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

Section 1 – Athletic Evaluation

Chapter 1 - Assessment and treatment of the elite athlete: helpful hints and pertinent pearls

Donald Baxter,
Lew Schon



Look at the big picture



“Conservative treatment was exhausted” may mean only that the athlete and medical team were exhausted



Conservative care may not conserve resources



Patience and relative rest are virtues



Think about the nerves



The tarsal coalition can be the great masquerader



Timing should never be underrated



Location, location, location



Despite #8, it is better to be lucky than good



A quick fix may buy time



Sometimes it is better to go for the base hit



Plan twice, cut once



A stealthlike incursion should leave ne'er a trace



Minimize surgery and maximize recovery



Identify injuries that are at high risk for failure



A little instability can go a long way: keep both eyes open



When is it okay to “spare the rod and spoil the athlete”?



Work backward in establishing a return to sport protocol



Everyone loves a winner



It is better to have no publicity than bad publicity




Although this textbook contains sections on specific entities, there are broader themes that must be considered. The authors have compiled a list of their favorite pearls and highlighted them with case presentations. The list is by no means profound or comprehensive, but like a mantra recited during meditation, it still can be a source of inspiration or focus. These points cut across many situations and can facilitate the assessment and care of the elite athlete.

#1 Look at the Big Picture

The proper history and physical examination is completed by keeping the big picture in mind and obtaining contributory static and dynamic factors that affect the athlete. This approach includes appreciating the patient's experience with the condition or injury; the character of the symptoms; the duration and onset of the problem; aggravating and ameliorating factors; and a description of the specific offending activity. In addition, other general sports activities should be noted, such as details about the gear; the surfaces; the opponents, teammates, and partners (dance); and the sporting environment. Training factors should be documented, especially the duration, intensity, and frequency of events, as well as the warm up and cool down. Motivational drives and the way that the condition is perceived relative to future ambitions are enlightening. Nutritional issues, general health, medical history, medications, vitamins and supplements, and prior surgeries or traumas often may be revealing.

The physical examination should be performed accordingly, taking both wide and focused perspectives and juxtaposing the examination with static and dynamic appraisals. The athlete should be observed during normal standing, walking, and sitting, as well as running or performing the particular maneuvers of the sport or dance. The musculoskeletal system, especially the lower extremities, warrants evaluation, because any one area can affect the foot and ankle and the clinician may find clues that are useful to determining a diagnosis and treatment. The synthesis of these protean elements can be challenging but carries a high reward for observing the human body at its finest physical performance.


#2 “Conservative Treatment was Exhausted” may Mean Only That the Athlete and Medical Team were Exhausted

In treating the elite athlete, as with treating any athlete or patient, there is an evaluation process that must include conservative consideration of all options before invasive treatment may be instituted. The orthopaedic foot and ankle and or sports medicine subspecialist must know the condition, its etiology, and its natural course. Timing relative to the disease state and the activity requirements is critical and must influence the approach. Operative treatment might be considered with the elite athlete, whereas conservative treatment would be used with the high school athlete and nonathlete having the same problem. Although simple and complex nonsurgical techniques exist for every orthopaedic malady, do not assume that the solution was applied appropriately or completely for the elite athlete. Often, a thorough evaluation of the dynamic and static conditions that contribute to the problem has not been synthesized to design a customized, multitiered approach best suited to the individual. As with surgery, there are “tricks and moves” that can render the standard treatment into a tour de force cure. Often the effort, including reassessments and tweaking of the protocol, can be more laborious and frustrating than an operative endeavor. Finally, despite good intentions, it must be remembered that nonoperative treatment carries risks and can be considered a waste of valuable time and resources. It is the norm for multiple opinions to be offered regarding treatment of elite athletes, and it is preferable for everyone involved, including the team physician, agent, and so forth, to agree with the treatment recommended by the clinician.

With that said, the following cases illustrate straightforward and unglamorous conservative interventions that carried little risk but made a major, beneficial impact.

A Major League Baseball player presented with a chronic, overuse strain of his left great toe. He was a left-handed pitcher, and the left great toe was being subluxed into a lateral valgus position during push-off. The problem was diagnosed as a form of a turf-toe, more specifically a sprain of the medial sesamoidal phalangeal ligament and the medial head of the flexor hallucis brevis tendon. After talking to the trainer, agent, team doctor, and orthotist, we designed and custom made a spacer to fit between the great toe and the second toe. After a slow start to the season and requisite reassurance, the pitcher won 22 games using a simple device ( Fig. 1-1 ).


Figure 1-1  Hallux valgus toe spacer is a useful means of conservative treatment for a metatarsophalangeal (MTP) capsular or ligamentous injury.



Another Major League Baseball player had ankle and hindfoot symptoms that were felt to limit his hitting. The ankle and hindfoot examination was unremarkable, with good stability, alignment, and strength. An examination of the whole musculoskeletal system brought to light an obvious genu varus, which resulted in varus of the ankle and the subtalar joint. When watching him simulate his swing, we noted that his ankle would subtly invert. By placing an off-the-shelf lateral wedge into the shoe, the player was able to get a better stance and more stability while batting and was able to increase his batting average significantly, winning the major league batting title ( Fig. 1-2 ).


Figure 1-2  Several views of wedged heel shock absorbers, Anti-Shox™ by Apex (Teaneck, NJ).



A professional quarterback asked for the opinion of three foot and ankle subspecialists. His ruptured Achilles tendon had been repaired one season before the examination. The repair had stretched out and did not allow adequate push-off. After careful discussion by the three orthopaedists who saw the quarterback simultaneously, it was decided to treat the elongated and weak tendon conservatively with an ankle-foot orthosis (AFO). This AFO was made with a plantar assist by using an anterior tibial stop for the AFO ( Fig. 1-3 ). The Hall of Fame quarter back played three more seasons with a similar brace and never had additional surgery to the Achilles tendon.


Figure 1-3  The Toeoff splint made of carbon graphite (Camp Scandinavia, Helsingborg, Sweden). The Toeoff is an AFO with an anterior tibial shell connected to a foot plate. The brace is open posteriorly.



A top-level and highly paid National Basketball Association (NBA) star sustained within 1 year three sequential injuries to his Achilles tendon that were diagnosed as partial tears. Following each injury, addressed by brief bouts of conservative treatment (physical therapy [PT], nonsteroidal anti-inflammatory drugs [NSAIDs], and rest), he was aggressively encouraged to continue to play despite persistent pain, swelling, and dysfunction. His third injury during the playoffs was the most incapacitating, both physically and emotionally. He lost faith in his doctors, whom he felt had allowed him to be reinjured by trivializing his trauma as insignificant. Much to the frustration of the team management, doctors, and fans, he decided to wait for complete resolution of the swelling, pain, and weakness before resuming play and missed numerous games. Further opinions were sought to bring the situation to resolution. The nonsurgical solution that we initiated satisfied all parties and permitted return with protection. A flexible plastic molded poster shell AFO, fabricated for each game (to avoid sudden and potentially catastrophic fatigue failure of the device), reduced the strain on the Achilles tendon while allowing somewhat restricted and controlled mobility. With the device, he returned to play after a 6-month hiatus and experienced progressive restoration of confidence while the injury continued to heal ( Fig. 1-4 ).



Figure 1-4  AFO for Achilles tendinitis.  Courtesy of John Rheinstein CPO, New York, NY and Otto Bock Healthcare, Minneapolis, MN.



#3 Conservative Care may not Conserve Resources

Many stress fractures of the talus and other bones seen on magnetic resonance imaging (MRI) have healed after months of treatment but without surgery. Occasionally these fractures can become long, drawn-out, chronic affairs. The cost of a prolonged convalescence can be overwhelming to the athlete and the team. With this potential for a long recovery, it is typical to use a bone stimulator, despite uncertainty that one truly is needed. Thus whereas the cost may be prohibitive in the nonelite athlete population, it can be justified for the elite performer.

An example of the economic impact of the conservative option is provided. A 2-mm, displaced supination-eversion II fibular fracture occurred in a top-level National Hockey League player immediately preseason ( Fig. 1-5, A through C ). He had no deltoid or syndesmotic tenderness. There were concerns about potential hardware prominence interfering with the skate if an open reduction internal fixation (ORIF) were performed. This would delay return to play until after the hardware was removed. Given the nature of this injury to heal quickly and uneventfully, it was decided to treat the ankle fracture without surgery. The ankle was placed in a cast and the player was kept nonweight bearing for 6 weeks, then given a removable, off-the-shelf, boot brace. He resumed conditioning and ankle strengthening progressively with low-impact activity and then subsequently began skating. At 3 months, he still had tenderness, focal edema, and warmth, and could not skate aggressively or confidently enough to perform choppy sprints or to make quick stops and precision turns. He also was concerned about getting checked and sustaining a complete fracture. The x-ray and computed tomography (CT) scan ( Fig. 1-5, D ) performed at 3 months showed approximately 20% healing along the proximal posterior aspect. All parties were frustrated, and the team suffered without his talent. Treatments discussed included operative and nonoperative modalities. Among all parties—trainers, manager, team doctor, and the patient—it was agreed that we perform shock wave treatment of the delayed union with the Sonocur extracorporeal machine (which requires no local or general anesthetic), begin an EBI bone stimulator (EBI, Parsippany, NJ), and fabricate a custom-molded, plastic AFO that could be worn in a sneaker. The patient continued to advance in his low-impact skating and nonskating workout, using the brace and bone stimulator when not conditioning. By two additional months, the fracture had progressed to 60% healing and the symptoms had abated to allow return to aggressive skating during the playoffs ( Fig. 1-5, E and F ).



Figure 1-5  (A-C) Lateral, mortise, and anteroposterior (AP) radiograph of the initial supination-eversion severity rating II fracture in this professional hockey player. (D) The player was still symptomatic and a sagittal computed tomography (CT) scan at 3 months shows insufficient bridging of the fracture site. (E) Lateral x-ray at 5 months. (F) Sagittal CT scan at 5 months shows bridging of >60%.




#4 Patience and Relative Rest are Virtues

A world record holder in the 100 meters had plantar fasciitis and could not compete for 12 months. He cross trained with water running, biking, and lower impact activities to stay in shape. Ultimately, with the use of an Achilles stretching protocol, orthotic devices, and a night splint, the fascia finally healed and he recovered. It was a year filled with many office visits and requests for a quick fix. Great runners and elite athletes often find it difficult to be patient. No one knows when or if the condition will resolve. On our side is the knowledge that most cases of plantar fasciitis (more than 90%) respond to conservative modalities by 12 months. The risk of an unusual complication following plantar fascia release and the loss of spring and push-off in this sprinter were outweighed by the benefits of a potentially faster recovery, given the demands of his sport. Of course, 20/20 hindsight is everything.


#5 Think About the Nerves

Many patients with a deep posterior compartment syndrome have pain at one specific area. This pain usually is isolated to the lower edge of the gastrocnemius on the medial side of the leg. With a history of chronic pain in this compartment and a negative scan, exercise compartment testing to rule out exertional compartment syndrome is recommended. On occasion, despite normal pressures, a local fascial release has been performed at the lower gastrocnemius, releasing what we have considered to be an isolated high tarsal tunnel syndrome. Occasionally, a specific nerve conduction test and electromyogram (EMG) can pick up a delay of the tibial nerve in the leg. However, because the nerve entrapment is a functional entrapment from a hypertrophied muscle and a squeezing effect on the nerve, the nerve conduction is not always positive. The symptoms may result from a compressed tibial nerve, rather than from lack of oxygen to leg muscles.

We have treated several elite athletes, particularly track runners, who have presented with a cramping-type sensation in the posterior calf in the midline area. After a full evaluation of standard posterior calf pain (deep venous thrombosis [DVT], exertional compartment syndrome, muscle tear, and so forth), we have attributed the pain to a sural nerve fascial constriction. Releasing fascia around the sural nerve in this isolated area may permit the cramping to subside and the leg pain to resolve.

Similarly, an athlete with what appears to be lateral exertional compartment syndrome may be suffering from superficial peroneal nerve entrapment. This may present with normal compartment pressures. One should be aware that this condition may occur because of an unstable ankle. In the latter cases, not only does a superficial peroneal nerve have to be released, but the unstable ankle must be repaired as well. There are anatomic variations of this nerve, and it may lie within the lateral or anterior compartments or both.

The jogger's foot is more common than most physicians realize. The medial plantar nerve may become entrapped at an isolated area at the knot of Henry. Abnormal range of motion may lead to a squeezing effect by the hypertrophied abductor hallucis muscle. A minimal incision releases the medial plantar nerve; because it is relatively deep, care must be taken to avoid damage.

The anterior tarsal tunnel syndrome also is fascinating because the deep peroneal nerve may be irritated for several reasons. It can be compressed because of a functional instability of the ankle or the talonavicular joint. The treatment includes a minimal release by cutting the inferior edge of the retinaculum and then carefully removing dorsal bone from the talus or navicular bone ( Fig. 1-6 ). The lateral branch of the deep peroneal nerve may be compressed by the fascia of the extensor brevis muscle, causing a sinus tarsi pain. This is an often-overlooked cause of the sinus tarsi syndrome. In this situation, the nerve should be released where it is focally tender, typically dorsal and medial to the sinus tarsi itself. The fascia of the extensor brevis muscle can be the causative structure, but the physician always must evaluate for ankle instability, as well. We do not recommend transecting this nerve branch as a means of reducing the pain.


Figure 1-6  Lateral radiograph of a dorsal osteophyte on naviculum caused a deep peroneal neuralgia.



Interdigital nerves are either entrapped and cut by the edge of the transverse metatarsal ligament or bulbous from chronic compression and scarring of the nerve. If the entrapment is treated before the nerve becomes “scarred and bulbous,” then a simple release of the intermetatarsal ligament may be considered. If the nerve is bulbous, we prefer to remove the affected nerve, proximal to the transverse metatarsal ligament.


#6 The Tarsal Coalition can be the Great Masquerader

When treating the younger, promising, future elite athletes, remember to consider the possibility of a tarsal coalition. Unlike the descriptions in the literature that portray the peroneal spastic flat foot, the tarsal coalitions in athletic individuals present as chronic ankle sprains; chronic calcaneal, navicular or talus stress fractures; posterior tibial tendinitis; tarsal tunnel syndrome; sinus tarsi syndrome; peroneal tendinitis; ankle impingement; or even Achilles tendinitis. They rarely have peroneal spasticity and typically do not have deformities. Often, subtalar motion will be restricted but may not be eliminated. The x-rays may not show the coalition because they may be incomplete, fibrous, or cartilaginous. MRI, CT scan, and/or technetium (Tc) bone scan may be needed to identify the site and extent of the coalition (Fig. 1-7 ).


Figure 1-7  Coronal magnetic resonance imaging (MRI) of a medial subtalar facet tarsal coalition in a young dancer with hindfoot pain. She was referred for evaluation of insertional Achilles tendinitis. She had tenderness medially along the posterior tibial tendon, laterally in the sinus tarsi, and posteriorly by the retrocalcaneal bursa. Following resection of the coalition, all three zones of tenderness resolved.




#7 Timing Should Never be Underrated

Some of the hardest injuries to treat include the nondisplaced navicular stress fracture, the nondisplaced medial-malleolar stress fracture, the nondisplaced Lisfranc strain, and the high ankle sprain. With many of these injuries, bone stimulators, cast immobilization or bracing, rest, careful PT, and, occasionally, well-placed percutaneous screws are invaluable. Yet the most influential factor is time. Insufficiency in this latter element may lead to more complicated problems, such as displaced fractures or dislocations, and a need for complex surgery.


#8 Location, Location, Location

A stress fracture of the navicular or medial malleolus generally is more ominous than a middle-lower one-third junction fibula stress fracture. Although the former stress fractures are more likely to preclude athletics, certain stress fractures, such as the latter, can be managed less aggressively.

A world record-holding, female, middle distance runner presented with a fibular stress fracture 4cm above ankle joint. She had excellent strength; good hip, knee, leg, and ankle biomechanics; and no ankle instability medially or laterally. She had some forefoot supination that was felt to cause a valgus moment at her ankle while she was striding. After careful analysis of her condition, it was agreed that she could, with use of a semirigid orthotic, run one race that she and her trainer felt was essential for her preparation for the World Championships. The plan was that, following this event, she would then do easy training for two and a half weeks before her next big race. During the event, not only were the symptoms controlled but she had the greatest race of her career, winning the world championship as her Eastern European challenger fell, chasing her at the finish.


#9 Despite #8, It is Better to be Lucky Than Good

One National Collegiate Athletic Association (NCAA) center for a Final Four basketball team sustained a nondisplaced navicular fracture. The athlete used both a high-intensity ultrasound machine and a bone stimulator for a month before gradually resuming play with an arch support. Two months after the injury, he played in the National Championship game without advancing to a complete fracture. This was a risky choice; a better option would have been to fix the fracture percutaneously without open grafting, in order to minimize the surgical trauma while reinforcing the weakened bone. The odds were not in our favor, but luck was. After the season, two small screws and a bone graft were used in the navicular, preventing reoccurrence in a 5-year professional basketball career ( Fig. 1-8 ).



Figure 1-8  (A) Centrally located navicular stress fracture seen on the anteroposterior (AP) x-ray (arrow). (B) Sagittal magnetic resonance imaging (MRI) demonstrates edema in the naviculum. (C and D) Two small screws were inserted from the medial pole.




#10 A Quick Fix may Buy Time

Unlike the aforementioned case, an NCAA college basketball center presented with a nonhealing proximal second metatarsal fracture (about 1.5cm distal to the metatarsocuneiform [MTC] joint) several weeks before the beginning of the season. The decision was made to place a screw across the fracture percutaneously and drill the nonunion site. Eight weeks later, the center was able to return to play. At the end of the season, the symptoms were escalating to the preseason level. After the season, the fracture underwent open bone grafting and insertion of a larger screw, and full recovery was permitted during the off season ( Fig. 1-9 ).



Figure 1-9  (A) An anteroposterior (AP) x-ray reveals the second metatarsal stress fracture in this basketball player that became symptomatic just before the season. (B-D) Magnetic resonance imaging (MRI) demonstrates the proximal fracture. (E) Intraoperative fluoroscan shows the insertion of the screw in a minimally traumatic fashion that permitted him to start the season. Toward the end of a relatively asymptomatic season, his symptoms increased and he underwent open bone grafting and insertion of a larger screw. Full recovery occurred in the off season.




#11 Sometimes It is Better to Go for the Base Hit

A middle distance runner was felt to have first tarsometatarsal (TMT) instability with hallux valgus, second metatarsophalangeal (MTP) subluxation, and lesser metatarsal overload. A Lapidus procedure with MTC fusion was recommended to correct the deformity. Because most of the symptoms were at the bunion and the runner could not take off more than 8 to 12 weeks, a chevron bunionectomy was performed, ignoring the first TMT instability. The runner did have a recurrence 10 years later, but that was after he had participated in two Olympics and set an American record on the roads ( Fig. 1-10 ).


Figure 1-10  Preoperative x-ray of an elite runner with hallux valgus and second metatarsophalangeal (MTP) joint instability who ultimately had a chevron bunionectomy instead of a Lapidus and second MTP joint procedure, as recommended elsewhere.




#12 Plan Twice, Cut Once

Treatments should be reviewed and rereviewed and should stand up to scrutiny readily provided by the athlete, family, coach, trainer, and agent. Similarly, when devising a surgical plan, it always is useful to review all the other alternatives for one's own benefit, even though one may have a preferred treatment that has worked well in the past. One should think about how the plan or the alternatives will affect any associated conditions, the rehabilitation, return to sport, and lifelong function beyond sports. Even though the exercise of mapping out the screw placement or osteotomy is tedious or may be considered remedial, it does permit concerted preoperative appraisal. Any “wasted” time often will be recouped intraoperatively or postoperatively.


#13 A Stealthlike Incursion Should Leave Ne'er a Trace

Our philosophy with the elite athlete is to restore the anatomic structure with the least surgery possible and then use a functional recovery. When surgery is performed, the tissues should be minimally disturbed. One should know where to go, not dissect widely, avoid disrupting soft tissue planes, save neurovascular structures, do the repair, and take care on the way out. Postoperative management should allow rehabilitation without compromising the integrity of the reconstruction. Initially a half-cast or U-splint and posterior splint are used, followed by removable bracing with early range of motion. This is especially important with Achilles tears. One gifted sprinter ruptured his Achilles tendon in the finals of the Olympic 100 meters. With a minimal incision and limited exposure, the Achilles was sutured. The anterior fat pad was reapposed, and the paratenon was repaired. Early plantarflexion range of motion was instituted postoperatively. The sprinter was kept in equinus for 1 month in a plantarflexed brace. Walking without the brace was permitted by 10 weeks. Progressive impact activities were permitted with careful monitoring by an excellent trainer/therapist. The sprinter was running aggressively by 9 months, and, by 1 year, full-out sprinting was comfortable. The sprinter came back in 18 months and ran the fastest 60-m indoor race of the year despite this potentially career-ending injury.


#14 Minimize Surgery and Maximize Recovery

A pole vaulter missed the pit, landing on his foot in abducted fashion. This led to the development of a spring ligament/deltoid complex detachment. Ecchymosis and tenderness were noted medially anterior to the medial malleolus. The foot assumed an abducted posture with bulging around the talonavicular joint. The posterior tibial tendon had excellent strength with full inversion power 45 degrees past the midline against resistance. An MRI showed changes in the spring ligament. Intervention with an anatomic and secure repair was critical to the pole vaulter's future career. The reconstruction was accomplished through a 4-cm incision ( Fig. 1-11 ). After the torn spring ligament was exposed at its navicular insertion, the edges and thinned portions were debrided. The proximal medial aspect of the pole of the navicular was roughened, establishing a cancellous bleeding surface through which an osseous suture anchor was placed, thereby avoiding inadvertent talonavicular joint penetration. A splint was applied following surgery. This was replaced by a brace that was worn for 16 weeks. A heel lift was used for 6 to 8 weeks subsequently. Rehabilitation succeeded in permitting this athlete to resume his career and to set the American pole vault record on his repaired foot.


Figure 1-11  Spring ligament repair. The torn spring ligament is seen after the posterior tibial tendon sheath is opened. The triangular open arrow demonstrates the posterior tibial tendon, the solid arrow points to the naviculum, and the open arrow shows the talonavicular ligament and spring ligament. The inset displays the ligament being held by forceps.




#15 Identify Injuries that are at High Risk for Failure

Stress fractures of the medial malleolus, especially vertical type stress fractures, need a vertical repair, not a horizontal repair. If a horizontal typical medial malleolar screw is used in a vertical stress fracture of the medial malleolus, the stresses are not adequately removed to allow healing, making it possible for the fracture to recur and the screw to break. For that reason, a buttress plate on the medial malleolus should be used to relieve the vertical stresses ( Fig. 1-12 ).


Figure 1-12  This medial malleolar stress fracture was unrecognized and went on to complete fracture. Notice the medial talar osteophyte. The fracture was fixed with horizontally placed compression screws and an Ace Depuy (Warsaw, IN) fibular plate.



One sprinter with an injured ankle and a medial malleolar stress fracture was treated with nonweight-bearing activity and with conservative care for 2 months. His ankle healed, and he went on to have a 15-year career, including an Olympic appearance 12 years later, and no further stress fractures occurred ( Fig. 1-13 ). Other athletes have had these vertical fractures, particularly those with some genu varus or heel varus. There is an inordinate amount of stress placed through the medial malleolus, and conservative care will not suffice. In these vertical fractures, extending above the articular cartilage, the stress fracture should be curetted and small local bone graft should be injected; then a medial buttress plate should be used to remove the vertical stresses.


Figure 1-13  The magnetic resonance imaging (MRI) showed this medial malleolar stress fracture that healed following conservative treatment.



An NBA guard had a vertical stress fracture with a medial malleolar screw and bone graft. The fracture healed; however, the following year, an additional fracture occurred in the same area and had to be fixed with a buttress plate and bone graft ( Fig. 1-14 ). Following treatment, the NBA guard has been able to play for 3 years with no further problems, playing 30 out of 48 minutes in each game. Functional problems with biomechanical stresses need repair, eliminating those stresses that caused the injury.



Figure 1-14  (A) The x-ray shows a medial malleolar stress fracture. (B) After fixation with a single screw, the fracture ultimately failed and the complete fracture was treated with bone graft and medial malleolar plating with a Synthes tibial plate.




#16 A Little Instability can Go a Long Way: Keep Both Eyes Open

Some joints are susceptible to ligamentous damage that can present with occult instability and therefore are often overlooked. Nearly all physicians can identify lateral ankle ligamentous injuries, but what about the spring ligament, the anterior deltoid, the Lisfranc ligament, or instability of the MTP joint's plantar plate?

A turf-toe injury of the great toe is a diagnosis that may represent many anatomic problems. The standard great toe strain, a first- or second-degree turf-toe, often can be treated by using rigid plate inserts in the shoe and taping the great toe. If there is a complete rupture or third-degree turf-toe type injury, there may be complete separation of the sesamoids from the proximal phalanx with rupture of the sesamoidal phalangeal ligament(s); or there may be a complete rupture of the adductor or abductor tendon from the base of the proximal phalanx of the great toe with or without collateral ligament injury, causing marked laxity of the first metatarsal phalangeal joint. There can be diastasis of a bipartite sesamoid or disruption of the flexor hallucal brevis tendons from the sesamoids. In these cases, performing bilateral anterior draw maneuver and checking flexor hallucis longus (FHL) and flexor hallucis brevis (FHB) function may reveal the deficit. Further testing with a varus or valgus stress also is helpful, as well. X-rays and MRIs can show irregular position of the sesamoids with ligament and/or tendon rupture. These instabilities can result in problems cutting, pivoting, running, and jumping. Long term, if unaddressed, the joint subjected to nonphysiologic shear stresses will suffer degenerative changes. If recognized early, the condition can be repaired and the cycle of deterioration halted. Although the rehabilitation period is 6 to 9 months, return to top performance is possible ( Fig. 1-15 ).


Figure 1-15  Sagittal magnetic resonance imaging (MRI) demonstrates the rupture of the plantar plate (solid arrow shows retracted sesamoid; open arrow points to intact flexor hallucis longus [FHL] tendon, which is directly plantar to the rupture of the sesamoid phalangeal ligament).



The plantar plate injury in the lesser MTP joints also can be a “small” problem with grave consequences if the joint subluxates or, even worse, dislocates. This is particularly true when there is a long second metatarsal. Again, early recognition with the anterior draw test and varus/valgus stresses is paramount. Although further subluxation of the second metatarsophalangeal joint may be prevented by initially treating a plantar plate strain of the metatarsal phalangeal joint (including plantarflexion stretching of the extensor tendon by use of a metatarsal pad and toe taping), surgical repair may be warranted. Once the plantar plate stretches out significantly, either acutely or chronically, surgery must be considered ( Fig. 1-16 ). In this case, a second MTP dislocation and hallux valgus were treated with a Chevron-Akin osteotomy and open reduction of the dislocation. The second MTP joint was stabilized with a 0.62 pin, which was left in place for 3 weeks. In the patient with a long second metatarsal and unstable MTP joint, we do an oblique osteotomy to shorten the metatarsal ( Fig. 1-17 ).


Figure 1-16  In this case, a second metatarsophalangeal (MTP) dislocation and hallux valgus was treated by open reduction and pinning of the second in conjunction with a Chevron-Akin osteotomy. The joint was stabilized with a 0.62 pin across the MTP joint that was left in place for 3 weeks.




Figure 1-17  (A and B) This ultra-marathon runner had been treated conservatively for a progressively more symptomatic second hammertoe, second metatarsophalangeal (MTP) subluxation, and hallux valgus. (C) Return to running was 10 weeks with this distal chevron osteotomy coupled with a distal second metatarsal oblique osteotomy and proximal interphalangel fusion.



Why do some fibular stress fractures and high ankle sprains lead to diastasis of the ankle joint, whereas other fractures of the fibula do not? ( Fig. 1-18 ). At times, incompetence of the anterior deltoid ligament or spring ligament is to blame. When rotary ankle injury occurs with or without fibula fracture, one should check for tenderness in the anterior deltoid ( Fig. 1-19 ). If there is excessive swelling and tenderness over the anterior deltoid or spring ligament, a repair should be considered in the high-performance athlete. If the anterior deltoid ligament is torn from the medial malleolus or off the navicular attachment, the ankle is allowed to rotate out of the ankle mortise. Unfortunately, if a diastasis screw is placed across the tibiofibular joint, the talus will continue to sublux forward in the ankle mortise. In severe injuries of the ankle in which there is a lateral malleolar fracture and a diastasis, consider repairing the injury by plating the distal fibula and putting anchors in either the medial malleolus or the navicular to repair the torn anterior deltoid. If there is some question about whether the diastasis needs support, a diastasis screw should be used after the anterior deltoid has been fixed.


Figure 1-18  Fibula stress fractures need to be evaluated for medial ankle ligamentous instability and occult syndesmotic instability. Although pain can be the best guide, stress views and a magnetic resonance imaging (MRI) may be helpful.




Figure 1-19  (A) This is an athlete whose magnetic resonance imaging (MRI) demonstrated a fibula stress fracture (open arrow); (B) Regular arrow shows fracture. There also is edema of the talus dome laterally, deltoid signal abnormalities, and changes in the anterior tibial fibular ligaments (open arrow shows the syndesmotic injury). (C) The coronal MRI views demonstrate the syndesmotic injury (regular and open arrows).




#17 When is It Okay to “Spare the Rod and Spoil the Athlete”?

Midtibial chronic stress fractures with the “dreaded black line” usually respond to drilling without the need for bone grafting ( Fig. 1-20 ). We have success with ballet dancers with a minimal drilling of the isolated tibial stress fracture under x-ray control. Dancers have gone on to long careers without reoccurrence of the stress fractures once this tibial stress fracture heals from isolated drilling. It is imperative for the ballet dancer or the athlete to avoid torque for 2 to 3 months before or after the drilling process so that the stress fracture does not lead to a complete catastrophic fracture.


Figure 1-20  The white arrow delineates the “dreaded black line” of the established tibial stress fracture.




#18 Work Backward in Establishing a Return to Sport Protocol

One should realize that designing an appropriate return to the sports program requires not only an appreciation of the competition or performance schedule but an assessment of the timing and requirements of a reconditioning program. The clinician should learn from the athlete, trainer, and coach what milestones and competencies are achieved in the typical preseason routine and how long they take to be mastered. Next, knowing the magnitude of the injury and requisite recovery to nonathletic baseline, one should anticipate the tasks and time for reestablishing the athletic baseline. Along the way, the clinician should determine what testing or standards will be used to permit safe advancement to the next level of activity.

A good example is a ballet dancer with chronic ankle instability who undergoes a lateral ligament reconstruction. To return to high-level dance, he or she must achieve not only full range of motion, strength, stability, and proprioception but also endurance. In our basic protocol, the athlete is off the foot and in a posterior splint for 10 to 14 days after surgery. Then a boot brace is applied and the athlete is allowed to be fully weight bearing. During this time, a strengthening program is initiated and the ankle can be put through a range of motion from maximum dorsiflexion to 30 to 40 degrees of plantarflexion, avoiding any inversion. Cardiovascular workout can be achieved using an exercise bike or elliptical trainer. At 6 weeks postoperatively, an Airsport or lace-up ankle brace is applied, allowing for more mobility. Dancing at the barre is permitted but relevé beyond the 40-degree plantarflexed position must be avoided so as not to stretch the repair. At 10 to 12 weeks, the relevé restrictions are gradually lifted, but full pointe should not be achieved until 14 weeks. Once full range of motion permits completion of the barre exercises without pain or swelling, the dancer may begin center work. The dancer should initially avoid pirouettes, large jumps, or leaps. As soon as the dancer masters the smaller jumps and rapid weight shift from side to side, he or she can advance to performing faster movement combinations that incorporate the pirouettes and jumps, ideally by 18 weeks. To reach the target release date, the dancer should be able to handle a full class and rehearsal by 20 weeks. During rehabilitation, the trainer, teacher, and/or orthopaedist must continuously assess the dancer's signs and symptoms to ensure that the reconstruction is not undone as these new stresses are introduced.


#19 Everyone Loves a Winner

The easy cases that require little worry and intervention are a pleasure to recap and ponder. The challenge is to stay engaged with the ones that are not following the typical pathway. One should be prepared to get additional advice. At the least, the clinician should step back, clear the mind of any assumptions, and acquire new or revisit old information about the case. This process of providing oneself with a second opinion generally is productive and will allow the less successful recoveries to switch to the winning category.


#20 It is Better to Have no Publicity Than Bad Publicity

It is the athlete's business to converse with the public through the media. The clinician must respect the wishes of the patient and his or her team for confidentiality. These days it is the law. The clinician's glory will come in a quieter manner long after the fans have lost intense interest as the athlete manages to return without a relapse or reinjury through the season. One should let the agents, athletes, and team handle the press. In addition, a worse situation is the negative press associated with failure or a complication, whether or not the physician was responsible.



The elite athlete presents a wide variety of challenges that require a keen knowledge of anatomy, biomechanics, physiology of healing, and psychology to interpret. Usually the physician and athlete are surrounded by issues, trainers, coaches, agents, team physicians, owners, and other consultants who influence the interaction. The big picture is visualized so that the static and dynamic factors can be assessed. Odd conditions present with uncharacteristic symptoms, and standard conditions may manifest in peculiar ways. The physician should think profoundly to determine the diagnosis and then create a customized treatment algorithm that incorporates conservative and surgical modalities. One should provide honest and evidence-based opinions.

The timing obviously is important. Being cost conscious is laudable, but the cost of a conservative or surgical treatment sometimes is dwarfed by the cost of missed games and bad seasons. If an operation is warranted, it should be well conceived, striving for a biomechanically logical and anatomically sound reconstruction with limited surgical trauma. Postoperative rehabilitation and return to sport or dance should be mapped and reassessed along the way to avoid a setback. Communication should flow to the patient and his or her immediate family and should involve the trainers, therapists, coaches, and agents as permitted by Health Insurance Portability and Accountability Act (HIPAA). The media should be directed to contact the player or his or her designee. Most importantly, one should keep an open and creative mind, work hard, treat people with dignity, and enjoy the journey. Once the athlete, the trainer, and the agent see positive outcomes, other cases will follow and the physician will slowly develop a good reputation for being a doctor who treats winners.