Lower-Leg and Ankle Injuries

CHAPTER 14


Lower-Leg and Ankle Injuries


Christopher E. Hubbard, MD, and William G. Hamilton, MD



Ankle injuries are extraordinarily common in sports, particularly in pivoting and contact sports such as basketball, soccer, and American football. The unique anatomy and relatively meager support of soft tissue make the ankle joint especially prone to sports injury.


The ankle joint consists of three bones: the talus, which is held firmly in an upside-down box-like structure called the mortise, and two bones of the lower leg—the shinbone (tibia) and the small narrow bone that runs down the outside of the leg (fibula). The talus moves only up and down, so a second joint exists to allow side-to-side motion, the subtalar joint. This joint is located under the ankle, and it moves side to side and thus provides additional motion the ankle itself lacks. Motion of the ankle is powered by several muscles: by the Achilles tendon in the back of the ankle; by the posterior tibial tendon on the inside of the ankle; by the peroneal tendons on the outside of the ankle; and by the extensor tendons (i.e., tibialis anterior), in front of the ankle.


The ankle is rotated outward by about 10 to 15 degrees in relation to the knee and is built to allow up-and-down motion but very little inward–outward rotation. If inward–outward rotation is forced on the ankle, an injury often results because the joint is not made to move that way. The subtalar joint allows us to walk on uneven ground, such as cobblestones or the side of a hill. This motion of the subtalar joint is surprisingly important, and when lost, through arthritis or injury, can be extremely disabling.


The primary purpose of the ankle (along with the foot) is to absorb energy when landing and then to propel us forward again off the toe. This occurs by means of the subtalar joint beneath the ankle, which transmits the power of the Achilles tendon efficiently through the foot onto the ground. Anything that limits or interferes with this motion in the subtalar joint significantly alters the function of the entire lower extremity.


Sports that involve jumping require the ankle to absorb energy well, whereas in repetitive sports such as running (there are 1,000 foot strikes in every mile, and each one is almost exactly the same), small differences such as a slight inequality in the length of the legs or stiffness in the subtalar joint can lead to repetitive stress injuries. In this chapter we look at the most common lower-leg and ankle injuries and discuss how to treat them.


LOWER-LEG AND ANKLE INJURIES























































Injury


Page


Shin Splints


287


Lower-Leg Compartment Syndrome


288


Lower-Leg Stress Fracture


289


Calf Strain or Tear


290


Achilles Tendon Rupture


291


Achilles Tendinitis


292


Ankle Sprain


293


Syndesmotic Ankle Sprain


295


Posterior Ankle Impingement


296


Anterolateral Soft Tissue Impingement of the Ankle


297


Osteochondral Lesion of the Talus


298


Peroneal Tendon Disorders


299


Ankle Fracture


300


Posterior Tibial Tendinitis


301


Bone Spurs on the Ankle


302



SHIN SPLINTS



Common Causes


Shin splints and medial tibial stress syndrome (a more severe form of shin splints) are caused by an inflammation of the periosteal sleeve of tissue surrounding the tibia. This type of injury frequently occurs in running or other repetitive cardiorespiratory activities in which the athlete suddenly increases the distance, duration, or frequency of a training regimen. A pronated foot type has been identified as a cause of this condition. The muscular insertions of the tibialis anterior, tibialis posterior, and soleus are frequently affected.


Identification


Symptoms typically include a burning or aching pain on the medial (nearer the middle of the body) aspect of the leg or shin after completion of the activity. This pain is a common complaint among runners who are training for a marathon or young athletes who are conditioning at the outset of a new sporting season. The area of pain and tenderness usually spreads out over an area of a three-finger width along the front or back edge of the posteromedial area of the lower end of the shinbone. X-rays are usually normal, but bone scan reveals localized stress areas along the edge of the bone.


Treatment


Treatment for shin splints involves a change in the athlete’s training regimen (e.g., decreased mileage, frequency, or intensity of exercise). Icing of the involved area after activity helps in the short term. If pain persists or gets worse, despite curtailing the level of activity, the athlete should seek professional attention to rule out a more serious injury such as a lower-leg stress fracture (see p. 289) or exertional lower-leg compartment syndrome (see p. 288). Examine the athlete’s footwear and feet for additional problems. Look for excessive and uneven wear on the soles of running shoes, which may represent biomechanical flaws. Also, if the athlete’s feet pronate excessively (the arch flattens as the foot strikes the ground under load), foot strengthening along with an orthotic to support the arch of the foot may be indicated.


Return to Action


Typically, a one- to two-week layoff from impact exercise allows for a rapid return. A return is recommended when the athlete can practice comfortably and is pain free after vigorous exercise. Taping is seldom useful in achieving a quicker recovery from shin splints.



LOWER-LEG COMPARTMENT SYNDROME



Common Causes


All muscles in the body are grouped into anatomical compartments, each of which is encased with a soft tissue covering called fascia. Within these compartments travel nerves and blood vessels that supply the muscles. In these tight compartments, the muscles may swell and expand with vigorous exercise, choking off their own blood supply or pressuring the local nerves so as to endanger the viability of the muscle tissue (or both). This injury usually occurs in distance runners or athletes who engage in continuous running activity. Some athletes have inherently tight compartments and may experience these symptoms at an earlier age.


Identification


The symptoms of compartment syndrome are more generalized than in other lower-leg conditions. The leg typically has four distinct compartments: lateral, anterior, and two posterior. Compartment syndrome can be traumatic in origin, such as resultant from a motor vehicle accident, or can be due to repetitive overuse, as in running. The repetitive overuse type is also known as exercise-induced compartment syndrome (EICS). Most commonly, EICS due to exercise is located in the anterior or lateral compartments. Typically, there is pain, swelling, and sensitivity of the involved muscular compartment that occurs either at a certain time or distance into the exercise (i.e., pain occurs three minutes or 4 miles [6.4 km] into the run) or during the peak of exercise. Symptoms typically get worse during the course of a workout and subside afterward. The condition is most accurately diagnosed by measuring the compartment pressures at rest and immediately after exercise. As a guide, if the pressure in the compartment is over 15 mmHg before exercise and is over 30 mmHg after exercise, it is considered positive for EICS. Another criterion is doubling of preexercise pressure after a workout or exercise.


Treatment


When rest and modifying activity to avoid stressing the lower extremity fail to alleviate symptoms, a minor surgery is required to release the tight fascia surrounding the affected compartment (fasciotomy).


Return to Action


Following surgery, athletes typically return to sport gradually, reaching maximum recovery by four to six months postoperation. Athletes can typically begin lower-extremity workouts two weeks postoperatively. Following conservative treatment, athletes should refrain from running or from full sport participation until pain is minimal upon repetitious striding, such as on a treadmill.



LOWER-LEG STRESS FRACTURE


Common Causes


A stress fracture is a process that occurs in response to abnormal stress placed on a normal bone. Such a fracture can occur when a bone is repetitively overloaded for a prolonged period of time. This is particularly apt to occur when a bone is weak to begin with. Patients vulnerable to stress fractures include those with osteoporosis, improper diet, sudden increases in a training regimen, or eating disorders. Vitamin D deficiency has been reported in up to 47 percent of patients with stress fractures. The tibia (49 percent), tarsals (25.3 percent), and metatarsals (8.8 percent) are the most frequently affected bones in the lower leg.


Identification


Pain associated with a stress fracture is typically activity related. There is a period of time prior to the actual presence of a fracture in which the bone structure is damaged but has not actually cracked yet; this is called a stress reaction. A good analogy is bending a paper clip repeatedly to weaken it (stress reaction) until it breaks (stress fracture). Once the fracture occurs, the pain increases considerably and can be localized (one finger-width) on examination to a very specific area. If the bone has been symptomatic for a long time, a small and tender bump might develop on the bone (callus) where it is trying to heal. The most accurate way to diagnose a stress reaction or stress fracture in the early stages is with a bone scan; an X-ray might not reveal the injury until the fracture has been present for at least one month or more. There have been several cases of a bone breaking all the way through during running or jumping on a chronic stress fracture.


Treatment


The treatment for both a stress fracture and a stress reaction is usually a marked reduction in activities to allow the fracture to heal. If symptoms are severe, partial weight bearing using crutches or wearing a walking boot is necessary. In addition, use of a bone stimulator (which may assist in the laying down of new bone and expedite the healing process) might be suggested.


Female athletes with chronic stress fractures should always be evaluated for symptoms of the female athlete triad, a condition of disordered eating, amenorrhea, and osteopenia or osteoporosis. If these related problems are present, the athlete should be treated for them while recovering from the injury.


Return to Action


Once treatment has started, stress fractures tend to take as long to heal as the athlete has been exercising with pain. For some athletes that means three to six months before a return to regular training and competing. However, athletes can often engage in nonimpact types of cross-training (such as deep water running and some forms of weightlifting) to maintain fitness while the fracture heals.



CALF STRAIN OR TEAR


Common Causes


A calf strain or tear, often called a calf pull, is usually caused by improper stretching before engaging in exercise or sports or by the inability of the calf muscles to accommodate the concentric (muscle shortening) and eccentric (muscle lengthening) forces generated by sudden changes in direction of the lower limbs that can occur in many sports. Calf strains are noted in tennis (the strains are sometimes called “tennis leg”), racquetball, paddleball, and in most cutting and pivoting sports. Calf strains seem to be more prevalent in weekend warriors and others who do not regularly engage in sport.


Identification


The athlete experiences a “popping” sensation in the calf, followed by well-localized tenderness over the inside calf muscle in the middle portion of the leg. Because of the immediate pain, athletes often have difficulty putting weight on the affected leg. The severity of this injury ranges from mild (grade I) to moderate (grade II) to severe (grade III) depending on the extent of damage to the muscle belly.


Treatment


The immediate treatment is PRICE (protection, rest, ice, compression, and elevation) followed by an evaluation by a physician. Severe pulls might need cast immobilization or a removable boot. Often, a simple leg sleeve will suffice. After healing is complete, physical therapy is important to restore strength and flexibility and to prevent recurrence. Given time to heal and proper rehab, calf strain is usually a benign injury with a good prognosis. Many people with this condition are more comfortable wearing clogs or shoes with an elevated heel, which takes tension off the Achilles tendon during the healing phase.


Return to Action


The athlete should avoid all cardiorespiratory exercise for at least one month from the time of injury. Activity should be increased as tolerated thereafter. Taping or strapping of the calf can be applied as needed. The key is not to return too soon. Often athletes are tempted to get back out there after only three weeks, but if the return to sports occurs prematurely, a retear could turn a four- to six-week recovery into a three-month recovery. As a general guideline, the athlete should not return to sport activity until at least one week of complete pain-free activity and normal strength.



ACHILLES TENDON RUPTURE



Common Causes


Achilles rupture is a serious injury that often occurs because of preexisting Achilles tendinitis or inadequate stretching before sports. This injury typically occurs during pivoting or twisting in sports such as soccer, American football, and basketball. The Achilles tendon assists in flexing the foot downward.


Identification


The athlete experiences a “pop” in the back of the ankle. A gap develops in the tendon that can be felt to the touch, and the tendon no longer functions. When asked to flex the ankle in a downward position (“step on the brake pedal”), injured athletes usually cannot do so. Because of the severity of the pain, athletes often have difficulty putting weight on the affected leg. However, some patients still can walk and flex the ankle in a downward direction as a result of the long toe flexors crossing the ankle, and 30 percent of these injuries have been shown to be missed by the initial examining physician.


Treatment


Again, the immediate treatment is PRICE, followed by an evaluation by a physician who will match treatment to the problem. Many Achilles ruptures are missed at the time of the injury if there is only a partial tear or if the examination is performed by an inexperienced clinician.


Two basic treatment approaches are available for a ruptured Achilles tendon: nonsurgical and surgical. Each has its advantages and disadvantages and, interestingly, the two approaches have the same complication rate (19 percent). The nonsurgical approach is cast immobilization in the foot-down position until the tendon heals, which takes six to eight weeks. The advantage here is the avoidance of surgery and all the associated potential complications, but the disadvantage is decrease in strength and a higher likelihood of rupturing the tendon again during the healing period. The administration of platelet-rich plasma (PRP) may be beneficial in treating a minor Achilles tear. The surgical approach can restore the normal length and strength of the tendon, but complications can arise in the form of phlebitis and wound infections. The decision as to which approach is best should be made by the athlete and a physician. Either way, rehabilitation plays a major role in the recovery process.


Return to Action


The recovery process following Achilles tendon rupture emphasizes rebuilding of muscle strength and restoration of range of motion. Return to the gym following either treatment approach begins between two and three months from the time of injury. Running can begin at about four months, and pivoting sports at six months. Full recovery may take up to one year. The athlete should be advised of this.



ACHILLES TENDINITIS



Common Causes


Achilles injuries are especially common in athletes who allow their Achilles tendons to become tight by not regularly stretching and conditioning the tendon.


Identification


Athletes experience chronic pain in the back and lower part of the calf and ankle that will not subside. A strained Achilles tendon usually occurs in either of two locations: within the tendon itself (usually in the isthmus or narrowest part just behind the ankle), or in the insertion of the tendon in the heel (called Haglund’s disease). In the acute phase when the tendon is hot, swollen, tender, and painful, this injury is called tendinitis. In the chronic phase when the inflammatory process has quieted but not gone away, the injury is called tendinosis. The tendon usually develops a painful lump.


Treatment


The healing process for Achilles tendinitis tends to be long and slow. During the healing phase, athletes might prefer to wear clogs or shoes with an elevated heel to prevent further straining of the Achilles. Athletes should avoid stretching until most of the pain has subsided. This injury can take months to heal and usually occurs in people who are already very active. You can usually measure the healing by the diminution of the symptoms and the decreased tenderness in the lump. When the condition finally heals, a small, firm lump remains, but it is typically asymptomatic. Extracorporeal shockwave therapy (ESWT) and PRP injections are other nonsurgical treatments that have demonstrated success. Surgery to debride and repair the tendon, and augmentation with tendon transfer if the tendinosis is severe, can be beneficial if pain does not respond to other treatments.


Return to Action


Athletes should delay a return to sport until they are completely pain free. During recovery, physical therapy and stretching exercises should be emphasized.



ANKLE SPRAIN


Common Causes


In the United States, ankle sprains account for 1 of every 10 visits to the emergency room. Most of these sprains are sustained during contact and pivoting sports.


Identification


Ankle sprains cause a painful, swollen, bruised area, most typically on the outside (lateral) aspect of the ankle. An inverting (rolling inward) of the ankle is the usual mechanism. The athlete might not be able to bear weight on the ankle. Ankle sprains are usually classified as mild (grade I), moderate (grade II), or severe (grade III) depending on the extent of the damage. There are two main ligaments on the outside of the ankle that hold it together: the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) (see p. 285). In most sprains, the ATFL tears first, and then the CFL tears. A grade I sprain is a partial tear of the ATFL; a grade II sprain is a complete tear of the ATFL with the CFL still intact; and a grade III sprain is a complete tear of both the ATFL and CFL. Fortunately, grade III sprains are very rare. An X-ray can help diagnose whether an ankle is fractured.


Treatment


The treatment of acute ankle sprains is like the treatment of most acute injuries: PRICE. Many sprains are minor injuries that improve after a few days, and these will usually take care of themselves. However, if pain is considerable and it is difficult to bear weight on the ankle, a physician should have a look at it. These injuries often require the use of crutches and some sort of a brace or support to protect the ankle while it is healing. Recovery usually begins with the healing phase, which involves elevation at night on one pillow to reduce swelling, protected motion, and weight bearing as tolerated. During this phase, ultrasound, massage, acupuncture, and nonsteroidal anti-inflammatory drugs can be useful. As healing progresses, the rehab phase begins with physical therapy to restore motion, strength, proprioception, and function to the ankle.


Sprained ankles often heal with residual weakness. If this weakness is not corrected, a cycle might develop: The weakness of the ankle makes it likely to roll over, and after it rolls over, the ankle is weaker. A common potential cause of recurrent problems with ankle sprains is incomplete rehabilitation and residual, unrecognized weakness. A sprained ankle that won’t heal usually involves one of the following:



  • Weak peroneal tendons. These two tendons span the outside (lateral) aspect of the ankle, preventing the ankle from rolling (inverting).
  • Sinus tarsi syndrome. There is a hollow area on the side of the ankle that can be painful because of scar tissue from a healed sprain.
  • Injured peroneal tendons. Chronic unstable ankles can develop partial tears in the peroneal tendons that cause pain and improper function. Tears often don’t show up well on magnetic resonance imaging (MRI). A sonogram might reveal the damage better.

Ankle instability is characterized by repetitive episodes of the ankle “giving way,” or recurrent, symptomatic sprains, and has been shown to occur in about 40 percent of athletes after initial sprain. If symptoms persist after functional rehabilitation, surgical repair of the injured ligaments can return stability to the ankle joint.


Return to Action


Return to sport for grade I sprains typically takes one to two weeks; grade II sprains take two to four weeks; and grade III injuries take four to six weeks. Taping or ankle braces can provide stability in the acute phases of healing.



SYNDESMOTIC ANKLE SPRAIN


Common Causes


A syndesmotic ankle sprain, or high ankle sprain, is caused by external rotation, or the foot everting or turning outward. This is opposite to the more common lateral, or inversion, ankle sprain.


Identification


Athletes often will be able to describe a different mechanism to their injury than the typical sprain, such as the football player whose foot remains planted and the body is tackled to the ground. Another example is the downhill skier who gets the tip of the ski caught in snow or a gate, and the ski tip rotates outward and injures the ankle at the level of the syndesmosis. Tenderness is slightly higher in location than the typical ankle sprain; it can be felt in the lower end of the leg. X-rays are negative unless there is separation (diastasis) between the tibia and fibula at the ankle level. A fracture of the back of the tibia (posterior malleolus) can be present. It is important to palpate the outer knee to assess for tenderness, because sometimes a syndesmotic injury at the ankle can also involve a fracture higher in the leg, of the fibula, known as a Maisonneuve fracture. If the athlete has pain that is palpable just below the knee, one should suspect this fracture and imaging must be done. Magnetic resonance imaging or computed tomography (CT) scan might be needed to be certain of no diastasis at the ankle.


Treatment


For a high ankle sprain without diastasis, a walking boot followed by physical therapy is the treatment. The goal of treatment with immobilization is to minimize swelling and allow the ligaments to heal at the correct tension, thereby producing a stable ankle syndesmosis. If there is any separation or diastasis, then surgery is needed.


Return to Action


High ankle sprains usually take longer to heal. The athlete will likely be out for up to 12 weeks. Return after surgery can be six weeks to four months depending on the severity of the sprain.



POSTERIOR ANKLE IMPINGEMENT


Common Causes


Posterior ankle pain and impingement occur most commonly in sports that require hyperplantar flexion (forceful movement of the foot downward as when depressing the gas pedal in a car) of the ankle. It is most commonly seen in dancers, especially ballerinas. The causes of posterior ankle pain include os trigone, flexor hallucis tendon (FHL) pathology, and posterior capsule thickening. The os trigone is an extra ossification center at the back of the ankle and present in 5 to 11 percent of the general population, but typically not symptomatic. The FHL can develop a thickening as it passes through tunnel along the back of the ankle, thus causing impingement.


Identification


Symptoms are pain, tenderness, and swelling along the back of the ankle. The pain can be associated with the jumping and dance positions of plié, tendu, or relevé. The plantar flexion test reproduces pain in the back of the ankle when forcibly flexing the ankle downward maximally.


Treatment


Treatment is rest, a walking boot, or image-guided steroid injection. Surgery to address the cause of the posterior impingement can include excision of the os trigone, release of the FHL tendon, or debridement of posterior capsule hypertrophy.


Return to Action


The athlete can return to sports or dance once able to walk pain free, and after completion of a rehabilitation program. Return after surgery can take 8 to 12 weeks.



ANTEROLATERAL SOFT TISSUE IMPINGEMENT OF THE ANKLE


Common Causes


Ankle inversion injuries can result in persistent anterolateral pain in 20 to 40 percent of athletes. Synovial scar tissue and abnormal hypertrophic healing of the ATFL or the anterior tibiofibular ligament (ATF), or both of these, are all possible causes of this condition. Basketball, soccer, and tennis are common sports in which athletes can injure their lateral ligaments; these can heal, but at times with abundant scar tissue. This scar tissue can then impinge, or “get caught” in the ankle in certain positions, most commonly when the foot bends upward.


Identification


The athlete will experience pain, swelling, and limited dorsiflexion of the ankle. The positive squat test reproduces the anterolateral pain by having the patient squat down while keeping the heels on the ground.


Treatment


Physical therapy and steroid injection can be helpful. If pain persists, arthroscopic debridement can remove the soft tissue impingement.


Return to Action


Athletes typically return to sports soon after injection if successful. If arthroscopic surgery is required, then recovery and return can require 8 to 10 weeks.



OSTEOCHONDRAL LESION OF THE TALUS


Common Causes


Osteochondral lesions of the talus (OLT) are focal injuries of the cartilage and underlying bone in the ankle joint and occur in up to 50 percent of all ankle sprains. They often are undetected initially. Football and basketball are common sports that can result in a significant sprain and stress the cartilage of the talus bone.


Identification


The athlete will typically experience pain that lingers longer than expected for the typical ankle sprain. The pain is felt deep in the ankle joint, and the athlete may experience catching, clicking, or at times, locking of the ankle. The discomfort is worse when performing cutting or rotational motions. X-rays can be negative, but MRI is diagnostic and is the preferred diagnostic test for this condition.


Treatment


A rehabilitation program to strengthen the peroneal tendons, and proprioceptive training, can potentially compensate for this injury. However, because OTLs are mechanical irregularities inside the ankle joint, ankle arthroscopy and microfracture are often needed to treat this entity. There are now biologic adjuvants such as bone marrow aspirate and allograft cartilage graft that can improve the quality of cartilage regrowth.


Return to Action


Recovery time can be prolonged after surgery, and return to sports is typically six months or longer. The cartilage repair can take four to six months to fill, and caution is advised to allow proper repair. A slow progression of low- to higher-impact activities is important in rehabilitation.



PERONEAL TENDON DISORDERS


Common Causes


The peroneal tendons (peroneus longus and peroneus brevis) are the major evertors of the foot (they move the foot outward). They originate from the fibula and interosseus membrane; the peroneus brevis attaches to the base of the fifth metatarsal, and the peroneus longus attaches to the undersurface of the base of the first metatarsal. They can be injured with inversion ankle injuries and can also be pushed out of their groove with everted dorsiflexion (extension and outward motion of the ankle) injuries, especially in skiing. The injuries can result in longitudinal tears or subluxation of the tendon.


Identification


Athletes with peroneal tendon tears often present with vague lateral ankle pain. Swelling behind the lateral ankle is common, and often the tendon is painful to palpation. Peroneal tendon subluxation can be replicated by having the athlete dorsiflex (extend upward) and evert the ankle. This maneuver often produces a click or subluxation. An MRI or ultrasound can confirm the diagnosis.


Treatment


Initial treatment for these tears include: a walking boot, possible PRP, and physical therapy. Surgical repair is required if signs and symptoms persist. Peroneal subluxation or complete peroneal dislocation can result in tearing of the peroneal retinaculum (ligament that maintains tendons in its groove), and surgery is usually necessary.


Return to Action


Rehabilitation after injury or surgery can be three to six months. Activities requiring forced eversion of the ankle are limited during recovery. When the athlete is pain free and has full range of motion of the ankle, return to sport is anticipated.



ANKLE FRACTURE


Common Causes


Ankle fractures are often the result of high-energy injuries, such as falls from height, motor vehicle accidents, or contact sports.


Identification


Much like ankle sprains only more severe, ankle fractures usually involve a painful, swollen, and bruised ankle. Most athletes cannot bear weight on a fractured ankle.


Treatment


If an ankle is broken but the bone is not displaced, the injury may be treated without surgery. If the bones are displaced, the fracture will almost always require surgical management to restore stability to the ankle and ensure adequate healing of the fracture.


Return to Action


Much like the recovery following Achilles tendon rupture, recovery from an ankle fracture requires many months of rehabilitation. Typically, an athlete whose broken ankle requires surgery will wear a cast and be unable to bear weight on the ankle for two months. Afterward, physical therapy begins, and return to the gym occurs between two and three months from the time of injury. Running can begin at about three to four months, and pivoting sports at four to six months. The patient should be advised that maximum recovery might not be achieved until one year from the time of injury.



POSTERIOR TIBIAL TENDINITIS


Common Causes


The posterior tibial tendon (PTT) is the large, strong tendon on the inside of the ankle that supports—holds up—the arch of the foot. The posterior tibial strain is commonly seen in pronated (flat-footed) runners or those whose lower legs are rotated outward (duck-footed).


Identification


Athletes often experience increasing or chronic pain on the inside (medial) aspect of the ankle. They might report a progressive worsening flat-foot deformity or collapse of the arch of the foot over time. Another problem related to PTT strain is a painful accessory navicular bone (see p. 309).


Treatment


Treatment usually involves immobilization of the ankle in a walking boot if the pain is significant, and supportive measures such as orthotics and strapping to support the arch of the foot are prudent. Cortisone injections are risky because they can damage the PTT. In athletes under 40, the injury tends to heal with time and physical therapy, whereas in athletes over 50, especially in overweight females, it tends not to heal well. For these individuals, the tendon inflammation can progressively worsen and lead to slow rupture of the tendon and collapse of the foot’s arch (like an old rope that stretches out and eventually comes apart). Surgery may be performed to reconstruct the deficient tendon and to realign the hindfoot.


Return to Action


Athletes may return to sport as soon as symptoms subside. They might consider using an orthotic during future sporting activities.



BONE SPURS ON THE ANKLE



Common Causes


Athletes engaged in jumping activities tend to develop bone spurs in the front of the ankle where the bones bang into each other. These form slowly over time.


Identification


Athletes experience persistent pain and swelling at the front of the ankle. The hallmark symptom of this condition is limitation in the upward motion (dorsiflexion) of the ankle caused by impaction of the bone spurs onto each other.


Treatment


If symptoms are severe enough, the spurs can be removed surgically with an arthroscope or a small open incision. Less severe cases are treated symptomatically with local icing and medications for pain.


Return to Action


These “cleanout” surgical procedures are usually quite effective, but the ankle is a touchy joint that tends to recover slowly after surgery. It may be several months before athletes are able to return to their usual levels of activity.


*The authors would like to acknowledge the contribution of Andrew A. Brief to this chapter.

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Apr 16, 2020 | Posted by in SPORT MEDICINE | Comments Off on Lower-Leg and Ankle Injuries
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