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IC 303-2022: Team Physician Update: It’s Not a Kne ...
Team Physician Update: It’s Not a Knee or a Should ...
Team Physician Update: It’s Not a Knee or a Shoulder Injury, Am I Doing it Right? (3/4)
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So who cares about the foot and ankle? These are my disclosures and a lot of people argue that they don't care, but as Craig said in some of the literature that's out, this makes up an extraordinary percentage of the injuries, whether that's from minor ankle sprains to larger injuries. And so it's certainly something we're all going to see covering teams and need to get familiar with. There have been multiple literature studies just pointing out that it is going to be somewhere between 25 and 40 percent of the total amount of injuries seen. So it's something that we need to get familiar with. I'm going to talk about four specific types of injuries today. We're going to talk about turf toe and its evaluation, in particular on the sidelines and what we see from there. Talk about Lisfranc injuries, Jones fractures, and high ankle sprains. So turf toe injuries, you know, a lot of times are misunderstood by what people think a turf toe injury is. And what the injury is is a tear or a sprain of the plantar plate and the connection of the ligaments that connect the sesamoids to the proximal phalanx. There are some variants that include proximal musculature, which we do see, but it's essentially a plantar injury to the great toe. There are three grades, just like we see all across the board. Mechanism of injury is usually an axial load. We see a lot in skill guys as they get run down from behind. You see a dorsiflexion injury to the great toe. You know, I tell our fellows and I talk to our athletic trainers, you typically, in an athlete that comes off the field who's had a turf toe injury, if they've had a significant turf toe injury, you usually only get one shot at a good exam. A lot of times they'll take off the shoe themselves because they know something's wrong and to check out their toe. And once you get a good toe Lachman exam where you feel that subluxation, they will not let you do it again. I promise. So you want to be the one that gets that exam. If you think they have a significant turf toe injury, I recommend you put your hands on the foot and get a feel for it, because you'll feel it once and it'll be a little, it can be startling for you and the athlete. We had it, we had an incident in the game this year where we had completely dislocated the great toe and then had to work pretty hard to get it back in. He wasn't having any more of that. So that's my sort of vignette for that. So you know, once we know we have a turf toe injury, you know, mandatory evaluation is radiographs, right? We're not the smartest people in the world, at least the foot and ankle world of us is not. You know, we can compare to the other side, right? We want an AP comparison view so we can see what the sesamoids are doing relative to the other side. And then MRI, right? We want to check out the plantar restraint. So here on the left side of the screen, you see a normal confluence of the of the ligament, the sesamoid attaching to the proximal phalanx. And here on the injured side, there's been clear disruption. And most important, fluid. The fluid gets into the plantar aspect, into the fatty tissue of the ball of the foot, and you know that there's been complete disruption there. So once we get this, I stress these. If I need to do a digital block, I will, but I want to put them under stress fluoro. And what I'm looking for is what does the excursion of those sesamoids look like? Are they sluggish compared to the other side? And does that gap between the proximal phalanx and the sesamoids grow? Obviously that shouldn't be the case if you have intact ligaments. And if you see a further separation of the phalanx and the sesamoid, you know that instability is a problem. So indication for surgery. Large capsular revulsions, diastasis of the bipartite sesamoid. That's far and away the most difficult of these to treat because operatively, there are not a lot of great options. And when you're trying to get those to heal, you're trying to get poor quality tissue to heal to poor quality tissue. And those tend to be the most difficult. Sesamoid retraction, obviously when we get our weight-bearing comparison views. And then osteochondral lesions, etc. Typically when we see these, this is what you see. You'll see a large hole in the plantar aspect. Of the soft tissue restraints. And you can see here, this was a defensive lineman for the 49ers who had a, not only a traumatic bunion, but a plantar plate tear. And he sheared off a large portion of his metatarsal head. And that's certainly concerning. So how do we do this surgically? In my case, I use this medial base J incision into the sesamoid. You can use a reverse J, but typically we use this J. I actually do it prone. And typically once you find the nerve, I can actually usually stick my finger all the way down into the MTP joint if you have a full disruption. It's usually a pretty large hole. Need to repair everything we can from medial to lateral and repair the collateral ligaments if needed. We put them in a toe spica cast and relax plantar flexion postoperatively. Get them off of it. We keep them off of it for a total of four weeks. And if needed, sometimes we'll take them out of the spica and allow for some plantar flexion to get the toe moving, but have a dorsal flexion block to it. We transition them to a cam boot. Begin foot intrinsic work. And then week 6 through 12, we'll transition them to a shoe with an insert. Begin alter G and progression. In these cases, you know, I think protecting them and a photoorthosis, understanding what their foot pressures are. Actually, this is an athlete who had ended up with a chronic turf toe from it being missed. And you can see his great toe doesn't even get to the ground. And that's a problem. So these are the situations we want to avoid. Ultimately, it ends up being about a four to five month return to play. It is a little bit of a muddy paper, but I did publish it's the only outcome study out there in grade three turf toe. These are all division one and professional athletes. Surprisingly, the return to play was about four months, sixteen and a half weeks. In all players, we have one who graduated from college who didn't continue to play. Everybody else returned to that level and was able to move on if necessary, which was a little bit surprising to us because a lot of the teaching of severe turf toe injuries is that they can't get back to the level that they once were. But if you recognize it, fix it appropriately, put them through a good rehabilitation program, you can expect to get them back. I'm going to show one quick case of conservative treatment. Most turf toe injuries are conservatively treated. You can see here there's clear injury to the plantar plate, but it was on this particular athlete. You can see he's still got some intact. His sesamoids are sitting in a good position. And this was an MRI day after. So we did put him in a cast for three weeks. We transitioned him to a walker boot and a slow progression to full speed recovery. We use a lot of GPS data. I use it extensively in return to play and it is very helpful. And you can see here, here are the things that I look at. This was a player back in 2016. He's actually currently an all-pro defensive back in the NFL. So as he's coming back, what I'm looking for is can he push off the affected foot and can he change directions? And you can see as he gets stronger and as he gets in his return to play, you know, he's lost speed. He's not as strong as he was. However, as he gets more comfortable, you can see here his strength of push-off gets better, his speed returns, his velocity returns, and it normalizes over time. And I can see here that as I look at this data, that he feels comfortable pushing off his toe. I have pre-injury data to go with and I feel comfortable putting him back on the field. Even though it's not operative, I have objective data. And ultimately this is what we want to avoid. I showed you the foot pressures earlier. That is this patient. And this is what we want to avoid. Where they lose the plantar restraint of the great toe, they ignore it. Unfortunately for this athlete, where he played, it would have been injected during the season, which is a no-no. He continued to play on it and ultimately he got this cock-up toe. He was a running back, a high-level collegiate running back, who ultimately did go to the NFL. But you want to be careful and avoid this. So getting the lisfranc injuries, it's a similar mechanism to turf toe. It's usually an axial load on the back of the foot. You know, oftentimes these injuries are missed or we don't really understand the severity of it and can be can be very frustrating when returned to play. People, you know, we want to look for subtle signs. We want to look for other things. You know, here the dislocation of the second toe that you get with that axial injury showing that it's a little bit of a higher grade injury. You know, the lisfranc ligament runs from the medial cuneiform to the base of the second metatarsal. On a high quality MRIs, you can see it. You can see here it's easy to see it's a small ligament, but it's very important. Non-operative treatments generally only reserve for those that have no displacement. This is, if you have complete disruption of the ligament and there's even the slightest amount of displacement, it needs to be fixed. Standing AP, as I said earlier, is a good stress test. You can see here once we weight bear this athlete, the second metatarsal clearly has lateral subluxation. This is an operative case every time. MRI, pretty much they all get MRIs. I'm looking for this edema between the first and the second end particularly. Does it get through the interosseous membrane into the plantar surface? And it can assist in making these decisions. Here's a quarterback that I treated this year. He knew it immediately. Previously had a lisfranc injury on his contralateral side. He went down. He actually told the trainers on the field, I have a lisfranc injury, which is an odd thing to hear. And they were like, what? He said, no, I have a lisfranc injury. It's just like I had on the other side. Sure enough, we get the MRI. He's got complete disruption. Can't even make out the ligament. He's got fluid extending all the way through. And he, sure enough, had instability. As I said, any displacement is an operative indication. You know, it's important to understand that they're variants. It's not always just the displacement of the second. You can see it extend all the way through into the cuneiforms. You can see it extend to the lateral side all the way across to the fourth and fifth cuboid articulation. You know, and so understanding those variants helps us understand. You can see this is a, this was a running back who had a complete homolateral dislocation. Had to take him to the operating room that night. All we did was do a provisional K-wire fixation, let the soft tissues calm down, go back to fix it. So non-operative treatment, as I said, is only for non-displaced injuries. Generally speaking, if you have complete tears, we end up in surgery. In non-operative treatment, we'll short leg cast them usually for four to five weeks. We'll transition them to a boot. They do get stiff. And so getting into the foot intrinsic workout, getting motion, making sure that both the ankle, the toes, the midfoot get moving again. If there's any degree of displacement surgery followed, we want to ultimately get them weight bearing by, full weight bearing in a shoe by ten weeks. Return to play is usually about six months. This is a injury that is very hard to speed up. Even in today's world of accelerated rehabilitation, better physical therapy techniques, better modalities in the athletic training room, this is just an injury that is very, very, very difficult to speed up. This is the typical construct we see in the athletic world, but this was that running back that I mentioned earlier. And so, you know, the variations between this and this are pretty significant, but ultimately you hope to get the same outcome, get them back on the field. So I'm going to talk about Jones fractures too. We all know what Jones fractures are. Fractures at the base of the fifth metatarsal. Jones fractures are particularly zone two injuries, where they extend into the fourth and fifth articulation. It kind of gets to be a catch-all term, whereas zone three, the stress fracture, is the more distal injury. Largely historical in today's world, certainly in the athletic realm, we very, very, very rarely treat these non-operatively. They have a pretty high rate of non-union, and the risk of re-fracture is real. And so typically, we fix these surgically. Screw fixation, percutaneous screw fixation, is the most common. There's certainly a lot of biomechanical arguments. Should that be our first line of treatment? Because we're putting a straight screw in a curved bone, and so we always talk about when we're fixing them, put them in the high and inside position. Is that correct? We've heard sort of some various arguments. And a lot of people are moving towards this. This is a case I did this year where I actually put a planter plate on. You can see how curved this athlete's fifth metatarsal is. This was really an acute on chronic injury. This had been brewing for a while. And the biology of the injury was bad. And sure enough, when we made the incision to put the planter plate on, there wasn't a drop of blood in there. And so we're fighting the biomechanics of the curved fifth metatarsal with bad biology. And the worry here is that you put a screw in, it heals 90% of the way. The planter surface doesn't heal. And you end up with a refracture, which is really just a re-injury to a non-union. And so I do think there's some indications for the planter plate where you can put it on the tension side of the bone. There are obviously some downsides because you have a little bit bigger dissection. But I do think there's a role for it. So I'm going to show you a case here. I call it my now wet case. So he was our starting middle linebacker at Alabama. He had no history of fifth metatarsal pain. Of course, about three weeks before our season opener, he comes in and he's got this. He's got a little bit of pain. He's uncomfortable, and he's got this small little crack in just the planter aspect of the fifth metatarsal. What do we do? Do we do surgery? Well, when I talk to an athlete like this, I tell him, you know, we're probably not any worse off letting you play. And if it fractures, we're going to go do the same thing we would do now. And so we made the decision to let him play based on his symptoms, knowing that it was a ticking time. I'm sure enough, about two weeks before we played Auburn, got all the way into the 10th game of the season, pop, so now he's got this. So now we need surgery. So we go in, put a screw in, looks good. I got all threads past the fracture. I don't think my screw's too long. I worry about putting too long of a screw in and straightening the bone. He's pain-free six weeks from surgery. Do you let him play? We've all been there with these. Do you let him go? X-rays don't show full healing. And the literature pretty clearly says, don't let him, or not don't let him play, but if you're going to let him play at this point and it's not fully healed, there's a pretty high risk of nonunion. So we did. He wanted to play in the semifinals. So we played Clemson in New Orleans. And here he is. He makes a huge play for us, really the game-changing play. He had an interception return for a touchdown that really changed the entire game for us. So limited off-season conditioning program, fourth quarter program. We allowed him to return to spring practice with no limitations. He was asymptomatic, full participant without restrictions. Here's the CT scan. All right. Now what do we do? So he's healed about 90% of the way, but he's clearly not fully healed. No issues through the spring. Do you revise it? Some people argument, take him back, drill in the OR and put PRP in there. We just kept him off of it. He played through the entire season with the plan to revise it after the season. We put our guys in these 3D orthosis. They're made by our engineering department. They're carbon fiber. We put them on the outside of the shoe. You can see how they hook into the cleat. They're far better tolerated than a clamshell orthosis inside the shoe. And the athletes love these far more than the other. And they weigh about two ounces. So we played all the way through the season with a plan to fix it after the season. Well, now he says, I'm going to go pro. Great. So now he's going to go pro. He gets to show my dirty laundry to everybody at the NFL combine. And what are we going to do? He's like, we ain't fixing this thing. I hear you, dog. We're not fixing it. I'll just show up. So I call every single person that I know that might be going to the combine. Hey, man, don't hold this against me, but he's coming. And you can see there's been resorption, right? So he ultimately went on and got drafted in the second round. He's still not been revised. He won't let anybody touch it. Doing fine. He currently starts in the NFL, just got picked up with the Patriots. And so we'll see what happens. So Jones fractures represent a significant injury to professional and amateur athletes. The technical aspects of doing the surgery, you think you're just putting a screw in. But it's got to be right. We've got to get all the threads past the fracture. Using a straight screw, should we use the plantar plate? But most importantly, multimodal approach is important. We're doing their vitamin D, and in some cases Forteo. We're using bone stimulator. Everything that we can do for a successful return to play. But it's still not a guarantee, even though it seems to be such a simple injury. All right, lastly, we're going to go through high ankle sprains. The topic I get asked about the most, and I think understanding the anatomy is the most critical. There are four parts, four main parts to the ligamentous structure. The AITFL, which provides about 35% of the overall strength. The PITFL, which in concert with the transverse tibia fibular ligament, makes up about 40% of the strength. And then the interosseous membrane, which makes about 22%. This was a great study that I have all our fellows read. In 94, it's a classic study by Ogilvie-Harris in arthroscopy, where they did a cutting study. Dr. Clanton, my mentor in Vail, corroborated this study and looked at the relative strengths of it. And I think that's important for you to ultimately understand why I end up doing what I do, because you can better understand the contributions of each ligament to the overall stability. So it's not a static structure. It's dynamic. Every time we move, the fibula moves distally with plantar flexion. There's an external rotation of the fibula that's linked with dorsiflexion of the ankle. And the intermalleolar distance wants to increase with dorsiflexion as the wide part of the talus comes through. And that has an implication for screw fixation. So understanding that is important. So these are all the different motions that the normal syndesmosis goes through. Well, when you have injury, what we see and what you need to sort of learn to focus on is the sagittal motion, the fibula, when we have injury to the AITFL wants to spit out the back. And then that external rotation as we lose that stability gets greater. And so when we injure the AITFL, external rotation increases by about 25%. Posterior translation increases by about 2 millimeters. But you include the interosseous membrane and start getting into the PITFL, that now doubles to 4 millimeters. And the external rotation increases by 35% to 40%. So now we've injured greater than 50% of the stability of the joint. And we've started seeing a larger and larger increase in abnormal motion at the ankle. And you include the PITFL, and we have gross instability. So what are we looking for? We're looking for rotational instability of the fibula, posterior translation of the fibula. And relative to an intact state, these conditions occur to a lesser degree prior to widening of the syndesmosis. That's an important line. Because in our training, we all think about, well, it's not wide. There's not a widening of the mortis. Well, you can have instability long before that. And Ken Hunt, one of my really good buddies who's actually here in Denver, has done some awesome work on this stuff. And that's one of the take-homes of his paper published about seven years ago. You can have instability without widening of the syndesmosis. You get that external rotation and that posterior translation that occurs before that widening. And that's how you see these athletes, that what you think is a normal x-ray, they're struggling. They can't push off. They can't go. So if there's no instability, classically, we would say, put them in a cast for a short period of time, transition them to a CAM boot and progress as tolerated. And we've all seen these injuries. And there have been some good studies out of West Point that showed that, in a lot of cases, the average return to duty, and this can be extrapolated to athletes, is nearly 60 days. And that's a long time. Syndesmosis tenderness, five centimeters above the joint, is indicative of a severe injury. And I think that is a critical part of the physical exam. That seems to be a pretty good cutoff in understanding about where we're going to go. So what are our goals? We want to restore anatomic relationships, restore stability, just like anything, and preserve the normal biomechanics of a strong joint. So in my algorithm, I looked at that inability to bear weight. Can they bear weight normally initially? Do they have a positive mid-shaft fibular squeeze? And then when you examine them from the knee down, not from the ankle up, does that tenderness extend five centimeters above the joint? If so, these get the MRI. If two ligaments are injured, if you go back to those original two studies, if you have two fully injured ligaments, there's a good chance we got instability, because more than 50% of the joint stability has been compromised. Those need to be further examined. So I'm going to go through our quarterback's case. A lot of you are familiar with this. This is G's problem now. But this is Tua. He's given me the permission to show this. And this was a case that got a lot of lay press. And when I show you the case, if you haven't seen it, you'll kind of understand where we go and you'll understand why I did what I did, despite some of the 1,000 opinions that were out there. So he was injured in the fourth play of the game, came off the field complaining that he couldn't push off his ankle. And I think this video needs to be in every textbook. This is what happens when you have a high ankle sprain. You'll see the Georgia athlete land on his foot. It gets stuck up under him, and he gets rotated around a planted foot that doesn't release from the turf. So that's the mechanism of injury for a syndesmosis injury. And that's a great view of it. So we took him back. We did x-ray it. He did not have a mason of injury. We let him play. He was dying to play. Unfortunately, he struggled throughout. It probably cost him the Heisman, because Kyler Murray had an awesome day that day. And he ended up not winning the Heisman. He struggled. Had his worst game by far. Ultimately, we ended up taking him out. He couldn't bear weight the following morning. Had pretty significant swelling. Pain extended 10 centimeters above the ankle. Minimal medial side of deltoid pain. And here's his MRI. If you look at his MRI, this is not gray. This is black and white. That fibula is not reduced. So people say, hey, we're operating on him so he can play in three weeks. No, we're operating on him because he needs to be operated on, because he's got instability. The fibula is not where it's supposed to be. And if you look at the very top cut on my syndesmosis MRIs, I get a different. I actually go higher up. And what I'm trying to look for is what I call the C-side, which is fluid extending all the way around the tibia, from the anterior side to the posterior side. Because if the interosseous membrane is intact, the fluid can't get through there. But if it's injured, which you can see it's pulled off the tibia, the fluid can extend up the leg and get all the way through. That's my own term for it. There's no radiologic sign for it, but that's what I call it. You can see how the fluid goes all the way around. So he's torn his interosseous membrane high up the leg. So you can see on the arthroscopy, you can see in the back, he's actually pulled off a little small piece of cartilage where the PITFL evolves off in the back. You can see the AITFL is torn in the front. You can see this is even without stress. You could drive a truck through that. So I use a two-hole end-of-button construct. So I use two tight ropes. I put my most distal one 1 and 1 half centimeters above the joint. I do use PRP in these. I put it in the joint, in the deltoid, because there is some component of the deltoid, even if the deltoid's not unstable. And then in the syndesmosis, I admit them to the hospital overnight a lot of times. And that's really just to get them tore at all, get them IV tore at all overnight, because I'm trying to hammer them right away. We put them in a game-ready, non-weight-bearing for three days for strict control. I don't put them in a splint. And then we begin weight-bearing in the boot. This is him 10 days out from surgery, working on ankle proprioceptive exercises. And we really start working on strength. Swelling is critical, because if you get the swelling out, you can get the motion. If you can get the motion, you can get the strength. If you can get the strength, you can get their gait. Once I see that their gait is normalized on an altered G, and that they're not splinting their ankle at all, I'll let them progress to the ground. And in his case, he actually ended up playing 27 days out. He was 24 of 27 for 318 yards and was the Orange Bowl MVP. And here's all his data. I'm not going to bore you all with it. But basically, these are pre-injury. This is what happened after he injured. If you remember, that's his left ankle. So one of the things I'm looking for is how he changes direction to the right. Can he push off his ankle? Can he rotate around his ankle? Clearly, as we started advancing back to practice, he could not do that. And as we got closer to game time, he got better and better. And ultimately, six days before the game, he could actually push off and change direction. And during the game, even with it taped up heavily, he was able to get back to his max speed and push off. And so I have objective data saying, I'm comfortable with you playing. So I think in these expedited rehabilitations, it's good for the athlete. Remember, quick return to play is a secondary benefit. That is not why we're doing it. We're doing it because we want to restore normal motion, get rid of the chronic pain, avoid the disability that can last long-term. That's why we do it. We don't do it so they can play a month from now. Thank you.
Video Summary
In the video, the speaker discusses the importance of foot and ankle injuries and their prevalence in sports. They focus on four specific types of injuries: turf toe, Lisfranc injuries, Jones fractures, and high ankle sprains. For turf toe injuries, the speaker explains that they are tears or sprains of the plantar plate and ligaments of the great toe. They discuss the evaluation, including physical exams and imaging techniques, and mention that severe cases may require surgery. In the case of Lisfranc injuries, the speaker emphasizes the need to check for subtle signs and the important role of MRIs. They explain that non-operative treatments are typically reserved for non-displaced injuries and that surgical options are available for other cases. Jones fractures, fractures at the base of the fifth metatarsal, are discussed, and the speaker explains that surgical intervention is common due to a high rate of non-union and re-fracture risk. They mention various surgical techniques and discuss a specific case where a planter plate was used. Lastly, the speaker focuses on high ankle sprains, explaining the anatomy and mechanisms of injury. They emphasize the importance of proper evaluation and the role of MRIs. Surgical treatment is discussed, along with the rehabilitation process for a specific case involving a quarterback. Overall, the video provides an overview of these foot and ankle injuries, their evaluation, treatment options, and rehabilitation processes.
Asset Caption
Norman Waldrop, MD
Keywords
foot and ankle injuries
prevalence in sports
turf toe
Lisfranc injuries
Jones fractures
high ankle sprains
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