WO Textbook. Sports Medicine Section. Chapter 77 Foot and Ankle

Editor: Eugene Sherry, MD MPH FRACS

Chapter  77                                                                                                


Foot and Ankle


Priority is a painfree and stable foot and ankle. ROM is a very secondary issue.






Stress fractures


Ankle sprains – lateral and medial, sub-talar


Syndesmotic (high ankle sprain) injuries


Sinus tarsi syndrome


Peroneal tendon injuries


Tibialis posterior tendon injuries


Tibialis anterior injury


Tendon achilles injury


Gastrocnemius injury


Fractures of the foot and ankle


Nerve entrapment syndromes


Acute and chronic compartment syndromes


Plantar fasciitis


OS trigonum


Turf toe


Tibio-talar spurs and impingement




Freiberg’s infraction


Hallux valgus


Hallux rigidus




Short leg-syndrome


The problem (painful) ankle


Note: Important surgical innovations include ability to anchor tendons to bone with bony anchors and the use of strong suture material such as FiberWire.



Foot and Ankle




The evolution of the human foot has allowed us to stand and move upright so freeing our hands to explore and control our environment. The foot changed from an arboreal grasping organ to an agent for motion – the big toe fell into line with the little toes (which shortened);  a stiffer subtalar joint;  a medial arch and bigger heel occurred.


You only have to see a young Fijian boy rapidly climb a tree to see how the foot still maintains its grasping function.


Our current foot shape dates 40 to 100,000 years.  We now stand perched on a ledge (the sustentaculum tali of the calcaneus) and topple frequently on the sporting field to sprain the lateral ligament conylex (Fig. 1).


Even worse where there is a high medial arch( eg pes cavus).

Design problems remain.


The foot and ankle is commonly injured in sport;  such injuries account for 25% of all sporting injuries (Fig. 2).




The tibio-talar articulation allows 25° dorsiflexion, 35° plantar flexion and 5° of rotation. The instant centre of motion lies on a line along the tips of the malleoli and postero-laterally on the talar dome. Up to 5 times body weight is transmitted across this joint.


Stability is gained by the talar mortise and ligament support. The subtalar joint functions like a hinge and allows eversion and inversion. The mid-foot permits abduction and adduction. The forefoot flexion and extension.  Pronation of the foot (5°) is coupled dorsiflexion, eversion and abduction, supination (up to 20° is coupled plantar flexion, inversion and adduction.  The foot transmits 3 times body-weight with running and has arches (medial, lateral, transverse). The second metatarsal is the keystone of the mid-foot in gait (the first metatarsal in the stance phase).


Gait (walking – one foot is always on the ground; running – both feet off the ground at one point) has two phases (stance and swing) (Fig. 3).


The usual gait cycle has gained credence through repetition but is well over due for a re examination and re –thinking.


Video analysis allows documentation and correction of abnormal running postures (Fig. 4).


Injuries in the region occur for the following reasons:  The athletes physical and personality traits;  training techniques, playing environment and equipment. The weekly running distance has been found to be the critical factor for injury among runners (>64 km per week).



Certain athletes are prone to injury and certain body types confer a biomechanical advantage (Fig. 5).


Stress fractures


Bone pain with a normal x-ray in an athlete suggests a stress fracture. There are two types:  fatigue type (abnormally increased load on a normal bone) or the insufficiency type (Normal loads on deficient bone (such as osteoporosis). They typically occur 3 to 5 weeks into an intensive training programme. Exclude steroid use (decreases trabecular bone). Muscles are able to adopt faster than bone and after 2 weeks of new intensive training the fracture  occurs. A small cortical crack occurs and spreads by subcortical infarction. Periosteal and endosteal new bone (callus) is seen at 2 to 3 weeks.  X-rays may show the dreaded “black line” of impending complete fracture (Fig. 6). Bone scans are positive early and diagnostic.  Common sites are described (Fig. 7).


Thee is localised bone pain and tenderness relieved by rest. The athlete limps. Examine the sports shoes for excessive wear.


Treatment should be comprehensive (Fig. 8).


Special considerations (Fig. 7).


Stress fracture of the neck of the femur need crutches for 3 to 4 weeks. If pain persists at 1 to 2 months (groin pain with rotation f the thigh) seriously consider surgical fixation of the fracture.


Navicular fractures are slow to be diagnosed and to heal. Immobilise for 6 to 8 weeks and surgically fix (and bone graft) if symptomatic at 1 to 2 months.


Ankle sprains

Lateral Ligament


Little wonder ankle sprains are common in sport. We stand perched upon the sustentaculum tali with the calcaneus bowed back under the ankle joint and all balanced (in tension) by the lateral ligament complex (Fig. 1). Inversion (with supination and plantar/dorsi flexion) causes injury of the lateral ligament complex;  usually (2/3 of cases) the anterior talo-fibular ligament (ATFL – the weakest), sometimes the extra-articular calcaneo-fibular ligament, CFL (seldom the PTFL – the strongest). Those at risk are large athletes, those with pes cavus (high medial arches) and a history of similar injury. High-top shoes and good splints may protect the ankle.



There is immediate pain and swelling with resultant anterior and inversion instability. The severity of the injured can be graded (Fig. 9). Careful examination in the post-acute phase can delineate the ligament components injured (Figs. 10, 11, 12).


Figure 9                                              Grading of Lateral

Ligament Ankle Injury


I      ATFL sprain (2/3 cases)

II     ATFL, CFL sprains (1/4 cases)

III    ATFL, CFL, PTFL tears

Or simply use



Incomplete:  end-point to anterior draw


Complete:  No end-point to anterior draw

In the acute phase treat with RICE, NSAIDS, ankle splint (S-Ankle), early rehabilitation/peroneal eversion exercises, water jogging, proprioceptive wobble board exercises) (Fig.13). 

Elite athletes may elect for early surgical repair of complete ruptures (controversial).


X-rays are necessary to exclude fractures with good talar dome views to exclude osteochondral fractures (ignore bony avulsion of the ligaments).  Do not miss a high fibular fracture with syndesmotic injuries (Maisonneuve #) (Fig. 14).  Stress x-rays are unreliable( and painful) but possibly helpful in the chronic phase where the patient does not give a clear history of instability (“going over” on the ankle).


Lateral ligamentous laxity


Chronic unsuccessful treatment of the acute lateral ligament injury may result in chronic lateral ligament laxity from “stretched-out” ligaments.


There is chronic lateral pain (over anterior border of the lateral malleolus sinus tarsi) exacerbated by repeated inversion injuries on irregular terrain.  Too often athletes are left to persist with months of unsuccessful physiotherapy instead of a quick effective lateral ligament reconstruction. (I favour the Bröstrom capsulorrhaphy with reinforcement from the inferior extensor retinaculum; exceopt in heavy patient where  a peroneal tenodesis is needed. ((Fig. 15).


Medial ligament injuries


These are rare (usually with (lat.lig) sprain) or fractures) and need to be differentiated from lesions of the nearby tibialis posterior or FHL tendons and syndesmotic injury.


Careful examination (for localised tenderness) with ultras=sound examination is useful (see tib post section).  It is a strong ligament.


X-rays (to exclude #) with bone scan and CT maybe necessary to exclude osteochondral fractures where there is severe, localised pain about the talar dome (Fig. 16). Weight-bearing x-rays may be useful (Fig. 14a).  Chondral damage (sometimes seen after lateral ligament injuries with medial impingement) may require arthroscopic attention (Fig 17).


Subtalar Instability


Difficult to diagnose as it is really a component of a lateral ligament injury (the CFL torn) from inversion.


Special stress – x-rays (Broden – 45° in rotation and 20° caudal tilt) or I>I> may help but are painful.. Treat as above with CFL reconstruction (as part of Brostrom operation) from chronic cases.


Spring ligament sprain


The mid-foot is prone to twisting injuries with pain localised to the medial arch from sprain of the calcaneo-navicular ligament (spring).


Cuboid Syndrome


Pain and tenderness over the cuboid in the region of the peroneal (exerting) tendons. S-ankle the foot.


Syndesmotic ankle injuries (high ankle sprain)

(distal tibiofibular diastasis)


Previously unrecognized but a probable cause of ongoing painful “ankle sprain”. 

Probably from an external rotation injury in the professional athlete. There is marked swelling both sides of the ankle with tenderness over the interosseous membrane. Suspect where an ankle sprain takes a long time to settle down;  perform the squeeze test or abduction/external rotation tests (Fig. 18) and check a mortise-view.  X-ray (>1 mm reduction in the medial clear space or <1 mm overlap) (Fig. 19). Late x-rays show calcification of the ligaments. Treat in NWB art for four weeks or later with diastasis screw fixation and ligament repair where refractory.


Sinus Tarsi Syndrome


The tunnel beneath the talar neck and upper calcaneus can be a source of pain from overactivity and inversion injury. It may be related to the strained ligament of the tunnel (talo-calcaneal ligament). Distinguish from lateral ligament strain. Treat with NSAID, activities (for hyperpronation)  and possible steroid injection and seldom surgical excision of contents.



Peroneal tendon injuries


The peroneal tendons work hard. They evert the foot (which wants to drift into equinus) and maintain the transverse/longitudinal arches. They are poorly anchored with a weak holding retinaculum.  Forced dorsiflexion of the ankle in skiing or football can produce tenosynovitis tendinitis tear;  partial or complete (peroneus brevis) or dislocation of these tendons. There is marked tenderness with reproducible subluxation. X-rays may show a rim fracture (Fig. 20). Strapping may help, otherwise decompression, repair, tenodesis to (peroneus longus) or early stabilisation in the groove (because of high recurrence rate). Graduated return to sport over 4-6 weeks avoiding “cutting” procedures or sprinting for 6 weeks.


Endoscopic tenosynovectomy is useful  for  refractory tenosynovial swelling and pain.


Tibialis Posterior Tendon Injury




These occur in middle-aged women who are unfit as a result of chronic degeneration.  The pathology is inflammation (tenosynovitis) or rupture (partial or complete). They experience pain and tenderness along the tibialis posterior tendon with difficulty lifting the heel off the ground in the single heel raise test (Fig. 21). An ultrasound may secure the diagnosis. The arch is flattened and foot pronated. They require NSAIDs, (a medial arch support (for tenosynovitis and partial ruptures), and debridement/tenosynovectomy for refractory cases. Reconstruct complete tears (use the FDL).


Tibialis Anterior Injury


Spontaneous rupture may occur but is unusual. There is localised tenderness, weakened dorsi flexion. Surgical repair is important (either direct repair or tendon/extensor transfer).


Tendo Achilles Injury(TA)


Injuries of this region are common and difficult to treat.  Overtraining will produce an inflammation around the TA peri-tendinitis), in the tendon (tendinitis) or by the tendon (retro calcaneal bursitis and retro-achilles bursitis).  The “painful arc sign” may help to make the distinction (Fig. 22).  Certain athletes are at risk (excessive training, poor hindfoot shoe support, on cambered surfaces).


A violent contraction of the gastrocnemius-soleus unit may rupture (partially or completely) the TA.  Patients report having been hit or kicked in the calf during the push-off phase of running or racquet sports.  Partial tears are difficult to diagnose;  ultrasound imaging is helpful.


Complete tears will invariably have pain, swelling, and a palpable gap (prior to swelling). Do not be fooled by the patient being able to plantar flex (from intact long flexors). Simmond’s test is easy to perform and diagnostic (Fig. 23).


Treatment of TA problems is outlined (Fig. 24).




A tear of the medial head of the gastrocnemius is common in middle-aged tennis players (tennis leg.




Cross-train (swim) during surgical recovery with slow re-introduction to pre-injury sports over 3 months.


Fractures of the foot and Ankle


Fractures of the ankle are common and require precise treatment to avoid later osteoarthritis (1 mm displacement causes 40% decrease in tibiotalar articulation).  They are variously classified (Fig. 25) and are usually from a fall with supination (or pronation) of the forefoot and eversion (or inversion) of the hindfoot.  Well fitted shoes with ankle support will eliminate such injuries.  The immediate pain, swelling and deformity is obvious, never hesitate to x-ray. 


A displaced fracture almost always requires open reduction and internal fixation (Fig. 26), a non-displaced <1 mm), careful follow-up (6 weeks in cast)  with x-ray review to detect early displacement.


A markedly displaced ankle fracture should be reduced in casualty to avoid skin problems (blisters/nervosas) (Fig. 27). Exclude a Maisonneuve fracture by careful examination (with x-ray) of upper fibular (Fig. 14). Post-operatively support the ankle in an S-Ankle splint for 6 weeks (NWB) and return to sports at 3 to 5 months.


Residual ankle pain after bony union may be residual traumatic synovitis (Fergel lesions) which require NSAIDs) or arthroscopic excision.


Fractures of the foot


These tend to be under-appreciated. Most can be managed in a below knee fracture walker.


Displaced an intraarticular fractures often require reduction and fixation.


Fractures of the talar neck may result in avascular necrons of the body and so need accurate reduction (Fig. 28).


Fractures of the calcaneus can be devastating (widened painful heel, nerve entrapment, tendinitis and later subtalar OA (Fig. 29). It is best to reduce to restore Bohler’s angle (usually requires surgery with bone grafting and early movement).


Navicular fractures can be avulsions, hairline, comminuted or stress type. It is best to reduce and fix the fracture (K-wires) (Fig. 0). Non-union, which is painful, may result.


Mid-foot (tarametatarsal) fractures (Lisframe) can be subtle and easily missed (Fig. 31).


Careful WB x-rays are important to sort out mid-foot pain following injury.


Mid-foot pain following injury. Reduction and fixation (with K-wires) is useful.


Avulsion of peroneus brevis (base of 5th MT) and proximal diaphyseal fracture of the 5th MT (Jones fracture) may take a long time to heal and eventually require surgical fixation (Fig. 32).



Most other fractures of the MT shafts and phalanges require reduction and seldom surgical fixation.


Dislocated MTP or PIP joints need prompt reduction otherwise they become irreducible and a source of severe pain (Fig. 33).


Nerve entrapments


These are not uncommon about the foot and ankle, difficult to diagnose and treat. Many are related to poor (eg ski boot) sports shoe fit or hard surfaces. Several have been described (Fig. 34).


All entrapments are diagnosed by localised tenderness over entrapped nerve at level of entrapment. Positive Tinel’s test, neuralgic pain (at rest or at night) nerve conduction studies are usually unhelpful. Treat with orthotics, NSAIDs, stretching;  massage. Surgically release (and excise neuroma) at level of anatomically located tenderness.


Compartment Syndrome


Increased pressure within a confirmed muscle compartment may lead to ischaemia, necrosis, contracture and a useless limb.  Its early recognition and prompt treatment is essential.  Causes are trauma (with fracture), post-operative and crush injuries (Fig. 35).


The symptoms and signs of an acute compartment are well described (Fig. 36). It usually involves the forearm, the lower leg and foot (when compartment pressures exceed 40 mmHg).  Measuring intra=compartmental pressures is fraught with problems of accuracy and should not override clinical judgement. Treatment is to externally split POP/bandages to skin and if necessary, internally release the compressed compartment

(fasciotomy Fig. 37, within 4 hours, by multiple incisions over the tight muscle.).


Chronic compartment syndrome (exertional) may be subtle in presentation and results from prolonged training (runners, court sports athletes). The muscles are overworked, swell and a vicious cycle is triggered. The extensor and flexor compartments are usually involved with crescendo pain and tenderness relieved by rest. There may only be paraesthesia with exercise. The differential diagnosis is important (Fig. 38).


Treatment is activity modification, massage, exclude footwear or surface problem, NSAIDs, orthotics (medial wedge for posterior compartment), cross-training (cycling) and fasciotomy (sometimes, 80% successful).


Here it is useful to carefully measure intra-compartment pressures before/during/after exercise;  (resting pressure >15 mmHg or delay in fall after exercise of >20 mmHg/over 3 minutes). Then consider a careful fasciotomy of the compartment involved with mini skin incisions and wound closure.


Plantar Fasciitis


Common and crippling subcalcaneal (usually medial) heel pain.  Related to hyperpronation and pes cavus (Fig. 39). There is localised tenderness;  a positive windlass effect (dorsiflexing the big toe exacerbates the pain). X-rays may show a heel spur (ignore it).


Exclude: stress fractures, nerve entrapment (medial branch of the lat plantar nerve) and Reiter’s Syndrome.


Treat with NSAID, stretching and a soft silicone heel cup. Seldom is surgery (release) helpful.


Os trigonum


This ossicle behind the posterior talus (medial tubercle of the posterior process of the talus) may be the cause of pain with plantar flexion in ballet dancers. It can be asymptomatic, fused, fractured, absent or big. X-rays confirm its presence and examination its problem. Treat with injection (not steroids) or excise. Do not confuse with FHL tendinitis (Fig. 40).


Turf Toe


This is caused by a forceful dorsiflexion of the 1st MTP joint in American football on a hard surface (artificial turf and flexible shoes – Fig. 41). X-rays may show a disruption of the plantar volar plate complex.  Exclude stress fracture, sesamoiditis, entrapment of FHL. Treat with RICE, taping, custom shoes and sometimes surgical repair of the disruption.


Tibiotalar Spurs


Osteophytic spurs may form on the adjoining surfaces of the lower anterior tibia and talar neck. There is impingement pain with dorsiflexion. Arthroscopic excision is useful (Fig.).




Forefoot pain beneath the metatarsal heads (with callosities) is vague in nature and related to impact sports. There may be claw toes and/or pes cavus. 

Exclude a neuroma, stress fracture, Freiberg ’s infraction. Treat with stretching, NSAIDs, transverse arch supports (HAPADs) and rarely a closing wedge osteotomy (where a single (usually the second) metatarsal is involved).


Freiberg ’s infraction


This is an osteonecrosis of the second metatarsal head typically in teenage females and with excruciating pain.

X-rays may show increased density, or collapse of the metatarsal head (Fig. 43).  Symptomatic treatment or debridement synovectomy or limited resection of the distal 2nd MT head.


Hallux Valgus


Common in the community fro improper shoe size seen in dancers and catchers from acute injuries (dislocation of 1st MTP joint) or chronic repetitive injury. Ballet dancers and sprinters are poor, surgical candidates (post-operative stiffness is debilitating here) and all other avenues must be exhausted (delay surgery as long as possible) (Fig. 44).


Hallux Rigidus


A stiff and painful 1st MTP joint from micro-trauma, osteonecrosis or OA. Seen in push-off sports where long, narrow pronated feet (long 1st MT).  Require stiff sole, HAPAD or cheilectomy (excision of painful dorsal osteophytes).




Localised pain usually below the 1st MTP joint which may be part of a FHL tendinitis/tethering;  seen in dancers. Exclude fracture, stress fracture, OA, dislocation, nerve entrapment and do not confuse with bipartite sesamoid. X-rays (sesamoid views).  Treat with metatarsal support, NSAID and rarely shave or excise.


Short Leg Syndrome


A short leg (>2 cm) is prone to injury (stress fractures, MCL knee sprain, patellar subluxation, plantar fasciitis and hyperpronation).  The longer leg is prone to iliotibial tendinitis. It may be real shortening or apparent (from tilt of tract with tendon contracture – needs stretching). Use partial heel build-up (and/mid-sole build-up).


Approach to the persistently painful ankle (Fig. 45).APAD or cheilectomy (excision of painful dorsal osteophytes).




Localised pain usually below the 1st MTP joint which may be part of a FHL tendinitis/tetHAPAD or cheilectomy (excision of painful dorsal osteophytes).







Fig. 24

Treatment – TA Injuries






    Rest, NSAIDs, heel raise, ultrasound, massage

    (stretching).  Rarely surgery with debridement.      


Retro-calcaneal bursitis




    As above but consider surgery.  Earlier with excision of

    associated retro-calcaneal exostosis.

    Rarely surgery for retro-achilles bursitis.


Haglund’s bump

Postero-superior prominence

of calcaneus


    Shoe modification, NSAID gel,

    Heel raise or excise.



Partial tendon rupture




    May require surgical excision of scar and

    Grandulation tissue.


Complete tendon rupture




·        Almost invariably surgically repair

(Open technique).

·        Later repair is difficult and may require

Fascial or tendon augmentation.



Warning:   Avoid steroids. Exclude Reiter’s, Infection, Gout, Tumour




                                                         Fig. 25


Classification of Ankle Fractures


























  (Position of Fibular #)

  A:  at/below joint line

   B:  at joint line

   C:  above joint line




  (Direction of damaging force)

·        supination/adduction

·        supination/ext. rotation

·        pronation/abduction

·        pronation/external rotation






·        lateral malleolus

·        medial malleolus

·        posterior malleolus

or combination



Fig. 34


Nerve entrapments








Tarsal tunnel





Posterior tibial nerve trapped behind medial malleolus under flexor retinaculum. Pain medial foot and sole.



Ant tarsal tunnel




Deep peroneal nerve trapped under inferior ext. retinaculum.  Pain 1st web space.



Jogger’s foot




Medial plantar nerve compressed at Knot of Henry. Pain over med toes.



Sural nerve



Medial border foot pain.



Comm peroneal n.



Behind the fibula neck from trauma.



Superf peroneal n.




Ant-lateral entrapment (12 cm from tip lat mal;  distinguish from compartment syndrome).



Saphenous Nerve




Injures in thigh (Hunter’s canal) or med knee (post-surgical).



Morton’s neuroma


Typically pain between 3rd/4th metatarsal heads from traumatic entrapment causing neuroma (runners) of interdigital nerve.  Compression of metatarsal heads reproduces symptoms and patient aware of mobile peeble.




                                                Fig. 38

Differential Diagnosis of

Chronic Compartment Syndrome




Stress # bone



    See bone scan (localised

    hot area)




(shin splints)

(pain over postero-medial distal tibia)




Maybe compartment problem of tib post or periostitis of soleus muscle. Do bone scan, consider fasciotomy, orthotics for hyper-pronation, massage.



Popliteal artery entrapment



Calf claudication with  reduced pulses (when knee extended, foot dorsiflexed).





Fig. 36


Diagnosis Compartment











 # bone present




Pain with sport

and slow to resolve









with swelling






   SEVERE  Pain     

with active

    (usually not

    possible) and

    passive movement















Are late signs where diagnosis

Has already been missed











For the Painful (persistent)

Ankle consider the following …






 synovitis ankle





 Avulsion tip fibula




 “Asymptomatic” ossicle



 unrecognised fracture

 ant. Process calcaneus





 Peroneal or tib

 Post/tendon problem

 (synovitis, partial tendon,



Surgery; consider  endoscopic tenosynoectomy





 Lat process # talus




 Sinus tarsi syndrome





 Subluxation cuboid




 “High ankle sprain

 (+ fracture Tilbux)

see text


 Impingement inferior band

 Of tibiotalar ligament




 Nerve entrapment

see text

 Tarsal coalition (children)







 RA or occult tumour




* NSAIDs – local application  * Cross-train

* Water jog  * S-Ankle splint

*Gentle PT (low frequency pulsed

ultrasound, TENS, WAX)





Fig. 2



Sports Specific

Foot and Ankle Injuries



Specific Foot and

      Ankle Injury





Peroneal tendon subluxation

Nerve entrapment

Plantar fasciitis




Lateral ligament sprains

Stress fractures

Shin splints



Os trigonum

FHL impingement


Stress fracture

Hallux valgus




Turf toe

Ankle and mid-foot fractures







TA injury

Stress fractures













Ankle sprains

Stress fractures


Lateral ligament sprains

Plantar fasciitis

Jones fracture


Sever’s disease



Fig. 5



Athletes prone to injury



Postural defects


Muscle weakness/inbalance


Lack of flexibility


Mal alignment problems

(pronated feet, LLD with pelvic tilt)


Athletes with

Biomechanical advantage


Pigeon toed

Good for sprinters, tennis and squash


Sway back





Duck feet



Inverted feet



Double jointed

Increased lumbar, lordosis with anterior pelvic tilt – good sprinters, jumpers and gymnasts.



Everted feet – good for breastroke



Good for backstroke and butterfly



Ligamentous laxity


·        Exception ...

Peter Snell (NZ) had body build of sprinter

Rather than middle-distance athlete -

(gold medal 800, 1500 m Rome , Tokyo ,

1960, 1964).



Fig. 7


Common sites


Stress fractures foot



Tibia (mid and distal)






Metatarsals (esp 2nd MT)


Sesamoids (1st MTP)



Less common


Med. Malleolus








Fig. 8


Treatment –

Stress fractures










Cross-training (swim/cycle to keep fit)


Long term


Correct mal-alignment – or use orthotics

(hyper pronation, ext. tibial torsion)


Better absorptive impact sports shoes


Hormone treatment female athletes


Alter training schedules


Exclude infection/tumour



(at 6 months – bone graft/drill

“dreaded black-line”)


Re-introduce activity at 6 to 12 months




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