Injuries to the foot and ankle in athletes.

Twenty-five percent of athletic injuries involve the foot and ankle. These injuries are seen primarily on an outpatient basis, regardless of the practice or competitive venue, and regardless of the level (high school, college, or professional). This article outlines the more common foot and ankle problems, including outpatient management and disposition. Misdiagnosis, underdiagnosis and undertreatment of foot and ankle injuries is very common among all providers of acute, urgent, and elective sports medicine care.

History and Physical

An acute injury requires immediate injury disposition. A more detailed background is needed for a more chronic or a repetitive-stress injury. The majority of foot injuries in sports are the result of overuse. The majority of ankle injuries in sport are acute.

The physical examination should not be limited to the foot and ankle, but should also include the spine, pelvis, hip, and knee. First, alignment of the foot and ankle in active, passive, and weight-bearing position is evaluated. The motion of the hindfoot, midfoot, and forefoot is evaluated and compared bilaterally. Length and alignment of the lower extremities needs to be assessed. Leg/heel and heel/forefoot are assessed. This exam, especially when chronic findings are present, should always be compared to the contralateral side. Walking or running gait history and exam is important in all overuse injuries. Gait analysis is a next-level measure and becomes important. Upper body mechanics may also contribute to overall pathology and should be noted.

A simple and rough grading of injuries allows staging for treatment and level of disability. Stage 1 injury does not interfere with recreation or sports but causes symptoms. Stage 2 injury affects athletic endeavors. Stage 3 stops all athletic activity.

Ankle Sprains

Ankle sprain is the most common injury in both recreational and elite athletes. Physical exam is mandatory and should note swelling, ecchymoses, localization and deformity, as well as circulatory and motor status. Palpation of the lateral anterior talofibular, calcaneofibular, and the medial deltoid ligament plus the medial and lateral malleolus may elicit tenderness. The anterior distal tibia-fibula joint and tibia-fibula interval tenderness is crucial to note in the "high sprain." In this case the appropriate "squeeze test" is manual compression of the tibia and fibula interval in the leg causing pain and suggesting a mortise or syndesmosis injury. This finding must be respected. Exam under anesthesia and possible tibia-fibula fixation is often indicated.

Grade 2 and 3 injuries or fibula tenderness warrants three views: anteroposterior, lateral, and mortise radiographs to rule out a fracture and/or mortise injury (overlap of tibia and fibula less than 10 mm).

Treatment of ankle sprain depends on the magnitude of the injury and competitive or recreational goals. Total rehabilitation takes up to twenty weeks. Acute treatment 24 to 48 hours after injury involves rest, ice, compression, and elevation (RICE). Isometric exercises with low resistance and high repetitions, protected weight-bearing, and stretching of the heel cord can be started as soon as tolerated. A short leg cast or "walking boot" may be needed to aid in initial weight-bearing if pain is significant. This "functional" treatment is important and mainstream for all ankle sprains. But accurate diagnosis is required since one-third of grade 2 or 3 ankle sprains have an associated injury such as osteochondral talar dome fracture, posterior impingement, peroneal or posterior tibial tendon injury etc.

Disorders of the Hindfoot

The bony hindfoot consists of the talus and calcaneus (os calcis) and their attachments. The important soft tissue elements include the calcaneal (heel) pad, plantar fascia, distal Achilles tendon and its insertion, intrinsic muscle origin, and the 13 passing extrinsic tendons. Only the flexor hallucis tendon has a bony groove.

Subtalar coalition. A coalition is a bar or connection of bone or soft tissue between either the calcaneus and navicular or between the calcaneus and talus. This bar secondarily limits movement of the foot and causes mechanical pain which can often be seen with adjacent bony edema on magnetic resonance imaging (MRI). If suspected, special Harris view radiograph and/or computed tomography (CT) can supplement plain radiographs to document presence or absence of the bar. Juveniles with an immature skeleton and residual adaptive capacity can improve with excision, whereas adults need a bony arthrodesis. Surgery is undertaken if there is pain, limp, functional limitation and, optionally, pain not always controlled at rest (night).

Plantar fasciitis (PF). Common heel pain or subcalcaneal pain is caused by micro tears of the plantar fascia at its origin at the tuberosity of the os calcis deep to the distal medial heel pad. Entrapment of the posterior tibial nerve or medial calcaneal nerve (tarsal tunnel syndrome) may mimic or complicate PF. Initial treatment includes ice, massage, nonsteroidal anti-inflammatory drugs (NSAIDs), peroneal and posterior tibial strengthening, and heel cord stretching. Ongoing avoidance of the inciting activity, viscoelastic heel cushion and/or orthoses along with corticosteroid injection (one or two only) may be needed. Casting in neutral helps in difficult cases. Night splinting to hold the heel cord under mild tension at 90[degrees] is a part of the global treatment. Surgery or noninvasive ultrasonic treatment should be considered after 6 to 12 months.

Retrocalcaneal bursitis. The most common Achilles tendon insertion problem, retrocalcaneal bursitis, is characterized by pain and tenderness localized by pinching on either side of the tendon, and anterior to its insertion. Radiographs may show calcification in the bursa. Treatment includes RICE, heel cord stretching and NSAIDs. Excision of the bursa may be indicated if conservative treatment fails. Injection with steroids is discouraged.

Retrocalcaneal bursitis with "pump bump" or os calcis exostosis. Characterized by pain at the Achilles tendon insertion site, a "pump bump" is associated with the bursa (as noted above) between the Achilles tendon insertion and the os calcis (see above). An additional Achilles tendonopathy above the insertion is often present in long-standing (more than 3 months) symptoms. Conservative treatment includes ice, heel cord stretching, NSAIDs, avoidance of friction and with heel counters preferably absent. Open (preferably with tendonopathy) or endoscopic excision is definitive. Steroid injections should not be used due to the risk of Achilles tendon rupture.

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Achilles tendonitis and rupture. Acute tendonitis causes local tenderness, mild swelling, and significant pain. Peritendonitis (no intrinsic anatomic abnormality) causes crepitus and pain. Chronic tendonitis results in thickening, is refractory to treatment, and may also include intratendonous confluent microruptures (tendonopathy), which can lead to gross rupture of the tendon. Treatment includes calf stretching, heel lifts, strengthening the plantar flexors, NSAIDs, ice, and limitation of activities.

With tendonopathy, complete rupture of the tendon is a risk. MRI is often needed (Fig. 1). Primary or secondary Achilles tendon rupture is often felt as a "pop" during eccentric loading sports activities. Inability to toe walk supports the diagnosis. Treatment can be closed with serial casting. Open surgical treatment, however, has less risk of rerupture, and is the more common option. Augmentation is occasionally indicated with severe tendonopathy.

Peroneal tendon problems. Tendonitis of the peroneus longus causes pain as it passes plantarward beneath the cuboid towards its insertion on the plantar base of the first metatarsal. Treatment is symptomatic with ice, NSAIDs and rest. Peroneus brevis ruptures occur 1 to 3 inches proximal to its insertion on the base of the fifth metatarsal near or just distal to the lateral malleolus. Symptoms and findings of swelling and tenderness follow recurrent inversion ankle sprains. Rest, NSAIDS, ice, strengthening, stretching and an ankle brace for support are options for nonoperative treatment for tendonitis. Surgery is necessary for significant and/or chronic ruptures. Split tendon (longitudinal) tears are also common. These may need repair with suture or excision of the torn portion. MRI is necessary prior to surgery to define significant peroneus longus or peroneus brevis injury.

Anterior and posterior ankle impingement. Impingement of the anterior tibiotalar joint can occur due to bony and/or soft tissue spurring (Fig. 2). This mechanism is common in most jumping and agility sports (lateral moves, cutting to the right or left, deceleration) causing dorsiflexion. Symptoms include localized anterior or posterior ankle pain partially relieved by a heel lift. The impinging spur is usually palpable and has surrounding tenderness. Arthroscopic or open removal of the spurs at either or both ends of the joint capsule is indicated if heel lifts, NSAIDs and other modalities are unsuccessful. Anteroposterior and lateral flexion/extension films help with differential diagnosis. Posterior, medial, and lateral impingement can also be present. Plain imaging is necessary for diagnosis. MRI and CT are used for more difficult cases.

Tarsal tunnel syndrome. This is caused by irritation or compression of the posterior tibial nerve as it runs deep to the medial retinaculum behind the medial malleolus. The irritation can be caused by bone, soft tissue, or vascular structures (ie, varicosity). There may be tenderness at the point of compression at the retinaculum or along the path of the medial or lateral plantar nerves. Hyperdorsiflexion, external rotation, and eversion may reproduce symptoms similar to provocative tests for carpal tunnel syndrome. Electromyography and nerve conduction studies are necessary for confirmation of the diagnosis. Release relieves symptoms. Rehabilitation takes longer than with carpal tunnel due to the dependent weight-bearing requirements.

[FIGURE 2 OMITTED]

Posterior tibial tendon rupture. The planovalgus foot, or flat foot, with pronation and loss of arch (Fig. 3), is predisposed to this common injury. Overuse is occasionally superimposed on acute injury and can produce longitudinal tears or tethering leading to dysfunction. The problem must be recognized early in both the athlete and the active exercising individual. MRI can confirm the pathology. Orthoses for arch support may need to be semirigid, or a UCBL (University of California Berkley Laboratory) for the foot or an ankle foot orthosis (AFO) for the leg, ankle, and foot may be needed. Modalities (such as phonophoresis and iontophoresis, icing, heat), eccentric strengthening, and hands-on physical therapy are immediately necessary. Surgical release with tenolysis and/or augmentation by another tendon may be necessary early on to prevent irreversible bony/joint changes. Augmentation makes it difficult to get elite athletes to the game level and is rarely necessary in that group.

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Injuries and Conditions of the Midfoot and Forefoot

Lisfranc Injuries. Lisfranc injuries are notorious for delayed diagnosis. In this common injury, excessive or injurious force travels the interval between the great and second toe to and into the midfoot, creating capsular/joint injury and/or fracture. This force travels to the cuneiform first metatarsal interval, between the metatarsal bones, or moves laterally along the tarsometatarsal interval. Severe secondary changes can occur with misdiagnosis or underdiagnosis even with the minimum Lisfranc ligament injury. That ligament tear creates tenderness dorsally between the first and the base of the second metatarsal. Standing films of both feet often show widening at the 1-2 metatarsal interval. CT scan or even MRI is often crucial to pinpoint the pathology and its extent. Immobilization or surgery with fixation screw may be necessary. Any ankle or foot sprain that is slow to improve or has an "arch" component needs to have the Lisfranc injury possibility revisited.

Fractures and stress fractures of the tarsal navicular. These injuries are common in jumping sports, ie, basketball, triathlon, soccer, volleyball. Unexplained arch pain, pain produced with firm hindfoot, midfoot angular and rotational stress, or a minimal response to orthoses and physical therapy can require a careful anatomic view of both feet. CT scan or MRI can be used if the diagnosis needs confirmation or is not definitive.

Proximal Fifth Metatarsal Fractures. Ninety percent of fifth metatarsal injuries are avulsion injuries of the peroneus brevis attachment. These must be differentiated from proximal diaphyseal fractures (Jones fracture). Avulsion injuries can be treated with an eversion splint or short leg cast for pain control. Most become stable within 3 weeks. Delayed union or nonunion is common for Jones fractures and particularly for proximal diaphyseal stress fractures. These must be immobilized in a short leg cast for 6 weeks at a minimum. In elite athletes and with delayed or nonunion, an intramedullary screw may be indicated.

Hallux Valgus and Bunions. This deformity derives from mechanical disadvantage with deformity, decreased push off and secondary pain, bursitis, or pinch callus at the medial eminence of the great toe. It may also cause the second metatarsal to bear more weight, creating a callus under the second metatarsal head. Most athletes can be handled with accommodative shoeing. Nonsurgical treatment includes shoes with a wide toe box, and a semirigid orthosis to place the foot in a more neutral position. Surgery can correct the deformity, but does not necessarily improve the athletic performance and should be cautiously considered, especially in the elite athlete. Rehabilitation can take four to six months.

Hallux Rigidus. Hallux rigidus is caused by direct injury, hyperextension injury (turf toe), varus/valgus stress, and leads to or is associated with degenerative changes. The metatarsophalangeal (MTP) joint is characterized by painful motion and variably less than 60 degrees dorsiflexion at the great toe MTP joint. Ice, shoe protection, NSAIDs, and therapeutic mobilization can all help symptoms. Orthoses with a first metatarsal extension can unload the MTP complex. Steroid injections can help symptoms if chronic inflammation is present. Surgical removal of spurs (cheilectomy) can improve motion and can alleviate but not eliminate pain. MTP fusion or Keller procedure (resection of the proximal portion of the proximal phalanx) are reliable salvage procedures but compromise athletic/recreational ability.

Sesamoid problems. Great toe medial and lateral sesamoid bones are important and can carry 3 times the body's weight with leg-based activity. Symptoms occur from acute fractures, stress fractures, and inflammation. These fractures must be differentiated from bipartite sesamoids, which are common in the general population. Conservative treatment includes ice, an orthosis to unload the sesamoids with a first metatarsal extension, NSAIDs, and heel cord stretching. Operative partial or complete excision or bone grafting may be necessary for delayed or nonunion of sesamoid fractures.

Morton neuroma. Neuromas are common causes of forefoot pain, numbness, and paresthesias in the digital nerve distribution, usually between toes 3 and 4, and less frequently 2 and 3. The neuroma arises due to swelling, perineural fibrosis, and prominence of the common digital nerve. Steroid injections, metatarsal pads, and wide toe boxes all help with symptoms, although surgical excision of the nerve may be necessary for persistent pain. Preserving and maximizing plantar flexion at the lesser toe MTP joints can prevent and treat Morton neuroma. In fact, this lesser toe MTP plantar flexion is very important in injury prevention in all forefoot problems.

Claw Toes, Hammer Toes, and Mallet Toes. These deformities can be flexible or can progress to fixed deformities. To treat the problems of calluses and clavi, and abnormal loading of the digit, a wide toe box, passive stretching of the deformity, and toe sleeves all help with symptoms. Surgery can correct the deformity and/or remove the exostoses causing the intractable clavi (corns).

Conclusion

All leg-based sports apply substantial loads to the foot and ankle that lead to problems. Instability and fracture or preexisting congenital or developmental problems can occur acutely or as a chronic problem. If a nonoptimal approach is unsuccessful, surgery with rehabilitation can return the competitive or recreational athlete to his or her activity.

Accepted May 21, 2004.

References

Baxter, Donald E. The Foot and Ankle in Sport. Philadelphia, Mosby, 1995.

Drez D, DeLee J, Miller M. DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, Saunders, 2003, ed 2, pp 2183-2623.

Angus M. McBryde Jr, MD, FACS and Jennifer L. Hoffman, MD

From the Department of Orthopaedic Surgery, University of South Carolina School of Medicine, Columbia, SC.

Reprint requests to Angus McBryde Jr, MD, Two Medical Park, Suite 404, Columbia, SC 29203. Email: [e-mail]