolateral portals are at the level of
ness, can be performed open, but has also been described MTP joint line medial and lateral to the extensor digi-
arthroscopically-assisted.88,89,90 torum longus (EDL) tendon. There is risk to injure the
dorsal digital branches of superficial peroneal nerve (Fig.
Freiberg Disease 19.12).84,90,96
Originally described in 1914, Freiberg reports a series of cases • Procedure :
with a similar “infarction” pattern of the metatarsal head.91 The portals are interchangeable as visualization and instru-
Smillie divided the macroscopic progression of Freiberg disease mentation portals. The articular cartilage of the proximal
into five stages.92 Patients frequently present with pain localized phalanx and metatarsal head, collateral ligaments, and
to the involved metatarsal head, and report a feeling that they dorsal capsule are examined; also the plantar plate can be
are walking on something hard. probed for any tear (Fig. 19.13).
362 SECTION 3  Anatomic Disorders in Sports

MTs Head

MTs Head
A B
Fig. 19.13  Plantar plate injury (A). Transversal (B) “7” shape.

In MTP synovitis, synovectomy of the dorsal, medial, and lapidus, trying to achieve less bone removal and better control
lateral gutters can be performed with a shaver. However of arthrodesis position, and decrease the malunion rate.84,100
for the plantar gutter, additional manual traction of the
joint is required.84 Operative Technique
Once MTP joint assessment is performed, instability has to The patient may be placed in supine position, with a tourniquet
be evaluated. If found, the arthroscopic-assisted plantar around the upper thigh.
plate tenodesis can be performed. First, the dorsal cap- • Instruments required:
sule is stripped from the metatarsal neck, the sutures are A small-diameter short scope (2.7 mm with an inclination
passed though the lateral and medial part of the plan- angle of 30 degrees) is used. The setting is similar to the
tar plate, and the suture is retrieved through a proxi- one already described for the Achilles tendoscopy.
mal wound at the diaphysis of the metatarsal. Then, it is • Portals:
secured to the EDL, reducing the MTP joint.90,97,98 Using Two portals are established at the plantarmedial and dorso-
the same portals, the arthroscopic interpositional arthro- medial corners of the first TMTJ (Fig. 19.14).
plasty is performed in cases of Freiberg’s disease. The EDB • Procedure:
is identified, cut proximally, and retrieved through the Once the portals are identified, the position can be checked
dorsolateral portal. It is rolled into a ball and inserted into under fluoroscopy if needed. Then, the first TMTJ is
the joint, under arthroscopic guidance.96 assessed, the articular cartilage is denuded exposing the
subcondral bone, which is then microfracturated.
Lisfranc (Tarsometatarsal) Joint The intermetatarsal angle is closed up manually and the first
Tarsometatarsal joints can be divided in three columns. The lateral metatarsal plantarflexed, then the fixation is performed
column consists of the fourth and fifth metatarsocuboid joints. with cannulated screws.84,100
The medial column is the first metatarsocuneiform joint, while the
middle column is composed of the second and third metatarso- Post-traumatic Arthritis
cuneiform joints. The stability is afforded through a combination After injuries to the TMTJ, post-traumatic arthritis is the most
of ligaments and bony architecture (roman arch configuration).99 common problem, but not all patients are symptomatic. The ini-
tial treatment in symptomatic patients is conservative; when the
Indications symptoms persists, arthrodesis of the painful tarsometatarsal
First Tarsometatarsal Instability joints is the management of choice. Lui in 2007 described six
Hypermobility of the medial column can be associated with portals to approach the five tarsometatarsal articulations. The
hallux valgus, transfer metatarsalgia, and arthritis of the second choice of the portals depends on which columns are included
TMTJ. In patients with symptomatic hypermobility of the joint in the fusion.84,101
who do not respond to conservative treatment, arthrodesis is
indicated. Traditionally, lapidus procedure is performed by open Operative Technique
means, but it has some problems, such as prolonged healing, The patient may be placed in a supine position, with a tourni-
high nonunion rate, and the tendency for dorsal angulation of quet around the upper thigh.
the first metatarsal. In 2005, Lui et al. described an arthroscopic • Instruments required:
 CHAPTER 19  Foot and Ankle Endoscopy 363

Fig. 19.15  Lisfranc joint arthroscopic portals.

be approached through the P4-5 and lateral portals.

The P3-4, P4-5, and lateral portals are interchangeable,
Fig. 19.14  First tarsometatarsal joint arthroscopic portals. because the third, fourth, and fifth TMTJ share a com-
mon synovial lining and joint capsule.
• A small-diameter short scope (2.7 mm with an inclination The fusion surfaces preparation technique is similar to the
angle of 30 degrees) is used. The setting is similar to the one already described to the arthroscopic Lapidus. Then, the
already described for the Achilles tendoscopy. joints are reduced into the desired position and transfixed
• Medial portal is located at the plantar medial aspect of the with cannulated screws.84,101
first metatarso-cuneiform joint.
•  P1-2 portal is located at the junction point between Chopart (Transverse Tarsal) Joint
medial cuneiform and first and second metatarsal bones. Calcaneocuboid (CC) joint functions as a unit with the talona-
The proximal P1-2 portal is located at the junction point vicular (TN) joint in the formation of the transverse mid-tarsal
between the second metatarsal, medial, and intermediate joint. It is supported plantarly by the short and long plantar lig-
cuneiform bones. aments and the PL. The CC ligaments provide dorsal support.
• P2-3 portal is located at the junction point between the The TN joint is supported primarily by the dorsal TN, deltoid,
second metatarsal and intermediate and lateral cuneiform and spring ligaments.102
bones. The distal P2-3 portal is located at the junction The Chopart joint helps to allow the foot to transition from
between the second and third metatarsal with the lateral a flexible structure when the hindfoot is in valgus during heel
cuneiform bone. strike to a rigid structure when the hindfoot is in varus during
• P3-4 portal is located at the junction point between lateral toe-off.
cuneiform and cuboid and third and fourth metatarsal Arthroscopy can be used as a diagnostic tool or to treat
bones. patients with joint arthritis; these can be post-traumatic, a
• P4-5 portal is located between the proximal articular sur- sequelae of pediatric foot deformities, or secondary to rheu-
faces of the fourth and fifth metatarsal. matoid arthritis. The arthroscopic arthrodesis can improve
• Lateral portal is located at the lateral corner of the fifth intra-articular visualization, minimize bone removal, and
metatarsal-cuboid joint (Fig. 19.15). fusion surface preparation. Theoretically, this can reduce the
• Procedure: risk for pseudoarthrosis and nonunion.84,102
Once the origin of the pain is identified, the portals used
depends on which columns need to be treated. The Operative Technique
medial portal and the P1-2 portal permit to assess the The patient may be placed in supine position, with a tourniquet
first TMTJ. The second TMTJ can be approached using around the upper thigh.
the proximal P1-2 and the P2-3 portals. To evaluate the • Instruments required:
third TMTJ, the distal P2-3 and the P3-4 portals are • A small-diameter short scope (2.7 mm with an inclination
necessary. The fourth TMTJ could be assessed using angle of 30 degrees) is used. The setting is similar to the one
the P3-4 and P4-5 portals. Finally, the fifth TMTJ can already described for the Achilles tendoscopy.
364 SECTION 3  Anatomic Disorders in Sports

Fig. 19.17  Talonavicular joint arthroscopic portals.

It can be used for arthroscopic resection of calcaneonavicular

coalition, symptomatic nonunion of the anterior calcaneus
process, and to fuse the CC and TN joints. The fusion sur-
face preparation, joint reduction, and fixation technique
are similar to arthroscopic Lapidus procedure.84,102

CONCLUSIONS
Endoscopic procedures in foot and ankle have been proven
extremely useful and with increasing indications. For the less
common indications, as the ones described in this chapter,
we recommend to be enthusiastic without forgetting the goal
Fig. 19.16  Calcaneo-cuboid joint arthroscopic portals. of arthroscopy, which is intended to be a minimally invasive
procedure.
For this reason, the less experienced surgeon may conclude
There are four mid-tarsal portals. The lateral portal is located at that instead of using arthroscopic vision to perform a chei-
the plantar lateral corner of the CC joint; the structures at risk lectomy in a hallux rigidus, it could be easier to use a mini-
are the peroneal tendons and the sural nerve. The dorsolateral mally invasive technique. The same principle could be true for
portal requires a fluoroscopic guidance, and is located over the Haglund deformity, midfoot arthroscopy, and some other pro-
space between the TN and CC joints; the lateral branch of the cedures described in literature with just few cases.
superficial peroneal nerve and the lateral terminal branch of So even though we encourage everyone to use endoscopic
the deep peroneal nerves are at risk (Fig. 19.16). assistance for diagnosis, assistance in fracture treatment,
The medial portal is located at the medial side of the TN arthrodesis, tendoscopies, etc., we think that there are limits
joint, dorsal to the PTT. Finally, the dorsomedial portal is depending on personal experience.
located at the midpoint between the medial and dorsolat-
eral portals; during the creation of this portal, the inter-
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 CHAPTER 19  Foot and Ankle Endoscopy 367

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 20
Lesser Toe Disorders
James R. Jastifer, Michael J. Coughlin

OUTLINE
Bunionettes, 369 Hammertoes, Mallet Toes, Claw Toes, 380
Conservative Treatment, 370 Conservative Treatment, 380
Surgical Treatment, 371 Surgical Treatment: Hammertoe Repair, 380
Intractable Plantar Keratoses, 372 Surgical Treatment: Early Flexible Mallet Toe Repair, 381
Conservative Treatment, 373 Claw Toe, 381
Surgical Treatment: Partial Condylectomy, 373 Surgical Treatment: Metatarsophalangeal Soft-Tissue Ar-
Surgical Treatment: Metatarsal Osteotomy, 374 throplasty, 382
Interdigital Neuromas, 376 Metatarsaophalangeal (MTP) Joint Instability, 383
Conservative Treatment, 377 Conservative Treatment, 384
Surgical Treatment: Excision of Interdigital Neuroma, 377 Surgical Treatment: Metatarsophalangeal Instability, 384
Hard Corns and Soft Corns, 377 Surgical Treatment: Weil Osteotomy, 385
Conservative Treatment, 378 Surgical Treatment: Plantar Plate Repair, 386
Surgical Treatment for Hard Corns, 378 Conclusion, 388
Surgical Treatment for Soft Corns, 379
 

Metatarsalgia in the athlete can be a debilitating disorder that activities increase symptoms? Which activities alleviate dis-
can lead to loss of function. Forefoot disorders encompass comfort? Is the pain dorsal or plantar, medial or lateral? Is there
lesser toe abnormalities such as claw toes, hammertoes, mallet an associated neuritis symptom with the pain? Are enlarged
toes, and hard and soft corns. More proximally, problems can exostoses or prominences associated with pain, swelling, or
include intractable plantar keratosis (IPK), bunionettes, neu- inflammation?
romas, and metatarsophalangeal (MTP) joint capsulitis and When a patient complains of metatarsalgia, the initial con-
instability. cern on physical examination is the presence of an associated
For the athlete, repetitive activities can lead to repeated callosity. This can be seen laterally over the fifth metatarsal head
stress reactions in soft tissues, bones, and joints. Abrasions and with a bunionette formation. It can be localized to the plantar
repeated trauma over bony prominences can lead to callus for- metatarsal region with an IPK. A callosity may develop over the
mation and bursitis. dorsal distal interphalangeal (DIP) joint (a mallet toe) or the
Ideally, avoiding the development of problems through the dorsal proximal interphalangeal (PIP) joint (hammertoe). On
use of good footwear, proper training practices, and education occasion a patient may complain of a callosity both overlying
should be the goal. Many of these problems may develop despite the PIP joint and beneath the associated metatarsal head. With
prophylactic care and thus require the intervention of the a concomitant contracture of this toe, the diagnosis of a claw toe
orthopedic surgeon either conservatively or surgically. Often, is made based on these clinical findings.
nonsurgical treatment is successful, leading to a rapid return to Development of a callus between two toes (a soft corn)
athletic activity. or over the lateral aspect of the fifth toe (a hard corn) can be
The complaint of forefoot pain can be frustrating for the extremely painful.
athlete and the physician. The pain must be differentiated in When a patient complains of metatarsalgia, but there is
order to make a correct diagnosis. The accompanying algo- no callosity present, the patient should be carefully examined
rithm (Fig. 20.1) may prove useful in determining the specific for nerve-related symptoms. When such a scenario is present
forefoot diagnosis when a patient complains of metatarsalgia. (along with other specific symptoms), the diagnosis of an inter-
Most important is the exact location of pain. In addition, the digital neuroma can be made. When neuritic symptoms are not
physician should ask the following questions: Which specific present, but symptomatic pain is still localized to the forefoot,

368
 CHAPTER 20  Lesser Toe Disorders 369

Fig. 20.1  Algorithm. IPK, Intractable plantar keratosis; MTP, metatarsophalangeal. (From Coughlin, MJ. Com-
mon causes of pain in the forefoot in adults. J Bone Joint Surg Br 2000;82:781-790)

metatarsophalangeal joint capsulitis and/or instability should

be considered. The presence of a positive drawer sign (dorsal
plantar instability) or malalignment of the involved toe at the
metatarsophalangeal joint aids in confirming the diagnosis of
second toe instability. Although this algorithm is not all-inclu-
sive, and much more goes into the specific diagnostic process
than this flow sheet allows, it does offer a method of approach-
ing the athlete with metatarsalgia. Sometimes symptoms over-
lap, frequently symptoms are vague—and repeated evaluation
and clinical and radiographic examination are necessary to con-
firm a diagnosis. The cooperation of patients in defining their
symptomatic complaints, and in defining their problem through
varying their athletic activity, is highly important. Likewise,
patient cooperation in modifying activities when conservative
management is attempted is a critical factor in any successful
treatment. When surgery is performed, patient cooperation in
allowing adequate healing to occur before resuming athletic Fig. 20.2 Bunionette with enlarged bursa. (From Mann RA, Coughlin
activity is instrumental not only in the recovery process but also MJ. Keratotic disorders of the plantar skin. In: Surgery of the Foot and
in the avoidance of other associated problems or complications. Ankle. St Louis, CV Mosby; 1993:443.)

BUNIONETTES
PEARL: LOCATION OF FOOT PAIN The development of inflammation, an enlarged bursa, or a callus
When evaluating forefoot pain, it can often be difficult to localize the exact over a prominent fifth metatarsal head may lead a physician to
location of a patient’s pain in order to make a correct diagnosis. Often, the diagnose a bunionette (Fig. 20.2). Just as bunions can present with
physical examination is inconclusive, especially when the patient presents differing magnitude and different characteristics, so too can a bun-
to clinic when asymptomatic. This is especially common in athletes whose ionette.1 A bunionette may appear radiographically as an enlarged
complaints are often activity related. To identify the location of pain, instruct fifth metatarsal head (type I). A flare in the metaphysis may cause
the patient to repeat the offending activity, recreating the patient’s symptoms.
bowing of the fifth metatarsal (type II), leading to symptoms, or
The patient is then instructed to mark the spot with a Sharpie marker. This
“spot” will stay with the patient for the next clinical examination.
a widened 4‒5 intermetatarsal angle (type III) characteristic of a
splayfoot may lead to pain and callus formation (Fig. 20.3).
370 SECTION 3  Anatomic Disorders in Sports

A B C
Fig. 20.3  (A) Bunionette with enlarged fifth metatarsal head. (B) Bunionette with bowing of the metaphysis.
(C) Bunionette with enlarged 4‒5 intermetatarsal angle.

Initially an athlete may complain of pain directly lateral When athletic activity is significantly impaired after conser-
over the fifth metatarsal head, but the examiner should be vative efforts, surgical intervention may be considered (see Case
aware of plantar symptoms as well. Neuritic symptoms involv- Study 20.1). The type of osteotomy selected is dependent upon
ing the fifth toe may occur due to pressure over the lateral dig- the location of the callosity, as specific osteotomies of the fifth
ital nerve to the fifth toe. Complaints of pain, inflammation, metatarsal can be used to direct the metatarsal head in different
blistering, ulceration, or infection may be noted by the athlete. directions. Surgical intervention in treating forefoot callosities
On physical examination, significant callus formation may be should be tailored to the patient. Extensive soft-tissue stripping,
observed on the lateral, plantar, or lateral-plantar position over- unsecured osteotomies, and multiple metatarsal osteotomies
lying the fifth metatarsal head. Any pronation of the longitudinal should all be avoided in athletes. Although a surgical procedure
arch should be noted, as should any restriction in hindfoot motion. may relieve the painful callosity, athletic performance of the
Radiographic evaluation may demonstrate an enlarged metatar- patient may be diminished, and thus the procedure would be
sal head, outflaring of the fifth metatarsal metaphysis, or widening considered unsuccessful. The two surgical procedures presented
of the 4‒5 intermetatarsal angle. Widening of the 4‒5 intermetatar- here fulfill the requirements of less surgical exposure, employ
sal angle is the most common. Abduction of the fifth toe in relation internal fixation, and appear better suited to athletes.
to the fifth metatarsal head may also be demonstrated.
CASE STUDY 20.1 
Conservative Treatment
Early treatment involves attempting to relieve pressure on the A 30-year-old skier developed pain and swelling over the plantar lateral aspect of
the fifth metatarsal head. An increased callosity was observed over the plantar lat-
underlying bony prominence. Stretching of shoes or obtaining
eral aspect of the bunionette. A painful inflamed bursa developed during the middle
shoes with a soft upper that is more forgiving will relieve over-
of ski season that was partially relieved by grinding down the inner aspect of the ski
lying pressure. Seams or stitching directly over the bunionette boot overlying the bunionette. Likewise, the area overlying the fifth metatarsal head
should be avoided. Moleskin applied to a blister may promote was relieved in the athlete’s everyday footwear by stretching the leather surface.
healing and protect the area while athletes continue their activ- On physical examination, a normal neurologic and vascular examination was
ities. Altering running and/or training activity may also dimin- noted. Prominence of the fifth metatarsal head was characterized by a callos-
ish symptoms. Nonimpact activities such as stationary cycles or ity both on the plantar and lateral aspects. Radiographic evaluation demon-
swimming can be integrated into the training program. A reduc- strated an enlarged fifth metatarsal lateral condyle (Fig. 20.4A).
tion in total miles per day/week may be required. Trimming the Conservative care, stretching of shoes, and padding were all recommended.
callus may significantly relieve symptoms. Physicians may teach At the end of ski season, the patient requested surgical treatment due to
their patients how to pare the callus appropriately. The callus is continued symptoms. An oblique osteotomy was performed and fixed with
screws. At 8 weeks following surgery, the osteotomy was healed and the
shaved in thin layers with the scalpel parallel to the toe. A pum-
patient began advancing gradually over a 2-month period. Fig. 20.4B shows
ice stone may also be used to pare down the callus. A pumice
the correction obtained. The patient skied the following season without
stone is safer and often more acceptable to patients for home use symptoms.
than using a scalpel.
 CHAPTER 20  Lesser Toe Disorders 371

A B
Fig. 20.4  Case study 1. (A) Bunionette preoperative x-rays. (B) Follow-up x-rays demonstrating correction.

osteotomy is performed. For a combined plantar lateral cal-

lus, a distal oblique osteotomy is performed.)
5A. Chevron osteotomy2,3: A lateral to medial drill hole is placed
in the center of the fifth metatarsal head, marking the apex
of the chevron osteotomy. A 60-degree angled osteotomy
based proximally is directed in a lateral to medial plane.
The metatarsal head is translated medially and fixed with a
percutaneous 0.045 K-wire (Fig. 20.6).
5B. Distal oblique osteotomy4,5: After exposing the metatarsal
head and metaphysis, an oblique osteotomy is performed
from a distal lateral to proximal medial direction. The
metatarsal head is displaced medially and slightly proxi-
mally and is allowed to “raise up” approximately 3 mm to
decrease plantar pressure beneath the fifth metatarsal head.
The osteotomy is fixed with a percutaneous 0.045 K-wire
Fig. 20.5  An L-shaped capsular incision is used to approach the bunio-
nette with dorsal and proximal capsular incisions.
(Fig. 20.7).
5C. Midshaft osteotomy6: After a distal lateral eminence resec-
tion is performed, in the case of an increased 4‒5 inter-
metatarsal angle, a diaphyseal midshaft osteotomy may be
Surgical Treatment necessary to achieve correction. A subperiosteal dissec-
1. The foot is prepped and draped in the routine sterile fash- tion is performed at the midshaft of the fifth metatarsal
ion. An Esmarch bandage is used to exsanguinate the foot. with care to protect the distal capsular tissue and attach-
The ankle is carefully padded and the Esmarch is used as a ments. Care must also be taken to prevent overdissection
tourniquet. of the metatarsal by dissecting no more than 50% of the
2. A longitudinal lateral incision is centered directly over the circumference of the metatarsal shaft. This preserves as
bunionette, extending from the midproximal phalanx to 1 much medial-based blood supply as possible. The oste-
cm above the metatarsal head. Care is taken to protect the otomy may be performed, but prior to completing the
neurovascular bundles. oblique osteotomy, which generally runs from plantar‒
3. The metatarsophalangeal joint capsule is detached on the proximal to dorsal‒distal, fixation is considered. Two
dorsal and proximal aspect and retracted plantarly, expos- screws are generally sufficient for fixation, and the more
ing the prominent lateral condyle (Fig. 20.5). proximal of the two screws is drilled and placed. After
4. A sagittal saw is used to resect the lateral condyle in line completing the osteotomy, with a depth gauge placed in
with the diaphyseal shaft of the fifth metatarsal. (At this the hole, this drill hole acts as the center of rotation of the
point, a decision must be made regarding the type of oste- osteotomy and allows easier placement of the screw for
otomy to be performed. For a pure lateral callus, a chevron definitive fixation after correction has been achieved.
372 SECTION 3  Anatomic Disorders in Sports

A B

C
Fig. 20.6  (A) A drill hole is placed in the center of the metatarsal head and drilled in a lateral to medial direc-
tion. (B) A chevron-shaped osteotomy is based proximally with the apex at the drill hole. (C) Medial translation
of the metatarsal head with K-wire fixation and shaving of the metaphyseal flare (shaded area denotes shaved
bone in metaphysic).

6. Any remaining prominent metaphysis is shaved with the

sagittal saw. A drill hole is placed in the dorsal proximal
INTRACTABLE PLANTAR KERATOSES
metaphysis, and the capsule is anchored with an inter- The development of a keratosis beneath one or more of the
rupted suture. Remaining interrupted sutures are placed to metatarsal heads is referred to as an IPK. A callus may be a
reinforce the capsular repair (Fig. 20.8). localized discrete lesion or a diffuse keratotic buildup (Fig.
7. The skin is closed in a routine fashion. A gauze and tape 20.9). Callus formation in athletes is not uncommon and, if
dressing is applied and changed on a weekly basis. The asymptomatic, rarely requires medical intervention. With sig-
patient is allowed to ambulate in a stiff postoperative shoe. nificant buildup, painful symptoms may occur requiring evalu-
Athletic activity is increased as swelling and pain diminish. ation and treatment.
Patients are allowed to heel weight bear as soon as pain and A diffuse callus may be due to repetitive abrasion associated
swelling permit. Radiographic confirmation of healing should with athletic activity. It also may be associated with a long second
be present before aggressive activity such as jogging, running, metatarsal or long second and third metatarsal. A discrete callus
or jumping is considered. In general, a patient can return to may occur beneath a single metatarsal head.7 It is typically asso-
nonimpact activities at 2 months and progress as tolerated ciated with an enlarged plantar metatarsal condyle. It is import-
thereafter. ant to distinguish this from a wart (Fig. 20.10). Although warts
 CHAPTER 20  Lesser Toe Disorders 373

PEARL: PRESSURE POINTS

A Harris mat is invaluable in identifying abnormal pressure points on the plan-
tar surface of a patient’s foot. The patient is instructed to walk in a normal
manner, stepping on the Harris mat. The test is repeated with the contralateral
foot. Abnormal pressures are illustrated as unusually dark regions and will aid
in making the correct diagnosis and appropriate treatment.

Conservative Treatment
Conservative treatment revolves around paring the IPK and
padding it to relieve the pressure (Fig. 20.11). A patient can be
instructed to trim the lesion every 7 to 10 days, and this will sig-
nificantly relieve discomfort. Placement of a metatarsal pad just
proximal to the IPK can transfer pressure to the metatarsal diaphy-
sis and relieve symptoms (see Case Study 20.2). Custom or prefab-
ricated orthotic devices also can be a significant help in relieving
symptoms. Athletes may consider altering their workout, or change
sporting activities, or change duration or intensity of the workout.

CASE STUDY 20.2 

A 50-year-old tennis player developed a painful callus beneath the second and
third metatarsals. It was a diffusely thickened callus that began to limit his
sports activities. On initial evaluation the diffuse callus was trimmed, and the
Fig. 20.7 Distal oblique osteotomy with K-wire fixation (shaded area patient instructed in how to care conservatively for the IPK. A pumice stone was
denotes shaved bone in metaphysic). used to pare the callus. The patient also obtained disposable scalpels to shave
his thickened callosity. When he returned for further follow-up, radiographs
demonstrated a long second and third metatarsal in relationship to the adjacent
metatarsals. A soft pad was placed in his shoe just proximal to the callos-
ity. Between shaving the callosity and padding it, symptoms were completely
relieved, and he returned to full sports activities. Later, a soft orthotic device
was fabricated to relieve pressure beneath the second and third metatarsals.
When all methods of conservative treatment have been exhausted, sur-
gical intervention may be considered. Caution is advised in considering any
metatarsal osteotomy in a high-level athlete. The possibility of delayed union,
nonunion, or malunion can significantly impair athletic activity. The develop-
ment of a transfer lesion beneath another metatarsal head is not uncommon.
Multiple metatarsal osteotomies are to be discouraged.

Surgical Treatment; Partial Condylectomy8

1. The foot is prepped and draped in a routine sterile fashion.
Fig. 20.8  L-shaped capsular closure. The dorsal proximal corner may be An Esmarch bandage is used to exsanguinate the foot. It is
fixed with a drill hole in the metaphysic to anchor the repair. carefully padded at the ankle and used as a tourniquet.
2. A longitudinal incision is centered over the metatarsal head with
(plantar verrucae) typically are not found beneath a metatarsal a “hockey stick” extension distal into the adjacent interspace if
head, on occasion they can occur in this region and thus must needed. (The extensor tendon may be temporarily released to
be differentiated from an IPK. Trimming of a wart will uncover aid exposure and is repaired at the conclusion of the procedure.)
end arterioles in the lesion characterized by punctuate hemor- 3. The MTP joint capsule is released and the toe is flexed to 90
rhages. Evaluation of the athlete with an IPK involves determin- degrees at the MTP joint.
ing the significance of the symptoms, length of duration, and 4. A McGlamry elevator is used to release the plantar plate
association, if any, with specific athletic activity. A patient with from the plantar metatarasal head in order to prevent dam-
minimal symptoms requires no treatment. age during the resection.
Radiographic evaluation entails weight-bearing films with 5. An osteotome is used to remove 25% of the plantar condyle.
markers to determine the exact location of the IPK (a long Care is taken to avoid fracture to the metatarsal head (Fig.
metatarsal may be associated with an IPK; likewise, a marker 20.12). The condyle is removed.
may be located directly beneath the plantar condyle of a meta- 6. A 0.045 K-wire introduced at the MTP joint is driven distally
tarsal head). out the tip of the toe. With the MTP joint reduced, the pin is
driven in a retrograde fashion stabilizing the joint.
374 SECTION 3  Anatomic Disorders in Sports

A B
Fig. 20.9  (A) Discrete callus in a tennis player with an enlarged fibular condyle. (B) Diffuse callus in a runner.
(From Mann RA, Coughlin MJ. Video Textbook of Foot and Ankle Surgery. St Louis: Medical Video Produc-
tions; 1991:86.)

Fig. 20.10 A wart is characterized by punctate hemorrhages, which Fig. 20.11  Padding an intractable plantar keratosis often is successful
are obvious when the callus is trimmed. (From Mann RA, Coughlin MJ treatment.
Video Textbook of Foot and Ankle Surgery. St Louis: Medical Video Pro-
ductions; 1991:86.)

7. The extensor tendon (if released) is repaired. The skin is immobilization. In general, a patient can return to nonimpact
closed in a routine fashion. activities at 1 month, limited impact activities such as jogging at
8. A gauze and tape dressing is applied and changed on a 6 weeks, and may progress as tolerated.
weekly basis. The patient is allowed to heel weight bear in a
wooden-soled shoe. Surgical Treatment: Metatarsal Osteotomy
9. At 3 weeks the K-wire is removed. 1. The foot is prepped and draped in a routine sterile fashion.
Athletic activity is permitted as swelling and pain decrease. An Esmarch bandage is used to exsanguinate the foot. It is
The toe is protected for 6 weeks following surgery with taping carefully padded at the ankle and used as a tourniquet.
 CHAPTER 20  Lesser Toe Disorders 375

A B
Fig. 20.12 (A) Plantar condylectomy for a discrete intractable plantar keratosis. (B) Interoperative view of
plantar condylectomy (one-fourth to one-third of the plantar metatarsal head is excised).

B
Fig. 20.13 (A) Distal oblique osteotomy (dotted line shows proposed Fig. 20.14  Distal chevron osteotomy with internal fixation. (From Mann
osteotomy site). (B) Following displacement and internal fixation with RA, Coughlin MJ. Video Textbook of Foot and Ankle Surgery. St Louis:
K-wire. Medical Video Productions; 1991:93.)

2. A dorsal longitudinal incision is centered over the involved (This has more coronal stability than a transverse osteot-
metatarsal. omy.) The metatarsal head is displaced upward 3 mm and
3A. If a distal oblique osteotomy9 is performed (Fig. 20.13), the cut fixed with a 0.045 K-wire.
is directed in a vertical direction. The metatarsal head is dis- 3C. If a proximal transverse osteotomy11 is performed (Fig.
placed upward 3 mm10 and fixed with a 0.045 K-wire. 20.15), a dorsally based closing wedge osteotomy is per-
3B. If a vertical chevron osteotomy2 is performed (Fig. 20.14), formed. The further proximal the osteotomy is located,
the V-shaped osteotomy is directed in a vertical direction. the more sagittal plane elevation is achieved with wedge
376 SECTION 3  Anatomic Disorders in Sports

interspace. Rarely (less than 3% of cases) do two neuromas

occur in the same foot simultaneously.13
Typically an athlete initially describes ill-defined forefoot
pain, often exacerbated with running or sports activities, which
is relieved by rest or removal of shoes.
Although ill-defined forefoot discomfort is common, the
treating physician needs to help patients define the exact area of
pain. With time and education, athletes may be able to pinpoint
the exact area of pain from the dorsal and plantar aspect of the
forefoot. Neuritic symptoms or numbness in either the second
or third common digital nerve distribution may be observed.
Intermetatarsal space neuromas are located in the third interme-
tatarsal space about 85% of the time and in the other intermetatar-
sal spaces less commonly. It is important to appreciate that more
generalized neuritic symptoms in the toes may have other causes.
Neuritis may cause irritation of all of the intermetatarsal spaces.
Alternatively, tarsal tunnel syndrome or compression of Baxter’s
nerve proximally at the ankle can cause generalized neuritis or,
in the case of compression of Baxter’s nerve, may preferentially
cause symptoms in the distribution of the lateral plantar nerve.
Fig. 20.15 Proximal closing wedge osteotomy with screw fixation. On physical examination, care is taken to observe for signs
(From Mann RA, Coughlin MJ. Video Textbook of Foot and Ankle Sur- of peripheral neuropathy, vascular insufficiency, or neuritic
gery. St Louis: Medical Video Productions; 1991:91.) symptoms at the ankle. Peripheral neuropathy is characterized
by a loss of cutaneous, positional, and vibratory sensation. The
removal. (Care must be taken not to overcorrect at the oste- Semmes-Weinstein 5.07 monofilament is the classic test for
otomy site in order to prevent transfer metatarsalgia.) The protective sensation. Vascular insufficiency is characterized by
wedge may be removed with a sagittal saw or with a small a loss of distal hair, lack of pulses, dependent rubor, varicose
rongeur. Internal fixation is recommended. A plate-and- veins, atrophic skin, and delayed capillary refill. The toes are
screw construct, screw-only construct, or K-wire is used. examined for fixed deformity. Any callus or IPK is noted, and
4. The wound is closed in a routine fashion. A gauze and tape the adjacent MTP joints are evaluated for pain or instability
dressing is applied and changed on a weekly basis. The (see section on Metatarsophalangeal Instability). MTP capsu-
patient is allowed to heel weight bear in a wooden-soled lar instability symptoms closely mimic those of an interdigi-
shoe. tal neuroma, especially in the second intermetatarsal space. 14
5. Sutures are removed 3 weeks following surgery. Percutane- This is thought to occur because the second intermetatarsal
ous K-wires are removed 3 to 4 weeks following surgery. space nerve is near the plantar-lateral second MTP joint capsule,
The forefoot is then strapped with tape and gauze until which is commonly inflamed in both second MTP instability as
symptoms resolve. well as second MTP joint capsulitis. In all three diagnoses, pal-
6. Radiographic union is important before aggressive athletic pation of the involved interspace usually elicits pain. Grasping
activity can begin. and compression of the transverse arch at the level of the meta-
Athletic activity is permitted as swelling and pain dimin- tarsal heads may elicit a click (Mulder’s sign),15 which occurs
ish. In general, a patient can return to nonimpact activities at 2 when the neuroma subluxates below the metatarsal head and
months, limited impact activities such as jogging at 3 months, transverse metatarsal ligament (TML).
and progress as tolerated.
In general, with a partial plantar condylectomy, satisfac-
tory results are attained for relieving the symptoms of a discrete PEARL: DIAGNOSIS OF MTP INSTABILITY
well-localized IPK.8 Likewise, a distal osteotomy9,11 may be effica- VERSUS INTERDIGITAL NEUROMA
cious for a similar lesion. A diffuse callus in the athlete is probably When a patient has difficulty isolating the location of pain, a 1% lidocaine
best padded and shaved, as a more extensive procedure involving injection may be used to determine the site of pain.16 During serial office visits
a diaphyseal osteotomy12 may require prolonged healing time and 1 week apart, the physician may inject the second IMS, then the third IMS,
place the athlete at greater risk for delayed healing, malunion, and then the second MTP joint, then the third MTP joint. Fluoroscopy and inject-
transfer metatarsalgia. A proximal closing wedge osteotomy9 may able contrast may be used to verify an intraarticular injection. It is important
be used to elevate a symptomatic long second or third metatarsal. to use small volumes (1‒3mL) to prevent extravasation of anesthetic agent
to adjacent structures. The patient is asked to repeat the activity that causes
the most discomfort while anesthetized and keep a “pain diary” carefully
INTERDIGITAL NEUROMAS describing how much of their symptoms improved and for how long. Within 1
An interdigital neuroma may be a source of ill-defined forefoot or 2 hours the anesthetic wears off. When temporary relief is achieved with
the injection, followed by recurrent symptoms, an anatomic diagnosis can be
pain. Most commonly located in the third intermetatarsal space
confirmed.14
(IMS), a neuroma is rarely isolated to the first, second, or fourth
 CHAPTER 20  Lesser Toe Disorders 377

Fig. 20.16 Dorsal incision demonstrates a large interdigital neuroma.

The transverse metatarsal ligament has been sectioned. (From Cough-
lin, MJ. Soft tissue afflictions. In: Chapman M, ed. Operative Orthopae-
dics. Philadelphia: JB Lippincott;1993:2289.) Fig. 20.17  Strapping of the foot is continued for 6 weeks postopera-
tively to promote healing of the transverse metatarsal ligament.

7. The interspace is inspected for any other nerve tissue that

may be a cause of pain. It is important to sever any adjacent
Conservative Treatment capsular nerve branches that prevent proximal migration of
Early conservative treatment may alleviate symptoms in the the nerve stump. The retractor is removed, and the surgical
athlete. With intermittent symptoms exacerbated by intense wound is irrigated and closed in a routine fashion.
athletic activity, or sports of significant duration, a change 8. A gauze and tape dressing is applied and changed on a weekly
in the type of activity or its duration may completely relieve basis, and the patient is allowed to ambulate in a postopera-
symptoms. tive shoe.
Placing a small metatarsal pad just proximal to the symp- 9. Suture removal is carried out 3 weeks following surgery, and
tomatic interspace may relieve symptoms. Change in athletic a circumferential gauze and tape strapping is continued for
shoes may also alleviate pain. 3 more weeks to allow adequate healing of the TML if it was
When conservative methods including the modification of sectioned (Fig. 20.17).
sports activities have not relieved symptoms, surgical interven- Aggressive walking can be commenced 4 weeks following
tion may be considered.17‒19 surgery, with increased activity as pain and swelling permit.
Patients can present with concurrent interdigital neuroma
Surgical Treatment: Excision of Interdigital and MTP joint capsular instability. Isolated treatment of one of
Neuroma these conditions is unlikely to resolve the patient’s symptoms.
1. The foot is prepped and draped in the usual sterile fashion. Simultaneous interdigital neuroma resection and stabilization
An Esmarch bandage is used to exsanguinate the foot. The of the MTP joint result in better outcomes than isolated proce-
ankle is carefully padded and the Esmarch is used as a tour- dures.14 Techniques to address capsular instability are addressed
niquet. later in this chapter.
2. A 3-cm dorsal incision is centered in the involved interspace.
3. The dissection is carried down to the TML (Fig. 20.16).
4. A 2-3 prong Weitlaner retractor is used to distract the adja-
HARD CORNS AND SOFT CORNS
cent metatarsals and place the TML under tension. A hard corn (Fig. 20.18) develops over the lateral aspect of
5. The TML is sectioned to expose the neuroma and common the fifth toe usually due to pressure of the shoe against an
digital nerve. underlying exostosis or condyle on the fifth toe. Patients may
6. The digital nerves distal to the bifurcation are severed at the complain of pain associated with a hypertrophic callus on the
level of distal webspace. The proximal stumps are tensioned. lateral aspect of the fifth toe. A soft corn (Fig. 20.19) develops
A nerve freer is used to dissect longitudinally to isolate the between the toes due to pressure between two adjacent bony
common digital nerve. Special attention is directed at freeing prominences. Patient may complain of exquisite pain; macer-
the plantar and capsular branches. With tension on the prox- ation sometimes occurs that resembles a mycotic infection.
imal nerve, a scalpel is used to transect the nerve as proximal Desiccation of the lesion may then help to distinguish it from
as possible in the interspace. an infection.20
378 SECTION 3  Anatomic Disorders in Sports

Fig. 20.18  Hard corn with keratotic buildup. (From Mann RA, Coughlin
MJ. Video Textbook of Foot and Ankle Surgery. St Louis: Medical Video
Productions; 1991:50.) Fig. 20.20 Radiograph demonstrating the location of a soft corn
(arrows). (From Mann RA, Coughlin MJ. Video Textbook of Foot and
Ankle Surgery. St Louis: Medical Video Productions; 1991:51.)

compression between the two toes. Shaving of the callosity also

may be indicated (see Case Study 20.3). When conservative
measures have failed, surgical resection of the involved condyle
may eliminate the prominence and alleviate the symptoms.

CASE STUDY 20.3 

A 40-year-old jogger developed exquisite pain beneath the fourth and fifth
toes. He recognized maceration in the fourth web space. It was unclear
whether this was a fungus infection or a soft corn.
On his initial evaluation, radiographs demonstrated impingement between
the PIP joint of the fourth toe and DIP joint of the fifth toe.
Initial treatment included used rubbing alcohol applied with a cotton-tipped
applicator three times a day to desiccate the area. Then, lamb’s wool was
placed between the toes to pad and alleviate pressure between the two prom-
inent condyles. Later, a foam spacer was placed between the toes, and the
patient was allowed to resume all jogging activity. No surgery was performed.
Fig. 20.19  A soft corn is demonstrated in the fourth web space, mim-
icking a mycotic infection. (From Mann RA, Coughlin MJ. Video Text-
book of Foot and Ankle Surgery. St Louis: Medical Video Productions; Surgical Treatment for Hard Corns21
1991:51.)
1. The foot is prepped and draped in the usual sterile fashion.
Often a digital anesthetic block is used, although a foot block
On physical examination, the obvious callosity occurs over- may also be considered.
lying a bony prominence. Radiographic evaluation may help to 2. A dorsolateral longitudinal incision is centered over the
define the location of the lesion (Fig. 20.20). prominent lateral condyle.
3. With sharp dissection, the capsular fibers are peeled off of
Conservative Treatment the condyle.
Padding of the hard corn (Fig. 20.21) may alleviate discomfort. 4. A rongeur is used to remove the prominent condyle, with
Stretching of shoes overlying the lesion may decrease symp- care taken to leave enough articular surface to retain joint
toms. Shaving of the callosity on a frequent basis may diminish stability (Fig. 20.23).
the painful symptoms. 5. The sharp bony edges are beveled with a rongeur.
With a soft corn, padding of one or both toes with either a 6. The capsule is closed with two or three interrupted absorb-
foam spacer (Fig. 20.22) or tubular foam gauze often eliminates able sutures.
 CHAPTER 20  Lesser Toe Disorders 379

Fig. 20.23  A dorsal incision is used for the condylectomy as the treat-
ment for a hard corn. (From Coughlin MJ. Soft tissue afflictions. In:
Chapman M, ed. Operative orthopaedics. Philadelphia: JB Lippincott;
1993:2223.)

A B
Fig. 20.21  (A) An underlying exotosis (arrow) combined with restrictive 9. Sutures are removed 3 weeks after surgery. The toe is then
footwear leads to a hard corn. (B) A pad may be used to relieve pressure. taped to the adjacent toe for 3 more weeks to promote stabil-
ity and avoid injury.
After suture removal, an increase in sports activity can
begin. Walking and cycling may be started when sutures are
removed. Running may begin after swelling has diminished
enough to allow shoes to fit comfortably, typically 6 weeks
postoperatively.

Surgical Treatment for Soft Corns

1. The foot is prepped and draped in the usual sterile fash-
ion. Often a digital anesthetic block is used, although a foot
block may also be considered.
2. A decision is made whether to treat both lesions on adja-
cent toes or to treat only one. (With a significant lesion on
one toe and a minor lesion on the corresponding toe, a
surgical repair of the larger lesion usually will successfully
eliminate the entire problem.)
3. A dorsolateral longitudinal incision is centered over the
prominent lateral condyle. This avoids an incision in the
affected webs pace.
4. With sharp dissection, the capsular fibers are peeled off of
the condyle.
5. A rongeur is used to remove the prominent condyle, with
Fig. 20.22  A pad is used to relieve pressure in the web space. (From care taken to leave enough articular surface to retain joint
Mann RA, Coughlin MJ. Video Textbook of Foot and Ankle Surgery. St
Louis: Medical Video Productions; 1991:51.)
stability (Fig. 20.24).
6. The sharp edges are beveled with a rongeur.
7. If a fixed contracture of the toes exists, a percutaneous
7. A percutaneous flexor tenotomy is performed at the MTP tenotomy of the flexor tendon is performed.
joint. 8. The capsule is closed with an interrupted absorbable suture.
8. The skin is closed with a running skin closure. A gauze 9. The skin is closed with a running skin closure. A gauze and
and tape dressing is applied and changed on a weekly tape dressing is applied and changed on a weekly basis. The
basis. The patient is allowed to ambulate in a postopera- patient is allowed to ambulate in a wooden-soled postoper-
tive shoe. ative shoe.
380 SECTION 3  Anatomic Disorders in Sports

Early on, it may present as a flexible deformity that in time may

become fixed. With a mallet toe (Fig. 20.26), there is a flexion
contracture at the DIP joint. Early on, it may present as a flex-
ible deformity due to tightness of the flexor digitorum longus
(FDL) tendon. With time it may become a fixed deformity. A
callus may develop dorsally over the DIP joint due to pressure
or abrasion from impacting against the toe box. A callus may
also develop at the tip of the toe due to pressure against the
insole of the shoe.
With a claw toe deformity, typically a flexion contracture
develops at the PIP joint with hyperextension at the MTP joint.
A callosity may develop over the PIP joint; with a long-standing
contracture, and IPK may develop beneath the metatarsal head.
Early on, a flexible contracture may be passively correctable,
although with time a fixed contracture may develop.
Subjectively a patient typically complains of pain over a
prominent callus on the involved toe; occasionally a painful cal-
lus will develop at the tip of the toe.
A B On physical examination, the flexibility or rigidity of the
Fig. 20.24  (A) A soft corn may develop over the base of the proximal deformity may determine the particular surgical repair, should
phalanx. (B) Resection of the bony prominence. it be necessary. The presence of multiple toe deformities, con-
tractures at adjacent joints, and neurologic deficits must be
appreciated during physical examination. With all of these
lesser toe deformities, an athlete may complain of blistering,
callus formation, swelling, or pain due to a dynamic or static
deformity. Occasionally an infection may develop in the over-
lying tissue.

Conservative Treatment
Conservative care includes relieving pressure over the painful
area.22 The use of roomy footwear will often relieve discomfort
in the athlete. Padding often allows return to sports activity.
Shaving of painful callosities may temporarily improve keratotic
buildup. Often conservative care will allow an athlete to con-
tinue activity, although decreasing the duration or intensity of
the workout or changing to a different sporting activity may be
necessary on a temporary or permanent basis. When conserva-
tive measures do not allow acceptable athletic activity, surgical
intervention may be considered.
Fig. 20.25  Hammertoe deformity. (From Coughlin MJ. Operative repair
of the fixed hammertoe deformity. Foot and Ankle Int. 2000;21:94–104, Surgical Treatment: Hammertoe Repair23
Fig. 1.) 1. The foot is prepped and draped in the usual sterile fashion.
Usually a digital nerve block is used as an anesthetic.
10. Sutures are removed 3 weeks after surgery. 2. A dorsal elliptical skin incision is centered over the PIP
11. A small gauze spacer is used between the toes for another joint. The incision is carried down to bone with excision of
3 weeks until the surgical incisions have softened. After an ellipse of skin, extensor tendon, and capsule exposing the
suture removal, walking and cycling may be started. Run- condyles of the proximal phalanx.
ning may begin after swelling has diminished enough to 3. The collateral ligaments of the PIP joints are severed, enabling
allow shoes to fit comfortably, typically 6 weeks postopera- the condyles to be delivered.
tively. 4. A bone-cutting forceps is used to osteotomize the proximal
phalanx in the supracondylar region (Fig. 20.27). The sharp
edges are beveled with a rongeur.
HAMMERTOES, MALLET TOES, CLAW TOES 5. The articular surface of the middle phalanx is exposed, and a
Deformities of the lesser toes include both flexible and fixed rongeur is used to remove the articular surface.
deformities. Typically callus formation occurs over bony prom- 6. A 0.045 K-wire is introduced at the PIP joint and driven dis-
inences, and at times during athletic activity these areas may tally, exiting the tip of the toe. Then with the toe reduced
become inflamed and painful. A hammertoe deformity (Fig. to the desired position, the K-wire is driven in a retrograde
2.25) is characterized by a flexion contracture at the PIP joint. fashion, stabilizing the hammertoe repair. The pin is bent at
 CHAPTER 20  Lesser Toe Disorders 381

A B
Fig. 20.26  Mallet toe deformity. (A) Dorsal and (B) plantar views. (From Mann RA, Coughlin MJ. Video Text-
book of Foot and Ankle Surgery. St Louis: Medical Video Productions; 1991:48.)

the tip of the toe to prevent proximal migration. An intra-

medullary implant may be considered to eliminate the need
CLAW TOE
for K-wire fixation. A claw toe deformity may be flexible, semirigid, or fixed.
7. A gauze and tape dressing is applied and changed on a Frequently it involves all of the toes on a foot. Although the
weekly basis. The patient is permitted to ambulate in a stiff etiology frequently is idiopathic, the treating physician should
soled postoperative shoe. Sutures and K-wire are removed 4 inspect the patient for other causes such as spasticity, muscular
weeks after surgery. dystrophy, spinal abnormality, and previous trauma (old frac-
8. The patient is then instructed to tape the toe to an adjacent tured tibia, old compartment syndrome, etc.).
toe for an additional 4 weeks to protect it from injury. Many cases may be effectively treated with roomy footwear,
After the K-wire is removed, increased walking activity padding, and pedicures; however, on occasion an athlete is so
is performed. Cycling may be allowed. Running or jogging is symptomatic that surgery is contemplated. Although claw toes fre-
usually avoided until swelling has diminished (6 to 8 weeks). quently involve multiple toes, they have similarities with different
Whether an arthrodesis occurs at the PIP joint is not of signifi- stages in the development and treatment of hammertoe deformity.
cant concern. Fibrous ankylosis with a small amount of motion Early on, flexible claw toes (although multiple in nature)
is equally acceptable. resemble flexible hammertoes. A flexor tendon transfer of the sec-
ond, third, and fourth toes may achieve adequate realignment by
Surgical Treatment: Early Flexible Mallet Toe releasing the contracted FDL tendon and depressing the proximal
Repair phalanx through the tendon transfer. Rarely is a flexor tendon
1. The foot is prepped and draped in the usual sterile fashion. A transfer performed on the fifth toe. A flexor tenotomy is occasion-
digital block is used for anesthesia. (With an early mallet toe ally performed, although often the fifth toe is asymptomatic.
deformity, the toe can be passively corrected to neutral with As a claw toe becomes fixed, a patient may develop symptoms
pressure.) of a hammertoe with callus formation overlying the PIP joint.
2. A #11 scalpel blade is introduced on the plantar aspect of the Because of the fixed dorsiflexion contracture at the MTP joint,
DIP joint and the FDL tendon is released. the toe buckles, depressing the metatarsal head. A plantar callus
3. The incision is closed with an interrupted skin suture. (IPK) may develop due to increased pressure beneath the meta-
4. A gauze and tape dressing is applied, and the patient is tarsal head. The treating physician needs to remember that the
allowed to ambulate in a postoperative shoe. IPK is usually due to the contracted toe rather than to a promi-
5. The sutures are removed 10 days after surgery. nent metatarsal condyle. Correction of the toe deformity often is
Athletic activity can be resumed rapidly following this pro- associated with diminution or resolution of the plantar callosity.
cedure with little downtime. In general, a patient can begin to The fixed claw toe resembles a fixed hammertoe, although the
advance activities at 2 weeks. Typically, full activities can be claw toe also has contracture at the MTP joint. A PIP joint con-
resumed by 4 weeks. tracture is surgically repaired (Fig. 20.29) with a condylectomy
When a fixed mallet toe is corrected, a similar procedure is of the proximal phalanx (see the section on Fixed Hammertoe
performed as is carried out for a hammertoe deformity. In this Repair). Once the PIP joint contracture has been corrected,
case the procedure is carried out at the DIP joint (Fig. 20.28).24 attention must be directed to the MTP joint contracture.
382 SECTION 3  Anatomic Disorders in Sports

A B

C D

E F
Fig. 20.27  Hammertoe repair. (A) An elliptical incision is made at the proximal interphalangeal joint, (B) the
extensor tendon is excised, (C) collateral ligaments are released, and (D) the distal aspect of the proximal pha-
lanx is removed, followed by (E) the proximal aspect of the middle phalanx. Finally, (F) a K-wire or intramedul-
lary device is used to fix the toe. (From Coughlin MJ. Operative repair of the fixed hammertoe deformity. Foot
and Ankle Int. 2000;21:94-104, Fig. 2.)

Surgical Treatment: Metatarsophalangeal Soft- 3. The long extensor tendon is split longitudinally and Z-length-
Tissue Arthroplasty24,25 ened.
1. The foot is prepped and draped in the usual sterile fashion. An 4. The medial, dorsal, and lateral capsule is completely released
Esmarch bandage is used to exsanguinate the foot. The ankle to allow reduction of the MTP joint. (This requires a signif-
is carefully padded and the Esmarch is used as a tourniquet. icant release in a plantar direction of both collateral liga-
2. An oblique or longitudinal incision is centered over the MTP ments.) When a toe still does not reduce completely following
joint. an MTP release, there may be adhesions between the plantar
 CHAPTER 20  Lesser Toe Disorders 383

tape dressing is applied and changed on a weekly basis.

The patient is allowed to ambulate in a postoperative shoe.
8. The K-wire and sutures are removed 3 to 4 weeks after sur-
gery.
The toe is taped in a corrected position for 4 to 6 weeks. After
removal of the K-wire, increased activity is permitted. Walking,
cycling, and swimming are allowed. Jogging and running are
A prevented until adequate healing has occurred and swelling has
subsided (6 to 8 weeks).

METATARSAOPHALANGEAL (MTP) JOINT

INSTABILITY
Instability of the metatarsophalangeal joint can be an extremely
B difficult diagnosis to make, especially early on when there is a
lack of clinical deformity. The second MTP joint is the most fre-
Fig. 20.28  mallet toe repair. (A) Proposed resection. (B) K-wire fixation
following condylectomy. quent location of instability due to the longer length of the sec-
ond ray. In a report on athletes with second MTP instability,26
Coughlin reported 100% of the patients to have an elongated
second metatarsal in relationship to adjoining metatarsals.
Most likely due to the stress of repeated and prolonged athletic
activity, pain without deformity develops in the forefoot. The
mechanism of instability is generally described as rupture or
attenuation of collateral ligaments and plantar plate of the MTP
joint.27
Typically an athlete initially describes ill-defined forefoot
pain often exacerbated by running and sports activities and
relieved by rest. Sometimes pain increases with intensity and/or
A duration of sports activities.
On physical examination, the treating physician needs to
initially isolate the exact point of tenderness. With palpation,
tenderness is typically elicited over the plantar, medial, or lateral
MTP capsule. Usually pain is not so pronounced in the third
or second intermetatarsal spaces. It may initially be difficult to
differentiate second MTP pain from a second IMS neuroma. A
critical differentiating finding, however, is that there are no neu-
ritis symptoms in the second or third toes and no numbness
associated with capsulitis or instability of the second MTP joint.
B It is worth pointing out, however, that neuritic symptoms may
be present due to inflammation of the nerve due to nearby MTP
Fig. 20.29  Claw Toe Deformity. (A) Prior to and (B) following metatarso-
phalangeal (MTP) joint release, extensor tenotomy, and proximal inter-
joint capsulitis.
phalangeal (PIP) joint arthoplasty. Capsulitis or inflammation of an MTP joint can be associ-
ated with MTP joint instability, but it can also be caused by a
capsule and the plantar metatarsal head. These usually can be systemic or localized arthritis. Frieberg’s infarction is one pos-
released with a curved Freer or McGlamry elevator. The toe sible cause of second MTP joint capsulitis or inflammation
should be then easily reducible in a dorsal plantar plane. caused by avascular necrosis of the metatarsal head bone (Fig.
5. An 0.045 K-wire is used to stabilize the repair. The pin is 20.30). Degenerative or posttraumatic osteochondral lesions are
introduced at the MTP joint and driven in a distal direction another possible cause of MTP joint degeneration, which may
exiting the tip of the toe. (When combined with hammertoe originate in the second MTP joint or the adjacent first MTP joint
repair, it is introduced at the PIP joint and driven proximally, causing generalized inflammation (Fig. 20.31). Systemic inflam-
exiting the base of the proximal phalanx. It is then driven matory conditions often involve other MTP joints. Whereas
distally, exiting the tip of the toe.) without a preexisting inflammatory arthropathy, only the sec-
6. The pin is then driven in a retrograde fashion, stabilizing the ond MTP joint is usually involved. A drawer sign28 (Fig. 20.32)
MTP joint. The pin is bent at the tip of the toe to prevent is typically the diagnostic test most helpful in defining capsulitis
proximal migration. and/or instability of the MTP joint. By grasping the involved
7. The extensor tendon is repaired in a lengthened fashion, toe between the fingers and stressing the MTP joint in a dor-
and the skin is closed in a routine fashion. A gauze and sal plantar direction, exquisite pain can be elicited, likely due to
384 SECTION 3  Anatomic Disorders in Sports

Fig. 20.30 Freiberg’s infarction. Anterior-posterior radiograph demon-

strating a Freiberg’s infarction of the second metatarsal head.

Fig. 20.32  A drawer sign is used to detect dorsal plantar instability.

Radiographic evaluation involves routine anterior-pos-

terior (AP) and lateral radiographs to determine if there is
widening of the joint space (effusion), narrowing (arthritis),
or malalignment in relationship to the adjoining MTP joints
(Fig. 20.34). Magnetic resonance imaging (MRI) can demon-
strate a plantar plate tear; however. these tears can be small
and visualization may be limited by the width of the cuts of
the MRI (Fig. 20.35).
A
Conservative Treatment
Early conservative treatment relies on early diagnosis by the
treating physician. Before deformity has developed at the sec-
ond MTP joint, early MTP instability is best treated with tap-
ing the involved toe, padding, and a change in athletic activity.
Taping requires stabilizing the toe to prevent dorsal plantar
flexion excursion. Taping to an adjacent toe may be effective.
A sling-type taping technique also may be effective (Fig. 20.36).
An athlete may need to tape the involved toe for several months,
although some athletes find it necessary to tape the toe only
B during sports activities. A metatarsal pad placed just proximal
Fig. 20.31  (A) T2 and (B) T1 saggital images of an osteochondral defect. to the metatarsal head may alleviate pressure and relieve symp-
Osteochondral lesion of the first metatarsal head causing pain in the toms on the involved MTP capsule. Restructuring workouts and
plantar metatarsophalangeal joint. modifying athletic activity can be helpful in relieving pain.
With unsuccessful resolution of discomfort, or insistence on
stress on the attenuated plantar capsule or collateral ligaments. a higher level of athletic activity, surgical intervention may be
(This finding is absent in an isolated interdigital neuroma.) considered.
With time, the diagnosis becomes obvious as the toe devi-
ates29,30 (Fig. 20.33). Initially the toe deviates medially and with Surgical Treatment: Metatarsophalangeal
time dorsally, developing into a crossover second toe deformity. Instability
This development can be acute, although typically in athletes it For patients that fail to respond to conservative treatment, several
occurs insidiously over several months. surgical techniques exist. Selection of the appropriate technique
 CHAPTER 20  Lesser Toe Disorders 385

A B
Fig. 20.33  (A) Instability of the second metatarsophalangeal joint with a crossover second toe may occur due to
degeneration of the lateral collateral ligament. (B) Malalignment as demonstrated with a crossover second toe.

Fig. 20.35  Sagittal MRI cut demonstrating a plantar plate tear (arrow).
(Courtesy Lowell Weil Jr, DPM)

lesser toe. This osteotomy should be avoided in patients with

a plantarflexed metatarsal as it does not dorsally displace the
distal fragment.31 The relative stability of this osteotomy with
weight bearing and the use of internal fixation make this an
ideal osteotomy for the active patient.
1. The foot is cleansed and draped in the routine fashion. The
foot is exsanguinated with an Esmarch bandage. The ankle is
carefully padded, and the Esmarch is used as an ankle tour-
niquet
2. A 3-cm incision is made in the intermetatarsal space just
proximal to the webspace. This allows access to adjacent
metatarsals should more than one require attention.
3. The metatarsal head is exposed through a lateral capsular
incision under the extensor tendon. The toe is plantarflexed
exposing the metatarsal head.
4. A narrow oscillating saw is used to make the osteotomy
Fig. 20.34 Axial malalignment may be demonstrated on radiographic
examination. parallel to the weight-bearing surface of the foot. The oste-
otomy originates in the dorsal quarter of the MTP joint
depends on clinical assessment of the deformity. Synovitis and (Fig. 20.37).
mild deviation of the MTP joint is classified as a mild deformity 5. The distal fragment is displaced proximally until the meta-
and can be treated with capsular reefing. Dorsomedial deviation tarsal head is at the level of line drawn from the MTP of the
at the MTP joint or overlapping of the adjacent toe is considered first and fourth rays. The fragment is fixed with two threaded
moderate deformity and can be treated with capsular reefing K-wires.
and direct repair of the plantar plate. 6. The overhanging bone is rongeured smooth.
7. The capsule is reefed if necessary, as described above. The
Surgical Treatment: Weil Osteotomy capsule is repaired with absorbable sutures.
The Weil osteotomy is a shortening osteotomy that primary 8. The patients are placed in surgical shoes and allowed to
benefits patients with painful instability associated with a long weight bear with crutches.
386 SECTION 3  Anatomic Disorders in Sports

A B
Fig. 20.36 Technique of taping a toe. (From Coughlin MJ. Crossover second toe deformity. Foot Ankle
1987;8:29-39.)

A B

C D
Fig. 20.37  The Weil osteotomy (A) Demonstrates MTP instability; (B) the toe plantarflexed to the dorsal
MTP joint can be accessed for the osteotomy, which is aligned parallel to the plantar aspect of the foot; (C)
the metatarsal head is slid proximally to the desired level and (D) fixed with a small screw from dorsal to plan-
tar (From Trnka H. Comparison of the results of the Weil and Helal osteotomies for the treatment of meta-
tarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot and Ankle 1999;20:72-79.)

The following is a technique for a direct repair through a dor-

Surgical Treatment: Plantar Plate Repair sal approach.
The plantar plate can be repaired from either a dorsal or a 1. The foot is prepped and draped in the routine sterile fash-
plantar approach. Several techniques have been described, the ion. The foot is exsanguinated with an Esmarch bandage.
outcomes of each have not been directly compared and the long- The ankle is carefully padded, and the Esmarch is used as
term outcomes of the repairs are limited. At least one study with an ankle tourniquet
1-year follow-up demonstrated 80% good to excellent results 2. A 3-cm dorsal midline incision is centered over the MTP
utilizing a dorsal approach to the repair.32 joint. If hyperextension of the toe is present, the extensor
 CHAPTER 20  Lesser Toe Disorders 387

A B

C D
Fig. 20.38  plantar plate types. Plantar plate tears: (A) grade 1, (B) grade 2, (C) grade 3, and (D) grade 4.

digitorum longus tendon may be lengthened and later 4. A Weil metatarsal osteotomy is performed (see previous
repaired at the conclusion of the procedure. section) parallel to the plantar aspect of the foot, and the
3. The dorsal MTP capsule is released. The medial and lateral metatarsal head is translated proximally 8 to 10 mm. It
collateral ligaments are released off the proximal phalanx. is fixed temporarily in a proximal position with a verti-
Care is taken to preserve the collateral ligament on the cal Kirschner wire. The remaining 2‒3 mm of the dorsal
metatarsal head in order to preserve blood supply to the metaphyseal bone is removed to improve visualization of
metatarsal head. and gain access to the plantar plate.
388 SECTION 3  Anatomic Disorders in Sports

Fig. 20.39  Bone tunnels. Figure demonstrating suture passage through the plantar plate in a horizontal mat-
tress fashion followed by passage through the proximal phalanx bone tunnels.

5. A second K-wire is placed in the proximal phalanx metaph- postoperatively. A graphite insole with a soft orthotic is placed
ysis. A joint distractor is positioned over the two K-wires in the shoe to prevent MTP dorsiflexion. It is recommended
and used to open the joint and directly inspect the plantar that this insert be used for 6 months postoperatively.
plate for pathology. The tear type guides the suturing tech-
nique (Fig. 20.38).
6. A distal transverse tear is repaired with one or two horizon-
CONCLUSION
tal mattress sutures. A longitudinal tear is often repaired When correctly diagnosed and treated, forefoot disorders
using a suture passer. Commercial devices can aid in this should not limit athletic endeavors. While many of these con-
technique. ditions are treated nonoperatively, the orthopedic surgeon often
7. Following suture placement in the plantar plate, two vertical is the most appropriate clinician to identify the problem and
holes are drilled in the base of the proximal phalanx. The sutures direct treatment. When operative treatment is required, the
are then passed through the phalangeal drill holes (Fig. 20.39). patient should be able to resume activities at their previous level
8. The Weil osteotomy is fixed in a corrected position. In of competition.
the event that the patient has a long second metatarsal,
the surgeon may consider fixing the Weil osteotomy in a
shortened position to better match the other lesser toes in REFERENCES
order to take stress off the second MTP joint with dorsi- 1. Coughlin MJ. Etiology and treatment of the bunionette deformity.
flexion. In: Greens WB, ed. American Academy of Orthopaedic Surgeons
9. After fixation of the Weil osteotomy, the sutures are tied instructional course lectures. Chicago, 1990; 39:37.
over the bone bridge of the proximal phalanx with the toe 2. Mann RA, Coughlin MJ. Bunionettes. In: Video Textbook of Foot
held in roughly 30 degrees of plantarflexion. The drawer and Ankle Surgery. St Louis: Medical Video Productions; 1991:96.
test will generally demonstrate improved stability immedi- 3. Throckmorton JK, Bradlee N. Transverse V sliding osteotomy:
ately after fixation. a new surgical procedure for the correction of Tailor’s bunion
deformity. J Foot Surg. 1978;18:117.
10. The wound is closed in a routine fashion. A gauze and tape
4. Coughlin MJ. Bunionettes. In: Mann RA, Coughlin MJ, eds.
dressing is applied and changed on a weekly basis. The
Surgery of the Foot and Ankle. 6th ed. St Louis: CV Mosby; 1992.
patient is allowed to ambulate in a wooden-soled shoe. 5. Sponsal KH. Bunionette correction by metatarsal osteotomy.
11. Sutures are removed 3 weeks after surgery. If a K-wire has Orthop Clin North Am. 1976;7:808.
been placed, it is removed at this time 6. Coughlin MJ. Treatment of bunionette deformity with longitudi-
For those returning to athletic activity, the patients are nal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle.
allowed to begin forefoot weight-bearing activities at 6 weeks 1991;11:195.
 CHAPTER 20  Lesser Toe Disorders 389

7. Mann RA. Intractable plantar keratosis. In: American Academy of 24. Coughlin MJ. Lesser toe abnormalities. In: Chapman M, ed. Oper-
Orhtopaedic Surgeons Instructional Course Lectures. St Louis: CV ative Orthopaedics. Philadelphia: JB Lippincott; 1988:1765.
Mosby; 1984;33:287. 25. Coughlin MJ, Mann RA. Lesser toe deformities. In: Mann RA,
8. Mann RA, DuVries H. Intractable plantar keratosis. Orthop Clin Coughlin MJ, eds. Surgery of the Foot and Ankle. 6th ed. St Louis:
North Am. 1973;4:67. CV Mosby; 1992.
9. Pedowitz WJ. Distal oblique osteotomy for intractable plantar 26. Coughlin MJ. Metatarsophalangeal joint instability in the athlete.
keratosis of the middle three metatarsals. Foot Ankle. 1988;9:7. Foot Ankle. 1993;14:309.
10. Dreeben SM, Noble PC, Hammerman S, Bishop JO, Tullos HS. 27. Haddad SL, Sabbagh RC, Resch S, et al. Results of flexor-to-ex-
Metatarsal osteotomy for primary metatarsalgia: radiographic and tensor and extensor brevis tendon transfer for correction of the
pedobarographic study. Foot Ankle. 1989;9:214–218. crossover second toe deformity. Foot Ankle Int. 1999;20:781–788.
11. Mann RA, Coughlin MJ. Intractable plantar kerotoses. In: Video 28. Coughlin MJ. Subluxation and dislocation of the second metatar-
Textbook of Foot and Ankle Surgery. St Louis: Medical Video Pro- sophalangeal joint. Orthop Clin North Am. 1989;20:535–551.
ductions; 1991:85. 29. Coughlin MJ. Crossover second toe deformity. Foot Ankle Int.
12. Giannestras NJ. Shortening of the metatarsal shaft in the treat- 1988;8:29–39.
ment of plantar keratosis. J Bone Joint Surg. 1958;49A:61. 30. Coughlin MJ. When to suspect crossover second toe deformity.
13. Thompson FM, Deland JT. Occurrence of two interdigital neuro- J Musculoskeletal Medicine. 1987;39–48.
mas in one foot. Foot Ankle Int. 1993;14:15–17. 31. O’Kane C, Kilmartin TE. The surgical management of central
14. Coughlin MJ, Schenck RC, Shurnas PJ, Bloome DM. Concurrent metatarsalgia. Foot Ankle Int. 2002;23:415–419.
interdigital neuroma and MTP joint instability: long-term results 32. Flint WW, Macias DM, Jastifer JR, Doty JF, Hirose CB, Coughlin
of treatment. Foot Ankle Int. 2002;23:1018–1025. MJ. Plantar Plate Repair for Lesser Metatarsophalangeal Joint
15. Mulder JD. The causative mechanism in Morton’s metatarsalgia. J Instability. Foot Ankle Int. 2017;38(3):234–242.
Bone Joint Surg. 1951;33B:94.
16. Coughlin MJ. Soft tissue afflictions. In: Chapman M, ed. Opera-
tive Orthopaedics. Philadelphia: JB Lippincott; 1988:1819. FURTHER READING
17. Betts LO. Morton’s metatarsalgia: neuritis of the fourth digital Coughlin MJ, Dorris J, Polk E. Operative repair of the fixed hammer-
nerve. Med J Aust. 1940;1:514. toe deformity. Foot Ankle Int. 2000;21:94–104.
18. Mann RA, Reynolds JC. Interdigital neuroma: a critical clinical Coughlin MJ. Common causes of pain in the forefoot in adults. J Bone
analysis. Foot Ankle. 1983;3:238. Joint Surg Br. 2000;82:781–790.
19. Morton TG. A peculiar painful infection of the fourth metatarso- Coughlin MJ, Pinsonneault T. Operative treatment of interdigital
phalangeal articulation. Am J Med Sci. 1876;71:37. neuroma: a long-term follow-up study. J Bone Joint Surg Am.
20. Mann RA, Coughlin MJ. Lesser toe deformities. In: American 2001;83:1321–1328.
Academy of Orthopaedic Surgeons Instructional Course Lectures. Coughlin MJ. Lesser-toe abnormalities. J Bone Joint Surg Am.
1987;36:137. 2002;84:1446–1469.
21. Mann RA, Coughlin MJ. Lesser-toe deformities. In: Jahss JM, ed. Coughlin MJ, Kennedy MP. Operative repair of fourth and fifth toe
Disorders of the Foot. 2nd ed. Philadelphia: WB Saunders; 1991:1205. corns. Foot Ankle Int. 2003;24:147–157.
22. Coughlin MJ. Mallet toes, hammer toes, claw toes, and corns– Trnka HJ, Muhlbauer M, Reinhard Z, et al. Comparison of the results
causes and treatment of lesser toe deformities. Postgrad Med. of the Weil and Helal osteotomies for the treatment of metatar-
1984;75:191. salgia secondary to dislocation of the lesser metatarsophalangeal
23. Coughlin MJ. Lesser toe deformities. Orthopedics. 1987;10:63. joints. Foot Ankle Int. 1999;20:72–79.
 21
Great-Toe Disorders
Robert B. Anderson, Scott B. Shawen

OUTLINE
Introduction, 390 Sesamoid disorders, 395
Anatomy, 390 Turf-toe, 398
Biomechanics, 391 Dislocations of the Hallux MTP Joint, 406
Specific Entities of the Great Toe, 391 Hyperflexion Injuries of the Hallux MTP Joint, 408
Hallux Rigidus, 391 Conclusion, 408

hallux MTP joint. In the simplest of terms, the motion of the

INTRODUCTION joint consists of rolling, sliding, and compression. More spe-
Injuries to the hallux metatarsophalangeal (MTP) joint are cifically, the morphology of this joint allows for plantarflexion
not uncommon, particularly in the running athlete, and may and dorsiflexion but very limited abduction and adduction. The
result in chronic pain and deformity. Causes of hallux injuries fact that there is more than one center of motion contradicts the
range from soft-tissue disruption to overuse and degeneration. theory of a simple, hinged joint. Instead, the joint is a dynamic
Trainers and physicians may fail to recognize the potential dys- acetabulum or “hammock” as described by Kelikian.3 The joint
function of these injuries, thus providing inadequate care and articulation provides little of the overall stability because of the
protection from further injury. Long-term sequelae of even shallow, glenoid-like cavity of the proximal phalanx. Most of
isolated soft-tissue injury include flexor hallucis longus (FHL) the stability comes instead from the capsular-ligamentous-sesa-
tendon tears, hallux valgus or varus, cock-up deformity with or moid complex, which is described in detail later.
without interphalangeal (IP) joint contracture, and degenera- There are two sets of ligaments that contribute to the stabil-
tive joint disease (DJD), i.e., hallux rigidus. ity of the metatarsal (MT) head as it articulates with the prox-
Clanton and Ford1 found that foot injuries rank third behind imal phalanx: the medial and lateral collateral ligaments and
ankle and knee injuries as the most common time-loss injury the metatarsosesamoid suspensory ligaments.4 The fan-shaped
among university athletes. Of these foot injuries, a large proportion medial collateral ligament is composed of the medial MTP lig-
were sprains of the forefoot and, more specifically, the hallux MTP ament and the medial metatarsosesamoid ligament (Fig. 21.1).
joint. Hunt and colleagues2 demonstrated that the incidence of turf The lateral collateral ligament is structured in a similar fashion.4
toe injures was 0.062 per 1000 athlete exposures, but were 14 times In addition to the collateral ligaments, the strong, fibrous
more likely to occur during games than practice and more com- plantar plate (see Fig. 21.1) also affords structural support. The
mon in running backs and quarterbacks. In the author’s practice, capsular ligamentous complex of the hallux MTP joint, distal to
we have seen a number of professional athletes with a broad range the sesamoids, is actually a confluence of structures including
of injuries to the great toe and base this chapter on our experiences. the plantar plate, collateral ligaments, the flexor hallucis brevis
Great-toe injuries can lead to significant functional disabil- (FHB), the adductor hallucis, and abductor hallucis tendons.
ity, especially when not recognized early. In the short term, This plantar plate is attached firmly to the base of the proximal
these injuries can result in difficulties with push-off strength phalanx and only loosely attached at the MT neck through the
and running. Long-term sequelae typically involve pain due to capsule.5
progressive degeneration. Physicians involved in the treatment The split tendon of the FHB runs along the plantar aspect
of foot and ankle injuries, especially those caring for athletes, of the hallux and envelops the sesamoids before inserting at
must become familiar with the spectrum of injuries about the the base of the proximal phalanx as the capsular-ligamentous
hallux MTP joint, the biomechanical implications, the conser- complex (Fig. 21.1). The two sesamoids are united by a thick,
vative and operative treatments for these injuries, and the late intersesamoid ligament, all of which help to maintain the course
sequelae encountered in these athletes. of the FHL tendon. Adding to the stability of the hallux MTP
joint are three other intrinsic muscles of the great toe. The
extensor hallucis brevis (EHB) originates at the fascia overlying
ANATOMY the sinus tarsi and runs obliquely to attach into the extensor
The provider responsible for the care of athletes with great- mechanism on the dorsum of the MTP joint. It functions pri-
toe injuries must have a keen knowledge of the anatomy of the marily as an extensor of the hallux MTP joint. On the plantar
390
 CHAPTER 21  Great-Toe Disorders 391

Medial capsular The range of motion (ROM) in the normal foot has been
Proximal phalanx ligament
1st metatarsal
studied extensively; it is noted to be highly variable and to
decrease with aging. In the resting position, the first MTP joint
is in a mean resting position of 16 degrees of dorsiflexion. The
passive arc of motion was noted by Joseph to be from 3 to 43
degrees of plantarflexion and from 40 to 100 degrees of dorsi-
flexion.9 The mean passive MTP joint dorsiflexion during push-
off was 84 degrees. One study found that at least 60 degrees of
Plantar plate
dorsiflexion is considered normal in barefoot walking on a level
Metatarsosesamoid
Flexor hallucis surface.10 Athletes may accommodate up to 50% reduction in
brevis MTP joint motion resulting from acute injury to the plantar
ligament Tibial sesamoid
Fig. 21.1  Medial diagrammatic representation of first metatarsophalan- plate or hallux rigidus by various gait adjustments such as foot/
geal joint. (From Adelaar RS, ed: Disorders of the great toe, Rosemont, leg external rotation, shortened stride, and increased ankle,
IL: American Academy of Orthopaedic Surgeons; 1997.) knee, or hip motion.5 In addition, a stiff-soled shoe is capable of
decreasing MTP joint dorsiflexion to 25 to 30 degrees without
significantly affecting gait.10
The effects on the push-off power of the great toe following
sesamoidectomy have been studied in vitro by Aper et al.11 They
confirmed the importance of this seemingly insignificant bone
to the function of the toe, particularly in the athlete, in whom
even a small loss of power will affect overall performance. The
study noted that the isolated excision of the tibial sesamoid
equated to an 11% loss of flexor power, there was 19% loss for a
fibular sesamoidectomy, and 32% when both are excised.11
Fig. 21.2  Twenty percent to 30% of the metatarsal head is removed, • Great toe supports twice the weight of each lesser toe.
as well as the exostosis. (From Coughlin MJ, Mann RA, eds: Surgery of • Hallux dorsiflexion during gait/running is 60 to 84 degrees.
the foot and ankle, 7th ed, St Louis: Mosby-Year Book; 1999.) • Up to 50% reduction in ROM can be accommodated through
gait adjustments such as foot/leg external rotation, shortened
aspect, the abductor and adductor hallucis tendons insert on the stride, and increased ankle, knee, or hip motion.
medial and lateral aspects of the hallux MTP joint, respectively. • Sesamoidectomy: tibial excision results in 11% loss of flexor
These tendons blend into the capsular-ligamentous complex, as power, fibular 19% loss, and 32% when both are excised.
well as the sesamoids, to provide additional structural support
(Fig. 21.2).6 SPECIFIC ENTITIES OF THE GREAT TOE
• Not a simple, hinged joint.
• Most of the stability comes instead from the capsular-liga- Hallux Rigidus
mentous-sesamoid complex. Hallux rigidus is defined as a localized degeneration of the hal-
• Capsular ligamentous complex: plantar plate, collateral lux MTP joint. It was first described as hallux flexus in 1887
ligaments, FHB, adductor hallucis, and abductor hallucis by Davies-Colley.12 In his first description of this condition,
­tendons. he discussed a plantarflexed posture of phalanx relative to MT
• Collateral ligaments have phalangeal and sesamoid inser- head. The actual term “hallux rigidus” was coined by Cotterill
tions. in 1888 and remains the most common term used today.13
• Split tendon of the FHB runs along the plantar aspect of the Numerous papers have theorized the etiology and pathophys-
hallux and envelopes the sesamoids before inserting at the iology of hallux rigidus. One such theory is that of metatarsus
base of the proximal phalanx. elevatus, a term describing the dorsiflexed posture of the first
ray in relationship to the foot and the subsequent plantar-
flexed posture of the hallux. This has been discussed by many
BIOMECHANICS authors, but the most current data indicate that the elevated
The hallux MTP joint lies in an intricate balance of opposing posture of the first MT improves after dorsal decompression
tendons and ligaments. The anatomy outlined previously, espe- of the hallux MTP joint.14–17 Overuse and repetitive dorsi-
cially with regard to the plantar plate, is important when con- flexion forces, such as those occurring in a runner or kicker,
sidering the biomechanical demands placed on the first MTP may lead to chondral lesions and other occult injuries18 or to
joint. During normal gait, the great toe typically supports twice osteochondritis dissecans.3, 19, 20 It also may result as a sequelae
the load of each of the lesser toes and accommodates forces to a turf-toe injury. Anatomic abnormalities that may lead to
reaching 40% to 60% of body weight.6 During athletic activity, hallux rigidus include the flat or pronated foot,16, 21, 22 a long
including jogging and running, the peak forces may approach first MT or hallux,22 and a flat MT head.23 At this time the
two to three times body weight, and the forces increase to eight- true potential etiologies for the development of hallux rigidus
fold when a running jump is performed.7,8 remain in question.
392 SECTION 3  Anatomic Disorders in Sports

Clinical grading from mild to severe (or I, II, and III) has to increase the shoe size to accommodate for it. Taping tech-
been proposed by many authors. Grading depends on the sever- niques can limit dorsiflexion and provide pain relief. Application
ity of disease and is based on ROM, pain or crepitus with motion, is the same as that for turf-toe; however, skin problems such as
the size of the dorsal osteophyte on the MT head, the presence blistering can occur. Steroid injections must be given judiciously
of sesamoid involvement, and the radiographic alignment of and perhaps only for unique/special game situations. Repeated
the hallux (on anterior-posterior [AP] and lateral views). A injections may accelerate the degenerative process.26
radiographic classification scheme was created by Hattrup and Surgery in the management of hallux rigidus is feasible, and
Johnson in 1986.24 Their grade I is considered mild; the joint there are many options. The decision to proceed with surgery
space is maintained and there is minimal spurring. Grade II is requires a lengthy discussion with not only the athlete but the
moderate disease in which the joint space is narrow, bony pro- trainer and possibly the athlete’s agent. It must be emphasized to
liferation is present on the MT head and phalanx, and there is all parties that this is an arthritic process, there is no “cure,” and
subchondral sclerosis and/or cyst formation. Grade III is the there is the potential for a lengthy rehabilitation with incomplete
severe type, with significant joint space narrowing and exten- resolution of the symptoms. The physician must determine the
sive bony proliferation that involves the entire periphery and following: What is causing the problem? Is it the bony promi-
includes loose bodies, a dorsal ossicle, or subchondral cyst for- nence over the MT head and secondary shoewear irritation? Is
mation.24 Easley et  al.33 described the prognostic importance there limited ROM? Are there biomechanical implications such
of midrange crepitance, and thereafter a grading scheme was as poor push-off? Does the athlete suffer from transfer pain
proposed by Coughlin and Shurnas,25 combining objective and issues and other compensatory problems? Lastly, and most con-
subjective clinical data with radiographic findings (Grades 0 cerning, is there the presence of global pain and diffuse arthritis,
to IV). Treatment recommendations are made on the basis of especially in sesamoid-MT articulation?
grade severity. The most commonly performed surgical procedure in the
Symptoms with which the typical athlete may present management of hallux rigidus is a cheilectomy. This procedure
include pain that is worse with push-off and more severe after can be defined in general as an excision of an irregular osse-
increased activity (i.e., twice-a-day practice regimens), as well as ous rim that interferes with motion of a joint. In this particular
swelling. Although there may be bilateral radiographic involve- instance it is the removal of the dorsal osteophyte of the MT
ment, the patient almost always presents with unilateral symp- head. As noted previously, the athlete should be counseled that
toms. Swelling and the bony prominence itself may interfere the underlying condition is DJD and that full symptom relief is
with athletic shoewear (especially in soccer and football, sports not realistic. A cheilectomy may prolong the athletic life of the
in which athletes prefer tightly fitting shoewear). A dysesthesia individual but probably does not slow the rate of joint degen-
in the dorsomedial cutaneous nerve can result from tight shoe- eration. As a general rule, the dorsal ridge does not recur, but
wear’s impinging on the bony prominence. Occasionally trans- progressive narrowing of the joint is expected to occur.
fer lesions and metatarsalgia may develop, secondary to the lack Indications for a cheilectomy include a lateral radiograph
of hallux dorsiflexion, which results in increased pressure on the showing that reasonable space exists in the plantar one-half of
lateral forefoot. the MTP joint. There should be an absence of pain or crepitus
In treating hallux rigidus in the athlete, one must consider with midrange motion and no sesamoid-MT pain or disease.
the sporting activity and position played (i.e., a lineman who This procedure allows for complete relief of dorsal impinge-
requires little hallux MTP dorsiflexion vs. a running back or ment. It increases dorsiflexion by decreasing the bulk of the
wide receiver), shoewear requirement, and ROM of the entire joint and subsequently relieving dorsal impingement pain. It
foot and ankle. Even more minor or early-presenting cases can also eliminates the source of painful shoe pressure. The true
be problematic because some athletes create more forceful dor- advantage of the cheilectomy is that “no bridges are burned,”
siflexion, which can limit the function of the runner and inca- and even in unsuccessful cases a salvage procedure is still tech-
pacitate the dancer. As one seeks to improve the overall motion nically possible.
of the effected joint, it is paramount that the patient understands The technique has been described and popularized by Mann
that if a bad joint is provided more motion, it may degenerate and Clanton.27 Their preference is a dorsal longitudinal incision
more quickly and lead to worsened symptoms. centered over the hallux MTP joint. The joint capsule is incised
Nonoperative treatment options include the use of nonste- on either side of the extensor hallucis longus (EHL) tendon and
roidal antiinflammatory drugs (NSAIDs) and shoewear modi- a complete synovectomy is performed. The joint is plantarflexed
fications. Shoes of adequate size and a more full-fitted toe box to permit inspection of the sesamoid articulation. Hamilton28
or increased depth are helpful and can be modified further recommends mobilizing the sesamoids by blunt dissection,
with a balloon patch over bony prominences. Turf-toe inserts for they often are anchored by adhesions and limit dorsiflex-
(Springlite, Otto Bock, Minneapolis, MN) that limit dorsiflex- ion even after removal of impinging osteophytes. The amount
ion and subsequent dorsal impingement are potentially useful of bone to be removed from the MT head is dictated by the
but may limit performance in the elite runner. Rigid rocker soles size of the dorsal exostosis and the degree of articular cartilage
function in the same manner as semirigid inserts and, although destruction. If degeneration of articular cartilage is not signifi-
helpful in the general population, are not popular with the athlete cant and the main problem is the dorsal exostosis, then 20% to
because of the increased weight and excessive stiffness. Orthotic 30% of the dorsal aspect of the MT head is removed along with
devices can unload the hallux MTP joint, but one must remember the exostosis (Fig. 21.2).
 CHAPTER 21  Great-Toe Disorders 393

It is reasonable to be relatively aggressive with this resec- ROM should be conducted at least three to four times per day.
tion, removing up to one-third of the dorsal head to achieve Close monitoring is required to ensure that the motion within
improved motion. The cheilectomy should include removal of the hallux MTP joint is at a functional level, a minimum of 40
all osteophytes and a rounding of the MT head. The cheilectomy degrees of dorsiflexion. No significant athletic activities gener-
should achieve a minimum of 70 to 80 degrees of dorsiflexion, ally are allowed for 6 to 8 weeks following a cheilectomy, giving
because approximately one-half of this will be lost in the post- the joint time to “mature” following surgery. Athletes can con-
operative period as a result of scar formation. It is Mann’s rec- tinue to train by bicycling, swimming, running in water, and
ommendation that if insufficient dorsiflexion is achieved after engaging in other activities that avoid significant impact against
cheilectomy, then a proximal phalangeal osteotomy (Moberg) the MTP joint. The patient should appreciate that swelling may
should be performed as described later. continue for many months but that maximal motion usually is
We have modified the cheilectomy technique through a achieved by 3 months.
medial approach. This allows for plantar debridement and A number of authors have reported their results of cheilec-
release of plantar capsule and adhesions, thus improving dor- tomy. Mann and Clanton27 found that 22 of 31 patients had
siflexion. In addition, the incision avoids the EHL tendon and complete relief, 6 of 31 achieved considerable relief, and ROM
the potential for tenodesis secondary to scar formation while increased an average of 20 degrees in 23 of 31 feet. Hattrup and
still providing access to lateral osteophytes. We recommend a Johnson31 reported that 53.4% were satisfactory and 27.6%
two-cut technique to avoid excessive resection of the MT head unsatisfactory. Their failure rate increased from 15% with
(Fig. 21.3). The first cut of the saw includes the dorsal exostosis grade I radiographic changes to 37.5% with grade III changes.
and is made flush with the dorsal diaphysis. The subsequent cut They concluded that cheilectomy is the procedure of choice in
removes the amount of articular surface necessary to achieve patients with hallux rigidus and grade I changes. Graves’32 expe-
the desired dorsiflexion while eliminating the risk of excessive rience showed little improvement in motion and stated that sat-
head removal that may jeopardize later arthrodesis. isfaction with cheilectomy was more likely if the patient and the
Hamilton28 describes a “radical cheilectomy,” similar to the physician had reasonable expectations regarding outcome. He
cheilectomy of Mann, but also removing the dorsal portion recommended careful patient selection. Myerson agreed that the
of the base of the proximal phalanx, matching the resection procedure improves pain, not motion. Easley et al.33 reported on
performed on the MT head. This modification serves as an 57 patients (75 feet) with greater than 3-year follow-up (aver-
option for dancers with end-stage disease and is similar to the age 63 months). Their cheilectomy was performed via a medial
Valenti29,30 procedure described later in this chapter. approach by a single surgeon. American Orthopaedic Foot and
A cheilectomy affords a fairly rapid postoperative course and Ankle Society (AOFAS) scores were 45 preoperative, 85 post-
return to activity. The patient is allowed to weight bear imme- operative, and 90% satisfied. The average dorsiflexion improved
diately, typically in a rigid-soled healing sandal. ROM can be from 19 degrees preoperative to 39 degrees postoperative. The
initiated by a therapist or trainer as soon as pain allows but not majority of patients had worsening of radiographic arthritis, but
so aggressively as to create wound dehiscence. Sutures gener- this did not correlate with symptoms. Three patients eventually
ally are removed at 10 days, at which time active and passive required an arthrodesis.
Phalangeal osteotomy has been advocated as a useful sur-
gical adjuvant to a cheilectomy. This technique was first pro-
posed by Bonney and Macnab in 1952.14 Kessel and Bonney20
described its use in 10 adolescents in 1958. Moberg is the name
most commonly associated with the procedure, after his case
series reported in 1979.34 The procedure involves a dorsal clos-
ing wedge osteotomy of the proximal third of the proximal
phalanx. It relies on the principle that the arc of motion of the
hallux MTP joint is translated to plantar aspect of head, thereby
increasing functional motion. Basically, it creates pseudodor-
siflexion, which in turn places less stress on the hallux with
push-off. Adequate plantarflexion of the joint is a prerequisite.
Thomas and Smith35 also found that the procedure appeared
to provide dorsal joint space decompression, as well, further
relieving stress from the arthritic joint (Fig. 21.4).
The indications for performing a Moberg osteotomy on the
proximal phalanx includes grade I or II hallux rigidus, adoles-
cent hallux rigidus, and the running athlete, perhaps regardless
Fig. 21.3  The first cut of the saw includes the dorsal exostosis and is of grade. Most authors now recommend combining the proce-
made flush with the dorsal diaphysis. The subsequent cut removes the dure with a dorsal cheilectomy.33,35,36
amount of articular surface necessary to achieve the desired dorsiflex-
ion while eliminating the risk of excessive head removal that may jeop-
The technique can be performed through a medial or dorsal
ardize later arthrodesis. (From Adelaar RS, ed: Disorders of the great incision, extending distally from the incision used for the chei-
toe, Rosemont, IL: American Academy of Orthopaedic Surgeons; 1997.) lectomy of the hallux MTP joint. It is important to protect the
394 SECTION 3  Anatomic Disorders in Sports

dorsomedial and plantar medial cutaneous nerves to limit par- The postoperative care is similar to that described for an
esthesia and the potential for neuritis or neuroma. Longitudinal isolated cheilectomy. Immediate full weight bearing is permit-
reflection of soft tissues at the proximal third of the phalanx is ted in a hard-soled sandal, with passive dorsiflexion exercises
performed, maintaining capsular insertion. The FHL and EHL begun at 1 to 2 weeks. In ranging the joint it is important to
tendons are protected as a dorsal closing wedge osteotomy is hold the entire toe as single unit. Plantarflexion exercises are
performed with a microsagittal saw approximately 3 to 5 mm delayed until 3 to 4 weeks postoperative. When a pin is present,
distal to the MTP joint. In the adolescent, it is necessary to removal is performed at 4 to 6 weeks, followed by transition to
avoid the physis. Intraoperative fluoroscopy can be useful in accommodative shoes.
confirming proper position of the osteotomy. The plantar cor- Published results of the proximal phalanx osteotomy include
tex is maintained to allow for a “greenstick” effect with manual Moberg’s review of older individuals at short follow-up. Eight
closure of the osteotomy. Generally, 2 to 6 mm of dorsal cor- patients were noted to have satisfactory results. Citron and Neil37
tex should be removed, with the actual amount determined by evaluated 10 feet in eight patients with 22-year follow-up (min-
the degree of joint stiffness and amount of plantarflexion of the imum 10 years) and identified five symptom free, others with
hallux available. The goal is to obtain 20 to 30 degrees of dor- progression of DJD, and one requiring arthrodesis. The average
siflexion relative to the first MT axis. The osteotomy should be postoperative motion was 43 degrees, 22 degrees being dorsi-
stabilized with a suture, K-wire, screw, or staple. If combined flexion, with late loss of plantarflexion noted. Asymptomatic
with a cheilectomy, stable, internal fixation is mandatory to compensatory hallux IP flexion contracture often was present.
allow for the initiation of early motion (Fig. 21.5, A and B). They felt that this osteotomy represented an especially good
option in the adolescent. Thomas and Smith35 performed the
osteotomy with a dorsal cheilectomy in 27 feet, 20 patients. At a
follow-up average of 5.2 years, there was a 100% union rate, the
average dorsiflexion increased 7 degrees, and 96% of patients
were satisfied or satisfied with reservation.
Complications of the Moberg osteotomy include nonunion
or malunion, a problem avoided by using internal fixation and
“greensticking” the plantar cortex to avoid gross instability.
Pre op Injury to the FHL and EHL tendons can occur, as can neuri-
tis or neuroma, although the latter typically is transient. The
Creates a
possibility of progressive arthritis of the hallux MTP joint is an
space outcome that must be discussed with the patient preoperatively.
Decreased push-off power can occur and may be of concern in
the athlete or dancer.
Salvage for advanced degeneration or for a failed cheilec-
tomy or osteotomy includes either arthrodesis or arthroplasty.
Post op Arthrodesis is best avoided in the “sprinting” athlete or dancer.
Fig. 21.4  Space created by dorsiflexion osteotomy of the proximal pha- If an arthrodesis must be performed, the toe tip should be at
lanx. (From Thomas PJ, Smith RWL: Foot Ankle Int. 1999;20:4.) least 10 mm off the ground. Failure to meet this requirement
will place significant stress on the distal hallux and IP joint.
Slight shortening of the hallux also is of benefit, further lessen-
ing the potential of the athlete’s having to “vault” over the hallux
during running activity.
Resection arthroplasty, like that of a Keller, is reserved for
the older individual. Capsular interposition is a modification
of this procedure devised by Hamilton.38,39 In this procedure
the proximal 5 to 10 mm of proximal phalanx is resected, fol-
lowed by transection of the EHB tendon and dorsal capsule.
This dorsal soft-tissue complex then is advanced to the plantar
A Protect FHL
complex. Some authors release the FHB tendon from the base
of the phalanx and suture this to the dorsal capsule. Temporary
pin fixation is not necessary (Fig. 21.6, A and B). Our own expe-
rience with the procedure has noted good relief of pain from
dorsal impingement and joint degeneration but a concerning
loss of push-off strength. Similarly, the Valenti29,30 procedure is
B a salvage technique in which an angled resection on both sides
Fig. 21.5 (A) Dorsal cheilectomy and dorsiflexion osteotomy of the
of the joint is performed, preserving the plantar complex and
proximal phalanx. (B) The amount of correction after fixation. (From overall length. The result is a “hinge” effect at the level of the
Thomas PJ, Smith RWL: Foot Ankle Int. 1999;20:4.) joint (Fig. 21.7).
 CHAPTER 21  Great-Toe Disorders 395

A B
Fig. 21.6 (A) Interposition arthroplasty as described by Hamilton. (B) Pin fixation is not necessary. (From
Hamilton WG, Hubbard CE: Foot Ankle Clin. 2000;5:663.)

however, in our experience it has not provided the expected

outcomes such that we recommend it for the athlete.
Arthroscopic intervention for disorders of the hallux MTP
joint has received some attention over recent years. It has been
shown to be more of a diagnostic modality than a therapeutic
one but may be a reasonable option for the removal of small
Fig. 21.7 Resection of the dorsal metatarsal head as well as dorsal dorsal osteophytes or loose bodies. It also may be used for
proximal phalanx. (From Coughlin MJ, Mann RA, eds: Surgery of the debridement of an osteochondral defect on the MT head but is
foot and ankle, 7th ed, St Louis: Mosby-Year Book; 1999.) not indicated in advanced hallux rigidus. Van Dijk et al.46 per-
formed a prospective study with 24 athletes and found that it
Soft-tissue interpositional arthroplasty of the hallux MTP was not favorable for hallux rigidus because of scar fibrosis.
joint has been performed in those individuals failing a chei- • X-rays: AP and lateral weight-bearing foot.
lectomy but needing to maintain hallux MTP motion. Conical • Multiple etiologies, occult trauma or overuse most common.
resection on both sides of the joint is followed by insertion of a • Large dorsal soft-tissue and/or bony mass.
semitendinosus allograft rolled into an “anchovy.” We have used • Dysesthesia in the dorsomedial cutaneous nerve can result
this technique on a number of young athletic patients, including from tight shoewear impinging on the bony prominence.
two professional football players, with good short-term results. • Nonoperative treatment: NSAIDs, large toe box shoes/bal-
Coughlin and Shurnas40 recently reported on their experience loon expansion, turf-toe plate, rocker bottom shoes.
with this technique in seven patients with excellent results. This • Surgical treatment: Cheilectomy if plantar joint space intact,
case series demonstrates that this is a good surgical option in Moberg phalanx osteotomy for running athletes, resection
patients who otherwise would be treated with MTP arthrodesis. arthroplasty in elderly patients, and interpositional arthro-
Our concern, however, is the amount of bone removed with this plasty for complete joint destruction.
procedure and future implications in regard to arthrodesis. For
this reason we have evolved to a modification of a technique Sesamoid disorders
described by Berlet et al., which employs a “parachute” dermal There are many etiologies for sesamoid pain. The general term
allograft coverage of the MT head and a mini-Keller/Valenti “sesamoiditis” is best considered a term for a symptom rather
resection of the base of the proximal phalanx preserving the than a diagnosis. This term implies pain in the sesamoid region
plantar plate.41 with negative radiographs and an equivocal magnetic reso-
Implant arthroplasty has been advocated by some authors; nance imaging (MRI). It represents a diagnosis of exclusion in
the options described include a silastic double-stem hinge, which soft-tissue ailments such as bursitis or flexor tendinitis
titanium hemiarthroplasty, or total toe replacement. These are considered and often is associated with a history of overuse
implants are unlikely to hold up in the running athlete, and the or trauma.47,48
surgeon is faced with a difficult revision should failure occur. Fracture of the sesamoid, acute or stress, typically involves
It remains our recommendation to avoid this procedure in the the tibial hallux sesamoid because of its larger size and greater
athlete, career or recreational. propensity for weight-bearing forces. The classic radiographic
Because of the suboptimal results with difficult reconstruc- appearance is a transverse fracture line, usually at the midwaist. It
tions following the above implant arthroplasty techniques, a also can occur as the result of an MTP dislocation (Jahss Type II).6
small hydrogel spacer has been recommended for hallux regi- Degenerative etiologies for pain in the sesamoid include
dus grades II, III, or IV.42–45 This implant offers a more simple chondromalacia, osteophytes, impingement, or plantar promi-
conversion to a hallux MTP fusion if it fails than others that nence. These particular problems may occur in an isolated fash-
require extensive resections. Mid-term results are promising; ion or in association with gout.
396 SECTION 3  Anatomic Disorders in Sports

Osteochondrosis has an unknown etiology but often is found Analgesics and antiinflammatory medication are useful adju-
as a late sequela to a crush injury or stress fracture. Avascular vants. A boot or cast is applied for the first week in more severe
necrosis (AVN) also has been described, most often affecting injuries. The cast can include a toe spica extension with the
the fibular hallux sesamoid. Painful fragmentation and cyst joint in mild plantarflexion, removing stress from the plantarly
formation with flattening of the sesamoid can be seen in either positioned sesamoids. Weight bearing is permitted as tolerated.
AVN or osteochondrosis, with radiographic changes following Taping of the hallux, as one would for a turf-toe, provides com-
symptoms by 6 to 12 months. pression and limits movement. This is found to be most helpful
Plantar prominence of a hallux sesamoid can occur with bur- in milder injuries. As the patient or player returns to athletic or
sitis or with an intractable plantar keratosis (IPK). Osteomyelitis recreational activity, orthoses and shoewear modifications are
of the sesamoid can be the result of direct extension from a mandatory. Off-the-shelf products, such as a Springlite turf-toe
neuropathic ulcer or puncture wound but is unusual in the ath- plate (Otto Bock, Minneapolis, MN) made of carbon fiber, in full
lete.49 Tumors of the sesamoid seldom occur but are considered or forefoot lengths, are useful in limiting dorsiflexion stresses.
more likely in the fibular side than the tibial.6 Custom-made devices can be fabricated with a Morton’s exten-
Diagnostic evaluation begins with a complete history of the sion to limit hallux MTP motion. A dancer’s pad, MT pad, or
problem. The typical patient will relate pain localized to the arch support placed just proximal to the symptomatic sesamoid
plantar hallux MTP joint with weight bearing, worsened with will assist in unloading weight-bearing pressures. Furthermore,
sports and stair climbing, and often with no precipitating event. the shoe itself can be stiffened with a plate incorporated into the
The clinical examination identifies the specific location of pain sole. The patient should maintain low heel heights to minimize
and tenderness. Plantarmedial signs relate to disorders of the weight-bearing pressures. Turf shoes are modified by removing
tibial sesamoid, whereas direct plantar tenderness is indica- the cleat under the area of pain. Cortisone and/or anesthetic
tive of fibular sesamoid pathology. In addition, the presence of injections are not advised in any injury. An anesthetic injection
swelling, warmth, and erythema should be documented. Joint alone may be used for localized pain in single-nerve distribu-
motion and stability are assessed, noting restriction of motion tion, but we would not completely anesthetize the toe or joint to
secondary to pain or associated hallux rigidus. Vertical insta- enable an athlete to return to play.
bility may follow a turf-toe or hyperextension injury. Sesamoid Surgeries for disorders of the sesamoid are directed to the
compression that produces pain and grind is consistent with pathology identified. The first problem to consider is the IPK,
metatarsosesamoid arthritis. attributable to the tibial hallux sesamoid. There are instances in
It is mandatory that the radiographic evaluation of sesa- which the plantar aspect of the sesamoid will develop a bony
moid disorders include standing AP and lateral foot views and prominence, or osteophyte, and an overlying distinct callus will
axial or tangential sesamoid views. These views are adequate in arise. This may occur in the presence of fat atrophy, and there
assessing for focal arthrosis, plantar osteophytes, or bony prom- may be an associated bursal component. Failure to improve
inences. The tangential sesamoid view is helpful for identifying with an orthosis to relieve pressure from this area may necessi-
fractures of tibial sesamoid. It is helpful to always place a marker tate surgical decompression. The recommendation is for a plan-
(B-B) on the skin overlying the site of tenderness. This simple tar shaving of the tibial sesamoid via a plantar-medial approach.
maneuver helps to differentiate which sesamoid is symptomatic, The periosteum overlying the sesamoid is reflected and the
or may help correlate a sesamoid location if there is a flexor ten- plantar 50% of the sesamoid is resected with a microsagittal saw.
don problem. The FHL tendon is protected and the joint itself is not entered.
A question that often arises is the differentiation of a frac- The overlying soft tissues then are repaired so that the FHB ten-
ture versus a bipartite sesamoid. A fracture has sharp, irregular don has been maintained in continuity, thus avoiding the risk
borders on both sides of the separation, whereas a bipartite has of instability. The patient is allowed to weight bear to tolerance
smooth, cortical edges and a relatively total size larger than that in the immediate postoperative period in a protective hard-sole
of a single sesamoid. Contralateral AP radiographs may be use- boot or postoperative shoe. Return to regular shoewear and
ful in this differentiation, as there is a reported 90% incidence of activity is expected over the following 6 to 8 weeks as pain and
bilateral occurrence.50 swelling subside.
Further diagnostic studies useful in the evaluation of sesa- Fractures of the sesamoid can occur as acute events or can
moid disorders include MRI, which helps to localize pathology be stress induced. Acute fractures occur as a result of direct
while differentiating between bone and soft-tissue abnormality. trauma, such as a forceful impact to the forefoot region. Because
It further assesses sesamoid viability, joint degeneration, and of its larger size and greater propensity for weight bearing, the
tendon continuity. A readily available tool that is sensitive yet tibial sesamoid is more likely to be involved.50 These fractures
inexpensive is the bone scan. Although there is a reported high generally heal with limitation of weight-bearing forces by use of
rate of false positives, a three-phase study with pinhole images such appliances as a cast (with a toe spica extension), boot, or
helps to identify the problematic sesamoid. Computed tomog- postoperative shoe. There have been anecdotal reports of inter-
raphy (CT) imaging can be performed to delineate the degree of nally fixing these midwaist fractures with small, dual-pitched
metatarsosesamoid arthrosis or to assess fracture healing. screws,51 but this is technically demanding and may not provide
The nonoperative treatment of sesamoid disorders is general significant benefit over traditional treatment methods.
and begins with the principle of rest, ice, compression, elevation Stress fractures of the tibial hallux sesamoid have been noted to
(RICE). Athletic activity and the training regimen are modified. occur in athletes involved in repetitive-impact exercises, such as
 CHAPTER 21  Great-Toe Disorders 397

long-distance running or aerobics. The diagnosis usually is made superior border of the abductor hallucis tendon. By performing
months after the onset of discomfort. By then the fracture likely the excision through an extra-articular approach, the overly-
has progressed to an established nonunion. Failure to improve ing FHB tendon can be repaired. A longitudinal incision and
the situation with orthoses designed to relieve pressure and limit reflection of overlying soft tissues (subperiosteal) allows for full
excessive dorsiflexion through the joint may necessitate surgical exposure of the sesamoid; the bone then can be shelled out cir-
intervention. Bone grafting of these tibial sesamoid nonunions cumferentially with a no. 69 Beaver blade. The defect then is
has been performed successfully in an effort to avoid excision and repaired side to side with absorbable suture (i.e., 4-0 Vicryl).
the subsequent risk of losing push-off strength in the hallux.11 The surgeon must be aware of the proximity to the FHL tendon,
Indications for this bone graft procedure include a mid- protecting this structure during the dissection. Although rarely
waist fracture location with minimal diastasis, preferably 1 performed because of the risk of residual pain, partial sesamoid
to 2 mm. The articular surface of the sesamoid should be free excisions can be considered if there is a small proximal or distal
of disease, and the two parts should not demonstrate gross fragment. The abductor hallucis tendon can be transferred into
motion between them. A plantarmedial incision is centered at large defects created by total excision of bipartite or fractured
the hallux MTP joint. The capsule is incised along the superior sesamoids. This transfer is performed by dissecting the distal
border of the abductor hallucis tendon, and the joint is exam- tendon off the capsule at the base of the proximal phalanx. A
ined. Should there be cartilage damage on the sesamoid or fasciotomy is performed proximally to allow for rerouting of
gross motion between the two halves, then sesamoidectomy is the tendon to the plantar aspect of the joint, where it is sutured
completed. Otherwise, an extra-articular approach to the sesa- into the defect with absorbable material. An adductor hallucis
moid is performed with reflection of overlying periosteum but tenotomy should accompany this abductor transfer to remove
preserving the FHB tendon. The fibrous material of the non- the now unopposed valgus force. A concomitant bunionectomy
union is curettaged back to viable bone surfaces. Care is taken should be considered if significant hallux valgus is present at
to avoid disruption of the overlying articular surface. Through the time of tibial hallux sesamoidectomy, because a progressive
the capsulotomy, a window is made in the medial cortex of the valgus deformity otherwise may develop.55
MT head, and a small amount of cancellous bone is harvested. When performing a fibular hallux sesamoidectomy, the deci-
Alternatively, cancellous bone graft may be acquired through a sion must be made whether to approach from dorsal or plantar
small incision in the lateral calcaneous. This graft is packed into surface. A dorsal approach is difficult unless there is a large inter-
the nonunion defect created, and the overlying soft tissues are metatarsal-angle with lateral subluxation of the sesamoid com-
approximated with absorbable suture. There is no need for inter- plex (i.e., bunion/hallux valgus). A longitudinal first webspace
nal fixation because the two fragments should remain stable. The incision is used in performing a dorsal-based excision. Following
capsulotomy is repaired and the wound closed. Postoperatively, superficial dissection, a laminar spreader placed between
the patient is placed in a posterior splint with the distal portion the MT heads is helpful. This approach requires the release
enveloping the hallux itself. At 2 weeks the sutures are removed of the adductor hallucis tendon and other lateral soft-tissue
and a short-leg cast with a toe spica extension is applied. The structures. The sesamoid is shelled out of the FHB tendon, tak-
patient is allowed to weight bear in such a device after 6 weeks, ing care to avoid the neurovascular structures plantarly.
advancing to a shoe protected with a turf-toe plate at 8 weeks. The plantar-based approach to fibular sesamoidectomy is
A CT scan at 12 weeks should confirm union, and if accom- preferable in that the soft-tissue structures balancing the hal-
plished, running is initiated with continued orthotic protection. lux MTP joint are not disrupted. In this approach, a curvilinear
We previously have reported on this technique in a series of 21 incision is placed over the palpable fibular sesamoid, but just off
patients, 19 of which were successful.52 of the weight-bearing pad of hallux MTP joint itself. It is neces-
Osteochondrosis of the sesamoid may occur with progres- sary to identify and protect the plantarlateral digital nerve (Fig.
sive fragmentation. This process may occur insidiously or as 21.8, A and B). Following the sesamoidectomy, the reflected
the sequela of a stress fracture nonunion48 or osteonecrosis.53,54 periosteum and FHB tendon (lateral head) are repaired. Skin
Subchondral cysts may characterize early stages. Patients will closure must carefully approximate the dermal edges to mini-
present with chronic discomfort worsened by weight-bearing mize hypertrophic scar formation.
activity. Attempts can be made at nonoperative management Postoperatively soft dressings are applied in such a manner
using a period of rest and immobilization followed by orthotic as to maintain plantarflexion and either varus (tibial sesamoid-
management. However, a sesamoidectomy often is necessary in ectomy) or valgus (fibular sesamoidectomy). Weight bearing is
order for a return to recreational activities.48,53,54 allowed in a hard-soled sandal or short walker boot for a tib-
Sesamoidectomy is the only option for the surgical manage- ial sesamoidectomy, whereas nonweight-bearing or heel touch
ment of a number of sesamoid disorders, including osteochon- protection is recommended for a fibular sesamoidectomy per-
drosis, osteomyelitis, advanced degeneration, or the rare tumor. formed through a plantar incision. With the latter, the patient
A tibial hallux sesamoidectomy is achieved through a medial is allowed to begin full weight bearing with the sutures in place
or plantarmedial approach, avoiding the plantarmedial digital at 2 weeks postoperatively. The sutures then are removed 1
nerve. The sesamoid can be excised from within the joint or week thereafter. Removable bunion splints help to maintain the
extra-articularly. As discussed for nonunions of the sesamoid, desired hallux alignment between the second and sixth week.
it often is helpful to assess the articular surfaces before exci- A gradual return to hard-soled shoes follows, using a turf-toe
sion; this can be accomplished by entering the joint along the plate in athletic or training shoes.
398 SECTION 3  Anatomic Disorders in Sports

A B
Fig. 21.8  (A) A curvilinear incision is made just lateral to the fibular sesamoid, just off the weight-bearing pad
of the hallux metatarsophalangeal joint. (B) Care must be taken to identify and protect the plantarlateral digital
nerve. (Drawn by Robert B. Anderson.)

The results of sesamoidectomy have been provided by a • AVN: fibular sesamoid more common.
number of authors. Inge and Ferguson56 reviewed 41 feet, 25 in • Nonoperative treatment: NSAIDs, rest, boot/cast in more
which both sesamoids were excised. Complete pain relief was severe injuries, turf-toe plate, arch support, and/or MT pad.
noted in 42%, whereas partial relief was noted in 82% with sin- • Surgical treatment: varies depending on diagnosis.
gle sesamoid excision and in 64% of those in whom both sesa-
moids were excised. Leventen57 found complete satisfaction in Turf-toe
18 of 23 sesamoidectomies. Mann et  al.58 identified 19 of his Since the term “turf-toe” was first used in the literature by
21 sesamoidectomies “improved,” but only 50% had complete Bowers and Martin61 in 1976, soft-tissue hyperextension inju-
pain relief and 66% had full motion. In this group, 1 of 13 tibial ries to the first MTP joint have received increasing attention
sesamoidectomies developed hallux valgus, 1 of 8 fibular ses- from physicians, trainers, and athletes. Although these inju-
amoidectomies developed hallux varus, and 12 patients devel- ries have been grouped under the general heading of turf-toe,
oped “weakness.” We assessed 12 patients who underwent a they actually represent a spectrum of injuries from the mild to
fibular sesamoidectomy via a plantar approach and identified the severe. In addition to the straight hyperextension injury of
9 who were very satisfied and 2 who were satisfied. In addition, the first MTP joint, we now recognize there are variations that
all would do it again, and 11 of 12 returned to preinjury activity account for injury to specific anatomic structures in the capsu-
level, citing no complications (for example, scar, neuroma).59 lar-ligamentous-sesamoid complex.
Our results with isolated tibial sesamoidectomy were similar, The true incidence of turf-toe injuries is difficult to quantify.
with no loss of overall alignment or perceptible loss of push-off At major universities, these injuries rank number three behind
strength.60 knee and ankle injuries.1, 62 When Coker et al.63 looked at the
Sesamoidectomy is a good procedure that provides reliable Arkansas football players, they found ankle injuries to be four
results. The surgeon and patient must be aware that there is times more common than hallux MTP joint injuries; however,
the potential for biomechanical implications such as the loss of the latter were more severe, accounting for a disproportionate
push-off strength. This is especially important in the running number of missed practices and games. Over a 3-year period,
athlete or elite dancer and must be discussed before intervening 18 of their players had a hallux MTP joint injury, equating to
surgically. six turf-toe injuries per year. At Rice University, over a 14-year
• X-rays: AP and lateral weight-bearing foot, axial/tangential period, the average was 4.5 turf-toe injuries per year and
sesamoid views, skin marker over tenderness, contralateral included all sports.64
views. The mechanism of injury can be direct or indirect and
• MRI: differentiates soft-tissue from bone abnormality. requires a basic knowledge of the mechanics required of the
• Bone scan: high false-positive rate, use three-phase with pin- great toe during athletics. When an athlete rises on the ball of
hole images to isolate problem area. the foot for such activities as initiating a jump, blocking, or run-
• Fractures: tibial sesamoid more common. ning, the hallux MTP joint extends upward of 100 degrees. As
 CHAPTER 21  Great-Toe Disorders 399

the proximal phalanx extends, the sesamoids are drawn distally, relationship by studying the impact of AstroTurf on the West
and the more dorsal portion of the MT head articular surface Virginia University’s football team. They coined the term “turf-
bears most of the load. As this plantar complex attenuates or toe” to describe injuries of the hallux MTP joint capsular-liga-
ruptures, unrestricted dorsiflexion can lead to impaction of mentous complex sustained on artificial turf that previously had
the proximal phalanx on the dorsal articular surface of the MT not been encountered on grass playing surfaces. The AstroTurf
head. This leads to a spectrum of joint injuries from partial tear- was alleged as a causative factor because of the hardness encoun-
ing of the plantar structures to frank dislocation. The typical tered with aging of the surface. However, Clanton and Ford1 and
scenario leading to this injury in the athlete involves an axial others investigated the relationship of turf-toe injuries to aging
load on a foot fixed in equinus. As an impact or force is placed artificial turf and found no significant correlation. In the three
on the heel, the forefoot progresses into dorsiflexion, creating seasons preceding the replacement of the artificial turf in Rice
hyperextension at the hallux MTP joint (Fig. 21.9). Stadium, there were 13 turf-toe injuries, versus 12 injuries in
However, not all turf-toe injuries are purely hyperextension. the three seasons following replacement with a more modern
Numerous variations have been identified. For instance, a val- synthetic playing surface. Nigg and Segesser68 demonstrated an
gus component to the hyperextension of the hallux MTP joint increased incidence of hallux MTP injuries on artificial turf and
results in injury to the plantarmedial ligamentous structures, attributed this to the enhanced friction inherent in the surface.
occasionally to the tibial sesamoid, and the eventual develop- This may account for the forefoot’s becoming fixed to the artifi-
ment of a traumatic bunion with contracture of the lateral struc- cial surface with applied external forces, causing hyperextension
tures (Fig. 21.10). Douglas et al.65 reported the case of a soccer and resulting hallux MTP injury.
player who sustained a hallux MTP joint injury when he was Bowers and Martin,61 as well as Clanton and Ford,1 have
slide-tackled during practice. He continued to complain of joint postulated that the shoe–surface interface most likely is respon-
instability and he failed conservative measures. MRI and oper- sible for these injuries. The majority of injuries are encoun-
ative findings were consistent with a medial collateral ligament tered on artificial turf in athletes wearing flexible, soccer-style
tear, which was repaired. shoes. The abandonment of the traditional grass shoe for the
Like valgus injuries, varus injuries also are rare. Mullis and lighter, more flexible, soccer-style shoe seems to have been a
Miller66 reported on a basketball player with an injury to the hal- major contributing factor in the evolution of the turf-toe prob-
lux MTP joint 3 months before presentation. He had difficulty lem. The trainers and physicians at Rice University could not
with running and was unable to return to sports participation. recall a single instance of a severe MTP joint sprain occurring
On physical examination, he was noted to have significant varus in a football player wearing the traditional grass shoe during the
instability of the hallux MTP joint. Surgical findings included a 25 years before 1986. This is most likely the result of the steel
torn conjoined tendon, lateral capsule, and lateral collateral lig- plate incorporated into the sole of the shoe for the attachment
ament. The plantar structures were noted to be intact. All struc-
tures were repaired primarily, and the conjoined tendon was
fixed to the base of the proximal phalanx through drill holes.
Over the years many theories have been investigated as caus-
ative factors in hallux MTP joint injuries. By far the two most
common etiologic factors mentioned in the literature are the
playing surface and flexibility of footwear. In a study by Rodeo
et  al.,67 80 active professional football players were surveyed,
and of those with a turf-toe injury, 83% sustained the initial
injury on artificial turf. Bowers and Martin61 addressed this

Fig. 21.9  An axial load applied to a foot fixed in equinus. As an impact

or force is placed on the heel, the forefoot progresses into dorsiflexion,
creating hyperextension at the hallux metatarsophalangeal joint. (From Fig. 21.10  Valgus component to the hyperextension causing injury to
Adelaar RS, ed: Disorders of the great toe, Rosemont, IL: American the plantarmedial structures, resulting in a traumatic bunion. (From Wat-
Academy of Orthopaedic Surgeons; 1997.) son TS, Anderson RB, Davis WH: Foot Ankle Clin. 2000;5:693.)
400 SECTION 3  Anatomic Disorders in Sports

of cleats, which has the secondary benefit of limiting forefoot Some authors have suggested that hallux MTP joint ROM
motion.1,69,70 In the study by Rodeo et al.,67 shoe type was not may play a role in turf-toe injuries. Many studies have looked
associated with turf-toe injury in professional football players. specifically at this factor and concluded that there is no rela-
However, the number of players wearing traditional grass cleats tionship between hallux MTP joint ROM and subsequent turf-
in this study was small (15 out of 80) and perhaps influenced toe injury.1,62,67 However, there may exist a relationship between
the outcome. increased ankle ROM and turf-toe injuries. In the study by
Rodeo et  al.,67 players with a turf-toe injury had mean ankle
dorsiflexion of 13.3 degrees, versus 7.9 degrees for uninjured
TABLE 21.1  Classification of Turf-Toe players, a statistically significant difference. It can be postulated
that an increased ankle ROM places the hallux MTP joint at risk
Type of Injury Grade Description for hyperextension injuries. Still other causative factors con-
Hyperextension I Stretching of plantar complex tributing to turf-toe have been suggested. These include player
(turf-toe) Localized tenderness, minimal swelling, no position, weight, age, years of participation, pes planus, hallux
ecchymosis IP DJD, and a flattened first MT head.1,62,67 The data for these
II Partial tear
variables are largely inconclusive, and it is unlikely that any of
Diffuse tenderness, moderate swelling,
these factors play a significant role in the etiology of turf-toe.
ecchymosis, restricted movement with pain
III Frank tear Acute injuries to the hallux MTP joint have been clas-
Severe tenderness to palpation, marked swell- sified into one of three general categories (Table 21.1).71
ing and ecchymosis, limited movement with Hyperextension injuries usually can be differentiated from
pain, (+) vertical Lachman’s if pain allows hyperflexion injuries by history and physical examination. The
Possible associated injuries clinician should recognize that turf-toe constitutes a broad
Medial/lateral injury spectrum of injury with marked variability in the extent of
Sesamoid fracture/bipartite diastasis soft-tissue involvement. To plan treatment and predict return to
Articular cartilage/subchondral bone bruise activity, a clinical classification system has been devised (Table
These may represent spontaneously reduced 21.2). The mechanism for each of these injuries was discussed
dislocations
previously. At the extremes of hyperextension, frank disloca-
Hyperflexion Hyperflexion injury to hallux MTP or inter- tion of the hallux MTP joint can be seen.
(sand toe) phalangeal joint
To determine the extent of the injured structures in the hal-
May also involve injury to additional MTP
lux, the clinician must start by taking a history from the ath-
joints (lesser toes)
lete. An exact determination of the events leading to the injury
Dislocations I Dislocation of the hallux with the sesamoid
should be sought in each case. Reviewing the video of the game
No disruption of the intersesamoid ligament
Frequently irreducible sometimes can aid in determining the mechanism. As with
IIA Associated disruption of intersesamoid most athletic injuries, an examination of the involved extremity
ligament shortly after the injury is ideal. The examination should begin
Usually reducible with observation of the hallux MTP joint for ecchymosis and
IIB Associated transverse fracture of one or swelling, with particular attention paid to the location (Fig.
both of the sesamoids 21.11). Palpation of the dorsal capsule, medial and lateral col-
Usually reducible lateral ligaments, and the plantar structures, including the sesa-
IIC Complete disruption of intersesamoid liga- moid complex, should help the physician to elucidate the injured
ment, fracture of one of the sesamoids structures. The hallux MTP joint then can be placed through an
Usually reducible
ROM and compared with the opposite side. Abnormalities such
MTP, metatarsophalangeal. as a mechanical block, hypermobility resulting from a plantar

TABLE 21.2  Clinical Classification System

Grade Objective Findings Activity Level Treatment
1 Localized plantar or medial tenderness Continued athletic participation Symptomatic
Minimal swelling
No ecchymosis
II More diffuse and intense tenderness Loss of playing time for 3‐14 days Walking boot and crutches as needed
Mild to moderate swelling
Mild to moderate ecchymosis
III Severe and diffuse tenderness Loss of playing time for at least 4–6 weeks Long-term immobilization in boot or cast
Marked swelling versus surgical repair
Moderate to severe ecchymosis
Range of motion painful and limited painful and limited
 CHAPTER 21  Great-Toe Disorders 401

A B
Fig. 21.11  (A) Plantar ecchymosis after injury to the plantar structures. (B) Medial ecchymosis after valgus
injury.

plate tear, or gross instability can be appreciated. Varus and medial or lateral capsular-ligamentous complex. In addition,
valgus stress testing then should be performed and also com- two oblique radiographs may be obtained. Other studies pre-
pared with the contralateral side. A dorsoplantar drawer test viously used in the diagnosis of turf-toe injuries include bone
(Lachman) of the MTP joint will test the integrity of the plantar scintigraphy to rule out stress fractures or arthrography to doc-
capsular-ligamentous complex. Plantarflexion and dorsiflexion ument capsular tears. However, in our experience, MRI best
of the hallux MTP joint against resistance should be performed defines soft-tissue injury and the presence of osseous and artic-
to check the integrity of the flexor and extensor tendons of the ular damage (Fig. 21.13). The use of a 1.5-Tesla MRI scanner (or
hallux. In reality, this detailed examination can be difficult in 3T now if available) with paired 3-inch-round phased array sur-
the acutely injured athlete because of pain. face coils can be used to obtain proton density and T2-weighted
Following clinical evaluation, radiographic analysis is images. These images, obtained in the coronal, axial, and sagit-
mandatory for all hyperextension injuries. In addition to the tal planes, provide anatomic detail of the nature and extent of
soft-tissue disruption, bony abnormalities may include capsular soft-tissue injuries in acute turf-toe injuries.74 We are liberal
avulsions, sesamoid fractures, impaction fractures, diastasis of in performing this test because it assists in grading, identifies
bipartite sesamoids, and proximal migration of the sesamoids. subtle injuries, provides timely decision making, and helps to
Recommended radiographs include a weight-bearing AP and formulate a prognosis.
lateral and a sesamoid axial view. A comparison AP view of the The treatment of all grades of turf-toe injuries in early stages
opposite foot is helpful. Prieskorn et  al.72 found that patients is similar.75 Principles, which apply to most acute sprains of the
with a complete plantar plate rupture had proximal migration musculoskeletal system, apply to the hallux MTP joint as well.
of the sesamoids. The easiest way to evaluate the radiograph is Once the injury is recognized, immediate application of ice
to compare the distal aspect of the sesamoid-to-joint distance with a compressive-type dressing may aid in reducing swelling.
on the affected side with the unaffected side. The difference Taping of the great toe in this acute stage is not recommended
between sides should be within 3.0 mm (tibial) and 2.7 mm (fib- because swelling could lead to compromise of circulation.
ular) 99.7% (3 SD) of the time. Looking at absolute numbers, if Clanton and Ford1 suggest using the RICE formula of rest, ice,
there was greater than 10.4 mm from the distal tip of the tibial compression, and elevation. In addition, an NSAID may be pre-
sesamoid to the joint and greater than 13.3 mm from the distal scribed. In some cases, a walker boot or a short-leg cast with
tip of the fibular sesamoid to the joint, then there was a 99.7% a toe spica in slight plantarflexion may be helpful to alleviate
chance of plantar plate rupture. symptoms during the first week (Fig. 21.14). Early joint motion
In addition to the standard views, special views and studies may begin within 3 to 5 days after initial injury if symptoms
may be indicated, depending on a clinician’s suspicion. Rodeo permit. At this point, a severity grading must be applied so the
et  al.73 have suggested a forced dorsiflexion lateral view (Fig. athlete can be advised regarding prognosis and the time neces-
21.12, A and B), which may delineate joint subluxation, sesa- sary for rehabilitation before a return to competition.76
moid migration, or separation of a bipartite sesamoid. Stress Athletes with a grade I injury usually are able to return to
radiographs may help to define complete disruption of the their sport with little or no loss of playing time. These athletes
402 SECTION 3  Anatomic Disorders in Sports

A B
Fig. 21.12  (A) Normal dorsiflexion lateral. (B) Forced dorsiflexion lateral demonstrating proximal migration of
the sesamoids.

Fig. 21.13  Magnetic resonance imaging notes injury to bones and soft
tissue. (From Watson TS, Anderson RB, Davis WH: Foot Ankle Clin.
2000;5:698.)

may benefit from taping of the great toe, as well as shoewear

modifications. The taping is designed to restrict hyperextension Fig. 21.14  Example of a short-leg walking cast with toe spica extension
of the hallux MTP joint. Another technique used to restrict in slight plantarflexion. (From Watson TS, Anderson RB, Davis WH: Foot
forefoot motion is the placement of an insole that includes a Ankle Clin. 2000;5:699.)
spring carbon-fiber steel plate in the forefoot region of the shoe.
A custom insole with a Morton’s extension may be better suited 60 degrees of painless passive dorsiflexion. However, this return
for the high-performance athlete but generally requires a lon- to athletics is individualized, dependent on the player’s position,
ger shoe with a wider toe box. Factory-made turf-toe shoes are the level of discomfort, and healing potential.
available that restrict forefoot bend, but most running athletes There is a paucity of literature on the surgical management
resist this treatment because of a perceived loss of mobility. of hallux MTP joint injuries. This stems from the general notion
Grade II injuries usually result in loss of playing time ranging that surgical management rarely is indicated in the treatment of
from 3 to 14 days, followed by the same modalities as mentioned this disorder. However, when an athlete fails to respond to con-
previously. The grade III injuries may result in loss of playing servative modalities, the treating physician should be suspicious
time of at least 4 to 6 weeks, often requiring long-term immo- for pathology that requires surgical intervention. Indications for
bilization and examinations weekly. In athletes who experience surgery include a cartilage flap or loose body within the hal-
continued swelling and edema, modalities such as whirlpool lux MTP joint, acute sesamoid fracture, separation of a bipar-
and ultrasound with cold compression may be used as adjuncts tite sesamoid, proximal migration of the sesamoids, evidence
to traditional therapy.77 In general, return to play is dictated of gross instability resulting in persistent pain or synovitis, and
by symptoms, preferably with the athlete demonstrating 50 to hallux rigidus.
 CHAPTER 21  Great-Toe Disorders 403

The study by Rodeo et al.70 revealed that four athletes were In the acute repair and reconstruction of these plantar
noted to have diastasis of a bipartite tibial sesamoid and under- complex injuries, exposure can be obtained through a medial,
went excision of the distal fragment with repair of the capsule. medial and plantar, or J-incision technique. Care is taken to
One of these four athletes underwent acute excision, and the avoid injury to the plantar medial digital nerve as it courses over
other three after failed conservative management. All of these the region at the tibial sesamoid. Plantarflexion of the joint can
players returned to their preinjury level of competition. assist with plantar exposure of the joint. Once the defect has
Our own experience in the repair or reconstruction of been identified in the plantar complex distal to the sesamoids,
hyperextension injuries has been derived from a number of advancement and primary repair can be achieved with nonab-
individuals who had sustained a turf-toe and subsequently sorbable sutures. Typically, sutures are placed into remnants of
were unable to perform athletically at their preinjury level. soft tissue on the base of the proximal phalanx. If found inade-
These athletes often complained of pain with running activ- quate, then suture anchors or drill holes in the plantar lip of the
ity, along with the inability to cut from side to side. Clinical proximal phalanx may be used. Fluoroscopic imaging should
findings included malalignment of the hallux, traumatic and be utilized to confirm proper location of the anchor as exces-
progressive bunion deformity, clawing of the great toe, dimin- sive medial placement may create a supinated toe deformity. On
ished flexor strength, generalized joint synovitis, and advanced rare occasions we have encountered a soft-tissue avulsion off of
degeneration of the joint. Radiographic analysis often showed the distal pole of the tibial sesamoid. In this instance a trans-
proximal migration of one or both sesamoids and cases of verse drill hole is placed and filled with a small nonabsorbable
progressive diastasis of bipartite sesamoids (Fig. 21.15). MRI suture that is used to advance the sesamoid distal to the base
performed confirmed pathology through the plantar complex of the phalanx. Fluoroscopic imaging, with comparison to pre-
of this joint, often associated with injuries to the joint surface operative images of the contralateral foot, ensure restoration of
or FHL tendon. All the cases of proximal sesamoid migration proper sesamoid position.
associated with hyperextension injury have been associated In cases of a progressive diastasis of a bipartite sesamoid, it is
with distal rupture. It appears that the sesamoids rupture dis- our recommendation to preserve one pole of the sesamoid only
tally and migrate proximally because of the preservation of the if that pole represents 75% of the entire sesamoid. Typically, the
flexor tendons, along with the abductor and adductor tendons, distal pole is excised and soft tissues are repaired through drill
and their ability to retract. holes in the remaining proximal pole (Fig. 21.16). Should both
Our surgical experience with this injury has included 12 poles of this sesamoid be fairly equal in size, degenerated or frag-
professional and collegiate athletes. Five surgeries were per- mented, then a complete sesamoidectomy is preferred. An MRI
formed acutely for proximal migration or diastasis of a bipartite may assist in determining the extent of pathology within each
sesamoid, whereas seven were performed for chronic injuries, pole. In these instances where the entire sesamoid is excised,
which included two traumatic bunions and one hallux varus a large soft-tissue defect will result leading to an incompetent
deformity.78 FHB and potential loss of plantar restraints; we recommend that

A B
Fig. 21.15  (A) Anterior-posterior (AP) radiographs of a professional football player following a turf-toe injury.
Note the diastasis of the tibial sesamoid. (B) AP radiograph repeated 1 year later demonstrating progression
of diastasis, which was associated with early clawing of the toe. (From Watson TS, Anderson RB, Davis WH:
Foot Ankle Clin. 2000;5:701.)
404 SECTION 3  Anatomic Disorders in Sports

an abductor hallucis tendon transfer be performed (Fig. 21.17). The reconstruction of the claw toe deformity that occurs as a
As previously mentioned, this transfer will act not only dynam- late sequela to hyperextension injuries is difficult. If the defor-
ically, helping to restore flexion power to the hallux, but also as mity is passively correctable at both the hallux MTP and IP joint
a plantar restraint to dorsiflexion forces. It is accompanied by levels, a flexor-to-extensor tendon transfer can be performed
an adductor hallucis release via a separate dorsal first web space successfully. This transfer can be achieved either by splitting the
incision. flexor tendon and reapproximating dorsally into the extensor
There are situations in which late reconstruction of these hood, as described by Girdlestone-Taylor, or by transferring
injuries is necessary, for example, when the athlete continues directly through a drill hole into the base of the proximal pha-
to perform despite injury or when the injury has been inade- lanx (Fig. 21.18). This is our preferred method as it allows for
quately treated and protected. In these situations, the sesamoids use of an interference screw for secure fixation. Occasionally,
may migrate well proximal, a problem often associated with a claw toe deformity will include a fixed contracture of the IP
hallux valgus, varus, or cock-up deformity. Reconstruction may joint. This situation can be addressed and corrected by perform-
include attempts at distal advancement of the sesamoids with ing a concomitant hallux IP arthrodesis.
soft-tissue reconstruction. This requires significant mobiliza- The postoperative management of athletes undergoing surgi-
tion of the soft tissues proximal to the sesamoids, necessitating cal reconstruction of hyperextension injuries is difficult because
fasciotomies or fractional lengthenings of the FHB and abduc- of the delicate balance between soft-tissue protection and early
tor hallucis muscles. Joint debridement and cheilectomy may ROM. First, it is important to avoid placing the hallux in greater
be necessary in cases of associated synovitis and osteochondral than 10 degrees of plantarflexion, either through surgical recon-
injury. Reconstruction of traumatic bunion deformities necessi- struction techniques or with postoperative external immobiliza-
tates not only reconstruction of the plantar medial soft tissues tion modes. Excessive plantarflexion to this joint may become
but also a release of the lateral soft-tissue contractures. fixed and difficult to compensate for in the running athlete. Our

C B
Fig. 21.16 (A) Avulsion injury with distal fragment excised. Small drill for transverse hole for fixation. (B)
C-arm fluoroscopy of transverse orientation of drill. (C) Permanent suture passed through drill hole in distal
sesamoid.
 CHAPTER 21  Great-Toe Disorders 405

A B

C
Fig. 21.17  Technique of abductor hallucis tendon transfer for reconstruction of hallux metatarsophalangeal
joint. (A) Abductor hallucis tendon dissected from underlying capsule and immobilized proximally. (B) Plantar
defect following sesamoid excision. (C) Transfer of abductor hallucis tendon completed with attachment to
proximal phalanx. (From Watson TS, Anderson RB, Davis WH: Foot Ankle Clin. 2000;5:703.)

protocol includes external immobilization with a toe spica splint had sustained a hyperextension injury. The most commonly
set in approximately 5 to 10 degrees of plantarflexion for a period reported late sequelae were joint stiffness and pain with ath-
of 5–7 days. At that time the athlete initiates protective, passive letic activity. Clanton et al.,64 in their study of 20 athletes with
plantarflexion under the direct guidance of the athletic trainer or turf-toe injury and 5 years of follow-up, noted a 50% incidence
physical therapist. We avoid active and passive dorsiflexion and of persistent symptoms. Other late sequelae include cock-up
active plantarflexion maneuvers. When at rest, the toe is pro- deformity, hallux valgus, hallux rigidus, arthrofibrosis, loose
tected with a bunion splint using a plantar Velcro restraint and bodies, and loss of push-off strength.
a removable posterior splint or cast boot. Nonweight-bearing • Turf-toe constitutes a broad spectrum of injury with marked
ambulation is continued for a period of 4 weeks. ROM of the variability in the extent of soft-tissue involvement.
hallux is increased gradually at that time, along with protected • Hyperextension injury to the plantar capsular-ligamen-
ambulation in a cast boot. At 2 months postoperative, the patient tous-sesamoid complex.
is placed into an accommodative athletic shoe with the protec- • Can have varus or valgus component to injury pattern.
tion of an insole plate that limits dorsiflexion. Active ROM is • Note ecchymosis, hypermobility, and varus/valgus on physi-
instituted, with running by 3 months. At 4 months postoperative, cal examination.
the patient is allowed to return to contact activity with the con- • X-rays: weight-bearing AP and lateral with contralateral
tinued protection of taping techniques and shoewear modifica- views, sesamoid view, forced dorsiflexion lateral with contra-
tions. We have found that it takes approximately 6 to 12 months lateral view. Note sesamoid-to-joint distance.
before the athlete can perform at the preinjury level of function. • MRI: coronal, axial, and sagittal planes. May identify subtle
Late sequelae of turf-toe injuries may occur after conserva- injuries.
tive management or, less commonly, after surgical treatment • Treatment: rest, ice, compression, elevation. Return to activ-
has been rendered. Coker et al.62 reported on nine athletes who ity depends on severity of injury (see Table 21.2).
406 SECTION 3  Anatomic Disorders in Sports

A B

K-Wire for Fixation

C D
Fig. 21.18  (A through D) Technique for reconstruction of a claw-toe deformity that is passively correctable.
(From Watson TS, Anderson RB, Davis WH: Foot Ankle Clin. 2000;5:706.)

• Shoe modifications and/or turf-toe insert to prevent hallux plantar plate, sesamoids, and intersesamoid ligament remain
hyperextension. intact and attached to the phalanx distally. This intact complex
• Surgical indications include a cartilage flap or loose body comes to lie just dorsal to the MT head, with the FHB ten-
within the hallux MTP joint, sesamoid fracture, separation don dorsally translated. A closed reduction in the emergency
of a bipartite sesamoid, proximal migration of the sesamoids, department always should be attempted under local anesthe-
evidence of gross instability resulting in persistent pain or sia. However, this injury typically is irreducible and requires an
synovitis, and hallux rigidus. open reduction of the MTP joint through a dorsal approach.80
If reduction cannot be obtained by reducing the sesamoids
Dislocations of the Hallux MTP Joint with an elevator, release of the adductor tendon and the deep
Frank dislocation of the hallux MTP joint most likely represents transverse MT ligament or intersesamoid ligament may be
the extreme along the spectrum of hyperextension injuries. required.81 If the joint is unstable after reduction, stabilization
Dislocation in the dorsal direction is by far most common, yet with a Kirschner wire is recommended; this can be removed
plantar and lateral dislocations have been described. Jahss clas- after 3 to 4 weeks.81
sified dislocation of the hallux MTP joint into two types.79 Type II injuries are subclassified into types IIA and IIB (Fig.
In the type I dislocation, the MT head buttonholes through 21.19). In type IIA dislocations, the intersesamoid ligament is
the weak capsular tissue proximal to the sesamoids. The distal disrupted and radiographs reveal widening of the space between
 CHAPTER 21  Great-Toe Disorders 407

A C

B D
Fig. 21.19  Dislocations. (A and B) Anterior-posterior (AP) and lateral radiograph of a type IIA hallux metatarso-
phalangeal (MTP) dislocation. (C and D) AP and lateral radiograph of a type IIB hallux MTP dislocation. (From
Watson TS, Anderson RB, Davis WH: Foot Ankle Clin. 2000;5:710.)

sesamoids and dislocation of the MT head into or through the TABLE 21.3  Radiographic Findings in
sesamoid split. Type IIB injuries produce a transverse fracture Hallux Metatarsophalangeal Joint Dislocations
through one (usually tibial) or both sesamoids. In the situation
of a single sesamoid fracture, the proximal fragment remains Dislocation Type Radiographic Findings
aligned with the intact sesamoid, and the distal fragment often I No widening between sesamoids on AP view
becomes a loose body in the joint, usually requiring surgi- IIA Wide separation between sesamoids on AP view
cal removal. In addition to these types described by Jahss,69 IIB Fracture of sesamoid (usually tibial)
Copeland and Kanat82 defined a type IIC that is a combination IIC Combination of type IIA and type IIB
of both IIA and IIB. The type IIC dislocation represents both a
AP, Anterior-posterior.
complete disruption of the intersesamoid ligament and a trans-
verse fracture of either sesamoid (Table 21.3).
Differentiating between type I and type II dislocations is Occasionally, gross instability will follow a type II dislocation,
important because operative intervention typically is required particularly when a fracture of the sesamoid(s) has occurred. In
for type I but not for type II dislocations. The general reduction this instance, the patient will experience pain with push-off and
maneuver is performed by placing gentle distraction with hyper- hallux rigidus type symptoms. A positive drawer sign is elicited,
extension on the MTP joint. If the joint is reducible, it typically is along with signs of generalized synovitis. Surgical correction in
stable and is placed into a cast or hard-soled shoe for 3 to 4 weeks. this setting includes plantar reconstruction to restore a restraint
A postreduction radiograph is required to confirm an anatomic to dorsiflexion forces. Specifically, sesamoidectomy and abduc-
reduction or to rule out the presence of any loose bodies.83 tor hallucis tendon transfer may be indicated. In the case of late
408 SECTION 3  Anatomic Disorders in Sports

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 22
Bunions in the Elite Athlete: The
Philosophy and Principles
Don Baxter

OUTLINE
Introduction, 411 Plan Treatment, 412
Experience, 411 Patient, 413
Philosophy, 411 Hallus Rigidus, 414
The WorkUp, 411 Rehabilitation, 415
X-Ray/Magnetic Resonance Imaging, 412 Outcome, 415

I learned the Chevron bunionectoemy from Ken Johnson at

INTRODUCTION the Mayo clinic in Arizona, later adding an occasional prox-
Sports medicine physicians treat many problems. One import- imal phalanyx osteotomy (Aiken). Bill Hamilton, MD in
ant area is the foot and ankle, with bunions being a common New York taught me about treating ballet dancers’ bunions
complaint. What do you do when an athlete comes to your office conservatively.
and says “My great toe hurts and has developed a prominence”?
This chapter is not an explanation of bunions and all the various
treatments. You can review those treatments in other textbooks
PHILOSOPHY
and articles. The trick to medicine, as I see it, is to first take a complaint, read
everything there is in the literature about that problem, and ask
yourself if the recommended treatments can be improved with
EXPERIENCE better outcomes.
What I want to do is share my experience of treating bunions, My philosophy of foot and ankle surgery of athletes evolved.
as well as secondary and tertiary problems, which develop as It is not the final answer. Your treatments will continue to evolve
a result of bunions. I will also discuss other foot and ankle during the many years of your practice.
problems that support my philosophical approach to bunion
treatment in the elite athlete. I don’t really care to review the
literature, but rather prefer to outline my observations and out-
THE WORKUP
comes of treating many elite athletes. Take a history (see Chapter 1). Find out not only about static
Between 1969 and 1974, all I saw was a bumpectomy, or a problems but more importantly the functional problems.
Keller bunionectomy during my internship and residency. In San What other problems exist? Where is the pain? When does
Francisco I came under the influence of Henri DuVries, MD and it occur?
Roger Mann, MD with a DuVries modification of the McBride Are other problems primary or secondary?
procedure. I was also shown the Lapidus procedure where the Can the problems be corrected with shoe changes, orthoses,
tarso-metatarsal joint was fused along with the soft-tissue bunion or medication or injections?
reconstruction (McBride). Later Mann taught me his proximal Is there a Morton’s foot or hypermobile first ray? Is there
first metatarsal (MT) osteotomy with a McBride procedure. forefoot supination causing a hindfoot valgus?
I came back to Houston, started jogging and running marathons For example, a lateral wedge was placed in a baseball player’s
during the running boom of the 1970s. Some of my friends and I spikes who had genu varus. That year he led the majors in hit-
started a running club in 1975, The Houston Harriers. I became ting, improving his back-foot stability.
the “go to” physician for joggers. I started a fellowship training pro- For example, an Olympic gold medalist in the long jump sent
gram, and with my 35 fellows at University of Texas medical school me a Russian jumper, and friend, who had foot pain. I noticed
and Baylor we started making observations and writing 27 peer he had a forefoot supination and a slight hallux valgus. We
review medical articles, many related to athletic injuries. simply inserted a very lightweight Morton’s extension into his
We looked at heel pain, bunions, Achilles tendon prob- jumping shoe. Not only was the pain eliminated but he jumped
lems, as well as primary, secondary, and tertiary problems. 6 inches further, and almost beat my American friend and gold

411
412 SECTION 3  Anatomic Disorders in Sports

medalist. The gold medalist later told me he did not plan on

such a favorable outcome in his competitor!
In the early days there were one-piece shoes, and I experi-
mented with pieces of felt glued into the insole.
Later, the shoe companies made shoes with removable
insoles so corrections could be made on the removable liner.

X-RAY/MAGNETIC RESONANCE IMAGING

Look at a standing x-ray of the feet. Is the articulation of the
bunion congruous or incongruous, and is the fibular sesamoid
more than 50% uncovered by the 1st MT?
Is the first metatarsal rotated (Fig. 22.1)?
Occasionally, magnetic resonance imaging (MRI) is needed
to review the tendons, ligaments, and articular cartilage. Is there
an intra-osseous stress fracture? What is the status of the sesa-
moids? Is there a volar plate injury?

PLAN TREATMENT
Ask yourself if the bunion is compensated or decompensated
(Figs. 22.2 and 22.3). If the bunion is compensated, such that no
pain occurs with appropriate shoes and orthosis during athletic
activity, then no surgery should be done. The dancer can dance,
the runner run, the jumper jump, and the pitcher pitch. Now if
the bunion is decompensated, with severe pain, unrelieved by
shoes or orthosis, or requires injections to play, then the decom-
pensated bunion must be made compensated. In other words,
restore function. Don’t try to make the anatomy perfect, but
rather restore the function as it was before the decompensation Fig. 22.1  With a decompensated bunion the joint is incongruous, and the
fibular sesamoid is more than 50% uncovered by the first metatarsal head.
occurred.

A B
Fig. 22.2  (A) The compensated bunion has a hallux vulgus that is usually less than 20 degrees and an inter-
metatarsal angle less than 11 degrees. The articular facet is congruous. (B) With a compensated bunion the
articular facet is congruous, and the fibular sesamoid is less than 50% uncovered by the first metatarsal head.
 CHAPTER 22  Bunions in the Elite Athlete: The Philosophy and Principles 413

In the plan, how can that be done without negatively

affecting function? Sometimes restoration of the anatomic
alignment is the enemy of better function, especially in the
elite athlete. Roger Mann in the 2nd edition of this book dis-
cussed at length congruous and incongruous great toe joints
(Fig. 22.4).
Often a congruent joint bunion is not symptomatic. In the
elite athlete, shoewear and lightweight flexible orthoses can be
prescribed, but no surgery should be done.
Roger Mann has recommended, with incongruous, painful
bunions, restoration of the anatomy fully to avoid re-occurrence
(Fig. 22.5). I agree with Roger Mann in the nonelite athlete, but,
as I will describe, I approach the elite athlete differently.

PATIENT
Let me tell you about an elite runner who I saw in 1983. This
young runner had been to two Olympics as a middle-distance
runner. Her foot had a severe bunion that had become decom-
pensated, incongruent, and there was a secondary painful neu-
roma between the second and third MTs. Daily injections of
numbing agents were needed to enable her to run.
I feared that a perfect realignment might adversely affect her
function. So, after discussing with the patient, we decided to
remove the neuroma, and do a chevron procedure on the bun-
ion, making the decompensated incongruent bunion a com-
pensated congruent bunion. Thirty-five years later, the bunion
has progressed. It is unsightly and affects shoewear. The thought Fig. 22.3  The decompensated bunion usually has more than 25 degrees
now becomes that the operation was a failure. Recently, I called hallux valgus and an intermetatarsal angle more than 12 degrees. The
her and asked how she was doing. joint is incongruous.

A B
Fig. 22.4  (A) Radiograph of a congruent metatarsophalangeal joint. There is no lateral subluxation of the prox-
imal phalanx on the metatarsal head. This maintains the function of the plantar aponeurosis and hence the
stability of the foot. (B) An incongruent metatarsophalangeal joint has lateral subluxation of the proximal pha-
lanx on the metatarsal head. This creates an unstable situation, progressive in nature, giving rise to decreased
function of the plantar aponeurosis and increasing instability of the medial longitudinal arch.
414 SECTION 3  Anatomic Disorders in Sports

Fig. 22.5  Preoperative and postoperative radiograph demonstrating correction following a distal soft-tissue
procedure and proximal metatarsal osteotomy.

She said, “my bunion has returned, but there is no pain. I Years ago, I had an American and world record holder
went to two additional Olympics and set an American record in my office. She had a long foot with a slight forefoot supi-
for 10 km on the road after the bunionectomy.” She was totally nation. I suggested a Morton’s extension thinking it might
happy with what I did in 1983. avoid secondary and tertiary problems. Over the years four
In 20 years, I never did a bunionectomy in an active ballet major problems occurred, all from this forefoot supination.
dancer. I have done bunionectomies in dancers after their career The first was a medial insertional achilles tendinosis, which
has been completed. took months to resolve. The second was a medial plantar fas-
There are some philosophical thoughts I have in elite athletes: ciitis, with entrapment of the first branch of the lateral plantar
1) be conservative; 2) be a minimalist; 3) don’t be a perfection- nerve. This required releasing the nerve 2 months before the
ist, but a functionalist; 4) always make the decision regarding olympic trials. She missed qualifying for the national team by
surgery with other experts and the athlete (see Chapter 30); 5) a few hundredths of a second. The third was a stress fracture
each athlete is an outcome study regarding the athletes’ prein- of the fibula a month before the world games. Her coach and I
jury performance and his/her postinjury performance. let her run in a limited manner until the games. With a heal-
My current approach to elite athletes with bunions is to treat ing stress fracture of the fibula, this world-class athlete won
the symptoms conservatively, with shoe changes and orthotic foot the biggest race of her life beating the Russians as they dove
control. This takes care of 85% of bunions that are compensated. for her at the finish. The fourth was the worst, a rupture of the
Fifteen percent become decompensated, so I do either a chevron posterior tibial tendon. Even with repair, her long successful
or occasionally a Chevron-Akin procedure. I have not done a career came to an end. I always wondered if a proper shoe, and
proximal osteotomy or a Lapidus fusion in the active elite athlete. Morton’s extension in the shoe, could have avoided all of these
There is definitely a place for the more definitive bunionec- problems. The most likely problem with a forefoot supination
tomy. There is a current trend to do a derotational fusion of the would be a hallux valgus.
tarso-MT joint. This Lapiplasty procedure perfectly realigns the But everything broke down because of the forefoot supina-
sesamoids and the rotation of the first MT. It perfectly realigns tion except the great toe. I also wonder if making the great toe
the 1–2 MT angle. It is a very good procedure for a severe perfectly aligned, such as with a first tarso-MT fusion, might
bunion. affect other structures such as with this elite athlete.
Jim Nunley, MD feels there is a place for this procedure in the These are all concerns for the next generation of foot surgeons.
elite athlete, but the lapiplasty procedure has not been done in the
elite athlete as of 2018, Lew Shon is concerned that a stress frac-
ture might develop as a result of the biomechanical changes or
HALLUS RIGIDUS
synovitis and arthritis in adjacent joints. David Porter, MD PhD Occasionally, bunions in the elite athlete have a rigid element.
and Bob Anderson, MD do not do fusions in the elite athlete. Restricted dorsiflexion may affect function. One athlete, who
Possibly in our next edition more outcomes may be reported. had won the national cross-country three times, became affected
I feel most problems in elite athletes are biomechanical. The by a rigid, painful hallux rigidus. His bunion was minimal. One
thousands of training miles accentuate and break down the of four of the dorsal first MT was removed. He returned to be a
weakest link. national-level runner, and an olympian.
 CHAPTER 22  Bunions in the Elite Athlete: The Philosophy and Principles 415

athlete surpasses his or her personal best or sets a record, you

REHABILITATION have a great outcome.
All athletes are different as to their rehab. Most are highly moti- That is what the treatment of elite athletes is all about—great
vated. My regimen is to have the athlete stay nonweight bear- outcomes, not perfection!
ing for 2–4 days, use a postop shoe, and start a stationary bike
on the fifth postop day, only using the heel to pedal. Minimal FURTHER READING
resistance is used for 3 days, and then progressive resistance.
Forefoot pressure is not used for 3 weeks on the stationary Coughlin MJ. The chevron procedure. Contemp Orthop.
bike. At 4 weeks a loose athletic shoe may be worn with a toe 1991;23(1):45.
spacer. The toe spacer is worn until 8 weeks postop when easy Coughlin MJ. Hallux valgus in the athlete. Sports Med Arthrosc Rev.
running can be resumed. Unlimited training is resumed at 12 1994;2:326.
Coughlin MJ, Mann RA. Adult hallux valgus. In: Coughlin MJ, Mann
weeks. The hallux rigidus cheilectomy athlete resumes running
RA, Saltzman C, eds. Surgery of the Foot and Ankle. 7th ed. St
by 3 weeks. But some variation is necessary for each athlete Louis: Mosby; 2007; Chap. 6.
depending on symptoms and healing. A lightweight orthosis Johnson K, Cofield R, Morrey B. Chevron osteotomy for hallux val-
is usually prescribed to eliminate any minor biomechanical gus. Clin Orthop. 1979;142:44.
imbalances. Mann RA, Rudicel S, Graves SC. Hallux valgus repair utilizing a distal
soft tissue procedure and proximal metatarsal osteotomy, a long
term follow-up. J Bone Joint Surg. 1992;74:124.
OUTCOME Treace Medical Concepts-lapiplasty Treace Medical Concepts, Inc.
When the runner or jumper returns to his or her preinjury 203 Fort Wade Road, Suite 150 Ponte Vedra, FL 32081 www.treace.
times or heights, a good outcome is achieved. When the elite com/lapiplasty.
 23
Chronic Leg Pain
Adam M. Huff, Jonathan P. Smerek, Peter Edwards, Peter Maurus

OUTLINE
Introduction, 416 Diagnostic Studies, 423
Medial Tibial Stress Syndrome, 416 Treatment, 424
History, 417 Operative, 424
Physical Examination, 417 Nerve Entrapment, 424
Diagnostic Studies, 417 History, 425
Treatment, 417 Physical Examination, 426
Stress Fractures, 418 Diagnostic Studies, 426
History, 419 Treatment, 426
Physical Examination, 419 Operative, 426
Diagnostic Studies, 419 Popliteal Artery and Vein Entrapment Syndrome, 427
Treatment, 420 History, 427
Operative, 421 Physical Examination, 429
Chronic Exertional Compartment Syndrome, 421 Diagnostic Studies, 429
History, 422 Treatment, 429
Physical Examination, 423 Summary, 430

occurring in 12.8%–82.4% of athletes.7 In a previous retrospec-

INTRODUCTION tive study of 150 patients with exercise-induced leg pain, CECS
Orthopaedic surgeons continue to see an increase in the inci- was the most prevalent cause of pain, representing 33% of cases;
dence of sports-related injuries with much of the population stress fractures and MTSS accounted for 25% and 13% of cases,
becoming active in more strenuous activity. Nonspecific com- respectively.6 More recently, however, studies have shown MTSS
plaints of pain in the foot, ankle, calf, or shin are often reported, to be the most common cause of chronic leg pain in the athlete,
with shin pain as the most common presentation.1,2 Evaluation accounting for 13%–22% of injuries in runners and dancers,
of leg pain requires not only knowledge of the anatomy and bio- 35% of injuries in Naval recruits, and 5% of all athletic injuries.8
mechanics of the lower extremity but also an understanding of This chapter focuses on the most common causes of chronic
the pathology of the injury. Conducting a thorough history and leg pain in athletes, including MTSS, stress fractures, CECS,
physical examination and appropriately interpreting diagnostic nerve entrapment, and PAES. The incidence, pathology, clini-
tests are essential to the establishment of an accurate diagnosis. cal presentation, and treatment options are discussed for each
In addition, specific details regarding physical activity, includ- condition.
ing training regimens, surface conditions, and shoewear, must
be determined because these factors also play a significant role
in the diagnosis.
MEDIAL TIBIAL STRESS SYNDROME
Because several etiologies may present with similar charac- “Shin splits” is a nonspecific diagnosis of posteromedial leg pain
teristics, patients must be evaluated for multiple conditions.3 commonly used to describe a wide variety of lower leg pain con-
The differential diagnosis of chronic leg pain includes the fol- ditions, including chronic ECS, fascial hernia, muscle strains,
lowing conditions: bony or soft-tissue tumors, chronic exer- periostitis, and stress fractures.2,3,5,9–11 One of the most com-
tional compartment syndrome (CECS), claudication, isolated mon sites of overuse pain is the distal one-third of the medial
leg trauma, medial tibial stress syndrome (MTSS), muscle border of the tibia.11–14 Because of this, MTSS may be the most
strains, nerve entrapment, popliteal artery entrapment syn- accurate term for this because it describes both the location and
drome (PAES), radiculopathy, referred pain from meniscal the likely pathophysiology of the syndrome.5,13–15
pathology, stress fractures, and tendinitis. Despite this wide MTSS typically is observed in runners and individuals
range of diagnoses, several studies demonstrate that certain involved in jumping activities such as basketball, volleyball,
conditions are more prevalent among athletes, in particular.1,4–6 and dancers.3,10,13,16–18 Both biologic and biomechanical factors
There have been reports in the literature of exertional leg pain have been reported as possible causes of MTSS.12–14 Although
416
 CHAPTER 23  Chronic Leg Pain 417

fractures tend to occur early in an athletic season as stresses

increase rapidly. Early in the development of MTSS, patients
may experience pain at the beginning of a workout or run but
feel a relief of symptoms with continued activity, only to be fol-
lowed by a recurrence of pain either at the conclusion of the
activity or some time afterward. Pain usually is alleviated with
rest and generally does not occur at night. However, as this
condition progresses, pain may occur throughout training or
during low activity, such as walking, and possibly may continue
during rest.

Physical Examination
The pathognomonic physical finding in MTSS is palpable ten-
derness along the posteromedial edge of the distal one-third
of the tibia. In rare cases, erythema or localized swelling over
the medial tibia also may be observed. Although studies have
reported conflicting ranges of motion associated with MTSS,
in theory, hypermobile pronating feet are at increased risk of
MTSS. Therefore evaluation for foot pronation or subtalar varus
A B also is recommended. Abnormal pulse, diffuse swelling, firm
compartments, neurologic deficits, and vibratory pain are not
Fig. 23.1  (A) During running, the medial portion of the soleus contracts
eccentrically as the foot pronates. Hyperpronating athletes, in particular, associated with this syndrome.
are at an increased risk for developing medial tibial stress syndrome
(MTSS). (B) The source of pain is at the origin of the flexor digitorum Diagnostic Studies
longus (FDL) and soleus fascial bridge on the posteromedial aspect of Roentgenograms generally are normal in patients with
the tibia.
MTSS3,9,13,27,34,35 but are recommended to rule out abnormal-
ities associated with other conditions such as stress fractures
the tibialis posterior muscle historically has been implicated and tumors.3,13,14 A three-phase bone scan is warranted to
as the source of this condition,11,18–21 a study of 50 cadaveric rule out stress fractures if a conservative treatment program
legs revealed that the tibial posterior muscle was more lateral, does not alleviate pain. This type of bone scan is a valuable
indicating that this muscle was not a likely source of MTSS.12 diagnostic tool used to differentiate between MTSS and stress
Other studies have identified the soleus, flexor digitorum lon- fractures, because each condition has a distinct scintigraphic
gus (FDL), and crural fascia as sources of the pain, with more pattern.9,11,13,22,27,36,37 A bone scan demonstrating a longitu-
focus on the soleus.12,22,23 Another theory suggests that the pain dinal and diffuse pattern in the distal one-third of the tibia
is due to bony overload of the tibia due to a bending stress pro- is indicative of MTSS (Fig. 23.2).11,13,22,37 In general, only
duced with weight bearing.24–26 delayed images are positive in cases of MTSS, whereas both
During running, heel strike occurs in relative supination, with early and delayed images demonstrate uptake in cases of stress
pronation of the foot increasing until midstance.13,27,28 Because fracture.13,22 In addition, magnetic resonance imaging (MRI)
the soleus is the primary plantarflexor and invertor of the foot, is another diagnostic tool for MTSS. MRI will show periosteal
it has been theorized that the medial portion of this muscle reaction and bony edema with a sensitivity of 78%–89% and
contracts eccentrically as the foot pronates (Fig. 23.1).27 The specificity of 33%–100%. 8
repetitive eccentric contraction that occurs in hyperpronating
athletes may explain the increased incidence of MTSS observed Treatment
in such athletes.5,11,13,23,27,29–32 In addition, hyperpronation is a Conservative
compensatory mechanism that occur in patients with hindfoot The recommended management of MTSS is multimodal,
and forefoot varus,23,28 tibia vara,28 tight Achilles tendon,28,31,32 consisting of rest, nonsteroidal antiinflammatory drugs
and tight gastrocnemius and soleus muscles,28 therefore such (NSAIDs), and ice.3,14 Physical therapy modalities such as
patients also are at increased risk for developing MTSS. Other iontophoresis and ultrasound also may be used.3,14 Initially,
risk factors for MTSS include female sex, increased weight, rest or a decrease in training for 2 to 3 weeks is suggested and
higher navicular drop, previous running injury, and greater hip may be curative without further workup.14 Cardiovascular
external rotation with the hip in flexion.33 conditioning may be maintained during this period with
swimming, upper body weightlifting, and deep-water run-
History ning.13,14 Stationary biking is another option but should be
The most common complaint associated with MTSS is a recur- performed with the heel on the pedal, a precaution that will
ring, dull ache localized over the distal one-third posterome- diminish muscular stress transmission to the leg. NSAIDs
dial cortex of the tibia (Case Study 23.1). MTSS tends to occur often are prescribed to relieve pain13,14 and to decrease possi-
late in the sport season after prolonged activity, whereas stress ble inflammation. Ice may be used to further reduce swelling
418 SECTION 3  Anatomic Disorders in Sports

PEARL
MTSS pain actually may subside during workout but will recur following ces-
sation of activity. Conversely, pain associated with chronic ECS and PAES does
not subside during activity and tends to remain until activity is completed.
Pain is localized to the distal one third of the tibia in MTSS but is usually
more proximal in the typical stress fracture.

CASE STUDY 23.1 

A 16-year-old female cross-country runner presented for evaluation of pro-
gressive right leg pain. Over the preceding 3 weeks, training intensity had
been increased in preparation for a season-ending tournament. During that
time, increasing pain developed over the distal medial leg. Initially, pain was
present only at the conclusion of training but progressed to include soreness
on first arising in the morning and with daily activities, forcing the patient to
decrease training. She denied constitutional symptoms, history of trauma, or
recent shoewear change.
Physical examination was remarkable only for tenderness along the pos-
teromedial cortex of the distal one-third of the tibia. Plain radiographs were
normal. On the basis of a clinical diagnosis of MTSS, conservative treatment,
Fig. 23.2  Classic bone scan demonstrating the increased linear uptake consisting of cessation of training for 2 weeks, NSAIDs, and ice, was recom-
along the posteromedial aspect of the tibia in the delayed phase indica- mended. At the 2-week follow-up, only minor improvement had been achieved
tive of medial tibial stress syndrome (MTSS). The linear uptake is most and the patient remained in significant pain. Consequently, a range-of-motion
commonly observed in the distal one third of the leg; however, in this boot was implemented and a bone scan was ordered to rule out a possible
specific case, the location is slightly more proximal. stress fracture. Because the bone scan was negative, as indicated by a diffuse
uptake in the delayed phase, the patient remained in the range-of-motion boot
for an additional 4 weeks. After this period, activities of daily living were con-
ducted without pain, permitting a gradual return to training over the ensuing
and inflammation.14,36 Addressing biomechanical abnormali-
6 weeks.
ties is also recommended.14,38,39 For example, excessive prona-
tion may be corrected with the use of custom or off-the-shelf
orthotics.38 Physical therapy modalities including massage,
electrical stimulation, iontophoresis, ultrasound, and kinesio
STRESS FRACTURES
taping have also been used.12,36,40,41 A combination a home Repetitive loading caused by overuse or overloading of the lower
training program with extra-corporeal shock wave therapy leg results in microtrauma to the bone that eventually may lead
has also been shown to be more effective than a home train- to stress fracture.6,40,44–46 Stress fractures of the tibia are more
ing program alone.42 If pain is present with walking or at rest, frequent3,13,44,47–51 and more problematic to treat than those of
range-of-motion boots and/or walkers are used. In rare cases, the fibula. Fibula stress fractures tend to heal more rapidly and
crutches may be necessary. generally do not require adjunctive therapy.48,50 Therefore, this
If the patient has not experienced pain during conserva- section will focus on tibial stress fractures.
tive treatment, a gradual return to training may be initiated. Athletes are particularly prone to stress fractures of the
Warm-up and cool-down routines, including stretching, are leg, and specific stress fractures are related to certain types of
advised with each workout to prevent recurrence of symp- activities. For example, the more common posteromedial stress
toms. If the patient remains asymptomatic, progression of fracture usually is associated with running activities.13,40,52
training is recommended at increments of 10% to 25% for 3 Conversely, midanterior tibial cortex stress fractures often are
to 6 weeks.13 If symptoms return, activity should cease for at associated with dancers and athletes involved in cutting and
least 2 weeks before training is resumed at a lower intensity jumping activities.40,45,53–57
and duration. Risk factors for developing a stress fracture include exces-
sive training, training errors, biomechanical variants, and
Operative menstrual irregularities with corresponding changes in bone
Fasciotomies of the posterior compartments of the tibia density.11,13,47,49,52,58,59 Excessive training, particularly common
are possible treatment options in patients with intractable early in the athlete’s season, causes overuse or overloading,
MTSS.6,13,29,39,43 In these rare cases, fasciotomies may alle- which may result in stress fracture.6,40,52 In addition, overlap-
viate the pull of the soleus and deep compartment muscles ping of sport seasons, which often occurs when teenage athletes
on the corresponding fascial insertions.6,13,29,39,43 However, participate in multiple sports, also may lead to an overuse sce-
conservative management alone has been successful in nario. Training errors, including changes in training surface,
treating MTSS cases, eliminating the need for surgical shoewear, and technique, often result in overloading, which may
intervention. result in stress fracture.6,40,44 Weather and seasonal differences
 CHAPTER 23  Chronic Leg Pain 419

affect surface conditions for many outdoor sport activities and Joint range of motion usually is normal, but gait analysis may
may increase the risk of stress fracture. For example, dry condi- reveal biomechanical risk factors. Neurovascular examination
tions and the fall season are both associated with hard ground typically is normal in the absence of any associated abnormal-
surfaces, which result in an overloading environment for soccer ities. Palpation will reveal tenderness localized to the fracture
players. Simple measures, such as watering soccer fields when site. In addition, erythema or localized swelling also may be
the ground is hard, may reduce the risk of stress fracture and noted. An ultrasound or a tuning fork will produce vibratory
other injuries by minimizing loading conditions. Biomechanical pain over the site of the stress fracture. Hopping on one foot
factors, such as cavus feet, leg-length inequality, and muscular may also reproduce pain. In long-standing fractures, a palpable
imbalance, also may increase the risk of developing a stress frac- bony thickening may be present.
ture.11,13,47,51 Finally, the female athletic triad of amenorhea,
disordered eating, and low bone mineral density have been asso- Diagnostic Studies
ciated with an increased incidence of stress fractures.46,47,49,58 A clinical diagnosis of stress fracture often may be made
The cause of stress fractures is multifactorial in nature and solely on the basis of the history and physical examina-
often results from an imbalance of natural bone formation and tion,44,59 but diagnostic imaging may confirm the diagnosis
resorption cycle because of repetitive loading.44,51,54,59 One the- or assist in identifying the stress fracture in questionable
ory proposed to explain the mechanism of stress fracture sug- cases. Plain radiographs should be performed as the first
gests that muscle fatigue results in the transmission of excessive imaging step but may be negative, because radiographic
forces to the underlying bone, ultimately leading to stress frac- abnormalities often are not observed until 2 to 3 weeks after
ture.15,44,51,54,58 Another hypothesis asserts that simple, repet- the onset of symptoms and may not appear at all if activity
itive weight bearing leads to a concentrated rhythmic muscle modification has been performed.3,44,51,52,61 Radiographic
action, which causes excessive transmission of forces beyond abnormalities may appear as a faint periosteal reaction, a
the threshold of bone, thereby resulting in fracture.15,44,51,54,60 fluffy area of callus, or a cortical lucency.46 If radiographic
Forces from large posterior muscle groups, in particular, may examination demonstrates the presence of a stress fracture,
cause increased tension on the anterior cortex of the tibia, no further imaging is necessary.
possibly leading to the problematic midanterior tibial stress A three-phase bone scan is indicated when suspicion of
fracture.54 stress fracture remains despite negative radiographs.46,52 The
specific scintigraphic pattern of a stress fracture demonstrates
History focal uptake in the area of fracture (Fig. 23.3).44,62 MRI, another
Pain associated with tibial stress fractures is typically more prox- diagnostic option, differentiates among fracture, tumor, and
imal than that caused by MTSS (Case Study 23.2). Although infection and also localizes the pathology.36,51,52,59,63 An MRI
pain is normally localized to the fracture site, diffuse pain also also is useful in differentiating between longitudinal stress
may occur. Stress fracture pain will develop gradually, occur- fractures and MTSS, the more commonly observed overuse
ring initially as a mild ache following a specific amount of exer- injury, because bone scans of these conditions demonstrate
cise and then subsiding. As the condition progresses, pain may identical diffuse uptake in the distal one third of the tibia
become severe and occur during earlier stages of exercise and (Case Study 23.3).64–66
after cessation of activity. In rare cases, night pain also is possi- In addition to its diagnostic capabilities, imaging also assists
ble. Any complaints of constitutional symptoms, including fever in differentiating among the various types of stress fractures. For
and fatigue, should raise concern of a possible tumor or infec-
tious process.
In addition to obtaining a history of pain and symptoms,
training and activity also should be investigated to identify pos-
sible errors that may increase the risk of stress fracture. Recent
changes in activity level, such as increased quantity or intensity
of training, modifications in training surface, shoewear alter-
ations, and technique should be noted. Inquiries regarding diet
also should be conducted because the presence of eating disor-
ders increases the risk for stress fracture. Furthermore, obtaining
menstrual histories of female athletes also is pertinent because
oligomenorrhea and delayed menarche both increase the risk of
stress fracture. Finally, a review of systems is suggested to assess
general health, medications, and personal habits to identify any
additional factors possibly influencing bone health.

Physical Examination
On gross physical examination, the leg will appear normal.
Compartments should be soft and the posteromedial aspect of Fig. 23.3  Bilateral bone scan demonstrating normal scintigraphy (left)
the middle to distal one-third of the tibia should not be tender. versus the focal uptake pattern of a typical tibial stress fracture (right).
420 SECTION 3  Anatomic Disorders in Sports

example, radiographs depicting a small lucency or a “dreaded In addition to rest, treatment should emphasize the impor-
black line” in the midanterior cortex of the tibia are indicative tance of modifying intrinsic risk factors to prevent future
of a midanterior cortex tibial stress fracture (Fig. 23.4, A).40,52 injury. This includes drawing lab work such as serum calcium,
Because of the relatively avascular nature of this portion of the albumin, alkaline phosphatase, and serum vitamin D levels.
tibia, a bone scan initially may be interpreted as negative, but Hormone levels should be drawn for patients with a history
closer examination will depict an area of decreased uptake at of hormonal imbalances or endocrinopathies.69 Contributing
the fracture site.52,57 If this type of fracture is not initially diag- factors, such as training errors, improper shoewear, and mus-
nosed and treated, a complete fracture may result. Conversely, cle imbalances that were identified in the history and phys-
plain radiographs of longitudinal tibial stress fractures often are ical examination, also must be addressed.6,46,51,70 Training
normal, whereas bone scans will demonstrate increased uptake regimens should be individualized for each patient including
in the lower tibia.67 examination of shoes for signs of wear and inadequate sup-
port. Shoes should be replaced every 500 km and, if necessary,
Treatment appropriate orthotics should be implemented.45,52 Treatment
Conservative plans for athletes with eating disorders or females with men-
Conservative treatment for stress fracture is focused on pain strual irregularities should involve dietary counseling and/or
relief and protection from further injury.46,52 Improvement estrogen replacement therapy to accelerate healing and to pre-
in muscular strength and endurance, continuation of cardio- vent future problems.44,52,71
vascular fitness, and management of biomechanical factors Use of pharmacologic agents in the treatment of stress
also are important. Relative rest, possibly with weight-bearing fractures. Teriparatide and other bisphosphonates are
restriction, is recommended for a minimum of 2 to 4 weeks. pharmacologic agents that increase bone formation in the
Cardiovascular fitness should be maintained with cycling, early stages of fracture healing, increase bone mass, and
swimming, deep-water running, or other nonloading activi- decrease the risk of fractures in osteoporotic bone. It has
ties.46,51,52,62 Upper body strength training is recommended to been approved for treatment of osteoporosis only, and there
maintain muscle mass and is not likely to jeopardize fracture has been frequent anecdotal cases of physicians using the
healing.51 Bracing or casting may be required for 3 to 12 weeks medication off-label for treatment of chronic tibial stress
to immobilize the fracture adequately in severe cases or if pain fractures and nonunion.
is not relieved after the initial 2- to 4-week rest period.38,68 Animal models and basic science research seem to support
Because prompt return to activity is a priority for elite athletes, the use of pharmacologic intervention. Significant improve-
electrical stimulation is highly recommended. Electrical stim- ments in callus volume, callus mineralization, bone mineral
ulation also has been effective in healing traumatic fracture content, strength and rate of successful union at the fracture
nonunions.40,52–54 site in both normal and delayed healing models has been

A B C D
Fig. 23.4  (A and B) Preoperative radiographs of a male runner who presented with a midanterior cortex
tibial stress fracture, also referred to as a “dreaded black line” which is visible in the lateral radiograph (B).
(C and D) Because of the severity of the fracture, intramedullary nailing was required. As demonstrated in
the 2-month postoperative radiographs, the fracture healed completely without the need for bone grafting.
 CHAPTER 23  Chronic Leg Pain 421

demonstrated.148 Unfortunately, clinical studies are sparse. CASE STUDY 23.2 

Aspenberg et al. found no significant statistical difference when
teriparatide was compared to placebo in normal healing of dis- A 16-year-old female soccer player related a 3-week history of anterior tib-
tal radius fractures.72 ial pain localized approximately 7 cm below the tibial tubercle. Initially, pain
was mild and occurred only with prolonged training. When the patient contin-
Various small clinical series have shown some benefit in
ued her training intensity, the pain progressed to the point at which training
the treatment of fracture nonunion, but unfortunately no
became difficult and persisted with daily activities; however, the patient did
studies have demonstrated accelerated healing in human not seek treatment at this time. Before her final game, the patient stated that
subjects with tibial stress fractures. The literature is replete her pain was so severe she was unsure whether she should/could continue
only with anecdotal use of the medication to assist in healing to play. Despite constant pain, the patient competed in the final game and
fracture union. Therefore, at this time, no definitive clinical experienced a noncontact tibial fracture while running.
evidence can support pharmacologic management of tibial Roentgenograms confirmed the presence of a tibial fracture with an intact
stress fractures.73–75 fibular that was located at the anterior tibial cortex approximately 7 cm below
Return to activity should be gradual and individualized the tibial tubercle, corresponding to the site of a presumed existing stress frac-
according to symptoms, with an emphasis on progress only ture. Conservative treatment was recommended and involved long-leg casting
when activity is accomplished without pain.51,52 It must be for 3 months. Because of minimal bone healing, determined by radiographic
evaluation, long-leg casting continued and pulsed electromagnetic stimulation
stressed that activity should cease if any pain occurs and should
was added for 1 month. Following the use of the long-leg cast, a long-leg
not be reattempted until the pain is alleviated.52,62 In addition,
fracture brace was used with continued pulsed electromagnetic stimulation.
once the pain is alleviated, the patient must return to the lower-­ After 6 months of conservative treatment, aching continued at the fracture
loading activity and not advance until each successive activ- site on weight-bearing ambulation. Subsequent plain radiographs and com-
ity has been accomplished without pain. A period of rest also puted tomography (CT) scan indicated small areas of spot weld healing but a
must be implemented between activities before advancing to largely inadequate bridging callus. Consequently, operative treatment involv-
a higher-loading activity. Although athletes may resume full ing reamed intermedullary nailing of the tibia without fibular osteotomy was
training in 8 to 16 weeks, patients must be aware that a pro- performed. Approximately 4 months following surgery the fracture was com-
longed recovery period may be required for more severe stress pletely healed, and by 8 months postsurgery the patient returned to playing
fractures.54,57 Midanterior cortex tibial stress fractures, in par- soccer.
ticular, require a significant period of rehabilitation.3,45,52–54,62
Despite this prolonged rehabilitation, conservative treatment
is similar to that for other tibial stress fractures and includes CASE STUDY 23.3 
avoidance of activity, bracing or casting, and possible electrical
A 47-year-old woman who regularly walks for cardiovascular fitness presented
stimulation.52,54,57
with complaints of left lower leg pain. The patient described a “deep-aching”
pain in the lower one-third of her leg. Over the past 3 months, pain increased
Operative
with continuation of the patient’s walking program and began to occur at
Although most stress fractures heal successfully with con- night, eventually resulting in limitation of activity. Her medical history was
servative treatment, surgery may be warranted for severe significant for osteoporosis and systemic lupus erythematosus, which was
stress fractures, such as midanterior or longitudinal tib- treated with multiple medications.
ial stress fractures, or for chronic nonunions of proximal Neurovascular and physical examinations were grossly normal. No swell-
medial stress fractures.45,53,54,57 Intramedullary nailing has ing was observed, but palpation revealed mild tenderness along the distal
yielded promising results in high-demand patients with tibia. Plain radiographs did not reveal the presence of a fracture or periosteal
problematic stress fractures.45,53,54,57 Our experience with reaction. An MRI was ordered to differentiate between the suspected lon-
intramedullary nailing also has been positive and involves gitudinal stress fracture and possible MTSS and subsequently demonstrated
a longitudinal stress fracture in the tibial metaphysis with surrounding bone
the treatment of three midanterior tibial stress fractures, all
edema (Fig. 23.5). Conservative treatment involving a range-of-motion boot
of which healed completely without the need for bone graft-
and nonweight-bearing ambulation was recommended. Six weeks following
ing (Fig. 23.4, B). treatment, plain radiographs demonstrated a slight callus formation, indica-
tive of the healing process. As a result, the patient was instructed to prog-
ress from partial to full weight-bearing ambulation over a 4-week period. Full
weight-bearing ambulation in a range-of-motion boot continued for an addi-
PEARL tional 4 weeks, with subsequent introduction of a regular shoe. At 4½ months,
Vibration from a tuning fork or ultrasound will produce pain corresponding to the patient resumed her walking program with a gradual increase in mileage.
the stress fracture site but will not elicit pain in cases of MTSS or chronic ECS.
If a stress fracture is suspected on the basis of the history and physical
examination despite negative plain radiographs, additional imaging, such as a CHRONIC EXERTIONAL COMPARTMENT
three-phase bone scan, is recommended to confirm the diagnosis.
Pain and swelling in the subcutaneous border of the tibia is indicative of a SYNDROME
midanterior tibial stress fracture, which requires careful radiographic evalua- Compartment syndrome of the lower leg generally is charac-
tion to confirm the presence of the subtle “dreaded black line.” If diagnosis
terized by severe intracompartmental swelling that impairs
remains questionable, a three-phase bone scan demonstrating a focal area
neuromuscular function within the involved compartment
of decreased uptake in the anterior tibial cortex will confirm the diagnosis.
which produces pain.76,77 This syndrome is classified into
422 SECTION 3  Anatomic Disorders in Sports

Anterior compartment

Deep peroneal nerve Tibia

Superficial peroneal
nerve

Saphenous
nerve
Fibula

Lateral
compartment

Tibial nerve
Deep posterior
compartment

Superficial posterior compartment

Fig. 23.6  Cross-sectional view demonstrating the compartments of the
lower leg and associated anatomy.

Fig. 23.5  Magnetic resonance imaging portraying the longitudinal sig- pressures may remain abnormally high for 20 minutes or longer
nal change in the distal tibia typical of a longitudinal tibial stress fracture. after exercise before returning to normal.78,91,96
Several theories have been proposed to explain tissue isch-
two forms: acute, the more severe form requiring immediate emia, the main symptom of chronic ECS. The first theory
surgical intervention; and chronic.76,78–86 Acute compart- suggests that increased compartmental pressure during exer-
ment syndrome, commonly caused by trauma, occurs when cise causes arterial spasm, which results in decreased arterial
intracompartmental pressure is elevated to such a degree inflow.88,97 An alternative hypothesis asserts that transmural
that immediate decompression is necessary to prevent intra- pressure disturbances produce arteriolar or venous collapse,
compartmental necrosis.76,78,79,83 Conversely, chronic ECS which subsequently leads to ischemia.88,97–99 Finally, and per-
develops when exercise sufficiently raises intracompart- haps more pertinent to athletes, venous obstruction recently has
mental pressure to produce small vessel compromise, which been advocated as a possible cause of tissue ischemia.78,79,83,88
subsequently causes ischemia and pain,80,82,87 but not to the According to this theory, eccentric exercise results in myofiber
degree exhibited in the acute form.76, 79 Athletes exhibiting damage, which causes release of protein-bound ions into the
chronic ECS who continue or increase training are at greater compartment. Such repetitive eccentric contractions therefore
risk of developing acute compartment syndrome.79,81,85 cause not only an increase in ion concentration within the com-
Chronic ECS often presents in bilateral form in young ath- partment but also a subsequent increase in osmotic pressure.
letes with equal incidence in males and females and typically This resulting arteriovenous gradient, in which venous pressure
is observed in runners or participants in sports involving ball is increased and arterial blood flow is decreased, consequently
or puck.3,10, 77,88–90 Anterior chronic ECS is more common leads to tissue ischemia.78,79,83,88 The association between repet-
than the lateral and posterior forms of this syndrome (Fig. itive eccentric contraction in the anterior compartment of run-
23.6).3,10,35,77,80,88,90–92 Although symptoms of chronic ECS, ners and the increased incidence of chronic ECS in the anterior
such as pain, muscle weakness, numbness, and swelling, are compartment lends support to this theory.77,79,80,88,90,91,100,101
general, the onset and subsidence patterns are specific to the
condition.78–80,88 Symptoms resolve after activity is discon- History
tinued but generally return at the same interval or intensity Patients experiencing chronic ECS may complain of cramp-
at the next training session.3,10 ing, burning, or pain over the involved compartment(s) with
Although the etiology of chronic ECS is not as well under- exercise (Case Study 23.4). Pain associated with anterior
stood as that of the acute form, raised intracompartmental chronic ECS may not be limited to the compartment but
pressure resulting in relative ischemia of the involved mus- also may radiate to the ankle and foot. The most character-
cles is likely the pathophysiologic mechanism producing this istic symptom of chronic ECS is pain occurring at a fixed
condition.1,77,83,84,88,89,93 Repeated muscle contractions during point in the patient activity. The pain will become progres-
exercise cause an increase in muscle volume by as much as sive with continued exercise or increased intensity but often
20% because of fiber swelling and increased intracompart- will dissipate or cease with rest, usually within 20 minutes of
mental blood volume.76,79,80, 88,92 The resulting increase in completion of activity. Although this pattern of pain relief
compartmental pressures is transient and typically will normal- is observed in the majority of athletes with chronic ECS,
ize within 5 minutes of completing exercise in asymptomatic it is not unusual for pain to ensue for a longer period. In
people.80,90,94,95 In chronic ECS, however, intracompartmental extreme cases, pain may be constant. In addition, patients
 CHAPTER 23  Chronic Leg Pain 423

with anterior and deep posterior compartment syndromes be obtained to eliminate MTSS and stress fracture diagnoses.
occasionally describe paresthesia in the dorsum of the foot Electrophysiologic testing generally is not necessary but may be
or in the instep, respectively. In severe cases, transient foot- beneficial in documenting the extent of motor loss in patients
drop may occur. with footdrop. An MRI/MRA is recommended only when
symptoms are accompanied by a visible or palpable mass in the
Physical Examination leg or when clinical evidence suggests possible popliteal artery
Results of physical and neurocirculatory examinations in compression.
patients exhibiting chronic ECS are normal before exercise. The most useful diagnostic tool to confirm chronic ECS
Because pre-exercise examinations may not yield insight into is compartmental pressure testing.3,15,101 Although many
the condition, examinations also must be conducted after the authors advocate performing pressure tests before, during,
patient has performed the exercise that initiates the symptoms. and after exercise,15,79,93,95,102–108 we prefer pre-exercise and
Following exercise, a sensation of increased fullness, swelling, postexercise testing only and do not recommend that mea-
tension, or increased leg girth may be produced in the involved surements be obtained during exercise because of techni-
compartments. The leg also may be tender over the involved cal difficulties and the unreliability of measurements. The
muscles. This diffuse muscular tenderness must be distin- side ported needle technique, involves the injection of small
guished from that associated with superficial nerve entrapment, amounts of normal saline into the compartments using an
which usually is focal at the site of entrapment. In cases of severe 18-gauge needle and a handheld compartmental measure-
chronic ECS, muscle weakness and paresthesia to a light touch ment device (Fig. 23.7, A). Patients are placed in a supine
may be observed. Pulses, however, will remain normal in all position with the knee extended and the ankle in neutral
cases of chronic ECS. dorsiflexion (Fig. 23.7, B). The needle tip location and
depth of penetration must be controlled to obtain reliable
Diagnostic Studies measurements.103 Pressure measurements are taken before
In addition to physical examination, diagnostic testing, such as exercise and at 1 minute and 5 minutes following exercise.
radiographs, bone scans, electrophysiologic testing, and MRI/ If 5-minute measurements are borderline, 15-minute com-
magnetic resonance angiography (MRA), may assist in differ- partmental pressure measurements are obtained following
entiating other possible lower leg conditions from chronic exercise. We use the compartmental pressure measure-
ECS. Radiographs typically are normal in cases of chronic ECS. ment guidelines to establish a diagnosis of chronic ECS and
Although rarely positive in chronic ECS, bone scans also should are supported by other surgeons, as summarized in Table

A B
Fig. 23.7  (A) Handheld compartmental pressure measurement device (Stryker Instruments, Kalamazoo,
Mich.). (B) To ensure accurate compartmental pressure measurements, the patient should be placed in a
supine position with the knee extended.

TABLE 23.1  Compartmental Pressure Measurement Guidelines for Establishing Chronic

Exertional Compartment Syndrome
Source Pre-exercise 1-min Postexercise 5-min Postexercise 15-min Postexercise
Edwards PH, Myerson MS79 ≥15 mm Hg ≥30 mm Hg ≥20 mm Hg N/A
Pedowitz RA, et al.90 ≥15 mm Hg ≥30 mm Hg ≥20 mm Hg N/A
Rorabeck CH96 ≥15 mm Hg N/A N/A ≥15 mm Hg
424 SECTION 3  Anatomic Disorders in Sports

23.1.79,90,95 Pressures usually return to normal within 3 to 5 CASE STUDY 23.4 

minutes after exercise in patients without this condition.15
If elevated pressures continue for 5 to 10 minutes, chronic A 15-year-old female soccer player presented with complaints of bilateral
ECS is diagnosed. leg pain during activity. The patient had been diagnosed with chronic ECS
approximately 1 year ago and underwent bilateral fasciotomies of four com-
Treatment partments at another facility. After her initial postoperative rehabilitation,
pain recurred on exercise. A second bilateral fasciotomy of four compartments
Conservative was performed, followed by recurrence of symptoms. Presently, pain devel-
Although some authors solely advocate surgical manage- oped approximately 15 minutes after beginning soccer practice and increased
ment for the treatment of chronic ECS, we recommend until activity ceased.
beginning with nonoperative treatment to address the The current evaluation revealed a normal examination at rest, with well-
extrinsic and intrinsic factors that contribute to the condi- healed surgical incisions. It was noted that the medial incision was quite
tion.10 Modification of extrinsic factors, including training proximal. Compartmental pressure measurements after provocative exercise
surface, shoe design, and training intensity may decrease confirmed bilateral compartment syndrome, based on pre-exercise and 1-min-
the symptoms of chronic ECS. Muscle imbalance, flexibil- ute and 15-minute postexercise readings. The 1-minute and 15-minute postex-
ity, and limb alignments are intrinsic factors that may be ercise measurements were greater than 21 and 17 mm Hg, respectively, in all
compartments.
addressed with either strengthening and stretching exer-
Edwards performed a third surgery involving bilateral fasciotomies of four
cises or orthoses. A short-leg cast used for approximately 4
compartments. Because of the proximal position of the medial incision and
weeks may cause atrophy of the leg musculature that in turn the suspicion that the soleus bridge previously was unreleased, a new 10-cm
may alleviate symptoms. Biomechanical abnormalities also medial incision was created to be used in addition to the previous midleg
should be addressed and corrected, usually with an orthotic, lateral incisions. The soleus bridge subsequently was released. Recurrent
before training is resumed. Because identifying and modify- scarring of the anterior and lateral fasciotomy incisions was noted, and repeat
ing all risk factors contributing to chronic ECS is difficult, extensile releases were completed. The patient recovered fully and returned
many athletes may continue to have symptoms of chronic to full activity at 12 weeks postoperatively, including twice-daily soccer prac-
ECS on resumption of activity and may be unable to return tice.
to competition.87 In such cases, an operative approach
may be warranted to enable return to the previous level of
intensity.
NERVE ENTRAPMENT
Operative Lower extremity nerve entrapment is a mechanical irritation
The surgical technique for treating chronic ECS involves of a peripheral nerve caused by impingement.111,112 The com-
decreasing intracompartmental pressure, as depicted in mon peroneal, superficial peroneal, and saphenous nerves are
Fig. 23.8.6,86,88,100 Fasciotomy generally is recommended if the most at risk for entrapment, which may produce neurogenic
symptoms persist for at least 3 months and produces favor- leg pain in the athlete (Fig. 23.9).113–118 Trauma is a primary
able results, especially in the anterior and lateral forms of the cause of all three forms of entrapment.115,118 Superficial pero-
condition.43,77,79,82,87–89, 91,95,103,108–110 Care must be taken to neal nerve entrapment also is observed in dancers and athletes
identify and protect the superficial peroneal nerve. In case of in a wide variety of sports, including bodybuilding, horse rac-
concomitant superficial peroneal nerve entrapment, release of ing, running, soccer, and tennis.111 113,115,118 Common peroneal
any fascial tethering or compression also may be performed. nerve entrapment often is associated with repetitive exercises
To prevent postoperative fascial scarring, early passive and involving inversion and eversion, which often occur in running
active range-of-motion exercises are implemented and and cycling.111,114, 115 External compressive sources, such as tight
weight-bearing ambulation as tolerated is permitted within plaster casts and anterior cruciate ligament (ACL) braces, and
2 weeks following surgery.79,88,91 Patients may begin exercise internal compressive sources, including osteophytes or proximal
on a stationary bicycle at 2 weeks postoperatively, followed by tibiofibular joint ganglion cysts, also may cause common pero-
isokinetic strengthening exercise 3 to 4 weeks after surgery. neal nerve entrapment.115,118,119 Knee surgery also may cause
Running may be initiated 5 to 6 weeks postoperatively, with common peroneal and saphenous nerve entrapments,115,120 the
speed and agility drills added during the eighth week.79,88 latter of which also may result from inflammatory conditions
Athletes generally return to full sports participation within 8 such as thrombophlebitis.120 Superficial peroneal nerve entrap-
to 12 weeks following surgery. ment, caused by either trauma or fascia hernias, is the most
common type of nerve entrapment that we have observed.
Although the causes of nerve entrapment are well established,
PEARL the mechanism responsible for this syndrome is unknown.114,117
Certain factors, however, can predispose nerves to entrapment.
Patients are able to predict the time of symptom onset.
The physical examination typically is normal at rest.
Nerves coursing through soft tissues are particularly at risk for
For the most accurate diagnosis, it is imperative to perform compartmental entrapment. Nerves branching near joints also are at increased
pressure testing after activity that initiates symptoms. risk for entrapment because joints are associated with a high
volume of movement and are common sites of trauma.112,119
 CHAPTER 23  Chronic Leg Pain 425

Soleus fascial bridge

ii iii

Tibia
Saphenous nerve and vein
A

Superficial peroneal nerve

ii iii iv

B Intermuscular septum
Fig. 23.8  (A) Fasciotomy technique for decompression of superficial and deep posterior compartments used
for the treatment of chronic exertional compartment syndrome (ECS). i, A longitudinal incision is created on
the posteromedial aspect of the leg. ii, The tibial posterior border is exposed, allowing full visibility of the
saphenous vein and nerve. iii, The soleus bridge is released providing exposure of the posterior compart-
ments. iv, The affected compartment is incised, using scissors or a fasciotome to extend the fasciotomies
proximally and distally. (B) Fasciotomy technique for decompression of anterior and lateral compartments
used for the treatment of chronic ECS. i, A longitudinal incision is created on the anterolateral aspect of the
leg, midway between the tibia and fibula. ii, Following exposure of the fascia, a transverse incision is created.
iii, The intermuscular septum is identified to assist in locating the superficial peroneal nerve. Care must be
taken to avoid the superficial branch of the peroneal nerve, which crosses laterally to anteriorly approximately
10 cm above the ankle. iv, The appropriate compartment is incised, using scissors or a fasciotome to extend
the fasciotomies proximally and distally.

Additionally, nerves, as opposed to circulatory and lymphatic History

vessels, are susceptible to impingement because of inherent Patients suffering from nerve entrapment of the lower extrem-
inelasticity.112 Because nerves lack independent movement, ity typically present with pain that is aggravated with continued
impact or compression from either trauma or internal pressure exercise. Common peroneal nerve entrapment pain is located
may cause neuropathy. in the region of nerve compression and is referred to the lateral
426 SECTION 3  Anatomic Disorders in Sports

nerve entrapment, tingling will occur 7 cm to 12 cm above the

lateral malleolus, whereas tingling will radiate from just above
the medial malleolus and more distally on the medial foot in
saphenous nerve entrapment.

Diagnostic Studies
Roentgenograms, MRI, compartmental pressure tests, electro-
A
myography (EMG), nerve conduction, and/or nerve block are
possible diagnostic tests conducted to confirm the diagnosis of
nerve entrapment.115,116,121 Radiographs typically are normal in
nerve entrapment syndromes but assist in identifying possible
compressing bony lesions and in excluding stress fractures and
bone tumors.116,121 An MRI is recommended if a pressure-caus-
ing mass is suspected. Compartmental pressure tests may be
conducted to distinguish between chronic ECS and nerve
B entrapments,113, 116,121 because elevated compartment pressures
are indicative of chronic ECS. To differentiate between common
and superficial peroneal nerve entrapments and to locate the
C anatomic point of compression, EMG and nerve-conduction
studies are recommended and should be performed before and
after exercise.115,116 A nerve-conduction velocity of less than 40
m/sec is considered abnormal and is indicative of nerve entrap-
ment of the lower extremity.122 If superficial nerve entrapment
is suspected on the basis of any of the aforementioned diag-
nostic tests, a nerve block should be performed. The anesthetic
should be injected where the Tinel’s sign is the strongest or
Fig. 23.9  Common sites of nerve entrapment in the lower extremity. at the location corresponding to maximal pain on pressure.
(A) Common peroneal nerve entrapment occurs as the nerve wraps Immediate pain relief following injection is suggestive of nerve
around the head of the fibula and exits the peroneal tunnel. (B) Entrap- entrapment.111, 112,117,118,120
ment of the superficial branch of the peroneal nerve typically occurs
as it pierces the deep fascia of the lateral or anterior compartments Treatment
of the leg. (C) A common site of saphenous nerve entrapment occurs
where the nerve branches, approximately 15 cm proximal to the medial Conservative
malleolus. Conservative treatment for nerve entrapment includes mod-
ification of precipitating activity, biomechanical correction,
leg and foot. In contrast, pain associated with superficial pero- physiotherapy, and/or soft-tissue massage.113,115,118 NSAIDs
neal nerve entrapment involves the lateral calf and/or dorsum of used in conjunction with tricyclic medications such as amitrip-
the foot (Case Study 23 5). Saphenous nerve entrapment often tyline and, occasionally, gabapentin may alleviate the pain and
occurs just above the medial malleolus, leading to local pain and associated swelling of all three forms of nerve entrapment.118
referred pain to the dorsum of the foot medially (Case Study Iontophoresis is another option that we prefer because of its less
23.6). Numbness, often described as a burning sensation, also invasive nature in comparison with a nerve block. However,
may be observed with all compressive neuropathies. In addition, nerve blocks may be necessary if iontophoresis fails. Because
some patients may experience localized swelling. Diffuse swell- constrictive clothing and/or devices, including ACL braces or
ing, on the other hand, is indicative of chronic ECS or a systemic patellar tendinitis straps, place additional stress on the nerves,
problem. Finally, motor weakness, such as footdrop, typically is the use of these devices is not recommended during treat-
observed late in common peroneal nerve entrapment. ment.115,118 In our experience, application of local anesthetic
patches may also help to alleviate symptoms.
Physical Examination
The lower back, hips, and ankle joints should be examined to Operative
confirm that an overriding neurologic condition is not pres- Although common peroneal and saphenous nerve entrapments
ent. Fascial hernia also should be ruled out. Range of motion often are successfully treated by conservative measures, superfi-
of all leg joints and stability of the knee and ankle should be cial peroneal nerve entrapment typically requires surgical treat-
assessed. Compression or percussion of the nerve is the hall- ment.115,118 If surgery is warranted, fasciotomy is performed
mark test used to determine a diagnosis of nerve entrapment. A to expose the nerve, and, if necessary, is followed by external
tingling sensation along the nerve or at its exit from the fascia neurolysis.113–115,120,121 In common peroneal nerve entrapment,
is indicative of entrapment syndrome. Tingling typically will be resection of osteophytes, ganglion cysts, or other obstruc-
elicited at the level of the fibular neck radiating distally in com- tions may be necessary before neurolysis is performed.115,118
mon peroneal nerve entrapment. Alternatively, in superficial In rare cases of trauma-induced saphenous nerve entrapment,
 CHAPTER 23  Chronic Leg Pain 427

neuroectomy may be required.12, 117,120 Because of the increased POPLITEAL ARTERY AND VEIN ENTRAPMENT
risks associated with neurologic surgical procedures, including
neuromas and reflex sympathetic dystrophy, surgical treatment
SYNDROME
requires a thorough knowledge of the peripheral neuroanat- PAES is more common in athletes than in the general popu-
omy.118 To minimize such risks, the nerve should be manipu- lation, especially as a result of increased participation in com-
lated as little as possible and the surrounding soft tissue should petitive sports.6,123 This condition results from an abnormal
be relatively undisturbed.118 Activity may be increased gradu- relationship between the popliteal artery and the surrounding
ally on wound healing. myofascial structures (Fig. 23.10), producing calf pain on exer-
tion.6,123–126 PAES is progressive and, in more severe cases, may
result in occlusion of the popliteal because of compression from
PEARL the medial head of the gastrocnemius muscle.6,123
A careful history and physical examination should be conducted to rule out Although PAES is a possible diagnosis in any athlete with calf
referred pain or an overriding neurologic condition. pain and intermittent claudication, it is predominantly observed
A positive Tinel’s sign is highly suggestive of nerve entrapment. in males under the age of 30.6,123–125,127–137 This condition typ-
If physical examination and all diagnostic tests, including compartmental ically occurs unilaterally, but may be observed bilaterally at an
pressure measurements, are normal, nerve compression often is the source incidence of 25%– 67%.129,138,139 Although relatively rare, it can
of the pain. affect athletes with more hypertrophied gastrocnemius and calf
The fascial exit of the superficial peroneal nerve is variable, ranging from
musculature.
approximately 7.5 cm to 12.5 cm from the tip of the lateral malleolus.
It is generally accepted that there are two types of popliteal
artery entrapment. The first type is anatomic, in which there can
be embryologic abnormalities within the gastrocnemius mus-
CASE STUDY 23.5  cle.6,123,124,129 The medial head of the gastrocnemius can have an
anomalous attachment to the distal femur, causing tight stric-
A 30-year-old male runner presented with complaints of lateral leg pain ture of the popliteal artery as it passes through the muscle. This
and foot numbness. The symptoms progressed after he began an aggressive
variant can be present in up to of 1% of patients, and is usu-
running program during the prior year. The pain was described as sharp and
tingling and typically occurred over the mid to distal aspect of his lateral leg
ally clinically silent. Compression can also possibly be caused
during running. He denied a history of injury. by either the soleus or plantaris muscles.123,140,141 Secondly,
On physical examination, a small prominence of soft tissue was noted over patients can also have functional popliteal artery entrapment.
the painful area. “Lightning-like” sensations and paresthesias corresponding This occurs due to compression of the artery due to a hypertro-
to the superficial branch of the peroneal nerve were elicited on percussion. phy gastrocnemius muscle or excessive positioning in passive
Gross neurovascular examination, including sensation, otherwise was normal. dorsiflexion of the ankle or excessive active plantar flexion of
After conservative treatment, including failed iontophoresis, a fasciotomy the ankle.139,142
was performed to release the nerve. Postoperatively, activity gradually was Although anatomically ubiquitous in the population, popli-
increased, with resumption of training at 6 weeks. teal venous entrapment syndrome is a much more rare vascu-
lar cause of chronic calf pain in the athlete. In a wide range of
studies in asymptomatic individuals, utilizing ascending duplex
ultrasonography or ascending contrast venography, entrapment
CASE STUDY 23.6 
of the popliteal vein was seen in 27% to up to 47% of healthy
A 52-year-old avid golfer presented with a 3-month history of distal medial individuals. Anatomically, the entrapment can occur from the
leg pain. The pain increased with activity and radiated to the dorsum of the medial head of the gastrocnemius muscle, or an anomalous
foot. Initially, pain was mild but progressed to the point at which the patient fibrous band over the vein. It can be more common in individu-
was unable to complete a round of golf without significant pain. NSAIDs and als or athletes with significant hypertrophy of the gastrocnemius
ice were implemented without improvement. Although the patient initially muscle.139
denied a history of trauma, on further inquiry, he recalled that he had hit his
distal tibia approximately about the medial malleolus on his daughter’s bicycle History
3 months before the present complaint.
Physical examination revealed full range of motion, with no swelling or Patients usually present with claudication symptoms, with
cutaneous changes about the distal third of the leg. In addition, no tender- vague calf pain present with exercise (Case Study 23.7). There is
ness was observed over the medial distal tibial cortex, and a vibratory test usually no pain at rest. Physical exam findings are usually unre-
was negative. However, a positive Tinel’s sign over the saphenous nerve markable. Diagnosis is usually confirmed by CT, MRI, MRA, or,
above the medial malleolus was elicited, reproducing the distal-radiating more than likely, lower extremity arteriography.
pain. On the basis of these clinical findings and the traumatic nature of the PAES should be considered in the differential diagno-
injury, a diagnosis of posttraumatic saphenous neuritis was established. sis of healthy young patients presenting with complaints of
Conservative treatment comprising NSAIDs, ice, and iontophoresis was pre- intermittent pain typically involving the foot and leg. Pain,
scribed. Symptoms improved markedly at 2 weeks following treatment and described as a deep ache or cramping, generally is posterior
completely resolved by 4 weeks, enabling the patient to return to regular
in location and typically occurs after vigorous exercise. It is
activity.
important to note, however, that claudication may be atypical
428 SECTION 3  Anatomic Disorders in Sports

A B C

D E
Fig. 23.10  Normal course of the popliteal artery versus possible aberrant pathways involving the medial head
of the gastrocnemius muscle that cause popliteal artery entrapment syndrome (PAES) (popliteal artery = dark,
popliteal vein = striped, tibial nerve = white). (A) Normal course of the popliteal artery in which the artery
and vein course distally between the heads of the gastrocnemius muscle, over the popliteus muscle, and
beneath the soleus muscle. (B) The popliteal artery deviates medially, wraps around the medial head of the
gastrocnemius muscle, and then resumes the normal distal course. (C) The popliteal artery deviates medially,
wraps around the medial head of the gastrocnemius muscle, and abnormally courses beneath the popliteus
muscle, consequently becoming entrapped. (D) The popliteal artery courses normally but is compressed by
the medial head of the gastrocnemius muscle, which is positioned laterally to its normal insertion. (E) The
popliteal artery courses normally but is entrapped between the medial head and an accessory tail of the gas-
trocnemius muscle. (Modified from Rich NM, et al: Arch Surg. 1979;114:1377.)
 CHAPTER 23  Chronic Leg Pain 429

early in the course of this condition, because it may occur portion of the medial head of the gastrocnemius, with full dis-
with walking and not with prolonged leg exercise. Symptoms section of the artery, and possible bypassed grafting if a portion
occurring less frequently include numbness, tingling, or of the artery is constricted or diseased.148 Full recovery in ath-
coolness of the foot; these symptoms may be relieved by letes can be upward of 6–8 months.
changing leg positions. Treatment of popliteal vein entrapment is almost always
Frequently, popliteal venous entrapment syndrome is a conservative with compression socks, activity modifica-
diagnosis of exclusion, once more common etiologies of calf tion, and therapy. Surgery is rarely indicated, and should be
pain have been ruled out. Patients may present with painful reserved for individuals with severe venous stasis ulceration.
edema, vague calf pain, stasis dermatitis, or, less likely, venous Surgical treatment consists of resection of the compressive
stasis ulceration. The finding can be unilateral or bilateral. medial head of the gastrocnemius musculature and release of
There are no predisposing factors, although it has been sug- the popliteal vein.
gested that a past medical history of deep vein thrombosis
can predispose an individual to popliteal venous entrapment
syndrome.139 PEARL
The knee may be warm on palpation because of increased collateral circula-
Physical Examination tion.
Physical examination often is normal at rest in PAES cases, espe- Bilateral pulses with provocation should be examined to determine whether
cially if the artery is still patent. Compartments may be soft, and reduction in pulse volume between limbs exists.
palpation of the bone and soft tissues may not elicit tenderness. If PAES is suspected on the basis of Doppler sonography, arteriography
The only possible pathognomonic physical exam finding would should be performed to confirm the diagnosis.
be diminishment or loss of popliteal, dorsalis pedis, and poste-
rior tibial pulses with full passive dorsiflexion or the extremes of
plantar flexion when compared to the normal contralateral leg.
On auscultation, a bruit may be heard after provocative exercise, CASE STUDY 23.7 
but the significance of this observation is unclear because it also A 19-year-old female competitive soccer player presented with complaints
may be observed in a normal athlete. of bilateral leg pain. Pain, described as a dull ache in the posterior aspect of
both legs, began during workouts. The pain continued to intensify until ces-
Diagnostic Studies sation of activity was required. However, the pain resolved after a short rest
Diagnosis is usually confirmed by CT, MRI, MR angio- period of 5 to 10 minutes. This pattern of intense pain during activity followed
gram, or, more than likely, lower extremity arteriography. If by relief after rest continued without progression with every successive prac-
tice and competition.
Doppler sonography indicates PAES, arteriography is rec-
The initial physical examination did not reveal any abnormalities, as
ommended to confirm the diagnosis.123,128,134,143,144 Often
demonstrated by soft compartments, no tenderness on palpation, and nor-
referred to as the “gold standard test” of PAES, arteriography mal neurovascular findings. Radiographs and resting compartmental pres-
is an invasive procedure involving radiographic imaging after sure measurements were normal. In an attempt to reproduce the patient’s
injection of a radiopaque material into the suspected arterial symptoms, the patient was instructed to exercise and subsequently
segment.123,133,135 Because arteriography may be normal in returned with complaints of posterior calf pain and mild tenderness on
PAES when the ankle is in the neutral position and the knee deep palpation of the calf. During this symptomatic period, neurovascular
is extended, it is important to repeat the studies bilaterally examination and compartmental pressure measurements remained nor-
after exercise or with the ankle in positions of provocation, mal. A subsequent three-phase bone scan and MRI also were normal. As
because extrinsic arterial obstruction may be demonstrated a result, conservative treatment consisting of rest was implemented for
with ankle plantarflexion.6,127,134,137,143,145,146 MRI/MRA also 1 month.
The patient returned for evaluation because of continued symptoms, but
may be beneficial in evaluating PAES and offers the added
the physical examination remained normal. Compartmental pressures were
benefit of showing the offending soft tissue structure in many
reevaluated at pre-exercise and postexercise intervals and remained within
cases.143,146,147 Compartmental pressure measurement test- normal limits. Examination of pedal pulses demonstrated normal dorsalis
ing and three-phase bone scans are recommended to rule out pedis and posterior tibial artery pulses. However, when this measurement
chronic ECS and stress fractures, respectively. was repeated with active plantarflexion or passive dorsiflexion with a
The diagnosis of popliteal venous entrapment can be straight leg, loss of all pulses was observed bilaterally. To confirm a diagno-
made diagnostically with dynamic duplex ultrasonography, sis of PAES, an arteriogram with provocative maneuvers was performed and
with active and passive dorsiflexion and plantar flexion demonstrated loss of flow at both popliteal arteries (Fig. 23.11). Because the
maneuvers of the calf. Infrequently, venography or MRA can patient desired to continue competitive soccer, she elected to undergo sur-
be utilized. gical release of the entrapped popliteal artery. Surgical inspection revealed
a popliteal artery coursing medially to the head of the gastrocnemius mus-
Treatment cle and anteriorly to the popliteus muscle belly (Fig. 23.12). These areas of
entrapment then were released. After wound healing, the patient gradually
Treatment of popliteal artery entrapment is most likely conser-
increased activity over a 6-week period and returned to competitive soccer
vative, with periods of rest, stretching, and activity modifica- 3 months postoperatively.
tion. Surgical intervention involves resection of the abnormal
430 SECTION 3  Anatomic Disorders in Sports

Fig. 23.12  Intraoperative photograph illustrates the abnormal pathway

of the popliteal artery as it courses medially to the head of the gas-
trocnemius and anteriorly to the popliteus muscle indicative of popliteal
artery entrapment syndrome (PAES). (Image courtesy Paul Cook, MD,
Riverside Methodist Hospital, Columbus, Ohio.)
A

TABLE 23.2  Pain Locations of the Common

Lower Leg Conditions
Localized or
Leg Condition Generalized Location of Pain
MTSS Generalized Posteromedial distal 1/3
Bony tenderness above
Stress fracture Localized distal 1/3
Involved compartments
Chronic ECS Generalized with exercise
Nerve entrapment Localized Fascial exit site
Posterior with
PAES Generalized exercise
ECS, Exertional compartment syndrome; MTSS, medial tibial stress
syndrome; PAES, popliteal artery entrapment syndrome.

is the hallmark symptom in all of these conditions, subtleties

B exist in the location and occurrence of pain among the var-
Fig. 23.11  Arteriograms obtained following provocative active plan-
ious conditions. Therefore, determining whether the pain is
tarflexion and passive dorsiflexion with a straight leg, demonstrating generalized or localized and isolating the onset and dimin-
normal flow (A) compared with the decreased flow (B) associated ishment of pain will assist in determining the appropriate
with popliteal artery entrapment syndrome (PAES). (Images courtesy diagnosis, as summarized in Table 23.2. Keys to making an
Louis J. Unverferth, MD, Riverside Methodist Hospital, Columbus, accurate diagnosis include conducting a thorough history,
Ohio.)
performing an exhaustive physical examination (Table 23.3),
and using the appropriate diagnostic tools to distinguish fur-
ther among these conditions (Table 23.4). Once a diagnosis
is established, the preferred treatment is conservative man-
SUMMARY
agement, consisting of rest from activity and modification
The most common conditions involving lower leg pain of extrinsic and intrinsic factors. Treatment should be indi-
in athletes are MTSS, stress fractures, chronic ECS, nerve vidualized according to the patient’s symptoms and involve
entrapment, and PAES. Similarities of symptoms among gradual rehabilitation and return to activity. Although a
these conditions make diagnosis difficult. The challenge for conservative approach typically is successful, surgical inter-
the sports medicine specialist is to differentiate among these vention may be required for cases in which conservative
similarities to establish an accurate diagnosis. Although pain treatment has failed.
 CHAPTER 23  Chronic Leg Pain 431

TABLE 23.3  Physical Examination Observations of Common Lower Leg Conditions

MTSS Stress Fracture Chronic ECS Nerve Entrapment PAES
Edema/warmth Posteromedial distal 1/3 Over site No No Possible around knee
Paresthesias No No Rarely Often Rarely
Pedal pulses with
Pedal pulse Normal Normal Normal Normal provocation
Involved compartment(s) Possible at site of
Palpation tenderness Posteromedial distal 1/3 At site with exercise compression Posterior with exercise
ECS, Exertional compartment syndrome; MTSS, medial tibial stress syndrome; PAES, popliteal artery entrapment syndrome.

TABLE 23.4  Diagnostic Studies Useful in Distinguishing Among Common Lower Leg
Conditionsa
Diagnostic Study MTSS Stress Fracture Chronic ECS Nerve Entrapment PAES
Roentgenograms Recommended Recommended Recommended Recommended Not recommended
Normal Periosteal reaction/early Normal Normal N/A
callus after 10–14 days
Bone scan Recommended Recommended Not routinely Not recommended Not routinely recom-
recommended mended
Linear uptake Focal uptake Normal N/A Normal
MRI Not routinely Not routinely Not routinely Not routinely Not recommended
recommended recommended recommended recommended
Signal changes Bone edema Normal Normal N/A
MRI/MRA Not recommended Not recommended Not recommended Not recommended Recommended
N/A N/A N/A N/A Flow with provocation
Compartmental pressure Not recommended Not recommended Recommended Not routinely Not routinely recom-
test recommended mended
N/A N/A ≥15 mm Hg at rest; >20mm Normal Normal
Hg 5-min postexercise
Arteriography Not recommended Not recommended Not recommended Not recommended Recommended
N/A N/A N/A N/A Obstruction with provo-
cation
aThe upper portion for each diagnostic study represents our recommendation; the lower portion indicates the results corresponding to the diagno-
sis.
ECS, Exertional compartment syndrome; MTSS, medial tibial stress syndrome; PAES, popliteal artery entrapment syndrome.

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 24
Foot and Ankle Injuries in Dancers
Cesar de Cesar Netto, John G. Kennedy, William G. Hamilton, Martin O’Malley

OUTLINE
Videos https://www.kollaborate.tv/ Lateral Ankle, 445
link?id=5c9d20f756b57, 436 Lateral Ankle Sprain, 445
Introduction, 436 Cuboid Subluxation, 446
Metatarsophalangeal Joint, 437 Anterior Ankle, 446
Bunions, 437 Posterior Ankle, 446
Hallux Rigidus, 438 Posterior Impingement Syndrome, 447
Injuries to Sesamoid Bones, 438 Flexor Hallucis Longus Tendinopathy, 448
Sesamoiditis, 438 Achilles Tendon, 449
Hallux Interphalangeal Joint, 440 Peritendinitis of the Achilles Tendon, 449
Lesser Metatarsophalangeal Joints, 440 Tendinosis of the Achilles Tendon, 449
Plantar Plate Tear and Metatarsophalangeal Instability, 440 Rupture of the Achilles Tendon, 450
Freiberg’s Infraction, 441 Pseudotumor of the Calf, 450
Metatarsal Injuries, 441 Heel Pain, 450
Second Metatarsal Base Stress Fracture, 441 Plantar Fasciitis, 450
Nutcracker Fracture at the Base of the Second Metatarsal, 441 Plantar Calcaneal Bursitis, 450
Fifth Metatarsal Spiral Diaphyseal Fracture (Dancer’s Frac- Baxter’s Nerve Neurapraxia, 450
ture), 441 Leg Pain, 450
Proximal Fifth Metatarsal Spiral Fracture, 441 Shin Splints (Medial Tibial Stress Syndrome), 450
Bunionette Deformity, 444 Stress Fractures, 451
The Medial Ankle, 444 Compartment Syndrome, 451
Medial Ankle Sprains, 444 Summary, 451

VIDEOS HTTPS://WWW.KOLLABORATE.TV/ Video 24.17 Stability—Core

Video 24.18 Tendu
LINK?ID=5C9D20F756B57 Video 24.19 Torsion—Hip Knee
Video 24.1 About Dance Smart Video 24.20 Triple Hop
Video 24.2 Airplane Test
Video 24.3 IMG_2030
Video 24.4 IMG_3395
INTRODUCTION
Video 24.5 IMG_8468 Ballet has all the elements of the arts in its makeup—drama,
Video 24.6 Jete poetry, literature, painting, sculpture, design, music, and, of
Video 24.7 Neural Mobility course, dance. Dancers, both male and female, are the physi-
Video 24.8 P to TO Yard Stick Test cal means by which the choreographer sculpts a composition of
Video 24.9 Pirouette expressive motion. The grace and art of the ballet performance
Video 24.10 Plie Passe belie the great physical strain on the body as a whole and the
Video 24.11 Plie foot and ankle in particular. From an early age the dancer must
Video 24.12 Range of Motion—Beighton Scale learn to be an artist, a gymnast, and an athlete. Most ballet
Video 24.13 Range of Motion—hip rotation dancers train for a minimum of 10 years before attaining the
Video 24.14 Saute Test skill set necessary to join a corps de ballet. Very few dancers
Video 24.15 Stability—Hip develop into soloists and fewer still attain the role of principle
Video 24.16 Stability—Toes ballerina. Throughout this time of training, the body is placed

436
 CHAPTER 24  Foot and Ankle Injuries in Dancers 437

Fig. 24.1  Illustration of the en pointe stance. Fig. 24.2  Illustration of the relevé stance (demi-pointe).

under great strain, and it is by a process of natural selection that young ballet dancer’s bones during the bone growth phase.4 As
those dancers who are flexible and technically proficient survive a result of endless practice barres, classes, and training, dancers’
the rigors of training to advance further. Hamstring strains, foot feet tend to be cavus and have thickened metatarsals to support
and ankle pathologies, and low back pain are the most com- when en demi-pointe. Calluses abound secondary to pressure
monly diagnosed musculoskeletal injuries.1,2 demands on the skin.
Female dancers spend a considerable time en pointe, or on the In general, five types of dancer’s feet have been described:
points of the toes (Fig. 24.1), whereas male dancers do not dance 1. Grecian (also known as Morton) foot has a relatively long
on their toes and spend much of their time in turning, lifting, second and third metatarsal in relation to the first and fifth
and holding female dancers. As such, male and female dancers metatarsal. However, dancers do not have the same problems
tend to present with distinct injuries. In addition to the myriad associated with transfer metatarsalgia as does the general
of physical injuries related to female dancers that follows, female population with this foot configuration.
dancers also are prone to the triad of anorexia, amenorrhea, and 2. Egyptian foot. Long first ray relative to the central metatar-
osteoporosis (see Chapters 4 and 28). This unfortunate triad sals. This can predispose the first MTP joint to degenerative
stems from the significant pressure on dancers to weigh less arthrosis or hallux rigidus.
and less. The most disturbing data suggest that female dancers 3. Simian foot. Metatarsus primovarus with hypermobile first ray
weigh more than 15% below the ideal weight for height. This has that causes transfer metatarsalgia to central metatarsal heads.
metabolic consequences leading to stress fractures and slower 4. Peasant foot. Uniform metatarsal length, giving broad, square
union rates in injured female dancers.3 In contradistinction, foot. Its stability makes it an ideal platform for dancing.
male dancers have fewer metabolic problems but are prone to 5. Model’s foot. This foot is long and slender with a taper exagger-
overuse injuries from repetitive motion and to stress fractures ated cascade from first to fifth metatarsal head. As such, it bears
(see Chapter 3) from the sudden deceleration of large leaps, volé, weight unevenly on demi-pointe and is a poor foot for dance.
sauté, or jeté. Dancers’ feet are the instruments on which their The following is a review of the more common dance injuries
art depends. They require, in addition to an extraordinary flexi- and problems in the foot and ankle.
bility and strength, a particular anatomic profile.
Over time a dancer’s foot will evolve and only the strongest METATARSOPHALANGEAL JOINT
will survive. Dancers’ feet typically are ‘‘intrinsic plus:’’ they
have narrow metatarsal width with straight toes. (Intrinsic- Bunions (see Chapter 22)
minus feet have wider metatarsal splaying and clawing of the Although dancing has been said to play a role in the pathogen-
toes.) Apart from muscle strength, dancers’ feet require great esis of bunions, it is unlikely that this is the case. Dancers, like
flexibility. In the relevé position (Fig. 24.2) the ankle is in a ver- the rest of the population, can be either resistant or prone to
tical position: 90 degrees of plantarflexion of the ankle-foot develop bunions.5 In those dancers that are prone to develop
complex. The dancer also requires 90 to 100 degrees of dorsi- bunions, it is imperative to delay surgical intervention for as
flexion in the first metatarsophalangeal (MTP) joint to go from long as possible. Bunion surgery adversely affects dorsiflex-
relevé to en pointe. These are extraordinary ranges of motion ion of the first MTP joint, a critical motion in dancers. Most
and can only be achieved with years of practice, which mold the bunions, specially the asymptomatic ones, can be treated with
438 SECTION 4  Unique and Exceptional Problems in Sports

In grade I disease, the joint is preserved and marginal osteo-

phytes can be resected (cheilectomy), either arthroscopically
or open dorsal approach, with excellent outcomes.
In grade II disease, the joint is involved. There is minor carti-
lage destruction evident as joint space narrowing on plain
radiograph, especially in its dorsal aspect. Surgical treatment
involves a more extensive surgical debridement with chei-
lectomy and resection of the dorsal one-third of the meta-
tarsal head.7 Intraoperative dorsiflexion of the hallux greatly
overestimates the degree of motion that can be expected
following surgery. Just over half of what is achieved at the
time of surgery will be evident in the postoperative follow-up
examination. It is important that dancers understand that,
although surgery will make the condition better, the joint
will never be normal. In addition, the length of recovery
time must be discussed with the dancer, because a full func-
tional recovery often takes 6 months. To improve functional
motion following surgery, a dorsally based closing osteotomy
(Moberg) can be used. This procedure improves dorsiflexion
but at the expense of plantarflexion, and the dancer should
be warned of this.
Grades III and IV hallux rigidus presents with dorsal and lat-
eral osteophytes in addition to clear degenerative arthrosis
Fig. 24.3  Clinical picture of a ballet dancer treating hallux valgus defor- on both sides of the joint. Arthrodesis is an acceptable sur-
mity conservatively using a toe spacer in between first and second toes. gical option in the general population but not feasible in a
dancer. To preserve motion, we recommend similar surgical
treatment utilized for grade II, with cheilectomy and Moberg
osteotomy (Fig. 24.6, A−C), with good clinical outcomes.8

INJURIES TO SESAMOID BONES (SEE

CHAPTER 21)
The sesamoid bones lie within the substance of the flexor hal-
lucis brevis tendons. They are commonly injured in dancers,
particularly in those who fail to perform a plié on landing,
absorbing the energy of the landing through partially flexed
knees. Without such absorption built into a dancer’s technique,
sudden deceleration with high impact of the sesamoid bones
Fig. 24.4  Illustration of hallux rigidus. predisposes to injury.

conservative methods, including toe spacers and horseshoe Sesamoiditis

pads (Fig. 24.3). The senior author has seen several aspiring The differential diagnosis of sesamoiditis is lengthy and requires
young dancers whose careers were ended by well-meaning bun- careful history taking and clinical examination. Magnetic reso-
ion surgery. If a bunion is precluding the dancer from activity nance imaging (MRI) aids diagnosis.
and surgery is warranted, then a chevron or metatarsal osteot- The following is a list of differentials:
omy can provide pain relief and stability without compromising • stress fracture of the sesamoid bone,
motion. A tarsometatarsal fusion will make the midfoot too stiff • avulsion fracture or sprain of the proximal pole of the sesa-
and limit the pointe position. moid,
• sprain of the distal pole,
Hallux Rigidus (see Chapter 21) • sprain of a bipartite sesamoid,
Any restriction to full dorsiflexion of the first MTP joint will • arthrosis of the sesamoid metatarsal joint,
prevent the dancer from performing relevé. Many dancers can and
accommodate by rolling out onto the lateral border of the foot, • preradiographic osteonecrosis of the sesamoids.
a process known as ‘‘sickling.’’ Several mechanisms are responsible for producing sesa-
The treatment of hallux rigidus depends on the grade of the moiditis in dancers. Most of these can be treated with a felt pad
disease (Fig. 24.4). A frequently used classification system was around the sesamoid for relief (“dancer’s pad”) (Fig. 24.7). In
proposed by Coughlin and Shurnas (Fig. 24.5)6: general, symptoms resolve without any additional interventions,
 Coughlin and Shurnas Classification

Grade Radiographic Clinical

Dorsal spur is main finding Mild or occasional subjective pain and stiffness
Minimal joint narrowing Pain at extreme of dorsiflexion and/or plantar flexion
I Minimal periarticular sclerosis on examination
Minimal flattening of metatarsal head

Dorsal, lateral, and possibly medial osteophytes give

flattened appearance to metatarsal head.
No more than 1/4 dorsal joint-space involvement on
lateral radiograph Moderate to severe subjective pain and stiffness that
may be constant.
II Pain extremes of dorsiflexion and/or plantar flexion
on examination
Mild to moderate joint-space narrowing and sclerosis.
Sesamoids not usually involved but may be irregular
in appearance

Same as grade II but with substantial joint-space

narrowing. Nearly constant subjective pain and substantial
Possibly periarticular cystic changes, more than 1/4 of stiffness
III dorsal joint may be involved on lateral side, Pain throughout range of motion on examination (but
sesamoids may be enlarged and/or cystic and/or not at midrange)
irregular.

Same as grade III but definite pain at midrange of

IV Same as grade III
motion

Fig. 24.5  Coughlin and Shurnas Staging for Hallux Rigidus (Grade I-IV). (From Coughlin, MJ, Shurnas PS.
Hallux rigidus. J Bone Joint Surg Am 2004;86A S1(Pt 2): 119−130.)

A B

C
Fig. 24.6  Hallux Rigidus Surgical Treatment in a Dancer. (A) Illustration of cheilectomy and Moberg Oste-
otomy; (B) clinical photograph of first metatarsophalangeal joint illustrating 75% degeneration of articular car-
tilage, substantial osteophyte formation, and joint-space narrowing (Grade III hallux rigidus); (C) postoperative
radiographs of a Grade III hallux rigidus treated with Cheilectomy and Moberg osteotomy.
440 SECTION 4  Unique and Exceptional Problems in Sports

Fig. 24.7  Dancer’s pad for sesamoiditis.

although it may take up to 6 months for full resolution. In those

cases requiring further diagnostic testing, an MRI can be use-
ful. The medial sesamoid is often bipartite, with rounded edges
on plain radiograph, distinguishing it from a recent fracture. In
those cases with recalcitrant pain, surgery may be warranted. Fig. 24.8  Taping of the toes.
A medial-based incision can locate the medial sesamoid; in the
surgical treatment of lateral sesamoid pathology we prefer a
dorsal approach in the first web space. A plantar incision should shoe. Hyperextension of the great toe IPJ also occurs, usually to
always be avoided because of the increased risk of plantar scar- compensate for lack of motion in adjacent joints. Rarely does
ring and chronic plantar pain. Surgery should be reserved only this need surgical intervention, despite radiologic appearances,
for patients with symptoms persisting for at least 6 months fol- because the joint is quite accommodating and typically asymp-
lowing initial conservative treatment. tomatic. In those who do complain of symptoms, lamb wool
Other conditions may mimic sesamoiditis, including bursitis wrapping can help to alleviate the discomfort problem (Fig. 24.8).
and nerve entrapment:
1. Sesamoid bursitis: Swelling and inflammation within the ses- LESSER METATARSOPHALANGEAL JOINTS
amoid bursa may mimic sesamoiditis. However, careful clin-
ical examination usually can identify a symptomatic bursa
(SEE CHAPTER 20)
when present. Treatment consists of a well-directed local Metatarsalgia is uncommon in dancers, and when it is encoun-
corticosteroid injection to the bursa. Bursitis still may take tered, the differential diagnosis must include plantar plate injury
some time to resolve, and it can be complicated by a fibrous with MTP instability and Freiberg’s infraction.
scar that causes repeated symptoms. In such cases, a bursec-
tomy can be performed through a careful medial approach. Plantar Plate Tear and Metatarsophalangeal
2. Joplin’s neuroma: Entrapment of the proper digital nerve, Instability
adjacent to and, rarely, under the tibial sesamoid, will cause As the dancer relevés, the phalanx subluxes dorsally, pushing the meta-
symptoms similar to sesamoiditis. Joplin’s neuroma, how- tarsal head plantarward and causing pain and overload of the plantar
ever, will display a characteristic nerve compression sign with plate of the lesser MTP joints. In the demi-pointe position, excessive
palpation. In those cases recalcitrant to conservative therapy, loads are transmitted through the second and third MTP joints.
neurolysis, and transposition of the nerve are required. Clinical examination will elicit a translation in the anterior-posterior
3. Lateral proper digital nerve entrapment: The lateral proper (AP) plane, positive drawer test, that is in excess of the adjacent joints.9
digital nerve may be compressed under the deep transverse MRI can be a useful diagnostic tool, demonstrating either acute or
ligament, causing pain in the great toe on the lateral side. chronic injury of the plantar plate (Fig. 24.9). Treatment initially is
Because of the position of the nerve, a compression test can- directed at taping to neighboring toes and stress-relieving padding.
not be performed. Diagnosis is made with a selective local We have used platelet-rich plasma (PRP) injections and prolother-
anesthetic injection to the nerve. Surgical resection of the apy (saline solution) with success. Surgical correction includes a very
transverse ligament is often curative. limited resection arthroplasty with a plantar condylectomy, through
dorsal approach. Alternately, a limited Weil osteotomy may be used
with screw fixation. A formal plantar plate repair should be used with
HALLUX INTERPHALANGEAL JOINT care, since it can cause joint stiffness, which is not tolerated by pro-
In young ballet dancers, hyperflexion of the great toe interphalan- fessional dancers. Motion should always begin early. Scarring at the
geal joint (IPJ) can occur when attempting en pointe. Here, weight plantar aspect of the wound facilitates tightening of the redundant
is distributed over the nail and dorsum of the toe in the pointe plantar plate.
 CHAPTER 24  Foot and Ankle Injuries in Dancers 441

Because of the cuneiforms’ Roman arch configuration, the sec-

ond metatarsal sits wedged between the medial and lateral cune-
iform bones. This causes a relative rigidity to the second ray and
consequently a potential site for a stress fracture. However, rela-
tive length of the second metatarsal is not considered a risk factor
for fracture occurrence.11 In fact, this is the most common site
for a stress fracture in the dancer’s foot, and when a patient com-
plains of pain and tenderness in the base of the second metatarsal,
it should be regarded as a stress fracture until proven otherwise.
The fracture line is usually transverse. Conventional radio-
graphs may not show the fracture, but a computed tomogra-
phy (CT) scan or an MRI will confirm clinical suspicion in such
instances (Fig. 24.11). As the second metatarsal hypertrophies
from years of pressure in the demi-pointe position, it may have
the appearance of a healing fracture. Again, MRI can be useful
in determining the true diagnosis.
Fig. 24.9 Magnetic resonance image (sagittal plane) demonstrating
Acute injuries require a cam walker for up to 6 weeks to
injury of the plantar plate of the second metatarsophalangeal joint.
allow time for the fracture to consolidate. Cast immobilization
usually is not required, provided that the dancer can be trusted
Freiberg’s Infraction to keep the cam walker in place as prescribed. Rarely, a frac-
Dancers have a propensity to develop Freiberg’s infraction equal ture may progress to a delayed union, and in these cases a small
to that of the general population. In general, conventional radi- ultrasound bone stimulator can be used to accelerate healing.
ography lags behind clinical symptoms by up to 6 months (Fig. Occasionally, internal fixation with a small plate and screws,
24.10, A, B and C). MRI facilitates early diagnosis. associated with bone grafting, may be required.
Four types of infraction occur:
• Type I: A localized osteonecrosis of the metatarsal head that Nutcracker Fracture at the Base of the Second
heals by creeping substitution. No cartilage defect is seen. Metatarsal
• Type II: Following metatarsal head osteonecrosis, the Represents a different modality of common fractures in the base
structural support of the head is lost. New bone formation of the second metatarsal of professional dancers.12 It is associ-
occurs but is not sufficient to prevent collapse of the head. ated with specific anatomical findings of a wide forefoot and the
The articular cartilage is preserved; however, osteophytes use of tight shoes. There is repetitive impingement of the base
on the dorsal lip limit dorsiflexion. Surgical debridement of the first metatarsal into the base of the second metatarsal sec-
is curative, with exostectomy of the dorsal ridge to facilitate ondary to forefoot compression in the toe shoe. Often seen in
dorsiflexion. young dancers with bunions and tight toe shoes who have not
• Type III: In addition to metatarsal head collapse, the artic- resized their toe shoes as they grow, but can also rarely occur in
ular cartilage is destroyed. Surgical management includes the absence of hallux valgus deformity, usually due to a valgus
excision of the dead bone and cartilage and osteophyte resec- strain of the forefoot during en pointe (Fig. 24.12).
tion. The plantar aspect of the joint usually is intact and can
be left alone. Fifth Metatarsal Spiral Diaphyseal Fracture
• Type IV: A rare entity with several heads involved. May rep- (Dancer’s Fracture)
resent a congenital epiphyseal dysplasia rather than a true These fractures occur when the dancer rolls over onto the lat-
infraction. eral border of the foot from a demi-pointe position. The usual
fracture pattern is a spiral, oblique fracture starting distal-lateral
METATARSAL INJURIES and running proximal-medial (Fig. 24.13). The average time to
pain-free walking is 6.1 weeks; return to barre exercises around
Second Metatarsal Base Stress Fracture (see 11.6 weeks; and return to performance after 19 weeks.13 Recent
Chapter 5) literature supports excellent outcomes with conservative treat-
Most high-level dancers have a mild cavus foot. Despite the ment,14 but surgical treatment might occasionally be needed in
mechanical advantages it brings, this anatomy creates vis- severely displaced fractures.
à-vis technique where the rigidity of the foot places high
stresses on the bones during impact.10 In those dancers who Proximal Fifth Metatarsal Spiral Fracture
start their careers early in life, the metatarsals hypertrophy The base of the fifth metatarsal has three different anatomic
and the cortices broaden to accommodate the increased fracture zones: zone 1, tuberosity; zone 2, metaphyseal-diaph-
stresses placed on them. In certain cases, however, stress yseal junction (Jones fracture); and zone 3, diaphyseal stress.
fractures occur despite cortical hypertrophy, because the Proper identification of the zone affected is important, since
repeated microtrauma of dancing exceeds the reparative healing characteristics and treatment modalities are usually dif-
capacity of the bone. ferent. Fractures can be classified as15:
442 SECTION 4  Unique and Exceptional Problems in Sports

B C
Fig. 24.10  Freiberg’s Infraction. (A) Preoperative and postoperative anterior-posterior radiographs of the
second metatarsal Freiberg’s infraction; (B) transverse T1 magnetic resonance image of a third metatarsal
Freiberg’s infraction; (C) intraoperative findings with cartilage delamination.

• Type I: Avulsion fracture on the lateral aspect of the fifth not have ossified and the fracture will not be visible on plain
metatarsal tuberosity, extending proximally into the meta- radiographs. The diagnosis must be made clinically. MRI can
tarsocuboid joint. Usually caused by sudden inversion of the supplement the diagnosis. The treatment is similar.
foot, the peroneus brevis attachment is avulsed, in addition • Type II (Jones fracture): Fracture line usually begins later-
to the lateral band of the plantar fascia and the abductor dig- ally in the distal part of the tuberosity and extends obliquely
iti minimi. In general, this injury can be treated with immo- and proximally into the medial cortex at the level of the base
bilization and functional rehabilitation and rarely requires of fourth and fifth metatarsal articulation. Subtle cavus-
surgical intervention. Fibrous union will invariably occur varus alignment and metatarsus adductus (supinated fore-
even in the presence of significant distraction of the frag- foot) are commonly associated anatomic deformities. These
ments. In a skeletally immature dancer, this apophysis will fractures are difficult to treat in a dancer because extensive
 CHAPTER 24  Foot and Ankle Injuries in Dancers 443

Fig. 24.11  Stress Fracture of the Base of the Second Metatarsal in Dancers. Radiographic anterior-poste-
rior view and computed tomography scan, sagittal and transverse plane views demonstrating the transverse
fracture line.

Fig. 24.12  Nutcracker Fracture at the Base of the Second Metatarsal. Radiographic anterior-posterior view
and zoom demonstrating compression around the forefoot (arrows) driving the base of the first metatarsal to
impinge in the base of the second metatarsal, creating a stress area and a traditionally oblique fracture line.
Valgus strain of the forefoot during en pointe acts as a deforming force.

Fig. 24.13  Dancer’s Fracture of the Fifth Metatarsal. Anterior-posterior and lateral radiographic views
demonstrating the spiral oblique fracture line running from distal-lateral to proximal-medial.
444 SECTION 4  Unique and Exceptional Problems in Sports

B
Fig. 24.14  Jones Fracture in Dancers. (A) Radiographic oblique view of an acute fracture; (B) anterior-poste-
rior and lateral views of a fracture fixed with single intramedullary screw and bone graft.

time in a nonweight-bearing immobilization is required. dancer because the time to recovery from the procedure is
Because of the high rate of nonunion and refracture with extensive.
conservative treatment, we recommend percutaneous intra-
medullary screw fixation to decrease time lost from danc-
ing. Bone graft and or bone marrow aspirate concentrate
THE MEDIAL ANKLE
may be used as an adjunct to help osteosynthesis.16 If the Although posterior tibial tendon pathology is relatively common
screw is removed, the fracture has a significant risk of recur- in other sports, it is rare in dancers. The reasons for this are multi-
ring (Fig. 24.14 A and B). ple. Typically, a dancer’s foot is cavus, which tends to protect him
• Type III (proximal diaphyseal stress): Fracture distal to the or her from tibialis posterior pathology in comparison to a more
fourth and fifth metatarsal base articulation right at the planus foot. Also, when a dancer is in equines, the posterior tibial
metaphyseal-diaphyseal junction is usually caused by acute tendon is relatively shortened as the subtalar joint is inverted.
or chronic overload. Similar treatment options as for type II
fractures, where surgical treatment with single intramedul- Medial Ankle Sprains
lary screw and bone graft expedites return to dance activities. Medial ankle sprains occur infrequently and are associated with
a pronated foot landing off balance, being more common in
Bunionette Deformity male dancers. Injury pattern depends on the position of the foot
Pain over bunionettes usually can be diminished with soft pad- during the injury. If the foot is in plantarflexion, the anterior
ding or paper surgical tape adhesive taping to reduce friction and deltoid is maximally affected, and the tension is greatest in the
callus formation. Surgical resection usually is reserved for a retired deltoid in this position. Similarly, when the foot is flat on the
 CHAPTER 24  Foot and Ankle Injuries in Dancers 445

A B
Fig. 24.15  Osteochondral Defect of the Talus in Dancers. Magnetic resonance image demonstrating a
posteromedial talar dome lesion in (A) coronal and (B) sagittal T1 views.

ground and hyperpronated, the tear will occur in the midpor- Another frequent associated condition in dancers with lat-
tion of the deltoid. eral ankle instability is hypermobility or generalized ligament
An accessory bone, the os subtibiale, can be occasionally laxity. Physical examination looking for findings of hypermo-
found in the substance of the deltoid ligament. When injured, it bility is mandatory.
may manifest as a trigger point of pain when ligamentous heal- Acute lateral ankle ligament tears can be classified as:
ing should be complete. A local injection of steroid is all that is • Grade I: Partial tear, usually of the ATFL. This is a stable
required to treat this symptom. injury, requiring rest, ice, compression, and elevation for 48
Chronic strain of the deltoid from poor form in rolling in hours. Thereafter, motion is encouraged with a light com-
(pronation) of the foot is a common overuse injury in dancers. pressive bandage. Dancers can begin light workouts at 48
Chronic strain of the anterior aspect of the deltoid ligament, hours with the aid of a brace or Aircast. Initially, therapy
anchored to the capsule of the talonavicular joint, may predis- should concentrate on range of motion. After 4 or 5 days,
pose the ankle to chronic rotatory instability. dancers begin to wean out of the brace and initiate proprio-
Recalcitrant medial ankle pain may also be caused by an ception, balance, and peroneal-strengthening exercises.
osteochondral defect of the talus following a sprain. Clinical • Grade II: Complete tear of the ATFL, occasionally including
suspicion warrants further investigation with CT or MRI, which the CFL as well. A positive drawer sign is usually found, with
will demonstrate the extent of the lesion (Fig. 24.15 A and B). a negative talar tilt test. Treatment is immobilization in a cam
The size of the symptomatic osteochondral defect determines walker or Aircast for up to 6 weeks. Initially, physical ther-
the most appropriate treatment. Arthroscopic debridement apy should focus on regaining appropriate range of motion.
with microfractures, chondrocyte transplant, allograft implants, Thereafter, a triple-phase rehabilitation program including
and osteochondral grafting are available techniques. peroneal-strengthening, balance, and proprioceptive train-
ing should be initiated early.
LATERAL ANKLE • Grade III: Unstable injury. Both the ATFL and the CFL are
injured. In addition to the drawer sign, the talar tilt test is
Lateral Ankle Sprain positive. Ankle is severely unstable. Treatment tradition-
Lateral ankle sprain is a common injury in dancers and can ally is immobilization for up to 4 months. In a professional
often lead to recurrent instability and repetitive injuries.17 dancer, primary repair is preferred, and the Brostrom-Gould
Chronic ankle instability can be found in up to 75.9% of the technique can be usually performed 1 week following the
professional dancers, causing long-term limitations, especially injury with predictable results and return of function.19
in female dancers, who place extreme stress on their lateral Regardless of the treatment used, attention must be paid
ankle ligaments from being en pointe or demi-pointe.18 to reestablishing a functionally stable ankle joint. Early func-
The anterior talofibular ligament (ATFL) and calcaneofibular tional treatment has been shown to produce the fastest recovery
ligament (CFL) are important stabilizers of the lateral ankle and of ankle range of motion and earliest return to activity with-
are stressed at different ankle positions. The ATFL sprains in a out affecting mechanical stability.20 Closed chain balance and
plantarflexed and inverted foot, whereas the CFL is more prone proprioception activities, along with peroneal muscle strength-
to injury when the foot is dorsiflexed. ening, will improve the neuromuscular control of the ankle. A
The subtalar joint can contribute to the occurrence of lateral therapist must be familiar with the modalities needed to achieve
ankle sprains. Dancers with decreased subtalar motion can trans- these goals to optimize outcomes in these dancers.
fer stresses to the ankle joint and being prone to lateral ankle Residual symptoms following lateral ankle sprains in dancers
sprains. It is important to check for decreased subtalar motion. may be secondary to:
446 SECTION 4  Unique and Exceptional Problems in Sports

• Avulsion fracture of the tip of the fibula,

• Avulsion fracture of the calcaneus at the calcaneocuboid
joint,
• Accessory ossicle or os subfibularae,
• Calcaneus fracture or avulsion of extensor digitorum brevis,
• Fractured os peroneum,
• Fractured lateral process of talus,
• Fractured anterior process of the calcaneus,
• Talar dome osteochondral injury,
• Cuboid subluxation,
• Soft tissue entrapment,
• Sinus tarsi syndrome,
• Fractured os trigonum or Shepherd’s fracture,
• Syndesmotic disruption,
• Maisonneuve injury,
• Bone edema,
Fig. 24.16  Cuboid Subluxation in Dancers. Radiographic lateral
• Anterolateral ankle impingement,
view demonstrating the plantar subluxation of the cuboid at the calca-
• Peroneal tendon dislocation or subluxation, neocuboid joint.
• Functional ankle instability, or
• Impingement of a lateral branch of the deep peroneal nerve
(LBDPN). Anterior impingement in dancers may be induced by repet-
The treatment for chronic lateral ankle instability in itive dorsiflexion during demi-plié, where the anterior edge of
dancers is usually surgical. The Brostrom-Gould technique the distal tibial articular surface contacts the dorsal neck of the
is again the preferred initial technique. It is always important talus, and is typically seen in male dancers who perform high
to evaluate the patient for possible and frequent associated jumps and deep pliés (bravura).23 It also can be associated with
injuries that should be addressed concomitantly and include the sequelae of lateral ankle sprain, including a hypertrophic tis-
peroneal tendon pathology, talar osteochondral defects, and sue response, or simply by impingement of anatomically normal
ankle impingement.21 In revision cases or patients with ini- ligamentous structures. There are both osseous and soft-tissue
tial severe instability and generalized ligament laxity, the causes of impingement symptoms. Impingement of the ante-
option is lateral ligament reconstruction with hamstring rior lip of the tibia against the talus causes the cambial layer of
autograft. the periosteum to produce reactive bone formation and osteo-
phytes or “kissing lesions.”24 This is a continuous cycle as more
Cuboid Subluxation bone forms, and eventually motion is significantly restricted.
Cuboid subluxation is a common but poorly recognized condi- Three main types of lesions are seen (Fig. 24.17):
tion in ballet dancers and might be resultant from prior repet- • Anterior tibial lip,
itive lateral ankle sprains. Its symptoms include lateral midfoot • Talar neck, or
pain and an inability to “work through the foot.” In addition, • A combination of both.
pressing on the plantar surface of the cuboid in a dorsal direc- Treatment for symptomatic cases is usually arthroscopic
tion produces pain. The normal dorsal/plantar joint play is debridement, which has been shown to be an effective method
reduced or absent when compared with the uninjured side, for the treatment of bony and soft-tissue anterior ankle impinge-
and subtle forefoot abduction is present. Frequently, there is a ment in dancers, with minimal morbidity.25 Special attention
shallow depression on the dorsal surface of the foot and palpa- should always be directed to the medial aspect of the joint,
ble fullness on the plantar aspect of the cuboid. Radiographic, where most of the osteophytes are usually located.
CT scan, or MRI evaluation is difficult because of the normal Extensive bone formation or degenerative arthritis might
variations found in the relationship between the cuboid and its require an anterior or anteromedial arthrotomy.
surrounding structures (Fig. 24.16). The diagnosis is primarily
subjective, and must be made on the basis of the patient’s his-
tory and physical findings. Treatment requires recognition of
POSTERIOR ANKLE (SEE CHAPTER 2)
the condition and manual reduction. Close follow-up is imper- Ideally, more than 100 degrees of plantarflexion should occur at
ative to certify that the cuboid remains in the correct reduced the foot-ankle complex in a professional ballet dancer. Much of
position.22 this has to be accomplished by the subtalar joint, and subtalar
motion is facilitated by the turned-out position of mild forefoot
pronation and abduction, unlocking the transverse tarsal joints.
ANTERIOR ANKLE (SEE CHAPTER 2) Any form of tarsal coalition, whether fibrous or bony, will pre-
The cavus foot is biomechanically ideal for dancers in that plan- vent the subtalar joint from supplementing the ankle joint in
tarflexion capacity is maximal. However, this is at the expense of full equinus. Consequently, most dancers with subtalar coali-
dorsiflexion, which is frequently limited. tions do not reach professional grade.
 CHAPTER 24  Foot and Ankle Injuries in Dancers 447

B C
Fig. 24.17  Anterior Ankle Impingement in Dancers. (A) Radiographic lateral view, (B) computed tomogra-
phy scan sagittal, and (C) three-dimensional reconstruction views of tibiotalar osteophytes.

Posterior Impingement Syndrome The differential diagnosis includes Achilles tendinitis, peroneal
The posterior tubercle of the talus varies greatly in size. In pos- tendinitis, or heel pain.
terior impingement syndrome, either a large posterior tubercle The os trigonum is present in up to 10% of the population
or an os trigonum is caught between the posterior lip of the and is bilateral in 50% of the patients. Anatomically, the os
tibia and the calcaneus when the dancer is in relevé, resulting trigonum represents the nonfused lateral tubercle of the poste-
in repetitive and overuse injuries (Fig. 24.18 A, B and C).26–28 rior process of the talus. The lateral and medial talar tubercles
A simple clinical sign, the forced plantarflexion sign, confirms form a fibro-osseous tunnel where the flexor hallucis longus
the diagnosis when pain is produced by full plantarflexion at (FHL) tendon runs on the back of the ankle joint. Most cases
the back of the ankle. The syndrome is usually a result of an os of os trigonum are asymptomatic in the general population, and
trigonum impinging the soft tissue rather than the bone itself. this is also true in dancers. However, in dancers this condition
448 SECTION 4  Unique and Exceptional Problems in Sports

is often unnecessarily operated. For this reason, a diagnostic Posterior impingement may also occur in association with
anesthetic injection is advised before deciding on any surgi- chronic lateral ankle instability. The talus slips forward and the
cal intervention. If there is no subsequent pain relief following posterior lip of the tibia impinges on the calcaneus. Treating
the injection, differential diagnosis should be considered and the lateral ligament instability usually addresses this form of
include FHL tendinopathy, peroneal tendinopathy, and stress impingement.
fracture of the posterior process of the talus.
Treatment of an os trigonum is generally nonsurgical. Once Flexor Hallucis Longus Tendinopathy
a diagnosis has been confirmed by local anesthetic injection, the The FHL is the most common site of lower extremity tendon dis-
next step is rest and activity modification. Local steroid can give orders in ballet dancers. This entity has become known as “danc-
dramatic relief of symptoms that often is long lasting or perma- er’s tendinitis.” As the tendon passes between the fibro-osseous
nent. When surgery is required, arthroscopic or open resection tunnel at the back of the talus, it runs deep to the sustentaculum
can be performed with similar reported outcomes. However, tali. Within this pulley system it can become inflamed and cause
patients treated endoscopically returned to full dance earlier irritation and swelling. Reduced vascularity is also an important
(mean of 9.8 weeks) than those undergoing open excision (14.9 factor contributing to tendon degeneration and rupture under
weeks).29,30 For open resection either a posteromedial or postero- strain.33
lateral approach can be used.31 In cases in which it is suspected that When the tendon has a thickening or a partial tear at a
there is an associated FHL pathology, a posteromedial approach particular area, it may cause triggering (Fig. 24.19). This
is preferred so that tenolysis can be performed safely. The tendon condition is known as hallux saltans.34,35 When the tendon
debridement can be also performed arthroscopically.32 becomes completely stuck down within the pulley system, a

C
Fig. 24.18  Posterior Ankle Impingement in Dancers. (A) Lateral radiographic view of an os trigonum; (B)
lateral radiograph of an os trigonum in relevé position; (C) illustration of os trigonum posterior impingement.
 CHAPTER 24  Foot and Ankle Injuries in Dancers 449

Fig. 24.19  Flexor Hallucis Longus Tendinopathy. Intraoperative find- Fig. 24.20 Lateral radiographic view of a Haglund’s deformity in a
ing. dancer with cavus-varus foot.

pseudohallux rigidus can be seen. Dancers tend to have symp-

toms for a longer period of time before seeking treatment than Tendinosis of the Achilles Tendon
non-dancers.36 Tendinosis is caused by microtears of the collagen fibers on
A trial of conservative treatment can be tried with resting the surface or in the substance of the tendon. Its most com-
and antiinflammatories. Local steroid injections should be mon form occurs at the isthmus of the tendon and involves a
avoided whenever possible secondary to increased risk of ten- localized swelling of the pseudosheath. This may be felt clini-
don rupture. However, this condition is frequently persistent cally as crepitus when the tendon is stretched and relaxed—the
and disabling, and open surgical tenolysis is frequently needed, so-called painful arc sign. Chronic tendinosis can be felt as mul-
with good reported results.36,37 Arthroscopic treatment is also tiple nodules on the surface of the tendon. More severe strains
described.32 result in a classic fusiform swelling of the tendon. This is slow to
Three areas of tendon pathology are typically found. The heal and carries a guarded prognosis.
most common location is behind the medial malleolus. It may Treatment requires rest initially, usually in a cam walker with
also be found at the knot of Henry, or at the base of the first a heel-raise insert for up to 6 weeks. Failure to comply with
metatarsal where the tendon passes beneath the sesamoid strict immobilization initially can result in prolonged symp-
bones. tomatology and rupture of the tendon. Treatment can be sup-
plemented with antiinflammatory medication. Rehabilitation
consists of stretching exercises and a gradual strengthening
ACHILLES TENDON (SEE CHAPTER 9) program. In more chronic cases, use of an overnight splint to
As the largest tendon in the body, the Achilles tendon incurs assist with a prolonged stretch in a dorsiflexed position can be
forces up to six times body weight during running and jump- helpful. Orthotic prescription may be considered to help correct
ing. Optimal lower leg function is critical for ballet dancers to any structural imbalances in the foot. A ‘‘stretch box’’ is a useful
meet their occupational requirements. The tendon is commonly tool to prevent injury that is used by many ballet schools. This
injured in dancers either from repetitive overload or excess allows dorsiflexion of the ankle with stretching of the Achilles
stress applied by poor technique. Although a common site of tendon before and between performances. However, dancers
injury in dancers, the tendon is rarely ruptured in this group of must exercise caution to avoid stretching the Achilles tendon
athletes.38 too aggressively, causing more tears and thereby worsening the
condition.
Peritendinitis of the Achilles Tendon Certain factors can predispose to Achilles pathology in
The Achilles tendon has no real synovial sheath and is sur- dancers:
rounded by a peritendon, which can become inflamed from • Cavus foot with associated Haglund’s disease (Fig. 24.20),
overuse or from the tight ribbons of ballet shoes. The peri- with tendinitis of the Achilles overlying the retrocalcaneal
tendinitis is classically seen as a diffuse swelling along the bursa. Cavus feet are common in this population because
Achilles tendon. When the tendon itself is inflamed, it pres- they afford the dancer a distinct anatomic advantage. For this
ents as a discrete swelling along the tendon. Treatment of reason, any prominence at the posterosuperior aspect of the
peritendinitis requires rest. A cam walker with a heel-raise calcaneus can cause irritation of the tendon and may neces-
insert worn for 23 hours/day should be worn for at least 2 sitate surgical resection of the prominence and debridement
weeks. This can break the cycle of inflammation and prevent of the tendon (Fig. 24.21 A and B).
the next step in the continuum of pathology—pathology of • ‘‘Rolling in’’ or pronation of the foot.
the tendon itself. • ‘‘Ribbon burn’’ from tight toe ribbon at the back of the leg.
450 SECTION 4  Unique and Exceptional Problems in Sports

A B
Fig. 24.21  Haglund’s Deformity in Dancers. (A) Preoperative lateral radiographic view and (B) intraoperative
lateral fluoroscopic view after resection of the superior aspect of the posterior calcaneal tuberosity.

• Congenitally thin tendon predisposed to overload injury. The plantar fascia is not intimately attached to the spur, giving
• Gastrocnemius contracture. rise to the flexor digitorum brevis.
Stretching of the fascia before rehearsing or performing can
Rupture of the Achilles Tendon reduce the incidence of this injury. Also, using a firm rubber
Achilles tendon ruptures are rare in female athletes and more ball for rolling into the plantar fascia while weight bearing helps
common in male dancers older than 30 years. Typically, a tear to loosen the fascia and make it more pliable. A silicone heel can
presents as a sharp pain of sudden onset and an inability to also give symptomatic relief in a dancer who has point tender-
walk on the toes. A Thompson test is the best clinical diagnostic ness in this area.
test. Feeling for a defect along the tendon usually is diagnostic;
however, an intact peritendon filled with hematoma may mimic Plantar Calcaneal Bursitis
an intact tendon. Ultrasound or MRI can confirm the diagno- Found beneath the calcaneus, this condition usually can be
sis with a high degree of sensitivity and specificity. Treatment diagnosed clinically; however, ultrasound can confirm the
is dependent on the requirements of the patient. Conservative diagnosis.
treatment was initially associated with a high rate of rerup-
tures. However, more recent studies have demonstrated simi- Baxter’s Nerve Neurapraxia
lar functional outcomes and rerupture rates when comparing The first branch of the lateral plantar nerve or nerve to abduc-
conservative functional treatment and surgical treatment.39 In tor digiti minimi may be trapped under the deep fascia of the
athletes, the operative intervention is still preferred with the abductor hallucis.42 This is exacerbated when the dancer ‘‘rolls
advantage of restoring the physiologic length of the tendon and in’’ or pronates. Although the cause is a neurapraxia of the lat-
optimizing functional outcome.40 This requires up to a full year eral branch of the plantar nerve, the condition is painful on the
of treatment and rehabilitation before the dancer can return to medial aspect of the heel, adjacent to the medial calcaneal tuber-
preinjury levels of dance. Limited open techniques with percu- osity. A local anesthetic is the treatment for recalcitrant cases.
taneous suturing facilitate early motion and reduce the risk of
associated skin problems.41 Correct tensioning of the repair is
critical to outcome regardless of the technique used.
LEG PAIN (SEE CHAPTER 23)
The three primary conditions in dancers that predispose to
Pseudotumor of the Calf leg pain include shin splints, stress fracture, and compartment
An accessory soleus muscle can present as a slowly enlarging syndrome.
mass on the medial side of the calf. It generally is painless, usu-
ally presenting as a feeling of tightness. Surgical division of the Shin Splints (Medial Tibial Stress Syndrome)
muscle sheath may be required and will generally relieve the Shin splints is a generic term often used to describe both trac-
symptoms. tion periostitis and stress fractures of the tibia. It has gained cre-
dence in the general population to describe generalized leg pain.
HEEL PAIN (SEE CHAPTER 11) A more useful nomenclature is medial tibial stress syndrome
(MTSS). For the purposes of this discussion, MTSS describes
Plantar Fasciitis a traction periostitis alone. This condition is associated with a
Pain on the medial aspect of the fascia origin is the most com- diffuse anteromedial or posteromedial tibial pain. Typically, the
mon presentation. The presence of a spur usually is not the cause pain is in the distal one-third of the tibia. It can be differentiated
of heel pain, despite often impressive radiographic evidence. from stress fracture, which has localized point tenderness and
 CHAPTER 24  Foot and Ankle Injuries in Dancers 451

motion, the number of stress fractures has reduced. This is in

contrast to the rapid deceleration motion seen in the Bravura
technique.

Compartment Syndrome
When the pressure within an enclosed fascial compartment
exceeds the pressure required to perfuse the muscle with blood,
the muscles and enclosed structures may become compromised.
This can lead to pain initially and may reach the point of muscle
ischemia in more severe cases. In dance, the blood volume to
the exercising muscle can increase up to 20%, thereby exceeding
the physiologic pressure within the muscle compartments. Most
cases of exertional compartment syndrome involve the anterior
compartment or the deep posterior compartment. Normal rest-
ing compartment pressures range from 0 to 8 mm Hg. During
exercise this can increase to 50 mm Hg. Following exercise, this
pressure should fall to 15 mm Hg within 15 minutes. Treatment
of exertional compartment syndrome usually is conservative,
with antiinflammatory medication and shoe modification and
A B activity modification. Rarely, a fasciotomy is required.
Fig. 24.22  Anterior Tibial Shaft Stress Fractures in Dancers. (A) Pre-
and (B) postoperative anterior-posterior and lateral views.
SUMMARY
is usually located in the mid-diaphysis of the tibia and distal Classical ballet offers a graceful and beautiful spectacle. This
one-third of the fibula. beauty comes at great physical, psychological, and economic cost
Typically, MTSS occurs at the beginning of the season after to the ballet dancer.43 It is estimated that up to 95% of dancers
a prolonged period of inactivity. Stress fractures, on the other employed for greater than 1 year will suffer a significant injury.
hand, happen secondary to repetitive trauma and occur usually Most of these physical injuries occur to the foot and ankle in
in mid to late dance season. female ballet dancers.44 Many of these injuries are as a result of
MTSS can be localized anteriorly or posteriorly. Posterior dancing on the point of the toe. This form of dancing was first per-
MTSS is the most common in dancers and arises at the origin formed by Genevieve Gosselin in 1818 at the Paris Opera house.
of the flexor digitorum longus (FDL) muscle, and not from the The illusion of weightlessness and the grace implied in en pointe
tibialis posterior, which arises from the interosseous membrane. dancing was further enhanced by the great dancers Taglioni and
Anterior MTSS, not as common in dancers, represents a perios- the immortal Istomina. Since their time, the beauty, romance,
titis at the origin of the tibialis anterior muscle. and grace of en pointe have been enjoyed by dancers all over the
world. Unfortunately, the ‘‘cruel little slipper’’ that is the en pointe
Stress Fractures shoe, as well as the physical demands of the dance itself, has left
Prolonged biomechanical imbalances and increased repetitive many dancers with significant injuries and permanent deformi-
loads beyond the body’s reparative capacity typify the causes ties. It must be emphasized that, when the orthopedist examines
of stress fractures. Thus these injuries generally occur at the a ballet dancer, the entire kinetic chain requires close inspection.
end of the dancer’s season, in contradistinction to MTSS, Isolated injuries to the foot and ankle may precipitate additional
which usually occurs at the beginning. Initially, radiographic injuries farther up the kinetic chain as a compensatory response
findings may be subtle with mild periosteal reaction, and the to the injury or inadequate and improper rehabilitation.45 Apart
best method of confirming a clinical suspicion is MRI. As from the physical examination, a careful history and biochemical
the process progresses, conventional radiographs may reveal profile should be investigated in those dancers showing any signs
the fracture line that is usually located on the anterior aspect of the aforementioned dancer’s triad: anorexia, amenorrhea, and
of the tibia and better seen in the lateral view (Fig. 24.22). osteoporosis.46 In addition to the biomechanical examination
The presence of the line is an indicator of severity and that and biochemical evaluation, the orthopedist should be cognizant
the fracture will be slow to heal, requiring an extremely long of the psychosocial aspects of a dancer’s makeup. Dancers, in gen-
period of 6 to 8 months of protected weight bearing, not eral, regard injury and pain as a way of life and are reluctant to
acceptable for a competitive dancer. We advocate anterolateral present to health care professionals for fear of long-term immo-
compression plating for those dancers with localized disease, bilization and eventual unemployment.43 As an advocate for the
but if there are multiple lines, intramedullary fixation with dancer as an athlete, the clinician should be aware of these con-
a locked rod is the treatment of choice. Since the introduc- cerns and strive to provide an accurate diagnosis and expeditious
tion of Balanchine method of dance, which emphasizes fluid treatment strategy.
452 SECTION 4  Unique and Exceptional Problems in Sports

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Fractures of the base of the fifth metatarsal distal to the tuberosity. 37. Kolettis GJ, Micheli LJ, Klein JD. Release of the flexor hal-
Classification and guidelines for non-surgical and surgical man- lucis longus tendon in ballet dancers. J Bone Joint Surg Am.
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16. O’Malley M, DeSandis B, Allen A, Levitsky M, O’Malley Q, 38. Zellers JA, van Ostrand K, Silbernagel KG. Calf endurance and
Williams R. Operative treatment of fifth metatarsal jones achilles tendon structure in classical ballet dancers. J Dance Med
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2016;37(5):488–500. 39. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M.
17. Hamilton WG. Sprained ankles in ballet dancers. Foot Ankle. Surgical versus nonsurgical treatment of acute Achilles tendon
1982;3(2):99–102. rupture: a meta-analysis of randomized trials. J Bone Joint Surg
18. Simon J, Hall E, Docherty C. Prevalence of chronic ankle insta- Am. 2012;94(23):2136–2143.
bility and associated symptoms in university dance majors: an 40. Kadakia AR, Dekker 2nd RG, Ho BS. Acute Achilles tendon
exploratory study. J Dance Med Sci. 2014;18(4):178–184. ruptures: an update on treatment. J Am Acad Orthop Surg.
19. Hamilton WG, Thompson FM, Snow SW. The modified Brostrom 2017;25(1):23–31.
procedure for lateral ankle instability. Foot Ankle. 1993;14(1):1–7. 41. Assal M, Jung M, Stern R, Rippstein P, Delmi M, Hoffmeyer P.
20. Lynch SA, Renstrom PA. Treatment of acute lateral ankle Limited open repair of Achilles tendon ruptures: a technique with
ligament rupture in the athlete. Conservative versus surgical a new instrument and findings of a prospective multicenter study.
treatment. Sports Med. 1999;27(1):61–71. J Bone Joint Surg Am. 2002;84-A(2):161–170.
 CHAPTER 24  Foot and Ankle Injuries in Dancers 453

42. Baxter DE, Pfeffer GB. Treatment of chronic heel pain by surgical 45. Macintyre J, Joy E. Foot and ankle injuries in dance. Clin Sports
release of the first branch of the lateral plantar nerve. Clin Orthop Med. 2000;19(2):351–368.
Relat Res. 1992;(279):229–236. 46. Warren MP, Brooks-Gunn J, Fox RP, Holderness CC, Hyle EP,
43. Kelman BB. Occupational hazards in female ballet dancers. Advo- Hamilton WG. Osteopenia in exercise-associated amenorrhea
cate for a forgotten population. AAOHN J. 2000;48(9):430–434. using ballet dancers as a model: a longitudinal study. J Clin Endo-
44. Nilsson C, Leanderson J, Wykman A, Strender LE. The injury crinol Metab. 2002;87(7):3162–3168.
panorama in a Swedish professional ballet company. Knee Surg
Sports Traumatol Arthrosc. 2001;9(4):242–246.
Video Legends - https://www.kollaborate.tv/link?id=5c9d20f756b57 Video 24.10  Title: Plie Passe.

Video 24.1  Title: About Dance Smart. Video 24.11  Title: Plie.

Video 24.2  Title: Airplane Test. Video 24.12  Title: ROM−Beighton Scale.

Video 24.3  Title: Example of modern dance. Video 24.13  Title: ROM−hip rotation.

Video 24.4  Title: Example of musical theater dance. Video 24.14  Title: SauteTest.

Video 24.5  Title: Example of newer dance form example blend of Video 24.15  Title: Stability−Hip.
jazz/ hip.
Video 24.16  Title: Stability−Toes.
Video 24.6  Title: Jete.
Video 24.17  Title: Stability Core.
Video 24.7  Title: Neural Mobility.
Video 24.18  Title: Tendu.
Video 24.8  Title: P to TO Yard Stick Test.
Video 24.19  Title: Torsion−Hip Knee.
Video 24.9  Title: Pirouette.
Video 24.20  Title: Triple Hop.

453.e1
 25
An International Perspective on
the Foot and Ankle in Sports
Lucas Furtado da Fonseca, Pedro Augusto Pontin,
Gustavo Damasio Magliocca, Gustavo Gonçalves Arliani,
Andrew Roney, Cesar de Cesar Netto
Gonzalo F. Bastías, Felipe Chaparro, Yuan Zhu, Xiangyang Xu, Carlos
Ramirez, Juan Kalb, Mostafa M. Abousayed, Ahmed Khedr, Amgad M.
Haleem, Rajiv Shah, Malhar Dave, Nikesh Shah, Alireza Mousavian,
Yasuhito Tanaka, Elias Hermida, Luis F. Hermida, Adriaan Van Zyl,
Ignatius Terblanche, Apisan Chinanuvathana, Jakrapong Orapin,
Apiporn Garnjanagoonchorn, Wisutthinee Thueakthong, Moosa Kazim,
Gabriel Khazen, Cesar Khazen

OUTLINE
Brazilian Foot and Ankle Injuries in Sports, 455 Kho Kho, 473
The Subtle Lisfranc Ligament Lesion, 455 Management, 474
Beach Toe Lesions, 456 The Athletic Foot and Ankle in Iran, 474
Posterior Ankle Impingement, 457 Mountain Tracking and Rock Climbing, 474
Loose Bodies of the Ankle Joint, 458 Chovgan, 475
Fifth Metatarsal Stress Fracture, 459 Wrestling, 475
Slaloming the Andes Mountains: Ski And Snowboard Inju- Pahlevaniv, 475
ries Of The Foot And Ankle In Chile, 460 Foot and Ankle Injuries Caused By Traditional Japanese
Introduction, 460 Martial Arts, 475
Equipment and Technical Considerations, 460 Judo, 476
Ankle Sprains and Fractures, 461 Sumo, 477
Snowboarder᾽s Fracture, 461 Kendo, 478
Morton᾽s Neuroma, 462 Foot and Ankle Injuries of Racetrack Jockeys in Mexico City,
Skier᾽s Toe, 462 479
Chilblains, 462 Introduction, 479
Chinese Traditional Concepts of Foot and Ankle Problems Mechanism of Injury (Box 25.1), 479
and Traditional Treatments, 463 Open Fractures, 480
Colombian Foot and Ankle Conditions in Sports, 465 Recovery Time on Bimalleolar Fractures, 480
Ankle Sprains and Ankle Impingement, 465 Protective Gear, 480
Achilles Tendon Lesions, 467 Summary, 481
Lisfranc Low-Grades Sprains, 468 Sports Injuries in South Africa, 481
An Egyptian Perspective on the Foot and Ankle in Sports, 468 Overload Injuries to the Second Metatarsal, 481
Osteochondral Lesions of the Talus, 468 Investigations, 482
Flexor Hallucis Longus Tendinitis/Posterior Ankle Impinge- A Perspective on the Foot and Ankle in Sports From Thai-
ment, 469 land, 483
Other Injuries, 469 Muay Thai, 483
An International Perspective on the Foot and Ankle in Sepak Takraw, 484
Sports: India, 472 Foot and Ankle Injuries in United Arab Emirates Sports, 486
Cricket, 472 Plantar Plate Rupture and Drum-Beat Dance in Venezuela, 488
Hockey, 473 Plantar Plate Rupture and Venezuelan Drum-Beat Dance, 489
Kabaddi, 473 Our Treatment Choice for Plantar Plate Rupture, 490

454
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 455

BRAZILIAN FOOT AND ANKLE INJURIES IN Excellent results have been reported with nonoperative treat-
ment when less than 2 mm of diastasis occurs.9 However, a low
SPORTS tolerance for displacement should be accepted in elite players, as
Epidemiological studies on sport injuries occurring at the foot some recent studies have shown a trend that a surgical approach
and ankle are not consistent and lack uniformity in published results in an earlier return to play.8,10
outcomes in Brazil. Current literature on sports injuries in the The intraoperative finding of proximal extension of a
country indicates that soccer is the most frequently investigated Lisfranc injury into the intercuneiform area and naviculocune-
and the first source of injury.1 Research has shown that soccer iform joints is not uncommon. Small intercuneiform diastasis
players have a 1000-fold increased risk of injury compared to can be misdiagnosed and represents a less stable injury pattern
industrial workers.1 Approximately 15.3 million people in Brazil that demands adequate open reduction and internal fixation
play soccer, which represents 39.3% of all sports practiced in the (Figs. 25.2 and 25.3).
country.2 Barefoot sports such as beach soccer and beach volley-
ball have also been gaining participants due to Brazil’s advanced
placements in recent international tournaments.
Among sport injuries, after the thigh, the foot and ankle
are the most common locations for injury.3 In one epidemio-
logical study, severe ankle and foot problems occurred in 33%
of the 200 healthy soccer players over 2 years of prospective
observation.4 Direct player-to-player contact (32%) and over-
use (26%) are the most commonly cited mechanisms of injury.5
Of these, by far the most common injuries are sprains (80%)
(which includes foot sprains such as Lisfranc lesions), followed
by bruises (9%–49%) and tendon lesions (2%–23%). Fractures
are rare and account for only 1% of all ankle injuries in soccer.6
Except for Achilles tendinopathies, which are higher during the
preseason, most injuries occur during competition.5
Here, we briefly describe some of the most common inju-
ries that are seen in our clinics, including subtle Lisfranc injury,
sand-toe, posterior ankle impingement, and loose bodies of the
ankle joint.

The Subtle Lisfranc Ligament Lesion

In athletes, Lisfranc lesions are mostly the result of indirect trauma, Fig. 25.1  Subsequent weight-bearing x-ray after 1 week of rest demon-
occurring as plantar flexion or abduction injuries.7 Plantar flex- strates widening at Lisfranc joint.
ion injuries often occur when the player suffers a slide tackle and
an axial load is applied to a plantar flexed foot while the toes are
dorsiflexed through the metatarsophalangeal (MTP) joints. The
ligamentous complex at the tarsometatarsal (TMT) joints usually
fails dorsally as rotational forces are applied to the midfoot, with
resulting subtle joint subluxation or dislocations. Abduction pat-
tern injuries are also common in Brazil and occur when the fore-
foot is suddenly abducted relative to a fixed hindfoot, such as in
equestrian sports in which riders have their feet stuck in the stirrup
and may suddenly be thrown out of the saddle.
Early diagnosis of Lisfranc injuries is critical to allow for
appropriate treatment and a speedier return to play. Misdiagnosis
or maltreatment of these potentially career-ending injuries may
not only prolong return to competitive play but can also lead to
posttraumatic degenerative changes and pain that limit activity
and quality of life in the future. Patients with subtle Lisfranc com-
plex injuries may present with varied degrees of swelling through-
out the midfoot, though they reliably report pain with attempted
weight-bearing activity.8 Several tests are described, but a high
index of suspicion is paramount for diagnosing these injuries.
Radiographic studies are critical. If it is too painful for patients to
cooperate with adequate standing x-rays, a couple of days of rest Fig. 25.2  A professional goalkeeper (same as Fig. 25.1). Dorsal
or intra-articular local anesthetic can be administered (Fig. 25.1). approach for subtle Lisfranc injury.
456 SECTION 4  Unique and Exceptional Problems in Sports

Subtle Lisfranc lesions in athletes are not typically associated Our postoperative care consists of a below-knee nonweight-
with a severe degree of swelling. Therefore, in subtle lesion cases bearing boot used for 6 weeks. Foot and ankle range-of-motion
swelling would not limit the ability to proceed with surgery as (ROM) exercises are initiated at 3 weeks. At 2 months, patients
soon as feasible. The authors generally attempt to avoid pene- are allowed to wean out of the boot as tolerated. Plates and
trating cartilage surfaces at internal fixation up to 3 months after screws are routinely removed during the fourth month, and
injury. In cases where the initial diagnosis was missed, or treat- patients are permitted to fully weight bear on the limb.
ment is delayed for more than 6 weeks, open reduction of the
involved joints is required to remove the thickened scar tissue Beach Toe Lesions
between the joints, preventing a stable closed reduction. Dorsal Barefoot sports seem to have a surprisingly low number of inju-
bridging plates with or without a C1M2 screw may be a better ries, sometimes even lower than the rates for athletes wearing
option for high-impact athletes and contact players (Fig. 25.4). shoes and doing the same or similar activities. For instance, in
beach volleyball, injury rates have been found to be fourfold
lower during competition on the sand compared to indoors.11
Competing barefoot on a sand interface may pose a unique risk
for injury that is mainly exclusive to beach volleyball, known as
“sand toe.” The mechanism of this injury is a hyper-plantarflexion
sprain of the great toe, which usually occurs when the player steps
down unsteadily and shifts forward, catching the big toe in the
sand (Fig. 25.5). This stresses the dorsal capsule of the MTP joint.
This is essentially the opposite mechanism of injury of turf toe.12
Clinically, athletes present with tenderness at the dorsum of the
MTP joint capsule and pain in the same area with toe plantarflex-
ion, which is worse with passive stretching. Active dorsiflexion is
not as painful, and strength is typically intact.
Diagnosis is made clinically, but x-rays should rule out frac-
tures or avulsions. A magnetic resonance image (MRI) should
be reserved for severe lesions with likely extensor hallucis lon-
gus (EHL) weakness, when dorsiflexion strength does not get
better after 6 to 8 weeks.
Treatment starts with taping that is typically continued for
the remainder of the competitive season, or until the toe can
be plantarflexed passively and fully without pain. On the other
Fig. 25.3  A proximal intercuneiform lesion is appreciated with manual hand, rupture of the dorsal hood resulting in EHL sublux-
stress. ation may result in pain that is most pronounced with resisted

Fig. 25.4  Dorsal plating after extensive removal of thickened scar tis- Fig. 25.5  Mechanism of the sand toe injury‒hallux in hyperflexed into
sue. This patient presented 6 weeks after the trauma. the sand.
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 457

dorsiflexion and may need surgical repair. In a series of 12 symptoms by changing sports habits and wearing braces to limit
patients, the average player took 6 months to fully recover from plantarflexion.16
the injury.12 Beach volleyball players will probably benefit most Os trigonum is present in 8% to 13% of the general popula-
if they do some portion of their rehabilitation on an uneven tion and can impinge against the tibia and calcaneus, especially
sand surface, since this is the surface on which they will be in ballet dancers and soccer players.17 When symptoms cannot
returning to play. be relieved by conservative measures, athletes tend to compen-
In beach soccer, most injuries occur in the feet and toes sate the loss of plantarflexion by placing the foot in a suboptimal
(36.4%), followed by the Achilles tendon (18.2%).13 A specific position in order to diminish symptoms, which leads to further
clinical syndrome characterized by progressive pain and swell- injuries. Therefore, surgical treatment should not be delayed in
ing in the dominant (kicking side) hallux MTP or interpha- order to avoid other related lesions (Fig. 25.9).
langeal (IP) joints can lead to an osteochondral injury of the
hallux (Fig. 25.6). Hyperextension or hyperflexion with repet-
itive trauma of the hallux MTP or IP joints is the postulated
mechanism of injury. Radiographic evaluation can show a mar-
ginal, often sclerotic, bony fragment within the lateral or medial
aspect of the symptomatic MTP or IP joints. This fragment usu-
ally represents marginal osteonecrosis that can be confirmed
with MRI. When a symptomatic bony fragment is identified
within the MTP or IP joints of the hallux, simple excision has
been reported to predictably relieve symptoms.14

Posterior Ankle Impingement

Posterior ankle impingement syndrome (PAIS) is a clinical
disorder defined as a painful limitation of ankle ROM—more
specifically, forced plantarflexion—usually caused by repetitive
stress. Causes include neurovascular lesions that involve the
Stieda process, malunion fractures of the posterior malleolus or
talus, os trigonum syndrome, flexor hallucis longus stenosing
tendinitis (Figs. 25.7 and 25.8), osteochondral lesions (OCLs),
and retrocalcaneal bursitis.15
Among soccer players, PAIS symptoms arise more com-
monly when the soccer player sprints or hits the ball, which
results in forced plantarflexion of the ankle. Approximately 60% Fig. 25.7  Flexor halluces longus tendinitis caused by impinging effect
of conservatively treated athletes show improvement of their from Os Trigonum Syndrome.

Fig. 25.8  Flexor halluces longus is involved with extensive tenosynovi-

Fig. 25.6  Osteochondral injury of the hallux in beach soccer. tis, proximal to its tunnel.
458 SECTION 4  Unique and Exceptional Problems in Sports

We prefer to endoscopically treat these patients through two Loose Bodies of the Ankle Joint
para-Achilles portals previously described in the literature,18 Loose fragments of the ankle joint in athletes usually result from
because we believe faster return to play can be achieved. Return anterior bone impingement with fracture of the anterior osteo-
to play usually occurs around 40 days. Full weight bearing with phytes (Fig. 25.12). The mechanism of loose bodies is related
crutches is allowed immediately, and after 1 week can be done to recurrent ball impact or the repetitive hyper-dorsiflexion,
without crutches or a cane. Sports activity is resumed on their which occurs in high-impact sports, such as volleyball and run-
second postoperative week and field training with their respec- ning. The classic presentation is anterior ankle pain (especially
tive teams from week 4 thereon. with compression of the soft tissues against the anteromedial
When resecting the Os Trigonum, one should release all aspect of the ankle), restriction of dorsiflexion, and swelling.
bands involving the flexor halluces longus (FHL), since a con- When fracture of the osteophytes occurs, pain may go away and
stricting effect may arise from scar tissue there (Figs. 25.10 and loose bodies may deposit into lateral or medial gutters.
25.11).

OS trigonum

Fig. 25.11  After removal of the Os Trigonum and soft tissues, subtalar
surface and flexor halluces longus tunnel are well delineated. Care must
Fig. 25.9  Os Trigonum impinging against posterior subtalar and ankle
be taken not to over-resect bone tissue and damage healthy cartilage.
joints. Note the narrowing of the flexor halluces longus tunnel.

*
OS

Fig. 25.10 Os Trigonum (OS) being resected. Fibers bands around

flexor halluces longus are seen (*). Fig. 25.12  Loose body in the anterior compartment of the ankle.
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 459

Lateral ankle radiographs reveal osteophytes on the anterior supination as the most likely position for maximal strain on
tibia and talar neck (kissing osteophytes). The diagnostic value the fifth metatarsal base. Whether any prodromal symptoms
of an oblique radiograph in addition to a lateral radiograph has existed or not, the athletes report acute pain in the lateral foot
been shown. When the lateral radiograph was combined with at the metaphyseal-diaphyseal junction of the fifth metatarsal.
an oblique anteromedial radiograph, the sensitivity and speci- Commonly, the athlete is unable or lacks confidence to continue
ficity of the method were high.19 MRI is useful to rule out any full play.21
associated soft tissue lesions (Fig. 25.13). Fifth metatarsal stress fractures typically involve the proxi-
We have a low threshold to maintain athletes in conservative mal to mid diaphysis, characteristically occurring more distal
treatment. Arthroscopy is usually indicated when diagnosis is than a traumatic base of fifth metatarsal tuberosity avulsion
confirmed. Results of ankle arthroscopic soft-tissue debridement fracture.
and osteophyte resection are good, satisfaction is high (94% to Physical examination confirms mild to moderate swelling
98%), and the rate of major complications is as low as 1%.20 localized to the lateral midfoot and sharp tenderness at the base
Postoperatively, the ankle is immobilized with a bandage, of the fifth metatarsal. It is important to examine the athlete,
and partial weight bearing is applied for 3 to 5 days. Full weight both sitting and standing, to assess the full lower leg align-
bearing is allowed 5 days after surgery, and postoperative reha- ment, especially the hindfoot and midfoot alignment. Cavus
bilitation is started. Athletes usually return to complete activity midfoot or varus hindfoot can be present but is not uniform.
after 4 weeks. More recent studies have demonstrated an everted rearfoot and
inverted forefoot alignment were associated with fifth metatar-
Fifth Metatarsal Stress Fracture sal stress fractures.23
Fifth metatarsal stress fractures account for less than 2% of Weight-bearing anteroposterior (AP), lateral, and oblique
metatarsal fractures in college football players, but can be a radiographic imaging of the involved foot is mandatory.
source of significant temporary disability and loss of playing Additional specialty imaging, such as a bone scan, MRI, or com-
time.21 puted tomography (CT), is used in unique circumstances.24
Athletes typically report an acute episode of lateral foot pain Radiographic and MRI findings of fifth metatarsal stress
that, in some cases, follows a 1- to 2-month prodromal history fractures include features of both diaphyseal (cortical-predom-
of a lateral foot “ache.” They also often report mild to moderate inant) and metaphyseal (trabecular-predominant) stress frac-
pain with ambulation but intense, sharp pain at the base of the tures given its location at the junction of the metaphysis and
fifth metatarsal with attempts to run, jump, cut on the involved diaphysis. Initial radiographic findings include periosteal reac-
foot, roll up on the lateral side, or land on the lateral side of the tion, with the degree of intramedullary sclerosis increasing in
foot.22 healing and chronic fractures. Important prognostic findings
The mechanism of injury is rarely from a direct blow or include the presence of a plantar gap at the fracture site, which
crush injury that may occur in actions such as a pileup. Some is associated with poorer healing. MRI demonstrates periosteal
have described the position of 30 degrees to 50 degrees of foot and intramedullary edema, with a cortical fracture line evident
in higher-grade injuries.24
Significant medical workup for athletes with Jones fractures
is not routinely needed. However, vitamin D deficiency, low cal-
cium intake, and general nutritional evaluation are helpful in
athletes at all levels. Vitamin D deficiency has been shown to
occur in up to 50% of Division I athletes and is noted in some
studies to be higher in African American populations.25
In the female athlete, a history of menstrual cycle irregular-
ity should be investigated, as low estrogen and other hormonal
imbalances may lead to a higher risk of delayed unions or non-
unions. Dual-energy x-ray absorptiometry (DEXA) scan eval-
uation is reserved for the athlete with multiple stress fractures
or recurring nonunions, as well as the middle-aged and older
athlete. Newer-technology DEXA scanning allows for a more
detailed evaluation of trabecular bone abnormalities despite
normal, generalized bone.26
Fractures of the proximal fifth metatarsal that occur in the
proximal diaphysis (greater than 1.5 cm from the tuberosity)
have an increased risk of poor healing, which is believed to be
due, at least partially, to the relative lack of blood supply of the
proximal diaphysis. In contrast to the metaphysis, which is sup-
plied by a rich network of metaphyseal arteries, the proximal
Fig. 25.13  Professional volleyball player with loose fragments of kiss- diaphysis is supplied by a sole nutrient artery, which may be dis-
ing osteophytes. rupted in proximal diaphyseal fractures.
460 SECTION 4  Unique and Exceptional Problems in Sports

In a recent review of the literature, it is described that oper-

ative treatment of fifth metatarsal stress fractures results in a
smaller number of delayed unions or nonunions, compared to
conservative treatment. Also, the goals of early surgical manage-
ment are to minimize the risk of nonunion and recurring frac-
ture, and to decrease the time to return to sport. Foot anatomy
must be taken into consideration, and additional procedures
such as the lateralizing calcaneal osteotomy for a cavovarus foot
should be considered.
Internal fixation with a solid stainless-steel IM screw has
become the procedure of choice.24 The patient is kept nonweight
bearing for 3 weeks; then partial weight bearing is allowed with a
removable boot, and stationary bicycle and pool therapy is initi-
ated. Transition to full weight bearing begins at 5 weeks. In general,
Fig. 25.14  Slalom at La Parva, Chile.
return to activity is allowed 2 months after surgery, depending on
the resolution of pain and radiographic evidence of healing.

SLALOMING THE ANDES MOUNTAINS: SKI

AND SNOWBOARD INJURIES OF THE FOOT
AND ANKLE IN CHILE
Introduction
The Andes Mountains is the world᾽s longest mountain range
extending from north to south for 4498 miles across seven coun-
tries: Venezuela, Colombia, Ecuador, Peru, Bolivia, Argentina,
and Chile. The chain has an average height of 12,000 feet and a
width of 149 miles, giving shape to the landscape and scenery of
most of western South America.
Providing a stunning backdrop to almost the entire Chilean
territory, the Andes mountains contribute with approximately
3000 miles of natural border running down from the arid
Atacama Desert to the Glaciers of the Patagonia. The above,
added to the narrowness of Chile᾽s geography, makes the moun-
tains accessible from almost every point of the country and
usually can be planned as a day trip from almost every major
city. This unique feature facilitated since the 1930s the develop-
ment of numerous ski areas and world-class resorts throughout Fig. 25.15 Chilean Olympic skier Henrik Von Appen during downhill
the central and south regions, being the firsts of their kind in competition.
South America and making Chile nowadays an internationally
renowned winter sports destination (Fig. 25.14). Foot and ankle injuries are far less frequent in these disci-
Skiing and snowboarding are the most popular activities plines. Nevertheless, there are several sport-specific injuries in
during the regular winter season that runs usually from May this category presenting unique characteristics that physicians
until October. These sports have been growing in popularity in charge of these winter sports athletes must consider for pre-
among the Chilean population during the last 20 years, as they vention and adequate treatment.
are more accessible and are no longer perceived as elite activ-
ities. Professional skiing has also seen great advances in the Equipment and Technical Considerations
current decade with consistent World Cup and Olympic partic- The basic modern skiing equipment considers the use of a boot-
ipation (Fig. 25.15). binding-ski system. This spring-actuated mechanism attaches
Injuries affecting skiers and snowboarders have been widely the boot to the ski in a fixed position until the bindings are
described.27-32 The most common injuries in skiers involve the released in response to torsional and upward forces (Fig. 25.16).
knee, specifically the anterior cruciate ligament and medial Release is determined by the spring tensions in two adjust-
collateral ligament, with a prevalence reported between 27% able toe and heel pieces.34 A significant decrease in foot and
and 33% of all injuries.28,30 On the other hand, snowboarders ankle injuries during downhill skiing has been evidenced after
usually sustain upper extremity injuries especially involving the 1970s due mainly to the breakthrough of better-designed
the wrist and shoulder, corresponding to almost 20% of all and -engineered ski boots and binding systems, transmitting
injuries.30,33 the torque forces more proximally in the lower limb.32,35 These
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 461

advances also included improved materials for harder boot is a soft “pack-type” boot, with a nonreleasable strap bind-
shells and weight/height-specific bindings that optimize the ing. Although less popular, hybrid and hard ski boots are
detaching process following falls and twisting forces. also used with either releasable or nonreleasable bindings.
However, the current popularity of snowboarding has Kirkpatrick and collaborators compared snowboarding inju-
meant an increase in foot and ankle injuries due to the use ries of the foot and ankle in relation to the type of boot used
of softer boots that allow better control and maneuverability (soft, hybrid, or hard) and found no significant correlation
(Fig. 25.17). In line with this trend, there are several stud- between boot type and overall injury rate. Nevertheless, in
ies showing that 12% to 38% of snowboarding lesions are their study, hard boots appeared to be protective for ankle
ankle-related, in comparison to only 1.7% to 6% of all ski- fractures not involving the lateral process of the talus (LPT).10
ing injuries.29,30,36 Several different types of boot-binding
combinations exist nowadays, but the most commonly used Ankle Sprains and Fractures
Ankle sprains and fractures are the most prevalent injuries of
the foot and ankle segment reported both in skiers and snow-
boarders.28,30,33 Differential diagnosis is crucial in patients sus-
taining an ankle sprain in this context, especially because there
are similar clinical findings on fractures of the LPT or peroneal
tendon injuries that can be easily misdiagnosed.
The most frequent mechanism of fractures of the lower leg
and ankle usually involves a fall in skiers, while a greater propor-
tion of snowboarders has jump-related injuries.37 Concerning
the level of injury, skiers present most commonly with oblique
or spiral distal tibial fractures at the edge of the skiing boot, or
“Boot-Top-Fractures.” On the other hand, malleolar fractures
are more common among snowboarders, with isolated fibula
fractures almost exclusively seen in this discipline. Ishimaru and
colleagues reported that most ankle fractures in snowboarders
were supination-external rotation type II injuries as described
by the Lauge and Hansen classification.38
Pilon fractures are common in the context of vertical impact
and axial load, especially in skiers landing from a high-altitude
jump. Energy tends to dissipate when the athlete lands on a
slope and then continues in a downhill direction. In cases where
the landing is effected on a flat surface, the energy is not capable
of dissipating, and this can result in a tibial plafond injury.33
Fig. 25.16  Boot-binding-ski system.
Management of these injuries is no different from lesions
occurring outside of the ski/snowboard context. Emphasis
should be on rehabilitation and complete healing of the fracture
site with a period of at least 12 weeks following open reduction
and internal fixation before returning to practice.

Snowboarder᾽s Fracture
Fractures of the LPT are a specific type of injury that was rarely
seen before the snowboard era but has become more prevalent
mimicking snowboarding popularity, which has contributed
to its current name, “Snowboarder´s fracture.”39 Kirkpatrick
in his series reported a talar fracture incidence of 17% within
all snowboarding injuries around the foot and ankle. LPT
fractures were particularly high, accounting for almost 95%
of these injuries.36
The LPT is a wedge-shaped prominence that comprises the most
lateral aspect of the talar body, being part of the talofibular and sub-
talar joints and serving for various ligamentous attachments.
Even though the mechanism of injury is controversial, the
most common accepted explanation for LPT fractures is an axial
impaction in dorsiflexion with the hindfoot in inversion and in
an externally rotated position. This axial impaction is typically
Fig. 25.17  Snowboarding soft boot. seen after landing from a height in snowboard jumping.39,40
462 SECTION 4  Unique and Exceptional Problems in Sports

In 1965, Hawkins described three types of LPT fractures41,42: may be indicated. Common complications include chronic
Type I, Simple (42%): Extends from the talofibular articular sur- pain, nonunion, ankle instability, and subtalar arthritis.40
face and the posterior subtalar facet.
Type II, Comminuted (34%): Involves both articular surfaces Morton᾽s Neuroma
and the entire lateral process. Erroneously classified as a neuroma, this entity is one of the
Type III, Chip (24%): Normally compromising only the subtalar most common causes of metatarsalgia. Morton᾽s neuroma is
joint, variable size. an entrapment neuropathy causing an interdigital neuralgia
Clinical presentation resembles an ankle sprain and may secondary to perineural fibrosis.45 This condition is frequent
result in pain and disability if not recognized and treated, espe- in skiers, in relation to narrow hard boots producing increased
cially because up to 41% of LPT are missed on initial presen- pressure on the forefoot. This leads to traction of the interdig-
tation.43 Typically, there will be local ecchymosis, edema, and ital nerves, which subsequently produces perineural fibrosis.
tenderness to perifibular palpation, with variable weight-bear- Other factors influencing the condition is repetitive trauma and
ing ability. ROM can be limited by pain, though deformity is stresses over the MTP joints producing swelling of underlying
usually not seen in these kind of injuries. metatarsal bursa and causing greater compression of the inter-
Imaging study includes x-rays to rule out other more prevalent digital nerve against the intermetatarsal ligament.46
injuries such as ankle fractures. LPT fractures can be identified Clinical features include pain and tingling at the involved web
more clearly on the Mortise view. However, there is a general space. Numbness may be present. Patients often describe a shoot-
agreement that the best diagnostic accuracy is obtained with ing electrical sensation during or after skiing that usually alleviates
CT-Scan, allowing classification of the type of fracture and assess- by taking the boot off. Ultrasound and MRI examination have been
ment of articular involvement, thus guiding the treatment plan.36 described to confirm the diagnosis.47 However, clinical findings
Treatment of LPT fractures is guided by the topographi- still have the highest accuracy for Morton᾽s neuroma diagnosis.48
cal Hawkins classification and the amount of displacement Conservative treatment options include ski boot modifica-
involved. Valderrabano proposed a treatment algorithm based tions, inserts to reduce pressure beneath the metatarsal heads,
on their series of 20 cases.44 Large displaced fragments (type I) or lidocaine/steroid injections. Surgical excision is indicated
should be surgically treated in order to restore articular congru- with persistent symptoms and has been shown to have between
ity and diminish long-term morbidity (Fig. 25.18). For nondis- 70% to 85% success in literature.45
placed fragments, a nonsurgical approach can be made but with
a higher risk of future morbidity. For type II and III, treatment Skier᾽s Toe
depends on the amount of displacement; nonoperative man- Skier᾽s toe or subungual hematoma is produced by excessive
agement if no displacement is seen, and surgical debridement compression of the toes against a narrow boot or by a repeti-
if there is any displacement. In general, this approach appears tive trauma of the affected toe secondary to a loose boot. The
to be reasonable and is accepted by the vast majority of authors. most affected toe is the hallux, and patients usually complain
Outcomes for type I fractures treated operatively, regardless of progressive pain due the increased pressure produced by the
of the method of fixation, are fairly good. Perera and colleagues hematoma on the nail bed.
reported that 88% of their patients presented mild or no symp- Another factor related to skier᾽s toe is improper skiing tech-
toms during follow-up. On the other hand, up to 38% of the nique. Sitting back on the skis forces the toes against the roof
patients treated conservatively persist with moderate or severe of the boot, while maintaining forward pressure on the shins
symptoms.42 Poor prognosis has to be expected if diagnosis diminishes this pressure on the toes. Long toenails also act as
is missed initially, which is a common reason for nonsurgical a lever, increasing pressure on the respective toes. We recom-
treatment. For patients with continued pain and morbidity, mend keeping toenails short when skiing or snowboarding in
depending on the type of fracture, excision or articular fusion order to avoid this complication.
Treatment of the subungual hematoma includes conserva-
tive measures such as applying ice and nonsteroid antiinflam-
matory drugs (NSAIDs). In cases of persistent pain or complete
involvement of the nail bed, aseptic fenestration of the nail to
drain the hematoma is indicated.

Chilblains
Chilblains, or pernio, is an injury that develops with prolonged
exposure (1 to 5 hours) to frigid or near-freezing temperature.
This condition appears as erythematous, well-defined, and ten-
der papules typically on the hands or feet of susceptible skiers
and snowboarders.
Treatment involves removing wet clothes or constrictive
boots, gentle washing and drying of the area, and covering the
Fig. 25.18 Fracture of the lateral process of the talus (black arrow). skin with dry and loose clothing. Nifedipine may decrease pain
Hawkins type I. and accelerate resolutions of symptoms.49
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 463

CHINESE TRADITIONAL CONCEPTS OF FOOT

AND ANKLE PROBLEMS AND TRADITIONAL
TREATMENTS
There are many traditional sports and performances that are
still popular in China at present, such as shuttlecock kicking
(Figs. 25.19 and 25.20), flipping in various Chinese local operas
(Figs. 25.21 and 25.22), and the Chinese martial art “wushu,”
which is also called Kung Fu (Figs. 25.23 and 25.24). Usually,
the Chinese do traditional sports for health purposes and

Fig. 25.22  Flipping is a maneuver in Chinese martial art “Wushu.”

Fig. 25.19  Shuttlecock kicking is a popular sport in China.

Fig. 25.23  Chinese martial art “Wushu.”

Fig. 25.20  Shuttlecock kicking performance is technically demanding.

Fig. 25.21  Flipping is often performed in many kinds of traditional Chi-

nese local operas. Fig. 25.24  Some kinds of “Wushu” are less competitive.
464 SECTION 4  Unique and Exceptional Problems in Sports

personal fulfillment. Thus there are infrequent opportunities acupuncture, and massage, accompanied by functional exer-
for the traditional Chinese sports to be competitive. However, cises, are the treatments for subacute injury.
it is not unusual to see foot and ankle injuries caused by these Acupuncture and massage are important components of
traditional sports in clinic. Soft-tissue injuries are much more restoring balance to the person’s vital energy channels, which
common than a real fracture. form the basis behind traditional Chinese medicine. The chan-
The most common reason for the shuttlecock players suffer- nels are a system of conduits throughout the body that carry and
ing a foot or ankle injury is players performing a trick. When distribute “Qi,” which can be considered as vital energy. Disease
there is uneven ground, there is more likely to be an accident. is present when the flow of vital energy through the channels is
Ankle sprain occurs and may lead to chronic ankle instability disrupted. This may occur when the integrity of the channels
several years later. Furthermore, injury may occur as a result of themselves is damaged by a sprain. The Chinese describe this
increasing body weight or decreasing strength of the ligament. as a disease of “Bi,” or pain, caused by a localized disruption to
Flipping is often performed in many kinds of traditional local the flow of “Qi.”
Chinese operas. This maneuver is more skillful and always per- The traditional Chinese explanation for soft-tissue injury is
formed by professional actors. Since the calf contracts suddenly that the channel running through the damaged tissue has been
and strongly when doing this, Achilles tendon injury (partial or physically disrupted, resulting in local pain, a disease of “Bi.”
complete rupture) may occur. Chronic injury is seen in Chinese To treat the pain, the integrity of the channel and the flow of
wushu players when they continue to practice wushu exercises vital energy through the channel must be restored. This can be
for decades after a primary injury. achieved by the selective use of points on the damaged channel,
There are many different kinds of foot and ankle injuries thereby restoring the flow of “Qi” and relieving the pain.
caused by these traditional Chinese sports and performances, The foot plantar surface is an important place for the body
including ankle sprain, fifth metatarsal avulsion fracture, because there are many points of channels, which represent
Achilles tendon rupture, diastasis of syndesmosis, MTP joint many internal organs. Therefore foot massage not only treats
capsular injury, instability of the ankle, and medial and lateral the injury of foot but also can treat diseases anywhere in the
malleolus fracture. body. In China, foot massage is looked on as a good method for
Many Chinese believe in traditional treatment and tradi- preventing and treating diseases and is popular throughout the
tional medicine when they have foot and ankle problems. There whole country.
are some special, traditional treatments for soft-tissue injuries Foot massage is used to stimulate the points of the channels
of the ankle joint in China that have a long history. These treat- that can activate the gates of the body, which are opened and
ments include acupuncture, Chinese herb ointment, poultices, closed to adjust circulation in the channels. Foot massage has
foot massage, and so on (Figs. 25.25 through 25.28). four functions: it can enhance the blood circulation, so as to
Chinese herb ointment and sometimes a semirigid splint accelerate the metabolism of the body1; it can regulate the ner-
made of bark are the usual management modalities for vous system; because there are many nerves endings in the foot,
soft-tissue injury in the early stage. Chinese herb ointment one can stimulate the reflex zone of the foot to regulate the cor-
can decrease the swelling effectively and quickly. Poultices, responding tissues and organs2; it can mobilize “Qi,” moisture,
and blood and promote proper function of the muscles, nerves,
vessels, glands, and organs3; and it brings the efficacy of release
and relaxation.4
Chinese traditional treatments for acute foot and ankle
injury are similar to modern treatments in some aspects,
such as rest, relieving the pain, and diminishing the swelling.

Fig. 25.25  Chinese herb ointment. Fig. 25.26  Acupuncture treatment at the foot.
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 465

Fig. 25.27  The points on the foot reflect the organs of the body.

is a widespread activity throughout the country, and profes-

sional dancing has a special place in some regions of the coun-
try. Athletic activities including 5, 10, 21, and 42 km racing
competitions, and cycling in two modalities (mountain biking
and road biking) is also very popular sports sometimes asso-
ciated with foot and ankle conditions. Since Colombia has no
seasons, these sports and recreational activities can be practiced
year-round, leading to frequent overuse syndromes.
Related to soccer, the most frequent injuries are ankle sprains
and anterior ankle impingement. Soccer is played on turf, which
can be soft in the rainy season and hard in the dry season. The
uneven grounds are also related to the frequency of ankle
sprains. Indoor soccer played on synthetic turf has also a very
high frequency of ankle sprains, due to shear forces on ankle
Fig. 25.28  Foot massage. and knee joints. Radiological evaluation of regular soccer play-
ers shows frequently medial, lateral, and anterior osteophytes
The treatments of acupuncture and foot massage are helpful associated with the repetitive trauma to the ankle. In recent lit-
to the patients during rehabilitation. Nowadays, the mod- erature, the origin of the tibial and talar osteophytes is related
ern treatment and rehabilitation methods have been widely to ankle instability or repetitive trauma at or near the joint line.
accepted and used throughout the country. The traditional Thus, these are called osteophytes and not enthesophytes. The
method and modern method supplement each other. traction theory is no longer valid as cited by Johannes et al.50,51

COLOMBIAN FOOT AND ANKLE CONDITIONS Ankle Sprains and Ankle Impingement
Patients with a history of frequent soccer games in the past
IN SPORTS present with multiple sprains and painful episodes after games.
Colombia has a varied geography and a variety of sports and They may have had an initial severe sprain that received med-
recreational activities. The most popular sport is soccer, which ical attention with adequate management. However, after
466 SECTION 4  Unique and Exceptional Problems in Sports

A B

C
Fig. 25.29  A, Preop x-rays. B, 7 months postop. C, 2 years postop.

ongoing sprains, patients do not search for medical attention immobilization period sent to physiotherapy. We put great
until symptoms evolve either with instability or limitation in value in a thorough rehabilitation program looking for a total
motion and impingement symptoms. In cases of ankle ante- restoration of full eversion strength, Achilles tendon flexibility,
rior impingement on physical exam, patients may complain and proprioception. Most of these patients get back to regular
of ankle reduced dorsiflexion compared to the contralateral sports after 6 to 8 weeks, and only those who continue having
side. Palpation on the anterior ankle joint can elicit pain, giving-way symptoms and recurrent pain are treated surgically
and depending on the size of the osteophyte, these can often with the open Bröstrom-Gould procedure.
be palpated. Stability testing of the ankle is carried out, and Other patients who have an instability sensation in more
sometimes instability findings can be associated. Patients must chronic cases can have an anterior impingement syndrome,
also be tested for peroneal tendon pathology and subtalar which affects their proprioceptive condition. In these cases,
symptoms, which are to be ruled out. Eversion strength and the surgical procedure is focused on the resection of the ante-
gastrocsoleus muscle contracture are also evaluated. rior osteophytes of the tibia and the dorsum of the talar neck.
Antero-posterior, lateral, and mortise standing comparative This procedure is preferably performed either with a 40-mm
views are taken in routine fashion (Fig. 25.29), and if a small arthroscope or with a mini-open technique. The joint is
osteophyte is seen, an additional van Dijk᾽s view is taken52 inspected first with a thorough complete ankle joint evaluation,
(Fig. 25.30). Only if any other instability-generating factor is with special attention to the medial and lateral gutters and at
suspected will a CT or MRI be ordered. the horizontal joint line. Temporary distraction of the ankle is
The ankle sprains are managed initially with the rest, ice, performed for inspection. The main procedure is performed
compression, elevation (RICE) protocol and after a short without traction, and we proceed to resect the osteophytes
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 467

Fig. 25.31  Rupture gap in Achilles tendon.

Fig. 25.30  Van Dijk᾽s view.

Achilles Tendon Lesions
Achilles tendon ruptures are increasing and causing morbidity
on both sides (tibia and talus). The extent of the resection is in our young population. These young adults are more involved
checked under fluoroscopy. Careful resection of the inflamed in indoor and outdoor soccer without a physical training pro-
synovial tissue of the anterior joint space is also performed. gram, which renders more lesions than in the professional
These patients are operated as outpatients under peripheral players.58 High frequency of games throughout the week (3–4
nerve block and sedation. Postoperatively they are immobilized times) generate overuse syndromes that predispose to tendi-
with a soft dressing and 48 hours bed rest and elevation. Weight nopathy and tendon ruptures.59 These lesions can be caused by
bearing is allowed after 2 days to tolerance, and sutures are either indirect or direct trauma to the tendon. Patients can pres-
removed after 12 to 15 days. A rehabilitation protocol centered ent with some prodromal symptoms before the acute rupture.
on dorsiflexion recovery, strength, and proprioception is begun Occasionally our patients have had previous visits with paraten-
at that time. donitis or paratendonitis with tendinosis that were not treated
On follow-up, we have experienced what the literature adequately.60
describes as recurrence of the osteophytes in a large percent- These patients come in to the emergency room with an acute
age of our cases,53,54 but less than a third of those patients have onset of pain and a sudden snapping or popping sensation at the
recurring symptoms. If instability persists, the recurrence is Achilles tendon during sports activity. On occasions, a previous
greater (see Fig. 25.30). history of Achilles tendon pain can be obtained from the patient.
Our main problems with surgical treatment of ankle instabil- On physical exam the patient walks with a limp and variable
ity, are neuropathic pain with superficial peroneal nerve lesion, edema around the rupture site. A positive Thompson test and a
arthrofibrosis, and medial or residual lateral instability.55,56 The palpable gap are typical of a complete rupture (Fig. 25.31). The
multimodal pain management or in combination with nerve plantar flexion strength can be diminished. In cases of doubt
blocks with the aid of ultrasound and open neurolysis are the we order an ultrasound or an MRI, but these are not routinely
common approaches to this clinical entity. Arthrofibrosis is not performed.
frequent after open or arthroscopic ligament reconstruction. If If the rupture is a palpable gap within 7 cm of the postero-
there is a mild to moderate case, physical therapy has been ben- superior calcaneal tuberosity with a positive Thompson test,
eficial. Uncommonly there are severe cases of arthrofibrosis that we proceed to perform a minimal incision repair within the
may require open debridement. first 10 days. If the rupture does not have a clear gap, but a
The residual instability of ankle is described more often in positive Thompson test, an ultrasound or an MRI is ordered
the recent literature, and the medial component of this pathol- to define the type of rupture to plan the surgical approach.
ogy has had more focus in the last years. We are focusing on this The mini-invasive technique has a lower complication rate
clinical problem and see it with a more prevalent frequency in with respect to the soft-tissue complications in simple rup-
our clinical practice. When rupture of the deltoid ligament in tures (horizontal), but in massive and irregular tears, an open
an acute setting is present, a repair of the ligament is performed. reparative technique is preferred.
In acute or chronic spring ligament ruptures, and an MRI with
positive findings, our choice is a repair with suture anchors in Surgical Technique
acute settings or debridement of scar tissue and direct repair in The patient is positioned prone with both legs prepped for
the chronic lesions.57 comparison of foot position at final tendon repair (Fig. 25.32).
468 SECTION 4  Unique and Exceptional Problems in Sports

the Achilles insertion, fixed with anchor sutures or biotenodesis

screws.62 We have used this transfer tendon technique in more
than 80 patients with solid results at this time.

Lisfranc Low-Grades Sprains

In other activities performed in Colombia, like dancing, cycling,
or horseback riding, trauma to the foot and ankle can involve
torsional forces that generate these sprains and have a relative
high incidence and are not properly diagnosed in local emer-
gency rooms. Sometimes these lesions are detected in patients
in a late form with residual pain and problems at their midfoot.
Persistent pain after 4 to 6 weeks of injury, with edema present
at the TMT point of first and second rays, with initial ecchymo-
sis described on the first visit at the emergency room, can be
indicative of severe ligament or soft-tissue damage.
Clinical findings, AP, lateral, and oblique standing bilateral
views can sometimes be sufficient to view subtle differences
of both feet to make the diagnosis. The fleck sign, which indi-
cates Lisfranc’s avulsion fracture, must also be considered.
Fig. 25.32  Positive Thompson test. CT scan or MRI can be indicated in cases of doubt, but they
are usually not ordered in a routine fashion. The open reduc-
tion and internal solid fixation are mandatory in all displaced
fracture-­dislocations.63-67
For low-grades lesions and symptomatic sprains, we use the
Nunley and Vertullo68 classification, with good and excellent
results in the 89% of our patients with surgical treatment in
grade II and III lesions with transarticular screws or the endo
button technique.

AN EGYPTIAN PERSPECTIVE ON THE FOOT

AND ANKLE IN SPORTS
In Egypt, soccer is the most common sport practiced both on
professional and recreational levels. People of all age groups play
soccer, and it is currently played on different terrains includ-
ing turf mostly, but also sand and concrete. An array of foot
and ankle injuries has been associated with soccer, including
but not limited to ankle sprains, Achilles tendon ruptures, turf
toes, FHL tendinitis, Lisfranc injuries, ankle impingement, and
OCLs of the talus. Other popular sports include squash, wres-
Fig. 25.33  Tension after surgical reconstruction of Achilles. tling, and martial arts. Recently, cycling and marathon running
have gained popularity and attracted a good proportion of the
A 4-cm skin incision is performed horizontally 1 cm above the youth population.
gap, and careful incision of the paratenon is also performed. One thing to mention is the delayed presentation of many of
The stumps are localized and pulled through the incision, and our patients. This is partly due to limited access to health care at
a commercial tendon repair kit is used to perform the repair on some areas. Moreover, patients tend to ignore their complaints
both sides of the ruptured tendon. Three strands of reinforced and try natural remedies and alternative medicine long before
nonabsorbable suture are knotted with the foot in a similar or they seek medical advice. This reflects on the chronicity of the
slightly more plantar-flexed ankle position as the contralateral case and therefore decision-making and available options to
limb (Fig. 25.33). Suture of the paratenon and skin incision are treat such problems.
performed. A bulky dressing with the foot in plantar flexion and We here report on our experience with management of
a posterior splint is applied for 12 days nonweight bearing. On some of the aforementioned injuries and our preferred surgical
day 12, the sutures are removed and a walker boot with a 40-mm techniques.
heel lift is applied with permission for progressive weight bear-
ing. Physiotherapy with the Mendelbaum protocol is started.61 Osteochondral Lesions of the Talus
For all chronic lesions, either partial or complete, with more It is estimated to occur in 2%–6% of ankle sprains; however,
than three months evolution, we use the FHL transfer deep to more than 80% of lesions are missed or diagnosed in a delayed
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 469

fashion.69 Many factors have to be considered when discussing Flexor Hallucis Longus Tendinitis/Posterior Ankle
surgical management of these injuries. These can be classified Impingement
into patient factors (age, body mass index [BMI], activity level, FHL tendinitis is a chronic overuse disease common among
and comorbidities) and lesion factors (size, containment, ballet dancers but can also affect soccer players due to repet-
condition of surrounding cartilage and subchondral bone). itive plantarflexion maneuvers. Symptoms and physical exam
Treatment strategies can generally be grouped into two major can mimic posterior ankle impingement.75 Both conditions
categories: can coexist and are sometimes considered as spectrums of the
1) Reconstruction techniques: fixation or reattachment of OCLs same pathology. Conservative management can be successful
and autograft or allograft osteochondral transplantation in up to 64% of cases with immobilization.76,77 Surgical treat-
2) Repair techniques or marrow-stimulation techniques: ment consists of surgical release/tenosynovectomy, which can
microfracture and drilling (with or without biologic aug- be done both open and arthroscopically. We now prefer doing
mentation), autologous or allogeneic cell implantation arthroscopic release to avoid the invasive open approach, which
While we have performed many of these options, our results carries higher risks of postoperative adhesions and increased
have been inconsistent and not fully satisfactory. This is in line morbidity. As previously described by van Dijk et  al,78 poste-
with data showing no superiority of one cartilage repair tech- rior arthroscopy is performed with the patient in prone position
nique over others.70,71 We recommend performing microf- with utilization of a thigh tourniquet and 30-degree 4.0-mm
racture for lesions <10 mm2. Lesions larger then 10 mm2 are arthroscope. Two main portals are established; a posterolateral
treated with either microfracture supplemented with biological and posteromedial portal. The posterolateral portal is estab-
augmentation (bone marrow aspirate concentrate [BMAC] or lished first 1 cm proximal to the tip of the lateral malleolus just
platelet-rich plasma [PRP]) or osteochondral autologous trans- lateral (5 mm) to the Achilles tendon. Subsequently the pos-
plantation (OATs) with allografts reserved for critically sized teromedial portal is performed just medial to the Achilles ten-
lesions that are not amenable to autografts. don at the same level as the posterolateral portal. A motorized
Recently, the senior author (AH) reported on the use of shaver is used to perform synovectomy and resection of soft
culture-expanded bone marrow–derived mesenchymal stem tissues between the talus and Achilles tendon, starting laterally
cells (MSCs) in treatment of large OCLs of the femoral con- until the FHL is visualized. The FHL serves as a “lighthouse” to
dyle. Their preliminary results were promising, and they this approach, and visualizing it is the key to the procedure. The
noted improvement in patient outcomes and MRIs.72 We sub- FHL is located typically about 1–2 cm proximal to the subta-
sequently decided to use the same technique with OCLs of lar joint. Identifying the tendon can be aided by passive motion
the talus. We started using second-generation bone marrow of the big toe. Extreme caution is warranted to avoid injury to
MSC implantation, which entailed culture-expanded MSCs, the neurovascular bundle located just medial to the FHL ten-
implanted on platelet-rich fibrin glue (PR-FG) scaffold. This don. In the presence of a symptomatic os trigonum, it can be
mixture was injected via all-arthroscopic technique into the excised via a combination of shaver and punches. At this point,
base of critical-sized OCLs, and patients were made non- the tendon is inspected for any pathology. In patients with
weight bearing for 6 weeks postoperatively (Fig. 25.34). We FHL tenosynovitis (Fig. 25.35A), the tendon can be entrapped
reported on a small case series of 16 patients treated with this underneath its sheath, which is then incised and subsequently
technique with an average size of OCL of 3.74 cm2 ± 1.12 and excised with a shaver (Fig. 25.35B). The entirety of the tendon is
mean follow-up of 18 months. Briefly, autologous bone mar- then examined to ensure absence of tears and smooth gliding of
row aspirate was acquired from patients in a first-stage pro- the tendon (Fig. 25.35C), including the most distal part within
cedure. This was transferred to the Tissue Engineering Unit its fibro-osseous tunnel (arrow in Fig. 25.35C). We believe ade-
at the Department of Biochemistry, Cairo University College quate portal placement is a must to be able to perform adequate
of Medicine, where MSCs were isolated and culture expanded FHL decompression. Inadvertent distal placement of the portals
for a minimum of five passages. The plasma was processed to makes this procedure extremely difficult, especially in the face
create PR-FG. In a second-stage all-arthroscopic procedure, of an os trigonum that can block access if not approached from
the base of the defect was curetted to a stable healthy rim of a “higher” portal. This higher portal also allows relative ease of
cartilage and underlying bleeding subchondral bone. Defects access into the FHL fibro-osseous tunnel.
deeper than 8 mm were grafted with autologous calcaneal bone
graft.73 The culture-expanded MSCs were then mixed with the Other Injuries
autologous PR-FG and injected in the base of the defect after Management of these injuries usually follows the general tech-
establishing dry arthroscopy. The mixture was let to clot and niques practiced worldwide. Ankle sprains are mostly treated
ankle ROM was tested under arthroscopy for stability of the conservatively. Patients with ankle instability are treated with
implant. Immobilization for 2 weeks was followed by active Brostrom-Gould repair when sufficient local tissue is available.
and passive ROM exercise while maintaining nonweight-bear- Insufficient local tissue has prompted us to use anatomic recon-
ing status for 6 weeks, followed by progressive weight bear- struction with gracilis autograft fixed with biotenodesis screws
ing. Our study showed improvement in postoperative AOFAS at the fibula and talus. More recently, we have been using the
scores compared to preoperatively, but this improvement did fibertape construct (Internal Brace, Arthrex, Naples, FL) for
not reach statistical significance.74 augmentation of repair in cases of insufficient tissues. Our
470 SECTION 4  Unique and Exceptional Problems in Sports

A B

C D

E
Fig. 25.34  Talar osteochondral defect (OCD) treated with mesenchymal stem cells (MSCs)/platelet-rich fibrin
glue (PR-FG) mixture. A, Medial talar dome OCD measuring 7 mm x 8 mm. B, OCD after debridement to a
stable rim and healthy bleeding subchondral bone. C, Establishing dry arthroscopy before implantation of the
MSC/Fibrin glue mixture. D, Injection of the MSCs/PR-FG from the dual barrel syringe arthroscopically into the
base of the defect. E, The mixture is set level with the surrounding cartilage and left to dry for 7 minutes after
which the construct’s stability is verified by ranging the ankle under arthroscopic visualization.
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 471

short-term experience has yielded comparable results to the provided for the health care sector. Moreover, there has been a
standard Brostrom-Gould reconstruction without augmenta- shift in paradigm lately in light of recent literature79,80 toward
tion while allowing an accelerated postoperative recovery due nonsurgical treatment with accelerated functional rehabili-
to the restraining effect of the fiber tape. tation protocols.81 This is gaining more popularity given the
Acute Achilles ruptures are treated via open repair using reduced expense and equivalent functional results of such treat-
Krackow technique. We started utilizing percutaneous tech- ment algorithm. Surgical repair, however, remains the preferred
niques more often recently but have not noticed a difference in method in professional and high-demand athletes due to stud-
outcomes with the latter. The price of the percutaneous kit is a ies showing slight increased difference in push-off during run-
limiting factor in its wide use in Egypt due to limited resources ning and jumping.82

FHL FHL
T
T

C C

A B

FHL

C
Fig. 25.35  Arthroscopic images of a 23-year-old soccer player who presented with severe posterior ankle
pain and exacerbation of symptoms with hallux dorsiflexion. MRI confirmed extensive FHL tenosynovitis
(C = calcaneus, T = talus, FHL = flexor halluces longus). A, Arthroscopic image demonstrating significant
tenosynovitis of FHL tendon with the tendon enclosed in hypertrophied inflamed synovium. B, Image after
FHL tenosynovectomy and debridement revealing properly oriented tendon fibers free of tears. C, FHL ten-
don was traced all the way down in its tunnel to ensure complete excision of tenosynovitis and exclusion of
tears in the tendon proper (arrow = fibro-osseous tunnel).
472 SECTION 4  Unique and Exceptional Problems in Sports

AN INTERNATIONAL PERSPECTIVE ON THE formats of this game have evolved to attract more and more
spectators from every age group. Such aggressive and attractive
FOOT AND ANKLE IN SPORTS: INDIA formats have increased viewership at the cost of increased rate
India is a big country with a huge, diverse population. Four of injuries to players. While the game has limited contact inju-
very commonly played sports in India are cricket, field hockey, ries, activities like bowling, fielding, throwing, diving, catching,
kabaddi, and khokho. Though hockey is a national sport, cricket and running lead to impaction and overuse injuries. Projectile
is ‘The religion’ in India and outnumbers every other sport injuries to any part of players’ body can occur by a hard-thrown
played in India.83 In today’s competitive world, no sports are heavy cricket ball in spite of protective gear.
immune from sporting injuries. The tendency of the body to In 2016, an international consensus statement on injury sur-
over perform against its capabilities is the key reason for most veillance in cricket was introduced. Countries like Australia,
of the sporting injuries. External factors like playing environ- England, South Africa, the West Indies, and India have all con-
ment, playing surfaces, lack of proper training, and poor protec- tributed data. Today the subcontinent has become the hub of
tive equipment are other important causes of sports injuries.84 cricket, but very limited data is published from these countries.
Internal factors like strength and endurance plus anatomical With fewer publications on cricketing injuries, very few pub-
abnormalities also can be responsible for sports injuries.84 lications have focused on the foot and ankle.83 Incidences of
In India, varying formats of these key sports are noticed. cricket injuries, in general, are found to be increasing because
A large number of children, adolescent, and adults play these of a greater number of games being played with decreasing rest
sports on streets on a daily basis for recreation. Street sports out- periods between games. The act of bowling and fielding (41.3%)
number competitive sports played on playing grounds. Street accounts for the highest number of injuries, with hamstring
sports are characterized by poor playing environment, poor sprain being the most common injury. Based on the mode of
surfaces, lack of training, and lack of protection (Fig. 25.36).85 onset, Dhillon et  al. classified cricket injuries as acute (64%–
Presumably, the rate of injuries must be very high, but data to 76%), acute on chronic (16%–22.8%), and chronic (8%–22%).83
support this are lacking. Next in count are school-level sports, Younger players under the age of 22 sustain more chronic over-
again with poor documentation of injury and treatment. Studies use injuries than do older players. Stretch et al. in his study men-
have focused mainly on injuries at a competitive level. The main tioned that lower limb injuries (48%) rate highest in numbers
objectives of studies are to analyze reasons for injuries and to followed by back injuries (22.8%), upper limb injuries (23.3%),
suggest preventive actions. No studies have specifically focused and neck injuries (4.1%). Hamstring and quadriceps sprains
on management aspects of foot and ankle injuries. With these form the most common lower limb injuries.86
inherent odds, we present sports foot and ankle injuries with its Studies have reported that 11% of injuries affecting fast
management modalities. bowlers involve the foot and ankle.83,86 In general, the forefoot
is more prone to acute injuries while the hindfoot is more prone
Cricket to chronic overuse injuries. Acute-onset foot and ankle injuries
Cricket is a globally popular sport being played in 105 coun- in cricket are hematomas, contusions, ankle ligament injuries,
tries. It is the second most popular spectator sport after football syndesmotic and midfoot sprains, Lisfranc injuries, and turf-toe
in the world. Cricket is played on an oval ground with a rect- injuries. Sudden-onset aggressive impact can lead to foot and
angular pitch with 11 players on each team. Activities done by ankle fractures. Acute-and chronic-onset foot and ankle inju-
a player involve batting, bowling, fielding, and wicket-keeping. ries result from overuse coupled with poor training and preex-
Though cricket is a noncontact sport played with ball and bat, isting unrecognized anatomical abnormalities. Posterior ankle
it requires physical fitness, skill, and strategy. Recently many impingement is one such common overuse injury in fast bowl-
ers. Modern lowcut boots with harder surfaces aggravate this
problem. Other problems include plantar fasciitis, tendoachilles
tendonitis, medial tibial stress syndrome, flexor hallucis ten-
donitis, peroneal tenosynovitis, intra-articular loose bodies,
ankle synovitis, and os trigonum disorders.
In an unpublished study the authors conducted foot and
ankle evaluations of 400 cricket players from district-level
cricket associations with interesting observations. We noticed
that more than 50% of cricketers had undiagnosed anatomi-
cal abnormalities in form of pes planus, accessory bones, and
pes cavus. Foot postures were found to be different among fast
bowlers (pronated) and spinners (supinated). More than 20% of
cricketers had a poor bowling posture resulting in easy fatigue,
loss of accuracy, and injuries in turn. In all cases coaches and
parents were unaware of such anatomical as well as postural
abnormalities in players. We even noticed a lack of knowledge
Fig. 25.36  Street sport (kabaddi) being played by children in a poor envi- about selection and evaluation of footwear among players and
ronment without the use of protective gear. coaches.
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 473

Hockey Inflammation of Achilles tendon due to overuse results in ten-

Field hockey is the second most popular sport in the world after donitis. One of the rare injuries documented by the correspond-
soccer and is played in more than 132 countries around the ing author was habitual medial dislocation of the first MTP joint
world. Though it is the national sport of India, it is more popu- (Fig. 25.38).
lar in northern Indian states. Prabhu et al. and Dhillon et al. in
their studies noted that the overall rate of injuries in field hockey Kho Kho
is around 6 per 1000 athlete exposuress with lower limbs being Kho kho is one of the most ancient and traditional games and
the most frequently injured site (51%).83,87 Out of all lower is a modification of a “Run Chase.” In the game, the player runs
limb injuries in hockey, ankle sprains are the most common around two poles chasing the opponent to touch him or her and
(14% to 19%). Improper footwear plus rapid rotational move- send the opponent out of the game (Fig. 25.39). It requires not
ments are the key factors responsible for higher rates of ankle only fast running but also sudden strategic stopping to inter-
sprains in hockey. Overuse injuries to the ankles and feet are change runners. Thus, it is a game of strength, speed, stamina,
also very common (18% to 32% of all hockey injuries). Typical and skill. The game develops endurance and intellectual capa-
examples of these injuries in hockey include tibial stress syn- bilities. The game also develops sportsmanship, team building,
drome, Achilles tendonitis, plantar fasciitis, and stress fractures. and obedience among players. Participation is highest among
Females are more prone to overuse injuries than males. Rarely schoolchildren (69%) followed by college (50%) and university
foot and ankle injuries do also result from direct injuries like (34%) students. Thus, in India the participation level decreases
being struck by the hockey stick or ball. These injuries range as the education qualification increases. In a study of 503 kho
from minor contusions to serious compound fractures. kho injury cases, Jayati Sen reported that knee (14%) and back
(13%) injuries were the most common form of injuries.88 Ankle
Kabaddi (11%) and foot (10%) injuries were next in line, with males being
Kabaddi is the most ancient sport played in urban as well as more prone to ankle and foot injuries than their female coun-
rural areas of India. It is a type of contact sport that is very sim- terparts. Ankle injuries comprise ankle sprains due to distortion
ple, inexpensive, and easy to organize. A player has to raid the followed by a concussion. Toe injuries are also common due to
opponent’s court to tag members of the opposite team while twisting and falls. Fractures of the foot and ankle do occur due
continuously chanting the word ‘Kabaddi’ and holding his
breath, while on the side of the opposition, they act as a team, to
prevent any kind of tagging of their team member (Fig. 25.37).
Because of its inherent nature of heavy contact in the form of
tackling each other with aggression, kabaddi is an injury-prone
game. Large pulling and pushing forces to the lower body result
in injuries like ligament and tendon sprains and tears in the
ankle and foot. Direct collision with other players also results
in ankle and foot injuries. Injuries also occur due to falls on the
hard or uneven ground. Hell and Schonle mentioned in their
study that ankle injuries form 55% of all injuries due to collision
with opponents.85 Ankle sprains are the most common injury
and occur due to sudden twisting while running or jumping. Fig. 25.37  Game of kabaddi being played at a competitive level.

Fig. 25.38  MRI pictures of a professional kabaddi player who injured lateral capsule-ligamentous structures
resulting in recurrent dislocation of the first metatarsophalangeal joint.
474 SECTION 4  Unique and Exceptional Problems in Sports

to falling to the ground or due to a violent collision. Common open reduction internal fixation (ORIF) rather than pri-
reasons for injuries in kho kho are lack of use of protective gear, mary fusion. Use of k-wires over screws for Lisfranc injuries
poor playing grounds, and poor training. is still common, while spanning plates are used at a few cen-
ters. Fractures, hematomas, and contusions are managed on
Management their merits as per standard AO (Arbeitsgemeinschaft fur
Foot and ankle orthopedics has yet to develop as a specialty in Osteosynthesefragen – German for Association for the Study of
India. Sports medicine is slightly better positioned. Available Internal Fixation) principles like elsewhere in the world.
data on foot and ankle sporting injuries is only from injuries Overuse injuries like tendonitis and fasciitis are primarily treated
happening at competitive level. Interestingly in India, the num- by team physiotherapists with rest, NSAIDs, and physiotherapy,
ber of games played at competitive level is much lower than failing which, qualified sports medicine specialists get involved.
games played at street level for recreation. There are no studies The most common diagnostic modality is MRI. Treatment is in the
focused on injuries happening in street-level sports. School- and form of rest, activity modifications, orthotics, and bracing. Modern
college-level sports do have data of injuries but are very scanty therapies like extracorporeal shock wave therapy, radiofrequency
because of lack of precise record keeping. No registry of sports ablation, and PRP injections are utilized by a few centers without
injuries has yet been created for any sport to date. Naturally, any published data on results. Stress fractures are quite commonly
the data we get represent just the tip of the iceberg. Street-level missed. Once diagnosed, they are treated with rest, orthotics, and
injuries presumably are being managed by home remedies like physiotherapy. Posterior ankle impingement is managed with open
local applications or by bonesetters with remedies in the form of surgery at most of the centers as hindfoot endoscopy is evolving.
manipulation plus local applications. Complications like cellu- Ankle joint issues like synovitis and impingement are treated with
litis, abscess, and stiffness follow such unscientific management ankle arthroscopy at many centers.
and are ultimately dealt with by qualified orthopedic surgeons. Improved record keeping and precise documentation of
Many of the street injury cases are also managed by family phy- sports injuries at every level are the need of the day in develop-
sicians. Neglected cases are quite common due to being ignored ing countries like India.
by player or coach in order to play out the season. At compet-
itive level, due to a handful of foot and ankle and sports medi-
cine specialists in India, foot and ankle sports injuries are being
THE ATHLETIC FOOT AND ANKLE IN IRAN
treated either by coaches and physiotherapists or by generalists. Iran is a vast country in the Middle East with high mountains,
Acute ankle sprains are treated with modalities like RICE green areas, dense jungles, deserts, and seasides. Four full sea-
supported with NSAIDS. Long-term plaster immobilization sons are experienced in Iran with all types of weather in any
is also practiced, unlike the recent trends noticed in the west- time of year. There are different ethnic groups living in this
ern world. There is no trend to acutely repair torn ligaments. country with different habits and sports preferences.
Pain and persistent disablement are very common after ankle All categories of sport are available in Iran, but ball games
sprains. A huge number of unresolved ankle sprain cases, in like football and volleyball are considered the most popular
fact, are missed injuries like peripheral talar process fractures, sports. Wrestling, rock climbing, and martial arts are other pop-
high ankle sprains, osteochondral injuries of talus, etc. In a ular activities. Most uniquely, Zurkhaneh (a form of martial arts
study of 482 foot and ankle injuries, the corresponding author and gymnastics) and Chovgan (a horse-riding team sport) are
reported missed injuries with ankle sprains being second high- traditional Iranian sports.
est after Lisfranc injuries.89 Chronic lateral ligament injuries
are being managed with Brostrom Gould reconstruction of the Mountain Tracking and Rock Climbing
lateral ligament. At some centers in India, arthroscopy-assisted These are popular sports in Iran and recently have changed with
lateral ligament reconstruction is also practiced. modern techniques (Fig. 25.40). This sport is part of real living
Lisfranc injuries are often misdiagnosed as midfoot sprains. in some western mountain areas.
Documented Lisfranc injuries are managed commonly with Rock climbing can be potentially risky for acute foot and ankle
injuries (Fig. 25.41). Although there are several reports, empha-
sizing safety of the legs, ankles, and feet as long as guidelines are
followed, up to 50% of acute injuries occur in lower extremi-
ties. These injuries increase in mountain tracking, especially in
the form of an acute ankle sprain and fractures of the calcaneus
and talus. The most common injuries occur in nonprofessionals
during the winter. Some of the injuries are related to flexible shoes
that may lead to hallux valgus or hallux rigidus over time. Most
climbers prefer to use rigid boots with better support in foot and
ankle on uneven ground. Still they may induce some overuse
injuries like subungual hematoma. Professional rock climbers use
specific shoes that are asymmetric and have forefoot turn-downs.
These shoes reduce pressure and injury on toes, although they are
Fig. 25.39  Game of kho kho being played at a competitive level. not suitable for long-distance walking.90-92
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 475

Chovgan and twisting motions, making it very strenuous on the foot.

Chovgan is a horse-riding team sport. Historically it has been Although there is also trauma from direct contact, overall injury
considered an aristocratic game done by kings in the first mil- is not common in this sport. Most injuries including ankle
lennium CE, and most injuries occur to the elbow and head, yet sprain, Achilles tendinosis, and peritendinitis, which occur
there are a few reports of leg and ankle injuries. during competition season.93,94

Wrestling Pahlevaniv
Wrestling is considered the most popular traditional sport of Pahlevaniv (bastani or zurkhganeh) is a unique traditional mar-
Iran especially in northern areas, with few variations (Figs. tial art of Iran, which is infused with ethical and moral rules. All
25.42 and 25.43). In this sport there are lots of pushing, cutting, parts of this sport are rigorous and include wrestling, whirling,
club exercises, and calisthenics synchronized with a special style
of music incorporating bells, drums, and chanting. This sport
is performed barefoot in a ceremony with a unique engraved
suit. Part of the activity consists of different kinds of running,
hopping, leaping, short jumping, and fast spinning.95,96 (Figs.
25.44 and 25.45)

FOOT AND ANKLE INJURIES CAUSED BY

TRADITIONAL JAPANESE MARTIAL ARTS
In Japan, there are many forms of traditional martial arts that
are still actively practiced today. This chapter explains in detail

Fig. 25.40 Mountain tracking has always been associated with foot

injuries; people usually use stiff boots that help them with long-distance
journeys but are not ideal for rock climbing.

Fig. 25.42  Wrestling with chookhe is one of popular traditional kinds of

wrestling. It was played in special ceremonies.

Fig. 25.41 Rock climbing as a growing sport; note the specific turn- Fig. 25.43  Wrestling with chookke is associated with increased risk of
down shoes that reduce pressure on forefoot and toenails. foot and ankle sprains.
476 SECTION 4  Unique and Exceptional Problems in Sports

foot and ankle injuries associated with the three most popular
martial arts: judo, sumo, and kendo. Although the origin of
these martial arts is not known, the earliest known mention of
their basic forms is found in Japanese documents written during
the eighth century. In the last half of the nineteenth century, the
modern rules for these martial arts were established, and peo-
ple began to practice them as sports. Because these martial arts
are practiced barefoot, there is a high incidence of ankle and
foot injuries among their practitioners. However, because play-
ing surfaces and styles of competition differ markedly among
these three martial arts, they are associated with different foot
injuries.

Judo
Fig. 25.44  Zurkhaneh federation with Pahlevani. The picture shows a
special form of spinning. This activity can produce acute and chronic
Because judo is an Olympic sport, the number of people who
high ankle sprains. practice judo is increasing worldwide. A judo contest is a fight

Tibia

Fibula

A B C

D E F
Fig. 25.45  High ankle sprain in an athlete from repetetive twisting activity. A and B, preoperative radiograph
shows no problem. C, Arthroscopy was performed because of persistent pain on anterior inferior tibiofibular
ligament (AITFL) and syndesmosis. There was a positive arthroscopic cotton test with marked synovitis. The
3-mm shaver is easily passed into syndesmosis space, indicative of instability. D and E, early postoperative.
F, Four months after operation the syndesmotic screw was removed.
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 477

between two contestants who wear judo suits and fight on Sumo
tatami (straw) mats. The first contestant to score a full point Sumo is a sport in which two wrestlers fight on a round ring
(“ippon”) wins. A contestant can score a full point by throw- that is made of packed earth and has a diameter of about 4 m.
ing the opponent on his or her back, holding the opponent for Sumo wrestlers wear nothing but a loincloth belt. In each bout,
30 seconds, or making the opponent concede. Injuries almost two wrestlers initially face each other from behind two parallel
always are caused by throwing moves. Many judo injuries occur lines at the center of the ring. Once the bout begins, they collide
in the lower extremities, particularly at the knees, ankles, and violently, like guards and tackles in American football. The loser
feet. Because mild foot injuries are so common, those who sus- is the first wrestler to touch the ring with any part of the body
tain them rarely seek treatment at a medical institution. other than the bottom of the feet or the first wrestler to go out
The most common foot injury is ankle sprain; about half of of the ring. Sumo wrestlers try to push each other out of the
all judo practitioners suffer an ankle sprain at some point (Fig. ring, and heavy body weight confers an advantage in this push-
25.46). Severe inversion sprains typically are accompanied by ing. Consequently, sumo wrestlers intentionally try to achieve
osteochondral fracture of the talar dome. Also, ankle instability and maintain a heavy body weight. Although the most common
persists in many cases, and many people who practice judo for clinical problem associated with sumo is lumbar pain, injuries
a long period develop osteoarthritis of the ankle. Also, when a in the lower extremities account for more than half of all inju-
strong external force is applied, a malleolar fracture occurs, but ries associated with sumo.
plafond fractures and talar fractures are rare. Ankle and foot injuries account for about 15% of all sumo-
The incidence of toe injury is high among judo practitioners. related injuries. It might seem that this is a low percentage for a
Turf-toe is a well-known injury associated with sports played sport that is practiced barefoot. The reason for this low percent-
on turf, such as American football. Most cases of turf-toe are age is the manner in which sumo wrestlers move, by shuffling
caused by excessive dorsiflexion of the great toe. When a foot their feet instead of lifting their feet off the ground (Fig. 25.48).
sweep is attempted in judo, the sweeping foot is in the equino- In sumo, the friction between the ground and the soles of the
varus position and is swung horizontally. If the sweeping foot feet is important in keeping a wrestler in position. If either foot
gets caught in the seams of the tatami mats or on the opponent’s comes off the ground for even a short time, the wrestler easily
foot, the MTP joint of the great toe is excessively plantarflexed can be pushed out of the ring. Thus, shuffling helps to prevent
(Fig. 25.47). Although this generally causes sprain without a a wrestler from being pushed out of the ring. During shuffling,
fracture, severe bending can cause a chip fracture. This type of the knees are bent in the valgus position, the lower legs are
toe injury is sufficiently unique to judo to merit its own name abducted, and the feet are pronated. As a result, sumo training
(perhaps “tatami toe”). If accompanied by osteochondral dam- strengthens the peroneal muscles, thus lowering the incidence
age to the MTP joint of the great toe, osteoarthritis can lead to of inversion sprain. Furthermore, even if a sprain occurs, it usu-
hallux rigidus. Although toe injuries most often affect the great ally does not cause persistent ankle instability.
toe, sometimes they can affect the lesser toe. Foot shuffling and squatting with knees spread apart are the
basic movements of sumo, and during these movements the
ankles are dorsally flexed. Thus, in competition, the ankle often

Fig. 25.46 Many judo injuries occur in the lower extremities. During

‘‘Ohsoto-gari,’’ a throwing technique, the foot and ankle assume an
equinovarus position. Inversion sprain can occur in the foot when Fig. 25.47  The great toe is easily plantarflexed (arrow) (‘‘tatami toe’’).
defensing (arrow). Tatami (straw) mats typically are used as a floor covering in judo.
478 SECTION 4  Unique and Exceptional Problems in Sports

is dorsally flexed (Fig. 25.49). Furthermore, when a wrestler a foot in the equinovarus position is swept sideways. However,
braces against being pushed out of the ring, the ankles are in lacerations of the skin on the plantar side of the first MTP joint
excessive dorsiflexion. On the anterior surface of the ankle, the are very common. Some sumo wrestlers prevent such lacera-
tibia often collides with the neck of the talus, causing impinge- tions by taping their toes or wearing Japanese thick-soled socks
ment exostosis. Because this condition exists in most sumo (“tabi”) (see Fig. 25.48).
wrestlers, and not many sumo wrestlers have ankle instability,
its onset must involve collision. Kendo
Because sumo wrestlers are heavy and collisions are violent, Japanese swords are the symbol of the Samurai culture. Unlike
there is a high incidence of bone fracture around the ankle. Western swords, Japanese swords are held using both hands.
Pronation-external rotation-type malleolar fracture is com- Kendo is a sport modeled after samurai sword fighting, using
mon because the lower leg is abducted and the foot is pronated, bamboo swords resembling Samurai swords. Practitioners wear
unlike the case in sports that are played with a ball. However, protective pads on the face (“men”), belly (“do”), and forearm
despite their severity, rehabilitation of such injuries is faster (“kote”). A point is scored when a bamboo sword cleanly hits
than for soft-tissue injury. one of the protective pads. A kendo practitioner holds a bam-
Severe toe injuries are less common than severe ankle inju- boo sword using both hands, with the right hand in front of the
ries. Unlike judo, sumo does not involve many moves in which left hand, somewhat like a right-handed baseball player holding
a bat. The two competitors face each other so that the tips of
their bamboo swords are lightly touching (Fig. 25.50). Right-
and left-handed practitioners take the same stance. The right
foot is placed in front, while the left foot stays back. Competitors
put their weight on the front half of each foot and slightly lift the
heels so that they can move very quickly.
Kendo is generally a safe sport, with a low incidence of frac-
ture, but mild toe injuries are quite common. Beginners often
complain of heel pain. Because kendo is practiced barefoot on
a wooden floor, there is great impact on the feet during kendo
moves. About 40% of kendo practitioners develop hemoglo-
binuria because red blood cells in the skin and subcutaneous
tissue of the sole are destroyed by the impact of the heel hit-
ting the floor. Some kendo practitioners develop a condition
called “black heel,” which is characterized by ecchymosis on
the sole of the feet. Usually, heel pads are used to treat this
condition.

Fig. 25.48 Exercise of shuffling. Keeping the feet on the ground

improves stability in this sport, which revolves around collisions and
pushing. The knees are bent in the valgus position, the lower legs are
abducted, and the feet are pronated. The playing surface is packed
earth. Sumo wrestlers tape their toes and wear ‘‘tabi’’ to prevent lacer-
ations on the soles of their feet.

Fig. 25.50  A starting posture of kendo is demonstrated. Note that the

Fig. 25.49  The ankles often are dorsally flexed in a bout. The incidence sport is practiced barefoot on a wooden floor. The right leg is in front of
of anterior ankle impingement exostoses is high in sumo wrestlers. the left. Weight is kept on the forefoot.
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 479

In kendo, the most common severe injury is rupture of the height between 1.62–1.64 m (5.3 ft) and can reach a speed of 60
Achilles tendon. This injury almost always occurs in the left leg, to 70 km/hour (37–43 mph).97 Jockeys have special equipment
because of the positions of the legs in the kendo stance (Fig. to protect them from trauma (riding helmet and special vests
25.51). During kendo moves, a great amount of force is applied for impact absorption), but there are still some parts of their
to the left leg. When the body pushes forward, the triceps muscle body exposed, such as their pelvis and lower limbs. Jockeys’
of the calf is tensed, and the Achilles tendon can rupture if there injuries during horse races have been published in the United
is a delay in plantarflexion of the ankle. In most sports, rupture States and Australia.98,99 These injuries include jockeys’ head or
of the Achilles tendon is rare among young people, but among neck (18.8%), the leg (15.5%), foot/ankle (10.7%), back (10.7%),
kendo practitioners, this injury is somewhat common in high arm/hand (11.0%), and shoulder (9.6%).
school students. This supports the theory that a great amount Jockeys’ lifestyle and nutrition status are a very important
of force is applied to the Achilles tendon in the left leg when the factor of vulnerability for this kind of injuries. Apart from the
body pushes forward in kendo. Rupture of the Achilles tendon risk of riding a high-speed racing horse in competition, these
is rare among beginners but is more common among skilled patients typically have an unbalanced diet. Occasionally they
practitioners. Most of those who sustain this injury chose to ingest alcohol, use diuretics, and have sauna sessions in order to
undergo surgery, and rehabilitation takes 6 to 12 months. maintain a low weight before races. All of this has been reported
to increase fracture risk.100
FOOT AND ANKLE INJURIES OF RACETRACK There are lots of minor to moderate injuries that are attended
JOCKEYS IN MEXICO CITY on the site of the accident or the racetrack emergency room,
such as minor head and limbs contusions and minor skin abra-
Introduction sions. Mild to moderate injuries that are treated at the hospital
Throughout the world since the time of the ancient Greeks, emergency room include lacerations and trauma involving the
horse races have been popular.97 Since the opening of the neck, wrist, knee, and ankle. Severe trauma is always treated on
Mexico City Racetrack, Hipòdromo de las Americas, in 1943, an inpatient basis in the hospital.
this sport has drawn public interest in Mexico. Although much Medical records of jockeys treated for orthopedics and
is known about the sport nationally, little has been written on trauma purposes since 1978 were reviewed identifying 1333
foot and ankle injuries of race track jockeys. This is a retrospec- cases that had musculoskeletal treatment.
tive review of 30 years of foot and ankle injuries as chronicled by The top cause of hospital admittance was upper extremity
their designated trauma orthopaedic surgeon. injury (52.36%) (Table 25.1). Of this, clavicle and wrist fractures
Every season (from January to October every year) the active were the most frequent.
jockey population is 24 to 30. These athletes typically have a Lower limb was second with 31.58% and a total of 421 patients.
petite physique with a weight between 42 kg (92.5lb) and 54 Starting in July 1978 until December 2014 (with a pause
kg (119.05 lb) and a height that ranges from 1.31 m (4.2ft) to between 1996 and 2001 while the racetrack was closed, 399
1.65 m (5.4 ft), while the thoroughbred horses they ride have a patients were admitted to the hospital for surgical treatment
because of foot and ankle injuries. (Table 25.2)

Mechanism of Injury (Box 25.1)

During preparation for the race, the horse is taken for saddle
placement, placing the jockeys at risk for a crush injury due to
being stepped on by the horse. Usually the jockey or the trainer
are vulnerable to a soft-tissue crush injury or a metatarsal fracture.
We had 18 feet with one to four metatarsal fractures that needed
reduction with internal fixation with K-wires or plates/screws.

TABLE 25.1  Injuries That Required Hospital

Admittance
Injuries that required
hospital admittance Cases
Upper Limb 52.36% 698
Lower Limb 31.58% 421
Pelvis 0.60% 8
Head Trauma 4.80% 64
Cervical/Lumbar Spine 9.52% 127
Fig. 25.51  An offense hit on a face guard (‘‘men’’). The right leg goes Multiple Costal Fractures 0.30% 4
forward during a lunge. Excessive force is loaded on the left Achilles Abdominal Trauma 0.80% 11
tendon during the sport. The incidence of Achilles tendon injuries is high  Total 1333
relative to the other martial arts.
480 SECTION 4  Unique and Exceptional Problems in Sports

A very specific area where foot and ankle injuries presented was Of course, the youth, low BMI, and nonchronic condition
the departure gate. This happens because whenever the gates are play a very important role in this recovery time.
suddenly opened, the horse jumps forward and the jockey’s foot
in the saddle stirrup locks within the gate, experiencing a violent Protective Gear
external rotation inducing a bimalleolar fracture. This occurred Apart from riding helmet, goggles, and rigid vest, further
in 22 cases. In our review, the most common mechanism was the improvement in this and new equipment has been advised in
jockey falling from or with the horse during a race. When a horse order to lower the incidence of fractures in jockeys.97 Foot and
falls while running, limb fractures are sustained, but due to the ankle protection is controversial. While racing, the jockey’s
speed and weight of the animal, sudden death may occur.99 An ankle must have 110–115 grades of dorsiflexion, so a more rigid
uneven surface on the racetrack could lead to a horse stumbling, or complex boot that could provide more protection definitely
a front limb fracture, and rear limbs collapsing. Since the jockey is would diminish this ROM and potentially the performance.
projected forward, the upper limbs sustain direct trauma.
This is why clavicle and wrist fractures were the most fre-
quent fractures in the 1333 patients in our study. Whenever a
jockey is down, other running horses can trample the athlete,
resulting in spine, pelvis, and/or abdominal trauma.

Open Fractures
There were 23 open fractures in this review. All of these were
treated with surgical irrigation and debridement before open
reduction internal fixation (ORIF). These cases are treated with
triple antibiotics: metronidazole, penicillin, and gentamycin,
given the contamination from the dirt and fecal matter.

Recovery Time on Bimalleolar Fractures

Jockeys, as with other elite athletes, have the determination to
quickly return to work.
All 201 patients were treated with regular ORIF with medial
screws, lateral plate, and screws as well as syndesmotic fixation
as needed. Typically, following the surgery, there was no weight
bearing until the sixth week. Syndesmotic screws were removed
between weeks 3 and 4. After this they started aggressive physi-
cal therapy (Figs. 25.52 through 25.55).
All of these patients returned to horse racing between week Fig. 25.52  Antero-posterior view of a preoperative distal tibial and fibu-
lar malleolus fracture.
9 and 12 postoperatively.

TABLE 25.2  Type of Foot and Ankle Injury

Type of Foot and Ankle Injury Feet/Ankles
Bimalleolar Ankle Fracture 201 50%
Unimalleolar Ankle Fracture 101 25.3%
Trimalleolar Ankle Fracture 25 6.2%
Distal Tibia Fracture 22 5.5%
Metatarsal/Phalanx Fractures 18 4.5%
Pilon Fracture 15 3.7%
Lisfranc Fracture/dislocation 13 3.2%
Syndesmotic Injury w/o Fracture 4 1%
Total 399

BOX 25.1  Mechanism of Injury

1. Falling from the horse while racing
2. Foot/ankle locking in the departure gate
3. Standing horse stepping on foot
4. Running horse stepping on foot
Fig. 25.53  Lateral view of a preoperative distal tibial and fibular malle-
olus fracture.
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 481

SPORTS INJURIES IN SOUTH AFRICA

Overload Injuries to the Second Metatarsal
South Africa is a country blessed with wonderful weather, so
most South Africans love their sporting and outdoor activities.
Golf, tennis, rugby, football, watersports, cycling, and running
are very popular, and sport-related injuries are thus very com-
mon. These include ankle sprains, Achilles’ tendon problems,
stress fractures, Lisfranc injuries, impingement syndromes, and
so forth.
People of all ages participate in running, and we are famous
for our ultra-marathon races, especially the Two Oceans
marathon (56 km) and the Comrades marathon (89 km).
Thousands of people line up at the start of the Comrades mar-
athon every year (23,818 participants in 2018). Few sportsmen
are as fanatic and passionate about their sport as the ultra-dis-
tance runner. The mean age of participants in this grueling
event is around 40 with the age range varying from 20 years
old to octogenarians.
This presents a special group of injuries to the sports physi-
Fig. 25.54  Antero-posterior view of an open reduction internal fixation cians and foot and ankle surgeons, namely injuries associated
(ORIF) of distal tibial and fibular malleolus fracture treated with plate and with forefoot pain due to overloading of the second metatarsal.
screws to distal tibia and fibular malleolus. Stress fracture of the second metatarsal is a common diagnosis,
but we want to highlight overload injuries of the second MTP
joint in this selected group of patients.
As in nonathletes, it is more common in women and usu-
ally unilateral. It initially presents with forefoot pain and
swelling only when running and then later progresses to pain
with daily activities. Deformities in the sagittal and coronal
plane develop later in the progression of the disease. Often
it is possible to find a biomechanical reason for the develop-
ment of this overload other than a long rigid second metatar-
sal (Morton foot), which should be addressed in treatment.
Surgical treatment of the symptoms and not the cause will
end in recurrence of the injury, including instability and
associated deformities.
Patho-anatomy that causes overloading of the forefoot
includes the following:
• Hypermobile first ray
• Abnormally long second metatarsal/Short first metatarsal
• Metatarsal primus elevates
• Hallux valgus
• Short gastro-soleus complex
This results in synovitis that causes the capsuloligamentous struc-
tures of the MTP joint to become stretched, leading to instability.
Fig. 25.55  Lateral view of an open reduction internal fixation (ORIF) of This can progress to attenuation of plantar plate and extension of the
distal tibial and fibular malleolus fracture treated with plate and screws
to distal tibia and fibular malleolus.
MTP joint (sagittal component) and an associated crossover defor-
mity (coronal component). Progression of instability can lead to dor-
sal dislocation of MTP joint, predisposing to hammer toe deformity.
Summary Overload injury can also present with different patho-anat-
Injuries to the musculoskeletal system are frequent in jockeys. omy including cartilage injury and synovitis.
They range from contusions and simple trauma to limb frac-
tures, head trauma, spine injuries, or death. Bimalleolar ankle Case report
fractures, Lisfranc injuries, and metatarsal fractures are com- Thirty-nine-year-old healthy female marathon runner with
mon. Open fractures are also frequent, requiring immediate a 15-month history of right forefoot pain and swelling.
treatment with triple antibiotics and aggressive debridement Diagnosed with a stress fracture of the second metatarsal and
and stabilization. treated with orthotics, twice with cortisone infiltration, a boot
482 SECTION 4  Unique and Exceptional Problems in Sports

Fig. 25.56 Cartilage was deficient centrally and was debrided and

drilled.

Fig. 25.58  Swelling, crepitus, and tenderness of the second metatarso-

phalangeal. The joint is stable.

On examination, it is easy to localize the pain to the sec-

ond MP joint, and there is usually obvious swelling present
on the dorsal aspect of this joint. The joint must be tested for
instability with the drawer test and compared to the other
foot. Tightness of the Achilles’ tendon should be excluded and
the Silfverskiold test performed. We always examine the first
ray for instability and alignment and exclude other reasons
for pain in the area like sesamoid pain, stress fracture, and
Morton’s neuroma.

Investigations
Plain standing radiographs are routinely performed. With
Fig. 25.57 X-ray showing a dysplastic first metatarsophalangeal joint
the high accuracy of clinical examination for most diagnoses
with a short proximal phalanx.
including plantar plate injury, MRI is reserved for cases when
brace, and ultimately 7 months of cessation of running. On the diagnosis and treatment plan cannot be established from the
physical exam there was swelling, crepitus, and tenderness of clinical findings or to exclude other pathology, e.g., OCLs.
the second MTP. The joint was stable (Fig. 25.56). Evaluation of Treatment should include:
the alignment and mobility of the rest of the foot and ankle was • Adaptation of shoewear as necessary (running and daily shoes)
normal. There was no gastrocnemius tightness. X-rays demon- • Orthotics—Medial arch supports with metatarsal pads
strated a shorter right first metatarsal. MRI revealed synovitis • Modification of mileage and cross training
of the second MTP (Fig. 25.57). Patient was treated with a Weil • NSAIDs
osteotomy to shorten the second metatarsal 2 mm. A double
cut was made to elevate the metatarsal. The cartilage was defi- Case report
cient centrally and was debrided and drilled (Fig. 25.58). A 44-year-old female marathon runner had gradual onset of pain
Mechanical pain associated with running will be the main in the left forefoot with running. Her usual distance for train-
initial complaint. A sudden increase in distance could be the ing was 100 km/week. She was treated elsewhere for a neuroma
initiating factor in this overuse injury. In obtaining a history with cortisone infiltration and physiotherapy. On physical exam
from these patients, it is important to inquire about previous she was noted to have a tight gastrocnemius, moderate hallux
surgery, i.e., previous Bunion surgery, with resultant shortening valgus, synovitis second metatarsal phalangeal joint, and slight
or elevation of the first ray. Complaints of swelling of the MTP valgus deviation of the first and second toes. X-rays revealed a
joint indicating synovitis of the MTP joint are common. Most dysplastic first MTP joint with a short proximal phalanx (Fig.
patients would have visited a sports physician and received cor- 25.59). Treatment began with shoewear modifications, rest, and
tisone injections into the MTP joint with the possible worsen- orthotics. Once symptoms subsided, she gradually built up her
ing of any deformities. A change of shoewear or worn-out shoes distances but stayed limited to training distances of 20–30 km/
might also contribute to the injury. week. She also began swimming for alternative exercise.
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 483

A PERSPECTIVE ON THE FOOT AND ANKLE IN

SPORTS FROM THAILAND
In Thailand, there are different kinds of unique cultural games
and sports that have implications in foot and ankle injury. Muay
Thai and Sepak Takraw are two that will be the focus of this
section.

Muay Thai
Muay Thai, an ancient traditional martial art of Thailand, has
been developed with the concept of using the body as a weapon
in close-range person-to-person combat. It is also referred to
the “Art of the Eight Limbs” because of its use of punches, kicks,
and elbow and knee strikes as opposed to other martial arts
such as Judo and Taekwondo in which only punches and kicks
are used. This is the reason why Muay Thai is widely regarded
as a devastating martial art, with a knockout rate ranging from
28% to 56% in all professional fights.
More than half (55.4%) of Muay Thai boxers reported an
injury in their most recent fight. The lower extremities (51%)
were the most commonly injured body region during fights.101
Fig. 25.59  MRI showing synovitis of the second metatarsophalangeal. Most of the reported injuries were soft-tissue injuries contrib-
uting to at least 80–90% of all injuries. The severity of these
We do not support injecting the joint with cortisone, as we soft-tissue injuries were usually lower on the injury severity
have seen disastrous results with it, especially if it allows the scale.102 Injury prevalence is also associated with fight experi-
patient to continue with running and participating in races. This ence level, use of protective equipment, level of competition,
includes deterioration of the stabilizing structures around the and previous injury history.101-103
joint and progress of intra-articular pathology. As this problem Even though Muay Thai is a type of kickboxing, it has a
is sometimes a critical injury preventing the athlete from con- distinctive kicking style. The kicks in Muay Thai have been
tinuing with running ultra-distance races, a change in approach divided into two types. The first is the front kick (Fig. 25.60)
and even sporting activity should be considered. using the forefoot, especially the first metatarsal head, to
Surgical treatment options differ from patient to patient. It is hit the target. The second is the side kick (see Fig. 25.60),
important to treat not only the joint problem (synovitis/cartilage in which the shin is used as a weapon to attack the target.
injury/instability) but also the underlying mechanical overload Because of these distinctive kicking styles, the most com-
of the MTP joint. This includes different metatarsal osteotomies, mon injury in Muay Thai is contusion of the shin. However,
stabilizing and aligning the first ray and gastrocnemius slides. because Muay Thai boxers can use their elbows and knees to
As mentioned above, these (e.g., gastrocnemius slide) may affect protect themselves from attack, if the kicks miss the target,
the patient’s ability to participate in running sports. When there there is a chance of hyperextension ankle injury or soft-tissue
is MTP instability, a plantar plate repair is performed through a injury of the dorsal portion of the foot. Thus, the rate of foot
dorsal approach. A Weil osteotomy is recommended for access to and ankle injuries in the well-trained Muay Thai boxers is
the plate and to alter the length and height slightly. Finally, any fewer when compared to other types of kickboxing. Regarding
IP deformity is addressed as indicated. When the plantar plate the prevalence of shin contusion, use of shin guards is recom-
is irreparable owing to insufficient tissue, a flexor-to-extensor mended (Fig. 25.61) for all Muay Thai beginners.
transfer is performed. More commonly a Cobb II type procedure There are unique types of attacks called Kon Muay, advanced
is performed. In this technique the extensor digitorum longus tactics to take down the opponent. Some of these Kon Muay
(EDL) is released distally and routed through a drill hole in the tactics (Fig. 25.62) can result in improper landings, causing
neck of the metatarsal or sutured to the plantar plate. sprains. Moreover, Muay Thai allows the boxers to sweep under
Postoperatively patients are allowed weight bearing in a rigid the legs of their opponents by using the dorsum of the foot and
shank postoperative shoe for 6 weeks. anterior aspect of ankle. With these types of attacks, twisted
The operated toe is strapped in a plantarflexed position ankles and Achilles tendon injuries are common.
for 6/52. Active and passive ROM exercises begin at 6 weeks. Vaseenon et  al.104 found that the most common foot and
Patients may advance to normal shoewear at this stage. ankle problem in Muay Thai boxers was callosity over high con-
Above-discussed patient group can be very demanding, as tact zones (77.5% forefoot, 16.3% malleoli, 3.1% midfoot, and
they are exremely passionate about their sport. Diagnosis is 3.1% heel), followed by gastrocnemius contracture, toe defor-
usually relatively straightforward. Unfortunately conservative mities, and heel pain. The causes of these common problems are
and surgical treatment can be challenging for the patient and barefoot training with tiptoe dancing and use of the forefoot as
the surgeon. a pivot point when kicking.
484 SECTION 4  Unique and Exceptional Problems in Sports

Fig. 25.60  The front kick (left) and the side kick (right).

In 1833, the Thai sport association introduced the volley-

ball-like style net and held the first contest. By the 1940s, the
first set of formalized rules were introduced, and the game took
the official name of Sepak Takraw with the International Sepak
Takraw Federation (ISTAF) governing the sport worldwide.
Like the volleyball game, the Sepak Takraw players are allowed
a maximum of three contacts with the ball to get it over the net.
Unlike volleyball, the players are allowed to use their legs, head,
and trunk to contact the ball but are prohibited from having any
contact with their arms or hands.
There are three basic player positions in this sport. These
consist of the server, Tekong (Back), feeder (setter), and kicker
(striker). Each particular position carries a particular risk for a
specific type of injury. The kicker position carries the highest risk
of foot and ankle injury, as they also function as a blocker and
striker near the net, their kicks consisting of a somersault-like
kick (Fig. 25.63). The server and the feeder have a lower chance of
injury, but their injuries are specific to their positions. The feeder
needs to reach the ball before it contacts the floor and try to feed
the ball back to the kicker to make the score, therefore they have
Fig. 25.61  Shin guards. a higher chance of tripping while chasing the ball. For the server,
when they serve by hitting the ball hard and they miss, they can
end up landing badly and may experience a foot or ankle sprain.
In the past, the grapefruit-sized balls were handwoven from
Sepak Takraw bamboo or rattan, but most modern ones are made of rattan or
Sepak Takraw is a game originating from Southeast Asia. The synthetic material with weights between 170–180 grams under
word “Sepak” is from the Malaysian language that means “kick” ISTAF regulations (Fig. 25.64). These balls are different from
and “Takraw” originates from the Thai language, meaning “rat- the balls used in volleyball, soccer, and rugby. There is no air
tan ball.” In the fifteenth century, the game rules varied slightly in the balls, making them stiffer with less bounce. As a result,
in different parts of Southeast Asia. Traditionally, Thai people it requires more energy from the players in order to propel the
formerly played this game by standing in a circle and used their ball across the court. When more energy is used, especially if
feet to pass the ball back and forth between them, which was the player is not properly trained in technique, there is a higher
called “Circle Sepak Takraw.” risk of uncontrolled landing when kicking.
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 485

Fig. 25.62  Kon Muay tactics.

As the ball does not recoil from the player’s foot, when kick-
ing, it is necessary to have a large contact area with it in order
to have more control. This has led to the requirement of special
shoes. Most Sepak Takraw players choose to use a local brand of
canvas shoes (Fig. 25.65) that have minimal outer sole in order
to maximize the contact surface to the longitudinal arch of the
foot during kicks. These canvas shoes are made of a thin cloth so
the ball can be felt while kicking, with a low, smooth outer sole
that is crafted from a particular type of rubber with high friction
and proper weight. With proper weight on these shoes, they can
create more momentum as well as increased control, which is
necessary because the ball is small and difficult to control.
The disadvantages to these types of shoes do exist. As the
insole is a flat surface, there is no support to the arch of the
foot, which can lead to plantar fasciitis. The lack of support from
Fig. 25.63  Summersault-like kick. the insole will also result in excessive pressure in certain parts
486 SECTION 4  Unique and Exceptional Problems in Sports

Fig. 25.64 Ball.

(42/58, 72%), but only 15% of the time do the players seek med-
ical attention for their sprains. The players are treated conserva-
tively and take less than 2 weeks off to recover. Residual laxity
in the ankle is found in 20% (20/58) of the players, but usually it
does not affect the player’s ability to play as their muscles in the
lower leg area are well trained and they are able to compensate.
We also noted common problems including callus formation
in 64% (37/58), gastrocnemius tightness (20/58, 34%), hamstring
tightness (16/58, 28%), plantar fasciitis (8/58, 14%), Achilles ten-
dinitis (3/58, 5%), stress fracture on the tibia (1/58), and turf-
toes (1/58). If improper stretching techniques are implemented,
strains and tightness can easily occur at the Achilles tendon, ham-
strings, adductor muscles, and iliotibial (IT) band. All this can
be corrected by proper stretching, which is emphasized in this
sport. If proper time is allocated for stretching, strengthening,
Fig. 25.65  A local-brand canvas shoe. and reconditioning then injuries are rare.

of the foot that are not accommodated, resulting in increased FOOT AND ANKLE INJURIES IN UNITED ARAB
callus formation in the forefoot. Moreover, with a certain type
of stiffer rubber, a great deal of force will transfer through the
EMIRATES SPORTS
first MTP joint and hallucal-sesamoid complex making these The United Arab Emirates (UAE) has a desert climate and is
structures vulnerable to injury during landing and pivoting on situated directly on the Arabian Gulf. This unique geography
the forefoot. These shoes also have no ankle support and lack a lends itself to a truly wide variety of sporting activities among
flared heel, so the ankle will be easily twisted and sprained. the residents. Water sports such as water skiing, wakeboarding,
In 58 professional Sepak Takraw national team players, we and kite surfing are hugely popular. Other sports such as soc-
found the most common injury in this sport is ankle sprain cer, rugby, tennis, and squash are commonplace. In the desert,
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 487

Fig. 25.66  A unique sport in the United Arab Emirates is hunting prey
with falcons. The sandals keep the foot high off the ground to prevent
entry of pebbles. They are discarded when running in soft sand.

sand boarding and motor sports command the winter months.

Most of the common injuries seen elsewhere are encountered
but with some unique scenarios.
Certain niche sports are found in the UAE. For example,
falcons are trained to hunt prey. This involves long periods of
bonding and progressive conditioning of the predator bird.
To accomplish this, the owner often has to run rapidly to tend
A
to his falcon, and in the soft sand this is better accomplished
barefoot. Sandals typically are worn (Fig. 25.66) to keep the
foot high off the ground to prevent entry of pebbles but are dis-
carded when running in soft sand. Still, minor stub and barb
injuries are common. Because the terrain underfoot is soft,
the barbs or other objects have little force for any penetration.
When training the falcons on the harder desert plain, one wears
enclosed shoes (Figs. 25.67 and 25.68) to prevent the entry of
foreign objects. Also, ankle sprains (mostly lateral) tend to be
relatively minor on the sand because the surface is not firm and
thus is very forgiving during inversion.
Arabs have a long tradition with horses. In the UAE, horse
racing (speed and marathon) and polo are two sports in which
injuries are relatively common. Most tend to be in the upper
extremities from falls, but foot and ankle injuries also occur. The
prolonged “heel down” position in the saddle can lead to impinge- B
ment syndromes of the anterior chamber of the ankle, requiring Fig. 25.67  On the harder desert plain, A, the hunter seen here with the
removal of any kissing osteophytes or soft tissues. Because these falcon uses B, enclosed shoes.
are mostly symptomatic early in their development, arthroscopic
debridement is very successful, with arthrotomy rarely being with walker-type removable braces allows rapid return to riding.
required. Minor crush injuries of the foot and ankle occur as the Occasionally, more severe problems such as Lisfranc injuries and
horses collide during play, but serious crush injuries from hooves subluxations or dislocations of the talocrural joint occur. When
are surprisingly uncommon in the UAE. This could possibly be surgical reconstruction is warranted, rigid internal fixation is
from the combination of a high standard of horsemanship and used, possibly including the repair of a deltoid ligament avulsion
well-trained thoroughbreds that are used in the sport. and concomitant syndesmosis stabilization (Fig. 25.70).
Motocross has its share of injuries because dirt bikes are rid- Long-distance bike riding is now becoming popular in the
den in the sand at high speeds. Riders are required to wear body UAE. A relatively common problem seen in these cyclists is
armor and protective footwear (Fig. 25.69). However, unlike Morton’s neuroma. This happens despite appropriate shoewear
hard dirt terrain that causes a violent plantarflexion force of and possibly results from a combination of the high heat and
short duration, sand produces a more moderate force of longer humidity causing edema of the foot. Conservative care with
duration. This leads to sprains of the anterior structures, with metatarsal pads and a wider toe box to accommodate the fore-
relatively frequent anterior capsular tears. Conservative care foot is very successful.
488 SECTION 4  Unique and Exceptional Problems in Sports

A C
Fig. 25.68  Another example of A, the falcon trainer with B, typical shoewear used for C, hard desert terrain.

Tendinopathies in the UAE are now increasingly diagnosed rituals, rhythm, songs, and instruments. There are usually seven
by ultrasound and treated with biologics. Platelet-rich plasma, different types of drums playing the beat.
mostly leukocyte-poor PRP, is the most common medium To celebrate Saint John on June 24, parishioners perform
employed. Success rates are similar to those in the published their rituals and dance the drum-beat for 3 days in many coastal
literature to date. Needle electrical stimulation (EIN or EPTE) town central squares or beach areas, although the dance has
is also used but less frequently. For Achilles tendon ruptures, the become so popular that it is performed all year long and all
trend is toward functional brace treatment instead of surgery. around the country.
The decision on the ground here is guided by dynamic diagnos- The dance is performed by a male and female couple sur-
tic ultrasound, looking for approach of the torn tendon ends rounded by drummers, singers, and spectators in a circle who
with passive ankle plantar flexion. In the UAE, we emphasize sing and cheer at the same time. The male dances around the
rapid rehabilitation and return to sports. Fast-track programs female pretending to trap her with sudden movements, and
and hydrotherapy for management of foot and ankle injuries the female pretends to ignore the male dancer turning her
provide an early start to the recovery process, with weight bear- back to him while he tries to face her again; it can become very
ing as soon as safely possible. Rapid progression to strengthen- fast, a bit aggressive and sensual at the same time. The male is
ing and proprioceptive feedback exercises has been beneficial to replaced after a short time by another male dancer who jumps
returning the player quickly to his or her sport. suddenly between the couple; the female remains longer and
can dance with many different males in the same song.
PLANTAR PLATE RUPTURE AND DRUM-BEAT The main characteristic of the Venezuelan drum-beat dance
is that the dancer’s rear foot has to remain in a forced MTP
DANCE IN VENEZUELA joint dorsiflexion position for long periods, exerting pressure
Drum-beat dance has become a very popular musical genre in in this area when the body position suddenly changes during
Venezuela for the last 200 years. It is strongly related to vener- the dance, which is mostly performed barefoot in sandy areas.
ation of saints Peter and John, and part of the African slaves’ This rear foot stance makes the dancer susceptible to forefoot
musical heritage. This dance is mainly from the country’s cen- problems, mainly metatarsalgia, toes deformities, and acute or
tral coast, and depending on the area, it may differ in dance chronic plantar plate rupture (Fig. 25.71).
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 489

Plantar Plate Rupture and Venezuelan Drum-Beat

Dance
Metatarsophalangeal plantar plate rupture can occur in an acute
or chronic setting.
Acute plantar plate rupture is an infrequent condition. The
patient reports having felt a sudden crepitation and pain in the
plantar plate area during the event, progressive second MTP

B
Fig. 25.69  A popular winter sport is motocross. The rider wears body
armor and protective footwear to minimize injury. A, The rider here is
preparing to land on a dune following a jump. B, The rider cuts across
the soft and at times unstable sand and is susceptible to ankle and leg Fig. 25.71  There are mainly seven different types of drums playing the
trauma. beat.

A B
Fig. 25.70  A, This syndesmotic injury was noted on a stress view of the ankle. B, Two syndesmotic screws
close the tibiofibular space and suture anchors stabilize the deltoid tear.
490 SECTION 4  Unique and Exceptional Problems in Sports

joint dorsiflexion days after the injury with swelling and even
hematoma around the area.
Metatarsophalangeal instability and chronic plantar plate
rupture can be present in drum-beat dancers, mainly in more
frequent dancers. Most patients with this condition, refer
plantar or dorsal gradual pain onset in the effected joint and
progressive long-standing MTP dorsiflexion, with coronal or
sagittal deviation.105-108 Depending on the clinical progression,
patients may have positive drawer test or discomfort with the
exam. Drum-beat dancers normally have clinical deformities of
grades 0, I, or II and very rarely grades III or IV according to the
Nery et al. staging system (Table 25.3).109 Fig. 25.72  In acute plantar plate rupture, progressive second metatar-
sophalangeal joint dorsiflexion is observed days after the injury.
Our Treatment Choice for Plantar Plate Rupture
Acute Plantar Plate Rupture
In acute plantar plate rupture we suggest repairing the plantar
plate acutely, by a plantar incision.110 The MTP joint is approached
directly after the flexor digitorum longus is retracted laterally (as
shown in the image), and the plantar plate is reinserted to the base
of the first phalanx with 2.0-mm suture anchors. Postoperatively
the injured joint in held in slight plantar flexion by strapping for
2 weeks and active or passive joint dorsiflexion is avoided for the
next 2 weeks, protecting the foot in a postop shoe for the first 4
postop weeks (Figs. 25.72 through 25.75).
Since these are normally acute injuries in balanced forefoot,
there is no need to alter the forefoot biomechanics with meta-
tarsal osteotomies or invade healthy joints to access and repair
the acutely ruptured plantar plate.
We operated on seven patients with acute plantar plate
rupture using the previously described technique, three were

TABLE 25.3  Clinical Staging System for

Lesser Toes MTP Joints Instability
Fig. 25.73 In acute plantar plate rupture we perform the plate repair
Grade Alignment Physical Exam through a plantar incision, the metatarsophalangeal joint is approached
directly after the flexor digitorum longus is retracted laterally.
0 Prodromal phase: no ­ Thickening or swelling of the
deformity MTP joint MTP joint.
alignment Reduction of the toe purchase
Negative drawer test
I Mild deformity: toe MTP joint pain, swelling of the
elevation + web space MTP joint.
­widening + medial Loss of toe purchase
deviation Mild positive drawer less than
50% subluxable
II Moderate deformity: toe MTP joint pain, reduction of
elevation + medial or ­swelling. No toe purchase
dorsomedial deviation Moderate positive drawer: more
than 50% subluxable
III Severe deformity: toe Joint and toe pain, little swelling.
­elevation + medial ­ No toe purchase
deviation toe overlap. Severe positive drawer: dislocatable
Flexible hammertoe MTP joint
IV Very severe deformity: Joint and toe pain, little or no
dorsomedial or dorsal ­swelling. No toe purchase
Cross over toe. Fixed Dislocated MTP
­hammertoe.
From Nery C, Coughlin MJ, Baumfeld D, Mann T. Lesser metatarso-
phalangeal joint instability: prospective evaluation and repair of plantar Fig. 25.74 Plantar plate is reinserted to the base of the first phalanx
plate and capsular insufficiency. Foot Ankle Int. 2012;33(4):301–311. with 2.0-mm suture anchors.
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 491

Fig. 25.75  Plantar plate is refreshed and reinserted to the base of the Fig. 25.76 Plantar plate is reinserted to the base of the first phalanx
first phalanx with 2.0-mm suture anchors. with 2.0-mm suture anchors forcing slight plantar flexion.

recreational male drum-beat dancers after a prolonged dance

round in sandy areas. The other four patients, two were
injured after playing beach racquet, one sliding into second
base while playing baseball, and the last one after a strong
golf swing.
After surgery three patients reported slight discomfort and
edema in the plantar plate area that lasted over 3 months and
eventually disappeared. One patient had transient plantar neu-
ritis for 2 months. No patient had any skin issues or complica-
tions from the plantar approach.

Instability and Chronic Plantar Plate Rupture

In clinical grade 0, with no deformity (or slight dorsiflexion)
and moderate joint pain increased with drawer test, treatment
consisted of strapping the MTP joint in slight plantar flexion
for 4 to 6 weeks.111 Twelve of 16 patients with grade 0 improved
their symptoms and did not develop deformity after 1 year (4
patients were drum-beat dancers). The other four patients did
not improve and toe dorsiflexion increased—they were treated
as grade I.107
Grade I patients presented with mild toe elevation and Fig. 25.77  Chronic plantar plate reconstruction is performed through a
medial deviation, grade II patients have a moderate defor- dorsal approach and Weil osteotomy.
mity with toe elevation and medial or dorsomedial devia-
tion, both grades with discomfort and positive drawer test.
We performed surgery in 24 patients grades I and II (five the 17 patients had edema and discomfort in the plantar plate
patients were drum-beat dancers). In 17 of 24 patients, sur- area that lasted over a year in most of the patients, and 7 of
gery consisted of plantar plate reconstruction using a dorsal 17 patients ended with mild to moderate floating toes. In the
approach,112-114 Weil osteotomy and lateral capsule reefing other group, 7 of 24 patients, treated only with Girdlestone
or extensor digitorum brevis (EDB) transfer. In 8 of the 17 Taylor flexor to extensor transfer and lateral capsule reefing
patients, Girdlestone Taylor flexor to extensor transfer was or EDB transfer, there were no plantar plate discomfort after
added to address flexible hammer toe.115 We found that 9 of 3 months and no floating toes (Figs. 25.76 through 25.78).
492 SECTION 4  Unique and Exceptional Problems in Sports

Fig. 25.78  After chronic plantar plate reconstruction is performed, Weil Fig. 25.80 We consider plantar plate repair and Weil osteotomy in
osteotomy is fixed in position. patients diagnosed of plantar plate rupture grade I or II, with long central
metatarsals, second and third toes divergence, plantar hyperqueratosis,
and metatarsalgia.

Fig. 25.81  According to Nery´s Clinical staging system for lesser toes
Fig. 25.79 Light to moderate floating toe is a common complication metatarsophalangeal joints instability (Nery et al, FAI 2012, vol 33-4),
after Weil osteotomy. right foot is grade III and left foot grade II.

For these reasons, our treatment choice is the Girdlestone Our treatment choice for grade III and IV is similar, but
Taylor flexor to extensor transfer with lateral capsule reefing116 without plantar plate reconstruction, since the tissue quality
or EDB transfer to treat grade I and II plantar plate rupture. We is not optimal to heal at this grade. We may also add in some
consider performing the plantar plate repair and Weil osteotomy of the patients a DuVries first proximal interphalangeal joint
in patients diagnosed with plantar plate rupture grade I or II, fusion for fixed hammer toes and EDB transfer (Figs. 25.81
with long central metatarsals, second and third toes divergence, and 25.82).
plantar hyperkeratosis, and metatarsalgia (Figs. 25.79 and 25.80).
 CHAPER 25  An International Perspective on the Foot and Ankle in Sports 493

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48. Claassen L, Bock K, Ettinger M, Waizy H, Stukenborg-Colsman agement of midfoot sprains: lisfranc injuries in the athlete. Am J
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 26
The Military Athlete
Tobin Eckel Scott Shawen

OUTLINE
Introduction, 497 Lisfranc Injuries, 499
Ankle Sprains and Instability, 498 Osteochondral Lesions of the Talus, 499
Fractures, 498 Plantar Fasciitis, 500
Achilles Tendinopathy and Rupture, 499 Bracing Options, 500

terrain, and potentially while maneuvering under enemy

INTRODUCTION fire. Biomechanical changes in gait patterns have been docu-
While the military generally represents a young, athletic pop- mented with these increased loads, to include increased step
ulation, it is distinct in many ways. Functional outcomes are rate, decreased stride length, and forward trunk lean. With a
different when compared to the civilian population, largely concomitant rise in lower extremity overuse injuries, it is rea-
because the definition of success and the functional demands sonable to infer a detrimental effect of these increased external
of the soldier are unique. To better understand this, one must loads.8 However, roughly 75% of musculoskeletal injuries can
first recognize what the military does. Simply stated, the pur- be attributed to physical training and sports-related activi-
pose of the military is to protect the nation and win wars.1 ties.9,10 These nonbattle injuries remain the leading cause of
However, with a military that is spread across the world and evacuation from Iraq and Afghanistan.11
has been at war for the past 16 years, the demands placed on The other unique aspect of the military athlete is that of
soldiers, sailors, marines, and airmen are unparalleled in the functional outcome. Historically, the outcomes within military
civilian population. The US military is an all-volunteer force populations do not mirror those of the civilian population. In
that only comprises 0.4% of the American population, yet we general, the military athlete is required to do more in less time.
place great demands on these select few, which can inherently There are strict physical fitness requirements tested on an annual
lead to increased physical strain and eventual musculoskeletal or biannual basis. Each of the services (Army, Air Force, Navy,
injury.2 Marines) has different requirements and frequency, all testing
The armed forces represent a highly active population with strength, endurance, and agility. The Air Force and Navy require
strenuous occupational demands. The routine physical fitness a passing score in a 1.5-mile timed run, timed push-ups, and
and rigorous combat training mirrors that of an athletic pop- timed sit-ups. The Navy can select a 500-meter swim as a test
ulation.3 Musculoskeletal injuries are exceedingly common of endurance instead of the 1.5-mile run. The Army requires a
and often present as either traumatic in nature or the result passing score in a 2-mile timed run, timed push-ups, and timed
of overuse injuries. Overuse injuries are seen most commonly sit-ups. The most strenuous, the Marine Corps requires a pass-
during initial entry training into the military, as well as in the ing score in a 3-mile timed run, timed crunches, and pull-ups/
later stages of a military career. In fact, it is estimated that 25% dead arm hang for males/females. The Marines also employ a
of males and 50% of females sustain a physical training injury combat fitness test (CFT) that evaluates simulated combat con-
during basic training, with the vast majority being overuse ditions with sprinting, lifting, and agility testing. Furthermore,
injuries.4–6 soldiers in combat arms branches, as well as elite units and spe-
Musculoskeletal injuries continue to place a huge bur- cial forces operators from each of the units, have even greater
den on our military force. They are the leading cause of lost physical demands and requirements. Most units require daily
work time and disability leading to medical separation.7 The physical training, usually in small groups. If a service member is
reason these injuries are so prevalent is multifactorial. There injured, they typically have a year to recover before the medical
has been much speculation regarding the effect of the com- separation process begins.12 Military outcomes focus predomi-
bat load that soldiers carry and its effect on overuse injuries. nantly on the ability to return to full duty in this finite period
Over the past two decades, the average external load carried of time.12
by a soldier has increased to roughly 100 pounds (Fig. 26.1). The focus of this chapter will be injuries sustained about the
This is often carried in austere environments with uneven foot and ankle of our military service members. This will include
497
498 SECTION 4  Unique and Exceptional Problems in Sports

Fig. 26.1  Example of the external load carried by a soldier.

the prevalence of these injuries and their outcomes. Ultimately, activity. However, outside of parachuting, there is little evi-
the goal will be to have a better understanding of the impact of dence to suggest a protective benefit of prophylactic bracing in
these injuries on our military forces and how they differ from a the military population.10
young, active population. Those who develop chronic instability refractory to phys-
ical therapy undergo a lateral ligament reconstruction with
concomitant procedures performed as necessary. In our
ANKLE SPRAINS AND INSTABILITY practice, we have found that the Broström-Gould–type ankle
Ankle sprains are one of the most common athletic injuries reconstruction (advancement of the ankle capsule and con-
and account for nearly half of all sport-related injuries.13,14 tained ligaments, augmenting with the inferior peroneal ret-
The incidence rates (IR) of ankle sprains in the general pop- inaculum) provides adequate stability without sacrificing
ulation range between 5–7 per 1000 person-years. Yet, the sub-talar joint mobility and range of motion.18,19 In selected
IR in the military is much higher. One study reported the IR cases where there is inadequate soft tissue for reconstruction,
of ankle sprains among service members at 34.95 per 1000 or the patient has failed a prior Broström-Gould reconstruc-
person-years, while a second study examining cadets at the tion, nonanatomic reconstructions are utilized. We favor the
United States Military Academy reported an IR of 58.4 per modified Broström-Evans described by Anderson for revision
1000 person-years.15,16 cases, as the ankle capsule and soft tissues can be repaired
These disparities are likely explained in part by the fact again and augmented with good outcomes.20,21 In cases where
that the military represents an athletic population that has there is not sufficient ankle capsule or soft-tissue we recom-
an increased exposure to at-risk activities. In fact, cadets mend augmentation with an allograft tendon (semitendino-
with higher levels of fitness and those that participated in sis) with a modified Chrisman-Snook.22 One study on the
intercollegiate athletics were more likely to sustain an ankle long-term outcomes of athletes undergoing ligament recon-
sprain.16 While there is no correlation between length of struction demonstrated that 58% were able to return to their
service and an isolated ankle sprain, those with recurrent pre-injury level of sport, 16% were able to compete at a lower
ankle sprains and instability tend to have shorter service level, and the other 26% discontinued sport but were still able
times when compared to those who do not sustain an ankle to remain physically active.23
sprain.15
While 95% of these service members are able to return to
sports and physical training within 6 weeks of injury, nearly
FRACTURES
half will still have residual pain at 6 months postinjury. Foot and ankle fractures are common in the military, second
Furthermore, the average rehabilitative period following an only to hand fractures. These present as either acute fractures or
ankle sprain is 40 days, creating a significant burden on force chronic stress fractures. Within the military, fractures account
readiness.17 Even with appropriate functional rehabilitation, for 40% of injury-associated hospitalizations and 26% of combat
10% to 30% will develop chronic ankle instability and possi- injuries. Orr et al. demonstrated that 83% of service members
bly require surgery.3 Because of the prevalence of these ankle undergoing operative fixation for an ankle fracture were able to
injuries, the Department of Defense recommends the use of a remain on active duty.24 However, at 3 years postsurgery, 36%
semirigid ankle brace when participating in high-risk physical were unable to return to the required level of running and 17%
 CHAPTER 26  The Military Athlete 499

were medically separated. This seems to coincide with civilian demonstrated a higher stiffness in the black athletes.32 While
outcomes, which demonstrate roughly 50% of patients have this difference can improve muscle performance, it may also
pain, stiffness, and swelling at 1-year postsurgery. Additionally, result in a higher rate of catastrophic failure. Another possible
only 25% of patients were able to return to sports at 1 year fol- explanation is the trend of higher BMI in black adults in the
lowing surgery.24 military compared to white adults, and the increased weight
Stress fractures, on the other hand, continue to be one of may predispose to tendinopathy and ultimately an increased
the leading causes of injury in new military recruits.4 The risk of rupture.30
incidence of lower extremity stress fracture for initial-entry Recent literature has demonstrated equivalent outcomes
military training is 0.8% to 6.9% for males and 3.4% to 21% with operative and nonoperative treatment when using a
for females.5 Prevention of overtraining, particularly in new functional rehabilitation protocol. This has led to a greater
recruits with lower baseline fitness levels, has proven effective trend toward nonoperative management of Achilles rup-
in reducing the incidence of stress fractures. In fact, the mil- tures.33 However, within a military population, operative
itary has decreased the number of stress fractures by 40% in intervention may have the advantage of earlier return to duty.
the past 15 years by implementing modified physical training Renninger et  al. demonstrated that service members under-
plans aimed at gradual progression of activity and appropriate going operative management of their Achilles tendon rupture
cross-training to reduce repetitive stress.4 Nonetheless, stress were able to return to duty 6 weeks faster than those managed
fractures continue to result in significant morbidity and often nonoperatively.33
require long recovery periods. Adequate nutrition is critical
to ensure balance between energy intake and expenditure.
Calcium and vitamin D supplementation can be both protec-
tive and therapeutic. Female Navy recruits placed on calcium
LISFRANC INJURIES
and vitamin D therapy had a 20% lower incidence of stress Lisfranc injuries encompass a broad spectrum of midfoot
fractures.25 injuries, ranging from isolated ligamentous injuries to frac-
Metatarsal stress fractures account for 16% of all stress frac- ture-dislocations. They can result from high-energy trauma,
tures. First described in Prussian soldiers in 1855, they were but low-energy, ligamentous injuries are becoming increasingly
initially named march fractures.25 Increased marching and recognized in athletic populations.34 Surgical intervention to
running in minimalist footwear without a gradual transition achieve anatomic reduction is associated with improved out-
are both risk factors for metatarsal stress fractures. The major- comes; however, there is still considerable debate between open
ity of the fractures can be managed with modified activity and reduction and internal fixation (ORIF) versus primary arthrod-
weight bearing in a fracture boot. If pain persists, then a period esis (PA) for these injuries.12 While similar outcomes have been
of nonweight bearing may be necessary. The one exception is reported with both techniques, there is a higher rate of second-
the fifth metatarsal stress fracture. Given the high nonunion ary hardware removal and the development of posttraumatic
rate, fifth metatarsal stress fractures are often treated with arthritis in 20%–50% of patients undergoing ORIF, which may
intramedullary screw fixation, with or without supplemental necessitate salvage arthrodesis (SA).34
bone grafting.25 The civilian literature demonstrates favorable results with PA
in an athletic population, with 75% being able return to play
at the same level in one study.35 Similar results have been pub-
ACHILLES TENDINOPATHY AND RUPTURE lished in military studies as well. Hawkinson et al. demonstrated
Achilles tendinopathy in older military service members is con- similar results in low-energy Lisfranc injuries treated with ORIF
sistent with this disorder in older, active civilian populations. and PA, with just over two-thirds being able to return to full
However, there is a disproportionate incidence of tendinopathy duty. More importantly, those who failed ORIF and required SA
in the military. Again, this may be due to the consequences of had worse outcomes, with only 29% able to return to full duty.34
years of physical training and the toll of multiple deployments.26 Evidence also suggests a more rapid and complete recovery with
Another distinction is the similar incidence in men and women PA in a military population. Cochran et al. demonstrated that
in the military, whereas in the general population, Achilles ten- patients treated with PA completed their fitness run 9 seconds
dinopathy occurs more frequently in men. Both populations slower per mile than pre-injury time, compared to 39 seconds
demonstrate a correlation between increasing body mass index slower per mile for the ORIF group. Additionally, the PA group
(BMI) and Achilles tendinopathy.26 returned to full duty at an average of 4.5 months compared to
Achilles tendon ruptures present similarly in both military 6.7 months in the ORIF group.36
members and civilians. Sporting activity accounts for nearly
70% of all ruptures, with basketball being the most com-
mon.27 The increase in Achilles ruptures has been credited to
the expanding number of older individuals participating in
OSTEOCHONDRAL LESIONS OF THE TALUS
high-impact sports.28 There is a higher incidence of Achilles Osteochondral lesions of the talus (OLT) commonly affect
rupture among African Americans in the military.29-31 A bio- athletic populations, although the incidence among active
mechanical study comparing the viscoelastic properties of populations has not been fully elucidated. They are typi-
the gastrocsoleus complex between black and white athletes cally caused by repetitive microtrauma, as seen in chronic
500 SECTION 4  Unique and Exceptional Problems in Sports

ankle instability previously discussed. They can also result limited-duty status and were not able to run or fully partici-
from an acute traumatic event, such as a severe ankle sprain pate in all military requirements).
or fracture.37 Osteonecrosis, inflammatory and degenera-
tive joint arthropathy, and genetic predisposition are other
potential etiologic factors. Recent evidence suggests that
PLANTAR FASCIITIS
these lesions are more common than previously expected. Plantar fasciitis is the most common cause of heel pain, affect-
The incidence of OLT in patients undergoing diagnostic ing up to 10% of the population. It is considered an overuse or
arthroscopy at the time of lateral ligament reconstruction is degenerative condition, and often presents in active adults. It
greater than 20%.38 is characterized by sharp pain with the first steps upon wak-
In a retrospective review of a large military database span- ing, or after periods of rest. Risk factors include prolonged
ning a decade, Orr et  al. demonstrated an OLT IR of 27 per weight-bearing, excessive running or walking, improper shoe
100,000 person-years.39 Additionally, predictors of OLT wear, obesity, and equinus contracture.41 Plantar fasciitis is not
included female gender, white race, junior and senior enlisted, just confined to the work place but also occurs frequently in
increasing age, and service in the Army and Marine Corps.39 running athletes.42
Females in the military have demonstrated nearly double Within the military, the IR of plantar fasciitis was reported
the incidence of ankle sprains compared to males, and this at 10.5 per 1000 person-years. The incidence was greater in
increased ligamentous laxity may account for the increase in females, African Americans, and those over the age of 40.
OLT.16 The increase in junior enlisted, as well as Army and Additionally, Army service was a risk factor for developing
Marines, is likely a product of at-risk behaviors, as these pop- plantar fasciitis when compared to the other branches of the
ulations constitute the bulk of our land-based combat force, armed services.41 Similarly, the incidence of plantar fasci-
operating on uneven terrain with heavy combat loads. This itis increases significantly during military deployments. This
would seem to be substantiated by the annual increase in OLT would further support the overuse model, as service members
from 2002–2008, corresponding to major combat operations are forced to walk on uneven terrain with heavy combat loads.
in Iraq and Afghanistan.39 Increasing age as a risk factor may Furthermore, it is common for soldiers to increase their nor-
represent physiologic cartilage degradation coupled with mal running regimens while deployed, again placing further
increased microtrauma from the physical demands of a mil- stress on the plantar fascia.26 This can have a markedly nega-
itary career. Nonetheless, these lesions are likely more com- tive impact on force readiness, as symptoms commonly persist
mon in both athletic and military populations than previously for months.42
reported.40 Successful treatment of plantar fasciitis remains elusive.
Our experience with OLT has varied depending on age of Many different modalities are possible, but none are univer-
the patient at presentation as well as the acuity of the injury, sally successful. In our practice, we do not routinely provide
location of the OLT, and size of the defect. In acute injuries, injections with corticosteroid into the origin of the plantar
simple removal of the osteochondral fragment, if not repair- fascia, as it has not proven to provide long-term relief,43,44
able, is performed with stabilization of the cartilage edge at and may affect outcomes if surgical intervention is pro-
the defect. With later presentation, which is not uncommon, vided in the future.45 Multiple other regimens have been
marrow stimulation techniques with stabilization of the carti- recommended, but we have had the greatest success with
lage rim are typically performed. In those with failed marrow Extracorporeal Shockwave Therapy.46,47 Our success mir-
stimulation, augmentation with either particulated juvenile rors that of others, with over 80% success rates in over 1200
cartilage (Zimmer Biomet, Warsaw, IN) or micronized car- patients treated.
tilage (Arthrex, Naples, FL) have been utilized with varying
success. Return to activity depends on the modality employed.
With simple removal of the fragment, return to running and
full activity depends mainly on other injuries or surgeries
BRACING OPTIONS
performed, such as ligament reconstruction or ankle frac- Recent advances in bracing technology combining the use of
ture repair. For patients undergoing marrow stimulation, we prosthetic as well as orthotic principles has led to the develop-
recommend that they be immobilized for 2 weeks nonweight ment of the Intrepid Dynamic Exosekeletal Orthosis (IDEO, US
bearing followed by protected weight bearing in a CAM boot Army and Hanger Prosthetics, Austin, TX).48,49,50 This brace
for an additional 4 weeks. Impact activity begins at the earliest transfers forces around the ankle to the proximal tibia and flexes
at 6 months. For particulated juvenile or micronized cartilage on impact, providing push-off power due to the carbon-fiber
grafts, we maintain nonweight bearing for 6 weeks followed construct. It has been used extensively in the military to return
by another 4 weeks of protected weight bearing in a CAM patients to impact activity following a large number of foot and
boot. Impact activity begins at the earliest at 9 months. In our ankle injuries, from soft tissue injuries to pan-talar fusions. Its
experience, over 80% of patients return to activity without use outside of the military has been somewhat limited due to
limitations. Regarding larger lesions requiring bulk allografts, manufacturing expenses, but has become more prevalent with
our experience is similar to that of Orr et al.,40 with no return use of off-the-shelf components and modular construction.
to full military duty without restrictions (all remained on (Fig. 26.2)
 CHAPTER 26  The Military Athlete 501

Fig. 26.2  Ankle brace.

  S U M M A R Y
The military represents a unique, physically active population with nearly two decades. For these reasons, there will continue to be a sig-
high occupational demands. Service members maintain required fit- nificant number of overuse musculoskeletal injuries in our service
ness levels through routine physical training and recreational sport- men and women, with recovery adequate to resume full military duties
ing activities. Additionally, military service is a physically demanding uncertain.
profession, heightened by a shrinking force that has been at war for

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2325967113492707. 40. Orr JD, et al. Results and functional outcomes of structural fresh
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2007;35(8):1308–1314. pain in adults. Cochrane Database Syst Rev. 2017;6:CD009348.
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primary partial arthrodesis for Lisfranc injuries in young patients. 48. Highsmith MJ, et al. Outcomes Associated With the Intrepid
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36. Cochran G, et al. Primary arthrodesis versus open reduction the Literature, Mil Med. 2016;181(S4):69–76.
and internal fixation for low-energy Lisfranc injuries in a young 49. Hsu JR, et al. Patient response to an integrated orthotic and re-
athletic population. Foot Ankle Int. 2017;38(9):957–963. habilitation initiative for traumatic injuries: the PRIORITI-MTF
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 27
Pediatric Problems and Rehabilitation
Geared to the Young Athlete
Walter Klyce, R. Jay Lee

OUTLINE
Introduction, 503 Freiberg’s Disease, 507
Congenital Problems in Young Athletes, 503 Osteochondral Lesions of the Talus, 508
Coalitions, 503 Ankle Fractures, 508
Pes Planus, 504 Distal Tibial Fractures, 508
Developmental Problems in Young Athletes, 505 Distal Fibular Fractures, 510
Hallux Valgus, 505 Foot Fractures, 511
Accessory Navicular, 505 Metatarsal and Jones Fractures, 511
Osteochondroses, 506 Calcaneal Fractures, 512
Sever’s Disease, 506 Ankle Sprains, 512
Iselin’s Disease, 507 Conclusion, 512
Kohler’s Disease, 507

often become symptomatic during childhood, when the coali-

INTRODUCTION tion starts to ossify.
The number of young athletes participating in organized sports The most common types of coalitions are calcaneonavicular
continues to expand in the United States, leading to an increas- coalitions (CNCs) and talocalcaneal coalitions (TCCs), which
ing number of both acute and overuse injuries of the foot and each make up about 45% of all coalitions, though the former may
ankle in this age group. The recent trend toward early special- be slightly more common.4 Other, less common coalitions that
ization in one sport poses additional risk for those children have been observed include calcaneocuboid, cuneiform-meta-
engaging in high-level activities. Foot and ankle pain in young tarsal, navciulocuneiform, and talonavicular.5 Although the
athletes requires special consideration, as injuries often involve true gender distribution of coalitions is not known, given their
part of their immature skeleton such as the apophysis or the overwhelming lack of symptoms, recent studies have indicated
physis, and long-term function and growth must be considered. a possible male predominance, with men receiving 50% more
In this chapter we focus on the major foot and ankle problems surgeries for tarsal coalitions.6
most applicable to the health of younger athletes, including con-
genital problems, osteochondroses, fractures, and ankle sprains. Calcaneonavicular Coalitions
CNCs, the most common type, are usually congenital, although
CONGENITAL PROBLEMS IN YOUNG ATHLETES they may also arise iatrogenically, posttraumatically, or from
other causes.4
Coalitions CNCs present between ages 8 and 12, during which time the
A coalition is the term used to describe the adjoining of two or foot is observed to stiffen.7 Patients may present with refrac-
more adjacent bones whose mesenchymal tissue fails to separate tory foot symptoms after an injury, or with frequently recur-
fully during normal segmentation in utero. For many people, this ring ankle sprains.3 On exam they will likely have diffuse pain,
coalition may be asymptomatic, and they will never even be aware though it may be localizable to the sinus tarsi. Spasming of the
that they have it. For others, however, the coalition can lead to peroneal muscles along with a rigid everted foot, called “pero-
considerable pain and disability, and they may even require sur- neal spastic flat foot,” may also be seen, though it is not highly
gical resection with or without realignment—or, rarely, fusion. specific for CNC.3,4
Tarsal coalitions may be found in anywhere from 2% to 13% Anterior-posterior (AP), lateral, and oblique radiography
of the population, half of whom will have them bilaterally. They should all be obtained for a suspected CNC, but it will be best
are believed to be heritable in an autosomal dominant pattern.1,2 seen on an internal oblique view, with an osseous-type coalition
Coalitions can be fibrous, cartilaginous, or osseous.3 They most being most visible. When viewed laterally, this osseous bridge
503
504 SECTION 4  Unique and Exceptional Problems in Sports

is called the “anteater nose sign” (Fig. 27.1). Other findings posteriorly at 45 degrees below horizontal, aiming down the
that suggest a CNC in the lateral view are dorsal beaking of the calcaneus, and offers the clearest view of a TCC.9 On the lat-
talar head and widening of the talar lateral process. Computed eral view, a TCC will often show a C-shaped line connecting the
tomography (CT) is not necessary to diagnose CNC, but it talar dome and sustentatculum tali, called the “C sign,” which
has a much higher sensitivity than x-ray and can rule out an is present in up to 83% of cases (Fig. 27.2); however, this sign
accompanying talocalcaneal coalition.5 MRI may also offer is also present in nearly half of flexible flat feet without TCCs.10
some utility for evaluating nonosseous CNCs.4 Occasionally the CT will confirm the diagnosis and determine what portion of
magnetic resonance imaging (MRI) will reveal a stress fracture the subtalar joint is involved. An MRI will be helpful in carti-
of the calcaneus or navicular in association with the coalition. laginous or fibrous coalitions. Typically, excision is the first-line
First-line treatment of CNCs should be activity modification treatment, offering perhaps the best return to full activity, while
and orthoses for medial arch support, escalating to immobili- arthrodesis is considered once more than 50% of the subtalar
zation with 6 weeks of bracing or short-leg casting if needed. joint is involved.8,11–13 Occasionally the foot deformity that
Given the inflammatory nature of the pain, nonsteroidal anti- remains after coalition resection requires calcaneal or midfoot
inflammatory drugs (NSAIDs) such as ibuprofen will also offer osteotomies for realignment.
some relief. However, CNCs are more likely to be refractory to
conservative treatment than are other types of coalitions.4 If sur- Pes Planus
gery is required, resection of the coalition is usually successful, Pes planus (or flatfoot) is typically an asymptomatic deformity
with up to 90% of adolescents treated having good outcomes.5 in which the medial longitudinal arch of the foot is noted to be
low or absent altogether, with associated valgus of the hindfoot
Talocalcaneal Coalitions and forefoot abduction. The mechanism of flatfoot is thought
TCCs are the other most common type of tarsal coalition. They to occur from either reduced strength of the longitudinal arch
will present similarly to CNCs, with activity-related pain mid- musculature or altered intrinsic structure of the bone-ligament
foot occurring at the age of 8 or older. Like CNCs, they may complex.14 Flatfoot presents in two general types: (1) flexible
present after an ankle injury, are frequently bilateral, and should flatfoot, which represents a normal anatomic variant and almost
be suspected if a patient has recurring or persistently painful always responds to conservative management, and (2) rigid
sprains.8 However, TCCs may present slightly later than CNCs, flatfoot, a less common and more painful condition that may
continuing to manifest beyond the age of 12 and into the mid- require correctional osteotomy.14 Congenital calcaneovalgus
teens.9 On physical exam, the oversized medial talocalcaneal and congenital vertical talus may also cause flat feet in children,
facet may be felt distal to the medial malleolus, and pain may but both of these conditions present long before children reach
localize to the sustentaculum tali. the age of sports participation.
Imaging of a suspected TCC will also include radiographs, Flatfoot has a much greater prevalence in children than in
but it is typically best seen on a Harris heel view, which is taken adults, as nearly 100% of infants lack a medial arch from the
ages of 0–2.15 However, the condition decreases throughout
development, with only 9.1% of children still having flat feet

Fig. 27.2  Lateral weight-bearing radiograph of the left ankle in a 14-year-

Fig. 27.1 Lateral weight-bearing radiograph of the right ankle in a old male baseball player with hindfoot valgus and bilateral talocalcaneal
9-year-old girl with a calcaneonavicular coalition, demonstrating the coalitions, demonstrating the “C sign” formed by the posterior border
“anteater nose sign” (arrow). When her pain persisted after casting, of the sustentaculum tali (blue arrows) and the medial border of the talar
she underwent excision with tendon interposition and had complete dome (red arrows). Symptoms resolved with coalition resection with fat
resolution of symptoms. interposition and calcaneal slide osteotomy.
 CHAPTER 27  Pediatric Problems and Rehabilitation Geared to the Young Athlete 505

at age 7. The direct role of sports participation on flatfoot is However, up to half of all adult bunions are believed to have
unknown. Children with obesity have been found to have a begun during adolescence and not become symptomatic until
threefold greater incidence of persistent flatfoot. Generalized later on.18
joint hypermobility, which is frequently observed in dancers, Hallux valgus typically presents with a prominence over
gymnasts, and divers, has also been associated with flatfoot.16 the medial first metatarsal phalangeal joint, with pain being a
A number of physical examination maneuvers can help to secondary complaint. It is often bilateral. In children there is a
identify the specific type of flatfoot. First, when the child is sit- strong female predominance, with a ratio of 4:1 and a known
ting with the legs dangling or when the hallux is dorsiflexed, matrilineal component to the disease. Pediatric bunions tend
the flexible flatfoot should show restoration of a medial arch, to skew toward younger children, with about 50% presenting
whereas rigid flatfoot will look no different from how it does younger than 10.19
while weight-bearing. Second, a flexible flatfoot will have arch Examination of pediatric hallux valgus should include eval-
elevation and realignment of the hindfoot valgus when the uation of other causes of foot pain, associated foot pathologies,
patient stands on tiptoes, whereas a rigid flatfoot will remain and examination of shoewear. A great toe deformity may be
flat and valgus. The Silfverskiold test can also help to identify called a hallux valgus if the angle between the axes of the first
an Achilles contracture, which is more likely to cause pain in metatarsal and proximal phalanx is 15 degrees or more in the
the flexible flatfoot. Passive dorsiflexion of <10 degrees with a AP view. Medial skin thickening or callus formation may also
neutral hindfoot in both knee flexion and extension suggests be seen over this area.5 Imaging should include weight-bearing
tightness of the entire Achilles tendon, whereas an increase in AP and lateral radiographs and a nonweight-bearing (NWB)
dorsiflexion with knee flexion suggests tightness of the gastroc- oblique radiograph. Hallux valgus angles much larger than 15
nemius alone.14 Imaging is not indicated for the asymptomatic degrees may be seen, but the angle size does not always correlate
flexible flatfoot, but weight-bearing AP and lateral radiographs with severity of symptoms, and a steep angle itself is not an indi-
may help to distinguish symptomatic flatfoot from other causes cation for surgery.19 A common underlying mechanism is varus
of foot pain such as coalitions and accessory naviculars. of the first tarsometatarsal joint or first metatarsal itself, which
Treatment for flexible flatfoot should typically center on edu- then leads to the observed metatarsophalangeal (MTP) protru-
cation and reassurance. The evidence for orthoses or shoe mod- sion. Metatarsus primus varus is defined as an intermetatarsal
ifications in flatfoot is lacking, and it may actually exacerbate angle between the first and second rays of >8 degrees. Potential
pain in a rigid flatfoot or tight Achilles tendon by increasing factors such as ligamentous laxity, pes planus, disproportionate
pressure on the medial midfoot.14,16 Thus, painless pes planus mobility, or length of the first ray may predispose a child for
should merely be observed. However, athletes with persistent metatarsus primus varus.19
pain from flexible flat feet can start with over-the-counter Young athletes presenting with painful hallux valgus should
orthotics prior to custom orthoses, for arch support. Flatfoot first undergo conservative management. Tight-fitting shoes are
can also cause asymmetric wearing of the medial sole of the often the cause of pain, and thus trialing wide box shoes that
shoe, and so worn-out shoes should regularly be replaced in accommodate the shape of the foot can help to alleviate symp-
order to assure appropriate footwear. Athletes with flexible flat- toms. Ibuprofen and activity modification may also provide
foot and tight Achilles tendons may also benefit from regular relief. There is limited evidence for the use of orthotics or brac-
heel cord stretching.14 ing, outside of one series that found foot exercises and night-
Surgical treatment of symptomatic flatfoot should proceed time splinting were effective in half of those treated and had a
only when significant pain and disability persists after pro- low recurrence rate.20 The authors prefer conservative treatment
longed conservative therapy. Osteotomies are the treatment of with shoewear modifications. Children, adolescents, and parents
choice when indicated, as tendon transfers and lengthenings in who are bothered by the appearance alone should be counseled
isolation alone are rarely successful, and arthrodesis introduces that surgery for bunions has a high complication rate and is not
undesirable complications.14 Calcaneal lengthening osteotomy recommended solely for cosmetic treatment. For those young
corrects the eversion deformity and can be performed con- athletes who do require operative intervention, it is recom-
currently with Achilles lengthening, which may be informed mended that intervention be postponed until skeletal maturity,
by an intraoperative Silfverskiold test. It has satisfaction rates as recurrent deformities are higher with earlier intervention.
over 90%.15,17 Alternately, the combination of calcaneo-cuboid-­
cuneiform osteotomy, via closing wedge osteotomies of the cal- Accessory Navicular
caneus and cuneiform and an opening wedge osteotomy of the An accessory ossicle is a common finding that represents a
cuboid, creates compensating deformities for the hindfoot val- normal variant of skeletal anatomy. Accessory ossicles, found
gus and has been shown to have comparable results.12 in more than 20% of the population, are small secondary ossi-
fication centers that lie separate from adjacent bones and are
DEVELOPMENTAL PROBLEMS IN YOUNG typically smooth and well defined.21 They may occur through-
ATHLETES out the body, but they are most associated with the foot, given
their higher prevalence and the wide range of ossicles that may
Hallux Valgus develop there. Most accessory bones have no clinical signifi-
The pediatric form of hallux valgus is distinguished from cance, but some, like an accessory navicular bone, may cause
the adult type by the presence or absence of an open physis. symptoms, particularly in a young athlete.
506 SECTION 4  Unique and Exceptional Problems in Sports

Accessory naviculars, the most common foot ossicles, may OSTEOCHONDROSES

be found in 2%–14% of people.22 When present, they are
found on the medial arch of the foot, posteromedial to the Sever’s Disease
navicular tuberosity. An accessory navicular is observed to be Sever’s disease is a traction calcaneal apophysitis that was first
more common in girls and is often bilateral. Most people who described by Dr. James Warren Sever as chronic heel pain in
have them are unaware of it and unbothered by them, but an growing children. At the time, it was thought to be an inflam-
accessory navicular may become painful in late childhood or matory injury, but since then it has been clarified to be more
adolescence. This will present as pain over the medial mid- so due to a combination of overuse microtrauma and traction
foot, with or without redness and swelling, that is worse with injury to the posterior calcaneal apophysis.28
weight-bearing.23 Sever’s disease is most common during or just before a child’s
Evaluation of a suspected accessory navicular should include peak growth velocity, which will typically occur from the ages
three-view radiographs, including an external oblique foot of 8–15.29 The true incidence of Sever’s disease is not known,
x-ray. However, providers must take care not to overdiagnose though it is believed to be a fairly common occurrence. It may
an accessory navicular as the source of an athlete’s symptoms often be bilateral, and it is observed to have a slight male pre-
when they are seen on imaging, given their widespread preva- dominance.30–32 It is commonly seen in young athletes who
lence and typical dormancy, and the many other diagnoses that participate in sports involving high-energy plantarflexion and
may cause midfoot pain. Accessory naviculars are classified in push-off, such as soccer. However, Sever’s disease is not exclu-
three types. Type I is a small, ovoid sesamoid that is completely sive to active children and may actually be more symptomatic
contained within the posterior tibialis and has no attachment to in heavier children.31,33 Children with Sever’s disease will pres-
the true navicular. This type makes up 30% of accessory navic- ent with pain along the postero-inferior heel that is worse with
ulars and is usually asymptomatic. Type II is larger and trian- activity, but they will not usually have associated redness or
gular and may be misinterpreted as a tuberosity fracture. It is swelling.
the type most likely to cause pain. Type III is attached to the In an active 8- to 15-year-old, subacute or chronic pain
navicular by an osseous bar. Although thought to represent the of the hindfoot with activity or palpation, in the absence of
end-result of Type II, it is also infrequently symptomatic. Type recent injury or other exam findings, strongly suggests the
II and type III together make up 70% of all accessory navicu- diagnosis of Sever’s disease. There will be pain over the cal-
lars.23 Radiographic studies have shown that in children with caneal apophysis, which may be exacerbated by stretching of
accessory naviculars, the native navicular itself is also wider and the Achilles. Achilles contracture can also be associated with
more prominent.24-27 Sever’s. Radiographs are not regularly required to make the
Initial treatment of a symptomatic accessory navicular diagnosis, unless the diagnosis is in question. A recent study
focuses on nonoperative management, such as activity modi- has shown that perhaps 5% of patients diagnosed with Sever’s
fication, shoe modification, and use of orthoses for comfort. If disease may have other radiographic findings—such as a cal-
these initial steps are not effective, a period of rest with a stir- caneal unicameral bone cyst, calcaneal stress fracture, or tibial
rup brace or boot brace should be helpful. If not, a below-knee nonossifying fibroma—that x-ray may help to exclude.30 In
cast may provide relief by preventing the regular traction of the the lateral view, diagnosis of Sever’s disease has been strongly
posterior tibialis.23 Surgery should be pursued only after fail- associated with an apophysis that has not yet extended to
ure of a long period of conservative treatment; however, recent within 2 mm of the plantar edge; if complete coverage or
evidence has shown that athletes are more likely to require sur- fusion of the plantar surface is seen, other diagnoses should
gery than nonathletes, and that for those who do progress to be considered.34
surgery, athletes (mean 16 years) tended to be younger than Sever’s is a benign, self-limiting disorder that should resolve
nonathletes (mean 24 years).22 Surgical treatment may involve with apophyseal fusion at the latest. The largest impact of Sever’s
simple excision with a tendon split (authors’ preferred method) disease is on a young athlete’s quality of life, as children with
or excision with simultaneous tendon advancement (Kidner).23 Sever’s report having lower levels of physical function, happi-
As with most rehab and recovery from lower extremity issues, ness, and satisfaction.32 There are isolated reports of Sever’s dis-
continued conditioning of the upper body and core are encour- ease resulting in avulsion fracture of the calcaneal apophysis,
aged in the young athlete. After surgical treatment, 6 weeks of but such occurrences are exceedingly rare and should not con-
toe-touch weight bearing in a short-leg cast with a well-molded cern providers and patients.35
arch is initiated for soft-tissue and tendon healing. Afterwards, Treatment of Sever’s disease centers on alleviating its symp-
the patient is transitioned to weight bearing in a CAM boot toms. Activity modification should be considered. Heel-cup
with orthotic inserts, and physical therapy is initiated for gait orthoses and medial arch supports relieve pain better than
training and range of motion (ROM) exercises. At 10–12 weeks heel lifts for those participating in sports.33 If there is associ-
the CAM boot is weaned, while strengthening, gait training, ated tightness of the Achilles, stretching would be appropriate.
and proprioception are initiated with physical therapy. Once If pain is severe, immobilization in a short-leg cast, or a CAM
strength and function in a sports-specific rehab are symmetric boot with a removable heel lift, can be tried. With time and con-
to the contralateral side, the young athlete is released to grad- servative treatment, the “growing pains” felt in Sever’s disease
ual, symptom-free participation in practice and unrestricted will eventually abate, and young athletes should anticipate full
sports. return to their prior levels of activity.
 CHAPTER 27  Pediatric Problems and Rehabilitation Geared to the Young Athlete 507

Iselin’s Disease complete blood cell count (CBC) and C-reactive protein (CRP)
Iselin’s disease, a traction apophysitis of the tuberosity of the prox- tests may be obtained if needed to help rule it out.5
imal fifth metatarsal, was described by Dr. Hans Iselin. Like Sever’s Kohler’s has a favorable prognosis and should eventually
disease, it is a benign osteochondrosis that causes overuse-related resolve with ice, rest, and NSAID medications. In more severe
foot pain in adolescents through repetitive microtraumas. cases, casting may be used. Although a history of Kohler’s might
The overall incidence of Iselin’s disease is not known, likely still be discernable by radiography in adults who had the disease
because of both scarceness and underreporting. It classically as children, this finding is typically asymptomatic.
presents in girls aged 8–11 and boys aged 11–14, who will present
with chronic or subacute pain over the lateral midfoot, with or Freiberg’s Disease
without mild swelling, which is worse with weight bearing. Pain Freiberg’s disease is osteochondrosis of the metatarsal head. It
can also start acutely after a foot inversion injury. Iselin’s occurs was described by Dr. Albert Freiberg and, like Kohler’s disease, is
because of the traction placed on the fifth metatarsal by the pero- believed to occur secondary to osteonecrosis, although mechanical
neus brevis with active eversion or passive inversion of the foot.36 and systematic mechanisms have also been proposed.41 It classi-
As in Sever’s disease, patients with suspected Iselin’s disease cally refers to deformation of the second metatarsal, but involve-
may benefit from radiography to rule out other causes. On AP ment of the third and other metatarsals has also been reported.42
view, providers may see widening and fragmenting at the base of Freiberg originally called it an “infraction” because of his theory
the fifth metatarsal, though absence of these does not rule out the (now tenuous) that the disease occurs as a result of trauma.
diagnosis. Also, given the spectrum of radiographic appearances, Among osteochondroses, Freiberg’s is unique in that it is the
the acute presentation of Iselin’s is difficult to differentiate from only one known to be more common in girls, with a 5:1 female
an avulsion at the base of the fifth metatarsal. In its radiographic predominance.43 Freiberg’s also onsets slightly later than other
findings, Iselin’s has more in common with Osgood-Schlatter foot and ankle osteochondroses, with a typical age range of
than with Sever’s, as the deformity is visible by imaging and the 11–17 years old.42 It is typically not bilateral.
tuberosity can remain enlarged after skeletal maturation. The most-used classification system for Freiberg’s disease is
Iselin’s disease is almost always self-limiting and resolves the radiographic classification proposed by Smillie. Stage I shows
with conservative management, such as shoe inserts and activ- the development of a narrow fissure and subchondral sclerosis
ity modification.37 There are rare reports of Iselin’s avulsion.36 after the epiphysis becomes ischemic. Stage II sees collapse of
With more severe symptoms, or if there is suspicion of a con- the lesion with bony resorption and subchondral bone collapse.
comitant avulsion, immobilization in a CAM boot for 4 weeks In Stage III, the collapse progresses and the lateral portions of
is appropriate. As with all osteochondroses, however, no single the epiphysis project above the lesion on either side. Stage IV is
blueprint works for every patient, and so the provider should marked by loose bodies and an epiphysis that has likely closed.
consider the athlete’s specific circumstances. Finally, Stage V will show a flattened top edge, a thickened and
dense metatarsal shaft, and resorption of the loose bodies.44
Kohler’s Disease Children with Freiberg’s disease will present with a tender
Kohler’s disease is an osteochondrosis of the navicular that and swollen MTP joint in the affected foot, with or without a
was described by Dr. Alban Kohler in 1908. It is an infrequent, preceding trauma. Ambulation that increases pressure on the
self-limiting condition that presents as midfoot pain with defor- joint, such as when using a heel lift, high-heeled shoes, or bare-
mation or sclerosis of the navicular. The proposed pathophysi- foot, tends to aggravate the pain. In later stages, the disease may
ology of the disease is an idiopathic osteonecrosis of childhood, resemble a crossed-over or clawed toe.45
similar to a diagnosis such as Legg-Calve-Perthes disease.38 It Workup should include AP, lateral, and oblique radiographs
may occur unilaterally or bilaterally and has a male predomi- of the foot while weight bearing. Bilateral images are unlikely
nance. A genetic component to the disease has been suggested.39 to identify disease in the opposite foot but may be useful for
Kohler’s presents slightly younger than the previously dis- comparison. In early stages, x-ray may be inconclusive, showing
cussed osteochondroses, being most common in boys from the only a subtle widening of the joint space or sclerosis of the meta-
ages of 2 to 9. Children with Kohler’s have pain over the mid- tarsal head. As it progresses, subchondral sclerosis may be more
foot and tend to walk on the outsides of affected feet in order to evident, followed by lucency and collapse.
avoid putting increased pressure on the navicular, though their For Freiberg’s disease judged to be stages I through III, con-
ROM is not affected. Erythema and swelling may or may not be servative treatment may be possible. This management should
seen over the area.40 include NSAIDs such as ibuprofen, activity modification to
Although Kohler’s is a clinical diagnosis, radiography can reduce running and jumping, and shoe modification focused on
confirm it by showing narrowing or flattening of the navicular reducing pressure on the affected metatarsal, such as with stiff
bone. This will also help to distinguish Kohler’s from a navic- shoes, custom orthotics, or casting.46 Some authors believe that
ular stress fracture. Radiography alone cannot make the diag- nonoperative management should be the first line of treatment
nosis, as flattened naviculars may be incidentally observed in for Freiberg’s regardless of Smillie stage.45
asymptomatic children. Imaging of both feet may be appropri- Surgery is necessary for patients who fail conservative treatment
ate, either to demonstrate bilaterality of the disease or to pro- and/or present at later stages of the disease. Multiple surgical tech-
vide a normal foot radiograph for comparison. More advanced niques may be undertaken, including both joint-sparing (for stages
imaging is not needed. Infection in this area is uncommon, but I–III) and joint-reconstructing (for stages IV and V) approaches.45
508 SECTION 4  Unique and Exceptional Problems in Sports

Osteochondral Lesions of the Talus plantarflexion radiographs will bring the posterior talar dome
Osteochondral lesions of the talus, i.e., OCDs, are an import- into view. Advanced imaging is useful for characterization and
ant cause of joint pain in adolescent athletes. They are believed for surgical planning. An MRI best visualizes early lesions and
to occur from a combination of repetitive microtrauma of the is also best for determining the stability of lesions. Detached
articular surface, which may lead to local ischemia, and a com- osteochondral fragments will have a hyperintense outline in
ponent of vascular insufficiency. T2-weighted images on MRI. CT offers better fidelity for eval-
The talus, with its highly cartilaginous surface and retrograde uating depth of lesions, but this advantage must be weighed
blood supply, is the bone in the foot most commonly affected against the risk of additional radiation.49
by OCD. Talar OCD most commonly develops over the talar Talar OCDs that are diagnosed early and are found to be sta-
dome, although it has been observed in case reports to occur in ble or only have mild signs of instability are treated conserva-
the talar head, as well.47 The total incidence of ankle OCD is low, tively with immobilization and activity modification in children.
at only about 6 per 100,000 children aged 6–19, but it is seven Lesions that fail a course of 6 months of conservative treatment
times more common in teenagers than in younger children. or are unstable would benefit from surgical intervention. As with
It is most likely to occur in the medial talus (72% of lesions), adult OCD, retrograde and transarticular drilling, excision and
followed by the lateral (22%) and middle talus (4%) (Fig 27.3). marrow stimulation, or osteochondral grafting are all options.50
Race and gender have both been postulated to be indepen- For those that have not yet reached skeletal maturity, lesions
dent risk factors for ankle OCD, with girls having 1.5 times as are often still accessible through open soft-tissue approaches,
many cases as boys, and with the disease being most common in place of medial malleolar osteotomies. The reoperation
among non-Hispanic whites and least common among African rates for surgery in young athletes can be high, with female
Americans. The largest epidemiological survey of OCD to date sex and high body mass index (BMI) being independent risk
has even suggested that, in girls, ankle OCD may be more com- factors for poorer outcomes.51 In a long-term follow-up study
mon than knee OCD.48 of debridement and bone marrow stimulation for ankle OCD,
Ankle OCD usually does not have a history of recent trauma, 76% of patients were able to return to sports, though no athletes
but may present after a history of recurrent sprains. Once symp- reported returning to their pre-injury level of function.52
tomatic, OCD will present in young athletes who complain of
sporadic ankle pain with joint-loading activities. Symptoms will ANKLE FRACTURES
escalate when a fragment detaches from the osteochondral sur-
face, leading to severe pain, swelling, instability, and possible Distal Tibial Fractures
catching of the joint.49 Ankle fractures are the second most common fracture in chil-
Diagnostic workup of ankle OCD should begin with radio- dren, representing 5% of all pediatric fractures. In the skeletally
graphs, which may miss early stage lesions. Mortise views immature athlete, the physes of the ankle require special atten-
will provide the best view of the lateral talar dome, while tion. On one hand, open physes and significant growth potential

Fig. 27.3 Sagittal and coronal T1-weighted MRI of the left ankle in a 14-year-old female soccer and field
hockey player. She had a history of bilateral pes planus and frequent ankle sprains and was subsequently
found to have osteochondral lesions over the superomedial talar dome in both ankles, as well as vitamin D
deficiency.
 CHAPTER 27  Pediatric Problems and Rehabilitation Geared to the Young Athlete 509

allows for fracture remodeling. On the other hand, injury to the reduced, in order to avoid a second physeal injury and further
physes can also put children at risk for growth arrest and subse- risk of physeal arrest.54 As with Salter Harris I fractures, these
quent leg length discrepancy or angular deformity, both compli- fractures should be reduced, with minimal coronal and sagittal
cations that are best treated when recognized early. plane displacement and minimal fracture gapping, and casted
The distal tibial ossification center appears around 6 months for 4–6 weeks. Open reduction is considered for any widely dis-
of age and grows an average of 4.5 mm per year axially during placed, gapped, or unstable fracture with interposed soft tissue.
preadolescence, contributing about 18% of the lower extremi- Salter-Harris III fractures make up 25% of distal tibial frac-
ty’s ultimate length.2 The distal tibial physis closes first centrally, tures and involve a fracture through the physis and epiphysis.
then medially, and finally laterally, a sequence that influences As these fractures typically extend to the articular surface, they
the unique fracture patterns that appear closer to skeletal matu- have greater potential long-term consequences, since inade-
rity. The distal tibial physis closes around age 14 in girls and quate or delayed correction of the articular incongruity may
age 16 in boys. Distinguishing normal developmental anat- lead to early arthritis. Although x-ray is the first-line imaging
omy from a fracture fragment is an important part of assess- modality, for displaced fractures that potentially would require
ing pediatric sports injuries. Secondary ossification centers of surgical intervention a CT or MRI is useful to determine
the medial malleolus are seen in up to 15% of girls aged 6–9 amount of displacement, to identify the fracture pattern, and
and boys aged 8–11.53 Clinical exam is important to distinguish to begin surgical planning. Anatomically reduced and nondis-
these from medial malleolus avulsions. placed fractures may be treated in a NWB cast for 4–6 weeks,
The Salter-Harris classification system, introduced in 1963, is with early radiographic follow-up between 1 and 2 weeks to
the most widely used method to evaluate physeal injuries. The monitor for loss of reduction. Fractures with more than 2 mm
numbering of the classification is thought to be predictive of the of persistent articular-side incongruity should be treated surgi-
risk of growth disturbance; however, this tends to be less true cally. Once surgical anatomic reduction is achieved, epiphyseal
around the ankle, where the physeal anatomy is more complex screws may be used to avoid further physeal injury. However,
and compressive forces may influence growth. Routine follow- smooth Kirschner wires crossing the physis can also be used
up after fracture healing, with radiographs at 6 or 12 months, for temporary fixation if it is required by the fracture pattern.
should be considered to monitor for growth arrest. Tillaux fractures are a unique type of Salter-Harris III.
A Salter Harris I fracture is a fracture straight through the Salter-Harris IV fractures account for another 25% of dis-
physis, while II is a physeal fracture with a metaphyseal com- tal tibial physeal fractures and include disruption of the phy-
ponent, and III is a physeal fracture with an epiphyseal com- sis, epiphysis, and metaphysis. They may occur either along the
ponent. Salter Harris IV fractures involve both a metaphyseal medial malleolus or in a special pattern along the lateral phy-
and epiphyseal component. Salter Harris V fractures are a crush sis called a triplane fracture. As with Salter Harris III fractures,
injury to the physis. Mechanisms that may lead to Salter-Harris the most important aspect of fracture treatment is an anatomic
fracture of the distal tibia include twisting on the foot during articular-side reduction. When nondisplaced, Salter Harris IV
play, or sports that involve high-velocity jumping or pushing off. distal tibial fractures may also be treated with 4–6 weeks of
Salter-Harris I tibial fractures are not especially common. NWB immobilization. However, more than 2 mm of displace-
While displaced fractures are evident on initial radiographs, ment must be surgically reduced. Fixation with metaphyseal
nondisplaced fractures may be diagnosed by careful clinical screws, epiphyseal screws, or a combination may be used to
exam and palpation. If a nondisplaced fracture is suspected, avoid further physeal injury. Again, smooth Kirschner wires
follow-up radiographs 7–10 days after injury may confirm the crossing the physis are useful for temporary fixation if needed.
diagnosis, showing periosteal reaction or early callous for- Salter-Harris V of the distal tibia is rare, representing about
mation around the physis. Displaced Salter-Harris I fractures 1% of distal tibial physeal fractures, and involves a compression
should be promptly treated with manual reduction followed injury to the physis. An adolescent athlete who landed on his
by 4–6 weeks of casting. With a closed reduction that results in or her foot after falling from a height, or otherwise sustained a
an unstable reduction or a large persistent gap, open reduction large axial load to the tibia, may be at risk for this. Salter-Harris
would be indicated to remove any entrapped tendon or perios- V is likely to have little or no displacement, and it may thus be
teal tissue.54 However, a closed reduction that is nonanatomic easy to miss by x-ray, but it also poses the greatest risk of growth
but stable, with minimal coronal and sagittal plane displace- arrest and poor prognosis, given the subsequent interruption of
ment and minimal fracture gapping, is acceptable. the physeal matrix and vascular supply. MRI will help to make
Salter-Harris II tibial fractures are the most common dis- the initial diagnosis, though these injuries often go months or
tal tibial physeal fracture, comprising 40% of such fractures. years before being recognized. In the early period, focal areas of
These fractures extend through both the physis and metaphy- growth arrest may be treated with surgical resection of the phy-
sis of the tibia. Their presentation and treatment are similar to seal bar and placement of a spacer. If the majority of the physis
Salter-Harris I fractures, with radiographs helping to make the is involved, the patient may benefit from epiphysiodesis of the
distinction. The characteristic metaphyseal fragment has a typi- bilateral distal tibial to prevent future limb length discrepancy.
cal triangular shape, often called a Thurstan-Holland fragment. Leg length deformity and angular deformity are the fore-
Again, nondisplaced fractures may require a follow-up radio- most complications to be avoided in pediatric physeal fractures.
graph to confirm the diagnosis. Physeal fractures that are dis- Clinically, up to 1 cm of leg length discrepancy, 5 degrees of
placed and present more than 7 days from injury should not be varus/valgus deformity in the coronal plane, or 10 degrees of
510 SECTION 4  Unique and Exceptional Problems in Sports

flexion/extension in the sagittal plane are likely to be asymp- epiphysis, an axial plane through the physis, and an oblique cor-
tomatic and considered acceptable. If the deformity exceeds onal plane through the metaphysis (Fig. 27.4). The mechanism
these thresholds, then corrective surgery, such as physeal bar of triplane fracture is similar to a Tillaux, involving traction on
resection, guided growth through hemiepiphysiodesis, epiph- the epiphysis during forceful external rotation of a supinated
ysiodesis, or limb-lengthening surgery, may prove necessary.55 foot.54
Compartment syndrome of the anterior tibia has also been Triplane fractures have multiple types and may present with
observed both after the fracture and after surgery. Pediatric anywhere from two to four fragments.60 In a 2004 study of
compartment syndrome may be challenging to diagnose, and 51 triplane fractures by Brown et  al. (the largest such series),
thus vigilance is needed. the median age was 12 for girls (range 10–15) and 14 for boys
(range 12–16), with older children significantly likelier to have
Tillaux Fractures epiphyseal separation.61 As in Tillaux fractures, radiographs are
Tillaux fractures are a subgroup of Salter-Harris III fractures. needed to make the diagnosis, but CT is useful to determine
They are transitional fractures that occur during the active amount of displacement and to guide surgical planning.
closure of the distal tibial growth plate and thus are unique Conservative treatment, consisting of 4–6 weeks of casting
to adolescents. They constitute 3%–5% of all pediatric ankle and a transition to a CAM boot, may be pursued if the patient
fractures.56 has <2 mm of displacement. For fractures with >2 mm of dis-
The shaft of the distal tibia fuses with the distal tibial epiph- placement, open reduction with fixation by internal screws is
ysis over a period of about 18 months. This closure begins in the preferred treatment, again with little growth arrest given the
the center of the physis, followed by fusion at the anteromedial, relative skeletal maturity.54
posteromedial, and finally lateral border of the physis.54 This
usually lasts from about age 12–14 in girls and 14–16 in boys. Distal Fibular Fractures
During this period, the unfused portions of the physis remain The pediatric fibula develops in parallel with the tibia, and
vulnerable to injury, particularly on the lateral side. so many of the same approaches used for the tibia—such as
Tillaux fractures occur by avulsion of the unfused antero- workup and Salter-Harris classification—may also be applied to
lateral quadrant of the tibial epiphysis from the already fused the fibula. Due to the fibula’s smaller size and structural load,
medial and central tibial epiphysis. This happens due to traction pediatric fibular fractures have less of an effect on the child’s
from the anterior inferior tibiofibular ligament. Forceful exter- ultimate limb length and mechanical axis. However, the fibula
nal rotation with supination, such as twisting on a planted foot, may also be more easily fractured, and thus it should not be
is the usual mechanism. overlooked in the young athlete.
Radiographs are the best first-line imaging for suspected The distal fibular ossification center appears slightly later
Tillaux fractures, with the fracture lines best seen on mortise than the tibia, at roughly 9–12 months of age, and it also closes
view. However, if the provider is concerned that there may be slightly later, around about 1–2 years after the distal tibia
more than 2 mm of displacement, a CT can be considered for fuses.2,62 Like the tibia, the distal fibula may also develop a sec-
confirmation, evaluation, and surgical planning.54 ondary ossification center, which is more likely to be medial
Nondisplaced Tillaux fractures may be treated with 4–6 than lateral and must be distinguished from an avulsion frac-
weeks in a NWB cast, followed by transition to a CAM boot. ture.55 Mid-shaft fibular fractures may accompany a tibial phy-
Close follow-up is recommended for the first several weeks seal fracture, but the pediatric fibular shaft tends not to require
to ensure maintenance of alignment, as insufficiently reduced anatomic reduction and should mend satisfactorily with reduc-
Tillaux fractures may lead to early ankle arthritis.57 Tillaux frac- tion fixation of the tibia.
tures with more than 2 mm of displacement should be treated Isolated fractures of the distal fibular physis are typically
with reduction and internal fixation.58 These fractures are less Salter-Harris I or II. They may occur from a lateral blow to the
likely to result in growth deformity, since they occur near the athlete’s ankle, such as from another player’s foot, or from an
end of vertical tibial growth.54 inversion injury that might cause only a sprain in an adult.55
Salter-Harris I and II fractures of the distal fibula can typically
Triplane Fractures be treated with 4 weeks in a short-leg, weight-bearing cast or
Triplane fractures, like Tillaux fractures, are a subgroup of CAM boot. Recent evidence has suggested that these injuries
distal tibial fractures that occur during the transitional phase. may be overdiagnosed, as a series of MRIs on 18 diagnosed
However, because they occur both above and below the partially Salter-Harris I fractures of the distal fibula ultimately revealed
fused growth plate, which may be at varying stages of fusion, 14 sprains, 11 contusions, and no growth plate injuries.62
they fit less neatly into the Salter-Harris classification system. At Salter-Harris III and IV injuries of the distal fibula are uncom-
minimum, triplane fractures consist of Salter Harris III fracture mon but should respond well to 4 weeks of weight-bearing
of the lateral tibial epiphysis (i.e., a Tillaux fragment) accompa- immobilization.
nied by Salter Harris II fracture of the posterior tibial metaph- Young athletes are at risk for early arthritis with malunion
ysis, making them most like a Salter-Harris IV.59 They make up or growth arrest associated with fibular fractures. Over time,
5%–15% of all pediatric ankle fractures.56 shortening or displacement of the fibula may cause disruption
Triplane fractures are so called because the fracture line of the tibiofibular syndesmosis and alter forces about the ankle.
consists of three distinct planes: a sagittal plane through the Shortening of the fibula will best be observed by a radiograph
 CHAPTER 27  Pediatric Problems and Rehabilitation Geared to the Young Athlete 511

A B

C D
Fig. 27.4  (A) Coronal and (B) sagittal CT of a 14-year-old boy who sustained a triplane fracture of the right
ankle after falling off his bicycle. The unique shape of the triplane fracture’s Thurstan-Holland fragment (white
arrow) is discernable in the sagittal view. (C) Oblique and (D) lateral radiographs of the same patient 3 months
later, after open reduction and internal fixation with two screws.

taken on the mortise view, whereas absolute displacement is remaining growth potential and remodeling may make most
best observed on a lateral radiograph.63 These malunions are foot fractures amenable to nonoperative treatment.
unlikely to be symptomatic while the athlete is young, but they
may become symptomatic in mid-adulthood. Metatarsal and Jones Fractures
Metatarsal fractures are a common pediatric fracture, repre-
senting nearly two-thirds of pediatric foot fractures and up to
FOOT FRACTURES 5% of all pediatric fractures of any type.66,67 The first metatarsal
Foot fractures are an important consideration in children, given is the most commonly fractured metatarsal in children 5 and
that they can make up anywhere from 5% to 13% of all pedi- younger, whereas the fifth metatarsal is the most commonly
atric fractures.64,65 In contrast to long-bone injuries, pediatric fractured metatarsal in children 6 and older. Both these are like-
foot fractures are less likely to result in clinically significant liest to occur as isolated fractures, whereas fracture of the sec-
length discrepancies from growth disturbance. A young athlete’s ond, third, and fourth metatarsals tend to occur in groups and
512 SECTION 4  Unique and Exceptional Problems in Sports

should encourage providers to screen carefully for other asso- Traumatic inversion with plantarflexion is the predominant
ciated fractures. In older children, which encompasses most mechanism for ankle sprains. The most commonly injured lig-
of those old enough to participate in sports, fall from standing aments, in order, are the anterior talofibular ligament (ATFL),
height is the most common mechanism.68 calcaneofibular ligament (CFL), and posterior talofibular lig-
Fractures of the fifth metatarsal typically appear as avul- ament (PTFL).72 Ankle sprains are the single most common
sion fractures of the base after a foot inversion injury. These injury in high school athletics, with 40% of all injuries occur-
are treated with short-leg walking cast or CAM boot for 4–6 ring in the foot or ankle.73 Basketball is a sport that has histori-
weeks, though NWB casts providing better relief than walk- cally had one of the highest percentages of ankle injuries, at 25%
ing casts.69 A nondisplaced or minimally displaced fracture for both genders, whereas baseball and softball have had some
of the fifth metatarsal is often difficult to differentiate from of the lowest, at 7% and 10%, respectively. Of note, women’s
an apophysitis or Iselin’s disease. A repeat radiograph 10 days lacrosse (23%) has been reported to have twice as many ankle
after injury may demonstrate a periosteal reaction with callous injuries as men’s lacrosse (11%).74
formation and confirm the diagnosis of fracture. If the diagno- Patients with ankle sprain will complain of pain and diffi-
sis is unclear, another approach would be simply placing the culty weight bearing immediately after injury. The Ottawa
patient in a CAM boot that can be weaned as tolerated. Young Ankle Rules are useful guidelines to indicate when radiographs
athletes with these injuries should return to prior levels of play are necessary with ankle injuries. They specify that radiography
after treatment.69 is not necessary unless there is bony point tenderness along the
Pediatric Jones fractures, fractures of the proximal diaphy- malleolus or the patient is unable to walk four steps.75 These
seal-metaphyseal junction, are a special concern, as in adults. rules were initially validated only for adults 18 and older, but
They are more frequently seen in athletes, and they are a higher-­ recent meta-analysis has confirmed that this guideline is appro-
risk fracture type because they lie at a watershed area of the priate to use in children 5 and up, as well.76
vascular supply and thus are more predisposed to nonunion, Ankle sprains are classified as having minimal loss of func-
particularly in children older than 13.69 Most pediatric patients tion and involving only the ATFL (mild/Grade I), moderate
heal and recover well from this fracture, with a NWB boot brace loss of function with some tissue disruption and involvement
or short-leg cast. Operative treatment is indicated for those that of the CFL (moderate / Grade II), or significant loss of function,
fail cast treatment and for adolescent patients, in order to facili- with complete tearing of all lateral ligaments (severe/Grade III).
tate a speedy return to sports. As with adults, surgical correction Grade III sprains may be accompanied by a high ankle syndes-
involves fixation with an intramedullary screw.70 motic injury, which is diagnosed by the squeeze test and is more
common in high-impact sports such as basketball, football,
Calcaneal Fractures hockey, rugby, and soccer.77–79 More than 5-mm widening of the
Calcaneal fractures in children are relatively rare. The usual syndesmosis, on AP radiograph, indicates syndesmotic injury.72
mechanism is landing on the heel after falling from a height. Acute lateral ankle sprains should undergo appropriate
These fractures may be intra-articular or extra-articular, with immobilization, rest, and rehabilitation. If shoe modification is
CT supplementing standard radiographs, as needed, to better desired, flares will provide the greatest improvements to stabil-
assess the location and extent of the injury. Most nondisplaced ity.80 If a physeal injury is suspected in the absence of an obvious
extra-articular fractures and minimally displaced intra-articu- fracture, lack of periosteal reaction on repeat radiographs 7–10
lar fractures in the younger child are amenable to casting for days after the initial injury will confirm the injury is a sprain
4–6 weeks. Grossly displaced extra- or intra-articular calcaneal and not a fibular fracture. In the interim, prior to diagnosis con-
fractures can be treated with reduction and internal fixation, firmation, weight-bearing immobilization is safe. Most young
similar to adults. Evidence has shown that closed reduction with athletes recover well from ankle sprains. Surgical intervention
percutaneous fixation of pediatric intra-articular calcaneal frac- is reserved for those who have failed a complete course of reha-
tures may offer similar functional outcomes while resulting in a bilitation and have recurrent instability episodes.81 There is a
lower complication rate.71 lack of Level I evidence to support one particular surgical treat-
ment for chronic ankle instability, but the Brostrom method—
direct repair and imbrication of the ATFL and CFL—is the most
ANKLE SPRAINS widely used approach.
Ankle sprains are common injuries in young athletes.
Traditionally it has been thought that, because of both the pli-
ability of pediatric bone and the cartilaginous physis, inversion
CONCLUSION
injuries cause fractures more often in children than they do in Foot and ankle problems are a common cause of deformity and
adults. Then, as children mature, fractures become less likely, as disability in children and young athletes. While they resemble
the bone becomes less pliable and the physis closes. While this adult concerns in many aspects, the pediatric skeleton differs
concept is true, it is important to remember that most inversion from that in adults, and thus a specialized approach is required
ankle injuries in children, as well as most suspected distal fib- to discern pathologic findings from typical development or
ular physeal fractures, are in fact ankle sprains. The pathology, an anatomic variant. Additionally, some presentations, rang-
evaluation, and treatment of a pediatric ankle sprain are similar ing from Sever’s disease to triplane fracture, are unique to the
to that of an adult sprain. growing skeleton. Children have excellent healing potential
 CHAPTER 27  Pediatric Problems and Rehabilitation Geared to the Young Athlete 513

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 28
Unique Considerations for Foot and Ankle
Injuries in the Female Athlete
Lara Atwater, Rebecca Cerrato

OUTLINE
Introduction, 516 Volleyball, 517
Sport-Specific Disorders, 516 Cheerleading, 517
Gymnastics, 516 Ballet, 518
Basketball, 517 Gender-Specific Considerations, 519
Soccer, 517 Conclusion, 520

artificial turf, such as women’s soccer and lacrosse, now have a

INTRODUCTION higher rate of ankle injuries and turf toe.3
The passage of Title IX is arguably the most important event in Men and women have slightly different physical attributes,
the timeline of women’s participation in US athletic endeavors. which have advantages and disadvantages. For example, wom-
By almost any measure, the numbers of female athletes have en’s lower extremities constitute less of their total height, which
exploded in multiple sports in the decades since 1972. lowers their center of gravity and makes them more amenable
to tasks such as the balance beam. Moreover, women’s andro-
“No person in the United States shall, on the basis of sex, be
genic makeup promotes maintenance of a higher percentage of
excluded from participation in, or denied the benefits of, or
body fat, which is less desirable in sports such as cross-country.
be subjected to discrimination under any educational pro-
Care of the female athlete must be grounded in awareness of the
gram or activity receiving federal assistance.”
Female Athlete Triad, which is a spectrum of decreased energy
Title IX of the Education Amendments of 1972
availability, menstrual dysfunction and low bone mass.
to the Civil Rights Act of 1964.
When approaching the study of foot and ankle problems in
Before Title IX, approximately 1 in 27 girls participated in female athletes, disorders can be divided into sport/activity-spe-
college sports; that number today is greater than 1 in 2.1 The cific disorders and gender-specific physiologic considerations.
National Collegiate Athletic Association (NCAA) tracks wom-
en’s sports participation in its member institutions; the data SPORT-SPECIFIC DISORDERS
are self-reported and are useful for evaluating general trends.
In 1981, total athletes numbered 74,239. By 1993, the total had Gymnastics
risen to 105,532 and then in 2016 to over 200,000.1,2 In general, The female gymnast is at higher risk for ankle injury than the
the increase in participation reflects the addition of women’s male gymnast.4 Areas of complaint in the foot in female gym-
teams to institutions. The increase also reflects the elevation to nasts include the bottom of the heel, the plantar fascia origin,
NCAA championship sport status of sports such as ice hockey, and the medial longitudinal arch. Direct blows during landings
water polo, and bowling. Additional emerging sports, such as or striking the heel on the floor while swinging under the lower
equestrian, triathlon, and beach volleyball, also have increased uneven parallel bar cause pain under the heel. Tumbling is the
the numbers of female athletes (Fig. 28.1).1 typical cause of pain at the origin of the plantar fascia, whereas
The increase in the number of women participating in sports landings cause pain in the medial longitudinal arch or the fore-
and the increase in their level of competition has provided a foot. Interestingly, analysis of flexibility parameters in gymnasts
new opportunity to study the effects of different sports on the compared with controls does not demonstrate a correlation to
female athlete. Some sports provide the opportunity to directly injury patterns or frequency.5 Ankle impingement syndrome
compare injury rates for both genders. Other sports are the (see Chapter 2) occurs in the female gymnast, with impinge-
exclusive domain of the female athlete. Prevention of injuries, ment occurring anteriorly when she lands short on her dis-
whether sport specific or gender specific, has been a primary mount, forcing her ankle into hyper dorsiflexion. If acute pain
focus in sports medicine. The sports identified as causing the occurs with an instance of injury, the ankle should be rested and
highest number of injuries in the female athlete are basket- iced. Physical therapy modalities and antiinflammatory drugs
ball, volleyball, field hockey, and gymnastics.2 Sports played on are useful adjuncts.6
516
 CHAPTER 28  Unique Considerations for Foot and Ankle Injuries in the Female Athlete 517

NCAA and High School

Female Participation Levels
3.5 Million
3,324,326
3,207,533

3
2,806,998

2.5

1,940,801
2
1,810,671

1.5

1.0

.5 195,657 211,886
94,922 153,601
64,390 (6.1%) (6.4%)
(4.9%) (5.5%)
(3.6%)

1982 1992 2002 2012 2016

NCAA Participation NFHS Participation
Fig. 28.1  NCAA and High School Female Participation Levels. (From 45 Years of Title IX The Status of Women
in Intercollegiate Athletics.) (http://www.ncaa.org/sites/default/files/TitleIX45-295-FINAL_WEB.pdf, pp. 17)

Basketball Volleyball
The most common injuries in athletes who play basketball affect Ankle sprain is the most common injury in women’s NCAA vol-
the knee and ankle. With increased participation of women in leyball, accounting for 22% of all injuries from 2013 to 2015.12
collegiate basketball, gender-related injury patterns have been In both men and women, 90% of these injuries are caused when
recognized. Previous studies have highlighted the increased one player lands on another.13 Predisposing factors for ankle
incidence in anterior cruciate knee injuries among female injury include prior ankle injury (80%), increased tibial varum,
basketball players compared with their male counterparts. increased calcaneal range of motion, and higher range of motion
Additionally, female basketball players are at a 25% greater risk through the first metatarsophalangeal joint. Prevention pro-
of sustaining a grade I ankle sprain than the male players. The grams in higher-risk athletes should focus on functional neuro-
risk was similar in both genders for grades II and III, ankle muscular control and improve joint position sense, kinaesthesia,
fracture, and syndesmotic sprains.7 A balance study comparing and joint force sense.14 Bracing has been shown to reduce the risk
NCAA Division I female athletes from soccer, gymnastics, and of ankle sprains, especially in those with prior ankle sprains.15
basketball found the basketball players demonstrated inferior
static balance compared with gymnasts and inferior dynamic Cheerleading
balance compared with soccer players.8 These studies emphasize Cheerleading, a sport that is 96% female, has steadily become
the need to create a gender-specific training program designed more popular over the past 30 years, with a corresponding
to strengthen and prevent ankle injuries. 400% increase in cheerleading-related emergency department
visits between 1980 and 2007. The percentage of ankle injuries
Soccer is between 28% and 45%.16–18 In a study by Shields et al., 45% of
A study evaluating the incidence of foot and ankle injuries at cheerleaders who sustained a sprain returned to full cheerlead-
a single NCAA Division I athletics program found injury rates ing activity by the very next performance or practice. As more
and missed-time injuries in women sports were higher than 5- to 11-year-olds participate in independent “all-star leagues,”
previously reported, and one of the four sports identified with providers should be aware these girls are 1.6 times more likely
the highest incidence rate is women’s soccer.9 Similar to basket- to sustain a fracture/dislocation than older cheerleaders (age
ball, studies have demonstrated the knee and ankle are the most 12–18).2 Coaches and providers can use anti–ankle sprain
common locations for injury in female players.10 Furthermore, strategies such as functional neuromuscular control training.
later prospective studies following young female elite soccer Moreover, cheerleading is not an NCAA championship sport
players noted ankle injuries to have the highest incidence.11 and is not recognized as a sport by high school athletic associa-
Over the past two decades, great attention has been placed on tions in some states. Studies suggest that lack of proper training
understanding the risk factors for ACL injuries in female ath- surfaces and coach education contribute to the rate of injury.
letes and placing focus on injury prevention protocols. As the Therefore, providers should be aware of the level of coach edu-
predominant proportion of injuries to female soccer players cation as well as the kinds of surfaces being used for practice
involve the ankle, a similar effort in creating prospective inter- and performance (fewer injuries occur on spring flooring than
ventional studies should be initiated. hard gymnasium floors made of rubber/polyurethane).19
518 SECTION 4  Unique and Exceptional Problems in Sports

Ballet (also see Chapter 24)

The female classical ballet dancer is unique in her requirements
for the lower extremities.19,20 The dancer uses either a thin-soled
slipper or pointe shoe. In pointe work, the stiff shank and hard
toe box of the pointe shoe support the foot. The lower extrem-
ities are called on to absorb all the force of landings on the
wooden dance floor. The consequence of the schedule of train-
ing and performance and the type of shoe for the foot leads to
chronic injuries such as tendinitis, tendinosis, and impingement
syndromes. The most common acute injury is the inversion
sprain, usually occurring on landing a jump.21 Overuse, fatigue,
improper technique, and anatomic variation from optimal body
type all can be factors in acute and chronic injuries. The lower
leg, foot, and ankle make up approximately 40% of dance inju-
ries in a sport in which the lifetime incidence of injury is 90%.22
Ballet requires extreme plantarflexion of the foot for en pointe
work. In this position, soft tissues posterior to the ankle can be
compressed and irritated. Structures vulnerable to these forces
include: an os trigonum, a Stieda process, or a large dorsal process
of the calcaneus. Symptomatic flexor hallucis longus (FHL) ten-
dinitis can be caused by these impingement scenarios. Diagnosis Fig. 28.2  Prominent Steida process (posterior lateral process of talus).
(From Kadel N. Foot and ankle problems in dancers. Physical Medicine
of this suspected condition can be supported by local tenderness and Rehabilitation Clinics. 2014;(25)4:829-844.)
proximal to the sustentaculum tali and pain with resisted plan-
tarflexion of the great toe. Magnetic resonance imaging (MRI)
typically will demonstrate fluid within the sheath of the tendon dancers with peroneal tendinitis. Treatment of this unusual con-
and sometimes marked tenosynovitis.23 Preservation of the dition requires reduction of the cuboid with a squeeze technique
function of the FHL tendon is paramount in dancers. Treatment after the hindfoot is mobilized and the forefoot is adducted.27
should be aimed at minimizing the inflammatory condition, Midfoot injuries in the dancer present a significant treatment
with surgical intervention timed to allow appropriate recovery. dilemma because of the prolonged healing time required for stabil-
In some instances, simple release of the FHL is adequate; in other ity of the foot and the difficulty of restoring the mobility required
cases, excision of the os trigonum or posterior process of the for dancing. Midfoot injuries occur when the dancer lands in full
talus may be required. Flexor hallucis longus tendon symptoms pointe position, with the posterior lip of the tibia resting and locked
are most commonly associated with ballet; however, participants on the calcaneus. In this position, the subtalar joint also is locked,
in other sports such as gymnastics and soccer increasingly are and the heel and forefoot both are in varus. Because the ankle joint
demonstrating the same entity (Fig. 28.2).24 is relatively stable in full pointe, the forces at landing are transferred
The most common acute ballet injuries occur as the dancer to the midfoot. Treatment of these acute injuries requires evalu-
lands with a loss of balance. If the dancer lands in en pointe posi- ation of both stabilities of the involved tarsometatarsal joints and
tion, the ankle is more stable, causing a midfoot injury rather amount of collapse of the longitudinal arch (see Chapter 7). Imaging
than the typical ankle sprain. The most commonly overlooked obtained should include bilateral weight-bearing foot radiographs,
fractures include the talar dome (see Chapter 16), the lateral possible stress radiographs, and in some cases, advanced imaging
process of the talus (see Chapter 16), the os trigonum (see such as an MRI or computed tomography (CT) scan.
Chapter 2), the anterior process of the calcaneus, and the prox- The fifth metatarsal is a common area of injury for dancers.
imal fifth metatarsal. Younger dancers can be more difficult to Zone 1 fractures of the fifth metatarsal involve an avulsion of the
evaluate, often requiring repetitive x-rays. A high index of sus- base. Open reduction internal fixation (ORIF) is recommended
picion should be maintained, especially in the face of soft-tissue only if the fracture fragment involves greater than 30% of the
swelling over the physes of ankle or foot bones.25, 26 articular surface and is significantly displaced. The most typical
As in other athletes, inversion injuries can cause dam- fracture involves only the most proximal 1 cm of the bone and
age to structures other than the anterior talofibular ligament. usually is associated with an inversion ankle sprain.27 It can be
Syndesmosis tears, osteochondral lesions of the talus, and sub- treated with appropriate immobilization and progressive activ-
luxation or longitudinal tears of the peroneal tendons all may ity as healing permits. The Jones fracture (see Chapters 5, 7)
occur. Dancers also are at risk for subluxation of the cuboid, occurs by the mechanism of adduction of the fifth metatarsal,
either associated with an inversion injury to the ankle or from usually while the foot is plantarflexed. Because of higher risk of
repetitive plantarflexion and dorsiflexion. In this clinical entity, nonunion combined with negative effects of prolonged immo-
the base of the fourth metatarsal becomes dorsally displaced bilization, many surgeons advocate for early operative manage-
and the fourth metatarsal head displaces in a plantar direction. ment for these fractures at the metaphyseal-diaphyseal junction.
Additionally, cuboid dysfunction can interfere with normal Repetitive adduction forces that occur with cutting or pivot-
function of the peroneal tendons and must be considered in ing movements can result in diaphyseal stress fractures. There
 CHAPTER 28  Unique Considerations for Foot and Ankle Injuries in the Female Athlete 519

usually are prodromal symptoms preceding an acute event. The Female gymnasts typically also have better joint mobility
history is informative, as is review of radiographs, which typi- than males. This improves their flexibility—another trait val-
cally demonstrate periosteal reaction, cortical thickening, intra- ued in gymnastics. The alignment differences between male
medullary sclerosis, and widening of the fracture line. Because and female at the hip and knee may be one factor, along with
this is a vascular watershed zone, these stress fractures should be the level of conditioning, contributing to higher percentages of
treated with intramedullary screw fixation, bone graft, or both. overuse syndromes in the lower extremity in female athletes.
When dancers perform the demi-pointe position, the foot is Clinicians caring for the female athlete must be aware of the
twisted and inverted and can incur an oblique or spiral fracture Female Athlete Triad. This phenomenon refers to the interrelated
of the mid- to distal portion of the fifth metatarsal. This “danc- problems of decreased energy availability (with or without disor-
er’s fracture” now has been shown to heal well with conservative dered eating), menstrual irregularity, and decreased bone mineral
and symptomatic treatment rather than ORIF.28 density.32 Each of these elements exists on a continuum, and the
female athlete may have dysfunction of one or all three elements.
The most severe manifestation of the triad would be low energy
GENDER-SPECIFIC CONSIDERATIONS availability with an eating disorder, functional hypothalamic
Anthropometric studies provide data concerning anatomic dif- amenorrhea, and osteoporosis. The prevalence of the Female
ferences between women and men.29 The increased number of Athlete Triad is higher in sports that select for a slim body habitus
androgens in males promotes lean body mass, with the percent- or involve subjective judging, but it has been reported in all sports.
age of body fat in men (12%–16%) being less than in women Physician awareness of the Female Athlete Triad begins
(22%–26%). Given the same body weight, women also have a during the preparticipation physical. The Female Athlete Triad
smaller heart, lower blood pressure, and smaller lungs, with a Coalition published a 2014 consensus statement on prepartic-
slightly lower aerobic capacity.30 ipation screening questions and risk factors triggering workup
For women, lower extremities constitute 51% of total height, and return to play. The preparticipation interview should
compared with 56% in men. This difference improves the mechan- involve questions that gauge the onset a menses and frequency
ical advantage for men in activities requiring striking, hitting, or of periods, weight-consciousness, history of food allergies or
kicking because greater force can be generated by their legs as lon- eating disorders, and/or stress fracture history.33 The Female
ger levers. The female has a wider pelvis, greater varus of the hips, Athlete Triad Coalition also developed a risk factor stratifica-
and greater genu valgus than the male, resulting in a lower center tion tool that aids in determining an athlete’s clearance of sport
of gravity. In sports requiring excellent balance, such as gymnas- participation. Important high-risk criteria include body mass
tics, this gives females a distinct advantage.31 As such, the balance index (BMI) <17.5, fewer than six menses over 12 months,
beam is a required element in competition for female gymnasts Z-score < -2.0, or more than two stress fractures (Fig. 28.3).
and is not included in the competition for male gymnasts. For all female athletes, the NIH recommends 1300 mg and

Magnitude of Risk
Risk Factors
Low Risk = 0 points each Moderate Risk = 1 point each High Risk = 2 points each

Low EA with or without No dietary restriction Some dietary restriction‡; Meets DSM V criteria for ED*
DE/ED current/past history of DE;

BMI ≥ 18.5 or BMI 17.5 < 18.5 or BMI ≤17.5 or < 85% EW or
Low BMI ≥ 90% EW** or < 90% EW or ≥ 10% weight loss/month
weight stable 5 to < 10% weight loss/month

Delayed Menarche Menarche < 15 years Menarche 15 to < 16 years Menarche ≥16 years

Oligomenorrhea and/or
> 9 menses in 12 months* 6-9 menses in 12 months* < 6 menses in 12 months*
Amenorrhea

Low BMD Z-score ≥ –1.0 Z-score –1.0*** < – 2.0 Z-score ≤ –2.0

None 1 ≥ 2; ≥ 1 high risk or of

Stress Reaction/Fracture
trabecular bone sites†

Cumulative Risk
(total each column, then points + points + points = Total Score
add for total score)
Fig. 28.3  Cumulative Risk Assessment. (From Joy E, De Souza MJ, Nattiv A, et al. 2014 Female Athlete Triad
Coalition consensus statement on treatment and return to play of the Female Athlete Triad. Curr Sports Med
Rep. 2014;13(4):219-232.)
520 SECTION 4  Unique and Exceptional Problems in Sports

1000 mg of calcium supplementation for women less than or

PEARLS
greater than 18 years of age, respectively. Six hundred inter-
national units of daily vitamin D are recommended for adults Ankle sprains are extremely common in female athletes, and prevention
<70 years of age.34 programs should focus on functional neuromuscular control to improve joint
Female gender is an independent risk factor for stress frac- position sense, kinaesthesia, and joint force sense.
The lower leg, foot, and ankle make up approximately 40% of dance injuries,
tures, regardless of Female Athlete Triad dysfunction. A prior
and the lifetime incidence of injury is 90% in the dancer.
stress fracture is the best predictor of future stress fractures in
The Female Athlete Triad consists of low energy availability, menstrual dys-
all age groups.35 The Female Athlete Triad makes women more function, and low bone mineral density. It places the female athlete at an
susceptible to stress fractures that occur as a result of repeti- increased risk of stress fractures in the foot and ankle.
tive, low-level stresses on bone and have multifactorial causes.
In addition, menstrual irregularities such as exercise-induced
amenorrhea may result in lower bone density, which increases
stress fracture risk. One study of 748 high school runners REFERENCES
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have a positive heel squeeze test; navicular stress fractures are 8. Bressel E, Yonker JC, Kras J, Heath EM. Comparison of static and
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will fall into either sport-specific or gender-specific categories, for volleyball athletes. Sports Med. 2014;44(9):1185–1195.
15. Barelds I, van den Broek AG, Huisstede BMA. Ankle bracing is
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1996;24(6):754–757. present, and future. J Am Acad Orthop Surg. 2015;23(7):424–432.
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N Am. 2006;17(4):813–826. 34. National Institutes of Health Office of Dietary Supplements. Cal-
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 29
Orthobiologics in Foot and Ankle Applications
Lew Schon, David Karli, Robert Anderson, Heath Gould, Zijun Zhang

OUTLINE
Introduction, 523 Clinical Applications, 529
Underlying Mechanisms of Therapeutic Benefit, 524 Posttreatment Protocol for BMC or PRP Injection, 529
Platelet-Rich Plasma, 524 Percutaneous Applications: Foot and Ankle, 529
Bone Marrow Concentrate, 525 Treatment Option for the Management of Chronic Bone
Dose–Response Relationships of PRP and BMC, 525 Marrow Lesions With Calcium Triphosphate, 532
Adipose Stem Cells, 525 Patient Presentation/Indications, 532
Placental/Amniotic Products, 526 Interpreting the MRI and Bone Marrow Lesions, 532
Recombinant Growth Factors, 527 Clinical Effect of Bone Marrow Lesions, 533
Synthetics, 527 Managing the Chronic (Nonhealing) Bone Marrow Lesion
Calcium Sulfate and Calcium Phosphate, 527 of the Foot and Ankle, 533
Hyaluronic Acid, 528 Technique, 534
Autologous Chondrocyte Implantation, 528 Future Directions, 536

cellular signaling may not be the same as that in  vitro or are
INTRODUCTION still unknown. Recombinant growth factors (e.g., recombinant
In recent years, as orthobiologic interventions for a variety of human bone morphogenetic protein [rhBMP] and recombinant
sports-related foot and ankle conditions have become more human platelet-derived growth factor [rhPDGF) and synthetic
readily available, results are beginning to appear in the literature. compounds (hyaluronic acid, calcium phosphate, or calcium
The notion that we can affect the biology of the musculoskeletal sulfate) are regulated by the FDA as devices or drugs and are
tissues with these treatments and trigger a healing response is released with specific indications for orthobiologic use.
generally accepted. What conditions can be affected, how these Often these biologic products are used in an “off-label” fash-
orthobiologics are delivered, the mechanism of action, and the ion for specific conditions “within the standard of care” (i.e.,
posttreatment modalities are being defined. Since these prepa- within the standards of appropriate medical practice without
rations can be delivered percutaneously, applied topically, and committing malpractice), even though they are not approved for
used in surgery as stand-alone or adjuvant approaches, there are that situation. Off-label use is not against the law, since the FDA
often confounding variables that affect their assessment. does not regulate the practice of medicine. The companies that
By the U.S. Food and Drug Administration (FDA) defini- provide the products must comply with the FDA and cannot
tion, biologics are biological products made from a variety of advertise or encourage an off-label use. Practitioners determine
natural sources (human, animal, or microorganism) or the final treatment on the basis of their clinical and scientific experience
products of advanced biotechnologies for medical applications in accordance with their medical community’s reasonable stan-
(www.Fda.gov/aboutfda). The most common autologous ortho- dards, given the patient’s specific condition and setting.
biologics, biologics for orthopaedic applications, in use today From a regulatory perspective, human cells and tissues that
are platelet-rich plasma (PRP) and bone marrow concentrate comply with standards of the American Association of Tissue
(BMC). There is an increasing frequency of use of autologous Banks are minimally manipulated in processing, and are mar-
fat tissue-derived treatment preparations, including stromal keted for homologous use are in compliance with US FDA reg-
vascular fraction (SVF) and “fractured fat.” There also are allo- ulation 21 CFR 1271 on human cells, tissues, and cellular and
geneic (donor tissue, cell, or growth factor) products obtained tissue products (HCT/P). Examples given in the regulation are
from donated placentas, amniotic membranes, or fluids. These “amniotic membrane when used alone or without added cells,
products contain growth factors with or without viable cells, bone, cartilage, cornea, fascia, ligament, pericardium, periph-
depending on the specific product. Because biologics are often eral or umbilical cord blood stem cells for autologous use or
a mixture of multiple biological components that are difficult use in a first or second degree blood relative), sclera, skin,
to quantify in many cases, their mechanisms of action through tendon, vascular graft, heart valves, dura mater, reproductive
523
524 SECTION 5  New Advances and Augmentations in the Foot and Ankle

cells, and tissues (e.g., semen, oocytes, embryos). On the other The distinction between the classical term “MSC” and the
hand, if an HCT/P product is “dependent upon the metabolic newer iteration “MMSC” must not be overlooked, as this distinc-
activity of living cells for its primary function,” it is not regu- tion is central to understanding the origin of these cells and how
lated as a section 361 product according to an FDA guidance they can be applied for therapeutic benefit. Historically, mesen-
document on minimal manipulation and homologous use of chymal stem cells were aptly named because they were thought
HCT/Ps, and requires FDA clearance.1 HCT/Ps that are not to derive from the connective tissue (stroma) of bone marrow
minimally manipulated or used for homologous applications and other tissue subtypes. The publication of a landmark article
need FDA approval, since they are considered to be biological by Crisan and colleagues in 2008 marked a significant paradigm
drugs. PRP and BMC are fully compliant with the existing reg- shift with the realization that MSCs are not stromal in nature,
ulatory framework established by the FDA, when used on an but rather derived from perivascular cells (pericytes).4 Indeed,
autologous basis and with homologous use. Interestingly SVF, Crisan’s data were so compelling that Arnold Caplan himself—a
although widely used in medical practice, is accepted as within pioneer of the MSC—actually went so far as to conclude that all
the standard of care but falls outside the current standards MSCs are pericytes.5
established by the FDA for point-of-care (POC) therapeutic This change in dogma is particularly significant because it
agents (e.g., 21 CFR 1271) as indicated in the FDA Guidance has had such a profound effect upon the way we view the func-
issued in late 2017. Placental products vary broadly and often tionality of MMSCs and, consequently, the way we view their
fall into a gray zone, in which the tissue may be treated as an therapeutic capacity. With the characterization of MMSCs as
allograft but may only be marketed for specific uses, or the pericytes, the therapeutic focus of these cells has shifted from
material contains living cells that require FDA clearance. The their multipotent differentiation to their secretory ability,
only noncontroversial placental-derived products on the mar- which leads to immunomodulatory and trophic effects.6 This
ket are sheet-forms used as a covering for wounds, or amniotic shift has paved the way for a “new era” of cell-based orthobi-
fluid without cells or micronized tissue. Neither of these types ologics to arise over the past decade, with applications rang-
of products are “cleared” by the FDA, although the agency has ing broadly from tendon healing to fracture union to cartilage
taken action against companies who advertise the sheet-form regeneration.7–13
for promoting healing or reducing pain. Use of the word “indi- The increased emphasis upon the secretory function of
cation” implies a formal clearance by the FDA. Manufacturers MMSCs is perhaps best illustrated by MMSC-derived exo-
can state what the material is used for, but not as an “indica- somes, which have recently gained traction in biomedical
tion for use” in the classic sense. Companies that produce these research for their paracrine therapeutic potential. The exosome
products must register and comply with current good manufac- is a type of extracellular vesicle that is released by the MMSC
turing procedures (cGMP) and donor screening and tracking and, much like its cellular counterpart, helps to maintain tissue
to qualify for regulatory clearance. In general, further defini- homeostasis.14 While the precise mode of action is not com-
tion and oversight for these products are expected to expand.1 pletely understood, exosomes are believed to deliver mRNA,
miRNA, and proteins to the target cell, thereby modulating the
UNDERLYING MECHANISMS OF THERAPEUTIC recipient cell function through complex cellular signaling cas-
cades.15,16 Furthermore, exosomes have several possible advan-
BENEFIT tages over traditional cell-based therapy: eliminated risk of
There are a number of biologically derived materials that have mutation, decreased likelihood of immune rejection, improved
been used for regenerative therapy, including autogenous (e.g., tissue migration, and circulation through small blood vessels
PRP, BMC, and SVF) and allogeneic materials (e.g., placental/ (e.g., capillaries).17,18
amniotic tissue–derived fluid and membranes). The therapeutic possibilities for MMSC-derived exosomes
A key distinction between PRP and BMC is the presence are extensive, with applications in orthopaedic surgery and sev-
of progenitor cells in the bone marrow, including multipo- eral other medical disciplines. With regard to musculoskeletal
tent mesenchymal stromal cells (MMSC) formerly known biology, in  vitro and animal studies have proposed a role for
as mesenchymal stem cells (MSC). In the lab, those cells can exosomes in fracture healing, osteoporosis, cartilage regenera-
be isolated from bone marrow and demonstrate two critical tion, intervertebral disc degeneration, and osteonecrosis of the
behaviors: 1) they can differentiate into adult tissue cells under femoral head.19–28 Although donor-derived exosomes currently
specific conditions (e.g., becoming chondrocytes, osteoblasts, remain in the preclinical phase, they have shown great promise
and adipocytes); and 2) they can replicate without undergoing in these early investigations and may prove to be an important
differentiation. Therefore, harvesting these stem cells does not component of nonoperative therapeutics for a variety of ortho-
create a deficiency given their ability to replenish their popu- paedic conditions in the not-so-distant future.
lation. These cells are, in fact, present in all tissues of the body
and produce trophic factors that help to coordinate/organize Platelet-Rich Plasma
repair and regeneration of pathologic tissue through the pro- PRP, being derived from whole blood, contains very few cir-
duction of growth factors and cytokines.2 The cells can immu- culating stem cells under normal conditions. What gives PRP
nomodulate and help control inflammation. They home to a therapeutic potential in treating certain types of pathologies
the site of injury and reside in the local injured tissues around is the concentrated level of platelets, which release vesicles like
blood vessels.3 exosomes, which might contribute to their therapeutic potential.
 CHAPTER 29  Orthobiologics in Foot and Ankle Applications 525

These exosomes are filled with a wide variety of growth factors that the stem cells present do not disappear shortly after initiating
and other biologically active proteins. The plasma component their paracrine effect, but continue to respond to the environment,
in PRP contains several proteins that have been shown to have thereby modulating their response as tissue is being repaired over
a beneficial effect, including interleukin 1-receptor antagonist a longer period.
protein (IL-1RAP or so-called IRAP ) and α-2- macroglobulin
(α-2-M).29,30 IL-1RAP directly blocks the pro-inflammatory Dose–Response Relationships of PRP and BMC
action of IL-1, a cytokine released by macrophages and neu- As indicated above, the important components in PRP and
trophils, in particular, at sites of inflammation, and is respon- BMC that are associated with a therapeutic benefit have been
sible for pain and sustaining a pro-inflammatory environment. identified. Counting the number of platelets present in a PRP
At the site of injection, platelets release growth factors that are sample and assessing the levels of critical growth factors con-
thought to stimulate/interact with adult tissue cells, enabling tained is possible, but very few of the clinical studies include
those cells to initiate a repair sequence. Releasing growth factors these data. Furthermore, the use of RBC- and/or WBC-reduced
in a small-volume tissue (i.e., intratendinous) creates a stimula- PRP preparations creates more challenges. More work is needed
tory gradient of growth factors as they diffuse away from the site to define these variables and their impact on healing.
of implantation. As a result of this gradient, adult stem cells in On the other hand, mostly due to the pioneering work
the adjacent tissue may migrate to the treatment site. Thus, the of Philippe Hernigou (Chief of Orthopaedic Surgery, Henri
benefit of PRP is an indirect one, since the growth factors act on Mondor Hospital, East University [University of Paris],
adult tissue cells and stem cells present in the adjacent tissue to Créteil, France), BMC preparations have been characterized
begin the reparative process. in terms of the levels of MMSCs present in the injectate. For
example, Hernigou and his coworkers observed that study
Bone Marrow Concentrate subjects receiving an autologous BMC treatment following
Bone marrow contains cells needed to continuously replenish the a standard surgical repair of a full-thickness supraspinatus
cellular components of blood: white blood cells (WBCs), red blood tendon tear were twice as likely to have an intact tendon at
cells (RBCs), and platelets. These adult peripheral blood compo- the 10-year milestone compared with patients receiving just
nents are derived from hematopoietic stem cells (HSCs). In bone the standard surgical repair.32 They showed that all of the
marrow, there are also MMSCs or MSCs, which don’t give rise to BMC-treated patients who had more than 30,000 MMSCs (as
blood cells. They were initially identified in bone marrow stroma determined by assessing the number of colony-forming unit
and believed to provide microenvironmental support to HSCs. In fibroblasts [CFU-Fs] in the preparation) per injectate had
the 1960s, the pioneering work by Alexander Friedenstein proved intact tendons at the 10-year milestone, whereas those patients
that they are multipotent stem cells, like HSCs, being able to differ- receiving fewer than 30,000 MMSCs all had tendon failures by
entiate to osteoblasts, chondrocytes, and adipocytes. the 10-year point. Hernigou and colleagues have also reported
In view of the high cellular content of BMC, which includes similar threshold effects in treating other pathologies, includ-
a wide variety of progenitor/stem cells, BMC provides a direct ing tibial nonunion and avascular necrosis of the femoral
therapeutic benefit at the site of implantation. The plasma of the head.33,34 The problem with trying to establish stem cell dos-
BMC preparation is a source of additional benefit, as mentioned ing guidelines is that each patient has their own level of adult
for PRP, but with some differences. For example, BMC has been stem cells in their bone marrow. Thus, an explicit knowledge
shown to contain 20-fold higher levels of IL-1RAP compared of the number of MMSCs in a preparation is of retrospective
with patient-matched PRP preparations, while BMC will con- benefit only due to the lag time in obtaining a CFU-F value,
tain less a-2-M compared to PRP, since a-2-M is actively secreted but it can help physicians refine how they aspirate bone mar-
into peripheral blood.29,30 One advantage of using BMC over row in order to maximize the potential to get a therapeutically
PRP is that cellular activity in BMC treatment is initiated much beneficial level of adult stem cells. Dr. Hernigou’s group has
more quickly, since the progenitor and stem cells are present published several papers on his bone marrow aspiration tech-
in the injectate and don’t need to migrate to the treatment site, nique, including specific recommendations on the practical
thereby shortening the time lag for initiation of repair.31 aspects of aspiration.35–37
Since MMSCs are able to differentiate into a wide variety of
tissue cells, it was thought that MMSCs were therapeutically ben-
eficial due to their ability to differentiate. However, after studies
ADIPOSE STEM CELLS
reported that MMSCs in most cases differentiated into adult tissue As early as the turn of the 21st century, adipose tissue was iden-
cells at a very low rate (< 2%–3%), research focus shifted to the tified as a potential autologous source of MMSCs.38 Much like
fact that MMSCs are able to secrete a diverse set of cytokines and bone marrow, adipose contains an easily isolated stroma-derived
growth factors. Murphy and colleagues have reviewed the exten- cell type that can differentiate into osteogenic, tenogenic, myo-
sive list of biologically active molecules MMSCs produce when genic, and chondrogenic lineages.39 These unique properties led
activated.2 For example, Murphy et al. indicated that there are five to the use of lipoaspiration as a means of harvesting adipose
separate biochemicals that MMSCs secrete in a pro-inflammatory from fat-rich areas, with the end goal of applying this tissue for
environment. This approach is called the paracrine effect and is therapeutic benefit in other parts of the body. However, before
similar to what platelets do when they degranulate and release the adipose tissue can be re-injected, it must first be processed
growth factors. An important advantage of working with BMC is in order to isolate an MMSC-rich product.
526 SECTION 5  New Advances and Augmentations in the Foot and Ankle

Several methods for processing adipose tissue have been with no adverse events and a significant improvement in Knee
proposed in the literature. Classically, the preferred technique Society Scores at 6 weeks and 12 months.48 Similarly, a larger
has relied upon manipulation of the cells through enzymatic study showed improvements in both International Knee Society
degradation.38 This method involves treating the lipoaspirate scores and Visual Analogue Scale (VAS) scores in 52 patients
with collagenase to digest the extracellular matrix, then cen- with knee OA who underwent microfragmented fat injection
trifuging the sample to obtain the product known as the stro- plus arthroscopic debridement.49 Given the lack of robust clin-
mal vascular fraction. Because the SVF contains a variety of ical data in the literature, a prospective randomized controlled
cell types, cultures are required to isolate the adipose-derived trial has recently been initiated to compare the efficacy of
stem cells (ASCs). The longer time required for culture has lim- microfragmented fat and hyaluronic acid for mild-to-moder-
ited the clinical utility of this technique, since it is not feasible ate knee OA.50 Further studies are necessary for foot and ankle
to perform during a single procedure in the operating room. applications before conclusions may be drawn regarding the
Moreover, the FDA has yet to approve the use of enzymatically utility of microfragmented fat injections in this patient popu-
digested ASCs for musculoskeletal disorders in humans. lation. Also, regulatory issues on the technique and technology
In an animal study, local injections of enzymatically digested are being clarified.
ASCs significantly increased the tissue volume of the foot fat
pad in rats.40 A few studies, all performed outside the US, have
reported clinical outcomes following the injection of enzymat-
PLACENTAL/AMNIOTIC PRODUCTS
ically digested ASCs or SVF for foot and ankle conditions.41–43 The human placenta supports fetal development and has been
In a study of 49 patients with varus ankle osteoarthritis (OA) used since 1910 as a source of allogeneic tissue to assist heal-
who underwent arthroscopic bone marrow stimulation with ing.51 The placenta is delivered after a birth and consists of the
lateral calcaneal osteotomy, clinical outcome scores were sig- chorion, the amnion, the umbilical cord, and the amniotic sac.52
nificantly better in patients who received a supplemental injec- These tissues are rich in cells and growth factors; they can be
tion of enzymatically digested ASCs compared with those who donated by consenting mothers and tested for viruses (human
underwent the surgical procedure alone. Similarly, a study of immunodeficiency virus, hepatitis, cytomegalovirus, human
49 patients with osteochondral lesions of the talus revealed that T-lymphotropic virus), then processed according to standards
bone marrow stimulation supplemented by SVF injections was established by the American Association of Tissue Banks.53,54
associated with superior clinical and MRI outcomes compared Placental tissue allografts have a role in the healing of conjunc-
with marrow stimulation alone. Further, SVF injections also tival lesions, ulcers, and wounds.55–57
showed benefit for Achilles tendinopathy in a randomized con- Currently, placental or amniotic-derived tissue products
trolled trial, with significantly better outcome scores at 15 and work as a delivery system of growth factors and as a scaffold
30 days postprocedure compared with PRP injections. that play a unique role in wound healing. In some products the
Recently, a novel processing method has been proposed presence of cells may provide additional benefit.58,59 Also, the
that employs mechanical forces to create a reduced-volume cells may not be fully immune-privileged and may incite a host
preparation with viable progenitor cells, including ASCs.44 response. While the allograft material for creating patches (non-
This technique, known by the trade name Lipogems (Lipogems micronized) from placental tissues contains viable stem cells
International SpA, Milan, Italy), is a closed system that processes and adult tissue cells, most products that are FDA-compliant
adipose tissue using microfragmentation as opposed to enzy- are those processed using techniques that kill any viable cells
matic digestion. Preclinical studies of microfragmented adipose present in the tissue. Both the growth factors and the matrix
tissue have demonstrated promising results when compared with itself are thought to be responsible for the therapeutic benefit
the conventional processing methods. In two studies, microfrag- of using placental tissue–derived membrane patches in wound
mentation produced a homogenous adipose tissue product with healing. It is thought that the growth factors migrate from the
a significantly higher percentage of ASCs and a lower number of tissue implant into the underlying wound bed to activate local
hematopoietic elements compared to enzymatic digestion.44,45 A stem and adult tissue cells residing there. These products also
separate study demonstrated that microfragmented adipose tis- act as a physical barrier, helping to reduce the chance of infec-
sue releases more growth factors and cytokines involved in tissue tion. Finally, the matrix of the tissue has been shown to promote
repair and regeneration compared with enzymatically degraded the activity of cells that have migrated into the tissue implant
adipose tissue.46 Finally, microfragmented lipoaspirate has also itself. This in-migration is thought to promote the melding of
shown the ability to induce the production of connective tissue the tissue patch with the wound bed, thereby aiding in re-epi-
in a paracrine fashion, suggesting that this technique may have a thelization of the wound.60
therapeutic role in cartilage regeneration or repair.47 Cellular products such as the Pluristem allogeneic cell
To date, the authors are not aware of any clinical studies in (Pluristem Therapeutics Inc., Haifa, Israel) can be harvested
the foot and ankle literature that have reported clinical out- and expanded for use as growth factor delivery agents. Studies
comes following the injection of microfragmented fat. However, have been initiated to establish a role for these cells in ortho-
preliminary data from the knee literature do suggest that this paedics.61 Currently, the use of this biologic in the musculo-
may be a safe and effective therapeutic option for cartilage skeletal system is still investigational in the United States.
disorders of the foot and ankle. In a small study of 17 patients Another cellular product associated with tissues that contain
with knee OA, microfragmented fat injections were associated growth factors is available, Grafix (Osiris Therapeutics, Inc.,
 CHAPTER 29  Orthobiologics in Foot and Ankle Applications 527

Columbia, Maryland). Currently it is in Phase 2/3 clinical stud- study of 124 foot and ankle patients for several conditions
ies for approval by the FDA as a biological drug product, per including open repair of peroneal and Achilles tendinopathy
an agreement reached between Osiris and the FDA in 2015. with an overall wound complication rate of 5.64% and a reoper-
This human-derived, viable wound matrix, composed of cryo- ation rate of 1.6% (2/124).59
preserved amniotic membrane, was applied weekly to treat In a randomized, controlled, double-blind pilot study of
diabetic foot ulcers (n = 50), resulting in a wound closure rate 23 patients with plantar fasciitis treated with either steroid or
of 62.0% at 12 weeks, compared to a 21.3% closure rate with cryopreserved human amniotic membrane, the amniotic mem-
standard of care (n = 47).62 brane was found to be safe and effective relative to the steroid
Amniotic fluid also has been found to contain MMSCs, but injection.80
applications of these cells in healing are largely experimen-
tal.63 There is debate about the viability of the cells in vivo and
their engraftment into local tissues. However, these fluids may
RECOMBINANT GROWTH FACTORS
contain growth factors that may provide symptomatic relief in Across the field of orthopedics, recombinant growth factors such
musculoskeletal conditions.64 In one study of 44 patients with as BMP and PDGF have become increasingly popular adjuncts to
plantar fasciitis and Achilles tendinopathy, good resolution of promote bone healing. Although BMP is only FDA-approved for
symptoms was demonstrated using an injection of cryopre- lumbar fusions and tibial nonunions, there is a mounting body
served amniotic membrane and amniotic fluid–derived cells.65 of evidence to support its use in foot and ankle surgery. Several
Umbilical cord–derived cells are currently banked as cord articles in the literature have reported increased fusion rates with
blood but do not yet have an indicated use in orthopaedics. the addition of BMP-2 and BMP-7 in high-risk patients undergo-
The umbilical cord consists of an umbilical vein and two arter- ing arthrodesis of the ankle or hindfoot.81–85 However, given the
ies surrounded by a collagenous, hyaluronan matrix called retrospective design of these studies, the overall level of evidence
Wharton jelly. The cord components can be processed and used regarding the efficacy of BMP in foot and ankle fusion remains
to produce growth factors, but there are no studies to support low. Randomized prospective data must be presented if BMP is
their efficacy.66–68 to become ubiquitous in this patient population.
Lyophilized human umbilical cord is decellularized and may In contrast to BMP, multiple randomized prospective trials
be a source of growth factors for certain applications. have compared PDGF to autogenous bone graft (ABG); the
Most of the placental products available are decellularized current gold standard in foot and ankle fusion.86,87 A review
and either dehydrated or cryopreserved. They are typically article by Sun and colleagues aggregated clinical, radiographic,
derived from the chorion, which is on the maternal side of the and safety data from the 634 patients included in these three
placenta, or the amnion, which is on the fetal side. These tis- high-quality studies.88 No significant difference was observed
sues are immune-privileged and, with proper processing, can between PDGF and ABG with regard to safety or radiographic
be used as sheets or particles of growth factors. In general, the outcomes. Comparative analysis of the clinical data also yielded
dehydrated tissues have been shown to decrease tissue fibrosis, similar outcomes between groups, with the exception of the
enhance soft-tissue healing, and modulate immune function.69 long-term SF-12 Physical Component scores, which were supe-
In addition to their widespread use for corneal lesions, pla- rior in the ABG cohort. Based upon these results, the authors
cental products have also shown benefit in the musculoskeletal concluded that PDGF is a viable alternative to ABG in foot and
system for wound healing.70–72 ankle fusion.
The various products are not equal due to procurement, In addition to the value of PDGF as an adjunct to enhance
processing, and preservation procedures. They are not all well bony fusion, emerging studies have begun to expand the
studied, but in general have been used for diabetic ulcers and scope of this growth factor in foot and ankle surgery. Novel
to promote healing. The best-studied products are EpiFix and arthroscopic procedures have utilized PDGF in the treatment
AmnioFix by MiMedx (MiMedx Group, Inc., Marietta, GA), of talar osteochondral defect (OCD) lesions, with encourag-
which has characterized over 226 growth factors.73 ing preliminary results in a proof-of-concept trial and a case
AmnioFix is one of the new regenerative medicine advanced report of a professional rugby player.89,90 Likewise, a recent
therapy (RMAT) category products that the FDA created after animal study used a chicken foot model to propose a role for
the 21st Century Cures Act, so it is in an investigational new PDGF as a bioinductive platform for flexor tendon repair.91
drug clinical study premarket approval program. AmnioFix and These innovative applications—including arthroscopic and
EpiFix have been used in clinical studies and have shown con- soft-tissue procedures—suggest that growth factors may prove
sistent safety and efficacy in diabetic wounds, vascular wounds, to be extremely versatile resources in the future of foot and
and plantar fasciitis.74–76 A case study of 22 patients has also ankle sports medicine.
shown benefit in Achilles tendonitis.77 The benefit of this path of
delivery is that it is relatively cost effective and requires minimal SYNTHETICS
processing by the physician to inject. Future studies may show
benefits in a greater number of indications including articular Calcium Sulfate and Calcium Phosphate
cartilage defects and osteoarthritis.78,79 In foot and ankle surgery, calcium sulfate and calcium phos-
A similar product by Amniox Medical, Inc., a TissueTech phate have long been used to augment the fixation of displaced
company in Miami, Florida, has been evaluated in a retrospective calcaneus fractures. In a randomized prospective study of 90
528 SECTION 5  New Advances and Augmentations in the Foot and Ankle

patients with displaced intra-articular calcaneus fractures, per- at 3 months following injections of HA compared with normal
cutaneous screw fixation with calcium sulfate cement grafting saline.113 Further randomized controlled studies are needed in
was associated with less blood loss, better range of motion, order to draw definitive conclusions regarding the efficacy of
lower infection rate, and superior functional outcome scores HA injections for subtalar and MTP osteoarthritis.
compared with open reduction and internal plate fixation.92 Outside the realm of osteoarthritis, HA has other notable
A separate prospective study reported a shorter time to union applications in foot and ankle sports medicine. Several studies
for displaced intra-articular calcaneus fractures augmented have reported decreased pain and increased functional outcome
with demineralized bone matrix calcium sulfate compared to scores with HA injections for OCD of the talus.114–116 Similarly,
those treated with open reduction and internal fixation alone.93 HA has demonstrated benefit as an adjunct to microfracture
Similarly, there is a substantial body of literature supporting the surgery that may offer improved outcomes for talar OCD com-
use of calcium phosphate bone cement to augment calcaneal pared with the operative procedure alone.117–119 Finally, peri-
fixation constructs. With the addition of calcium phosphate articular HA injections have also been successful in reducing
bone cement, studies have demonstrated superior compressive pain and accelerating return to play in athletes with lateral ankle
strength and earlier return to full weight bearing postopera- sprains.120,121
tively, with comparable clinical outcome scores to conventional
bone grafting.94–97 Autologous Chondrocyte Implantation
Aside from their well-documented utility in calcaneus frac- Autologous chondrocyte implantation (ACI) is a two-stage sur-
ture fixation, calcium phosphate and calcium sulfate have also gical procedure in which chondrocytes are harvested from a
been used to improve screw purchase in a biomechanical model patient’s joint, expanded ex vivo, and re-implanted over an artic-
of osteoporotic ankles.98 Additionally, there may be a role for ular cartilage defect. This method was originally promoted for
calcium phosphate cement in patients with symptomatic bone focal cartilage defects of the knee, but the indications for ACI
cysts of the foot and ankle. In a case series of 16 young ath- and the technique itself are evolving. The newer-generation ACI
letes with symptomatic unicameral cysts of the calcaneus, technique, so-called Matrix-assisted ACI (MACI), incorporates
endoscopic curettage with injection of calcium phosphate bone collagen matrix or other materials with chondrocytes for implan-
substitute was associated with significantly improved pain and tation.122 The matrix supports chondrocytes with a three-dimen-
functional outcome scores, as well as an early return to play (< 8 sional structure and helps cell manipulation during surgery.
weeks) and zero instances of recurrence or pathologic fracture at ACI has also expanded its applications to foot and ankle sur-
2 years postoperatively.99 However, given the paucity of literature gery. There is now a growing body of evidence in the foot and
investigating the use of calcium sulfate and calcium phosphate ankle literature to suggest that it is an effective therapeutic strat-
outside the realm of calcaneus fracture, further high-quality egy for talar OCD.123,124 Classically, the chondrocytes are har-
studies are needed to establish them as a mainstream therapeu- vested from a nonweight-bearing portion of the ipsilateral knee
tic option in foot and ankle sports medicine. or ankle, though the talar OCD cartilage itself has also proven
to be a viable donor site.125 ACI can be performed as either an
Hyaluronic Acid open or arthroscopic procedure, with positive long-term clin-
Hyaluronic acid (HA) injections have a well-established role ical outcomes reported for both approaches.126–129 Long-term
in the treatment of OA. With regard to ankle (tibiotalar joint) MRI results have also been encouraging, as the T2-mapping
OA, many prospective studies have reported positive results values of ACI-produced cartilage are compatible with normal
in terms of pain, functional scores, and patient-reported out- hyaline cartilage.130,131 Two recent studies have investigated the
comes following HA injections.100–108 In a recent systematic relationship between MRI T2 mapping and clinical outcomes,
review, Vannabouathong and colleagues pooled the results of with conflicting results reported in terms of whether these
three high-quality randomized controlled trials (109 patients) metrics may be used as a surrogate for one another in the post-
and concluded that Ankle Osteoarthritis Scale scores improved operative setting.132,133 Despite the promising early results in
significantly with HA compared with normal saline at 6 months support of ACI for the treatment of talar OCD, prohibitive cost
(mean difference of 12.47 points between groups).109 Early-stage and low-level evidence have limited the widespread adoption of
disease and shorter symptom duration have been identified as this technique in foot and ankle sports medicine.134
favorable prognostic factors for improvement with HA injection Still, the utility of ACI continues to be a source of considerable
for ankle OA.110 Some data in the literature also suggest that debate. First, chondrocytes lose their original phenotype during lab-
imaging guidance may further optimize the success rate of HA oratory culture. From the viewpoint of cartilage biology, the dediffer-
injection for ankle OA.111 entiated chondrocytes produce mechanically inferior fibrocartilage,
In addition to their utility in the tibiotalar joint, HA injec- rather than hyaline articular cartilage, which could certainly be
tions have been investigated as a therapeutic strategy for osteo- detrimental to the outcome of ACI. Next, the incorporation of the
arthritis of other joints within the foot. Mei-Dan and colleagues reparative cartilage into the surrounding host cartilage is another key
reported significant improvements in pain, walking distance, aspect of a functional repair product. Technical advances, including
and clinical outcomes at 7 months after a series of three HA the advent of new matrices, may eventually help to address these
injections were administered to the subtalar (talocalcaneal) fundamental issues in cartilage repair. Finally, it is worth noting
joint.112 In the metatarsophalangeal (MTP) joint, however, that joints of the foot and ankle are anatomically different from the
Munteanu and colleagues found no difference in pain scores knee joint, particularly with regard to the quality and thickness of
 CHAPTER 29  Orthobiologics in Foot and Ankle Applications 529

articular cartilage. As a result, the original ACI techniques that were Posttreatment Protocol for BMC or PRP Injection
developed for knee surgery may need to be modified to better suit After BMC injection, patients are instructed to rest the leg and
the foot and ankle. High-quality randomized controlled trials are minimize weight bearing. A boot brace and ambulatory aids
necessary in order to establish ACI as a treatment strategy that is (walker, crutches, knee scooter, or cane) are used. Surgical dress-
both successful and cost-effective for talar OCD. ings are kept in place until follow-up in 2 weeks. The patients are
given a small prescription for oxycodone and instructed to take
Clinical Applications acetaminophen to control their pain. After the 2 week follow-up,
Biologic therapies can be applied in both stand-alone percutane- patients are allowed to ambulate with or without the boot brace,
ous injection and surgical augmentation modes. The decision to according to tolerance, but advised to maintain minimal activity
choose injection rather than surgical implantation depends on until follow-up at 6 weeks.
many factors, notably the mechanism for dysfunction (inflamma-
tory versus mechanical), severity and acuity of injury or disease, Percutaneous Applications: Foot and Ankle
and healing capacity of the target tissue. The decision is also based Tendinopathy/Soft Tissue
on risk assessment and cost. In orthopedic disorders, biologics A growing body of peer-reviewed evidence is available regard-
have been used to target tendon, ligament, cartilage, bone, mus- ing use of PRP in tendon pathology. This includes the first Level
cle, meniscus, labrum (hip and knee), fascial tissue, and interver- 1 data generated from a study of PRP versus placebo in chronic
tebral disc. The decision to utilize allogeneic growth factors in the lateral epicondylitis, demonstrating significant and sustained
form of placental/amniotic material, PRP, BMC, SVF, or alloge- improvements at 2 years posttherapy.135 Results of published
neic cells versus expanded autologous cells in a specific indication clinical data have been mixed but suggest a general positive
has not been clearly elucidated. Clinical trends, based in part on trend toward efficacy in percutaneously delivered therapies for
published data and in part on anecdotal reports, have suggested treating soft-tissue pathology. Optimal volumes, periodicity of
that allogeneic growth factors or PRP may be a good first-line repeat interventions, and utility of adjunctive techniques like
choice in mild–moderate soft-tissue extra-articular applications, needle fenestration and postprocedure rehab protocols remain
whereas BMC or SVF may be a better option for more severe and largely undetermined.
chronic soft-tissue pathologies and intra-articular applications. Acute Versus Chronic Pathology. While commonalities
Expanded autogenous cells require two interventions: one for exist regarding origins of pain and dysfunction between
harvesting and one for implanting after expansion and may have acute and chronic pathologies, enough differentiators exist to
limited current usage for cartilage defects. Allogeneic cells do not consider different approaches from the perspective of biologic
require a surgical harvest like BMC or SVF but only provide one therapies. In acute conditions, disruption at the connective
cell type. They may have a potential role for more severe stages of tissue and cellular levels with associated rapid activation of the
disease or for situations where the patient’s own cells are inade- inflammatory cascade results in an effort to initiate repair. Thus,
quate due to systemic disease or exposure to certain medications. biologic approaches, depending on the tissue involved, should
focus on supporting and augmenting the natural processes set
Harvest of Bone Marrow Aspirate. in motion. Healing occurs in phases and application of healing
Bone marrow aspirate can be harvested from the anterior or pos- elements may augment more efficient progression through the
terior iliac crest. It can be also harvested from the proximal or healing phases, which sometimes can be overwhelmed by the
distal femur, proximal or distal tibia, or calcaneus. Typically, the injury severity, tissue disruption, and perfusion to the tissue
author, Lew C. Schon, MD, uses the following protocol to harvest involved. High cellularity in acute injury is typically present,
a high yield of cells from the anterior iliac crest. The crest is selected suggesting a potential role for acellular (indirect) approaches
as it has the proper cell density and volume and is relatively safe like PRP as initial therapeutic considerations.
to approach due to palpable landmarks. The patient is positioned With chronicity there is fibrosis, loss of intrinsic tissue integ-
supine on the operating room table. Anesthesia or sedation is rity, abnormal biomechanics, and typically chronic inflammation.
used. The lower extremity and pelvis are prepped and draped in Healing capacity and progression are halted with a subsequent
standard sterile fashion. The local area 3–7 cm proximal to the shift from healing to scaring. A theoretical biologic approach
anterior–superior iliac spine is blocked with 0.5% Marcaine and would look to re-initiate and amplify healing mechanisms, pro-
1% lidocaine without epinephrine. A 2 mm incision is made 3–4 viding the cellular and protein building blocks that are rendered
cm posterior to the anterior–superior iliac spine. The trocar tre- inaccessible to the damaged tissue due to fibrosis. Remodeling
phine device with a 2 mm central bore is inserted. Bone marrow of the tissue with re-establishment of perfusion and/or alterna-
is harvested in 5 mL aliquots via multiple trajectories from the tive supportive pathways to maintain integrity would reactivate
iliac crest. The obtained bone marrow is then concentrated for the healing process. Considering challenges with innate cellular
15 minutes using a specialized commercially available chamber migration to the pathologic tissue, cell-based biologic approaches
and centrifugation system (e.g., Spinesmith or Biomet). BMC is (direct, i.e., BMC) have therapeutic value in jump-starting local
then delivered back onto the surgical field and applied via injec- remodeling to treat chronic pathology.
tion to the site of disease. The iliac crest incision is irrigated. 4-0 Plantar Fasciitis. Plantar fasciitis (PF) is a challenging soft-
Monocryl is used to close the skin. A simple dressing is applied. tissue disorder, often suboptimally responsive to conservative
The patient is reversed from anesthesia and allowed to recover management. The location of the PF can be targeted
under monitored conditions. percutaneously by palpation or with imaging studies such as
530 SECTION 5  New Advances and Augmentations in the Foot and Ankle

fluoroscopy, MRI, and/or ultrasound. In acute or subacute the sural nerve, which is lateral to the tendon in the distal quarter
manifestations, PRP infiltration into the intra-substance of the of the leg and travels from a lateral position to a central posterior
PF near the insertion into inferomedial calcaneus represents position in the third quarter of the leg.
an early-intervention treatment option for a process that often For more chronic, postop, or scarred presentations, serial
becomes chronic and more refractory to treatment. Using a rounds of PRP spaced several months apart could be considered
22-gauge needle, 3–10 cc of injectate can be implanted at the versus BMC infiltration. Optimized post-implantation care and
insertion and just distal to insertion if pathology is noted to rehab protocols to augment the treatment have not been well
extend into this area. Often 3–6 punctures are made to cover established.137
a large area of fascia. Through one skin puncture, multiple When using BMC, after harvest and concentration, it is ster-
trajectories (4–6) into the affected tissues can be performed. ilely injected through five different punctures with 5–7 trajec-
After each needle withdrawal from the skin, a finger is used to tories per puncture in multiple directions, avoiding the sural
apply local pressure and avoid back flow of injectate. Care must nerve going from the medial side to posterior and to lateral
be taken not to penetrate the plantar fat pad in the area of weight along the zone of maximal tenderness, which is marked prior to
bearing. Also, avoiding the tibial nerve and its branches— surgery. The sites are manually compressed to minimize leaking
specifically the first branch of the lateral plantar nerve, the out of the BMC after injection. Postop minimal-weight-bearing
lateral plantar nerve, and the calcaneal nerves—is important to protocol is used for 2 weeks followed by protected activity for
decrease the risk of neuralgia or dysesthesias. Procedural and 2–6 weeks. The patient is instructed that the pain may be flared
postprocedural pain control is required for administration in an for 6 weeks following the injection.
outpatient setting. Smaller tendon and ligamentous pathologies involving foot
Considering the load-bearing nature of the structure, cau- and ankle are common, and include: peroneal tendons, anterior
tion is warranted with needle fenestration in addition to biologic tibialis, posterior tibialis, digital tendons, and medial and lateral
implantation. Thus, post-procedure, the patient is requested to collateral ligaments. Natural healing with standard conserva-
be nonweight bearing with use of cane, crutches, knee scooter, tive modalities can occur without intervention depending on
and/or brace. For more chronic, postop, or scarred presentations, the injury and chronicity. Those structures that are completely
serial rounds of PRP spaced several months apart could be con- disrupted or stretched beyond functional limits are not good
sidered versus BMC infiltration. Postop minimal-weight-bearing candidates for biologic treatments except as a supplement to
protocol is used for 2 weeks followed by protected activity for 2–6 surgical repair of reconstruction. A thorough history, physical,
weeks. The patient is instructed that the pain may be flared for and appropriate imaging studies are mandatory to determine
6 weeks following the injection. Optimized post-implantation the extent of tissue damage and the prognosis for recovery.
care and rehab protocols to augment the treatment have not been Studies suggesting efficacy of PRP applied via intra-tendinous
well established.136 injection reveal a potential role for PRP in pathology involving
Achilles Tendon. Achilles tendon pathologies are a common these structures.135 All these structures are relatively accessible and
but challenging problem to address with purely conservative are low-risk interventions when targeted with ultrasound-guided
measures. Research on PRP infiltration for chronic Achilles intervention and utilizing meticulous technique. Attention to
tendinopathy has yielded mixed results.137 Variability in clinical anatomical relationships with associated neurovascular structures
study protocols, including implantation and post-procedure and care to avoid needle trauma to such structures is notable to
care standpoint, further serve to complicate identifying a useful minimize potential for procedural complications.138
treatment protocol. From a clinical perspective, refractory Osteoarthritis. Limitations of valid therapeutic options for
nonsurgical Achilles pathologies are good candidates for arthritis remain a source of frustration for the musculoskeletal
application of biologics. Patients with elongated tendons from provider. Many factors including trauma and overuse result in
a missed rupture are not good candidates as they need surgical joint instability, tendon pathology, and abnormal biomechanics
tightening and or grafting with surgical reconstructions. that contribute to the development of the condition. Treatment
Consistent with general approaches to subacute versus chronic options to alter the course of the disease process have been
tendon conditions, for subacute problems, allogeneic growth fac- limited, and mostly involve surgical reconstruction to improve
tors or PRP are easy to use and have a low potential for harm, alignment, stability, and tendon function. Debridement of
making them reasonable options with ultrasound guidance and arthritic lesions with or without application of orthobiologic
intra-substance placement. Considering the size and tension-bear- materials (BMC, PRP, bone grafts, chondrocytes, synthetics) is
ing nature of the structure, the authors suggest using a 22- or being studied. Ultimately joint replacement or fusion may be
25-gauge needle for penetrating the tendon. The authors also rec- the only alternatives.
ommend placement of multiple small aliquots of injectate at the It has been suggested that intra-articular and/or subchon-
borders and within the region of injury/pathology, as opposed to dral applications of biologic therapeutics represent potential
a single higher-volume injection through a single needle, creat- options as both a stand-alone treatment and an adjunct to sur-
ing a fluid void and raising concern for excessive intra-substance gery. There are limited published data for such applications per-
pressure. Special mention is made to consider co-treatment of the taining to treating OA in joints of the foot and ankle. Limited,
retrocalcaneal bursa, which often becomes inflamed and fibrotic, small-scaled studies have suggested potential utility of PRP and
in combination with chronic morbidity of the tendon. Using a BMC for intra-articular pathology, mostly involving hip and
medial approach to the tendon avoids inadvertent penetration of knee joints.139
 CHAPTER 29  Orthobiologics in Foot and Ankle Applications 531

Intra-articular injection of HA for ankle OA has been inves- For application at point of care, there are arthroscopic and open
tigated in small cohorts, using varied protocols and follow-up, uses. In arthroscopic procedures, following completion, excess
and demonstrated contradictory results.103,140 arthroscopy fluid is drained from the joint and the portals are
There are applications of intra-articular injection of HA closed. The biologic preparation is infiltrated once closure is
for OCD of the talus.114,115 In general, HA improved the ankle complete to avoid egress of the fluid. In an open procedure, the
function, as assessed with the American Orthopaedic Foot biologic preparation can be infiltrated into target tissue during
and Ankle Society’s Ankle-Hindfoot Scale, and relieved pain, or following repair. Biologic preparations can be converted into
as measured with VAS scores. However, there was no direct or an autologous fibrin matrix by reversing anticoagulation in the
indirect evidence that HA facilitated the healing of OCD lesion. sample for physical implantation or infiltrating the final prepa-
Treatments may have an effect by stabilizing chondral lesions, ration into target tissue by bathing or injecting in and around
treating subchondral bone reaction or on the synovium. the repair, debridement, and/or implant. The material can also
Techniques of intra-articular injection have been described.141 be combined with a demineralized bone graft or with a syn-
The tibiotalar joint is accessible via palpation, ultrasonographic, thetic calcium carrier and placed into a defect or zone of desired
or fluoroscopic approaches. The author, Lew C. Schon, MD, union in the bone or soft tissue.
accesses the ankle joint via a medial approach in the Hardy notch, Some physicians prefer application percutaneously following
medial to the anterior tibial tendon. The author, David Karli, MD, surgical closure with a lag time to allow the immediate postop
uses an anterior approach, medial or lateral to the dorsalis pedis environment to stabilize. Some surgeons are electing to wait days
artery and nerve bundle. A 22- or 25-gauge needle can be advanced to weeks following surgical repair to deliver biologic prepara-
through the joint capsule into the anterior joint recess, maintain- tions in an effort to optimize the potential stimulation and effect.
ing care to avoid any direct needle trauma to the articular surfaces. Two primary rationales drive this preference. Residual joint fluid
Typical volume of PRP or BMC infiltrated into the joint is 5–12 mL. immediately following arthroscopy may dilute the potency/con-
Subchondral applications of BMC for more advanced degen- centration of the biologic in the treatment site. There is already
erative OA, particularly with evidence of bony edematous a good deal of anabolic stimulation in a freshly repaired or
changes or erosion noted on radiographic workup is under debrided tissue. To prolong that stimulation, the biologic can be
study as an alternative to, or in conjunction with, intra-artic- implanted at a later date. The optimal timing of a biologic appli-
ular implantation. This intraosseous injection is performed in cation following surgical intervention has yet to be determined.
the operating room. Injection of calcium phosphate can also be It is also unclear if a single application or serial applications cre-
performed for these lesions in the operating room (see Section: ates the greatest potential for tissue healing in a surgical setting.
Treatment Option for the Management of Chronic Bone More research is needed to optimize this strategy.
Marrow Lesions with Calcium Triphosphate).
The subtalar joint can be accessed via lateral oblique Soft-Tissue Repair: Potential Applications.
approach through the sinus tarsi, or less commonly posteriorly, Three options exist for a soft-tissue repair. In the first option, the
lateral to the Achilles tendon. The joint is irregular and typically repair can be bathed with a biologic preparation at the time of
can hold 4–10 mL of a biologic preparation. repair. With the second option, the biologic can be injected into the
The talonavicular (TN) joint is narrow and low volume but repair prior to or at closure (the author, Lew C. Schon, MD, prefers
can be accessed via a medial approach by palpating the navic- method). Finally, the implant can be used with an activated biologic
ular and injecting proximally in to the depression that exists at (requires reversal of anticoagulation of the biologic preparation at
the TN joint with a small (25-G) needle. Ultrasound or fluoro- implantation) into the tissue at the time of repair. These techniques
scopic guidance is recommended. Target volumes typically are can be used for repair, debridement, or reconstruction of the ten-
limited to 3–6 mL. dons (peroneal, Achilles, posterior/anterior tibial tendons) or with
The metatarsal cunieform (MTC) joints can be injected via a medial or lateral ligamentous repair or reconstruction.
dorsal approach adjacent to tendons and nerves. Ultrasound or
x-ray guidance can be helpful, and 3–6 mL of injectate can be Chondral/Subchondral Application.
administered. The intent of the chondral/subchondral application is to
The first MTP joint can be accessed via guided dorsal approach increase longevity of the cartilage repair, prevent progression of
adjacent to the extensor hallucis longus tendon with a small gauge the degenerative process, increase aggrecan content, stimulate
needle. Small injectates of 0.5–2 mL can be accommodated. chondrogenesis, and minimize formation of fibrocartilage with
microfracture, with osteoarticular transfer system procedures,
Surgical Implantation. with allograft tissue, or in association with scaffold applications.
From a surgical perspective, potential benefits of biologics The addition of BMC to bone marrow stimulation techniques
would be in promoting efficient and complete tissue recov- (BMS) such as microfracture showed superiority over BMS
ery following surgical repair, control of inflammation postop, alone.143 In general, there are beneficial outcomes for biologic
recruitment of progenitor cells and macrophages to the oper- and BMS treatment of moderately sized chondral defects with-
ative site, angiogenesis, hemostasis, and, with the exception out any reports of serious complications. Rates of return to
of leukocyte reduced PRP, potential for antibacterial effect.142 high-level activity and MRI documentation of good filling of
Timing of application related to surgical augmentation is still cartilage defects have been described.144 Favorable outcomes in
not well defined, with two strategies utilized in the field to date. short- to medium-term reports for BMC-augmented treatment
532 SECTION 5  New Advances and Augmentations in the Foot and Ankle

of knee OA have been published.145 Ilas et  al. have described care, and radiographs are not explanatory of the clinical situa-
subchondral implantation of BMC for percutaneous treatment tion, a diagnostic MRI is felt appropriate. As opposed to standard
modeling in cartilage degeneration.146 At the time of surgery, radiographs, an MRI can assess soft-tissue injury, can quantitate
the biologic can be mixed with autograft, allograft, synthetics, inflammation, and can demonstrate bone injury including BMLs.
or collagen carriers and packed into the lesion. Another option While these BMLs may be juxta-articular and associated with
is to inject the biologic into the joint once the wound is closed. arthritis, many are intraosseous and result from stress/overuse,
Fusion, Fracture, or Nonunion Augmentation. Any fusion of osteochondral lesions, and direct trauma with bony contusion.
the foot and ankle can be supplemented with biologics.147 Also,
high-risk fractures or nonunions can be repaired or reconstructed Interpreting the MRI and Bone Marrow Lesions
with augmentation by biologics. At the time of surgery, the A BML is best visualized on fat-suppressed MRI sequences, often
biologic can be mixed with autograft, allograft, synthetics, or labeled as T2, and appears as a white hazy signal (Fig. 29.1).
collagen carriers and packed in and around the fusion site. Radiologists may refer to a BML as an “osteochondral frac-
Another option is to inject the biologic into and around the site ture,” “subchondral fracture,” “stress fracture or reaction,” “insuf-
once the wound is closed. In some cases where there is good ficiency fracture,” “microtrabecular fracture,” or “bone edema.”
alignment and stability of the fracture or nonunion, percutaneous Histopathologists have identified the white signal apparent on an
treatment may be considered. Hernigou treated stable nonunions MRI as the body’s response to a trabecular fracture. Numerous
of the tibia successfully with percutaneous BMC treatment.148 histopathologic, morphologic, and histochemical investigations
of bone marrow lesions have been published. This research has
TREATMENT OPTION FOR THE MANAGEMENT consistently demonstrated that subchondral bone in the region
OF CHRONIC BONE MARROW LESIONS WITH of a chronic BML is substantially altered from healthy, normal
subchondral bone. When analyzed, subchondral bone affected
CALCIUM TRIPHOSPHATE by the BML demonstrates areas of trabecular compromise
The use of intraosseous-injected calcium triphosphate is per- with fracture, bone marrow necrosis, and osteoblastic activity
formed for the treatment of patients with chronic trabecular consistent with attempted fracture healing and regions where
fractures (bone marrow lesions [BML]). The term “subchon- subchondral bone has been replaced by non-osseous elements
droplasty” is a company trade name (Zimmer Biomet, Warsaw, reflecting nonhealing of bone fracture.149–151
Indiana) applied to a procedure which has been in use for sev- Replacement of normal subchondral bone with nonosseous
eral years. It was originally developed for patients with OA bone essentially creates a bone void region, structurally compro-
of the knee, where there is scientific literature to support the mises the support of that bone, and may lead to an environment in
association of pain from OA and bone marrow “edema” as seen which normal subchondral bone will not spontaneously replace
on MRI. However, the diagnosis and treatment principles sur- nonosseous tissue. Burr et al. explained that BMLs involve high
rounding this technique have been around for decades and can bone turnover, microcracks, and increased bone mineral density
now be applied to a variety of entities outside the knee. The similar in appearance to that seen with a fracture nonunion.152
procedure consists of core decompression and the insertion of
an injectable hard-setting bone substitute material (calcium tri-
phosphate) as internal fixation to treat BMLs in the subchondral
bone. The material injected needs to be fairly viscous, as many
of these lesions are not cystic in character. The application is
analogous to the vertebroplasty/kyphoplasty philosophy and
techniques of the compromised vertebral body of the lumbar
spine. This approach provides an effective, minimally invasive
option for the clinical management of chronic, painful BMLs as
an alternative to more invasive techniques, thus attractive to the
athlete with performance-limiting issues yet time constraints.

Patient Presentation/Indications
The typical patient may be an athletic individual who presents
with localized pain in the foot or ankle of greater than three-
month duration. Their symptoms have failed to improve with
rest, antiinflammatory pain medications, and activity modifica-
tion. Their function is limited with compromise of athletic activ-
ity involvement and performance. The initial evaluation and
physical examination are often unremarkable, specifically with-
out soft-tissue abnormalities, restricted motion, or instability.
Radiographs of the affected area often fail to demonstrate
any obvious fracture or joint disorder and are generally inter-
preted as normal. In this situation where significant symptoms Fig. 29.1 Sagittal T2-weighted MRI image of a foot, highlighting the
and dysfunction have persisted despite extensive nonoperative bone marrow abnormality in the talar body.
 CHAPTER 29  Orthobiologics in Foot and Ankle Applications 533

As mentioned previously, chronic BMLs can occur with direct underlying pain given the lack of pain fibers in those structures.
trauma or in association with excessive stress or adjacent joint Extrapolating from Cicuttini and the knee literature, a study of
deterioration. Focal joint injury, as seen with articular carti- 250 patients (500 knees) found that “the presence or absence
lage damage and thinning, often in association with ligament of joint space narrowing…was not significantly associated with
injury with instability, can increase and focalize stress on the knee pain.”155 This finding was confirmed by Hunter et al., who
joint articular surface and create underlying bone compromise in a review of 243 papers for OA biomarkers found that pain
with inflammation. Chronic, increased stress on the subchon- is strongly related to the large bone marrow lesions, moder-
dral bone may lead to microfractures and, in response, increased ately related to synovitis and effusion, and only weakly related
bone healing activity. When this stress exceeds the patient’s abil- to cartilage volume and thickness.156 The correlation between
ity to repair the resulting damage, a chronic BML results and the patient’s pain and the presence of BMLs has been shown in
is indicative of a stress reaction or fracture, with insufficiency several large studies as highlighted in Table 29.1. There has been
of the bone. Quoting Erekson et al., “bone marrow lesions have similar support in the foot and ankle literature.157–160
been demonstrated in a wide variety of lesions in bone, but the Zanetti states that the edema-like bone marrow abnormali-
common denominator for these conditions is some kind of ties of the foot are clinically relevant and predictive of long-last-
injury to the bone and bone marrow through mechanical stress, ing pain. Similarly, Rios and his colleagues found that the
inflammation, or ischemia. A common denominator for these painful BMLs seen in the foot and ankle are secondary to bone
lesions seems to be cortical or trabecular bone defects or micro- impaction or contusion and related to trabecular microfractures
trauma.”153 An important distinction is that these bone lesions of or reaction after stress.
the athlete are unrelated to osteoporosis. Both Burr and Lo have
described the body’s response to the damaged area as “thicken- Managing the Chronic (Nonhealing) Bone Marrow
ing” and actually creating more bone density.152,154 Lesion of the Foot and Ankle
Some BMLs, particularly in the younger athletic population who
Clinical Effect of Bone Marrow Lesions have joints with little deterioration or chondral loss, may heal
Numerous large-scale MRI studies have greatly contributed to with nonsurgical intervention. However, the BMLs that persist
knowledge of the significance of BMLs and their relationship to greater than 6 months and remain painful with functional lim-
progressive bone and joint issues. Significantly, the presence of a itation may be candidates for a subchondroplasty procedure.
BML has been shown to be highly predictive of patient-reported There are numerous applications for the procedure in the foot
pain. While synovitis or cartilage loss may be present in a patient and ankle. Most common are bone marrow lesions of the talus,
with chronic BMLs, those conditions are not the cause of the underlying an osteochondral defect or abnormality. There may

TABLE 29.1  Studies Correlating Bone Marrow Lesions (BML) and Pain
Authors No. of Patients Results Conclusions
Felson et al.164 401 (351 with pain, 50 without pain) BML found in 77.5% of patients with pain; “Bone Marrow Lesions on MRI are strongly associ-
BML found in 30% of patients with no pain ated with the presence of pain in knee OA.”
Felson et al.165 330 (110 case; 220 control) 49.1% of case patients showed an increase in “Development of knee pain is associated with an
Case – initially no pain progressed BML score compared to 26.8% of control increase in BML as revealed on MRI.”
to pain Control – initially no pain
Hayes et al.166 117 women (232 knees) Large BML lesions were common in the pain “In middle‐aged women, there were significant
and OA of the knee group; this group was associations between pain, radiographic severity of
significantly more likely to have defects OA of the knee, and seven MR imaging–identified
of cartilage, meniscal tears, osteophytes, parameters [including BML].”
subchondral cysts, sclerosis, joint effusion,
and synovitis
Zhai et al.167 500 adults (239 with knee pain) Prevalent knee pain was significantly associ- “Knee pain in older adults is independently associated
ated with…bone marrow lesions (OR 1.44, with both full and non–full‐ thickness medial tibial
95% CI; 1.04–2.00 per compartment) chondral defects, bone marrow lesions, greater
BMI, and lower knee extension strength, but is not
associated with radiographic knee OA.”
Sowers et al.168 363 patients (724 knees) The prevalence of bone marrow lesions in the “Large bone marrow lesions in the medial femoral
medial, lateral, and patellofemoral compart- condyle or the medial or lateral plateau were
ments were 21.3% (154 knees), associated with substantially increased odds of
13.4% (97 knees), and 45.4% (329 knees), reported pain”
respectively. “BML in medial compartments was associated with
The Kellgren‐Lawrence scores were highly ‘marked decreases in walking and stair‐climbing
correlated with bone marrow lesions in the performance.’”
medial femoral and tibial compartments
Zhang et al.169 1042 patients “The resolution of knee pain was associated with
shrinkage or resolution of bone marrow lesions.”
534 SECTION 5  New Advances and Augmentations in the Foot and Ankle

or may not be a cystic component to the lesion. These lesions are response and carry the same properties as natural trabecular
often situated in the medial quadrant of the talus and accessible bone.163 The theory is that it will stabilize the area of the microf-
from an entry point in the lateral talar process. (Fig. 29.2) racture, providing fairly rapid pain relief and also will eventually
Perhaps the most intriguing role for this procedure is a recal- remodel into host bone to heal the lesion or defect.
citrant stress reaction or fracture of the cuboid or cuneiform in
which there have been very few options for treatment. In this Technique
scenario, a surgeon can utilize this technique to provide a bio- The subchondroplasty® procedure is a minimally invasive sur-
logic internal fixation to stabilize and heal the microtrabecular gery performed on an outpatient basis that accesses and fills
fracture evident by the BML. While a formal open internal fix- chronic subchondral defects, intraosseous lesions, and other
ation procedure with plate and screws has been described as an symptomatic bone marrow lesions. While this procedure can
option for these recalcitrant stress fractures and reactions, it is be used to address cystic lesions of the foot and ankle, the BMLs
a more invasive technique than necessary for a microtrabecular are often noncystic, and therefore a viscous form of the inject-
fracture that is often without cortical compromise161 (Fig. 29.3). able mineral is paramount. During the procedure, the surgeon
The idea of injecting a bone graft substitute to strengthen will rely heavily on fluoroscopy, arthroscopy, and mini-open
compromised bone is not new. Russell et  al. in a prospective, techniques to target a small, drillable cannula (11- or 15-gauge)
randomized trial of 119 subjects showed the effectiveness and into the area of the bony concern as seen on the MRI. Both T1-
healing capabilities of using a hard-setting calcium phosphate and T2-weighted images assist with precise targeting, utilizing
bone filler to treat tibial plateau fractures with superior results axial/coronal/sagittal views. The limb being addressed is placed
compared with autograft.162 The product described by Russell on a bump or blanket elevation to assist with clear intraoper-
was enhanced and developed into one that could be injected ative fluoroscopic imaging. Care is taken to avoid numerous
with flow into trabecular bone canals, leaving the cortical shell errant passes into the lesion, or more than one cortical entry
intact. Ideally, the material should set hard via an endothermic site, as appropriate filling is compromised, and extravasation

A B

C D
Fig. 29.2  T2-weighted MRI, (A) coronal and (B) sagittal images noting an osteochondral lesion in the medial
talar dome. Intraoperative fluoroscopic (C) anterior-posterior and (D) lateral views of the ankle illustrating the
placement of the drilling trochar into the talar lesion, entering from the lateral talus.
 CHAPTER 29  Orthobiologics in Foot and Ankle Applications 535

may occur. Following the core decompression, the surgeon disorders, or concurrent surgical procedures such as arthros-
will deliver a precise amount of the bone graft substitute into copy. In general, nonweight bearing is instituted until the
the lesion where it hardens endothermically to a material with pain associated with the procedure dissipates. This averages
properties that mimic cancellous bone. The material is radi- 48 hours. In the case of a stable stress reaction, patients may
opaque and can often be seen on the fluoroscan imaging. As bear weight by 2–3 days and return to sport in 10–14 days, as
mentioned previously, the calcium phosphate used is eventu- symptoms allow. X-rays and CT may be used to follow bone
ally resorbed and is replaced with new bone, a process that may healing. Postoperative MRIs are not helpful given the artifact
require 2–3 years depending on the bone injected. In theory, produced by the calcium phosphate material injected. Given
the body recognizes the material as normal bone and replaces it that it takes 2–3 years for bone turnover and remodeling to
with new bone through a cell-mediated remodeling process.163 occur, the MRI may remain difficult to interpret for some
While this is a minimally invasive procedure with an expected time.
low risk of complications and a short postoperative recovery Chronic BMLs can arise from a number of etiologies in the
period, it is important that the surgeon appreciates the location foot and ankle and are often a source of debilitating pain in the
of neighboring neurovascular structures and minimizes extrava- athlete, affecting his or her performance. Athletes can suffer
sation into any adjacent joint or soft tissues. When extravasation from chronic stress reactions and fractures, as well as periartic-
is recognized, the material can be fully irrigated and removed via ular bone lesions associated with chondral loss for which there
arthroscopy or direct access. Most important is to not inject an are few treatment options available. The literature supports the
excessive amount of material into the lesion or bone itself. Most idea that many of these lesions identified on MRI result from a
lesions of the foot and ankle only require 0.5–1.5 cc of volume, trabecular fracture in varying stages, and often prior to cortical
depending on the size of the bone and the lesion itself. Excessive disruption. In orthopaedics, the standard for bone fractures is to
filling of the bone may lead to trabecular congestion and vascu- stabilize and create a biologic environment conducive for heal-
lar compromise, and subsequent avascular necrosis. One bone of ing. A subchondroplasty procedure employing the placement of
obvious concern is the navicular, where this procedure may be an injectable, hard-setting calcium phosphate into the BML pro-
contraindicated due to its already tenuous blood supply. vides a minimally invasive, joint preserving, and clinically ben-
Postoperative management is dependent on the location eficial treatment for patients who fail to heal with nonoperative
of the BML undergoing the injection technique, associated means.

A B

C D
Fig. 29.3  (A) Sagittal T2 MRI image of the foot of a 23-year-old athlete with chronic lateral midfoot pain. Bone
marrow lesions are noted in the cuboid and consistent with a stress reaction. Intraoperative fluoroscopic (B)
anterior-posterior and (C) lateral images noting placement of the cannulated trochar into the cuboid. (D) Standing
anterior-posterior radiograph performed 4 weeks after injection of 1 cc of calcium phosphate into the cuboid.
536 SECTION 5  New Advances and Augmentations in the Foot and Ankle

FUTURE DIRECTIONS 2. Murphy MB, Moncivais K, Caplan AI. Mesenchymal stem cells:
environmentally responsive therapeutics for regenerative medi-
Building on the platform of quantitatively controlled biolog- cine. Exp Mol Med. 2013;45:e54.
ics creates opportunity to further understand the science and 3. Caplan AI. Mesenchymal stem cells: time to change the name!.
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5. Caplan AI. All MSCs are pericytes?. Cell Stem Cell. 2008;3(3): 229–30.
sitions specific to indication and individual represents a logi-
6. Caplan AI. New era of cell-based orthopedic therapies. Tissue
cal progression of the field by characterizing and quantifying Eng Part B Rev. 2009;15(2):195–200.
biologic preparations to establish dose–response trends from 7. Devana SK, Kelley BV, McBride OJ, et al. Adipose-derived
which validation can occur. Standards and training pathways for human perivascular stem cells may improve Achilles tendon
best-practice techniques for biologic implantation in both sur- healing in rats. Clin Orthop Relat Res. 2018;476(10):2091–2100.
gical and percutaneous applications are limited. Opportunity in 8. Bragdon BC, Bahney CS. Origin of reparative stem cells in frac-
residency and fellowship training programs are sparse, creating ture healing. Curr Osteoporos Rep. 2018;16(4):490–503.
the need for formal resources within industry and academia to 9. Konig MA, Canepa DD, Cadosch D, et al. Direct transplantation of
fill this void to frame the basis of best-practice strategies. native pericytes from adipose tissue: a new perspective to stimulate
In addition, establishing patient screening methods to aid in healing in critical size bone defects. Cytotherapy. 2016;18(1):41–52.
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on patient counseling, treatment decision making, and customiza-
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evant parameters with the potential for predictive value. one-stage cartilage cell transplantation: a first-in-man trial in 35
In the future, we may see the integration of synthetic or bio- patients. Stem Cells. 2017;35(8):1984–1993.
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113. Munteanu SE, Zammit GV, Menz HB, et al. Effectiveness of in- 132. Pagliazzi G, Vannini F, Battaglia M, Ramponi L, Buda R. Autologous
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The use of percutaneous autologous bone marrow transplanta- 167. Zhai G, Blizzard L, Srikanth V, et al. Correlates of knee pain in
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Skeletal Radiol. 2008;37(5):423–431. 169. Zhang Y, Nevitt M, Niu J, et al. Fluctuation of knee pain and
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and histologic findings. Radiology. 2000;215(3):835–840. 170. Adams SB, Thorpe MA, Parks BG, et al. Stem cell-bearing suture
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30
Rehabilitation of Specific
Foot and Ankle Issues
Norman E. Waldrop, Kenneth Sanders Smith, Jr.

OUTLINE
Introduction, 542 Phase I, 547
Protection, Rest, ICE, Compression, and Elevation, 542 Phase II, 547
Range of Motion/Mobilization, 543 Phase III, 547
Protected Weight Bearing, 544 Rehabilitation of Achilles Tendon Repair, 548
Gait Evaluation, 545 Rehabilitation After Lateral Ankle Reconstruction, 549
Strengthening, 545 Rehabilitation of High Ankle Sprains (Syndesmosis
Proprioception, 546 ­Injuries), 550
Cardiovascular Activities, 546 Rehabilitation of Ankle Fractures, 551
Functional Progression, 546 Conclusion, 552
Phases of Rehabilitation, 547

competitive athlete. The principles of rehabilitation must con-

INTRODUCTION tinue to develop with the continuing advances made through
Injuries to the foot and ankle are some of the most common improving technologies. An appropriate and advanced reha-
injuries in sport. These injuries can significantly affect the bilitation can provide the athlete with a full, complete, and
performance of an athlete and can often lead to disability and functional recovery.
missed playing time. In a series of over 1600 athletic inju-
ries, Garrick and Requa reported that more than 25% of the PROTECTION, REST, ICE, COMPRESSION,
injuries occurred in the foot and ankle.1 More recently, Hunt
et al. reported on over 3800 musculoskeletal injuries in NCAA
AND ELEVATION
Division 1 athletics. Foot and ankle injuries made up 27% of Initial treatment of acute foot and ankle injuries and postop-
those injuries, with over one-fifth of those resulting in time erative pain remains protection, rest, ice, compression, and
loss from sport. The average length of time missed was over elevation (PRICE) therapy despite any high-quality evidence
12 days.2 These injuries are some of the most common inju- that it works better than placebo.8 Protection involves any inter-
ries leading to time loss in sport.3-7 This missed time has led vention aiming to prevent re-injury to the foot and ankle. Rest
to advances in rehabilitation over the past 20 years aimed at involves offloading the affected area to decrease the stress on the
reducing injury time, improving outcomes, and preventing the injured tissues. Ice, compression, and elevation are all methods
injuries from becoming chronic. to control edema and pain.
Athletes provide unique challenges in rehabilitation because There are many common devices to aid in the protection of
of the significant demands required to participate in sports. the healing tissues about the foot and ankle. These consist of
The foot and ankle are especially vulnerable to these demands. elastic wrapping, taping/strapping, semi-rigid pneumatic ankle
It serves as the connection of the body to the weight-bearing brace, non-rigid functional ankle brace, and the author’s pre-
surface. As a result, the foot and ankle are designed to allow ferred method, a removable walking boot (Fig. 30.1). The device
efficient energy expenditure in both stance and locomotion. allows patients to weight bear immediately, work on range of
The foot and ankle are a small area of the body with special- motion (ROM) by removing the boot, and use a continuous
ized function and intricate muscle, tendon, ligament, and cold/compression device. Once the ankle has healed, a more
bone interactions designed to meet the strenuous demands functional brace is used for return to activity (2–4 weeks after
of weight bearing and ambulation. Recent technologic and injury). We particularly stress the use of the boot at night for
procedural advances contribute greatly to the treatment of the the first 3 to 4 weeks to keep the foot and ankle complex in a

542
 CHAPTER 30  Rehabilitation of Specific Foot and Ankle Issues 543

Fig. 30.1  Walking Boots of various sizes and types.

90-degree dorsiflexion position during sleep, when the relax-

ation of muscular control and the forces on the heel passively Fig. 30.2  Cold compression device for swelling control.
place the complex in a plantar-flexed and inverted position. The
rigid boot counteracts this position.
There are several cold agents to choose from, including the Likewise, Thordarson et al. showed a 60 mL reduction in total
reusable cold pack, ice bags, cold whirlpool, ice immersion, and foot and ankle volume when using a similar compression device
pneumatic cold compressive devices (Fig. 30.2). The primary compared to standard splint immobilization prior to surgery
objective of ice is to reduce swelling and help manage pain. for displaced Weber B and C fibula fractures.20 In our experi-
Physiologically, cryotherapy acts through several mechanisms ence, we have found cold compressive devices for the ankle and
of action. The application of cold agents results in arteriolar foot to be most effective, as they combine the positive benefits
vasoconstriction, thus decreasing local metabolism, oxygen uti- of cryotherapy and compression simultaneously. These devices
lization, and inflammation.9 Applying an ice pack to the knee work even better when used in conjunction with elevation to
for 20 minutes has been shown to decrease soft tissue blood reduce hydrostatic pressure and diminish edema.
flow 26% and bone uptake (reflecting changes in blood flow A contraindication to cryotherapy is individuals with hyper-
and metabolism) 19%.10 It has been found that cold therapy sensitivity to cold. Cold should be avoided in patients with
increases the pain threshold while decreasing the nerve conduc- Raynaud’s syndrome or peripheral vascular disease. Cold ther-
tion velocity.11 Further, as the temperature decreases, there is apy also must be monitored closely in postoperative patients
a corresponding decrease in sensory and motor nerve velocity, who have wet dressings because the combination of wet dress-
eventually causing synaptic transmission to be blocked.12 ings with cold application can decrease the skin temperature to
Cryotherapy has been validated as an effective analgesic in a dangerous level. There have been case reports of severe frost-
many surgical fields including plastic surgery,13 otolaryngol- bite occurring due to prolonged cryotherapy.21
ogy,14 obstetrics and gynecology,15 and maxillofacial surgery.16
The application of cold is most effective immediately after injury.
Hocutt et al. found that patients with grade III ankle sprains that
RANGE OF MOTION/MOBILIZATION
were treated with ice in the first day returned to functional activ- There has long been a rehabilitation dilemma between the need
ities such as running and jumping after 6 days, whereas those for early ROM and the need to immobilize tissues to decrease
treated on the second day went 11 days before they could run swelling, allow the injured tissues to heal, and protect against
or jump.17 In contrast, those who received heat in the first day pathologic motion. There has been ongoing research across all
had a recovery time of 14.8 days. Cote et al. showed that cold sections of orthopedics that promote the idea that early mobili-
therapy alone in the first 3 days after a severe ankle sprain lim- zation is best for most injuries. For example, early mobilization
ited the foot and ankle swelling to a 3.3 mL increase in volume has been shown to have earlier return to work and better ROM
versus a 25.3 mL increase seen when heat therapy was used.18 when compared to splint immobilization for simple elbow dis-
In addition to ice therapy, compression devices have been locations.22 Another randomized controlled trial reported no
shown to be effective tools for edema control. Myerson et  al. increased risk of dislocation with improved pain scores, faster
showed a 50% reduction in edema in both the acutely swol- return of functional ROM, and increased patient satisfaction
len and chronically swollen ankle when using an intermittent with accelerated rehabilitation following arthroscopic Bankart
pneumatic device versus a control device daily for one month.19 repair of the shoulder.23
544 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration and Teamwork

In 1892, Julius Wolff, a German anatomist, explained that significantly less tendo-Achilles lengthening and quicker return
every change in the function of a bone is followed by certain to full running than patients with traditional immobilization.37
definite changes in internal architecture and external confirma- Another study found that early ROM after anterior talofibular
tion in accordance with mathematical laws. Stated simply, “form ligament reconstruction for chronic ankle instability led to a
follows function.” Wolff ’s law also may apply to these soft tissues, 5-week earlier return to full athletic activity when compared to
and physiologic stress may allow more functional and stronger a 4-week period of immobilization with no cases of re-injury or
healing of soft tissues. Experimental studies of ligaments after differences in postoperative outcomes.38 These and other stud-
injury indicate that exercise and joint motion stimulate healing ies have led us to adopt early ROM as a staple in the post-injury
and influence the strength of ligaments after injury.24-28 In addi- and post-surgical management of almost all foot and ankle
tion, it has been shown in animal models that complete removal pathologies.
of load is detrimental to rotator cuff tendon healing, especially
when combined with immobilization.29
Some of the early research on restoration of early ROM was
PROTECTED WEIGHT BEARING
performed in the hand. These historical papers revealed insight Early protected weight bearing has been shown in several
on how early ROM decreases complications and enhances the well-conducted studies to provide excellent clinical outcomes
healing process. Early mobilization may result in an earlier without an increased rate of complications. One randomized
return to work and daily activity, less muscle atrophy, and better controlled trial showed improved patient reported outcomes
mobility compared with immobilization by casting.27,30,31 The and ankle ROM with weight bearing begun at 2 weeks post-
value and benefit of early motion was investigated after flexor operatively versus the control group (6 weeks of nonweight
tendon repairs of the hand. The obvious need for full motion in bearing, NWB) for operatively treated unstable ankle frac-
the hand prompted investigation into safe rehabilitation prac- tures.39 Another study found no increased rates of rerupture
tices, which would eliminate postoperative adhesions and stiff- or other complication with same-day weight bearing versus
ness but still allow reliable healing of the tendon. Gelberman 4 weeks of NWB for conservatively treated Achilles tendon
et al. noted an improved healing response, improved strength, ruptures.40
and a more normal pattern of vascularity to the healing tendon Recent investigations have published promising results
with protected early mobilization.32,33 Several other studies also with early weight bearing after procedures that have long been
noted that early ROM decreased adhesions around the repaired thought to require long periods of NWB. Mann et al. reported
tendon and had a positive influence to the healing tissue.34 Early a >95% fusion rate in 21 first metatarsophalangeal joint fusions
motion after flexor tendon repair has become standard today. using a titanium plate and full weight bearing at 2 weeks.41
Robert Salter and associates investigated the effect of joint Another study showed no increased rate of nonunion with early
motion on cartilage nutrition. They found that early, continuous full weight bearing in a multicenter study of 367 patients under-
passive motion in synovial joints promotes cartilage nutrition going a modified Lapidus arthrodesis.42
and health.35 Salter demonstrated that small cartilage defects Weightlessness, as seen in space travel, has been shown to
could heal with continuous motion, further supporting the have a detrimental effect on muscle. Costill et al. reported that a
benefit of motion on articular cartilage nutrition and healing. 17-day space flight resulted in an 11% decrease in peak muscle
Joint motion produces mechanical signals that are perceived by power, a decrease in muscle fiber diameter, and a 21% decrease
chondrocytes that in turn influence and stabilize the internal in force when the muscle was contracted at peak power veloc-
cartilage structure and prevent the cartilage thinning seen with ity.43 The single fiber muscle diameter decreased 20%. This
prolonged immobilization.36 research helps us understand the atrophy and deconditioning
Eiff et al. used a prospective randomized study to determine that occurs in our patients when they are made to be NWB for
which treatment for first-time ankle sprains, early mobiliza- periods much longer than 17 days after certain procedures or
tion or immobilization, is more effective. They reported that, injuries.
in first-time lateral ankle sprains, early mobilization allows ear- We favor a postoperative protocol that allows for early weight
lier return to work and may be more comfortable for patients bearing whenever possible. We recognize there are times when
than prolonged immobilization.30 Both active and passive ROM this is not possible, such as comminuted intra-articular frac-
are utilized to regain motion in cardinal and diagonal planes. tures. However, in the sports population, early weight bearing
Passive ROM allows the muscles to relax while active ROM can have such a positive impact that we try to tailor our surgical
requires independent muscle action and incorporates muscle and nonoperative approach to allow early protected weight bear-
re-education. It is important to first work ROM in the direction ing. Research suggests that early loading of damaged soft tissue
opposite of the mechanism of injury (i.e., we allow dorsiflexion can enhance collagen fiber realignment and healing.26,27,28,44,45
and eversion and avoid plantarflexion and inversion initially Using a removable walking boot allows the patient to progress
after a grade II or III lateral ankle sprain). Once the injury has to weight bearing immediately after injury. Being in a walking
healed, ROM should include all directions. boot instead of an ankle cast allows the patient to take the boot
Several recent publications have shown promising clinical off to begin rehabilitation activities.
results with accelerated rehabilitation protocols. One random- In the instances where immediate weight bearing is not
ized controlled trial showed that patients undergoing an accel- feasible, we are using an antigravity treadmill (AlterG®) to aid
erated rehabilitation protocol after Achilles tendon repair had in rehabilitation (Fig. 30.3). The antigravity treadmill allows
 CHAPTER 30  Rehabilitation of Specific Foot and Ankle Issues 545

prevent abnormal gait habits from becoming permanent. It is

likely that some failure to return to full strength after a lower-
extremity injury is related to adaptive gait changes that become
permanent in unloading the injured extremity. One study on
patients with chronic ankle instability found a 16% slower walk-
ing velocity, 7% lower step length, and a 43% wider base of sup-
port when compared to healthy controls.47
In chronic injuries or before return to activity, a clinician
should take a closer look at lower-extremity biomechanics and
gait abnormalities to facilitate return to function while pre-
venting future problems. Observation of gait should include
lateral, anterior, and posterior views. It is important to observe
and evaluate the foot, ankle, knee, and hip/pelvis position and
biomechanics during the gait cycle. Treatment of gait devia-
tions includes flexibility, strengthening, and proprioception. An
orthotic can be an excellent adjunct to rehabilitation if the gait
deviation is a result of abnormal biomechanics and structural
problems within the foot.

STRENGTHENING
Fig. 30.3  Athlete on the Alter-G™, anti-gravity treadmill.
Muscle strengthening should be initiated once the patient has
recovered 95% to 100% of the ROM of that joint. Initiating
walking and running with significantly reduced weight. This strengthening too early can cause an increase in joint stiff-
allows the athlete to normalize gait and promote muscle and ness, therefore decreasing the function of the joint. Isotonic
tendon function while providing the necessary protected weight strengthening, whereby the force is kept constant, is most
bearing in some situations. commonly performed. There are two types of isotonic exer-
cises: concentric, which causes muscle shortening; and eccen-
tric, which allows the muscle to lengthen. Both phases are
GAIT EVALUATION extremely important and should be included in a comprehen-
The evaluation of a patient’s gait immediately after injury and sive rehabilitation program.
before return to activity can provide a clinician with valuable There are several methods of strengthening, including
information on how abnormalities in ambulation contribute weights, TheraBand, and water resistance. TheraBand is a use-
to the rehabilitation and prevention of injuries. Often abnor- ful tool to provide dynamic resistance in all directions of the
mal gait mechanics can predispose the other joints of the foot and ankle (Fig. 30.4). It has different levels of resistance
lower extremity and back to overload and pain. Restoring nor- to allow the athlete to progress. Once the athlete can complete
mal gait after acute injuries can help to prevent these abnor- 3 sets of 15 repetitions through a full range of movement, the
mal mechanics and significantly reduce the amount of time next level of resistance should be started. This same concept can
required for return to normal function. It is important that a be used with ankle weights. Care should be taken to include
clinician evaluates the entire lower extremity and its function
during gait.
Normal gait is composed of two phases, a stance phase
(60%) and a swing phase (40%). The stance phase is composed
of five categories, including initial contact (heel strike), load-
ing response (foot flat), midstance (single leg support), termi-
nal stance (heel off), and pre-swing (toe-off). The swing phase
consists of initial swing (acceleration), mid-swing, and terminal
swing (deceleration). 46
In acute injuries, a clinician will notice gait abnormalities
because of pain, decreased ROM, strength deficits, and lack
of proprioception. An antalgic gait is most common, with a
decreased stance phase on the affected limb. Crutches can be
beneficial for this gait pattern to help the patient remove some
percentage of weight/stress on the affected limb and thus allow
for a more normal stance phase. A patient may discontinue assis-
tive devices when he or she can walk normally. It is extremely
important that as clinicians we correct gait immediately to Fig. 30.4  Thera-band exercises to strengthen foot and ankle.
546 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration and Teamwork

strengthening of the foot intrinsic muscles in addition to the

primary extrinsic muscles responsible for inversion/eversion,
CARDIOVASCULAR ACTIVITIES
supination/pronation, and dorsiflexion/plantarflexion. During the rehabilitation program, it is extremely important
to keep the patient active. If the patient becomes sedentary,
the cellular metabolism levels decrease and the individual will
PROPRIOCEPTION lack energy. Additionally, the patient may experience both
Many rehabilitation programs often fail to pay attention to pro- diminished desire and blunted motivation because of a form
prioception deficits. Proprioception is the ability of the body of depression seen after injury in athletes.54 Lastly, low levels
to vary the forces of muscles in response to outside forces. of physical activity have been linked to dysregulated appetite
Muscles, tendons, and joint receptors provide this information, and subsequent weight gain.55 These factors consequently can
which affects posture, muscle tone, kinesthetic awareness, and present a challenge for recovery and rehabilitation. Early in the
coordination.48,49 When an individual is injured, the proprio- rehabilitation, we feel that it is vital to start a sensible regimen of
ceptive input to that joint is altered and diminished. Diminished low-resistance exercise bike or pool therapy training 3 to 4 days
proprioception can lead to a recurrence of injury because of the a week for 10 to 15 minutes with a progression by 5 to 10 min-
joint’s decreased ability to respond to outside forces. utes of training per session per week. If the bike is used, then
Proprioception can be improved with a number of treat- a walking boot or protective brace is used. Pool therapy is not
ment techniques. Early weight bearing can help to decrease the initiated until the sutures are removed and the wound is fully
amount of proprioception loss. A patient can practice standing healed. This early exercise provides physiologic benefits in the
with equal weight on both feet, progressing to single leg stance, form of maintained cellular metabolism as well as psychological
first on solid ground and then working toward standing on soft benefits for the athlete as physical activity has been proven to
surfaces. A biomechanical ankle proprioception system (BAPS) reduce depressive symptoms.56
board (Fig. 30.5) or kinesthetic awareness trainer (KAT) can be Our experience with and observation of clinical healing and
used as a patient advances through rehabilitation. postoperative wound healing have proven that it is import-
Proprioceptive training leads to quantifiable improvements ant to progress the patient’s activity gradually. Increasing the
in functional ankle stability. One study showed improvements time increments of 10 minutes a week on a bike will allow the
in dynamic stability in all planes after 12 weeks of training on patient to be working approximately 30 minutes per session
a stability board trainer in 28 young speed skaters.50 Another in a 3-week span. Typically, low-impact, weight-bearing exer-
study showed that after 6 weeks of balance training, individuals cise will be introduced when the athlete can walk normally
with chronic ankle instability demonstrated enhanced dynamic in a protective device and regular shoe. The rehabilitation
balance, inversion joint position sense, and changes in motor program will begin replacing 1 day of bike with an elliptical
neuron pool excitability compared to healthy controls who did machine each successive week until the athlete has been con-
not train.51 These improvements in proprioception and stability verted to 4 to 6 days per week of elliptical. The athlete will
have been proven to lead to a decreased risk of re-injury. In fact, continue to increase low-impact, weight-bearing exercise as
proprioceptive training can reduce the incidence of ankle sprains tolerated. We have found that when an athlete can work out
in athletes with recurrent ankle sprains to the level of an athlete on the elliptical machine 4 to 6 days a week for 30-plus min-
that has no prior history of sprain.52 Proprioceptive training has utes, it is safe to initiate running. Running should gradually
also been found to be cost effective in the prevention of recur- replace the elliptical training each week. It is important to give
rent sprains as compared to standard therapy alone.53 the athlete a set of running guidelines that allows for a gradual
progression of activity.

FUNCTIONAL PROGRESSION
A functional progression is a series of sport-specific skills that
increase in the level of difficulty that an athlete must complete
before he or she can safely return to competition. Yamamoto
and Fragi described a functional progression in the rehabil-
itation of injured West Point cadets.57,58 The emphasis in this
program was placed on restoring agility through dynamic exer-
cise after knee injury. Kegerreis et al. added specific movement
patterns and skills to the program and introduced the impor-
tance of addressing the psychological needs of the injured ath-
lete.59 They also addressed the scientific principles that play
an important role in the functional progression and the need
to break down sport-specific functions to be addressed in the
order of difficulty.
Fig. 30.5 Athlete on the biomechanical ankle proprioception system The functional progression is vital to a complete sport-spe-
(BAPS) board. cific rehabilitation program. It serves to translate the gains from
 CHAPTER 30  Rehabilitation of Specific Foot and Ankle Issues 547

clinical rehabilitation onto the playing field. Each sport has cer- Phase I
tain demands and skills that stress the foot and ankle differently. Phase I emphasizes pain modulation and inflammatory control
It is extremely important that the athlete advance one step at a of the soft tissues. Controlling pain and inflammation will allow
time without pain or apprehension. Once the athlete has com- patients to be better able to perform their rehabilitation exer-
pleted the list of activities in order without pain or apprehen- cises. Restoration of normal ROM and joint accessory motions,
sion, he or she may return to full sport activity. including glide, roll, and spin, are stressed in this phase. Early
There are several physical and psychological benefits that the return of pain-free ROM will enhance the rehabilitative process
functional progression will address. The functional progression and allow the patient to begin isolated and functional rehabil-
promotes healing through the application of Davis’ law and itation exercises in phase II with greater effectiveness. Once a
Wolfe’s law, which were discussed earlier. It is important that the patient has minimal pain and has normal to near-normal ROM,
healing tissue be stressed in the way required of it before injury he or she may be advanced to phase II.
so that the tissue will be ready to fully accept preinjury activity
requirements. In this way, the injured tissue and bone will be Phase II
stressed in a controlled, functional manner leading to further Once inflammation is decreased, pain has subsided, and ROM
tissue and bone healing. In addition, the functional progres- is near normal, phase II may begin. Foot and ankle flexibility
sion breaks up the monotony of traditional rehabilitation and with functional strengthening are initiated and are the focus of
allows the athlete to begin performing activities related to func- this phase. In addition, cardiovascular conditioning and pro-
tion. Psychologically it allows the athlete to increase self-confi- prioceptive training also are started at this time. The goals of
dence and mentally prepares him or her to return to sport. As this particular phase are to improve flexibility, restore strength,
the athlete completes each step, confidence will increase and and begin light, sport-specific functional training. A patient
apprehension will decrease, allowing the athlete to enter the may be progressed to phase III when he or she is ready for a
competitive environment at the level of function needed for gradual return to activity and participation in sports.
playing standards.
Phase III
Emphasis in phase III is on functional return to activities of
PHASES OF REHABILITATION daily living (ADLs) and previous activity/sport participation.
The cornerstone to appropriate rehabilitation is an accurate Advanced activity-specific exercise should be implemented with
diagnosis, so that an appropriate rehabilitation program can be special attention to mechanics of the activity. Proper mechanics,
established efficiently and safely. For any injury or condition, as well as maintenance of flexibility and strength, can prevent
the rehabilitation can be divided into three general phases. Each further chance of re-injury. To ensure safe return to sport, ath-
phase has specific goals, and, although there is a time frame letes should perform a functional progression. External sup-
assigned to each phase, advancement from one phase to another ports such as braces, straps, taping, and orthotics may be used at
should be based on the patient’s achieving the prescribed goals this time to allow the patient to participate in his or her activity
rather than on time. A clinician must be willing to adapt and pain free.
modify the exercise program for each patient. As the rehabili-
tation landscape is ever-changing, it is important to stay up to
date with current trends.
One interesting field that we have begun utilizing in clinical
practice is global positioning systems (GPS) tracking devices
(Fig. 30.6). These devices are worn by our football players on
their shoulder pads and give us instant, real-time data on veloc-
ity, acceleration, and change of direction. We use this informa-
tion relative to baseline data we have collected on the player
to compare where he is in his rehabilitation. This allows us a
real-time feedback tool that can provide us data as to how the
affected limb is reacting to certain situations. This is invaluable
data in making decisions to allow athletes to return to the field
safely despite previously accepted return to play norms. This
objective data provides a real comparison to pre-injury levels,
allowing us to know where deficits remain so we can tailor the
final phases of rehabilitation to the specific needs of the athlete.
This gives both the surgeon and the athlete the confidence that
they are returning to play at a level at or near previous levels
prior to the injury. While there is still much research to gather
in regards to its application in sport, this emerging technology
is another tool that we have to better help the rehabilitation of
our athletes. Fig. 30.6  Catapult™ GPS system.
548 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration and Teamwork

REHABILITATION OF ACHILLES TENDON TABLE 30.1  Progressive Weight-Bearing

REPAIR (SEE CHAPTER 9) Protocol
Over the past 10 years, functional rehabilitation of Achilles ten- Weight-Bearing Progression Protocol
don ruptures has become more prevalent. In the past, treatment Day 1–2 25 lbs of pressure in boot with two crutches
of Achilles tendon ruptures has focused on immobilization, Day 3–5 50 lbs of pressure in boot with two crutches
initially with long-leg casting and ultimately transitioning to Day 6–8 75–100 lbs of pressure in boot with transition to one crutch
short-leg casting. In recent years, however, early weight bearing Day 9–11 100–125 lbs of pressure in boot with one crutch
with accelerated rehabilitation and earlier motion has become 150 lbs to full weight bearing with transition to no crutch
the standard of care.60,61 The functional, accelerated rehabili- Wear boot in times of excessive walking, ankle brace
tation allows the athlete to return to sports more quickly and should be worn when out of boot if instructed by
readily, without a reported increase in re-rupture rates or com- Day 12–14 physician
plications.62 Despite the best advances in surgery and rehabil-
itation of these injuries, athletic performance after a complete
Achilles rupture is often affected.63,64 plantarflexion, and seated calf raises. We use the concept of
Mendelbaum et  al. initiated an early motion protocol in early protected motion and resistance training, which encour-
29 patients after surgical repair of the Achilles tendon. They ages stronger tendon healing and protects against disuse atro-
reported 93% of the patients returned to full activity by 6 phy. Exercises are performed at a higher frequency with a low
months and functional deficits were less than 3%. This proto- load to continuously stimulate the tendon to heal. It is extremely
col focused on early motion at 3 days postsurgery with weight important to avoid ankle dorsiflexion activity or a heel cord
bearing initiated 2 weeks post repair.65 Others have advocated stretch to protect the tendon from overstretching.
a similar early, protected motion protocol using a walking boot The second phase of rehabilitation begins approximately 6
with a dorsiflexion block at -20 degrees. This alternative can weeks after repair. At this time, an increase in weight-bear-
result in a quick return to sports activity in a reliable, motivated ing exercise is allowed, and proprioception retraining with an
patient.66 Early weight bearing after surgical repair of an acute emphasis on normal gait is initiated. Athletes at this time are
Achilles tendon rupture improved health-related quality of life instructed in a program to wean out of the boot into an ath-
in the early postoperative period and had no detrimental effects letic shoe with one 9/16th inch felt heel lift. Our goal is to
on recovery. Similar results have been shown with the newer wean the patient out of the boot over 2 weeks with normal
percutaneous repair techniques.67 pain-free gait.
Over 80 Achilles tendon ruptures have been performed over During this phase, it is important to stress to the athlete not
the past 5 years at Andrews Sports Medicine. Our protocol has to overtrain or attempt to push the therapy faster than the ten-
evolved over time and we now allow full weight bearing at 2 don can handle. While many of the athletes are motivated at a
weeks in a walking boot with ROM exercises initiated after the level higher than the average patient, it is stressed that protocol
first postoperative visit. We subsequently begin strengthening compliance during this phase of the rehabilitation is important.
exercises at 1 month with a stationary bike program and toe At this point, the athlete is weaned from weight-bearing pro-
raises initiated by 6 weeks. After 8 weeks, the patients are out of tection into regular shoewear, which can provide a false sense
protective devices and back in to regular shoewear. Once the ath- of comfort. During this phase, calf raises are initiated, balance
lete has reached this stage, the focus turns to slowly regaining full and strengthening exercises are progressed, and elliptical/anti-­
motion and strengthening of the gastroc-soleus complex. Using gravity treadmill programs are started. Once the goal of a nor-
this protocol, we have only had a single rerupture of the tendon, malized gait is achieved, proprioceptive strengthening exercises
which is consistent with, or better than, accepted published pro- become important. After 8 weeks, dorsiflexion exercises past
tocols. The following is an example of our rehabilitation protocol. neutral are started with slow increase toward full ROM over the
Initially, the patient is placed in a postoperative splint in next 4 weeks. During this period, sitting and standing strength-
slight equinus position to relax the soft tissues and remove any ening exercises are progressed, while jumping and explosive
tension from the incision. After 10–12 days, the patient returns exercises are prohibited. It is important to avoid forced dorsi-
to clinic and sutures are removed. Once the incision is healed, flexion, as the final few degrees of motion will come over the
we transition the patient into a walking boot with two ¼ inch following months as the patient progresses back to normal
heel lifts stacked in the boot. We initiate a weight bearing pro- activity. The final phase of rehabilitation starts approximately
gression protocol that is outlined in Table 30.1. Compression at the 3-month mark. Patients will continue to work on bal-
and elevation are stressed to the patient during this period as ance, ankle strength, and unilateral calf raises. At this time,
edema control is paramount to early progression. Formal phys- full lower-extremity strengthening will be initiated. Exercise
ical therapy is begun. We initiate an exercise bike program will include step-downs, leg press, knee extensions (Fig. 30.7),
wearing the walking boot with active and active assist ROM and hamstring curls that can be advanced per patient tolerance.
exercises. We avoid passive ROM exercises past neutral in order Weighted calf raises typically are initiated around 4 months.
to avoid stretching out the repair. Explosive exercises are avoided until at least 4 months after sur-
We also utilize a home therapy program. The home exercise gery. These types of sudden motion, i.e., jumping and landing,
program includes toe curls, active plantarflexion, resistive-band put the tendon most at risk for re-rupture.
 CHAPTER 30  Rehabilitation of Specific Foot and Ankle Issues 549

Immobilization is often used in the early rehabilitation phase.

Use of splints, casts, or removable walking boots are common in
the acute phase. Immobilization, particularly with a CAM walk-
ing boot, puts the ankle in a stable, neutral position and helps
to avoid compromising positions. These immobilization devices
will allow the athlete to weight bear with the mortise in its most
stable position.
After ankle reconstruction, historically, immobilization for
prolonged periods of time was the standard treatment. More
recently, however, early, protected motion has become the
norm. With early mobilization of the ankle, appropriate stress
can be applied to the ankle that will allow the ligaments and soft
tissues to heal in an oriented manner that will promote both
motion and stability. Functional exercises have been shown to
be important to stress the healing tissues without compromising
their integrity.38 The following goals are important for any reha-
Fig. 30.7  Athlete using knee extension exercise to strengthen lower limb. bilitation program: decreased swelling, pain, and initial inflam-
matory response and protection of the joint so that a secondary
inflammatory response does not develop from overly aggres-
TABLE 30.2  Foot and Ankle Return to sive rehabilitation. Similarly, ROM, muscular strength, power,
Sport Test and endurance must be returned to preinjury levels so that full,
Determine loaded and Pain free and 90% of asymptomatic functional activities may be performed.
Knee to Wall functional dorsiflexion ROM the unaffected side A similar approach can be used following a lateral ankle
Assess core control, balance, Pain free and <4 cm in reconstruction. For the reliable athlete with close medical
Y-Balance proprioception, ROM, strength anterior reach monitoring and sturdy tissue at the time of reconstruction,
Assess single leg jump height Pain free and 90% of there may be a place for intermittent immobilization with early
Jump for Height to determine power the unaffected limb weight bearing and specific ROM exercise. Overall the objective
Challenge running/change of Bilateral times within is to obtain as normal an ankle as possible.69
Running Agility direction in multiple areas 90% of each other In our practice, the patient is initially placed in a postopera-
tive splint for 10–12 days to allow the soft tissues to quiet down,
Data from Clanton TO, Matheny LM, Jarvis HC, et al. Return to play in
with the athlete relying on elevation and decreased mobility to
athletes following ankle injuries. Sports Health. 2012;4(6):471-474.
help control the swelling. Once the incision is healed and sutures
are removed, the athlete is transitioned into a CAM walker boot
Once an athlete is capable of double leg heel rise, walking and the first phase of rehabilitation is begun. Initially the focus
without altered gait, and is using the elliptical for 30 minutes on is on swelling control, ROM in dorsiflexion and eversion, and
a daily basis, he or she may begin light jogging outside of the restoring the normal gait cycle. Once these exercises are com-
anti-gravity treadmill (usually 3–4 months after the repair). menced, under supervision of a physical therapist or athletic
Sport-specific activities are begun 4 months from surgery. Agility trainer, light strengthening is begun. Care is taken to avoid
drills should be advanced gradually per patient tolerance using compromising positions of the ankle, specifically plantarflexion
the functional progression as discussed above. Once the athlete is and inversion. Swelling control is emphasized, both through the
nearing return, we use objective, validated, functional testing to use of elevation and cold compression devices.
confirm the athlete is truly ready to return to play.68 (Table 30.2) A home exercise program is also utilized during this period.
Return to sports normally occurs at 5 to 8 months after surgery. Typically, our athletes utilize TheraBands for early ROM exer-
cises and strengthening. The athlete is instructed on this pro-
REHABILITATION AFTER LATERAL ANKLE gram to ensure that ROM limits are set and the patient is
understanding of the need to avoid inversion and plantarflex-
RECONSTRUCTION (SEE ALSO CHAPTER 15) ion. Cardiovascular exercises are begun, specifically using the
The goals of ankle sprain rehabilitation, or rehabilitation after stationary bike, while wearing the walking boot.
lateral ligament repair, are to put the ankle in a healing posi- Partial weight bearing is typically started 2 weeks from sur-
tion that avoids elongation and tension on the lateral ligaments. gery. A progressive weight bearing program is implemented to
In each case, stress shielding of the healing ligaments followed avoid excessive stresses placed across the foot and ankle (Table
by integrating functional rehabilitation with graduated stress 30.1). This progression allows the athlete to reintroduce stress
application and strengthening will allow the ligament to appro- across the foot and ankle. Once full weight bearing is achieved,
priately heal. Ultimately, our goal of athletic rehabilitation is to we will begin weaning out of the walking boot, which will allow
return the athlete to sport as quickly and efficiently as possible the athlete to return to normal shoes. We have the athlete wear
without compromising the athlete, or the injured limb, while a brace at all times during this phase to protect the ankle from
avoiding the potential for future problems. accidental injury. During the boot wean phase, ROM exercises
550 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration and Teamwork

TABLE 30.3  Progressive Boot

Wean Protocol
Boot Wean Protocol
Day 1–2 1 hour in morning/1 hour in afternoon
Day 3–5 2 hours in morning/2 hours in afternoon
Day 6–8 3 hours in morning/3 hours in afternoon
Day 9–11 4 hours in morning/4 hours in afternoon
Day 12–14 Progress to full time weight bearing out of boot

opposite hip/leg exercise. Cardiovascular exercise should be

advanced from the bike to an elliptical machine (4–6 weeks
after surgery) and eventually to light jogging (6–10 weeks after
surgery).
The final phase of rehabilitation, which occurs between weeks
10 and 14, focuses on sport specific activities. The progression
to explosive activities is dependent upon continued improve-
ment with minimal swelling and pain-free exercise. This phase
is focused on ankle and leg strengthening, restoring the flexi-
Fig. 30.8  Athlete in Ankle Stabilizing Orthosis (ASO) brace. bility of the lower limb, and proprioceptive activity. There are
no restrictions placed on the athlete as long as swelling is con-
trolled and the ankle remains pain-free. A stirrup-strap type
and strengthening exercises in all planes are commenced. Our brace is utilized and on-field activities are started. Before return
main goal during this phase is to restore full, unrestricted ROM. to sport, the patient should successfully complete a sport-spe-
Once the athlete is out of the boot, more aggressive therapy is cific functional progression program to ensure safe return to
begun. competition. Return to sports participation is typically seen at
Desensitization massage is an important part of the early 12 to 14 weeks.
rehabilitation program. Because of the highly innervated foot
and ankle, the patient often will experience some surface hyper- REHABILITATION OF HIGH ANKLE SPRAINS
sensitivity after surgery. It is important to stimulate this tissue (SYNDESMOSIS INJURIES) (SEE ALSO
with light massage and tactile stimulation to reeducate and
desensitize the tissue to normal pressure and touch. This can be
CHAPTER 15)
accomplished with a light massage 3 to 5 minutes several times High ankle sprains, or syndesmosis injuries, have become more
a day. prevalent in recent years. While it is difficult to tell if this is
The second phase of rehabilitation begins 4–6 weeks post- because of better recognition of the injury by treatment pro-
operatively. At this time patients are instructed to wean out of viders or other variables, such as shoe wear or playing surfaces,
the boot into a stirrup or ankle stabilizing orthosis brace (Fig. the treatment of these injuries has been evolving over the past
30.8; Table 30.3). Our goal is to gradually wean the athlete out decade. For isolated ligamentous injuries, conservative treat-
of the boot within a 2-week time period and obtain a normal, ment was almost always the standard treatment. Recently,
pain-free gait. however, operative stabilization of the ankle with endobutton
Exercises in the second phase include ROM/strengthen- constructs has allowed us to rehabilitate athletes at a quicker
ing in all four directions, aggressive heel-cord stretching, calf pace and has allowed quicker return to play.
raises, and proprioception exercise. Dorsiflexion and inversion As with any injury, our goal is to return the athlete to the field
strengthening still are performed with Thera-tubing. Aggressive in a safe, efficient manner without compromising the future
peroneal strength is accomplished by having the athlete lie in health of the athlete. Because of the high incidence of continued
a lateral position with ankle weights hung over the end of the problems with chronic syndesmosis injuries, a recent trend has
foot and the toes pointed to isolate the peroneal tendons. The been for operative fixation of the more severe grade II injuries
athlete then everts the foot and ankle to strengthen the tendons. and all grade III type injuries. This allows a faster rehabilitation,
We have found this to be a very effective means of maximizing enabling the athlete to return to play in less time.
peroneal strength. Bilateral calf raises are initiated with pro- In our practice, typical repair includes ankle arthroscopy to
gression to single calf raise. We like to have the patient work on debride the joint and assess the cartilage, and stabilization with
eccentric phase of calf raise by going up on both and lowering a divergent endobutton construct over a lateral plate. The first 4
slowly on the injured side. Once the patient has no difficulty days following surgery are spent in a splint for soft tissue rest.
with the eccentric phase of the exercise, he or she may add the On day 4, the splint is removed and the athlete is transitioned
concentric phase of the exercise. Proprioception exercise should into a CAM walker boot. Edema control modalities are initiated
begin with one-foot balance, with progression of balance with to limit the amount of swelling. The quicker we can decrease the
 CHAPTER 30  Rehabilitation of Specific Foot and Ankle Issues 551

swelling, the quicker we can regain full motion, thus allowing

for a shorter return to play. Weight bearing as tolerated is ini-
tiated on day 4, though it often takes the athlete several days to
become fully comfortable weight bearing in the boot. Once the
athlete has progressed to full weight bearing, we begin weaning
from the boot. Typically, this is done over 7–10 days.
Exercise bike and anti-gravity treadmill are begun 1 week
from surgery. As gait normalizes, the progression to faster pace
and full weight bearing is initiated. TheraBand exercises as well
as proprioceptive exercises are also performed during this phase.
The goal is to limit strength loss while maintaining motion.
Avoiding excessive dorsiflexion can help avoid discomfort as
the rehabilitation phase is started. Once the patient has returned
to normal gait with full weight bearing, we transition them to
explosive cutting and jumping exercises. This typically occurs in
the day 14–21 range. At this point the therapy is directed by the
athlete’s symptoms as long as the swelling remains controlled Fig. 30.9  Single-leg heel rise.
and gait remains normal. Once the athlete can do single leg
heel rise without difficult and a single leg hop test is completed,
return to sport can be considered. Typically, this occurs between can be started (20 seconds, 5 repetitions) if there is no contrain-
weeks 3 and 6. If the athlete can sustain a faster pace of rehabili- dicating ligament injury. Early active controlled motion in this
tation, he or she is not prevented from doing so. manner has been reported to improve the ultimate outcomes
in ankle fractures.70 The home exercise program will consist
REHABILITATION OF ANKLE FRACTURES of toe curls, ROM in appropriate directions, resistive band in
appropriate directions, desensitization massage, and a light bike
(SEE ALSO CHAPTER 14) program wearing the boot.
Rehabilitation of athletes who sustain ankle fractures can be both Partial weight bearing is started at 2 weeks, with progression
challenging and rewarding for the treating team. Treatment of to full weight bearing in the walking boot in 2 weeks (if the frac-
ankle fractures focuses on the restoration of a congruent, stable ture is stable and does not involve a weight-bearing surface).
joint while providing rigid, anatomic fixation of the fractured Patients are instructed to use axillary crutches and increase
bones. This allows us to be confident as we progress the athletes weight bearing as tolerated. After the first week of partial
quickly through phases of immobilization to early ROM and weight bearing, the patient may begin using one crutch under
protected weight bearing. In minimizing immobilization, we the opposite arm and eventually progress to full weight bearing
can maximize swelling control, improve early-phase strength- over the next week. Once a patient can walk normally with the
ening, and normalize gait quicker. This allows the athlete to walking boot (typically within 3 to 4 weeks), we begin weaning
return to play quicker than traditional methods with long peri- the patient out of the boot and into a stirrup brace and regular
ods of immobilization. shoe over the next 2 weeks. Patients with highly comminuted
In the immediate postoperative period, the patient is placed fractures and those with a weight-bearing joint injury or signifi-
in a splint for swelling control and to allow the incision to cant cartilage injury do not follow this same protocol.
heal without complications. Patients are instructed to elevate The second phase of rehabilitation begins approximately 1
the extremity as much as possible to help decrease swelling. month after surgery. At this time, an increase in weight-bear-
Nonweight bearing with axillary crutches or a rolling knee ing exercise, proprioception, and gait training with an athletic
scooter is initiated initially after surgery to reduce the risk of shoe is initiated. Exercises consist of progression of Thera-band
immediate postoperative swelling. The patient should also wig- activities to include directions originally avoided because of lig-
gle the toes and perform leg lifts every 3 to 4 hours while awake. ament complications. Standing calf stretching, balancing exer-
After 10–14 days, the athlete is transitioned into a CAM cises, double to single leg calf raises, and elliptical/anti-gravity
walker boot to allow for cold compression and physical therapy. treadmill progression is included during this phase. TheraBand
If stable bone alignment is demonstrated on radiographs, range- exercise should continue to be high repetitions (15–20) in all
of-motion exercises are started. ROM should be initiated in a directions. Single leg balance is first initiated in a regular shoe
manner that does not put tension on an injured or repaired liga- and then progressed to bare foot on a hard surface (Fig. 30.9).
ment. For an isolated fibula or stable bimalleolar fracture, ROM Our goal is approximately 60 seconds. Balance can be advanced
can include all directions. If the patient has a medial ligament by use of a soft surface and balance board. The patient should
injury or syndesmosis disruption, dorsiflexion with eversion work aggressively with calf stretching using a stair or an incline
should be avoided until the ligament is healed. Range of motion board for 3 minutes three times a day. Bilateral standing calf
and light Thera-tubing exercises are guided by pain and should raises should be initiated with progression to single-leg calf
be performed several times a day in high repetitions (15–20); raises. Once completely out of the boot, elliptical or anti-grav-
towel stretch for the Achilles and manual plantarflexion stretch ity treadmill progression should be substituted for the bike
552 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration and Teamwork

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­major surgery to the foot and ankle. Foot & Ankle. 1993;14(4):
you to further challenge yourself in your treatment of athletes.
198–203.
20. Thordarson DB, Ghalambor N, Perlman M. Intermittent
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65. Mandelbaum BR, Myerson MS, Forster R. Achilles tendon 68. Clanton TO, Matheny LM, Jarvis HC, Jeronimus AB. Return to
ruptures. A new method of repair, early range of motion, and play in athletes following ankle injuries. Sports Health. 2012;4:471.
functional rehabilitation. Am J Sport Med. 1995;23:392. 69. Petrera M, Dwyer T, Theodoropoulos JS, Ogilvie-Harris DJ.
66. Suchak A, Bostick G, Beaupre L, et al. The influence of early Short-to medium-term outcomes after a modifie brostrom repair
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Rehabil Epub Ahead of Print. 2017.
 31
Principles of Rehabilitation
for the Foot and Ankle
Erin Richard Barill, Debbie Carroll, David A. Porter

OUTLINE
Introduction, 555 Phase I, 564
Cryotherapy/Rest, ICE, Compression, and Elevation, 555 Phase II, 564
Range of Motion/Mobilization, 556 Phase III, 564
Protection/Immobilization, 557 An Updated Rehabilitation of Achilles
Protected Weight Bearing, 557 Tendon Repair, 564
Gait Evaluation, 558 Rehabilitation After Open Reduction and Internal Fixation
Strengthening, 558 of Lisfranc, 567
Proprioception, 558 Fifth Metatarsal Open Reduction and Internal Fixation
Cardiovascular Activities, 559 Rehabilitation, 569
Additional Treatment Considerations, 559 High Ankle Sprains, 571
Functional Progression, 562 Surgical Intervention for Syndesmotic
Phases of Rehabilitation, 563 Disruption With Ligament Damage, 572

and advanced approach to rehabilitation can provide an envi-

INTRODUCTION ronment conducive to a complete, full, and functional recovery.
This chapter provides an overview of the rehabilitation princi-
ples, appropriate progression of exercise, and return-to-play cri- CRYOTHERAPY/REST, ICE, COMPRESSION,
teria when dealing with foot and ankle injuries. Rehabilitative
protocols and progressions must be based primarily on the
AND ELEVATION
physiological responses of the tissues to injury and on an under- Rest, ice, compression, and elevation (RICE) are almost uni-
standing of how various tissues heal. The foot and ankle often versally accepted as best practice by athletic trainers and other
are injured during sporting events, recreational activities, and health care professionals immediately after acute foot and ankle
occupational accidents. Injuries to the foot and ankle may be injuries.9 Rest is always important to allow the inflammatory
acute or chronic in nature and often cause considerable disabil- process to run its course, but initiating initial treatment prin-
ity in athletes. Garrick and Requa1 reported that foot and ankle ciples in combination will allow for a faster recovery process.
injuries represented more than 25% of the 1600 athletic injuries There are several cold agents to choose from, including the
in their series.2,3 It has been suggested that the sprained ankle is cold pack, ice bags, cold whirlpool, and ice immersion. There
the single most common injury in sports.2,4–7 are other popular commercial ice units that include Aircast
The foot and ankle serve as the junction of the body to the Cryocuff (DJO, Vista, CA) and Game Ready (Concord, CA).
weight-bearing surface. This elegant collection of tissues, each These units help provide cold and compression at the same
with a variety of specialized functions, allows efficient, upright time. The primary objective of ice is to reduce swelling and
stance and locomotion.8 Athletic populations have unique and help manage pain. It has been found that pain is inhibited by
strenuous demands. Even with minor injuries, improper or cold through a decrease in nerve conduction velocity. As the
incomplete rehabilitation can lead to significant impairment. temperature decreases, there is a corresponding decrease in
A detailed, focused approach to rehabilitation of the foot and sensory and motor nerve velocity, eventually causing synaptic
ankle is crucial to the athlete. Fortunately, most competitive ath- transmission to be blocked.10 In our experience, as well as in
letes have access to daily evaluation and monitoring of progress, the research, we have found the ankle and foot Cryocuffs to be
as well as skilled assistance to help them comply with rehabil- an inexpensive and effective way to provide compression and
itation protocols. Recent technologic and procedural advances cold.11
contribute greatly to the treatment of the competitive athlete. The application of cold is most effective immediately after
Principles of rehabilitation must continue to advance and keep injury or within the first 72 hours. Hocutt et  al.12 found that
up to date with technologic and procedural advances. A proper patients with grade III ankle sprains that were treated with ice
555
556 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

in the first day returned to functional activities such as running revealed insight on how early ROM decreases complications
and jumping after 6 days, whereas those treated on the second and actually enhances the healing process. Early mobilization
day went 11 days before they could run or jump. In contrast, may result in an earlier return to work and daily activity, less
those who received heat in the first day had a recovery time of muscle atrophy, and better mobility compared with immobili-
14.8 days. Ice should not be used longer than 30 minutes, espe- zation by casting.17,20,21 The value and benefit of early motion
cially in areas of superficial nerves as it may cause a transient was investigated in the area of rehabilitation after flexor tendon
nerve palsy.13 repairs of the hand. The obvious need for full motion in the
A contraindication to cryotherapy is individuals with hyper- hand prompted investigation into safe rehabilitation practices,
sensitivity to cold. Cold should be avoided in patients with which would eliminate postoperative adhesions and stiffness
Raynaud’s syndrome or peripheral vascular disease (see Chapter but allow reliable healing of the tendon. Gelberman et  al.22,23
12). Cold therapy also must be monitored closely in postopera- noted an improved healing response, improved strength, and a
tive patients who have wet dressings because the combination of more normal pattern of vascularity to the healing tendon with
wet dressings with cold application can decrease the skin tem- protective early mobilization. Several other studies also noted
perature to a dangerous level. that early ROM decreased adhesions around the repaired ten-
Elevation decreases hydrostatic pressure to decrease fluid don and had a positive influence to the healing tissue.24,25 Early
loss, and also assists venous and lymphatic return through grav- motion after flexor tendon repair has become standard today.
ity.13 Physiologically, the application of cold agents also results Over the past several decades, there have been significant
in arteriolar vasoconstriction, a decrease in local metabolism, studies in the area of rehabilitation after knee injury and sur-
and an elevation in pain threshold. Patients should be encour- gery. The focus of knee rehabilitation has centered on obtain-
aged to elevate as much as possible over the first 24–48 hours ing full symmetrical ROM following a knee injury or surgery.
following injury. Obtaining full knee extension was one of the most important
Compression has been commonly used both immediately criteria in allowing the anterior cruciate ligament to heal ana-
post injury and during the rehab process to decrease edema. It tomically and yet still avoid a knee flexion contracture. Close
typically involves the application of external pressure in a cir- observation of patients who were doing well demonstrated that
cumferential or focal manner to the tissues or surrounding tis- early ROM was not detrimental to the ligament (and in fact
sues injured. Elastic wraps and tape have commonly been used could be advantageous to proper ligament healing/strength-
over the years to apply immediate compression. Over the years ening) while allowing an earlier and safe return to function.26
there have been several compression modalities utilized for Early motion and weight bearing led to a significant decrease in
both injury management and recovery in later stages of rehab.13 muscle atrophy and decreased complications from arthrofibro-
sis with an earlier return to function.
Robert Salter and associates27 investigated the effect of joint
RANGE OF MOTION/MOBILIZATION motion on cartilage nutrition. Early continuous passive motion
There always has been an interesting rehabilitation dilemma in synovial joints allows and promotes cartilage nutrition and
between the need for early range of motion (ROM) and the need health. Salter et al.27 demonstrated that small cartilage defects
to immobilize tissues to decrease swelling, protect injuries, and actually could heal with continuous motion, further support-
protect against pathologic motion. This section discusses the ing the benefit of motion on articular cartilage nutrition and
advantages of early ROM and mobilization. healing.
Galileo first recognized the relationship between applied load These advances in hand and knee rehabilitation gave us rea-
and bone morphology. In 1892, Julius Wolff, a German anato- son to approach the foot and ankle with a similar approach.
mist, was the first to link these two vital concepts in his land- Thus early mobilization of the foot and ankle following injury is
mark thesis, The Law of Bone Transformation. Wolff explained our currently favored treatment method when applicable. This
that every change in the function of a bone is followed by cer- method specifically avoids or reduces immobilization. We have
tain definite changes in internal architecture and external con- followed the principle that unnecessarily protracted immobili-
firmation in accordance with mathematical laws; stated simply, zation can prolong the recovery period. Early mobilization can
“form follows function.” expedite the return to work and resumption of athletic activity
Application of early motion on ligament healing demon- while potentially decreasing the risk of complications.
strates that the ligament hypertrophies to compensate for Eiff et  al.20 used a prospective randomized study to deter-
decreased tensile strength of the individual fibers. Obviously the mine which treatment for first-time ankle sprains, early mobili-
amount of tension and stress must not overcome the ultimate zation or immobilization, is more effective. They reported that,
load to failure of the tissue and must not lead to fatigue or plas- in first-time lateral ankle sprains, although both immobiliza-
tic deformation. Wolff ’s law also may apply to these soft tissues, tion and early mobilization prevent late residual symptoms and
and physiologic stress may allow more functional and stronger ankle instability, early mobilization allows earlier return to work
healing of soft tissues. Experimental studies of ligaments after and may be more comfortable for patients. Active and passive
injury indicate that exercise and joint motion stimulate healing ROM is useful to regain motion in cardinal and diagonal planes.
and influence the strength of ligaments after injury.14–19 Passive ROM allows the muscles to relax while working the
Some of the early research on restoration of early ROM was mobility of the joint. Active ROM requires independent muscle
performed in the hand and the knee. These historical papers action and incorporates muscle re-education. It is important to
 CHAPTER 31  Principles of Rehabilitation for the Foot and Ankle 557

work ROM in the direction opposite of the mechanism of injury passively place the complex in a PF and IN position. The rigid
(i.e., we allow dorsiflexion (DF) and eversion (EV) and avoid boot counteracts this relaxed position.
plantarflexion (PF) and inversion (IN) initially after a grade II
or III lateral ankle sprain). Once the injury has healed, ROM
should include all directions.
PROTECTED WEIGHT BEARING
In addition to active and passive ROM, joint mobilization Early weight bearing has been shown to increase the stability
should be incorporated in the rehabilitation program. Accessory of the lateral ankle ligaments after injury while decreasing the
movements, termed joint play, are not volitional but accompany amount of muscle atrophy. Protected weight bearing provides a
voluntary movements or occur passively in response to the safe and earlier return to activity when appropriate by decreas-
ground or other forces. The amount of joint play is a function of ing joint stiffness, muscular strength deficits, and propriocep-
ligament and soft-tissue compliance as well as bony configura- tion dysfunction. We favor a postoperative protocol that allows
tion.28 Mobilization techniques involve oscillation, distraction, for early weight bearing whenever possible. We recognize there
and gliding movements of the joints in the planes of accessory are times when this is not possible, such as in hindfoot fusions.
motions. The range of mobilization is always advanced in a However, in the sports population, early weight bearing can
graded manner but always stays within the physiologic limits have such a positive impact that we try to tailor our surgical
of the joint.28 and nonoperative approach to allow early protected weight
bearing.
An intriguing area of research that is revealing to us is
PROTECTION/IMMOBILIZATION the investigation of weightlessness. Costill et al.29 examined
There is much discussion with regard to immediate, short-term the effect of a 17-day space flight (essentially, total weight-
protection of foot and ankle injuries. These devices can be uti- lessness) on muscle. They reported that there was an 11%
lized in both conservative and surgical management of injuries. decrease in peak muscle power, a decrease in muscle fiber
A protective device allows the foot and ankle to be rested in an diameter, and a 21% decrease in force when the muscle was
optimum position for healing, while allowing for early rehabili- contracted at peak power velocity. More specifically, Costill
tation principles. Some of the more common methods consist of et al.29 examined single muscle fiber changes after weightless-
elastic wrapping, taping/strapping, semi-rigid pneumatic ankle ness. The single fiber diameter decreases were 20% after 17
brace, nonrigid functional ankle brace, and a removable walk- days suspended leg weightlessness (for example crutch-assisted
ing boot. non–weight bearing) and demonstrated similar profound
A device we like is the Aircast walking boot with built-in muscular atrophy.
Aircast Cryocuff (Fig. 31.1). The device allows patients to Research suggests that early loading of damaged soft tissue
weight bear immediately, work on ROM by removing the boot, can enhance collagen fiber realignment and healing.16,17,19,30,31
and use a continuous cold/compression device. Once the ankle Using a removable Aircast walking boot allows the patient to
has healed, a more functional brace is used for return to activ- progress to weight bear immediately after injury (Fig. 31.2).
ity (2–4 weeks after injury). We particularly stress the use of Being in a walking boot instead of an ankle cast allows the
the boot at night for the first 3 to 4 weeks to keep the foot and patient to take the boot off to begin rehabilitation activities.
ankle complex in a 90-degree DF position during sleep, when The walking boot provides more support than elastic wrap-
the relaxation of muscular control and the forces on the heel ping, taping, and other semirigid bracing systems, and it
also allows the patient the ability to apply cold compression
simultaneously.

Fig. 31.1  Aircast Cryocuff and walking boot. Fig. 31.2 Boot.

558 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

GAIT EVALUATION
The evaluation of a patient’s gait immediately after injury and
before return to activity can provide a clinician with valuable
information on how abnormalities in ambulation contribute
to the rehabilitation and prevention of injuries. Often abnor-
mal gait mechanics can predispose the other joints of the lower
extremity and back to overload and pain. Restoring normal gait
after acute injuries can help to prevent these abnormal mechan-
ics and significantly reduce the amount of time required for
return to normal function. It is important that a clinician evalu-
ate the entire lower extremity and its function during gait.
Normal gait is composed of two phases, a stance phase
(60%) and a swing phase (40%). The stance phase is composed
of five categories, including initial contact (heel strike), load-
ing response (foot flat), midstance (single-leg support), termi- Fig. 31.3 Dorsiflexion.
nal stance (heel off), and preswing (toe-off). The swing phase
consists of initial swing (acceleration), midswing, and terminal
swing (deceleration).32–34
In acute injuries, a clinician will notice gait abnormalities
because of pain, decreased ROM, strength deficits, and lack of
proprioception. The majority of the time, a patient will pres-
ent antalgic with a decreased stance phase. If a patient is unable
to walk without antalgia, a clinician should educate the patient
on normal gait mechanics using assistive devices; for example,
crutches. A patient may discontinue assistive devices when he
or she can walk normally. It is extremely important that as cli-
nicians we correct gait immediately to prevent abnormal gait
habits from becoming permanent. It is likely that some failure
to return to full strength return after a lower-extremity injury
is related to adaptive gait changes that become permanent in
unloading the injured extremity.
In chronic injuries or before return to activity, a clinician
should take a closer look at lower-extremity biomechanics and Fig. 31.4  Plantarflexion with tubing.
gait abnormalities to facilitate return to function while pre-
venting future problems. Observation of gait should include There are several methods of strengthening, including
lateral, anterior, and posterior view. It is important to observe weights, Thera-Band, and water resistance. Thera-Band is a use-
and evaluate the foot, ankle, knee, and hip/pelvis position and ful tool to provide resistance in all directions of the foot and
biomechanics during the gait cycle. Treatment of gait devia- ankle. It has different levels of resistance to allow the athlete to
tions includes flexibility, strengthening, and proprioception. An progress. Once the athlete can complete 3 sets of 15 repetitions
orthotic can be an excellent adjunct to rehabilitation if the gait through a full range of movement, the next level of resistance
deviation is a result of abnormal biomechanics and structural should be started. This same concept can be used with ankle
problems within the foot. weigh (Fig. 31.3 through 31.6, 31.7, A and B).

STRENGTHENING PROPRIOCEPTION
Muscle strengthening should be initiated once the patient has Many rehabilitation programs often fail to pay attention to pro-
recovered 95% to 100% of the ROM of that joint. Initiating prioception deficits. Proprioception is the ability of the body
strengthening too early can cause an increase in joint stiffness, to vary the forces of muscles in response to outside forces.
therefore decreasing the function of the joint. Working isomet- Muscles, tendons, and joint receptors provide this information,
rically, isotonically, or isokinetically can achieve strengthening. which affects posture, muscle tone, kinesthetic awareness, and
Isotonic strengthening, which is most commonly performed, coordination.32,33 When an individual is injured, the proprio-
uses concentric and eccentric contractions. Concentric con- ceptive input to that joint is altered and diminished. Diminished
traction causes muscle shortening, whereas in an eccentric con- proprioception can lead to a recurrence of injury because of the
traction the muscle lengthens while maintaining a load. Both joint’s decreased ability to respond to outside forces.
phases are extremely important and should be included in a Proprioception can be improved with a number of treat-
comprehensive rehabilitation program. ment techniques. Early weight bearing can help to decrease the
 CHAPTER 31  Principles of Rehabilitation for the Foot and Ankle 559

Fig. 31.5 Inversion. Fig. 31.6  Ankle eversion with tubing.

amount of proprioception loss. A patient can practice standing Our experience with and observation of clinical healing and
with equal weight on both feet, progressing to single-leg stance. postoperative wound healing have proven that it is important
A biomechanical ankle proprioception system (BAPS) board to progress the patient’s activity gradually. Increasing the time
or kinesthetic awareness trainer (KAT) can be used as a patient increments of 10 minutes a week on a bike will allow the patient
advances through rehabilitation (Fig. 31.8). to be working approximately 30 minutes per session in a 3-week
span (Table 31.1). Typically, low-impact weight-bearing exercise
will be introduced when the athlete is able to walk normally in a
CARDIOVASCULAR ACTIVITIES protective device and regular shoe. The rehabilitation program
During the rehabilitation program it is extremely important to will begin replacing 1 day of bike with a StairMaster/elliptical
keep the patient active. If the patient becomes sedentary, the cel- machine (Table 31.2). We allow an additional day of StairMaster
lular metabolism levels will decrease and the individual will lack or elliptical each successive week until the athlete has been
energy, and may experience both diminished desire and blunted converted to StairMaster or elliptical 4 to 6 days per week. The
motivation because of a form of depression seen after injury in athlete will continue to increase low-impact weight-bearing
athletes. This consequently can present a challenge for recovery exercise as tolerated. We have found that when an athlete can
and rehabilitation. Early in the rehabilitation, we feel that it is work out on the StairMaster or elliptical machine 4 to 5 days a
vital to start a sensible regimen of low-resistance exercise bike week for 30-plus minutes, it is safe to initiate running. Running
or pool therapy training 3 to 4 days a week for 10 to 15 minutes should gradually replace StairMaster/elliptical each week. It is
with a progression by 5 to 10 minutes of training per session important to give the athlete a set of running guidelines that
per week. If the bike is used, then a walking boot or protective allows for a gradual progression of activity (Table 31.3).
brace is used. Pool therapy is not initiated until the sutures are
removed and the wound is fully healed. By initiating early activ-
ity during the rehabilitation program, the cellular metabolism
ADDITIONAL TREATMENT CONSIDERATIONS
will be maintained. The early exercise also provides psycholog- Personalized blood flow restriction training (PBFR): PBFR
ical benefits for the athlete. Physically it allows an active blood training involves decreasing blood flow to working muscles in
flow to the involved extremity, and psychologically it helps to order to promote hypertrophy and prevent disuse atrophy of
keep the patient motivated and counteracts the potential for muscles. The technique utilizes the application of pneumatic
depression. cuff, similar to a blood pressure cuff, on the proximal aspect
560 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

A B
Fig. 31.7  A, Resisted eversion using Thera tubing. B, Side-lying eversion with tubing.

TABLE 31.2  Wean out of Boot

Wean off Crutches
Week 1 Use both crutches and bear as much weight as tolerated
Week 2 Use one crutch on side opposite of your injury

Wean out of Boot

Daytime (8–4 pm) Evenings (4 pm On)
Week 1  Boot Shoe   Boot Shoe 
 Brace Insert   Brace Insert 
Week 2  Boot Shoe   Boot Shoe 
(Mon, Wed, Fri)  Brace Insert   Brace Insert 
(Tues, Thurs,  Boot Shoe   Boot Shoe 
Sat, Sun)  Brace Insert   Brace Insert 
Week 3  Boot Shoe   Boot Shoe 
Fig. 31.8  Biomechanical ankle proprioception system (BAPS) board for  Brace Insert   Brace Insert 
balance and range of motion.
Cardiovascular Exercise
Boot Brace Shoe Insert
TABLE 31.1  Cardiovascular Exercise Exercise Times
Equipment Minutes Per Week
CARDIOVASCULAR EXERCISE
Week 1  Stationary Bike 10 15 20 3 4 5
Boot Brace Shoe Insert  Stairmaster
 Elliptical
Exercise Times Per
Equipment Minutes Week Week 2  Stationary Bike 15 20 25 3 4 5
 Stairmaster
Week 1  Stationary Bike 10 15 20 3 4 5
 Elliptical
 Stairmaster
 Elliptical Week 3  Stationary Bike 20 25 30 3 4 5
 Stairmaster
Week 2  Stationary Bike 15 20 25 3 4 5
 Elliptical
 Stairmaster
 Elliptical
Week 3  Stationary Bike 20 25 30 3 4 5 the muscle fibers leads to up-regulation of the muscle hypertro-
 Stairmaster phy-signaling cascade (Fig. 31.9, A through C).36,37
 Elliptical This can be used during all phases of rehab to help enhance
strength gains. An important application of PBFR training has
been to treat patients in the rehabilitation phase following a
of an upper or lower extremity. A selected pressure is used to period of injury or deconditioning after injury or surgical inter-
provide venous occlusion to the distal aspect of the limb.35,36 vention. Postoperative rehabilitation can require prolonged
PBFR creates an anaerobic environment. At the lower oxygen treatment to achieve preinjury muscular strength. Furthermore,
tension level the body recruits muscle fibers normally reserved some surgical interventions require delays in high intensity train-
for more strenuous exercise. In return, the mechanical stress on ing to allow postoperative healing of repaired or reconstructed
 CHAPTER 31  Principles of Rehabilitation for the Foot and Ankle 561

TABLE 31.3A  Distance Running TABLE 31.3B  Distance Running

Progression (Distance Goal) Progression (Time Goal)
Methodist Sports Medicine—The Orthopedic Specialists Methodist Sports Medicine—The Orthopedic Specialists
Distance Running Progression Distance Running Progression
Distance Goal Time Goal
Your injury has resolved enough to let you begin running again, but it is Your injury has resolved enough to let you begin running again, but it is
necessary to return to previous mileage gradually. The following guidelines necessary to return to previous mileage gradually. The following guidelines
will help to ensure a safe return “to the road.” will help to ensure a safe return “to the road.”
• Make sure that you stretch before and after running. • Make sure that you stretch before and after running.
• Keep the running surface as soft, smooth, and level as possible. • Keep the running surface as soft, smooth, and level as possible.
• Emphasize form. • Emphasize form.
• Ice the involved area 20–30 minutes after running. • Ice the involved area 20–30 minutes after running.
• Follow the mileage guidelines listed below. Do not progress to the next • Follow the time guidelines listed below. Do not progress to the next step
step if the previous one caused pain or compensation. if the previous one caused pain or compensation.

Previously Running 15–20 Miles per Week Previously Running 15–30 Minutes per Day
DAY DAY
1 2 3 4 5 6 7 Total Miles 1 2 3 4 5 6 7 Total Minutes
1 .5 0 .5 0 .75 0 1 2.75 1 5 0 5 0 8 0 8 26
2 0 1 0 1 0 1.5 0 3.5 2 0 10 0 10 0 12 0 32
Week

Week
3 1.5 0 2 0 2 2 0 7.5 3 12 0 15 0 15 12 0 54
4 2 0 2.5 2 0 3 0 9.5 4 15 0 18 15 0 20 0 68
5 3 0 3.5 3 0 4 0 13.5 5 20 0 25 20 0 25 0 90
6 4 3 0 4.5 4 4 0 19.5 6 30 25 0 30 25 25 0 135

Previously Running 20–35 Miles per Week Previously Running 30–45 Minutes per Day
DAY DAY
1 2 3 4 5 6 7 Total Miles 1 2 3 4 5 6 7 Total Minutes
1 .5 0 .75 0 1 0 1 3.25 1 5 0 5 0 8 0 10 28
2 0 1 0 1.5 0 2 0 4.5 2 0 10 0 12 0 15 0 37
Week

Week

3 2 0 2.5 2 0 3 0 9.5 3 15 0 15 0 15 12 0 57
4 3 3 0 4 3 0 2 15 4 20 0 20 15 0 25 0 80
5 0 4 4 0 5 4 3 20 5 25 25 0 30 25 25 0 135
6 0 6 5 0 5 5 4 25 6 30 30 30 0 35 0 40 165

A B C
Fig. 31.9  Blood Flow Restriction (BFR).
562 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

A B
Fig. 31.10 Cupping.

joints. BFR therapy needs to be discussed and approved by the movement impairments. The term “dry” needle is used because
Ortho MD prior to utilizing on the athlete/patient. the needle is inserted in the skin without medication or fluids.
A lower-extremity exercise program would be utilizing the It has been most commonly used to treat myofascial trigger
BFR in conjunction with an exercise the patient is capable of points. A trigger point is a taut band of skeletal muscle located
doing during the rehab process.38,39 The occlusion can be set within a larger muscle group, which may cause pain and cause
between 60% and 80% depending on patient comfort. Eighty muscular dysfunction (Fig 31.11, A and B).
percent is the highest setting used on the lower extremity. The Dry needling will cause the body to release calcitonin
patient will then complete 30,15,15,15 reps with a 30-sec rest gene-related peptide (CGRP), which causes a cascade of reac-
between sets or to failure. Some examples of exercises can tions resulting in vasodilation, increased blood vessel forma-
include Thera-Band ankle strengthening, calf raises (seated or tion, and increased tissue repair.44 In addition, an enkephalin
standing), and body weight squats. release will occur resulting in a local pain response.45 Moreover,
The Owens Recovery Science provides education and certifica- a beta endorphin release from the brain creating an analgesic
tion to utilize PBFR training. (www.owensrecoveryscience.com) effect will result in an overall systemic response.45
Myofascial Decompression Techniques (MDT; cupping) has Physical therapists use dry needling with the goal of releas-
been used for recovery, pain relief, and soft-tissue manipulation ing or deactivating trigger points to relieve pain or improve
(Fig. 31.10, A and B). The biomechanical and neurophysiologi- ROM. Dry needling depends upon physical examination and
cal effects of myofascial cupping remain theoretical. Myofascial assessment to guide the treatment; moreover, this allows you
cupping appears to temporarily exaggerate the condition so as to test and retest after a dry needling treatment has been per-
to “kick-start” the physiologic changes necessary to “reset” the formed. It gives you the opportunity to show tangible changes
tissue.40 By propagating the tissue’s hypoxic state, more lactate pre and post treatment. Preliminary research46 supports that
is produced, thereby increasing the acidity.40 In skeletal muscle, dry needling improves pain control, reduces muscle tension,
the added acidity has been shown to combat fatigue41 and stim- and normalizes dysfunctions of the motor end plates, the sites
ulate nitric oxide release, resulting in improved microcircula- at which nerve impulses are transmitted to muscles. It expedites
tion and blood flow via vasodilation.42 the healing process and repair of tissue while decreasing pain
Myofascial Decompression Technique is reported by many cli- and increasing ROM; this response allows athletes and clients to
nicians to reduce pain and increase pressure-pain thresholds in return back to their sport or activity much quicker.
athletes with myofascial pain and/or localized myofascial trigger There are several schools of thought regarding dry needling.
points with the effects comparable to other instrument-assisted My personal experience has been through Kinetacore training.
soft-tissue mobilization (e.g., Graston) and ischemic compression Before utilizing any type of needling, it is critical to go to an
techniques.43 It is usually utilized in Phase I and Phase III rehab appropriate course and become certified (www.kinetacore.com).
as an additional soft-tissue therapy. Typically a practitioner will In addition, you should discuss with the patient’s surgeon before
utilize cupping in conjunction with movement to help decrease utilizing postoperative.
trigger activity and improve the quality of movement. Myofascial
Decompression Technique therapy should be discussed and
approved by the Ortho MD prior to utilizing on the athlete/patient.
FUNCTIONAL PROGRESSION
Practitioners should take a course before applying MDT A functional progression is a series of sport-specific skills that
therapy to patients. (www.MyofascialDecompression.com) increase in the level of difficulty that an athlete must complete
Functional dry needling is a technique utilized, by qualified before he or she can safely return to competition. Yamamoto and
practitioners allowed by state law, for the treatment of pain and Fragi described a functional progression in the rehabilitation
 CHAPTER 31  Principles of Rehabilitation for the Foot and Ankle 563

A B
Fig. 31.11  Dry needling.

of injured West Point cadets.47,48 The emphasis in this pro- TABLE 31.4  Field Sports Functional
gram was placed on restoring agility through dynamic exercise Progression
after knee injury. Kegerreis et  al.49 added specific movement
patterns and skills to the program and introduced the impor- Methodist Sports Medicine—The Orthopedic Specialists
tance of addressing the psychological needs of the injured Field Sports Functional Progression
Once you have completed the appropriate phases of rehabilitation it will be
athlete. They also addressed the scientific principles that play
possible to begin a functional progression. The functional progression is
an important role in the functional progression and the need an ordered sequence of activities that enable you to reacquire the skills
to break down sport-specific functions to be addressed in the necessary for safe and effective return to athletic endeavors.
order of difficulty. Begin with step one. If you can do the prior step without pain or limping, you
The functional progression is vital to a complete sport-spe- may proceed to the next step. It is very important that you perform each
cific rehabilitation program. It serves as the key element in exercise correctly and without apprehension. When you have successfully
advancing the athlete from clinical rehabilitation to athlet- completed each step of the functional progression you may then attempt to
ics. Each sport has certain demands and skills that stress the return to your sport. You should wear any protective equipment recom-
foot and ankle differently. Sport-specific functional progres- mended by your physical therapist or athletic trainer.
sions need to be designed to incorporate the demands of the 1. Heel raises on the injured leg - 10 times
sport or activity that the athlete will return to. This chapter 2. Walk at fast pace for 50 yards
3. Jump on both legs - 10 times
will include specific functional progressions to show the dif-
4. Jump on the injured leg - 10 times
ferences. It is extremely important that the athlete advance one 5. Jog straight - 50 yards
step at a time without pain or apprehension. Once the ath- 6. Jog straight and curves - two laps each direction
lete has completed the list of activities in order without pain 7. Sprint - 1/2, 3/4, full speed - 40 yards
or apprehension, he or she may return to full sport activity 8. Run figure 8’s - 1/2, 3/4, full speed - 15 yard distance
(Tables 31.3 through 31.7). 9. Cariocas (cross-overs) 40 yards - both directions
There are several physical and psychological benefits that the 10. Backward run - 40 yards
functional progression will address. The functional progression 11. Cutting - 1/2, 3/4, full speed for 40 yards
promotes healing through the application of Davis’ law and 12. Position drills ________________________________
Wolff ’s law, which were discussed earlier. It is important that
the healing tissue be stressed in the way required of it before
injury so that the tissue will be ready to fully accept preinjury
PHASES OF REHABILITATION
activity requirements. As described in Davis’ law and Wolff ’s The cornerstone to appropriate rehabilitation is an accurate diagno-
law, injured tissue and bone stressed in this controlled manner sis, so that an appropriate rehabilitation program can be established
will lead to further tissue and bone healing and strength. In efficiently and safely. For any injury or condition, the rehabilitation
addition, the functional progression breaks up the monotony can be divided into three general phases. Each phase has specific
of traditional rehabilitation and allows the athlete to begin per- goals, and although there is a time frame assigned to each phase,
forming activities related to function. Psychologically it allows advancement from one phase to another should be based on the
the athlete to increase self-confidence and mentally prepares patients achieving the prescribed goals rather than on time. A cli-
him or her to return to sport. As the athlete completes each step, nician must be willing to adapt and modify the exercise program
confidence will increase and apprehension will decrease, allow- for each patient. There are a variety of rehabilitative techniques to
ing the athlete to enter the competitive environment at the level choose from; each can have benefit to the patient. As a clinician, it
of function needed for playing standards. is important to stay up to date with current rehabilitative trends.
564 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

TABLE 31.5  Court Sports Functional TABLE 31.6  Ballet Dance Functional
Progression Progression
Methodist Sports Medicine–The Orthopedic Specialists Ballet Dance Functional Progression
Court Sports Functional Progression Lower Extremity
Once you have completed the appropriate phases of rehabilitation, it will be Once you have completed the appropriate phases of rehabilitation, it will be
possible to begin a functional progression. The functional progression is possible to begin functional progression. The functional progression is an
an ordered sequence of activities that enable you to reacquire the skills ordered sequence of activities that enable you to reaquire the skills necessary
necessary for safe and effective return to athletic endeavors. for safe and effective return to dance. Begin with step one. If you can do this
Begin with step one. If you can do the prior step without pain or limping, you exercise correctly without pain, you may proceed to the next step. It is very
may proceed to the next step. It is very important that you perform each important that you perform each exercise properly, without apprehension.
exercise correctly, without apprehension. When you have successfully When you have completed each step of the functional progression, you may
completed each step of the functional progression, you may then attempt return to dance. Begin with one basic technique class, then slowly add
to return to your sport. You should wear the Air-cast, Swedo, knee brace, or other classics, then rehearsals. If you must do rehearsals sooner due to an
tape as instructed by your physical therapist or athletic trainer. upcoming performance, reduce the number of class hours accordingly to a
minimum of one technique class.
1. Heel raises on the injured leg - 10 times Triangle Drills 1. 16 demi plies on both legs then single leg on injured side
2. Walk at fast pace full court - 2 times 2. 16 releves on both legs, then single leg on injured side
3. Jumping on both legs - 10 times 3. Barre activities (limiting sustained releve sequences) or floor work
4. Jumping on the injured leg - 10 times warm-ups
5. Jog straight - full court 4. Center practice (adagio, barre exercises done in center, standing jazz or
6. Jog straight and curves - two laps each direction modern combinations)
7. Sprint - ½, ¾, full speed - full court 5. Pirouettes or pivoting on one leg
8. Run figure 8’s - ½, ¾, full speed - baseline to a. Promenades, retire balances (piroutte preparation)
1/4 court b. Simple turns from fourth, fifth, or second position
9. Triangle drills - sprint baseline to ½ court, c. Soutenu, pique, and chaine turns
backward run to baseline, defensive slides d. Grand pirouettes (attitude orarabesque turns, tours a la seconde)
along baseline, both directions e. Avoid fouettes or repeated releves on one leg
10. Cariocas (cross-overs) - ½, ¾, full speed 6. Simple across the floor combinations
11. Cutting – - ½, ¾, full speed – full court 7. Jumping
12. Position drills _______________________ a. Double leg low impact — sautés, changements echappes, soubresauts
____________ b. Double to single leg — assembles, jetes, glissades, pas de chats,
sissonnes
c. Batterie (add beats and speed to basic jumps)
Phase I d. Single leg — repeated single-leg jumps temp leves
Phase I emphasizes pain modulation and inflammatory control 8. Pointe work at barre following above progression
of the soft tissues. Controlling pain and inflammation will allow 9. Pointe work in center- simple releves, soutenus, echappes, piques
patients to be better able to perform their rehabilitation exer- 10. Fouettes or repeated turns on one leg not en pointe
cises. Restoration of normal ROM and joint accessory motions, 11. Grand allegro/traveling leaps
including glide, roll, and spin, are stressed in this phase. Early 12. Complex pointe work- fouettes, hops en pointe, grands pirouettes
return of pain-free ROM will enhance the rehabilitative process
and allow the patient to begin isolated and functional rehabil- Advanced activity-specific exercise should be implemented with
itation exercises in phase II with greater effectiveness. Once a special attention to mechanics of the activity. Proper mechanics,
patient has minimal pain and has normal to near-normal ROM, as well as maintenance of flexibility and strength, can prevent
he or she may be advanced to phase II. further chance of reinjury. To ensure safe return to sport, athletes
should perform a functional progression. External supports such
Phase II as braces, straps, taping, and orthotics may be used at this time
Once inflammation is decreased, pain has subsided, and ROM to allow the patient to participate in his or her activity pain free.
is near normal, phase II may begin. Foot and ankle flexibility
with functional strengthening are initiated and are the focus of An Updated Rehabilitation of Achilles
this phase. In addition, cardiovascular conditioning and pro- Tendon Repair
prioceptive training also are started at this time. The goals of The research suggests that the incidence of Achilles tendon rup-
this particular phase are to improve flexibility, restore strength, ture is increasing and the majority (68%) of ruptures occurred
and begin light, sport-specific functional training. A patient during sports participation (Raiken). Only 4% of Achilles rup-
may be progressed to phase III when he or she is ready for a tures have an associated Achilles tendinopathy, and two-thirds
gradual return to activity and participation in sports. of ruptures report no pain prior to the rupture (tallun).
The rehabilitation after an Achilles repair is an example
Phase III of progression toward a more functional recovery. Recently,
Emphasis in phase III is on functional return to activities of rehabilitation after an Achilles repair has progressed from
daily living (ADLs) and previous activity/sport participation. long-leg casting to short-leg casting to the use of intermittent
 CHAPTER 31  Principles of Rehabilitation for the Foot and Ankle 565

TABLE 31.7  Contemporary Dance

Functional Progression
Contemporary Dance Functional Progression
Lower Extremity
Once you have completed the appropriate phases of rehabilitation, it will
be possible to begin functional progression. The functional progression is
an ordered sequence of activities that enable you to reacquire the skills
necessary for safe and effective return to dance. Begin with step one. If you
can do this exercise correctly without pain, you may proceed to the next
step. It is very important that you perform each exercise properly, without
apprehension.
When you have completed each step of the functional progression, you may
return to dance. Begin with one basic technique class, then slowly add
other classes, and then rehearsals. If you must do rehearsals sooner due to
an upcoming performance, reduce the number of class hours accordingly to
a minimum of one technique class.
1. 16 plies (mini-squats) on both legs, then single leg on injured side
2. 16 heel raises on both legs, then single leg on injured side
3. Floor work warm-ups
4. Standing warm-ups and combinations in center without jumps
5. Turning and pivoting on one leg
a. Simple turns in place
b. Traveling turns across the floor
c. Attitude fouettes or similar repeated turns in one second
d. Pitch turns, illusions
e. Avoid fouettes or similar repeated turns on one leg
6. Simple across the floor combinations
7. Combinations including floor work and transitions to floor (falls, rolls)
8. Jumping Fig. 31.12  Toe curls.
9. Fouettes or repeated turns on one leg
10. Large traveling jumps across the floor (split leaps, stag leaps)
instructed to be non weight bearing for the first 5 to 7 days and
is appropriately trained in axillary crutch use (or rolling cart for
immobilization and early weight bearing. Mandelbaum et al.50 the involved knee if preferred by the patient) for walking and
have established an accelerated rehabilitation protocol for the negotiating stairs. This decreases the risk of early postoperative
Achilles repair. Their protocol involves early ROM at 72 hours swelling and allows appropriate initial wound healing.
and early weight bearing at 2 weeks post repair. This functional The immediate postoperative protocol consists of rest, eleva-
approach allows the competitive athlete to return to sports more tion, and continuous daytime Cryocuff use. The patient also is
quickly without a reported increase in complications. instructed to wiggle toes and perform leg lifts every 3 to 4 hours
At Methodist Sports Medicine, over 300 acute Achilles in the first postoperative week.
repairs have been performed over the past 22 years using an Dressing changes and rehabilitation will begin 1-week post-
ankle-block anesthetic, no casting, intermittent immobilization operatively. Physical therapy will consist of a home exercise pro-
with a removable boot, and cryotherapy. Patients have been full gram, gradual progression of weight bearing, and a light bike
weight bearing by 2 weeks, and ROM is started at the first post- program to maintain cellular metabolism. The rehab program
operative visit, along with a bike program and sitting toe raises. will start with isometric calf contractions, toe curls (Fig. 31.12),
We use the concept that early-protected ROM and weight bear- and leg raises in all four directions. After the first 7–10 days
ing encourage strong tendon healing and protect against dis- the program will include active PF, resistive-band PF (see Fig.
use atrophy. The goal of the surgery is to return full strength, 31.4), and sitting calf raises (Fig. 31.13). We use the concept of
power, and function in the shortest and safest amount of time. early-protected motion and resistance training, which encour-
The re-rupture rate has been consistent with that of less accel- ages stronger tendon healing and protects against disuse atro-
erated protocols (<2%). The general rate of return to strength is phy. Exercises are performed at a higher frequency with a low
75% by 3 months and 90% by 6 months. This is an example of load (see phase I exercise prescription) to continuously stimu-
our rehabilitation program that is consistent with all accelerated late the tendon to heal. It is extremely important to avoid ankle
programs. DF activity or a heel cord stretch to protect the tendon from
Immediately postoperatively the patient is placed in an overstretching.
Aircast walking boot with a built-in Cryocuff. The walking boot Partial weight bearing is started at 1 week with a gradual pro-
also has one 9/16-inch felt heel lift placed inside to put the foot/ gression to full weight bearing at 2 to 3 weeks postoperatively.
ankle in a slight equinus position for healing. (We will use two The first week of rehabilitation allows partial weight bearing
heel lifts if the repair is 3–8 weeks after the tear.) The patient is in the walking boot with axillary crutches and the amount of
566 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

Fig. 31.13  Seated calf raise. Fig. 31.14  Biking in boot.

weight bearing is increased as tolerated by pain and swelling. approximately 60 seconds. Once that is achieved, balance is
After the first week, the patient may begin using one crutch progressed to a soft surface with other possible variations (i.e.,
under the opposite arm and then progress to full weight bearing ball toss). Patients will begin bilateral calf raises (Fig. 31.16)
when the athlete is able to walk normally. with a progression to single calf raises (Fig. 31.17). Thera-
A bike program is initiated in the first week using the walk- Band exercise is performed in all directions to incorporate the
ing boot. The program consists of 10 minutes three times entire ankle. However, DF past neutral is not allowed. Once
the first week and increases by 10 minutes per week and to 4 completely out of the boot, 1 day of elliptical/StairMaster may
days over the first month. We progress this slowly to give the be substituted for the bike each week, so that over a 4-week
incision/wound time to heal without increasing the moisture period the athlete transitions into full cardiovascular workouts
or swelling to the ankle. Once clinical wound healing has with a StairMaster/elliptical 4 to 5 days a week. It is important
occurred, a patient can be more aggressive with cardiovascular to avoid passive DF or Achilles tendon stretching to protect
activity (Fig. 31.14). the Achilles repair from stretching out. We have found that
The second phase of rehabilitation begins approximately 6 normal DF will return naturally without being aggressive with
weeks after repair. At this time, an increase in weight-bear- DF motion.
ing exercise is allowed, and proprioception retraining with an Swimming is permitted at the 6-week mark for condition-
emphasis on normal gait is initiated. Athletes at this time are ing. A weight-bearing pool program can be initiated at 8–10
instructed in a program to wean out of the boot into an ath- weeks depending on the progress of the patient. This program
letic shoe with one 9/16-inch felt heel lift. Our goal is to wean will start at chest-high water and advance to waist-high water as
the patient out of the boot over 2 weeks with normal pain-free the patient tolerates. The program will consist of light agilities,
gait. jogging, and eventually running (Tables 31.3, 31.8, 31.9).
Exercises in the second phase consist of balance, standing The final phase of rehabilitation starts approximately at the
calf raises, and elliptical/StairMaster progression. Single-leg 3-month mark. Patients will continue to work on balance, ankle
heel raise performance is critical for an athlete to return to strength, and unilateral calf raises. At this time, full lower-
function. Long-term deficits can lead to altered biomechan- extremity strengthening will be initiated. Exercise will include
ics and therefore to a decrease in performance (Silbernage, stepdowns (Fig. 31.18), leg press (Fig. 31.19), knee extensions
Olssun). Fifty percent of patients can perform a full single- (Fig. 31.20), and hamstring curls that can be advanced per
leg heel raise by 3 months. Single-leg balance (Fig. 31.15) patient tolerance. Weighted calf raises typically are initiated
is first initiated barefoot on a hard surface with a goal of around 4 months.
 CHAPTER 31  Principles of Rehabilitation for the Foot and Ankle 567

Fig. 31.15  Single-leg balance with sissel. Fig. 31.17  Single-leg calf raise.

Once an athlete is capable of using a StairMaster/elliptical

machine for 30 minutes 5 days a week, he or she may begin
light jogging (usually at 3–4 months after the repair). A tread-
mill progression can be started at this time. Once an athlete can
complete a treadmill progression with good running mechanics
and no symptoms, they can advance to field or court agilities.
Agility drills should be advanced gradually per patient toler-
ance. Before return to sport, the patient should successfully
complete a functional progression to ensure a safe return to
competition. Return to sports normally occurs at 5 to 8 months
after surgery. Typically, at 6 months and 1 year postoperative the
patient will undergo isokinetic strength testing in our clinic. It
is our desire and experience that almost every patient achieves
80% of PF strength, which is the critical level of strength for
return to sport. In our experience, DF strength on the operative
side is typically stronger due to the altered strike patterns post-
operative. (Fig 31.21, A and B)

Rehabilitation After Open Reduction and Internal

Fixation of Lisfranc
The rehabilitation process after a Lisfranc open reduction and
internal fixation (ORIF) begins by having the patient non–
weight bearing in an AirCast boot for 6 weeks to allow for heal-
ing. Crutches or a “roll-a-bout” may be used with an AirCast
boot to help the patient maintain the non–weight-bearing status.
Phase I of the rehabilitation will be from day 1 postop to 6
wks. The goals for phase I are to allow healing, control swell-
Fig. 31.16  Bil calf raises. ing, increase ROM, light subtalar strengthening, and eliminate
568 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

TABLE 31.8  Weight-Bearing Pool incision sensitivity. Gentle active ROM into DF, PF, IN, EV,
Training Program Achilles tendon stretch with a towel (Fig. 31.22), toe curls, and
desensitization massage all begin at 1-week postoperative. We
Phase I (warmup 2 lengths) use an Aircast Cryocuff in the boot to provide cold and com-
Jogging pression. Patients utilize either crutches or a roll about for
High knees
ambulation in order to maintain their non–weight-bearing sta-
Butt kicks
A skips
tus. At the 2-week status postop we will begin seated calf raises,
B skips tubing DF, PF, IN, and EV. If the incision is healed at 2 weeks,
Shuffle aquatic therapy can be added as well as icing with a vasopneu-
Carioca matic device.
Clawing exercise - 2 set 8
Quick feet scissors - 2 set 10
Quick fit long stride - 2 set 10
Quick feet hip rotation - 2 set 10
Jogging/running - 4 x 10 sec
Phase II (plyo series)
Straight leg plyos (ankle emphasis)
straight leg - 4 x 8
single leg - 4 x 6 each
Diagonal Bounding one 1 leg with stick (bounding over a hurdle)
3 set 6 (3 per side)
Waist-deep jumps (2 foot landing-stick)
3 x 4 jumps/30 sec rest
Waist-deep jumps (1 foot landing-stick)
2 x 4 (alternate feet)
Waist-deep rebound jumps (2 foot landing)
3 x 4 jumps/30 sec rest
Phase III (conditioning)
Chest-deep running
8–12 set 30 sec with 15–30 sec rest (start at 30 and progress to 60
resistance)
Waist-deep running
8–12 set 30 sec with 15–30 sec rest (start at 50 and progress to 80
resistance)

TABLE 31.9  Deep Pool Training Program Fig. 31.18  Four in step down side view.

Program I
Rep 1- 20 sec run – 20 sec rest
Rep 2- 18 sec run – 20 sec rest
Rep 3- 15 sec run – 20 sec rest
Rep 4- 12 sec run – 20 sec rest
Rep 5- 10 sec run – 20 sec rest
Rep 6- 8 sec run – 20 sec rest
Rep 7- 6 sec run – 20 sec rest
Rep 8- 18 sec run – 20 sec rest
Rep 9- 12 sec run – 20 sec rest
Rep 10- 8 sec run – 20 sec rest
Rep 11- 20 sec run – 20 sec rest
Rep 12- 15 sec run – 20 sec rest
Rep 13- 10 sec run – 20 sec rest
Rep 14- 6 sec run – 20 sec rest
Rep 15- 18 sec run – 20 sec rest
Program II
15 reps 20 sec run – 15 sec rest
Fig. 31.19  Single-leg press.
 CHAPTER 31  Principles of Rehabilitation for the Foot and Ankle 569

Phase II begins at 6 weeks and is when weight bearing in the wean out of the boot over 2 weeks into a shoe and carbon fiber
boot can be initiated. The patient will utilize crutches with their plate. At 8 weeks s/p, the patient may bike in an athletic shoe
boot for ambulation until they are able to ambulate pain free and carbon fiber plate. The patient may gradually add time on
and limp free in the boot. In our experience, the patient is able the bike using pain as their guide. Once the patient is able to
to wean off the crutches on average in 7–10 days. Proprioception achieve 30 minutes of biking pain free, the StairMaster/elliptical
retraining is initiated in the boot. This allows the patient to gain (upright, low impact cardio) is substituted. Aggressive Achilles
confidence by weight bearing through the affected extremity as tendon stretching is initiated in the shoe and CFP at this time
well as reactivate the proprioceptors. Biking is also begun in the (Fig. 31.23). Standing bilateral calf raises in progressing to single-
boot. The patient may progress toward 30 minutes in the boot leg calf raises in shoes/CFP begin at 6–8 weeks in order to
as their foot tolerates. The patient is instructed in a schedule to aid the patient in proper push off as well as strengthening the
gastrocnemius.
Phase III begins at 12 weeks. Typically, a functional pro-
gression to the patient’s particular sport is initiated. The patient
must have full ROM, flexibility, and strength in order to begin
the functional progression. The patient must also be able to tol-
erate >30 minutes of cardiovascular exercise on the elliptical or
StairMaster on 5 consecutive days prior to starting the func-
tional progression. The functional progression is used to allow
the patient to gradually and safely return to sport. Removal of
hardware is performed no earlier than 3 months after the initial
operation.

Fifth Metatarsal Open Reduction and Internal

Fixation Rehabilitation
Phase I of rehabilitation after the ORIF of the fifth metatarsal
goals are to allow for fracture site healing, obtain full subtalar
and talocrual ROM actively and passively, control swelling,
Fig. 31.20  Single-leg knee extension machine. and eliminate incision site sensitivity. The patient will remain

A B
Fig. 31.21  A, Dorsiflexion cybex. B, Plantarflexion cybex.
570 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

Fig. 31.22  Achilles tendon stretching with strap.

Fig. 31.24  C splint.

crutches and be full weight bearing in the boot in 7–10 days.

Proprioceptive retraining is started in the boot. This will help
the patient become more confident in weight bearing on the
surgical limb as well as reactivate proprioceptors in their foot
and ankle. Biking in the boot should begin, and the patient may
increase the time on the bike as their foot tolerates and should
use pain/swelling as their guide. Thera-tubing into eversion is
initiated to begin strengthening the peroneals.
At 6 weeks postop, phase II of the rehabilitation process
begins. The patient will wean out of the boot into a running
shoe with a semi-rigid carbon-fiber plate over 2 weeks. The
patient can begin biking in their shoe/plate and rework up to
30 minutes. Standing bilateral calf raises are initiated to help
the patient with toe-off during gait as well as recover strength
in the gastrocnemius. The patient will use pain as their guide
Fig. 31.23  Step stretch side view. in order to progress toward a single-leg calf raise. Peroneal
strengthening should be advanced in this phase using a side-
lying eversion exercise. See Fig. 31.7, A and B. Advanced pro-
non–weight-bearing for the first 2 weeks postop. The patient prioceptive training on uneven surfaces, ball tossing, or kicking
will utilize a short Aircast boot and either crutches or a roll-a- with contralateral foot should also be initiated.
bout to maintain their non–weight-bearing status on the oper- Phase III of the rehabilitation involves return to sport
ative side. Active ROM DF, PF are initiated at week 1. Seated (approximately 8–12 weeks). A fifth metatarsal clamshell splint
calf raises, toe towel curls as well as desensitization massage is made for the patient to wear during all sport activities. The
also begin at 1-week s/p. Beginning at 2-week s/p, the sutures splint is made of perforated aquaplast by the physical thera-
are removed. If the incision is healing well, aquatic therapy and pist. The patient is to wear the splint directly on their skin with
use of a vasopneumatic device are allowed. The patient will their sock/cleat over it. The splint provides support to the screw
begin to gradually initiate weight bearing using crutches and fixation and decreases stress on the lateral foot and fifth meta-
the boot. In our experience, patients typically can wean off the tarsal (Fig. 31.24). If x-rays show good healing, the functional
 CHAPTER 31  Principles of Rehabilitation for the Foot and Ankle 571

progression may be started as early as 8–10 weeks. If the x-rays TABLE 31.10  Treadmill Warm-Up &
do not show complete healing, return to play is delayed until Progression
10–12 weeks postop. The sport-specific functional progression
must be passed without pain or compensatory patterns in order Move incline to 1.0
Warm-Up: This is done consecutively
to be released to play.
1 Min Each Speed
The carbon fiber plate is discontinued for everyday activities
3.0 mph, 3.5, 4.0, 5.0
at 12 weeks postop. The athlete is to continue to use the plate for Progression starts at 6.0 mph and bouts are 30 sec run with a 30 sec rest in
all sporting activities until 6 months postop. between.
We increase by .5 mph every run up to 10.0 mph, then the run time decreases
High Ankle Sprains to 15 sec run with 30 rest. The top speed that we like to see for Lineman is
Phase I (7–10 days) 12.0 mph and up to 14 mph.
We place the patient/athlete in full walking boot. We teach If the athlete is running better but has not made it to the top speed but has
proper gait mechanics in the walking boot. We emphasize heel run a couple of times, the .5 increments can be skipped at the lower speeds.
to toe to avoid hip rotation and turn out of the leg. If the patient We also like a 2 min cool down at a brisk walk or light jog.
still has antalgic gait pattern, we utilize axillary crutches or 3.0 – 1 min 7.5 – Run 30 Rest
one of strand crutches. The goal would be to move from two 3.5 – 1 min 30 Rest 10.5 - Run
crutches, to one crutch and eventually full weight bearing as 4.0 – 1 min 8.0 – Run 30 Rest
soon as the patient can walk normal. The idea of early weight 4.5 – 1 min 30 Rest 11.0 - Run
bearing will help stimulate the lower extremity muscles to help 5.0 – 30 sec 8.5 – Run 30 Rest
diminish any additional strength and atrophy concerns. The 5.5 – 30 sec 30 Rest 11.5 - Run
boot allows for protected weight bearing and will allow the liga-
6.0 – 30 sec 9.0 – Run 30 Rest
ment to heal and avoid rotational stresses.
6.5 – Run 30 Rest 12.0 – Run
Early rehabilitation goals focus on pain and swelling reduction
while starting some specific ROM and exercises. During the first 30 Rest 9.5 – Run 2 Min Cool Down 3.5
mph
3 days we will focus on cryotherapy (Game Ready, ice, etc...) and
compression. We will also use Hivamat, soft-tissue massage, and 7.0 – Run 30 Rest
other compression modalities to help promote lymphatic drain- 30 Rest 10.0 – 15 Sec Runs Start
age and decrease swelling. The early rehab consists active and
passive DF, towel toe curls, seated calf raises without resistance
to comfort, and tubing for DF. During the week we will add PF stair stretch, or utilizing a slant board. Stretch times should
ROM and tubing as the patient tolerates. Some additional exer- range between 3 and 5 minutes with either using a sustained
cises to help the lower extremity are multidirectional leg raises, stretch or booted stretching if sore. Strengthening will follow
knee extensions/leg curls, and core work. We will start the patient the same pattern with Thera Band, manual resistance, or sand
on a bike program once they can walk full weight bearing in a weights for DF and IN. Weight bearing exercises will focus
boot. on calf raises (double to single), single-leg balance progres-
The home exercise program consists of active ROM for sion step-downs, and bosu squats to begin functional training.
DF and PF. Passive DF or calf stretching can be started with a Additional lower-extremity strengthening can be started in a
stretch strap or towel. regular shoe that includes leg press, squats, lunges, multi-hip
strength, and core.
Phase II (10–21 days) At this point we will advance into more cardio and a func-
The plan is to discontinue the boot for activity and work into a tional progression to return to running activity. The progres-
brace. There are several bracing options that can be used from a sion starts with elliptical or StairMaster in a regular shoe with
custom AFO to a lower-profile DonJoy velocity or Ultra. Proper a brace. Training time will start at 15 minutes and advance
gait instruction is always necessary to help decrease substitution 5 minute every 2 days as tolerated. We will also introduce
patterns. The patient can still rest in the walking boot if soreness pool agilities and running at this time. The patient will begin
persists. in chest-high water and then progress to waist-high water.
Rehabilitation goals will be to focus on restoring nor- Typically, the patient will do well with these activities. Once
mal joint mobility, ROM, strength, and proprioception. they tolerate back-to-back stairmaster/elliptical for 20–30 min
Introduction of grade II–III joint mobilizations can help or pool running, we will advance them to a treadmill progres-
improve any subtalar joint stiffness from the walking boot. sion (Tables 31.10, 31.11). Our goal is pain-free normal run-
It will also help improve the active range of motion (AROM) ning mechanics at 12–14 mph before we consider advancing
and passive range of motion (PROM) of the ankle. Range of to field drills.
motion will focus on DF, PF, and IN. The patient will work
on eversion and progress as tolerated, with some attention to Phase III (3–6 weeks)
external rotation of the foot/ankle on the lower leg. Calf flexi- The focus will continue to be on full restoration of ROM and
bility is critical to rehab and prevention of other issues. Passive strength. Aggressive joint mobilizations and stretching to help
stretching can be performed several ways from a wall stretch, get end ROM back. Calf stretching can be accomplished by
572 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

Surgical Intervention for Syndesmotic

TABLE 31.11  Functional Progression
Disruption With Ligament Damage
Guidelines
Phase I (1 month)
Phase I: Elliptical Progression The patient will be placed in a walking boot and will be non-
Elliptical 20–30 minutes weight bearing for the first month postop. The goal will be to
2 consecutive days without setbacks → progress to Phase II
allow the repair structure time to heal without placing weight
Phase II: Treadmill Progression on the ankle. Weight bearing too early can put too much stress
Treadmill warm-up
on the ankle joint, causing the joint to spread. We will focus
Progressive speed intervals 7–9 mph, increase in .5 mph increments 30
second run/30 second rest
on controlling soreness and swelling with ice or game ready.
Progressive speed intervals 9.5-14mph, increase .5 mph increments 15 second We will monitor the wound and follow basic wound care
run/30 second rest (7–10 mph), 10 second run/15 second rest (10–14) guidelines.
If player completes 12–14 mph without hesitation and pain, move to Phase III During the first 2 weeks, we can start active toe ROM, light
Phase III: Field Functional Progression desensitization massage, multidirectional leg raises, and core
Jog 2 x 50 yards work. At weeks 3–4, we can start some AROM for ankle DF/PF.
Perform warm-up exercise We can add some light towel/strap stretching for the Achilles
High knees 2 x 10 yards and calf complex. We will start some seated calf raise without
Butt kicks 2 x 10 yards weight to stimulate the calf some. At 2 weeks the athlete can
A skips 2 x 10 yards start bike conditioning in the boot. When the wound is healed,
B skips 2 x 10 yards deep-water conditioning can be started without flippers.
Back pedal 2 x 5 yards
Lateral shuffle 2 x 10 yards both directions Phase II (2–3 months)
Cariocas 2 x 15 yards both directions
Double-leg jump x 10 We will begin AROM and PROM for the ankle in all directions.
Single-leg jump x 10 We will monitor eversion or external rotation of the ankle on
3 x 40 yards accelerations (50–75-full) the lower leg. The goal will be to restore normal joint mobil-
2 x 30 yards arc left 10, arc right 10, sprint straight 10 ity during this phase. Grade II–IV joint mobilizations to help
2 x 5 yard zig zags for 25 yards advance ROM. Calf stretching can be accomplished by a slant
W drill both directions board, stair, or basic standing wall stretch. Multidirectional
Triangle drill both directions ankle strengthening can be started with tubing or manual resis-
Individual period specific to position/sport tance. Advance as tolerated and monitor pain and soreness with
If player can complete all aspects of progression without hesitation and pain IN. If the athlete is uncomfortable with IN resistance, gradually
progress to Phase IV
add it into the rehab program based on soreness. We want the
Phase IV exercises to be comfortable.
Conditioning/Return to Practice
The athlete can advance the weight bearing status during this
phase. They will progress from two crutches to one crutch in
the first week and then to full weight bearing during the first 2
a slant board, wall stretch or a simple stair stretch (see Fig. weeks (4–6 weeks). The athlete will continue to utilize walking
31.23). Calf stretching should range from 3 to 5 minutes. boot during this time. Over the next 2 weeks (6–8 weeks) the
Plantarflexion stretching can be accomplished by sitting back athlete will begin to wean out of the boot into a brace. Some of
on you heels. Strengthening should still be addressed in all the more common braces include DonJoy velocity, Ultra, ASO,
directions. We also like to include working on resistance to and the Arizona brace (Fig. 31.25). There are many other brace
IN of the ankle on the lower leg in both a DF and PF position. options that can be considered. The brace used will depend on
Also, advancement back to weight room exercises that include the desired support and protection needed as determined by
squatting, lunges, and dynamic step-ups in multiple direc- the physician. Weight-bearing exercises include calf raises, step-
tions. Some advanced functional strengthening will include downs/ups, and proprioception activities. We will start with
shuttle jumps, mini tramp jumps, slide board, box jumps, and double-leg calf raises and progress to single-leg calf raises as
landing. tolerated. The athlete will focus on good eccentric control of the
We will continue to focus on cardio as we progress the calf raise. Step-downs/up will be initiated at this time to focus
patient to field work. The field work may include basic field on some single-leg control and strengthening. The step-up is
agilities, cutting, ladders, hurdles, and cone work. A field test generally easier for the athlete and will help improve push-off
will be conducted once the patient has become comfortable and power through the foot. Step-downs will focus more on bal-
with the field work. This test will include full-speed work, ance and control as the athlete lowers through good hip, knee,
change of direction, and sport-specific drills. If an athlete can and ankle control. Balance exercise will include a progression
complete all of the field progression at full speed and look nor- from balancing in the walking boot to a regular shoe and then
mal, they will be cleared to return to full sport and activity. finally barefoot. We will also challenge the balance surface (hard
Time table will change based on the demand of the sport and to soft).
even the position in the sport (i.e., offensive line versus wide At this time the athlete can start a general lower extremity
receiver). (LE) strengthening program. The program can include shuttle
 CHAPTER 31  Principles of Rehabilitation for the Foot and Ankle 573

Fig. 31.25  Elliptical in ultra brace. Fig. 31.26  Sit on heels.

press, leg press, knee extension, leg curls, and multidirectional completed prior to advancing into heavier lifts to ensure
hip strength. During the early part of this phase they can start symmetry and balance. The exercises can include a variety
these activities and work in the boot. They can progress into of squats, double/single-leg deadlifts, lunges, cleans, and
a regular shoe as they move through the wean-out-of-boot squats. In addition, a plyometric progression can be started
program. Cardio exercises should include bike, StairMaster, that should include landing mechanics and jump mechanics.
elliptical, and pool activities if available. A general progression This progression should move from double-leg to single-leg
on the cardio equipment would be 3–4 times per week, start- work.
ing at 15 minutes. We will advance both time and resistance Functional activities and field work should be initi-
as tolerated. We like to get athletes to 4 days of 30 minutes ated once the athlete has passed a treadmill progression
on cardio equipment before advancing to treadmill work. A for time, volume, and running mechanics. Field drills
treadmill progression can be initiated in this phase if the ath- should begin with basic agility drills and ladder work.
lete is ready. The treadmill progression will include an interval Ladder drills will help with ankle position and quick-
speed progression. ness. If the athlete tolerates those activities well, then
change of direction, deceleration, and arc running should
Phase III (3+ months) be initiated. The final progression will include sport-
During this phase we want to make sure that we restore normal specific drills and function. Once an athlete has completed
joint mobility and ROM. Aggressive stretching for both DF and all phases of the field progression, they will be cleared for
PF (see Figs. 31.23 and 31.26) should be continued throughout sports activity. Isokinetic testing is performed in DF, PF, IN,
the process. Basic ankle strengthening should be continued with and EV to evaluate symmetry between the involved and non-
tubing, manual resistance, and other weighted activities. Single- involved sides (see Figs. 31.21, A and B, 31.27, A and B).
leg balance and strength work should be initiated and advanced Once an athlete has returned to full activity, a maintenance
as tolerated. Balance can include different surfaces, catching a program should be carried out until he or she feels a 100%. This
ball, bosu squats, and opposite-side hip tubing while balancing. program should continue to focus on joint mobility, aggres-
Slide board can be initiated to improve single-leg push-off and sive ROM (especially DF), ankle strengthening, and balance.
stability. Sometimes athletes will need some extended warm-up time
Strengthening activities should be monitored for good prior to sport participation. We will continue to utilize taping or
form and ankle mobility. Corrective exercises should be bracing until completely comfortable.
574 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

A B
Fig. 31.27  A, Ankle cybex eversion. B, Ankle cybex inversion

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 32
The Team in the Care of the Athlete
David A. Porter

OUTLINE
Bill Polian (Former NFL general manager and executive), 576 Bob Anderson, MD (Orthopedic Foot and Ankle Consultant
Dave Hammer, ATC (Head Athletic Trainer, Indianapolis to NFL and NBA), 580
Colts), 578 Luan, Parent of Elite Athletes Samantha and
Mark Bartelstein (Professional Agent), 578 Jessica Peszek, 581
Gordon Hayward (Professional Athlete), 579 Acknowledgments, 582

When we set out to be a team physician or to take care of the how consultants team physicians interact in the care of the ath-
athlete with foot and ankle problems, it is a noble deed. How- lete. I have chosen to go to those we actually serve and provide
ever, it is important to remember, we are just one part of the care for in this endeavor. The remainder of the chapter is taken
TEAM that takes care of the athlete. We play a critical role both from interviews I conducted with an athletic trainer, general
diagnostically and therapeutically, but we cannot misunder- manager, agent, professional player, colleague, and a generous
stand our role, misplace where we fit in the care, or in any way parent. I have interjected stories and anecdotes that I person-
minimize the role so many others have in the care of the athlete. ally have experience that support and give example to the points
From a distance, it can appear glamorous to be involved in made by the kind folks I interviewed. So please understand
the care of some of the greatest athletic specimens who have some of what you read is a bit editorialized by me, and I think
ever walked this earth. It can be incredibly rewarding to be a it will be obvious to you what are my examples and what are the
part of a great outcome and see the results literally played out key words enlightening our understanding from the contribu-
on a field or court right before you and the world. There is tors. I hope you enjoy it and can agree with much of it, or at least
so much at stake for the player and his/her team, owner, and be challenged by their thoughts, concerns, and needs.
administration. However, I always remember what my mentor
for my Masters and PhD in Exercise and Sports Performance BILL POLIAN (FORMER NFL GENERAL
Physiology, David L. Costill, PhD, told me, “You will likely be
remembered more for the mistakes you make than the successes
MANAGER AND EXECUTIVE)
you enjoy!” We are supposed to be successful, but when an out- Competence: The doctor has to be good! He or she must be
come is not so great (and we all have them), increasingly the right most of the time! Specifically, these are athletes, and it’s not
media and fans react harshly and unsympathetically. enough just to know about their foot and ankle condition from
Just like most facets of medicine, taking care of the athlete is an orthopedic standpoint; we have to know the sports medi-
a lot more about work, tireless and selfless service, and not so cine context. In its unique demands and contexts, sport creates
much about glamour! That’s okay. We still get plenty of moments extreme demands on the same structures, causing them to be
when an athlete will say to us, “Thanks, Doc, for keeping my affected differently. The sports medicine physician and health
wheels a-turning, so I could do all I wanted to do!” That really care provider need experience and understanding of what goes
is reward enough. Put all the marketing, recognition, fame, and on for that specific athlete, realizing that each athlete and posi-
fortune aside, and the personal involvement we get to have in the tion is different. I remember when a ballet dancer came to our
lives of these amazing athletes, more importantly, these amazing clinic for a lateral ankle sprain. She was diagnosed appropri-
people and families, is why we chose this field to begin with. ately, given appropriate guidance regarding the natural history,
I have thought a lot about all we present in this book regard- was explained the anatomy of the injury, and was sent to physi-
ing the science, studies, innovation, and analysis that we do, all cal therapy where she was given a large bulky brace and told to
so that individuals can have a better outcome and have a “nor- come back in a month if it wasn’t better. She went home and was
mal” life (even when “normal” can mean trying to help an ath- in tears. She had a performance in 3 weeks, which was before
lete get back to a level only experienced by less than 1% of the her next visit with her doctor to clear her to dance. She cried as
population). I thought it only appropriate that we take a little she put on the brace the first and only time as she saw clearly she
interlude and talk just a bit about HOW we care for and about could not dance “in that thing!” Now, our approach is different.
the athlete. This is my feeble attempt to discuss our role and We get our dancers in with a physical therapist who is a former
576
 CHAPTER 32  The Team in the Care of the Athlete 577

dancer, use a low-profile support for the ankle, start them on see a problem when dealing with any medical issue, leading to
Barre work immediately, see them back every 1 to 2 weeks to the mind set of “that part is broken, and it’s my job to fix it.”
ensure they are clear and safe to dance, and work directly with Though that mindset is technically not wrong, the situation is so
the therapist to follow their recovery. much more involved and delicate than that. When athletes end
Honesty: How bad is it? What is the prognosis? How quickly up in our offices, they have just experienced something that has
can the team count on the player? What does the future hold? the potential to change the trajectory of their entire career path
We can’t just be optimistic. We need to explain the worst-case and possibly their long-term health. They will be worried about
scenario and the realistic outline on how to plan for this week, the next step, stressed about wanting to return to play, and they
next week, and the weeks to come! These are the questions the may even be scared. Not only is it our job to treat their physi-
team asks and wants to know about. The need for prognosis and cal needs, but we must also treat the needs/fears/concerns that
timetable is critical both at the recreational, collegiate, and pro- x-rays and magnetic resonance imaging (MRI) do not show. To
fessional levels. Not only are we setting practical expectations do that, we must empathize with them. We need to be able to
for the athlete and the team, but by giving an honest prognosis, understand what this means for the athlete and the additional
we are giving the staff and administration time to logistically stresses/concerns/worries that come along with injuries. They
change their program if necessary. The next man or woman up are not just a fractured foot or a sprained ankle, so we should
needs clarity so he or she has time to prepare, while the coach- not see ourselves as just a technician there to fix an injured part.
ing staff and management need time for roster adjustments, if We need to remember that every injured foot, ankle, or toe is
needed. The list goes on and on, which is why honesty is essen- attached to a real human being.
tial to building a strong “team” and reliable approach. There Selfless: It not about the “doc,” it’s about the athlete. The
was a time when one of our physicians had to tell a player that proliferation of interest in the health of competitors and play-
his spine condition would not allow him (the player) to safely ers, and its impact on play and entertainment, is astounding!
continue to play his collision sport. Mr. Polian mentioned how Getting your name in the paper for treating a well-known ath-
impressed and thankful he was with how the physician handled lete can seem almost dreamy, but it can turn into a nightmare
the honesty of the situation but with empathy and compassion when “things go a bit wrong.” Again, this is another area where
(Fig. 32.1). reminding ourselves of the importance of our professional
Neutrality: We can’t just be a fan. Though we love cheer- relationship is critical. The athlete came to us for medical care,
ing for our teams or players, we must remain objective when the team is counting on us to give the highest quality of care.
treating athletes. We have to be able to keep a level of detach- Marketing of ourselves, at a minimum, plants a seed of self-in-
ment from the desire to see our patients “get back quickly” and terest but can lead to a deterioration of the entire patient–phy-
do what is best for their long-term good. Essentially, we should sician relationship.
have passion for the athlete, not for the score. We are physicians, Communication: Check your pride at the door.
surgeons, and health care professionals, not coaches, owners, or Communication is not about which “team member” gets all the
even just fans. Our professionalism and skills are tools that allow glory; it’s about upholding the highest ideals of collaboration
us to perform in the best interest of the athlete. Usually every- and treatment. So, get the language right and do it in a way
one can tell when our interests are divided, which sets us up for that works. Speak a common language and develop a commu-
failure. A distrust can form between us and the patient/athlete if nication method that works for all involved. If communication
they feel we have our own agenda. They need to know that our is lacking the first few times, do not just give up, but work at
number-one priority is their well-being and not the name on understanding a common language for whomever you’re com-
the front of their jersey or the boost in our name or recognition municating. Be creative; analogies can help the non-athlete a
Empathy: Can you understand the significance to the ath- great deal. For example, an osteochondral lesion (OCL) of the
lete? Can you see the situation as they see it? It is easy to just talus can be analogous to a pot-hole in the road. We all (espe-
cially those of us in the Midwest!) have experienced the bumpy
ride our vehicle takes over an uneven surface or pot-hole. An
athlete or parent can understand better how an OCL might
cause pain or inflammation from this perspective. Talk to oth-
ers on the team and see what will help them understand better.
Do not fall victim to communicating in a silo (speaking in a way
only a medical professional can understand). Poor communi-
cation only leads to confusion and less than ideal outcomes.
Additionally, encourage the athlete to ask questions, not only
so they feel integral in his or her own care, but so you may truly
understand the issue at hand. This is especially important when
delivering the “your career is over” message. First, we need to
make sure this is the best decision for all involved and we are
doing right by everyone. Then, we must make sure our message
is delivered in a clear and compassionate way. Again, we must
remain neutral from an allegiance standpoint and focus on the
Fig. 32.1  Bill Polian. (Courtesy Bill Polian and the Indianapolis Colts.) well-being of the athlete.
578 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

I get the right diagnosis? It taught me to interview the athlete and

DAVE HAMMER, ATC (HEAD ATHLETIC examine in a way that leads to a diagnosis. We are not the reporter
TRAINER, INDIANAPOLIS COLTS) of the athlete’s complaints but specialized analysis experts who are
Communicate: Letting the team and the head athletic trainer discovering what has gone awry. It goes without saying that we
know what you think and getting back with them on a timely basis have to give the player and his team a clear prognosis, an expecta-
is critical to how the athletic trainer can interact with the athlete tion within a reasonable range of when the athletes will be able to
and the team including the athletic training staff, the coaches, and practice and play again. Being correct in this way over time builds
the general manager. The athletic training staff have to treat the confidence in us and helps everyone set realistic goals.
player daily and at times more than once a day. The coaches need to Be Realistic and Honest: Don’t say what you think someone
know who they can count on for practice and the upcoming game. wants to hear. We often want to please everyone, and there is a
The general manager needs to know if there is a need to replace the temptation to say what we think the player wants to hear. Then
player on the roster. At a particular point in the season, is this an when we talk to management, coaches, athletic trainers, etc., we
injury that will require the player to be replaced permanently or say what they want to hear, and it leads to mismatched expecta-
temporarily? Typically, we as consultants or team physicians will tion and frustration. Consistency in communication is critical
need to be able to contact the responsible person with the team to create a unified approach. Someone in the process may not be
within 24 hours of being asked to review information or obtain- as pleased, but honesty, in my opinion, it serves everyone best.
ing the information. If the player is seen by you in consultation, It is difficult but necessary to be honest with everyone. There
a phone call is expected the same day as the consult. As you can are different goals sometimes, and different impacts, but I have
see, this can involve a lot of calling. When I was a fellow with Don found keeping it straightforward, realistic, and consistent serves
Baxter, MD, in Houston, TX, we were consulted on a Division I everyone best and creates peace and unity.
athlete from my home state. He asked me to handle all the calls Be Effective: Be right more often than wrong. I realize every-
and keep track of how many calls were made. From the time of the body is wrong occasionally, but we can’t always be wrong. This
first call until the time we performed the surgery and got the rehab area is not an area of just effort and goodwill. Keeping up pro-
set up post-op, there were nine calls I had made or fielded. It helps fessionally, using your intellect, attending professional meetings,
to somewhat enjoy communicating, as it may often involve calls at having good, smart, and up-to-date colleagues are invaluable
night, on weekends, or in a car as you travel. Communication is in order to be effective. Some of this may be giftedness that we
key! It builds trust, reliability, and clarity (Fig. 32.2). can’t fully change, but training ourselves, being life-long learners,
Be Definitive: Take a stand so there is a directive to act. For and humbly seeking advice, in my experience, can go a long way
any of us or our ATC/PT colleagues to treat and have a direc- in augmenting our natural abilities. Evaluate your outcomes on
tive to care for the athlete, we need a firm diagnosis. I remem- a long-term basis by following up; having your patients assess
ber during my training, Frank Mannarino, MD, of Dayton, OH their subjective outcome is also a great way to continue to hone
(Sports Ortho MD), was always asking me when I came out of our skills and process for outcomes (rehabilitation, surgical
the athlete’s exam room, “What is the diagnosis?” I wanted to tell approaches, return to play process, etc.). As we all know, we can
him all that I had found out, but what was important was, could often learn more from our mistakes and poor outcomes as long
as we are honest about it and face up to those that don’t do as well.

MARK BARTELSTEIN (PROFESSIONAL AGENT)

Collaborative: We are in a profession of the best, taking care
of the best. Realize we need to work with the others in our field
and related fields, strength training, athletic training, nutrition-
ist, exercise scientist, etc. Can we put our egos aside? It is often
more of an art than just a science. Injuries can be unique, so it is
important to talk to other professionals and get a good amount
of input from other experts in order to get the best opinion. It
cannot be “my way or the highway.” Again, we must leave our
pride at the door. We have to have the humility to look at the
problem from all different angles, including how nonmedical
people look at it. For example, can we look at a problem and ask
ourselves, “Can we plate it and allow the athlete to get the same
result with a quicker return?”
Communication/Accessibility: Athletes get hurt at all hours
of the day and all days of the week. They need peace of mind, so
don’t be in a hurry. Sports medicine physicians need to under-
stand injuries are career impacting; therefore, we must commu-
Fig. 32.2 Dave Hammer, ATC. (Courtesy of and permission by Dave
nicate every step of the way. Many agents can be very heavily
Hammer and the Indianapolis Colts Used with permission of the India- involved throughout the process, so it is important to make sure
napolis Colts.) they are in the know, just as much as the player, athletic training
 CHAPTER 32  The Team in the Care of the Athlete 579

staff, and coaching staff. Depending on the agent–athlete rela- He used to tell me, “You don’t always have to be first to do some-
tionship, the agent may be the one who helps the athlete make thing, but you should not be the last to do it either!” So, be com-
the final decision. Obviously, having approval and permission petent with your skills and keep up with innovation and testing
from the player to speak to his/her agent are necessary before that are coming out. I find it very helpful to talk directly with
any conversations of this nature (Fig. 32.3). those who are working through a new procedure or technique
Education: As medical professionals, it is important to edu- and find out what really works for them and what to be aware of
cate all involved, including the agent. Weigh the risk and bene- also. Developing a network of colleagues around the country and
fits with the athlete, agent, coaches, and other members of the the world has served my patients well with how I have continued
team so they are able to clearly see the options available. It may to grow and develop as a physician and surgeon. There should be
be a long, thorough process, and that is okay. Those involved need some areas that each of us are developing in our field, but we are
to understand the situation and options so they can help make not going to be the latest expert on every injury we treat. However,
the best decision. Always make sure to explain the procedure, we can and should be part of the greater conversation that is going
whether it is fixed surgically or by trying a new orthobiologic. on in the medical field in which we work. Researching our own
Don’t gloss over it! Other members of the team look to us, as the patient outcomes and pursuing academic understanding and
acting physician, to hold the knowledge of the injury, treatment, shaping our field with our expertise takes time, effort, organiza-
and recovery. They expect that you will educate them and lead tion, and money. But it is necessary and worth it!
them in the right direction. We cannot just leave them hanging
with little or no explanation. “This is the way we do it” doesn’t
work for an explanation!
GORDON HAYWARD (PROFESSIONAL ATHLETE)
Serving the Master as the Athlete: Though there are lots Transparency: The player wants to clearly know the diagnosis.
of influences, we need to remain focused on the athlete as the “What is actually going on?” “What is wrong?” It is important
patient. The team is the employer, which means they have a sig- that the athlete is not told something different than management
nificant stake and influence on all involved. However, we have and the athletic training staff. It usually becomes obvious if the
to maintain the balance. That includes giving agents a peace of athletic training staff has a different opinion regarding the player’s
mind that we are doing what is in the best long-term interest return and eventual outcome. Transparency also means educating
of the athlete. We can’t be seen as just “employees of the team.” the athlete on the anatomy and normal outcome at the level the
Competence: We all know there is an art to treating athletes, athlete can understand and is interested in. Some athletes want
but being competent is much more than that. We have to give a more than others, but an inability to clearly explain the problem
reasonable timeline of treatment and recovery and be able to hit and expected outcome creates some mistrust. It is important to
the milestones we have set! One way to do this is to remain up-to- bring “peace of mind” so the athlete has confidence his physi-
date with techniques, innovations, and research. Alan Habansky, cian understands his or her problem and that the plan is clear and
MD, from Muncie, IN, has been a great mentor to me and was one “makes sense.” Setting a realistic expectation regarding recovery
of the first orthopedic sports medicine physicians in the country. is important right at the outset of the treatment (Fig. 32.4).

Fig. 32.3 Mark Bartlestein. (Courtesy of and permission by Mark Fig. 32.4  Gordon Hayward. (Courtesy Gordon Hayward and the Boston
Bartlestein and Priority Sports Courtesy of Julie Magrane.) Celtics.)
580 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

Confirmation and Clarity: As the treatment unfolds, the Be a Team Supporter but Not a Fan: Most of us have gone
patient will ask, “Am I on track?” “Am I coming along like I into sports medicine because we are fans of sports. However, in
should?” If you can relate, confidentially, to the athlete regard- our roll as physicians and health care providers, we have to be
ing other athletes that have had a similar injury and what their a supporter of the teams we cover, as well as those we provide
outcome was, it helps build confidence and confirms the right opinions for. However, we can’t treat the patient for the hope
treatment. If the doctor can set good, trackable goals, follow-up they might provide for our teams. Rather, the treatment for the
evaluations can be a time to confirm the set goals are being met. athlete must be objective, clear, and in the best interest of the
Step-by-step progress is important because the athlete cannot athlete’s health. I have found, in the long run, this is the best
get back to play all at once! It takes time. This often has to be way to support the team, as well. There could be a temptation
reiterated, so small goals are key in helping the athlete’s rehab to want our team to benefit from our athlete’s recovery to a
because they delineate the timeline and assure progress is being point that it could “cloud our judgment.” This must not happen!
made. Another way of saying this might be, “Stick to what’s right for
Empathy and Care: The athlete wants to know his doctor your patient” and stand your ground to parents, coaches, and
understands his/her situation particularly. We, as physicians agents, among others.
and/or surgeons, see a lot of the same injuries, but the athlete Listen. Watch. Educate: To help the player and his or her
needs to know he or she is not just a problem, but a person with family make a decision, you must first listen, watch, and then
an injury. Do you understand “my situation?” Teddy Roosevelt educate. We need to always remember that this athlete is a per-
is famously known for the adage, “People don’t care how much son in a unique situation with individual and team goals that
you know… until they know how much you care!” We need to are specific to his or her situation. We must listen to what their
keep that in mind. A stoic, distant, unemotional interaction may situation is and understand the time frames that are involved.
not communicate to the athlete a genuine empathy and can put For instance, the late-season Jones fracture might be amenable
up a barrier to trust. Outcome depends on mutual respect and to supportive care and a wraparound orthoses for a high school
cooperation. Cooperation does not happen if our patients don’t student to finish his senior year. During off-season, however,
believe in us and our treatment. the Jones fracture that is picked up on a routine image might
be best served with a more aggressive surgical approach so that
BOB ANDERSON, MD (ORTHOPEDIC FOOT AND it does not re-fracture during the season. An in-season Jones
fracture will require operative intervention, but the athlete and
ANKLE CONSULTANT TO NFL AND NBA) the team must understand the risk of returning in the same sea-
Don’t let your ego get in the way: The very fact we have made son, which could lead to a higher risk of re-fracture and possibly
it to this point in our career indicates that we have some God- a second off-season surgery. We need to watch the interaction
given talent and ability. The years of training where we have that the athlete has with family and team. It is important to also
succeeded compared to others can lead to pride and an inflated look closely on physical exam at predisposing factors for injury.
ego. We need to recognize our strengths and weaknesses. Refer After we understand the athlete’s situation and have done a very
when uncertain. I remember two situations when I was asked to thorough examination, we then can educate the athlete, the
see an elite high school athlete and an elite professional athlete. family, the team, and all those involved regarding clear options
I understood both of the problems the respective athletes were that the athlete can then choose to follow. Good education
facing, and I thought surgery was the most reliable solution in allows all involved to understand the options and the treatment
each case. But it was not the type of surgery I performed a lot, course that best fits their needs and desires. This obviously takes
so I recommended they get the surgery with a different surgeon. time. A rushed interaction and exam could provide the correct
The high school athlete’s family was a bit condescending toward diagnosis but create a lack of trust if we have not listened well,
me, saying, “I thought you could do everything.” My pride did watched well, and educated well (Fig. 32.5).
well up inside me, but I stood my ground because I knew the Offer Second Opinions: Be Content (and relieved) When
athlete would be better served elsewhere. The professional ath- an Athlete Goes Elsewhere for Surgery. Second opinions can
lete was actually very grateful and went to the other surgeon I be extremely valuable for athletes. It often seems like a bit of
recommended, with whom he has since had a great result. Much a hassle, but it can be an excellent way to bring clarity, confir-
like sports teams, there are specialties even in coaching and on mation, or a new approach to the athlete’s injury or illness. I
the field. Know where we are strong and where we need to refer. remember one of the general managers that our group worked
The Player Is Patient #1: Similar to “empathy” as noted by with telling us, “I love whenever our players go get a second
Gordon Hayward and Bill Polian, we have to remember first and opinion outside of our team. They always seem to come back
foremost that these athletes are people and patients. It could with the even more trust in our physicians and our medical
be easy to get caught up in all the surroundings of the player’s team’s approach.” There is a lot of communication required with
career and all the other individuals involved in their life. But second opinions, and all the other issues we have discussed
remember, they are still patients that are looking to us for a cor- come front and center with giving a second opinion: that is,
rect diagnosis and a clear treatment plan to help them overcome understanding the situation of the player and the team, being
their injury or illness. If we can keep in mind that these elite empathetic toward the player, putting the player first, checking
athletes are people who need our attention and expert medical our pride at the door, and being skilled in our diagnostic and
care, much of the other issues fall by the wayside very easily. treatment acumen. We should also feel comfortable when our
 CHAPTER 32  The Team in the Care of the Athlete 581

once have I (David Porter, MD, PhD) spoken to the media

regarding an athlete that I have treated. It was a situation where
a professional football player had injured his foot, and there was
so much controversy in the media regarding the diagnosis and
the treatment, the player and the team asked me to make a state-
ment. We formulated the consultation in comment/statement
with the player and the team so that we were all on the same
page. Other than that situation, I fortunately have stayed out of
the media.

LUAN, PARENT OF ELITE ATHLETES

SAMANTHA AND JESSICA PESZEK
Communication: As with most things, communication is
essential to treating patients, especially when the patients are
elite athletes that are surrounded by an entire team of various
professionals who are supporting their recoveries. After a thor-
ough evaluation and delivering the diagnosis to the “team,” the
acting physician must be able to delineate a clear plan of action
so the patient, coaching staff, athletic trainers, and other mem-
Fig. 32.5  Bob Anderson, MD. (Courtesy Robert Anderson, MD.) bers of the team are attentive to the same treatment plan out-
lined by the physician. Open and constant communication not
only ensures the proper training and treatment of the athlete
patients seek second opinions. It can be a relief for the patient to but demonstrates a mutual respect among all team members. If
be treated elsewhere. I remember, when I first started in prac- there was ever lack of or miscommunication, the strength and
tice, I sometimes tended to second-guess myself if my patients effectiveness of the team would suffer tremendously, impairing
sought other opinions. Early in my career I was seeing one of the recovery of the athlete and bringing fear and anxiety to the
professional football players who had a significant midfoot athlete’s parents.
injury. I diagnosed him with a Lisfranc instability that required Teamwork: Imagine a group of well-intended, skillful
surgery. The patient wanted another opinion. I actually was able professionals all trying to accomplish a common goal, yet all
to be on the phone with the second-opinion physician who fully trying to do it on their own. While an individual’s skill-set
supported my view and said this approach was correct. What may complete one aspect of the goal, more than likely the
started off as a bit of a fearful and insecure situation ended up overall objective would never be accomplished because key
giving me a great deal of support and encouragement in the contributors to the process are missing. The same principle
direction I recommended. I ended up treating the patient, and can be applied to treating patients, especially treating elite
he did very well. I have never forgotten that interaction. Bill athletes, where multiple disciplines are involved. Teamwork
Hamilton, MD, was the orthopedist who provided that second is fundamental to achieving the goal of returning the player
opinion and supported me early in my career. to full participation. The athlete, coaches, ATCs, parents, and
We Can Clear Based on Our Specialty: As an orthopedist, physicians collaborating as an efficient and reliable team is a
we clear “orthopedically.” The physical therapist decides when requirement so the athlete can progress. Should there be any
the recovering patient’s strength and range of motion are appro- miscommunication, lack of mutual respect, or any other det-
priate. Athletic trainers clear regarding functional progression rimental cause to effective teamwork, the patient’s outcome
once the patients are cleared medically and orthopedically. The would not be realized to its highest potential. For example,
conditioning coach clears them to have the stamina and neces- there was miscommunication on the severity of a stress frac-
sary aerobic and anaerobic conditioning to withstand practice ture. This could lead to inappropriate training and worsening
and competition. The coaches then determine when the perfor- of the injury. However, had all members of the “team” made
mance level is back to the level needed to contribute on the field. sure to clarify the situation, a setback in recovery could have
I have always said that, in general, the medical team clears the been avoided (Fig. 32.6).
player to practice and the coaches determine who actually plays. Accessibility: Players, families, coaches, trainers, and team
But as you see, clearance requires a great deal of communication managers all rely on the physician to be readily available to
and clarity of responsibility. As an orthopedist, I do not have the answer any number of questions or solve any problems that may
ability to determine when one is ready to return to play (RTP). arise throughout treatment. Accessibility comes in many forms.
That is a team decision and is based on functional recovery and Can you be reached? Can you work the patient into the schedule
performance measures as noted. during a hectic day at the office in a timely fashion? The answer
Never Talk to the Media: Enough said! There is never really to those questions should be “yes” the majority of the time. Elite
much good that can come out of talking to the media about athletes cannot miss a thing. Time is crucial not only to their
players. Obviously HIPPA violations come into play also. Only recovery but to developing their skills on and off the field. Aside
582 SECTION 6  Rehabilitation and Recovery: Principles, Collaboration, and Teamwork

providers will do right by them. Having the best interest of the

patient, and validating that dedication to his or her safety, is
vital to creating a trusting patient–provider relationship. If the
patient and/or the parents of that athlete feel that a doctor is
just going through the motions and only sees a problem to be
fixed, not a person who needs healing, a wedge of distrust can
be driven between them. Trust fosters an ideal environment for
healing, as there is no second-guessing or hesitation to follow
the best plan of action for the quickest recovery set forth by the
physician. Parents just want their children well cared for and to
have a “normal” life if possible!

Fig. 32.6  Luan and Ed Peszek, mother and father of Samantha (2015 ACKNOWLEDGMENTS
NCAA all-around champion-UCLA, 2008 Olympic silver medalist, 2007
World Championships gold medalist) and Jessica (Division 1 Western
The author would like to thank Bill Polian of ESPN and for-
Michigan gymnast, MAC Senior Gymnast of the Year). (Courtesy of and mer General Manager/President of Indianapolis Colts, Carolina
permission by Luan Peszek Image courtesy of Luan Peszek) Panthers, and Buffalo Bills of the NFL; Dave Hammer, ATC,
current Head Athletic Trainer Indianapolis Colts; Mark
from delaying their return, inaccessibly could lead the patient to Bartelstein, owner and president of Priority Sports Agency
believe that there is a lack of urgency or empathy for his or her Chicago, IL; Gordon Hayward, former Brownsburg, IN
situation. An injury or setback of any kind places great stress Bulldog, former Butler University Bulldog, former Utah Jazz,
on the player, coaching staff, parents, and managerial team. current Boston Celtic NBA basketball player; Robert (Bob)
Thus physicians needs to confirm that they are dedicated to the Anderson, MD, past president of AOFAS, PFATS; Jerry “hawk”
patient and his or her needs. Ray, NFL team physician, award winner, and orthopedic foot
Trust: Their safety is in our hands. Patients (and parents) put and ankle consultant to NFL and NBA; and lastly, thank you to
their wellbeing, even their careers, in the hands of physicians. one of our elite athlete patient’s parent, Luan Peszek! Thank
They trust not only that the medical professionals are compe- you to my family and medical staff who supported me and proof
tent and highly skilled at what they do, but they also trust that read much of my work!
 INDEX

A Achilles tendinopathy (Continued) Achilles tendon (Continued)

AAOS. See American Academy of extracorporeal shock wave therapy results in, 352
Orthopaedic Surgeons for, 167–169 treatment for, 350–351
Abaloparatide Comparator Trial in in military athletes, 499 noninsertional tendinopathy,
Vertebral Endpoints (ACTIVE), nonsurgical treatment of, 167, 170f 164–165, 164f–165f, 165b
65–66 postoperative management for, surgical treatment for, 170–178,
Abaloparatide (Tymlos) PTHrP (1-34), 178–182, 190f 170f, 176b
64–66 surgical treatment for, 169–176, 171f rehabilitation of, 548–549, 548t–549t,
Abduction stress test, 5 debridement of tendon, 549f, 564–567, 565f–569f
Abductor hallucis tendon transfer, 171, 172f stretching of, 213
403–404, 405f tendon transfer, 171–172 tendinopathy, 164, 164b
Abductor strength test, 5 turndown procedure, 175–176, Achilles tendon lesions, in Colombia,
Aberdeen Prospective Osteoporosis 178f–179f 467–468, 467f–468f
Screening Study, 38 V-Y advancement, 173–175, 177f Achilles tendon rupture
Accessory anterolateral talar facet, treatment of, 167–182 acute, 182, 182–192, 191f
11–12 Achilles tendinosis in Egypt, 471
Accessory navicular bone, chronic, 449 mini-open technique for, 187–189,
505–506 in dancers, 449–450, 449f–450f 197f, 200–201
in children, 505–506 nonsurgical treatment of, 449 nonsurgical treatment for, 182–184,
imaging of, 210f treatment of, 449 193–197
radiographs of, 506 Achilles tendon percutaneous technique for, 200
symptoms of, 505 anatomy of, 349–350, 449–450 results of acute surgical repair, 189
treatment of, 506 biomechanics of, 350 standard technique for, 187–192,
Achilles tendinitis blood supply to, 163 192f–194f, 195t, 198–200
insertional, 352 disorders of, 163–205.e1, 166f surgical treatment for, 186–187,
after care of, 353 foot and ankle surgery for, 530 197–198
classification of, 344 Haglund’s deformity, 166, 169f chronic, 192, 189–191
diagnosis of, 352, 352f surgical treatment for, 177–178, autograft/allograft reconstruction
evidence-based recommendations 183f–189f for, 200, 199f
for, 354 indications for, 350–353 nonsurgical treatment of, 193,
operative technique for, 353, 353f insertional pathology of, 352 191–192
results in, 353 after care of, 353 primary repair for, 193
surgical technique of, 344 diagnosis of, 352, 352f surgical treatment of, 191, 192–200,
treatment for, 352–353 evidence-based recommendations 193f, 197t
noninsertional, 350 for, 354 tendon transfer for, 198,
after care of, 351–352 operative technique for, 353, 353f 198f–199f
diagnosis of, 350 results in, 353 V-Y advancement for, 197
operative technique for, 351, treatment for, 352–353 in dancers, 450
351f–352f insertional tendinopathy of, 165, in military athletes, 499
results in, 352 167f–168f postoperative protocol for, 195t–196t
treatment for, 350–351 surgical treatment for, 176–177, Achilles tendon tendinitis,
paratendinitis, 343–344 180f–182f peritendinitis, in dancers, 449–450
posterior ankle impingement caused nomenclature for, 164 Achillotendoscopy, 344, 344f
by, 343–344 noninsertional pathology of, 350 ACI. See Autologous chondrocyte
Achilles tendinopathy, 164, 164b after care of, 351–352 implantation
allogenic factor injection for, 169 diagnosis of, 350 ACSM. See American College of Sports
autologous platelet-rich plasma for, operative technique for, 351, Medicine
169 351f–352f Activation phase, of bone remodeling, 35

Note: Page numbers followed by “f ” indicate figures, “t” indicate tables, and “b” indicate boxes.

583
584 INDEX

ACTIVE. See Abaloparatide Aircast walking boot, 557, 557f, 565 Ankle impingement (Continued)
Comparator Trial in Vertebral weaning out of, 568t posterior, 12–16, 13f–14f, 13t,
Endpoints Allogenic factor injection, for Achilles 337–339
Acupuncture, 464, 464f tendinopathy, 169 bony avulsions, 338
Acute Achilles tendon rupture, 182, American Academy of Orthopaedic causes of, 337
182–192, 191f Surgeons (AAOS), 30–31 flexor hallucis longus pathology,
mini-open technique for, 187–189, American College of Sports Medicine 339–341, 340f
197f, 200–201 (ACSM), 30–31, 74–75 insertional tendonitis, 344, 344f
nonsurgical treatment for, 182–184, American Society for Bone and Mineral loose bodies, 338
193–197 Research (ASBMR), 30–31 os trigonum syndrome, 337–338,
percutaneous technique for, 200 AMIC. See Autologous matrix-induced 338f–339f
results of acute surgical repair, 189 chondrogenesis osteochondral lesions, 339, 340f
standard technique for, 187–192, AmnioFix, 527 peritendinitis, 343–344, 343f
192f–194f, 195t, 198–200 Amniotic products, 526–527 peroneal tendon pathology,
surgical treatment for, 186–187, Anabolic agents, for bone, 55–72 342–343, 342f
197–198 abaloparatide (Tymlos) PTHrP (1- posterior tibial tendon pathology,
Acute ankle injury, authors’ preferred 34), 64–66 341–342, 341f
treatment approach for, 250–251 teriparatide (Forteo) rh PTH (1-34), posttraumatic calcifications, 338
Acute ankle instability, nonsurgical 57–61 retrocalcaneal bursitis, 344, 344f
treatment of, 246–254.e1 Anatomic reduction, of posterior tendinosis, 343–344, 343f
Acute lateral ankle sprain, 255–257 malleolus fracture, 108 posterolateral, 13–15, 14f–15f
assessment of, 255–256, 256t Anderson, MD, Bob, 580–581, 581f posteromedial, 15–16, 16f
nonoperative treatment of, 256 Ankle Ankle instability, 255–274
operative treatment of, 256–257, 257f, hindfoot anatomy of, 276f chronic lateral, 257–261
257b–258b, 258t–259t osteochondral lesions of, 290 assessment of, 256t, 257–259
Acute ligament injuries, 247–251 radiographs, 209–211, 210f operative treatment of, 259–261,
acute phase treatment of, 247–249 sprains, high, rehabilitation, 550–551 260f–261f
edema management, 249 stability of, 106 in Egypt, 469–471
mobility, 249 Ankle arthroscopy, for talus fracture, rehabilitation for, 269–270
role for immobilization, 247–248, 290 Ankle radiographs, for sustantaculum
248f Ankle fractures, 107–116 tali fractures, 281
diagnosis of, 247, 248f acute, arthroscopic evaluation of, Ankle sprains, 247, 255–274
progressive phase treatment of, 115–116, 117f in Colombia, 465–467, 466f–467f
249–250 bimalleolar/trimalleolar, 112–115, combination injuries and, 255, 256t
loading tolerance, 249–250 113f–115f in Egypt, 469–471
postural control, 249, 249f–250f clinical evaluation for, 105 epidemiology of, 255
return to sport testing, 250 and dislocations, 105–124 failed prior surgery of, 261, 261f–262f
strengthening, 249 lateral, 110–112, 111f–112f in female athletes, 520b
Acute medial ankle sprain, 261–265 medial, 107, 107f–108f. See also high, rehabilitation for, 570f, 571–572,
assessment of, 262–264, 262f–263f Medial ankle fractures. 572t
nonoperative treatment of, 264 pediatric, 116, 118f–119f lateral, 255–261
operative treatment of, 264–265, 264f posterior malleolus, 108–110, 109f in dancers, 445–446
Acute plantar plate rupture, treatment radiographic evaluation for, 105–106, residual symptoms after, 445
of, in Venezuela, 490–491, 106f medial, 261–266
490f–491f rehabilitation for, 116 in dancers, 444–445, 445f
Acute syndesmosis sprain, 266–268 Salter-Harris classification, 509–510 in military athletes, 498
assessment of, 266 in ski and snowboard, 461 rehabilitation for, 269–270
nonoperative treatment of, 266–267, treatment of, 106–107 in ski and snowboard, 461
266b Ankle impingement tarsal coalition and, 319
operative treatment of, 267–268, 267b, anterior, 8–11, 333, 333b, 334f in women’s NCAA volleyball, 517
268f anterocentral, 10 Ankle syndesmosis, space
Adductor strength test, 5 anterolateral, 10–11 measurements, 106, 106f
Adipose stem cells, 525–526 anteromedial, 8–10, 9f–10f Ankle x-rays, for talus fracture, 288,
Adolescents, fifth metatarsal base in Colombia, 465–467, 466f–467f 292f–293f
fractures in, 137 lateral, 11–12 Ankylosing spondylitis, 231
 INDEX 585

Anterior ankle impingement, 8–11, Arthrodesis (Continued) Arthroscopy (Continued)

333–336 subtalar, 221–222 tendinitis treated with, 343–344
arthroscopic treatment of, 333–336, triple, 221–222 two-portal approach in, 338, 340f
333b, 334f Arthroscopic exploration, of sinus tarsi, ASBMR. See American Society for Bone
bony impingement associated with, 317, 317f and Mineral Research
326–327 Arthroscopy Athletes
in dancers, 446, 447f Achilles tendon paratendinitis treated bone-building snack for, 75t
location of, 333 with, 343–344, 343f bunions in, 411–415
scoring systems for, 333 anatomy, 330–332 compensated, 412, 412f
Anterior process calcaneal fracture, anterior and posterior, 345–346, 347f decompensated, 412, 412f
120–122, 122f anterior ankle impingement treated experience and, 411
clinical evaluation for, 105 with, 333, 333b, 334f hallus rigidus and, 414
radiographic evaluation for, 105–106, considerations for, 333–346 magnetic resonance imaging for,
106f contraindications for, 326–327 412, 412f
treatment of, 106–107 diagnostics for, 333–336 patient and, 413–414
Anterior talofibular ligament equipment for, 327–328 philosophy in, 411
sprain of, 445 examination using plan treatment for, 412–413,
tear of, 445 14-point, 330, 331b 412f–414f
Anterior talofibular ligament (ATFL) 21-point, 330, 331b rehabilitation for, 415
injury, 255–256 anterior ankle, 330–331 work up for, 411–412
Anterior tarsal tunnel syndrome, 228, posterior ankle, 331–332, 332f–333f x-ray for, 412, 412f
228f grasper for, 328 decision to return to play of,
Anterior tibia, 333–334 hallux rigidus treated with, 395 74–78
Anterior tibial tendon, rupture of, history of, 326 diet and nutrition of, 72–74, 74t
144–148 indications for, 326–327 medical and metabolic consideration
anatomy for, 144 instrumentation for, 328 in, with stress fractures, 30–94,
diagnosis of, 144 irrigation for, 328 31b
extensor hallucis longus tendon of loose bodies, 336, 338 in military, 497–502
transfer for, 147, 149f operative setup for, 327, 327f–328f Achilles tendinopathy, 499
graft for, 146–147, 146f–148f of ossicles, 336 Achilles tendon rupture, 499
methods of repair for, 144–145, 145f of osteochondral defects of the talus, ankle sprains, 498
outcomes of treatment for, 147–148 334–335, 336f bracing options, 500, 501f
skin incision and approach to, osteochondral lesions treated with, fractures, 498–499
145–146 334–335, 335f–337f instability, 498
Anterocentral impingement, 10 patient positioning for, 327f Lisfranc injuries, 499
Anterolateral impingement, 10–11 of peroneal tendons, 333f osteochondral lesions of talus,
Anteromedial impingement, 8–10, portals in, 328–330 499–500
9f–10f accessory inferior, 329 plantar fasciitis, 500
Antigravity treadmill (AlterG™), anterior, 328–329 nutritional history in, 76f–77f
544–545, 545f anterolateral, 329, 329f physical therapy for, 74
Aquatic therapy, for ankle rehabilitation, anteromedial, 328–329, 328f posterior tibialis tendon injury in,
116 function of, 328 206–223
Arterial disease, 235–236 posterior, 329–330 abduction deformity secondary to,
Arthritic disorders, 230–238 posterolateral, 329, 330f 211f
Arthritis posteromedial, 329–330, 330f acute pain or injury, 208
enteropathic, 231–232 transmalleolar, 330 chronic or acute, 208
gouty, 232 transtibial, 330 conservative treatment of, 213
psoriatic, 231 in prone position, 338 diagnosis of, 207–212
in Reiter’s syndrome, 231 rehabilitation after, 346 differential diagnosis of, 212t
rheumatoid, 232 of subtalar joint, 317f, 326–348, 327f, hindfoot inversion associated with,
Arthrodesis 345f 209f
calcaneocuboid distraction, 221–222 and intraosseous talar cysts, history-taking, 208
hallux rigidus treated with, 394 344–345, 345f–347f magnetic resonance imaging
posterior tibialis tendon injury treated surgical techniques for, 327–346 evaluations of, 211–212, 212f
with, 221–222 synovitis treated with, 334 perils and pitfalls of, 222
586 INDEX

Athletes (Continued) Bassett’s ligament, 10–11, 10f Bone marrow aspirate concentrate
physical examination of, 208, Baxter’s nerve neurapraxia, 450 (BMAC), 307, 307f
208f–209f Beach toe lesions, in Brazil, 456–457, Bone marrow concentrate (BMC),
predisposing factors, 208 456f–457f 524–525
radiographic imaging of, 209 Bike program, for rehabilitation, 566, Bone marrow–derived cell
staging of, 212–213, 213b 566f transplantation (BMDCT), 307
surgical treatment of, 213 Bilateral toe raise, 3 Bone marrow edema syndrome, 67–69
tenderness evaluations, 208, 208f Bimalleolar fractures, 112–115, Bone marrow lesions (BML), chronic,
“too many toes” sign, 208, 209f 113f–115f treatment of, 532–535
treatment of, 213–222 recovery time on, 480, 480f–481f clinical effect, 533, 533t
rest for, 74 Biologics, definition of, 523 interpreting MRI, 532–533, 532f
stress fractures in, 23, 24t Biomechanical ankle proprioception management, 533–534, 534f–535f
team in care of, 576–582 system (BAPS), 546, 546f patient presentation/indications, 532
Anderson, MD, Bob, 580–581, 581f Bisphosphonates, 234 technique, 534–535
Bartelstein, Mark, 578–579, 579f for stress fracture, 55–72 Bone material strength index (BMSI), 48
Hammer, Dave, 578, 578f Black heel, 241, 241f Bone metabolism, 49
Hayward, Gordon, 579–580, 579f BMA. See Bone marrow aspirate Bone micro-indentation, 49
Peszek, Jessica, 581–582, 582f BMAC. See Bone marrow aspirate Bone mineral content (BMC), of
Peszek, Luann, 581–582, 582f concentrate amenorrheic and eumenorrheic
Peszek, Samantha, 581–582, 582f BMC. See Bone marrow concentrate athletes, 42
Polian, Bill, 576–577, 577f BMD. See Bone mineral density Bone mineral density (BMD), low,
Autologous chondrocyte implantation BMDCT. See Bone marrow–derived cell diagnosis of, 44b
(ACI), 528–529 transplantation Bone modeling, 35
for osteochondral lesions of the talus, BML. See Bone marrow lesions Bone morphogenetic protein (BMP),
303 BMP. See Bone morphogenetic protein 527
Autologous matrix-induced BMSI. See Bone material strength index Bone remodeling, 22
chondrogenesis (AMIC), for Bone Bone resorption, 22
osteochondral lesions of the talus, anabolic agents for, 55–72 Bone scans, tarsal navicular stress
303 densitometry, 42–45, 44b fracture imaging using, 96
Autologous platelet-rich plasma, for deposition of, 36 Bone scintigraphy, sesamoid pain
Achilles tendinopathy, 169 growth stimulators of, 55–72 evaluations, 101
Avascular necrosis of the sesamoid, 396 of human, 37 Bone-specific alkaline phosphatase
Average vertical loading rate (AVLR), 41 metabolism of, 49 (BSAP), 49, 52
AVLR. See Average vertical loading rate modeling of, 35 Bone stimulators, 26
Avulsion fractures, fifth metatarsal base quality, 45–49, 45f Bone stress injuries (BSI), 30
fracture, 133 osteoprobe for, 48–49, 48f–49f classification systems of, 31–33, 33t
Avulsion injuries, 120, 122f trabecular bone score for, 35, definition of, 30–31, 31t–32t
with distal fragment excised, 404f 46–48, 46t, 48f epidemiology of, 33
therapy for, 55–72 Bony alignment, correction of, 219
B anabolic agents for, 55–72 Borrelia burgdorferi, 233
Bacterial infections, of skin, 243–244, bisphosphonates, 55–72 Brazilian foot and ankle injuries, in
243f calcium, 55–72, 55t sports, 455–460
Ballet, 436–437, 451, 518–519, 518f growth stimulators, 55–72 beach toe lesions, 456–457, 456f–457f
BAPS. See Biomechanical ankle vitamin D, 55–72, 55t fifth metatarsal stress fracture, 459–460
proprioception system “Bone bruise”, 68 loose bodies of ankle joint, 458–459,
Bartelstein, Mark, 578–579, 579f Bone-building snack, for athletes, 75t 458f–459f
Basic foot and ankle physical exam, “Bone contusion”, 68 posterior ankle impingement,
1–6.e1 Bone densitometry, 42–45, 44b, 234 457–458, 457f–458f
in athlete, 2 Bone fatigue fractures, 34 subtle Lisfranc ligament lesion,
musculoskeletal exam, 3–4 Bone formation, adaptive, 35–36 455–456, 455f–456f
neurologic exam, 2 Bone grafts, 397 Brevis tendon
patient history, 4–6 Bone growth stimulators, stress fracture peroneus longus and, tears of,
pulses and edema, 2–3 and, 55–72 155–156, 156f
Basketball, and female athletes, 517 Bone marrow aspirate (BMA), harvest tears of, 152–155, 153f–155f, 157f
“Basketball foot”, 317 of, 529 British Journal of Sports Medicine, 75
 INDEX 587

Brostrom-Gould reconstruction Calcifications, posttraumatic, 338 Chopart (transversal tarsal) joint,

technique, 315, 316f, 498 Calcitonin gene-related peptide 363–364, 364f
BSAP. See Bone-specific alkaline (CGRP), 562 Chovgan, foot and ankle injuries in, 475
phosphatase Calcium, 55–72, 55t Chronic Achilles tendinopathy, 351–352
BSI. See Bone stress injuries Calcium deficiency, 235 Chronic Achilles tendon rupture, 192,
Bunionettes, 369–372 Calcium phosphate, 527–528 189–191
case study of, 370b Calcium pyrophosphate dihydrate autograft/allograft reconstruction for,
clinical presentation of, 369 crystal deposition, 232–233, 233b 200, 199f
in dancers, 437–438, 444 Calcium sulfate, 527–528 nonsurgical treatment of, 193,
fifth metatarsal head and, 370f Calcium triphosphate, 532–535 191–192
illustration of, 369f clinical effect of, 533, 533t primary repair for, 193
physical examination of, 370 interpreting MRI, 532–533, 532f surgical treatment of, 193, 192–200,
radiographs of, 371f for management of BML, 533–534, 193f, 197t
treatment of 534f–535f tendon transfer for, 198,
conservative, 370 patient presentation/indications, 532 198f–199f
osteotomy, 371 technique for, 534–535 V-Y advancement for, 197
surgical, 371–372, 371f Calf raise, 550, 565, 566f–567f Chronic ankle instability, 251–252, 251f
Bunions, in elite athletes, 411–415 Calf stretching, 570f, 571–572 authors’ preferred treatment approach
compensated, 412, 412f Calf tone, 3 for, 252
decompensated, 412, 412f Callus(es) prevention of, 252
experience and, 411 bunionettes, 369 Chronic exertional compartment
hallus rigidus and, 414 description of, 240, 240f syndrome, 421–424, 422f
magnetic resonance imaging for, 412, diffuse, 372–373 case study of, 424b
412f discrete, 372–373, 374f diagnostic studies for, 423–424, 423f,
patient and, 413–414 in intractable plantar keratoses, 372 423t
philosophy in, 411 Cancellous bone graft, 138 history for, 422–423
plan treatment for, 412–413, Capsular avulsion injuries, 284–285 physical examination for, 423
412f–414f Capsular interposition, 394, 395f treatment for, 424
rehabilitation for, 415 Capsular reefing, 384–385 conservative, 424
work up for, 411–412 Cardiovascular rehabilitation, 546, 559, operative, 424, 424b, 425f
x-ray for, 412, 412f 560t–561t Chronic lateral ankle instability,
Burr (personal communication), 81 Cartilage repair, biologic adjuvants to, 257–261
Bursectomy, 440 307 assessment of, 256t, 257–259
Bursitis Cast and boot treatment, for cuboid operative treatment of, 259–261,
calcaneal, 450 fractures, 285 260f–261f
retrocalcaneal, 344, 344f Cavus feet, 40 Chronic leg pain, 416–434, 430t–431t
sesamoid, 440 Cellulitis, 234, 243–244, 244f Chronic medial instability, 265–266
CFT. See Combat fitness test assessment of, 265
C CGRP. See Calcitonin gene-related nonoperative treatment of, 265
Calcaneal bursitis, 450 peptide operative treatment of, 265–266, 265f
Calcaneal stress fractures, 26–27 Cheerleading, 517 Chronic plantar plate rupture, treatment
Calcaneocuboid distraction arthrodesis, Cheilectomy of, in Venezuela, 491–492,
221–222 hallux rigidus treated with, 392 491f–493f
Calcaneocuboid ligaments, 278 postoperative course after, 393 Chronic syndesmosis sprain/instability,
Calcaneofibular ligament, 280f, 445 results of, 393 268–269
Calcaneonavicular coalitions (CNCs), Chevron osteotomy assessment of, 268, 269f
319, 320f–322f, 321, 503–504, 504f bunionette treated with, 371, 372f operative treatment of, 268–269
Calcaneonavicular ligaments, 278 distal oblique, 371, 373f Clamshell splint, fifth metatarsal,
Calcaneus intractable plantar keratoses treated 570–571, 570f
anatomy of, 278 with, 376f Claudication, 236
blood supply to, 278 Chilblains, in ski and snowboard, 462 Claw toe, 380–383, 383f, 404
ligaments of, 280f Chinese herb ointment, 464, 464f deformity, reconstruction of, 406f
occult fractures of, 280–283 Chinese traditional concepts of foot CNCs. See Calcaneonavicular coalitions
Calcaneus fractures, anterolateral and ankle problems and traditional Cold compressive devices, 543, 543f
process of, 282–283, 282f–284f, 284t treatments, 463–465, 463f–465f Collateral ligaments, 390
588 INDEX

Colombian foot and ankle conditions, in Cortisone injection, for calcaneus Dancers (Continued)
sports, 465–468 fractures, 283 heel pain in, 450
Achilles tendon lesions, 467–468, Cricket, foot and ankle injuries in, 472 lateral ankle injuries in, 445–446
467f–468f Crohn’s disease, 231 leg pain in, 450–451
ankle sprains and ankle impingement, Cross-sectional area (CSA), of long medial ankle injuries in, 444–445
465–467, 466f–467f bone, 44–45 medial tibial stress syndrome in,
Lisfranc low grades sprains, 468 Cross-sectional moment of inertia 450–451
Combat fitness test (CFT), 497 (CSMI), of long bone, 44–45 metatarsal injuries in, 441–444
Combination injuries, and ankle sprains, Cryotherapy, 543, 555–556 metatarsophalangeal joint injuries in,
255, 256t CSA. See Cross-sectional area 437–438
Compartment syndrome CSMI. See Cross-sectional moment of bunions, 437–438, 438f
chronic exertional, 421–424, 422f inertia hallux rigidus, 438, 438f–439f
case study of, 424b CT. See Computed tomography instability, 440, 441f
conservative treatment for, 424 C-terminal propeptide of type I lateral proper digital nerve
diagnostic studies for, 423–424, procollagen (PICP), 49 entrapment, 440
423f, 423t Cuboid plantar fasciitis in, 450
history for, 422–423 anatomy of, 278 posterior ankle injuries in, 446–449
operative treatment for, 424, 424b, compressive injuries of, 133, flexor hallucis longus tendinopathy,
425f 135f–136f 448–449, 449f
physical examination for, 423 occult fractures of, 284–285, 285f impingement syndrome, 447–448,
treatment for, 424 Cuboid fractures, “chip” fractures, 133 448f
in dancers, 451 Cuboid subluxation, 446, 446f proximal fifth metatarsal spiral
Compressive injuries, 120, 122f Cuneiforms fracture, 441–444, 444f
Compton bone densitometer, 42 bipartite, 133, 134f second metatarsal base stress fracture
Computed tomography (CT), 105 configuration of, 441 in, 441, 443f
for calcaneus fractures, 282, 284f dislocation of, 133 sesamoid bone injuries in, 438–440
for cuboid fractures, 285 fracture of, 133 “shin splints” in, 450–451
of ossicles, 337, 339f medial, 134f stress fractures in, 451, 451f
for osteochondral defects of the talus, Cupping, 562, 562f Dancer’s pad, 101
336, 336f Cushing’s disease, 235 Davis’ law, 547, 563
for posterior malleolus fracture, Deep peroneal nerve (DPN), palpation
108–109 D of, 5
for posterior talus fractures/posterior Dancers, 435–453.e1 Deformity, foot and ankle, 3
impingement syndrome, 287 Achilles tendon injuries in, 449–450 Delayed union, Jones fracture, 139
for sustantaculum tali fractures, 281 peritendinitis, 449–450 Deltoid ligament
for talonavicular avulsion injuries, pseudotumor of calf, 450 posterior, 278f
285, 287f rupture, 450 strain of, 445
for talus fracture, 288, 292f–293f tendinosis, 449–450, 449f–450f Demi-pointe stance, 437, 437f
Condylectomy ankle sprains in Dermatologic disorders, 239–245
hard corn treated with, 379f lateral, 445–446 Desensitization massage, 550, 567–568
partial, 373–374, 375f medial, 444–445, 445f 3D-GA. See Three-dimensional
Conservative treatment anterior ankle injuries in, 446 instrumented gait analysis
of bunionettes, 370 bunionettes in, 444 Diabetes mellitus, 233–234
of fifth metatarsal base fractures, 139, compartment syndrome in, 451 Diet, of athletes, 72–74, 74t
139f demi-pointe stance, 437, 437f 1,25dihydroxyvitamin D, 38
of hammertoes, mallet toes, claw toes, en pointe stance, 437, 437f 1,25 dihydroxyvitamin D resistant
380–381 feet of, 437 rickets, 38
of hard corns and soft corns, 378, 379f fifth metatarsal spiral diaphyseal Dislocation
of intractable plantar keratoses, 373, fracture (dancer’s fracture), 441, of peroneal tendons, 156–160
374f 443f anatomy of tissue and, 156–157
of metatarsophalangeal joint flexor hallucis longus tendinopathy, complications and potential pitfalls
instability, 384, 386f 448–449, 449f of, 160
of turf-toe, 405 Freiberg’s infraction in, 441, 442f direct groove deepening approach
Contact dermatitis, 242 hallux interphalangeal joint injuries, for, 158, 159f
Corns, 240, 240f 440, 440f historical perspective for, 156
 INDEX 589

Dislocation (Continued) Extensor hallucis longus tendon Fifth metatarsal base fractures, 133–141,
history and exam for, 157–158 transfer, for rupture of anterior 140f
indirect groove deepening approach tibial tendon, 147, 149f in adolescent athlete, 137
for, 158–159 Extensor tendoscopy, 360–361 avulsion, 137
intrasheath peroneal dislocation External load, of soldiers, 497, 498f classification of, 133, 136f
without SPR avulsion, 159 External rotation (ER) test, 4 delayed union of, 139
nature of problem for, 157 diagnosis, 137
osteotomy for, 158 F historical description of, 133–135
rehabilitation for, 159–160 Falcons, hunting with, in UAE, 487, nonunions, 141
treatment of, 158 487f–488f physical examination for, 137
of subtalar joint, 317–318 Fasciotomy, 397 radiographs, 133, 137
Distal fibula avulsion fractures, 11, 12f Fatigue, stress fracture and, 34 recurrent, 141
Distal oblique osteotomy, 371, 373f, FEA. See Finite element analysis stress fractures of, 102
375f Female athlete triad, 519 treatment of
Dorsal foot pain, 6 Female athletes cancellous bone graft, 138
Dorsalis pedis artery, 2, 277f considerations for foot and ankle conservative, 139, 139f
Dorsiflexion, 4 injuries in, 516–521 inlay bone grafting, 138
DPA. See Dual photon absorptiometry ballet, sport-specific disorders of, medullary curettage, 138
DPN. See Deep peroneal nerve 518–519, 518f percutaneous intramedullary screw
Drawer sign, 368–369 basketball, sport-specific disorders fixation, 138, 140f
Dual-energy X-ray absorptiometry of, 517 tuberosity
(DXA), 42, 62–63, 63t–64t, 64f cheerleading, sport-specific description of, 137
limitations of, 45–46 disorders of, 517 treatment of, 138
Dual photon absorptiometry (DPA), 42 gender-specific, 519–520, 519f zone 1, 133–135, 141
DXA. See Dual-energy X-ray gymnastics, sport-specific disorders zone 2, 133–135, 141
absorptiometry of, 516 zone 3, 133–135, 141
soccer, sport-specific disorders of, Fifth metatarsal fractures
E 517 proximal spiral, 441–444, 444f
Edema, 3 sport-specific disorders of, 516–519 spiral diaphyseal (dancer’s fracture),
management of, 249 volleyball, sport-specific disorders 441, 443f
Egyptian foot, 437 of, 517 stress fractures of, 101–102
Egyptian perspective on foot and ankle, stress fractures in, 23 case study of, 102b, 103f
in sports, 468–471 Female athletic triad, 234–235, 235b, Fifth metatarsal head, bunionettes on,
flexor hallucis longus tendinitis/ 437 370f
posterior ankle impingement, Ferkel’s disease, 11 Fifth metatarsal stress fractures, 27
469, 471f FGF 23. See Fibroblast growth factor 23 Finite element analysis (FEA), 35
osteochondral lesions of talus, FHL. See Flexor hallucis longus First metatarsophalangeal joint
468–469, 470f Fibroblast growth factor 23 (FGF 23), anatomy of, 391f
other injuries, 469–471 37 in hallucal sesamoid fractures, 100
Elmslie procedure, 316f Fibular fractures Fist Test, 40
En pointe, 437, 437f displacement of, 110 Flatfoot, 319, 504
Endoscopy Salter-Harris I, 510 adult, symptomatic, 354
arthroscopies and, 354 Fibular hallux sesamoidectomy, 397 Flexor digitorum longus transfer,
of foot and ankle, 349–367 Fibular ligaments, anterior talofibular Achilles tendinopathy and, 172–
tendoscopies and, 359–361 sprain of, 445 173, 172f–173f
Enteropathic arthritis, 231–232 tear of, 445 Flexor hallucis brevis, split tendon of,
Enthesopathies, 231 Fifth metatarsal 390–391
Entrapment, lateral proper digital nerve, avulsion of, 507 Flexor hallucis longus
440 injury to, in dancers, 518 release of, 331–332, 333f
Eversion strength test, 5 proximal end of, 136 tendinitis
Excision stress fracture, in Brazil, 459–460 in ballet dancers, 518
of interdigital neuroma, 377, 377f tendon attachments of, 136f in Egypt, 469, 471f
of talocalcaneal coalition, 322f tuberosity of, 136 os trigonum syndrome and, 338
Exostosis, 377 vascular anatomy of, 137, 137f osteochondral defect as cause of,
Extensor hallucis brevis, 390–391 watershed area, 137 339–340
590 INDEX

Flexor hallucis longus (Continued) Foot and ankle injuries, in sports Fracture
pain caused by, 340–341 (Continued) avulsion, fifth metatarsal base
posterior impingement syndrome, Pahlevaniv, 475, 476f fracture, 133
339–341 wrestling, 475, 475f biochemical risk factors for, 51b
tendinopathy in Japan, 475–479 cuboid, “chip”, 133
in dancers, 448–449 judo, 476–477, 477f in foot and ankle, 532
illustration of, 449f kendo, 478–479, 478f–479f in military athletes, 498–499
tenolysis, 16, 17f sumo, 477–478, 478f nonunion of, 62–64, 63t–64t, 64f
transfer, Achilles tendinopathy and, of racetrack jockeys in Mexico City, stress, 418–421
173, 174f–176f 479–481, 479t–480t btom in, 49–54
Flexor hallucis longus (FHL) mechanism of injury, 479–480, case studies in, 61–64, 62f, 63t–64t,
tendoscopy, 359–360, 360f 480b 64f–65f, 421b, 422f
Flexor retinaculum, release of, 341f open fractures, 480 classification of, 33t
Flipping, 463f, 464 protective gear for, 480 diagnostic studies for, 419–420,
Folate deficiency, 235 recovery time on bimalleolar 419f–420f
Folliculitis, 243, 244f fractures, 480, 480f–481f genetic predisposition in, 37–39
Foot and ankle injuries, in sports, ski and snowboard injuries of the history of, 39–41, 419
454–496 foot and ankle in Chile, 460–462, laboratory workup in, 49–54, 50t,
Brazilian, 455–460 460f–461f 51b
beach toe lesions, 456–457, ankle sprains and fractures, 461 medical and metabolic
456f–457f chilblains, 462 considerations in athletes with,
fifth metatarsal stress fracture, equipment and technical 30–94
459–460 considerations in, 460–461, pathophysiology of, 33–37, 34f
loose bodies of ankle joint, 458– 460f–461f physical examination of, 39–41, 40t,
459, 458f–459f Morton’s neuroma, 462 419
posterior ankle impingement, skier’s toe, 462 prevention of, 78–81
457–458, 457f–458f Snowboarder´s fracture, 461–462, proposed classification system of,
subtle Lisfranc ligament lesion, 462f 33t
455–456, 455f–456f in South Africa, 481–483 risk factors of, 39
Chinese traditional concepts and investigations in, 482–483, 483f treatment for, 420–421
treatment of, 463–465, 463f–465f overload injuries to the second conservative, 420–421
Colombian, 465–468 metatarsal, 481–482, 482f operative, 421, 421b
Achilles tendon lesions, 467–468, in Thailand, 483–486 Freiberg’s disease/infraction, 361
467f–468f Muay Thai, 483, 484f–485f in children, 507
ankle sprains and ankle Sepak Takraw, 484–486, 485f–486f in dancers, 441, 442f
impingement, 465–467, in United Arab Emirates, 486–488, types of, 441
466f–467f 487f–489f Frost, Harold M., 34
Lisfranc low grades sprains, 468 in Venezuela, 488–492, 489f Functional dry needling, 562, 563f
Egyptian perspective, 468–471 Foot dorsiflexion, 402f Functional nerve disorders, 224–229
flexor hallucis longus tendinitis/ Foot fractures and dislocations anterior tarsal tunnel syndrome, 228,
posterior ankle impingement, ankle. See Ankle fractures 228f
469, 471f clinical evaluation of, 105 case studies of, 226b–227b
osteochondral lesions of talus, lateral process talar fracture. See medial plantar nerve entrapment
468–469, 470f Lateral process talar fracture “Jogger’s foot”, 227, 227b
other injuries, 469–471 physical examination of, 105 tarsal tunnel syndrome, 224,
in India, 472–474, 472f radiographic evaluation of, 105–106 225f
cricket, 472 treatment of, 106–107 author’s approach to, 226–227,
hockey, 473 Foot massage, 464, 465f 227f
Kabaddi, 473, 473f Foot pain, location of, 369b Functional progression, 546–547, 561t,
Kho Kho, 473–474, 474f Foot plantar surface, 464 562–563, 563t–565t
management of, 474 Foot radiographs, 209–211, 210f–211f Fungal infection
in Iran, 474–475 for sustantaculum tali fractures, 281 of nail, 242–243, 243f
chovgan, 475 Forced plantarflexion sign, 447 of skin, 242, 242f
mountain tracking and rock Forteo Patient Registry (FPR), 61 Furunculosis (boils), 244
climbing, 474, 475f FPR. See Forteo Patient Registry Fusion, in foot and ankle, 532
 INDEX 591

G Hallux rigidus (Continued) I

Gait, 3 arthrodesis, 394 IDEO. See Intrepid Dynamic Exoskeletal
evaluation of, 545, 558 cheilectomy, 392 Orthosis
phases of, 545, 558 implant arthroplasty, 395 Iliac crest graft, 347f
Gait deviation index (GDI), 40–41 interposition arthroplasty, 394, 395f Immobilization
Gait profile score (GPS), 40–41 Moberg osteotomy. See Moberg fifth metatarsal stress fractures
Gait retraining, stress fracture and, 41 osteotomy managed with, 102
GDI. See Gait deviation index options for, 392 posterior tibialis tendon injury, 213
Gegenbaur, Carl, on osteocytes, 36 phalangeal osteotomy, 393, 394f role for, acute ligament injuries and,
Global positioning systems (GPS), and resection arthroplasty, 394, 395f 247–248, 248f
rehabilitation, 547, 547f symptoms of, 392 Impetigo, 243
Gout, 232 Hallux sesamoid, 396–397 Impingement syndromes, of ankle,
GPS. See Gait profile score stress fractures of, 100–101 7–21.e1, 8, 9f
Grafix, 526–527 case study of, 101f, 101b medial, 19
Great-toe disorders, 390–410 Hallux valgus open medial approach-FHL tenolysis
acute, 400 in children, 505 and excision os trigonum, 16, 17f
anatomy of, 390–391 shoewear examination for, 505 osteophyte removal, general technique
biomechanics of, 391 treatment of, 505 tips for, 8–20
in dancers, 440 Hammer, Dave, 578, 578f anterior, 8–11
description of, 390 Hammertoe, 380–381 anterocentral, 10
functional disability caused by, 390 characteristics of, 380 anterolateral, 10–11
specific entities of, 391–408 surgical treatment of, 380–381, anteromedial, 8–10, 9f–10f
Great toe pain, 6 382f lateral, 11–12
Grecian foot, 437 Hard corns, 377–380, 378f posterior, 12–16, 13f–14f, 13t
GRF. See Ground reaction force case study of, 378b posterolateral, 13–15, 14f–15f
Ground reaction force (GRF), 41 surgical treatment of, 378–379, 379f posteromedial, 15–16, 16f
Growth stimulators, of bone, 55–72 Harris axial x-ray, for sustantaculum tali posterior ankle and hindfoot
Gymnastics, and female athletes, 516 fractures, 281 arthroscopy, 16–19, 18f–19f
Hayward, Gordon, 579–580, 579f sinus tarsi, 19–20, 20f
H Heel spur, 450 India, foot and ankle injuries in sports
HA. See Hyaluronic acid Heel strike, during running, 417, 417f in, 472–474, 472f
Haglund’s deformity, 166 HFI. See Hip flexor index cricket, 472
cavus foot with, 449, 449f High-resolution peripheral CT hockey, 473
radiographs of, 450f (HRpQCT), 35 Kabaddi, 473, 473f
surgical treatment for, 177–178, 178b, Hindfoot Kho Kho, 473–474, 474f
183f–188f anatomy of, 275–276, 276f management of, 474
Hallus rigidus, bunions and, 414 inversion of, in posterior tibialis Infectious disorders, 239–245
Hallux metatarsophalangeal joint tendon injury, 209f Inlay bone grafting, 138
anatomy of, 390 occult fractures of, 275–280 Insertional Achilles tendinitis, 352
biomechanics of, 391 tendons attaching to, 278–280 after care of, 353
dislocations of, 400t, 406–408, 407f, Hindfoot angle, 3 classification of, 344
407t Hindfoot arthroscopy, 16–19, 18f–19f diagnosis of, 352, 352f
hyperflexion injuries of, 408 Hindfoot valgus, 265 evidence-based recommendations for,
injuries to. See Great-toe disorders Hip flexor index (HFI), 40–41 354
range of motion, 391 Hip flexor strength test, 5 operative technique for, 353, 353f
Hallux rigidus, 391–395, 393f–394f Hockey, foot and ankle injuries in, results in, 353
in dancers, 438, 438f–439f 473 surgical technique of, 344
definition of, 391 Horse racing, in UAE, 487 treatment for, 352–353
grade I, 438 HRpQCT. See High-resolution Insertional Achilles tendinopathy, 165,
grade II, 438 peripheral CT 167f–168f
grade III, 438 Hyaluronic acid (HA), 307, 528 surgical treatment for, 176–177,
grade IV, 438 Hyperflexion injuries, of hallux 180f–182f
nonoperative treatment of, 392 metatarsophalangeal joint, 408 Instability
severity of, 392 Hyperparathyroidism, 235 of metatarsophalangeal joint, 440, 441f
surgical treatment of Hyperuricemia, 232 subtalar, 313–315
592 INDEX

Interdigital neuroma, 376–377, 376b, 377f “Jogger’s foot”. See Medial plantar nerve Lateral proper digital nerve entrapment,
Interfragmentary fixation, for lateral entrapment 440
malleolus fracture, 111 Jones fracture, 64 Leg pain, chronic, 416–434, 430t–431t
Intermetatarsal diastasis, 130f in dancers, 518 Lesser-toe disorders, 368–389
International Consensus Meeting on diagnosis of, 137 bunionettes. See Bunionettes
Cartilage Repair of the Ankle, 308 fifth metatarsal, 441–444, 444f claw toe, 380–383, 383f
International Federation of Sports historical description of, 133. See also hammertoes, 380–381
Physical Therapy, 75 Fifth metatarsal base fractures. hard corns, 377–380, 378f
International Society for Clinical in pediatric patients, 511–512 mallet toes, 380–381, 380f–381f
Densitometry (ISCD), 42 treatment of, 139, 139f, 512 soft corns, 377–380, 378f
Interphalangeal joint, great toe, 440 Joplin’s neuroma, 440 LIFT. See Lateral inverted osteochondral
Interposition arthroplasty, 394, 395f Judo, foot and ankle injuries in, 476– fractures of the talus
Intractable plantar keratoses, 372–376, 477, 477f Ligaments
373b anterior talofibular
callus formation associated with, 372, K sprain of, 445
374f Kabaddi, foot and ankle injuries in, 473, tear of, 445
case study of, 373b 473f calcaneocuboid, 278
discrete, 374f KAT. See Kinesthetic awareness trainer calcaneofibular, 280f, 445
radiographs of, 373 Kendo, foot and ankle injuries in, calcaneonavicular, 278
treatment of 478–479, 478f–479f collateral, 390
conservative, 373, 374f Kho Kho, foot and ankle injuries in, medial metatarsosesamoid, 390, 391f
metatarsal osteotomy, 374–376, 473–474, 474f talocalcaneal interosseous, 276–277,
375f–376f Kinesthetic awareness trainer (KAT), 276f
padding, 373, 374f 546 talofibular, 278
partial condylectomy, 373–374, 375f Knee alignment, 3 talonavicular, 276f, 278–280
proximal closing wedge osteotomy, Knee strength talotibial, 278
376f examination of, 5 Lipogems, 526
surgical, 373–374 flexion of, 5 Lisfranc injuries, 126
warts vs., 372–373, 374f Kohler’s disease, 507 athletic events occurrence of, 126
Intraosseous talar cysts, 344–345, cuboid injuries presenting with, 133,
345f–347f L 135f–136f
Intrasheath peroneal dislocation, 159 Lace-up ankle brace, for ankle sprain, diastasis, 127, 130f–131f
Intrepid Dynamic Exoskeletal Orthosis 248f frequency of, 126
(IDEO), 500 Lachman test, 400–401 injury patterns, 127
Inversion strength test, 5 Lateral ankle fractures, 110–112, in military athletes, 499
Iran, foot and ankle injuries in sports in, 111f–112f Myerson classification, 127, 129f
474–475 Lateral ankle impingement, 11–12 Nunley classification, 128f
chovgan, 475 Lateral ankle sprains, 255–261 physical examination of, 127
mountain tracking and rock climbing, acute, 255–257 radiographs of, 128, 130f
474, 475f assessment of, 255–256, 256t simple lateral, 127
Pahlevaniv, 475, 476f nonoperative treatment of, 256 “subtle” injuries, 126–127
wrestling, 475, 475f operative treatment of, 256–257, treatment of, 128
ISCD. See International Society for 257f, 257b–258b, 258t–259t closed, 131, 131f
Clinical Densitometry Lateral gutter, 331 open reduction, 129–131
Iselin’s disease, 507 Lateral inverted osteochondral fractures outcomes, 129–131
Isoform 5b tartrate resistant acid of the talus (LIFT), 297 rehabilitation after, 133
phosphatase (TRACP5b), 49 Lateral ligament complex, 247 screw fixation, 131, 132f
Lateral Malleolus fractures, 26 Weber clamp, 131, 131f
J Lateral plantar nerve (LPN), 5 variants of, 133
J incision, for medial ankle fractures, 107 Lateral process talar fracture, 119–120, Lisfranc (tarsometatarsal) joint, 362
Japan, foot and ankle injuries in sports 120f–121f Lisfranc low grades sprains, in
in, 475–479 clinical evaluation for, 105 Colombia, 468
judo, 476–477, 477f radiographic evaluation for, 105–106, Loading tolerance, in acute ligament
kendo, 478–479, 478f–479f 106f injuries, 249–250
sumo, 477–478, 478f treatment of, 106–107 “Logsplitter” injury, 266–267
 INDEX 593

Long-distance bike riding, in UAE, 487 Medial displacement calcaneal slide Metatarsals (Continued)
Loose bodies, 336, 338 osteotomy (MDCO), 219, 220f second
of ankle joint, in Brazil, 458–459, Medial malleolus fractures base of, 97–98, 98f, 441, 443f
458f–459f imaging of, 107f stress fractures of, 97–98, 98f, 441,
Lower leg pain, 6 magnetic resonance imaging of, 100f 443f
LPN. See Lateral plantar nerve nonunion of, 107 stress fractures of, 22, 27
Lyme disease, 233 stress fractures, 26, 98–99 in military, 499
Lymphatic disease, 235–237 anatomy of, 98–99 Metatarsophalangeal instability, 361
case study of, 99f–100f, 99b–100b Metatarsophalangeal joints (MTP)
M imaging of, 99, 99f–100f capsulitis of, 383–384
Magnetic resonance imaging (MRI) physical examination, 98 first
for Achilles tendinopathy, 171–176, presentation of, 98–99 anatomy of, 391f
171f treatment of, 99 hallucal sesamoid fractures, 100
for bunions, 412, 412f Medial metatarsosesamoid ligament, gouty arthritis of, 232
for flexor hallucis longus tendinitis, 390, 391f hallux
518 Medial plantar nerve, palpation of, 5 anatomy of, 390
of fractures, 105 Medial plantar nerve entrapment biomechanics of, 391
of medial malleolus, 99 (“Jogger’s foot”), 227, 227b dislocations of, 400t, 406–408, 407f,
for os peroneum avulsion fractures, Medial shift calcaneal osteotomy, 220f, 407t
283 221 hyperflexion injuries of, 408
for posterior talus fractures/posterior Medial talar dome osteochondritis injuries to. See Great-toe disorders
impingement syndrome, 287 dissecans, 210f range of motion, 391
for posterior tibialis tendon injury Medial tibial stress syndrome (MTSS), inflammation of, 383–384
evaluations, 211–212, 212f 31, 416–418, 417f instability of, 361, 383–388, 384f–385f
for rupture of peroneal tendons, bone scan for, 417, 418f axial misalignment associated with,
149–150, 151f case study of, 418b 385f
for sinus tarsi syndrome, 316–317 in dancers, 450–451 capsular reefing and flexor tendon
for talonavicular avulsion injuries, diagnostic studies for, 417, 418f transfer for, 384–385
285, 287f history for, 417 conservative treatment of, 384,
for talus fracture, 288 physical examination for, 417 386f
Mallet toes, 380–381, 380f–381f posterior, 451 in dancers, 440, 441f
surgical treatment of, 381, 383f sites of, 416 diagnosis of, 383
MAP. See Movement analysis profile treatment of, 417–418 pain associated with, 383
March fractures, 30, 36, 499 conservative, 417–418 surgical treatment of, 384–385
MDCO. See Medial displacement operative, 418, 418b toe taping for, 386f
calcaneal slide osteotomy Medullary curettage, 138 of lesser toes, 361, 361f
MDT. See Myofascial decompression Membrane/matrix autologous plantar surface of, 100
techniques chondrocyte implantation, for second, instability of, 383–384
Mechanical loading program, 36 osteochondral lesions of the talus, synthetic orthobiologic for, 531
Mechanical stresses/trauma, skin 303, 304f Metatarsophalangeal soft tissue
conditions caused by, 239–241 Mesenchymal stem cells (MSC), 524 arthroplasty, 382–383
black heel, 241, 241f in nonunion, clinical evidence for use Metatarsophalangeal synovitis, 361
blisters, 239, 240f of, 71t MIAMI (marrow isolated adult
calluses, 240, 240f Metabolic bone disease, 234–235 multilineage inducible) cell,
nodules, 240 Metabolic disorders, 230–238 305–306
piezogenic pedal papules, 241, 241f Metallic cap implant, 306 Microcracks, 37
Medial ankle fractures, 107, 107f–108f Metatarsal bar, 101 Microdamage, 35
Medial ankle impingement, 19 Metatarsalgia Micronized cartilage, for osteochondral
Medial ankle sprains, 261–266 description of, 368 lesions of the talus, 304, 305f
acute, 261–265 evaluative algorithm for, 368, 369f Microstain (με), 35
assessment of, 262–264, 262f–263f Metatarsals MicroVectorTM, 306–307
nonoperative treatment of, 264 head of Midfoot
operative treatment of, 264–265, ligaments that stabilize, 390 articulation of, 127
264f removal of, 391f fractures and dislocations of,
Medial clear space, 106, 106f osteotomy of, 374–376, 375f–376f 125–143.e1, 105–124
594 INDEX

Midfoot (Continued) Mulder’s sign, 376 Nonunions

anterior process calcaneal, 120–122, Multipotent mesenchymal stromal cell fifth metatarsal base fractures, 141
122f (MMSC), 524 of fracture, 62–64, 63t–64t, 64f
clinical diagnosis of, 125–126 Muscle strengthening, 545–546, 545f, treatment of, 102
clinical evaluation for, 105 558, 558f–560f Norland Corporation, 42
fifth metatarsal. See Fifth metatarsal Myofascial decompression techniques Normalcy index (NI), 40–41
base fractures (MDT), 562, 562f N-terminal cross-linking telopeptide of
lateral process talar, 119–120, type I collagen (u-NTx), 49
120f–121f N Nutrition, of athletes, 72–74, 74t
radiographic evaluation for, Nail disorders, 239–245
105–106, 106f Nail infection, 242–244 O
tarsal bone, 133 fungal, 242–243, 243f OAT. See Osteochondral autograft
tarsometarsal. See Lisfranc injuries National Collegiate Athletic Association transplantation
treatment of, 106–107, 126 (NCAA), 516, 517f OC. See Osteocalcin
injuries to Navicular bone, accessory, 505–506 Occlusive disease, 235
in ballet dancers, 518 in children, 505–506 Occult fractures
classification system for, 127, imaging of, 210f of calcaneus, 280–283
128f–129f radiographs of, 506 of cuboid, 284–285, 285f
pain in, 96 symptoms of, 505 of hindfoot, 275–280
Midfoot injuries, 284–285 treatment of, 506 clinical anatomy in, 275–280,
Military athletes, 497–502 Navicular fractures, stress, description 276f–281f
Achilles tendinopathy of, 499 of, 27 of talus, 285–290
Achilles tendon rupture of, 499 NCAA. See National Collegiate Athletic Off-label use, of biologic products, 523
ankle sprains of, 498 Association Ollier approach, for lateral process talar
bracing options for, 500, 501f Nerve entrapment, 424–427, 426f fracture, 120
fractures of, 498–499 case study for, 427b OLT. See Osteochondral lesions of talus
instability of, 498 diagnostic studies for, 426 OLTP. See Osteochondral lesions of the
Lisfranc injuries of, 499 history for, 425–426 tibial plafond
osteochondral lesions of talus of, treatment of, 426 Onychocryptosis (in-grown toenail),
499–500 conservative, 426 241–242
plantar fasciitis of, 500 operative, 426–427, 427b Onychomycosis, 242
Mineralization, stress fracture and, 35 Nerve pain, palpation of, 5–6 Open fractures, in racetrack jockeys in
MMSC. See Multipotent mesenchymal Neuroma Mexico City, 480
stromal cell interdigital, 376–377, 376b, Open reduction and internal fixation
Moberg osteotomy 377f (ORIF)
complications of, 394 Joplin’s, 440 for acute ankle fractures, 115
indications for, 393 suspicion of, 6 for calcaneus fractures, 283
postoperative care, 394 NF-κβ (RANK), 52 for medial malleolar fracture, 107
procedure for, 393 NI. See Normalcy index for sustantaculum tali fractures, 281
Mobility, acute ligament injuries and, 249 Nitinol step staples, 219–220, 220f OPG. See Osteoprotegerin
Mobilization, 543–544, 556–557 Nodules, 240 ORIF. See Open reduction and internal
Model’s foot, 437 Noninsertional Achilles tendinitis, fixation
Mortise views, 105, 106f 350 Orthobiologics, 522–540
Morton’s neuroma, 462 after care of, 351–352 adipose stem cells as, 525–526
Motocross, in UAE, 487, 489f diagnosis of, 350 for chronic bone marrow lesions,
Mountain tracking, foot and ankle operative technique for, 351, 532–535
injuries in, 474, 475f 351f–352f clinical effect, 533, 533t
Movement analysis profile (MAP), results in, 352 interpreting MRI, 532–533, 532f
40–41 treatment for, 350–351 management, 533–534, 534f–535f
MRI. See Magnetic resonance imaging Noninsertional tendinopathy, 164–165, patient presentation/indications,
MSC. See Mesenchymal stem cells 164f–165f, 165b 532
MTP. See Metatarsophalangeal joints surgical treatment for, 170–178, 170f, technique, 534–535
MTSS. See Medial tibial stress syndrome 176b placental/amniotic products as,
Muay Thai, foot and ankle injuries in, Nonunion augmentation, in foot and 526–527
483, 484f–485f ankle, 532 recombinant growth factors as, 527
 INDEX 595

Orthobiologics (Continued) Osteochondral autograft transplantation Osteophytes

synthetics as, 527–532 (OAT), for osteochondral lesions of anterior, 335–336
acute versus chronic pathology in, the talus, 300–302, 301f removal, general technique tips for,
529 Osteochondral lesions of ankle, 290 8–20
autologous chondrocyte authors preferred treatment of, 297–298 anterior, 8–11
implantation, 528–529 acute, 297–298, 298b, 299f anterocentral, 10
calcium phosphate, 527–528 chronic, 298, 300f, 300b anterolateral, 10–11
calcium sulfate, 527–528 classification of, 294–296, 295f–296f, anteromedial, 8–10, 9f–10f
chondral/subchondral application 296t lateral, 11–12
of, 531–532 examination of, 293–294 posterior, 12–16, 13f–14f, 13t
clinical applications of, 529 future cell strategies of, 305–306 posterolateral, 13–15, 14f–15f
hyaluronic acid, 528 history and incidence of, 291–292 posteromedial, 15–16, 16f
percutaneous applications of, imaging of, 294 tibiotalar, 447f
529–532 mechanism of, 292–293, 294f Osteoporosis, description of,
posttreatment protocol for, 529 treatment of, 296–297, 297t 234–235
soft tissue repair with, 531 acute, 296 Osteoprobe, 48–49, 48f–49f
surgical implantation of, 531 chronic, 296–297, 297t Osteoprotegerin (OPG), 52
therapeutic benefits of, mechanisms Osteochondral lesions of talus (OLT), Osteotomy
of, 524–525 290 chevron
Orthoses, sesamoid disorders treated alternative treatments of, 298–304 bunionette treated with, 370–371,
with, 396 anterolateral located, 336f 372f
Os calcis arthroscopy of, 336f distal, 371, 373f
Achilles tendinoscopy and, 344 cartilage replacement strategies of, intractable plantar keratoses treated
fractures, 11 300–304 with, 375f
anterior process of, 11, 12f classification of, 335 midshaft, 371, 373f
Os peroneum, 138 computed tomography of, 336, 336f metatarsal, 374–376, 375f–376f
avulsion fractures, 283 definition of, 334–335 Moberg
Os subtibiale, 445 dome, in children, 508, 508f complications of, 394
Os trigonum, 278, 279f in Egypt, 468–469, 470f indications for, 393
excision, 16, 17f magnetic resonance imaging of, 445f postoperative care, 394
nonsurgical treatment of, 448 in military athletes, 499–500 procedure for, 393
posterior ankle impingement caused posterior ankle impingement caused phalangeal, 393, 394f
by, 448 by, 334–335 proximal closing wedge, 376
radiographs of, 448f posteromedially located, 335f proximal phalanx, 394
Os trigonum syndrome, 338f–339f staging of, arthroscopic, 335 Weil, 385, 386f, 440
definition of, 337 Osteochondral lesions of the tibial Overload injuries to the second
flexor hallucis longus tendinitis plafond (OLTP), 306–307 metatarsal, 481–482, 482f
associated with, 338 technique of, 306–307, 306f Overuse injuries, 26
plantarflexion test for, 337, 339f Osteochondritis dissecans, 291
posterior ankle impingement caused medial talar dome, 210f P
by, 337–338 Osteochondroses, 506–508 P2X7 nucleotide receptor, 38
prevalence of, 337 Freiberg’s disease, 507 Pahlevaniv, foot and ankle injuries in,
tests for, 337 Iselin’s disease, 507 475, 476f
Os vesalianum, 138 Kohler’s disease, 507 PAI. See Posterior ankle impingement
Ossicles lesions of talus, 508, 508f Pain, stress fracture and, 39–40
ankle impingement caused by, 336 of sesamoid, 396–397 Parathyroid hormone (PTH), 57–58
arthroscopic removal of, 336 Sever’s disease, 506 Parathyroid hormone receptor type 1
computed tomography of, 337, 339f Osteoclasts, 22 (PTHR1), 64–65
Osteoarthritis, foot and ankle surgery Osteocytes, 35, 37 Partial condylectomy, 373–374, 375f
for, 530–531 activation, 35 Partial weight bearing, 549–551,
Osteoblasts, 22 apoptosis of, 37 565–566
Osteocalcin (OC), 49 cell death, 37 Particulated juvenile cartilage, for
Osteochondral allograft transplantation, Osteopenia, 234 osteochondral lesions of the talus,
for osteochondral lesions of the causes of, 234–235, 234b 303–304, 305f
talus, 302–303, 302f treatment of, 234 PB. See Peroneal brevis
596 INDEX

PBFR. See Personalized blood flow Peroneal dislocation, 357 Peszek, Jessica, 581–582, 582f
restriction training Peroneal subluxation, 357 Peszek, Luann, 581–582, 582f
PDGF. See Platelet-derived growth factor Peroneal tendon dysfunction, 12, 13f Peszek, Samantha, 581–582, 582f
Peasant foot, 437 Peroneal tendon rupture, 357 PF. See Plantar fasciitis
Pedal posterior tibial artery, 2 Peroneal tendons Phalangeal osteotomy, 393, 394f
Pediatric patients arthroscopy of, 333f Physical examination
accessory navicular in, 505–506 dislocation of, 156–160 of fifth metatarsal base fractures, 137
ankle fractures in, 508–511 anatomy of tissue and, 156–157 of foot fractures and dislocations, 105
classification of, 509 complications and potential pitfalls of Lisfranc injuries, 127
distal fibular, 510–511 of, 160 of medial malleolus stress fractures,
distal tibial, 508–510 direct groove deepening approach 98
physeal, 509 for, 158, 159f PICP. See C-terminal propeptide of type
radiographs of, 509 historical perspective for, 156 I procollagen
Salter-Harris I, 509 history and exam for, 157–158 Piezogenic pedal papules, 241, 241f
Salter-Harris II, 509 indirect groove deepening approach PITFL. See Posterior inferior tibiofibular
Salter-Harris III, 509 for, 158–159 ligament
Salter-Harris IV, 509 intrasheath peroneal dislocation Pitted keratolysis, 244, 244f
Salter-Harris V, 509 without SPR avulsion, 159 PL. See Peroneus longus
ankle sprains in, 512 nature of problem for, 157 Placental products, 526–527
calcaneal fractures in, 512 osteotomy for, 158 Plain radiographs
coalitions in, 503–504 rehabilitation for, 159–160 for os peroneum avulsion fractures,
fifth metatarsal avulsion fracture in, treatment of, 158 283
512 rupture of, 148–156, 156f–157f for talonavicular avulsion injuries,
flat feet in, 504 brevis tendon, tears of, 152–155, 285, 287f
foot fractures in, 511–512 153f–155f Plantar ecchymosis, 401f
hallux valgus in, 505 peroneus longus, tears of, 151–152, Plantar fasciitis (PF)
Jones fractures in, 511–512 151f–153f in dancers, 450
metatarsal fractures in, 511–512 subluxation of, 156–160 foot and ankle surgery for,
osteochondroses in, 506–508 tendinitis of, 342–343 529–530
Freiberg’s disease, 507 tenosynovitis of, 148–150, 150f–151f in military athletes, 500
Iselin’s disease, 507 Peroneal tendoscopy, 342, 342f, 356–359 Plantar heel pain, 224–229
Kohler’s disease, 507 evidence-based recommendations for, case studies of, 226b–227b
osteochondral lesions of talus, 508, 358–359 Plantar plate injury, 362f
508f operative technique for, 357–358, Plantar plate instability, treatment of, in
Sever’s disease, 506 358f–359f Venezuela, 491–492
tarsal coalition in, 503–504 results in, 358 Plantar plate repair, surgical treatment
Percutaneous intramedullary screw Peroneus brevis, anatomy of, 278–280 of, 386–388, 387f–388f
fixation, 138, 140f Peroneus longus (PL) Plantar plate rupture, and Venezuelan
Peripheral neuropathy, 235 anatomy of, 356 drum-beat dance, 489–490, 490t
Peritendinitis biomechanics of, 356–357 Plantarflexion (PF), 4
arthroscopy for, 343–344, 343f brevis tendon and, tears of, 155–156, Plantarflexion stretching, 571–572
in dancers, 449–450 156f–157f Plantarflexion test, 337, 339f
Pernio, 236 dislocation of, 357 Platelet-derived growth factor (PDGF),
Peroneal brevis (PB) indications for, 357–358 527
anatomy of, 356 rupture of, 357 Platelet-rich plasma (PRP), 307,
biomechanics of, 356–357 after care of, 358 524–525
dislocation of, 357 diagnosis of, 357 therapies, 70
indications for, 357–358 operative technique for, 357–358, Pluristem allogeneic cell, 526–527
rupture of, 357 358f–359f PMF. See Posterior malleolus fractures
after care of, 358 treatment for, 357 Polian, Bill, 576–577, 577f
diagnosis of, 357 subluxation of, 357 Polo, in UAE, 487
operative technique for, 357–358, tears of, 151–152, 151f–153f Popliteal artery and vein entrapment
358f–359f Personalized blood flow restriction syndrome, 427–430, 428f
treatment for, 357 training (PBFR), 559–560, 561f case study for, 429b, 430f
subluxation of, 357 Pes planus, in children, 504–505 diagnostic studies for, 429
 INDEX 597

Popliteal artery and vein entrapment Posterior inferior tibiofibular ligament Posterior tibialis tendon injury, in
syndrome (Continued) (PITFL), 108 athlete (Continued)
history for, 427–429 Posterior lateral approach, for posterior characteristics of, 212–213, 213b
physical examination for, 427–429 malleolus fracture, 110 surgical treatment of, 213–214, 214t
treatment for, 429b Posterior malleolus fractures (PMF), stage II
Popliteal artery entrapment, 236b 108–110, 109f characteristics of, 212–213, 213b
Portals, in arthroscopy, 328–330 biomechanics of, 108 medial shift calcaneal osteotomy
accessory inferior, 329 non-displaced, 109–110 for, 220f, 221
anterior, 328–329 treatment of, 110 surgical treatment of, 214–221,
anterolateral, 329, 329f Posterior talofibular ligament, 278 214t, 215f–221f
anteromedial, 328–329, 328f Posterior talotibial ligament, 278 stage III
function of, 328 Posterior talus fractures, 286–288 characteristics of, 212–213, 213b
posterior, 329–330 imaging of, 287 medial shift calcaneal osteotomy
posterolateral, 329, 330f mechanism of injury in, 286–287, for, 221–222
posteromedial, 329–330, 330f 288f–290f percutaneous Achilles, 220–221
transmalleolar, 330 presentation and physical exam of, surgical treatment of, 221–222,
transtibial, 330 287, 290f–291f 221f
Posterior ankle arthroscopy, 16–19, rehabilitation and return to sports for, staging of, 212–213, 213b
18f–19f 288 tenderness evaluations, 208, 208f
Posterior ankle impingement (PAI), 5, treatment of, 287–288 “too many toes” sign, 208, 209f
12–16, 13f–14f, 13t, 337–339 Posterior tibial artery, 277f treatment of, 213–222
bony avulsions, 338 Posterior tibial nerve (PTN), 224 conservative, 213
in Brazil, 457–458, 457f–458f palpation of, 5–6 surgical, 213
causes of, 337 Posterior tibial rim, 338 Posteroanterior dancer’s view, 97
in dancers, 447–448, 448f Posterior tibial tendon (PTT), 206 Posterolateral ankle impingement,
in Egypt, 469, 471f anatomy and biomechanics of, 13–15, 14f–15f
flexor hallucis longus pathology, 206–207, 207f Posteromedial ankle impingement,
339–341, 340f anatomy of, 278–280, 354 15–16, 16f
forced plantarflexion sign, 447 attenuated, 214 Posttraumatic arthritis, 362, 363f
insertional tendonitis, 344, 344f biomechanics of, 354 Posttraumatic calcifications, 338
lateral ligament sprain as cause degenerative, 214, 215f–219f Postural control, for acute ligament
of, 448 function of, 341 injuries, 249, 249f–250f
loose bodies, 338 indications for, 354 PRICE. See Protection, rest, ice,
os trigonum, 448 systemic inflammatory and compression, and elevation
os trigonum syndrome, 337–338, autoimmune disorders of, 355 Primary mineralization, 35
338f–339f tendinitis of, 341–342 stress fracture and, 35
osteochondral lesions, 339, 340f trauma of, 354–356 Pronated feet, 40
peritendinitis, 343–344, 343f Posterior tibial tendoscopy, 341, Proprioception, 546, 546f, 558–559,
peroneal tendon pathology, 342–343, 354–356, 355f–356f 560f
342f Posterior tibialis tendon injury, in Protected weight bearing, 544–545,
posterior tibial tendon pathology, athlete, 206–223 545f, 557, 557f
341–342, 341f abduction deformity secondary to, Protection, rest, ice, compression, and
posttraumatic calcifications, 338 211f elevation (PRICE), 542–543, 543f
retrocalcaneal bursitis, 344, 344f diagnosis of, 207–212 Proximal closing wedge osteotomy,
tendinosis, 343–344, 343f differential diagnosis of, 212t 376f
Posterior impingement syndrome, hindfoot inversion associated with, Proximal phalanx osteotomy, 394
286–288 209f PRP. See Platelet-rich plasma
imaging of, 287 history-taking, 208 Pseudogout, 232–233
mechanism of injury in, 286–287, magnetic resonance imaging Psoriatic arthritis, 231
288f–290f evaluations of, 211–212, 212f PTH. See Parathyroid hormone
presentation and physical exam of, perils and pitfalls of, 222 PTHR1. See Parathyroid hormone
287, 290f–291f physical examination of, 208, receptor type 1
rehabilitation and return to sports for, 208f–209f PTN. See Posterior tibial nerve
288 radiographic imaging of, 209 PTT. See Posterior tibial tendon
treatment of, 287–288 stage I Purine nucleotides, role of, 38
598 INDEX

Q Rehabilitation (Continued) Rheumatologic disorders (Continued)

QCT. See Quantitative computed functional progression in, 546–547, gout, 232
tomography 561t, 562–563, 563t–565t pseudogout/calcium pyrophosphate
Quantitative computed tomography gait evaluation in, 545, 558 dihydrate crystal deposition,
(QCT), 42 for high ankle sprains, 550–551, 570f, 232–233, 233b
571–572, 572t psoriatic arthritis, 231
R immobilization as, 557, 557f Reiter’s syndrome, 231
Racetrack jockeys in Mexico City, foot of lateral ankle reconstruction, 548t, rheumatoid arthritis, 232
and ankle injuries in, 479–481, 549–550, 550f, 550t Still’s disease, 230
479t–480t mobilization as, 543–544, 556–557 RICE. See Rest, ice, compression, and
mechanism of injury, 479–480, 480b muscle strengthening as, 545–546, elevation
open fractures, 480 545f, 558, 558f–560f Rock climbing, foot and ankle injuries
protective gear for, 480 phases of, 547, 547f, 563–573 in, 474, 475f
recovery time on bimalleolar proprioception as, 546, 546f, 558–559, Romosozumab, 72
fractures, 480, 480f–481f 560f Royal marine (RM) training, 43–44
Radiographic evaluation, of foot protected weight bearing as, 544–545, RPI. See Reference point identification
fractures and dislocations, 105–106 545f, 557, 557f
Radiographs protection, rest, ice, compression, and S
for bone marrow lesions, 532 elevation as, 542–543, 543f SA. See Salvage arthrodesis
for fifth metatarsal base fractures, 133, protection as, 557, 557f Salter, Robert, 544, 556
137 range of motion, 543–544, 556–557 Salter-Harris classification system
for Iselin’s disease, 507 rest, ice, compression and elevation I, 509
for Kohler’s disease, 507 as, 555–556 II, 509
for Lisfranc injuries, 128, 130f of syndesmosis injuries, 550–551 III, 509
for posterior tibialis tendon injury, for syndesmotic disruption, 569f, IV, 509
209 572–573, 573f–574f V, 509
for soft corns, 378f Reiter’s syndrome, 231 Salter-Harris (S-H) fractures, 116, 118f
for subtalar dislocation, 318 Releve´ position, 437, 437f Salvage arthrodesis (SA), 499
for subtalar instability, 313–314, Remodeling, stress fracture and, 35 Sand toe, 400t
314f Resection Sarcoidosis, 233
Range of motion, 543–544, 556–557 of calcaneonavicular coalitions, 321 Sclerostin, 37, 72
testing, 3 of talocalcaneal coalition, 322, Screw fixation
RANKL, 52 322f–323f fifth metatarsal base fractures treated
RANK/RANKL/OPG pathway, 39 Resection arthroplasty, 394, 395f with, 138, 140f
Rat ulna axial loading model, 36 Resisted eversion, 560f Lisfranc injuries with, 131, 132f
Raynaud’s phenomenon, 235 Resorption phase, of bone remodeling, percutaneous intramedullary, 138,
Recombinant growth factors, 527 35 140f
Reference point identification (RPI), of Rest, for athletes, 74 s-CTx. See Serum C-Telopeptide
osteoprobe, 48 Rest, ice, compression, and elevation Second metatarsals
Reflex examinations, 5 (RICE), 106, 555–556 base of, 97–98, 98f, 441, 443f
Rehabilitation, 541–554 for acute ligament injuries, 247 stress fractures of, 97–98, 98f, 441,
of Achilles tendon repair, 548–549, for subtalar instability, 315 443f
548t–549t, 549f, 564–567, Retrocalcaneal bursa, 163 Second metatarsophalangeal joint,
565f–569f Retrocalcaneal bursitis, 166–167, 169f, instability of, 384, 385f
after open reduction and internal 344, 344f Secondary mineralization, stress
fixation Retro-fibula pain, 150 fracture and, 35
fifth metatarsal, 569–571, 570f Reversal phase, of bone remodeling, Section modulus (Z), 44–45
Lisfranc, 567–569, 570f 35 Selective estrogen receptor modulators,
of ankle fractures, 551–552, 551f Rheumatoid arthritis, 232 234
for bunions, 415 Rheumatologic disorders, 230–233 Sepak Takraw, foot and ankle injuries in,
cardiovascular activities as, 546, 559, ankylosing spondylitis, 231 484–486, 485f–486f
560t–561t case studies of, 233b Serum C-Telopeptide (s-CTx), 43–44
cryotherapy as, 555–556 enteropathic arthritis, 231–232 Sesamoid bursitis, 440
 INDEX 599

Sesamoid disorders, 395–398 Skin infection, 242–244 Stress fractures (Continued)

avascular necrosis, 396 bacterial, 243–244, 243f in female athletes, 24
bipartite, 403–404 fungal, 242, 242f of fifth metatarsal, 101–102,
bone grafts for, 397 Snowboarder´s fracture, 461–462, 462f 102f–103f
diagnosis of, 396 Soccer, 517 case study of, 102b, 103f
magnetic resonance imaging of, 396 Soft corns, 377–380, 378f gender differences, 23
nonoperative treatment of, 396 case study of, 378b genetic predisposition in, 37–39
osteochondrosis of, 396–397 surgical treatment of, 379–380, 380f hallucal sesamoids, 100–101
plantar prominence of, 396 Soft tissue distraction, 336, 337f historical perspective of, 22
radiographs of, 396 Soft tissue injury, 464 history of, 39–41, 419
surgical treatment of, 398 Soleus muscle, accessory, 450 laboratory workup in, 49–54, 50t, 51b
Sesamoid fracture, 396–397 South Africa, foot and ankle injuries in, medical and metabolic considerations
Sesamoidectomy, 391 481–483 in athletes with, 30–94
fibular hallux, 397 investigations in, 482–483, 483f in men, 23
incisions for, 398f overload injuries to the second metatarsals, 22
indications for, 397 metatarsal, 481–482, 482f in military athletes, 499
results of, 398 SPA. See Single photon absorptiometry pathophysiology of, 33–37, 34f
tibial hallux, 397 SPN. See Superficial peroneal nerve physical examination of, 39–41, 40t, 419
Sesamoiditis, 395, 438–440, 440f Sport testing, return to, for acute prevention of, 78–81
Sever’s disease, 506 ligament injuries, 250 clinical application of, 81
SFCA. See Stress fracture clinical Squeeze test, 4 proposed classification system of, 33t
assessment Stability, foot and ankle physical exam, 4 radiographs, 451, 451f
SFEA. See Stress Fracture in Elite Athletes Star Excursion Balance Test, 249 recurrence of, 23
Shenton’s line, of ankle, 105, 106f Stem cells, stress fractures and, 70–72, risk factors for, 23–24, 24t, 39
Shepherd’s fracture, 286–287 71t second metatarsal base, 441, 443f
Shin splints, 31 Stieda’s process, 278 surgical intervention of, 26
“Shin splints”, 416, 450–451 Still’s disease, 230 of tarsal navicular, 95–97
Shoes, hallux valgus and, 505 Straight leg raise, 3 treatment for, 25–26, 420–421
Shuttlecock kicking, 463f, 464 Strain, 35 conservative, 420–421
Simian foot, 437 Street sports, 472, 472f operative, 421, 421b
Single limb hop test, in ankle Strength, assessment of, in athletes, 5 “Stress reaction”, 31
rehabilitation, 116 Strengthening, for acute ligament Subluxation, of peroneal tendons,
Single photon absorptiometry (SPA), 42 injuries, 249 156–160
Single toe raise, 3 Stress fracture clinical assessment Subtalar arthrodesis, 221–222
Sinus tarsi, anatomy of, 312 (SFCA), 40 Subtalar joint
Sinus tarsi impingement, 19–20, 20f Stress Fracture in Elite Athletes (SFEA), anatomy of, 312, 313f–314f
Sinus tarsi syndrome, 315–317 39 arthroscopy of, 326–348, 327f, 345f
clinical presentation of, 315 Stress fractures, 22–29, 28b, 418–421 articulating surfaces of, 312
nonoperative treatment of, 317 acute fractures vs., 95 dislocation of, 317–318
physical examination of, 315–316 in athletes, epidemiology of, 23, 24t clinical presentation of, 317
radiographic evaluation of, 316–317 btom in, 49–54 nonoperative treatment of, 318
surgical treatment of, 317, 317f case studies in, 61–64, 62f, 63t–64t, physical examination of, 317–318
Ski and snowboard injuries, of foot and 64f–65f, 421b, 422f radiographic evaluation of, 318
ankle in Chile, 460–462, 460f–461f classification of, 33t surgical treatment of, 318
ankle sprains and fractures, 461 common, 26–28, 27f–28f instability of, 313–315
chilblains, 462 in dancers, 451, 451f clinical presentation of, 313
equipment and technical diagnostic studies for, 25, 419–420, nonoperative treatment of, 315
considerations in, 460–461, 419f–420f physical examination of, 313
460f–461f differential diagnosis of, 25 radiographic evaluation of, 313–
Morton´s neuroma, 462 epidemiology of, 23, 23t–24t 314, 314f
skier’s toe, 462 etiology of, 22–23 surgical treatment of, 315, 316f
Snowboarder´s fracture, 461–462, 462f evaluation of, 25 medial, 317
Skier’s toe, 462 female athlete triad and, 520 synthetic orthobiologic for, 531
600 INDEX

Subtalar motion, 4 Talar joint, pathology of, 339–346 Tarsometatarsal instability, first, 362,
“Subtalar sling”, 315 Talar tilt, 4, 106, 106f 363f
Subtle Lisfranc ligament lesion, in Talocalcaneal coalitions (TCCs), Tarsometatarsal joint, 362
Brazil, 455–456, 455f–456f 321–322, 322f–323f, 504, 504f anatomy of, 126
Sumo, foot and ankle injuries in, Talocalcaneal interosseous ligament, dislocations of. See Lisfranc injuries
477–478, 478f 276–277, 276f osseous anatomy of, 126
Superficial peroneal nerve (SPN), Talocrural angle, 106, 106f vascular structures of, 127
palpation of, 5 Talofibular ligament, 278 TBS. See Trabecular bone score
Sural nerve, palpation of, 6 Talo-first metatarsal angle, 211, 211f TCCs. See Talocalcaneal coalitions
Surgery, for cuboid fractures, 285 “Talon noire”, 241 Team, in care of athletes, 576–582
Sustantaculum tali, 280–281 Talonavicular avulsion injuries, Anderson, MD, Bob, 580–581, 581f
Sustantaculum tali fractures, 280–281 285–286, 286f–287f Bartelstein, Mark, 578–579, 579f
Swimming, for rehabilitation, 566, 568t, Talonavicular (TN) joint, synthetic Hammer, Dave, 578, 578f
571t orthobiologic for, 531 Hayward, Gordon, 579–580, 579f
Swiss Sport Physiotherapy Association, Talonavicular ligaments, 276f, 278–280 Peszek, Jessica, 581–582, 582f
75 Talotibial ligament, 278 Peszek, Luann, 581–582, 582f
Symptomatic os subfibulare, 11 Talus Peszek, Samantha, 581–582, 582f
Syndesmosis anatomy of, 275–276, 276f–278f Polian, Bill, 576–577, 577f
ankle, space measurements, 106, 106f blood supply to, 276–277, 277f Tendinitis, 164, 357
injury to, rehabilitation of, 550–551 lateral process of, 276–277, 277f Tendinopathy, 164
Syndesmosis fixation, 113 fracture of, 11 Achilles, 164, 164b
Syndesmosis injuries, 255–274 occult fractures of, 285–290 allogenic factor injection for, 169
rehabilitation for, 269–270 osteochondral defect of, 445 autologous platelet-rich plasma for,
Syndesmosis sprains, 266–269 posterior, anatomy of, 279f, 340f 169
acute, 266–268 posterior process of, 278, 279f debridement of tendon,
chronic, 268–269 vascular anatomy of, 277f 171, 172f
Synovial impingement, 11 Talus fracture, lateral process of, extracorporeal shock wave therapy
Synovitis, 334 288–290, 291f–293f for, 167–169
classification of, 334 Targeted remodeling, 35 nonsurgical treatment of, 167,
of metatarsophalangeal joint, 361 Tarsal coalition, 318–321 170f
Synthetic orthobiologics, 527–532 ankle sprains and, 319 surgical treatment for, 169–176,
acute versus chronic pathology in, 529 in children, 503–504 171f
autologous chondrocyte implantation clinical presentation of, 319 tendon transfer, 171–172
as, 528–529 definition of, 318 treatment of, 167–182
calcium phosphate as, 527–528 etiology of, 318 turndown procedure, 175–176,
calcium sulfate as, 527–528 incidence of, 318 178f–179f
chondral/subchondral application of, magnetic resonance imaging of, V-Y advancement, 173–175, 177f
531–532 319–320, 320f foot and ankle surgery for, 529–531
clinical applications of, 529 physical examination of, 319, 319b in UAE, 488
hyaluronic acid as, 528 radiographic evaluation of, 319–320, Tendinosis, 164
percutaneous applications of, 529–532 320f Tendon graft, for rupture of anterior
posttreatment protocol for, 529 radiographs of, 503–504, 504f tibial tendon, 146–147, 146f–148f
soft tissue repair with, 531 treatment of, 504 Tendon rupture, Achilles
surgical implantation of, 531 nonoperative, 320 acute, 182, 182–192, 191f
Systemic lupus erythematosus, 232 surgical, 320–321 mini-open technique for, 187–189,
Tarsal navicular stress fractures, 197f, 200–201
T 95–97 nonsurgical treatment for, 182–184,
TAIHOD. See Total Army Injury and anatomy of, 95–96, 96f 193–197
Health Outcomes Database imaging of, 96, 96f percutaneous technique for, 200
Talar cysts, 344–345, 345f–347f presentation of, 95–96, 96f results of acute surgical repair, 189
Talar dome treatment of, 97 standard technique for, 187–192,
anatomy of, 335–336, 335f Tarsal tunnel syndrome (TTS), 224, 192f–194f, 195t, 198–200
osteochondral defects in, 335–336 225f surgical treatment for, 186–187,
in children, 508 author’s approach to, 226–227, 227f 197–198
 INDEX 601

Tendon rupture, Achilles (Continued) Tibial tendon, anterior, rupture of Turf-toe (Continued)
chronic, 192, 189–191 (Continued) literature regarding, 402
autograft/allograft reconstruction graft for, 146–147, 146f–148f postoperative management,
for, 200, 199f methods of repair for, 144–145, 145f 404–405
nonsurgical treatment of, 193, outcomes of treatment for, 147–148 treatment of
191–192 skin incision and approach to, conservative, 405
primary repair for, 193 145–146 principles, 401
surgical treatment of, 193, 192–200, Tibialis anterior, anatomy of, 127 short-leg cast, 401, 402f
193f, 197t Tibialis anterior (TA) tendoscopy, 360 valgus injuries, 399, 399f
tendon transfer for, 198, Tibiotalar joint, synthetic orthobiologic varus injuries, 399
198f–199f for, 531 Turf-toe inserts, 392
V-Y advancement for, 197 Tibiotalar osteophytes, 447f
postoperative protocol for, 195t–196t Tillaux and triplane fractures, 116, 119f U
Tendon transfer Tillaux fractures, 510 Ulcerative colitis, 231
of abductor hallucis, 403–404, 405f Tinea pedis, 242, 242f United Arab Emirates, foot and
for Achilles tendinopathy, 171–172 Tinea unguium, 242 ankle injuries in, 486–488,
of extensor hallucis longus, for Toe raise, 3 487f–489f
rupture of anterior tibial tendon, “Too many toes” sign, 208, 209f u-NTx. See N-terminal cross-linking
147, 149f Total Army Injury and Health telopeptide of type I collagen
posterior tibialis tendon injury with, Outcomes Database (TAIHOD),
214–219 39 V
Tendons, pathology of, 339–346 Trabecular bone score (TBS), 35, 46–48, Varicose veins, 236
Tendoscopy 46t, 48f Vascular disorders, 230–238
Achilles, 349–354 TRACP5b. See Isoform 5b tartrate arterial disease, 235–236
extensor, 360–361 resistant acid phosphatase venous disease, 236
flexor hallucis longus, 359–360, 360f Transchondral fracture, of talus, 291 VDR. See Vitamin D Receptor; Vitamin
peroneal, 342, 342f, 356–359 Trauma, nail conditions caused by, D receptor
posterior tibial, 341, 354–356, 355f 241–242, 241f–242f Venezuela, foot and ankle injuries in,
tibialis anterior, 360 onychocryptosis (in-grown toenail), 488–492, 489f
Tenosynovitis, 148–150, 150f–151f, 355, 241–242 Venezuelan drum-beat dance,
357 Traumatic inversion, in ankle sprains, plantar plate rupture and,
Teriparatide (Forteo) rh PTH (1-34), 512 489–490, 490t
57–61 Trimalleolar fractures, 112–115, Venous claudication, 236
Texture Research Investigation Platform 113f–115f Venous disease, 236
(TRIP), 35 TRIP. See Texture Research Investigation Venous thrombus, 236
Thailand, foot and ankle injuries in, Platform Vertical loading rate (VLR), 41
483–486 Triplane fractures, 510, 511f Vitamin B12 deficiency, 235
Muay Thai, 483, 484f–485f Triple arthrodesis, 221–222, 321 Vitamin D, 55–72, 55t
Sepak Takraw, 484–486, 485f–486f TTS. See Tarsal tunnel syndrome clinical application of, 57
TheraBand, 545–546, 545f, 551–552 Turf-toe, 398–406, 399f system, 38
Thompson test, 4 causative factors, 399 Vitamin D receptor (VDR), 38
Three-dimensional instrumented gait classification of, 400, 400t VLR. See Vertical loading rate
analysis (3D-GA), 40–41 grade I, 401–402 Volleyball, female athletes, 517
Thrombophlebitis, 236 grade II, 402
Tibial fractures incidence of, 398 W
Salter-Harris I, 509 magnetic resonance imaging Walking boot, 542–543, 543f
stress fractures, in dancers, 451, 451f of, 402f for lateral fracture management,
Tibial plafond, 327 mechanism of injury, 398–399 111
Tibial tendon, anterior, rupture of, radiographs of, 401, 402f–403f Warts, 372–373, 374f
144–148 sequelae of, 405 Warwick Hip Trauma Study
anatomy for, 144 shoe–surface interface and, 399–400 (The WHiT Study), 70
diagnosis of, 144 surgical treatment of Weber A variant, of lateral malleolus
extensor hallucis longus tendon abductor hallucis tendon transfer, fracture, 112
transfer for, 147, 149f 403–404, 405f “Weekend warriors”, 191
602 INDEX

Weight bearing, 544–545, 545f, 557, Wolff, Julius, 544, 556 X

557f Wolff ’s law, 547, 563 X-rays
Weightlessness, effect on muscle, Women, stress fractures in, for bunions, 412, 412f
544 23 for calcaneus fractures, 282, 283f
Weil osteotomy, 385, 386f, 440 Women’s health initiative (WHI), for cuboid fractures, 285, 285f
Wharton jelly, 527 72–73
WHI. See Women’s health initiative Wrestling, foot and ankle injuries in, Y
WHiT Study. See Warwick Hip Trauma 475, 475f Y balance test, in ankle rehabilitation,
Study Wushu, 463f 116