Review Article
Management of Common
Robert B. Anderson, MD
Kenneth J. Hunt, MD
Jeremy J. McCormick, MD
From the Carolinas Medical Center,
OrthoCarolina Foot & Ankle Institute,
Charlotte, NC (Dr. Anderson), the
Department of Orthopaedics,
Stanford University, Stanford, CA
(Dr. Hunt), and the Department of
Orthopaedic Surgery, Washington
University, St. Louis, MO
(Dr. McCormick).
Dr. Anderson or an immediate family
member serves as a board member,
owner, officer, or committee member
of American Orthopaedic Foot and
Ankle Society; has received royalties
from DJ Orthopaedics, Wright
Medical Technology, and Arthrex;
serves as a paid consultant to or is
an employee of Wright Medical
Technology; and has received
research or institutional support from
Wright Medical Technology. Dr. Hunt
or an immediate family member is a
member of a speakers’ bureau or
has made paid presentations on
behalf of Smith & Nephew.
Dr. McCormick or an immediate
family member is a member of a
speakers’ bureau or has made paid
presentations on behalf of Smith &
Nephew and has received research
or institutional support from Midwest
Stone Institute and Wright Medical
Technology.
J Am Acad Orthop Surg 2010;18:
546-556
Copyright 2010 by the American
Academy of Orthopaedic Surgeons.
546
Sports-related Injuries About
the Foot and Ankle
Abstract
Foot and ankle injuries are commonplace in competitive sports.
Improvements in injury surveillance programs and injury reporting
have enabled physicians to better recognize and manage specific
foot and ankle injuries, with a primary goal of efficient and safe
return to play. Athletes are becoming stronger, faster, and better
conditioned, and higher-energy injuries are becoming increasingly
common. Close attention is required during examination to
accurately identify such injuries as turf toe, ankle injuries,
tarsometatarsal (ie, Lisfranc) injuries, and stress fractures. Early
diagnosis and management of these injuries are critical. Ultimately,
however, pressure to return to play must not compromise
appropriate care and long-term outcomes.
I njuries about the foot and ankle
are common among competitive
athletes. In recent decades, public
ies have developed injury data collec-
tion and surveillance programs to
allow coaches, trainers, clinicians,
health surveillance programs have and athletes to create a safer athletic
more accurately quantified the fre- experience. This has resulted in the
quency and breadth of foot and an- implementation of several rules and
kle injuries in many sports and at measures that have been shown to
various levels of competition. Man- effectively reduce rates of injury.
agement of these injuries typically In 1982, the National Collegiate
entails aggressive rehabilitation and Athletic Association (NCAA) devel-
early return to competitive activity oped the Injury Surveillance System
without compromising healing or
(ISS), one of the original injury sur-
long-term functional outcomes. veillance programs.1 This system was
These objectives are frequently influ- created with the intent of improving
enced by the high expectations of safety by providing data on injury
teams, coaches, parents, and the ath- trends in intercollegiate athletics.
lete. Through comprehensive data analy-
sis, the ISS is able to highlight the ep-
Incidence and Magnitude idemiology of the most common in-
of Injury jury descriptions, illustrate notable
disparities in injury rates, and influ-
The ultimate goal of sports medicine ence injury prevention. Data from
is to enable athletes to perform to the ISS have been used to implement
their maximum capabilities while rule changes and equipment recom-
minimizing the risk of injury. Ath- mendations, which has resulted in re-
letic associations and governing bod- ducing the number of injuries.
Journal of the American Academy of Orthopaedic Surgeons

Hootman et al2 reported 16-year
results of the ISS data for 15 sports
in all three collegiate divisions
(1988-89 through 2003-04). Overall,
ankle ligament sprains were reported
to be the most common injury dur-
ing practice and competition, mak-
ing up 14.9% of all injuries, with an
injury rate of 0.83 per 1,000 athlete-
exposures. By comparison, anterior
cruciate ligament injuries accounted
for 2.6% of all injuries, with 0.15 in-
juries per 1,000 athlete-exposures.
Concussions made up 5.0% of all in-
juries, with 0.28 injuries per 1,000
athlete exposures. Although anterior
cruciate ligament injuries and con-
cussions were less common than an-
kle sprains, they resulted in greater
time lost from participation.
At the high school level, 39.7% of
athletic injuries are to the foot and
ankle, with sprains being the most
common.3 A report on the 2004
Olympic Summer Games in Athens,
Greece, noted that 22% of injuries
were ankle sprains.4 Foot and ankle
injuries were second only to knee in-
juries in the 2002 Olympic Winter
Games in Salt Lake City, Utah.5 A re-
view of more than 12,000 injuries in
19 sports demonstrated that 25% of
injuries occurred at the ankle or
foot.6
Injury in Collegiate
Athletes
Approximately 380,000 student-
athletes participate annually in
NCAA sports, with countless others
involved at the high school level.7
Training and medical care of these
athletes are changing as we improve
our ability to efficiently identify, di-
agnose, and manage injuries. Table 1
shows the findings of the NCAA ISS
review of foot and ankle injuries sus-
tained in game situations in select
sports.8-16
Several studies have been done in
September 2010, Vol 18, No 9
Table 1
Summary of Findings From the National Collegiate Athletic Association
Injury Surveillance System on Foot and Ankle Injury
Game Injuries Relating
Sport to the Ankle (%)
Men’s baseball8 7.4
Women’s softball9 10.3
Men’s basketball10 26.2
Women’s basketball11 24.6
Men’s football12 15.6
Men’s lacrosse13 11.3
Women’s lacrosse14 22.6
Men’s soccer15 18.8
Women’s soccer16 19.4
an attempt to evaluate risk factors
associated with various sports. Janda
et al17 studied base sliding and the ef-
fect of breakaway bases on the inci-
dence of foot or ankle injury in
men’s baseball and women’s softball.
In 1988, Janda et al18 reported that
71% of recreational softball injuries
were attributed to sliding into sta-
tionary bases. The introduction of
breakaway bases reduced the inci-
dence of sliding injuries from 7.2%
of games played to 0.3% of games
played.18
Hosea et al19 evaluated collegiate
basketball players and found a
higher rate of grade I ankle sprains
in women than in men, which
suggests an anatomic or strength pre-
disposition to injury in women. Al-
though taping, bracing, and proprio-
ceptive training have been shown to
be effective in preventing sprains,
studies on definitive injury preven-
tion are lacking.
In general, football has a higher in-
jury rate than do other sports, with
more time lost to recovery. As ath-
letes become faster and stronger,
their increased speed and collision
force on the playing field lead to
more violent contact and increased
risk of injury. Improved equipment
and concentration on improved tech-
Robert B. Anderson, MD, et al
Game Injuries Relating
to the Foot (%)
0
0
2.6
2.4
1.1
0
1.3
4.2
2.7
nique, particularly with tackling,
have led to decreased rates of injury.
Other sports have specific risk fac-
tors associated with method of play
or technique. For instance, the direct
contact of a slide tackle in soccer
puts players at significant risk of
twisting injury and can be a mechan-
ism for fracture. Sport-specific risk
factors may predispose an athlete to
injury, with the greatest risk in run-
ning, cutting, and jumping sports.20
Initial Evaluation
The initial approach to evaluating
the athlete with an injury about the
foot or ankle involves identifying
and localizing the injured bony and
soft-tissue structures. This allows a
focused physical examination and
narrows the differential diagnosis to
determine the need for additional
testing or radiographic studies.21,22 It
is important to determine the mech-
anism of injury because it can offer
vital clues regarding the location and
severity of the injury as well as alert
the caregiver to potential concomi-
tant injuries that may otherwise be
overlooked. It also is important to
determine whether preventive mea-
sures are available and have been ap-
547
Management of Common Sports-related Injuries About the Foot and Ankle
propriately implemented.23
Perhaps the most important issue in
the initial evaluation of an athlete is de-
termining when it is safe to return to
play. These decisions may differ slightly
depending on the injury, the sport, and
temporal issues (eg, in-season versus
off-season, practice versus competition).
The goal of treatment and surgical
decision-making is to ensure safe return
to play and to reduce the risk of further
or recurrent injury.
Injury prevention and prognosis are
of particular importance for the com-
petitive athlete because the goal is not
simply to return to participation but to
perform at a high level while avoiding
long-term consequences. Injury preven-
tion strategies and programs are a vi-
tal part of education and training in ath-
letes at all levels.2
Diagnosis and
Management of Select
Injuries
A comprehensive review of the diag-
nosis and treatment of all sports-
related foot and ankle injuries is be-
yond the scope of this article.
Instead, we review four injuries that
can present diagnostic and treatment
dilemmas for team physicians and
trainers: turf toe, ankle sprains, tar-
sometatarsal joint (ie, Lisfranc) inju-
ries, and stress fractures. Manage-
ment of these injuries can be
challenging and often requires refer-
ral to a subspecialist. Prompt diagno-
sis can make a dramatic difference in
care and outcome.
Turf Toe
Turf toe is a hyperextension injury
to the hallux metatarsophalangeal
(MTP) joint. It occurs when an axial
load is delivered to the heel with the
ankle in plantar flexion and the hal-
lux in dorsiflexion or extension. The
hyperextension moment at the MTP
joint causes attenuation or tearing
548
of the plantar capsuloligamentous
structures, which may lead to joint
instability.
Turf toe injury is occurring with
increasing frequency at all levels of
competition. The injury was first de-
scribed in 1976 by Bowers and Mar-
tin,24 who found an average of 5.4
turf toe injuries per football season
in players at the University of West
Virginia. Rodeo et al25 attempted to
quantify the incidence of turf toe in-
jury by surveying 80 active players in
the National Football League (NFL).
They found that 45% of players had
experienced a significant turf toe in-
jury, with 83% of these occurring on
artificial turf.
Diagnosis
Diagnosis of turf toe injury starts
with a heightened index of suspicion
in a patient presenting with hallux
MTP pain and swelling following an
acute incident. In addition to the
mechanism of axial load, the patient
may report decreased push-off
strength and inability to participate
in cutting activities. It is important to
determine the mechanism of injury
because many of these injuries are
not solely the result of hyperexten-
sion but rather are the result of a de-
gree of valgus stress. Such a force
may create a more medially based
soft-tissue injury pattern and put the
athlete at risk of progressive hallux
valgus. The physical examination fo-
cuses on evaluating hallux MTP sta-
bility and hallux flexion strength.
Comparison radiographs are help-
ful in evaluating for sesamoid frac-
ture and diastasis of a bipartite sesa-
moid. Particular attention should be
paid to the position of the sesamoids
on the AP radiograph. Proximal mi-
gration of the sesamoids from the
normal position beneath the metatar-
sal head is suggestive of capsular dis-
ruption (Figure 1, A). Plain radio-
graphs can aid in demonstrating a
lag in sesamoid tracking; this is evi-
Journal of the American Academy of Orthopaedic Surgeons
denced most clearly on the lateral
view (Figure 1, B). Magnetic reso-
nance images can be conclusive in
evaluating the integrity of the plantar
capsular structures of the hallux
MTP joint as well as concomitant in-
juries to the joint surface (Figure 1,
C).
Management
Management of turf toe injury is de-
pendent on the grade of injury26 (Ta-
ble 2). Grade I injuries are character-
ized by attenuation of plantar
structures, localized swelling, and
minimal ecchymosis. These injuries
are managed with taping and early
rehabilitation (eg, range-of-motion
exercises, gradual strengthening),
with return to play as tolerated.
Grade II injuries involve partial tear
of plantar structures, moderate
swelling, and restricted motion as the
result of pain. Athletes with such in-
jury frequently require at least 2
weeks before returning to competi-
tive play. Grade II injuries are also
managed with rehabilitation and
taping. A turf-toe plate or carbon-
fiber orthosis that limits hallux MTP
extension can be helpful in protect-
ing grade I and II injuries before re-
turn to competitive play.
Grade III injuries may involve
complete disruption of plantar struc-
tures, significant swelling or ecchy-
mosis, hallux flexion weakness, or
frank instability of the MTP joint.
Management of these injuries can be
nonsurgical, with immobilization in
plantar flexion to allow the plantar
structures to oppose and heal. Re-
cently, however, Anderson27 reported
on the surgical outcomes of 19 colle-
giate and professional athletes with
grade III turf toe injury who under-
went open repair of the ruptured
capsuloligamentous complex. All but
two athletes returned to their previ-
ous level of participation; this find-
ing validates the use of more aggres-
 Robert B. Anderson, MD, et al

sive management in grade III turf toe Figure 1

injury.
Our preferred technique for man-
aging complete rupture is direct pri-
mary repair of the plantar capsu-
loligamentous complex through a
two-incision approach (ie, medial
and plantar).28 An important aspect
of recovery is appropriate player ex-
pectations regarding return to play.
Following surgical repair, it may take
6 to 12 months before the player can
return to full competition without
the need for a protective orthosis or
taping. The necessity of surgery ap-
pears to be sport- and position-
dependent.

Ankle
Inversion
Ankle sprains are the most common
injury in competitive athletics. Usu-
ally, rotational ankle injuries involve
inversion mechanisms with lateral
ligament sprain. Athletes often re-
port having “rolled” their ankle
while taking an awkward step in
running or landing after a jump. A
patient who can bear weight and
who demonstrates the ability to per-
form the jumping, running, or cut-
ting techniques necessary to play his
A, AP radiographs demonstrating turf toe injury with sesamoid retraction (left)
or her sport may return to play im- and normal sesamoid position in the contralateral foot (right). B, Lateral
mediately. If the patient cannot per- radiographic image demonstrating sesamoid retraction with hallux
form the necessary techniques, then dorsiflexion. C, Sagittal T2-weighted magnetic resonance image
further evaluation is needed, includ- demonstrating complete disruption of the plantar plate distal to the sesamoid.
ing radiographic studies to assess for
fracture or dislocation. the injury consists of neurapraxia walk without crutches. Partial tear of
that causes sensory change, which the lateral ligament is classified as
Diagnosis tends to resolve without specific in- grade II injury, which presents with
Acute swelling or ecchymosis may tervention. Several subtle injuries swelling and ecchymosis. The patient
aid the physician in localizing the in- mimic a routine lateral ankle sprain, is able to walk a few steps unas-
jury and assessing its magnitude. A and care should be taken not to miss sisted. Grade III injury consists of
more extensive evaluation may also subtalar dislocation, fracture of the complete tear, with swelling, ecchy-
be indicated when a severe sprain anterior process of the calcaneus or mosis, a feeling of instability, and
arouses suspicion of a fracture or ar- lateral talar process, or avulsion of difficulty walking.30
ticular injury and in cases in which the base of the fifth metatarsal.
symptoms fail to resolve within 4 to Lateral ankle sprain may be cate- Management
6 weeks. There is a high incidence of gorized as grade I, II, or III. Grade I Regardless of the grade of ankle
peroneal nerve injury with severe sprain involves a stretched lateral lig- sprain, most athletes with so-called
sprains, and such injury should be ament. Symptoms include pain and classic inversion ankle injuries re-
carefully documented.29 Frequently, swelling, and the patient is able to cover with nonsurgical treatment, in-

September 2010, Vol 18, No 9 549

Management of Common Sports-related Injuries About the Foot and Ankle
Table 2
Classification and Management of Turf Toe Injury
Grade Description/Findings
I Attenuation of plantar
structures
Localized swelling
Minimal ecchymosis
II Partial tear of plantar
structures
Moderate swelling
Restricted motion
because of pain
III Complete disruption of
plantar structures
Significant
swelling/ecchymosis
Hallux flexion weakness
Frank instability of the
hallux metatarsopha-
langeal joint
Adapted with permission from Anderson RB, Shawen SB: Great toe disorders, in Porter DA,
Schon LC, eds: Baxter’s The Foot and Ankle in Sport, ed 2. Philadelphia, PA, Elsevier
Health Sciences, 2007, p 424.
cluding rest, ice, compression, and
elevation. Early mobilization and
strengthening exercises are helpful,
with the use of taping or bracing as
an adjunct to provide additional an-
kle support. Several treatment algo-
rithms have been reported with vary-
ing success, including no treatment,
functional rehabilitation, casting,
and acute ligament reconstruction. In
our experience, an aggressive physi-
cal rehabilitation program that in-
cludes brief immobilization followed
by functional rehabilitation allows
the athlete to return to play within 6
to 8 weeks without the need for fur-
ther treatment. If the patient has not
improved within that time, then a
more thorough evaluation should be
performed. This typically includes
MRI evaluation. Findings may in-
clude an osteochondral lesion of the
talus or a peroneal tendon tear that
warrants further management.31 A
study of recurrent injuries in high
school athletes found that most such
injuries involve the ankle (28%).32
The most predictable way to avoid
recurrent or chronic instability is to
550
Treatment Return to Play
Individualized based As tolerated
on the symptoms
Walking boot, Taping may be
crutches as needed required for ≥2 wk
Long-term immobili- 10-16 wk, depending
zation in a boot or on sport and
a cast or surgical position
reconstruction Taping or bracing
likely needed
complete rehabilitation of the initial
injury by focusing on the recovery of
both proprioception and peroneal
strength.33
Eversion
Eversion ankle injury, the so-called
high ankle sprain, can result in injury
to the tibiofibular syndesmosis. High
ankle sprains account for only 1% of
ankle sprains, but they are predictive
of a longer period of recovery and
residual symptoms.28,34 These injuries
occur most frequently in collision
sports. A review of players on one
NFL team over a 6-year period
found 15 players with syndesmotic
ankle sprain.35 Athletes in the syn-
desmotic group required substan-
tially more treatment and missed sig-
nificantly more games and practices
than did the 28 players with signifi-
cant lateral ankle sprain.
Diagnosis
The most common mechanism of in-
jury is direct contact to the lateral leg
while the foot is fixed to the ground.
Journal of the American Academy of Orthopaedic Surgeons
The resultant valgus moment on the
knee leads to an external rotation or
eversion force at the ankle with the
foot in dorsiflexion, which places
stress on the syndesmotic liga-
ments.36 There may be an associated
injury to the medial collateral liga-
ment of the knee.
The physical examination elicits
tenderness directly over the syndes-
mosis, with swelling or ecchymosis
proximal to the ankle joint. The
squeeze test is performed by attempt-
ing to compress the fibula to the
tibia more proximally on the injured
leg. Pain with this maneuver is con-
sidered to be a pathognomonic
symptom.28 An external rotation test
can be performed. As the athlete
stands on the affected limb, the ex-
aminer asks him or her to recreate
the mechanism of injury by rotating
the pelvis away from the affected
side (ie, single-limb standing stress
test). An attempt at a single-limb calf
raise may also be helpful in identify-
ing a clinically significant high ankle
sprain. An increase in pain or tender-
ness or a semblance of instability
with any of these maneuvers is con-
sidered to be diagnostic.
Imaging studies are helpful in de-
lineating the degree of acute syndes-
motic injury (Table 3). MRI may
demonstrate edema through the syn-
desmosis ligament complex or flexor
hallucis longus muscle in the region
of the posteroinferior tibiofibular lig-
ament. However, MRI may not be
helpful in determining definitive
management because this static test
fails to highlight instability patterns.
To help elicit instability, three ra-
diographic views of the ankle should
be obtained; special attention should
be paid to the syndesmosis and the
medial clear space. Radiographic pa-
rameters for tibiofibular overlap are
demonstrated in Figure 2, A.37,38 Me-
dial clear space is a measure of the
distance between the lateral border
of the medial malleolus and the me-
 Robert B. Anderson, MD, et al

dial border of the talus. With the an- Table 3

kle in neutral position, the medial
Radiographic Classification of Acute Syndesmosis Injury
clear space should be equal to the su-
perior clear space on the mortise Type Description Radiographic Finding
view.37 Both deviation from the ra- 1 Sprain without diastasis Normal
diographic syndesmotic parameters 2 Latent diastasis Normal non–weight-bearing film
and widening of the medial clear Positive external rotation stress view
space are suggestive of syndesmotic 3 Frank diastasis Edwards and DeLee classification: type I,
injury and ankle instability (Figure 2, lateral subluxation without fracture; type
B). II, lateral subluxation with plastic defor-
mation of fibula; type III, posterior
Diastasis and instability can be fur- subluxation/dislocation of the fibula; type
ther highlighted on a single-limb IV, superior subluxation/dislocation of the
standing AP ankle radiograph, which talus into the mortise
serves as a simple stress maneuver. If
Adapted with permission from Edwards GS, DeLee JC: Ankle diastasis without fracture. Foot
doubt persists regarding ankle stabil- Ankle Clin 1984;4:305-312.
ity, an external rotation stress radio-
graph, aided by fluoroscopic imag-
ing, should be obtained as a Figure 2
definitive diagnostic tool. This is per-
formed by manually applying an ex-
ternal rotation and abduction force
to the ankle and evaluating the mor-
tise view using the same parameters
as those used with standard radio-
graphs. Some biomechanical evi-
dence suggests that lateral views of
the ankle are more sensitive than the
true mortise view on stress testing.
Thus, when the stability of the syn-
desmosis remains in question, the
surgeon should consider obtaining a
lateral radiograph under stress test-
ing.36

Management
The absence of radiographic widen-
ing is indicative of a stable injury,
and the patient can be treated non-
surgically. A tall boot is worn until
the injury is no longer tender, at
which time therapeutic exercise is be-
gun and the patient is allowed grad-
ual return to activity. The athlete
should be given appropriate expecta-
tions about recovery time because it
can take as long as 6 weeks to
achieve full recovery.28 The ability to
hop on the affected extremity 15
times is a good indicator for an at-
tempted return to sport.
Widening of the medial clear space
or syndesmosis on external rotation
Ankle radiographic parameters. A, Normal syndesmotic relationships include
a tibiofibular clear space (open arrows) <6 mm in both the AP and mortise
views, as well as a tibiofibular overlap (solid arrows) >6 mm or >42% of the
width of the fibula on the AP view, or >1 mm on the mortise view. The
overlap is measured 1 cm proximal to the plafond. B, AP radiograph
demonstrating a widened syndesmosis and increased medial clear space.
(Panel A reproduced from Stephen D: Ankle and foot injuries, in Kellam JF,
Fischer TJ, Tornetta P III, Bosse MJ, Harris MB, eds: Orthopaedic
Knowledge Update: Trauma 2. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2000, p 210.)
or standard plain radiographs indi- tion, with some evidence of more
cates instability requiring surgical rapid recovery and improved out-
stabilization. This typically consists come scores.28,39 Our preferred
of open reduction of the syndesmosis method of fixation in the elite athlete
and screw fixation. Recently, there includes the use of a small plate in-
has been increased use of a suture- corporating one syndesmotic screw
button device for syndesmotic fixa- as well as one suture button (Figure

September 2010, Vol 18, No 9 551

Management of Common Sports-related Injuries About the Foot and Ankle
Figure 3
Postoperative AP fluoroscopic
image demonstrating our preferred
method of syndesmotic fixation,
with placement of a one-third
semitubular plate with 3.5-mm
screws placed in the proximal and
distal screw holes, a 4.5-mm
tricortical screw across the
syndesmosis, and a single suture-
button device.
3). The syndesmotic screw is re-
moved at 10 to 12 weeks, but the su-
ture button is left in place as an ad-
junctive fixation tool that affords
protection while allowing motion be-
tween the tibia and fibula. The re-
tained fibular plate protects against
stress fracture through the empty
screw hole.
Tarsometatarsal (Lisfranc)
Joint Injury
Injuries to the tarsometatarsal (ie,
Lisfranc) joint suffered during ath-
letic activity are much different from
those occurring from high-energy
trauma. Such injuries most com-
monly occur as a result of an axial
loading mechanism (ie, force to the
back of the heel with the forefoot
fixed to the ground), which usually
creates a purely ligamentous injury
pattern.40 These athletic injuries may
have subtle clinical and radiographic
findings, and they are easy to miss
on initial evaluation; thus, a high in-
dex of suspicion is necessary to diag-
552
Figure 4
Standard weight-bearing radiograph demonstrating widening at the Lisfranc
joint in the right foot. The contralateral left foot demonstrates typical anatomy.
nose and treat these injuries appro-
priately.
Diagnosis
Athletes often describe feeling a
‘‘pop’’ in the foot at the time of in-
jury and midfoot pain that is aggra-
vated by weight bearing. Pain is elic-
ited with compression of the
midfoot, swiveling into pronation
and supination, or stressing the first
ray into dorsal and plantar deviation
while stabilizing the second metatar-
sal head.41
Standard weight-bearing radiographs
of both feet should be obtained, includ-
ing a 30° internal oblique view, with the
radiograph of the uninjured foot used
for comparison. The diagnosis of an un-
stable Lisfranc injury has historically
been based on displacement of >2 mm
between the first and second metatar-
sal bases compared with the contralat-
eral foot (Figure 4). A small avulsion
fragment may be seen arising from ei-
ther the lateral edge of the medial cu-
neiform or the medial aspect of the sec-
ond metatarsal base (ie, fleck sign).42
Journal of the American Academy of Orthopaedic Surgeons
Stress radiographs taken with the
foot held in a pronated and abducted
position are important when a diag-
nosis of midfoot injury is suspected
but the radiographic findings are
normal or equivocal.43 MRI can be
used to diagnose subtle and purely
ligamentous midfoot injuries in the
absence of subluxation or disloca-
tion, but it is not necessary when di-
astasis is clearly seen on plain or
stress radiographs.44
Management
In the athlete, nonsurgical treatment
is indicated for Lisfranc sprain with
a nondisplaced, stable midfoot docu-
mented on stress radiographs. Sur-
gery is recommended in the presence
of unstable ligamentous injuries.
Most authors set the threshold for
surgical intervention as displacement
of ≥2 mm compared with the con-
tralateral foot.40,45
Obtaining and maintaining ana-
tomic reduction, thereby preserving
the posture of the midfoot, is the
most important objective of surgical

treatment.46,47 When anatomic reduc-
tion of the joints cannot be achieved
by closed means, a low threshold for
open reduction is advocated. Recom-
mended fixation options include
solid transarticular screws (ie, home-
run screw, that is, medial cuneiform
to the second metatarsal and, when
necessary, first and second metatar-
socuneiform screws plus one or two
intercuneiform screws); dorsal plat-
ing, which avoids the articular dam-
age of screw fixation; and a combi-
nation of the two.40 Some authors
have advocated use of the suture-
button device based on biomechani-
cal data,48 but there are currently few
clinical data available for this indica-
tion. We do not recommend the use
of Kirschner wire fixation or primary
arthrodesis in the athlete.
Postoperative care includes strict
non–weight-bearing restrictions for 6
weeks, allowing for early active mo-
tion once the incisions heal. Progres-
sive weight bearing in a boot that in-
cludes an arch support device is
initiated at 6 weeks. Pool therapy (ie,
running suspended) and stationary
bicycling are helpful. Return to sport
can occur as early as 4 months, but
the elite athlete may need to wait 1
year. The need for hardware removal
is controversial. Hardware should be
removed approximately 4 months af-
ter surgical fixation provided that
there is radiographic evidence of
fracture healing and clinical evidence
of ligament healing.
Stress Fracture
Stress fractures are among the most
common overuse injuries and are po-
tentially serious in the athlete. The
great majority of such fractures in-
volve the lower extremity, especially
the tibia and bones of the foot.49
Stress fractures are common in ath-
letes who engage in repetitive activi-
ties, especially runners. Such fracture
may result in complete fracture that
September 2010, Vol 18, No 9
may heal slowly and/or incompletely.
Stress fractures are often associated
with an increase in training intensity,
major change in training program,
change in shoe wear, and hard run-
ning surfaces.
The cause of stress fracture is re-
lated to repetitive loads; the highest
incidence generally is found in dis-
tance runners and dancers. The inci-
dence of tarsal and metatarsal stress
fracture is higher in runners with
forefoot varus50 and hindfoot
varus.51 Despite increased awareness
of the injury, certain stress fractures
about the foot and ankle remain
particularly problematic, including
those of the navicular, proximal fifth
metatarsal, and medial malleolus.
These injuries are often misdiag-
nosed and may occur at a higher fre-
quency than was previously under-
stood. For example, the navicular is
at risk for delayed healing because of
areas of poor blood supply, and me-
dial malleolar stress fractures have a
high incidence of displacement and
nonunion. These injuries frequently
require surgical stabilization.
Diagnosis
A thorough history and physical ex-
amination can aid in diagnosis. The
athlete with a stress fracture often
describes prodromal activity-related
pain associated with varying
amounts of swelling. This pain is fre-
quently associated with an abrupt
change in the training regimen. Point
tenderness often develops at the site
of the stress fracture. A one-legged
hop test may also elicit pain, as may
percussion over the site that is con-
cerning.
Plain radiographs are often nega-
tive, and the examiner should have a
low threshold for obtaining a more
sophisticated imaging study.49 Bone
scan is sensitive but not specific.
MRI is the preferred test because it
has a very high sensitivity and speci-
ficity. Once the fracture is identified,
Robert B. Anderson, MD, et al
CT is performed to determine
whether the fracture is incomplete or
complete. We define high-risk stress
fractures as follows: fifth metatarsal
metaphyseal fracture, medial malleo-
lar stress fracture, navicular stress
fracture, and stress fracture of the
anterior tibial cortex.52 These deserve
special consideration because they
are more likely to result in fracture
displacement and/or nonunion.
Management
Most stress fractures can be man-
aged nonsurgically. This initially en-
tails immobilization in a boot or cast
along with protected weight bearing
until the symptoms have resolved,
usually for approximately 6 to 8
weeks. Impact activities are avoided,
but low-impact cross-training, such
as swimming, biking, and elliptical
machines, can be continued to main-
tain aerobic conditioning. Frequent
physical examination is helpful in
identifying resolution of symptoms.
Orthoses can be used and shoe modi-
fications made to prevent further in-
jury. Nutritional considerations are
important because eating deficiencies
can contribute to the development of
stress fracture. Recent data recom-
mend early surgical management of
high-risk stress fractures in the elite
athlete because of the risk of high
displacement and nonunion; early
surgical management is also associ-
ated with a quicker return to sports
activities53 (Table 4).
Preventive Measures
In general, care of foot and ankle in-
juries is improving as physicians and
trainers become better educated
about these injuries and their man-
agement. Athletes are becoming big-
ger, stronger, and better conditioned,
and higher-energy injuries are be-
coming more common. Fortunately,
sporting leagues such as the NCAA,
553
Management of Common Sports-related Injuries About the Foot and Ankle
Table 4
Authors’ Preferred Management for High-risk Stress Fracture
Fracture Location Management
Navicular Two 4.0-mm partially threaded, cannulated, or solid
compression screws
Fifth metatarsal (ie, Jones) Solid intramedullary screw
Medial malleolus Open reduction and internal fixation with a one-third
tubular plate and 3.5-mm screws. Bone graft for
nonunion.
Anterior tibial cortex Prolonged immobilization and protected weight bear-
ing until symptoms resolve. Intramedullary nailing
when no healing is evident within 4-6 mo.
NFL, and Fédération Internationale popular with many basketball and
de Football Association have been football players. However, in a pro-
reporting on injuries to their athletes spective study of intramural basket-
in an attempt to establish risk factors ball players, no difference was found
and create preventive measures to in the rate of ankle injury between
keep their athletes on the field. Mod- players with and without high-top
ifications in shoe wear and playing shoes.58
surface may further help in reducing Recent research has focused on the
the number and severity of injuries playing surface as a variable in in-
about the foot and ankle in athletes creased foot and ankle injury. Early
at all levels. artificial turf surfaces showed a trend
Shoe wear may have a role in in- toward increased rates of injury;
creased rates of injury. Use of light- cleats could lock within the seams of
weight, flexible shoes with less cush- the turf, leading to twisting injuries
ion and midfoot support may place with increased torque. Artificial sur-
the athlete at risk because these faces are often slick, leading to the
shoes may offer less protection use of longer cleats, thus potentially
against potentially harmful forces in increasing the risk of injury. New-
the foot. Studies on the use of insoles generation surfaces better replicate
have demonstrated variable results. natural turf. One study of high
One study showed a decreased rate school athletes recently showed com-
of overuse injury with the use of in- parable rates of injury between the
soles,54 but another study showed no modern style turf and natural grass.59
difference in the rate of injury.55 It is likely that a combination of
North American football cleat de- factors has led to increased rates of
signs demonstrate significant vari- foot and ankle injury in athletes. Op-
ability in forefoot loading patterns timal shoe-surface interaction would
during cutting activities.56 Shoe wear allow for high friction and traction
is an important factor in injury pre- with low risk of torque-related in-
vention, and broad generalizations jury. The threshold for torque injury
are difficult. has yet to be determined, and there
In theory, high-top shoes offer in- remains a delicate balance between
creased support of the ankle liga- performance (ie, high traction coeffi-
ments.57 Perhaps as a compromise to cient) and risk (ie, excessive torque).
enhance player performance while Today, most competitive athletes
providing some additional ankle sta- seek high performance whenever
bility, mid height shoes have become possible. It is our responsibility as
554 Journal of the American Academy of Orthopaedic Surgeons
physicians to educate these athletes
on the medical risks of seeking per-
formance over safety.
Summary
Foot and ankle injuries in competitive
sports are prevalent and appear to be
increasing in number. Expanded report-
ing by sports governing bodies on ath-
letic injuries enables us to better recog-
nize and manage specific foot and ankle
injuries with a primary goal of efficient
and safe return to play. A thorough ini-
tial evaluation is the most important
part of care for any athlete. Close at-
tention to subtle examination findings
may help accurately identify injuries
such as turf toe, high ankle sprain, Lis-
franc ligament injury, and stress frac-
ture, for which early diagnosis and
management are paramount to success-
ful return to play. Investigators continue
to seek methods of protection for ath-
letes as their training and abilities con-
tinue to progress to new levels. It is im-
portant to keep in mind that, ultimately,
the athlete is a patient, and appropri-
ate care and long-term outcomes should
not be compromised by the pressure to
return to play.
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