»» Okay. Thank you. Good morning. There might be a few points of overlap. So lower extremity or foot and ankle injuries account for more than a third of all sports injuries. They're the most common cause of time loss in sport. The key is that every injury is a spectrum of severity which makes the decision-making a little bit more complex. So everything needs to be individualized. You can't just take every injury and say he's got this injury, he's out six weeks. He might be out two weeks. He might be out three months. And so you need to understand the pathophysiology. So making effective return to play decisions, you have to understand the injury, if it's a stable or unstable situation, and if it's low risk or high risk. And again, Pete went through these things already. I think these should be in your mind every time you're assessing one of these injuries. And so these are the questions that you have to answer. Can the athlete play safely? Can the athlete play effectively? And can they play pain-free? And then, you know, that's not the end. Then other people involved in the decision-making, as was already stated, the athlete, the coach, the trainer. And there's lots of factors. The game situation. Again, Pete covered these things. The athlete's status on the team is also an important consideration. So sometimes, you know, you have really big games, big situations. This was one game that happens once in a lifetime where you have somebody like Zion Williamson here. This is right in the first minute of the game, see he slips there, and has a mild knee injury. It wasn't a very severe injury. And you see his foot went through the shoe and caused the mild sprain of the knee. This was, you know, he's like the top player, going to be the, you know, top player in the NBA draft. And everybody's concerned. There's his shoe, completely destroyed. And we got blown out that game. But anyways, when you're making the decision, you know, you have to take all those things into consideration. So if we were at an NCAA tournament, he probably could have gone back and played. But since it was just a regular season game, we decided to keep him out, make sure we assess the injury fully. We got an MRI the next day and got everything assessed. So you know, you got to look at the whole situation. This is in our locker room. And again, you got to keep these things in mind in terms of communication and trust. And I think this applies to the medical team as well as the basketball team. So you always got to do the right thing. And make sure you keep the interest of the athlete in mind. And really don't hesitate to evaluate and re-evaluate. Again this goes with every injury. So I was going to cover the five most common injuries that deal with around the foot and ankle and leg. And just to give some examples. So this was a basketball player, acute sprain. And the X-rays were normal. And we expected early return but the athlete was unable to return after a few days, was not able to play. Here's the X-rays. And then after further investigation you can see there's an anterior process fracture, the calcaneus. And here's the CT scan. And so this was the reason he couldn't return to play. It wasn't just a routine ankle sprain. It was more than an ankle sprain. So the most common reason people can't return after an ankle sprain, the same game or a few days later, is because there's a more significant injury involved. There's other ligaments involved or avulsion fractures or other things that are going to keep the athlete from able to function and progress. So you're going to need to do more investigation and decide what's wrong. Syndesmotic injuries. This is an example of a syndesmotic injury. Offensive lineman sprained their ankle. This was the fourth game of the season. He finished the game. And then after the game said, you know, I've got some pain in my ankle. And we diagnosed him with a quote, mild syndesmotic sprain. You can see he really didn't have any deltoid tenderness. Didn't have any positive stress indicating a more significant syndesmosis injury. We did an MRI. He was our starting center. He had normal fluoroscopy, normal X-rays. And this is the MRI, which is pretty normal. I mean, there really wasn't a lot. You know, the ligaments around the ankle were intact. The deltoid ligament was intact. The syndesmotic ligaments were not disrupted. And so we let him rehab and played the next game. He didn't miss any games. He played the next five games. He said he was around 80 or 90%. And then at the end of game five, he had a re-injury. And he was unable to weight bear. He was much more severe of an injury. And now here's the X-rays. This is five weeks after the original injury. So what do I learn from this? So he's got calcification along the syndesmosis. You see the calcification there. And now he's got widening. And so did we make the right decision and the right diagnosis? This probably was a little bit more unstable than we originally diagnosed. And that's why he's got calcification there because he's been trying to heal that on his own for the last five weeks. And so he's got more instability. Here's the MRI now five weeks later. He's got the syndesmotic ligaments are disrupted. He's got edema. He's got edema on the tibia. And so here you got a very tough football player, probably played with pain. I made the diagnosis he was stable. We made the diagnosis he was stable. And it didn't create any problems. But I think you need to be aware that this is a spectrum of severity. And we ended up doing surgery at that point. Here's the arthroscopic images. You can see the drive-through sign. This is the tibia, fibula. And the anterior and posterior ligaments are disrupted. And here's the pre-reduction and then post-reduction. And we stabilized it. And he ended up doing fine. And by six weeks, he was back on his feet and started his gradual weight-bearing program to get back to activity. So the syndesmosis, I think I'll just pay a little bit more attention to it. It's a common diagnosis, syndesmotic sprains. Here's the normal arthroscopic view of the distal fibers of the tib-fib ligament. And so here's the normal ligament. Here's just the anterior fibers disrupted. Here's a more significant disruption. You can see now there's just a little bit of opening. And now there's lateral Taylor shift in this view. So in this injury, obviously this one is normal. This one is a mild injury. And they can probably not miss any time. And this probably happens a lot. And they can return to play. But when they have these injuries, they're probably going to need some stabilization. So you have to understand the anatomy and what's involved in syndesmotic stability. The anterior-posterior ligaments and the deltoid. And obviously the injury can involve all these three. And so if you have a mild injury to the distal AITFL, they're usually mild. But then as it starts to get more severe, going to the interosseous membrane, and then the posterior ligament, and then having medial tenderness, I think you should be aware and concerned that they may have more instability. So in these cases where you have normal X-rays, normal stability, you don't really have a test to really tell how severe it is. So you need to look at the injury mechanism. Examine and re-examine over the first few days. You can do the MRI imaging, stress X-rays. And you may even consider arthroscopy. Say it's your starting quarterback. And it's six weeks before a championship game. And you're not sure. You might want to do arthroscopy to confirm if it does need any stabilization or not. And then look at their functional progression. If they're painful on Sunday, and then by Tuesday or Wednesday they're feeling pretty good, they're ambulating, they're moving well, it's probably more stable. And you can consider it a more stable injury that doesn't need any intervention. Stress fractures around the foot and ankle. Again, those are common. And I think this is the question. Is it a high-risk or low-risk stress reaction or stress fracture? This was one of our basketball players this last year who was picked in the first round of the NBA draft this year. And he started having some lateral pain. His X-rays were normal. He had some kind of distal third fibular pain. And here's the MRI. You can see the edema around the fibula. So he had a stress reaction with an incomplete stress fracture of the distal fibula. Tibia was normal. Ankle was normal. And so this is a low-risk stress fracture. They can weight-bear, they can function. And really pain is the determining factor if they can return to play or not. So he missed about a week, a week and a half before he was able to go back and play. We repeated the MRI about four weeks after that. Here's the X-rays four weeks after the initial X-rays. So he never really fractured through the fibula and did well. So this is a low-risk. So you can let them weight-bear. You can functionally progress. You don't have to do anything. And they usually get better. Make sure the vitamin D, get calcitonin, all those things to make sure they heal. So the tibial stress fracture, the dreaded black line, that's a different story. That's a high-risk fracture. And you don't want this to happen. So a high-risk fracture is totally different. And you need to be much more aggressive. You either limit their activity or do surgery and treat the fracture. So here's the dreaded black line. This was an offensive lineman from NC State this year. And he was monitored for four to six weeks with a reduction in volume of activity but continued to have pain. X-rays didn't change. So we ended up rotting the fracture. So this one's totally different. You have to be aware of the consequences if you don't limit their activity, their volume of activity. I think you can let them play as long as they're aware of the potential risk. But I think this is probably the better decision if it's early in the season or it's obviously the end of the season. Other stress fractures that are common, fifth metatarsal stress fracture. You can see the base of the fifth right here at the junction of the metapsys and diapsys. Again, this is a common fracture. And it is a fracture that is easy to fix surgically and stabilize surgically. And so I think you can consider this kind of an intermediate fracture because there's a high risk of fracturing. But it can be treated aggressively early with surgery to prevent problems. So doing an intramedullary fixation percutaneously. There we're putting some BMAC to augment the healing. You can let these players weight bear early. So this was a linebacker. We let them weight bear, return to play at three weeks. Now that's a very aggressive timeline. And maybe that's a little bit too aggressive. But if you treat them appropriately, get them good shoes, orthotics, make sure their metabolism is good. And I think you can get by with these. So this case did well. But if you look at the literature, there is a risk of refracture of fifth metatarsal fractures. And I think that is a concern. So people have become a little bit more conservative with these and allowing the fracture to heal and maybe not getting them back to play until six or eight weeks. But again, in some situations, you can let them get back early, like particularly hockey. They have a skate. I think football linemen that can wear good boots and good cleats that protect the shoe and orthotics, I think you may let them go back early. Bob Anderson, I speak with him all the time. And he lets them go back when they're asymptomatic. So maybe at four weeks, maybe at six weeks, maybe at eight weeks. But I'm sure there'll be questions about that. And this is from Bob Anderson, who's treated a lot of non-unions and delayed unions. But again, you need to understand the fracture and understand the injury. Need to change the biomechanics of the foot and use orthotics after the fixation. And I generally let them progress as tolerated based on their symptoms and function and don't necessarily wait for full radiographic healing. So again, with stress fractures, high risk or low risk, I think those are the questions that should go through your mind. So low risk fractures, proximal or distal tibia, metaphyseal fractures, fibula, calcaneus, metatarsals, you can be aggressive and let these athletes participate based on their symptoms without any necessary immobilization or surgery. The high risk fractures are different. So femoral neck, the dreaded black line, navicular, there are different fractures that need to be treated, stabilized, and make sure the fracture heals. And Lisfranc injuries, just cover that. Do I still have time? So Lisfranc sprains are another spectrum of severity. Obviously, the ones on the right are motor vehicle accidents. That's what you see. But the ones on the left, these are what we see in football and basketball, where they have some very mild widening between the base of the first and the base of the second. And so these are relatively stable. It's like a high ankle sprain, and they can function. And so what do you do with these cases? So generally, if they have any radiographic widening like this, they're too unstable to function, and they need stabilization. But if they don't have widening and they're aligned, you see the base of the second is aligned with the middle cuneiform, and they don't have any significant widening compared to the other side. They may be stable. And so anyways, this one we treated with stabilization. You can see the Lisfranc screw and fixation. So these are mild injuries that can be treated percutaneously and stabilized, but they're going to be out for the season. These take about three to four months to heal well enough to start weight-bearing activity and ground-based functional rehab. It's important to understand that the medial column is important for stability. So you need to determine if the Lisfranc injury is stable. And so how do you determine if it's stable? Well, this was a paper by Steve Rakin. Basically said you can predict stability if you can see the Lisfranc ligaments on MRI. And if you can't see the ligaments well, if they're ruptured or intact, then you need to do a stress test. And the problem with the stress test is painful to do a real good stress test under fluoroscopy. So if I'm really concerned, I'll do a stress test in the operating room under anesthesia. So again, this is the stress test right here. So it's a valgus stress test, and you're looking for this opening and gap in between the base of the first and the base of the second. So again, you do all the examination, the weight-bearing x-rays. Assuming the x-rays are normal, how do you determine stability? Then you do the stress fluoroscopy. And you can do that in the training room, but often it's a bit too painful. But that may give you information. But if that doesn't give you enough information, I tend to take them to the operating room. There's a lot of literature on Lisfranc sprains. And this was by Jim Nunley on the classification. And so again, what I'm talking about is these early stage 1 versus stage 2. The stage 3, they all need surgery. They have radiographic abnormalities. And even stage 2 with this radiographic widening are unstable, and they need surgery. They need to be stabilized. You want to determine if it's a stage 1. Then you can let them go and play after they get over the initial sprain, which would be within a week or two. So here's a couple examples. This is a lineman, unable to weigh, bare, tender, around the base of the first, second, and tarsomen or tarsal joint. Here's the x-rays. They're normal x-rays. But he has symptoms of a Lisfranc sprain. He's a starting lineman. How do you determine if they should be out or not? Do you just immobilize them and just wait and see how he does? Or can you do something to make the decision clearer? So we took him to the operating room. And this is under anesthesia. And you see that he's very stable. So this is me cranking on it as hard as I can. And really don't get any widening. You got a little bit of motion here, but nothing significant. And so we treated him non-operatively and waited till his symptoms returned, locomodalities, pool therapy. And then we got him back to play after a couple of weeks. We got him an orthotic with a UCBL type makeup. And did fine. Here's a similar example, another starting lineman. Now his x-ray, you get a feeling maybe he's a little bit of widening here compared to the other side. This is a weight-bearing AP of both feet. There's no loss in the longitudinal arch. So he does have some stability. And then in the operating room, you can see there's much more widening and instability and lateral shift of the base of the second. So then we ended up just fixing it in the operating room. And he was out for the rest of the season. Sometimes you do a delayed diagnosis. This is a case with mild widening. This was diagnosed at four weeks following the injury. And the longitudinal arch was stable. And the athlete was getting better. And so we decided to just leave him and treat him non-operatively and to not do surgery. Because at four weeks, it's just too far gone. And so we're just going to let him finish the season. And if they're symptomatic after that, you'd have to do an open reduction, remove the scar tissue, and reduce the syndesmosis. So with Lisprank sprains, that's the key question. Is this a stable injury? Then you can let him play. And if it's an unstable injury, you need to stabilize it and do surgery. OK, is that good? Thank you. All right.

foot and ankle injuries

individualized treatment

return-to-play decisions

diagnosis and treatment options

communication and trust