Injury Rate (%) Common Foot and Ankle Injuries in the Football Player Surgery or Not Ankle Foot Collegiate 12 3 High School 18 3 Youth 15 4 Daniel Murawski, MD April 22, 2016 1 2 Common Injuries 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. Common Injuries Injury % Time Loss (d) Surgery Lateral sprain 45 6/7 0.4% 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 4 Mechanisms Ligament Injury Grades of Injury Lateral Grade Anatomic Injury History Gait Anterior Drawer I Stretching Minimal continue stable swelling sport II Partial tearing Moderate swelling painful gait 1+ asymmetry, firm III Complete rupture Severe swelling, ecchymosis inability to walk 2+ asymmetry, soft Inherently stable in DF Collateral ligs at risk in PF 5 1
Lateral Grade III Injuries No treatment suboptimal Immobilization for 6 weeks suboptimal 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. Surgery Versus Rehab Pijnenburg et al, JBJS (Br) 2003. Randomized 0perative vs Functional, 8 year f/u 78% of both groups resumed sports Functional Surgery Pain 25% 16% Recurrent sprains 34% 22% Giving way 32% 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 10 Grades of Injury Syndesmosis Stress X-rays - Syndesmosis Type XR Findings 1 Sprain without diastasis 2 (Latent Diastasis) Diastasis on stress x-rays only 3 Frank diastasis without fracture Right Comparison Left Injured Left stressed Left reduced Edwards and DeLee. Ankle diastasis without fracture. FAI 1984. 12 2
Type 2 Syndesmosis Injury 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 Type 3 Syndesmosis Injury Open or percutaneous Number and type of fixation Location Small plate Clamp or no clamp Hardware removal 13 14 Lisfranc Injury Stage Clinical Findings Weight Bearing X-rays I able to bear weight, cannot play < 2 mm diastasis 1 st and 2 nd met bases II able to bear weight, cannot play 2-5 mm diastasis1 st and 2 nd 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 16 Case 1 Case 2 17 18 3
19 20 Hallux MTPJ Injury Hyperflexion injuries (sand toe) Hyperextension injuries (turf toe) Valgus or varus components Anatomy MTPJ Bony anatomy minor Capsuloligamentous key Plantar plate, FHB, and sesamoids (plantar complex) Abductor and adductor hallucis Collateral and metatarsosesamoid ligaments 21 Grades Turf Toe Grade 1 stretch injury 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 Anderson. Turf toe injury of the hallux metatarophalangeal joint. TFAS 2002. Conservative Treatment RICE, boot, taping Equipment modification Stiffer shoe Steel or carbon fiber plate OTC insole, reinforced forefoot Custom-molded insole with Morton s extension 4
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 Pain, stiffness, progressive valgus or rigidus Coker et al, Am J Sp Med 1978 18 patients, at least 2 did not return to support Surgery for capsular avulsion, sesamoid fx, or inability to jog without pain (3 wks) 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 Outcome Continued Clanton and Ford, Clin J Sp Med 1994 20 athletes underwent surgery, 5 yr f/u 50% persistent symptoms Anderson, TFAS 2002 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 Tuberosity avulsion fracture True Jones fracture Diaphyseal stress fracture Screw fixation of Jones fractures is treatment of choice in competitive athletes Lareau, Hsu, Anderson. Return to play in NFL players after operative Jones fracture treatment. FAI 2016. 29 8 weeks NWB cast 72* 93%** union rate Time to union ranges 7** 21* weeks 33% refracture rate*** * Clapper et al. Fractures of the fifth metatarsal CORR 1995. ** Torg et al. Fractures fifth metatarsal distal to the tuberosity. JBJS 1984. *** Quill. Fractures of the proximal fifth metatarsal. Orthop Clin North Am 1995. 30 5
Randomized Study Cast Versus Screw Nonunion Refracture TTU RTS Cast n=14 26% 11% 14.5 15 Screw n=19 5% - 7.5 8 Screw Fixation 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 34 Lateral Malleolus Surgery? 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
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
Weber C 43 44 Medial Malleolar Surgery indicated unless completely nondisplaced 45 46 Controversial Directly repairing deltoid ligament in bimalleolar equivalent fractures 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. Summary 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 47 48 8