Baxters The Foot and Ankle in Sport, 2nd Edition by David A. Porter MD PHD, Lew C. Schon MD

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BAXTER’S THE FOOT AND ANKLE IN SPORT ISBN: 978-0-323-02358-0

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Notice
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary or
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dose or formula, the method and duration of administration, and contraindications. It is the
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Library of Congress Cataloging-in-Publication Data

Baxter’s the foot and ankle in sport / [edited by] David A. Porter, Lew C. Schon.—2nd ed.
p. ; cm.
Rev. ed. of: The foot and ankle in sport / edited by Donald E. Baxter. c1995.
ISBN 978-0-323-02358-0
1. Foot—Wounds and injuries. 2. Ankle—Wounds and injuries. 3. Foot—Abnormalities.
4. Ankle—Abnormalities. 5. Sports injuries. I. Baxter, Donald E. II. Porter, David A.,
1959- III. Schon, Lew. IV. Title: Foot and ankle in sport.
[DNLM: 1. Ankle Injuries. 2. Foot Injuries. 3. Ankle—abnormalities. 4. Foot
Deformities. 5. Sports Medicine—methods. WE 880 B355 2007]
RD563.F638 2007
617.50 85044 dc22
2007022810
Acquisitions Editor: Emily Christie

Editorial Assistant: Faith Brody
Project Manager: David Saltzberg
Design Direction: Lou Forgione
Printed in USA
Last digit is the print number: 9 8 7 6 5 4 3 2 1
......................................... CONTRIBUTORS
Abrao M. Altman, MD Michael W. Bowman, MD, FACS

Professor, Orthopaedics Clinical Assistant Professor
Santa Cecilia University Department of Orthopaedic Surgery
Orthopaedic Surgeon University of Pittsburgh
Casa de Saude de Santos Consultant, Pittsburgh Steelers Football Club
Santos, Brazil Pittsburgh, Pennsylvania
Robert B. Anderson, MD W. Grant Braly, MD
Chief, Foot and Ankle Service Clinical Professor, Foot and Ankle Fellowship
Department of Orthopaedics Foundation for Orthopaedic Athletic
Carolinas Medical Center and Reconstruction Research
Charlotte, North Carolina Department of Orthopaedic Surgery
University of Texas Health Science Center at Houston
Erin Richard Barill, PT, ATC
Clinical Assistant Professor
Director of Rehabilitation
Department of Orthopaedic Surgery
Indianapolis Colts
Baylor College of Medicine
Indianapolis, Indiana
Active Staff, Orthopaedic Surgery
Donald E. Baxter, MD Texas Orthopaedic Hospital
Former Clinical Professor of Orthopaedic Surgery Houston, Texas
Head of Foot and Ankle Surgery
Peter Brukner, MBBS, FACSP
Director of Foot and Ankle Fellowship Programs
Associate Professor in Sports Medicine
Centre for Health, Exercise and Sports Medicine
University of Texas Medical School
University of Melbourne
Houston, Texas
Melbourne, Australia
Christoph Becher, MD
Thomas O. Clanton, MD
Center for Knee and Foot Surgery/Sports Trauma
Professor and Chairman
ATOS Clinic Center
Heidelberg, Germany
The University of Texas Health and Science Center
Kim L. Bennell, BAppSci (physio), PhD at Houston
Professor Team Physician, Rice University
Centre for Health, Exercise and Sports Medicine Team Orthopaedist, Houston Texans
University of Melbourne Team Physician, Houston Rockets
School of Physiotherapy Houston, Texas
Melbourne, Australia
J.A. Colombier, MD
Gregory C. Berlet, MD, FRCSC Foot and Ankle Surgery
Chief, Section of Foot and Ankle Clinique de l’Union
Department of Orthopaedics Toulouse, France
The Ohio State University
Fellowship Director
Orthopaedic Foot and Ankle Center
Columbus, Ohio
v
...........
Contributors
Michael J. Coughlin, MD Kevin B. Gebke, MD

Director, Idaho Foot and Ankle Fellowship Assistant Professor of Clinical Family Medicine
Boise, Idaho Primary Care Sports Medicine Fellowship Director
Clinical Professor, Department of Orthopaedic Surgery IU Center for Sports Medicine
and Rehabilitation Family Medicine
Oregon Health Science University Indiana University
Portland, Oregon Indianapolis, Indiana
Private Practice of Orthopaedic Surgery
Sandro Giannini, MD
St. Alphonsus Regional Medical Center
Professor
Boise, Idaho
Orthopaedics
Past President, American Orthopaedic Foot and Ankle
Bologna University
Society
Chief of VI Department
P.A.J. DeLeeuw, PhD Istituti Ortopedici Rizzoli
Fellow Bologna, Italy
Department of Orthopaedics
John S. Gould, MD
Academic Medical Centre
Professor of Surgery
University of Amsterdam
Division of Orthopaedic Surgery
Amsterdam, The Netherlands
University of Alabama at Birmingham
A. Lee Dellon, MD Chief of Medical Staff
Professor of Plastic Surgery and Neurosurgery UAB Highlands Hospital
The Johns Hopkins University Birmingham
Baltimore, Maryland Clinical Professor
Clinical Professor of Plastic Surgery, Neurosurgery and Orthopaedic Surgery
Anatomy University of South Alabama
University of Arizona Mobile, Alabama
Tucson, Arizona
J. Speight Grimes, MD
Director, the Dellon Institutes for Peripheral Nerve
Assistant Professor
Surgery
Orthopedic Surgery
Jonathan C. Dick, MB, BCh, BAO, LRCP & SI Texas Tech University Health Sciences Center
Associate Lecturer Lubbock, Texas
School of Medicine
Florian W. Gruber, MD
University of Queensland
Resident
Brisbane, Australia
1st Orthopaedic Department
Peter H. Edwards, Jr., MD Orthopedic Clinic Gersthof
Senior Attending Vienna, Austria
Orthopaedic Surgery
William G. Hamilton, BSE, MD
Ohio Orthopedic Center of Excellence
Senior Attending
Columbus, Ohio
Orthopaedic Surgery
David G. Ford, C. Ped St. Luke’s Roosevelt Hospital
Board Certified Pedorthist Assistant Attending Orthopaedic Surgeon
Orthopaedic Sports Medicine The Hospital for Special Surgery
Birmingham, Alabama Clinical Professor of Orthopaedic Surgery
College of Physicians & Surgeons
Carol Frey, MD
Columbia University
Fellowship Co-Director
New York, New York
Foot & Ankle
West Coast Orthopedic & Sports Medicine Foundation Travis W. Hanson, MD
Manhattan Beach, California Foot and Ankle Surgery & General Orthopaedics
KSF Orthopaedic Center
Houston, Texas
vi
...........
Contributors
Christopher W. Hodgkins, MD Rover Krips, MD, PhD

Orthopaedic Fellow Department of Orthopaedic Surgery
Foot and Ankle Surgery Academic Medical Center
Hospital for Special Surgery University of Amsterdam
New York, New York Amsterdam
Afdelind Orthopaedie
Hong-Geun Jung, MD, PhD
Diaconessenhuis Leiden
Associate Professor
Leiden, The Netherlands
Attending Staff Surgeon
Department of Orthopedic Surgery, Foot and Ankle Kyung-Tai Lee, MD
Service Professor, Chief
Konkuk University School of Medicine Foot and Ankle Service
Seoul, South Korea Department of Orthopedics
Eulji University Hospital
Jon Karlsson, MD, PhD
Seoul, South Korea
Professor of Orthopaedics and Sports Traumatology
Department of Orthopaedics Thomas H. Lee, MD
Sahlgrenska University Hospital Assistant Clinical Professor
Goeteborg, Sweden Department of Orthopaedics
The Ohio State University
Moosa Kazim, MD, FRCS (C)
Columbus, Ohio
Director, Department of Sports Medicine
Orthosports Medical Center Nicola Maffulli, MD, PhD, FRCS
Dubai, United Arab Emirates Sports Med, Ltd.
The London Independent Hospital
John G. Kennedy, MD, FRCS (Ortho)
London
Assistant Professor of Orthopaedic Surgery
Professor of Trauma and Orthopaedic Surgery
Cornell University
University of Keele School of Medicine
Ithaca
University Hospital of North Staffordshire
Attending Surgeon
Stoke-on-Trent, United Kingdom
Foot and Ankle in Sports
Hospital for Special Surgery Ansar Mahmood, MB, ChB, MRCS
New York, New York Specialist Registrar in Trauma & Orthopaedic Surgery
University of Keele School of Medicine
Cesar Khazen, MD
Registrar in Trauma & Orthopaedics
Foot and Ankle Surgeon
Queens Hospital Burton
Burton-upon-Trent, United Kingdom
Hospital de Clinicas Caracas
Caracas, Venezuela Roger A. Mann, MD
Associate Clinical Professor
Gabriel Khazen, MD
Orthopaedic Surgery
Foot and Ankle Surgeon
University of California School of Medicine
San Francisco
Hospital de Clinicas Caracas
Director
Caracas, Venezuela
Foot and Ankle Fellowship
Daniel E. Kraft, MD Oakland, California
Assistant Clinical Professor
John V. Marymont, MD
Pediatrics
Associate Professor
Indiana University
Chief, Foot & Ankle Section
Methodist Sports Medicine Clinic
Staff Physician
Methodist Hospital
Houston, Texas
vii
...........
Contributors
Peter B. Maurus, MD Glenn B. Pfeffer, MD

Orthopaedic Surgeon, Foot and Ankle Surgery Director, Foot and Ankle Center
Mercy Hospital Cedars-Sinai Medical Center
Steindler Orthopedic Clinic Los Angeles, California
Iowa City, Iowa
Terrence Philbin, DO
William C. McGarvey, MD Assistant Clinical Professor
Associate Professor Department of Orthopaedics
Director of Foot and Ankle Surgery The Ohio State University
Department of Orthopaedic Surgery Medical Director of Foot and Ankle Orthopaedics
University of Texas-Houston Health Science Center Grant Hospital
Houston, Texas Columbus, Ohio
Eyal Melamed, MD David A. Porter, MD, PhD
Foot and Ankle Service Voluntary Clinical Associate Faculty
Department of Orthopaedics B Orthopaedics, Indiana University
Rambam Medical Center Indianapolis
Foot and Ankle Clinic Adjunct Clinical Associate Professor of
Kelalit HMO Polyclinic Health, Kinesiology and Leisure Studies
Kiriat Bialik Foot and Ankle Consultant
Haifa, Israel Purdue University
Secretary, Israeli Foot and Ankle Society West Layfayette
Foot and Ankle Consultant
Larry L. Nguyen, MD
Indianapolis Colts
Orthopaedic Surgeon
Indianapolis
Physician
Foot and Ankle Consultant
OrthoArkansas, P.A.
Co-Director Department of Research and Education
Little Rock, Arkansas
Methodist Sports Medicine – The Orthopedic
James A. Nunley, MD Specialists
J. Leonard Professor and Chief of the Division of Indianapolis, Indiana
Orthopaedics
Anthony S. Rhorer, MD
Department of Surgery
Director, Orthopaedic Trauma
Duke University
Scottsdale Healthcare
Durham, North Carolina
President
Padraic R. Obma, MD Sonoran Orthopaedic Trauma Surgeons
Resident, Orthopaedic Surgery Scottsdale, Arizona
Indiana University School of Medicine
Gregory A. Rowdon, MD
Team Physician
Yong-Wook Park, MD, PhD Purdue University
Professor of Orthopaedics West Lafayette, Indiana
Hangang Sacred Heart Hospital
G. James Sammarco, MD
Seoul
Volunteer Professor
Professor of Orthopaedics
Orthopaedic Surgery
Chunchon Sacred Heart Hospital
University of Cincinnati
Chunchon
Cincinnati SportsMedicine and Orthopaedic Center
Supervisor of Orthopaedics
Cincinnati, Ohio
The Armed Forces Medical Command
Yangju, South Korea V.J. Sammarco, MD
Co-Director Foot and Ankle Fellowship
Mihir M. Patel, MD
University of Cincinnati
Fellow, Foot and Ankle Service
Cincinnati SportsMedicine and Orthopaedic Center
Cincinnati, Ohio
The Hospital for Special Surgery
New York, New York
viii
...........
Contributors
Melanie Sanders, MD Roman A. Sibel, MD

Leesburg, Virginia Fellow, Foot and Ankle
Department of Orthopaedics
Mikael Sansone, MD
The Hospital for Special Surgery
Resident, Department of Orthopaedics
New York, New York
Sahlgrens University Hospital
Gothenburg, Sweden Yasuhito Tanaka, MD
Assistant Professor
Scott T. Sauer, MD
Clinical Instructor
Nara Medical University
Kashihara, Japan
Georgetown University School of Medicine
Washington, DC David D. Taylor, MD
Sports Medicine Fellow
Terence S. Saxby, FRACS (Ortho)
Methodist Sports Medicine
Consultant Orthopaedic Surgeon
Brisbane Foot and Ankle Center
Brisbane, Australia Hajo Thermann, MD, PhD
Professor, Trauma Department
Robert C. Schenck, Jr., MD
Hannover Medical School
Professor and Chairman
Hannover
Center for Knee and Foot Surgery/Sports Trauma
University of New Mexico School of Medicine
ATOS Clinic Center
Albuquerque, New Mexico
Heidelberg, Germany
Lew C. Schon, MD Craig Ives Title, MD
Assistant Professor Department of Orthopaedics
Department of Orthopaedic Surgery Lenox Hill Hospital
The Johns Hopkins University New York, New York
Baltimore
Clinical Associate Professor of Orthopaedic Surgery C. Niek van Dijk, MD, PhD
Department of Orthopaedic Surgery Head
Georgetown University Medical Center Department of Orthopedic Surgery
Washington, DC Academic Medical Center
Director of Foot and Ankle Services Amsterdam, The Netherlands
Department of Orthopaedic Surgery Francesca Vannini, MD
The Union Memorial Hospital Department of Orthopaedic Surgery
Baltimore Bologna University
Active Staff, Part Time Consultant, VI Department
Department of Orthopaedic Surgery Istituti Ortopedici Rizzoli
The Johns Hopkins Medical Institutions Bologna, Italy
Baltimore, Maryland
Sergio Vianna, MD
Scott B. Shawen, MD, MAJ(P), MC Chief, Section of Foot and Ankle Surgery
Assistant Professor Instituto Nacional de Traumato-Ortopedia
Surgery Rio de Janeiro, Brazil
Uniformed Services University of the Health Sciences
Veronica Vianna, MD
Bethesda, Maryland
Member, Section of Foot and Ankle Surgery
Director, Orthopaedic Foot & Ankle Surgery
Instituto Nacional de Traumato-Ortopedia
Orthopaedics & Rehabilitation
Rio de Janeiro, Brazil
Walter Reed Army Medical Center
Washington, DC Xu Xiangyang, MD
Staff Orthopaedic Surgeon Professor
Surgery Department of Orthopaedics
Kimbrough Ambulatory Care Center Shanghai Jiaotong University Medical College
Fort Meade, Maryland Ruijin Hospital
Shanghai, China
ix
...........
Contributors
Zhu Yuan, MM Chaim Zinman, MD

Attending Doctor The Bruce Rappaport Faculty of Medicine
Department of Orthopaedics Technion-Israel, Institute of Technology
Ruijin Hospital Chairman, Department of Orthopaedics B
Shanghai Rambam Medical Center
Jiaotong University Haifa, Israel
Shanghai Orthopaedics Institute
Shanghai, China Jerett Zipin, DO
Attending
Mohammed S. Zafar, BSc, MBBS, MRCS Sports Medicine
Specialist Registrar in Trauma and Orthopaedic Surgery Health Care Partners
University of Keele School of Medicine Pasadena, California
Staffordshire
University Hospitals
Birmingham
Selly Oak Hospital
Birmingham, United Kingdom
x
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......................................... P R E F A C E
The original volume of The Foot and Ankle in Sport by treatment. The chapter on the subtalar joint has been
Don Baxter has become a widespread authority on the expanded and the ever elusive topic of subtalar instability
diagnosis and treatment of athletic injuries to the foot has been addressed and hopefully clarified. We have
and ankle. It is an ominous task to improve on this text. added a chapter on new advances in the treatment of
In fact, our attempt with the second edition is to update the foot and ankle. We have tried to focus more on the
the already authoritative text and provide the same rehabilitation needs in the chapter on Unique Problems
authoritative resource today. in Sports and Dance. We have also added a new chapter
We have decided to keep the basic format with sec- on the principles of rehabilition for the foot and ankle.
tions on Athletic Evaluation, Sports Syndromes, Ana- The advancements in treatment for athletic injuries to
tomic Disorders, Unique Problems in Sports and the foot and ankle have continued to explode. We have
Dance and a section on shoewear, orthoses, and rehabil- therefore updated each chapter to keep the clinician at
itation. We hope you have enjoyed this approach and the forefront of this exciting field. We have tried to keep
find it helpful to your treatment of athletes and sports the length similar so as to be an easy access for all health
enthusiasts. care providers. The field of sports medicine of the foot
We have memorialized the chapter provided by and ankle has become global in its scope, therefore the
the late Ken Johnson, MD, by having one of his former reader will note a more international flavor to the
fellows compile this chapter. We have expanded the chap- authorship of this edition.
ter on trauma to focus on the treatment of ankle fractures We hope you enjoy this edition of the foot and ankle
(both acute and stress), midfoot ligamentous injuries and in sport. We have enjoyed working with our contributor
occult fractures of the foot and ankle. We have included friends and colleagues in the field of foot and ankle
a chapter on the problematic stress fractures also. The sports medicine. We have also enjoyed thinking of our
section on ankle injuries has been focused more closely readers and their needs and interests. We hope this edi-
on ankle instability, ankle sprains, and their updated tion meets all your interests, needs, and expectations.
xi
...........
........................................... C H A P T E R 1
Assessment and treatment of the elite athlete:

helpful hints and pertinent pearls
Donald Baxter and Lew Schon
......................
CHAPTER CONTENTS
#1. Look at the big picture 3 #12. Plan twice, cut once 12
#2. ‘‘Conservative treatment was exhausted’’ may #13. A stealthlike incursion should leave ne’er a trace 13
mean only that the athlete and medical team
were exhausted 4 #14. Minimize surgery and maximize recovery 15
#3. Conservative care may not conserve resources 5 #15. Identify injuries that are at high risk for failure 15
#4. Patience and relative rest are virtues 6 #16. A little instability can go a long way: keep both
eyes open 16
#5. Think about the nerves 7
#17. When is it okay to ‘‘spare the rod and spoil the
#6. The tarsal coalition can be the great masquerader 10 athlete’’? 18
#7. Timing should never be underrated 10 #18. Work backward in establishing a return to sport
protocol 18
#8. Location, location, location 10
#19. Everyone loves a winner 21
#9. Despite #8, it is better to be lucky than good 11
#20. It is better to have no publicity than bad publicity 21
#10. A quick fix may buy time 11
Conclusion 25
#11. Sometimes it is better to go for the base hit 11
Although this textbook contains sections on specific addition, other general sports activities should be noted,
entities, there are broader themes that must be consid- such as details about the gear; the surfaces; the opponents,
ered. The authors have compiled a list of their favorite teammates, and partners (dance); and the sporting envi-
pearls and highlighted them with case presentations. ronment. Training factors should be documented, espe-
The list is by no means profound or comprehensive, cially the duration, intensity, and frequency of events, as
but like a mantra recited during meditation, it still can well as the warm up and cool down. Motivational drives
be a source of inspiration or focus. These points cut and the way that the condition is perceived relative to
across many situations and can facilitate the assessment future ambitions are enlightening. Nutritional issues,
and care of the elite athlete. general health, medical history, medications, vitamins
and supplements, and prior surgeries or traumas often
may be revealing.
#1. LOOK AT THE BIG PICTURE
The physical examination should be performed ac-
cordingly, taking both wide and focused perspectives
The proper history and physical examination is com- and juxtaposing the examination with static and dynamic
pleted by keeping the big picture in mind and obtaining appraisals. The athlete should be observed during normal
contributory static and dynamic factors that affect standing, walking, and sitting, as well as running or
the athlete. This approach includes appreciating the performing the particular maneuvers of the sport or dance.
patient’s experience with the condition or injury; the The musculoskeletal system, especially the lower extremi-
character of the symptoms; the duration and onset of ties, warrants evaluation, because any one area can affect
the problem; aggravating and ameliorating factors; and the foot and ankle and the clinician may find clues that
a description of the specific offending activity. In are useful to determining a diagnosis and treatment. The
CHAPTER 1 Assessment and treatment of the elite athlete: helpful hints and pertinent pearls
synthesis of these protean elements can be challenging but second toe. After a slow start to the season and requisite
carries a high reward for observing the human body at its reassurance, the pitcher won 22 games using a simple
finest physical performance. device (Fig. 1-1).
Another Major League Baseball player had ankle and
hindfoot symptoms that were felt to limit his hitting.
The ankle and hindfoot examination was unremarkable,
#2. ‘‘CONSERVATIVE TREATMENT WAS
with good stability, alignment, and strength. An exami-
EXHAUSTED’’ MAY MEAN ONLY THAT
nation of the whole musculoskeletal system brought to
THE ATHLETE AND MEDICAL TEAM
light an obvious genu varus, which resulted in varus of
WERE EXHAUSTED
the ankle and the subtalar joint. When watching him
simulate his swing, we noted that his ankle would subtly
In treating the elite athlete, as with treating any athlete invert. By placing an off-the-shelf lateral wedge into
or patient, there is an evaluation process that must the shoe, the player was able to get a better stance and
include conservative consideration of all options before more stability while batting and was able to increase
invasive treatment may be instituted. The orthopaedic his batting average significantly, winning the major
foot and ankle and or sports medicine subspecialist must league batting title (Fig. 1-2).
know the condition, its etiology, and its natural course. A professional quarterback asked for the opinion of
Timing relative to the disease state and the activity three foot and ankle subspecialists. His ruptured
requirements is critical and must influence the approach. Achilles tendon had been repaired one season before
Operative treatment might be considered with the elite the examination. The repair had stretched out and did
athlete, whereas conservative treatment would be used not allow adequate push-off. After careful discussion
with the high school athlete and nonathlete having the by the three orthopaedists who saw the quarterback
same problem. Although simple and complex nonsurgi- simultaneously, it was decided to treat the elongated
cal techniques exist for every orthopaedic malady, do and weak tendon conservatively with an ankle-foot
not assume that the solution was applied appropriately orthosis (AFO). This AFO was made with a plantar
or completely for the elite athlete. Often, a thorough assist by using an anterior tibial stop for the AFO
evaluation of the dynamic and static conditions that (Fig. 1-3). The Hall of Fame quarter back played three
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 reas-
sessments 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 con-
sidered 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 every-
one 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 straight-
forward 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 pha-
langeal ligament and the medial head of the flexor hallu-
cis brevis tendon. After talking to the trainer, agent, Figure 1-1 Hallux valgus toe spacer is a useful means of
team doctor, and orthotist, we designed and custom conservative treatment for a metatarsophalangeal (MTP) cap-
made a spacer to fit between the great toe and the sular or ligamentous injury.
4
...........
#3. Conservative care may not conserve resources
#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 conserva-
tive 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 syndes-
motic tenderness. There were concerns about potential
hardware prominence interfering with the skate if an
open reduction internal fixation (ORIF) were per-
formed. This would delay return to play until after the
Figure 1-2 Several views of wedged heel shock absorbers, hardware was removed. Given the nature of this injury
Anti-Shox by Apex (Teaneck, NJ). to heal quickly and uneventfully, it was decided to treat
the ankle fracture without surgery. The ankle was placed
more seasons with a similar brace and never had addi- in a cast and the player was kept nonweight bearing for 6
tional surgery to the Achilles tendon. weeks, then given a removable, off-the-shelf, boot brace.
A top-level and highly paid National Basketball Asso- He resumed conditioning and ankle strengthening pro-
ciation (NBA) star sustained within 1 year three sequen- gressively with low-impact activity and then subse-
tial injuries to his Achilles tendon that were diagnosed as quently began skating. At 3 months, he still had
partial tears. Following each injury, addressed by brief tenderness, focal edema, and warmth, and could not
bouts of conservative treatment (physical therapy [PT], skate aggressively or confidently enough to perform
nonsteroidal anti-inflammatory drugs [NSAIDs], and choppy sprints or to make quick stops and precision
rest), he was aggressively encouraged to continue to play turns. He also was concerned about getting checked
despite persistent pain, swelling, and dysfunction. His and sustaining a complete fracture. The x-ray and com-
third injury during the playoffs was the most incapacitat- puted tomography (CT) scan (Fig. 1-5, D) performed
ing, both physically and emotionally. He lost faith in his at 3 months showed approximately 20% healing along
doctors, whom he felt had allowed him to be reinjured the proximal posterior aspect. All parties were frustrated,
by trivializing his trauma as insignificant. Much to the and the team suffered without his talent. Treatments
frustration of the team management, doctors, and fans, discussed included operative and nonoperative modal-
he decided to wait for complete resolution of the swelling, ities. Among all parties—trainers, manager, team doctor,
pain, and weakness before resuming play and missed and the patient—it was agreed that we perform shock
numerous games. Further opinions were sought to bring wave treatment of the delayed union with the Sonocur
the situation to resolution. The nonsurgical solution that extracorporeal machine (which requires no local or gen-
we initiated satisfied all parties and permitted return with eral anesthetic), begin an EBI bone stimulator (EBI,
protection. A flexible plastic molded poster shell AFO, Parsippany, NJ), and fabricate a custom-molded, plastic
fabricated for each game (to avoid sudden and potentially AFO that could be worn in a sneaker. The patient
catastrophic fatigue failure of the device), reduced the continued to advance in his low-impact skating and
strain on the Achilles tendon while allowing somewhat nonskating workout, using the brace and bone stimula-
restricted and controlled mobility. With the device, he tor when not conditioning. By two additional months,
returned to play after a 6-month hiatus and experienced the fracture had progressed to 60% healing and the
progressive restoration of confidence while the injury symptoms had abated to allow return to aggressive
continued to heal (Fig. 1-4). skating during the playoffs (Fig. 1-5, E and F).
5
...........
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.
an Achilles stretching protocol, orthotic devices, and

#4. PATIENCE AND RELATIVE REST
a night splint, the fascia finally healed and he recovered.
ARE VIRTUES
It was a year filled with many office visits and requests
for a quick fix. Great runners and elite athletes often
A world record holder in the 100 meters had plantar fas- find it difficult to be patient. No one knows when or
ciitis and could not compete for 12 months. He cross if the condition will resolve. On our side is the knowl-
trained with water running, biking, and lower impact edge that most cases of plantar fasciitis (more than
activities to stay in shape. Ultimately, with the use of 90%) respond to conservative modalities by 12 months.
6
...........
#5. Think about the nerves
The risk of an unusual complication following plantar

#5. THINK ABOUT THE NERVES
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 Many patients with a deep posterior compartment syn-
course, 20/20 hindsight is everything. drome have pain at one specific area. This pain usually
Figure 1-4 AFO for Achilles tendinitis. (Courtesy of John Rheinstein CPO, New York, NY and Otto Bock
Healthcare, Minneapolis, MN.)
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.
(continued)
7
...........
Figure 1-5 cont’d. (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.
is isolated to the lower edge of the gastrocnemius on the syndrome. Occasionally, a specific nerve conduction test
medial side of the leg. With a history of chronic pain in and electromyogram (EMG) can pick up a delay of the
this compartment and a negative scan, exercise compart- tibial nerve in the leg. However, because the nerve
ment testing to rule out exertional compartment syn- entrapment is a functional entrapment from a hypertro-
drome is recommended. On occasion, despite normal phied muscle and a squeezing effect on the nerve, the
pressures, a local fascial release has been performed nerve conduction is not always positive. The symptoms
at the lower gastrocnemius, releasing what we have may result from a compressed tibial nerve, rather than
considered to be an isolated high tarsal tunnel from lack of oxygen to leg muscles.
8
...........
#5. Think about the nerves
Figure 1-5 cont’d. (F) Sagittal CT scan at 5 months shows bridging of >60%.
We have treated several elite athletes, particularly permit the cramping to subside and the leg pain to
track runners, who have presented with a cramping-type resolve.
sensation in the posterior calf in the midline area. After Similarly, an athlete with what appears to be lateral
a full evaluation of standard posterior calf pain (deep exertional compartment syndrome may be suffering
venous thrombosis [DVT], exertional compartment from superficial peroneal nerve entrapment. This may
syndrome, muscle tear, and so forth), we have attributed present with normal compartment pressures. One
the pain to a sural nerve fascial constriction. Releasing should be aware that this condition may occur because
fascia around the sural nerve in this isolated area may of an unstable ankle. In the latter cases, not only does
9
...........
a superficial peroneal nerve have to be released, but the affected nerve, proximal to the transverse metatarsal
unstable ankle must be repaired as well. There are ana- ligament.
tomic 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 physi- #6. THE TARSAL COALITION CAN BE
cians realize. The medial plantar nerve may become THE GREAT MASQUERADER
entrapped at an isolated area at the knot of Henry.
Abnormal range of motion may lead to a squeezing
When treating the younger, promising, future elite ath-
effect by the hypertrophied abductor hallucis muscle.
letes, remember to consider the possibility of a tarsal
A minimal incision releases the medial plantar nerve;
coalition. Unlike the descriptions in the literature that
because it is relatively deep, care must be taken to avoid
portray the peroneal spastic flat foot, the tarsal coalitions
damage.
in athletic individuals present as chronic ankle sprains;
The anterior tarsal tunnel syndrome also is fascinating
chronic calcaneal, navicular or talus stress fractures; pos-
because the deep peroneal nerve may be irritated for sev-
terior tibial tendinitis; tarsal tunnel syndrome; sinus tarsi
eral reasons. It can be compressed because of a func-
syndrome; peroneal tendinitis; ankle impingement; or
tional instability of the ankle or the talonavicular joint.
even Achilles tendinitis. They rarely have peroneal spas-
The treatment includes a minimal release by cutting
ticity and typically do not have deformities. Often, sub-
the inferior edge of the retinaculum and then carefully
talar motion will be restricted but may not be eliminated.
removing dorsal bone from the talus or navicular bone
The x-rays may not show the coalition because they may
(Fig. 1-6). The lateral branch of the deep peroneal nerve
be incomplete, fibrous, or cartilaginous. MRI, CT scan,
may be compressed by the fascia of the extensor brevis
and/or technetium (Tc) bone scan may be needed to
muscle, causing a sinus tarsi pain. This is an often-over-
identify the site and extent of the coalition (Fig. 1-7).
looked cause of the sinus tarsi syndrome. In this situa-
tion, 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 #7. TIMING SHOULD NEVER BE
the causative structure, but the physician always must UNDERRATED
evaluate for ankle instability, as well. We do not recom-
mend transecting this nerve branch as a means of reduc-
ing the pain. Some of the hardest injuries to treat include the non-
Interdigital nerves are either entrapped and cut by displaced navicular stress fracture, the nondisplaced
the edge of the transverse metatarsal ligament or bul- medial-malleolar stress fracture, the nondisplaced Lis-
bous from chronic compression and scarring of the franc strain, and the high ankle sprain. With many of these
nerve. If the entrapment is treated before the nerve injuries, bone stimulators, cast immobilization or brac-
ing, rest, careful PT, and, occasionally, well-placed percu-
becomes ‘‘scarred and bulbous,’’ then a simple release
taneous screws are invaluable. Yet the most influential
of the intermetatarsal ligament may be considered.
factor is time. Insufficiency in this latter element may lead
If the nerve is bulbous, we prefer to remove the
to more complicated problems, such as displaced frac-
tures 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, cer-
tain stress fractures, such as the latter, can be managed
less aggressively.
A world record-holding, female, middle distance run-
ner presented with a fibular stress fracture 4 cm above
Figure 1-6 Lateral radiograph of a dorsal osteophyte on na- ankle joint. She had excellent strength; good hip, knee,
viculum caused a deep peroneal neuralgia. leg, and ankle biomechanics; and no ankle instability
10
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#11. Sometimes it is better to go for the base hit
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 tender-
ness 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.
medially or laterally. She had some forefoot supination surgical trauma while reinforcing the weakened bone.
that was felt to cause a valgus moment at her ankle while The odds were not in our favor, but luck was. After
she was striding. After careful analysis of her condition, the season, two small screws and a bone graft were used
it was agreed that she could, with use of a semirigid in the navicular, preventing reoccurrence in a 5-year
orthotic, run one race that she and her trainer felt was professional basketball career (Fig. 1-8).
essential for her preparation for the World Champion-
ships. The plan was that, following this event, she would
then do easy training for two and a half weeks before her
#10. A QUICK FIX MAY BUY TIME
next big race. During the event, not only were the
symptoms controlled but she had the greatest race of Unlike the aforementioned case, an NCAA college bas-
her career, winning the world championship as her East- ketball center presented with a nonhealing proximal
ern European challenger fell, chasing her at the finish. second metatarsal fracture (about 1.5 cm distal to the
metatarsocuneiform [MTC] joint) several weeks before
the beginning of the season. The decision was made to
#9. DESPITE #8, IT IS BETTER TO place a screw across the fracture percutaneously and drill
BE LUCKY THAN GOOD the nonunion site. Eight weeks later, the center was able
to return to play. At the end of the season, the symp-
toms were escalating to the preseason level. After the
One National Collegiate Athletic Association (NCAA) season, the fracture underwent open bone grafting and
center for a Final Four basketball team sustained a non- insertion of a larger screw, and full recovery was permit-
displaced navicular fracture. The athlete used both ted during the off season (Fig. 1-9).
a high-intensity ultrasound machine and a bone stimula-
tor for a month before gradually resuming play with an
arch support. Two months after the injury, he played
#11. SOMETIMES IT IS BETTER TO GO
in the National Championship game without advancing
FOR THE BASE HIT
to a complete fracture. This was a risky choice; a better
option would have been to fix the fracture percutane- A middle distance runner was felt to have first tarsome-
ously without open grafting, in order to minimize the tatarsal (TMT) instability with hallux valgus, second
11
...........
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.
metatarsophalangeal (MTP) subluxation, and lesser two Olympics and set an American record on the roads
metatarsal overload. A Lapidus procedure with MTC (Fig. 1-10).
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,
#12. PLAN TWICE, CUT ONCE
a chevron bunionectomy was performed, ignoring the
first TMT instability. The runner did have a recurrence Treatments should be reviewed and rereviewed and
10 years later, but that was after he had participated in should stand up to scrutiny readily provided by the
12
...........
#13. A stealthlike incursion should leave ne’er a trace
Figure 1-8 cont’d. (C and D) Two small screws were inserted from the medial pole.
athlete, family, coach, trainer, and agent. Similarly, it does permit concerted preoperative appraisal. Any
when devising a surgical plan, it always is useful to ‘‘wasted’’ time often will be recouped intraoperatively
review all the other alternatives for one’s own benefit, or postoperatively.
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 associa-
#13. A STEALTHLIKE INCURSION SHOULD
ted conditions, the rehabilitation, return to sport,
LEAVE NE’ER A TRACE
and lifelong function beyond sports. Even though
the exercise of mapping out the screw placement or Our philosophy with the elite athlete is to restore the
osteotomy is tedious or may be considered remedial, anatomic structure with the least surgery possible and
13
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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) demon-
strates 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.
14
...........
#15. Identify injuries that are at high risk for failure
#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 tib-
ial 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 accom-
plished 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
Figure 1-10 Preoperative x-ray of an elite runner with inadvertent talonavicular joint penetration. A splint was
hallux valgus and second metatarsophalangeal (MTP) joint applied following surgery. This was replaced by a brace
instability who ultimately had a chevron bunionectomy that was worn for 16 weeks. A heel lift was used for 6 to
instead of a Lapidus and second MTP joint procedure, as 8 weeks subsequently. Rehabilitation succeeded in per-
recommended elsewhere. mitting this athlete to resume his career and to set the
American pole vault record on his repaired foot.
#15. IDENTIFY INJURIES THAT ARE AT HIGH

RISK FOR FAILURE
then use a functional recovery. When surgery is per-
formed, the tissues should be minimally disturbed.
One should know where to go, not dissect widely, avoid Stress fractures of the medial malleolus, especially ver-
disrupting soft tissue planes, save neurovascular struc- tical type stress fractures, need a vertical repair, not a
tures, do the repair, and take care on the way out. Post-
operative management should allow rehabilitation
without compromising the integrity of the reconstruc-
tion. 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 Figure 1-11 Spring ligament repair. The torn spring ligament
sprinter was running aggressively by 9 months, and, by is seen after the posterior tibial tendon sheath is opened.
1 year, full-out sprinting was comfortable. The sprinter The triangular open arrow demonstrates the posterior tibial
came back in 18 months and ran the fastest 60-m indoor tendon, the solid arrow points to the naviculum, and the open
race of the year despite this potentially career-ending arrow shows the talonavicular ligament and spring ligament.
injury. The inset displays the ligament being held by forceps.
15
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horizontal repair. If a horizontal typical medial malleolar An NBA guard had a vertical stress fracture with a
screw is used in a vertical stress fracture of the medial medial malleolar screw and bone graft. The fracture
malleolus, the stresses are not adequately removed to healed; however, the following year, an additional frac-
allow healing, making it possible for the fracture to recur ture occurred in the same area and had to be fixed with
and the screw to break. For that reason, a buttress plate a buttress plate and bone graft (Fig. 1-14). Following
on the medial malleolus should be used to relieve the treatment, the NBA guard has been able to play for
vertical stresses (Fig. 1-12). 3 years with no further problems, playing 30 out of
One sprinter with an injured ankle and a medial mal- 48 minutes in each game. Functional problems with
leolar stress fracture was treated with nonweight-bearing biomechanical stresses need repair, eliminating those
activity and with conservative care for 2 months. His stresses that caused the injury.
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
#16. A LITTLE INSTABILITY CAN GO A LONG
athletes have had these vertical fractures, particularly
WAY: KEEP BOTH EYES OPEN
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 Some joints are susceptible to ligamentous damage that
vertical fractures, extending above the articular cartilage, can present with occult instability and therefore are
the stress fracture should be curetted and small local often overlooked. Nearly all physicians can identify lat-
bone graft should be injected; then a medial buttress eral ankle ligamentous injuries, but what about the
plate should be used to remove the vertical stresses. spring ligament, the anterior deltoid, the Lisfranc liga-
ment, 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 tap-
ing the great toe. If there is a complete rupture or third-
degree turf-toe type injury, there may be complete separa-
tion of the sesamoids from the proximal phalanx with rup-
ture 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 maneu-
ver and checking flexor hallucis longus (FHL) and flexor
hallucis brevis (FHB) function may reveal the deficit. Fur-
ther 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 condi-
tion 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).
The plantar plate injury in the lesser MTP joints also
Figure 1-12 This medial malleolar stress fracture was unrec- can be a ‘‘small’’ problem with grave consequences if
ognized and went on to complete fracture. Notice the medial the joint subluxates or, even worse, dislocates. This is
talar osteophyte. The fracture was fixed with horizontally particularly true when there is a long second metatarsal.
placed compression screws and an Ace Depuy (Warsaw, IN) Again, early recognition with the anterior draw test and
fibular plate. varus/valgus stresses is paramount. Although further
16
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#16. A little instability can go a long way: keep both eyes open
Figure 1-13 The magnetic resonance imaging (MRI) showed this medial malleolar stress fracture that healed
following conservative treatment.
subluxation of the second metatarsophalangeal joint

may be prevented by initially treating a plantar plate
strain of the metatarsal phalangeal joint (including plan-
tarflexion 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 signifi-
cantly, either acutely or chronically, surgery must be
considered (Fig. 1-16). In this case, a second MTP dis-
location 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).
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 Figure 1-14 (A) The x-ray shows a medial malleolar stress
in the high-performance athlete. If the anterior deltoid fracture.
ligament is torn from the medial malleolus or off the (continued)
17
...........
Figure 1-14 cont’d. (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.
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.
#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 bal-
let 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
Figure 1-15 Sagittal magnetic resonance imaging (MRI) fractures once this tibial stress fracture heals from
demonstrates the rupture of the plantar plate (solid arrow
isolated drilling. It is imperative for the ballet dancer
shows retracted sesamoid; open arrow points to intact flexor
hallucis longus [FHL] tendon, which is directly plantar to the
or the athlete to avoid torque for 2 to 3 months before
rupture of the sesamoid phalangeal ligament). or after the drilling process so that the stress fracture
does not lead to a complete catastrophic fracture.
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 con-
#18. WORK BACKWARD IN ESTABLISHING
tinue to sublux forward in the ankle mortise. In severe
A RETURN TO SPORT PROTOCOL
injuries of the ankle in which there is a lateral malleolar
fracture and a diastasis, consider repairing the injury by One should realize that designing an appropriate return
plating the distal fibula and putting anchors in either to the sports program requires not only an appreciation
18
...........
#18. Work backward in establishing a return to sport protocol
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. 19
...........
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.
20
...........
#20. It is better to have no publicity than bad publicity
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 exer-
cises without pain or swelling, the dancer may begin
center work. The dancer should initially avoid pirou-
ettes, large jumps, or leaps. As soon as the dancer mas-
ters 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 continu-
ously assess the dancer’s signs and symptoms to ensure
that the reconstruction is not undone as these new
stresses are introduced.
Figure 1-18 Fibula stress fractures need to be evaluated
for medial ankle ligamentous instability and occult syndes-
motic instability. Although pain can be the best guide, stress
views and a magnetic resonance imaging (MRI) may be #19. EVERYONE LOVES A WINNER
helpful.
The easy cases that require little worry and intervention
are a pleasure to recap and ponder. The challenge is to
of the competition or performance schedule but an stay engaged with the ones that are not following the
assessment of the timing and requirements of a recondi- typical pathway. One should be prepared to get addi-
tioning program. The clinician should learn from the tional advice. At the least, the clinician should step back,
athlete, trainer, and coach what milestones and compe- clear the mind of any assumptions, and acquire new or
tencies are achieved in the typical preseason routine revisit old information about the case. This process of
and how long they take to be mastered. Next, knowing providing oneself with a second opinion generally is pro-
the magnitude of the injury and requisite recovery to ductive and will allow the less successful recoveries to
nonathletic baseline, one should anticipate the tasks switch to the winning category.
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
#20. IT IS BETTER TO HAVE NO PUBLICITY
the next level of activity.
A good example is a ballet dancer with chronic ankle
THAN BAD PUBLICITY
instability who undergoes a lateral ligament reconstruc-
tion. To return to high-level dance, he or she must It is the athlete’s business to converse with the public
achieve not only full range of motion, strength, stability, through the media. The clinician must respect the
and proprioception but also endurance. In our basic wishes of the patient and his or her team for confidenti-
protocol, the athlete is off the foot and in a posterior ality. These days it is the law. The clinician’s glory will
splint for 10 to 14 days after surgery. Then a boot brace come in a quieter manner long after the fans have lost
is applied and the athlete is allowed to be fully weight intense interest as the athlete manages to return without
bearing. During this time, a strengthening program is a relapse or reinjury through the season. One should let
initiated and the ankle can be put through a range of the agents, athletes, and team handle the press. In ad-
motion from maximum dorsiflexion to 30 to 40 degrees dition, a worse situation is the negative press associ-
of plantarflexion, avoiding any inversion. Cardiovascular ated with failure or a complication, whether or not the
workout can be achieved using an exercise bike or physician was responsible.
21
...........
Figure 1-19 (A) This is an athlete whose magnetic resonance imaging (MRI) demonstrated a fibula stress frac-
ture (open arrow);
(continued)
22
...........
#20. It is better to have no publicity than bad publicity
Figure 1-19 cont’d. (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).
(continued)
23
...........
Figure 1-19 cont’d. (C) The coronal MRI views demonstrate the syndesmotic injury (regular and open arrows).
24
...........
Conclusion
by issues, trainers, coaches, agents, team physicians,

owners, and other consultants who influence the inter-
action. The big picture is visualized so that the static
and dynamic factors can be assessed. Odd condi-
tions present with uncharacteristic symptoms, and stan-
dard conditions may manifest in peculiar ways. The
physician should think profoundly to determine the
diagnosis and then create a customized treatment algo-
rithm that incorporates conservative and surgical modal-
ities. One should provide honest and evidence-based
opinions.
The timing obviously is important. Being cost con-
scious is laudable, but the cost of a conservative or sur-
gical 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 recon-
struction 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
Figure 1-20 The white arrow delineates the ‘‘dreaded black her immediate family and should involve the trainers,
line’’ of the established tibial stress fracture. 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
CONCLUSION keep an open and creative mind, work hard, treat people
with dignity, and enjoy the journey. Once the athlete,
The elite athlete presents a wide variety of challenges the trainer, and the agent see positive outcomes,
that require a keen knowledge of anatomy, biome- other cases will follow and the physician will slowly
chanics, physiology of healing, and psychology to inter- develop a good reputation for being a doctor who treats
pret. Usually the physician and athlete are surrounded winners.
25
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........................................... C H A P T E R 2
Impingement syndromes of the foot and ankle

William G. Hamilton, Mihir M. Patel, and Roman A. Sibel
......................
CHAPTER CONTENTS
Introduction 29 Specific anatomic areas 29

General technique tips for osteophyte removal 29 References 43
INTRODUCTION 2. Make the skin incisions carefully to avoid inci-

sional neuromas. Nothing is more discourag-
ing than a good clean-out that is spoiled by a
‘‘Impingement’’ is derived from the Latin verb impin-
hypersensitive scar.
gere, meaning ‘‘to force against.’’ The periosteum is
3. Be sure to get all the osteophytes out; there can be
composed of two layers: the superficial (fibrous layer)
hidden spurs or more than one. If there is any
and the deep (cambium) layer. The cambium layer has
doubt, it is best to take an x-ray in the operating
osteogenic potential. This can be seen following condi-
room at the end of the case to make sure nothing
tions that strip the periosteum from the underlying
has been missed.
bone (e.g., tumors and fractures). In impingement,
one bone’s repetitively striking the other can stimulate
the cambium layer to form osteophytes. Once the osteo-
phytic prominence forms, impingement occurs more SPECIFIC ANATOMIC AREAS
easily, so that the impingement spur, once formed, often
increases in size and eventually may break off, forming
a loose body. Conservative treatment should be aimed The interphalangeal joint of the hallux
at breaking this repetitive cycle so that the impingement Dorsal impingement with spur formation similar to
spurs do not enlarge and produce irritation. In ballet that seen in the first metatarsophalangeal (MP) joint
we tell the dancer not to ‘‘hit bottom’’ in the plié can occur in this joint. It can be a sign of degenerative
(knee-bend) when he or she lands from a jump and joint disease (DJD) but usually is secondary to stiffness
the ankle is forced into maximal dorsiflexion. These and lack of motion in the adjacent MP joint. When
restrictions often are difficult to follow or are too re- hallux rigidus forms in the first MP joint, the inter-
strictive. Therefore if the symptoms warrant, and con- phalangeal (IP) joint will be forced into excessive dorsi-
servative treatment is not working, surgery usually is flexion in an attempt to compensate for the lack of
indicated. motion in the proximal joint. At times this can be dra-
matic. I once saw a female dancer who was born with
congenital ankylosis of both first MP joints. They were
totally rigid. She had Grecian (Morton’s) feet with
GENERAL TECHNIQUE TIPS FOR
short first rays and had developed 90 degrees of dor-
OSTEOPHYTE REMOVAL
siflexion in her IP joints so that she had a full demi-
pointe relevé. Rigidity in this joint can be treated
1. Get adequate exposure and visualization. If one is similarly to the condition found in the first MP joint.
using the arthroscope and struggling, one should One should remember, however, that this joint is
open it up and do the job right. forgiving, and surgery is rarely necessary.
CHAPTER 2 Impingement syndromes of the foot and ankle
The lesser metatarsophalangeal joints

Dorsal impingement in these joints usually is associated
with Freiberg’s disease.1 This condition is no more
common in athletes and dancers than it is in the general
population. One should remember, however, that it
can be symptomatic for as long as 6 months before it
appears on x-ray and should be considered in unex-
plained metatarsalgia in young patients. A bone scan or
magnetic resonance imaging (MRI) usually will confirm
the diagnosis before plain radiographic changes are
evident. Freiberg’s infarction comes in the following
four variations.1
Type I
The head of the metatarsal (MT) dies and then heals by
‘‘creeping substitution’’ (Phemister2). In this form it Figure 2-1 A rare case of multiple Freiberg’s disease.
may heal completely, with little or no collapse, leaving
the articular surface intact and almost as good as it was
before the event occurred. Surgery often is not necessary.
Type II
The head collapses during revascularization and the
articular surface settles and remains intact, but periph-
eral osteophytes form along the dorsal margin of the
joint, limiting dorsiflexion. This type is amenable to
a dorsal clean-out (cheilectomy), which should leave
the joint intact and restore dorsiflexion. (The surgeon
should remember to remove more bone than he or she
thinks is necessary when performing this operation.)
Type III
The head collapses and the articular surface loosens and
falls into the joint, leaving the joint totally destroyed. Figure 2-2 ‘‘Boxer’s fracture’’ of the distal fifth metatarsal
Obviously simply removing the osteophytes will not (arrow).
suffice in this case—an arthroplasty is required. All the
necrotic bone must be excised from the MT head and
all the dorsal osteophytes must be removed. Usually
the plantar portion of the head is left when this has been Lesser MP joint instability
done. The surgeon should be generous in the excision Metatarsalgia is not common in the young, healthy
to permit full dorsiflexion later, but the entire MT head athletic population. When it is encountered, one should
should not be removed. Either a dorsiflexion osteotomy suspect either early Freiberg’s disease or MP instability.1
of the MT head or a capsular arthroplasty, similar to the This subtle problem often goes unrecognized because
one described for use in the first MP joint, can be useful the x-rays are normal. The patient presents with isolated
in this situation. metatarsalgia. There is plantar tenderness under the MT
head and dorsal tenderness where the phalanx sub-
Type IV luxes on top of the head when the patient relevés or
Multiple heads are involved in the process (Fig. 2-1). goes up on the ball of the foot. The subluxated phalanx
This type is rare and actually may be a form of epiphyseal pushes the head of the metatarsal downward, produc-
dysplasia. Each MT head must be evaluated and treated ing the metatarsalgia, the so-called dropped metatarsal.
individually. It is recognized easily on physical examination if one
A Freiberg-like syndrome can occur in the fifth MT remembers to observe for it. The Lachman test of
head following a nondisplaced or minimally displaced the MP joint will be positive.1 The base of the proximal
fracture of the distal MT shaft, similar to the ‘‘boxer’s phalanx is grasped in the fingers, and a dorsal-plantar
fracture’’ of the fifth metacarpal (Fig. 2-2). force is applied. The instability is recognized easily
30
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Specific anatomic areas
inflammatory medication; and, if necessary, giving the

patient one or two (at most) intra-articular injections
of steroids. If this fails, exploration and appropriate sur-
gery are indicated. Surgical options include (1) extensor
tendon lengthening with resection of the plantar con-
dyles of the MT head, (2) Girdlestone-Taylor3 proce-
dure, (3) DuVries-type arthroplasty,3 and (4) resection
arthroplasty with partial syndactyly to the adjacent digit.
Medial midfoot impingements

True impingements in the midfoot are rare. Occasion-
ally, accessory ossicles can be seen between the bases of
the metatarsals or the cuneiforms; symptoms may war-
rant their removal. These bones, more often than not,
will be asymptomatic.
An isolated osteophyte on the dorsum of the midfoot
Figure 2-3 Lachman test of the metatarsophalangeal (MP)
joint.
occasionally can cause entrapment of the deep peroneal
nerve or irritation of the extensor hallucis longus (EHL)
tendon as they pass over it. Initially, extra padding on
the undersurface of the tongue of the shoe may resolve
when the phalanx subluxes on the top of the MT head pain. If this fails, removal of the osteophyte may be neces-
(Fig. 2-3). sary. The painful accessory navicular is not due to an
Conservative treatment consists of padding to unload impingement and is discussed in Chapters 8, 14, and 27.
the painful MT head and taping or wearing a toe
retainer to try to control the instability (Fig. 2-4). It
often is a frustrating situation for the dancer or athlete
because he or she does not want to undergo surgery,
but once the ligaments and plantar plate are stretched,
they can be tightened again only by surgery. The surgi-
cal options for this problem in a dancer are tricky. The
usual operations for this condition (stabilizing pro-
cedures such as the Girdlestone-Taylor operation3) are
inappropriate for athletes because they stabilize the
joint but also limit dorsiflexion—an unacceptable solu-
tion for dancers, gymnasts, and so forth. We have had
success in a limited number of dancers and athletes with
a resection arthroplasty and partial syndactyly, especially
in the fourth MP joint, which seems especially prone
to this problem. As previously noted, one should not
remove too much of the proximal phalanx (one-fourth
to one-third at most), and one should remove the plan-
tar condyles of the MT head, use a toe wire, and remove
it early (2 weeks).
Idiopathic synovitis
Idiopathic synovitis4 is characterized by MP swelling,
the so-called sausage toe. Its cause is controversial. (It
usually is not caused by systemic inflammatory diseases,
but of course these must be ruled out.) It usually is
associated with laxity of the joint and MP instability.
Whether the looseness irritates the joint and leads to
chronic synovitis or the synovitis loosens the joint is
not known. Conservative therapy involves stabilizing
the joint by using tape or toe retainers (see Fig. 2-4); Figure 2-4 Taping to control metatarsophalangeal (MP)
having the patient reduce activities and take anti- instability.
31
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Lateral midfoot impingements

In the lateral midfoot, three related conditions are
a combination of impingement and subluxation: (1)
derangement of the cuboid—base of the fourth and fifth
metatarsal joints, (2) cuboid subluxation, and (3) sinus
tarsi syndrome.
Subluxation of the cuboid5 and derangement of the
cuboid—base of the fourth and fifth metatarsal joints—
often are seen together. The subluxing cuboid is a com-
mon but poorly recognized condition. It presents as
lateral midfoot pain and an inability to ‘‘work through’’
the foot. Pressing on the plantar surface of the cuboid
in a dorsal direction is painful. The normal dorsal-plantar
joint play is reduced or absent when compared with the
uninjured side. (Because of this immobility, the con-
dition sometimes has been referred to as a ‘‘locked
cuboid.’’) Often there is a shallow depression on the
dorsal surface, a palpable fullness on the plantar aspect
of the cuboid, and subtle forefoot valgus. Documenta-
tion by x-ray, computed tomography (CT) scan or
MRI is difficult because of the normal variations found
in the relationship between the cuboid and its sur-
rounding structures. The diagnosis must be made on
the basis of the history and physical findings. Treatment
involves recognition of the pathology and manual Figure 2-5 A ‘‘dropped’’ fourth metatarsal head resulting
reduction by a therapist or physician familiar with the from elevation of its base. (From Marshall PM, Hamilton WG:
condition and follow-up to be certain that it remains in Am J Sports Med 20:170, 1992.)
place. Therapists and orthopaedists involved in the care
of athletes and dancers should be aware of the subluxed sinus tarsi, and forceful abduction-pronation of the heel
cuboid and be able to recognize it when it occurs. When and midfoot may be painful. The condition usually can
the cuboid subluxes plantarward, the bases of the fourth be confirmed with an injection of 0.5 ml of lidocaine
and/or fifth metatarsals often are elevated, causing the into the trigger point. If the pain is relieved by the local
head of the fourth metatarsal to be depressed (Fig. 2-5, anesthetic, a second injection of 0.15 ml of cortico-
Table 2-1). steroids often can be highly effective. The condition is
There usually are two types of cuboid subluxations: thought to have several etiologies: (1) soft tissue entrap-
acute and chronic/recurrent. Treatment consists of rec- ment or partial tear of the interosseous talocalca-
ognition and manual reduction by a therapist familiar neal ligament, (2) osteophyte impingement (Fig. 2-7),
with the condition. The cuboid then must be held in (3) neural entrapment (motor nerve to the extensor
place by taping and padding for several weeks to prevent digitorum brevis [EDB]), (4) degenerative arthrosis,
recurrence. If the subluxation has gone unrecognized
and the joint has been subluxed for any length of time,
reduction can be difficult. The forefoot valgus must be Table 2-1 Cuboid subluxation
corrected and the lateral column lengthened manually
before the reduction can be performed. In the chronic Symptoms Signs
condition, it may not be possible to keep the cuboid
reduced if it goes in and out at random. In these cases, Lateral midfoot pain Tender plantar mass
athletes often can be taught to reduce the subluxation
Weakness in push-off Decreased joint play
themselves (Fig. 2-6).
Sinus tarsi syndrome4 is a controversial condition that Inability to ‘‘work Shallow depression
produces pain deep in the sinus tarsi that increases with through’’ the foot over the cuboid
activity and is exacerbated by impact (jumping and run-
ning) and pronation. It is often, but not always, a sequel Function limited by pain Subtle forefoot
to a sprained ankle. On physical examination, there is abduction
discrete tenderness, or a ‘‘trigger point’’ deep in the
32
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from bleeding into the joint in conjunction with an

ankle sprain, can cause residual symptoms after the
sprain has healed.
Conservative treatment consists of anti-inflammatory
medication, physical therapy, a medial heel wedge or
arch support to open up the sinus tarsi, and, if necessary,
the previously mentioned cortisone injection. If symp-
toms persist and the diagnosis has been confirmed with
lidocaine injection, surgical exploration and clean-out
is indicated. This is one area in which an injection—
if placed in the right spot—often is dramatically effective
and will avoid surgery. Finally, the sinus tarsi syndrome
often is found in conjunction with lateral ankle ligament
laxity, and, in these cases, sinus tarsi exploration and
debridement should be considered if ankle ligament
reconstruction is planned. More about the subtalar joint
can be found in Chapter 15.
The ankle
When considering ankle impingement, one should
remember the basic anatomy of the ankle. The talus sits
sidesaddle on the os calcis so that the axis of the talus is
roughly in line with the first web space of the foot and
the axis of the os calcis is in line with the fourth web
Figure 2-6 Reduction of a subluxed cuboid by the patient. space (Fig. 2-8). In dorsiflexion, bony impingement
occurs anteromedially between the neck of the talus
and the anterior lip of the tibia. In plantarflexion, bony
impingement occurs posterolaterally between the os
calcis and the posterior lip of the tibia. Therefore
anteromedial and posterolateral problems usually are
associated with bony impingement, whereas anterolat-
eral and posteromedial problems usually are soft tissue
in origin (there is no bony impingement in these areas).
The anterior ankle is an extremely common location for
impingement, but impingements can be found in all
quadrants around the ankle: anterior, lateral, posterior,
and medial.
Anterior (medial, central, lateral)

Anteromedial ankle pain often comes from impinge-
ment of the anterior portion of the medial malleolus
against an impingement spur on the medial shoulder
of the talus. This spur is hard to see on x-ray because
Figure 2-7 Sinus tarsi syndrome; note osteophytes (arrow).
it cannot be visualized on standard lateral radiographs.
However, nonweight-bearing, oblique x-rays of the foot
may detect these spurs. The spur often can be palpated on
and (5) arthrofibrosis. It can be difficult to differentiate physical examination and should be looked for in any
this syndrome from subtalar dysfunction, and osteo- anterior ankle clean-out. It is easy to miss, the ‘‘hidden
phytes can be found in the sinus tarsi that are not caus- spur.’’ To visualize and resect this spur arthroscopically,
ing symptoms. The two areas are anatomically close the surgeon must hold the ankle in dorsiflexion.
together. One of the best ways to differentiate one from Anterocentral is the location of the classic anterior
the other is to pay close attention to subtalar motion. ankle impingement. It comes in the following four types:
Mann and Coughlin3 have shown how important subta- 1. Spurs are primarily on the lip of the tibia. This
lar motion is to normal foot mechanics. Subtle loss of type is ideal for arthroscopic debridement. Under
this motion, such as arthrofibrosis of the subtalar joint direct vision, the lip of the tibia can be removed
33
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back to a small anterior arthrotomy on these com-

plex cases, with the use of a headlamp and Army-
Navy retractors to allow adequate visualization.
4. Multiple anterior osteophytes can be present sec-
ondary to frank osteoarthritis of the ankle. Anterior
clean-out in these cases is of questionable effective-
ness and probably should not be performed for this
condition.
Anterolateral ankle pain usually is not due to bony
impingement because the tibia and talus do not come
together in this location. Difficulties in this area usually
are due to one of two conditions: Basset’s ligament
and Ferkel’s phenomenon.
Basset’s ligament7 is an abnormal distal slip of the
anterior tibiofibular ligament extending so far distally
on the lateral malleolus that the lateral shoulder of the
talus impinges against it when the ankle is plantarflexed
(Fig. 2-9). It is difficult to diagnose but, when present,
can be resected with the arthroscope.
Ferkel’s phenomenon8 is an accumulation of scar tis-
sue and synovitis in the anterolateral gutter of the ankle,
usually following trauma. It causes symptoms similar to
Figure 2-8 Axis of talus versus axis of os calcis.
Basset’s ligament and also is amenable to arthroscopic
debridement.
fairly easily with a thin osteotome or burr. Care Anterior syndesmosis pathology usually is not the
should be taken not to damage the dome of the result of impingement but can cause anterolateral ankle
talus, either by holding the ankle in maximal dor- pain that is exacerbated by dorsiflexion of the ankle
siflexion or by using an osteotome with blunt because the wide portion of the talus spreads the mal-
edges, as described by Scranton and McDermott.6 leoli and places tension on the anterior tibiofibular
2. Spurs are primarily on the neck of the talus. This ligament. There are three types of pathology:
type is more difficult to treat with the arthroscope, 1. A sprain of the syndesmosis, the ‘‘high ankle
because the osteophytes often are within the cap- sprain’’ sometimes can take an extraordinarily long
sular insertion on the neck of the talus, and it is time to heal.
necessary to strip off the capsule distally to visua-
lize the pathology. It is easy to miss some of the
osteophytes; therefore intraoperative imaging may
be needed to ensure adequate removal.
3. Spurs are present on both the lip of the tibia and
the neck of the talus, sometimes with loose bodies
that have broken off the osteophytes. This type is
common and is the most difficult to deal with. In
the early 1980s, I thought professional dancers
would return to dancing sooner if their anterior
debridement could be done with the arthroscope.
I found that, in all but the most uncomplicated
cases, it took 3 months for them to return
whether the operation was performed with the
arthroscope or with a small anterior arthrotomy.
Use of the arthroscope often was taking more
than an hour and required an x-ray to be certain
that I had not missed anything, whereas the
arthrotomy took 30 to 40 minutes and rarely
required intraoperative imaging. I thought that
I was doing a better job, with less surgical time, Figure 2-9 Basset’s ligament. (Arthroscopic view seen
with the open technique. I have therefore gone from the medial portal.)
34
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2. The Tillaux fracture is an avulsion fracture of the misdiagnosed as an ankle sprain, because routine
insertion of the distal tibiofibular ligament into plain radiographs often are read as normal. CT is
the tibia. On rare occasions, the avulsion can the study of choice for diagnosis. Surgical treat-
occur on the fibular side. ment options range from excision to open reduc-
3. Synovial hernias into rents in the tibiofibular tion internal fixation (ORIF), depending on the
ligament have been described.9 size of the fragment.14 Talus pathology is covered
The lateral ankle can be a complex site of pain and in more detail in Chapter 14.
discomfort, and an accurate diagnosis in this area can 4. An accessory ossicle, the os subfibulare, which had
be difficult. Symptoms in this area often have their onset been asymptomatic, can be loosened by injury and
following ankle sprains. The original trauma often can become symptomatic.
be mild—for example, a first-degree sprain with no 5. Avulsion fractures of the tip of the fibula can
resultant lateral instability. Cuboid subluxation and become trapped in or under the lateral ankle joint
the sinus tarsi syndrome were discussed earlier. Other and become symptomatic. The bony fragment
conditions to consider are as follows: often is in the insertion of the calcaneofibular lig-
1. The ‘‘meniscoid’’ of the ankle10 is thought to be ament. If it is small, it should be excised and the
soft tissue trapped between the lateral shoulder stump of the ligament sutured into the tip of the
of the talus and the lateral malleolus. McCarroll lateral malleolus. If it is large, it often can be reat-
et al.11 described this lesion in four soccer players tached with a screw or K-wire. Infrequently the
who had a history of frequent ankle sprains and, same situation can be found at the anterior edge
after failing conservative treatment, underwent of the lateral malleolus at the insertion of the
arthroscopic debridement of the lesion. After anterior talofibular ligament (ATFL) (Fig. 2-11).
appropriate rehabilitation, all four returned to
competition with cessation of symptoms, with
one player having only rare pain.
2. An avulsion fracture of the anterior process of the os
calcis12 is not an impingement. It is an avulsion frac-
ture of the origin of the EDB and EHB. It usually
can be seen on an x-ray (Fig. 2-10) and diagnosed
on physical examination by the specific tenderness at
the anatomic site or pain with pronation-supination
of the forefoot. Persistent symptoms may warrant
excision of the fragment (see Fig. 2-10).
3. Fracture of the lateral process of the talus13 also
can cause impingement beneath the lateral mal-
leolus. This fracture has been labeled the ‘‘snow-
boarder’s fracture’’ for its increased incidence in
this patient population. A high index of suspi-
cion is required to identify this injury, often
Figure 2-11 Fracture of the tip of the fibula trapped under the
Figure 2-10 Fracture of the anterior process of the os calcis. lateral malleolus.
35
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Impingement under the tip of the fibula following os The posterior aspect of the talus has two tubercles: the
calcis fractures is a common complication of this injury. medial and the lateral (Fig. 2-14). The lateral tubercle
Often it is difficult to differentiate the impingement pain is the origin of the posterior talofibular ligament. The
from subtalar joint pain. A small injection of a local tubercle can be small or large. When it is large it is
anesthetic beneath the tip of the lateral malleolus, but referred to as the posterior process of the talus or Stie-
not into the subtalar joint, can indicate how much of da’s process. In 7% to 11% of people, this posterior pro-
the pain is coming from the impingement, versus an cess is separate from the talus and connected by a fibrous
arthritic subtalar joint. If the pain relief with the local synostosis; then it is called the os trigonum (OT).17 The
anesthetic is dramatic, it might be worthwhile to excise OT is the second most common accessory bone in the
this portion of the os calcis before recommending foot, the accessory navicular being the most common.18
subtalar arthrodesis (Fig. 2-12). For a more detailed Bony impingement can occur posterolaterally when
discussion of calcaneal fractures, refer to Chapter 5. the trigonal process or OT is compressed between the
Peroneal dysfunction, although not an impingement, posterior lip of the tibia and superior portion of the
also can produce pain in this area and should be con- os calcis in extreme plantarflexion (Fig. 2-15).
sidered in the differential diagnosis. This includes pero- The flexor hallucis longus (FHL) tendon passes
neal subluxation, longitudinal splits in the tendons,15 through the fibro-osseous tunnel between the two pos-
and even fracture of the os perineum with retraction of terior tubercles as it runs from its origin on the fibula
the peroneus longus16 (Fig. 2-13). (laterally) to its insertion in the distal phalanx of the
Posterior ankle pain is common in athletes such as hallux (medially) (Fig. 2-16). Chronic tendinitis and
dancers, gymnasts, soccer players, and skaters who must dysfunction within this tunnel can produce posterior
work or kick in the equines position. A review of poste- medial pain, ‘‘dancer’s tendinitis.’’19-22 Thus there usu-
rior ankle anatomy will help to explain the two common ally are two sources of posterior ankle pain: lateral (tri-
pain syndromes found in this area (Tables 2-2 and 2-3). gonal impingement) and medial (FHL tendinitis), or
a combination of the two.
Posterolateral ankle pain

The posterior impingement syndrome of the ankle, or
talar compression syndrome,21,23,24 is the natural conse-
quence of full weight bearing in maximal plantarflexion
of the ankle in the demi-pointe or full pointe position,
especially if an OT is present. It presents as posterolat-
eral pain in the back of the ankle when the posterior
lip of the tibia closes against the superior border of the
os calcis. It can be confirmed on physical examination
by tenderness behind the peroneal tendons in the back
of the lateral malleolus (it often is mistaken for peroneal
tendinitis) and pain with forced passive plantarflexion of
the ankle, the ‘‘plantarflexion sign.’’
This syndrome is often, but not always, associated
with an OT or trigonal process in the back of the ankle.
As previously noted, the posterior aspect of the talus
normally has two tubercles: the medial and the lateral.
Between the two lie the fibro-osseous tunnel and the
FHL tendon (Fig. 2-17). Most people who have an
OT are not aware of its presence, and the posterior
impingement syndrome is rare in most athletes. In dan-
cers it may or may not be symptomatic, and the degree
of symptoms is not always related to its size. Large
OTs can be minimally symptomatic and small ones
sometimes can be disabling. Usually the symptoms are
mild and, on the whole, the OT often is more asymp-
tomatic than symptomatic. Many world-famous balleri-
nas have asymptomatic OTs, and they work with them
Figure 2-12 Impingement under the tip of the fibula, follow- without any trouble. It is important to stress this fact
ing a fracture of the os calcis and lateral malleolus. to the dancer when discussing the problem, because
36
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Figure 2-13 Retraction of the os peroneum (arrow), following rupture of the peroneus longus tendon.
Table 2-2 FHL tendonitis versus posterior impingement Table 2-3 Medial versus lateral posterior ankle pain in
of the ankle athletes and dancers
Posterior Posteromedial Posterolateral
FHL tendonitis impingement
FHL tendinitis Posterior
Posteromedial Posterolateral impingement
(OT syndrome)
Tenderness over FHL Tenderness behind
tendon fibula Soleus syndrome Fx. trigonal process
(Shepherd’s fracture)
Pain or triggering with Pain with plantar
motion of the hallux flexion of the ankle PT tendonitis Peroneal tendonitis
Thomasen’s sign14 Plantar flexion sign Posteromedial Pseudomeniscus syndrome
fibrous tarsal
Mistaken for PT tendonitis Mistaken for peroneal coalition
tendonitis
FHL, flexor hallucis longus; Fx., fracture; OT, os trigonum; PT,
FHL, flexor hallucis longus; PT, posterior tibial. posterior tibial.
37
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Figure 2-16 Medial anatomy of the flexor hallucis longus.

Figure 2-14 Anatomy of the posterior talus.
the condition often is overdiagnosed by paramedical

practitioners, who may recommend surgery unnecessar-
ily, perhaps because of the dramatic appearance of the
bone on x-ray. It is seen best on a lateral view of the
ankle en pointe or in full planter flexion (Fig. 2-15).
The diagnosis can be confirmed, if necessary, by inject-
ing 0.5 ml of a local anesthetic into the posterior soft
tissues behind the peroneal tendons. If the pain that
was present is relieved by this small injection, the
diagnosis is almost certain.
Treatment of the posterior impingement syndrome
should be graded. The first step, similar to the treatment
for tendinitis, is modification of activities (‘‘Don’t do
what hurts!’’), nonsteroidal anti-inflammatory drugs
(NSAIDs—if the dancer is older than age 16), and
physical therapy. In cases in which this approach has
failed, or the symptoms recur, an injection of 0.25 to
0.5 ml of a mixture of a long-acting and a short-acting
corticosteroid often can give dramatic and permanent
relief of symptoms. This can be done accurately with
the use of sonography. Before injecting the steroid prep-
aration, the clinician should confirm the diagnosis with a
local anesthetic. If the local anesthetic does not relieve
the symptoms, there is no point in injecting the steroids.
It should be stressed that the OT usually is not a surgical
problem; most dancers with an OT do not need to have
it removed surgically.
Occasionally, the OT does cause enough disability
to warrant surgical excision, but, as with most elective
surgery, it is indicated only after the failure of conser-
vative treatment in a serious dancer at least 16 years of
age or older. If the problem is an isolated OT with no
medial symptoms, it can be approached posterolaterally
Figure 2-15 Posterior impingement on the os trigonum. between the FHL and the peroneal tendons (with the
38
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Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Talus
Tibia
Fibula
Tibialis
posterior
Flexor
retinaculum Superior peroneal
retinaculum
Flexor digitorum
longus Os trigonum
Flexor
hallucis
longus
Achilles tendon
Figure 2-17 Superior view of relationship of flexor hallucis longus to os trigonum.
sural nerve protected). Not infrequently, there is a Excision of the OT using the lateral approach
combined problem of FHL tendinitis and posterior Under anesthesia, the patient is placed in the lateral
impingement. The posteromedial approach is used in decubitus or prone position with a pneumatic tourni-
these patients so that the neurovascular bundle can be quet on the leg or thigh over cast padding. Because dan-
isolated and protected. A tenolysis of the FHL and cers have increased external rotation of the hip, it is
removal of the adjacent OT then can be performed extremely difficult to perform this operation with the
safely. patient supine. A curvilinear incision is made at the level
Other causes of posterolateral ankle pain include the of the posterior ankle mortise in line with the posterior
following: border of the peroneal tendon sheath. The sural nerve
1. A previously asymptomatic OT may become per- is identified or carefully avoided in the subcutaneous
sistently symptomatic following an ankle sprain, tissues. The dissection is carried down to the interval
resulting from disruption of its ligamentous con- between the peroneal tendons laterally and the muscle
nections and a subtle shift in position. belly of the FHL medially. A posterior capsular incision
2. Posterior impingement can follow an ankle sprain then is made with the ankle in neutral or slight dorsi-
that stretches out the lateral ligaments that hold flexion. The OT or trigonal process (a Stieda process)
the talus under the tibia in the relevé.22 As the can be found on the superior surface of the posterior
talus slips forward, the posterior lip of the tibia talus, just on the lateral side of the FHL tendon,
comes to rest on the os calcis. The treatment for between the ankle and subtalar joints. It has attachments
this type of posterior impingement is to tighten on all its sides: (1) superior—the posterior capsule of the
the lateral ankle ligaments (preferably by the talocrural joint; (2) inferior—the posterior talocalcaneal
Broström-Gould procedure).25 If the drawer sign ligament, at times thick and fibrous; (3) medial—the
can be corrected, the posterior impingement FHL tunnel with its sheath; and (4) lateral—the origin
usually disappears. of the posterior talofibular ligament.
3. A posterior pseudomeniscus or plica in posterior The bone can be removed by circumferential dis-
ankle,22 with or without an OT, can cause the section. One should be careful not to stray too far
posterior impingement syndrome in the absence medially—the posterior tibial nerve rests on the FHL
of an OT or ligament laxity. We have seen bucket- tunnel. The proximal entrance of the FHL tunnel can
handle tears in this structure causing locking and be opened if there are muscle fibers attaching distally
other mechanical symptoms that are seen more on the FHL tendon that crowd into the tunnel when
often in the knee than the ankle. the hallux is brought into dorsiflexion (see Tomasen’s
39
...........
sign10). One should not dissect medial to the FHL ten-

don without adequate visualization; the posterior tibial
nerve lies directly medial to the FHL tendon. The sur-
geon should check thoroughly for loose bodies; I have
found them even in the FHL tunnel. The foot should
be brought into maximal plantarflexion to look for any
residual impingement. At times it is necessary to remove
more of the posterior lateral tubercle. Often there is
a facet on the cephalad portion of the os calcis that arti-
culated with the OT, and this can be large enough to
impinge against the posterior lip of the tibia after the
OT has been removed. Careful hemostasis will prevent
a postoperative hematoma, which can delay recovery
and make early motion difficult for the patient. A lay-
ered closure then is performed with plain catgut suture
with the ankle in neutral dorsiflexion. We usually close
the wound with a running absorbable suture and Steri-
Strips. The patient is placed in a bulky dressing, and
weight bearing with crutches is begun as tolerated. Early
motion is essential to prevent fibrosis and resultant lim-
ited range of motion. The dancer is encouraged to swim
and progress to barre exercises as discomfort subsides.
Average return to full dancing is 2 to 3 months.
Posteromedial ankle pain

Tendinitis of the FHL tendon behind the medial mal- Figure 2-18 A nodule in the flexor hallucis longus (FHL)
leolus of the ankle is so common in dancers that it is tendon causing triggering of the great toe; ‘‘hallux saltans.’’
known as dancer’s tendinitis.19-22,26 The FHL is the
‘‘Achilles tendon of the foot’’ for the dancer. It passes
through a fibro-osseous tunnel behind the talus like athletes, FHL tendinitis may be recurrent and disabling.
a rope through a pulley. As it passes through this pulley, In refractory cases, operative tenolysis may be indicated,
it is easily strained. When this occurs, rather than mov- but only after failure of conservative therapy. The situa-
ing smoothly in the pulley, it begins to bind. This bind- tion is similar to de Quervain’s stenosing tenosynovitis
ing causes irritation and swelling, which, in turn, causes in the wrist.
further binding, irritation and swelling—setting up FHL tendinitis usually occurs behind the medial
the familiar cycle: because it is swollen and irritated, malleolus, but occasionally it can be found at the knot
it binds; and because it binds, it is swollen and irritated. of Henry under the base of the first metatarsal where
If a nodule or partial tear is present, triggering of the the flexor digitorum longus (FDL) crosses over the
big toe may occur. This is known as hallux saltans FHL, and under the head of the first metatarsal where
(Fig. 2-18). At the extreme, the tendon may become it passes between the sesamoids. A fibrous subtalar coa-
completely frozen in the sheath, causing pseudo hallux lition may be present in the posteromedial ankle, mim-
rigidus. This tendinitis typically responds to the usual icking FHL tendinitis or tarsal tunnel syndrome. This
conservative measures. Rest is an important compo- condition should be suspected when there is less than
nent of the therapy so that the chronic cycle previously normal subtalar motion on physical examination.
described can be broken. NSAIDs can help, but they The differential diagnosis of posterior ankle pain
should be used only as part of an overall treatment pro- includes the following:
gram and not as medicine to kill the pain so that the 1. Posterior process (Shepherd’s)27 fracture; nondis-
patient can continue dancing and ignore the symp- placed or stress.
toms. As with other tendon problems, steroid injections 2. FHL tendinitis (dancer’s tendinitis).
should be avoided in the office setting because of the 3. Peroneal tendinitis.
danger of injecting the steroid into the tendon. How- 4. Posteromedial localized talocalcaneal coalition.
ever, diagnostic and therapeutic injections can be per- 5. Osteoid osteoma.
formed into the FHL tendon sheath more accurately Operative treatment is indicated when conservative
and safely under sonographic control. On some occa- therapy has failed. The posterior clean-out can be
sions, in professional or high-level amateur dancers and performed from either the medial or lateral side of the
40
...........
Achilles tendon. The lateral approach should be used if There also may be reduplication of the tendons—the
the patient has an isolated posterior impingement with- flexor hallucis accessorius. With the neurovascular bun-
out a history of FHL tendinitis or medial difficulties. dle retracted posteriorly, the FHL is identified easily by
A medial incision in indicated if the patient has a moving the hallux (Fig. 2-19, E). The thin fascia over-
combined problem of FHL tendinitis and posterior lying the muscle fibers of the FHL is opened proxi-
impingement, or if he or she primarily has FHL tendini- mally, and a tenolysis is performed by opening the
tis with an incidental OT that the surgeon wishes to sheath from proximal to distal. Usually it is stenotic
remove along with an FHL tenolysis. The medial inci- and tough, and the FHL often can be seen entering it
sion is safer and more utilitarian because one can work at an acute angle. Care should be taken distally because
safely on the lateral side from the medial approach, but the FHL tunnel and the nerve are close together here.
it is dangerous to work medially from the lateral As the tenolysis approaches the area of the susten-
approach because the neurovascular bundle cannot be taculum tali, the sheath thins so that there no longer
isolated and protected from the lateral side. seems to be anything to divide. The tendon should
be retracted with a blunt retractor and inspected for
Tenolysis of the FHL and excision of the OT nodules or longitudinal tears. If present, these should
from the medial approach be carefully debrided or repaired. At this point the
This procedure can be performed with the patient FHL can be retracted posteriorly with the neurovascular
supine because dancers usually have increased external bundle. The OT or trigonal process will be found just on
rotation of the hip and knee that allows easy visuali- the lateral side of the FHL tunnel. If the posterior aspect
zation of the posterior ankle from the medial side. of the talus cannot be visualized, a capsulotomy should
A bloodless field is desirable, so we use a tourniquet be performed. If there is difficulty in visualizing the
on the thigh over cast padding. For this reason, the pro- OT, it helps to identify the superior border of the os
cedure cannot be performed with the patient under local calcis and the subtalar joint (by moving the os calcis
anesthesia or ankle block. A curvilinear incision is made into adduction and abduction). The subtalar joint then
over the neurovascular bundle behind the medial mal- is dissected from medial to lateral, and this will take the
leolus beginning just above the superior border of the surgeon underneath the OT. Once identified, it can be
os calcis and continuing to a line just posterior to the removed by circumferential dissection. Care should be
tip of the medial malleolus (Fig. 2-19, A). This incision taken to stay on the bone when performing this part of
should be made carefully. The deep fascia and lacinate the procedure. This can be somewhat difficult, especially
ligament in this area often are thin. If the incision is if the OT is large. Once it is removed, the posterior ankle
made too enthusiastically, the surgeon may find him- joint should be inspected for remnants, bone fragments
self or herself in the midst of the neurovascular bundle or loose bodies, soft tissue entrapment, or a large articu-
before he or she had planned to be there. The deep fas- lar facet on the upper surface of the os calcis that articu-
cia then is divided carefully to avoid damage to the lated with the OT. If this articulation is large, it may need
artery and nerve beneath it. to be removed with a thin osteotome. The FHL sheath is
At this point one must decide whether to go in front not closed. The wound then is irrigated, checked for any
of the bundle or behind it. The posterior approach can residual impingement by putting the foot in maximal
take the surgeon into the variable neural branches to plantarflexion, and closed in layers with plain catgut
the os calcis. It is safer to go anteriorly to the bundle. and with the ankle in neutral flexion. We begin weight
All branches of the tibial nerve at this level go posteri- bearing as tolerated with crutches as soon as possible
orly, thus the safe plane is between the posterior aspect and proceed with swimming and physical therapy when
of the medial malleolus and the neurovascular bundle. the wound is healed. If the tenolysis is performed with-
The bundle can be taken down off the malleolus by out excision of the OT, the recovery period is about 6
blunt dissection (Fig. 2-19, B). Often there are several weeks. If the OT is removed along with the tenolysis,
small vessels here that need to be ligated, but once the the recovery time is 8 to 12 weeks. It is important to
bundle is mobilized it can be held with a blunt retrac- get patients moving early to prevent stiffness. In dancers
tor such as a loop or Army-Navy retractor (never with with a rather large OT, it is necessary to warn them that,
a rake) (Fig. 2-19, C). The posterior tibial nerve is once it is removed, the ankle does not just drop down
much larger than one expects; it usually is about the into maximal plantarflexion. They must realize that the
size of a pencil (Fig. 2-19, D). The surgeon should bone has been there since they were born, and removing
examine the nerve and the artery and note where they it does not lead to immediate motion. The increased
each divide into medial and lateral plantar branches plantarflexion is obtained slowly and can be accompa-
as they leave the tarsal canal. It is not unusual for either nied by many strange symptoms, both anteriorly and
the artery or the nerve, or both, to divide above posteriorly, as the soft tissues adjust to the new range
this area, leading to reduplication within the tunnel. of motion.
41
...........
Figure 2-19 (A) Posteromedial incision. (B) Neurovascular bundle beneath a thin layer of fascia. (C) Neurovas-
cular bundle taken down from the posterior medial malleolus. (D) Posterior tibial nerve protected with a blunt
retractor. Underneath lies the flexor hallucis longus (FHL) sheath. (E) FHL sheath opened.
The medial ankle through its pulley behind the medial malleolus. In addi-
Posterior tibial tendinitis, so common in athletes, is rare tion, dancers are selected for, and usually have, cavus
in dancers—an example of altered kinesiology producing feet, which are less prone to posterior tibial (PT) tendi-
altered patterns of injury. Working primarily in the equi- nitis. Indeed, more often than not, a dancer diagnosed
nus position produces less stress on the posterior tibial with PT tendinitis, on careful examination, will be found
tendon but more on the FHL tendon as it passes to have FHL tendinitis instead (dancer’s tendinitis).
42
...........
References
Medial sprains of the ankle are rare because the treatment. On rare occasions, a fracture of the medial
medial structures are strong and rigid in comparison tubercle or disruption of an accessory navicular can
with the lateral ones. Persistent symptoms on the medial occur. In this setting, the injury should be treated in
side may be due to an unrecognized fracture of the sus- a short-leg walking cast or cam walker boot for 4 to
tentaculum tali, which can be picked up on a bone scan, 6 weeks to prevent the injury from becoming chronic.
or to a localized fibrous tarsal coalition. Sprains of the Strains of the spring ligament and plantar fascia can
medial ankle do occur, usually from landing off balance be mistaken for medial ankle pain, but a careful physical
with sudden pronation, but again, this is more likely to examination should make the diagnosis apparent.
produce a sprain of a portion of the deltoid ligament A rare cause of medial ankle pain is an unrecognized
than a strain of the PT tendon, although this can occur. fracture of the colliculus located on the medial portion
The sprain usually affects the portion of the ligament of the posterior tibia. This occult injury can be difficult
under tension when the force was applied: the anterior to diagnose. It usually can be documented by a bone
deltoid if the foot was in equinus, the middle deltoid scan and CT scan.
if the foot was plantigrade, and the posterior portion if Another cause of medial pain just above the medial
the foot was in dorsiflexion (rare). An accessory bone, malleolus is the soleus syndrome.28 This presents as
the os subtibiale, may be present in the deep layer chronic pain resembling a shin splint but is too far distal
of the deltoid; this bone can be involved in the sprain, on the posteromedial tibial metaphysis to be a true shin
becoming symptomatic when it had not been before. splint. It is caused by an abnormal slip in the origin of
The treatment of these medial sprains and strains in the soleus muscle. The condition, similar to the exer-
the acute phase consists of the usual RICE regimen tional compartment syndrome, is much more common
(i.e., rest, ice, compression, and elevation), an aircast in athletes than dancers. It usually responds to conserva-
stirrup brace, crutches if necessary, and physical therapy. tive therapy, but, on rare occasions, release of the tight
An x-ray should be taken to rule out bone or physeal band may be necessary.
injury. Recovery usually is uneventful. Occasionally a In summary, treatment of dancers can be as challeng-
trigger point can form in the deltoid, usually around ing as it is rewarding. Dancers often have unusual diffi-
a chip fracture or accessory ossicle. These may require culties related to the altered kinesiology required by
a corticosteroid injection if they do not respond to their individual dance form—ballet, modern dance, jazz,
conservative therapy. Only rarely will surgical excision tap, ethnic, Broadway, and so forth. A thorough under-
be necessary. Nodules may form on the EDL or PT standing of these movements will help guide the physi-
tendons following medial strains, but these usually are cian to the cause of the disability, particularly in the
asymptomatic. setting of overuse injuries. This knowledge, coupled
In dancers, the most common cause of pain around with a careful physical examination, is essential for the
the medial malleolus comes from ‘‘rolling in’’ (pronat- accurate diagnosis and treatment of the dancer, who is
ing) to obtain proper turnout (Table 2-4). This produces both athlete and artist.
a chronic strain on the deltoid ligament, particularly the
deep portion, and is one of many overuse syndromes
seen in dancers. REFERENCES
Contusion of the medial prominence of the tarsal
navicular can occur. This usually happens when one
foot is brought forward past the other and, as it passes 1. Thompson FM, Hamilton WG: Problems of the second meta-
tarso-phalangeal joint, Orthopedics 10:83, 1987.
the navicular, strikes the medial malleolus of the other
2. Phemister DB: Necrotic bone and the subsequent changes which
ankle. These contusions usually heal with symptomatic it undergoes, JAMA 64:211, 1915.
3. Mann RA, Coughlin MJ: Surgery of the foot and ankle, ed 6,
Table 2-4 Differential diagnosis of medial ankle pain in St Louis, 1993, Mosby Year Book.
athletes and dancers 4. Taillard W, et al: The sinus tarsi syndrome, Int Orthop 5:117,
1981.
5. Marshall PM, Hamilton WG: Cuboid subluxation in ballet
Most common PT tendonitis (athletes)
dancers, Am J Sports Med 20:169, 1992.
FHL tendonitis (dancers) 6. Scranton PE, McDermott JE: Anterior tibiotalar spurs: a compari-
son of open versus closed debridement, Foot Ankle 13:125, 1992.
Common Deltoid ligament strain 7. Bassett FH, et al: Talar impingement by the anteriorinferior tibio-
fibular ligament, J Bone Joint Surg 72-A:55, 1990.
Rare FDL tendonitis 8. Ferkel RD, et al: Arthroscopic treatment of anteriorlateral im-
Soleus syndrome pingement of the ankle, Am J Sports Med 19:440, 1991.
9. McLaughlin HL: Trauma, Philadelphia, 1960, WB Saunders.
FDL, flexor digitorum longus; FHL, flexor hallucis longus; 10. Tomasen E: Diseases and injuries of ballet dancers, Denmark,
PT, posterior tibial. 1982, Universitetsforlaget I.Arhus.
43
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11. McCarroll JR, et al: Meniscoid lesions of the ankle in soccer 21. Hamilton WG: Stenosing tenosynovitis of the flexor hallucis
players, Am J Sports Med 15:255, 1987. longus tendon and posterior impingement upon the os trigonum
12. Harburn T, Ross H: Avulsion fracture of the anterior calcaneal in ballet dancers, Foot Ankle 3:74, 1982.
process, Phys Sports Med 15, 1987. 22. Hamilton WG: Foot and ankle injuries in dancers. In Yokum L,
13. Hawkins LG: Fractures of the lateral process of the talus, J Bone editor: Sports clinics of North America, Philadelphia, 1988,
Joint Surg 52A:991, 1970. Williams & Wilkins.
14. Valderrabano V, et al: Snowboarder’s talus fracture: treatment 23. Howse AJG: Posterior block of the ankle joint in dancers, Foot
outcome of 20 cases after 3.5 years, Am J Sports Med 33:871, Ankle 3:81, 1982.
2005. 24. Quirk R: The talar compression syndrome in dancers, Foot Ankle
15. Sammarco JG, DiRaimondo CV: Chronic peroneus brevis tendon 3:65, 1982.
lesions, Foot Ankle 9:163, 1989. 25. Hamilton WG, Thompson FM, Snow SW: The modified
16. Thompson FM, Patterson AH: Rupture of the peroneus longus Broström procedure for lateral ankle instability, Foot Ankle 14:1,
tendon, report of three cases, J Bone Joint Surg 71-A:293, 1989. 1993.
17. Grant JCB: A method of anatomy, Baltimore, 1985, Williams & 26. Hamilton WG: Ballet, In Reider B, editor: The school-age athlete,
Wilkins. Philadelphia, 1991, WB Saunders.
18. Sarrafian SK: Anatomy of the foot and ankle, Philadelphia, 1983, 27. Shepherd FJ: A hitherto undescribed fracture of the astragalus,
JB Lippincott. J Anat Physiol 17:79, 1882.
19. Hamilton WG: ‘‘Dancer’s tendonitis’’ of the FHL tendon, Durango, 28. Michael RH, Holder LE: The soleus syndrome, Am J Sports Med
CO, 1976, American Orthopedic Society for Sports Medicine. 13:87, 1985.
20. Hamilton WG: Tendonitis about the ankle joint in classical ballet
dancers; ‘‘Dancer’s tendonitis’’, J Sports Med 5:84, 1977.
44
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........................................... C H A P T E R 3
Stress fractures: their causes and

principles of treatment
Peter D. Brukner and Kim L. Bennell
......................
CHAPTER CONTENTS
Introduction 45 Differential diagnosis 68

Epidemiology 46 Treatment 68
Risk factors for stress fractures 52 Conclusion 70
Diagnosis 63 References 70
INTRODUCTION crack fractures.4,6-10 Virtually all of these terms have been

intended to describe some etiologic attribute of the stress
injuries of bone. In recent years the most commonly used
Physical exercise has beneficial effects on a number of phy-
term has been stress fracture.
siologic systems, including the skeleton. However, unwise
Following the radiographic description of metatarsal
training practices, combined with potential risk factors,
stress fractures, many theories were set forth to explain
may harm these systems. A stress fracture represents one
the etiology of this injury. Most of the reports were based
form of breakdown in the skeletal system.1 It can be
on series that were small, and the theories proposed were
defined as a partial or complete fracture of bone that results
concerned with either mechanical factors, such as spasm
from the repeated application of a stress lower than that
of the interossei, or flat feet,4,11,12 or with inflammatory
required to fracture the bone in a single loading situation.2
reactions, such as nonsuppurative osteomyelitis.7,8
Historical perspective
Stress fractures were first described in 1855 by Etiology of stress fractures
Briethaupt, a Prussian military physician who observed It is now recognized that the development of a stress frac-
foot pain and swelling in young military recruits unac- ture represents the end product of the failure of bone to
customed to the rigors of training. He considered it to adapt adequately to the mechanical loads experienced dur-
be an inflammatory reaction in the tendon sheaths ing physical activity. Ground reaction forces and muscular
resulting from trauma and called the condition Fuss- contraction result in bone strain. It is these repetitive
geschwulst. It was not until the advent of radiographs strains that are thought to cause a stress fracture. Bone nor-
that the signs and symptoms were attributed to fractures mally responds to strain by increasing the rate of remodel-
in the metatarsals.3 The condition then became known ing. In this process, lamellar bone is resorbed by
as a ‘‘march’’ fracture because of the close association osteoclasts, thereby creating resorption cavities that subse-
between marching and the onset of symptoms. Stress quently are replaced with more dense bone by osteoblasts.
fractures were first noticed in civilians in 1921 by Because there is a lag between increased activity of the
Deutschlander,4 who reported six cases in women. osteoclasts and osteoblasts, bone is weakened during this
However, it was not until 1956, more than a century time.13,14 If sufficient recovery time is allowed, bone mass
following their identification in military recruits, that eventually increases. However, if loading continues, micro-
they were recognized in athletes.5 damage may accumulate at the weakened region.14,15
A variety of terms have been used over time to Remodeling is thought to repair normally occurring micro-
describe stress fractures. These include march fractures, damage.16,17 The processes of microdamage accumulation
Deutschlander’s fractures. pied forcé, fatigue fractures, or and bone remodeling, both resulting from bone
CHAPTER 3 Stress fractures: their causes and principles of treatment
strain, play an important part in the development of a Both studies suggest that track athletes are at one of the
stress fracture. If microdamage accumulates, repetitive highest risks for stress fracture. However, because neither
loading continues, and remodeling cannot maintain the expressed incidence in terms of exposure, it may not be
integrity of the bone; a stress fracture may result.15,18,19 strictly valid to compare the risk of stress fracture in such
This may occur because the microdamage is too extensive diverse sports. To our knowledge, there is only one athlete
to be repaired by normal remodeling, because depressed study that has expressed stress fracture incidence rates in
remodeling processes cannot adequately repair normally terms of exposure.24 This 12-month prospective study fol-
occurring microdamage, or because of some combination lowed a cohort of 95 track and field athletes. Results
of these factors.18 showed an overall rate of 0.70 stress fractures per 1000
training hours. Further research is needed to quantify inci-
dence rates in this manner to allow more valid comparison
EPIDEMIOLOGY between studies.
Retrospective studies have measured stress fracture rates
Stress fractures have been reported to occur in association in specific sporting populations, mostly runners and ballet
with a variety of sports and physical activities. Clinical dancers.20-23,25-27,29-31 Variation in reported rates reflects
impression suggests that stress fractures are more common differences in methodology, particularly cohort demo-
in weight-bearing activities, particularly those with a run- graphics and method of data collection. A history of stress
ning or jumping component. However, it is difficult to fracture has been reported by 13% to 52% of female run-
compare the incidence of stress fractures in different sports ners. The lowest rate was found in one study that included
or to identify the sport or activity with the greatest risk recreational, as well as competitive, runners. Ballet dancers
because of a lack of sound epidemiologic data. This section are another population in which stress fracture rates appear
reviews the descriptive epidemiology of stress fractures. high, with 22% to 45% of dancers reporting a history of
Most of the literature in this area pertains to female runners stress fracture. However, most studies failed to confirm
and to male military populations. There is no information the accuracy of subject recall, a failure that may introduce
about stress fracture rates in the general community. bias into the figures reported. Nevertheless, it is clear that
stress fracture is a relatively common athletic injury.
.............................................................
Stress fracture injury rate
Stress fracture rates in the military
Stress fracture rates in athletes Reports of the incidence of stress fractures in male
recruits undergoing basic training for periods of 8 to
Studies investigating stress fracture rates in athletes are
14 weeks are remarkably similar and generally range
shown in Table 3-1.20-31 Of these, only two allow a direct
from 0.9% to 4.7%.32-40 However, in two particular
comparison of annual stress fracture rates in different
studies involving the Israeli army, the reported incidence
sporting populations.28,29 Johnson et al.28 conducted a
was 31%41 and 24%.42 The authors attributed this much
2-year prospective study to investigate sports-related
higher incidence to several factors, including meticulous
injuries in collegiate male and female athletes. In total, 34
follow-up, a high index of suspicion, and the use of the
stress fractures were diagnosed during the study period.
radioisotope bone scan for diagnosis. In addition,
Track accounted for 64% of stress fractures in women and
asymptomatic areas of uptake on bone scan also were
50% of stress fractures in men. The stress fracture incidence
classified as lesions, and this would inflate the reported
rate (expressed as a case rate) in males was highest for track
figures. Stress fracture rates in female military recruits
(9.7%), followed by lacrosse (4.3%), crew (2.4%), and
during basic training generally are higher than those in
American football (1.1%). The stress fracture incidence rate
males, ranging from 1.1% to 13.9%.32,33,35,37,39,43
in women was highest for track athletes (31.1%), followed
by crew (8.2%), basketball (3.6%), lacrosse (3.1%), and
soccer (2.6%). No athlete sustained a stress fracture in Stress fracture recurrence rates
fencing, hockey, golf, softball, swimming, or tennis. Clinically it seems that recurrence of stress fractures at new
Goldberg and Pecora29 reviewed medical records of sites is common. In female track and field athletes, half of
stress fractures occurring in collegiate athletes during a those who reported a history of stress fracture had experi-
3-year period. Approximate participant numbers were enced a stress fracture on more than one occasion.23 How-
available to allow calculation of estimated incidence case ever, few studies have reported recurrence rates in either
rates in each sport. The greatest incidence occurred in soft- athletes or the military. When male and female track and
ball (19%), followed by track (11%), basketball (9%), field athletes were followed prospectively for 1 year, 60%
lacrosse (8%), baseball (8%), tennis (8%), and gymnastics of those who sustained a stress fracture had a previous stress
(8%). However, participant numbers were small in some fracture history.24 The athlete recurrence rate in this study
of these sports, possibly leading to a bias in incidence rates. was particularly high at 12.6%. A large number of male
46
...........
Table 3-1 Stress fracture (SF) rates in athletes expressed as participant rates unless otherwise stated
Resp
rate
Subject Method of of
Study sex & data quest Observation Diagnosis SF
Reference design Population number collection (%) period of SF rate (%)
Barrow & Saha, R Collegiate 240-F Self-admin. 24 Hx x-ray or 37.0
198820 distance question BS
runners
Brunet et al., R Recreational/ 375-F Self-admin. NS Hx NS 13.2-F

199021 competitive 1130-M question 8.3-M
runners
Cameron et al., R State/ 263-F Self-admin. 67 Hx NS 26.6-F

199222 national level 287-M question 28.0-M
runners
Bennell et al., R Track & field 53-F Self-admin. 100 Hx x-ray, BS, 51.5
199523 athletes question or CT 84.9*
Bennell et al., P Track & field 46-F Monitoring NA 1 yr BS þ CT 21.7-F

199624 athletes 49-M 20.4-M
30.4-F*
24.5-M*
Warren et al., R Professional 40-F Self-admin. 100 Hx x-ray or 45.0

198625 ballet question BS 67.5*
dancers
Frusztajer R Ballet 45-F Interview 100 1 yr NS 22.0

et al., 199026 dancers þ question
Kadel et al., R Professional 54-F Self-admin. 100 Hx x-ray or 31.5

199227 ballet question BS 50.0*
dancers
Epidemiology
Johnson et al., P Collegiate 321-F Monitoring NA 2 yr x-ray or 6.9-F*{
199428 athletes 593-M BS 2.0-M*{
(Continued)
............
47
............
48
CHAPTER 3
Stress fractures: their causes and principles of treatment
Table 3-1 Stress fracture (SF) rates in athletes expressed as participant rates unless otherwise stated (cont’d)
Resp
rate
Subject Method of of
Study sex & data quest Observation Diagnosis SF
Reference design Population number collection (%) period of SF rate (%)
Goldberg & R Collegiate 1200-F Review of NA 3 yr x-ray or 2.7-F*{
Pecora, 199429 athletes 1800-M medical BS 1.4-M*{
records
Pecina et al., R Elite ice 42 Self-admin. 100 Hx NS 21.0

199030 skaters M/F question
Dixon & Fricker, R Elite 74-F Review of NA 10 yr x-ray or 27.0-F*

199331 gymnasts 42-M medical BS 14.3-M*
records
From Bennell KL, Brukner PD: Epidemiology and site specificity of stress fractures, Clin Sports Med 16:183, 1997.
BS, Bone scan; CT, computed tomography; F, females; Hx, history; M, males; NA, not applicable; NS, not stated; P, prospective cohort; quest, questionnaire; R, retrospective cohort; resp,
response.
*Stress fracture rates expressed as case rates: number of stress fractures per 100 athletes.
{Annual incidence.
Epidemiology
military recruits were followed for a minimum of 1 year relative risk of stress fracture for women compared with
after basic training.44 The recurrence rate of stress fractures men from studies in which stress fracture rates can be
at a different site in those who had sustained a stress frac- directly compared is shown in Table 3-2. In the military,
ture during basic training was 10.6%. In the control group reported incidence rates during an 8-week training period
of 60 recruits who did not develop a stress fracture during vary from 1.1% to 13.9% in women and from 0.9% to
basic training, the incidence of stress fracture after basic 3.2% in men. These studies consistently show that female
training was only 1.7%. This finding could indicate the recruits have a greater risk of stress fracture than male
persistence of risk factors in susceptible individuals. recruits, with relative risks ranging from 1.2 to
10.32,33,35,37,39,43 This increased risk persists even when
Comparison of stress fracture rates in different training loads gradually are increased to moderate levels
age groups and when incidence rates are separated by age and race.
It is unclear whether age, as an independent factor, The most likely explanation for these findings in the
influences the risk of stress fracture because results in the military is lower initial physical fitness in the female
military are conflicting and there are no studies in recruits. Other possible reasons include differences in
athletes investigating the incidence of stress fractures bone density and geometry, gait, biomechanical features,
in different-aged individuals engaged in identical train- body composition, and endocrine factors, particularly
ing. In a retrospective cohort study of 20,422 military estrogen status.
recruits, review of clinical records found a positive asso- In contrast, a gender difference in stress fracture rates
ciation between increasing age in the range 17 to 34 is not as evident in athletic populations.21,22,24,28,29,31
years and the incidence of stress fractures in both men Studies either show no difference between male and
and women.35 Similar results, even after adjusting for female athletes or a slightly increased risk for women,
pretraining physical activity, were reported by Gardner up to 3.5 times that of men (see Table 3-2). A possible
et al.36 in a large prospective study. These suggest that confounding variable is that, unlike the military, in
increasing age, within the range studied, may be which the amount and intensity of basic training is rig-
associated with a higher incidence of stress fractures. It idly controlled, it is difficult to assume equivalence of
is surmised that this may be because bone of older training between men and women in most of these stud-
individuals is less resistant to fatigue failure.45,46 ies. However, Bennell et al.24 found no significant dif-
However, a prospective study by Milgrom et al.42 in ference between gender incidence rates even when
the Israeli army contradicts the hypothesis that stress expressed in terms of exposure. Women sustained 0.86
fracture incidence increases with age in military recruits. stress fractures per 1000 training hours, compared with
For each year of increase in age from 17 to 26 years, the 0.54 in men. It is feasible that a gender difference in
risk for stress fracture at all sites decreased by 28%. The stress fracture risk is reduced in athletes because female
authors suggested that the decreasing risk with age athletes may be more conditioned to exercise than
may be related to increased structural maturity, female recruits; hence the fitness levels of male and
increased bone density, larger cross-sectional moment female athletes may be closer.
of inertia, or changes in bone quality in the older
recruits. It also is possible that injury-prone older indivi- Comparison of stress fracture rates in different races
duals may be less likely to apply for military training. Both male and female Caucasians appear to be at greater risk
However, it should be noted that the number of recruits for stress fractures than blacks, with relative risks ranging
older than the age of 19 was very small in this study. from 2.3 to 24 (Table 3-3). This may be related to higher
A case series of 1407 patients presenting to a sports bone density in blacks48 or to different biomechanical
medicine center found that stress fractures or periostitis features that may be protective against stress fractures.49
comprised a greater percentage of injuries in the ‘‘youn-
ger’’ group (mean age of 30 years), compared with that Relative frequency of stress fractures as a proportion
in the ‘‘older’’ group (mean age of 57 years).47 How- of total injuries
ever, because of the study design, it is not known Numerous case series have reported that stress fractures
whether this reflects selection of stress fracture-resistant comprise between 0.7% and 15.6% of all injuries sus-
individuals in the older group, modification of training tained by athletic populations.31,50-54
regimens to lower musculoskeletal stress, or an indepen- In those investigating runners only, the relative fre-
dent age effect on stress fracture development. quency is much higher, ranging from 6.0% to 15.6%. In
track and field athletes, stress fractures appear to comprise
Comparison of stress fracture rates in men a large proportion of overuse injuries: 34.2% in women
and women and 24.4% in men reported by one study,24 and 42.0%
It often is suggested that women sustain a disproportion- by men and women combined in another.50 In elite gym-
ately higher number of stress fractures than men. The nasts, stress fractures comprised 18.3% of overuse injuries
49
...........
............
50
CHAPTER 3
Table 3-2

Relative risk of stress fracture for women compared with men from studies in which stress fracture rates can be directly compared
Brunet et al., Cameron et al., Johnson et al., Goldberg & Pecora, Zernicke et al.,
Variable 199021 199222 199428 199429 199393
Type of study R R P R NS
Sport population Runners* Runners Variety{ Variety{ Runners
Age, females 33 NS 18–22 18-22 18-22
Age, males 39 NS 8-22 18-22 18-22
Female number 375 263 321 1200 NS
Male number 1130 287 593 1800 NS
Observation History History 2 yr 3 yr 12 months
Data collection Q Q Clinic Records NS
Response rate NS 67% NA NA NS
% of SF, females 13.2 26.6 6.9 2.7 20-25
% of SF, males 8.3 28.0 2.0 1.4 10.0
Relative risk F:M 1.6 0.95 3.5 1.9{ 2.2
From Bennell KL, Brukner PD: Epidemiology and site specificity of stress fractures, Clin Sports Med 16:179, 1997.
NA, Not applicable; NS, not stated; P, prospective; Q, questionnaire; R, retrospective.
*Mainly novice runners.
{
Collegiate athletes.
{
Population at risk was estimated, therefore providing an approximate incidence rate.
Table 3-3 Studies investigating the rates and relative risk of stress fractures (SFs) comparing caucasians (C) and blacks (B). All rates are expressed as participant
rates unless stated
Study SF rates SF Rates Relative risk

Reference Population design Number C Number B C (%) B (%) C vs. B
Men
Brudvig et al., Military R NS NS 1.1 0.2 4.7*

198335
Gardner et al., Military P 2050 975 1.6{ 0.7{ 2.3*

198836{
Milgrom et al., Military P 765 18 24.8 0.0 24.8*

199442
Women
Brudvig et al., Military R NS NS 11.8 1.4 8.5*

198335
Barrow & Saha, Athletes R 220 12 39.0 17.0 2.3

198820
From Bennell KL, Brukner PD: Epidemiology and site specificity of stress fractures. Clin Sports Med 16:187, 1997.
NS, Not stated; P, prospective cohort; R, retrospective cohort.
*Statistically significant difference between races.
{
Blacks include all racial and ethnic groups apart from whites.
{
Stress fracture rates expressed as case rates: number of stress fractures per 100 recruits.
Epidemiology
............
51
in women and 9.2% in men.31 It seems that the relative been reported that females sustain more metatarsal,52,58
frequency of stress fractures is greater in female than in pelvic,52,58 and navicular stress fractures28 than males.
male athletes. The variation in results probably reflects Age differences also may play a part; Matheson et al.59
differences in the composition of each case series. found significantly more femoral and tarsal stress frac-
tures in older athletes and more tibial and fibular stress
fractures in younger athletes. However, an interaction
.............................................................
Stress fracture sites between age and site of stress fracture was not con-
firmed in another large series.58
Athletes
Stress fractures are most common in bones of the lower Military recruits
extremity but also occur in nonweight-bearing bones, The location of stress fractures in military personnel has
including the ribs, upper limb, and pelvis. Numerous appeared to change over the years, probably as a result of
studies have reported the anatomic distribution of series changes in training, with a greater emphasis on running
of stress fractures20,22,24,27-29,50,52,53,55-63 (Table 3-4). instead of marching; changes in footwear, with athletic
Although there is great variation in the percentage of shoes often replacing combat boots; and changes in initial
stress fractures reported at each bony site, the most fitness levels with fitter recruits. Original reports described
common sites appear to be the tibia, metatarsals, and primarily injuries of the foot, with most diagnosed stress
fibula. A number of factors may influence the reported fractures occurring in the metatarsals.10,65 However, in
distributions of stress fractures. These include type and the last 2 decades, a greater number of stress fractures have
level of activity, gender, age, and, in particular, method been found in the leg, particularly the tibia, thus more
of diagnosis. For example, tarsal navicular stress frac- closely approximating that observed in athletic popula-
tures rarely are evident on radiographs. If diagnosis is tions. In a recent prospective study in 626 male U.S.
confined to radiographs, these therefore will be underre- Marine Corps recruits, 27 stress fractures were sustained.40
ported in comparison with stress fractures at other sites. The most common site was the tibia (41%), followed by
Stress fractures develop at skeletal sites that are sub- the metatarsals (26%), the femur (19%), and the tarsals
jected to repetitive mechanical loading during a particu- (15%). The site distribution of stress fractures in military
lar activity. The site specificity of stress fractures was populations has been well reviewed by Jones et al.43
illustrated in a prospective study in 95 track and field
athletes.24 Although stress fracture incidence rates were
similar in power and endurance athletes, the site distri-
RISK FACTORS FOR STRESS FRACTURES
bution differed. Power athletes (sprinters, hurdlers, and
jumpers) sustained significantly more foot fractures,
whereas endurance athletes (middle-distance and dis- Risk factors are markers that can be used to identify athletes
tance runners) sustained more long bone and pelvic frac- who are more likely to sustain a stress fracture. Preventative
tures. In a series of 180 stress fractures, the percentage strategies then can be directed toward these individuals.
distribution of sports among the five most common sites Although the risk factors themselves may not be involved
is shown in Table 3-5.63 Dancers were the most com- in stress fracture pathogenesis, they directly or indirectly
mon group sustaining metatarsal stress fractures, and increase the chance of a stress fracture’s developing. This
track and distance runners sustained the most tibial stress occurs by their influence on either the mechanical environ-
fractures, whereas distance runners and dancers were ment of bone or the remodeling process. Although numer-
prominent among fibula stress fractures. Track athletes ous risk factors for stress fractures have been proposed,
were by far the most common among the navicular stress research is needed to confirm anecdotal observations. Pres-
fractures. Pars fractures were seen in athletes in field ently most studies in athletes are case series, confined to
events, racquet sports, cricket, dancing, and basketball. injured groups only, or are cross-sectional designs that do
It therefore is apparent that different sports show typical not allow the temporal relationship between risk factor
patterns of stress fractures; these are summarized in and injury to be assessed. Methodologic issues, such as
Table 3-6.64 Other sports associated with certain stress small subject numbers, different definitions of stress frac-
fractures are rowing or golf (rib stress fractures), pitch- tures, and failure to assess the independent contributions
ing (humeral fractures), and gymnastics (pars fractures). of risk factors also limit their usefulness. There also are
Conditioned athletes may sustain stress fractures dif- few data about risk factors in male athletes. Results from
ferent from those in persons unaccustomed to activity. large military epidemiologic studies cannot be readily
In a series of 368 fractures, competitive athletes had generalized to athletes because of important differences
stress fractures in the tibia significantly more often, in training, fitness levels, footwear, and surfaces. However,
whereas recreational athletes had significantly more these may provide additional insights, especially given the
metatarsal and pelvic bone fractures.52,58 It also has deficiencies in the athletic literature.
52
...........
Table 3-4 Anatomic distribution of stress fractures (SFs) in athletes expressed as a percentage of the total number of stress fractures in each series
No. of SF Diagnosis Tibia Fibula Metatarsal Navicular Femur Pelvis

Reference Sport in series of SF (%) (%) (%) (%) (%) (%)
Brubaker & Runners 17 NS 41.2 17.6 29.4 5.9 0 0
James, 197450
Orava, 198052 Variety 200 x-rays 53.5 12.5 18.0 2.0 6.0 1.5
þ/ BS
Pagliano & Runners 99 self-report 20.2 15.2 37.4 NS NS NS

Jackson,
198053
Taunton Runners 62 x-rays or BS 55.0 11.3 16.1 3.2 6.5 0

et al., 198155
Clement Runners 87 NS 57.5 9.2 20.7 3.4 4.6 0

et al., 198156
Sullivan Runners 57 x-ray or BS 43.9 21.0 14.0 0 3.5 10.5

et al., 198457
Barrow & Runners 140 self-report 63.0 9.0 21.0 0.7 4.0 1.4
Saha, 198820
Hulkko & Variety 368 x-ray 49.5 12.0 19.8 2.5 6.3 1.9
Orava, 198758 þ/ BS
Matheson Variety 320 bone scan 49.1 6.6 8.8 NS 7.2 1.6
et al., 198759
Courtenay & Variety 108 x-ray or BS 38.0 29.6 18.5 4.6 2.8 0.9
Bowers,
Risk factors for stress fractures

199060
Ha et al., Variety 169 x-ray or BS 31.5 10.7 7.1 4.7 12.5 4.1
199161
Cameron Runners 253 self-report 37.5 12.0 22.5 10.0 NS NS

et al., 199222
(Continued)
............
53
............
54
CHAPTER 3
Table 3-4 Anatomic distribution of stress fractures (SFs) in athletes expressed as a percentage of the total number of stress fractures in each series (cont’d)
No. of SF Diagnosis Tibia Fibula Metatarsal Navicular Femur Pelvis

Reference Sport in series of SF (%) (%) (%) (%) (%) (%)
Benazzo Track & 49 x-ray, CT or 26.5 12.2 14.3 28.6 0 0
et al., 199262 field BS
Kadel et al., Ballet 27 self-report 22.0 0 63.0 NS 4.0 0

199227
Goldberg & Variety 58 x-ray or BS 18.9 12.1 25.9 NS 10.0 3.4

Pecora,
199429
Johnson Variety 34 x-ray þ/ BS 38.2 0 20.6 11.8 23.5 0

et al., 199428
Bennell et al., Track & 26 BS & CT 45.0 12.0 8.0 15.0 8.0 4.0
199624 field
Brukner Variety 180 x-ray, CT or 20.0 16.7 23.3 20.0 3.3 1.1
et al., 199663 BS
From Bennell KL, Brukner PD: Clin Sports Med 16:190, 1997.
BS, Bone scan; CT, computed tomography; NS, not stated.
Table 3-5 Percentage distribution of sports among the most common stress fracture sites
Tarsal Pars
Metatarsal Tibia Fibula navicular interarticularis
Sport (n ¼ 42) (n ¼ 36) (n ¼ 30) (n ¼ 26) (n ¼ 17)
Track 21.4 38.9 16.7 73.1 5.8
Jog/distance 11.9 41.7 26.7 3.8 0

running
Dance 42.9 2.8 23.3 0 17.6
Australian football 4.8 8.3 10 7.7 0
Racquet sports 2.4 2.8 6.7 3.8 17.6
Field events 0 0 6.7 0 23.5
Rowing/canoeing 2.4 0 3.3 3.8 0
Triathlon 2.4 0 3.3 3.8 0
Basketball 2.4 0 0 3.8 11.8
Cricket 0 0 0 0 17.6
Aerobics 7.2 0 3.3 0 0
Field hockey 0 0 0 0 5.9
Rugby 0 2.8 0 0 0
Martial arts 2.4 0 0 0 0
Work-related 0 0 0 0 5.9
From Brukner P, et al: Clin J Sport Med 6:85, 1996.
Genetic predisposition Although Myburgh et al.71 failed to find a difference in

A large component of the variation in bone mass can be the incidence of a family history of osteoporosis in a group
attributed to genetic factors.66 Not surprisingly, then, a of 25 athletes with stress fractures and a group without
family history of osteoporosis is considered to be a risk fac- stress fractures, this may reflect the small sample. At pres-
tor for low bone density and osteoporosis in both men and ent, there is little evidence to show that genetic factors pre-
women.67,68 Similarly, a significant relationship between a dispose an athlete to this injury.
family history of osteoporosis and yearly change in bone
density has been demonstrated in studies of runners and Menstrual disturbances
nonrunners.69 It therefore is feasible that some individuals Because hypoestrogenic postmenopausal women are at an
may be genetically predisposed to stress fractures when increased risk of developing osteoporotic fractures, it has
exposed to suitable environmental conditions, such as vig- been suggested that stress fractures may be more preva-
orous exercise. This was implied in a case report in which a lent in female athletes with menstrual disturbances. It is
pair of 18-year-old monozygotic twins undergoing basic feasible that estrogen deficiency could promote stress
military training sustained identical multiple stress fractures fracture development by the following:
in the femoral and tarsal bones.70 The authors proposed Accelerating the process of bone remodeling, lead-
that identical environmental conditions served to unmask ing to weakened areas of bone because of the lag
a genetically determined deficiency in the affected bones. period between resorption and formation
55
...........
Table 3-6 Sports and activities commonly associated with different stress fracture sites
From Brukner PD, Khan KM: Clinical sports medicine, rev ed 2, Sydney, 2002, McGraw-Hill Book Company.
Increasing calcium excretion, resulting in greater Although progesterone may be a promoter of bone
calcium requirements that may not be adequately formation, particularly in cortical bone,72 and luteal
met by dietary intake phase deficiency in athletes is associated with lowered
Causing premature bone loss and hence lower bone progesterone levels, a possible link between luteal phase
density deficiency and stress fracture risk has not been sought.
56
...........
Research to date has focused on the relationship index and the incidence of stress fractures in 16 female
between stress fracture incidence and menstrual irregu- runners. Conversely, Barrow and Saha20 found that life-
larity (amenorrhea and oligomenorrhea), age of menar- time menstrual history did affect the risk of stress frac-
che, and use of the oral contraceptive pill (OCP). ture. They showed the incidence of stress fracture to
The findings of numerous studies suggest that stress be 29% in the regular group and 49% in the very irregu-
fractures are more common in athletes exhibiting men- lar group. The results of a prospective study also demon-
strual disturbances20,25-27,71,73-78 (Fig. 3-1). Although strated that those with a lower menstrual index were at
not all results were statistically significant, power may greater risk of stress fracture. Myburgh et al.71 found
have been limited by relatively small samples in some stud- that, although athletes with stress fractures had a higher
ies. In general, athletes with menstrual disturbances had frequency of current menstrual dysfunction than athletes
a relative risk for stress fracture that was between two without stress fractures, there was no difference in past
and four times greater than that of their eumenorrheic menstrual status. This suggests that changes associated
counterparts. However, in ballet dancers, logistic regres- with menstrual dysfunction are reversible and do not
sion analysis showed that amenorrhea for longer than 6 affect future stress fracture risk if regular menses return.
months’ duration was an independent contributor to In summary, it would appear that there is a higher
the risk of stress fracture, with the estimated risk being incidence of menstrual disturbances in female athletes
93 times that of a dancer with regular menses.27 with stress fracture than in those without. These findings
The risk of multiple stress fractures also seems to be have led some authors to assume that this is a direct result
increased in those with menstrual disturbances.20,79 of decreased bone mineral density (BMD) in athletes with
Clark et al.79 found that, although amenorrheic and menstrual disturbances. However, athletes with men-
eumenorrheic groups reported a similar prevalence of strual disturbances also exhibit other risk factors, such as
single stress fractures, 50% of the amenorrheic runners lower calcium intake,81 greater training load,82 and differ-
reported multiple stress fractures, compared with only ences in soft tissue composition.83 Because these were not
9% of those regularly menstruating. always controlled for in the studies discussed, it is difficult
Grimston et al.80 developed a menstrual index that to ascertain which are the contributory factors.
summarized previous and present menstrual status. The relationship between age of menarche and risk of
They found no relationship between this menstrual stress fracture is uncertain. Some authors have found
that athletes with stress fractures have a later age of men-
arche,25,84,85 whereas others have found no differ-
100 * ence.26,27,71 In a prospective study, age of menarche was
Regular menses an independent risk factor for stress fracture, with the risk
Menstrual disturbance increasing by a factor of 4.1 for every additional year of
*p <0.05
80
age at menarche.78 However, the mechanism for this rela-
tionship is unclear, because a later age of menarche also is
* associated with an increased likelihood of menstrual
*
% of athletes with SF
disturbance,86 a lower energy intake,87 decreased body

60 fat or weight,87 and excessive premenarcheal training,86
*
all of which could influence stress fracture risk.
*
Some authors have claimed that the OCP may pro-
40 tect against stress fracture development. Barrow and
Saha20 found that runners using the OCP for at least
1 year had significantly fewer stress fractures (12%) than
nonusers (29%). This was supported by the findings of
20
* Myburgh et al.71 Although no difference in OCP use
was reported in ballet dancers with and without stress
fractures,27 few dancers were taking the OCP. Because
0 these studies are cross-sectional or retrospective in
1 2 3 4 5 6 7 8 9 10 11 nature, it is not known whether the athletes were taking
Figure 3-1 Studies in which the percentage of athletes with
the OCP before or following the stress fracture episode.
stress fractures could be compared in groups with and In addition, athletes may or may not take the OCP for
without menstrual disturbances. 1, Lindberg et al., 198473; reasons that in themselves could influence stress fracture
2, Marcus et al., 198574; 3, Lloyd et al., 198675; 4, Warren et al., risk. A prospective study did not support a protective
198625; 5, Nelson et al., 198776; 6, Barrow and Saha, 198820; 7, effect of OCP use on stress fracture development.78
Myburgh et al., 199071; 8, Frusztajer et al., 199026; 9, Grimston Nevertheless, it is not known whether the risk of stress
et al., 199177; 10, Cameron et al., 199222; 11, Kadel et al., 1992.27 fracture is decreased in athletes with menstrual
57
...........
disturbances who subsequently take the OCP. This is an to stress fracture. However, single measurements of
important area for future research. serum calcium, parathyroid hormone, 25 OH-vitamin
D and 1,25-dihydroxyvitamin D have not been found
Low bone density to differ between stress fracture and nonstress fracture
Theoretically, low BMD could contribute to the devel- groups in military recruits.25,71,85 This may reflect samp-
opment of a stress fracture by decreasing the fatigue ling procedures or the fact that many of these biochemi-
resistance of bone to loading and by increasing the accu- cal parameters are tightly regulated.
mulation of microdamage.45,88 Results from a limited
number of studies comparing regional bone density in Nutritional status
military or athletic groups with and without stress Low calcium intake may contribute to stress fracture
fracture have been inconclusive26,40,71,77,78,84,85,89,90 development by directly influencing the processes of
(Table 3-7). The discrepancy may reflect differences in bone remodeling and bone mineralization or by indi-
populations, type of physical activity, measurement tech- rectly affecting soft tissue composition and ovarian func-
niques, and bone regions. However, the findings of tion. Other dietary factors, such as fiber, protein, and
a 12-month prospective study using dual energy x-ray caffeine intake, may play a role but have not been well
absorptiometry (DEXA) to measure bone mass indicate studied.
that low bone density is a risk factor for stress fractures There is limited evidence to suggest that low calcium
in women and possibly in men.78 Female athletes who intake may be associated with an increased risk for stress
sustained tibial stress fractures had 8.1% lower tibia/fib- fracture.71,93 Myburgh et al.94 found a significantly lower
ula BMD than athletes without stress fractures (p < .01). intake of calcium in athletes with shin soreness in compar-
In the men, the tibial stress fracture group had 4.0% less ison with a matched control group. However, because
tibia/fibula BMD than the nonstress fracture group, exact diagnoses were not made, stress fracture may not
although this was not significant (p ¼ .17). However, have been the only pathology included in this group. A
it is important to note that in this study the athletes with follow-up study in athletes with scintigraphically diag-
stress fractures still had bone density levels that were nosed stress fractures confirmed the original results.71
similar to or greater than less-active control subjects. Current calcium intake was significantly lower in the stress
This implies that the level of bone density required by fracture group, being 87% of the recommended daily
athletes for short-term bone health is greater than that intake (RDI). This is consistent with their reduced con-
required by the general population. sumption of dairy products. The authors claimed that
a calcium intake of greater than 800 mg/day protects
Bone geometry against stress fracture development.
Bone geometry influences the ability of the bone to Conversely, other investigators have failed to confirm
resist mechanical loads. A prospective study of 295 male the relationship between stress fractures and dietary
Israeli military recruits assessed the influence of bone calcium.26,27,78,84,85,95
geometry on stress fracture risk.91,92 Significantly fewer Many ballet dancers were found to consume less than
stress fractures were sustained by those with a greater the RDI for calcium regardless of their stress fracture
mediolateral tibial width, measured using standard status,26,27 implying that other factors may be more
radiographs, than by those with a narrower tibia. This important as risk factors in dancers. A calcium index based
may be due to a greater area moment of inertia and on the variability in calcium intake during the ages of 12
hence increased ability of the bone to resist bending to 23 years did not differ in runners with and without
forces in the anteroposterior direction. However, the stress fractures.77 In a prospective study of track and field
incidence of stress fractures did not correlate with corti- athletes, risk of stress fracture was not associated with cur-
cal thickness. These findings were confirmed by a recent rent calcium intake, current intake of nutrients known to
prospective study of 626 U.S. male recruits.40 Using influence calcium bioavailability and bone mass, or
DEXA to derive structural geometry, the authors found calcium supplementation use. Because the majority of
significantly smaller tibial cross-sectional area, smaller athletes in this study were consuming more than the
tibial section modulus, and smaller tibial width in the RDI for calcium, the results suggest that the relative risk
stress fracture cases. These remained after adjusting for of stress fracture is not influenced by daily intakes above
body weight differences between groups. There are no this level. This is consistent with the concept of calcium
data that investigate whether bone geometry predisposes as a threshold nutrient whereby effects on the skeleton
to stress fractures in athletes. are apparent only up to a certain level.96 However, it does
not rule out an association between calcium deficiency
Endocrine factors and a higher incidence of stress fracture.
Alterations in calcium metabolism could affect bone re- There are no intervention studies assessing the effect of
modeling and bone density, and theoretically predispose calcium supplementation on stress fracture incidence in
58
...........
Table 3-7 Summary of studies directly investigating the relationship between bone density and stress fractures
Study Sample Results %

Reference design Subjects Sex size Techn Sites diff{
Pouilles et al., 198989 CS Military M 41-SF DPA Femoral neck 5.7*
48-NSF Ward’s triangle 7.1*
Trochanter 7.4*
Carbon et al., 199085 CS Various F 9-SF DPA LSp 4.0*

athletes 9-NSF SPA Femoral neck 7.0
Distal radius 7.7
Ultradistal 0.0
radius
Frusztajer et al., CS Ballet F 10-SF DPA LSp 4.1

199026 dancers 10-NSF SPA First metatarsal 0.0
Radial shaft 0.0
Myburgh et al., 199071 CS Various M/F 25-SF DXA LSp 8.5*

athletes 25-NSF Femoral neck 6.7*
(19 F, 6 M) Ward’s triangle 9.0*
Trochanter 8.6*
Intertrochanter 5.5
Proximal femur 6.5*
Giladi et al., 198792 P Military M 91-SF SPA Tibial shaft –6.0

198-NSF
Grimston et al., 199177 CS Runners F 6-SF DPA LSp 8.2*

8-NSF Femoral neck 7.6*
Tibial shaft 9.7
Warren et al., 199184 CS Ballet F 14-SF DPA LSp NS

dancers 34-NSF First metatarsal NS
Distal radius NS

Bennell et al., 199678 P Track & F 10-SF DXA Upper limb 3.3
field 36-NSF Thor sp 6.7
athletes LSp 11.9*
Femur 2.2
Tibia/fibula 4.2
Foot 6.6*
(Continued)
............
59
............
60
CHAPTER 3
Table 3-7 Summary of studies directly investigating the relationship between bone density and stress fractures (cont’d)
Study Sample Results %

Reference design Subjects Sex size Techn Sites diff{
M 10-SF DXA Upper limb 4.9
39-NSF Thor sp 4.1
LSp 0.8
Femur 2.9
Tibia/fibula 4.0
Foot 0.3
Beck et al., 199640 P Military M 23-SF DXA Femur 3.9*

587-NSF Tibia 5.6*
Fibula 5.2
CS, Cross-sectional; DPA, dual photon absorptiometry; DXA, dual energy x-ray absorptiometry; F, females; LSp, lumbar spine; M, males; NS, not stated but not significantly different;
P, prospective; SPA, single photon absorptiometry; Techn, technique; Thor sp, thoracic spine.
*Statistically significant.
{
Results are given as the percent difference comparing stress fracture subjects (SF) with nonstress–fracture subjects (NSF).
athletes. A randomized controlled study in male military However, recruits with a larger calf muscle circumference
recruits showed a similar incidence of stress fractures during developed significantly fewer stress fractures.91 This finding
a 9-week training program in 247 recruits taking 500 mg of also was evident in female athletes, in whom every 1 cm
calcium daily and in 1151 controls.97 However, because decrease in calf girth was associated with a fourfold greater
both groups had a baseline dietary calcium intake greater risk of stress fracture78 (Fig. 3-2). Using a biomechanical
than 800 mg/day, this may have been sufficient to provide model, Scott and Winter105 calculated that, during run-
protection against stress fracture. Alternatively, a longer ning, the tibia is subjected to a large forward bending
duration of calcium intervention may be necessary for effects moment as a result of ground reaction force. The calf mus-
to become apparent, particularly at cortical bone sites. cles oppose this large bending moment by applying a back-
Other nutrients, such as protein, total energy, phos- ward moment as they contract to control the rotation of the
phorus, fiber, sodium, alcohol, and caffeine could poten- tibia and the lowering of the foot to the ground. The total
tially affect bone health and therefore stress fracture risk. effect is a smaller bending moment. Extrapolating from
At present, no associations have been found between these this, a stress fracture could result if the calf muscles are
and the incidence of stress fractures in athletes.26,78,84,85 unable to produce adequate force to counteract the loading
Dietary behaviors and eating patterns may differ in at ground contact and decrease excessive bone strain. The
those with stress fractures. Ballet dancers with stress frac- findings of a smaller calf girth in those with stress fractures
tures were more likely to diet and restrict food intake, tend to support the hypothesis that muscles act to protect
avoid high-fat dairy foods, consume low-calorie products, against rather than cause stress fractures.
have a self-reported history of an eating disorder, and have However, there have been no studies comparing
weight fluctuations down to a lower percentage of ideal muscle mass or muscle strength, particularly peak force
body weight than those without stress fractures.26
However, scores on a validated test relating to dieting, 1.0
bulimia and food preoccupation, and oral control
(EAT-26) did not differ between ballet dancers or track 0.9
and field athletes with and without stress fracture.25,26,78
0.8
Anthropometry and soft tissue composition
Anthropometric characteristics, such as height and 0.7
weight, and soft tissue composition, such as lean mass
and fat mass, theoretically could affect stress fracture risk
Probability of SF
0.6
directly by influencing the forces applied to bones98 or
indirectly via effects on bone density99,100 and menstrual 0.5
function.83
Unlike the military, in which anthropometric charac- 0.4
teristics appear to be related to stress fractures incidence,40
no study in athletes has reported a difference in height, 0.3
weight, body mass index, or fat mass between those with
and without stress fractures.20,21,25,27,75,77,78,85 Failure to 0.2
find a relationship in athletes may be due to the relative
homogeneity in these characteristics, unlike the military, 0.1
in which a range of somatotypes would be expected.
Another explanation is that the relationship may be 0.0
nonlinear. 10 11 12 13 14 15 16 17 18 19 20
Muscles could play a dual role in stress fracture develop- Age of menarche (years)
ment. Some investigators consider that muscles act dynami-
cally to cause stress fractures by increasing bone strain at Corrected calf girth
sites of muscle attachment.101,102 Greater muscle mass with Small Average Large
greater ability to generate force would be associated with an
increased risk for stress fracture. Others feel that, because Figure 3-2 Plot of the probability of stress fracture at
muscles act to attenuate and dissipate forces applied to different ages of menarche for different corrected calf girths in
bone,103 muscle fatigue or muscle weakness would predis- female athletes. The plot for small corrected calf girth was
pose to stress fracture by causing an increase and redistribu- calculated using the minimal value measured in the cohort; the
tion of stress to bone.62,104 In the military, leg power was average girth was calculated using the mean value; and the
not associated with stress fracture occurrence, although large girth was calculated using the maximal value. (From
the testing method was relatively crude and nonspecific.90 Bennell KL, et al: Am J Sports Med 24:814, 1996.)
61
...........
production and tendency to fatigue, in athletes with and surfaces but provided no further details. Other research-
without stress fractures. Grimston et al.106 found that, ers also have implicated training surface or change in
during the latter stages of a 45-minute run, females with surface as a risk factor but do not provide substantial evi-
a past history of stress fracture recorded increased dence in support.29,57
ground reaction forces, whereas ground reaction forces Older or worn running shoes have been related to an
did not vary during the run in the control group. The increase in stress fractures,36 possibly as a result of
authors surmised that this may indicate differences in decreased shock absorption.112 However, the use of a
fatigue adaptation and muscle activity. shock-absorbing viscoelastic insole made no difference
to the incidence of tibial stress fractures in rabbits113 or
Training to the overall incidence of stress fractures in military
Repetitive mechanical loading arising from athletic recruits.36,44,114 It is not clear why Milgrom et al.41 found
training contributes to stress fracture development. a significant insole effect limited to femoral stress fractures
However, the contribution of each training component only. Another prospective study showed that a semirigid
(volume, intensity, frequency, surface, and footwear) to orthotic device significantly reduced the incidence of
the risk of stress fracture has not been elucidated. Training femoral stress fractures in recruits with high-arched feet
also may influence bone indirectly through changes in and the incidence of metatarsal fractures in recruits with
levels of circulating hormones, through effects on soft low-arched feet.115 The incidence of tibial stress fractures
tissue composition, and through associations with was not affected by the use of this orthotic device. Because
menstrual disturbances. the device had a hindfoot post at 3 degrees varus, altering
Large military studies have shown that various train- the biomechanics of the foot, it is difficult to know
ing modifications, such as inclusion of rest periods,34,107 whether the results of the study can be attributed to this
elimination of running and marching on concrete,33,108 feature or to the shock-absorption capability.
use of running shoes rather than combat boots,32,108 In track and field, clinical observation suggests that
and reduction of high-impact activity32,34,37,38,108 can the use of running spikes may influence the likelihood
decrease the incidence of stress fractures in recruits. of stress fracture. However, little research has focused
In contrast, there is little controlled research in athletes. on the kinetic and kinematic effects of this form of foot-
Most research consists of anecdotal observations or case wear or on the relationship of spikes to stress fracture.
series in which training parameters are examined only in
those athletes with stress fractures. Surveys have reported Biomechanics
that up to 86% of athletes can identify some change in their Biomechanical features may predispose to stress frac-
training before the onset of the stress fracture.22,29,57 tures by creating areas of stress concentration in bone
Other researchers have blamed training ‘‘errors’’ in a vary- or by promoting muscle fatigue. Although various bio-
ing proportion of cases but do not adequately define these mechanical features have been examined in military
errors.30,55,60,109 Brunet et al.21 surveyed 1505 runners recruits, there are few data pertaining to athletes. Failure
and found that increasing mileage correlated with an to report measurement reliability or to analyze data
increase in stress fractures in women but not in men. An appropriately makes results difficult to interpret.
explanation for the apparent gender difference is unclear. High arches (pes cavus) may be associated with an
Australian track athletes with a past history of stress fracture increased risk for stress fracture, particularly at femoral
tended to report more weekly hours of training and run- and tibial sites in male military recruits.115-117 In a pro-
ning and greater weekly distances in the 5 years preceding spective study, the overall incidence of stress fracture in
the study, compared with those who had never sustained the low-arched group was 10%, as opposed to 40% in
a stress fracture.22 In a study of ballet dancers, a dancer the high-arched group.116 A similar trend was noted for
who trained for more than 5 hours per day had an esti- tibial and femoral stress fractures. However, assessment
mated risk for stress fracture that was 16 times greater than of foot type was based on observation in a nonfunctional
a dancer who trained for fewer than 5 hours per day.27 This position, and recruits with extreme pes planus were
study supports a role for training volume as a risk factor for excluded. Nevertheless, these findings were supported
stress fracture, but that factor may be related to increased by a study using a contact pressure display method to
exposure to injury. provide foot-ground pressure patterns and derived stress
Training surface has long been considered to contrib- intensity parameters.117 Although there may be a rela-
ute to stress fracture development.5 Anatomic and bio- tionship between foot type and stress fracture, this may
mechanical problems can be accentuated by cambered vary depending on the site of stress fracture. Using radio-
or uneven surfaces, whereas ground reaction forces are graphs to assess foot type, femoral and tibial stress frac-
increased by less compliant surfaces.110,111 In a study tures were more prevalent in the presence of higher
of female runners, Zernicke et al.93 claimed that those arches, whereas the incidence of metatarsal fractures was
who sustained stress fractures tended to train on harder higher with lower arches.115 The authors proposed that,
62
...........
Diagnosis
because a low-arched foot is more flexible, it reduces the and using a force platform suggest a possible role for
forces transmitted proximally to the tibia and femur but external loading kinetics and load magnitude in the
concentrates the forces in the foot. development of a stress fracture.77,106 This is an
Limited observations in athletes tend to differ from important area for future research.
military findings. Pes planus (pronated) was the most
common foot type in athletes who presented to sports
clinics with stress fractures.55,57 However, the incidence DIAGNOSIS
of pes planus in noninjured athletes was not assessed. In
another series of stress fractures, pes planus was more
In the assessment of a patient presenting with a possible
common in tibial and tarsal bone stress fractures and
diagnosis of stress fracture, there are three questions
least common in metatarsal stress fractures.59 This
that need to be answered:
implies a possible heterogenous effect of biomechanical
1. Is the pain bony in origin?
features on stress fracture risk, depending on the ana-
2. If so, which bone is involved?
tomic location of the injured region.
3. At what stage in the continuum of bone stress is
A leg-length discrepancy is another feature that has
this injury?
been postulated as a potential risk factor because of result-
To obtain an answer to these three questions, a thor-
ing skeletal realignment and asymmetries in loading, bone
ough history, precise examination, and appropriate use of
torsion, and muscle contraction.118 Using a radiologic
imaging techniques are used. In many cases, the diagnosis
method to assess leg length, Friberg119 found that, in
of stress fracture will be relatively simple. In others, espe-
130 cases of stress fracture in military recruits, the longer
cially when the affected bone may lie deeply (e.g., femur)
leg was associated with 73% of tibial, metatarsal, and fem-
or the pattern of pain may be nonspecific (e.g., navicular),
oral fractures, whereas 60% of fibular fractures were found
the diagnosis can present a challenge for the clinician.
in the shorter leg. In a prospective analysis, he observed
a positive correlation between the degree of leg-length
inequality and the incidence of stress fractures. However,
no statistical analyses were performed to assess the signifi-
.............................................................
History
cance of these results. A leg-length discrepancy also has The history of the patient with a stress fracture typically is
been found to be associated with a significant increase in one of insidious onset of activity-related pain. Usually the
the incidence of stress fractures in athletes.21,78 Seventy pain will be described initially as a mild ache occurring after
percent of women who developed stress fractures dis- a specific amount of exercise. If the patient continues to
played a leg-length difference of more than 0.5 cm, exercise, the pain may well become more severe or occur
compared with 36% of women without stress fractures.78 at an earlier stage of exercise. The pain eventually may
Large prospective studies in the Israeli military have increase to the point that it limits the quality or quantity
included an orthopaedic examination in addition to as- of the exercise performed or, occasionally, forces cessation
sessment of other risk factors for stress fractures.42,90,120 of all activity. In the early stages, pain usually will cease soon
Of the biomechanical variables, only range of hip external after exercise is terminated. However, with continued
rotation was found to correlate with the incidence of exercise and increased severity of symptoms, the pain may
stress fracture. Soldiers in whom hip external rotation persist after exercise cessation. Night pain occasionally
was greater than 65 degrees were at a higher risk for tibial may occur.
and total stress fractures than those with a range less In addition to obtaining a history of the patient’s
than 65 degrees. The risk for tibial stress fracture pain and its relation to exercise, it is important to deter-
increased 2% for every 1 degree increase in hip external mine the presence of predisposing factors. Therefore
rotation range.42 However, a large prospective study in a training or activity history is essential. In particular,
American recruits failed to confirm these findings.121 note should be taken of recent changes in activity level,
Greater forefoot varus and restricted ankle joint dorsi- such as increased quantity of training, increased intensity
flexion also have been associated with an increased risk of training, and changes in surface, equipment (espe-
of stress fracture in military recruits.122 The only prospec- cially shoes), and technique. It may be necessary to
tive study to examine a number of clinical biomechanical obtain information from the patient’s coach or trainer.
measurements in athletes, including range of hip rotation A full dietary history should be taken; particular atten-
and ankle dorsiflexion, calf and hamstring flexibility, tion should be paid to the possible presence of eating
lower limb alignment, and static foot posture, did not find disorders. In females a menstrual history should be
any to be useful predictors of stress fracture occurrence.78 taken, including age of menarche and subsequent
Most studies have included static biomechanical menstrual status.
measures, which may not adequately reflect the dynamic A history of previous similar injury or any other mus-
situation.123 Preliminary studies analyzing running gait culoskeletal injury should be obtained. It is essential to
63
...........
obtain a brief history of the patient’s general health, training if at all possible and requires more specific knowl-
medications, and personal habits to ensure that there edge of his or her condition, there are various imaging
are no factors that may influence bone health. It also is techniques available to the clinician.
important to obtain from the history an understanding
of the patient’s work and sporting commitments. In par- Radiography
ticular, it is important to know at what level of sport and Radiography has poor sensitivity but high specificity in the
how serious the patient is about his or her sport, as well diagnosis of stress fractures. The classic radiographic
what significant sporting commitments are ahead in the abnormalities seen in a stress fracture are new periosteal
short term and medium term. bone formation, a visible area of sclerosis, the presence of
callus, or a visible fracture line. The diagnosis of stress frac-
.............................................................
Physical examination ture can be confirmed if any of these radiographic signs are
present.
On physical examination the most obvious feature is Unfortunately, in the majority of stress fractures there is
localized bony tenderness. Obviously this is easier to no obvious radiographic abnormality. The abnormalities
determine in bones that are relatively superficial and on radiography are unlikely to be seen unless symptoms
may be absent in stress fractures of the shaft or neck of have been present for at least 2 to 3 weeks. In certain cases
femur. It is important to be precise in the palpation of they may not become evident for up to 3 months, and in a
the affected areas, particularly in regions such as the percentage of cases never become abnormal.
foot, in which there are a number of bones and joints
in a relatively small area that may be affected. Occasion- Isotopic bone scan (scintigraphy)
ally redness and swelling may be present at the site of the If plain radiography demonstrates the presence of a stress
stress fracture. There also may be palpable periosteal fracture, then there seldom is any need to perform further
thickening, especially in a long-standing fracture. Per- investigations. However, in cases in which there is a high
cussion of long bones may result in the production of index of suspicion of stress fracture and a negative bone
pain at a point distant from the percussion. radiograph, the triple-phase bone scan is the next line of
Joint range of motion usually is unaffected except in investigation. The bone scan is highly sensitive but has
situations in which the stress fracture is close to the joint low specificity. Prather et al.127 stated that the bone scan
surface, such as a stress fracture of the neck of femur. had a true-positive rate of 100%, and false-negative scans
Some authors have suggested that the presence of are relatively rare.128,129
pain when therapeutic ultrasound is applied over the Technetium-99 methylene diphosphonate usually is
area of the stress fracture is of potential use in the detec- used as the radionuclide substance. Other possibilities
tion of stress fractures.124-126 Similarly it is reported that include gallium citrate (Ga 67) and indium 111-labeled
application of a vibrating tuning fork to the affected leukocytes.130 The advantage of technetium-99 methylene
bone and subsequent increase in pain is indicative of a diphosphonate (MDP) is its short half-life (6 hours), allow-
stress fracture. Our own experience suggests that these ing a higher dose to be administered with improved
methods are not particularly helpful. resolution.131
The physical examination also must take into account In the first phase of the bone scan, flow images are
the potential predisposing factors; and, in all stress frac- obtained immediately after the intravenous injection of the
tures involving the lower limb, a full biomechanical tracer. These initial images usually are taken every 2 seconds
examination must be performed. Any evidence of leg- and correspond roughly to contrast angiography, albeit
length discrepancy, malalignment (especially excessive with much lower spatial and temporal resolution. This first
subtalar pronation), muscle imbalance, weakness, or lack phase of the bone scan evaluates perfusion to bone and soft
of flexibility should be noted. tissues from the arterial to the venous circulation.
The second phase of the bone scan consists of a static
.............................................................
Imaging ‘‘blood pool’’ image taken 1 minute after the injection
and reflects the degree of hyperemia and capillary per-
Imaging plays an important role in supplementing meability of bone and soft tissue. Generally speaking,
clinical examination to determine the answers to the three the more acute and severe the injury, the greater the
questions mentioned at the start of this section on diagno- degree of increased perfusion and blood pool activity.
sis. In many cases a clinical diagnosis of stress fracture is suf- The third phase of the bone scan is the delayed image
ficient. The classic history of exercise-associated bone pain taken 3 to 4 hours after injection, when approximately
and typical examination findings of localized bony tender- 50% of the tracer has concentrated in the bone matrix
ness have a high correlation with the diagnosis of stress through the mechanism of chemisorption to the
fracture. However, if the diagnosis is uncertain, or in the hydroxyapatite crystals. On the 3-hour delayed image,
case of the serious or elite athlete who wishes to continue the uptake of the tracer is proportional to the rate of
64
...........
Diagnosis
osteoblastic activity, extraction, and efficiency, as well as authors postulated that this may be nonspecific stress changes
to the amount of tracer delivered per unit time or blood related to bone remodeling,133 a false-positive finding,150 and
flow.132 The inclusion of the first and second phases of an uncertain finding.151 Rosen et al.148 found asymptomatic
the bone scan permits the estimation of the age of uptake in 46% of cases, with focal uptake more common than
stress-induced focal bony lesions and the severity of diffuse uptake.
bony injuries and helps to differentiate soft tissue Matheson et al. in Vancouver, BC,152 proposed the
inflammation from bony injury.133 As the bony lesion concept of bone strain. They noted that the radionu-
heals, the perfusion returns to normal first, followed by clide bone scan, because of its sensitivity, was able to
normalization of the blood pool image a few weeks demonstrate the adaptive changes in bone at any point
later. Focal increased uptake on the delayed scan in the continuum from early remodeling to stress frac-
resolves last because of ongoing bony remodeling and ture. The term ‘‘bone strain’’ was coined to reflect the
generally lags well behind the disappearance of pain. As true dynamic response of bone to stress and to allow
healing continues, the intensity of the uptake diminishes the interpretation of bone changes along the continuum
gradually during a 3- to 6-month period following an to be correlated with the wide range of presentations
uncomplicated stress fracture, with a minimal degree of seen in clinical practice. They stated that excessive
uptake persisting for up to 10 months132 or even longer. loading from overuse, abnormal biomechanics, reduced
Changes on bone scan may be seen as early at 48 to shock absorption, or altered gait produced a mechanical
72 hours after the commencement of symptoms. The stress that is translated into bone remodeling via piezo-
radionuclide scan may be positive as early as 7 hours electric stimuli. The relative contribution of these fac-
after bone injury.134 tors, as well as the athlete’s activity pattern after the
The bone scan is virtually 100% sensitive, at least onset of remodeling, determines the extent of bone
twice as sensitive as x-ray,135 and consistently more sen- strain seen clinically. Pain during activity may indicate
sitive that ultrasound,136 thermography,137 and compu- small areas of remodeling, which have low-intensity
terized tomography (CT).138 In several studies, only uptake on bone scan and negative x-rays. On the other
10% to 25% of bone–scan-positive stress fractures had hand, pain that persists after exercise and during rest
radiographic evidence of stress fracture.139-142 may indicate more extensive remodeling, with intense
In the appropriate clinical setting, the scintigraphic uptake on scan and possibly abnormal radiographs.
diagnosis of a stress fracture is defined as focal increased This concept of a continuum of bone strain’s existing
uptake in the third phase of the bone scan. However, both clinically and scintigraphically is now widely accepted.
bone scintigraphy lacks specificity because other non- It is clear now that bone stress can appear as an area of
traumatic lesions, such as tumor (especially osteoid oste- increased uptake on isotope bone scan before any symptoms
oma), osteomyelitis, bony infarct, and bony dysplasias
also can produce localized increased uptake. Therefore
it is vitally important to correlate the bone scan appear-
ance with the clinical features.
The radionuclide scan will detect evolving stress frac-
tures at the stage of accelerated remodeling. At that
stage, which may be asymptomatic, the uptake usually
is of mild intensity, progressing to more intense and bet-
ter defined uptake as microfractures develop.13,143
In stress fractures all three phases of the triple-phase
bone scan are positive.133,144 Other bony abnormalities,
such as periostitis (shin splints), are positive only on
delayed images,133,145 whereas certain other overuse
soft-tissue injuries would be positive only in the angio-
gram and blood pool phase, thus allowing one to differ-
entiate between bony and soft-tissue pathology. The
characteristic bone scan appearance of a stress fracture
is of a sharply marginated or fusiform area of increased
uptake involving one cortex or occasionally extending
the width of the bone13 (Fig. 3-3).
Increased radionuclide uptake often is found in asymp-
tomatic sites.108,146,147 Originally the presence of in-
creased tracer uptake at nonpainful sites in athletes was Figure 3-3 Typical bone scan appearance of stress fracture of
interpreted as unrecognized stress fractures.13,148,149 Other tibia.
65
...........
occur. It is not clear what percentage of these cases progress in the elite athlete, this may considerably affect his or her
to symptomatic bone stress and ultimately to stress fracture rehabilitation program and forthcoming competition
if exercise is continued. It also is not clear what treatment is program.
appropriate in these cases of asymptomatic bone stress.
Many athletes and dancers in hard training show numerous Magnetic resonance imaging
areas of bone stress on an isotope bone scan. These are Magnetic resonance imaging (MRI), although not
indicators of active remodeling and are not necessarily bone imaging cortical bone as well as CT scan, has certain
at risk for the development of stress fracture. advantages in the imaging of stress fractures. Specific
Attempts have been made to classify the bony contin- MRI characteristics of stress fracture include new bone
uum into ‘‘bone strain’’ or ‘‘asymptomatic stress reaction’’ formation and fracture lines appearing as very low signal
and stress fracture. A summary of these features may be medullary bands that are contiguous with the cortex;
seen in Table 3-8. A scheme for grading bone scan appear- surrounding marrow hemorrhage and edema seen as
ance on the basis of severity has been proposed by Zwas low signal intensity on T1-W images (Fig. 3-5) and as
et al.141 This is shown in Table 3-9. high-signal on T2-W and short T1 inversion and recov-
ery (STIR) images; and periosteal edema and hemor-
Computerized tomography rhage appearing as high signal intensity on T2-W and
CT may be useful in differentiating those conditions STIR images.155 These changes are seen best if the
with increased uptake on bone scan that may mimic MRI is performed within 3 weeks of symptoms.156
stress fracture. These include osteoid osteoma, osteomy- MRI is thought to be more sensitive than conventional
elitis with a Brodie’s abscess, and other malignancies. radiography. MRI visualizes marrow hemorrhage and
CT scans also are particularly valuable in imaging edema well, a characteristically difficult finding with
fractures in which this may be important in treatment. CT. Although CT scan visualizes bone detail, another
CT scanning of the navicular bone is particularly help- advantage of MR imaging is in distinguishing stress
ful.153,154 CT scanning also may be valuable in detecting fractures from a suspected bone tumor or infectious
fracture lines as evidence of stress fracture in long bones process.155
(e.g., metatarsal and tibia) in which plain radiography Stafford et al.157 reported findings of stress fractures in
is normal and isotope bone scan shows increased MRI. Zones of decreased signal of T1 images are seen in
uptake (see Fig. 3-3). CT scanning will enable the clinician the affected region, whereas T2-weighted images show
to differentiate between a stress fracture, which will be visi- increased signal. A low signal line may be seen running
ble on CT scan, and a stress reaction (Fig. 3-4). Particularly through the medullary cavity, presumably corresponding
Table 3-8 Continuum of bony changes with overuse
From Brukner PD, Khan KM: Clinical sports medicine, rev ed 2, Sydney, 2002, McGraw-Hill Book Company.
CT, Computed tomography; MR, magnetic resonance.
66
...........
Diagnosis
Table 3-9 Grading of tibial or long bone stress fractures by bone scan or magnetic resonance imaging (MRI) appearance
Grade Bone scan appearance MRI appearance

Grade I Small, ill-defined cortical area of Periosteal edema: mild to moderate on T2-weighted images.
mildly increased activity Marrow edema: normal on T1- and T2-weighted images.
Grade II Better defined cortical area of Periosteal edema: moderate to severe on T2-weighted images.
moderately increased activity Marrow edema on T2-weighted images.
Grade III Wide, fusiform cortical-medullary Periosteal edema: moderate to severe on T2-weighted images.
area of highly increased activity Marrow edema on T1- and T2-weighted images.
Grade IV Transcortical area of increased Periosteal edema: moderate to severe on T2-weighted images.
activity Marrow edema on T1- and T2-weighted images. Fracture line
clearly visible.
Figure 3-4 Computed tomography (CT) appearance of stress

fracture of navicular.
to the zone of localized fracture. Further advances in

marrow imaging have occurred, such as STIR sequences
that help to better identify such marrow pathology.
The appearance of a stress fracture on MRI is charac- Figure 3-5 Magnetic resonance imaging (MRI) appearance of
teristic with intraosseous bands of very low signal inten- stress fracture.
sity that are continuous with the cortex and surrounding
areas of decreased signal intensity of the marrow space
on T1-weighted images. T2 images show prominent edema, as well as bone marrow edema on T2-weighted
intramedullary areas of high signal intensity and juxta- images only. Grade III showed moderate to severe edema
cortical and/or subperiosteal areas of high signal of both the periosteum and marrow on both T1- and
intensity.156,158 T2-weighted images. Grade IV demonstrated a low signal
Fredericson et al.159 proposed a grading scheme for fracture line on all sequences with changes of severe mar-
MRI appearances of stress fractures using STIR images. row edema on both T1- and T2-weighted images. Grade
The authors felt that their grades I to IV were equivalent IV also may show severe periosteal and moderate muscle
to the bone scan grading described by Zwas et al.,141 men- edema. The comparison of grading of stress fractures
tioned in the previous section. In this grading system, between bone scan141 and MRI159 is shown in Table 3-9.
grade I indicated mild to moderate periosteal edema on Steinbronn et al.158 advocated the use of MRI in
T2-weighted images, only with no focal bone marrow patients who have negative radiographs, a positive bone
abnormality. Grade II showed more severe periosteal scan, and a diagnosis still not firmly established.
67
...........
of 45 minutes. Once this is achieved without pain, we then

DIFFERENTIAL DIAGNOSIS
recommend introducing initially a period of 5 minutes of
slow jogging within the 45-minute walk. Assuming that
The differential diagnosis of stress fracture can be divided this increase in activity does not reproduce the patient’s
into nonbony causes or bony causes. Nonbony causes, in symptoms, then the amount of jogging can be increased
particular, relate to muscle or tendon injury; either muscle on a daily basis until the whole 45 minutes is completed
strain, hematoma or delayed-onset muscle soreness, or at jogging pace. Once this is achieved, then strides can be
tendon inflammation or degenerative change. introduced, initially half-pace and then gradually increas-
Bony pathologies that can mimic stress fracture include ing to full-pace striding. Once full sprinting is pain free,
tumor and infection. Osteoid osteoma commonly is then gradual functional activities, such as hopping, skip-
mistaken for a stress fracture because it presents with pain ping and jumping, twisting, and turning can be introduced
and a discrete focal area of increased uptake on isotope gradually. It is important that this process is a graduated
bone scan. Two distinguishing features of osteoid oste- one, and it is important to err on the side of caution rather
oma are the presence of night pain and the relief of pain than try to be too hasty.
with the use of aspirin. In addition, a CT scan or MRI A typical program for an uncomplicated lower limb
can clearly distinguish the nidus of an osteoid osteoma stress fracture resuming activity after a period of initial
from the cortical abnormality of a stress fracture. rest and activities of daily living is shown in Figure 3-6.
Progress should be monitored clinically by the pres-
ence or absence of symptoms and local signs. It usually
is not necessary to monitor progress by radiography,
TREATMENT
scintigraphy, CT, or MRI. Radiologic healing often lags
behind clinical healing.
The basis of treatment of stress fractures involves rest from
the aggravating activity, a concept known as ‘‘relative rest.’’ Fitness maintenance
The amount of time from a diagnosis of a stress fracture to It is important that the athlete with a stress fracture be
full return to sport depends on a number of factors, includ- able to maintain strength and cardiovascular fitness while
ing the site of the fracture, the length of the symptoms, and undergoing the appropriate rehabilitation program. It
the stage in the spectrum of bone strain. Most stress frac- should be emphasized to the athlete that the rehabilita-
tures with a relatively brief history of symptoms will heal tion program is not designed to maintain or improve the
in a straightforward manner, and return to sport should patient’s fitness but rather to allow the damaged bone
occur within 6 to 8 weeks. However, there is a group of time to heal and gradually develop or regain full strength.
stress fractures that require additional treatment to relative Fitness should be maintained in other ways.
rest, and these are considered later. The most common ways are biking, swimming, water
The primary aim of initial management of stress frac- running, and using upper body weights. These workouts
ture is pain relief. This may involve the use of mild should mimic the athlete’s normal training program as
analgesics or nonsteroidal anti-inflammatory drugs much as possible in both duration and intensity. Water
(NSAIDs). In some cases in which activities of daily liv- running is particularly attractive to runners for this reason.
ing are painful, it may be necessary for the patient with a Water running involves the use of a buoyancy vest as a
stress fracture to be nonweight bearing or partial weight flotation device.
bearing on crutches for a period of up to 7 to 10 days. Stretching should be performed to maintain flexibility
In the majority of cases this is not necessary, and mere during the rehabilitation process. Muscle strengthening
avoidance of the aggravating activity will be sufficient. also is an important component of the rehabilitation phase.
The rate of resumption of activity should be modified In addition to maintaining these parameters of
according to symptoms and physical findings. At all time, physiologic fitness, it is possible in most cases for the
activity should be pain free; and, if any bony pain occurs, athlete to maintain specific sports skills. In ball sports
then activity should be ceased for 1 to 2 days and then these can involve activities either seated or standing still.
resumed at a lower level. The patient should be clinically This active rest approach also greatly assists the athlete
reassessed at regular intervals, in particular looking for psychologically.
bony tenderness.
When activities of daily living are pain free and there is Modified risk factors
no focal tenderness, then resumption of the aggravating As with any overuse injury, it is not sufficient merely to
activity can occur on a graduated basis. For lower limb treat the stress fracture itself. An essential component of
stress fractures in which running is the aggravating activity, the management of an athlete with an overuse injury
we recommend a program that involves initial brisk walk- involves identification of the factors that have contrib-
ing increased by 5 to 10 minutes per day, up to a length uted to the injury and, when possible, correction or
68
...........
Treatment
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

(mins) (mins) (mins) (mins) (mins) (mins) (mins)
Week 1 Walk 5 Walk 20 Walk 25 Walk 30 Walk 35 Walk 40 Walk 45
Walk 20 Walk 15 Walk 15 Walk 10 Walk 5 Walk 5

Week 2 Jog 5 Jog 15 Jog 20 Jog 25 Jog 30 Jog 35 Jog 45
Walk 15 Walk 15 Walk 15 Walk 10 Walk 10 Walk 5
Jog 45 Jog 45 Jog 45 Jog 45 Jog 45 Jog 45 Jog 45

Week 3
Sprint 10 Sprint 10 Sprint 15 Sprint 15 Sprint 10 Sprint 10 Sprint 15
Add
Week 4 functional Gradually increase all week
activities
Week 5 RESUME FULL TRAINING
Figure 3-6 Activity program following uncomplicated lower limb stress fracture following period of rest and
activity of daily living (ADL).
modification of some of these factors to reduce the risk on the previously injured area and reduce the likelihood
of the injury’s recurring. The fact that stress fractures of a recurrence.
have a high rate of recurrence is an indication that this
part of the management program often is neglected. Stress fractures requiring specific treatment
The risk factors for the development of stress frac- Although the majority of stress fractures of the foot and
tures have been discussed at length in a previous section. ankle will heal without complications in a relatively short
Although not yet supported by rigorous scientific evi- time frame, there are a number of stress fractures that
dence, one possible precipitating factor is training require specific additional treatment. These are as follows:
errors. Therefore it is important to identify these and Medial malleolus
to discuss them with the athlete and his or her coach Navicular
when appropriate. Another important contributing fac- Base of second metatarsal
tor may be inadequate equipment, especially running Proximal fifth metatarsal
shoes. These shoes may be inappropriate for the particu- Sesamoids
lar foot type of the athlete, may have general inadequate These ‘‘difficult stress’’ fractures are covered in
support, or may be worn out (see Chapter 26). Chapter 4.
Biomechanical abnormalities also are thought to be
an important factor contributing to the development
of overuse injuries in general and stress fractures in
particular. Both excessively supinated and excessively 4 PEARL
pronated feet can be contributing factors in the develop- Stress fractures of the second, third, or fourth metatarsals
ment of stress fractures. Excessively supinated feet gen- swell and the pain is dorsal, whereas neuromas of the
erally give poor absorption and require footwear that forefoot do not swell and the pain typically is plantar.
gives good absorption. Excessively pronated feet will Most stress fractures of the foot and ankle heal with
relative rest. Navicular, fifth metatarsal Jones, base of
require appropriate footwear for their foot type and also second, medial malleolus, sesamoid, and lateral process of
may require the use of custom-made orthotics (see the talus require more involved care for healing.
Chapter 27). Stress fractures are fatigue fractures and result from
It is important that these risk factors are corrected by repeated overuse, and they are common in the athlete.
the time the athlete resumes training. When training For stress fractures, always investigate for eating
abnormalities, and in females ask about their menstrual
resumes, it is important to allow adequate recovery time history.
after hard sessions or hard weeks of training. In view of Bone scans and MRI are helpful to diagnose a
the history of stress fracture, it is advisable that some stress fracture early in its presentation (<3 weeks of
form of cross training, for example, swimming and symptoms).
cycling for a runner, be introduced to reduce the stress
69
...........
23. Bennell KL, et al: Risk factors for stress fractures in female track-
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72
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........................................... C H A P T E R 4
Problematic stress fractures of the

foot and ankle
James A. Nunley and Anthony S. Rhorer
......................
CHAPTER CONTENTS
Introduction 73 Stress fracture of the fifth metatarsal 81

Stress fracture of the tarsal navicular 73 Summary 83
Stress fracture of the base of second metatarsal 75 References 83
Stress fracture of the medial malleolus 76
the mechanisms of diagnosis therefore should be requisite
4 PEARL in the armamentarium of physicians treating athletes.

A stress fracture is a complete or incomplete fracture
of bone secondary to failure over a prolonged period
1. Subtle, unexplained pain in the foot or ankle in an
athlete often is a stress fracture. The best screening
and marked by repeated stress in a rhythmic, reproduc-
examination is a bone scan. ible fashion.
Stress fractures differ from acute fractures in that their
2. Stress fractures of the medial malleolus may be associated
with pathologic varus coming from the knee, ankle, course generally is more gradual and their radiographic
or hindfoot. One should search for this because appearance can be elusive.1 Stress fractures of the foot
treatment without addressing biomechanics is not always and ankle are most common in running athletes, espe-
successful. cially those who jump. For example, track athletes, ballet
3. Navicular stress fractures are becoming more recognized; dancers, and basketball players have a high incidence of
they occur only in the competitive athlete, and surgical
stress injury. Many studies have implicated biomechanical
intervention often is required in the professional athlete.
factors, such as leg-length discrepancies, cavus foot de-
4. Second metatarsal base stress fractures in elite dancers
must be treated aggressively because they put the dan- formities, and limb malalignment. Women have a higher
cers’ careers at risk. incidence of stress fractures, and amenorrhea often is a con-
comitant finding in female athletes with these injuries.2
Several stress fractures are treated easily with cessation
of activity, orthoses, and modification in training. How-
ever, there exists in the foot and ankle a subset of stress
INTRODUCTION fractures that are difficult to diagnose and treacherous to
treat. These are truly the problematic stress fractures of
the foot and ankle.
The insidious onset of ill-defined foot and ankle pain in the
athlete is a confusing problem for trainers, physicians, and
patients. As Americans become more interested in recrea- STRESS FRACTURE OF THE
tional sports and the number of professional and college- TARSAL NAVICULAR
level athletes continues to grow, stress fractures of the foot
and ankle will continue to become more prominent in
the training room, the primary care setting, and the ortho- Unexplained pain of the midfoot in the everyday and
paedic surgeon’s office. Understanding the predispositions high-performance athlete can be a conundrum for both
to such injuries, the various themes common to them, and the patient and treating physician. The diagnosis of stress
CHAPTER 4 Problematic stress fractures of the foot and ankle
fracture of the tarsal navicular remains an elusive and Radionuclide bone scanning always demonstrates
poorly understood facet of midfoot pain in sports. Treat- increased isotope uptake and can be a useful adjunct in
ment of this unusual stress fracture requires an understand- the diagnosis of ill-defined midfoot pain. Views should
ing of its presentation, anatomy, imaging, and response include a medial, lateral, and plantar view. Uptake gen-
to conservative and surgical management. The proper erally will appear in the shape of the navicular on the
diagnosis of this unusual condition portends an excellent plantar view.5 Although radionuclide scanning can assist
prognosis for the athlete and a rapid return to sport. There- in localizing the area of concern to the navicular, defini-
fore it should be part of the repertoire for any physician tive diagnosis and definition of the fracture pattern
treating conditions of the foot and ankle in athletes. require tomography or computer-aided tomography.
The majority of fractures occur in the middle third of
Anatomy and presentation the navicular. An anatomic anteroposterior (AP) tomo-
The tarsal navicular serves as a keystone in the medial gram views the middle third of the navicular en face and
longitudinal arch and consequently is subjected to tre- therefore is more likely to identify fractures.5 However,
mendous forces through the foot. Moreover, nutrient modern computer-aided tomography has supplanted the
arteries arising from both the anterior and posterior tibial use of tomography and is essential in the delineation of
arteries create a generous supply of blood to the medial fracture pattern. Fine, 1.5-mm cuts are necessary in the
and lateral thirds of the navicular. The result is a poorly vas- axial plain to ensure that small incomplete fractures on
cularized zone in the middle third of the bone.2 Incredible the dorsal surface of the bone are not ‘‘skipped.’’ The role
stresses and decreased nutrition make the middle third of of MRI has not been clearly defined but likely will prove
the navicular the most common location for stress fracture. useful in the early diagnosis of this condition. Successful
Misdiagnosis of stress fracture of the tarsal navicular identification of the injury and its anatomy is crucial to
generally is the rule rather than the exception. There are effective management of the fracture.
several sources of midfoot pain that are more common,
including plantar fasciitis, anterior tibial and posterior Treatment
tibial tendinitis, spring ligament injury, Lisfranc sprain, Complete elucidation of the fracture pattern is impor-
and degenerative joint disease.3 Therefore unrelenting tant in dictating management of the athlete. Patients
symptoms in the seemingly normal midfoot merit further with incomplete and nondisplaced complete fractures
diagnostic workup and probably referral. can respond well to conservative management. When
Towne et al.4 first reported stress fracture of the tarsal treated in a nonweight-bearing cast for at least 6 weeks,
navicular in 1970. In this series of two patients, each was 86% to 100% of patients will go on to union.2-4
a distance runner who had experienced midfoot pain with
swelling and failure to respond to conservative therapy.
Plain radiographs were negative, and only specialized
studies were able to reveal the occult fracture. Subsequent
reports have corroborated a history of insidious pain in
the midfoot that is relieved by rest and exacerbated by
forceful striking of the forefoot and with direct palpation
of the navicular.5-7 A common thread in these reports
is the normal appearance of plain radiographs. In most cases
the diagnosis must be confirmed by computed tomography
(CT), magnetic resonance imaging (MRI), or bone scan.
Imaging
Stress fracture of the tarsal navicular often is overlooked
secondary to the low sensitivity of plain radiographs in
diagnosing this condition. Some characteristics appre-
ciated on anteroposterior views of the foot have been
shown to correlate with navicular stress fractures. These
include sclerosis of the proximal border of the navicular;
a short first metatarsal; metatarsus adductus and hyperos-
tosis; and stress fracture of the second, third, and fourth
metatarsals. Improved imaging techniques have demon-
strated that most fractures are linear, lie in the middle third
of the navicular, and can be complete or partial.8 Oblique Figure 4-1 An oblique radiograph of the tarsal navicular
or supinated radiographs can be useful (Fig. 4-1). demonstrates a stress fracture.
74
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Stress fracture of the base of second metatarsal
Patients with displaced fractures or those who have failed stresses placed on the midfoot when the dancer is in the en
nonoperative management benefit from bone grafting with pointe position. When en pointe, the ballerina (male dancers
or without open reduction and internal fixation. Most of dance only on demi-pointe) stands on the tips of her toes
these athletes will return to sport within 5 to 7 months.2-4 with the foot in maximal plantarflexion.13 Consequently
High-performance career athletes and the treating surgeon the mechanical axis of the lower extremity is directed
may elect a more aggressive approach to nondisplaced straight through the plantarflexed foot. The middle cunei-
fractures. Theoretically, surgical management of the injury form serves as a keystone in an arch-type configuration
could expedite the return to sport. reminiscent of the sturdy arch first introduced in Roman
architecture. The base of the second metatarsal is counter-
sunk into this keystone. Furthermore, the plantar liga-
ments of the second metatarsal base are powerful, owing
STRESS FRACTURE OF THE BASE OF
to the tensile forces experienced from push-off during
SECOND METATARSAL
normal gait. This fortified anchor of the proximal second
metatarsal generates a substantial stress riser at the junction
Stress fracture of the base of the second metatarsal is an of the metaphysis and diaphysis when the dancer is
often-misdiagnosed condition that seemingly is exclusive en pointe. Understanding this relationship is important
to elite-level ballet dancers. However, fractures of the because treatment can be as simple as restricted dance
other metatarsals also are seen in new military recruits with a moratorium on en pointe maneuvers until union is
and running athletes.9 These stress metatarsal fractures achieved.
tend to be more diaphyseal and behave somewhat differ-
ently from the base of the second metatarsal. The unique Imaging
biomechanics of ballet dancing, coupled with the high
The evaluation of the painful foot in a ballerina must
incidence of hypoestrogenism among female performers,
include clear weight-bearing views of the foot and ankle.
generates an environment conducive to stress fracture of
O’Malley et al.10 recommended a specialized view called
the base of the second metatarsal. High-level ballerinas
the posteroanterior (PA) dancer’s view. The dancer’s foot
generally have a narrow window of opportunity and
is placed with the dorsum on the cassette to eliminate
short-lived careers. Therefore rapid diagnosis and treat-
overlap of metatarsals. Approximately 30% of plain films
ment of conditions in this population is essential. Out-
will demonstrate a stress fracture. Bone scintigraphy is
comes from treatment of second metatarsal fractures are
positive in 100% of second metatarsal stress fractures; yet
excellent, and this injury usually is not considered to be
Harrington et al.12 reported positive bone scans in two
a career-threatening disability.
of their patients diagnosed with synovitis of the second
Anatomy and presentation tarsometatarsal joint. In this series, T1-weighted and
short tau inversion recovery (STIR) MRI images were
The most common presentation of stress fracture of the
used to differentiate stress reaction, fracture, and synovi-
second metatarsal is the insidious onset of midfoot pain.
tis. CT with fine cuts also is an effective method to dem-
However, ballerinas intermittently will report sudden
onstrate a stress fracture of the base of the second
onset of pain after an increase in training or after a jump-
metatarsal. The role of MRI has not been clearly defined,
ing maneuver. Many performers will be able to ‘‘dance
but eventually it may supplant scintigraphy as a more
through’’ the pain and often do not present until 2 to
effective method for defining pathology at the base of
6 weeks after the onset of symptoms.10 Hamilton11
the second metatarsal. Differentiation can help to direct
reported five risk factors for stress fracture in the ballet
a less disruptive management routine for professional
dancer. They include amenorrhea, anorexia nervosa,
dancers. For example, nonsteroidal treatment and dance
cavus foot, anterior ankle impingement, and a Morton’s
modifications for traumatic synovitis may seem more
foot (short first metatarsal). Delayed menarche or abnor-
attractive to a professional dancer than 6 weeks of rest.
mally long intervals between menses should motivate the
clinician to suspect a stress fracture in the presence of pain.
Examination of the foot often is more obfuscating Treatment
than revealing because patients will exhibit generalized The timing of this injury, in concert with the goals
tenderness of the midfoot with palpation and motion. and aspirations of the dancer, should lead the clinician in
Occasionally tenderness can be localized to the base treatment. Patients usually can expect a full recovery in
of the second metatarsal; however, this does not differ- approximately 6 to 8 weeks. Initial management should
entiate metatarsal stress fracture from synovitis of the include cessation of all dance activity and application of
Lisfranc joint.12 a hard-soled shoe. Pain at the base of the second metatarsal
The nature of this injury is due primarily to the interest- then serves as a barometer for return to activity. The dancer
ing biomechanics of ballet and specifically to the incredible may begin working out but should delay return to
75
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jumping and en pointe maneuvers. The rate of recurrence

can be as high as 12%. Ballerinas should be reassured that
this is rarely if ever a career-ending injury.
C A S E S T U D Y
An 18-year-old, college-level, female basketball player

presented to the sports medicine clinic with a long-
standing history of left midfoot pain that had gotten acutely
worse. The pain was exacerbated by play and persisted the
majority of the season. She had a history of a similar injury
that was treated successfully in high school.
Examination demonstrated bilateral pes planovalgus
deformities with tenderness over the base of the second
metatarsal. Pain was reproduced with motion of the
second, third, and fourth tarsometatarsal joints. Plain
radiographs and a CT scan (Figs. 4-2, 4-3, and 4-4) showed
a chronic stress fracture at the base of the second
metatarsal. She was given a walker boot for daily activity
and a rigid shank for her shoe to wear during play. The boot Figure 4-3 An oblique radiograph shows a chronic
was worn during off times, and the shank was worn during stress fracture of the base of the second metatarsal.
games. She successfully completed the season without
limitations. Follow-up images showed a nonunion of the
second metatarsal and a healed third metatarsal fracture.
At last follow-up, she continued to play at the collegiate
level asymptomatically.
Figure 4-4 A sagittal computed tomogram (CT)

shows a chronic stress fracture of the base of the
second metatarsal.
STRESS FRACTURE OF THE MEDIAL

MALLEOLUS
Stress fracture of the medial malleolus is a rare yet con-

sternating condition of the medial ankle often experi-
enced by running and jumping athletes. Although
Figure 4-2 An anteroposterior (AP) oblique radiograph there is a paucity of literature regarding this unusual
shows a chronic stress fracture of the base of the injury, there are similarities among the patients reported
second metatarsal. with this condition. In some of the series, patients went
on to develop an acute fracture of the medial malleolus.14
76
...........
Stress fracture of the medial malleolus
This point underscores the necessity of making the appro- Treatment

priate diagnosis in the avid athlete before a simple injury Initial management of stress fracture of the medial mal-
progresses to a more complex and debilitating injury. leolus should include cessation of sport, with nutritional
Anatomy and presentation and endocrine interventions when appropriate. Recrea-
tional athletes with small fracture lines can be treated
The majority of patients with stress fracture of the medial nonoperatively in a short-leg cast or removable boot.
malleolus are running and jumping athletes who present Disabling rotation about the ankle and dorsiflexion are
with gradual onset of pain over the medial ankle. Pain is key factors in neutralizing the tensile forces that can lead
exacerbated by activity and is localized to the medial mal- to displacement and delayed union of the injury. Patients
leolus.15-18 The ratio of male to female occurrence is 3:1, treated conservatively should not return to sport until
and the mean age of injury is 24 years. Most case reports they are asymptomatic, a period of time that averages
represent high-performance athletes, of which several are 6 weeks. Furthermore, patients treated nonoperatively
professional.11 Commensurate with the complete history will go on to complete union in about 6.7 months.11
involving any stress fracture, the treating physician should Conversely, many authors prefer operative manage-
identify risk factors such as amenorrhea, nutritional defi- ment of this injury, citing the possibility of nonunion
ciency, changes in footwear, and changes in training. and faster return to sport as incentives.
Shelbourne et al.18 identified three criteria for the evalua- The objective of operative management is to create a
tion of medial malleolar stress fracture. They include ten- construct that counters the tensile forces of the medial
derness over the medial malleolus with an ankle effusion, malleolus and allows quick rehabilitation. Standard AO
pain during activity preceding an acute episode, and a technique should be used with either cancellous or cortical
vertical line from the tibial plafond proximally. lag screws positioned perpendicular to the fracture line.
Physical examination often demonstrates edema of Some surgeons advocate the use of lag screws through a
the medial malleolus with bony tenderness. Patients buttress plate. Patients treated with internal fixation return
often will have normal motion in the ankle and subtalar to sport on average at 4.5 weeks and have evidence of union
joints and should not have tenderness of the lateral ankle by 4.2 months.11 The elite or professional athlete may
or posterior tibial tendon. Analysis of hindfoot align- prefer this option because it portends a faster return to
ment is critical to assess any varus deformity that may activity and theoretically reduces the risk of nonunion or
exacerbate stresses on the medial malleolus. complete fracture. Reider et al.19 reported a nonunion in
A true biomechanical explanation for medial malleo- a college-level football player who was misdiagnosed and
lar stress fracture is not described. However, the tensile managed conservatively for several months. This athlete
forces of the medial ankle ligamentous structures osten- went on to heal after operative intervention.
sibly generate significant stress on the posteromedial Although such reports are seemingly anecdotal, they
concave side of the tibia. The majority of these fractures highlight the importance of diagnosing and aggressively
are vertical. This concept becomes important when one treating this injury in the high-performance athlete.
considers proper screw placement for internal fixation. A malleolar nonunion can lead to significant lost play-
Imaging time and potentially can be career ending. Isolated
medial ankle pain with normal radiographs merits fur-
Plain film radiography is requisite in the diagnosis of ther workup with either bone scintigraphy or MRI, fol-
medial malleolar stress fractures and can be more useful lowed by an appropriate scheme of management tailored
with other problematic stress fractures of the foot. to the athlete’s goals and aspirations.
Roentgenograms often show a small area of fissuring at
the junction of the tibial plafond and the medial malleo-
lus. Infrequently, this fissure will be accompanied by
radiolucent cysts along the fracture line.12 When one C A S E S T U D Y
has normal radiographs, bone scintigraphy can be
extremely useful. Increased uptake in the area of the
medial malleolus is seen uniformly in the presence of a
stress fracture. The cases reported in the literature also An elite-level, male, college basketball player began to
note pain in the anteromedial distal ankle early in the
have used CT and MRI. Although the role of these
season. As the season progressed, he had to stop playing
modalities has not been clearly defined, in isolated cases
because of recalcitrant pain. Physical examination
they have proven useful in defining the anatomy of a demonstrated tenderness along the anteromedial aspect
fracture or in confirming the diagnosis. Perhaps modern of the tibia and pain with dorsiflexion. Plain films
MRI will supplant the use of scintigraphy, given its abil- (Figs. 4-5 and 4-6) showed a small lucency in the
ity to clearly delineate bony and ligamentous anatomy anteromedial plafond that may have been consistent with
while defining inflammatory or reactive pathology.
77
...........
an osteochondral defect. An MRI (Figs. 4-7 and 4-8) did

not show a definitive chondral lesion; however, there was
high signal in the anterior and medial tibial plafond,
suggesting a stress fracture of the medial malleolus.
The patient was treated conservatively, and he sat out the
remainder of the season. He returned the following year
and played successfully without incident.
Figure 4-7 T2 coronal images show increased signal in

the anterior medial malleolus. Note that this area
appears normal on the initial plain radiographs.
Figure 4-5 An anteroposterior (AP) radiograph in an

elite college athlete does not show obvious fracture of
the medial malleolus.
Figure 4-8 T2 sagittal images show increased signal in

the anterior medial malleolus. Note that this area
appears normal on the initial plain radiographs.
C A S E S T U D Y
An elite-level, male athlete experienced debilitating pain

Figure 4-6 A lateral radiograph in an elite college athlete in the ankle. Examination and imaging were consistent
does not show obvious fracture of the medial malleolus. with a stress fracture of the medial malleolus. Axial CT
78
...........
Stress fracture of the medial malleolus
images clearly demonstrated involvement of the Anatomy and presentation

anteromedial tibial plafond (Fig. 4-9). The player was not Rarely will a patient report focal pain of his sesamoid
able to return to preinjury performance after nonoperative bones. Rather, he or she often describes a gradual onset
management. Therefore he was treated with internal of pain about the plantar surface of the great toe. This
repair of the vertical fracture fragment (Fig. 4-10). pain often is exacerbated by dorsiflexion of the hallux.
In some instances, pain may be replaced by paresthesia
of the great toe. Conversely, the patient may recall a
specific incident in which he or she experienced a loud
pop or snap on toe-off. Key features of the history
should include changes in activity level, adequacy of
footwear, and other important risk factors for stress frac-
ture previously described.20
Physical examination should include a detailed,
segmental analysis of the hindfoot, midfoot, and forefoot.
Cavus feet have a penchant for sesamoid injury because of
the increased load placed on the first metatarsal head.
Direct palpation of the sesamoid will elicit pain. The
tibial or medial sesamoid is most commonly involved.
Furthermore, one may note decreased dorsiflexion of
the first MTP joint and pain with range of motion. The
corollary to this finding may be decreased strength of
plantarflexion of the first toe.17
The hallucal sesamoids increase the mechanical
advantage of the flexor hallucis brevis by acting in a
Figure 4-9 Axial computed tomography (CT) scan mechanism similar to that of the patella; they are intrin-
showing stress fracture of the anteromedial tibial plafond. sically located at the level of the MTP joint within the
substance of the short flexor tendon. This location
affords them an articulation with the metatarsal head
and subjects them to enormous amounts of force when
the phalanx is dorsiflexed and planted. The medial sesa-
moid is injured more often, owing to its larger size and
more demanding role in weight bearing. Approximately
10% of patients have a bipartite sesamoid. This fact
becomes important when interpreting plain radiographs
of the sesamoid.17
Imaging
Plain radiographs of the foot can be more perplexing
than useful in the diagnosis of sesamoid stress fracture.
The clinician first must understand that a standard
Figure 4-10 Internal repair of vertical stress fracture of lateral view is essentially useless, and an AP of the foot
the medial malleolus. is infrequently revealing. Medial and lateral oblique
views of the sesamoids will more clearly visualize the
tibial and fibular sesamoids, respectively. Several patients
will have normal radiographs or the appearance of a
Stress fracture of the hallucal sesamoids bipartite sesamoid. The role of scintigraphy, CT, and
Clandestinely located on the plantar surface of the great toe MRI continues to evolve.
metatarsophalangeal (MTP) joint, the hallucal sesamoids Many authors have recommended the use of bone
are an often neglected and inadequately respected pair of scintigraphy in the evaluation of sesamoid pain. How-
tiny bones. They are capable of causing an enormous ever, the ordering physician must communicate the
amount of pain, discomfort, and disability in the running need to perform oblique scans because a traditional
and jumping athlete. Stress fracture of the sesamoid is an anteroposterior bone scan of the foot can reveal first
unusual and rare diagnosis that requires clinical and radio- MTP activity that can obscure the sesamoids. A study
graphic perseverance on the part of the treating clinician. of army recruits found no difference in sesamoid bone
79
...........
scan activity between soldiers in basic training for several pain that is refractory to initial conservative manage-
weeks in comparison with sedentary adults. They cau- ment. Notwithstanding that the diagnosis largely is clin-
tioned readers about the interpretation of increased ical, axial imaging is extremely useful. Longitudinal CT
uptake in the sesamoid, warning that this may be normal is recommended for definitive revelation of fracture lines
physiologic activity for this bone.21 and surgical planning. Surgeons and patients will find
Perhaps axial imaging serves a more important role that diligent treatment of these seemingly diminutive
to the surgeon who potentially will treat the patient and insignificant bones can lead to a full recovery and
with excision of one of the sesamoid fragments. CT is return to competitive sport.
an excellent modality for detection of sesamoid stress
fractures. However, obtaining only axial images of the
sesamoid can result in a false negative by ‘‘skipping’’
the fracture line. This error can be prevented by supple-
menting axial CT images with longitudinal cuts through C A S E S T U D Y
the sesamoid.22
Improved availability of high-quality MRI may sup-
plant the use of CT and bone scan because it enables
the treating physician to obtain axial and longitudinal A 30-year-old, recreational athlete presented to a foot
images, as well as indicators of stress fracture such as and ankle surgeon after a several-day history of right
edema. Imaging facilities must use the appropriately forefoot pain. The pain was associated with a long walk
sized coil for imaging of the sesamoids to ensure the and progressed significantly in the week before the office
proper resolution. High-resolution MRI of the sesa- visit. Examination demonstrated edema of the first MTP
moid will show fragmentation and marrow changes in joint and pain with dorsiflexion. The patient was
exquisitely tender over the tibial sesamoid. Plain x-rays
the face of acute stress fracture. Although MRI may
showed a fracture of the tibial sesamoid (Fig. 4-11). This
not clearly define stress fracture versus avascular necrosis
was confirmed with CT. She was placed in a compressive
or chronic nonunion, this point is moot because treat- boot with no weight bearing on the forefoot for 6 weeks.
ment ultimately will be the same.23 She was progressively weaned out of the boot and
back to full weight bearing. At last follow-up she had full
Treatment return to activity and radiographic evidence of callous
Treatment of this relatively debilitating condition can formation.
be rewarding yet frustrating. Most clinicians favor a con-
servative approach consisting of a nonweight-bearing,
short-leg cast for 6 to 8 weeks.17 Return to jumping
and running activity should be graded on the basis
of symptomatology. Furthermore, custom orthoses
designed to unload the first MTP joint, such as a dan-
cer’s pad or a metatarsal bar, can be instituted after com-
pleting a course of casting. Because of the obscure
diagnosis and the vulnerable physiologic location of
the injury, nonunion and delayed union of the hallucal
sesamoids is a common occurrence.
Management of the recalcitrant sesamoid fracture is
surgeon specific and may include bone grafting or exci-
sion of the sesamoid. Authors have reported excellent
results for all types of procedures. Potential pitfalls of
operative intervention include digital nerve injury and
weakness of the great toe flexor. A recent study reported
good or excellent outcomes in dancers and in a long
jumper treated with a partial excision of the medial sesa-
moid.24 Athletes should expect a full recovery but
should remain nonweight bearing for 4 to 6 weeks in
the postoperative setting, followed by protection of the
first MTP joint for another 4 to 6 weeks and a gradual
return to activity by 3 to 4 months. Figure 4-11 A plain radiograph demonstrates stress
Stress fracture of the hallucal sesamoid should be sus- fracture of the hallucal sesamoid.
pected in the jumping or running athlete with first MTP
80
...........
Stress fracture of the fifth metatarsal
joint, the cuboid-fifth metatarsal joint, and the fourth

STRESS FRACTURE OF THE FIFTH
and fifth intermetatarsal articulation. The peroneus bre-
METATARSAL
vis has a broad, fan-like insertion on the dorsal surface
of the tuberosity, whereas the peroneus tertius inserts
No stress fracture of the foot and ankle has received on the diaphysis of the bone slightly more distally.
more discussion and enamored more orthopaedic sur- A styloid on the plantar surface of the tuberosity
geons than the often-misunderstood stress fracture of receives the fibers of the lateral band of the plantar
the fifth metatarsal. A constant stream of dialogue exists aponeurosis.26
in the literature regarding the history and treatment Variations in the anatomy of the proximal fifth metatar-
of fracture disorders of the proximal fifth metatarsal. sal are described and can be misleading clues for diagnosing
Accordingly, misuse of the eponym ‘‘Jones fracture’’ fracture of the tuberosity. These variations include the
is both propagated and defied. True stress fractures os peroneus, the os vesalianum, and the secondary ossifica-
in this anatomic location in fact represent an entirely tion center of the tuberosity. The os peroneum is a sesa-
different injury, with its own mechanism and behavior, moid bone located in the tendon of the peroneus longus
and should not be confused with the traditional Jones that may occur in up to 15% of normal feet. The os vesalia-
fracture or an avulsion fracture of the tuberosity num is a similar sesamoid, with a less regular shape, occur-
(Fig. 4-12). This point becomes critical because there ring only 0.1% of the time. The secondary ossification
are nuances in the treatment of these three distinct center or apophysis of the fifth metatarsal does not appear
injuries. until after age 8 in females and age 11 in males. The apoph-
ysis may be present only in up to 50% of feet. This structure
Anatomy and presentation can be differentiated from a fracture because the physeal
line runs parallel to the shaft of the bone. Conversely,
The history and presentation of this injury is useful in
a fracture in this anatomic location generally is in a plane
discerning the diagnosis of stress fracture over an acute
orthogonal to the diaphysis of the bone.27 Although
Jones fracture. DeLee et al.25 defined stress fractures in
the task seems daunting, organization and diagnosis of
the metatarsal as spontaneous fractures of normal bone
the myriad fractures of the fifth metatarsal can be simplified
that result from the summation of stresses, any of
by applying a classification scheme.
which by themselves would be harmless. They also
Fractures of the base of the fifth metatarsal are sub-
reported on a series of patients who met three criteria.
divided into three types. They include type I tuberosity
These include a prodrome of pain in the lateral foot,
avulsion fractures, type II Jones fractures, and type III
ultimately leading to debilitating pain; radiographic
stress fractures of the diaphysis.28 Stress fractures are sub-
evidence of stress fracture; and no history of previous
divided further into types A, B, and C, which correspond
fracture and treatment of the fifth metatarsal. Con-
to early stress fracture, delayed union, and nonunion.24
sequently, patients often report a prolonged period
This classification scheme is useful because it is anatomi-
of pain on the lateral border of the foot that may be
cally based and describes separate fractures with differing
exacerbated by a jumping or running maneuver. This
mechanisms. The scope of this topic is large, and there-
final event generally is the impetus for a visit to a health
fore we discuss here treatment of stress fracture of the
care provider.
fifth metatarsal.
Understanding the diagnosis of fifth metatarsal stress
fracture necessitates a thorough understanding of the
anatomy of the lateral border of the foot. The fifth Imaging
metatarsal itself consists of a head, neck, shaft, base,
Radiographic diagnosis of fifth metatarsal stress fracture
and tuberosity. The base of the metatarsal has three
typically is not as elusive as the other bones of the foot
articulations. They are the cuboid-fourth metatarsal
and ankle. However, clear interpretation of roentgen-
ograms is critical in defining the type of fracture.
Patients who present early in the course of their lateral
foot pain may have normal radiographs. The first feature
to appear is thickening of the cortex and a small perios-
2 3 Shaft teal reaction.29 The three subtypes of stress fractures
1
can be differentiated radiographically. Type I, or acute
or chronic fractures, are characterized by a straight line
at the junction of the proximal and middle third of
Figure 4-12 The three zones of injury at the base of the fifth the diaphysis. The bone ends are sclerotic, there is mini-
metatarsal. Modified from: Lawrence ST, Botte MJ: Foot Ankle mal periosteal reaction, and there is no widening.
Int 4:358, 1993. Type II fractures, or delayed unions, will demonstrate
81
...........
widening with hypertrophic periosteum and a wide band less than 8 weeks, with return to sport averaging less
of radiolucency across the diaphysis. The medullary than 9 weeks.22 However, patients should be aware
canal may be sclerotic. The type III fracture, or non- that nonunion is a potential complication and possibly
union, differs in that the bone ends will appear to be is related to screw diameter.32
entirely sclerotic, as though the medullary canal were Stress fracture of the base of the fifth metatarsal is a
nonexistent.23 debilitating injury that requires expertise in diagnosis on
The clinical and plain radiograph diagnosis of fifth behalf of the treating surgeon. Mistaking this injury for a
metatarsal stress fractures rarely requires the use of bone less benign fracture, such as a tuberosity avulsion, can result
scan or MRI. Scintigraphy will demonstrate increased in painful nonunion and significant loss of playing time.
uptake within 72 hours of acute injury but is less specific. Therefore commensurate management demands a thor-
As in other stress fractures, MRI will clearly demonstrate ough understanding of the anatomy of the fifth metatarsal
a fracture line with surrounding edema and signal and the variable fracture patterns existing in this location.
change.26 Athletes treated correctly can often expect an excellent
prognosis.
Treatment
Management of fifth metatarsal stress fractures is
determined on the basis of the needs and goals of the
athlete, as well as the radiographic classification of C A S E S T U D Y
the injury. Surgeons may opt to be more aggressive in
professional athletes, who are dependent on a rapid
return to play. Conversely, patients may advocate a less
invasive approach to initial management. All athletes A 22-year-old, college-level, female soccer goalie noted
with this injury should be counseled on the pitfalls that lateral border of the foot pain after kicking a soccer ball.
may be encountered, including nonunion and tempo- Physical examination was consistent with fifth and fourth
rary disability. Authors favoring conservative manage- metatarsal tenderness. Plain films demonstrated a
fracture at the base of the fifth metatarsal (Fig. 4-13).
ment have reported lackluster results. Specifically,
She underwent percutaneous screw fixation with a 4.5-mm
patients are prone to prolonged immobilization and
shaft screw (Figs. 4-14 and 4-15) and had full return to
nonunion.25 Improved results have been demonstrated sport 6 weeks postoperatively.
with surgical intervention, and as such this modality is
advocated in most athletes who desire early definitive
treatment.
Torg et al.30 have demonstrated that acute, nondis-
placed stress fractures of the fifth metatarsal can be treated
successfully with nonweight-bearing immobilization.
The importance of compliance with nonweight-bearing
status should be emphasized for the first 6 to 8 weeks,
as weight bearing has been shown to diminish healing.
The management of type II delayed unions is less
clear. Nonweight-bearing immobilization is effective but
prolonged, and the specter of nonunion is not unreal.
Athletes with a strong penchant for an expedited recovery
may opt for intramedullary fixation.31
Nonunions, or type III stress fractures, have been
treated with pulse electromagnetic fields and bone
grafting. However, most surgeons now agree that
intramedullary fixation promises the most success.
Although the type of fixation varies among surgeons,
the common theme is a minimally invasive procedure
in which the base of the fifth is exposed and a screw
is inserted through the canal under fluoroscopic guid-
ance. Drilling of the canal in preparation for the fixa-
tion creates an autogenous intramedullary bone graft Figure 4-13 Stress fracture of the base of the fifth
and stimulates healing at the fracture site. Initial metatarsal in a female soccer player.
reports of this treatment demonstrated 100% union in
82
...........
References
Therefore a global approach to care of the athlete is

advised. This should involve activity modification,
improvements in training, nutritional and psychological
counseling, as indicated, and definitive orthopaedic inter-
vention. Athletics are an important facet of life, and dis-
ability related to sports can be devastating. Accurate
diagnosis and successful treatment of problematic
stress fractures of the foot and ankle is a rewarding and
attainable goal for all trainers and physicians.
REFERENCES
1. McBryde AM: Stress fractures. In Baxter DE, editor: Foot and

Ankle in Sport, St. Louis, 1995, Mosby.
2. Korpelainen R, et al: Risk factors for recurrent stress fractures in
athletes, Am J Sports Med 29:304, 2001.
3. Nunley JA, Vertullo CJ: Classification, investigation and manage-
ment of midfoot sprains: Lis Franc injuries in the athlete, Am J
Sports Med 30:871, 2002.
4. Towne LC, Blazina ME, Cozen LN: Fatigue fracture of the tarsal
navicular, J Bone Joint Surg 52-A:376, 1970.
5. Torg JS, et al: Stress fracture of the tarsal navicular, J Bone Joint
Figure 4-14 Anteroposterior (AP) radiograph after Surg 64-A:700, 1982.
percutaneous fixation with a 4.5-mm shaft screw. 6. Fitch KD, Blackwell JB, Gilmour WN: Operation for non-union of
stress fracture of the tarsal navicular, J Bone Joint Surg 71-B:105, 1989.
7. Kahn KM, et al: Outcome of conservative and surgical manage-
ment of navicular stress fracture in athletes, Am J Sports Med
20:657, 1992.
8. Pavlov H, Torg JS, Freiberger RH: Tarsal navicular stress
fractures: radiographic evaluation, Radiology 148:641, 1993.
9. Weinfeld SB, Haddad SL, Myerson MS: Metatarsal stress fractures,
Clin Sports Med 16:319, 1997.
10. O’Malley MJ, et al: Stress fractures at the base of the second
metatarsal in ballet dancers, Foot Ankle Int 17:89, 1996.
11. Hamilton WG: Physical prerequisites for ballet dancers, J Muscu-
loskel Med 10:61, 1986.
12. Harrington T, Crichton JK, Anderson IF: Overuse ballet injury of
the base of the second metatarsal, Am J Sport Med 21:591, 1993.
13. Hardaker WT: Foot and ankle injuries in classical ballet dancers,
Orthop Clin North Am 20:621, 1989.
Figure 4-15 Lateral radiograph after percutaneous 14. Shabat S, et al: Stress fractures of the medial malleolus—review of
fixation with a 4.5-mm shaft screw. the literature and report of a 15 year old elite gymnast, Foot Ankle
Int 23:647, 2002.
15. Schils J, et al: Medial malleolar stress fractures in seven patients:
review of the clinical and imaging features, Radiology 185:219, 1992.
16. Orava S, et al: Stress fracture of the medial malleolus, J Bone Joint
SUMMARY Surg 77A:362, 1995.
17. Okada K, et al: Stress fracture of the medial malleolus: a case
report, Foot Ankle Int 16:49, 1995.
Poorly defined foot and ankle pain in the athlete can be 18. Shelbourne KD, et al: Stress fractures of the medial malleolus, Am
a consternating and often frustrating condition for ath- J Sports Med 16:60, 1988.
19. Reider B, Falconeiro R, Yurkofsky J: Nonunion of a medial mal-
letes, trainers, and physicians. Stress fractures represent a leolus stress fracture, Am J Sports Med 21:478, 1993.
subset of maladies of the foot and ankle that require dili- 20. Richardson GE: Hallucal sesamoid pain: causes and surgical
gence on behalf of the diagnostician. Careful history and treatment, JAAOS 7:270, 1999.
physical examination will illuminate mechanisms of injury 21. Chisin R, Peyser A, Milgrom C: Bone scintigraphy in the assess-
specific to each fracture type and risk factor, such as ment of the hallucal sesamoids, Foot Ankle Int 16:291, 1995.
22. Biedert R: Which investigations are required in stress fracture of
weight loss, amenorrhea, and eating disorders. Moreover, the great toe sesamoids? Arch Orthop Tr Surg 112:94, 1993.
the clandestine fracture often will require advanced imag- 23. Burton EM, Amaker BH: Stress fracture appearance of the great toe
ing modalities, such as CT, bone scintigraphy, and MRI. sesamoid in a ballerina: MRI appearance, Pediatr Radiol 24:37, 1994.
83
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24. Biedert R, Hinterman B: Stress fractures of the medial great toe 29. Harmath C, et al: Radiologic case study: stress fracture of the fifth
sesamoids in athletes, Foot Ankle Int 24:137, 2003. metatarsal, Orthopedics 24:204, 2001.
25. DeLee JD, Evans P, Julian J: Stress fracture of the fifth metatarsal, 30. Torg JS, et al: Fractures of the base of the fifth metatarsal distal to
Am J Sport Med 11:349, 1983. the tuberosity: classification and guidelines for non-surgical and
26. Rosenberg GA, Sferra JJ: Treatment strategies for acute fractures and surgical management, J Bone Joint Surg 66:209, 1984.
nonunions of the proximal fifth metatarsal, JAAOS 8:332, 2000. 31. Nunley JA: Fractures of the base of the fifth metatarsal, Orthop
27. Quill GE: Fractures of the proximal fifth metatarsal, Orthop Clin Clin North Am 32:171, 2001.
North Am 26:353, 1995. 32. Nunley JA: Jones fracture technique, Tech Foot Ankle Surg 1(2):1,
28. Lawrence SJ, Botte MJ: Jone’s fracture and related fractures of the 2002.
proximal fifth metatarsal, Foot Ankle 14:358, 1993.
84
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........................................... C H A P T E R 5
Ankle and midfoot fractures and dislocations

William C. McGarvey
......................
CHAPTER CONTENTS
Introduction 85 Anterior process calcaneal fracture 100

Clinical diagnosis 85 Tarsometatarsal dislocations 102
Treatment 87 Tarsal bone fractures 108
Ankle fractures 88 Fractures of the base of the fifth metatarsal 109
Lateral process talar fractures 97 References 118
INTRODUCTION as a sensory examination, is performed. Vascular examina-

tion, including Doppler studies, is essential. Radiographs
are guided by the examiner’s history and physical exam-
Fractures and dislocations of the foot are among the
inations. Standard views of the foot include anteropos-
most common injuries in the musculoskeletal system.
terior (AP), lateral, and oblique views. The oblique
With the recent explosion of interest in athletic activity,
view, for example, is particularly useful for evaluating
the foot and ankle have been exposed to a variety of new
joints, such as the calcaneal cuboid joint, that typically
stresses. The disability and time away from sports result-
are hidden or poorly examined in AP view. Specialty
ing from these injuries warrant close attention to diag-
views, such as axial views of the heel, Broden’s view of
nosis and management (Figs. 5-1, 5-2, 5-3, and 5-4).
the subtalar joint, and stress views of the foot also are
helpful in certain circumstances. Because of the com-
plexity of the anatomy and lack of uniform appreciation
CLINICAL DIAGNOSIS
or interpretation of the foot radiographs, adjunctive
studies, such as computed tomography (CT), bone scan,
In evaluating patients with trauma to the foot, it is and magnetic resonance imaging (MRI), can be of tre-
essential to obtain a thorough, detailed history to direct mendous value. These also are particularly useful because
the examiner in physical and radiographic examination. of the subtle nature of many foot and ankle injuries.
In addition, it will provide a clue to the associated Standard radiographic examination of the ankle
degree of soft tissue injury. includes three views: AP, lateral, and mortise. From
Physical examination should be meticulous and sys- these, a remarkable amount of information may be
tematic. It is recognized that although most forefoot obtained, not only about fracture patterns but, more
injuries are easily diagnosed, midfoot injuries often go importantly, about the relationship of the three bones
undetected. Because of the high incidence of multiple that comprise the ankle mortise—tibia, fibula, and talus.
fractures or fracture/dislocations in the injured foot, Use of measurements of mortise width; medial or tibio-
careful examination and palpation of points of tender- fibular clear space; talocrural angle; ‘‘Shenton’s’’ line of
ness should be performed to detect evidence of occult the ankle (that space that demonstrates a mirrored con-
injury. Evaluation of range of motion of the ankle, gruity between the lateral talar wall and the corresponding
subtalar midtarsal, and metatarsophalangeal joints is curvature of the distal medial fibula); and talar tilt all are
incorporated into every routine examination. A careful helpful in determining the subtle abnormalities of the ankle
motor examination, both intrinsic and extrinsic, as well mortise (Fig. 5-5).
CHAPTER 5 Ankle and midfoot fractures and dislocations
Figure 5-3 Athletes often will find ways to return to sport

Figure 5-1 Conservative modalities for managing acute injuries.
earlier than expected.
Figure 5-4 Inset from Figure 5-3.

Figure 5-2 Rehabilitation methods involve patient
participation.
When in doubt, the clinician also may obtain contra- dorsal tibiotalar, and lateral fibulotalar. The distance
lateral views to determine that which constitutes normal between these bone margins should be equivalent. In
anatomy for that particular patient, because there tends addition, a congruous relationship should exist between
to be a high degree of variability in what is considered lateral talus and medial fibula, the so-called Shenton’s
normal from patient to patient. Medial clear space is as line of the ankle. Abnormalities, as evidenced by incon-
viewed in anterior/posterior radiographs. It is the mea- gruity, provide clues to malalignment resulting from
sure of distance between the medial talar wall and lateral bony or soft tissue injury.
portion of medial malleolus. Although this is a linear The talocrural angle helps to define the appropriate
measure, it reflects a rotational (external) abnormality fibular length. This is measured as the angle between
of the talus with respect to the tibia. Injury leading to the line parallel to the distal tibial joint surface and
abnormality of this relationship with measurements another line drawn between tips of the medial and
of less than 1 mm or greater than 4 mm has been shown lateral malleoli. Normal values average 83 4 degrees.
to correlate with poor outcomes, including chronic Differences of more than 2 degrees to the contralateral
pain, instability, and arthrosis.1-3 normal side suggest fibular shortening.
Mortise views should demonstrate relative congruity Talar tilt is measured by determining the angle between
of the joint space circumferentially—medial tibiotalar, articular surface lines drawn parallel to the distal tibia and
86
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Treatment
Any fracture or dislocation of the foot or ankle that

results in focal skin pressure or evidence of neurovascu-
lar compromise must be addressed immediately. Ma-
nipulation or even open reduction must be carried out
to reduce the potential sequelae, including skin necrosis,
neuropraxia, ischemia, and/or pressure-induced necro-
sis of articular surfaces, because of abnormal loading
A B C secondary to malpositioning after fracture or dislocation.
Even anatomic restoration does not guarantee opti-
mal functional outcome, but it certainly provides the
athlete with a significantly reduced risk of morbidity
associated with sequelae of delayed or untreated injury.
However, injuries that present without gross distortion
of anatomy or imminent threat to the viability of the
limb may be treated better after an appropriate ‘‘cooling
down’’ period. This is not to say that they should be
D E splinted and ignored, but a short period should be
devoted to rest, ice, compression, and elevation (RICE)
Figure 5-5 A to F, Schematic representation of radiographic to allow the soft tissue integrity and oxygenation to
parameters. (A) Medial clear space should equal the articular reestablish itself, particularly before the clinician
distance at any point around the mortise. (B) Talo-crural angle. embarks on any invasive procedures.
(C) Talar tilt. (D) ‘‘Shenton’s line’’ of the ankle. (E) Tibio-fibular The evolution of treatment of the traumatized foot
clear space. (F) Tibio-fibular overlap. (From Myerson MS: Foot
and ankle of the athlete has directed more attention
and ankle disorders, St Louis, 1999, Mosby.)
to aggressive intervention than to ‘‘benign neglect.’’
Recognition of the fact that long periods of immobili-
zation after trauma may lead to muscular atrophy, myo-
static contracture, reduction of joint mobility, associated
proximal talus. Although uniform agreement on what is
connective tissue proliferation leading to scarring, syno-
considered normal does not exist, a side-to-side differ-
vial adhesion, and cartilage degeneration has prompted
ence of more than 5 degrees (or 2 mm) is considered
a more aggressive approach to foot and ankle injuries,
pathologic.
using appropriate surgical intervention to stabilize
Syndesmotic space probably is the most confounding
injuries and institute earlier range of motion and weight
of all radiologic measures. Measurements should be per-
bearing when possible. These tenets provide for the abil-
formed to account for the space existing between the
ity to institute potential prevention against previously
medial edge of the fibula and the lateral edge of the tib-
disabling factors such as disuse osteopenia, limb atro-
ial incisura, determined at 1 cm proximal to the joint
phy, proprioceptive losses, and chronic, persistent
line to ensure reproducibility. Average distance should
pain.4-8 Introduction of early range of motion, physical
be less than 5 mm but may vary up to 6 mm in larger
therapy modalities, appropriate splinting, and bracing,
individuals. Another measure of syndesmotic integrity
as opposed to casting, allows for the earlier restoration
is the tibiofibular overlap. The distance between the
of function and avoidance of complications. The static
medial fibula and the lateral edge of the anterior tibia
accumulation of hematoma, fluid extravasation, and
should be 10 mm (see Fig. 5-5).
resultant articular and tendinous adhesions is far less
Ancillary studies, such as stress radiographs, CT scan-
with treatment that promotes earlier rehabilitation.4
ning, and MRI are used liberally to provide more infor-
This type treatment also helps to prevent disabling
mation regarding ankle relationships and stability.
sequelae, such as arthrofibrosis and regional pain
syndromes.7
Although the realm of athletically related foot and
TREATMENT
ankle injuries is too vast to be encompassed in this chap-
ter, the more common injury patterns encountered are
Generic goals in the treatment of fractures and disloca- addressed. Diagnostic and management controversies
tions of the foot are as follows: are discussed and elucidated for the reader. Rather than
Avoiding stiffness and loss of mobility. a trauma compendium, this is meant to be a guide for
Removing bony prominences, which may result in the treatment of frequently occurring sports and athletic
pressure phenomena. injuries to the foot and ankle for one’s reference and
Restoring the articular surfaces. perusal.
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talus will not shift abnormally with integrity of medial

ANKLE FRACTURES
structures. Therefore attention should be directed to
anatomic restoration of the medial ankle if it is dis-
Medial fractures rupted. Repair may be performed percutaneously with
Isolated medial fractures are unusual but not rare cannulated screw fixation but should be reserved for
(Fig. 5-6, A and B). One must have suspicion for a absolutely anatomic reductions. Any incongruity, as evi-
‘‘bimalleolar variant’’ in which lateral ligamentous injury denced by articular irregularity, necessitates open repair
has occurred in deference to bony injury. Generally, with restitution of the articular surfaces. I prefer open
medial malleolar fractures indicate loss of stability of the techniques because radiographs often may disguise an
ankle. Anywhere from 5% to 15% of untreated fractures occult malreduction. Often, anterior/posterior reduc-
may go on to nonunion (Fig. 5-7, A through D). tion appears anatomic, but evaluation via live fluoros-
Fracture patterns may vary from vertical, oblique, or copy will demonstrate some degree of articular step-off
horizontal, depending on the mechanism of injury. with internal rotation toward a mortise view. I prefer
However, because of the risk of sequelae and potential an open reversed J incision with attention to interposed
for instability and abnormal mechanics, all but those periosteum and unrecognized comminution at the frac-
that are nondisplaced should be repaired. Even those ture site. Additionally, open reduction affords the oppor-
demonstrating minimal (<2 mm) displacement carry tunity to inspect the articular surface, which provides
some advantage to stabilization, such as reliable fixation, useful prognostic information. Fixation is dictated by
early range of motion, lack of immobilization, and fracture pattern. Most often, one or two partially
potentially early return to activity. threaded cancellous screws are sufficient; however, with
As evidenced by Ramsey and Hamilton,9 as well as a more vertical fracture pattern, several screws with
Yablon,10 ankle stability is dependent on medial integ- washers or even a small one-third tubular anti-glide
rity. Michelson and others1,11-20 have shown that the plate will be indicated.
Figure 5-6 (A and B) Medial malleolar fracture in a 16-year-old basketball player. The athlete elected to undergo
nonoperative treatment and healed uneventfully in 6 weeks.
88
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Ankle fractures
Figure 5-7 (A and B) Computed tomography images of a 17-year-old offensive lineman with delayed union of
repaired medial malleolar fracture. (C and D) Union was achieved with local bone grafting from the calcaneus
and revision internal fixation.
89
...........
Once wound healing is stable, range of motion and compromise in clinical outcomes.22-25,26 Physiologic
resistance exercises are instituted. Weight bearing is loading studies of the normal and compromised ankle
restricted until 4 weeks and is advanced on the basis of suggest that the medial structures are, in fact, most
symptoms. Results generally are good. important for stability.1,10-19,26,27 It also has been
shown by CT analysis that fibular displacement occur-
Lateral fractures ring as a result of an external rotation force with intact
Isolated lateral malleolar fractures present one of the medial structures (Lauge-Hansen SER2) is the result of
most challenging management dilemmas in the realm internal rotation of the proximal fragment.18 This implies
of sports injuries. Associated syndesmosis widening or that the distal fibula maintains its relationship with the
medial injury, bony or ligamentous, make the choice mortise and that no functional incongruity is present
of treatment fairly simple and obvious.15,21,22,23 How- (Fig. 5-8, A through D). Clinical studies have supported
ever, fibular fractures at any level without concomitant this notion, demonstrating good results with up to
injury or significant radiographic displacement generate 30-year follow-up on nonoperative treatment of isolated
varied and controversial opinions as to what is consid- lateral malleolar fractures.24,28-30
ered appropriate intervention. Alternatively, an argument may be made for repairing
On one hand, arguments may be made that surgery is all but nondisplaced fibular fractures, the rationale being
unnecessary because, even though the lateral stability is that even small increments of displacement may lead
compromised, it is not completely diminished. Intact to fibular shortening or mortise widening.4,10 Early
medial structures, specifically the malleolus and deltoid mechanical testing suggested that the lateral talar dis-
ligament, provide primary resistance to lateral talar placement of as little as 1 mm would significantly increase
translation, thus limiting or preventing abnormal ankle contact pressures in the tibiotalar joint, thus creating
mechanics. Several studies support displacement, lateral a potential predisposition to early arthritic changes.9
or posterior, of up to 5 mm without significant In addition, it was shown that the talus would routinely
Figure 5-8 (A and B) Nondisplaced distal fibula fracture that this athlete elected to treat without surgery.
90
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Ankle fractures
Figure 5-8 cont’d. (C and D) Note that, despite clinical healing, radiographs still disclose fracture line at
4 months. The athlete was asymptomatic and back to full activity.
follow the displacement of the fibula, thus lending itself earlier return to weight-bearing; and stabilizing weight
to anatomic malpositioning and subsequent abnormal bearing; rehabilitation; and shorter duration of pain.
loading stresses10 (Fig. 5-9, A through F). All are anecdotal, and none have been demonstrated
However, these studies9,10 are some of the most in a prospective comparison study of operative versus
often misquoted or misinterpreted in the literature. nonoperative treatment specific to this injury pattern.
These analyses were performed in vitro and, as such, Controversy persists surrounding the process of deci-
focused specifically on the relationship between the fib- sion making. Despite evidence to the contrary, many
ula and talus after eliminating all other attachments. surgeons perform, and athletes elect to undergo, repair
There was no medial restraint to motion; thus, even of the injured lateral malleolus, presumably for fear of
though the results can be viewed as reliable and truthful, abnormal and untoward results of pathologic mechanics
they bear limited clinical applicability because the contri- and to resume activity as quickly as possible. A large
bution of the medial osseous and ligamentous structures body of clinical evidence favoring this faction is the
was ignored. Appropriate interpretation of these studies demonstrated lack of reliability of reproducible medial
suggests that abnormal ankle mechanics may be encoun- tenderness on clinical examination in disclosing the
tered when a fibular fracture exists in the face of medial presence or absence of deltoid ligament injury.31 It is
deficiency. In these cases, operative treatment should be unclear as to what degree of deltoid injury in the face
used.15 However, these studies fail to speak to the long- of the fibular fracture will allow for clinical instability.10
term, clinical consequences of a truly isolated lateral Therefore many surgeons ascribe to the philosophy that
malleolar fracture. it is better to be aggressive, especially in someone whose
More practical arguments for operative fixation in the livelihood may depend on the anatomic function of
athlete are more reliable reduction in the face of unclear an ankle or lower extremity. Again, the perspective is
medial injury; anatomic bone-to-bone contact, facili- anecdotal but reasonable. Surgical treatment often is
tating primary bone healing, faster recovery times, and pursued, as detailed later.
91
...........
Nonoperative management consists of immobiliza- recovery. Debate still exists regarding the use of inter-
tion until swelling and pain allow motion, usually about fragmentary fixation combined with lateral buttress
10 to 14 days. Subsequent weight bearing ensues in a plating versus posteriorly placed, anti-glide fixation. Lat-
walking boot, again, when symptoms abate. In most eral plating is technically easier, whereas posterior
instances, athletes are back to protected weight bearing plating theoretically provides greater mechanical stabil-
somewhere between 3 and 4 weeks. The walking boot ity.32,33 Both seem to perform well clinically. No current
is maintained until full weight bearing and nearly normal consensus exists, and the method remains the preference
range of motion are restored. Physical therapy focuses and comfort level of the surgeon.
on maintaining muscle tone, joint mobility, and pro- A recent resurgence of interest has been noticed in
prioception during the healing phase. Return to an older technique of fibular fixation—intramedullary
activity is dictated by relief of pain, normal symmetric nailing. This method of fixation has some limited appli-
joint range, and strength equal to 75% of that in the cation in the treatment of fibular fractures but really
normal, unaffected side. Sports-specific activities are has no place in the operative fixation of a high-demand
resumed with protective taping or bracing as necessary. individual or high-performance athlete. What little
Radiographs are monitored frequently in the first advantage one can gain from biomechanical stability of
month to ensure no displacement, but after 4 weeks an intramedullary device quickly is counteracted by the
these typically are not helpful as long as no changes notorious inability to correct or control rotation and
are noted, specifically no mortise widening. length. In fact, my experience suggests that the insertion
Should one embark on the surgical management of of the device often will alter or displace a previously ana-
the isolated lateral malleolus fracture, operative princi- tomic reduction because of the force required to install
ples of anatomic restoration and rigid fixation apply. it, as well as the angled flange on the interlocking nails.
The goal is to allow early mobilization and quick These are not recommended when one is in need of an
Figure 5-9 (A and B) Displaced fractures of the fibula with mortise widening require open reduction and internal
fixation, with possible attention to the deltoid ligament if the mortise remains widened.
92
...........
Figure 5-9 cont’d. (C and D) Even after anatomy is restored through closed reduction, stability is in question.
(E and F) Open reduction and internal fixation (ORIF) ensures anatomic restoration of the joint and allows early
93
institution of joint motion and therapy.
...........
anatomic restoration of the joint and should be reserved the syndesmotic ligaments while applying a laterally
for lower-demand, medically compromised patients in directed pull on the fibula with a towel clamp, reduction
need of surgical stabilization. tool, or other grasping object. Any laxity in tibiofibular
One indication for this type of fixation would be in stability associated with a fibular fracture more than
the athlete with a displaced, low (Weber A) fibula frac- 3.5 to 4.0 cm from the joint should be stabilized with
ture. In this instance, an intramedullary, 4.0-mm, can- syndesmotic fixation11 (Fig. 5-11, A through D).
cellous screw would be reasonable, provided that an I prefer to use a 3.5-mm screw with three cortex
anatomic reduction can be achieved. fixation and a plate long enough to incorporate the
screw proximally to the distal-most hole (see Fig. 5-11,
Bimalleolar/trimalleolar fractures D). Routine screw removal is performed after 12 weeks
Little debate exists regarding treatment of bimalleolar/ on the basis of biomechanical evidence of abnormal
trimalleolar ankle fractures. In an athletic population, ankle mechanics in the face of restricted talofibular
uniform agreement exists regarding the need for opera- motion.34 This reduces the risk of a free-standing screw
tive intervention21,22 (Fig. 5-10, A through D). hole as a stress riser and theoretically allows quicker,
Some caveats do exist, however. Particularly attention safer, and more reliable return to activity.
should be paid to the fibular length and rotation. Any degree Trimalleolar fractures at least should have the medial
of malreduction may lead to abnormal mechanics and possi- and lateral components repaired. Fixation of the poste-
bly could hasten the advance of degenerative arthritis. rior fragment of tibia is performed on the basis of size
High fibular fractures associated with bimalleolar of the segment and, more importantly, percentage of
fracture patterns should be stabilized rigidly and anato- articular surface involved. Those with more than 25%
mically. All injuries should be tested for syndesmotic sta- to 30% of the joint involved in the fracture should
bility, but especially those demonstrating a medial soft undergo stabilization with at least one anterior to pos-
tissue injury. This test can be done by directly visualizing terior screw (see Fig. 5-10, C and D).
Figure 5-10 (A through D) Bimalleolar and trimalleolar fractures require open treatment.
94
...........
Ankle fractures
Figure 5-10 cont’d.
Figure 5-11 (A through D) Syndesmosis repairs should be performed at the level of injury occurrence and
be based on the stability of the joint after malleolar repair. (A and B) Displaced bimalleolar fracture in an
adolescent wrestler. Note the avulsion of the anterior inferior tibiofibular (AITF) ligament from the distal tibia. 95
(continued)
...........
Figure 5-11 cont’d. (C) Malleolar repair with a screw in the syndesmotic fragment. (D) More traditional fixation
for a higher level fibula fracture and persistent tibio-fibular widening.
Pediatric ankle fractures Tillaux and triplane fractures are considered adult,
Pediatric ankle fractures constitute a wide variety of and issues regarding treatment should be viewed as
patterns and complexity. However, these often are such (Fig. 5-15). The focus of treatment should be
encountered in the growing population of high school, based on congruity of articular reduction because the
junior high, and primary school athletes. complications surrounding these injuries arise from non-
Salter-Harris (S-H) fractures not involving the joint anatomic incongruous relationships, leading to early
adhere to principles of all generic, pediatric fracture degenerative changes rather than the more popular but
management protocols (Fig. 5-12). Closed anatomic erroneous presumption of growth arrest. Abnormalities
reduction often is successful simply by reversing the or asymmetry in growth actually are rare and not terribly
mechanism of injury. Cast immobilization typically is consequential in these scenarios.
effective for management, and bony remodeling usually Any question of articular irregularity should be set-
compensates for any minor malalignments. Immobili- tled by obtaining advanced imaging studies, specifically
zation usually is required for 6 to 8 weeks, at which CT scanning, to eliminate the possibility of articular
point gradual weight bearing and range of motion may step-off. Separations of more than 2 mm in distance
be advanced as tolerated. Any articular incongruity along the joint surface, regardless of congruity, should
necessitates open management (Fig. 5-13, A and B). be repaired. No compromise should be accepted at the
Complexity increases in the diagnosis and manage- articular surface for fear of early degenerative changes.
ment of the adolescent variants of the Tillaux (S-H III) Percutaneous techniques using large reduction clamps
and triplane (S-H IV) fractures. These typically occur or devices and cannulated screw fixation are acceptable,
in the 12- to 14-year age range as the medial tibial but the surgeon must be certain of anatomic restoration
physis begins to close, creating an irregular stress distri- and no interposed tissue. If there is any question regard-
bution and resistance to forces applied across the ankle ing adequacy of reduction, open treatment is required.
(Fig. 5-14). Once stability is ensured, motion may be introduced;
96
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Lateral process talar fractures
C
D
Figure 5-12 Dias, Tachdjian modification of Salter-Harris’ classification of ankle fractures in the immature
skeleton. (From Green NE, Swiontkowski MF: Skeletal trauma in children, Philadelphia, 2002, WB Saunders.)
however, weight bearing should be withheld for 6 to One review demonstrates 74 lateral process fractures of
8 weeks until healing is confirmed. the talus that occurred as the result specifically of snow-
boarding, accounting for 2.3% of all snowboard injuries.
This is, to date, the largest series reported.36
Lateral process fractures often are missed, commonly
LATERAL PROCESS TALAR FRACTURES
masquerading as chronic ankle sprains. It is easy to
understand why this happens because of the relative ana-
Fractures of the lateral process of the talus previously tomic proximity of this injury to the anterior talofibular
have been considered an uncommon injury. Historically, ligament, as well as the lack of reliability of reproducible
this injury was thought to occur as the result of high- evidence of fracture on standard radiographic studies.
energy trauma and would result from a peritalar disloca- Early diagnosis and treatment, however, are important
tion that caused avulsion of the subtalar ligamentous because studies have suggested that late recognition
attachments on loading. More recently, however, this and failure to implement treatment routinely lead to poor
injury has gained notoriety because of its strong predi- outcomes, such as chronic pain, stiffness, instability, and
lection for presentation after snowboarding injuries. arthritis.37-44
Before the advent of this relatively new winter sport, Traditionally, lateral process fractures were purported
reports were infrequent. However, with the explosion to arise from a sudden dorsiflexion inversion force on a
of attention to this activity by a predominantly young, fixed foot. However, mechanical loading studies have
risk-taking population, the incidence and recognition demonstrated that an acute external rotation or shear
have risen dramatically—so much so that this injury has force is a key element in reproducing this fracture
been deemed by some as the ‘‘snowboarder’s ankle.’’35,36 pattern in a cadaveric model.35
97
...........
Figure 5-13 (A and B) Supination-inversion injury of the ankle. (B) With repair. Care is taken to avoid the tibial
physis and articular surface. The fibular pin is removed after 4 to 6 weeks.
Hawkins39 has classified these fractures into three are not reproducibly diagnostic because of the irregular
subcategories (Fig. 5-16). Type I is a simple fracture anatomy and overlap of joints in this area.37,45 Special
of the lateral process extending from the tibiofibular radiographic views have been proposed to help elucidate
articulation down to the posterior talocalcaneal articular these fractures, including a 20-degree internal rotation
surface of the subtalar joint, with or without displace- view with the foot in neutral dorsiflexion.46 Alternatively,
ment of the fragment. Type II fractures involve commi- Dimon37 has suggested that the ankle be placed in 45-
nution of the fibular and posterior calcaneal articular degree internal rotation and the foot plantarflexed at 30
surfaces, as well as the lateral process. Type III is an avul- degrees to show the posterior facet in profile. If the diag-
sion or chip fracture off the anterior and inferior part of nosis is entertained, the best and most reliable study
the posterior articular processes of the talus. Another remains CT scanning. This not only provides the exam-
classification system has been proposed by Fjeldborg,38 iner with diagnostic evidence but also demonstrates the
who described stages of injury with type I fissuring, type degree of displacement and comminution of fragments.
II lateral process fracture with displacement, and type Because of the poor outcomes obtained, all fractures must
III lateral process fracture with subtalar dislocation. be sought and treated aggressively. Nondisplaced frac-
Diagnostically, this fracture pattern presents a dilemma, tures should not be ignored but immobilized in a cast
and a high index of suspicion is needed by the clinician. for 6 to 8 weeks with no weight bearing and then reeval-
Injury pattern reports by the patient often are unreliable uated at that time for bony union. Failure to aggressively
and inaccurate. Physical examination findings often are treat larger displaced fracture fragments or comminuted
similar to those found with an acute, severe ankle sprain fractures may and often does result in malunion, non-
with tenderness just anterior and inferior to the tip of union, heterotopic overgrowth, subtalar instability, and,
the fibula, along with swelling and ecchymosis. ultimately, disabling arthritis.39,40,42,43,47-53 Late symp-
Radiographs sometimes are helpful when large frag- toms have been shown often to not respond to excision
ments or significant comminution are present but, again, of the offending fragments.37,47,51
98
...........
Lateral process talar fractures
Epiphyseal plate
Anterior
Lateral
Posterior
Medial
A
12.5 yr. 13 yr.
13.5 yr. 14 yr.
Figure 5-14 Demonstrating the unusual closure of the distal tibial B

physis. First, it starts in the middle of the growth plate, then moves
anteromedially and finally laterally. (From Green NE, Swiontkowski Figure 5-15 (A and B) Tillaux and triplane ankle fracture
MF: Skeletal trauma in children, Philadelphia, 2002, WB Saunders.) variants in the adolescent athlete. (From Green NE,
Swiontkowski MF: Skeletal trauma in children, Philadelphia,
2002, WB Saunders.)
Superior
Treatment is fracture type dependent. Large displaced
fractures are managed with anatomic restoration of the
articular surface with internal fixation (Fig. 5-17, A
through E). These often are large enough to accept at
least one small fragment screw for fixation (2.7 or
3.0 mm usually will suffice). This most often can be done
through a typical Ollier approach to the sinus tarsi and Anterior Posterior
subtalar joint region. Comminuted fracture patterns are A
more ominous and carry a more unpredictable outcome.
These often are refractory to repair and necessitate excision
for all fragments. This at least removes any potentially
abrasive surfaces and areas of future impingement.
If repaired, early range of motion, focusing on inver-
sion/eversion, will promote restoration of subtalar B
mechanics.
Sequelae of untreated or missed fractures are well
documented. Malunion, nonunion, instability, over-
growth, and/or arthritis of the subtalar joint can be
debilitating. Missed fractures that present late often are
refractory to repair or remove fragments and will neces-
sitate subtalar arthrodesis.37,47,51 Therefore it is critical
C
that awareness of this injury pattern remains prevalent
and a high index of suspicion be maintained for any Figure 5-16 (A through C) Hawkins classification of lateral
patient presenting with atypical or persistently painful talar process fractures. (From: Boon AJ, Smith J, Zobitz ME,
99
ankle sprains.35,36,47 Amrami KM, et al: Am J Sports Med, 29(3):333, 2001.)
...........
Figure 5-17 (A) Schematic of a lateral process talus fracture. (B and C) Direct visualization of the lateral process
fragment before (B) and after (C) reduction.
presentation is similar with respect to mechanism in

ANTERIOR PROCESS CALCANEAL
the onset of lateral foot or ankle pain, ecchymosis, and
FRACTURE
swelling. However, tenderness typically occurs 1 to
2 cm more distally in the region of the sinus tarsi. The
Anterior process calcaneal fractures often are missed in fracture fragment often is small and extra-articular,
the acute setting. This fracture must be sought in any- occurring as a plantarflexion and inversion force tensions
one with recalcitrant lateral foot pain or ankle sprain; the bifurcate ligament, which overcomes the attachment
if untreated, it will lead to problematic sequelae. There of the distal-most calcaneus.
are two types of anterior process fractures, and they Alternatively, compressive injuries occur with sudden
occur by opposing mechanisms of injury: avulsion and abduction forces across the foot and are much more
compression.50,54 ominous. These often will be intra-articular and involve
Avulsion injuries occur as a result of a plantarflexion, variably sized fragments of joint surface, as well as caus-
inversion force (Fig. 5-18). As such, these often are ing displacement of the fragments posterior, dorsal, or
misrepresented as lateral ankle sprains.55-57 The overall lateral, sometimes leading to substantial incongruity.
100
...........
Anterior process calcaneal fracture
Figure 5-17 cont’d. (D and E) Fixation is achieved with a posteromedially directed screw. A talar neck fracture is
fixed here, as well. (A from Myerson MS: Foot and ankle disorders, St Louis, 1999, Mosby.)
Figure 5-18 Anterior process fracture of the calcaneus. (From Myerson MS: Foot and ankle disorders, St Louis,
1999, Mosby.)
101
...........
Because of the similarity in presentation to lateral ankle cuneiforms and the cuboid, is named after Lisfranc, a
sprain, a high index of suspicion should be maintained French surgeon in the army of Napoleon, who originally
and careful clinical inspection performed. Radiographs described an amputation through that joint.4,50,54,60 The
are helpful, but a clear and obvious fragment is not dislocations or fracture/dislocations of the tarsometatarsal
always visible. Because these often are confused with joint are reported to occur at the rate of one injury
ankle sprains, it is not uncommon that only ankle x-rays per 55,000 people per year.50,60 These are recognized
are obtained. Suspicion should prompt the clinician to more commonly in a polytrauma patient because of the
obtain foot radiographs, particularly obliques, to verify severity,61-63 but also are increasingly recognized to occur
the diagnosis.58 Occasionally, a small fragment or ossi- in the athletic population.
cle, the calcaneus secondarium, will be noted on a lateral Faciszewski et al.64 have reported on patients with
ankle or oblique foot radiograph. This is smooth and ‘‘subtle’’ injuries to the Lisfranc joint, defined as diasta-
regular in its contours and should be differentiated from sis of 2 to 5 mm between the bases of the first two meta-
the rough, irregular edges of an acute anterior process tarsals. A third of their patients’ injuries were sports
fracture. CT may be helpful to determine specific char- related. Other reports support the increasing frequency
acteristics of acute fracture versus ossicle presence.50,58 of occurrence of Lisfranc injuries in athletic events.65-68
Additionally, this is recommended for those patients Any patient diagnosed with a midfoot sprain should
presenting with compressive injuries to determine the arouse suspicion for an undiagnosed tarsometatarsal
degree of articular involvement. ligament disruption.
Early diagnosis aids in the quality of treatment for In the athletic population, the occurrence and sever-
this injury. Healing, particularly of the avulsion type of ity varies by sport. Lisfranc injuries are reported to be
fracture, is reliable if identified early. Typically, immobi- the second most common athletic injury to the foot,
lization in a walking boot or a cast for 4 weeks is suffi- after metatarsophalangeal joint injuries, presenting in
cient. Delay in diagnosis and lack of immobilization 4% of football players per year, with a preponderance
can lead to persistent symptoms and affect the ultimate occurring in linemen (29.2%).67 Although complete
outcome. Occasionally, excision will be required to injuries resulting in diastasis of more than 5 mm are eas-
remove a nonunited fragment after delayed or missed ier diagnostically and more dogmatic in treatment plan,
diagnosis. Compressive injuries, especially those with more subtle injuries (1 to 5 mm) often are overlooked
displacement, are more complex and carry less-predict- and, even when diagnosed, may lead to therapeutic
able outcomes because of the articular damage sustained dilemmas for the surgeon, as well as frustration for the
at the time of the injury. Displacement of the fragments injured athlete. Partial capsule tears with no diastasis,
requires early reduction and fixation to restore congru- for instance, can be a compounding problem resulting
ity. Still, these patients may develop degenerative disease in prolonged disability for the elite performer.
at the calcaneal cuboid articulation, depending on The tarsometatarsal joint really is more of an articu-
the energy of the injury. Results of treatment for any lating complex providing both motion and stability—
form of these fractures are few and anecdotal. Degan much more so the latter. The osseous anatomy reveals
et al.59 reported on surgical treatment of seven patients multiple, wedge-shaped bones coalescing to form an
who developed symptomatic nonunions after anterior arch in the transverse plane. The second metatarsal often
process fractures. Late excision provided pain relief in has been referred to as the keystone of this Roman arch
five of six. Surgical treatment may involve a need to analogy, reflecting its overall importance to the integrity
osteotomize the calcaneus just below the area of non- of the maintenance of this structure. Structural
union to excise the entire affected area. Care should be rigidity of the shape of the foot is dependent on the sta-
taken to immobilize the foot for 6 weeks after this pro- bility of this relationship of the midfoot bones. Because
cedure, because destabilization may occur as a result of the bases of the metatarsals are wider dorsally, collapse
removing the bifurcate ligament, which connects the of the arch in any plane is prevented in the face of
hind foot to the midfoot at the navicula and cuboid, weight-bearing load.
respectively. Resumption of full athletic activity after sur- The 2nd through 5th metatarsals are interconnected
gical treatment may take up to 6 months; and rarely, in by a dense weave of short, broad-based ligaments and
some patients, persistent residual degenerative joint dis- capsular ligamentous structures. These tend to be bun-
ease symptoms may persist and limit return to sport.50,59 dled together and often will move as one unit. However,
there is a notorious absence of ligamentous connection
between the bases of the first and second metatarsals.
TARSOMETATARSAL DISLOCATIONS
This is thought to account for the predominance of
diastasis in this interval. Instead, there exists a dense,
The tarsometatarsal joint, consisting of the bases of the plantar-based, oblique ligament extending from the base
five metatarsals and their articulation with the three of the second metatarsal to the lateral portion of the
102
...........
Tarsometatarsal dislocations
medial cuneiform—Lisfranc’s ligament. This ligament as may be seen in ballet dancers en pointe.70-72 Alterna-
anchors the lesser metatarsal complex to the medial tively, supination or inversion of the hindfoot on a fixed
column of the foot. plantarflexed forefoot will result in a more dissociative
The tibialis anterior, with its insertion on the medial pattern of injury because the medial column is dis-
aspect of the proximal first metatarsal and the peroneus rupted, followed by the lateral dislocation of the lesser
longus, which inserts into the lateral proximal first meta- metatarsal and associated tarsal cuneiforms.73 A third
tarsal, also contributes to the stability of the Lisfranc type of injury occurs when the fixed plantarflexed foot
articulation. In certain phases of gait, these two tendons is forced into extreme equinus as a result of being struck
provide dynamic restraint. Plantar fascia, intrinsic mus- from behind.60 This is more common in turf sports
culature, and plantar tarsometatarsal ligaments provide such as football. Elements of torque, rotation, and com-
additional structural support against arch collapse and pression are all present and cumulatively lead to a dorsal
plantarward dislocation. The midfoot articulation may capsule ligamentous disruption.
be divided mechanically by columns. The medial col- Many classification systems have been proposed
umn includes the first metatarsal and medial cunei- to describe the multitude of injury patterns that may
form. The middle column consists of the second and occur.60,61,63,69,74,75 Because of the tremendous varia-
third metatarsals, as well as the middle and lateral tion, no one system has been universally accepted. These
cuneiforms. The lateral column is formed with the classification systems usually apply to high-energy injuries
fourth and fifth metatarsals, along with the cuboid and are based on segmental patterns of metatarsal-tarsal
bone. This column provides the greatest motion bone displacement.
throughout the tarsometatarsal joint. Recently a useful classification has been proposed
Vascular structures in this region deserve mention specifically for the athletic midfoot injury, including
because of their proximity to the area of potential injury. undisplaced sprains, and is based on clinical findings,
The dorsalis pedis artery and the plantar arterial arch weight bearing, x-rays, and bone scan results67 (Fig.
are structures at risk, particularly when the dorsalis 5-19). Stage I patients were found to have pain at the
pedis dives down between the bases of first and second midfoot and were unable to play sports but had no
metatarsals. Disruptions here, especially with a tethered radiographically visible changes. Bone scan results did
vessel, can result in kinking, vasospasm, and, ultimately, demonstrate increased uptake in the area of Lisfranc
ischemia. Lisfranc dislocation derives its name, in fact, as joint. Pathoanatomy is thought to include dorsal capsu-
previously stated, from the Napoleonic surgeon who so lar tear without elongation of Lisfranc’s ligament. Stage
definitely amputated cavalrymen after midfoot injuries II is described as clinical findings similar to those in
resulting in vascular catastrophes.50,60-63 Although less stage I, but with diastasis of 1 to 5 mm between the
common compared with the high-energy version of this bases of the medial two metatarsals present on plain
injury, anecdotal reports of associated vascular injuries AP radiographs. No loss of longitudinal arch was noted
abound and should be sought for fear of missing an on weight-bearing lateral x-rays. Pathoanatomy here dif-
ischemic sequela. fers from stage I in that the Lisfranc ligament is elon-
Patterns of injury to the tarsometatarsal joint have gated, but the plantar structures remain stable and
been described as a result of both direct trauma to the prevent arch collapse. Stage III was defined as diastasis
foot and indirect violence. The majority of nonathletic greater than 5 mm and loss of lateral arch height,
traumatic midfoot injuries can occur as a result of signi- defined by loss of space between the fifth metatarsal
ficant direct force, usually applied to a foot in plantar- and the medial cuneiform on lateral radiograph.38,67,75
flexion or abduction, and typically will accompany high- All capsuloligamentous structures are thought to be
velocity or high-energy trauma, such as motor vehicle injured in stage III. Other forms of injury, such as gross
accidents or falls from heights.60,61,63,69 These can result disruption with fracture and/or dislocation, were
in significant soft-tissue compromise, neurovascular defined by these authors in the method originally pro-
injury, and compartment syndrome.62 posed by Myerson,76 which was based on segmental
Indirect injury is more relevant to this discussion. instability (Fig. 5-20). The advantage of such a classifi-
Athletes may sustain direct violence to the foot as the cation is that treatment may be predicated on the level
result of an awkward collision or in the melee of a colli- of injury.
sion in certain sports. However, more commonly the Up to one in five Lisfranc injuries are missed or
athlete is injured because of low-velocity, indirect energy improperly diagnosed on initial screening, whether it
imparted to the foot. Most will describe some sort of be in the emergency department or at practitioner’s
axial longitudinal force while the foot is plantarflexed office. This often can be ascribed to the presentation
and, often, slightly rotated.67 Two specific patterns have of these injuries as part of a polytrauma, with other,
been described. Simple lateral dislocations result from more severe and more obvious injuries demanding the
eversion of the hind foot on a fixed plantarflexed foot, bulk of attention.77-79
103
...........
Lisfranc Ruptured 2–5 mm

ligament Lisfranc diastasis
sprain ligament
No diastasis
Stage I Stage II
Ruptured 2–5 mm
Lisfranc diastasis
ligament
Diastasis and
loss of longitudinal
arch height
Stage III
Figure 5-19 Nunley classification of athletic Lisfranc injuries. (From: Nunley JA, Vertullo CJ: Am J Sports Med, 30:6, 2002, p.872,
Figure 1.)
In the athlete, however, it is the subtle or complete of the foot (AP, lateral, and oblique) should be
absence of radiographic diastasis that may occur that obtained. Assessment in suspicious injuries should be
confounds the examiner.64,67,77,80 A high index of made of all of the following relationships:
suspicion must be maintained for athletes presenting 1. Diastasis of metatarsals 1 and 2.
with midfoot pain after athletic contact or activity, even 2. Cuneiform diastasis, especially medial and middle.
without radiographic evidence of injury. Consideration 3. Widening between the second and third metatarsals.
should be given to stress radiographs as a means of 4. Widening between middle and lateral cuneiforms.
furthering diagnostic abilities. 5. Small fracture, ‘‘fleck sign’’ at the medial base of
Physical examination is especially important with the second metatarsal or medial cuneiform, repre-
subtle injury. Gross distortion of the bony architecture senting an avulsion of Lisfranc’s ligament.
of the foot is readily identified. Clinical and radiographic 6. Horizontal plane malalignment of metatarsals on
findings of fractures and dislocations are relatively simple lateral x-ray.
to determine. The patient presenting with no overt dis- 7. Relationship of medial border of the second meta-
ruption or equivocal radiographic divergence becomes a tarsal should be parallel to the medial edge of the
diagnostic dilemma. middle cuneiform.
Examination typically demonstrates tenderness at the 8. Relationship of the medial fourth metatarsal should
midfoot that is worsened by provocative maneuvers such be parallel to the medial edge of the cuboid.
as pronation or abduction of the foot. Swelling is often 9. General loss of parallelism of metatarsal bases with
significant, and ecchymosis is variably present. Neurovas- respect to one another.
cular injuries are unusual in the lower energy traumas, but 10. A small compression fracture at the lateral edge of
the possibility of impending compartment syndrome the cuboid.45,52,74,76,77,80-85
always should be considered, because there often is Even after perusing the radiographs with these pa-
tremendous edema accompanying these injuries. rameters in mind, the clinician may find it difficult to
Classic radiograph findings and markers have been make a diagnosis. Weight-bearing, contralateral radio-
well established. A minimum of three radiographic views graphs often are helpful in discerning any asymmetry.
104
...........
A B C
D E F
Figure 5-20 Myerson classification of Lisfranc injuries. (From Myerson MS: Foot and ankle disorders, St Louis, 1999, Mosby.)
105
...........
In more subtle and problematic cases, multiple Only one study demonstrates reasonable results with
advanced imaging studies have been suggested, includ- nonanatomic reductions. Shapiro et al.68 reported on
ing CT, MRI, static stress radiographs, and stress nine athletes with diastasis between 2 to 5 mm. Eight
fluoroscopy under anesthesia.54,63,65,86-88 However, elected for nonoperative treatment and returned to
the best and most reliable studies seem to be a set of sport within 3 months, with good results reported in
standing radiographs (Fig. 5-21, A through E) and an average of 33 months after the injury.
bone scan, if necessary, in the completely undisplaced On the basis of these reports and personal experience,
metatarsal that manifests persistent pain.67,68 There are my recommendation is for operative treatment in all
two advantages to weight-bearing radiographs. First, but nondisplaced injuries of the tarsometatarsal joint.
the dynamic nature of the injury can be determined Although percutaneous techniques have been proposed,
in a more appropriate physiologic and mechanical an open approach is more reliable and eliminates the
state, thus determining the need for treatment. Second, possibility of retained or interposed tissue, as well as
prognostic value exists in determining the presence of allowing direct visualization of the joint for an anatomic
collapse or instability.64 reduction (Fig. 5-22). Closed or percutaneous techniques
Principles of treatment of Lisfranc injuries are univer- using the large Weber reduction clamp carry the risk
sal and include providing an anatomic reduction in of malreduction, especially in a horizontal plane, even in
stabilization. Care must be taken to observe and manage the face of an anatomic appearing anterior/posterior
the soft tissue and neurovascular consequences, as well. image (Fig. 5-23).
Debate still exists as to how much diastasis is accept- Open treatment affords the surgeon the opportunity
able in the injured athlete. The literature is heavily to extricate any incarcerated bony fragments or soft
weighted toward high-energy trauma management, tissue that may have been interposed, including the
and little has been proposed regarding management Lisfranc’s ligament itself or, in high-energy injuries,
of the athletic midfoot sprain. Most recent literature the tibialis anterior tendon. Anatomic restoration of
suggests that residual diastasis may result in a poor the arch is achieved and verified, as well as providing
outcome, such as persistent pain, deformity, and arthro- direct visualization for hardware placement.
sis.45,60,65,67,76,81,87-92 Nonanatomic reductions have Screw fixation is preferable because K-wire fixation is
been shown to be inferior with respect to outcome and tenuous, at best, and not as reliable in maintaining an
the need for secondary procedures, such as revision anatomic reduction. In addition, especially in unstable
repairs or fusions. injuries, the motion at the joint surfaces will induce
Athletic injuries are sparsely documented, but the pin loosening and migration with predictable loss of
evidence that is available seems to support the conclusion stability, thus requiring concurrent cast immobilization,
that injuries resulting in diastasis will lead to poor out- which prevents early rehabilitation. Conversely, screw
comes. Curtis, et al.65 reviewed 19 athletes with varying fixation is reliable and allows for early mobilization of
degrees of tarsometatarsal (TMT) injury, citing poor the foot and ankle, as well as edema control after wound
functional results despite ‘‘relatively nondisplaced inju- healing has been achieved.
ries’’ in patients with delays in diagnosis and those not Screw configuration is dependent on injury pattern
treated adequately, with three failing to return to sport. and extent of ligamentous disruption. My preference is
Meyer et al.66 reported on nonoperative management of to use fully threaded, 4.0 mm or larger screws. Partially
23 collegiate football players with good outcomes after threaded screws are acceptable, but because this is a
nonoperative treatment of midfoot injuries. In this study, ‘‘position screw’’ to maintain reduction, the surgeon
20 of 23 had no diastasis, but of those that did, one of must guard against the tendency to compress across
three had significant pain with high-demand activity. the TMT joints. Typically, the first screw is placed on
Nunley and Vertullo67 showed that 14 of 15 patients the orientation of the disrupted Lisfranc’s ligament, that
had good results when treated within the algorithm is, from medial cuneiform to second metatarsal base.
based on a classification they proposed that guided treat- Additional screws are placed as needed across the base
ment on the basis of displacement. Patients were assessed of the first and third TMT joints from distal to proximal
on the basis of plain x-rays and bone–scan-documented (Fig. 5-24, A through C). Should the injury extend
injury. Only completely nondisplaced injuries (seven through the medial and middle cuneiforms, an intercu-
patients) were treated nonoperatively. All others were neiform screw should be placed first.
treated by open reduction with internal fixation. The The patient is kept on weight bearing for 6 to
only patient with residual pain was one treated by open 8 weeks. Early motion and therapy modalities such
reduction and internal fixation after 10 months of failed as muscle stimulation can begin as soon as soft tissue
conservative treatment. Return to sport in the operative healing allows. Partial weight bearing in a boot begins
group averaged 14.4 weeks, which was comparable to at 6 to 8 weeks and is advanced until 12 weeks. Screws
nonoperative results. are maintained for no fewer than 16 weeks and often,
106
...........
Figure 5-21 (A) Radiograph of a 34-year-old professional

waterski jumper with acute midfoot pain after a fall. There is
a suggestion of subtle intermetatarsal diastasis. (B through D)
Various advanced imaging studies confirm the Lisfranc
ligament disruption by avulsion of the base of the second
metatarsal. (B) Bone scan shows increased uptake about the
midfoot. (C) Computed tomography demonstrates the avulsed
fragment. (D) Magnetic resonance imaging reveals edema in
the region of the ligament with suggestion of bony injury.
(E) Plain anteroposterior weight-bearing x-rays of the injured
and comparative contralateral side clearly disclose the
diastasis.
107
...........
but not routinely, are removed. The athlete is returned

to athletic activity with a molded, semirigid insole and
a semirigid extended steel shank device.
Frank disruptions are treated in the way that trauma
guidelines dictate and uniformly are managed with open
reduction and internal fixation. Postoperative protocols
are similar to those described previously, but usually
require larger periods of rehabilitation, and return to
activity is less predictable in these patients.
TARSAL BONE FRACTURES
Anatomic variants of Lisfranc’s injuries do exist. There

have been reports citing evidence of bipartite cuneiforms
and anatomic variations in anatomy throughout the
midfoot bones (Fig. 5-25, A through F). These should
be encountered but pursued and treated aggressively,
with the same guidelines as those for the previously
described injuries.93-95
Fractures or dislocations exclusive to the cuneiforms
Figure 5-22 Planned incision for approach to the diastasis of or cuboid area are unusual. These often are present in
Lisfranc’s joint. (From Myerson MS: Foot and ankle disorders, conjunction with a tarsometatarsal joint injury, in which
St Louis, 1999, Mosby.) the force of the injury has disrupted further proximally
through the navicula, cuneiform, or talonavicular joints,
or even through the body of the cuboid. Although rare,
these injuries have been identified.96,97 Because cunei-
form fractures and dislocations often occur as part of a
midfoot dislocation, treatment principles should follow
those of the injured tarsometatarsal joint.
Isolated cuboid injuries most often present as insig-
nificant ‘‘chip’’ fractures along the lateral side. Typically,
these occur as a result of an inversion injury and often
are seen secondarily after the patient has been diagnosed
with ‘‘sprain.’’ Treatment requires supportive immobili-
zation in either a walking cast or hard-soled shoe for
approximately 4 weeks or until symptoms allow resump-
tion of activity. A rigid orthosis may allow earlier return
to sport. Fracture instability is not usually a concern.
Compressive cuboid injuries can occur with a sudden
abduction force. So-called nutcracker injuries are far
more severe. Again, this is considered a variant of the
mechanism for Lisfranc injuries, and the same principles
are applied. Early anatomic reduction is necessary
(Fig. 5-26, A through E). Manipulation alone is often
unsuccessful in restoring the length of the lateral col-
umn. Open treatment frequently is required. Placing a
small plate to span the collapsed intercalary segment is
necessary on occasion. Often, there is poor-quality bone
Figure 5-23 Percutaneous reduction technique with a large
fixation in the subarticular cuboid; therefore a spanning
Weber clamp. Surgeons must be aware of the tendency for plate to the distal calcaneus represents a good alter-
dorsal plane malalignment as a result of overtightening or native. For severe comminution, I prefer structural
improper clamp placement. Lateral fluoroscopy should always tricortical graft to reestablish the length. This may be
be employed to verify anatomic reduction. (From Myerson MS: interposed between subchondral bone proximally and
Foot and ankle disorders, St Louis, 1999, Mosby.) distally, because the articular surfaces often are not
108
...........
Fractures of the base of the fifth metatarsal
Figure 5-24 (A and B) Repair of injury seen in Figure 5-19

performed through dorsal incision. (C) Patient returned to
sport in 6 months.
severely comminuted. If necessary, fixation can be Something gave way midway down my foot. . .the 5th
applied as previously stated, or a spanning external fixa- metatarsal was found fractured about 3/4 inch from its
tor from distal calcaneus to proximal metatarsals may be base.’’ Jones originally described the fracture of the
used to distract the lateral column. metaphyseal diaphyseal junction without extension distal
to the anterior metatarsal (4-5 intermetatarsal) junction.
Currently, a Jones fracture is recognized as any fracture
involving the fifth metatarsal metaphyseal-diaphyseal
FRACTURES OF THE BASE OF THE
junction. This fracture often is confused with, although
FIFTH METATARSAL less commonly encountered than, its cohort, the avul-
sion of the tuberosity encountered more proximally.
Fractures of the base of the fifth metatarsal are the most The significance of the true Jones fracture is that it can
common metatarsal fracture. However, there are many mis- develop delayed or nonunion. Zelko et al.,99 Kavanaugh
conceptions regarding the description, the understanding, et al.,100 and DeLee101 have reported difficulty treating
and thus the treatment of these injuries throughout the fractures of this region in which diagnoses initially
the literature. The classic Jones fracture was named after were missed or that, in reality, were stress fractures.
Sir Robert Jones,98 who originally described the fracture Stewart102 originally introduced a classification to
in his own foot in 1902. He sustained the fracture help clarify fractures in this region. Type I fractures are
‘‘Whilst dancing, I trod on the outer side of my foot, at the junction of the base and shaft of the metatarsal.
my heel at the moment being off the ground. Subgroups include noncomminuted (IA) and
109
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Figure 5-25 (A) Weight-bearing anteroposterior radiograph, with comparison, of a high school quarterback with
acute midfoot injury. (B) Close-up suggests unusual arrangement in the area of medial cuneiform. (C) Lateral
radiograph demonstrates separation of dorsal and plantar halves of medial cuneiform. (D) Computed tomography
confirms bipartite tarsal bone.
(continued)
comminuted (IB) variants. Type II fractures involve only symptoms. Radiographs demonstrated what appeared
the styloid process. Again, these are subdivided into to be acute fracture line and no evidence of any chronic
extra-articular (IIA) and intra-articular (IIB). Stewart change, defined as periosteal reaction or intramedullary
established a treatment plan that is based on his classifi- sclerosis. Group 2 demonstrated an acute injury but also
cation system. reported a prodrome of mild lateral foot pain. Radio-
Zelko et al.99 tried to define fractures on the basis of graphs in these patients evidenced a clear fracture pat-
clinical history and initial radiographic findings. Group 1 tern. However, there also was demonstration of some
patients reported an acute injury with no previous periosteal reaction. Group 3 patients were categorized
110
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Figure 5-25 cont’d. (E and F) Open repair requires attention to both the separated bipartite cuneiform with
removal of synchondrosis and closure of the intermetatarsal diastasis, as well.
Figure 5-26 (A through C) Radiographs of an 18-year-old female athlete with acute injury after awkward landing.
Note the homolateral metatarsal displacement pattern and the cuboid compression injury.
111
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Figure 5-26 cont’d. (D and E) Open repair addresses the metatarsal displacement but also distracts the cuboid
to buttress the lateral column of the foot.
as a reinjury after one or more previous injuries. Radio- DeLee and colleagues50,101have attempted to com-
graphs of these patients demonstrate lucent fracture line, bine classifications and divides these into multiple frac-
periosteal reaction, and intramedullary sclerosis, and this ture types. Type I fractures are those at the junction of
group presented with chronic pain or multiple recurrent the base of the shaft and the base and are subcategorized
injuries with sclerotic margins bordering a lucent frac- into Type A for nondisplaced and Type B for comminu-
ture line. ted fractures in this area. Type II fractures occurred
112
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again at the junction of the shaft and the base but car- current management protocols use some form of zone
ried clinical and radiographic evidence of prior injury. concept in classifying and reporting fractures. Therefore
To fall into this category, patients had to report prior the bulk of the discussion regarding treatment will reflect
lateral foot pain and/or an established radiographic this trend and be focused on management of fractures by
periosteal stress reaction or frank fracture line. Type III type and location.
fractures included those of the styloid process or tuber- An alternative classification system also exists that
osity and again were classified into subcategories A, defines fractures on the basis of chronicity of symptoms,
nonarticular, and B, articular. presence of stress fracture, and recurrence of injury.103
The recommended current classification includes a Again, these are poorly defined and not terribly useful
combination of all the classifications discussed and divides from a management standpoint. Stress fractures involv-
the metatarsal injuries into classification that correlates to ing the proximal shaft of the fifth metatarsal differ in their
zones of vascular anatomy (Fig. 5-27). Currently, pre- behavior and somewhat in their treatment, and therefore
ferred classification uses three separate zones. Zone 1, or are not discussed in this section on acute injuries.
the most proximal zone, includes the cancellous fifth The fifth metatarsal itself has been subdivided into
metatarsal, the so-called tuberosity fragment. It includes main segments, including the head, neck, shaft, base,
the insertion of the peroneus brevis tendon and calcaneo- and tuberosity or styloid process. The metaphyseal
metatarsal ligamentous branch of the plantar fascia. Frac- portion of the bone tapers into a tubular diaphyseal
tures in this zone typically extend into the fifth metatarsal segment. The size and the shape of this bone vary some-
cuboid joint but may be extra-articular. Zone 2 injuries what but typically demonstrate that a larger, wider,
involve the metaphyseal-diaphyseal junction. This encom- more triangular proximal portion becomes a fairly
passes the articulation of the proximal fourth and fifth narrow tubular structure that has a slightly lateral curve
metatarsals. The ligaments holding the fourth and fifth as it traverses distally. The radius of curvature as the
metatarsals together proximally are secure both dorsally bone proceeds distally is highly variable and can lead to
and plantarly and provide tremendous stability. Finally, tremendous distortions in the shape and stress applied
zone 3 injuries are fractures of the fifth metatarsal shaft. to the distal end of this structure.104
This zone begins just distal to the fourth and fifth interme- The proximal end of the fifth metatarsal not only
tatarsal ligaments and extends distally into the tubular por- articulates with the cuboid at the tarsometatarsal joint
tion of the diaphysis approximately 1.5 to 2.0 cm. Most but also has an intermetatarsal articulation with the base
of the fourth metatarsal. This is a true joint. The bases of
the fourth and fifth metatarsals are bound closely to the
cuboid by dense, ligamentous structures on every side.
The stability of the tarsometatarsal complex is provided
by capsular ligamentous structures, the dorsal and plan-
tar cubometatarsal ligaments, the lateral band of the
plantar aponeurosis, and the broad insertion of the per-
oneus brevis tendon (Fig. 5-28). It is believed that these
capsular ligamentous structures contribute greatly to the
genesis of a true Jones fracture45,100 because the proxi-
mal portion of the fifth metatarsal and its articulation
Figure 5-27 Fracture zone classification at the base of the Figure 5-28 Anatomy of tendon attachments at the base of
fifth metatarsal. (From Lawrence SJ, Botte M: Foot Ankle the fifth metatarsal. (From Lawrence SJ, Botte M: Foot Ankle
14:360, 1993.) 14:360, 1993.)
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with the cuboid is held fast while torsional forces pro- the shaft is the result.45 Kavanaugh et al.100 used high-
duce stress that is relieved through the fracture line just speed cinematography and force platform analysis in an
distal to these structures, approximately 0.5 cm distal to attempt to recreate the position of the foot at the time
the insertion of the peroneus brevis and just distal to the of the index injury. Conclusions of this study suggested
joint between the fifth and fourth metatarsals. The base either an axial or mediolateral force or a combination of
of the fifth metatarsal proceeds laterally and inferiorly these acting on the fixed base of the fifth metatarsal.
beneath the inferior edge of the cuboid on the lateral This would bring the patient up on the metatarsal heads,
radiograph. There is a tremendous variability in size concentrating the axial and mediolateral forces on the
and shape of this prominence, accounting for its variable lateral metatarsal. It was postulated that failure to invert
susceptibility to injury. the foot would produce a tremendous axial and medio-
The vascular anatomy in this region also is relatively lateral ground force culminating in fracture.
important (Fig. 5-29). This has been thought to be a fairly Other factors also have been implicated in the genesis of
tenuous vascular supply, particularly at the proximal diaph- the injury here, including repetitive use, such as prolonged
ysis. The arterial plexus at this level has been well established running or jumping activities; vascular contribution, par-
by Shereff et al.105 and Smith et al.,106 demonstrating only ticularly at the avascular or watershed zone; and certain
a small nutrient vessel in the so-called watershed area. This morphologies of foot shape. Individuals with more cavus
is unique contradistinction to the fairly abundant blood foot alignment have been shown to be more likely to
supply more proximal to this watershed area. develop this injury pattern because of the increased rigidity
Direct and indirect mechanisms have been implicated of the foot, as well as the propensity to have a stress transfer
in the genesis of the fifth metatarsal fracture.45 Certainly, to the lateral foot.50,99-101,103,105-107 Individuals with pla-
the prominence of the tuberosity makes it particularly at novalgus foot also have been suggested to be predisposed
risk to a more direct mechanism of injury when discussing to this injury because of increased loads forced along
this version of the fracture.104 Jones himself alluded to the the lateral border of the foot during the latter part of
indirect nature of injuries, describing a ‘‘cross-breaking stance, phase, and gait. These relationships have not been
strain directed anteriorly to the metatarsal base and caused demonstrated in any formal mechanical studies.
by body pressure on an inverted foot while the heel is Clinical diagnosis of the Jones fracture is dependent on
raised.’’98 Presumably, he is describing the commonly making an appropriate diagnosis and localizing the specific
accepted foot in fixed equinus sustaining rotatory and/or type of injury with respect to zone as well as acuity. His-
tensile forces overcoming the thinning cortical bone in tory may be vague, but typically involves an aching sensa-
the proximal metaphyseal-diaphyseal junction. tion on the lateral aspect of the foot related to some sort
Fractures of the tuberosity occurring indirectly are of push-off or inversion-type injury. Prodromal symptoms
more common because of the number of structures that may be reported for up to several weeks before any
attach to the prominence.104 These structures have been evidence of the actual documented injury suggestive of a
identified previously. The importance of the pull of the prefracture state or impending fracture.99,101,103
peroneus brevis has been emphasized in the creation of Physical examination findings are fairly reproducible
a separation stress that forces the proximal fragment of and include an improved tenderness, specifically over the
the metatarsal away from the shaft. Because of the base of the fifth metatarsal. Ecchymosis and swelling are
strong peroneus brevis contraction in stance phase, the present to variable degrees and, again, depend on the acu-
tendon already is contracted when an inversion stress is ity of the injury. There is typically an accentuation of pain
applied to a weight-bearing, plantarflexed foot. This by inversion of the foot. However, there is little motion at
tendon holds fast while the force causes the shaft to be the fracture site, and therefore no crepitus or palpable
pulled away from it. Avulsion of the base away from mobility of the fracture site on manipulation.
Figure 5-29 Vascularity of the fifth metatarsal. (From Smith J, Arnoczky SP, Hersh A: Foot Ankle 13:144, 1992.)
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Radiographs often will confirm the diagnosis, oversized, yielding a tight fit. The postoperative proto-
although in some instances some fractures may present col includes nonweight-bearing cast applied for 6 weeks,
as occult or incomplete. Careful radiographic assessment with gradual resumption of activities determined on the
is important to determine the presence of a fracture line basis of pain tolerance after that.
because this may be particularly subtle. If the diagnosis Percutaneous intramedullary screw fixation also has
is in question, studies such as MRI or bone scintigraphy been described.50,54,101,108-120 This is performed
tend to be particularly helpful.45,102 through a small incision initially at the base of the fifth
Diagnosis of fractures can be especially confounding metatarsal between the peroneus brevis tendon and the
in the adolescent athlete because secondary centers of lateral band of the plantar fascia. The interval is devel-
ossification at the base of the fifth metatarsal are present oped, and a guidewire for a cannulated screw is inserted
and sometimes are confused with acute fractures. The under fluoroscopic guidance. The key point to remem-
ossification center typically occurs between 8 and 12 ber about placement of the screw is that, on the basis
years of age and usually is united by 12 years in girls of the anatomy, the wire should be initiated ‘‘high and
and by 15 years in boys. A secondary ossification center inside.’’ Theis suggests that the guidepin should be
occurs in approximately one-fourth of all children.104 started on the dorsal and medial aspect of the bone just
Distinction between these secondary centers of ossifi- inside and superior to the edge of the tuberosity. Once
cation and acute fracture is relatively straightforward. the guidepin is positioned appropriately and verified
Distinguishing characteristics include the orientation of under fluoroscopic guidance, a canal is drilled and an
the apophyseal line, which reproducibly traverses the appropriate length screw is placed. Choices for the size
tubercle parallel to the long axis of the shaft. Addition- of the screw typically are based on the size of the bone,
ally, the apophysis occurs lateral to and does not extend and it is well accepted that the largest screw that the
into the tarsometatarsal joint.104 Ossification centers canal can accommodate should be placed. One tech-
also tend to have smooth, regular edges, as opposed to nique tip is to overdrill using the cannulated guidepin
a more irregular appearance of fracture. system and then to remove the guidepin and place a
Two other ossicles often will occur in this region. The os solid screw to provide greater tensile strength to the
peroneum is present in approximately 10% to 15% of all bone. It is crucial to avoid fracturing the metatarsal,
radiographs. The os vesalianum is variably present as well. and thus maintenance of the intramedullary position is
Again, a smooth, sclerotic, appositional surface often is of utmost importance. No cortex should be violated
present and differentiates this from fracture. These ossicles, on passage of the screw. Postoperatively, the patient is
which are independent, sesamoidal-type bones, should be placed in a splint for approximately 1 week, and
distinguished easily from acute fracture situations. a short-leg, nonweight-bearing cast is applied for an
Treatment is injury specific and fracture type depen- additional 2 to 3 weeks. At 3 weeks, stationary bicycling,
dent. Treatments vary and range from weight bearing in swimming, and stair climbing are allowed in a protective
a protective shoe as soon as pain allows to various forms boot, with weight bearing progressed as tolerated,
of open reduction and internal fixation and, sometimes, depending on pain. Running is encouraged only when
bone grafting. The literature is replete with information evidence of significant fracture healing is present radio-
to support just about any stance one may want to take. graphically, and typically this takes 5 to 7 weeks. Return
It is crucial that a clear understanding of the injury pat- to sports-specific activity is prohibited until the patient
tern, the outcomes of nonoperative versus operative can run and cut painlessly. Caveats with respect to this
treatment, and the potential complications be under- procedure involve injury to the sural nerve, which is as
stood by the surgeon before embarking on a treatment close as 2 to 3 mm from the position of the screw head.109
plan. Various forms of surgical treatment have been Lastly, a combination of the previous two procedures
described and are addressed independently by procedure. mentioned has been applied.54 The technique for screw
First, the technique of medullary curettage and inlay placement is as previously stated. However, this is done
bone grafting has been well established.103,107 The base with a larger incision, and access is gained through the
of the fifth is approached via a curvilinear dorsolateral canal before placement of the screw. Bone graft should be
incision. The fracture site is exposed subperiosteally. placed dorsally, medially, and plantarly before insertion of
A rectangular section of bone measuring 0.7 2.0 cm the screw. Once bone graft is placed, the screw is inserted
centered over the fracture is outlined by four drill holes and the wound is closed. An alternative to this method is
and removed with a sharp osteotome. The medullary a so-called strain-relieving cancellous bone graft, which
canal is curetted free of all sclerotic bone, and the conti- can be placed in similar fashion, but specifically in a
nuity of this cavity is reestablished. The original descrip- dorsomedial trough spanning the fracture site. Once the
tion includes a tibial corticocancellous graft that is screw has been placed, additional bone graft can be packed
fashioned and replaced into the fracture defect. No fixa- in and around the fracture site. Return to activity is similar
tion typically is applied because the graft often is slightly to that as previously stated for screw fixation alone.
115
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As previously stated, literature abounds regarding of the literature demonstrates a rate of delayed union
multiple forms of fractures. It is somewhat confusing as high as 38% and a definite nonunion rate of 14%
because, in some of the earlier literature, either specific with nonoperative treatment of these fractures.127 It
type of fracture is not specified or uniform treatment is was additionally noted by Zelko et al. that, even after
applied to all fracture types. An attempt will be made an extended period of nonweight-bearing, short-leg
to dissect the literature and apply it in a relatively simple casting for a period of 10 to 12 weeks, refracture was
yet appropriate fashion.50,54,99,103,107-122 possible, and surgical treatment would be indicated for
Extra-articular tuberosity fractures typically require these patients.99 Still, there exists a fairly large and repu-
no more than supportive therapy and weight bearing table group of surgeons who suggest that only in cir-
as tolerated as soon as the patient is able to manage pain cumstances in which previous conservative treatment
and swelling appropriately. Multiple forms of ‘‘benign has failed should surgical treatment be implemented.
neglect’’ have been described, including suggestions These authors suggest that fractures that occur with no
for compressive dressings, adhesive taping, supportive intramedullary sclerosis or no prior attempts at treat-
footwear with padding around the prominence, and ment not only will heal, but will allow athletes to return
even short-leg casting.45,102 There has been no consen- to weight bearing within 6 weeks and to activity by 12
sus on the type of protective device necessary. However, weeks122,128,129 (Fig. 5-30, A through D).
it has been reported that even short-leg walking casts In general, however, most authors agree that because
probably are overprotective in the management of this of the potential for refracture, the cited delayed union
fracture.45,83 The pain usually has subsided significantly rate, and the incapacitation required from nonweight
by the second week to allow reasonably functional bearing and immobilization as a result of casting, high-
walking and transition into a more sports-specific shoe performance athletes and high-demand individuals
and resumption of activity, again, as pain would allow. be given the option for and be treated with some form
It also is important to note that radiographic union surgical management.99,101,115
may not be present for a minimum of 4 to 6 weeks, Paired comparisons of operative versus nonoperative
and often longer. However, this should not preclude an treatments have been analyzed. Josefsson et al.113
athlete’s returning to sport should symptoms subside described 63 patients in which one third of the patients
appropriately. It also has been suggested that, on occa- were treated operatively and two thirds conservatively.
sion, the fracture will heal with fibrous union, and that Average follow-up was 5 years, and, on the basis of
typically this also is not symptomatic and, again, will delayed union or refracture, in almost 25% of the non-
allow the athlete to return to activity appropriately.123 surgically treated patients subsequent surgical treatment
Indications for surgery in this region are reserved was required. Late surgery was required in 12% of the
for those patients that have either significantly displaced acute fractures and 50% of chronic fractures. Clapper
tuberosity fractures or intra-articular involvement with dis- indirectly supported operative intervention, based on a
placement.102,123 Open reduction need not require an review of 100 patients treated for acute Jones fractures
intramedullary screw as previously described, but only a with 8 weeks of nonweight-bearing casting. Results
small interfragmentary screw. Recognition and treatment demonstrated only a 72% success rate with this form of
after delayed presentation may require that excision of the treatment and average time to union of 21 weeks.121
fragment be performed, as opposed to standard open On the basis of the historical literature and currently
reduction. My experience with this fracture, even with available techniques and prevailing opinions, a protocol
intra-articular, nondisplaced varieties, suggests that the has been established that is my preference for the
nonoperative treatment is and continues to be the standard approach to the fifth metatarsal-based fracture. This
of care. However, if there is any question regarding man- should be fractures of zone 1, acute fractures of the tuber-
agement, a more aggressive approach should be instituted. osity portion that are nondisplaced, typically are treated
Poor results with tuberosity fractures are largely anec- with a removable boot, and typically require 6 to 8 weeks
dotal124,125 and may be a result of a painful fibrous union, for full healing. Surgery virtually is never indicated in this
because lack of bony consolidation can approach 19%.126 type of patient unless a painful nonunion develops.
Other factors involved in poor outcomes would be articular Should the fracture be displaced or comminuted, the
incongruity or sural nerve entrapment in the fracture after activity level of the patient must be assessed. In a younger,
healing ensues, necessitating surgical management. high-performance athlete, surgical management certainly
Treatment of the true acute Jones fracture has is offered and may be helpful to reduce the risk of late
evolved. Initially, universal treatment was considered complications and speed to recovery.
to be the application of short-leg walking cast.45,122 In zone 2 injuries, the classic acute Jones-type frac-
However, even in reports advocating this form of ture, completely nondisplaced fractures may be treated
treatment, there were found to be nonunions occurring in a nonweight-bearing cast for 6 to 8 weeks in a mod-
that required subsequent surgical treatment. Review erate-demand to low-demand type of patient. High-
116
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Figure 5-30 (A and B) Acute fifth metatarsal or ‘‘Jones fracture.’’ (C and D) The patient elected for conservative
treatment and healed uneventfully after 6 weeks of nonweight-bearing casting.
performance athletes should be offered intramedullary bone grafting or possibly even a minifragment plate
percutaneous screw fixation in a technique as previously and screw fixation.
described (Fig. 5-31, A and B). Displaced fractures as A zone 3 injury, a true shaft fracture, usually involves
a result of higher-energy trauma actually may require a distraction-type force and typically behaves differently
a true open reduction. Fixation is performed in similar from a Jones fracture. These injuries often will present
fashion as that described for nondisplaced fractures. An in a delayed fashion and may in fact even be stress frac-
exception to this would be an excessively comminuted tures. An acute fracture in this region typically will heal
metaphyseal-diaphyseal junction, which might require with a nonweight-bearing cast in a lower-demand
117
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Figure 5-31 (A and B) Percutaneous fracture reduction and treatment with intramedullary screw fixation.
individual, but again, operative treatment as described 9. Ramsey PL, Hamilton W: Changes in tibiotalar area of contact
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Frank nonunions and chronic injuries should be trea- Indications for the syndesmotic screw—a cadaver study, Foot
ted with internal fixation and bone grafting. My prefer- Ankle Intl 14:153, 1993.
ence here is for the large intramedullary screw fixation 13. Clark HJ, Michelsen JD, Cox QG, et al: Tibiotalar stability in
and concomitant bone grafting as described. bimalleolar ankle fractures: A dynamic in vitro contact area study,
Foot Ankle Intl 11:222, 1991.
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........................................... C H A P T E R 6
Injuries to the tibialis anterior, peroneal

tendons, and long flexors of the toes
Vincent James Sammarco and G. James Sammarco
......................
CHAPTER CONTENTS
Introduction 121 Tibialis anterior 126

Flexor hallucis longus 121 Peroneal tendons 131
Flexor digitorum longus 126 References 144
INTRODUCTION importance because of their attachments to other mus-

cles and tendons within the foot itself. Injury to these
muscles and tendons, whether partial or complete, can
The extrinsic muscles of the anterior, lateral, and deep
compromise a sports career. This is particularly true with
posterior compartments of the leg play an important
respect to the flexor hallucis longus in the classical ballet
part in both static and dynamic body support. Actions
dancer. Injury to the nerves that innervate the deep flex-
of these muscles serve to stabilize the body during
ors of the leg result in weak push-off and decreased sta-
stance, as well as provide power and stability during all
bility. This chapter deals with injuries to muscles and
lower-extremity motion. They are of particular impor-
tendons in the anterior compartment, the tibialis ante-
tance because they provide balance and power during
rior, extensor hallucis, and extensor digitorum longus,
push-off, as well as decelerating the body while stop-
as well as those in the lateral compartment, the peroneus
ping, turning, and cutting. They also stabilize the foot
brevis, and peroneus longus, and the deep posterior
on both even and uneven surfaces. The muscles of the
compartment, the flexor hallucis longus and flexor digi-
anterior compartment, the tibialis anterior, extensor hal-
torum longus. Conditions of the tibialis posterior and
lucis longus, extensor digitorum longus, and peroneus
Achilles tendons are presented elsewhere. Early diagno-
tertius, are important because of their location, func-
sis is emphasized. Special diagnostic studies, including
tioning to dorsiflex the ankle and toes and to control
magnetic resonance imaging (MRI) computed tomo-
the forefoot during the swing phase of gait. Injuries to
graphy (CT), and electrodiagnostic testing, are useful,
nerve, muscle, or tendon may lead to pain, weakness,
special diagnostic studies that help to confirm a diag-
and dropfoot. Muscles of the lateral compartment
nosis. Surgical intervention often is necessary to correct
include the peroneus longus, an important lateral foot
these problems, and rehabilitation ultimately is required
stabilizer that also controls pressure beneath the first
to return the athlete to preinjury status.
metatarsal head, which is so important in jumping activ-
ities, cutting, and turning as in skiing. The peroneus
brevis is the strongest abductor of the foot, and both
peroneal muscles act as accessory flexors of the ankle
FLEXOR HALLUCIS LONGUS
and foot. Muscles of the deep posterior compartment
of the leg, the posterior tibialis, flexor digitorum longus, The flexor hallucis longus muscle arises in the deep pos-
and flexor hallucis longus, likewise serve important terior compartment of the calf. From its attachment on
functions by stabilizing the longitudinal arch of the foot. the interosseus membrane, lower two thirds of the fibula
They also provide additional power during running, and intermuscular septa, it passes from the deep com-
cutting, turning, and stopping. The flexor digitorum partment into its own tunnel at the posterior aspect of
longus and flexor hallucis longus are of particular the talus, lateral to the flexor digitorum longus tendon
CHAPTER 6 Injuries to the tibialis anterior, peroneal tendons, and long flexors of the toes
and deep to the posterior tibial artery and nerve. It then MRI helps to rule out a mass but may show a ‘‘dumb-
passes beneath the sustentaculum tali of the calcaneus in bell’’-shaped configuration of fluid in the tendon sheath
a fibro-osseous tunnel from the posterior talus to the around the ankle, narrowing beneath the sustenta-
master knot of Henry, where it lies beneath the flexor culum and enlarged distal to the sustentaculum tali
digitorum longus tendon. Here it gives a slip of tendon (Fig. 6-1).
that inserts on the medial fibers of the flexor digitorum In the well-conditioned athlete, the muscles of the
longus tendon. It then passes beneath the first meta- calf are hypertrophied. Because of the low insertion of
tarsal between the sesamoids to insert onto the distal the fibers of the flexor hallucis longus muscle onto
phalanx of the hallux. A sesamoid may be present within its tendon, dorsiflexion of the ankle draws the enlar-
the tendon at the metatarsophalangeal joint. Like all ged lower muscle fibers into the fibro-osseous tunnel
polyarthrodial muscles, the extrinsic muscles of the foot through which the tendon passes behind the ankle. This
in the anterior, lateral, and posterior compartments of causes inflammation at the musculotendinous junction,
the leg have a complex function. The flexor hallucis lon- the stopper bottle sign, and symptoms of posterior ankle
gus muscle functions as a flexor of the distal and prox- pain. Treatment includes anti-inflammatory medication
imal phalanges of the hallux; aids in flexion of the and a flexibility program including gentle stretching.6
midtarsal joints and supination of the foot, as well as If symptoms do not abate, surgical intervention with
plantarflexion of the ankle; and also supports the longi- release of the pulley and tenosynovectomy may be
tudinal arch during ambulation, particularly in the latter necessary. In cases in which significant hypertrophy of
part of the stance phase of gait. the muscle is present, a myoplasty, excision of impinging
muscle fibers, may be necessary. The tendon is debrided,
Tendinitis and fibrosed muscle fibers that attach on the tendon
Acute tendinitis occurs most commonly at the posterior just above the pulley also are excised to permit smooth
ankle.1 This injury is common in dancers and has been passage of the tendon in the tunnel throughout its full
termed ‘‘dancer’s tendinitis.’’2-4 It is less common than excursion.
Achilles tendinitis and occurs in inexperienced dancers Other areas of chronic tenosynovitis of the tendon
and in athletes who are not conditioned. Tendinitis also include the midfoot and metatarsophalangeal joint.7
develops when athletes change sports without proper Symptoms of pain with tenderness usually occur in the
conditioning for the new activity. Symptoms begin specific area of stenosis. To relieve symptoms, the pulleys
within a few days following a change of technique or
at the beginning of the season. When the dancer rises
on the ball of the foot, pain occurs in the posterior
aspect of the ankle. The pain initially is vague and occurs
with flexion of the ankle and foot. Passive dorsiflexion of
the ankle with deep palpation 1 cm anterior and medial
to the Achilles tendon at the ankle joint elicits tenderness
and crepitus.2
Radiographs exclude bony abnormalities such as os
trigonum and posterior talar fracture. Treatment inclu-
des improving dance technique or reducing running in
the athlete. Noninflammatory medication is prescribed,
and a program of flexibility and power-building exercises
is instituted.
Chronic tendinitis produces symptoms of tenderness
in the same region with active flexion and also on deep
palpation of the tendon during flexion and extension.5
Crepitus is present over the tendon. Radiographs differ-
entiate this from os trigonum syndrome and arthritis
of the subtalar joint. Symptoms of os trigonum syn-
Figure 6-1 Magnetic resonance imaging (T2-weighted sagittal
drome include pain in the posterior ankle when the cut) of a patient with symptomatic tendinitis of the flexor
patient actively rises on the ball of the foot. The pro- hallucis longus tendon. There is significant swelling of the
vocative test is reproduction of pain with passive forced tendon sheath (arrows) starting at the musculotendinous
plantarflexion of the foot and ankle. The differential junction above the ankle joint, narrowing as the tendon
diagnosis includes pseudocyst of the flexor hallucis sheath is compressed beneath the sustentaculum, and then
longus tendon, symptomatic subtalar cyst, posterior im- ballooning out again as the tendon passes into the midfoot,
pingement syndrome, and insertional Achilles tendinitis. ‘‘dumbbell sign.’’
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Flexor hallucis longus
in either of these areas are released surgically, and tendon excursion is limited by the nodule’s position at
a tenosynovectomy is performed. Injections of cortico- the distal end of the tarsal canal. Once the dancer has
steroids should be avoided because inadvertent injection achieved demi-pointe, pain may occur in the posterior
directly into the tendon may cause it to rupture.2 ankle. As the dancer further rises onto her toes (sur
les pointes), the great toe plantarflexes from 90 degrees
dorsiflexion to neutral position to support the body.
4 PEARL
The pull of the flexor hallucis longus muscle is strong
enough to force the nodule proximally through the
stenotic tunnel, triggering the great toe into flexion.
Flexor Hallucis Longus Tendinitis While the dancer is en pointe, the nodule lies proximal
(1) Crepitus on deep palpation of the tendon behind to the tunnel. As the dancer returns from pointe to
the medial malleolus during active plantarflexion and
dorsiflexion of the ankle and foot. (2) Pain posterior to the
flat foot, the tendon is passively pulled distal, and the
ankle when rising on toes or on dorsiflexion of the ankle fuseform thickening in the tendon snaps forward dis-
against resistance. (3) No pain with passive plantarflexion of tally through the stenotic tunnel again. As the great
the ankle. toe snaps straight, it produces pain and may alter the
dancer’s appearance in the dance step. The longitudinal
tendon tear usually is single, but it may be multiple, and
measures from 3 to 5 cm in length.
Trigger toe Radiographs exclude bony abnormalities. MRI reveals
Partial rupture of the flexor hallucis longus tendon con- a tear with degeneration of the tendon. A pseudocyst
sists of a longitudinal tear in the tendon and a fusiform of the tendon may be present.13 The differential
thickening at the distal end of the tendon tear beneath diagnosis includes a posterior impingement syndrome
the sustentaculum tali.4,8,9 of the ankle, os trigonum syndrome, retrocalcaneal
Occasionally the tendon may be trapped in a frac- bursitis, and Achilles tendinitis. Conservative therapy
ture.10-12 When the nodule on the tendon lies distal to consisting of gentle stretching exercises, and anti-
the sustentaculum, the narrow tunnel through which inflammatory medication to reduce swelling may be
the tendon passes restricts motion in a manner similar effective. Patients with compromised performance who
to that of the flexor pulley of trigger finger. The result fail to respond to conservative measures are surgical
is triggering of the great toe. The condition occurs candidates.
commonly in ballet dancers and is more common in Surgical approach consists of a 5-cm incision on the
females in their second to fourth decades. As the dancer posteromedial aspect of the ankle. The posterior tibial
begins to rise (relevé) on the ball of the foot (demi- neurovascular structures are retracted medially. The
pointe), the great toe dorsiflexes and remains in contact tendon is delivered through the wound with a tendon
with the floor (Fig. 6-2: photos of toe flexed and hook, and the pulley is released at its lateral attachment
extended). The flexor hallucis longus contracts, but the to the talus and calcaneus distally. The nodular swelling
Figure 6-2 Left and right, Clinical appearance of the trigger toe sign. Left, With ankle and foot actively flexed,
the interphalangeal joint of the hallux snaps into flexion. Right, When the ankle and foot are actively extended,
the interphalangeal joint of the Hallux remains locked in flexion (left) or snaps straight.
123
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Figure 6-3 Left, Operative photograph of a ballet dancer with trigger toe. The flexor hallucis longus tendon is
exposed and delivered into the wound. A longitudinal tear is visible distally (at the right). The thickening of
the tendon seen in the region of the tear is causing triggering as the ankle and foot are flexed and extended.
Right, The tendon is repaired using a 4-0 nonabsorbable Dacron running suture.
present at the distal end of the tear is trimmed to con-

form to the uniform diameter of the tendon throughout
C A S E S T U D Y 1
its length (Fig. 6-3). The tear is repaired with a running
4-0 braided nonabsorbable suture. The tendon must be
trimmed to slide easily in the canal throughout full flex-
ion and extension. Following closure, a splint is applied A 28-year-old, female, classical ballet dancer noticed
until two weeks postoperatively. A gentle active range of increasing pain in her posterior ankle following dance
motion (ROM) program is begun 3 weeks following class for 2 months. She then developed a snapping of her
surgery. The foot and ankle are protected for 3 addi- great toe when rising from the demi-pointe position (on
tional weeks in a splint, and the patient then is transi- the ball of the foot) to en pointe position (on her toes).
tioned to an ankle stirrup brace. Dancing en pointe A triggering sensation was felt behind the ankle. When
may take up to 4 months, whereas return to full athletic descending from en pointe position to a flat foot, the
great toe snapped again as the toe dorsiflexed. Pain was
routine usually occurs by 3 months. Full recovery may
felt behind the ankle. The snapping of the foot was visible
take 6 months.
and became unaesthetic as well as disabling. Physical
examination revealed a palpable popping sensation felt
posteriorly at the ankle as the foot, ankle, and great toe
were moved repeatedly from dorsiflexion to plantarflexion.
4 PEARL At surgery, a 5-cm incision was made at the posteromedial

aspect of the ankle, and the flexor hallucis longus
muscle and tendon were identified. Traction with a
Trigger Toe tendon hook revealed a 5-cm longitudinal tear in the
(1) A snap noted on palpation of the tendon behind the tendon beginning at the musculotendinous junction and
medial malleolus with active flexion, and extension of
extending distally (see Fig. 6-3, A and B). The fibro-osseous
the ankle and hallux with patient in sitting position.
(2) Toe snaps backward and forward with flexion and
canal through which the tendon passed was noted to
extension of the ankle and hallux. (3) Dancer complains be tight. A fusiform thickening of the tendon was
of pain in the posterior ankle region and a snapping present at the distal end of the tear. The thickened tendon
sensation of the great toe when rising up (relevé) or was trimmed sharply so that the width of the tendon was
landing from a leap. (4) Occurs most commonly in uniform throughout, and the tendon sheath was carefully
female, classical ballet dancers who dance on their released, allowing the tendon to slide its length
pointes. unimpeded through a full ROM of the ankle and foot. The
124
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tear was repaired with 4-0 braided Ethibond suture. A

also has been reported in basketball players and aerobic
splint was applied for 3 weeks, followed by gentle active walkers at the sustentaculum tali. Symptoms occur over
ROM and a supervised physical therapy program. Three a 6-week period.
months later, the dancer was able to resume dance. She Treatment in the high-performance athlete consists
returned to dancing sur les pointes 4 months after surgery. of surgical repair. If the tendon has retracted proximally
Six months following surgery, she was asymptomatic. and cannot be reapproximated, a tendon graft using
plantaris tendon may be necessary to reestablish con-
tinuity. Reconstruction returns strength to flexion of
Complete rupture the metatarsophalangeal joint, although a flexion lag
Complete rupture of the flexor hallucis longus is at the interphalangeal joint commonly results.2,4
uncommon but can occur in several areas. Iatrogenic Complete rupture of the flexor hallucis longus ten-
surgical laceration has been described.14 Avulsion frac- don within the tarsal tunnel and beneath the sustenta-
ture from the hallux distal phalanx is caused by great culum tali may be treated by transfer of the flexor
resistance to flexion on the distal phalanx as the foot is digitorum longus to the stump of the flexor hallucis
forcibly plantarflexed. If the avulsed tendon contains longus.15,16 Resection of the degenerated portion
a fragment of bone, anatomic open reduction is recom- of the flexor hallucis longus tendon also is performed.
mended. Tear of the tendon at its insertion without The flexor digitorum longus tendon lies adjacent
a bony fragment permits the tendon to retract proxi- to the flexor hallucis longus beneath the sustentaculum
mally, allowing the great toe to dorsiflex. Surgical repair tali. Suturing of the flexor hallucis longus tendon stump
is performed through a medial incision along the proxi- to the flexor digitorum longus tendon proximal to the
mal phalanx of the hallux above the neurocirculatory master knot of Henry permits good function, if not
bundle. The tendon sheath is exposed at or just proxi- complete return of strength.
mal to the metatarsophalangeal joint with a direct repair An alternative method of treatment for complete rup-
of the tendon to the distal phalanx. ture is to use a tendon graft. The graft is sutured pro-
Tendon rupture also can result following corticoste- ximally and distally following resection of the diseased
roid injection into the tendon at the metatarsophalan- portion of the flexor hallucis longus tendon. The foot
geal joint (Fig. 6-4). Symptoms include pain, sudden and ankle are immobilized for 6 weeks.17 Both methods
loss of active flexion at the interphalangeal joint, and provide good function of the flexor hallucis longus
weakness in flexion at the metatarsophalangeal joint. but do not necessarily return normal flexion to the
This is accompanied by a dramatic change in athletic hallux interphalangeal joint. In some patients with low
performance. Chronic, complete, spontaneous rupture demands on the foot, complaints of a hyperextended
distal phalanx rubbing on top of the shoe persist.
Arthrodesis of the hallux interphalangeal joint in
20 degrees of flexion provides relief of symptoms with-
out altering performance.
Tumor masses
The most common mass of the flexor hallucis longus
tendon is a pseudocyst located at the posterior ankle.
It may extend distally into the foot along the tendon
sheath and is associated with degeneration or tears of
the tendon. Symptoms of fullness and achiness along
with decreased performance are common. Symptoms
of tarsal tunnel syndrome also have been reported. An
MRI reveals a cystic mass, often bilobed, with one end
at the posterior ankle and the other end distal to the
tarsal tunnel in the midfoot (Fig. 6-1). If symptoms
warrant, excision of the cyst and tenosynovectomy
are performed through a posteromedial ankle incision.
Figure 6-4 An operative photograph taken through a medial
incision at the level of the metatarsophalangeal joint. The
Associated tendon tears are repaired as described previ-
two ends of the ruptured flexor hallucis longus tendon are ously. Postoperatively, the ankle is protected in a splint
visible held by two Adson forceps. The athlete received several for 3 weeks, followed by initiation of a flexibility and
injections of corticosteroids beneath the first metatarsal head power-building program. Return to play is permitted
for ‘‘metatarsalgia.’’ Following debridement the tendon was when postoperative pain subsides and foot function
reconstructed using a plantaris tendon graft. approaches the level of the normal, contralateral side.
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first metatarsal and medial cuneiform. Approximately

FLEXOR DIGITORUM LONGUS
10% of tendons have variations to the insertion, the
most common being a bifid insertion to the cuneiform
Isolated injury to the flexor digitorum longus tendon is and first metatarsal, or insertions reaching proximally
uncommon. This muscle takes origin deep in the poste- or distally along the medial column of the foot.19,20
rior calf on the tibia and distal one-third of the fibula Accessory tibialis anterior tendons have been reported,
and passes medial to the flexor hallucis longus tendon but are rare and have not been reported to cause
posterior to the ankle in its own tunnel. It lies close to pathology.
the tibialis posterior tendon at the sustentaculum tali, The tibialis anterior is bounded proximally to the
then crosses superficially to the flexor hallucis longus at ankle by the superior extensor retinaculum, and variably
the master knot of Henry distally. The tendon receives may enter a synovial tendon sheath within the retinacu-
the insertion of the quadratus plantae muscle as it lar fibers at this level. More distally, the tibialis anterior
divides into four slips, one to each of the toes. A slip tendon predictably enters a synovial sheath as it passes
of the flexor hallucis longus tendon also inserts on its into the inferior extensor retinaculum complex. An early
medial fibers. Each of the four lumbricals originates on study using a modified Spaltehoz technique failed to
the individual tendon slips. The lumbricals pass forward reveal any zones of hypovascularity within the tendon,21
to insert on the extensor hoods of their respective toes. but a later study using immunohistochemical methods
The tendon then passes through the distal split in the suggests that such a zone exists within the inferior reti-
flexor digitorum brevis of each of the toes to insert on nacular system where tendon rupture is most likely to
its respective distal phalanx. This muscle functions pri- occur.22,23
marily to flex the toes. Accessory functions include foot The tibialis anterior acts primarily in dorsiflexion of
and ankle flexion, as well as a stabilization of the foot the ankle and also as a strong inverter of the subtalar
during the stance phase of gait. joint. It is active during the first phase of gait and
contracts eccentrically from heel strike to toe-off. Its
Tendinitis primary function is to decelerate the foot during the ini-
Tendinitis often is associated with tendinitis of associated tial plantarflexion that occurs immediately following
flexor tendons, including the flexor hallucis longus and heel strike, and to clear the foot during toe-off. Absence
posterior tibialis. Isolated lesions of the tendon are rare of this muscle in active individuals is poorly tolerated,
and are associated with penetrating injuries, most com- causing a slapping of the foot during heel strike and a
monly in the forefoot. Generalized disease such as gout steppage gait, with difficulty clearing the foot during
can result in tophus deposition within the tendon at the swing.
ankle. Small longitudinal rents have been noted. Symp-
toms consist of tenderness deep beneath the medial mal- Tibialis anterior tendinitis
leolus of the ankle in the region of the sustentaculum Tendinitis of the tibialis anterior is an uncommon entity
tali. An MRI reveals fluid in the sheath about the tendon. that may be caused by overuse of the tendon or poor
Treatment primarily is nonoperative and consists of conditioning. It is seen most commonly in runners and
anti-inflammatory medication and stretching exercises. usually accompanies a rapid increase in mileage or
In recalcitrant cases that compromise athletic performance, change in training techniques. Both uphill and downhill
surgical debridement and repair are recommended. running significantly increase demands on the tibialis
anterior, as does the practice of running stairs. A tight
gastrocsoleus muscle also contributes to increased strain
TIBIALIS ANTERIOR in the myotendinous unit. Symptoms include anterior
ankle pain with activity that often continues for a few
hours after exercise. Other diagnoses that must be con-
Anatomy sidered are exertional compartment syndrome, tibial
The tibialis anterior muscle lies in the anterior compart- stress fracture, intra-articular ankle pathology, and tibial
ment of the leg and originates from the proximal lateral periostitis.
tibial metaphysis and proximal two thirds of the tibial The diagnosis is readily appreciated on physical exam-
shaft and interosseous membrane. The tendon twists ination. Physical findings include pain with palpation
and crosses the extensor hallucis longus tendon at the of the tendon and pain with resisted dorsiflexion. The
level of the ankle at which it enters a synovial tendon tendon may be tender, particularly as it passes under
sheath. The tendon courses dorsomedially across the the superior extensor retinaculum. Palpable synovitis,
foot and rotates 90 degrees from the myotendinous swelling, and crepitance are variably present. In cases in
junction to the broad insertion.18 The majority of which weakness in dorsiflexion is present, or when
tendons insert at the plantar medial border of the swelling and tenderness exist more distally within the
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Tibialis anterior
inferior extensor retinaculum or at the tendon inser- can be helpful because of the subcutaneous position-
tion, a more aggressive workup is required to rule out ing of the tendon. Phase III involves return to activity.
intrasubstance degeneration or impending rupture. In Running should be initiated on a flat surface such as a
these instances, MRI or ultrasound are useful tools track or treadmill, with gradual advance of mileage
for evaluating tendon continuity and tendonosis24-26 and hilly terrain as tolerated. We avoid the use of steroid
(Fig. 6-5). injections around the tendon sheath because of the risk
In younger, athletic individuals, the area of inflam- of rupture.28,29 Rarely, proximal degeneration of the
mation usually involves the superior extensor retinacu- tendon occurs that does not resolve with appropriate
lum and responds well to conservative management. rehabilitation techniques. In these recalcitrant cases,
A three-phase rehabilitation protocol is used to resolve surgical exploration and tenosynovectomy may be
the tendinitis.6,27 Phase I involves limiting the extent required to resolve symptoms. Pain and swelling of the
of injury and diminishing inflammation. An oral anti- tendon at or near its insertion represents a different dis-
inflammatory is initiated, and the area may be iced and ease process and may represent significant degeneration
wrapped with an ACE bandage to diminish pain and and impending rupture, as discussed in the next section.
swelling. Immobilization is rarely indicated, but dis-
continuation of the exacerbating activity is required
for 10 to 14 days. Phase II is started after pain and
swelling have diminished and involves guided rehabilita- 4 PEARL
tion. Equinus contracture must be addressed with fre- Tibialis Anterior Tendinitis
quent stretching exercises. Resistive exercises with Tenderness and often crepitus on palpation over the tendon
elastic tubing can isolate the tibialis anterior for at the superior extensor retinaculum, a ‘‘leather bottle sign.’’
pliability and strengthening. Therapeutic modalities also
Figure 6-5 Magnetic resonance imaging demonstrating distal avulsion of tibialis anterior tendon. (A) The
tendon usually retracts proximally to the level of the inferior extensor retinaculum. (B) Axial cuts demonstrate
intrasubstance degeneration of the tendon.
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Tibialis anterior rupture and laceration diagnosis can mimic peroneal nerve or L5 nerve root
The tibialis anterior tendon is vulnerable to laceration dysfunction.40,44,45 Diagnosis may be made by physical
because of its subcutaneous position over the anterior examination and presents as the classic triad of ankle
aspect of the foot and ankle.30 The tendon may be cut in dorsiflexion by hyperextension of the toes, a slapping
a ‘‘boot top’’ laceration when a sharp object such as a gait, and a mass over the anterior ankle (pseudotu-
skate, ski edge, or sharp cleat cuts the skin and underlying mor) (Fig. 6-6). Weakness in ankle dorsiflexion occurs
structures.31,32 Dropping a sharp object onto the dorsum because the tibialis anterior function is lost, but ankle
of the foot also can result in laceration. A high index of dorsiflexion is still present because of the secondary
suspicion is required to make the diagnosis because these function of the digital extensors. The patient complains
lacerations typically look benign, with minimal bleeding of a slapping gait and has notable difficulty clearing his
or pain. Dorsiflexion of the ankle will be weakened and or her toes during swing phase. The mass over the ante-
lack full extension but will be intact because of the sec- rior ankle, or pseudotumor, is the avulsed tibialis ante-
ondary action of the extensor hallucis longus (EHL) and rior tendon stump, which becomes entrapped at the
extensor digitorum longus (EDL). Routine exploration inferior border of the superior extensor retinaculum.
of all dorsal foot and ankle lacerations should be per- Repair may be performed early or late, but the results
formed if there is suspicion of partial or complete tendon of surgery are better if repair is performed within the
laceration. These structures heal well and have minimal first 3 to 6 weeks. Nonoperative treatment is acceptable
dysfunction when repaired acutely. Traumatic rupture for elderly, inactive patients, but primary or delayed repair
may occur because of higher energy blunt trauma and is is preferred for active individuals regardless of age.46-49
associated with anterior compartment syndrome.33-38
Spontaneous rupture of the tendon at or near its
insertion is the more common presentation of tibialis
anterior deficiency. It typically occurs in middle-aged
4 PEARL
athletes and often accompanies other comorbid con- Tibialis Anterior Rupture and Laceration
ditions, such as diabetes, inflammatory arthritis, gout, The triad of (1) pseudotumor anterior to the ankle; (2) loss
obesity, and steroid use.24,39-42 The tendon in this loca- of normal anatomy of the tibialis anterior tendon at the
tion may demonstrate a zone of relative hypovascularity medial aspect of the ankle and foot when compared with the
contralateral normal side; and (3) the use of accessory
near its insertion that may predispose it to tendinosis
dorsiflexors, extensor digitorum longus, and extensor
and rupture in this area. A prodrome of pain and hallucis longus, to dorsiflex in the ankle. A less consistent
swelling along the medial arch variably precedes rupture. finding is a slapping gait on the affected side.
Pain and tenderness at the insertion of the tibialis ante-
rior tendon should be treated as an impending rupture.
The patient is immobilized in an ROM boot unlocked
in dorsiflexion but locked at 0 degrees of plantar- Surgical treatment of tibialis anterior
flexion. This allows active tendon remodeling and tendon rupture
motion while protecting the tendon from further In rupture of the tibialis anterior tendon, the ruptured
degeneration. Physical therapy is initiated with the goals tendon end often becomes caught at one of the extensor
of decreasing inflammation and encouraging tendon retinacular layers and easily may be palpated beneath
remodeling through therapeutic exercises and modal- the skin. The skin incision is made in line with the axis
ities. The ROM boot is unlocked gradually to allow of the tendon from 1 to 2 cm proximal to the palpable
more plantarflexion as symptoms permit. The boot tendon end and carried distally to the terminal insertion
may be discontinued after 4 to 6 weeks. In recalcitrant at the plantar medial aspect of the first tarsometatarsal
cases or elderly individuals, a hinged ankle foot orthosis joint (Fig. 6-7). Deeper dissection involves incision of
(AFO) with a plantarflexion stop may be necessary to the inferior extensor retinacular sheath for the tibialis
control symptoms and prevent tendon rupture. anterior tendon, which usually is well defined. If the
Rupture of the tibialis anterior in the middle-aged delay to surgery has been greater than 3 or 4 weeks,
athlete often is the result of a minor trauma. The mech- the tendon sheath will have filled with fibrous tissue,
anism of injury involves a strong contraction of the which must be excised sharply or removed with a small
muscle with the ankle in plantarflexion. The rupture rongeur. In more acute cases, the sheath may be filled
may be painless, but dysfunction is noted immediately with fluid or hematoma. Atraumatic tendon rupture
by the patient, who develops a slapping gait and usually occurs by partial avulsion from the insertion
experiences tripping on his or her toes. Medical atten- and elongation of the degenerative tendon within the
tion may not be sought for weeks, and the diagnosis inferior extensor retinaculum. Twenty percent to 30%
often is missed at the initial evaluation.5,43 The of the distal tendon stump may remain in continuity
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Tibialis anterior
Figure 6-6 Physical findings with tibialis anterior avulsion. (A) Absence of the usually pronounced tibialis ante-
rior tendon is appreciated with compared active dorsiflexion of both ankles. (B) The affected ankle demonstrates
a pseudotumor, which represents the proximally migrated tendon stump at the level of the ankle. Ankle
dorsiflexion is incomplete and weak and occurs by hyperextension of the hallux and lesser digits.
Figure 6-7 Surgical technique of repair of the tibialis anterior. (A) The tendon end usually can be teased
distally without violating the inferior edge of the superior extensor retinaculum. Avoiding incision of the latter
helps to prevent tendon adhesions and wound problems. (B) Once the tendon is pulled distally, it can be grasped
with a Krackow-style suture and pulled to full excursion. Adhesions are disrupted to free the tendon by gently
passing a freer around the tendon and muscle belly.
(continued)
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Figure 6-7 cont’d. (C) Repair is accomplished by pulling the tendon distally to its insertion. One or two suture
anchors usually are needed to secure the repair.
with the anatomic insertion and, if present, should be If the tendon is at the inferior edge of the retinacu-
preserved for use in the repair. In exposing the proximal lum or just under it, it can be grasped with an Alice clamp
tendon stump, consideration should be given to the and teased distally, then secured with a Krackow-type,
superior extensor retinaculum. When possible, the supe- locking suture. Once the tendon has been secured, ten-
rior extensor retinaculum should be left intact during sion is applied, and a blunt elevator such as a small Cobb
exposure of the tendon. The retinaculum at the level or Freer is passed proximally within the retinaculum and
of the ankle often is thin, and repair can be difficult. used to break up adhesions and gain excursion of the
Adhesions of the repaired tendon to the retinaculum tendon. In delayed cases in which adequate tendon
are common and difficult to avoid because of the im- excursion cannot be gained by blunt dissection, or when
mobilization required in the postoperative protocol. In more significant tendon retraction has occurred, the
patients with comorbid conditions, the retinaculum superior retinaculum must be divided for exposure.
may not be repairable, possibly leading to subcutaneous Once the tendon end has been recovered and ade-
adhesions, bowstringing of the tendon, and wound quate excursion obtained, the tendon end must be
healing problems. Often retraction of the tendon will debulked of fibrous material and degenerative tendon.
stop at the inferior margin of the superior extensor Dissection of the scarred end usually will reveal intact
retinaculum, either because the tendon end has formed tendon fibrils mixed with degenerative tendon and a
a pseudotumor that becomes entrapped here or because mass of scar tissue. Degenerative tendon and scar tissue
some of the more proximally inserting fibers are still in must be excised before repair, but maximal length of
continuity. the tendon must be maintained.
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Peroneal tendons
Lacerated tendons may be sutured primarily if longus originates in the head of the fibula and the prox-
repaired within 2 or 3 days using a Krackow, Kessler, imal two thirds of the shaft and interosseous membrane.
or Bunnell suturing method. In cases of delayed treat- The peroneus brevis originates more distally from the
ment, reattachment of the tendon to its anatomic in- lateral shaft of the fibula and intermuscular septum.
sertion is ideal but not always possible. For cases in The superficial peroneal nerve innervates the lateral
which the repair is under tension, we reconstruct the compartment, and its sensory branches exit the com-
insertion of the tendon and augment fixation with one partment proximal to the ankle and divide to become
or more suture anchors. The distal tendon tract overly- the medial and lateral dorsal cutaneus nerves of the foot.
ing the medial cuneiform is incised before repair, and The peroneus longus and brevis become synovial ten-
a curette is used to roughen the underlying medial dons at the level of the ankle joint, with the longus
cuneiform to encourage attachment of the tendon. becoming completely tendinous 2 to 3 cm proximal to
The tendon is pulled distally, using the previously the ankle and the brevis usually retaining some muscle
applied suture, and is sewn to the distal tendon stump fibers to the level of the ankle joint. Both tendons enter
or attached to a suture anchor at the insertion. An a series of fibro-osseous tunnels as they approach their
anchor also is applied dorsally along the course of the insertion points. The retromalleolar tunnel is bounded
tendon, usually in the medial cuneiform, and is used to anteriorly by the fibula, which usually has a natural con-
suture the tendon tightly down to the curetted tendon cavity to hold the tendons, and posterolaterally by the
tract. In cases in which repair is delayed more than superior peroneal retinaculum. The peroneus brevis sits
6 weeks, successful results can still be achieved but may anterior to the longus as the muscles enters the retro-
require a free tendon graft, either as a reinforcement of malleolar tunnel, and at this level is flat or cupped
the primary repair or as an intercalated graft if adequate around the longus tendon. Both tendons course around
length cannot be obtained.50 The extensor hallucis the distal fibula, passing superficial to the calcaneofibular
longus tendon also may be used as a transfer in chronic ligament, and enter separate tunnels along the anterior
cases because it is easily accessible. process of the calcaneus. These tunnels are parallel and
After the tendon has been repaired or reconstructed, divided by the peroneal tubercle, with the peroneus bre-
the overlying extensor retinaculum is repaired with ab- vis passing dorsal to the tubercle and the longus tendon
sorbable suture. Meticulous repair of the retinaculum passing plantar to the tubercle. The peroneus brevis pro-
is important to prevent tendon adhesions, bowstring- ceeds over the cuboid and then fans out to its broad
ing or wound dehiscence. If 5 to 10 degrees of ankle insertion on the lateral styloid of the fifth metatarsal.
dorsiflexion is not present with the patient under anes- The peroneus longus tendon continues plantarly and
thetic, we perform a gastroc-soleus recession to length- enters an osseous groove at the lateral cuboid, where it
en the tendo-Achilles complex. Layered closure of the is redirected medially across the midfoot to its main inser-
skin and subcutaneous tissue is performed, and the tion at the plantar lateral tubercle of the first metatarsal.
extremity is splinted in neutral dorsiflexion. This is Variable lesser insertions usually are present at the medial
changed to a shortleg walking cast at 10 days. Cast cuneiform, second metatarsal base, and fibrous septae of
immobilization is discontinued at 3 to 4 weeks, depend- the medial interossei. An osseous (approximately 20%)
ing on the quality of the tendon repair, at which time or fibrocartilaginous sesamoid is present as the peroneus
an ROM boot is applied. This device is left unlocked longus tendon changes directions at the cuboid later-
in dorsiflexion and locked to prevent plantarflexion ally.20,51 Stenosing tenosynovitis can occur at any of the
beyond 0 degrees, thereby allowing active motion of fibro-osseous tunnels in either or both tendons.52
the tendon during walking but protecting the repair. Accessory muscles and tendons are common, parti-
Physical therapy is initiated after casting is discontinued cularly tendinous slips from the peroneus brevis to
and begins with gentle, passive ankle dorsiflexion and the fifth toe.20 Complete accessory muscles may origi-
plantarflexion. Active strengthening may be started at nate from the distal fibula, the lateral calcaneus, or the
6 weeks with elastic tubing. The ROM boot is discon- peroneal muscles and tendons themselves.53,54 Well-
tinued at 6 to 8 weeks. Activities are progressed as developed accessory muscles can cause impingement,
tolerated. particularly if the muscle enters the fibro-osseous tunnel
system distal to the fibula.
The peroneus brevis tendon is the primary everter of
PERONEAL TENDONS the subtalar joint and acts to balance the forces of the
foot against inversion during weight acceptance and to
stabilize the subtalar joint during stance phase and
Anatomy push-off. The peroneus longus tendon acts to plan-
The lateral or peroneal compartment of the leg houses tarflex the first metatarsal and aids in eversion of the
the peroneus longus and brevis tendons. The peroneus subtalar joint. Loss of function of either of these
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tendons may result in varus of the hindfoot because of Varus alignment of the hindfoot predisposes to
loss of opposition to the posterior tibialis, and loss of both lateral ankle instability and peroneal tendon
the peroneus longus may cause cavus of the midfoot be- pathology.56,57,63-66
cause of lack of opposition to the tibialis anterior and Initiation of a nonsteroidal anti-inflammatory drug
posterior. (NSAID), a brief period of immobilization, and avoid-
ance of exacerbating activities usually are effective in
Tendinitis diminishing acute pain and inflammation. Cross train-
Tendon injury occurs through one of three mechanisms. ing with swimming, biking, a cushioned treadmill, or
Direct injury occurs primarily with laceration. Indirect other low-impact activities can be used to maintain
injury occurs when a musculotendinous unit is loaded aerobic conditioning. A stirrup ankle brace usually is
beyond its ultimate strength and fails primarily. This effective in diminishing tendon demands and may
occurs most often as an avulsion fracture at the tendon diminish pain and inflammation, although if subluxa-
insertion or as a tear at the myotendinous junction. tion at the distal fibula is present, the pressure from
The peroneus longus tendon may avulse from its inser- the brace may worsen the symptoms. If boggy synovi-
tion at the base of the first metatarsal,55 or the os pero- tis, crepitance, or significant weakness is present,
neum may fracture and be pulled proximally.56,57 Acute a short period of immobilization in a ROM boot is
injuries usually are incomplete, but if the myotendi- indicated. Weight bearing is allowed as tolerated, and
nous unit loses continuity, prompt surgical repair is active ranges of motion exercises are initiated. Active
recommended. eversion uses both the peroneus longus and brevis
Tendon overuse and entrapment is seen more com- muscles. The muscles are isolated best when eversion
monly. Repetitive microtrauma may lead to small tears exercises are performed in plantarflexion. Stretching
of the collagen fibrils. Localized hemorrhage and infil- of the peroneal tendons occurs as the ankle is brought
tration of inflammatory cells result in pain and edema. into maximal inversion and dorsiflexion. Graduated
If the condition becomes chronic, the paratenon and peroneal strengthening and open-chain exercises are
synovial lining will hypertrophy and scar. Hypertrophy advanced as tolerated. Therapeutic ultrasound is help-
of the synovium causes further entrapment of the ten- ful and may improve the quality of the tendon as it
don at the fibro-osseous tunnels, further impairing remodels. Cryotherapy, particularly ice massage, is
healing by compromising blood flow. As microtears effective for the peroneal tendons because of their sub-
develop in the tendon, the resultant load on the re- cutaneous position. Underlying hindfoot varus should
maining intact fibrils increases, potentially causing be addressed with a laterally posted orthotic. Shoewear
further tears and elongation of the structure. Calci- must be examined because the heel counter may
fication of the peroneus longus tendon is associ- impinge directly on the tendons, or a laterally worn
ated with chronic tendinitis and may complicate running shoe may cause a slight varus thrust at heel
treatment.58,59 strike.
Tendinitis of the peroneal tendons is encountered Chronic or recurrent tenosynovitis reflects a more
most commonly as an overuse phenomenon and typi- difficult entity to treat. Once secondary changes in the
cally responds well to conservative treatment.6 Lateral tendon occur, surgery often is required to resolve symp-
ankle pain after vigorous exercise is the usual present- toms. Attritional tears of the peroneus brevis tendon;
ing complaint and often occurs early in the athlete’s stenosing tenosynovitis or peroneal entrapment; chronic
season or during a period of increased intensity in or acute peroneal dislocation; accessory peroneal mus-
training. Downhill skiing, basketball, skating sports, cles; traumatic rupture; or posttraumatic sequelae repre-
ballet, running, and soccer are the sports at highest sent the spectrum of entities that may require surgical
risk. Poorly fitting footwear, particularly ski boots intervention.
and hockey skates, often is an inciting factor. Tendini-
tis may be present at the myotendinous junction or in Peroneus brevis entrapment and
the fibro-osseous tunnel system beginning at the distal attritional tendinitis
fibula. Tendinitis in the synovial sheath may progress The peroneus brevis tendon is subject to both tension
to the stenosing condition that often requires surgery. and significant compression during standing and the
Pain proximal to the myotendinous junction that weight-bearing portion of gait. As it passes around the
worsens with exercise may represent an exertional distal fibula, it lies between the peroneus longus tendon
compartment syndrome or superficial peroneal nerve and the fibula and takes on a flattened or semilunar
entrapment and warrants investigation.60-62 A stress shape. The tendon is tightly constrained at this level,
fracture of the fibula, particularly in dancers, also and similarly as it passes superior to the lateral process
may create pain at the distal one-third of the fibula of the calcaneus. Entrapment can occur because of syno-
and can be difficult to differentiate from tendinitis. vial swelling with overuse or inflammatory conditions.
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Peroneal tendons
It has been theorized that hypovascularity may occur in Hypertrophy of the synovium may stretch the peroneal
pathologic states and may be responsible for impaired retinaculum, allowing subluxation over the lateral fibula,
tendon repair, although there does not appear to be and this may initiate and propagate tears (Fig. 6-8).
a distinct hypovascular zone.67 Certain anatomic fea- Complete rupture of the tendon is unusual in the ath-
tures, such as low-lying muscle fibers on the peroneus letic population but can occur, particularly in the
brevis, anomalous tendons or muscles, or bony irregula- middle-aged athlete.
rities can initiate and exacerbate entrapment. In an More distally, the peroneus brevis can become en-
anatomic study, Sobel noted an 11.3% incidence of attri- trapped along the lateral border of the anterior process
tional tears of the peroneus brevis tendon in cadavers.68 of the calcaneus. An accessory muscle can act as a
Histologic examination of the attritional tears showed space-occupying lesion in this area, causing entrapment.
minimal inflammatory response, suggesting that these The peroneus brevis tendon passes superior to the pero-
tears are mechanical in nature.69 The peroneus longus neal tubercle, where it can become entrapped and
muscle acts as a wedge against the tendon, and even undergo degeneration. A large, peroneal tubercle may
small tears are propagated proximally and distally as predispose to entrapment at this level.70 As the tendon
the ankle moves in dorsiflexion and plantarflexion. courses distally, anomalous slips of the tendon passing
Figure 6-8 Peroneal tendinitis with synovitis at the superior retinaculum. (A) Physical examination demon-
strates tenderness and a boggy synovitis posterior to the fibula. (B) Surgical exploration shows the stretched
tendon sheath. (C) Hypertrophied synovium requiring excision. (D) Attritional tears of the brevis tendon at the
level of the fibula. Excision of the degenerative tendon and side-to-side repair is performed.
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Figure 6-9 Accessory peroneal tendons. (A) Most commonly, these exist as an accessory muscle that lies within
the peroneal compartment. Mass effect can cause tendinitis and impingement as the tendons enter the superior
peroneal retinaculum. (B) Distally, accessory tendon slips may branch from the brevis and extend to various
insertions along the fifth metatarsal or toe. In this instance, a large accessory muscle was present beneath the
inferior extensor retinaculum, causing pain and impingement.
4 PEARL
distally to the fifth digit are common and can be a
source of pain and entrapment, particularly if a muscle
belly arises in this area (Fig. 6-9).
Diagnosis can be determined on the basis of history Peroneus Brevis Tendon Tear
and physical examination. Lateral ankle pain, weakness, (1) Tenderness over the peroneus brevis tendon behind and
inferior to the lateral malleolus. (2) Pain in the same area
and episodes of giving way are typical complaints. Pain,
on active flexion and abduction of the foot and ankle against
tenderness, and swelling posterior to the distal fibula resistance.
or pain with palpation of the tendon during resisted
eversion are diagnostic. Swelling and palpable synovitis
of the sheath often are present once secondary changes
begin to occur. Weakness and pain with resisted eversion
are present. An MRI can be helpful in defining the Peroneus longus entrapment and tendinitis
extent of involvement and the presence of accessory The peroneus longus tendon also is subject to a combi-
muscles. nation of tensile and compressive forces as it enters the
We prefer not to inject corticosteroids into the tendon fibro-osseous tunnels of the ankle and foot. Like the
sheath because this may impair the recovery process and peroneus brevis tendon, the peroneus longus can
can lead to tendon rupture. Injection of local anesthetic become entrapped as it enters the synovial sheath poste-
into the peroneal tendon sheath has been described as a rior to the fibula, although pathology of the peroneus
method of verifying the diagnosis, although communica- brevis is much more common at this level. The tendon
tion of the tendon sheaths with the ankle or subtalar courses inferior to the peroneal tubercle and can develop
joint may make it less specific.71 Early in the disease stenosing tenosynovitis at this level, particularly in the
course, oral anti-inflammatory medication, a short presence of a large peroneal tubercle.56,70,72,73 The most
period of immobilization with a boot walker, or bracing common site of pathology in the peroneus longus ten-
with a stirrup ankle brace can help to diminish acute don is at the osseous groove beneath the cuboid. It is
inflammation. Functional rehabilitation as outlined here that the tendon sharply changes direction, resulting
above should be initiated. Once secondary changes occur in a combination of tensile and compressive forces
in the tendon, conservative treatment usually is ineffec- within the tendon fibers. A bony sesamoid or cartilagi-
tive. If symptoms are not controlled after 4 to 6 weeks, nous thickening is variably present at this level and often
surgical exploration, debridement, and repair should be is the site of rupture in advanced cases.55,57,74 More dis-
considered to prevent further progression and possible tal avulsion from the medial cuneiform may occur, but
tendon rupture. this is rare because of the multiple attachments in the
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Peroneal tendons
4 PEARL
plantar midfoot. Rupture can occur as the result of a
sudden inversion injury and usually occurs at the level
of the cuboid.52,57,75-77 Fracture of the os peroneum
also can occur and will result in proximal migration of Peroneus Longus Entrapment and
part or all of the ossicle.78-82 Rupture
Stenosing tendinitis occurs with chronic overuse in (1) Tenderness over the peroneus longus tendon along
athletes. Calcification of the peroneus longus tendon the lateral distal calcaneus. (2) A mass may be present
and its synovium is associated with inflammatory arth- on the lateral calcaneus. Palpable os perineum noted on
the lateral calcaneus with complete rupture and proximal
ropathy, and if present it warrants rheumatologic migration of the sesamoid. Lateral x-ray of the foot
workup.58,59,83,84 Diagnosis of the condition is similar reveals proximal migration of the os perineum (when
to peroneus brevis tendinitis. Pain, swelling, and tender- ossified).
ness along the course of the tendon and pain with
resisted eversion are the hallmarks of diagnosis. Sam-
marco noted that 8 of 14 cases had no prodrome before
peroneus longus rupture, whereas 6 of 14 patients had a Surgical treatment of stenosing tenosynovitis,
prodrome of increasing pain and discomfort during attritional tendinitis, rupture, and laceration
activity.57 In this series, diagnosis was delayed more In addressing pathology of the peroneal tendons, it is
than 6 months in all cases but one. Brandes and Smith helpful to divide the course of the tendons into ana-
noted a cavovarus position of the foot in 82% of tomic zones. Brandes and Smith divided the areas of
patients, although it is not clear whether this was sec- pathology into three zones for the peroneus longus ten-
ondary to chronic tendon insufficiency or the inciting don, but this same system can be useful in evaluating the
event in tendonopathy.56 Plain x-rays of the foot may peroneus brevis tendon, as well56 (Fig. 6-10). Zone
demonstrate a fractured os peroneus. If the tendon is A includes the superior peroneal retinaculum and distal
no longer in continuity, the proximal fragment will fibula. Zone B is the inferior peroneal retinaculum at
migrate proximally and become entrapped just distal to the level of the peroneal tubercle of the calcaneus. Zone
the peroneal tubercle, where it can be palpated and is C is the cuboid notch where the peroneus longus turns
typically exquisitely tender. Unusually, the tendon will and enters the osseous groove. We have added an addi-
avulse from its insertion at the medial cuneiform and tional zone D to this classification that involves avulsion
first metatarsal base and present with longitudinal arch of the tendons from their insertion at the respective
pain with progressive cavus of the midfoot. Early MRI metatarsal base. If the tendons are diffusely involved,
is useful in the diagnosis and may demonstrate attri- the entire tendon sheath may need to be explored; how-
tional tears or complete rupture.85 ever, if the pathology is limited to one or two zones,
Tendon rupture is poorly tolerated and results in surgery often can be limited to the affected zone.
muscular imbalance of the foot and development of Attritional tears of the peroneus brevis tendon are most
pes cavovarus.56,86 Early repair results in better out- commonly affected in zone A, although both tendons
come; therefore a high index of suspicion is necessary, often have an associated hypertrophic synovitis. During
and early diagnostic studies are indicated. Fracture of exploration, it is important to evaluate the stability of
the os peroneum with even a small separation of the the tendons, and, if instability is present, this should be
fragments should be treated as a complete rupture addressed. Attritional tears of the brevis typically are lon-
and warrants exploration and repair. As noted previ- gitudinal, and complete rupture is infrequent. After the
ously, early tenosynovitis can be treated conservatively, retinaculum is incised, the tendons are inspected, and
but once attritional changes in the tendon occur, surgery any redundant synovium is excised. If an accessory pero-
often is necessary to alleviate symptoms and restore neal muscle or tendon is present, this also is excised.
function. Degenerative and frayed tendon edges are debrided. If a
thickening of the tendon is present, this represents an area
of intrasubstance tendinopathy, and an incision is made in
4 PEARL the tendon overlying the affected area in line with its
fibers. Any central fibrosed or degenerative tendon is
Peroneus Longus Tendinitis sharply excised, taking care not to transect the normal
peripheral tendon fascicles. A side-to-side repair of the
(1) Tenderness over the peroneus longus tendon at the infe-
rior calcaneus laterally and distally and at the calcaneocu- tear then is performed with 2-O nonabsorbable suture.
boid joint inferiorly. (2) Pain in the same area on active ankle Deepening of the fibular groove and repair of the superfi-
flexion and with depression of the first metatarsal head. cial peroneal retinaculum should be performed if neces-
sary, as discussed in the section on tendon dislocation.
135
...........
Figure 6-10 Zones of entrapment of the peroneal tendons. (A) Zones A, B, and C. (B) Zone D: Rarely, avulsion
may occur at the insertion of the peroneus brevis at the base of the fifth metatarsal or the peroneus longus
distal to the os peroneus. (A, modified and reprinted from Brandes CB, Smith RW: Foot Ankle Int 21:462, 2000.)
Tendon pathology in zone B may involve both the

longus and brevis tendons. The primary site of entrap-
ment is the peroneal tubercle, where the inferior pero-
neal retinaculum attaches to the peroneal tubercle and
divides the peroneal tendons into two separate tendon
sheaths. The peroneus brevis tendon courses superior
to the tubercle and the longus inferiorly. Entrapment
of the longus or brevis tendons can result from a large
or hypertrophic peroneal tubercle or, alternatively, from
an accessory muscle or tendon (Fig. 6-11). Chronic
tenosynovitis can result in fusiform swelling of the ten-
don that worsens the entrapment phenomenon and
may result in longitudinal tears. The surgical incision
for lesions isolated to zone B is directly over the pero-
neal tubercle, in line with the axis of the tendons. Care
must be taken to identify and protect the sural nerve in
this area, because it usually lies directly in the surgical
field and may have branches that cross dorsally over
the tendons. The tendon sheath must be incised in
a way that it can be closed without tension over the
tendons. The retinaculum is incised just inferior to
the tubercle and split from proximal to distal over the
peroneus longus tendon. The superior portion of the
sheath then is elevated subperiosteally from its insertion
on the lateral wall of the calcaneus and peroneal tuber-
cle, and the central coalescence of fibers that insert
on the tubercle then can be split to add length to the
retinaculum (Fig. 6-12). The entire peroneal tubercle
should be excised with an osteotome or chisel so that Figure 6-11 Case Study: Entrapment of the peroneus longus
136 the area is flush with the lateral wall of the calcaneus. (continued)
...........
Peroneal tendons
Figure 6-11 cont’d. at the peroneal tubercle. A 13-year-old

girl with pain over the lateral ankle and peroneal tubercle.
(A) Anteroposterior ankle radiograph demonstrating enlarged
peroneal tubercle. (B) Peroneal tubercle is best visualized with
oblique foot film, which demonstrates the tubercle in profile.
(C) Coronal magnetic resonance imaging demonstrates syno-
vitis of peroneus longus and brevis and the large peroneal
tubercle. (D) Operative findings: The peroneus longus tendon
was subluxing over the enlarged tubercle. Excision of the
tubercle, localized tenosynovectomy, and reconstruction of the
inferior peroneal retinaculum resolved the patient’s symptoms.
137
...........
Inferior
peroneal
retinaculum
PB 2
Peroneal
Tubercle 3
PL
A B
Figure 6-12 Excision of the peroneal tubercle and reconstruc-

tion of the inferior peroneal retinaculum. (A) The peroneal
tubercle lies between the peroneus brevis and longus tendons
and can be a source of impingement. (1) The tubercle is
6 approached through the longus sheath, inferior to the coales-
cence of fibers that insert onto the tubercle. (B) (2) The dorsal
portion of the inferior retinaculum is elevated subperiosteally,
exposing the peroneal process. (3) A sharp chisel is used to
excise the process. (C) (4) The bony process is removed flush
with the lateral wall of the calcaneus. (5) The retinaculum is
carefully split with a sharp scalpel to add length, and (6)
138 repaired with suture.
C
...........
Peroneal tendons
The longus and brevis tendons are inspected for intra- to the fibula may be required. An os peroneum that
substance degeneration or gross attritional tears, de- has fractured or avulsed may require excision of the
brided, and repaired side to side as described previously. fragment, and direct repair of the tendon should be
Any anomalous muscles or tendons or hypertrophic accomplished with at least a four-strand repair of 2-O
synovium should be excised. The peroneal sheath then nonabsorbable braided suture. If the fragments are large
is closed, and the surgeon must make certain that there or the tendon has avulsed from the proximal pole, direct
is adequate room for the tendons to glide. If not repair may be accomplished, retaining the os peroneum
enough length has been gained during the approach by freshening the osseous surface, drilling through the
for a loose closure of the retinaculum, a Z-lengthening ossicle with a K-wire, and locking the suture into the adja-
of the inferior retinaculum can be performed. cent tendon.
Zone C involves the peroneus longus tendon where it Zone D injuries involve avulsion of the insertion of
changes course abruptly to enter the osseous groove on the tendon. Peroneus brevis tendon avulsion usually is
the plantar surface of the cuboid. Tendon pathology traumatic and incomplete. Avulsion may accompany
at this level often presents as complete rupture of the a fracture of the metaphyseal area of the fifth metatarsal
peroneus longus tendon. Fracture of the os peroneus and usually carries a small piece of bone. Most avulsions
may be complete with retraction of the proximal fragment heal with a short period of immobilization and limited
or incomplete with some separation of the fragments weight bearing. Chronic avulsions can be painful and
(Fig. 6-13). Complete or partial rupture of the tendon may require surgical repair by fixation and bone grafting
requires repair. An incision is made overlying the pero- of the avulsed fragment or by excision of smaller frag-
neus longus tendon, and dissection is carried distally, ments with direct repair to the metatarsal. Avulsion of
extending from the peroneal tubercle to the osseous the distal insertion of the peroneus longus tendon is rare
groove of the cuboid. If the tendon is ruptured, the because of its multipenate insertion. Clinical diagnosis is
proximal end must be sought, and dissection proximal difficult, and early diagnosis is required if reattachment
Figure 6-13 (A) A fractured os peroneus following inversion injury in a 35-year-old man. This was treated with
casting. (B) Repeat radiographs 2 weeks later revealed proximal migration of the fragment to the peroneal
tubercle. Surgical repair was accomplished with good functional results.
139
...........
is to be successful. Surgical repair may be accomplished inferred to predispose some individuals to dislocation.
using medial and lateral incisions, avoiding incision of Edwards described anatomic variations of the distal fib-
the plantar aspect of the foot. If diagnosis or treatment is ula in relation to the peroneal tendons (Fig. 6-14).87
delayed, transfer of the longus to the brevis at the lateral In an anatomic study of 178 fibulas, 82% of specimens
ankle is preferred over delayed reconstruction because had a definite sulcus posteriorly, whereas 11% were flat
the tendon tract will obliterate with fibrous tissue. and 7% were convex. At the posterolateral edge of the
Laceration of the peroneal tendons may occur in fibula, a bony or cartilaginous flange88 often is present
sport because of sharp penetration by cleats or skates that helps to contain the peroneal tendons. Absence of
or by direct injury from a fixed object, such as the a lateral bony ridge was noted to be 30% in Edwards’
metal supports of gymnastic equipment. Any laceration series. The presence of a distinct sulcus and lateral ridge
directly overlying the course of the tendons must be give bony support to the peroneal tendons and is pro-
treated with a high index of suspicion because substitu- tective for dislocation. Absence of these anatomic fea-
tion by the uninvolved peroneal may mask injury. Surgi- tures may predispose to acute dislocation and often
cal repair usually is successful with limited morbidity. accompanies chronic subluxation, which can lead to
Absence of either of the peroneals is poorly tolerated. tendon degeneration.65,89-91
Surgical repair is always indicated.30 Classification of these injuries was first proposed by
Delayed diagnosis of rupture or laceration of the Eckert and Davis88 and modified by Oden.92 In Type 1,
peroneal tendons presents a challenging problem. The the osseous attachments of the retinaculum to the fibula
resultant muscular imbalance may cause varying degrees are disrupted, whereas the attachment to the periosteal
of midfoot cavus and hindfoot varus deformity. Most sleeve remains intact. The tendons dislocate to a sub-
neglected ruptures still can be repaired if they are treated periosteal location at the lateral fibula, and the periosteal
within 4 to 6 months, although surgical results are sleeve remains intact with the superficial peroneal reti-
not as good as those repaired primarily.57 Typically, naculum. Type 2 represents a rupture of the retinaculum
the entire tendinous portion must be exposed laterally, at the fibular insertion. Type 3 represents an avulsion
and the lateral muscular compartment of the leg also fracture of the posterolateral fibula at the insertion of
must be entered so the muscular unit can be freed up. the retinaculum, and type 4 represents an avulsion of
The proximal portion of the tendon is grasped with the retinaculum from the posterior origin at the Achilles
a running locked suture, and tension is pulled distally fascia (Fig. 6-15).
while a medium-sized Cobb or other blunt elevator is Diagnosis of acute peroneal tendon dislocation often
used to free the muscle belly from any surrounding is delayed because the tendons often spontaneously relo-
adhesions. Approximately 3 to 4 cm of excursion is nec- cate following the injury. Pain and tenderness at the
essary for delayed repair to be successful. If the muscle is insertion of the peroneal retinaculum is the hallmark of
fibrosed and no meaningful excursion can be regained, the injury. Swelling and ecchymosis over the lateral fib-
transfer of the distal stump of the tendon to the un- ula often is present. If the tendons remain dislocated,
involved tendon should be performed. If good excur- more commonly in type 3 and type 4 injuries, they can
sion can be obtained but primary repair of the tendon be palpated along the lateral edge of the fibula. Resisted
ends still cannot be accomplished, a bridging tendon eversion with the ankle in plantarflexion may cause the
graft can be harvested from the Achilles or the plantaris. tendons to redislocate or sublux. Ankle radiographs
Longer standing cases tend to develop inflexible defor- may reveal an avulsion fracture in type 3 injuries but
mity that may require calcaneal and metatarsal oste- usually are not diagnostic.93 If the diagnosis is in ques-
otomies or arthrodesis to achieve a plantigrade foot.64 tion, CT or MRI can be helpful and may demonstrate
dislocated tendons, avulsion of the retinaculum, or
Peroneal tendon dislocation a fluid collection laterally over the fibula.73,94-96
Acute dislocation of the peroneal tendons is an uncom- Treatment is controversial. Some authors recom-
mon injury that results from forceful contraction of the mend treatment for 6 weeks in a short leg cast with
peroneal tendons with the ankle in a position of risk. the ankle in slight plantarflexion if the tendons are
The exact mechanism has not been demonstrated; how- reducible and stable.88,92 Recurrent dislocation can be
ever, it has been our experience that traumatic dislo- problematic with nonoperative treatment even if reduc-
cation can accompany both eversion and inversion tion is accomplished in a timely manner. Recurrent ten-
sprains. Fracture of the calcaneus also is associated with don instability following closed treatment of acute
dislocation of the tendons. Dislocation occurs at the tendon dislocation may be as high as 50%.91,97-99 A
level of the fibula and is accompanied by avulsion of high recurrence rate and the extended cast immobi-
the superficial peroneal retinaculum; this in turn may lization required for nonoperative treatment has led
avulse the distal lateral rim of the peroneal groove in to the recommendation for surgical repair as the pri-
the fibula. The anatomy of the distal fibula has been mary treatment recommendation in active and athletic
140
...........
Peroneal tendons
Figure 6-14 Edward’s anatomic observations of the distal

fibula. (A) In 82% there is a distinct concave groove for
peroneal containment. (B) In 11% the posterior fibula is flat
with no groove. (C) In 11% the posterior fibula is convex,
which predisposes the tendons to subluxation and
dislocation.
individuals.52,97,99-102 Type III dislocations represent a effective in the presence of gross instability, and surgical
disruption of the osseous fibular groove and are inher- reconstruction should be considered in symptomatic
ently unstable. These injuries are best treated surgically. individuals to prevent progressive degeneration of the
In type IV dislocations, the peroneal retinaculum itself tendons.52,89,90,99,102-106
may become entrapped behind the tendons, preventing
reduction and necessitating surgery.92
Chronic subluxation of the peroneal tendons is
a common cause of lateral ankle pain and peroneal ten- 4 PEARL
dinitis. Recurrent sprains and chronic ankle instability Acute Peroneal Tendon Dislocation
are associated with chronic subluxation of the tendons
(1) Tenderness and swelling at the lateral malleolus with
because of progressive incompetence of the peroneal the tendons easily subluxing on flexion of the ankle with
retinaculum.66 As discussed previously, some individuals rotation of the foot internally and/or externally. (2) AP and
without an adequate osseous groove at the posterior fib- oblique x-rays of the ankle may reveal a ‘‘flake’’ fracture at
ula are anatomically predisposed to tendon subluxation the lateral malleolus.
even without trauma. Conservative treatment is rarely
141
...........
Figure 6-15 Classification of peroneal tendon dislocation. I, Superior peroneal retinaculum remains in
continuity with fibular periosteum. II, Avulsion of retinaculum from fibula. III, Avulsion fracture of distal fibula.
IV, Avulsion of the retinaculum from posterior origin. Retinaculum becomes interposed between tendons and
osseous groove in fibula.
4 PEARL
and fracture of the fibula. It also is important to address
any anatomic features that increase the risk of dislocation
or subluxation.
Chronic Peroneal Tendon Dislocation An incision is made posterior to the fibula directly
(1) The tendons are palpable lateral or anterior to the over the peroneal tendon sheath and extends proximal
lateral malleolus at the ankle. (2) Weakness is noted with
to the tip of the fibula 4 or 5 cm. This approach lies dis-
gait and tenderness over the dislocated tendons.
tinctly between the sural nerve and superficial peroneal
nerve. Care must be taken during the dissection to avoid
aberrant branches that may lie in the field of dissection
because injury to a branch may lead to painful neuroma
Surgical management of peroneal tendon formation.
subluxation and dislocation Inspection of the sheath at this point will determine
The surgical approach to acute and chronic dislocation of the deeper approach. Incision of the retinaculum is
the peroneal tendons is similar. The goals of surgery are dependent on the pathology at hand and is extremely
to repair the injured structures, which may include tears important for successful reconstruction. For type 1
of the peroneal tendons, avulsion of the retinaculum, dislocations, in which the retinaculum remains in
142
...........
Peroneal tendons
continuity with the periosteum, it is helpful to incise recovery, particularly if the ankle is immobilized for a
anterior to the fibular border and harvest 3 or 4 mm of significant period of time (>2 weeks). We prefer a mod-
periosteum in continuity with the retinacular sleeve. ification of the method described by Zoellner and
This will ensure that enough tissue is present for ade- Clancy.107 The posterolateral edge of the fibula is
quate repair of the retinaculum during closure. Chronic incised with a sharp chisel or thin oscillating saw from
or congenital subluxation mimics the anatomy of a type the inferior tip of the fibula 3 or 4 cm proximally. The
1 dislocation, in which the retinaculum is in continuity medial cortex is left intact, and the posterior fibular cor-
with avulsed periosteum, and incision of the retinaculum tex, with its cartilaginous lining, is hinged open to
should similarly harvest a slip of contiguous periosteum expose the cancellous bone of the distal fibula. Three
for aid in later repair. In types 2 and 3 dislocations, the or 4 mm of the underlying cancellous bone are removed
retinaculum is avulsed from the fibula, either with or with a curette or burr, and the cortical flap in hinged
without a small piece of bone. The tendons overlie the back into place, then impacted into the defect with a
fibula in the subcutaneous tissue, and the peroneal reti- bone tamp to create an osseous groove. This effectively
naculum must be dissected posteriorly so that it can be deepens the groove and creates a lateral ridge of fibular
repaired later. Large avulsion fractures should be left in cortex, preventing recurrence of the subluxation. The
continuity with the retinaculum and repaired directly tendons are allowed to relocate, and the ankle and sub-
to the fibula, whereas the typical small fleck fracture talar joints are brought through a full ROM. The ten-
should be excised. It is important to recognize type 4 dons should remain reduced in all positions, even
dislocations because the retinaculum should not be without repair of the superior peroneal retinaculum.
incised. The retinaculum is avulsed from the deep poste- The avulsed retinaculum then can be repaired directly
rior tissues, and this torn edge must be identified with to the lateral cortical ridge with nonabsorbable suture
the anterior retinaculum left intact. In the type 4 dis- during closure.
locations, the avulsed retinaculum may lie within the In acute dislocations, direct repair of the retinaculum
peroneal groove posterior to the fibula holding the is accomplished with multiple nonabsorbable sutures
tendons displaced. that are passed and tied directly through drill holes in
Direct inspection of the tendons is performed after the lateral fibula. If a large piece of bone is avulsed, this
adequate exposure has been obtained. Traumatic dislo- may be reduced and sutured into place or fixed with
cations are associated with tendon pathology infre- 3.0-mm compression screws. In type 4 dislocations,
quently, whereas chronic subluxation or acute or the tendons are reduced, and the posterior torn edge
chronic dislocation often are associated with attritional of the peroneal retinaculum must be sutured to its pos-
tears of the peroneus brevis. Redundant synovium terior insertion. Proximally, this is the deep posterior
should be excised. Attritional tears are debrided and compartment fascia overlying the distal aponeurosis of
repaired side to side with 2–0 or 3–0 nonabsorbable the Achilles tendon, and distally the retinaculum is
suture. If the peroneus brevis muscle belly extends distal repaired to the periosteum of the lateral calcaneus.20
to the tip of the fibula, the muscle fibers should be In chronic dislocations, the superficial peroneal reti-
excised to diminish impingement within the fibro- naculum often is attenuated, if not entirely absent. This
osseous tunnel. Similarly, accessory muscles may cause is particularly problematic when the dislocation was
impingement and lend to instability because of mass unrecognized following surgical treatment of severe
effect and should be excised. ankle trauma or following closed or open treatment
It is important to assess the anatomy of the distal fib- of calcaneus fracture. In these instances, secondary
ula because a flat or convex fibula lends to instability reconstruction can be accomplished with a tendon
of the tendons that must be addressed at the time of graft104,108-110 or in conjunction with reconstruction
repair. Multiple procedures have been described to of the calcaneofibular ligament.102,107,111-113 If ankle
assess this problem.98,100 We have found that deepening instability is not an issue, the retinaculum can be recon-
of the fibular groove is highly effective in preventing structed with a split graft from the peroneus brevis or
recurrent subluxation or dislocation.52,89,107 The pero- Achilles tendon, or with an accessory tendon if one is
neal tendons are pulled anteriorly with a tendon hook, present. A 5-cm slip of tendon is harvested as a free graft
and the distal fibula inspected. A shallow or absent sul- and sutured to the deep fascia overlying the Achilles
cus necessitates deepening of the groove. We do not complex. The graft then is attached to the fibula 3 cm
recommend deepening the groove by burring or rasping proximal to the tip of the fibula either by suturing it to
a trough in the posterior aspect of the fibula because the periosteum of the fibula or attaching it directly to
this removes the cortical bone and cartilaginous surface bone. The graft then is attached distally to the tip of
necessary for the smooth tendon glide. If the posterior the fibula in a similar fashion and sutured to the calca-
surface is simply burred or rasped, adhesions between neofibular ligament near its calcaneal insertion or
the tendon and rough cancellous surface may impede attached directly to the calcaneus with a suture anchor.
143
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146
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........................................... C H A P T E R 7
Achilles tendon disorders including

tendinosis and tears
Craig I. Title and Lew C. Schon
......................
CHAPTER CONTENTS
Introduction 147 Acute Achilles tendon rupture 173

Achilles tendinitis 148 Chronic Achilles tendon rupture 178
Treatment of Achilles tendinitis 151 Conclusion 180
Role of ultrasound and shock wave therapy 173 References 180
INTRODUCTION composed of synovium, provide lubrication to assist

with tendon gliding and to minimize tendon irritation.
A large, sometimes abnormal prominence of the poste-
The Achilles tendon is formed by a coalescence of fibers
rior superior calcaneus, Haglund’s deformity,2 may cre-
from the gastrocnemius and soleus muscles. This com-
ate repetitive frictional irritation on the Achilles tendon
plex spans both the knee and ankle joints, making that can lead to tendinitis (Fig. 7-1, A and B).
it more susceptible to injury than muscles that span The Achilles tendon is the strongest and longest
a single joint. The Achilles tendon is notably susceptible tendon in the body, measuring approximately 12 to
to injury with concomitant knee extension and ankle 15 cm in length. Although it is the main plantarflexor
dorsiflexion. The medial and lateral heads of the gastroc- of the ankle, it also functions to invert the heel during
nemius originate from the medial and lateral femoral late stance phase and thereby locks the transverse tarsal
condyles, respectively. The soleus muscle originates from joint for push-off along with the posterior tibial ten-
the posterior proximal tibia and fibula. More distally, the don. It is subject to forces up to 10 times body weight
medial and lateral gastrocnemius and soleus tendons during running, experiencing up to 7000 N of
coalesce to form the triceps surae complex. The Achilles force.1,3,4
tendon then rotates 90 degrees such that the medial The blood supply to the Achilles tendon is segmen-
gastrocnemius position is more posterior and superficial. tal and is predominantly derived from anterior
This rotation may result in torque stresses that can in- branches of the paratenon. Additional sources include
crease the risk of tendinitis.1After passing distal to the intratendinous vessels, the posterior tibial artery, and dis-
posterior superior calcaneal tuberosity, the Achilles ten- tal osseous and periosteal branches. A relative zone of
don inserts into the posterior and plantar calcaneal tuber- hypovascularity exists within 2 to 6 cm proximal to the
osity about halfway between the dorsal and plantar aspects calcaneal insertion, corresponding to the site of
of the calcaneus. most Achilles tendon ruptures and noninsertional
The retrocalcaneal bursa lies between the distal Achil- tendinitis.5,6
les tendon and the posterior superior calcaneal tuberos- Similar to other tendons, the Achilles is composed
ity. It is horseshoe shaped and sits around the insertion of predominantly type I collagen. Collagen fibrils are
of the Achilles, which has more fibers centrally and prox- bundled into fascicles, held together by the endotenon,
imally. Anteriorly it is composed of fibrocartilage, which contain elastin, lymphatics, and neurovascular
whereas posteriorly it blends with the paratenon and structures. The epitenon surrounds the group of fasci-
commonly connects to the posterior Achilles tendon. cles, forming the structural unit of the tendon. The
The pre-Achilles bursa lies superficial to the Achilles paratenon further surrounds the epitenon and consists
between the Achilles and the skin. These bursae, of an inner parietal layer, lying directly on the epitenon,
CHAPTER 7 Achilles tendon disorders including tendinosis and tears
Figure 7-1 (A) Lateral radiograph of calcaneus demonstrating Haglund’s deformity. (B) Sagittal magnetic
resonance imaging of the same patient showing changes at Achilles tendon from bony prominence and its effect
on Achilles tendon, with thickening and fibrosis as it passes by the bone and more proximally.
and an outer, visceral layer. The paratenon, containing a paratenon and Achilles tendon. Tendinosis reflects isolated
small amount of fluid between its layers, facilitates glide Achilles degeneration. Clain and Baxter1 later created an
and minimizes posterior adhesion formation. anatomic classification, separating tendinitis into inser-
tional disorders, affecting the area of the enthesis, and
noninsertional disorders, commonly affecting the tendon
2 to 6 cm proximal to the calcaneus.
ACHILLES TENDINITIS Whereas noninsertional tendinitis occurs more often
in younger, more active athletes, insertional Achilles ten-
Achilles tendinitis is common among athletes, affecting dinitis develops more often in those athletes who are
nearly 18% of runners.7-9 Repetitive impact-loading older, less active, and sometimes overweight. Addition-
activities (overuse) such as jumping are responsible for ally, the presentation of bilateral insertional tendinitis
the majority of cases.1 Other predisposing factors typically occurs in young athletic men and is commonly
include poor extremity biomechanics (foot pronation, associated with inflammatory disorders, including sero-
cavus foot, genu varum), improper training techniques negative spondyloarthopathies.11,12
(excessive running, sudden increase in intensity, uphill
running), and poor shoewear.8 Another potential risk Noninsertional tendinitis
factor includes the previous use of fluoroquinolone Peritendinitis is inflammation affecting only the parate-
antibiotics. Athletes commonly affected by tendinitis non. The Achilles tendon itself is uninvolved. In chronic
are involved in running, dancing, tennis, racquetball, cases, adhesions may form between the paratenon and
basketball, and soccer (unnumbered box 7-1). tendon, leading to more profound pain and tenderness.
Puddu et al.10 classified Achilles tendinitis into three Pain is noted most often at the initiation of activity
categories. Peritendinitis is characterized by inflamma- (start-up pain) and improves with continued exercise.
tion affecting only the paratenon. Peritendinitis with Acute pain typically resolves with rest. In chronic cases,
tendinosis refers to inflammation involving both the however, the pain may persist and significantly impair
further athletic participation. On examination, a loca-
lized, increased diameter that more commonly affects
Achilles tendinitis risk factors
the medial side is appreciated with palpation of the ten-
don. Tenderness, and at times crepitus, is noted through-
Repetitive impact-loading activities
out all ankle range of motion (Fig. 7-2). Radiographs
Abnormal lower-extremity biomechanics (foot prona-
generally are unremarkable.
tion/supination, stiff joints, genu varum)
Improper training techniques (intensity, frequency, Peritendinitis with tendinosis represents further
duration, speed, terrain) inflammation with associated intratendinous degenera-
Poor shoewear selection tion. Pain is more marked and constant. The tendon
Fluoroquinolone antibiotics is thickened and infrequently has palpable intrasubstance
calcifications (Fig. 7-3). The painful arc sign may help
148
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Achilles tendinitis
Figure 7-2 Tenderness with squeezing the Achilles and crepitance with range of motion are hallmarks of
peritendinitis. The discomfort related to peritendinitis will be constant in location as the ankle is brought through
a range of motion. With Achilles tendinosis the tenderness moves with the thickened tendon during range of
motion.
Figure 7-3 (A) Noninsertional Achilles tendinitis with characteristic swelling 2 to 5 cm above dorsal aspect
of calcaneus. (B) Magnetic resonance imaging shows thickened Achilles tendon. A Haglund’s deformity also is
noted.
(continued)
149
...........
Peritendinitis affects the paratenon; the Achilles

tendon is not involved:
Overuse etiology
Tends to be in younger athletes
Pain at the initiation of activity (start-up pain)
Improves with continued exercise
A localized increased diameter
Tenderness, and sometimes crepitus, throughout all
ankle range of motion
Tendinosis, noninflammatory, atrophic degeneration of
the Achilles:
Associated with normal aging
Accelerated by overuse
Pain and weakness in push-off
Tender thickening 2 to 5 cm proximal to calcaneus
Ankle dorsiflexion commonly is limited
Less typically, tendon elongation may develop
Palpation during range of motion reveals tenderness
that moves with movement of the tendon
Calcific deposits may be present
Insertional achilles tendinitis

Insertional tendinitis is an inflammatory reaction within
the Achilles tendon affecting the enthesis, or tendon
insertion onto the calcaneus. This disorder more com-
monly affects older, heavier, and less active athletes but
can be seen in competitive athletes as well.12 An abnor-
mally enlarged, bony prominence may aggravate this
Figure 7-3 cont’d. (C) Technetium bone scan demonstrating condition. There is a high association with Haglund’s
increased uptake in the Achilles tendon; the third phase deformity and retrocalcaneal bursitis, but unlike these
of the scan, indicative of advanced intrasubstance disorders, insertional tendinitis involves the tendon
degeneration. itself. This most often results from chronic overuse and
poor training habits. Improper techniques include inad-
equate stretching, rapid increase in training, running
to distinguish between tenderness associated with peri- on harder surfaces, and heel running. Although pain
tendinitis and that associated with tendinosis. Tenderness initially follows exercise, particularly uphill running,
related to peritendinitis will be constant in location as symptoms may become continuous over time.
the ankle is brought through a range of motion, whereas Pain, swelling, and warmth are noted specifically at
tenderness associated with tendinosis will change position the tendon-bone junction, the enthesis. In athletes, there
with ankle motion.13 often is a localized area of pain with a small spur. Ankle
Isolated tendinosis, or noninflammatory atrophic range of motion is painful, with dorsiflexion typically
degeneration, is associated with normal aging and limited because of a tight Achilles tendon. External irri-
typically is accelerated by overuse. Most affected are tation from a shoe’s heel counter plays less of a role in
middle-aged, recreational athletes. With repetitive trauma, provoking symptoms in athletes with Achilles tendinitis
microtears develop within the tendon, mostly in the than in retrocalcaneal bursitis and Haglund’s deformity.
hypovascular zone, leading to further fibrosis and Radiographs generally reveal calcifications or a bony
degeneration.14 These athletes complain of weakness in spur at the most distal aspect of the Achilles insertion
push-off, with pain localized to the area approximately (Fig. 7-4, A). Magnetic resonance imaging (MRI) will
2 to 5 cm proximal to calcaneus. Whereas ankle dorsi- show degeneration where the tendon attaches to the
flexion commonly is limited, tendon elongation may calcaneus (Fig. 7-4, B).
develop with an associated increase in passive ankle
dorsiflexion. Pathologic examination reveals fatty degen- Haglund’s deformity
eration with disorganized collagen. Calcific deposits may Haglund is credited with first describing the presence of
be present (unnumbered box 7-2). a prominent posterolateral superior calcaneal tuberosity
150
...........
Treatment of Achilles tendinitis
in 1927.2 This enlarged superolateral tuberosity predis- to the Achilles tendon above its insertion in the retrocal-
poses the precalcaneal bursa to be compressed between caneal region (Fig. 7-6).
it and any tightly fitting shoe heel counter, possibly
leading to skin irritation and inflammation. Because of
the association of shoewear, this disorder also has TREATMENT OF ACHILLES TENDINITIS
been referred to as a ‘‘pump bump’’ and ‘‘winter heel.’’
Although there is a frequent association with retrocalca-
neal bursitis and insertional Achilles tendinitis, Haglund’s Nonsurgical treatment
deformity generally does not involve the Achilles tendon. The initial treatment for Achilles tendinitis is nonoperative.
Poorly fitting shoes generally are responsible for the The majority of symptoms respond to rest; activity modi-
development of symptoms of Haglund’s disorder. Other fication; improved training techniques; stretching; and,
predisposing risk factors include the presence of at times, shoe modifications and heel lifts. Surgical inter-
a cavus foot and hindfoot varus. In rare cases, childhood vention should be considered only for recalcitrant cases.
apophyseal trauma may be a cause. In the nonathletic Initial treatment should include anti-inflammatory
population, repetitive injury or trauma may result in medications and a supervised program of Achilles stret-
bone overgrowth. Most affected are young women ching. At times, a heel lift (one-fourth to three-eighths
who wear fashionable high-heeled shoes. In the athletic inch), night splint, or temporary immobilization in
population, we have observed this condition more com- slight plantarflexion with a removable walking boot
monly in males who participate in running sports. Long- or cast may be required. Relative rest with limitations
distance runners are susceptible to this condition, as well on intensity, duration, or frequency of training and
as to the other Achilles tendon disorders (see Figs. 7-1 concomitant institution of nonstressful cross training
and 7-5).
On examination, the affected heel has a swollen, red,
and tender posterior prominence, predominantly on the
lateral side of the calcaneus. The Achilles tendon itself is
not tender. Numerous radiographic measurements have
been used to quantify the size of the posterosuperior
prominence. These techniques generally are not used
by orthopaedists because they do not always correlate
with the clinical findings.
Retrocalcaneal bursitis
Retrocalcaneal bursitis refers to inflammation affecting
the bursa immediately anterior to the Achilles tendon.
As with Haglund’s deformity and Achilles tendinitis, this
condition is common in running athletes, including
long-distance runners. In the general population, as with
insertional tendinitis, those most commonly affected are
older, less active recreational athletes. As the disorder
becomes chronic, the bursa enlarges and may become
adherent to the Achilles tendon. A prominent postero-
superior bony projection may be present.
Athletes typically complain of pain with activities that
force the ankle into dorsiflexion, particularly uphill run-
ning, and thereby compress the inflamed bursa between
the posterosuperior calcaneus and the Achilles tendon.
Schepsis et al.14 described the two-finger squeeze test,
in which pain is noted when two fingers compress medi-
ally and laterally immediately superior and anterior to
Achilles insertion. This area will be warm with a notable Figure 7-4 A lateral x-ray (A) and a series of sagittal magnetic
soft-tissue bulge. Pain is elicited with passive dorsiflex- resonance imagings (B, p. 152) of the same patient with
ion. Radiographs often are not useful but may demon- insertional degeneration of the Achilles tendon with tendon
strate loss of the retrocalcaneal soft-tissue shadow, thickening and fibrosis from about 2 cm proximal to its
as well as the presence of a posterosuperior bony promi- insertion on the calcaneus.
nence. MRI demonstrates soft-tissue changes anterior (continued)
151
...........
(exercise bike, pool running, elliptical trainer) also open-back shoe may benefit those with Haglund’s or
should be helpful. If the athlete has notable foot pro- retrocalcaneal bursitis (Fig. 7-7). Additionally, deepen-
nation, a semirigid orthotic may improve overall foot ing the heel counter or use of a heel pad or sleeve may
biomechanics by supporting the medial arch. An be considered.
152
...........
we advise against corticosteroid injections and use them

only in very limited and specific circumstances.
For refractory peritendinitis, we have found that
brisement may provide symptomatic relief in a third to
half of total cases.18 Brisement consists of injecting
5 to 10 ml of sterile saline or local anesthetic agents into
the Achilles tendon sheath; this may forcibly disrupt any
adhesions between the paratenon and Achilles tendon.
Repeating the injections two to three times over several
weeks may be necessary to achieve success.14,18
After initial symptoms resolve, it is imperative to cor-
rect predisposing factors, including improper technique,
excessive training, inappropriate shoewear, and poor
flexibility. In addition, it may be critical to temporarily
or permanently eliminate provocative, more rigid, and
less compliant surfaces and terrain.
Reported results of nonoperative treatment of inser-
tional and noninsertional Achilles tendinitis have been
generally successful. Studies have found that 70% to
90% of patients have found symptomatic improvement
after corrections in their shoewear, training habits, and
Figure 7-5 Clinical photograph of Haglund’s deformity. mechanics.8,18-22 There are, however, fewer predictable
results with nonsurgical management in those with
chronic tendinopathy and in the older athlete, as a result
of greater degenerative tendon involvement.21
In our experience, athletes with isolated Haglund’s
deformity can be managed with shoewear modification
about 50% of the time. We have seen improvement
in about 30% of patients with retrocalcaneal bursitis
and in about 25% of those with insertional tendinitis.
The presence of a prominence does not mandate sur-
gery. One should not perform prophylactic resection
because the degenerative process may be improved
with mechanical means, rest, and other modalities, as
described above.
.............................................................
Surgical treatment
Surgical intervention is considered only after approxi-

mately 3 months of good, nonoperative treatment mea-
sures. The surgical technique is chosen on the basis of
Figure 7-6 Magnetic resonance imaging demonstrates location of pathology. For a symptomatic athlete with
Haglund’s deformity with enlarged posterior superior aspect of a normal tendon, determined by physical examination
the calcaneus. and possibly by MRI, we generally try to avoid a pro-
cedure that may irritate or traumatize the tendon.
Intratendinous corticosteroid injections should be A medial or lateral approach 5 to 10 mm anterior to
avoided because local use of these injections has been the Achilles tendon and paralleling its course is best in
associated with tendon attrition and potential rupture. these cases because it runs through thicker skin with
Although there is no strong evidence of similar deleteri- more substantial subcutaneous tissues. If the tendon is
ous effects after peritendinous corticosteroid injections, involved, an approach directly through the posterior
there are similar worries with an injection in the bursa. aspect of the tendon is possible. This approach has the
It would be advisable to immobilize the ankle temporar- additional benefit of obtaining even greater exposure
ily after a retrocalcaneal injection because the retrocalca- and improved debridement of bone and tendon.
neal bursa has a direct communication to the Achilles Other issues must be taken into consideration to help
and may injure the Achilles tendon.12,15-17 In general, guide the surgical approach and choice of technique,
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Figure 7-7 Shoe alternatives and modifications for patients with Achilles tendinitis. Clockwise from the top left:
(A) A higher-heeled, backless shoe, ‘‘a mule.’’ (B) A completely removed heel counter. (C) A partial heel counter
cut to relieve external pressure. (D) A backless sneaker.
such as identifying whether Haglund’s deformity, retro-

calcaneal bursitis, or insertional tendinitis is involved
and determining the extent of tendon involvement
(length, width, and depth of pathology). Any promi-
nence of the bone, as well as the location of the promi-
nence relative to the insertion of the tendon (above, at,
or below the insertion of the tendon), should be noted,
and the surgeon should determine whether the bursa
is inflamed and how much additional debridement is
necessary. In general, the points of tenderness dictate
where the exposure must occur. Thus if there is more
medial and central Achilles tendinitis versus lateral,
the tendon in the medial and central aspect has to be
elevated off the calcaneus, the tendon must be debrided
there, and the underlying bone must be resected and
recontoured.
Figure 7-8 Release of the paratenon. Note that the incision
Noninsertional tendinitis is made 1 cm anterior to the margin of the Achilles tendon.
For noninsertional tendinitis, the choice of procedure is The incision can be made much smaller than shown in this
case.
based on whether the disease involves the paratenon,
tendon, or both. In peritendinitis, all adhesions are
excised, and the surgeon also performs a limited resection
of any thickened paratenon. The extremity is immobi-
lized for 3 to 5 days, followed by a range of motion pro- In this technique a no. 11 or no. 15 blade is introduced
gram to limit the recurrence of scar formation (Fig. 7-8). posteriorly through the skin and tendon. With the blade
When there is tendinitis and peritendinitis, elliptical held stationary, the ankle is dorsiflexed and the tendon is
excision of the tendon and longitudinal paratenon release cut longitudinally. Next the blade direction is reversed
is performed. Maffulli et al.23 have reported a success rate 180 degrees and the ankle is plantarflexed. The process
of approximately 70% after percutaneous longitudinal is repeated through four additional incisions in the zone
tenotomy of the middle third of the Achilles tendon. of the degenerative tendon (Fig. 7-9).
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Tendinosis
The type of procedure chosen for treatment of ten-
dinosis depends on many factors, the largest, in our
experience, being the extent of tendon involvement,
determined by clinical findings, ultrasound, or MRI.
When less than 50% of the tendon is involved, we longi-
tudinally ellipse the diseased tendon; and when more
than 80% of the tendon is involved, a debridement
and tendon augmentation (e.g., turndown) or transfer
is recommended (Fig. 7-10). When there is between
50% and 80% involvement, the decision is determined
by the patient, the sport, and the surgeon’s preference.
Debridement of tendon. For tendinosis, typically the
degenerative portion of the Achilles tendon is debrided
Figure 7-9 The Maffulli technique: an incision is made with and the paratenon is released. If less than 50% of the
a no. 11 or no. 15 blade. The blade is held stationary and the tendon width is debrided, then the remaining section
ankle is dorsiflexed creating a longitudinal cut in the tendon. of intact longitudinal tendon should be strong enough
The blade then is turned 180 degrees, and the ankle is
to withstand stresses.
plantarflexed. The process is repeated until there are five
longitudinal cuts.
Figure 7-10 Magnetic resonance imaging cross section of the Achilles tendon demonstrating more than 80%
tendon involvement. This would indicate the need for tendon augmentation or transfer following debridement.
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been that the transfer becomes more critical to restore

function. Alternative procedures in this latter scenario
include a turndown procedure, tendon allograft, and
V-Y advancement.
The flexor hallucis longus (FHL), flexor digitorum
longus (FDL), or, less commonly, the peroneal tendons
can be transferred. We prefer to use the FHL tendon in
a nonsprinting athlete, nondancer, or rock climber.
Transferring the FHL or any other tendon in a sprinting
athlete or ballet dancer could lead to loss of agility,
power, or balance. In these athletes, it is better to con-
sider performing a turndown procedure, a V-Y advance-
ment, or an allograft if a wide area of tendon is involved.
The patient is positioned prone and both legs are
prepped for any tendon transfer, turndown procedure,
or V-Y advancement because it usually is necessary to
Figure 7-11 Intraoperative photo of debridement of the compare resting tensions with those of the contralateral
Achilles tendon. Once the degenerative tissue is ellipsed side. In a tendon transfer, our preferred technique is to
from within the substance of the tendon, buried sutures are use a medial approach to the Achilles tendon, typically
used to close the defect. staying 1 cm anterior to the medial edge of the tendon.
The incision is extended more inferiorly. The paratenon
Typically a medial incision is made just anterior and is opened, the degenerative tendon is excised, and the
parallel to the border of the tendon that is thickened, deep fascia between the superficial and deep compart-
and the paratenon is entered. On the basis of maximal ment is released. It is felt that, by opening the fascia
tenderness, MRI, or ultrasound localization of the and exposing the deeper FHL muscle belly, there is an
degenerative zone of the tendon, an elliptical longi- improved vascular bed for the Achilles. Ranging the
tudinal excision of the diseased tendon is performed, big toe should facilitate identification of the moving
leaving intact the anterior and posterior surfaces of the FHL muscle belly and tendon. The FHL tendon may
tendon. Essentially the zone of ellipsed tissue should have a more distal origin and may not be viewed readily
include the degenerative fibers and the thickened ten- in the wound. Care should be taken while dissecting
don (Fig. 7-11). The tendon then is repaired with inter- along the course of the muscle because the tibial nerve
nally placed, nonabsorbable sutures with buried knots. runs immediately medial to the tendon (Fig. 7-12, A
The subcutaneous tissues are apposed, followed by clo- through E).
sure of the skin. The leg is immobilized for 3 to 5 days Follow and release the FHL tendon from the sheath
in a splint, followed by range of motion exercise, (fibroosseous tunnel) as it travels between the medial
strengthening, and nonimpact activities. A boot brace and lateral tubercles of the posterior talus. Continue to
is worn for 6 to 12 weeks during ambulation to unload release the tendon for as much length as possible from
the healing tendon. Jogging and running may be intro- the posterior approach, dissecting toward the underside
duced at 3 months, depending on the extent of involve- of the sustentaculum tali. Cut the tendon as distally
ment and the nature of the patient’s athletics. as possible, again avoiding the tibial nerve. The FHL
Tendon transfer. If more than 50% of the tendon tendon then is either sewn to the Achilles repair or
width is involved, then one must consider the risks and inserted into the calcaneus or its periosteum, depending
benefits of either longitudinal tenotomy, debridement, on tendon length. A useful technique involves drilling a
or tendon transfer. The decision to consider tendon hole the width of the tendon (typically 5 mm) through
transfer is determined by the structural weakening of the calcaneus from dorsal to plantar (Fig. 7-13). A small
the tendon that may result from a large debridement. incision made over a K-wire passed through this tunnel
Because most athletes use all their tendons for ulti- can facilitate placement of a small-bore suction tip over
mate, lower-extremity performance, it is difficult to the wire from plantar to dorsal and out the planned
justify harvesting a working structure to improve the entry point for the tendon. The whip suture in the
function of the Achilles. Thus depending on the FHL tendon then can be passed through the suction
demands of the athlete and nature of his or her skills, tip and pulled plantarly to permit tensioning. An inter-
we have to balance the pros and cons of using the ten- ference screw can be inserted through the tunnel. Alter-
don transfer. If 50% to 80% of the width of the tendon natively, an anchor can be placed obliquely in the tunnel
is resected, we consider these factors. However, if 80% wall just distal to the opening but not obscuring the pas-
or more of the tendon is involved, our experience has sageway. After the proper tension has been determined,
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Figure 7-12 (A) A medial approach 1 cm anterior to the

medial edge of the Achilles tendon. (B) The deep fascia
between the superficial and deep compartment is released.
Ranging the big toe should allow palpation and identification
of the moving flexor hallucis longus (FHL) (marked with two
arrows). The tibial nerve runs immediately medial to the
tendon, therefore dissection of the tendon must be carefully
performed. (C) The tendon is released distally and secured
with a whipstitch. The degenerative Achilles tendon is excised.
(D) 4-0 or 2-0, nonabsorbable suture is buried within the
tendon. (E) The defect is closed and the FHL tendon is sewn to
an anchor into the calcaneus. This area of the calcaneus is
prepared by locally elevating the periosteum. In this case the
Achilles tendon length was normal, so the FHL was tensioned
to permit full dorsiflexion.
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t
Figure 7-13 (A) Following debridement of the Achilles and harvest of the flexor hallucis longus (FHL),
the thickness of the FHL is determined to properly select the drill size. (B) A guidewire is passed through the
calcaneus and then is advanced to pierce the plantar soft tissues. The exit point plantarly is just anterior to the fat
pad of the heel. (C) A drill matching the width of the FHL is used to create a channel in the calcaneus but should
not penetrate the soft tissues. (D) A small incision is made and a small-bore suction tip is placed over the wire
from plantar to dorsal and out the planned entry point for the tendon. (E) The whip suture in the FHL tendon then
can be passed through the suction tip and pulled plantarly to permit tensioning. (F) An interference screw
is inserted through the tunnel. As an alternative, an anchor can be placed obliquely in the tunnel wall just distal
158 to the opening but not obscuring the passageway.
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the tendon is secured. Occasionally there is a need to

resect the posterior superior calcaneus; this procedure
is determined by the presence of Haglund’s deformity
and bursitis. We do not close the deep fascia between
the compartments because the FHL muscle belly may
provide for improved healing following the Achilles
repair.
V-Y advancement. A V-Y advancement may be
required if more than 80% of the tendon width and
2 to 3 cm in length is involved. With this large amount
of tendon involvement, the remaining normal tendon
may not be thick or wide enough to safely flap. The
V-Y advancement is accomplished by extending the
initial posterior incision more proximally toward the
musculotendinous junction (Fig. 7-14, A through
C). A V-shaped fascial incision is made with the apex
proximal. With traction on the tendon distally, an
Figure 7-13 cont’d. (G) A corkscrew anchor is inserted to advancement of 2 to 3 cm then can be achieved; this
repair the Achilles tendon onto bone. should close the distal gap sufficiently. The distal repair
Figure 7-14 The V-Y advancement. (A) The section of

the diseased Achilles is debrided, and the new edges are
sutured with a whipstitch for anastomosis. (B) A V-shaped
fascial incision is made with the apex proximal. With traction
on the tendon distally, an advancement of 2 to 3 cm can then
be achieved. (C) The final tendon tensioning is performed by
checking the resting posture of the ankle and testing the
‘‘springiness’’ of the foot as it sits in the normal slightly
plantarflexed position. A comparison with the other side is
helpful. The V-Y is then sutured. If it appears that there is
too large a gap to close, a turndown or a tendon transfer
may span the defect.
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can be performed with a modified Krackow or whip- such as with a semitendinosus tendon may be used as
stitch, and then balancing of the tendon tension is per- a connecting bridge.
formed by checking for the resting posture of the foot Turndown procedure. A turndown procedure provides
and testing the ‘‘springiness’’ of the foot as it sits in substrate for healing and may limit the possibility of
the normal, slightly plantarflexed position. rerupture when there is between 50% and 80% of
The V-Y advancement is performed with the patient tendon width involvement. The patient is positioned
prone. Because it usually is necessary to compare resting prone with both legs prepped to compare the two and
tensions with those of the contralateral side, both legs re-create normal resting tension. A medial incision is
are prepped as for any tendon transfer or turndown pro- used, with care taken on deeper exposure to avoid
cedure. However, the tendon may begin to tear and pull branches of the sural nerve. After the rupture or degen-
off the muscle base beyond an advancement of 3 to eration site is exposed, the end of the proximal tendon is
5 cm. If it appears that there is not enough fascia/ten- mobilized, then grasped with Alice clamps and gently
don substrate or if too large a defect exists for advance- distracted by pulling distally on the Alice clamps for 5
ment, then a turndown or an allograft tendon transfer to 10 minutes (Fig. 7-15, A).
Figure 7-15 The turndown procedure. (A) After the rupture or degeneration site is exposed, the end of the
proximal tendon is mobilized and then grasped with Alice clamps, and tension is pulled. (B) The size of the
gap is measured while the foot is maintained in a neutral position. (C) An additional 4 cm then are added to the
tendon defect (a 2-cm distal hinge that is overlapped by the turned-down flap, or 2 cm plus 2 cm). Another 1 cm
is added to account for the intended 1-cm overlap of the tendon ends distally. Thus the flap begins proximally
at a point 5 cm more than the size of the gap. (D) A strip of tendon 1 cm wide is harvested centrally.
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Figure 7-15 cont’d. (E and F) The tendon graft now can be turned distally to span the void. (G) Two no. 1
Ethibond sutures are used to anchor the corner of the turned-down graft (arrows) reinforcing the high stress
junction. The central slip typically is passed anteriorly deep to the tendon to decrease the bulk. The distal tendon
end then is secured to the remaining viable Achilles or to the bone. Comparison with the nonoperative side
facilitates tensioning of the graft.
The size of the gap is measured while the foot is used to anchor the corner of the turned-down graft,
maintained in a neutral position (Fig. 7-15, B). An addi- reinforcing the high stress junction so there is no prop-
tional 4 cm then is added to the tendon defect (a 2-cm agation of the split between the strip and the main body
distal hinge that is overlapped by the turned-down flap, of the tendon (Fig. 7-15, G). To decrease the bulk
or 2 cm plus 2 cm). Another 1 cm is added to account created by this method, the tendon then is passed
for the intended 1-cm overlap of the tendon ends dis- anteriorly deep to the tendon instead of posteriorly.
tally (Fig. 7-15, C). Thus the flap begins proximally at The distal tendon end then is secured to the remain-
a point 5 cm more than the size of the gap. For example, ing viable Achilles or to the bone. Tensioning of the
if the gap is 6 cm, then a flap is initiated 11 cm proximal graft requires checking the range of motion and the
to the gap (Fig. 7-15, D). A strip of tendon approxi- springiness of the operative side versus the normal side.
mately 1 cm wide and 1 cm thick is harvested centrally. Usually, the foot should have a resting position of
The tendon graft now can be turned distally to span 15 degrees of plantarflexion. The graft and the turned-
the void (Fig. 7-15, E and F). At approximately 2 cm down flap are held in place by hand or by suture. Once
proximal to the defect, two no. 1 Ethibond sutures are the appropriate tension and position are established,
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whipstitches are used for final anastomosis. The resting Insertional tendinitis
tension and springiness are checked once again at the Insertional tendinitis is surgically treated by excising
end of the procedure (unnumbered box 7-3). the retrocalcaneal bursa and any prominent postero-
superior bone. Additionally, the Achilles tendon is
Noninsertional tendinitis surgical alternatives debrided of any intratendinous calcifications and degen-
erated tissue, including detachment of part of the ten-
Paratendinitis: release paratenon don’s insertion. Achilles tendon reattachment through
Tendinosis: degree of width involved calcaneal bone tunnels or with suture anchor is advised.
<50% ellipse and repair A central splitting or paralateral Achilles approach both
>80% ellipse and augment have been advocated.12 Our preference is a central
Tendinosis: degree of length involved approach for optimal visualization (Fig. 7-16, A through
1-3 cm V-Y
H). The direct posterior central approach for the distal
3-5 cm turndown
Achilles tendonopathies requires an incision through
>5 cm turndown with consideration for FHL
thick, well-vascularized skin. This is distinct from the
or FDL tendon transfer
thinner skin found proximal to the calcaneus that is
Figure 7-16 Insertional Achilles tendinitis. (A) Sagittal magnetic resonance imaging of a patient with insertional
Achilles tendinitis and retrocalcaneal bursitis. Note the bony prominence, the fluid in the bursa anterior to the
tendon, and the abnormal signal at the insertion consistent with degeneration at the interface.
(continued)
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Figure 7-16 cont’d. (B) A central incision is made through the

site of maximal tenderness through the tendon down to the
bone. (C) The tendon is released from its insertion posteriorly
and the posterior superior calcaneus is exposed. (D) Two
human retractors are placed, and the chisel is used to resect
the insertion site and the posterior superior bony prominence.
(E) A side view of the chisel angle to resect the bony
prominence. Care is taken not to inadvertently penetrate too
anteriorly and end up in the subtalar joint. The medial lateral
and dorsal edges are checked for remaining bone. (F) The
bone has been resected and the suture anchor is placed
centrally into the calcaneus about 5 to 8 mm proximal to the
previous insertion site.
(continued)
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Figure 7-16 cont’d. (G) An intraoperative image demonstrating the anchor placement. (H) The sutures are
placed close to the midline, penetrating the tendon directly over the anchor with very minimal divergence to
maximize tendon apposition to the bone. The knots should be buried so that postoperative irritation is avoided.
potentially more problematic with delayed healing of a precalcaneal bursal projection. Any inflamed retrocalca-
wound. neal bursa also is excised. Because the lateral side is more
Through the central incision, we debride both the commonly affected, it is easier to approach through
bone and the tendon at the junction and resect the a lateral incision (Fig. 7-18, A). A medial approach is
posterior superior process. Tendon augmentation may warranted when the bony prominence is found medially
be required, depending on the extent of debridement. (Fig. 7-18, B). When the tendon is not involved, the
When more than 80% of the tendon is involved or when insertion can be avoided through the lateral or medial
the Achilles is degenerative at the insertion and pro- approaches. Either way, it is critical to resect a sufficient
ximally, an FHL graft should be considered (Fig. 7-17, amount of bone to prevent impingement on the tendon
A through C). The FHL can be harvested in the arch and avoid creating a sharp edge after resection that
of the foot or, as we prefer, behind the ankle. After the may irritate the tendon (Fig. 7-18, C and D). Too much
FHL is attached to the bone through a tunnel or into resection can weaken the tendon insertion, and the
a trough, the Achilles tendon is reattached with one or subtalar joint may be penetrated if the surgeon is not
two suture anchors. careful. Jones and James25 advocated a combined medial
A biomechanical study by Kolodziej et al.24 demon- and lateral approach to ensure a thorough bony resec-
strated that as much as 50% of the Achilles tendon may tion (Fig. 7-18, E). This exposure helps to avoid inad-
be safely resected through this approach. Despite this vertent creation of a sharp, bony edge.
study, we still recommend placing suture anchors to opti- We recommend a lateral approach or the combined
mize tendon bone contact and healing. When reattach- medial and lateral exposure. The central posterior
ing the tendon, it is important to restore normal resting approach for Haglund’s deformity should not be used
tension, using the remaining intact portions of medial because it is better to avoid disrupting the insertion of
and lateral slips of tendon as a guide. Inadvertent over- the tendon unless there is a clinically relevant compo-
tensioning of the repair when using anchors could cause nent of insertional tendinitis (Fig. 7-19, A through D).
an equinus contracture or difficulty squatting or lunging. Bone resection should be performed just proximal
to the insertion of the tendon (Fig. 7-19, E). A power
Haglund’s deformity reciprocating rasp should be used to help contour
Surgical treatment for Haglund’s deformity and re- the cut edges by the tendon (Fig. 7-19, F). A mini-C
trocalcaneal bursitis focuses on resecting the enlarged arm should be used to help identify any remaining
posterior bony prominence, including the attached prominences (Fig. 7-19, G).
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Figure 7-17 When the Achilles is degenerative at the

insertion and proximally or when more than 80% of the tendon
is involved a flexor hallucis longus (FHL) graft should be
considered. (A) The central approach is used to detach the
Achilles posteriorly, and the prominent bone is resected.
(B) The degenerative tendon is debrided. (C) The FHL tendon
is harvested from behind the ankle and will be reattached
through a tunnel or into a trough before repairing the Achilles
tendon.
Figure 7-18 The incisions for treatment of the Haglund’s deformity. (A) A lateral incision is more common because
the prominence is usually more pronounced on this side. (B) A medial approach is warranted for a medial bony
prominence.
(continued)
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Figure 7-18 cont’d. (C and D) Radiographs preoperatively and

postoperatively show sufficient bone resection without
impingement at the tendon insertion. (E) A combined medial
and lateral approach ensures a thorough bony resection and
edge contouring.
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Figure 7-19 (A) through (C) This athlete’s x-rays and sagittal magnetic resonance imagings demonstrate a
Haglund’s deformity, retrocalcaneal bursitis, posterior calcaneal bony edema, and some insertional Achilles
tendon changes.
167
(continued)
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Figure 7-19 cont’d. (D and E) Because all the tenderness and prominence were lateral and there was no
tenderness at the Achilles insertion, a lateral approach was chosen, with the intraoperative option of an
additional medial incision to contour the sides.
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Figure 7-19 cont’d. (F) Bone resection should be performed just proximal to the insertion of the tendon.
A power reciprocating rasp should be used to help contour all edges by the tendon. (G) A mini-C arm should
be used to help identify any remaining prominences.
Endoscopic Haglund’s resection as presented by Niek (Fig. 7-21). It should be reserved for atypical cases
van Dijk (see Chapter 16) recently has gained popular- (unnumbered box 7-4).
ity. In this technique, the patient is placed in a prone
position, and a lateral incision is made just dorsal to Postoperative management
the calcaneus and anterior to the tendon (Fig. 7-20). Our postoperative management for the athlete is deter-
A 4.5-mm, 30-degree arthroscope is introduced. A spi- mined on the basis of the extent of tendon involvement.
nal needle then is introduced medially just dorsal to If there is no tendon repair or reconstruction, a non-
the calcaneus, and the 5.0-mm full-radius resector is weight-bearing posterior and U-splint is applied in mild
inserted. With the shaver on the superior surface of plantarflexion for the first 10 days. The sutures then are
the bone, the periosteum is removed. In plantarflexion removed, and progressive, full weight bearing is per-
the Haglund’s prominence can be resected with the mitted with a boot brace in neutral position. Between
shaver. A burr may be needed to remove bone at and 6 and 12 weeks, the athlete is weaned out of the boot
near the insertion point of the tendon. The site of the as tolerated. Early range of motion and strengthening
burr placement should be confirmed with fluoroscopy. exercises are encouraged. Impact activities are avoided
Adequate decompression is achieved at the posterior for about 8 to 12 weeks. Swimming and exercise bicy-
medial and lateral edges by alternating portals. The por- cling are encouraged by 3 weeks, followed by the el-
tals are sutured after the bursa and Haglund’s promi- liptical trainer by 4 weeks. Beyond 12 weeks, the athlete
nence have been removed with fluoroscopic assistance. may progress to sports-specific activities. Our average
This technique avoids the creation of tender scars in this time for athletes to return to sports has been 3 to
region, has low morbidity, and may shorten recovery 6 months.
relative to the open procedures. If the tendon was repaired or reconstructed or if a
Alternatively, some authors have advocated a dorsal tendon was transferred, a postoperative splint is applied
closing wedge osteotomy of the posterior tuberosity in a relaxed resting position (25 to 45 degrees of equi-
of the calcaneus. It is rarely used in athletes because nus). At 10 days, the sutures are removed, and a boot
of inherent complications with this procedure, including brace is applied in 20 degrees of plantarflexion. We
nonunion or malunion, potentially longer recovery permit active dorsiflexion progressively up toward the
times, difficult fixation, painful prominent hardware, neutral point but recommend reaching the neutral point
broken hardware, and altered mechanics. This pro- at 6 weeks. Exercises are encouraged with the knee
cedure may have a role if an athlete has a notice- flexed to eliminate extra pulling of the gastrocnemius
ably deformed posterior and superior calcaneal muscle during dorsiflexion. Ankle inversion and eversion
prominence, which we call the ‘‘pregnant heel’’ strengthening may be performed. Flexing the toes
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Figure 7-20 Endoscopic portal landmarks. With the patient in

a prone position, the lateral incision is made just dorsal to the
calcaneus and anterior to the tendon. (A) The posterior view
demonstrating the lateral portal (black arrow) and the medial
portal (white arrow). The area of pain is marked on the
patient’s skin. A dotted line is marked at the superior site of
the Achilles insertion below the area of pain. (B) The lateral
perspective of the portal site. (C) The medial perspective of the
portal. A 4.5-mm, 30-degree arthroscope is introduced
laterally. A spinal needle is introduced medially just dorsal to
the calcaneus. The 5.0-mm. full-radius resector then is
inserted.
against resistance is avoided if a tendon transfer was of hip, knee, ankle). With the ankle in plantarflexion
performed but encouraged if no transfer was done. and the ipsilateral leg remaining anterior to the body
Partial weight bearing in a boot is allowed while at all times, the patient leads with that leg in gait
maintaining the ‘‘triple flex walk’’ (Fig. 7-22) (flexion and keeps the sole of the foot in contact with the
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Figure 7-21 Top left corner shows the preoperative appearance of this large posterior prominence. It is
uncharacteristically inferior, although the patient did not have insertional tendinitis. Title calls this the
‘‘pregnant heel.’’ This is a rare exception to consider, a dorsal closing wedge osteotomy of the posterior
tuberosity of the calcaneus. Top left shows the lateral approach anterior to the Achilles tendon. Bottom left
shows the preoperative radiograph. The bottom right demonstrates the calcaneus following the resection of the
dorsally based closing wedge and fixation with a screw. The technique is used rarely because of inherent
complications with this procedure, including nonunion or malunion, potentially longer recovery times, difficult
fixation, painful prominent hardware, broken hardware, and altered mechanics.
ground by flexing the knee and hip, similar to a fencer’s Symptoms and surgery
advance. Although the appearance is awkward, this
method permits ambulation without crutches. Haglund’s/retrocalcaneal bursitis
Ankle neutral position is achieved by 6 weeks, per- Tender over posterior superior bony prominence
mitting full weight bearing with the boot adjusted at and/or anteromedial and anterolateral Achilles
a right angle to the leg. Then progressive dorsiflexion Surgery: resect bone through medial and/or lateral
exercises beyond neutral are performed, with caution incision over prominence
Insertional Achilles tendinitis
not to overstretch. Dorsiflexion is progressed slowly,
Tender at the insertion of the Achilles halfway between
depending on the integrity of the repair. Swimming,
the dorsal and plantar aspect of the calcaneus
bicycling, and other nonimpact activities are com- Surgery: central posterior Achilles splitting incision,
menced at 6 weeks. At 12 weeks, the boot is discontin- debride tendon and bone
ued, and lower-impact activities such as the elliptical
trainer are instituted and increased. The patient then
is progressed to jogging and then running. It may take 9 months, depending on the extent of the tendon dis-
4 to 6 months to return to play, or perhaps more than ease and the integrity of the repair.
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Figure 7-22 Partial weight bearing in a boot in plantarflexion is allowed while maintaining the ‘‘triple flex walk’’
(flexion of hip, knee, ankle). (A) With the ankle and the ipsilateral leg remaining anterior to the body at all times,
the patient leads with that leg in gait and keeps the sole of the foot in contact with the ground by flexing the
knee and hip, similar to a fencer’s advance. (B) The back leg is now brought forward but does not advance
beyond the front healing leg so that the Achilles can be kept unloaded. Next the braced leg is advanced again as
in A. This method permits ambulation without crutches.
Surgical results typically correspond to the athlete’s retrocalcaneal bursitis. Leach et al.29 reported in a
age, with patients younger than 50 years generally hav- small series of athletes that the long-term success rate
ing less tendon involvement, more rapid return to work was 85% following surgical treatment. However, the
and sports, and fewer postoperative problems. Patients authors noted that symptoms recurred in two patients
older than 50 years typically have more tendon involve- and required reoperation. A study by Schepsis et al.26
ment, require greater debridement, and have longer also demonstrated initially high satisfactory results,
postoperative recovery.18,21 mostly in athletes with paratendinitis, although long-
term results deteriorated with time. In a recent study
Expected success rates and return to sport by Saxena,30 return to activity was fastest in elite ath-
Success rates have ranged from 50% to 90%, depending letes requiring only soft tissue procedures, particularly
on the extent and location of tendon involvement. Sur- peritenolysis. Return to competition was approxi-
gical debridement for Haglund’s syndrome and chro- mately 6 months. Although many studies in the litera-
nic tendinosis generally has less favorable results.26,27 ture have quoted high success rates, this optimism for
Watson et al.28 reported that those with insertional ten- surgical treatment must be tempered by the fact that
dinosis are older athletes, have greater tendon involve- these were retrospective analyses that often did not
ment, take a longer time to recover, and often do not differentiate among the various Achilles tendon
achieve results as satisfying as those with isolated disorders.14,18,21,25-27,29,31,32
172
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Acute Achilles tendon rupture
missed on initial presentation. Achilles tendon ruptures

ROLE OF ULTRASOUND AND SHOCK
typically occur in men in their 30s and 40s, with more
WAVE THERAPY
than 75% of these injuries occurring during athletic
participation. Most of these patients are recreational
The use of extracorporeal shock wave therapy (ESWT) athletes. Those engaged in abrupt repetitive jumping
for the treatment of Achilles tendinitis has not been or sprinting sports, such as basketball, football, and
widely studied. Most information on shock wave therapy soccer, are particularly at risk.40
comes from research on kidney stone lithotripsy, upper Sports-related injuries are most often the result of a
extremity tendinitis, and plantar fasciitis. Shock wave rapid eccentric load that is applied to a tensioned tendon
therapy works by creating a pressure change that propa- with ankle dorsiflexion and simultaneous knee exten-
gates rapidly through a medium. When transmitted sion. This occurs during the loading phase of a rapid
through a water medium, it can either directly create push-off or sudden jump. Most ruptures occur in an
high tension at a given structure or indirectly create area of relative hypovascularity of the Achilles tendon,
microcavitations. Theories behind its analgesic effect in 2 to 4 cm proximal to the superior aspect of the calca-
orthopedic applications include an alteration of the per- neus.41 Additional risk factors include intratendinous
meability of neuron cell membranes and induction of an degeneration, vascular impairment, corticosteroid or
inflammatory-mediated healing response by increasing fluoroquinolone use, mechanical malalignment, and sys-
local blood flow.33 Studies on ESWT on Achilles tendi- temic disorders such as gout, hyperthyroidism, and renal
nitis have shown a success rate of approximately 30% to insufficiency.40,41
40%.34,35 In our experience, we have found a similar An athlete typically reports an audible snap and a sen-
success rate of approximately 30% in athletes, although sation of being struck or shot from behind following a mis-
more severe cases are indicated for surgery. Even with step or sudden jump. The player will note significant loss
this lower success rate, we try ESWT for 3 months on of push-off strength and normally will be unable to con-
all patients before surgery because this treatment has tinue sports participation. Diffuse swelling, ecchymosis,
minimal side effects. Depending on the immediate and residual strength from remaining ankle plantarflexors
results, we may allow sports play with only 1 or 2 weeks can make diagnosing an initial injury difficult. However,
off. If the athlete is in midseason, then this modality is findings consistent with an acute Achilles tendon rupture
his or her best chance to resume play. If the athlete is include a palpable tendon gap (Fig. 7-23), positive
at the end of the season, then we may try shock wave Thompson test (absence of passive ankle plantarflexion
therapy and a boot brace for 2 to 6 weeks and then allow with calf squeeze in prone position; Fig. 7-24), loss of the
the athlete to resume impact activities. After the season, normal plantarflexion resting tone while prone in compar-
when there is more time for recovery, decisions regard- ison with the unaffected side, inability to perform a single
ing further treatment can be made. Contraindications toe heel rise, and weak active plantarflexion. Although
to ESWT quoted in the literature include pregnancy, imaging generally is unnecessary in acute cases, lateral
coagulopathies, bone tumors, bone infection, and radiographs may show an avulsion fracture (Fig. 7-25).
skeletal immaturity.33 MRI and ultrasound are useful in equivocal or late cases
Saggini et al.36 noted successful outcomes after two (Fig. 7-26).
treatments with no complications using shock wave ther-
apy on Achilles tendinitis. Several later studies reported Nonsurgical treatment
promising results after ESWT with those affected with Although the treatment of choice for most athletes with
chronic Achilles tendinitis.37-39 The cost of shock wave an acute Achilles tendon rupture is surgical repair fol-
treatment can be an important consideration because lowed by early, protected range of motion and weight
the therapy may not be covered by insurance. With bearing, nonoperative treatment of Achilles ruptures
lower-energy shock wave machines, three treatments using cast immobilization has some advocates. The ill
are used, at a cost of $500 to $800 each. One treatment effects of ‘‘cast disease’’42,43 include calf atrophy and
(at a cost of about $1500) is the norm for the higher- resultant muscle weakness, as well as the consequences
energy machines. The temporary pain with this procedure of immobilizing joints, ligaments, and uninvolved mus-
is considerable and requires an ankle block or general cles and tendons. Furthermore, nonoperative manage-
anesthesia, which increases both the risk and the cost. ment of an Achilles tendon rupture typically does not
restore the normal functional length of the tendon,
and the athlete will note significant muscle weakness.
ACUTE ACHILLES TENDON RUPTURE
Although operative management is associated with
inherently potential surgical risks, including poor wound
Although the incidence of Achilles tendon ruptures has healing, infection, and nerve injury, the risks are balanced
increased over the past few decades, many still are by a lower incidence of tendon rerupture rates, less
173
...........
Figure 7-23 (A) The side with the Achilles rupture has a
visible indentation (white arrow). (B) The normal side.
(C) The ruptured side has a palpable defect.
than 2%, compared with 13% to 35% after nonoperative to shorten the time needed for rehabilitation and return
care.42 Further, studies have demonstrated improved to activities.46 A more recent study found similar success
strength and ankle motion with a greater potential of with operative and nonoperative treatment in the
sports resumption following surgical repair.42,44 athlete.47
Nonoperative management generally is better than More recent postoperative trends have focused on
operative management in those with systemic disorders, a functional rehabilitation program with early con-
such as diabetes, peripheral vascular disease, lower-extrem- trolled range of motion and strengthening exercises.48-50
ity edema, or overlying skin conditions. However, these Early mobilization limits the dystrophic effects of
comorbidities are not often found in the athletic popula- prolonged cast use and has been shown to reduce
tion. Following nonoperative management, a short-leg, tendon adhesion, improve healing, and maximize ten-
nonweight-bearing cast in slight equinus is used for 6 weeks. don strength without increasing the risk of rerup-
This is followed by a weight-bearing cast or walking boot ture or infection. We favor operative repair unless
with progressively increased dorsiflexion. contraindicated.
Results similar to those of operative management
have been reported for nonoperative treatment with
a functional boot brace guided by ultrasound.45 Ultra-
.............................................................
Surgical treatment
sound is used to ensure that the ends of the torn tendon Athletes with well-controlled systemic disorders, such as
remain apposed as the ankle is progressively dorsiflexed diabetes, should be considered for operative treatment.
during the first 6 weeks. Additionally a successful non- This higher-risk situation requires close attention to
operative protocol has been reported using a functional wound closure and postoperative management, including
brace to minimize the ill effects of immobilization and meticulous and frequent follow-up.
174
...........
Figure 7-24 A positive Thompson test in the near leg with the
Achilles tendon rupture. The calf muscles are squeezed and there Figure 7-25 A lateral radiograph shows an avulsion fracture in
is an absence of passive ankle plantarflexion in the prone position. a patient with a history of retrocalcaneal bursitis. There was no
history of steroid injection.
Standard technique
Acute Achilles tendon ruptures in an athlete should be is made, and then the subcutaneous soft tissue is
treated operatively with the goal of recreating normal spread bluntly before passing the suture/wire. A mini-
tendon length and tension. After positioning the patient open technique using a new instrument, the Achillon
prone, the contralateral leg is additionally prepped to (Newdeal SA, Vienne, France), or Giannini’s device
help match resting ankle tension. A medial approach (Citieffe, Calderara di Reno, Bologna, Italy), combines
1 cm anterior to the Achilles tendon border avoids the advantage of direct visual repair with minimizing
injury to the sural nerve and is located in relatively thick potential complications of wound and nerve problems.
tissues, which are biomechanically better suited to provide A small skin incision is made, and the Achillon or
a healthy closure farther away from the tendon (Fig. 7-27). Giannini’s device is introduced under the paratenon.
Care is taken to minimize soft-tissue handling. A A needle with suture is passed from the external guide
Krackow-type stitch technique with nonabsorbable, no. through the skin into the tendon and out the opposite
2 sutures is used to reapproximate the ‘‘mop end’’ rup- side. Three sutures are passed through the proximal
ture (Fig. 7-28). Whenever possible, the paratenon is tendon end, and three are used in the distal tendon
reapproximated to minimize scar formation and improve end. The device and the suture ends are pulled out from
tendon glide. Additionally, reapproximation of the fat under the paratenon and incision such that the ends of
pad anterior to the tendon can be performed. Initially, the sutures grasping the tendon now rest entirely within
we immobilize the leg for 10 days until the wounds the paratenon. The tendon ends are reapproximated,
have healed. The same postoperative protocol described and the sutures are tied. Assal et al.51 reported their
above for tendon reconstructions is used. Return to sport experience using the Achillon device in 82 patients, not-
for the athlete after repair is 4 to 6 months. ing that all patients who were elite athletes were able to
return to their same level of competition.
Mini-open technique
To minimize the possibility of injury to the sural nerve Expected results of acute surgical repair
inherent in a purely percutaneous suture technique, One may expect return to sports generally at 4 to
a mini-open approach can be used. A small stab incision 6 months after acute repair and a program of early
175
...........
Figure 7-26 The sagittal magnetic resonance imaging shows a long, complex Achilles tear (white arrows).
Figure 7-27 (A) An acute Achilles tendon rupture repair is performed with the patient in a prone position.
(B) A medial approach made 1 cm anterior to the Achilles tendon border avoids injury to the sural nerve.
176
...........
Figure 7-27 cont’d. (C) The approach is with the scalpel, avoiding blunt dissection. (D) The exposure is through
relatively thick tissues, which are biomechanically better suited to provide a closure that provides a barrier to the
tendon, which is 1 to 1.5 cm away from the incision. (E) The exposed mop ends of the tendon.
Figure 7-28 (A) Another acute Achilles repair with exposure of the frayed tendon ends. (B) Care is taken to minimize
soft-tissue handling. A Krackow-type stitch technique with nonabsorbable, no. 2 sutures is used to reapproximate the
‘‘mop end’’ rupture.
(continued)
177
...........
diagnosis or after a failed acute repair. Chronic ruptures

typically are defined as those diagnosed more than 4 to
6 weeks after initial injury.53 After this period, the
gap between the separated tendon ends fills with fibri-
nous material. This scar tissue contains disorganized
fibroblasts and does not possess the same biomechanical
strength as normal tendon. Over time, the tissue will
elongate and lead to further functional weakness.14
Typically, a patient will complain of loss in push-off
strength and be unable to perform toe walking and
repetitive heel rise. When the patient lies prone, the
injured extremity will demonstrate less resting plan-
tarflexion tone as compared with the contralateral
ankle. The involved ankle will display a relative increase
in passive dorsiflexion and significantly less plantar-
flexion with calf squeeze. A palpable tendon gap is
not typically evident, but the contour of the tissues will
Figure 7-28 cont’d. (C) The edges of the anastomosis should be altered, with thickening and loss of defined
be made neat with a 2-0 or 4-0, absorbable suture. The resting margins. The appearance of the affected calf muscle
tension should be restored. can be different from the contralateral side. Often
the muscle belly is more proximally situated (‘‘balled
up’’) as a result of its detachment distally. MRI and
protected weight bearing.14,44,52,53 Cetti et al.42 previ- possibly ultrasound evaluation are useful in evaluating
ously showed less calf atrophy and improved ability the size of the tendon gap and assist in surgical
to resume preinjury level of athletic play after surgi- planning.
cal repair as compared with nonoperative treat-
ment.42,44,48-50,52 In a meta-analysis of acute Achilles Nonsurgical treatment
tendon treatment, Bhandari et al.54 confirmed a statisti- Nonoperative management may be considered in those
cally significant reduction in rerupture rates after surgical without functional deficits or potentially high-risk
repair (3.1%) as compared with nonoperative treatment patients, but surgical management is the treatment of
(13%). However, infections occurred only in the surgi- choice for the athlete.
cally treated group (infection rates ranging from 4% to
20%). The proportion of patients who regained normal
function was similar in the operative and nonoperative
treatment groups.
.............................................................
Surgical treatment
In another meta-analysis, Kahn et al.55 identified Operative reconstruction generally will restore optimal
12 suitable papers for inclusion. They found that the rel- musculotendinous length and improve strength and
ative risk of rerupture was 0.27 with operative versus endurance. Direct repair often is not possible because
nonoperative treatment. Complications including infec- of the relative immobility of the separated tendon ends
tion, adhesions, and altered skin sensitivity had a relative with associated muscular retraction and atrophy. The
risk of 10.6 (operative vs. nonoperative). Functional size of the gap after debridement of interposed scar
bracing postoperatively had lower complications than tissue determines whether a repair or reconstruction
casting postoperatively (relative risk 1.88). They con- should be done and also determines which type of
cluded that operative treatment significantly reduced reconstruction should be done.
the risk of rerupture but significantly increased the risk If the delayed diagnosis is made within 4 to 6 weeks
of complications. of injury, we perform tendon end debridement. We
then mobilize the tendon by applying tension, holding
the tendon in a stretched position for 10 minutes, and
attempt a direct repair. After the tendon apposition, if
CHRONIC ACHILLES TENDON RUPTURE it appears that the repair is too tight, we do a V-Y
lengthening proximally to adjust the tension.
More than 20% of patients with an Achilles tendon rup- After 6 to 12 weeks postinjury, it is not likely that the
ture are missed on initial examination,14 and it therefore tendon ends can be mobilized sufficiently for direct
is not uncommon to diagnose a late injury. Chronic repair with proper tension. If the gap is between 1 and
Achilles tendon ruptures generally present for delayed 3 cm after debridement and mobilization, a V-Y
178
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Chronic Achilles tendon rupture
procedure can be performed (see Fig. 7-14). To perform For those cases with preoperative atrophy of the
the V-Y advancement, a direct reapproximation is per- gastrocnemius/soleus muscle, an FHL tendon transfer
formed using a no. 2, nonabsorbable suture in a Krackow may be considered (see Figs. 7-12 and 7-13). The FHL
or whipstitch. This allows further ability to stretch out the can be harvested from the posterior ankle in the depths
tendon. If reapproximating the tendon ends results in too of the posterior approach (Fig. 7-29, A) to the Achilles,
much tension, we then proceed with the V-Y advance- or, if a longer graft is felt to be advantageous, from the
ment. We allow the V-Y gap distance to reduce the con- arch of the foot. The graft harvest can be performed
traction and restore proper tension as compared with the through a medial approach just plantar to the posterior
contralateral side. tibial tendon and the talonavicular joint (Fig. 7-29, B)
For more chronic cases seen more than 12 weeks after or through the plantar aspect through the plantar fascia
a missed rupture or after a previous completely failed (Fig. 7-29, C). For the latter approach, once the incision
repair, a V-Y advancement or turndown likely will be is made through the plantar fascia, care is taken to avoid
required, depending on the size of the defect after the medial plantar nerve. The FHL and FDL tendons
repair. For defects between 2 and 3 cm, a V-Y advance- can be found in the depth of the wound next to the first
ment is possible, as mentioned previously. For defects metatarsal and medial cuneiform. Once the tendons
longer than 3 to 5 cm, a turndown procedure with pos- have been identified, the FHL is sutured to the FDL dis-
sible tendon augmentation is required, as discussed ear- tal to the point at which the tendon will be transected
lier (see Fig. 7-15). (at or near the knot of Henry). A suture placed in the
Figure 7-29 (A) The flexor hallucis longus (FHL) can be

harvested from the posterior ankle in the depths of the
posterior approach to the Achilles. (B) The graft harvest
through a medial approach just plantar to the posterior tibial
tendon and the talonavicular joint. (C) The graft harvest
through the plantar aspect of the foot. After incising the
plantar fascia and reflecting the medial plantar nerve, the FHL
and flexor digitorum longus (FDL) tendons can be found next
to the bones. The FHL is sutured to the FDL distal to where the
tendon will be transected. Next, the FHL is cut proximal to the
tenodesis and withdrawn out the proximal ankle incision.
179
...........
FHL proximal to the transection is helpful in case the 13. Marks RM: Achilles’ tendinopathy, Foot Ankle Clin 4:789, 1999.
tendon does not pull through into the proximal wound. 14. Schepsis AA, Jones H, Haas AL: Achilles tendon disorders in
athletes, Am J Sports Med 30:287, 2002.
Den Hartog56 described a technique of harvesting 15. Fredberg U: Local corticosteroid injection in sport: review of
the FHL tendon near the tip of the medial malleolus literature and guidelines for treatment, Scand J Med Sci Sports
for chronic Achilles tendinosis. Good to excellent results 7:131, 1997.
were reported in 23 of 26 treated patients without any 16. Paavola M, et al: Treatment of tendon disorders. Is there a role for
deficit to first-toe function. A recent biomechanical corticosteroid injection? Foot Ankle Clin 7:501, 2002.
17. Shrier I, Matheson GO, Kohl HW 3rd: Achilles tendonitis: are
study showed little pressure change under the first or corticosteroid injections useful or harmful? Clin J Sport Med 6:245,
second metatarsophalangeal (MTP) joint and no clinical 1996.
functional deficit after FHL harvesting.57 Prior studies 18. Johnston E, Scranton P Jr, Pfeffer GB: Chronic disorders of the
also showed promising clinical results.58,59 Achilles tendon: results of conservative and surgical treatments,
Foot Ankle Int 18:570, 1997.
19. Angermann P, Hovgaard D: Chronic Achilles tendinopathy in
athletic individuals: results of nonsurgical treatment, Foot Ankle
CONCLUSION Int 20:304, 1999.
20. Gerken AP, McGarvey WC, Baxter DE: Insertional Achilles
tendonitis, Foot Ankle Clin North Am 1(112):237, 1996.
Achilles tendon disorders are common in the athlete. 21. McGarvey WC, et al: Insertional Achilles tendinosis: surgical
If diagnosed early, the process usually is a tendinitis treatment through a central tendon splitting approach, Foot Ankle
and is amenable to nonoperative treatment such as Int 23:19, 2002.
22. Paavola M, et al: Long-term prognosis of patients with
intermittent immobilization, stretching, modalities such Achilles tendinopathy. An observational 8-year follow-up study,
as ultrasound and iontophoresis, and use of anti- Am J Sports Med 28:634, 2000.
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longer to treat and have a higher risk of requiring oper- for Achilles tendinopathy in middle- and long-distance runners,
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24. Kolodziej P, Glisson RR, Nunley JA: Risk of avulsion of the
to 90% successful but requires 3 to 6 months for return Achilles tendon after partial excision for treatment of insertional
to athletic participation. Achilles rupture typically tendonitis and Haglund’s deformity: a biomechanical study, Foot
will require operative treatment in the athlete, and 6 to Ankle Int 20:433, 1999.
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bursitis, Am J Sports Med 12:72, 1984.
26. Schepsis AA, Wagner C, Leach RE: Surgical management of
Achilles tendon overuse injuries. A long-term follow-up study,
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181
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........................................... C H A P T E R 8
Posterior tibialis tendon dysfunction

W. Grant Braly
......................
CHAPTER CONTENTS
Introduction 183 Treatment 191

Anatomy and biomechanics 183 Perils and pitfalls (with illustrative case reports) 200
Diagnosis 185 Summary 202
Disease staging 190 References 202
INTRODUCTION the proximal one third of the tibia and intraosseous

membrane. Distally, its tendon travels posterior, then
inferior, through the medial malleolar groove, changing
Acute posterior tibialis tendon injury in the athlete is
direction abruptly almost 90 degrees. The stout retin-
rare1,2 but must be considered in the differential diagnosis
aculum of the long flexors prevents the tendon from
of a patient who presents primarily with tenderness,
subluxating over the medial malleolus.10 Because the
swelling, and pain over the medial ankle or plantar medial
posterior tibialis tendon is without a mesotenon, there
midfoot. Antecedent to the acute presentation, there often
is an area of relative hypovascularity from this acute turn
is a history of less severe prodromal symptoms more consis-
at the medial malleolus to the medial navicular insertion.
tent with a chronic interstitial rupture with tendinosis. The
These factors of hypovascularity and the mechanical
chronic picture is seen more often in the middle-aged to
stress of an acute turn of the tendon as part of a strong,
elderly patient, athlete or not, that was especially popular-
weight-bearing leg muscle (second only to the gastroc-
ized by the late Kenneth A. Johnson, MD,3-5 with whom
nemius) make the tendon predisposed to injury in this
I had the honor of fellowship training. Others,1,2,6-9 of
area.
course, also have contributed to a further understanding
Because the posterior tibial tendon travels posterior
of the diagnosis and treatment of this condition.
to the axis of the ankle and medial to the axis of the sub-
Although most of the literature emphasizes chronic
talar joint, it serves as an ankle plantarflexor and foot
posterior tibialis tendon disease, the ultimate presenta-
invertor via the transverse tarsal joint (talonavicular and
tion of the acutely injured athlete may be very similar
calcaneocuboid joints).11 The tendon also has multiple
to the chronic form. Therefore given the rarity of acute
slip attachments to the capsule of the naviculocuneiform
injury versus the more commonly seen chronic presen-
joint, all three of the cuneiforms, the cuboid, and their
tation, posterior tibialis tendon ‘‘dysfunction,’’ rather
respective metatarsal bases in the plantar arch.4,12 The
than ‘‘injury,’’ probably is a more accurate description
posterior tibialis tendon therefore is primarily a midfoot
and title for this chapter.
invertor and dynamically supports and elevates the
medial longitudinal arch. It also indirectly supports the
hindfoot because of its medial malleolar pulley action
ANATOMY AND BIOMECHANICS
and intimate relationship to the deep deltoid ligament,
plantar medial talonavicular joint capsule, and spring lig-
The posterior tibialis muscle is a resident of the deep ament (calcaneonavicular ligament).13 With relatively lit-
posterior compartment of the leg, originating along tle elongation because of rupture, the tendon becomes
CHAPTER 8 Posterior tibialis tendon dysfunction
incompetent to support the medial longitudinal arch frank rupture of these structures eventually leads to a
initially, resulting in the acquired adult flatfoot with valgus inclination of the hindfoot and external rotation
forefoot pronation and abduction (Fig. 8-1). However, of the calcaneus, also resulting in contracture of the
over time other ligamentous structures are affected, Achilles tendon as it becomes a hindfoot everter11
including the talonavicular joint capsule, deltoid liga- (Fig. 8-2). Clinically, this may result in impinging pain
ment, and spring ligament. The stretching out or even and swelling in the subfibular or sinus tarsi area as the
Figure 8-1 Dorsal-plantar view demonstrating the normal foot (A) and the posterior tibialis tendon incompetent
foot (B). With external rotation or abduction of the forefoot, the medial talar head becomes more uncovered by
the navicular as it rotates externally. The calcaneus also secondarily rotates externally and tilts into more valgus.
Figure 8-2 Posterior-anterior view of the normal (A) and posterior tibialis tendon incompetent ankle and
hindfoot (B). With external calcaneal rotation, the talar head translates plantarward. This also leads to
increased valgus tilting of the calcaneus and subfibular or sinus tarsi impingement.
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Diagnosis
calcaneus abuts against the lateral malleolus. In very

severe or neglected cases, a valgus tilt of the ankle may
be seen as the deltoid ligament becomes incompetent.
DIAGNOSIS
Usually, a detailed history, conscientious physical exam-

ination, and x-rays will establish the diagnosis of a
posterior tibialis tendon injury.
History and questions to be answered

Sometimes the history alone will provide the examiner
with enough information to suggest the diagnosis.
What was the mechanism of injury? Specifically, did
the foot sustain an eversion twisting injury, espe- Figure 8-3 Usual area of maximal tenderness and swelling
cially on impact from tripping or a fall? Or, was there along the terminal course of the posterior tibialis tendon
a sudden increase in the level of athletic activity between the medial malleolus and medial navicular insertion.
temporally related to the onset of symptoms? Occasionally, this can extend to the area posterior to the
Were there prodromal symptoms of possible medial malleolus.
tendon degeneration before the acute injury?
Has the athlete noticed that the arch on the involved
side is ‘‘flatter,’’ the foot is ‘‘turned out,’’ the ankle
‘‘turned in,’’ or complained that the injured foot is
‘‘weaker’’?
When unshod on a hard, wet floor surface, such
as at bath time, does the patient notice a different
footprint or a ‘‘sucking sound’’ because of a vacuum
effect of the collapsed arch on the symptomatic side?
Has the athlete noticed more medial shoe sole wear
or ‘‘running over’’ the medial vamp?
Is there any history of gout, pseudogout, or auto-
immune disease?
Are there sensory (dysesthesias or paresthesias)
complaints?
In terms of predisposing risk factors, is there a his-
tory of oral steroid use, injected steroids in the area
of the tendon, diabetes, smoking, vasculopathy, Figure 8-4 The positive ‘‘too many toes’’ sign in the posterior
obesity, or worsening of a preexisting pes planus tibialis dysfunctional right foot is appreciated when examining
deformity? the weight-bearing patient from behind. The forefoot is
abducted/pronated and the hindfoot is in greater valgus,
Physical examination and questions to be answered resulting in more toes seen laterally in the right foot when
For comparison, both unclothed and unshod lower compared with the left.
extremities from the midthigh distally to the toes should
be carefully examined. Is there tenderness in the insertional area of the
Is there a valgus knee deformity (genu valgum) of anterior tibialis tendon?
the symptomatic side? (This may precipitate or In viewing the weight-bearing patient from behind,
exacerbate posterior tibialis tendon dysfunction, is there increased forefoot abduction or pronation
especially if chronic.) (the so-called ‘‘too many toes sign’’) (Fig. 8-4)?
Is there tenderness and swelling along especially the Does the patient have difficulty heel rising with all
terminal course of the tendon, generally between of his or her weight on the injured side (‘‘single
the medial malleolus and the navicular insertion foot heel rise’’ test), or if he or she is able to heel
or, less commonly, in the posterior aspect of the rise, does the hindfoot fail to invert or invert less
medial malleolus (Fig. 8-3, A and B)? than the normal side (Fig. 8-5)?
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Figure 8-5 Notice hindfoot inversion in the normal left foot. Although patients with posterior tibialis tendon
dysfunction may be able to perform the single-foot heel-rise test, notice that the hindfoot does not invert, or
inverts less, than the normal foot. This may be due to some residual function of the posterior tibialis muscle
tendon unit with assistive recruitment of the long toe flexors.
Is there tenderness and swelling laterally in the sinus

tarsi or subfibular area, suggesting impingement,
especially in the patient with deformity (Fig. 8-6)?
Is the Achilles tendon contracted?
Are there abnormal sensory findings that might
suggest peripheral neuropathy, especially in the
diabetic patient?
Is there a positive Tinel’s sign over the tibial nerve
in the medial ankle or plantar foot sensory deficits
that might suggest a tarsal tunnel syndrome?
Is there a tender and swollen bony prominence in
the area of the medial navicular, suggesting an
accessory navicular or stress fracture?
Is the medial malleolus itself tender, thus suggest-
ing a stress fracture?
Are there any dysvascular findings (absent posterior
tibial or dorsalis pedis pulses, delayed capillary refill,
cyanosis, toe hair loss, and dystrophic nail changes)? Figure 8-6 Zone of tenderness and swelling indicative of
impingement in the subfibular or sinus tarsi area, often seen
.............................................................
X-rays and questions to be answered with more severe posterior tibialis tendon dysfunction with
hindfoot valgus deformity.
Ideally, weight-bearing x-rays of the symptomatic foot
and ankle should be taken. Also, comparison views of
the other foot and ankle often are helpful diagnostically. Foot x-rays
Is there an accessory navicular or possible avulsion
Ankle x-rays fracture of the medial navicular (see Fig. 8-7, B)?
Do films demonstrate a medial or valgus tilt Do the films of the foot reveal arthritic changes of
(Fig. 8-7, A)? the medial subtalar (additional Broden’s views
Are there arthritic changes with joint space narrow- may be helpful), talonavicular, naviculocuneiform,
ing, osteophytes, or loose bodies medially? or medial tarsometatarsal joints (Fig. 8-7, D)?
Is there any evidence of a medial malleolar stress Is there any evidence of a tarsal coalition, especially
fracture or medial talar dome osteochondritis disse- in the periadolescent athlete?
cans (Fig. 8-7, C)? On the lateral view, is the talo-first metatarsal angle
Is there major arterial (anterior and posterior tibial) negative, especially if it is more so than a compari-
calcification? son view of the contralateral foot (Fig. 8-8)?
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Diagnosis
Figure 8-7 Radiographs of patients with medial ankle or midfoot pain and swelling demonstrating medial talar
tilt because of primary deltoid ligament incompetency (A) accessory navicular (B) medial talar dome osteo-
chondritis dissecans with a coronal magnetic resonance imaging (MRI) view (C) and medial column arthritis.
(continued)
On the anteroposterior (AP) view, is there an As in the ankle, is there arterial calcification of the
increased talo-first metatarsal angle or increased dorsalis pedis or posterior tibialis arteries?
‘‘uncovering’’ of medial talar head at the talona-
vicular joint, thus indicating forefoot abduction, Magnetic resonance imaging (MRI)
again especially when compared with the contralat- Although rarely necessary, if the history, physical exami-
eral foot (Fig. 8-9)? nation, and x-rays fail to conclusively determine the
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Figure 8-7 cont’d. (D) all of which can mimic to varying degrees the clinical presentation of posterior tibialis
tendon dysfunction.
Figure 8-8 Lateral weight-bearing views demonstrating the midfoot sag of the posterior tibialis incompetent
right foot. I prefer this more simplistic measurement of the angle between the long axis of the talus (a) and
the I metatarsal (b). The resultant angle (c) is greater in the involved foot. In this case in the normal left foot,
these lines are virtually parallel. Also, notice that the subtalar joint is less clearly seen in the symptomatic right
foot because of superimposition of the talus and calcaneus from a hindfoot valgus deformity.
diagnosis of a posterior tibialis tendon injury, or to con- to posterior tibialis tendon disease8,10,13,16,17 (Table
firm the diagnostician’s impression, then an MRI may 8-1). Perhaps of historical interest, others have proposed
be indicated.14,15 An MRI also is helpful to determine the diagnostic use of tenography7 or ultrasound,18 but
the extent of acute injury or chronic tendinosis and thus their sensitivity is significantly less than that of a high-
guide treatment, especially if surgery is planned, and quality MRI.
may predict the postoperative clinical outcome.15 Finally, Generally, the MRI will reveal fibrous tendinotic
the MRI may help to determine other conditions that longitudinal hypertrophy or bulbous enlargement of
may mimic, be concomitant with, or even contribute the tendon, sometimes with cystic or longitudinal voids
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Diagnosis
Figure 8-9 Anteroposterior (AP) weight-bearing views demonstrating abduction deformity resulting from poste-
rior tibialis tendon incompetency in the right foot. Again, I prefer this more simplistic measurement of the ankle
between the long axis of the talus (a) and the I metatarsal (b). The resultant angle (c) is great in the involved
right foot. Also, notice that the medial talar head is more uncovered by the navicular in the involved foot (d).
Table 8-1 Differential diagnosis
Medial ankle arthritis Medial subtalar joint or medial column arthritis
Medial ankle instability with deltoid ligament Symptomatic accessory navicular with synchondrosis disruption
rupture/laxity
Medial malleolar or talar stress fracture Medial navicular bony avulsion or stress fracture
Medial talar dome osteochondritis dissecans Acute injury or tendinosis of the flexor hallucis longus or flexor
digitorum longus tendons
Tarsal tunnel syndrome Peri-insertional anterior tibialis tendon rupture or

tendinosis
Tarsal coalition, especially in periadolescent Medial ankle or hindfoot/midfoot crystalline or autoimmune arthritis
athletes
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Figure 8-10 Magnetic resonance imaging (MRI) findings of posterior tibialis tendon dysfunction. (A) Sagittal
view at the level of the medial malleolus (MM) demonstrating longitudinal void within the tendon. (B)
Transverse view at the level of the talus (T) also demonstrating intratendinous voids and increased fluid
around the tendon.
(Fig. 8-10, A). Also, there usually is increased tenosyno- Table 8-2 Disease stages
vial fluid within the sheath surrounding the tendon18,19
(Fig. 8-10, B). These findings usually are seen between Stage I Peritendinitis and/or tendon degeneration
the medial malleolus and navicular but also can extend (tendinosis)
proximally into the posterior medial malleolar area.
No deformity
DISEASE STAGING Stage II Tendon elongated/incompetent
Mild flexible deformity

Once the diagnosis is firmly established, the stage
of posterior tibialis tendon disease, as popularized by Stage III Findings of Stage I and II
Kenneth A. Johnson’s seminal work, is important to
determine the proper course of treatment. Johnson initi- Moderate-to-severe deformity that may be rigid
ally described stages I to III,5 but a stage IV11,20 has more with possible subfibular or sinus tarsi
recently been described that involves a valgus inclination impingement
of the talus with degenerative arthritis of the ankle joint
(Table 8-2). This is exceedingly rare in the active athlete Radiographic arthritic changes of triple joint complex
and will not be elaborated upon beyond its mention. and/or naviculocuneiform joints
Stage I is essentially peritendinitis and/or tendon
(Stage IV, which involves a valgus talar tilt and early
degeneration (tendinosis) with a normal tendon length
ankle joint degeneration, also has been described but
and no deformity. Stage II is characterized by an in- probably is not applicable to this discussion, given its
competent or lengthened tendon with a mild flexible extreme rarity in the active athlete.)
deformity. Stage III encompasses the findings of the
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Treatment
preceding stages, but with a greater degree of deformity management includes supportive and often-replaced,
that also may be rigid. X-rays of the stage III foot may high-quality athletic shoes. Finally, if it is an issue in
further reveal significant arthritic changes in any or all the overweight athlete, weight loss obviously is recom-
of the triple joint complex (subtalar, talonavicular, mended. Other comorbid conditions also should be
and/or calcaneocuboid joints) or naviculo-cuneiform addressed, for example smoking cessation and good
joints, as well as clinical signs and symptoms of subfibular control of diabetes and autoimmune disease.
or sinus tarsi impingement.
Surgical treatment
The following discussion includes surgical treatment of
TREATMENT the stages of posterior tibial tendon rupture gleaned
from the literature but also is biased by my own experi-
ence (Table 8-3).
Conservative
In general, conservative treatment is recommended ini- Stage I—tendon length normal
tially, especially for the stage I and II presentation in Intraoperative findings include tenosynovitis, often with
the otherwise healthy athlete. However, in the patient granulation tissue, increased tenosynovial fluid, and an
who has significant comorbid conditions (e.g., diabetes, interstitial longitudinal rupture, usually between the
smoking, vasculopathy, obesity, etc.) that makes surgical medial malleolar tip and the navicular insertion of the
treatment ill advised, conservative treatment may be the tendon.5,9 Fusiform hypertrophy with tendinotic ‘‘crab-
definitive treatment. In the young, competitive athlete, meat’’ tissue often is encountered, as well as possible
these comorbidities are uncommon, but, in the mid- cystic degeneration, especially in a more chronic
dle-aged athlete, they are not rare. presentation.
As with any inflammatory condition or injury, Surgical treatment involves opening the tendon sheath
immobilization is therapeutic. Either casting or rigid from at least the medial malleolus to the navicular inser-
bracing is recommended for several weeks, the length tion. If disease is noted proximal to the medial malleolus,
of immobilization depending on the response then it is important to preserve, if possible, an approxi-
of such treatment with diminution of the associated mately 1-cm section of the sheath at the medial malleolar
swelling or tenderness. The cast that is well molded level to prevent subluxation of the tendon. (If this is not
to support the arch or the incorporation of an arch possible because of extensive proximal disease, then
support and/or medial wedge if a brace is chosen is that portion of the tendon should be repaired after the
further recommended. Weight bearing during tendon itself is addressed.) Tenosynovitis and granulation
the immobilization treatment period is allowed as tissue are debrided with a small rongeur. The hyper-
tolerated. In the less acute or chronic presentation, trophied portion with tendinosis within the tendon
or after a positive response to immobilization, cus- then is debrided and debulked sharply via a longitudi-
tom-molded arch supports, perhaps with medial nal incision in the tendon itself. The incision then is
wedging incorporated either in the orthotic and/ repaired with absorbable, interrupted suture with
or on a supportive shoe on the symptomatic side are inverted knots.
advised for several months. Postoperatively, cast immobilization is recommended
Nonsteroidal anti-inflammatory medications also are for 3 weeks, followed by rigid bracing, stirrup bracing,
helpful, but chronic oral steroids should be avoided. or a short articulating AFO for another 3 weeks. After
Steroid injections also should be shunned because these immobilization, supportive shoewear with a custom-
may lead to complete rupture7,21 or at least exacerbate a made arch support is recommended for 3 months.
tendinotic condition, especially if an injection is inadver- In the athlete, repetitive impact-loading sports or condi-
tently intratendinous. tioning endeavors are avoided until at least 3 months
In terms of athletic activity during the conservative postoperatively.
treatment period, and perhaps for several weeks after,
the injured athlete also should avoid any repetitive Stage II—tendon elongated, deformity
impact-loading sports or conditioning. Cross training mild and flexible
(e.g., bicycling, swimming, perhaps walking and/or pri- Similar, but more severe, pathologic findings as seen in
marily upper-extremity bench weight training) is stage I are encountered in stage II disease. There usu-
advised. ally is a longer area of interstitial rupture with accompa-
In the athlete with a tight Achilles tendon, stretching nying bulbous enlargement of the tendon that may even
is helpful,22 especially to avoid reinjury once he or she extend proximal to the medial malleolus. The tendon
has been successfully treated conservatively and returns is found to be elongated, and thus incompetent, allow-
to the preinjury level of activity. Also, ideal long-term ing excessive pronation and abduction of the forefoot.
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Table 8-3 Surgical management
Return to
sports
Technique Postoperative regimen postoperative
Stage I
Tenosynovectomy Cast: 3 weeks 3 months
Repair of interstitial rupture Rigid brace: 3 weeks
Possible medial shift calcaneal osteotomy for severe Supportive shoes with custom-
cases? molded arch supports: until 3
months postoperative
Stage II
Repair and advance/shorten tendon Cast: 6 weeks 6 months
Imbricate talonavicular joint plantar medial capsule Rigid brace: 6 weeks
Flexor digitorum longus tendon transfer Supportive shoes with custom-

molded arch supports: until 6
months postoperative
Medial shift calcaneal osteotomy with flexible deformity
Possible Achilles tendon lengthening or gastrocnemius

recession
Stage III
Repair/reconstruction of tendon may not be necessary? Cast: 9-12 weeks 9-12 months
Medial shift calcaneal osteotomy and/or lateral column Rigid brace: 6-9 weeks
lengthening if deformity is flexible
Arthrodesis if deformity rigid and/or arthritic changes Supportive shoes with custom-
present molded arch supports?
Possible Achilles tendon lengthening or gastrocnemius

recession
(The function of the posterior tibialis is easily compro- or through drill holes4,5,9,11,13,23,24 (Fig. 8-11, F, H, and
mised with even a small increase in length because the I). The surgeon also may consider elliptically excising a
normal excursion in the healthy tendon rarely exceeds transverse segment and imbricate the attenuated plantar
1 to 2 cm.) medial capsule of the talonavicular joint in severe cases,11,23
The tendon is repaired as described for stage I. Also, or, obviously, repair it if it is torn (Fig. 8-11, B, D, and G).
shortening of the tendon is advised by advancing its With extensive stage II findings, and especially if the
plantar medial insertion on the navicular. It usually is tendon is completely torn, a tendon transfer is recom-
necessary to detach the medial insertion and excise mended (Fig. 8-11, A). Most surgeons harvest the flexor
excess peri-insertional tendon before securing it to the digitorum longus3-5,7,9-11,13,19,23,24 for this purpose,
decorticated plantar medial aspect of the navicular with which is in close proximity to the posterior tibialis tendon
nonabsorbable sutures incorporated in bone anchors9 (Fig. 8-11, C and E). Within the same surgical incision,
192
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Treatment
B
Figure 8-11 Intraperative photographs and corresponding schematic drawings demonstrating my preferred method of reconstruc-
tion of a complete rupture of the posterior tibialis tendon. This patient had a flexible deformity without degenerative triple joint
arthritis. A medial shift calcaneal osteotomy was added to the medial soft-tissue reconstruction. (A) Complete rupture of the
posterior tibialis tendon. The two ends could not be approximated because of proximal migration of the proximal end. (B)
Subsequent to debridement of the distal end of the posterior tibialis tendon, the plantar medial talonavicular joint capsule was
incised and an elliptical segment removed to later imbricate it.
(continued)
the flexor digitorum longus is cut sharply as distally as the level of flexor digitorum longus cut. Other tendons
possible and is secured to the navicular or as a side-to- have been suggested for transfer, but these transfers
side transfer to the repaired and advanced posterior may be of historical interest only. Although the flexor
tibialis tendon. It generally is not necessary to sew hallucis longus has a stronger muscle than the flexor
the distal stump of the flexor digitorum longus tendon digitorum longus, its transfer is not recommended
to the flexor hallucis longus tendon because of the because the dissection associated with its harvesting is
many soft-tissue connections between them distal to technically challenging and risky, given its close
193
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D
Figure 8-11 cont’d. (C) The flexor digitorum longus tendon is harvested as distally as possible. It is not necessary to tenodese the
distal end of the flexor digitorum longus to the flexor hallucis longus tendon to maintain adequate lesser toe flexor function.
(D) Heavy absorbable stay sutures are placed and tagged in the plantar medial talonavicular joint capsule.
(continued)
proximity to the neurovascular bundle. Also, The effect of this osteotomy is to translate the pull of
the resultant weakness of great toe flexion may be a sig- the gastrocsoleus muscle via the Achilles tendon more
nificant problem for a high-performance athlete. medial to the axis of the subtalar joint, which enhances
More recently, as primarily popularized by the varus force on the hindfoot. Another indirect, ben-
Myerson11,23 and described by others,10,19,22,26 a eficial effect therefore is to decrease tension on the
medial shift or slide calcaneal osteotomy has been reconstructed posterior tibialis tendon. The medial dis-
advocated for stage II disease. (There also may be an placement also may at least partially reestablish the
indication for this osteotomy in severe stage I cases.11) height of the medial longitudinal arch.
194
...........
Treatment
F
Figure 8-11 cont’d. (E) The flexor digitorum longus tendon is passed through and tenodesed with maximal tension to the proxi-
mal end of the posterior tibialis tendon. (F) A bone anchor is placed in the decorticated medial aspect of the navicular.
(continued)
The osteotomy is a straight cut from the lateral hind- the posterior plantar edge of the calcaneal body,
foot at an angle of approximately 45 degrees to thereby avoiding the insertion of the Achilles tendon
the plantar surface of the heel roughly equidistant and the plantar fascia origin.11,19,23,24 A slightly curved
between the posterior facet of the subtalar joint and incision is made, and great care is taken to protect
195
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H
Figure 8-11 cont’d. (G) The plantar medial talonavicular joint capsular stay sutures are tied. (H) The flexor digitorum longus
tendon is secured to the medial navicular under tension with the nonabsorbable sutures from the bone anchor.
(continued)
the sural nerve in the lateral approach to the calcaneal posterior heel incision can be used for internal fixation.
wall (Fig. 8-12, A). A power saw can be used until The proper placement of this screw should be guided
the surgeon approaches the medial calcaneal wall, but fluoroscopically to avoid penetration of the subtalar
an osteotome is recommended to complete the osteot- joint and medial or lateral calcaneal wall. Countersink-
omy medially to prevent injury to the neurovascular ing the screw head is advised to prevent symptomatic
bundle (Fig. 8-12, B and C). A medial shift hardware.
of approximately 10 mm is recommended.11,19,23,24 Recently I have been using two dynamic compres-
Provisional fixation is achieved with two percutaneous sion nitinol step staples for definitive internal fixation
pins in the sinus tarsi area until definitive internal (Fig. 8-13, A through C). This eliminates the need
fixation is placed (Fig. 8-12, D). A partially threaded for a second incision associated with the screw place-
cannulated cancellous screw via a separate plantar ment, is technically less challenging and time
196
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Treatment
I
Figure 8-11 cont’d. (I) Final appearance of the reconstruction. Heavy absorbable sutures also are used to further secure the
flexor digitorum longus tendon transfer to the fibrous tissue of posterior tibialis tendon sheath and the surrounding periosteum.
consuming, and decreases the likelihood of symptom- nemius recession is indicated.22 This procedure serves to
atic hardware. Also, there is potentially less fluoro- diminish the stress on the reconstruction and may help
scopic radiation exposure because usually only to prevent recurrent rupture and deformity
intraoperative radiographic demonstration of the final postoperatively.
proper staple position in the axial heel and lateral Postoperatively, casting is advised for 6 weeks, initi-
planes is necessary, versus perhaps multiple fluoro- ally with the foot in plantarflexion and inversion for the
scopic guidance images that may be required for screw first 2 weeks. The foot is brought to a neutral position
placement. gradually by the end of the fourth week, when partial
If, after the reconstruction of the posterior tibialis weight bearing is permitted. If a medial shift calcaneal
tendon, the foot cannot be passively dorsiflexed to at osteotomy is performed, then serial axial and lateral
least 10 degrees with the knee fully extended, then a x-rays of the heel are taken to monitor healing. Follow-
percutaneous Achilles tendon lengthening or gastroc- ing casting, rigid bracing with an arch support is
Figure 8-12 Medial shift calcaneal osteotomy. (A) Recommended location of lateral hindfoot incision. (B) Power saw used initi-
ally for osteotomy. Multiple retractors are recommended to protect the surrounding soft tissues.
(continued)
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Figure 8-12 cont’d. (C) Osteotomy completed through the medial calcaneal wall using an osteotome to minimize any potential
damage to the neurovascular bundle. (D) Temporary percutaneous smooth pin internal fixation until definitive internal fixation
is placed.
recommended for 6 weeks, with progression to full synchronous function of the talonavicular and subtalar
weight bearing as tolerated. The patient may remove joints, possibly leading to early degenerative arthritis,
the brace for bathing, sleeping, and active ankle range which may be the result of diminution of circulating
of motion exercises. Supportive shoewear with a synovial fluid delivery of nutrition to the cartilage of
custom-made arch support is worn until 6 months these unfused, but now stiffer, joints. Theoretically, an
postoperatively. Return to repetitive impact-loading anterior calcaneal opening wedge osteotomy may have
sports or conditioning is ill advised before 6 months an advantage in preserving more motion and thus pre-
postoperatively. venting long-term arthritic disease.22 An opening wedge
plantarflexion osteotomy with bone graft of the dorsal
Stage III—Tendon Elongated, Flexible or medial cuneiform also has been described20 to further
Rigid Moderate to Severe Deformity correct residual forefoot varus deformity with res-
toration of a more balanced, ‘‘tripod,’’ weight-bearing
Stage III presentation is rare, especially in the younger
foot. These procedures are technically challenging,
athlete. Intraoperative pathologic findings often eclipse
those of stage II, and the tendon is grossly incompetent
even if still intact or may be completely ruptured with
retraction of the proximal end of the tendon in the distal
medial leg. Surgical repair or reconstruction of the ten-
don as described in stage II disease may not be necessary
when a bony stabilization procedure (fusion or opening
wedge osteotomy) is performed in stage III disease.
A soft-tissue reconstruction alone, even with a medial
shift calcaneal osteotomy, probably will not prevent
recurrent deformity and associated symptoms, especially
in the heavier patient.
If the deformity, although moderate to severe, is
still flexible and there are no significant degenerative
arthritic changes, then the surgeon may consider
a medial shift calcaneal osteotomy combined with a lat-
eral column lengthening, with either a calcaneocuboid
joint distraction arthrodesis or anterior calcaneal open- Figure 8-13 Intraoperative photograph (A) and lateral (B) and
ing wedge with bone graft proximal to the calcaneocu- axial (C) heel views demonstrating nitinol step staple internal
boid joint.20,22 However, a calcaneocuboid distraction fixation of the medial shift calcaneal osteotomy of approxi-
arthrodesis usually will limit hindfoot motion signifi- mately 10 mm for patients with primarily stage II and III pos-
cantly and unduly stress the articulations of the terior tibialis tendon dysfunction.
198
...........
Treatment
and overcorrection can be a problem. Also, if autoge- varus, or in the preexisting cavovarus foot that is under-
nous iliac tricortical bone graft is chosen, the surgeon corrected, just the opposite can occur, with lateral talar
must consider the associated morbidity. Finally, as with tilt, instability, and arthritis.
any distraction arthrodesis or opening wedge osteot- Converse to the argument against a limited versus tri-
omy, the delayed or nonunion rates may be signifi- ple arthrodesis, a case can be made, especially in the
cantly higher.22 Rigid internal fixation may lessen this younger patient, for selected arthrodesis of one of the
complication. joints of the triple joint complex if the deformity is
However, if degenerative arthritis also is an issue, severe but still flexible, because limitation of motion in
then an arthrodesis is indicated. There are many propo- the other unfused joints, even if they are somewhat car-
nents of an arthrodesis of the subtalar5,20,25 or talona- tilage deficient, may prevent arthritic symptoms from
vicular joint alone, calcaneocuboid and talonavicular developing. Based on that rationale, I prefer an isolated
joint arthrodesis (double arthrodesis),9 or triple arthro- talonavicular joint arthrodesis with bone graft and
desis.26 Perhaps it may not make much difference which believe that it better corrects the abduction/pronation
type of arthrodesis is chosen, because, again, the fusion deformity and may indirectly correct a flexible hind-
of even one of these joints severely limits the motion foot valgus deformity. Others feel that the subtalar
of the other two, thus maintaining the desired correc- joint,4,5,24 and not the talonavicular, is the ‘‘keystone’’
tion. However, long-term pain and eventual arthritis to correction of the deformity. Rather than proceeding
may develop because of the limited motion in the with a subtalar or triple arthrodesis, I feel that if hind-
remaining unfused joints for the same reason as an foot valgus still is an issue intraoperatively after a talo-
isolated calcaneocuboid distraction arthrodesis as previ- navicular joint arthrodesis, then a medial shift calcaneal
ously described. A triple arthrodesis with deformity cor- osteotomy can be added.
rection would, of course, prevent this, but over time As with stage II cases, and regardless of the chosen
may lead to usually valgus ankle instability and arthri- arthrodesis or osteotomy for stage III disease, a percuta-
tis.11,22 This is the result of long-term attenuation of neous Achilles tendon lengthening or gastrocnemius
the deltoid ligament usually resulting from undercor- resection22 is further indicated if the foot cannot be
rection of hindfoot valgus that is rigid and therefore passively dorsiflexed beyond 10 degrees with the knee
incapable of inversion/eversion torque conversion, thus fully extended.
translating those forces to the medial ankle. On rare Postoperatively, cast immobilization generally is in
occasions, especially if the hindfoot is overcorrected to the 9- to 12-week range, depending on the progress
199
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of healing of the osteotomy or arthrodesis. Some limited

Physical examination revealed mild tenderness and a
weight bearing usually is allowed at 6 weeks postopera- modicum of swelling in the area of the terminal course
tively, depending on the level of healing on serial x-rays. of the posterior tibialis tendon. The ‘‘too many toes’’
Rigid bracing after casting is advised for 6 to 12 weeks. sign was inconclusive, and he was able to perform the
Supportive shoes with custom-molded arch supports single-foot heel-rise test bilaterally, although neither
may not be necessary, especially if a fusion is performed. hindfoot inverted. Bilateral flexible pes planus was noted.
Return to athletic activity is allowed 9 to 12 months There was no clinical evidence of subfibular or sinus
postoperatively. tarsi impingement. The Achilles tendon was not
contracted with passive dorsiflexion of the foot to
20 degrees.
Weight-bearing x-rays of the involved foot were essen-
PERILS AND PITFALLS (WITH ILLUSTRATIVE tially unremarkable, save for pes planus. There was no
CASE REPORTS) evidence of an accessory navicular, tarsal coalition, or tri-
ple joint degenerative arthritis. A recent MRI suggested
an interstitial rupture with tendinosis of the posterior
Lack of recognition or misdiagnosis of posterior tibialis tibialis tendon and excess fluid around it but otherwise
tendon injury in the athlete can be avoided with a con- was unremarkable.
scientious history, physical examination, and weight- Given the chronicity of the patient’s symptoms and
bearing x-rays. The differential diagnostic possibilities failed response to conservative treatment, he was sched-
(see Table 8-1) also should be kept in mind when en- uled for surgical reconstruction for severe stage I or early
countering the athlete with a suspected posterior tibialis stage II disease.
tendon injury to prevent the perils and pitfalls of misdi- Intraoperatively, there was indeed mild attenuation and
agnosis and to aid selection of the proper treatment. incompetency of the posterior tibialis tendon with a small
If the presenting patient’s diagnosis then is still in ques- longitudinal interstitial rupture and tenosynovitis. Also,
tion, then an MRI is recommended. However, even the the plantar medial capsule of the talonavicular joint
most astute diagnostician can fail to determine the was completely ruptured (Fig. 8-14, A and B). This pathol-
ogy had not been detected in the preoperative MRI. In
proper diagnosis.
addition to repair and imbrication of the capsular tear,
the posterior tibialis tendon was repaired and advanced,
and a medial shift calcaneal osteotomy was performed.
After 6 weeks of casting and 6 weeks of bracing
postoperatively, the patient was fitted with bilateral,
C A S E S T U D Y 1 custom-molded, soft, longitudinal arch supports, espe-
cially in his running shoes, and returned to running at
6 months.
This case points out that other traumatic pathology
One dilemma of determining the correct diagnosis may mimic (see Table 8-1) and other conditions (e.g.,
and treatment is especially evident in the patient who pes planus) may contribute to posterior tibialis tendon
may have preexisting bilateral pes planus, because insufficiency. More specifically, the examiner and
unilaterality of the traumatically acquired pes plano surgeon should consider diagnostically and surgically
valgus deformity with a positive ‘‘too many toes’’ sign repair a ruptured plantar medial talonavicular joint
may not be a conclusive physical finding. Also, in the capsule.
patient who has a more chronic presentation, swelling
and tenderness may not be impressive. Furthermore,
because of the abnormal biomechanics in the patient with
bilateral pes planus, the single-foot heel-rise test (or lack
of hindfoot inversion if the patient is successful in heel
rise) may be positive in both feet.
I recently encountered such a case in a 58-year-old
healthy man who had been an active runner until he began C A S E S T U D Y 2
experiencing medial right ankle and midfoot pain and
swelling 1 year before presentation. Conservative treat-
ment by the referring physician had included cessation of
running and impact-loading exercise, immobilization for 6 Another case serves to illustrate the importance of the
weeks, nonsteroidal anti-inflammatory medication, physi- differential diagnosis (see Table 8-1).
cal therapy, and the use of bilateral, custom-molded, soft, A 17-year-old presented with a several-month history of
longitudinal arch supports with medial posting for the pain, swelling, and stiffness of the left foot after a twist-
involved foot in supportive shoes. ing eversion injury was incurred while he was playing
200
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Perils and pitfalls (with illustrative case reports)
Figure 8-15 Bony calcaneonavicular tarsal coalition in

Case 2.
‘‘arch supports.’’ A report of x-rays of the left foot taken

recently was described as ‘‘normal.’’
Physical examination revealed normal ankle range of
motion but a rigid pes plano valgus deformity with pero-
neal muscle spasm. The uninjured right foot
was flexible, with a normal range of hindfoot motion.
A Tenderness and swelling was appreciated along the
terminal course of the posterior tibialis tendon. The
‘‘too many toes’’ sign was positive and the hindfoot
failed to invert in the left-foot single-foot heel-rise test.
Save for the rigidity of the hindfoot, the physical find-
ings and perhaps much of the history would have
suggested that the patient had sustained a posterior
tibialis tendon injury with dysfunction. However, x-rays
taken in my office clearly were not ‘‘normal’’ and
demonstrated a skeletally mature left foot with an
obvious bony calcaneonavicular tarsal coalition and
significant degenerative arthritis of the triple joint
complex (Fig. 8-15).
Given the severe rigidity of the hindfoot, pes planus
deformity, triple joint degenerative arthritis, and failure
of conservative treatment, the patient underwent a triple
arthrodesis with corrective joint osteotomies. It was
felt that a resection of the mature bony coalition, given
the degree of the deformity and arthritic changes of
the triple joint complex, would not have resulted in a suc-
B cessful outcome. One year postoperative from the triple
arthrodesis, the patient was asymptomatic and had
Figure 8-14 Intraoperative photograph (A) and returned to some limited, repetitive, impact-loading
schematic drawing (B) of complete rupture of the sports.
plantar medial talonavicular joint capsule as seen
in Case 1. The hyperemic interstitially torn poste-
rior tibialis tendon is retracted inferiorly.
C A S E S T U D Y 3
soccer. As reported by his mother, the patient also had
recently experienced a ‘‘growth spurt’’ several months
before the injury. Before referral to my office, conserva-
tive treatment had been rendered by his pediatrician The final case further emphasizes the differential diagno-
that included bracing, over-the-counter nonsteroidal sis and potential diagnostic pitfalls of posterior tibialis
anti-inflammatory medication, physical therapy, and tendon injury and dysfunction.
201
...........
A 16-year-old patient presented to my office with the SUMMARY

recent history of an eversion injury of the right foot when
she twisted it running to first base while playing softball.
There were no prodromal symptoms before the injury. Again, although rare, the acute rupture or dysfunction
She complained of swelling and pain along the distal of the posterior tibialis tendon in the athlete demands
medial navicular insertional area of the posterior tibialis timely diagnostic recognition and proper treatment.
tendon. Conservative treatment is recommended initially, espe-
Physical examination confirmed tenderness, swelling, cially in the patient without deformity (stage I). Surgical
and ecchymosis in the anatomic area of her symptoms treatment is advised if conservative treatment fails in any
as described. The ‘‘too many toes’’ sign was negative, stage, but especially if there is significant deformity
but she complained of pain in the plantar medial midfoot (stage II and III). Prompt treatment, whether conserva-
with the single-foot heel-rise test, although the injured tive or surgical, may prevent the development of pri-
side hindfoot inverted normally when compared with the
marily triple joint or even ankle degenerative arthritis
uninjured foot.
and resultant need for an arthrodesis, which may spell
X-rays demonstrated a medial navicular avulsion-type
the end of an athlete’s participation in repetitive,
fracture versus a small, nonunited accessory navicular
with presumed synchondrosis disruption (Fig. 8-16).
impact-loading conditioning and sports.
Comparison x-rays of the other foot also revealed
a similar small, nonunited accessory navicular, thus
suggesting the latter diagnosis. (Serial x-rays during REFERENCES
the treatment period did not reveal bony healing of the
possible avulsion fracture to the main body of the
1. Kettelkamp DB, Alexander HH: Spontaneous rupture of the
navicular, thus again suggesting that this was a synchon-
posterior tibialis tendon, J Bone Joint Surg 51A:759, 1969.
drosis disruption of a nonunited accessory navicular and 2. Mueller TJ: Ruptures and lacerations of the tibialis posterior
not a fracture.) tendon, J Am Podiatr Med Assoc 3:109, 1984.
Treatment consisted of immobilization and a well- 3. Funk DA, Cass JR, Johnson KA: Acquired adult flatfoot secondary to
molded, short-leg, nonweight-bearing cast for 3 weeks, posterior tibial-tendon pathology, J Bone Joint Surg 68 A:95, 1986.
followed by rigid bracing with an arch support with 4. Johnson KA: Tibialis posterior tendon rupture, Clin Orthop
progressive weight bearing as tolerated for another 177:140, 1982.
3 weeks. She returned to sports, asymptomatic, 3 months 5. Johnson KA, Strom DE: Tibialis posterior tendon dysfunction,
Clin Orthop 239:196, 1989.
postinjury.
6. Goldner JL, et al: Progressive talipes equinovalgus due to trauma
This case also demonstrates the importance of or degeneration of the posterior tibial tendon and medial plantar
comparison x-rays in determining the correct diagnosis ligaments, Orthop Clin North Am 5:39, 1974.
and thus the appropriate treatment. 7. Jahss MH: Spontaneous rupture of the tibialis posterior tendon:
clinical findings tenographic studies, and a new technique of
repair, Foot Ankle 3:158, 1982.
8. Leach RE, DiIorio E: Pathologic hindfoot condition in the
athlete, Clinic Orthop 177:116, 1983.
9. Mann RA, Thompson FM: Rupture of the posterior tibialis
tendon causing flatfoot, J Bone Joint Surg 67A:556, 1985.
10. Pomperoy GC, et al: Acquired flatfoot in adults due to dysfunction
of the posterior tibialis tendon, J Bone Joint Surg 81A:1173, 1999.
11. Myerson MS: Adult acquired flatfoot deformity, J Bone Joint Surg
78A:780, 1996.
12. Bloome DM, Marymont JV, Varner KE: Variations in the inser-
tion of the posterior tibialis tendon: a cadaveric study, Foot Ankle
Int 24:780, 2003.
13. Gazdag AR, Cracchiolo A: Rupture of the posterior tibialis
tendon, J Bone Joint Surg 79A:675, 1997.
14. Alexander IJ, Johnson KA, Berquist TH: Magnetic resonance
imaging in the diagnosis of disruption of the posterior tibial ten-
don, Foot Ankle 8:144, 1987.
15. Conti S, Michelson J, Jahss M: Clinical significance of magnetic
resonance imaging in pre-operative planning for reconstruction
of posterior tibialis tendon ruptures, Foot Ankle 13:208, 1992.
16. Koff FJ, Marcus RE: Clinical outcome of surgical treatment of the
symptomatic accessory navicular, Foot Ankle Int 25:27, 2004.
Figure 8-16 Coned down and magnified view of non- 17. Yeap JS, Singh D, Birch R: Tibialis posterior tendon dysfunction:
united accessory navicular with presumed synchondrosis a primary or secondary problem? Foot Ankle Int 22:51, 2001.
disruption in Case 3. 18. Perry MD, et al: Ultrasound magnetic resonance imaging, and
posterior tibialis dysfunction, Clin Orthop 408:225, 2003.
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19. Trnka HJ: Dysfunction of the tendon of tibialis posterior, J Bone 24. Wacker JT, Hennessy MS, Saxby TS: Calcaneal osteotomy and
Joint Surg 86B:939, 2004. transfer of the tendon of flexor digitorum longus for stage-II
20. Johnson JE, Yu JR: Arthrodesis techniques in the management of dysfunction of tibialis posterior, J Bone Joint Surg 84B:54,
stage II and III acquired adult flatfoot deformity, J Bone Joint 2002.
Surg 87A:1866, 2005. 25. Russotti GM, Cass JR, Johnson KA: Isolated talocalcaneal
21. Ford LT, DeBender J: Tendon rupture after local steroid injec- arthrodesis, J Bone Joint Surg 70A:1472, 1988.
tion, South Med J 7:827, 1979. 26. Coetzee JC, Hansen ST: Surgical management of severe deformity
22. Coetzee JC, Castro MD: The indications and biomechanical ratio- resulting from posterior tibialis tendon dysfunction, Foot Ankle
nale for various hindfoot procedures in the treatment of posterior Int 22:944, 2001.
tibialis tendon dysfunction, Foot Ankle Clin North Am 8:453, 27. Marks RM, Schon LC: Post-traumatic posterior tibialis tendon
2003. insertional elongation with functional incompetency: a case
23. Myerson MS, et al: Tendon transfer combined with calcaneal report, Foot Ankle Int 19:180-183, 1998.
osteotomy for treatment of posterior tibialis tendon insufficiency:
a radiological investigation, Foot Ankle Int 16:712, 1995.
203
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........................................... C H A P T E R 9
Nerve disorders and

plantar heel pain
A. Lower-extremity nerve injuries in athletes
A. Lee Dellon
......................
CHAPTER CONTENTS
A. Lower-extremity nerve injuries in athletes 205 B. Plantar heel pain 226

Introduction 205 Fat pad insufficiency 226
Joint pain of neural origin 207 Insertional plantar fasciosis 227
Peroneal nerve injuries 210 Entrapment of the first branch of the lateral plantar
nerve 233
Posterior tibial nerve injuries 215
Tarsal tunnel syndrome 236
Less common lower-extremity peripheral nerve
problems 222 Midsubstance plantar fasciitis 236
References 224 Summary 237
Further reading 226 References 238
INTRODUCTION
Language is a critical part of our ability to make a
diagnosis that relates appropriately to our treatment
It is my honor to write this chapter for the current edi- options. In that regard, today the word ‘‘functional’’
tion of the book first edited by Donald E. Baxter, MD, often is used in contrast to ‘‘organic,’’ and therefore I
and now edited by David Porter, MD, PhD, and Lew C. feel it is better to describe peripheral nerve problems
Schon, MD. Lew Schon, MD, and Don Baxter, MD, related to muscular activity as ‘‘exercise-induced’’ rather
wrote correspondingly the first two authoritative chap- than ‘‘functional,’’ because ‘‘functional’’ might connote
ters on this subject in 1994.1,2 Much of what they wrote a psychogenic origin. During diagnostic testing for such
is now among the ‘‘classical’’ knowledge base of foot an exercise-induced problem, the examiner may use
and ankle surgeons everywhere. Understandably, it is techniques that ‘‘provoke’’ the symptoms by creating
with trepidation that one approaches any changes in compression of the peripheral nerve through certain
‘‘the classics.’’ Yet, over the past decade, much has been maneuvers, such as the Phalen sign, wrist flexion test
learned related to the pathophysiology, neuroanatomy, for carpal tunnel syndrome, or maintaining the elbow
and neurodiagnostic testing techniques that can solidify flexed to provoke the symptoms of cubital tunnel syn-
and augment our approach to that base of knowledge drome. Therefore the young athlete who complains of
related to lower extremity nerve injuries in the athlete. dorsolateral foot pain radiating from the lower leg early
CHAPTER 9 Nerve disorders and plantar heel pain
Figure 9A-1 Neuronal swelling proximal to the site of chronic compression can cause the appearance of
a neuroma, such as in the interdigital nerve to the third webspace (A), or the deep peroneal nerve over the dorsum
of the foot (B). In B the extensor hallucis brevis tendon, the source of the compression, has been excised.
in the training process, whether running or dancing, by Sir Herbert Seddon into three groups (neurapraxia,
should have an exercise-induced compartment syn- axonotmesis, neurotmesis), then by Sir Sydney Sunder-
drome included in the differential diagnosis, because land into five groups (I-V), and finally by Mackinnon
the basis of that pain is acute nerve compression. Simi- and Dellon into six groups,3 permits diagnosis and
larly, a ‘‘neuroma’’ is the pathophysiologic process of prognostication. One could use the knee as an exam-
entrapment of axonal sprouts regenerating into scar tis- ple. The soccer or football player who sustains suffi-
sue.3 A painful neuroma should be treated surgically by cient force to the medial knee may have a direct
resection and implantation of the proximal end into contusion to the infrapatellar branch of the saphenous
muscle, a technique that has withstood the test of time nerve and medial knee pain, which is independent from
for the past 20 years for both the upper and lower ligamentous or meniscal structural problems identifi-
extremity.4-8 In contrast, chronic compression of a able on a magnetic resonance imaging (MRI). If the
nerve will create an area of narrowing of the nerve with infrapatellar branch is simply crushed, recovery of nerve
a swelling resulting from axoplasmic accumulation prox- function will be to a normal level, and this will occur
imal to that point (Fig. 9A-1, A and B). That swelling within 3 weeks. In contrast, if the force was sufficient
may appear to be a neuroma but is not a true neuroma. to cause disruption of the nerve, bruising, and adher-
This situation occurs distally in the foot related to the ence to the pes anserinus, there will be loss of sensory
interdigital nerve and the transverse intermetatarsal liga- function and formation of a painful neuroma. If the
ment. The appropriate name for this painful condition force of impact is sufficiently great, there may be dam-
should be ‘‘interdigital nerve compression’’ and not age to the meniscus or the collateral ligament, and, in
‘‘interdigital neuroma.’’ The history of the origin of addition to those structural problems, there may be
this unusual nomenclature has been reviewed recently,9 pain resulting from direct damage to the innervation
and the term ‘‘interdigital nerve compression in the of the knee joint.10 This leads to knee pain of neural
(given)-interspace,’’ although cumbersome, is used in origin in addition to the musculoskeletal problems.
this chapter. Resection of a Morton’s neuroma (which There may be sufficient lateral force exerted on the
is not a true neuroma) results in a true (painful or not) knee to cause complete loss of continuity of the com-
neuroma. Resection is the appropriate surgical treatment mon peroneal nerve in addition to the knee joint or
for a painful neuroma, and neurolysis is the appropriate fibular injuries (Fig. 9A-2), resulting in peroneal motor
surgical treatment for chronic nerve compression.3 The and sensory palsy. Therefore ‘‘nerve injury’’ is an insuf-
name we ascribe to a given neuropathologic condition ficient term to specify the neuropathophysiologic cause
therefore has implications for the surgeon. of the athlete’s pain. Even the term ‘‘peroneal nerve
The mechanism of injury results in different degrees palsy’’ creates ambiguity: Is the correct treatment a
of nerve injury. Mechanisms may include direct contu- period of observation, a neurolysis, or a nerve recon-
sion, stretch/traction, laceration, or acute or chronic struction? In this chapter the application of computer-
compression. The pathophysiology, initially subdivided assisted neurosensory testing is included in an attempt
206
...........
Joint pain of neural origin
Figure 9A-2 During a badminton game, this woman sustained a twisting injury to the right knee and fell,
fracturing the fibular head (A). There was an associated complete footdrop. Intraoperatively, at the time of
fracture fixation, the common peroneal nerve was completely divided by the stretch/traction injury. The first
surgeon reunited the nerve and referred the patient for peripheral nerve reconstruction. The neuroma-in-
continuity is identified at the time of reconstruction (B).
to add measurements to the staging of peripheral nerve

injury,11 and therefore to the decision-making process.
Peripheral nerve surgery requires the use of a pneu-
matic thigh tourniquet, loupe magnification, and bipo-
lar coagulation to properly identify and protect the
nerves. In some cases a disposable nerve stimulator is
required to identify certain motor functions of the
nerve. General anesthesia is preferred. The following is
a personal approach to the problems I have encountered
in athletes.
JOINT PAIN OF NEURAL ORIGIN
Knee joint pain can be defined to be of neural origin

after any musculoskeletal problems with the integrity
of the knee joint have been eliminated from the differen- Figure 9A-3 Partial knee denervation patient 3 months after
tial diagnosis or have been treated. A common situation the left and 6 months after the right knee each had a medial
is knee pain in the athlete with an MRI that has and lateral knee denervation. The 3-cm scars over the medial
been interpreted to be normal. Rest, nonsteroidal anti- (right) and the lateral (left) knees are apparent.
inflammatory drugs, and intraarticular steroid injections
have not been successful at relieving pain. Arthritis may have been stretched or torn and have formed a painful
or may not be present radiographically, and if it is, the neuroma within the joint structures. Indeed, these
patient may have failed to improve with treatment nerves may have been injured by the arthroscopy itself.
designed to form new cartilage. More than likely the (Figure 9A-3 is an example of a man with bilateral knee
patient will have had one or more knee arthroscopies, pain after years of martial arts, for whom all of the previ-
at which plica has been removed, cartilage has been ously mentioned treatments were ineffective and for
debrided, or a synovectomy has been performed, but whom partial knee denervation permitted resumption
there is still pain. Could this pain be of neural origin? of daily activities, but not martial arts, without pain.
With the description in 1994 of the innervation of Demonstration of neural origin for the pain is accom-
the human knee,10 it becomes reasonable to consider plished by (1) local anesthetic block of the suspected
that the medial or lateral retinacular nerves, or both, nerves, (2) the patient having a decrease in his visual
207
...........
Figure 9A-4 Innervation of the human knee joint is illustrated for the lateral (A) and medial (B) views of the
knee region. The lateral retinacular nerve originates from the sciatic nerve, crosses deep to the biceps tendon,
and innervates the lateral retinacular region. The medial retinacular nerve is the continuation of the femoral
nerve branch to the vastus medialis, exits distal and deep to this muscle, and innervates the medial retinacular
region.
analog scale level of pain by at least 5 points, and (3) bone fragments within the joint as the source of the
observation of improved pain after the block while walk- pain. Any athlete in any sport can suffer this type of
ing, climbing stairs, and kneeling. If there has been preinjury. If there is a lax lateral ankle joint, surgery to cor-
vious knee surgery, a neuroma of a cutaneous nerve, like rect it with ligament reconstruction or tendon transfers
the infrapatellar branch of the saphenous nerve or the (Crisman-Snook, or Watson Jones-types) still may have
medial cutaneous nerve of the thigh, also must be con- failed to relieve the pain, although providing good sta-
sidered in the examination and the nerve blocks. bility (see Fig. 9A-12, C). If the symptoms extend to
Figure 9A-4 illustrates the location of these nerves. the dorsal lateral aspect of the foot, a stretch/traction
The first report of partial knee denervation was for injury to the peroneal nerve must be considered in the
patients after total knee arthroplasty,12 but a subsequent differential diagnosis, and this is considered later in this
report includes patients with knee pain after sports inju- chapter. If direct pressure into the sinus tarsi reproduces
ries.13 A complete description of this subject appeared in the pain, a local anesthetic block and steroid injection
the year 2000.14 The advantage of this approach is that into this region may be given for both diagnosis and
the surgery is performed on an outpatient basis, does for treatment. If the pain persists, then sinus tarsi syn-
not require invasion of the knee joint, and permits drome is present. Traditional treatment for this dis-
immediate ambulation, and rehabilitation can begin abling condition has been either a ‘‘curettage’’
when the sutures are removed. Success rates should (debridement) of the sinus tarsi, resection of the lateral
approach 90% with the previous criteria. Charcot joint shoulder of the talus, or a subtalar fusion. Could this
does not occur because this is a partial knee joint dener- pain be of neural origin? Recently, the innervation of
vation. The athlete must be counseled that posttrau- the sinus tarsi has been demonstrated to come from
matic arthritis and synovitis still will occur, but their the deep peroneal nerve.15 The innervation arises most
pain may be significantly lessened. commonly from the most lateral fascicle of the deep
Lateral ankle joint (sinus tarsi) pain can be of neural peroneal nerve, just proximal to the origin of the inner-
origin in the athlete who has had repetitive inversion vation of the extensor digitorum brevis in all patients
sprains or a fracture/dislocation of the lateral malleolus. (Fig. 9A-5). About 25% of patients have a dual innerva-
Typically, the inversion sprain is treated with immobili- tion of the sinus tarsi from the sural nerve.15 With this
zation and anti-inflammatories, and then a progressive knowledge, lateral ankle pain can be proven to be of
regimen of stretching and strengthening is begun. If neural origin by blocking the deep peroneal nerve prox-
pain persists and x-rays have not demonstrated a frac- imal to the ankle. At this site, the nerve is lateral to the
ture, then a computed axial tomography (CAT) scan extensor hallucis longus and medial to the extensor digi-
with three-dimensional reconstruction is suggested to torum longus (Fig. 9A-6, A). If there is not complete
be sure there are not occult intra-articular fractures or relief, then the sural nerve is blocked proximal to the
208
...........
Joint pain of neural origin
lateral malleolus (Fig. 9A-6, B). The first case of sinus

tarsi denervation was reported in 2002 using the tech-
nique of resecting just the fascicle that innervates this
joint, identifying this by intraoperative nerve stimulation
(the most medial fascicle is to the dorsal skin of the first
webspace, the central fascicle causes contraction of the
extensor brevis muscle on stimulation, and the lateral fas-
Deep peroneal n.
cicle is the one innervating the joint).16 In a subsequent
series of 13 patients reported in 2005, there were some
Nerve to tarsal
sinus failures related to this partial resection of the deep pero-
Extensor neal nerve because of joint afferents passing also through
digitorum
brevis m.
the other fascicles.17 The current recommendation
therefore is to resect the entire deep peroneal nerve.
This is accomplished through an incision located 10 to
12 cm proximal to the lateral malleolus. The anterior
compartment is opened with an 8-cm long fasciotomy.
The deep peroneal nerve can be identified by dissecting
superficial to the interosseous towards the tibia, at which
point the nerve is identified with the anterior tibial ves-
sels. A 2-cm length is resected. Immediate weight bear-
ing is permitted. Rehabilitation is begun when the
sutures are removed. In these patients, related to the ini-
tial stretch/traction injury, there already may be
decreased sensibility in the dorsal first webspace and
decreased bulk or weakness of the extensor brevis. These
should be pointed out to the patient. The numbness
present during the block should be pointed out to the
patient, who must be informed that this may be perma-
nent after the nerve is resected. The successful relief of
Figure 9A-5 Innervation of the sinus tarsi from the deep pain should approach 90% with this approach. Examples
peroneal nerve occurs with a branch that arises proximal to of a patient resuming beach activities and one resuming
the lateral malleolus. In 25% of patients, there is a second downhill skiing after this procedure are given in
innervation from the sural nerve. Figure 9A-7.
Figure 9A-6 Local anesthetic block of the sinus tarsi is performed by first blocking the deep peroneal nerve
proximal to the ankle (A), and then, if sinus tarsi pain still is present to some degree, by blocking the sural
nerve proximal to the ankle (B). (Photos courtesy Stephen L. Barrett, DPM, Phoenix, AZ.)
209
...........
Figure 9A-7 Results of denervating the sinus tarsi is demonstrated in this 19-year-old who has resumed playing
Frisbee on the beach (A) and in this 49-year-old who has resumed downhill skiing (B). The first patient was
injured running on the beach and the second during a fall while rock climbing.
include direct trauma to the knee in contact sports, such

PERONEAL NERVE INJURIES
as sliding into base in baseball, football, or soccer, and
stretch/traction injuries related to inversion sprains of
The peroneal nerve arises in the popliteal fossa from the the ankle. Positions such as catcher in baseball put the
sciatic nerve and travels distally around the fibular neck. common peroneal nerve at risk from chronic compres-
There are no sites of entrapment in the popliteal fossa, sion. The most common symptoms include paresthesias
although the nerve can be injured in this location iatro- into the lateral aspect of the leg and the dorsum of the
genically. Figure 9A-8 illustrates the three most com- foot or the perception that the leg is going to ‘‘give
mon sites for injury to athletes of this nerve, which out.’’ The first symptom set is related to neural ische-
consist of sites of anatomic narrowing at which the mia, which gives rise to the paresthesias in the reversible
branches of this nerve are at the risk, namely, the com- ischemic block degree of nerve injury. The second set of
mon peroneal nerve at the fibular neck, the superficial symptoms, I believe, is related to a similar phenomenon
peroneal nerve in the distal leg, and the deep peroneal in the motor innervation of the muscles that control
nerve in structures over the dorsal ankle and foot. ankle dorsiflexion and toe extension. These symptoms
The common peroneal nerve can be injured in many are transient and worsen with activity. There may be
athletic activities. The common mechanisms for injury no positive physical findings with the exception of
210
...........
Peroneal nerve injuries
Skin incision
Head of
fibula
Common
peroneal n.
Deep
peroneal n.
Peroneus
longus m.
Common
peroneal
nerve
Deep
peroneal
nerve
Deep peroneal n.
Nerve to tarsal
Superficial Extensor sinus
peroneal digitorum
nerve brevis m.
Figure 9A-8 The peroneal nerve is at risk for injury in athletes because of stretch/traction and compression
of the common peroneal nerve at the fibular neck, the superficial peroneal nerve as it exits the fascia in
the distal third of the leg, and the deep peroneal nerve as it crosses the dorsum of the ankle and the foot.
For the deep peroneal nerve, the most common site of entrapment is beneath the extensor hallucis longus
tendon. These three sites are noted by arrows. (Courtesy www.DellonIPNS.com Web site, patient-interactive
tutorial.)
tenderness of the common peroneal nerve at the neck of persistent, the earliest sensory change will be the pres-
the fibula. At this stage of treatment, awareness of this sure required to distinguish one- from two-point static
diagnosis is critical, and the treatment is related to touch using the Pressure-Specified Sensory Device
relieving pressure on the nerve by changing the athlete’s (Fig. 9A-9). Electrodiagnostic testing most likely will
workout regimen. As symptoms become more still be normal. The first muscle to demonstrate
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Combined Deep Peroneal Combined Lateral Calf
100 Left Right 100 Left Right
80 80
GM/SQ MM
GM/SQ MM
60 60
40 40
% %
20 20
1 PT 2 PT 1 PT 2 PT 1 PT 2 PT 1 PT 2 PT
Static Moving Static Moving
Line indicates 99% Normal Confidence Level Line indicates 99% Normal Confidence Level
(gm/sq mm) 9.9 26.4 1.0 11.0 (gm/sq mm) 4.5 25.6 1.8 14.3
5.5 mm 6.4 mm 6.5 mm 6.2 mm
C
Figure 9A-9 Physical examination and neurosensory testing related to common peroneal nerve entrapment.
(A) Weakness of the extensor hallucis longus is the first muscle to show physical findings related to the motor
function. (B) Weakness or atrophy of the extensor digitorum brevis should be evaluated. Complete dropfoot is
obvious. (C) Evaluation of the sensory component with the Pressure-Specified Sensory Device results in a
computer printout in which the pressure required to discriminate one- from two-point static touch is measured.
In this report the left, blue bars are above the 99% confidence limit for pressure for age (the horizontal black
bar), indicating abnormal function for the left side, whereas the right side, in red, is below the bar. The asterisk
denotes abnormal distance for the measurement, indicating axonal loss. The sensibility is abnormal for both the
deep and superficial peroneal nerve, indicating either that both of these nerves are abnormal or that the location
of the problem is proximal, at the fibular neck.
weakness usually is the extensor hallucis longus (see oblique at the fibular neck. Care is taken not to injure
Figure 9A-9). With the onset of muscle weakness or the occasionally present lateral cutaneous nerve of the
the increase in distance required for two-point discrimi- calf. The fascia is opened and the common peroneal
nation, the degree of compression is sufficiently chronic nerve identified. The nerve is followed distally to the
and severe to justify neurolysis of the common peroneal entrapment site at the peroneus longus muscle. If there
nerve. This is illustrated in Figure 9A-10. The incision is has been direct knee trauma, the fascia will be adherent
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Peroneal nerve injuries
to the nerve, and the neurolysis then is continued prox- patients will have a fibrous band deep to the peroneus
imally into the popliteal fossa. Recent observations have longus muscle. This must be searched for and divided
made the following modifications to the procedure as if present, and there often will be a notch at this location
previously described18: 20% of cadavers but 80% of in the nerve (Fig. 9A-11). A smaller percentage of
patients also will have fibrous bands on the surface of
the lateral head of the gastrocnemius muscle, deep to
the nerve, and these must be released. Finally, a high
origin of the soleus muscle may narrow the entrance of
the nerve into the anterolateral compartment, and this
origin must be released from the fibula.19
The superficial peroneal nerve has a variable anatomy
in the leg. Up to 40% of cadavers have the superficial
peroneal nerve either completely in the anterior com-
partment (Fig. 9A-12) or a branch in the anterior and
a branch in the lateral compartment (Fig. 9A-13).20,21
The superficial peroneal nerve exits from beneath the
deep fascia to become subcutaneous in the distal third
of the leg. This site is quite variable but is most com-
monly located 10 to 12 cm proximal to the lateral mal-
leolus (see Fig. 9A-8). In young athletes, such as
runners or dancers, this site can be compressed because
the muscles of the anterior and lateral compartment
Figure 9A-10 Intraoperative view follows neurolysis of the
bulge during exercise, creating ischemic neuralgia. This
common peroneal nerve. Note that the fascia superficial to pain goes away with cessation of the physical activity.
the peroneus longus has been divided and is held by two The diagnosis should be made with compartment pres-
clamps. The muscle has not been divided. Fascial bands deep sure measurements while the patient is in a controlled
to the peroneus longus often are present and must be divided. exercise environment, such as on a treadmill. Elevation
Similar structures deep to the nerve may be present on the of pressure to greater than 30 mm Hg coinciding with
lateral gastrocnemius muscle belly and should be divided. the pain is an indication for fasciotomy. Although the
Finally, the entrance of the nerve into the anterolateral fasciotomy incision does not need to be long, the fas-
compartments must be widened. The blue vessel loop is on ciotomy should be extensive to prevent a small muscle
the sural nerve, which can be identified through this incision herniation, which itself can be painful. The fascia is well
for the treatment of a painful sural neuroma.
Figure 9A-11 Intraoperative view of common peroneal nerve being compressed by a fibrous band beneath the
peroneus longus muscle. (A) The muscle is retracted. The white fibrous edge of the band is apparent, and it
extends deep to the muscle. (B) After the band is resected, the indentation or notch in the common peroneal
nerve is evident.
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Figure 9A-12 A female catcher injured her right leg sliding into base and ultimately required a lateral ankle
stabilization (A). At 3 years after her injury, and with her no longer able to play softball, she was found to
have a painful sinus tarsi, a nonpainful scar, and a positive Tinel sign over both the superficial and common
peroneal nerve. A block was administered to the deep peroneal above the ankle, relieving her of her sinus tarsi
(lateral ankle) pain. (B) In surgery, the superficial peroneal nerve was found to be completely within the anterior
compartment. This view demonstrates the fasciotomy of this compartment and complete neurolysis. (C) This view
demonstrates the fascia separating the two compartments, attached to the fibular, and the small retractor lies
beneath the deep peroneal nerve, to denervate the sinus tarsi.
vascularized, and its edges should be cauterized to min- peroneal nerve are paresthesias from the distal leg into
imize postoperative bruising or hematoma. Care is taken the top of the foot, without motor symptoms. There
to not injure the nerve, and the neurolysis must be will be a positive Tinel sign at the site of compression.
extended proximally until the nerve is surrounded by Sensory testing will demonstrate normal sensibility in
muscle and distally until the nerve enters the subcutane- the dorsal first webspace and abnormal sensibility over
ous tissue (see Fig. 9A-12). For soccer players, this nerve the dorsolateral foot. Results of neurolysis of this nerve
can be injured directly by the ball or by being kicked. are good to excellent in 85% of patients.21,22 Surgery is
Similar injuries can occur in field hockey and lacrosse. performed on an outpatient basis, and immediate ambu-
Symptoms of chronic compression of the superficial lation is encouraged to permit gliding of the nerve
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Posterior tibial nerve injuries
spins. Loosening the laces on her skates did not help.

There was a positive Tinel sign at this location. Radio-
graphic evaluation, including MRI, had been normal.
Her electrodiagnostic studies had been normal (with
the more proximal anterior tarsal tunnel location, elec-
tromyogram [EMG] of the extensor brevis digitorum
brevis muscle can help in the diagnosis), but her neuro-
sensory testing with the Pressure-Specified Sensory
Device demonstrated increased pressure threshold and
abnormal two-point static threshold for distance. At
surgery, her deep peroneal nerve clearly was indented
by the extensor hallucis brevis tendon (see Fig. 9A-1,
A), and this tendon was removed. She was able to
resume ice skating at 10 days and return to doing jumps
and spins without pain.
Figure 9A-13 Intraoperative view of neurolysis of superficial

peroneal nerve. In this patient, there was a branch of the
nerve in both the anterior and the lateral compartment, POSTERIOR TIBIAL NERVE INJURIES
emphasizing, as in Figure 9A-12, the need to release both
compartments. There is no ‘‘anterior tibial nerve,’’ and therefore some
writers use the term ‘‘tibial nerve’’ instead of ‘‘posterior
through the surgical site. Rehabilitation begins when tibial nerve.’’ An informal survey of anatomy texts and
the sutures are removed. recent publications continues to demonstrate that the
The deep peroneal nerve has been described classically most common usage is ‘‘posterior tibial nerve.’’ This nerve
as being entrapped beneath the extensor retinaculum is in close proximity to the posterior tibial artery and vein,
in front of the ankle, with this location being called and therefore this is the name used in this chapter.
the anterior tarsal tunnel, and the clinical symptoms The proximal posterior tibial nerve arises from the
being termed the anterior tarsal tunnel syndrome.23-25 sciatic nerve in the popliteal fossa, and there is no ana-
In my experience, this is a capacious region, with the tomic site of entrapment in that location, although the
deep peroneal nerve between tendons, bone, extensor nerve can be injured iatrogenically here. For example, a
retinaculum, and fat and little chance for compression 21-year-old college student injured her knee skiing.
unless there has been a crush, a burn, an ankle fusion, During her arthroscopy, the scope perforated the posterior
or previous surgery (see Fig. 9A-8). In contrast, just dis- capsule of the knee and avulsed the popliteal artery and
tal to the inferior crus of the extensor retinaculum the vein and the posterior tibial nerve. After her emergent
extensor hallucis longus tendon crosses the deep pero- vascular reconstruction, she was referred at 3 months for
neal nerve in close proximity to the base of the first nerve reconstruction. This required direct neurotization
metatarsal and the cuneiform. This is the area in which of the gastrocnemius muscles because their motor
ganglions arise, and a dorsal exostosis forms. This exact branches were avulsed, and nerve grafting to provide
site was described as a location of chronic nerve com- distal sensation to the plantar aspect of her foot. By
pression in 1990.26 The deep peroneal nerve at this 2 years after this reconstruction, she had active plan-
location innervates the joints of the first and second tarflexion of the ankle and protective sensation to the
metatarsals and the cuneiform bones, and therefore plantar aspect of her foot.28 The posterior tibial nerve
symptoms of pain from the dorsum of the foot through continues distally to enter the distal leg by passing
to the plantar surface, like a ‘‘knife stabbing’’ this loca- between a fibrous arcade formed between the two heads
tion, can occur, in addition to the aching in the forefoot of the gastrocnemius and the soleus muscle. Theoreti-
and paresthesia in the webspace. This is a site that has cally, this can be a site of compression, and decompres-
been illustrated by Schon2 to be a risk for ballet dancers sion at this level has been described by Baxter1 as the
in the pointe position and can be directly injured and the ‘‘high tarsal tunnel.’’ I have had occasion to decompress
source of persistent pain following metatarsal stress frac- the nerve in this region in two patients who had chronic
tures or Lisfranc fracture/dislocations. Tightly fitting compartment syndrome, and one of these was related
athletic shoes have been reported to cause compression to a sports injury. That patient developed an acute com-
of the deep peroneal nerve,23-25 including by ski boots. 27 partment syndrome related to a tight ski boot, which
I have seen this to be the problem in an ice skater who went without a proper diagnosis. When the leg was
had pain in this area on the take-off and landing of her decompressed, about 48 hours later, the fasciotomy
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was proximal and inadequate. Muscle was debrided, and lollipops. The pain was relieved and all motor function
the wound skin grafted secondarily. By the time the recovered by carrying out a neurolysis of the tibial nerve
patient was referred to me 3 years later, there was in the calf, along with a four-compartment fasciotomy
a chronic compartment syndrome associated with severe and a neurolysis of the common peroneal nerve at the
pain from the knee to the toes. There was inability to flex knee. The superficial peroneal nerve had been divided
or extend the toes or ankle. The patient required a during the original fasciotomy, requiring for the neu-
wheelchair and was under pain management, requiring roma now to be resected and implanted into muscle
a Duragesic patch, methadone, Neurontin, and fentanyl (Fig. 9A-14). However, the term ‘‘tarsal tunnel’’ should
Fig. 9A-14 Neurolysis of the tibial nerve in the leg and the peroneal nerve from the knee to the ankle in
a patient who had a chronic compartment syndrome. The acute compartment syndrome 3 years earlier was
related to a tight ski boot (A). The initial fasciotomy was proximal and divided the superficial peroneal nerve. The
extreme swelling of the common peroneal nerve proximal to the site of compression is noted in B, with the nerve
encircled by the vessel loop. In C, the four compartment fasciotomy is noted, and the extensive release required
to decompress the tibial nerve compression in the leg.
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Table 9A-1 Relationship between the four medial ankle tunnels and the nerve compression sites in the upper extremity
Sites of nerve compression

Lower extremity Upper extremity
Tarsal tunnel Forearm
Medial plantar tunnel Carpal tunnel
Lateral plantar tunnel Guyon’s canal
Calcaneal tunnel Palmar cutaneous branch of median nerve tunnel33
be reserved for a compression site in relation to the tarsal paresthesias progress to constant numbness. Electro-
bones and not in the midcalf. diagnostic testing can document this problem but has
Tarsal tunnel syndrome was described in 1962 but a high false-negative rate. Neurosensory testing with
remains relatively misunderstood. It is often referred to the Pressure-Specified Sensory Device (NK Biotechnical,
as the ‘‘carpal tunnel syndrome of the foot.’’ When my Minneapolis, MN) can document this problem at an
first patient was referred to me in about 1980, and earlier stage than electrodiagnostic testing.30-32 An
I studied this statement, I realized that in fact the tarsal example of the documentation of tarsal tunnel syn-
tunnel region was analogous to the forearm and not the drome with neurosensory testing is given in Figure 9A-
carpal tunnel. Subsequently the appropriate relation- 16, B. Rehabilitation after decompression of the four
ships were published and are given in Table 9A-1.29 medial ankle tunnels is critical to the success of the sur-
The patient with carpal tunnel syndrome would not be gery. It should be clear that if a nerve is permitted to
relieved by a forearm fasciotomy, and so an operation remain immobilized during the wound healing process,
was designed to decompress the four medial ankle tun- the formation of collagen in that process will result in
nels (Fig. 9A-15). It is not appropriate to call this oper- scarring of the nerve into the surgical field, causing fail-
ation ‘‘tarsal tunnel decompression’’ alone because four ure of the original neurolysis.34 Early if not immediate
separate tunnels are decompressed. It is confusing to mobilization of the nerve must be part of the postoper-
speak of the tarsal tunnel as the ‘‘upper tarsal tunnel’’ ative regimen for the tibial nerve at the ankle as it is for
and the medial and lateral plantar tunnels as the ‘‘distal’’ the ulnar nerve at the elbow.35 Although there are many
or ‘‘lower tarsal tunnel.’’ In this chapter, each tunnel is reviews of tarsal tunnel syndrome, for example the one
called by its correct anatomic name. Compression of by Lau and Daniels,36 there are no reported series larger
the nerves in the four medial ankle tunnels can occur than 68 patients, and their reported surgical results vary
in an athlete through several different mechanisms. considerably. For example, an often-quoted study, in
The medial ankle may be injured directly. Inversion which long-term follow-up was obtained, reported just
sprains may create sufficient bruising and swelling so 44% of the patients with excellent outcomes and a 13%
that the posterior tibial nerve and its branches become complication rate,37 whereas a more recent report indi-
adherent during the immobilization of the ankle for cated 72% of the patients with satisfactory results but a
3 weeks, subsequently giving rise to chronic compres- 30% complication rate.38 The most recent report, using
sion. Repetitive trauma can occur in runners, cyclers, outcome assessment, found 51% of the patients having
those who do step aerobics, and so forth. The pronated a marked improvement in the quality or their life despite
foot theoretically is more likely to have pressure applied 85% of the patients stating they had excellent relief of
to the posterior tibial nerve branches, although this their pain, with a 7% rate of complications.39 Using
remains to be proven. A fracture/dislocation of the the technique I described previously, a consecutive series
ankle or severe inversion sprain may directly contuse of 87 legs in 77 patients had the four medial ankle tun-
the tibial nerve and its branches. Swelling or blood pro- nels decompressed between January of 1987 and
ducts related to posterior tibial nerve tears or avulsion of December of 1994. The follow-up was a mean of 3.6
a portion of the navicular may cause compression of the years. The results were 82% excellent, 11% good, 5% fair,
medial plantar nerve. Symptoms of tarsal tunnel and 2% failure.40 Using a numerical grading scale,41
syndrome include aching, paresthesias, or numbness in there was a statistically significant improvement at the
the heel, arch, forefoot, or toes. Nighttime discomfort p < .001 level for each preoperative grade of impairment
is common. In time, muscle weakness and clawing of with the exception of level 10, intrinsic contracture. My
the intrinsic muscles occur (Fig. 9A-16, A) and the experience has grown considerably in posterior tibial nerve
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Medial
Post. tibial n. plantar n.
Flexor
rectinaculum
Looped: calcaneal
Med. plantar br. of med.
vess. and n. plantar n.
Abd. hallucis m.
retracted to expose
fascia
Lat. plantar
vesws. and n.
Fascial roof of
medial and lateral
tunnels divided
Calcaneal
tunnel
Septum divided
at origin; roof of
calcaneal tunnel
opened
Septum removed;
vessels and nerves
shared a common tunnel
Figure 9A-15 Illustration of the four medial ankle tunnels and the surgical approach for decompression. (A) The
traditional tarsal tunnel is almost never the site of compression, but opening it permits neurolysis of the
posterior tibial nerve, identification of any mass lesion that might be present, and identification of anomalies.
(B) The fascia superficial to the abductor hallucis brevis is divided, and the branch of the medial plantar nerve
that innervates the skin of the arch in this region in 50% of patients is identified and preserved. The muscle is
retracted to reveal the fascial roof of the medial and lateral plantar tunnels. (C-D) Each of these tunnels is
opened, and the septum between them is removed to create one large tunnel. (Courtesy www.DellonIPNS.com
Web site, patient-interactive tutorial.)
decompression, with more than 600 procedures being Heel pain syndrome of neural origin is an important
listed in my computer between January 2000 and June concept. Historically, heel pain was commonly was
2005. This large experience is due, in part, to the applica- attributed to the presence of a medial calcaneal bone
tion of this technique to relief of pain and restoration spur. This gave rise to medial heel pain’s being related
of sensation to patients with neuropathy resulting from to plantar fasciitis. However, if the traditional treatment
diabetes,42-44 chemotherapy,45 or idiopathic causes.46 for heel pain in the athlete fails to give relief, is it possi-
None of the patients have required repeat surgery with ble that the pain can be of neural origin? And if so,
the previously mentioned operative and postoperative which is the nerve along the anatomic path of which
regimen. Results of an ongoing, multicenter prospective these pain impulses are transmitted? For heel pain
study are available online at www.neuropathyregistry.com. symptoms, and especially if they are associated with
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Combined Great Toe Pulp Combined Heel
100 Left Right 100 Left Right
80 80
GM/SQ MM
60 GM/SQ MM 60
40 40
% % % %
20 20
1 PT 2 PT 1 PT 2 PT 1 PT 2 PT 1 PT 2 PT
Static Moving Static Moving
Line indicates 99% Normal Confidence Level Line indicates 99% Normal Confidence Level
(gm/sq mm) 1.6 25.7 1.0 12.8 (gm/sq mm) 5.0 50.0 2.8 11.1
7.8 mm 6.6 mm 6.5 mm 6.2 mm
B *Measurement made at non-normative spacing
Figure 9A-16 Physical examination and neurosensory testing related to posterior tibial nerve compression.
(A) Clawing, a sign of lateral plantar nerve compression, often is mistaken for hammertoes. In this patient
with bilateral severe tarsal tunnel syndrome related to neuropathy, decompression of the four medial ankle
tunnels on the right side has permitted reversal of the clawing on one side, while it remains on the other,
nonoperated side. (B) Evaluation of the sensory component with the Pressure-Specified Sensory Device results in
a computer printout in which the pressure required to discriminate one- from two-point static touch is measured.
In this report the left, blue bars are above the 99% confidence limit for pressure for age (the horizontal black
bar), indicating abnormal function for the left side, whereas the right side, in red, is below the bar. The asterisk
denotes abnormal distance for the measurement, indicating axonal loss. The sensibility is abnormal for both the
medial plantar nerve (hallux pulp) and the medial calcaneal nerve (heel, medial surface), indicating that both of
these nerves are abnormal and that the location of the compression is in both the medial plantar tunnel and the
calcaneal tunnel. The surgical approach is given in Figure 9A-15.
poststatic dyskinesia, the treatment modalities must may have been directly injured by repetitive running acti-
include strapping, stretching, changing shoes, using a vities or that a nerve entrapment is due to inflammation
heel cup, taking nonsteroidal anti-inflammatory medica- or immobilization after an ankle or heel injury. Although
tion, and getting a cortisone injection. The definition of x-ray and ultrasound are appropriate for bone and plantar
‘‘recalcitrant heel pain’’ varies, but if heel pain symp- fascia evaluation, traditional electrodiagnostic studies
toms persist, it is appropriate to consider that a nerve cannot truly measure the small medial calcaneal branches,
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Orgins of the Medial Calcaneal Nerve: Origins of the Medial Calcaneal Nerve:
One origin Two origins
A. B.
A. B. C.
16% 14%
13% 8% 7%
C. D. E.
D. E. F. G. H.
5% 1% 1% 4% 4% 2% 2% 1%
Origins of the Medial Calcaneal Nerve: Origins of the Medial Calcaneal Nerve:
Three origins Four origins
A. B.
10% 3%
C. D. E. F. A. B.
2% 2% 1% 1% 2% 1%
Figure 9A-17 Variations in the innervation of the medial heel. There can be from one to four different nerves
innervating the medial heel, with these arising in almost every conceivable variation from the posterior tibial,
medial plantar, lateral calcaneal, or any combination of these.55
and techniques that measure the motor or sensory com- branch of the lateral plantar nerve often is clearly not the
ponent of the lateral plantar nerve have been used as surro- branch carrying the pain impulses from the periosteum
gates.47 The origin of pain from plantar fasciitis presumably of the medial calcaneal tubercle. Those periosteal nerves
is the periosteum, where this fascia originates from the always, ultimately, become part of the posterior tibial
medial calcaneal tubercle. This nerve, as I interpret the con- nerve, and most often are within the lateral plantar nerve.
cept, is the nerve described first by Rondhuis and Huson If the site of nerve compression is within the lateral plantar
in 198648 and subsequently popularized as the source of tunnel, then there will be symptoms of numbness or pares-
this heel pain by Baxter’s group.49-51 It was Rondhuis thesia present in addition to heel pain, and measurement of
and Huson who first gave this nerve the name ‘‘first branch the medial calcaneal skin surface will identify an abnormal
of the lateral plantar nerve.’’ Ultimately, the nerve has cutaneous pressure threshold. It is better therefore didacti-
come to be known as ‘‘Baxter’s nerve.’’52 Anatomic studies cally to say that heel pain can be due to entrapment of a
have defined the saphenous, sural, and tibial contributions branch of the posterior tibial nerve, which usually is a
to the heel.53,54 Most recently, a detailed analysis of branch of the lateral plantar nerve, but until the anatomy
the posterior tibial nerve branches to the heel in 85 is defined at surgery, it is not possible to know which
patients, performed in a bloodless intraoperative field with branch is the source of the pain. In a recent study,56
3.5-loupe magnification, has outlined the many variations approximately 40% of patients presenting with heel pain
of the medial calcaneal nerve.55 There are many patients had abnormal medial calcaneal cutaneous pressure thresh-
with three or four branches that innervate the medial calca- old measurements, and another 20% had abnormal medial
neal region (Fig. 9A-17). In many patients there is more plantar plus medial calcaneal nerve abnormal cutaneous
than one branch from the lateral calcaneal nerve. The first pressure threshold measurements. The Pressure-Specified
220
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Sensory Device was used to make these measurements. Interdigital plantar nerve entrapment is the most
Therefore in the patient with heel pain, there may be appropriate name for the forefoot pain syndrome that
a neurogenic mechanism, it may be chronic nerve athletes experience related to the common plantar
compression, and it can be identified by conducting an nerve, the intermetatarsal ligament, and the metatarsal
evaluation of sensibility. If the surgical approach involves heads.9 When this pain syndrome occurs to the common
just releasing the nerve to the periosteum, the approach plantar digital nerve in the interspace between the third
described by Baxter, then the pain either may never and fourth toe, it traditionally is termed Morton’s neu-
be relieved or may take up to 1 year to improve.1,2 Fur- roma. Repetitive impact on the forefoot in runners, peo-
thermore, Baxter’s approach includes an open medial ple doing step aerobics or kickboxing, or those wearing
plantar fasciotomy.1,2,49-52 If an ultrasound examination athletic shoes that are too pointed are the athletic set-
or MRI is normal for plantar fascial thickness and neuro- tings in which this problem may occur. The important
sensory testing is abnormal, then a plantar fascia release distinction to be made is that Morton’s ‘‘neuroma’’ is
theoretically is not necessary. However, if the surgical actually chronic nerve compression and not a true neu-
approach is the same as that described previously for roma (Fig. 9A-19). Therefore my approach to this is a
the four medial ankle tunnels, then all the variations neurolysis of the common plantar digital nerve through
of the medial calcaneal nerve can be identified, and a dorsal approach.59 The intermetatarsal ligament is
each nerve followed and released. In my experience, this completely divided, and fibrous edges to intrinsic mus-
is sufficient to treat heel pain of neural origin. A con- cles are divided. The swelling in the nerve is left alone.
founding pain problem for heel pain is the patient who
has had a medial plantar fasciotomy and who has a pain-
ful (DuVries-type) scar.57 This may be called ‘‘failed’’
or ‘‘recurrent’’ fasciitis or heel pain when it actually is Deep transverse
a true neuroma of one of these medial calcaneal nerve intermetatarsal ligament
branches.58 In this situation, the neuroma can be
resected, an internal neurolysis of the medial plantar
branch from the lateral plantar nerve accomplished, and
the proximal end, after neuroma resection, is turned and
implanted into the distal flexor hallucis longus muscle
(Fig. 9A-18).
Common plantar
digital nerve
Figure 9A-19 Interdigital nerve compression. The common

plantar nerve must glide beneath the intermetatarsal
ligament during the initiation of gait. It can become
compressed in this area between the metatarsal heads (left).
The swollen nerve may appear to be a neuroma (right), but, in
the absence of direct, not repetitive, trauma, it is not a true
Figure 9A-18 Pain in the medial heel in the patient who neuroma. Neurolysis by division of the intermetatarsal
previously has had a medial plantar fasciotomy may be due ligament instead of nerve resection is recommended (left).
to a true neuroma of one of the branches of the medial Resection creates a true neuroma. It often is stated that this
calcaneal nerve(s). In this intraoperative photo, the previous occurs most commonly in the third interspace because the
Devries incision is noted with black marker. The neuroma of formation of the third interdigital nerve from both the medial
the calcaneal nerve is seen. This neuroma will be resected, and lateral plantar nerves restricts gliding of this common
and the proximal end of the medial calcaneal nerve will be plantar digital nerve; however, there is great variability in the
implanted into the flexor hallucis longus muscle proximal to formation of this nerve. (Courtesy www.DellonInstitutes.com
the ankle.58 Web site, patient-interactive tutorial.)
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Figure 9A-20 Interdigital plantar nerve compression can occur in adjacent webspaces. This incision permits
entry into each webspace, avoiding parallel incisions.59 In this patient, whose foot was crushed, there was an
interdigital nerve compression in each interspace. On the left, the incisions are seen at 2 weeks after surgery and
on the right 6 months after surgery. Note that the incision is centered over the metatarsal, and the distal end of
the incision then goes off into each interspace.
The nerve is left loose to shift its position in the widened compression usually can be achieved by inserting a
space with all phases of gait. There is support for metatarsal bar into the shoe, changing the shoebox to
this approach now in several reports, using both an incorporate a wider toe, administering nonsteroidal
open60,61 and an endoscopic technique.62 In more than anti-inflammatory medications and cortisone injections,
50 patients, I have not had to take a patient back to sur- persistent pain requires surgical treatment. Repetitive
gery to resect this nerve (unpublished observations). cortisone injections may weaken the capsule of the
I have one failure so far in a patient with a painful neuro- metatarsophalangeal joint or induce tendon or volar
pathy of unknown etiology who remained with forefoot plate rupture. The results of resecting the common plan-
pain after the neurolysis and probably was a poor choice tar interdigital nerve can approach 90%,67-69 but failure
to have only the interdigital neurolysis. This raises the results in a true neuroma, the correction of which
concept of the ‘‘double crush’’ phenomenon,63-65 in requires a plantar approach and implantation of the
which a proximal site of compression renders the distal resected interdigital nerve into muscle in the arch of
nerve susceptible for compression, as well. In the poste- the foot.6,8
rior tibial nerve region, entrapment of the posterior tib-
ial nerve branches in the medial ankle region will reduce
the gliding of the interdigital nerve system, rendering
them more susceptible to compression. Each patient
LESS COMMON LOWER-EXTREMITY
with a clinical interdigital nerve compression must be
PERIPHERAL NERVE PROBLEMS
evaluated for a coexisting neuropathy or tarsal tunnel
syndrome by measuring the sensibility of the hallux The lateral femoral cutaneous nerve usually is depicted as
pulp, heel, and dorsal foot surface. It is possible that being below the inguinal ligament and about 2 cm
patients with an interdigital nerve compression in a web- medial to the anterior superior iliac crest. Athletes who
space other than the third have a proximal nerve com- fall directly on the anterior iliac crest may have pain
pression site. For patients with more than one related to such a ‘‘hip pointer’’ injury. This may occur
interdigital nerve compression, the adjacent webspaces in wrestling during a takedown, in football during a
can be approached through a single incision, as noted tackle, or in rugby. Numbness in the anterior and lateral
by Schon,2 and our preferred incision for this is given thigh and anterior hip pain can be the result of acute and
in Figure 9A-20.66 Although relief of interdigital nerve then chronic compression of this nerve (Fig. 9A-21).
222
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Less common lower-extremity peripheral nerve problems
Regions of Cutaneous Nerve Distribution:
Nerve Regions
Iliohypogastric
Genitofemoral:
Genital branch
Femoral branch
Ilioinguinal
Lateral femoral
Figure 9A-22 Intraoperative view of neurolysis of the right

lateral femoral cutaneous nerve. This nerve is located
adjacent to the anterior superior iliac crest. The narrowed area
of the nerve is clear after division of the inguinal ligament. The
neurolysis must continue proximally dividing the internal
Figure 9A-21 Groin pain of neural origin can be evaluated by oblique fibers until the superficial circumflex iliac vessels is
considering the skin territory innervated by each nerve, shown reached.
in different colors, below. The surgical incisions that are
responsible for creating neuroma and pain syndrome of these inflammatory medication and use methods to reduce
nerves also are shown. The lateral femoral cutaneous nerve
the swelling while maintaining gliding of the nerve so it
has a large territory, and most often this nerve has chronic
does not become scarred. Ultrasound with steroid ionto-
compression, rather than a true neuroma. Its territory extends
to the knee, and compression of this nerve can give rise to phoresis may be helpful in the subacute phase. If the
knee pain in athletes with repetitive hip flexion, such as symptoms have been present for more than 6 months
cyclists. Pain in the groin after hernia repair is the usual cause of and cannot be relieved by massage or by wearing clothes
the painful neuromas in the other territories. (Courtesy www. without a tight belt, then surgical decompression must be
DellonInstitutes.com Web site, patient-interactive tutorial.) considered. The results of neurolysis of lateral femoral
cutaneous nerve have been reported showing excellent
results in more than 80% of patients.72
This problem was known decades ago as meralgia pares- Hernia repair in athletes can cause pain in the groin
thetic or a painful thigh. Because this nerve can extend related to either tightening of the inguinal ligament suf-
to the lateral surface of the knee, it can even present ficient to cause compression of the lateral femoral cuta-
as knee pain, which I have seen in a slim, female, long- neous nerve or iatrogenic injury to the ilioinguinal and
distance biker. In biking, the repetitive hip flexion/ iliohypogastric nerves.72 The typical pain pattern (skin
extension can cause irritation of this nerve, especially innervation territory) for each of these nerves is given
when it is located within the inguinal ligament and adja- in Figure 9A-21. Pain from a neuroma of the ilioingu-
cent to the anterior superior iliac crest. Indeed, this inal or genitofemoral nerve may be confused with pain
nerve is so commonly found in this location at surgery from tendinitis of the origin of the gracilis muscle or
(Fig. 9A-22), that it prompted a cadaver study, reported other adductors from the pubic ramus.
in 1995.70 This demonstrated that more than one third The saphenous nerve can be compressed in the midthigh
of cadavers have this nerve located within the inguinal in the adductor canal. This is a rare entrapment.73–75
ligament and adjacent to the bone or the origin of the I have seen it in the setting of cyclists who have fallen
sartorius muscle. Patients with this nerve compression and have had bruising in the thigh and in motorcycle
have discomfort sitting up straight and often will be riders who have fallen and in whom the bike has com-
observed to be sitting in the examining room with the pressed the midthigh. This also has been observed in
affected leg slightly extended at the hip. Neurosensory a martial artist as a stretch/traction problem. If this
testing of the lateral versus the medial thigh skin can does not resolve, the surgical approach requires a large
document the present of this nerve compression, which midthigh incision and division of the fascia between
is difficult to identify with electrodiagnostic testing.71 the rectus lateralis and the adductor group of muscles
In the acute situation, it is important to administer anti- (Figure 9A-23).
223
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Figure 9A-23 Adductor canal syndrome. This patient had an injury to the left knee and thigh. Previous
operations resected the infrapatellar branch of the saphenous nerve, but the patient had persistent pain in
the saphenous distribution. With the leg abductor and externally rotated at the hip, a positive Tinel sign was
present at the site of the adductor canal, which has been exposed (A). The saphenous nerve is encircled with a
vessel loupe (B). For chronic compression, a neurolysis is sufficient. If there is a distal pain syndrome, the
saphenous nerve can be resected at this level and implanted into an adductor muscle.
The sural nerve can be entrapped theoretically where 6. Dellon AL: Treatment of recurrent metatarsalgia by neuroma
it exits the fascia in the distal lateral calf. Its surgical resection and muscle implantation: case report and algorithm for
management of Morton’s ‘‘neuroma’’, Microsurgery 10:256, 1989.
anatomy has been described well, and the variability of 7. Dellon AL, Aszmann OC: Treatment of dorsal foot neuromas by
the location for the lateral sural joining the medial sural translocation of nerves into anterolateral compartment, Foot Ankle
is significant.53 A stretch-traction injury to the sural 19:300, 1998.
nerve in this distal location has been described, but it 8. Wolfort S, Dellon AL: Treatment of recurrent neuroma of the
is rare.76 More likely, the athlete will have had a direct interdigital nerve by neuroma resection and implantation of proxi-
mal nerve into muscle in the arch, J Foot Ankle Surg 40:404, 2001.
injury to this nerve from sports trauma,77 or the nerve 9. Larson EE, et al: Accurate nomenclature of forefoot nerve entrap-
will be injured iatrogenically related to a lateral ankle ment: a historical perspective, J Am Podiatr Med Assoc 95:298, 2005.
surgery. 10. Horner G, Dellon AL: Innervation of the human knee joint and
implications for surgery, Clin Orthop Rel Res 301:221, 1994.
11. Dellon AL: Clinical grading of peripheral nerve problems, Neu-
rosurg Clin North Am 12:229, 2001.
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3. Mackinnon SE, Dellon AL: Surgery of the peripheral nerve, New
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4. Dellon AL, Mackinnon SE, Pestronk A: Implantation of sensory
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38. Bailie DS, Kelitian AS: The tarsal tunnel syndrome: surgical tech- diabetic nerve to chronic compression, Ann Plast Surg 20:117,
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39. Gondring WH, Shields B, Wenger S: An outcomes analysis of surgi- 65. Dellon AL, Mackinnon SE: Chronic nerve compression model for
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40. Mullick T, Dellon AL: Results of decompression of four medial 66. Rosson G, Dellon AL: Surgical approach to multiple interdigital
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J Reconstruct Microsurg, 2007. (in press). 67. Bradley N, Miller WA, Evans JP: Plantar neuromas, analysis of
41. Dellon AL: Clinical grading of peripheral nerve problems, results following surgical excision in 145 patients, South Med J
Neurosurg Clin North Am 12:229, 2001. 69:853, 1976.
42. Dellon AL: Treatment of symptoms of diabetic neuropathy by 68. Mann R, Reynolds JC: Interdigital neuroma: a critical clinical
peripheral nerve decompression, Plast Reconstr Surg 89:689, 1992. analysis, Foot Ankle 32:38, 1983.
43. Aszmann OC, Kress K, Dellon AL: Results of decompression of 69. Keh RA, et al: Long-term follow-up of Morton’s neuroma, J Foot
peripheral nerves in diabetics: a prospective, blinded study utiliz- Surg 31:93, 1992.
ing computer-assisted sensorimotor testing, Plast Reconstr Surg 70. Aszmann OC, Dellon ES, Dellon AL: The anatomic course of the
106:816, 2000. lateral femoral cutaneous nerve and its susceptibility to compres-
44. Aszmann OC, Tassler PL, Dellon AL: Changing the natural sion and injury, Plast Reconstr Surg 100:600, 1997.
history of diabetic neuropathy: incidence of ulcer/amputation 71. Coert JH, Connolly J, Dellon AL: Documenting compressive
in the contralateral limb of patients with a unilateral nerve neuropathy of the lateral femoral cutaneous nerve, Ann Plast Surg
decompression procedure, Ann Plast Surg 53:517, 2004. 50:373, 2003.
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72. Lee CH, Dellon AL: Surgical management for groin pain of 77. Gould N, Trevino S: Sural nerve entrapment by avulsion
neural origin, J Am Coll Surg 191:137, 2000. fracture at the base of the fifth metatarsal bone, Foot Ankle 2:153,
73. Mozes MM, Ouaknine G, Nathan H: Saphenous nervous entrap- 1981.
ment simulating a vascular disorder, Surgery 77:299, 1975.
74. Worth RM, et al: Saphenous nerve entrapment, Am J Sports Med
12:80, 1984. FURTHER READING
75. Romanoff ME, et al: Saphenous nerve entrapment of the adductor
canal, Am J Sports Med 17:478, 1989.
76. Pringle RM, Protheroe K, Mukherjee SK: Entrapment neuropathy Dellon AL: Deciding when heel pain is of neural origin, J Foot and
of the sural nerve, J Bone Joint Surg 56B:465, 1974. Ankle Surgery, 40:341-345, 2001.
B. Plantar heel pain

Lew C. Schon, Florian Gruber, and Glenn B. Pfeffer
Plantar heel pain is one of the most common foot prob- peripheral neuropathy ruled out when heel pain is diffuse,
lems in the athlete/dancer. Running, cutting, pivoting, nonfocal, and bilateral. The seronegative arthropathies
and jumping, especially on unyielding surfaces, places should be considered in an athlete with bilateral heel
tremendous, acute, and repetitive stresses on the heel. pain.1 Chronic pain at rest is an unusual presentation for
Often it is difficult to determine the exact etiology of plantar heel pain, and if a neurologic cause is not responsi-
the heel pain because several different underlying ble, a tumor of the calcaneus should be considered.
problems can occur simultaneously with symptoms.
The complex anatomy of the heel challenges the prac-
titioner to distinguish among several potentially patho-
FAT PAD INSUFFICIENCY
logic structures that lie within a small area. The
difficulty in establishing the specific etiology and subse- With each heel strike, the calcaneal fat pad cushions the
quently reversing underlying processes correlates with foot and body from direct and potentially catastrophic
the complexity of achieving a cure. impact. A healthy, middle-aged man has a gait velocity
Focal causes of plantar heel pain include the following: of approximately 82 m/minute and a cadence of 116.
1. Fat pad insufficiency This rate results in 58 heel strikes per minute with
2. Plantar fascial rupture a force of up to 110% of body weight. A sprinter does
3. Insertional plantar fasciosis not place a direct increased stress on the heel, but a mid-
4. Midsubstance plantar fasciitis dle- or long-distance runner may generate a force of up
5. Nerve entrapment: (a) tarsal tunnel syndrome and to 200% of body weight. Considering timing, impact
(b) first branch of the lateral plantar nerve forces, and average heel pain area (23 cm2), the loading
6. Stress fracture of the calcaneus pressure of a 70-kg man is approximately 9.3 kg/cm2
7. Tumor. when he is running.
In differentiating these diagnoses, a comprehensive Anatomic studies of the human heel pad have identi-
physical examination and medical history are essential. fied structural specialization capable of withstanding
Knowing the onset of the pain (e.g., acute trauma vs. these high loads.2 The anatomy of the heel pad was first
overuse) and the precipitating activity is useful to establish described by Tietze in 1921.3 He emphasized the
etiology. The exact location, character (i.e., musculoskel- specialized anatomy of the heel pad, with elastic adipose
etal or neuritic), and duration of pain should be noted. tissue organized as spiral-formed, fibrous tissue septa
The relationship of pain to a particular action or a specific anchored to one another, the calcaneus, and the skin.
activity modification is useful for realizing a diagnosis Designed to resist and absorb compressive loads, the tis-
and treatment plan. The history should include an over- sue septa are U-shaped or comma-shaped fat-filled col-
view of the patient’s general medical and orthopaedic umns with a vertical orientation. The septa are
conditions to determine whether there is systemic or reinforced internally with elastic transverse and diagonal
more global musculoskeletal disorder contributing to the fibers that connect the thicker walls and separate the fat
local problem. Radiculopathy in the L5-S1 distribution into compartments or cells. The thickness of the heel
should be considered in a patient with back pain, and a pad is the most important factor in determining the
226
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Insertional plantar fasciosis
Plantar aponeurosis
Plantar fasciitis
Heel pain syndrome
Compression of the first

branch of the lateral
Fat pad atrophy plantar nerve
of shear
Figure 9B-1 Focal causes of plantar heel pain.
stresses seen in the tissues beneath it.4 After age 40, the absorbent footgear. A plastic or silicone heel cup that
adipose tissue usually begins to deteriorate gradually, elevates the heel may be helpful both by protecting the
with the insidious loss of collagen, elastic tissue, water, painful area and by shifting some of the weight bearing
and overall thickness of the heel pad. The result is an more anteriorly. Cross training with swimming or bik-
inescapable softening, flaccidness, and thinning in the ing is useful in maintaining physical condition while
heel pad and a concomitant loss of shock attenuation. avoiding the offending activity. Avoidance of cortisone
Some patients experience these changes earlier because injections for this condition limits further atrophy.
of genetic factors. There is no surgical treatment for this condition.
An athlete with heel pain secondary to fat pad incom-
petence usually complains of diffuse plantar heel discom-
fort aggravated by sports on harder surfaces, such as
INSERTIONAL PLANTAR FASCIOSIS
a basketball court, concrete floors, or cinder track. By
clinical examination the patient has a soft, flattened heel
pad that allows easy palpation of the calcaneal tubercles. The most common site for plantar heel pain is where the
Sometimes the pad has a particularly small surface area plantar fascia and intrinsic muscles arise from the medial
or thickness. Compression of this area by the examiner calcaneal tuberosity on the anteromedial aspect of the
duplicates the symptoms, with pain maximal over the heel (Fig. 9B-1). During sports activities, particularly
central weight-bearing portion of the heel pad overlying long-distance running, the plantar fascia is placed under
the bone. Initially there is no radiation of the pain, and repetitive traction, which contributes to high stresses at
the plantar fascia is not tender. The area of maximal ten- the bone-fascia junction. The plantar fascia arises pre-
derness is proximal and central on the heel (Fig. 9B-1). dominantly from the medial calcaneal tuberosity and
With prolonged duration of the condition, patients may inserts distally through several slips into the plantar
develop calcaneal stress fractures, fasciitis/fasciosis, or plates of the metatarsophalangeal joints, the flexor ten-
local neuralgia. don sheaths, and the base of the proximal phalanges of
The only intervention for this condition is avoidance the digits.5,6 When the metatarsophalangeal joints are
of high-impact activity, especially on unyielding hard dorsiflexed with running or jumping, the inelastic plan-
surfaces, using a cushioned heel cup and/or shock- tar fascial fibers place traction on the calcaneus.5
227
...........
Typically with recurrent stresses the junction of two

structures with different biomechanical properties will
be the site of stress concentration. This is particularly
true in the heel, where the plantar fascia, which is strong
under traction or tension stresses, meets the calcaneus,
which is strongest in compression load.
Over time, microtears can occur in the plantar fascia
near the medial calcaneal tuberosity. A reparative
response develops, along with continued traumatic
fatigue in the fascia. Surgical biopsy specimens of the ori-
gin of the plantar fascia in athletes with chronic heel pain
reveal collagen necrosis, angiofibroblastic hyperplasia,
chondroid metaplasia, and matrix calcification. Thus it is
appropriate to use the term ‘‘fasciosis’’ to reflect a degen-
erative process, rather than ‘‘fasciitis,’’ an inflammatory
process. Periostitis of the medial calcaneal tuberosity
often occurs in conjunction with degenerative changes
in the plantar fascia, causing a positive delayed techne-
tium-99 bone scan in the majority of painful heels.7
Because of the close proximity of the medial calcaneal
tuberosity and the origin of the plantar fascia, it is not
possible to differentiate clinically a fascial or bony source
of an athlete’s pain. Both structures usually are involved,
much like other insertional tendon and fascial condi- Figure 9B-2 Windlass mechanism.
tions.8 Patients may have local, soft-tissue swelling and
focal tenderness over the medial calcaneal tuberosity
directly and the plantar fascia distally for several milli-
meters. The examiner often must apply a considerable
amount of pressure to localize the painful area. Interest-
ingly, patients almost never have increased pain or dupli-
cation of symptoms with passive dorsiflexion of the toes,
which causes traction on the plantar fascia by the Wind-
lass mechanism (Fig. 9B-2). Associated tightness of the
Achilles tendon is commonly seen with this condition,
because limited ankle dorsiflexion places increased stress
on the plantar fascia.
Insertional plantar fasciosis is insidious in onset and is
seen most often as an overuse condition of long-distance
runners.8 In athletes with an acute onset of symptoms,
rupture of the plantar fascia should be considered9
(Fig. 9B-3). Rupture is much less common than chronic
insertional plantar fasciosis and easily can be differen-
tiated on the basis of physical examination and history.
A palpable defect in the plantar fascia is present when a
rupture occurs, and often there is ecchymosis. The fascia Figure 9B-3 Rupture of plantar fascia.
will be less taut with a rupture than with fasciosis. An
old partial rupture of the plantar fascia can present with prolonged running. It is not unusual for athletes to
a palpable nodularity in the fascia near the medial calca- complain of heel pain that occurs only during the first
neal tuberosity and a lower arch. few miles of a workout. No clear correlation between
Athletes with insertional plantar fasciosis usually insertional plantar fasciosis and pes planus or pes cavus
experience symptoms during the first minutes of walk- has been established. A positive correlation with obesity
ing, especially in the morning when first out of bed. exists, although most athletic patients do not have this
The pain gradually decreases. Discomfort is intensified concern. A lateral x-ray of the heel will exclude a stress
by athletic activity, especially jumping or running. Some fracture or tumor of the calcaneus. Even among high-
athletes have symptoms only during periods of performance athletes, a stress fracture is extremely rare.
228
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Leg lengths always should be examined when evaluat- cast for 2 to 6 weeks followed by a custom-made ortho-
ing athletes with chronic heel pain. If one leg is longer sis may help break a painful cycle. An off the shelf
than the other, often there is a history of repeated injury boot brace typically is not helpful in this condition
to the shorter leg. Heel pain is seen more often in the because the orthosis tends to concentrate the stresses
shorter leg and may be treated effectively with an appro- on the heel.
priate lift. A functional short-leg syndrome can result In athletes with refractory symptoms, a steroid injec-
from running on the same tilt of road or in the same tion often is beneficial. Care should be taken to inject
direction on the track. In both instances, after many the steroid deep to the plantar fascia so as not to cause
miles of training, one heel will be more stressed than atrophy of the fat pad. A medial approach of the injec-
the other. By using both sides of the road or intermit- tion is best used so that the steroid can be spread
tently changing directions on a training track, stress along the broad origin of the plantar fascia. A 25-gauge
between both heels can be equalized. needle is walked across the anterior border of the cal-
The cornerstone of conservative treatment in athletes caneus just deep to the plantar fascia, thereby avoiding
is modification in training. Mileage reduction, alternat- the plantar nerves (Fig. 9B-4). Two to three milliliters
ing activities, work reduction, and shortened workouts of an equal mixture of lidocaine, bupivacaine, and
should be considered.10 Low-resistance cycling and long-acting steroid should be administered. Multiple
swimming pool running are effective cardiovascular ac- steroid injections may predispose the athletic patient to
tivities that usually are not stressful to the heel. Oral plantar fascia rupture and should be avoided.14 A major-
anti-inflammatory agents, contrast baths, ice massage, ity of patients respond to these conservative measures.
and soft-soled shoes or sneakers also are used. Plantar fas- A patient may have some persistent symptoms for up
cia stretching exercises should be instituted. If the athlete to 6 months, but usually only 4 to 6 weeks will be lost
has Achilles tightness, this should be stretched as well. from training or competitive athletics if treatment is
A study of 101 patients (complete data for 66 patients) started early.
with symptoms longer than 10 months compared a Extracorporeal shock wave therapy (EWST) has been
specific plantar fascia stretching program (group A) with introduced for the treatment of chronic plantar fasciosis.
an Achilles stretching program (group B) for 8 weeks.11,12 Alvarez15 reported on the use of high-energy shock
Patients in both groups used full-length, prefabricated wave before surgical management is considered. The
orthoses. Patients in group A were instructed to perform safety and early preliminary efficacy of the high-energy
a stretch by placing the affected foot on the thigh of
the contralateral leg. While hyperextending the toes with
the ipsilateral hand until a stretch in the arch is felt, the
contralateral hand palpates the degree of tension of
the plantar fascia. This position was held for 10 seconds
and repeated 10 times. The plantar–ascia-stretching
group was advised to perform the stretching before any
weight bearing. All patients in the other group were
instructed to stretch three times a day.
After this treatment period, the Achilles tendon
group was given the plantar fascia-specific stretching
protocol. The results were evaluated after 8 weeks and
2 years. At 8 weeks the plantar–fascia-stretching group
had significantly fewer complaints of pain at its worst
and pain at the first steps in the morning. At the 2-year
follow-up, there was no statistically significant difference
between the groups. After 2 years, 94% reported less or
no pain and 58% reported no pain. The majority of
patients (62%) achieved the best results within the first
6 months.
Low dye taping and a one-eighth-inch medial heel
wedge may be added in an attempt to reduce the stress
on the plantar fascia. A night splint ankle-foot orthosis
with the ankle fixed in 5 degrees of dorsiflexion also Figure 9B-4 A steroid injection from the medial side of the
may be indicated. Using this technique, Wapner heel. To avoid steroid-induced atrophy of the fat pad, the
et al.13 had a 79% success rate after an average of solution is injected deep into the plantar fascia. The heel spur
4 months of splint use. In refractory cases, a short-leg arises within the origin of the flexor digitorum brevis muscle.
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shock wave using the OssaTron was evaluated. Twenty subfascial injection of 100 units of botulinum toxin A
heels of 20 patients were treated with 1000 extracorpo- in the first 6 patients to determine the optimal treatment
real shock waves from the OssaTron to the affected heel dose and with 200 units in the other 19 patients. The
after administration of a heel block. Each patient under- group that received 200 units reported a substantial
went an extensive evaluation, including x-ray, KinCom, reduction of maximal and continuous pain 2 and 14
physical examination, and a 10-cm visual analog scale. weeks after the injection and no signs of muscular weak-
Of the 20 patients treated, 17 were improved or pain ness in a clinical exam. Babcock et al.23 presented a ran-
free. There were no complications or adverse effects domized placebo-controlled, double-blind study of 27
attributed to the procedure. Zingas and colleagues16 patients (43 feet). They applied 40 units at the tender
also studied the safety and efficacy of musculoskeletal area at the medial tuberosity of the calcaneus and 30
shock wave therapy in 29 patients with chronic plantar units between an inch distal of the heel and the middle
fasciitis. In this study the patients were enrolled in a ran- of the foot. The placebo group received injections with
domized, 1:1 allocated, placebo-controlled, prospective, the same volume of saline. Main outcome measures
double-blind clinical study with two groups: one receiv- included the pain visual analog scale, Maryland foot
ing ESWT with the Dornier Epos Ultra and the other score, pain relief visual analog scale, and pressure al-
receiving sham treatment. The authors concluded that gometry response. Patients were assessed before injec-
shock wave therapy is useful in the treatment of chronic tion, at 3 weeks, and at 8 weeks. The botulinum group
plantar fasciitis that has failed conventional conservative improved significantly in all measures and showed no
methods. The Food and Drug Administration now has adverse side effects.
approved this treatment for chronic plantar fasciitis, Another possible treatment option for enthesopathies
but only some insurance plans cover the treatment. that has been used for patients with elbow tendinosis
The decision whether to use high-energy or lower- involves injection of platelet-rich plasma (PRP). Mishra
energy shock wave also has been debated. To date there and Pavelko24 studied 20 patients with persistent pain
is no consensus on how to define the terms high-dose for a mean of 15 months despite conservative therapy.
and low-dose shock wave. The pain level measured with a visual analog scale from
An advantage of the lower energy machine is that the 0 to 100 was 82 on average (60-100). Fifteen patients
patient does not need general anesthesia or an invasive received a single percutaneous injection of PRP. The con-
nerve block to tolerate the procedure. An advantage of trol group (n ¼ 5) got an injection with bupivacaine. Eight
the high-energy machines is that typically only one treat- weeks after treatment, the patients in the PRP group had a
ment is required, as opposed to three for the lower-energy 60% improvement in visual analog scores and the control
machines. Different therapy-regimens seem to result in group showed only 16% improvement (p ¼ .001). Only
different efficacy of treatment. In 2003, Speed et al.17 the platelet-injection group could be observed in further
found no significant difference between the treatment follow-up. At 6 months and at final follow-up after a mean
and placebo group. In their study the authors applied 25.6 months (range, 12-38 months), 81% and 93% of
shock waves (0.12 mJ/mm2) monthly for 3 months. these patients noted improvement in their pain visual ana-
The authors concluded that efficacy may be highly depen- log score. The authors concluded that PRP injection
dent on machine types and treatment protocols. reduces pain significantly in their patient group. Research
Porter et al.18 concluded that ESWT was less effective is needed to determine whether this result is applicable
than a single corticosteroid injection in patients who to treatment of plantar fasciitis.
underwent a standardized Achilles tendon and plantar In those few patients who fail prolonged, conserva-
fascia stretching program. Kudo et al.19 found signifi- tive treatment, surgical release of the plantar fascia
cantly better outcome of an ESWT group in comparison should be considered. However, every attempt should
with a placebo group 3 months after treatment. Treat- be made to avoid this procedure in competitive athletes.
ment consisted of approximately 3800 total shock waves Release of the plantar fascia may have a detrimental
(10) reaching an approximated total energy delivery of effect on function. Daly et al.25 demonstrated in
1300 mJ/mm2 (EDþ) in a single session versus placebo their study a change in both arch height and the ratio
treatment. Several studies focusing on the durability of of arch height to arch length following a plantar fascia
pain relief show good results for EWST for chronic plan- release. A less energetic pattern of walking following
tar fasciitis for follow-up times from 2 to 6 years.20,21 a plantar fascia release also was seen. Further, if the plan-
Further research is needed to develop evidence-based tar fascia is divided surgically, increased compressive
recommendations for using ESWT for treatment of this forces are transmitted to the dorsal aspect of the
condition. midfoot, with decreased flexion forces on the metatarso-
A recent therapeutic approach for plantar fasciitis is phalangeal joint complex.6 These changes can lead to
local injection of botulinum toxin A. Placzek et al.22 dorsal midfoot pain and metatarsalgia postoperatively
performed a pilot study with 25 patients using a single (Fig. 9B-5).
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Figure 9B-5 If the plantar fascia is divided surgically, there are increased compressive forces transmitted to the
dorsal aspect of the midfoot and decreased flexion forces on the metatarsophalangeal joint complex.
If surgery is performed, it is necessary to discuss the

role of the spur with the patient. In general, resection Surgical technique
of the heel spur is not performed because it does not Plantar fascia release may be performed using a regional
contribute to the pathophysiology. In addition, resection anesthetic with intravenous sedation and a standby
of the spur can lead to a slightly more aggressive release general anesthetic. An ankle block is highly useful,
of the fascia to gain exposure and may lead to some using a 1:1 solution of 0.25% bupivacaine hydrochlo-
more bleeding because of the presence of raw bone. ride (Marcaine) and 1% lidocaine, both without
On the other hand, at times the spur is quite large and epinephrine.
the patient is fixated on its presence. It can be easier to An oblique incision is begun along the inferomedial
remove the spur than to explain at each visit that the aspect of the heel, just anterior to the calcaneus where
pain that remains while he or she is healing is common the inferior abductor fascia joins the medial plantar fas-
and will resolve. It is useful to advise the patient that cia (Fig. 9B-6). This 2.5- to 4-cm incision is planned
the heel spur arises deep to the plantar fascia in the anterior to the medial calcaneal branch of the posterior
nonweight-bearing substance of the flexor brevis muscle tibial nerve, avoiding inadvertent division of the nerve
and therefore is probably not involved in producing the and the formation of a painful postoperative neuroma.
pain. Most patients are informed that the calcaneal Care should be taken to search for this nerve branch
spur was of great importance in the treatment of heel during the operative approach because its course can
pain historically. They also are told that many patients be more anterior than expected.
without heel pain have spurs and that many patients Using blunt dissection, the medial edge of the plantar
without spurs have pain. Tanz26 demonstrated that only fascia origin is visualized easily. Isolate the fascia from
50% of patients with plantar heel pain had a heel spur the adipose tissue, which lies inferiorly, and the fascia
and that 16% of nonpainful heels also had a heel spur. of the abductor hallucis muscle, which lies superiorly.
Rubin and Whitton27 determined that only 10% of If necessary, the incision can be extended a few centi-
patients with heel spurs were symptomatic. Finally they meters transversely across the nonweight-bearing aspect
are told that the spur can be left alone, but that they of the sole.29 A Freer elevator is used to isolate the plan-
still can have successful conservative or surgical treat- tar fascia along its origin on the calcaneus. The plantar
ment for the plantar fasciitis. Lapidus and Guidotti28 fascia often will be thickened in this area from chronic
showed that the successful treatment of heel pain was changes. A scalpel then is used to divide the plantar fas-
not contingent on the surgical removal of a heel spur cia as it arises from the calcaneus. Any degenerated por-
and concluded that plantar calcaneal spurs do not cause tions of the plantar fascia should be excised. Typically a
the painful heel, as they have been postulated to do. piece of fascia is removed measuring 3 to 4 mm wide
We leave the decision about spur resection to the and a thickness of 2 to 4 mm. The depth of the release
surgeon’s discretion. should be 4 to 5 mm.
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Figure 9B-6 Incision used to release the plantar fascia. The incision may be extended along the nonweight-
bearing aspect of the foot.
If a heel spur is present in the origin of the flexor brevis calcaneus and had good results. Hassab and El-Sherif 30
muscle, it easily can be removed using a small osteotome drilled the os calcis to obtain relief of recalcitrant heel
and rongeur. Care should be taken not to remove cortical pain. They performed 68 operations in 60 patients and
bone of the calcaneus and thereby create a stress riser. A reported excellent results in 62, good in 2, and poor in
reciprocating rasp works well for both gross reduction 4. Santini et al.31 presented a retrospective study of 25
and final smoothing of the calcaneal surface. One should feet in 21 patients treated with drilling of the calcaneus.
protect the first branch of the lateral plantar nerve (nerve The indication was chronic heel pain in combination with
to the abductor digiti quinti), which runs across the heel increased uptake in the delayed bone scans. Under local
just deep to the heel spur and the flexor brevis muscle. If anesthesia, three holes were drilled in the medial cortex
a tourniquet is used, it should be deflated and hemostasis of the calcaneus. After an average follow-up time of 21
obtained. A bulky compression dressing is used, and the months, the authors noted a decrease in pain from 8.8
patient is instructed not to bear weight for 3 to 4 days (4-10) preoperatively and 2.4 (0-10) using the visual ana-
to allow for wound healing. After the fourth day, weight log score. Six of seven patients who had another bone
bearing can progress as tolerated using crutches. scan postoperatively showed resolution of the increased
Minimal incision surgery is not recommended for uptake. The outcome was worse in patients with rheuma-
release of the plantar fascia. Direct visualization of the toid and other systemic diseases and Haglund deformity.
plantar fascia is required to gain an adequate release, Santini states that his results of calcaneal drilling are com-
and inadvertent division of the medial calcaneal sensory parable to other surgical options for treatment of chronic
nerve easily can occur when an incision of 1 cm or less heel pain.
is used. Benton-Weil reported on percutaneous plantar Endoscopic plantar fascia release is another method
fascia release in a retrospective study with 35 patients for treating this condition. The technique was first
using a questionnaire and the visual analog score at an popularized by Barrett and Day,32 who proposed this
average follow-up time of 34 months. He described technique as causing less tissue damage than open treat-
improvement of the visual analog score from 8.2 to ment. In a follow-up, multicenter study of 652 proce-
2.1. In 83% the results of the procedure met or dures, they reported 62 complications in 53 patients
exceeded the patient’s expectations. but felt that it afforded satisfactory results. O’Malley
An interesting technique that has been used for plan- and associates33 reviewed the surgical results following
tar fasciosis involves drilling the calcaneus. Some autho- endoscopic plantar fasciotomy in 16 patients (20 feet)
rities add this to their surgical protocol when there is with an average preoperative duration of symptoms of
any suspected calcaneal stress fracture, determined on 4 years. Nine had complete relief of pain, and another
the basis of a hot bone scan or tenderness along the 9 feet were improved. One patient with bilateral symp-
wall of the calcaneus. Schon uses this method as an adju- toms had no relief in either foot. The average American
vant for these cases but at times has drilled only the Orthopaedic Foot and Ankle Society hindfoot score
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Entrapment of the first branch of the lateral plantar nerve
improved from 62 to 80, a statistically significant differ- (Fig. 9B-7). The first branch innervates the periosteum
ence. Patients with unilateral symptoms did better than of the medial calcaneal tuberosity, the long plantar liga-
those with bilateral symptoms. There were no iatrogenic ment, and the abductor digiti quinti and flexor brevis
nerve injuries. muscles.41 Entrapment of the nerve accounts for
Other authors have reported various complications approximately 20% of chronic heel pain. Entrapment
from endoscopic plantar fascial release, including stress occurs as the nerve changes from a vertical to a horizon-
fractures,34 pseudoaneurysm formation,35 and recur- tal direction around the medial plantar aspect of the heel
rence of pain.36 A prospective study by Saxena37 com- (Fig. 9B-8). The exact site of compression is between
pared uniportal endoscopic release of the medial 50% of the heavy, deep fascia of the abductor hallucis muscles
the plantar fascia in athletes versus nonathletes. All and the medial caudal margin of the medial head of
patients had undergone at least 8 months of conservative the quadratus plantae muscle (see Fig. 9B-9). Athletes
treatment. Good and excellent results were reported in all who spend a significant amount of time on their toes,
16 athletically active patients using the Modified Plantar such as sprinters, ballet dancers, and figure skaters are
Fascia Score (MPFS) and an average return-to-activity prone to entrapment of the first branch of the lateral
time of 2.6 months. Of the 10 patients in the control plantar nerve by the well-developed abductor hallucis.
group (at time of surgery 12 years older than athletic The medial calcaneal nerve branches that innervate the
patients), 5 had poor outcome. All of the control patients plantar medial aspect of the heel pass superficial to the
had a body mass index (BMI) higher than 27. abductor hallucis muscle and are not involved with
Most authors believe that only the medial one half or entrapment of the first branch. Another potential site
medial two thirds of the plantar fascia be released of entrapment of the first branch is the point at which
because of the high incidence of lateral foot pain follow- the nerve passes just distal to the medial calcaneal tuber-
ing more aggressive release. osity.40 Inflammation and spur formation in the origin
of the flexor brevis muscle can produce sufficient
swelling to cause compression of the nerve against the
long plantar ligament (Fig. 9B-10). The inflammatory
ENTRAPMENT OF THE FIRST BRANCH OF changes of heel pain syndrome (HPS) therefore can pre-
THE LATERAL PLANTAR NERVE
dispose to chronic entrapment of the nerve.
The diagnosis of entrapment of the first branch of the
One of the most commonly overlooked causes of lateral plantar nerve is made on the basis of clinical
chronic plantar heel pain in the athlete is entrapment grounds. It therefore is incumbent on the examiner to
of the first branch of the lateral plantar nerve38-40 differentiate first-branch entrapment from other, more
First branch of
lateral plantar nerve
Medial plantar nerve
Nerve tomedial
calcaneal tuberosity Lateral plantar nerve
Figure 9B-7 First branch of the lateral plantar nerve.

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Calcaneal
nerve
Quadratus
plantae
Medial
Lateral plantar
First branch of the
plantar nerve
lateral plantar nerve
nerve
Figure 9B-8 Entrapment of the first branch of lateral plantar nerve occurs as the nerve changes direction from
vertical to horizontal around the medial plantar aspect of the heel.
Medial plantar nerve

Lateral plantar nerve
Quadratus plantar
(medial and lateral heads)
Abductor digiti quinti
Pronation
Flexor brevis
Abductor hallucis
Plantar fascia
Site of nerve compression

Heel spur (if present)
Figure 9B-9 Site of compression of the first branch of the lateral plantar nerve.
common causes of heel pain (Fig. 9B-11). Early-morning of the lateral plantar nerve. The patient therefore may
pain is not as prominent with nerve entrapment, which have some tenderness over the proximal plantar fascia
tends to cause pain more at the end of the day or after and medial calcaneal tuberosity. Without maximal ten-
prolonged activity. The pathognomonic sign of entrap- derness over the course of the nerve on the plantar
ment of the first branch of the lateral plantar nerve is medial aspect of the foot, however, the diagnosis of
maximal tenderness where the nerve is compressed entrapment should not be made (see Fig. 9B-1). Some
between the taut deep fascia of the abductor hallucis patients may have paresthesias elicited with pressure over
muscle and the medial caudal margin of the quadratus the nerve at the entrapment site, although this does not
plantae muscle. Chronic inflammation of the plantar occur commonly. Entrapment of the isolated medial
fascia may predispose to entrapment of the first branch plantar nerve, ‘‘jogger’s foot,’’ occurs more distally at
234
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Entrapment of the first branch of the lateral plantar nerve
entrapment of the first branch of the lateral plantar

nerve.42 Measurement of nerve conduction slowing across
the site of entrapment is technically demanding, and
denervation potentials in the intrinsic foot muscles may
occur only rarely because of the possible dynamic nature
of this particular compression neuropathy. A comparison
may be drawn to the diagnosis of a posterior interosseous
nerve entrapment in the upper extremity.
Treatment for athletes with entrapment of the first
branch of the lateral plantar nerve is similar to that of
HPS, with rest, nonsteroidal anti-inflammatory agents,
contrast baths, ice massage, physical therapy, and steroid
injection serving as the foundation for conservative care.
A shock-absorbent viscoelastic heel insert also will help
to decrease inflammation in the area. In athletic patients
with excessive pronation, especially long-distance run-
ners, a nonrigid, mediolongitudinal arch support can
decrease compression of the nerve.
In 1984, Baxter and Thigpen39 presented the first
large clinical series of patients treated operatively for
Figure 9B-10 The plantar fascia is retracted. The first branch entrapment of the first branch of the lateral plantar
of lateral plantar nerve is exposed (arrow). A large heel spur is nerve. Twenty-six patients with 34 involved heels under-
marked (S). (From Kenzora JE: The painful heel syndrome: an went operative decompression; 82% of the patients expe-
entrapment neuropathy, Bull Hosp Joint Dis 47:178, 1987.) rienced complete relief of their symptoms. In 1992,
Baxter and Pfeffer38 published a series of 69 heels in
53 patients with chronic heel pain who had surgical
release of the first branch of the lateral plantar nerve.
The average duration of heel pain symptoms was 23
months. No patient had fewer than 6 months of conser-
vative treatment before surgery. The average duration of
preoperative conservative treatment was 14 months.
Postoperatively 61 heels (89%) had excellent or good
results. The average follow-up was 49 months. Approxi-
mately half the patients in Baxter’s second study devel-
oped heel pain as a result of a sports activity, usually
long-distance running. Other activities included aero-
bics, basketball, volleyball, and tennis. Eighty-five per-
cent of this group had good or excellent results from
surgery. The mean recovery time of the athletic sub-
group to resumption of sports activities was 3 months.
This amount of time was not considered excessive, given
the mean of 23 months of preoperative symptoms.
Entrapment of nerve to the abductor digiti quinti m. Surgical Technique

between deep fascia of the abductor hallucis m. and
the medial caudal margin of the quadratus plantae m.
The surgical approach to release the first branch of the
lateral plantar nerve should be from the medial side of
Figure 9B-11 Entrapment of nerve to the abductor digiti quinti. the heel. The patient is supine on the operating table.
No tourniquet is required, although an ankle tourniquet
the level of the navicular tuberosity and should not can be used. A 4-cm oblique incision is made on the
be confused with entrapment of the first branch of the medial heel over the proximal abductor hallucis muscle.
lateral plantar nerve more proximally. The incision is centered over the course of the first
Motor weakness in the abductor digiti quinti muscle branch of the lateral plantar nerve. The medial calcaneal
may on occasion be detected, although no cutaneous sensory nerve branches are not encountered as they
sensory deficit occurs. Electromyography and nerve course posterior to the incision. Care is taken, however,
conduction studies are not yet consistent in diagnosing to preserve any aberrant branches.
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The superficial fascia of the abductor hallucis is divided The salient clinical feature of tarsal tunnel syndrome
with a no. 15 blade, and the muscle is retracted superiorly is direct focal tenderness over the nerve as it passes
using a Ragnell retractor. A section of deep fascia of the beneath the flexor retinaculum. Percussion of the nerve
inferior abductor hallucis is removed directly over in this area will reproduce the patient’s symptoms,
the area where the nerve is compressed between this taut which can include pain, burning, or tingling on the
fascia and the medial border of the quadratus plantae plantar aspect of the foot. Subjective numbness of the
muscle. A small portion of the medial plantar fascia may toes may occur, although objective decreased sensibility
be removed to facilitate exposure and clearly define the is rarely demonstrated. Some patients may complain
plane between the deep abductor fascia and the plantar of proximal radiation of their symptoms. Electromyo-
fascia. The deep fascia of the abductor hallucis then graphy and nerve conduction studies can be helpful
is divided from inferior to superior to sufficiently free in making a diagnosis. A normal study, however, does
the nerve from entrapment. If present, a heel spur is not exclude the diagnosis of tarsal tunnel syndrome.
removed, using a Freer elevator to protect the nerve that In general, the plantar heel pain produced by tarsal
runs superiorly. The abductor hallucis muscle belly and tunnel syndrome is more diffuse and less focal than that
its superficial fascia are left intact. A plantar fascia release of either HPS or entrapment of the first branch of the
is not performed unless the patient has been symptomatic lateral plantar nerve. A careful clinical examination
over the plantar aspect of the medial calcaneal tuberosity should easily distinguish among these three entities.
and direct visualization provides evidence of pathology A medial heel wedge will decrease tension on the
in the proximal portion of the plantar fascia. nerve. Steroid injection into the tarsal tunnel also may
At the end of each case, a small hemostat is used be beneficial but usually produces only transient relief
to palpate along the course of the nerve to make sure of symptoms. Surgical release of the flexor retinaculum
it is free from any adhesions proximally or distally. The and exploration of the tarsal tunnel can be expected to
wound is closed with interrupted horizontal mattress provide relief of symptoms in 90% of athletic patients.
nylon sutures. No subcutaneous sutures are used. Decompression of both the medial and lateral plantar
A bulky dressing is placed. Patients are allowed to bear nerves into the midfoot should be performed in any
weight in a postoperative shoe as tolerated and to grad- patient with preoperative tenderness along the course
ually return to sports activities after 3 to 4 weeks. of these nerves (Fig. 9B-12). Internal neurolysis of the
A plantar heel spur forms in the insertion of the flexor nerve is rarely indicated.
brevis muscle on the calcaneus. The first branch of the
lateral plantar nerve courses from medial to lateral
directly above this muscle. Although it is unlikely that
MIDSUBSTANCE PLANTAR FASCIITIS
a heel spur is a direct mechanical cause of plantar heel
pain, inflammation in the area of the spur is a theoretical
source of compression of the first branch of the lateral Tenderness over the plantar fascia in the midfoot is aptly
plantar nerve as it passes above the spur. A heel spur, if called midsubstance plantar fasciitis. This condition pre-
present, therefore should be excised. Care should be sents with tenderness over the midportion of the plantar
taken when excising the spur to protect the first branch fascia. As opposed to insertional plantar fasciosis, dorsi-
of the lateral plantar nerve. The plantar fascia should flexion of the toes almost always exacerbates the
not be divided to preserve its biomechanical advantage patient’s symptoms by the Windlass mechanism stretch-
during sports activities. ing the midfascial fibers (Fig. 9B-13). There is usually is
only minimal tenderness over the most proximal fascial
fibers, which are painful in insertional plantar fasciosis.
Plantar fasciitis is seen more often in sprinters and
TARSAL TUNNEL SYNDROME
middle-distance runners, who spend more time on their
toes during athletic activity.
Another nerve entrapment capable of producing chronic Tendinitis of the flexor hallucis longus tendon can
heel pain is tarsal tunnel syndrome. Posttraumatic present with pain in the plantar medial midfoot. This
adhesions, bony spurs, chronic inflammation, benign condition can be distinguished easily from plantar fasciitis.
tumors, and varicosities all can all cause compression of Passive dorsiflexion of the great toe aggravates both
the posterior tibial nerve within the tarsal tunnel. Exces- plantar fasciitis and flexor hallucis longus tendinitis, but
sive pronation in a long-distance runner may predispose resisted flexion of the toe is painful only with involve-
to tarsal tunnel syndrome by placing repeated stress on ment of the tendon. Careful palpation with motion of
the structures on the medial side of the heel. Hindfoot the tendon usually is sufficient to confirm the diagnosis.
varus, in association with excessive pronation, also may A painful plantar fibromatosis involving the midplantar
be associated with tarsal tunnel syndrome. fascia also can be detected by careful examination.
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Summary
Tibialis posterior
Flexor digitorum
longus
Posterior tibial artery
and nerve
Flexor retinaculum
Abductor hallucis
Figure 9B-12 Decompression of medial and lateral plantar nerves into the midfoot should be performed in any
patient with preoperative tenderness along the course of the nerves.
eighth-inch medial heel wedge may take tension off

the plantar fascia. If these modalities fail, the corner-
stone of treatment is the University of California Biome-
chanics Laboratory (UCBL) orthosis.43 The theory of
the UCBL orthosis is to hold the foot in a position that
relieves tension on the plantar fascia. The orthosis
accomplishes this reduction in tension by holding the
heel in inversion and applying forces against the navicu-
lar and lateral aspect of the forefoot, without direct pres-
sure on the soft tissue underneath the longitudinal arch.
The UCBL insert usually is not helpful in patients with
insertional plantar fasciosis because the rigid material
used in constructing the insert often aggravates the
inflamed heel. It is extremely unusual to operate on a
patient for true midfoot plantar fasciitis. If prolonged,
conservative treatment of more than 6 months fails,
however, a similar operative approach to that used for
insertional plantar fasciosis is indicated.
SUMMARY
Figure 9B-13 Dorsiflexion of the toes causing tension on the
plantar fascia. The symptoms of true plantar fasciitis are
reproduced with this maneuver. Ninety-eight percent of patients with heel pain can be
treated successfully with conservative treatment. If treat-
ment is begun soon after the onset of symptoms, most
A mediolongitudinal arch support often is not toler- athletes can minimize their downtime to 6 weeks or less.
ated in a patient with plantar fasciitis because it pushes Understandably many athletic patients are reluctant to
up on the plantar fascia and increases tension on its give up or significantly modify their sports activities.
fibers. Circumferential taping of the foot with 1-inch They continue to train through the pain and thereby
adhesive tape applied over a nonadhesive elastic wrap establish a chronic and refractory condition. In those
usually is beneficial. Rest, alteration of training, nonste- few patients who require surgery, an excellent result
roidal anti-inflammatory agents, ice massage, contrast can be obtained if the correct diagnosis is made and
baths, and physical therapy, including ultrasound and the surgeon addresses the specific cause of the athlete’s
plantar fascial stretching, also are indicated. A one- plantar heel pain.
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C A S E S T U D Y 1 C A S E S T U D Y 4
A 23-year-old, nationally ranked middle-distance A 24-year-old, female, long-distance runner had a plantar
runner had chronic heel pain. She failed all conservative fascia release. Postoperatively she developed
treatment, including prolonged physical therapy, heel metatarsalgia and dorsolateral midfoot pain. She was
cups, an orthotic device, and shoe modification. She seen in consultation after repeated attempts at
did not want to use a cast. She had maximal tenderness conservative treatment failed to relieve her midfoot pain.
over the medial plantar hindfoot consistent with the Her plantar heel pain had resolved after surgery. She
diagnosis of entrapment of the first branch of the lateral required 8 weeks of casting to alleviate the midfoot
plantar nerve. Her symptoms had been present for symptoms.
1 year. Under regional anesthesia she had a surgical
release of the deep abductor fascia, freeing up the
nerve. Her plantar fascia was left intact. Six weeks
later she resumed training with complete relief of
pain.
C A S E S T U D Y 5
An aerobics instructor was seen for chronic hindfoot pain

C A S E S T U D Y 2 following a plantar fascia release. A longitudinal incision
had been used. A small portion of the medial heel was
numb. A neuroma in the superficial medial calcaneal
nerve was identified. Symptoms persisted despite two
A 44-year-old, competitive long-distance runner had steroid injections into the neuroma. The nerve was
2 years of heel pain consistent with insertional plantar resected surgically to its origin within the tarsal tunnel.
fasciosis. His mileage had decreased from 80 miles The patient experienced continued tenderness at the
per week to 0. Under regional anesthesia through an nerve ending. Another patient with a similar problem
oblique medial incision his plantar fascia was released. developed a reflex sympathetic dystrophy that remained
No heel spur was present. His plantar heel pain gradually refractory to conservative treatment.
resolved over 4 months. He returned to 40þ miles
per week.
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239
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.........................................C H A P T E R 1 0
Arthritic, metabolic, and vascular disorders

Gregory Rowdon and David Taylor
......................
CHAPTER CONTENTS
Introduction 241 Metabolic disease 245

Inflammatory/rheumatologic 241 Vascular/lymphatic disorders 247
Other 244
INTRODUCTION INFLAMMATORY/RHEUMATOLOGIC
Foot and ankle problems are common complaints to the Still’s disease (adult onset)
physician who cares for athletes. Most of these complaints Still’s disease is a seronegative polyarthritis that usually
can be attributed directly to the athlete’s training and com- affects young adults. It is characterized in its initial mani-
petition with their sport. However, athletes are not festation as a spiking fever and a red/salmon colored rash,
immune from disease. Most of these athletes will present usually over the trunk and extremities. The rash is tran-
to the sports medicine physician assuming their complaints sient and appears at the time of the fever spikes. The
are related to their participation, and many will try to inflammatory arthritis is a polyarthritis or oligoarthritis.
explain their complaints as being secondary to some aspect It commonly affects the proximal interphalangeal (PIP)
of their training. Although the vast number of complaints and metacarpophalangeal (MCP) joints, as well as the
evaluated by the sports medicine physician is directly wrists, knees, hips, and shoulders. Occasionally, the cervi-
attributable to a primary musculoskeletal source, the physical spine, intertarsal joints, temporomandibular joints
cian must maintain an appropriate differential diagnosis to (TMJ), and the distal interphalangeal (DIP) joints are
include those disease states that also can affect the muscu- affected. It may lead to fusion of the carpal-metacarpal
loskeletal system. The foot and ankle are common sites for and the intercarpal joints. Laboratory evaluation com-
these disease states to present as they mimic sports injuries. monly shows an elevated white blood cell count as well
Many of the individuals who present to a sports med- as an elevated erythrocyte sedimentation rate (ESR).
icine clinic are not ‘‘highly competitive’’ athletes but are Anemia of chronic disease is commonly present. Second-
athletes nonetheless. These individuals are commonly ary nonmusculoskeletal findings include lymphade-
referred to as ‘‘recreational athletes’’ and generally are nopathy, hepatosplenomegaly, pericarditis, and carditis.
older. They strive to maximize their abilities in their The disease is treated with either high-dose aspirin or
own chosen activity while attempting to reap the myriad other nonsteroidal anti-inflammatory medicines. Often,
of benefits of a healthy lifestyle. This group of athletes oral steroids are required to control the disease. Overall,
may have concurrent disease states that must be taken Still’s disease has a good prognosis.
into account as they attempt to maintain their healthy,
active lifestyle. Diseases such as diabetes, gout, thyroid Ankylosing spondylitis
conditions, osteoporosis, and so forth can present with Ankylosing spondylitis is an insidious onset seronegative
musculoskeletal complaints. The purpose of this chapter inflammatory condition affecting young individuals, that
is to review those disease states, which may mimic a is, generally younger than 40 years old. It has a uniform
primary musculoskeletal problem in both the competitive sex distribution, but the disease seems to be milder in
and recreational athlete. Knowledge of these conditions females. Also, females have more peripheral involve-
is essential to the physician caring for athletes. ment, rather than spine involvement. Ankylosing
CHAPTER 10 Arthritic, metabolic, and vascular disorders
spondylitis affects the sacroiliac (SI) joints, followed by falls into one of three courses; the majority of athletes
the spine and peripheral joints, respectively. There usu- experience recurrent attacks of arthritis, whereas others
ally is symmetric loss of spine movement. The peripheral experience a single, self-limited episode or a continuous,
joint involvement occurs in 20% to 30% of ankylosing unremitting course.
spondylitis patients and has a predilection for the lower
extremities. Achilles’ tendinitis, plantar fascitis, and cos- Psoriatic arthritis
tochondritis also are associated with the disease process. Psoriatic arthritis is the combination of psoriasis and
It is common to have fatigue, weight loss, low-grade inflammatory arthritis. To make a definitive diagnosis of
fever, and in more severe cases, uveitis, pulmonary psoriatic arthritis, skin or nail changes of psoriasis must
fibrosis, and cardiac abnormalities. Laboratory findings be present at some point in the course of the disease.
include an elevated ESR. The natural history of ankylosing The arthritic changes can be present before skin changes
spondylitis is poorly defined, with some patients experien- develop. The joint pattern in psoriatic arthritis is variable
cing minimal disease and some patients experiencing but commonly includes a pauciarticular asymmetric arthri-
severe disease. Treatment usually involves physical therapy tis involving the peripheral joints. It is common to have
and anti-inflammatories. the spine involved in combination with peripheral joints
as well as inflammation of tendon and insertion points of
Reiter’s syndrome tendons, that is, enthesitis. Digits may become sausage
Reiter’s syndrome involves the triad of arthritis, uveitis, like. There often are associated eye changes, including
and conjunctivitis. It commonly occurs following an conjunctivitis, iritis, and episcleritis. Psoriatic arthritis has
episode of either genitourinary or gastrointestinal an equal sex distribution and usually has onset in the 30-
infection. It has associated features of inflammatory eye to 40-year-old age group. Laboratory results are often
lesions, balanitis, oral ulcers, and keratodermatitis. normal, but some athletes will present with an elevated
Reiter’s syndrome has a male to female occurrence of ESR and/or a normocytic normochromic anemia. Syno-
5:1. The arthritis experienced in Reiter’s syndrome is vial fluid evaluation typically reveals a mild inflammatory
a reactive arthritis rather than an infectious arthritis. process. Radiographs often reveal DIP erosive disease,
It usually occurs 2 to 6 weeks following the onset of sacroiliitis, and enthesopathy and/or periostitis. Treat-
an infectious episode. It is asymmetric and mainly affects ment of psoriatic arthritis involves the use of anti-inflam-
knees and ankles. It is usually of acute onset. There may matory medications, physical therapy, and intra-articular
be diffuse swelling of fingers and toes, that is, sausage corticosteroids to treat the inflammatory arthritis. The
digits. There is commonly inflammatory change at both focus of treatment, however, involves treating the athlete’s
the Achilles’ tendon insertion and the plantar fascial skin lesions. Oral methotrexate is a common therapeutic
origin. There also may be associated low-back pain with choice because it treats both the skin lesions and the arthri-
involvement of the SI joints, making it difficult to distin- tis. Overall, psoriatic arthritis has a good prognosis.
guish it at times from ankylosing spondylitis. The con-
junctivitis in Reiter’s syndrome is either unilateral or Enteropathic arthritis
bilateral. It usually is mild and transient and is a non- Enteropathic arthritis is arthritis associated with in-
infectious source like the arthritis. Common skin lesions flammatory gastrointestinal (GI) conditions including
in Reiter’s syndrome are small, shallow, painless, penile ulcerative colitis and Crohn’s disease, and infectious GI
ulcers called balanitis circinata. Another associated skin conditions, including Shigella, Salmonella, Campylobacter,
lesion is keratoderma blenorrhagica, which represents Yersinia, and Whipple’s disease. The arthritis, when
hyperkeratotic skin lesions mainly involving the soles of associated with ulcerative colitis or Crohn’s disease,
the feet, but they also can be found on the palms and usually is one of a peripheral arthritis with associated
the scrotum. Radiographic findings may demonstrate sacroiliitis and less often enthesopathies. It often is
erosions or periosteal changes, particularly at the a transient, oligoarticular, migratory, nondestructive
Achilles’ tendon insertion or plantar fascial origin. Also, arthritis associated with the bowel disease activity. The
an asymmetric sacroiliitis may be present that is in knees and ankles are most often involved. Synovial fluid
contrast to the symmetric involvement of ankylosing from the affected joints contains mild to severe inflam-
spondylitis. Reiter’s syndrome also is seronegative but mation. There are a variety of associated cutaneous
usually demonstrates an elevated ESR and elevated white lesions with the disease, and mucosal, serosal, and ocular
blood count. Treatment for Reiter’s syndrome involves lesions may occur. The arthritis with ulcerative colitis
anti-inflammatory medications and intra-articular steroid and Crohn’s disease often resolves with medical or surgi-
injections as well as physical therapy. Systemic oral ster- cal treatment of the intestinal disease.
oids have been shown to be of minimal benefit. Topical The arthritis associated with enteropathic infection
steroids are used for the skin lesions and for the con- often comes on a few weeks following the bowel symp-
junctivitis. The prognosis for Reiter’s syndrome usually toms. The arthritis, in this case, is a reactive arthritis
242
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Inflammatory/rheumatologic
and, again, affects mainly knees and ankles. There also female to male ratio. The arthralgias and arthritis are
may be axial joint involvement. Enthesopathies, although a common presenting complaint. The arthralgia/
not common in association with ulcerative colitis and arthritis often is symmetric. Joint capsule, ligamentous,
Crohn’s disease, are common in association with infec- and tendon involvement can be prominent in the dis-
tious GI conditions and typically involve the plantar ease, and hand or foot deformities may develop. There
fascia and Achilles’ tendon insertions. The arthritis is often are marked laboratory abnormalities, including
usually self-limited, resolving weeks to months after a normocytic, normochromic anemia, leukopenia, throm-
the bowel infection. Treatment is symptomatic involv- bocytopenia, elevated ESR, and positive antinuclear
ing the use of anti-inflammatory medications, physical antibody (ANA) and double-stranded DNA. Treatment
therapy, and intra-articular corticosteroid injections. is with anti-inflammatories, topical/oral steroids, anti-
malarials, and immunosuppressive agents.
Rheumatoid arthritis
Gout
Rheumatoid arthritis is a chronic, systemic inflammatory
The pathogenesis of gouty arthropathy involves tissue
disease characterized by significant joint involvement.
deposition of uric acid crystals from a supersaturated
It affects multiple systems extensively, and thus a full
extracellular fluid. Gout involves recurrent attacks of
detailed description of the disease is beyond the scope
severe articular or periarticular inflammation. Late
of this chapter. It involves symmetric upper extremity,
involvement of the disease involves crystal deposition
knee, and foot destructive changes, sparing the DIP
of uric acid within articular, osseous, soft tissue, and
joints of the hands and feet. It results in progressive
cartilaginous structures. These tophi occur late (>10
joint destruction and deformity. Again, there are mul-
years) in the disease. There may be renal impairment
tiple extra-articular features, including rheumatoid
with or without uric acid urinary calculi. Hyperuricemia
nodules, arteritis, neuropathies, scleritis, and pericardi-
may be demonstrated in individuals without gout and
tis. Lymphadenopathy and splenomegaly are common.
uric acid levels may be within the normal range in
The incidence in females is two to three times greater
individuals showing clinical gouty arthropathy. Gout is
than in males. It may occur at any age and increases in
a disease of middle-aged men and postmenopausal
frequency with increasing age. Hand, wrist, knee, and
women. It increases in frequency with age.
foot are most commonly involved, but any diarthrodial
An acute, gouty, arthritic flare most commonly
joint can be affected. The elbows, shoulders, sternoclavi-
involves the great toe metatarsophalangeal (MTP) joint
cular (SC) joints, hips, ankles, and temporomandibular
but also commonly involves the ankle. It usually involves
joints (TMJ) are less commonly involved. Spine involve-
a single joint with an acute onset, often during the
ment is limited to the upper cervical spine.
evening hours. The joint often appears warm, red, and
Feet and ankle changes are similar to those seen in
swollen and usually is exquisitely tender. The flare may
the hands. Cocking up of the toes may occur secondary
subside spontaneously 3 to 10 days following onset
to subluxation of the metatarsal heads. This gives the
without treatment. Individuals often are symptom free
digits a claw-like appearance. Fibular deviation of the
following an acute attack, but over time, if untreated,
first through fourth toes may occur. Bursal inflam-
the attacks may increase in frequency, increase in the
mation about the foot/ankle also occurs with the
number of joints affected, and increase in duration of
retrocalcaneal bursa being most common. Laboratory
symptoms when flared. The flares may be triggered by
evaluation usually shows a normocytic, normochromic
trauma, alcohol, drugs, stress, or medical illness. Tophi
or hyperchromic anemia. There often is an elevated
when present occur most commonly in the synovial
ESR and positive rheumatoid factor. Joint fluid evalua-
tissue, subchondral bone, olecranon bursa, patellar
tion reveals mild inflammation. Treatment involves
and Achilles’ tendons, subcutaneous tissue on the exten-
anti-inflammatory medications, as well as physical ther-
sor surface of the forearms, and overlying joints. Radio-
apy. Intra-articular corticosteroid injections are used
graphic findings in gout usually are negative. Often they
for symptomatic joints not responsive to initial treat-
are obtained to rule out other joint processes, such as
ment. Second-line therapy involves disease-modifying
a septic joint, or to evaluate for the presence of chondro-
antirheumatic drugs (DMARDs) with the trend toward
calcinosis. More chronic cases can show periarticular
more aggressive/earlier use of these drugs.
erosions and frank degenerative changes, especially in
the great toe MTP joint. The gold standard for diagno-
Systemic lupus erythematosus (SLE) sis is monosodium uric crystals demonstrated in joint
SLE is a chronic, multisystem inflammatory disease fluid. The white blood cell count from a symptomatic
affecting bone, joints, tendons, skin, kidney, heart, joint usually reveals moderate inflammation. Treatment
lungs, GI tract, and central nervous system (CNS). in the acute setting may involve colchicine, anti-
Again, a full and detailed description of the disease pro- inflammatory medications, steroids, or intramuscular
cess is beyond the scope of this text. SLE has a 9:1 adrenocorticotrophic hormone (ACTH). Treatment in 243
...........
the chronic setting may also involve the use of colchicine with the joint erythemic and warm. The ankle is diffusely
as well as allopurinol or probenecid. and significantly tender. The rest of the examination is
noncontributory. X-rays are normal. Laboratory studies
Pseudogout show a normal complete blood count (CBC), ESR, renal
Pseudogout involves acute, gout-like, inflammatory function, and uric acid. Joint aspiration demonstrates a
attacks that occur secondary to calcium pyrophosphate mild to moderate inflammatory response and is positive
dihydrate crystal deposition within joints. The incidence for monosodium urate crystals. The patient was treated
of clinically symptomatic pseudogout is one half that of with indomethacin and demonstrated a complete
true gout. Calcium pyrophosphate dihydrate crystal response over the next few days.
deposition may occur as an incidental finding in a
symptom-free joint with radiographic evaluation. The
term ‘‘chondrocalcinosis’’ is used to describe this x-ray
appearance. The male to female ratio of pseudogout is
1.4:1 and is in marked contrast to the distribution in
gout. The pseudogout flare usually involves one or more C A S E S T U D Y 2 : R E I T E R ’ S
joints lasting for several days. It usually is abrupt in onset
S Y N D R O M E
but self-limited. Findings may be as severe as in true
gout, but typically the attacks of pseudogout are less
painful. The knee is the most commonly affected joint, A 24-year-old, professional basketball player presents
but all joints are susceptible, including the first MTP with a left ankle that is painful, swollen, red, and warm.
joint. The flare may be triggered by trauma, surgery, He also notes several toes that are swollen and right heel
stress, or medical illness. Individuals usually are symptom pain. His past medical history and family history are
free between flares. Treatment is with anti-inflammatory noncontributory, except that he was treated for a
medications and intra-articular steroid injections. Chlamydia infection 1 month ago. He is on no medications
except for Visine for ‘‘irritated’’ eyes. Physical
examination demonstrates an erythemic, warm left
4 PEARL ankle with mild effusion. Several sausage digits are

noted. The right plantar fascia origin is tender. Both
conjunctiva are injected. The rest of the examination is
Suspect inflammatory disease in a joint that has no history noncontributory. X-rays are normal. Laboratory studies
of trauma and that is swollen and warmer than expected for are negative, including an inflammatory workup, except
the history. that the ESR is elevated and the WBC is at the upper
limits of normal. The athlete was treated with
nonsteroidal anti-inflammatory drugs (NSAIDs) and
physical therapy. The athlete returned to baseline and
there were no recurrences.
4 PEARL
Suspect inflammatory disease if there is a history of multi-
ple joint involvement or other systemic complaints that is,
skin, GI, constitutional, and so forth.
OTHER
Lyme disease
Lyme disease is a multisystem illness caused by the tick-
borne spirochete Borrelia burgdorferi. The disease is
characterized by a rash at the bite site (erythema chron-
C A S E S T U D Y 1 : G O U T icum migrans), constitutional symptoms, neurologic
abnormalities, cardiac involvement, musculoskeletal
complaints, and a reactive arthritis. Early in the disease
course, there often is migratory pain without specific
A 46-year-old, male runner awakens with a swollen,
inflammation to the joints. Tendon, bursal, and mus-
warm, red right ankle, which is exquisitely painful. He
cular inflammation is common. The reactive arthritis
denies injury but did go for his usual 3-mile run 1 day ago.
The rest of his history is noncontributory. On physical usually occurs in intermittent attacks. It can be monoar-
examination he demonstrates an effusion to the ankle ticular to oligoarticular and has a preference for large
joints, especially the knees. It can last for months, with
244
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Metabolic disease
chronic flares over several years. The treatment for Lyme foot and ankle, skin integrity can be a concern, regardless
disease early in its course is tetracycline, penicillin, or of diabetes. Callus formation, blisters, abrasion, and
erythromycin. Late in the course of the disease, intrave- fungal infections are very common in athletes. In the
nous penicillin usually is the treatment of choice. setting of diabetes, these conditions can lead to ulceration
and bacterial infection and potentially may develop a
Sarcoidosis serious complication faster than in a nondiabetic athlete.
Sarcoidosis is a multisystem illness characterized by Skin ulceration is a significant concern for all diabetic
noncaseating epithelioid granulomas in affected tissues. athletes. Cellulitis can develop quickly. Even worse is the
It has a tendency to affect young adults of either sex. possibility of osteomyelitis. Left untreated, these com-
It most often begins as bilateral hilar lymphadenopathy, plications could be career altering or even career ending.
pulmonary infiltrates, and skin and eye lesions. However, Most plantar wounds or ulcers in a diabetic are poly-
there may be bone lesions, localized muscular granulo- microbial. Superficial skin infections on the dorsum of
mas, and acute inflammatory arthritis. The arthritis is the foot or around the ankle may be less likely to be
the most common rheumatologic manifestation and polymicrobial, but if empiric treatment is warranted,
can be the initial complaint. The arthritis most com- standard regimens to cover typical pathogens for dia-
monly affects the ankles and knees. The most severe betic ulcerations should be used. Proper wound care is
attacks usually occur during active disease. These flares essential, and weight-bearing activities may have to be
usually last for 2 to 3 weeks. Chronic arthritic changes restricted temporarily. One special note is that deep
are much less common. The prognosis in sarcoidosis foot ulcers with signs of cellulitis may be infected with
is favorable. Treatment usually is anti-inflammatory Pseudomonas because athletic shoes may harbor these
medication or a short course of oral corticosteroids. bacteria. Lastly, deep ulcers need debridement and/or
other investigation to search for osteomyelitis, although
this would be unusual in the athlete.
METABOLIC DISEASE Diagnosis and testing of diabetes is beyond the scope
of this chapter, but it is important to note that mono-
filament tactile and vascular examinations are essential
Metabolic diseases are an uncommon cause of concern for the evaluation and monitoring of diabetic neuropa-
in the athletic foot and ankle. The most common meta- thy. Routine diabetic care is essential for tight control
bolic disease that may present with foot and ankle issues of glucose levels and prevention of complications. It
is diabetes mellitus. The neuropathy and microvascu- also is important to note that sports participation should
lopathy in the extremities, especially the foot and ankle, be encouraged in the diabetic population because phy-
can result in a wide range of sequelae. Metabolic bone sical activity can have beneficial effects on the disease as
disease is another common metabolic disease that a whole. Simply keep in mind that more attention must
uncommonly affects an athlete’s foot and ankle. In cases be paid to lower-extremity skin care in the athlete.
of recurrent stress fractures, metabolic bone disease such In individuals with foot alignment prone to callus for-
as osteoporosis may be the underlying cause. Medica- mation, such as a cavus foot, professional callus shaving
tions and/or supplements can cause metabolic bone dis- may be warranted. Orthotics may be useful in spreading
ease or can cause other conditions that are risk factors out load-bearing surface of the foot and may help to
for metabolic bone disease. Examples include steroid alleviate pressure spots before they can ulcerate.
use (or abuse), which causes drug-induced osteopenia, Diabetics have other complications that can affect the
or vitamin B12 deficiency, which can cause a neuropathy athlete’s performance and general health, but one that
that may present with diabetes-like complications. can have specific foot and ankle relevance is the fact that
diabetics have a higher incidence of osteoporosis and
Diabetes mellitus may have an increased rate of stress fractures. The key
Diabetes mellitus is a common disorder. Younger ath- is focusing on the foot and ankle but remembering to
letes are more likely to be type I, but many type II dia- see the athlete as a whole person.
betics are involved with athletics, especially on a
recreational or fitness level. The most important factor Metabolic bone disease
is achieving optimal control of the athlete’s diabetes. Metabolic bone disease encompasses any disorder that
Tighter control usually equates with fewer complica- changes the mineralization of the normal skeleton.
tions. In the setting of the foot and ankle, the most Osteoporosis is the most common metabolic bone dis-
important complication is peripheral neuropathy, which ease that could affect the foot or ankle. This is a concern
usually occurs in a long standing diabetic. Peripheral primarily in the mature or elderly athlete.
neuropathy leads to the possibility of skin breakdown Osteoporosis and osteopenia are common disorders,
and subsequent ulceration and infection. In an athlete’s especially in postmenopausal women. However, they
245
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do not usually affect the foot and ankle. The most com-
Table 10-1 Secondary causes of osteoporosis
mon sites of fracture in osteoporosis are the spine, wrist,
ribs, pelvis, hip, and humerus. Osteoporosis is a concern
Nutritional
in mature or elderly athletes because weaker bones may
lead to an increased fracture rate or recurrent fractures. Inadequate calcium intake
Osteoporosis and osteopenia are abnormalities of the
bony matrix, where bone is less dense but of normal Malabsorption
architecture. Other metabolic bone diseases may not
have normal bony architecture, such as osteomalacia. Bulimia or anorexia nervosa
Bone densitometry (dual energy x-ray absorptiometry
[DEXA] scan) is the test of choice for diagnosis of Exogenous Substances
osteoporosis. Standard radiographs are unreliable. DEXA
scanning will differentiate osteoporosis from osteopenia. Glucocorticoids
A DEXA score of 2.5 standard deviations below the mean
Some chemotherapeutic agents
is diagnostic of osteoporosis. Scores of 1.0 to 2.5 are
diagnostic of osteopenia. Excessive alcohol
Treatment of osteoporosis is beyond the scope of this
chapter, but a brief summary follows. The best treat- Some anticonvulsants
ment is prevention. Calcium intake should be at least
1000 mg/day in an adult, and vitamin D is needed to Cyclosporine
aid in the absorption of the calcium. Weight-bearing
resistance exercise also is important in building and Tacrolimus
maintaining strong bones. Once osteoporosis has been
diagnosed, several treatment options exist. Calcium Thyroxine
and vitamin D need to be taken, but they will not ade-
Bone Marrow Disease
quately increase bone density. At this time bisphospho-
nates (e.g., alendronate and risedronate) are a first-line Leukemia
treatment for increasing bone density. Estrogen in-
creases bone density in postmenopausal osteoporosis Lymphoma
but has other significant tissue effects that need to be
taken into account before use. Selective estrogen-receptor Myeloma
modulators (raloxifene and tamoxifen) can prevent bone
density loss and decrease fractures. Calcitonin can di- Metastatic carcinoma
rectly inhibit osteoclasts and prevent further bone loss.
Parathyroid hormone actually can stimulate osteoblastic Bone cysts
activity if the concentration is not too high. Follow-up
Rheumatologic/Connective Tissue Disease
DEXA scanning is important to monitor therapy.
Most cases of osteoporosis are idiopathic, age-related, Rheumatoid arthritis
or postmenopausal. There are many secondary causes
that are not as common but need to be kept in mind. Marfan’s syndrome
Please see Table 10-1 for a list of these secondary causes.
The majority of patients with osteoporosis will be older Ehlers-Danlos syndrome
recreational athletes, but bone loss can occur in a youn-
ger athlete. The classic scenario in a younger patient Osteogenesis imperfecta
would be a college-age, female runner with recurrent
stress fractures and an eating disorder and who is an- Endocrine Disease
ovulatory. This is the classic female athletic triad (see
Diabetes mellitus
Chapter 24). The results of the female athletic triad syn-
drome include metabolic bone disease and can lead to Hyperparathyroidism
an increased rate of stress fractures. Any patient with
recurrent stress fractures or problems healing existing Hyperthyroidism
fractures must be evaluated for possible metabolic bone
disease. Clinical judgment is needed to determine when Cushing’s syndrome
to test an athlete for metabolic bone disease in the
setting of recurrent stress fractures. There are no Vitamin D deficiency (rickets/osteomalacia)
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Vascular/lymphatic disorders
In addition, medications, supplements, or deficiency

Table 10-1 Secondary causes of osteoporosis (cont’d)
states can lead to other conditions that can affect the
foot and ankle. Vitamin B12 or folate deficiency can lead
Hypogonadism
to a peripheral neuropathy, which in turn could lead to
Growth hormone deficiency some of the same concerns that a diabetic athlete may
have. The bottom line is to search for clues to the
Functional underlying cause and, if possible, correct the disorder,
discontinue the medicine or replete the deficiency.
Prolonged immobilization or disuse
Miscellaneous
C A S E S T U D Y 3 : F E M A L E
Postsurgical A T H L E T E T R I A D
Subtotal gastrectomy
Celiac disease A 19-year-old, female, college freshman, cross country/

track athlete presents with a 2-week history of gradually
Renal worsening left foot pain. The pain initially was present at
the start of her runs and became worse as she tried to run
Renal tubular acidosis through the pain. Now the pain is present with activities
of daily living (ADLs). Over the last 24 hours, her pain has
Hypercalciuria worsened significantly. She has noted some mild swelling
in the area of her dorsal midfoot/forefoot. About 1 month
ago she added some runs outside of her usual training
established guidelines for the number or frequency of runs/practices. She has concern for a possible stress
fractures that necessitate further investigation. In our fracture as she has a history of prior stress fractures
opinion there is no specific number of fractures needed (three fractures during her senior and junior years of high
to prompt workup for metabolic bone disease, but if school). The rest of her history of present illness is
there is enough clinical evidence to suggest metabolic noncontributory. She is on no medications but admits to
bone disease, a work-up is warranted (i.e., two to three the use of over-the-counter (OTC) diet pills. She has a
history of ‘‘spotty’’ periods and has not had a period
stress fractures within a 2-year period).
since she was a sophomore in high school. The rest of her
Workup for metabolic bone disease is directed toward
past medical history is noncontributory. Physical
the suspected cause. For example, in a mature fitness examination demonstrates a height of 5 feet 6 inches and
athlete with recurrent stress fractures the cause is most a weight of 105 lb (BMI ¼ 17), minimal erosions of the
likely to be a result of idiopathic or primary osteopo- enamel of the teeth and fine hair on the arms but is
rosis, and initial workup would start with a DEXA scan. otherwise noncontributory. X-rays show a completed
A significantly different approach would be the case for a fourth metatarsal stress fracture. Laboratory studies
teenage girl with recurrent stress fractures and would including CBC, electrolytes, thyroid, and hormonal status
include a more detailed dietary and menstrual history, tests are noncontributory. DEXA testing shows bone
as well as laboratory workup. mineral density 2.5 standard deviations below the mean
of young adults. A multiteam approach was used to treat
Medications/supplements/deficiency states the athlete and involved the team internist, a dietician,
and a sports psychologist. Treatment included a walking
Several medications, supplements, or deficiencies can boot for the stress fracture with activity modification,
result in disease-like states that can result in foot and increased caloric intake and calcium supplementation to
ankle issues in an athlete. Most cases concern medi- 1500 mg per day, hormonal supplementation, counseling,
cations or supplements that result in metabolic bone and involvement of the athlete’s family for emotional
disease. Table 10-1 has several examples of medications support.
that can cause osteoporosis. Also, deficiencies can result
in metabolic bone disease. The obvious is calcium defi-
ciency, but other states can lead to osteoporosis as well. VASCULAR/LYMPHATIC DISORDERS
Examples include growth hormone deficiency, thyroid
hormone deficiency, and hypogonadism. Please see
Table 10-1 for more examples. In some cases, excess Arterial disease
states can lead to metabolic bone disease. Hyperpara- Arterial disease represents decreased blood flow to the
thyroidism and Cushing’s disease would be examples. lower extremity. The most common cause is occlusive
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disease secondary to atherosclerosis and associated examination. Occasionally, some bluish discoloration of
embolic phenomenon. It is uncommon in young healthy the tips of the digits may be present between attacks.
athletes unless there is a genetic predisposition or severe A typical attack causes the digits to become pale and
risk factors. It is most common in middle-aged to older- cyanotic with a sharp demarcation of these findings with
aged recreational athletes, especially those who have the skin more proximally. Raynaud’s may be associated
concurrent disease, that is, diabetes or elevated triglycer- with other diseases such as scleroderma, and when this
ides or cholesterol. It presents as claudication of the lower occurs it is referred to as Raynaud’s phenomenon. When
extremities, which is defined as exercise-related pain. just the Raynaud’s findings are present without concur-
Evaluation at rest, unless late in the disease, may be rent other disease, then it is called Raynaud’s disease.
entirely normal, although decreased lower-extremity The prognosis for Raynaud’s patients generally is
pulses may be present. The disease usually is progressive, good. For athletes who are exposed to cold weather
causing increased pain at lesser workloads. Evaluation conditions, protective clothing is usually sufficient.
may include arteriography, and definitive treatment may More severe cases may require a pharmacologic treat-
require vascular surgery. ment, which may include calcium channel blockers,
Claudication in a young athlete may be caused by alpha-adrenergic blockers, or vasodilators.
popliteal artery entrapment (see Chapter 20). Its cause Another condition that may affect the foot during
is either an entrapment of the popliteal artery in the cold weather outdoor activities is chilblain or pernio.
popliteal fossa secondary to an anatomic variation of Chilblain is an inflammatory disorder of the skin in-
the popliteal artery and surrounding myofascial struc- duced by cold temperature. It often affects women
tures or a functional entrapment compressing the artery in the second or third decade of life. The etiology of
by the exercising muscles and surrounding bone. It has chilblain is unknown. It presents as bluish red edema-
an 85% male preponderance and usually occurs in the tous areas of the skin overlying the lower extremities.
second or third decade. It is bilateral in 25% of cases. Patients may complain of itching/burning to the areas
The athlete usually complains of cramping to the calf of skin change. Repeated exposure may cause the lesions
and foot with associated numbness or paresthesias. to become chronic and ulcerative. The lesions generally
In 10% of patients, there are acute or chronic ischemic resolve with avoidance of the cold. Often, however,
changes of the lower extremity, including skin and tem- there will be a permanent area of hyperpigmentation at
perature changes as well as rest pain and possible tissue the prior site of the lesions.
necrosis. Physical examination usually is normal, but
the diagnosis may be suspected if pulses diminish in Venous disease
the affected extremity with maximal ankle dorsiflexion Thrombophlebitis is uncommon in a young, healthy
or with active plantarflexion with the knee fully athlete. It may occur from direct trauma from a contact
extended. However, these examination findings also sport, especially in association with postgame travel in an
are found in normal individuals who have no lower- away team returning to the home location or following
extremity complaints. Evaluation usually includes non- limited activity after a significant injury or elective
invasive vascular studies, including lower-extremity surgery. A previous history of thrombophlebitis may
Doppler, preexercise and postexercise ankle/brachial predispose an individual to a second episode. Three fac-
blood pressure indices, continuous wave Doppler ultra- tors as part of Virchow’s triad may lead to the formation
sound with provocative maneuvers, mentioned previ- of a thrombosis, and these include venous stasis, injury
ously, and a duplex ultrasound that combines anatomic to the venous wall, and a hypercoagulable state. Any
evaluation with quantitative and qualitative analysis of unexplained swelling associated with lower-extremity
arterial blood flow. The gold standard for evaluation, erythema and increased temperature should raise the
however, is arteriography. Treatment involves surgical suspicion of a venous thrombus.
release of the entrapped artery. Although few long-term The main concern in detecting a venous thrombus is
studies exist regarding the prognosis of popliteal artery to determine whether the lesion occurs within the
entrapment syndrome, studies suggest that the progno- superficial venous system or the deep venous system.
sis is most favorable if no arterial damage has occurred at Superficial lesions are treated symptomatically and may
the time of diagnosis and treatment. present as tender, erythemic, palpable cords within the
Raynaud’s phenomenon is manifested by pallor and subcutaneous tissue. However, because of the potential
cyanosis of the digits in response to some type of serious complications of a deep venous thrombus, de-
stressor, usually exposure to the cold but also possibly finitive study should be obtained to rule out any deep
secondary to an emotional distress. It can present at system involvement if there is any question regard-
any age but is most common in women between the ing the presentation. Testing involves noninvasive,
ages of 20 and 40 years. It has an unknown etiology. lower-extremity Doppler examination that provides an
Patients usually have no findings at the time of physical approximate 90% accuracy. If deep venous thrombosis
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Vascular/lymphatic disorders
is discovered, treatment involves rest and initiation of to many of the same forces that affect the venous system
anticoagulation therapy. Anticoagulation therapy usu- and include trauma, mechanical obstruction, and sur-
ally is instituted for 3 to 6 months for the first episode gical removal of lymph nodes as well as venous
and may require chronic anticoagulation therapy for hypertension.
repeated episodes. Anticoagulation reduces the likelihood Primary lymph edema is a disease of the lymph sys-
of further formation of the thrombus and lessens the tems with an unknown cause. It is most common in
potential complications of embolic phenomenon. Mea- females and often is unilateral. It usually has onset
sures aimed at correcting any underlying risk factors such before the age of 40. The diagnosis may be confirmed
as minimizing immobilization and treating any cause for with either lymphogram or contrast lymphangiography.
the hypercoagulable state, also are recommended. Treatment is symptomatic and aimed at reducing
Varicose veins are prominent, abnormally distended, the lower-extremity edema with elevation, support
tortuous, superficial veins of the lower extremities that stockings and, occasionally, diuretics. Chronic lymph-
occur in approximately 20% of adults. The cause is usu- edema may cause recurrent skin infections, which in
ally one of defective valves within the veins or congeni- turn lead to an overload of the lymph system, causing
tally absent valves. They are more common in females further edema. Rarely, surgical intervention may be
and often are associated with a family history of varicos- necessary.
ities. Any condition that decreases venous outflow from
the lower extremities, that is, pregnancy, also may cause
varicosities.
Normal venous return from the lower extremities C A S E S T U D Y 4 : P O P L I T E A L
usually is accomplished by contraction of the lower- A R T E R Y E N T R A P M E N T
extremity musculature to pump the blood back up the
venous gradient. Intact/competent venous valves pre-
vent back flow. When the valves are incompetent or
absent, pooling blood distends the veins, leading to fur- A 17-year-old, high school senior CC runner presents with
a several-month history of exercise-related left calf and
ther obstruction that causes worsened flow from the
foot pain. The pain is described as cramp-like in quality
lower extremities. An exercising athlete with varicose
and has become progressively worse with time. The pain
veins further worsens this condition because of increased has become more intense and has onset earlier in his
arterial flow into the exercising lower extremities. Usu- runs. There are no associated paresthesias, increased
ally this worsening of the venous return during exercise tension to the calf musculature, or loss of foot or ankle
has little effect on exercise tolerance. Some athletes, control during the runs. The pain will resolve after several
however, may complain of a nonspecific heavy sensation minutes of rest but with return to running after resolution
to the extremities with exercise. This vague, exercise- the pain will return almost immediately. There are no
related discomfort is known as ‘‘venous claudication.’’ symptoms noted on the right or symptoms outside of
If venous congestion of the superficial system pro- activity. Past medical history and family history are
gresses it may lead to involvement of the deep venous noncontributory. Physical examination is noncontributory
except that with the knee in full extension and forced
return. This may then result in chronic edema, venous
dorsiflexion or active plantarflexion the dorsalis pedis and
dermatitis, and/or stasis ulcers. Treatment is initially
posterior tibialis pulses diminish. X-rays are negative.
symptomatic using elevation and support stockings. Sur- Superficial and deep posterior chronic exertional
gical vein stripping also may be an option for persistent compartment testing is negative. Arteriography
problems, which do not respond to a more conservative demonstrates entrapment of the artery at the knee.
approach. Proper skin care to treat the chronic dermati- The athlete is treated surgically with release of the
tis and any ulcers that may develop also is necessary. artery and makes a gradual return to running.
Lymphatic disease
Other sources of edema of the lower extremities, but In summary, inflammatory metabolic, vascular diseases
usually not associated with pain, are abnormalities of are common in the general population but uncommon
the lymphatic system. Lymph vessels serve to transport causes of foot and ankle concerns in athletes. However,
lymph fluid back to the venous system through the being attuned to the possibility of these disease processes
thoracic duct at the left jugular vein. At lymph node complicating an athlete’s ability to perform his or her cho-
junctions along the lymph system, immunologic and fil- sen sport can allow the physician to address these issues
tering is done to the lymph fluid. Lymphatic channels, and enhance the athlete’s performance or enjoyment
which normally follow the venous tree, are susceptible of sport.
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.........................................C H A P T E R 1 1
Dermatologic, infectious, and nail disorders

Kevin Gebke
......................
CHAPTER CONTENTS
Introduction 251 Infectious disorders 257

Dermatologic disorders: environmental/anatomic 251 Nail disorders 259
Dermatologic disorders: traumatic 255 References 262
INTRODUCTION formation in acute cases. In chronic cases, a presentation

with papules, scarring, and lichenification can be seen.1
Allergic contact dermatitis will be seen in individuals
Athletes present with a wide range of dermatologic
who previously have been sensitized to the allergen.
afflictions, including traumatic conditions, anatomic
A delayed hypersensitivity reaction will be seen over
abnormalities, and various infections. Identifying pat-
the course of several hours. In athletes, contact dermati-
terns of wear and anatomic variation may give key
tis is seen most commonly on the dorsum of the foot
insight into the cause of the presenting complaint. The
and toes. Fisher2 stressed that the moist environment
purpose of this chapter is to discuss the more common
within the athletic shoe is a major component in the
disorders seen in sports medicine and to give insight
development of contact dermatitis. It was stated that
into the treatment options. The ultimate goal is to assist
feet that were kept dry would not develop this form of
in early recognition of common problems and to pre-
dermatitis.
vent performance impairment in our athletic patients.
The initial approach to treatment of contact dermati-
Initial examination of the foot and ankle always should
tis is to remove exposure to the offending agent. A wet
include a thorough inspection of the skin and nails.
compress with an astringent such as aluminum acetate
is effective in soothing the affected areas. Topical and
systemic steroids are used for their anti-inflammatory
DERMATOLOGIC DISORDERS: and mineralocorticoid effects. Antihistamines are used
ENVIRONMENTAL/ANATOMIC when significant pruritus is associated with the dermati-
tis. As the dermatitis starts to resolve, it is advocated to
apply emollients to moisturize the healing skin.
Contact dermatitis
Contact dermatitis (Fig. 11-1) is fairly common in an
athletic population. Athletes encounter multiple expo-
sures, including adhesive tape, compound of benzoin,
4 PEARL
topical medications (antibiotics, antifungals, and anti- Clinical pearls in treatment and prevention of contact
septics), and rubber-containing sports equipment. Some dermatitis include regular changing of damp footwear,
athletes even have reactions to the leather products of avoidance of potentially irritating or allergenic substances
applied to the foot and ankle, and early identification of
which most sports shoes are composed. Contact derma-
signs and symptoms of dermatitis. It is recommended
titis presents as an inflammatory response of the skin to to maintain a high index of suspicion for secondary
an offending irritant. The main pathologic feature of bacterial infections and to treat with systemic antibiotics
contact dermatitis is intracellular edema of the epi- as needed.
dermis, resulting in intraepidermal vesicle and bullae
CHAPTER 11 Dermatologic, infectious, and nail disorders
hemorrhagic, that eventually results in a black eschar

within a couple of weeks. Fourth-degree injury generally
refers to complete tissue necrosis. Considering that it is
nearly impossible to classify frostbite into one of these
categories on initial presentation, many clinicians simply
describe frostbite as either superficial or deep. Superficial
frostbite includes the first- and second-degree types
described and deep describes the third- and fourth-
degree categories. Physical examination findings on ini-
tial presentation can allow the clinician to arrive at
a general prognosis. Findings such as sensation to pin-
prick, normal skin color, and enlarged blisters with clear
fluid are favorable indicators that predict more of
a superficial injury. On the other hand, if dark fluid-
filled blisters; hard, nondeforming skin; and nonblanch-
Figure 11-1 Contact dermatitis. (From Habif, Clinical
dermatology, St Louis, 2004, Mosby: p. 92, Figure 4-16.) ing cyanosis are seen, this is more diagnostic of a deeper
injury. Patients with frostbite of the foot are likely to
have involvement of the toes. They typically will com-
plain of symptoms of numbness and tingling with possi-
Frostbite ble associated electric–shock-type sensations. Symptoms
Injury induced by cold exposure has been recognized of cold sensitivity, sensory loss, and hyperhidrosis may
for thousands of years.3 Frostbite involves the skin and be described for months to years following the injury.
potentially the soft tissues of the foot and ankle in ath- The diagnosis of frostbite is made on the basis of
letes that are exposed to prolonged cold environments. history and physical examination. It is difficult to predict
Injury can occur, however, even with brief exposure the degree of tissue injury for weeks following the
of an unprotected foot to a cold, conductive surface exposure. With severe injury, it may take months before
(metal, concrete). Several terms are used to describe this a clear delineation of viable versus nonviable tissue can
phenomenon, including frostnip, chilblains, and frost- be made. There is no current radiologic technique
bite. Frostnip is described as nonfreezing injury to the that can reliably distinguish the line of demarcation
skin tissues that can commonly be seen in the toes. of injured tissues in the immediate postinjury period.
Associated symptoms include numbness and tingling. Continued research using technetium scintigraphy and
Cellular injury is absent in frostnip. Chilblains is asso- magnetic resonance techniques is needed to identify
ciated with a more significant nonfreezing cold injury whether any available radiographic procedure may allow
seen at temperatures below 59 F in which mild tissue for early distinction of viable tissues.4
damage is seen in the form of minor vascular injury The treatment of frostbite injuries can be divided into
and tissue swelling. Frostbite is the destruction of body three phases, including initial evaluation, acute care,
tissues because of freezing (below 32 F) and ice crystal and long-term follow-up. McCauley et al.5 described a
formation in the tissues, which causes cell lysis and tissue treatment protocol for frostbite. This protocol can be
destruction. The tissue damage seen in association with applied to active individuals who suffer injuries to the
frostbite is caused by two distinct mechanisms. First, lower extremity. Initially, the athlete should be admitted
ice crystal formation in the intracellular space leads to for rapid rewarming of the affected area in warm water
cellular dehydration and destruction. Second, damage (104 to 108 F for 15 to 30 minutes or until thawing
to the vascular endothelium leads to inefficient deli- has completed). After the completion of rewarming,
very of blood to the injured tissues, further compli- the affected parts should be treated as follows: white
cated by edema and swelling. Ultimately, further cell blisters should be debrided and topical treatment with
deterioration is seen secondary to hypoxia.4 aloe vera should be applied every 6 hours. Hemorrhagic
Several classification schemes have been used to cate- blisters should be left intact, with topical aloe vera
gorize frostbite injury. Historically, frostbite has been administration every 6 hours. The patient’s lower extre-
categorized into four degrees of injury, with first degree mities should be elevated and splinted as needed. The
being described as a numb central white plaque with athlete should be given antitetanus prophylaxis. Regular
surrounding erythema. Second-degree injury is des- administration of anti-inflammatory medications is
cribed as blister formation of clear or milky fluid with recommended. Analgesia should be accomplished using
surrounding erythema and edema, all seen within the narcotic medications. Antibiotic coverage should be
first 24 hours. Third-degree injury is characterized by started and continued for the first 2 to 3 days or until
blisters filled with a dark fluid, possibly appearing signs of superinfection have cleared. Daily hydrotherapy
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Dermatologic disorders: environmental/anatomic
should be implemented for 30 to 45 minutes at a tem- who develop hyperhidrosis later in life warrant a workup
perature of 104 F. Lastly, the patient should avoid for systemic disease on presentation.
smoking during this time to prevent peripheral vasocon- The treatment for hyperhidrosis can be challenging.
striction. When evaluating and treating patients with Topical agents such as glutaraldehyde solution can
frostbite, the clinician should avoid rubbing the be administered in an attempt to reduce perspiration
involved region because this can cause additional dam- through the denaturation of keratin with resultant
age to the injured tissue. It also is important to ensure occlusion of the pores of the sweat glands. Aluminum
that there is not a possibility of refreezing after the compounds such as aluminum chloride function as anti-
rewarming process has taken place. If the potential for perspirants and can be used topically, as well. Darrigrand
refreezing exists, rewarming should be delayed until fur- et al.6 studied the application of antiperspirants to the
ther cold injury can be avoided. If refreezing does occur, feet of cadets in an attempt to decrease foot sweat
significantly more tissue injury can manifest. Most ath- accumulation and injuries. They demonstrated a 50%
letes with frostbite injuries of the foot and ankle will decrease in foot sweat accumulation and a reduced
present with findings consistent with a superficial injury. occurrence of trench foot and friction blisters. There
After rewarming, the athlete can be treated in an outpa- was, however, an increased incidence of contact derma-
tient setting using appropriate topical formulations and titis. Oral administration of anticholinergic agents such
analgesics. Close follow-up is necessary. as propantheline, glycopyrrolate, benztropine, and oxy-
butynin also has been advocated. In addition, neuro-
muscular blocking agents such as botulinum toxin can
4 PEARL be used to inhibit transmission of nerve impulses at
the neuromuscular junction of skeletal muscle and/or
Clinical pearls in the treatment and prevention of frostbite the autonomic ganglia. It is recommended to perform
include many commonsense principles. First of all, athletes a nerve block of the posterior tibial nerve and the sural
should be educated on the use of appropriate clothing not
only to protect the lower extremities but also to help
nerve before to botulinum toxin treatment for plantar
maintain core body temperature. As the core body temper- hyperhidrosis.7
ature begins to decrease, blood is shunted away from the
lower extremity, further predisposing to frostbite injury.
Adequate hydration should be stressed. Regular changing of
damp socks and footwear should be recommended. Lastly, 4 PEARL
during times of anticipated cold exposure, it should be
recommended that the athlete wear two pairs of socks, Clinical pearls in the treatment of hyperhidrosis include
with the inner layer made of synthetic fiber such as early multimodality intervention in an attempt to control
polypropylene to wick away water from the skin and an sweating. It is important to remember that hyperhidrosis
outer layer made of wool or cotton for increased insulation. is not associated with mortality, but multiple morbidities
can be seen that will impair athletic participation and
performance. Many times, a dermatologist will need to
be consulted, especially if botulinum toxin therapy is
considered.
Hyperhidrosis
Hyperhidrosis is defined as excessive sweating outside
the range required for normal thermal regulation. It typ-
ically presents in early childhood or adolescence and can Hyperkeratosis
affect the soles of the feet. The condition can be idio- Hyperkeratosis (Fig. 11-2) in the form of corns and
pathic or secondary to systemic disease, metabolic disor- calluses is a standard feature for many athletes. These
der, febrile illness, or medication use. Three forms lesions are produced as pressure and friction are applied
of hyperhidrosis are described, including emotionally repeatedly to the skin overlying the osseous structures.
induced, localized, and generalized. The sole of the foot In an attempt to protect from skin breakdown, the body
can be affected by the emotionally induced and localized produces these regions of hyperkeratotic tissue. Many
types. It occurs equally in both sexes and there seems to athletes who have symptoms related to their hyperkera-
be a predisposition in those of Japanese descent. tosis complain of localized pain and discomfort. Inter-
Athletes will seek medical attention most commonly estingly, the hyperkeratotic tissue itself is not what
after they have suffered secondary effects from the plan- causes the pain, but rather underlying bursitis and nerve
tar hyperhidrosis. They will describe excessive sweating irritation. The most common types of hyperkeratosis
in this area and a history of recurrent skin maceration, include helomas, tylomas, and intractable plantar kera-
blistering, dermatitis, and/or infections. Depending on toma. Helomas are synonymous with corns and usually
the pattern of hyperhidrosis described, a workup for an are found on the toes. Tylomas also are known as cal-
underlying systemic disorder may be justified. People luses and they usually are found over bony prominences,
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Figure 11-2 Hyperkeratosis (corn). (From Habif, Clinical dermatology, St Louis, 2004, Mosby: p. 928,
Figure 27-5.)
especially in the region of the metatarsal heads. Intrac- on the placement of padding between the toes. Surgical
table plantar keratoma is defined as a cone-shaped treatment usually is aimed toward correction of an
keratotic plug within a tyloma. underlying bony deformity but is rarely necessary.
Corns usually are broken down into two types. Hard Calluses are seen almost universally on the feet of ath-
corns are located over the lateral aspect of the proximal letes. As described earlier, this is the body’s response to
interphalangeal (PIP) joint of the fifth toe or over the wear and tear. Many times, athletes are protected from
proximal or distal interphalangeal joints of the second, skin breakdown and potential infection by this hyperker-
third, and fourth toes dorsally. Athletes with hammertoe atotic process. Callus formation becomes problematic
deformities and mallet-toe deformities are particularly when there is an overproliferation of the keratin tissue
predisposed to developing hard corns. leading to underlying bursitis, neuroma, or neuritis.8
Soft corns appear between the toes and can be attrib- Intractable plantar keratoma is a highly painful lesion
uted to the moist environment and high pressure seen in the region of the plantar aspect of the metatarsal
with improper footwear. Large, hyperkeratotic, boggy heads. Intractable plantar keratoma can be extensive
masses can appear over time and develop central ulcera- and symptomatic enough to affect an athlete’s perfor-
tion. The most common location is the interdigital space mance.9 Deformities of the metatarsophalangeal joint
of the third, fourth, and fifth toes. that produce increased plantarflexion in this area lead
Treatment of hard corns can be achieved using scalpel to the development of intractable plantar keratoma in
debridement techniques and/or regular buffing with a the metatarsal head regions receiving the most plantar
pumice stone. The athlete should be educated on proper pressure.
footwear, with close attention to an appropriate size toe Calluses should be treated systematically. Early scal-
box to ensure adequate toe spacing and decreased pel debridement and intervention by means of footwear
potential for rubbing. Soft corns can be treated with changes are essential. Daily work on these lesions with
debridement of the loose skin and adjustments in foot- a pumice stone or callus file should be advocated. Meta-
wear. The athlete should be encouraged to attempt to tarsal pad fabrication and placement of custom foot
keep the feet as dry as possible and can be instructed orthotics will aid in prevention of recurrence.
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Dermatologic disorders: traumatic
4 PEARL
complexion are much more predisposed to this type
of injury. The dorsum of the foot is a region that is
not often sun exposed and is prone to severe burn.
Clinical pearls for treatment of hyperkeratotic conditions Sunburn reaction occurs in several stages, including
primarily focus on prevention. Try to personalize footwear
for your athletes through identification of predisposing immediate erythema, delayed erythema, vascular per-
factors such as bony deformities, lesions currently present, meability with the development of edema and blisters,
and history of previous complications. Also, avoid aggres- and finally desquamation. Immediate erythema is seen
sive treatment to prevent exacerbation of symptoms and within a few minutes before fading. This gives way to a
always assess for other potential causes (viral warts). delayed erythema after a period of time. With more
severe injury, vascular permeability with intradermal
edema and epidermal blister formation will be seen
Xerosis within the span of a few hours. The desquamation pro-
Xerosis simply is severely dried skin. Skin drying is more cess takes place within a week, giving way to new skin,
pronounced in cold environments and especially during albeit sun-damaged skin. Sun damage has an additive
the winter months in temperate regions. Low humidity effect. Long-term changes increase the risk of skin can-
in the air leads to increased drying of the skin that man- cers such as melanoma, squamous cell carcinoma, and
ifests as roughening and fine scaling. In more severe basal cell carcinoma.
forms of xerosis, the scaling becomes coarser and fissures Treatment after sun exposure depends on the degree
may occur. Athletes that are exposed to chemicals (swim- of injury. Less severe burns can be treated with cool, wet
mers) and adhesives are particularly at risk. For the most compresses, emollient therapy, and protection from
part, xerosis is a benign condition and athletes will further exposure. Severe burns may need to be treated
complain of pruritus in the lower leg and dorsal foot. with a 4- to 6-day course of oral steroids in an attempt
This drying can predispose to fissure formation, allowing to prevent intense immune reaction. Again, it should
fungal or bacterial organisms to colonize the area. also be stressed that these injuries should be protected
The treatment of xerosis should include regular from further ultraviolet exposure.
emollient therapy. More severe cases respond well to
4 PEARL
12% lactate lotion. Temporary relief of pruritus symp-
toms can be achieved using antihistamines such as
diphenhydramine and cetirizine.
The key clinical pearl for sunburn treatment and prevention
is preparation. Any anticipated sun exposure should be pre-
4 PEARL
ceded by application of a sunscreen compound. Sun protection
factor (SPF) is an indicator of sunscreen efficacy, with a higher
SPF being more protective. When treating sunburn acutely,
Clinical pearls for the treatment and prevention of xerosis topical anesthetic preparations containing benzocaine should
include decreasing shower frequency and duration, be avoided secondary to a photosensitization effect.
minimizing hot water use, using regular emollient therapy,
and protecting from epidermal excoriation.
Sunburn
DERMATOLOGIC DISORDERS: TRAUMATIC
Sun exposure for prolonged periods of time in bare-
foot sports such as sand volleyball, swimming, and Black heel (calcaneal petechiae, talon noir)
surfing lead to light-induced skin changes manifest as Darkening of the posterior and posterolateral aspect
either suntan or sunburn. A suntan is the body’s proof the heel was first described by Crissey and Peachey11
tection mechanism from photoinjury after exposure in basketball players. This discoloration is caused by
to ultraviolet light. Suntan occurs in two stages; the repeated lateral shearing force of the epidermis sliding
first stage involves a photochemical change of existing over the rete pegs of the papillary dermis, resulting in
melanin to produce a darkening of the skin color, intraepidermal hemorrhage.12 The dark appearance gave
whereas the second stage involves the synthesis of rise to the terms black heel and calcaneal petechiae.
new melanin in the dermal layer that typically becomes In addition to basketball players, black heel (Fig. 11-3)
visible within 72 hours.10 Sunburn occurs as a has been described in other sports that require fre-
response to excess ultraviolet exposure with the degree quent starting and stopping such as lacrosse and football.
of damage being dependent on duration of exposure The pathophysiologic changes previously described are
and sensitivity of the skin. Individuals with a light caused by heel trauma from rubbing against the back
255
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Figure 11-3 Black heel. (From Habif, Clinical dermatology, St Louis, 2004, Mosby: p. 375, Figures 12-18a and b.)
of the shoe. It is seen most commonly in adolescents have these pedal papules. They arise from herniation of
and young adults and usually is asymptomatic. Sports the subcutaneous fat into the dermis. Their presence
activities should not be limited by this condition. is identified easily while pressure is being applied, but
The diagnosis of black heel usually will be readily they usually disappear with the removal of that force.
apparent by history and physical examination. The The distribution of piezogenic papules in an athletic
lesions usually appear as multiple petechiae with central population is primarily along the medial and lateral
aggregation and scattered satellite patches. Often the plantar heel pad. The potential exists for these lesions
dyschromia is horizontally arranged across the posterior to become painful, especially in long-distance runners,
and lateral aspect of the heel but can be seen in circular who place a great deal of repetitive stress on their feet.
and oval patches, as well. If the diagnosis is in doubt, When painful, piezogenic papules can be detrimental
other diagnoses such as viral warts and malignant mela- to athletic performance. It is thought that the pain
noma must be considered. Rarely, skin biopsy with his- associated with the papular lesions is secondary to
tochemical staining is required to confirm the diagnosis inflammatory changes in the deep dermal layers.15
of black heel and to rule out malignant melanoma.13 Treatment options for piezogenic papules are limited.
The treatment of black heel is quite simple. The clini- Some degree of symptomatic relief may be achieved with
cian should educate and reassure the athlete that this heel cups or shoe orthotics. There are no medical or
condition is benign and will resolve with cessation of surgical therapies described for this malady.
the causal mechanism.
4 PEARL
4 PEARL Regarding treatment pearls, with piezogenic pedal papules
The most important clinical pearl in black heel evaluation it is more of a case of what not to do than what to do.
is distinguishing this lesion from malignant melanoma. Corticosteroid injections into painful lesions are contrain-
If there is any doubt, an excisional biopsy should be dicated. If steroid injections are administered, the athlete
performed with dermatopathology evaluation. Black heel will be predisposed to fat atrophy and weakening of the
can be prevented by placing a felt pad in the heel of the supportive collagen matrix in this region that can be
shoe. If a cosmetic effect is desired, the lesion can be pared complicated by an even more painful heel.
down with a scalpel with nearly complete clearance of the
dyschromia.
Friction blisters
Repetitive rubbing of the skin has been shown to pro-
Piezogenic pedal papules duce blisters in multiple controlled trials. These frictional
The term piezogenic refers to ‘‘pressure giving rise to.’’ forces cause a mechanical separation of the epidermal
Piezogenic papules occurring in the heel are more com- cells at the level of the stratum spinosum. With continued
mon than previously thought. Zaidi et al.14 described mechanical trauma and separation of the epidermal cells,
80 subjects out of a random sample of 100 people to midepidermal necrosis will occur and a clear transudate
256
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Infectious disorders
will accumulate in this space.16 These blisters are more

INFECTIOUS DISORDERS
likely to occur in skin areas that have a thick, horny layer
held tightly to underlying structures, such as the soles
of the feet.17 Moisture of the foot can either exacerbate Viral warts
or relieve the degree of frictional force present. A damp It is estimated that approximately 10% of the adolescent
skin surface will see an increase in the frictional force, population in the United States is affected by plantar
whereas very moist/wet feet actually will benefit from warts (Fig. 11-4). With this in mind, it becomes evident
a lubrication effect. Friction blisters can be seen in many that many athletes will fall into this category. Human
parts of the body in many types of athletes but are most papillomavirus (HPV) types 1, 2, and 4 are responsible
common on the feet of distance runners. In addition for this form of hyperkeratotic lesion. After exposure
to a damp environment, friction blisters also can be to the virus, HPV attacks the epidermal layers of dam-
caused by poorly fitted shoes, bulky socks that bunch aged, cracked skin. Unlike viral wart lesions elsewhere
up and cause an area of increased pressure, and training on the body, plantar warts grow deep into the tissue sec-
on hard surfaces such as concrete or pavement. ondary to the constant pressure application to the sole
The diagnosis of friction blisters usually can be made of the foot. Plantar warts seem to thrive in the warm,
by history alone. A physical examination will identify a moist environment of the shoe. The virus typically is
bullous-appearing lesion corresponding to the region encountered by direct contact of the bare foot to a sur-
of discomfort. Friction blisters tend to be tender to pal- face harboring the virus. Johnson21 identified that the
pation and are fluctuant when pressure is applied. The use of public locker rooms increased the risk of con-
clinician should examine the region surrounding a fric- tracting plantar warts, especially when the subjects used
tion blister carefully to evaluate for the possibility of communal showers.
a superficial infection (cellulitis). The diagnosis of plantar warts can be challenging
The consensus is that blisters should be drained, mul- because these lesions sometimes are difficult to dis-
tiple times if needed, within the first 24 hours. Cortese tinguish from callus formation. Athletes will present
et al.18 described a shorter healing time with this early with symptoms of pain in the region corresponding
intervention. They also stressed that the blister region to the lesion. Direct observation may identify centra-
healed more rapidly if the overlying roof was kept intact. lized cratering of a warty lesion. If the diagnosis remains
Again, close attention should be paid for signs of in doubt, the hyperkeratotic tissue should be pared
infection, with appropriate use of systemic antibiotics away using a no. 15 blade scalpel until the hypertro-
to treat early cellulitis or impetigo. Placement of phic epithelium gives way to a dermal layer revealing
padding (moleskin) over the blister region is advocated multiple ‘‘seeds.’’ These seeds represent the throm-
until healing has occurred. bosed vessels that supply the warty lesion.22 Localized
spread along the plantar surface results in a cluster of
4 PEARL warty lesions that may resemble a mosaic. Plantar warts

can be seen anywhere along the plantar surface but tend
Clinical pearls for the treatment and prevention of friction to spare the region corresponding to the metatarsal
blisters focus primarily on decreasing the amount of heads.
frictional force across a given dermatologic region. Some Plantar warts are benign, and most will resolve spon-
studies including Knapik et al.19 have shown foot antiper- taneously. Many forms of therapy have been described
spirants to be efficacious in the reduction of foot blisters
to eradicate plantar warts. Close attention should be
during recreational sports activities. It should be noted,
however, that the use of antiperspirants on the feet as a paid to the potential adverse reactions associated with a
prevention for friction blisters is controversial. Also, the use given therapy. If lesions are causing symptoms of pain
of antiperspirant agents is confounded by a high incidence or impairment in function, a noninvasive therapeutic
of irritant contact dermatitis, which can be more debilitating approach should be considered. Paring of the hyperker-
than the original friction blisters. Knapik et al.20 identified a
atotic superficial layer should be followed by regular
reduction in frictional blister formation with the use of
polyester-lined socks. With this information, now it is application of keratolytic agents such as salicylic acid
recommended that endurance athletes use acrylic-based (15% to 60%), cantharidin, or dichloroacetic acid. Daily
socks or thin polyester socks combined with a thick application of these topical therapies with regular use
polypropylene sock. Neoprene insoles combined with of a pumice stone will aid in the gradual resolution of
appropriately fitted shoes are a great starting point for
plantar warty lesions without significant impairment in
those initiating training activities. Early exposure to
low-intensity frictional coefficients allows for cellular function. Multiple other therapeutic modalities are de-
adaptation and epidermal thickening which may reduce the scribed, including cryotherapy, injection therapy, immu-
likelihood of blisters, as well.17 notherapy, electrical therapy, chemical destruction, and
surgical therapy.23 More aggressive/invasive treatments
257
...........
Figure 11-4 Plantar warts. (From DeLee J, Drez D, Miller, M: DeLee and Drez’s orthopedic sports medicine, ed 2, Philadelphia,
2002, Elsevier, Figure 30-J-73.)
should be reserved for recalcitrant cases of plantar warts

that have not responded to conservative management.
4 PEARL
The first clinical pearl to remember is that plantar
warts cause localized pain symptoms but can be over-
looked on physical examination. Many athletes present
with painful plantar lesions that are mistaken as overuse
injuries such as metatarsal stress fractures because a
plantar dermatologic examination was not performed.
Encouraging the use of shower thongs or sandals in
communal showers can reduce the risk of HPV exposure.
Surgical treatment should be strongly discouraged because
the resultant scar tissue can lead to symptoms of continued
pain.
Tinea pedis
The term athlete’s foot refers to the most common
infection in sports participants. Fungal infection of the
feet usually affects the interdigital spaces, especially
between the fourth and fifth toes. The warm, moist en-
vironment within an athletic shoe provides an ideal envi- Figure 11-5 Tinea pedis. (From Rakel: Textbook of family
ronment for fungus to prosper. The dermatophyte practice, ed 6, Philadelphia, 2002, WB Saunders, Figure 41-28.)
linked to tinea pedis (Fig. 11-5) in most cases is Tricho-
phyton rubrum. Less commonly, Trichophyton menta-
grophytes and Epidermophyton floccosum are isolated. The interdigital spaces are most commonly affected in
Men are affected more commonly than women or tinea pedis; however, a moccasin distribution also can be
children. A 70% rate of lifetime incidence is estimated.24 identified on physical examination. The ‘‘moccasin’’ dis-
Much like the viruses associated with plantar warts, der- tribution refers to scaling along the medial and lateral
matophytes can survive on the warm, moist floors of sides of the foot and potentially also the plantar surface.
locker rooms and communal showers. Physical examination findings will vary depending on
258
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Nail disorders
the stage of infection. Early infection presents as fine

NAIL DISORDERS
scaling with associated pruritus. As the infection pro-
gresses, maceration of the superficial skin occurs, with
gradual epidermal breakdown. At this point, superin- Subungual hematoma
fection by resident bacteria progresses skin breakdown Many sports predispose participants to direct foot
and increases symptomatology. Leyden and Kligman25 trauma, especially to the toes. This trauma may be in
demonstrated progressively decreased rates of fungal the form of repetitive pounding against the anterior
recovery as the severity of symptoms worsened. Con- shoebox or it may be suffered as a result of another
versely, more severe symptomatology correlated with player’s stepping on the foot. Subungual hematoma
increasing numbers of resident aerobic bacteria, espe- (Fig. 11-6) formation can occur as a result of this
cially large colony diphtheroids. In rare cases, highly trauma. Blood collects in the space between the nail
inflamed sterile vesicles and pustules can be seen dis- bed and the toenail, with pain generated from increasing
tant from the tinea infection. This is referred to as pressure within this space. Symptoms range from mild
a ‘‘dermatophytid’’ or ‘‘id’’ reaction, representing an discomfort to extreme pain. Acute traumatic injuries
immunologic response to the fungus.26 tend to be more painful. Associated injuries include
Dermatophyte infections of the interdigital space usu- phalanx fractures and soft-tissue contusion.
ally respond well to topical therapy with antifungal agents The evaluation process for a subungual hematoma
of the imidazole and allylamine groups. Examples from should include a thorough history, including the timing
these groups include clotrimazole 1% and terbinafine, of the injury and musculoskeletal, neurologic, and vas-
respectively. Other potential choices include econazole, cular assessment. With repetitive pounding injuries as
ketoconazole, miconazole, oxiconazole, ciclopirox, nafti- seen in runners and tennis players, the physical examina-
fine, and butenafine. Topical therapy must be continued tion may reveal early subungual discoloration, but this
for 4 weeks with clotrimazole and 1 to 4 weeks with terbi- may be delayed. Acute traumatic injuries usually will
nafine. Patients with moccasin-type tinea pedis can be dif- have a more obvious subungual bloody accumulation
ficult to treat and occasionally will require oral antifungal that is identified easily on examination.
therapy. Oral antifungals include itraconazole, terbina-
fine, fluconazole, ketoconazole, and griseofulvin. Flucon-
azole should be administered 150 mg daily for a total of
2 to 4 weeks for recalcitrant cases. If the diagnosis of tinea
pedis is in doubt after several weeks of topical and/or oral
therapy, a potassium hydroxide preparation with micro-
scopic examination for hyphae should be performed to
confirm the diagnosis. Oral antibiotic therapy should be
prescribed for severe cases with associated cellulitis.
Immunocompromised individuals are especially prone
to this complication. Coverage for typical skin flora
including Staphylococcus and Streptococcus is appropri-
ate. First-line therapy is dicloxacillin 500 mg every 6 hours
for 7 days (Gilbert et al.27). Erythromycin can be substi-
tuted if penicillin is contraindicated. Other interventions
in treating tinea pedis include the use of drying agents
such as aluminum acetate solution and keratolytic agents
such as ammonium lactate lotion.
The prevention of tinea pedis is challenging.
4 PEARL
Clinical pearls include education of athletes to avoid direct
contact of the feet with flooring in showers and locker
rooms. Also, maintaining a dry environment for the feet can
limit the potential for fungal growth. Lastly, sharing
footwear and towels should be discouraged. Figure 11-6 Subungual hematoma. (From Habif, Clinical
dermatology, St Louis, 2004, Mosby: p. 882, Figure 25-36.)
259
...........
The treatment for subungual hematoma depends on

symptomatology and the degree of involvement. Ath-
letes presenting with extreme pain, especially with a brief
period of symptoms, will benefit from a decompression
procedure. Decompression can be achieved in one of
three ways: a battery-operated cautery device can be
used to burn a small hole through the nail, a large-
diameter needle can be used to bore into the nail to
create a hole, or a paper clip tip can be heated to burn
through the nail plate as well. All of these interventions
will allow the blood to drain, effectively relieving the
pressure and pain. On occasion, a nail bed laceration
will be identified. This requires nail removal and lacera-
tion repair.28 Early intervention will allow for prevention
of nail dystrophy and further impairment.
4 PEARL
Clinical pearls for the prevention of subungual hematoma
include working with athletes to choose appropriate foot-
wear. Excessive forefoot anterior motion and tight dorsal
Figure 11-7 Onychocryptosis (ingrown toenail). (From
toe boxes can exacerbate this problem. During the recovery
phase from subungual hematoma, it is beneficial to provide
Habif, Clinical dermatology, St Louis, 2004, Mosby: p. 881,
pressure relief over the involved toes by cutting the leather Figure 25-35.)
overlying the involved digits.29
improper nail care (aggressive nail trimming), excessive

foot moisture, and repetitive trauma.
Onychocryptosis Initial evaluation for onychocryptosis should involve
Ingrown toenails can lead to severe functional im- a thorough history and focused physical examination.
pairment, especially in those who depend on their feet Symptoms described will vary from minimal discomfort
in competition. Onychocryptosis (Fig. 11-7) is the most to incapacitating pain. A family history of ingrown nails
common of all toenail problems in athletes, and the lat- or a previous history of similar problems may aid in
eral margins of the great toe are most often affected. determining the underlying cause. Physical examination
The condition also can be complicated by paronychia of type 1 lesions will reveal erythema, edema, and ten-
formation, which can lead to osteomyelitis or sepsis. derness to palpation in the involved nail border. The nail
Ingrown toenails can be seen secondary to abnormal nail can be lifted easily to identify an intact layer of skin
plate anatomy or secondary to external factors. Abnor- within the nail groove. Type 2 lesions will be character-
mal nail plate anatomy can be hereditary or secondary ized by crusting at the nail fold and nail plate junction,
to previous trauma. When there is an improper fit of with or without an expressible purulence. Lifting the
the nail plate in the nail groove, sharp spicules of the lateral nail border will reveal early dermal breakdown.
lateral nail margin are driven gradually into the dermis Stage 3 lesions appear very uncomfortable and have
of that region. A foreign body reaction is seen, leading signs of chronic infection and extensive granulation tis-
to localized erythema, edema, purulence, and granula- sue (proud flesh). Evaluation of nail morphology may
tion tissue. Compromise of the tegument can lead to point toward a specific causal factor (incurvated nail
the introduction of typical skin flora into the break in plate, subungual exostosis, or nail dystrophy).
the skin. Typically, ingrown toenails are divided into Treatment approach to ingrown nails varies depend-
three stages: the first stage involves erythema, edema, ing on the stage of involvement. Ilfeld31 described
and focal tenderness. The second stage is marked by a successful therapy for onychocryptosis with stage 1
crusting and expressible purulence at the nail fold and findings. The treatment consisted of placement of a
nail plate junction. The third stage shows signs of collodion-coated cotton wisp between the edge of the
chronic infection, with protuberant granulation tissue ingrown nail and the adjacent soft tissue. This water-
extending over and under the nail plate. The prevalence proof barrier allows for immediate pain relief and pro-
of ingrown toenails is 3:1, male to female.30 The factors vides a firm runway for further growth of the nail. This
that put athletes at risk for onychocryptosis include procedure may need to be repeated after 3 to 6 weeks
260
...........
Nail disorders
or sooner if displacement occurs. A similar intervention

can be applied initially for stage 2 involvement. The col-
lodion-coated cotton wisp can be inserted between the
lateral nail edge and the soft tissues if there is not sig-
nificant spicule formation. If there is a component of
the nail that has broken through the dermal layer that
prevents placement in a reasonable fashion, the lateral
nail border should be removed. This therapeutic
approach is contiguous with that recommended for
stage 3 onychocryptosis. Wedge-shaped nail resection
is recommended on the involved side in the following
manner: first, a digital block should be performed using
1% or 2% lidocaine injection at the base of the digit. Figure 11-8 Onychomycosis. (From Rakel: Textbook of family
practice, ed 6, Philadelphia, 2002, WB Saunders, Figure 41-30.)
Next, a tourniquet should be placed proximal to the
toenail. After thorough cleansing with Betadine solu-
tion, a nail splitting scissors should be inserted under Less commonly, Candida albicans and nonpathogenic
the ingrown nail plate parallel to the lateral nail fold. fungi are implicated. The most common distribution is
On meeting resistance proximally in the region of the the distal subungual region. Other patterns include
matrix, the wedge should be cut and removed. Any white superficial onychomycosis, proximal subungual
granulation tissue present should be treated with silver onychomycosis, and Candida onychomycosis. In distal
nitrate application or removed via curettage. Wound subungual onychomycosis, the dermatophytes invade
care following this procedure entails regular application the distal area of the nail bed leading to the develop-
of wet compresses until inflammation has subsided. ment of an accumulation of hyperkeratotic debris. This
Gentle cleansing is recommended but should be delayed subsequent nail thickening causes separation from the
for the first 24 to 48 hours. For cases of recurrent underlying nail bed and allows the fungus to grow fur-
ingrown nails, athletes may require the use of liquid ther into the substance of the plate. With time, this
phenol for permanent destruction of the lateral nail invasion slowly moves more proximally with the poten-
matrix. This should be applied immediately after wedge tial to involve the entire nail. Proximal subungual ony-
resection, with care taken to avoid the soft tissues other chomycosis is caused by the same organisms, but is
than the nail matrix. more associated with immunosuppressed states. Psoria-
Ingrown toenails will be encountered on a fairly sis should be kept high on the differential diagnosis
regular basis. because this disorder can cause similar nail features. Fac-
tors that predispose individuals to the development of
onychomycosis are humidity, heat, trauma, diabetes
4 PEARL mellitus, and underlying tinea pedis.32

Historically, affected individuals will present with
Clinical pearls for the treatment of this malady include early a chronic history of gradual nail thickening and discolor-
intervention in an attempt to avoid advanced-stage lesions. ation. Runners seem to be predisposed to this condition
Treatment interventions can lead to symptom exacerbation secondary to repetitive trauma to the nail from contact
and further loss of performance capacity. There is not with the toe box, whereas basketball players are more
absolute contraindication to participation after nail resec-
predisposed secondary to the direct trauma of having
tion unless the athlete has signs/symptoms of systemic
infection. Participation should be based on pain tolerance. their toes stepped on by other competitors. Physical
Nail resection should be reserved for those athletes who examination will reveal hyperkeratosis of the nail bed,
are unable to perform or whose schedule allows for a with a yellowish to brown discoloration and onycho-
period of recovery. Lastly, complete nail extraction should lysis. The diagnosis should be confirmed with both
be avoided if possible because this can predispose to
a potassium hydroxide (KOH) examination and a fungal
further nail dystrophies.
culture.
On confirmation of a fungal offending agent, thera-
peutic modalities can be discussed. Within recent years,
Onychomycosis (tinea unguium) effective systemic antifungal therapy has become avail-
Onychomycosis (Fig. 11-8) is the most common cause able for the treatment of onychomycosis. Included in
of toenail thickening. Up to 20% of the population in the treatment options are fluconazole, itraconazole,
various age groups is afflicted with this problem.10 The and terbinafine. These drugs have replaced griseofulvin
most common pathogens include the dermatophytes as the systemic treatment options. Terbinafine should
Trichophyton rubrum and Trichophyton mentagrophytes. be administered at a dosing schedule of 250 mg/day
261
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for a total of 12 weeks. Itraconazole can be administered 11. Crissey J, Peachey J: Calcaneal petechiae, Arch Derm 83:501,
at 200 mg/day for a total of 12 weeks or through pulse 1961.
12. Levine N, Baron J: Black heel (calcaneal petechiae), www.
dosing at 400 mg/day for the first week of 4 consecu- emedicine.com/derm/topic53.htm (Last updated Oct. 2, 2006).
tive months. Lastly, fluconazole is an option at 150 mg 13. Hafner J, et al: Benzidine stain for the histochemical detection
once weekly for a total of 6 to 12 months (Gilbert of hemoglobin in splinter hemorrhage (subungual hematoma)
et al.27). Extreme care should be taken to avoid the and black heel, Am J Dermatopathol 17:362, 1995.
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.........................................C H A P T E R 1 2
Nonsurgical treatment of acute and chronic

ankle instability
Jon Karlsson and Mikael Sansone
......................
CHAPTER CONTENTS
Introduction 265 Prevention 268

Acute ligament injuries 265 Conclusion 270
Chronic ankle joint instability 267 References 270
INTRODUCTION frequency of less than 10% of all injuries.2,3 The mecha-

nism of injury to the lateral ligaments is most commonly
a plantarflexion inversion injury from landing
Ligament injuries to the lateral ankle ligaments are the
(Fig. 12-2). Prevention of ligament injuries has gained
most common sports-related injuries. It is estimated that
much attention recently, because it has been shown that
these injuries account for approximately 25% of all sports-
approximately 75% of all injuries are recurrences and
related injuries, and the incidence has been shown to be
may thus potentially be prevented, provided a sound pro-
approximately 5600 injuries daily in the United Kingdom
tocol is used.4-6 Prevention by either coordination train-
and 23,000 in the United States. There are three different
ing using balance boards or by external support can
strategies in terms of treatment alternatives, that is, cast
significantly reduce the number of ligament injuries.
immobilization, surgical treatment, and functional treat-
Ankle tape and/or functional splinting, proficiently com-
ment. Despite the extremely high number of injuries,
pleted by the use of a stirrup splint (Fig. 12-3) is preferred
there are only a few well-conducted studies, and even
by many athletes. It also has been shown that there is
though many or even most authors advocate early mobili-
hardly any place for surgical repair after acute ligament
zation, there is little scientific evidence to support it.
ruptures.7,8 After the recommended treatment using a
The best studies are summarized in three Cochrane
rehabilitation program with functional treatment, active
reviews. All three reviews concluded that more high-
range of motion exercises, coordination training, pero-
quality studies are needed.
neal strengthening, and early weight bearing, the func-
tional results are reported as excellent or good in
approximately 80% to 90%, whereas 10% to 20% of
ACUTE LIGAMENT INJURIES patients develop secondary symptoms of chronic instabil-
ity and/or pain.9,10 Despite this, the treatment of acute
It has been shown in several studies that early diagnosis, lateral ankle ligament injuries is still controversial; some
functional treatment, and rehabilitation are the keys to authors have recommended that these injuries be treated
prevention of chronic lateral ligament instability of the with early mobilization, whereas others recommend cast
ankle.1-3 The on-field treatment of fresh ruptures is well or brace immobilization for 3 to 6 weeks or even early sur-
known, for example, the rest, ice, compression, and eleva- gical repair. However, even though there is substantial
tion (RICE) principle. The most vulnerable of the lateral evidence to suggest that early mobilization with active
ligaments is the anterior talofibular ligament (ATFL; rehabilitation probably is the treatment of choice, there
Fig. 12-1, A), followed by a combined rupture of this are only a few randomized, controlled studies comparing
ligament and the calcaneofibular ligament (CFL; different treatment modalities.11 In a recent meta-analysis
Fig. 12-1, B). Other injuries, such as injuries to the medial it was shown that no treatment of lateral ankle ligament
deltoid ligament are much less frequent and occur with a ruptures led to an increased number of residual
CHAPTER 12 Nonsurgical treatment of acute and chronic ankle instability
Figure 12-1 Anterior talofibular ligament (ATFL) (A) and calcaneofibular ligament (CFL) (B). Note ATFL (A) over
probe and peroneal tendons running posterior to fibula. Note CFL under probe with peroneal tendons removed.
Figure 12-3 Ankle stirrup brace used in rehabilitation after

acute and chronic lateral ankle instability.
symptoms.12 Surgical treatment produced better results

than functional treatment; however, functional treatment
Figure 12-2 Mechanism of injury for lateral ankle ligament was found to be superior to cast immobilization for 6
sprain. Position at time of landing is plantarflexion and weeks. The authors pointed out that surgical treatment
inversion. was associated with higher costs, as well as increased risk
266
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Chronic ankle joint instability
of complications, such as disturbance of wound healing, participate in sports with high demands of stable ankle
nerve damage, and possibly infections. In one Cochrane joints, such as soccer, volleyball, basketball, and all sports
review, it has been shown that functional treatment appears involving jumping, sidestepping, turning, and twisting.
to be the favorable strategy for treating acute ankle liga- In the literature, more than 50 different surgical meth-
ment injuries when compared with immobilization.13 ods have been described to correct chronic ankle joint
Concerning surgical versus nonsurgical treatment for acute instability.4,6,9,10,19 The clinical diagnosis initially is
injuries of the ligament complex, there is insufficient scien- based on a thorough clinical assessment, for instance,
tific evidence from randomized, controlled studies to testing the anterior drawer sign (Fig. 12-4) and the
determine the relative effectiveness of surgical and conser- inversion (supination) test (Fig. 12-5). Comparison
vative treatment of these injuries, as concluded in a second always must be made with the contralateral ankle. It
Cochrane review.14 This might imply that surgical treat- must be remembered, however, that functional instabil-
ment is not necessarily superior. It also is obvious that in ity is a complex syndrome, and there are several factors
case of failed conservative treatment, late reconstructive at play, such as increased laxity, proprioceptive deficit,
procedures can be performed with satisfactory results, even and peroneal muscle weakness, either alone or most
several years after the initial injury. The extent of injury, often in combination. Excessive laxity must be corrected
that is, being grade I, II, or III, might play a role. Two pro- with some kind of surgical procedure, but proprioceptive
spective, randomized studies have evaluated the effect of deficit and muscular weakness can and should be treated
early range of motion training, full early weight bearing, by rehabilitation.20 In the acute phase the main objective
combined with either an ankle stirrup brace or specially is for pain relief, but soon after injury the treatment is
designed compression pads. Both studies showed that early aimed at restoring range of motion, and this should be
functional treatment resulted in significantly shorter sick done without any loss of proprioception.
leave and facilitated earlier return to sports, without the risk The general principle is that early rehabilitation is the
of inferior functional results in the long term. One main goal. Immobilization probably should never be
Cochrane review compared different functional treatment used, not even in case of grade III injury. There are sev-
strategies for the treatment of acute ankle ligament inju- eral studies in the literature comparing immobilization
ries.15 It was shown that the use of elastic bandage was cor- and early mobilization, and none favor immobilization.
related with fewer complications than tape but was In fact, immobilization may result in joint stiffness, mus-
associated with slower return to work and sport. Semirigid cle atrophy, and loss of proprioception. Some clinicians
ankle braces produced less ankle laxity than elastic ban- do use intermittent immobilization for the acute phase
dages. Lace-up ankle support was more effective in reduc- of recovery, allowing early mobilization also, but there
ing swelling in the short term compared with semirigid is no literature documenting this approach.
braces, elastic bandage, and tape. Thus either semirigid Rehabilitation can be divided into four phases, that is,
brace or lace-up support probably is preferred. the initial phase, early rehabilitation, late rehabilitation,
It appears that early weight training, combined with and functional phase. The length of each phase depends
range of motion training, is beneficial. The long-term much on the individual process of healing. The initial
prognosis likely is unaffected by early functional train-
ing.16,17 Studies have shown that the best external
support is strong evertor muscles. Therefore a combina-
tion of isokinetic strength training with proprioception L
training is most favorable; this combination can shorten
rehabilitation and serve as secondary prophylaxis.
CHRONIC ANKLE JOINT INSTABILITY
It has been shown in several studies that chronic lateral

ankle joint instability may develop in approximately
10% to 30% of all patients who sustain an acute injury
of the ligaments.18-20 The functional instability, irrespec-
tive of the mechanical laxity (indeed, there is no constant
correlation between the functional instability and the
laxity of the joint), does not always produce disability Figure 12-4 Radiograph of ankle demonstrating the
of such grade that surgical reconstruction is needed. Sur- subluxation that occurs with an anterior drawer test for lateral
gical reconstructions have been well described during the ankle instability with anterior talofibular ligament (ATFL)
last 3 decades and are needed most often in athletes who ligamentous laxity.
267
...........
Figure 12-6 Balance board used in rehabilitation after acute

and chronic lateral ankle instability.
increased. The main goal of this phase is training of

muscular strength, endurance, and neuromuscular func-
Figure 12-5 Radiograph of ankle demonstrating the
tion. The final functional phase starts around week 9
subluxation that occurs with a talar tilt test for lateral ankle
and is aimed at return to full sports activity, including
instability with calcaneofibular ligament (CFL) ligamentous
laxity. jumping, turning, and twisting. External support should
be worn during the entire functional phase, and one of
the main aims is to reduce the risk of recurrence of the
phase is directed at reduction of swelling, most often
ankle sprain. Supervised programs such as the one
with compression bandage but also with anti-inflamma-
described and detailed in Table 12-1, can be used both
tory medication, short rest (maximum of 1 to 2 days),
after first-time injury and in the case of chronic or recur-
ice and elevation, that is, the RICE principle. Sometimes
rent ankle insufficiency.
ultrasound and electrotherapy are added, but their effect
Before any decision is made on surgical treatment in
has not been shown with any convincing evidence. In
the case of the chronically unstable ankle, a well-planned
order not to lose neuromuscular coordination, gait
rehabilitation protocol (such as the one shown in the
training including early weight bearing and balance
Table 12-1) should be carried out. This protocol is based
board training, is started as early as possible. The initial
on isokinetic strength training of the peroneal muscles
phase is for the most part the first week after injury.
and proprioceptive training. One study has shown that
The second phase, that is, weeks 2 to 4, the early reha-
approximately 50% of patients with chronic ligament
bilitation phase is aimed at restoring normal range of
insufficiency will regain satisfactory functional stability
motion of the ankle with active exercises, and sometimes
after a 12-week program.16 The obvious goal of the reha-
manual treatment and kinetotherapy are added. Some-
bilitation program is to decrease the muscle weakness,
times, gentle passive movement of the ankle joint can
regain normal or near-normal proprioceptive function,
be used to increase the range of motion in the sagittal
and reestablish the protective reflexes. The last few weeks
plane. Stretching of the calf muscles also is important
of the rehabilitation program should concentrate on
during this phase, especially to increase dorsiflexion.
sports activity. Patients with the highest grade of ligament
The tilt or balance board exercises (Fig. 12-6) are used
laxity are those least likely to benefit from this protocol.
progressively during this phase, both in terms of time
The program is described in detail in Table 12-1.
and intensity. The training is aimed first at balance on
both legs, and thereafter on one leg (the injured one).
Cryotherapy may be continued during this phase, as well
as anti-inflammatory medication. During this phase, the
PREVENTION
athlete is allowed to return to sports activities, provided
an external support is used, such as ankle tape or func- The best way to treat ligament injuries obviously would
tional bracing.16 be to prevent them, and even though this is practically
The late rehabilitation phase usually is reached impossible, it is true that prevention can play a signifi-
around week 5, and the weight-bearing exercises are cant role. The two main methods that have been proven
268
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Prevention
Table 12-1 Rehabilitation program for patients who Weeks 5-8

have chronic instability of the ankle
Increased strength training:
Week 1 2 20 repetitions
Range of motion exercises (flexion-extension), for Toe raises in one leg
increased blood circulation Step-ups on a box back and forth and from side to side
3 20 repetitions; 3 times/day Step-ups using two boxes, 1 m apart
Cycling Jog up and down with different steps in between the
boxes
Weeks 2-4
Use a weight shoe for heavy weight training of flexion,
Isometric contractions in flexion, extension, and pronation extension, and pronation
3 10 sec; relax for 2-6 sec between each contraction Week 9
Foot exercises
Increased coordination training:
3 minutes, 2 times/day
Walk on uneven surfaces
Roll a small ball under the foot back and forth and side to
side Use different kinds of jumps
Wrinkle a towel Jog in intervals
Pick up marbles and/or small rocks Train with a ball
Closed chain (weight bearing) Weeks 10-12
Balance and coordination training
Add to the program:
3 20 repetitions
Turnings while jogging
Bilateral toe raises
Starts, stops, and rushes
Walk on tiptoe
Cone training
Jog in place and jog on a soft mattress
Slope training
Walk along zigzag lines, back and forth, and side to side
Sports activity, individual and team training
The training should be increased from week to week by
increasing the tempo and by turning 90/180 degrees A modified program also can be successfully used after acute
Walk with a surgical tube around the ankle, back and ligament injuries. (Modified from Karlsson et al., 1991.)
forth, and side to side
Stand on one leg (hold the balance), and when this is successful in clinical practice are proprioceptive training
easily accomplished, then stand on one leg and flex and and external ankle support. There is, however, little sci-
extend the knee entific evidence to support the preventive effect of ankle
Hold for 10-30 sec taping. A few studies have shown that balance board
Stand on one leg, with the eyes closed for 40 sec training can reduce the risk of ankle ligament injuries,
Increase the balance training by standing on a balance especially in those with previous injuries.21-23 However,
board, first on both feet and thereafter on one foot while the effect is either less pronounced or unknown in ath-
flexing and extending the knee simultaneously. The knee letes with previously uninjured ligaments.18,24 This
should be kept over the ankle as much as possible means that the question whether the first-time ligament
Stand on the balance board on one foot; roll a ball around injury can be prevented using proprioceptive training is
the balance board with the other foot still unanswered. The second measure is external ankle
Use 2-3 balance boards and try to walk from one to support, either ankle tape or brace.25-27 There is little
another, and keep the balance at the same time evidence for the use of ankle tape, and the mechanism
Endurance and strength training behind the function of ankle tape is not fully under-
Training with a surgical tube—flexion, extension, and stood. It has been suggested that tape may reduce ankle
pronation; 3 20 repetitions laxity, limit the extremes of ankle motion, and/or
Increase the training after a while by shortening the shorten the reaction time of the peroneal muscles,
surgical tube thereby affecting the proprioceptive function of the liga-
Stretch the gastrocnemius and soleus muscles with
ments and joint capsule around the ankle joint.28 How-
straight and flexed knee ever, as the tape becomes loose after 15 to 30 minutes of
use, it never has been proven how it really works.29,30
2 15-20 sec
Despite this, ankle tape is extremely common and has
269
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been found empirically to be useful. There is more evi- 7. Glick JM, Gordon RB, Nishimoto D: The prevention and
dence for the use of ankle braces, especially the semirigid treatment of ankle injuries, Am J Sports Med 4:136, 1976.
8. Hertel J, Denegar CR, Buckely WE: Effect of rear foot orthotics
Air-stirrup brace.31-37 on postural sway after lateral ankle sprain, Arch Phys Med Rehabil
Taken together, treating deficits of the proprioceptive 82:1000, 2001.
system probably is the most important aspect of ankle 9. Karlsson J, et al: Lateral instability of the ankle treated by the
rehabilitation after lateral sprains. Consideration of Evans procedure. A long-term clinical and radiological follow-up,
improvements in proprioception should be the most J Bone Joint Surg 70B:476, 1988.
10. Karlsson J, et al: Reconstruction of the lateral ligaments of the
important when deciding on a rehabilitation protocol. ankle for chronic lateral instability, J Bone Joint Surg 70A:581,
Moreover, a combination of different exercises and 1988.
modalities should always be a part of a thorough rehabil- 11. Karlsson J, Eriksson BI, Swärd L: Early functional treatment for
itation program. Ankle disk training and/or semirigid acute ligament injuries of the ankle joint, Scand J Med Sci Sports
ankle brace appear to the effective cornerstones of treat- 6:341, 1996.
12. Pijenburg ACM, et al: Treatment of ruptures of the lateral
ment and prevention.38-41 ankle ligaments: a meta-analysis, J Bone Joint Surg 82A:761, 2000.
13. Kerkoffset GM, Struijs PA, et al: Different functional treatment
strategies for acute lateral ankle ligament injuries in adults,
CONCLUSION Cochrane Database Syst Rev 3:CD002938. DOI: 10.1002/
14651858:CD002938, 2002.
14. Kerkoffset GM, Handholl HH, et al: Surgical versus conservative
Ankle ligament injuries are common, time consuming, treatment for acute injuries of the lateral ligament complex of the
and expensive. Most of the injuries are to the lateral lig- ankle in adults, Cochrane Database Syst Rev 3:CD000380. DOI:
10.1002/14651858:CD000380, 2002.
ament complex, and the outcome may be satisfactory, 15. Kerkoffs GM, Rowe BH, et al: Immobilisation and functional
even without treatment. However, nonsurgical treat- treatment for acute lateral ankle ligament injuries in adults,
ment of acute ligament injuries may lead to shorter sick Cochrane Database Syst Rev 3:CD003762. DOI: 10.1002/
leave and faster return to sports activities without risking 14651858. CD003762, 2002.
the functional outcome in the short term and medium 16. Karlsson J, Lansinger O, Faxén E: Conservative treatment of
chronic lateral instability of the ankle, Swedish Med J 88:1404, 1991.
term. Well-planned rehabilitation protocol has been 17. Karlsson J, Faxén E, Eriksson BI: Ankle joint ligament injuries:
shown repeatedly to produce satisfactory outcome in prevention, evaluation and treatment, Crit Rev Phys Rehab Med
terms of functional stability and return to sports. 8:183, 1996.
Despite this, approximately 10% to 30% of all patients 18. Konradsen L, Ravn JB: Ankle instability caused by prolonged
will suffer from sequels in the short term and medium reaction time, Acta Orthop Scand 61:388, 1990.
19. Krips R, et al: Long-term outcome of anatomical reconstruction
term. The symptoms usually are pain and/or functional versus tenodesis for the treatment of chronic antero-lateral
instability. Studies have shown that approximately 50% instability of the ankle joint: a multicenter study, Foot Ankle Int
of all patients who have chronic ligament insufficiency 22:415, 2001.
will recover after having undergone a 12-week rehabili- 20. Komi PV, Viitasalo JT, Rauramaa R: Effect of isometric strength
tation program based on strength and proprioceptive training on mechanical, electrical and metabolic aspects of muscle
function, Eur J Appl Physiol 40:45, 1978.
training. However, it should be borne in mind that even 21. Osborne MD, Chou LS, Laskowski ER: The effect of ankle disk
though rehabilitation programs may work well, preven- training on muscle reaction time in subjects with a history of ankle
tion is the most important nonsurgical treatment. sprain, Am J Sports Med 29:627, 2001.
22. Sheth P, Yu B, Laskowski ER: Ankle disk training influences
reaction time of selected muscles in a simulated ankle sprain, Am J
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2. Broström L: Sprained ankles: A pathologic, arthrographic, and proprioception in the management and rehabilitation of athletic
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26:692, 1998. sprained ankles, Practioner 218:586, 1977.
31. Löfvenberg R, Kärrholm J: The influence of an ankle orthosis on 39. Mascaro TB, Swanson LE: Rehabilitation of the foot and ankle,
the talar and calcaneal motions in chronic lateral instability of the Orthop Clin North Am 25:147, 1994.
ankle, Am J Sports Med 21:224, 1993. 40. Evans DL: Recurrent instability of the ankle. A method of surgical
32. Matsuaka N, Yokoyama S, Tsurusaki T: Effect of ankle disk treatment, Proc R Soc Med 46:343, 1953.
training combined with tactile stimulation to the leg and foot on 41. Zöch C, Fialka-Moser V, Quitton M: Rehabilitation of
functional instability of the ankle, Am J Sports Med 29:25, 2001. ligamentous ankle injuries: a review of recent studies, Br J Sports
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.........................................C H A P T E R 1 3
Ankle sprains, ankle instability, and

syndesmosis injuries
Thomas O. Clanton
......................
CHAPTER CONTENTS
Introduction 273 Failed lateral ankle ligament reconstruction 278

Surgical treatment 273 Medial ankle sprains 280
Results 275 Chronic medial ankle instability 284
Complications 275 Syndesmosis injury 286
Direct ligament repair (modified Brostrom procedure) 275 References 290
INTRODUCTION diagnosis of chronic lateral ankle instability has been

associated with the intraoperative findings of peroneal
tendon pathology (tenosynovitis, tears, dislocation),
Because it generally is agreed that most acute lateral
anterolateral impingement lesions, ankle synovitis,
ankle sprains can be treated nonoperatively while
intraarticular loose bodies, talar osteochondral lesions,
acknowledging an incidence of late problems in 10% to
and medial ankle tenosynovitis.3 A comprehensive phys-
20% it is no surprise that lateral ankle ligament recon-
ical therapy program should be initiated first. Symptoms
struction is commonplace.1 This approach to the treat-
often will resolve with correction of the deficits in pro-
ment of lateral ankle sprains is reasonable only if
prioception, strength, and flexibility. Regardless, ther-
reconstructive procedures for the lateral ankle ligaments
apy can improve the results in patients who ultimately
can be as successful as primary repair. Recent consensus
require surgery. The nonoperative treatment also
of orthopaedic opinion supports this viewpoint. How-
includes activity and/or shoe modification (e.g., lateral
ever, there is still controversy that persists regarding
heel wedge), an ankle-foot orthosis, and/or orthotic
the best method of treatment of acute lateral ankle
devices incorporating a lateral heel wedge. Brostrom4
sprains because of the paucity of scientific studies in this
found that symptoms of instability remained in 20% of
field that meet the requirements for proof of method in
his patients who were treated in a conservative fashion.
outcomes-based research.2
Athletes may use a nonoperative approach to get through
Most patients with chronic lateral ankle sprains and
a season but rarely consider this an acceptable long-term
instability present with either recurrent ankle sprains
solution unless their symptoms are minimal.
after an initial acute sprain or with the feeling of
looseness in the ankle and the sensation of ‘‘giving
way.’’ These patients may complain of ankle pain, but
it is not a prerequisite feature of this problem, although
SURGICAL TREATMENT
the examination confirms the presence of a positive
anterior drawer test and/or a positive inversion stress Indications for surgical treatment include young to
test. Tenderness may be present, but often is more middle-aged, active individuals who have failed a well-
indicative of associated pathology, as noted later. The designed, nonoperative treatment program. I use the
examiner must be thorough enough to rule out other radiographic criteria of an anterior drawer greater than
sources of symptoms (Table 13-1) because the clinical 1 cm (or a side-to-side difference of >3 mm), and a
CHAPTER 13 Ankle sprains, ankle instability, and syndesmosis injuries
Table 13-1 Sources of chronic pain or instability after ankle sprain
Articular injury Impingement
Chondral fractures Anterior tibial osteophyte
Osteochondral fractures Anterior inferior tibiofibular ligament
Nerve injury Miscellaneous conditions
Superficial peroneal Failure to regain normal motion (tight Achilles)
Posterior tibial Proprioceptive deficits
Sural Tarsal coalition
Tendon injury Meniscoid lesions
Peroneal tendon (tear or Accessory soleus muscle

dislocation)
Posterior tibial tendon Unrelated ongoing pathology masked by routine sprain
Other ligamentous injury Unsuspected rheumatologic condition
Syndesmosis Occult tumor
Subtalar Chronic ligamentous laxity (collagen disease)
Bifurcate Neuromuscular disease (Charcot-Marie-Tooth disease)
Calcaneocuboid Neurologic disorders (L5 radiculopathy, poststroke )
talar tilt greater than 15 degrees (or a side-to-side differ- might include patients with known collagen disease,
ence of >10 degrees) as guidelines but have found that unusually large individuals (e.g., patients larger than
the symptoms and signs are most critical. An in-office 250 lb), or patients with a failure of a prior anatomic
mini C-arm is a convenient tool to confirm the radio- repair. Avoidance of nerve injury and preservation of ankle
graphic instability. Contraindications to surgery include and subtalar joint motion are major factors in preventing
other causes of instability (collagen diseases, tarsal coali- morbidity when performing lateral ankle stabilization.
tions, neuromuscular diseases, neurologic disorders, or Diagnostic and surgical arthroscopy is warranted
functional instability), older patients with sedentary life- before ankle stabilization. Chondral injury is the most
styles, patients with serious medical conditions that common problem discovered at arthroscopy, with
would preclude anesthesia and major surgery, circulatory almost 30% of acute ankle injuries and 95% of chronic
impairment, presence of ongoing infection, lateral ankle ankles having this lesion in one study of an athletic pop-
pain without documented lateral instability, history of ulation.5 A more recent study by Komenda and Ferkel6
complex regional pain syndrome, or degenerative ar- found only a 25% incidence of chondral injury in their
thritis. A relative contraindication is failure of the patient chronic ankle instability series. Regardless, the value of
to participate in a preoperative rehabilitation program. ankle arthroscopy, particularly in cases of chondral frac-
The goals of a reconstruction or repair procedure are ture, loose bodies, and soft-tissue impingement has
correction of instability, elimination of pain, and avoid- been confirmed in several studies.6-9 Hintermann and
ance of surgical morbidity. Anatomic repair or recon- co-workers9 concluded that essential information was
struction is preferable in restoring normal joint obtained by performing ankle arthroscopy at the time
kinematics. If there is associated pathology present, it of surgery for ankle instability.
must be recognized and treated simultaneously. Inade- Operations for stabilization of the lateral ankle in
quate local tissue to stabilize the ankle may dictate the cases of chronic instability are numerous. When instabil-
use of a tendon transfer or tendon graft. Such occasions ity persists despite conservative treatment, the surgeon
274
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Direct ligament repair (modified Brostrom procedure)
can choose from more than 50 methods of reconstruct- well as having the greatest mechanical strength.38
ing the lateral ankle ligaments. Fortunately, the reported Another study, a prospective, randomized comparison
short-term success rate is greater than 80% for all these of Chrisman-Snook and modified Brostrom, found that
procedures, according to the literature.10 The primary both procedures had greater than 80% good or excel-
difference in the various procedures is whether or not lent results, but there were more complications in the
they are designed to anatomically reconstruct the liga- Chrisman-Snook group (five with wound problems,
ments. In a manner reminiscent of the surgical history eight with sural nerve injury, and six with the feeling
of shoulder and knee instability, more anatomic recon- that the ankle was ‘‘too tight’’). Brostrom complications
structions are gaining popularity for ankle instability. were almost nonexistent and included no wound pro-
This began with the introduction of the secondary repair blems, no nerve injury, and only two with a feeling that
of the previously injured ligaments by Lennart Brostrom the ankle was ‘‘too tight.’’13 In a long-term, multicenter
in 1966.11 It has taken almost four decades for the accu- outcome study of anatomic reconstruction versus teno-
mulation of scientific evidence to cast doubt on the desis, Krips and associates39 found that more patients
tenodesis procedures described by Evans, Watson-Jones, with tenodesis procedures had positive anterior drawer
Larsen, and Chrisman and Snook.12-16 The following signs, medial ankle degenerative changes, higher mean
discussion focuses on the anatomic procedures, whether talar tilt, and anterior talar translation. In addition, signif-
by direct repair in the tradition of Brostrom or by the icantly fewer patients in the tenodesis group had excellent
use of tissue transfer or tissue grafts done through ana- results, and more patients had a fair or poor result. In a
tomically placed bone tunnels. follow-up study, patients who underwent tenodesis pro-
Brostrom described his anatomic repair as a delayed cedures underwent more revision procedures, demon-
procedure for chronic lateral ankle instability. The pro- strated more osteoarthritis, more instability, tenderness,
cedure is a straightforward division and imbrication of chronic pain, and limited dorsiflexion. Good to excellent
the anterior talofibular ligament. The calcaneofibular results were found in 80% of patients at 30-year follow-up
ligament is not addressed. Various modifications have after anatomic reconstruction, versus only 33% after
been described, the most popular being a reinsertion Evans tenodesis.40 Overall, it appears that tenodesis pro-
into a bony trough,17 imbrication of the calcaneofibular cedures fail to restore the normal anatomy, resulting
ligament,18 and reinforcement with the inferior extensor in lessened mechanical stability and a decrease in patient
retinaculum.19 Other authors have described the use of satisfaction. Because of these well-documented inherent
different graft sources to rebuild the lateral ankle liga- problems of nonanatomic tenodesis procedures, ana-
ments while emphasizing the anatomic placement of tomic ligamentous reconstruction is the preferable treat-
bone tunnels. Graft sources for this include the plantaris ment approach in almost all circumstances.
tendon,20-22 the split peroneus brevis tendon,23,24
hamstring tendons,25-27 and allograft tendons.28,29
COMPLICATIONS
RESULTS Neurologic damage and wound complications are not

infrequent. Injury to the superficial nerves is the most
common complication following operative repair of the
Results of the Brostrom anatomic reconstruction are
lateral ankle ligaments. Depending on the report and
excellent. In Brostrom’s original study, 51 of 60 patients
the type of surgical approach used, the incidence ranges
demonstrated minimal or no instability at follow-up.11
from 7% to 19%.41 The sural nerve is at greater risk with
Other reported results from the Brostrom procedure
tenodesis procedures.42 Wound dehiscence, superficial
or a modification thereof include large and small series
and deep infection, loss of ankle and/or subtalar
of patients from around the world, with more than
motion, and deep venous thrombosis are less-often
500 cases reported and results ranging from 85% to
reported complications. Wise patient selection and good
100% successful.13,30-37 Lesser results are associated
surgical technique are paramount in keeping these
with heel varus, inadequate rehabilitation, nerve injury,
complications to a minimum.
preexisting arthritis, and significant repeat sprains.
Objective results of comparison studies that include
anatomic procedures such as the Brostrom versus ten-
DIRECT LIGAMENT REPAIR (MODIFIED
odesis procedures all favor the former procedure. In
BROSTROM PROCEDURE)
a cadaveric study comparing the Chrisman-Snook,
Watson-Jones, and modified Brostrom procedures, the
modified Brostrom procedure produced the least For most cases of chronic lateral ankle instability in the
amount of talar tilt and anterior drawer translation, as athletic population, a modified Brostrom technique is
275
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applicable. Its advantage is that it is an anatomic repair,

with no tenodesis effect and no major change in the
ankle and subtalar joint biomechanics. A second advan-
tage is that it does not sacrifice adjacent healthy tissue.
Indications include those patients with chronic lateral
ankle ligament instability who are unresponsive to phys-
ical therapy. Contraindications include patients with
structural varus deformities, previously failed lateral
ligament reconstructions, genetic collagen disorders
(Marfan’s and Ehlers-Danlos syndromes), or posttrau-
matic conditions with soft-tissue loss. Relative contrain-
dications are obese patients (more than 250 lb) or
patients whose instability exceeds 10 years duration with
history of multiple severe sprains.17 For these patients,
consideration is given to use a free tendon graft (allo-
graft or autograft) for augmentation.
My operative technique includes planned day surgery
or a 23-hour hospital stay. General, spinal, or regional
anesthesia may be used. The patient is positioned supine
with a bolster under the ipsilateral hip. A thigh tourni-
quet is placed. The procedure is performed through an Figure 13-1 Anterior lateral incision paralleling the border of
anterior lateral incision paralleling the border of the fib- the fibula used for anatomic repairs and reconstructions.
ula unless a more extensile longitudinal incision is neces- (Courtesy Matthew Morrey, MD.)
sary to address additional pathology.
Technique
1. The incision begins at the level of the plafond
and extends distally to the level of the peroneal
tendons (Fig. 13-1). The lateral branch of the
superficial peroneal nerve and the sural nerve
are protected.
2. Dissection is carried down to the capsule. To iso-
late the remaining portion of the anterior talofib-
ular ligament (ATFL), it is helpful to enter the
anterolateral capsule at the plafond level and
carefully dissect distally to expose the ATFL
fibers. If the ligaments appear stretched
(Fig. 13-2) and there is no obvious rupture, the
capsule and ligament are divided a few milli-
meters from their fibular origin and imbricated.
3. To locate the calcaneofibular ligament (CFL),
the peroneal sheath is opened and the peroneal
tendons are first checked for a tear. Then the ten-
dons are retracted exposing the CFL, and the
quality of the CFL is determined. A ligament
that is simply stretched can be divided and imbri- Figure 13-2 Stretched anterior lateral ligaments found in
cated (Fig. 13-3). The previously ruptured ATFL typical chronic ankle sprains. (Courtesy Matthew Morrey, MD.)
or CFL often is scarred down to capsule and ten-
don sheath and requires dissection to disclose
their location and character. For the CFL, it is hardware in the event of future ankle problems
necessary to determine whether the remaining that might call for a drill hole in this location.
tissue can be used in the secondary repair. A dis- A proximal avulsion can be reattached with
tal avulsion from the calcaneus can be reattached sutures through drill holes in the fibula (being
with suture anchors. I prefer to use a bioabsorb- careful to consider the anterior talofibular recon-
able anchor to avoid problems from retained struction) or with a suture anchor. The greatest
276
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Direct ligament repair (modified Brostrom procedure)
in neutral dorsiflexion and slight eversion

(Fig. 13-5). The surgeon must be careful to
ensure that there is no anterior displacement
force on the ankle while the sutures are being
tied. To prevent this, a bump is placed under
Figure 13-3 Imbrication of stretched ligaments in anatomical

reconstructive procedure. (Courtesy Matthew Morrey, MD.)
difficulty arises with a midsubstance tear that has

extensively scarred to the surrounding tissue. Figure 13-4 Bony trough used for attachment of anterior
Careful dissection usually will define a ligamen- talofibular and calcaneofibular ligaments to bone. (Courtesy
tous remnant that can be imbricated. Matthew Morrey, MD.)
4. In the case of an ATFL avulsed from the fibula,
and to be certain of sufficient tissue for the
ATFL reconstruction, a periosteal flap that is
continuous with the capsule and the anterior
talofibular scar can be created.
5. Nonabsorbable or slowly absorbable sutures are
placed in the ligament. A small bony trough is
created above the anterior and inferior border
of the distal end of the fibula, and several drill
holes are made with a small drill bit or Kirschner
wire (Fig. 13-4). This permits imbrication of the
ends of the cut ligament and capsule, as well as
the anchoring of the ligament into bone. In the
few cases in which the ATFL has avulsed from
the fibula, it also is feasible to reattach the ATFL
with suture anchors. As mentioned under num-
ber 3 previously, it is preferable to use bioabsorb-
able anchors here to avoid the potential problem
of extricating a metal anchor that is situated in
the exact location where a bone tunnel must be
placed for a tendon graft reconstruction should
the anatomic reconstruction fail or be disrupted
in a future injury.
6. The sutures are tied over a bony bridge on the Figure 13-5 Sutures tied over bony bridge on anterior lateral
lateral aspect of the fibula, with the ankle held fibula. (Courtesy Matthew Morrey, MD.)
277
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the distal leg to relieve any anterior directed force Postoperative care
on the heel. For athletes, the patient is placed in a short-leg splint
7. Sutures are placed in the CFL first, followed by with the foot in neutral dorsiflexion and slight eversion.
the ATFL, and then the lateral capsule. The The splint remains in place until the first postoperative
sutures are tagged or grouped to be tied only visit, which usually occurs between 6 and 10 days from
after all sutures are in place. Sutures are tied the day of surgery. The patient is on crutches—
beginning with the CFL, then the ATFL, and nonweight bearing until this visit. At the first postoper-
concluding with the anterior capsule. The ankle ative visit, the patient is placed in a walking boot or cast
is positioned in relaxed plantarflexion when the and begins weight bearing as tolerated. This is
sutures in the CFL are secured and in slight dor- continued for 3 to 4 weeks until the next office visit.
siflexion and eversion for tying the sutures in the During this second phase, the patient may start dorsi-
ATFL. flexion and eversion movement if in a boot, and at
8. After securing the repair, the stability is checked 4 weeks, the patient is placed in an ankle stirrup brace.
and further imbrication performed as needed. Gentle active inversion is begun at 4 weeks in association
9. Before closure, attention is directed to the infe- with Achilles stretching. At the same time, propriocep-
rior extensor retinaculum, which is imbricated tive training and resistive exercises with rubber tubing
or sutured to the periosteum over the fibula are begun. The patient is allowed to progress from sta-
(Fig. 13-6). This provides additional stability to tionary biking to pool running to outdoor walking and
the subtalar area and protection to the ATFL straight-line running. As long as the patient shows no
and may add some proprioceptive feedback. I pain or undue swelling, rehabilitation continues as toler-
believe that it is an important addition to the ated with figure-eight running in progressively smaller
Brostrom technique, as noted by Gould and loops, and ultimately, cutting drills are instituted. The
others.35,43-45 athlete then is allowed to resume activities specific to
10. The subcutaneous tissues are reapproximated his or her sport, with return to competition once each
with absorbable sutures, and the skin is closed task of the sport can be accomplished. For 6 months
with a subcuticular technique. following the repair, the patient is instructed to use a
11. A U-shaped splint and a posterior splint or a protective ankle brace and/or taping to protect the
walking boot is applied. repair. The typical return to competitive sport participa-
tion is 12 weeks (range 10 to 16 weeks), although it may
take closer to 6 months for swelling and discomfort to
resolve fully.
For nonathletes, a 10- to 12-week period of protec-
tion is warranted, the first 4 to 6 weeks with the patient
being in a cast or walking boot with limited exercise and
the second 6 weeks with the patient being in a remov-
able brace or walking boot when a more aggressive reha-
bilitation program is begun. Resumption of vigorous
exercise or recreational sports generally takes longer
in this population. Although I believe in individualizing
the rehabilitation program to the patient and the
pathology, a table is provided as a general guideline
(Table 13-2).
FAILED LATERAL ANKLE LIGAMENT

RECONSTRUCTION
Of patients who undergo a lateral ankle reconstruction,

5% to 15% may proceed to failure, requiring further
intervention. Perhaps the most common cause for fail-
ure is recurrent instability. The primary surgical proce-
dure may have been inadequate, the patient may have
Figure 13-6 Imbrication of inferior extensor retinaculum to reinjured the ankle, or there may have been inherent fac-
periosteum of distal fibula. (Courtesy Matthew Morrey, MD.) tors that predisposed a patient to failure (benign joint
278
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Failed lateral ankle ligament reconstruction
Table 13-2 Rehabilitation program for surgically reconstructed lateral ankle ligaments
Days
Doctor visits (weeks) Immobilization Weight bearing Rehabilitation
Surgery to first 0-7 (1) Immobilized in Crutches No exercises with ankle

postoperative splint or walking nonweight bearing but general conditioning
visit boot as tolerated
First visit to 8-28 (2-4) Walking boot with Crutches with General conditioning,
second visit dorsiflexion and weight bearing as stationary bike starting
eversion allowed tolerated, with stirrup brace and
progressing to full weight on heel, pool
weight and no walking and running, light
crutches balance work
Second visit to 29-42 (5-6) Stirrup brace at all Full weight Biking with increased
third visit 43-56 times except sleep resistance, outdoor
(7-8) Stirrup brace for walking and straight line
exercise running, aggressive
proprioceptive education
Start figure-8 running,
cutting, sports-specific
drills
Third visit to 57-70 up to Brace or tape for Progress drills, speed and
return to play 84 (9-12) practice endurance
hypermobility syndrome, Marfan’s syndrome, or Ehlers- management of recurrent instability; however, these
Danlos syndrome).42 The patient often describes a loose patients typically require a second attempt at surgical
feeling in the ankle or the sensation of ‘‘giving way’’ or stabilization.
‘‘turning easily.’’ Another cause of failure in lateral ankle
reconstruction is chronic pain, constant or only during Treatment
activity, resulting from intra-articular pathology or post- Reconstructing the lateral ligament with a free tendon
operative stiffness. transfer using the semitendinosus or the gracilis ten-
In addition to a thorough history, it is important to don is recommended, performed in a manner similar
obtain a record of the primary procedure, if possible. to the method used when harvesting for an anterior cru-
Stress tests of the lateral ligaments should demonstrate ciate ligament autologous graft. After the graft has been
laxity. Limited range of motion of the ankle and subtalar harvested, it is prepared by sizing it for diameter and
joints can be observed in patients who were overtigh- length. Generally, the doubled semitendinosus is 9 to
tened at their original reconstructive procedure. The 11 cm in length and approximately 5 to 6 mm in diam-
alignment of the hindfoot should be evaluated. Varus eter, whereas the gracilis is somewhat smaller. It also is
alignment of the heel will predispose a patient to failure possible to use an allograft tendon, and a larger tendon
of a lateral ligament reconstruction. such as the anterior tibial tendon can be cut to the
Radiographs of the foot and ankle should be appropriate diameter for drill holes.
obtained to evaluate the presence of bony pathology. The lateral ankle is exposed through one of two inci-
Stress radiographs or fluoroscopy can aid in the diag- sions chosen on the basis of the underlying pathology.
nosis of recurrent instability or an excessively tight When the pathology is limited to the previously recon-
reconstruction. Intra-articular pathology, such as osteo- structed lateral ligamentous complex, a small, curvilinear
chondral lesions, can be diagnosed with magnetic re- incision paralleling the anterior and distal border of the
sonance imaging (MRI). Computed tomography (CT) fibula is used, similar to the incision for the previously
scans are helpful in defining previous bone tunnels. described Brostrom procedure (see Fig. 13-1). For cases
Nonoperative measures may be effective in the with more extensive pathology (peroneal tendon tears
279
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or anterior osteophytes), a longitudinal incision is made

over the posterior border of the fibula, curving distally
to the sinus tarsi and the anterior process of the calca-
neus. With both approaches, the ankle joint is exposed
and the anterolateral capsule is divided, preserving as
much potentially useful tissue as possible.
For proper graft placement, the insertion sites of the
ATFL (talus and distal fibula) and CFL (distal fibula
and calcaneus) are exposed. The surgeon then drills
a 4.5- to 6.0-mm tunnel in the talus, depending on
the size of the graft and the size of the interference fit
screw being used. Bioabsorbable screws currently vary
in size from 4 to 11 mm. I have found that the 5- to
5.5-mm screw works best in the ankle. The tendon graft
is captured with a suture loop using the Arthrex Biote-
nodesis System and inserted into the bone tunnel to a
depth of approximately 20 mm before the bioabsorbable
screw is tightened against the tendon within the bone
tunnel. Another option is to drill a tunnel in the talus Figure 13-7 Bioabsorbable screws placed with an
to a depth of 25 to 30 mm and use a Beath pin to pass interference fit in the talar and calcaneal bone tunnels to
the sutures from the end of the tendon graft through secure the tendon graft.
the tunnel in the talus and out the medial side of the
foot. With tension applied to the tendon through
Biotenodesis System can be used to insert the tendon
the sutures, an interference screw can be placed next to
in the bone tunnel and fixate the graft with the bioab-
the tendon to secure the graft in the talus. Once the
sorbable screw. Once the graft is secured and the ten-
graft is secure in the talus, a tunnel is drilled from the
sion is judged to be adequate, the ankle is tested for
anterior distal fibula at the origin of the ATFL through
stability and range of motion, and stress radiographs
the distal fibula and into the area of the proximal pero-
are performed under fluoroscopy. If the ankle is still
neal groove. When the procedure is performed through
unstable, the screw in the calcaneus is removed, the graft
a Brostrom-type incision, a separate 2-cm incision is
further tensioned, and the screw replaced with the heel
made for insertion of a retractor to protect the peroneal
in slight eversion. The graft is secured to the periosteum
tendons. A second fibular bone tunnel is drilled at the
of the fibula at the entrance and exit holes with absorb-
origin of the CFL and passed posterior to exit at the
able suture. The inferior extensor retinaculum or other
posterior fibula at the same exit site as the previously
local tissue can be used for augmentation if further sta-
drilled fibular tunnel. Now a V-shaped channel in the
bility is required.
distal fibula exists. A suture passer is placed through
Postoperatively, the ankle is protected in a splint or
the posterior fibular tunnel, exiting anterior, and the
boot, nonweight bearing for 1 to 2 weeks. After this
sutures in the tendon graft are passed into the fibula,
time period, progressive weight bearing is allowed over
creating an ATFL graft. The suture passer next is passed
2 to 3 weeks, with discontinuation of crutches by
posterior through the distal fibular tunnel, and the
4 weeks postoperatively. Compliant patients, under
sutures in the tendon graft are passed out the distal fib-
supervision, can be managed in a removable walking
ula to create a CFL graft. It is important to keep a clamp
boot and started on active range of motion immediately.
around the graft at the posterior fibula to allow tension-
The typical ankle rehabilitation program for range of
ing of the separate limbs of the graft. A tunnel is drilled
motion, strength, Achilles stretching, and propriocep-
in the lateral calcaneus at the site of insertion of the CFL
tive reeducation begins at about 3 to 4 weeks and pro-
for the tendon graft, with the depth of the tunnel being
gresses as tolerated. Other pathology often dictates any
sufficient enough to pull the entire tendon graft length
alterations that must be made to this general protocol.
into the bone tunnel. A Beath pin or Keith needle then
is used to pass the tendon graft sutures through the
plantar medial heel. MEDIAL ANKLE SPRAINS
While holding the ankle in neutral dorsiflexion and
neutral inversion/eversion, the surgeon applies tension
to the graft. A bioabsorbable screw is placed with an The medial ankle ligamentous complex is composed
interference fit in the calcaneal bone tunnel to secure solely of the deltoid ligament. The overwhelming major-
the graft (Fig. 13-7). Alternatively, the Arthrex ity of deltoid ligament injuries occur in association with
280
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Medial ankle sprains
lateral malleolus fractures, syndesmotic disruptions, or

injuries to the lateral ankle ligaments. Isolated deltoid
ligament sprains account for only 2% to 3% of all ankle
sprains.46-48 Chronic medial ankle instability is rarely
Tibionavicular/
a clinical problem, but its prevalence probably is Tibiospring (reflected)
underestimated.49,50
Anatomy and biomechanics

Deep posterior
The deltoid ligament is a broad, fan-shaped complex of Deep anterior tibiotalar tibiotalar
ligaments that together serve as the medial collateral lig-
ament of the ankle. The deltoid ligament consists of
both a superficial layer and a deep layer and has enough
anatomical variation that there has been some confusion
in the nomenclature.51-54 Milner and Soames’51 detailed
anatomic study found six different bands, with three
being consistently present (two superficial and one
deep), and three bands were not found in all specimens.
The constant superficial bands originate from the ante-
Figure 13-9 Deep deltoid ligaments. (A) Deep posterior
rior colliculus of the medial malleolus and are divided tibiotalar ligament. (B) Deep anterior tibiotalar ligament.
into the tibiospring ligament (TSL) and tibiona-
vicular ligament (TNL). The less constant portions of
the superficial deltoid are the tibiocalcaneal ligament
(TCL) and superficial posterior tibiotalar ligament ligaments cross two joints (ankle and either talocalcaneal
(STTL) (Fig. 13-8). By their nature, the medial liga- or talonavicular). The deep layer of the deltoid origi-
ments blend together, forming an indistinct origin from nates from the intercollicular groove and posterior col-
the medial malleolus, and are characterized primarily by liculus of the medial malleolus.
their distal attachment. The deltoid ligament is the primary restraint to
The constant band of deep deltoid ligament is the valgus tilting of the talus within the ankle mortise.55
deep posterior tibiotalar ligament (PTTL). The deep Both the superficial deltoid and the deep deltoid indi-
anterior tibiotalar ligament (ATTL) was found in only vidually resist eversion of the hindfoot. Valgus tilting
10% of specimens51 (Fig. 13-9). The deep bands cross of the talus does not occur if only the superficial or the
only the single joint of the ankle, whereas the superficial deep portion of the deltoid is divided.55,56 Complete
rupture of the entire deltoid complex is required to
produce valgus tilting of the talus in otherwise intact
ankles.55
The deep deltoid ligament is also a secondary
restraint against both lateral talar shift and anterior talar
excursion, with the fibula and lateral ankle ligaments
Deltoid ligament being the primary restraint.55 Multiple anatomic studies
Posterior tibitalar have shown that, with an intact deltoid, up to 3 mm of
Tibiocalcaneal lateral talar shift is possible if the lateral malleolus has
Tibionavicular been resected.55,57,58 Conversely, no increase in lateral
Anterior tibiotalar shift or anterior excursion of the talus occurs when
the entire deltoid is sectioned if the lateral malleolus
and ligaments are intact.57 However, sectioning of
the entire deltoid, or just the tibiospring (or tibiocalca-
neal) portion of the superficial deltoid, has been shown
to dramatically decrease tibiotalar contact area and
increase peak ankle joint pressures up to 30%. These sig-
nificant changes in contact area and peak pressures occur
before radiographic evidence of medial talar tilt is pres-
ent.59,60 The deltoid ligament clearly is involved in
Figure 13-8 Superficial deltoid ligaments. (A) Tibial spring rotary stability of the talus within the mortise, but its
ligament. (B) Tibionavicular ligament. (C) Tibiocalcaneal exact function in this regard is the subject of some
ligament. debate.56,61,62
281
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Mechanisms of injury
Although the deltoid ligament may be injured in con-
junction with the lateral ligamentous structures by a
variety of mechanisms, the classic mechanism of injury
for an isolated deltoid rupture is forced abduction or
eversion.63 In these forced abduction injuries, the super-
ficial deltoid ligament ruptures first, followed by the
deep deltoid.64 The deep deltoid has a significantly
higher load to failure than the lateral collateral ankle
ligaments, with its dominant mode of failure being an
intrasubstance rupture near its talar insertion.65,66 Con-
sequently, a deltoid injury requires considerably more
force than the average lateral ankle sprain. Athletic inju-
Site of pain localization
ries to the deltoid typically involve jumping sports or con-
tact sports such as football or wrestling. A basketball
player might sustain an eversion injury by landing on
another player’s foot after coming down from a jump,
whereas a football player might sustain a forced abduc-
tion injury when an opponent falls on or steps on his lat-
eral ankle with the foot in a pronated position. Garrick67
noted an inordinately high frequency of ankle sprains in
wrestlers, presumably resulting from their wide stance
and having their feet everted to gain traction on the mat.
Diagnosis
As stated previously, the majority of deltoid injuries
Figure 13-10 Squeeze test for syndesmosis injury.
occur in conjunction with lateral ankle sprains, syndes-
mosis injuries, or fibula fractures. Obtaining an accurate
description of the patient’s mechanism of injury may
provide important clues to the presence of these asso- (FHL) tendons or to the spring ligament. The patient
ciated injuries. Patients with acute deltoid ligament rup- with a deltoid injury may develop an increasingly flat
tures usually recall the specific injury and often feel or foot or pronated foot deformity with weight bearing
hear a pop on the medial side of their ankle. A history after the injury that is actively correctable with contrac-
of immediate pain and swelling over the deltoid liga- tion of the posterior tibial muscle.50 Finally, a brief sen-
ment is typical, along with a variable degree of difficulty sory examination of the foot and ankle, including
with ambulation and a feeling of medial instability. attempts to elicit a Tinel’s sign, can help to identify
Because of the high prevalence of associated injuries, acute traction injuries of the tibial or saphenous nerves.
examination of an athlete with a suspected deltoid liga- Radiologic evaluation should begin with standard
ment injury should include evaluation of the entire views of the ankle to detect associated ankle fractures
lower leg. Careful palpation of the entire length of the or frank diastasis of the syndesmosis. Supplemental
fibula should be performed to assess for a high fibula anterior-posterior (AP) and lateral views of the leg
fracture that might be seen with a Maisonneuve-type should be obtained if the physical examination is sugges-
injury. An injury to the ankle syndesmosis must be ruled tive of a high fibula fracture or proximal tibiofibular
out by squeeze test (Fig. 13-10) or external rotation test pathology. Weight-bearing AP ankle radiographs may
(Fig. 13-11) or, if still in question, by MRI. A thorough show valgus tilt in a complete deltoid rupture.
assessment of each of the lateral ankle ligaments also If an isolated deltoid ligament rupture is clinically
must be performed. When examining the medial ankle suspected, manual valgus stress radiographs should be
structures, it is important to keep in mind the intimate obtained. Greater than 5 degrees of valgus talar tilt with
spatial relationships of the deltoid ligament to the con- valgus stress in neutral ankle flexion, or a side-to-side
tents of the tarsal tunnel. Careful localization of the difference of greater than 2 degrees, is indicative of an
point of maximal tenderness and evaluation of tendon isolated complete deltoid injury.68 It should be noted
function can help to distinguish between deltoid liga- that plain radiographs typically are normal in patients
ment ruptures and injuries of the posterior tibial, flexor with ruptures of only the superficial portion of the
digitorum longus (FDL), or flexor hallucis longus deltoid ligament.
282
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Medial ankle sprains
Figure 13-11 External rotation test for syndesmosis injury.
Although MRI is considered the gold standard for by Hintermann et al.50 He suggests using the criteria
visualizing the deltoid ligament, it has been used rarely described in Table 13-3 for grading the degree of insta-
in clinical practice except in professional athletes. As bility by arthroscopy.
with lateral ligament injuries, MRI can be helpful in
the evaluation of associated ankle pathology in a patient Treatment
who fails conservative management. MRI also is useful In general, the treatment of acute deltoid ligament rup-
in special cases in which the diagnosis of an acute deltoid tures is nonoperative. However, the presence of an asso-
rupture must be objectively confirmed. Clinical correla- ciated fibular fracture or syndesmotic injury most often
tion between MRI and physical examination findings will require operative treatment for these entities.
is critical because MRI is highly sensitive and may dem- Although it is the subject of historical controversy, most
onstrate clinically insignificant changes in the deltoid recent studies have concluded that the deltoid does not
ligament.69 Schneck et al.70 have emphasized the impor- need to be surgically repaired once the lateral malleolus
tance of separate dorsiflexion and plantarflexion imaging and/or syndesmosis have been anatomically reduced
sequences to optimally visualize the individual compo- and stabilized.72-77 The anatomy of the deltoid ligament
nents of the deltoid ligament. With newer high field allows for maintained apposition of its torn ends if the
strength magnets, updated three-dimensional imaging talus is appropriately stabilized within the mor-
software, and the use of a dedicated ankle coil, foot posi- tise.20,78,79 The main indication for deltoid ligament
tion may be less important.71 When ordering an MRI to surgery is the infrequent case in which the deltoid or
evaluate the deltoid, direct consultation with the radiol- posterior tibial tendon becomes entrapped between the
ogist before the study helps to determine the appropri- talus and the medial malleolus, preventing anatomic
ate imaging protocol for their specific equipment. reduction of the talus within the mortise. In these cases,
Another alternative for diagnosis when nonoperative medial ankle arthrotomy with exploration of the poste-
treatment fails is arthroscopy of the ankle and direct rior tibial tendon and repair of the deltoid is recom-
assessment of the ligamentous integrity, as described mended. There are other situations that occasionally
283
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Table 13-3 Arthroscopic grading and findings in medial ankle instability
Opening
Grade of medially
instability (mm) Device used Finding
Stable Up to 3 2-mm hook Minimal translation of talus

probe/2.7-mm
scope
1 3-4 2-mm hook Translation discernible with probe, scarring seen in superficial
probe/2.7-mm deltoid
scope
2 4-5 5-mm scope/ Obvious translation with easy movement of large joint scope
4.5-mm shaver into medial tibiotalar space, scarring of medial ligaments or
disruption both deep and superficial
3 More than 5 5-mm scope/ Obvious translation with easy movement of large joint scope
4.5-mm shaver into medial tibiotalar space with free visualization to the
posterior aspect of the ankle joint even without valgus stress
applied
Modified from Hintermann B, et al: Medial ankle instability—a missed diagnosis, Presented at AAOS Annual Meeting, AOFAS Specialty Day,
March 13, 2004.
warrant repair of the deltoid in association with syndes- in a hinged ankle brace; at 9 weeks, he was running with
mosis disruption, and the best determinant that I have his ankle taped; and at 12 weeks, he was running pat-
found is stress evaluation intraoperatively following the terns without pain or instability. One of Brostrom’s4
lateral side repair. early reports of a series of ankle sprains included eight
Treatment of athletes with low-grade, isolated, del- isolated deltoid ruptures. All patients underwent arthro-
toid ligament sprains is similar to the nonoperative treat- graphy to confirm the diagnosis; three were treated
ment of acute lateral ankle sprains, but return to sports operatively, one was casted, and four were treated with
generally is more prolonged. Immediate cold therapy, ankle strapping. At a mean follow-up of 3.8 years, he
antiedema measures, and the use of a functional stirrup- reported no residual symptoms in any of the deltoid lig-
type brace or walking boot are begun as quickly as possi- ament treatment groups. It is unclear whether surgical
ble, with return to sports in 3 to 6 weeks. For high-grade repair of complete deltoid ruptures offers any advantage
sprains or complete ruptures of the deltoid, anatomic in terms of quicker return to sports or improved out-
reduction must be confirmed before treatment, with come when compared with conservative treatment.
6 to 8 weeks of immobilization in a walking cast or walk- Nevertheless, extrapolating from the findings of Hinter-
ing boot to prevent external rotation of the talus as the mann et al.50 related to chronic medial instability, exam-
deltoid heals. Although I do not routinely perform ination under anesthesia, arthroscopy, and acute repair
surgery on athletes with complete deltoid ligament rup- with sutures or suture anchor can be justified in the ath-
tures (even in conjunction with fibular fracture or syndes- lete with an acute injury who is suspected to have insta-
mosis injury), I consider failure to achieve anatomic bility. Until further scientific work elucidates a clear
alignment of the medial clear space an indication for sur- difference between the results of operative and non-
gical repair.80 Determining this may require examination operative repair, controversy will persist in determining
under anesthesia and arthroscopy. the best approach to the acute, severe medial ankle
There is very little in the scientific literature regarding sprain.
the acute repair of deltoid ligament injuries. Jackson
et al.81 have described the surgical repair of an isolated,
complete rupture of the anterior portion of the deltoid
in a high-performance football player. Jackson used a
CHRONIC MEDIAL ANKLE INSTABILITY
Kessler-type suture tied over drill holes in the medial
malleolus and has described his post-operative protocol Chronic medial ankle instability is an uncommon but
in detail. At 6 weeks, the patient began weight bearing severely disabling problem.20,49,82 When chronic deltoid
284
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Chronic medial ankle instability
insufficiency does occur, it usually can be related to lat- may include any combination of supportive taping, brac-
eral ankle pathology. Deformity of the lateral malleolus ing (e.g., short articulated ankle foot orthosis [AFO]),
from fibular fracture malunion or distal physeal arrest, casting, functional rehabilitation, and orthoses (e.g.,
as well as chronic syndesmotic diastasis, can all be contri- medial heel wedge and first metatarsal lift). If the ath-
buting factors.15,82,83 In these cases, the lateral malleo- lete’s symptoms are not reduced to a tolerable level with
lus fails to appropriately buttress the talus within the conservative measures, surgical reconstruction of the
mortise, causing the deltoid to heal in a lengthened deltoid ligament is warranted.
position or to gradually attenuate. Additionally, arthro- Several different methods of deltoid ligament recon-
scopic findings in patients with chronic ankle instability struction have been described in detail. If the remaining
indicate that combined medial and lateral ankle instabil- ligamentous tissue is of adequate quality, simple imbri-
ity is more than twice as common as medial ankle insta- cation using a method analogous to the lateral Brostrom
bility alone.49 procedure may be performed.82 When possible, it seems
Patients with chronic medial ankle instability usually advantageous to advance the ligament to bone using
complain of recurrent episodes of giving way along with suture anchors in the talus and naviculum to accomplish
medial ankle pain. Physical examination may reveal mild this goal.84 Alternatively, when the remaining deltoid is
pes planovalgus, tenderness over the deltoid ligament of poor quality, ligamentous reconstruction with a ten-
and anteromedial joint line, and a variable degree of don graft is recommended. Wiltberger and Mallory85
instability to valgus stress. The ability of the patient to have described a method for deltoid reconstruction
correct the planovalgus or pronation deformity actively using the anterior half of the posterior tibialis tendon.
while weight bearing by contracting the tibialis posterior The split tendon graft is left attached at its insertion
muscle is confirmatory.50 Manual valgus stress radio- and the free end is passed through a bone tunnel in
graphs in neutral ankle flexion should be obtained to the medial malleolus before being tied back on itself
document the degree of valgus talar tilt. Although fibu- (Fig. 13-12). In view of the serious potential problems
lar length can be adequately evaluated by plain radio- created by posterior tibial tendon pathology, it seems
graphs, a rotational malunion of the fibula or a subtle less than ideal to take a portion of the posterior tibial
syndesmosis deformity is assessed more easily with axial tendon for use as a graft to reconstruct the deltoid liga-
CT imaging. MRI also is reasonable in these cases, ment. More complex reconstruction of the deltoid in a
because Hintermann et al.49 have reported a high associ- patient with traumatic loss of the medial malleolus using
ation of talar articular cartilage lesions with complete a free tendon graft also has been described.86 Allograft
ruptures of the deltoid ligament. tendon or autologous hamstring tendon grafts can be
Treatment of chronic medial ankle instability depends used with bioabsorbable interference fit screw fixation
on the associated pathology. In patients with fibular into bone tunnels. The postoperative protocol recom-
malunion, derotational and/or lengthening fibular mended by Jackson includes 2 weeks of nonweight-
osteotomy should be performed before addressing the bearing immobilization in a short-leg cast. This is fol-
deltoid ligament. Similarly, chronic syndesmosis injuries lowed by 4 weeks of weight bearing as tolerated in a
first require stabilization or reconstruction of the syn- walking boot, while active range-of-motion exercises
desmosis. In cases of chronic medial ankle instability are initiated. Strengthening exercises are started at
without associated lateral ankle pathology, patients may 6 weeks, and the patient may begin weight bearing in
benefit from a period of conservative treatment. This a hinged ankle brace. At 9 weeks, light running is
Figure 13-12 Split posterior tibial tendon graft for deltoid ligament reconstruction.
285
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inferior tibiofibular ligament (PITFL), and (3) the

Posterior Anterior interosseous ligament. The AITFL runs obliquely at
approximately a 45-degree angle from the anterolat-
eral tubercle of the tibia to the anterodistal fibula
(Fig. 13-14). It is the most often-injured ligament in
syndesmosis sprains and in frank diastasis.64 The PITFL
Insertion site of has two components (Fig. 13-15). The superficial com-
interosseous ponent runs from the posterolateral tubercle on the
Attachment of
ligament
interosseous
membrane
Fibular
notch
AITF origin
Figure 13-13 Anatomy of the fibular notch.
Anterior tibiofibular
allowed, and by 12 weeks, a gradual return to the ath- ligament
lete’s specific sport begins. Return to competition is
expected at 4 to 6 months.81
Anterior talofibular
ligament
SYNDESMOSIS INJURY
Syndesmosis injury, or the high ankle sprain, has

become the injury de rigueur in the sports medicine
world related to the foot and ankle. No National Foot-
ball League injury report is complete, it seems, without
there being some athlete who is out of action because Figure 13-14 Anatomy of the anterior syndesmosis.
of this entity. Although the injury clearly has been
around since antiquity, it does seem to be diagnosed
presently with more frequency. This probably is due
not only to the larger, faster, and stronger athletes play-
ing on surfaces with more torsional friction but also to
improved diagnostic tools and physician awareness.
Anatomy and biomechanics

The stability of the distal tibiofibular complex is depen- Posterior tibiofibular
dent on bony and ligamentous anatomy, and the distal ligament
tibia and fibula comprise the bony anatomy of the syn-
Posterior talofibular
desmosis. The fibular notch (Fig. 13-13), or incisura ligament
fibulare, is a vertically oriented triangular groove in the
lateral tibia with which the fibula articulates. As the fib- Deltoid
ligament
ula rests in this notch, it is supported anteriorly and pos-
teriorly by the distal tibial tubercles. The size of these Calcaneofibular
ligament
tubercles correlates with the depth of the notch. Radio-
graphically, the notch appears concave only 75% of the
time, and in 16% of patients it takes on a convex
appearance.87
There are three main ligaments that add stability to
the distal tibiofibular syndesmosis: (1) the anterior infe-
rior tibiofibular ligament (AITFL), (2) the posterior Figure 13-15 Anatomy of the posterior syndesmosis.
286
...........
Syndesmosis injury
posterior surface of the tibia to the posterior aspect of suspected to have an abduction component, a rupture
the distal part of the fibula. It covers the back of the of the deltoid ligament or a fracture of the medial mal-
tibiotalar joint. The deep portion of the PITFL is called leolus will produce tenderness at the medial ankle. The
the transverse tibiofibular ligament. It lies anterior to examiner also must ensure that the fibula is palpated
the superficial component of the PITFL and forms the from distal to proximal, including the proximal tibiofib-
most distal aspect of the tibiotalar articulation. It func- ular joint, to rule out the possibility of a Maissoneuve’s
tions as a virtual labrum and deepens the tibiotalar artic- fracture or a proximal tibiofibular joint disruption.
ulation. The combination of strength and elasticity Delayed swelling and ecchymosis are frequent findings.
makes the PITFL the last syndesmotic structure to
tear.20 The interosseous ligament interconnects the tibia Special clinical tests
and fibula from 0.5 to 2 cm above the plafond. It sur- The ‘‘squeeze test,’’ described in 1990 by Hopkinson
rounds the synovial recess that extends up approximately et al.,93 is a method of detecting ‘‘stable’’ syndesmosis
1 cm from the tibiotalar joint. Although it is the shortest injuries (see Fig. 13-10). A recent biomechanical study
structure interconnecting the distal tibia and fibula, it is confirmed separation at the origin and insertion sites
considered the primary bond between these two bones of the AITFL caused by compression of the fibula and
at the ankle.58,88,89 At the superior margin, the inteross- tibia proximal to the midpoint of the calf.95 The authors
eous ligament blends with the interosseous membrane. further reported that the distance of separation increased
The membrane itself adds very little additional strength as the syndesmotic ligaments were sectioned sequen-
to the stabilizing effect of the syndesmotic ligaments. tially. The pain elicited during this maneuver could be
In the normal relationship between the tibia and fib- caused by tension in the remaining fibers of the distal
ula, there is motion in the frontal, transverse, and sagit- tibiofibular complex. I have not found the squeeze test
tal planes.90 An increase in the intramalleolar distance of to be a reliable indicator of syndesmosis injury.
about 1.5 mm takes place from full plantarflexion to full When the injury is isolated to the syndesmosis, one
dorsiflexion. Rotation of the ankle also is possible expects the anterior drawer and talar tilt test to be nega-
through the syndesmosis. A rotation of the tibia on tive. These tests should be performed routinely.
the talus of 5 to 6 degrees occurs during dorsiflexion The external rotation test is the most reliable test for
and normal walking.58 In addition, the fibula migrates syndesmosis injury, with a high interrater correlation
distally an average of 2.4 mm during the stance phase (Fig. 13-11).96 The test is performed by stabilizing the
of gait.91 leg with the knee flexed at 90 degrees while externally
rotating the foot. Pain is produced at the syndesmosis
Mechanism of injury when it is injured. The tibiofibular shuck test or Cotton
Most clinicians agree that external rotation is the most test is another adjunctive test to detect instability in the
significant force in a syndesmosis injury.20,64,92,93 The distal tibiofibular articulation.97-99 The distal leg is
AITFL is the first to fail with an external rotation force, steadied with one hand while the plantar heel is grasped
followed by the interosseous ligament and membrane. with the opposite hand and the heel is moved side to
The PITFL usually is preserved. A syndesmosis sprain side. Excessive movement when compared with the
may also occur with an abduction force, requiring rup- opposite ankle suggests an unstable mortise. A medial
ture of the deltoid ligament or fracture of the medial or lateral malleolus fracture should be ruled out before
malleolus. performing this test.
Clinical diagnosis Radiographic diagnosis

Patients with acute syndesmosis injuries generally have Routine radiography is the next step in the evaluation of
anterolateral ankle pain directly over the anterior syndes- a patient with a suspected syndesmosis sprain. Careful
mosis. The pain and swelling may be more precisely evaluation of the distal tibiofibular relationship with
localized than in patients with the traditional lateral regard to the medial clear space, the tibiofibular clear
ankle sprain, but this is not always the case, particularly space, and the tibiofibular overlap is crucial (Fig. 13-16).
after the first 24 hours. Uys and Rijke94 studied the clin- An increase in the medial clear space is defined as a widen-
ical association between acute lateral ankle sprain and ing in the space between the medial malleolus and the
syndesmotic ligament involvement and found that medial border of the talus, normally no more than 2 to
severe syndesmosis injuries were not associated with 4 mm.100 The tibiofibular clear space at the incisura fibu-
tears of the lateral ankle ligaments. Although one would laris tibiae and the absolute amount and percentage of
expect minimal tenderness over the ATFL or CFL in overlap of the tibia and fibula at the incisura are other
syndesmosis injuries, this often is not the case, and the radiographic landmarks. A radiograph of the uninjured
physical examination is notoriously unreliable in ankle ankle can be used to clarify the relationship between the
sprain injuries. When the mechanism of injury is uninjured distal tibia and fibula. Criteria for the diagnosis
287
...........
A B C D
1 cm
1 cm
E F
A. Lateral border of fibula

B. Lateral border of anterior tibial prominence
C. Medial border of fibula
D. Lateral border of posterior tibial malleolus
E. Medial border of talus Figure 13-17 External rotation and abduction stress x-ray to
F. Lateral border of medial malleolus expose a latent diastasis.
CD. Tibiofibular clear space
BC. Tibiofibular overlap
EF. Medial clear space
discontinuity, (2) wavy or curved ligament contour,
Figure 13-16 Landmarks for radiologic diagnosis of and (3) nonvisualization of the ligament (Fig. 13-18,
syndesmosis injury. A and B). Using these criteria, Oae et al.105 found a sen-
sitivity of 100%, a specificity of 93%, and an accuracy of
97% in diagnosing a syndesmosis injury.
of diastasis are (1) medial clear space widening, (2) Treatment

increased tibiofibular clear space, and (3) less tibiofibular The treatment of syndesmosis injuries discussed here
overlap. However, the absence of radiographic findings will focus on those cases in which etiology is traumatic.
does not completely rule out the possibility of a significant In the acute injury, initial management includes rest,
sprain. Stress radiographs with application of an external ice, compression, and elevation (RICE). The affected
rotation and abduction force can expose an occult diastasis extremity should be immobilized, the patient should
(Fig. 13-17). Some clinicians advocate the use of stress remain nonweight bearing, and the appropriate diagnos-
radiography as standard practice in the diagnosis of syndes- tic tests ordered. Sprains without diastasis can be treated
mosis injury.101 Other clinicians question its role.102,103 nonsurgically. Patients may bear weight as tolerated in a
Bone scan, CT, and MRI are other radiographic walking boot or brace. Crutches are used if pain pre-
modalities used in the diagnosis of syndesmosis injury. vents weight bearing. Physical therapy can start when
Bone scan can be a particularly useful diagnostic tool pain subsides and weight bearing becomes easier. These
in evaluating a patient with chronic pain after a lateral injuries take longer than most sprains to return to nor-
ankle sprain.90 CT is excellent for showing bony detail mal activity. One study showed that although 86% of
of the tibiofibular syndesmosis and can be more precise patients reported good to excellent ankle function, stiff-
in evaluating the presence of a diastasis. In one study, ness and activity-related pain were persistent.106 Patients
CT was able to detect 2- and 3-mm diastases that were with latent diastasis can be treated conservatively once a
not otherwise apparent on routine radiographs.104 congruent distal tibiofibular joint is confirmed after
MRI allows an accurate picture of ligamentous anat- reduction. After confirmation of the anatomical reduc-
omy and the distal tibiofibular joint. MRI has become tion by CT or MRI, the patient is immobilized in a
the preferred diagnostic study when syndesmosis injury non-weight-bearing cast or cast boot. Weight-bearing
is suspected in professional and collegiate athletes in radiographs should be done at 2 to 3 weeks postinjury
the United States. The criteria for making an MRI diag- to confirm anatomic reduction. Gradual weight bearing
nosis of a syndesmosis injury are (1) ligament can be allowed at 4 weeks, with full weight bearing by
288
...........
Syndesmosis injury
Figure 13-18 Magnetic resonance image of syndesmosis injury with tear of anterior inferior tibiofibular
ligament, interosseous ligament, and avulsion of posterior inferior tibiofibular ligament. (A) Axial section. (B)
Coronal section.
8 weeks postinjury. In some situations, such as the elite through small percutaneous incisions to reduce
athlete, latent diastases may do better with surgical treat- the diastasis. Be certain to correct the malrotation
ment. On the other hand, frank diastasis always requires during the reduction (usually by internal rotation
surgical management, unless there are overriding medical pressure).
contraindications. Any lateral displacement of the mor- 6. If this reduction is confirmed to be anatomic by
tise and fibula requires internal fixation. fluoroscopic imaging, then the AITFL is repaired.
My preferred technique for acute syndesmosis injuries 7. If reduction is difficult or impossible, a medial
with diastasis and without fracture is as follows:90 incision is made to confirm that there is no debris
1. Make a 4- to 6-cm anterolateral incision centered or infolded ligament blocking the reduction. The
over the ankle joint. deltoid ligament is repaired with sutures or by
2. Curve the incision slightly posterior at its distal using a suture anchor. The anatomic reduction is
arm, beginning at the level of the plafond, to confirmed before continuing with the syndesmo-
expose the AITFL insertion on the fibula. sis repair.
3. Expose and avoid the superficial peroneal nerve by 8. Fix the anatomically reduced fibula with a trans-
using blunt dissection through the subcutaneous syndesmotic screw.
layers. Be certain to warn the patient preopera- a. Direct the drill slightly anterior, starting at the
tively about the probability of at least temporary posterolateral fibula, 2 to 3 cm above the
numbness on the dorsal foot following the plafond.
operation. b. Four cortices are penetrated, and two 4.5-mm,
4. Identify the remnant of the AITFL. fully threaded cortical screws are placed. Plac-
5. A large bone-reduction forceps clamped to the ing the screws across a four-hole plate provides
medial malleolus and the fibula can be used some additional stability and protection to the
289
...........
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.........................................C H A P T E R 1 4
Osteochondral lesions of the talus and occult

fractures of the foot and ankle
Michael Bowman
......................
CHAPTER CONTENTS
Occult fractures of the hindfoot 293 Occult fractures of the talus 308
Talonavicular avulsion injuries 298 Osteochondral lesions of the talus 317
Cuboid fractures 303 References 336
Fractures of the anterolateral process of the calcaneus 305
OCCULT FRACTURES OF THE HINDFOOT surface is articular1,2 with the ankle joint superiorly,
the talonavicular joint anteriorly, and the subtalar joint
inferiorly. Blood supply to the talus therefore is lim-
Occult fractures of the hindfoot represent a common
ited,1,3 coming from its ligamentous attachments and a
source of prolonged pain and disability after athletic
leash of vessels surrounding the talar neck that receive
injuries. Increased knowledge about the existence and
contributions from the artery to the tarsal canal medi-
mechanisms of such injuries and a healthy suspicion
ally, the dorsalis pedis artery anteriorly, and the artery
about ‘‘soft-tissue injuries’’ that do not get better allow
to the sinus tarsi laterally (Fig. 14-3, A through C).
the health care provider to make a prompt diagnosis of
The internal vasculature of the talus varies considerably4
occult foot and ankle fractures. Through history, physical
(Fig. 14-4). External athletic injuries to the talus that
examination, and proper use of diagnostic tests one can
involve disruption of the vascular leash or the ligamen-
confirm the diagnosis and select the proper treatment.
tous attachments often produce vascular insult to the
talar body or talar neck and may produce talar fractures
Pertinent anatomy or compression injuries that heal slowly or do not heal.
With 28 bones, multiple joints, and connecting liga- The lateral process of the talus is a wide, triangular-
ments, the foot and ankle are vulnerable to compression shaped process that slopes down to meet the lateral
and avulsion injuries with many complex movements calcaneus (see Fig. 14-5, A). On the lateral view it is
during competitive sports. The bones comprising the wedge-shaped and articulates superiorly with the fibular
hindfoot are the tibia, fibula, talus, calcaneus, navicular, surface and inferiorly with the calcaneus (see Fig. 14-5, A).
and cuboid. The talus is especially prone to injury The lateral talocalcaneal ligament attaches to the lateral
because it is involved in both dorsiflexion/plantarflexion process (Fig. 14-5, B).
and inversion/eversion motions. The talus is connected The posterior process of the talus originates from the
at the ankle joint to the tibia medially through the del- convex-curved posterior half of the talar dome and
toid ligament (Fig. 14-1, A) and to the fibula laterally slopes down and back to form the posterior talar
through the anterior talofibular ligament and posterior ‘‘beak.’’ Inferiorly, it is concave and articulates with
talofibular ligament (Fig. 14-1, B). The talus is con- the posterior subtalar facet of the calcaneus. The posterior
nected to the calcaneus by the talocalcaneal interosseous process has both a posteromedial tubercle and postero-
ligament and the cervical ligament (Fig. 14-2, A). The- lateral tubercle. In between lies the flexor hallucis longus,
dorsal (see Fig. 14-2, A) and plantar (Fig. 14-2, B) talona- which is commonly involved in posterior talar injuries
vicular ligaments connect the talus and navicular. (Fig. 14-6). This posterior process is widely variable in
The talus is unique in that it has no direct muscular shape, from a short, rounded end to a long ‘‘beak’’ that
attachments. Approximately 60% to 70% of the talar is prone to injury.
CHAPTER 14 Osteochondral lesions of the talus and occult fractures of the foot and ankle
Fibula
Deltoid ligament
Post. talofibular Ant. talofibular
ligament ligament
Talus
Calcaneus
Calcaneofibular
A B ligament
Figure 14-1 Hindfoot anatomy of the ankle. Note the (A) medial attachment of the talus the tibia with the deltoid
and (B) laterally to the fibula with the anterior and posterior talofibular ligaments.
Cuboid
Navicular
Dorsal
talonavicular Plantar
ligament calcaneonavicular
“spring”
Interosseous Talus ligament Plantar
talocalcaneal
talonavicular
ligament
ligament
Calcaneus
Calcaneus
Cervical
ligament
A B
Figure 14-2 Hindfoot anatomy of the subtalar joint. Note the attachment of the talus to the calcaneus via
the (A) talocalcaneal and cervical ligaments and the talus to the navicular via the (A) dorsal and (B) plantar
talonavicular ligaments.
The posterolateral tubercle (Stieda’s process) is larger posterior talofibular ligament attaches the fibula to the pos-
than the posteromedial tubercle. In approximately 7% to terolateral tubercle or the os trigonum (see Fig. 14-7, B).
10% of humans a separate os trigonum may exist— The posterior deltoid or posterior talotibial ligament
connected to the posterolateral tubercle by a fibrous car- attaches the posterior tibia to the posteromedial tubercle
tilaginous synchondrosis (Fig. 14-7, A and B). The of the talus. The Y-shaped transverse or bifurcate ligament
294
...........
Occult fractures of the hindfoot
Dorsalis pedis artery

Artery to the sinus tarsi branches
Dorsalis pedis
artery
Peroneal
artery
Artery to the
tarsal canal
Artery to the sinus tarsi Artery to the tarsal canal

branches
Post. tibial Figure 14-4 Internal vasculature anatomy of the talus.

artery
A
Dorsalis pedis
artery
Lateral talar
Peroneal process
Artery to the artery
sinus tarsi
A
B
Dorsalis pedis Ant. talofibular

artery ligament
Post. tibial Calcaneofibular

artery ligment
Peroneal
artery
Talocalcaneal
ligament
Artery to the
C sinus tarsi
Figure 14-3 Vasculature supply anatomy for the talus. Note B

contributions from the (A-C) dorsal pedis artery, (A-C)
Figure 14-5 Anatomy of the talus. Note the (A) predominance
peroneal (artery to the sinus tarsi), (A) artery to the tarsal
of articular surface and (B) laterally the attachment of the
canal, and (A and C) posterior tibial artery.
talocalcaneal ligament to the lateral process.
295
...........
FHL
Post. inferior
tibiofibular
ligament
Transverse
ligament
Posterolateral Posteromedial
tubercle tubercle
Post. deltoid
ligament
Post. talofibular
ligament
Posteromedial
tubercle
Posterolateral
tubercle
FHL
Figure 14-6 Posterior anatomy of the talus. Note the (A) posterior process of the talus, the (B) flexor hallucis
longus between the two tubercles of the posterior talus, and (C) the posterior ligamentous anatomy.
Synchondrosis
Flexor
hallucis
longus
Os trigonum Os trigonum
B
A
Figure 14-7 (A) Lateral view. Anatomy of the os trigonum. Note that the os trigonum is the posterior process that is
attached to the talus via a synchondrosis and (B) is attached to the posterior talofibular ligament (axial view).
296
...........
Occult fractures of the hindfoot
Fibula
Talus
Calcaneofibular
ligament
Interosseous
Calcaneus talocalcaneal Cervical
ligament ligament
Figure 14-8 A meniscus-like ‘‘marsupial meniscus’’ often noted

in the posterior ankle superior to the posterior process of the
talus. Figure 14-9 Calcaneal ligaments. Note laterally the calcaneo-
fibular, cervical, and lateral talocalcaneal ligaments.
is a thickening in the posterior ankle capsule that holds the

two tubercles together and restrains the flexor hallucis The saddle-shaped cuboid articulates with the ante-
longus. A meniscus-like ‘‘marsupial meniscus’’ also often rior process of the calcaneus and may be involved in
exists in the posterior ankle superior to the posterior pro- either compression or avulsion tension-type injuries.
cess of the talus (Fig. 14-8). The tarsal navicular is a ‘‘C’’ or saucer-shaped bone
The calcaneus is a complex, bony structure providing articulating with the talus posteriorly and the cuboid lat-
attachment for the Achilles posteriorly and the plantar erally. The dorsal talonavicular ligament and capsule
fascia and plantar intrinsic muscles of the foot inferiorly. may produce avulsion injuries of the navicular from
It articulates with the talus superiorly, as well as with the plantarflexion-type injuries. Compression-type injuries
cuboid and navicular anteriorly. The anterolateral pro- also may be produced by the impact of the talar head
cess of the calcaneus extends forward to form the calca- on the navicular. The blood supply to the midportion
neocuboid joint. The saddle-shaped anterior surface of the navicular is poor (Fig. 14-11) and may contribute
articulates with the cuboid anteriorly, and the superior to delayed healing or nonunion of such fractures. The
tip articulates to a varying degree with the lateral navic- articulation between the cuboid and the navicular varies
ular. The extensor digitorum brevis also originates from from a true articulating joint to a fibrous connection to
this calcaneal process. a bony bridge (tarsal coalition).
The blood supply to the calcaneus is quite robust, Various important and powerful tendons attach to
and fractures of the calcaneus tend to heal more easily. the hindfoot; these produce considerable forces during
The ligamentous attachments at the calcaneus are the athletic activities and can create injuries. The posterior
talocalcaneal interosseous ligament, lateral talocalcaneal tibial tendon attaches to the navicular (Fig. 14-12, A
ligament and cervical ligament to the talus and the calca- and B), producing inversion/supination and adduction
neofibular ligament laterally (Fig. 14-9). The posterior, while elevating the arch. It fires twice during each gait
lateral, and anterior calcaneocuboid ligaments and the cycle or step—both eccentrically as a shock absorber
plantar calcaneonavicular (spring ligament) and lateral and concentrically during push-off. The anterior tibial
calcaneonavicular ligaments connect the calcaneus ante- tendon, with attachments to the cuneiform and first
riorly to the cuboid and navicular, respectively. metatarsal, is the primary dorsiflexor for the ankle and
The strong plantar calcaneonavicular or ‘‘spring’’ also inverts the foot. It also fires eccentrically during heel
ligaments acts as a ‘‘sling’’ to hold the talar head strike to decelerate and cushion the landing foot. The per-
in place. The bifurcate ligament (Y-ligament) is com- oneus brevis and longus tendons (Fig. 14-13) both evert
posed of the anterior and lateral calcaneocuboid ligament the foot and ankle and resist inversion injuries. The pero-
(Fig. 14-10, A and B) and is commonly injured during neus brevis attaches to the base of the fifth metatarsal.
‘‘sprain-type’’ inversion injuries, producing an avulsion The peroneus longus wraps around the cuboid at the
fracture at the anterolateral process of the calcaneus. trochlea to insert broadly underneath the foot near the
Inversion/adduction injuries of the midfoot also may base of the first metatarsal, which allows the longus also
produce avulsion fractures at the base of the cuboid. to help plantarflex and stabilize the medial foot.
297
...........
Anterior
Fibula
Lateral
Talus calcaneonavicular
ligament
Medial
Lateral
Navicular
Bifurcate Anterior
Calcaneus ligament calcaneocuboid
ligament
Posterior
Cuboid
Long calcaneocuboid lig. Lateral Figure 14-11 Vasculature anatomy of the tarsal navicular.
calcaneocuboid Note the central area of decreased blood supply
Deep calcaneocuboid
ligament
A ligament corresponding to areas of navicular stress fractures.
Calcaneus common than thought, because many occur and are

not treated immediately. They are seen in practices
such as mine years later, asymptomatic with x-ray find-
Talus ings on films taken for an unrelated injury. Many of
these minor fractures heal untreated by either painless
Long
CC bony or fibrous nonunion. However, a painful non-
ligament union also may occur. Bony union of the fracture can
result in the athlete’s having pain from a bony promi-
Deep nence over the joint (Fig. 14-15) or painful arthritis
CC of the talonavicular joint.
ligament
Lateral An avulsion fracture from the medial or proximal end
Spring CC of the tarsal navicular at the distal insertion of the poste-
ligament ligament
rior tibial tendon is less common in athletics. This injury
occurs in running sports in which a sudden change of
direction is common. The athlete plants the foot,
decelerates, and twists a plantarflexed foot to reacceler-
ate and push off. The force of the posterior tibial tendon
Navicular on the navicular may produce an avulsion at its inser-
Cuboid tion. In cases in which the athlete has a congenital acces-
sory navicular, the injury may occur through the
cartilaginous synchondrosis between the main and
‘‘extra’’ (or accessory) bone (Fig. 14-16).
B
Figure 14-10 Lateral plantar transverse tarsal ligaments. Diagnosis
With dorsal navicular avulsion fractures, the athlete
complains of anterior ‘‘ankle’’ pain after a sprain-type
TALONAVICULAR AVULSION INJURIES injury. In acute cases, ecchymosis may exist over the
anterior ankle. Point tenderness will be noted over the
dorsum of the navicular (Fig. 14-17) or the talar head.
Incidence and mechanism Inversion or eversion may produce pain and plantarflex-
Avulsion fractures involving the tarsal navicular or talar ion of the foot. In chronic cases, a firm, bony ‘‘lump’’
head are not unusual after a plantarflexion injury of (tender or nontender) will be noted over the dorsal
the ankle (Fig. 14-14). The dorsal talonavicular cap- navicular or talar head.
sule or ligament pulls off a small fragment with In medial navicular avulsion injuries, the athlete will
this injury (see Fig. 14-14). This injury is more have ecchymosis, swelling, and tenderness over the
298
...........
Talonavicular avulsion injuries
Posterior tibial
Tibia tendon
Fibula
Peroneus
Talus Talus brevis
Navicular tendon
Navicular
Calcaneus
Calcaneus Cuboid
5th met.
A Peroneus
longus
tendon
Figure 14-13 Anatomy lateral ankle depicting peroneus

longus and brevis tendons.
Imaging
X-rays usually will show a wafer-like avulsion fracture on
Long the dorsum of the navicular or talar head (Fig. 14-18).
Peroneus
Post. plantar longus In chronic cases, x-ray may show a rounded-off non-
tibial ligament tendon union of the fragment or a healed, bony, beak-like pro-
tendon
jection, often with some arthritic changes in the dorsal
talonavicular joint (Fig. 14-19). More involved navicular
Peroneus
brevis body fractures also occur in the athlete but are not com-
tendon mon. These larger body fractures require a computed
tomography (CT) scan with axial and lateral views
(Figs. 14-20 and 14-21) to assess joint alignment and
fracture orientation for surgical decision making. A CT
scan also is helpful in chronic cases for assessment of
joint irregularities and arthritis and to rule out a navicu-
lar stress fracture. In medial navicular avulsion fractures,
x-rays will show calcified flecks or fragments on the
medial navicular (Fig. 14-22). Additional supination
oblique views (Fig. 14-23) sometimes are helpful, espe-
cially when an accessory navicular is present. Widening
of the synchondrosis may or may not be seen.
B Treatment
Figure 14-12 Posterior tibial tendon anatomy. Note For acute, minimally displaced (less than 1 mm) frac-
the attachment to the medial navicular, medial cuneiform, and tures, boot immobilization for 6 to 8 weeks usually will
lateral cuneiform that produces inversion, supination, and result in healing, either a bony union or a painless,
adduction. fibrous nonunion. The unusual large fragment (greater
than 5 mm) fracture may require internal fixation if dis-
placed. The athlete is protected in a boot postopera-
tively, and nonweight bearing for approximately 6 weeks
medial and plantar navicular. Posterior tibial tendon until the fracture is healed.
function usually is still intact but may be painful against When a painful nonunion develops, an injection of
resistance to plantarflexion and inversion. corticosteroid sometimes will relieve the symptoms.
299
...........
Figure 14-16 Anterior-posterior radiograph of athlete’s foot

depicting painful medial accessory navicular attached by
synchondrosis.
Figure 14-14 Fracture of navicular caused by plantarflexion of

foot and ankle with avulsion of dorsal fragment.
Figure 14-17 Clinical examination of athlete’s foot depicting

Figure 14-15 Nonunion of dorsal navicular avulsion fracture. area of pain noted on foot with dorsal avulsion fracture of
This can cause a dorsal prominence and pain in the athlete. navicular.
300
...........
Talonavicular avulsion injuries
Figure 14-18 Radiographic findings of dorsal, wafer-like Figure 14-20 Computed tomography (coronal view)
fracture with acute injury. demonstrating more involved navicular body fracture with
comminution.
Figure 14-19 Radiographic findings of chronic, dorsal, Figure 14-21 Computed tomography (axial view)
navicular nonunion. Note rounded edges and smooth contour demonstrating navicular body fracture with displacement.
in distinction from acute fracture in Fig 14-18.
Alternative shoe lacing (Fig. 14-24), or a donut-type also may be helpful. If nonsurgical care is unsuccessful,
pad may reduce pressure in the area. If conservative the prominent and arthritic portion of the talus or navic-
treatment fails, the usual surgical treatment is excision ular may be resected in a V-shaped fashion (Fig. 14-25),
of the fragment through a small dorsal longitudinal leaving healthy joint behind. In severe cases of posttrau-
incision. Postoperatively the patient is nonweight bear- matic talonavicular arthritis, fusion may be needed.
ing in a boot for approximately 2 weeks, followed by Treatment of acute medial navicular fractures usually is
progressive weight bearing and active range of motion conservative. Protection in a nonweight-bearing boot for
(AROM). 6 weeks until nontender followed by appropriate therapy
In chronic cases in which a bony union has resulted for the posterior tibial tendon, usually will produce good
in a painful bony prominence or dorsal talonavicular results. The avulsion fragments may or may not demon-
joint arthritis, conservative treatment is nonsteroidal strate bony union on follow-up x-rays in successful cases.
anti-inflammatory drugs (NSAIDs), alternative shoe The rare large displaced fragment may require open reduc-
lacing or a donut-type pad dorsally, and molded foot tion internal fixation (ORIF) (Fig. 14-26, A and B). The
orthoses with good arch support. A cortisone injection conservative treatment may be tried for nondisplaced
301
...........
Painful
area
Figure 14-22 Anterior-posterior radiograph of foot

demonstrating comminute medial navicular avulsion fracture.
Figure 14-24 Lacing pattern on athlete’s shoe to decrease

pressure on a painful dorsal prominence of the foot such as
a dorsal navicular avulsion nonunion.
Figure 14-25 V-shaped excision of dorsal prominence and

portion of joint that has become arthritic.
by protection in a nonweight-bearing boot for 6 weeks,

may be needed.
Rehabilitation and return to sports

Postoperative care of the previously described injuries
involve nonweight-bearing protection in a boot until
Figure 14-23 Supination oblique (10 to 15 degrees of the fracture and associated ligament/tendon injury are
supination) demonstrating clear view of accessory navicular. This healed (usually 6 weeks), followed by an ankle rehabilita-
view also can give a clearer view of a navicular stress fracture. tion program working on edema control, range of motion
(ROM), proprioception, and progressive resisted exercises
(PREs) (especially the posterior tibial tendon). Running is
accessory navicular injuries but in my experience is less added first and jumping activities are added next, followed
successful. Excision of the accessory navicular and by sports-specific exercises. The athlete may return to
repair of the posterior tibial tendon to the navicular practice/play on successful completion of the program
with bony anchors (Fig. 14-27, A through G, followed (6 to 10 weeks postinjury).
302
...........
Cuboid fractures
Figure 14-26 Fixation of large accessory navicular with two screws. (A) Anterior-posterior and (B) lateral
radiographs depicting placement of screws.
will show swelling and possible ecchymosis of the lateral

CUBOID FRACTURES
foot, just proximal to the insertion of the peroneus brevis.
There will be tenderness to palpation over the cuboid and
Incidence and mechanism possible pain with manipulation of the calcaneocuboid joint.
Cuboid fractures are much more rare in an athletic foot
and ankle practice but tend to be overlooked and dis- Imaging
missed as a foot sprain. Two basic types are seen as ath- The small avulsion fractures may be seen with careful
letic injuries: (1) an avulsion injury, caused by an inspection of lateral or oblique x-rays (Fig. 14-28). Com-
inversion/adduction injury while landing (basketball, pression injuries of the cuboid often do not show on
volleyball, and so forth) or rapid direction change (soc- standard x-rays. Posthealing x-rays may show increased
cer, rugby, football) and (2) a compression injury, radiodensity (Fig. 14-29). A magnetic resonance imaging
caused by forced eversion while plantarflexed or dorsi- (MRI) (Fig. 14-30, A and B) or bone scan (Fig. 14-31)
flexed in a pileup (e.g., football, rugby). In the avulsion can be used to confirm the fracture. Healing then must
cuboid injury, the calcaneocuboid capsule and plantar be followed by either routine radiographs or CT.
C-C ligament are torn, producing a usually small avul-
sion fragment off the plantar posterior cuboid. In the Treatment
compression injury, the cuboid is crushed between the Usually conservative treatment is used to successfully
calcaneus and fifth metatarsal. treat both types of cuboid injuries. Avulsion-type
cuboid fractures are treated with a protective boot
Diagnosis and allowed weight bearing as tolerated (WBAT).
The athlete will complain of lateral foot pain, swelling, and Ice and edema control are started immediately. Run-
difficulty walking, especially during push-off. Examination ning and return to sports exercises are initiated
303
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Figure 14-27 Radiographs (A and B) of displaced accessory navicular requiring (C-F) excision of fragment, repair
of posterior tibial tendon to medial navicular, and
(continued on page 305)
304
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Fractures of the anterolateral process of the calcaneus
Figure 14-28 Oblique radiograph of foot demonstrating small

Figure 14-27 cont’d. (G) postoperative anterior-posterior fracture of cuboid.
radiograph noting excision of accessory bone.
when weight bearing is comfortable in a shoe. Usually

a painless, fibrous nonunion of the fragment will result.
In the rare case of a painful fragment, excision is per-
formed. Compression cuboid injuries also are treated
with edema control and WBAT in the boot. When
the athlete is pain free, walking in the boot, and non-
tender to palpation, weight bearing in the shoe and
progressive activities are allowed.
FRACTURES OF THE ANTEROLATERAL

PROCESS OF THE CALCANEUS
Incidence and mechanism

The anterolateral process fracture represents up to 23% Figure 14-29 Lateral radiograph of foot depicting increased
of all calcaneus fractures.5 Two mechanisms of injury density of cuboid indicating healing of prior occult cuboid
to the anterolateral process of the calcaneus have been fracture.
noted.6,7 An inversion injury to a plantarflexed foot
(much like the mechanism for a common ankle sprain)
will produce an avulsion fracture of the tip of the antero- The second mechanism of injury to the anterolateral
lateral process through tension on the bifurcate ligament process is an eversion abduction injury (Fig. 14-33) that
(Fig. 14-32). produces a compression-type horizontal fracture through
305
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Figure 14-31 Bone scan of athlete with occult cuboid fracture.

Note increased signal center over area of cuboid.
Figure 14-30 (A) Sagittal and (B) axial magnetic resonance

imaging (MRI) demonstrating increased bone edema with Figure 14-32 Diagram of right foot demonstrating supination
occult compression fracture of cuboid. and inversion of hindfoot causing avulsion of anterior process
of calcaneus with tension on bifurcate ligament.
the calcaneus.5,7 Degan et al.7 proposed the following

classification for fractures of the anterior lateral pro- Diagnosis
cess of the calcaneus: type I—nondisplaced tip avulsion, Athletes with a fracture of the anterolateral process
type 2—displaced avulsion fracture not involving the cal- will complain of lateral ankle and foot pain, increased
caneocuboid joint, and type 3—displaced larger frag- by weight-bearing activity, push-off, or a change in
ments involving the calcaneocuboid joint. direction. A history of an ‘‘inversion sprain’’ may be
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Fractures of the anterolateral process of the calcaneus
Figure 14-33 Diagram of right foot demonstrating

dorsiflexion and compression of calcaneocuboid joint with
fracture of anterior process of calcaneus.
Figure 14-35 Clinical photograph of right foot demonstrating

assessment of transverse tarsal instability by stressing the
hindfoot in (A) supination and (B) pronation.
by inversion stress through the subtalar joint (distracting

the fragment). There may be instability of the transverse
Figure 14-34 Clinical photograph of right foot demonstrating tarsal joint, which is tested by holding the heel stable
area of hindfoot that is tender with underlying anterior process with one hand and pronating and supinating the mid-
fracture of calcaneus. foot with the other hand (Fig. 14-35, A and B).
obtained. Often the diagnosis is delayed, and the athlete Imaging

will give a history of an ankle sprain treated by the nor- As stated previously, initial x-rays may be interpreted as
mal rest, ice, compression, and elevation (RICE) mech- negative if the fracture is nondisplaced. However, review
anism and physical therapy regimen that do not lead to of the old x-rays or new anterior-posterior (AP), lateral,
improvement. Initial x-rays may have been taken and and oblique x-rays of the foot may show a displaced frac-
interpreted as negative. ture through the tip of the anterolateral process of the
Examination will show point tenderness over the calcaneus (Fig. 14-36). Alternatively, a large, blunted,
bifurcate ligament and the anterolateral process of the irregular and indistinct process may be visualized
calcaneus (Fig. 14-34). Lateral ankle instability tests (Fig. 14-37). In cases in which point tenderness exists
(drawer test, talar tilt test, and flexion rotation drawer over the anterolateral process but x-rays are not conclusive,
test) often are negative. Often pain may be produced a CT scan (Fig. 14-38, A through C) often will show the
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In cases of chronic nonunion of the anterolateral pro-

cess of the calcaneus, asymptomatic athletes are treated
with observation only. For large fragments greater
than 1 cm or involving a significant portion of the
articular surface, the fracture site is debrided and internal
fixation is applied. For smaller fragments, the fragment is
excised. The calcaneocuboid joint is inspected and deb-
rided if necessary. The bifurcate ligament may be repaired
back to the calcaneal process if any instability of the trans-
verse tarsal joint exists.
For cases of malunited fractures of the anterolateral
process of the calcaneus, arthritic changes in the supe-
rior portion of the calcaneocuboid joint and/or the
junction between the process of the calcaneus and navic-
ular may exist. In these cases, a trial injection of corti-
sone in the calcaneocuboid joint and calcaneonavicular
Figure 14-36 Lateral radiograph of hindfoot demonstrating space may provide relief or help to establish the diagno-
small anterior process fracture (arrows) of calcaneus. sis of arthritic changes. A CT scan or MRI with magni-
fied views will help to provide information about the
joints. Surgical treatment involves open resection of a
portion of the anterolateral process of the calcaneus,
trimming it back to a point at which a healthy calcaneo-
cuboid joint is present. Recently, arthroscopic resection
through a subtalar approach has been described.8

In cases in which excision is required, boot immobiliza-
tion and nonweight bearing are used for 2 weeks, fol-
lowed by gentle AROM of the foot and protected
weight bearing in the boot for an additional 4 weeks.
General ankle rehabilitation then is begun, followed by
sports-specific exercises.
Athletes with anterolateral process fractures treated
by ORIF or excision and ligament repair are placed in
a non-weight-bearing boot for 6 weeks until healed.
Figure 14-37 Lateral radiograph of hindfoot demonstrating General ankle rehabilitation followed by sports-specific
healed fracture of anterior lateral process (ALP) of calcaneus.
exercises then is started. Return to sports usually is
within 8 to 12 weeks.
fracture and help in assessing the amount of healing. The
CT also is helpful in surgical planning (ORIF vs. excision).
A bone scan is used as a screening tool to distinguish this
injury from other soft-tissue types of lateral ankle injuries. OCCULT FRACTURES OF THE TALUS
Treatment Occult fractures of the talus fall into several categories:

For acute, nondisplaced fractures (less than 8 weeks) posterior process fractures, lateral process fractures, glo-
and small fractures less than 2 mm, cast or boot immo- bal compression injuries of the talus (GCTs), and osteo-
bilization and nonweight bearing for approximately 6 chondral lesions of the talus (OLTs).
weeks is used until the fracture is healed. For acute or
semiacute fractures that are displaced (more than 5 mm Posterior talus fractures/posterior
in diameter), either excision or open reduction internal
fixation is suggested. If any instability of the transverse
.............................................................
impingement syndrome (see also Chapter 2)
tarsal joint exists on testing, the bifurcate ligament may

be repaired back to the remaining process of the calca- Incidence and mechanism
neus with a suture anchor or with internal fixation of As noted previously, athletes with a long, slender, posterior
the fragment. talar ‘‘beak’’ may be more prone to posterior talar injuries.
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Occult fractures of the talus
Figure 14-38 (A) Sagittal reconstruction, (B) coronal, and

(C) axial computed tomography view of occult anterior process
fracture (arrows) of calcaneus. Plain radiographs did not reveal
fracture but athlete had tenderness over anterior process.
Two major athletic mechanisms exist that produce poste- applied to the back of a dorsiflexed ankle at the bottom of a
rior process fractures.6,9,10 A forced ankle dorsiflexion scrum or pileup (Fig. 14-40) may produce an avulsion
and pronation injury such as forced planting of the foot fracture of the posteromedial tubercle by traction on the pos-
backward with force applied (Fig. 14-39, A) or weight terior deltoid ligament (see Fig. 14-39, B).6,11-13 A similar
309
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Post.
deltoid
ligament
Posteromedial
tubercle
of the talus
B
Figure 14-39 (A) Lateral view of posterior talus process fracture caused by forced dorsiflexion of the
ankle against a planted foot. (B) Posterior view, showing avulsion forces produced by the posterior
deltoid ligament on the posterior medial tubercle of the talus.
310
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Tibia
Talus
Figure 14-40 Posterior talus process fracture caused by force on the back of the ankle, causing avulsion of the
posterior talar process through tension on the posterior deltoid ligament.
Figure 14-41 Common mechanism for posterior process fracture with compression of posterior process between
calcaneus and posterior tibia in severe plantarflexion of ankle.
forced dorsiflexion/inversion injury also may produce injury posterior ankle pain, or pain with push-off, jumping,
to the posterolateral tubercle or os trigonum by traction on and landing.
the posterior talofibular ligament.2,9,13
Another and more common mechanism for pro- Diagnosis
ducing posterior talar process fractures/os trigonum The diagnosis of posterior process fracture often is
injuries is forceful plantarflexion.13-15 Repetitive plantar- delayed. In one study, five to eight physician visits were
flexion and push-off activities (ballet, running, soccer), necessary until the diagnosis was made.18 The posterior
jumping and landing activities (gymnastics, basketball, ‘‘ankle sprain’’ that does not get better should alert
volleyball, football), or twisting the ankle in a plan- the physician to the possible presence of this fracture.
tarflexion/inversion ‘‘sprain’’ position16,17 force the The athlete often will give a history of posterior ankle
long talar beak/os trigonum against the posterior tibia pain worse with planting the foot back (tennis, football,
and produce a fracture (Fig. 14-41). Injuries to the racquetball), jumping and landing (basketball, volleyball),
posterior talus may result in chronic posterior im- kicking (swimming), or tiptoe position (ballet). They may
pingement syndrome,6,9 in which athletes complain of give a history of an ankle sprain or ‘‘Achilles pain.’’
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Examination toe, producing stretch on the flexor hallucis longus, also

Ankle ROM may be normal or painful posteriorly with may produce posterior ankle pain. Acutely, there also
limits at both dorsiflexion (traction) and plantar fraction may be ecchymosis in the posterolateral or posterome-
(compression). Passive subtalar joint motion, producing dial ankle region.
inversion and eversion with the ankle slightly plantar-
flexed, also may produce posterior ankle pain because Imaging
the subtalar joint also may be affected. The ‘‘pinch test’’ AP, lateral, and oblique x-rays may be negative if the frac-
posteromedially or posterolaterally just posterior to the ture is nondisplaced or at a slight angle (Fig. 14-44, A).
ankle (Fig. 14-42) will produce pain. The posterior An os trigonum may appear normal. Repeat x-rays
impingement test (Fig. 14-43, A and B) will produce (especially lateral views) later may show the fracture
pain and possibly clicking. Manipulation of the great (Fig. 14-44, B). A CT scan or MRI (Fig. 14-44, C) can
be the standard for establishing the diagnosis, showing
presence of the fracture, location, and size.19 An MRI also
will show compression injuries of the posterior talus
(Fig. 14-45) that did not exhibit a discreet fracture line,
as well as surrounding edema. A bone scan (Fig. 14-46) is
useful to confirm a symptomatic os trigonum injury.19-21
An injection of cortisone into the os trigonum synchon-
drosis may provide temporary relief and help with the
diagnosis.
Treatment
For acute nondisplaced fractures/os trigonum injury,
immobilization in a boot/cast and limited weight bear-
ing may lead to healing in 4 to 6 weeks. A repeat CT
scan may be needed in subtle fractures to demonstrate
healing.
For large displaced fractures (especially ones that extend
Figure 14-42 Clinical demonstration of ‘‘pinch test.’’ into the weight-bearing talar body region), internal
Compression of posterior process fracture of talus fixation through a posterolateral or posteromedial
(os trigonum) in athlete just behind ankle from medial and approach with cannulated 4.5 screws or headless screws is
lateral sides cause pain. indicated.22-25 The flexor hallucis longus and medial
Figure 14-43 Clinical demonstration of ‘‘posterior compression test.’’ Forced maximal plantarflexion (A and B)
of ankle produces pain in athlete with posterior process fracture (os trigonum).
312
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Figure 14-44 Lateral radiograph and magnetic resonance

imaging (MRI) ankle demonstrating os trigonum. Lateral x-ray
shows (A) intact posterior process but repeat lateral
radiograph demonstrated os trigonum with mild displacement.
MRI clearly demonstrates the os trigonum as a separate
fragment and area of chronic fracture.
Figure 14-45 Sagittal magnetic resonance imaging of talus

demonstrating occult fracture of posterior facet, which
causes posterior ankle pain in athlete and can be similar in Figure 14-46 Lateral bone scan image of ankle
presentation to posterior ankle impingement. Note edema in demonstrating increased uptake in posterior ankle consistent
posterior talus and fluid posterior ankle. with posterior ankle impingement and painful os trigonum.
313
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neurovascular bundle must be protected with this nonweight bearing for 6 weeks with early AROM out of
approach. The head of the screws should be countersunk. the boot to prevent stiffness. When the fracture is healed,
For smaller fractures/symptomatic os trigonum that progressive weight bearing and ankle rehabilitation is
do not heal or chronic fracture cases, excision of the begun, followed by sports-specific exercises. ROM and
posterior tubercle (Fig. 14-47, A through D) and strengthening of the flexor hallucis longus (FHL) is
debridement of the adjacent ankle and subtalar joint is emphasized.
the method of treatment.16,17 Although Marumoto After excision of the fracture fragment or os trigonum,
and Ferkel26 and others5,27 have advocated arthroscopic the athlete is protected nonweight bearing in a boot for
resection of the os trigonum, most surgeons still prefer 2 weeks with gentle AROM of the ankle and subtalar
resection through a small posteromedial9,28 or postero- joint allowed out of the boot. At 2 weeks, progressive
lateral16 approach for medial process/lateral process WBAT in the boot is allowed, and the athlete is weaned
fractures, respectively. back into a shoe as tolerated. At 4 to 6 weeks postopera-
tively (depending on comfort), general ankle rehabilita-
Rehabilitation and return to sports tion is permitted, followed by sports-specific exercises.
Postoperatively, in cases in which internal fixation is Athletes may return to sports on successful rehab
required, the athlete is placed in a protective boot, completion, ranging from 4 to 8 weeks postinjury.
Figure 14-47 Symptomatic os trigonum. (A) Lateral radiograph and (B) sagittal magnetic resonance imaging
confirm os trigonum. (C) Clinical appearance of os trigonum removed through lateral incision and (D) lateral
radiograph demonstrating excision.
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and pain may be produced with dorsiflexion and plantar-

.............................................................
Lateral process fractures of the talus
flexion and/or inversion.
Incidence and mechanism X-rays

An AP, lateral, and oblique ankle x-rays may show an
Lateral process fractures of the talus are another com-
avulsion-type fragment laterally (Fig. 14-49, A) or be
monly missed hindfoot injury in athletes. They represent
negative if the fracture is nondisplaced (Fig. 14-49, B
the second-most common talar body fracture (almost
and C). The mortise view is felt to be best to visualize
25%).2,13 It is estimated that they are present in 0.86% of
these fractures.32 A CT scan is the gold standard for
all lateral ankle sprains.28 Although more commonly seen
identification of lateral talar process fractures, aiding in
in motor vehicle accidents and high-energy traumatic inju-
sizing and surgical planning (Fig. 14-50). MRIs also
ries to the ankle, athletically produced lateral process frac-
may show associated talar cartilage and/or bony inju-
tures of the talus have increased to an estimated 2000 per
ries.33 A bone scan may be useful as a screening tool in
year in the U.S.29 because of the recent popularity of
cases of chronic lateral pain in which the fracture was
snowboarding. They account for 2.5% of all snowboarding
undetected.
injuries.30 In ‘‘snow boarder’s ankle,’’ dorsiflexion and
inversion applied to the ankle and talus are the most Classification
accepted mechanism for production of athletic lateral pro-
Two commonly used classifications for lateral talus pro-
cess fractures of the talus.13,28,29,31,32 However, experi-
cess fracture exist: the Hawkins classification13: type1—
mental studies suggest that external rotation applied to a
simple two-part fracture, type 2—comminuted fracture,
dorsiflexed inverted foot (Fig. 14-48) may produce a force
and type 3—avulsion fracture of the anterior inferior
to the lateral process and result in a fracture.6,32 Both the
process and the Funk classification29 (Fig. 14-51): type
body and the snowboard act as a lever arm on the ankle
A—small, minimally displaced, extra-articular avulsion
and talus. The leading leg is injured twice as often.29,30
fracture, type B—a medium-sized fracture involving
Diagnosis only the talocalcaneal joint surface, and type C—a larger
The athlete may give a history of a twisting injury to the fracture involving both the talocalcaneal and talofibular
ankle and complain of lateral ankle pain increased with joint articulations.
weight bearing.
Treatment
Examination For acute, nondisplaced lateral process fractures, immo-
Athletes may exhibit ecchymosis on the lateral ankle. bilization in a boot and nonweight bearing for 4 to 6
Tenderness is present inferior to the lateral malleolus, weeks is indicated. Repeat CT scan may be necessary
Lateral
talar
process
Figure 14-48 Diagram noting mechanism for lateral process fractures of talus. Forced external rotation with the
ankle in dorsiflexion and inversion results in a lateral process fracture.
315
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Figure 14-49 (A) Anterior-posterior (AP) radiograph of ankle

demonstrating lateral process fracture of talus (arrows)
noted just inferior to the tip of fibula. (B) Lateral and AP
radiographs of athlete with lateral process fracture not able to
be visualized on x-rays.
to document healing. For small, displaced fractures (less of the calcaneofibular ligament for exposure is indicated.
than 5 mm) conservative treatment with boot or cast Postoperative, nonweight-bearing boot immobilization
immobilization and nonweight bearing also is indicated. is used, with immediate, gentle AROM until healing is
Early excision of displaced small fragments and progres- accomplished.
sive weight bearing also has been proposed.30 For larger For chronic cases (previously undetected) or cases of
displaced fractures (>1 cm) and/or with joint surface nonunion after immobilization, treatment of large frag-
irregularity greater than 2 mm, open reduction internal ments (greater than 1 cm) or fragments involving the artic-
fixation5,6,13,19,28,30 with headless or countersunk ular surfaces require debridement and/or internal fixation.
screws through a subfibular approach with sectioning Small fragments (less than 1 cm) may be excised.13
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Osteochondral lesions of the talus
Figure 14-50 Axial computed tomography scan of talus demonstrating lateral process fracture that was not
identified on ankle radiographs in athlete.

Dorsal
Postinjury, athletes are treated in a nonweight-bearing
boot until the fracture is healed. In most cases a repeat
Posterior Posterior CT scan is needed to assess healing. Athletes with intra-
articular lateral talus fractures requiring internal fixation
are allowed to start gentle AROM exercises of the ankle
and subtalar joints during this healing and nonweight-
bearing phase to maintain joint mobility. When all frac-
tures are healed, progressive weight bearing and ankle
Type A rehabilitation are begun, followed by sports-specific exer-
cises and return to sports. In cases involving the subtalar
joint, this may be up to 3 months.
Type B Type C
OSTEOCHONDRAL LESIONS OF THE TALUS
Figure 14-51 Funk classification for lateral process fracture
talus. Type A involves only a small avulsion fragment, type B
involves only the talocalcaneal joint, and type C involves both Intra-articular ankle injuries to the talar body are a com-
the talocalcaneal and talofibular articulations. mon source of athletic disability. Cartilage injuries to the
317
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talus may be partial thickness or full thickness, or may by such an injury may lead to cystic changes in the sub-
involve bone (OLTs). chondral bone when joint fluid is forced repetitively into
the defect under pressure. Chronic lateral ankle instability
Mechanism after an ankle sprain also may produce repetitive forces on
Historically, various origins for OLT have been pre- the talus resulting in an OLT.1,16
sented. König34 coined the term ‘‘osteochondritis desic- GCTs represent a small minority of athletic injury to
cans’’ to describe loose osteochondral fragments in the the talus. Usually the results of massive trauma, they
knee, and the theory of spontaneous necrosis for these can cause significant ankle pain and synovitis and inabil-
lesions in the knee and ankle was postulated. Various the- ity to bear weight, and their diagnosis may be delayed
ories concerning vascular insult to the talus have been because of lack of initial findings on routine radiographs
described.2,27,34-36 The body of the talus has a generally (Fig. 14-53, A and B). An MRI best defines the lesion,
poor blood supply because of its large articular surface, with significant signal changes indicating edema and bony
as noted earlier. There also is considerable variation in injury in the talar neck and/or body (Fig. 14-53, C and D).
the intra-articular blood supply of the talar body. Embolic Because of the poor blood supply of the of the talar body,
phenomena, sickle cell anemia, and corticosteroid use these lesions are slow to heal, if they heal at all. Literature
have been noted as causes for bony infarcts in the talar reports of the natural history and my anecdotal experience
body.1,36 Inflammatory conditions such as rheumatoid show that talar collapse, chondrolysis, and gross ankle
arthritis, systemic lupus erythematosus, psoriatic arthritis, arthritis may be the result of such injuries.
and ankylosing spondylitis, as well as genetic predisposi-
tion, parathyroid disease, and osteoarthritis have been Incidence
associated with OLTs.1,36 However, these cases of Ankle sprains occur at the rate of approximately
nontraumatic talar body osteochondral lesions generally 27,000,000 per year. OLTs have been estimated to
are more diffusely involved than the discrete OLT seen occur in approximately 6.5% of these injuries.16,41-43
with sports injuries that we will discuss in this chapter. Thirty-eight percent of supination and external rota-
The more well-defined and distinct OLTs seen in the tion-4 type ankle injures are felt to produce an OLT.16
athletic population usually result from an acute traumatic Sixteen percent to 23% of cases treated surgically for
injury or chronic lateral ligament instability of the ankle. chronic instability of the ankle are found to have an
Most OLTs are located in the anterolateral (Fig. 14-52, OLT.13,16 Posteromedial lesions are more common than
C and D) or posteromedial corner (see Fig. 14-52, C anterolateral and tend to be deeper in thickness. The aver-
and D). Bruns and Behrens37 postulated that an inversion age patient is 25 to 35 years of age, male (70%),13,16 with
injury to a plantarflexed foot (Fig. 14-52, A and B), similar 10% to 25% incidence of bilaterality.16 OLT is most com-
to a common ankle sprain, would produce shear forces on monly seen in sports in which running, jumping, or change
the lateral talus and compression forces in the medial of direction are common, all factors that typically lead to
talus.13 The posteromedial lesions likely occur with more the production of ankle sprain injuries.
concomitant ankle plantarflexion, and anterolateral lesions
occur with more ankle dorsiflexion with inversion. Such
forces could produce a compressive injury to the subchon-
.............................................................
Diagnosis and evaluation
dral bone posteromedially and lead to shear forces with

avulsion on the lateral talus. Berndt and Harty35 experi- Diagnosis
mentally produced lateral OLTs with application of inver- The diagnosis of OLT often is delayed. In several studies
sion to a dorsiflexed foot while the tibia is internally and in my own practice, there often are 5 to 9 months
rotated. Medial OLTs were produced by applying inver- between the initial injury and the definitive diagno-
sion force to a plantarflexed foot with tibial external rota- sis.37,44,45 The diagnostic tools have improved, but a
tion. Yao and Weiss38 postulated that eversion of high index of suspicion on the part of the surgeon for
dorsiflexed ankles with the tibia internally rotated produces ‘‘ankle sprains that do not get better’’ is essential. The
lateral OLTs. history of an ‘‘ankle sprain’’ is common. The athlete
The overlying articular cartilage coverage still may be may give a history of continued anterior ankle pain and
intact or partially intact while producing an injury to the swelling despite initial radiographs that were read as
underlying bone. The subchondral fracture fragment has negative and appropriate conservative treatment for an
no direct blood supply. Left unrecognized, with con- ankle sprain. A history of ‘‘catching’’ or ‘‘locking’’ may
tinued weight bearing, the bony defect may not heal, suggest a loose osteochondral fragment.
leading to a fibrous nonunion or collapse, and result in Another common scenario is that of an ‘‘old ankle
a cartilage defect, loose osteochondral fragment, and cys- sprain’’ months or years before presentation in which
tic changes. Scranton and McDermott39 and Ferkel40 the initial symptoms seemed to improve and then recur
have postulated that an articular cartilage defect produced without addition injury. These cases most likely
318
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Medial
compression
Lateral
shear
B
Anterior
Lateral
Medial
Medial Lateral
C Posterior D
Figure 14-52 Osteochondral lesions of the talus. Mechanism is (A) inversion of the ankle causing a (B) shear
force on the lateral dome and compression force on medial talus. (C and D) Location of resultant lesions are
anterolateral and posteromedial in the talus.
represent progression of the disease process. A third pre- and tenderness in the anterior ankle or posteromedial
sentation is one in which an initial ankle sprain results ankle. There also may be swelling or an ankle effusion
in chronic lateral ankle instability, producing painful and synovitis. A drawer or talar tilt test (see Chapters
‘‘giving way’’ episodes and further talar injury. 12 and 13) may be positive. There may be crepitus or
‘‘catching’’ with ankle ROM when a displaced OLT
Examination exists.
Physical examination in acute OLT cases may closely In cases associated with chronic ankle instability, the
resemble that of an acute ankle sprain with ecchymosis anterior drawer test, talar tilt test, and/or flexion/rotation
319
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Figure 14-53 Global talar compression injury. Routine radiographs (A and B) fail to demonstrate talus injury.
Magnetic resonance imaging notes edema and ‘‘fracture’’ line (arrows) on (C) coronal and (D) sagittal images.
drawer test will be positive. In chronic cases, only swelling subchondral fracture line, displacement of a fragment,
and joint tenderness may be present. or an area of radiolucency on the anterolateral or poster-
omedial talus (Fig. 14-54, A). A mortise view taken with
Imaging a 4-cm heel rise may increase detection with conven-
Initial radiographs often are negative unless the fracture tional radiographs (Fig. 14-54, B). A bone scan, CT
is displaced.46 Serial or subsequent x-rays may show a scan, or MRI may be used as a screening tool for chronic
320
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Figure 14-54 Anterior-posterior radiograph of ankle (A) demonstrating radiolucency in talus (arrows) suggesting
medial dome osteochondral lesion of talus. Oblique radiograph of ankle (B) showing clear evidence of large
medial dome cyst and osteochondral lesion of talus.
ankle pain. A CT scan with 1-mm overlapping cuts, Finally, intra-articular ankle injection with Xylocaine
axial, coronal, and sagittal views is the gold standard and Marcaine is helpful in cases in which there is doubt
for lesion location, sizing, and surgical planning.16 Similar about whether the osteochondral lesion is producing the
views on MRI are helpful in evaluating early or compres- patient’s symptoms.
sion injuries, demonstrating the amount of edema asso- I use MRI as a screening tool to detect OLTs when
ciated with the injury and assessing cartilage injuries. routine radiographs are negative, to localize and size
Arthroscopic evaluation47,48 has been proven to be essen- osteochondral lesions preoperatively, and to assess and
tial for demonstrating the viability and stability of the confirm healing of osteochondral lesions. However,
overlying cartilage and whether the cartilage surface is still as discussed later, actual treatment often depends on
intact. At arthroscopic evaluation, the underlying sub- arthroscopic evaluation and determination of the intact-
chondral bone can also be probed to determine its struc- ness and viability of the cartilage.
tural integrity. CT and MRI, however, have been shown
to allow better assessment of the size of the OLT.49
Although Verhagen et al.46 found that CT and MRI Classification
evaluation were equally valuable in assessing OLTs, my Several classification and staging systems for OLTs
experience has shown that MRI tends to show a much have been devised as diagnostic capabilities have devel-
larger lesion because of the bony edema surrounding oped. The Berndt and Harty35 radiograph-based clas-
the fracture (Fig. 14-55, A through E). An MRI usually sification introduced in 1959 is still the most widely
is much better in assessing early-stage lesions and as a used classification (Fig. 14-56). Stage I represents an
screening tool. When an OLT is present with a more area of osteochondral compression. Stage II is a par-
global compression injury, CT scan is helpful to accu- tially loose fragment. Stage III is a completely detached
rately localize the specific osteochondral fracture. fragment without displacement. Stage IV represents a
The history, physical examination, and these diagnostic completely detached and displaced fragment. This has
tests all are helpful together to detect an OLT, to deter- been appended to include Stage 0, which is an x-ray-
mine its size and location and to help with staging. How- negative but MRI-positive lesion. Scranton and others
ever, the surgeon should be cautioned to determine that have added stage V39,50 to describe lesions with deep cystic
the presence of an osteochondral lesion is in fact the lesion changes (Fig. 14-57). Ferkel51 advanced a classification
producing the athlete’s symptoms. I personally have seen system based on CT in 1996 (Fig. 14-58). Hepple et al.43
several cases in which a chronic asymptomatic OLT was presented an MRI-based classification system in 1999.
detected on evaluation or was sent to me on discovery, Pritsch et al.,52 Ferkel,40 Mintz et al.,47 and Taranow
and, in fact, another condition was causing the patient’s et al.53 have all noted that arthroscopic evaluation of
symptoms. We discuss treatment of asymptomatic OLTs these lesions is essential to assess the overlying cartilage.
later. However, the lesson here is to treat the patient not An arthroscopic classification system was proposed by
the imaging study. Ferkel.51
321
...........
Figure 14-55 Osteochondral lesion of lateral dome of talus.

(A) Anterior-posterior radiograph of ankle demonstrating
lateral dome of talus osteochondral lesion. Coronal and
sagittal (B and C) computed tomography images and (D and E)
magnetic resonance imaging delineates more clearly chronic
and cystic nature of lesion.
322
...........
Stage II Stage III Stage IIIA Stage IV
Figure 14-56 Berndt and Hardy classification for osteochondral lesions of talus. Stage I represents an area of
osteochondral compression. Stage II is a partially loose fragment. Stage III is a completely detached fragment
without displacement. Stage IV represents a completely detached and displaced fragment.
.............................................................
OLT Treatment combination of x-ray, CT scan, and/or MRI evaluation
along with arthroscopic assessment of the cartilage sur-
face allows accurate staging. Most cases of chronic
Treatment of acute injuries OLT involve partially or totally displaced cartilage and
Nonoperative treatment commonly is used for acute bony fragments. Excision of the OLT alone yields
OLTs.3,13,35,40,41,54 Immobilization, nonweight bearing approximately 38% good to excellent results.3 Excision
and crutches are used until healing is complete. Follow- and curettage (Fig. 14-60, A through C) yields 78%
up routine x-rays, CT scan, or MRI may be used to fully good to excellent results, whereas excision, curettage
evaluate healing. Cases that are not healed may be treat- and drilling, or microfracture (Fig. 14-61, A and B)
ed as chronic cases. There is some controversy whether have produced 86% good to excellent results.1,18,56 For
immobilization and/or nonweight bearing are critical deep cystic lesions (stage V), excision, curettage, and
to the success rate of nonoperative treatment.1,40 bone grafting have yielded reasonable results.6 ‘‘Second
Acute OLTs that are displaced have been treated look’’ procedures have shown the fibrocartilage tissue39
most commonly by arthroscopy and excision (if less than that forms in the lesions treated by excision and drilling
1 cm) or by arthroscopy/arthrotomy and ORIF.40 or when microfracture is present (Fig. 14-61, C). The
Bioabsorbable pins or headless screws also may be used. thickness and biomechanics of this fibrocartilaginous tis-
For posterior medial lesions, transmalleolar pinning sue is not identical to normal articular cartilage11 but
through a drill hole (Fig. 14-59) or a medial malleolar often can produce a good functional result.
osteotomy have been used. Anterolateral lesions often For OLTs in which the articular cartilage is found to
can be approached through an arthroscopic approach be intact on arthroscopy, retrograde drilling of the talus
or by a small arthrotomy and/or excision of a small and bone grafting has been suggested (Fig. 14-62, A
anterolateral edge of the distal tibia.50,55 In the case of through I).53,57 Under simultaneous arthroscopic and
a nonunion, the patient is then treated as a chronic case. fluoroscopic control, a Micro Vector drill guide is used
to place a guidepin from a lateral incision across the talus
Treatment of chronic injuries to just underneath the posteromedial lesion (Fig. 14-62,
Nonoperative treatment with or without immobilization F and G). A cannulated drill bit then is used to drill a
has been shown to produce only approximately 50% 4.5-mm ‘‘tunnel’’ just up to the lesion. Any necrotic
good to excellent results1,3,38,42 and less than 33% good bone in the lesion is removed with small ring curette
to excellent results in younger patients. Arthroscopic (Fig. 14-62, F and G). Four-millimeter bone plugs are
evaluation is essential in selecting the proper operative taken from the lateral calcaneus (Fig. 14-62, H) and
treatment of symptomatic patients with OLTs. A tamped into place until the articular cartilage surface
323
...........
Stage I Stage II Stage III
Stage IV Stage V
39,50
Figure 14-57 Classification of osteochondral lesions with addition of stage V to describe lesions with deep
cystic changes.
‘‘tents up’’ a millimeter while visualized through the ‘‘nested’’ for larger lesions. For osteochondral lesions
arthroscope (Fig. 14-62, I). on the flatter part of the talus, the intercondylar notch of
When excision, curettage and drilling, or microfrac- the knee is preferable as a donor site, where the lateral fem-
ture do not produce a satisfactory result in treating an oral ridge is used for OLTs located in the ‘‘corner’’ region
OLT (Fig. 14-63, A), osteochondral transfer or osteo- of the talus.64,65 Despite the thicker articular cartilage of
chondral autograft transfer system (OATS) procedures the knee as compared with the talus, good results have
have proven useful (Fig. 14-63, B through F). Intro- been achieved. Sammarco and Makwana66 described
duced by Hangody in 199758 and supported by several using the nonweight-bearing articular surface of the
other studies,59-63 cartilage and bone ‘‘plugs’’ are har- talus as an ipsilateral donor site. Most cartilage/bone
vested from nonweight-bearing portions of the femoral plugs used in OATS procedures are approximately
condyle arthroscopically (Fig. 14-63, C and D) or 1 cm in depth. Deeper plugs have been used for treat-
through a knee arthrotomy. Various-size plugs then ing cystic, type-V lesions.39
are implanted into a similarly sized hole drilled into All of the previously mentioned procedures have been
the OLT (Fig. 14-63, E). The plugs may be single or used to treat focal, reasonably well-circumscribed lesions
324
...........
Stage I Stage IIA Stage IIB
Stage III Stage IV
Figure 14-58 Classification of osteochondral lesions as described by Ferkel51 based on computerized

tomography.
of the talus. Their success rates fall when matched

against more diffuse areas of articular cartilage damage.
Autologous chondrocyte implantation (ACI) has been
one of the newer methods to help treat larger (>1.5 cm)
talar chondral lesions. Brittberg et al.67 described treatment
for articular lesions of the knee in 1994, using cultured
chondrocytes implanted under a periosteal blanket. The
OLT is debrided back to stable cartilage borders and
down to subchondral bone. Chondrocytes obtained from
an initial cartilage biopsy are cultured and grown for later
implantation. Fibrin ‘‘glue is used to secure and seal
the periosteal cover. Giannini in 200168 reported use of
this technique for resurfacing talar lesions. OLTs up to
3.3 cm were treated with improvement to an American
Orthopaedic Foot and Ankle Society (AOFAS) ankle score
of 91. Patients were begun on continuous passive ROM
and kept nonweight bearing for 12 weeks. Kouvalis
et al.69 described a series of patients treated with ACI that
had failed previous surgery. Good results were achieved
with ACI and weight bearing after 6 to 7 weeks. Schafer1
Figure 14-59 Diagram demonstrating transmalleolar pinning and Ferkel70 suggested that this method could be used
of medial dome osteochondral lesion through drill hole in to treat patients up to 55 years of age with unipolar lesions
medial malleolus. that were constrained and with a history of previous failed
325
...........
Figure 14-60 Arthroscopic views of (A) osteochondral lesion

(OCL), (B) curettage, and (C) postexcision and curettage.
Note bloody base and stable rim (arrows) at donor site for
OCL.
surgery. Results treating ‘‘shoulder’’ lesions have not been ACI in the knee versus 69% using mosaicplasty,
as good.70 ‘‘Sandwich’’ procedures with cultured chondro- although other studies show equivalent results.71
cytes between two periosteal layers have been used to cover Talar body partial or total allografts recently have
deeper, cystic, type-V lesions filled with cancellous bone been reported for use in the treatment of more global
graft. talar cartilage damage. In 2001, Gross et al.72 noted
Recently, various commercially prepared collagen- using matched allograft talar replacements (Fig. 14-64).
based ‘‘scaffolds’’ or matrices that can be impregnated Meehan et al.73 have presented initial good results with
with cultured chondrocytes have been introduced to this technique. However, long-term follow-up has shown
replace periosteum as the ‘‘blanket’’ holding the chon- complications of resorption, graft fracture, and failure.
drocytes. This Matrix-induced Autologous Chondrocyte Tissue matching is not required for this procedure.
Implantation (MACI) offers to eliminate harvesting of Access to a large tissue bank where size-matched allograft
periosteum. These methods are an exciting new oppor- can be obtained is essential for this new procedure,
tunity to treat larger OLTs that previously had been left thereby limiting availability. The technical and immuno-
untreated or treated with fusion or total ankle replace- logic complexity of this technique must be weighed
ment. The technique is expensive, demanding, and against the alternatives of ankle fusion or replacement.
often considered ‘‘experimental’’ by many health Review of the literature shows very little detailed, evi-
insurers but likely will be more widely available in the dence-based information about the role of weight bearing
future as more good long-term results are reported. or nonweight bearing in the treatment of these lesions.
Recently, Bently et al.65 reported 89% good results with The literature also is scarce on surgical treatment options
326
...........
Figure 14-61 Osteochondral lesion treated with (A) K-wire

drilling or (B) microfracture results in (C) replacement with
fibrocartilage noted at second-look arthroscopy.
on GCTs other than to recognize that they exist and that 0 and 1 lesions, the athlete is treated nonweight bearing
fusion or total ankle replacement is difficult when such a with active ankle ROM. Salter76 reported that ROM is
lesion is present. Mont74 has written about drilling these helpful in cartilage nutrition and healing. When swelling
talar lesions if conservative measures fail. Methyl methac- is down and tenderness of the talus to palpation is gone,
rylate or talar body prosthetic replacements75 have been a progressive weight-bearing program is begun, fol-
proposed in isolated cases. A talar body allograft may be lowed by general ankle rehabilitation focusing on edema
used.72,73 Tibiocalcaneal fusion or ankle replacement also control, ROM, PREs (especially the posterior tibial ten-
have been described as treatment. don and peroneal tendons), and proprioception. If the
talus remains painful to palpation, a repeat CT scan
may be performed to evaluate healing. After successfully
.............................................................
My suggested treatment completing sports-specific exercises, the athlete may
return to sports.
Stage 2 lesions with a fracture line present are
Acute injuries (less than 4 to 6 weeks) treated by nonweight bearing in a boot without AROM
For acute lesions I prefer to use the Berndt and Harty until radiographic evidence of healing. A CT scan may
classification but I often obtain a CT scan to further be needed to document healing. Return to sports comes
evaluate the size and position of the lesion. For stage after successful completion of ankle rehabilitation and
327
...........
Figure 14-62 Medial dome osteochondral lesion (OCL) treated with retrograde drilling and bone graft. (A and B)
Anterior-posterior and lateral radiographs noting only mild medial dome radiolucency, whereas (C and D) coronal
and sagittal magnetic resonance imaging clearly demonstrate medial lesion.
sports-specific exercises. In some cases involving pro- Stage 3 and stage 4 lesions are treated with excision
fessional players and large fragments, arthroscopy and and either drilling or microfracture if less than 1 cm.
pinning with bioabsorbable pins or headless screws may ORIF is performed, either arthroscopically or through
allow earlier ROM, healing, and return to sports. a malleolar osteotomy, if the OLT is more than 1 cm.
328
...........
Figure 14-62 cont’d. (E-G) Micro Vector drill guide is used to

place a guidepin from a lateral incision across the talus to just
underneath the posteromedial lesion. (H) Bone graft taken
from calcaneus is (I) tamped into area curetted out under OCL
causing mild tenting up of cartilage surface.
Choice of fixation is either bioabsorbable pins or head- in a boot with gentle AROM until routine radiographs
less screws, depending on the size of the fragment. or a repeat CT scan reveal healing, General ankle reha-
Any fibrous tissue under the fragment is curetted. These bilitation is then initiated, followed by sports-specific
patients are treated postoperatively nonweight bearing exercises.
329
...........
Figure 14-63 (A) Osteochondral lesion (OCL) treated with microfracture with continued pain and poor cartilage
production. This lesion required (B-F) osteochondral grafting by taking (C and D) 10-mm autograft plug from
medial femoral condyle of knee and (continued on page 331)
Chronic OLT lesions (more than 6 weeks old or failed Treatment of asymptomatic OLTs visualized on inci-
previous treatment) dental radiographs, CT scan, or MRI presents a treat-
It is important to assess the patient’s symptoms and the ment and ethical dilemma for the sports physician.
imaging study when caring for these athletes. As noted Several of my colleagues and I have been consulted
previously, the presence of an OLT on x-ray, CT scan, when an athlete has a totally asymptomatic OLT found
or MRI does not make it the source of the patient’s cur- on imaging studies of the ankle obtained for unrelated
rent symptoms. It is critical to properly assess the athlete problems. In such situations, the OLT is almost always
and his or her complaints to make sure the symptoms or chronic. In these situations the best option is complete
disability are indeed from the OLT. This evaluation is education of the patient. I explain to the athlete that
sometimes difficult. the lesion may become partially or totally loose and
330
...........
Figure 14-63 cont’d. (E) placement into the OCL site of talus via a (F) medial malleolar osteotomy fixed with two
cannulated screws.
symptomatic in the future, with the possibility of ankle If the articular cartilage surface of the talus is intact
arthritis. The nature of surgical treatment with accom- with either a stage 1 or stage 5 lesion, the preferred
panied risks, such as becoming symptomatic, is also dis- treatment is retrograde drilling of the talus, with bone
cussed. The patient is presented with two general grafting for stage 5 lesions. Postoperatively, athletes
options: first is serial evaluation at yearly intervals with begin early AROM and are in a boot nonweight bearing
a repeat x-ray and/or MRI. The patient is told to call until an x-ray or CT scan demonstrates bone healing.
or report immediately if he or she has any ankle discom- General ankle rehabilitation followed by sports-specific
fort or swelling. I have followed several patients with exercises then is started.
large OLTs for several years that are completely asymp- For lesions at stage 2, 3, or 4 that are shallow (less
tomatic and continue to run and engage in recreational than 2 mm deep) and less than 1 cm in diameter, exci-
athletics without pain or discomfort. Patients with sion of the lesion and drilling or microfracture (depend-
asymptomatic stage 1 lesions are encouraged to take this ing on the location of the lesion) are performed.
option. Athletes are nonweight bearing with AROM, as
The other option is prophylactic surgical treatment, described previously, for 6 to 8 weeks until swelling
often at the end of the current athletic season. In the and tenderness are gone. Rehabilitation and weight
case of cystic lesions without an overlying osteochondral bearing then are started as discussed previously.
fragment, it is not unreasonable to offer the athlete ret- When treating stage 2, 3, and 4 OLT lesions in which
rograde drilling and bone grafting during the off season. the surface area is more than 1 cm I prefer osteochondral
Patients are nonweight bearing with AROM for approx- transfer from the knee (OATS procedure). As long as the
imately 6 weeks until healing is confirmed by repeat lesion appears to be located on the edge or medial or lat-
radiographs or CT scan. Rehabilitation then is begun. eral surface of the talus and can be reached by a malleolar
For asymptomatic stage 2 or 3 lesions, arthroscopy, osteotomy or arthroscopy, single or nested matched
excision, curettage and drilling with microfracture, or osteochondral plugs provide very good results. Careful
osteochondral transfer is selected. Athletes must under- orientation of the drill holes perpendicular to the articular
stand that this treatment may result in increased symp- surface is critical. Proper matching of the plug contour to
toms and therefore must be approached with caution. the natural contour of the talus also is important. As
In treating symptomatic chronic OLTs, ankle radio- other authors have described,64 the plug or plugs are left
graphs are obtained for baseline evaluation and to help very slightly ‘‘proud’’ at the time of surgery. The post-
with serial examinations. MRI is used as a screening tool operative regimen is the same as described previously.
and to evaluate the extent of bony edema. Often a CT For cystic lesions at stage 2, 3, or 5 (in which the car-
scan may be used to clearly define the location and size tilage surface is disrupted) less than 1 cm, excision,
of the OLT before surgery. Patients are advised that curettage, and placement of cancellous bone graft as
the exact treatment depends on the findings noted at suggested by Lanny Johnson have proven successful.
the time of arthroscopy. The same nonweight bearing and early AROM
331
...........
Figure 14-64 Anterior-posterior radiograph after allograft total ankle. Note two screws in tibia to hold graft in
place and increased density of allograft in tibia and talus.
332
...........
Figure 14-64 cont’d. 333

(continued)
...........
postoperative protocol is prescribed. On occasions in less than 3 cm. Larger lesions (>1.5 cm diameter) may
which I have had the opportunity to do a ‘‘second look’’ be treated with ACI or MACI. I do not have any expe-
procedure on these patients, the fibrocartilage healing is rience with this technique, although increasingly reports
similar to those with more shallow lesions treated by seem to indicate this is the procedure of choice for these
excision and drilling/microfracture. For larger cystic large lesions. Expense and insurance approval are major
lesions at stage 2, 3, or 4, an osteochondral transfer with hurdles to its use. Larger lesions or bipolar lesions
a deeper plug may be used, or cancellous bone graft may involving both talar and tibial surfaces lend to treat-
be inserted39 before placing the plug. ment with talar allografts.16 Immunologic difficulties,
In cases in which initial surgical treatment for OLT limited access to a large, talar bone bank, and lack of
has failed, medial malleolar osteotomy and the OATS long-term experience have limited the use of this salvage
procedure seem to be the procedure of choice for lesions procedure.
334
...........
Treatment of GCTs ankle. The initial radiographs usually are negative and
As noted previously, these injuries are commonly the diagnosis rests with initial suspicion, talar tenderness
missed, both in the acute or chronic setting after a sig- on palpation, and MRI confirmation. Acute or chronic
nificant compression and/or twisting injury to the GCT is treated with protection in a boot, nonweight
Figure 14-65 Global compression injury of talus treated with drilling as preferred by me. (A) Sagittal magnetic
resonance imaging denoting global talar edema, with (B) normal cartilage noted on arthroscopy. (C-F)
Fluoroscopically guided drilling of talus with multiple passes to improve blood supply and encourage healing.
(continued) 335
...........
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Orthop Surg 13:152, 2005. 2003.
43. Hepple S, Winson IG, Glew D: Osteochondral lesions of the talus: 66. Sammarco GJ, Makwana NK: Treatment of talar osteochondral
a revised classification, Foot Ankle Int 20:789, 1999. lesions using local osteochondral graft, Foot Ankle Int 22:693, 2002.
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67. Brittberg M, et al: Treatment of deep cartilage defects in the knee 71. Smith GD, Knutsen G, Richardson JB: A clinical review of
with autologous chondrocyte transplantation, N Engl J Med cartilage repair techniques, J Bone Joint Surg 87B:445, 2005.
331:889, 1994. 72. Gross AE, Zgnidis Z, Hutchinson CR: Osteochondral defects of
68. Giannini S, et al: Autologous chondrocyte transplantation the talus treated with fresh osteochondral allograft transplant, Foot
in osteochondral lesions of the ankle joint, Foot Ankle Int 22:513, Ankle Int 22:385, 2001.
2001. 73. Meehan R, et al: Fresh ankle osteochondral allograft transplant for
69. Kouvalis D, Shultz W, Heyden M: Autologous chondrocyte tibiotalar joint arthritis, Foot Ankle Int 26:793, 2005.
transplantation for osteochondritis dissecans of the talus, Clin 74. Mont MA, et al: Avascular necrosis of the talus treated by core
Orthop 395:186, 2002. decompression, J Bone Joint Surg 78B:827, 1996.
70. Ferkel RD: Autologous chondrocyte implantation. In Easley 75. Harnroongroj T, Vanadurongwan V: The talar body prosthesis,
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338
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.........................................C H A P T E R 1 5
Disorders of the subtalar joint, including

subtalar sprains and tarsal coalitions
Scott T. Sauer, Travis W. Hanson, and John V. Marymont
......................
CHAPTER CONTENTS
Introduction 339 Tarsal coalition 345

Anatomy 339 Calcaneonavicular coalitions 348
Subtalar instability 339 Talocalcaneal coalitions 348
Sinus tarsi syndrome 342 Acknowledgment 351
Subtalar dislocation 344 References 351
INTRODUCTION of the intermediate root of the inferior extensor ret-

inaculum and the cervical ligament. The deep layer
consists of the medial root of the inferior extensor reti-
Pathology in the subtalar joint can be debilitating,
naculum and the interosseous talocalcaneal ligament
difficult to diagnose, and can lead to significant loss of
(Fig. 15-1).
time for the athlete. Subtalar instability is becoming
The joints move in a triaxial plane, which allows for
more recognized in association with lateral ankle insta-
the motions of flexion/extension, inversion/eversion,
bility and also as an isolated source of ‘‘giving way’’ in
and adduction/abduction.
the athlete. We try to elucidate some recent advance-
The sinus tarsi is a space on the lateral aspect of the
ments in this sometimes-confusing area. Sinus tarsi syn-
foot that lies anterior to the posterior facet between
drome has been a common complaint in the past and we
the talus and the calcaneus. It is in continuity with the
try to update our readers regarding how to diagnose this
tarsal canal. The tarsal canal is a cone-shaped opening
syndrome and how to differentiate it from other forms
within the subtalar joint and is situated in a posterome-
of subtalar pathology. Tarsal coalitions often are symp-
dial-to-anterolateral direction. Soft tissues within the
tomatic in the athlete. Although the coalition is found
sinus tarsi include the artery of the tarsal canal, bursae,
in approximately 2% of the population, the athlete often
nerve endings, and multiple ligaments.
becomes symptomatic with its presence.
SUBTALAR INSTABILITY
ANATOMY
The role that instability of the subtalar joint plays in the
The subtalar joint is comprised of three articulating patient with lateral ankle instability has been elucidated
surfaces, referred to as the posterior facet, the middle only recently. It has been estimated that 10% to 30%
facet, and the anterior facet. The bony articulations proof patients with functional ankle instability, that is,
vide inherent stability and soft tissues provide additional patients that have pain, swelling, or a sense of ‘‘giving
stabilization. The lateral soft-tissue stabilizers have been way’’ of the ankle, have evidence of instability of the
classified into three separate layers.1 The superficial layer subtalar joint.2,3 Some have suggested that consider-
is composed of the lateral root of the inferior extensor ation should be given to the concept of global hindfoot
retinaculum, the lateral talocalcaneal ligament, and the instability rather than simply functional instability about
calcaneofibular ligament. The intermediate layer consists the ankle joint.4
CHAPTER 15 Disorders of the subtalar joint, including subtalar sprains and tarsal coalitions
Figure 15-1 The anatomy of the subtalar joint. (From Mann RA, Coughlin MJ, editors: Surgery of the foot
and ankle, ed 7, St Louis, 1999, CV Mosby, p 1147, Figure 26-57.)
Instability of the subtalar joint was first described in Physical examination

1962 by Rubin and Whitten.5 They proposed a series The most notable finding on physical examination is
of stress radiographs to further evaluate this disorder. increased inversion of the subtalar joint. This should
Brantigan et al.6 were the first to detect radiographic be compared with the presumably uninjured opposite
evidence of subtalar instability in their series of three limb. The increased inversion can result from subtalar
patients. Chrisman and Snook7 in 1969 were able to instability or a combination of subtalar and ankle insta-
document clinical subtalar instability in three of seven bility.4,8 It is extremely difficult to detect the location
patients who were undergoing their tendon transfer of increased inversion by examination. In addition to
procedure for lateral instability. Clanton and Berson8 increased inversion of the hindfoot, an increased transla-
described subtalar injuries as a continuum of other in- tion of the calcaneus in the medial direction has been
juries in athletes, particularly sprains of the lateral ankle noted by Thermann et al.9 In their study, a valgus stress
ligaments. was applied to the calcaneus, followed by an abrupt
Clinical presentation internal rotation stress. Results showed a medial shift
of the calcaneus in relation to the talus or an opening
The typical injury that leads to instability of the subtalar of the talocalcaneal angle in patients with subtalar
joint is a severe supination or supination-inversion instability.
force applied to the hindfoot. This results in a progres- Following an acute injury, there may be swelling,
sive injury to the talonavicular ligament and talonavic- bruising, and tenderness laterally. In the more chronic
ular capsule, followed by injury to the calcaneofibular setting, increased inversion and lateral tenderness are
and lateral talocalcaneal ligaments.8 The presenting more likely. It is easier to detect instability in the chronic
complaint often is a sensation of giving way of the ankle. setting because the athlete will be less apt to guard
The patient may report pain localized to the region of because of pain.
the sinus tarsi. Athletic activities can exacerbate the
symptoms, resulting in a dependence on bracing or tap-
ing. Uneven surfaces may cause pain and a feeling of Radiographic evaluation
instability. The initial radiographic workup of the patient with
It is difficult to differentiate lateral ankle instability subtalar instability involves a weight-bearing anterior-
from subtalar instability on the basis of patient history. posterior, lateral, and mortise view of the affected ankle,
A thorough clinical and radiographic workup can help as well as weight-bearing anterior-posterior, lateral,
define the source of the athlete’s complaints, but the and oblique radiographs of the affected foot to rule
differentiation still can be elusive. out evidence of bony pathology.
340
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Subtalar instability
4 PEARL (Fig. 15-2).6,10-12 In a series of three patients, Brantigan

et al.6 were able to radiographically demonstrate subtalar
instability. They attributed the instability to an injured
When possible, obtain weight-bearing radiographs to calcaneofibular ligament. Heilman et al.12 sequentially
assess the bony articulations under physiologic stress. sectioned ligaments in cadaver limbs and then obtained
Plain radiographs often are negative, and further lateral and Broden’s radiographs. They found that
investigation must be carried out to arrive at the diagnosis. sectioning of the calcaneofibular joint caused a 5-mm
There have been multiple investigations into the use of opening of the subtalar joint. With subsequent sectioning
stress radiographs in the workup of subtalar instability of the interosseous ligament, the joint opened up to 7 mm.
The usefulness of stress radiographs has come into
question by multiple authors.13-15 Harper13 reported a wide
range of subtalar tilt with stress radiographs in his group of
asymptomatic patients. Louwerens et al.14 examined 33
patients with chronic ankle instability and 10 control
patients who were asymptomatic. Broden’s views were
checked under fluoroscopy and they detected no difference
between symptomatic and asymptomatic feet with regard
to subtalar tilt or medial shift. Van Hellemondt et al.15
examined both stress radiographs and stress computed
tomography (CT) scans in 15 patients with unilateral chronic
ankle instability with suspected subtalar instability.
Although three of the symptomatic feet and one of the
asymptomatic feet had increased subtalar tilt on plain
films, there was no significant difference between the
symptomatic and asymptomatic sides. None of the patients
had increased subtalar tilt on the stress CT scans.
The authors therefore doubted that a Broden’s stress
examination reveals the true amount of subtalar tilt.
Nonoperative treatment
In an acute injury, the usual treatment regimen for lateral
ankle sprains will suffice for subtalar ligamentous injuries,
as well. Rest, ice, compression, and elevation (RICE) are
part of a good protocol, as well as immobilization and
physical therapy, when needed. The same can be said
for management of chronic subtalar instability. The rou-
tine nonoperative regimen used for chronic lateral ankle
instability is initiated. This may include proprioceptive
training, peroneal strengthening, and bracing or strap-
ping.8,16 With bracing, it is important to understand the
delicate balance in providing an athlete with enough sup-
port without impeding his or her performance. Taping by
an athletic trainer before participation can be effective.
Wilkerson17 examined a modification of the standard
method of ankle taping with the incorporation of a ‘‘sub-
talar sling.’’ He found that addition of the sling enhances
the protective function of taping but cautioned that it
may impede performance of certain activities.
Surgical treatment
Patients with residual symptomatic instability despite an
adequate program of nonoperative management will
require a surgical stabilization of their subtalar joint.
If both ankle and subtalar instability exist and require
Figure 15-2 Stress radiographs. (A) Stress anterior- surgery, both problems should be corrected at the
posterior (AP) radiograph with subtalar tilt. (B) Stress time of surgery.4 Surgical stabilization involves direct
Broden view showing subtalar instability. ligament repair or tendon transfers to substitute for
the irreparable ligaments.
341
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Lateral
Anterior talofibular ligament malleolus
Lateral
malleolus
Extensor Extensor
retinaculum retinaculum
Peroneal
tendons
Calcaneofibular
ligament
Calcaneofibular Peroneal
D ligament E tendons
Figure 15-3 (A) Chrisman-Snook modification of Elmslie procedure. (B) Triligamentous reconstruction. (C) Larsen
procedure. (D) Lateral ankle ligament reconstruction. (E) Reinforcing repair with inferior extensor retinaculum. (A-E
from Mann RA, Coughlin M.J., editors: Surgery of the foot and ankle, ed 7, St Louis, 1999, CV Mosby; A from p 1128,
Figure 26-35; B from p 1153, Figure 26-64; C from p 1127, Figure 26-34; D and E from p 1128, Figure 26-36.)
Surgical techniques resulting in ankle and subtalar sta- calcaneofibular ligament (CFL) and anterior talofibular
bility concurrently are numerous (Fig. 15-3, A through ligament (ATFL) buttressed by the inferior extensor
C).2,7,9,18-26 Most techniques require some form of extra- retinaculum, subtalar stability is effectively restored.8,22
articular tendon transfer to provide stability. Kato25 and
Pisani26 described techniques involving intraarticular lig-
ament reconstruction of the interosseus ligament
SINUS TARSI SYNDROME
between the calcaneus and talus.
A less invasive technique that, according to Clanton
and Berson8 and Gould et al.,22 provides a good treat- Symptoms of sinus tarsi syndrome may overlap with
ment for subtalar instability is the Brostrom-Gould those associated with subtalar instability. Some authors
reconstruction technique for lateral ankle instability consider this syndrome simply a variant of subtalar insta-
(Fig. 15-3, D and E). With the reconstruction of the bility.27 Sinus tarsi syndrome describes pain localized
342
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Sinus tarsi syndrome
to the region of the sinus tarsi. Characteristic findings Under normal circumstances there is a small recess that
on clinical and radiographic examination have not been projects anteriorly from the subtalar joint. The absence
well defined. Likewise, the pathologic changes found of this synovial recess has been associated with sinus tarsi
at the time of surgery are unclear. The most widely syndrome.30,32
reported description of the pathologic anatomy asso- The use of magnetic resonance imaging (MRI) in the
ciated with this condition is degenerative changes to evaluation of sinus tarsi syndrome has been investigated.
the soft tissues of the sinus tarsi.28,29 The majority of The key MRI features have been reported as replace-
cases are posttraumatic in nature but also may be related ment of the normal fat signal intensity in the sinus tarsi
to inflammatory arthropathies, gout, ganglion cysts, and with fluid, inflammatory tissues, or fibrosis.31,32 The
structural foot abnormalities.30,31 inflammatory changes often will obscure the ligaments
that normally are visualized in the sinus tarsi. Additional
Clinical presentation findings may include ligament injury, ganglion cysts,
The typical complaint is pain over the lateral and antero- and degenerative joint disease.33
lateral ankle and hindfoot centered in the region of the
sinus tarsi. The patient may report a sensation of mild Nonoperative treatment
hindfoot instability. It has been estimated that as many Injections of local anesthetic and steroid into the sinus
as 70% of patients with sinus tarsi syndrome have had a tarsi may be both diagnostic and therapeutic. If the
previous inversion injury to the hindfoot.32 patient does not report even temporary relief following
injection, then skepticism must be directed at a diagno-
Physical examination sis of sinus tarsi syndrome. Some patients may report
Tenderness over the lateral ankle and hindfoot overlying permanent resolution of their symptoms after a series
the sinus tarsi is the most common finding on clinical of injections.18 Surgery is indicated if pain recurs after
examination. Patients may have findings of mild sub- a series of one to three injections.
talar instability; however, this is difficult to elicit and
often absent. Swelling overlying the sinus tarsi is variably Surgical treatment
present. Open and arthroscopic techniques are available. Open
excision of the tissue filling the sinus tarsi has been
Radiographic evaluation reported to have good results.18,29,30 Typically a lateral
Plain films often are negative in this condition. Stress oblique incision is made over the region of the sinus
views may reveal mild subtalar instability, but, as stated tarsi. The lateral branch of the superficial peroneal nerve
in the previous section, these are of uncertain value. is avoided. The inferior extensor retinaculum and the
Subtalar arthrograms have been used in the workup of origin of the extensor digitorum brevis are reflected
this condition. The normal subtalar joint will accept distally. The sinus tarsi is entered, and debridement is
3 ml of contrast dye and will demonstrate multiple performed. Arthroscopic exploration (Fig. 15-4) of the
recesses and interdigitations within the joint capsule.18 sinus tarsi for diagnosis and treatment has been
Figure 15-4 (A) Arthroscopic examination of the subtalar joint with anterior working portal. (B) Posterior
working portal.
343
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described with good results, but often the postoperative soft tissues in the region of the tented skin if reduction
diagnosis is changed from sinus tarsi syndrome to another is not prompt.
more anatomic pathology, following direct visualization
of the sinus tarsi area and the subtalar joint.27 Radiographic evaluation
A standard three-view series of the foot and/or ankle
(anterior/posterior, lateral, oblique) is obtained but
SUBTALAR DISLOCATION can be suboptimal, given the distortion of normal ana-
tomic relationships in the midfoot. The most helpful
radiograph is the anterior-posterior view of the foot.
A subtalar dislocation involves the dislocation of the The relationship between the talar head and navicular
talocalcaneal and talonavicular joints. With this injury can best be evaluated. The relationship of the talar head
there is no associated dislocation of the calcaneocuboid to the concave proximal side of the navicular on this
or tibiotalar joints. It was first described separately by view normally is congruent on all views of the foot.
DuFaurest34 and Judcy35 in 1811. Broca36 later classified On the lateral radiograph, the talar head lies superior
these injuries as medial, lateral, and posterior. In 1856, to the navicular with medial subtalar dislocations. With
Malgaigne37 revised this classification and added anterior lateral subtalar dislocations the opposite is true, and
subtalar dislocations as a specific entity. Frequency of the talar head appears inferiorly displaced.
the different subtypes of subtalar dislocations has been Associated fractures about the foot and ankle are
reported as 80% medial, 17% lateral, 2% posterior, and common. These are better identified on postreduction
1% anterior.38 radiographs. DeLee and Curtis44 reported a 47% inci-
dence of associated osteochondral fractures of the talo-
Clinical presentation
navicular or talocalcaneal joints in their series of 17
These injuries typically are the result of high-energy patients. Osteochondral fractures were more common
mechanisms such as motor vehicle accidents or falls from with lateral subtalar dislocations in this series. Other
a height. They also can result from a twisting athletic series have reported an incidence of associated foot and
injury. In 1964, Grantham39 used the term ‘‘basketball ankle injuries of 64% to 88%.42,43
foot’’ to describe medial dislocations because four of Because of the difficulty in identifying associated
the five patients in his series injured their foot playing fractures on plain radiographs, postreduction CT
basketball. Low- and high-energy mechanisms create scans have been recommended as a means of identify-
two subtypes of subtalar dislocations. High-energy inju- ing associated injuries.44 Bohay and Manoli45 reported
ries are more likely to be open, more likely to be lateral, four cases of patients who had normal films following
have a higher incidence of associated fracture, and have a reduction of subtalar dislocations. CT scans revealed
worse long-term prognosis.40 intra-articular fractures in all four cases. The authors
Forced inversion of the foot results in a medial subta- recommended CT scanning in all patients with normal
lar dislocation, whereas eversion causes a lateral disloca- radiographs following reduction of subtalar disloca-
tion. During medial dislocations, the sustentaculum tali tions. Diagnosis is important because associated intra-
serves as the fulcrum around which the foot rotates. articular fractures have been associated with a poor
With lateral dislocations, the foot rotates around the prognosis.43,44,46
anterior process of the calcaneus.
Significant foot deformity is found in all patients with
subtalar dislocation, although this may be somewhat Nonoperative treatment
obscured by swelling. Approximately 20% to 40% of The majority of subtalar dislocations can be reduced
subtalar dislocations are open.41-43 However, open using closed methods. Depending on the time from
injuries are unusual in the athlete. injury, reduction can be achieved with minimal sedation.
Injuries left unreduced more than a few hours may
Physical examination require heavier sedation in the emergency department
The deformity is usually clinically obvious. With medial or operating room. The reduction process involves
dislocations, the skin is tented over the lateral malleolus bending the knee to relax the gastrocnemius. Traction
and the dorsolateral talar head. With lateral dislocations, is applied to the heel and countertraction is applied to
the skin is tented over the prominent medial talar head the thigh. As traction is being applied, the deformity is
and the medial malleolus. A thorough neurovascular accentuated by inverting the foot for medial dislocations
examination should be performed, although ischemia and everting it for lateral dislocations. The deformity
of the foot is uncommon with these injuries, especially then is reversed as direct pressure is placed over the
in the athlete. There is a risk of local ischemia to the prominent talar head to aid in reduction.
344
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Tarsal coalition
Following reduction, the foot is placed into a bulky calcaneonavicular joints. These locations account for
splint. Slight eversion of the hindfoot in the splint will approximately 90% of all coalitions.52 Less commonly,
help to stabilize medial dislocations, and inversion coalitions have been described at the talonavicular, cal-
will hold lateral dislocations. Plain radiographs then are caneocuboid, navicular cuneiform, and cuboid navicular
obtained to verify reduction. A CT scan is recom- joints.
mended to rule out associated fractures. Dislocations Previously it had been suggested that the etiology of
without fractures are immobilized for 4 weeks to allow tarsal coalition involved the incorporation of accessory
soft-tissue healing. Injuries with associated fractures ossicles into adjacent tarsal bones.53 In 1955, Harris54
will require a longer period of immobilization, typically performed microscopic dissection of fetal hindfeet and
in the range of 6 to 8 weeks. Following casting, a pro- demonstrated a failure of mesenchymal separation. This
gram of strengthening and range of motion exercises is failure of segmentation has become the most widely
initiated. accepted theory regarding the etiology of this disorder.
It generally is described as an autosomally dominant
Surgical treatment disorder with incomplete penetrance.55,56
The incidence of tarsal coalition has been estimated
The indications for operative intervention are open inju-
to be less than 1%.57 The incidence probably was under-
ries and inability to achieve a congruent reduction using
estimated before the use of CT scans. Further con-
closed methods. Lateral dislocations are more likely to
founding the incidence is the asymptomatic nature of a
require open reduction than medial dislocations.43,47
large percentage of coalitions. In 1974, Leonard58 stud-
In their series of 25 patients, Bibbo et al.43 reported that
ied the first-degree relatives of 31 patients with tarsal
closed reduction was unsuccessful in 8 patients (32%).
coalition. He found that 39% of the first-degree relatives
Four of these cases had identifiable soft-tissue interposi-
had coalitions on radiographs, but all were asymptom-
tion that blocked reduction. None of the patients with a
atic. Approximately 50% of coalitions are bilateral,
low-energy mechanism of injury required an open
with calcaneonavicular coalitions more likely to occur
reduction.
bilaterally.57,59
Blocks to reduction with medial dislocations may
include buttonholing of the talar head through the
extensor retinaculum or capsule of the talonavicular Clinical presentation
joint.48,49 There have been reports of the deep peroneal Patients with this condition often are asymptomatic
nerve interposition blocking reduction, as well.48 Finally, until ossification of the fibrous or cartilaginous coalition
the lateral navicular bone may impact into the medial occurs. Before this time, some degree of motion is pre-
talar head and thereby block reduction.49 With lateral served at the affected joint. Once the coalition ossifies,
dislocations, impingement of the posterior tibial or the motion at the affected joint is lost and symptoms
flexor digitorum longus tendons, as well as impaction may arise. The timing of this ossification may vary,
of the medial navicular bone onto the lateral talar depending on the location of the coalition. Patients with
head, may block reduction.49-51 calcaneonavicular coalitions may become symptomatic
For open reduction of medial dislocations, a longitu- earlier (age 8-12 years) than patients with talocalcaneal
dinal anteromedial incision is made along the talar neck coalitions (age 12-16 years).60
extending to the talar head. This allows access to the Patients with tarsal coalition can present with pain,
structures that have entangled the talar head. At the stiffness, and/or a deterioration of athletic perfor-
same time, inspection of impaction fractures of the artic- mance. Increased stresses are placed on surrounding
ular surfaces can be carried out. For lateral dislocations, structures as motion in the hindfoot is restricted,
a more medial longitudinal incision is made over the and this may lead to pain. Although a planovalgus
prominent talar head. Interposed tendons are released position of the foot has been classically described,
and joint surfaces are inspected. Any tears found in the feet with normal arches or even a cavovarus deformity
tendons should be repaired. may contain a coalition.61 The symptoms are often
low grade and not severe enough to prompt a visit
to the doctor until a traumatic event causes a flare-up
of pain.
TARSAL COALITION Recurrent ankle sprains often are described in athletes
with tarsal coalitions.62 Forced motion beyond that
Tarsal coalition involves a congenital union between two which can be accommodated by the abnormal joints
or more tarsal bones. This union may be bony, cartilag- may lead to partial or complete ligamentous injuries.
inous, or fibrous in nature. The two most common The abnormal joints are unable to dissipate the forces
locations for coalition are at the talocalcaneal and generated by athletic activities, and therefore the
345
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increased stresses are transferred to the ligamentous (Fig. 15-5, A) that is a sign of the calcaneonavicular
structures. coalition, as described by Oestreich et al.66 The axial
heel view is the best plain radiograph for diagnosing
Physical examination coalitions of the middle facet of the subtalar joint. Sec-
ondary signs of a talocalcaneal coalition also may be
Patients tend to have a rigid flatfoot involving heel
detected on the lateral view. These include narrowing
valgus, loss of the midfoot arch, and abduction of the
of the posterior facet of the subtalar joint, blurriness of
forefoot.
the middle facet of the subtalar joint, beaking of the
dorsal head of the talus, and rounding of the lateral
process of the talus.67
4 PEARL CT has been established as the gold standard study
for the identification of talocalcaneal coalitions.68,69
This should be differentiated from an asymptomatic flexible A CT scan (Fig. 15-5, B) allows one to identify the coa-
flatfoot, in which heel varus and medial arch is restored
with single-foot and double-foot heel rise.
lition, determine the extent of joint involvement, and
The degree of the deformity can be quite variable. assess any areas of surrounding degenerative changes.
Talocalcaneal coalitions are associated with a more severe It can be particularly useful for preoperative planning
hindfoot valgus deformity than coalitions at other sites.63 and determining whether a coalition is resectable. It also
Talocalcaneal coalitions typically eliminate motion of the may be used postoperatively to assess the completeness
subtalar joint.
of resection, progressive degenerative changes, and recur-
rence of the coalition.
Less commonly, MRI has been used in the workup of
tarsal coalitions (Fig. 15-5, C). It may better identify
nonosseous coalitions.70 The surrounding joints and
4 PEARL soft tissues can be evaluated, as well. A radionuclide
bone scan also may be useful in the diagnosis of the
Calcaneonavicular coalitions may cause only a partial symptomatic patient with suspected tarsal coalition,
reduction of subtalar motion, with more restriction of particularly as a screening procedure.71 This test can be
Chopart’s motion.
The patient may be tender about the hindfoot/midfoot,
positive when the patient is symptomatic. Accumulation
depending on the location of the coalition. Calcaneonavicu- of the radionuclide most likely is the result of increased
lar coalitions often cause anterolateral tenderness directly stresses at the surrounding joints or within the coalition
over the joint. Talocalcaneal coalitions may cause lateral itself.
tenderness over the sinus tarsi and peroneal tendons, as
well as medially just anterior to the medial malleolus.
A bony eminence from talocalcaneal coalitions has been Nonoperative treatment
described as a cause of tarsal tunnel symptoms. In one Typically a trial of nonoperative management is indi-
series, 30% of patients with tarsal tunnel syndrome were
found to have an eminence from a talocalcaneal coalitions
cated in the treatment of tarsal coalitions. A study by
as a source of the symptoms.64 Jayakumar and Cowell72 in 1977 found that one third
Peroneal spasm may or may not be present. This finding of their patients responded favorably to conservative
has been suggested as part of the classic presentation treatment. When the diagnosis is made in the adolescent
of this disorder; however, it is found only in the minority who is a competitive athlete, then definitive treatment
of cases.57,65
on a more expedient basis may be appropriate. In this
manner, the time off from competition may be reduced.
Morgan and Crawford73 looked at 12 adolescent ath-
letes with coalitions (8 calcaneonavicular and 4 talocal-
Radiographic evaluation caneal). Nonoperative treatment was successful in none
Initial evaluation of the patient should include weight- of the patients, and 8 of the 12 elected to undergo
bearing anterior-posterior, lateral, and oblique radio- surgery.
graphs of the affected foot. An axial heel view should The usual regimen of nonoperative management for
be added to these three views of the foot so that the patients with mild symptoms includes anti-inflammatory
talocalcaneal joint can be inspected. These may identify medications and orthotics. For more severe symptoms,
the presence of a coalition and degenerative changes in patients may undergo a trial of a short-leg walking cast
the surrounding joints. A calcaneonavicular bar is best for a period of 6 weeks. If the patient responds favorably
seen on the 45-degree medial oblique view. A lateral to immobilization, then orthoses are used. The patient
x-ray may show the ‘‘anteater nose,’’ a projection from is considered to have failed nonoperative treatment if
the anterior process of the calcaneus to the navicular pain persists after two cast applications.
346
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Tarsal coalition
Figure 15-5 (A) Radiograph of calcaneonavicular coalition, with ‘‘anteater nose’’ projection from anterior
process of calcaneus to navicular. (B) Computed tomography scan. (C) Magnetic resonance imaging of middle
facet coalition.
Surgical treatment adolescent athletes, they reported their results in 8 ath-

The most common procedures performed for tarsal letes who underwent resection of tarsal coalitions. They
coalition include resection of the coalition, selected found that 5 out of 6 athletes who had calcaneonavicu-
arthrodesis, and triple arthrodesis. Previous reports have lar bars were able to return to play. Both athletes with
examined resection of tarsal coalitions in adolescent talocalcaneal bars were also able to return to play
athletes. In Morgan and Crawford’s73 review of 12 following resection. Elkus74 examined 15 feet with
347
...........
calcaneonavicular coalitions and 8 with talocalcaneal joint, sinus tarsi, and calcaneonavicular coalition. The
coalitions in a population of young athletes. All patients coalition is resected in parallel cuts from each surface,
underwent resection of their coalitions with or without avoiding convergence. The hindfoot is mobilized to
soft-tissue interposition. The majority of the patients test for adequate subtalar motion. Bone wax is generously
had relief from pain (no numbers reported) with variable packed into the bony surfaces. The extensor digitorum
return of subtalar motion. The author did note that all brevis is placed into the resection site and sutured in place.
8 cases of talocalcaneal bar resection had improvement Closure is done in layers (Figs. 15-6 and 15-7).
in motion, had decreased pain, and were able to return
to athletic activity.
TALOCALCANEAL COALITIONS
CALCANEONAVICULAR COALITIONS Resection of the coalition also is the treatment of choice

in patients with symptomatic talocalcaneal coalitions.
Skeletally immature patients with smaller bars and no evi-
The accepted treatment for calcaneonavicular coalitions
dence of degenerative changes in the subtalar joint are
is resection with soft-tissue interposition unless degener-
most likely to benefit from resection.69 Contraindications
ative changes are present in the subtalar or midtarsal
to resection include patients with rigid flatfeet or degen-
joints. Although talar beaking previously was thought
erative changes of the subtalar and transverse tarsal
to be evidence of degenerative changes, it is not a con-
joints. These patients are better served with a subtalar or
traindication to resection.75 One contraindication to
triple arthrodesis. In carefully selected patients, generally
resection is the presence of a concomitant talocalcaneal
80% to 90% will report satisfactory results following a
coalition. Generally the bar should be resected during
resection.79-81
adolescence, but resection of bars in the adult popula-
The decision whether to resect the coalition or per-
tion has been shown to be beneficial, as well.76 There
form a fusion may be influenced by the size of the bar.
is evidence that results are improved after resection of
Some feel that involvement of more than one half of
cartilaginous coalitions rather than bony bars.77
the joint will preclude a successful resection.81 Wilde
The reported outcomes following surgical excision of
et al.82 reported unsatisfactory outcomes with middle
the coalition have been variable. Cohen et al.76 in 1996
coalition resection and fat interposition in the presence
reviewed their results when resecting coalitions in
of middle facet coalition area greater than 50% of the
adults. They examined 12 patients, 77% of whom dis-
area of the posterior facet. On the other hand, Kumar
played degenerative changes before resection. All but
et al.80 did not find a correlation between the extent of
two of the patients reported subjective relief of the pre-
middle facet coalition and the postoperative results in
operative symptoms. Gonzalez and Kumar77 reported
18 feet on which resection was performed.
on 75 feet in 48 patients with calcaneonavicular coali-
tions. Their results with resection and interposition with
the extensor digitorum brevis muscle was good or excel- Technique of resection of talocalcaneal coalition
lent in 77% of the patients. The authors noted that their
A 6- to 7-cm linear incision is made just below the
best results were in patients who had a cartilaginous coa-
medial malleolus, just above the sustentaculum tali
lition and who were younger than 16 years. In contrast,
(Figs. 15-8, A and 15-9, A). Tenotomy scissors are used
Andreasen78 reported results of 31 bar resections that
to dissect and identify the posterior tibial tendon, flexor
were examined 10 to 22 years following surgery. He
digitorum longus, and tibial neurovascular bundle. The
found 30% of the patients had mild pain and 26% had
middle facet lies just under the flexor digitorum longus
severe pain. A recurrence of the bar was seen in 67% of
(FDL), often covered by minimal periosteum. The mid-
patients despite the use of interpositional muscle, and
dle facet with coalition is identified and dissected,
96% of feet had osteoarthritic changes. Six patients
showing the extent of the coalition (Figs. 15-8, C and
required triple arthrodesis.
15-9, B). Once the corners of the coalition are identi-
fied, excision is done using small straight osteotomes
Technique of resection of calcaneonavicular and rongeurs. The excised surfaces should be parallel
coalition to prevent contact and potential osseous fusion
A 5- to 6-cm curvilinear incision is made just below the (Figs. 15-8, D and 15-9, C). Bone wax is placed gener-
fibula, exposing the fascia overlying the extensor digi- ously on the excised surfaces, and Gelfoam is interposed.
torum brevis. One should avoid branches of the superfi- Other authors interpose fat from the surrounding
cial peroneal and sural nerves. The extensor digitorum tissue.76 Closure of the FDL sheath is included in the
brevis is reflected distally, exposing the calcaneocuboid layered closure.
348
...........
Talocalcaneal coalitions
Figure 15-6 Drawing demonstrating excision of calcaneonavicular coalition and interposition of extensor brevis.
(A) Skin incision. (B) Exposure of the extensor brevis. (C) Reflection of the extensor brevis forward demonstrates
the area of coalition. (D) Demonstration of the area of coalition to be resected. (E) Interposition of the extensor
brevis muscles. (From Mann RA, Coughlin MJ, editors: Surgery of the foot and ankle, ed 6, St Louis, 1992,
CV Mosby. Used by permission.)
349
...........
Figure 15-7 Calcaneonavicular coalition. (A) A 45-degree oblique view of the foot demonstrates the
Calcaneonavicular coalition. (B) Postoperative 45-degree oblique view of the foot demonstrates adequate
excision of the Calcaneonavicular coalition.
Figure 15-8 Excision of talocalcaneal coalition. (A) Skin incision. (B) Reflection of structures dorsally and
plantarward to expose the area of coalition. (C) Outlining the coalition with needles. (D) Postexcision
appearance of the coalition. (From Mann RA, Coughlin MJ, editors: Surgery of the foot and ankle, ed 6, St Louis,
1992, CV Mosby. Used by permission.)
350
...........
References
Figure 15-9 (A) Incision marked on medial hindfoot. (B) Middle facet coalition with corners defined, flexor
digitorum longus retracted inferiorly. (C) Coalition excised, flexor digitorum longus retracted superiorly.
patients treated by a new modification of the Elmslie procedure,
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353
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.........................................C H A P T E R 1 6
Diagnostic and operative ankle and subtalar

joint arthroscopy
C. Niek van Dijk, P.A.J. deLeeuw, and Rover Krips
......................
CHAPTER CONTENTS
History of the technique 355 Specific indications 364

Indications and contraindications 355 References 381
Surgical technique 356 Further reading 382
HISTORY OF THE TECHNIQUE grow. Ankle arthroscopy has become an integral part of
modern orthopaedic surgery. Arthroscopic procedures
can be used most successfully when practiced with a firm
Arthroscopy has revolutionized the practice of ortho-
understanding of their subtle refinements, limitations,
paedic surgery since the mid-1970s. After a long history
and risks.
of sporadic attempts at arthroscopy, technologic break-
throughs in Japan and several surgical pioneers in
North America launched widespread interest in percuta-
neous joint surgery. Tagaki in 1939 described systematic
arthroscopic assessment of the ankle joint.1 Watanabe
INDICATIONS AND CONTRAINDICATIONS
published a series of 28 ankle arthroscopies in 1972, fol-
lowed by Chen in 1976.2 In the 1980s, several publica- The key point in the assessment of ankle joint pathology
tions followed.3,4 Over the last 15 years, arthroscopy of is the clinical diagnosis. By means of a clinical diagnosis,
the ankle joint has become the most important diagnostic an indication is set for an arthroscopic intervention.
and therapeutic procedure for chronic and posttraumatic Furthermore, the clinical diagnosis is essential for pre-
complaints of the ankle joint. Interest in ankle arthros- operative planning.7 The clinical diagnosis is based on
copy has increased steadily following successful clinical history, symptoms and signs, and radiographic examina-
experience with arthroscopy of the knee and shoulder.5 tion. Anterior problems include soft-tissue or bony
This rapid rise in the popularity of foot and ankle arthros- impingement, synovitis, loose bodies, or ossicles. More
copy is partly because other noninvasive techniques can- centrally located complaints can originate from an
not adequately diagnose disorders in these joints. To osteochondral defect or arthrosis, whereas posterior
operate in the central and posterior ankle, some type of problems can be caused by intra-articular pathology,
distraction device is needed. Invasive external distraction such as posterior impingement syndrome (os trigo-
was tried in the early 1980s. A noninvasive technique num); posttraumatic calcifications; loose bodies or syno-
was first described by Yates and Grana in 1988.6 With vitis; or by periarticular posterior ankle pathology, such
the advent of better small-joint arthroscopes and as peroneal tendon, posterior tibial tendon, or flexor
instrumentation, and the production of more efficient hallucis longus (FHL) pathology. In posterior ankle dis-
noninvasive distraction devices, the development of ten- orders, especially, differentiation from subtalar pathology
doscopic surgery, and the introduction of a two portal is sometimes difficult.
technique for posterior ankle problems, ankle arthros- The relative contraindications for ankle arthroscopy
copy further developed to the current state. However, include moderate degenerative joint disease with re-
the dynamic nature of arthroscopy necessitates constant stricted range of motion, a significantly reduced joint
improvements that will continue to allow this field to space, severe edema, and tenuous vascular status.8
CHAPTER 16 Diagnostic and operative ankle and subtalar joint arthroscopy
The absolute contraindications for ankle arthroscopy perform the procedure without distraction. In this dorsi-
include absence of a clinical diagnosis, severe degenera- flexed position, the talus is concealed in the joint, thereby
tive joint disease, and localized soft-tissue infection. protecting the cartilage from potential iatrogenic damage.
However, if septic arthritis already is present, ankle Loose bodies usually are located in the anterior compart-
arthroscopy is indicated, because it is a useful tool for ment of the ankle joint. Dorsiflexion creates an anterior
drainage, debridement, and lavage of the joint.9 working area and makes removal easy.10 Distracting the
joint makes it possible for the loose body to ‘‘fall’’ into
the posterior aspect of the joint, thus making removal more
SURGICAL TECHNIQUE difficult or impossible by an anterior approach. The same is
true for the removal of ossicles and bony spurs by chisel or
.............................................................
Operative setup burr. Distraction of the joint results in tightening of the
anterior capsule, thus making it more difficult to identify
The procedure generally is carried out as outpatient sur- anterior osteophytes, ossicles, loose bodies, and soft-tissue
gery under general anesthesia or epidural anesthesia. impediments. Furthermore, when portals are created and
Patients can be placed in various positions. Most sur- instruments are introduced in the distracted position, this
geons prefer the supine position with slight elevation may result in iatrogenic cartilage damage at the talar dome.7
of the ipsilateral buttock. A tourniquet is placed around The main reason for inspection of the talar dome
the upper thigh. The heel of the affected foot rests on and tibial plafond is for treatment of an osteochondral
the very end of the operating table, thus making it pos- defect. A clinical diagnosis must be established pre-
sible for the surgeon to fully dorsiflex the ankle by operatively using history, physical examination, and stan-
leaning against the sole of the patient’s foot. For the dard x-rays. In case of doubt about the existence or
treatment of posterior ankle problems, the patient is the exact location and size of a defect, a preoperative
placed in prone position (Fig. 16-1). A tourniquet is spiral computed tomography (CT) scan or magnetic reso-
applied and a small support is placed under the lower nance imaging (MRI) can be performed. Knowing the
leg, making it possible to move the ankle freely. exact location of a defect makes it possible to decide pre-
There are some important considerations in deciding operatively whether distraction will be necessary or
whether to use dorsiflexion or traction for routine anterior whether the osteochondral defect can be approached in a
ankle arthroscopy. When saline is introduced in the dorsi- forced plantarflexed position of the foot. In our experience,
flexion position, the anterior working area ‘‘opens up’’ more than 90% of medial and lateral talar dome lesions can
and any bony or soft-tissue impediment in front of the be treated in a hyperplantarflexed position.7 Distraction
medial malleolus, in front of the lateral malleolus, at the may be beneficial when an osteochondral defect is located
talar neck, or at the distal tibia can be visualized and treated. in the posterior part of the medial or lateral talar dome or
For the treatment of anterior impingement lesions, synovi- tibial plafond or when a soft-tissue impediment, ossicles,
tis, ossicles, and loose bodies, it therefore is beneficial to or an impregnated loose body is located in the joint space
between fibula and tibia (intrinsic syndesmotic area).11,12
For posterior ankle problems, for example an osteochon-
dral defect in the posterior quarter of the talar dome or in
the posterior part of the tibial plafond, two-portal posterior
ankle arthroscopy is an important alternative (Fig. 16-2).13
.............................................................
Arthroscopic equipment
A 4.0-mm and 2.7-mm arthroscope with 30-degrees

obliquity can be used for ankle arthroscopy. The new
small-diameter, short arthroscopes yield an excellent
picture that is difficult to distinguish from a standard
4.0-mm scope. The small-diameter arthroscope sheet,
however, cannot deliver the same amount of irrigation
fluid per time as the standard sheet. This is an important
drawback when motorized instruments are used because
these cases must benefit from an adequate amount of
Figure 16-1 For posterior ankle arthroscopy, the patient is irrigation fluid. For routine arthroscopic procedures
placed in prone position. A tourniquet is applied and a small such as anterior impingement syndrome, loose body
support is placed under the lower leg, making it possible to removal, treatment of synovitis, and the vast majority
move the ankle freely. of osteochondral defects, it is beneficial to use the
356
...........
Surgical technique
with fine teeth can be used. For larger loose bodies and
soft-tissue fragments, a cup-shaped, jaw-grasping for-
ceps with serrated edges can be used. Small-joint
basket forceps with different tip designs help to remove
soft-tissue and chondral fragments. Various small-joint
curettes, either straight or curved, are available. These
instruments are particularly valuable for removing osteo-
chondral lesions and trimming of articular cartilage
edges. Small-joint osteotomes and chisels are available
to remove osteophytes and ossicles and can facilitate
tissue elevation. Sometimes a small periosteal elevator
can be useful. Motorized instruments can excise larger
volumes of tissue than conventional hand instruments
and suction it quickly out of the joint. They also can
be used for debridement of large osteochondral defects.
A power burr is useful for abrading or excising hard
Figure 16-2 Two-portal posterior ankle arthroscopy is an bone fragments. Holes can be drilled in the subchondral
important alternative for the treatment of posterior ankle bone to enhance vascularization and to stimulate the
problems. repair process.
4.0-mm arthroscope. A 2.7-mm arthroscope should be

reserved for the treatment of osteochondral defects of
.............................................................
Portals for anterior ankle arthroscopy
the posterior third of the talar dome (when not Portals provide an entry to visualize the structures of
approached by a posterior ankle arthroscopy), pathology the ankle and foot. Proper portal placement is critical
of the articular part of the tibiofibular joint, such as a to performing good diagnostic and therapeutic arthros-
soft-tissue impediment or impregnated ossicles or loose copy.14 If the portals are positioned improperly, visuali-
bodies, or other posterior ankle problems that are trea- zation can be impaired, making diagnosis and treatment
ted by an anterior approach. Use of a 2.7-mm scope more difficult. Two primary portals are used in routine
usually necessitates the creation of a third posterolateral ankle arthroscopy: the anteromedial and anterolateral
portal to maintain adequate flow in the joint. portals. The anteromedial portal always is made first
because it is easy to access. This is especially true with
Irrigation the ankle in hyperdorsiflexion. The exact point of entry
Different fluids can be used for arthroscopic irrigation in this position is easily reproducible, and the risk of
during ankle and foot arthroscopy. Lactated Ringer’s is neurovascular damage is minimal. Accessory anterior
the most commonly used fluid because it is physiologically portals are located just in front of the tip of the medial
compatible with articular cartilage and is rapidly reab- or lateral malleolus. Some authors recommend routine
sorbed if extravasated from the joint. Glycine and normal placement of posterior portals in ankle arthroscopy.
saline also can be used. When a 4-mm arthroscope is used, In these cases, a posterolateral portal is recommended.
gravity inflow usually is adequate if the fluid is introduced Because of the potential for serious complications, most
through the arthroscope sheet. When a 2.7-mm arthro- authors feel that the posteromedial portal is contraindi-
scope is used, the gravity inflow should be introduced cated when performing anterior ankle arthroscopy.15
through a separate (posterolateral) cannula. An alternative
is to use an arthroscopic pumping device. Anteromedial portal
The anteromedial portal is placed just medial to the
Accessory instruments anterior tibial tendon at the joint line (Fig. 16-3). Care
An 18-gauge spinal needle is used to distend the joint must be taken not to injure the saphenous vein and
and to locate the anterolateral portal. The spinal needle nerve transversing the ankle joint along the anterior
allows precise positioning under direct vision of the por- edge of the medial malleolus. In the hyperdorsiflexed
tals. The probes used in ankle arthroscopy should be position, a local depression can be palpated. In the hori-
about 1.5 mm in diameter to reach the small recesses zontal plane, this depression is located between the
of the gutters and to lift up under loose articular carti- anterior tibial rim and the talus. The surgeon’s palpating
lage. An angled tip is desirable to touch over the thumb first detects the interval in the horizontal plane
dome-shaped talus and flat tibia. Another important and subsequently locates the vertical position. In the
instrument is the grasper. For the removal of small, vertical position, the anterior tibial tendon is the land-
loose bodies in soft tissue, a flat-tipped grasping forceps mark. One should palpate the anterior tibial in the
357
...........
peroneal nerve because it runs subcutaneously. This

subcutaneous nerve often can be palpated or visualized
by placing the foot in forced hyperplantarflexion and
supination. The lateral dorsocutaneous branch of the
superficial peroneal nerve thus can be visualized.
The intermediate dorsal cutaneous branch of the super-
ficial peroneal nerve crosses the anterior aspect of the
ankle joint superficial to the common extensor tendons.
Damage to this branch can be avoided by staying lateral
to the extensor tendons. Once the lateral branch is iden-
tified, its position can be marked with a marking pen on
the skin.
The location of the anterolateral portal may vary
depending on the location of the lesion in the ankle
joint. For the treatment of anteromedial ankle pathol-
ogy, the anterolateral portal can be placed slightly above
Figure 16-3 Left ankle. The anteromedial portal is placed just the level of the ankle joint and as close to the peroneal
medial to the anterior tibial tendon at the joint line. Care must tertius tendon as possible. For the treatment of lateral
be taken not to injure the saphenous vein and nerve pathology, the anterolateral portal is placed at the level
transversing the ankle joint along the anterior edge of the of the joint line and more laterally. After a small skin
medial malleolus.
incision has been made, the subcutaneous layer and
capsule are divided bluntly with a mosquito clamp.
dorsiflexed position. In this dorsiflexed position the
anterior tibial tendon moves 1 cm lateral. The location Accessory inferior anteromedial and
of the anteromedial portal now can be marked onto the anterolateral portals
skin just medial from the anterior tibial tendon. By The lateral accessory portal is placed just below the ante-
moving the ankle joint from the plantarflexed position rior talofibular ligament. After introduction of a spinal
to the dorsiflexed position, the talus can be felt to move needle, a skin incision is made in line with the anterior
in relation to the distal tibia. The surgeon’s thumb gets talofibular ligament. The bladeknife can be introduced
locked into this ‘‘soft spot’’ in the hyperdorsiflexed posi-
tion. A small longitudinal incision is made through the
skin only just medial from the anterior tibial tendon.
Blunt dissection is performed with a mosquito clamp
through the subcutaneous layer and through the capsule
into the ankle joint. With the ankle in the forced dorsi-
flexed position, cartilage damage is avoided. In this
forced dorsiflexed position, the arthroscope shaft with
the blunt trocar is introduced. When the trocar is felt
to contact the underlying bony ‘‘joint line,’’ the shaft
with the blunt trocar is gently pushed further into the
anterior working area in front of the ankle joint toward
the lateral side. The anterior compartment is irrigated
and inspected. The next portal to make is the anterolateral
portal.
Anterolateral portal
The anterolateral portal is the second standard anterior
portal. It is placed just lateral to the tendon of the pero-
neus tertius at or slightly proximal to the joint line
(Fig. 16-4). It is made under direct vision by introdu-
cing a spinal needle. In the horizontal plane, it is
situated at the level of the joint line. In the vertical
plane, the anterolateral portal is located lateral to the Figure 16-4 Left ankle. The anterolateral portal is placed just
common extensor tendons and the peroneus tertius lateral to the tendon of the peroneus tertius at or slightly
tendon. Care must be taken to avoid the superficial above the joint line.
358
...........
Surgical technique
into the joint under direct vision. On the medial side stab incision, the subcutaneous layer is split by a mos-
(after locating the portal with the spinal needle), the quito clamp. The mosquito clamp is directed anteriorly,
incision is made in line with the fibers of the deltoid lig- pointing in the direction of the interdigital webspace
ament. The knife can be introduced directly into the between the first and second toe (Fig. 16-5, B). When
joint under direct vision. the tip of the clamp touches the bone, it is exchanged
for a 4.5-mm arthroscope shaft with a blunt trocar
Transtibial and transmalleolar portals pointing in the same direction. By palpating the bone
A transmalleolar portal may be used for debridement and in the sagittal plane, the level of the ankle joint and
drilling of lesions of the talar dome. It is used most often subtalar joint most often can be distinguished because
in combination with ankle distraction. A special guide the prominent posterior talar process can be felt as
facilitates the placement of the portal and of the Kirschner a posterior prominence between both joints. It is not
wires that are used to drill the defect. Transtibial or trans- necessary to enter either joint capsule. The blunt trocar
malleolar drilling with a guiding system is especially useful is situated extra-articularly at the level of the ankle
for tibial plafond lesions. For the treatment of talar dome joint. The blunt trocar is exchanged for a 30-degree,
lesions, the transmalleolar portal has the disadvantage of 4.0-mm arthroscope. The direction of view is lateral to
causing damage to the cartilage of the medial malleolus prevent damage to the lens system.
opposite the osteochondral talar defect and therefore is
not recommended to perform on a routine basis. Posteromedial portal
This portal is made just medial to the Achilles tendon.
Portals for posterior and subtalar ankle In the horizontal plane, it is located at the same level
.............................................................
arthroscopy as the posterolateral portal (Fig. 16-6). After the skin
incision has been made, a mosquito clamp is introduced
The anatomic structures in the posterior ankle compart- and directed toward the toward the arthroscope shaft,
ment are in close relation to each other. Operative treat- which already was introduced through the posterolateral
ment can use either a posterolateral or a posteromedial portal. When the mosquito clamp touches the shaft of
approach.13 Both imply the risk of damaging neurovascu- the arthroscope, the shaft is used as a guide to travel
lar structures. Posterolaterally, branches of the sural nerve anterior in the direction of the ankle joint. All the way,
and the lesser saphenous vein are at risk; posteromedially, the mosquito clamp must touch the arthroscope shaft
the neurovascular bundle and its branches are at risk.14,15 until the mosquito clamp touches the bone. The arthro-
scope is pulled slightly backward and slides over the tip
Posterolateral portal of the mosquito clamp until the tip of the mosquito
The posterolateral portal is made at the level or slightly clamp comes to view. The clamp is used to spread the
above the tip of the lateral malleolus, just lateral to the extra-articular soft tissue in front of the tip of the cam-
Achilles tendon (Fig. 16-5, A). After making a vertical era. In situations in which scar tissue or adhesions are
Figure 16-5 (A) Right ankle. The posterolateral portal is made level to or slightly above the tip of the lateral
malleolus just anteriorly to the Achilles tendon. (B) Left ankle. The mosquito clamp is directed toward the first
interdigital webspace.
359
...........
Figure 16-6 Right ankle. The posteromedial portal is made

just medial to the Achilles tendon. In the horizontal plane, it
is located at the same level as the posterolateral portal.
Figure 16-7 Left ankle. After removal of the thin joint capsule,
present, the mosquito clamp is exchanged for a 5-mm, the posterior ankle and subtalar joint can be visualized. The
full-radius shaver. posterior talar process can be freed of scar tissue and the
The fatty tissue overlying the joint capsule can be par- flexor hallucis longus tendon can be identified. This is an
tially removed. At the level of the ankle joint, the poste- important landmark to prevent damage to the more medially
rior tibiofibular ligaments and the posterior talofibular located neurovascular bundle.
ligament can be recognized. After removal of the very
thin joint capsule of the subtalar joint, the posterior
compartment of the subtalar joint can be visualized.
The posterior talar process can be freed of scar tissue,
and the FHL tendon can be identified. The FHL is an
important landmark to prevent damage to the more
medially located neurovascular bundle (Fig. 16-7).
On the medial side, the tip of the medial malleolus
and the deep portion of the deltoid ligament can be
visualized. By opening the joint capsule from inside
out at the level of the medial malleolus, the tendon
sheath of the posterior tibial tendon can be opened
and the arthroscope can be introduced into the tendon
sheath. The posterior tibial (PT) tendon can be
inspected. The same procedure can be followed for the
flexor digitorum longus (FDL) (Fig. 16-8).
With application of manual distraction to the os cal-
cis, the posterior compartment of the ankle opens up
and the arthroscope and shaver can be introduced into
the posterior ankle compartment. A total synovectomy
and/or capsulectomy can be performed. The talar dome
can be inspected over almost its entire surface, as can
the complete tibial plafond. An osteochondral defect
or subchondral cystic lesion can be identified, debrided,
Figure 16-8 Right ankle. By opening the joint capsule from
and drilled. The posterior syndesmotic ligaments are
inside out at the level of the medial malleolus, the tendon
inspected and, if hypertrophic, partially resected. sheath of the posterior tibial tendon can be opened and the
Removal of a symptomatic os trigonum, a nonunion scope can be introduced into the tendon sheath of the
of a fracture of the posterior talar process, or a symp- posterior tibial tendon. This patient has a tendinitis of the
tomatic large posterior talar prominence involves partial posterior tibial tendon, recognized by the increased vascularity
detachment of the posterior talofibular ligament and on and around the tendon. Higher up, a vincula is identified.
release of the flexor retinaculum, both of which attach The direction of the view is from distal to proximal.
360
...........
Surgical technique
to the posterior talar prominence, and removal of the visualization of the posterior compartment of the ankle
scar tissue on the posterior talar process. Removal of and subtalar joint. He developed a 14-point systematic
the pathologic bony fragment can be done by reduction examination for the hindfoot and posterior ankle joint
from medial to lateral with a burr or by use of a 4-mm (Table 16-2).
osteotome or a small rasp. When using the osteotome
it is important not to start too far anterior to prevent
damage to the subtalar joint.
Release of the FHL involves detachment of the flexor
Table 16-1 The 21-point arthroscopic examination of
retinaculum from the posterior talar process. Adhesions
the ankle
surrounding the flexor tendon can be removed. On
the lateral side, the peroneal tendons can be inspected Anterior:
(Fig. 16-9).
When a tight and thickened crural fascia is present, Deltoid ligament
this can hinder the free movement of instruments. It can
be helpful to enlarge the hole in the fascia by means of a Medial gutter
punch or shaver. Bleeding is controlled by electrocautery
Medial talus
at the end of the procedure.
Central talus and overhang
.............................................................
Arthroscopic anatomy
Lateral talus
The ankle joint can be divided into anterior and poste-
rior cavities, each of which can then be subdivided Trifurcation of the talus, tibia, and fibula
further into three compartments for methodologic
inspection of the ankle joint. Ferkel15 developed a Lateral gutter
21-point systematic examination (Table 16-1) of the
anterior, central, and posterior ankle joint to increase Anterior gutter
the accuracy and reproducibility of the arthroscopic
Central:
examination. For posterior ankle problems, Van Dijk
et al.13 reported on a two-portal approach with the
Medial tibia and talus
patient in the prone position, specifically for close
Central tibia and talus
Lateral tibiofibular or talofibular articulation
Posterior inferior tibiofibular ligament
Transverse ligament
Reflection of the flexor hallucis longus
Posterior:
Posteromedial gutter
Posteromedial talus
Posterocentral talus
Posterolateral talus
Posterior talofibular articulation
Posterolateral gutter
Posterior gutter
Figure 16-9 Left ankle. During posterior ankle arthroscopy,
the peroneal tendons can be inspected on the lateral side. From Ferkel, Fischer 199615
361
...........
the talus. Areas of articular damage here should be care-

Table 16-2 The 14-point hindfoot endoscopic
fully noted. The tibia articulates with the medial dome
examination
of the talus. This is the medial corner of the ankle. In
this region, the anterior articular margin of the tibia
1. Lateral talocalcaneal articulation
deviates from its more horizontal configuration centrally
2. Flexor hallucis longus retinaculum and laterally to a more convex configuration in the
coronal plane. At this medial articular notch, the arthro-
3. Flexor hallucis longus tendon scope may be maneuvered most easily into the central
and posterior aspects of the joint without damaging
4. Posterior talar process the articular surfaces.
The distal portion of the tibial lip directs slightly
5. Posterior talofibular ligament anteriorly in the sagittal plane. This portion of the tibia
articulates within a depression in the talar surface and
6. Posterior tibiofibular ligament is called the sagittal groove. This groove lies between
the medial and lateral shoulders of the talus and projects
7. Transverse tibiofibular ligament
from anterior to posterior. At the area between the ante-
8. Tip of the medial malleolus/medial malleolus rior tibial lip and the capsule is a periosteum-covered
subchondral bone, the synovial recess. This extends
9. Posteromedial gutter from medial all the way to the lateral portion of the
ankle. This is where tibial osteophytes develop and syno-
10. Posteromedial talus/tibia vium and capsule become adherent at the margins of the
osteophyte. More laterally, the trifurcation includes the
11. Posterocentral talus/tibia distal lateral tibial plafond, the lateral dome, and the fib-
ula and is bounded by the anterior inferior tibiofibular
12. Posterolateral talus/tibia ligament superiorly. This relation is important in the
ankle, because this is often the site of soft-tissue pathol-
13. Posterolateral gutter
ogy. The syndesmotic or anterior inferior tibiofibular
14. Tip of lateral malleolus ligament runs at approximately a 45-degree angle from
the lateral portion of the distal tibia to the fibula, just
Additional (when indicated): below the level of the lateral talus. The anterolateral talar
dome also is the site of osteochondral lesions of
Posterior tibial tendon the talus, and access into ankle joint usually is easy in
this region. The lateral gutter is the space between the
Flexor digitorum tendon medial border of the fibular articulation and the lateral
border of the talar articulation. It extends from below
Peroneal tendons the anterior inferior tibiofibular ligament to the anterior
From Van Dijk CN, Scholten PE, Krips R: Arthroscopy
talofibular ligament. This often is the site of chondro-
16:871, 2000. malacia and ossicles at the tip of the fibula within the
ligament substance. The anterior talofibular ligament
lies intracapsular and runs from the tip of the fibula to
Anterior ankle examination the inferior lateral portion of the talus. It can be easily
The anterior arthroscopic examination always is per- reached for a shrinkage procedure in case of laxity in
formed initially through the anteromedial portal and patients with chronic anterolateral ankle instability.
then through the anterolateral portal. The structures The anterior gutter represents the capsular reflection
that can be visualized are the following (from medial anteriorly of the ankle as it inserts along the talar neck.
to lateral): (1)The deep portion of the deltoid ligament There is a normal bare area proximal to the capsular
as it arises from the tip of the medial malleolus and its insertion, similar to the area on the central portion of
fibers run vertically down to the medial trochlear surface the distal tibia. A synovial recess also can be found at
of the talus. This is an area where ossicles may be the anterior inferior aspect of the talar dome. In this
hidden, and it should be evaluated carefully for pathol- area, anterior talar osteophytes may articulate or butt
ogy. (2) Also noted is the articular surface of the tip against osteophytes of the anterior tibial lip.10
of the medial malleolus as it corresponds and articulates
with the medial talar dome and the posterior recess and Posterior ankle examination
posterior ligaments. The medial gutter includes the area Using a posterolateral and posteromedial portal with
from the deltoid ligament to below the medial dome of the patient in the prone position, one first approaches
362
...........
Surgical technique
Figure 16-10 Right ankle. Using a posterolateral and

posteromedial portal with the patient in the prone position,
one first approaches the fatty tissue overlying the joint Figure 16-11 Left ankle. Removal of a symptomatic os
capsule. This tissue can be partially removed. trigonum (OT) or a nonunion of fracture of the posterior talar
process involves partial detachment of the posterior talofibular
ligament and release of the flexor retinaculum, both of which
the fatty tissue overlying the joint capsule (Fig. 16-10). attach to the posterior talar prominence.
This tissue can partially be removed. At the level of
the ankle joint, the posterior tibiofibular ligaments and
the posterior talofibular ligament can be recognized.
After removal of the very thin joint capsule of the sub-
talar joint, the posterior compartment of the subtalar
joint can be visualized. The posterior talar process can
be freed of scar tissue and the FHL tendon identified.
The FHL tendon is an important landmark to prevent
damage to the more medially located neurovascular
bundle. When manual distraction is applied to the os
calcis, the posterior compartment of the ankle joint
opens up and can be visualized. The arthroscope and
instruments can be introduced into the posterior ankle
compartment. Procedures such as a synovectomy and/
or capsulectomy of both ankle and subtalar joint can
be performed. On the medial side, the tip of the medial
malleolus, as well as the deep portion of the deltoid lig-
ament, can be visualized. Opening the joint capsule
from inside out at the level of the medial malleolus per-
mits the tendon sheath of the posterior tibial tendon
to be opened and the arthroscope to be introduced into
Figure 16-12 Left ankle. Removal of a symptomatic os
the tendon sheath. The posterior tibial tendon can be
trigonum (OT) involves partial detachment of the posterior
inspected. The talar dome and nearly the entire surface
talofibular ligament (PTFL) and release of the flexor
of the complete tibial plafond can be inspected, as well. retinaculum, both of which attach to the posterior talar
An osteochondral defect or subchondral cystic lesion prominence (see also Fig. 16-13).
can be identified, debrided, and drilled. The posterior
syndesmotic ligaments are inspected and, if hypertro-
phic, partially resected. The intrinsic syndesmotic area talofibular ligament and release of the flexor retinaculum,
and the posterior talofibular ligament can be inspected both of which attach to the posterior talar prominence.
(Figs. 16-11 and 16-12). Removal of a symptomatic os Release of the FHL tendon involves detachment of
trigonum or a nonunion of fracture of the posterior talar the flexor retinaculum from the posterior talar process
process involves partial detachment of the posterior (Fig. 16-13). Adhesions surrounding the flexor tendon
363
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SPECIFIC INDICATIONS
.............................................................
Anterior ankle impingement
Anterior ankle impingement syndrome is a clinical diag-

nosis characterized by anterior ankle pain with recog-
nizable pain and a (slightly) limited dorsiflexion.10,16
Clinically, the patient complains of anterior joint pain
made worse after activity such as walking up stairs or
hills. Squatting or running is especially bothersome.
Tenderness with recognition is localized over the ante-
rior aspect of the ankle joint. Forced ankle dorsiflexion
sometimes can provoke the complaints, but in most
patients this test is negative. Plain radiographs may dem-
onstrate anterior osteophytes. Additional oblique views
(AMI views) can be helpful to demonstrate anterome-
dially located osteophytes (Fig. 16-14, A and B).16,17
In case of anterior ankle pain with negative x-ray find-
ings, the most likely cause of the complaints is an ante-
Figure 16-13 Left ankle. Release of the flexor hallucis longus rior soft-tissue impediment.18 Congenital plicae within
retinaculum from the posterior talar process to remove a the ankle, posttraumatic scar tissue, adhesions, or gang-
symptomatic os trigonum (OT) (see also Figs. 16-11 and 16-12). lions all may act as a local soft-tissue impediment with
local swelling and recognizable pain on palpation.
Scoring systems for anterior impingement use the
can be removed. On the lateral side, the peroneal location (tibia or talus) and size of osteophytes as prog-
tendons can be inspected. A tight and thickened crural nostic factors for postoperative success. Scranton et al.19
fascia can hinder the free movement of instruments; it compared open resection with arthroscopic resection of
can be helpful to enlarge the defect in the fascia by means painful anterior impingement spurs. They categorized
of a punch or shaver. ankle spurs from grades 1 through 4 according to the
Figure 16-14 (A) Plain lateral radiographs do not always demonstrate anterior located osteophytes, especially
when they are located anteromedially. (B) Additional oblique views (AMI) in the same patient as in A now
demonstrate anteromedially located osteophytes.
364
...........
Specific indications
size of spurs and degree of involvement of the ankle, and In normal anatomy, the lower surface of the anterior
demonstrated that the treatment and recovery correlated tibia and the anterior part of the medial malleolus
with the grade. Grades 1, 2, and 3 spurs could be are covered with cartilage. The anterior joint capsule
resected arthroscopically or by arthrotomy. Grade 4 attaches onto the tibia above this cartilage rim,
spurs initially were not thought to be appropriate for approximately 5 mm above the joint line.21 It is this
arthroscopic resection. However, as experience has nonweight-bearing anterior cartilage rim that undergoes
increased, grade 4 spurs also can be resected arthro- the osteophytic transformation (Fig. 16-15). Damage to
scopically. The reproducibility of this classification sys- this anterior cartilage rim is known to occur in the
tem may be doubtful because the correlation was majority of inversion traumas. Depending on the degree
assessed with outcomes at short-term follow-up (10 of damage, a repair reaction with cartilage proliferation,
weeks postoperatively). It has been determined that the scar tissue formation, and calcification follows. Addi-
degree of osteoarthritic changes influences the outcome tional damage by recurrent instability or forced ankle
of treatment. Osteophytes without joint space narrowing movement will further this process. Recurrent direct
are not a manifestation of osteoarthrosis; subsequently a (micro) trauma to this anteriorly located cartilage rim
‘‘normal’’ joint remains after removal of these spurs. could be another important factor.21 Except for a thin
A classification for anterior ankle impingement based on subcutaneous layer, parts of the involved anterior carti-
the degree of degeneration was developed (Table 16-3).10 lage rim (especially the anteromedial and anterolateral
The results at long-term follow-up show that the use segments) are covered only by skin. Osteophytes are
of this osteoarthritic classification is more discriminating seen most commonly with a beak-like prominence of
than the impingement classification of Scranton and bone at the anterior lip of the tibia, usually associated
McDermott as a predicting value for the outcome of with a corresponding area over the anterior neck of the
arthroscopic surgery for anterior ankle impingement.10,19 talus. The talar abnormality may be a defect or an
Soft-tissue pathology accounts for about 30% to 50% opposing osteophyte (‘‘kissing lesion’’).
of lesions seen in the ankle joint.18 The lesions usually A common location for a soft-tissue impingement is
involve the synovium, but the capsule or ligamentous the anterolateral gutter.22 Several studies report on
tissues also may be affected. Soft-tissue impingement patients with persistent pain and swelling over the
often is the primary cause of chronic ankle pain, usually
after an ankle sprain. This can occur along the syndes-
mosis, the anterior gutter, or the syndesmotic interval
between the tibia and fibula; underneath the ankle; or
posteriorly in the syndesmosis and posterior gutter.20
Impingement of soft tissue often occurs in conjunc-
tion with bony impingement. Osteophytes can impinge
into the capsule and synovium, resulting in an inflam-
matory reaction. The pain in a patient with bony im-
pingement is most likely caused by this soft-tissue
impingement and not by the bony impediments itself.10
Table 16-3 Classification system for degenerative

changes of the ankle
Grade X-ray finding

1 Normal joint or subchondral sclerosis
2 Osteophytes without joint space narrowing
3 Joint space narrowing with or without Figure 16-15 Histologic sample of anterior joint capsule
osteophytes covering the anterior rim of the distal tibia and talus at the
level of the ankle joint. In normal anatomy, the lower surface of
4 (Sub) total disappearance or deformation the anterior tibia and the anterior part of the medial malleolus
of the joint space are covered with cartilage. The anterior joint capsule attaches
onto the tibia above this cartilage rim, approximately 5 mm
From Van Dijk CN, Tol JL, Verheyen CCPM: Am J Sports Med above the joint line.21 It is this nonweight-bearing anterior
25:737, 1997. cartilage rim that undergoes the osteophytic transformation.
365
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anterolateral aspect of the ankle after an inversion sprain.

Arthrotomy of these ankles reveals hyalinized connective
tissue extending into the joint from the anterior inferior
portion of the talofibular ligament. This tissue is called a
‘‘meniscoid’’ lesion by some authors.23
Patients generally have a synovitis surrounding the
anterior inferior tibiofibular ligament, both in front
and behind, as well as synovitis of the anterior talofibular
ligament. In addition, a small ossicle or loose body may
be hidden in the soft tissues at the tip of the fibula.
Rarely, an adhesive thick scar band, previously described
as a meniscoid lesion, is present, extending from the
anterolateral aspect of the distal tibia to the lateral
gutter. After surgical reconstruction of the lateral
ankle ligaments, soft-tissue impingement may be pres-
ent between the reconstructed ligaments and the
talus.
In case of anterior and anteromedial located osteo-
phytes, an additional soft-tissue impediment usually is
present. During dorsiflexion, hypertrophic synovial tis-
sue impinges between the osteophytes. Tol et al.21,24
concluded that the cause of pain is not the osteophyte
itself but a soft-tissue impingement that occurs between
the osteophytes. It can be hypothesized that removal of
the soft-tissue impediment without removal of spurs
would be sufficient. The presence of talar and tibial
osteophytes, however, reduces the anterior joint space.
After an arthroscopic intervention, a hematoma will be
formed postoperatively that subsequently will develop Figure 16-16 The heel of the affected ankle rests on the end
into scar tissue. The scar tissue that fills the defect will of the operating table, thus making it possible for the surgeon
to dorsiflex the ankle joint fully by leaning against the sole of
act instantly as a new anterior soft-tissue impediment.
the patient’s foot.
It therefore is important to remove the osteophytes to
enhance more anterior and anteromedial space and
diminish the chance for a recurrence of symptoms.16,21,24
Visualization of the anterior ankle joint can be impro- anterior to the tip of the lateral or medial malleolus are
ved by bringing the ankle into a forced dorsiflexion posi- used only when indicated. Osteophytes are removed by
tion because in this position the anterior working area a 4-mm chisel and burr. These spurs can be identified
opens up. Distraction makes the anterior capsule more easily when the ankle is in a fully dorsiflexed position to
tense over the osteophyte, and its use therefore is not prevent the anterior joint capsule from covering the
recommended.10 It is important to identify the anterior osteophytes. Another advantage of the forced dorsiflex-
and superior borders of the osteophyte, and this often ion position is the fact that the talus is concealed in the
requires careful elevation or peeling of soft tissues from joint, thereby protecting the weight-bearing cartilage of
the confines of the osteophyte. the talus from potential iatrogenic damage. The contour
of the anterior tibia is first identified by shaving away the
Surgical technique tissue just superior to the osteophyte. An overcorrection
The patient is placed in a supine position with slight of the medial malleolus generally is pursued by shaving
elevation of the ipsilateral buttock. The heel of the some of it away after resection of the osteophyte.
affected ankle rests on the very end of the operating
table, thus making it possible for the surgeon to fully Rehabilitation
dorsiflex the ankle joint by leaning against the sole of Postoperative rehabilitation consists of a compressive
the patient’s foot (Fig. 16-16). After making an antero- bandage and partial weight bearing for 3 to 5 days.
medial skin incision, the surgeon bluntly divides the The patient is instructed to actively dorsiflex his or her
subcutaneous layer with a hemostat. A 4-mm, 30-degree ankle and foot on awakening and to continue this exer-
arthroscope routinely is used. The anterolateral portal is cise a few times every hour for the first 2 to 3 days after
made under arthroscopic control. Additional portals just surgery.
366
...........
Synovitis underestimated because these lesions often remain

Synovitis can be a noninflammatory, inflammatory, or undetected. The incidence has been reported to be as
septic process of the synovium, which is most character- high as 6.5% after ankle sprains. Osteochondral defects
ized by joint swelling and tenderness. Synovitis can be of the talus most often occur in young adults, with a
caused by trauma or previous surgery. A generalized nearly equal distribution between the sexes. In the acute
or localized synovitis can occur, most often with situation, symptoms depend on the amount of damage
fibrous bands and adhesions. Synovitis accounts for to the periarticular tissues and the involvement of affer-
approximately 30% of pathology seen in the ankle joint.15 ent pain fibers in the subchondral bone. Usually the
Patients usually have complaints of aching, swelling, lesion is located in the anterolateral or posteromedial
tenderness, and other signs of joint inflammation. A his- aspect of the talar dome. Histologically the medial and
tory of trauma or injury is more likely to cause a nonspe- lateral lesions are identical, but morphologically they
cific type of synovitis, either localized or generalized; differ. The lateral lesions are shallow and more wafer
however, trauma also can trigger an underlying specific shaped, indicating a shear mechanism of injury. In con-
pathologic process. Radiographs often are negative. trast, medial lesions generally are deep, cup shaped,
The clinical manifestation of soft-tissue lesions can be and located posteriorly, indicating a mechanism of tor-
divided into the following: sional impact. From an etiologic point of view, trauma
1. Impingement, lesions with local pain and swelling. is the most common cause of osteochondral lesions of
2. Diffuse pain, swelling, calor, restriction of range the talus, but idiopathic osteonecrosis often may be
of ankle motion in all directions. the underlying pathologic process. In the literature the
3. Deep ankle pain without recognizable pain on latter has been associated with alcohol abuse, use of
palpation, no local swelling, and only minor rest- steroids, endocrine disorders, and some hereditary con-
riction of range of motion. ditions. Although initial symptoms may be absent, in
4. Absence of symptoms. chronic cases most patients present with intermittent
Synovitis of the ankle may be a difficult diagnostic pain located deep in the ankle joint that increases on
problem. Even after careful history, physical examina- weight bearing. On physical examination, signs often
tion, and diagnostic testing, the diagnosis may not be are lacking. A discrete limitation of range of motion
readily apparent. with some synovitis may be present. Local tenderness
During arthroscopy, localized or generalized inflam- on palpation with recognition is absent in most cases.
mation of the synovia can be present. It may contain Because there are no specific pathognomonic signs or
hemosiderin or fibrin debris. Scarring, fibrosis, and symptoms, it is essential that the examining physician
adhesions often are seen in relation to the synovitis. and radiologist be aware that an osteochondral lesion
In 1997, Cheng and Ferkel25 proposed the following can be present. The frequent absence of radiographic
classification system for synovial disorders: changes on conventional radiographs has led to the
Congenital: plicae or congenital bands within the use of more sensitive methods for detection. A heel-rise
ankle; plicae, or shelves, have been demonstrated in view can be helpful to detect an osteochondral lesion.
the knee but are difficult to find in the ankle. Con- A recent prospective study of Verhagen26 demonstrated
genital bands are seen as an incidental finding when that with this additional view the chance of finding an
examining the ankle for other types of pathology osteochondral lesion of the talus with x-ray examination
Traumatic: sprains, fractures, and previous surgery is doubled (Fig. 16-17). CT scan and MRI can be help-
Rheumatic: rheumatoid arthritis, pigmented villo- ful for the diagnosis and preoperative planning. In the
nodular synovitis, crystal synovitis, hemophilia, and prospective study of Verhagen, there was no statistically
synovial chondromatosis significant difference between the sensitivity and speci-
Infectious: bacterial and fungal ficity of CT and MRI in detecting an osteochondral
Degenerative: primary and secondary lesion of the talus.
Neuropathic: Charcot joint Pritsch, Cheng, Ferkel, and Applegate developed
Miscellaneous: ganglions, arthrofibrosis an arthroscopic staging system that correlated well
with the CT classification of Ferkel and Sgaglione
(1994)27-29 and the MRI classification of Anderson
et al. (1989).27-32 Recently, a new arthroscopic staging
Osteochondral defects system was developed by Taranow et al.,33 who classified
An important cause of residual pain after an ankle sprain cartilage as viable and intact (stage A) or breached and
is an osteochondral lesion of the talus. It is defined as nonviable (stage B). The bone component was deter-
the separation of a fragment of articular cartilage, with mined as follows: (1) stage 1 is a subchondral compres-
or without subchondral bone. The incidence of an sion or bone bruise, (2) stage 2 lesions are subchondral
osteochondral lesion after an ankle sprain probably is cysts and are not seen acutely (these develop from stage
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Figure 16-17 A heel-rise view (left) demonstrates a posteromedially located osteochondral defect. Because of the
relative posterior location of the defect, a plain anterior-posterior view (right) is not able to demonstrate this lesion.
1 lesions), (3) stage 3 lesions are partially separated or

detached fragments in situ, and (4) stage 4 represents
displaced fragments. The condition of the cartilage and
bone together determines the type of surgical treatment.
Despite the existence of these classification systems,
few authors base their decision for a specific treatment
on these systems. A meta-analysis of Tol et al.34 showed
that the value of preoperative radiologic staging systems
was of minor value in the preoperative planning because
they hardly correlate with the perioperative findings.
This demonstrates the shortcoming of preoperative Figure 16-18 From anterior to posterior the talar dome can be
radiologic staging systems as a guide for the treatment divided into four equal parts. When an osteochondral defect
strategy. Perioperative staging of osteochondral defects is located in one of the three anterior parts it can be reached
therefore seems more appropriate. Eventually, the most by a routine anterior ankle arthroscopy. Soft-tissue distraction
rational way of preoperative assessment of osteochondral might be necessary. When the lesion is located in the most
lesions is to determine whether they are symptomatic or posterior quarter, it can be reached only by posterior ankle
asymptomatic. arthroscopy.
Surgical technique the anterior working area by forcing the ankle into full
From anterior to posterior the talar dome can be divided plantarflexion. The osteochondral defect in the posterior
into four equal parts (Fig. 16-18). When the osteochon- quarter of the talar dome is difficult to reach in the hyper-
dral defect is located in one of the three ‘‘anterior’’ parts plantarflexed position in patients having a diminished
of the talar dome, it can be treated by a routine anterior plantarflexion or in case of anterior osteophytes.33,35
ankle arthroscopy. When it is located in the most poste- Routinely the procedure is performed without dis-
rior quarter of the talar dome, the defect should be traction. The standard anteromedial and anterolateral
approached by a posterior ankle arthroscopy or by approaches are created as described earlier. In an osteo-
means of a medial malleolar osteotomy. The current chondral defect located medially, the 4-mm arthroscope
treatment consists of removal of dead bone and overly- is moved over to the anterolateral portal and the in-
ing cartilage.34 After debridement, the subchondral scle- struments are introduced through the anteromedial
rotic zone is perforated with a burr or K-wire or by portal. For an anterolateral defect, the arthroscope
microfracturing. Preoperatively, it is desirable to decide remains in the anteromedial portal and the instruments
whether to use mechanical distraction in combination are introduced through the anterolateral portal. If
with a 2.7-mm arthroscope or to use a standard 4-mm osteophytes are present, they are removed first by chisel
arthroscope and to treat the osteochondral defects in and/or burr. Synovitis located anterolaterally (in case of
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an anterolateral defect) or anteromedially (in case of an but it also should be possible to visualize at least the
anteromedial defect) is removed by a 4.5- or 5.5-mm most anterior part of the lesion. It can be helpful to
synovator. The extent of removal of osteophytes and add soft-tissue distraction (Fig. 16-20, A and B).24
synovitis is checked by bringing the ankle into plantar- If possible, a 3.5- or 4.5-mm synovator is now intro-
flexion. It now should be possible to palpate and visua- duced into the defect. After the defect has been de-
lize the osteochondral defects (Fig. 16-19). If this is brided by the synovator or curette, the arthroscope is
not the case, then a further synovectomy is performed moved over to the portal opposite the defect (the
in the dorsiflexed position. After sufficient synovectomy, anteromedial portal in case of an anteromedial
it should be possible to identify the lesion in the forced osteochondral defect) to check the completeness of
plantarflexed position by palpating the cartilage with a the debridement. The scope then is brought back to the
probe. Not only can the lesion be palpated with a probe opposite portal and further debridement is performed.
It is important to remove all dead bone and overlying,
unsupported, unstable cartilage. Every step in the
debridement procedure should be checked by regularly
switching portals. A precise and complete debridement,
with removal of all loose fragments, thus can be per-
formed. Introduction of the instruments and the arthro-
scope is performed with the ankle in the fully dorsiflexed
position, thus preventing iatrogenic cartilage damage.
After full debridement, the sclerotic zone is performed
by microfracturing technique, or multiple drill holes
are made with a 2-mm burr or a 1.6-mm K-wire. A K-
wire has the advantage of flexibility, whereas a 2-mm
drill can break more easily if the position of the ankle
is changed during drilling. When a 2-mm drill is used,
a drill sleeve is necessary to protect the tissue.
In posteriorly located lesions for which an anterior
approach is chosen, a noninvasive traction device that
allows the surgeon to change quickly from the fully
dorsiflexed position (introduction of the instruments)
to the distraction position offers obvious advantages.
The distraction device consists of a belt around the waist
Figure 16-19 An anterolateral located osteochondral defect of the surgeon that is connected to a noninvasive dis-
of the talus. By bringing the ankle in full plantarflexion, the traction loop placed around the ankle. The amount of
defect can be fully debrided. Completeness of the distraction can be adjusted by leaning more or less
debridement can be checked by switching portals. backward (see Fig. 16-20, B).
Figure 16-20 (A) A resterilizable soft-tissue distractor can be helpful to visualize lesions that are located more
posteriorly in the ankle joint. (B) The amount of soft-tissue distraction can be adjusted by leaning more or less
backward.
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Loose bodies and ossicles calcifications, loose bodies, and bony avulsions; osteo-
A loose body can be bony, chondral, or osteochondral. chondral defects; tendinitis of the FHL tendon; tendini-
It arises from osteophytes or defects in the talus or tibia. tis of the posterior tibial tendon; tendinitis the peroneal
Ossicles, broken osteophytes, and chondral or osteo- tendons; tendinitis of the Achilles tendon; and ankle and
chondral fragments arising from defects in the talus subtalar arthrosis.13,35
or tibia all can be considered loose bodies in the ankle Os trigonum syndrome
joint. Sometimes, such a loose body is attached with scar
tissue to the capsule or other structures, and then it is The os trigonum is an inconsistently present accessory
called a ‘‘corpus liberum pendulans.’’15 A small, loose bone of the foot situated at the posterolateral aspect of
body may cause catching symptoms along with pain, the talus. It appears between the ages of 8 and 11 as a
swelling, and limitation of motion. Symptoms of inter- secondary center of ossification and usually fuses to the
nal derangement may resolve if a small loose body talus within 1 year after its appearance. When this ossi-
becomes fixed to the synovial lining, ceasing to cause fication center remains separate from the talus it is
joint irritation. A loose body may grow by proliferation referred to as the os trigonum. According to Sarrafian,
of chondroblasts/osteoblasts or may shrink because of the prevalence of this ossicle ranges from 1.7% to
the action of chondroblasts/osteoclasts. 7.7%.36 When fusion does occur and there is a large,
The physical examination may not be very revealing, intact posterolateral process, it is referred to as a fused
with vague areas of tenderness, possible limitation of os trigonum. Since Rosenmuller first described the os
motion, and catching. Rarely is a loose body palpable. trigonum in 1804, there has been controversy con-
As with all ankle problems, a careful physical exami- cerning its origin.37 McDougall38 believed it to be a
nation must rule out extra-articular entities that can secondary ossification center of the talus, whereas other
cause symptoms similar to intra-articular lesions. Pero- authors state that it is a nonnunited fracture of the
neal subluxation, posterior tibial tendon attrition or posterolateral talar process. The os trigonum usually
rupture, tarsal tunnel syndrome, sinus tarsi syndrome, remains asymptomatic, but an otherwise normal os tri-
stress fracture, and tendinitis must be carefully excluded gonum can become symptomatic during or after stren-
by both physical examination and ancillary studies. Plain uous physical activities or following an injury to the
radiographs usually reveal an osseous loose body, but ankle. Sometimes an acute trauma in plantarflexion
chondral loose bodies are not visible on routine studies. may result in contusion, compression, or fracture of
A CT or MRI study is best suited to make the distinc- the os trigonum or posterior process of the talus. These
tion between an intra-articular versus an extra-articular injuries may cause an overload posttraumatic syndrome
or intracapsular abnormality. of the os trigonum. In this condition, the os trigonum
The arthroscopic approach to loose bodies is becomes painful but appears undisrupted on the lateral
straightforward. Loose bodies localized to the anterior x-rays (Fig. 16-21). On the other hand, chronic im-
compartment, particularly in patients with ligamentous pingement of the posterior process of the talus against
laxity, can be approached with a routine setup using the tibia caused by chronic microtrauma or overuse by
anteromedial and anterolateral portals. However, the repeated hyperplantarflexion movements can lead to an
posterior joint also should be examined for the pres- inflammatory process of the os trigonum. It also can
ence of loose bodies, which can hide in the posterior result in degenerative changes in the posterior capsule
recess of the joint.13,35 A posterolateral portal can be of the ankle joint, adjacent ligaments, tendon, and
made. Posteriorly located loose bodies can be removed chondrosynovial surface.
best by means of a two-portal posterior approach. Clinically, the patient complains of pain during push-
off while running. The pain often is absent during
walking on level ground but appears on uneven terrain.
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Posterior ankle impingement Usually pain is complained of posterolaterally in the ankle
joint but sometimes it may be located in the posterome-
Posterior ankle syndrome is a pain syndrome. The dial region. Physical examination can reveal the presence
patient experiences posterior ankle pain that is present of moderate swelling on only the medial or on both sides
mainly on forced plantarflexion. Posterior ankle im- of the Achilles tendon, with tenderness on palpation.
pingement is caused by overuse or trauma.13 Distinction A forced passive plantarflexion of ankle and foot will
between these two disorders seems important because reproduce the recognizable symptoms. With this test
posterior impingement through overuse has a better the examiner performs repetitive, quick, passive forced
prognosis. A posterior ankle impingement syndrome is plantarhyperflexion movements. The test can be repeated
found mainly in ballet dancers and runners. in slight exorotation or endorotation of the foot relative
There are at least 10 specific causes for posterior to the tibia. The investigator should apply this rotation
ankle pain: os trigonum syndrome; posttraumatic movement on the point of maximal plantarflexion,
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Figure 16-21 Posttraumatic syndrome of the os trigonum of the right ankle. Plain lateral x-rays (left) reveal an
undisrupted os trigonum. Additional posteromedial impingement views (PIM) with the foot in 25-degrees
external rotation in the same patient show that the os trigonum is disrupted.
thereby ‘‘grinding’’ the posterior talar process/os trigo- excellent access to the posterior ankle compartment of
num between the posterior tibial rim and calcaneus the ankle joint. The posterior compartment of the ankle
(Fig. 16-22). A negative test rules out a posterior im- joint thus can be visualized, and the subtalar joint, os
pingement syndrome. A positive test in combination trigonum, and FHL can be inspected. After inspection,
with pain on posterolateral palpation can be followed by the posterior talofibular ligament must be detached
a diagnostic infiltration. The infiltration is performed from the posterior talar process. The superior border
from the posterolateral position between the prominent of the posterior talar process is cleaned with the shaver,
posterior talar process and the posterior edge of the tibia. after which the FHL tendon can be inspected (Fig. 16-
If the pain disappears on forced plantarflexion, the diag- 24). The flexor retinaculum can be cut. After this has
nosis is confirmed. After clinical examination, a routine been performed, the posterior talocalcaneal ligament
lateral radiograph of the ankle should reveal an os tri- must be cut. Finally, the os trigonum can be detached
gonum. Bone scanning can effectively localize osseous with a chisel or small osteotome and subsequently
injuries in and around the talus by demonstrating removed (Fig. 16-25).
increased uptake in the posterior talar region but is not
very specific. A CT scan enables the surgeon to determine Posttraumatic calcifications, loose bodies, and
the exact location, size, and shape of the ossicle and bony avulsions
therefore is valuable for preoperative planning (Fig. 16-23, Calcifications, loose chondral or osteochondral frag-
A and B). ments, and bony avulsions may result from major
FHL tendinitis often is present in patients with a trauma to the ankle joint.15 When the fragments are
symptomatic os trigonum with pain located posterome- located in the posterior compartment of the ankle, they
dially. The FHL tendon can be palpated behind the are most likely the result of a hyperplantarflexion trauma
medial malleolus. By asking the patient to flex the toes or a combination of strong inversion, plantarflexion, and
repetitively with the ankle in 10- to 20-degrees plantar- external rotation of the tibia. In either case, an unsus-
flexion, the FHL tendon can be palpated in its gliding pected chondral or osteochondral lesion may occur
channel behind the medial malleolus. During palpation and result in a loose body floating in the posterior com-
there may be crepitus and recognizable pain. partment of the ankle or subtalar joint.
A two-portal (posterolateral and posteromedial) Osteophytes of the posterior tibial rim, an os trigo-
approach with the patient in the prone position gives num, and even part of the posterior talar process may
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Figure 16-22 Forced passive plantarflexion test. This test will

reproduce the recognizable symptoms. The examiner performs
repetitive, quick, forced passive plantarhyperflexion
movements. The investigator should apply rotational
movements on the point of maximal plantarflexion, thereby
‘‘grinding’’ the posterior talar process/os trigonum between
the posterior tibial rim and calcaneus.
break off during a hyperplantarflexion trauma and act

as a loose body. After a severe inversion trauma, the pos-
terior talofibular ligament may avulse a bony fragment Figure 16-23 (A and B) A computed tomography scan enables
the surgeon to determine the exact location, size, and shape
from posterior talar process and may cause posterior
of loose ossicles and is therefore valuable for preoperative
ankle impingement. planning. (A) A loose fragment posterolateral in the ankle joint
Multiple loose cartilaginous or osteocartilaginous on a sagittal reconstruction. (B) Loose fragments between the
bodies also may form in synovial chondromatosis. distal fibula and talus of the left ankle.
A small, loose body may cause catching symptoms
with joint motion along with pain. Plantarflexion may
be limited and painful during the hyperplantarflexion routine radiographs to be loose bodies may actually
test. Plain lateral radiographs usually reveal an osseous be intra-articular, intracapsular, or extra-articular in loca-
loose body, but when located posteromedially it may tion, particularly in the posterior ankle joint compart-
overproject. An additional posteromedial impingement ment. The location of the lesions should be determined
view (PIM) with the foot in 25-degree external rotation preoperatively to avoid embarrassment of performing
relative to the tibia is helpful when there is suspicion for an arthroscopic examination for loose body removal
bony pathology in posteromedial compartment of the only to find the joint free of any abnormality. A CT
ankle joint (see Fig. 16-21). Lesions that appear on scan is best suited to make the distinction between an
372
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in this manner. However, when the lesion is located in

the most posterior quarter, the lesion can be treated
by posterior ankle arthroscopy. A preoperative CT scan
with sagittal image reconstructions is important to
determine the exact location of the lesion (Fig. 16-26).
In case of a posteromedially located osteochondral
defect, the FHL tendon should be inspected routinely.
The tendon can be affected because of shredding of
the tendon against the defect during flexion of the great
toe while walking. When the tendon is affected, the
flexor retinaculum should be cut and thus the tendon
released and debrided.
Tendinitis of the FHL tendon

Tendinitis of the FHL tendon is caused most often by
posterior overuse and posttraumatic injuries in ballet
dancers and soccer players.39 In the majority of cases it
is a concomitant finding with other pathology, such as
an os trigonum, loose bodies, bony avulsions, ankle
and subtalar arthrosis, and their combinations. An un-
expected but consequent finding that may cause FHL
Figure 16-24 Right ankle. Inspection of the flexor hallucis tendinitis is a posteriorly located osteochondral defect.
longus tendon in its channel. The view is from proximal to The defect is located in the posterior quarter of the talar
distal. See also Figs. 16-6 and 16-13. dome on the medial side. The tendinitis is maintained
during the stance phase when walking. During this
phase the ankle joint is in dorsiflexion. In this position
the posterior talar dome is in closest contact with the
tendon. The tendon, meanwhile, is moving in the oppo-
site direction because the toes are actively flexed to start
with the push-off phase. The tendon shreds against the
Figure 16-25 Removal of an os trigonum with a chisel. On the

left the flexor hallucis longus tendon is located.
intra-articular abnormality versus an extra-articular or

intracapsular abnormality and to determine the exact
location in the posterior ankle joint compartment.
Osteochondral defects
Figure 16-26 A preoperative computed tomography (CT) scan
In sagittal plane the talar dome can be divided into four
with sagittal image reconstructions is important to determine
equal quarters. When an osteochondral lesion is located the size and location of posterior located osteochondral
in one of the anterior three quarters of the talar dome, it defects. A sagittal CT reconstruction of a left ankle with an
can be approached and treated by routine anterior ankle osteochondral defect that is located at the posterior end of the
arthroscopy. The majority of the lesions can be treated talar dome.
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the foot and thus prevents valgus deformity. Several

authors have described a series of stages of posterior
tibial tendon dysfunction as the disease progresses from
peritendinitis to elongation and degeneration of the
tibialis posterior tendon with fixed valgus deformation
of the foot.39 Tenosynovitis is often seen in association
with flatfoot deformity or a prominent navicular tuber-
cle and, to a lesser extent, in association with psoriatic
and rheumatoid arthritis. In the early stage of posterior
tibial tendinitis, tenosynovectomy can be performed
if conservative treatment fails. Postsurgery and post-
fracture adhesions and irregularity in the contour of
the posterior aspect of the tibia/medial malleolus can
account for a symptomatic posterior tibial tendon. Post-
traumatic calcification in the posteromedial joint capsule
can produce symptoms of posterior tibial tendinitis
because of the close connection of joint capsule and pos-
terior tibial tendon sheath in this region. In a cadaveric
Figure 16-27 In a cadaver specimen it is shown that the flexor study, we found a consistent membranous mesotendi-
hallucis longus tendon shreds against the posterior part of the neal structure between tendon and tendon sheath.39
talus (often the place where osteochondral defects are This thin, vincula-like structure runs between the poste-
located) during dorsiflexion (see text). rior tibial tendon and tendon sheath and attaches to the
tendon sheath of the flexor digitorum tendon. It runs
osteochondral defects and becomes irritated and in- from the proximal end all the way with a free edge
flamed (Fig. 16-27). In this way a posteriorly located approximately 4 to 5 cm above the level of the postero-
osteochondral defect can cause an FHL tendinitis. In a medial tip of the malleolus. After traumatic injury to the
consecutive series of patients with FHL tendinitis, the ankle, these mesotendineal structures may have clinical
tendinitis was accompanied by os trigonum syndrome, implications.
bony avulsions, calcifications, and localized synovitis The main portal for posterior tibial tendoscopy is
in 40 of 50 patients. In 7 patients the FHL tendinitis located directly over the tendon, 2 cm distal to the pos-
was combined with a posteromedial osteochondral terior edge of the medial malleolus. The distal portal is
defect, all located in the posterior quarter of the talar made first, with an incision through the skin. The ten-
dome. Thus in only 3 patients did we find an isolated don sheath is penetrated by the arthroscope shaft with
FHL tendinitis to be present.
The pain of an FHL tendinitis is located posterome-
dially. The tendon can be palpated behind the medial
malleolus. By asking the patient to flex the toes repeti-
tively with the ankle in 10- to 20-degrees plantarflexion,
the FHL tendon can be palpated in its gliding channel
behind the medial malleolus. The tendon glides up and
down under the palpating finger of the examiner.
In case of stenosing tendinitis or chronic inflammation,
there may be crepitus and recognizable pain. Sometimes
a nodule in the tendon can be felt to move up and down
under the palpating finger.40
During posterior ankle arthroscopy, the FHL tendon
is an important landmark to prevent damage to the more
medially located neurovascular bundle.13,35 When a
tendinitis is present, it is treated by performing a release
of the flexor retinaculum (Fig. 16-28). Adhesions
surrounding the FHL tendon can be removed.
Tendinitis of the posterior tibial tendon

Figure 16-28 Release of the flexor retinaculum in a left ankle.
The posterior tibial tendon plays an important role in Adhesions surrounding the flexor hallucis longus tendon are
normal hindfoot function. It plantarflexes and supinates removed.
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tendon disorders often are associated and secondary to

chronic lateral ankle instability.41 Because the peroneal
muscles act as lateral ankle stabilizers, more strain is
placed on their tendons in the presence of chronic
lateral instability, resulting in hypertrophic tendinopa-
thy, tenosynovitis, and ultimately in (partial) tendon
tears. The diagnosis may be difficult in patients with
lateral ankle pain. Recurrent peroneal tendon dislocation
and tenosynovitis can be established by clinical examina-
tion. In the case of subtotal tears of the peroneus brevis
or longus tendon, supplemental investigations such as
MRI or ultrasonography can be helpful for establishing
the diagnosis. Postsurgery and postfracture adhesions
and irregularities in the posterior aspect of the fibula
where the gliding channel of the tendon is located can
be responsible for symptoms in this region.
Figure 16-29 Right ankle. The distal portal for posterior tibial The main portal for peroneal tendoscopy is located
tendoscopy is located directly over the tendon 2 cm distal to directly over the tendons, 2 cm distal to the posterior
the posterior edge of the medial malleolus. A 2.7-mm edge of the lateral malleolus. The distal portal is made
arthroscope is introduced. first, with an incision through the skin. The tendon
sheath is penetrated by the arthroscope shaft with a
blunt trocar. A 2.7-mm arthroscope with an inclination
a blunt trocar. A 2.7-mm arthroscope with an inclina- angle of 30 degrees is introduced (Fig. 16-30). After a
tion angle of 30 degrees is introduced (Fig. 16-29). spinal needle is introduced under direct vision, an inci-
After a spinal needle is introduced under direct vision, sion is made through the skin into the tendon sheath
an incision is made through the skin into the tendon to create a proximal portal. Instruments such as shaver
sheath to create a proximal portal. Instruments such as system can be introduced. Through the distal portal on
shaver system can be introduced. Through the distal the lateral side, a complete overview can be obtained
portal a complete overview can be obtained of the poste- of both peroneal tendons. The inspection starts ap-
rior tibial tendon, from its insertion (navicular bone) to proximately 6 cm proximal from the posterior tip of
approximately 6 cm above the level of the tip of the the lateral malleolus, where a thin membrane splits the
medial malleolus. tendon compartment into two chambers (Fig. 16-31).
The complete tendon sheath can be inspected by More distally, both tendons lie in one compartment.
rotating the scope over the tendon. Special attention The complete compartment can be inspected by
should be given to inspect the tendon sheath covering
the deltoid ligament, the posterior medial malleolus
surface, and the posterior joint capsule. More proximal,
the free edge of the vincula is inspected. The posterior
joint capsule can be palpated and removed with a shaver
system. The arthroscope is placed from the distal portal
between tendon and medial malleolus. The shaver
comes down from the proximal portal. Once the ar-
throtomy is made, the arthroscope and instruments can
be manipulated into the posteromedial compartment of
the ankle joint. Synovectomy or loose body removal thus
can be performed.
Tendinitis of the peroneal tendons

Tenosynovitis of the peroneal tendons, (recurrent) dis-
location, rupture, and snapping of one of the peroneal
tendons account for most of the symptoms at the pos-
Figure 16-30 Left ankle. The main portal for peroneal
terolateral side of the ankle joint.39,40 This disorder tendoscopy is located directly over the tendons 2 cm distal
must be differentiated from fatigue fractures of the fib- to the posterior edge of the lateral malleolus. The distal portal
ula, lesions of the lateral ligament complex, and postero- is made first. A 2.7-mm scope can be introduced. The proximal
lateral impingement (os trigonum syndrome). Peroneal portal is created under direct vision.
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Tendinitis and paratendinitis in the Achilles tendon

Overuse injuries of the Achilles tendon can be divided
into insertional and noninsertional tendinitis. Because
there is no evidence of inflammation in patients with
‘‘tendinitis,’’ the term tendinosis has been proposed.39,43
Noninsertional tendinitis can be divided into three
subgroups: paratendinitis, paratendinitis þ tendinosis,
and tendinosis.
Paratendinitis is characterized by inflammation on only
the lining of the tendon. With acute tendinitis there is dif-
fuse swelling around the tendon. Most cases of isolated
paratendinitis respond well to conservative treatment.
In patients with paratendinitis plus tendinosis there is
localized swelling, most often 4 to 7 cm above the inser-
tion of the Achilles tendon (Fig. 16-32). On examination
there is pain, particularly when the tendon is squeezed.
Most often the pain is localized predominantly on the
medial side. MRI demonstrates marked thickening of
the tendon.
In patients with Achilles tendinosis, fields of local
degeneration in the tendon are present. With advanced
tendinosis, the tendon elongates because of chronic
degeneration and is no longer in functional continuity.
There often is an increase in passive range of dorsiflexion.
Heavy-load eccentric calf-muscle training has been
Figure 16-31 Through the distal portal a complete overview demonstrated to be effective treatment for chronic
can be obtained of both peroneal tendons. The inspection Achilles þ paratendinitis. For operative treatment of para-
starts approximately 6 cm proximal from the posterior tip of tendinitis, the diseased and thickened paratenon is excised.
the lateral malleolus where a thin membrane splits the tendon Operative treatment of chronic tendinosis consists of
compartment into two chambers (1). More distally (2, 3) both
tendons lie in one compartment.
rotating the endoscope over and between the two

tendons. The vincula-like membrane by which both ten-
dons are attached to the tendon sheath allows the
arthroscope to rotate freely all around each tendon.
The muscle fibers of the peroneus brevis can be recog-
nized in the thin membrane up to the tip of the fibula.
At this location both tendons cross the calcaneofibular
ligament, which usually gives some fibers to the anterior
talofibular ligament. Approximately 3 to 5 cm distal
from the fibula the tendons cross each other and again
get divided by a membrane and a bony prominence.
With the tendoscopy a pathologic thickened vincula or
tendon sheath can be released, adhesions can be
removed, and a symptomatic prominent tubercle can
be removed. A rupture of the peroneal longus or brevis
tendon can be sutured. When a total synovectomy of
the tendon sheath is to be performed, it is advisable to
create a third portal more distal or more proximal from
the previously described portals. In case of treatment
for recurrent peroneal tendon dislocation, it is possible Figure 16-32 Left ankle. In patients with paratendinitis and
to deepen the groove of the peroneal tendons with a tendinosis there is localized swelling approximately 4 to 7 cm
burr.42 above the insertion of the Achilles tendon.
376
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debridement of the paratenon and removal of degenera- Insertional tendonitis and retrocalcaneal bursitis
tive necrotic tissue. The thickened degenerative portion Insertional tendonitis can be classified as retrocalcaneal
of the tendon is excised, and the defect is closed primarily. bursitis, retrocalcaneal bursitis þ insertional tendonitis,
Revascularization is stimulated by making multiple and insertional tendonitis.
longitudinal incisions into the tendon. Open surgery Chronic retrocalcaneal bursitis is accompanied by
produces a guarded prognosis. In fact, Maffulli et al.44 deep pain and swelling of the posterior soft tissue just
reported poor results in more than 60% of patients. in front of the Achilles tendon (Fig. 16-34). The pro-
For peritendinitis of the Achilles tendon, the portals minent bursa can be palpated medially and laterally
are created 2 cm proximal and 2 cm distal of the lesion from the tendon at its insertion. The lateral radio-
(Fig. 16-33). The distal portal is made first: an incision graph demonstrates the characteristic prominent supe-
is made through to the skin only. The crural fascia is rior calcaneal deformity. Operative treatment involves
penetrated by the arthroscope shaft with a blunt trocar, removal of the bursa and resection of the lateral and
and a 2.7-mm arthroscope with an inclination angle of medial posterosuperior aspect of the calcaneus. Retro-
30 degrees is introduced. After a spinal needle is intro- calcaneal bursitis often is accompanied by midportion
duced under direct vision, an incision is made at the insertional tendinosis. Often a partial rupture of the mid-
location of the proximal portal. An instrument such as portion of the tendon is present at its insertion. When
a probe or a small shaver is introduced. The pathologic operative treatment for retrocalcaneal bursitis is indi-
paratenon is removed by use of the shaver. The Achilles cated, debridement of the midportion of the Achilles
tendon can be inspected by rotation of the scope over insertion should be considered in case of a partial
the tendon. The plantaris tendon can be recognized rupture.39
and released, or resected when indicated. In case of insertional tendinosis, there is pain at the
bone-tendon junction that worsens after exercise. The
tenderness is specifically located directly posterior to
the junction. Radiographic signs of ossification at the
most distal extent of the insertion of the tendon (bone
spur) are typical signs of insertional Achilles tendi-
nosis. Most patients can be managed with nonoper-
ative means, such as widening and deepening of
the heel counter of the shoe. When operative treatment
is indicated, the pathologic ossifications and spurs
can best be approached by a central heel-splitting
incision.
Open surgery for insertional tendinitis with removal
of the chronically inflamed bursa and the postero-
superior prominence of the calcaneus can be associated
with a poor outcome. Open surgical treatment re-
quires plaster immobilization to prevent equines mal-
formation and to stimulate wound healing. Angermann
and Hovgaard45 reported a cure rate of only 50% after
open surgery for chronic retrocalcaneal bursitis. En-
doscopic treatment offers the advantage of less mor-
bidity, reduced postoperative pain, and outpatient
treatment.
Achillotendoscopy for retrocalcaneal bursitis is per-
formed with the patient in the prone position. Two
portals are created, medial and lateral to the Achilles
tendon, at the level of the superior border of the os cal-
cis. A 4-mm arthroscope with an inclination angle of 30
degrees is introduced through the posterolateral portal.
A probe and subsequently a 5-mm, full-radius resector
are introduced through the posteromedial portal. After
Figure 16-33 For peritendinitis of the Achilles tendon, the removing of the bursa and inflamed soft tissue, the sur-
portals are created 2 cm distal and proximal of the lesion. geon uses a full-radius resector and small acromionizer
After a spinal needle is introduced under direct vision, an to remove the calcaneal prominence.
incision is made at the location of the proximal portal.
377
...........
Figure 16-34 (A) Achillotendoscopy: retrocalcaneal bursitis. (B) After removal of the bursa and inflamed soft
tissue, the calcaneal prominence is removed with a full-radius resector and small acromionizer.
Subtalar joint arthroscopy, intraosseous talar cysts

Subtalar arthroscopy was first described in 1985.46 The
procedure may be applied as a diagnostic and therapeu-
tic tool. As with any other joint, the subtalar joint
should be compartmentalized and examined. Indica-
tions are the evaluation of subtalar instability, debride-
ment of osteochondral lesions, and excision of avulsion
fragments or loose bodies. The anterior subtalar joint
consists of the anterior facet, middle facet, talonavicular
joint, and spring ligament. The dividing axis through
the subtalar joint consists of the sinus tarsi, tarsal canal,
cervical ligament, talocalcaneal interosseous ligament,
inferior extensor retinaculum, and fat pad. The posterior
subtalar joint consists of the posterior facet that is 40 to
45 degrees lateral to the longitudinal axis of the foot,
the capsule, the posterior recess, the lateral recess (thick-
ened by the calcaneofibular ligament), and calcaneus. Figure 16-35 Subtalar joint arthroscopy: the posterior lateral
The patient may be positioned supine or laterally with portal is made approximately 1 cm posterior and 1 cm proximal
to the tip of the fibula.
a bolster under the foot at the edge of the table.
A 1.9- to 2.7-mm arthroscope with 30-degree wide angle
is used. Small joint shavers and burrs can be introduced. portal is made 1 cm posterior and 1 cm proximal to
When needed, soft-tissue distraction can be performed. the tip of the fibula (Fig. 16-35). Caution should be
Four portals have been described.46 The anterior lateral taken not to injure the sural nerve, lesser saphenous
portal is made in the sinus tarsi 2 cm anterior and 1 cm vein, and peroneal tendons. The medial portal is made
inferior to the tip of the lateral malleolus. Caution in the sinus tarsi approximately 2 cm anterior to the tip
should be taken not to injure the superficial peroneal of the lateral malleolus. A blunt trocar is introduced
nerve. The inframalleolar portal is made anterior to through the deep fascia and guided gently through
the calcaneofibular ligament. Caution should be taken the tarsal canal to the medial skin surface. The foot is
not to injure the peroneal tendons. The posterior lateral placed in equinus to relax the neurovascular structures.
378
...........
An incision is made over the trocar. A blunt trocar is patient in the prone position.13 The therapeutic indica-
introduced from the medial portal. The joint is in- tions include debridement of chondromalacia, excision
sufflated and the arthroscope is introduced to view of osteophytes, the removal of a loose body, lysis of
the anterior lateral and posterior medial subtalar joint. adhesions with posttraumatic arthrofibrosis, and syno-
Caution is taken to avoid the neurovascular structures, vectomy. Intraosseous talar cysts can be approached
which are approximately 2.5 cm distal to the tip of the through the subtalar joint.47 Retrograde curettage of
medial malleolus. A systematic examination of the sub- these lesions with destruction of the surrounding zone
talar joint is performed by varying the portal placement of sclerosis, along with bone grafting, is our treatment
of the scope. An arthroscope in the anterior lateral por- of choice. Lesions with a communication to the subtalar
tal enables evaluation of the sinus tarsi, interosseous joint can be treated with the patient in the prone posi-
ligament, cervical ligament, and lateral and posterior tion (see Fig. 16-1). For proper preoperative planning,
gutters. An arthroscope in the posterior lateral portal a CT scan is indispensable.
enables evaluation of the lateral gutter and lateral com- A shaver is introduced through the posteromedial
partment. An arthroscope in the medial portal enables portal. After identification of the FHL tendon, the pos-
evaluation of the anterior lateral and posterior medial terior talar process is freed from its capsular attachments.
compartments. The major complications specific to this The joint capsule of the subtalar joint is resected, and
procedure are sural nerve injury at the posterior lateral the opening of the cyst in the subtalar joint is identified
portal, superficial peroneal nerve injury at the anterior by direct vision and palpation by means of a small probe
lateral portal, and peroneal tendon disruption at the (Fig. 16-36, A and B). With the endoscope in the pos-
inframalleolar portal. The arthroscope may be placed teromedial portal and the probe in place through the
inadvertently in the ankle joint or may penetrate the same posterolateral portal, the drill guide is introduced.
capsule of the ankle and enter the lateral ankle gutter. The drill guide is parallel to the probe of which the
For this reason, fluoroscopic confirmation of position curved tip is in place in the opening of the cyst in
can be useful. the subtalar joint. The drill guide is positioned onto
Assessment of the posterior articulation of the sub- the posterior talar process and a hole is drilled into the
talar joint can best be performed by means of a two- cystic lesion with a 4.5-mm drill (Figs. 16-37 and
portal endoscopic approach of the hindfoot with the 16-38). The lesion is curetted and debrided with a
Figure 16-36 (A and B) A computed tomography (CT) scan is indispensable for proper preoperative planning.
This CT scan shows an intraosseous cyst of the right talus that has communication with the subtalar joint.
379
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Figure 16-37 The opening of the cyst (see Fig. 16-36, A and B
and text) in the subtalar joint is identified by direct vision and Figure 16-39 Cancellous bone obtained from the iliac crest is
palpation by means of a small probe. packed into the cystic lesion through a trocar.
two-portal endoscopic approach offers an excellent alter-

native to open techniques with obvious advantages.
An arthrotomy or malleolar osteotomy is prevented.
The articular origin of a cyst can be identified under
direct arthroscopic vision. A second portal makes it pos-
sible to probe and subsequently treat the lesion by
debridement, drilling, and transtrocar bone grafting.
Excellent results at follow-up have been reported by
using this technique.13,47
Combined anterior and posterior ankle

arthroscopy
In case of combined anterior and posterior ankle pathol-
ogy, anterior arthroscopy can be combined with poste-
rior arthroscopy of ankle in the same operative setting.
Indications are rheumatoid arthritis, pigmented villo-
nodular synovitis, chondromatosis, or ankylosis.
The patient first is placed in the prone position.
A tourniquet is applied and a small support is placed under
the lower leg. A two-portal endoscopic approach of the
hindfoot is performed and the pathology treated. When
Figure 16-38 The drill guide is positioned, parallel to the
the procedure has been finished and the portals closed
probe, onto the posterior talar process. With a 4.5-mm drill,
and the wounded draped, a strap is placed around the
a hole is drilled into the cystic lesion.
foot, the knee is flexed approximately 90 degrees, and
the strap is attached with a string to the ceiling of the
closed-cup curette. The opening of the cyst is enlarged operating room. The foot is now hanging upside down
to 6.5 mm, and a 6.5-mm blunt trocar is introduced. (Fig. 16-40). Next, the portals for the anterior ankle
Multiple drill holes are made through the cystic wall arthroscopy are made and synovectomy or capsulectomy
from inside the lesion with a K-wire (Fig. 16-38). Can- is performed in the anterior ankle compartment. We have
cellous bone obtained from the iliac crest is packed into successfully performed this combined procedure with
the cystic lesion through the trocar (Fig. 16-39). This various indications in seven patients.
380
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382
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.........................................C H A P T E R 1 7
Lesser-toe disorders
Michael J. Coughlin, Jerry Speight Grimes, and Robert C. Schenck, Jr.
......................
CHAPTER CONTENTS
Bunionettes 384 Claw toe 402

Intractable plantar keratoses 387 Metatarsophalangeal joint instability 403
Interdigital neuromas 392 Conclusion 408
Hard corns and soft corns 394 References 408
Hammertoes, mallet toes, and claw toes 397 Further reading 409
Metatarsalgia in the athlete can be a debilitating disorder neuritic symptom with the pain? Are enlarged exostoses
leading to loss of competitiveness or even loss of or prominences associated with pain, swelling, or
the ability to participate in a recreational fashion. Fore- inflammation?
foot disorders encompass lesser-toe abnormalities such
as claw toes, hammertoes, mallet toes, and hard and
soft corns. More proximally, problems can include
intractable plantar keratosis (IPK), bunionettes, neuro-
mas, and metatarsophalangeal (MTP) joint capsulitis
4 PEARL
and instability. Location of Foot Pain
For the athlete, repetitive activities can lead to When a patient complains of metatarsalgia, the initial
repeated stress reactions in soft tissues, as well as bones concern on physical examination is the presence of an
and joint. Abrasions and repeated trauma over bony associated callosity. This can be seen laterally over the
fifth metatarsal head with a bunionette formation. It can
prominences can lead to callus formation and bursitis. be localized to the plantar metatarsal region with an
Ideally, the goal should be to avoid the development IPK. A callosity may develop over the dorsal distal inter-
of problems through the use of good footwear, proper phalangeal (DIP) joint (a mallet toe) or the dorsal proxi-
training practices, and education. Many foot problems mal interphalangeal (PIP) joint (hammertoe). On occasion
may develop despite prophylactic care and thus require a patient may complain of a callosity both overlying the
PIP joint and beneath the associated metatarsal head.
the intervention of the orthopaedic surgeon either con- With a concomitant contracture of this toe, the diagnosis
servatively or surgically. When possible, nonsurgical of a claw toe is made based on the basis of clinical
treatment is preferred, usually leading to a rapid resump- findings.
tion of athletic activity.
The complaint of pain in the forefoot must be differ-
entiated to make a correct diagnosis. The accompanying
algorithm (Fig. 17-1) may prove useful in determining Development of a callus between two toes (a soft
the specific forefoot diagnosis when a patient complains corn) or over the lateral aspect of the fifth toe (a hard
of metatarsalgia. Most important is the exact location of corn) can be extremely painful.
pain. In addition, the physician should ask the following When a patient complains of metatarsalgia but there
questions: Which specific activities increase symptoms? is no callosity present, the patient should be examined
Which activities alleviate discomfort? Is the pain dorsal carefully for neuritic symptoms. When such a scenario
or plantar, medial or lateral? Is there an associated is present (along with other specific symptoms), the
CHAPTER 17 Lesser-toe disorders
Figure 17-1 Algorithm. (From Coughlin MJ: J Bone Joint Surg 82B:781, 2000.)
4 PEARL
diagnosis of an interdigital neuroma can be made. When
neuritic symptoms are not present but symptomatic
pain still is localized to the forefoot, suspicion of MTP
joint capsulitis and/or instability should be considered. Location of Foot Pain
The presence of a positive drawer sign (dorsal plantar When evaluating forefoot pain, it often can be difficult to
instability) or actual malalignment of the involved toe localize the exact location of a patient’s pain to make a correct
diagnosis. Often, the physical examination is inconclusive,
at the MTP joint aids in confirming the diagnosis of especially when the patient presents to clinic when asympto-
second toe instability or ‘‘cross-over toe.’’ Although this matic. This is especially common in athletes, whose com-
algorithm is not all-inclusive and much more enters plaints often are activity related. To identify the location of
into the specific diagnostic process than this pain, instruct the patient to repeat the offending activity,
flowsheet allows, it does offer a method of approaching recreating the patient’s symptoms. The patient then is
instructed to mark the spot with a felt tip marker pen. This
the athlete with metatarsalgia. Sometimes symptoms ‘‘spot’’ will stay with the patient for the next clinical
overlap; frequently symptoms are vague, and repeated examination.
evaluation and physical and radiographic examinations
are necessary to confirm a diagnosis. The cooperation
of patients in defining their symptomatic complaints
and in defining their problem through varying
their athletic activity is highly important. Likewise,
BUNIONETTES
patient cooperation in modifying activities when con-
servative management is attempted is a critical factor
in any successful treatment. When surgery is per- The development of inflammation, an enlarged bursa, or
formed, patient cooperation in allowing adequate a callus over a prominent fifth metatarsal head may lead
healing to occur before resuming athletic activity is a physician to diagnose a bunionette (Fig. 17-2). Just as
instrumental not only in the recovery process but also bunions can present with differing magnitude and
in the avoidance of other associated problems or different characteristics, so too can a bunionette.1
complications. A bunionette may appear radiographically as an enlarged
384
...........
Bunionettes
Initially an athlete may complain of pain directly lat-

eral over the fifth metatarsal head, but the examiner
should be aware of plantar symptoms as well. Neuritic
symptoms involving the fifth toe may occur because of
pressure over the lateral digital nerve to the fifth toe.
The athlete may note complaints of inflammation,
blistering, ulceration, or infection.
On physical examination, the aforementioned com-
plaints usually are obvious. Significant callus formation
may be observed on the lateral, plantar, or in a lateral
plantar position overlying the fifth metatarsal head.
Any pronation of the longitudinal arch should be noted,
as well as any restriction in hindfoot motion.
Radiographic evaluation may demonstrate an enlar-
ged metatarsal head, outflaring of the fifth metatarsal
metaphysis, or widening of the 4-5 intermetatarsal
angle. Widening of the 4-5 angle is the most common.
Figure 17-2 Bunionette with enlarged bursa. (From Mann RA,
Abduction of the fifth toe in relation to the fifth meta-
Coughlin MJ: In Surgery of the foot and ankle, St Louis, 1993, tarsal head also may be demonstrated.
CV Mosby, p. 443.)
Conservative treatment
Early treatment involves attempting to relieve pressure
fifth metatarsal head (type I). A flare in the metaphysis on the underlying bony prominence. Stretching of shoes
may cause outbowing of the fifth metatarsal (type II), or obtaining shoes with a soft upper that is more
leading to symptoms, or a widened 4-5 intermetatarsal forgiving will relieve overlying pressure. Seams or stitch-
angle (type III) characteristic of a splayfoot may lead ing directly over the bunionette should be avoided.
to pain and callus formation (Fig. 17-3). Moleskin applied to a blister may promote healing and
Figure 17-3 (A) Bunionette with enlarged fifth metatarsal head. (B) Bunionette with bowing of metaphysic.
(C) Bunionette with enlarged 4-5 intermetatarsal angle.
385
...........
protect the area while athletes continue their activities.

Altering running and/or training activity also may
diminish symptoms. Nonimpact activities such as sta-
tionary cycles or swimming can be integrated into the
training program. A reduction in total miles per day
and per week may be required. Trimming the callus
may significantly relieve symptoms. Physicians may
teach their patients how to pare the callus appro-
priately. The callus is shaved in thin layers with the scal-
pel parallel to the toe. A pumice stone also may be used
to pare down the callus. A pumice stone is safer and
often more acceptable to patients for home use than a
scalpel.
When athletic activity is significantly impaired after
conservative efforts, surgical intervention may be con-
templated (see Case Study 1). The type of osteotomy
selected is dependent on the location of the callosity
because specific osteotomies of the fifth metatarsal
are oriented to redirect the metatarsal in different direc-
tions. Surgical intervention in treating forefoot callosities
should be tailored to the patient. Extensive soft-tissue
stripping, unsecured osteotomies, and multiple metatar-
sal osteotomies all should be avoided in athletes.
Although a surgical procedure may relieve the painful
callosity, athletic performance of the patient may be
diminished and thus surgery may be considered unsuc-
cessful. The two surgical procedures presented here
fulfill the requirements of exposing the patient to less
extensive surgery, use internal fixation, and appear better
suited to athletes. Again, when possible, conservative
treatment should be advocated by the treating physician
until it obviously is incompatible with continued athletic
function.
C A S E S T U D Y 1
A 30-year-old skier developed pain and swelling over the

plantar lateral aspect of the fifth metatarsal head. An
increased callosity was observed over the plantar lateral
aspect of the bunionette. A painful, inflamed bursa Figure 17-4 Case study 1. (A) Bunionette preoperative
developed during the middle of ski season that was x-rays. (B) Follow-up x-rays demonstrating correction.
partially relieved by grinding down the inner aspect of the
ski boot overlying the bunionette. Likewise, the area Conservative care, stretching of shoes, and padding all
overlying the fifth metatarsal head was relieved in the were recommended.
athlete’s everyday footwear by stretching the leather At the end of ski season, the patient requested
surface. surgical treatment because of continued symptoms. An
On physical examination, a normal neurologic and oblique osteotomy was performed and fixed with screws.
vascular examination was noted. Prominence of the fifth At 8 weeks following surgery, the osteotomy was healed
metatarsal head was characterized by a callosity on both and the patient began progressive walking that evolved
the plantar and lateral aspect. Radiographic evaluation over the ensuing 2 months to jogging and sports activities.
demonstrated an enlarged fifth metatarsal lateral condyle Figure 17-4, B shows the correction obtained. The patient
(Fig. 17-4, A). skied the following season without symptoms.
386
...........
Intractable plantar keratoses
Surgical treatment head. The osteotomy is fixed with one or two

1. The foot is cleansed and draped in the routine percutaneous 0.045 K-wires (Fig. 17-7).
fashion. An Esmarch bandage is used to exsangui- 6. Any remaining prominent metaphysis is shaved
nate the foot. The ankle is padded carefully and with the sagittal saw. A drill hole is placed in the
the Esmarch is used as a tourniquet. dorsal proximal metaphysis, and the capsule is
2. A longitudinal lateral incision is centered directly anchored with an interrupted suture. Remaining
over the bunionette, extending from the mid- interrupted sutures are placed to reinforce the
proximal phalanx to 1 cm above the metatarsal capsular repair (Fig. 17-8).
head. Care is taken to protect the neurovascular 7. The skin is closed in a routine fashion. A gauze
bundles. and tape dressing is applied and changed on a
3. The MTP capsule is detached on the dorsal and weekly basis. The patient is allowed to ambulate
proximal aspect and turned downward, exposing in a wooden-soled shoe.
the prominent lateral condyle (Fig. 17-5). Athletic activity is increased as swelling and pain
4. A sagittal saw is used to resect the lateral condyle diminish. Radiographic confirmation of healing should
in line with the diaphyseal shaft of the fifth meta- be present before aggressive activity such as jogging,
tarsal. (At this point, a decision must be made running, or jumping is commenced. In general, a
regarding the type of osteotomy to be performed. patient can return to nonimpact activities at 2 months.
For a pure lateral callus, a chevron osteotomy is Limited-impact activities such as jogging are per-
performed. For a combined plantar lateral callus, mitted at 3 months. Full-contact/impact activities can
a distal oblique osteotomy is performed.) be resumed at 4 months, depending on radiographic
5A. Chevron osteotomy2,3—A lateral to medial drill evidence of healing.
hole is placed in the center of the fifth metatarsal In general, resolution of the symptomatic bunionette
head, marking the apex of the chevron osteotomy. can be achieved with one of the above procedures for
A 60-degree angled osteotomy based proximally type I or type II bunionettes. With a splayfoot and a
is directed in a lateral to medial plane. The meta- significantly wide 4-5 metatarsal angle, a diaphyseal
tarsal head is translated medially and fixed with a midshaft osteotomy may be necessary to achieve more
percutaneous 0.045 K-wire (Fig. 17-6). correction.6 More extensive procedures such as this
5B. Distal oblique osteotomy4,5—After exposing the should be reserved for athletes with significant limita-
metatarsal head and metaphysis, an oblique tions, because the extensive nature of this surgery may
osteotomy is performed from a distal lateral to limit postoperative athletic expectations.
proximal medial direction. The metatarsal head is
displaced medially and slightly proximally and is INTRACTABLE PLANTAR KERATOSES
allowed to ‘‘raise up’’ approximately 3 mm to
decrease plantar pressure beneath the fifth metatarsal
The development of a keratosis beneath one or more of
the metatarsal heads is referred to as an intractable plan-
tar keratosis or IPK. A callosity beneath the fifth meta-
tarsal when associated with a bunionette already has
been discussed. A callus may be a localized discrete
lesion or a diffuse keratotic buildup (Fig. 17-9). Callus
formation in athletes is not uncommon, and if
asymptomatic rarely requires medical intervention.
With significant buildup, painful symptoms may occur,
requiring evaluation and treatment.
A diffuse callus may be due to repetitive abrasion
associated with athletic activity. It also may be associated
with a long second metatarsal or a long second and third
metatarsal. A discrete callus may occur beneath a single
metatarsal head.7 It typically is associated with an
enlarged fibular metatarsal condyle. It is important to
distinguish this from a wart (Fig. 17-10). Although
warts (plantar verrucae) typically are not found beneath
a metatarsal head, on occasion they can occur in this
Figure 17-5 An L-shaped capsular incision is used to region and thus must be differentiated from an
approach the bunionette. IPK. Trimming of a wart will uncover end arterioles in
387
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Figure 17-6 (A) A drill hole is placed in the center of the metatarsal head and drilled in a lateral to medial
direction. (B) A chevron-shaped osteotomy is based proximally with the apex at the drill hole. (C) Medial
translation of the metatarsal head with K-wire fixation and shaving of the metaphyseal flare (shaded area
denotes shaved bone in metaphysic).
the lesion characterized by punctuate hemorrhages.

Evaluation of the athlete with an IPK involves determin-
ing the significance of the symptoms, length of dura-
4 PEARL
tion, and association, if any, with specific athletic Pressure Points
activity. A patient with minimal symptoms requires no A Harris mat imprint is invaluable in identifying abnormal
treatment. pressure points on the plantar surface of a patient’s foot.
Radiographic evaluation entails weight-bearing films The patient is instructed to walk in a normal manner,
stepping on the Harris mat. The test is repeated with the
with markers to determine the exact location of the contralateral foot. Abnormal pressures are illustrated as
IPK (a long metatarsal may be associated with an IPK; unusually dark regions and will aid in making the correct
likewise a marker may be located directly beneath the diagnosis and appropriate treatment.
fibular condyle of a metatarsal head).
388
...........
can transfer pressure to the metatarsal diaphysis and

relieve symptoms (see Case Study 2). Custom or
prefabricated orthotic devices also can aid in relieving
symptoms. Athletes may alter their workout, change
sporting activities, or change duration or intensity of
the workout, all with gratifying results.
C A S E S T U D Y 2
A 50-year-old tennis player developed a painful callus

beneath the second and third metatarsals. It was a
diffusely thickened callus that began to limit his sports
activities. On initial evaluation, the diffuse callus was
trimmed and the patient instructed in how to care
conservatively for the IPK. A pumice stone was used to
pare the callus. The patient also obtained disposable
scalpels to shave his thickened callosity. When he
returned for further follow-up, radiographs demonstrated
a long second and third metatarsal in relation to the
adjacent metatarsals. A soft pad was placed in his shoe
just proximal to the callosity. With the combination of
shaving the callosity and padding it, symptoms were
Figure 17-7 Distal oblique osteotomy with K-wire fixation completely relieved and the patient returned to full sports
(shaded area denotes shaved bone in metaphysic). activities. Later, a soft orthotic device was fabricated to
relieve pressure beneath the second and third
metatarsals. This convenient orthotic device can be
moved from shoe to shoe and replaced the temporary soft
pads that were used to alleviate his initial symptoms.
When all methods of conservative treatment
have been exhausted, surgical intervention may be
considered. Caution is advised in considering any
metatarsal osteotomy in a high-level athlete. The
possibility of delayed union, nonunion, or malunion can
significantly impair later athletic activity. The
development of a transfer lesion beneath another
metatarsal head is not uncommon. Multiple metatarsal
osteotomies are to be discouraged. Likewise, floating
metatarsal osteotomies without internal fixation have
a high rate of malunion with resultant transfer lesions.
Figure 17-8 L-shaped capsular closure. The dorsal proximal Surgical treatment: partial condylectomy8
corner may be fixed with a drill hole in the metaphysic to 1. The foot is cleansed and draped in a routine fash-
anchor the repair. ion. As Esmarch bandage is used to exsanguinate
the foot. It is padded carefully at the ankle and
used as a tourniquet.
2. A longitudinal incision is centered over the meta-
Conservative treatment tarsal head with a ‘‘hockey stick’’ extension distal
Conservative treatment revolves around paring the IPK into the adjacent interspace. (The extensor tendon
and padding it to relieve the pressure (Fig. 17-11). A may be released temporarily to aid exposure and is
patient can be instructed to trim the lesion every 7 to repaired at the conclusion of the procedure.)
10 days, and this will significantly relieve discomfort. 3. The MTP joint capsule is released and the toe is
Placement of a metatarsal pad just proximal to the IPK flexed to 90 degrees at the MTP joint.
389
...........
Figure 17-9 (A) Discrete callus in a tennis player with an enlarged fibular condyle. (B) Diffuse callus in a runner.
(Courtesy Roger A. Mann, MD, and Michael J. Coughlin, MD.)
Figure 17-10 A wart is characterized by punctate hemorrhages Figure 17-11 Padding an intractable plantar keratosis often is
that are obvious when the callus is trimmed. (Courtesy Roger A. successful treatment.
Mann, MD, and Michael J. Coughlin, MD.)
4. An osteotome is used to osteotomize 25% of the 5. A 0.045 K-wire introduced at the MTP joint is
plantar condyle. Care is taken to avoid fracture to driven distally out the tip of the toe. With the
the metatarsal head (Fig. 17-12). The condyle is MTP joint reduced, the pin is driven in a retro-
removed. grade fashion, stabilizing the joint.
390
...........
Figure 17-12 (A) Plantar condylectomy for a discrete intractable plantar keratosis. (B) Interoperative view of
plantar condylectomy (one fourth to one third of the plantar metatarsal head is excised).
6. The extensor tendon (if released) is repaired. The

skin is closed in a routine fashion.
7. A gauze and tape dressing is applied and changed
on a weekly basis. The patient is allowed to ambu-
late in a wooden-soled shoe.
8. At 3 weeks, the sutures and K-wire are removed.
Athletic activity is permitted as swelling and pain
decrease. The toe is protected for 6 weeks following sur-
gery with taping immobilization. In general, a patient can
return to nonimpact activities at 1 month. Limited-impact
activities such as jogging are permitted at 6 weeks. Full-
contact/impact activities can be resumed at 3 months.
Surgical treatment: metatarsal osteotomy

1. The foot is cleansed and draped in a routine fash-
ion. An Esmarch bandage is used to exsanguinate
the foot. It is carefully padded at the ankle and
used as a tourniquet.
2. A dorsal longitudinal incision is centered over the
involved metatarsal.
3A. If a distal oblique osteotomy9 is performed (Fig. 17-
13), the cut is directed in a vertical direction. The Figure 17-13 (A) Distal oblique osteotomy (dotted line shows
metatarsal head is displaced upward 3 mm10 and proposed osteotomy site). (B) Following displacement and
fixed with a 0.045 K-wire. internal fixation with K-wire.
391
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Figure 17-14 Distal chevron osteotomy with internal fixation. Figure 17-15 Proximal closing wedge osteotomy with screw
(Courtesy Roger A. Mann, MD, and Michael J. Coughlin, MD.) fixation. (Courtesy Roger A. Mann, MD, and Michael J.
Coughlin, MD.)
3B. If a vertical chevron osteotomy2 is performed activities at 2 months. Limited-impact activities such as
(Fig. 17-14), the V-shaped osteotomy is directed jogging are permitted at 3 months. Full-contact/impact
in a vertical direction. (This is more stable side activities can be resumed at 4 months based on radio-
to side than a transverse osteotomy.) The metatar- graphic healing.
sal head is displaced upward 3 mm and fixed with In general, with a partial plantar condylectomy, satis-
a 0.045 K-wire. factory results are attained for relieving the symptoms of
3C. If a proximal transverse osteotomy11 is performed a discrete, well-localized IPK.8 Likewise, a distal osteot-
(Fig. 17-15), a dorsal based wedge is excised. omy9,11 may be efficacious for a similar lesion. A diffuse
The farther proximal the osteotomy is located, callus in the athlete probably is best treated with
the more elevation is achieved with wedge padding and shaving because a more extensive proce-
removal. (Care must be taken not to overcorrect at dure involving a diaphyseal osteotomy12 may require
the osteotomy site.) The wedge may be removed prolonged healing time and place the athlete at greater
with a sagittal saw or with a small rongeur. Inter- risk for delayed healing, malunion, and transfer metatar-
nal fixation is recommended. A screw, pin, or wire salgia. A proximal closing wedge osteotomy9 may be
loop fixation is used. used to elevate a symptomatic long second or third
4. The wound is closed in a routine fashion. A gauze metatarsal. Meticulous attention to the osteotomy and
and tape dressing is applied and changed on fastidious postoperative care are necessary to avoid
a weekly basis. The patient is allowed to ambulate complications.
in a wooden-soled shoe bearing weight on his or
her heel.
5. Sutures are removed 3 weeks following surgery.
INTERDIGITAL NEUROMAS
Percutaneous K-wires are removed 3 to 4 weeks
following surgery. The forefoot then is strapped
with tape and gauze until symptoms remit. An interdigital neuroma may be a source of ill-defined
6. Radiographic confirmation of union is important forefoot pain. Located in the second or third intermeta-
before aggressive athletic activity can be tarsal space (IMS), a neuroma is rarely isolated to
commenced. the first or fourth interspace. Rarely, in less than 3% of
Athletic activity is permitted as swelling and pain cases, do two neuromas occur in the same foot
diminish. In general, a patient can return to nonimpact simultaneously.13
392
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Interdigital neuromas
Typically an athlete initially describes ill-defined fore- Conservative treatment

foot pain, often exacerbated with running or sports
Early conservative treatment may alleviate symptoms in the
activities, which is relieved by rest or removal of a pair
athlete. With intermittent symptoms exacerbated by
of shoes. Sometimes pain increases with intensity and/
intense athletic activity or sports of significant duration,
or duration of sports activities.
a change in the type of activity or its duration may
The physical examination includes educating patients
completely relieve symptoms (i.e., a person who jogs 4
regarding which symptoms to watch for. Although ill-
miles at a time and develops pain at 2.5 miles may jog for
defined forefoot discomfort is common, the treating
2 miles and bicycle for 2 to 3 miles and be symptom free).
physician must help patients define the exact area of
Placing a small metatarsal pad just proximal to the
pain. With time and education, athletes may be able
symptomatic interspace may relieve symptoms. Change
actually to pinpoint the exact area of pain from the
in athletic shoes also may alleviate pain.
dorsal and plantar aspect, usually in either the second
When conservative methods including the modifi-
or third interspace. Neuritic symptoms or numbness in
cation of sports activities have not relieved symptoms,
either the second or third common digital nerve distri-
surgical intervention may be considered.17-19
bution may be observed.
On physical examination, care is taken to observe for Surgical treatment: excision of interdigital neuroma
evidence of peripheral neuropathy or vascular insuffi-
1. The foot is cleansed and draped in the usual fash-
ciency. Peripheral neuropathy is characterized by a loss
ion. An Esmarch bandage is used to exsanguinate
of cutaneous, positional, and vibratory sensation. The
the foot. The ankle is padded carefully and the
Semmes-Weinstein 5.07 monofilament is the classic test
Esmarch is used as a tourniquet.
for protective sensation. Vascular insufficiency is charac-
2. A 3-cm dorsal incision is centered in the involved
terized by loss of distal hair, lack of pulses, dependent
interspace.
rubor, varicose veins, atrophic skin, and delayed capillary
3. The dissection is carried down to the transverse
refill. The toes are examined for fixed deformity. Any
metatarsal ligament (TML) (Fig. 17-16).
callus or IPK is noted, and the adjacent MTP joints are
4. A two- to three-prong Weitlaner retractor is used
evaluated for pain or instability (see section on MTP
to distract the adjacent metatarsals and place the
Instability). MTP capsular instability symptoms closely
TML under tension.
mimic those of an interdigital neuroma.14 Palpation of
the involved interspace usually elicits pain. Grasping
and compressing the transverse arch at the level of the
metatarsal heads may elicit a click (Mulder’s sign),15
which occurs when the neuroma subluxates below
the metatarsal head and transverse metatarsal ligament
(TML).
4 PEARL
Diagnosis of MTP Instability versus
Interdigital Neuroma
When a patient has difficulty isolating the location of pain,
a 1% lidocaine injection may be used to determine the site
of pain.16 During serial office visits 1 week apart, the
physician may inject local anesthetic into the second IMS,
then the third IMS, then the second MTP joint, and then
the third MTP joint. Fluoroscopy and injectable contrast
may be used to verify an intra-articular injection. It is
important to use small volumes (1-3 ml) to prevent
extravasation of anesthetic agent to adjacent structures.
While anesthetized, the patient is asked to repeat the Figure 17-16 Dorsal incision demonstrates a large interdigital
activity that causes the most discomfort, Within 1 or neuroma. The transverse metatarsal ligament has been
2 hours the anesthetic wears off. When temporary relief is sectioned. (From Coughlin MJ: In Chapman M, editor:
achieved with the injection, followed by recurrent symp- Operative orthopaedics, Philadelphia, 1993, JB Lippincott,
toms, an anatomic diagnosis is confirmed.14 p. 2289.)
393
...........
5. The TML is sectioned only when necessary to

expose the neuroma and common digital nerve.
6. The digital nerves distal to the bifurcation are sev-
ered at the level of distal webspace. The proximal
stumps are tensioned. A nerve freer is used to dis-
sect longitudinally to isolate the common digital
nerve. Special attention is directed at freeing the
plantar branches. With tension on the proximal
nerve, a scalpel is used to transect the nerve as
proximal as possible in the interspace.
7. The interspace is inspected for any other nerve tis-
sue that may be a cause of pain. It is important to
sever any adjacent capsular nerve branches that
prevent proximal migration of the nerve stump.
The retractor is removed, and the surgical wound
is irrigated and closed in a routine fashion.
8. A gauze and tape dressing is applied and changed
on a weekly basis, and the patient is allowed to
ambulate in a postoperative shoe.
9. Suture removal is carried out 3 weeks following Figure 17-18 Hard corn with keratotic buildup. (Courtesy
surgery, and a circumferential gauze and tape Roger A. Mann, MD, and Michael J. Coughlin, MD.)
strapping is continued for 3 more weeks to allow
adequate healing of the TML if it was sectioned
(Fig. 17-17).
Aggressive walking can be commenced 4 weeks fol- Patients can present with concurrent interdigital neu-
lowing surgery, with increased activity as pain and roma and MTP joint capsular instability. Isolated treat-
swelling permit. Limited-impact activities such as jog- ment of one of these conditions is unlikely to resolve
ging are permitted at 2 months. Full-contact/impact the patient’s symptoms. Simultaneous interdigital neu-
activities can be resumed at 3 months. roma resection and stabilization of the MTP joint results
in better outcomes than isolated procedures.14 Techni-
ques to address capsular instability are addressed later
in this chapter.
HARD CORNS AND SOFT CORNS
A hard corn (Fig. 17-18) develops over the lateral aspect

of the fifth toe usually because of pressure of the shoe
against an underlying exostosis or condyle on the fifth
toe. Patients may complain of pain associated with a
hypertrophic callus on the lateral aspect of the fifth
toe. A soft corn (Fig. 17-19) develops between the toes
because of pressure between two adjacent bony promi-
nences. Patient may complain of exquisite pain; macera-
tion sometimes occurs that resembles a mycotic
infection. Desiccation of the lesion then may help to
distinguish it from an infection.20
On physical examination, the obvious callosity occurs
overlying a bony prominence. Radiographic evaluation
may help to define the location of the lesion (Fig. 17-20).
Figure 17-17 Strapping of the foot is continued for 6 weeks Conservative treatment
postoperatively to promote healing of the transverse Padding of the hard corn (Fig. 17-21) may alleviate dis-
metatarsal ligament. comfort. Stretching of shoes overlying the lesion may
394
...........
Hard corns and soft corns
often eliminates compression between the two toes.

Shaving of the callosity also may be indicated (see Case
Study 3). When conservative measures have failed, surgi-
cal resection of the involved condyle may eliminate the
prominence and alleviate the symptoms.
C A S E S T U D Y 3
A 40-year-old jogger developed exquisite pain beneath

the fourth and fifth toes. He recognized maceration in
the fourth webspace. It was unclear whether this was
a fungus infection or a soft corn.
On his initial orthopaedic evaluation, radiographs
demonstrated impingement between the PIP joint of the
fourth toe and DIP joint of the fifth toe.
Initial treatment used rubbing alcohol applied with
a cotton-tipped applicator three times a day to desiccate
Figure 17-19 A soft corn is demonstrated in the fourth
the area. Then lamb’s wool was placed between the toes
webspace, mimicking a mycotic infection. (Courtesy Roger A.
to pad and alleviate pressure between the two prominent
Mann, MD, and Michael J. Coughlin, MD.)
condyles. Later, a foam spacer was placed between the
toes and the patient was allowed to resume all jogging
activity. No surgery was performed.
Figure 17-20 Radiograph demonstrating the location of a

soft corn. (Courtesy Roger A. Mann, MD, and Michael J.
Coughlin, MD.)
decrease symptoms. Shaving of the callosity on a fre-

quent basis may diminish the painful symptoms. Figure 17-21 (A) An underlying exostosis combined with
With a soft corn, padding of one or both toes with restrictive footwear leads to a hard corn. (B) A pad may be
either a foam spacer (Fig. 17-22) or tubular foam gauze used to relieve pressure.
395
...........
Figure 17-22 A pad is used to relieve pressure in the Figure 17-23 A dorsal incision is used for the condylectomy
webspace. (Courtesy Roger A. Mann, MD, and Michael J. as the treatment for a hard corn.
Coughlin, MD.)
Surgical treatment for hard corns21,33 Surgical treatment for soft corns33
1. The foot is cleansed and draped in the usual fash- 1. The foot is cleansed and draped in the usual fash-
ion. Often a digital anesthetic block is used, ion. Often a digital anesthetic block is used,
although a foot block also may be considered. although a foot block also may be considered.
2. A dorsolateral longitudinal incision is centered 2. A decision is made whether to treat both lesions
over the prominent lateral condyle. on adjacent toes or to treat only one. (With a sig-
3. With sharp dissection, the capsular fibers are nificant lesion on one toe and a minor lesion on
peeled off the condyle. the corresponding toe, a surgical repair of the
4. A rongeur is used to remove the prominent con- larger lesion usually will successfully eliminate
dyle, with care taken to leave enough articular sur- the entire problem.) Whether one or both lesions
face to retain joint stability (Fig. 17-23). are surgically treated remains the decision of the
5. The sharp, bony edges are beveled with a rongeur. operating surgeon.
6. The capsule is closed with two or three inter- 3. A dorsolateral longitudinal incision is centered
rupted absorbable sutures. over the prominent lateral condyle. This avoids
7. A percutaneous flexor tenotomy is performed at an incision in the affected webspace.
the MTP joint. 4. With sharp dissection, the capsular fibers are
8. The skin is closed with a running skin closure. peeled off the condyle.
A gauze and tape dressing is applied and changed 5. A rongeur is used to remove the prominent con-
on a weekly basis. The patient is allowed to ambu- dyle, with care taken to leave enough articular
late in a postoperative shoe. surface to retain joint stability (Fig. 17-24).
9. Sutures are removed 3 weeks after surgery. The 6. The sharp edges are beveled with a rongeur.
toe then is taped to the adjacent toe for 3 more 7. If a fixed contracture of the toes exists, a percu-
weeks to promote stability and avoid injury. taneous tenotomy of the flexor tendon is
After suture removal, an increase in sports activity can performed.
be commenced. Walking and bicycling may be started 8. The capsule is closed with an interrupted absorb-
when sutures are removed. Running may commence able suture.
after swelling has diminished sufficiently to allow shoe- 9. The skin is closed with a running skin closure.
wear to fit adequately, typically 6 weeks. A gauze and tape dressing is applied and
396
...........
Hammertoes, mallet toes, and claw toes
Figure 17-25 Hammertoe deformity. (From Coughlin MJ: Foot

Ankle Int 21:94, 2000.)
Figure 17-24 (A) A soft corn may develop over the base of the
proximal phalanx. (B) Resection of the bony prominence.
the toe box. A callus may also develop at the tip of the
toe because of pressure against the insole of the shoe.
With a claw toe deformity, typically a flexion contrac-
ture develops at the PIP joint with hyperextension at the
changed on a weekly basis. The patient is
MTP joint. A callosity may develop over the PIP joint;
allowed to ambulate in a wooden-soled postop-
with a long-standing contracture an IPK may develop
erative shoe.
beneath the metatarsal head. Early on, a flexible contrac-
10. Sutures are removed 3 weeks after surgery.
ture may be passively correctable, although with time a
11. A small gauze spacer is used between the toes for
fixed contracture may develop.
another 3 weeks until the surgical incisions have
Subjectively a patient typically complains of pain over
softened. After suture removal, walking and
a prominent callus on the involved toe; occasionally a
bicycling may be started. Running may com-
painful callus will develop at the tip of the toe.
mence after swelling has diminished successfully
On physical examination, the treating physician not
to allow shoewear to fit adequately, typically
only observes a keratotic buildup over the deformity
6 weeks.
but also examines the attitude of the toe. The flexibility
or rigidity of the deformity may determine the particular
surgical repair, should it be necessary. The presence of
HAMMERTOES, MALLET TOES, AND
multiple toe deformities, contractures at adjacent joints,
CLAW TOES
and neurologic deficits must be appreciated during the
evaluation. With all of these lesser-toe deformities, an
Deformities of the lesser toes include both flexible and athlete may complain of blistering, callus formation,
fixed deformities. Typically callus formation occurs over swelling, or pain because of a dynamic or static defor-
bony prominences, and at times during athletic activity mity. Occasionally an infection may develop in the over-
these areas may become inflamed and painful. A hammer- lying tissue.
toe (Fig. 17-25) is characterized by a flexion contracture
at the PIP joint. Early on, it may present as a flexible Conservative treatment
deformity that in time may become fixed. With a mallet Conservative care includes relieving pressure over the
toe (Fig. 17-26), there is a flexion contracture at the painful area.22 The use of roomy shoewear often will
DIP joint. Early on, it may present as a flexible deformity relieve discomfort in the athlete. Padding often allows
because of tightness of the flexor digitorum longus return to sports activity. Shaving of painful callosities
(FDL) tendon. With time it may become a fixed defor- may temporarily relieve keratotic buildup. Often conser-
mity. A callus may develop dorsally over the DIP joint vative care will allow an athlete to continue activity,
because of pressure or abrasion from impacting against although decreasing the duration or intensity of the
397
...........
Figure 17-26 Mallet toe deformity.
workout or changing to a different sporting activity may the hammertoe repair. The pin is bent at the tip of
be necessary on a temporary or permanent basis. When the toe to prevent proximal migration.
conservative measures do not allow acceptable athletic 8. A gauze and tape dressing is applied and changed
activity, surgical intervention may be necessary. on a weekly basis. The patient is permitted to
ambulate in a bunion shoe. Sutures and K-wire
Surgical treatment: hammertoe repair23,28 are removed 3 weeks after surgery.
1. The foot is cleansed and draped in the usual fash- 9. The patient then is instructed to tape the toe to an
ion. Usually a digital nerve block is used as an adjacent toe for an additional 4 weeks to protect it
anesthetic. from injury.
2. A small Penrose drain may be used as a tourniquet After the K-wire is removed, increased walking activ-
(optional). ity is permitted. Cycling may be allowed. Running or
3. A dorsal elliptical or longitudinal skin incision is jogging usually is avoided until swelling has diminished
centered over the PIP joint. The incision is carried (6 to 8 weeks). Often there will be 10 to 15 degrees
down to bone with excision of an ellipse of skin, of motion at the involved joint following adequate heal-
extensor tendon, and capsule, exposing the con- ing. Whether an arthrodesis occurs is not of significant
dyles of the proximal phalanx. concern. Fibrous ankylosis with a small amount of
4. The collateral ligaments of the PIP joints are sev- motion is equally acceptable.
ered, enabling the condyles to be delivered. For a hammertoe that can be passively corrected and
5. A bone-cutting forceps is used to osteotomize the has no element of fixed contracture, a flexor tendon
proximal phalanx in the supracondylar region transfer may be used. The procedure is technically more
(Fig. 17-27). The sharp edges are beveled with difficult than a condylectomy but leaves the toe more
a rongeur. flexible. The FDL tendon is transferred to the dorsum
6. The articular surface of the middle phalanx is of the proximal phalanx. This procedure removes a
exposed, and a rongeur is used to remove the deforming force and at the same time makes the FDL
articular surface. a plantarflexor of the proximal phalanx. Whether it is
7. A 0.045 K-wire is introduced at the PIP joint and a dynamic transfer or a tenodesis is unclear, but it is a
driven distally, exiting the tip of the toe. Then, useful procedure for repair of the flexible hammertoe.
with the toe reduced to the desired position, the This procedure also is used for a flexible claw toe and
K-wire is driven in a retrograde fashion, stabilizing for the unstable MTP joint (both discussed later).
398
...........
Figure 17-27 Hammertoe repair. (From Coughlin MJ: Foot Ankle Int 21:94, 2000.)
399
...........
Surgical treatment: early flexible mallet toe repair37

ion. A digital block is used for anesthesia. (With
an early mallet toe deformity, the toe can be cor-
rected passively to neutral with pressure.)
2. A no. 11 scalpel blade is introduced on the plantar
aspect of the DIP joint and the FDL tendon is
released, and a K-wire is used to stabilize the
DIP joint repair.
3. The incision is closed with an interrupted skin
suture.
Figure 17-29 The flexor digitorum longus is the largest of the
4. A gauze and tape dressing is applied, and the patient tendons and is characterized by a midline raphe.
is allowed to ambulate in a postoperative shoe.
5. The sutures are removed 10 days after surgery.
Athletic activity can be resumed rapidly following this
procedure with little downtime. In general, a patient can
a mosquito clamp on either side of the proximal
begin to advance activities at 2 weeks. Full activities typ-
phalanx, a tunnel is created for transfer of each
ically can be resumed by 4 weeks.
limb of the FDL tendon. The tunnel is created
When a fixed mallet toe is corrected, a procedure
deep to the neurovascular bundles and superficial
similar to that for hammertoe deformity is performed
to the extensor expansion.
as is carried out for a hammertoe deformity. In this
4. On the plantar aspect of the toe, a transverse
case the procedure is carried out at the DIP joint
incision is made at the proximal plantarflexion
(Fig. 17-28).24
crease of the toe. With blunt dissection, the long
Surgical treatment: flexor tendon transfer25 flexor tendon sheath is identified.
5. A longitudinal incision is made in the tendon
sheath and the flexor tendons are observed. The
ion. A foot block may be used for anesthesia.
FDL tendon is the larger of the two tendons
2. The foot is exsanguinated with an Esmarch ban-
and is characterized by a midline raphe (Figs. 17-
dage. The ankle is padded carefully and the
29 and 17-33). Tension is placed on the FDL
Esmarch is used as a tourniquet.
and a small plantar tenotomy puncture wound
3. A 1-cm longitudinal incision is centered in the
is made at the level of the DIP joint, releasing
midline over the dorsum of the proximal phalanx.
the FDL (Fig. 17-30).
The dissection exposes the extensor digitorum
6. The FDL tendon then is withdrawn through the
longus tendon. Then with blunt dissection, with
more proximal plantar wound and is split longi-
tudinally along its median raphe (Fig. 17-31).
7. Each limb of the FDL is passed on either side of
the proximal phalanx.
8. With the ankle held in neutral position, and the
involved toe held in 10 degrees of plantarflexion,
the tendon limbs are sutured to themselves with
interrupted nonabsorbable suture (Fig. 17-32).
Reinforcement sutures may be placed between
the tendon and the extensor expansion.
9. The toe then is inspected to ensure that proper
alignment has been achieved. The tourniquet is
released to ensure that it has not affected the ten-
sion of the repair. On occasion it is necessary to
retension the repair, with tightening or loosening
of one or both of the tendon limbs.
10. The skin then is approximated in a routine fash-
ion. A gauze and tape dressing is applied and
changed on a weekly basis. The patient is
Figure 17-28 Mallet toe repair. (A) Proposed resection. allowed to ambulate in a postoperative shoe.
(B) K-wire fixation following condylectomy. 11. Sutures are removed 3 weeks after surgery.
400
...........
Figure 17-30 (A) Lateral view of toe demonstrating long flexor tendon and other important tendons. (B) Long
flexor tendon is demonstrated on the plantar aspect of the foot. (From Coughlin MJ: Orthopedics 10:63, 1987.)
Figure 17-31 Flexor digitorum longus is released distally. (From Coughlin MJ: Orthopedics 10:63, 1987.)
12. At 3 weeks, increased walking activity is per- toe 4 weeks after surgery. The toe may become
mitted. Careful cycling also is an acceptable stiff because of immobilization, and frequent
activity. Running, jogging, and aggressive manipulation during this period increases the
sports should be avoided until swelling has sub- passive motion of the toe. Considerable active
sided (6 to 8 weeks). The patient should be motion is sacrificed with the flexor tendon
instructed to start passive manipulation of the transfer.
401
...........
Figure 17-32 Flexor digitorum longus is transferred dorsally. (From Coughlin MJ: Orthopedics 10:63, 1987.)
Many cases may be treated effectively with roomy

footwear, padding, and pedicures; however, on occasion
an athlete is so symptomatic that surgery is contem-
plated. Although claw toes frequently involve multiple
toes, they have similarities with different stages in the
development and treatment of hammertoe deformity.
Early on, flexible claw toes (although multiple in
nature) resemble flexible hammertoes. A flexor tendon
transfer of the second, third, and fourth toes may
achieve adequate realignment by releasing the con-
tracted FDL tendon and depressing the proximal pha-
lanx through the tendon transfer (see the section on
Flexible Hammertoe Repair). Rarely is a flexor tendon
transfer performed on the fifth toe. A flexor tenotomy
Figure 17-33 Cross section of lesser toe at level of metatarsal occasionally is performed, although often the fifth toe
head demonstrating flexor digitorum brevis and longus. is asymptomatic.
As a claw toe becomes fixed, a patient may develop
symptoms of a hammertoe, with callus formation overly-
ing the PIP joint. Because of the fixed dorsiflexion con-
tracture at the MTP joint, the toe buckles, depressing
the metatarsal head. A plantar callus (IPK) may develop
CLAW TOE
because of increased pressure beneath the metatarsal
head. The treating physician must remember that the
A claw toe deformity may be flexible, semirigid, or fixed. IPK usually is due to the contracted toe rather than to
Frequently it involves all of the toes on a foot. Although a prominent metatarsal condyle. Correction of the toe
the etiology frequently is idiopathic, the treating physi- deformity often is associated with diminution or resolu-
cian should inspect the patient for other causes, such tion of the plantar callosity.
as spasticity, muscular dystrophy, spinal abnormality, The fixed claw toe resembles a fixed hammertoe,
and previous trauma (old fractured tibia, old compart- although the claw toe also has a contracture at the
ment syndrome, and so forth). MTP joint. A PIP joint contracture is repaired surgically
402
...........
Metatarsophalangeal joint instability
combined with hammertoe repair, it is introduced

at the PIP joint and driven distally, exiting the tip
of the toe. It then is driven proximally through
the proximal phalanx.)
6. The pin then is driven in a retrograde fashion, sta-
bilizing the MTP joint. The pin is bent at the tip
of the toe to prevent proximal migration.
7. The extensor tendon is repaired in a lengthened
fashion, and the skin is closed in a routine fashion.
A gauze and tape dressing is applied and changed
on a weekly basis. The patient is allowed to ambu-
late in a postoperative shoe.
8. Three weeks following surgery, the K-wire and
sutures are removed.
The toe is taped in a corrected position for 4 to 6
weeks. After removal of the K-wire, increased activity is
permitted. Walking, cycling, and swimming are allowed.
It is wise to progress slowly, with the introduction of
jogging and running, until adequate healing has
occurred and swelling has subsided (6 to 8 weeks).
Figure 17-34 (A) Claw toe deformity. (B) Following METATARSOPHALANGEAL JOINT
metatarsophalangeal joint release and extensor tenotomy INSTABILITY
and proximal interphalangeal joint arthroplasty.
Instability of the MTP joint can be an extremely difficult
diagnosis to make, especially in the early stage, when
(Fig. 17-34) with a condylectomy of the proximal pha- there is a lack of clinical deformity. The second MTP
lanx (see the section on Fixed Hammertoe Repair). joint is the most frequent location of instability because
Obviously, once the PIP joint contracture has been of the longer length of the second ray. In a report on
corrected, attention must be directed to the MTP joint athletes with second MTP instability, Coughlin26
contracture. reported 100% of the patients to have an elongated sec-
ond metatarsal in relation to adjoining metatarsals. Most
Surgical treatment: MTP soft-tissue arthroplasty24,25 likely because of the stress of repeated and prolonged
1. The foot is cleansed in the usual fashion. An athletic activity, pain without deformity develops in the
Esmarch bandage is used to exsanguinate the foot. forefoot. The mechanism of instability generally is
The ankle is padded carefully and the Esmarch is described as rupture or attenuation of the collateral liga-
used as a tourniquet. ments and volar plate of the MTP joint.27
2. An oblique or longitudinal incision is centered Typically an athlete initially describes ill-defined fore-
over the MTP joint. foot pain, often exacerbated by running and sports activ-
3. The long extensor tendon is split longitudinally ities and relieved by rest. Sometimes pain increases with
and Z-lengthened. intensity and/or duration of sports activities.
4. The medial, dorsal, and lateral capsule is On physical examination, the treating physician initially
completely released to allow reduction of the must isolate the exact point of tenderness. With palpation,
MTP joint. (This requires a significant release in tenderness typically is elicited over the plantar, medial, or
a plantar direction of both collateral ligaments.) lateral MTP capsule. Usually pain is not so pronounced
When a toe still does not reduce completely fol- in the third or second intermetatarsal spaces (IMSs). Initi-
lowing an MTP release, there may be adhesions ally it may be difficult to differentiate second MTP pain
between the plantar capsule and the plantar meta- from a second IMS neuroma. A critical differentiating
tarsal head. These usually can be released with a finding, however, is that there are no neuritic symptoms
McGlanery elevator. The toe then should be easily in the second or third toes and no numbness associated
reducible in a dorsal plantar plane. with capsulitis or instability of the second MTP joint.
5. A 0.062 K-wire is used to stabilize the repair. The (An IMS neuroma may occur along with MTP instability.)
pin is introduced at the MTP joint and driven in a Capsulitis or inflammation of an MTP joint can be
distal direction exiting the tip of the toe. (When associated with systemic or localized arthritis. These
403
...........
With time, the diagnosis becomes obvious as the

toe deviates29,30 (Fig. 17-36). Initially, the toe deviates
medially and with time dorsally, developing into a
cross-over second-toe deformity. This development can
be acute, although typically in athletes it occurs insidi-
ously over several months.
Radiographic evaluation involves routine anterior-
posterior (AP) and lateral radiographs to determine
whether there is widening of the joint space (effusion),
narrowing (arthritis), or malalignment in relationship
to the adjoining MTP joints (Fig. 17-37). Occasionally
an arthrogram may be obtained, but this is not routinely
performed.
Conservative treatment
Early conservative treatment relies on early diagnosis by
the treating physician. Before deformity has developed
at the second MTP joint, early MTP instability is best
treated with taping the involved toe, padding, and a
change in athletic activity. Taping requires stabilizing
the toe to prevent dorsal plantarflexion excursion. Taping
to an adjacent toe may be effective. A sling-type taping
technique also may be effective (Fig. 17-38). An athlete
may need to tape the involved toe for several months,
Figure 17-35 A drawer sign is used to detect dorsal plantar
instability. although some athletes find it necessary to tape the
toe only during sports activities. A metatarsal pad placed
conditions often involve other MTP joints, whereas just proximal to the metatarsal head may alleviate pres-
without a preexisting inflammatory arthropathy only sure and relieve symptoms on the involved MTP cap-
the second MTP joint usually is involved. A drawer sign28 sule. Restructuring workouts and modifying athletic
(Fig. 17-35) typically is the diagnostic test most helpful activity can be helpful in relieving pain. A runner may
in defining capsulitis and/or instability of the MTP find that pain occurs only with greater than 2 miles of
joint. Grasping the involved toe between the fingers and jogging and that shorter distances can be accomplished
stressing the MTP joint in a dorsal plantar direction can pain free.
elicit exquisite pain, likely because of stress on the attenu- With unsuccessful resolution of discomfort, or insis-
ated plantar capsule or collateral ligaments. (This finding tence on a higher level of athletic activity, surgical inter-
is absent in an isolated interdigital neuroma.) vention may be contemplated. What is presented is a
Figure 17-36 (A) Instability of the second metatarsophalangeal joint with a cross-over second toe may
occur because of degeneration of the lateral collateral ligament. (B) Malalignment as demonstrated with a
cross-over second toe.
404
...........
step-by-step approach to MTP instability (see Case

Study 4).
C A S E S T U D Y 4
A 25-year-old, female aerobic instructor developed the

onset of insidious but increasing pain in the area of her
second MTP joint over 6 months. No specific injury was
noted. She denied neuritic-type pain. She became unable
to tolerate aerobic activity and then noted slight medial
deviation of her second toe.
On physical examination, she was noted to have
normal sensation and no evidence of a neuroma. She had
a negative Mulder sign. She had pain on palpation over
the second MTP joint capsule. She had a positive drawer
sign, and exquisite pain was elicited. Radiographic
examination showed slight medial inclination of the
second MTP joint.
Initially the patient taped her second toe to the third
toe for 3 months and was able to walk without pain.
However, her pain resumed with aerobic activity. She
requested surgical intervention. A medial MTP release,
lateral capsular reefing, and flexor tendon transfer were
performed. She then taped her toe to stabilize it for 6
Figure 17-37 Axial malalignment may be demonstrated on weeks postoperatively.
radiographic examination.
Figure 17-38 Technique of taping toe. (From Coughlin MJ: Foot Ankle 8:29, 1087.)
405
...........
instability, a flexor tendon transfer then is per-

She resumed aggressive walking 6 weeks after
surgery, jogging at 3 months, and aerobic instruction at
formed (see section earlier in this chapter).
4 months. She achieved resolution of her pain and is very 5. The wound is closed in a routine fashion. A gauze
satisfied with her repair. and tape dressing is applied and changed on a
weekly basis. The patient is allowed to ambulate
Surgical treatment: MTP instability in a wooden-soled shoe.
For patients who fail conservative treatment, several sur- 6. Sutures are removed 3 weeks after surgery. If a K-
gical techniques exist. Selection of the appropriate tech- wire has been placed, it is removed at this time
nique depends on clinical assessment of the deformity. (Fig. 17-40). The toe is taped in appropriate posi-
Synovitis and mild deviation the MTP joint is classified tion for 6 weeks postoperatively (see Fig. 17-38).
as a mild deformity and can be treated with capsular The patient is permitted to do aggressive walking 6
reefing. Dorsomedial deviation at the MTP joint or weeks following surgery and may increase sporting activ-
overlapping of the adjacent toe is considered moderate ity as swelling diminishes and pain permits. Results with
deformity and can be treated with capsular reefing and this type of approach are gratifying. Significant pain
an flexor tendon transfer. This is the most likely situa- relief can be achieved, although Coughlin26 reported
tion for an athlete who does not respond to conservative that several patients had to modify their athletic routine
treatment. This procedure is described in the following. postoperatively.
Finally, complete dislocation at the MTP joint is a severe When possible, the successful conservative treatment
deformity that necessitates an osteotomy of the MTP of lesser-toe problems will allow rapid return to athletic
joint.29 activity with limited downtime. Surgical procedures on
the lesser toes take time to heal, are prone to swell,
Surgical treatment: capsular reefing and flexor and leave an element of stiffness at the involved joint,
tendon transfer31 which may be of some concern to the athlete. Adequate
1. The foot is cleansed and draped in the routine preoperative counseling is important to identify areas of
fashion. The foot is exsanguinated with an concern, problem areas of recovery, and patient
Esmarch bandage. The ankle is padded carefully, expectations.
and the Esmarch is used as an ankle tourniquet Surgical treatment: Weil osteotomy36,38
2. A 2-cm dorsal midline incision is centered over
the MTP joint. If hyperextension of the toe The Weil osteotomy is a shortening osteotomy that pri-
is present, the extensor digitorum longus tendon marily benefits patients with painful instability associated
is lengthened and later repaired at the conclusion with a long lesser toe. This osteotomy should be
of the procedure. avoided in patients with a plantarflexed metatarsal
3. The dorsal MTP capsule is released. With medial because it does not dorsally displace the distal frag-
deviation of the phalanx, the medial capsule is ment.31 The relative stability of this osteotomy with
completely released. In this case the lateral capsule weight bearing and the use of internal fixation make this
then is reefed (Fig. 17-39) with two interrupted, an ideal osteotomy for the active patient.
2-0 nonabsorbable sutures to realign the toe in 1. The foot is cleansed and draped in the routine
a medial lateral plane. With lateral deviation, the fashion. The foot is exsanguinated with an
lateral capsule is released and the medial capsule Esmarch bandage. The ankle is padded carefully,
reefed. (This is quite uncommon.) and the Esmarch is used as an ankle tourniquet.
4. In the presence of remaining hyperextension of 2. A 3-cm incision is made in the adjacent IMS just
the MTP joint, or with remaining dorsal plantar proximal to the webspace. This allows access to
adjacent metatarsals should more than one require
attention.
3. The metatarsal head is exposed through a lateral
capsular incision under the extensor tendon. The
toe is plantarflexed, exposing the metatarsal head.
4. A narrow oscillating saw is used to make the osteot-
omy parallel to the weight-bearing surface of the
foot. The osteotomy originates in the dorsal one
fourth of the MTP joint (Fig. 17-41).
5. The distal fragment is displaced proximally until the
metatarsal head is at the level of a line drawn from
Figure 17-39 Technique of capsular reefing for repair of axial the MTP of the first and fourth rays. The fragment
malalignment. is fixed with one or two more fragment screws.
406
...........
Figure 17-40 (A) Clinical appearance of a cross-over toe deformity. (B) Radiographic appearance of a cross-over
second toe. (C) Three-year follow-up demonstrating excellent alignment. (D) Three-year radiographic follow-up
demonstrating excellent alignment. (From Coughlin MJ: Foot Ankle 8:29, 1987.)
407
...........
Figure 17-41 The Weil osteotomy. (From Trnka H: Foot Ankle 20:72, 1999.)
6. The overhanging bone is rongeured smooth. 3. Throckmorton JK, Bradlee N: Transverse V sliding osteotomy:
7. The capsule is reefed if necessary as described pre- a new surgical procedure for the correction of Tailor’s bunion
deformity, J Foot Surg 18:117, 1978.
viously. The capsule is repaired with absorbable 4. Coughlin MJ: Bunionettes. In Mann RA, Coughlin MJ, editors:
sutures. Surgery of the foot and ankle, ed 6, St Louis, 1992, CV Mosby.
8. The patient is placed in a surgical shoe and 5. Sponsal KH: Bunionette correction by metatarsal osteotomy,
allowed to weight bear with crutches. Orthop Clin North Am 7:808, 1976.
6. Coughlin MJ: Treatment of bunionette deformity with
longitudinal diaphyseal osteotomy with distal soft tissue repair,
Foot Ankle 11:195, 1991.
CONCLUSION 7. Mann RA: Intractable plantar keratosis. In American Academy of
Orthopaedic Surgeons instructional course lectures, Vol 33. St
Louis, 1984, CV Mosby.
When correctly diagnosed and treated, forefoot disorders 8. Mann RA, DuVries H: Intractable plantar keratosis, Orthop Clin
should not limit athletic endeavors. Although many of North Am 4:67, 1973.
these conditions are treated nonoperatively, the ortho- 9. Pedowitz WJ: Distal oblique osteotomy for intractable
paedic surgeon often is the most appropriate practioner plantar keratosis of he middle three metatarsals, Foot Ankle
9:7, 1988.
to identify the problem and direct treatment. When oper- 10. Dreeben SM, et al: Metatarsal osteotomy for primary
ative treatment is required, the patient should be able to metatarsalgia: radiographic and pedobarographic study, Foot
resume activities at the previous level of competition. Ankle 9:214, 1989.
11. Mann RA, Coughlin MJ: Intractable plantar keratoses. InVideo
textbook of foot and ankle surgery, St Louis, 1991, Medical Video
Productions.
REFERENCES 12. Giannestras NJ: Shortening of the metatarsal shaft in the
treatment of plantar keratosis, J Bone Joint Surg 49A:61, 1958.
13. Thompson FM, Deland JT: Occurrence of two interdigital
1. Coughlin MJ: Etiology and treatment of the bunionette deformity. neuromas in one foot, Foot Ankle Int 14:15, 1993.
In Greens WB, editor: American Academy of Orthopaedic Surgeons 14. Coughlin MJ, et al: Concurrent interdigital neuroma and MTP
instructional course lectures, 39:1037-1048, AAOS-Chicago, p. 37, joint instability: long-term results of treatment, Foot Ankle Int
1990. 23:1018, 2002.
2. Mann RA, Coughlin MJ: Bunionettes. In Video textbook of foot 15. Mulder JD: The causative mechanism in Morton’s metatarsalgia,
and ankle surgery, St Louis, 1991, Medical Video Productions. J Bone Joint Surg 33B:94, 1951.
408
...........
Further reading
16. Coughlin MJ: Soft tissue afflictions. In Chapman M, editor: 30. Coughlin MJ: When to suspect crossover second toe deformity,
Operative orthopaedics, Philadelphia, 1988, JB Lippincott. Musculo Skel Med 4:39, 1987.
17. Betts LO: Morton’s metatarsalgia: neuritis of the fourth digital 31. O’Kane C, Kilmartin TE: The surgical management of central
nerve, Med J Aust 1:514, 1940. metatarsalgia, Foot Ankle Int 23:415, 2002.
18. Mann RA, Reynolds JC: Interdigital neuroma: a critical clinical
analysis, Foot Ankle 3:238, 1983.
19. Morton TG: A peculiar painful infection of the fourth
metatarsophalangeal articulation, Am J Med Sci 71:37, 1876. FURTHER READING
20. Mann RA, Coughlin MJ: Deformities of the lateral toes. In
American Academy of Orthopaedic Surgeons instructional course
Coughlin MJ: Operative repair of the mallet toe, Foot Ankle
lectures, 36:137-159, 1987.
21. Mann RA, Coughlin MJ: Lesser-toe deformities. In Jahss JM, editor: 16(3):109-116, 1995.
Disorders of the foot, ed 2, Philadelphia, 1991, WB Saunders. Coughlin MJ: Common causes of pain in the forefoot in adults, J Bone
Joint Surg[Br] 82-B:781-790, 2000.
22. Coughlin MJ: Mallet toes, hammer toes, claw toes, and corns—
Coughlin MJ: Lesser-toe abnormalities, J Bone Joint Surg [Am] 84-
causes and treatment of lesser toe deformities, Postgrad Med
75:191, 1984. A:1446-1469, 2002.
23. Coughlin MJ: Lesser toe deformities, Orthopedics 10:63, 1987. Coughlin MJ, Dorris J, Polk E: Operative repair of the fixed
hammertoe deformity, Foot Ankle Int 21:94-104, 2000.
24. Coughlin MJ: Lesser toe abnormalities. In Chapman M. editor:
Operative orthopaedics, Philadelphia, 1988, JB Lippincott. Coughlin MJ, Grimes JS: Geometric analysis of the Weil osteotomy,
25. Coughlin MJ, Mann RA: Lesser toe deformities. In Mann RA, Foot Ankle Int 27:985-992, 2006.
Coughlin MJ, editors: Surgery of the foot and ankle, ed 6, St Louis, Coughlin MJ, Kennedy MP: Operative repair of fourth and fifth toe
corns, Foot Ankle Int 24:147-157, 2003.
1992, CV Mosby.
26. Coughlin MJ: Metatarsophalangeal joint instability in the athlete, Coughlin MJ, Pinsonneault T: Operative treatment of interdigital
Foot Ankle 14:309, 1993. neuroma: a long-term follow-up study, J Bone Joint Surg [Am] 83-
A:1321-1328, 2001.
27. Haddad SL, et al: Results of flexor-to-extensor and extensor brevis
Trnka HJ, Muhlbauer M, Reinhard Z, et al: Comparison of the results
tendon transfer for correction of the crossover second toe
deformity, Foot Ankle Int 20:781, 1999. of the Weil and Helal osteotomies for the treatment of metatarsalgia
28. Coughlin MJ: Subluxation and dislocation of the second secondary to dislocation of the lesser metatarsophalangeal joints,
Foot Ankle Int 20:72-79, 1999.
metatarsophalangeal joint, Orthop Clin North Am 20:535, 1989.
29. Coughlin MJ: Cross-over second toe deformity, Foot Ankle 8:29,
1987.
409
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.........................................C H A P T E R 1 8
Great-toe disorders
Robert B. Anderson and Scott B. Shawen
......................
CHAPTER CONTENTS
Introduction 411 Specific entities of the great toe 413

Anatomy 411 Conclusion 431
Biomechanics 412 References 432
INTRODUCTION conservative and operative treatments for these injuries,

and the late sequelae encountered in these athletes.
Injuries to the hallux metatarsophalangeal (MTP) joint
are not uncommon, particularly in the running athlete,
ANATOMY
and may result in chronic pain and deformity. Causes
of hallux injuries range from soft-tissue disruption to
overuse and degeneration. Trainers and physicians may To the surgeon responsible for the care of athletes with
fail to recognize the potential dysfunction of these great-toe injuries, knowledge of the anatomy of the
injuries, thus providing inadequate care and protection hallux MTP joint is paramount. In the simplest of terms,
from further injury. Long-term sequelae of even isolated the motion of the joint consists of rolling, sliding, and
soft-tissue injury include flexor hallucis longus (FHL) compression. More specifically, the morphology of this
tendon tears, hallux valgus or varus, cock-up defor- joint allows for plantarflexion and dorsiflexion but very
mity with interphalangeal (IP) joint contracture, and limited abduction and adduction. The fact that there is
degenerative joint disease, that is, hallux rigidus. more than one center of motion contradicts the theory
Clanton and Ford1 found that foot injuries rank third of a simple, hinged joint. Instead, the joint is a dynamic
behind ankle and knee injuries as the most common acetabulum or ‘‘hammock,’’ as described by Kelikian.2
time-loss injury among university athletes. Of these foot The joint articulation provides little of the overall sta-
injuries, a large proportion were sprains of the forefoot bility because of the shallow, glenoid-like cavity of the
and, more specifically, the hallux MTP joint. In our proximal phalanx. Most of the stability comes instead
practice, we have seen a number of professional athletes from the capsular-ligamentous-sesamoid complex, which
with a broad range of injuries to the great toe and base is described in detail later.
this chapter on our experiences. There are two sets of ligaments that contribute to the
Great-toe injuries can lead to significant functional stability of the metatarsal (MT) head as it articulates
disability, especially when not recognized early. In the with the proximal phalanx: the medial and lateral collat-
short term, these injuries can result in difficulties with eral ligaments and the metatarsosesamoid suspensory
push-off and running. Long-term sequelae include ligaments.3 The fan-shaped medial collateral ligament
continued difficulty with pain and push-off strength, as is composed of the medial MTP ligament and the
well as progressive degeneration. Physicians involved in medial metatarsosesamoid ligament (Fig. 18-1). The lat-
the treatment of foot and ankle injuries, especially those eral collateral ligament is structured in a similar fashion.3
caring for athletes, must become familiar with the spec- In addition to the collateral ligaments, the strong,
trum of injuries about the hallux MTP joint, the fibrous plantar plate (see Fig. 18-1) also affords structural
CHAPTER 18 Great-toe disorders
BIOMECHANICS
The hallux MTP joint lies in an intricate balance of

opposing tendons and ligaments. The anatomy outlined
previously, especially with regard to the plantar plate, is
important when considering the biomechanical demands
placed on the first MTP joint. During normal gait, the
great toe typically supports twice the load of the lesser
toes and accommodates forces reaching 40% to 60%
of body weight.6 During athletic activity, including jog-
ging and running, the peak forces may approach two
Figure 18-1 Medial diagrammatic representation of first to three times body weight, and the forces increase to
metatarsophalangeal joint. (From Adelaar RS, editor: Disorders eightfold when a running jump is performed.7
of the great toe, Rosemont, IL, 1997, American Academy of The range of motion (ROM) in the normal foot has
Orthopaedic Surgeons.) been studied extensively; it is noted to be highly vari-
able and to decrease with aging. In the resting position,
the first MTP joint is in a mean resting position of
16 degrees of dorsiflexion. The passive arc of motion
support. The capsular ligamentous complex of the hallux was noted by Joseph to be from 3 to 43 degrees of plan-
MTP joint actually is a confluence of structures including tarflexion and from 40 to 100 degrees of dorsiflexion.8
the plantar plate, collateral ligaments, the flexor hallucis The mean passive MTP joint dorsiflexion during push-
brevis, the adductor hallucis, and abductor hallucis ten- off was 84 degrees. One study found that at least
dons. This plantar plate is attached firmly to the base of 60 degrees of dorsiflexion is considered normal in bare-
the proximal phalanx and only loosely attached at the foot walking on a level surface.9 Athletes may accommo-
MT neck through the capsule.4 date up to 50% reduction in MTP joint motion resulting
The split tendon of the flexor hallucis brevis runs along from acute injury to the plantar plate or hallux rigidus
the plantar aspect of the hallux and envelops the sesa- by various gait adjustments such as foot/leg external
moids before inserting at the base of the proximal phalanx rotation, shortened stride, and increased ankle, knee,
as the capsular-ligamentous complex (see Fig. 18-1). The or hip motion.4 In addition, a stiff-soled shoe is cap-
two sesamoids are united by a thick, intersesamoid liga- able of decreasing MTP joint dorsiflexion to 25 to
ment and maintain the course of the FHL tendon. Adding 30 degrees without significantly affecting gait.9
to the stability of the hallux MTP joint are three other The effects on the push-off power of the great toe
intrinsic muscles of the great toe. The extensor hallucis following sesamoidectomy have been studied in vitro
brevis originates at the fascia overlying the sinus tarsi by Aper et al.10 They confirmed the importance of this
and runs obliquely to attach into the extensor mechanism seemingly insignificant bone to the function of the toe,
on the dorsum of the MTP joint. It functions primarily particularly in the athlete, in whom even a small loss
as an extensor of the hallux MTP joint. On the plantar of power will affect overall performance. The study
aspect, the abductor and adductor hallucis tendons insert noted that the isolated excision of the tibial sesamoid
on the medial and lateral aspects of the hallux MTP joint,
respectively. These tendons blend into the capsular-
ligamentous complex, as well as the sesamoids, to provide
additional structural support (Fig. 18-2).5
Not a simple, hinged joint.
Most of the stability comes instead from the capsular-
ligamentous-sesamoid complex.
Capsular ligamentous complex: plantar plate, col-
lateral ligaments, flexor hallucis brevis, adductor
hallucis, and abductor hallucis tendons.
Collateral ligaments have phalangeal and sesamoid
insertions.
Split tendon of the flexor hallucis brevis runs Figure 18-2 Twenty percent to 30% of the metatarsal head is
along the plantar aspect of the hallux and envelopes removed, as well as the exostosis. (From Coughlin MJ, Mann
the sesamoids before inserting at the base of the RA, editors: Surgery of the foot and ankle, ed 7, St Louis, 1999,
proximal phalanx. Mosby-Year Book.)
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Specific entities of the great toe
equated to an 11% loss of flexor power, there was 19% space is narrow, bony proliferation is present on the MT
loss for a fibular sesamoidectomy, and 32% when both head and phalanx, and there is subchondral sclerosis
are excised.10 and/or cyst formation. Grade 3 is the severe type, with
Great toe supports twice the weight of each lesser significant joint space narrowing and extensive bony
toe. proliferation that involves the entire periphery and
Hallux dorsiflexion during gait/running is 60 to includes loose bodies, a dorsal ossicle, or subchondral
84 degrees. cyst formation. A more recent grading scheme, pro-
Up to 50% reduction in ROM can be accommo- posed by Coughlin and Shurnas,24 combines objective
dated through gait adjustments such as foot/leg and subjective clinical data with radiographic findings
external rotation, shortened stride, and increased (Grades 0 to 4). Treatment recommendations are made
ankle, knee, or hip motion. on the basis of grade severity.
Sesamoidectomy: tibial excision results in 11% loss Symptoms with which the typical athlete may pre-
of flexor power, fibular 19% loss, and 32% when sent include pain that is worse with push-off and more
both are excised. severe after increased activity (i.e., twice-a-day practice
regimens), as well as swelling. Although there may be
bilateral radiographic involvement, the patient almost
SPECIFIC ENTITIES OF THE GREAT TOE always presents with unilateral symptoms. Swelling and
the bony prominence itself may interfere with athletic
shoewear (especially in soccer and football, sports in
Hallux rigidus which athletes prefer tightly fitting shoewear). A dys-
Hallux rigidus is defined as a localized degeneration of esthesia in the dorsomedial cutaneous nerve can result
the hallux MTP joint. It was first described as hallux from tight shoewear’s impinging on the bony promi-
flexus in 1887 by Davies-Colley.11 In his first descrip- nence. Occasionally transfer lesions may develop. This
tion of this condition, he discussed a plantarflexed pos- presents as metatarsalgia secondary to the lack of hallux
ture of phalanx relative to MT head. The actual term dorsiflexion, causing increased pressure on the lateral
‘‘hallux rigidus’’ was coined by Cotterill in 1888 and forefoot.
remains the most common term used today.12 Numer- In treating hallux rigidus in the athlete, one must
ous papers have theorized the etiology and pathophysi- consider the sporting activity and position played (i.e.,
ology of hallux rigidus. One such theory is that of a lineman who requires little hallux MTP dorsiflexion
metatarsus elevatus, a term describing the dorsiflexed vs. a running back or wide receiver), shoewear require-
posture of the first ray in relationship to the foot and ment, and ROM of the entire foot and ankle. Even
the subsequent plantarflexed posture of the hallux. This more minor or early-presenting cases can be problematic
has been discussed by many authors, but the most cur- because some athletes create more forceful dorsiflexion,
rent data indicate that the elevated posture of the first which can limit the function of the runner and incapaci-
MT improves after dorsal decompression of the hallux tate the dancer. Also important is the fact that if a bad
MTP joint.13-16 Overuse and repetitive dorsiflexion joint is provided more motion, it may hurt more and
forces, such as those occurring in a runner or kicker, degenerate more quickly.
may lead to chondral lesions and other occult injuries17 Nonoperative treatment options include the use of
or to osteochondritis dissecans.2,18,19 It also may result nonsteroidal anti-inflammatory drugs (NSAIDs) and
as a sequelae to a turf-toe injury. Anatomic abnormalities shoewear modifications. Shoes of adequate size and a
that may lead to hallux rigidus include the flat or pro- more full-fitted toe box or increased depth are helpful
nated foot,15,20,21 a long first MT or hallux,21 and a flat and can be modified further with a balloon patch over
MT head.22 To this time the true potential etiologies bony prominences. Turf-toe inserts (Springlite, Otto
for the development of hallux rigidus remain in question. Bock, Minneapolis, MN) that limit dorsiflexion and
Clinical grading from mild to severe (or I, II, and III) subsequent dorsal impingement are potentially useful
has been proposed by many authors. Grading depends but may limit performance in the elite runner. Rigid
on the severity of disease and is based on ROM, pain rocker soles function in the same manner as semirigid
or crepitus with motion, the size of the dorsal osteo- inserts and, although helpful in the general population,
phyte on the MT head, the presence of sesamoid invol- are not popular with the athlete because of the increased
vement, and the radiographic alignment of the hallux weight and excessive stiffness. Orthotic devices can
(on anterior-posterior [AP] and lateral views). A radio- unload the hallux MTP joint, but one must remember
graphic classification scheme was created by Hattrup to increase the shoe size to accommodate for it. Taping
and Johnson in 1988.23 Their grade 1 is considered techniques can limit dorsiflexion and provide pain relief.
mild; the joint space is maintained and there is minimal Application is the same as that for turf-toe; however,
spurring. Grade 2 is moderate disease in which the joint skin problems such as blistering can occur. Steroid
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injections must be given judiciously and perhaps only the MT head is dictated by the size of the dorsal exosto-
for ‘‘big game’’ situations. Repeated injections may sis and the degree of articular cartilage destruction. If
accelerate the degenerative process.25 degeneration of articular cartilage is not significant and
Surgery in the management of hallux rigidus is fea- the main problem is the dorsal exostosis, then 20% to
sible, and there are many options. The decision to pro- 30% of the dorsal aspect of the MT head is removed
ceed with surgery requires a lengthy discussion with along with the exostosis (see Fig. 18-2).
not only the athlete but the trainer and possibly the It is reasonable to be relatively aggressive with this
athlete’s agent. It must be emphasized to all parties that resection, removing up to one third of the dorsal head
this is an arthritic process, there is no ‘‘cure,’’ and there to achieve improved motion. The cheilectomy should
is the potential for a lengthy rehabilitation with incom- include removal of all osteophytes and a rounding of
plete resolution of the symptoms. The physician must the MT head. The cheilectomy should achieve a mini-
determine the following: What is causing the problem? mum of 70 to 80 degrees of dorsiflexion because
Is it the bony prominence over the MT head and sec- approximately one half of this will be lost in the postop-
ondary shoewear irritation? Is there limited ROM? Are erative period as a result of scar formation. It is Mann’s
there biomechanical implications such as poor push- recommendation that if insufficient dorsiflexion is
off? Does the athlete suffer from transfer pain issues achieved after cheilectomy, then a proximal phalangeal
and other compensatory problems? Lastly, and most osteotomy (Moberg) should be performed as described
concerning, is there the presence of global pain and later.
diffuse arthritis, especially in sesamoid-MT articulation? We have modified the cheilectomy technique through
The most commonly performed surgical procedure a medial approach. This allows for plantar debride-
in the management of hallux rigidus is a cheilectomy. ment and release of plantar capsule and adhesions, thus
This procedure can be defined in general as an excision improving dorsiflexion. In addition, the incision avoids
of an irregular osseous rim that interferes with motion the EHL tendon and the potential for tenodesis second-
of a joint. In this particular instance it is the removal ary to scar formation while still providing access to lateral
of the dorsal osteophyte of the MT head. As noted pre- osteophytes. We recommend a two-cut technique to
viously, the athlete should be counseled that the under- avoid excessive resection of the MT head (Fig. 18-3).
lying condition is degenerative joint disease and that The first cut of the saw includes the dorsal exostosis
full symptom relief is not realistic. A cheilectomy may and is made flush with the dorsal diaphysis. The
prolong the athletic life of the individual but probably
does not slow the rate of joint degeneration. As a gen-
eral rule, the dorsal ridge does not recur, but progressive
narrowing of the joint is expected to occur.
Indications for a cheilectomy include a lateral radio-
graph showing that reasonable space exists in the plantar
one half of the MTP joint. There should be an absence
of pain or crepitus with midrange motion and no sesa-
moid-MT pain or disease. This procedure allows for
complete relief of dorsal impingement. It increases dor-
siflexion by decreasing bulk of joint and subsequently
relieving dorsal impingement pain. It also eliminates
the source of painful shoe pressure. The true advantage
of the cheilectomy is that ‘‘no bridges are burned,’’
and even in unsuccessful cases a salvage procedure is still
technically possible.
The technique has been described and popularized
by Mann and Clanton.26 Their preference is a dorsal
longitudinal incision centered over the hallux MTP
joint. The joint capsule is incised on either side of the
Figure 18-3 The first cut of the saw includes the dorsal
extensor hallucis longus (EHL) tendon and a complete
exostosis and is made flush with the dorsal diaphysis. The
synovectomy is performed. The joint is plantarflexed to subsequent cut removes the amount of articular surface
permit inspection of the sesamoid articulation. Hamil- necessary to achieve the desired dorsiflexion while eliminating
ton27 recommends mobilizing the sesamoids by blunt the risk of excessive head removal that may jeopardize later
dissection, for they often are anchored by adhesions arthrodesis. (From Adelaar RS, editor: Disorders of the great
and limit dorsiflexion even after removal of impinging toe, Rosemont, IL, 1997, American Academy of Orthopaedic
osteophytes. The amount of bone to be removed from Surgeons.)
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subsequent cut removes the amount of articular surface of radiographic arthritis, but this did not correlate
necessary to achieve the desired dorsiflexion while eli- with symptoms. Three patients eventually required an
minating the risk of excessive head removal that may arthrodesis.
jeopardize later arthrodesis. Phalangeal osteotomy has been advocated as a useful
Hamilton27 describes ‘‘radical cheilectomy’’ similar surgical adjuvant to a cheilectomy. This technique was
to the cheilectomy of Mann but also removing the first proposed by Bonney and Macnab in 1952.13 Kessel
dorsal portion of the base of the proximal phalanx, and Bonney19 described its use in 10 adolescents in
matching the resection performed on the MT head. This 1958. Moberg is the name most commonly associated
modification serves as an option for dancers with end- with the procedure, after his case series reported in
stage disease and is similar to the Valenti28,29 procedure 1979.33 The procedure involves a dorsal closing wedge
described later in this chapter. osteotomy of the proximal third of the proximal pha-
A cheilectomy affords a fairly rapid postoperative lanx. It relies on the principle that the arc of motion
course and return to activity. The patient is allowed to of the hallux MTP joint is translated to plantar aspect
weight bear immediately, typically in a rigid-soled heal- of head, thereby increasing functional motion. Basically
ing sandal. ROM can be initiated by a therapist or it creates pseudodorsiflexion, which in turn places less
trainer as soon as pain allows but not so aggressively as stress on the hallux with push-off. Adequate plantar-
to create wound dehiscence. Sutures generally are flexion of the joint is a prerequisite. Thomas and
removed at 10 days, at which time active and passive Smith34 also found that the procedure appeared to pro-
ROM should be conducted at least three to four times vide dorsal joint space decompression, as well, further
per day. Close monitoring is required to ensure that relieving stress from the arthritic joint (Fig. 18-4).
the motion within the hallux MTP joint is at a func- The indications for performing a Moberg osteotomy
tional level, a minimum of 40 degrees of dorsiflexion. on the proximal phalanx includes grade I or II hallux
No significant athletic activities generally are allowed rigidus, adolescent hallux rigidus, and the running ath-
for 6 to 8 weeks following a cheilectomy, giving the lete, perhaps regardless of grade. Most authors now
joint time to mature following surgery. Athletes can recommend combining the procedure with a dorsal
continue to train by bicycling, swimming, running in cheilectomy.32,34,35
water, and engaging in other activities that avoid signi- The technique can be performed through a medial
ficant impact against the MTP joint. The patient should or dorsal incision, extending distally from the incision
appreciate that swelling may continue for many months used for the cheilectomy of the hallux MTP joint. It is
but that maximal motion usually is achieved by important to protect the dorsomedial and plantar medial
3 months. cutaneous nerves to limit paresthesia and the potential for
A number of authors have provided their results neuritis or neuroma. Longitudinal reflection of
of cheilectomy. Mann and Clanton26 found that 22 of soft tissues at the proximal third of the phalanx is per-
31 patients had complete relief, 6 of 31 achieved con- formed, maintaining capsular insertion. The FHL and
siderable relief, and ROM increased an average of 20
degrees in 23 of 31 feet. Hattrup and Johnson30
reported that 53.4% were satisfactory and 27.6% unsa-
tisfactory. Their failure rate increased from 15% with
grade I radiographic changes to 37.5% with grade III
changes. They concluded that cheilectomy is the proce-
dure of choice in patients with hallux rigidus and grade
I changes. Graves’31 experience showed little impro-
vement in motion and stated that satisfaction with chei-
lectomy was more likely if the patient and the physician
had reasonable expectations regarding outcome. He
recommended careful patient selection. Myerson agreed
that the procedure improves pain, not motion. Easley
et al.32 reported on 57 patients (75 feet) with greater
than 3-year follow-up (average 63 months). Their chei-
lectomy was performed via a medial approach by a
single surgeon. American Orthopaedic Foot and Ankle
Society (AOFAS) scores were 45 preoperative, 85 post-
operative, and 90% satisfied. The average dorsiflexion Figure 18-4 Space created by dorsiflexion osteotomy of the
improved from 19 degrees preoperative to 39 degrees proximal phalanx. (From Thomas PJ, Smith RWL: Foot Ankle
postoperative. The majority of patients had worsening Int 20:4, 1999.)
415
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EHL tendons are protected as a dorsal closing wedge arthrodesis. The average postoperative motion was 43
osteotomy is performed with a microsagittal saw approx- degrees, 22 degrees being dorsiflexion, with late loss of
imately 3 to 5 mm distal to the MTP joint. In the adoles- plantarflexion noted. Asymptomatic compensatory hal-
cent, it is necessary to avoid the physis. Intraoperative lux IP flexion contracture often was present. They felt
fluoroscopy can be useful in confirming proper position that this osteotomy represented an especially good
of the osteotomy. The plantar cortex is maintained to option in the adolescent. Thomas and Smith34 per-
allow for a ‘‘greenstick’’ effect with manual closure of formed the osteotomy with a dorsal cheilectomy in 27
the osteotomy. Generally 2 to 6 mm of dorsal cortex feet, 20 patients. At a follow-up average of 5.2 years,
should be removed, with the actual amount determined there was a 100% union rate, the average dorsiflexion
by the degree of joint stiffness and amount of plan- increased 7 degrees, and 96% of patients were satisfied
tarflexion of the hallux available. The goal is to obtain or satisfied with reservation.
20 to 30 degrees of dorsiflexion relative to the first MT Complications of the Moberg osteotomy include
axis. The osteotomy should be stabilized with a suture, nonunion or malunion, a problem avoided by using
K-wire, screw, or staple. If combined with a internal fixation and ‘‘greensticking’’ the plantar cortex
cheilectomy, stable, internal fixation is mandatory to to avoid gross instability. Injury to the FHL and EHL
allow for the initiation of early motion (Fig. 18-5, A tendons can occur, as can neuritis or neuroma, although
and B). the latter typically is transient. The possibility of pro-
The postoperative care is similar to that described for gressive arthritis of the hallux MTP joint is an outcome
an isolated cheilectomy. Immediate full weight bearing that must be discussed with the patient preoperatively.
is permitted in a hard-soled sandal, with passive dor- Decreased push-off power can occur and may be of
siflexion exercises begun at 1 to 2 weeks. In ranging concern in the athlete or dancer.
the joint it is important to hold the entire toe as single Salvage for advanced degeneration or for a failed chei-
unit. Plantarflexion exercises are delayed until 3 to 4 lectomy or osteotomy includes either arthrodesis or
weeks postoperative. When a pin is present, removal is arthroplasty. Arthrodesis is best avoided in the ‘‘sprint-
performed at 4 to 6 weeks, followed by transition to ing’’ athlete or dancer. If an arthrodesis must be per-
accommodative shoes. formed, the toe tip should be at least 10 mm off the
Published results of the proximal phalanx osteotomy ground. Failure to meet this requirement will place
include Moberg’s review of older individuals at short significant stress on the distal hallux and IP joint. Slight
follow-up. Eight patients were noted to have satisfactory shortening of the hallux also is of benefit, further less-
results. Citron and Neil36 evaluated 10 feet in 8 patients ening the potential of the athlete’s having to ‘‘vault’’
with 22-year follow-up (minimum 10 years) and iden- over the hallux during running activity.
tified 5 symptom free, others with progression of Resection arthroplasty, like that of a Keller, is reserved
degenerative joint disease (DJD), and one requiring for the older individual. Capsular interposition is a modi-
fication of this procedure devised by Hamilton.37,38 In
this procedure the proximal 5 to 10 mm of proximal pha-
lanx is resected, followed by transection of the extensor
hallucis brevis (EHB) tendon and dorsal capsule. This
dorsal soft-tissue complex then is advanced to the plantar
complex. Some authors release the flexor hallucis brevis
(FHB) tendon from the base of the phalanx and suture
this to the dorsal capsule. Temporary pin fixation is not
necessary (Fig. 18-6, A and B). Our own experience with
the procedure has noted good relief of pain from dorsal
impingement and joint degeneration but a concerning
loss of push-off strength. Similarly, the Valenti28,29 proce-
dure is a salvage technique in which an angled resection
on both sides of the joint is performed, preserving the
plantar complex and overall length. The result is a
‘‘hinge’’ effect at the level of the joint (Fig. 18-7).
Most recently, an ‘‘anchovy’’ interposition of the
hallux MTP joint has been performed in those indivi-
Figure 18-5 (A) Dorsal cheilectomy and dorsiflexion duals failing a cheilectomy but needing to maintain hal-
osteotomy of the proximal phalanx. (B) The amount of lux MTP motion. Conical resection on both sides of
correction after fixation. (From Thomas PJ, Smith RWL: Foot the joint is followed by insertion of a semitendinosus
Ankle Int 20:4, 1999.) allograft rolled into an ‘‘anchovy.’’ We have used this
416
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Figure 18-6 (A) Interposition arthroplasty as described by Hamilton. (B) Pin fixation is not necessary.
(From Hamilton WG, Hubbard CE: Foot Ankle Clin 5:663, 2000.)
Dysesthesia in the dorsomedial cutaneous nerve can

result from tight shoewear impinging on the bony
prominence.
Nonoperative treatment: NSAIDs, large toe box
shoes/balloon expansion, turf-toe plate, rocker
bottom shoes.
Surgical treatment: Cheilectomy if plantar joint
Figure 18-7 Resection of the dorsal metatarsal head as well space intact, Moberg phalanx osteotomy for running
as dorsal proximal phalanx. (From Coughlin MJ, Mann RA, athletes, resection arthroplasty in elderly patients,
editors: Surgery of the foot and ankle, ed 7, St Louis, 1999, and interpositional arthroplasty for complete joint
Mosby-Year Book.)
destruction.
technique on three patients, one a professional football Sesamoid disorders

player, with good short-term results. Coughlin and There are many etiologies for sesamoid pain. The gen-
Shurnas39 recently reported on their experience with eral term ‘‘sesamoiditis’’ is best considered a term for a
this technique in seven patients with excellent results. symptom rather than a diagnosis. This term implies pain
This case series demonstrates that this is a good surgical in the sesamoid region with negative radiographs and
option in patients who otherwise would be treated with an equivocal magnetic resonance imaging (MRI). It
MTP arthrodesis. represents a diagnosis of exclusion in which soft-tissue
Implant arthroplasty has been advocated by some ailments such as bursitis or flexor tendinitis are consid-
authors; the options described include a silastic dou- ered and often is associated with a history of overuse
ble-stem hinge, titanium hemiarthroplasty, or total toe or trauma.41,42
replacement. These implants are unlikely to hold up in Fracture of the sesamoid, acute or stress, typically
the running athlete, and the surgeon is faced with a involves the tibial hallux sesamoid because of its larger
difficult revision should failure occur. It remains our rec- size and greater propensity for weight-bearing forces.
ommendation to avoid this procedure in the athlete, The classic radiographic appearance is a transverse frac-
career or recreational. ture line, usually at the midwaist. It also can occur as
Arthroscopic intervention for disorders of the hallux the result of an MTP dislocation (Jahss Type II).5
MTP joint has received some attention over recent Degenerative etiologies for pain in the sesamoid
years. It has been shown to be more of a diagnostic include chondromalacia, osteophytes, impingement,
modality than a therapeutic one but may be a reasonable or plantar prominence. These particular problems may
option for the removal of small dorsal osteophytes or occur in an isolated fashion or in association with gout.
loose bodies. It also may be used for debridement of Osteochondrosis has an unknown etiology but often
an osteochondral defect on the MT head but is not in- is found as a late sequela to a crush injury or stress frac-
dicated in advanced hallux rigidus. Van Dijk et al.40 per- ture. Avascular necrosis (AVN) also has been described,
formed a prospective study with 24 athletes and found most often affecting the fibular hallux sesamoid. Painful
that it was not favorable for hallux rigidus because of fragmentation and cyst formation with flattening of
‘‘scar fibrosis.’’ the sesamoid can be seen in either AVN or osteochon-
X-rays: AP and lateral weight-bearing foot. drosis, with radiographic changes following symptoms
Multiple etiologies, occult trauma or overuse most by 6 to 12 months.
common. Plantar prominence of a hallux sesamoid can occur
Large dorsal soft-tissue and/or bony mass. with bursitis or with an intractable plantar keratosis.
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Osteomyelitis of the sesamoid can be the result of direct the training regimen are modified. Analgesics and anti-
extension from a neuropathic ulcer or puncture wound inflammatory medication are useful adjuvants. A boot
but is unusual in the athlete.43 Tumors of the sesamoid or cast is applied for the first week in more severe inju-
seldom occur but are considered more likely in the ries. The cast can include a toe spica extension with
fibular side than the tibial.5 the joint in mild plantarflexion, removing stress from
Diagnostic evaluation begins with a complete history the plantarly positioned sesamoids. Weight bearing is
of the problem. The typical patient will relate pain loca- permitted as tolerated. Taping of the hallux, as one
lized to the plantar hallux MTP joint with weight bear- would for a turf-toe, provides compression and limits
ing, worsened with sports and stair climbing, and often movement. This is found to be most helpful in milder
with no precipitating event. The clinical examination injuries. As the patient or player returns to athletic or
identifies the specific location of pain and tenderness. recreational activity, orthoses and shoewear modifica-
Plantarmedial signs relate to disorders of the tibial sesa- tions are mandatory. Off-the-shelf products, such as
moid, whereas direct plantar tenderness is indicative of a Springlite turf-toe plate (Otto Bock, Minneapolis,
fibular sesamoid pathology. In addition, the presence MN) made of carbon fiber, in full or forefoot lengths,
of swelling, warmth, and erythema should be docu- are useful in limiting dorsiflexion stresses. Custom-made
mented. Joint motion and stability are assessed, noting devices can be fabricated with a Morton’s extension to
restriction of motion secondary to pain or associated limit hallux MTP motion. A dancer’s pad, MT pad, or
hallux rigidus. Vertical instability may follow a turf-toe arch support placed just proximal to the symptomatic
or hyperextension injury. Sesamoid compression that sesamoid will assist in unloading weight-bearing pres-
produces pain and grind is consistent with metatarso- sures. Furthermore, the shoe itself can be stiffened with
sesamoid arthritis. a plate incorporated into the sole. The patient should
It is mandatory that the radiographic evaluation of maintain low heel heights to minimize weight-bearing
sesamoid disorders include standing AP and lateral pressures. Turf shoes are modified by removing the cleat
foot views and axial or tangential sesamoid views. These under the area of pain. Cortisone and/or anesthetic
views are adequate in assessing for focal arthrosis, plan- injections are not advised in any injury. An anesthetic
tar osteophytes, or bony prominences. The tangential injection alone may be used for localized pain in
sesamoid view is helpful for identifying fractures of single-nerve distribution, but we would not completely
tibial sesamoid. It is helpful to always place a marker anesthetize the toe or joint to enable an athlete to return
(B-B) on the skin overlying the site of tenderness. This to play.
simple maneuver helps to differentiate which sesamoid is Surgeries for disorders of the sesamoid are directed
symptomatic, or may not correlate with a sesamoid to the pathology identified. The first problem to con-
location if there is a flexor tendon problem. sider is the intractable plantar keratosis (IPK), attribut-
A question that often arises is in the differentiation of able to the tibial hallux sesamoid. There are instances
a fracture versus bipartite sesamoid. A fracture has sharp, in which the plantar aspect of the sesamoid will develop
irregular borders on both sides of the separation, a bony prominence, or osteophyte, and an overlying dis-
whereas a bipartite has smooth, cortical edges and a rel- tinct callus will arise. This may occur in the presence
atively total size larger than that of a single sesamoid. of fat atrophy, and there may be an associated bursal
Contralateral AP radiographs may be useful in this dif- component. Failure to improve with an orthosis to
ferentiation as there is a reported 90% incidence of relieve pressure from this area may necessitate surgical
bilateral occurrence.44 decompression. The recommendation is for a plantar
Further diagnostic studies useful in the evaluation of shaving of the tibial sesamoid via a plantar-medial
sesamoid disorders include MRI, which helps to localize approach. The periosteum overlying the sesamoid is re-
pathology while differentiating between bone and soft- flected and the plantar 50% of the sesamoid is resected
tissue abnormality. It further assesses sesamoid viabi- with a microsagittal saw. The FHL tendon is protected
lity, joint degeneration, and tendon continuity. A readily and the joint itself is not entered. The overlying soft
available tool that is sensitive yet inexpensive is the bone tissues then are repaired so that the FHB tendon has
scan. Although there is a reported high rate of false been maintained in continuity, thus avoiding the risk
positives, a three-phase study with pinhole images helps of instability. The patient is allowed to weight bear to
to identify the problematic sesamoid. Computed tolerance in the immediate postoperative period in a
tomography (CT) imaging can be performed to delin- protective hard-sole boot or postoperative shoe. Return
eate the degree of metatarsosesamoid arthrosis or to to regular shoewear and activity is expected over the
assess fracture healing. following 6 to 8 weeks as pain and swelling subside.
The nonoperative treatment of sesamoid disorders Fractures of the sesamoid can occur as acute events
is general and begins with the RICE principle of rest, or can be stress induced. Acute fractures occur as a result
ice, compression, and elevation. Athletic activity and of direct trauma, such as a forceful impact to the
418
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forefoot region. Because of its larger size and greater Osteochondrosis of the sesamoid may occur with pro-
propensity for weight bearing, the tibial sesamoid is gressive fragmentation. This process may occur insidi-
more likely to be involved.44 These fractures generally ously or as the sequela of a stress fracture nonunion42 or
heal with limitation of weight-bearing forces by use of osteonecrosis.47,48 Subchondral cysts may characterize
such appliances as a cast (with a toe spica extension), early stages. Patients will present with chronic discom-
boot or postoperative shoe. There have been anecdotal fort worsened by weight-bearing activity. Attempts can
reports of internally fixing these midwaist fractures with be made at nonoperative management using a period of
small, dual-pitched screws,45 but this is technically rest and immobilization followed by orthotic manage-
demanding and may not provide significant benefit over ment. However, a sesamoidectomy often is necessary in
traditional treatment methods. order for a return to recreational activities.42,47,48
Stress fractures of the tibial hallux sesamoid have Sesamoidectomy is the only option for the surgical
been noted to occur in athletes involved in repetitive- management of a number of sesamoid disorders, includ-
impact exercises, such as long-distance running or aero- ing osteochondrosis, osteomyelitis, advanced degenera-
bics. The diagnosis usually is made months after the tion, or the rare tumor. A tibial hallux sesamoidectomy
onset of discomfort. By then the fracture likely has pro- is achieved through a medial or plantarmedial approach,
gressed to an established nonunion. Failure to improve avoiding the plantarmedial digital nerve. The sesamoid
the situation with orthoses designed to relieve pressure can be excised from within the joint or extra-articularly.
and limit excessive dorsiflexion through the joint may As discussed for nonunions of the sesamoid, it often is
necessitate surgical intervention. Bone grafting of these helpful to assess the articular surfaces before excision;
tibial sesamoid nonunions has been performed success- this can be accomplished by entering the joint along
fully in an effort to avoid excision and the subsequent the superior border of the abductor hallucis tendon.
risk of losing push-off strength in the hallux.10 By performing the excision through an extra-articular
Indications for this bone graft procedure include a approach, the overlying FHB tendon can be repaired.
midwaist fracture location with minimal diastasis, prefer- A longitudinal incision and reflection of overlying soft
ably 1 to 2 mm. The articular surface of the sesamoid tissues (subperiosteal) allows for full exposure of the ses-
should be free of disease, and the two parts should not amoid; the bone then can be shelled out circumferen-
demonstrate gross motion between them. A plantar- tially with a no. 69 Beaver blade. The defect then is
medial incision is centered at the hallux MTP joint. repaired side to side with absorbable suture (i.e., 4-0
The capsule is incised along the superior border of the Vicryl). The surgeon must be aware of the proximity
abductor hallucis tendon, and the joint is examined. to the FHL tendon, protecting this structure during
Should there be cartilage damage on the sesamoid or the dissection. Although rarely performed because of
gross motion between the two halves, then sesamoidec- the risk of residual pain, partial sesamoid excisions can
tomy is completed. Otherwise, an extra-articular be considered if there is a small proximal or distal frag-
approach to the sesamoid is performed with reflection ment. The abductor hallucis tendon can be transferred
of overlying periosteum but preserving the FHB tendon. into large defects created by excision of bipartite or
The fibrous material of the nonunion is curettaged back fractured sesamoids. This transfer is performed by dis-
to viable bone surfaces. Care is taken to avoid disruption secting the distal tendon off the capsule at the base of
of the overlying articular surface. Through the capsulot- the proximal phalanx. A fasciotomy is performed proxi-
omy, a window is made in the medial cortex of the MT mally to allow for rerouting of the tendon to the plantar
head, and a small amount of cancellous bone is harvested. aspect of the joint, where it is sutured into the defect
This graft is packed into the nonunion defect created, with absorbable material. A concomitant bunionectomy
and the overlying soft tissues are approximated with should be considered if significant hallux valgus is pres-
absorbable suture. There is no need for internal fixation ent at the time of tibial hallux sesamoidectomy, because
because the two fragments should remain stable. The a progressive deformity otherwise may develop.49
capsulotomy is repaired and the wound closed. Postoper- When performing a fibular hallux sesamoidectomy,
atively, the patient is placed in a posterior splint with the the decision must be made whether to approach from
distal portion enveloping the hallux itself. At 2 weeks the dorsal or plantar surface. A dorsal approach is difficult
sutures are removed and a short-leg cast with a toe spica unless there is a large intermetatarsal 1-2 angle with lat-
extension is applied. The patient is allowed to weight eral subluxation of the sesamoid complex (i.e., bunion/
bear in such a device after 6 weeks, advancing to a shoe hallux valgus). A longitudinal first webspace incision is
protected with a turf-toe plate at 8 weeks. A CT scan at used in performing a dorsal-based excision. Following
12 weeks should confirm union, and if accomplished, superficial dissection, a laminar spreader placed between
running is initiated with continued orthotic protection. the MT heads is helpful. This approach requires the
We previously have reported on this technique in a series release of the adductor hallucis tendon and other lateral
of 21 patients, 19 of which were successful.46 soft-tissue structures. The sesamoid is shelled out of the
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FHB tendon, taking care to avoid the neurovascular was noted in 82% with single sesamoid excision and in
structures plantarly. 64% of those in whom both sesamoids were excised.
The plantar-based approach to fibular sesamoidec- Leventen51 found complete satisfaction in 18 of 23
tomy is preferable in that the soft-tissue structures bal- sesamoidectomies. Mann et al.52 identified 19 of his 21
ancing the hallux MTP joint are not disrupted. In this sesamoidectomies ‘‘improved,’’ but only 50% had com-
approach, a curvilinear incision is placed over the palpa- plete pain relief and 66% had full motion. In this group,
ble fibular sesamoid, but just off of the weight-bearing 1 of 13 tibial sesamoidectomies developed hallux valgus, 1
pad of hallux MTP joint itself. It is necessary to identify of 8 fibular sesamoidectomies developed hallux varus,
and protect the plantarlateral digital nerve (Fig. 18-8, A and 12 patients developed ‘‘weakness.’’ We assessed 12
and B). Following the sesamoidectomy, the reflected patients who underwent a fibular sesamoidectomy via a
periosteum and FHB tendon (lateral head) are repaired. plantar approach and identified 9 who were very satisfied
Skin closure must carefully approximate the dermal and 2 who were satisfied. In addition, all would do it again,
edges to minimize hypertrophic scar formation. and 11 of 12 returned to preinjury activity level, citing no
Postoperatively soft dressings are applied in such a complications (for example, scar, neuroma).
manner as to maintain plantarflexion and either varus Sesamoidectomy is a good procedure that provides
(tibial sesamoidectomy) or valgus (fibular sesamoidec- reliable results. The surgeon and patient must be aware
tomy). Weight bearing is allowed in a hard-soled san- that there is the potential for biomechanical implications
dal or short walker boot for a tibial sesamoidectomy, such as the loss of push-off strength. This is especially
whereas nonweight-bearing or heel touch protection is important in the running athlete or elite dancer and
recommended for a fibular sesamoidectomy performed must be discussed before intervening surgically.
through a plantar incision. With the latter, the patient X-rays: AP and lateral weight-bearing foot, axial/
is allowed to begin full weight bearing with the sutures tangential sesamoid views, skin marker over
in place at 2 weeks postoperatively. The sutures then tenderness, contralateral views.
are removed 1 week thereafter. Removable bunion MRI: differentiates soft-tissue from bone abnormality.
splints help to maintain the desired hallux alignment Bone scan: high false-positive rate, use three-phase
between the second and sixth week. A gradual return with pinhole images to isolate problem area.
to hard-soled shoes follows, using a turf-toe plate in Fractures: tibial sesamoid more common.
athletic or training shoes. AVN: fibular sesamoid more common.
The results of sesamoidectomy have been provided Nonoperative treatment: NSAIDs, rest, boot/cast
by a number of authors. Inge and Ferguson50 reviewed in more severe injuries, turf-toe plate, arch support,
41 feet, 25 in which both sesamoids were excised. Com- and/or MT pad.
plete pain relief was noted in 42%, whereas partial relief Surgical treatment: varies depending on diagnosis.
Figure 18-8 (A) A curvilinear incision is made just lateral to the fibular sesamoid, just off the weight-bearing pad
of the hallux metatarsophalangeal joint. (B) Care must be taken to identify and protect the plantarlateral digital
nerve. (Drawn by Robert B. Anderson, MD.)
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Turf-toe
Since the term ‘‘turf-toe’’ was first used in the literature
by Bowers and Martin54 in 1976, soft-tissue hyperex-
tension injuries to the first MTP joint have received
increasing attention from physicians, trainers, and ath-
letes. Although these injuries have been grouped under
the general heading of turf-toe, they actually represent
a spectrum of injuries from the mild to the severe. In
addition to the straight hyperextension injury of the
first MTP joint, we now recognize there are variations
that account for injury to specific anatomic structures Figure 18-9 An axial load applied to a foot fixed in equinus.
in the capsular-ligamentous-sesamoid complex. As an impact or force is placed on the heel, the forefoot
The true incidence of turf-toe injuries is difficult to progresses into dorsiflexion, creating hyperextension at the
quantify. At major universities, these injuries rank num- hallux metatarsophalangeal joint. (From Adelaar RS, editor:
ber three behind knee and ankle injuries.1,55 When Disorders of the great toe, Rosemont, IL, 1997, American
Coker et al.56 looked at the Arkansas football players, Academy of Orthopaedic Surgeons.)
they found ankle injuries to be four times more com-
mon than hallux MTP joint injuries; however, the latter
were more severe, accounting for a disproportionate
number of missed practices and games. Over a 3-year
period, 18 of their players had a hallux MTP joint injury,
equating to six turf-toe injuries per year. At Rice Univer-
sity, over a 14-year period the average was 4.5 turf-toe
injuries per year and included all sports.57
The mechanism of injury can be direct or indirect
and requires a basic knowledge of that which is required
of the great toe during athletics. When an athlete rises
on the ball of the foot for such activities as initiating
a jump, blocking, or running, the hallux MTP joint
extends upward of 100 degrees. As the proximal phalanx
extends, the sesamoids are drawn distally and the more
dorsal portion of the MT head articular surface bears
most of the load. As this plantar complex attenuates or
ruptures, unrestricted dorsiflexion can lead to impaction
of the proximal phalanx on the dorsal articular surface
of the MT head. This leads to a spectrum of joint inju-
ries from partial tearing of the plantar structures to frank
dislocation. The typical scenario leading to this injury
in the athlete involves an axial load on a foot fixed in
equinus. As an impact or force is placed on the heel,
the forefoot progresses into dorsiflexion, creating
Figure 18-10 Valgus component to the hyperextension
hyperextension at the hallux MTP joint (Fig. 18-9).
causing injury to the plantarmedial structures, resulting in a
However, not all turf-toe injuries are purely hyperex- traumatic bunion. (From Watson TS, Anderson RB, Davis WH:
tension. Numerous variations have been identified. For Foot Ankle Clin 5:693, 2000.)
instance, a valgus component to the hyperextension of
the hallux MTP joint results in injury to the plantar-
medial ligamentous structures, occasionally to the tibial consistent with a medial collateral ligament tear, which
sesamoid, and the eventual development of a traumatic was repaired.
bunion with contracture of the lateral structures Like valgus injuries, varus injuries also are rare. Mullis
(Fig. 18-10). Douglas et al.58 reported the case of a and Miller59 reported on a basketball player with an
soccer player who sustained a hallux MTP joint injury injury to the hallux MTP joint 3 months before presen-
when he was slide-tackled during practice. He con- tation. He had difficulty with running and was unable
tinued to complain of joint instability and he failed con- to return to sports participation. On physical examina-
servative measures. MRI and operative findings were tion, he was noted to have significant varus instability
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of the hallux MTP joint. Surgical findings included a Some authors have suggested that hallux MTP joint
torn conjoined tendon, lateral capsule, and lateral collat- ROM may play a role in turf-toe injuries. Many studies
eral ligament. The plantar structures were noted to be have looked specifically at this factor and concluded
intact. All structures were repaired primarily, and the that there is no relationship between hallux MTP joint
conjoined tendon was fixed to the base of the proximal ROM and subsequent turf-toe injury.1,55,60 However,
phalanx through drill holes. there may exist a relationship between increased ankle
Over the years many theories have been investigated ROM and turf-toe injuries. In the study by Rodeo
as causative factors in hallux MTP joint injuries. By far, et al.,60 players with a turf-toe injury had mean ankle
the two most common etiologic factors mentioned in dorsiflexion of 13.3 degrees, versus 7.9 degrees for
the literature are the playing surface and flexibility of uninjured players, a statistically significant difference.
footwear. In a study by Rodeo et al.,60 80 active pro- It can be postulated that an increased ankle ROM places
fessional football players were surveyed, and of those the hallux MTP joint at risk for hyperextension
with a turf-toe injury, 83% sustained the initial injury injuries. Still other causative factors contributing to
on artificial turf. Bowers and Martin54 addressed this turf-toe have been suggested. These include player posi-
relationship by studying the impact of AstroTurf on tion, weight, age, years of participation, pes planus,
the West Virginia University’s football team. They hallux interphalangeal degenerative joint disease, and a
coined the term ‘‘turf-toe’’ to describe injuries of the flattened first MT head.1,55,60 The data for these vari-
hallux MTP joint capsular-ligamentous complex sus- ables are largely inconclusive, and it is unlikely that any
tained on artificial turf that previously had not been of these factors play a significant role in the etiology of
encountered on grass playing surfaces. The AstroTurf turf-toe.
was alleged as a causative factor because of the hardness Acute injuries to the hallux MTP joint have been clas-
encountered with aging of the surface. However, Clan- sified into one of three general categories (Table 18-1).64
ton and Ford1 and others investigated the relationship Hyperextension injuries usually can be differentiated
of turf-toe injuries to aging artificial turf and found from hyperflexion injuries by history and physical
no significant correlation. In the three seasons preced- examination. The clinician should recognize that turf-
ing the replacement of the artificial turf in Rice Stadium, toe constitutes a broad spectrum of injury with marked
there were 13 turf-toe injuries, versus 12 injuries in the variability in the extent of soft-tissue involvement. To
three seasons following replacement with a more mod- plan treatment and predict return to activity, a clinical
ern synthetic playing surface. Nigg and Segesser61 classification system has been devised (Table 18-2).
demonstrated an increased incidence of hallux MTP The mechanism for each of these injuries was discussed
injuries on artificial turf and attributed this to the en- previously. At the extremes of hyperextension, frank
hanced friction inherent in the surface. This may ac- dislocation of the hallux MTP joint can be seen.
count for the forefoot’s becoming fixed to the artificial To determine the extent of the injured structures in
surface with applied external forces, causing hyperexten- the hallux, the clinician must start by taking a history
sion and resulting hallux MTP injury. from the athlete. An exact determination of the events
Bowers and Martin,54 as well as Clanton and Ford,1 leading to the injury should be sought in each case.
have postulated that the shoe-surface interface most Reviewing the videotape of the game sometimes can
likely is responsible for these injuries. The majority of aid in determining the mechanism. As with most ath-
injuries are encountered on artificial turf in athletes letic injuries, an examination of the involved extremity
wearing flexible, soccer-style shoes. The abandonment shortly after the injury is ideal. The examination should
of the traditional grass shoe for the lighter, more flexi- begin with observation of the hallux MTP joint for
ble, soccer-style shoe seems to have been a major contri- ecchymosis and swelling, with particular attention paid
buting factor in the evolution of the turf-toe problem. to the location. Palpation of the dorsal capsule, medial
The trainers and physicians at Rice University could and lateral collateral ligaments and the plantar struc-
not recall a single instance of a severe MTP joint sprain tures, including the sesamoid complex, should help the
occurring in a football player wearing the traditional physician to elucidate the injured structures. The hallux
grass shoe during the 25 years before 1986. This is most MTP joint then can be placed through an ROM and
likely the result of the steel plate incorporated into the compared with the opposite side. Abnormalities such
sole of the shoe for the attachment of cleats, which has as a mechanical block, hypermobility resulting from a
the secondary benefit of limiting forefoot motion.1,62,63 plantar plate tear, or gross instability can be appreciated.
In the study by Rodeo et al.,60 shoe type was not as- Varus and valgus stress testing then should be per-
sociated with turf-toe injury in professional football formed and also compared with the contralateral side.
players. However, the number of players wearing tradi- A dorsoplantar drawer test (Lachman) of the MTP joint
tional grass cleats in this study was small (15 out of will test the integrity of the plantar capsular-ligamentous
80) and perhaps influenced the outcome. complex. Plantarflexion and dorsiflexion of the hallux
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Table 18-1 Classification of turf-toe
Type of injury Grade Description

Hyperextension I Stretching of plantar complex
(turf-toe)
Localized tenderness, minimal swelling, no ecchymosis
II Partial tear
Diffuse tenderness, moderate swelling, ecchymosis, restricted movement with pain
III Frank tear
Severe tenderness to palpation, marked swelling and ecchymosis, limited movement

with pain, (þ) vertical Lachman’s if pain allows
Possible associated injuries
Medial/lateral injury
Sesamoid fracture/bipartite diastasis
Articular cartilage/subchondral bone bruise
These may represent spontaneously reduced dislocations
Hyperflexion Hyperflexion injury to hallux MTP or interphalangeal joint

(sand toe)
May also involve injury to additional MTP joints (lesser toes)
Dislocation I Dislocation of the hallux with the sesamoids
No disruption of the intersesamoid ligament
Frequently irreducible
IIA Associated disruption of intersesamoid ligament
Usually reducible
IIB Associated transverse fracture of one or both of the sesamoids
Usually reducible
IIC Complete disruption of intersesamoid ligament, fracture of one of the sesamoids
Usually reducible
MTP, metatarsophalangeal.
MTP joint against resistance should be performed to include capsular avulsions, sesamoid fractures, impaction
check the integrity of the flexor and extensor tendons fractures, diastasis of bipartite sesamoids, and proximal
of the hallux. In reality, this detailed examination can migration of the sesamoids. Recommended radiographs
be difficult in the acutely injured athlete because of pain. include a weight-bearing AP and lateral and a sesamoid
Following clinical evaluation, radiographic analysis is axial view. A comparison AP view of the opposite foot
mandatory for all hyperextension injuries. In addition is helpful. Prieskorn et al.65 found that patients with a
to the soft-tissue disruption, bony abnormalities may complete plantar plate rupture had proximal migration
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Table 18-2 Clinical classification system
Grade Objective findings Activity level Treatment

1 Localized plantar or medial tenderness Continued athletic Symptomatic
participation
Minimal swelling
No ecchymosis
2 More diffuse and intense tenderness Loss of playing time for Walking boot and crutches
3-14 days as needed
Mild to moderate swelling
Mild to moderate ecchymosis
3 Severe and diffuse tenderness Loss of playing time for Long-term immobilization
at least 4-6 weeks in boot or cast versus
Marked swelling surgical repair
Moderate to severe ecchymosis
Range of motion painful and limited
Figure 18-11 (A) Normal dorsiflexion lateral. (B) Forced dorsiflexion lateral demonstrating proximal migration of
the sesamoids.
of the sesamoids. The easiest way to evaluate the radio- In addition to the standard views, special views and
graph is to compare the distal aspect of the sesamoid- studies may be indicated, depending on a clinician’s sus-
to-joint distance on the affected side with the unaffected picion. Rodeo et al.66 have suggested a forced dorsi-
side. The difference between sides should be within flexion lateral view (Fig. 18-11, A and B), which may
3.0 mm (tibial) and 2.7 mm (fibular) 99.7% (3 SD) of delineate joint subluxation, sesamoid migration, or
the time. Looking at absolute numbers, if there was separation of a bipartite sesamoid. Stress radiographs
greater than 10.4 mm from the distal tip of the tibial may help to define complete disruption of the medial
sesamoid to the joint and greater than 13.3 mm from or lateral capsular-ligamentous complex. In addition,
the distal tip of the fibular sesamoid to the joint, then two oblique radiographs may be obtained. Other studies
there was a 99.7% chance of plantar plate rupture. previously used in the diagnosis of turf-toe injuries
424
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Figure 18-12 Magnetic resonance imaging notes injury to

bones and soft tissue. (From Watson TS, Anderson RB, Davis
WH: Foot Ankle Clin 5:698, 2000.)
include bone scintigraphy to rule out stress fractures

or arthrography to document capsular tears. However,
in our experience, MRI best defines soft-tissue injury
and the presence of osseous and articular damage
(Fig. 18-12). The use of a 1.5-Tesla MRI scanner with
paired 3-inch–round phased array surface coils can be
used to obtain proton density and T2-weighted images.
These images, obtained in the coronal, axial, and sagittal
planes, provide anatomic detail of the nature and extent
of soft-tissue injuries in acute turf-toe injuries.65 We are
liberal in performing this test because it assists in grad-
ing, identifies subtle injuries, provides timely decision
making, and helps to formulate a prognosis.
The treatment of all grades of turf-toe injuries in early
stages is similar.67 Principles, which apply to most acute Figure 18-13 Example of a short-let walking cast with toe
sprains of the musculoskeletal system, apply to the hal- spica extension in slight plantarflexion. (From Watson TS,
Anderson RB, Davis WH: Foot Ankle Clin 5:699, 2000.)
lux MTP joint as well. Once the injury is recognized,
immediate application of ice with a compressive-type
dressing may aid in reducing swelling. Taping of the great toe, as well as shoewear modifications. The taping
great toe in this acute stage is not recommended is designed to restrict hyperextension of the hallux
because swelling could lead to compromise of circu- MTP joint. Another technique used to restrict forefoot
lation. Clanton and Ford1 suggest using the RICE motion is the placement of an insole that includes a
formula of rest, ice, compression, and elevation. In addi- spring carbon-fiber steel plate in the forefoot region of
tion, an NSAID may be prescribed. In some cases, a the shoe. A custom insole with a Morton’s extension
walker boot or a short-leg cast with a toe spica in slight may be better suited for the high-performance athlete
plantarflexion may be helpful to alleviate symptoms dur- but generally requires a longer shoe with a wider toe
ing the first week (Fig. 18-13). Early joint motion may box. Factory made turf-toe shoes are available that
begin within 3 to 5 days after initial injury if symptoms restrict forefoot bend, but most running athletes resist
permit. At this point, a severity grading must be applied this treatment because of a perceived loss of mobility.
so the athlete can be advised regarding prognosis and Grade 2 injuries usually result in loss of playing time
the time necessary for rehabilitation before a return to ranging from 3 to 14 days, followed by the same
competition. modalities as mentioned previously. The grade 3 injuries
Athletes with a grade 1 injury usually are able to may result in loss of playing time of at least 4 to 6 weeks,
return to their sport with little or no loss of playing often requiring long-term immobilization and exam-
time. These athletes may benefit from taping of the inations weekly. In athletes who experience continued
425
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swelling and edema, modalities such as whirlpool and In the acute repair and reconstruction of these plantar
ultrasound with cold compression may be used as complex injuries, exposure can be obtained through a
adjuncts to traditional therapy.68 In general, return to medial, medial and plantar, or J-incision technique. Care
play is dictated by symptoms, preferably with the athlete is taken to avoid injury to the plantar medial digital
demonstrating 50 to 60 degrees of painless passive nerve as it courses over the region at the tibial sesa-
dorsiflexion. However, this return to athletics is indivi- moid. Plantarflexion of the joint can assist with plantar
dualized, dependent on the player’s position, the level exposure of the joint. Once the defect has been identi-
of discomfort, and healing potential. fied in the plantar complex distal to the sesamoids,
There is a paucity of literature on the surgical man- advancement and primary repair can be achieved with
agement of hallux MTP joint injuries. This stems from nonabsorbable sutures. Typically, sutures are placed into
the general notion that surgical management rarely is remnants of soft tissue on the base of the proximal pha-
indicated in the treatment of this disorder. However, lanx. If found inadequate, then suture anchors or drill
when an athlete fails to respond to conservative modal- holes in the plantar lip of the proximal phalanx may be
ities, the treating physician should be suspicious for used.
pathology that requires surgical intervention. Indica- In cases of a progressive diastasis of a bipartite sesa-
tions for surgery include a cartilage flap or loose body moid, it is our recommendation to preserve one pole
within the hallux MTP joint, acute sesamoid fracture, of the sesamoid if possible. Typically, the distal pole is
separation of a bipartite sesamoid, proximal migration excised and soft tissues are repaired through drill holes
of the sesamoids, evidence of gross instability resulting in the remaining proximal pole. Should both poles
in persistent pain or synovitis, and hallux rigidus. of this sesamoid be damaged, or if fragmentation of
The study by Rodeo et al.63 revealed that four ath- the sesamoid is encountered, complete sesamoidectomy
letes were noted to have diastasis of a bipartite tibial may be necessary. In this instance, a large soft-tissue
sesamoid and underwent excision of the distal fragment defect will result, leading to an incompetent FHB
with repair of the capsule. One of these four athletes and potential loss of plantar restraints. We recommend
underwent acute excision, and the other three after that an abductor hallucis tendon transfer be performed
failed conservative management. All of these players (Fig. 18-15). This transfer will act not only dynamically,
returned to their preinjury level of competition. helping to restore flexion power to the hallux, but also
Our own experience in the repair or reconstruction as a plantar restraint to dorsiflexion forces.
of hyperextension injuries has been derived from a num- There are situations in which late reconstruction of
ber of individuals who had sustained a turf-toe and these injuries is necessary, for example, when the athlete
subsequently were unable to perform athletically at their continues to perform despite injury or when the injury
preinjury level. These athletes often complained of pain has been inadequately treated and protected. In these
with running activity, along with the inability to cut situations the sesamoids may migrate well proximal, a
from side to side. Clinical findings included malalign- problem often associated with hallux valgus, varus, or
ment of the hallux, traumatic and progressive bunion cock-up deformity. Reconstruction may include at-
deformity, clawing of the great toe, diminished flexor tempts at distal advancement of the sesamoids with
strength, generalized joint synovitis, and advanced soft-tissue reconstruction. This requires significant mobi-
degeneration of the joint. Radiographic analysis often lization of the soft tissues proximal to the sesamoids,
showed proximal migration of one or both sesamoids necessitating fasciotomies or fractional lengthenings of
and cases of progressive diastasis of bipartite sesamoids the flexor hallucis brevis and abductor hallucis muscles.
(Fig. 18-14). MRI performed confirmed pathology Joint debridement and cheilectomy may be necessary
through the plantar complex of this joint, often asso- in cases of associated synovitis and osteochondral injury.
ciated with injuries to the joint surface or FHL tendon. Reconstruction of traumatic bunion deformities neces-
All the cases of proximal sesamoid migration associated sitates not only reconstruction of the plantar medial
with hyperextension injury have been associated with soft tissues but also a release of the lateral soft-tissue
distal rupture. It appears that the sesamoids rupture contractures.
distally and migrate proximally because of the preserva- The reconstruction of the claw toe deformity that
tion of the flexor tendons, along with the abductor occurs as a late sequela to hyperextension injuries is
and adductor tendons, and their ability to retract. difficult. If the deformity is passively correctable at both
Our surgical experience with this injury has included the hallux MTP and IP joint levels, a flexor-to-extensor
12 professional and collegiate athletes. Five surgeries tendon transfer can be performed successfully. This
were performed acutely for proximal migration or dia- transfer can be achieved either by splitting the flexor
stasis of a bipartite sesamoid, whereas seven were per- tendon and reapproximating dorsally into the extensor
formed for chronic injuries, which included two hood, as described by Girdlestone-Taylor, or by trans-
traumatic bunions and one hallux varus deformity. ferring directly through a drill hole into the base of
426
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Figure 18-14 (A) Anterior-posterior (AP) radiographs of a professional football player following a turf-toe injury.
Note the diastasis of the tibial sesamoid. (B) AP radiograph repeated 1 year later demonstrating progression of
diastasis, which was associated with early clawing of the toe. (From Watson TS, Anderson RB, Davis WH: Foot
Ankle Clin 5:701, 2000.)
the proximal phalanx (Fig. 18-16). Occasionally, a claw plantarflexion for a period of 7 to 10 days. At that time
toe deformity will include a fixed contracture of the IP the athlete is initiated on protective, passive plantar-
joint. This situation can be addressed through hallux flexion under the direct guidance of the athletic trainer
IP arthrodesis and a flexor-to-extensor tendon transfer, or physical therapist. We avoid active and passive dorsi-
as described previously. flexion and active plantarflexion maneuvers. When at
The postoperative management of athletes under- rest, the toe is protected with a bunion splint using a
going surgical reconstruction of hyperextension injuries plantar Velcro restraint and a removable posterior splint
is difficult because of the delicate balance between soft- or cast boot. Nonweight-bearing ambulation is con-
tissue protection and early ROM. First, it is important tinued for a period of 4 weeks. ROM of the hallux is
to avoid placing the hallux in greater than 10 degrees increased gradually at that time, along with protected
of plantarflexion, either through surgical reconstruction ambulation in a cast boot. At 2 months postoperative,
techniques or with postoperative external immobiliza- the patient is placed into an accommodative athletic
tion modes. Excessive plantarflexion to this joint may shoe with the protection of an insole plate that limits
become fixed and difficult to compensate for in the dorsiflexion. Active ROM is instituted, and by 3 to 4
running athlete. Our protocol includes external im- months postoperative, the patient is allowed to return
mobilization in approximately 5 to 10 degrees of to contact activity with the continued protection of
427
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Figure 18-15 Technique of abductor hallucis tendon transfer

for reconstruction of hallux metatarsophalangeal joint.
(A) Abductor hallucis tendon dissected from underlying capsule
and immobilized proximally. (B) Plantar defect following
sesamoid excision. (C) Transfer of abductor hallucis tendon
completed with attachment to proximal phalanx. (From Watson
TS, Anderson RB, Davis WH: Foot Ankle Clin 5:703, 2000.)
taping techniques and shoewear modifications. We Can have varus or valgus component to injury
have found that it takes approximately 6 to 12 months pattern.
before the athlete can perform at the preinjury level of Note ecchymosis, hypermobility, and varus/valgus
function. on physical examination.
Late sequelae of turf-toe injuries may occur after con- X-rays: weight-bearing AP and lateral with contra-
servative management or, less commonly, after surgical lateral views, sesamoid view, forced dorsiflexion lat-
treatment has been rendered. Coker et al.55 reported eral with contralateral view. Note sesamoid-to-joint
on nine athletes who had sustained a hyperextension distance.
injury. The most commonly reported late sequelae were MRI: coronal, axial, and sagittal planes. May iden-
joint stiffness and pain with athletic activity. Clanton tify subtle injuries.
et al.,57 in their study of 20 athletes with turf-toe injury Treatment: rest, ice, compression, elevation. Return to
and 5 years of follow-up, noted a 50% incidence of per- activity depends on severity of injury (see Table 18-2).
sistent symptoms. Other late sequelae include cock-up Shoe modifications and/or turf-toe insert to pre-
deformity, hallux valgus, hallux rigidus, arthrofibrosis, vent hallux hyperextension.
loose bodies, and loss of push-off strength. Surgical indications include a cartilage flap or loose
Turf-toe constitutes a broad spectrum of injury body within the hallux MTP joint, sesamoid frac-
with marked variability in the extent of soft-tissue ture, separation of a bipartite sesamoid, proximal
involvement. migration of the sesamoids, evidence of gross insta-
Hyperextension injury to the plantar capsular- bility resulting in persistent pain or synovitis, and
ligamentous-sesamoid complex. hallux rigidus.
428
...........
A B
K-Wire for Fixation
C D
Figure 18-16 (A-D) Technique for reconstruction of a claw-toe deformity that is passively correctable. (From
Watson TS, Anderson RB, Davis WH: Foot Ankle Clin 5:706, 2000.)
Dislocations of the hallux MTP joint transverse MT ligament or intersesamoid ligament may
Frank dislocation of the hallux MTP joint most likely be required.71 If the joint is unstable after reduction,
represents the extreme along the spectrum of hyperex- stabilization with a Kirschner wire is recommended; this
tension injuries. Dislocation in the dorsal direction is can be removed after 3 to 4 weeks.71
by far most common, yet plantar and lateral dislocations Type II injuries are subclassified into types IIA and
have been described. Jahss classified dislocation of the IIB (Fig. 18-17). In type IIA dislocations, the intersesa-
hallux MTP joint into two types.69 moid ligament is disrupted and radiographs reveal wid-
In the type I dislocation, the MT head buttonholes ening of the space between sesamoids and dislocation
through the weak capsular tissue proximal to the sesa- of the MT head into or through the sesamoid split. Type
moids. The distal plantar plate, sesamoids, and intersesa- IIB injuries produce a transverse fracture through one
moid ligament remain intact and attached to the phalanx (usually tibial) or both sesamoids. In the situation of a
distally. This intact complex comes to lie just dorsal to single sesamoid fracture, the proximal fragment remains
the MT head, with the flexor hallucis brevis tendon aligned with the intact sesamoid, and the distal fragment
dorsally translated. A closed reduction in the emergency often becomes a loose body in the joint, usually requir-
department always should be attempted under local ing surgical removal. In addition to these types
anesthesia. However, this injury typically is irreducible described by Jahss,69 Copeland and Kanat72 defined a
and requires an open reduction of the MTP joint type IIC that is a combination of both IIA and IIB.
through a dorsal approach.70 If reduction cannot be The type IIC dislocation represents both a complete dis-
obtained by reducing the sesamoids with an elevator, ruption of the intersesamoid ligament and a transverse
release of the adductor tendon and the deep fracture of either sesamoid (Table 18-3).
429
...........
Figure 18-17 Dislocations. (A and B) Anterior-posterior (AP) and lateral radiograph of a type IIA hallux
metatarsophalangeal (MTP) dislocation. (C and D) AP and lateral radiograph of a type IIB hallux MTP
430 dislocation. (From Watson TS, Anderson RB, Davis WH: Foot Ankle Clin 5:710, 2000.)
...........
Conclusion
possible varus or, more commonly, a valgus component.

Table 18-3 Radiographic findings in hallux metatarso-
Rodeo et al.,60 in their report on turf-toe injuries in
phalangeal joint dislocations
professional football players, concluded that 12% of the
Dislocation players had a hyperflexion injury to this joint. Hyper-
type Radiographic findings flexion injuries clearly do not fit into the classification
system for turf-toe. In fact, the mechanism and pathol-
I No widening between sesamoids on ogy are much different, and these injuries should not
AP view be grouped together.
Frey et al.74 reported on a series of professional beach
IIA Wide separation between sesamoids
on AP view
volleyball players with a hyperplantarflexion injury to
the hallux MTP joint, an injury referred to as ‘‘sand
IIB Fracture of sesamoid (usually tibial) toe.’’ This injury can result in significant functional dis-
ability noted with push-off, forward drive, running, and
IIC Combination of type IIA and type IIB jumping. Although described in volleyball players, it also
can be seen in football players, soccer players, and
AP, Anterior-posterior. dancers.
The hyperflexion injury occurs when the weight of
the body lands on a neutral or slightly plantarflexed hal-
Differentiating between type I and type II dislo- lux MTP joint. Frey et al.74 reported on 12 volleyball
cations is important because operative intervention players, 11 of whom had sustained an injury to the hal-
typically is required for type I but not for type II disloca- lux MTP joint. The treatment for this injury mainly is
tions. The general reduction maneuver is performed conservative: taping, rest, ice, and NSAIDs. Once the
by placing gentle distraction with hyperextension on inflammation has resolved, the athlete should undergo
the MTP joint. If the joint is reducible, it typically is a rehabilitation program that includes strengthening
stable and is placed into a cast or hard-soled shoe for of the intrinsic and extrinsic muscles of the foot. How-
3 to 4 weeks. A postreduction radiograph is required ever, the time to recovery was, on average, 6 months
to confirm an anatomic reduction or to rule out the (range 1-12 months). The most common problem after
presence of any loose bodies.73 injury was loss of dorsiflexion of 25% to 50% at the
Occasionally, gross instability will follow a type II dis- hallux MTP joint, as well as residual pain. No toe defor-
location, particularly when a fracture of the sesamoid(s) mities were noted. The authors attribute the loss of
has occurred. In this instance, the patient will experience motion to capsular damage, synovitis, and arthrofibrosis.
pain with push-off and hallux rigidus type symptoms. Whether or not arthroscopic debridement would benefit
A positive drawer sign is elicited, along with signs of these athletes remains a question for future study.
generalized synovitis. Surgical correction in this setting Different mechanism and injury pattern than turf-toe.
includes plantar reconstruction to restore a restraint to Often referred to as sand toe.
dorsiflexion forces. Specifically, sesamoidectomy and Treatment normally nonoperative with rest, ice,
abductor hallucis tendon transfer may be indicated. In and NSAIDs.
the case of late clawing, an FHL transfer should be Rehabilitation after inflammation subsides with
considered, as described previously. intrinsic/extrinsic strengthening.
Most extreme hyperextension injury with two main Motion loss of from 25% to 50% is common.
types (see Table 18-1).
Type I: MT head buttonholes through intact
plantar complex and likely irreducible. Surgical
CONCLUSION
intervention to release blocks to reduction. Usually
stable but may require K-wire fixation.
Type II: three subtypes with injury to the plantar The great toe and its articulations are of paramount
complex. Usually reducible, may require delayed importance to the athlete. Great forces are transferred
reconstruction. through this area with running, jumping, changing
direction, and landing. Minor injuries can affect the abil-
Hyperflexion injuries of the hallux MTP joint ity even to walk or stand. A complete knowledge of the
As stated previously, turf-toe injuries involve primarily anatomy, forces involved, and treatment regimens are
a hyperextension injury to the hallux MTP joint with a paramount when treating patients with these disorders.
431
...........
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433
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.........................................C H A P T E R 1 9
Bunion deformity in elite athletes

Roger Mann
......................
CHAPTER CONTENTS
Introduction 435 Radiographic evaluation 439

Biomechanics of the first metatarsophalangeal joint 435 Decision making 439
Types of hallux valgus deformity 435 Surgical procedures 441
Conservative management 436 Postoperative management 443
Physical examination 438 Further reading 443
INTRODUCTION the longitudinal arch and aids in inversion of the calca-

neus (Fig. 19-2). When a hallux valgus deformity devel-
ops and lateral subluxation of the proximal phalanx on
The hallux valgus deformity in the athlete is no different
the metatarsal head occurs, the sesamoid sling is no lon-
from the deformity in the nonathlete, but it becomes
ger beneath the first metatarsal head; therefore the wind-
almost a philosophical question because a foot is to an
lass mechanism becomes less functional (Fig. 19-3). This
athlete what a hand is to a musician. Its function must
is because when dorsiflexion of the phalanx occurs, plan-
be respected because without it, the athlete, whether a
tarflexion of the metatarsal and weight transfer to the hal-
ballerina or lineman, may not be able to perform at an
lux are diminished resulting in progressive loss of the
acceptable level. In most cases, unless the athlete’s
stability of the longitudinal arch. As it progresses, this loss
career is jeopardized by his or her hallux valgus
of stability weakens the medial longitudinal arch, result-
deformity, surgical correction probably should not be
ing in weight transfer from the first metatarsal to the sec-
undertaken for fear that a less than perfect result may
ond. This subsequently can result in excessive fatigue of
jeopardize the athlete’s career.
the foot and possibly callus formation beneath the second
metatarsal. This combination of effects results in dimin-
ished performance in the athlete, although it could be
BIOMECHANICS OF THE FIRST tolerated by the nonathlete.
METATARSOPHALANGEAL JOINT
TYPES OF HALLUX VALGUS DEFORMITY
The main function of the first metatarsophalangeal joint
is to stabilize the longitudinal arch through the windlass
mechanism. Anatomically the windlass mechanism con- The hallux valgus deformity can be divided into two
sists of the plantar fascia inserting into the base of the basic groups—persons with a congruent joint and those
proximal phalanx via the plantar plate (Fig. 19-1). As with a noncongruent or subluxed joint. In those with
the windlass mechanism becomes functional in the last the congruent deformity, the windlass mechanism is
half of stance by the dorsiflexion of the proximal phalanx not disrupted, and therefore the stability of the foot is
on the metatarsal head, the metatarsals are depressed as not a problem (Fig. 19-4, A). In these individuals, the
weight is transferred to the toes. The effect of the wind- main disability is a large medial eminence, which results
lass mechanism is greatest for the hallux and least for the in chafing against their shoe. In the noncongruent
small toe. Secondarily the windlass mechanism elevates deformity, there is progressive subluxation of the
CHAPTER 19 Bunion deformity in elite athletes
Figure 19-1 Plantar aponeurosis. (A) Cross section. (B) Division of plantar aponeurosis around flexor tendons.
(C) Components of plantar pad and its insertion into the base of the phalanx. (D) Extension of toes draws
plantar pad over metatarsal head, pushing them into plantarflexion. (From Mann RA: In Coughlin MJ, Mann RA,
editors: Surgery of the foot and ankle, ed 7, St Louis, 1999, Mosby.)
Figure 19-2 Dynamic function of plantar aponeurosis (A) foot at rest. (B) Dorsiflexion of metatarsophalangeal
joints activates windlass mechanism, bringing about elevation of the longitudinal arch, plantarflexion of
metatarsal heads, and inversion of heel. This produces stability of the longitudinal arch of the foot. (From Mann
RA: In Coughlin MJ, Mann RA, editors: Surgery of the foot and ankle, ed 7, St Louis, 1999, Mosby.)
metatarsophalangeal joint that leads to instability and

CONSERVATIVE MANAGEMENT
weight transfer (Fig. 19-4, B). In these individuals, the
problem is more than an enlarged medial eminence
because of the instability that occurs. If the enlarged Conservative management of the athlete with a hallux
medial eminence results in sufficient disability for the valgus deformity begins with specifically pinpointing
athlete and he or she can no longer function at the level the area of maximal pain because our conservative man-
needed to participate in his or her sport, a hallux valgus agement must be directed toward relieving that prob-
repair can be considered. lem. Generally, pain is over the medial eminence and
436
...........
Conservative management
not infrequently where the dorsal medial cutaneous

nerve crosses over the bony medial eminence. First, the
size of the shoe must be evaluated carefully in relation
to the foot. Next, the pattern of the seams that cross
over the medial eminence must be evaluated, because,
although leather will give way to pressure from the
medial eminence, the stitching will not. Sometimes just
altering the seams that cross over the bony prominence
will result in a great deal of relief. If it appears that the
shoe is of adequate size, then the area over the painful
spot can be relieved by having the shoe enlarged over
this area. This is particularly useful in the athlete who
requires a rigid boot, such as a skier, hockey player, roll-
erblader, and so forth. Even the ballet slipper can be
expanded to a certain extent to relieve the pressure over
the medial eminence.
The shoe itself could be stiffened to decrease stress
across the first metatarsophalangeal joint if the patient’s
athletic performance would not be diminished. Obvi-
ously a lineman can tolerate a stiffer shoe than a ballerina
or gymnast.
Figure 19-3 Severe hallux valgus deformity with subluxed As a general rule, an orthotic device per se will not do
metatarsophalangeal joint. A deformity of this severity anything to relieve the problems associated with a hallux
significantly alters the function of the plantar aponeurosis, valgus deformity unless there is sesamoid pain or a trans-
giving rise to progressive instability of the longitudinal arch. fer lesion beneath the second metatarsophalangeal joint.
Although this is tolerated by the nonathlete, it may present a
significant disability for the athletic individual.
Figure 19-4 (A) Radiograph of a congruent metatarsophalangeal joint. There is no lateral subluxation of the
proximal phalanx on the metatarsal head. This maintains the function of the plantar aponeurosis and hence
the stability of the foot. (B) An incongruent metatarsophalangeal joint has lateral subluxation of the proximal
phalanx on the metatarsal head. This creates an unstable situation, progressive in nature, giving rise to
decreased function of the plantar aponeurosis and increasing instability of the medial longitudinal arch.
437
...........
One must be careful when using an orthotic device the spectrum of hallux valgus deformities and the shape
because it will take up a certain amount of volume in of the foot are extremely variable. One could be evaluat-
the shoe and as a result may aggravate the patient’s ing a National Basketball Association (NBA) player who
problem rather than relieve it. An orthotic device will often has a large, rather flat foot, with multiple lesser-
not prevent a bunion from occurring. toe deformities as well as the hallux valgus or a ballerina
If the hallux valgus deformity has progressed to the with a moderate to severe hallux valgus deformity asso-
point at which a transfer lesion is occurring beneath ciated with multiple lesser toe deformities because of
the second metatarsal head, then some type of an pressure from the dancing shoes. Obviously, there is
orthotic device to relieve the pressure will be useful. the entire spectrum in between these types of athletes.
One must keep in mind, however, that whenever some- During the physical examination, the patient should
thing is added to a shoe it takes up volume; if the shoe is be asked to put his or her finger on the area that causes
already small, this can aggravate the problem. A change the most pain, and in this way the clinician is directed to
in shoewear may be necessary if an orthotic device is to the place at which the most attention must be focused.
be used. With the patient sitting, the clinician should deter-
Sometimes when an individual has a large medial mine the range of motion of the ankle, subtalar, and
eminence that is painful, there is tendency to place transverse tarsal joint, as well as the posture of the fore-
a pad over the involved area, with the thought that this foot in relation to the hindfoot. To determine gastroc-
will relieve pressure, but in actuality doing this increases nemius tightness, the overall tightness of the Achilles
the pressure. The person should be advised to cut out an tendon should be evaluated with the knee both flexed
area in the pad so that pressure is taken off of the medial and extended.
eminence rather than applied to it. The range of motion of the first metatarsophalangeal
joint must be observed carefully, and any crepitation or
dorsal impingement should be noted. During this pro-
cedure, one is observing the total range of motion,
PHYSICAL EXAMINATION
whether or not there is an element of hallux rigidus
present, which may be the source of the patient’s
The physical examination begins with the patient stand- pain, rather than the deformity itself. One also should
ing so that the clinician can observe the overall posture see how much passive correction of the deformity can
of the foot, deformity of the first metatarsophalangeal be achieved because this provides insight regarding the
joint and the alignment of the lesser toes. In athletes, degree of correction possible. The clinician palpates the
Figure 19-5 Subluxation of the tibial sesamoid beneath the first metatarsal head. As a result of this alignment,
there often is pain beneath the metatarsal head because the sesamoid rides against the cresta on the plantar
aspect of the metatarsal.
438
...........
Decision making
Figure 19-6 Radiographic analysis of a hallux valgus (HV) deformity (A). Hallux valgus angle should be less than
15 degrees, and the intermetatarsal (IM) angle less than 8 degrees. (B) The distal metatarsal articular angle
(DMAA) should be less than 10 degrees of lateral deviation. (C) An increased DMAA may result in a clinical
situation in which there is a hallux valgus deformity without subluxation of the metatarsophalangeal joint. To
correct this problem, a distal metatarsal osteotomy, carrying out a medial closing wedge osteotomy to realign the
articular surface, will be necessary. One cannot correct the hallux valgus deformity with an increased DMAA
without realigning the metatarsal head because stiffness of the joint will result.
sesamoid area, looking for the possibility that the prob- oblique x-rays. For accurate evaluation of a foot, the
lem may be due to a fractured or collapsed sesamoid. At radiograph must be weight bearing. The measurements
times the sesamoid pain is due to the sesamoid’s being obtained are the same as those used for evaluation of
positioned beneath the cresta (Fig. 19-5). Occasionally, other patients with hallux valgus deformity: hallux val-
particularly in the ballerina or the younger gymnast, one gus angle, intermetatarsal angle, joint congruency, distal
may encounter avascular necrosis of a sesamoid (usually metatarsal articular angle (DMAA), and evidence of
fibular) as the source of the discomfort. The clinician arthrosis (Fig. 19-6). One should determine whether
examines the plantar aspect of the foot, looking for the the first metatarsophalangeal joint is congruent or
possibility of transfer lesions, which would occur if the incongruent, identify osteophyte formation around the
person had an advanced hallux valgus deformity. first metatarsophalangeal joint, observe the sesamoids
The lesser toes must be evaluated by checking the and their location in relation to the cresta, and observe
range of motion of the metatarsophalangeal joint and the alignment of the lesser metatarsophalangeal joints.
the stability of the lesser metatarsophalangeal joints.
Sometimes with a severe hallux valgus deformity there
can be instability and possible subluxation of the second DECISION MAKING
metatarsophalangeal joint. The presence of hammertoes
or mallet toes also must be observed carefully to deter-
If the decision is made to carry out correction of the hal-
mine whether or not these are painful.
lux valgus deformity, the operative procedure must be
The neurovascular status of the foot should be
selected carefully. In the patient who has primarily an
checked, but this obviously is rarely a problem in the
enlarged medial eminence with a congruent metatarso-
athletic population.
phalangeal joint, the distal soft-tissue procedure alone
can provide satisfactory correction. In this situation,
the main problem is the enlarged medial eminence, with
RADIOGRAPHIC EVALUATION no subluxation of the metatarsophalangeal joint, so that
little or no correction is required. In this case the hallux
Radiographic evaluation is carried out by obtaining valgus angle would be less than 30 degrees and the
weight-bearing anterior-posterior (AP), lateral, and intermetatarsal angle less than 11 degrees. If the
439
...........
intermetatarsal angle is much more than 11 degrees, of motion of the metatarsophalangeal joints is limited
the possibility of a recurrence will be significant because to no more than 45 to 50 degrees. In a foot such
complete correction of the IM angle probably cannot as this, obtaining correction of the bunion deformity
be achieved. The athlete who is large and has a large can be technically difficult; and for the soft-tissue pro-
foot often has an extremely ‘‘stiff’’ foot. By a stiff cedure to succeed, an osteotomy must be performed
foot we mean one that is quite rigid so that the arc (Fig. 19-7).
Figure 19-7 (A) Preoperative and postoperative radiographs demonstrating a satisfactory reduction of a
moderate severe hallux valgus deformity using a distal soft-tissue procedure and proximal crescentic osteotomy.
(B) A somewhat less than optimal result following a distal soft-tissue procedure and proximal osteotomy in a
male with a very ‘‘stiff’’ foot, which made complete reduction of the deformity not possible. The problem with an
incomplete correction is that it has a greater possibility of recurrence than one that is completely corrected, and
the incompletely reduced sesamoid may be a source of plantar pain.
440
...........
Surgical procedures
The chevron procedure can be used if there is a very of the head then is identified with a K-wire, after which a
large medial eminence, a somewhat larger deformity of chevron cut is made. It is important that the blade not pass
the intermetatarsal angle, up to 13 degrees, but the hal- too far laterally after it passes the lateral cortex to protect
lux valgus angle should not be more than 30 degrees. the blood supply laterally. The chevron osteotomy then is
The chevron can be used with a mildly subluxed or displaced in a lateral direction approximately one quarter
incongruent joint or may be useful if the patient has an to one third of the width of the head, depending on the
increased DMAA that requires correction. It is impor- severity of the deformity. If the DMAA is a problem, then
tant to keep in mind, however, that if the sesamoids possibly a medial closing wedge-type of procedure can be
have subluxed they often are not corrected by the chev- carried out.
ron procedure itself; and, if the sesamoid lies beneath The osteotomy site is stabilized with either a pin or
the cresta, this may be a source of pain in the future. screw and the capsule is plicated (Fig. 19-8).
Lastly, the patient with a subluxed metatarsophalangeal Postoperatively the patient is then kept in a dressing
joint and an increased intermetatarsal angle will require a and postoperative shoe for approximately 6 to 8 weeks.
correction with a distal soft-tissue procedure and proximal If adequate stabilization of the capital fragment has been
metatarsal osteotomy. In patients with a subluxed metatar- achieved, the patient probably could start stationary
sophalangeal joint, complete correction should be bicycle riding about 2 weeks after the surgical procedure
obtained; otherwise the metatarsophalangeal joint may to maintain cardiovascular fitness.
be painful because the sesamoids have not been
completely reduced, resulting in pain beneath the cresta. The distal soft-tissue procedure and
The error that sometimes is made when trying to cor- proximal osteotomy
rect a hallux valgus deformity is to correct the deformity This procedure is used for the incongruent (subluxed)
incompletely by using a procedure that does not ade- metatarsophalangeal joint with a hallux valgus deformity
quately correct both the bony and the soft-tissue com- of more than 30 degrees and an intermetatarsal angle
ponents of the deformity. It is critical that a partial more than 13 degrees. The principle of this procedure
correction be avoided if an early recurrence is to be pre- is to carry out a complete distal release of the deformity
vented. This is never a good event for the patient or and then to carry out some type of a proximal metatarsal
doctor; but, in the case of the athlete, when there has osteotomy. The type of metatarsal osteotomy used
been downtime from his or her profession and the prob- depends on the surgeon. I prefer the proximal crescentic
lem recurs, the result is an extremely difficult situation.
SURGICAL PROCEDURES
It is beyond the scope of this chapter to present in detail

surgical procedures that could be used to treat the hal-
lux valgus deformity. Only a brief description of the
procedures is discussed, and more details of the surgery
can be found in standard foot and ankle textbooks.
The chevron procedure

The chevron procedure, as stated previously, is for the
patient who primarily has a congruent metatarsophalan-
geal joint with a large medial eminence as the main
source of discomfort. The chevron procedure should
not be used in the athletic population to correct a joint
that has more than 1 to 2 mm of incongruency
(subluxation).
The operation is carried out through a medial approach,
which is carried down to the joint capsule. With this type of
approach, the dorsomedial cutaneous nerve is not
endangered, as it is when a dorsal approach is used. The joint
capsule is opened, and the medial eminence then is removed
starting at the sagittal sulcus and then angled in a medial Figure 19-8 Preoperative and postoperative radiograph
direction (not in line with the metatarsal shaft) to obtain as demonstrating a chevron procedure.
wide a base as possible for the osteotomy site. The center (continued)
441
...........
Figure 19-8 cont’d
osteotomy; others prefer a proximal chevron or a short The distal soft-tissue procedure is carried out through
oblique. The principle involved is that the intermetatar- a dorsal incision in the first webspace, releasing the
sal angle must be corrected along with the distal soft- adductor tendon, the sesamoid sling, and the transverse
tissue procedure to obtain a correction that will stand metatarsal ligament. The lateral joint capsule also is
the test of time. released from its insertion into the metatarsal head.
Figure 19-9 Preoperative and postoperative radiograph demonstrating correction following a distal soft-tissue
procedure and proximal metatarsal osteotomy.
442
...........
Further reading
The second incision is made on the medial side of the At the same time that the hallux valgus deformity is
metatarsophalangeal joint where it is carried down to corrected, any existing symptomatic hammertoes can
the joint capsule. Care is taken to retract the dorsal be corrected, if necessary. If there is a dislocation of
and plantarmedial cutaneous nerves. A capsulotomy the second metatarsophalangeal joint, I think that this
then is performed, and a segment of the joint capsule can be treated with a distal metatarsal osteotomy to
is removed. The enlarged medial eminence is removed, decompress the joint and permit adequate reduction of
starting 2 mm medial to the sagittal sulcus and remov- the deformity to occur.
ing the fragment in line with the medial aspect of the
first metatarsal. This is different from the resection made
for the chevron procedure. A third incision is used to POSTOPERATIVE MANAGEMENT
carry out the proximal crescentic osteotomy. This is
a dorsal approach, starting approximately at the midshaft No matter what bunion procedure is carried out, the
of the metatarsal and carried just proximal to the meta- foot obviously is weakened by the procedure; and it is
tarsocuneiform joint. The osteotomy site is carried out important that, after the dressings are removed, the
approximately 1 cm distal to the metatarsocuneiform patient undergoes a period of physical therapy to regain
joint, and a screw is used for fixation. the range of motion of the metatarsophalangeal joint.
The postoperative immobilization is carried out by I believe that one should wait at least 1 month before
using a Kling and adhesive dressing, which holds the allowing the athlete to return to impact-type activities
toe in proper alignment for a period of 8 weeks to allow the bones and soft tissues to mature adequately.
(Fig. 19-9). The patient is permitted to ambulate in
a postoperative shoe during this period. If one feels that
the osteotomy site is sufficiently stable, cardiovascular FURTHER READING
training on a stationary bicycle can be started after
approximately 2 weeks.
I do not feel that a metarsocuneiform joint arthrode- Coughlin MJ: The chevron procedure, Contemp Orthop 23(1):45,
1991.
sis should be carried out in the active athlete. I think
Coughlin MJ: Hallux valgus in the athlete, Sports Med Arthrosc Rev
that this procedure carries with it too much morbidity, 2:326, 1994.
and the possibility exists of both nonunion at the fusion Coughlin MJ, Mann RA: Adult hallux valgus. In Coughlin MJ, Mann
site and the fusion site spilling over into the second meta- RA, Saltzman C, editors: Surgery of the foot and ankle, ed 7,
tarsocuneiform area, which would further stiffen the foot. St Louis, 2007, Mosby, Chap. 6.
Mann RA, Rudicel S, Graves SC: Hallux valgus repair utilizing a distal
Although this is tolerated by the nonathlete, I do not
soft tissue procedure and proximal metatarsal osteotomy, a long
think it is a good idea in the athletic population. term follow-up, J Bone Joint Surg 74:124, 1992.
443
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.........................................C H A P T E R 2 0
Chronic leg pain

Peter H. Edwards, Jr. and Peter B. Maurus
......................
CHAPTER CONTENTS
Introduction 445 Popliteal artery entrapment syndrome 458

Medial tibial stress syndrome 445 Operative 460
Stress fractures 448 Summary 462
Chronic exertional compartment syndrome 452 References 464
Nerve entrapment 456
INTRODUCTION track and field athletes with athletic-related injuries,

28% of injuries were due to overuse of the leg.4 Further-
more, chronic exertional shin pain accounts for approxi-
As the general population in the United States has
mately 10% to 15% of all running injuries and may be
become more active, orthopaedists have observed an
responsible for approximately 60% of all leg pain syn-
increase in the incidence of sports-related injuries. Non-
dromes.1 In another retrospective study of 150 patients
specific complaints of pain in the foot, ankle, calf, or
with exercise-induced leg pain, chronic ECS was the
shin are often reported, with shin pain as the most com-
most prevalent cause of pain, representing 33% of cases;
mon presentation.1,2 Evaluation of leg pain not only
stress fractures and MTSS accounted for 25% and 13% of
requires knowledge of the anatomy and biomechanics
cases, respectively.6 Conversely, in our experience MTSS
of the lower extremity but also an understanding of
has been more prevalent than either chronic ECS or
the pathology of the injury. Conducting a thorough
stress fractures. This chapter focuses on common causes
history and physical examination and appropriately
of chronic leg pain in athletes, including MTSS, stress
interpreting diagnostic tests are essential to the estab-
fractures, chronic ECS, nerve entrapment, and PAES.
lishment of an accurate diagnosis. In addition, specific
The incidence, pathology, clinical presentation, and
details regarding physical activity, including training
treatment options are discussed for each condition.
regimens, surface conditions, and shoewear must be
determined, because these factors also play a significant
role in the diagnosis.
MEDIAL TIBIAL STRESS SYNDROME
Because several etiologies may present with similar
characteristics, patients must be evaluated for multiple
conditions.3 The differential diagnosis of chronic leg ‘‘Shin splits’’ is a nonspecific diagnosis of posteromedial
pain includes the following conditions: bony or soft- leg pain commonly used to describe not only MTSS but
tissue tumors, chronic exertional compartment syn- also a wide variety of other lower leg pain conditions,
drome (ECS), claudication, isolated leg trauma, medial including chronic ECS, fascial hernia, muscle strains,
tibial stress syndrome (MTSS), muscle strains, nerve periostitis, and stress fractures.2,3,5,7-9 One of the most
entrapment, popliteal artery entrapment syndrome common sites of overuse pain is the distal one third of
(PAES), radiculopathy, referred pain from meniscal the medial border of the tibia.9-12 Several terms, includ-
pathology, stress fractures, and tendinitis. Despite this ing medial tibial syndrome, MTSS, tibial stress syn-
wide range of diagnoses, several studies demonstrate drome, posterior tibial syndrome, soleus syndrome,
that certain conditions are more prevalent among ath- and periostitis have been proposed to link this common
letes, in particular.1,4-6 In a retrospective review of 72 clinical presentation to a specific condition.2,11-19 Medial
CHAPTER 20 Chronic leg pain
tibial stress syndrome may be the most accurate of these

terms, however, because it describes both the location
and the likely pathophysiology of the syndrome.5,11,12,20
MTSS typically is observed in runners and individuals
involved in jumping activities such as basketball and
volleyball.3,8,11,18,21,22 In our experience it also repre-
sents the most common cause of chronic leg pain. Both
biologic and biomechanical factors have been reported
as possible causes of MTSS.10-12 Although the tibialis
posterior muscle historically has been implicated as the
source of this condition,9,16,22-24 a recent study of 50
cadaveric legs revealed that the tibial posterior muscle
was more lateral, indicating that this muscle was not
a likely source of MTSS.10 Other recent studies have
identified the soleus, flexor digitorum longus (FDL),
and crural fascia as sources of the pain.10,15,25 More
specifically, a three-phase bone scan study of 10 patients
with MTSS demonstrated low-grade uptake along a
diffuse region of the posteromedial tibia, suggesting that
the condition is related to the soleus muscle.15
During running, heel strike occurs in relative sup-
ination, with pronation of the foot increasing until Figure 20-1 (A) During running, the medial portion of the
midstance.11,17,26 Because the soleus is the primary soleus contracts eccentrically as the foot pronates.
plantarflexor and invertor of the foot, it has been theo- Hyperpronating athletes, in particular, are at an increased risk
rized that the medial portion of this muscle contracts for developing medial tibial stress syndrome (MTSS). (B) The
eccentrically as the foot pronates (Fig. 20-1).17 The source of pain is at the origin of the flexor digitorum longus
(FDL) and soleus fascial bridge on the posteromedial aspect of
repetitive eccentric contraction that occurs in hyper-
the tibia.
pronating athletes may explain the increased incidence
of MTSS observed in such athletes.5,9,11,14,17,25,27-29
In addition, hyperpronation is a compensatory mecha- Physical examination
nism that occur in patients with hindfoot and forefoot The pathognomonic physical finding in MTSS is pal-
varus,25,26 tibia vara,26 tight Achilles tendon,26,28,29 pable tenderness along the posteromedial edge of the
and tight gastrocnemius and soleus muscles;26 therefore distal one third of the tibia. In rare cases, erythema or
such patients also are at increased risk for developing localized swelling over the medial tibia also may be
MTSS. observed. Although studies have reported conflicting
ranges of motion associated with MTSS, in theory,
hypermobile pronating feet are at increased risk of
History MTSS. Therefore evaluation for foot pronation or
The most common complaint associated with MTSS is a subtalar varus also is recommended. Abnormal pulse,
recurring, dull ache localized over the distal one-third diffuse swelling, firm compartments, neurologic defi-
posteromedial cortex of the tibia (Case Study 1). In cits, and vibratory pain are not associated with this
our experience, MTSS tends to occur late in the sport syndrome.
season after prolonged activity, whereas stress fractures
tend to occur early in an athletic season as stresses Diagnostic studies
increase rapidly. Early in the development of MTSS, Roentgenograms generally are normal in patients with
patients may experience pain at the beginning of a work- MTSS3,7,11,17,30 but are recommended to rule out
out or run but feel a relief of symptoms with continued abnormalities associated with other conditions such as
activity, only to be followed by a recurrence of pain stress fractures and tumors.3,11,12 A three-phase bone
either at the conclusion of the activity or some time scan is warranted to rule out stress fractures if a con-
afterward. Pain usually is alleviated with rest and gener- servative treatment program does not alleviate pain.
ally does not occur at night. However, as this condition This type of bone scan is a valuable diagnostic tool used
progresses, pain may occur throughout training or dur- to differentiate between MTSS and stress fractures,
ing low activity, such as walking, and possibly may con- because each condition has a distinct scintigraphic
tinue during rest. pattern.7,9,11,15,17,31,32 A bone scan demonstrating
446
...........
Medial tibial stress syndrome
muscular stress transmission to the leg. NSAIDs often are

prescribed to relieve pain11,12 and to decrease possible
inflammation. Ice may be used to further reduce swell-
ing and inflammation.12,31 Addressing biomechanical
abnormalities is also recommended.12,33,34 For example,
excessive pronation may be corrected with the use of
custom or off-the-shelf orthotics.33 Physical therapy
modalities, including massage, electrical stimulation, ion-
tophoresis, and ultrasound also have been used.10,31,35 If
pain is present with walking or at rest, range-of-motion
boots and/or walkers are used. In rare cases, crutches
may be necessary.
If the patient has not experienced pain during conser-
vative treatment, a gradual return to training may be
initiated. Warm-up and cool-down routines, including
stretching, are advised with each workout to prevent
recurrence of symptoms. If the patient remains asymp-
tomatic, progression of training is recommended at
increments of 10% to 25% for 3 to 6 weeks.11 If symp-
toms return, activity should cease for at least 2 weeks
before training is resumed at a lower intensity and
Figure 20-2 Classic bone scan demonstrating the increased duration.
linear uptake along the posteromedial aspect of the tibia in
the delayed phase indicative of medial tibial stress syndrome Operative
(MTSS). The linear uptake is most commonly observed in the Fasciotomies of the posterior compartments of the tibia
distal one third of the leg; however, in this specific case, the are possible treatment options in patients with in-
location is slightly more proximal.
tractable MTSS.6,11,14,34,36 In these rare cases, fas-
ciotomies may alleviate the pull of the soleus and deep
a longitudinal and diffuse pattern in the distal one third compartment muscles on the corresponding fascial
of the tibia is indicative of MTSS (Fig. 20-2).9,11,15,32 In insertions.6,11,14,34,36 However, in our experience, con-
general, only delayed images are positive in cases of servative management alone has been successful in treat-
MTSS, whereas both early and delayed images demon- ing MTSS cases, eliminating the need for surgical
strate uptake in cases of stress fracture.11,15 In addition, intervention.
magnetic resonance imaging (MRI) is another diagnos-
tic tool for MTSS recommended by some authors.11,31
However, we believe that MRI has a limited role in the
evaluation of MTSS because of its higher cost compared 4 PEARL
with other imaging options7 and its difficulty in deli- MTSS pain actually may subside during workout but will
neating MTSS from stress fractures. recur following cessation of activity. Conversely, pain asso-
ciated with chronic ECS and PAES does not subside during
activity and tends to remain until activity is completed.
.............................................................
Treatment Pain is localized to the distal one third of the tibia in
MTSS but is usually more proximal in the typical stress
fracture.
Conservative
The recommended management of MTSS is multi-
modal, consisting of rest, nonsteroidal anti-inflamma-
tory drugs (NSAIDs), and ice.3,12 Physical therapy
modalities such as iontophoresis and ultrasound also
C A S E S T U D Y 1
may be used.3,12 Initially, rest or a decrease in training
for 2 to 3 weeks is suggested and may be curative with-
out further workup.12 Cardiovascular conditioning may
be maintained during this period with swimming, upper A 16-year-old, female, cross-country runner presented for
body weightlifting, and deep-water running.11,12 Sta- evaluation of progressive right leg pain. Over the
tionary biking is another option but should be performed preceding 3 weeks, training intensity had been increased
with the heel on the pedal, a precaution that will diminish
447
...........
in preparation for a season-ending tournament. During

causes overuse or overloading, which may result in stress
that time, increasing pain developed over the distal fracture.6,35,46 In addition, overlapping of sport seasons,
medial leg. Initially, pain was present only at the which often occurs when teenage athletes participate in
conclusion of training but progressed to include soreness multiple sports, also may lead to an overuse scenario.
on first arising in the morning and with daily activities, Training errors, including changes in training surface,
forcing the patient to decrease training. She denied shoewear, and technique often result in overloading,
constitutional symptoms, history of trauma, or recent which may result in stress fracture.6,35,37 Weather and
shoewear change. seasonal differences affect surface conditions for many
Physical examination was remarkable only for outdoor sport activities and may increase the risk of
tenderness along the posteromedial cortex of the distal stress fracture. For example, dry conditions and the fall
one third of the tibia. Plain radiographs were normal. On season are both associated with hard ground surfaces,
the basis of a clinical diagnosis of MTSS, conservative
which result in an overloading environment for soccer
treatment, consisting of cessation of training for 2 weeks,
NSAIDs, and ice, was recommended. At the 2-week
players. Simple measures, such as watering soccer fields
follow-up, only minor improvement had been achieved when the ground is hard, may reduce the risk of stress
and the patient remained in significant pain. fracture and other injuries by minimizing loading condi-
Consequently, a range-of-motion boot was implemented tions. Biomechanical factors, such as cavus feet, leg-
and a bone scan was ordered to rule out a possible stress length inequality, and muscular imbalance also may
fracture. Because the bone scan was negative, as increase the risk of developing a stress fracture.9,11,40,44
indicated by a diffuse uptake in the delayed phase, the Finally, low body weight and menstrual abnormalities
patient remained in the range-of-motion boot for an in female runners have been associated with an increased
additional 4 weeks. After this period, activities of daily incidence of stress fractures.39,40,42,55
living were conducted without pain, permitting a gradual The cause of stress fractures is multifactorial in nature
return to training over the ensuing 6 weeks.
and often results from an imbalance of natural bone for-
mation and resorption cycle because of repetitive load-
ing.37,44,51,56 One theory proposed to explain the
mechanism of stress fracture suggests that muscle
STRESS FRACTURES
fatigue results in the transmission of excessive forces to
the underlying bone, ultimately leading to stress frac-
Repetitive loading caused by overuse or overloading of ture.20,37,44,51,55 Another hypothesis asserts that simple,
the lower leg results in microtrauma to the bone that repetitive weight bearing leads to a concentrated rhyth-
eventually may lead to stress fracture.6,35,37-39 Stress mic muscle action, which causes excessive transmission
fractures of the tibia are more frequent3,11,37,40-44 and of forces beyond the threshold of bone, thereby result-
more problematic to treat than those of the fibula. ing in fracture.20,37,44,51,57 Forces from large posterior
Fibula stress fractures tend to heal more rapidly and muscle groups, in particular, may cause increased ten-
generally do not require adjunctive therapy.41,43 The sion on the anterior cortex of the tibia, possibly leading
focus of this section is on tibial stress fractures because to the problematic midanterior tibial stress fracture.51
most fibula stress fractures occur about the ankle and
are covered elsewhere. History
Most fractures of the tibia occur in the proximal Pain associated with tibial stress fractures is more proxi-
metaphyseal or upper diaphyseal regions,35,44,45 whereas mal than that caused by MTSS (Case Study 2). Although
tibial fractures that are longitudinal in nature46-49 or pain typically is localized to the fracture site, diffuse pain
occurring in the midanterior region9,35,37,38,50,51 are less also may occur. Stress fracture pain will develop gradually,
prevalent. Athletes, in particular, are subject to stress occurring initially as a mild ache following a specific
fractures of the leg. Specific stress fractures also are amount of exercise and then subsiding. As the condition
related to certain types of activities. For example, the progresses, pain may become severe and occur during
more common posteromedial stress fracture usually is earlier stages of exercise and after cessation of activity.
associated with running activities.11,35,46 Conversely, In rare cases, night pain also is possible. Any com-
midanterior tibial cortex stress fractures often are asso- plaints of constitutional symptoms, including fever
ciated with dancers and athletes involved in cutting and fatigue, should raise concern of a possible tumor
and jumping activities.35,38,50-54 or infectious process.
Risk factors for developing a stress fracture include In addition to obtaining a history of pain and symp-
excessive training, training errors, biomechanical var- toms, training and activity also should be investigated
iants, and menstrual irregularities with corresponding to identify possible errors that may increase the risk of
changes in bone density.9,11,40,42,46,55,56 Excessive train- stress fracture. Recent changes in activity level, such as
ing, particularly common early in the athlete’s season, increased quantity or intensity of training, modifications
448
...........
Stress fractures
in training surface, shoewear alterations, and technique

should be noted. Inquiries regarding diet also should
be conducted because the presence of eating disorders
increases the risk for stress fracture. Furthermore,
obtaining menstrual histories of female athletes also is
pertinent because oligomenorrhea and delayed menar-
che both increase the risk of stress fracture. Finally,
a review of systems is suggested to assess general
health, medications, and personal habits to identify any
additional factors possibly influencing bone health.
Physical examination
On gross physical examination, the leg will appear nor-
mal. Compartments should be soft and the posterome-
dial aspect of the middle to distal one third of the tibia
should not be tender. Joint range of motion usually is
normal, but gait analysis may reveal biomechanical risk
factors. Neurovascular examination typically is normal
in the absence of any associated abnormalities. Palpation Figure 20-3 Bilateral bone scan demonstrating normal
will reveal tenderness localized to the fracture site. In scintigraphy (left) versus the focal uptake pattern of a typical
addition, erythema or localized swelling also may be tibial stress fracture (right).
noted. An ultrasound or a tuning fork will produce
vibratory pain over the site of the stress fracture. In demonstrate identical diffuse uptake in the distal one
long-standing fractures, a palpable bony thickening third of the tibia (Case Study 3).
may be present. In addition to its diagnostic capabilities, imaging also
assists in differentiating among the various types of
Diagnostic studies stress fractures. For example, radiographs depicting a
A clinical diagnosis of stress fracture often may be made small lucency or a ‘‘dreaded black line’’ in the midan-
solely on the basis of the history and physical exami- terior cortex of the tibia are indicative of a midanterior
nation,37,56 but diagnostic imaging may confirm the cortex tibial stress fracture (Fig. 20-4, A).35,46 Because
diagnosis or assist in identifying the stress fracture in of the relatively avascular nature of this portion of the
questionable cases. Plain roentgenograms should be tibia, a bone scan initially may be interpreted as negative,
performed as the first imaging step but may be negative, but closer examination will depict an area of decreased
because radiographic abnormalities often are not uptake at the fracture site.46,54 If this type of fracture is
observed until 2 to 3 weeks after the onset of symp- not initially diagnosed and treated, a complete fracture
toms.3,37,44,46 Radiographic abnormalities may appear may result. Conversely, plain radiographs of longitudinal
as a faint periosteal reaction, a fluffy area of callus, or tibial stress fractures often are normal, whereas bone
a cortical lucency.39 If radiographic examination dem- scans will demonstrate increased uptake in the lower
onstrates the presence of a stress fracture, no further tibia.60
imaging is necessary.
A three-phase bone scan is indicated when suspicion
of stress fracture remains despite negative radio-
.............................................................
Treatment
graphs.39,46 The specific scintigraphic pattern of a stress

fracture demonstrates focal uptake in the area of fracture Conservative
(Fig. 20-3).37,58 MRI, another diagnostic option, differ- Conservative treatment for stress fracture is focused on
entiates among fracture, tumor, and infection and also pain relief and protection from further injury.39,46
localizes the pathology.31,44,46,56,59 However, because Improvement in muscular strength and endurance, con-
a diagnosis often may be determined by plain radio- tinuation of cardiovascular fitness, and management of
graph or bone scan, both of which are more cost effec- biomechanical factors also are important. Relative rest,
tive than an MRI, we reserve MRI for special cases, possibly with weight-bearing restriction, is recom-
including a history of allergic response to dye, an aver- mended for a minimum of 2 to 4 weeks. Mild analgesics
sion to needles, or an atypical presentation. An MRI also or NSAIDs also may be prescribed in conjunction with
is useful in differentiating between longitudinal stress physical therapy modalities, such as ice or cross train-
fractures and MTSS, the more commonly observed ing.38,46 Cardiovascular fitness should be maintained
overuse injury, because bone scans of these conditions with cycling, swimming, deep-water running, or other
449
...........
Figure 20-4 (A and B) Preoperative radiographs of a male runner who presented with a midanterior cortex tibial
stress fracture, also referred to as a ‘‘dreaded black line,’’ which is visible in the lateral radiograph (B).
(C and D) Because of the severity of the fracture, intramedullary nailing was required. As demonstrated in the
2-month postoperative radiographs, the fracture healed completely without the need for bone grafting.
nonloading activities.39,44,46,58 Upper body strength alleviated, the patient must return to the lower loading
training is recommended to maintain muscle mass and activity and not advance until each successive activity
is not likely to jeopardize fracture healing.44 Bracing or has been accomplished without pain. A period of rest
casting may be required for 3 to 12 weeks to immobilize also must be implemented between activities before
the fracture adequately in severe cases or if pain is not advancing to a higher loading activity. Although athletes
relieved after the initial 2- to 4-week rest period.33,61 may resume full training in 8 to 16 weeks, patients
Because prompt return to activity is a priority for elite must be aware that a prolonged recovery period may
athletes, electrical stimulation is highly recommended. be required for more severe stress fractures.51,54 Midan-
Electrical stimulation also has been effective in healing terior cortex tibial stress fractures, in particular, require a
nonunioned traumatic fractures.35,46,50,51 significant period of rehabilitation.3,38,46,50,51,58 Despite
Contributing factors, such as training errors, this prolonged rehabilitation, conservative treatment
improper shoewear, and muscle imbalance that were is similar to that for other tibial stress fractures and
identified in the history and physical examination also includes avoidance of activity, bracing or casting, and
must be addressed.6,39,44 Training regimens should be possible electrical stimulation.46,51,54
individualized for each patient. Treatment plans for ath-
letes with eating disorders or females with menstrual
irregularities should involve dietary counseling and/or Operative
estrogen replacement therapy to accelerate healing Although most stress fractures heal successfully with
and to prevent future problems.37,46 Shoes should be conservative treatment, surgery may be warranted for
examined for signs of wear and inadequate support and severe stress fractures, such as midanterior or longitu-
also must be replaced every 500 km.38,46 If necessary, dinal tibial stress fractures, or for chronic nonunions
appropriate orthotics should be implemented. of proximal medial stress fractures.38,50,51,54 Intramedul-
Return to activity should be gradual and indivi- lary nailing has yielded promising results in high-demand
dualized according to symptoms, with an emphasis on patients with problematic stress fractures.38,50,51,54 Our
progress only when activity is accomplished without experience with intramedullary nailing also has been
pain.44,46 It must be stressed that activity should cease positive and involves the treatment of three midan-
if any pain occurs and should not be reattempted until terior tibial stress fractures, all of which healed com-
the pain is alleviated.46,58 In addition, once the pain is pletely without the need for bone grafting (Fig. 20-4, B).
450
...........
Stress fractures
4 PEARL C A S E S T U D Y 3
Vibration from a tuning fork or ultrasound will produce pain
corresponding to the stress fracture site but will not elicit
pain in cases of MTSS or chronic ECS.
If a stress fracture is suspected on the basis of the his- A 47-year-old woman who regularly walks for
tory and physical examination despite negative plain radio- cardiovascular fitness presented with complaints of left
graphs, additional imaging, such as a three-phase bone lower-leg pain. The patient described a ‘‘deep-aching’’
scan, is recommended to confirm the diagnosis. pain in the lower one third of her leg. Over the past
Pain and swelling in the subcutaneous border of the tibia
3 months, pain increased with continuation of the
is indicative of a midanterior tibial stress fracture, which
patient’s walking program and began to occur at night,
requires careful radiographic evaluation to confirm the
presence of the subtle ‘‘dreaded black line.’’ If diagnosis eventually resulting in limitation of activity. Her medical
remains questionable, a three-phase bone scan demon- history was significant for osteoporosis and systemic
strating a focal area of decreased uptake in the anterior lupus erythematosus, which was treated with multiple
tibial cortex will confirm the diagnosis. medications.
Neurovascular and physical examinations were grossly
normal. No swelling was observed, but palpation revealed
mild tenderness along the distal tibia. Plain radiographs
did not reveal the presence of a fracture or periosteal
reaction. An MRI was ordered to differentiate between
C A S E S T U D Y 2 the suspected longitudinal stress fracture and possible
MTSS and subsequently demonstrated a longitudinal
stress fracture in the tibial metaphysis with surrounding
bone edema (Fig. 20-5). Conservative treatment involving
A 16-year-old, female soccer player related a 3-week a range-of-motion boot and nonweight-bearing
history of anterior tibial pain localized approximately 7 cm ambulation was recommended. Six weeks following
below the tibial tubercle. Initially, pain was mild and treatment, plain radiographs demonstrated a slight callus
occurred only with prolonged training. When the patient formation, indicative of the healing process. As a result,
continued her training intensity, the pain progressed to the patient was instructed to progress from partial to full
the point at which training became difficult and persisted weight-bearing ambulation over a 4-week period. Full
with daily activities; however, the patient did not seek weight-bearing ambulation in a range-of-motion boot
treatment at this time. Before her final game, the patient
stated that her pain was so severe she was unsure
whether she should could continue to play. Despite
constant pain, the patient competed in the final game and
experienced a noncontact tibial fracture while running.
Roentgenograms confirmed the presence of a tibial
fracture with an intact fibular that was located at the
anterior tibial cortex approximately 7 cm below the tibial
tubercle, corresponding to the site of a presumed existing
stress fracture. Conservative treatment was
recommended and involved long-leg casting for 3 months.
Because of minimal bone healing, determined by
radiographic evaluation, long-leg casting continued and
pulsed electromagnetic stimulation was added for
1 month. Following the use of the long-leg cast, a long-leg
fracture brace was used with continued pulsed
electromagnetic stimulation.
After 6 months of conservative treatment, aching
continued at the fracture site on weight-bearing ambula-
tion. Subsequent plain radiographs and computed
tomography (CT) scan indicated small areas of spot weld
healing but a largely inadequate bridging callus. Con-
sequently, operative treatment involving reamed interme-
dullary nailing of the tibia without fibular osteotomy was
performed. Approximately 4 months following surgery the Figure 20-5 Magnetic resonance imaging portraying the
fracture was completely healed, and, by 8 months post- longitudinal signal change in the distal tibia typical of
surgery the patient returned to playing soccer. a longitudinal tibial stress fracture.
451
...........
Anterior compartment
continued for an additional 4 weeks, with subsequent
introduction of a regular shoe. At 41/2 months, the patient Deep peroneal nerve Tibia
resumed her walking program with a gradual increase in
mileage. Superficial peroneal
nerve
Saphenous
nerve
Fibula
CHRONIC EXERTIONAL COMPARTMENT Lateral

SYNDROME compartment
Chronic ECS of the lower leg generally is induced by

Tibial nerve
exercise that impairs neuromuscular function within
Deep posterior
the involved compartment and is characterized by pain compartment
and swelling.62,63 This syndrome is classified into two
forms: acute, the more severe form requiring immediate
surgical intervention, and chronic.62,64-72 Acute ECS, Superficial posterior compartment
commonly caused by trauma, occurs when intracom- Figure 20-6 Cross-sectional view demonstrating the
partmental pressure is elevated to such a degree that compartments of the lower leg and associated anatomy.
immediate decompression is necessary to prevent intra-
compartmental necrosis.62,64,65,69 Conversely, the
chronic form of ECS develops when exercise sufficiently Several theories have been proposed to explain tissue
raises intracompartmental pressure to produce small ves- ischemia, the main symptom of chronic ECS. The first
sel compromise, which subsequently causes ischemia theory suggests that increased compartmental pressure
and pain,66,68,73 but not to the degree exhibited in the during exercise causes arterial spasm, which results in
acute form.62,65 Athletes exhibiting chronic ECS who decreased arterial inflow.74,83 An alternative hypothesis
continue or increase training are at greater risk of develop- asserts that transmural pressure disturbances produce
ing acute ECS.65,67,71 Chronic ECS often presents in arteriolar or venous collapse, which subsequently leads
bilateral form in young athletes with equal incidence in to ischemia.74,83-85 Finally, and perhaps more pertinent
males and females and typically is observed in runners or to athletes, venous obstruction recently has been advo-
participants in sports involving ball or puck.3,8,63,74-76 cated as a possible cause of tissue ischemia.64,65,69,74
Anterior chronic ECS is more common than the According to this theory, eccentric exercise results in
lateral and posterior forms of this syndrome (Fig. 20- myofiber damage, which causes release of protein-
6).3,8,30,63,66,74,76-78 Although symptoms of chronic bound ions into the compartment. Such repetitive
ECS, such as pain, muscle weakness, numbness, and eccentric contractions therefore cause not only an
swelling are general, the onset and subsidence patterns increase in ion concentration within the compartment
are specific to the condition.64-66,74 Symptoms resolve but also a subsequent increase in osmotic pressure. This
after activity is discontinued but generally return at the resulting arteriovenous gradient, in which venous pres-
same interval or intensity at the next training session.3,8 sure is increased and arterial blood flow is decreased,
Although the etiology of chronic ECS is not as well consequently leads to tissue ischemia.64,65,69,74 The
understood as that of the acute form, raised intra- association between repetitive eccentric contraction in
compartmental pressure resulting in relative ischemia the anterior compartment of runners and the increased
of the involved muscles is likely the pathophysiologic incidence of chronic ECS in the anterior compartment
mechanism producing this condition.1,63,69,70,74,75,79 lends support to this theory.63,65,66,74,76,77,86,87
Repeated muscle contractions during exercise cause an
increase in muscle volume by as much as 20% because History
of fiber swelling and increased intracompartmental Patients experiencing chronic ECS may complain of
blood volume.62,65,66,74,78 The resulting increase in cramping, burning, or pain over the involved compart-
compartmental pressures is transient and typically will ment(s) with exercise (Case Study 4). Pain associated
normalize within 5 minutes of completing exercise in with anterior chronic ECS may not be limited to the
asymptomatic people.66,76,80,81 In chronic ECS, how- compartment but also may radiate to the ankle and foot.
ever, intracompartmental pressures may remain abnor- The most characteristic symptom of chronic ECS is pain
mally high for 20 minutes or longer after exercise occurring at a fixed point in the patient activity. The
before returning to normal.64,77,82 pain will become progressive with continued exercise
452
...........
Chronic exertional compartment syndrome
or increased intensity but often will dissipate or cease

with rest, usually within 20 minutes of completion of
activity. Although this pattern of pain relief is observed
in the majority of athletes with chronic ECS, it is not
unusual for pain to ensue for a longer period. In
extreme cases, pain may be constant. In addition,
patients with anterior and deep posterior compartment
syndromes occasionally describe paresthesia in the dor-
sum of the foot or in the instep, respectively. In severe
cases, transient footdrop may occur.
Physical examination
Results of physical and neurocirculatory examinations in
patients exhibiting chronic ECS are normal before exer-
cise. Because pre-exercise examinations may not yield
insight into the condition, examinations also must be
conducted after the patient has performed the exercise
that initiates the symptoms. Following exercise, a sensa-
tion of increased fullness, swelling, tension, or increased
leg girth may be produced in the involved compart-
ments. The leg also may be tender over the involved
muscles. This diffuse muscular tenderness must be dis-
tinguished from that associated with superficial nerve
entrapment, which usually is focal at the site of entrap-
ment. In cases of severe chronic ECS, muscle weakness
and paresthesia to a light touch may be observed. Pulses,
however, will remain normal in all cases of chronic ECS.
Diagnostic studies
In addition to physical examination, diagnostic testing,
such as radiographs, bone scans, electrophysiologic test-
ing, and MRI/magnetic resonance angiography (MRA)
may assist in differentiating other possible lower leg con- Figure 20-7 (A) Hand-held compartmental pressure
ditions from chronic ECS. Radiographs typically are measurement device (Stryker Instruments, Kalamazoo, Mich.).
normal in cases of chronic ECS. Although rarely positive (B) To ensure accurate compartmental pressure
in chronic ECS, bone scans also should be obtained to measurements, the patient should be placed in a supine
eliminate MTSS and stress fracture diagnoses. Electro- position with the knee extended.
physiologic testing generally is not necessary but may
be beneficial in documenting the extent of motor loss
in patients with footdrop. An MRI/MRA is recom-
mended only when symptoms are accompanied by a vis- in a supine position with the knee extended and the
ible or palpable mass in the leg or when clinical evidence ankle in neutral dorsiflexion (Fig. 20-7, B). The needle
suggests possible popliteal artery compression. tip location and depth of penetration must be controlled
The most useful diagnostic tool to confirm chronic to obtain reliable measurements.88 Pressure measure-
ECS is compartmental pressure testing.3,20,87 Although ments are taken before exercise and at 1 minute and
many authors advocate performing pressure tests 5 minutes following exercise. If 5-minute measure-
before,20,65,81,88 during,19,20,79,88-92 and after exer- ments are borderline, 15-minute compartmental pres-
cise,20,65,88,93 we prefer pre-exercise and postexercise sure measurements are obtained following exercise.
testing only and do not recommend that measurements We use the compartmental pressure measurement
be obtained during exercise because of technical diffi- guidelines to establish a diagnosis of chronic ECS and
culties and the unreliability of measurements. The slit- are supported by other surgeons, as summarized in
catheter technique, which we use, involves the injection Table 20-1.65,76,81 Pressures usually return to normal
of small amounts of local anesthetic into the skin using within 3 to 5 minutes after exercise in patients without
an 18-gauge needle and a hand-held compartmental this condition.20 If elevated pressures continue for 5 to
measurement device (Fig. 20-7, A). Patients are placed 10 minutes, chronic ECS is diagnosed.
453
...........
Table 20-1 Compartmental pressure measurement guidelines for establishing chronic exertional compartment syndrome
1-min 5-min 15-min

Source Pre-exercise postexercise postexercise postexercise
Edwards PH, Myerson 15 mm Hg 30 mm Hg 20 mm Hg N/A

MS65
Pedowitz RA, et al.76 15 mm Hg 30 mm Hg 20 mm Hg N/A
Rorabeck CH82 15 mm Hg N/A N/A 15 mm Hg
by isokinetic strengthening exercise 3 to 4 weeks after

.............................................................
Treatment
surgery. Running may be initiated 5 to 6 weeks post-
operatively, with speed and agility drills added during
Conservative the eighth week.65,74 Athletes generally return to full
sports participation within 8 to 12 weeks following
Although some authors solely advocate surgical manage-
surgery.
ment for the treatment of chronic ECS, we recommend
beginning with nonoperative treatment to address the
extrinsic and intrinsic factors that contribute to the
condition.8 Modification of extrinsic factors, including
training surface, shoe design, and training intensity 4 PEARL
may decrease the symptoms of chronic ECS. Muscle Patients are able to predict the time of symptom onset.
imbalance, flexibility, and limb alignments are intrinsic The physical examination typically is normal at rest.
factors that may be addressed with either strengthening For the most accurate diagnosis, it is imperative to
and stretching exercises or orthoses. A short-leg cast perform compartmental pressure testing after activity that
used for approximately 4 weeks may cause atrophy of initiates symptoms.
the leg musculature that in turn may alleviate symptoms.
Biomechanical abnormalities also should be addressed
and corrected, usually with an orthotic, before training
is resumed. Because identifying and modifying all risk
factors contributing to chronic ECS is difficult, many C A S E S T U D Y 4
athletes may continue to have symptoms of chronic
ECS on resumption of activity and may be unable to
return to competition.73 In such cases, an operative
approach may be warranted to enable return to the A 15-year-old, female soccer player presented with
previous level of intensity. complaints of bilateral leg pain during activity. The
patient had been diagnosed with chronic ECS
Operative approximately 1 year ago and underwent bilateral
fasciotomies of four compartments at another facility.
The surgical technique for treating chronic ECS involves
After her initial postoperative rehabilitation, pain recurred
decreasing intracompartmental pressure, as depicted in on exercise. A second bilateral fasciotomy of four
Fig. 20-8.6,72,74,86 Fasciotomy generally is recommended compartments was performed, followed by recurrence of
if symptoms persist for at least 3 months and produces symptoms. Presently, pain developed approximately 15
favorable results, especially in the anterior and lateral minutes after beginning soccer practice and increased
forms of the condition.36,63,65,68,73-75,77,81,88,93-95 Care until activity ceased.
must be taken to identify and protect the superficial The current evaluation revealed a normal
peroneal nerve. In case of concomitant superficial examination at rest, with well-healed surgical incisions.
peroneal nerve entrapment, release of any fascial tethering It was noted that the medial incision was quite
or compression also may be performed. To prevent post- proximal. Compartmental pressure measurements after
operative fascial scarring, early passive and active range- provocative exercise confirmed bilateral compartment
syndrome, based on pre-exercise and 1-minute and
of-motion exercises are implemented and weight-bearing
15-minute postexercise readings. The 1-minute and
ambulation as tolerated is permitted within 2 weeks
15-minute postexercise measurements were greater
following surgery.65,74,77 Patients may begin exercise on
a stationary bicycle at 2 weeks postoperatively, followed
(continued on page 456)
454
...........
Chronic exertional compartment syndrome
Soleus fascial bridge
ii iii
Tibia
Saphenous nerve and vein
A
Superficial peroneal nerve
ii iii iv
B Intermuscular septum
Figure 20-8 (A) Fasciotomy technique for decompression of superficial and deep posterior compartments used
for the treatment of chronic exertional compartment syndrome (ECS). i, A longitudinal incision is created on the
posteromedial aspect of the leg. ii, The tibial posterior border is exposed, allowing full visibility of the saphenous
vein and nerve. iii, The soleus bridge is released providing exposure of the posterior compartments. iv, The
affected compartment is incised, using scissors or a fasciotome to extend the fasciotomies proximally and
distally. (B) Fasciotomy technique for decompression of anterior and lateral compartments used for the treatment
of chronic ECS. i, A longitudinal incision is created on the anterolateral aspect of the leg, midway between the
tibia and fibula. ii, Following exposure of the fascia, a transverse incision is created. iii, The intermuscular septum
is identified to assist in locating the superficial peroneal nerve. Care must be taken to avoid the superficial
branch of the peroneal nerve, which crosses laterally to anteriorly approximately 10 cm above the ankle. iv, The
appropriate compartment is incised, using scissors or a fasciotome to extend the fasciotomies proximally and
distally.
455
...........
than 21 mm and 17 mm Hg, respectively, in all

compartments.
Edwards performed a third surgery involving
bilateral fasciotomies of four compartments. Because of
the proximal position of the medial incision and the
suspicion that the soleus bridge previously was
unreleased, a new 10-cm medial incision was created to
be used in addition to the previous midleg lateral
incisions. The soleus bridge subsequently was released.
Recurrent scarring of the anterior and lateral fasciotomy
incisions was noted, and repeat extensile releases were
completed. The patient recovered fully and returned to
full activity at 12 weeks postoperatively, including
twice-daily soccer practice.
NERVE ENTRAPMENT
Lower extremity nerve entrapment is a mechanical irrita-

tion of a peripheral nerve caused by impingement.96,97
The common peroneal, superficial peroneal, and saphe-
nous nerves are the most at risk for entrapment, which
may produce neurogenic leg pain in the athlete
(Fig. 20-9).98-103 Trauma is a primary cause of all three
forms of entrapment.100,103 Superficial peroneal nerve
entrapment also is observed in dancers and athletes in Figure 20-9 Common sites of nerve entrapment in the lower
a wide variety of sports, including bodybuilding, horse extremity. (A) Common peroneal nerve entrapment occurs as
racing, running, soccer, and tennis.96,98,100,103 Com- the nerve wraps around the head of the fibula and exits the
mon peroneal nerve entrapment often is associated with peroneal tunnel. (B) Entrapment of the superficial branch of
repetitive exercises involving inversion and eversion, the peroneal nerve typically occurs as it pierces the deep
fascia of the lateral or anterior compartments of the leg. (C) A
which often occur in running and cycling.96,99,100
common site of saphenous nerve entrapment occurs where the
External compressive sources, such as tight plaster casts nerve branches, approximately 15 cm proximal to the medial
and anterior cruciate ligament (ACL) braces, and in- malleolus.
ternal compressive sources, including osteophytes or
proximal tibiofibular joint ganglion cysts, also may cause
common peroneal nerve entrapment.100,103,104 Knee impingement because of inherent inelasticity.97 Because
surgery also may cause common peroneal and saphenous nerves lack independent movement, impact or compres-
nerve entrapments,100,105 the latter of which also may sion from either trauma or internal pressure may cause
result from inflammatory conditions such as throm- entrapment.
bophlebitis.105 Superficial peroneal nerve entrapment,
caused by either trauma or fascia hernias, is the most History
common type of nerve entrapment that we have Patients suffering from nerve entrapment of the lower
observed. extremity typically present with pain that is aggravated
Although the causes of nerve entrapment are well with continued exercise. Common peroneal nerve en-
established, the mechanism responsible for this syn- trapment pain is located in the region of nerve compres-
drome is unknown.99,102 Certain factors, however, sion and is referred to the lateral leg and foot. In
predispose nerves to entrapment. Nerves coursing contrast, pain associated with superficial peroneal nerve
through soft tissues are particularly at risk for entrap- entrapment involves the lateral calf and/or dorsum of
ment. Nerves branching near joints also are at increased the foot (Case Study 5). Saphenous nerve entrapment
risk for entrapment because joints are associated with a often occurs just above the medial malleolus, leading
high volume of movement and are common sites of to local pain and referred pain to the dorsum of the foot
trauma.97,104 Additionally, nerves, as opposed to circu- medially (Case Study 6). Numbness, often described as a
latory and lymphatic vessels, are susceptible to burning sensation, also may be observed with all
456
...........
Nerve entrapment
compressive neuropathies. In addition, some patients

may experience localized swelling. Diffuse swelling, on .............................................................
Treatment
the other hand, is indicative of chronic ECS or a sys-
temic problem. Finally, motor weakness, such as foot- Conservative
drop, typically is observed late in common peroneal
Conservative treatment for nerve entrapment includes
nerve entrapment.
modification of precipitating activity, biomechanical
correction, physiotherapy, and/or soft-tissue mas-
Physical examination sage.98,100,103 NSAIDs used in conjunction with tricy-
The lower back, hips, and ankle joints should be exam- clic medications such as amitriptyline and, occasionally,
ined to confirm that an overriding neurologic condition gabapentin may alleviate the pain and associated swell-
is not present. Fascial hernia also should be ruled out. ing of all three forms of nerve entrapment.103 Iontopho-
Range of motion of all leg joints and stability of the knee resis is another option that we prefer because of its less
and ankle should be assessed. Compression or percus- invasive nature in comparison with a nerve block. How-
sion of the nerve is the hallmark test used to determine ever, nerve blocks may be necessary if iontophoresis fails.
a diagnosis of nerve entrapment. A tingling sensation Because constrictive clothing and/or devices, including
along the nerve or at its exit from the fascia is indicative ACL braces or patellar tendinitis straps, place additional
of entrapment syndrome. Tingling typically will be elic- stress on the nerves, the use of these devices is not
ited at the level of the fibular neck radiating distally in recommended during treatment.100,103
common peroneal nerve entrapment. Alternatively, in
superficial nerve entrapment, tingling will occur 7 cm Operative
to 12 cm above the lateral malleolus, whereas tingling Although common peroneal and saphenous nerve
will radiate from just above the medial malleolus and entrapments often are successfully treated by conserva-
more distally on the medial foot in saphenous nerve tive measures, superficial peroneal nerve entrapment
entrapment. typically requires surgical treatment.100,103 If surgery
is warranted, fasciotomy is performed to expose the
nerve, and, if necessary, is followed by external neuroly-
Diagnostic studies sis.98-100,105,106 In our experience, however, fasciotomy
Roentgenograms, MRI, compartmental pressure tests, alone typically is sufficient. In common peroneal nerve
electromyography (EMG), nerve conduction, and/or entrapment, resection of osteophytes, ganglion cysts,
nerve block are possible diagnostic tests conducted to or other obstructions may be necessary before neurolysis
confirm the diagnosis of nerve entrapment.100,101,106 is performed.100,103 In rare cases of trauma-induced
Radiographs typically are normal in nerve entrapment saphenous nerve entrapment, neuroectomy may be
syndromes but assist in identifying possible com- required.10,102,105 Because of the increased risks asso-
pressing bony lesions and in excluding stress fractures ciated with neurologic surgical procedures, including
and bone tumors.101,106 An MRI is recommended if a neuromas and reflex sympathetic dystrophy, surgical
pressure-causing mass is suspected. Compartmental treatment requires a thorough knowledge of the periph-
pressure tests may be conducted to distinguish between eral neuroanatomy.103 To minimize such risks, the nerve
chronic ECS and nerve entrapments,98,101,106 because should be manipulated as little as possible and the sur-
elevated compartment pressures are indicative of rounding soft tissue should be relatively undisturbed.103
chronic ECS. To differentiate between common and Activity may be increased gradually on wound healing.
superficial peroneal nerve entrapments and to locate
the anatomic point of compression, EMG and nerve-
conduction studies are recommended and should be
performed before and after exercise.100,101 A nerve- 4 PEARL
conduction velocity of less than 40 m/sec is considered A careful history and physical examination should be con-
abnormal and is indicative of nerve entrapment of the ducted to rule out referred pain or an overriding neurologic
lower extremity.107 If superficial nerve entrapment is condition.
suspected on the basis of any of the aforementioned A positive Tinel’s sign is highly suggestive of nerve
entrapment.
diagnostic tests, a nerve block should be performed.
If physical examination and all diagnostic tests, including
The anesthetic should be injected where the Tinel’s compartmental pressure measurements, are normal, nerve
sign is the strongest or at the location correspond- compression often is the source of the pain.
ing to maximal pain on pressure. Immediate pain The fascial exit of the superficial peroneal nerve is vari-
relief following injection is suggestive of nerve able, ranging from approximately 7.5 cm to 12.5 cm from
the tip of the lateral malleolus.
entrapment.96,97,102,103,105
457
...........
POPLITEAL ARTERY ENTRAPMENT

C A S E S T U D Y 5 SYNDROME
PAES is more common in athletes than in the general

A 30-year-old, male runner presented with complaints of population, especially as a result of increased partici-
lateral leg pain and foot numbness. The symptoms pation in competitive sports.6,108 This condition results
progressed after he began an aggressive running program from an abnormal relationship between the popliteal
during the prior year. The pain was described as sharp artery and the surrounding myofascial structures
and tingling and typically occurred over the mid to distal (Fig. 20-10), producing calf pain on exertion.6,108-111
aspect of his lateral leg during running. He denied a PAES is progressive and, in more severe cases, may
history of injury. result in occlusion of the popliteal because of compres-
On physical examination, a small prominence of soft sion from the medial head of the gastrocnemius
tissue was noted over the painful area. ‘‘Lightning-like’’ muscle.6,108
sensations and paresthesias corresponding to the
Although PAES is a possible diagnosis in any ath-
superficial branch of the peroneal nerve were elicited on
lete with calf pain and intermittent claudication, it
percussion. Gross neurovascular examination, including
sensation, otherwise was normal. After conservative is predominantly observed in males under the age of
treatment, including failed iontophoresis, a fasciotomy 30.6,108-110,112-122 This condition typically occurs uni-
was performed to release the nerve. Postoperatively, laterally6,111,114,117,118,121,123 but may be observed bila-
activity gradually was increased, with resumption of terally at an incidence as high as 67%.108,109,114,116,123
training at 6 weeks. PAES often results from high-intensity exercise with
excessive dorsiflexion and plantarflexion of the ankle,
which commonly occurs in football, basketball, soccer,
and running.6,108,111
Two forms of PAES, anatomic and functional, have
been suggested to explain the mechanism of this con-
C A S E S T U D Y 6 dition.6,108,109,114 In anatomic PAES, an abnormal
relationship between the popliteal artery and the sur-
rounding myofascial structure occurs during embryonic
development as the medial head of the gastrocnemius
A 52-year-old, avid golfer presented with a 3-month muscle migrates medially and cranially. The popliteal
history of distal medial leg pain. The pain increased with artery becomes entrapped during this migration and
activity and radiated to the dorsum of the foot. Initially, subsequently is swept medially with the gastrocnemius.
pain was mild but progressed to the point at which the Rignault et al. proposed the functional theory after
patient was unable to complete a round of golf without observing no anatomic abnormalities within the popli-
significant pain. NSAIDs and ice were implemented
teal fossa during surgical exploration.108,124 According
without improvement. Although the patient initially
to this theory, muscle contraction, particularly active
denied a history of trauma, on further inquiry, he recalled
that he had hit his distal tibia approximately about the plantarflexion of the ankle, compresses the artery
medial malleolus on his daughter’s bicycle 3 months between muscle and the underlying bone. This func-
before the present complaint. tional theory was further substantiated by Turnipseed
Physical examination revealed full range of and Pozniak,125 who also provided an explanation for
motion, with no swelling or cutaneous changes about the claudication by suggesting involvement of the popliteal
distal third of the leg. In addition, no tenderness was nerve. It was hypothesized that entrapment may be
observed over the medial distal tibial cortex, and a due to compression of the popliteal neurovascular bundle
vibratory test was negative. However, a positive Tinel’s against the lateral condyle of the femur.125 Repetitive
sign over the saphenous nerve above the medial muscle contraction from plantarflexion causes trauma
malleolus was elicited, reproducing the distal-radiating on the popliteal nerve, resulting in the subsequent
pain. On the basis of these clinical findings and the
neuromuscular form of claudication.125
traumatic nature of the injury, a diagnosis of
posttraumatic saphenous neuritis was established. History
Conservative treatment comprising NSAIDs, ice, and
iontophoresis was prescribed. Symptoms improved PAES should be considered in the differential diagnosis
markedly at 2 weeks following treatment and completely of healthy young patients presenting with complaints
resolved by 4 weeks, enabling the patient to return to of intermittent pain typically involving the foot and leg
regular activity. (Case Study 7). Pain, described as a deep ache or cramp-
ing, generally is posterior in location and typically occurs
458
...........
Popliteal artery entrapment syndrome
Figure 20-10 Normal course of the popliteal artery versus possible aberrant pathways involving the medial head
of the gastrocnemius muscle that cause popliteal artery entrapment syndrome (PAES) (popliteal artery ¼ dark,
popliteal vein ¼ striped, tibial nerve ¼ white). (A) Normal course of the popliteal artery in which the artery and
vein course distally between the heads of the gastrocnemius muscle, over the popliteus muscle, and beneath the
soleus muscle. (B) The popliteal artery deviates medially, wraps around the medial head of the gastrocnemius
muscle, and then resumes the normal distal course. (C) The popliteal artery deviates medially, wraps around the
medial head of the gastrocnemius muscle, and abnormally courses beneath the popliteus muscle, consequently
becoming entrapped. (D) The popliteal artery courses normally but is compressed by the medial head of the
gastrocnemius muscle, which is positioned laterally to its normal insertion. (E) The popliteal artery courses
normally but is entrapped between the medial head and an accessory tail of the gastrocnemius muscle. (Modified
from Rich NM, et al: Arch Surg 114:1377, 1979.)
459
...........
after vigorous exercise. It is important to note, however, activity is the only suggested form of conservative treat-
that claudication may be atypical early in the course of ment. Because this is not a viable option for many
this condition, because it may occur with walking and athletes, a surgical approach may be warranted.6,130
not with prolonged leg exercise. Symptoms occurring
less frequently include numbness, tingling, or coolness
of the foot; these symptoms may be relieved by chang-
ing leg positions.
OPERATIVE
Physical examination To prevent long-term arterial damage, early operative

Physical examination often is normal at rest in PAES treatment is recommended if PAES recurs following
cases, especially if the artery is still patent. Compart- resumption of activity.110,127,128,131 The principles
ments may be soft, and palpation of the bone and soft involved in surgical treatment of PAES include releasing
tissues may not elicit tenderness. Bilateral pulses should the entrapped nerve and restoring normal arterial flow.
be examined to determine whether reduction in pulse If the physical examination did not indicate evidence of
volume exists between limbs. The pulse should be pal- arterial damage, a myotomy is performed with the
pated with the ankle in passive dorsiflexion or active release of the offending fibrous band.108,110,128 How-
plantarflexion with the knee in extension because this ever, if the condition is more advanced and involves
maneuver places tension on the gastrocnemius muscle popliteal endofibrosis or arteriosclerosis, endarterectomy
and will lead to extrinsic compression of the popliteal and vein-patch angioplasty is recommended.110,118,128
artery. On auscultation, a bruit may be heard after pro- In cases of complete occlusion, a saphenous vein-bypass
vocative exercise, but the significance of this observation graft is required.110,118,123,128
is unclear because it also may be observed in a normal
athlete.
Diagnostic studies
Doppler sonography is recommended when PAES is
4 PEARL
suspected.6,108,123,126 Pulses should be measured in a The knee may be warm on palpation because of increased
neutral position and also while the leg is maneuvered collateral circulation.
toward knee hyperextension and ankle dorsiflex- Bilateral pulses with provocation should be examined to
ion.6,111,119,126 Obliteration of the pulse or reduction determine whether reduction in pulse volume between
limbs exists.
in pulse pressure after exercise is suggestive of If PAES is suspected on the basis of Doppler sonography,
PAES.6,108,110,116,120,127 If Doppler sonography indi- arteriography should be performed to confirm the
cates PAES, arteriography is recommended to confirm diagnosis.
the diagnosis.108,113,119,128 Often referred to as the
‘‘gold standard test’’ of PAES, arteriography is an inva-
sive procedure involving radiographic imaging after
injection of a radiopaque material into the suspected
arterial segment.108,118,120 Because arteriography may
be normal in PAES when the ankle is in the neutral posi-
tion and the knee is extended, it is important to repeat C A S E S T U D Y 7
the studies bilaterally after exercise or with the ankle in
positions of provocation, because extrinsic arterial
obstruction may be demonstrated with ankle plan-
tarflexion.6,112,119,122,127-129 MRI/MRA also may be A 19-year-old, female, competitive soccer player
beneficial in evaluating PAES.128,129 Compartmental presented with complaints of bilateral leg pain. Pain,
pressure measurement testing and three-phase bone described as a dull ache in the posterior aspect of both
scans are recommended to rule out chronic ECS and legs, began during workouts. The pain continued to
intensify until cessation of activity was required.
stress fractures, respectively.
However, the pain resolved after a short rest period of 5
to 10 minutes. This pattern of intense pain during activity
.............................................................
Treatment followed by relief after rest continued without
progression with every successive practice and
competition.
Conservative
The initial physical examination did not reveal any
Because PAES typically recurs on activity and may lead abnormalities, as demonstrated by soft compartments, no
to long-term arterial damage if untreated, avoidance of
460
...........
Operative
Figure 20-12 Intraoperative photograph illustrates the

abnormal pathway of the popliteal artery as it courses
medially to the head of the gastrocnemius and anteriorly
to the popliteus muscle indicative of popliteal artery
entrapment syndrome (PAES). (Image courtesy Paul
Cook MD, Riverside Methodist Hospital, Columbus, Ohio.)
tenderness on palpation, and normal neurovascular

findings. Radiographs and resting compartmental
pressure measurements were normal. In an attempt to
reproduce the patient’s symptoms, the patient was
instructed to exercise and subsequently returned with
complaints of posterior calf pain and mild tenderness on
deep palpation of the calf. During this symptomatic
period, neurovascular examination and compartmental
pressure measurements remained normal. A subsequent
three-phase bone scan and MRI also were normal. As a
result, conservative treatment consisting of rest was
implemented for 1 month.
The patient returned for evaluation because of
continued symptoms, but the physical examination
remained normal. Compartmental pressures were
reevaluated at pre-exercise and postexercise intervals
and remained within normal limits. Examination of pedal
pulses demonstrated normal dorsalis pedis and posterior
tibial artery pulses. However, when this measurement
was repeated with active plantarflexion or passive
dorsiflexion with a straight leg, loss of all pulses was
observed bilaterally. To confirm a diagnosis of PAES, an
arteriogram with provocative maneuvers was performed
and demonstrated loss of flow at both popliteal arteries
Figure 20-11 Arteriograms obtained following provocative (Fig. 20-11). Because the patient desired to continue
active plantarflexion and passive dorsiflexion with a competitive soccer, she elected to undergo surgical release
straight leg, demonstrating normal flow (A) compared with of the entrapped popliteal artery. Surgical inspection
the decreased flow (B) associated with popliteal artery revealed a popliteal artery coursing medially to the head of
entrapment syndrome (PAES). (Images courtesy Louis J. the gastrocnemius muscle and anteriorly to the popliteus
Unverferth, MD, Riverside Methodist Hospital, Columbus, muscle belly (Fig. 20-12). These areas of entrapment then
Ohio.) were released. After wound healing, the patient gradually
increased activity over a 6-week period and returned to
competitive soccer 3 months postoperatively.
461
...........
diagnosis, as summarized in Table 20-2. Keys to making

SUMMARY
an accurate diagnosis include conducting a thorough
history, performing an exhaustive physical examination
The most common conditions involving lower leg pain (Table 20-3), and using the appropriate diagnostic tools
in athletes are MTSS, stress fractures, chronic ECS, to distinguish further among these conditions (Table 20-
nerve entrapment, and PAES. Similarities of symptoms 4). Once a diagnosis is established, the preferred treat-
among these conditions make diagnosis difficult. The ment is conservative management, consisting of rest
challenge for the sports medicine specialist is to differen- from activity and modification of extrinsic and intrinsic
tiate among these similarities to establish an accurate factors. Treatment should be individualized according
diagnosis. Although pain is the hallmark symptom in to the patient’s symptoms and involve gradual rehabili-
all of these conditions, subtleties exist in the location tation and return to activity. Although a conservative
and occurrence of pain among the various conditions. approach typically is successful, surgical intervention
Therefore determining whether the pain is generalized may be required for cases in which conservative treat-
or localized and isolating the onset and diminishment ment has failed or for diagnoses of nerve entrapment
of pain will assist in determining the appropriate and PAES.
Table 20-2 Pain locations of the common lower-leg conditions
Leg condition Localized or generalized Location of pain

MTSS Generalized Posteromedial distal 1/3
Stress fracture Localized Bony tenderness above distal 1/3
Chronic ECS Generalized Involved compartments with

exercise
Nerve entrapment Localized Fascial exit site
PAES Generalized Posterior with exercise
ECS, Exertional compartment syndrome; MTSS, medial tibial stress syndrome; PAES, popliteal artery entrapment syndrome.
Table 20-3 Physical examination observations of common lower-leg conditions
Stress Nerve
MTSS fracture Chronic ECS entrapment PAES
Edema/ Posteromedial Over No No Possible
warmth distal 1/3 site around knee
Paresthesias No No Rarely Often Rarely
Pedal pulse Normal Normal Normal Normal Pedal pulses

with
provocation
Palpation Posteromedial At site Involved Possible at Posterior

tenderness distal 1/3 compartment(s) site of with
with exercise compression exercise
462
...........
Table 20-4 Diagnostic studies useful in distinguishing among common lower-leg conditions*
Nerve
Diagnostic study MTSS Stress fracture Chronic ECS entrapment PAES
Roentgenograms Recommended Recommended Recommended Recommended Not
recommended
Normal Periosteal reaction/early Normal Normal N/A

callus after 10-14 days
Bone scan Recommended Recommended Not routinely recommended Not Not routinely
recommended recommended
Linear uptake Focal uptake Normal N/A Normal
MRI Not routinely Not routinely Not routinely recommended Not routinely Not
recommended recommended recommended recommended
Signal Bone edema Normal Normal N/A

changes
MRI/MRA Not Not recommended Not recommended Not Recommended

N/A N/A N/A N/A Flow with

provocation
Compartmental Not Not recommended Recommended Not routinely Not routinely

pressure test recommended recommended recommended
N/A N/A 15 mm Hg at rest; Normal Normal

>20mm Hg 5-min
postexercise
Arteriography Not Not recommended Not recommended Not Recommended

N/A N/A N/A N/A Obstruction

with
provocation
Summary
*The upper portion for each diagnostic study represents our recommendation; the lower portion indicates the results corresponding to the diagnosis.
............
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466
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.........................................C H A P T E R 2 1
Foot and ankle injuries in dancers

John G. Kennedy, Christopher W. Hodgkins, Jean-Alain Columbier, and William G. Hamilton
......................
CHAPTER CONTENTS
Introduction 469 Anterior ankle 477

Metatarsophalangeal joint 470 Posterior ankle 477
Great hallux interphalangeal joint 472 Achilles tendon 479
Lesser metatarsophalangeal joints 472 Heel pain 480
Metatarsal injuries 473 Leg pain 481
The medial ankle 474 Summary 482
Lateral ankle 475 References 482
INTRODUCTION dancers also are prone to the triad of anorexia, amen-

orrhea, and osteoporosis. This unfortunate triad stems
from the significant pressure on dancers to weigh less
Ballet has all the elements of the arts in its makeup— and less. The most disturbing data suggest that female
drama, poetry, literature, painting, sculpture, design, dancers weigh more than 15% below the ideal weight
music, and, of course, dance. Dancers, both male and for height. This has metabolic consequences leading to
female, are the physical means by which the choreogra- stress fractures and slower union rates in injured female
pher sculpts a composition of expressive motion. The dancers.1 In contradistinction, male dancers have fewer
grace and art of the ballet performance belie the great metabolic problems but are prone to overuse injuries
physical strain on the body as a whole and the foot from repetitive motion and to stress fractures from the
and ankle in particular. From an early age the dancer sudden deceleration of large leaps, volé, sauté, or jeté.
must learn to be an artist, gymnast, and athlete. Most Dancer’s feet are the instruments on which their art
ballet dancers train for a minimum of 10 years before depends. They require, in addition to an extraordinary
attaining the skill set necessary to join a corps de ballet. flexibility and strength, a particular anatomic profile.
Very few dancers develop into soloists and fewer still Over time a dancer’s foot will evolve and only the stron-
attain the role of principle ballerina. Throughout this gest will survive. Dancers’ feet typically are ‘‘intrinsic
time of training, the body is placed under great strain, plus:’’ they have narrow metatarsal width with straight
and it is by a process of natural selection that those dan- toes. (Intrinsic-minus feet have wider metatarsal splay-
cers who are flexible and technically proficient survive ing and clawing of the toes.2) Apart from muscle
the rigors of training to advance further. strength, dancers’ feet require great flexibility. In the
Female dancers spend a considerable time en pointe, relevé position (Fig. 21-2) the ankle is in a vertical posi-
or on the points of the toes (Fig. 21-1), whereas male tion—90 degrees of plantarflexion of the ankle-foot
dancers tend not to dance on their toes and spend much complex. The dancer also requires 90 to 100 degrees
of their time in turning, lifting, and holding ballet dan- of dorsiflexion in the first metatarsophalangeal (MTP)
cers. As such, male and female dancers tend to present joint to go from relevé to en pointe. These are extra-
with distinct injuries. In addition to the myriad of physi- ordinary ranges of motion and can only be achieved with
cal injuries related to female dancers that follows, female years of practice, which mold the young ballet dancer’s
CHAPTER 21 Foot and ankle injuries in dancers
to the first and fifth metatarsal. However, dancers

do not have the same problems associated with
transfer metatarsalgia as does the general popula-
tion with this foot configuration.
2. Egyptian foot. Long first ray relative to the central
metatarsals. This can predispose the first MTP
joint to degenerative arthrosis or hallux rigidus.
3. Simian foot. Metatarsus primavarus with hyper-
mobile first ray that causes transfer metatarsalgia
to central metatarsal heads.
4. Peasant foot. Uniform metatarsal length, giving
broad, square foot. Its stability makes it an ideal
platform for dancing.
5. Model’s foot. This foot is long and slender with
a taper exaggerated cascade from first to fifth
metatarsal head. As such, it bears weight unevenly
on demi-pointe and is a poor foot for dance.
The following is a review of the more common dance
injuries and problems in the foot and ankle.
Figure 21-1 Illustration of the en pointe stance. METATARSOPHALANGEAL JOINT
Bunions
Although dancing has been said to play a role in the patho-
genesis of bunions, it is unlikely that this is the case.
Dancers, like the rest of the population, can be either
resistant or prone to develop bunions.7 In those dancers
that are prone to develop bunions, it is imperative to
delay surgical intervention for as long as possible. Bunion
surgery adversely affects dorsiflexion of the first MTP
joint, a critical motion in dancers. Most bunions can be
treated with conservative methods, including toe spacers
and horseshoe pads. The senior author has seen several
aspiring young dancers whose careers were ended by
well-meaning bunion surgery. If a bunion is precluding
the dancer from activity and surgery is warranted, then a
chevron osteotomy can provide pain relief and stability
without compromising motion.
Hallux rigidus
Any restriction to full dorsiflexion of the first MTP joint
will prevent the dancer from performing relevé. Many
Figure 21-2 Illustration of the relevé stance (demi-pointe). dancers can accommodate by rolling out onto the lateral
border of the foot, a process known as ‘‘sickling.’’
bones during the bone growth phase.3-5 As a result of The treatment of hallux rigidus depends on the grade
endless practice barres, class, and training, dancers’ feet of the disease (Fig. 21-3).
tend to be cavus and have thickened metatarsals to sup- In grade I disease, the joint is preserved and marginal
port when en demi-pointe. Calluses abound secondary to osteophytes can be resected, with excellent outcome
pressure demands on the skin. expected.
In general, five types of dancer’s feet have been In grade II disease, the joint is involved, with minor
described:6 cartilage destruction evident as joint space narrowing
1. Grecian (also known as Morton) foot has a rela- on plain radiograph. Treatment involves resection of
tively long second and third metatarsal in relation marginal osteophytes (cheilectomy). In addition, the
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Metatarsophalangeal joint
Sesamoiditis
The differential diagnosis of sesamoiditis is lengthy and
requires careful history taking and clinical examination.
Magnetic resonance imaging (MRI) aids diagnosis.
The following is a list of differentials:
Stress fracture of the sesamoid bone,
Avulsion fracture or sprain of the proximal pole of
the sesamoid,
Sprain of the distal pole,
Sprain of a bipartite sesamoid,
Arthrosis of the sesamoid metatarsal articulation,
and
Preradiographic osteonecrosis of the sesamoids.
Figure 21-3 Illustration of hallux rigidus.
Several mechanisms are responsible for producing
sesamoiditis in dancers. Most of theses can be treated
with a felt pad around the sesamoid for relief (‘‘dancer’s
dorsal one third of the metatarsal head is resected.8 pad’’). In general, symptoms resolve without any addi-
Intraoperative dorsiflexion of the hallux greatly over- tional interventions although this may take up to 6
estimates the degree of motion that can be expected months for full resolution. In those cases requiring
following surgery. Just over half of what is achieved at further diagnostic testing, a bone scan or MRI can be
the time of surgery will be evident in the postoperative useful. The medial sesamoid is often bipartite, with
follow-up examination. It is important that dancers rounded edges on plain radiograph, distinguishing it
understand that, although surgery will make the condi- from a recent fracture.
tion better, the joint will never be normal. In addition, In those cases with recalcitrant pain, surgery is war-
the length of recovery time must be discussed with the ranted. A medial-based incision can locate the medial
dancer, because a full functional recovery often takes sesamoid; however, a plantar incision is always needed
6 months. To improve functional motion following sur- for a lateral sesamoid. Partial excision is preferred to
gery, a dorsally based closing osteotomy can be used prevent varus or valgus malalignment. Surgery should
(Moberg). This procedure improves dorsiflexion but at be reserved for those patients with symptoms persisting
the expense of plantarflexion, and the dancer should be for at least 6 months following initial treatment.
warned of this. Other conditions may mimic sesamoiditis, including
In some cases we also can use a shortening scarf instability, bursitis, and nerve entrapment:
osteotomy to decompress the MTP joint and allow 1. Sesamoid instability. Rarely, the medial collateral
reestablishment of the mobility. ligament of the tibial sesamoid is torn, causing a
Grade III hallux rigidus presents with dorsal and clear ‘‘clunk’’ as the sesamoid dislocates laterally
lateral osteophytes in addition to clear degenerative when the dancer relevés. Repair of the medial collat-
arthrosis on both sides of the joint. Arthrodesis, an eral ligament usually requires release of the lateral
acceptable surgical option in the general population, is ligament as an adjunct. The medial ligament may
not feasible in a career dancer. To preserve motion, a be frayed or not repairable end to end. In this case,
capsular arthroplasty can be performed with reproduc- local soft tissue is used to supplement the repair.
ible outcomes9 (Fig. 21-4, A and B). It is important to Care must be taken not to overtighten the medial
select these patients carefully because transfer metatar- aspect of the joint and disrupt MTP joint motion.
salgia is common in those patients with a foreshortened 2. Sesamoid bursitis. Swelling and inflammation
first ray. within the sesamoid bursa may mimic sesamoidi-
tis. However, careful clinical examination usually
.............................................................
Injuries to the sesamoid bones can identify a symptomatic bursa when present.
Treatment consists of a well-directed local corti-
The sesamoid bones lie within the substance of the costeroid injection to the bursa. Bursitis still
flexor hallucis brevis tendons. They are commonly may take some time to resolve, and it can be com-
injured in dancers, particularly in those who fail to plicated by a fibrous scar that causes repeated
perform a plié on landing, absorbing the energy of the symptoms. In such cases, a bursectomy can be
landing through partially flexed knees. Without such performed through a careful plantar incision. Care
absorption built into a dancer’s technique, sudden should be taken in identifying the proper digital
deceleration with high impact of the sesamoid bones nerve, and a precise and meticulous skin closure
predisposes to injury. is critical to a good outcome.
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Extensor hallucis brevis
Extensor hallucis longus
Flexor
hallucis Capsule
brevis
Figure 21-4 (A) Diagrammatic representation of an interpositional arthroplasty of the first metatarsophalangeal
joint. (B) Intraoperative photograph of an interpositional graft in situ.
3. Joplin’s neuroma. Entrapment of the proper digi-

LESSER METATARSOPHALANGEAL JOINTS
tal nerve, adjacent to and, rarely, under the tibial
sesamoid, will cause symptoms similar to sesamoi-
ditis. Joplin’s neuroma, however, will display a Metatarsalgia is uncommon in dancers, and when it is
characteristic nerve compression sign with palpa- encountered the differential diagnosis must include MTP
tion. In those cases recalcitrant to conservative instability and Freiberg’s infraction.
therapy, neurolysis and transposition of the nerve
are required. MTP instability
As the dancer relevés the phalanx subluxes dorsally,
Lateral proper digital nerve entrapment pushing the metatarsal head plantarward and causing
The lateral proper digital nerve may be compressed pain. In the demi-pointe position, excessive loads are
under the deep transverse ligament, causing pain in the transmitted through the second and third MTP joints.
great toe on the lateral side. Because of the position of Clinical examination will elicit a translation in the ante-
the nerve, a compression test cannot be performed. rior-posterior (AP) plane that is in excess of the adjacent
Diagnosis is made with a selective local anesthetic injec- joints.10 Treatment initially is directed at taping to neigh-
tion to the nerve. Surgical resection of the transverse boring toes and stress-relieving padding. Surgical correc-
ligament is curative. tion includes a very limited resection arthroplasty with
a plantar condylectomy. Alternately, a limited Weil os-
teotomy may be used with screw fixation. Motion is begun
early. Scarring at the plantar aspect of the wound facilitates
GREAT HALLUX INTERPHALANGEAL JOINT
tightening of the redundant plantar plate.
In young ballet dancers, hyperflexion of the great toe Dislocation of the MTP joints
interphalangeal joint (IPJ) can occur when attempting Acute injuries should be reduced and immobilized until
en pointe. Here, weight is distributed over the nail and soft-tissue healing can occur. In cases of delayed diag-
dorsum of the toe in the pointe shoe. nosis, reduction often is impossible secondary to scarring
Hyperextension of the great toe IPJ also occurs, and the risk of neurovascular stretching. In such instances,
usually to compensate for lack of motion in adjacent a resection arthroplasty or Weil osteotomy reducing the
joints. Rarely does this need surgical intervention, length of the metatarsal will facilitate reduction.
despite radiologic appearances, because the joint is quite
accommodating and typically asymptomatic. In those Freiberg’s infraction
who do complain of symptoms, lambs wool wrapping Dancers have a propensity to develop Freiberg’s infrac-
can help to alleviate the discomfort problem. tion equal to that of the general population. In general,
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Metatarsal injuries
Figure 21-5 Preoperative and postoperative radiographs of Freiberg’s infraction.
conventional radiography lags behind clinical symptoms may provide benefit. If surgical exploration is required,
by up to 6 months (Fig. 21-5). Bone scan or MRI facili- a very limited resection arthroplasty with a plantar con-
tate early diagnosis. dylectomy is used. Alternately a limited Weil osteotomy
Four types of infraction occur: is performed if the ray is long and plantarflexed relative
Type I: A localized osteonecrosis of the metatarsal to adjacent metatarsals. Scarring at the plantar aspect
head that heals by creeping substitution. No carti- of the wound causes the plantar plate to tighten by scar-
lage defect is seen. ring fibrosis. Motion is encouraged early to facilitate the
Type II: Following metatarsal head osteonecrosis, flexibility needed by the dancer. This is a fine balance
the structural support of the head is lost. New bone between flexibility and instability.
formation occurs but is not sufficient to prevent
collapse of the head. The articular cartilage is
preserved; however, osteophytes on the dorsal lip METATARSAL INJURIES
limit dorsiflexion. Surgical debridement is curative,
with exostectomy of the dorsal ridge to facilitate
dorsiflexion. Second metatarsal base stress fracture
Type III: In addition to metatarsal head collapse, Most high-level dancers have a mild cavus foot, and
the articular cartilage is destroyed. Surgical man- despite the mechanical advantages this creates vis-à-vis
agement includes excision of the dead bone and technique, the rigidity of the foot places high stresses
cartilage and osteophyte resection. The plantar on the bones on impact.11 In those dancers who start
aspect of the joint usually is intact and can be left their careers early in life, the metatarsals hypertrophy
alone. and the cortices broaden to accommodate the increased
Type IV: A rare entity with several heads involved. stresses placed on them. In certain cases, however, stress
May represent a congenital epiphyseal dysplasia fractures occur despite cortical hypertrophy because the
rather than a true infraction. repeated microtrauma of dancing exceeds the reparative
capacity of the bone.
Idiopathic MTP synovitis Because of the cuneiforms’ Roman arch configuration,
Characterized by the appearance of a ‘‘sausage toe,’’ this the second metatarsal sits wedged between the medial
clinical entity is associated with MTP joint laxity and and lateral cuneiform bones. This causes a relative rigidity
instability. Anti-inflammatory medication and taping to the second ray and consequently a potential site for a
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Figure 21-7 Jones fracture.
occur, a single screw down the diaphysis is required.

Figure 21-6 Stress fracture of the second metatarsal neck. This may or may not need to catch the medial
cortex, depending on the grip of the screw within
the diaphysis. Bone graft may be used as an adjunct
stress fracture. In fact, this is the most common site for to help osteosynthesis. If the screw is removed, the
a stress fracture in the dancer’s foot, and when a patient fracture has a significant risk of recurring.
complains of pain and tenderness in the base of the sec- 3. Avulsion fracture of the fifth metatarsal. Usually
ond metatarsal, it should be regarded as a stress fracture caused by sudden inversion of the foot, the pero-
until proven otherwise (Fig. 21-6). neus brevis attachment is avulsed, in addition to
Conventional radiographs may not show the fracture, the lateral band of the plantar fascia and the
but a bone scan or MRI will confirm clinical suspicion in abductor digiti minimi. In general this injury can
such instances. As the second metatarsal hypertrophies be treated with immobilization and rarely requires
from years of pressure in the demi-pointe position, it surgical intervention, because a fibrous union will
may have the appearance of a healing fracture. Again, invariably occur even in the presence of significant
MRI can be useful in determining the true diagnosis. distraction of the fragments. In a skeletally imma-
Acute injuries require a cam walker for up to 6 weeks ture dancer, this apophysis will not have ossified
to allow time for the fracture to consolidate. Cast immo- and the fracture will not be visible on plain radio-
bilization usually is not required, provided that the graphs. The diagnosis must be made clinically.
dancer can be trusted to keep the cam walker in place The treatment is similar.
as prescribed. Rarely, a fracture may progress to a
delayed union, and in these cases a small ultrasound Bunionettes
bone stimulator can be used to accelerate healing. Pain over bunionettes usually can be diminished with soft
padding or Micropore adhesive tape to reduce friction
Fifth metatarsal fractures
and callus formation. Surgical resection usually is reserved
1. Spiral diaphyseal fracture of the fifth metatarsal. for a retired dancer because the time to recovery from the
These fractures occur when the dancer rolls over procedure is extensive.
onto the lateral border of the foot from a demi-
pointe position.12 The fracture invariably heals
but may take several months to heal sufficiently
to allow further dance.
THE MEDIAL ANKLE
2. Jones fracture of the proximal diaphysis. This is a
difficult fracture to treat in a dancer because it Although posterior tibial tendon pathology is relatively
requires extensive time in a nonweight-bearing common in other sports, it is rare in dancers. The rea-
cast (Fig. 21-7). Nonunions are rare in a non- sons for this are multiple. Typically a dancer’s foot is
weight-bearing cast despite the tenuous blood cavus, which tends to protect him or her from tibialis
supply. Weight-bearing casts, on the other hand, posterior pathology in comparison to a more planus
have a greater risk of nonunion. Should nonunion foot. Also, when a dancer is in equines, the posterior
474
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Lateral ankle
Figure 21-8 Magnetic resonance imaging (MRI) scan demonstrating coronal (A) and sagittal (B) views of an
osteochondral defect (OCD) in the talus.
tibial tendon is relatively shortened as the subtalar joint computed tomography (CT) or MRI, which will demon-
is inverted. strate the extent of the lesion (Fig. 21-8, A and B). The
size of the osteochondral lesion determines the most
Medial ankle sprains appropriate treatment. Microfracture treatment, chon-
Medial ankle sprains occur infrequently and are asso- drocyte transplant, allograft implants, and osteochondral
ciated with a pronated foot landing off balance. If the grafting are available techniques.
foot is in plantarflexion, the anterior deltoid is maxi- Osteochondral autologous transplant surgery (OATS)
mally affected, and the tension is greatest in the deltoid is indicated for large lesions with cartilage collapse
in this position. Similarly, when the foot is flat on the or deficit and extensive underlying bone necrosis. The
ground and hyperpronated, the tear will occur in the lesion is cored out of the talus and filled with osteo-
midportion of the deltoid. chondral autograft, commonly from a nonweight-bearing
An accessory bone, the os subtibiale, can be found in location in the lateral femoral condyle (Fig. 21-9,
the substance of the deltoid. When injured, it may man- A and B).
ifest as a trigger point of pain when ligamentous healing
should be complete. A local injection of steroid is all
that is required to treat this symptom. LATERAL ANKLE
Chronic strain of the deltoid from poor form in roll-
ing in (pronation) of the foot is a common overuse
injury in dancers. Chronic strain of the anterior aspect Lateral ankle sprain
of the deltoid ligament, anchored to the capsule of the The most common injury in dancers involves the lateral
talonavicular joint, may predispose the ankle to chronic ligament ankle stabilizers.13 The anterior talofibular liga-
rotatory instability. ment (ATFL) and calcaneofibular ligament (CFL) are
Recalcitrant medial ankle pain also may be caused by stressed at different ankle positions. The ATFL sprains
osteochondritis dissecans of the talus following a sprain. in a plantarflexed and inverted foot, whereas the CFL
Clinical suspicion warrants further investigation with is more prone to injury when the foot is dorsiflexed.
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Figure 21-9 (A) Talus after ‘‘coring’’ of the osteochondral defect (OCD). (B) Talus following implantation of the
autologous osteochondral graft.
Three grades of tears commonly are seen: of ankle mobility and earliest return to activity
Grade I: Partial tear, usually of the ATFL. This is a without affecting mechanical stability.15 Closed
stable injury, requiring rest, ice, compression, and chain balance and proprioception activities, along
elevation for 48 hours. Thereafter, motion is encour- with peroneal muscle strengthening, will improve
aged with a light compressive bandage. Dancers can the neuromuscular control of the ankle. A therapist
begin light workouts at 48 hours with the aid of a must be familiar with the modalities needed to
brace or Aircast. Initially, therapy should concentrate achieve these goals to optimize outcomes in these
on range of motion. After 4 or 5 days, dancers begin dancers.
to wean out of the brace and initiate proprioception, Residual symptoms following lateral ankle sprains in
balance, and peroneal strengthening exercises. dancers may be secondary to:
Grade II: Complete tear of the ATFL, occasionally 1. Avulsion fracture of the tip of the fibula,
including the CFL as well. A positive drawer sign 2. Accessory ossicle or os subfibularae,
but negative talar tilt are observed. Treatment is 3. Os calcis fracture or avulsion of extensor digi-
immobilization in a cam walker or Aircast for up torum brevis,
to 6 weeks. Initially, physical therapy should focus 4. Fractured os peroneum,
on regaining appropriate range of motion. There- 5. Fractured lateral process of talus,
after, a triple-phase rehabilitation program including 6. Cuboid subluxation,
peroneal strengthening, balance, and proprioceptive 7. Soft tissue entrapment,
training should be initiated early. 8. Sinus tarsi syndrome,
Grade III: Unstable injury. Both the ATFL and 9. Fractured os trigonum or Shepherd’s fracture,
the CFL are injured. In addition, the drawer sign 10. Syndesmotic disruption,
and talar tilt are positive. Treatment traditionally 11. Maisonneuve injury,
is immobilization for up to 4 months. In a profes- 12. Anterolateral gutter scarring or Ferkel’s pheno-
sional dancer, primary repair is preferred, and the menon,
Brostrom-Gould usually can be performed 1 week 13. Talar irritation from a slip of the ATFL inserting
following the injury with predictable results and at the extreme tip of the fibula or the Bassett’s
return of function.14 Regardless of the treatment ligament,
used, attention must be paid to reestablishing a 14. Peroneal tendon dislocation or subluxation,
functionally stable joint. A comprehensive literature 15. Functional ankle instability, or
evaluation and meta-analysis showed that early 16. Impingement of a lateral branch of the deep
functional treatment produced the fastest recovery peroneal nerve (LBDPN).
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Posterior ankle
LBDPN Impingement
Persistent dorsolateral foot pain following ankle sprain
is common. It often is attributed to chronic ligament
dysfunction, sinus tarsi syndrome, anterior tarsal tunnel
syndrome, or functional ankle instability. The pain is
triggered most commonly in a plantarflexed and inverted
position. In those cases recalcitrant to a rehabilitation
program, an impingement of an LBDPN over the ante-
rolateral corner of the talus (Fig. 21-10) or underneath
the extensor digitorum brevis (EDB) muscle should be
sought. Diagnosis is confirmed with persistent pain,
exclusion of the above differentials, a positive Tinel’s
sign over the anterolateral talus, and response to a loca-
lized subcutaneous anesthetic injection.
Shoewear modification can often alleviate any exter-
nal compression. However specifically guided injections
and ultimately release of the EDB is often necessary.16
ANTERIOR ANKLE
The cavus foot is ideal for dancers in that plantar-

flexion is maximal. However, this is at the expense of Figure 21-11 Radiograph of tibiotalar osteophytes.
dorsiflexion, which is limited. The most common form
of anterior impingement typically is seen in male dancers Three main types of lesions are seen (Fig. 21-11):
who perform high jumps and deep pliés (bravura). 1. Anterior tibial lip,
Impingement of the anterior lip of the tibia against 2. Talar neck, or
the talus causes the cambial layer of the periosteum to 3. A combination of both.
produce reactive bone formation and osteophytes or Treatment of type I is resection using the arthroscope.
‘‘kissing lesions.’’17 This is a continuous cycle as more Type II and III lesions often may require an anterior
bone forms, and eventually motion is significantly arthrotomy. Attention always should be directed to the
restricted. medial joint whether using an arthroscopic approach or
a formal arthrotomy. A medial impingement exostosis
on the talus that impinges on the medial malleolus can
be found and resected.
POSTERIOR ANKLE
Ideally, more than 100 degrees of plantarflexion should

occur at the foot-ankle complex in a professional ballet
dancer. Much of this has to be accomplished by the
subtalar joint, and subtalar motion is facilitated by the
turned-out position of mild forefoot pronation and abduc-
tion. Any form of tarsal coalition, whether fibrous or bony,
will prevent the subtalar joint from supplementing the
ankle joint in full equinus. Consequently, most dancers
with subtalar coalitions do not reach professional grade.
Posterior impingement syndrome

The posterior tubercle of the talus varies greatly in size. In
posterior impingement syndrome, either a large posterior
Figure 21-10 Illustration of branching pattern of the lateral tubercle or an os trigonum (Fig. 21-12, A through C)
branch of the deep peroneal nerve (LBDPN). is caught between the posterior lip of the tibia and the os
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Figure 21-12 (A) Radiograph of an os trigonum. (B) Radiograph

of an os trigonum in relevé. (C) Illustration of os trigonum
posterior impingement.
calcis when the dancer is in relevé.18 A simple clinical of an os trigonum impinging the soft tissue rather
sign, the forced plantarflexion sign, confirms the diag- than the bone itself. The differential diagnosis
nosis when pain is produced by full plantarflexion at includes Achilles tendinitis, peroneal tendinitis, or
the back of the ankle. The syndrome is usually a result heel pain.
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Achilles tendon
The os trigonum is present in up to 10% of the popu-

lation and is bilateral 50% of the time. Anatomically, the
os trigonum represents the nonfused lateral process of
the talus. This forms the lateral border of a fibro-osseous
tunnel, the medial border being the medial talar tubercle.
Through this tunnel runs the flexor hallucis longus. Most
cases of an os trigonum are asymptomatic in the general
population, and this is also true in dancers. However, in
dancers this condition often is operated on unnecessarily.
For this reason, a diagnostic injection of local anesthesia
is mandatory before any surgical intervention. If there is
no subsequent pain relief, one must seek an alternative
diagnosis such as:
1. Flexor hallucis tendinitis (FHL) tendinitis,
2. Peroneal tendinitis,
3. Hairline or stress fracture of the posterior process,
4. Localized coalition, or Figure 21-13 Flexor hallucis longus tendinosis.
5. Osteoid osteoma.
Treatment of an os trigonum generally is nonsurgical.
Once a diagnosis has been confirmed by local anesthetic
adjunct. Local steroid injections should be avoided
injection, the next step is rest and activity modification.
whenever possible. When the condition is recurrent
Local steroid can give dramatic relief of symptoms
or disabling surgical, tenolysis is warranted. Three
that often is long lasting or permanent. When surgery
areas of FHL tendinitis typically are found. The most
is required, either a posteromedial or posterolateral
common location is behind the medial malleolus. It
approach can be used. In cases in which it is suspected
also may be found at the knot of Henry, or at the base
that there is an associated FHL tendinitis, a postero-
of the first metatarsal where the tendon passes
medial approach is preferred so that tenolysis can be
beneath the sesamoid bones.
performed safely.
Posterior impingement also may occur following a
lateral ligament sprain. With lateral ligamentous lax-
ACHILLES TENDON
ity, the talus slips forward and the posterior lip of
the tibia impinges on the os calcis. Treating the lateral
ligament instability usually addresses this form of As the largest tendon in the body, the Achilles tendon
impingement. incurs forces up to six times body weight during run-
A pseudomeniscus, with or without an os trigonum, ning and jumping.1 Therefore the tendon is commonly
causes another, less common, form of posterior impin- injured in dancers either from repetitive overload or
gement. This embryologic remnant, similar to a plica, excess stress applied by poor technique. Although a
can cause symptoms of locking and pain following a tear common site of injury in dancers, the tendon is rarely
in its substance. ruptured in this group of athletes.
Flexor hallucis longus tendinitis Peritendinitis of the achilles tendon

This entity has become known as ‘‘dancer’s tendinitis.’’19 The Achilles tendon has no real synovial sheath and is
As the tendon passes between the fibro-osseous tun- surrounded by a peritendon, which can become inflamed
nel at the back of the talus, it runs deep to the susten- from overuse or from the tight ribbons of ballet shoes.
taculum tali. Within this pulley system it can become The peritendinitis is classically seen as a diffuse swelling
inflamed and cause irritation and swelling. When the along the Achilles tendon. When the tendon itself is
tendon has a partial tear or becomes swollen at a inflamed, it presents as a discrete swelling along the
particular area, it may cause triggering (Fig. 21-13). tendon. Treatment of peritendinitis requires rest. A cam
This condition is known as hallux saltans.12 When walker with a heel-raise insert worn for 23 hours/day
the tendon becomes completely stuck down within should be worn for at least 2 weeks. This can break the
the pulley system, a pseudohallux rigidus can be seen. cycle of inflammation and prevent the next step in the
Treatment of this condition requires a compliant continuum of pathology—inflammation of the tendon
patient to rest. Anti-inflammatories are a useful itself.
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Tendinitis of the achilles tendon prominence at the posterosuperior aspect of the

Tendinitis is caused by microtears of the collagen fibers os calcis can cause irritation of the tendon. This
on the surface or in the substance of the tendon. The may necessitate resection of the prominence
most common form of tendinitis occurs at the isthmus (Fig. 21-15).
of the tendon and involves a localized swelling of the 2. ‘‘Rolling in’’ or pronation of the foot.
pseudosheath. This may be felt clinically as crepitus 3. ‘‘Ribbon burn’’ from tight toe ribbon at the back
when the tendon is stretched and relaxed—the so-called of the leg.
painful arc sign. Chronic tendinitis can be felt as multi- 4. Congenitally thin tendon is predisposed to over-
ple nodules on the surface of the tendon. More severe load injury.
strains result in a classic fusiform swelling of the tendon. 5. Tight heel cord.
This is slow to heal and carries a guarded prognosis.
Treatment requires rest initially, usually in a cam
Rupture of the achilles tendon
walker with a heel-raise insert for up to 6 weeks. This Achilles tendon ruptures are rare in female athletes
should be worn continuously, including bed, for the and more common in male dancers older than 30 years.
first 2 to 3 weeks. Failure to comply with strict immobi- Typically a tear presents as a sharp pain of sudden onset
lization initially can result in prolonged symptomatology and an inability to walk on the toes. A Thompson test
and rupture of the tendon. Treatment can be supplemen- is the best clinical diagnostic test. Feeling for a defect
ted with anti-inflammatory medication. Rehabilitation along the tendon usually is diagnostic; however, an intact
consists of stretching exercises and a gradual strengthen- peritendon filled with hematoma may mimic an intact ten-
ing program. In more chronic cases, use of an overnight don. Ultrasound can confirm the diagnosis with a high
splint to assist with a prolonged stretch in a dorsiflexed degree of sensitivity and specificity. Treatment is depen-
position can be helpful. Orthotic prescription may be dent on the requirements of the patient. Cast immobi-
considered to help correct any structural imbalances in lization is associated with up to 30% rate of rerupture
the foot. A ‘‘stretch box’’ is a useful tool to prevent injury and will allow up to 80% normal strength and function.
that is used by many ballet schools. This allows dorsi- Operative intervention has the advantage of restoring
flexion of the ankle with stretching of the Achilles tendon the physiologic length and thus optimizing functional
before and between performances. However, dancers outcome. This requires up to a full year of treatment and
must exercise caution to avoid stretching the Achilles rehabilitation before the dancer can return to preinjury
tendon too aggressively, causing more tears and thereby levels of dance. Newer techniques of limited open incisions
worsening the condition. with percutaneous suturing facilitate early motion and
Certain factors can predispose to tendinitis in dancers: reduce the risk of associated skin problems.20 Correct
1. Cavus foot with associated Haglund’s disease tensioning of the repair is critical to outcome regardless
(Fig. 21-14), with tendinitis of the Achilles overly- of the technique used.
ing the retrocalcaneal bursa. Cavus feet are common
in this population, because they afford the dancer a Pseudotumor of the calf
distinct anatomic advantage. For this reason, any An accessory soleus muscle can present as a slowly
enlarging mass on the medial side of the calf. It generally
is painless, usually presenting as a feeling of tightness.
Surgical division of the muscle sheath will generally
relieve the symptoms.
HEEL PAIN
1. Heel spurs syndrome: The spur usually is not

the cause of heel pain, despite often-impressive
radiographic evidence. The plantar fascia is not
intimately attached to the spur, giving rise to the
flexor digitorum brevis. A silicone heel can give
symptomatic relief in a dancer who has point
tenderness in this area.
2. Plantar fasciitis: Pain on the medial aspect of the
fascia origin is the most common presentation.
Figure 21-14 Cavus foot with Haglund’s deformity. Stretching of the fascia before rehearsing or
480
...........
Leg pain
Figure 21-15 Preoperative (A) and intraoperative (B) radio-graphs of Haglund’s deformity.
performing can reduce the incidence of this injury. in the distal one third of the tibia. It can be differen-
Also, using a firm rubber ball for rolling into the tiated from stress fracture, which has localized point ten-
plantar fascia while weight bearing helps to loosen derness and usually is in the middiaphysis of the tibia
the fascia and make it more pliable. and distal one third of the fibula.
3. Plantar calcaneal bursitis: Found beneath the calca- Typically, MTSS occurs at the beginning of the
neus, this condition usually can be diagnosed clini- season after a prolonged period of inactivity. Stress
cally; however, ultrasound can confirm the diagnosis. fractures typically are from repetitive trauma and occur
4. Baxter’s nerve neurapraxia: The first branch of the usually in mid to late dance season. Posterior MTSS is
lateral plantar nerve or nerve to abductor digiti most common in dancers and arises at the origin of
minimi may be trapped under the deep fascia of the flexor digitorum longus (FDL), and not from the
the abductor hallucis.21 This is exacerbated when tibialis posterior, which arises from the interosseous
the dancer ‘‘rolls in’’ or pronates. Although the membrane. Anterior MTSS, not as common in dancers,
cause is a neurapraxia of the lateral branch of represents a periostitis at the origin of the tibialis ante-
the plantar nerve, the condition is painful on the rior muscle. Soleus syndrome, pain at the posteromedial
medial aspect of the heel, adjacent to the medial aspect of the medial malleolus, is caused by an abnormal
calcaneal tuberosity. A local anesthetic directed slip of soleus muscle. Treatment is a decrease in activity,
into the area may make the diagnosis. Surgical cross training, and isometric exercises in addition to
resection of the fascia yields excellent outcomes. well-cushioned shoes. Rarely, a fasciotomy of the soleus
insertion may be required.
LEG PAIN Stress fractures

Prolonged biomechanical imbalances and increased
The three primary conditions in dancers that predispose repetitive loads beyond the body’s reparative capacity
to leg pain include shin splints, stress fracture, and typify the causes of stress fractures. Thus these injuries
compartment syndrome. generally occur at the end of the dancer’s season, in con-
tradistinction to MTSS, which occurs at the beginning.
Shin splints (medial tibial stress syndrome) In the initial phases radiographic evidence may be slim,
‘‘Shin splints’’ is a generic term often used to describe and the best method of confirming a clinical suspicion
both traction periostitis and stress fractures. It has is a bone scan or MRI. Delayed subtle periosteal reac-
gained credence in the general population to describe tion occasionally can be seen (Fig. 21-16).
generalized leg pain. A more useful nomenclature is In chronic stress fractures, conventional radiographs
medial tibial stress syndrome (MTSS). For the purposes may reveal the ‘‘dreaded black line’’ seen on the anterior
of this discussion, MTSS describes a traction periostitis aspect of the tibia. This represents granulation tissue in a
alone. This condition is associated with a diffuse antero- slowly healing fracture. The line is an indicator that the
medial or posteromedial tibial pain. Typically the pain is fracture will be slow to heal, requiring at least 6 to
481
...........
a high tarsal tunnel syndrome should be made before

embarking on a fasciotomy in a dancer.
SUMMARY
Classical ballet offers a graceful and beautiful spectacle.

This beauty comes at great physical, psychological, and
economic cost to the ballet dancer.22 It is estimated that
up to 95% of dancers employed for greater than 1 year
will suffer a significant injury. Most of these physical
injuries occur to the foot and ankle in female ballet dan-
cers.23 Many of these injuries are as a result of dancing
on the point of the toe. This form of dancing was first
performed by Genevieve Gosselin in 1818 at the Paris
Opera house. The illusion of weightlessness and the
grace implied in en pointe dancing was further en-
hanced by the great dancers Taglioni and the immortal
Istomina. Since their time, the beauty, romance, and
grace of en pointe have been enjoyed by dancers all over
the world. Unfortunately, the ‘‘cruel little slipper’’ that
Figure 21-16 Tibial stress fracture.
is the en pointe shoe, as well as the physical demands
of the dance itself, have left many dancers with signifi-
8 months. In a competitive dancer this is an extremely
cant injuries and permanent deformities.
long period. A drilling procedure may be used to accel-
It must be emphasized that, when the orthopaedist
erate healing and can be performed using a small drill
examines a ballet dancer, the entire kinetic chain
percutaneously with the aid of a FluoroScan, if available.
requires close inspection. Isolated injuries to the foot
The drill is used to penetrate the anterior cortex and
and ankle may precipitate additional injuries farther up
stimulate neovascularization and callus formation.
the kinetic chain as a compensatory response to the
Return to activity is titrated against radiographic healing
injury or inadequate and improper rehabilitation.24
of the stress fracture line. Since the introduction of
Apart from the physical examination, a careful history
Balanchine method of dance, which emphasizes fluid
and biochemical profile should be investigated in those
motion, the number of stress fractures has reduced. This
dancers showing any signs of the aforementioned dan-
is in contrast to the rapid deceleration motion seen in
cer’s triad: anorexia, amenorrhea, and osteoporosis.25
the Bravura technique.
In addition to the biomechanical examination and
Compartment syndrome biochemical evaluation, the orthopaedist should be cog-
nizant of the psychosocial aspects of a dancer’s makeup.
When the pressure within an enclosed fascial com-
Dancers, in general, regard injury and pain as a way
partment exceeds the pressure required to perfuse the
of life and are reluctant to present to health care profes-
muscle with blood, the muscles and enclosed structures
sionals for fear of long-term immobilization and even-
may become compromised. This can lead to pain initi-
tual unemployment.22,26 As an advocate for the dancer
ally and may reach the point of muscle ischemia in more
as an athlete, the clinician should be aware of these
severe cases. In dance, the blood volume to the exercis-
concerns and strive to provide an accurate diagnosis
ing muscle can increase up to 20%, thereby exceeding
and expeditious treatment strategy.
the physiologic pressure within the muscle compart-
ments. Most cases of exertional compartment syndrome
involve the anterior compartment or the deep posterior
compartment. Normal resting compartment pressures
REFERENCES
range from 0 to 8 mm Hg. During exercise this can
increase to 50 mm Hg. Following exercise, this pressure 1. Warren M, et al: Scoliosis and fractures in young ballet dancers:
should fall to 15 mm Hg within 15 minutes. Treatment relationship to delayed menarchal age and amenorrhea, N Engl
of exertional compartment syndrome usually is conser- J Med 314:1338, 1986.
2. Hamilton WG: Surgical anatomy of the foot and ankle, Ciba Clin
vative, with anti-inflammatory medication and shoe Symp 37(3):1, 1985.
modification, as well as activity modification. Rarely, a 3. Hamilton WG: Physical prerequisites for ballet dancers, J Muscu-
fasciotomy is required. Careful attention to ruling out loskel Med 13:61, 1986.
482
...........
References
4. Hamilton WG: Ballet. In Reider B, editor: The school-age athlete, 16. Kennedy JG, Brunner JB, Bohne WH, et al: Clinical importance of
Philadelphia, 1991, WB Saunders. the lateral branch of the deep peroneal nerve, Clin Orthop Relat
5. Hamilton WG, et al: A profile of the musculoskeletal characteris- Res 459(Jun):222-228, 2007.
tics of elite professional ballet dancers, Am J Sports Med 20:267, 17. Kleiger B: Anterior tibiotalar impingement syndromes in dancers,
1992. Foot Ankle 3:69, 1982.
6. Viladot A: Patologia del Antepie, Barcelona, 1957, Ediciones 18. Hamilton WG: Stenosing tenosynovitis of the flexor hallucis
Toray. longus tendon and posterior impingement upon the os trigonum
7. Einarsdottir H, Troell S, Wykman A: Hallux valgus in ballet dan- in ballet dancers, Foot Ankle 3:74, 1982.
cers: a myth? Foot Ankle Int 16:92, 1995. 19. Hamilton WG: ‘‘Dancer’s tendinitis’’ of the FHL tendon Read
8. Mann RA, Clanton TO: Hallux rigidus: treatment by cheilectomy, before the 2nd annual meeting of the American Orthopedic Soci-
J Bone Joint Surg Am 70:400, 1988. ety of Sports Medicine, Durango, Colo, 1976, July 11-14.
9. Hamilton WG, O’Malley MJ, Thompson FM: Capsular interposition 20. Assal M, et al: Limited open repair of Achilles tendon ruptures:
arthroplasty for severe hallux rigidus, Foot Ankle Int 18:68, 1997. a technique with a new instrument and findings of a prospective
10. Thompson FM, Hamilton WG: Problems of the second metatar- multicenter study, J Bone Joint Surg Am 84:161, 2002.
sophalangeal joint, Orthopedics 10:83, 1987. 21. Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical
11. O’Malley MJ, Hamilton WG, Munyak J: Stress fractures at the release of the first branch of the lateral plantar nerve, Clin Orthop
base of the second metatarsal in ballet dancers, Foot Ankle Int 279:229, 1992.
17:89, 1996. 22. Kelman BB: Occupational hazards in female ballet dancers. Advocate
12. Hamilton WG: Foot and ankle injuries in dancers, Clin Sports Med for a forgotten population, AAOHN J 48:430, 2000.
7:143, 1988. 23. Nilsson C, et al: The injury panorama in a Swedish professional
13. Hamilton WG: Sprained ankles in ballet dancers, Foot Ankle 3:99, ballet company, Knee Surg Sports Traumatol Arthrosc 9:242, 2001.
1982. 24. Macintyre J, Joy E: Foot and ankle injuries in dance, Clin Sports
14. Hamilton WG, Thompson FM, Snow SW: The Brostrom/Gould Med 19:351, 2000.
repair for lateral ankle instability, Foot Ankle 14:1, 1993. (Pub- 25. Warren MP, et al: Osteopenia in exercise-associated amenorrhea
lished erratum appears in Foot Ankle 14:180, 1993.) using ballet dancers as a model: a longitudinal study, J Clin Endo-
15. Lynch SA, Renstrom PA: Treatment of acute lateral ankle liga- crinol Metab 87:3162, 2002.
ment rupture in the athlete. Conservative versus surgical treat- 26. Turner BS, Wainwright SP: Corps do ballet: the case of the
ment, Sports Med 27:61, 1999. injured ballet dancer, Social Health Illn 25:269, 2002.
483
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.........................................C H A P T E R 2 2
An international perspective on
the foot and ankle in sports
A. Personal perspective on foot and
ankle sports conditions
S. Giannini and F. Vannini
......................
CHAPTER CONTENTS
A. Personal perspective on foot and E. Foot and ankle injuries caused by traditional Japanese
ankle sports conditions 485 martial arts 507
Ankle instability 486 Judo 507
Osteochondral lesions of the talar dome 487 Sumo 508
Achilles tendon lesions 488 Kendo 509
Plantar fasciitis 489
F. Foot and ankle problems caused by some traditional
Lisfranc sprains 490 Chinese habits and sports 511
References 491
G. Foot and ankle sports injuries in Korea 514
Further reading 492
Introduction 514
Ssireum (Korean traditional wrestling) 514
B. Treatment of Achilles tendon ruptures 492
Taekwon-do (Korean martial arts) 515
Introduction 492
Basketball, soccer, rugby, and baseball 516
Diagnostics 492
Accessory navicular syndrome 516
Treatment 493
Rehabilitation 497 H. Australian foot and ankle conditions in sport 516
Conclusion 497 Foot/ankle injuries in surf lifesaving 517
References 498 References 519
Further reading 519
C. Foot and ankle injuries in United Arab Emirates sports 498
I. Soccer: hallux osteochondral lesion and rupture of the
Achilles tendon 519
D. Nerve injuries complicating inversion ankle sprains 502
Hallux osteochondral lesion in beach soccer players 520
Anatomy 502
Neglected rupture of the Achilles tendon 521
Clinical picture 503
References 522
Treatment 503
References 506 J. Footballer’s (soccer) ankle in Venezuela 522
Further reading 507 Clinical evaluation 523
CHAPTER 22 An international perspective on the foot and ankle in sports
Additional studies 524 Biology 527

Treatment 524 Principles of tendinopathy management 529
Complications 526 Surgical management 530
References 526 Discussion 532
Conclusion 532
K. The biologic perspective of sports disorders affecting
foot and ankle 527 References 532
Introduction 527
ANKLE INSTABILITY Because of these considerations, our choice technique

is a modified Brostrom with a reinforced flap when the
local tissues are strong enough. Otherwise an ‘‘anatomic
The lateral ligamentous complex of the ankle may be the
reconstruction’’ is performed with a tendon graft using
most commonly damaged structure in sport injuries.1,2
the plantaris. When no plantaris is available, a tibialis pos-
Garrik3 reported a frequency of 45% in basketball practice,
terior hemisection harvested from a cadaver is used.
31% in soccer, and 25% in volleyball.
Primary repair of the ligaments was previously recom- Surgical technique 1
mended; nonoperative treatment also has been recently The anatomic reconstruction has been described previ-
recommended.2,4 However, despite adequate primary ously by Brostrom4 and consists of the direct suture
functional treatment, some patients develop chronic insta- of the stumps of residual tissue. In our experience, to
bility. In 20% of the cases, ligamentous reconstruction reinforce the reconstructed ligaments a periosteal flap
is required.5 Indications for ligament reconstruction are should be harvested from the anterolateral aspect of the
mechanical and functional instability and failure of fibula and turned down and sutured as talofibular liga-
rehabilitative treatment. The goal of surgical treatment ment or split in two and used also to reinforce the calca-
is to improve stability and proprioceptive sensation neofibular ligament (Fig. 22A-1).
maintaining complete range of motion (ROM).
Ankle instability surgery has been divided into an ana- Surgical technique 2
tomic repair consisting of imbrications of the local tissue When the residual tissues are not strong enough to
of the lateral ligamentous complex and an ankle-ligament permit direct suture or after failure, we perform a recon-
reconstruction involving tendon grafts. A nonanatomic struction of the talofibular and calcaneofibular ligaments
tenodesis results in stiffness of the operated ankle, prolong- using the plantaris, if present, or a cadaveric tibialis pos-
ing recovery and decreasing sport6 because of the incorrect terior graft. The tendon is fixed through a transosseous
orientation of the reconstructed ligaments. tunnel or with an anchor on the neck of the talus.
Figure 22A-1 To reinforce the

reconstructed ligaments, a periosteal flap should
be harvested from the anterolateral aspect of the
fibula and turned down and sutured as talofibular
ligament or split in two and used also to reinforce
the calcaneofibular ligament.
486
...........
Osteochondral lesions of the talar dome
A tunnel is created through the anterior aspect of the sprains.10,11 Procedures for the treatment of osteochon-
lateral malleolus where the talofibular is inserted and dral lesions of the talus including debridement of the
the tendon is passed in and sutured to the periosteum. joint, shaving of fibrillated cartilage, and resection or
In case of an associated calcaneofibular lesion, the perforation of subchondral bone in the last decade have
tendon will be passed through the apex of the lateral been performed arthroscopically with low morbidity.
malleolus and be sutured on the lateral wall of the These surgeries are not effective in lesions larger than
calcaneus (Fig. 22A-2). We pay particular attention to 1.5 cm2 and have not been histologically effective in
reconstruct the ligament with a proper length, direction, restoring the hyaline cartilage.12–20
and tightness similar to those of the healthy anatomic Autologous chondrocyte transplantation (ACT) has
complex to obtain an isometry of the new ligaments proved to be capable of restoring the articular hyaline
permitting a physiologic ROM and avoiding stiffness.7 cartilage surface, including defects larger than 2 cm2
In a 1983 study, Giannini et al.8 concluded that 67% of (Figs. 22A-3, 22A-4, and 22A-5).17 In the past, this prac-
ankle sprains in sports activity were in athletes with cavus tice required a medial or lateral malleolar osteotomy, and,
foot. Because of this observation, in cases with a cavus although there were good clinical and histologic results,
foot associated with a varus of the calcaneus, evaluated as the technique was quite invasive and technically demand-
reducible according to the Coleman test,9 a mini-invasive ing.17 Recently, advancement in tissue engineering permit-
dorsiflexion metatarsal osteotomy (see Fig. 22A-2) asso- ted the development of absorbable synthetic scaffolds,
ciated with the ligamentous reconstruction is indicated. permitting a completely arthroscopic technique through
This procedure will rebalance the foot, helping to prevent the traditional anteromedial and anterolateral approaches.
further sprains and improving function. Because of this improvement, it appears to be reasonable,
mostly in the young athletes, to extend the indications of
OSTEOCHONDRAL LESIONS OF ACT even in smaller lesions traditionally treated with
THE TALAR DOME microfractures.
Surgical technique
Osteochondral lesions of the talar dome are very com- The first step requires ankle arthroscopy with cartilage
mon in sports activity as a consequence of ankle harvesting for cell culture, performed directly from the
Figure 22A-2 (A) A tunnel is performed through the anterior aspect of the lateral malleolus where the
talofibular is inserted. The tendon is passed and sutured to the periosteum. In case of an associated
calcaneofibular lesion, the tendon will be passed through the apex of the lateral malleolus and be sutured on the
lateral wall of the calcaneus. (B) A bone procedure such as a dorsiflexion metatarsal osteotomy may be
performed to correct the associated cavus deformity of the foot.
487
...........
Figure 22A-3 Immunohistochemical staining for collagen Figure 22A-5 Alcian blue staining for proteoglycans
type II. detection.
The Hyalograft-C scaffold, made of hyaluronic acid,

is sized and prepared in the right shape and placed on
the positioner (Fig. 22A-6).
Through an appropriate cannula, the self-adhesive
scaffold is positioned to cover the lesion (Fig. 22A-7).
Immediate daily continuous passive motion (CPM) for
6 to 8 hours begins after surgery and continues for a
period of 6 weeks. Touchdown (20%-30%) crutch walk-
ing is permitted for 6 weeks. After 6 weeks, progressive
increased weight bearing and active ROM are permitted.
Full weight bearing will be allowed at 8 weeks. Return
to cutting, turning, or jumping sport is permitted only
after 1 year.
ACHILLES TENDON LESIONS
Achilles tendon lesions in soccer are 31% to 34% of all

traumas, according to Lanzetta et al.21 The Achilles tendon
rupture usually is caused in soccer by direct or indirect
trauma during jumping, cutting, or turning.22 Predis-
Figure 22A-4 Immunohistochemical staining for
posing factors in the soccer player are due to an overuse
proteoglycans.
of the calcaneal-Achilles-plantar system, possibility of
preexisting tendinopathy, or corticosteroid injections.
affected joint using the osteochondral fragment. After The clinical presentation is variable. Pain may be mild
30 days, a second step ankle arthroscopy through tradi- for the preexisting degeneration of the tendon because
tional anteromedial and anterolateral accesses is per- functionality may be performed by the retromalleolar pro-
formed. The focus of the lesion is carefully shaved, and nator and supinator muscles with different percentages,
care is taken to reach the healthy cartilage. making the clinical evidence less clear. Rerupture occurs
488
...........
Plantar fasciitis
tissue, and disturbance of sensation,23,24 our choice is sur-

gical repair with a mini-invasive technique. The advantages
of mini-invasive surgery are less surgical trauma, better
quality of reparative scar tissue, avoidance of damage to
the local vascularity, faster recovery, and return to sport
activity. Indications for the mini-invasive treatment are
lesions from 6 to 8 cm from the calcaneal insertion
and no more than 6 days after the rupture.
Surgical technique
The Achilles tendon repair system (Fig. 22A-8) permits
a suture of the tendon through a 1.5-cm incision. Both
stumps of the ruptured tendon are identified. The
instrument is introduced in the closed position, under
the paratenon, in a proximal direction. When the ten-
don lies between the two branches of the instrument,
the sutures are passed, and the end of each is held with
a small clamp to keep the sutures separate from each
other. When the instrument is withdrawn, the sutures
slide to a peritendinous position. Afterward, the same
sequence is performed on the distal stump, and the
tendon reduction is performed under visual control.
Postoperative treatment consists of a boot worn for
Figure 22A-6 The Hyalograft-C (FIDIA s.r.l. Abano PD, Italy) 8 weeks. Mobilization is permitted only in plantarflexion
scaffold, made of hyaluronic acid, is sized and prepared in the from the first to the sixth week, after which complete
right shape and placed on the positioner. ROM is achieved.
Partial weight bearing (15 kg) is permitted with the
boot in plantarflexion for 3 weeks. Partial weight bear-
ing (15 kg) is permitted with the boot at 90 degrees
for 3 weeks. Total weight bearing is permitted with boot
ROM from 10 degrees plantarflexion to 10 degrees
dorsiflexion for 2 weeks.
PLANTAR FASCIITIS
Plantar fasciitis is common in high-performance athletes,

mostly runners and basketball and volleyball players
because of the high stress concentrated at the fascia
insertion in running and jumping.26
Commonly cited risk factors for plantar fasciitis are
the flat or cavus foot, a tight Achilles tendon, the type
of training shoes worn, and errors in the training
routine.27
Anti-inflammatory medications may be helpful in
Figure 22A-7 Arthroscopic view showing the self-adhesive providing symptomatic relief. Some improvement is
scaffold positioned to cover the lesion.
possible with the use of a shoe insert providing 1 cm
height at the hindfoot and daily stretching exercises of
the Achilles tendon-plantar fascia complex.
in 10% to 30% of high-performance active patients with A safe and effective nonoperative treatment that we
nonoperative treatment;23-25 therefore surgery generally feel should be considered before surgery is the applica-
is recommended. Because formal open procedures have tion of low-energy shock waves at the fascia insertion
been associated with a high rate of complications related (three applications of 2100 impulses of low-energy
to poor wound healing, deep infection, adhesion of scar shock waves), usually providing good results.28 If the
489
...........
Figure 22A-8 The Achilles tendon repair system permitting a suture of the tendon through a 1.5-cm incision.
fasciitis does not respond to the nonoperative treatment,

in a minimum of 4 months for a professional athlete,
surgical treatment should be attempted.
Because the open technique has a high failure rate, with
15.5% of the patients reporting dissatisfaction,29 we prefer
the use of a percutaneous fasciotomy. It is important to
note that this technique does require surgical experience
and may be associated with complications.
Surgical technique
A 14-mm K-wire is inserted manually in the medial aspect
of the foot to identify the level of the insertion of the fas-
cia. The fasciotomy is performed with a tenotomy blade
while the foot is maintained in dorsiflexion and the fascia
is probed externally with a finger (Fig. 22A-9).
This method reduces the formation of scars and pro-
Figure 22A-9 The fasciotomy is performed with a tenotomy,
vides for a fast recovery at a low cost. Surgery should be
maintaining the foot in dorsal hyperflexion and probing the
followed by early ROM, stretching exercises, and ankle
fascia with a finger.
dorsiflexion. An orthosis that maintains the foot and
ankle in 10 degrees of ankle dorsiflexion should be worn
during the night for the first 3 weeks. after an indirect trauma when the foot is plantarflexed
and slightly rotated. This is a frequent condition in
soccer players.
LISFRANC SPRAINS Lisfranc sprains represent a spectrum of injuries to
the Lisfranc ligament complex, from partial sprains with
Injuries to the Lisfranc ligament complex in the general no displacement to complete tears with frank diastasis31
population are uncommon and typically occur as a result (Fig. 22A-10). Although the nondisplaced injuries often
of high-velocity and indirect trauma that causes an obvi- heal uneventfully, patients with displacement should
ous displacement and disruption of the tarsometatarsal undergo a closed reduction and internal fixation with
anatomy.30 Low-velocity Lisfranc sprains also can occur cannulated screws.
490
...........
References
Postoperatively, a nonweight-bearing boot is main-

tained for 4 weeks, followed by 4 weeks of boot with
progressive weight bearing. Screw removal occurs from
14 to 24 weeks.
Return to sport activity should be permitted after a
functional rehabilitation program, usually after 4 months.
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20. Kumai T, et al: Arthroscopic drilling for the treatment of
Surgical technique osteochondral lesions of the talus, J Bone Joint Surg 81A:1229, 1999.
21. Lanzetta A, Meani E, Tinti G: Le lesioni dell’Achilleo nella pratica
A percutaneously placed large bone clamp is used to
sportiva: considerazioni etiopatogenetiche e indicazioni
assist the reduction. Under C-arm control, percutane- terapeutiche, Ital J Sport Traumatol 3:113, 1989.
ous guidewires are inserted, followed by placement of 22. Hattrup SJ, Johnson KA: A review of ruptures of the Achilles
cannulated screws (Fig. 22A-11). tendon, Foot Ankle 6:34, 1985.
491
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23. Carden DG, et al: Rupture of the calcaneal tendon. The early and 29. Clanton TO, DeLee JC: Osteochondritis dissecans: history,
late management, J Bone Joint Surg Br 69:416, 1987. pathophysiology and current treatment concepts, Clin Orthop
24. Cetti R, et al: Operative versus nonoperative treatment of Achilles 167:51, 1982.
tendon rupture. A prospective randomized study and review of the 30. Mantas JP, Burks RT: Lisfranc injuries in the athlete, Clin Sports
literature, Am J Sports Med 21:791, 1993. Med 13:719, 1994.
25. Roberts C, et al: Dynamised cast management of Achilles tendon 31. Nunley JA, Vertullo CJ: Classification, investigation, and
ruptures, Injury 32:423, 2001. management of midfoot sprains: Lisfranc injuries in the athlete,
26. Snider MP, Clancy WG, Mc Beath AA: Plantar fascia release Am J Sports Med 30:871, 2002.
for chronic plantar fasciitis in runners, Am J Sports Med 11:215,
1983.
27. Warren BL: Plantar fasciitis in runners. Treatment and prevention, FURTHER READING
Sports Med 10:338, 1990.
28. Rompe JD, et al: Shock wave application for chronic plantar
fasciitis in running athletes. A prospective, randomized, Davies MS, Weiss GA, Saxaby TS: Plantar fasciitis: how successful is
placebo-controlled trial, Am J Sports Med 31:268, 2003. surgical intervention? Foot Ankle Int 20(12):803-807, 1999.
B. Treatment of Achilles tendon ruptures

Hajo Thermann and Christoph Becher
INTRODUCTION transition is 10% to 15% and is caused by degenerative

changes. Ruptures near the calcaneal insertion are rare
and mostly are found in hyperpronators with a heel spur
The rapidly growing trend for participation in recrea-
(Haglund’s heel). In contrast to impulsive injury mecha-
tional and competitive sport is accompanied by an
nism in tendinous ruptures, bony avulsions usually are
increase of overuse syndromes. In the foot and ankle,
caused by continuously increasing tension and strength
the incidence of Achilles tendon rupture and subsequent
or direct impact.9 The rupture mechanism usually is a
problems has increased significantly in recent decades.1-3
consequence of an indirect loading and traction mecha-
In Germany the incidence of acute Achilles tendon rup-
nism, such as a push-off with the foot in plantarflexion
ture is estimated to be 15,000 cases/year.3 The rupture
and simultaneous knee extension or a sudden, unex-
usually does not occur at the time of top-level sporting
pected dorsiflexion of the ankle with powerful contrac-
activities. Most studies show a peak between the ages of
tion of the calf muscles.9 Direct impact, such as a kick
30 and 45 years.4-9 The patient collective has a remark-
or hit on the tensed tendon, accounts for only 1% to
ably large portion of leisure-time athletes and patients
10% of ruptures.11,12 The degenerative and the mechani-
with sedentary occupations.10 The portion of injuries in
cal theory of etiopathogenesis of Achilles tendon rupture
track-and-fields athletics is cited as only 10%. These are
face each other. Aseptic inflammations (tendinitis, para-
mostly young patients who sustained a tendon rupture
tendinosis) and reduced vascular supply lead to degener-
as a result of an incompletely treated achillodynia or an
ative changes with cell loss and disorders of
enormous training workload.9 In the future, an increas-
mucopolysaccharide content, even to fatty, mucoid, or
ing number of older patients (older than 50 years) will
calcifying degeneration.13 Repetitive or single stresses
sustain Achilles tendon rupture as strenuous sports activ-
result in minor microtrauma. Low temperature and
ities become more and more common in this age group.
fatigue of athletes (lactic acid) lead to decreased maximal
Of all the tendons of the human body, the Achilles ten-
load resistance.9 If regenerative healing processes cannot
don seems to be the most susceptible to degenerative
keep pace, the sum of microtrauma leads to rupture.
changes. The male-to-female ratio of persons with Achil-
les tendon rupture ranges between 5:1 and 10:1 in most
studies, and on average the men are older.9,11 According
to the literature and our experience, Achilles tendon rup-
DIAGNOSTICS
tures occur most often (in 80% to 90% of cases) 2 to 6 cm
proximal to the calcaneal insertion.9 The incidence of The typical characteristic of a tendon rupture is a hit or
proximal ruptures distal to the musculotendineal whiplash-like sudden pain. Ruptures happening in
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Treatment
contact sports often are perceived as a hit by an ax or a

bar. A crack or a popping sound often is heard. A palpable
gap and a positive Thompson test are the first clinical
signs of an acute Achilles tendon rupture. Because of
hematoma, these signs are not always visible but usually
are palpable. The strength of plantarflexion typically is
decreased or completely lost, resulting in an inability of
heel rise and weak rolling of the foot with stalking land-
ing of the leg and an externally rotated foot. A remaining
plantarflexion does not indicate an intact tendon because
extrinsic flexors such as the plantaris muscle also are able
to produce this movement.
Although most Achilles tendon ruptures can be diag-
nosed clinically, evaluation by ultrasonography and mag-
netic resonance imaging (MRI) enables a definitive
diagnosis and is decisive for the choice of treatment Figure 22B-2 Ultrasonography of an acute Achilles tendon
(Figs. 22B-1 and 22B-2). Ultrasonographic appearance rupture. Interrupted continuity and demarked tendon stumps
of acute Achilles tendon rupture shows broad variations. (arrows).
The most common signs are interruption of continuity
and demarked tendon stumps. Hypoechogenic accumu- validity.9 The soleus muscle must be examined with sagit-
lations of liquid at the rupture site and loss of the typical tal and axial scans. Furthermore the differentiation of rup-
parallel hyperechogenic reflex patterns are depicted regu- ture area and tendon ends enables an exact determination
larly by experienced examiners. Because some ruptures of the diastase and distance to the calcaneal insertion.
do not show a visible diastase of the stumps from the
hematoma, dynamic examination in dorsiflexion and
plantarflexion is essential. Even if there is no visible gap, TREATMENT
a spreading of fine parallel echoes, corresponding to a loss
of cross-wise network of elastic fibers, reveals a rupture. Conservative treatment
Inflammatory tendinosis with edematous dissolution of
the structures must be differentiated. Disrupted or Primary conservative immobilizing treatment and post-
retracted soleus fibers, which are detected mostly in top- operative aftercare in a cast are not justified concerning
level athletes, are significant for the choice of treatment the disadvantages of muscle atrophy and loss of coordi-
and especially for the surgical technique. Although this nation and proprioception. The concept of primary
can be detected by ultrasonography, MRI shows a better functional treatment considers the ultrasound or MRI
morphology as a basis for treatment strategy. The ultra-
sonographic or MRI depiction of complete adaptation
of tendon ends in 20-degrees plantarflexion is required.
The validity of this method, compared with operative
treatment, could be proven in a series of more than 550
patients using a high-shaft shoe, comparable to a modified
boxer boot (Variostabil, Orthotech, Germany)*14
(Fig. 22B-3). Indication for primary functional treatment
independent of the ultrasonographic or MRI findings
should be preferred in the elder nonactive patient or in
patients with altered operative risk or reduced capacity
for tissue regeneration (e.g., after organ transplantation
surgery, systemic corticosteroid treatment, diabetes).15
Operative treatment
Issues that comprise the decision for operative treatment
include the following:
Figure 22B-1 T1-weighted magnetic resonance imaging (MRI)

sagittal. Complete rupture of the Achilles tendon with diastase *Available from Orthotech GmbH, 82131 Gauting, Germany (www.
of the tendon stumps. orthotech-gmbh.de).
493
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Figure 22B-3 The Variostabil boot (Orthotech GmbH, 82131 Gauting, Germany; www.orthotech-gmbh.de).
Patients with dubious compliance for primary func-

tional treatment.
Patients who insist on or feel safer with a surgical
procedure.
Patients in whom no adaptation of the tendon
stumps was found sonographically or on MRI.
Patients with a demonstrable disruption of the
soleus muscle.
Patients such as top athletes for whom surgery is
intended to prevent medial gastrocnemius atrophy.
Patients with distal ruptures (2 cm) near the
calcaneal insertion.
It generally is possible to appose the tendon stumps
within 3 weeks of rupture. In older ruptures the tendon
ends usually are retracted and need reconstructive
modalities.
Techniques
In acute Achilles tendon ruptures, simple end-to-end or
three-bundle sutures have been the methods of choice
to date (Fig. 22B-4). In recent years in the United
States the suture technique by Krackow (Fig. 22B-5) Figure 22B-4 End-to-end suture technique according to
has become popular because it provides strong mechanical Bunnel-Mason.
stability that allows early functional rehabilitation.16,17
A biomechanical study by Watson et al.,17 however, tendon stumps adaptation for the first healing
proved the weak stability of the suture realized by the period is addressed by the percutaneous technique
different open techniques and questioned the advantages described by Buchgraber and Pässler18 (Fig. 22B-6).
of the open surgical treatment. Using only five small incisions, a 1.3-mm
The combination of the advantages of the biology of polydioxanone suture (PDS) is guided percutane-
tendon healing from the primary functional treatment ously by means of an awl. It connects the proximal
along with minimally invasive surgery to stabilize the tendon with the calcaneal insertion and crosses the
494
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Treatment
The lace technique by Segesser pays special atten-

tion to the rotation of radiating tendon bundles, as
described by Cummins. With his technique he provides
an adequate reinsertion of the medial gastrocnemius
and soleus fibers, which often are disrupted or retracted
in Achilles tendon ruptures in top-level athletes
(Fig. 22B-7).
For rehabilitation, functional aftertreatment in the Var-
iostabil boot is an essential part of an optimal outcome.
Treatment of reruptures
In the treatment of reruptures there are two options.
If an adaptation of the tendon stumps is seen in plant-
arflexion either sonographically or by MRI, a simple
percutaneous suture can be performed.
In cases with a tendon gapping, a shortening of
the gastroc-soleus-Achilles complex with adhesions is
probable. This happens in the majority of delayed cases.
In these circumstances, a small medial incision (4-5 cm)
at the former incision is made. Then the gastro-soleus
Figure 22B-5 The suture technique according to Krackow. complex is released distally (Fig. 22B-8). A normal subcu-
taneous suture is performed and serves as an ‘‘internal fixa-
tor’’ of the ruptures tendon. In addition, classic Krakow
rupture site, thereby acting as an internal fixator. sutures are applied for the tendon stumps (Fig. 22B-9).
To tighten the cord into the tendon, multiple dorsi- The aftertreatment has the same protocol with the
flexions of the foot are performed. Another advan- Variostabil boot.
tage of this technique is the remaining integrity of
the paratendon, which is important for the healing Treatment of chronic ruptures
process. To prevent the potential risk of injuring The problem of chronic rupture is retraction of the ten-
the sural nerve, an endoscopically assisted percuta- don stumps with the lack of an efficient regenerate.
neous technique with a 2.8-mm arthroscope can be Sometimes a primary reconstruction is possible, but in
used. 9 most cases reconstructive techniques are indispensable.
Figure 22B-6 The percutaneous technique described by Buchgraber and Pässler.

495
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Figure 22B-7 The lace technique by Segesser.
Figure 22B-8 Digital distal release of the gastro-soleus

complex.
Figure 22B-9 Subcutaneous suture in addition to Krackow’s
technique in the treatment of reruptures.
The decision for the correct reconstructive technique
depends on the amount of insufficient tissue. Therefore the year 2000. For reconstruction, two flaps of
evaluation by MRI is mandatory. Defects of 2 to 5 cm are- the aponeurosis of the triceps surae muscle are used.
the indication for reconstruction with a modified In the first step, the muscle is released proximal by a medial
‘‘two flaps technique,’’ first described by Thermann in incision, followed by the preparation of the two flaps
Figure 22B-10 The modified ‘‘two flaps technique.’’

496
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Conclusion
Figure 22B-11 The transfer of the flexor hallucis longus tendon or the peroneus brevis tendon. In both techniques, the distal and
proximal stumps are sewn together with the transferred tendon.
from the medial and lateral part of the aponeurosis. functional potential regarding gastrocnemius activities
Essential for the modification is the turning down was proved by electromyography, which showed compa-
and 180-degree rotation of the medial flap approxi- rable amplitudes to the uninjured side after 3 months.15
mately 1.5 cm proximal to the corresponding lateral With the fitted boot the patient is allowed to perform
part. This offset considerably facilitates the skin closure full weight bearing and to continue the previously
later. After fixing the flaps medially and laterally at the begun isometric exercises. The patient wears the boot
distal stump, suturing is performed continuously with for 6 weeks, day and night (or alternatively uses a night
a 3.0-mm PDS cord in a ‘‘tubulation technique,’’ thus splint to protect the tendon) and for the following
creating a ‘‘neotendon’’ as a consequence (Fig. 22B- 2 weeks only during the daytime. After 3 weeks the
10). The neotendon should be stretched in a manner patient is allowed to exercise on a stationary bike, but
that forces a slight plantarflexion. For wound healing, only with little application of power. In ambitious
a cleaved cast is applied, followed by rehabilitation in patients, a physiotherapeutic treatment with well-dosed
the Variostabil boot for 8 weeks according to primary strengthening exercises (isometric exercises, isokinetic
functional treatment.9,19 bicycle), proprioceptive neuromuscular facilitation
Reconstruction of larger defects requires a transfer (PNF), and coordination exercises in the boot is allowed
of the flexor hallucis longus tendon20 or the peroneus after 4 weeks. In addition, ultrasound application (1 Hz)
brevis tendon.21 In both techniques the distal and prox- and cryotherapy are performed to enhance tendon
imal stump are sewn together with the transferred ten- regeneration. From the sixth week on, leg-press training
don. Also, the neotendon should be adequately is begun in the boot. After 8 weeks, an ultrasonographic
stretched to put the foot in an equine position control evaluates the restoration of continuity and
(Fig. 22B-11). Because the peroneal tendon is not ‘‘in tendon regeneration. After an appropriate tendon
phase,’’ there are only very limited indications for this regeneration has been achieved (8 to 12 weeks MRI
procedure. Rehabilitation protocol corresponds to the or sonography control), the treatment in the boot
‘‘two flaps technique.’’ is discontinued. A small heel lift in the normal shoe is
recommended for a further 6 to 8 weeks. Jogging
is allowed after 3 months if coordination and muscle
power are appropriate.
REHABILITATION
The Variostabil boot plays a major role in rehabilitation

and regaining of functional performance. The general
CONCLUSION
concept is to prevent stress at the rupture site while hav-
ing axial loading, which promotes a safe and powerful The goal of treatment today is not only the restoration
tendon healing. of the tendon continuity but also the regaining of the
This boot has a plastic tongue to prevent dorsiflexion; former activity level at the earliest possible time. This is
the lateral shaft-stabilization reduces torsion, and the achievable by the appropriate surgical technique and also
reducible heel pad allows a gradual adjustment of depends on the adequate aftertreatment and rehabilita-
20 degrees from plantarflexion to neutral position. Its tion protocol.
497
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12. Arner O, Lindholm A: Subcutaneous rupture of the Achilles tendon;

REFERENCES a study of 92 cases, Acta Chir Scand 116(suppl 239):1, 1959.
13. Kannus P, Jozsa L: Histopathological changes preceding
spontaneous rupture of a tendon. A controlled study of 891
1. Christensen J: Rupture of Achilles’ tendon, Acta Chir Scand patients, J Bone Joint Surg Am 73:1507, 1991.
106:50, 1953. 14. Thermann H, Zwipp H, Tscherne H: [Functional treatment
2. Schönbauer HR: Diseases of the Achilles’ tendon, Wien Klin concept of acute rupture of the Achilles tendon. 2 years
Wochenschr 14(suppl 1):23, 1986. results of a prospective randomized study], Unfallchirurg 98:
3. Thermann H: Treatment of Achilles’ tendon ruptures, Foot Ankle 21, 1995.
Clin 4:773, 1999. 15. Thermann H: [Rupture of the Achilles tendon–conservative
4. Cetti R, et al: Operative versus nonoperative treatment of Achilles functional treatment], Z Orthop Ihre Grenzgeb 136:20, 1998.
tendon rupture. A prospective randomized study and review of the 16. Mandelbaum BR, Myerson MS, Forster R: Achilles tendon
literature, Am J Sports Med 21:791, 1993. ruptures. A new method of repair, early range of motion,
5. Inglis AE, Sculco TP: Surgical repair of ruptures of the tendo and functional rehabilitation, Am J Sports Med 23:
Achillis, Clin Orthop 156:160, 1981. 392, 1995.
6. Jakobs D, et al: Comparison of conservative and operative treatment 17. Watson TW, et al: The strength of Achilles tendon repair: an
of Achilles’ tendon rupture, Am J Sports Med 3:107, 1978. in vitro study of the biomechanical behavior in human
7. Lo IK, et al: Operative versus nonoperative treatment of acute cadaver tendons, Foot Ankle Int 16:191, 1995.
Achilles tendon ruptures: a quantitative review, Clin J Sport Med 18. Buchgraber A, Pässler HH: Percutaneous repair of Achilles tendon
7:207, 1997. rupture. Immobilization versus functional postoperative
8. Nistor L: Surgical and non-surgical treatment of Achilles tendon treatment, Clin Orthop 341:113, 1997.
rupture. A prospective randomized study, J Bone Joint Surg Am 19. Lindholm A: A new method of operation in subcutaneous
63:394, 1981. rupture of the Achilles tendon, Acta Chir Scand
9. Thermann H: [Treatment of Achilles tendon rupture], 117:261, 1959.
Unfallchirurg 101:299, 1998. 20. Monroe MT, et al: Plantarflexion torque following reconstruction
10. Jozsa L, et al: The role of recreational sport activity in Achilles of Achilles tendinosis or rupture with flexor hallucis longus
tendon rupture. A clinical, pathoanatomical, and sociological augmentation, Foot Ankle Int 21:324, 2000.
study of 292 cases, Am J Sports Med 17:338, 1989. 21. Trillat A, et al: [Treatment of former rupture of the
11. Riede D: Therapy and late results of subcutaneous Achilles’ Achilles tendon (transfer-plasty of the lateral peroneus brevis)],
tendon rupture, Beitr Orthop Traumatol 6:328, 1972. Lyon Chir 63:603, 1967.
C. Foot and ankle injuries in United Arab

Emirates sports
M. Kazim
The United Arab Emirates (UAE) has a desert climate

and is situated directly on the Persian Gulf. This unique
geography lends itself to a truly wide variety of sporting
activities among the residents. Water sports such as
water skiing, wakeboarding, and kite surfing are hugely
popular. Other sports such as soccer, rugby, tennis, and
squash are commonplace. In the desert, sand boarding
and motor sports command the winter months. Most
of the common injuries seen elsewhere are encountered
but with some unique scenarios.
Certain niche sports are found in the UAE. For
example, falcons are trained to hunt prey. This involves
long periods of bonding and progressive conditioning Figure 22C-1 A unique sport in the UAE is hunting prey with
of the predator bird. To accomplish this, the owner falcons. The sandals keep the foot high off the ground to
often has to run rapidly to tend to his falcon, and in prevent entry of pebbles. They are discarded when running in
the soft sand this is better accomplished barefoot. soft sand.
498
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Foot and ankle injuries in united arab emirates sports
Figure 22C-2 On the harder desert plain, the hunter seen here with the falcon (A) uses enclosed shoes (B).
Sandals typically are worn (Fig. 22C-1) to keep the serious crush injuries from hooves are surprisingly
foot high off the ground to prevent entry of pebbles uncommon in the UAE. This could possibly be from the
but are discarded when running in soft sand. Still, combination of a high standard of horsemanship and
minor stub and barb injuries are common. Because well-trained thoroughbreds that are used in the sport.
the terrain underfoot is soft, the barbs or other objects Motocross has its share of injuries because dirt
have little force for any penetration. When training the bikes are ridden in the sand at high speeds. Riders are
falcons on the harder desert plain, one wears enclosed required to wear body armor and protective footwear
shoes (Figs. 22C-2 and 22C-3) to prevent the entry (Fig. 22C-4). However, unlike hard dirt terrain that
of foreign objects. Also, ankle sprains (mostly lateral) causes a violent plantarflexion force of short duration,
tend to be relatively minor on the sand because the sand produces a more moderate force of longer dura-
surface is not firm and thus is very forgiving during tion. This leads to sprains of the anterior structures, with
inversion. relatively frequent anterior capsular tears. Conservative
Arabs have a long tradition with horses. In the UAE, care with walker-type removable braces allows rapid
horse racing (speed and marathon) and polo are two return to riding. Occasionally, more severe problems
sports in which injuries are relatively common. Most tend such as Lisfranc injuries and subluxations or dislocations
to be in the upper extremities from falls, but foot and of the talocrural joint occur. When surgical reconstruc-
ankle injuries also occur. The prolonged ‘‘heel down’’ tion is warranted, rigid internal fixation is used, possibly
position in the saddle can lead to impingement syndromes including the repair of a deltoid ligament avulsion and
of the anterior chamber of the ankle, requiring removal of concomitant syndesmosis stabilization (Fig. 22C-5).
any kissing osteophytes or soft tissues. Because these are Long-distance bike riding is now becoming popular
mostly symptomatic early in their development, arthro- in the UAE. A relatively common problem seen in these
scopic debridement is very successful, with arthrotomy cyclists is Morton’s neuroma. This happens despite
rarely being required. Minor crush injuries of the foot appropriate shoewear and possibly results from a combi-
and ankle occur as the horses collide during play, but nation of the high heat and humidity causing edema of
499
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Figure 22C-3 Another example of the falcon trainer (A) with typical shoewear (B) used for hard desert terrain (C).
the foot. Conservative care with metatarsal pads and a for management of foot and ankle injuries provide an early
wider toe box to accommodate the forefoot is very start to the recovery process, with weight bearing as soon
successful. as safely possible. Rapid progression to strengthening and
In the UAE, we emphasize rapid rehabilitation and proprioceptive feedback exercises has been beneficial to
return to sports. Fast-track programs and hydrotherapy returning the player quickly to his or her sport.
500
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Foot and ankle injuries in united arab emirates sports
Figure 22C-4 A popular winter sport is motocross. The rider wears body armor and protective footwear to minimize injury.
(A) The rider here is preparing to land on a dune following a jump. (B) The rider cuts across the soft and at times unstable
sand and is susceptible to ankle and leg trauma.
Figure 22C-5 (A) This syndesmotic injury was noted on a stress view of the ankle. (B) Two syndesmotic screws
close the tibiofibular space and suture anchors stabilize the deltoid tear.
501
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D. Nerve injuries complicating inversion

ankle sprains
E. Melamed and C. Zinman
Inversion, plantarflexion, and twisting forces put the lateral course. It emerges from underneath the biceps
ankle ligaments and bones under tension and strain that tendon near its insertion to fibula head and courses
eventually may cause them to fail, culminating in ankle around the neck of the fibula, where it divides to the
sprain and fractures. Diagnostic workup in the athlete SPN and deep peroneal nerves (DPN). The SPN travels
usually is directed to rule out fractures, assess the sever- in the lateral compartment underneath the peroneus
ity of the ankle ligaments injury, and tailor treatment longus and exits the crural fascia to become subcutane-
and rehabilitation to ensure healing of the ligaments in ous about 10 to 15 cm proximal to the tip of the lateral
the desired length and strength. The proprioceptive malleolus in most cases.2,3 There are variations, how-
mechanism and peroneal muscle strength also must be ever, in the exit mode, some of which carry special clini-
addressed to ensure safe return to sporting activities. cal relevance. The nerve can have a low exit point (5 cm
Inversion injury imposes stretch and stress also on the from the tip in 2% and 7.5 cm in 5%).4 It also may pene-
more superficial structures, the nerves and integument. trate into the anterior compartment first and then
Skin swelling and hematoma formation are caused by in- through the crural fascia. The SPN bifurcates to main
jury to the skin and its lymphatics, small venules, and capil- two branches, the intermediate dorsal cutaneous nerve,
laries (in addition to bleeding from the torn ligaments) supplying the dorsolateral aspect of the foot, and the
and is a sin qua non of ankle sprain. It usually resolves with dorsomedial cutaneous branch, which innervates the skin
time and is not a reason for concern to the treating phy- on the medial aspect of the dorsal forefoot and the hallux.
sician or coach. However, there often is less awareness Occasionally it also supplies the second toe and some
of the existence and importance of stretch to the nerves.1 cross innervation with the DPN in the first webspace.3
Overall, the superficial peroneal nerve (SPN) is the
most commonly injured nerve in ankle sprain as well as
ankle fractures. The spectrum of injury to the SPN runs
Pathoanatomy of nerve injury with ankle sprain
from mild (hardly noticeable stretch resulting in mild Normal excursion of the peroneal nerve during ankle
numbness, dysesthesia, or transient burning sensation inversion is about 4 cm.5 This excursion is transferred
in the distribution of that nerve) to severe allodynia, and shared by the whole nerve up to the level of the com-
sudomotor changes, severe spontaneous pain, and pare- mon peroneal nerve through several gliding mechanisms.
sis involving whole or large parts of the foot and ankle. Severe ankle inversion may stretch the nerve beyond its
These changes may evolve rapidly into a florid pain physiologic capability to withstand stretch and gliding.6
syndrome, reflex sympathetic dystrophy (RSD) by the Anatomic variations and preexisting conditions may
older nomenclature or complex regional pain syndrome hamper the gliding mechanisms and predispose to more
(CRPS) type 2 by the new one. severe injury.7 The exit level is important because if there
In this section we briefly review the anatomy of the is impedance to nerve gliding through the fascial hiatus
SPN, the pathomechanics and pathology of its stretch and the exit is low, the same stretch is imposed on a
injury, and the myriad of symptomatology, focusing on shorter nerve segment. Even with a normal exit, over-
early diagnosis of injury to the nerve. We equip the stretching because of severe inversion-plantarflexion
reader with some useful tips regarding early institution may result in nerve damage. Typically a combination of
of therapy for these individuals by the primary care sport the two will result in a more severe injury. Nerves that
physician or orthopaedist. We review the algorithm and penetrate to the anterior compartment before emerging
treatment options for the more severe cases. through the fascia cruris also are prone to stretch injury.8
We postulate other possible mechanisms that may
contribute to gliding impedance and that have not been
studied. The ‘‘acute on chronic entrapment’’ means that
ANATOMY because of chronic entrapment there is fibrosis,
thickening, or other changes in the fascial opening that
The peroneal branch of the sciatic nerve separates from impede gliding. In the case of severe sprain and extreme
the tibial one at the popliteal fossa, where it takes a more nerve stretch, the excursion of the nerve is relatively slow
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Treatment
in the canal. The excessive stretch is loaded mainly on In general, we divide the clinical presentation of nerve
the distal part of the nerve. injuries after ankle sprain to three groups on the basis of
We assume that muscle swelling and increased intra- their myriad of symptoms and severity. Group 1 repre-
compartmental pressure created during rigorous athletic sents those with mild traction neuritis. They typically have
activity9 presses the nerve against the fascia cruris and mild numbness and/or allodynia. Their pain level is mod-
impedes nerve gliding through the hiatus. Another erate (visual analogue score [VAS] score usually 4–7). The
hypothesis is the ‘‘intraperoneal entrapment.’’ During nerve is tender to palpation, percussion, and inversion.
acute inversion the nerve glides distally. At the same time, These patients usually heal well within 1 to 2 months.
rigorous contraction of the peroneal muscles may com- Patients in group 2 have significant symptoms and signs
press and entrap the SPN, which courses between them. of neuritis. Pathologically there is perineural fibrosis, scar-
The contracting muscles pull the nerve proximally, in the ring, or intraneural microscopic changes. They may well
opposite direction, thus increasing the stretch on the nerve. have entrapment of the nerve in the fascial hiatus. They
There may be damage to the subcutaneous tissue either have constant pain (usually burning, tingling, or
because of shearing and ruptures of subcutaneous fat, electric shooters), which exacerbates with activities, or they
small blood vessels, and lymphatics. Scarring will ensue, may have only provoked pain. The nerve may look and feel
and the areolar tissue, which allows the nerve to glide thickened. Plantarflexion of the foot and fourth toe causes
smoothly, will lose its pliability. The clinical relevance the nerve to be more prominent, and usually there is
of this phenomenon per se may be the experience of tenderness to percussion along the course of the nerve.
pain on inversion (sometimes even at night because of Further plantarflexion and inversion is unpleasant and
the plantarflexed-inversion position of the foot at sleep) aggravates the athlete’s symptoms. Occasionally the ten-
and/or chronic, occasional subclinical entrapment, derness will be confined to the exit site of the nerve from
which may manifest itself only in a future sprain episode. the fascia at the distal anterolateral aspect of the leg. In such
Quite often the picture is mixed, with intraneural, cases entrapment is the probable diagnosis and the pro-
perineural, and nerve bed changes. gnosis is favorable after surgical decompression.
Histologically, in the severe cases stretching injury to Group 3 was composed of patients with neuropathic
nerve will result in perineural tears, which may lead to pain whose pain and symptoms are beyond the distribu-
intraneural and perineural fibrosis.10,11 In cases in which tion of the injured SPN. These patients suffer from
we had to resect the nerve following inversion ankle increased general activity of the pain system and actually
injury, we saw on histology laceration and discontinua- may have CRPS type 2.15 Their pain score is high (VAS
tion of nerve fibers. In one extreme case we observed 7–10). They have spontaneous and provoked pain in
fatty degeneration with marked thickening of the nerve. which pain often is worse at night. It is characterized
Macroscopically the picture varies from a nerve that by a burning quality, deep ache, or electric shooters.
appears normal to a thickened one. The fascial exit site There often is diffuse swelling from the toes to the
may show frank cicatrization. Extensive scarring may distal leg, transient color and temperature (vasomotor)
be seen at the nerve bed at the dorsum of the foot, changes, and sudomotor disturbances, which may mani-
which interferes with nerve gliding (Fig. 22D-1). fest as edema and hyperhydrosis or dry skin. The skin
New evidence sheds light on the role of inflammation often is swollen and shiny. Allodynia (pain in response
in the pathology and perpetuation of nerve pain with the to nonpainful stimuli, e.g., light touch) is common.
development of pain syndromes.12-14 Although the Sensation typically is disturbed beyond the territory of
importance of the inflammatory mechanism is not the injured nerve. Weight bearing is limited and often
completely clear, and the research was focused on patients impossible. The prognosis for these patients typically is
with CRPS, the available data suffice to justify the addition grave. We assume that early intervention with pain treat-
of anti-inflammatory agents to the treatment protocol. ment may halt the progression to florid pain syndrome
in many of these patients. The role of early surgical
intervention has not been established yet, but certainly
CLINICAL PICTURE
in some of the cases it is justified.
Symptoms related to nerve injury in association with

ankle sprain or inversion injury vary according to the
severity of nerve damage. They often are masked by the
TREATMENT
associated mechanical derangement. The clinician may
tend to ascribe the symptoms and pain to the mechanical
ligamentous or bony injury and miss the opportunity to
.............................................................
Nonsurgical treatment
initiate early treatment, which in the severe cases may As a routine, nonsurgical treatment should be used first.
prevent deterioration to florid pain syndrome. In some of the cases, however, nonoperative modalities
503
...........
Figure 22D-1 A 22-year-old sustained an ankle sprain 3 years before surgery. She developed pain in the
distribution of the superficial peroneal nerve (SPN) that worsened with walking and at night. SPN block relived
80% of her pain. She was not improved with nonsurgical therapy. At surgery to release the nerve, dense scarring
was found along the course of the nerve (A-C). A stepwise release was carried out (B and C). Nerve release and
dissection must continue proximally to the exit point of the nerve from the peroneal muscle
compartment (C). The nerve is freed distally until unscarred nerve can be seen (in this case far beyond the
bifurcation to its two main branches. At completion of release, the fascia has been opened and the nerve can be
seen emerging freely from the muscular compartment (D). The patient felt complete relief immediately after
surgery, but over the course of the next year worsened to some extent. Two years after surgery she has mild pain
on daily activities but does not take pain medications. She can perform limited sport activities.
will not be effective, and occasionally, delaying surgery Oral medications

has its own risks. For example, traction injury to the We prescribe pain medications, which affect the various
SPN, which flares out the adjacent nerves and the pain modalities of the altered pain pathways. Such treatment
system with evolving CRPS, may be treated best with may include a combination of acetaminophen (or dipyr-
early nerve release or transection. In such cases, a short one), nonsteroidal anti-inflammatory drugs (NSAIDs)
course of aggressive medical treatment may need to be (e.g., celecoxib, rofecoxib, etodolac, diclofenac), nerve
followed by early surgery. pain medication that is usually either antidepressants or
Nonsurgical means include oral medications, topical antiepileptics, and tramadol (Ultram; Ortho-McNeil,
applications, repeated nerve blocks, physical therapy, and Inc., Raritan, NJ) and/or narcotic medications.16,17
pain modalities. More complicated pharmaceutic interven- The selection of treatment modality is determined
tions, sympathetic or epidural blocks, or spinal cord stimu- mainly according to the severity and intensity of symp-
lation can be performed by physiatrists and pain specialists. toms. The relationship between the type of pain and
504
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Treatment
specific drug selection is not so clear. In the mild to Carbamazepine (Tegretol; Novartis Pharmaceuticals,
moderate cases an ascending prescription attitude can East Hanover, NJ) is an antiepileptic medication with
be adapted. In this approach either a new or additional known antineuralgic effect. For many physicians this
medication or higher dose of a given one is added grad- is the drug of choice for neuralgic pain. The dose for that
ually as needed. Simple pain medication (e.g., acetamin- indication usually is 400 to 800 mg/day. The initial dose
ophen or dipyrone) is sufficient in group 1 or mild is 100 mg twice a day, and it can be increased in 200-mg
group 2 cases. (Dipyrone is an antianalgesic and antipy- daily increments. Timonil (carbamazepine sustained
retic but not an anti-inflammatory medication; it is release; Desitin Pharmaceuticals, Hamburg, Germany)
approved for use in many parts of the world but not in is a prolonged-release version, manufactured in 300-mg
United States because of the rare incidence of agranulo- tablets that can be divided to quarters. One quarter of a
cytosis). An NSAID is prescribed concomitantly or sub- tablet daily is taken initially and the dose is increased by
sequently. If pain is refractory to these medications, or another quarter every week. Drowsiness, dizziness, and
in the presence of neuropathic symptoms (allodynia, blurred vision are the main side effects. Discontinuation
burning sensation), nerve pain medication is added. should be implemented gradually.
Nerve pain medications usually are either antidepres- Gabapentin (Neurontin; Pfizer, New York, NY), also
sants or antiepileptics. Their role is to decrease the spon- an antiepileptic drug, may be the most effective medica-
taneous nerve activity and reset the correct pain tion available for neuropathic pain, with fewer side
threshold. Typically, the dose is increased gradually. effects and good tolerability. Its main limitation is high
The next step is a more potent pain medication. Trama- cost, and in many countries it is not approved yet for
dol is a weak m receptor agonist and N-methyl-D-aspar- peripheral neuritic pain. The initial dose is 300 mg once
tate (NMDA) receptor inhibitor. Although it is not a day, increased every 3 days by 300 mg to 300 mg four
regulated as a narcotic medication, it resembles narcotics times a day (e.g., change from once to twice to three
in its affinity to m receptors and in having (uncommon) and four times a day, with every change made after
addictive potential. Narcotics can be prescribed for 3 days of getting used to the new dosage). Higher doses
severe or refractory cases. In common use is oxycodone, may be required, but we recommend in such cases that
which is available in a controlled-release preparation the patient be seen by a pain specialist or a physiatrist.
(daily every 8–12 hours) or in combination with aspirin
(Percodan; Endo Pharmaceuticals, Chadds Ford, PA) or Topical preparations
acetaminophen (Percocet; Endo Pharmaceuticals, Few topical preparations are available.
Chadds Ford, PA). OxyContin (sustained-release oxyco- Capsaicin (Zostrix; Rodlen Laboratories, Health Care
done; Purdue Pharma L.P., Stamford, CT) usually is Products, Amityville, NY) is an active ingredient of red
prescribed at 10 mg twice a day initially, and the dose pepper that causes substance P depletion, thus inter-
can be increased to 20 mg twice a day. If a higher dose rupting nerve transmission at the peripheral level. It is
is needed, we recommend urgent referral to pain clinic. applied on the tender regions (or along the course of
It is worthwhile for the orthopaedist or sport physi- the nerve if it is tender) three or four times daily. The
cian to have in his or her armamentarium two or three main side effect is burning sensation at the site of appli-
nerve pain medications. cation. If severe, this sensation can be relieved by pre-
Our first choice drug is amitriptyline (Elavil; Astra- ventive lidocaine application (EMLA cream) before
Zeneca Pharmaceuticals LP, Wilmington, DE), which applying Zostrix. It may take a few days to 1 month
is a tricyclic antidepressant, 10 mg daily at night. The before Zostrix exerts its analgesic effect. Once the burn-
goal and treatment rationale should be discussed with ing sensation has decreased, one can change from the
the patient; otherwise he or she may not comply. The low to the higher potency (0.075%).
patients typically will read on the package that this is Another alternative is the lidocaine patch (Lidoderm;
an antidepressant therapy and are reluctant to take the Endo Pharmaceuticals, Chadds Ford, PA), which is
medicine, unless they had received the needed explana- applied once daily and releases the local anesthetic in a
tion. The dose may be increased in weekly intervals to controlled mode.
20 (two 10-mg pills), 25, 35, and 50 mg. The main side Topical NSAID preparations may have a role in
effect is sedation, which may be beneficial in case of mild cases but we have not seen great benefit in cases
night pain. The patient should be warned against of neuropathic pain. In the United States, Custom
driving or performing tasks that mandate alertness. Meds (Inverness, FL) a custom compounding company,
Other common side effects are dry mouth, blurred formulates nearly all of the previously mentioned medi-
vision, and constipation. Because of the relative low cations into an absorbable, topically applied gel. The
doses (in comparison with that required for depression) formulations, combinations of various doses of medica-
the side effects usually are not severe, and approximately tions, can be applied to the affected area with good
three quarters of patients can tolerate the drug. results.
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Nerve blocks Neurolysis of the nerve often is successful in the case

Nerve block with local anesthetic often is essential to of entrapment. The crural fascia is opened 3 to 5 cm
confirm the diagnosis. In some patients the block has a from the original exit site. Smooth excursion of the
therapeutic effect with symptomatic improvement that nerve is checked intraoperatively. The surgeon observes
outlasts the pharmacologic effect of the local anesthetic. that there also is free movement of the nerve in the fatty
The physiologic basis for this phenomenon is not tissue more distally. If the fat and nerve seem normal,
completely clear. There is cessation of bombardment of there is no need to extend the surgical incision distally.
the central nervous system with painful impulses that In case of adhesion bands, the nerve is freed as far dis-
may affect the central sensitization of the pain system. tally as needed, usually beyond the division to its two
We combine a short-acting local anesthetic (e.g., lido- main branches (Fig. 22D-1).
caine) with a longer-acting one. Bupivacaine is a long- Scar tissue may be formed around the nerve. Dense
acting local anesthetic with average effect of 6 to 12 adhesions imply damage to the nerve bed and increase
hours. The main hazard is inadvertent intravenous injec- the likelihood of rescarring. The typical result will
tion, which may cause lethal arrhythmia (ventricular be temporary relief with worsening of symptoms begin-
fibrillation). Alternatively, the addition of adrenaline ning after 6 weeks. In the milder cases, new adhesions
may double its duration. Ropivacaine (Naropin; Astra- may be formed up to 1 or 2 years from surgery.
Zeneca Pharmaceuticals LP, Wilmington, DE) has a If there is no relief after surgery, either an incomplete
local anesthetic effect for nearly 24-hours and has the release or an intrasubstance nerve lesion is the cause.
benefit of a good safety profile. Its main disadvantage The nerve may have looked normal or grossly disturbed.
is high cost. When performing a nerve block we gener- If there are no adhesions or entrapment, intranerve
ally use a 25-gauge needle to minimize the additional damage is the probable cause. The surgeon then should
risk of inadvertent damage to the nerve. consider whether to resect the nerve. If the symptoms
We estimate that up to one third of patients will are severe (VAS score 8–10), the nerve probably should
respond favorably to repeated nerve block. If the patient be resected. We bury the stump in the fibula and have
experiences a beneficial effect that lasts several days, not experienced stump tenderness.19 Loss of sensation
there is a role for repeated nerve blocks. on the dorsum of the foot usually is unpleasant but
tolerable. If there is a flare-up of the pain in adjacent
nerves and the patient shows signs of CRPS, then more
.............................................................
Surgical treatment aggressive management is indicated.
If nerve resection fails to relieve pain and the pain is
If nonsurgical means fail to achieve the desired effect, confined to the specific nerve distribution, PNS is the
surgery may be contemplated. In general, entrapment next step.20,21 In this procedure an electrode is implanted
of the SPN at its exit site from the compartment will on the nerve and is connected to an internal pacemaker
respond favorably to surgical release of the fascia. The that can stimulate the nerve. Stimulation of the nerve
surgical findings will dictate whether fascial release will generates nonpainful stimuli that ‘‘close the gate’’ to
be sufficient and will help to establish the prognosis. painful impulses and thus relieve the pain. The surgery
In cases in which adhesions are found, release of the involves a wake-up test after the nerve is isolated and
nerve should provide immediate relief. If there is a thick the wound anesthetized. During this portion of the
scar bed, the risk that new adhesions will form is signifi- implantation, the patient is reversed from anesthesia
cant. In the case of intrasubstance damage to the nerve, and the 4-electrode lead is placed in various locations
a nerve release probably is not going to help. In addi- around the nerve until pain relief is achieved. If the test
tion, it is important to consider and to inform the is favorable, the patient is placed under anesthesia to
patient that there is an element of unpredictability in the permit tunneling of the wires and insertion of the pace-
response of nerve to surgery (and insult). This is particu- maker device in the thigh. In severe cases, some surgeons
larly true if resection of a diseased nerve is indicated. In advocate considering the combination of concomitant
this case, there is considerable risk for temporary and even nerve resection and PNS. In a long-term follow-up study
permanent pain exacerbation, often in adjacent nerves. (3–16 years), good results (more then 50% relief of pain
with abstinence from analgesic medications) were
Type of surgery selected reported by 36 out of 46 patients (78%).20
As a rule, the choice of surgery follows Schon’s algo-
rithm of surgical treatment for nerve pain.18 The com-
mon surgeries are nerve release, revision nerve release REFERENCES
(with or without containment), nerve resection (usually
with burial of the nerve stump), and peripheral nerve 1. Nitz AJ, Dobner JJ, Kersey D: Nerve injuries and grade II and
stimulation (PNS). III ankle sprains, Am J Sports Med 13:177, 1985.
506
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Judo
2. Blair JM, Botte MJ: Surgical anatomy of the superficial peroneal 14. Weber M, et al: Facilitated neurogenic inflammation in complex
nerve in the ankle and foot, Clin Orthop 305:229, 1994. regional pain syndrome, Pain 91:251, 2001.
3. Saraffian SK:In Anatomy of the foot and ankle: descriptive, 15. Stanton-Hicks M, et al: Reflex sympathetic dystrophy: changing
topographic, functional, ed 2, Philadelphia, 1993, Lippincott. concepts and taxonomy, Pain 63:127, 1995.
4. Horwitz NT: Normal anatomy and variations of the peripheral 16. McQuay HJ, et al: A systematic review of antidepressants in
nerves of the leg and foot, Arch Surg 36:626, 1938. neuropathic pain, Pain 68:217, 1996.
5. Kleinrensik GJ, et al: lowered motor conduction velocity of the 17. Monfared H, Sferra JJ, Mekhail N: The medical management of
peroneal nerve after inversion trauma, Med Dci Sports Exerc chronic pain, Foot Ankle Clin North Am 9:373, 2004.
26:887, 1994. 18. Schon CL, Easley ME: Chronic pain. In Myerson MS, editor:
6. Millesi H, Zoch G, Rath T: The gliding apparatus of peripheral Foot and ankle disorders, vol 2. Philadelphia, 2000,
nerve and its clinical significance, Ann Chir Main Memb Super WB Saunders.
9(2):87, 1990. 19. Melamed EA, Schon LC: Deep burial of resected nerve in bone—a
7. Styf J, Morberg P: The superficial peroneal tunnel syndrome. simple technique, Foot Ankle Int 23:952, 2002.
Results of treatment by decompression, J Bone Joint Surg 20. Eisenberg E, Waisbrod H, Gebershagen HU: long term
79B:801, 1997. peripheral nerve stimulation for painful nerve injuries, Clin J Pain
8. Acus RW 3rd, Flanagan JP: Perineural fibrosis of superficial 20:143, 2004.
peroneal nerve complicating ankle sprain: a case report, Foot Ankle 21. Schon LC, et al: Prelimunary results of peripheral nerve
11:233, 1991. stimulation for intractable, lower extremity nerve pain, Pain Med
9. Styf JR, Korner LM: Chronic anterior compartment syndrome of 1:195, 2000.
the leg, J Bone Joint Surg 68A:1338, 1986.
10. Kwan MK, et al: Strain, stress and stretch of peripheral nerve.
Rabbit experiments in vitro and in vivo, Acta Orthop Scand
63:267, 1992.
11. Lundborg G: Structure and function of the intra-neural FURTHER READING
microvessels as related to trauma, edema formation and nerve
function, J Bone Joint Surg 57A:938, 1975.
12. Bennet GJ: Are the complex regional pain syndromes due to Schon LC, Easley ME: Chronic Pain. In Myerson MS, editor: Foot
neurogenic inflammation? Neurology 57:2161, 2001. and ankle disorders, London, England, 2000, WB Saunders.
13. Oyen WJ, et al: Reflex sympathetic dystrophy of the hand: an Styf J: Entrapment of the superficial perineal nerve, J Bone Joint Surg
excessive inflammatory response? Pain 55:151, 1993. 71B:131, 1989.
E. Foot and ankle injuries caused by

traditional Japanese martial arts
Yasuhito Tanaka
In Japan, there are many forms of traditional martial arts

JUDO
that are still actively practiced today. This chapter
explains in detail foot and ankle injuries associated with
the three most popular martial arts: judo, sumo, and Because judo is an Olympic sport, the number of people
kendo. Although the origin of these martial arts is not who practice judo is increasing worldwide. A judo contest
known, the earliest known mention of their basic forms is a fight between two contestants who wear judo suits
is found in Japanese documents written during the eighth and fight on tatami (straw) mats. The first contestant to
century. In the last half of the nineteenth century, the score a full point (‘‘ippon’’) wins. A contestant can score
modern rules for these martial arts were established, and a full point by throwing the opponent on his or her back,
people began to practice them as sports. Because these holding the opponent for 30 seconds, or making the
martial arts are practiced barefoot, there is a high inci- opponent concede. Injuries almost always are caused
dence of ankle and foot injuries among their practitioners. by throwing moves. Many judo injuries occur in the lower
However, because playing surfaces and styles of com- extremities, particularly at the knees, ankles, and feet.
petition differ markedly among these three martial arts, Because mild foot injuries are so common, those who
they are associated with different foot injuries. sustain them rarely seek treatment at a medical institution.
507
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Figure 22E-1 Many judo injuries occur in the lower Figure 22E-2 The great toe is easily plantarflexed (arrow)
extremities. During ‘‘Ohsoto-gari,’’ a throwing technique, the (‘‘tatami toe’’). Tatami (straw) mats typically are used as a
foot and ankle assume an equinovarus position. Inversion floor covering in judo.
sprain can occur in the foot of a defense (arrow).
the metatarsophalangeal joint of the great toe is exces-

The most common foot injury is ankle sprain; about sively plantarflexed (Fig. 22E-2). Although this generally
half of all judo practitioners suffer an ankle sprain at causes sprain without a fracture, severe bending can cause
some point (Fig. 22E-1). Severe inversion sprains typi- a chip fracture. This type of toe injury is sufficiently unique
cally are accompanied by osteochondral fracture of the to judo to merit its own name (perhaps ‘‘tatami toe’’). If
talar dome. Also, ankle instability persists in many cases, accompanied by osteochondral damage to the metatarso-
and many people who practice judo for a long period phalangeal joint of the great toe, osteoarthritis can lead to
develop osteoarthritis of the ankle. Also, when a strong hallux rigidus. Although toe injuries most often affect the
external force is applied, a malleolar fracture occurs, great toe, sometimes they can affect the lesser toe.
but plafond fractures and talar fractures are rare.
The incidence of toe injury is high among judo practi-
tioners. Turf-toe is a well-known injury associated with
sports played on turf, such as American football. Most
SUMO
cases of turf-toe are caused by excessive dorsiflexion of
the great toe. When a foot sweep is attempted in judo, Sumo is a sport in which two wrestlers fight on a round ring
the sweeping foot is in the equinovarus position and is that is made of packed earth and has a diameter of about
swung horizontally. If the sweeping foot gets caught 4 m. Sumo wrestlers wear nothing but a loincloth belt. In
in the seams of the tatami mats or on the opponent’s foot, each bout, two wrestlers initially face each other from
508
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Kendo
Figure 22E-4 The ankles often are dorsally flexed in a

bout. The incidence of anterior ankle impingement exostoses
Figure 22E-3 Exercise of shuffling. Keeping the feet on the is high in sumo wrestlers.
ground improves stability in this sport, which evolves around
collisions and pushing. The knees are bent in the valgus position,
the lower legs are abducted, and the feet are pronated. The movements the ankles are dorsally flexed. Thus in com-
playing surface is packed earth. Sumo wrestlers tape their toes petition, the ankle often is dorsally flexed (Fig. 22E-4).
and wear ‘‘tabi’’ to prevent lacerations on the soles of their feet. Furthermore, when a wrestler braces against being
pushed out of the ring, the ankles are in excessive dorsi-
behind two parallel lines at the center of the ring. Once the flexion. On the anterior surface of the ankle, the tibia
bout begins, they collide violently, like guards and tackles often collides with the neck of the talus, causing impin-
in American football. The loser is the first wrestler to touch gement exostosis. Because this condition exists in most
the ring with any part of the body other than the bottom of sumo wrestlers, and not many sumo wrestlers have ankle
the feet or the first wrestler to go out of the ring. Sumo instability, its onset must involve collision.
wrestlers try to push each other out of the ring, and heavy Because sumo wrestlers are heavy and collisions are
body weight confers an advantage in this pushing. Conse- violent, there is a high incidence of bone fracture around
quently, sumo wrestlers intentionally try to achieve and the ankle. Pronation-external rotation-type malleolar
maintain a heavy body weight. Although the most com- fracture is common because the lower leg is abducted
mon clinical problem associated with sumo is lumbar pain, and the foot is pronated, unlike the case in sports that are
injuries in the lower extremities account for more than half played with a ball. However, despite their severity, rehabil-
of all injuries associated with sumo. itation of such injuries is faster than for soft-tissue injury.
Ankle and foot injuries account for about 15% of all Severe toe injuries are less common than severe ankle
sumo-related injuries. It might seem that this is a low injuries. Unlike judo, sumo does not involve many
percentage for a sport that is practiced barefoot. The moves in which a foot in the equinovarus position is
reason for this low percentage is the manner in which swept sideways. However, lacerations of the skin on
sumo wrestlers move, by shuffling their feet instead of the plantar side of the first metatarsophalangeal joint
lifting their feet off the ground (Fig. 22E-3). In sumo, are very common. Some sumo wrestlers prevent such
the friction between the ground and the soles of the feet lacerations by taping their toes or wearing Japanese
is important in keeping a wrestler in position. If either thick-soled socks (‘‘tabi’’) (Fig. 22E-3).
foot comes off the ground for even a short time, the
wrestler easily can be pushed out of the ring. Thus shuf-
fling helps to prevent a wrestler from being pushed out
of the ring. During shuffling, the knees are bent in the
KENDO
valgus position, the lower legs are abducted, and the feet
are pronated. As a result, sumo training strengthens Japanese swords are the symbol of the Samurai culture.
the peroneal muscles, thus lowering the incidence of Unlike Western swords, Japanese swords are held using
inversion sprain. Furthermore, even if a sprain occurs, both hands. Kendo is a sport modeled after samurai
it usually does not cause persistent ankle instability. sword fighting, using bamboo swords resembling Samu-
Foot shuffling and squatting with knees spread apart rai swords. Practitioners wear protective pads on the face
are the basic movements of sumo, and during these (‘‘men’’), belly (‘‘do’’), and forearm (‘‘kote’’). A point
509
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Figure 22E-6 An offense hit on a face guard (‘‘men’’). The

right leg goes forward during a lunge. Excessive force is
loaded on the left Achilles tendon during the sport. The
incidence of Achilles tendon injuries is high relative to the
other martial arts.
the sole are destroyed by the impact of the heel hitting

the floor. Some kendo practitioners develop a condition
Figure 22E-5 A starting posture of kendo is demonstrated.
called ‘‘black heel,’’ which is characterized by ecchymo-
Note that the sport is practiced barefoot on a wooden floor. The
sis on the sole of the feet. Usually, heel pads are used to
right leg is in front of the left. Weight is kept on the forefoot.
treat this condition.
is scored when a bamboo sword cleanly hits one of the In kendo, the most common severe injury is rupture
protective pads. A kendo practitioner holds a bamboo of the Achilles tendon. This injury almost always occurs
sword using both hands, with the right hand in front in the left leg, because of the positions of the legs in the
of the left hand, somewhat like a right-handed baseball kendo stance (Fig. 22E-6). During kendo moves, a
player holding a bat. The two competitors face each other great amount of force is applied to the left leg. When
so that the tips of their bamboo swords are lightly touch- the body pushes forward, the triceps muscle of the calf
ing (Fig. 22E-5). Right- and left-handed practitioners is tensed, and the Achilles tendon can rupture if there
take the same stance. The right foot is placed in front, is a delay in plantarflexion of the ankle. In most sports,
while the left foot stays back. Competitors put their rupture of the Achilles tendon is rare among young
weight on the front half of each foot and slightly lift the people, but among kendo practitioners, this injury is
heels so that they can move very quickly. somewhat common in high school students. This sup-
Kendo is generally a safe sport, with a low incidence ports the theory that a great amount of force is applied
of fracture, but mild toe injuries are quite common. to the Achilles tendon in the left leg when the body
Beginners often complain of heel pain. Because kendo pushes forward in kendo. Rupture of the Achilles ten-
is practiced barefoot on a wooden floor, there is great don is rare among beginners but is more common
impact on the feet during kendo moves. About 40% of among skilled practitioners. Most of those who sustain
kendo practitioners develop hemoglobinuria because this injury chose to undergo surgery, and rehabilitation
red blood cells in the skin and subcutaneous tissue of takes 6 to 12 months.
510
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Kendo
F. Foot and ankle problems caused by some

traditional Chinese habits and sports
Xu Xiangyang and Zhu Yuan
There are some traditional sports that are still popular in Chinese sports in clinic, usually a soft-tissue injury
China, such as shuttlecock kicking, rope skipping, and without a major fracture (Fig. 22F-1).
Chinese ‘‘wushu,’’ often called kung fu. Although The frequent reasons for foot and ankle injury stem
Chinese wushu is changing to be more competitive, from the players performing a trick when they kick the
most of the time traditional Chinese sports are pursued shuttlecock and/or skip rope. Coupled with uneven
for health purposes and personal fulfillment. Thus there ground, this is a typical setup for an accident. Although
are infrequent opportunities for competitive athletics some players did this well when they were young, their
among the general public. Still it is not unusual to see mental capabilities may be greater than their physical
foot and ankle injuries caused by these traditional competence in their later years. Furthermore, injury
Figure 22F-1 ‘‘Wushu,’’ a popular traditional sport.
511
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Figure 22F-2 ‘‘Wushu,’’ a popular traditional sport.
Figure 22F-3 ‘‘Wushu,’’ a popular traditional sport. Figure 22F-4 Shuttlecock kicking.
may occur as a result of increasing body weight, decreas- Most of the time we manage these kinds of injuries
ing strength of their ligaments, or declining general with traditional Chinese medicine unless we find the
fitness. Chronic injury is seen in Chinese wushu when injury unstable or prone to sequelae. There are some
the player continues to practice wushu exercises for special, traditional treatments for soft-tissue injuries of
decades after a primary injury that occurred when he the ankle joint in China that have a long history. These
or she was younger. include acupuncture needles, Chinese herb ointment,
There are many different kinds of foot and ankle injuries fomentation, and foot massage.
caused by these traditional Chinese sports. They include Ice, Chinese herb ointment, and sometimes a splint are
ankle sprain, fifth metatarsal base avulsion fracture, medial the usual management for soft- tissue injury in the early
and lateral malleolus fracture, Achilles tendon rupture, stage of trauma. Chinese herb ointment can effectively
diastasis of syndesmosis, metatarsophalangeal joint decrease the swelling and dissipate the sludge (edema,
capsular injury, and instability of the ankle. etc.) quickly. Fomentation, needles, and massage,
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Kendo
Figure 22F-5 Rope skipping.
Figure 22F-6 Chinese herb ointments and their original materials.
accompanied by functional exercises, are the treatments of ‘‘Bi,’’ or pain, caused by a localized disruption to
for subacute injury. the flow of Qi.
Needles and massage are important components of The traditional Chinese explanation for soft-tissue
restoring balance to the person’s vital energy channels, injury is that the channel running through the damaged
which form the basis behind traditional Chinese medi- tissue has been physically disrupted, resulting in
cine. The channels are a system of conduits throughout local pain, a disease of Bi. To treat the pain, the integrity
the body that carry and distribute Qi, or vital energy. of the channel and the flow of vital energy through
Disease is present when the flow of vital energy through the channel must be restored. This can be achieved
the channels is disrupted. This may occur when the by the selective use of points on the damaged
integrity of the channels themselves is damaged by a channel, thereby restoring the flow of Qi and relieves
sprain or strain. The Chinese describe this as a disease the pain.
513
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Figure 22F-7 Foot massage. Figure 22F-8 Foot massage.
The foot plantar surface is an important place for the one can stimulate the reflex zone of the foot to regulate
body because there are many points of channels, which the corresponding tissues and organs; (3) it can mobilize
represent many internal organs. Therefore foot massage Qi, moisture, and blood and invigorate proper function
not only treats the injury of foot but also can treat dis- of the muscles, nerves, vessels, glands, and organs; and
eases anywhere in the body. In China, foot massage (4) it brings the efficacy of release and relaxation.
hygiene is looked on as a good method for preventing Generally, foot and ankle soft-tissue injury can be cured
and treating diseases and is popular throughout the with Chinese traditional medicine in 2 to 3 weeks. Even if
whole country. there is instability of the ankle, most patients can get good
Foot massage is used to stimulate the points of the results after these treatments. Only a few patients need
channels that can activate the gates of the body, which surgery for ligament repair. Certainly, if there is a
are opened and closed to adjust circulation in the relatively severe fracture of the ankle and foot, surgery
channels. Foot massage has four functions: (1) it can or casting is necessary. In general, foot massage is the
enhance the blood circulation, so as to accelerate the mainstay of treatment and is used for healthy care as well.
metabolism of the body; (2) it can regulate the nervous
system; because there are many nerves endings in the foot,
G. Foot and ankle sports injuries in Korea

Hong-Geun Jung, Kyung-Tai Lee, and Yong-Wook Park
INTRODUCTION Furthermore, we present some specific injuries that

seem to show a higher incidence in Korea.
Overall, foot and ankle sports injuries in Korea are
similar to those in the rest of the world, because most
of the sports that are played at present, such as soccer,
SSIREUM (KOREAN TRADITIONAL
WRESTLING)
basketball, and baseball originated in non-Asian
countries. Distinct sports injuries occurring during
some of popular Korean traditional sports and martial Ssireum is a contest of physical strength and technique
arts, such as ssireum and taekwon-do, are reviewed. in which two contestants compete in direct contact
514
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Taekwon-do (Korean martial arts)
against one another. It is a form of traditional wrestling weight, poor balancing, and repetitive lifting of the
found in Korea. There also are some sports similar to large opponents on the sand are factors that contrib-
Korean ssireum in other countries, such as sumo in ute to the rupture of the Achilles tendon. In addition,
Japan. buh in Mongolia. sambo in Russia, and kara kuçak fracture of the base of the fifth metatarsal, ankle frac-
or yağli gureš in Turkey. tures, and big toe fracture or sprain have been
Ssireum involves two contestants grasping, pulling, observed and are due partly to the uneven ground
lifting, twisting, pushing, and tumbling as each compet- surface made of sands.
itor attempts to throw the opponent to the ground
(Fig. 22G-1). If a competitor can force any part of the
opponent’s body above the knee to touch the ground,
the competitor wins the bout. There are hundreds of
TAEKWON-DO (KOREAN MARTIAL ARTS)
techniques, categorized into hand techniques (throwing
the opponent to the ground by using the hands), leg Taekwon-do is a well-known Korean martial art that is
techniques, and trunk techniques (using the back). established as an international sport and is also being
Studies have shown that rupture of the Achilles accepted for the Olympic Games. It is the martial art
tendon, ankle sprains, acute dislocation of the pero- that mainly uses the lower extremities for hitting the
neal tendon, chronic lateral ankle instability, osteoar- opponent in the match. The various dazzling kicking
thritis of the ankle, and osteochondral lesion of techniques such as front kick, side kick, and roundhouse
the talus are not infrequently experienced during kick (the most commonly used kick in sparring) are the
ssireum. key weapons in winning the game. These maneuvers
Acute ankle sprains and chronic lateral ankle (Fig. 22G-2) subject the participants to injuries around
instability are the most commonly experienced injuries the foot and ankle.
in ssireum because of the repeated turnings and the The most common injury occurs on the dorsal lateral
difficulty in maintaining balance against force in aspect of the midfoot when the player hits the opponent
the sand. Two frequent mechanisms occur when the with this part of the foot with the ankle at maximum
opponent pushes the trunk while the foot is stuck in plantarflexion. Typically, the foot strikes the opponent’s
the sand, causing ankle twisting injury, and when the elbow, dorsal foot, or even pelvis, leading to Lisfranc
opponent lets the player down on the sand, abruptly joint trauma or metatarsal fractures. Likewise, the ante-
causing ankle imbalance and ligament injury. Osteo- rior aspect of the ankle and shin often are bruised under
chondral lesions of the talus are also experienced the same circumstances as they strike against the guard-
because of the weight of the players and the frequency ing elbow. Fortunately these impacts rarely require
of injuries of the ankle. Similarly the high body surgical treatments.
Figure 22G-1 The ankle often is injured when the two Figure 22G-2 A taekwon-do expert attacks the opponent in
ssireum contestants forcefully try to tumble the opponent the head with roundhouse kick; the forefoot or midfoot often
down on the uneven ground. gets injured during these kicks.
515
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Big toes at the metatarsophalangeal (MTP) and (6/23) of the players also experienced posterior im-
interphalangeal (IP) joints are the second most com- pingement of the ankle.
mon sites of foot and ankle injuries, often because of Rugby players often experienced ankle sprains (97%)
incorrect kicking and unbalanced landing on the floor. during stumbling, feint motions, or tackles. Thirty-five
These are mainly ligamentous traumas that sometimes percent (11/31) experienced Achilles tendinitis, and
result in MTP or IP dislocations and rarely involve 55% (17/31) experienced tibial stress fractures.
fractures. Front kick injuries can cause toe sprains, Most of the baseball players sustained ankle sprains
dislocations, or fractures, as well as acute and chronic (95%, 19/20), which often happened while catching
posterior ankle impingement. Sever’s disease, calcaneal side-passing balls during defense plays.
apophysitis, also can occur in children who engage
in the sport.
Ankle sprains often occur while kicking the opponent
or while landing on the mattress or floor after the kick. ACCESSORY NAVICULAR SYNDROME
Chronic lateral ankle instability is quite common because
of repeated inversion injuries. Approximately 40% of a
Although the overall incidence of accessory navicular
college taekwon-do team experienced at least three
syndrome (ANS) in Korea is similar to that in other
ankle sprains in a year, and 60% experienced ankle pain
countries (4%-12%), type-2 symptomatic ANS seems to
during the match.
show relatively high incidence in Korean athletes.
One foot and ankle institution in Korea experienced
more than 200 cases of type 2 ANS, most of them symp-
BASKETBALL, SOCCER, RUGBY, tomatic. They were treated with bony ossicle excision
AND BASEBALL
and posterior tibialis tendon (PTT) reattachment.
Rehabilitation started at 4 weeks after operation and
Survey of the foot and ankle injuries in Korean college players returned to sports at about 3 months postopera-
basketball, soccer, rugby, and baseball teams was per- tively. In a retrospective review of 84 operated ANS
formed. Ankle sprains (100%) and chronic lateral instabi- patients, 70% were professional or amateur athletes
lity (50%) were very common among basketball players involved in activities such as football, basketball, or mara-
because of frequent jumping and landing in the limited thons. The follow-up period averaged 17 months.
space. This also led to second and fifth metatarsal and Ninety-four percent (79/84) of the patients showed
navicular stress fractures. excellent or good results postoperatively and returned to
Soccer players often experienced ankle sprains (100%, previous sports activity within 3 months after operation.
23/23) on the artificial lawn after jumps and tackles. Poor results came from one heavyweight volleyball player
Ankle and toe fractures, as well as tibial and metatarsal and other patients who had associated PTT insufficiency
stress fractures, also were noted. Approximately 26% greater than grade 2.
H. Australian foot and ankle conditions

in sport
Terence S. Saxby and Jonathan C. Dick
Australia is a very isolated country. The population is Games originating in North America, including
approximately 20 million people and the landmass of baseball, basketball, and even American football are
the country is approximately the size of the United played in Australia. However, because of its historical
States of America. links with Great Britain and Europe, sports played in
Sport is extremely important to the Australian way of these countries predominate. Rugby union, netball,
life. Almost every sport would be played to some extent hockey, and soccer are extremely popular sports in
in Australia. this country. Foot and ankle injuries sustained by
516
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Foot/ankle injuries in surf lifesaving
participants in such sports are much the same the world

over.
Because of its isolation and historical independence,
Australia has produced its own novel sports including
Australian football, which is a combination of Gaelic
football, soccer, and rugby. This is an extremely popular
sport with a large following in certain states of Australia.
It is a fast-flowing game played on a large field requiring
athleticism rather than brawn. A profile of Australian
Football League (AFL) injuries presenting to sports
medicine clinics found that foot and ankle injuries
accounted for 14.2% of all injuries.1 These are most
often sprains of the lateral ligament complex of the ankle
and therefore not unique to Australian sport.
Australia is an island continent; therefore water
sports, including surf lifesaving and other water-based
recreational activities, are extremely popular.
Because of the large variety of sports and recreational
activities carried out in Australia by a large number of
individuals, sporting injuries are quite common. Injury
profiles for the majority of these activities reflect
patterns of injuries seen overseas. However, there is Figure 22H-1 Inflatable rescue boat.
one particular injury to the foot/ankle complex that is
unique to Australian sport. recently for some of the unique injuries sustained by
Australian lifesavers.3
Bigby2 reported on the workers compensation
FOOT/ANKLE INJURIES IN SURF claims made by Surf Lifesaving members in Queensland
LIFESAVING (northeastern state) for a 12-month period from July
1997 to assess the incidence of serious injuries sustained
Surf lifesaving is an intrinsic part of Australian culture. from IRBs and to describe their nature.2 In Queensland
Australians love to participate in activities based around alone there are 2819 rescues per year, and in 731(26%)
the surf beach. Australian beaches can be extremely
dangerous for swimmers. Therefore the volunteer Surf
Life Saving Association was developed to reduce the risk
of participation in this activity. Inflatable rescue boats
(IRBs) are used to a large extent by the Surf Lifesaving
Association (Fig. 22H-1). These inflatable vessels are
now the primary rescue aid used by surf lifesavers in
Australia. The use of IRBs has resulted in a number of
serious foot and ankle injuries to the boat crew, as
demonstrated by recent studies.1,2
IRBs have been designed essentially for inshore
search and rescue but also are used in training and
competitions.2 They are powered by a 25-horsepower
outboard motor and structurally are composed of two
rigid, nylon mesh pontoons with a removable light-
weight laminate floor to prevent craft deformation.
They are manned by a driver and a crewman. The driver
sits at the rear left side of the boat and the crewman at
the forward right side. The crew requires foot straps,
one for the driver and two for the crewman, to give
them some anchor to the boat in the often-trying condi-
tions (Fig. 22H-2). These foot straps are not adjustable
to foot size or stance position and do not allow any rota-
tion. As a result, these foot straps have been blamed Figure 22H-2 Inflatable rescue boat showing foot straps.
517
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an IRB was used. For the year there were 37 insurance Anatomy
claims to the workers compensation board specifically The tarsometatarsal joints are inherently stable because
from IRB injuries. Incidence of claim for injury annually of their joint congruency and ligamentous supporting
is 1.2% in IRB crewmen. Sixty-eight percent of claims structures. There is little range of motion (ROM) at
involved injury to the lower limbs. Fifty percent were these joints, the first and fifth being most mobile.
associated with fracture or fracture dislocations. The The bony configuration, with the base of the second
crewman (81%) rather than the driver was injured more metatarsal being recessed and the bone being shaped
often. The right side (79%) was more commonly trapezoidally, provides economical load-bearing charac-
injured. Bigby concluded that the crewman was more teristics. The Lisfranc ligament is a large, strong, short
likely to be injured because the crewman is unable to ligament connecting the base of the second metatarsal
brace himself or herself, with two foot straps being the to the medial cuneiform. No ligament connecting the
only fixed support. base of the first and second metatarsals has yet been
Ashton reviewed 12 significant foot and ankle injuries described. This leaves a relative weakness inherent at this
sustained while riding in an IRB that were admitted level. The dorsalis pedis artery crosses over this area, and
to his regional hospital emergency department.3 Ten of a branch dives down between the bases of the first and
these injuries required operative surgery as the initial second metatarsal to join the plantar supply. Also the
form of treatment. They consisted of six Lisfranc injuries deep sensory branch of the common peroneal nerve is
(dislocation of the midfoot), four ankle fractures, one medial to the artery at this level. These structures may
tibia and fibula fracture, and one traumatic dislocation be damaged when open reduction and internal fixation
of peroneal tendons. These injuries were sustained on are performed.
three occasions when the IRB overturned, four on
landing after going over a wave, and four from hitting Lisfranc injuries
a broken wave. One occurred when a crewman alighted
The mechanism of Lisfranc injuries sustained by IRB
from the boat as it approached the beach at speed.
crew is thought to be due to abduction injuries because
Eleven of the 12 injuries were to the crewman. The
the feet are constrained by hard foot straps. This gener-
crewman takes the initial impact of the wave and has
ally causes a homolateral type of injury.
no control of the boat’s direction. This contributes to
Lisfranc dislocations have since been classified by
his or her being less stable than the driver and therefore
several authors, but none of the classification systems
at more risk of injury3 (Fig. 22H-3).
provide a helpful system that aids in treatment meth-
ods. The simplest classification, by Quenu and Kuss
(1909)4, divided these injuries into three groups
(Fig. 22H-4):
1. Homolateral
2. Unilateral
3. Divergent
This by no means is a comprehensive classification
system but is useful when describing this injury.
Investigation
Investigation of these injuries initially is by plain x-ray.
To assess normal anatomy, the continuous line along
the medial border of the second metatarsal and medial
cuneiform and medial border of the fourth metatarsal
and medial cuboid should be present on both anterior-
posterior (AP) and oblique views. If there is any doubt
about the diagnosis or further investigation is war-
ranted, a computed tomography (CT) scan is helpful
and often aids in making decisions and determining
options for treatment.
Treatment
Treatment of displaced Lisfranc injuries usually requires
open reduction and internal fixation with either small
Figure 22H-3 Inflatable rescue boats at work. fragment/cannulated screws and K-wires. Outcome
518
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Further reading
Figure 22H-4 Lisfranc classification.
from these injuries is variable with a guarded prognosis, 3. Ashton A, Grujic L: Foot and ankle injuries occurring in inflatable
although there is an abundance of literature that sup- rescue boats (IRB) during surf life saving, J Orthop Surg 9:39, 2001.
4. Quenu E, Kuss G: Étude sur les luxations du metatarse, Rev Chir
ports the practice of anatomic reduction’s leading to 39:1, 1909.
optimal conditions for a reasonable outcome.
FURTHER READING
REFERENCES
Hardcastle P, et al: Injuries to the tarsometatarsal joint incidence,
classification and treatment, J Bone Joint Surg 64-B:349, 1982.
1. Gabbe B, Finch C: A profile of Australian football injuries Arntz CT, Veith RG, Hansen ST: Fractures and dislocations of the
presenting to sports medicine clinics, J Sci Med Sport 4:386, 2001. tarsometatarsal joint, J Bone Joint Surg 70-A:173, 1988.
2. Bigby J, McClure R, Green A: The incidence of inflatable rescue boat Adelaar R: The treatment of tarsometatarsal fracture-dislocation,
injuries in Queensland surf lifesaver, Med J Aust 172:485, 2000. Instruct Course Lect 39:141, 1990.
I. Soccer: hallux osteochondral lesion and

rupture of the Achilles tendon
Verônica Vianna, Sergio Vianna, and Abrão Altman
Soccer is one of the most popular sports in the world, beaches, backyards, and public squares), and on diverse
played by more than 60 million people in more than terrain (grass, dirt, and sand). Therefore Brazilian sports
150 countries, according to the Fédération Internatio- specialists see a great number of foot and ankle lesions
nale de Football Association (FIFA).1 In Brazil soccer that affect all levels of athletes, not only professional
represents a true passion among all ages and social levels. players. Among these are two lesions that we feel are
It is practiced all over (schools, streets, soccer fields, of particular interest regarding diagnosis and treatment.
519
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HALLUX OSTEOCHONDRAL LESION IN

BEACH SOCCER PLAYERS
Beach soccer is a popular soccer modality practiced bare-

foot along the Brazilian coast. During the game, the hal-
lux is subjected to trauma—direct trauma against the
ball, the ground, or another player and indirect trauma
because of the forces from running over the sand.2 Fur-
thermore, the hallux metatarsophalangeal (MTP) and
interphalangeal (IP) joints are stressed in a repetitive
mode, particularly in dorsiflexion with pivoting and run-
ning. Unlike the aforementioned stresses, kicking will
induce lesions that tend to be on the dominant side,
the side used to kick the ball. Milani et al.3 described
19 patients with hallux osteochondral lesions. All were
males between the ages of 14 and 67 who practice beach
soccer for a mean of 12.8 years. The lesions were located
at the IP joint with the distribution shown in Fig. 22I-1.
In all cases the lesion involved the dominant foot (the
one used to kick the ball).
Typically the pain and swelling during the acute phase Figure 22I-2 Radiographic aspect of a typical hallux
does not stop the patient from practicing soccer. By the osteochondral lesion.
time the orthopaedic surgeon sees the athlete, the symp-
toms are more dramatic and there often is a ‘‘tumor’’
noted at the dorsomedial aspect of the IP joint of the
hallux. Many will develop a callus over the lesion that can
be particularly symptomatic in shoes during daily activity.
The radiographic study shows an osteolytic, punched
lesion with a sclerotic border (Fig. 22I-2).
Altman classified these lesions as types I to V, accord-
ing to the anatomic location (Fig. 22I-3). Type I, lesion
at the lateral border of the distal phalanx articular facet,
is responsible for 40% of the lesions.
Figure 22I-3 Altman’s classification for the hallux
osteochondral lesions.
Conservative treatment may be successful when

performed during the acute phase. It consists of anti-
inflammatory medication and immobilization of the
hallux with taping for pain relief. In general, if the
patient stops playing soccer, the pain is not a big issue.
Technique
Surgical treatment consists of resection of the osteochon-
dral fragment and articular debridement. The results
are uniformly good and the patients are able to resume
playing soccer approximately 1 month after surgery.
A gauze-and-tape compression dressing is applied at the
conclusion of surgery and is changed the following day,
when passive motion starts. Two weeks after surgery,
the patient resumes walking barefoot on the sand at the
beach. The athlete can start running and kicking barefoot
Figure 22I-1 Distribution of the hallux osteochondral lesion. 1 month after surgery.
520
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Neglected rupture of the achilles tendon
NEGLECTED RUPTURE OF THE ACHILLES

TENDON
‘‘Weekend athletes’’ typically are older soccer enthusiasts

who used to play soccer routinely but now participate
only on weekends. They are particularly vulnerable to
injury and will not uncommonly sustain a rupture of the
Achilles tendon. Unfortunately the diagnosis often is
missed in the acute phase, probably because of inadequate
initial care. It is a problem not only in our practice but
throughout Brazil both in private and public practice.
Therefore it is not uncommon that Brazilian specialists
encounter these chronic lesions of the Achilles tendon.
Our approach has been to use the flexor hallucis longus
Figure 22I-4 Identification of the flexor hallucis longus in the
(FHL)4 as a substitute for the ruptured tendon. Hansen5
medial aspect of the foot.
was the first to describe the use of the FHL for chronic
Achilles rupture. This is the strongest tendon after the
Achilles, and it contracts in phase with the gastro- Technique
cnemius-soleus complex. In addition, the force axis of We position the patient prone on the surgical table
the transferred FHL reproduces the one of the Achilles and drape out the affected side. The FHL is harvested
tendon. Its position facilitates its use during the sur- in the medial aspect of the foot while the knee is flexed
gical procedure without injuring the neurovascular to 90 degrees during identification of the tendon8
bundle and preserves the muscle balance around the ankle (Fig. 22I-4). A longitudinal incision is made along the
joint. medial border of the midfoot just above the level of
The role of the FHL during gait, running, and jump- the abductor muscle, from the navicular to the neck of
ing is yet to be determined. Frenette and Jackson,6 the first metatarsal. The abductor muscle is reflected
studying complete tears of the FHL in athletes, con- dorsalward, and the FHL and the flexor digitorum
cluded that its integrity is not essential for push-off longus are identified within the substance of the mid-
and balance during gait. Motivated by a chronic lacera- foot. The FHL is divided as far distally as possible, and
tion of the FHL in an 11-year-old runner, the authors the distal stump is retained to be sutured to the flexor
studied nine cases of lacerations of the FHL in athleti- digitorum longus. The tendons must be dissected from
cally inclined patients. All of them returned to their
activities, even those patients who had no appreciable
active IP joint flexion after surgery. In these cases the
lack of active flexion was felt most likely to be due to
adherence of the repaired tendon in the scar tissue.
Perhaps the return to function despite the lack of IP
flexion relates to the tendon’s role during gait, running,
and jumping. MacConaill and Basmajian7 reported that
the FHL shows its greatest electromyographic activity
during midstance, whereas during heel-off there is negli-
gible activity in normal subjects. In our series of FHL
transfers for chronic Achilles tendon ruptures, all 37
patients had normal passive IP flexion, and despite no
active IP flexion there was no limitation to daily activities
or to the return to sports. Our patients have returned to
the practice of sports, including soccer, modern dance,
and capoeira (an Afro-Brazilian dance form that incorpo-
rates self-defense maneuvers). Preliminary studies of the
gait analysis in our series have not shown discrepancies
between the operated and the nonoperated side on
the parameters of the gait. Perhaps if we had treated
ballet dancers or sprinters, who stress their FHL more
aggressively, there would have been some limitation. Figure 22I-5 Tendon transfer through the calcaneus.
521
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one another, detaching any decussating tendons at the walking cast, and weight bearing is allowed. A rehabilita-
knot of Henry to allow the FHL to be withdrawn tion program for strengthening and range of motion is
through the posterior incision. begun 8 weeks postoperatively. Running, jumping, and
We prefer to transfer the tendon through a hole in impact sports such as soccer and volleyball are restricted
the calcaneus tuberosity despite the level of the lesion for 6 months after surgery.
in the Achilles tendon (Fig. 22I-5). With the foot held
in approximately 10 to 15 degrees of plantarflexion,
the tendon of the FHL is passed through the hole from REFERENCES
medial to lateral and sutured to itself with absorbable
suture. The FHL and the gastrocnemius-soleus complex
1. Cohen M, et al: Lesões ortopédicas no futebol, Rev Bras Ortop
are sutured together proximally.
32:940, 1997.
2. Nery C: Tornozelo e Pé–Diagnóstico e Tratamento. In Cohen M,
Postoperative protocol editor: Lesões nos Esportes, São Paulo, 2003, Revinter.
Full recovery takes an average of 6 months. At this time 3. Milani C, et al: Lesione osteocondrale dell’alluce in giocatori di
the patient may resume all sport activities, including soc- cálcio sulla spiaggia. In Turra S, editor:. Ortopedia e Traumatologia
delo Sport in Etá Evolutiva, SIOT, Pisa, 1994.
cer. After surgery, compressive dressings and plaster are
4. Wapner KL, et al: Repair of chronic Achilles tendon rupture with
applied to maintain 15 degrees of ankle plantarflexion. flexor hallucis longus tendon transfer, Foot Ankle 14:443, 1993.
Before discharge, the patient is placed in a short-leg, 5. Hansen ST: Trauma to the heel cord. In Jahss MH, editor: Disorders of
nonweight-bearing cast at 15 degrees of equinus for the foot and ankle, ed 2, Philadelphia, 1991, WB Saunders.
2 weeks. At that time the sutures are removed and the 6. Frenette JP, Jackson DW: Lacerations of the flexor hallucis longus
in the young athlete, J Bone Joint Surg 59-A:673, 1977.
wound inspected. Then, another short-leg, nonweight-
7. MacConaill MA, Basmajian JV: Muscles and movements. A basis for
bearing cast at 15 degrees of equines is placed for 2 more human kinesiology, Baltimore, 1969, William & Wilkins.
weeks. Following that period, the ankle is positioned 8. Vianna V, Vianna S: Ruptura Crônica do tendão de Aquiles: reparo
into neutral for an additional 4 weeks of a short-leg com tendão flexor longo do hálux, Ver Brás Ortop 31:542, 1996.
J. Footballer’s (soccer) ankle in Venezuela

Gabriel Khazen and Cesar Khazen
Football (soccer) is the most popular sport worldwide, The exact etiology of this syndrome is still unknown,
and even though Venezuela does not have a strong although there are many hypotheses that have attempted
reputation for its national team, football is the favorite to explain it. The first and traditionally accepted is
sport among young people in our country. Although McMurray’s hypothesis that recurrent traction on the
baseball has a better organization and infrastructure, joint capsule during forced ankle plantarflexion when
particularly for teenagers and professionals, football can kicking the ball was the cause of these osteophytes.
be played anywhere by any number of players and needs However, recent studies have shown that the capsule
only a ball made of any material. For these reasons it is par- attaches on average 6 mm proximal to the anterior carti-
ticularly popular with people of all socioeconomic means. lage rim in the tibia and 3 mm distal to the cartilage
The special characteristics of this sport make its ath- border of the talus, where the osteophytes form.3 Other
letes prone to acute and overuse injuries.1 Footballer’s hypotheses suggest that direct trauma to the rim of the
ankle is characterized by chronic anterior ankle imping- anterior ankle cartilage in combination with recurrent
ing tibial and/or talar osteophytes, resulting in painful microtrauma caused by the soccer ball impact, will
limited range of motion, mainly in dorsiflexion. It was induce inflammation and scar tissue, which calcifies and
first described by Morris in 1943; McMurray2 in 1950 forms the osteophytes4 (Fig. 22J-1).
named it footballer’s ankle and suggested osteophyte Massada5 described the morphologic adaptation of the
excision as treatment. It has been reported that this talus in football players to compensate for overuse and
pathology can affect 50% or 60% of the professional overstress; these changes produced in the talus by the
football players, but it has been described in many other impingement of the anterior articular distal epiphysis
activities, such as running and dancing. of the tibia can be similar to the ‘‘squatting facet’’ found
522
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Clinical evaluation
Figure 22J-1 Forced ankle plantarflexion and direct trauma Figure 22J-2 The majority of football grounds are uneven and
when kicking the ball. sandy in Venezuela.
in certain societies in which this crouched position is

common. In these situations, the exostoses would be with-
out important clinical significance in the majority of cases.
Ankle instability seems to be an important issue in
this pathology; Cannon and Hackney6 described osteo-
phyte formation and recurrence when lateral ankle insta-
bility was not addressed at the time of resection of the
impinging lesions. Conversely, there was no osteophyte
recurrence following resection when anatomic lateral
ligament reconstruction was performed in the presence of
lateral ankle instability. This may be the key to the high
incidence of footballer’s ankle in Venezuela; most of the
patients with this syndrome on whom we have had to oper-
ate needed simultaneous anatomic lateral ankle ligament
reconstruction. Perhaps in our country two factors are
responsible for this. First, because most of the football
grounds are uneven and sandy, there is a higher incidence
Figure 22J-3 There is a higher risk of ankle sprain in uneven
of ankle sprain and subsequent instability. Second, the
grounds.
majority of the population cannot afford appropriate
footwear and equipment, leaving them more vulnerable
to injury when an accident occurs (Figs. 22J-2 and 22J-3). motion is limited and painful, mostly in ankle dorsiflex-
ion. Pain might be caused by synovial impingement
between the osteophytes and the distal tibia or talar
bone surface. It is important to note that 45% of football
CLINICAL EVALUATION
players with anterior ankle osteophytes are asympto-
matic. In advanced cases, osteophytes can be palpated,
The main symptom of footballer’s ankle is anterior ankle and generalized synovitis may cause important swelling.
pain. Patients complain of joint stiffness and pain, Joint stability should be examined carefully. We like
exacerbated by activities that force ankle dorsiflexion to perform an ankle anterior drawer test to assess ante-
such as walking uphill or squatting. McMurray in 1950 rior talofibular ligament. Subtalar forced inversion with
pointed out that the footballer manifested stronger 15-degrees ankle dorsiflexion is used to test the calca-
pain when kicking a ‘‘dead ball.’’ Physical examination neofibular ligament.
should be performed carefully to establish a diagnosis Other causes of anterior ankle pain should be ruled
and eliminate other causes of ankle pain and impinge- out, including talar or tibial osteochondral defects; loose
ment. Palpation of the anterior distal tibia and dorsal bodies; tendinitis; rheumatoid, posttraumatic, or crystal-
talus causes tenderness and discomfort; and range of line arthropathies; and pigmented villonodular synovitis.
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Figure 22J-4 X-ray showing characteristic anterior tibial and

talar osteophytes in footballer’s ankle.
ADDITIONAL STUDIES
Ankle anterior-posterior (AP), lateral, and mortise view

radiographs should be performed routinely. Anterior tib-
ial and talar neck osteophytes can be seen in lateral views
and are described as ‘‘kissing’’ osteophytes.7 Recently, an
oblique anteromedial view has been suggested, with the Figure 22J-5 X-ray showing characteristic medial tibial and
radiographic beam tilted in a 45-degree craniocaudal medial talar osteophytes in footballer’s ankle.
direction with the leg in 30-degrees external rotation to
detect medially located tibial and talar osteophytes8
first, with rest, braces, nonsteroidal anti-inflammatory
(Figs. 22J-4 and 22J-5).
medication, and physical therapy.
Anterior and lateral stress radiographs under sedation
If conservative treatment fails to diminish pain and
or general anesthesia should be performed if lateral
restore joint function in the absence of advanced joint
ankle stability is suspected. Although the efficacy of this
osteoarthritis, osteophyte removal is the treatment of
study is hotly debated, we think it is helpful. Most of the
choice. This procedure can be performed arthroscopi-
studies that found this procedure unreliable were done
cally or by small arthrotomy. Arthroscopy has the advan-
in vitro; the few studies made in vivo show good corre-
tage of being a minimally invasive procedure and
lation between lateral stress radiographs and instability.
provides a magnified and extensive ankle view, with a
Computed tomography (CT) scan is a helpful in
low risk of complications.10-12
determining the precise size and location of osteophytes.
We like to place the patient supine on the operating
Berberian et al.9 showed that talar spurs on average lie
table, with the ipsilateral hip and knee flexed 45 degrees
medial to the midline of the talus and that tibial spurs
and supported by a leg holder. A tourniquet is applied
are wider and lie lateral to the midline. Thus overlapping
and, after draping, the ankle is placed in a noninvasive
spurs are less likely.
distractor and force is applied. The ankle joint, tibialis
Magnetic resonance imaging (MRI) should be
anterior tendon, and superficial peroneal nerve are
ordered if the diagnosis is not clear or concomitant
delineated in the skin as landmarks to safe and correct
soft-tissue lesions must be identified.
portals placement. We create the anterolateral portal
through a 1-cm longitudinal skin incision, 1 cm lateral
to the superficial peroneal nerve at the ankle joint level
TREATMENT that has been identified previously with an 18-gauge
needle. Careful dissection of the joint is performed
The treatment of the footballer’s ankle depends on the with a hemostat and a 3.5-mm arthroscope is inserted
duration and severity of symptoms as well as the ankle (we use this arthroscope size because it gives a larger
joint condition. Conservative treatment should be attempt ankle view). The anteromedial portal is identified under
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Treatment
direct vision (from the anterolateral portal) and a needle

inserted 0.5 cm medial to the tibialis anterior tendon,
following the same steps for the anterolateral portal.
First we perform a joint evaluation, examining the
medial gutter and deltoid ligament and looking for the
presence of tibial or talar chondral defects. The lateral
gutter, anterior inferior tibiofibular ligament, anterior
talofibular ligament, calcaneofibular ligament, and joint
synovium are visualized.
Shaving of synovitis, scar tissue, and any ligament
thickening is performed first, to improve joint space
and osteophyte visualization.
Anterior tibial and talar osteophytes can be reached
without joint distraction; extensive distal tibia and talus
evaluation is performed, switching portals to identify the
position and extent of the osteophytes, which are de-
brided aggressively with a powered 4.0 burr. Intraoperative
ankle fluoroscopy or radiographs can be used to assess
osteophyte resection (Figs. 22J-6, 22J-7, and 22J-8).
If mechanical lateral ankle instability is present, it Figure 22J-7 Anterior tibial osteophyte arthroscopic
should be addressed in the same procedure by anatomic debridement with a powered 4.0-mm burr.
lateral ankle ligament reconstruction; we like to perform
the Brostrom-Gould technique. As stated earlier, we After the procedure, we recommend that our patients
believe that ankle instability and anterior ankle osteo- avoid weight bearing on the operated ankle for 8 days
phytes are causally related, and thus combined surgery and start active and passive ankle motion on the third
for both conditions may reduce the recurrence of exos- postoperative day; a week later physiotherapy is begun
tosis as well as improve the outcome. to improve ankle range of motion, tendon strengthen-
In the presence of large or abundant osteophytes, ing, and proprioception.
open resection can be performed by extending the If the patient requires lateral ankle ligament reconstruc-
arthroscopy portals. In case lateral ligament reconstruction, we immobilize the ankle in a cast for 4 weeks and then
tion is necessary, the osteophytes can be removed by put the patient in a sport Aircast (DJO, San Diego, CA)
direct vision, slightly extending the incision. brace to be worn day and night for 4 weeks and then only
Figure 22J-8 Anterior distal tibia after arthroscopic

Figure 22J-6 Anterior tibial osteophyte arthroscopic image. osteophyte debridement.
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during the night for another 2 weeks. We start passive the patients played in the veterans’ football division;
physiotherapy at 4 weeks postoperatively in these patients one patient could return to play at the same level, and
and active physiotherapy at 6 weeks postoperatively. one patient needed subsequent ankle arthrodesis.
Good results have been reported widely for arthro-
scopic resection of anterior bony ankle impingement.
Olesen reported that dorsiflexion improved in 59% of COMPLICATIONS
the patients, 70% had less pain, and 59% returned to sports,
but 23% had given up because of the symptoms.10,11
Tol et al.13 reported a mean 6.5-year follow-up for The incidence of complications after this procedure
arthroscopic excision of soft-tissue overgrowth and is low. The main complication can be neurovascular
osteophytes. They found that patients without osteoar- damage related to the portal placement, infection, and
thritis all had excellent or good results; patients with formation of scar tissue.
grade I osteoarthritis had 77% good or excellent results, Osteophyte recurrence is the main chronic compli-
despite two thirds of the patients developing partial or cation and, although the incidence has been discussed
complete recurrence of osteophytes. Fifty-three percent earlier in this chapter, it is clear that an aggressive and
of the patients with grade II osteoarthritis had excellent efficacious osteophyte resection and a stable ankle joint
or good results without joint narrowing progression. leads to a satisfactory result and the least incidence of
Between 1999 and 2002 we operated on 36 footbal- osteophyte recurrence.
lers with anterior ankle osteophytes who had not achieved
symptomatic improvement with conservative treatment.
Seventeen were high-level footballers, and the rest played REFERENCES
for local leagues. The age of the patients ranged between
23 and 48 years. Fourteen patients needed anatomic lat- 1. Lees A, Nolan L: The biomechanics of soccer: a review, J Sports Sci
eral ankle ligament reconstruction because of mechanical 16:211, 1998.
lateral ankle instability. Using the Scranton McDermott 2. McMurray TP: Footballer’s ankle, J Bone Joint Surg 32B:68, 1950.
classification, 21 patients were classified as either type I 3. Tol JL, van Dijk C: Etiology of the anterior ankle impingement
syndrome: a descriptive anatomical study, Foot Ankle Int 25:382,
or II (type I: tibial spurs 3 mm or less; type II: tibial spurs
2004.
larger than 3 mm without talar spurs); 9 patients were 4. Tol JL, Slim E, van Dijk CN: The relationship of the kicking
type III (tibial and talar osteophytes), and 6 patients were action in soccer and the anterior ankle impingement syndrome.
classified as type IV (tibial and talar osteophytes with A biomechanical analysis, Am J Sports Med 1:1, 2001.
ankle joint osteoarthritis signs). 5. Massada JL: Ankle overuse injuries in soccer players.
Morphological adaptation of the talus in the anterior
Seventeen of 21 patients with type I or II underwent
impingement, J Sports Med Phys Fitness 31:447, 1991.
follow-up examination. Fifteen reported less pain in 6. Cannon LB, Hackney RG: Anterior tibiotalar impingement associated
the ankle after the surgery (visual analog scale [VAS]); with chronic ankle instability, J Foot Ankle Surg 39:383, 2000.
12 patients experience improvement in their range of 7. Robinson P, White LM: Soft-tissue and osseous impingement
the ankle dorsiflexion by 5 degrees or more; 15 patients syndromes of the ankle: role of imaging in diagnosis and
management, Radiographics 22:1457, 2002.
returned to play at the same level; and only 3 patients
8. Van Dijk CN, et al: Oblique radiograph for the detection of bone
experienced recurrence of tibial osteophyte. spurs in anterior ankle impingement, Skeletal Radiol 31:214, 2002.
Eight of 9 patients with type III ankle osteophytes were 9. Berberian W, et al: Morphology of tibiotalar osteophytes in
available for follow-up. Because of the size of the osteo- anterior ankle impingement, Foot Ankle Int 22:313, 2001.
phytes, 4 of these patients needed a small arthrotomy for 10. Ogilvie-Harris DJ, Mahomed N, Demaziere A: Anterior
impingement of the ankle treated by arthroscopic removal of bony
the resection; 5 of the patients reported less ankle pain
spurs, J Bone Joint Surg 75-B:437, 1993.
after the procedure (visual analog scale [VAS]); 4 experi- 11. Olesen S, Breddam M, Nielsen AB: ‘‘Footballer’s ankle.’’ Results
enced improvement in the range of ankle dorsiflexion by of arthroscopic treatment of anterior talocrural ‘‘impingement,’’
5 degrees or more; 5 players returned to play at the same Ugeskr Laeger 163:3360, 2001.
level and 3 experienced recurrence of ankle osteophytes. 12. Rasmussen S, Hjort Jensen C: Arthroscopic treatment of
impingement of the ankle reduces pain and enhances function,
Of the four patients with type IV ankle osteophytes,
Scand J Med Sci Sports 12:69, 2002.
three needed open resection of the osteophytes; two 13. Tol JL, Verheyen CP, van Dijk CN: Arthroscopic treatment
reported less pain after the procedure (VAS); and none of anterior impingement in the ankle, J Bone Joint Surg 83-B:9,
experienced improvement in ankle dorsiflexion. All of 2001.
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Biology
K. The biologic perspective of sports disorders

affecting foot and ankle
Mohammad Zafar, Ansar Mahmood, and Nicola Maffulli
INTRODUCTION and tendinitis should be used only after histopathologic

examination. Various types of degeneration may be seen
in tendons, but in the Achilles tendon mucoid or lipoid
Achilles tendinopathy is common among athletes. Its
degeneration is usually found.
prevalence is approximately 11% in runners, 9% in dancers,
and less than 2% in tennis players.
Healing
Tendon healing occurs in three overlapping phases. The
initial inflammatory phase comprises recruitment of
BIOLOGY
inflammatory cells, phagocytosis of necrotic materials,
release of vasoactive factors, initiation of angiogenesis,
Etiology and stimulation of tenocyte proliferation.
The etiology of tendinopathy remains unclear, and many After a few days, the proliferative phase begins.
factors have been implicated. Tendon injuries can be Synthesis of type III collagen peaks during this stage,
acute or chronic and are caused by intrinsic or extrinsic which lasts for a few weeks.
factors, either alone or in combination. Overuse injuries After approximately 6 weeks, the remodeling phase
generally have a multifactorial origin. Tendon vascularity, commences, with decreased cellularity and decreased
gastrocnemius-soleus dysfunction, age, gender, body collagen and glycosaminoglycan synthesis, and the repair
weight and height, pes cavus, and lateral ankle instability tissue changes from cellular to fibrous. A higher propor-
are common intrinsic factors. Excessive motion of the tion of type I collagen is synthesized during this stage.
hindfoot in the frontal plane, especially a lateral heel After 10 weeks, the maturation stage occurs, with
strike with excessive compensatory pronation, is thought gradual change of fibrous tissue to scar-like tendon tissue
to cause a‘‘whipping action’’ on the Achilles tendon and over the course of 1 year. During the latter half of
predispose it to tendinopathy. this stage, tenocyte metabolism and tendon vascularity
Changes in training pattern, poor technique, exces- decline.
sive loading, previous injuries, footwear, and environ-
mental factors such as training on hard, slippery, or Role of metalloproteases and growth factors
slanting surfaces are common extrinsic factors. In acute Matrix metalloproteases (MMPs), a family of zinc and
trauma, extrinsic factors predominate. calcium-dependent endopeptidases active at a neutral
Free radical damage occurring on reperfusion after pH, are important regulators of extracellular matrix
ischemia, hypoxia, hyperthermia, impaired tenocyte remodelling via their broad proteolytic capability, and
apoptosis, cytokines, prostaglandins, and fluoroquino- their levels are altered during tendinopathy. Twenty-
lones have all been linked with tendinopathy. three human MMPs have been identified, with a wide
range of extracellular substrates. MMPs can be sub-
Histopathology divided into four main groups: collagenases, gelatinases,
Histologically, tendinopathy is characterized by an stromelysins, and membrane-type MMPs. Some of the
absence of inflammatory cells and a failed healing studies suggest that MMP-9 and MMP-13 participate
response, with noninflammatory intratendinous collagen only in collagen degradation, whereas MMP-2, MMP-3
degeneration, fiber disorientation and thinning, hyper- and MMP-14 participate in both collagen degradation
cellularity, scattered vascular in-growth, and increased and collagen remodelling. Wounding and inflammation
interfibrillar glycosaminoglycans. Frank inflammatory also provoke release of growth factors and cytokines from
lesions and granulation tissue are infrequent and are platelets, polymorphonuclear leukocytes, macrophages,
associated mostly with tendon ruptures. and other inflammatory cells. These growth factors
Hence the term tendinopathy should be used as a induce neovascularization and chemotaxis of fibroblasts
generic descriptor of the clinical conditions in and around and tenocytes and stimulate proliferation of fibroblast
tendons arising from overuse, and the terms tendinosis and tenocytes, as well as synthesis of collagen.
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Insulin-like growth factor (IGF) is expressed in avian MSCs can be applied directly to the site of injury or
flexor tendons and induces tenocyte migration, division, can be delivered on a suitable carrier matrix, which func-
and matrix expression. IGF-I and II increase collagen tions as a scaffold while tissue repair takes place.
synthesis in a dose-dependent manner in animal models Tissue engineering also may prove useful for manag-
and also increase proteoglycan synthesis ing tendon ruptures. A 1-cm-long gap injury model in
IGF-I acts synergistically with platelet-derived growth rabbit Achilles tendons was used to compare suture
factor BB (PDGF) to stimulate tenocyte migration. alone versus a cell-collagen gel composite contracted
Intratendinous injection of IGF-1 has been evaluated onto a pretensioned suture. Evaluation at 4, 8, and 12
in a rat Achilles tendon transection model. Rats in the weeks following surgery revealed that structural and
IGF-1–treated group had higher Achilles functional material properties of the cell-treated implants typically
index scores and accelerated recovery compared with were approximately twice the value of controls. Cell-
control groups treated repairs were larger in cross section and histologi-
Vascular endothelial growth factor (VEGF) is an cally better organized than suture alone repairs.
endothelial mitogen that promotes angiogenesis and Polyglycolic acid scaffolds seeded with tenocytes were
increases capillary permeability. It is expressed in rup- implanted into hen flexor tendon defects. Twelve weeks
tured and fetal human Achilles tendons but not in nor- after surgery, tenocytes and collagen fibers became
mal adult Achilles tendons. VEGF plays a key role in longitudinally aligned. At 14 weeks, engineered tendons
tendon healing by inducing vasodilatation results partly displayed a typical tendon structure, with a breaking
through stimulation of nitric oxide synthase in endothe- strength of 83% of normal.2
lial cells. At present, tissue engineering is an emerging field,
VEGF treatment at the time of surgical repair of and many difficulties must be overcome before it
transected rat Achilles tendons resulted in significantly becomes a real option in the management of tendon dis-
improved tensile strength at 2 weeks. However, no orders. It is important to determine whether effective
significant difference was present by 4 weeks.1 vascularization and innervation of implanted tissue-
Increased levels of transforming growth factor b2 engineered constructs takes place. Vascularization is
(TGF-b2) have been reported in tendinopathic human important for the viability of the construct. Innervation
Achilles tendons and in rabbit flexor tendons after is required for proprioception and to maintain reflexes,
injury. TGF-b induces increased collagen production in mediated by Golgi tendon organs, to protect tendons
rabbit tenocytes, and upregulation of TGF-b receptors from excessive forces.
occurs following flexor tendon injury and in tendino-
pathic human Achilles tendons. Gene therapy
Cartilage-derived morphogenetic proteins (CDMPs), Gene therapy delivers genetic material to cells to alter
the human analogs of growth and differentiation factors, protein synthesis and cell function and can be achieved
are members of the TGF- superfamily and are related to via viral vectors or liposomes. Liposome constructs
bone morphogenetic proteins. Injection of CDMP-1, have been used to deliver galactosidase to rat patellar
CDMP-2, and CDMP-3 into lacerated rat Achilles ten- tendons. Animal studies have demonstrated that gene
dons results in a significant dose-related increase in therapy can be used to alter the healing environment
strength and stiffness. of tendons. Adenoviral transfection of focal adhesion
Not all cytokines prove beneficial for tendon heal- kinase into partially lacerated chicken flexor tendons
ing. The ideal cytokine or combinations of cytokines resulted in an expected increase in adhesion formation.
that will improve tendon healing are still to be deter- Although this study reports an adverse outcome, it
mined. Cytokine effects often are dose dependent, and proves the feasibility of gene therapy as a management
optimal dosage regimes must be established. The ideal modality.3
form of administration also remains to be determined. Complementary deoxyribonucleic acid (cDNA) for
Options include direct injection at the injury site or PDGF–B was transfected into rat patellar tendons using
gene therapy. Further research will help to resolve these liposomes, resulting in an early increase in angiogenesis,
issues. and collagen deposition and matrix synthesis were
greater at 4 weeks. However, there were no differences
Tissue engineering/stem cells between the treated and control groups by 8 weeks.
Mesenchymal stem cells (MSCs) prevalent in bone Gene therapy can be used to manipulate the healing envi-
marrow, muscle, fat, skin, and around blood vessels are ronment for up to 8-10 weeks. This may be long enough
capable of undergoing differentiation into a variety of to be clinically significant. Many genes may prove beneficial
specialized mesenchymal tissues, including bone, tendon, to tendon healing, and further research is required to estab-
cartilage, muscle, ligament, fat, and marrow stroma. lish the most advantageous genes to transfer.
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Principles of tendinopathy management
to work when compared with concentric exercise,

PRINCIPLES OF TENDINOPATHY
stretching, splinting frictions, and ultrasound. EEs are
MANAGEMENT
low cost, relatively easy to perform and noninvasive.
The results can be seen after 12 weeks of daily EE
Conservative management training.5
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Laser therapy
Although tendinopathy is a noninflammatory condition,
NSAIDs are widely used in attempts at treatment. There Laser therapy also has been studied in tendon healing.
is no biologic basis for NSAID effectiveness in treating Using a placebo-controlled, double-blind prospective
this condition, and no evidence of any benefit particu- study model in 25 patients with 41 digital flexor tendon
larly in athletes. NSAIDs appear to be effective, to some repairs, laser therapy reduced postoperative edema but
extent, only for pain control. This causes patients to provided no improvement in pain, grip strength, or
ignore early symptoms and thus may lead to further functional evaluation compared with controls.6 Further
damage of the tendon and delay definitive healing. The- well-controlled clinical studies should be performed
oretically NSAIDs could benefit patients with tendinop- using different laser types and dosages to delineate the
athy by increasing the tensile strength of tendons via role of laser phototherapy in the management of tendon
accelerated formation of cross linkages between collagen injuries.
fibers. COX-2 inhibitors should be avoided in the early
period following tendon injury because of their deleteri- Radiofrequency coblation
ous effect on tensile strength. During remodelling, on This is a new application of bipolar radiofrequency
the other hand, inflammation has a negative influence, energy used for volumetric tissue removal. Under appro-
and NSAIDs such as COX-2 inhibitors might be valuable priate conditions, a small vapor layer forms on the active
for the final outcome. electrode of the device. The electrical field of on the
energized electrode causes electrical breakdown of
Aprotinin the vapor, producing a highly reactive plasma that is able
to break down most of the bonds found in soft-tissue
In recent years, aprotinin has been used in the manage- molecules. Rapid pain relief has been reported in a pre-
ment of chronic tendinopathy. Aprotinin is a broad liminary prospective, nonrandomized, single-center, sin-
spectrum serine protease inhibitor derived from bovine gle-surgeon study of 20 patients with tendinopathy of
lungs. It acts on trypsin, plasmin, and kallikrein, blocks the Achilles tendon, patellar tendon, and of the com-
matrix metalloproteinases, and may specifically act as a mon extensor origin. Six months after the procedure,
collagenase inhibitor in tendinopathy. magnetic resonance imaging (MRI) showed complete
Until recently, evidence for aprotinin use in the man- or nearly complete resolution of the tendinopathy lesion
agement of Achilles tendinopathy was based on uncon- in 10 of the 20 patients enrolled in the study.7
trolled studies, reporting success rates of approximately
80%. In the only randomized controlled trial to examine Sclerosing injections
the role of aprotinin in Achilles tendinopathy, the
Using ultrasonography and color Doppler during eccen-
authors concluded that there was no statistical signifi-
tric calf-muscle contraction, we found that the flow in
cant improvement in outcome. However, this study
the neovessels disappeared when the ankle was dorsi-
was underpowered.4
flexed. These observations raised the question of whether
The main reported side effect of aprotinin is that
the good clinical effects demonstrated with eccentric
of allergic reactions. The risk of hypersensitivity/ana-
training could be due to action on the neovessels, and
phylactic reaction with aprotinin is less than 0.1% on
whether the neovessels and accompanying nerves were
first exposure but rises to 2.7% with re-exposure.
the main source of pain. In a recent study, ultrasound
Maffulli has used aprotinin since 1988 for the man-
and color Doppler follow-up showed that most patients
agement of chronic tendinopathy in more than 1200
with good clinical results had no residual neovessels.
patients. To his knowledge, only two cases of systemic
Patients with a poor result showed residual neovasculari-
allergic reactions have been reported, both in middle-
zation. These findings indicate that the area with neoves-
aged active but nonathletic women.
sels may be important to the pain suffered during Achilles
tendon loading activity.8
Eccentric exercise In a further noncontrolled pilot study, a sclerosing
Limited levels of evidence exist to suggest that Eccentric agent (Polidocanol) was injected into the area with neo-
Exercise (EE) has a positive effect on clinical outcomes vessels on the ventral side of the tendon. The short-term
such as pain, function, and patient satisfaction/return (6 months) results were promising, but no real benefit
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was achieved in long term.9 For this reason we do not and protein synthesis in human tenocytes. Even 15 min-
use sclerosing injections in our center. However, the utes of cyclic biaxial mechanical strain applied to human
results of a randomized controlled study comparing tenocytes results in cellular proliferation.
the effects of injections of a sclerosing substance with The precise mechanism by which cells respond to
injections of a nonsclerosing substance are presently load remains to be elucidated. However, cells must
under evaluation. respond to mechanical and chemical signals in a coordi-
nated fashion. Intercellular communication to mount
Shock wave therapy mitogenic and matrigenic responses is achieved via gap
Several studies evaluated the application of electrical and junctions ex vivo. Tissue-engineered tendons must
magnetic fields to tendons. Pulsed magnetic fields with allow for this intercellular communication. Mechanical
a frequency of 17 Hz resulted in improved collagen loading of cells in monolayer or three-dimensional
fiber alignment in a rat Achilles tendinopathy model.10 constructs can result in increased cell proliferation and
Extracorporeal shock wave therapy applied to rabbit collagen synthesis.
Achilles tendons at a rate of 500 impulses of 14 kV in
20 minutes resulted in neovascularization and an
increase in the angiogenesis-related markers endothelial SURGICAL MANAGEMENT
nitric oxide synthase and vascular endothelial growth
factor. Extracorporeal shock wave therapy also promotes
healing of Achilles tendinopathy in rats. The authors Indications
proposed that improvement in healing resulted from Surgery is recommended for patients in whom non-
an increase in growth factor levels, because they noted operative management has proved ineffective for at least
elevated levels of TGF-1 in the early stage and persis- 6 months. Twenty-four percent to 45.5% of the patients
tently elevated levels of IGF-1.11 However, caution with Achilles tendon problem fail to respond to
should be exercised when using extracorporeal shock conservative treatment and eventually require surgical
wave therapy because dose-dependent tendon damage, intervention. Paavola et al., in a prospective long-term
including fibrinoid necrosis, fibrosis, and inflammation, follow-up study, showed that the prognosis of patients
has been reported in rabbits. with acute to subchronic Achilles tendinopathy managed
nonoperatively is favorable.12
Glyceryl trinitrate
Review of literature showed that tropical Glyceryl trinitrate Principles of surgery
(GTN) is a well-tested medication with no irreversible side There are minor variations in surgical technique for tendi-
effects and that use of this therapy is warranted to treat nopathy. Nevertheless, the objective is to excise fibrotic
chronic tendinopathies. However, further investigations adhesions, remove degenerated nodules, and make
are required to define the mechanism of action of GTN multiple longitudinal incisions in the tendon to detect
in tendinopathy and to delineate the most effective dosage intratendinous lesions and to restore vascularity, and
regime to maximize effect and limit side effects. possibly to stimulate the remaining viable cells to initiate
cell matrix response and healing. Most authors report
Mobilization and mechanical loading excellent or good result in up to 85% of cases.13,14
Animal experiments have demonstrated that training Management of paratendinopathy includes releasing
results in improved tensile strength, elastic stiffness, the crural fascia on both sides of the tendon. Adhesions
along with increase in weight, and cross-sectional area around the tendon are then trimmed and the hyper-
of tendons. These effects in the tendon can be explained trophied adherent portions of the paratenon are excised.
by an increase in collagen and extracellular matrix syn- In tenolysis, classically longitudinal tenotomies are made
thesis by tenocytes. Little data exist on the effect of exer- along the longitudinal axis of the tendon in the abnormal
cise on human tendons, although intensively trained tendon tissues, excising areas of mucinoid degeneration.
athletes are reported to have thicker Achilles tendons Reconstruction procedure may be required if large lesions
than control subjects. are excised.
Early resumption of activity promotes restoration of
function, and motion therapy strategies aim to facilitate Preoperative planning
healing, reduce adhesion formation, and increase range Each patient should be managed on an individual basis,
of motion. Many studies have shown the benefit of early and appropriate workup for theatre should be instituted.
mobilization following tendon repair, and several post- Diagnosis is made on the basis of history of burning pain
operative mobilization protocols have been advocated. in the posterior aspect of the calf and ankle, often worse
Repetitive motion results in increased DNA content at the beginning of a training session and after exercise.
530
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Surgical management
Some patients have difficulty taking the first few steps in obliquely because transverse excision may produce a
the morning. Pain during activities of daily living constriction ring, which may require further surgery.
include prolonged walking and stairs. Areas of thickened, fibrotic, and inflamed tendon are
Clinically, diagnosis is made mostly on the basis of excised. The pathology is identified by the change in
palpation and on the use of the painful arc sign. In para- texture and color of the tendon. The lesions then are
tendinopathy, the area of tenderness and thickening excised, and the defect can either be sutured in a side-
remains fixed in relation to the malleoli when the ankle to-side fashion or left open. Open procedures on the
is moved from full dorsiflexion into plantarflexion. If Achilles tendon may lead to difficulty with wound heal-
the lesion lies within the tendon, the point of tenderness ing because of the tenuous blood supply and increased
and any swelling associated with it move with the ten- chance of wound breakdown and infection. Hemostasis
don as the ankle is brought from full dorsiflexion into is important because the reduction of postoperative
plantarflexion. In mixed lesions, both motion and fixa- bleeding speeds up recovery, diminishes the chance of
tion of the swelling and of the tenderness can be wound infection, and diminishes any possible fibrotic
detected in relation to the malleoli. inflammatory reaction.
Ultrasound scan is a diagnostic aid to the surgeon. In patients with isolated Achilles tendinopathy with
Ideally, a real time U.S. machine equipped with at least no paratendinous involvement and a well-defined nodu-
a 10-MHz sectorial transducer should be used. Com- lar lesion less than 2.5 cm long, multiple percutaneous
mercially available soft polymer echo-free material can longitudinal tenotomies can be used when conservative
be used to provide adequate contact between the skin management has failed. An ultrasound scan can be
and the probe and to improve the image quality by plac- used to confirm the precise location of the area of
ing the tendon in the optimal focal zone of the trans- tendinopathy.
ducer. The variables considered in the evaluation of the
tendon and of the peritendinous tissues are tendon size Postoperative management
and borders, intratendinous and peritendinous ultra-
On admission, patients are taught to perform isometric
sonographic pattern, and possible surgical sequelae. An
contractions of their triceps surae. Patients are instructed
ultrasonographic diagnosis of tendinopathy can be made
to perform the isometric strength training at three differ-
when the tendon presents altered intratendinous struc-
ent angles, namely at maximal dorsiflexion, maximal
ture, at times with a well-defined focus. An ultrasono-
plantarflexion, and at a point midway between the two.
graphic diagnosis of paratendinopathy is made when
The foot is kept elevated on the first postoperative
the peritenon is thickened or shows altered echogenicity.
day, and nonsteroidal anti-inflammatory medications
Any relevant comorbidity should be highlighted and
are given for pain control. Early active dorsiflexion and
managed. Although the techniques reported in this arti-
plantarflexion of the foot are encouraged. On the sec-
cle are performed under local anesthesia, there is a small
ond postoperative day, patients are allowed to walk
chance that general anesthesia may be necessary, and
using elbow crutches, weight bearing as able. Full
therefore baseline investigations such as blood tests,
weight bearing is allowed after 2 or 3 days, when the
electrocardiogram and chest radiographs should be
bandage is reduced to a simple adhesive plaster over
undertaken if deemed necessary. Patients should have
the wounds. Stationary bicycling and isometric, concen-
deep vein thrombosis prophylaxis. Valid informed con-
tric, and eccentric strengthening of the calf muscles are
sent should be achieved before the operation, and the
started under physiotherapy guidance after 4 weeks.
patient should be aware of risks of infection, bleeding,
Swimming and water running are encouraged from the
wound and scar problems, and operation failure, and
second week. Gentle running is started 4-6 weeks after
that further surgery may be required.
the procedure, with mileage gradually increased. Hill
Surgical technique workouts or interval training are allowed after a further
6 weeks, when return to normal training is allowed.
When an open surgical approach is necessary, we use
Patients normally discontinue physiotherapy by the sixth
a longitudinal curved incision, with the concave part
postoperative month. For open surgery, the cast is
toward the tendon and centered over the abnormal part
applied for 2 weeks and the whole rehabilitation process
of the tendon. Placing the incision medially avoids
described above is started later.
injury to the sural nerve and short saphenous vein, and
the curvature of the incision prevents direct exposure
of the tendon in case of skin breakdown. Complications
The paratenon and crural fascia are incised and dis- Subcutaneous hematoma
sected from the underlying tendon. If necessary, the Superficial infection
tendon is freed from adhesions on the posterior, medial, Hypersensitivity of the stab wounds
and lateral aspects. The paratenon should be excised Hypertrophic painful scar
531
...........
formation focus on flexor tendons. Further research

DISCUSSION
is required to determine whether the results also are
applicable to extrasynovial tendons.
The management of Achilles tendinopathy aims to return
the patient to a level of activity similar to that before acqui-
sition of tendinopathy in the shortest possible time and CONCLUSION
without significant residual pain. Physiotherapy and conser-
vative treatment should be the first form of management. Tendon injuries give rise to significant morbidity, and at
If conservative measures fail, multiple percutaneous present only limited scientifically proven management
longitudinal tenotomy is simple, requires only local anes- modalities exist. A better understanding of tendon func-
thesia, and can be performed without a tourniquet. If tion and healing will allow specific management strategies
postoperative mobilization is carried out early, preventing to be developed. Many interesting techniques are being
the formation of adhesions, this will allow the return to pioneered. The optimization strategies discussed in this
high levels of activity in the majority of patients. article are currently at an early stage of development.
Although these emerging technologies may develop into
Current concepts and research/the future
substantial clinical management options, their full impact
Current management strategies, such as nonsteroidal must be critically evaluated in a scientific fashion.
anti-inflammatory drugs or corticosteroids, offer symp-
tomatic relief but do not result in definitive disease
resolution. Surgery may be appropriate for certain REFERENCES
patients, but recovery may be protracted and is asso-
ciated with pain and discomfort. The ideal management
1. Zhang F, Liu H, Stile F, et al: Effect of vascular endothelial
should accomplish its goal in a relatively short period of growth factor on rat Achilles tendon healing, Plast Reconstr Surg
time with little discomfort or disability to the patient. 112(6):1613–1619, 2003.
Novel management methods should aim to stimulate 2. Cao YL, Liu YT, Liu W, et al: Bridging tendon defects using
a healing response to restore the normal biomechanical autologous tenocyte engineered tendon in a hen model, Plast
properties of tendon. Reconstr Surg 110(5):1280–1289, 2002.
3. Lou J, Kubota H, Hotokezaka S, et al: In vivo gene transfer
and overexpression of focal adhesion kinase (pp 125 FAK)
Adhesion prevention mediated by recombinant adenovirus-induced tendon
The most important factor implicated in adhesion adhesion formation and epitenon cell change, J Orthop Res
formation is trauma. Many attempts have been made 15(6):911–918, 1997.
to reduce adhesion formation using materials acting as 4. Brown R, Orchard J, Kinchington M, et al: Aprotinin in the
management of Achilles tendinopathy: a randomised controlled
mechanical barriers such as polyethylene or silicone, or trial, Br J Sports Med 40:275–279, 2001.
using pharmacologic agents such as indomethacin and 5. Silbernagel KG, Thomee R, Rhomee P, Karlsson J: Eccentric
ibuprofen, but no simple method is widely used. overload training for patients with chronic Achilles tendon pain–a
Hyaluronate, a high molecular weight polysaccharide randomized controlled study with reliable testing of the evaluating
found in synovial fluid around tendon sheaths, decreased methods, Scand J Sports Med 11:197–206, 2001.
6. Ozkan N, Altan L, Bingol U, et al: Investigation of the
adhesion formation in rabbit flexor tendons. However, supplementary effect of GaAs laser therapy on the rehabilitation of
no statistically significant difference in adhesion forma- human digital flexor tendons, J Clin Laser Med Surg
tion was found in a rat Achilles tendon model.15 The 22(2):105–110, 2004.
absence of a synovial membrane around the Achilles ten- 7. Tasto JP, Cummings J, Medlock V, et al: The tendon treatment
don may explain this difference. 5-Fluorouracil, an anti- center: new horizons in the treatment of tendinosis, Arthroscopy
19(Suppl 1):213–223, 2003.
metabolite with anti-inflammatory properties, effectively 8. Öhberg L, Alfredson H: Effects on neovascularisation behind the
preserves tendon gliding in experimentally lacerated good results with eccentric training in chronic mid-portion
chicken flexor tendons.16 Achilles tendinosis? Knee Surg Sports Tramatol, Arthrosc online,
Physical modalities also have been used to try to limit 2004.
adhesion formation. Direct current applied to rabbit 9. Öhberg L, Alfredson H: Ultrasound guided sclerosing of
neovessels in painful chronic Achilles tendinosis: pilot study of a
tendons in vitro results in increased collagen type I pro- new treatment, Br J Sports Med 36:173–177, 2002.
duction and reduced adhesion formation. However, 10. Lee EW, Maffulli N, Li CK, Chan KM: Pulsed magnetic and
pulsed electromagnetic field stimulation resulted in no electromagnetic fields in experimental Achilles tendonitis in the
difference in adhesion formation in rabbit flexor tendons rat: a prospective randomized study, Arch Phys Med Rehab
after 4 weeks.17 78(4):399–404, 1997.
11. Chen YJ, Wang CJ, Yang KD, et al: Extracorporeal shock waves
Despite many efforts, adhesion formation after trauma promote healing of collagenase-induced Achilles tendinitis and
to tendons still remains a clinical problem, and no ideal increase TGF-beta1 and IGF-I expression, J Orthop Res
method of prevention exists. Most studies of adhesion 22(4):854–861, 2004.
532
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References
12. Paavola M, Paakkala T, Kannus P, et al: Ultrasonography in the 16. Khan U, Occleston NL, Khaw PT, McGrouther DA: Single
differential diagnosis of Achilles tendon injuries and related exposures to 5-fluorouracil: a possible mode of targeted therapy to
disorders, Acta Radiol 39:612–619, 1998. reduce contractile scarring in the injured tendon, Plast Reconstr
13. Anderson DL, Taunton JE, Davidson RG: Surgical management Surg 99(2):465–471, 1997.
of chronic Achilles tendonitis, Clin J Sport Med 2(1):39–42, 1992. 17. Greenough CG: The effect of pulsed electromagnetic fields on
14. Calder JD, Saxby TS: Surgical treatment of insertional Achilles flexor tendon healing in the rabbit, J Hand Surg Br 21
tendinosis, Foot Ankle Int 24(2):119–121, 2003. (6):808–812, 1996.
15. Tuncay I, Ozbek H, Atik B, et al: Effects of hyaluronic acid on
postoperative adhesion of tendocalcaneus surgery: an experimental
study in rats, J Foot Ankle Surg 41(2):104–108, 2002.
533
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.........................................C H A P T E R 2 3
Pediatric problems and rehabilitation geared

to the young athlete
Dan Kraft and Jerett Zippin
......................
CHAPTER CONTENTS
Introduction 535 Osteochondroses 541

Congenital problems 535 Nonarticular osteochondrosis 543
Developmental problems in young athletes 537 Conclusion 545
Acute injuries 538 References 545
Pediatric ankle fractures 539
INTRODUCTION symptoms. In many congenital problems, the natural

history is unmasked with the longer duration and
increased intensity of the activity, although the develop-
As young athletes become more active in organized and
mental and growth stage actually may be the determin-
specialized activities today, sports medicine physicians
ing factor in the onset of symptoms. Tarsal coalition is
are diagnosing an increasing number of both acute and
one congenital abnormality that may present in later ele-
overuse injuries in this age group. Many of these inju-
mentary- and middle school-aged athletes as they begin
ries involve the foot and/or ankle. These injuries often
increasing their participation in organized sports.
involve either the apophysis or the epiphysis and require
Tarsal coalition is a congenital bridging of two or more
specific treatment and care that is different from that for
tarsal bones of the foot, which can be either bony or soft
adults. The growth plates give young athletes a unique
tissue (cartilage or fibrous tissue). The overall incidence
set of problems and do not allow physicians to treat
of tarsal coalitions has been noted in studies to range from
the young patients simply as smaller versions of adults.
less than 3% to as high as 12.9% of the population.1 Coali-
In this chapter we review some of the major foot and
tions can be seen between any two tarsal bones, but the
ankle problems that are seen clinically in young athletes.
two most common types are calcaneonavicular (bilateral
The problems are grouped into congenital problems,
in 60%) and talocalcaneal coalitions (bilateral in 50%).2
developmental problems, acute injuries, and problems of
These athletes typically present when the coalition
osteochondroses. We discuss the approach to rehabili-
begins to ossify. In early childhood and at elementary
tation under each topic and in particular that which is
school age, coalition bridging is mostly nonossified,
most applicable to treatment of younger athletes.
which allows some motion between the bones and keeps
these patients typically asymptomatic.3 Motion becomes
CONGENITAL PROBLEMS restricted when the bridging begins to ossify between
8 and 12 years of age for the calcaneonavicular coalition
and between 12 and 16 years for the talocalcaneal coali-
Coalitions tion. This often is a prime age for middle school and
Congenital abnormalities often become symptomatic early high school athletes to raise the level of their play
when increased stress, such as intense activity, is applied and intensity, thus giving the appearance that the
to the area. Therefore an inactive child may not com- increased sports activity is causing the symptomatic foot
plain of pain until he or she enters organized sport and pain. In reality, the combination of the two factors
the congenital problem may appear to trigger the probably is the main reason for symptoms.
CHAPTER 23 Pediatric problems and rehabilitation geared to the young athlete
The young athlete may complain of insidious onset of in the young, symptomatic athlete may increase the risk
pain or remember an acute onset of arch, ankle, or mid- of arthritis later in life.
foot pain. The pain can be vague or localized over the
coalition and be due to many factors, such as inflam- Flexible flat feet
mation of the joints, nerve irritation or entrapment, Flat feet, or pes planus/pes valgus, is a common
muscle spasm, and microfractures (stress fractures) problem in young athletes. Pes planus is a normal foot
within the coalition.4,5 Any adolescent athlete with an position up to 6 years of age.8 Most young athletes with
inversion ankle injury that does not resolve after a full flat feet are asymptomatic and do not require any inter-
rehabilitation program should have tarsal coalition vention. Wenger et al.6 demonstrated that intervention
in the differential diagnosis. Other athletes who have with orthotics did not change the natural course of
not experienced an injury can present with pain located asymptomatic flat feet. The cause of this congenital
in the cuboid/navicular area that is aggravated by problem is excess laxity of the joint capsule and liga-
increased impact activities. ments, which allows the longitudinal arch to collapse
On physical examination, the patient classically pre- during weight bearing. The arch re-forms when non-
sents with a valgus heel, pronation deformity, and weight bearing and is accentuated with dorsiflexion of
abduction of the forefoot. The pronation deformity is the first toe.
rigid, meaning that the arch does not reform when A full examination should be performed in a young
nonweight bearing and is stiff to clinical examination. athlete with flat feet, whether symptomatic or not.
Furthermore, a weight-bearing calcaneal valgus is present Among other questions in the history, the clinician
and fails to go into varus on toe raising. This is distin- should determine the length of symptoms, the effect of
guishable from the usually asymptomatic flexible flatfoot, these symptoms on sports activity, and any systemic
which re-forms its arch with nonweight bearing. Subtalar symptoms. Subtalar motion is one factor that can help
motion is diminished on examination. Passive inversion differentiate pes planus from tarsal coalitions. The calca-
may elicit pain as the shortened peroneal tendon is neus should move passively between 20 and 60 degrees
stretched. Examination findings sometimes are subtle in of inversion and eversion. When Achilles tendon flexi-
early stages and may require further radiologic studies. bility is measured with the knee extended and the
Radiologic evaluation begins with plain films, which ankle/foot held in varus, ankle dorsiflexion less than
include anterior-posterior (AP), lateral, and oblique 10 degrees below neutral indicates tight heel cords and
views of the foot and a tangential view of the calcaneus. may contribute to pes planus. If the athlete has no
The AP may demonstrate a talonavicular coalition. The symptoms and the examination does not suggest a
oblique angle best demonstrates the calcaneonavicular secondary cause, no further workup is necessary. These
coalition. The tangential view of the calcaneus (Harris young athletes should be allowed to participate in all
axial view) best demonstrates a talocalcaneal coalition activities without restrictions. There is no evidence to
(middle facet). Bone scan typically is not used but may date that preventative treatment with orthotics or
have a place as a screening procedure in cases that are other shoe inserts will prevent the development of
difficult to determine. The gold standard remains com- symptomatic pes planus in the future. Children with
puted tomography (CT). It is used to confirm diagnosis, unilateral, asymptomatic pes planus require more careful
determine surgical planning, follow up postoperatively, monitoring, as well as evaluation for neurologic and
and evaluate degenerative changes. Magnetic resonance spinal causation.
imaging (MRI) is becoming more useful, particularly If the athlete is seeking medical advice because of
in the young, growing population. MRI can detect discomfort, then radiographs should be obtained to
soft-tissue bridging before ossification takes place.6 evaluate further for secondary causes. These may include
Treatment initially should be conservative for young accessory navicular, fractures, tumors, or coalitions.
athletes with tarsal coalitions. Both rehabilitation with Painful, flexible flat feet without secondary causes
aggressive Achilles stretching and custom orthotics can often respond to conservative measures. The young ath-
be used to improve the biomechanics of the foot and lete must understand that this may be a chronic prob-
improve symptoms. Immobilization also can be used at lem, but that extra work may help to alleviate the
times during a season to help the athlete calm the symp- symptoms. Orthotics, aggressive heel cord stretching,
toms and possibly finish a season. Surgical intervention and strengthening of the intrinsic muscle of the foot
usually is the long-term treatment for athletes and can and posterior tibial muscle are the mainstay of treat-
be done during the adolescent years or as dictated by ment. Time also should be spent examining the foot-
nonresolving symptoms with sports. Athletes with no wear of young athletes. Worn-out shoes should be
significant degenerative changes can expect to have an replaced with supportive footwear, especially a shoe with
excellent or good surgical outcome.7 Avoiding surgery good medial longitudinal arch support.
536
...........
Developmental problems in young athletes
athletes may develop symptoms that relate directly to

DEVELOPMENTAL PROBLEMS IN
the variant, such as the accessory navicular, or naviculare
YOUNG ATHLETES
secundarium. The accessory navicular is one of several
supernumerary ossicles first identified in 1605 by
Hallux valgus Bauhin (see Ref. 15). There are two types of accessory
Bunions in children are less common than in adults. navicular. The first type is found within the posterior
However, some studies have reported the prevalence to tibial tendon. The accessory navicular is present in about
be as high as 35% in the adolescent population.9 10% of children; however, only 2% do not fuse by matu-
Bunions of the great toe are more common in girls than rity. Anatomic studies have revealed that this accessory
in boys. The developmental etiology of bunions is mul- navicular ossicle is independent of the navicular bad
tifactorial, with an association of ligamentous laxity, break and can be thought of as a sesamoid bone.
hypermobile forefoot, pronation deformity, and meta- The second type is an accessory ossification center
tarsus primus varus with hallux valgus.10,11 Shoes that medial to the navicular. During early development,
place excessive stress on the first ray, such as narrow fit- this ossification center is surrounded by cartilage
ting and high heeled shoes, also are associated with that is congruent with the cartilage of the navicular.
increased irritation of bunions. Heredity is thought by The secondary ossification center typically fuses with
some to play a role.12 A young athlete with a congenital the navicular near maturity, usually between 9 and
angle between the first and second metatarsals greater 11 years. This type may be associated with symptomatic
than 10 degrees is more prone to developing hallux medial foot pain, especially in the adolescent athlete.
valgus in the future.11 This ossicle accounts for approximately 70% of all
Parents and young athletes alike need to be aware of accessory naviculars.
proper-fitting shoes. Children with rapidly growing The symptomatic accessory navicular should be
feet may need several shoe changes during a single year. thought of as an overuse injury. Increased stress on
Prevention of this condition is the best treatment. the overlying soft tissue causes inflammatory irritation
If symptoms begin, the child may need to weigh the and pain, especially if tenosynovitis has developed.
benefits of flat, wide shoes outside of sports versus the It typically presents with pain and tenderness over
looks of more trendy narrow, heeled shoes. As with the medial aspect of the foot, particularly the medial
adults, weight-bearing x-rays and a physical examination navicular. The athlete complains of pain with weight-
usually are warranted when a young athlete complains bearing activity that is aggravated by tight-fitting
of pain over the first ray. Because the natural history shoes. The medial arch may be flattened secondary
of this condition occurs over many years, initial to posterior tibialis muscle fatigue or congenital foot
workup may find the exostosis and thickened bursa at pronation. Often the symptoms begin at the beginning
the medial head of the first toe to be less impressive than of a new season. There is a higher predominance in
findings in an adult. Adolescent bunions also differ from girls than in boys, and the majority of patients first
late findings in adults in the lack of arthritic changes complain of symptoms during their adolescent years.
and spurs.13 Prominence is noted on the medial navicular on clinical
Treatment is similar to that for the adult with regard examination.
to conservative measures. These include proper foot- Radiographically, the two types of accessory navicular
wear, avoidance of aggravating activity, nonsteroidal should be distinguished because the first type does not
anti-inflammatory drugs (NSAIDs), heel-cord stretch- commonly have symptoms. An oval or circular sesamoid
ing, orthotics, and education. Surgery should be post- on plain film is associated with the first type. Type II, or
poned until after maturation of growth because the commonly symptomatic ossicle, has a triangular and
recurrence of the deformity after osteotomies and more irregular appearance.16 Bone scan of a symptom-
capsulorrhaphies is common in young athletes.14 Joint atic navicular will demonstrate an area of increased
stiffness and discomfort at extremes of motion also uptake over the medial navicular ossicle.
is a problem for young athletes after surgery, and the Treatment initially should be aimed at conservative
athlete may never be able to return to his or her previ- measures. These include a period of avoiding aggravating
ous level. activities and using orthotics to eliminate pressure over
the prominence. If pain is intolerable, immobilization in
Accessory navicular a short walking boot with or without an orthotic may
Most accessory bones about the foot and ankle are be helpful to eliminate the muscle spasm and discomfort.
normal variants and often represent secondary centers Surgery is reserved for the persistent symptomatic ossicle
of ossification. These variants often are asymptomatic that does not respond to several months of conservative
and without clinical significance. However, some young treatment.
537
...........
be seen for several months and generally lags behind

ACUTE INJURIES
clinical symptoms.
A small percentage of avulsion fractures in young
Avulsion fracture of fifth metatarsal athletes will progress into nonunions. These athletes
As in adults, young athletes often have inversion and will have a history of a significant inversion injury
supination injuries to their feet and ankles. In young that typically was treated with some type of immobili-
athletes these inversion injuries often can lead to an zation. The athlete will present to the office over
avulsion fracture at the base of the fifth metatarsal. the next 6 to 24 months with the complaint of
The middle school- or early high school-aged athlete continued injuries and pain involving the base of the
will present with lateral foot pain and swelling. He or fifth metatarsal with sports activities. Plain films that
she typically notes a history of a significant inversion include a comparison of the unaffected foot typically
injury and the inability to continue participation. On will be diagnostic. Surgical intervention then is typi-
examination the athlete will have palpable pain at the cally required to allow the athlete to effectively return
base of the fifth metatarsal that is more significant than to sports.
pain at the lateral ligaments. Plain films of the foot,
including AP, lateral, and oblique views, will easily Fifth metatarsal apophyseal avulsion
detect the usually transversely oriented fracture. If The tendon of the peroneus brevis inserts into the
concern exists regarding whether the plain films show apophysis. The apophysis can be distracted and avulsed
a fracture or an unfused metatarsal physis, comparison with an acute inversion injury. Chronic repetitive stress
films of the nonaffected foot may help to differentiate. results in Iselin’s disease, as discussed later in the chap-
Because this injury occurs with the injury mechanism ter. Patients present with pain over the base of the fifth
commonly seen with lateral ankle sprains, the metatarsal, and there may be widening of the apophysis
avulsion fracture may be missed if ankle films alone are on plain films.
obtained. The normal apophysis is parallel to the long axis
The most common fracture of the fifth metatarsal of the metatarsal. The apophysis develops between the
seen in young athletes is a transversely oriented avul- ages of 9 and 11 in females and 11 and 14 in males.
sion fracture at the base of the fifth metatarsal and It typically fuses several years later.5
through the metaphysis. As noted previously, the injury If there is minimal displacement, then nonoperative
commonly arises from an acute forceful inversion and treatment consists of boot immobilization for 3 to 6
supination injury of the foot/ankle. The mechanism is weeks followed by progression to running and then to
similar to twisting that produces lateral ligament injury sports (2-3 months). If there is more than 2 to 3 mm
of a sprained ankle. Recent cadaveric studies indicate of displacement, surgery should be considered.
that the lateral band of the plantar fascia is the structure
responsible for the tuberosity avulsion, and not the Os vesalianum sesamoid
peroneus brevis, as once thought.17 It generally does This normal variant must be distinguished from an avul-
not involve the articular surface but occasionally sion injury in the skeletally immature athlete.
may extend into the cuboid-metatarsal articulation.18
As mentioned, on roentgenographs this injury Jones fracture
sometimes is confused with an unfused apophysis in a As first described in 1902, the Jones fracture has a simi-
growing athlete. lar appearance to the avulsion fracture but is more distal
If there is minimal displacement, conservative in position.19 It is located about 1.5 to 2.0 cm from the
treatment is indicated using symptomatic immobili- proximal end, involving the metaphyseal-diaphyseal
zation. Our preference is to use a below-knee walking junction. This fracture also has a transverse orientation
boot. However, a hard-soled shoe or a cast also is that is intra-articular. Although it commonly is
acceptable. The walking boot allows the athlete to described as occurring from an acute traumatic event,
almost immediately begin nonimpact conditioning it can be secondary to chronic repetitive stress, such as
with a stationary bike, stair-stepper machine, or ellipti- from running.
cal trainer during the recovery time. After 3 to 4 weeks This fracture is not commonly seen in the same age
in the boot, the athlete can be weaned out of the boot group as the fifth metatarsal avulsion fracture. It usually
into a steel-shank shoe insert. Limited impact sports occurs in the older adolescent (15 to 20 years). Risk fac-
activities can be started at 4 to 6 weeks while the steel- tors for this type of fracture include intense level of
shank insert is worn, and progression is allowed using repetitive running and jumping, as seen in basketball
pain as a guide. Both plain films and symptoms are fol- and volleyball players. Another physical risk factor is
lowed to assess healing. Radiographic healing may not the athlete who has hindfoot varus because of the
538
...........
Pediatric ankle fractures
increased stress of the lateral aspect of the foot. A high guidelines to determine when additional studies should
rate of delayed union or nonunion is due to the tenuous be used, several investigations have provided guidelines.
blood supply to this area. CT or MRI may be beneficial in the patient with persis-
Treatment for this fracture is somewhat controversial tent unexplained symptoms and normal radiographs.
and is beyond the scope of this chapter. In general, we MRI and spiral CT have been shown to detail fractures
prefer to use intramedullary screw fixation if the growth that were not visible on plain films. MRI or CT also
plate is closed because it allows a quicker return to com- may be helpful when surgery is contemplated and more
petitive sports as compared with bone grafting without detail of the injury, particularly nonossified areas, is
screw fixation. required.24,25
This fracture and its treatment options are discussed There are several systems of classifying ankle fractures
in Chapter 4. in the literature. In the pediatric population, the Salter-
Harris classification has been used since 1963 for
planning treatment and predicting the long- term out-
come of the injury.25 Dias and Tachdjian (see Ref. 23)
PEDIATRIC ANKLE FRACTURES applied these principles and combined the mechanism
of injury to assist with treatment. However, this system
In young athletes with open growth plates, acute is difficult to discuss and beyond the scope of the chap-
injuries to bone around the foot and ankle most ter. In general, prognosis is determined by the grade of
commonly are fractures (bone or physeal). In adults, the fracture and the effectiveness of the reduction. As in
rotational forces and low-velocity sporting injuries adults, fractures that involve chondral surfaces have a
generally cause ligamentous injuries, whereas in young better long-term prognosis the more anatomic the
athletes these same forces often result in physeal inju- chondral surfaces are approximated.26 Skeletal maturity
ries. The growing bone in the young athlete differs at the time of injury also is important to consider
from the adult in terms of the mechanical properties. because patients who are near skeletal maturity
Although the long bones in children are more compli- will have less risk of leg-length discrepancies in the
ant than in the adult, the physeal plate is vulnerable long term.
because it is the weakest link in the ligament-bone- Salter-Harris I distal fibula fractures, which are the
tendon complex. most common ankle fracture in pediatric sports, typically
There are several pediatric fractures around the foot occur from supination/inversion injuries.27 This injury
and ankle that are common yet can easily be overlooked. typically has the same injury mechanism as the adult
These fractures may have subtle clinical and radiographic lateral ankle sprain. Athletes will present with the his-
findings. At the other extreme, a physician may treat an tory of an acute injury with pain and swelling over the
accessory ossification center noted on radiographs as lateral ankle. These athletes present similar to typical lat-
an acute fracture. Recognition of the common fracture eral ankle sprains, and the fractured growth plate can be
patterns and awareness of the pediatric bony variants missed easily. Careful palpation during the physical
are extremely helpful for the physician who cares for this examination will elicit maximal tenderness at the distal
population. fibula physis rather than the lateral ligaments. The dis-
Approximately 5% of all pediatric fractures are around tal fibula physis is palpated approximately 2 to 3 cm
the ankle. They most commonly occur in the growing proximal to the tip of the fibula. Plain films most often
athlete involved in organized sports. The age range most are normal but rarely show widening of the physeal plate
commonly involved is 10 to 15 years.20,21 The annual with evidence of surrounding soft-tissue swelling.28
incidence in this population is one physeal injury per Because plain films typically are normal, physical exami-
thousand.22 Radiographically, the distal tibial ossific nation findings and an appropriate history are required
nucleus appears between the second and third years, to make the diagnosis. Once the clinical diagnosis is
and physeal closure begins about age 15 in girls and 17 made, then the patient should be treated empirically
in boys. The distal fibula ossific nucleus is apparent dur- with immobilization for 2 to 4 weeks. Immobilization
ing the second year and fuses with the shaft by 20 years.23 can be accomplished with a walking boot, cast, or
In most cases, conventional radiographs with com- crutches and nonweight bearing. The walking boot
parison views allow adequate visualization of growth- allows the athlete to be more active in conditioning
plate injuries, and evaluation and treatment can be based activities during the recovery phase. The athlete then
solely on these findings. However, the role of additional can be weaned into a stirrup or lace-up–type brace,
imaging is being used more often with the knowledge which will be used when returning to play at the 4- to
that better visualization of soft tissue and bone is appar- 6-week mark. Although rare, Salter I fractures of the dis-
ent with CT and MRI. Although the role of additional tal fibula can develop into nonunions. These athletes
studies is still controversial, and there are no set complain of continued lateral ankle pain with sports
539
...........
activity and often need surgical intervention to resume fracture can be attempted; however, if there is greater
pain-free sports activity. than 2 mm of displacement, then an open reduction
Salter-Harris I distal tibia fractures are less common with smooth pinning is advised.29 Long-term follow-
than distal fibula fractures. Careful palpation of the dis- up is important to recognize early signs of growth arrest
tal tibia will help to differentiate this injury, as with the and deformities.
distal fibula injury. Immobilization with a boot or cast Tillaux are a special form of Salter-Harris III fractures
for 4 to 6 weeks generally will result in a good outcome. of the distal tibia. Tillaux fractures were described in
Patients should be followed with standing radiographs 1848 and involve the distal anterolateral quadrant of
and comparison films for at least 1 year to ensure normal the tibial physis.30 The mechanism of injury is thought
growth continues after the injury. to be supination/external rotation with the foot planted.
Salter-Harris II distal tibia fractures involve a fracture As a result of the pattern of fusion, central to medial
through the physis and metaphysis. Diagnosis often can and then lateral, the lateral corner is avulsed off with
be made with routine radiographs, but further imaging the attachment of the anterior inferior tibiofibular
with a CT scan or MRI may be needed if the diagnosis ligament.22 These fractures occur in adolescents (12-14
is in question. This type also has a low risk of physeal years in girls and 14-18 years in boys) during the 18
arrest. Most displaced Salter-Harris II distal tibia frac- months when the growth plate begins to fuse.31 They
tures can be treated with closed reduction with sedation. account for approximately 5% of all pediatric ankle frac-
If soft tissue blocks closed reduction attempts, then an tures.25 This injury is complex, and additional studies
open reduction is indicated. Immobilization with a usually are required to reveal the degree of displacement
long-leg cast for approximately 3 weeks is followed by and extent of injury. Treatment of a nondisplaced frac-
below-knee immobilization for approximately 3 more ture consists of closed reduction with internal rotation
weeks. As with Salter-Harris I fractures, patients should and axial distraction. If 2 mm or more of displacement
be followed with routine radiographs for at least 1 year remains, then open reduction and anatomic reduction
to ensure normal growth. are indicated.32 Poor anatomic reduction may result in
Salter-Harris III fractures involve the fracture line growth deformities and long-term arthrosis.
proceeding from the articular surface dorsally to the In general, Salter-Harris IV fractures account for
physis and then laterally along the physis (Fig. 23-1). approximately 25% of all distal tibial fractures.21 If a pos-
These injuries have more potential long-term con- terior metaphyseal fragment accompanies the type III
sequences. There often is intra-articular damage that Tillaux fracture, then it is classified as a Salter-Harris
cannot be seen on plain films. Closed reduction of the IV fracture, called a triplane fracture. Although there is
a distinction between Salter-Harris III and IV distal tibia
fractures by classification, similar treatment probably
should be followed to avoid complications in the future.
The fracture begins at the articular surface, extends
through the epiphysis along the physis and into the
posterior tibial metaphysis in three planes: sagittal,
transverse, and then most proximally in the coronal
plane. It can contain several fragments.33 Two to four
fragments are seen, depending on the maturity of the
growth plate. Because of the complexity, CT or MRI is
helpful in defining the fracture pattern, the amount of
displacement, and the adequacy of postreduction align-
ment. Significant shorting after this injury is uncommon
because the athlete usually is close to maturity.
Salter-Harris V fractures account for approximately
1% of distal tibial physeal injuries. The mechanism
involves a compressive force across the physis. The plain
films underestimate the damage to the physes. Unfortu-
nately, the injury is discovered months to years after
the event, when the patient has noticeable leg-length
discrepancy or angular deformity. The treatment then
is aimed at addressing these late complications. A high
index of suspicion is required to detect these often-missed
Figure 23-1 Anterior-posterior radiograph of young athlete severe injuries. One clue to the diagnosis radiographically
with a Salter Harris III fracture of the distal tibial physis. is the presence of multiple, small bone fragments at
540
...........
Osteochondroses
the level of the physis. Long-term complications are com- involved the articular surface had an increased rate of
mon despite early detection and appropriate management. osteoarthritis as compared with those without involve-
ment of the chondral surface. Several other studies have
Complications of physeal ankle fractures concluded that anatomic reduction decreases the rate of
Complications have been well documented after treat- osteoarthritis.
ment of ankle fractures involving the growth plate. All injuries involving any joint may result in stiffness,
Obviously, the initial injury and the damage that muscle atrophy, and, rarely, complex regional pain
occurred during the event are unpreventable. However, syndrome. Careful follow-up and physical therapy
the treatment following the inciting event can have a addressing early range of motion and strengthening
dramatic impact on long-term results. Further damage the supporting muscles may have a role in preventing
can be minimized by limiting the attempts at reduction. these long-term complications.
Early recognition and immobilization have an impact
on healing and long-term outcome. The importance of
the physical examination is that it may prevent ongoing
OSTEOCHONDROSES
injury from being missed. Compartment syndrome
of the anterior compartment has been described in the
literature, and sign and symptoms should not be over- The osteochondroses comprise a group of clinical
looked on the initial examination.34 syndromes that occur during years of growth and affect
Although growing athletes have an incredible ability the primary and secondary growth centers. Typically
to heal quickly and often without complications, frac- young athletes present with symptoms of pain during
tures involving the epiphyseal plate can result in perma- sports activities. Although there have been a number
nent disability and deformity. The degree of angular of studies looking at the cause of these growth-plate
deformity and leg-length discrepancy resulting from problems, the etiology is still unknown. Physical activity
premature closure of the plate depends on the age and appears to play an important role, but it is not clear
bone maturity of the athlete when the injury occurs as whether this is the major contributing factor.36 Osteo-
well as the amount of displacement of the physis and chondroses of the foot and ankle typically do not cause
fracture. The distal tibial physis contributes approxi- long-term problems and can be treated conservatively.
mately 4 mm of growth per year.22 An injury to this area Understanding the presentation and treatment of these
at the end of growth most likely will not have a dramatic overuse problems can help get young athletes back to
affect on leg length. Bony fusion generally is completed sports activity more quickly and safely.
by 14 years in females and 16 years in males. Age and
family history will help guide the physician in determin- Kohler’s disease
ing the predicted remaining growth of the tibia. Less Kohler’s disease is a foot disorder in children character-
than 1 cm of discrepancy is considered acceptable and ized by sclerosis and collapse of the developing tarsal
does not have reproducible long-term deleterious effects navicular. The problem is seen most typically in active
on the foot and ankle. Follow-up radiographs should children between 4 and 7 years of age and seems to
be obtained to evaluate for growth disturbance. affect boys more commonly than girls.37 The navicular
Inaccurate physeal reduction leading to an asymmet- typically is fully ossified by adolescence, and thus
rical growth arrest is a potential problem in the young Kohler’s disease presents at this younger age.38
athlete. If accurate reduction of the articular surface Patients often present with a noticeable limp and
cannot be maintained with closed means, then open complain of medial foot pain that is associated directly
reduction must be undertaken. In a study by Kling with physical activity or immediately following activity.
et al.,20 patients with Salter-Harris III and IV ankle The pain can range from vague discomfort to disabling
fractures had less growth arrest when open reduction/ pain with ambulation. The physical examination may
internal fixation was the treatment of choice versus reveal an area of erythema and swelling over the navicu-
closed reduction. When considerable angle deformity lar. On examination the area overlying the navicular may
exists after initial treatment of an unrecognized fracture, appear erythematous and swollen. Palpation over the
then an osteotomy can be the best solution to correct medial aspect of the navicular produces pain.
the alignment and prevent further long-term stress and Routine radiographs are an important first step in
complications on the joint. diagnosing Kohler’s disease. Plain films also will help
As with adult fractures, osteoarthritis may result from to rule out other possible diagnoses such as tumor,
the inciting injury, particularly when the chondral infection, and stress fractures. Most cases are unilateral,
surface is involved. A study by Caterini et al.35 looked so comparison films of the uninvolved foot are helpful.
at the long-term follow-up after physeal injuries of the The diagnosis is confirmed by the typical appearance of
ankle. They concluded that Salter-Harris injuries that a narrowed or flattened navicular and/or increased
541
...........
The athlete typically presents with forefoot pain that

is worsened with impact activities. Activities that cause
extremes of motion at the metatarsal heads during
weight-bearing activities such as sprinting and repetitive
jumping particularly seem to exasperate symptoms.
Athletes usually will complain that the pain symptoms
are continuing to worsen by the time they seek medical
help. The physical examination may show some mild
swelling over the metatarsal head. Palpation of the mid-
foot and forefoot typically isolates pain to the affected
metatarsal head and its metatarsophalangeal (MTP) joint.
Motion at the affected MTP joint will be decreased and
Figure 23-2 Lateral radiograph of the foot demonstrating painful.
Kohler’s disease. Note the sclerosis of the navicular. Radiographs of the foot should be obtained when
a young athlete presents with these symptoms and
density (Fig. 23-2).39 Occasionally there is a fragmented physical examination findings to evaluate for Freiberg’s
and patchy appearance. The joint spaces of the sur- disease and to rule out other causes, such as infection
rounding bones are well preserved to help rule out other or stress fractures. Initial plain film findings, such as wid-
systemic illnesses. A bone scan will be positive for ening of the affected MTP joint space, may be subtle.
increased uptake in the navicular with Kohler’s disease. Osteosclerosis of the metatarsal head may be seen within
CT scan also can be used to confirm the diagnosis
but may not be needed if the clinical examination and
radiographics are diagnostic.
Treatment consists of a conservative approach at first.
NSAIDs have been shown to help alleviate the pain initi-
ally. Several studies have looked at different treatment
options from orthotics to casting for several months.
It has been found that immobilization has affected the
duration of symptoms. Immobilization in a walking cast
or boot decreases time of symptoms by an average of
7 months. Long-term studies have not shown a differ-
ence with respect to the type of treatment used.
The prognosis is excellent, with few athletes having
long-term disability. Young patients can be allowed to
return to play when the symptoms subside. Immobiliza-
tion should be for 6 to 12 weeks. An orthotic often is
used to help alleviate stress over the involved joint.
When poor results do occur with conservative manage-
ment, arthrodesis of the talonavicular joint sometimes
is required.
Freiberg’s disease
Osteochondrosis of the metatarsal head, or Freiberg’s
disease, involves an evolutionary process of deterioration
and collapse of the articular surface and underlying sub-
chondral bone. It occurs more commonly in adolescents
when the epiphysis is still present, and 75% of the cases
are female.40 The second metatarsal is the most com-
mon site (68%) followed by the third and forth meta-
tarsal heads being affected.41 The second metatarsal
head is involved more commonly when it is longer than
the first. It has been proposed that this results in
increased pressure over the head and possibly disruption Figure 23-3 Anterior-posterior radiograph of the foot
of the vascular supply with repeated microtrauma (i.e., demonstrating sclerosis of the second metatarsal head and
running or dancing en pointe). early evidence for collapse consistent with Freiberg’s infraction.
542
...........
Nonarticular osteochondrosis
several weeks on plain films (Fig. 23-3). As the disease articular cartilage intact. Grade II is a fragment that is
progresses, there is increased resorption of necrotic incompletely separated. Grade IIa has formation of a sub-
bone with resulting fragmentation and collapse of the chondral cyst seen on MRI. Grade III is a detached frag-
metatarsal head.42 Bone scan may be helpful when ment that may have some articular cartilage still
the clinical examination and history are suspicious but attached. The fragment is not displaced. Grade IV is a dis-
radiographs are negative. The bone scan will show in- placed fragment.
creased uptake in the proximal metatarsal head and Routine three-view radiographs of the ankle should
decreased uptake over the necrotic area. be obtained before MRI, because grade IV lesions may
Treatment consists of taking anti-inflammatories not be readily apparent on MRI. Stage I lesions do not
and decreasing the load to the area for a period of time. show up on plain film. If suspicious for this type of
Initial immobilization in a walking boot will help to lesion, a mortise view with the foot in full plantarflexion
calm symptoms. The athlete then may be transitioned will help the clinician to view posterior medial lesions,
into an orthotic and started back to nonimpact activities and dorsiflexing the ankle with AP radiographs will help
initially. It is not always possible to stabilize the joint in visualizing the lateral dome lesions. MRI will show a
and prevent pain and progressive deformity. In severe well-demarcated area of abnormal signal. The bone scan
cases with persistent pain, surgery may be required to will show a focal increase of tracer uptake. Grade II to
alleviate symptoms and remove impingement. In later IV lesions may be visible on plain films.
stages, it is believed that the discomfort is associated Treatment depends on the grade of the lesion. There
with loose bodies. There are several procedures, depend- have been higher failure rates in nonoperative treatment
ing on the extent of the disease and whether loose bodies for adults as compared with young athletes.44 It is
are present. All have reported very good results. acceptable to immobilize a low-grade lesion to see
whether symptoms resolve. If conservative measures fail,
Osteochondral talar dome lesions then surgical treatment is recommended. This may be
Osteochondral lesions of the talar dome, also called an evolutionary process with grade I lesions progressing
osteochondritis dissecans, may be a cause of ankle pain to grade IV lesions. Grade IIa and above may require
in children, as well as in young adult athletes. Lesions immediate excision to avoid long-term arthosis.45
of the talar dome are well documented in the adult pop-
ulation (see Chapter 14); however, with advances of MRI
and the growing awareness of this condition in young NONARTICULAR OSTEOCHONDROSIS
athletes, it is more common among adolescents than
once thought. An article published by Canale and Beld-
ing43 in 1980 found the majority of the subjects to have Sever’s disease
symptoms dating back to adolescence. This disorder The differential diagnosis for heel pain in young athletes is
should be suspected in an adolescent with a history of similar to that for adults, with few additional consi-
an ankle sprain that does not improve as expected. derations. Overuse injuries in children were relatively rare
The etiology of the lesion is controversial. Canale and until the advent of organized sport. With rapid bone
Belding43 found the lesions to be caused by trauma in growth and increased activity levels during youth, increase
31 reported lateral talar dome lesions. Medial lesions stresses are placed on developing apophyseal bone. Sever’s
were not as conclusive, with only 64% of the cases disease, or calcaneal apophysitis, was first described in
related to a traumatic event. Like many other types of 1912 as a cause of posterior heal pain and thought to
osteochondral lesions, vascular insufficiency may play a occur in physically active, overweight children.46 It now
role in the development and progression of the lesion. is known to occur in nonobese children as well.
Central lesions are rare. The male-to-female ratio ranges Sever’s disease is a traction apophysitis that causes
from 3:1 to 2:1.44 pain along the secondary calcaneal ossification center.
Athletes usually present with a history of an inversion The insertion of the Achilles tendon over the longitudi-
injury. Acutely, there often is a large effusion and diffuse nally oriented surface subjects the epiphysis to strong
pain. Range of motion often is limited. Palpation over traction forces. The apophysis typically is irregular look-
the anterior joint line is tender. Absence of tenderness ing with multiple fragments and increase density;
over the lateral ligamentous complex should further raise however, it is radiographically similar to the opposite
suspicion of a talar dome lesion. Although locking and asymptomatic heel. For this reason, x-rays are not diag-
a catching sensation are classically described for loose nostic but can be helpful in ruling out stress fractures or
body formation, this is an uncommon presentation. bone tumors.47 The epiphysis begins to fuse between 12
Berndt and Hardy in 1959 (see Ref. 43) published a and 15 years of age. This area therefore is most
classification system based on standard radiographs. vulnerable before this age, and the incidence of Sever’s
Grade I is a depressed chondral fracture with the overlying disease is highest between 6 and 8 years of age.48
543
...........
There appear to be several predisposing factors that stretching usually is curative. If the pain returns after
contribute to Sever’s disease. Biomechanical abnormal- treatment, one should consider orthotics if biomechani-
ities, overuse during activity, and increased stresses all cal abnormalities exist. If there is persistent heel-cord
play a role.49 Hallux valgus, pes planus, and pes cavus inflexibility, then nighttime splints may be helpful.
all may have an association with Sever’s disease. Forefoot Rarely is pain debilitating enough to require a walking
pronation is most commonly associated. These struc- boot. Often the pain subsides in several weeks to
tural abnormalities alter the biomechanics and forces 2 months, and the athlete can return to sport with a
applied to the heel, decreasing shock absorption and functional progression program.
exposing the heel to abnormal stresses.
Most sports such as running require repetitive Iselin’s disease
heel-cord loading and expose this area to microtrauma. Iselin’s disease, or traction apophysitis at the base of the
Athletes may ignore the discomfort initially and con- fifth metatarsal, was first described in 1912 as occurring
tinue with long, intense workouts before seeking med- in adolescents.53 The confusing pathology of this meta-
ical advice. One should be aware of the sports most tarsal can make fractures or os vesalianum difficult to
commonly associated with this syndrome. Basketball, distinguish from Iselin’s disease on roentgenographs.
soccer, track, and gymnastics have been found to The apophysis develops between the ages of 9 and
have the highest association.50 Sports played on hard 11 years in girls and 11 and 14 years in boys. It begins
surfaces also may contribute to the increased stress to fuse 2 to 3 years later. The apophyseal growth carti-
and microtrauma. lage is the weakest site for ligament and tendon attach-
The final predisposing factor probably is the most ment in growing children.26 With intense training, this
significant in terms of treatment. Abnormal stresses area can develop microavulsion fractures or traction
may be secondary to inflexibility. The heel-cord com- apophysitis.
plex, as a result, has diminished dorsiflexion and may The proximal fifth metatarsal is the site of three
contribute to abnormal stresses on the apophysis during ligament attachments: the plantar fascia and the fourth
activity.51 and fifth metatarsal ligaments. The peroneus brevis and
The child may present with heel pain, particularly peroneus tertius also insert into this area. During
with running. Often the young athlete is starting a growth, the secondary growth center of ossification is
new season. The pain is absent in the morning, begins located on the lateral plantar aspect of the tuberosity.
with exercise, and lessens during nonweight-bearing This bone is within the cartilaginous flare onto which
activity. The pain may begin insidiously, or the athlete the peroneus brevis tendon inserts.54 With continued
may remember an inciting history of direct trauma to longitudinal stress, this bone may become irritated and
the heel.52 The pain may become debilitating and painful.
prevent the athlete from participating in his or her Young athletes, more often male, present with
sport. tenderness over the proximal fifth metatarsal. Similar
On examination, one should look for the previously to Sever’s disease, Iselin’s disease often occurs at the
mentioned biomechanical abnormalities. Dorsiflexion beginning of a season. The onset may be insidious or
of the ankle is important to document. If the dorsiflex- acute with a history of an inversion injury. The pain
ion is less than 10 degrees, then a severe Achilles con- usually is worse during activity. Any activity that fires
tracture is present. The patient may limp or complain of the peroneal muscle will elicit pain. Maneuvers such as
reproducible pain when he or she rises up on the toes. running, especially lateral and cutting movement, will
This is known as a positive Sever’s sign. Pain to palpa- produce discomfort.
tion over the posterior mediolateral heel and a positive On examination the area will be tender to touch.
squeeze test are suggestive of Sever’s disease. Resisted eversion or passive, extreme plantarflexion with
Although radiographs may not help to distinguish inversion may elicit pain. Occasionally the area may
Sever’s disease from a normal-appearing asymptomatic appear erythematous and swollen. Weakness on resisted
heel, they may rule out other mimicking conditions such eversion may be evident because of protective pain.
as a fracture, coalition, or tumor. Radiographically, AP and lateral views may not show
Treatment varies depending on the severity of the the secondary ossification center. A third medial oblique
pain and the reliability of the patient. There have been view should be taken when examination findings are
no studies to date that have shown long-term sequelae suspicious. This may show a small piece of bone oblique
after treatment for Sever’s disease. Initial management to the fifth metatarsal shaft on the lateral plantar aspect
is conservative, and aggravating activities should be of the tuberosity. Bone scan will show increased uptake
avoided until symptoms improve. Icing, heel lifts, anti- over the proximal fifth metatarsal. Plain films will be
inflammatories, and physical therapy also are helpful. helpful in ruling out similar conditions such as Jones
In our practice, a home program of aggressive heel-cord fractures. Therefore history, physical examination, and
544
...........
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546
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.........................................C H A P T E R 2 4
Unique considerations for foot and ankle

injuries in the female athlete
Melanie Sanders
......................
CHAPTER CONTENTS
Introduction 547 Conclusion 551

Sport-specific disorders 548 References 551
Gender-specific disorders 550
INTRODUCTION genders. Other sports are the exclusive domain of the

female athlete. There is great interest in identifying pre-
ventable injuries, whether they are sport specific or gen-
The passage of Title IX* is arguably the most important
der specific. The sports identified as causing the highest
event in the timeline of women’s participation in U.S.
number of injuries in the female athlete are basketball,
athletic endeavors. By almost any measure, the numbers
volleyball, field hockey, and gymnastics. Sports engen-
of female athletes have exploded in multiple sports in
dering the fewest injuries are golf, swimming, squash,
the decades since 1972. Before Title IX, approximately 1
and archery.2-7 Additional information also has been
in 27 girls participated in sports; that number is now
garnered by the study of female military recruits and
nearly 1 in 3.1 The National Collegiate Athletic Asso-
their physical performance compared with male peers.
ciation (NCAA) tracks women’s sports participation in
Military studies are intriguing because the male and
its member institutions; the data are self-reported and
female populations are subjected to the same conditions
are useful for evaluating general trends. In 1981, total
of training and physical standards.
athletes numbered 74,239. By 1993, the total had risen
Their data reveal significant and more rapid improve-
to 105,532 and then in 2001 to 155,513 (Fig. 24-1).
ment in performance over sequential years for women
In general, the increase in participation reflects the
compared with men. The higher injury rates initially re-
addition of women’s teams to institutions. The increase
ported in women have gradually begun to decline as
also reflects the elevation of previously emerging sports
women have adapted to the rigorous schedule.8 Physio-
such as ice hockey and water polo to normal status and
logic differences, particularly in upper body strength in
championship competition. Additional emerging sports,
women, may be permanently limiting, although women
such as synchronized swimming, archery, badminton,
appear to have comparable or better aerobic capacity.9
equestrian events, squash, and team handball also have
Other preliminary studies seemed to indicate a signifi-
increased the numbers of athletes reported.
cantly higher rate of injury in the female athlete; how-
The increase in the number of women participating
ever, follow-up studies demonstrated the injury rate to
in sports and the increase in their level of competition
be sport specific. In these studies, proper conditioning
has provided a new opportunity to study the effects of
resulted in injury rates equivalent to male athletes.
different sports on the athlete. Some sports provide the
Anthropometric studies provide interesting data con-
opportunity to directly compare injury rates for both
cerning anatomic differences between women and men.10
In women, lower extremities constitute 51% of their
*‘‘No person in the United States shall, on the basis of sex, be total height, compared with 56% in men. This difference
excluded from participation in, or denied the benefits of, or be sub- improves the mechanical advantage for men in activities
jected to discrimination under any educational program or activity
requiring striking, hitting, or kicking because of the
receiving federal assistance.’’—Title IX of the Education Amendments
of 1972 to the Civil Rights Act of 1964. greater force than can be generated by their legs as longer
CHAPTER 24 Unique considerations for foot and ankle injuries in the female athlete
Female Participation in NCAA sports

180000
160000
Number of Female Athletes

140000
120000
100000
80000
60000
40000
20000
0
Year '82 through '02
Figure 24-1
levers. The female has a wider pelvis, greater varus of the of amenorrhea and evasiveness about eating habits,
hips, and greater genu valgus than the male. As a result, should prompt further investigation. Failure to make
females have a lower center of gravity, and in sports the appropriate diagnosis can allow repetitive injuries
requiring excellent balance, such as gymnastics, females to occur, possibly with significant changes in the normal
have a distinct advantage. As a result, the balance beam bony architecture of the foot. The incidence of the dis-
is a required element in competition for female gymnasts order in young girls has been reported to be as low as
and is not included in the competition for male gym- 15% and as high as 65%. The prevalence may be higher
nasts. Female gymnasts typically also have better joint in sports that select for a slim body habitus, but it has
mobility, improving their flexibility—another trait val- been reported in all sports.
ued in gymnastics. The alignment differences at the hip When approaching the study of foot and ankle prob-
and knee may be one factor, along with the level of con- lems in female athletes, disorders can be divided into
ditioning, contributing to higher percentages of overuse gender-specific disorders and sport-specific disorders.
syndromes in the lower extremity in female athletes.
The musculoskeletal system in women contains less
muscle mass and more fat for the same body weight SPORT-SPECIFIC DISORDERS
than in men. In males and females with equal training,
female muscle mass is approximately 23% of body
weight, compared with 40% in males. This limitation Ballet (also see Chapter 21)
of muscle mass handicaps females in their attempts to The female classical ballet dancer is unique in her
increase their power and speed. The larger percentage requirements for the lower extremities.11,12 The dan-
of fat, however, is an advantage in distance swimming cer uses either a thin-soled slipper or toe shoe. The
events because of the improvement in insulation and dancer typically will participate in several classes, rehear-
buoyancy for the female swimmer. For instance, the sal for performances, and then the performance or per-
speed record for swimming the English Channel is held formances. The lower extremities are called on to
by Penny Dean. Her one-way time in 1978 was 7 hours, absorb all the force of landings on the wooden dance
40 minutes. floor. The consequence of the schedule of training
It is important to preface any remarks on the female and performance and the type of shoe for the foot leads
athlete with the gender-specific clinical diagnosis of the to chronic injuries such as tendinitis, tendinosis, and
female athlete triad. The diagnosis refers to the inter- impingement syndromes. The most common acute in-
related problems of disordered eating, amenorrhea, jury is the inversion sprain, usually occurring on landing
and osteoporosis. Specific to the foot, these athletes a jump. Fatigue, improper technique, and anatomic vari-
are more at risk for stress fractures in the foot; and, in ation from optimal body type all can be factors in acute
this instance, consideration of the diagnosis should be and chronic injuries. The lower leg, foot, and ankle make
entertained and appropriate history sought. Any impres- up approximately 40% of dance injuries in a sport in
sion of osteopenia on plain x-ray, coupled with a history which the lifetime incidence of injury is 90%.13
548
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Sport-specific disorders
Posterior ankle pain (also see Chapter 2) at risk for subluxation of the cuboid, either associated
Ballet requires extreme plantarflexion of the foot for with an inversion injury to the ankle or from repetitive
en pointe work. In this extreme position, soft tissues pos- plantarflexion and dorsiflexion. In this clinical entity,
terior to the ankle can be compressed and irritated. Any the base of the fourth metatarsal becomes dorsally dis-
one of the following structures posterior to the ankle placed and the fourth metatarsal head displaces in a
can cause symptoms: an os trigonum, a large posterior plantar direction. Additionally, cuboid dysfunction
process of the talus, or a large dorsal process of the can interfere with normal function of the peroneal ten-
calcaneus. Symptomatic flexor hallucis longus (FHL) dons and must be considered in dancers with peroneal
tendinitis can be caused by these impingement sce- tendinitis. Treatment of this unusual condition
narios. Diagnosis of this suspected condition can be requires reduction of the cuboid with a squeeze tech-
supported by local tenderness proximal to the sustenta- nique after the hindfoot is mobilized and the forefoot
culum tali and pain with resisted plantarflexion of the is adducted.17
great toe. Magnetic resonance imaging (MRI) typically Midfoot injuries in the dancer present a significant
will demonstrate fluid within the sheath of the tendon treatment dilemma because of the prolonged healing
and sometimes marked tenosynovitis.14 Preservation of time required for stability of the foot and the difficulty
the function of the FHL tendon is paramount in dan- of restoring the mobility required for dancing. Midfoot
cers. Treatment should be aimed toward minimizing injuries occur when the dancer lands in full pointe, with
the inflammatory condition, with surgical intervention the posterior lip of the tibia resting and locked on the
timed to allow appropriate recovery. In some instances, calcaneus. In this position the subtalar joint also is
simple release of the FHL is adequate; in other cases, locked, and the heel and forefoot both are in varus.
excision of the os trigonum or posterior process of Because the ankle joint is relatively stable in full pointe,
the talus may be required. FHL tendon symptoms are the forces at landing are transferred to the midfoot.
most commonly associated with ballet; however, partici- Treatment of these acute injuries requires evaluation of
pants in other sports such as soccer increasingly are both stability of the involved tarsometatarsal joints
demonstrating the same entity. and amount of collapse of the longitudinal arch (see
Chapter 5). Some diastasis may be acceptable if weight-
bearing views do not demonstrate collapse of the longitu-
Acute injuries dinal arch. Workup should include weight-bearing views,
Nearly half of reported dance injuries are categorized as comparison weight-bearing views, and computed tomo-
acute. The most common injuries occur as the dancer graphy (CT) scan if necessary.
lands with a loss of balance. If the dancer lands in en pointe The fifth metatarsal is a common area of injury for
position, the ankle is more stable, causing a midfoot dancers. The most innocuous fracture is that of avulsion
injury rather than the typical anterior talofibular liga- of the base of the fifth metatarsal. Open reduction inter-
ment injury. Radiographs should be obtained in the dan- nal fixation (ORIF) is recommended only if the fracture
cer who cannot walk more than three steps (limping is fragment involves greater than 30% of the articular sur-
acceptable) and in whom there is tenderness over impor- face and is significantly displaced. The most typical frac-
tant anatomic landmarks. Foot x-rays should be obtained ture involves only the most proximal 1 cm of the bone
if there is tenderness over the navicular bone or the base and usually is associated with an ankle sprain. It can be
of the fifth metatarsal. If there is tenderness over either treated with appropriate immobilization and progressive
the fibula or the medial malleolus from the tip to 6 cm activity as healing permits. The Jones fracture (see
proximal to the tip, ankle films should be obtained.15,16 Chapter 4) occurs by the mechanism of adduction of the
The most commonly overlooked fractures include the fifth metatarsal, usually while the foot is plantarflexed.
talar dome (see Chapter 14), the lateral process of the Because of the negative effects of prolonged immobiliza-
talus (see Chapter 14), the os trigonum (see Chapter tion, early operative management for these fractures
14), the anterior process of the calcaneus, and the prox- at the metaphyseal-diaphyseal junction is preferred.
imal fifth metatarsal. Younger dancers can be more diffi- Repetitive adduction forces that occur with cutting or
cult to evaluate, often requiring repetitive x-rays. A high pivoting movements can result in diaphyseal stress frac-
index of suspicion should be maintained, especially in tures. There usually are prodromal symptoms preceding
the face of soft-tissue swelling over the physes of ankle an acute event. The history is critical, as is review of
or foot bones. radiographs, which typically will demonstrate periosteal
As in other athletes, inversion injuries can cause reaction, cortical thickening, intramedullary sclerosis,
damage to structures other than the anterior talofibu- and widening of the fracture line. Because this is a vas-
lar ligament. Syndesmosis tears, osteochondral lesions cular watershed zone, these stress fractures should be
of the talus, and subluxation or longitudinal tears of treated with intramedullary screw fixation, bone graft,
the peroneal tendons all may occur. Dancers also are or both.
549
...........
When dancers perform the demi-pointe position, the women participating in this sport increase, the data will
foot is twisted and inverted and can incur an oblique clarify further the risk of injury to female athletes.21-23
or spiral fracture of the mid- to distal portion of the
fifth metatarsal. This ‘‘dancer’s fracture’’ now has been
shown to heal well with conservative and symptomatic GENDER-SPECIFIC DISORDERS
treatment rather than ORIF.18
Gymnastics Posterior tibial tendinitis (see also Chapter 8)

The female gymnast has been reported to be at higher Hyperpronation of the foot in the female can cause
risk for ankle injury than the male athlete. This is either chronic posterior tibial tendinitis or insertional
presumably because of the difference in alignment of posterior tibial tendinitis. The previously discussed genu
the female lower extremity, with accentuated varus posi- valgum in the female requires relatively more pronation
tion of the heel. Landings on this varus position increase in the foot to maintain the plantigrade position. Initial
the probability of ankle sprain. Areas of complaint in the treatment for excessive pronation should include medial
foot in female gymnasts include the bottom of the heel, heel and forefoot wedge or posting within the athletic
the plantar fascia origin, and the medial longitudinal shoe, although benefit can be obtained with full-time
arch. Direct blows during landings or striking the heel use of mechanical correction in all shoes. Custom foot
on the floor while swinging under the lower uneven orthoses can be beneficial early in treatment. The inser-
parallel bar cause pain under the heel. Tumbling is the tional form of posterior tibial tendinitis can be more
typical cause of pain at the origin of the plantar fascia, recalcitrant and difficult to treat. This disorder may be
whereas landings cause pain in the medial longitudinal associated with the presence of an accessory navicular
arch or the forefoot. Interestingly, analysis of flexibility bone. In addition to foot orthotics, other treatments
parameters in gymnasts compared with controls does should include rest, ice massage, anti-inflammatory
not demonstrate a correlation to injury patterns or fre- medications, stretching of the Achilles-gastrocnemius
quency.19 Ankle impingement syndrome (see Chapter 2) complex, and brace treatment with a short, articulated,
occurs in the female gymnast, with impingement occur- ankle-foot orthosis or Arizona brace. In the very rare
ring anteriorly when she lands short on her dismount, case, excision of the accessory navicular bone with repair
forcing her ankle into hyperflexion. If acute pain occurs or advancement of the posterior tibial tendon may
with an instance of injury, the ankle should be rested and be indicated. In some instances, this also will require
iced. Physical therapy modalities and anti-inflammatory supplementary tendon transfer.
drugs are also useful adjuncts. With return to the inciting
activity, a large protective pad can be taped as a mechan- Bunions (see also Chapter 19)
ical block along the anterior aspect of the ankle to help The incidence of bunions always has been reported as
prevent reinjury.20 significantly higher in women versus men, with the
implication that women’s shoes have a slow deforming
Recreational ice hockey effect on the forefoot. The female athlete typically
There has been a phenomenal increase in the numbers is well motivated to consider aggressive conservative
of women participating in organized ice hockey within treatment for bunions to remain active in her sport.
the last several decades. Estimated numbers in the Several aspects of bunions should be considered when
United States and Canada increased by 250% in the evaluating potential causes of pain or dysfunction in
latter 1990s; and because women’s ice hockey was the woman athlete with bunions. First, direct pressure
included in the 1998 Winter Olympic Games, participa- from the shoe and especially from stitching lines on
tion is expected to continue to rise. Interest in injuries the shoe may cause soft-tissue irritation over the bun-
generated by the contact and collisions in ice hockey ion. The structures most at risk for this type of irrita-
has led to many studies on male hockey players. The play tion include the dorsal digital nerve and the capsular
rules are modified for women; intentional body check- structures of the metatarsophalangeal joint. Second,
ing is not allowed and the players are required to wear the athlete may have suffered a capsular injury to the
full-face protection (men wear one half). As a result, joint that will respond to rest or the use of a bunion
women suffer no dental or facial injuries, in sharp con- night splint, combined with topical anti-inflammatory
trast to the high rate in men. When six male and six products. Women athletes with significant deformity
female collegiate teams were compared in a cohort may have first-metatarsocuneiform instability, which
study, the risk of severe injury (14 or more missed ses- will respond well to treatment with an appropriately
sions) was 5.33 times higher for women than for men. posted, custom, trilaminar foot orthosis. Because the
The most common injuries in women were concussion, risk of a significant change in the mechanical function
adductor strain, and ankle sprain. As the numbers of of the foot can occur after bunionectomy, surgery
550
...........
References
should be avoided if possible.24 Postoperative changes First, the number of females involved in all sports has
in the foot can include residual stiffness in the metatar- increased dramatically and will continue to increase. Sec-
sophalangeal joint and imbalance in the forefoot load, ond, like their male peers, female athletes will continue
potentially causing transfer metatarsalgia or stress frac- to push their limits, likely incurring injury in the process.
ture. Stress fractures of the base of the proximal pha- Third, injuries in the female athlete will fall into either
lanx of the great toe have been reported in athletes sport-specific or gender-specific categories, the latter of
with hallux valgus. which require a higher index of suspicion and perhaps
greater depth of knowledge for diagnosis and treatment.
Stress fractures (see also Chapters 3 and 4) This is a pivotal time for women’s sports medicine, with
Stress fractures occur as a result of repetitive, low-level great opportunity to gather data, to refine optimal treat-
stresses on bone and have multifactorial causes. In many ment recommendations, and to develop strategies to
athletic settings, women appear to be at higher risk for prevent injury. This chapter delineates many of the inju-
stress fracture than men.25-28 In particular, a woman exhi- ries that the medical personnel will encounter and, we
biting the female athlete triad, previously mentioned, may hope, has given the reader a better understanding of
be predisposed to stress fracture. If women with irregular salient features of diagnosing and treating these injuries.
menses are compared with women with regular menses,
4 PEARL
the frequency of stress fractures is increased by a factor
of four. If all fractures are evaluated, the increase is three
times the rate for athletes with regular menses.29 Some
of the factors that have been identified as causative for The female athlete triad consists of disordered eating,
stress fracture include dietary imbalance, foot structure, amenorrhea, and osteoporosis and places the female
athlete at an increased risk of stress fractures in the foot
training surface, footwear, training variations, and tempo- and ankle.
rary cessation of activity.30 Any impression of osteopenia on plain x-ray, coupled
Lower bone density and potentially lower calcium with a history of amenorrhea and evasiveness about eating
intake compared with male athletes also may make the habits, should prompt further investigation.
female athlete more susceptible to stress fracture. Men- Women with irregular menses have a fourfold increase
in stress fracture risk compared with women with regular
strual irregularities such as exercise-induced amenor- menses.
rhea may result in lower bone density. In particular, The lower leg, foot, and ankle make up approximately
females who begin their running career before menar- 40% of dance injuries, and the lifetime incidence of injury
che may delay menarche because of excessive weight is 90% in the dancer.
Because the risk of a significant change in the mechanical
loss, low body fat, and subsequent loss of normal hor-
function of the foot can occur after surgery, bunionectomy
monal stimulation. High-level female runners demon- should be avoided if possible in the competitive female
strate an incidence of menstrual irregularity of 50%.31 athlete.
The use of oral contraceptives as an estrogen therapy
can provide some protection by helping to maintain
bone density.32
Clinical symptoms of stress fracture can be insidious
in onset, often interfering with the athlete’s participa- REFERENCES
tion in the sport but not necessarily causing complete
cessation of the inciting activity. Swelling may or may
not be apparent, but there generally is point tenderness 1. Callahan LR: The evolution of the female athlete: progress and
problems, Pediatr Ann 29:3, 2000.
over the fracture. History of change in the training 2. Dahm DL: Understanding ankle sprains and other foot problems
schedule or other causative factors may be difficult in female athletes, Womens Health Orthop Ed 5:60, 2002.
to obtain. Careful physical examination is paramount 3. Delee JC, et al: Incidence of injury in Texas girls’ high school
because any bone in the foot or the tibia and fibula basketball, Am J Sports Med 24:684, 1996.
can be fractured. Radiographs may be required sequen- 4. Gillette JV, Haycock CE: Susceptibility of women athletes to
injury, Depart Surg 236:163, 1976.
tially because they are not always positive for the first 5. Haycock CE, Hillette JV: Susceptibility of women athletes to
3 to 6 weeks. Bone scan is extremely valuable in making injury, JAMA 236:163, 1976.
an earlier diagnosis in the athlete. 6. Murtaugh K: Injury patterns among female field hockey players,
Am Coll Sports Med 1:201, 2001.
7. Noble BH, et al: A comparison of men’s and women’s professional
CONCLUSION basketball injuries, Am J Sports Med 10:297, 1982.
8. Cox JS, Lenz HW: Women midshipmen in sports, Am J Sports
Med 12:241, 1984.
All medical support personnel involved in the care of the 9. Protzman RR: Physiological performance of women compared to
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10. Griffin LY: The female athlete: In Hunter-Griffen L, editor: 21. Dryden DM, et al: Epidemiology of women’s recreational ice
Athletic training and sports medicine, ed 2, Park Ridge, IL, 1991, hockey injuries, Am Coll Sports Med 2:1378, 1999.
American Academy of Orthopaedic Surgeons. 22. Dryden DM, et al: Personal risk factors associated with injury
11. Hardaker WT Jr: Foot and ankle injuries in classical ballet dancers, among female recreational ice hockey players, J Sci Med Sport
Orthop Clin North Am 20:621, 1989. 3:140, 2000.
12. Wiesler ER, et al: Ankle flexibility and injury patterns in dancers, 23. Schick DM, Meeuwisse WH: Injury rates and profiles in female ice
Am J Sports Med 24:754, 1996. hockey players, Am J Sports Med 31:47, 2003.
13. Macintyre J, Joy E: Foot and ankle injuries in dance, Clin Sports 24. Baxter DE, Lillich JS: Bunionectomies and related surgery in the
Med 19:351, 2000. female middle-distance and marathon runner, Am J Sports Med
14. Sammarco GJ, Miller EH: Partial rupture of the flexor hallucis 14:491, 1986.
longus tendon in classical ballet and modern dance, J Bone Joint 25. Bennel KL, et al: Risk factors for stress fractures in track and field
Surg 61A:149, 1979. athletes, Am J Sports Med 24:810, 1996.
15. Pigman EC, et al: Evaluation of the Ottawa clinical decision 26. Benson JE, et al: Relationship between nutrient intake, body mass
rules for the use of radiography in acute ankle and midfoot injuries index, menstrual function and ballet injury, J Am Diet Assoc
in the emergency department: An independent site assessment, 89:58, 1989.
Ann Emerg Med 24:41, 1994. 27. Dempsey RL, et al: Stress injury to the bone among women
16. Stiehll IG, et al: Decision rules for the use of radiography in acute athletes, Tough Top Sports Med 11:929, 2000.
ankle injuries, JAMA 269:1127, 1993. 28. Eisele SA, Sammarco GJ: Fatigue fractures of the foot and ankle in
17. Marshall P, Hamilton WG: Cubiod subluxation in ballet dancers, the athlete, J Bone Joint Surg 75:290, 1993.
Am J Sports Med 20:169, 1992. 29. Baker ER, et al: Women athletes with menstrual irregularity have
18. O’Malley MJ, Hamilton WG, Munyak J: Fractures of the distal increased musculoskeletal injuries, Med Sci Sports Exerc 18:374, 1986.
shaft of the fifth metatarsal, Am J Sports Med 24:240, 1996. 30. Zeni AI, et al: Stress injury to the bone among women athletes,
19. Kirby RL, et al: Flexibility and musculoskeletal symptomatology in Phys Med Rehabil Clin North Am 11:929, 2000.
female gymnasts and age-matched controls, Am J Sports Med 31. Barrow GW, Saha S: Menstrual irregularity and stress fractures in
9:160, 1981. collegiate female distance runners, Am J Orthop Med 16:209, 1988.
20. Hunter LY: Women’s athletics: the orthopedic surgeon’s 32. Carbon R, et al: Bone density of elite female athletes with stress
viewpoint, Clin Sports Med 3:809, 1984. fractures, Med J Aust 153:373, 1990.
552
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.........................................C H A P T E R 2 5
New advances in the foot and ankle

Gregory C. Berlet, Peter B. Maurus, Terrence Philbin, and Thomas H. Lee
......................
CHAPTER CONTENTS
Introduction 553 Chronic ankle instability 558

Osteochondral lesions of the talus 553 Foot and ankle arthroscopy 559
On the horizon 556 References 562
INTRODUCTION Acute traumatic events are typically the cause of

lateral lesions. Lesions on the anterolateral aspect of
the talar dome are caused by inversion and dorsiflexion,
Orthopaedic surgery is a dynamic field of medicine with
resulting in the anterolateral aspect of the talar dome’s
ever-changing advances in knowledge and techniques.
impacting the fibula. These lesions usually more shallow
As our patient populations continue to grow younger
and ‘‘wafer shaped’’ than medial lesions.9
and more active, we search for more anatomic and less
Medial lesions usually are caused by repetitive overuse
invasive methods of addressing pathology. The sub-
syndromes; ; only a small number of medial lesions can be
specialty of surgery of the foot and ankle likewise is parti-
attributed to trauma. Posteromedial lesions result from
cipating in this exciting evolution of understanding and
inversion, plantarflexion, and external rotational forces.
approaches to common acute and chronic conditions of
The posteromedial talar dome impacts the tibial articular
the foot and ankle. In this chapter we discuss newer tech-
surface, leading to a deep, cup-shaped lesion in the talus.
niques and treatment options for foot and ankle disorders.
The classic presentation for the OLT is characterized
by chronic ankle pain with swelling. The pain usually is
localized to the side of the ankle where the lesion is
OSTEOCHONDRAL LESIONS OF THE TALUS located. Other symptoms include weakness, stiffness,
catching, and giving way with repeated inversion inju-
Osteochondral lesions of the talus (OLT) are rare, ries. Initial physical examination signs include tender-
representing just 4% of all such lesions in the body.1 ness on palpation behind the medial malleolus with the
The term OLT evolved from an 1888 report that ankle dorsiflexed (posteromedial lesions) and over the
described ‘‘osteochondritis dissecans’’ as a loose body anterolateral ankle joint when in maximal plantarflexion
associated with articular cartilage and subchondral bone (anterolateral lesions). A joint effusion is a clear sign of
fracture.2 Because inflammation is not an important intra-articular involvement.
factor in the etiology of OLT, many authors do not Weight-bearing plain radiographs should be used to
use the term ‘‘osteochondritis dissecans.’’ evaluate the ankle (anterior-posterior, lateral, and mor-
The two locations most often seen in which OLTs are tise views). Posteromedial lesions are evaluated best by
involved are posteromedial and anterolateral. Trauma imaging the ankle in various degrees of plantarflexion.
is cited as the etiology in more that 85% of patients.3-7 Anterolateral lesions are evaluated best by imaging the
Although the etiology of nontraumatic OLT is unknown, ankle in various degrees of dorsiflexion. In our experi-
some reports have cited a primary ischemic event or ence, magnetic resonance imaging (MRI) is the most
genetic predisposition (e.g., identical medial talar lesions appropriate imaging modality to evaluate for OLT.
in identical twins, multiple lesions occurring in the same Areas of low signal intensity on T1-weighted images
patient) as a cause.8 indicate a chronic lesion resulting from sclerosis of the
CHAPTER 25 New advances in the foot and ankle
immature ankles have the best prognosis for healing

Table 25-1 Classification system for staging osteo-
with conservative treatment. In summary, asymptomatic
chondral lesions of the talus using magnetic resonance
and nondisplaced OLT should undergo conservative
imaging
treatment, whereas displaced or continued symptomatic
Stage I Articular cartilage damage only lesions should be treated surgically.
Stage IIa Articular cartilage injury with Operative

underlying fracture and edema There are three surgical options for the displaced OLT.
These are acute open reduction and internal fixation
Stage IIb Stage II without edema
(ORIF), open or arthroscopic debridement and/or exci-
Stage III Detached fragment (rim signal) but sion with drilling, and cartilage restoration procedures.
nondisplaced
Internal fixation
Stage IV Displaced fragment ORIF is most appropriate for acute lesions with a signi-
ficant osseous piece remaining attached to the chondral
Stage V Subchondral cyst formation flap. Internal fixation historically has been accomplished
with hardware (Kirschner wires, screws), although
recent trends move toward biologic fixation. Biologic
fixation can be accomplished using antegrade or retro-
bed of the talus.10 High signal rims on T2-weighted grade bioabsorbable screws and/or antegrade biologic
images indicate an unstable osteochondral fragment.11,12 pins (SmartNail, Bionx Implants, Finland). An interest-
Intra-articular, gadolinium-enhanced MRI can provide ing recent advantage is the use of osteochondral
images of articular cartilage, assess stability, and detect plug transfer to internally fix an unstable osteochondritis
intra-articular bodies.13 Significant ankle effusions may dissecans (OCD) lesion. In two separate articles, Berlet
provide a ‘‘physiologic arthrogram,’’ negating the need and Yoshizumi reported on their technique for fixation
for gadolinium. and grafting of an OCD lesion about the knee.18,19 This
The OLT should be staged before treatment is deter- technique (COR, Mitek Worldwide, Westwood, MA),
mined. In 1959, Berndt and Harty14 devised a system which uses smaller diameter plugs, can function both
for staging OLT. Since that time, various researchers to stabilize the lesion and graft across the lesion into
have revised and refined their original classification healthy bone. It is the authors’ experience that most
systems as newer technologies, such as arthroscopy, com- acute lesions may be reduced and secured using ante-
puted tomography (CT), and MRI became available. grade biologic pins. Fibrin sealant may be an appropriate
Table 25-1 is a staging classification developed by Hepple adjuvant to the internally stabilized OLT and has been
et al.15 and is based on MRI imaging. shown to be effective in clinical studies.20
.............................................................
Treatment Debridement, microfracture, and drilling
If a lesion is detached or sufficiently fragmented such that
it is not amenable to internal fixation, excision of the
Nonoperative fragments, debridement, and drilling are warranted. The
Generally, conservative treatment should be attempted cartilage edges are trimmed and smoothed, and the bony
first. Two studies reviewed the long-term outcomes base is debrided down to bleeding bone. Subchondral
of patients with OLT and the possible development drilling provides vascular access channels. Mesenchymal
of osteoarthrosis. Conservative treatment consists of stem cells released from the underlying bone proliferate
protected ambulation for pain relief and an appropriate and undergo chondrocyte differentiation to provide a
sports brace during activity. Conservative treatment fibrocartilage cap for the chondral defect. Studies have
should be attempted for at least 6 months. McCullough shown this method to be more effective than simple
and Venugopal16 followed 10 patients for 15 years and excision and curettage or simple excision alone.21-23
found that although conservative treatment often does Retrograde drilling is ideal for cystic subchondral
not lead to radiographic union, osteoarthrosis was lesions with intact articular cartilage. Using specialized
uncommon unless the fragment was detached. They systems, accurate drilling of the lesion is possible. This
stated that patients with nondisplaced fragments could drill path provides revascularization, and the bone graft
be treated conservatively but that acute displaced frac- serves as osteoconductive and osteoinductive material.
tures should undergo immediate reduction and internal This technique has advantages over antegrade drilling
fixation. Bauer et al.17 concurred that osteoarthrosis of in that it does not alter the actual articular surface integ-
the ankle is a rare occurrence and found that skeletally rity. Retrograde drilling of a talar OCD was first
554
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described in 1981 as an isolated case.24 More recently, but critics have found that up to 20% to 40% of the defect
a modification of this technique with arthroscopic assis- is replaced by fibrocartilage.27 Gautier et al.28 showed
tance was described. Clinical research has shown good good to excellent results in 11 patients at an average of
clinical results with this technique.23 A study by Taranow 24 months, using Sulzermedica’s SDS ‘‘Soft Delivery
et al.23 looked at 16 patients after retrograde drilling System.’’ The lesions in this study averaged 18 10 mm,
and grafting of OLTs. There were no complications and the authors made no recommendations for absolute
and a significant increase in the American Orthopaedic size limits. Previous studies, however, recommended a
Foot and Ankle Society (AOFAS) Ankle/Hindfoot score. lower size limit of 10 mm. Hangody et al.25 looked at
This technique is recommended for the subchondral cyst 36 patients treated with mosaicplasty at 2- to 7-year fol-
on the basis of its early surgical success and the absence of low-up. All of these lesions were greater than 10 mm in
complications associated with transmalleolar osteotomies, diameter. Ninety-four percent of these patients reported
transmalleolar drilling, and chondrolytic debridement. good to excellent results using the Hannover scoring
system, with no long-term knee donor site morbidity.
Cartilage restoration procedures Osteochondral plugs can also be harvested from the
Although microfracture and drilling techniques produce ipsilateral talus. Sammarco and Makwana29 harvested
a fibrocartilage tissue in the affected area, it does not pro- osteochondral plugs form the medial and lateral talar
duce normal hyaline cartilage. In efforts to restore a joint facets in 12 patients. The authors reported significant
surface with more anatomic and favorable biomechanical improvement in the AOFAS Ankle/Hindfoot scores and
properties, newer procedures have been developed to found no structural failures in the donor site or graft site.
restore a hyaline cartilage surface. Lesions greater than
10 mm in diameter may be best managed primarily with Autogenous chondrocyte implantation
cartilage restoration procedures instead of excision and If the osteochondral lesion is large (greater than
drilling. 25 2 1 cm), it is not amenable to OATS or mosaicplasty
because of the expected size of the donor defect.
Autologous osteochondral grafting (osteoarticular Autogenous chondrocyte implantation (ACI) is a new
transfer system, mosaicplasty) technique that is showing promise for these larger lesions
The osteoarticular transfer system (OATS) and mosaic- in the knee and ankle. In 1994, Swedish investigators first
plasty transplant viable plugs of cartilage and subchondral reported on this novel technique for large osteochondral
bone from various donor sites into the talar dome. lesions in the knee.30 They looked at 23 patients over a
Single-plug systems, such as OATS, harvest a single, 2- to 7-year follow-up period with lesions measuring from
large plug to match the size of the lesion. This method 1.5 to 6.5 cm in diameter and in whom all prior treat-
is postulated to reduce the fibrocartilage ingrowth seen ments had failed. Eighty-eight percent of their patients
in multiple-plug system. Donor site morbidity, however, had good or excellent results. Studies in the United States
is a bigger concern because of the size of the graft. and further extensive studies in Sweden have validated
Arthrex OATS procedures were used in nine patients these results at up to 10 years.31-34
in a study by Assenmacher et al.26 At an average of 9.3 ACI is indicated in younger patient15-59 with focal osteo-
months, MRI revealed stable graft osteointegration by chondral defects without diffuse arthritis. A ‘‘kissing lesion’’
DeSmet criteria in all patients. Patients reported on the tibial plafond is a contraindication to this procedure
significant clinical improvement on the basis of visual because results are very poor when this is present. Other
analog pain scales and the AOFAS Ankle/Hindfoot patients who could benefit from this procedure are those
scores (average 80.2).4 Al-Shaikh et al.27 reviewed the with failed prior surgeries and those who have large lesions
results of 19 patients who underwent the Arthrex OATS with extensive subchondral cystic changes. Multifocal
technique for lesions averaging 12 10 mm in 19 lesions could be treated with ACI in some cases. Patients
patients. Sixty-eight percent of these patients had failed who should not undergo ACI are those who have not had
prior attempts at excision, curettage, and/or drilling. At an attempt at other forms of surgical treatment, those with
an average of 16 months, patients reported improvement early degenerative changes or osteoarthritis, or those with
in AOFAS Ankle/Hindfoot scores (88 average) and uncorrected malalignment or instability.
reported no significant donor site morbidity. Eighty-nine The basic principle is to harvest viable chondrocytes
percent of these patients stated that they would have from the patient, culture the chondrocytes, and reim-
this procedure done again. Al-Shaikh et al.27 concluded plant them into the patient. This technique requires a
that the OATS procedure is a viable salvage technique two-stage procedure. First, an arthroscopic evaluation
for patients who failed prior debridement procedures. of the lesion is undertaken. Arthroscopy allows a thor-
In multiple-plug systems (mosaicplasty), a number of ough evaluation of the size and shape of the lesion, as
osteochondral plugs are harvested to fill the defect. well as the overall integrity of the adjacent and opposite
These plugs can recontour the surface of the talar dome, cartilage surfaces. A biopsy of healthy articular cartilage
555
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(approximately 200-300 mg) then is taken from a

ON THE HORIZON
nonweight-bearing area of articular cartilage (typically
the intercondylar notch of the knee in a separate arthro-
scopic procedure). This biopsy is sent for laboratory Tissue engineering and gene therapy currently are being
culture and growth of additional chondrocytes. The studied as a way to provide a growth mechanism for
process involves enzymatic digestion of the tissue and normal hyaline cartilage. This current technique already
cultivation, which leads to a tenfold increase in chondro- has shown early success in animal models but still remains
cytes. After 2 to 3 weeks in culture under the presence in the early experimental stages.40-45 Filling cartilage defects
of antibiotics to ensure sterility, approximately 10 to 12 with scaffolds of collagen or synthetic carbons promotes cell
million cells will be available for transplantation. The sec- migration provides a template for matrix formation. The
ond stage of this procedure is the implantation of the chondrocyte response may be amplified by embedding
cultured cells. Postoperative care is essential in ensuring growth factors into the scaffold.46 These newer modalities
a good result. possibly will revolutionize our approach to cartilage lesions.
Giannini et al.35 reported excellent results at up to 26
months in eight patients who underwent ACI for OLT.
4 PEARL
They not only showed improved clinical scores (AOFAS
Ankle/Hindfoot scores improving from 32 to 91/100)
but also showed regenerated areas of cartilage on fol-
low-up arthroscopy and normal type II hyaline cartilage The time relationship between pain and instability is
by histology. Minas and Peterson published a study of important. That is, pain followed by instability often is due
to intra-articular pathology. Pain inhibition of normal
14 patients with ACI at an average follow-up of 28 neuromuscular pathways can mimic ligamentous instability.
months.36 They reported an 11/14 good to excellent Therefore ankle instability episodes can originate from an
outcome, with two poor results and one lost to follow- OLT with ligamentous laxity.
up. In a recent study on the economics and quality of A persistent ankle joint effusion points to an intra-articular
life profile of this procedure, Minas37 showed significant pathology, and an articular cartilage lesion should be suspected.
ACI and OATS are salvage procedures to be used after
improvement in quality of life at 2 years, and the tech- debridement, microfracture, or drilling have failed.
nique was found to be cost effective in comparison with Literature supports debridement, microfracture, or
other treatment modalities. drilling as the first-line treatment when an OCD fragment
cannot be stabilized.
Other new techniques Internal fixation of OLT provides the best prognosis
because you are saving the patient’s own cartilage.
There is a new interest in bulk fresh osteochondral allo-
grafts for the replacement of large areas of focal cartilage
damage. Candidates are matched to donors on the basis
of joint size, and the surgery is performed within 5 days
of tissue recovery to optimize the survival of the donor
cartilage. Tontz et al. report on 12 patients at an average
of 21-month follow-up who had bulk tibiotalar allo-
C A S E S T U D I E S 1 A N D 2
grafts.38 They reported intraoperative fracture in one
patient and graft collapse in another, but overall satisfac-
tion and relief of pain in the other 10 patients. They
concluded that this technique shows promise for the A 40-year-old, male physician presents to the office
treatment of articular cartilage defects in young, active with severe pain and swelling in his right ankle after an
patients. Gross et al.39 performed fresh osteochondral eversion injury while playing basketball. He complains
graft transplantation in nine patients for OLT (one case of pain along the anterolateral aspect of his ankle. He
was for acute open fracture of the talus). Six of the nine also has a great deal of crepitus, catching, and locking
grafts remained viable at an average of 11 years. Three with any motion. On examination, the ankle is grossly
cases went on to arthrodesis because of graft resorption. swollen with lateral ecchymosis. Range-of-motion testing
In a literature review on the treatment of OLT, Caylor elicits severe pain and crepitus along the lateral aspect of
the ankle. Ankle stability is grossly normal on
and Pearsall40 conclude that bulk fresh allografts can
examination. Plain radiographs of the ankle illustrate a
provide excellent results. The concern with these fresh lateral talar defect (Fig. 25-1, A). The ankle mortise is
bulk allografts is the host immune reaction to viable cells intact. MRI examination shows a 0.5- to 1.0-cm
within the graft and the possibility of major infections. osteochondral defect with fluid surrounding the lesion
Also, graft collapse has been shown to occur in some (Fig. 25-1, B). This represents a detached osteochondral
cases.41 More research in this area is needed to ensure lesion of the talus. An ankle arthroscopy was performed
the safety and efficacy of this procedure. that allowed the visualization of a large osteochondral
556
...........
On the horizon
Figure 25-1 (C) Intraoperative arthroscopic image of a

large displaced OLT. (D) Intraoperative image of the OLT
from C after open reduction and internal fixation with
bioabsorbable pins. (Photographs courtesy Gregory C. Berlet,
MD, Orthopedic Foot and Ankle Center, Columbus, Ohio.)
fragment (Fig. 25-1, C). The talus then was approached

through a lateral incision (Fig. 25-1, D). The fragment was
Figure 25-1 (A) Plain radiography of an ankle reduced and fixed with bioabsorbable pins (SmartNail,
illustrating an anterolateral osteochondral lesion of the
Bionx Implants, Finland). The patient tolerated the
talus (OLT). (B) Magnetic resonance imaging (MRI) of the
procedure well and has returned to normal activities
ankle from A illustrating a displaced OLT.
without pain at 8 months.
557
...........
A 30-year-old woman presents with complaints

of continued right ankle pain after an inversion injury
3 months prior. She has suffered from pain, swelling,
locking, and catching since that time. She has no history
of prior ankle injuries. On examination, she has an
antalgic gait on the right. The foot and ankle are
neurovascularly intact. There are no obvious deformities,
and the ankle is stable on drawer testing. There is,
however, an ankle effusion. Plain radiographs of the
ankle do not show any abnormalities. An MRI showed an
obvious osteochondral lesion off the posteromedial
aspect of the talus. The lesion measured approximately
1 cm2, with clear fluid seen within the cavity. This
represents a displaced osteochondral lesion (Fig. 25-2, A).
For a lesion that cannot be fixed, first-line treatment is
ankle arthroscopy with debridement and drilling. Only if
this technique were to fail would we consider cartilage
restoration procedures. She underwent the arthroscopy
and followed a conservative rehabilitation protocol. After
8 months, she has continued pain and swelling in her right
ankle. A repeat MRI shows edema and incongruity of the
talus in the area of the OCD. Because of her continued
symptoms, we decided to perform osteochondral autograft
reconstruction of the defect (mosaicplasty) (Fig. 25-2, B).
She is now 1 year out from surgery and has no pain or
swelling and has returned to her normal activities.
CHRONIC ANKLE INSTABILITY
Lateral ankle sprains are one of the most common

sports-related injuries, representing as many as 40% of
presenting complaints.47 Chronic lateral ankle instability
has been estimated to occur in up to 42% of patients
who sustain acute injuries.48,49 Functional lateral insta-
bility, as introduced by Freeman50 describes a subjective
complaint of giving way in the ankle joint. Work by
Tropp et al.51 further described this condition as motion
beyond voluntary control but not exceeding the physio-
logic range of motion. Mechanical instability is motion
beyond the normal physiologic limits of the ankle joint.
This is manifested as excessive anterolateral ankle laxity.
The lateral ankle ligaments (anterior talofibular ligament
and calcaneofibular ligament) work to prevent inversion
of the talus in the ankle mortise. Conservative treatment
for chronic lateral ankle instability consists of rest, anti-
inflammatories, and physical therapy. Persistent failure
(repeated giving way) of this lateral ligament complex,
Figure 25-2 (A) Magnetic resonance imaging of an ankle however, is an indication for surgical stabilization of
illustrating a large, displaced posteromedial osteochondral the ankle.
lesion of the talus (OLT). (B) Intraoperative image of the OLT
from A after mosaicplasty reconstruction of the defect. Surgical options
(Photographs courtesy Gregory C. Berlet, MD, Orthopedic
Foot and Ankle Center, Columbus, Ohio.)
There are multiple surgical options for surgical stabiliza-
tion of the chronically unstable ankle, both anatomic
and nonanatomic. One should refer to Chapter 13 for
558
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Foot and ankle arthroscopy
a more exhaustive review of the traditional surgical Medical Center, Boston, MA) physical and mental com-
approaches for ankle instability. ponents. Patients’ SF-12 scores returned to normal
Nonanatomic lateral ligament stabilizations are char- when compared with age and sex matched controls with
acterized by extra-articular tendon weave techniques. no history of ankle pain.54
These techniques risk overconstraining the ankle joint
and are not isometric in their kinematic effect on the
ankle joint. Thus they should be reserved for revisions
or unique clinical situations.
Anatomic lateral ligament stabilizations accept the C A S E S T U D Y 3
patient’s natural ligament insertion points but adjust the
tension on that ligament. Isometry is not disturbed, and
overconstraint is rare. Anatomic reconstructions include
the modified Brostrom lateral ligament reconstruction A 20-year-old, college cheerleader presents to the office
and thermal capsular modification. The Brostrom recon- with recurrent ankle sprains. An aggressive rehabilitation
program with physical therapy has been performed for
struction is described in Chapter 13.
each significant injury (once a year for the last 3 years).
Thermal capsular modification Her recovery from the sprains is becoming more
prolonged. Her last sprain resulted in the loss of a
Thermal capsular modification has been shown to be 3-month period of cheering. She has never felt that she
a new and effective treatment of lateral ankle laxity. has returned to her full strength. On physical
A thermal probe applied to the anterior talofibular examination, she has normal hindfoot alignment (no
ligament and lateral capsule causes denaturing and varus) and poor proprioception (could single balance for
‘‘shrinkage’’ of the tissue by breaking the intramolecu- only 10 seconds). An anterior drawer examination showed
lar bonds within the type I collagen. Thermal energy redundancy compared with the contralateral uninjured
applied through a feedback-controlled probe at 65 side (translation of 3-mm side-to-side difference) and
to 70 C results in a 30% contracture of the tissue.52 normal peroneal strength. X-rays were normal. MRI
showed the anterior talofibular ligament to be in
Through stabilization and immobilization, these liga-
continuity but with evidence of previous injury. A thermal
ments can assume a new, shortened position on heal-
capsular modification was performed. Postoperative
ing. Postoperative immobilization is mandatory for immobilization was 3 weeks nonweight bearing in a cast,
a 9-week period to prevent stretching of the treated 3 weeks in a weight-bearing cast, and 3 weeks in a boot
tissue. This procedure is indicated for patients with walker. Physician-supervised physical therapy was
moderate builds, nonavulsed ligaments, no prior stabi- initiated at 9 weeks and emphasized proprioception
lization procedures, and a commitment to the strict retraining and peroneal strengthening. This patient
postoperative protocol. Moreover, with this technique, returned to competition at 16 weeks with no recurrent
other intra-articular pathology can be identified and instability at 2-year follow-up.
treated arthroscopically. Clinical results with thermal
capsular modification have been encouraging.53 Berlet
et al. presented the largest series in the literature, reporting
on 42 patients who underwent thermal capsular shrinkage
for chronic lateral ankle instability.54 At an average follow- FOOT AND ANKLE ARTHROSCOPY
up of 12 months, there was a significant increase in
the AOFAS Ankle/Hindfoot scores and the SF-12
The introduction of arthroscopy to the armamentarium
(SF-12 Health Survey, The Health Institute, New England
of orthopaedic surgeons has revolutionized the treatment
of many commonly seen injuries. In 1918, Dr. Takagi of
Tokyo University first applied an endoscopic technique
4 PEARL to the knee joint.1-4 Since that time, arthroscopy has
grown to be a safe and successful treatment modality
An anatomically based physical examination will guide the that has gained widespread acceptance in diagnosing
physician to the appropriate diagnosis in chronic ankle pain and treating disorders of the foot and ankle.55-71 The
in the athlete. advantages of arthroscopy are the ability to closely inspect
Thermal capsular modification can be considered for the articular and synovial surfaces without the need for
patients with functional ankle instability and grade I/II ankle
instability. Grade III and revision situations are addressed
extensile surgical approaches. The typical arthroscopic
best with open techniques. portals used in the ankle are the anteromedial, antero-
lateral, and anterocentral portals. Chapter 16 addresses
559
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ankle arthroscopy more extensively. In this chapter, portal. Structures at risk with the posteromedial portal
we describe a newer approach to posterior ankle include the FHL, tibial nerve, and tibial artery, which
arthroscopy. average 2.7 mm, 6.4 mm, and 9.6 mm away from the
portal, respectively.73 Using a posteromedial portal
Posterior ankle arthroscopy directly behind the medial malleolus adjacent to the
posterior tibial tendon, the average distance from the
In certain circumstances, posterior portals are neces-
cannula to the posterior tibial nerve was 5.7 mm and
sary. On the basis of studies in which patients were
6.4 mm to the tibial artery. The para-Achilles postero-
placed in the standard supine position, most investiga-
medial portal is best used with the patient in the prone
tors have commented that the anterior portals and the
position, whereas the posteromedial portal may be used
posterolateral portal are safe and so have recommended
with the patient in the standard supine position.
the use of those portals. The most common posterior
Ankle arthroscopy with the patient in the prone posi-
portals are the posterolateral, the trans-Achilles, and
tion has been discussed infrequently. Zimmer and
the posteromedial portals.72 Posterior access is benefi-
Ferkel79 discussed the use of posterior portals with the
cial in visualizing posteromedial and posterolateral
patient in the prone position but for endoscopy of the
talar lesions (OLT) and mandatory to address flexor
retrocalcaneal bursa only. In a cadaveric study Sitler
hallucis longus (FHL) stenosing tenosynovitis, pos-
et al.73 demonstrated that, during posterior ankle
terior ankle impingement, displaced fractures of the
arthroscopy with the limb in the prone position, the
os trigonum, insertional Achilles tendinitis, and retro-
posteromedial and posterolateral portals could be used
calcaneal bursitis.
with a relatively small risk to the neurovascular struc-
Of the three posterior portals, the posterolateral
tures. The prone posterior ankle arthroscopy approach
portal has been subjected to the most clinical research.
allows for visualization and accessibility to the posterior
With the patient in the prone position, this portal is
half of the tibiotalar joint, subtalar joints, and the FHL
made at the level or just slightly above the level of the
tendon and its sheath. It is the authors’ experience that
tip of the lateral malleolus just lateral to the Achilles ten-
50% of the posterior ankle can be visualized from the
don. Typical scope placement technique is used, and a
posterior portals, although only 30% can be manipulated
30-degree, 4.5-mm arthroscope is used. A coaxial portal
directly because of the curvature of the talus and tibia.
placed directly posterior to the peroneal tendons also
Prone positioning for posterior ankle arthroscopy is
can be used. Care must be taken not to injure the sural
most helpful for resection of pathologic os trigonum
nerve or the small saphenous vein, which run within
and retrocalcaneal bursitis, where the pathology is all
3.2 mm and 4.8 mm of the portal, respectively.73 Ferkel
in the posterior recesses of the ankle.
et al.74 reports a neurologic complication of rate of 4.4%
using both anterior and posterior portals.
A review by Drez et al.75 of 56 ankle arthroscopies Arthroscopy of the great toe
performed with a combination of anterior and posterior Wantanabe80 described the first arthroscopy of the
portals found that the posterolateral portal allowed for first metatarsophalangeal (MTP) joint in 1972. This
excellent access to the posterior recess and that the pos- procedure is indicated for osteophytes, hallux rigidus,
teromedial portal was rarely needed. Ferkel et al.74 con- chondromalacia, osteochondral dissecans, loose bodies,
firmed this finding in their study and recommended arthrofibrosis, and synovitis. Dorsal osteophytes, hallux
posterolateral ankle arthroscopy to ensure a thorough rigidus, and osteochondral lesions are common indica-
visualization of the ankle joint. tions among athletes. Diagnostic first MTP arthroscopy
The posteromedial portal is made in a para-Achilles may be indicated for patients who fail conservative treat-
location or in a truly posteromedial location, between ment of recurrent edema, locking pain, and diminished
the posterior tibial tendon and flexor digitorum ten- range of motion.81
dons.76-78 The Achilles tendon posteromedial portal The dorsal medial, dorsal lateral, and straight medial
is made just medial to the Achilles tendon in the hori- portals are used most commonly for arthroscopic
zontal plane at the same level as the posterolateral por- evaluation and treatment of the first MTP joint. van
tal. Typical scope placement technique is used, and a Dijk et al.82 reported that two portals are needed to
30-degree, 4.5-mm arthroscope is used. Before placing visualize and treat disorders of the lateral sesamoid—
the portal, position can be checked through the use of one in the first webspace and another 4 cm proximal
a needle and visualization through the posterolateral to the joint line between the short abductor and the
portal. Developing the interval between the posterior flexor hallucis brevis muscle. When making portals,
tibial tendon and the flexor digitorum longus behind care must be taken to avoid injuring the branches
the medial malleolus makes the alternative posteromedial of the deep peroneal nerve laterally, branches of the
560
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Foot and ankle arthroscopy
superficial nerve medially, and branches of the saphe- Davies and Saxby84 performed first MTP arthroscopy
nous around the medial aspect of the first MTP joint on 11 patients ranging from 15 to 58 years of age
(Fig. 25-3). (mean, 30 years) with a mean follow-up of 19.3 months.
There is a paucity of literature on the clinical results At the final follow-up, all the patients exhibited minimal
of first MTP arthroscopy. Ferkel and Van Buecken83 or no pain, decreased edema, and increased range of
reported the results of 22 patients whose ages ranged motion. One patient had a minor wound complication.
from 18 to 70 years (mean age, 40), with a mean follow- Three patients required an arthrotomy during the sur-
up of 54 months. They reported a good outcome in 73% gery. In summary, first MTP arthroscopy is an evolving
of the cases, fair in 13.5%, and poor in 13.5%. All patients technique. The best indications are osteochondral
in the fair and poor categories had degenerative joint lesions. Debridement of marked degenerative joint dis-
disease and required a fusion later. van Dijk et al.82 ease should be discouraged.
reported on 23 patients who underwent first MTP
arthroscopy. The patients averaged 33 years of age (range, Endoscopic calcaneal prominence resection
16-61 years), and the follow-up period averaged 2 years.
In 1928, Haglund85 described a clinical condition in
They reported excellent or good results for 14 patients
which the retrocalcaneal bursa and Achilles tendon are
and fair or poor results for nine patients. One patient
compressed and irritated by a posterior-superior calca-
experienced transient loss of medial hallux sensation and
neal prominence. When nonoperative treatment fails,
another experienced loss of lateral hallux sensation. The
the condition can be treated by open calcaneal resection,
authors advocate sesamoid removal laterally with the
retrocalcaneal bursectomy, and Achilles debridement
scope but state that removing the medial sesamoid
with repair, when necessary. Recently, endoscopic calca-
arthroscopically has not proven promising.
neoplasty has been described. The procedure is per-
formed with the patient in a prone position, and
posteromedial and posterolateral portals are used. The
portals are placed just medial and lateral to the Achilles
tendon and just proximal to the superior aspect of the
calcaneus. A 2.7-mm arthroscope and small joint equip-
ment are recommended.
Extra-articular endoscopic decompression of the
retrocalcaneal space can be useful for treating retro-
calcaneal bursitis, Haglund’s spur, and impingement.
The arthroscopic approach may decrease postoperative
recovery time and incisional complications. Using lateral
and accessory medial portals, Leitze et al. showed at an
average of 22 months postoperatively a comparable
result to open retrocalcaneal decompression as measured
by the AOFAS Ankle/Hindfoot scoring system.
We believe that this technique is useful in minimizing
wound complications and decreasing the postoperative
recovery time. Leitze et al. studied this procedure in a
prospective study in 2003. They performed endoscopic
decompressions on 33 heels (30 patients) in which non-
operative treatments had failed. This group was com-
pared with 17 heels (14 patients) treated with a
traditional open technique. Postoperatively, the clinical
scores were not significantly different on the basis of
AOFAS Ankle/Hindfoot scales, but operative time was
shorter, there were fewer complications, and cosmetic
results were better.86 It is our experience that endo-
scopic resection of the Haglund’s process is rewarding
when the pathology involves bursitis with a prominent
Haglund’s process. Intratendinous calcifications of the
Achilles insertion are handled best with conventional
Figure 25-3 Illustration of metatarsophalangeal joint scope
placement. (Illustrated by Peter Maurus, MD.)
open techniques.
561
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4
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.........................................C H A P T E R 2 6
The shoe in sports

Carol Frey
......................
CHAPTER CONTENTS
General considerations 567 Shoe fit 572

Materials 567 Sports-specific shoes 574
Lasting techniques 569 Court sport shoes 577
Upper designs and cuts 569 Field sport shoes 578
Bottoming process 569 Winter sports 579
The outer sole 570 Other sports 581
Midsoles and wedges 571 Injuries related to athletic footwear 581
Other component parts 571 Conclusions 583
New components and designs 572 References 583
The relationship of the athlete and the shoe is extre- the shoe toe box, instep, girth, and foot curvature are
mely important to athletic performance. The desire for determined by the last. The biggest last variations occur
improved performance affects all athletes and influences in girth (or widest part of the forefoot) and in heel width.
not only training but also equipment research and design.
Athletic shoe manufacturers rely on scientific research and Straight and curved lasts
prior experience in the development of their products.
Most feet have a slight inward curve. Most sport shoe
This chapter covers important aspects of design, technol-
companies use a last that is curved inward approximately
ogy, sports-specific needs, and medical and orthopaedic
7 degrees. The greater the curve, the more foot mobility
considerations in the development of athletic shoewear.
is allowed, a benefit for the underpronator. The straigh-
ter the shoe, the more medial support it will provide;
GENERAL CONSIDERATIONS this can help to control overpronation.
Combination lasts
Construction
The term ‘‘combination lasts’’ refers to any last that varies
Although product development and marketing methods from a standard proportional last to lasts that accommo-
are different, manufacturers use most of the major date a combination of fitting or movement requirements.
methods of shoe construction in the production of sport
shoes (Fig. 26-1).
The last MATERIALS

The last, a three-dimensional (Fig. 26-2) form on which
the shoe is made, is considered by many to be the founda-
tion for shoe production and development. Foot shape
.............................................................
Upper materials
may vary with sports activities, and this is a major area Leather, rubber, plastic injection molding, soft nylon,
of concern in the development of the last. The shape of mesh nylon, polyvinyl chloride (PVC)-coated fabrics,
CHAPTER 26 The shoe in sports
Figure 26-1 Generic athletic shoe. (From Reyatt T: The first step: know your feet. SHAPE Magazine, Nov 1992.)
.............................................................
Sole materials
Rubber is the most widely used sole material because

of its versatility, durability, and performance. The most
commonly used forms of rubber are a highly compres-
sed molded form or a blown microcellular form. Carbon
rubber and styrene-butadiene rubber are the two most
common rubber compounds used in athletic shoes.
Often used in running-shoe soles, black carbon rubber
is the hardest wearing. Styrene-butadiene rubber also is
hard and is used in tennis and basketball shoes.
Microcellular rubber
Microcellular rubber (MCR) is a compound composed
of natural rubber plus additives. MCR contains a blow-
ing agent in powder form that decomposes during
vulcanization, forming a cellular structure. MCR is used
Figure 26-2 Different lasts used in athletic shoes. (From mainly for midsoles and wedges, but in some shoes it
Reyatt T: The first step: know your feet. SHAPE Magazine, can be used as an outsole material.
Nov 1992.)
Ethyl vinyl acetate
polyurethane-coated fabrics, and canvas have been Ethyl vinyl acetate (EVA) contains ethylene and vinyl
used in the manufacture of uppers. Most uppers used acetate and a powdered blowing agent that decomposes
in sports shoes are made of soft nylon, mesh nylon, during vulcanization to form a cellular structure.
leather, canvas, suede, and synthetic materials such as Because of its lightness, flexibility, density, elongation,
Kangoran. and impact resistance, EVA is a common material used
568
...........
Bottoming process
in good-quality running shoes. EVA is available in

prefabricated sheet or compression-molded forms.
Polyurethane
Polyurethane (PU) is a liquid polyester that can be
formed into a blown cellular structure. PU is versatile
and can be used as a midsole and heel wedge material,
and its lightness and durability make it a satisfactory out-
sole material. PU can be injected directly or used as a
unit sole. PU can be used in the blown cellular state
and as a hardened elastomer form in multistudded soles
such as golf shoes.
Hytrel
Hytrel is a thermoplastic polyester elastomere developed
by DuPont (E.I. duPont de Nemours and Company,
Wilmington, DE).
Nylon
Nylon is a polyester resin with a high melting point
that forms a hard outsole when injected. It is used for
spike plates and as a base for screw-in studs. The hard-
ness grade of nylon refers to the number of carbon
atoms in the nylon molecule and is graded as nylon 6,
11, and 12 (nylon 6 being the hardest).
Leather
Split-leather and coarse full hides are used in the con- Figure 26-3 Methods of lasting.
struction of some athletic shoes.
UPPER DESIGNS AND CUTS

LASTING TECHNIQUES
1. U-throat—The U-throat offers a U-shaped full
lacing system that extends down to the toes.
The most common methods of lasting used in shoemak- 2. Vamp or blucher pattern—This upper has no
ing are slip lasting, board lasting, and combination seam construction across the dorsum of the mid-
lasting (Fig. 26-3). foot, and the tongue piece continues with the
1. Slip lasting—A slip-lasted shoe is constructed by uppers. Lace stays are not fixed to the throat.
sewing together the upper like a moccasin and 3. Balmoral or brogue pattern—This design is a low-
then gluing it to the sole. The last usually is forced cut, laced shoe, usually with a long wingtip trimmed
into the upper, which then takes the shape of the with pinking and perforations. The tongue, throat,
last. A sock liner usually takes the place of an insole. and lace stays are seamed as one unit. This type of
This lasting method makes a lightweight and flexi- upper construction allows less space for the dorsal
ble shoe with no torsional rigidity. aspect of the midfoot and often is used in golf shoes.
2. Board lasting—The upper is placed over the last 4. Lace-to-toe pattern—This pattern offers lacing
and fastened to the insole with cement, tacks, or similar to the U-throat pattern, but in addition
staples. This construction promotes stability and both quarters are pulled together across the foot
torsional rigidity but decreases flexibility. for maximal support.
3. Combination lasting—More than one lasting
technique can be used on the same shoe. Usually
the shoe is board lasted in the rear foot for stabil-
BOTTOMING PROCESS
ity but slip lasted in the forefoot for flexibility.
Combination lasting can offer customized features Bottoming is the process in which the sole components
necessary for some athletes. are attached to the upper. The upper determines the
569
...........
shoe fit and provides support, and the sole provides

traction and cushioning.
THE OUTER SOLE
The outsole is the most plantar surface of the shoe that

makes contact with the ground and usually is attached
to a midsole to form a complete sole. Most athletic
shoes have outer soles of hard carbon rubber or blown
rubber compounds. Blown rubber is the lightest out-
sole material but is not as durable as carbon rubber.
Many outsoles are composed of both blown and carbon
rubber, with blown rubber in the forefoot and mid-
foot and carbon rubber used in the high-wear area of
the heel. Gum rubbers are hard wearing and grip well Figure 26-4 Outsole patterns. (From Reyatt T: The first step:
on most surfaces. PU is less versatile but also suitable know your feet. SHAPE Magazine, Nov 1992.)
for outsole material and seems to possess good dura-
bility. Nylon, leather, and PVC have specific outsole
applications for certain sports. rubber used in running shoes usually is blown rubber
(air injected to lighten it) or hard carbon rubber.
Cleated shoes must address a compromise between
Outer sole designs performance and protection of the athlete. Rotational
Patterns can enhance stability and traction. They also traction, which is expressed by the torque about a nor-
can improve shoe lightness by exposing the middle part mal axis that is developed to resist rotation of a shoe
of the midsole, thereby eliminating part of the outsole on a playing surface, must be reduced to decrease the
and the associated weight. The design of the outsole incidence of injury while providing sufficient traction.
(Fig. 26-4) can provide cushioning, traction, pivot Both cleat length and outsole material affect friction.
points, flexpaths, and wear plugs. Torg and Quendenfeld1 concluded that the increased
Outsoles are specific for surface, weather condition, rotational traction characteristics of some football shoes
and sport. Outsole options include: are related to an increase in number of significant knee
Wear-area reinforcement (running shoes). injuries.
Cantilevered designs for shock absorption (running The necessity for lateral movement with court sports
shoes). makes the traction characteristics of court shoes im-
Pivot points (court shoes). portant. A flat outsole pattern develops the greatest fric-
Herringbone (court shoes). tional forces, whereas a herringbone pattern develops
Suction-cup designs (court shoes). less.2 With sprinting, initial ground contact is made with
Multiclaw or stud designs (field shoes). the front of the shoe. At foot strike a large horizontal
Radial edges (court shoes). velocity is created, resulting in a high braking force that
Asymmetric studs (field shoes). can cause a backward slide. Anterior spikes help to pre-
Traction and wear lugs (hiking and climbing vent slipping. With jumping events, an athlete converts
boots). the large horizontal momentum of run-up to a vertical
Traction provided by the outsole is an important momentum at foot plant. The spikes prevent foot slip
consideration in the design of a sport shoe and is directly and allow the development of large propulsive forces
related to the ability of the shoe to develop frictional necessary for long jump and triple jump.
forces with the playing surface. Traction needs depend With golf shoes, motion is primarily stationary with
on the specific sports needs. Too little traction may have little horizontal velocity. Golf shoes provide a base of
a negative effect on athletic performance, and too much support that allows the performance of coordinated
traction may put the athlete at risk for injury.1 body movements needed in hitting the ball. A non-
A running shoe should create a grip firm enough with vertical alignment of the spikes prevents slipping in
the ground so that propulsion forces created by the this sport, which mainly requires anterior and lateral
runner will not be lost with push-off. Push-off has the forces.
highest traction needs; therefore the forepart of the Boating shoes require a large amount of natural
outsole should provide the most traction. The outsole rubber to prevent slippage on wet surfaces.
570
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Other component parts
are made of a durable plastic, thermoplastic, stytherm,

MIDSOLES AND WEDGES
or polyvinyl. The medial side of the heel counter may be
extended or reinforced for additional pronation control.
Most of the recent advances in the athletic shoe industry Contoured or notched counters also reduce irritation
have been made in midsole design and materials. The of the Achilles tendon, especially in plantarflexion.
midsole and heel wedge are sandwiched between the
upper and the outsole, attaching to both. These compo- Toe box
nents provide cushioning, shock absorption, lift, and The toe box provides a stiff material inserted between
control. the lining and upper in the toe area to prevent collapse
and protect the toes.
Unit soles
Unit soles usually contain the outsole, midsole, and heel Foxing
wedge as one unit. This design is used for roller-skate Foxing is a stripping material that gives medial and lat-
boots and for other sports in which the sole does not eral support to the outside of the shoe and usually is
contact the ground. This design usually is heavy and made of suede or rubber. In running shoes, the most
provides little flexibility but excellent torsional rigidity. important foxing is at the toe, where it is called the toe
Combination or prefabricated soles cap. In court shoes, the foxing runs completely around
the sole for lateral support.
Midsoles are manufactured from a combination of two
basic materials: EVA and polyurethane. EVA is light, Cantilevered or angled radial outsole
has excellent cushioning properties, and can be manu-
A cantilevered outsole provides a concave outsole design
factured in various densities. The firmest densities in a
in which the outer edges flare out on impact to dissipate
multidensity midsole usually are designated by a darker
shock. This design is used extensively by AVIA.
color. These can be placed at critical points in the mid-
sole to aid in motion control. PU is a denser, heavier,
Shank
and more durable material than EVA. New forms of
lighter PU are being developed. The shank is the bridge between the heel and the ball
Both EVA and PU are used to encapsulate other area of the shoe. It is a reinforcing material that is arched
cushioning materials such as air bags (Nike and Etonic), and somewhat narrowed to conform roughly to the
gel (Ascics), silicone (Brooks), honeycomb pads (Reebok narrow underpart arch area of the midfoot. Shanks are
and Puma), and EVA (New Balance). not common in wedge-soled shoes but are important
Some midsoles can be contoured to the foot and are for torsional rigidity in shoes with heels to support the
referred to as more stable, anatomic midsoles. metatarsal arch.
The effect of shoe midsole composition on the
amount of tibial strain produced with walking has been Tongues
studied by Milgrom et al.3 Their study was designed to Tongues are designed primarily to protect the dorsum
test the hypothesis that shoe sole composition can affect of the foot from dirt, moisture, and lace pressure.
the level of bone strain and strain rates that can lead to a Lacing loops or tongue slits help to prevent the tongue
stress fracture. The sole materials tested were various from slipping.
polyurethane midsoles and one of polyurethane with
embedded air cells. The sole composed of polyurethane Sock linings, arch supports, and inserts
with embedded air cells had significantly lower com- Sock linings cover the insole and improve comfort and
pression and shear strains and shear strain rates. They appearance. A prime function of the sock lining is to
concluded that the polyurethane sole with the embed- serve as a buffer zone between the shoe and the foot.
ded air cells potentially could protect against stress Sock linings are molded, soft support systems that can
fractures in a walking shoe. function in aeration, moisture absorption, hygiene,
shock absorption, and motion control. Arch supports,
heel cups, and other types of padding can be added to
OTHER COMPONENT PARTS provide support, cushioning, and motion control. Cus-
tom-molded ‘‘foothotics’’ have been made popular by
the ski industry. These semirigid insole devices are
Heel counters custom molded to the foot and may help increase com-
The heel counter is a firm cup built into the rear of fort, shock absorption, and performance. Custom
the shoe that holds the heel in position and helps to insoles can be used in any sport shoe, provided there is
control excessive foot motion. Most heel counters today enough room to accommodate the insert.
571
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the motion-control features fall into two categories:

NEW COMPONENTS AND DESIGNS
(1) a harder density material built into the medial aspect
of the midsole and/or heel to counteract pronation
Air soles and (2) an added medial component to the inside or
First introduced in 1979 by Nike, this concept used outside of the shoe that limits pronation. In the past,
encapsulated air units in the midsole to enhance cush- most of the pronation-control devices have focused on
ioning. Ambient air (Etonic) or Freon (Nike) also can the rear foot. More attention now is placed on
be used. Depending on the model, the air units may controlling the entire foot.
be in the heel, forefoot, or both. Initial reports noted
that, although air systems had superior shock absorption Women’s shoes
and potential energy rebound, stability was poor.4 Sta- There has been a lot of recent interest in manufacturing
bility in the context of sports refers to the ability of women’s athletic shoes, but only a few companies have
the shoe to resist excessive or unwanted motions of the tried to market shoes for women. In the past, most
foot and ankle. Shoes with soft, well-cushioned midsoles women’s models were simply men’s models with cos-
allow significantly more motion than firmer shoes, and metic changes. It has been hard to change the common
a poor design can encourage instability. Newer designs perception that men’s shoes are better than women’s.
have addressed the stability problem with success. Air
systems are not as susceptible to compaction as EVA,
PU, and other midsole materials and therefore are SHOE FIT
thought to be more durable.
Energy return A last is a three-dimensional facsimile of a foot and the

Compression of a viscoelastic midsole material allows a form over which the upper is fashioned. The fit of all
small amount of strain energy to be stored in the com- shoes depends largely on the shape of the last. In fitting
pressed elastic components of the midsole. Theoreti- a shoe correctly, the shape of the athlete’s foot is
cally, when weight is released the elastic components important in that the shape of the shoe should match
spring back and stored energy is returned to the athlete. the shape of the foot.
It has been suggested that by increasing the energy Curved lasts are better suited for athletes with high
return of a shoe, the oxygen cost of an activity can be arches who do not overpronate. These shoes offer less
reduced and performance enhanced. There is little evi- medial support but greater foot mobility. Furthermore,
dence to support these claims. The arch of the human a curve-lasted shoe is desirable for a faster runner who
foot is also a viscoelastic system and therefore can return wants a more responsive shoe.
energy.5,6 Straight lasts provide more support to the medial side
of the foot and are better suited for athletes with low
The ‘‘pumps’’ arches or those who overpronate. Shoes should feel
comfortable and fit well the first time they are put on.
The pumps are actually inflatable linings in the tongue
Runners and athletes should shop for shoes after a run
and other parts of the shoe that are pumped up by a
or after a training session, when their feet are at their
device built into the top of the shoe. This provides
largest. The shoe should be fit to the largest foot. There
a tight, secure fit. Both Nike and Reebok have used this
should be a finger’s breadth from the end of the toe
fit feature.
box to the end of the longest toe, and the athlete should
be able to fully extend all toes.
Replaceable plug systems
One should keep in mind that although the most
A heel plug is found in multidensity outsoles, where common regular shoe width is C for men and B for
the most durable rubber is placed in the high-wear area women, the average athletic shoe width is a D for men
of the heel. Adidas designed a rear-foot plug system that and C for women. This reflects additional allowances
allows three different hardnesses of replaceable plug to for foot expansion and movement during sport. Width
be inserted into the heel wedge to improve shock fittings are not commonly available in athletic footwear.
absorption. Brooks marketed a pronation control system Athletic shoes generally are built on ‘‘universal’’ lasts,
that allows pronation to be controlled by inserting and width adjustments are incorporated into lacing
medial heel plugs of varying hardness. patterns.
When fitting new shoes, the athlete should wear the
Pronation control devices socks normally used while training. If the athlete nor-
Control over pronation in runners and other athletes is mally wears orthotics, these should replace the sock liner
a major concern of the sport shoe industry. Most of of the shoe during fitting.
572
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Shoe fit
Variable lace patterns (Fig. 26-5, A and B)

.............................................................
Laces
Many sport shoes incorporate a lacing system that pro-
Beginning at the bottom, laces should be pulled one set vides a variable or wavy eyelet pattern allowing lacing
of eyelets at a time to tighten. This provides a more to be adjusted for wider or narrower feet. The eyelets
comfortable shoe fit and distributes stress evenly across placed more widely allow the lacing to pull the quarters
the eyelets and the dorsum of the foot. in more tightly and are more suitable for narrow feet.
The majority of athletes can use the conventional The more narrowly placed eyelets allow for more girth
crisscross to the top of the shoe technique, aiming for and thus are more suitable for a wider foot.
a snug but comfortable fit. However, there are many
lacing techniques (Fig. 26-5), and shoe manufacturers Independent lacing (Fig. 26-5, C)
have added extra eyelets so that athletes can lace them One lace is provided near the throat of the shoe and one
for a custom fit. for the forefoot, which can be tied at different tensions
for a custom fit.
Figure 26-5 Lacing techniques.

573
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For pain and/or prominences on the dorsum 1. Running, training, and walking shoes—includes
of the foot (Fig. 26-5, D) most shoes used for running and walking.
This lace pattern can relieve pressure over prominences 2. Court sport shoes—-includes all shoes used for
and painful areas on the dorsum of the foot. The athlete major and minor court sports.
starts with a conventional lacing system until just distal 3. Field sport shoes—cleated, studded, and spiked
to the problem area. The lace is then moved vertically shoes used in most field sports.
to the next eyelet so that it does not cross over the dor- 4. Winter sport shoes—shoes for all winter sports
sum of the foot. A conventional lacing is used to com- activities, including skating and skiing.
plete the shoe closure. Many soccer players prefer this 5. Outdoor sport shoes—shoes for recreational
lacing pattern. sports, such as hunting, fishing, and boating.
6. Track and field shoes—diverse area of sports that
Square-box lacing (Fig. 26-5, E) has its own category of shoes.
7. Specialty sport shoes—shoes for all minor spe-
In this method, the laces never cross over the dorsum
cialized sports and some major ones not covered
of the foot but rather pass under the eyelet. This helps
under other groups, such as golf and aerobic
to distribute lace pressure more evenly over the dorsum
dancing.
of the foot than the crisscross lacing system. Square-box
lacing is useful for an athlete with a high arch, rigid .............................................................
Running, training, and walking
feet, or a dorsal prominence or for an athlete with a deep
Hiking, race walking, and exercise walking are included
peroneal nerve entrapment.
in this category.
Single-lace cross (Fig. 26-5, F)
Hiking boots
The single-lace cross may help the athlete who is having
problems with black or sore toenails. One lace runs from These are used on rugged terrain. The upper of a hiking
the inside most proximal eyelet to the opposite most boot should be water resistant. There should be few
distal eyelet. The other end of the lace goes side to side seams for both comfort and water resistance. The soles,
through every remaining eyelet. This pattern pulls up which are heavily lugged for traction and durability,
the toe box of the shoe, relieving pressure on the toes. are made of rubber, PU, or PVC compounds. There
should be some flexibility in the forepart of the shoe
For heel spillage (Fig. 26-5, G) at the metatarsophalangeal joints. Other features of a
good hiking boot include a firm heel counter, a padded
This is a conventional pattern of lacing until the last
area around the ankle area, a smooth or seam-free lining,
eyelet. By looping the end of each lace and using the
loop as an eyelet, one can obtain a more secure fit and a high, wide toe box. A wedge or a heel with a
shank is required. Climbing boots are different from
around the heel. This method is helpful to prevent heel
hiking boots in that they have inflexible soles and
slippage.
a thicker upper (Fig. 26-6).
Show lacing
Show lacing is not practical for wearing purposes. Re-
tailers and manufacturers use this method to show their
shoes.
Elastic lacing
Elastic laces can be beneficial to athletes with wide or
expanding feet. However, with the use of elastic laces,
shoes will lose some stability because, as the foot rolls
in, the laces will give. The elastic lace eliminates the need
for lacelocks used by many triathletes because the extra
stretch allows shoes to be pulled on easily.
SPORTS-SPECIFIC SHOES
Manufacturers group athletic shoes into the following

sales categories: Figure 26-6 Hiking boots.
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Sports-specific shoes
Race-walking shoes
The construction of a race-walking shoe is similar to
that of a track shoe. A firm, light midsole is important.
Outsoles are made from carbon rubber or gum rubber.
A firm heel counter is desirable.
Exercise walking shoes

The design of this shoe is similar to a training running
shoe that has many of the features needed in walking
such as lightness; flexible forefoot; comfortable, soft
upper; and good shock absorption (Fig. 26-7).
For the urban walker, weight is not as important a
consideration, and leather often is used for the upper Figure 26-8 Spikes.
material. An ample toe box and soft sock liner are added
for comfort. The sole is also different, with a wedge
incorporated into the design. The tread has a smooth,
low profile with a herringbone pattern. Many outsoles A slight wedge in the shoes for longer races gives
have a rocker profile to encourage the natural roll of more torsional rigidity and support. Torsional rigidity
the foot during the walking motion. This feature also often is omitted in track shoes for lightness. Track shoe
helps to reduce excessive flex at the metatarsophalangeal lasts are designed to hug the foot at the heel, waist,
joints and will reduce stress on the midfoot. and girth. The toe box is semipointed to prevent the
A walking shoe should have a firmer landing area on toes from splaying under the pressure of landing and
the heel than most running shoes. The bias-out or take-off.
upswept heel of many running shoes does not offer the Certain specifications for track spikes may vary for dif-
landing platform needed by walkers. Most walkers also ferent events. A maximum of six sole and two heel spikes
benefit from the use of a more resilient compound in is permitted; spikes must not project more than 25 mm
the rear part of the shoe. A heel height of 10 to or exceed 4 mm in diameter. Added spike receptacles
15 mm is recommended for exercise walking to support may be present for optimal adjustment and may be filled
the correct walking motion and reduce overstretching of with flat screws when not in use. Grooves, ridges, and
the Achilles tendon. appendages are permitted on the sole and heel.
With the use of synthetic and rubber tracks, track
.............................................................
Running spikes have shortened to approximately 9 mm and
reverted to six spikes for better traction. With the use
Spikes of shorter spikes, shoe manufacturers invented remov-
able plastic ‘‘claws.’’ When used in conjunction with
Little body weight is placed on the heel in sprinting. replaceable variable length spikes, track shoes have more
For most track runners, even those who run the longer versatility for different track surfaces.
distances, landing and propulsion are carried out on Nylon sole plates receive the spike receptacles. These
the ball and middle part of the foot. For this reason, often are covered with textured rubber for added trac-
track shoes used in the faster and shorter races have just tion. For curve running (200- to 400-m races) adequate
enough padding at the heel to prevent a contusion torsional stability is recommended. Lightweight MCR,
(Fig. 26-8). PU, or EVA foams are used to provide some padding,
particularly in the heel area. A spikeless track shoe, usu-
ally made with a thin rubber outsole covering a mid-
sole with a maximum heel height of 13 mm, may be
preferred if the track surface is hard.
Following the same pattern as sprint shoes, middle-
distance shoes vary only in the midsole area. A thin
wedge or shank may help to control overpronation and
torque during bend running.
Participants in the short and long hurdles require
sprint shoes with lasts that are wider in the toe and
shorter front spikes to avoid clipping the hurdle with
the lead foot. A more heavily padded heel is desirable
Figure 26-7 Exercise walking shoes. to cushion the landing.
575
...........
Flats maximal durability and support. Because of tremendous

More research and design has been done in this area stresses applied to the medial and lateral portion of the
than in all other areas of athletic footwear. shoe, the uppers are made with extra support around
The features most required in a running shoe used for the girth. A shot-put shoe should have reinforced
training on hard road surfaces are shock absorption, leather uppers, a sturdy heel counter, firm toe box,
flexibility, control and stability in the heel counter area, and reinforcement in the quarter for lateral support.
torsional rigidity in the waist or shank, lightness, traction, A good grip from a rubber sole and adequate shank pro-
comfort, motion control, and good fit. vides some control for anterior and lateral movements
Because of the specific needs of individual runners, across the circle. Discus shoes are similar to shot-put
athletic shoewear companies now produce models for shoes but have more flexibility in the forefoot and
specific foot types, gait patterns, and training styles. a wrap-up sole for improved turning motion in the circle.
There are designs for light runners, heavy runners, heel Javelin boots are the only throwing shoes made with
strikers, motion control, stability, lightweight trainers, spikes for run-up and planting. Soles have a heavy-duty
and rugged terrain. This segmentation of the market is forefoot and heel spike plates containing six front and
crossing over into other major segments of the athletic two back spikes, which may be as long as 25 mm for
shoe market such as tennis and basketball. competition on grass runways. A buckle or strap may
Uppers usually are made of lightweight soft or mesh be used across the girth to provide additional support.
nylon. A rigid heel counter is a requirement because,
like walkers, most runners land heel first. The midsoles .............................................................
Jumping events
of training shoes should be lightweight and offer good
shock-absorbing properties. PU and EVA are the most For jumping events, the spike placement changes from
commonly used materials, but ambient air, Freon, and the asymmetric pattern, with two spikes in front for
silicone also can be used. All these materials have good stability (the International Association of Athletics Fed-
to excellent shock absorbency and are built into heel erations [IAAF] rules that there may be a maximum of
wedge and midsole combinations. The shape of the sole six forepart spikes and two heel spikes). Most long jum-
is wedged from heel to toe, with approximately a double pers do not use heel spikes. The forepart spike plate is
thickness at the heel to the metatarsophalangeal joint sturdy for extra support. Heel cushioning is used for
flexion points. A flared heel increases stability in the heel shock absorption.
area (Fig. 26-9). Similar to long-jump shoes, triple-jump shoes vary
Traction is obtained by rubber outsole materials and only in the midsole, where a sturdy wedge gives better
a good tread design. To obtain the best traction on loose support for landing during the midstance and toe-off
or open terrain surfaces, a deeper sole tread is desired. On stress during this event. Most triple jumpers use heel
smoother, harder surfaces such as pavement, a lower- spikes.
profile sole offers better stability and adequate traction. Regardless of their style, high jumpers use a one-foot
Flexpath designs on the outsole increase flexibility. take-off. Because foot plant and take-off are critical for
a successful jump, the ‘‘jump foot’’ shoe is emphasized
.............................................................
Throwing events by designers. The take-off shoe is made in right and
left foot versions. Forward and backward ascent styles
Shoes for throwing events, in which athletes tend to (‘‘Fosbury Flop’’) have different spike placements and
be larger, are primarily made of leather or suede for gradient on the sole for take-off. The jump shoe can
Figure 26-9 Flats.

576
...........
Court sport shoes
be built with a maximal elevation of 10 mm in the fore-

part to aid lift-off. Six forepart spikes and two heel spikes
may be used. Most shoe companies now produce coun-
terpart trailing shoes that are lighter, with fewer spikes
and more flexibility to assist the run-up.
COURT SPORT SHOES
Racquet sports
These sports require forward, backward, and side-to-side
movements. The body must be moved with control in
all directions. Wear patterns produced in even a short Figure 26-10 Tennis shoes.
time show that court shoes used in racquet sports are
subjected to heavy abuse.
excellent for forward stops but not for good lateral
Tennis stops). High-cut designs are available for full ankle sup-
Tennis requires body control with quick side-to-side port. In addition to offering added ankle support, high-
movement, sprinting, jumping, and stretching. The cut uppers must not restrict ankle flexion. Proprioceptor
sport is played on lawn, clay, asphalt, and synthetic and straps are popular. Some players prefer low-cut uppers
rubberized courts. The selection of an appropriate sole for better ankle flexibility, but the incidence of ankle inju-
must be made for each surface. On clay courts, soles ries may increase with use of these shoes7 (Fig. 26-11).
with too deep a tread pattern may be prohibited because The emphasis of recent design research in basketball
of excessive court maintenance, even though most shoes has been the reduction of inversion injuries to
players would prefer the traction. On artificial or syn- the ankle. Shoes with increasing amounts of ankle
thetic surfaces, harder soles with high rubber content restriction in the upper significantly reduce ankle joint
or dual-density PU are preferred for durability. inversion.8 However, with increasing amounts of ankle
A tennis shoe should provide good lateral support; restriction, movements not only are restricted in the sag-
light to medium weight; a flat sole with a good heel ittal plane but also in the frontal plane, leading to
wedge; a firm heel counter; a well-cushioned insole reduced agility. Therefore a design compromise must
and midsole; ample toe box; good ventilation; nonslip be met between performance and protection of the
traction; a pivot point; and reinforcement for toe drag. athlete from injury.
The upper should provide a sufficiently high quarter Barrett et al.9 studied 622 college basketball players to
pattern to provide good ankle and lateral foot support. see whether shoe type and height had an effect on the in-
Over-the-ankle-line midcut models are available for cidence of ankle sprains. In a prospective, randomized
those players who prefer more ankle support. study, the player was given a pair of high-top, high-top
Manufacturers of tennis shoes recommend more with inflatable air chambers, or low-top basketball shoes
cushioning in the ball of the foot for the serve-and- to wear during all games during the season. There was
volley player. For the baseline player, a solid heel counter, no significant difference noted among the three groups
strong reinforcement in the heel and midfoot area, and
good rear-foot stability are recommended (Fig. 26-10).
Basketball
Basketball requires backward, forward, and vertical
accelerations; quick stops; and side-to-side movements.
The playing surface usually is wood but may be synthetic
or rubberized material. The shoe should provide good
lateral and medial support; light to medium weight; a
flat sole; a slight heel wedge; good cushioning; a large,
firm heel counter; toe drag reinforcement; ventilation,
a pivot point; and good traction. High rubber content
in the sole is recommended. Soles with multiple-edge
patterns, such as circles, squares, or diamonds offer
better traction than herringbone patterns (which are Figure 26-11 Basketball shoes.
577
...........
in this study, and there was no significant relationship Football

between shoe type and incidence of ankle sprains. Running is the primary motion in football, along with
quick lateral movements and the production of great
Volleyball forces secondary to blocking and hitting. Studies have
Volleyball requires quick movements, sudden stops, shown that injuries may be caused from wearing fewer,
jumping, and side-to-side motion. The indoor sport usu- longer cleats, which produce excessive pressure beneath
ally is played on wood surfaces. The shoe should provide the cleats from increased foot fixation.1 More specifi-
lateral support, be lightweight, provide a flat-herringbone cally, the excessive resistance to rotation causes knee
or deep-ripple rubber sole, good cushioning, ventilation, injuries during the twisting motions of football. The
firm heel counter, and toe-drag protection. maximal diameter of a cleat tip should be seven six-
teenths of an inch, and the maximal overall length is
one-half inch. A seven-stud pattern is preferred on natu-
FIELD SPORT SHOES ral grass. Nylon soles are preferred because they shed
dirt easily and prevent caking of mud between the studs.
Field sports combine many types of movement and Multistudded rubber soles are common on natural
a variable degree of body contact. Running is basic to grass.
all these sports. Spike and stud formations vary from Shoewear exists for linemen, backs, and kickers. Up-
sport to sport but almost all have replaceable or detach- pers for linemen must provide support and protection.
able cleats, studs, or spikes affixed into nylon soles. Gen- High-cut or semi-high-cut boot designs are preferred.
erally, smaller studs in a denser formation help to A sturdy toe box and firm heel counter are recom-
prevent ankle and knee injuries secondary to less pene- mended. Astroturf linesmen’s shoes are multistudded
tration of the cleat into the playing field. In addition, for grass and have shorter, more numerous studs for
weight distribution is better in multistudded designs. traction and stability.
The uppers used for backs are similar as for linemen.
Soccer For added mobility, a low-cut design usually is pre-
ferred. Lightweight Astroturf shoes with nylon or
Soccer involves mainly running, kicking, jumping, slid- cotton mesh uppers reinforced with suede are popular.
ing, stretching, and multidirectional movements. The These shoes usually have a rubber outsole with a waffle
playing surfaces are natural grass and artificial turf. Soc- design that wraps up at the toe and front quarter for
cer is played almost entirely by the feet, with the ball better lateral support.
being kicked off the medial, lateral, and dorsal aspects For placekickers, a shoe with a square toe box usually
of the foot. Soccer shoe lasts tend to be snug fitting, is hand made for the kicking foot and conventional for
often using European lasts, which are somewhat nar- the nonkicking foot. The shoe usually is custom made
rower than American lasts. Thinner soft leathers are pre- for the individual kicker at the professional level. A soc-
ferred for the upper because players like to feel the ball, cer shoe usually is preferred for kickers who kick from
but the tongue should be well padded to reduce lace the side of the foot. For punting, either a soccer or a
pressure and to cushion the dorsal kicking area of the back’s shoe is used. Some players kick in a traditional
foot. Some players use the tongue and lace area to pro- football back’s shoe (Fig. 26-13).
duce spin and control the ball (Fig. 26-12). Soles should Heidt et al.10 evaluated the shoe-surface interaction
be flexible at the metatarsophalangeal joints for running in anterior translation and rotation of 15 football shoes
and have torsional stability. produced by three manufacturers. The shoes evaluated
in this study included traditional cleated football shoes,
court shoes, molded-cleat shoes, and turf shoes. No
overall differences among shoes on grass versus Astro-
turf were reported. There were significant differences
noted for cleated and turf shoes. Shoes tested in condi-
tions for which they were not designed were found to
have excessive or extreme minimal friction characteristics
that could be unsafe.
Torg et al.11 found that an increase in ambient tem-
perature could affect shoe-surface interface friction and
potentially place the knee and ankle at increased risk of
injury. They tested artificial turf football shoes, a natural
grass soccer-style shoe, and a basketball-style turf shoe.
Figure 26-12 Soccer shoes.
578
...........
Winter sports
Figure 26-13 Football shoes.
Only the basketball-style shoe could be called ‘‘safe’’ or in the front and two in the heel are used extensively.
‘‘probably safe’’ at all five temperatures studied. Removable cleats are available in steel, PU, and nylon.
Lambston et al.12 reported on a study of football For pitchers, a pitching toe often is added for toe-drag
cleat design. The four major football shoe styles in the reinforcement.
study included edge (longer irregular cleats placed at
the periphery of the sole and smaller pointed cleats Rugby
placed at the interior), flat (cleats in the forefoot area The movements in rugby are similar to those of a foot-
are the same height, shape, and diameter, similar to a ball lineman or back. A drop kick is used, but the ball
soccer shoe), screw-in (seven screw-in cleats 0.5 inches must touch the ground before it is kicked. The surface
in height and diameter), and pivot disk (10-cm circular is natural grass. The rugby boot is similar in design to
edge on the sole of the forefoot with one 0.5-inch cleat a soccer shoe with four front cleats and two heel cleats.
in the center) type shoes. The edge design was found to A semicut or three-quarter cut style commonly is used
produce a higher torsional resistance than the other for ankle protection. For linemen and some wing quar-
three designs combined. This higher torsional resistance terbacks, a hard, square toe box is used. Multistudded
was associated with a significantly higher rate of anterior versions of rugby boot models also are made for firm
cruciate ligament injuries.12 playing surfaces.
Baseball
The sport of baseball requires sprinting, throwing, and
WINTER SPORTS
complex batting movements. The playing surface usually
is natural but may be artificial turf with dirt or clay on
infield base paths. A traditional baseball shoe has a
.............................................................
Skating
U-throat, and a conventional lacing system is the ulti- Skating mechanics are similar for all skating events,
mate design. Lasts are similar to those used for a football although footwear and blades are specialized. Ankle
shoe. On natural turf, steel cleats with a design of three movement and support are essential to skating
579
...........
performance. However, the subtalar joint must be free over the Achilles tendon for protection. A molded boot
to allow positioning of the blade on the ice. with a hinged upper can provide additional protection
The traditional leather boot and the injection- and durability. High-grade boots have a leather lining.
molded model are the two main types of boots available. The goalie wears a specially designed molded or
A leather boot should have good ankle support and a leather boot with a protective casing. The boots have a
firm heel counter with elongation of the medial side. low-cut design at the ankle, which allows increased flex-
Uppers are made from thick-grade leather or split ibility and also accommodates goalie pads. The blades
leather, with a leather or textile lining that gives the are thick and reinforced, with increased surface area in
foot and ankle stability but allows some flexibility. Metal contact with the ice to block shots at the goal.
eyelets are used in the lower portion of the throat, and
metal hooks above the ankle. Speed skating
Ice hockey skates were the first to use injection- Speed skating requires balanced skating with a low cen-
molded models. A viscous plastic is injected under pres- ter of gravity in the lunge position. Skaters often com-
sure into molds to form the lower and upper parts of pete with bare feet in skates. The skating surface is ice
the boot. The two parts are placed together, completing on artificial or natural ice tracks. The uppers have a
a hinged outer shell. A soft foam liner then is added. deep-cut U-throat with a full lacing pattern to the toes.
The hinged, two-piece design gives the boot some of A three-quarter ankle boot is the preferred design, with
the lateral flexibility needed in ice skating. Leather boots a firm heel counter elongated on the medial side.
tend to become more flexible with age. Thin (one-sixteenth inch), straight blades of either
tubular steel or plastic frames are used. The blade is long
(30 to 45 cm) and is placed distal to the skating boot
Figure skating
via a high-profile frame to allow a lean of low angle
Figure skating requires the athlete to jump, skate, bal- between the skate and the track. Higher-quality blades
ance, spin, dance, and lift. The performing surface is are chrome plated.
the ice on artificial or natural rinks. The upper is either
full- or top-grain cowhides. Good-quality boots are
lined with lightweight, top-grain leather or suede. A
.............................................................
Alpine skiing
firm heel counter, usually elongated on the medial side Alpine skiing requires ankle and knee flexion, forward
for added arch support, is important. Soles are PVC or lean, and balance on snow-covered surfaces. Ski boots
PU molded units with a shank for added support. provide a high-cut upper of a hinged or one-piece, injec-
Screw-in blades often are used so that the position of tion-molded plastic, outer shell to support the lower
the blades may be changed. The lasts used in figure leg. The boot should provide rigid support for the foot
skating are semipointed, with a narrow shank and heel and ankle and allow forward ankle flexion. Adjustable
to contain the foot and maintain position. buckles, dial closure devices, or straps are used for instep
The quality of the blades helps to determine the qual- support and a comfortable, snug fit. More recently, rear-
ity of the skate. Blades commonly are made of tubular entry and midentry boots have eliminated buckles and
steel or plastic frame with high-tempered steel that is overlaps on the vamp, instep, and ankle regions to
hollow ground to give two skating edges to the blade. reduce pressure. Inner liners can contain a foot bed, a
The blades can be nickel- or chrome plated. Figure variety of wedges, or adjustable canting devices. To
skating and free-style blades have a front to back curva- relieve pressure, conforming foam or pressure-flow bags
ture called a radius or rocker. The placement of the can be used (Fig. 26-14).
blades usually is slightly medial to the midline of the Ski boots are one of the last categories of athletic
sole. For jumps or spins, a toe rake or pick is used. With footwear to accommodate the female athlete. Important
forward motion, the picks also can help to prevent the design differences include an elevated heel for a shorter
blade from sliding sideways. For figures, a pair of skates female Achilles tendon, easier forward flexion, and a
without a pick and with less sharply ground blades often more flared ankle cuff.
is preferred.
Ice hockey
Ice hockey requires skating, quick stops, quick turns, and
.............................................................
Cross-country skiing
balance on the ice of artificial and natural rinks. A high-cut Cross-country skiing requires fast walking movements,
model of leather or ballistic nylon with leather rein- running, jogging, downhill skiing, and balance on
forcement is available. A good skating boot requires a snow-covered terrain. Boot and bindings act together
firm, protective, leather toe box of polyethylene or firm as a hinge between the foot and the ski and must be
fiber and comfortable ankle padding, with a high cut compatible. Boots are made of leather, Gore-Tex, nylon,
580
...........
Injuries related to athletic footwear
of smooth calf or kid leather with perforations for venti-

lation. Racing shoes usually are unlined and tend to
stretch. Rigid soles are made of reinforced steel, nylon,
or PU and can protect the foot from pedal pressure.
Depending on the system, shoes are affixed to pedals
by cleats, which improve cycling efficiency by locking
the foot to the pedal for upward and downward thrust.
Most shoes have adjustable cleats, permitting angular
and fore and aft adjustments (Fig. 26-15). Clips hold
the foot to the pedal, but clipless systems are available.
INJURIES RELATED TO ATHLETIC

FOOTWEAR
A properly designed and constructed athletic shoe can

Figure 26-14 Ski boots. help to protect athletes from both external and internal
forces that may lead to injury.
or poromeric materials that allow air to circulate and

transpire. Boots should be waterproof, as seam free as
.............................................................
Toes
possible, with rigid heel counters. Good forefoot flexion Ingrown and black toenails (subungual hematoma)
is essential. Rubber soles are preferred for use on snow are common problems seen in athletes and usually
and ice. are the result of tight-fitting shoes or shear forces that
cause the toes to abut the end of the toe box. An ade-
quate high and wide toe box and proper shoe fit should
OTHER SPORTS reduce the incidence of this injury.
Corns result from pressure on the toes from the toe
box. If the athlete has hammertoes, then the proximal
Aerobic dancing
interphalangeal joint is more prominent, and a corn
Aerobic dancing requires stationary running, skipping, can result in this location. A high toe box and proper
jumping, stretching, dancing, and stair climbing. The shoe fit usually eliminate this problem. The use of
dance surface is on carpet or covered surfaces. The shoe various pads, splints, and lambs wool can be helpful.
requirements are a combination of a lightweight, shock-
absorbing running shoe and a modified indoor court
shoe. Medial and lateral support is needed, as well as a
wrap-up toe and heel protection. The forefoot requires
.............................................................
Forefoot
stabilization and good shock absorption. EVA and PU Blisters

combinations, air systems, and gel are used in shock- Blisters are caused by friction of the skin’s rubbing
absorbing forefoot pads. Flexibility in the forepart is against a shoe, sock, or other material. Applying a piece
important. of moleskin or paper tape can be helpful. A cushioned
Bicycling
Bicycling involves use of the gluteus, quadriceps, ham-
strings, and calf muscles to generate the power necessary
to perform upward and downward thrusts through the
forefoot. The foot often is placed into a valgus or varus
position on the pedal, causing pressure to develop on
the lateral or medial sides of the foot. Cleat and pedal
placement can be changed to prevent this canting.
A cycle racing shoe has a last similar to that used for
a sprinting shoe, with a wide girth, semipointed toe,
narrow waist, and narrow heel. A high toe box is
required for toe movement. Uppers usually are made Figure 26-15 Cycle racing shoes.
581
...........
liner such as Spenco (Spenco Medical Products, Waco, the metatarsal heads can take pressure off of the
TX) may help to cut down on shearing and sliding inflamed nerve.
inside the shoe.
Nerve entrapment
Calluses Cutaneous nerves, including the sural, saphenous, deep
Similar to corns, calluses are hyperkeratoses caused by peroneal, and superficial peroneal nerves, can lie under
friction and pressure that may or may not be painful. pressure areas of an athletic shoe and result in a painful
Calluses may occur over the ball of the foot at sites of nerve irritation. Their location makes them vulnerable
pressure on the skin from underlying bone. A cushioned to compression. Nerve compression is a direct result of
shock liner can help to equalize the weight load. Cal- wearing irritating or tight-fitting shoes. Ski boots and
luses may be pared, and pads made from adhesive felt ice skates are the two major types of athletic footwear
or foam rubber may be placed proximal to the callus. that produce this problem. To avoid this problem, shoes
A Spenco insole, contoured anatomic foot bed, or other should be padded, lacing techniques modified, and
shock-absorbing and friction-reducing materials are careful shoe fit followed.
used in many athletic shoes to prevent calluses. Follow-
ing proper lacing techniques will help to improve foot
stability and reduce shear forces between the foot and .............................................................
Heel
the shoe.
Plantar fasciitis
To prevent this common injury, a shoe must have excel-
Metatarsalgia lent shock-absorbing abilities in the heel. A varus heel
Metatarsalgia is a nonspecific diagnosis that describes pad or wedge also can be indicated to decrease forces on
pain in and about the head of the metatarsal, metatarso- the medial aspect of the heel. Once the problem develops,
phalangeal joint, and adjacent soft-tissue structures. heel cups, foam pads with a cutout, or orthotics with a
Metatarsalgia can result from atrophic fat pad, basic well-cushioned heel and a well to float the painful area
anatomy of the metatarsals, increased pressure on the can be indicated. A shoe with a firm medial heel counter
metatarsal heads, neurologic dysfunction, postsurgical can decrease pronation and stress on the plantar fascia.
changes, metabolic disorders, and inflammation. A well-
cushioned liner and midsole material in addition to a Bursitis
rocker sole, which allows the athlete to roll off the The retrocalcaneal and pre-Achilles bursa can be
painful forefoot, can be useful. irritated during sports. This disorder can result from
poor shoe fit, an ill-padded heel counter, or excessive
Sesamoiditis
heel motion. The athlete should be advised to buy a
The sesamoid bones are prone to injury because of shoe with well-padded heel counter, an Achilles notch
their location under each big toe joint. Cavus feet, equi- that accommodates the Achilles tendon in plantarflex-
nus of the first metatarsal, or rigid foot can cause ex- ion, and an adequate heel height of at least 15 mm.
cessive pressure to be placed on the sesamoids. A shoe
with a good, shock-absorbing, midsole material extend- Achilles tendon
ing out into the forefoot must be worn to protect the Low heel elevation in an athletic shoe often is a factor in
area. A rocker sole can be helpful. Orthotics that in- the development of Achilles tendinitis. To prevent irrita-
corporate a sesamoid pad placed just proximal to the tion of the tendon, a shoe with a well-padded Achilles
injured sesamoid to float the painful area is a useful tendon pad or notch should be worn. Heel lifts can be
way to treat this problem. worn to elevate the foot in the shoe and reduce tension
on the tendon. A firm heel counter can reduce the side-
Interdigital neuroma to-side motion of the heel and the Achilles tendon, thus
The most common location for an interdigital neuroma reducing irritation of the tendon.
is in the third webspace. Excessive pressure on the ball of
the foot or a shoe that does not fit well in the girth may
contribute to this problem. A shoe with excellent shock-
.............................................................
Ankle
absorbing properties that extend out into the forefoot Sports involving walking, running, or jumping often can
must be worn to protect the area. A rocker sole can be result in inversion injuries to the ankle. If an athlete has
helpful. Orthotics incorporating a metatarsal pad placed a tendency to inversion injuries of the ankle, a shoe
just proximal to the involved webspace to help spread should be worn that has a firm heel counter, a
582
...........
References
moderately flared heel for a runner, and the stability of a 2. Valiant GA: The effect of outsole pattern on basketball shoe
high-cut model rather than a low-cut model for field or traction, In Terauds J, Gowitzke BA, Hole LE, editors:
Biomechanics in sports III & IV, Del Mar, CA, 1986, Academic
court sports. Hockey skates and alpine ski boots should Publishers.
provide good ankle support. Taping, various shoe 3. Milgrom C, et al: The effect of shoe sole composition on
wedges, braces, and orthoses all are used in the treat- in vivo tibial strains during walking, Foot Ankle Int 22:598,
ment and prevention of ankle sprains. 2001.
4. Clarke TE, et al: The effects of shoe design parameters on rear
foot control in running, Med Sci Sports Exerc 15:376, 1983.
5. Alexander RM: How elastic is a running shoe? New Sci 123:45,
CONCLUSIONS 1989.
6. Kerr RF, et al: The spring in the arch of the human foot,
Nature 325:147, 1987.
Each year athletic shoes tend to get better. In the last 7. Garrick JG, Requ RK: Role of external support in the
10 years, motion control has improved, shock absorp- prevention of ankle sprain, Med Sci Sports Exerc 5:200, 1973.
tion has followed a pendulum and found its middle 8. Robinson JR, Frederick EC, Cooper LB: Systematic ankle
ground, and the trend is toward lighter materials. stabilization and the effect on performance, Med Sci Sports
Exerc 18:625, 1986.
Although maximal foot speed may increase slightly in a 9. Barrett JR, et al: High versus low-top shoes for the prevention
lighter shoe, protection of the foot must not be com- of ankle sprains in basketball players. A prospective randomized
promised. Footwear should be designed to enhance study, Am J Sports Med 21:582, 1993.
athletic performance and prevent overuse. 10. Heidt RS, et al: Differences in friction and torsional resistance in
athletic shoe-turf surface interfaces, Am J Sports Med 24:834,
1996.
11. Torg JS, Stilwell G, Rogers K: The effect of ambient
temperature on the shoe-surface interface release coefficient,
REFERENCES Am J Sports Med 24:79, 1996.
12. Lambston RB, Barnhill BS, Higgins RW: Football cleat design
and its effect on anterior cruciate ligament injuries. A three-year
1. Torg JS, Quendenfeld T: Effect of shoe type and cleat length prospective study, Am J Sports Med 24:155, 1996.
on incidence of severity of knee injuries among high school
football players, Res Q 42:203, 1971.
583
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.........................................C H A P T E R 2 7
Orthoses and insert management of common

foot and ankle problems
John S. Gould and David Ford
......................
CHAPTER CONTENTS
Introduction 585 Ankle 593

Forefoot 585 Knee pathology 593
Midfoot 588 Conclusions 593
Hindfoot 590 Suggested reading 593
INTRODUCTION this arrangement and have such persons in their own

foot and ankle clinics. Sports medicine specialists usu-
ally have ready access to pedorthists and always to
The proper use of shoe inserts (orthotic devices/ortho-
physical therapists, who can act as an intermediary
ses), shoe modifications, and, on occasion, braces, pro-
between the physician and the pedorthist. It is totally
vides an armamentarium of nonoperative solutions to a
outdated for a physician to mix his or her own medica-
wide range of foot problems. These approaches may be
tions or make his or her own orthoses in the office,
curative or palliative, permanent or temporizing, and
although this comment does not exclude the use of
may avoid the need for surgery or be an adjunct to it.
some over-the-counter devices that may be available
It is essential that the pedorthist has the knowledge of
in such circumstances.
materials, their durability and wear characteristics, fabri-
In this chapter, we present information anatomically,
cation skills, fitting capabilities, and imagination to carry
starting with the forefoot and progressing proximally,
out his or her part of the equation. To assist in the
as the physician may encounter in a patient. Problems
details of the prescription, he or she should also know
in the athlete are highlighted. A variety of diagnoses that
enough biomechanics to understand the effect that the
present in these areas are covered. It is fully accepted
device or modification will have on the foot. If the phy-
that there are various alternative methods to achieve
sician—whether an orthopaedist, a rheumatologist, a
the same effect. We do not attempt to be comprehensive
physiatrist, or even an endocrinologist managing a dia-
in suggesting solutions but discuss the options we use
betic—is personally to prescribe, he or she must know
that have proved to be effective in our practice.
something about these devices or refer to someone
who does. We do not feel that the pedorthist should be
the prescriber any more than a pharmacist should FOREFOOT
prescribe drugs. Consequently, the physician should
know what effects he or she wishes to achieve with
the device and shoe modification and generally how Intractable plantar keratosis (IPK)
the device should be made. He or she does not need IPKs are calluses under bony prominences on the plan-
to know about specific materials or fabrication or fit- tar aspect of the foot. They may be caused by a plantar-
ting. The ideal arrangement for patient care is for the flexed metatarsal head because of a hammertoe or a
pedorthist actually to attend the clinic with the physi- fracture, the elevation of an adjacent lesser toe meta-
cian so that there is a complete understanding of these tarsal head that causes a transfer of pressure, or develop-
issues when the patient is seen and a disposition pro- mental problems of a similar nature (second metatarsal
vided. Many orthopaedic foot and ankle specialists have head callus adjacent to a bunion; a rotated fifth
CHAPTER 27 Orthoses and insert management of common foot and ankle problems
metatarsal head in a bunionette, a prominent sesamoid,

and so forth). The solution is relatively simple: material
is placed proximal to or around the prominent area
(‘‘posting’’) to ‘‘offload’’ the prominent area and softer
material is placed under the callus and prominence
to cushion it. Using a material such as cork built into
the insert material, we make a full-length, total-contact
insert (TCI) with posting proximal to the lesion and cre-
ate a well under the lesion. We then fill this well with a
viscoelastic polymer, which adds excellent cushion, does
not flow out of the well, and compresses more slowly
than most other materials (Figs. 27-1 and 27-2). A sim-
ilar solution is used for apical calluses (on the tips of
hammer, claw, or mallet toes).
Morton’s neuroma or intermetatarsal neuritis

Irritation of the intermetatarsal nerve, which leads to
neuritis or intraneural fibrosis (the Morton’s neuroma),
is anatomically caused by the distal edge of the inter-
metatarsal ligament between the adjacent plantar plates
of the metatarsophalangeal (MTP) joint. A metatarsal
pad made of felt or other less compressible materials Figure 27-2 Plantar surface of total-contact insert (TCI), with
can be placed under the adjacent metatarsals proximal to cork posting around the area of intractable plantar keratosis
the condylar heads of the adjacent metatarsals, thereby (IPK). The relief well within the posted area is filled with a
elevating them to decrease the contact of the edge of viscoelastic polymer.
the plate when the patient is standing and walking.
Some doctors place the pad on the patient’s foot with for the patient (Figs. 27-3 and 27-4). We also may add
some adhesive or attach it to the sock liner in the shoe. other features to the insert, such as longitudinal arch sup-
We prefer to incorporate the pad into a total-contact port when a symptomatic, flexible flatfoot accompanies
insert, professionally placing the pad in the right place the problem.
Figure 27-1 Total-contact insert (TCI) under construction Figure 27-3 Total-contact insert (TCI) under construction, with
(before adding topping), with posting pad proximal to posting pad proximal to the 3/4 intermetatarsal space (for
intractable plantar keratosis (IPK) site. intermetatarsal neuritis or Morton’s neuroma).
586
...........
Forefoot
metatarsal bar was placed in this location of the outer

sole, but the rocker sole allows much easier walking than
the bar. Before this stage of care, some surgeons may
use total-contact casting, various commercially available
boots that unweight the sole of the foot, and heel-
weight-bearing–only postsurgical shoes. All of these
measures may, at one stage or another, be adjunctive
during the care of these problems. The orthoses and
modified shoe may be used after the acute care to
prevent later recurrence.
Metatarsopharangeal joint synovitis, ‘‘turf-toe,’’

arthritis, hallux rigidus, and rheumatoid arthritis
The treatment of an inflammatory condition of these
joints should be immobilization while still allowing the
patient to ambulate. This can be accomplished by using
a stiff-sole shoe or insert. This effect can be obtained by
placing a thin, spring-steel shank between the cush-
ioned, total-contact insert and the insole on the shoe,
or by incorporating the stiff material within the insert,
or adding it to the sole of the shoe between the outer
Figure 27-4 Plantar surface of total-contact insert (TCI) with sole and midsole, or using a shoe that is made with a stiff
metatarsal pad in place proximal to 2/3 and 3/4 interspaces. shoe from the factory (Figs. 27-6 and 27-7). It is essen-
tial, however, to also use a rocker sole on the shoe (see
Fig. 27-5) so that the patient can walk without the
Ulcers under the metatarsal heads foot lifting up within the shoe; this would not only
Ulcers or deep blisters may occur under the metatarsal make the walking difficult but also increase the symp-
heads. This is a particularly common and challenging tomatology. In a patient with hallux rigidus, there are
condition with the insensate foot but can occur in ath- two problems: pain in the joint from impingement,
letes as well. Although it is critical to analyze why the arthritis, and synovitis, and lack of motion. The previous
ulcer or blister occurred and to recognize the presence prescription deals with these problems well, but some
of structural problems, the pedorthic approach is an physicians will use the more rigid insert ‘‘Morton’s
important adjunct to care. The insert should be full extension,’’ which lies from the heel to the end of the
length, with posting around a relief well under the ulcer. great toe but not all the way across the foot (Fig. 27-8).
Again, we fill this well with the viscoelastic polymer. In the rare athlete with rheumatoid arthritis foot,
In addition, a relief well also is created in the insole of not only is there arthritis of the joints but also there
the shoe by use of a burring tool. Finally, a mild rocker may be dislocations at the MTP joints with hammer-
sole is placed on the outside of the shoe with the apex toes, plantar prominences, and nodules. Again, the stiff
proximal to the ulcer site (Fig. 27-5). In the past, a rocker sole is essential, but one must add the proximal
posting, relief wells filled with viscoelastic material, and
Figure 27-6 Full-length, spring-steel shank, which may be

placed under a total-contact insert (TCI), incorporated within
Figure 27-5 Rocker sole on a running shoe. it, or placed in the sole of the shoe.
587
...........
over the counter and are lighter in weight than the

calfskin (although perhaps less durable for scuffing and
wear). We seldom prescribe custom shoes (made specif-
ically for the individual patient) rather than these ‘‘pre-
scription shoes,’’ which are more readily available, less
costly, and better in appearance. Finally, we use a
multi-ply insert for rheumatoid patients to provide
increased cushioning.
Other joint conditions can affect the forefoot locally.
Freiberg’s infraction is treated as an inflammatory arthri-
tis of the MTP joint with a stiff rocker sole and a relief
well under the metatarsal head if it is tender. The turf-
toe is a general term for a hyperextension injury to the
plantar plate of the MTP joint of the great toe. The
injury can be as simple as a minor tear of the plate, with
or without intra-articular synovitis, or as complex as
complete avulsion of the plate, with retraction of the
sesamoids and with or without subluxation of the joint.
Various articular surface injuries can occur, from a
chondral abrasion to an osteochondral fracture. Severe
injuries should be treated surgically, for example when
Figure 27-7 Plantar surface of a total-contact insert (TCI) with retraction of the sesamoids is noted or when an injury
a steel shank before incorporation. and symptoms become chronic. The rocker sole is essen-
tial, and a stiffening device is added to the insert or sole
of the shoe, as noted. For many running athletes, the
rocker sole is a routine modification to their shoes, and
a stiff insert or sole is compatible with their sporting
function. A professional tour golfer can wear an insert
but cannot modify his or her shoe. A rocker sole can
be tolerated in football and lacrosse, but less so in
basketball and tennis.
Sesamoid pathology
For sesamoiditis, the stiff-sole approach with a rocker is
appropriate, but we also add a relief well with the visco-
elastic polymer (Fig. 27-9). When there is an IPK under
a prominent sesamoid, the relief well alone is sufficient,
with proximal or surrounding posting. For avascular
necrosis and fracture care, the stiff rocker sole may be
a satisfactory temporizing approach until definitive
surgical measures can be taken.
MIDFOOT
Figure 27-8 Plantar surface of a total-contact insert (TCI) with Plantar fibromatosis
a steel-shank Morton’s extension before incorporation.
Thickening of the plantar fascia because of plantar fibro-
matosis, a benign but aggressive tumor, can cause pain
one additional orthotic plus two other shoe modifica- resulting from tenderness of the lesion in its early stages
tions. The first is increased depth of the toe box to or because of pressure on the underlying tissues, includ-
accommodate the toe deformities. The second is softer ing the plantar nerves. Good total-contact inserts with
materials for this hypersensitive foot, such as deerskin an appropriately placed relief well filled with the visco-
or an elastic synthetic material (e.g., Spandex). Both elastic polymer can be adequate treatment. If the lesion
the elastic-material shoe and the deerskin are available is particularly large, the insole also can be burred out;
588
...........
Midfoot
Figure 27-9 Plantar surface of a total-contact insert (TCI) with

a relief well filled with viscoelastic polymer under first
metatarsal head and sesamoids.
Figure 27-10 Double rocker sole for midfoot plantar lesions.
and finally, the sole of the shoe can be modified by use

of what is called a ‘‘double rocker’’ sole. In this situa-
tion, the sole of the shoe becomes concave under the
lesion and convex on either side of it (Fig. 27-10).
Midfoot arthritis
Tarsometatarsal (TMT), naviculocuneiform, and trans-
verse tarsal arthritis all are treated with a stiff rocker
sole shoe and total-contact inserts. The two more prox-
imal levels and, to a slight degree, the TMT, also have
some degree of varus/valgus and abduction/adduction
and pronation/supination movement. This is controlled Figure 27-11 (A) Full-length University of California Biomec-
by use of an insert, which cups the heel more and is hanical Laboratories (UCBL) insert with deep heel cup and high
higher distally, medially, and laterally; this is the Univer- sides to control subtalar and transverse tarsal motion (forefoot
sity of California Biomechanical Laboratories (UCBL) component of the insert has not been trimmed to final contour).
type (Fig. 27-11, A and B). (B) Close-up view of deep heel cup and sides in UCBL insert.
589
...........
a ‘‘topping’’ on the insert that is both nonskid and

HINDFOOT
washable.
Plantar fasciitis Tarsal tunnel syndrome with or without chronic

Plantar fasciitis, an enthesopathy of the origin of the
plantar fasciitis
plantar fascia on the medial tubercular process of the Patients with plantar fasciitis may become chronic with
calcaneus, usually is a self-limited disease. Stretching attenuation of the fascia and, at times, neuritic symp-
exercises and a device to cushion the heel are the funda- toms. In these patients, the insert with its posted arch
mental approaches to treatment. Over-the-counter heel increases their pain. In these patients, we use a full-
cups and various heel cup and longitudinal arch sup- length, total-contact insert, post the arch, and add a
portive devices have been prescribed (Fig. 27-12). The ‘‘nerve- relief channel,’’ filled with the viscoelastic mate-
pedorthic concept is to support the plantar fascia to rial. The channel starts at the medial wall of the insert
decrease the strain on this structure and to provide a under the posterior tibial nerve and its lateral plantar
heel cup to gather the fat pad and decrease the pressure nerve branch over the soft spot on the medial aspect of
on the sensitive point on the medial aspect of the heel. the heel pad where the nerve enters the foot. It con-
In chronic cases, we prescribe a custom-made insert, tinues onto the plantar aspect of the heel, following
either full length or three-quarter length (with Velcro the nerve course (Fig. 27-13, A and B). In cases of cen-
on the underside to prevent the device from slipping tral heel-pad syndrome, which includes the first branch
out of place). A shallow cup is created with posting of the lateral plantar nerve, the channel is widened pos-
of the longitudinal arch, thus satisfying the pedorthic teriorly and on the plantar pad to include this nerve
concept. It also is important to flatten out the outside area. This also is done when the patient complains of
of the heel component so that the insert will not rock pain around the peripheral margin of the heel or on
in the shoe. In the athlete, it also is important to use the lateral border, all symptoms of involvement of this
nerve branch.
Flexible flatfoot with or without an

accessory navicular
Flexible flatfoot is treated with a full-length or three-
quarter–length total-contact insert, usually of the UCBL
variety. The three-quarter length does not add material
under the forefoot and therefore is easier to wear in a
variety of shoes, including loafers (Fig. 27-14, A and
B). When the insertion of the posterior tibial tendon is
tender, particularly with a prominent accessory navicu-
lar, a relief channel with the viscoelastic filler is used.
In early adolescence, when this condition is most prev-
alent and the foot is still growing, the inserts may
need adjustment at frequent intervals, and many ped-
Figure 27-12 Silicone heel cups. orthists will adjust their fees to make this approach
Figure 27-13 (A) Total-contact insert (TCI) with posteromedial nerve-relief channel filled with viscoelastic
polymer for tarsal tunnel syndrome. (B) Plantar aspect of TCI with nerve-relief channel filled with viscoelastic
polymer carried onto plantar surface for tarsal tunnel syndrome (channel is extended more posteriorly and more
centrally on the heel for central heel pad syndrome—note the proximal and distal cork posting on this insert).
590
...........
Hindfoot
The insert is a well-stabilized UCBL (the outer surface

is flattened to prevent rocking) with a relief channel
under the high contact area (Fig. 27-16).
Cavus or cavovarus foot

The patient with the cavus foot has numerous symptoms
at various times. First, there is tripod weight bearing
with high contact and often with callusing under the
first and fifth metatarsal heads and the heel. The high
arch causes dorsal pressure on the foot, possibly irritat-
ing the superficial peroneal nerve. Dorsal arch pain also
may occur, with or without plantar fasciitis. The lack
of flexibility also contributes to higher impact on the
heel. Finally, the varus position of the heel places lateral
stress on the ankle ligaments. A total-contact insert,
which fills the arch, helps to distribute the weight bear-
ing better, and posting behind the first and fifth meta-
tarsal heads, with relief under them and the heel, is
added. A wedge of solid ankle cushion heel (SACH)
material, which has more flexibility than the usual heel
leather, is added to the shoe heel, along with a lateral
heel flare to decrease the tendency for the heel to roll,
Figure 27-14 (A) Full-length, total-contact insert (TCI). an action that puts stress on the ankle (Fig. 27-17).
(B) Three-fourths length TCI. A crepe sole is more flexible than leather and also is
desirable, along with a rocker design, to compensate
more acceptable to parents. If the patient has a juvenile for the lack of flexibility. The middle-aged patient’s
bunion associated, the shoewear also must be forgiving, now-symptomatic cavus foot can be relieved with this
and shoes made of flexible material and with available combination of insert and shoe modification.
wider widths are needed. Because this flatfoot is flexible,
it is essential that the fitting of the insert be done in a Insertional tendinitis of the tendo achilles and
nonweight-bearing mode to properly position the foot Sever’s disease
in a neutral position of the talonavicular and naviculocu- Although the insertional tendinitis of the tendo Achilles
neiform joints (no sag in the talometatarsal angle or occurs in middle age and Sever’s disease occurs in ado-
abduction or uncovering of the talus at the talonavicular lescence, both are treated similarly. A lift of 3=8 to 5=8
joint on the anterior-posterior view) (Fig. 27-15). inch is added inside or outside the shoe to decrease
Fixed flatfoot deformity in the adolescent

Fixed flatfoot often is a condition that requires surgery
for various tarsal coalitions. When an insert is indicated,
it must be accommodative and must cushion the foot
properly, particularly under the prominent talar head.
Figure 27-16 Before (L) and after (R) views of the heel
Figure 27-15 Plaster mold of the plantar aspect of the foot portion of an insert in the fabrication process. The plantar
made from an impression taken of a patient’s foot with a aspect of the insert’s heel component is squared off with
foam box or casting. The total-contact insert (TCI) is vacuum grinding and sanding to stabilize the insert in the shoe and has
formed from the mold. the desired effect of properly supporting the foot.
591
...........
Figure 27-18 An over-the-counter anklet to protect the tendo

Achilles for insertional tendinitis. Padding is provided on either
side of the tendon to help cushion the structure. A heel cup/
extension or lift also is shown and is used with the anklet.
Some brands also incorporate the heel lift into the lining of the
Figure 27-17 A lateral heel flare has been added to the heel anklet.
of this running shoe to prevent a varus roll and increased
stress on the lateral ankle. The flare can be increased when
heel varus is more pronounced. fiberglassing of the counter (which does not seem to
hold up) to adding material to the outside, such as a
stress on the tendon, and the heel counter is padded synthetic foam material (to avoid adding significant
with a cushioning material, or a backless shoe is used. weight to the shoe) covered by leather (Fig. 27-19).
Alternatively, there are over-the-counter devices in
which a silicone pad is attached to a little sock, which
can be worn with the heel lift. In addition, an over-
the-counter device also has been fabricated that pads
around the sensitive heel area and includes a lift under
the heel (Fig. 27-18).
Posterior tibial tendon dysfunction

Although posterior tibial tendon dysfunction is com-
mon in middle age, tenosynovitis, stage one and early
stage two of the posterior tibial tendon dysfunction syn-
drome occur in the younger patient. Support of the lon-
gitudinal arch is essential, along with control of the
hindfoot to prevent valgus. We tend to use the UCBL
insert with posting of the longitudinal arch to control
this foot. The standard total-contact insert with the
posted arch can be sufficient, along with various similar
over-the-counter devices. In addition, it is essential to
use a firm medial counter. This can be provided over Figure 27-19 A medial stabilizer is added to the medial
the counter in many brand-name running shoes. It also counter of the shoe for posterior tibial tendinitis or posterior
can be added by various means, ranging from simple tibial tendon dysfunction.
592
...........
Suggested reading
When a sufficient course of a good, nonoperative

KNEE PATHOLOGY
regimen is not successful, surgery may be indicated.
Some sports medicine and knee specialists will prescribe

ANKLE orthotic devices with medial or lateral heel wedges to
load or unload the medial or lateral knee compartments,
and after sprains, strains, and suspected menisci injuries.
Subtalar arthritis, sinus tarsi syndrome Such wedges also may be helpful in early unicompart-
For subtalar arthritis, the UCBL insert can support and mental arthritis.
control the motion in the subtalar joint and is the device
of choice. Sinus tarsi syndrome, apparently synovitis of
the subtalar joint secondary to intra-articular ligament
injury, is treated primarily by splinting with an orthotic CONCLUSIONS
device and prescribing medications, with arthroscopic
debridement as a subsequent alternative. Orthotic devices and modification of standard and pre-
Peroneal subluxation, peroneal tenosynovitis, scription shoes are an essential part of the armamen-
peroneal tears tarium of the orthopaedic surgeon specializing in foot
and ankle and sports medicine. Some over-the-counter
Orthotic treatment of peroneal subluxation, peroneal devices are appropriate, and, in other instances, custom
tenosynovitis, and peroneal tears constitutes, in our devices should be fabricated. Many of these approaches
opinion, a minor adjunct to what often are surgical con- may return an athlete to participation rapidly. When sur-
ditions. In synovitis, in particular, a lateral heel wedge gery is indicated, the devices may also be a valuable
with an insert to create a valgus heel position to help adjunct to care.
splint these tendons may be used.
Ankle ligament sprains

Taping, bandaging, and over-the-counter ankle sup- SUGGESTED READING
ports constitute part of the treatment of ankle ligament
sprains. We may use elastic sheath supports, which pro-
Baxter DE, editor: The foot and ankle in sport, St Louis, 1995, Mosby.
vide medial/lateral support and compression, or lace- Janisse DJ, editor: Introduction to pedorthics, Columbia, MD, 1998,
up devices with Velcro-strap support in the early stages Pedorthic Footwear Association.
of management, along with physical therapy. Many ath- Pedorthic Footwear Association desk reference and directory, 1994/95
letes who wear cleated shoes have their ankles taped for ed, Columbia, MD, 1994, Pedorthic Footwear Association.
practice and games. Few tolerate braces for prophylaxis
of sprains.
593
...........
.........................................C H A P T E R 2 8
Principles of rehabilitation for the

foot and ankle
Erin Richard Barill and David A. Porter
......................
CHAPTER CONTENTS
Introduction 595 Functional progression 599

Cryotherapy/rest, ice, compression, Phases of rehabilitation 601
and elevation (RICE) 595
Rehabilitation of Achilles tendon repair 601
Range of motion/mobilization 596
Rehabilitation after lateral ankle reconstruction 604
Protected weight bearing 597
Rehabilitation of ankle fractures 607
Gait evaluation 598
Conclusion 609
Strengthening 598
References 609
Proprioception 598
Further reading 610
Cardiovascular activities 599
INTRODUCTION rehabilitation must continue to advance and keep up

to date with technologic and procedural advances.
A proper and advanced approach to rehabilitation can
The foot and ankle often are injured during sporting
provide an environment conducive to a complete, full,
events, recreational activities, and occupational acci-
and functional recovery.
dents. Injuries to the foot and ankle may be acute or
chronic in nature and often cause considerable disability
in athletes. Garrick and Requa1 reported that foot and
ankle injuries represented more than 25% of the 1600
CRYOTHERAPY/REST, ICE, COMPRESSION,
athletic injuries in their series.2,3 It has been suggested
AND ELEVATION (RICE)
that the sprained ankle is the single most common injury
in sports.2,4-7 Initial treatment of acute foot and ankle injuries and
The foot and ankle serve as the junction of the body to postoperative ankles still follows the RICE principle.
the weight-bearing surface. This elegant collection of tis- There are several cold agents to choose from, including
sues, each with a variety of specialized functions, allows the cold pack, ice bags, cold whirlpool, ice immersion,
efficient, upright stance and locomotion.8 Athletic popu- and the Aircast Cryocuff. The primary objective of ice
lations have unique and strenuous demands. Even with is to reduce swelling and help manage pain. It has been
minor injuries, improper or incomplete rehabilitation found that pain is inhibited by cold through a decrease
can lead to significant impairment. A detailed, focused in nerve conduction velocity. As the temperature
approach to rehabilitation of the foot and ankle is cru- decreases, there is a corresponding decrease in sensory
cial to the athlete. Fortunately, most competitive ath- and motor nerve velocity, eventually causing synaptic
letes have access to daily evaluation and monitoring of transmission to be blocked.9 In our experience, we have
progress, as well as skilled assistance to help them com- found the ankle and foot Cryocuffs to be effective
ply with rehabilitation protocols. Recent technologic because they combine compression and cold. In addi-
and procedural advances contribute greatly to the tion, elevation can help to reduce hydrostatic pressure
treatment of the competitive athlete. Principles of and diminish edema. Physiologically, the application of
CHAPTER 28 Principles of rehabilitation for the foot and ankle
cold agents also results in arteriolar vasoconstriction, a actually enhances the healing process. Early mobilization
decrease in local metabolism, and an elevation in pain may result in an earlier return to work and daily activity,
threshold. less muscle atrophy, and better mobility compared with
The application of cold is most effective immediately immobilization by casting.14,17,18 The value and benefit
after injury or within the first 72 hours. Hocutt et al.10 of early motion was investigated in the area of rehabi-
found that patients with grade III ankle sprains that litation after flexor tendon repairs of the hand. The
were treated with ice in the first day returned to func- obvious need for full motion in the hand prompted
tional activities such as running and jumping after 6 days, investigation into safe rehabilitation practices, which
whereas those treated on the second day went 11 days would eliminate postoperative adhesions and stiffness
before they could run or jump. In contrast, those who but allow reliable healing of the tendon. Gelberman
received heat in the first day had a recovery time of et al.19,20 noted an improved healing response,
14.8 days. improved strength, and a more normal pattern of vascu-
A contraindication to cryotherapy is individuals with larity to the healing tendon with protective early mobili-
hypersensitivity to cold. Cold should be avoided in zation. Several other studies also noted that early range
patients with Raynaud’s syndrome or peripheral vascular of motion decreased adhesions around the repaired ten-
disease (see Chapter 10). Cold therapy also must be don and had a positive influence to the healing tis-
monitored closely in postoperative patients who have sue.21,22 Early motion after flexor tendon repair has
wet dressings because the combination of wet dressings become standard today.
with cold application can decrease the skin temperature Over the past 2 decades, there have been significant
to a dangerous level. studies in the area of rehabilitation after knee injury
and surgery. The focus of knee rehabilitation has cen-
tered on obtaining full symmetrical range of motion
following a knee injury or surgery. Obtaining full knee
RANGE OF MOTION/MOBILIZATION extension was one of the most important criteria in
allowing the anterior cruciate ligament to heal ana-
There always has been an interesting rehabilitation tomically and yet still avoid a knee flexion contracture.
dilemma between the need for early range of motion Close observation of patients who were doing well
and the need to immobilize tissues to decrease swelling, demonstrated that early range of motion was not detri-
protect injuries, and protect against pathologic motion. mental to the ligament (and in fact could be advanta-
This section discusses the advantages of early motion. geous to proper ligament healing/strengthening) while
Galileo first recognized the relationship between allowing an earlier and safe return to function.23 Early
applied load and bone morphology. In 1892, Julius motion and weight bearing led to a significant decrease
Wolff, a German anatomist, was the first to link these in muscle atrophy and decreased complications from
two vital concepts in his landmark thesis, ‘‘The Law of arthrofibrosis with an earlier return to function.
Bone Transformation.’’ Wolff explained that every Robert Salter and associates24 investigated the effect
change in the function of a bone is followed by certain of joint motion on cartilage nutrition. Early continuous
definite changes in internal architecture and external passive motion in synovial joints allows and promotes
confirmation in accordance with mathematical laws. cartilage nutrition and health. Salter et al.24 demon-
Stated simply, ‘‘form follows function.’’ strated that small cartilage defects actually could heal
Application of early motion on ligament healing with continuous motion, further supporting the benefit
demonstrates that the ligament hypertrophies to com- of motion on articular cartilage nutrition and healing.
pensate for decreased tensile strength of the individual These advances in hand and knee rehabilitation gave
fibers. Obviously the amount of tension and stress must us reason to approach the foot and ankle with a similar
not overcome the ultimate load to failure of the tissue approach. Thus early mobilization of the foot and ankle
and must not lead to fatigue or plastic deformation. following injury is our currently favored treatment
Wolff’s law also may apply to these soft tissues, and physi- method when applicable. This method specifically avoids
ologic stress may allow more functional and stronger or reduces immobilization. We have followed the prin-
healing of soft tissues. Experimental studies of liga- ciple that unnecessarily protracted immobilization can
ments after injury indicate that exercise and joint prolong the recovery period. Early mobilization can expe-
motion stimulate healing and influence the strength dite the return to work and resumption of athletic activity
of ligaments after injury.11-16 while potentially decreasing the risk of complications.
Some of the early research on restoration of early Eiff et al.17 used a prospective randomized study to
range of motion was performed in the hand and the determine which treatment for first-time ankle sprains,
knee. These historical papers revealed insight on how early mobilization or immobilization, is more effective.
early range of motion decreases complications and They reported that, in first-time lateral ankle sprains,
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Protected weight bearing
although both immobilization and early mobilization patients to weight bear immediately, work on range of
prevent late residual symptoms and ankle instability, motion by removing the boot, and use a continuous
early mobilization allows earlier return to work and cold/compression device. Once the ankle has healed,
may be more comfortable for patients. Active and pas- a more functional brace is used for return to activity
sive range of motion is useful to regain motion in cardi- (2-4 weeks after injury). We particularly stress the use
nal and diagonal planes. Passive range of motion allows of the boot at night for the first 3 to 4 weeks to keep
the muscles to relax while working the mobility of the the foot and ankle complex in a 90-degree dorsiflexed
joint. Active range of motion requires independent position during sleep, when the relaxation of muscular
muscle action and incorporates muscle re-education. control and the forces on the heel passively place the
It is important to work range of motion in the direction complex in a plantarflexed and inverted position. The
opposite of the mechanism of injury (i.e., we allow dor- rigid boot counteracts this position.
siflexion and eversion and avoid plantarflexion and
inversion initially after a grade II or III lateral ankle
PROTECTED WEIGHT BEARING
sprain). Once the injury has healed, range of motion
should include all directions.
In addition to active and passive range of motion, Early weight bearing has been shown to increase the sta-
joint mobilization should be incorporated in the reha- bility of the lateral ankle ligaments after injury while
bilitation program. Accessory movements, termed decreasing the amount of muscle atrophy. Protected
joint play, are not volitional but accompany voluntary weight bearing provides a safe and earlier return to activity
movements or occur passively in response to the when appropriate by decreasing joint stiffness, muscu-
ground or other forces. The amount of joint play is a lar strength deficits, and proprioception dysfunction
function of ligament and soft-tissue compliance as well (Fig. 28-2). We favor a postoperative protocol that
as bony configuration.25 Mobilization techniques allows for early weight bearing whenever possible. We
involve oscillation, distraction, and gliding movements recognize there are times when this is not possible such
of the joints in the planes of accessory motions. The as in hindfoot fusions. However, in the sports popula-
range of mobilization is always advanced in a graded tion, early weight bearing can have such a positive
manner but always stays within the physiologic limits impact that we try to tailor our surgical and nonopera-
of the joint.25 tive approach to allow early protected weight bearing.
There is much discussion with regard to immediate, An intriguing area of research that is revealing to us is
short-term protection of ankle injuries. Some of the more the investigation of weightlessness. Costill et al.26 exam-
common methods consist of elastic wrapping, taping/ ined the effect of a 17-day space flight (essentially, total
strapping, semirigid pneumatic ankle brace, nonrigid weightlessness) on muscle. They reported that there
functional ankle brace, and a removable walking boot. was an 11% decrease in peak muscle power, a decrease
A device we like is the Aircast walking boot with in muscle fiber diameter, and a 21% decrease in force
built-in Aircast Cryocuff (Fig. 28-1). The device allows when the muscle was contracted at peak power velocity.
Figure 28-1 Aircast Cryocuff and walking boot. Figure 28-2 Patient wearing Aircast walking boot.
597
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More specifically, Costill et al.26 examined single muscle to adaptive gait changes that become permanent in
fiber changes after weightlessness. The single fiber diam- unloading the injured extremity.
eter decreases were 20% after 17 days suspended leg In chronic injuries or before return to activity, a
weightlessness (for example crutch-assisted nonweight clinician should take a closer look at lower-extremity
bearing) and demonstrated similar profound muscular biomechanics and gait abnormalities to facilitate return
atrophy. to function while preventing future problems. Obser-
Research suggests that early loading of damaged soft vation of gait should include lateral, anterior, and
tissue can enhance collagen fiber realignment and heal- posterior view. It is important to observe and evaluate
ing.13,14,16,27,28 Using a removable Aircast walking boot the foot, ankle, knee, and hip/pelvis position and bio-
allows the patient to progress to weight bear immedi- mechanics during the gait cycle. Treatment of gait
ately after injury. Being in a walking boot instead of deviations includes flexibility, strengthening, and pro-
an ankle cast allows the patient to take the boot off prioception. An orthotic can be an excellent adjunct
to begin rehabilitation activities. The walking boot to rehabilitation if the gait deviation is a result of
provides more support than elastic wrapping, taping, abnormal biomechanics and structural problems within
and other semirigid bracing systems, and it also allows the foot.
the patient the ability to apply cold compression
simultaneously. STRENGTHENING
Muscle strengthening should be initiated once the

GAIT EVALUATION patient has recovered 95% to 100% of the range of
motion of that joint. Initiating strengthening too early
The evaluation of a patient’s gait immediately after can cause an increase in joint stiffness, therefore decreas-
injury and before return to activity can provide a clini- ing the function of the joint. Working isometrically, iso-
cian with valuable information on how abnormalities tonically, or isokinetically can achieve strengthening.
in ambulation contribute to the rehabilitation and pre- Isotonic strengthening, which is most commonly per-
vention of injuries. Often abnormal gait mechanics can formed, uses concentric and eccentric contractions. Con-
predispose the other joints of the lower extremity and centric contraction causes muscle shortening, whereas
back to overload and pain. Restoring normal gait after in an eccentric contraction the muscle lengthens while
acute injuries can help to prevent these abnormal maintaining a load. Both phases are extremely important
mechanics and significantly reduce the amount of time and should be included in a comprehensive rehabilitation
required for return to normal function. It is important program.
that a clinician evaluates the entire lower extremity and There are several methods of strengthening, includ-
its function during gait. ing weights, Thera-Band, and water resistance. Thera-
Normal gait is composed of two phases, a stance Band is a useful tool to provide resistance in all
phase (60%) and a swing phase (40%). The stance phase directions of the foot and ankle. It has different levels
is composed of five categories, including initial contact of resistance to allow the athlete to progress. Once the
(heel strike), loading response (foot flat), midstance athlete can complete 3 sets of 15 repetitions through
(single leg support), terminal stance (heel off), and a full range of movement, the next level of resistance
pre-swing (toe-off). The swing phase consists of initial should be started. This same concept can be used with
swing (acceleration), midswing, and terminal swing ankle weights.
(deceleration).29-31
In acute injuries, a clinician will notice gait abnormal-
ities because of pain, decreased range of motion,
PROPRIOCEPTION
strength deficits, and lack of proprioception. The major-
ity of the time, a patient will present antalgic with Many rehabilitation programs often fail to pay attention
a decreased stance phase. If a patient is unable to walk to proprioception deficits. Proprioception is the ability
without antalgia, a clinician should educate the patient of the body to vary the forces of muscles in response
on normal gait mechanics using assistive devices; for to outside forces. Muscles, tendons, and joint receptors
example, crutches. A patient may discontinue assistive provide this information, which affects posture, muscle
devices when he or she can walk normally. It is extre- tone, kinesthetic awareness, and coordination.29,30 When
mely important that as clinicians we correct gait imme- an individual is injured, the proprioceptive input to that
diately to prevent abnormal gait habits from becoming joint is altered and diminished. Diminished proprio-
permanent. It is likely that some failure to return to full ception can lead to a recurrence of injury because of the
strength return after a lower-extremity injury is related joint’s decreased ability to respond to outside forces.
598
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Functional progression
Table 28-1 Increase exercise capacity program

(with boot/postoperative shoe/brace on)
Exercise 10 minutes on a stationary bike 3 days a

week.

week.

week.
Once you are able to ride the bike 30 minutes a day for
4 days a week, then you may start replacing one of your days
of biking per week with 1 day of StairMaster or elliptical
trainer. You will do the StairMaster or elliptical for the same
amount of time you normally would ride the bike.
Figure 28-3 Biomechanical ankle proprioception system
(BAPS) board for balance and range of motion.
Proprioception can be improved with a number of

is important to progress the patient’s activity gradually.
treatment techniques. Early weight bearing can help to
Increasing the time increments of 10 minutes a week
decrease the amount of proprioception loss. A patient
on a bike will allow the patient to be working approxi-
can practice standing with equal weight on both feet,
mately 30 minutes per session in a 3-week span
progressing to single leg stance. A biomechanical ankle
(Table 28-1). Typically, low-impact, weight-bearing
proprioception system (BAPS) board or kinesthetic
exercise will be introduced when the athlete is able to
awareness trainer (KAT) can be used as a patient
walk normally in a protective device and regular shoe.
advances through rehabilitation (Fig. 28-3).
The rehabilitation program will begin replacing one
day of bike with a StairMaster/elliptical machine
(Fig. 28-4, A and B). We allow an additional day of
CARDIOVASCULAR ACTIVITIES StairMaster or elliptical each successive week until the
athlete has been converted to StairMaster or elliptical
During the rehabilitation program it is extremely impor- 4 to 6 days per week. The athlete will continue to
tant to keep the patient active. If the patient becomes increase low-impact, weight-bearing exercise as toler-
sedentary, the cellular metabolism levels will decrease ated. We have found that when an athlete can work
and the individual will lack energy, and may experience out on the StairMaster or elliptical machine 4 to 5 days
both diminished desire and blunted motivation because a week for 30-plus minutes, it is safe to initiate running.
of a form of depression seen after injury in athletes. This Running should gradually replace StairMaster/elliptical
consequently can then present a challenge for recovery each week. It is important to give the athlete a set of
and rehabilitation. Early in the rehabilitation, we feel running guidelines that allows for a gradual progression
that it is vital to start a sensible regimen of low- of activity (Table 28-2).
resistance exercise bike or pool therapy training 3 to 4
days a week for 10 to 15 minutes with a progression by
FUNCTIONAL PROGRESSION
5 to 10 minutes of training per session per week. If the
bike is used, then a walking boot or protective brace is
used. Pool therapy is not initiated until the sutures are A functional progression is a series of sport-specific skills
removed and the wound is fully healed. By initiating early that increase in the level of difficulty that an athlete must
activity during the rehabilitation program, the cellular complete before he or she can safely return to com-
metabolism will be maintained. The early exercise also petition. Yamamoto and Fragi described a functional
provides psychological benefits for the athlete. Physically progression in the rehabilitation of injured West Point
it allows an active blood flow to the involved extremity, cadets.32,33 The emphasis in this program was placed
and psychologically it helps to keep the patient motivated on restoring agility through dynamic exercise after knee
and counteracts the potential for depression. injury. Kegerreis et al.34 added specific movement pat-
Our experience with and observation of clinical heal- terns and skills to the program and introduced the
ing and postoperative wound healing have proven that it importance of addressing the psychological needs of
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Figure 28-4 (A) Patient performing StairMaster with Aircast walking boot. (B) Patient performing StairMaster
with ankle stabilizing orthosis (ASO) brace.
Table 28-2 Running progression
Day
Week no. 1 2 3 4 5 6 7 Total minutes
1 10 0 10 0 12 0 14 36
2 0 16 0 18 0 20 0 54
3 25 20 0 25 25 0 30 125
4 30 0 30 35 0 35 40 170
Previously running 30-45 minutes per day.

Subtract times from time spent on low-impact aerobic training.
the injured athlete. They also addressed the scientific functional progression promotes healing through the
principles that play an important role in the functional application of Davis’ law and Wolfe’s law, which were
progression and the need to break down sport-specific discussed earlier. It is important that the healing tissue
functions to be addressed in the order of difficulty. be stressed in the way required of it before injury so that
The functional progression is vital to a complete sport- the tissue will be ready to fully accept preinjury activity
specific rehabilitation program. It serves as the key ele- requirements. As described in Davis’ law and Wolfe’s
ment in advancing the athlete from clinical rehabilitation law, injured tissue and bone stressed in this controlled
to athletics. Each sport has certain demands and skills that manner will lead to further tissue and bone healing
stress the foot and ankle differently. It is extremely impor- and strength. In addition, the functional progression
tant that the athlete advance one step at a time without breaks up the monotony of traditional rehabilitation
pain or apprehension. Once the athlete has completed and allows the athlete to begin performing activities
the list of activities in order without pain or apprehension, related to function. Psychologically it allows the athlete
he or she may return to full sport activity. to increase self-confidence and mentally prepares him
There are several physical and psychological benefits or her to return to sport. As the athlete completes each
that the functional progression will address. The step, confidence will increase and apprehension will
600
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Rehabilitation of Achilles tendon repair
Phase I
Table 28-3 Functional progression—court sports
Phase one emphasizes pain modulation and inflamma-
Begin with step one. If you can do this exercise without tory control of the soft tissues. Controlling pain and
pain or limping, you may proceed to the next step. It is inflammation will allow patients to be better able to per-
very important that you perform each exercise correctly, form their rehabilitation exercises. Restoration of nor-
without apprehension. When you have successfully mal range of motion and joint accessory motions,
completed each step of the functional progression, you
including glide, roll, and spin, are stressed in this phase.
may then attempt to return to your sport. You should wear
the Aircast, Swedo, knee brace, or tape as instructed.
Early return of pain-free range of motion will enhance
the rehabilitative process and allow the patient to begin
Heel raises injured leg—10 times isolated and functional rehabilitation exercises in phase
II with greater effectiveness. Once a patient has minimal
Walk at fast pace—full court pain and has normal to near normal range of motion, he
or she may be advanced to phase II.
Jumping on both legs—10 times
Phase II
Jumping on the injured leg—10 times Once inflammation is decreased, pain has subsided, and
range of motion is near normal, phase II may begin.
Jog straight—full court
Foot and ankle flexibility with functional strengthening
Jog straight and curves—2 laps
are initiated and are the focus of this phase. In addition,
cardiovascular conditioning and proprioceptive training
Spring: 12, 34, full speed—baseline to court also are started at this time. The goals of this particular
phase are to improve flexibility, restore strength, and
Run figure eights: 12, 34, full speed-baseline to 1
4 court begin light, sport-specific functional training. A patient
may be progressed to phase III when he or she is ready
Triangle drills: sprint baseline to 12 court, backward run to 12 for a gradual return to activity and participation in
court, defensive slides along baseline, both directions sports.
Cariocas (cross-over drill) 12, 34, full speed—12 court Phase III
Emphasis in phase III is on functional return to activities
Cutting 12, 34, full speed—full court
of daily living (ADLs) and previous activity/sport parti-
cipation. Advanced activity-specific exercise should be
implemented with special attention to mechanics of the
activity. Proper mechanics, as well as maintenance of
flexibility and strength, can prevent further chance of
decrease, allowing the athlete to enter the competitive reinjury. To ensure safe return to sport, athletes should
environment at the level of function needed for playing perform a functional progression. External supports
standards (Table 28-3). such as braces, straps, taping, and orthotics may be used
at this time to allow the patient to participate in his or
her activity pain free.
PHASES OF REHABILITATION
The cornerstone to appropriate rehabilitation is an accu-

REHABILITATION OF ACHILLES
rate diagnosis, so that an appropriate rehabilitation pro-
TENDON REPAIR
gram can be established efficiently and safely. For any
injury or condition, the rehabilitation can be divided into The rehabilitation after an Achilles repair is an example
three general phases. Each phase has specific goals, and, of progression toward a more functional recovery.
although there is a time frame assigned to each phase, Recently, rehabilitation after an Achilles repair has pro-
advancement from one phase to another should be based gressed from long-leg casting to short-leg casting to
on the patient’s achieving the prescribed goals rather the use of intermittent immobilization and early weight
than on time. A clinician must be willing to adapt and bearing. Mandelbaum et al.35 have established an
modify the exercise program for each patient. There are accelerated rehabilitation protocol for the Achilles
a variety of rehabilitative techniques to choose from; each repair. Their protocol involves early range of motion at
can have benefit to the patient. As a clinician, it is impor- 72 hours and early weight bearing at 2 weeks postrepair.
tant to stay up to date with current rehabilitative trends. This functional approach allows the competitive athlete
601
...........
to return to sports more quickly without a reported

increase in complications.
At Methodist Sports Medicine, more than 75 acute
Achilles repairs have been performed over the past
8 years using an ankle-block anesthetic, no casting,
intermittent immobilization with a removable boot,
and cryotherapy. Patients have been full weight bearing
by 2 weeks, and range of motion is started at the first
postoperative visit, along with a bike program and sit-
ting toe raises. We use the concept that early-protected
range of motion and weight bearing encourage strong
tendon healing and protect against disuse atrophy. The
re-rupture rate has been consistent with that of less
accelerated protocols (<2%). This is an example of our
rehabilitation program.
Immediately postoperatively the patient is placed in
an Aircast walking boot with a built-in Cryocuff. The

walking boot also has one 9 16 -inch felt heel lifts placed
inside to put the foot/ankle in a slight equines position
for healing. (We will use two heel lifts if the repair is
3-8 weeks after the tear.) The patient is instructed to
be nonweight bearing for the first 5 to 7 days and is
appropriately trained in axillary crutch use for walking
and negotiating stairs. This decreases the risk of early
postoperative swelling and allows appropriate initial
wound healing.
The immediate postoperative protocol consists of rest,
elevation, and continuous daytime Cryocuff use. The
patient also is instructed to wiggle toes and perform leg
lifts every 3 to 4 hours in the first postoperative week.
Dressing changes and rehabilitation will begin
1-week postoperatively. Physical therapy will consist of
a home exercise program, gradual progression of weight
bearing, and a light bike program to maintain cellular
metabolism. Biking is performed with the ankle immo-
bilized in the boot. The home exercise program includes
toe curls (Fig. 28-5 A), active plantarflexion, resistive-
band plantarflexion (Fig. 28-5, B), and sitting calf raises
(Fig. 28-5 C). We use the concept of early-protected
motion and resistance training, which encourages stron-
ger tendon healing and protects against disuse atrophy.
Exercises are performed at a higher frequency with a
low load (see phase I exercise prescription) to continu-
ously stimulate the tendon to heal. It is extremely
important to avoid ankle dorsiflexion activity or a heel
cord stretch to protect the tendon from overstretching.
Partial weight bearing is started at 1 week with a
gradual progression to full weight bearing at 2 to
3 weeks postoperatively. The first week of rehabilitation
allows partial weight bearing in the walking boot with
axillary crutches and the amount of weight bearing is
increased as tolerated by pain and swelling. After the
first week, the patient may begin using one crutch under
the opposite arm and then progress to full weight bear- Figure 28-5 (A) Towel toe curls. (B) Resisted plantarflexion
ing when the athlete is able to walk normally. using Thera tubing. (C) Single-leg balance for proprioception.
602
...........
Rehabilitation of Achilles tendon repair
A bike program is initiated in the first week using the Achilles tendon stretching to protect the Achilles repair
walking boot. The program consists of 10 minutes three from stretching out. We have found that normal dorsi-
times the first week and increases by 10 minutes per flexion will return naturally without being aggressive
week and to 4 days over the first month. We progress with dorsiflexion motion.
this slowly to give the incision/wound time to heal The final phase of rehabilitation starts approximately
without increasing the moisture or swelling to the ankle. at the 3-month mark. Patients will continue to work
Once clinical wound healing has occurred, a patient can on balance, ankle strength, and unilateral calf raises. At
be more aggressive with cardiovascular activity. this time, full lower-extremity strengthening will be
The second phase of rehabilitation begins approxi- initiated. Exercise will include stepdowns (Fig. 28-8, A)
mately 6 weeks after repair. At this time, an increase in leg press (Fig. 28-8, B), knee extensions (Fig. 28-8, C),
weight-bearing exercise is allowed, and proprioception
retraining with an emphasis on normal gait is initiated.
Athletes at this time are instructed in a program to wean

out of the boot into an athletic shoe with one 9 16 -inch
felt heel lift. Our goal is to wean the patient out of
the boot over 2 weeks with normal pain-free gait
(Table 28-4).
Exercises in the second phase consist of balance,
standing calf raises, and elliptical/StairMaster progres-
sion. Single-leg balance (Fig. 28-6) is first initiated
barefoot on a hard surface with a goal of approximately
60 seconds. Once that is achieved, balance is pro-
gressed to a soft surface with other possible variations
(i.e., ball toss). Patients will begin bilateral calf raises
(Fig. 28-7) with a progression to single calf raises.
Thera-Band exercise is performed in all directions to
incorporate the entire ankle. However, dorsiflexion
past neutral is not allowed. Once completely out of
the boot, 1 day of elliptical/StairMaster may be substi-
tuted for the bike each week, so that over a 4-week
period the athlete transitions into full cardiovascular
workouts with a StairMaster/elliptical 4 to 5 days a
week. It is important to avoid passive dorsiflexion or
Figure 28-6 Single-leg balance for proprioception.
Table 28-4 Wean out of boot/postoperative shoe
Week 1: Wear your boot/postoperative shoe from 8 AM to

4 PM.
Wear the brace/shoe insert/steel shank after 4 PM.
Week 2: Wear your boot/postoperative shoe every

Monday, Wednesday, and Friday from 8 AM to 4 PM.
After 4 PM, wear the brace/shoe insert or steel shank.
Wear your brace/shoe insert/steel shank all day Tuesday,
Thursday, Saturday, and Sunday.
Week 3 and beyond: Wear your brace/shoe insert/steel

shank every day of the week.
You should wear the boot if you are doing excessive

walking.
Figure 28-7 Bilateral calf raise.
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...........
Figure 28-8 (A) Stepdown for balance and strengthening.

(B) Leg press using single leg. (C) Knee extension machine for
quadriceps strengthening.
and hamstring curls that can be advanced per patient

REHABILITATION AFTER LATERAL ANKLE
tolerance. Weighted calf raises typically are initiated
RECONSTRUCTION
around 4 months.
Once an athlete is capable of using a StairMaster/
elliptical machine for 30 minutes 5 days a week, he or The treatment and rehabilitation after acute ankle
she may begin light jogging (usually at 3-4 months sprains begins by positioning the ankle in a position that
after the repair). It also is important to begin sport- reapproximates the torn ligament ends (neutral dorsi-
specific skills, such as shooting a basketball or hitting flexion with weight bearing). The application of a
a tennis ball. Agility drills should be advanced gradually removable walking boot with an Aircast Cryocuff and
per patient tolerance. Before return to sport, the immediate weight bearing place the ankle mortise in its
patient should successfully complete a functional pro- most stable position. Early range of motion, Achilles
gression to ensure a safe return to competition. Return stretching, and peroneal strengthening is started imme-
to sports normally occurs at 5 to 8 months after diately after injury. However, plantarflexion and inver-
surgery. sion will result in separation and possible elongation of
604
...........
Rehabilitation after lateral ankle reconstruction
Figure 28-9 (A) Resisted eversion using Thera tubing. (B) Resisted dorsiflexion using Thera tubing.
the injured ligaments and therefore should be avoided.

Once the ligaments have healed, then advancing the
rehabilitation is safe.
A similar approach can be used following a lateral
ankle reconstruction. For the reliable athlete with close
medical monitoring and sturdy tissue at the time of
reconstruction, there may be a place for intermittent
immobilization with early weight bearing and specific
range-of-motion exercise. Overall the objective is to
obtain as ‘‘normal’’ an ankle as possible. This is an
example of our rehabilitation program.
Immediately after surgical reconstruction, the athlete
is placed in an Aircast walking boot with a Cryocuff
placed inside the boot. Dressing changes and rehabilita-
Figure 28-10 Achilles/calf stretch with towel.
tion will begin 3 days postoperatively. The clinical goals
in the first phase of rehabilitation (4 weeks) consist of
restoring full eversion and dorsiflexion, normalizing gait,
increasing calf flexibility, and beginning light strengthen- next 7 to 10 days in the walking boot. A bike program
ing. Physical therapy will consist of a home exercise is initiated the first week postreconstruction with the
program, progression to full weight bearing, a light walking boot. The program will advance each week as
bike program, Cryocuff, and desensitization massage. the incision/wound has had time to heal. Once clinical
Competitive athletes with training room availability use wound healing has occurred, a patient can be more
on-site athletic trainers’ and physical therapists’ expertise. aggressive with cardiovascular activity.
The home exercise program consists of range of Desensitization massage is an important part of the
motion exercises and strengthening with Thera-tubing early rehabilitation program. Because of the highly
(Fig. 28-9, A and B) in the directions of eversion and innervated foot and ankle, the patient often will experi-
dorsiflexion. Over the first 4 weeks, the patient is ence some surface hypersensitivity after surgery. It is
instructed to avoid inversion and plantarflexion to pro- important to stimulate this nerve tissue with light mas-
tect the integrity of the newly reconstructed ligaments. sage and tactile stimulation to reeducate and desensitize
It also is important to begin Achilles tendon stretching the tissue to normal pressure and touch. This can be
using a towel (Fig. 28-10) with progression to a stair accomplished with a light massage 3 to 5 minutes several
stretch. Exercises are performed at a high frequency times a day.
with a low load to stimulate the ligament to heal with- The second phase of rehabilitation begins 1-month
out creating swelling or reinjury. The Cryocuff will be postoperatively. At this time patients are instructed to
used to help control swelling and inflammation and is wean out of the boot into a stirrup ankle brace
most helpful in the first week after surgery. (Fig. 28-11). Our goal is to wean the athlete out of
Partial weight bearing is started immediately after the boot within 2 weeks and obtain a normal, pain-free
surgery with progression to full weight bearing in the gait (see Table 28-4).
605
...........
the toes pointed to isolate the peroneal tendons. The

athlete then everts the foot and ankle to strengthen
the tendons. We have found this to be a very effective
means of maximizing peroneal strength. Bilateral calf
raises are initiated with progression to single calf raise.
We like to have the patient work on eccentric phase of
calf raise by going up on both and lowering slowly on
the injured side. Once the patient has no difficulty with
the eccentric phase of the exercise, he or she may add
the concentric phase of the exercise. Proprioception
exercise (Fig. 28-14) should begin with one-foot bal-
ance, with progression of balance with opposite hip/
leg exercise. Cardiovascular exercise should be
advanced from the bike to StairMaster/elliptical
machine (4-6 weeks after surgery) and eventually to
light jogging (6-10 weeks after surgery).
Figure 28-11 Patient using active ankle brace.
Exercises in the second phase include range of

motion/strengthening in all four directions, aggressive
heel-cord stretching (Fig. 28-12), calf raises, and pro-
prioception exercise. Dorsiflexion and inversion
strengthening still are performed with Thera-tubing.
Aggressive peroneal strength (Fig. 28-13) is accom-
plished by having the athlete lie in a lateral position
with ankle weights hung over the end of the foot and
Figure 28-13 Aggressive peroneal strengthening with cuff

weight.
Figure 28-14 Single-leg balance for proprioception using

Figure 28-12 Aggressive Achilles/calf stretch on step. opposite hip strengthening with Thera tubing.
606
...........
Rehabilitation of ankle fractures
and protected weight bearing. The goal of rigid, stable,

internal fixation is to allow a more functional recovery.
This is an example of our rehabilitation program.
Immediately after surgery, the patient is placed in
an Aircast walking boot with a Cryocuff for cold and
compression. Early immobilization consists of rest, ele-
vation, and continuous daytime Cryocuff use. Patients
are instructed to stay down as much as possible to help
decrease swelling. Nonweight bearing with axillary
crutches is initiated initially after surgery to reduce the
risk of immediate postoperative swelling. The patient
should also wiggle the toes and perform leg lifts every
3 to 4 hours while awake.
Dressing changes and rehabilitation will begin 1 week
postoperatively. If stable bone alignment is demon-
strated on radiographs, range-of-motion exercises are
Figure 28-15 Cybex isokinetic strengthening for inversion/ started. Range of motion should be initiated in a man-
eversion. ner that does not put tension on an injured or repaired
ligament. For an isolated lateral fibula or stable
There are several other ways to strengthen the ankle bimalleolar fracture, range of motion can include all
postoperatively, including Cybex/Biodex (Fig. 28-15) directions. If the patient has a medial ligament injury,
and the multiaxial machine. As long as the emphasis is dorsiflexion with eversion should be avoided until the
on pain-free strengthening involving dorsiflexion, ever- ligament is healed. Range of motion and light tubing
sion and plantarflexion these exercise follow the same exercises are guided by pain and should be performed
clinical guideline set in this phase. The final phase of several times a day in high repetitions (15-20); towel
rehabilitation (2 months) should focus on advance stretch for the Achilles and manual plantarflexion stretch
strengthening of the entire lower extremity and sport- can be started (20 seconds, 5 repetitions) if there is no
specific agility drills. The final goal of this phase is return contraindicating ligament injury. The home exercise
to sport after finishing a sport-specific functional program will consist of toe curls (see Fig. 28-5, A),
progression. range of motion in appropriate directions, resistive band
Exercises in the final phase will continue to focus on in appropriate directions, desensitization massage, and a
ankle strengthening, flexibility, and proprioception acti- light bike program wearing the boot (Fig. 28-16).
vity. Advanced lower-extremity exercise can include leg Partial weight bearing is started at 1 week, with pro-
press, knee extension, and hamstring curls as tolerated. gression to full weight bearing in the walking boot in
Sport-specific skills, such as kicking a soccer ball, ball 2 weeks (if the fracture is stable and does not involve a
handling drills, or catching a football should be imple- weight-bearing surface). Patients are instructed to use
mented at this time. The intensity of these activities
can be increased as tolerated. Before return to sport,
the patient should successfully complete a sport-specific
functional progression program to ensure safe return
to competition. Return to sports participation is 10 to
12 weeks.
REHABILITATION OF ANKLE FRACTURES
The treatment and rehabilitation after acute displaced

ankle fractures in the athlete can be particularly exciting
with the ability to anatomically and rigidly fix bony frac-
tures and anatomically repair torn ligaments. Displaced
fractures should be treated with anatomic open reduc-
tion and internal fixation. We have progressed from
short-leg casting and nonweight bearing to the use of
intermittent immobilization, early range of motion, Figure 28-16 Stationary bike using Aircast walking boot.
607
...........
be substituted for the bike with use of the brace and

athletic shoes (see Fig. 28-4, B). Patients typically are
given a home exercise program to be performed two
to three times a day. Athletes who have athletic training
resources should work under the guidance of the athletic
training staff.
The final phase of rehabilitation (2 months) should
focus on advance strengthening of the entire lower
extremity and sport-specific agility drills. The final goal
of this phase is the return to sport after finishing a
sport-specific functional progression program.
Figure 28-17 Patient using Aircast stirrup brace.
axillary crutches and increase weight bearing as toler-

ated. After the first week of partial weight bearing, the
patient may begin using one crutch under the opposite
arm and eventually progress to full weight bearing over
the next week. Once a patient can walk normally with
the walking book (typically within 3 weeks), we begin Figure 28-18 Single-leg balance for proprioception on Thera
weaning the patient out of the boot and into a stirrup disk.
brace (Fig. 28-17) and regular shoe over the next
2 weeks. Patients with highly comminuted fractures
and those with weight-bearing joint injury or significant
cartilage injury do not follow this same protocol.
The second phase of rehabilitation begins approxi-
mately 1 month after surgery. At this time, an increase
in weight-bearing exercise, proprioception, and gait
training with an athletic shoe is initiated. Exercises con-
sist of progression of Thera-Band activities to include
directions originally avoided because of ligament com-
plications. Standing calf stretching, balancing exercises,
double to single leg calf raises, and elliptical/StairMaster
progression are included during this phase. Thera-Band
exercise should continue to be high repetitions (15-20)
in all directions. Single leg balance is first initiated in a
regular shoe and then progressed to bare foot on a hard
surface. Our goal is approximately 60 seconds. Balance
can be advanced by use of a soft surface and balance
board (Fig. 28-18). The patient should work aggres-
sively with calf stretching using a stair or an incline
board for 3 minutes three times a day. Bilateral standing
calf raises should be initiated with progression to single-
leg calf raises (Fig. 28-19). Once completely out of
the boot, elliptical or StairMaster progression should Figure 28-19 Unilateral calf raise.
608
...........
References
Exercises in the final phase will continue to focus on

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of the foot and ankle will continue to progress as we 14. Glasoe WM, et al: Weight-bearing immobilization and early
understand more clearly the appropriate use of weight exercise treatment following a grade II lateral ankle sprain, J
bearing, early motion, and function resistance. Also, as Orthop Sport Phys Ther 29:394, 1999.
our understanding of proper anatomic repair and recon- 15. Kellet J: Acute soft tissue injuries—a review of the literature, Med
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16. Vailas AC, et al: Influence of physical activity on the repair process
advance also. This is an exciting time in the treatment of medial collateral ligaments in rats, Connect Tissue Res 9:25,
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this chapter both encourages you and challenges you 17. Eiff MP, Smith AT, Smith GE: Early mobilization versus
in your treatment of your athletes. immobilization in the treatment of lateral ankle sprains, Am
Orthop Soc Sport Med 22:83, 1994.
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19. Gelberman RH, et al: The effects of mobilization on the
4 PEARL vascularization of healing flexor tendons in dogs, Clin Orthop

153:283, 1980.
20. Gelberman RH, et al: Influences of the protected passive
Rehabilitation Pearls mobilization interval on flexor tendon healing, A prospective
Every injury has a position that must be protected and an randomized clinical study, Clin Orthop 264:189, 1991.
opposite motion that must be rehabilitated. 21. Aoki M, et al: Biomechanical and histological characteristics of
Every week of immobilization will add 2 weeks to the canine flexor repair using early postoperative mobilization, J Hand
rehabilitation. Surg 22A:107, 1997.
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he or she may start running. JM, et al, editors: Rehabilitation of the hand, St Louis, 1978,
A good surgery that is poorly rehabilitated will equal a Mosby.
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24. Salter RB, et al: The biological effect of continuous passive motion 34. Kegerreis S, Malone T, McCarroll J: Functional progressions: an
on the healing of full thickness defects in articular cartilage, J Bone aid to athletic rehabilitation, Phys Sport Med 12:67, 1984.
Joint Surg 62A:1232, 1980. 35. Mandelbaum BR, Myerson MS, Forster R: Achilles tendon
25. Davis P, Baxter DE, Pati A: Rehabilitation strategies and protocols ruptures. A new method of repair, early range of motion, and
for the athlete. In Sammarco GJ, editor: Rehabilitation of the foot functional rehabilitation, Am J Sport Med 23:392, 1995.
and ankle, St Louis, 1995, Mosby.
26. Costill DL, et al: Comparison of a space shuttle flight (STS-78)
and bed rest on human muscle function, J Appl Physiol 91:57,
2001. FURTHER READING
27. Linde F, et al: Early mobilizing treatment in lateral ankle sprains,
Scand J Rehab Med 18:17, 1986.
28. Scheuffelen C, et al: Orthotic devices in functional treatment of Clanton CO: Athletic injuries to the soft tissues of the foot and ankle.
ankle sprains: stabilizing effects during real movement, Int J Sports In Coughlin MJ, Mann RA, editors: Surgery of the foot and ankle,
St Louis, 1999, Mosby.
Med 14:140, 1993.
Kern-Steiner R, Washecheck HS, Kelsey DD: Strategy of exercise
29. Campbell MK: Rehabilitation of soft tissue injuries. In Hammer
WI, editor: Functional soft tissue examination and treatment by prescription using an unloading technique for functional
manual methods: the extremities, Gaithersburg, MD, 1991, Aspen. rehabilitation of an athlete with an inversion ankle sprain, J Orthop
Sport Phys Ther 29:282, 1999.
30. DeCarlo M, Barill E, Oneacre K: Conservative treatment of soft
tissue injuries. In Hammer WI, editor: Functional soft tissue Pugia ML, et al: Comparison of acute swelling and function in subjects
examination and treatment by manual methods: the extremities, with lateral ankle injury, J Orthop Sport Phys Ther 31:348, 2001.
Gaithersburg, MD, 1991, Aspen. Rozzi SL, et al: Balance training for persons with functionally unstable
ankles, J Orthop Sport Phys Ther 29:478, 1999.
31. Epler M: Gait. In Richardson JK, Iglarsh ZA, editors: Clinical
orthopaedic physical therapy, Philadelphia, 1994, Saunders. Smith LS, et al: The effects of soft and semi-rigid orthoses upon
32. Tippett SR, Voight ML: Functional progression for sport rearfoot movement in running, J Am Podiatr Med Assoc 76:227,
1986.
rehabilitation, Champaign, IL, 1995, Human Kinetics.
33. Yamamoto SK, et al: Functional rehabilitation of the knee: a
preliminary study, J Sport Med 3:288, 1975.
610
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.........................................C H A P T E R 2 9
Epidemiology and management tips in the

professional athlete
David A. Porter, Padraic Obma, and Larry L. Nguyen
......................
CHAPTER CONTENTS
Introduction 611 Lateral ankle sprains 618

Epidemiology 611 High ankle sprains/syndesmotic injuries 619
Turf-toe/hallux rigidus 614 Achilles tendinitis/rupture 619
Base of fifth metatarsal fractures/Jones fractures 616 Difficult injuries 620
Midfoot sprains/Lisfranc injuries 616 Acknowledgments 621
Navicular fractures 617 Bibliography 621
Medial ankle sprains/deltoid injuries 618
injuries in this specific population. Our hope is that this

INTRODUCTION information will help providers be more aware of the
common and unique injuries encountered by profes-
Athletic competition has become normative in culture sional athletes in their sport. This chapter will not delve
today. People enjoy competing against a worthy rival deeply into treatment protocols because the previous
in the name of sportsmanship, the thrill of pushing the chapters have attempted to cover treatment in far
limits of the human body, for fitness, for the thrill of vic- greater depth than merited here. This chapter, however,
tory, and more recently as a full-time career. Evaluation does comment on the epidemiology of sport-specific
and management of the elite athlete has been covered in foot and ankle injuries and addresses some thoughts
Chapter 1. Foot and ankle injuries are among the most on the management of such injuries in the professional
common maladies that plague the elite athlete. In pro- athletes. The management comments come from the
fessional sports, these injuries can result in the inability senior author (D.A.P.). We are indebted to the profes-
to participate and hinder a team’s chances for victory. sional trainers for their cooperation and contributions
For the individual, a prolonged recovery can lead to loss to this chapter (see later).
of playing time, a depressed sense of worth, an inability
to contribute, and even a substantial loss of revenue,
EPIDEMIOLOGY
while jeopardizing a career.
As more emphasis is placed on professional and inter-
collegiate athletics, awareness has heightened con- To ascertain the occurrence and sport-specific injuries
cerning the incidence of foot and ankle injuries in in professional athletes a survey was delivered to the
these elite athletes. The injuries in the elite athlete are head athletic trainers of each professional team in the
similar to those seen in recreational and lower-level National Football League (NFL), the National Basket-
competitive athletes, but the demands can be greater ball Association (NBA), Major League Baseball (MLB),
and the ramifications more profound. This chapter is the National Hockey League (NHL), and Major League
intended to provide information on the epidemiology Soccer (MLS). Thirty-four of 132 surveys were
of sport-specific foot and ankle injuries, to facilitate returned: 2 NFL, 7 NBA, 13 MLB, 8 NHL, and
and guide physicians, physical therapists, athletic train- 4 MLS. The following head athletic trainers responded
ers, and students in the recognition of foot and ankle for their respective teams.
CHAPTER 29 Epidemiology and management tips in the professional athlete
Minnesota Wild Don Fuller

NFL
Montreal Canadiens Graham
Cincinnati Bengals Paul Sparling Rynbend
New Orleans Saints Scottie Patton Phoenix Coyotes Gord Hart
NBA San Jose Sharks Ray Tufts
Atlanta Hawks Wally Blasé Tampa Bay Lightning Dave Boyer
Charlotte (New Orleans) Terry Kofler MLS

Hornets
Chicago Fire Rich Monis
Golden State Warriors Tom Abdenour
Colorado Rapids Theron Enns
Los Angeles Lakers Gary Vitti
DC United Rich Guter
Milwaukee Bucks Troy Wenzel
New England Revolution Mike Fritz
Orlando Magic Ted Arzonico
Utah Jazz Gary Briggs
MLB The participants responded to a list of questions

about foot and ankle disorders in the professional ath-
Anaheim Angels Ned Bergert lete. This included a survey of the most common foot
and ankle injuries in the trainer’s sport and a series of
Arizona Diamondbacks Paul Lessard questions about treatment and rehabilitation protocols
for the more occult and controversial foot and ankle
Baltimore Orioles Richie Bancells
maladies. The specific topics about which we inquired
Chicago White Sox Herm Schneider
were turf-toe, base of fifth metatarsal/Jones fractures,
midfoot sprains/Lisfranc injuries, navicular fractures,
Colorado Rockies Tom Probst medial ankle sprains/deltoid injuries, lateral ankle
sprains, high ankle sprains/syndesmotic injuries, and
Florida Marlins Larry Starr Achilles tendinitis/rupture. Also, the head athletic train-
ers were asked about their anecdotal experiences with
Houston Astros — their most memorable/difficult/unusual professional
athletic injury.
Milwaukee Brewers Roger Caplinger The 34 participants were asked to list the five most
common foot and ankle injuries treated among their
Montreal Expos Ron McClain
professional athletes. Equal weight was given to all
New York Yankees Gene Monham
responses, whether listed first or last, and to each
responder. The results are listed below. The results also
Oakland Athletics Larry David were subdivided among each particular sport and are
plotted in Figs. 29-1, 29-2, 29-3, 29-4, and 29-5.
Texas Rangers Danny Wheat The five most common foot and ankle injuries (and
the number of responses) were lateral ankle sprains
Toronto Blue Jays Scott Shannon (27), plantar fasciitis (21), corns and callosities (21),
ingrown toenails (20), and Achilles tendinitis or rup-
NHL tures (12). Additional injuries listed (in descending
number of responses) include subungual hematomas
Buffalo Sabres Jim Pizzutelli
(10), shin splints (10), medial ankle sprains (9), syn-
Columbus Blue Jackets Chris Mizer
desmotic sprains (9), hallux rigidus (7), base of fifth
metatarsal fractures (7), phalangeal fractures (5), leg
Dallas Stars Dave Suprenant contusions (5), metatarsal fractures (3), Lisfranc/
612
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Epidemiology
Most Common Football Injuries

2
Turf-toe
Corns/callosities
Number reported
Med ankle sprain

Plantar fasciitis
1 Lat ankle sprain
Achilles tendonitis
High ankle sprain
Midfoot sprain/Lisfranc
Jones fracture
Navicular fracture
0
Injuries
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.
Most Common Basketball Injuries

8
6 Ingrown toenail
Corns/callouses
Number reported
5 Plantar fasciitis
Med ankle sprain
4 Lat ankle sprain
High ankle sprain
3 Achilles tendonitis
Other
2
0
Injuries
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).
midfoot sprains (3), ankle fractures (2), metatarsalgia must be well versed in a variety of foot and ankle injuries
(1), interdigital neuromas (1), medial malleolus frac- that can be both a real nuisance (ingrown toenail) to a
tures (1), and heel exostosis (1). Thus there were nearly career-threatening syndesmotic ankle injury. We hope
equal numbers of injuries among the foot and the ankle. that the first 28 chapters addressed these injuries and
Also, one notes that the severity of the injuries can ailments to you, the reader, in a satisfactory fashion.
extend from a subungual hematoma or callus to a frac- This chapter focuses specifically on the professional
ture dislocation of the ankle or foot. Thus the provider athlete.
613
...........
Most Common Baseball Injuries

14
Midfoot sprains/Lisfranc
12
Plantar fasciitis
Lateral ankle sprain
10 High ankle sprain/syndesmosis
Number reported
Achilles tendonitis
8 Shin splints
Turf-toe/hallux rigidus
Base of 5th/Jones fracture
6
Ingrown toenail
Corns/callouses
4 Subungual hematoma
Other
2 Navicular fractures
0
Injuries
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).
Common Hockey Injuries

8
6 Ingrown toenail
Subungual hematoma
Number reported
5 Corns/calluses
Toe Fx
4 Lat ankle sprain
3 High ankle sprain/syndesmosis
Other
2 Navicular fractures
0
Injuries
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).
and ‘‘traumatic bunion.’’ The joint capsule is strained,

TURF-TOE/HALLUX RIGIDUS
the plantar plate can be stretched, and the articular
cartilage can be contused and lead to long-term joint
Turf-toe involves a severe dorsiflexion injury to the arthrosis. These injuries are commonly described in
great toe metatarsophalangeal (MTP) joint as described football, with hard turf and flexible shoes increasing
in Chapter 18. Other, less common mechanisms include the incidence. This can be quite debilitating, with long
varus/valgus stresses resulting in a combined turf-toe periods of recovery, especially if the plantar plate is
614
...........
Turf-toe/hallux rigidus
Most Common Soccer Injuries

3
Ingrown toenail
Subungual hematoma
Midfoot sprains/Lisfranc
2
Number reported
Plantar fasciitis
Med ankle sprain
Lat ankle sprain
Achilles tendonitis
High ankle sprain
1 Turf-toe
Navicular fracture
0
Injuries
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).
disrupted. One can imagine the difficulty in a football steroid injections, iontophoresis, and electrical stimula-
player dependent on push-off if there is significant limi- tion. Full-length or extended shank, rigid orthotic
tation of motion and loss of power. Turf-toe (hyper- inserts, and shoewear modifications were key elements
extension with primary plantar soft-tissue injury) does of conservative treatment. Return to play was based on
occur in other sports but is much less frequent and being pain free and having stable, full range of motion
typically is less severe. That being said, we have treated and the ability to perform with an orthotic insert and
a Division I baseball pitcher who suffered a complete modified shoewear. A sports-specific functional assess-
plantar plate disruption coming off the mound to field ment examination also was used as a criterion for
the ball, necessitating surgical repair. He is now in the return to sports. In general, the period of recovery lasted
minor leagues pitching without pain. from weeks to months, depending on the degree of the
Hallux rigidus is arthrosis of the first MTP joint turf-toe injury or the extent of arthrosis. Chronic
and is characterized by a painful loss of motion (exten- aggravating symptoms may persist for several months,
sion) with the formation of prominent dorsal osteo- and a severe turf-toe injury can be career threatening.
phytes. The cause is multifactorial, but it is considered Hallux rigidus has rarely been career ending. We have
a degenerative process. noted some football players who were able to compete
Twenty-six athletic trainers from all the sports polled at a very high level for several years without surgical
responded with their experiences with hallux rigidus. intervention yet with profound arthrosis. For the athlete
Baseball injuries consisted of acute hyperdorsiflexion who requires surgery, we prefer a combined cheilec-
injury to the great toe MTP joint caused by stepping tomy and dorsal proximal-phalanx closing-wedge
on the front edge of the base or running into a wall or osteotomy (Moberg) for the athlete with dorsal spurs,
by an exacerbation of a chronic condition from push- early joint space narrowing and limited extension (60
off running. Basketball players commonly were injured degrees). We believe that the health providers should
acutely from sudden stops or jumps causing hyper- be aggressive with turf-toe injury management whether
dorsiflexion of the great toes. Football trainers described the approach is nonoperative treatment or operative.
the classic hyperextension injury to the great toe as a We favor anatomic repair for magnetic resonance imag-
player pushes off on the playing field or another player ing (MRI)-documented plantar plate rupture and for
lands on the injured player’s heel with the athlete’s great athletes with acute proximal migration of the sesamoids
toe extended and the foot in equinus. Hockey injuries on weight-bearing radiographs.
were less common; some were associated with off-the- The trainers reported surgical experience in three
ice workouts. cases of turf-toe, from two baseball trainers and one
Turf-toe and hallux rigidus commonly were treated soccer athletic trainer. It was reported that these sur-
nonoperatively with taping, ice, anti-inflammatories, geries were performed after a period of conservative
615
...........
treatment. Injuries involved a disruption of the plantar including open reduction internal fixation, was reserved
MTP soft tissues that required surgical reconstruction for intra-articular fractures displaced more than 2 to
of the plantar complex. Return to play was allowed after 3 mm or Jones fractures.
10 to 12 weeks of immobilization followed by aggres- The trainers responding had many experiences related
sive physical therapy (PT) and range of motion. The to base of the fifth metatarsal fractures. Baseball injuries
trainers did not relate experiences with surgery for were commonly treated nonoperatively with PT and
hallux rigidus. taping. Football injuries were treated more aggressively
with casting or surgical intervention because of the more
forceful nature of the trauma. Basketball injuries also
BASE OF FIFTH METATARSAL were treated aggressively with rest, immobilization, cast-
FRACTURES/JONES FRACTURES ing, 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
Base of the fifth metatarsal fractures occur commonly treated operatively to shorten the disability period and
with foot-twisting injuries. There are two basic fracture presumably because of a higher incidence of Jones
patterns seen. The first and most common pattern is fractures in these athletes. Soccer injuries were treated
an avulsion fracture off of the proximal tuberosity. The with a mixture of nonoperative and operative interven-
pull of the peroneus brevis tendon insertion and, per- tions. One soccer trainer describes ‘‘inosine treatment.’’
haps more truly, the insertion of the lateral plantar fascia Hockey trainers described a variety on nonoperative
and abductor digiti minimi to the base of the fifth meta- measures that included casting, taping, elastic braces,
tarsal can avulse a fragment of bone and can be treated and modified shoewear. PT modalities included ultra-
nonoperatively in almost all instances, even in the pro- sound, cryotherapy, iontophoresis, whirlpools, micro-
fessional athlete. Less common but more debilitating current treatments, and bone stimulators. One can see
are the metaphyseal-diaphyseal transverse fractures or that there will be a variety of approaches encountered
true Jones fractures that occur at the vascular watershed even when dealing with the professional athlete and
area of the fifth metatarsal (see Chapters 3 and 4). It fifth metatarsal injuries. Since this survey was completed,
can appear as an acute injury or as a chronic stress frac- we see the use of a bone stimulator becoming almost
ture. This fracture occurs in a location with less than routine in all fifth metatarsal fractures, whether an
optimal perfusion and requires a longer healing time. avulsion or in conjunction with operative treatment for
Fracture healing can be unreliable, especially when trea- Jones fractures. We favor operative treatment with a
ted nonoperatively. 4.5 to 6.5 intramedullary screw for all Jones fractures
Twenty-two professional athletic trainers describe in the professional athlete and nonoperative boot im-
their experiences with base of the fifth metatarsal frac- mobilization for the avulsion fracture. There should
tures and Jones fractures. Five baseball injuries resulted be greater than 95% healing in both cases with this
from inversion-plantarflexion midfoot twisting injuries treatment.
associated with running on inclined uneven surfaces
such as running the bases. The two football injuries oc-
curred with ankle inversion injuries and direct trauma/
MIDFOOT SPRAINS/LISFRANC INJURIES
supination of the foot. Seven basketball injuries are
reported. Some trainers relayed the more common acute
inversion sprain injuries, yet in basketball these fractures Sixteen professional athletic trainers relayed their
were more commonly a result of overuse jumping and experiences with midfoot injuries. Four baseball injuries
running and appeared more commonly as stress frac- resulted from sudden trauma to the foot’s being caught
tures of the fifth metatarsal. Two soccer injuries also in unusual positions, whether plantarflexion-inversion
represent a mix of acute trauma and stress reactions or dorsiflexion-eversion. Two football injuries resulted
associated with running the playing field. Six hockey from a forceful heel impact to the plantarflexed foot.
players reportedly suffered a fifth metatarsal injury, with Four basketball injuries consisted of sudden unusual
the majority of injuries occurring with direct blows to positions of the foot in a sudden sprint, landing, or step-
the foot from puck impact trauma. ping on another player’s foot. Three soccer injuries
Treatment options depended on the type of fracture. resulted from an opponent’s strike to the unsuspecting
The more common avulsion fractures were treated player with the foot planted. Two hockey injuries
symptomatically with rest, ice, compression, elevation, occurred on dry land exercises.
and taping. Immobilization in a walking boot or cast Experiences from the responding trainers varied
was indicated for more comminuted, more painful inju- widely. Immobilization with a walking boot occasionally
ries or mildly displaced fractures. Surgical treatment, was used, depending on the severity of the injury, by
616
...........
Navicular fractures
one baseball, two football, and two soccer trainers. It radiograph of the foot. Stress fractures usually present
seemed that hockey players were allowed sooner return with insidious onset and pain related to activity and have
to sports, possibly because of the more supportive become recognized more commonly in the last 10 years.
nature of the ice skate. In general, athletes were allowed The navicular stress fracture is easily missed on initial ex-
return to play with a pain-free full range of motion and amination because the fracture often is not visible on
the ability to perform with an orthotic insert and modi- routine foot radiographs. The posterior tibial tendon
fied shoewear. The ability to function at a tolerable level insertion onto the medial navicular tuberosity provides
of comfort and to run, in addition to undergoing a a traction point for midfoot twisting injuries and the
sport-specific functional assessment examination, were medial anchoring point for dorsal stress. The bifurcate
criteria used to judge return to sports by these trainers. ligament attachment on the lateral navicular is the lateral
A grading system was used by one football trainer that anchoring point for dorsal tension stress. The dorsal
encompassed a grade 1 sprain requiring 4 to 6 weeks tension created by these opposing forces results in the
of rehabilitation, grade 2 sprain requiring 8 to 12 weeks, fracture’s perpetuating from the dorsal articulation with
and a grade 3 sprain requiring 12 to 24 weeks of the talar head. The palpable pain is noted dorsally on
immobilization/rehabilitation. Depending on surgeon the navicular just lateral to the anterior tibial tendon
preference and radiographic evidence of stability or bony insertion (‘‘N’’ spot).
union, if a fracture was involved, screws were removed Eleven trainers described experiences with navicular
12 to 16 weeks after surgery and the patient was given fractures. In baseball, one trainer described a plantarflex-
arch supports and a rigid-soled shoe. ion twisting injury during a throw. Two other cases were
Surgical intervention for Lisfranc injuries was reported described as an overuse phenomenon to an accessory
infrequently. One baseball trainer reported surgery for a navicular and a stress fracture from running the bases.
prolonged duration of symptoms. Two football trainers One football injury was described as an overuse stress
and one basketball trainer related surgery for displaced reaction. Basketball players incurred injuries from poor
injuries (presumed midfoot dislocation). The hardware foot mechanics, pes cavus anatomy, and overuse. Hockey
commonly was removed at 3 to 6 months. Baseball players and soccer players suffered navicular fractures as a result
and football players did not return to play the same of a direct blunt trauma (four cases).
season. Conservative treatments reported consisted of orthot-
We favor an aggressive approach to this injury. We ics and modified shoewear to accommodate the stresses
believe that complete disruption of the midfoot liga- of the midfoot arch for stress and overuse injuries. Direct
ments requires surgical anatomic stabilization with trauma and acute fractures were treated with immobiliza-
4.0- to 4.5-mm screws to decrease the risk of a career- tion in a boot, cast, or ankle-foot orthosis (AFO) with a
threatening chronic ligament insufficiency, arch col- period of rest. Return to play generally was directed
lapse, and pain. Either evidence of widening of the toward an asymptomatic ability to play. When the players
interval between the medial cuneiform and base of the were pain free with provocative testing, they were
second metatarsal on weight-bearing radiographs or allowed return to sports. For a direct traumatic injury,
MRI evidence of the tarsometatarsal ligament disruption this generally took 7 to 10 days of initial immobilization
is an indication to operative stabilization. Close reexam- followed by 2 to 3 weeks of PT strengthening and propri-
ination with weight-bearing radiographs weekly also is oceptive retraining with accommodative arch supports.
required for the ‘‘stable’’ midfoot sprain to ensure main- Navicular fractures can cause prolonged pain and an
tained anatomic alignment because late diastasis (1-4 extended duration for recovery. Three athletes required
weeks post injury) can occur. Further information can 2 to 3 months for recovery and still played through
be found in Chapter 5. enduring pain. This was seen most commonly in basket-
ball players.
Two players required surgical intervention. One base-
ball player had prolonged symptoms greater than 6
NAVICULAR FRACTURES
months and underwent surgery to return to play in
6 to 8 weeks. One basketball player underwent surgery
The most common types of navicular fractures seen in after a computed tomography (CT) scan identified a dis-
athletics are dorsal chip avulsion fractures and stress placed fracture and returned to play after healing and
fractures. The navicular stress fracture is discussed in pain-free rehabilitation. Presumably these two athletes
Chapters 3 and 4. Avulsion fractures from the dorsal had a navicular stress fracture.
lip are the most common type of navicular fracture. Our approach to the dorsal lip chip fracture com-
They usually are related to excessive plantarflexion forces monly is nonoperative. We see a lot of athletes with
with eversion or inversion components. The avulsion this on routine radiographs. It is important to rule out
fracture normally is easily recognized on a lateral a navicular stress fracture if the pain is not associated
617
...........
with acute trauma. We use CT radiography to ensure One football player required operative repair of the
that there is not an associated stress fracture. Only occa- medial deltoid ligament in association with a mortise
sionally is there a need to remove the symptomatic dislocation and widening. He was allowed return to sport
dorsal chip fracture. Navicular stress fractures should after full range of motion and pain-free sport-specific
be treated aggressively with either nonoperative immo- activities. The time to return was not reported.
bilization and/or screw fixation (4.0-5.0 screws). With We most commonly see medial ligament injury in
either approach, the athlete will have to be nonweight association with either a syndesmosis injury or fibula
bearing for 6 weeks. We have taken a more aggressive fracture. Isolated medial deltoid ankle injury mechan-
surgical approach with screw fixation because we note isms are as described by these trainers. We have had to
about 90% success with operative fixation and only repair only two isolated deltoid ligaments in the compet-
70% with nonoperative treatment. We have moved away itive athlete. Chronic medial ligament insufficiency is a
from bone grafting in most of our operative cases un- very difficult problem to treat, so we are aggressive with
less there is significant cyst formation or significant repair if the ligament is disrupted in a professional athlete.
‘‘displacement’’ (2 mm). This is most commonly associated with operative fixation
of a fibula fracture.
MEDIAL ANKLE SPRAINS/DELTOID

INJURIES LATERAL ANKLE SPRAINS
Twenty-nine trainers described their experience with All the professional athletic trainers responded with their
medial ankle injuries. (See Chapter 13 for a more exhaus- experiences involving lateral ankle sprains. The lateral
tive discussion of this injury.) Ten baseball trainers ankle sprain continues to be the most common sports
described most commonly an ankle trauma as a result of injury, as noted by these results, and is discussed in more
running the bases with an eversion axial-loading injury. detail in Chapter 12. Operative management is dis-
Football injuries occurred as a result of a plantarflexion cussed in Chapter 13. Baseball injuries commonly were
external rotation injury (pile-up or chop block). Basket- related to plantarflexion inversion injuries. This injury
ball players routinely described an eversion injury related occurs during the course of running in the outfield to
to stepping on another player’s foot. Soccer players catch a ball or running around the bases. Basketball inju-
most commonly suffered an eversion injury as a result ries notoriously resulted from stepping on another
of an opponent player’s applying a laterally directed player’s foot or landing awkwardly. Football injuries
force to the planted foot. Hockey players experienced occurred with the foot planted and the player twisting
a plantarflexion-eversion twisting injury during play of and rolling to the ground. Soccer-player injuries hap-
having the skate caught in the ice or on the puck. pened as a mixture of all these. Hockey injuries were
The cornerstone of treatment was nonoperative, con- caused as the skate was caught in the ice or were
sisting of rest, ice, compression, taping, and elevation reported as a common plantarflexion inversion injury
during the initial 2 to 3 days. Anti-inflammatory medi- during on- or off-the-ice training.
cations were prescribed along with PT early range of The treatment of lateral ankle sprains was determined
motion protocols. PT modalities included pulsed ultra- by severity of injury and length of symptoms. Initial
sound, electrical stimulation, cold therapies, propriocep- treatment of acute injury involved protection, rest, ice,
tion, and strengthening programs. Most athletes were compression, and elevation (PRICE) to limit the extent
placed in removable, prefabricated walking boots, and of injury, control edema, and minimize pain. A regimen
rarely was casting immobilization used. Orthotic shoe of anti-inflammatory drugs commonly was used. After
inserts were used commonly, especially in basketball, to the initial treatment, strengthening exercises were
help support the medial arch and counteract pronation. initiated, concentrating on the peroneal muscles and
Criteria for return to play were based on a pain-free dorsiflexors. This was followed by proprioception exer-
range of motion with no swelling or symptoms related cises, functional conditioning, and endurance training,
to stress testing, such as a single-leg stance or hop. then by return to play when asymptomatic. Indications
Grading systems similar to lateral ankle sprains were for surgery in the acute phase are controversial.
used. Grade 1 injures required 2 to 4 weeks of rehabili- Responding trainers relayed that conservative treat-
tation. Grade 2 injuries required 3 to 8 weeks. Grade 3 ment consisted of rest, ice, compression, taping, and ele-
injuries required 8 or more weeks. The ability to return vation during the initial 2 to 3 days. Anti-inflammatory
to sports was determined by a pain-free full range of medications were prescribed, along with PT early
motion and a functional assessment based on sport- range-of-motion protocols thereafter. PT modalities in-
specific task exercises. cluded pulsed ultrasound, electrical stimulation, edema
618
...........
Achilles tendinitis/rupture
control, cold therapies, and proprioceptive and strength- sprains. Conservative treatment consisted of rest, ice,
ening programs. Most athletes commonly were placed in compression, taping, and elevation during the initial
removable, prefabricated splints, and rarely was casting 2 to 3 days. Anti-inflammatory medications were pre-
immobilizations used. Grading systems were used. scribed along with PT early range of motion protocols
Grade 1 sprains were allowed to continue play as toler- thereafter. PT modalities included pulsed ultrasound,
ated to pain with anti-inversion taping and modified electrical stimulation, and proprioceptive and strength-
shoe inserts. Grade 2 sprains were treated with ening programs. Most injuries commonly were placed
variable periods of restriction for 1 to 3 weeks. Grade in removable, prefabricated splints, and rarely was cast-
3 sprains required 3 to 5 weeks of immobilization ing immobilization used. High ankle sprains reportedly
and activity limitations. Football injuries were treated were treated more conservatively (regarding return to
more conservatively, with a 1- to 2-week longer period play) than their lateral ankle injury counterparts, with
of restrictions, presumably because of the greater an initial period of protective, partial weight bearing.
amount of forceful contact used on the field of play. Grading systems again were used. Grade 1 sprains were
The criteria for return to play consisted of pain-free full protected for 3 to 6 weeks. Grade 2 sprains were treated
range of motion; ability to perform a balanced, single- with variable periods of restriction for 6 to 12 weeks.
leg stance; and completion of a sport-specific function Grade 3 sprains required more than 3 months for return
assessment test. to play. Athletes were allowed return to play after a pain-
No cases of surgical intervention were presented for free full range of motion, a painless external rotation or
acute lateral ankle sprains. compression testing, and a sports-specific functional
We are aggressive with intermittent immobilization, assessment examination.
cold compression therapy (Aircast Cryocuff, Summit, Two football trainers and one baseball trainer de-
NJ), and aggressive PT. We are happy to use the expert scribed experiences with operative repair of syndesmosis
and available training staff employed by the professional injury. The indication for operative fixation depended
teams. The PT opportunities available enable a quicker on the severity of the injury and the degree of joint dis-
return to play. We encourage use of the boot immobi- placement. Two compression screws commonly were used
lization at night (when relaxation of the muscles and to support the syndesmosis and commonly were removed
nonweight bearing lead to a position of plantarflexion at 12 weeks after the initial surgery.
[PF] and inversion) for 4 full weeks but allow daily activ- We believe that operative fixation is optimal for grade
ities in a stirrup brace as soon as the ankle is stable to 2 (occult complete disruption), grade 3 (overt dis-
talar tilt on clinical examination (1-3 weeks). We operate location of the tibia fibula interval and deltoid), and
on acute routine lateral ankle sprains only if there is an Maisonneuve injuries. Chronic and incompetent syndes-
associated osteochondral fracture requiring fixation. mosis injuries can be career threatening, and thus stable,
anatomic alignment must be obtained and maintained.
HIGH ANKLE SPRAINS/SYNDESMOTIC

INJURIES ACHILLES TENDINITIS/RUPTURE
Twenty-two professional athletic trainers reported their Achilles tendon injuries can plague the elite athlete.
experiences with high ankle sprains. High ankle sprains Injuries include tendinopathy, insertional problems
are discussed in Chapter 13. Baseball injuries were a (bursitis and tendinopathy), and complete rupture (see
result of unusual positioning of the foot (presumably Chapter 7). Acute ruptures can result in a long period
dorsiflexion and eversion) as an unexpected force was of rehabilitation, and have the potential for long-stand-
applied. This occurred often as players collided into ing weakness. Acute and chronic Achilles tendinitis, usu-
one another as an opponent was sliding into a baseman ally the result of an overuse injury, can be a chronic
or suddenly misstepping on uneven surfaces. Football nuisance injury resulting in suboptimal performance.
injuries were reported with the classic plantarflexion All 26 professional athletic trainers described their
(or dorsiflexion) external rotation injury and a pileup. experiences with Achilles tendon disorders. Baseball
Basketball injuries occurred with stepping on another injuries ranged from the acute traumatic eccentric ankle
player’s foot. Soccer injuries happened as an opponent dorsiflexion injury to the recurrent aggravation of pre-
slid into the player. Hockey injuries occurred as the existing chronic tendinitis associated with running the
player’s foot was suddenly plantarflexed into the ice bases and overuse. Occasional injuries occurred early in
and a rotational force applied. the season with poor conditioning and foot mechanics
According to respondents, high ankle sprains were from the off season. Football and basketball injuries
treated nonoperatively in similar fashion to lateral ankle occurred with sudden push-off explosive jumping forces
619
...........
and overuse stress phenomenon. Soccer injuries more operate on midsubstance tendinosis in the professional
commonly were listed as repetitive stress injuries exacer- athlete despite a common experience in the nonprofes-
bated by push-off drills and backpedaling. Hockey inju- sional, middle-aged athlete.
ries 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
DIFFICULT INJURIES
nonoperatively with PT, stretching, proprioceptive
training, and taping modalities (avoiding extremes of The professional athletic trainers polled were polled
dorsiflexion). Orthotic inserts and heel lifts commonly about the most difficult/memorable/unusual foot and
were prescribed but quickly discontinued in most cases ankle injury they had experienced in the past 5 years.
to ‘‘avoid contracture.’’ Rarely were casting and immo- Six trainers cited chronic plantar fasciitis and heel pain
bilization used for more acute Achilles tears. Chronic as the most recalcitrant injury poorly amenable to
injuries may benefit from hydrotherapy, whirlpools, rehabilitation. Six trainers listed high ankle syndesmotic
and electrical stimulation. Football injuries are treated sprains as difficult to treat, inasmuch as two players had
more aggressively with immobilization, night splints, required surgery for prolonged symptoms and all the
and anti-inflammatory medications. Athletes were al- players required a lengthy respite from play, often
lowed return to play after a pain-free examination and frustrating the players. The high ankle sprains would
full range of motion. A sports-specific functional assess- reach a plateau of recovery before recurring setbacks in
ment test with the ability to run, jump, and weight bear progress. Four trainers cited Achilles tendon rupture
with multidirectional take-off exercises defined the level for their magnitude of injury and the prolonged rehabil-
of proficiency at which the player may return to the itation period following surgical intervention. Both
field. Occasional chronic irritation and the ability to play football trainers and one baseball trainer mentioned
through mild soreness may be required of the chronic Lisfranc fracture/dislocations on the basis of the severity
injury. Acute ruptures required several months of re- of the injury, with multiple tarsal joint involvements,
covery with intense therapy before obtaining a suitable necessitating surgery and prolonged periods of recovery.
level of function for play. One soccer trainer mentioned Lisfranc fracture/disloca-
Surgical intervention is required with a complete ruption for its subtle appearance and difficulty in diagnosing
ture and occasionally chronic, debilitating tendinitis. the occult injury, which further prolonged the return to
Fourteen trainers described their experiences with oper- play. Three trainers listed navicular stress fractures as
ative intervention in the elite athlete. Most commonly, their most intriguing injuries because of their gradual
acute complete and high-grade partial ruptures con- symptomatic onset and the moderate workup for mid-
firmed by a positive Thompson’s test and MRI scan war- foot pain before the detection of this injury. Two lateral
ranted operative intervention in the professional athlete. ankle sprains developed recurring symptoms that
One baseball trainer cited an instance of nonoperative plagued the player but were treated with taping and
casting for an Achilles tear necessitating 9 to 12 months never underwent surgical intervention. One lateral mal-
of rehabilitation before return to play. One baseball leolus refracture in a hockey player was under constant
trainer and one basketball trainer described episodes stresses from ice skating. One medial malleolus fracture
of operative treatment of chronic Achilles tendinitis was listed. One medial malleolar fracture developed a
(insertional) with Hagland’s deformity. Surgical rehabil- nonunion that required multiple surgeries and bone
itation generally requires 12 to 16 weeks of rehabilita- grafts and had an associated talar osteochondral lesion
tion before achieving a pain-free range of motion and that prolonged the recovery process. Three episodes
the ability to return to sports. were cited of base of the fifth metatarsal fractures—one
We believe that complete ruptures of midsubstance nonunion, one revision surgery, and one somewhat
or insertional avulsion have a better chance of full recov- humorous episode of falling after being bitten by the
ery and a lower rerupture rate with operative repair. We pet dog.
tend to be aggressive with repair in the professional As professional and recreational sports become a
athletes but tell trainers, athletes, and management that more integral part of our society, more athletes will
the time to return to play can be 6 to 12 months. We experience these common and uncommon injuries.
have only occasionally had to operate on insertional ten- The rehabilitation of the elite athletes related to our
dinitis in the professional athlete and prefer a posterior readers by the experiences of the contributing profes-
tendon-splitting approach to disrupt as little of the ten- sional athletic trainers will, we hope, aid in expediting
don insertion as possible. With localized debilitating the recovery of future players. We hope that this chapter
pain, this approach lets us get to problem with minimal has helped you to be on guard concerning these com-
incisions and maximal benefit. We have not had to mon and difficult foot and ankle injuries in professional
620
...........
Bibliography
athletes. We also hope that the management pearls Nunley JA, Vertullo CJ: Classification, investigation, and management
aid you in making decisions and in educating the ever- of midfoot sprains, Am J Sports Med 30:871, 2002.
Nussbaum ED, et al: Prospective evaluation of syndesmotic ankle sprains
concerned athlete. without diastasis, Am J Sports Med 29:31, 2001.
Paavola M, et al: Achilles tendinopathy, J Bone Joint Surg Am 84A:
2062, 2002.
ACKNOWLEDGMENTS Porter DA: Ligamentous injuries of the foot and ankle. In: Fitzgerald R,
Kaufer H, Malkani A, editors: Orthopedics, St Louis, 2002, Mosby.
Vanore JV, et al: Diagnosis and treatment of first metatarsalphalangeal
We acknowledge Sara Carpenter, MS, PT, OrthoArkan- joint disorders. Section 2: hallux rigidus, J Foot Ankle Surg 42:124,
sas, PA and Josh Landers, DPT, OrthoArkansas, PA. 2003.
Yoshino N, et al: Bilateral isolated tarsal navicular fracture dislocation: a
case report, J Orthop Trauma 15:77, 2001.
BIBLIOGRAPHY
Mizel MS, Miller RA, Scioli MW, editors: Orthopaedic knowledge

update foot and ankle 2, Rosemont, IL, 1998, AAOS.
621
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................................................. I N D E X
A Achilles tendinitis (Continued) Achilles tendon rupture (Continued)

Abductor digiti quinti muscle, 235, 235f surgical treatment of, 153, 620 Thompson test for, 175f, 529
Abductor hallucis tendon transfer, 426, 428f ankle neutral position, 171 chronic, 178, 530
Accessory navicular bone, 537 partial weight bearing after, 170–171, 172f in dancers, 480
in children, 537 postoperative management, 169 diagnosis of, 493f, 529
description of, 36, 43 return to sport after, 172 epidemiology of, 529
displaced, 304f splinting, 169–170 flexor hallucis longus repair of, 521, 521f
flexible flatfoot with, 590 success rates, 172 gastro-soleus release, 496f, 530
imaging of, 187f, 202f, 300f, 303f treatment of, 151, 153, 480, 620 incidence of, 529
in Korea, 516 Achilles tendinopathy in Kendo, 510, 510f
orthoses for, 590, 591f adhesion prevention, 532 neglected, 521
radiographs of, 537 biology of, 527 pain associated with, 488–489
signs and symptoms of, 537 etiology of, 527 percutaneous technique for, 495f
treatment of, 537 gene therapy for, 528 in professional athletes, 619
Achilles tendinitis, 148 healing of, 527 proximal, 529
ankle-foot orthosis for, 7f histopathology of, 527 rehabilitation after, 530
chronic, 480 management of, 529 repair of, 489, 490f, 529
classification of, 148 aprotinin, 529 reruptures, 530
in dancers, 480 Eccentric Exercise, 529 signs and symptoms of, 529
extracorporeal shock wave therapy for, 173 glyceryl trinitrate, 530 in soccer players, 488–489
insertional, 150, 377 laser therapy, 529 tendon transfers for, 531
classification of, 377 nonsteroidal anti-inflammatory drugs, 529 Thompson test for, 175f, 529
magnetic resonance imaging of, 151f, 162f, radiofrequency coblation, 529 treatment of, 529
167f resumption of activity after, 530 surgical, 494f, 495f, 529, 530
nonsurgical treatment of, 153 sclerosing injections, 529 “two flaps technique,” 496f
orthoses for, 591 shock wave therapy, 530 Achillotendoscopy, 377
retrocalcaneal bursitis. see Retrocalcaneal surgical, 530 Adductor canal syndrome, 223, 224f
bursitis prevalence of, 527 Adhesions, 532
surgical treatment of, 162, 162f, 377 stem cells for, 528 Adolescents
symptoms of, 171b, 377 tissue engineering for, 528 fifth metatarsal base
noninsertional, 148 ultrasound of, 529 fractures in, 115
adhesion excision, 154 Achilles tendon fixed flatfoot deformity in, 591
classification of, 376 anatomy of, 147, 479 Tillaux fracture in, 96, 99f
imaging of, 149f blood supply to, 147 triplane fracture in, 96, 99f
nonsurgical treatment of, 153, 162b collagen fibrils of, 147–148 Aerobic dancing, 581
surgical treatment of, 154 contracture of, 183–185 Air soles, 572
tenotomy, 154 degeneration of, 165f Aircast walking boot, 597, 597f, 605
nonsurgical treatment of, 151, 480 length of, 147 Allodynia, 503
paratendinitis, 376 magnetic resonance imaging of, 155f Allografts, 326, 334f, 556
peritendinitis noninflammatory atrophic degeneration of, 150 Alpine skiing, 580, 581f
adhesion excision, 154, 154f reattachment of, 162–164, 162f Amitriptyline, 505
arthroscopy for, 377 rehabilitation of, 601 Ankle
in dancers, 479 rupture of. see Achilles tendon rupture anatomy of, 33, 34f
definition of, 148 stretching of, 191 degenerative changes of, 365t
refractory, 153 Achilles tendon rupture hindfoot anatomy of, 294f
signs and symptoms of, 149f acute, 173 “meniscoid” of, 35
with tendinosis, 148–150 clinical findings, 174f osteophytes, 33
treatment of, 153 etiology of, 173 plantarflexion of, 311, 311f
posterior ankle impingement caused by, 376 magnetic resonance imaging of, 176f radiographs of, 186, 187f
prevalence of, 148 mechanism of, 173 Shenton’s line of, 87f
in professional athletes, 619 mini-open technique for, 175 stability of, 88
risk factors, 148b nonsurgical treatment of, 173 subluxation of, 267f, 268f
shoes, 154f, 582 surgical treatment of, 174, 176f, 177f supination-inversion injury of, 98f
623
...........
Index
Ankle fractures, 88 Ankle sprain Anterior talofibular ligament (Continued)

bimalleolar, 94, 94f high, 17–18, 34, 619 in modified Brostrom technique, 276, 278
lateral malleolus. see Lateral malleolus, incidence of, 318 sprain of, 475
fractures instability after, 274t tear of, 35, 476
medial malleolar, 88, 88f. See also Medial inversion, 532 Anterior tarsal tunnel syndrome, 10
malleolus fractures lateral, 273. See also Ankle ligaments, lateral Anterior tibia, 365
pediatric, 96 in dancers, 475 Anterior tibiofibular ligaments, 24f
in pediatric patients. see Pediatric patients, ankle incidence of, 558 anatomy of, 286–287, 286f
fractures in in professional athletes, 618 Basset’s ligament, 34, 34f
rehabilitation of, 607 residual symptoms after, 476–477 insertion of, 35
Salter-Harris classification of, 96, 97f, 539–540, treatment of, 273, 618 Anthropometric measurements, 61
540–541 lateral process talar fractures vs., 97 Antifungal agents
trimalleolar, 94, 94f medial, 43, 280 onychomycosis treated with, 261–262
Ankle impingement, 33 anatomy of, 281 tinea pedis treated with, 259
anterior. see Anterior ankle impingement arthroscopic grading of, 284t Aprotinin, 529
anterocentral, 33–34 biomechanics of, 281 Arch supports, 571
flexor hallucis longus tendonitis vs., 37t chronic, 284 Arterial disease, 247
lateral, 35 in dancers, 475 Arthritis
os trigonum. see Os trigonum in professional athletes, 618 enteropathic, 242
posterior, 36, 37t, 38, 370 nerve injury with gouty, 243–244
causes of, 370 anatomy of, 530 midfoot, 589
characteristics of, 370 clinical presentation of, 531 psoriatic, 242
flexor hallucis longus tendinitis, 373 nerve blocks for, 529 in Reiter’s syndrome, 242
loose bodies, 372–373 nonsurgical treatment of, 531 rheumatoid, 243
os trigonum syndrome, 370, 371f oral medications for, 532 subtalar, 593
osteochondral defects, 373 pathoanatomy of, 530 Arthrodesis
peroneal tendon tendinitis, 375 surgical treatment of, 506 calcaneocuboid distraction, 198–199
posterior tibial tendinitis, 374 topical medications for, 532 hallux rigidus treated with, 416
posttraumatic calcifications, 371 treatment of, 531 metarsocuneiform joint, 443
posterolateral, 36 nonoperative management of, 273 posterior tibialis tendon dysfunction treated
spurs, 33–34 orthoses for, 593 with, 198–199
Ankle instability, 486 osteochondral lesions of talus and, 318 subtalar, 199
after ankle sprain, 274t pain after, 274t triple, 199
chronic, 267, 558 posterior impingement secondary to, 39 Arthroscopy, 559
osteochondral lesions of the talus associated signs and symptoms of, 273 accessory instruments, 357
with, 319–320 surgical treatment of, 273 Achilles tendon peritendinitis, 377
surgical treatment of, 558 arthroscopy, 274 anatomy imaged using, 361
thermal capsular modification for, 559 contraindications, 273–274 for ankle sprain, 274
footballer’s ankle, 523 goals, 274 anterior and posterior, 380
lateral indications for, 273–274 anterior ankle impingement treated with, 364,
modified Bromstrom technique for. radiographic criteria for, 273–274 366
see Modified Bromstrom technique tarsal coalition and, 345–346 contraindications, 355–356
stabilization operations for, 274–275 Ankle stirrup brace, 266f equipment for, 356
medial, 280–281 Ankle syndesmosis examination using
rehabilitation for, 267–268, 269t pathology of, 34–35 anterior ankle, 362
subtalar instability and, 339 repair of, 95f 14-point, 361, 362t
surgical repair of, 486 space measurements, 87, 87f posterior ankle, 362
Ankle joint sprain of, 34 21-point, 361, 361t
diastasis of, 17–18 Ankle tunnels, 217t, 218f grasper, 357
lateral, pain in, 208–209 Ankle-foot orthosis great toe, 560
Ankle ligaments, 265 Achilles tendinitis, 7f hallux rigidus treated with, 417
anterior talofibular ligament, 265–267, 266f case study use of, 4–5, 6f history of, 355, 559–560
calcaneofibular ligament, 265–267, 266f Ankylosing spondylitis, 241 indications for, 355
lateral, 265, 266f Anterior ankle impingement, 33, 364 irrigation for, 357
failed reconstruction of, 278 arthroscopic treatment of, 366 loose bodies, 370
free tendon transfer for, 279–280 bony impingement associated with, 365 operative setup for, 356
modified Brostrom procedure for. see Modified in dancers, 477 ossicles, 370
Brostrom procedure definition of, 364 osteochondral defects of the talus, 367
rehabilitation program for, 279t lesions associated with, 365 patient positioning for, 356
prevention of, 268 location of, 365–366 peroneal tendons, 376f
summary of, 270 radiographs of, 364f portals, 357
Ankle pain rehabilitation of, 366 accessory inferior, 358
anterolateral, 34 scoring systems for, 364–365 anterolateral, 358, 358f
anteromedial, 33 Anterior drawer test, 267, 267f anteromedial, 357, 358, 358f
lateral Anterior process calcaneal fractures, 100 function of, 357
causes of, 35 avulsion etiology of, 100, 101f posterolateral, 359, 359f, 560
description of, 35–36 compression etiology of, 100–102, posteromedial, 359, 360f, 361f, 560
medial, 42 101f transmalleolar, 359
posterior, 36, 37t mechanism of, 100–102, 101f transtibial, 359
differential diagnosis, 40 treatment of, 102 posterior ankle, 560
posterolateral, 36, 37t, 39 Anterior syndesmosis, 34 in prone positioning, 560
posteromedial, 37t, 40 Anterior talofibular ligament, 265–267, 266f subtalar joint, 343f, 378, 378f
Ankle reconstruction, 604 anatomy of, 286f surgical technique, 356
624
...........
Index
Arthroscopy (Continued) Bunionettes, 384 Calcium deficiencies (Continued)

synovitis treated with, 367 callus reduction, 385–386 supplementation for, 58–61
two-portal posterior, 356, 357f clinical presentation of, 384–385 Calcium deficiency, 247
Athletes in dancers, 470, 474 Calcium pyrophosphate dihydrate crystal
Achilles tendon injuries in, 619 fifth metatarsal head and, 385f deposition, 244
ankle injuries in, 612–613 illustration of, 385f Calf raise, 603f, 608f
ankle sprains in physical examination, 385 Callus
high, 619 radiographs of, 386f bunionette, 385–386
lateral, 618 treatment of definition of, 582
medial, 618 conservative, 385 description of, 254–255
deltoid injuries in, 618 osteotomy, 386, 387 diffuse, 387–388
female. see Female athletes surgical, 386, 387 discrete, 387–388, 390f
foot injuries in, 612–613 Bunions. see Hallux valgus in intractable plantar keratoses, 387, 390f
Lisfranc injuries in, 616 Bursectomy, 471 shoe-related, 582
midfoot sprains in, 616 Bursitis Cancellous bone graft, 115
navicular fractures in, 617 calcaneal, 481 Candida onychomycosis, 261
stress fractures in, 46, 47t retrocalcaneal, 151, 167f, 171b, 175f, 377, 582 Capsaicin, 505
turf-toe in, 614 sesamoid, 471 Capsular interposition, 416, 417f
Athlete’s foot. see Tinea pedis shoe-related causes of, 582 Capsular reefing, 406, 406f
Australian sports Carbamazepine, 505
description of, 516–517 C Cardiovascular rehabilitation, 599, 599t
surf lifesaving, 517, 517f Calcaneal bursitis, 481 Cartilage-derived morphogenetic proteins, 528
Autologous chondrocyte implantation, 325–326, Calcaneal fat pad insufficiency, 226 Cavovarus foot, 591
487, 555 Calcaneal fractures Cavus foot, 591
matrix-induced, 326 anterior process, 100 Cellulitis, 245
Avascular necrosis of the sesamoid, 417, avulsion etiology of, 100, 101f Cheilectomy
438–439 compression etiology of, 100–102, 101f hallux rigidus treated with, 414–415
Avulsion fractures mechanism of, 100–102, 101f postoperative course after, 415
anterior process calcaneal, 100, 101f treatment of, 102 results of, 415
fifth metatarsal base fracture, 114, 616 anterolateral process, 305 Chevron osteotomy
os calcis, 35f, 35 classification of, 305–306 bunionette treated with, 387, 388f
diagnosis of, 306, 307f hallux valgus treated with, 441, 441f
eversion abduction mechanism of, 305–306, intractable plantar keratoses treated with, 392f
B 307f Chevron-Akin osteotomy, 16–17, 19f
Balance board training, 268–270 imaging of, 307, 308f, 309f Chilblain, 248, 252
Ballet, 469, 482, 548. See also Dancers incidence of, 305 Children. see Pediatric patients
Baseball shoes, 579 inversion mechanism of, 305, 306f Chinese habits and sports
Basketball shoes, 577, 577f malunited, 308 ankle injuries, 511–512
Basset’s ligament, 34, 34f mechanism of, 305, 306f foot injuries, 511–512
Baxter’s nerve neurapraxia, 481 nondisplaced, 308 herb ointment therapies, 512–513
Bicycling, 581, 581f nonunion of, 308 traditional Chinese medicine for, 513
Biomechanics, 62, 69 physical examination, 307, 307f Chondrocytes, 555–556
Bisphosphonates, 246 rehabilitation of, 308 Chronic Achilles tendon rupture, 178
Black heel, 255, 256f return to sports after, 308 Chronic exertional compartment syndrome, 452
Blisters, 581 signs and symptoms of, 306–307 causes of, 452
Boating shoes, 570 treatment of, 308 compartment pressure testing, 453, 453f
Bone densitometry, 246, 247 peroneal tendon dislocation and, 140 diagnostic studies, 453, 463t
Bone density, 58, 59t Calcaneal nerve fasciotomy for, 455f
Bone grafts, 419 medial, 220f history-taking, 452
Bone remodeling, 45–46, 55 neuroma of, 221f pain associated with, 452–453
Bone resorption, 45–46 Calcaneal osteotomy, 194, 197f pathophysiology of, 452
Bone scans Calcaneal tuberosity, 147 physical examination, 453
procedure for, 64–65 Calcaneocuboid distraction arthrodesis, 198–199 treatment of, 454, 455f
stress fracture imaging using, 64, 65f Calcaneocuboid joint Claudication, 248
tarsal navicular stress fracture imaging compression of, 307f Claw toe, 397, 402, 426–427
using, 74 dorsiflexion of, 307f Cleated shoes, 570
Bone scintigraphy Calcaneocuboid ligaments, 297 Collateral ligaments, 411
procedure for, 64–65 Calcaneofibular ligament, 143–144, 265–267, 266f, Comminuted fractures, 99
sesamoid pain evaluations, 79–80 276–277, 295f, 475 Common peroneal nerve
stress fracture imaging using, 64, 65f Calcaneonavicular coalitions, 346, 347f, 348, 350f anatomy of, 210–213
Bone stimulator, 5 Calcaneonavicular ligament, 297, 298f compression of, 210–213, 213f
Bone strain Calcaneonavicular tarsal coalition, 201f injuries to, 212f, 213f
definition of, 65 Calcaneus Communication, 25
features of, 66, 66t anatomy of, 297 Compartment syndrome
history of, 65 blood supply to, 297 anterior, 215–217
scintigraphy of, 65–66 Haglund’s deformity, 147, 148f in dancers, 482
Borrelia burgdorferi, 244–245 ligaments of, 297f posterior, 7–8
Botulinum toxin injections, 230 posterior tuberosity of, 169, 171f Complementary deoxyribonucleic acid, 528
Boxer’s fracture of fifth metatarsal, 30f prominence, endoscopic resection of, 561 Computed tomography
Bromstrom technique, 274–275. See also Modified Calcifications, 371 footballer’s ankle, 524
Bromstrom technique Calcitonin, 246 ossicles, 370–371, 372f
Brostrom-Gould reconstruction technique, 342, Calcium deficiencies osteochondral lesions of the talus, 320–321, 373,
342f stress fractures and, 58 373f
625
...........
Index
Computed tomography (Continued) Dancers (Continued) Dermatologic disorders (Continued)

stress fracture evaluations demi-pointe stance, 469–470, 470f, 550 sunburn, 255
description of, 66 en pointe stance, 469, 470f traumatic, 255
navicular bone, 66, 67f feet of, 470 xerosis, 255
syndesmotic injuries, 288 fifth metatarsal fractures in, 474, 474f, 549 Dermatophyte infections, 259
Condylectomy flexor hallucis longus tendinitis in, 479, 549 Desensitization massage, 605
hard corn treated with, 396f Freiberg’s infraction in, 472, 473f Diabetes mellitus, 245
partial, 389, 391f great hallux interphalangeal joint injuries, 472 Dicloxacillin, 259
Conservative treatment, 4 heel pain in, 480 Dislocations
bunionettes, 385 lateral ankle injuries in, 475 foot. see Foot fractures and dislocations
case studies of, 4–5 lateral branch of the deep peroneal nerve metatarsophalangeal joints, 472
costs of, 5 impingement in, 477, 477f peroneal tendon, 140, 142f
description of, 4 leg pain in, 481 subtalar joint, 344
economic impact of, 5 medial ankle injuries in, 474 Distal metatarsal articular angle, 439f
fifth metatarsal base fractures, 116, 117f medial tibial stress syndrome in, 481 Distal oblique osteotomy, 387, 389f, 391f
flexor hallucis longus tendinitis, 40 metatarsal injuries in, 473 Dorsal closed wedge osteotomy, 169, 171f
hallux valgus, 436 metatarsophalangeal joint injuries in, 470 Dorsal osteophyte, 10f
impingement syndromes, 29 bunions, 470 Dorsal pedis artery, 295f
insertional plantar fasciosis, 229 dislocation, 472 “Double crush” phenomenon, 221–222
intractable plantar keratoses, 389, 390f hallux rigidus, 470, 471f Drawer sign, 404f, 384
medial tibial stress syndrome, 447 idiopathic synovitis, 473 Dropfoot, 212f
metatarsophalangeal joint instability, 31, 31f, instability, 472 Dropped metatarsal, 30–31
404, 405f lateral proper digital nerve entrapment, 472 Dual energy x-ray absorptiometry, 58
plantar fasciosis, 229 midfoot injuries in, 549 DuVries-type arthroplasty, 31
sinus tarsi syndrome, 33 plantar fasciitis in, 480
stress fractures, 449 posterior ankle injuries in, 477 E
turf-toe, 428 flexor hallucis longus tendinitis, 479, 549 Eccentric Exercise, 529
Contact dermatitis, 251, 252f impingement syndrome, 477 Egyptian foot, 470
Continuous passive motion, 488 posterior ankle pain in, 549 Ehlers-Danlos syndrome, 278–279
Corns, 253–254, 581 second metatarsal base stress fracture in, 473, Elastic lacing, 574
Corticosteroids 474f Elavil. see Amitriptyline
flexor hallucis longus rupture caused by injection sesamoid bone injuries in, 471 Elsmlie procedure, 342f
of, 125 “shin splints” in, 481 En pointe, 469, 470f
plantar fasciosis treated with, 229, 229f stress fractures in, 481 Endoscopy
Cotton test, 287 summary of, 482 calcaneal prominence resection, 561
Crohn’s disease, 242 trigger toe in, 123 Haglund’s deformity resection using, 169, 170f,
Cross-country skiing, 580 Dancer’s pad, 80 561–562
Cryotherapy, 132, 595 Dancer’s tendinitis, 40, 42, 122 plantar fascia release using, 232–233
Cuboid Davis’ law, 600–601 Enteropathic arthritis, 242
anatomy of, 297 Deep peroneal nerve, 215, 532 Enthesopathies, 242–243
compressive injuries of, 108–109, 111f lateral branch of the, 476, 477f Entrapment
“locked,” 32 Delayed hypersensitivity reaction, 251 common peroneal nerve, 210–213, 212f
subluxation of, 32, 32t, 33f, 549 Delayed union lateral proper digital nerve, 472
Cuboid fractures, 303 Jones fracture, 116 peroneus brevis, 132
“chip,” 108 medial malleolus fractures, 89f Epitenon, 147–148
diagnosis of, 303 Deltoid ligament Ethyl vinyl acetate, 568
imaging of, 303, 305f, 306f anatomy of, 281, 281f Excision
incidence of, 303 chronic insufficiency, 284–285 interdigital neuroma, 393, 393f
magnetic resonance imaging of, 303, 306f deep, 281, 281f os trigonum, 39
mechanism of, 303 injury to indications for, 38–39
occult, 306f acute repair, 284 lateral approach, 39
treatment of, 303 diagnosis of, 282 medial approach, 41
Cuneiforms magnetic resonance imaging of, 283 talocalcaneal coalitions, 350f
bipartite, 108, 110f mechanisms of, 282 Exercise walking shoes, 575, 575f
configuration of, 473–474 in professional athletes, 618 Exertional compartment syndrome, 43
dislocation of, 108 radiologic evaluations, 282 Exostosis, 395f
fracture of, 108 reconstruction, 285–286, 285f Extensor hallucis brevis, 412
medial, 108, 110f surgical treatment of, 283–284 Extensor retinaculum, 131
Cushing’s disease, 247 syndesmosis injury associated with, 282, 282f, External rotation test, for syndesmosis injury, 282,
Cytokines, 528 283–284 283f
treatment of, 283 Extracorporeal shock wave therapy. See also Shock
D posterior, 296f, 308–311, 311f wave therapy
Dancers restraint functions of, 281 Achilles tendinitis treated with, 173
Achilles tendon injuries in, 479 strain of, 475 plantar fasciosis treated with, 229–230
peritendinitis, 479 Demi-pointe stance, 469–470, 470f, 550
rupture, 480 Dermatologic disorders, 251 F
tendinitis, 480 black heel, 255, 256f Fasciotomy, 419, 490f, 528
ankle sprains in contact dermatitis, 251, 252f Fat pad insufficiency, 226
lateral, 475 friction blisters, 256 Female athletes. See also Women
medial, 475 frostbite, 252 acute injuries in, 549
anterior ankle injuries in, 477 hyperhidrosis, 253 bunions in, 550
bunionettes in, 474 hyperkeratosis, 253, 254f dancers, 548
compartment syndrome in, 482 piezogenic pedal papules, 256 gymnasts, 550
626
...........
Index
Female athletes (Continued) Fifth metatarsal base fractures (Continued) Foot

ice hockey, 550 percutaneous intramedullary screw dorsiflexion of, 424f
increases in, 547 fixation, 115, 118f radiographs of, 186, 187f, 188f
male athletes vs., 547–548 tuberosity stress fracture risks and, 62–63
menstrual disturbances in, 57 description of, 114 Foot arch, 62–63
musculoskeletal system, 548 treatment of, 116 Foot fractures and dislocations
posterior tibial tendinitis in, 550 zone 1, 113, 113f, 116 ankle. see Ankle fractures
stress fractures in, 49, 551 zone 2, 113, 113f, 116–117, 118f diagnosis of, 85
Female athletic triad, 246–247, 469 zone 3, 113, 113f, 117–118 lateral process talar fracture. see Lateral process
Ferkel’s phenomenon, 34 Fifth metatarsal fractures talar fracture
Fibroblasts, 527 avulsion fracture, 35 physical examination of, 85
Fibro-osseous tunnel, 36–38, 39f base. see Fifth metatarsal base fractures radiographs of, 85
Fibula in dancers, 474, 549 treatment of, 87
distal, 140, 141f, 143 Jones fracture, 474, 474f Foot shuffling, 509f, 509
supination-eversion fracture of, 7f spiral diaphyseal, 474 Football shoes, 578, 579f
Fibular fractures stress fracture of, 81, 82, 83, 538 Footballer’s ankle
bimalleolar fracture and, 94, 95f Figure skating shoes, 580 ankle instability, 523
displaced, 90, 92f First metatarsophalangeal joint clinical evaluation of, 523
head, 207f anatomy of, 412f computed tomography of, 524
nondisplaced, 90–91 arthroscopy of, 560, 561, 561f diagnostic studies, 524, 524f
Salter-Harris I, 539–540 biomechanics of, 435 etiology of, 522
stress fractures dorsal impingement, 29 magnetic resonance imaging of, 524
ankle joint diastasis caused by, 17–18 hallucal sesamoid fractures, 80 morphologic adaptation, 522–523
magnetic resonance imaging of, 24f hallux rigidus in, 29 radiographs, 524f
Fibular hallux sesamoidectomy, 419–420 range of motion for, 438–439 signs and symptoms of, 523
Fibular ligaments Flatfoot, 346, 536, 590, 591 treatment of, 524
anterior talofibular, 265–267, 266f Flats, 576, 576f Forced plantarflexion sign, 477–478
anatomy of, 286f Flexor digitorum longus, 126 Forefoot
in modified Brostrom technique, anatomy of, 126 pain in, 221–222
276, 278 release of, 401f shoe-related injuries, 581
sprain of, 475 tendinitis of, 126 Foxing, 571
tear of, 35, 476 transfer of Fractures
anterior tibial, 24f for hammertoe repair, 401f, 402f ankle. see Ankle fractures
anterior tibiofibular, 24f for tendinosis, 156 avulsion
anatomy of, 286–287, 286f Flexor hallucis brevis, 16 anterior process calcaneal, 100, 101f
Basset’s ligament, 34, 34f split tendon of, 412 fifth metatarsal base fracture, 114, 616
insertion of, 35 Flexor hallucis longus, 16, 121 os calcis, 35, 35f
Fibular notch, 286, 286f Achilles tendon repair using, 521, 521f calcaneal. see Calcaneal fractures
Fibular tip anatomy of, 36, 38f, 39f, 121–122 cuboid, 303
fracture of, 35f, 35 functions of, 121–122 “chip,” 108
impingement under, 36, 36f os trigonum excision, 39–40 diagnosis of, 303
Fifth metatarsal pseudocyst, 125 imaging of, 303, 305f, 306f
apophyseal avulsion of, 538 release of, 361 incidence of, 303
boxer’s fracture of, 30f rupture of magnetic resonance imaging
bunionette on, 385f complete, 125 of, 303, 306f
Freiberg-like syndrome of, 30 partial, 123. See also Trigger toe mechanism of, 303
proximal end of, 113–114 sheath of, 42f occult, 306f
tendon attachments of, 113f tendinitis of, 122 treatment of, 303
tuberosity of, 114 chronic, 122 fifth metatarsal. see Fifth metatarsal
vascular anatomy of, 114, 114f clinical findings of, 123 fractures
watershed area, 114 conservative treatment of, 40 foot. see Foot fractures and
Fifth metatarsal base fractures, 109, 616 in dancers, 479 dislocations
in adolescents, 115 differential diagnosis, 122, 236 location of, 10
avulsion, 114, 616 etiology of, 122 medial malleolus. see Medial malleolus
in basketball players, 616 illustration of, 479f fractures
classification systems, 109–110, 110–112, magnetic resonance imaging of, 122f navicular. see Navicular fractures
112–113, 113f os trigonum and, 38–39, 371 os peroneus, 139, 139f
delayed union of, 116 osteochondral defect as cause of, 373–374 stress. see Stress fractures
diagnosis, 114, 115 pain caused by, 374 talus. see Talus fractures
etiology of, 114 plantar medial midfoot pain caused Freiberg’s disease/infraction
historical description of, 109 by, 236 in children, 542, 542f
nonunions, 118 posterior impingement syndrome, 37t, 373 in dancers, 472, 473f
patterns of, 616 radiographs, 122 description of, 30, 30f
physical examination, 114 treatment of, 122 orthoses for, 588
in professional athletes, 616 tenolysis of, 38–39, 41 types of, 473
radiographs, 115 transfer of Friction blisters, 256
recurrent, 118 for Achilles tendon rupture, 179–180, 179f Frostbite, 252
stress fractures, 82 for tendinosis, 156, 157f, 158f classification of, 252
treatment of trigger toe. see Trigger toe diagnosis of, 252
cancellous bone graft, 115 tumor masses, 125 prevention of, 253
conservative, 116, 117f Flexor retinaculum release, 374f treatment of, 252–253
inlay bone grafting, 115 Fluconazole, 259, 261–262 Frostnip, 252
medullary curettage, 115 Folate deficiency, 247 Functional progression, 599, 601t
627
...........
Index
G Hallux saltans, 40, 40f Immobilization (Continued)

Gabapentin, 505 Hallux sesamoid, 419 posterior tibialis tendon dysfunction managed
Gait stress fractures, 79, 80 with, 191
evaluation of, 598 Hallux valgus Impingement syndromes
phases of, 598 chevron procedure for, 441, 441f ankle, 33
Gastrocnemius muscle, 210–213 in children, 537 anterior. see Anterior ankle impingement
Gene therapy, 528 conservative management of, 436 anterocentral, 33–34, 35
Girdlestone-Taylor procedure, 31 decision making associated with, 439 flexor hallucis longus tendonitis vs., 37t
Glutaraldehyde solution, 253 distal soft-tissue procedure, 441 lateral, 35–36
Glyceryl trinitrate, 530 in female athletes, 550 os trigonum. see Os trigonum
Golf shoes, 570 orthotic device associated with, posterior. see Posterior ankle impingement
Gout, 243 437–438 posterolateral, 36
Great-toe disorders physical examination, 438 spurs, 33–34
acute, 422 proximal osteotomy for, 441 conservative treatment of, 29
anatomy of, 411 radiographs of, 439f fibular tip, 36, 36f
arthroscopy of, 560 second metatarsophalangeal joint dislocation idiopathic synovitis, 31
in dancers, 472 and, 19f interphalangeal joint, 29
description of, 411 shoe considerations, 537 lesser metatarsophalangeal joints, 30
functional disability caused by, 411 toe spacer for, 4f midfoot
hallux rigidus. see Hallux rigidus treatment of, 537 lateral, 32
metatarsophalangeal joint. types of, 435 medial, 31
see Metatarsophalangeal joint windlass mechanism of, 435–436 os trigonum, 38f
sesamoid disorders. see Sesamoid disorders Hammertoe, 397 word origin of, 29
turf-toe. see Turf-toe characteristics of, 397 Infectious disorders, 257
Grecian foot, 469 surgical treatment of, 398, 399f tinea pedis, 258, 258f
Groin pain of neural origin, 223, 223f Hard corns, 394, 394f viral warts, 257, 258f
Gymnasts, 550 Hawkins classification, of lateral process talar Inflammatory phase, of healing, 527
fractures, 98, 99f Inflatable rescue boats, 517–518, 517f
H Healing, 527 Ingrown toenail. see Onychocryptosis
Haglund’s deformity, 150 Health Insurance Portability and Accountability Inlay bone grafting, 115
cavus foot with, 480, 480f Act, 25 Insertional Achilles tendinitis, 150, 377
clinical findings, 151 Heel counters, 571 classification of, 377
description of, 147 Heel cups, 590f magnetic resonance imaging of, 151f, 162f, 167f
endoscopic resection of, 169, 170f, 561–562 Heel disorders nonsurgical treatment of, 153
history of, 150–151 black heel, 255, 256f orthoses for, 591
illustration of, 148f, 149f piezogenic pedal papules, 256 retrocalcaneal bursitis. see Retrocalcaneal bursitis
insertional Achilles tendinitis and, 150 Heel pad insufficiency, 226 surgical treatment of, 162, 162f, 377
magnetic resonance imaging of, 167f, 562f Heel pain symptoms of, 171b, 377
nonsurgical treatment of, 153 of neural origin, 218–221 Insertional plantar fasciosis, 227
radiographs of, 481f plantar. see Plantar heel pain botulinum toxin injections for, 230
risk factors for, 151 recalcitrant, 218–221 conservative treatment of, 229
surgical treatment of, 164, 166f, 167f Heel spurs, 236, 480 corticosteroid injections for, 229, 229f
symptoms of, 171b Heel strike extracorporeal shock wave therapy for, 229–230
Hallux metatarsophalangeal joint during running, 446, 446f leg length evaluations, 229
anatomy of, 411 during walking, 226 onset of, 228
biomechanics of, 412 Helomas, 253–254 platelet-rich plasma injections for, 230
dislocations of, 423t, 429, 430f, 431t High ankle sprain, 17–18, 34, 619 surgical treatment of, 230, 231, 232f
hyperflexion injuries, 431 Hiking boots, 574, 574f symptoms of, 228
injuries to. see Great-toe disorders Hindfoot training modifications for, 229
range of motion, 412, 422 anatomy of, 293, 294f Instability
turf-toe injury. see Turf-toe inversion of, in posterior tibialis tendon disease or ankle. see Ankle instability
Hallux osteochondral lesions, 520f dysfunction, 186f subtalar, 339
Hallux rigidus, 413 occult fractures of, 293 Insulin-like growth factor, 528
in dancers, 470, 471f plantar fasciitis. see Plantar fasciitis Interdigital nerve entrapment, 10
definition of, 413, 615 tendons attaching to, 297–298, 299f Interdigital neuroma, 392, 393f, 582
in first metatarsophalangeal joint, 29 “Hip pointer,” 222–223 Interdigital plantar nerve entrapment, 221–222,
grade I, 470 History taking, 3 221f, 222f
grade II, 470–471 Hyaluronate, 532 Interdigital spaces
grade III, 471 Hyaluronic acid, 489f dermatophyte infections of, 259
nonoperative treatment of, 413–414, 615 Hyperflexion injuries, of hallux metatarsophalangeal tinea pedis in, 258–259
orthoses for, 413–414, 587 joint, 431 Intermetatarsal angle, 439–440
severity of, 413 Hyperhidrosis, 253 Intermetatarsal diastasis, 107f
surgical treatment of Hyperkeratosis, 253, 254f Interphalangeal joint
arthrodesis, 416 Hyperparathyroidism, 247 great toe, 472
arthroscopy, 417 Hyperuricemia, 243 impingement syndrome of, 29
cheilectomy, 414–415 Interposition arthroplasty, 416, 417f
I Intractable plantar keratoses, 387, 585
implant arthroplasty, 417
interposition arthroplasty, 416–417, 417f Ice hockey, 550, 580 callus formation associated with, 387, 390f
Moberg osteotomy. see Moberg osteotomy Idiopathic synovitis, 31 case studies, 389
options for, 414 Iliac crest graft, 380f definition of, 387, 585–586
phalangeal osteotomy, 415, 415f Immobilization discrete, 391f
resection arthroplasty, 416, 417f fifth metatarsal stress fractures managed illustration of, 390f
symptoms of, 413 with, 82 radiographs of, 388–389
628
...........
Index
Intractable plantar keratoses (Continued) Lateral plantar nerve (Continued) Lisfranc injuries (Continued)
treatment of decompression of, 236, 237f “subtle” injuries, 102, 104
chevron osteotomy, 392f first branch of, entrapment of, 233, 233f, 234f, in surf lifesaving, 518, 519f
conservative, 389, 390f 235f treatment of, 106
metatarsal osteotomy, 391, 391f, 392f Lateral process talar fractures, 97, 315, 315f, 316f, closed, 106, 108f
padding, 389, 390f 317f guidewires, 491f, 529
partial condylectomy, 389, 391f ankle sprain vs., 97 open reduction, 106
proximal closing wedge osteotomy, 392f comminuted, 99 outcomes, 106
surgical, 389, 391 description of, 35 rehabilitation after, 106–108
warts vs., 387–388, 390f etiology of, 97 screw fixation, 106, 109f
Intramedullary nailing, 92–94 Hawkins classification of, 98, 99f Weber clamps, 106, 108f
Intraosseous talar cysts, 378, 379f, 380f radiographic evaluations, 98 variants of, 108
Iselin’s disease, 544 sequelae of, 99 “Locked” cuboid, 32
Isolated tendinosis, 150 sports with high rates of, 97 Loose bodies, 370, 372–373
Isotopic bone scan treatment of, 99, 100f Lower leg disorders
stress fracture imaging using, 64, 65f Lateral proper digital nerve entrapment, 472 chronic exertional compartment syndrome.
technetium-99 methylene diphosphonate, 64 “Leather bottle sign”, 127 see Chronic exertional compartment
Itraconazole, 261–262 Leg compartments, 452f syndrome
Leg-length discrepancy, 63 diagnostic studies, 463t
J Lesser-toe disorders nerve entrapment. see Nerve entrapment
Japanese martial arts bunionettes. see Bunionettes pain locations of, 462t
Judo, 507, 508f claw toe, 397, 402, 403f physical examination findings, 462t
Kendo, 509, 510f hard corns, 394, 394f popliteal artery entrapment syndrome.
Sumo, 508, 509f intractable plantar keratoses. see Intractable see Popliteal artery entrapment syndrome
Jogger’s foot, 10, 233–235 plantar keratoses summary of, 462
Jones fracture. See also Fifth metatarsal mallet toe, 397, 398f, 400, 400f Lower-extremity nerve injuries
base fractures soft corns, 394, 395f compression sites, 217t
diagnosis of, 114 Lidocaine patch, 505 differential diagnosis, 206f
fifth metatarsal, 474, 474f Ligaments knee joint pain, 207–208
historical description of, 109 anterior talofibular, 265–267, 266f lateral ankle joint pain, 208–209
in pediatric patients, 538 anatomy of, 286f lateral femoral cutaneous nerve, 222–223
treatment of, 116, 117f, 539 in modified Brostrom technique, 276, 278 mechanism of, 206–207
Joplin’s neuroma, 472 sprain of, 475 overview of, 205
Judo, 507, 508f tear of, 35, 476 pathophysiology of, 206–207
anterior tibiofibular, 24f peroneal nerve, 210
K anatomy of, 286–287, 286f anatomy, 210, 211f
Kendo, 509, 510f Basset’s ligament, 34, 34f common, 210–213, 212f, 213f
Knee joint insertion of, 35 deep, 215
denervation of, 207–208, 207f Basset’s, 34, 34f superficial, 213–215, 214f, 215f
innervation of, 208f calcaneocuboid, 297 posterior tibial nerve. see Posterior tibial nerve
pain in, 207–208 calcaneofibular, 143–144, 265–267, 266f, saphenous nerve, 223, 224f
Knot of Henry, 40, 121–122 276–277, 295f, 475 sural nerve, 224
Kohler’s disease, 541 calcaneonavicular, 297, 298f Luteal phase deficiency, 56–57
Korean sports collateral, 411 Lyme disease, 244
accessory navicular incidence in, 516 deltoid. see Deltoid ligament Lymph edema, 249
basketball, 516 medial metatarsosesamoid, 411, 412f Lymphatic disease, 249
soccer, 516 posterior inferior tibiofibular, 286–287
ssireum, 514 spring M
Taekwon-do, 515, 515f repair of, 15f Maffulli technique, 154, 155f
strains of, 43 Magnetic resonance imaging
L superficial posterior tibiotalar, 281 Achilles tendinitis, 149f
Laceration talocalcaneal interosseous, 293, 294f Achilles tendon rupture, 176f
peroneal tendons, 140 talofibular, 294–297 cuboid fractures, 303, 306f
tibialis anterior, 128 talonavicular, 294f, 297 deltoid ligament injury, 283
Laces, of shoes, 573, 573f talotibial, 294–297 flexor hallucis longus tendinitis, 122f
Lachman test, 30–31, 31f, 422–423 tibiocalcaneal, 281 global compression injuries of the talus, 335f
Lapidus procedure, 11–12 tibionavicular, 281 insertional Achilles tendinitis, 151f
Laser therapy, 529 tibiospring, 281 medial malleolus, 73, 78
Lateral compartment muscles, 121 tibiotalar, 281 osteochondral lesions of the talus, 321
Lateral exertional compartment syndrome, 9–10 Liposomes, 528 posterior tibialis tendon disease or dysfunction
Lateral femoral cutaneous nerve Lisfranc injuries, 102, 529, 616 evaluations, 187, 190f
anatomy of, 222–223 causes of, 529 sinus tarsi syndrome, 343
compression of, 222–223, 223f cuboid injuries presenting with, 108–109, 111f stress fractures, 66, 67f, 67t, 449
neurolysis of, 223f diastasis, 106, 107f, 108f, 491f, 529 syndesmosis injury, 288, 289f
Lateral gutter, 362 frequency of, 102 tarsal coalition, 10, 11f
Lateral malleolus injury patterns, 103 Maissoneuve’s fracture, 287
deformity of, 284–285 misdiagnosis of, 103 Mallet toe, 397, 398f, 400, 400f
fractures of, 90 Myerson classification, 103, 105f Marfan’s syndrome, 278–279
fibular displacement secondary to, 90 Nunley classification, 103, 104f “Marsupial meniscus,” 297f, 294–297
nonoperative management of, 92 physical examination of, 104 Martial arts
operative management of, 90–91, 92–94 radiographic evaluations, 104, 107f Judo, 507, 508f
Lateral plantar nerve simple lateral, 103 Kendo, 509, 510f
compression of, 219f sports-specific occurrence of, 102 Sumo, 508, 509f
629
...........
Index
Matrix metalloproteases, 527 Metatarsophalangeal joints Modified Bromstrom technique (Continued)

Matrix-induced autologous chondrocyte capsulitis of, 403–404 contraindications, 275–276
implantation, 326 congruent, 437f postoperative care, 278
Maturation stage of healing, 527 dislocation of, 472 results of, 275
Medial calcaneal nerve, 220f dorsiflexion of, 436f sutures used in, 277–278, 277f
Medial clear space, 86, 87f first technique, 276, 276f, 277f, 278f
Medial malleolus fractures anatomy of, 412f tenodesis vs., 275
delayed union of, 89f arthroscopy of, 560, 561, 561f Morton’s feet, 29
imaging of, 88, 88f biomechanics of, 435 Morton’s neuroma, 221–222, 586
magnetic resonance imaging, 73f, 78f dorsal impingement, 29 surgical resection of, 205–206
stress fractures, 76 hallucal sesamoid fractures, 80 Motocross, 501f, 531
anatomy of, 77 hallux rigidus in, 29 Mulder’s sign, 393
description of, 10 range of motion for, 438–439 Muscle mass, 61
illustration of, 16f, 17f, 18f gouty arthritis of, 243–244 Muscle strengthening, 598
imaging of, 73f, 78f, 77 hallux Musculoskeletal system evaluation, 3–4
physical examination, 77 anatomy of, 411
presentation of, 77 biomechanics of, 412 N
treatment, 77 dislocations of, 423t, 429, 430f, 431t Nail disorders, 259
vertical repair, 15–16 hyperflexion injuries, 431 onychocryptosis, 260, 260f
Medial malleolus osteotomy, 331f injuries to. see Great-toe disorders onychomycosis, 261, 261f
Medial metatarsosesamoid ligament, 411, 412f range of motion, 412, 422 subungual hematoma, 259, 259f
Medial plantar nerve decompression, 236, 237f turf-toe injury. see Turf-toe Narcotics, 504–505
Medial shift calcaneal osteotomy, 194, 197f, incongruent, 437f Navicular bone. See also Talonavicular avulsion
198–199 inflammation of, 403–404 injuries
Medial talar dome osteochondritis instability of, 403 accessory, 537
dissecans, 187f axial misalignment associated with, 405f in children, 537
Medial talar osteophyte, 16f capsular reefing and flexor tendon transfer description of, 36, 43
Medial tibial stress syndrome, 445 for, 406, 406f displaced, 304f
athletes with susceptibility to, 446 case study of, 405 flexible flatfoot with, 590
bone scan evaluations, 446–447, 447f conservative treatment of, 31, 31f, 404, 405f imaging of, 187f, 202f, 300f, 303f
case study of, 447–448 in dancers, 472 in Korea, 516
in dancers, 481 diagnosis of, 403 orthoses for, 590, 591f
diagnostic studies, 446 illustration of, 15f radiographs of, 537
history-taking, 446 interdigital neuroma vs., 393 signs and symptoms of, 537
pain associated with, 447 pain associated with, 403 treatment of, 537
physical examination, 446 surgical treatment of, 406, 407f, 408f blood supply to, 297, 298f
posterior, 481 surgical treatments for, 31 dorsal osteophyte on, 10f
sites of, 445–446 toe taping for, 405f tarsal, medial prominence of, 43
treatment of, 447 Lachman test, 30–31, 31f Navicular fractures
conservative, 447 lesser avulsion, 298, 299
operative, 447 dorsal impingement of, 30 dorsal
Medullary curettage, 115 instability of, 30 computed tomography of, 301f
Menarche, age of, 57, 61f plantar plate injury in, 16–17 description of, 298
“Meniscoid lesion,”, 365–366 plantar surface of, 79 nonunion of, 300f, 301f
Menstrual disturbances, 55 second physical examination, 300f
Meralgia paresthesia, 222–223 dislocation of, 19f medial
Mesenchymal stem cells, 528 instability of, 403, 404f description of, 299
Metabolic bone disease, 245 subluxation of, 20f treatment of, 301–302
Metabolic diseases, 245 soft-tissue arthroplasty, 403 in professional athletes, 617
Metatarsal bar, 80 subluxated, 437f, 441 stress
Metatarsalgia synovitis of, 473, 587 computerized tomography of, 67f, 66
definition of, 582 Midfoot description of, 12f, 10, 52
description of, 383 arthritis of, 589 Nerve blocks, 529
differential diagnosis, 384 articulation of, 103 Nerve compression, 205–206
evaluative algorithm for, 383, 384f dorsal osteophyte on, 31 Nerve entrapment, 7–8
signs and symptoms of, 30–31 impingement syndromes of, 31, 32 causes of, 456
Metatarsals injuries to diagnostic studies, 457, 463t
displacement of, 111f classification system for, 103, 104f, 105f history-taking, 456
dropped, 30–31 in dancers, 549 lower extremity, 456
fifth. see Fifth metatarsal lateral, 32 peroneal nerve, 456, 457–458
fourth medial, 31 physical examination, 457
“dropped,” 32f pain in, 75 shoe-related, 582
stress fractures of, 69 sprains of, 616 signs and symptoms of, 456–457
head of, 30 Moberg osteotomy sites of, 456f
dislocation, 429 complications of, 416 treatment of, 457
ligaments that stabilize, 411 indications for, 415 Nerve injuries with ankle sprain
ulcers under, 587 postoperative care, 416 anatomy of, 530
osteotomy of, 391, 391f, 392f procedure for, 415–416 clinical presentation of, 531
second Mobilization, 596 nerve blocks for, 529
base of, 74f, 76f, 75, 473, 474f Moccasin-type tinea pedis, 258–259 nonsurgical treatment of, 531
stress fractures of, 69, 74f, 76f, 75, 473 Model’s foot, 470 oral medications for, 532
stress fracture of, 14f, 45, 69 Modified Bromstrom technique pathoanatomy of, 530
third, 69 complications of, 275 surgical treatment of, 506
630
...........
Index
Nerve injuries with ankle sprain (Continued) Os peroneum, 115 Osteochondral lesions of the talus (Continued)
topical medications for, 532 Os peroneus, 139, 139f stage 1, 554t
treatment of, 531 Os subfibulare, 35 stage 2, 327–328, 331, 554t
Neurolysis Os subtibiale, 43, 475 stage 3, 328–329, 331, 554t
of lateral femoral cutaneous nerve, 223f Os trigonum, 122, 294–297, 296f stage 4, 328–329, 331, 554t
of tibial nerve, 215–217, 216f asymptomatic, 36–38 stage 5, 331–334, 554t
Neuroma attachments, 39 treatment of, 323, 554
calcaneal nerve, 221f definition of, 36, 370 acute injuries, 323
illustration of, 206f flexor hallucis longus tendinitis associated allografts, 326, 334f
interdigital, 392, 393f, 582 with, 38–39, 371 author’s suggested approach, 327
Joplin’s, 472 magnetic resonance imaging of, 313f, 314f autologous chondrocyte implantation,
Morton’s, 221–222, 586 nonsurgical treatment of, 479 325–326, 487, 555
surgical resection of, 205–206 plantarflexion test for, 370–371, 372f chronic injuries, 323
treatment of, 205–206 posterior ankle impingement caused by, 38f, 370, debridement, 554
Neurontin. see Gabapentin 479 drilling, 554
Nitinol step staples, 196–197, 198f prevalence of, 370 excision and curettage, 323, 326f, 327f
Noninsertional Achilles tendinitis, 148 radiographs of, 314f, 371f, 478f matrix-induced autologous chondrocyte
adhesion excision, 154 removal of, 360–361, 362–364, 363f implantation, 326
classification of, 376 signs and symptoms of, 370 microfracture, 554
imaging of, 149f surgical excision of, 39 nonoperative, 323, 554
nonsurgical treatment of, 153, 162b indications for, 38–39 open reduction and internal fixation, 554
surgical treatment of, 154 lateral approach, 39 osteochondral autograft transfer system, 324,
tenotomy, 154 medial approach, 41 331f, 334
Nonsteroidal anti-inflammatory drugs talar compression syndrome associated tunnel technique, 487f
Achilles tendinopathy treated with, 529 with, 36–38 Osteochondral plugs, 555
nerve injuries treated with, 504–505 tests for, 370–371 Osteochondritis dissecans. See also Osteochondral
pain management using, 504–505 Os vesalianum, 115, 538 lesions of the talus dome
peroneal tendinitis treated with, 132 Ossicles in children, 543
posterior ankle impingement syndrome treated ankle impingement caused by, 370 definition of, 318
with, 38 arthroscopic removal of, 370 medial talar dome, 187f
posterior tibialis tendon dysfunction managed computed tomography of, 370–371, 372f Osteochondroses, 541
with, 191 Osteoblasts, 45–46 Freiberg’s disease, 542, 542f
Nonunions Osteochondral allografts, 556 Iselin’s disease, 544
fifth metatarsal base fractures, 118 Osteochondral autograft transfer system, 324, 331f, Kohler’s disease, 541
treatment of, 82 334, 475, 555 nonarticular, 543
Nutrition, 58 Osteochondral lesions of the talus, 317, 527, 553 of the sesamoid, 417, 419
Nylon sole plates, 575 acute, 323, 327 Sever’s disease, 543, 591
Altman’s classification, 520f Osteoclasts, 45–46
O anterolateral located, 369f Osteoid osteoma, 68
Occlusive disease, 247–248 arthroscopy of, 326f, 367 Osteopenia, 245–246
Onychocryptosis, 260, 260f articular cartilage intact, 323–324, 329f, 331 Osteophytes
Onychomycosis, 261, 261f asymptomatic, 330–331 ankle, 33
Open reduction and internal fixation chronic, 323, 330 anterior, 366
lateral malleolar fractures treated with, 92f classification, 321, 323f, 324f, 325f, 327, anteromedial, 366
medial malleolar fracture, 88 367–368 medial talar, 16f
Oral contraceptive pills, 57–58 clinical presentation of, 553 midfoot, 31
Orthoses computed tomography of, 320–321, 373, 373f naviculum, 10f
accessory navicular treated with, 590, 591f “coring” of, 476f removal of, 29
ankle sprain treated with, 593 definition of, 367 sinus tarsi syndrome caused by, 32–33, 33f
ankle-foot description of, 317–318 tibiotalar, 477f
Achilles tendinitis, 7f diagnosis of, 318 Osteoporosis
case study use of, 4–5, 6f dome, 527 causes of, 246–247, 246t
cavovarus foot treated with, 591 in children, 543 description of, 245–246
description of, 585 description of, 318 stress fractures affected by, 55
Freiberg’s infraction treated with, 588 radiographs of, 329f treatment of, 246
hallux rigidus treated with, 587 retrograde drilling and bone graft for, 329f Osteotomy
insertional Achilles tendinitis treated surgical treatment of, 487 bunionette treated with, 386
with, 591 transmalleolar pinning of, 325f Chevron
intermetatarsal neuritis treated with, 586 epidemiology of, 367 bunionette treated with, 387, 388f
intractable plantar keratosis treated with, 585 imaging, 320 hallux valgus treated with, 441, 441f
midfoot arthritis, 589 incidence of, 318, 553 intractable plantar keratoses treated with, 392f
Morton’s neuroma treated with, 586 lateral, 553 Chevron-Akin, 16–17, 19f
plantar fibromatosis, 588 locations of, 553 distal oblique, 387, 389f, 391f
sesamoid disorders treated with, 418 magnetic resonance imaging of, 321, 475f, 558f medial malleolus, 331f
sinus tarsi syndrome treated with, 593 mechanism of, 318, 319f metatarsal, 391, 391f, 392f, 442f
subtalar arthritis treated with, 593 medial, 553 Moberg
tarsal tunnel syndrome treated with, 590 physical examination, 319 complications of, 416
total-contact insert, 585–586, 586f, 587f posterior ankle impingement caused by, 373–374 indications for, 415
turf-toe treated with, 587 posteromedially located, 368f postoperative care, 416
University of California Biomechanics radiographs, 320–321, 321f, 553–554, 557f procedure for, 415–416
Laboratory, 237, 589f staging of phalangeal, 415, 415f
Os calcis, 360 arthroscopic, 367–368 proximal, 441
avulsion fracture of, 35f, 36f, 35 classification system for, 554t proximal closing wedge, 392f
631
...........
Index
Osteotomy (Continued) Peroneal retinaculum Plantar fasciitis (Continued)

proximal crescentic, 440f in peroneal tendon dislocations, 143 midsubstance, 236, 237f
proximal phalanx, 416 repair of, 143 nonoperative treatment of, 528
Weil, 406, 408f, 472 Peroneal subluxation, 36, 37f pain from, 218–221
Overuse injuries, 49–52 Peroneal tendons risk factors, 528
Oxycodone, 504–505 accessory, 134f shoe-related causes of, 582
arthroscopy of, 376f silicone heel cups for, 590f
P dislocation of, 140 surgical treatment of, 529
Pain classification, 142f tarsal tunnel syndrome with, 590
Achilles tendon rupture, 488–489 surgical management of, 142 Plantar fasciosis, 227
ankle. see Ankle pain distal fibula morphology and, 143 botulinum toxin injections for, 230
nonsteroidal anti-inflammatory drugs fusiform swelling of, 136–139 conservative treatment of, 229
for, 504–505 laceration of, 140 corticosteroid injections for, 229f, 229
stress fracture-related, 63, 64, 68 subluxation of extracorporeal shock wave therapy for,
Paratenon, 147–148 chronic, 141 229–230
release of, 154f orthoses for, 593 leg length evaluations, 229
Partial condylectomy, 389, 391f retinaculum repair, 143–144 onset of, 228
Partial weight bearing, 170–171, 172f, 489, surgical management, 142 platelet-rich plasma injections for, 230
607–608 tendinitis of, 375 surgical treatment of, 232f, 230, 231
Patience, 6 tenosynovitis of, 593 symptoms of, 228
Peasant foot, 470 zone A, 135, 136f training modifications for, 229
Pediatric patients zone B, 136–139, 136f Plantar fibromatosis, 588
accessory navicular in, 537 zone C, 136–139, 136f Plantar heel pain
ankle fractures in, 96, 539 zone D, 139–140 case studies of, 238
classification of, 539 zones of, 122f, 135 causes of, 226
osteoarthritis secondary to, 541 Peroneal tubercle description of, 226
physeal, 541 excision of, 138f differential diagnosis, 226
radiographs of, 539 illustration of, 136–139, 136f entrapment of first branch of lateral plantar nerve
Salter-Harris I, 539–540 Peroneus brevis as cause of, 233, 233f, 234f, 235f
Salter-Harris III, 540 anatomy of, 131, 132–133, 297–298, 299f fat pad insufficiency, 226
Salter-Harris IV, 540 attritional tears of, 135 insertional plantar fasciosis. see Insertional plantar
Salter-Harris V, 540–541 avulsion of, 139–140, 142–143 fasciosis
site of, 539 description of, 121 midsubstance plantar fasciitis as cause of, 236,
coalitions, 535 entrapment of, 132 237f
fifth metatarsal avulsion fracture in, 538 function of, 131–132 tarsal tunnel syndrome as cause of, 236
flat feet, 536 tear of, 134 Plantar heel spur, 236
hallux valgus in, 537 tendinitis, 132, 133f, 134, 135 Plantar keratoma, 253–254
Jones fracture in, 538 Peroneus longus Plantar keratoses. see Intractable plantar keratoses
os vesalianum sesamoid in, 538 anatomy of, 131, 299f Plantar nerve
osteochondroses in, 541 calcification of, 135 interdigital, entrapment of, 221–222,
Freiberg’s disease, 542, 542f entrapment of, 134, 135, 136f 221f, 222f
Iselin’s disease, 544 rupture of, 37f, 135 lateral, compression of, 219f
Kohler’s disease, 541 tendinitis, 132, 133f, 134 Plantar plate
nonarticular, 543 Pes cavus description of, 435, 436f
Sever’s disease, 543 in children, 536 rupture of, 16–17, 18f
tarsal coalition in, 535, 536 stress fractures and, 62–63 Plantar warts, 258f
Percutaneous intramedullary screw fixation, 115, 118f Pes planus causes of, 257
Percutaneous longitudinal tenotomy, 532 in children, 536 diagnosis of, 257
Periosteum stress fractures and, 63 treatment of, 257–258
anatomy of, 29 Phalangeal osteotomy, 415, 415f “Plantarflexion sign,” 36
cambium layer of, 29 Physical examination Plantarflexion test, 370–371, 372f
Periostitis, 65 description of, 3–4 Platelet-derived growth factor, 528
Peripheral nerve surgery, 207 fifth metatarsal base fractures, 114 Platelet-rich plasma injections, 230
Peripheral neuropathy, 245, 393 foot fractures and dislocations, 85 Polyglycolic acid, 528
Peritendinitis Lisfranc injuries, 104 Popliteal artery entrapment syndrome, 458
adhesion excision, 154, 154f medial malleolus stress fracture, 77 anatomic, 458
arthroscopy for, 377 stress fracture evaluations, 64 anatomy of, 458, 459f, 461f
in dancers, 479 talar compression syndrome, 36 arteriogram of, 461f
definition of, 148 tibialis anterior tendinitis, 126–127 diagnostic studies for, 460, 463t
refractory, 153 Piezogenic pedal papules, 256 functional, 458
signs and symptoms of, 149f Plantar aponeurosis, 436f history-taking, 458
with tendinosis, 148–150 Plantar fascia pain associated with, 458–460
treatment of, 153 anatomy of, 227–228 physical examination, 460, 462t
Pernio, 248 chronic inflammation of, 233–235 treatment of, 460
Peroneal nerve, 210 endoscopic release of, 232–233 Posterior ankle impingement, 36, 37t, 38, 370
anatomy, 210, 211f microtears in, 228, 228f causes of, 370
common, 210–213, 212f, 213f release of, 230, 231, 232f characteristics of, 370
deep, 215 rupture of, 228, 228f in dancers, 477
entrapment, 456, 457–458 Plantar fasciitis, 489 flexor hallucis longus tendinitis, 373
superficial, 213–215, 214f, 215f botulinum toxin injections for, 230 forced plantarflexion sign, 477–478
anatomy of, 213–215, 532 in dancers, 480 lateral ligament sprain as cause of, 479
compression of, 213–215, 214f, 215f definition of, 590 loose bodies, 372–373
injuries to, 213–215, 214f, 215f fasciotomy for, 490f, 528 os trigonum, 38f, 370, 371f, 479
632
...........
Index
Posterior ankle impingement (Continued) Proteoglycans, 488f Rheumatologic disorders (Continued)

osteochondral defects, 373 Proximal closing wedge osteotomy, 392f Still’s disease, 241
peroneal tendon tendinitis, 375 Proximal crescentic osteotomy, 440f systemic lupus erythematosus, 243
posterior tibial tendinitis, 374 Proximal osteotomy, 441 RICE, 595
posttraumatic calcifications, 371 Proximal phalanx osteotomy, 416 Rocker sole, 587f
Posterior compartment muscles, 121 Pseudocyst, 125 Rugby shoes, 579
Posterior compartment syndrome, 7–8 Pseudogout, 244
Posterior inferior tibiofibular ligament, 286–287 Pseudomeniscus, 479 S
Posterior pseudomeniscus, 39 Psoriatic arthritis, 242 Salter-Harris classification, 96, 97f
Posterior talofibular ligament, 294–297 Publicity, 21 III, 540
Posterior talotibial ligament, 294–297 IV, 540
Posterior tibial artery, 295f Q V, 540–541
Posterior tibial nerve Qi, 513 Sand toe, 423t
anatomy of, 41, 42f Saphenous nerve compression, 223, 224f
branches of, 218–221 R Sarcoidosis, 245
injuries to, 215 Race-walking shoes, 575 Sclerosing injections, 529
compression of, 217–218, 219f Racquet sport shoes, 577 Screw fixation
heel pain syndrome of neural origin, 218–221 Radiofrequency coblation, 529 fifth metatarsal base fractures treated with, 115,
tarsal tunnel syndrome. see Tarsal tunnel Radiographs 118f
syndrome fifth metatarsal base fractures, 115 Lisfranc injuries repaired with, 106, 109f
proximal, 215–217 flexor hallucis longus tendinitis, 122 percutaneous intramedullary, 115, 118f
Posterior tibial rim, 371–372 foot fractures and dislocations, 85 Second metatarsals
Posterior tibial tendon Iselin’s disease, 544–545 base of, 74f, 76f, 75, 473, 474f
anatomy of, 183–185, 184f, 297–298, 299f Kohler’s disease, 541 stress fractures of, 69, 74f, 76f, 75, 473
dysfunction of, 592, 592f lateral process talar fractures, 98 Second metatarsophalangeal joint
functions of, 183–185, 374 Lisfranc injuries, 104, 107f dislocation of, 19f
graft of, 285f osteochondral lesions of the talus, 320–321, 321f instability of, 403, 404f
tendinitis of, 374, 550 posterior tibialis tendon disease or dysfunction subluxation of, 20f
Posterior tibial tendoscopy, 374–375 evaluations, 186 Selective estrogen receptor modulators, 246
Posterior tibialis muscle, 183, 185 soft corns, 395f Sesamoid bursitis, 471
Posterior tibialis tendon disease or dysfunction stress fracture imaging, 64 Sesamoid disorders, 417
abduction deformity secondary to, 189f subtalar dislocation, 344 avascular necrosis, 417
case studies, 200, 201f subtalar instability, 340, 341f bipartite, 426
description of, 183 trigger toe, 123 bone grafts for, 419
diagnosis of, 185 Range of motion, 596 diagnosis of, 418
differential diagnosis, 189t Raynaud’s phenomenon, 248 instability, 471–472
hindfoot inversion associated with, 186f Rehabilitation magnetic resonance imaging of, 418
history-taking, 185 Achilles tendon repair, 530, 601 nonoperative treatment of, 418
magnetic resonance imaging evaluations, 187, ankle fractures, 607 osteochondrosis, 417, 419
190f ankle joint instability, 267–268, 269t plantar prominence, 417–418
physical examination, 185 cardiovascular activities, 599, 599t radiographs of, 418
radiographic evaluations, 186 cryotherapy, 595 surgical treatment of, 418
stage I functional progression, 599, 601t tibial, 438f
characteristics of, 190–191, 190t gait evaluation, 598 Sesamoid fracture, 417, 418–419
surgical treatment of, 191, 192t lateral ankle reconstruction, 604 Sesamoidectomy, 413
stage II mobilization, 596 biomechanical sequelae of, 420–421
characteristics of, 190–191, 190t muscle strengthening, 598 fibular hallux, 419–420
medial shift calcaneal osteotomy for, 194, 197f phases of, 601 incisions for, 420f
surgical treatment of, 191, 192t, 193f proprioception, 598, 606f indications for, 419
stage III protected weight-bearing, 597 postoperative care, 420
characteristics of, 190–191, 190t range of motion, 596 results of, 420
medial shift calcaneal osteotomy for, 198–199 stress fractures, 68 tibial hallux, 419
percutaneous Achilles tendon lengthening Reiter’s syndrome, 242 Sesamoiditis, 417, 471, 582, 588
for, 199 Relevé position, 469–470, 470f Sever’s disease, 543, 591
surgical treatment of, 192t, 198 Remodeling phase, of healing, 527 Shank, 571
staging of, 190, 190t Resection Shenton’s line, 87f
tenderness evaluations, 185, 185f calcaneonavicular coalitions, 348 Shin splints, 445–446, 481. See also Medial tibial
“too many toes” sign, 185, 185f Haglund’s deformity, 169, 170f stress syndrome
treatment of, 191 Morton’s neuroma, 205–206 Shock wave therapy, 530. See also Extracorporeal
conservative, 191 talocalcaneal coalitions, 348, 350f, 351f shock wave therapy
immobilization, 191 Resection arthroplasty, 416, 417f Shoes
Posterior tibiotalar ligament, 281 Resisted eversion, 605f aerobic dancing, 581
Posteroanterior dancer’s view, 75 Rest, 6–7 air soles, 572
Postmenopausal women, 55–56 Retrocalcaneal bursa, 147 alpine skiing, 580, 581f
Posttraumatic calcifications, 371 Retrocalcaneal bursitis, 151, 167f, 171b, 175f, 377, arch supports, 571
Pre-Achilles bursa, 147 582 Balmoral pattern, 569
Pressure-specified sensory device, 210–213, 212f, Retrocalcaneal space, 561–562 baseball, 579
219f Rheumatoid arthritis, 243, 587–588 basketball, 577, 577f
Primary lymph edema, 249 Rheumatologic disorders, 241 bicycling, 581, 581f
Progesterone, 56–57 ankylosing spondylitis, 241 board-lasting, 569f, 569
Proliferative phase, of healing, 527 enteropathic arthritis, 242 boating, 570
Proprioception, 598, 606f psoriatic arthritis, 242 bottoming, 569
Protected weight-bearing, 597, 602 Reiter’s syndrome, 242 cleated, 570
633
...........
Index
Shoes (Continued) “Snowboarder’s ankle,” 97 Stress fractures (Continued)

combination-lasting, 569f, 569 “Snowboarder’s fracture,” 35 grading of, 66, 67, 67t
construction of, 567 Soccer hallucal sesamoids, 79, 81
cross-country skiing, 580 Achilles tendon injuries and disorders in history of, 45
curved lasts, 572 lesions, 488–489 history-taking, 448
cuts, 569 rupture, 521 incidence of, 46
energy return in, 572 beach, 520 leg-length discrepancy and, 63
exercise walking, 575, 575f description of, 519 location of, 10
field sport, 578 hallux osteochondral lesions in, 519, 520f magnetic resonance imaging of, 449
figure skating, 580 popularity of, 519 medial malleolus. see Medial malleolus
fit of, 572 Soccer shoes, 578, 578f in men, 49
flats, 576, 576f Sock linings, 571 metatarsal, 14f, 45
football, 578, 579f Soft corns, 394, 395f midtibial, 18, 25f
foxing, 571 Soft-tissue distractor, 368–369, 369f in military
golf, 570 Soleus muscle, 147 epidemiology of, 46, 49
hallux valgus, 537 accessory, 479 gender differences, 49
heel counters, 571 Soleus syndrome, 43 training factors, 62
hiking boots, 574, 574f Speed skating, 580 multifactorial nature of, 448
ice hockey, 580 Sports program muscle mass and, 61
jumping events, 576 rehabilitation, 21 navicular, 10, 12f
laces, 573, 573f return to, 18 oral contraceptive pills and, 57–58
lace-to-shoe pattern, 569 Spring ligament osteoid osteoma vs., 68
lasting techniques, 569 repair of, 15f pain associated with
lasts used in, 567, 568f, 572 strains of, 43 description of, 63, 64
materials used in, 567 Spurs treatment of, 68
ethyl vinyl acetate, 568 ankle impingement caused by, 33–34 pes planus and, 63
Hytrel, 569 talus neck, 34 physical examination, 449, 462t
microcellular rubber, 568 tibial lip, 33 racial differences, 49, 51t
nylon, 569 Square-box lacing, 573f, 574 recurrence of, 46
polyurethane, 569 Squeeze test, for syndesmosis injury, 282, 282f, 287 relative frequency of, 49, 51t
sole, 568 Ssireum, 514 return to activity after, 450
upper, 567 Stem cells, 528 risk factors for, 52, 448
midsoles, 571 Stenosing tenosynovitis anthropometry, 61
outer sole of, 570, 570f causes of, 135 biomechanics, 62, 69
pronation control devices, 572 chronic, 136–139 bone geometry, 58
“pumps,”, 572 description of, 131 calcium metabolism alterations, 58
race-walking, 575 overuse and, 135 diet, 58
racquet sports, 577 surgical treatment of, 135 low bone density, 58, 59t
replaceable plug systems, 572 Stieda’s process, 294–297 menstrual disturbances, 55
rugby, 579 Still’s disease, 241 modification of, 68
running, 570, 575 Stress fractures, 448 nutritional status, 58
shank, 571 acute fractures vs., 73 osteoporosis, 55
skating, 579 in age groups, 49 soft tissue composition, 61
slip-lasting, 569f, 569 age of menarche and, 57, 61f training, 62
soccer, 578, 578f anatomic distribution of, 52, 53t second metatarsal base, 473
sock linings, 571 in athletes sites of, 52, 55t
speed skating, 580 epidemiology of, 46, 47t summary of, 70
spikes, 575 sites, 52, 55t tarsal navicular, 73
straight lasts, 572 training factors, 62 tibial. see Tibial fractures, stress
tennis, 577, 577f bone scan of, 449, 449f treatment of, 68, 449
throwing events, 576 bony tenderness associated with, 64 activity resumption after, 68, 69f
toe box, 571 case studies, 451–452 additional, 69
toe injuries caused by, 581 cause of, 448, 551 conservative, 449
tongues, 571 in dancers, 481 fitness maintenance, 68, 69f
unit soles, 571 diagnosis of, 63 intramedullary nailing, 450–451
upper designs, 569 computerized tomography, 66 operative, 450
U-throat, 569 history-taking, 63 rest, 68
Vamp pattern, 569 imaging, 64 types of, 45
volleyball, 578 isotopic bone scan, 64, 65f in women, 49, 551
wedges, 571 magnetic resonance imaging, 66, 67f, 67t Subluxation
winter sports, 579 physical examination, 64 cuboid, 33f, 32, 32, 32t
Show lacing, 574 predisposing factors, 63 peroneal tendon
Simian foot, 470 radiographs, 64, 481–482, 482f chronic, 141
Single-lace cross, 573f, 574 diagnostic studies, 449, 449f, 463t retinaculum repair, 143, 143–144
Single-leg balance, 608f dietary behaviors and, 58 surgical management, 142
Sinus tarsi differential diagnosis, 68 Subtalar arthritis, 593
anatomy of, 339 epidemiology of, 46 Subtalar arthrodesis, 199
denervation of, 208–209, 210f etiology of, 45 Subtalar coalition, 40
innervation of, 208–209, 209f evolving, 65 Subtalar dysfunction, 32–33
local anesthetic block of, 209f in female athletes, 49, 551 Subtalar joint
pain in, 208–209 fifth metatarsal, 82f, 83f, 81 anatomy of, 294f, 339, 340f
Sinus tarsi syndrome, 32–33, 33f, 342, 593 foot arch and, 62–63 arthritis of, 122
Skating shoes, 579 gender differences, 49 arthroscopy of, 378, 378f
634
...........
Index
Subtalar joint (Continued) Talo-first metatarsal angle, 186, 188f Tarsal coalition (Continued)
articulating surfaces of, 339 Talonavicular avulsion injuries surgical, 347
dislocation of, 344 alternative shoe lacing for, 299–301, 302f Tarsal navicular stress fracture, 73
instability of, 339 corticosteroids for, 299–301 Tarsal tunnel, 218f
medial, 344 diagnosis of, 298 Tarsal tunnel syndrome
Subungual hematoma, 259, 259f, 581 imaging of, 299, 301f, 302f anterior, 10
Sumo, 508, 509f incidence of, 298 causes of, 236
Sunburn, 255 mechanism of, 298 clinical features of, 236
Superficial peroneal nerve rehabilitation of, 302 high, 7–8
anatomy of, 213–215, 532 return to sports after, 302 history of, 217–218
compression of, 213–215, 214f, 215f treatment of, 299 medial heel wedge for, 236
injuries to, 213–215, 214f, 215f Talonavicular ligaments, 294f, 297 orthoses for, 590
Superficial posterior tibiotalar ligament, 281 Talotibial ligament, 294–297 with plantar fasciitis, 590
Sural nerve, 224 Talus. See also Talonavicular avulsion injuries plantar heel pain caused by, 236
fascial constriction, 9 anatomy of, 33, 34f, 293, 294f studies of, 217–218
tenodesis risks for, 275 beak of, 308–311 symptoms of, 217–218
Surf lifesaving, 517, 517f blood supply to, 293, 295f treatment of, 217–218
Syndesmosis global compression injuries of Tarsometatarsal instability, 11–12, 15f
anatomy of, 286, 286f description of, 308 Tarsometatarsal joint
ankle drilling of, 336 anatomy of, 102
pathology of, 34–35 imaging of, 307f dislocations of. see Lisfranc injuries
repair of, 95f magnetic resonance imaging of, 335f osseous anatomy of, 102–103
space measurements, 87, 87f mechanism of, 318 vascular structures of, 103
sprain of, 34 treatment, 335, 335f Technetium-99 methylene diphosphonate isotopic
anterior, 286f lateral process of, 293, 295f bone scan, 64
injury to osteochondral lesions of. see Osteochondral Tegretol. see Carbamazepine
chronic, 285, 290 lesions of the talus Tendinitis. See also Peritendinitis
clinical tests for, 287 osteochondritis dissecans of, 475 Achilles. see Achilles tendinitis
computed tomography of, 288 posterior flexor digitorum longus, 126
deltoid injuries and, 282, 282f, 283–284 anatomy of, 36, 38f, 296f, 360f flexor hallucis longus, 122
description of, 24f lateral tubercle of, 36–38 chronic, 122
diagnosis of, 282, 282f, 283f, 287 medial tubercle of, 36–38 clinical findings of, 123
fixation of, 619 posterior process of, 293, 296f conservative treatment of, 40
magnetic resonance imaging of, 288, 289f stress fractures of, 5 differential diagnosis, 122
mechanism of, 287 vascular anatomy of, 293, 295f etiology of, 122
in professional athletes, 619 Talus fractures magnetic resonance imaging of, 122f
radiographic diagnosis of, 287, 288f, 501f lateral process, 97, 315, 315f, 316f, 317f os trigonum and, 38–39
squeeze test for, 282, 282f, 287 ankle sprain vs., 97 posterior impingement syndrome vs., 37t
subacute, 290 comminuted, 99 radiographs, 122
surgical treatment of, 289–290 description of, 35 treatment of, 122
treatment of, 288 etiology of, 97 peroneus brevis, 132, 135
ligaments that stabilize, 286–287, 286f Hawkins classification of, 98, 99f peroneus longus, 132, 133f, 134
medial clear space, 287–288 radiographic evaluations, 98 tibialis anterior, 126
posterior, 286–287, 286f sequelae of, 99 Tendinopathy. see Achilles tendinopathy
Synovial hernias, 35 sports with high rates of, 97 Tendinosis
Synovitis, 367 treatment of, 99, 100f peritendinitis with, 148–150
classification of, 367 posterior process, 308 surgical treatment of, 155
idiopathic, 31 diagnosis of, 311 debridement of tendon, 155
metatarsophalangeal joint, 587 imaging of, 312, 313f tendon transfer, 156
signs and symptoms of, 367 incidence of, 308 turndown procedure, 160, 160f, 161–162
Systemic lupus erythematosus, 243 internal fixation of, 312–314 V-Y advancement, 156, 159f
mechanism of action, 308, 311f Tendon transfers
T occult, 313f abductor hallucis, 426, 428f
Taekwon-do, 515, 515f physical examination for, 312 Achilles tendinitis treated with, 156, 157f, 158f
Talar compression syndrome, 36 “pinch test,” 312f, 312, 312f Achilles tendon ruptures treated with, 179–180,
Talar cysts, 378, 379f, 380f plantarflexion as cause of, 311 179f, 531
Talar dome, 24f, 322f “posterior compression test,” 312f hammertoe treated with, 400, 400f, 401f
anatomy of, 368, 368f, 373 rehabilitation of, 314 lateral ankle ligament injuries reconstructed using,
osteochondral defects in, 368, 527 return to sports after, 314 279–280
in children, 543 treatment of, 312 posterior tibialis tendon dysfunction repaired
description of, 318 Tarsal coalition, 10, 345 with, 192–194
radiographs of, 329f ankle sprain and, 345–346 Tendoscopy
retrograde drilling and bone graft for, 329f in children, 535, 536 peroneal, 375–376, 375f
surgical treatment of, 487 clinical presentation of, 10, 345 posterior tibial, 374–375
transmalleolar pinning of, 325f definition of, 345 Tennis shoes, 577, 577f
Talar neck etiology of, 345 Tenodesis
fracture of, 100f incidence of, 345 modified Bromstrom technique
spurs on, 34 magnetic resonance imaging of, 11f, 10, 347f, vs., 275
Talar tilt, 86–87 346 sural nerve risks, 275
Talocalcaneal coalitions, 348, 350f, 351f physical examination findings, 536 Tenosynovitis, 593
Talocalcaneal interosseous ligament, 293, 294f radiographic evaluation of, 347f, 346, 536 Tenotomy, 154
Talocrural angle, 86 treatment of Terbinafine, 261–262
Talofibular ligament, 294–297 nonoperative, 346, 536 Thermal capsular modification, 559
635
...........
Index
Thompson test, 175f, 529 Training Turndown procedure, 160, 160f, 161–162
Thrombophlebitis, 248 documentation of, 3 Tylomas, 253–254
Tibial fractures stress fractures and, 62
Salter-Harris I, 540 Training surfaces, 62 U
stress fractures Transforming growth factor b2, 528 Ulcerative colitis, 242
bone density and, 58 Treatments. See also specific disorder, treatment of United Arab Emirates
in dancers, 481, 482f review of, 12–13 bike riding, 531–532
description of, 18, 25f, 448 timing of, 10, 25 description of, 531
foot arch and, 62–63 Trichophyton rubrum, 258, 261 falcon hunting, 498f, 500f, 531
grading of, 66, 67t Trigger toe, 123 horses, 531
longitudinal, 451f case study of, 124–125 motocross sports, 501f, 531
midanterior cortex, 449, 450, 450f clinical appearance of, 123f, 124f niche sports in, 531
pain associated with, 448 clinical findings of, 124 University of California Biomechanics Laboratory
site of, 448 differential diagnosis, 123 orthosis, 237, 589f
Tibial lip spurs, 33 etiology of, 123 Upper-extremity nerve injuries, 217t
Tibial physis, 99f radiographs of, 123
Tibial plafond, 356 surgical treatment of, 123–124, 124f V
Tibial sesamoid subluxation, 438f Triplane fracture, 96, 99f Varicose veins, 249
Tibialis anterior, 126 Triple arthrodesis, 199, 347–348 Variostabil boot, 494f, 531
anatomy of, 103, 126 Turf-toe, 421 Vascular disorders, 247
avulsion of, 127f, 129f causative factors, 422 arterial disease, 247
functions of, 126 classification of, 422, 423t, 424t venous disease, 248
laceration of, 126, 128 grade 1, 425 Vascular endothelial growth factor, 528
rupture of, 128 grade 2, 425–426 Venous claudication, 249
extensor retinaculum grade definition of, 614–615 Venous disease, 248
repair, 131 history of, 421 Venous thrombus, 248–249
mechanism of, 128 incidence of, 421 Viral warts, 257, 258f
spontaneous, 128 in Judo, 508, 508f Vitamin B12 deficiency, 247
surgical treatment, 128, 129f magnetic resonance imaging of, 425f Volleyball shoes, 578
tendinitis of, 126 mechanism of injury, 421 V-Y advancement, 156
Tibiocalcaneal ligament, 281 in professional athletes, 614 chronic Achilles tendon rupture repaired
Tibiofibular shuck test, 287 radiographs of, 423–424, 424–425, using, 178–179
Tibionavicular ligament, 281 426, 427f patient positioning for, 160
Tibiospring ligament, 281 sequelae of, 428–429 procedure for, 159f
Tibiotalar ligament, 281 shoe-surface interface and, 422
Tibiotalar osteophytes, 477f surgical treatment of W
Tillaux fracture abductor hallucis tendon transfer, 426, 428f Warts, 257, 258f, 387–388, 390f
adolescent variants of, 96, 99f literature regarding, 426 Wedged heel shock absorbers, 5f
description of, 35 open synovectomy and cheilectomy, 428 Weight-bearing, 597, 602, 607–608
Timing, 10, 25 postoperative management, 427–428 Weil osteotomy, 406, 408f, 472
Tinea pedis, 258, 258f treatment of, 16, 615 Windlass mechanism, 228, 228f, 236
Tinea unguium. see Onychomycosis conservative, 428 Wolfe’s law, 600–601
Toe box, 571 nonoperative, 425 Women. See also Female athletes
Toe curls, 602f orthoses, 587 postmenopausal, 55–56
Toe spacer, 4f principles, 425 stress fractures in, 49
Toeoff splint, 6f short-leg cast, 425, 425f
“Too many toes” sign, 185, 185f surgical. see Turf-toe, surgical treatment of X
Total-contact insert, 586f, 587f, 590f, 591f, valgus injuries, 421, 421f Xerosis, 255
585–586 varus injuries, 421–422
Traditional Chinese medicine, 513 Turf-toe inserts, 413–414 Z
Zostrix. see Capsaicin
636
...........

Baxters The Foot and Ankle in Sport, 2nd Edition by David A. Porter MD PHD, Lew C. Schon MD

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1600 John F. Kennedy Blvd.

BAXTER’S THE FOOT AND ANKLE IN SPORT ISBN: 978-0-323-02358-0

Library of Congress Cataloging-in-Publication Data

Acquisitions Editor: Emily Christie

Abrao M. Altman, MD Michael W. Bowman, MD, FACS

Michael J. Coughlin, MD Kevin B. Gebke, MD

Christopher W. Hodgkins, MD Rover Krips, MD, PhD

Peter B. Maurus, MD Glenn B. Pfeffer, MD

Melanie Sanders, MD Roman A. Sibel, MD

Zhu Yuan, MM Chaim Zinman, MD

Assessment and treatment of the elite athlete:

#3. CONSERVATIVE CARE MAY NOT

Many stress fractures of the talus and other bones seen

an Achilles stretching protocol, orthotic devices, and

The risk of an unusual complication following plantar

#8. LOCATION, LOCATION, LOCATION

A stress fracture of the navicular or medial malleolus

#14. MINIMIZE SURGERY AND MAXIMIZE

A pole vaulter missed the pit, landing on his foot in

#15. IDENTIFY INJURIES THAT ARE AT HIGH

subluxation of the second metatarsophalangeal joint

the medial malleolus or the navicular to repair the torn

#17. WHEN IS IT OKAY TO ‘‘SPARE THE

Midtibial chronic stress fractures with the ‘‘dreaded

navicular attachment, the ankle is allowed to rotate out

Figure 1-17 (A and B) This ultra-marathon runner had been

elliptical trainer. At 6 weeks postoperatively, an Airsport

by issues, trainers, coaches, agents, team physicians,

Impingement syndromes of the foot and ankle

Introduction 29 Specific anatomic areas 29

INTRODUCTION 2. Make the skin incisions carefully to avoid inci-

The lesser metatarsophalangeal joints

inflammatory medication; and, if necessary, giving the

Medial midfoot impingements

Lateral midfoot impingements

from bleeding into the joint in conjunction with an

Anterior (medial, central, lateral)

back to a small anterior arthrotomy on these com-

Posterolateral ankle pain

Figure 2-16 Medial anatomy of the flexor hallucis longus.

the condition often is overdiagnosed by paramedical

Extensor hallucis longus

Extensor digitorum longus

Figure 2-17 Superior view of relationship of flexor hallucis longus to os trigonum.

sign10). One should not dissect medial to the FHL ten-

Posteromedial ankle pain

Stress fractures: their causes and

Introduction 45 Differential diagnosis 68

INTRODUCTION crack fractures.4,6-10 Virtually all of these terms have been

Brunet et al., R Recreational/ 375-F Self-admin. NS Hx NS 13.2-F

Cameron et al., R State/ 263-F Self-admin. 67 Hx NS 26.6-F

Bennell et al., P Track & field 46-F Monitoring NA 1 yr BS þ CT 21.7-F

Warren et al., R Professional 40-F Self-admin. 100 Hx x-ray or 45.0

Frusztajer R Ballet 45-F Interview 100 1 yr NS 22.0

Kadel et al., R Professional 54-F Self-admin. 100 Hx x-ray or 31.5

Pecina et al., R Elite ice 42 Self-admin. 100 Hx NS 21.0

Dixon & Fricker, R Elite 74-F Review of NA 10 yr x-ray or 27.0-F*

Stress fractures: their causes and principles of treatment

Sport population Runners* Runners Variety{ Variety{ Runners

Age, females 33 NS 18–22 18-22 18-22

Age, males 39 NS 8-22 18-22 18-22

Female number 375 263 321 1200 NS

Male number 1130 287 593 1800 NS