Gee, I appreciate this opportunity. We're going to fly through this. There's certainly a lot of slides and kind of hit some of the high points here, my disclosures. Foot and ankle injuries have become more and more common. If you look at the NFHS data, it's about 40% of all high school injuries are foot and ankle injuries. Most of those are ankle sprains. But certainly, as a catchment, you're going to see a lot of them as a team physician. The data is out there. It's been shown that this is something that we should expect to see and become comfortable with taking care of these athletes, certainly when we're on the sidelines. I'm going to go through some of the more common. We'll talk about turf toe lisfranc. We're going to talk a little bit about Achilles tendons, Jones fractures, and then we'll get into syndesmotic injuries. So turf toe injuries tend to be a little bit nebulous. And I think some people don't fully understand what we're looking for. It's really a sprain or tear of the plantar ligaments, the ligaments that connect the sesamoid to the proximal phalanx of the great toe. There are certainly some variants that can get back into the musculature, but in particular, it's the ligaments, it's those plantar ligaments. There are three grades of severity, and understanding that really can guide your treatment from a non-operative to an operative standpoint. Typically, the mechanism of injury is an axial load on the heel with forced dorsiflexion of the great toe. When you're examining these athletes, the Lachman exam, the vertical shift test is really what we're looking for. We're looking for the lack of plantar restraints. And my one advice to physicians and athletic trainers is, if they have a significant turf toe injury, they usually know it. They're coming to the sideline. They're ripping their shoe off because something's wrong. You get one good shot at a Lachman. And so I tell the physicians, they need to be the one that check it, because when you do it once, they will not let you do it again. They will kick you the second time. So you want to be the one that gets that good exam when you're testing for that instability. So radiographically, we want to evaluate it. Us orthopedists aren't the smartest people, so we can compare it to the other side, right? That's why the good Lord gave us two of them. So we want to look at the opposite side and see if there's been any proximal migration of the sesamoids. That's a telltale sign that you have complete disruption of the plantar ligaments. And then certainly MRI. What we're looking for here is disruption. Is that joint fluid inflammation getting all the way through the plantar structures, and you see the proximal migration of the sesamoids? That's what we're looking for. And if so, typically, you can confirm this with stress tests, put it under fluoro if the sesamoids don't migrate, then we have instability. So what are those indications? Well, the avulsion, large capsule avulsion with an unstable joint, diastasis of a bipartite sesamoid, which is the most difficult to treat, sesamoid retraction, and then the various variants. And then sometimes you get these situations where you have a large osteochondral lesion of the head where the injury or dislocation has sheared off some of the cartilage. When we fix these, I do these through a J approach. I use a medial incision. It extends across the flexor surface. You can use the reverse J, but typically I use the medial J. And almost always, it's either a primary suture-based repair or if they've avulsed it off, the proximal phalanx will use suture anchors and pull it back. Occasionally, you'll have the exposed sesamoids. That makes it a little difficult. I've even had to go as far as putting little small anchors into the sesamoid itself and pulling it back the opposite direction. Post-operatively, we put them at a toe spike of cast. The patients hate it, but it's necessary because we want to avoid any forced dorsiflexion. We keep them off of it for four weeks, and then we progress into a cam boot at four to six weeks, full weight-bearing at six weeks. Into a shoe insert, we've got an altered G, work at about 10 weeks, and progress. And our center actually has the largest and only outcome study on turf toe. It's some 15 Division I players. And interestingly, the return to play, they all return to play at or above the level with the exception of one whose eligibility had come up. And they actually get back fairly quickly. Our average return to play was about 17 and a half weeks, which is a little faster than we thought. Post-operatively, I think it's very important to work with your athletic trainer, your equipment managers, the surgeons, to devise a plan for return to play, in particular their shoe wear, so that you have a good plan for them moving forward into the season. And that shoe wear is very important. Most of these football players, in particular, would like to play basically barefoot at a lot of them. Some of the speed shoes are highly flexible and not great for these types of conditions. So you can expect to get them back. The long-term, back in the day, the teaching was that it's gonna be difficult to get them back, but we can expect now that you can get them back and get them back reliably. Here was the study I was referring to. Good outcomes, minimal pain, and you can expect to get them back to play. Conservative treatment, though, is the mainstay. We operate on grade threes, we operate on unstable ones, but these are the difficult ones. This is a very high level, at the time, All-American, currently All-Pro, defensive back, who's clearly got damage to his plantar restraints here, but the sesamoid's sitting in good position. There's fluid that's trying to get through. It doesn't get all the way through. It's really a grade two. So we put him in a TOSPICA cast for three weeks. We treated him non-operatively. The ligament has great blood supply. It wants to heal, but it's a slow progression, and if you're treating it non-operatively, we don't want setbacks, because this is definitely an injury that you can take from a non-operative, conservative treatment scenario, and create an operative one. So you gotta be very careful, and certainly when they return to play, do not inject or anesthetize these pre-game, because you can change your outcomes. So looking at our GPS data of this particular player, you can see this was him before his injury. You get a good idea about how he backpedals, about how he changes direction off the injured foot. So once he injured it, he was having significant difficulty slowing down. He couldn't push off the injured foot, but we have good objective data as he's going through his rehab that he's getting better and more comfortable returning, and then once his numbers return to what they were pre-injury level, I've got objective data to say, you're good to go. Ultimately, this is what we wanna avoid, the chronic turf toe. It's certainly easy to ignore turf toe, but we don't want to. Grade three shouldn't be ignored. They're surgical, and as I mentioned, please beware of injecting the turf toe. So lift-frank injuries, very similar mechanism of injury to the turf toe. It's usually an axial load on the back of the foot. Essentially, the midfoot folds like an accordion. It's often purely, certainly in the sports world, purely ligamentous, and it's often missed. Radiographs, good place to start, obviously, and look for the other injuries and other subtle signs like dislocated second toe here that can lead you down that road. MRI is a very good tool. You usually can visualize, and certainly in the higher tesla magnets, get a good visualization of the ligament. In non-operative treatments, usually certainly a mainstay if there's no displacement, but this is one of the areas where we will not accept any displacement. Those outcomes are terrible. So standing AP certainly is a good stress test. Oftentimes, in the acute setting, they don't wanna do it, but if you can get your athlete to give you a weight-bearing X-ray, oftentimes they'll bring out the result themselves, but certainly MRI tends to be our go-to, and certainly more helpful if they have sort of that vague presentation, and what we're looking for is that edema and the disruption between the first and second, intermetatarsal area into the cuneiform. You can see here, this is a good example where it just seems like there's no good structure. If it is intact, like I showed on that normal MRI earlier, you'll see nice, solid fibers running from the medial cuneiform to the base of the second. In this case, they're completely disrupted. You don't get a good feel for them. So any displacement's an indication for surgery, and it's important to understand the variance, the proximal variance, the ones that extend into the cuneiforms and the first TMT instability. Certainly, surgical stabilization is required in these. This was actually a Division I running back, had sustained this in a game. This is something, obviously, we need to look at fixing more emergently versus some of the others, and then once we fix it, what do we do with the hardware removal? I tell all the athletes, this is really two surgeries in one. Expect that you're gonna get the one to fix it, and then we're gonna get the one to take the hardware out. As the paperclip example was given earlier, ultimately, you're gonna break that hardware just like that paperclip that you're gonna bend back and forth. So non-operative treatments only for non-displaced injuries. We're looking at usually four to six weeks in a cast. Oftentimes, I actually put a plaster support inside the cast for the arch. I'll have our cast tech build him a plaster support and put a fiberglass cast around it, and anatomic reduction, as with anything in orthopedics, is essential. With surgery, it's non-weight bearing for six weeks, typically five to six weeks, followed by a full weight bearing by 10 weeks, return to play is about six months. This is an injury, as much as we like to push the envelope with rehabilitation and some of the better techniques that our athletic trainers have, this is a very difficult injury to speed up. And I counsel the athletes to that and that they need to understand that this is a long time. And oftentimes, they'll tell you it takes a year to 18 months before their foot feels right. So quickly on Achilles tenor ruptures, I just really wanna hit on one sort of newer topic. There's all kinds of literature out there about non-operative treatment. It's certainly a common injury. But in young, healthy athletes, I'm not aware of any high-level athletes that have been treated non-operatively. It tends to be a surgical issue. Certainly, one of the things that we wanna avoid are soft tissue problems. And that is our take-home message when we talk to patients is, surgery can lead to the one complication that we get most worried about, which is wound complications. So this is our nightmare. So this is one of the times where I think the size of the incision does matter. If we can make a smaller incision, even though it certainly heals side to side, it's less soft tissues to heal. So have we improved our soft tissue techniques enough? And some of the newer techniques have led us to be able to avoid these nightmare scenarios. And so one of the ways that we're fixing them now is using the PARS technique, which is the percutaneous Achilles repair system. And it's an excellent system that allows us to use a small incision. You can use either a transverse or a horizontal incision to allow us to percutaneously fix them. My mentor, Bob Anderson, is now doing them on all his athletes. He's on the NFL guys. He's letting them return to play and feels very comfortable that we can get a good repair. And the literature is certainly showing that. And you can see here, it's really a pretty simple technique. As long as you feel comfortable that you are grasping the tendon, the nice part is if you throw an air ball, it's very easy to reinsert the jig, place your suture back in. It does allow for us to lock sutures. We lock one proximally, one distally and get a good repair. I don't think you can over tighten these. You can certainly overstretch them and so I try to get them as tight as we can and you can feel good about the repair as you get comfortable with this technique. And it certainly allows us to avoid some of the soft tissue issues. Certainly the most significant change in the treatment of Achilles tendons, early range of motion and early weight bearing. If you look at some of the basic science literature, getting them into a walking boot with a heel lift and getting the tendon moving earlier allows for better organization of the tendon, better healing. Patients don't like being immobilized and so if we can avoid that, that's good and this is one of those areas where that motion can play to our advantage. So in our rehabilitation, I usually start some gentle range of motion after a week. In week two to three, we'll take the sutures out, we'll put them in a hinge type orthosis, start partial weight bearing with a heel lift. We'll start bike work usually about week three or four. We'll allow them to start progressing on their own, increased intensity of exercise. We'll start running in a pool and in the Alter G sometime around week eight, week nine, week 10. Then once we hit week 12, start increasing their activity level, and then what I call ballistic type movements, usually sometime around week 14 to week 16. We're going to get into the Jones fracture next. We all know what Jones fractures are. They're the zone two injuries. It's a unfortunately very common injury, and that number is increasing with the types of shoe wear that's out there. These narrow shoes, highly flexible. Oftentimes these bigger athletes fall off the side of the shoe. Their fourth and their fifth metatarsals are unsupported, and it puts them at risk for the injury. So how do we treat them? Screw fixation is the go-to, though there is a camp of surgeons out there that are using the plantar plate technique, which I think certainly has some merit because it places the plate on the tension side of the bone, but most surgeons go to is screw fixation. That tends to be our out-of-the-gate choice of fixation. So I'm going to show a case here that kind of highlights some of the difficulties of Jones fractures. So this is our starting middle linebacker. He has no history of fifth metatarsal pain. In training camp, has this little tiny nick in his fifth metatarsal. He has some intermittent pain. You can see better here. His surgery, what we should do. So we talk with him. We make some difficult decisions. This is his first year as a starter. He's got significant potential. Where do we go? So he makes the decision he wants to try to play based on his symptoms, which are intermittent. It's clear understanding this is a ticking time bomb. You know, he can fracture this thing at any moment. If that happens, surgery is the way we're going to go. So he makes it 10 games into the season. Pop, he feels it. We're two weeks away from playing Auburn. We're ranked number one, and this is what he's got. So now it's completed. So now the decision's easy, right? Put a screw in. So the problem with these is you put a screw in. This is one of those surgeries that you put the screw in, and three days later, they feel great. They want to play. They do not think that they should be held out. He's pain-free. Six weeks from surgery, do we let him play? It's probably not healed. You have that discussion with him. He's certainly a very high-level guy at this point. He's first team all Southeastern Conference. X-rays don't show full healing, but he decides he wants to play. This is a decision he made in the national semifinals. Here he is with a pick six, six weeks out. So we limited him in the fourth quarter program, trying to get this thing to finish healing. Returns to spring practice with no limitations. He's asymptomatic, but this is a CT scan. So now we have a problem. What do we do? So we take him back to the OR. He essentially refuses a second surgery, but so we do a drilling, a PRP under sedation, kept him non-weight-bearing for four weeks. Should you revise it? So he played through the entire season asymptomatic. No issues, no problems. This is one of the things that we do with our engineering department. We put him in a 3D-printed orthosis that wraps around the side of the shoe. They don't really like clamshell orthosis inside the shoe, so this thing weighs two ounces. They tolerate it well, hooks onto the side of the cleats, keeps them from falling off, and they can cut without problems. He decides to turn pro after the national championship game, and here's a CT scan. Oh, Lord. So now he's going to the combine looking like this. What are you doing, Norman? But he's still asymptomatic, and now all my mentors get to see this and call me and go, what in the world? These are difficult decisions, even though you see the fracture. It's not always cut and dry. It's not always black and white. Jones fractures are significant injuries to both professional and amateur athletes alike. Decisions aren't always the easiest. The technical aspects of fixation are very important, getting the screw in the right position, making the right decisions. It's a multimodal approach for fracture healing using vitamin D, in some scenarios Forteo, and it can allow for successful return to play, but remember, these Jones fractures can be frustrating, and it's not a guarantee. So we're going to get into syndesmosis injuries and talk about high ankle sprains. This is a little bit of my baby, and it's probably the boiling it down. It's really important to understand the anatomy. That's really what it boils down to, and there's some cutting studies done by my mentor, Dr. Clanton, but the original Ogilvy-Harris study in 1994, I would tell, I would encourage everybody to take time to read it. Gives you a good idea about the relative strength of each ligament, the AITFL being about one third of the strength, 35%, and it's the most important ligament to resisting external rotation. Posteriorly, the PITFL, which makes up two separate bands, the transverse and the PITFL, make up about 40 to 45% of the strength. It's the strongest of the ligaments, and certainly the interosseous membrane. It's really important to understand this is a dynamic structure. Every step you take, the fibula moves distally. It externally rotates with dorsiflexion of the ankle, and this has an implication, really, for how we fix it. It's one of the reasons why I discourage screw use, because you're essentially pinning the fibula to the tibia, and you're not allowing for that normal motion. It's a joint. Don't forget that. So when we have an injury, it's important to understand what the normal motion is, and most of the motion at the syndesmosis occurs with posterior translation and external rotation. These are the two important keys. So when we knock out the AITFL, the posterior translation increases by about two millimeters and the external rotation increases by about 25%, but you include the interosseous membrane, and you've doubled that posterior rotation, and you start losing that foot, or you start gaining a fulcrum on the back of the ankle for external rotation, and you start getting into an unstable ankle, and certainly if you have complete injury, it's unstable. So what are we looking for? We're looking for rotational instability of the fibula. We're looking for that posterior translation, and as Ken Hunt said, there can be instability without syndesmosis widening, and if you are waiting until you see widening, you've probably missed the boat. So classically, with no diastasis but instability, we put them in a cast or a cam walker boot, rehab them, progress them as tolerated, and you're looking at four to six weeks, sometimes even longer. If you look at some of the data out of the West Point in their grade one, grade two injuries, it took the average cadet about 55 days to return to full duty, and probably the most important part of one of their studies is that five centimeter cutoff looks to be your physical exam, sort of key in understanding the severity, that tenderness greater than five centimeters above the ankle was more indicative of a severe injury. So what are our goals? Just like with anything in orthopedics, we want to restore anatomic relationships, restore stability, prevent long-term wear, and have normal mechanics of the joint. So personally, my algorithm is, if that athlete has initial inability to bear weight, and by that I mean bear weight normally, can they push off their toe? Do they have a positive mid-shaft fibular squeeze test? And don't forget that's pain at the ankle, not pain where you're squeezing them. Do they have pain at the ankle? Does that tenderness extend five centimeters above the joint? Do they have pain with external rotation? And despite what the weight-bearing X-rays may tell you, I get an MRI. If there are two ligaments that are injured, if you go back to our anatomic cutting studies, if you have two ligaments injured, you've compromised 50% of the stability of the joint. So I recommend an EUA and stress fluoroscopy. So I'm going to show this case. This is Tua, and this is a case that got put out into the media and had some, I would say, misperceptions about what happened. Fortunately, he's fantastic. Gee knows him. He is more than happy for us to use this for an educational tool. So I'm going to show his injury and allow you to sort of understand my thinking. So in the fourth play of the game, he injured his left ankle. He threw an interception on the following play. He came off the field saying he could not push off. He's left-handed. It's his push-off foot said he couldn't push off. This video needs to be in a textbook. This is exactly how high ankle sprains occur, and this is very well captured. And you'll see the rotational force that goes around his ankle as it's planted and stuck underneath the athlete. The ankle doesn't give way, and he rotates around it. That's a classic syndesmotic injury. So he returned to play in the game. We got x-rays initially to make sure he didn't have amazing enough fracture. He didn't. He tried to play. He was 10 of 25 through two interceptions in the game. He had two all year long. Probably cost him the Heisman Trophy, because if you remember, Kyler Murray had a great game that day in the Big 12 Championship game, and he lost the Heisman probably based off his performance that day. Later in the game, he was stepped on on his opposite ankle by a teammate. And at that point, we didn't feel like he could protect himself. We pulled him out. Fortunately, Jalen came in, and we were able to win the game. But the following morning, he had significant swelling. He had pain extending about 10 centimeters above the ankle, minimal medial sided pain. So unlike at USC, where they wait till Monday to see what's going on, we're Sunday morning at work. So maybe that should tell you a difference. Here's his MRI. So despite all the information or misperceptions that are out there, this is very black and white. This is not we're operating to allow him to play. We're operating because he's got an unstable ankle. If you see this MRI, there's not one person here who doesn't think there's a pretty significant syndesmotic injury. His fibula is not reduced. It's subluxed out of the incisura. This is a no brainer. If you look here, so my syndesmotic algorithm for MRIs goes higher than the normal foot and ankle, because I want to get well above the joint. And what I'm looking for is do I see fluid that extends around both sides of the tibia? That means the interosseous membrane has been disconnected from the tibia and it can get around both sides. And clearly that's the case here. So we take him to surgery. You can see back here, the PITFL has got a little avulsion off the posterolateral tibia. His AITFL is completely torn in the front. He's got a drive through sign. You can see how wide the area between the tibia and the fibula is. So he got a two-hole plate. He got an end-to-button construct using tight ropes. I placed PRP in the deltoid. He had a minor anterior deltoid tear, which is always involved in this injury. Placed it in the joint, in the syndesmosis. I put him in, I admitted him overnight, gave him Toradol. Post-operative leak is swelling, swelling, swelling, control is the most important part of this. We put him in a game ready. I don't immobilize him. I put him in a boot for comfort, but I put him in a game ready, impact you. I make him non-weight bearing for three days and do everything under the sun to get the swelling out. Once we get the swelling out, they can get their motion back and they get more comfortable. And avoiding stiffness is vital. We begin weight bearing at day three, and here he is day 10. He's getting much more comfortable getting off his foot. He's doing proprioceptive exercises to allow him to work on control with his perineal tendons, which helps stabilize that fibula and support our construct. And we work hard on getting that, or not losing the strength in the post-operative period while we're trying to regain our motion. Once we get all that and his gait is normal, we get him on the Alter-G. When I get him on the Alter-G, I get daily videos from our trainers looking at their gait. When I'm comfortable that he has good push-off and can accelerate through the foot, I'll get him out of the Alter-G onto land. Once they can do that on land, we'll start cutting. And usually somewhere between day 12 and day 21, we'll get him back on. I never promise anybody how long it's gonna take. What I tell them is that I won't slow you down. And he played in the Orange Bowl. It was 24 of 27 for 318 yards and was the Orange Bowl MVP 26 days out from surgery. And so all of that really has more to do with not a great surgeon. It has more to do with fantastic physical therapy, fantastic athletic training staff and communication, and then everyone buying into the same process. If you're comfortable with it, and what I've learned is I'm comfortable with the humps and bumps of it to allow them to return to play in an expedited manner. But probably the most important part, and I'll skip through this, this is his GPS data. And all our players get GPS data. And what I'm looking for is, I feel comfortable allowing them to return to play when it gets back to normal. And you can see here as he got better all the way across and as we got closer to the Orange Bowl, his ability to cut off that injured ankle improved. And so ultimately I think expedited rehabilitation is good for the athlete. It restores normal motion, it reduces chronic pain, and return to play is a secondary benefit. That is not why we're doing it. And that's important to understand. People think we put the tightropes in everybody so we can allow them to play. That's just not the truth. We do it because they need it. And we allow them to return to play because they can. Thanks. Thank you.

foot and ankle injuries

athletes

prevalence

healthcare providers

turf toe

lisfranc injuries