By Sourendra Raut, M.D.
From ATLANTA Medicine, Vol. 86, No. 1
Foot and ankle injuries are common in both recreational and competitive athletes. As we encourage our patients to become more active, we will begin to see an increasing number of these ailments, both on the sideline and in our clinics.
At the collegiate level, ankle ligament sprains accounted for 14.9 percent of all injuries during practice and competition, a staggering number when compared to ACL tears (2.6 percent) and concussions (5.0 percent). At the high school level this is even more pronounced, with almost 40 percent of athletic injuries being to the foot and ankle.
The appropriate initial evaluation and management of athletic foot and ankle injuries is crucial to a successful recovery process, and the physician should be on the lookout for many serious and unique injuries for an accurate diagnosis.
When approaching the evaluation of an athlete with an injury in the foot and ankle, it is important to first localize the injured bony or soft tissue structures. This allows a focused physical examination and will assist in formulating a good differential diagnosis. It will also guide the need for further testing and radiographic studies.
The mechanism of injury often yields clues regarding the injured structures and the severity of the injury, including injuries to other parts of the skeletal system and body.
Another critical component of the initial evaluation is determining the timeframe for a safe return to play. This decision must take into account the severity of the injury, the sport, temporal issues and the level of competition.
Injury prevention is of vital importance when dealing with the athletic population, and it should be an integral component of training and education in all athletes. When specifically evaluating the foot and ankle, one should begin by observing the patient’s gait, following this with a thorough exam of the patient’s ankle strength in inversion, eversion, plantar and dorsiflexion. Range of motion of the hind foot and forefoot joints should be performed, as well as palpation for any points of tenderness. A detailed exam for any sensory deficits, loss of pulses and capillary refill should be included in every physical exam.
Special attention should be paid to four specific injuries that are frequently seen and often missed when evaluating foot and ankle injuries in the athlete. These include the turf toe injury, ankle sprains (specifically high ankle sprains), Lisfranc injuries and stress fractures.
The classic turf toe injury is caused by a hyperextension of the big toe metatarsophalangeal joint (MTP). The classic mechanism of injury consists of a direct axial stress on the heel when the foot is in plantar flexion with the toe in dorsiflexion.
In this type of injury, the plantar ligament and capsule of the MTP joint are disrupted, which can often lead to joint instability. The incidence of this injury is increasing at all levels of competition. A recent study by Rodeo et al2 found that 45 percent of professional football players had experienced a significant turf toe injury.
Patients with this injury will frequently describe the aforementioned mechanism and complain of a difficulty with push-off activities and challenges with cutting drills. The keys to examining these injuries include evaluation of the MTP stability and flexion strength at the MTP joint.
Athletes presenting with this type of injury should get weight-bearing comparative radiographs of both feet. The position of the sesamoid bones should be carefully compared, with any proximal migration suggestive of a plantar capsule injury. Care should be taken to look for fractures of the sesamoid bones.
If differences in either the the position or the separation between the sesamoid fragments are noted, an MRI can often be a supplemental tool to assess the soft tissue structures.
Based on the severity, these injuries can be treated with simple immobilization in a hard-soled sandal, casting and protected weight-bearing or surgical approximation of the disrupted sesamoid bone.
A return to play is dictated by the severity of the injury but can extend all the way up to 4 to 6 months post-injury.
There are two major categories of ankle sprains: inversion and eversion sprains. Inversion sprains are the most common injury in competitive athletics and usually involve injuries where athletes report having “rolled” their ankle.
Athletes who can bear weight after such an injury and can demonstrate running, cutting and jumping techniques can return to sports immediately. If they can’t do these things, then further evaluation is necessary.
Inversion injuries are associated with copious acute swelling and bruising anterolateral in the ankle. These injuries can be classified into three grades depending on severity. Grade 1 injuries result from a stretched lateral ligament, grade 2 injuries are due to a partial tear of the ligament and grade 3 injuries consist of a complete tear of the ligaments.
A patient’s clinical presentation mimics the severity of tear, with grade 1 injuries resulting in swelling and pain but ability to weight bear, while grade 2 and 3 injuries often present with increased swelling and impaired ability to walk.
The initial management of these injuries consists of rest, ice, compression and elevation. Immobilization for a short period of time in a walking boot, followed by early mobilization with lace-up brace support and directed rehabilitation is the mainstay of treatment for these injuries.
The vast majority of people with this type of injury recover with non-operative management within an 8-week time frame. Those that do not often need an MRI for further evaluation, with the possibility of requiring surgical intervention to stabilize the ligamentous structures.
Eversion injuries are more commonly known as high ankle sprains or syndesmosis injuries. These are rarer injuries, occurring only 1 percent of the time, but require a much longer recovery with a high incidence of residual symptoms.
The index of suspicion for these injuries should be higher in collision sports. The most common mechanism is direct contact to the leg with the foot fixed on the ground. This causes the knee to externally rotate, stressing the ligaments between the tibia and fibula.
For these injuries, one will find swelling or ecchymosis proximal to the ankle, and squeezing the fibula above the injury can elicit pain in these ligaments.
Radiographic imaging should be initially used, with care taken to look at the tibiofibular overlap on single leg standing ankle X-rays. MRI imaging can be helpful in demonstrating findings that are in keeping with a more subtle injury.
If radiographs show no widening, then the injury is considered stable and can be managed with immobilization until the patient is pain free, an expected recovery time for this lower level of injury. Hopping 15 times on the affected extremity is a good measure of when an athlete can return to play with such an injury.
If there is radiographic evidence of widening of the tibiofibular space or of the medial clear space in the ankle, surgery is the preferred method of treatment.
Return to play is often protracted with these injuries, often approaching 9 months for those treated operatively.
Tarsometatarsal Joint Injuries
Injuries to the tarsometatarsal joints (midfoot) in an athletic environment occur as a result of an axial loading mechanism. These injuries are often very subtle clinically and radiographically, and so a high index of suspicion is needed to appropriately treat them.
Most athletes will describe feeling a “pop” in the foot followed by great difficulty bearing any weight. When examining these patients, pain can be elicited with compression of the midfoot, twisting it or pushing the first ray dorsally or plantarly.
Weight-bearing radiographs of both feet should be obtained, and on these radiographs, there should be a displacement of >2 mm between the first and second metatarsal bases when compared to the opposite side. Sometimes a small fleck of bone can be seen arising from the lateral edge of the medial cuneiform or medial side of the second metatarsal base.
An MRI can be used to diagnose more subtle injuries if there are no findings on X-ray, but this investigative tool is not necessary if the X-rays show clear evidence of a diastasis.
The treatment of these injuries can range from non-surgical management for injuries showing no displacement on radiographs to surgical stabilization with plates and screws. The goal of surgery is to restore the normal anatomy of the affected joints and to preserve this anatomy until the body has a chance to heal the injuries.
These injuries require adherence to a strict protocol of non-weight bearing for 6 weeks, followed by progression of weight bearing with an arch support at 6 weeks. The typical return to sports is 4 months, although elite-level athletes will often need to wait a full year.
Stress fractures are the most common overuse injury seen in the athlete and can potentially be one of the most serious. The vast majority of these fractures involve the lower extremity, especially the tibia and bones of the foot.
These injuries are frequently seen in athletes who engage in repetitive activities, such as runners. If care is not taken to manage them appropriately, they may progress to full fractures or heal slowly.
Typical findings within a patient’s history that should lead one to think of a stress fracture include an increase in training intensity, major changes in a training program, changes in shoe wear and running on hard surfaces.
Three stress fracture patterns in particular are highly missed, and special care should be taken to evaluate for these injuries. They include navicular stress fractures, fifth metatarsal stress fractures and medial malleolar stress fractures. These three injuries are at the highest risk of progressing to a more complicated recovery.
Patients with stress fractures will frequently present with swelling and pain located in a specific part of the foot and ankle. A one-legged hop test may also elicit pain, as would percussion over the site of the injury.
It is not uncommon for plain radiographs to be negative with this type of injury, so one should have a very low threshold for obtaining further imaging, specifically an MRI that has a very high sensitivity and specificity. Once identified, a CT scan can often delineate any subtle displacement at the fracture site.
The vast majority of stress fractures can be managed non-surgically, either in a boot or cast with protected weight bearing for 6 to 8 weeks.
Impact activities should be avoided, but low-impact and limited weight-bearing activities like biking, swimming and elliptical machines can be used.
In the setting of recurrent or frequent stress fractures, nutritional considerations are important, specifically eating deficiencies that may predispose an athlete to repeatedly fracturing.
As more individuals become athletic, and as our high school and collegiate athletes get bigger, stronger and better conditioned, higher-energy injuries are becoming more common. Changes in shoe wear, from more robust, stiffer shoes to softer, lightweight flexible shoes also puts athletes at a greater risk of injury.
The physician taking care of the athletic patient has to act as an intermediary among multiple parties, including parents, coaches, teams and the athlete themselves, tempering expectations while still striving for the fastest return to activity.
Management of foot and ankle injuries in a highly active patient population therefore involves a delicate balancing act between aggressive rehabilitation and early return to sport while taking care not to compromise healing or long-term clinical outcomes in these patients.
The challenge is formidable, but with appropriate attention paid to all of the medical, social and environmental details surrounding an injury, the outcomes are generally quite rewarding.
References: Anderson RB et al. Management of Common Sports-related Injuries About the Foot and Ankle J Am Acad Orthop Surg 2010;18: 546-556