WO Textbook. Sports Medicine Section. Chapter 77 Foot and Ankle
Editor: Eugene Sherry, MD MPH FRACS
Foot and Ankle
Priority is a painfree and stable foot and ankle. ROM is a very secondary issue.
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
Fractures of the foot and ankle
Nerve entrapment syndromes
Acute and chronic compartment syndromes
Tibio-talar spurs and impingement
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).
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.
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
Or simply use
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).
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).
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
IMPORTANT TO PICK UP AND MANAGE ACTIVELY.
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).
SURGERY WHEN THE TA IS TORN.
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).
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.
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.
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.
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).
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.
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.
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).
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).