Foot and Ankle

Priority is a painfree and stable foot and ankle. ROM is a very secondary issue.
 

Introduction
 

Biomechanics
 

Stress fractures
 

Ankle sprains – lateral and medial, sub-talar

 

Syndesmotic (high ankle sprain) injuries

 

Sinus tarsi syndrome

 

Peroneal tendon injuries

 

Tibialis posterior tendon injuries

 

Tibialis anterior injury

 

Tendon achilles injury

 

Gastrocnemius injury
 

Fractures of the foot and ankle

 

Nerve entrapment syndromes

 

Acute and chronic compartment syndromes

 

Plantar fasciitis
 

OS trigonum
 

Turf toe
 

Tibio-talar spurs and impingement

 

Metatarsalgia
 

Freiberg’s infraction
 

Hallux valgus
 

Hallux rigidus
 

Sesamoiditis
 

Short leg-syndrome
 

The problem (painful) ankle

 

Note: Important surgical innovations include ability to anchor tendons to bone with bony
anchors and the use of strong suture material such as FiberWire.
 

Foot and Ankle

 

Introduction
 

The evolution of the human foot has allowed us to stand and move upright so freeing our
hands to explore and control our environment. The foot changed from an arboreal
grasping organ to an agent for motion – the big toe fell into line with the little toes
(which shortened); a stiffer subtalar joint; a medial arch and bigger heel occurred.
 
You only have to see a young Fijian boy rapidly climb a tree to see how the foot still
maintains its grasping function.
 

Our current foot shape dates 40 to 100,000 years. We now stand perched on a ledge
(the sustentaculum tali of the calcaneus) and topple frequently on the sporting field to
sprain the lateral ligament conylex (Fig. 1).
 

Even worse where there is a high medial arch( eg pes cavus).

Design problems remain.
 

The foot and ankle is commonly injured in sport; such injuries account for 25% of all
sporting injuries (Fig. 2).
 

Biomechanics
 

The tibio-talar articulation allows 25° dorsiflexion, 35° plantar flexion and 5° of rotation.
The instant centre of motion lies on a line along the tips of the malleoli and postero-laterally
on the talar dome. Up to 5 times body weight is transmitted across this joint.
 

Stability is gained by the talar mortise and ligament support. The subtalar joint functions
like a hinge and allows eversion and inversion. The mid-foot permits abduction and
adduction. The forefoot flexion and extension. Pronation of the foot (5°) is coupled
dorsiflexion, eversion and abduction, supination (up to 20° is coupled plantar flexion,
inversion and adduction. The foot transmits 3 times body-weight with running and has
arches (medial, lateral, transverse). The second metatarsal is the keystone of the mid-foot
in gait (the first metatarsal in the stance phase).
 

Gait (walking – one foot is always on the ground; running – both feet off the ground at one
point) has two phases (stance and swing) (Fig. 3).
 

The usual gait cycle has gained credence through repetition but is well over due for a re
examination and re –thinking.
 

Video analysis allows documentation and correction of abnormal running postures (Fig. 4).
 
Injuries in the region occur for the following reasons: The athletes physical and
personality traits; training techniques, playing environment and equipment. The weekly
running distance has been found to be the critical factor for injury among runners (>64 km
per week).
 

Certain athletes are prone to injury and certain body types confer a biomechanical
advantage (Fig. 5).
 

Stress fractures
 

Bone pain with a normal x-ray in an athlete suggests a stress fracture. There are two
types: fatigue type (abnormally increased load on a normal bone) or the insufficiency
type (Normal loads on deficient bone (such as osteoporosis). They typically occur 3 to 5
weeks into an intensive training programme. Exclude steroid use (decreases trabecular
bone). Muscles are able to adopt faster than bone and after 2 weeks of new intensive
training the fracture occurs. A small cortical crack occurs and spreads by subcortical
infarction. Periosteal and endosteal new bone (callus) is seen at 2 to 3 weeks. X-rays may
show the dreaded “black line” of impending complete fracture (Fig. 6). Bone scans are
positive early and diagnostic. Common sites are described (Fig. 7).
 

Thee is localised bone pain and tenderness relieved by rest. The athlete limps. Examine the
sports shoes for excessive wear.
 

Treatment should be comprehensive (Fig. 8).

 

Special considerations (Fig. 7).

 

Stress fracture of the neck of the femur need crutches for 3 to 4 weeks. If pain persists at
1 to 2 months (groin pain with rotation f the thigh) seriously consider surgical fixation of the
fracture.
 

Navicular fractures are slow to be diagnosed and to heal. Immobilise for 6 to 8 weeks and
surgically fix (and bone graft) if symptomatic at 1 to 2 months.
 

Ankle sprains
Lateral Ligament
 

Little wonder ankle sprains are common in sport. We stand perched upon the
sustentaculum tali with the calcaneus bowed back under the ankle joint and all balanced (in
tension) by the lateral ligament complex (Fig. 1). Inversion (with supination and
plantar/dorsi flexion) causes injury of the lateral ligament complex; usually (2/3 of cases)
the anterior talo-fibular ligament (ATFL – the weakest), sometimes the extra-articular
calcaneo-fibular ligament, CFL (seldom the PTFL – the strongest). Those at risk are large
athletes, those with pes cavus (high medial arches) and a history of similar injury. High-top
shoes and good splints may protect the ankle.
 

There is immediate pain and swelling with resultant anterior and inversion instability. The
severity of the injured can be graded (Fig. 9). Careful examination in the post-acute phase
can delineate the ligament components injured (Figs. 10, 11, 12).
 

Figure 9 Grading of Lateral

Ligament Ankle Injury
 

I      ATFL sprain (2/3 cases)

II     ATFL, CFL sprains (1/4 cases)

III    ATFL, CFL, PTFL tears
▼
Or simply use
 

Incomplete:  end­point to anterior draw

Complete:  No end­point to anterior draw
▼
In the acute phase treat with RICE, NSAIDS, ankle splint (S-Ankle), early
rehabilitation/peroneal eversion exercises, water jogging, proprioceptive wobble board
exercises) (Fig.13).
Elite athletes may elect for early surgical repair of complete ruptures (controversial).
 
X-rays are necessary to exclude fractures with good talar dome views to exclude
osteochondral fractures (ignore bony avulsion of the ligaments). Do not miss a high fibular
fracture with syndesmotic injuries (Maisonneuve #) (Fig. 14). Stress x-rays are unreliable(
and painful) but possibly helpful in the chronic phase where the patient does not give a clear
history of instability (“going over” on the ankle).
 

Lateral ligamentous laxity

 

Chronic unsuccessful treatment of the acute lateral ligament injury may result in chronic
lateral ligament laxity from “stretched-out” ligaments.
 

There is chronic lateral pain (over anterior border of the lateral malleolus sinus tarsi)
exacerbated by repeated inversion injuries on irregular terrain. Too often athletes are left to
persist with months of unsuccessful physiotherapy instead of a quick effective lateral
ligament reconstruction. (I favour the Bröstrom capsulorrhaphy with reinforcement from
the inferior extensor retinaculum; exceopt in heavy patient where a peroneal tenodesis is
needed. ((Fig. 15).
 

Medial ligament injuries

 

These are rare (usually with (lat.lig) sprain) or fractures) and need to be differentiated from
lesions of the nearby tibialis posterior or FHL tendons and syndesmotic injury.
 

Careful examination (for localised tenderness) with ultras=sound examination is useful (see
tib post section). It is a strong ligament.
 

X-rays (to exclude #) with bone scan and CT maybe necessary to exclude osteochondral
fractures where there is severe, localised pain about the talar dome (Fig. 16). Weight-
bearing x-rays may be useful (Fig. 14a). Chondral damage (sometimes seen after lateral
ligament injuries with medial impingement) may require arthroscopic attention (Fig 17).
 

Subtalar Instability
 

Difficult to diagnose as it is really a component of a lateral ligament injury (the

CFL torn) from inversion.
 
Special stress – x-rays (Broden – 45° in rotation and 20° caudal tilt) or I>I> may help but
are painful.. Treat as above with CFL reconstruction (as part of Brostrom operation) from
chronic cases.
 

Spring ligament sprain

 

The mid-foot is prone to twisting injuries with pain localised to the medial arch from sprain
of the calcaneo-navicular ligament (spring).
 

Cuboid Syndrome
 

Pain and tenderness over the cuboid in the region of the peroneal (exerting) tendons. S-
ankle the foot.
 

Syndesmotic ankle injuries (high ankle sprain)

(distal tibiofibular diastasis)
 

Previously unrecognized but a probable cause of ongoing painful “ankle sprain”.

Probably from an external rotation injury in the professional athlete. There is marked
swelling both sides of the ankle with tenderness over the interosseous membrane. Suspect
where an ankle sprain takes a long time to settle down; perform the squeeze test or
abduction/external rotation tests (Fig. 18) and check a mortise-view. X-ray (>1 mm
reduction in the medial clear space or <1 mm overlap) (Fig. 19). Late x-rays show
calcification of the ligaments. Treat in NWB art for four weeks or later with diastasis screw
fixation and ligament repair where refractory.
 

Sinus Tarsi Syndrome

 

The tunnel beneath the talar neck and upper calcaneus can be a source of pain from
overactivity and inversion injury. It may be related to the strained ligament of the tunnel
(talo-calcaneal ligament). Distinguish from lateral ligament strain. Treat with NSAID,
activities (for hyperpronation) and possible steroid injection and seldom surgical excision of
contents.
 

Peroneal tendon injuries

 

The peroneal tendons work hard. They evert the foot (which wants to drift into equinus) and
maintain the transverse/longitudinal arches. They are poorly anchored with a weak holding
retinaculum. Forced dorsiflexion of the ankle in skiing or football can produce tenosynovitis
tendinitis tear; partial or complete (peroneus brevis) or dislocation of these tendons. There
is marked tenderness with reproducible subluxation. X-rays may show a rim fracture (Fig.
20). Strapping may help, otherwise decompression, repair, tenodesis to (peroneus longus)
or early stabilisation in the groove (because of high recurrence rate). Graduated return to
sport over 4-6 weeks avoiding “cutting” procedures or sprinting for 6 weeks.
 

Endoscopic tenosynovectomy is useful for refractory tenosynovial swelling and pain.

 

Tibialis Posterior Tendon Injury

 

IMPORTANT TO PICK UP AND MANAGE ACTIVELY.

 

These occur in middle-aged women who are unfit as a result of chronic degeneration.
The pathology is inflammation (tenosynovitis) or rupture (partial or complete). They
experience pain and tenderness along the tibialis posterior tendon with difficulty lifting the
heel off the ground in the single heel raise test (Fig. 21). An ultrasound may secure the
diagnosis. The arch is flattened and foot pronated. They require NSAIDs, (a medial arch
support (for tenosynovitis and partial ruptures), and debridement/tenosynovectomy for
refractory cases. Reconstruct complete tears (use the FDL).
 

Tibialis Anterior Injury

 

Spontaneous rupture may occur but is unusual. There is localised tenderness, weakened
dorsi flexion. Surgical repair is important (either direct repair or tendon/extensor transfer).
 

Tendo Achilles Injury(TA)

 

Injuries of this region are common and difficult to treat. Overtraining will produce an
inflammation around the TA peri-tendinitis), in the tendon (tendinitis) or by the tendon
(retro calcaneal bursitis and retro-achilles bursitis). The “painful arc sign” may help to
make the distinction (Fig. 22). Certain athletes are at risk (excessive training, poor hindfoot
shoe support, on cambered surfaces).
 
A violent contraction of the gastrocnemius-soleus unit may rupture (partially or completely)
the TA. Patients report having been hit or kicked in the calf during the push-off phase of
running or racquet sports. Partial tears are difficult to diagnose; ultrasound imaging is
helpful.
 

Complete tears will invariably have pain, swelling, and a palpable gap (prior to swelling). Do
not be fooled by the patient being able to plantar flex (from intact long flexors). Simmond’s
test is easy to perform and diagnostic (Fig. 23).
 

Treatment of TA problems is outlined (Fig. 24).

 

SURGERY WHEN THE TA IS TORN.

 

A tear of the medial head of the gastrocnemius is common in middle-aged tennis players
(tennis leg.
 

Rehabilitation
 

Cross-train (swim) during surgical recovery with slow re-introduction to pre-injury sports
over 3 months.
 

Fractures of the foot and Ankle

 

Fractures of the ankle are common and require precise treatment to avoid later
osteoarthritis (1 mm displacement causes 40% decrease in tibiotalar articulation). They are
variously classified (Fig. 25) and are usually from a fall with supination (or pronation) of the
forefoot and eversion (or inversion) of the hindfoot. Well fitted shoes with ankle support will
eliminate such injuries. The immediate pain, swelling and deformity is obvious, never
hesitate to x-ray.
 

A displaced fracture almost always requires open reduction and internal fixation (Fig. 26),
a non-displaced <1 mm), careful follow-up (6 weeks in cast) with x-ray review to detect
early displacement.
 

A markedly displaced ankle fracture should be reduced in casualty to avoid skin

problems (blisters/nervosas) (Fig. 27). Exclude a Maisonneuve fracture by careful
examination (with x-ray) of upper fibular (Fig. 14). Post-operatively support the ankle in an
S-Ankle splint for 6 weeks (NWB) and return to sports at 3 to 5 months.
 

Residual ankle pain after bony union may be residual traumatic synovitis (Fergel lesions)
which require NSAIDs) or arthroscopic excision.
 

Fractures of the foot

 

These tend to be under-appreciated. Most can be managed in a below knee fracture walker.
 

Displaced an intraarticular fractures often require reduction and fixation.

 

Fractures of the talar neck may result in avascular necrons of the body and so need
accurate reduction (Fig. 28).
 

Fractures of the calcaneus can be devastating (widened painful heel, nerve entrapment,
tendinitis and later subtalar OA (Fig. 29). It is best to reduce to restore Bohler’s angle
(usually requires surgery with bone grafting and early movement).
 

Navicular fractures can be avulsions, hairline, comminuted or stress type. It is best to

reduce and fix the fracture (K-wires) (Fig. 0). Non-union, which is painful, may result.
 

Mid-foot (tarametatarsal) fractures (Lisframe) can be subtle and easily missed

(Fig. 31).
 

Careful WB x-rays are important to sort out mid-foot pain following injury.
 

Mid-foot pain following injury. Reduction and fixation (with K-wires) is useful.
 

Avulsion of peroneus brevis (base of 5th MT) and proximal diaphyseal fracture of the
5th MT (Jones fracture) may take a long time to heal and eventually require surgical
fixation (Fig. 32).
 

 
Most other fractures of the MT shafts and phalanges require reduction and seldom surgical
fixation.
 

Dislocated MTP or PIP joints need prompt reduction otherwise they become irreducible
and a source of severe pain (Fig. 33).
 

Nerve entrapments
 

These are not uncommon about the foot and ankle, difficult to diagnose and treat. Many are
related to poor (eg ski boot) sports shoe fit or hard surfaces. Several have been described
(Fig. 34).
 

All entrapments are diagnosed by localised tenderness over entrapped nerve at level of
entrapment. Positive Tinel’s test, neuralgic pain (at rest or at night) nerve conduction
studies are usually unhelpful. Treat with orthotics, NSAIDs, stretching; massage. Surgically
release (and excise neuroma) at level of anatomically located tenderness.
 

Compartment Syndrome
 

Increased pressure within a confirmed muscle compartment may lead to ischaemia,

necrosis, contracture and a useless limb. Its early recognition and prompt treatment is
essential. Causes are trauma (with fracture), post-operative and crush injuries (Fig. 35).
 

The symptoms and signs of an acute compartment are well described (Fig. 36). It usually
involves the forearm, the lower leg and foot (when compartment pressures exceed 40
mmHg). Measuring intra=compartmental pressures is fraught with problems of accuracy
and should not override clinical judgement. Treatment is to externally split POP/bandages
to skin and if necessary, internally release the compressed compartment
(fasciotomy Fig. 37, within 4 hours, by multiple incisions over the tight muscle.).
 

Chronic compartment syndrome (exertional) may be subtle in presentation and results

from prolonged training (runners, court sports athletes). The muscles are overworked, swell
and a vicious cycle is triggered. The extensor and flexor compartments are usually
involved with crescendo pain and tenderness relieved by rest. There may only be
paraesthesia with exercise. The differential diagnosis is important (Fig. 38).
 
Treatment is activity modification, massage, exclude footwear or surface problem, NSAIDs,
orthotics (medial wedge for posterior compartment), cross-training (cycling) and fasciotomy
(sometimes, 80% successful).
 

Here it is useful to carefully measure intra-compartment pressures before/during/after

exercise; (resting pressure >15 mmHg or delay in fall after exercise of >20 mmHg/over 3
minutes). Then consider a careful fasciotomy of the compartment involved with mini skin
incisions and wound closure.
 

Plantar Fasciitis
 

Common and crippling subcalcaneal (usually medial) heel pain. Related to hyperpronation
and pes cavus (Fig. 39). There is localised tenderness; a positive windlass effect
(dorsiflexing the big toe exacerbates the pain). X-rays may show a heel spur (ignore it).
 

Exclude: stress fractures, nerve entrapment (medial branch of the lat plantar nerve) and
Reiter’s Syndrome.
 

Treat with NSAID, stretching and a soft silicone heel cup. Seldom is surgery
(release) helpful.
 

Os trigonum
 

This ossicle behind the posterior talus (medial tubercle of the posterior process of the talus)
may be the cause of pain with plantar flexion in ballet dancers. It can be asymptomatic,
fused, fractured, absent or big. X-rays confirm its presence and examination its problem.
Treat with injection (not steroids) or excise. Do not confuse with FHL tendinitis (Fig. 40).
 

Turf Toe
 

This is caused by a forceful dorsiflexion of the 1st MTP joint in American football on a hard
surface (artificial turf and flexible shoes – Fig. 41). X-rays may show a disruption of the
plantar volar plate complex. Exclude stress fracture, sesamoiditis, entrapment of FHL. Treat
with RICE, taping, custom shoes and sometimes surgical repair of the disruption.
 

Tibiotalar Spurs
 

Osteophytic spurs may form on the adjoining surfaces of the lower anterior tibia and talar
neck. There is impingement pain with dorsiflexion. Arthroscopic excision is useful (Fig.).
 

Metatarsalgia
 

Forefoot pain beneath the metatarsal heads (with callosities) is vague in nature and related
to impact sports. There may be claw toes and/or pes cavus.
Exclude a neuroma, stress fracture, Freiberg ’s infraction. Treat with stretching, NSAIDs,
transverse arch supports (HAPADs) and rarely a closing wedge osteotomy (where a single
(usually the second) metatarsal is involved).
 

Freiberg ’s infraction
 

This is an osteonecrosis of the second metatarsal head typically in teenage females and with
excruciating pain.
X-rays may show increased density, or collapse of the metatarsal head (Fig. 43).
Symptomatic treatment or debridement synovectomy or limited resection of the distal 2nd
MT head.
 

Hallux Valgus
 

Common in the community fro improper shoe size seen in dancers and catchers from acute
injuries (dislocation of 1st MTP joint) or chronic repetitive injury. Ballet dancers and sprinters
are poor, surgical candidates (post-operative stiffness is debilitating here) and all other
avenues must be exhausted (delay surgery as long as possible) (Fig. 44).
 

Hallux Rigidus
 

A stiff and painful 1st MTP joint from micro-trauma, osteonecrosis or OA. Seen in push-off
sports where long, narrow pronated feet (long 1st MT). Require stiff sole, HAPAD or
cheilectomy (excision of painful dorsal osteophytes).
 

Sesamoiditis
 
Localised pain usually below the 1st MTP joint which may be part of a FHL
tendinitis/tethering; seen in dancers. Exclude fracture, stress fracture, OA, dislocation,
nerve entrapment and do not confuse with bipartite sesamoid. X-rays (sesamoid views).
Treat with metatarsal support, NSAID and rarely shave or excise.
 

Short Leg Syndrome

 

A short leg (>2 cm) is prone to injury (stress fractures, MCL knee sprain, patellar
subluxation, plantar fasciitis and hyperpronation). The longer leg is prone to iliotibial
tendinitis. It may be real shortening or apparent (from tilt of tract with tendon contracture –
needs stretching). Use partial heel build-up (and/mid-sole build-up).
 

Approach to the persistently painful ankle (Fig. 45).APAD or cheilectomy (excision of painful
dorsal osteophytes).
 

Sesamoiditis
 

Localised pain usually below the 1st MTP joint which may be part of a FHL
tendinitis/tetHAPAD or cheilectomy (excision of painful dorsal osteophytes).
 

Sesamoiditis
 

Fig. 24
Treatment – TA Injuries
      

Tendinitis/peritendinitis     Rest, NSAIDs, heel raise, ultrasound, massage

      (stretching).  Rarely surgery with debridement.      

 
   

Retro­calcaneal bursitis     As above but consider surgery.  Earlier with excision of

      associated retro­calcaneal exostosis.

      Rarely surgery for retro­achilles bursitis.
   

Haglund’s bump     Shoe modification, NSAID gel,

Postero­superior prominence     Heel raise or excise.

of calcaneus  
   

Partial tendon rupture     May require surgical excision of scar and

      Grandulation tissue.

 
   

Complete tendon rupture ∙        Almost invariably surgically repair

  (Open technique).

  ∙        Later repair is difficult and may require

Fascial or tendon augmentation.

 
 

Warning:   Avoid steroids. Exclude Reiter’s, Infection, Gout, Tumour
 

Fig. 25
 

Classification of Ankle Fractures
   

 B    Weber (MOST USEFUL)

 e   (Position of Fibular #)

 s   A:  at/below joint line

 t    B:  at joint line

     C:  above joint line

   

 L  

 o    Lauge­Hansen

 g   (Direction of damaging force)

 i ∙        supination/adduction

 c ∙        supination/ext. rotation
 a ∙        pronation/abduction

 l ∙        pronation/external rotation

    

   

 S  

 I  

 M    Henderson 

 P ∙        lateral malleolus

 L ∙        medial malleolus

 e ∙        posterior malleolus

  or combination
 

Fig. 34
 

Nerve entrapments
   

Type Detail

   
   

Tarsal tunnel Posterior tibial nerve trapped behind medial malleolus under flexor 

  retinaculum. Pain medial foot and sole.

   

 
   

Ant tarsal tunnel Deep peroneal nerve trapped under inferior ext. retinaculum.  Pain 1st 

  web space.

   

   

Jogger’s foot Medial plantar nerve compressed at Knot of Henry. Pain over med 

  toes.

   

   

Sural nerve Medial border foot pain.
   
   

Comm peroneal n. Behind the fibula neck from trauma.

   
   

Superf peroneal n. Ant­lateral entrapment (12 cm from tip lat mal;  distinguish from 

  compartment syndrome).

   

   

Saphenous Nerve Injures in thigh (Hunter’s canal) or med knee (post­surgical).

   

 
   

Morton’s neuroma Typically pain between 3rd/4th metatarsal heads from traumatic 
entrapment causing neuroma (runners) of interdigital nerve.  
Compression of metatarsal heads reproduces symptoms and patient 
aware of mobile peeble.
 

Fig. 38
Differential Diagnosis of 

Chronic Compartment Syndrome
Problem     Action
     

Stress # bone     See bone scan (localised

      hot area)
   

  Maybe compartment problem of tib 

Periostitis post or periostitis of soleus muscle. 
Do bone scan, consider fasciotomy, 
(shin splints)
orthotics for hyper­pronation, 
(pain over postero­ massage.
medial distal tibia)
 
 

 
    

Popliteal artery  Calf claudication with  reduced 
entrapment pulses (when knee extended, foot 

  dorsiflexed). 

 
 

Fig. 36
 

Diagnosis Compartment

Syndrome
   

            Acute        Chronic

 
       

1  # bone present Pain with sport

    and slow to resolve

 
     

2     Localised Tenderness

      Tenderness with swelling
     

3    SEVERE  Pain       

  with active  

      (usually not   

    possible) and  

    passive movement

 
     

4     Paraesthesia  Paraesthesia
 

Pallor/paralysis/pulselessness

Are late signs where diagnosis

Has already been missed
  
 

 
 

Fig.45
 

For the Painful (persistent)

Ankle consider the following …
    

 Problem Action
 “Meniscoid” Arthroscopic

 synovitis ankle Synovectomy

   
 Avulsion tip fibula excise

   
 “Asymptomatic” ossicle excise
   

 unrecognised fracture excise

 ant. Process calcaneus  
   

 Peroneal or tib Surgery; consider  

 Post/tendon problem endoscopic 
tenosynoectomy
 (synovitis, partial tendon,
 
 subluxation)
 

 
   

 Lat process # talus fix/excise
   

 Sinus tarsi syndrome surgery

   
 Subluxation cuboid  

   
 “High ankle sprain see text

 (+ fracture Tilbux)  
 Impingement inferior band arthroscopic

 Of tibiotalar ligament excision

 
 Nerve entrapment see text
 Tarsal coalition (children) excise

 
 Osteochondral arthroscopy

 Fracture/dissecans  
 RA or occult tumour refer 

 
Management

* NSAIDs – local application  * Cross­train

* Water jog  * S­Ankle splint

*Gentle PT (low frequency pulsed

ultrasound, TENS, WAX)
 

Fig. 2
 

Sports Specific

Foot and Ankle Injuries
   Specific Foot and

 Sport       Ankle Injury
   

 Skiing Peroneal tendon subluxation

  Nerve entrapment

Plantar fasciitis

 
 Running Lateral ligament sprains

  Stress fractures

Shin splints

 
 Ballet Os trigonum

FHL impingement

Sesamoiditis

Stress fracture

Hallux valgus
   

 Football Turf toe

Ankle and mid­foot fractures

 
   

 Tennis Gastrocnemius

Strains

TA injury

Stress fractures

 
   

 Soccer Ankle sprains

  Stress fractures

   

Basketball Lateral ligament sprains

  Plantar fasciitis

  Jones fracture

   

Gymnastics Sever’s disease

 
 

Fig. 5

 
 Athletes prone to injury

 
  

Postural defects

∙       

Muscle weakness/inbalance

∙       

Lack of flexibility

∙       

Mal alignment problems

(pronated feet, LLD with pelvic tilt)

 
Athletes with

Biomechanical advantage

 
Pigeon toed Good for sprinters, tennis and squash

 
Sway back Increased lumbar, lordosis with anterior pelvic 

  tilt – good sprinters, jumpers and gymnasts.

   

   

  Everted feet – good for breastroke

Duck feet  

   

  Good for backstroke and butterfly

Inverted feet  

   

  Ligamentous laxity

Double jointed gymnasts

∙        Exception ...

Peter Snell (NZ) had body build of sprinter

Rather than middle­distance athlete ­

(gold medal 800, 1500 m Rome , Tokyo ,

1960, 1964).
 

Fig. 7
 

Common sites

Stress fractures foot

Tibia (mid and distal)

∙       

Calcaneus

∙       

Navicular

∙       

Metatarsals (esp 2nd MT)

∙       

Sesamoids (1st MTP)

 
 

Less common

Med. Malleolus

∙       

Cuboid

∙       

Calcaneus

 
 

Fig. 8
 

Treatment – 
 Stress fractures

 
Immediate

 
Rest

∙       

Immobilise

∙       

RICE, NSAIDs

∙       

Cross­training (swim/cycle to keep fit)
 

Long term
 

Correct mal­alignment – or use orthotics

(hyper pronation, ext. tibial torsion)

∙       

Better absorptive impact sports shoes

∙       

Hormone treatment female athletes

∙       

Alter training schedules

∙       

Exclude infection/tumour

∙       

Surgery

(at 6 months – bone graft/drill

“dreaded black­line”)

∙       

Re­introduce activity at 6 to 12 months