foot$and$ankle$problems$ $in$athletes$forms.acsm.org/15tpc/pdfs/10 demaio.pdfsyndesmosis$ •...

FOOT AND ANKLE PROBLEMS IN ATHLETES

Marlene DeMaio, MD Prof, Orthopaedic Surgery, Marshall University; VAMC

John J. Jasko, MD Asst Prof, Orthopaedic Surgery, Marshall University

ACMS Team Physician CourseSan AntonioFeb 2015

ANKLE ANATOMY

Seto, Foot and Ankle Anatomy, Slideshare

Syndesmosis

•  Syndesmosis: –  Ant. Inf. Tibiofibular ligament

–  Post. Inf. Tibiofibular ligament

–  Transverse ;biofibular ligament

–  Interosseous membrane

SoN Tissue Injuries

•  Sprains •  Tendon strains and tears

Primemed.com.au

ANKLE SPRAINS •  27,000 per day in U.S. –  25% of all MSK injuries

•  Most common sports injury –  25-‐50% of all sports injuries –  >50% of all ankle injuries –  #1 NCAA surveillance data and ballet, classical dance

–  45% of all basketball injuries

“It’s just a sprain.” •  Not a benign injury – 75% athletes report recurrence – Up to 25% lead to chronic lateral ankle instability and/or pain

– Self assessed disability is high – Lost days of work, prac;ce, games •  10-‐15% of all ;me lost in football •  3-‐5 weeks lost •  Even for lower grade injuries

“It’s just a sprain.” •  Misdiagnosis, incomplete diagnosis – Bone •  Fracture: Ankle, Talus, Maissoneuve, 5th metatarsal •  Tarsal coali;on

– SoX ;ssue •  Global laxity, Ehlers Danlos •  Tendon injury: Peroneals, Achilles

– Nerve disorder •  HNP, drop foot •  Charcot Marie Tooth

DeMaio, Orthopedics 1992:87-‐96

Anatomy •  Ligament = condensa;on of capsule

AITF

ATFL CFL

•  ATF Ligament – Fails at 138N – Can undergo greater plas;c deforma;on than CFL

•  CF Ligament – Cord like – Fails at 345N – Deep to peroneals – 105° b/t ATFL CFL Clanton T, et.al. Anatomic study of Lateral Ligaments.

Poster at AAOS 2014

Anatomy: Lateral Ligament Morphology

LIGAMENT WIDTH, mm LENGTH, mm ORIGIN INSERTION

ATF 5 12 Anterior border lateral malleolus

Neck of talus

CF 6 6-‐25 Fossa lateral malleolus, 10-‐45 deg angle

Lateral tubercle,

calcaneus post process

PTF 6 9 Post lat malleolus, post to CF ligament

Lateral tubercle, talus post process

Hollinshead, Textbook of Anatomy, 3rd ed, 1974: 423-‐488 Ruth, JBJS-‐Am, 1961 43: 229-‐239

Mechanism of Injury: Lateral Ankle Sprains

•  Weight bearing •  Low energy trauma •  Example: 230 lb RB, terminal velocity of 22.2 X/sec, decelera;ng at 13.5 m/sec2 – Force on ankle: 7760N – Stress lateral ankle: 1264.4 lbs

– ATF fails at 138 N, CF at 345N

Guise, AJSM 1976 4: 1-‐6.

Lateral Ankle Sprains •  Func;on and alignment changes with mo;on

•  Primary inversion stabilizer –  Plantarflexion: ATFL –  Dorsiflexion: CFL

PF Neutral DF

Mechanism of Injury •  Lateral ankle sprain: a cascade of injury – Supina;on/Inversion in Plantar-‐flexion or Neutral

•  ATFL injured first (“essen;al lesion”) •  CFL injured as ankle DF during con;nued inversion

–  ATFL + CFL 30-‐60%

•  PFL last to rupture in extreme inversion, DF

Lateral Ankle Sprain: Exam •  Anterior drawer –  Tests the ATFL –  Slight plantarflexion –  Translate anterior and slightly medial

•  Talar Ult –  Tests CFL – Neutral flexion –  Inversion of hindfoot –  Look for dimple

•  Always compare to other side •  Most sensi;ve at ;me 0, then day 7

Lateral Ankle Sprains: Grades Grade Injury Swelling Weight Bearing

I ATFL stretch, tear

Mild Mild limp, but can WB with brace

II ATFL and capsular tear + CFL

Moderate swelling and Bruising

Difficult

III AFTL, capsule, CFL tears

Severe swelling and bruising

Unable to bear weight

Note: Grade IV with avulsion fracture

Lateral Ankle Sprains

•  Classifica;on: systems not comparable –  AMA : Grades I-‐IV –  Severity –  Ligaments

•  Single: ATF ligament and capsule

•  Double: ATF and CF ligaments

•  Triple: ATF, CF, and PTF ligaments

Imaging: X-‐ray IndicaUons •  Onawa Rules •  Inability to bear weight •  Bony tenderness

AP, lateral, morUse

OXowa Rules

•  Xrays are indicated to r/o fx if: – Presenta;on within 10 days of injury –  Inability to bear weight at ;me of injury or at presenta;on

– Tenderness over then distal 6cm of malleoli, posterior aspect

– Tenderness over the base of the 5th metatarsal or navicular

Imaging: MRI IndicaUons •  If isolated injury, f/u exam in 1-‐2 weeks •  MRI if – Persistent significant swelling – Tenderness:

•  Peroneals •  Lateral talus •  Anterior calcaneus

– Syndesmosis injury suspected

•  R/o concomitant pathology

Lateral Ankle Sprains: Treatment •  Isolated acute Grade I & II lateral ankle sprains – Universal consensus –  Ini;al non-‐opera;ve treatment of

•  Grade III – “Near” consensus – Some new evidence may change this

Lateral Ankle Sprains: Treatment

•  Benign Neglect –  Not appropriate –  75% recurrence rates –  RR=2.3 for CAI without func;onal rehab

Lateral Ankle Sprains: Treatment •  RICE: 24-‐48 hours

•  Control pain •  Limit swelling •  Reduce hypoxic injury during acute inflamma;on

•  Protect Ligaments, Stabilize the Joint – Trauma creates temporary instability – True healing takes >8 weeks – External support: Braces, cast, boot, tape

•  FuncUonal RehabilitaUon – Neuromuscular and sport/task training

DeMaio, Orthopedics 1992 15:87-‐96 and 241-‐248

FuncUonal RehabilitaUon •  AXer LAS pa;ents exhibit deficits in –  Joint posi;on sense –  Isometric strength in mul;ple planes of mo;on – Postural control on the involved and uninvolved limb •  Posi;ve modified Rhomberg

– Abnormal EMG (Nitz AJSM 1985 13:177-‐182)

•  Peroneal nerve, 86% Grade III •  Tibial nerve, 83% Grade III

•  Lack of neuromuscular retraining leads to recurrent injury, chronic problems – 2.3 x risk of recurrence

FuncUonal Rehab: Components •  Early Joint mobilizaUon •  Strengthening •  Sensorimotor/balance – Wobble board – Trampoline

•  Single/double leg Postural control •  ConUnue external support

•  Propriocep;ve feedback •  Con;nued protec;on of ligaments

Meta-‐Analyses/Level 1 Evidence •  FuncUonal Rehab > prolonged immobilizaUon – Faster return to sport, work – Fewer long term symptoms – Bener ROM

•  Semi-‐rigid external support beXer than cast & Ace – S;rrup ≥ Lace up brace > tape > Elas;c wrap – SLC/boot useful in G3 (Lamb et al. Lancet 2009) •  Short tem use (days) only

Meta-‐Analyses: Level 1 Evidence

•  Petersen et al. Arch Ortho Trauma 2013 •  Lamb,et al. Lancet 2009 •  Beynnon et al. AJSM 2006 •  Ardevol et al. KSSTA 2002 •  Kerkhoffs et al. Cochrane 2002 •  Kerkhoffs et al. Acta Ortho Scand. 2003

Taping

•  Pros –  Custom –  Provides propriocep;ve feedback

–  Lightweight, low bulk – May be useful when swelling prevents fitng of an orthosis

•  Cons –  Rapid loosening

•  AXer 10 mins, 40% of strength lost

•  50% decrease in ROM aXer 2 1/2 -‐3 hrs

•  45-‐60 minutesàminimal effect

–  Trained personnel –  Expensive over the season –  Variable effects on performance

DeMaio, Orthopedics 1992 15:87-‐96

Taping vs. Brace for Sports •  Both shown to prevent ankle sprains – Braces overall more effec;ve – Braces cost less per season

•  Much more effec;ve on athlete with h/o prior ankle sprain

“Marshall” Algorithm •  Brace: S;rrup/ Lace up /Combo •  Boot in G3 – To brace in few days

•  TED hose •  WBAT with crutches if limping – NWB A/PROM

•  Func;onal Rehab

Return to Play

•  Subjec;ve symptoms – Foot and Ankle Ability Measure (FAAM)

•  Func;onal tests – Star Excursion Balance

•  Simplfied to Y

– Single leg balance – Single leg heel to toe raises

•  60/minute

Ankle Sprains: Treatment •  Func;onal rehab bener than immobiliza;on – Start with DF, eversion – Ac;ve resistance: isometric first

•  Peroneals •  Dorsiflexors •  Evertors

•  Role for acute surgical interven;on in selected cases?

Ankle Sprains: Treatment •  Pinjenburg, et al. 2002 –  RPT Level II – Acute repair vs. func;onal rehab –  317 pa;ents, 8 yr follow up –  Surgery group fared bener

•  Pain (16% vs. 25%) •  Subjec;ve giving way (20% vs. 32%) •  Recurrent sprains (22% vs. 34%) •  Func;onal scores

“operaBve treatment for lateral ligament ruptures can be adopted in cases when higher funcBonal demands…such as sports at a compeBBve level… are required”

Ankle Sprains: Treatment •  Pihlajamaki, et al. JBJS 2010 – Level 1, 14 yr follow-‐up –  Male Finish military cadets, Grade III sprains – Acute repair vs. func;onal rehab – Lower risk of re-‐injury in surgery group (6% vs. 58%)

– Higher incidence of Mild OA (Grade 2) on MRI in surgery group (27% vs. 0%)

Paradigm ShiN?

•  Early surgery for Acute ankle sprain? •  Similar to 1st ;me shoulder disloca;ons? •  Poten;al problems –  Increased complica;ons – Higher costs – Availability of OR

•  Secondary reconstruc;on of G3 injuries is possible even years out, outcomes similar to those of acute repairà More data needed

Chronic Lateral Ankle Instability •  ~10-‐25%

•  Func;onal instability –  Impaired propriocep;on, neuromuscular control

•  Mechanical instability – Pathologic laxity – Synovial changes – Chondral damage – Loose bodies

DeMaio, Orthopedics 1992 15:241-‐248

Chronic Lateral Ankle Sprain: Predisposing Factors

•  Previous ankle sprain •  Propriocep;on deficiency •  Varus hindfoot (Cavus foot) •  Ligamentous laxity – Collagen deficiency – Beighton’s Criteria

Chronic Lateral Ankle Instability •  History – Pt c/o: Can’t trust ankle, Feeling of giving way, Ankle just gives out

– Mul;ple sprains – Con;nued subacute or chronic pain following sprain

•  Pain signifies other pathology as well – Peroneal tendons – OCD or OA – Anterolateral guner impingement

Chronic Lateral Ankle Instability: Physical Exam

•  More subtle findings than acute •  Ligament laxity more easily noted – Less swelling – Less pain inhibi;on

•  Careful palpa;on •  Examine hindfoot alignment – Look for cavus – Peek-‐a-‐boo heel

Chronic Lateral Ankle Instability: Imaging

•  Stress x-‐rays – Ques;onable value without Telos machine – Pain inhibi;on – No consensus on normal and pathological # – Must compare to “normal” side •  But is that side normal? •  >3 mm ant. Transla;on •  >10 deg talar ;lt

– Adds a data point •  Signs and symptoms more important

Chronic Lateral Ankle Instability: Imaging

•  MRI –  OXen done to rule out other pathology •  OCDs •  Peroneal tendons

–  Surgical planning

Chronic Lateral Ankle Instability: Treatment

•  FuncUonal & Neuromuscular Rehab – Esp. subjec;ve instability pa;ents

•  Bracing/Taping – Get through season

•  Surgical interven;on is indicated when func;onal rehab has failed and pt has chronic symptoms

Chronic Lateral Ankle Instability: Surgery

•  Address all pathology – 93% intra-‐ar;cular path (Ferkel, Brostrum) – Always scope

– Consider Peroneal tendon pathology

Chronic Lateral Ankle Instability: OpUons for Surgery

•  > 50 described procedures – 80% G/E results

•  How to choose? – Quality of ;ssue – Degree of laxity – Revision?

Op;ons for surgery

Surgical Technique •  Insufficient evidence exists to support any one specific surgical technique

•  Non-‐anatomic/tenodesis procedures –  Inferior outcomes – Tendency to over;ghten •  Ankle, subtalar OA

– Sacrifice peroneals •  Dynamic stabilizer

Anatomic Repair •  Brostrom (1966)

•  Brostrom-‐Gould (1980)

Pictures from: Baxter’s Foot and Ankle in Sport. Mosby, Inc. 2008

Bone Tunnels vs. Suture Anchors

•  No difference in strength or s;ffness •  Neither as strong as na;ve ATFL at T=Ø – 80N vs 160N

Waldrop, et al. Anatomic Suture Anchor Versus the Brostrom Technique for ATFL Repar. AJSM 2012

Outcomes: Pooled Data

•  Brostrom/Modified Brostrom (500 cases) – 85-‐100% successful – Poor results in

•  Heel varus •  Inadequate rehab •  Nerve injury •  Pre-‐exis;ng arthri;s •  Significant repeat sprains

Anatomic Reconstruc;on

Anatomic Reconstruc;on •  As s;ff and strong as na;ve ATFL T=Ø

–  Implica;on for Rehab –  More technically demanding –  Need for graX

•  Indica;ons –  Heavy athlete or laborer –  Severe laxity –  Weak or Deficient ;ssue precluding direct repair –  Revision surgery

•  Clanton, et al. Biomechanical Comparison of Anterior Talofibular Ligament ReconstrucUon Using Semitendinosus AllograNs With the Intact Ligament; Anterior Talofibular Ligament Ruptures, Part 2:. AJSM 2014

Approaches

Post-‐op Management

•  Similar to acute sprain – Week 1 : Protect for 7-‐10 days – Week 2-‐5: WBAT boot; DF, PF, no inversion – Week 6: Brace; Func;onal Rehab – RTP 10-‐12 weeks

Post-‐op Management

•  Accelerated Rehab vs. Delayed – No immobiliza;on vs. cast 4 weeks – Func;onal rehab started at 2 weeks

•  Allowed progression as tolerated – Return to sport 5 weeks sooner – Equal outcomes at 2 years

Miyamoto, et al. Accelerated Versus TradiYonal RehabilitaYon AZer Anterior Talofibular Ligament ReconstrucYon for Chronic Lateral Instability of the Ankle in Athletes. AJSM 2014

Arthroscopic Brostrom

•  “all-‐inside” anatomic repair •  Anchors placed percutaneously •  Biomechanically = to open •  Short term f/u good

Anatomic Repair + Synthe;c Augment

Stronger than na;ve ATFL at T=Ø

Could allow earlier RTP

Eversion Ankle Sprains

•  5-‐15% of all ankle sprains •  AKA: high ankle sprains, medial ankle sprains, deltoid ligament sprains

•  Anatomic classifica;on – Tibiofibular syndesmosis – Deltoid ligament – Both

Roberts, Orthopedics 1995 18:299-‐304

Medial Ankle: Deltoid Ligament

•  Major ligament complex

•  Strongest of the ankle ligaments


Anatomy

Deltoid Ligament •  Superficial

–  Tibionavicular ligament –  Anterior talocalcaneal ligament

–  Posterior ;biotalar ligament

•  Deep –  Anterior ;biotalar ligament –  Posterior ;biotalar ligament

Flexor reUnacula –  Superficial –  Deep

4 fibrosseous canals –  Posterior ;bial tendon –  Flexor hallucis longus –  Posterior ;bial nerve –  Posterior ;bial a & v

Olney in Reckling & Reckling, Orthopaedic Anatomy &Surgical Approaches, 1990: 421-‐481

Medial Ankle: Tendons

•  Posterior ;bialis (inverter and plantar flexor)

•  Flexor digitorum longus •  Flexor hallucis longus


Mechanism of Injury

•  External rota;on and or forced DF – Talus rotates laterally striking the fibula

•  External rota;on with the foot pronated – Maissoneuve injury

BoyYm AJSM 1991 19:294 Lauge-‐Hansen Acta Chir Scand 1949 97:544

Injury ClassificaUon LIGAMENT INJURY STABLE UNSTABLE

Syndesmosis Incomplete disrup;on Complete disrup;on of deep and superficial AND Anterior ;biofibular por;on of the deltoid

Deltoid Incomplete tear Complete disrup;on of the superficial and deep fibers; may be associated with fracture

Deltoid and Anterior talofibular

Incompletle tear Complete tear

Eversion Ankle Injuries: H&P •  History – Mechanism of injury –  Pt c/o: medial pain, pain with weight bearing – Neurological symptoms

•  Physical –  Tenderness –  Provoca;ve tests

•  External Rota;on Stress Test: knee at 90°, foot in neutral •  Squeeze Test: bimalleolar compression

– Neuro: combined deltoid and syndesmo;c injury •  86% peroneal nerve •  83% posterior ;bial nerve

Nitz, AJSM 1985 13:177-‐182

Eversion Ankle Injuries: Imaging

•  X-‐rays – AP, lateral, mor;se

•  Mor;se view: > 3mm medial clear space widening

– Stress views •  DF and external rota;on •  Abduc;on

•  MRI

Eversion Ankle Injuries: Treatment

•  RICE •  Progressive mo;on •  Strengthening: isometric first •  Balance training and func;onal rehab •  Orthoses – Taping not effec;ve Myburgh AJSM 1984 12:441-‐446

Tendons of the Lateral Ankle

•  Peroneus brevis •  Peroneus longus –  Both serve as the major everters of the ankle

–  Also serve as plantar flexors


Peroneal Tendon Injuries

•  Strains •  Tears –  Complete –  Par;al

•  Isolated •  Associated with –  Ankle sprains –  5th MT fx –  Talar OCD

Achilles Tendon Injuries

•  Achilles –  Greek chieXain –  Dipped in the river Styx by his mother The;s.

–  Killed in the Trojan War by an arrow striking his heel where is mother dunked him.

Achilles Tendon Anatomy

•  6 cm long, twists 90° laterally

•  Tendon of the triceps surae, no tendon sheath –  2 heads of the gastroc –  Soleus

•  Nerve: ;bial n •  Superficial posterior compartment

Achilles Tendon Anatomy

•  Blood supply – Muscle and bony anachments

–  Avascular zone 2-‐6cm proximal to inser;on •  Site of tendinopathy and chronic tears

Achilles Tendon Joint EffecUve

PF Gastroc Crosses

knee & ankle

Knee extended

Soleus Crosses ankle

Ankle in PF & knee flexed

•  FuncUon: transmit load from gastroc & soleus to calcaneus

•  Forces – Walking

•  1962-‐2354N •  2-‐3x BW

–  Running •  3924-‐5886N •  4-‐6x BW

DeMaio Orthopedics 1995 18:195-‐204

Achilles TendiniUs •  Common in runners, dancers

•  Risk factors –  Exposure – Malalignment

•  Cavus •  Pes planovalgus

–  Obesity –  Fluoroquinolones –  Inflammatory arthropathy

–  Hyperlipoproteinemia (xanthoma)

•  Classifica;on –  Chronicity –  Loca;on

•  Inser;on •  Muscle tendon jxn •  Tendon

–  Tendon condi;on •  Microtear •  Par;al tear •  Complete tear

–  Tissue involved

Achilles Histopathology

Puddu, AJSM 1976 4:145-‐150 Kvist, J Pathol 1987 19:1-‐11

Chart From Hartog, AAOS OKO, Midsubstance Achilles TendiniUs

Achilles TendiniUs: Diagnosis •  History –  Acute

•  Pop, pain, inability to walk

–  Chronic •  Pain

–  Running –  Push off –  On pointe

•  Swelling •  Bump or “squeaking” •  Weakness with push off

–  Acute on chronic

•  DifferenUal Diagnosis – Muscle disorders

•  Tear, medial head of the gastroc

•  Soleus straing •  Compartment syndrome

–  Tarsal tunnel syndrome –  Bony disorders

•  Os trigonum •  Sever’s disease •  Haglund’s (pump bumps)

–  Inflammatory arthropathies

Achilles TendiniUs: Diagnosis

•  Pain: Acute or Chronic? – Localized – Arc of tenderness

•  Nodules may change posi;on with DF and PF (moving with the tendon) •  Tendon sheath pain does not change with the ROM

•  ROM •  Thompson test

Achilles TendiniUs: Imaging

•  Xray –  Normal –  Dystrophic calcifica;on

•  Ultrasound •  MRI

Echometric

Treatment of Chronic Achilles TendiniUs

•  Correct –  Training -‐Flexibility –  Strength & endurance -‐Footwear

•  Protect the tendon –  3/8” heel liX – Night splint –  Rest 7-‐10 days or cast/boot 1 month

•  Local modali;es •  Surgery: no response aXer 6-‐12 months, par;al tears

Treatment of Acute Achilles Tendon Tears

•  Non-‐opera;ve vs. Opera;ve & Early Loading – Prospec;ve, Level 1, 100 pts –  f/u at 3, 6, 12 months: sx, ac;vity, func;on, QOL – Primary outcome: Achilles Total Rupture Score – Results

•  No significant difference: sx, ac;vity, QOL •  Trend toward improved func;on with surgery •  No reruptures in surgical group, 5 in non-‐surgical

Olsson, AJSM 2013 41:2867-‐2876

Treatment of Acute Achilles TendiniUs

•  Surgery—Another Paradigm ShiX?

Treatment of Acute Achilles TendiniUs

•  Surgery –  Open reconstruc;on –  Percutaneous repair

•  Early weightbearing with ankle plan;grade –  Not detrimental to outcome

–  Shortens rehabilita;on –  No effect on strength, muscle atrophy Mafulli AJSM 2003 31 692-‐700

Treatment of Acute Achilles Tendon Tears

•  Effect of Loading aXer Repair, Meta-‐analysis – 9 studies: 6 RCT, 3 quasi RCT with 402 pts

•  6 early wt bearing & ROM, 3 early ROM only

– Results •  Bener outcomes for early wt bearing and ROM •  Similar rerupture rates, complica;ons •  No advantage of delayed wt bearing

Huang AJSM 2014

Ankle Fractures

•  Stable = Non-‐opera;ve management – Avulsion fractures –  Intact syndesmosis –  Intact ;biotalar joint

•  Unstable = Surgery – Disrup;on of syndesmosis – Unstable ;biotalar joint

Talar Stability

•  Mor;se stability = talar stability

•  Anterior talus is wider than the posterior talus

FOOT INJURIES

ANATOMY

Fractures

•  Forefoot –  Sesamoid fractures –  Stress fractures

•  Midfoot –  LisFranc fracture disloca;ons

–  FiXh metatarsal fracture

•  Hindfoot –  Calcaneus fractures

Myerson, ICL 58, Chapt 56 2009:583-‐594

LisFranc Fracture DislocaUons

•  OXen missed, up to 20% – About 30% associated with sports

•  Spectrum of injury – Ligamentous, bony, both – Associated injury: compartment syndrome

•  Mechanism: indirect trauma – Axial loading of the foot in PF


•  History •  Exam –  Inability or pain w/ weight bearing – Medial ecchymosis – Midfoot tenderness – “Stress” tests

•  Compression of midfoot •  Dorsal and plantar transla;on of the 1rst MT


Prona;on abduc;on test Medial column squeeze test

Myerson, ICL 58, Chapt 56 2009:583-‐594

LisFranc Fracture DislocaUons: Imaging

•  X-‐ray –  AP, lateral, oblique (30 deg) •  Fleck sign: avulsion from base of 2nd MT

•  Nutcracker sign: cuboid fx w/ lateral column shortening

–  Weight bearing comparison AP •  Pain may limit FWB

•  Fluoroscopy: spring test •  CT scan •  MRI Myerson, ICL 58, Chapt. 56 2009:583-‐594

LisFranc Fracture DislocaUons:

•  Aggressive management and close follow up – Must prove the sprain

•  <2mm diastasis, stable stress tests •  6 wks NWB

– Unstable midfoot, diastasis > 2mm •  Early surgery with screw fixa;on •  NWB 6-‐8 wks then progressive loading •  Planned screw removal

Stress Fractures

•  2nd metatarsal – AKA march fracture – Loca;on

•  2nd MT: hallux valgus, Hallux rigidus, Morton’s foot •  3rd, 4th MT: most common sites

Stress Fractures

•  5th metatarsal – Loca;on

•  I: proximal to tuberosity •  II: into the 4-‐5 ar;cula;on •  III: proximal metaphyseal-‐diaphyseal junc;on

– Treatment •  Torg: 92% healed in NWB cast at a mean of 7 wks •  DeLee: screw fixa;on, return at 6 wks

SoN Tissue Injuries

•  Plantar Plate Injury •  Plantar Fascii;s •  Entrapment of the first branch of the lateral plantar nerve (of Baxter)

•  Posterior Tibial Tendon Inflamma;on & Tears

Other Injuries and CondiUons

•  Freiberg’s Infrac;on •  Painful accessory navicular •  Tarsal coali;on

•  Inser;onal tendini;s of the ;bialis anterior

Freiberg’s Infrac;on

•  AVN of the 2nd metatarsal head •  Risk factors: Morton’s foot, trauma, surgery •  Management – Modify footwear, ac;vi;es; treat pain – Surgery

•  Microfracture; Debridement & dorsal wedge osteotomy •  AllograX •  Arthrodesis, arthroplasty

foot$and$ankle$problems$ $in$athletes$forms.acsm.org/15tpc/pdfs/10 demaio.pdfsyndesmosis$ •...

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