Introduction

Athletic competition has become normative in culture today. People enjoy competing against a worthy rival in the name of sportsmanship, the thrill of pushing the limits of the human body, for fitness, for the thrill of victory, and more recently as a full-time career. Evaluation and management of the elite athlete has been covered in Chapter 1. Foot and ankle injuries are among the most common maladies that plague the elite athlete. In professional sports, these injuries can result in the inability to participate and hinder a team’s chances for victory. For the individual, a prolonged recovery can lead to loss of playing time, a depressed sense of worth, an inability to contribute, and even a substantial loss of revenue, while jeopardizing a career.

As more emphasis is placed on professional and intercollegiate athletics, awareness has heightened concerning the incidence of foot and ankle injuries in these elite athletes. The injuries in the elite athlete are similar to those seen in recreational and lower-level competitive athletes, but the demands can be greater and the ramifications more profound. This chapter is intended to provide information on the epidemiology of sport-specific foot and ankle injuries, to facilitate and guide physicians, physical therapists, athletic trainers, and students in the recognition of foot and ankle injuries in this specific population. Our hope is that this information will help providers be more aware of the common and unique injuries encountered by professional athletes in their sport. This chapter will not delve deeply into treatment protocols because the previous chapters have attempted to cover treatment in far greater depth than merited here. This chapter, however, does comment on the epidemiology of sport-specific foot and ankle injuries and addresses some thoughts on the management of such injuries in the professional athletes. The management comments come from the senior author (D.A.P.). We are indebted to the professional trainers for their cooperation and contributions to this chapter (see later).

Epidemiology

To ascertain the occurrence and sport-specific injuries in professional athletes a survey was delivered to the head athletic trainers of each professional team in the National Football League (NFL), the National Basketball Association (NBA), Major League Baseball (MLB), the National Hockey League (NHL), and Major League Soccer (MLS). Thirty-four of 132 surveys were returned: 2 NFL, 7 NBA, 13 MLB, 8 NHL, and 4 MLS. The following head athletic trainers responded for their respective teams.

The participants responded to a list of questions about foot and ankle disorders in the professional athlete. This included a survey of the most common foot and ankle injuries in the trainer’s sport and a series of questions about treatment and rehabilitation protocols for the more occult and controversial foot and ankle maladies. The specific topics about which we inquired were turf-toe, base of fifth metatarsal/Jones fractures, midfoot sprains/Lisfranc injuries, navicular fractures, medial ankle sprains/deltoid injuries, lateral ankle sprains, high ankle sprains/syndesmotic injuries, and Achilles tendinitis/rupture. Also, the head athletic trainers were asked about their anecdotal experiences with their most memorable/difficult/unusual professional athletic injury.

The 34 participants were asked to list the five most common foot and ankle injuries treated among their professional athletes. Equal weight was given to all responses, whether listed first or last, and to each responder. The results are listed below. The results also were subdivided among each particular sport and are plotted in Figs. 29-1, 29-2, 29-3, 29-4, and 29-5.

Figure 29-1 The most common injuries reported among football players were turf-toe or hallux rigidus, plantar fasciitis, and lateral ankle sprains (two responses each). Additional responses include corns and callosities, medial ankle sprains, syndesmotic injuries, and Achilles tendinitis.

Figure 29-2 Basketball injuries were noted to include lateral ankle sprains (8), plantar fasciitis (7), corns/calluses (6), ingrown toenails (4), and Achilles tendinitis (4).

Figure 29-3 Baseball injuries most commonly were plantar fasciitis (11); lateral ankle sprains (10); and ingrown toenails, corns/calluses, and shin splints (9 each).

Figure 29-4 Hockey players were reported to incur injures commonly related to skatewear and trauma such as ingrown toenails (6), corns/calluses (5), lateral ankle sprains (5), toe fractures (4), and high ankle/syndesmotic sprains (4).

Figure 29-5 Soccer injuries most commonly were subungual hematomas, midfoot sprains, medial ankle sprains, lateral ankle sprains, and high ankle/syndesmotic sprains (2 each).

The five most common foot and ankle injuries (and the number of responses) were lateral ankle sprains (27), plantar fasciitis (21), corns and callosities (21), ingrown toenails (20), and Achilles tendinitis or ruptures (12). Additional injuries listed (in descending number of responses) include subungual hematomas (10), shin splints (10), medial ankle sprains (9), syndesmotic sprains (9), hallux rigidus (7), base of fifth metatarsal fractures (7), phalangeal fractures (5), leg contusions (5), metatarsal fractures (3), Lisfranc/midfoot sprains (3), ankle fractures (2), metatarsalgia (1), interdigital neuromas (1), medial malleolus fractures (1), and heel exostosis (1). Thus there were nearly equal numbers of injuries among the foot and the ankle. Also, one notes that the severity of the injuries can extend from a subungual hematoma or callus to a fracture dislocation of the ankle or foot. Thus the provider must be well versed in a variety of foot and ankle injuries that can be both a real nuisance (ingrown toenail) to a career-threatening syndesmotic ankle injury. We hope that the first 28 chapters addressed these injuries and ailments to you, the reader, in a satisfactory fashion. This chapter focuses specifically on the professional athlete.

Turf-Toe/Hallux Rigidus

Turf-toe involves a severe dorsiflexion injury to the great toe metatarsophalangeal (MTP) joint as described in Chapter 18. Other, less common mechanisms include varus/valgus stresses resulting in a combined turf-toe and “traumatic bunion.” The joint capsule is strained, the plantar plate can be stretched, and the articular cartilage can be contused and lead to long-term joint arthrosis. These injuries are commonly described in football, with hard turf and flexible shoes increasing the incidence. This can be quite debilitating, with long periods of recovery, especially if the plantar plate is disrupted. One can imagine the difficulty in a football player dependent on push-off if there is significant limitation of motion and loss of power. Turf-toe (hyperextension with primary plantar soft-tissue injury) does occur in other sports but is much less frequent and typically is less severe. That being said, we have treated a Division I baseball pitcher who suffered a complete plantar plate disruption coming off the mound to field the ball, necessitating surgical repair. He is now in the minor leagues pitching without pain.

Hallux rigidus is arthrosis of the first MTP joint and is characterized by a painful loss of motion (extension) with the formation of prominent dorsal osteophytes. The cause is multifactorial, but it is considered a degenerative process.

Twenty-six athletic trainers from all the sports polled responded with their experiences with hallux rigidus. Baseball injuries consisted of acute hyperdorsiflexion injury to the great toe MTP joint caused by stepping on the front edge of the base or running into a wall or by an exacerbation of a chronic condition from push-off running. Basketball players commonly were injured acutely from sudden stops or jumps causing hyperdorsiflexion of the great toes. Football trainers described the classic hyperextension injury to the great toe as a player pushes off on the playing field or another player lands on the injured player’s heel with the athlete’s great toe extended and the foot in equinus. Hockey injuries were less common; some were associated with off-the-ice workouts.

Turf-toe and hallux rigidus commonly were treated nonoperatively with taping, ice, anti-inflammatories, steroid injections, iontophoresis, and electrical stimulation. Full-length or extended shank, rigid orthotic inserts, and shoewear modifications were key elements of conservative treatment. Return to play was based on being pain free and having stable, full range of motion and the ability to perform with an orthotic insert and modified shoewear. A sports-specific functional assessment examination also was used as a criterion for return to sports. In general, the period of recovery lasted from weeks to months, depending on the degree of the turf-toe injury or the extent of arthrosis. Chronic aggravating symptoms may persist for several months, and a severe turf-toe injury can be career threatening.

Hallux rigidus has rarely been career ending. We have noted some football players who were able to compete at a very high level for several years without surgical intervention yet with profound arthrosis. For the athlete who requires surgery, we prefer a combined cheilectomy and dorsal proximal-phalanx closing-wedge osteotomy (Moberg) for the athlete with dorsal spurs, early joint space narrowing and limited extension (≤60 degrees). We believe that the health providers should be aggressive with turf-toe injury management whether the approach is nonoperative treatment or operative. We favor anatomic repair for magnetic resonance imaging (MRI)-documented plantar plate rupture and for athletes with acute proximal migration of the sesamoids on weight-bearing radiographs.

The trainers reported surgical experience in three cases of turf-toe, from two baseball trainers and one soccer athletic trainer. It was reported that these surgeries were performed after a period of conservative treatment. Injuries involved a disruption of the plantar MTP soft tissues that required surgical reconstruction of the plantar complex. Return to play was allowed after 10 to 12 weeks of immobilization followed by aggressive physical therapy (PT) and range of motion. The trainers did not relate experiences with surgery for hallux rigidus.