#1 Look at the Big Picture

The proper history and physical examination is completed by keeping the big picture in mind and obtaining contributory static and dynamic factors that affect the athlete. This approach includes appreciating the patient’s experience with the condition or injury; the character of the symptoms; the duration and onset of the problem; aggravating and ameliorating factors; and a description of the specific offending activity. In addition, other general sports activities should be noted, such as details about the gear; the surfaces; the opponents, teammates, and partners (dance); and the sporting environment. Training factors should be documented, especially the duration, intensity, and frequency of events, as well as the warm up and cool down. Motivational drives and the way that the condition is perceived relative to future ambitions are enlightening. Nutritional issues, general health, medical history, medications, vitamins and supplements, and prior surgeries or traumas often may be revealing.

The physical examination should be performed accordingly, taking both wide and focused perspectives and juxtaposing the examination with static and dynamic appraisals. The athlete should be observed during normal standing, walking, and sitting, as well as running or performing the particular maneuvers of the sport or dance. The musculoskeletal system, especially the lower extremities, warrants evaluation, because any one area can affect the foot and ankle and the clinician may find clues that are useful to determining a diagnosis and treatment. The synthesis of these protean elements can be challenging but carries a high reward for observing the human body at its finest physical performance.

#2 “Conservative Treatment was Exhausted” may Mean Only That the Athlete and Medical Team were Exhausted

In treating the elite athlete, as with treating any athlete or patient, there is an evaluation process that must include conservative consideration of all options before invasive treatment may be instituted. The orthopaedic foot and ankle and or sports medicine subspecialist must know the condition, its etiology, and its natural course. Timing relative to the disease state and the activity requirements is critical and must influence the approach. Operative treatment might be considered with the elite athlete, whereas conservative treatment would be used with the high school athlete and nonathlete having the same problem. Although simple and complex nonsurgical techniques exist for every orthopaedic malady, do not assume that the solution was applied appropriately or completely for the elite athlete. Often, a thorough evaluation of the dynamic and static conditions that contribute to the problem has not been synthesized to design a customized, multitiered approach best suited to the individual. As with surgery, there are “tricks and moves” that can render the standard treatment into a tour de force cure. Often the effort, including reassessments and tweaking of the protocol, can be more laborious and frustrating than an operative endeavor. Finally, despite good intentions, it must be remembered that nonoperative treatment carries risks and can be considered a waste of valuable time and resources. It is the norm for multiple opinions to be offered regarding treatment of elite athletes, and it is preferable for everyone involved, including the team physician, agent, and so forth, to agree with the treatment recommended by the clinician.

With that said, the following cases illustrate straightforward and unglamorous conservative interventions that carried little risk but made a major, beneficial impact.

A Major League Baseball player presented with a chronic, overuse strain of his left great toe. He was a left-handed pitcher, and the left great toe was being subluxed into a lateral valgus position during push-off. The problem was diagnosed as a form of a turf-toe, more specifically a sprain of the medial sesamoidal phalangeal ligament and the medial head of the flexor hallucis brevis tendon. After talking to the trainer, agent, team doctor, and orthotist, we designed and custom made a spacer to fit between the great toe and the second toe. After a slow start to the season and requisite reassurance, the pitcher won 22 games using a simple device (Fig. 1-1).

Figure 1-1 Hallux valgus toe spacer is a useful means of conservative treatment for a metatarsophalangeal (MTP) capsular or ligamentous injury.

Another Major League Baseball player had ankle and hindfoot symptoms that were felt to limit his hitting. The ankle and hindfoot examination was unremarkable, with good stability, alignment, and strength. An examination of the whole musculoskeletal system brought to light an obvious genu varus, which resulted in varus of the ankle and the subtalar joint. When watching him simulate his swing, we noted that his ankle would subtly invert. By placing an off-the-shelf lateral wedge into the shoe, the player was able to get a better stance and more stability while batting and was able to increase his batting average significantly, winning the major league batting title (Fig. 1-2).

Figure 1-2 Several views of wedged heel shock absorbers, Anti-Shox™ by Apex (Teaneck, NJ).

A professional quarterback asked for the opinion of three foot and ankle subspecialists. His ruptured Achilles tendon had been repaired one season before the examination. The repair had stretched out and did not allow adequate push-off. After careful discussion by the three orthopaedists who saw the quarterback simultaneously, it was decided to treat the elongated and weak tendon conservatively with an ankle-foot orthosis (AFO). This AFO was made with a plantar assist by using an anterior tibial stop for the AFO (Fig. 1-3). The Hall of Fame quarter back played three more seasons with a similar brace and never had additional surgery to the Achilles tendon.

Figure 1-3 The Toeoff splint made of carbon graphite (Camp Scandinavia, Helsingborg, Sweden). The Toeoff is an AFO with an anterior tibial shell connected to a foot plate. The brace is open posteriorly.

A top-level and highly paid National Basketball Association (NBA) star sustained within 1 year three sequential injuries to his Achilles tendon that were diagnosed as partial tears. Following each injury, addressed by brief bouts of conservative treatment (physical therapy [PT], nonsteroidal anti-inflammatory drugs [NSAIDs], and rest), he was aggressively encouraged to continue to play despite persistent pain, swelling, and dysfunction. His third injury during the playoffs was the most incapacitating, both physically and emotionally. He lost faith in his doctors, whom he felt had allowed him to be reinjured by trivializing his trauma as insignificant. Much to the frustration of the team management, doctors, and fans, he decided to wait for complete resolution of the swelling, pain, and weakness before resuming play and missed numerous games. Further opinions were sought to bring the situation to resolution. The nonsurgical solution that we initiated satisfied all parties and permitted return with protection. A flexible plastic molded poster shell AFO, fabricated for each game (to avoid sudden and potentially catastrophic fatigue failure of the device), reduced the strain on the Achilles tendon while allowing somewhat restricted and controlled mobility. With the device, he returned to play after a 6-month hiatus and experienced progressive restoration of confidence while the injury continued to heal (Fig. 1-4).

#3 Conservative Care may not Conserve Resources

Many stress fractures of the talus and other bones seen on magnetic resonance imaging (MRI) have healed after months of treatment but without surgery. Occasionally these fractures can become long, drawn-out, chronic affairs. The cost of a prolonged convalescence can be overwhelming to the athlete and the team. With this potential for a long recovery, it is typical to use a bone stimulator, despite uncertainty that one truly is needed. Thus whereas the cost may be prohibitive in the nonelite athlete population, it can be justified for the elite performer.

An example of the economic impact of the conservative option is provided. A 2-mm, displaced supination-eversion II fibular fracture occurred in a top-level National Hockey League player immediately preseason (Fig. 1-5, A through C). He had no deltoid or syndesmotic tenderness. There were concerns about potential hardware prominence interfering with the skate if an open reduction internal fixation (ORIF) were performed. This would delay return to play until after the hardware was removed. Given the nature of this injury to heal quickly and uneventfully, it was decided to treat the ankle fracture without surgery. The ankle was placed in a cast and the player was kept nonweight bearing for 6 weeks, then given a removable, off-the-shelf, boot brace. He resumed conditioning and ankle strengthening progressively with low-impact activity and then subsequently began skating. At 3 months, he still had tenderness, focal edema, and warmth, and could not skate aggressively or confidently enough to perform choppy sprints or to make quick stops and precision turns. He also was concerned about getting checked and sustaining a complete fracture. The x-ray and computed tomography (CT) scan (Fig. 1-5, D) performed at 3 months showed approximately 20% healing along the proximal posterior aspect. All parties were frustrated, and the team suffered without his talent. Treatments discussed included operative and nonoperative modalities. Among all parties—trainers, manager, team doctor, and the patient—it was agreed that we perform shock wave treatment of the delayed union with the Sonocur extracorporeal machine (which requires no local or general anesthetic), begin an EBI bone stimulator (EBI, Parsippany, NJ), and fabricate a custom-molded, plastic AFO that could be worn in a sneaker. The patient continued to advance in his low-impact skating and nonskating workout, using the brace and bone stimulator when not conditioning. By two additional months, the fracture had progressed to 60% healing and the symptoms had abated to allow return to aggressive skating during the playoffs (Fig. 1-5, E and F).

#4 Patience and Relative Rest are Virtues

A world record holder in the 100 meters had plantar fasciitis and could not compete for 12 months. He cross trained with water running, biking, and lower impact activities to stay in shape. Ultimately, with the use of an Achilles stretching protocol, orthotic devices, and a night splint, the fascia finally healed and he recovered. It was a year filled with many office visits and requests for a quick fix. Great runners and elite athletes often find it difficult to be patient. No one knows when or if the condition will resolve. On our side is the knowledge that most cases of plantar fasciitis (more than 90%) respond to conservative modalities by 12 months. The risk of an unusual complication following plantar fascia release and the loss of spring and push-off in this sprinter were outweighed by the benefits of a potentially faster recovery, given the demands of his sport. Of course, 20/20 hindsight is everything.

#5 Think About the Nerves

Many patients with a deep posterior compartment syndrome have pain at one specific area. This pain usually is isolated to the lower edge of the gastrocnemius on the medial side of the leg. With a history of chronic pain in this compartment and a negative scan, exercise compartment testing to rule out exertional compartment syndrome is recommended. On occasion, despite normal pressures, a local fascial release has been performed at the lower gastrocnemius, releasing what we have considered to be an isolated high tarsal tunnel syndrome. Occasionally, a specific nerve conduction test and electromyogram (EMG) can pick up a delay of the tibial nerve in the leg. However, because the nerve entrapment is a functional entrapment from a hypertrophied muscle and a squeezing effect on the nerve, the nerve conduction is not always positive. The symptoms may result from a compressed tibial nerve, rather than from lack of oxygen to leg muscles.

We have treated several elite athletes, particularly track runners, who have presented with a cramping-type sensation in the posterior calf in the midline area. After a full evaluation of standard posterior calf pain (deep venous thrombosis [DVT], exertional compartment syndrome, muscle tear, and so forth), we have attributed the pain to a sural nerve fascial constriction. Releasing fascia around the sural nerve in this isolated area may permit the cramping to subside and the leg pain to resolve.

Similarly, an athlete with what appears to be lateral exertional compartment syndrome may be suffering from superficial peroneal nerve entrapment. This may present with normal compartment pressures. One should be aware that this condition may occur because of an unstable ankle. In the latter cases, not only does a superficial peroneal nerve have to be released, but the unstable ankle must be repaired as well. There are anatomic variations of this nerve, and it may lie within the lateral or anterior compartments or both.

The jogger’s foot is more common than most physicians realize. The medial plantar nerve may become entrapped at an isolated area at the knot of Henry. Abnormal range of motion may lead to a squeezing effect by the hypertrophied abductor hallucis muscle. A minimal incision releases the medial plantar nerve; because it is relatively deep, care must be taken to avoid damage.

The anterior tarsal tunnel syndrome also is fascinating because the deep peroneal nerve may be irritated for several reasons. It can be compressed because of a functional instability of the ankle or the talonavicular joint. The treatment includes a minimal release by cutting the inferior edge of the retinaculum and then carefully removing dorsal bone from the talus or navicular bone (Fig. 1-6). The lateral branch of the deep peroneal nerve may be compressed by the fascia of the extensor brevis muscle, causing a sinus tarsi pain. This is an often-overlooked cause of the sinus tarsi syndrome. In this situation, the nerve should be released where it is focally tender, typically dorsal and medial to the sinus tarsi itself. The fascia of the extensor brevis muscle can be the causative structure, but the physician always must evaluate for ankle instability, as well. We do not recommend transecting this nerve branch as a means of reducing the pain.

Figure 1-6 Lateral radiograph of a dorsal osteophyte on naviculum caused a deep peroneal neuralgia.