Sports-Related Injuries of the Foot and Ankle

Johnny Lin, MD

Dr. Lin or an immediate family member has received research or institutional support from Arthrex, Inc. and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research-related funding (such as paid travel) from Medwest.

This chapter is adapted from Berkowitz MJ: Sports-Related Injuries of the Foot and Ankle in Chou LB, ed: Orthopaedic Knowledge Update: Foot and Ankle 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2014, pp 371-386.

ABSTRACT

The foot and ankle are often injured during athletic activities, and even when appropriately managed, such injuries can progress to become chronic conditions impacting both sports participation and routine activity. The most common athletic injury to the ankle is an acute sprain of the lateral ankle ligament complex. The initial treatment of an acute lateral ankle sprain is a combination of walking boot immobilization, functional bracing treatment, and neuromuscular rehabilitation. Chronic ankle instability can also be debilitating to the athlete and is initially managed nonsurgically, but often ultimately require surgical intervention. Assessing and correcting deformity of the hindfoot, in addition to ligament reconstruction, is necessary to optimize results. Acute syndesmotic ankle sprains are more severe than lateral ankle sprains and require longer treatment before return to sport. High-grade injuries require immediate surgical intervention. Midfoot sprains are less common and require careful assessment to avoid a delay in diagnosis. Stable injuries are successfully treated nonsurgically, whereas unstable injuries require surgical intervention. Stress fractures of the foot and ankle are common in athletes and can be associated with vitamin D deficiency. Most stress fractures can be successfully treated nonsurgically.

Introduction

Acute traumatic injuries and cumulative stress injuries involving the foot and ankle can affect the sports participation and performance of both elite competitive athletes and people engaged in recreational or fitness activities. A thorough understanding of common injuries of the foot and ankle allows a logical and organized approach to treating these injuries and facilitates the patient’s return to play.

Ankle Anatomy

The stability of the ankle is the result of a combination of osseous, ligamentous, and musculotendinous components. The ankle generally is described as a mortise in which the talus is housed in the dome-shaped tibial plafond and the medial, lateral, and posterior malleoli. The talus is wider anteriorly than posteriorly so that the ankle intrinsically is most stable in the dorsiflexed position when the wider portion of the talus is engaged in the mortise. Conversely, in the plantarflexed position the narrower posterior talus is engaged in the mortise and the ankle therefore is more unstable. Therefore, in the plantarflexed position the stability of the ankle is more dependent on the lateral ligament complex. Not surprisingly, most acute inversion sprains occur when the ankle is somewhat plantarflexed.

The lateral ankle ligament complex primarily is composed of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). The ATFL prevents anterior translation of the plantarflexed ankle. The CFL is a collateral ligament that stabilizes both the ankle and the subtalar joint preventing varus of the ankle and subtalar joint. In more severe inversion sprains, the CFL is injured along with the ATFL.

The peroneal musculotendinous unit is an important contributor to ankle stability. The peroneal tendons rapidly contract to resist and prevent excessive inversion. The peroneal complex is also part of an important proprioceptive feedback loop that enables an athlete to instinctively sense and control the position of the foot and ankle in space.

Acute Lateral Ankle Ligament Injuries

Acute lateral ankle sprain is one of the most common injuries sustained during sports activity. An epidemiologic study of ankle sprains reported that more than three
million sprains occurred during the 4-year study period and that more than half of these injuries occurred during athletic activity.¹ Acute ankle sprain was most common in individuals aged 10 to 19 years. Boys and men aged 15 to 24 years sustained more ankle sprains than girls and women in the same age range, but women older than 30 years sustained more sprains than their male counterparts.

An acute ankle sprain causes a variable amount of mechanical injury to the lateral ligament complex of the ankle. Such an injury can lead to lingering symptoms such as instability and pain, which can impede or preclude return to play. Proper initial management and detection of concomitant injuries (ie, talar chondral injuries, peroneal tendon pathology, fractures) minimizes the risk of long-term morbidity and speeds the resumption of athletic participation.

Patient History and Physical Examination

Successful treatment of an acute ankle sprain begins with a careful history and meticulous physical examination. Important components of the history include the time since injury, the ability to tolerate weight bearing, whether the injury is improving, or if there have been previous sprains of the same ankle. The physical examination should document the location and severity of swelling and ecchymosis. Probably the most important component of the physical examination is assessing the location of tenderness to palpation. After an acute lateral ankle ligament injury, swelling, ecchymosis, and tenderness usually are noted over the ATFL and CFL in the region just anterior and distal to the tip of the fibula. However, tenderness should be checked over several different structures to look for signs that could implicate an alternative or concomitant diagnosis. Laterally, the distal syndesmosis, lateral malleolus, peroneal tendons, fifth metatarsal, anterior process of the calcaneus, and lateral process of the talus should be palpated in addition to the lateral ligament complex. Medially, the medial malleolus, deltoid ligament, sustentaculum tali, and navicular should be examined and assessed for tenderness. Routine palpation of the Achilles tendon, tibialis anterior tendon, and midfoot articulations should also be included; injury to these structures sometimes is neglected when a diagnosis of ankle sprain is presumed. Manual muscle testing is also performed despite the effects of acute swelling and pain to verify continuity of these structures and to aid in the detection of acute peroneal dislocation. Resistance to inversion with the ankle in a dorsiflexed everted position and circumduction of the ankle are used to improve the sensitivity of detecting peroneal dislocation. Despite use of a careful physical examination, many findings can still be obscured by diffuse swelling and poorly localized tenderness during the first 10 to 14 days after an acute ankle inversion injury. As a result, it is important to repeat the examination 10 to 14 days later, when the findings will be more specific and revealing.

Instability tests such as the anterior drawer and talar tilt tests generally do not have a significant role in the evaluation of an acute ankle sprain. With an acute injury, the ankle often is too swollen and uncomfortable to allow an unguarded and accurate assessment of stability. The results of these tests generally do not affect the initial treatment of an acute sprain, and they should be reserved for evaluating chronic ankle instability.

Radiographic Evaluation

Appropriate radiographic studies are helpful for avoiding a misdiagnosis and facilitating a prompt diagnosis of associated injuries. In the emergency department, the Ottawa ankle rules provide guidance as to whether radiographs are necessary or can be deferred. Ankle radiographs are indicated if the presence of a fracture is suggested by tenderness along the distal 6 cm of the posterior edge of the fibula or the tip of the lateral malleolus, tenderness along the distal 6 cm of the posterior edge of the tibia or the tip of the medial malleolus, or inability to tolerate weight bearing for at least four steps. In the absence of these findings, the diagnosis usually is an acute sprain, and radiographs are unnecessary. Adherence to these guidelines reduces the patient’s cost, time in the emergency department, and exposure to radiation.

The Ottawa ankle rules were designed for implementation and use in the emergency department. However, many patients who sustain an acute lateral ankle ligament injury are evaluated by an orthopaedic surgeon in an outpatient clinical office several days to a few weeks after injury. In this more specialized environment, the threshold for radiographic evaluation is lower because the definitive diagnosis and treatment plan are based on the evaluation. An orthopaedic surgeon should attempt to obtain a series of weight-bearing ankle radiographs for most patients with an acute lateral ankle sprain. Additional weight-bearing radiographs of the foot can be added when there is suspicion for a concomitant foot injury based on either the history or physical examination. Weight-bearing views provide substantially better imaging of relevant osseous structures than non-weight-bearing views and thereby minimize the possibility of missing an injury. Simulated weight-bearing views can be obtained at the initial evaluation if full weight bearing is too painful. Obtaining full weight-bearing views is deferred until symptoms improve. The AP and mortise ankle radiographs of the ankle should be evaluated for medial clear space and syndesmotic widening, malleolar fracture, lateral process of talus fracture, and talar osteochondral fracture (Figure 1). The lateral views of the ankle and foot can reveal dorsal talar avulsion fractures,
anterior process of the calcaneus fractures, or the presence of an os trigonum injury. The AP and oblique foot views can reveal navicular fractures, midfoot injuries, cuboid fractures, or fifth metatarsal fractures. Radiographic and physical examination findings always must be correlated to provide an accurate and complete diagnosis.

FIGURE 1 A, Mortise ankle radiograph in a patient with an acute ankle sprain. Lucency in the lateral talar dome suggests a fracture. B, Magnetic resonance image confirms that the patient has an acute unstable lateral talar osteochondral fracture.

CT and MRI have limited indications in the evaluation of an acute ankle sprain. CT is used to detect an associated fracture suspected on the basis of plain radiographs; these include fracture of the lateral process of the talus and the anterior process of calcaneus, posterior talar fracture, and osteochondral fracture. CT provides an accurate assessment of fracture size, displacement, and comminution that ultimately can guide treatment. CT, preferably weight-bearing, can also detect malalignment or displacement of the syndesmosis through visualizing the clear space in the axial plane. MRI rarely is indicated to evaluate an acute ankle sprain and should be obtained only if suspicion is high for an osteochondral lesion of the talus or an associated soft-tissue injury such as an Achilles tendon rupture or peroneal tendon dislocation. MRI is useful for distinguishing a preexisting chronic osteochondral lesion from an acute osteochondral fracture. MRI has also been found to be superior to physical examination for the detection of syndesmotic injuries in the setting of ambiguous plain radiographs.²

Classification and Treatment

Acute lateral ankle sprains are graded based on the involved ligaments and the severity of the structural injury to the lateral ligament complex. A grade I acute sprain is a minor injury to the ATFL characterized by microscopic tears in the ligament fibers without gross structural damage. In a grade II sprain, partial macroscopic structural damage has occurred without complete loss of integrity; a grade II sprain primarily affects the ATFL, but the CFL may be involved to a lesser extent. A grade III sprain involves complete rupture of the lateral ligament complex, with loss of integrity of both the ATFL and the CFL.

The severity of a lateral ankle sprain affects both its treatment and prognosis. Patients with a grade I or II sprain typically do not require crutches and are able to perform activities of daily living with minimal discomfort. A grade I or II sprain appears to recover best when an early rehabilitation regimen is implemented. In fact, a recent randomized controlled study demonstrated that grade I and II sprains achieve earlier recovery when an immediate functional range of motion protocol is initiated compared with early immobilization.³ The timing of the patient’s return to sports activity primarily is based on the level of discomfort and ability to perform necessary sport-specific activities. Generally, the patient can return to sports 2 to 6 weeks after a grade I or II ankle sprain, with the use of a protective brace and initiation of peroneal strengthening and proprioceptive exercises aimed at preventing reinjury.

Patients with a grade III injury often initially experience discomfort during ambulation and while performing activities of daily living. A period of immobilization and protected weight bearing often is beneficial. However, the optimal length of time and the exact method of immobilization is not well established, as there have been conflicting results in various studies. A prospective randomized study compared the efficacy of four different modes of immobilization (tubular compression sleeve, walking boot, stirrup brace, cast) for the initial treatment of an acute grade III ankle sprain.⁴ Somewhat surprisingly, the results favored initial cast immobilization for a severe ankle sprain. Patients who had initial casting experienced the most rapid overall recovery, with less pain and an earlier return to activity. The use of a walking boot was found to confer no significant benefit over that of a tubular compression sleeve. In another randomized trial of acute management of lateral ankle sprains, the use of a walking boot for 3 weeks followed by progression to a functional brace was compared with immediate initiation of functional bracing treatment without any period of immobilization.⁵ There was no observed difference between groups in pain or instability; however, the immediate functional bracing treatment group had better functional scores and a more rapid recovery period. In a related randomized study comparing functional bracing treatment, neuromuscular training, and a combination of these interventions for lateral ankle sprains, authors found that bracing treatment was the most cost-effective of these interventions.⁶

After the initial pain, swelling, and discomfort have resolved over 2 to 4 weeks, a patient with a grade III sprain receives a functional brace, and formal physical therapy is initiated to decrease swelling, improve range of motion, and restore strength to the ankle. With symptom improvement, the therapeutic exercises gradually advance to proprioceptive exercises and sport-specific functional drills. Plyometric drills should be incorporated into the rehabilitation program because they are superior to standard peroneal strengthening exercises for restoration of subjective ankle stability and resumption of athletic participation.⁷ The return to sport after a grade III sprain typically requires 6 to 12 weeks of rehabilitation. Although nonsurgical functional rehabilitation for a grade III ankle sprain remains the standard of care in North America, a body of evidence from Europe suggests that superior results are possible when an acute grade III sprain is surgically treated.⁸^,⁹ A meta-analysis of 27 studies revealed less giving way and overall better functional results when the initial treatment of grade III sprains was surgical rather than nonsurgical.⁸ A subsequent prospective, randomized comparison of surgical treatment and functional rehabilitation in grade III ankle sprains found comparable functional results and fewer recurrent sprains in the patients treated surgically.⁹ Additional high-quality studies are necessary before surgical treatment can supplant functional rehabilitation as the treatment of choice for grade III ankle sprains.

Chronic Lateral Ankle Ligament Injuries

With proper treatment, most patients who sustain an acute lateral ankle sprain successfully recover and return to their desired sports and preinjury level of activity. However, the outcome of a lateral ankle sprain, particularly a grade III injury, is not always favorable. A multiple database study of acute ankle sprains found that as many as 33% of patients still had pain 1 year after injury, and as many as 34% of patients sustained a recurrent sprain within a 3-year period after the initial injury.¹⁰ The evaluation of a patient with chronic symptoms after ankle ligament injury must help identify the source of the lingering symptoms and initiate appropriate nonsurgical treatment. When necessary, surgical intervention is required to facilitate a return to sports.

Patient History

The history should elicit details of the initial injury, subsequent reinjury, and current symptoms. It is important to assess whether the patient’s symptoms primarily involve instability, pain, or both. A detailed characterization of the instability and pain components of the patient’s symptoms should be sought. The duration, frequency, and severity of instability episodes should be recorded and should include the number of sprains per month or year. The examiner should assess whether the recurrent sprains occur only during sports activities or also during activities of daily living. Patients with severe chronic instability may report frequent sprains with seemingly innocuous mechanisms such as stepping on a pebble, a curb, or a crack in a sidewalk. The examiner should document the extent of earlier treatment, including physical therapy, and to what extent bracing treatment controls the instability.

The timing, severity, and location of the pain component should also be assessed. The patient should be asked whether pain is present constantly or only after a sprain. Patients sometimes report surprisingly little pain after recurrent ankle sprains because of the overall laxity of the ligaments. Other patients report pain as the primary symptom and describe pain that precipitates the giving way episode. This type of pain should alert the examiner to the possibility that functional instability symptoms may be the result of concomitant mechanical pathology. It is particularly important for the patient to identify the location of the pain as specifically as possible. Determining whether the pain primarily is medial, anterolateral, or retrofibular will suggest the most likely causes and guide the choice of imaging.

Physical Examination

The goals of the physical examination of a patient with symptoms of chronic instability are to characterize the severity of ligament laxity, identify sources of pain, and assess for anatomic factors that predispose the patient to instability or affect the response to treatment. Ankle ligament laxity is assessed using the anterior drawer and talar tilt maneuvers. The anterior drawer test is used to assess the integrity of the ATFL and is performed with the ankle in a resting equinus position. This position of relative plantar flexion orients the fibers of the ATFL in line with the examiner’s pull. The examiner stabilizes the tibia above the ankle with one hand, wraps the other hand around the heel, and translates the foot and ankle anteriorly on the stationary tibia. The examiner can feel the extent of anterior translation and can see a dimpling of the skin over the ATFL if significant laxity is present. The talar tilt maneuver assesses the laxity of the CFL. It is important to perform this maneuver with the ankle in a relatively neutral position to orient the CFL vertically and allow it to be tested as a true collateral ligament of the ankle. Failure to adequately dorsiflex the ankle during the talar tilt test can make it difficult to distinguish normal subtalar motion from true talar tilt. Again, the examiner secures the tibia with one hand, positions the ankle in neutral with the other hand, and exerts an inversion stress on the ankle and hindfoot. Placing a thumb beneath the
fibula allows the examiner to feel the talus tilt within the ankle mortise. With both of these tests, it is crucial to examine the contralateral side as well as the general laxity of other joints. Hyperextension of knees, elbows, and fingers can point to the presence of general ligamentous laxity, which can predispose a patient to recurrent instability. The Beighton criteria for joint hypermobility are used in identifying patients with signs of generalized laxity, which can significantly affect the outcome of specific treatments.

The foot and ankle should be examined for strength, range of motion, tenderness, swelling, and gait, in addition to ligament laxity. The presence of claw toes or weak ankle dorsiflexion and eversion may suggest the presence of a neurologic condition such as Charcot-Marie-Tooth disease. Isolated peroneal weakness with painful resisted eversion often accompanies a peroneal tendon tear. Tenderness, swelling, popping, subluxation, or frank dislocation of the peroneal tendons provides further evidence of peroneal tendon pathology. Decreased passive ankle dorsiflexion may result from the presence of distal tibial osteophytes or a gastrocnemius-soleus complex contracture. Limited passive subtalar inversion can be a clue to the presence of a tarsal coalition.

It is critical to assess for cavovarus deformity while the patient is standing and walking. The importance of early diagnosis of cavovarus deformity cannot be overstated because these patients are at substantially increased risk for ankle inversion injury, are more likely than other patients to experience chronic symptoms, and are less likely to have a successful outcome after standard nonsurgical or surgical treatment. When a patient with cavovarus alignment is examined from the front, a so-called peek-a-boo heel sign can be seen, in which the medial portion of the heel pad is visible (Figure 2). When examined from the back, the heel rests in varus relative to the axis of the tibia, with weight bearing concentrated on the lateral border of the foot. A Coleman block test is then performed to determine the flexibility of the hindfoot. The patient is observed from behind while standing on a 1-inch block with the first ray allowed to hang off the edge of the block. Improvement in hindfoot varus during this test suggests that first ray plantar flexion is driving the hindfoot deformity and that correcting the first ray will produce adequate correction of the hindfoot. If the hindfoot varus is not corrected or only partially corrected during Coleman block testing, the varus deformity is coming primarily from the hindfoot, possibly necessitating an additional hindfoot procedure to obtain full correction of the deformity.

FIGURE 2 Clinical photographs of a patient with chronic left ankle instability and cavovarus. A, The so-called peek-a-boo heel sign. B, Hindfoot varus as seen from behind, with weight bearing on the outer border of the heel. C, Correction of hindfoot varus with the Coleman block test.

Radiographic Evaluation

Standard weight-bearing radiographs of the ankle and foot are used to evaluate a patient for chronic lateral ligament injury. AP and mortise views of the ankle should be scrutinized for lucent lesions in the talar dome that may signify osteochondral injury. The physician also should look for a large avulsion fracture off the distal tip of the fibula, which may accompany chronic ATFL injury. The lateral radiograph allows detection of anterior distal tibial osteophytes that can cause anterior ankle impingement. Radiographs can provide confirmation of subtle cavovarus malalignment. On a lateral radiograph of the foot, a cavus arch is suggested by a positive Meary angle formed by the axis of the talus and the axis of the first metatarsal. In cavovarus, a lateral radiograph fails to capture the talus in true profile, the fibula appears posterior, and the posterior facet is extremely well visualized, as in a Broden view. An AP foot radiograph may reveal so-called stacking of the metatarsals or metatarsus adductus. Each of these radiographic signs should raise the examiner’s suspicion for concomitant malalignment.

Stress evaluation of the ankle involves the anterior drawer and talar tilt maneuvers done with fluoroscopy
or plain radiography. Stress images are useful if it is desirable to quantify the severity of the instability, as for a research study. Stress fluoroscopy also is helpful for distinguishing true talar tilt from subtalar motion (Figure 3).

FIGURE 3 Stress fluoroscopic view showing laxity of the calcaneofibular ligament with a resulting increase in talar tilt.

MRI has a more significant role in chronic lateral ankle ligament injuries than in acute injuries. MRI is recommended if the patient’s history, physical examination, or plain radiographs suggest the possibility of osteochondral lesions of the talus or peroneal tendon injury. MRI also is indicated if the patient has poorly defined ankle pain because it can reveal conditions such as anterolateral soft-tissue impingement lesions, loose bodies, or subtle fractures.¹¹ If possible, 1.5- or 3.0-Tesla MRI should be obtained; the image resolution of open MRI is inadequate to provide meaningful information.

A recent retrospective cohort study compared MRI with stress radiographs among 187 patients.¹² Although MRI was highly sensitive compared with stress radiographs (83% versus 66%), the specificity of MRI was lower (53% versus 97%). The overall accuracy of stress radiographs was 74%, whereas the overall accuracy of MRI was 71%. The authors concluded that although MRI is a useful screening tool for concomitant ankle pathology associated with lateral ankle instability, it should not be used on its own for the diagnosis of chronic ankle instability.

Treatment

The treatment of a patient with chronic lateral ankle ligament injury begins with nonsurgical interventions designed to improve ankle stability and decrease pain. Bracing treatment should be implemented for a high-risk sports activity, such as basketball, volleyball, or tennis, or for any activity performed on uneven ground, such as hiking or lawn mowing. A course of neuromuscular physical therapy designed to optimize peroneal tendon strength, balance, and proprioception should be used unless previously completed. However, the long-term success of such a protocol for controlling instability symptoms is uncertain.¹³ Unfortunately, nonsurgical treatments often do not adequately control symptoms, particularly in patients who desire to return to an active athletic lifestyle.

Surgical intervention may be indicated if nonsurgical treatment does not provide sufficient stability and pain relief. The four types of lateral ligament reconstruction techniques are anatomic, anatomic-augmented, nonanatomic tenodesis, and anatomic free tendon graft. The goals of all surgical strategies and techniques are to improve mechanical ankle stability, decrease pain, and facilitate return to sports.

The preferred technique for lateral ankle ligament reconstruction remains the anatomic Broström technique. This is the most commonly used technique, and it is successful in treating chronic instability in most patients.¹⁴^,¹⁵ This technique involves incising and reefing the ATFL alone or both the ATFL and CFL to eliminate the laxity and elongation produced by chronic inversion injuries¹⁶ (Figure 4). The ligament can be reefed midsubstance in a vest-over-pants fashion or reefed directly to the fibula using drill holes or suture anchors.¹⁷ The inferior extensor retinaculum can be advanced to the fibula (the Gould modification) to further stabilize the ligament repair¹⁸ (Figure 5). Although this modification has been often-advocated, a recent study compared patients undergoing isolated and modified Broström procedures and found no difference in clinical or radiographic outcomes.¹⁹ The authors concluded that an isolated ligament reconstruction (ie, without the Gould modification) may be sufficient to restore stability. In a related study, authors compared attachment of the ligaments to the fibula using suture anchors versus suture bridges, finding that both options showed similar functional outcomes with the suture bridge being more expensive.²⁰

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