• LecturehallSports Specific Injuries of the Foot and Ankle
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Dr. Williams: He is currently serving as a chief resident in his third year residency at Chino Valley Medical Center, PMS-RRA program. He is also working as a clinical faculty member for Western University for the past two years, a graduate from Western University Health Science College of Podiatric Medicine and also serves as a creative writer and video producer for Present Podiatry news flash. Dr. Kamel has an interest in podiatric trauma, reconstructive surgery and sports medicine. Without any other introduction, which you don't need, come on up to the podium. He is going to speak to you about sports specific injuries of the foot and ankle.

    Dr. Benjamin Kamel: Thank you Dr. Williams. Thank you Present for inviting me out here today. It's a pleasure to be here and I'm honored. So I'm going to talk to you guys today about sports-specific injuries in the foot and ankle. Unfortunately, I don't have any disclosures to make but what I am going to talk to guys about today is sports-specific injuries of foot and ankle, how you guys can treat these pathologies and how you can compare those treatment options between the athletic population and the non-athletic population. So when it comes to the pathologies of the foot and ankle and sports, it's important to know some of the movements that are involved in these injuries and lateral side-to-side motion is important and it can contribute to foot and ankle injuries as well as continuous running with repetitive trauma that can cause stress and strain over a long period of time as well as direct trauma. In sports, there is a lot of direct trauma that can cause injury and you can't forget about the shoe gear.


    A shoe gear and equipment in sports can play a role and affect how these patients can get injured. So there is an increased incidence of foot and ankle injuries in sports and this can be attributed to a few things; one, it's better recognized. Physicians are little bit better whether ER doctors or orthopedics. In podiatry, they are little better recognized and more reported in the literature. Also athletes are playing sports year around. So you're not allowing themselves to have any rest between seasons, do not give them the opportunity to rehab and if they have any repetitive stresses during their sports season, it's happening throughout the entire year. Also, athletes are bigger, stronger and faster. I don't know about you guys who now is young. I don't remember seeing any athletes looking like this. There has been an evolution in shoe gear in sports and we have come a long way. And the first shoes having spiky bottoms to them and progressing to adding rubber soles and then now we are moving into -- we had barefoot running almost 10 years ago and now it's the very light and feathery type shoe, which is very flexible but not so supportive for these athletes. An important thing to recognize is what do these athletes want. So with their shoes, they want that tight fitting shoe. They wanted to be firm fitting and light so that they can have better performance. They get more traction from these types of shoes and that's what leads to the better performance.


    However, as a consequence, this leads to more torque and unfortunately for them more injury. So here is sort of an overview of what we are going over today. The pathologies in red are the ones I am going to discuss and you can see that there are so many different types of injuries in sports. The ones in red are the ones I am going to highlight and just keep in mind of the torque that is involved in these injuries and how it can relate to the injuries. So we are going to start with Achilles tendon ruptures. Everyone knows the weekend warrior, the 30 and above male athletes who plays on the weekend, not so conditioned. Overtime, the vascularity of the tendon decreases, so with these deconditioned athletes when they go out, the stress and the strain that they apply on their Achilles tendon outdoes the amount of vascularity available in their tendon. So this causes focal ischemia, micro trauma and eventually Achilles tendon ruptures. It's not just the weekend warrior, the middle-aged weekend warrior that suffers from these types of injures. In fact, elite athletes who have repetitive trauma over a long period of time can also have ruptures. Just take Kobe Bryant for an example. Apparently, you don’t need your Achilles tendon to make a free throw.


    So I am not sure if any of you guys have been watching what has been going on the MBA finals. Recently, in the last couple of months, the Golden State Warriors were dethroned by the Toronto Raptors and there was a lot of controversy involved with this loss for the Golden State Warriors. There were a lot of injuries of key players but one specifically is Kevin Durant who suffered from an Achilles tendon rupture. Now, the controversy lies in that four weeks prior to his rupture he had a calf strain. Now from what we know, calf strain the most common place where that you can have a tear is at the myotendinous junction. You could also have tear in the muscle belly itself and also in the myofascial layer. So let's say for argument sake that what was reported in the media is that he had a calf strain and the most common place is the myotendinous junction. Let's take a deeper dive into it. So the myotendinous junction is a network of nerves, receptors, the muscle and the tendon, which all worked together to help create a healthy functioning muscle and tendon. Within the myotendinous junction is the Golgi tendon organ, which is a closed feedback loop, which win the tendon stretched. It sends a feedback to your spinal cord and then to your muscle telling your muscle to just hold back a little bit and to prevent overstretching of that tendon and ultimately prevent damage or rupture. In the case of Kevin Durant, he suffered from an Achilles tendon rupture within 10 minutes of coming back to play. The controversy and the question is did he come back too early?


    He had a calf strain and within four weeks he came back, he played and within 10 minutes he had a rupture. If you are to look in the literature, there is nothing regarding the correlation between a calf strain and an Achilles tendon rupture; however, from what we know if you have damage to the myotendinous junction, then you would have a dysfunctional Golgi tendon organ, which would then become your body not being able to inhibit the amount of overstretching within the tendon, which would then theoretically lead to an Achilles tendon rupture. And in the case of Kevin Durant, I believe that if he had more neuromuscular training, more rehab and four weeks was definitely not enough time in my opinion, he may not have had this Achilles tendon rupture. When he was asked his thoughts on whether or not the medical staff had mistreated the situation, this was his response and what I would say to you, Kevin Durant is it was not just the game, it was your Golgi tendon organ. So when taking a look at these patients with Achilles tendon ruptures, on history you may hear things like I was kicked in the calf or I have a pop in my tendon. When you examine them clinically, you will see that they have an inability to plantarflex the ankle but will have a positive Thompson test, which has a high spasticity and sensitivity according to the literature and you may see a history of steroid or quinolone use. MRIs, the common modality to imaging modality for these patients with Achilles tendon ruptures and quite frankly just staring right at your face, there is ruptured ends with some fluid in between.


    There still remains some controversy with the fixation of Achilles tendon ruptures, whether or not to surgically fix them. So let's go back in time, 1993, Cetti and his group did a prospective study looking at operative versus nonoperative. They looked at 111 patients with near equal groups and they concluded that operative was preferable and the reason for that was there was a higher rate of resumption of sports at the same level, less calf atrophy and better ankle range of motion. Fast forward to almost 20 years later, Willets and his group out of Canada did a prospective study where they looked at 144 patients and they had an accelerated functional rehab protocol for both groups, the operative and nonoperative and their conclusion was that there was no significant difference in re-rupture rate, strength, range of motion, calf circumference and functional outcomes scores. So they concluded that as long as you have a functional rehab protocol in place that you can't treat these patients nonoperatively and they will do fine. We are going back to our friend, Kevin Durant, who posted these pictures on his Instagram recently where he is clearly rehabbing from his injury. He had his surgically fixed and if you look at the Willets protocol here, he is following [indecipherable] [0:11:32] air cast boot with 2cm heel lift, protected weightbearing with crutches and hydrotherapy. And if you continue along the protocol, there is just more advancement of weightbearing status and more sports-specific activities. Another type of fixation or another fixation for surgical repair is the percutaneous fixation.


    Mufalli did this retrospective study on lead athletes where they looked at 17 athletes with Achilles tendon ruptures and they found good results with full weightbearing at eight weeks and return to play within four to six months. They took it a step further with a systematic review, which had five randomized control trials out of the 12 total studies and they found that out of 781 patients that they concluded that there was comparable peak isokinetic strength with the percutaneous fixation. So we are going to move on away from the Achilles tendon. We are going go to the plantar fascia, not plantar fascitis but plantar fascial rupture. These patients you will see that it's another part of the body that can pop just like the Achilles tendon though oftentimes report a history of previous steroid use. Their shoe gear you may find that they either are flatfooted and their shoes are very flexible with not much support in the arch or they are not wearing orthotics. You will see plantar ecchymosis not quite like Mondor sign in the calcaneal fracture and they won't be able to engage and win this mechanism or stand on their toes. Saxena and his group did a study where they looked at 18 athletes with plantar fascial ruptures and surprisingly -- at least surprisingly to me, only four of the 18 athletes with plantar fascial rupture had a previous history of a steroid injection. A 16 out of the 18 had a medial band rupture and the way that they treated these patients was for a few weeks of nonweightbearing, few weeks of weightbearing with PT being initiated at seven days and custom foot orthotics.


    Now we move on to metatarsal fractures. Whenever in orthopedics or in podiatry that we name a fracture, it's likely not a good thing. So with the Jones fractures, it can be from an acute break or it can be from repetitive trauma and the same thing with stress fracture for the central metatarsals. If you have repetitive stresses, it can cause the stress fracture. Usually, we see these in military recruits and athletes who are running continuously over a long period of time. And here he is again. He is no stranger to foot and ankle injuries. Kevin Durant also suffered from a Jones fracture; however, his was not in an acute break. His was more from repetitive stressors over a long period of time. He reported to a staff. They took them away for some time and he went on to be okay. Neymar, soccer star out of Brazil, he however had an acute break of the fifth metaphyseal diaphyseal junction. Note the classic position of his foot with the plantarflexed and inverted foot, which led to his Jones fracture. So as we know the Jones fracture is located here in zone II of the fifth metatarsal and as I had alluded to before, it may be in this type of fracture that the shoe gear may be important. I have here an example with the soccer shoe but any shoe that's flexible or narrow or not fitting very well can lead to more stresses as you can see in this foot this is a narrow shoe for this cartoon's foot and you can see the amount of the fifth metatarsal that is essentially hanging off from the shoe and you can imagine if there is a lot of stressors during sports, that can lead to a fifth metatarsal fracture.


    When treating these patients with Jones fractures, it's safe to say that the go-to option is a percutaneous fixation. Few tips, be sure not to go too long on your screw because you can actually straighten out a naturally curved bone. Don't go too big on the screw because you can crack the cortex. Making sure to drop your hand as much as possible and checking in all planes with fluoroscopy that you are going right down the middle of the shaft. Open repair is usually reserved for that of revision cases and literature showing that does very well as a safety in that option. So bone marrow augmentation is oftentimes considered. I certainly always try to consider using bone marrow aspirate for the fixation of Jones and this study looked at 26 patients where they injected bone marrow aspirate percutaneously after a percutaneous repair and they had good results with an average time to union of five weeks with one delayed union and one refracture. This study looked at open repair as a revision where they had either a screw exchange with bone graft or with bone marrow aspirate and of 21 patients with CTs to confirm union of all those patients and return to play 12 weeks and all of them healed with only having a refracture. Moving on now to Lisfranc injuries, the mechanism for this is due to hyper plantarflexion or dorsiflexion, which leads to abnormal stresses to the tarsometatarsal joint and often times patients will report pain with pronation and abduction.


    Most common sports associated with these injuries are soccer or football or rugby. And when taking a look at weightbearing radiographs in Lisfranc injuries, if you have over 2 to 4mm of widening, likely there is damage to that Lisfranc complex. You also have to consider the two velocities of injuries. It could be high velocity injury due from like motor vehicle accident or fall from a height or low velocity injury, which likely happens in sports and you can assume that there is a ligamental injury involved with these types of low velocity injuries. It's important to know that when looking at these with an MRI that most of us are looking at the interosseous Lisfranc ligament, which is indicated here in the blue; however, the most supportive structure of the entire complex is actually the plantar Lisfranc ligament, which is indicated here in the green and I would urge you to try to find it on an MRI as it is a little more difficult to find but it can help gear your treatment option. As I had mentioned before when you are looking at the radiographic weightbearing images for a patient with Lisfranc injury if you have under 2 to 4mm of widening, it's safe to treat these patients nonoperatively as they oftentimes go onto to do very well. However, it's when you have over 2 to 4mm of widening that you have to consider surgery and the debate still is on with ORIF versus primary arthrodesis.


    I beg you to remember the Kotze article that concluded that arthrodesis was superior to that of ORIF in the ligamental injuries of Lisfranc; however, there is another article by Henning et al that looked at and studied the similar things and to compare Henning's article, used two TMT screws versus one in Kotze's. They had three months of nonweightbearing versus the six weeks of nonweightbearing in Kotze's article. Screws were routinely removed at four months in Henning's and 16 out of the 20 were removed when symptomatic. So this was a range between two to six months. And in Henning's they found no loss of correction at the latest followup with RAF versus the Kotze's article, they had 15 out of 20 patients had a loss of reduction. So when comparing these two studies, the question arises whether the poor outcomes that Kotze reported for an ORIF in ligamental injuries was due to the ligamental injury itself or the period of immobilization or the fixation method. Perhaps if the study was done differently in Kotze's. There may be different results if there was a more conservative postoperative protocol. This study looked at elite professional soccer and rugby players where they treated 17 patients or 15 out of 17 patients with ORIF and two fusion and they had a removal of hardware routinely at 16 weeks and these patients all did well and the only difference in their return to play depended on whether or not they had a ligamental injury or a bony injury. So this shows that ORIF might actually be the superior treatment option to arthrodesis in athletes.


    Another type of fixation for Lisfranc. This study looked at professional dancers and they used the suture button fixation and they found that after six months that these professional the athletes were able to return to full pre-injury level within six months. Now, we are going to move on from Lisfranc we are going to go to turf toe. So turf toe, the mechanism of injury is from hyper dorsiflexion, which causes damage to the plantar structures of the first metatarsophalangeal phalangeal joint. Right here on the right, I have the professional All Star Wide Receiver AJ Green from the Cincinnati Bengals who suffered from a turf toe injury last year, which put him out for the duration of the season just shows how significant of an impact a small joint can have on these athletes and their ability to play. So we are going to take a look at the anatomy of the turf toe. We are looking plantarly here. We have the sesamoids with the capsular structures surrounding it and some of the ligaments that support that, the short flexor tendons as well as the long flexor tendons. Taking a look in an MRI on the top left, we have disruption of the sesamoidal phalangeal ligament and on the bottom right here we have a fracture of the fibular sesamoid. When considering surgery for these patients, I want you to make a distinction between an athlete versus an non-athlete. With your non-athletic population, you can probably get away with not treating them.


    Immobilizing them for some period of time and that may reduce their pain, get rid of their pain and they may be able to do the normal functions of daily living. However, with athletes, it's important to have that push-off strength with the big toe. Whether it's a sprinter coming off of the block, a Wide Receiver who needs to push off into his route and change directions quickly or even a basketball player who needs to jump. If you surgically fix these patients, this may be better for their strength and mobility. When surgically fixing, you want to try to reapproximate any of the damaged structures and the way to confirm that you have done this correctly is with fluoroscopy. If you dorsiflex the hallux, you can see that the sesamoids would be running properly underneath the first metatarsal phalangeal joint. And finally, we are going to move on lastly to syndesmotic injuries or also known as high ankle sprains. This can happen with an ankle fracture or isolated without any bony fractures. We all know the classic article by Ramsey and Hamilton with any slight shift in the talus that there can be significant damage to the cartilage and this was later repeated in 2006 where they saw that they had similar results to that of Ramsey and Hamilton. The mechanism of this injury is usually rotational, external rotation specifically. It happens mostly in football, skiing or hockey and usually involves a Weber C or PER, SER fracture. However, it's not just those fractures that this type of injury can occur.


    When looking at radiographic image of the ankle, you want to be sure that if you do not see widening of the syndesmosis, that doesn't eliminate your diagnosis of the syndesmotic injury. However, if you do see widening on a radiograph, it's more than likely that there is syndesmotic damage. There are some tests that you can use intraoperatively to test the stability of the syndesmosis, the external rotation stress test and the cotton hook test and you could see that this study looked at the sensitivity and specificity of both of those tests and the specificity was very high for both of those and the sensitivity was higher in that of external rotation stress test. To conclude diagnosing syndesmotic injuries, don't rely on the level of fibular fracture to tell you whether or not there is syndesmotic damage. A negative x-ray does not mean that there is no syndesmotic injury and stress every ankle intraoperatively. If you stress it then you will know. You will know if there is an injury or not. This study took a look at 68 ankle fractures and they followed them two years out with CT scans and surprisingly, 40% of those patients were malreduced and this was a predictor of poor outcome. When in the scenario of -- you have a posterior malleolar fracture, sometimes people fake, sometimes they don't. But the important thing is that it's correctly reduced because you can see if you look at this image here on the left that the posterior malleolus has a very intimate relationship with the incisura and if not reduced properly, then the fibula will be displaced and therefore you have a malreduced syndesmosis. This image here on the left clearly doesn't have enough hardware in it but the posterior malleolus is malreduced and you can see here on the right that there is clear frank dislocation of that fibula and that syndesmosis is not reduced.


    This is a cadaveric study done that of Iowa where they took a look at the forceps clamps to reduce the syndesmosis and unsurprisingly, these reduction clamps if not placed in the proper position can drive the fibula either anteriorly or posteriorly and this can cause dislocation of the fibula and malreduced syndesmosis. AO teaches us that the syndesmosis should be fixed 30 degrees from posterior lateral to anterior medial. However, that's not based on very much and that's hard to estimate intraoperatively. So this study by Cosgrove took a look at reduction clamps and where should you place the medial clamp tine in order to reduce the syndesmosis. So they found a good spot on the lateral side for all the patients where they placed the lateral tine of the clamp and they placed that on the peroneal tubercle of the fibula and interestingly what they did is they split the tibia into third. So when you look at it on the lateral view, they wanted to see if you put the medial clamp tine on the anterior, central or posterior aspect of the tibia what that would do for malreduction. And you can see here as you move from anterior to posterior, there were more malreduction. So where there is A is anterior and there were no malreductions and they are in the middle, they had 20% malreduction and then posteriorly there was about 60% malreduction. I did some time in the residency at the Camp Pendleton Naval Hospital and orthopedic department there almost everyone praised this article and they used this article with their ankle fractures and the way that this study was run in the way that they treat their patients with ankle fracture is that they would prep and drape both extremities.


    And before fixing the ankle they would take true talar dome laterals of the unaffected ankle and after fixing the fibula of the affected ankle, they would then compare the true talar dome lateral to that of the unaffected side and what we are looking at is the amount of posterior malleolus that is posterior to the posterior aspect of the fibula. And they found that if you can match those two to be identical, then they had significantly less malreduction in the syndesmosis. And finally, one of the hot topics in the literature now is the tight rope versus the syndesmotic screw fixation and this is one of the first perspective studies that looked at it at Finland. They compared 43 patients with CT scan and two-year followup and they found no significant difference in malreduction or functional outcomes scores. And this perspective randomized trial also looked at 70 patients that were randomized with the comparison of tight rope versus screw with reduction by clamp and fluoroscopy; however, this study found better clinical and radiographic results with tight rope at all time points. So in conclusion, torque leads to injuries. So think of all the pathologies that you are dealing with and the amount of torque that is involved and how that causes their injury. Think of the shoe gear and the equipment that impacts these athletes. Achilles tendon ruptures can be safely treated nonoperatively with a postoperative accelerated functional rehab protocol. Percutaneous ORIF is the go-to option for Jones fracture with a great revision option in an open repair. ORIF can lead to better outcomes in athletes than arthrodesis in Lisfranc injury and make sure to test every syndesmosis and to take your time to be accurate with fixating the syndesmosis. The best thing in life is to do things with the people that you love in the places that you love and to create memories along the way. Thank you for your time.

    TAPE ENDS [32:29]