Foot and Ankle Injuries in

Athletics
Brett Haywood M.D.
PGY IV
 Outline
• Incidence
• Anatomy
• Ankle Sprains
• Achilles Tendon Injury
• Posterior Tibialis Injury
• Peroneal Tendon Injury
• Flexor Hallucis Longus Tendon Injury
• OCD lesions of talus
• Impingement syndromes
• Plantar Fasciitis
• Lis Franc Injuries
• MTP Injuries
 Outline
• Fx’s that mimic sprains
• Stress fx’s
• Ankle fx’s
 Incidence
• Garrick and Requa studied 16,745 sports
injuries to Center for Sports Medicine in San
Francisco between ’79 and ’87:

– Ankle sprain most common sports injury. Over half of

the injuries at the ankle were sprains
– Foot and ankle injuries accounted for 25.2% of all
injuries.

Clinics in Sports Medicine, ‘98

 Incidence
• Ankle sprains represent 7-10% of ER
cases
• Most occur in patients under 35 yrs of age
Delee. Orthopaedic Sports Medicine, ‘94
 Anatomy
• The ankle is a
modified hinge joint
consisting of three
bones (tibia, fibula,
talus)
• Primary motions are
PF, DF, and small
amounts of inversion,
eversion, and rotation
 Anatomy
• The ankle is stabilized
medially by the
Deltoid ligament

• Stabilized laterally by
the anterior talofibular
ligament,
calcaneofibular
ligament, and the
posterior talofibular
ligament
 Anatomy
• Distal articulation of
the tibia and fibula or
syndesmosis is
stabilized by:
– Anterior inferior
tibiofibular ligament
– Posterior inferior
tibiofibular ligament
– Inferior transverse
ligament
– Interosseous ligament
 Anatomy
• The subtalar joint is made up of three articular
facets (ant, medial, and post).
• Subtalar joint permits inversion and eversion.
• Talonavicular joint is part of more mobile medial
column.
• The calcaneocuboid joint forms more rigid
lateral column
• The talonavicular and calcaneocuboid joint work
with subtalar joint to allow inversion, eversion,
and rotation of hindfoot
Anatomy
 Lateral Ankle Sprains
• Lateral ligamentous
complex consists of
the ant talofibular
ligament (ATFL),
calcaneofibular
ligament (CFL), and
the post talofibular
ligament (PTFL)
 Lateral Ankle Spains
• The ATFL is the primary restraint to inversion in plantar
flexion. It also resists anterolateral translation of the talus
in the mortise. The weakest of the lateral ligaments.

• The CFL is the primary restraint to inversion when the

ankle is in the neutral or dorsiflexed position.

• The PTFL is the strongest of the collateral ligaments and

bridges the posterolateral tubercle of the talus to the
posterior aspect of the lateral malleolus
 Lateral Ankle Spains
• Mechanism :
– the ankle is in a position of instability in PF and
inversion as a consequence of the narrow diameter of
the talus posteriorly.
– The anterolateral joint capsule fails first; followed by
rupture of the ATFL; finally the CFL fails as the arc of
injury progresses. PTFL is usually not disrupted.
– ATFL is involved in 85% of lateral sprains; CFL is
injured concomitantly in 20% - 40%.
 Lateral Ankle Sprains
• Grading:
– Grade 1 injuries involve stretching of the
ATFL, mild tenderness, no evidence of
mechanical stability, ability to bear wt.
– Grade 2 injuries involve complete tear of the
ATFL and usually a partial tear of the CFL
and moderate laxity with ant drawer test
– Grade 3 injuries involve complete rupture of
both the ATFL and CFL. Ant drawer and talar
tilt test positive
 Lateral Ankle Sprains
• Treatment -
– Nonsurgical: tx of choice for all grades;
Grades 1 & 2 may be tx’ed with brief
immobilization, followed by PT
– Grade 3 tx’ed with extended immobilization,
followed by PT
– Few indications for acute surgical repair
 Sequelae of Lateral Ankle Sprains

• Up to 50% of patients will continue to

experience sx’s of pain, pain and
instability, or instability alone
• Initial tx is PT
• If sx’s persist, patient may benefit from
arthroscopy and lateral ligamentous repair
 Syndesmotic Injuries
• Also referred to as “high
ankle sprains”

• Mechanism – external
rotation and pronation

• Estimated to be involve in
1% to 10% of all ankle
sprains.

OKU: Sports Medicine 3

 Sydesmotic Injuries
• Treatment –
– Immobilization in NWB cast or splint for 2-3
weeks. Usually take 8-12 weeks to resolve.
Functional therapy that uses brace to prevent
external rotation.

– Surgical tx for patients who are refractory to

conservative tx, displaying diastasis on plain
or stress xrays, and those presenting longer
than 3 months after injury.
Achilles Tendon
 Achilles Tendon Injury
• Anatomy – the two heads of the gastrocnemius from the
medial and lateral femoral condyles blend with the
soleus to form the Achilles tendon. Inserts into the
middle 1/3 of the post tuberosity of the calcaneus.

• Load may reach tensile forces of 1,400 to 2,600N during

walking and 3,100N to 5,330N during running

• Decreased in the number of blood vessels in the

midportion of the tendon. This is about 3-4cm prox to
insertion and corresponds to weakest area of the tendon.
 Achilles Tendon Injury
• Tendonitis/ tendonosis common.
– Tx with stretching, shoe modifications, heel lifts,
activity modifications.
– If longstanding or fails conservative tx may require
tenolysis or debridement
• Rupture
– Typically occurs in 30-40 y.o. “weekend warrior”
– Pt’s c/o sudden pain and snapping sensation
– Absent PF, positive Thompson test
– Tx surgically
– Initially splinted in PF, then walking boot with heel lifts
Posterior Tibialis Tendon
Posterior Tibial Tendon Injuries
• Associated with pes planus or flat foot
deformity
• Usually seen in sports that require rapid
change in direction, including basketball,
soccer, football.
• The tendon is subject to great mechanical
stress after heel strike because hindfoot
moves from position of loaded eversion to
inversion.
 Posterior Tibial Tendon Injuries
• The portion of the tendon from the medial
malleolus to the navicular tuberosity is relatively
avascular.
• Usually starts as tenosynovitis which can lead to
tendonosis and partial tears.
• Valgus hindfoot late finding
• Tenosynovitis tx’ed with conservative therapy
• Acute ruptures and refractory tendinosis
surgically tx’ed
Peroneal Tendons
 Peroneal Tendon Injuries
• Can occur from direct trauma, ankle sprains,
calcaneal fx’s.

• Tendonitis
– Caused by repetitive rubbing against fibula
– Tendons are relatively avascular from the tip of the
fibula to their insertion
– Partial longitudinal tears are common, may require
repair
– Tx with NSAIDs, lateral heel wedge, rest, casting,
physical therapy
 Peroneal Tendon Injuries
• Subluxation
– Caused by rupture of the
superior peroneal
retinaculum secondary to
forceful plantarflexion and
inversion from a dorsiflexed
position.
– Tx with NWB and casting
has 50% success rate
– Acute reconstruction of
retinaculum is preferred tx
with young athletes
 Peroneal Tendon Injuries
• Traumatic rupture may occur in
association with ankle fx’s and severe
sprains.
– Complete tears can lead to recurrent sprains
and ankle instability
– Tx with primary repair
Flexor Hallicus Longus
Flexor Hallucis Longus Tendon
• Stenosing tenosynovitis
– Common in ballet dancers
– Most common location is medial calcaneus within the
fibro-osseous tunnel
– Resisted active PF of great toe typically reproduces
pain
– Conservative tx first, may need surgical release of
fibro-osseous tunnel
• Complete rupture uncommon – direct repair
indicated
Osteochondral Lesions of the Talus
• Lesions in talar dome that can range from
a small defect in the articular cartliage to
subchondral cysts or osteochondral
defects.
• May result from ankle sprains or
degenerative changes caused be
repetitive microtrauma
• Present with usually poorly defined pain
• Tx based on age of pt, size, and location
Osteochondral Defects of Talus
 Anterolateral Impingement
• Characterized by anterolateral ankle pain
with limited and painful dorsiflexion.

• Soft tissue –
– Entrapment of thickened synovial
– Often occurs after sprain or fx
– Tx with PT, NSAIDS, steroid injections,
arthroscopic debridement
 Anterolateral Impingement
• Bony –
– Kissing osteophytes on anterior tibia and talar
neck.
– Often seen with cavus foot
– Xray appearance may lag behind clinical
picture
– Tx with open debridement
 Posterior Impingement
• Usually the result of the FHL becoming irritated
by the os trigonum (ununited lateral tubercle of
the post talus). May be associated with fx of the
os trigonum.
• Commonly seen in activities with repetitive
jumping and pivoting.
• Pain between medial malleolus and Achilles
• Conservative tx, local steriod injection, bracing,
excision of os trigonum, debridement of FHL
 Plantar Fasciitis
• Presents with acute tenderness at the medial
tubercle of the calcaneus over the course of the
plantar fascia.
• Common in runners, accounts for about 10% of
running injuries.
• Microtrauma caused by over pull of the plantar
fascia and by tight heel cords.
• Associated with flatfoot deformities because
there is an increased stress on the origin of the
plantar fascia
 Plantar Fasciitis
• Tx – NSAIDs, activity
modification,
orthotics, Achilles
tendon stretching,
steroid injection, night
splinting.
• Operative tx rarely
indicated - release
 Lisfranc Injuries
• Anatomy –
– the tarsometatarsal joints
are made up of
articulations between the
bases of the medial three
metatarsals and three
cuneiforms.
– The main stabilizer is the
2nd metatarsal base which
lies between the medial
and lateral cuneiforms
– Lisfranc ligament is an
oblique ligament that
extends from the base of
the 2nd metatarsal to the
medial cuneiform.
 Lisfranc Injuries
• Caused by
hyperextension of the
tarsometatarsal joint
• Pt’s present with pain,
swelling, ecchymosis
on dorsum of foot
• Tx is ORIF, NWB for
6 weeks
 MTP Injuries
• Turf toe
– Caused by hyperextension of the hallux MTP
with an applied axial load to the heel of the
foot in a fixed equinus position
– Tx with RICE, NSAIDs, boot or cast for 1
week duration, orthotics (rigid forefoot
component)
• Sand toe
– Caused by hyperflexion of hallux MTP
– Tx with RICE
 MTP Injuries
• Hallux rigidus –
– Sequelae of either turf
toe or sand toe
– Leads to loss of MTP
extension
– Osteophytes seen on
lateral xray of foot
– Tx with resection of
osteophytes
 Fractures that Mimic Sprains
• Lateral process of talus
fx’s “Snowboarder’s fx”
– Tx in cast after reduction
– Excise small fragments

• Fx of anterior process of
calcaneus
– Tenderness distal to the
ATFL
– Tx in cast
 Stress Fractures
• Calcaneal Stress fx’s
– Seen in runners
– Heel pain, pain with squeeze test
– If recognized early, tx with heel cushion and
restricting inciting activity
– Later in disease course, tx with walking cast or boot
for 6 weeks

• 2nd, 3rd, 4th Metatarsal Stress fx’s

– Rarely displace
– Tx supportively
 Stress Fractures
• Navicular Stress Fracture –
– Seen in sports that require sudden acceleration and
deceleration (basketball, football)
– Long 2nd MT or short 1st MT possible predisposing
factors
– Occur in central portion
– Nondisplaced fx’s and no evidence of sclerosis,
immobilize and NWB for 6-8 weeks
– Displaced fx’s, fx’s with sclerosis, and those that
failed conservative therapy, tx with curettage, drilling,
internal fixation
 Jones Fracture
• Stress fx within the 5th metatarsal proximal
metaphyseal-diaphyseal junction.
• This is watershed area
• Noncompetitive athletes tx with short leg
cast for 6-8 weeks, followed by protective
weightbearing for another 6 weeks
• Surgical tx for those who have failed
conservative therapy and for competitive
athletes
 Ankle Fractures
• Are among the most common fractures,
with over 250, 000 per year
• External rotation is the most common
mechanism
• If only the lateral malleolus is minimally
displaced and there are no signs of other
ligamentous injury, tx with cast and NWB.
• Otherwise ORIF and NWB