This document discusses common foot and ankle injuries in athletes. It notes that foot and ankle injuries account for around 25% of sports injuries and cost an average of $21,000-$24,000 per claim. The most common acute injuries are sprains, fractures, tendon ruptures, and toe fractures/dislocations. The most common overuse injuries are plantar fasciopathy, tendinopathy, stress fractures, and joint instability. Treatment options for various injuries like ankle sprains, Achilles tendon injuries, and plantar fasciopathy are also outlined. The document emphasizes the importance of early treatment to prevent long-term disability.

1. Andre D. Ross, DPM
Foot and Ankle Reconstruction
Summit Medical Group
Common Ankle and Foot Injuries in Athletes

2. Epidemiology
• Foot and Ankle injuries make up roughly
25% of sports related injuries. (garrick,
regua – clin sp med 1988)
• Type of injury varies from sport to sport
• According to National Safety Council –
average cost of per claim of a foot and
ankle injury $21,000 to $24,000

3. Most Common Sports Injuries
• Urgent Setting
 Foot and Ankle Sprains
 Foot and Ankle Fractures
 Tendon Ruptures
 Toe Fractures/Dislocations

4. Most Common Sports Injuries
• Non-Urgent Setting
(Overuse)
 Plantar Fasciopathy
 Foot and Ankle
Tendinopathy
 Tibial Stress Syndrome
 Foot and Ankle Stress
Fractures
 Joint Instability

5. Ankle Sprains
• Affect approximately one in 10,000 people each day
• The most common injury in sports according to many
sources
• Accounts for 40% of all athletic injuries and
 53% of basketball injuries
 29% of soccer injuries
• Peak incidence ages 15-19
• Most resume normal activity within 4-8 weeks
however 20-40% of those with severe sprains
experience residual pain/instability

6. Ankle Sprains
• Grading Sprains
 Grade 1 – Stretch
» RTA: 1-2 weeks
 Grade 2 – Partial Tear
» RTA: 2-4 weeks
 Grade 3 – Complete Tear
» RTA: 8-10 weeks

7. Ankle Sprains
• Inversion Ankle Sprains
 Most common – accounts for 75% of all
sprains
 Classic “rolled ankle”
 Structures of Interest
» Anterior Talofibular Ligament (ATFL)
» Calcaneofibular Ligament (CFL)
» Posterior Talofibular Ligament

8. Ankle Anatomy

9. Ankle Sprains
• Inversion Ankle Sprains
 Anterior Drawer Test
 Talar Tilt Test
 Go on Clinical Suspicion due to acute injury
 Often associated with other orthopedic
injuries/fractures!
• Anterior process, lateral talar process, posterior
talar process, 5th metatarsal base, osteochondral
injury.

10. Ankle Sprains
• Eversion Ankle Sprains
 Much Less common
 Can be far more devastating, especially
when associated with external rotation
 Structures of Interest
• Deltoid Ligament
• Posterior tibial tendon
• Spring Ligament

11. Ankle Sprains
• High Ankle Sprains
 Palpate medial ankle
 Proximal Squeeze Test
 Palpate Fibular head

12. Ankle Sprains
• High Ankle Sprains
 Seen in gymnastic when landing short
 Offensive linemen with push-off
 Soccer players plant foot
 If mild, can usually return to sporting activity
with bracing support in 4-5 weeks
 If surgical intervention is necessary – 4
months

13. Ankle Instability
• Most often occurs with mismanagement of original
sprain injury
• Positive anterior drawer and Talar Tilt
• Recurrent ankle sprains
• “weak ankles”
• Chronic Pain
• Can be associated with other pathology:
• peroneal tendon tearing
• loose bodies in ankle
• Ankle impingement
• Osteochondral injury

14. Ankle Instability
Anterior Drawer Test – 10mm (+)

15. Ankle Instability
Talar Tilt >9 degrees (+)

16. Ankle Instability
• Typical Case
• Former collegiate gymnast suffers from
recurrent sprains and chronic pain
• Failed Bracing and Physical therapy
• MRI findings normal
• Physical exam shows positive Talar tilt or
Anterior drawer
• Goes onto stabilization surgery

17. Ankle Impingement
• Anterior Impingement
 Fibular Impingement – occurs from
cartilaginous transformation from rupture
ATFL or synovitis
 Physical exam: pain on palpation of lateral
gutter of the ankle
 Can be excised arthroscopically with good
success

18. Ankle Impingement
• Posterior ankle impingement
 Seen most often in ballet dancers
 Can be caused by multiple structures
• Os trigonum
• Posterior capsule thickening
• Tendinopathy of Flexor Hallucis Longus
 Physical examination: Pain on end range
of motion/plantarflexion

20. Medial Tibial Stress Syndrome
• “Shin Splints”
• Overuse injury – most often seen in runners
• Often due to poor biomechanical support and
stretching habits
• Cause: Abnormal tension of muscle origin (TA/PT)
• Although not seen as serious, can be quite disabling
• Women 1.5 -3.5 times higher risk for this developing
into stress fractures.

21. Medial Tibial Stress Syndrome
• Physical Exam: Palpate anterior and posterior borders of
the tibia. Clinical History of activity very important
• Treatment: RICE, Biomechincal Support, Rigorous
stretching, Physical therapy, Acupuncture, ESWT

22. Achilles Tendon

23. Achilles Tendon Ruptures
• ¼ are initially misdiagnosed as ankle sprains (rothman
study - 2015)
• Incidence – 18:100,000 per year
• More common in men than women.
• Ages 30-40
• “Weekend Warrior”
• Other Risk Factors
• Fluoroquinalone treatment
• Cortisone injections

24. Achilles Tendon Ruptures
• Mechanism
• Sudden force plantarflexion
• Violent dorsiflexion in a plantarflexed foot
• Pathoanatomy:
• Rupture can occur in 3 areas
1) Myotendinous Junction
2) “Watershed Area” (4-6 cm above calcaneal insertion) **
3) From Calcaneal Insertion

25. Achilles Tendon Ruptures
• Clinical History:
• Patient reports hearing a pop during activity.
• Classic Case – I was running and felt
like someone kicked the back of my leg.
I turned around and nobody was there.

26. Achilles Tendon Ruptures
• Physical Exam:
 Inspection
• Increased Resting Plantarflexion
• Weak Active Ankle plantarflexion
• Increased Passive Dorsiflexion
• Calf Atrophy (chronic cases)
 Palpation
• Palpable Dell/Gap
 Provocative Test
• Thompsons Test

27. Achilles Tendon Ruptures
• Treatment :
 Non-operative
• Casting/Functional Bracing in resting equinus
• Functional outcomes equal to that of operative management
• Increased Risk of Re-rupture
• Fewer complications
 Operative
• Open end to end repair
» Lower Risk of re-rupture (contradicting new Level 1 evidence)
• Percutaneous
» Lower Risk of wound complications
» Better Cosmesis
» Many studies show equal Functional Outcome compared to open

28. Achilles Tendon Ruptures
Percutaneous Achilles Tendon Repair

29. Achilles Tendon Pathology
• Non-insertional
 Most often a problem due to lack of stretching or
tight posterior muscle group (equinus)
 Area most commonly affected is hypovascular
region. (Watershed)
 Treatments:
• Stretching**
• Temporary Heel lift to reduce symptoms
• Prolotherapy/Platelet Rich Plasma
• ESWT

30. Achilles Tendon Pathology
• Insertional
 Most often a problem due to irritation from shoe
with a hard heel counter. (Football/Soccer
Cleats/Ice Skates)
 Also related to stretching
 In the pediatric patient, contributes to Severs
Disease.
 Treatments:
• Stretching (not when acutely inflamed)
• Temporary Heel cup to offload insertion site
• RICE

31. Lisfranc Injuries
Lisfranc injuries are characterized as a disruption
between the articulation of the medial cuneiform
and the 2nd metatarsal base

32. Lisfranc Injuries
• Anatomy
 Lisfranc Ligament
• Vital for stabilizing the 2nd
metatarsal and midfoot arch
• Interosseous ligament that spans
medial cuneiform to 2nd metatarsal
base on plantar surface
• Ligament tightens with pronation
and abduction of forefoot
• Dorsal ligaments weaker thus
dorsal dislocation often seen.

33. Lisfranc Injuries
• Biomechanics
 Roman Arch
• Mechanism of Injury
 Axial load through
plantarflexed foot
• Common Causes
 Car accidents,
football/soccer, fall from
height

34. Lisfranc Injuries
• Case Scenario: 21 year old female
collegiate soccer player suffered an
sprain when another player tackled her
from behind 8 weeks ago. Ankle feels
great however patient has chronic pain
to the midfoot when running.

35. Lisfranc Injuries
• Diagnosis
 Missed injuries can lead to progressive foot deformity, chronic
pain and dysfunction
 One of the most commonly missed injuries in the urgent
setting. Devastating consequences on function results.
• Physical exam
 Instability Test
• Grasp metatarsal heads and apply dorsal force to the forefoot while
stabilizing midfoot with other hand
• Dorsal subluxation suggests instability. Can also have 1st and 2nd
metatarsal displacement medial and lateral.
 Provocative test
• May reproduce pain with pronation and abduction of the forefoot

36. Lisfranc Injuries
Pronation Abduction Stress Test

37. Lisfranc Injuries
• Radiographs
 Fleck Sign
 Stress WB Films*
• CT scan
 Necessary for Surgical
Planning
• MRI
 Good at detecting purely
ligamentous injuries

38. Lisfranc Injuries
• Non-operative Treatment
 Indications:
• No displacement on WB and stress radiographs
• No evidence of bony injury on CT (dorsal sprain)
• Non-operative candidates
• Operative Treatment
 Indications:
• > 2mm shift on radiographs
• Primary Arthrodesis vs. ORIF
• Level I evidence favoring primary arthrodesis

39. Lisfranc Injuries
• Long Term Prognosis
 Devastating injuries
 Post-traumatic Arthritis
 Altered Gait  Orthopedic Issues

40. Plantar Fasciopathy
• Plantar Fascia
• Thick Aponeurosis spanning the bottom of the foot.
– Functions as a tie-rod, undergoing tension during WB
– Some studies say that it carries up to 14% of total body
weight
• Consists of 3 components:
– Medial Band**
– Central Band
– Lateral Band
• In younger patients it shares a continuous
connection with Achilles which disappears with age.

41. Plantar Fasciopathy
• Plantar Fasciits
• Medial Band most often affected at the calcaneal
insertion
• Actual Cause is still debated
• Associated with Risk Factors:
– Obesity
– Over-pronation
– Tight Achilles
– Poor Footwear

42. Plantar Fasciopathy
• Plantar Fasciits
• Diagnosis:
– Symptoms:
» Sharp heel pain, usually with first step out of bed
» Pain relieved by walking
– Physical Exam
» Pain on palpation of medial tuberosity of calcaneus
» Provocative Test: Heel Squeeze (+)
» Can have referred pain (Baxter’s Neuritis) to lateral heel

43. Plantar Fasciopathy
Heel Squeeze Test

44. Plantar Fasciopathy
• Plantar Fasciits
• Treatment:
– Orthotics
– Shoe changes
– RICE
– Physical Therapy
– Steroid Injections
• Steroid injections not given in Athletes!

45. Plantar Fasciopathy
• Plantar Fascia Rupture
• Risk Factors
– Athletes
– Minimalist Runners
– Prior Corticosteroid Injection**
– Tight Calf Muscle (Equinus)
• Presentation
– Severe pain
– Felt pop on bottom of foot
• Treatment
– Cast Immobilization 3-4 weeks

46. Turf Toe
Sprain of the plantar 1st Metatarsophalangeal Joint

47. Turf Toe
• Epidemiology
 More prevalent in contact sports on rigid surfaces
 Lighter/more flexible sports shoes/cleats
• Mechanism
 Hyperextention injury to plantar plate and sesamoid complex
 Forefoot fixed to ground, hallux hyperextended, axial load through
the heel
• Pathoanatomy
 Tear of the capsular-ligamentous-sesamoid complex
 Tear occurs off the proximal phalanx, not the metatarsal

48. Turf Toe
• Prognosis
 Can be a devastating injury to an athlete,
especially if left untreated.
 Leads to inability to push-off
 Reduced Agility

49. Turf Toe
• Diagnosis
 Inspection:
• Plantar swelling and bruising
• Malalignment of the MTP joint
 Motion
• Provocative Test: Hyperextension causes
severe pain/discomfort
• Verticle Lachmans Test

50. Turf Toe

51. Turf Toe
• Classification
 Grade I
• Sprain of plantar plate
 Grade II
• Partial tear
 Grade III
• Complete tear Jahss Classification of Dislocations

52. Turf Toe
• Treatment
 Non-operative
– Indicated in most injuries (Grade I-III)
– RICE, NSAIDS, Taping, Stiff Soled Shoe/boot, Orthotics
– Severe injuries may require cast for 2-6 weeks
– Aggressive physical therapy – restore ROM
 Operative
– Severe Grade III injuries only
– Failed conservative treatment
– Retracted Sesamoids/Loose fragments in joint
– Return to sport 3-4 months (season ending)

53. Take Home Points
• Trainers, Teammates, Family members
• At the front lines of treatment
• Most significant period of injury
• Can make the difference between early return
to sport with full function vs. long term disability
• When in doubt
– Immobilize
– Remain non-weight bearing
– Schedule appointment with healthcare professional
for evaluation and treatment