Good morning, I don't have any conflicts with this presentation, but foot and ankle injuries in sports are very common. They basically occur about more than a third of the time in all weight-bearing sports, and these are the most common causes of time loss from sport, and each of these injuries is a spectrum of severity, like we just heard. With deltoid, with syndesmosis, it's a spectrum, so you need to individualize your treatment for these injuries. And so, as far as less frank injuries go, you know, you can have very severe injuries like this that are very clear, and you know what to do and the treatment that's required. I'll be speaking about this injury that's a little bit more subtle, a little bit more difficult to diagnose, and therefore decision-making for the athlete on a team is a little bit more difficult and individualized. In general, making return to play decisions in sports, you know, what do you need to know? This again, in my view, you need to understand the injury and the pathophysiology of the injury, and you need to understand what's stable and what's unstable. So if something's stable, you can progress the therapy and treatment. If it's unstable, you may have to do surgery. And then some injuries are high risk and some are low risk. In other words, you can take a risk and let them go back to sport early without too much risk of sequelae. And so, what's the key question, you know, to answer in each of these situations? And I think this is the way I approach less frank injuries. So here's a less frank injury, and there's a little fracture avulsion. You can see here right in the area of the less frank ligament. So when you have this avulsive fracture, you know that it's an unstable injury and will require stabilization. And because it's reduced, you can just do percutaneous fixation like we do here and put a compression screw across that area. And again, you can assess the reduction under fluoroscopy and immobilize them. And obviously, this is a unstable, mild injury, but it requires stabilization. Just to understand the pathophysiology for less frank injuries in the foot, you have the medial column and the lateral column. And the medial column is the stability column. In other words, you need to have stability of the medial column. So if you have an injury in the medial column, and in particular, the less frank area, you need to stabilize it so that the athlete can weight bear and do what they're supposed to do and push off and land. The mechanism of injury can happen in many ways, both directly and indirectly with an abduction force. You have an axial load, as you can see here in the picture, a crush injury that we see in motor vehicle accidents. And you can have associated injuries with the more severe injuries. But with the mild injuries, you can have intercaneiform diastasis, like you see here. So you have diastasis between the first and second, but you're kind of seeing subtle diastasis between the medial and the middle caneiform as well. And that's important to diagnose too. In terms of diagnosis, and again, Kirk mentioned this in terms of weight-bearing x-rays and stressing the less frank joint. So non-weight-bearing x-rays can definitely be normal. And standing views are recommended. And you should do bilateral standing views and compare one foot to the other. And stress views should be performed when possible. In other words, when the patient is able to be stressed. Sometimes they're very, very painful. And it's hard to get a really good stress view without anesthesia. And then on every x-ray view, you should assess each column. In other words, the medial caneiform with the first metatarsal, the middle caneiform with the second, or the lateral caneiform with the third metatarsal. So no matter which x-ray you get, standing AP, oblique view, lateral view, you should assess these relationships. And again, this was a really good paper from John Femino. And that you should always be careful, even with normal x-rays. If you suspect there's a less frank, you need to do a little bit more testing, a little bit more investigation to make sure they don't have a less frank. And MRI and CT can be very valuable as well in terms of further investigation. This was a paper by Raken, basically concluding from the paper that if you can see the less frank ligament on MRI, then that's good and you know that it's stable. But sometimes it's hard to see the less frank ligaments on MRI just because of the cut and because of the view on MRI. And so a stress test is recommended in those situations. So here's an example. Again, you see the widening on the standing AP of both views. But again, you don't see a lot of displacement. There may be a little bit of widening between the medial and the middle cuneiform. When you look at the MRI, you can see the less frank ligament there. And again, it's a little bit concerning based on the x-ray. So in these types of cases, I would generally bring them to the operating room and do a stress view under anesthesia. And again, this is the stress view or the stress test. This is a nice dissection from John Famino. And this was a part of the study that he did with these cadavers where you did weight bearing only the less frank ligament did not open up. But when you did an abduction stress view, it opened up. So you know, how do you make the diagnosis? I think the clinical exam is really important. Get the bilateral weight bearing x-rays and compare one foot to the other. And then I do an MRI to look for the less frank ligaments. And then if that's still not clear, then do stress fluoroscopy. And I do that under anesthesia. So we'll go through a few cases. In terms of classification, I think this is a good article by Jim Nunley and Christopher Tullow. And we're basically talking about stage one and stage two injuries. The stage three are very clear, and they need stabilization and surgery. So with a less frank sprain, what's the key question? I think the key question is, is it stable or unstable? So you need to go through this. We just went through the diagnosis. So if these are negative, in other words, it's normal, then you can rehab these and let them return to play as tolerated. And there's no need to make it stable with surgery. So here's an example. 21-year-old football player, a severe twisting injury, unable to weight bear. He's tender at the base of the first and second tarsal metatarsal joint. Here's his X-ray. There is some suggestion of widening. You can see it's not a bilateral weight-bearing X-ray. We should do that. And you can look at the alignment of the base of the second with the middle cuneiform. On this oblique view, you can look at the third, fourth, and fifth. And then the lateral view, you can look at the arch and the alignment. And so we decided this was one of our starting linemen, and he couldn't weight bear. And in order to make a clear diagnosis, I told them we're going to bring him to the operating room. If he had a non-stable stress test, we'd stabilize it. If it was stable, then we would not stabilize it, and we'd let him rehab. So here's his stress test under anesthesia, and you can see there's really just a little bit of opening here, but there's no displacement. And therefore, we diagnosed this as a stable injury and did non-operative treatment. We put him in a boot, did physical therapy, rehab, and reexamined him every day or two, and then got him back to sports as tolerated, as soon as he could tolerate weight-bearing. And this particular athlete got back playing on the field at two weeks following the injury. Here's another example, which is very similar to this example. Again, very similar X-ray. And we decided to take him to the operating room. And here's his stress test. It's a little bit different. Both the first and second metatarsals are displacing laterally, a little bit more instability than the last one. So we decided to stabilize this with a compression screw. Here's another example of a gymnast, a loading injury, axial loading. You can see the widening between the first, second displacement, the base of the second, and the middle cuneiform, and intercuneiform instability. So we put two screws in to stabilize that whole complex. And after surgery, I treat these with immobilization for six weeks, non-weight-bearing. Then six weeks, four to six weeks of immobilization and a boot with range of motion and gradual physical therapy. Return to ground-based physical therapy and sport-specific therapy at three months. Use an orthotic after these injuries to support the arch. And I generally leave these screws in place, the Lisfranc screw, and I don't take those out unless they're giving the athlete some problems. Now once in a while you run into these cases. This was a medical student, came back three weeks after she injured her foot. She was on a trip overseas. And when I saw her, she was very minimally tender, but she definitely had a Lisfranc injury. And this is her x-rays. And you can see the widening and a little bit of a step here at the base of the second. And there's a little bit of calcification there between the first and second. And she was really getting better. And so we decided to leave this alone. And you know, Kirk can comment on this if you would like. But generally, if you have these subtle injuries that are missed and they're late, I usually let them rehab and see how they do without doing surgery at this point. So that's what we did. We just progressed her gradually after some immobilization, non-operative treatment, and she did well without any surgery. So this is the summary in this injury, Lisfranc sprains. You know, is it a stable injury or not? Do the x-rays, MRI, and then if necessary, stress test under anesthesia and make a final decision. And if they're unstable, then you do surgery. If they're stable, then go ahead and rehab and return to play as tolerated. Thanks for your attention.

foot and ankle injuries

individualized treatment

diagnosis techniques

treatment approaches

surgery evaluation