Managing Foot and Ankle Injuries in the Athlete

By: Terry Stanton

Symposium addresses Lisfranc and stress fractures, other sports medicine challenges

During Wednesday’s Symposium K, “Foot and Ankle Surgery for the Sports Medicine Physician,” five prominent surgeons took on some of the most common problems seen on the field, offering advice on management of Lisfranc fractures, stress fractures, lateral ankle instability and peroneal tendon pathology, cartilage and osteochondral defect (OCD) lesions of the talus, and Achilles tendon rupture.

Providing an overview of Lisfranc fractures was Robert B. Anderson, MD, of OrthoCarolina in Charlotte, N.C. He first noted that “an elite athlete” crosses all age groups and sports, and even a third-string player on a college team is elite. Lisfranc injuries, he explained, typically occur with cleated shoes on turf and with higher-level contact sports. They can represent a serious injury—often season-ending—to the midfoot, with discomfort persisting at an average of 1.3 years post–injury fixation.

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Robert B. Anderson, MD: Lisfranc injuries can be season-ending.

As many as 20 percent of Lisfranc injuries may go untreated, potentially leading to loss of normal foot posture and, eventually, degenerative joint disease necessitating fusion. In the classic description, injury mechanism is typically indirect and involves an axial load to the heel with the foot planted.

In research done in conjunction with the National Football League, said Dr. Anderson, team orthopaedist for the Carolina Panthers, investigators found it difficult to reproduce the injury using cadaver testing and computer modeling. They did find that to create the injury, the forefoot and, especially the second ray, has to be engaged in turf, and (hyper-) dorsiflexion must occur through metarsophalangeal (MP) joints.

Certain shoe types may be implicated in Lisfranc injury, and in actual play and practice, “frank dislocations and fractures are rare and not always the result of an axial load,” he said, and a twisting component is commonly involved in the elite athlete, particularly in American football. Twisting-type injuries, which can be subtle, may manifest with painful weight bearing, difficult heel rise, plantar ecchymosis, and swelling and point tenderness, often in the medial column.

Strapping of the arch with tape that results in improved ability with single-limb heel rise may reflect subtle instability. Contralateral radiographic views may reveal asymmetry, and standing anteroposterior views “can be a good stress test,” Dr. Anderson said. A single-limb view should be taken when pain allows. Serial examinations are also recommended, as frank diastasis may not always appear, and progressive diastasis highlights instability.

MRI imaging is a static test, he said, and “is not going to tell you whether there are unstable patterns based on weight bearing. But what it can tell you is whether the Lisfranc ligament is intact. If it is not intact, that means you may have some clinical instability pattern.”

Lisfranc injuries “don’t have to be frank dislocations to do poorly,” Dr. Anderson said.

On the question of who can play and who needs surgery, he said that “even stable ligament injuries take time to heal”—an average of 4 to 6 weeks. Initial immobilization is helpful. Documented instability and significant diastasis require surgery, he said. The treatment goal for an unstable and displaced midfoot joint is to obtain and maintain anatomic reduction. Injured joints are stabilized to eliminate the risk for progression and to assist with rehabilitation, and a “normal” posture of the foot is maintained to improve the prognosis.

Frank dislocations and bony injuries, while somewhat uncommon, “need to be fixed and realigned surgically,” said Dr. Anderson. Length should be restored and maintained, and if significant comminution and/or chondral injury is seen, primary fusion is indicated. The medial column Lisfranc injury, also known as the proximal variant type of injury (Fig. 1) is an absolute indicator for surgery, as it tends to progress over time and lead to arthritis.

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Fig. 1 Radiograph revealing medial column Lisfranc injury, aka the proximal variant type.
Courtesy of Robert B. Anderson, MD

In terms of surgical technique, “I do highly recommend that you do an open approach and not the percutaneous approach,” Dr. Anderson said. The articular surface should be assessed, the intercuneiform joint should be manipulated to check for instability, and anatomic reduction and stability can be confirmed.

For fixation, solid/cortical screws are preferred and bridge plates may be used to avoid iatrogenic chondral injury.

Postoperatively, patients typically are placed in a splint for 2 weeks, then in a boot, and are non–weight bearing for 3 or 4 weeks. “These ligament injuries take a long time to heal,” Dr. Anderson said, and hardware removal is delayed until at least 12 weeks. “Your athlete needs to understand that breakage of the hardware may occur prior to the time of removal, but fortunately breakage is rarely an issue as long as the screw is not intra-articular.”

Typical rehabilitation involves running at 3 months and antigravity work in the pool. Lateral floor exercise is done wearing a special shoe with full-length protection to protect the midrange area. Under the supervision of the training staff, a gradual return to contact is accomplished as function and symptoms allow.

Stress fracture: A challenging injury
Martin J. O’Malley, MD,
of the Hospital for Special Surgery, provided an overview of management of stress fractures. Although his presentation focused on injury in the professional athlete, he noted, “Most of the stress fractures we see are not in professional athletes. We mostly see them in high school athletes—commonly in gymnastics, cross-country, and track, because these are kind of full-year sports. We treat the majority [of these patients] nonsurgically. They are young, they will heal, and taking your sophomore season off is not that big of a deal. It’s a bigger deal in the professional athlete.”

The most common symptoms of stress fractures are pain in the leg, ankle, or foot. About 86 percent of athletes can identify some change in their training before the onset of the stress fracture. “That’s the first thing you ask about,” said Dr. O’Malley. “It is very common in the preseason.”

A stress fracture results from repetitive multitrauma to bone that does not completely fracture but outpaces the body’s ability to remodel and heal. It occurs most commonly in the tibia (24 percent), the navicular (18 percent) and metatarsal (16 percent) bones, and the femur (7 percent). Risk factors include weight-bearing activities, such as running and jumping. Stress fractures are common in ballet dancers, of whom 45 percent have a history.

Fractures can be categorized as caused by either fatigue or insufficiency. “Is it excessive, repetitive stress on normal bone, or is it normal stress on abnormal bone?” Dr. O’Malley queried. “Many people have subtle metabolic bone disease that we don’t have techniques to diagnose and that cause these fractures not to heal. My approach to patients with stress fractures is metabolic work-up plus surgery. Vitamin D insufficiency is a huge issue. And almost everyone is at risk. I test everyone.”

Conservative treatment involves optimizing bone health, with “relative rest” as well as immobilization and limited weight bearing. Calcium and vitamin D supplementation is prescribed and a complete diet is recommended. Ultrasound stimulation and shockwave therapy may be tried, although Dr. O’Malley recommended against its use as a primary treatment.

Low-risk stress fractures include compression sites such as the first to fourth metatarsals, calcaneus, and posterior tibial diaphysis. High-risk tension sites include the anterior tibial diaphysis, medial malleolus, navicular, and proximal fifth metatarsal. Low-risk fractures rarely risk surgical intervention. Return to play can be based on pain. A common recommendation is to add a 10 percent increase in activity per week of training.

For high-risk fractures, return to play should only be recommended after proper treatment and complete healing of the injury, Dr. O’Malley said. Complications include delayed union, nonunion, and refracture. In surgical management, he noted, “I use bone marrow aspirate for every case.” He cited a study that showed a 100 percent increase in bone formation with its use. He also uses bone graft using the aspirate needle.

Dr. O’Malley, team physician for the Brooklyn Nets of the National Basketball Association (NBA), admitted that he has been “humbled” by numerous stress fractures that recurred in professional athletes under his care. An anterior tibial stress fracture can potentially be a “career ender,” he noted. “Most of the patients have symptoms for
6 months, and if you do not operate, it is usually a year for them to heal. This is unacceptable in a world-class athlete.”

With surgery, there is controversy over plating versus nailing.

“We know that anterior knee pain can be a factor after intramedullary (IM) nailing,” said Dr. O’Malley. “If you have a jumping athlete and you do IM nailing for a fracture, you can anticipate some knee pain.” A conservative approach to the anterior tibial injury has poor results; a return to play with either plating or nailing is relatively quick, he noted.

Cosmesis with plating may be a concern for some patients, such as ballet dancers; an anterior plate is better biomechanically but more prominent than a lateral plate. In surgical cases for athletes such as basketball players, “I will do a plate unless the injury is really long and I am worried that I cannot get a plate to cover,” Dr. O’Malley said.

Medial malleolus fractures are “sneaky” injuries, he said. “We’ve seen a lot of them in the NBA recently.” It is caused by impingement of the talus on the medial malleolus during dorsiflexion and tibial rotation. In research he and Dr. Anderson conducted on NBA players, the take-home message was to address ankle impingement at the time of operation and to use plate fixation, not parallel screws.

For navicular stress fractures, the management of which can be controversial, computed tomography (CT) is the gold standard for imaging.  Dr. O’Malley’s recommendation is to treat them surgically. For type I fractures, he favors percutaneous screw fixation; for type II and III fractures, he favors open reduction and internal fixation (ORIF) with bone marrow and graft. Return to play can occur when a CT scan documents healing.

In summary, he said, stress fractures are subject to delayed union, nonunion, and refracture, even with optimal care. “It is probably best to overtreat—with bone graft—in the elite athlete,” he said. CT scans should be used to monitor healing. The surgeon should determine if the bone is normal and, if it is not, prescribe and administer medical treatment, with calcium, vitamin D, and bone stimulators in addition to surgical intervention.

“If you get a nonunion or a refracture, keep in mind that we all get them,” Dr. O’Malley said. “It’s not you. It’s the bone.”

Also presenting at the symposium were Richard D. Ferkel, MD—Lateral Ankle Instability and Peroneal Tendon Pathology; Eric Giza, MD—Cartilage and OCD Lesions of the Talus; and Timothy Charlton, MD (moderator)—Achilles tendon injury. Watch for coverage of these presentations in the monthly edition of AAOS Now.

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