common injuries of foot and ankle in sports and common during activity, overview of foot and ankle injuries.

1. FOOT AND ANKLE INJURIES IN ATHLETES
BY- SUNIL
CPRS, JMI
drsuniljmi@gmail.com

2.  Foot and ankle injuries are very common among
athletes.
 Increased competition means professional athletes
and dedicated amateur athletes push themselves to
their limits, so there are more foot and ankle injuries
than ever.

4. Mobile Joints of the foot and ankle:
Ankle joint
Sub-talar joint
Talo-navicular joint
Metatarso-phalangeal (MTP) joints.

12. POTT'S FRACTURE
• A fracture affecting one or more of the malleoli
(lateral, medial, posterior) is known as a Pott's fracture.
• It can be difficult to distinguish a fracture from a moderate-to-
severe ligament sprain as both condilions may result from similar
mechanisms of injury and cause severe pain and inability to weight-
bear.
• Careful and gentle palpation can generally localize the greatest
site of tenderness to either the malleoli (fracture) or just distal to
the ligament attachment (sprain).

13.  The management of Pott's fractures requires
restoration of the normal anatomy between the
superior surface of the talus and the ankle mortise
(inferior margin of the tibia and fibula).
 If this relationship has been disrupted, internal
fixation is almost always required.

14. Osteochondral lesions of the talar dome
 It is not uncommon for osteochondral fractures of the talar
dome to occur in association with ankle sprains, particularly
when there is a compressive component to the inversion injury,
such as when landing from a jump.
 The talar dome is compressed by the tibial plafond, causing
damage to the osteochondral surface the lesions occur most
commonly in the superome dial corner of the talar dome, less
commonly on the superolateral part.

15.  The patient often gives a history of progressing well
following a sprain but then developing symptoms of
increasing pain and swelling, stiffness and perhaps
catching locking as activity is increased.
 Reduced range of motion is often a prominent
symptom.
 Examination with the patient's foot plantarflexed at
45degree to rotate the talus out of the ankle
mortise reveal tenderness of the dome of the talus.

18.  Chronic grade I and II lesions should be treated
conservatively.
 The patient should avoid activities that cause pain and
be encouraged to pedal an exercise bicycle with low
resistance.
 If there is pain, or symptoms of clicking, locking or
giving persist beyond two to three months of this
conservative management, ankle arthroscopy is
indicated.
 A grade IIa, III or IV lesion also requires arthroscopic.

19. Evalsion fracture of the base of the 5th
metatarsal
 Inversion injury may result in an
evalsion fracture of the base of
the 5th metatarsal.
 This fracture result from evalsion
of the peroneus brevis tendon
from its attachment to the base of
the 5th metatarsal.
 X-rays should be examined
closely. Avulsion frature is
characterized by its involvement
of the joint surface of the base of
the fifth metatarsal.

20.  Fracture of the base of the
fifth metatarsal may be
treated conservatively with
immobilization for pain
relief followed after one to
two weeks by protected
mobilization and
rehabilitation.

21. Calcaneal stress fractures
 Calcaneal stress
fractures22 are the second
most common tarsal stress
fracture.
 They occur most commonly
at two main sites: the upper
posterior margin of the os
calcis or adjacent to the
medial tuberosity, at the
point where calcaneal
spurs occur.
occur in runners, ballet dancers and jumpers

22. Clinical features
 Patients give a history of insidious onset of heel
pain that is aggravated by weight- bearing
activities,especially running.
 Examination reveals localized tenderness over the
medial or lateral aspects of the posterior calcaneus
and pain that is produced by squeezing the
posterior aspect of the calcaneus from both sides
Simultaneously.

23. Investigations
 Plain X-ray may show a typical sclerotic
appearance on the lateral X-ray, parallel to the
posterior margin of the calcaneus

24. Treatment
 Treatment involves a reduction in activity and for
those with marked pain a short period ofnon-
weightbearing may be required. Once pain-free, a
program of gradually increased weight-bearing
can occur.
 Stretching of the calf muscles and plantar fascia,
and joint mobilization are important for long-term
recovery.
 Soft heel pads, in conjunction with orthoses if
required, are recommended.

25. Stress fracture of the navicular
 Stress fractures of the
navicular are among the most
common stress fractures Seen
in the athlete, especially in
sports that involve sprinting,
jumping or hurdling.
 The stress fracture commonly
occurs in the mi dle third of the
navicular bone, a relatively
avascular region of the bone.

26. Cause
 A comhination of overuse and training errors plays
a significant role in the development of navicular
stress fractures.
 Although the exact cause ofa navicular stress
fracture is not known, it is believed that
impingement of the navicular bone occurs between
the proximal and distal tarsal bones when the
muscles exert compressing and bending forces.

27. Clinical features
 The onset of symptoms is usually insidious, consisting
of a poorly localized midfoot ache associated with
activity.
 The pain typically radiates along the medial aspect
of the longitudinal arch or the dorsum of the foot.
 The symptoms abate rapidly with rest.

28. Stress fractures of the metatarsals
 Stress fractures of the metatarsals in most series
have been shown to be the second most common
stress fracture, second to the tibia.
 The most common metatarsal stress fracture is at
the neck of the second metatarsal.
 This occurs in the pronating foot, when the first ray is
dorsiflexed, resulting in the second metatarsal being
subjected to greater load.

29. Clinical features
 The patient with a metatarsal stress fracture
complain of forefoot pain aggravated by activity
such as turning or dancing.
 The pain is not severe initially but gradually
worsens with activity.

30. Investigation
 X-rays reveal a radiolucent line or periosteal
thickening if the fracture has been present for a few
weeks .
 If the X- ray is negative, an isotopic
 bone scan or MRI may confirm the diagnosis.

31. Treatment
 The management of most stress fractures is straightforward, involving
rest from weight-bearing aggravating activities for approximatly
four weeks.
 If the patient is required to be on his or her feet excessively, the use
of an air cast may be required for one to two weeks until pain
settles.
 The athlete Should be allowed to recommence activity when he or
she does not experience pain when walking and there is no local
tenderness at the fracture site.
 A graduated exercise program should be instituted to return the
athlete to full training and competition.

32. TARSAL TUNNEL SYNDROME
 Tarsal tunnel syndrome occurs as a result of
entraptment of the posterior tibial nerve in the
tarsal tunnel where the nerve winds around
the medial malleolus.
 It may also involve only one of its terminal
branches distal to the tarsal tunnel.

33. Causes
In approximately 50% of cases the cause of tarsal tunnel
syndrome is idiopathic . It may also occur as a result of trauma
(e.g. inversion injury to the ankle or overuse associated with
excessive pronation. Other less common causes include:
• Ganglion
 Talonavicular coalition
 Varicose veins
 Synovial cyst
 Lipoma
 Accesory muscle- flexor digitorum accessories longus
 Tenosynovitis
 Fracture of the distal tibia or calcaneus.

34. Clinical features
 Poorly defined burning, tingling or numb sensation on the
plantar aspect of the foot, often radiating into the toes.
 Pain is usually aggravated by activity and releived by rest.
 In some patients the symptoms are worse in bed at night and
relieved by getting up and moving or massaging the foot.
 Swellings, varicosities or thickenings may be found on
examination around the medial ankle or heel.

35.  A ganglion or cyst may be palpable in the tendon
sheaths around the medial ankle.
 Tenderness in the region of the tarsal tunnel is common.
 Tapping over the posterior tibial nerve ( Tinel's sign) may
elicit the patient's pain and occasionally cause
fasciculations but
this 'classic' sign is not commonly seen.
 There may be altered sensation along the arch of the
foot.

36. Treatment
• Conservative treatment should be attempted in those
with either an idiopathic or biomechanical cause.
•Treatment with NSAID and, if required an injection of a
corticosteroid agenr into tarsal tunnel may be helpful. If
excessive pronation is present, an orthosis should be
utilised.
•Surgical treatment is required if there is mechanical
pressure on the nerve. A decompression of the posterior
tibial nerve and its branches should be performed, but
only after both the diagnosis and the site of nerve
entraptment have been confirmed.

37. PERONEAL TENDINOPATHY
 The most common overuse injury causing lateral ankle pain is peroneal
tendinopathy.
 The peroneus longus and peroneus brevis tendons cross the ankle joint within
a fibro-osseous tunnel, posterior the lateral malleolus.
 The peroneus brevis tendon insert into the tuberosity on the lateral aspect of
the of the fifth metatarsal. The peroneus longus tendon passes under the
plantar surface of the foot to insert into the lateral side of the base of the
first metal and medial cuneiform.
 The peroneal tendons share a common tendon sheath proximal to the distal
tip of the fibula, after which they have their own sheaths.
 The peroneal muscles serve as ankle flexors in addition to being the primary
evertors of the ankle.

38. Causes
Peroneal tendinopathy may occur as a result of
an acute ankle inversion injury or secondary to an overuse injury.
Common causes of an overuse injury are:
• Excessive eversion of the foot, such as occurs when running on
slopes or on cambered surfaces.
• Excessive pronation of the foot.
• Secondary to tight ankle plantarflexors (most commonly soleus)
resulting in excessive load on lateral muscles.
• Excessive action on the peroneals (e.g. dancing, football,
volleyball).

39.  It has been suggested that peroneal tendinopathy may be due
to the excessive pulley action of, and abrupt change in
direction of, the peroneal tendons at the lateral malleolus.
 There are three main sites of peroneal tendinopathy:
1. posterior to the lateral malleolus
2. at the peroneal trochlea
3. at the plantar surface of the cuboid.
Clinical features
The athlete commonly presents with:
 lateral ankle or heel pain and swelling which is aggravated
by activity and relieved by rest

40.  local tenderness over the peroneal tendons on
examination, sometimes associated with swelling
and crepitus (a true paratenonitis)
• painful passive inversion and resisted eversion,
although in some cases eccentric contraction may be
required to reproduce the pain
 a possible associated calf muscle tightness
 excessive subtalar pronation or stiffness of the
subtalar or midtarsal joints.

41.  Treatment
 Treatment initially involves settling the pain with rest from
aggravating activities, analgesic medication if needed and
soft tissue therapy.
 Stretching in conjunction with mobilization of the subtalar
and midtarsal joints may be helpful. Footwear should be
assessed and the use of lateral heel wedges or orthoses
may be required to correct biomechanical abnormalities.
 Strengthening exercises should include resisted eversion (e.g.
rubber tubing, rotagym), especially in plantarflexion as this
position maximally engages the peroneal muscles.
 In severe cases, surgery may be required, which may involve
a synovectomy, tendon debridement or repair

42. SINUS TARSI SYNDROME
 The sinus tarsi is a small osseous canal running from an opening anterior and
interior to the lateral malleolus in a posteromedial direction to a point
posterior to the medial malleolus.
 The interosseus ligament occupies the sinus tarsi and divides it into an
anterior portion, which is part of the talocalcaneonavicular joint, and a
posterior part, which represents the subtalar joint.
 It is lined by a synovial membrane and in addition to ligament it contains
small blood vessels, fat and connective tissue.

44. Causes
 Although injury to the sinus tarsi may result from chronic overuse
secondary to poor biomechanics (especially excessive pronation),
approximately 70%of all patients with sinus tarsi syndrome have
single or repeated inversion injury to the ankle may also occur
after repeated forced eversion of the ankle, such as high jump
take off.
 The sinus tarsi contains abundant synovial tissue that is prone to
synovitis and inflammation when injured. An influx of
inflammatory cells may result in the development of a low-grade
inflammatory synovitis.
 Other causes of sinus tarsi syndrome may include chronic
inflammation in conditions such as gout, inflammatory
arthropathies and osteoarthritis.

45. Clinical features
The symptoms of sinus tarsi syndrome include:
• pain which may be poorly localized but is most often centered just anterior to the
lateral malleolus
• pain that is often more severe in the morning and may diminish with exercise
• pain that may be exacerbated by running on curve in the direction of the affected
anklepatientmayalso complain of ankle and foot stiffness, a feeling of instability of
the hind f and occasionally of weakness
• difficulty walking on uneven ground
• full range of pain-free ankle movement on examination but the subtalar joint may
be stiff.
• pain on forced passive eversion of the subtal joint; forced passive inversion may also
be painful due to damage to the subtalar Iigam
• tenderness of the lateral aspect of the ankle a“ the opening of the sinus tarsi and
occasionall also over the anterior talofibular ligament; th may be minor localized
swelling.

47. TREATMENT
 Conservative management includes relative rest, ice.
 NSAID and electrotherapeutic modalities. Mobilization of the
subtalar joint is essential. Rehabilitation involves proprioception
and strenght to the anterior talofibular ligament may promote
synovial thickening and exudation.

48. MORTON’S NEUROMA
 The most common presentation of an interdigital (Morton's) neuroma is pain
located between the third and the fourth metatarsal heads (in the third
interspace) that radiates into the third and fourth toes.
 Patients often describe this as a burning pain that intermittently "moves
around." Usually, the pain is exacerbated by tight-fitting and/or high-
heeled shoes or increased activity on the foot. The pain is often relieved by
removing the shoe and rubbing the forefoot. Occasionally, these symptoms
occur in the second interspace with radiation into the second and third toes.
Seldom do neuromas occur in both interspaces simultaneously.

50. Anatomy and Pathophysiology
 The "classic" Morton neuroma is a lesion of the common
digital nerve that supplies the third and fourth toes. This
is not a true neuroma, but rather an irritated perineural
fibrosis where the nerve passes plantar to the
transverse metatarsal ligament.
 It has been speculated that because the common digital
nerve to the third interspace has branches from the
medial and lateral plantar nerves (and thus increased
thickness) that this accounts for the third interspace
being the one most commonly involved.

51. Diagnosis-
 The diagnosis of a Morton neuroma is clinical. There are no useful
radiographic or electrodiagnostic tests.
 Serial examinations may be necessary to establish the correct
diagnosis.
Examination-
 Direct palpation and palpation with a stripping motion of the
interspace will usually reproduce the patient's pain. This maneuver,
called "Mulder's sign,“ often reproducing the third (or second)
interspace. The examiner places the index finger and thumb
proximal to the metatarsal heads in the interspace, and while
pushing firmly into the interspace, "strips" distally to the end of the
interspace, often feeling a click or pop that elicits pain (Mulder's
click) a clicking or popping sensation and pain.

54. HALLUX RIGIDUS
 The term hallux rigidus describes a limited arthrosis
of the first MTP joint. The first MTP joint and the
great toe (hallux) provide significant weight
transfer from the foot to the ground as well as
active push-off. An intact first MTP joint implies a
complete and pain-free ROM,and full intrinsic
and extrinsic motor strength.

55.  Hallux rigidus is an arthritic condition limited to the dorsal
aspect of the first MTP joint. Also known as a dorsal bunion
or hallux limitus, the condition is most commonly idiopathic
(but may be associated with posttraumatic OCD of the
metatarsal head) and is characterized by an extensive
dorsal osteophyte and dorsal third cartilage damage and
loss. An associated synovitis may further aggravate the
limited and painful ROM.
 A foot with increased first ray ROM and increased
pronation may be predisposed to the condition.
 Excessive flexibility of the shoe forefoot increases the
potential for hyperdorsiflexion of the hallux MTP joint
 For this reason, this type of shoewear should be avoided.

56. CLASSIFICATION

64. METATARSALGIA
 Metatarsalgia describes an assortment of
conditions that cause plantar pain in the
forefoot.
 Metatarsalgia is best characterized by
pain under the metatarsal heads
exacerbated by weight-bearing. The fatty
cushion of the forefoot is a highly
specialized tissue.
 When weight is applied, hydrostatic
pressure builds within the compartments,
dampening and dispersing forces on the
plantar skin. This mechanism acts as a
cushion, protecting the area from
potentially damaging focal concentrations
in pressure arising.

65.  Inflammatory arthritis, trauma, or neuromuscular disorders can
cause imbalances of flexion and extension forces around the
small joints of the toes.
 Toe deformity is a consequence of this imbalance.
Hyperextension at the MTP joint is a common component of
these deformities and draws the fatty cushion of the forefoot
distally and dorsally with the proximal phalanx . When this
occurs, the weight transferred through the metatarsal heads is
applied to the thinner proximal skin without the intervening
fatty cushion.

67. It is common in following factors:
• Pesplantaris
• Pescavus
• Muscular weakness in the toe flexors due to
inactivity or immobilization
• Wearing high heels
• Tightness of plantar aponeurosis

68. Treatment
1. Painful stage: warm water bath, contrast bath
TENS, ultrasonic, diapulse or hot packs.
2. When associated with swelling : suitable
cryotherapy with leg in elevation.
3. Speedy ankle and toe movements to reduce
oedema and to improve circulation.
4. Faradism under pressure (elastic bandage) with leg
in elevation.
5. Faradic foot bath synchronised with voluntary
intrinsic exercise.
6. Gradual re-education of walking with appropriate
shoe wedge, pad or metatarsal bar.

69. FLEXOR HALLUCIS LONGUS
TENDINOPATHY
 The flexor hallucis longus tendon flexes the big toe
and assists in plantarflexion of the ankle.
 It passes posterior to the medial malleolus, and runs
between the two sesamoid bones to insert into the
base of the distal phalanx of the big toe.

70. Causes
 Flexor hallucis longus tendinopathy may occur secondary to
overuse, a stenosing tenosynovitis, pseudocyst or tendon tear.
 A common cause is overuse in a ballet dancer, as dancers
repetitively go from flat foot stance to the en pointe position,
when extreme plantarflexion is required.
 Wearing shoes that are too big and require the athlete to 'toe-
grip' may also result in flexor hallucis longus tendinopathy.

71. Clinical features
 Pain on toe-off or forefoot weight-bearing(e.g. rising in ballet), maximal
over the posteromedial aspect of the calcaneus around the sustentaculum
tali.
 Pain may be aggravated by resisted flexion of the first toe or stretch into
full dorsiflexion of the hallux.
 In more severe cases, there may be 'triggering‘ of the first toe, both with
rising onto the balls of the foot (e.g. in ballet) and in lowering from this
position. Triggering occurs when the foot is placed in plantarflexion and the
athlete, unable to flex the hallux, but then with forcible active contraction of
the flexor halluds longus, is able to extend the interphalangeal or
metatarsophalangeal joints of the toe.
 A snap or pop occurs in the posteromedial aspect of the ankle when this
happens. Subsequent passive flexion or extension of the interphalangeal
joint produces a painless snap posterior to the medial malleolus.

74. TARSAL COALITION

75.  Management may require orthotic therapy.
Surgical excision with severe symptoms or after
failure of conservative therapy. The
cartilaginous bar may recur after surgery.

76. THANK YOU
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