Millers - Sports Medicine - Section 3 Leg, Foot, And Ankle

Front 1

Saphenous nerve entrapment

Back 1

—When compressed at Hunter's canal or in the proximal leg, the saphenous nerve can cause painful symptoms inferior and medial to the knee.

Front 2

Peroneal nerve entrapment

Back 2

—The common peroneal nerve can be compressed behind the fibula or injured by a direct blow to this area. The superficial peroneal nerve can be entrapped about 12 cm proximal to the tip of the lateral malleolus, where it exits the fascia of the anterolateral leg, as a result of inversion injuries. Fascial defects can be present as well, contributing to the problem. Compartment release is sometimes indicated. The deep peroneal nerve can be compressed by the inferior extensor retinaculum, leading to anterior tarsal tunnel syndrome and sometimes necessitating release of this structure.

Front 3

Tibial nerve entrapment

Back 3

—When the tibial nerve is compressed under the flexor retinaculum behind the medial malleolus, it may result in tarsal tunnel syndrome. Electromyography/nerve conduction evaluation is helpful, and surgical release is sometimes indicated. Distal entrapment of the first branch of the lateral plantar nerve (to the adductor digiti quinti), between the fascia of the abductor hallucis longus and the medial side of the quadratus plantae, has also been described.

Front 4

Medial plantar nerve entrapment

Back 4

—Occurs at the point where the flexor digitorum longus and flexor hallucis longus cross (knot of Henry) and is most commonly caused by external compression from orthoses. Commonly called jogger's foot, this condition usually responds to conservative measures.

Front 5

Sural nerve entrapment

Back 5

—Can occur anywhere along its course but is most vulnerable 12-15 mm distal to the tip of the fibula as the foot rests in equinus. Surgical release is usually effective.

Front 6

Interdigital nerve entrapment

Back 6

—Commonly called Morton's neuroma, entrapment can occur during the push-off phase while running in athletes and with the demi-pointe position in dancers. It usually occurs between the third and fourth metatarsals plantar to the transverse metatarsal ligament and responds to surgical resection if conservative measures fail.

Front 7

Gastrocnemius-soleus strain

Back 7

—Nicknamed tennis leg because of its common association with tennis, this injury is probably much more common than rupture of the plantaris tendon. Supportive treatment is indicated.

Front 8

Peroneal tendon Subluxation/dislocation

Back 8

Violent dorsiflexion of the inverted foot can result in injury of the fibro-osseous peroneal tendon sheath. Diagnosis is confirmed by observing the subluxation or dislocation by means of eversion and dorsiflexion of the foot. Plain radiographs may demonstrate a rim fracture of the lateral aspect of the distal fibula. Treatment of acute injuries includes restoration of the normal anatomy (Fig. 4–31). Chronic reconstruction involves direct repair, groove-deepening procedures, tissue transfers, or bone block techniques.

Front 9

Posterior tibialis tendon injury

Back 9

—This injury can occur in older athletes. Patients complain of midarch foot pain, with difficulty pushing off. D?bridement of partial ruptures and flexor digitorum longus transfer for chronic injuries are recommended.

Front 10

Achilles Tendinitis/tendinosis

Back 10

—Overuse injury to the Achilles tendon usually responds to rest and physical therapy, with an eccentric loading program and local modalities. Progression to partial rupture may necessitate surgical excision of scar and granulation tissue.

Front 11

Achilles Tendon Rupture

Back 11

—Complete rupture of the tendon is caused by maximum plantar flexion with the foot planted. Patients may relate that they felt as if they were “shot.” The Thompson test (squeezing the calf results in normal plantar flexion of the foot) is helpful for confirming the diagnosis. Treatment remains controversial; however, recurrence rates are reduced with primary repair, while other complications (i.e., wound problems) are increased with surgical repair.

Front 12

Chronic Exertional Compartment Syndrome

Back 12

Although it is more commonly encountered with trauma, sports-related compartment syndrome is becoming more frequently diagnosed. Athletes (especially runners and cyclists) may note pain that has a gradual onset during exercise, ultimately restricting their performance. Compartment pressures taken before, during, and after exercise (pressures >20 mm Hg 5 minutes after exercise or absolute values above 15 mm Hg while resting or above 30 mm Hg 1 minute after exercise) can help establish the diagnosis. The anterior compartment of the leg is the most frequently involved. Fasciotomy is sometimes indicated for refractory cases

Front 13

Tibial shaft stress fractures

Back 13

—This is a complication of unrecognized tibial stress fractures and can be a difficult problem. Persistence of the “dreaded black line” (Fig. 4–33) for more than 6 months, especially with a positive bone scan, can be an indication for bone grafting and/or intramedullary nailing.

Front 14

Tarsal navicular stress fractures

Back 14

—This injury is often found in basketball players. Immobilization and non–weight bearing are important during the early management of these stress fractures. Open reduction with internal fixation is occasionally indicated with linear fractures (as seen on CT).

Front 15

Freiberg infarction

Back 15

—Flattening of the second metatarsal head, usually due to stress overloading in a child's foot. Conservative management is indicated unless the patient is having mechanical symptoms

Front 16

Jones fractures

Back 16

—Fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal in an athlete can be treated more aggressively with early intramedullary screw fixation to allow earlier healing and an earlier return to conditioning activities. A screw with a minimum diameter of 4 mm should be used

Front 17

Plantar fasciitis

Back 17

—Inflammation of the plantar fascia, usually in the central to medial subcalcaneal region, is common in runners. Rest, orthoses, stretching, NSAIDs, and local steroid injections are helpful. Partial plantar fasciotomy is occasionally necessary, but recovery can be protracted. Refractory cases may be treated with extracorporeal shock wave therapy.

Front 18

Os trigonum

Back 18

(posterior impingement) syndrome—An os trigonum can cause impingement with plantar flexion of the foot, especially in ballet dancers. Treatment may include local anesthetic injection and other supportive measures. Surgical excision of the offending bone with or without release of the flexor hallucis longus (FHL) is occasionally necessary, and arthroscopic techniques have been described.

Front 19

Ankle sprains and instability

Back 19

—These injuries are common in athletes and most often involve the anterior talofibular ligament (ATFL) and occasionally the calcaneofibular ligament (CFL).

The posterior talofibular ligament (PTFL) is rarely involved. The Ottawa ankle rules indicate that radiographs are required only in patients with distal (especially posterior) tibia or fibula tenderness, tenderness at the base of the fifth metatarsal or navicular, and an inability to bear weight. Surgical treatment is reserved for recurrent, symptomatic ankle instability with excessive tilt and a positive anterior drawer on examination/stress radiographs that have not responded to orthoses and peroneal strengthening/proprioceptive exercises over an extended period. Anatomic procedures (modified Brostrom) are usually successful. Involvement of the subtalar joint requires tendon rerouting procedures that include this joint. Patients with “high” ankle sprains involving the syndesmosis require recovery periods of almost twice those for patients with common ankle sprains.

Front 20

Turf toe

Back 20

—Severe dorsiflexion of the metatarsophalangeal (MTP) joint of the great toe (injuring the plantar plate) can result in a tender, stiff, swollen toe. Treatment includes motion, ice, and taping in plantar flexion. If symptoms persist, a stress fracture of the proximal phalanx should be ruled out with a bone scan or MRI.

Front 21

Snowboarder's foot and ankle

Back 21

—Fracture of the lateral process of the talus (Fig. 4–36). The injury involves the leading leg on the board. A CT scan can help confirm the diagnosis. A fracture with small fragments (<2 mm) can be treated in a short leg cast for 6 weeks, whereas a fracture with large fragments should undergo open reduction with internal fixation.

Front 22

Osteochondral injuries of the talus

Back 22

—Treatment includes drilling of the base of these lesions and fixation of replaceable lesions. Lateral lesions are usually traumatic, shallow, and anterior, while medial lesions are atraumatic, deeper, and posterior. The modification to the Berndt and Harty classification scheme (Fig. 4–37) by Loomer and coworkers is helpful in the management of these osteochondral lesions of the talus.

Front 23

Indications for Ankle Arthroscopy

Back 23

—Include treatment of osteochondral injuries of the talus, d?bridement of post-traumatic synovitis, anterolateral impingement secondary to chronic pain from an ankle sprain, removal of anterior tibiotalar spurring, os trigonum excision, and cartilage d?bridement in conjunction with ankle fusions.