4/13/2016
Injury Rate (%)
Ankle
12
18
15
Collegiate
High School
Youth
Common Foot and Ankle Injuries
in the Football Player –
Surgery or Not
Foot
3
3
4
Daniel Murawski, MD
April 22, 2016
1
2
Common Injuries
Common Injuries
•
•
•
•
•
•
•
Injury
%
Time Loss (d)
Surgery
Lateral sprain
45
6/7
0.4%
Lateral ankle sprains
High ankle sprains
Hallux MTPJ injury
Fibular fracture
Jones fracture
Lisfranc sprains
Medial ankle sprains
Kaplan et al. Incidence… foot and ankle injuries elite college football
players. Am J Orthop 2011. 320 players 2006 NFL combine.
High ankle sprain
17
12/23
2.8%
Medial ankle sprain
8
7/32
3.8%
Lisfranc sprain
7
6/20
5.3%
Hallux MTPJ
4
5/20
1.4%
Metatarsal fracture
2
38
35.6%
Lateral mall fracture
1
37
46.4%
Medial mall fracture
1
26
33.3%
Lievers and Adamic. Incidence and severity foot and ankle injuries collegiate
football. OJSM 2015. NCAA ISS 2004-2009 - 3,326 injuries.
3
Mechanisms Ligament Injury
4
Grades of Injury – Lateral
Grade
I
II
III
Anatomic Injury
Stretching
Partial tearing
Complete rupture
History
Minimal swelling
Moderate swelling
Severe swelling, ecchymosis
Gait
continue sport
painful gait
inability to walk
Anterior Drawer
stable
1+ asymmetry, firm
2+ asymmetry, soft
Inherently stable in DF
Collateral ligs at risk in PF
5
1
4/13/2016
Lateral Grade III Injuries
Surgery Versus Rehab
• No treatment suboptimal
• Immobilization for 6 weeks suboptimal
• Pijnenburg et al, JBJS (Br) 2003. Randomized
0perative vs Functional, 8 year f/u
• 78% of both groups resumed sports
– stiffness, atrophy, loss of proprioception
• Modest advantage to surgery over early mobilization
– recurrent sprains and subj/obj instability favor surgery
– outcome scores and return to play are similar
• Acute repair same results as delayed repair
• Disadvantages to surgery
– Longer recovery times, stiffness, ↓ mobility, and complications
White et al. Return to sport following acute lateral ligament repair of the ankle in
professional athletes. Knee Surg Sports Traum Athros 2015. RTT 63d, RTS 77d.
• Pain
• Recurrent sprains
• Giving way
Functional
25%
34%
32%
Surgery
16%
22%
22%
Pihlajamäki H, et al. Surgical vs functional treatment for acute ruptures… a
randomized controlled trial. JBJS 2010.
Medial Ankle Sprain
Medial Ankle Sprain
• Rarely see a deltoid
injury in isolation
• Little guidance in the
literature for grade III
injuries in athletes
White et al. Return to sport following acute lateral ligament repair of the ankle in
professional athletes. Knee Surg Sports Traum Athros 2015. 17% of patients had
deltoid ruptures that were directly repaired – median RTT 86d, RTS 105d.
9
Grades of Injury – Syndesmosis
Type
XR Findings
1
Sprain without diastasis
2 (Latent Diastasis)
Diastasis on stress x-rays only
3
Frank diastasis without fracture
10
Stress X-rays - Syndesmosis
Right Comparison
Left Injured
Left stressed
Left reduced
Edwards and DeLee. Ankle diastasis without fracture. FAI 1984.
12
2
4/13/2016
Type 2 Syndesmosis Injury
Type 3 Syndesmosis Injury
•
•
•
•
• Open or percutaneous
• Number and type of
fixation
• Location
• Small plate
• Clamp or no clamp
• Hardware removal
MRI study of choice if x-rays equivocal
Weight-bearing bilateral CT scan helpful
Stress exam under anesthesia
Controversial
– Cast versus surgery in elite athlete
– Quicker RTP with surgery?
– Not substantiated by biomechanical or
clinical data
13
14
Lisfranc Injury
Stage
Clinical Findings
Weight Bearing X-rays
I
able to bear weight, cannot play
< 2 mm diastasis 1st and 2nd met bases
II
able to bear weight, cannot play
2-5 mm diastasis1st and 2nd met bases
III
cannot bear weight
> 5 mm diastasis, loss arch height
Nunley and Vertullo. Classification, investigation, and management of midfoot
sprains: Lisfranc injuries in the athlete. AJSM 2002.
Meyer et al. Midfoot sprains in college football players. AJSM 1994. 24
injuries. All returned to sport that year. At 31 month follow-up, 3/19 played pro
football. 4/19 reported residual functional problems.
15
Case 1
16
Case 2
17
18
3
4/13/2016
19
20
Anatomy MTPJ
Hallux MTPJ Injury
• Bony anatomy → minor
• Capsuloligamentous → key
• Plantar plate, FHB, and
sesamoids (plantar complex)
• Abductor and adductor hallucis
• Collateral and metatarso-
• Hyperflexion injuries (sand toe)
• Hyperextension injuries (turf toe)
• Valgus or varus components
sesamoid ligaments
21
Grades – Turf Toe
Conservative Treatment
• Grade 1 – stretch injury
• RICE, boot, taping
• Equipment modification
– Weight bear with minimal symptoms
• Grade 2 – partial tear
– Some restriction in ROM/guarding
– Moderate pain, swelling, impaired performance
• Grade 3 – complete tear
– Severe ↓ ROM/ecchymosis/swelling, (+) Lachman’s
– Proximal migration sesamoids, possible sesamoid fx,
impaction metatarsal head, other varus/valgus
– Stiffer shoe
– Steel or carbon fiber plate
– OTC insole, reinforced
forefoot
– Custom-molded insole
with Morton’s extension
Anderson. Turf toe injury of the hallux metatarophalangeal joint. TFAS 2002.
4
4/13/2016
Surgical Indications
Medial J Incision
• Positive Lachman’s
• Large capsular avulsion/unstable joint (MCL)
• Retraction of sesamoids, sesamoid fracture or
diastasis of bipartite
• Serial examination shows instability:
– Progressive hallux valgus (traumatic bunion)
– Progressive retraction or diastasis of sesamoids
• Failure of conservative treatment
26
Outcome
Outcome Continued
• Pain, stiffness, progressive valgus or rigidus
• Coker et al, Am J Sp Med 1978
• Clanton and Ford, Clin J Sp Med 1994
– 20 athletes underwent surgery, 5 yr f/u
– 50% persistent symptoms
– 18 patients, at least 2 did not return to support
– Surgery for capsular avulsion, sesamoid fx, or
inability to jog without pain (3 wks)
• Anderson, TFAS 2002
–
–
–
–
• Clanton et al, FAI 1986
– 53 of 56 athletes returned within 3 weeks
– One required surgery for capsular avulsion
– Unofficial f/u showed several cases arthritic change
Evaluated 19 athletes over a ten year period
9 athletes underwent surgery (1 wk – 7 mo)
All had complete plantar plate disruption
7 returned to sport
28
Jones Fracture
8 weeks NWB cast
•
•
•
•
• 72* – 93%** union rate
• Time to union ranges 7**– 21* weeks
• 33% refracture rate***
Tuberosity avulsion fracture
True Jones fracture
Diaphyseal stress fracture
Screw fixation of Jones
fractures is treatment of
choice in competitive athletes
* Clapper et al. Fractures of the fifth metatarsal… CORR 1995.
** Torg et al. Fractures… fifth metatarsal distal to the tuberosity. JBJS 1984.
Lareau, Hsu, Anderson. Return to play in NFL players after
operative Jones fracture treatment. FAI 2016.
*** Quill. Fractures of the proximal fifth metatarsal. Orthop Clin North Am 1995.
29
30
5
4/13/2016
Randomized Study Cast
Versus Screw
Nonunion
Cast n=14
Screw n=19
26%
5%
Screw Fixation
Refracture
TTU
RTS
11%
-
14.5
7.5
15
8
Malogne et al. Early screw fixation versus casting in treatment of acute Jones
fractures. AJSM 2005.
31
32
Malleolar Fractures –
Surgery?
• Lateral malleolus
– Weber A (Depends)
– Weber B (Depends)
– Weber C (Yes)
• Bimalleolar equivalent (Yes)
• Medial malleolar (Yes)
• Bimalleolar (Yes)
33
Lateral Malleolus – Surgery?
34
Case 1
• 2-4 mm may be acceptable (A,B) if:
– Mortise is stable
– No excessive shortening or external
rotation
• Option for surgery to allow quicker
return to sport
Jelinek and Porter. Management of unstable ankle fractures in athletes. Foot
Ankle Clin 2009.
35
36
6
4/13/2016
Case 2
37
38
39
40
Bimalleolar Equivalent
Weber B
• Always assess for deltoid rupture
• Some Weber B
• Essentially all Weber C
41
42
7
4/13/2016
Weber C
43
44
Medial Malleolar
• Surgery indicated unless completely
nondisplaced
45
46
Controversial
Summary
• Directly repairing deltoid ligament
in bimalleolar equivalent fractures
• Foot and ankle injuries are common in
football players
• Recognize injuries that need further work
up for potential surgery
• Vast majority treated without surgery
• Controversies still exist
• In some cases, early surgery can help
athlete return to sport faster and safer
Porter et al. Functional outcome after operative treatment for ankle fractures in
young athletes. FAI 2008.
Hsu, Lareau, Anderson. Repair of acute superficial deltoid complex avulsion
during ankle fracture fixation in NFL players. FAI 2015.
47
48
8