By Terry Stanton
JAAOS article reviews management techniques
Injuries to the foot and ankle are common in competitive sports and are typically managed with aggressive rehabilitation, which can permit early return to sport without compromising healing or long-term outcomes.
A review of these injuries—from turf toe to joint injuries to ankle sprains—appears in the September issue of the Journal of the AAOS. In an interview, principal author Robert B. Anderson, MD, discussed the issues and concerns that arise in treating patients with foot and ankle injuries.
Robert B. Anderson, MD
AAOS Now: Can you identify specific distribution patterns in sports-related foot and ankle injuries?
Dr. Anderson: The overall incidence of foot and ankle injuries in any given sport is difficult to obtain; they often occur in unorganized play, and many minor injuries may go unreported. Basketball may account for the greatest number of foot and ankle injuries, largely due to the high number of inversion ankle sprains that occur. Interestingly, woman basketball players sustain ankle sprains more often than men, possibly due to inherent ligamentous laxity.
AAOS: Now: What are the priorities in the initial examination?
Dr. Anderson: Take a good history. Ask how the injury occurred, whether it’s happened before, and whether the athlete could bear weight. The exam itself assesses for areas and patterns of ecchymosis, joint instability, and tendon function and stability (subluxation and dislocation). The contralateral uninjured foot/ankle provides a good reference for comparison.
AAOS Now: How are turf toe injuries classified and treated?
Dr. Anderson: Turf toe injuries have been previously classified by Clanton, Anderson, and others (Table 1). Fluoroscopic imaging is very beneficial in determining the extent of the soft-tissue injury and resultant instability. Grade I and II injuries may require a period of immobilization and protection from dorsiflexion forces at the hallux metatarsophalangeal joint. Time to return to play in even these more minor injuries can range from 2 to 8 weeks. In general, a grade III injury will require surgical repair, particularly in the elite running athlete, followed by a 4- to 6-month recovery.
AAOS Now: What about classification and treatment for ankle sprains—inversion and eversion?
Dr. Anderson: Classification schemes that attempt to describe the degree of injury (partial or complete) have not been very useful in determining treatment or prognosis. The initial examination must assess the status/stability of the peroneal and posterior tibial tendons, which can be injured in association with either an inversion or eversion ankle sprain.
Initial treatment for uncomplicated sprains of the ankle include cold, compression, and protected weight bearing, when symptoms allow. Inversion ankle sprains are very common and are typically expected to do well regardless of the treatment rendered. However, chronic pain and dysfunction develop in 20 percent of patients, often related to incomplete rehabilitation.
The eversion injury pattern is associated with a longer recovery, chronic discomfort, and the potential for chronic deltoid instability.
AAOS Now: You write that the so-called high ankle sprains (eversion injuries) are uncommon but more serious than inversion injuries. What special considerations or precautions should be taken in treating these injuries?
Dr. Anderson: The high ankle sprain includes injury to the syndesmotic ligaments and the deltoid ligament. In more severe injuries, an instability of the ankle mortise can develop, identified by frank diastasis of the syndesmosis or joint, or by stress radiographs, and surgical intervention is indicated.
AAOS Now: What about tarsometatarsal (Lisfranc) joint injuries?
Dr. Anderson: Lisfranc injury is primarily a ligamentous injury in the athletic population and is managed by the same principles as a syndesmotic injury of the ankle; diastasis of the joints or an instability pattern identified by stress radiographs typically indicate the need for surgical intervention. Historically these injuries have been managed with transarticular screw fixation, but bridge plating is becoming more popular to avoid iatrogenic joint injury.
AAOS Now: Do stress fractures have any treatment protocols? You offer your own treatment preferences for high-risk fractures.
Dr. Anderson: Stress fractures of the foot and ankle have a better prognosis when identified early. Many of these fractures go unrecognized on initial plain radiographs, so if they are suspect, additional imaging—MRI, bone scan—is recommended. If imaging studies are abnormal, computed tomography (CT) will help guide treatment. Stress fractures of the fifth metatarsal, navicular, and medial malleolus are typically managed with surgical fixation. CT imaging can again be utilized at 12 to 14 weeks.
AAOS Now: What preventive measures can athletes take to reduce injuries?
Dr. Anderson: Intrinsic protection can be gained from proper conditioning and strengthening. Athletes will also benefit from stretching before activity. In general, shoes should provide adequate support and stability for any given sport. Athletes seek lighter weight and more flexible footwear, but in doing so may place themselves at greater risk for injury. Overtraining is also a concern.
AAOS Now: Do you have pearls and pitfalls to share?
Dr. Anderson: Several athletic injuries to the foot and ankle can be subtle and require a high suspicion by the practitioner. The athlete with “ankle pain” and no obvious pathology may have a navicular stress fracture. Not all inversion ankle injuries are ligamentous; peroneal tendon injuries, osteochrondral lesions of the talus, and avulsion injuries of the talus/calcaneus or fifth metatarsal base are possible. Plain radiographs are often negative, so additional imaging studies are useful when the injury history and exam are not in sync. Chronic pain and dysfunction with these injuries is often a result of incomplete rehabilitation, in regard to both strength and proprioceptive re-education.
Disclosure information: Dr. Anderson—The American Orthopaedic Foot & Ankle Society, Arthrex, DJ Orthopaedics, and Wright Medical Technology.
Terry Stanton is senior science writer for AAOS Now. He can be reached at email@example.com
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