Porter & Schon: Baxter's The Foot and Ankle in Sport, 2nd ed.

Section 5 - Athletic Shoes, Orthoses, and Rehabilitation

Chapter 29 - Epidemiology and management tips in the professional athlete

David A. Porter,Padraic Obma,
Larry L. Nguyen


CHAPTER CONTENTS

  

 

Introduction

  

 

Epidemiology

  

 

Turf-toe/hallux rigidus

  

 

Base of fifth metatarsal fractures/Jones fractures

  

 

Midfoot sprains/Lisfranc injuries

  

 

Navicular fractures

  

 

Medial ankle sprains/deltoid injuries

  

 

Lateral ankle sprains

  

 

High ankle sprains/syndesmotic injuries

  

 

Achilles tendinitis/rupture

  

 

Difficult injuries

  

 

Acknowledgments

  

 

Bibliography

Introduction

Athletic competition has become normative in culture today. People enjoy competing against a worthy rival in the name of sportsmanship, the thrill of pushing the limits of the human body, for fitness, for the thrill of victory, and more recently as a full-time career. Evaluation and management of the elite athlete has been covered in Chapter 1 . Foot and ankle injuries are among the most common maladies that plague the elite athlete. In professional sports, these injuries can result in the inability to participate and hinder a team's chances for victory. For the individual, a prolonged recovery can lead to loss of playing time, a depressed sense of worth, an inability to contribute, and even a substantial loss of revenue, while jeopardizing a career.

As more emphasis is placed on professional and intercollegiate athletics, awareness has heightened concerning the incidence of foot and ankle injuries in these elite athletes. The injuries in the elite athlete are similar to those seen in recreational and lower-level competitive athletes, but the demands can be greater and the ramifications more profound. This chapter is intended to provide information on the epidemiology of sport-specific foot and ankle injuries, to facilitate and guide physicians, physical therapists, athletic trainers, and students in the recognition of foot and ankle injuries in this specific population. Our hope is that this information will help providers be more aware of the common and unique injuries encountered by professional athletes in their sport. This chapter will not delve deeply into treatment protocols because the previous chapters have attempted to cover treatment in far greater depth than merited here. This chapter, however, does comment on the epidemiology of sport-specific foot and ankle injuries and addresses some thoughts on the management of such injuries in the professional athletes. The management comments come from the senior author (D.A.P.). We are indebted to the professional trainers for their cooperation and contributions to this chapter (see later).

 

Epidemiology

To ascertain the occurrence and sport-specific injuries in professional athletes a survey was delivered to the head athletic trainers of each professional team in the National Football League (NFL), the National Basketball Association (NBA), Major League Baseball (MLB), the National Hockey League (NHL), and Major League Soccer (MLS). Thirty-four of 132 surveys were returned: 2 NFL, 7 NBA, 13 MLB, 8 NHL, and 4 MLS. The following head athletic trainers responded for their respective teams.

NFL

Cincinnati Bengals

Paul Sparling

New Orleans Saints

Scottie Patton

NBA

 

Atlanta Hawks

Wally Blasé

Charlotte (New Orleans) Hornets

Terry Kofler

Golden State Warriors

Tom Abdenour

Los Angeles Lakers

Gary Vitti

Milwaukee Bucks

Troy Wenzel

Orlando Magic

Ted Arzonico

Utah Jazz

Gary Briggs

MLB

 

Anaheim Angels

Ned Bergert

Arizona Diamondbacks

Paul Lessard

Baltimore Orioles

Richie Bancells

Chicago White Sox

Herm Schneider

Colorado Rockies

Tom Probst

Florida Marlins

Larry Starr

Houston Astros

Milwaukee Brewers

Roger Caplinger

Montreal Expos

Ron McClain

New York Yankees

Gene Monham

Oakland Athletics

Larry David

Texas Rangers

Danny Wheat

Toronto Blue Jays

Scott Shannon

NHL

 

Buffalo Sabres

Jim Pizzutelli

Columbus Blue Jackets

Chris Mizer

Dallas Stars

Dave Suprenant

Minnesota Wild

Don Fuller

Montreal Canadiens

Graham Rynbend

Phoenix Coyotes

Gord Hart

San Jose Sharks

Ray Tufts

Tampa Bay Lightning

Dave Boyer

MLS

 

Chicago Fire

Rich Monis

Colorado Rapids

Theron Enns

DC United

Rich Guter

New England Revolution

Mike Fritz

 

 

The participants responded to a list of questions about foot and ankle disorders in the professional athlete. This included a survey of the most common foot and ankle injuries in the trainer's sport and a series of questions about treatment and rehabilitation protocols for the more occult and controversial foot and ankle maladies. The specific topics about which we inquired were turf-toe, base of fifth metatarsal/Jones fractures, midfoot sprains/Lisfranc injuries, navicular fractures, medial ankle sprains/deltoid injuries, lateral ankle sprains, high ankle sprains/syndesmotic injuries, and Achilles tendinitis/rupture. Also, the head athletic trainers were asked about their anecdotal experiences with their most memorable/difficult/unusual professional athletic injury.

The 34 participants were asked to list the five most common foot and ankle injuries treated among their professional athletes. Equal weight was given to all responses, whether listed first or last, and to each responder. The results are listed below. The results also were subdivided among each particular sport and are plotted in Figs. 29-1, 29-2, 29-3, 29-4, and 29-5 [0010] [0020] [0030] [0040] [0050].

 
 

Figure 29-1  The most common injuries reported among football players were turf-toe or hallux rigidus, plantar fasciitis, and lateral ankle sprains (two responses each). Additional responses include corns and callosities, medial ankle sprains, syndesmotic injuries, and Achilles tendinitis.

 

 

 
 

Figure 29-2  Basketball injuries were noted to include lateral ankle sprains (8), plantar fasciitis (7), corns/calluses (6), ingrown toenails (4), and Achilles tendinitis (4).

 

 

 
 

Figure 29-3  Baseball injuries most commonly were plantar fasciitis (11); lateral ankle sprains (10); and ingrown toenails, corns/calluses, and shin splints (9 each).

 

 

 
 

Figure 29-4  Hockey players were reported to incur injures commonly related to skatewear and trauma such as ingrown toenails (6), corns/calluses (5), lateral ankle sprains (5), toe fractures (4), and high ankle/syndesmotic sprains (4).

 

 

 
 

Figure 29-5  Soccer injuries most commonly were subungual hematomas, midfoot sprains, medial ankle sprains, lateral ankle sprains, and high ankle/syndesmotic sprains (2 each).

 

 

The five most common foot and ankle injuries (and the number of responses) were lateral ankle sprains (27), plantar fasciitis (21), corns and callosities (21), ingrown toenails (20), and Achilles tendinitis or ruptures (12). Additional injuries listed (in descending number of responses) include subungual hematomas (10), shin splints (10), medial ankle sprains (9), syndesmotic sprains (9), hallux rigidus (7), base of fifth metatarsal fractures (7), phalangeal fractures (5), leg contusions (5), metatarsal fractures (3), Lisfranc/midfoot sprains (3), ankle fractures (2), metatarsalgia (1), interdigital neuromas (1), medial malleolus fractures (1), and heel exostosis (1). Thus there were nearly equal numbers of injuries among the foot and the ankle. Also, one notes that the severity of the injuries can extend from a subungual hematoma or callus to a fracture dislocation of the ankle or foot. Thus the provider must be well versed in a variety of foot and ankle injuries that can be both a real nuisance (ingrown toenail) to a career-threatening syndesmotic ankle injury. We hope that the first 28 chapters addressed these injuries and ailments to you, the reader, in a satisfactory fashion. This chapter focuses specifically on the professional athlete.

 

Turf-Toe/Hallux Rigidus

Turf-toe involves a severe dorsiflexion injury to the great toe metatarsophalangeal (MTP) joint as described in Chapter 18 . Other, less common mechanisms include varus/valgus stresses resulting in a combined turf-toe and “traumatic bunion.” The joint capsule is strained, the plantar plate can be stretched, and the articular cartilage can be contused and lead to long-term joint arthrosis. These injuries are commonly described in football, with hard turf and flexible shoes increasing the incidence. This can be quite debilitating, with long periods of recovery, especially if the plantar plate is disrupted. One can imagine the difficulty in a football player dependent on push-off if there is significant limitation of motion and loss of power. Turf-toe (hyperextension with primary plantar soft-tissue injury) does occur in other sports but is much less frequent and typically is less severe. That being said, we have treated a Division I baseball pitcher who suffered a complete plantar plate disruption coming off the mound to field the ball, necessitating surgical repair. He is now in the minor leagues pitching without pain.

Hallux rigidus is arthrosis of the first MTP joint and is characterized by a painful loss of motion (extension) with the formation of prominent dorsal osteophytes. The cause is multifactorial, but it is considered a degenerative process.

Twenty-six athletic trainers from all the sports polled responded with their experiences with hallux rigidus. Baseball injuries consisted of acute hyperdorsiflexion injury to the great toe MTP joint caused by stepping on the front edge of the base or running into a wall or by an exacerbation of a chronic condition from push-off running. Basketball players commonly were injured acutely from sudden stops or jumps causing hyperdorsiflexion of the great toes. Football trainers described the classic hyperextension injury to the great toe as a player pushes off on the playing field or another player lands on the injured player's heel with the athlete's great toe extended and the foot in equinus. Hockey injuries were less common; some were associated with off-the-ice workouts.

Turf-toe and hallux rigidus commonly were treated nonoperatively with taping, ice, anti-inflammatories, steroid injections, iontophoresis, and electrical stimulation. Full-length or extended shank, rigid orthotic inserts, and shoewear modifications were key elements of conservative treatment. Return to play was based on being pain free and having stable, full range of motion and the ability to perform with an orthotic insert and modified shoewear. A sports-specific functional assessment examination also was used as a criterion for return to sports. In general, the period of recovery lasted from weeks to months, depending on the degree of the turf-toe injury or the extent of arthrosis. Chronic aggravating symptoms may persist for several months, and a severe turf-toe injury can be career threatening.

Hallux rigidus has rarely been career ending. We have noted some football players who were able to compete at a very high level for several years without surgical intervention yet with profound arthrosis. For the athlete who requires surgery, we prefer a combined cheilectomy and dorsal proximal-phalanx closing-wedge osteotomy (Moberg) for the athlete with dorsal spurs, early joint space narrowing and limited extension (≤60 degrees). We believe that the health providers should be aggressive with turf-toe injury management whether the approach is nonoperative treatment or operative. We favor anatomic repair for magnetic resonance imaging (MRI)-documented plantar plate rupture and for athletes with acute proximal migration of the sesamoids on weight-bearing radiographs.

The trainers reported surgical experience in three cases of turf-toe, from two baseball trainers and one soccer athletic trainer. It was reported that these surgeries were performed after a period of conservative treatment. Injuries involved a disruption of the plantar MTP soft tissues that required surgical reconstruction of the plantar complex. Return to play was allowed after 10 to 12 weeks of immobilization followed by aggressive physical therapy (PT) and range of motion. The trainers did not relate experiences with surgery for hallux rigidus.

 

Base of Fifth Metatarsal Fractures/Jones fractures

Base of the fifth metatarsal fractures occur commonly with foot-twisting injuries. There are two basic fracture patterns seen. The first and most common pattern is an avulsion fracture off of the proximal tuberosity. The pull of the peroneus brevis tendon insertion and, perhaps more truly, the insertion of the lateral plantar fascia and abductor digiti minimi to the base of the fifth metatarsal can avulse a fragment of bone and can be treated nonoperatively in almost all instances, even in the professional athlete. Less common but more debilitating are the metaphyseal-diaphyseal transverse fractures or true Jones fractures that occur at the vascular watershed area of the fifth metatarsal (see Chapters 3 and 4 [] [] ). It can appear as an acute injury or as a chronic stress fracture. This fracture occurs in a location with less than optimal perfusion and requires a longer healing time. Fracture healing can be unreliable, especially when treated nonoperatively.

Twenty-two professional athletic trainers describe their experiences with base of the fifth metatarsal fractures and Jones fractures. Five baseball injuries resulted from inversion-plantarflexion midfoot twisting injuries associated with running on inclined uneven surfaces such as running the bases. The two football injuries occurred with ankle inversion injuries and direct trauma/supination of the foot. Seven basketball injuries are reported. Some trainers relayed the more common acute inversion sprain injuries, yet in basketball these fractures were more commonly a result of overuse jumping and running and appeared more commonly as stress fractures of the fifth metatarsal. Two soccer injuries also represent a mix of acute trauma and stress reactions associated with running the playing field. Six hockey players reportedly suffered a fifth metatarsal injury, with the majority of injuries occurring with direct blows to the foot from puck impact trauma.

Treatment options depended on the type of fracture. The more common avulsion fractures were treated symptomatically with rest, ice, compression, elevation, and taping. Immobilization in a walking boot or cast was indicated for more comminuted, more painful injuries or mildly displaced fractures. Surgical treatment, including open reduction internal fixation, was reserved for intra-articular fractures displaced more than 2 to 3mm or Jones fractures.

The trainers responding had many experiences related to base of the fifth metatarsal fractures. Baseball injuries were commonly treated nonoperatively with PT and taping. Football injuries were treated more aggressively with casting or surgical intervention because of the more forceful nature of the trauma. Basketball injuries also were treated aggressively with rest, immobilization, casting, PT, and orthotics to allow return to play. One trainer described the use of a bone stimulator device to hasten fracture healing. Many basketball injuries were treated operatively to shorten the disability period and presumably because of a higher incidence of Jones fractures in these athletes. Soccer injuries were treated with a mixture of nonoperative and operative interventions. One soccer trainer describes “inosine treatment.” Hockey trainers described a variety on nonoperative measures that included casting, taping, elastic braces, and modified shoewear. PT modalities included ultrasound, cryotherapy, iontophoresis, whirlpools, microcurrent treatments, and bone stimulators. One can see that there will be a variety of approaches encountered even when dealing with the professional athlete and fifth metatarsal injuries. Since this survey was completed, we see the use of a bone stimulator becoming almost routine in all fifth metatarsal fractures, whether an avulsion or in conjunction with operative treatment for Jones fractures. We favor operative treatment with a 4.5 to 6.5 intramedullary screw for all Jones fractures in the professional athlete and nonoperative boot immobilization for the avulsion fracture. There should be greater than 95% healing in both cases with this treatment.

 

Midfoot Sprains/Lisfranc Injuries

Sixteen professional athletic trainers relayed their experiences with midfoot injuries. Four baseball injuries resulted from sudden trauma to the foot's being caught in unusual positions, whether plantarflexion-inversion or dorsiflexion-eversion. Two football injuries resulted from a forceful heel impact to the plantarflexed foot. Four basketball injuries consisted of sudden unusual positions of the foot in a sudden sprint, landing, or stepping on another player's foot. Three soccer injuries resulted from an opponent's strike to the unsuspecting player with the foot planted. Two hockey injuries occurred on dry land exercises.

Experiences from the responding trainers varied widely. Immobilization with a walking boot occasionally was used, depending on the severity of the injury, by one baseball, two football, and two soccer trainers. It seemed that hockey players were allowed sooner return to sports, possibly because of the more supportive nature of the ice skate. In general, athletes were allowed return to play with a pain-free full range of motion and the ability to perform with an orthotic insert and modified shoewear. The ability to function at a tolerable level of comfort and to run, in addition to undergoing a sport-specific functional assessment examination, were criteria used to judge return to sports by these trainers. A grading system was used by one football trainer that encompassed a grade 1 sprain requiring 4 to 6 weeks of rehabilitation, grade 2 sprain requiring 8 to 12 weeks, and a grade 3 sprain requiring 12 to 24 weeks of immobilization/rehabilitation. Depending on surgeon preference and radiographic evidence of stability or bony union, if a fracture was involved, screws were removed 12 to 16 weeks after surgery and the patient was given arch supports and a rigid-soled shoe.

Surgical intervention for Lisfranc injuries was reported infrequently. One baseball trainer reported surgery for a prolonged duration of symptoms. Two football trainers and one basketball trainer related surgery for displaced injuries (presumed midfoot dislocation). The hardware commonly was removed at 3 to 6 months. Baseball players and football players did not return to play the same season.

We favor an aggressive approach to this injury. We believe that complete disruption of the midfoot ligaments requires surgical anatomic stabilization with 4.0- to 4.5-mm screws to decrease the risk of a career-threatening chronic ligament insufficiency, arch collapse, and pain. Either evidence of widening of the interval between the medial cuneiform and base of the second metatarsal on weight-bearing radiographs or MRI evidence of the tarsometatarsal ligament disruption is an indication to operative stabilization. Close reexamination with weight-bearing radiographs weekly also is required for the “stable” midfoot sprain to ensure maintained anatomic alignment because late diastasis (1-4 weeks post injury) can occur. Further information can be found in Chapter 5 .

 

Navicular Fractures

The most common types of navicular fractures seen in athletics are dorsal chip avulsion fractures and stress fractures. The navicular stress fracture is discussed in Chapters 3 and 4 [] [] . Avulsion fractures from the dorsal lip are the most common type of navicular fracture. They usually are related to excessive plantarflexion forces with eversion or inversion components. The avulsion fracture normally is easily recognized on a lateral radiograph of the foot. Stress fractures usually present with insidious onset and pain related to activity and have become recognized more commonly in the last 10 years. The navicular stress fracture is easily missed on initial examination because the fracture often is not visible on routine foot radiographs. The posterior tibial tendon insertion onto the medial navicular tuberosity provides a traction point for midfoot twisting injuries and the medial anchoring point for dorsal stress. The bifurcate ligament attachment on the lateral navicular is the lateral anchoring point for dorsal tension stress. The dorsal tension created by these opposing forces results in the fracture's perpetuating from the dorsal articulation with the talar head. The palpable pain is noted dorsally on the navicular just lateral to the anterior tibial tendon insertion (“N” spot).

Eleven trainers described experiences with navicular fractures. In baseball, one trainer described a plantarflexion twisting injury during a throw. Two other cases were described as an overuse phenomenon to an accessory navicular and a stress fracture from running the bases. One football injury was described as an overuse stress reaction. Basketball players incurred injuries from poor foot mechanics, pes cavus anatomy, and overuse. Hockey and soccer players suffered navicular fractures as a result of a direct blunt trauma (four cases).

Conservative treatments reported consisted of orthotics and modified shoewear to accommodate the stresses of the midfoot arch for stress and overuse injuries. Direct trauma and acute fractures were treated with immobilization in a boot, cast, or ankle-foot orthosis (AFO) with a period of rest. Return to play generally was directed toward an asymptomatic ability to play. When the players were pain free with provocative testing, they were allowed return to sports. For a direct traumatic injury, this generally took 7 to 10 days of initial immobilization followed by 2 to 3 weeks of PT strengthening and proprioceptive retraining with accommodative arch supports. Navicular fractures can cause prolonged pain and an extended duration for recovery. Three athletes required 2 to 3 months for recovery and still played through enduring pain. This was seen most commonly in basketball players.

Two players required surgical intervention. One baseball player had prolonged symptoms greater than 6 months and underwent surgery to return to play in 6 to 8 weeks. One basketball player underwent surgery after a computed tomography (CT) scan identified a displaced fracture and returned to play after healing and pain-free rehabilitation. Presumably these two athletes had a navicular stress fracture.

Our approach to the dorsal lip chip fracture commonly is nonoperative. We see a lot of athletes with this on routine radiographs. It is important to rule out a navicular stress fracture if the pain is not associated with acute trauma. We use CT radiography to ensure that there is not an associated stress fracture. Only occasionally is there a need to remove the symptomatic dorsal chip fracture. Navicular stress fractures should be treated aggressively with either nonoperative immobilization and/or screw fixation (4.0-5.0 screws). With either approach, the athlete will have to be nonweight bearing for 6 weeks. We have taken a more aggressive surgical approach with screw fixation because we note about 90% success with operative fixation and only 70% with nonoperative treatment. We have moved away from bone grafting in most of our operative cases unless there is significant cyst formation or significant “displacement” (≥2mm).

 

Medial Ankle Sprains/Deltoid Injuries

Twenty-nine trainers described their experience with medial ankle injuries. (See Chapter 13 for a more exhaustive discussion of this injury.) Ten baseball trainers described most commonly an ankle trauma as a result of running the bases with an eversion axial-loading injury. Football injuries occurred as a result of a plantarflexion external rotation injury (pile-up or chop block). Basketball players routinely described an eversion injury related to stepping on another player's foot. Soccer players most commonly suffered an eversion injury as a result of an opponent player's applying a laterally directed force to the planted foot. Hockey players experienced a plantarflexion-eversion twisting injury during play of having the skate caught in the ice or on the puck.

The cornerstone of treatment was nonoperative, consisting of rest, ice, compression, taping, and elevation during the initial 2 to 3 days. Anti-inflammatory medications were prescribed along with PT early range of motion protocols. PT modalities included pulsed ultrasound, electrical stimulation, cold therapies, proprioception, and strengthening programs. Most athletes were placed in removable, prefabricated walking boots, and rarely was casting immobilization used. Orthotic shoe inserts were used commonly, especially in basketball, to help support the medial arch and counteract pronation. Criteria for return to play were based on a pain-free range of motion with no swelling or symptoms related to stress testing, such as a single-leg stance or hop. Grading systems similar to lateral ankle sprains were used. Grade 1 injures required 2 to 4 weeks of rehabilitation. Grade 2 injuries required 3 to 8 weeks. Grade 3 injuries required 8 or more weeks. The ability to return to sports was determined by a pain-free full range of motion and a functional assessment based on sport-specific task exercises.

One football player required operative repair of the medial deltoid ligament in association with a mortise dislocation and widening. He was allowed return to sport after full range of motion and pain-free sport-specific activities. The time to return was not reported.

We most commonly see medial ligament injury in association with either a syndesmosis injury or fibula fracture. Isolated medial deltoid ankle injury mechanisms are as described by these trainers. We have had to repair only two isolated deltoid ligaments in the competitive athlete. Chronic medial ligament insufficiency is a very difficult problem to treat, so we are aggressive with repair if the ligament is disrupted in a professional athlete. This is most commonly associated with operative fixation of a fibula fracture.

 

Lateral Ankle Sprains

All the professional athletic trainers responded with their experiences involving lateral ankle sprains. The lateral ankle sprain continues to be the most common sports injury, as noted by these results, and is discussed in more detail in Chapter 12 . Operative management is discussed in Chapter 13 . Baseball injuries commonly were related to plantarflexion inversion injuries. This injury occurs during the course of running in the outfield to catch a ball or running around the bases. Basketball injuries notoriously resulted from stepping on another player's foot or landing awkwardly. Football injuries occurred with the foot planted and the player twisting and rolling to the ground. Soccer-player injuries happened as a mixture of all these. Hockey injuries were caused as the skate was caught in the ice or were reported as a common plantarflexion inversion injury during on- or off-the-ice training.

The treatment of lateral ankle sprains was determined by severity of injury and length of symptoms. Initial treatment of acute injury involved protection, rest, ice, compression, and elevation (PRICE) to limit the extent of injury, control edema, and minimize pain. A regimen of anti-inflammatory drugs commonly was used. After the initial treatment, strengthening exercises were initiated, concentrating on the peroneal muscles and dorsiflexors. This was followed by proprioception exercises, functional conditioning, and endurance training, then by return to play when asymptomatic. Indications for surgery in the acute phase are controversial.

Responding trainers relayed that conservative treatment consisted of rest, ice, compression, taping, and elevation during the initial 2 to 3 days. Anti-inflammatory medications were prescribed, along with PT early range-of-motion protocols thereafter. PT modalities included pulsed ultrasound, electrical stimulation, edema control, cold therapies, and proprioceptive and strengthening programs. Most athletes commonly were placed in removable, prefabricated splints, and rarely was casting immobilizations used. Grading systems were used. Grade 1 sprains were allowed to continue play as tolerated to pain with anti-inversion taping and modified shoe inserts. Grade 2 sprains were treated with variable periods of restriction for 1 to 3 weeks. Grade 3 sprains required 3 to 5 weeks of immobilization and activity limitations. Football injuries were treated more conservatively, with a 1- to 2-week longer period of restrictions, presumably because of the greater amount of forceful contact used on the field of play. The criteria for return to play consisted of pain-free full range of motion; ability to perform a balanced, single-leg stance; and completion of a sport-specific function assessment test.

No cases of surgical intervention were presented for acute lateral ankle sprains.

We are aggressive with intermittent immobilization, cold compression therapy (Aircast Cryocuff, Summit, NJ), and aggressive PT. We are happy to use the expert and available training staff employed by the professional teams. The PT opportunities available enable a quicker return to play. We encourage use of the boot immobilization at night (when relaxation of the muscles and nonweight bearing lead to a position of plantarflexion [PF] and inversion) for 4 full weeks but allow daily activities in a stirrup brace as soon as the ankle is stable to talar tilt on clinical examination (1-3 weeks). We operate on acute routine lateral ankle sprains only if there is an associated osteochondral fracture requiring fixation.

 

High Ankle Sprains/syndesmotic injuries

Twenty-two professional athletic trainers reported their experiences with high ankle sprains. High ankle sprains are discussed in Chapter 13 . Baseball injuries were a result of unusual positioning of the foot (presumably dorsiflexion and eversion) as an unexpected force was applied. This occurred often as players collided into one another as an opponent was sliding into a baseman or suddenly misstepping on uneven surfaces. Football injuries were reported with the classic plantarflexion (or dorsiflexion) external rotation injury and a pileup. Basketball injuries occurred with stepping on another player's foot. Soccer injuries happened as an opponent slid into the player. Hockey injuries occurred as the player's foot was suddenly plantarflexed into the ice and a rotational force applied.

According to respondents, high ankle sprains were treated nonoperatively in similar fashion to lateral ankle sprains. Conservative treatment consisted of rest, ice, compression, taping, and elevation during the initial 2 to 3 days. Anti-inflammatory medications were prescribed along with PT early range of motion protocols thereafter. PT modalities included pulsed ultrasound, electrical stimulation, and proprioceptive and strengthening programs. Most injuries commonly were placed in removable, prefabricated splints, and rarely was casting immobilization used. High ankle sprains reportedly were treated more conservatively (regarding return to play) than their lateral ankle injury counterparts, with an initial period of protective, partial weight bearing. Grading systems again were used. Grade 1 sprains were protected for 3 to 6 weeks. Grade 2 sprains were treated with variable periods of restriction for 6 to 12 weeks. Grade 3 sprains required more than 3 months for return to play. Athletes were allowed return to play after a pain-free full range of motion, a painless external rotation or compression testing, and a sports-specific functional assessment examination.

Two football trainers and one baseball trainer described experiences with operative repair of syndesmosis injury. The indication for operative fixation depended on the severity of the injury and the degree of joint displacement. Two compression screws commonly were used to support the syndesmosis and commonly were removed at 12 weeks after the initial surgery.

We believe that operative fixation is optimal for grade 2 (occult complete disruption), grade 3 (overt dislocation of the tibia fibula interval and deltoid), and Maisonneuve injuries. Chronic and incompetent syndesmosis injuries can be career threatening, and thus stable, anatomic alignment must be obtained and maintained.

 

Achilles Tendinitis/Rupture

Achilles tendon injuries can plague the elite athlete. Injuries include tendinopathy, insertional problems (bursitis and tendinopathy), and complete rupture (see Chapter 7 ). Acute ruptures can result in a long period of rehabilitation, and have the potential for long-standing weakness. Acute and chronic Achilles tendinitis, usually the result of an overuse injury, can be a chronic nuisance injury resulting in suboptimal performance.

All 26 professional athletic trainers described their experiences with Achilles tendon disorders. Baseball injuries ranged from the acute traumatic eccentric ankle dorsiflexion injury to the recurrent aggravation of preexisting chronic tendinitis associated with running the bases and overuse. Occasional injuries occurred early in the season with poor conditioning and foot mechanics from the off season. Football and basketball injuries occurred with sudden push-off explosive jumping forces and overuse stress phenomenon. Soccer injuries more commonly were listed as repetitive stress injuries exacerbated by push-off drills and backpedaling. Hockey injuries were seen with sudden eccentric contraction during loading for push-off. One trainer described an acute laceration from another skate blade.

Achilles tendinitis injuries were commonly treated nonoperatively with PT, stretching, proprioceptive training, and taping modalities (avoiding extremes of dorsiflexion). Orthotic inserts and heel lifts commonly were prescribed but quickly discontinued in most cases to “avoid contracture.” Rarely were casting and immobilization used for more acute Achilles tears. Chronic injuries may benefit from hydrotherapy, whirlpools, and electrical stimulation. Football injuries are treated more aggressively with immobilization, night splints, and anti-inflammatory medications. Athletes were allowed return to play after a pain-free examination and full range of motion. A sports-specific functional assessment test with the ability to run, jump, and weight bear with multidirectional take-off exercises defined the level of proficiency at which the player may return to the field. Occasional chronic irritation and the ability to play through mild soreness may be required of the chronic injury. Acute ruptures required several months of recovery with intense therapy before obtaining a suitable level of function for play.

Surgical intervention is required with a complete rupture and occasionally chronic, debilitating tendinitis. Fourteen trainers described their experiences with operative intervention in the elite athlete. Most commonly, acute complete and high-grade partial ruptures confirmed by a positive Thompson's test and MRI scan warranted operative intervention in the professional athlete. One baseball trainer cited an instance of nonoperative casting for an Achilles tear necessitating 9 to 12 months of rehabilitation before return to play. One baseball trainer and one basketball trainer described episodes of operative treatment of chronic Achilles tendinitis (insertional) with Hagland's deformity. Surgical rehabilitation generally requires 12 to 16 weeks of rehabilitation before achieving a pain-free range of motion and the ability to return to sports.

We believe that complete ruptures of midsubstance or insertional avulsion have a better chance of full recovery and a lower rerupture rate with operative repair. We tend to be aggressive with repair in the professional athletes but tell trainers, athletes, and management that the time to return to play can be 6 to 12 months. We have only occasionally had to operate on insertional tendinitis in the professional athlete and prefer a posterior tendon-splitting approach to disrupt as little of the tendon insertion as possible. With localized debilitating pain, this approach lets us get to problem with minimal incisions and maximal benefit. We have not had to operate on midsubstance tendinosis in the professional athlete despite a common experience in the nonprofessional, middle-aged athlete.

 

Difficult Injuries

The professional athletic trainers polled were polled about the most difficult/memorable/unusual foot and ankle injury they had experienced in the past 5 years. Six trainers cited chronic plantar fasciitis and heel pain as the most recalcitrant injury poorly amenable to rehabilitation. Six trainers listed high ankle syndesmotic sprains as difficult to treat, inasmuch as two players had required surgery for prolonged symptoms and all the players required a lengthy respite from play, often frustrating the players. The high ankle sprains would reach a plateau of recovery before recurring setbacks in progress. Four trainers cited Achilles tendon rupture for their magnitude of injury and the prolonged rehabilitation period following surgical intervention. Both football trainers and one baseball trainer mentioned Lisfranc fracture/dislocations on the basis of the severity of the injury, with multiple tarsal joint involvements, necessitating surgery and prolonged periods of recovery. One soccer trainer mentioned Lisfranc fracture/dislocation for its subtle appearance and difficulty in diagnosing the occult injury, which further prolonged the return to play. Three trainers listed navicular stress fractures as their most intriguing injuries because of their gradual symptomatic onset and the moderate workup for midfoot pain before the detection of this injury. Two lateral ankle sprains developed recurring symptoms that plagued the player but were treated with taping and never underwent surgical intervention. One lateral malleolus refracture in a hockey player was under constant stresses from ice skating. One medial malleolus fracture was listed. One medial malleolar fracture developed a nonunion that required multiple surgeries and bone grafts and had an associated talar osteochondral lesion that prolonged the recovery process. Three episodes were cited of base of the fifth metatarsal fractures—one nonunion, one revision surgery, and one somewhat humorous episode of falling after being bitten by the pet dog.

As professional and recreational sports become a more integral part of our society, more athletes will experience these common and uncommon injuries. The rehabilitation of the elite athletes related to our readers by the experiences of the contributing professional athletic trainers will, we hope, aid in expediting the recovery of future players. We hope that this chapter has helped you to be on guard concerning these common and difficult foot and ankle injuries in professional athletes. We also hope that the management pearls aid you in making decisions and in educating the ever-concerned athlete.

 

Acknowledgments

We acknowledge Sara Carpenter, MS, PT, OrthoArkansas, PA and Josh Landers, DPT, OrthoArkansas, PA.

 

Bibliography

Mizel 1998. In: Mizel MS, Miller RA, Scioli MW, ed. Orthopaedic knowledgeupdate foot and ankle, 2. Rosemont, IL, AAOS, 1998.

Nunley 2002. Nunley JA, Vertullo CJ: Classification, investigation, and managementof midfoot sprains.  Am J Sports Med  2002; 30:871.

Nussbaum 2001. Nussbaum ED, et al: Prospective evaluation of syndesmotic ankle sprainswithout diastasis.  Am J Sports Med  2001; 29:31.

Paavola 2002. Paavola M, et al: Achilles tendinopathy.  J Bone Joint Surg Am  2002; 84A:2062.

Porter 2002. Porter DA: Ligamentous injuries of the foot and ankle.   In: Fitzgerald, Kaufer, Malkani, ed. Orthopedics,  St Louis: Mosby; 2002.

Vanore 2003. Vanore JV, et al: Diagnosis and treatment of first metatarsalphalangealjoint disorders. Section 2: hallux rigidus.  J Foot Ankle Surg  2003; 42:124.

Yoshino 2001. Yoshino N, et al: Bilateral isolated tarsal navicular fracture dislocation: acase report.  J Orthop Trauma  2001; 15:77.