Gee, for the invitation, we're going to try to race through this, but just so everyone in the audience, all these will be on the handouts as far as what the slide content is, because I'm going to fly through this so we at least have some time, certainly for questions and maybe even some cases. Here's my disclosures, no royalties associated with this. One of the important things to understand foot and ankle-wise is why do we care? I mean, the reality is that there's a lot of sports injuries that involve the foot and ankle. Each injury is a spectrum of pathology, though, and we can't just lump things into, hey, I've got pain in my big toe, it's got to be a turf toe. But ankle ligament sprains, very common. High school data show at least 40% of injuries are related to foot and ankle, with once again those sprains being the most common. Quick little disclosure, I think it's really, really important, do not discount shoe wear. You've got to understand what's going on with the cleat surface interaction as well. Difficult balance between performance and protection. So make sure that people have their shoes that are fitting appropriately, these cleats that are fitting appropriately. When we've looked at this at the NFL Foot and Ankle Committee, the reality is that this is an apparel industry item. So there is a variety. Even though you say it's a 13, hey, I wear a 13, the reality is that 13 in an Adidas with one is going to be different than a 13 in a Nike of another. And at least as it relates to injury mitigation, that certainly matters. So at least at the NFL Foot and Ankle Committee measures, we're certainly looking at this, how these interactions occur. Talking about it, that's a resource you can take a look at as far as what we think even about turf. Just understand that these surfaces that they play on matter. So when we look at things as far as return to play, what do we need to know? We need to know the pathophysiology of the injury, stable versus unstable injuries. What's low risk? What's high risk? What can we push? What do we need to pull back on? And what's the key question to answer in each situation? This is what we're going to talk about briefly, the first MTP, ankle sprains, Liz Frank and Jones. As you can imagine, we've got to try to fly here. So turf toe, we know this is a hyperextension injury in most cases. There also can be the valgus variants where you're getting even a medial-sided injury. But this is a classic turf toe that we've described. But as we mentioned, it can be highly variable. This is the anatomy that we're all somewhat familiar with. Certainly the plantar plate and then the medial and lateral sesamoid phalangeal ligaments that become involved. As far as the effects of the MT point to the great toe, there's obviously a variety of severity of these. Most of these can be treated conservatively. It is rare that you need surgery. The key is understanding that the injury is there, how you protect it, and certainly trying to avoid things, particularly steroids in these athletes as an injection which may further weaken the tissue. As far as the alignment, a Lachman exam, a vertical shear stress type of exam, no different than what we would do with the knee. Understanding FHL function, is there clawing, is there anything as you're seeing them stand and also sit as far as their engagement to their big toe. Because you put about 35-40% of your weight through your big toe and being able to get up on your big toe as an athlete is critical. So the function therefore is critical. As far as radiographic evaluation, looking at that x-ray on the right compared to the left and seeing the proximal migration, think of a weight-bearing x-ray as they can tolerate is very important in addition to that clinical exam. Need to understand asymmetry. But also you need to understand what are normal variants. Having two fragments, having bipartite fragments of the medial, lateral, or both, getting bilateral foot views, understanding what is simply just something that they developed with rather than starting to say that it's a fracture. You start saying those things, there's a lot of connotations to saying, oh, you have an acute fracture. That may be a bipartite that's been that way all their life. So just understand how both with x-ray, even with fluoro, you know, in a forced dorsiflexion lateral view as you can see here, just understanding what exactly it is that's seeing you but you may not be seeing it. Diagnosis is not just about images. You have to understand the inability to be able to perform a single limb heel rise, persistent pain with activity, and a lack of improvement. Any of these things, whether it's a syndesmosis, big toe injury can point to problems. So assessing the trailing motion of the sesamoids with fluoro, if they're not moving along with it as you passively dorsiflex it, that's a problem. Certainly allows you to then educate as to whether or not it's unstable or simply just the sesamoids that are not moving. Obviously this is significantly unstable. And fluoro can help with that. But once again, this variable injury, this medial-sided injury, understand how you can protect this both with shoe wear and even with spacers to be able to prevent ultimately this problem, which is a lot more difficult to manage. Often these are progressive. You can't push off and cut. I mean there are a variety of surgical techniques. We don't need to get into all that. But it is sport and position dependent. And certainly you've got to avoid the chronic long-term issue, which is a chronic clawing. Is it simply just isolated sesamoiditis? Certainly can offload it, get special inserts made. But restoration of the anatomy when these things are severely disrupted to prevent that claw is the key. And so you must be able to understand that. And as far as post-operative management, it's a balance between early motion so you don't get a stiff first MTP, but also not overstretching it. And so that goes through that post-op management there. So flying through that, now going to ankle sprains. Lateral ankle sprains are the most common injuries we'll see. The important thing to understand is it's simply just an inversion sprain. Is it simply a lateral sprain? Is it a constellation of acute on chronic injury? You're starting to take lateral instability, transfer it to medial instability. And you've just got to understand other things, malalignment, dynamic instability, weak hips. As Craig was talking about before, I mean it all affects everywhere along that runner's chain from the core all the way down. And is there medial involvement as we were talking about? So where's the tenderness? Can they weight bear? Can they single limb rise and hop? Is there something to do on the sideline to be able to say they can safely return? Are the tendons firing well? If you have an X-ray, or is there an X-ray or not? Early management of the simple ankle sprain, swelling and edema are great. Early weight bearing, get them off crutches, get them at least weight bearing in a boot. Having them wear that at night to limit the contracture, allow them to get early healing and scarring and tightening of that lateral ligament, transitioning them as soon as possible to the ASO and then functional physical therapy. But the late pain after the ankle sprain, just the one that doesn't get better, you've got to be aware of this. Clinically significant, certainly if it's greater than four to six weeks duration. And it's just a diagnostic approach, soft tissue versus bone. But these are some of the things you need to be thinking about. Things that pop up of significant concern, ankle sprain that doesn't get better, obviously the dorsal navicular fracture, understanding where that navicular spot is where they can have tenderness, certainly don't want to miss that. Differentiate pain associated with recurrent sprains from chronic pain. Chronic pain usually due to some type of underlying pathology and be persistent in seeking the cause. Getting to the one that's tough, so syndesmotic instability. We know, particularly in cleated athletes, we see this a lot. It's a ligamentous complex that we don't need to belabor, that most of us completely understand. But it is a complex and it's not simply just the syndesmosis laterally, it's the understanding of how the deltoid is involved with that medially. But with a foot typically in a fixed stable position on the ground, the body is externally rotated relative to that, or the body is internally rotated and the foot is externally rotated relative to that. And it brings that wider portion of the talus into the mortis. And then what ends up happening is, as you can see even with some of these modeling here, the first thing that occurs actually is you're rupturing a portion of the deltoid before you rupture the syndesmosis. So you must be aware of that. And as we start to certainly have looked at this with the NFL Foot and Ankle Committee and our colleagues at the University of Virginia, it is a spectrum of pathology. So you need to understand where the injury is with that athlete on that spectrum to be able to understand ultimately what your treatment is going to be, whether it be non-operative or whether it ultimately ends up being operative. So it usually involves contact with another player, but not always. Certainly with cleated athletes and that engaging the turf and it not releasing can be a concern. A lot of these are unavoidable, but some of them can happen even with non-contact. So history is helpful, but certainly not definitive. The external rotation stress test can be suggestive, but evaluate that entire extremity. The squeeze test, is the deltoid injured? Is there tenderness? Is there not? You know, even for chronic ones, the syndesmotic taping test that Ned Amendola popularized and published on for a chronic subtle instability can certainly in the office help you differentiate that. Knowing if there's a posterior malleolar fracture is important. CT scans can be helpful, particularly if you compare them bilaterally in a weight-bearing CT stance. An MRI can certainly be helpful as well to understand acuity of injury, but can become a little bit complex when just dealing with acute on chronic. Arthroscopy is by far the best way to understand the subtle instabilities. Recommend it when possible and certainly the understanding of when you think it's a simple fracture, a lot of times there's involvement with the syndesmosis as well that allows you to fix it. It's a medial drive-through sign that should never be able to happen. You should never be able to take a four millimeter shaver into the syndesmosis from the anterior aspect. But my current algorithm, inability of that athlete to bear weight, pain with external rotation and tenderness that is four centimeters or more proximal, in my opinion that needs further imaging and better understanding. And so with obtaining that and then understanding that and seeing, hey, is it just an anterior based on the injury? There's no diastasis. You got to understand that it may take longer to get back. You can use injections to sometimes shorten that window, just a little bit of recovery. But certainly their ability to do a single limb hop test allows you to then safely progress them and not having pain with that external rotation can allow them to even progress out of a boot. The two ligament injuries are the most controversial. These are the ones where there's the consideration of where are we at in the season? Where's the athlete at in their contract? The understanding that ultimately there may be stuff that's seeing you that you're not appreciating and that ultimately sometimes this requires a scope to really understand that. But this must be a player-coach, player-supporter, player-supporters kind of discussion and certainly management as well, just to be able to understand kind of where is this, what are we trying to do, and setting appropriate expectations. Certainly on an MRI when you see that the deltoid is more serpiginous like that and not straight, that is a complete avulsion of that medial deltoid complex. That is a problem that must be addressed to prevent the long-standing flat foot deformity. Edema in the back and certainly that you know as well, which is what's circled there, that's a chondroosseous avulsion of the posterior aspect of the inferior tib-fib ligament. As far as fixation, we have gone away from doing screw-only fixation of this. Rarely do I ever use that. Does fixation matter? Certainly reduction does, but the ability to be able to use these tightrope-type suture button devices and fix this dynamically has allowed us to do quite a bit more. And even our trauma colleagues have published on this and showing the benefit of that. Certainly before there was a lot of pushback between the cost of a screw compared to the cost of these implants. But there's certainly a cost for having to go back and take hardware out compared to sutures. And so with this, as it's borne out, the decreased risk of malreduction, increased risk of being able to return and not have to worry about screw removal certainly helps. One versus two, you can use them to dynamically stabilize this. You can also use an internal brace, not unlike Steve was talking about in the wrist, to be able to dynamically, to statically and dynamically stabilize this early. Arthroscopic evaluation, fixed fractures if present. I will fix even a proximal fibular fracture, not all the way up at the fibular neck, but approximately to create that length-stable and rotation-stable alignment than to just fix it dynamically distally. A buttress plate, always in a contact athlete. I think it centers the buttons and certainly provides ability to be able to protect them from any type of an injury such as this, which is a major problem. So you want to try to avoid that. Obviously this has gotten a ton of attention with everything that's gone on in Alabama. Not every high ankle sprain automatically needs ropes. But at the same time, you shouldn't withhold the ability to fix it when it's bad enough when you can do it. You just have to make sure you also understand what's the severity of injury immediately and don't undertreat the medial injury. And that's what we're talking about here as far as Andy Hsu and Bob Anderson's paper talking about the evulsion of the superficial deltoid. This is where with a bad external rotation mechanism it pulls that entire complex off medially. You make an incision through skin and you're staring right at the medial joint. That is not going to heal compared to the deep deltoid, which if the ankle mortise is insured and aligned will heal. And so that's what that looks like. This remains a common difficult injury for cleated athletes. Continue to improve diagnostic criteria but the management is controversial and certainly want to leave time for questions. So Liz Frank, frequent subtle injuries. You've got to see these because certainly they can see you sometimes. Inability for the athlete to push off, change directions. These are certainly compared to the motor vehicle collision injuries, more subtle, more rotational, more proximal variant. But weight-bearing imaging, acutely they're not going to want to put a lot of pressure on this but a single leg weight-bearing stress view done serially, even if they can't do it day one, can they do it at day seven and understand asymmetry. That's the critical thing about that because whether it's an MRI or CT, unless it's a weight-bearing CT, it's really hard sometimes to understand this. And you can do a stress fluoroscopy but that's pretty painful unless they're anesthetized. So those are ways to look at it. The proximal variant, you've got to understand this because once again, instead of just simply the Liz Frank injury, this is a Liz Frank injury that extends through the medial navicular and the medial cuneiform joint. These are a little bit more subtle but certainly create significant difficulty with push off and coming around a corner. So you must be able to understand that. This is the classic non-liver tear-low classification but we advocate for open exploration, understanding what's unstable. That's a freer in that articulation between the base of the second metatarsal and the medial navicular and the medial cuneiform. So you've got to be able to understand that. You've got to be able to reduce it and then see that when you do and you fix it, that it is stable. So fixation of that, bridge plating for the first TMT if there's instability there, K-wire fixation for the lateral column. These are static plates though. So you don't put a bridge plate over something and say look, you're going to be fine because you're otherwise a closet fuser of this. Because it's either going to break or it's going to continue to cause pain. Those need to be removed typically. Not uncommonly. Craig and myself have certainly seen these at the combine where someone's been fixed and they come in and they've got broken hardware and then what do you do? So we tend to remove that after five to six months. Partial arthrodesis only if they've got significant arthritis. We try to avoid crossing the tarsal metatarsal joints because those screws will break like you can see in that bottom right-hand picture. And that's a problem because it's hard to get that out. Fixation of all the dynamic unstable segments. You can sometimes use these suspensory devices. But in general in these large male athletes, we do not tend to do that and fix them instead of the screws that are removed at six months. But it is possible to be able to fix certain ones like that. That's otherwise the post-op protocol of that. This is how it looks as far as how these athletes will do. Once again the key is identification, support, fixing the ones that are significantly enough unstable. And so now last, Jones fractures. So Jones fractures, they're common yet sometimes difficult. People just think hey, it's a Jones fracture. It's broken. It's going to heal through and it's going to be fine. Proper treatment does not guarantee success and the key is setting appropriate expectations. Refracture can occur, particularly if you're very aggressive with early rehab. So once again, this is all about setting expectations and understanding where the athlete is at. Because if you immediately start weight bearing them on this, there is a 5 to 10% risk that it may not heal. Now that may be fine and they may need surgery after the season and that season may be important to get them back as soon as possible. It's just all about setting expectations. The Jones fracture is that zone 2 that you see right here. That's the classic zone for the Jones fracture. Tuberosity fractures, almost all of them unless they're very large are treated non-operatively. So that's what it's not. When they're large you can fix them with a screw that captures the cortex just like that. The zone 3 are diaphysial stress fractures. Those are also pretty hard to heal and those can either be plated or fixed with a screw as well. Understanding how foot alignment matters, understanding why it happens, explaining that to the athlete. Non-operative treatment is largely historical in these athletes. We tend to fix them. But placing a screw in it does not automatically guarantee success. And so that percutaneous fixation, I tend to bone graft these fairly routinely even if it's just through an iliac crest aspirate to be able to place down along there. The plating that you see down along there can be an option. Sometimes it's a little bit more prominent. It certainly requires more dissection, but can be very useful in the revision setting. Screw selection does matter. Placement of that screw matters. Going in and placing a screw that's cannulated and it's titanium, certainly if it doesn't have a head on it can be a problem if it doesn't heal and it breaks. But not going into the technical aspects of that, this is not just something just drill and fill. You've got to be able to put it in, put it in the right way. You've got to think about biologics, but you also have to understand in addition to doing that and taking the aspirate, placing it in there like I'm showing there which I do on all of them. You've also got to understand the other adjuvants. Vitamin D is important. Shoe wear is important like we talked about before. Bad injuries, Forteo, something that we've used a lot more even in the league. So rehab, once again controversial, do you push, do you not? Very specific to the athlete and what their situation is. You can, but just realize it may increase the risk of needing to do a revision. But athletes can do well. There just can be the risk of refracture. So it represents significant injury to professional and amateur athletes and the technical aspects in addition to those setting of expectations is very important. And I think we just ran through that real quick. Gee, we've got some time.

foot and ankle injuries

sports

ankle ligament sprains

turf toe

individualized treatment approaches