1. Foot and Ankle Sports
Selene G. Parekh, MD, MBA
Associate Professor of Surgery
Partner, North Carolina Orthopaedic Clinic
Department of Orthopaedic Surgery
Adjunct Faculty Fuqua Business School
Duke University
Durham, NC
919.471.9622
http://seleneparekhmd.com
Twitter: @seleneparekhmd

2. Ankle Problems in the
Athlete

3. Athletic Injuries
• Participation in organized/recreational sports
continues to increase
• Injuries can be debilitating
• Recognition, prompt treatment and rehabilitation
• Prevent long term disability

4. Athletic Injuries
• 59% of adults participate in
exercise
• 11% jog
• 25% run ≥ 2 miles/day
• 800 footstrikes/mile
• Impact 3-8 x body wt
• Running injuries vary between
37%-57%

5. Athletic Injuries
• Risk Factors
• Intrinsic
• Individual’s physical and
personality traits
• Extrinsic
• Training techniques
• Weekly running mileage
greater than 40 miles
• Playing surfaces
• Equipment
• Break-away bases

6. Athletic Injuries
• Etiologic Factors
• Biomechanical abnml
• Flexibility
• Strength
• Footwear & orthoses
• Playing surfaces

7. Athletic Injuries: Etiology
• Biomechanical abnormalities
• Pelvic obliquity only predictor of injury
• <10% running injuries are due to biomechanical
problems
• 70-80% runners treated with orthoses improve
• Need to wean use

8. Athletic Injuries: Etiology
• Flexibility
• Prevention
• Tight Achilles
• Decreased DF
HV, turf toe, midfoot
strain, ankle sprain,
Achilles tendinitis,
calf strain
• Decr. MTP ROM
• HR dancers predispose
to injury
• Hypermobility
• Posterior ankle pain
• Pathologic laxity
• Recurrent ankle sprain

9. Athletic Injuries: Etiology
• Strength
• Weakness  injury
• >10% difference in extremity strength puts player
at risk
• Soccer & volleyball players risk for injury and
recurrence due to weakness
• Restore normal strength ratio though isotonic and
isokinetic strengthening

10. Athletic Injuries: Etiology
• Footwear and orthoses
• Improper fit
• Tight/loose, neurapraxia
• Load  cushioning
• Reduced calcaneal stress fx in military recruits
• Loss of sensory feedback
• Torque
• Cleating  ankle injuries
• Too much, too little traction

11. Athletic Injuries: Etiology
• Playing Surfaces
• Concrete, synthetic track
• Grass vs. artificial turf
• Role not completely defined

12. Chronic Leg Pain
• Concurrent with foot/ankle complaints
• Differential
• Chronic compartment syndrome
• Medial tibial stress syndrome
• Stress fractures
• Muscle strain/tendinitis
• Nerve entrapment
• Vascular disease
• Fascial herniation
• Radiculopathy

13. Chronic Leg Pain
• Incidence
• 150 patients
• 33% chronic compartment syndrome
• 25% stress fx
• 14% muscle strain, 13% medial tibial stress syndrome
• 10% nerve entrapment, 4% venous disease
• Shin splints
• Periostitis
• 10-15% all running injuries

14. Exercise-Induced Compartment Syndrome

15. Exercise-Induced Compartment Syndrome
• Incidence
• Unclear
• 70% runners, 20% ball and puck
• Clinical Features
• Pain predictable after certain distance, duration,
speed
• Aching, cramping, stabbing, fullness
• Neurologic symptoms
• Anterior, deep posterior compartments

16. Exercise-Induced Compartment Syndrome
• Diagnosis
• Clinical
• Rest: Minimal tenderness
• Exercise to provoke sx
• Muscle herniation 20-60% pts
• DPN/SPN
• Radiologic
• Stress fx
• Occult tumor
• Bone scan
• MRI

17. Exercise-Induced Compartment Syndrome
• Criteria for Diagnosis
• Pressure measurements
• Resting, post-exercise measurements
• Secondary
• Pressure >15mmHg pre-exercise
• Pressure >30mmHg 1 min post-exercise
• Pressure >15mmHg 5-10 min post-exercise

18. Exercise-Induced Compartment Syndrome
• Conservative treatment
• Dependent on athletes goals
• Activity modification
• Rest  gradual increase in exercise
• Ice, NSAID’s
• Insoles, orthoses
• Surgical treatment
• Fasciotomies

19. Exercise-Induced Compartment Syndrome
• Results
• Good with proper patient and techniques
• 80-95% excellent results
• 20% decrease in strength
• Complications
• Swelling
• Hematoma
• Infection
• Herniation
• Nerve entrapment
• Recurrence

20. Stress Fractures: Tibia & Fibula
• Abnormal repetitive loads causing imbalance of
resorption over formation
• Running > basketball > soccer > skating >
aerobics > ballet
• Athletes with decreased mineral content
• Amenorrheic females

21. Stress Fractures: Tibia & Fibula
• Clinical features
• Recent change in routine
• Insidious, localized tenderness, swelling
• Diagnosis
• X-ray initially negative
• (2-3 weeks) radiodense haze, periosteal rxn
• Transverse cortical lucency
• Bone scan

22. Stress Fractures: Tibia & Fibula
• Conservative Treatment
• Rest, cessation of activity
• NWB PWB to WBAT
• As symptoms allow
• Swimming, pool running, cycling
• Resume competition full motion, strength, minimal
tenderness
• Surgical Treatment
• Excision, bone grafting
• PEMF bone stimulation
• Intramedullary fixation

23. Gastrocnemius-Soleus Strain
• Common injury
• Racquet sports, basketball, running, skiing
• Plantaris tear
• Clinical Features
• Sudden knee extension while crouched w/ ankle DF
• Sudden sharp pain
• Difficulty with toe-off

24. Gastrocnemius-Soleus Strain
• Treatment
• Casting/immobilization
• RICE
• WBAT
• Active dorsiflexion
• Gentle passive stretching more functional
recovery

25. Nerve Entrapment Syndromes
• Superficial Peroneal Nerve
• Neuritic pain, burning, tingling, radiation
• Tenderness over area of compression
• R/o compartment syndrome, double-crush
• Tx
• Injections, modalities, thermogesic creams,
neuroactive medications, shoe modifications
• Surgical nerve release, fasciotomy

26. Popliteal Artery Entrapment Syndrome
• Rare, mimics pain chronic compartment
syndrome
• Recognition important as may lead to
amputation

27. Popliteal Artery Entrapment Syndrome

28. Popliteal Artery Entrapment Syndrome
• Clinical
• Cramping pain, intermittent claudication
• 67% bilaterality
• Pulses diminished or absent
• Knee hyperextended, ankle dorsiflexed
• Knee warm, foot cool
• Ischemia, thrombosis; palpable mass

29. Popliteal Artery Entrapment Syndrome
• Diagnostics
• Provocative testing (treadmill) absent pulses
• Doppler, U/S  flow, aneurysm
• Biplanar arteriography after exercise
• Deviation, occlusion, dilatation
• Treatment
• Release
• Bypass grafting

30. Venous Disease
• Effort thrombosis
• Pain, edema, distended veins, discoloration
• Venography
• Tx: anticoagulation  heparin, coumadin
• Thrombophlebitis
• Immobilization after injury
• Air travel
• Dehydration
• Oral contraceptives
• Alcohol/drug use

31. Delayed-Onset Muscle Soreness
• Unaccustomed to activity
• Eccentric muscle contraction  microinjury,
subcellular level
• Inability to generate maximal force
• Pain, fatigue
• Loss of performance 24-48hrs
• Resolve 5-7 days
• Tx
• Symptomatic treatment

32. Medial Ankle Sprains
• Rare, associated with lateral, bony injuries
• 2 portions:
• Superficial deltoid
• Deep deltoid
DeepSuperficial

33. Medial Ankle Sprains
• Biomechanics of deltoid
• Prohibits abduction
• Secondary restraint against anterior translation ankle
• Deep deltoid
• Greatest restraint lateral translation (after fibula)
• Highest load to failure
• Valgus tilt  superficial & deep rupture

34. Medial Ankle Sprains
• Clinical Evaluation
• Lateral injury, fracture, syndesmotic injury
• Abduction, eversion
• Other injuries
• Maisonneuve, FDL, PTT, FHL, tibial & saph n

35. • Radiographs
• Assoc fx, AP stress  valgus tilt, normal with
incomplete injury
• MRI
Medial Ankle Sprains

36. • Conservative Treatment
• Dependent upon associated injuries
• Walking cast, boot 6-8wks
• Functional treatment
• Surgical treatment
• Inability to reduce medial clear space
• Direct repair
• Suture, suture anchors
• Stirrup brace 6 months after surgery
Medial Ankle Sprains

37. Sinus Tarsi Syndrome
• Related to subtalar instability
• Nebulous condition w/ pain in lateral ankle &
sinus tarsi
• Pathologic anatomy not clearly defined
• Scarring or degenerative changes to soft tissues
within sinus tarsi
• Loss of nerve function  loss of proprioception

38. Sinus Tarsi Syndrome
• Diagnosis
• Clinical Evaluation
• Pain lateral ankle, sinus tarsi
• Prior inversion injury
• Instability rare
• Radiologic Evaluation
• X-rays- normal
• Subtalar arthrography
• Absence of microrecesses, interdigitation
• MRI
• Fibrosis, fluid collections

39. Sinus Tarsi Syndrome
• Conservative treatment
• Injection
• Surgical treatment
• Exploratory, sx may persist
• Resect fibrofatty tissue & extensions from IER
• Subtalar arthroscopy
• Results
• 96 cases; 69% excellent, 25% good, 6% failures

40. Os Trigonum/Posterior
Impingement
• First Described
Rosenmuller
• First Described as
Fx Shepherd 1822
• Asymptomatic
• Separate
Ossification Center
• Age 8-11
• Incidence 1.7 - 7%

41. Os Trigonum/Posterior
Impingement
• No side predominence
• Vary in size
• Normal anatomic variation
• Mild extension
• Thumb shaped projection - 1 cm (Stieda’s
Process)

42. Os Trigonum/Posterior
Impingement
• Symptoms
• Pain with PF
• Young Athlete/Dancer
• Spectrum
• Acute – Fx
• Gradual - FHL Tendinitis

43. Os Trigonum/Posterior
Impingement
• Conservative
• Immobilization
• NSAID
• Surgical – Excision

44. Prone Ankle Scope

45. Evaluation
• 54% of talar dome
• Os trigonum
• Haglund’s
• Achilles insertion site

46. Foot Problems in the
Athlete

47. Goals & Objectives
• Specific problems
• Midfoot
• Forefoot

48. Os Peroneum
• Ossification
• Complete
• Less than complete
• Multipartite
• Location
• Lateral border calc & plantar lateral cuboid
• Useful marker for ruptured PL

49. Painful Os Peroneum Syndrome
(POS) & PL Disruption

50. POPS/Peroneus Long.
Tendonitis/Tear
• Conservative treatment
• Cast immobilization (20% success)
• Physical therapy
• Surgical treatment
• Os peroneum excision/tendon repair
• Peroneal tenodesis

51. Forefoot Sprains
•First MTP joint/ “turf toe”
•Etiology
•Hard artificial surface, flexible shoes
•True incidence not defined, but many
reports indicate a fairly common entity
•Functional disability
•Push-off impaired
•Compromised forward drive and
running
•More missed games & practices than
other injuries

52. Forefoot Sprains
• Mechanisms of injury
• Hyperextension of the MTP joint
• Foot dorsiflexed, forefoot fixed, heel raised
• Joint capsule tears, compression injury to the dorsal articular
surface with extremes of dorsiflexion

53. Forefoot Sprains
• Etiologic factors
• Shoe-surface interface
• Flexible shoes
• Hardness of surface
• Loss of resiliency with time
• Enhanced friction
• Fixes foot allows extremes of motion
• Excessive DF
• In those with limited DF

54. Forefoot Sprains
• Radiographs
• R/o fx, avulsions, impaction
• Other methods usually not necessary

55. Forefoot Sprains
• Conservative treatment
• RICE, NSAID’s
• Taping, boot
• Increase stiffness in shoe
• Custom molded insert/Morton’s extension
• Rehab once decrease in sx allows

56. Forefoot Sprains
• Surgical treatment
• Rarely necessary
• Instability
• Loose bodies, osteochondral injury
• Ligamentous disruption
• Sesamoid retraction
• Repair plantar plate, FHB, long flexor transfer

57. Metatarsal Stress Fractures
• Etiology
• Injury to opposite limp 
increased stress to normal
limb
• Muscle fatigue  increase in
loading
• Hard surfaces, poorly
cushioned shoes, heavy heel
strike
• Rigid cavus feet  decrease
shock absorption of the
midfoot  increase stress on
MT’s
• Hypermobile first ray or long
2nd MT

58. Stress Fractures
• High index of suspicion
• Focal tenderness
• Min/no swelling
• X-rays nl < 3-4 wks
• Bone scan, MRI, & CT scans

59. Treatment
• Activity modifications
• Non-impact sports
• Avoid casting if possible

60. Treatment
• Shoe modifications
• Rigid cavus foot
• Flexible, cushioned arch support
• Hyperpronation/hypermobile 1st ray
• Soft medial arch support
• Long 2nd MT
• MT pad

61. RE
ECT
the ankle
the foot