Springer Science+Business Media, LLC

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1 Sports Injuries of Ankle and Foot

2 Springer Science+Business Media, LLC

3 Richard A. Marder George J. Lian University of California Davis School of Medicine Sports Injuries of the Ankle and Foot Line Illustrations by Justin Green With 151 Figures, 16 in Color Springer

4 Richard A. Marder, MD Associate Professor University of California Davis School of Medicine Chief, Sports Medicine Service 1631 Stockton Boulevard, Suite 120 Sacramento, CA 95816, USA George J. Lian, MD Assistant Clinical Professor University of California Davis School of Medicine Department of Orthopaedic Surgery 1201 Alhambra Boulevard, Suite 310 Sacramento, CA 95816, USA Library of Congress Cataloging in Publication Data Marder, Richard A. Sports injuries of the ankle and foot / Richard A. Marder, George J. Lian p. cm. Includes bibliographical references and index. ISBN ISBN (ebook) DOI / Foot-Wounds and injuries. 2. Ankle-Wounds and injuries. 3. Sports injuries. I. Marder, Richard A. II. Title. [DNLM: 1. Ankle Injuries-therapy. 2. Foot Injuries-therapy. 3. Sports Medicine. WE 880 L693s 1996] RD563.L '85044-dc20 DNLM/DLC for Library of Congress Printed on acid-free paper Springer Science+Business Media New York Originally published by Springer-Verlag New York, Inc. in 1997 Softcover reprint of the hardcover 1st edition 1997 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Production coordinated by Chernow Editorial Services, Inc. and managed by Terry Kornak; manufacturing supervised by Jeffrey Taub. Typeset by TechType, Inc., Ramsey, NJ ISBN

5 To our families, for their love and support

6 Preface The ultimate aim of a medical textbook is to benefit patients. In this instance it is directed at the treatment of ankle and foot injuries and disorders in both recreational and high performance athletes. Our goal is not to proselytize but to present cogent, practical information in the framework of a readable text. The book is not encyclopedic in its contents; instead, we focus on the treatment of common injuries and conditions, both operative and nonoperative treatment, as well as the all important rehabilitation phase, which facilitates the athlete's return to sport. A chapter on taping, orthotics, and braces has been included to enhance the understanding of their use for treatment and injury prevention. We have organized the book into sections based on anatomic region where appropriate and by type of injury otherwise. The differential diagnosis of presenting symptoms and signs is discussed, leading to some repetition of material. The book is intended to reflect our philosophies regarding treatment. Despite myriad treatment possibilities, we have chosen only those primary and alternative methods with which we have had significant experience. The inspiration for this book comes from patients, therapists, instructors, and colleagues who have educated and stimulated us to continue to improve our efforts to help patients. We hope this reference will be useful to other physicians and ultimately their patients. vii

7 Contents Preface vii Introduction: Special Considerations in the Athlete... xi 1 Ankle... 1 Ligament Injuries... 1 Ankle Fractures Osteochondral Lesions of the Talus Posterior Ankle Pain Tibiotalar Spurs References... " Hindfoot Heel Pain Tarsal Coalition Avulsion Fractures References Midfoot Sprains Stress Fractures Accessory Navicular Plantar Fibromatosis References Forefoot Great Toe Lesser Toes and Metatarsals References

8 x Contents 5 Tendon Disorders Achilles Tendonitis and Partial Tears Peroneal Tendon Posterior Tibialis Tendon Flexor Hallucis Longus Tendon Tibialis Anterior Tendon References Nerve Injuries Morton's Neuroma Tarsal Tunnel Syndrome Peroneal Nerve Compression Sural Nerve Entrapment References Skin and Nails Specific Skin Disorders Toenail Disorders Foreign Bodies and Puncture Wounds Thermal Injuries References Orthotics, Bracing, and Taping The Role of Athletic Footwear Shoe Modifications Orthoses Braces Taping Techniques Injection Techniques References Index

9 Introduction: Special Considerations in the Ath lete Injuries of the foot and ankle occur frequently in sports. Moreover, a significant number of atraumatic conditions, not manifest during normal activity, can become symptomatic owing to the increased demands of sport. Although certain of these injuries and conditions resolve spontaneously, a significant number require formal treatment. The fundamental tenet of orthopaedic treatment is to restore function whenever possible. Maximizing functional recovery is of utmost importance in the athlete. Whereas postinjury functional deficits may not be noticeable in the less active individual, even slight functional loss in an athlete can impair performance or potentially prevent participation. As there are currently no standards by which to predict return to sport after an injury, the treating physician should strive to achieve full anatomic and functional restoration of the foot and ankle. In most cases treatment of the injured athlete starts with several advantages that help to promote an optimal outcome. Despite injury, the athlete usually has a high level of fitness, which is conducive to prompt, uneventful healing. The motivation of the athlete to return to sport usually ensures compliance with a rigorous rehabilitation regimen necessary to promote maximal soft tissue recovery. The importance of dedicated trainers and therapists, who assist the athlete in his or her endeavors, usually on a daily basis, cannot be overemphasized. Given the large numbers of potential injuries with time lost from sport, prevention is paramount. For the foot and ankle, shoewear, orthotics, braces, and taping are frequently utilized. Use of these devices and methods varies considerably, based on the experiences of the individual player, trainer, and physician. Scientific studies have been undertaken to demonstrate their efficacy. It is helpful for the physician treating athletes with ankle and foot disorders to have a working knowledge of such protective equipment. When treating the athlete the physician must be aware that the recommended treatment may not be accepted by the patient. For xi

10 xii Introduction instance, although rest from activity may be indicated for an overuse injury, the serious athlete in the middle of the season may not be willing to stop unless forced to do so by the injury. Instead, simultaneous treatment and activity modification may have to be utilized in which the athlete may reduce the intensity of practice and the number of minutes played, as well as forego "back to back" games, for example. Of more potential seriousness is the timing of surgery for chronic or even acute conditions in the high performance athlete. Whereas immediate surgery may be the optimal treatment, the athlete may choose to continue playing for the season, deferring surgery until afterward. The physician must discuss, in detail, the consequences of postponing treatment (e.g., the development of degenerative arthritis, which could impair future ability to play and interfere with even routine activities). Such discussion should be well documented in the medical record and, if the player concurs, discussed with his or her family, coach, and trainer. Of added importance for treatment of the high performance athlete (high school, college, professional) is the need to formulate a detailed treatment plan at the outset that covers not only the proposed surgical procedure, for instance, but potential complications and contingency plans, formal rehabilitation, and finally transition to functional exercises and activities in preparation for return to sport. Inclusion of family, coaches, trainers, management, and agents in the initial discussion of the injury and treatment plan, per the approval of the player, can greatly improve the chances for a successful outcome. Notwithstanding the ever-increasing numbers of high performance athletes, most patients with foot and ankle injuries are recreational-level participants. For these patients limited time for rehabilitation exercises and, in many instances, restricted access to formal therapy may require some modification of treatment programs customarily utilized for the high performance athlete. Especially for the recreational athlete, who may be knowledgeable about injuries in famous professional and amateur athletes, it is helpful for the treating physician to discuss with the patient that no two injuries are alike and that different outcomes may result, even with the same treatment from the same physician. Finally and most importantly, the physician must remember that the athlete, regardless of stature and fame, is susceptible to frustration, anger, and despair when dealing with an injury that does not heal quickly and uneventfully. Frequent communication, appropriate compassion, and second opinions are helpful for maintaining a successful doctor-patient relationship during this time.