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Athletic injuries of the foot and ankle

ΑTHANASIOS  BADEKAS MD

Orthopaedic Foot & Ankle Surgeon

 

In athletes the injuries of the foot and ankle are separated into three categories:

a)       acute injuries,

b)      chronic syndromes and,

c)      Syndromes caused from overuse and distress.

Epidemiologically speaking, the injuries of the foot and ankle constitute together the 31% of the total athletic injuries that occur in athletes. Table 1 shows analytically the percentages of such injuries in some sports.

It is shown that climbing can cause a dramatic exhaustion in the lower legs, basketball and soccer two of the most prevalent sports distress especially the ankle, while dancing and racing the foot. The predisposing factors that can potentially lead to foot and ankle injuries in an athlete, are many and sententiously are as follows:

a)      The biomechanic variations and abnormalities of the foot and ankle.

A valgus flatfoot or a light hyperpronation of the foot that in a normal environment will not be accompanied from pathological clinical manifestation, in an athlete and especially athletes from track and field sports, can lead in an over-distension of the Achilles tendon and of the posterior tibial tendon.Τhose can cause tendonitis, tenondosynovitis or even ruptures of the above tendons.

b)      Lack of elasticity especially in the ankle with inability of full dorsiflexion of the ankle joint can lead to persistent pain in the anterior ankle and to the creation of anterior and ankle osteophytes, having as a result a greater limitation in the motion. Skiers and runners are the most vulnerable athletes in syndromes like that. The hyperelasticity itself can also lead to an unpleasant situation such as, frequent sprains and joint dislocations.

c)      Muscle strength plays an important role in the injuries of the foot. It is well known than athletes with weak peroneal tendons are more likely to sprains. Certainly most of the problems are caused by muscle imbalances.

d)     Footwear and foot insoles (orthotics).

Our body causes a momentum in the athletic foot insole shoe and this is one of the most important factors that can lead to an injury, as well as the improper application of the footwear, the quality of the material that has been made from and its anatomy. The orthopaedic foot insoles are especially made for the needs of each athlete exclusively. These come, to repair the anatomic variations, to offer medial arch support and relief wherever is needed. A specialist will make the diagnosis for the “where” and “how” an intervention with a special foot insole has to be made, so that will either prevent an injury or increase the performance.

e)      Field courts and other competition areas of sports.

Their surfaces are responsible for syndromes and injuries from distress, and especially the hard and uncompromising surfaces or surfaces with small unbalances. These surfaces can lead to sprains, distress of the subtalar joint and to chronic instabilities. The classic study of Mueller and Blyth about injuries in colleges of the United States has shown a decrease of 30% for athletic injuries after proper configuration and maintenance of the turf in the fields.

Sprains are the most common injuries of the ankle and the term means the distension or the rupture of one or some of the ligaments that join the bones around the talus. These spains constitute the 15% percentage of all the athletic injuries and the 42% percent of total lesions that occur in basketball.

The ligament support of the ankle consists of four anatomical groups: a) the ligaments of the external compartment, these are, the anterior talofibular, the fibulocalcaneal and the posterior talofibular. b) The external ligaments of thesubtalar joint, which are, the cervical and the external talocalcaneal. c) The ligaments of the internal compartment, which are, the deltoid ligament with its internal and superficial segment. And d) the tibiofibular ligaments, the anterior and the posterior.

The external retinaculum contributes remarkably to the further consolidation of the ankle. The most common strains are these of the external compartment and its usual mechanism is, the violent plantar flexion and the inwards turn of the ankle relative to the rest of the body.

Usually with the ankle in a dorsiflexion and in external rotation, the fibulocalcaneal and the subtalar joints ligaments are damaged.

Clinically the patient reports a sensation of “breaking” or “rupturing” in the external side of the ankle, that becomes immediately swollen, sensitive to the palpation and weightbearing with accompanied bruises of the surrounding area.

Ιit’s essential to recognize the mechanism of the injury and apart from the seriousness of the sprain, a radiological checking, it should always be done.

Now relative to the therapy of the strains the opinions diverge. Lately in the referral Orthopaedic centers for athletic injuries of the Foot and Ankle, the initial treatment is conservative independently of the severity of the sprain. This kind of therapy suggests relaxation during the first days, cold dressings, elevation of the foot and placement of a functional splint (νάρθηκας), continuing with early functional rehabilitation, during which the muscular strength of the external rotatorsis emphasized, with the ankle in a plantar flexion.

Ninety percent (90%) of the athletes with all types of strains will be cured completely by the conservative therapy. From the rest 10%, 2 to 3% will present instability of the ankle or of thesubtalar joint. In the other 7%, associated injuries coexist, such as tendonitis and dislocations of the fibular tendons that simply elongate the time of the restoration.

Chronic instability of the ankle can be described by an athlete as recurrent episodes of a joint that twists very easily, does not have mechanic stability and gives the sensation of laxity. Also, there is a history of recurrent sprains and anatomically there is distension or rupture of the external compartment ligaments of the ankle and thesubtalar joints. The instability of the ankle can be estimated clinically and radio logically by three tests, the anterior drawer test, the varus stress test, and the lateral sulcus test (just clinical). The testing should always be done relative to the corresponding ankle testing.

For the repair of the injury surgical treatment is also applied. Two are the most commonly used surgical treatments: the first one is the modified Brostrom technique, during which direct repair and suturing of the anterior talofibular (ATF) the fibulocalcaneal (CF) and reinforcement of the repairing ligaments with advancement of the external retinaculum that stabilizes furthermore the ankle joint, takes place. This is the method that is used mainly in dancers and gymnasts, who desire full range of motion

Τhe technique of Chrisman – Shook is especially useful in heavy athletes, such as American football players and Basketball players. Their ligament stability and the reinforcement of the ankle play a more important role than flexibility.

It is also used in athletes with weak fibular ligaments. In this technique, the anterior half of theperoneus brevis is harvested and driven out in a way, that it will reconstitute the talofibular (ATF) and the fibulocalcaneal (CF) ligament.

Just the last decade the instability of the subtalar joint has started to become a clinical entity. It’s very hard to distinguish the symptoms between the instability of the subtalar and the instability of the ankle joint.

Patient’s complaints and symptoms are very similar. Pain in the sinus tarsi is more diagnostic, particularly if one is able to localize isolated pain just anterior and inferior to the fibula. The diagnosis of subtalar instability is made easier if a patient with symptoms of chronic instability does not have any significant talar tilt or drawer sign on stress testing.   Radio logically, stress Broden’s views, can reveal sublaxation of the subtalar joint and can be used to visualize the location of the posterior facet of the subatalar joint. Therapeutically speaking, eversion strengthening and proprioceptive training may suffice to improve symptoms. Inflammation in the sinus tarsi is often present requiring a more directed treatment approach fibular ligaments is useful. From the surgically point of view, the Chrisman – Snook technique can be also be used at this case.

The injuries of the fibular tendons are also common. These tendons, the longus and the brevis, go posteriorly to the lateral malleolus, inside a fibre – elastic groove. More precisely, the injury that can occur is the acute dislocation of the fibular tendons. This happens when a violent contraction of the tendons takes place, with the foot in a dorsiflexion or in outwards turn. This is very common in injuries with skies. In this injury surgical treatment is suggested, that includes re-setting of the tendons and reinforcing suture of the fibroelastic groove.

The acute dislocation can fall into a repetitive chronic dislocation of the fibular tendons when it’s not treated properly. It’s very likely that the patient can dislocate by himself the tendons thus, causing instability that is accompanied by pain at the posterior external side of the ankle. The suggested surgical treatment is the deepening of the peroneal groove behind the lateral malleolus. As the fibroelastic membrane has been degenerated and does not exist is replaced by the external retinaculum ligament, as it is being mobilized and stabilized posteriorly and externally to the lateral malleolus.

Tendonitis and tenondosynovitisof the peroneal tendons are more common in athletes of older age. Rupture is rare. Acute tendonitis responds well in rest, in non-steroids antiflammatory drugs, as well as in the mobilization with a functional brace. If the acute tendonitis falls into chronic degenerative tendonitis it will be needed surgical debridement of the degenerative or excision of the necrotic portion and possible side-to-side tenodesis to the peroneus longus tendon proximal and distal to the longitudinal rupture.

Τhe dysfunction and the injuries of the Achilles tendon happen mainly in two groups of athletes. The first group is between the age of 35-50, amateurs and weekend athletes. The second group is young athletes of higher level, that before the rupture reveal symptoms of the Achilles tendon. Seventy five percent (75%) of the ruptures happen in male athletes aged between 30 and 40.

They are mainly runners of large distances and tennis players. Tendonitis of the Achilles tendon is known as the aseptic inflammation of the tendon, and if there is a coexistent damage of the tendon sheath or the paratendon, then tendonosynovitisis caused. Μany times the bursa that is found posterior and superior of the heel just between the insertion of Achilles tendon and the heel, is inflamed. This can cause a situation called retrocalcaneal bursitis. This can progress to the syndrome of Haglood with gradual detachment or elongation of the posterior – superior part of the heel.

Biomechanically, a factor that can lead to tendonitis or rupture of the Achilles tendon, if it coexists also with other factors, it’s the hyperpronationof the foot and the contraction of the gastrocnemius and thesoleuscomplex.

The treatment of the tendonitis and tenondosynovitis of the Achilles tendon is mainly conservative and usually consists of immobilization of the ankle with the use of a functional splint, non – steroid and antiflammatory drugs. When the acute inflammation subsides, the therapy continues with stretching exercises, reinforcement of the Achilles and the gastrocnemius, use of foot insoles that can control the hyperpronationand lift inserts of the posterior foot. The athletic activities recommended are swimming and cycling

The therapy with injections of cortico-steroids is contraindicated. In the case of persistence of the symptoms, surgical therapy can be applied with removal of the inflammated-degenarative tendon tissue as well as the paratendon if it is inflamed, and longitudinal repair of the tendon. The athletes return gradually to their activities within a month.

The retrocalcaneal bursitis and the Haglood syndrome are not responding well to conservative therapy. A therapy of choice is the removal of the bursa as well as the posterior / superior part of the heel, which during the dorsiflexion of the ankle rubs against the internal surface of the Achilles tendon.

In the rupture of the Achilles tendon, conservative therapy cannot be used. The therapy of choice is the end-to-end reinforcing repair of the tendon using locking sutures. Ιn the case of degenerated lesions of the tendon that the abscission of part of the degenerated tendon is necessary, reinforcement has to be done with transfer of flexor hallucis longus (FHL). Τhe athlete returns to the court in about 3,5 months, starting progressive strengthening and is ready for a full return within 5 to 6 months.

These are overall some of the most important athletic injuries of the ankle. Each one constitutes a clinical entity that needs more studying and has many parameters.

Table 1.

Sports                               Injuries of the ankle  Injuries of the foot

Soccer                               36%                             8%

Basketball                         46%                             8%

Volleyball                          18%                             6%

Racing                               26%                             26%

Classical dancing              17%                             22%

Climbing                           40%                             35%

Figure 1. Causative factors. A) Biomechanic variations – valgus flatfoot, hyperpronation. Β)Laxity. C)  Orthotics-foot insoles. D) Athletic surfaces.

Figure 2. Radiological parameters of the instability of the ankle. Face – profil. The clinical (sulcus test) in the region of the anterior talofibular ligament.

Figure 3. Suture of the anterior talofibular ligament during the modified Brostrom technique.

Figure 4. Chrisman – Snook technique: Separation and use of the anterior part of the peroneus brevisfor the replacement of the anterior talofibular and the fibulocalcaneal ligament.

Figure 5. Combination with medial calcaneal displacement in varus deformity

Of the hindfoot

Figure 6. Tenonditis of the peroneal tendons.

Figure 7. Haglood (pregnant heel) syndrome – bone ostectomy of the posterior superior apophysis of the heel.

Figure 8. Rupture of Achilles in an MRI – technique of final suture with locking sutures according (Krakow technique)

Διεύθυνση 1: Λαζαράκη 10, 16675 Γλυφάδα
Διεύθυνση 2: Νοσοκομείο ΕΡΡΙΚΟΣ ΝΤΥΝΑΝ Μεσογείων 117, 115126 Αθήνα
 

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