Sports Injuries Leg, Foot and Ankle

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Muscle injuries
Gastrocnemius-soleus strain this injury is probably much more common than rupture of the plantaris tendon. Supportive treatment is indicated.
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Tendon Injuries
- Posterior tibialis tendon injury This injury can occur in older athletes. Patients complain of midarch foot pain, with difficulty pushing off. Débridement of partial ruptures and flexor digitorum longus transfer for chronic injuries are recommended.
- Peroneal Tendon Injuries
- Subluxation/dislocation - Violent dorsiflexion of the inverted foot can result in injury of the fibro-osseous peroneal tendon sheath. Diagnosis is confirmed by observing the subluxation or dislocation by means of eversion and dorsiflexion of the foot. Chronic reconstruction involves direct repair.
- Tenosynovitis - These injuries are being recognized more frequently with MRI and often lead to tears of the peroneal tendons.
- Longitudinal tears of the peroneal tendons (especially the peroneus brevis tendon) - These injuries are now recognized with increasing frequency. Repair and decompression are generally recommended.
- Achilles tendon injuries
- Tendinitis/tendinosis - Overuse injury to the Achilles tendon usually responds to rest and physical therapy. Progression to partial rupture may necessitate surgical excision of scar and granulation tissue.
- Rupture - Complete rupture of the tendon is caused by maximum plantar flexion with the foot planted. Patients may relate that they felt as if they were “shot.” The Thompson test is helpful for confirming the diagnosis. Treatment remains controversial; however, recurrence rates are reduced with primary repair, while other complications (i.e., wound problems) are increased with surgical repair.
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Chronic Exertional Compartmnet Syndrome
Although it is more commonly encountered with trauma, sports-related compartment syndrome is becoming more frequently diagnosed. Athletes (especially runners and cyclists) may note pain that has a gradual onset during exercise, ultimately restricting their performance. Compartment pressures taken before, during and after exercise (pressures >20 mm Hg 5 minutes after exercise or absolute values above 15 mm Hg while resting or above 30 mm Hg 1 minute after exercise) can help establish the diagnosis. The anterior compartment of the leg is the most frequently involved. Fasciotomy is sometimes indicated for refractory cases.
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Nerve entrapment Syndrome
- Peroneal nerve entrapment The common peroneal nerve can be compressed behind the fibula or injured by a direct blow to this area. The superficial peroneal nerve can be entrapped about 12 cm proximal to the tip of the lateral malleolus. Compartment release is sometimes indicated. The deep peroneal nerve can be compressed by the inferior extensor retinaculum, leading to anterior tarsal tunnel syndrome and sometimes necessitating release of this structure.
- Saphenous nerve entrapment - Όταν συμπιέζεται μπορεί να προκαλέσει επώδυνα συμπτώματα κάτω και έσω του γόνατος.
- Κνημιαίο νεύρο When compressed, the saphenous nerve can cause painful symptoms inferior and medial to the knee.
- Tibial nerve entrapment When the tibial nerve is compressed under the flexor retinaculum behind the medial malleolus, it may result in tarsal tunnel syndrome. Electromyography/nerve conduction evaluation is helpful and surgical release is sometimes indicated.
- Medial plantar nerve entrapment Occurs at the point where the flexor digitorum longus and flexor hallucis longus cross (knot of Henry) and is most commonly caused by external compression from orthoses. Commonly called jogger's foot, this condition usually responds to conservative measures.
- Sural nerve entrapment Can occur anywhere along its course but is most vulnerable 12-15 mm distal to the tip of the fibula. Surgical release is usually effective.
- Interdigital nerve Commonly called Morton's neuroma, entrapment can occur during the push-off phase while running in athletes and with the demi-pointe position in dancers. It usually occurs between the third and fourth metatarsals plantar and responds to surgical resection if conservative measures fail.
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Stress fractures
Common in athletes who have undergone a change in their training routines and in female endurance athletes (must ask about a menstrual history). Usually responds to rest and activity modification. Recalcitrant fractures may need operative fixation.
- Tibial shaft fractures: This is a complication of unrecognized tibial stress fractures and can be a difficult problem. Persistence of the “dreaded black line” for more than 6 months, especially with a positive bone scan, can be an indication for bone grafting and/or intramedullary nailing.
- Tarsal navicular fractures: This injury is often found in basketball players. Immobilization and non–weight bearing are important during the early management of these stress fractures. Open reduction with internal fixation is occasionally indicated with linear fractures (as seen on CT).
- Freiberg infarction: Flattening of the second metatarsal head, usually due to stress overloading, in a child's foot. Conservative management is indicated unless the patient is having mechanical symptoms .
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Jones fractures
Fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal in an athlete can be treated more aggressively with early intramedullary screw fixation to allow earlier healing and an earlier return to conditioning activities.
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Os trigonum (posterior impingement) syndrome
An os trigonum can cause impingement with plantar flexion of the foot, especially in ballet dancers. Treatment may include local anesthetic injection and other supportive measures. Surgical excision of the offending bone is occasionally necessary.
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Plantar fasciitis
Inflammation of the plantar fascia, usually in the central to medial subcalcaneal region, is common in runners. Rest, orthoses, stretching, NSAIDs, and local steroid injections are helpful. Partial plantar fasciotomy is occasionally necessary but recovery can be protracted. Refractory cases may be treated with extracorporeal shock wave therapy.
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Snowboarder's foot and ankle
Fracture of the lateral process of the talus .The injury involves the leading leg on the board. A CT scan can help confirm the diagnosis. A fracture with small fragments (<2 mm) can be treated in a short leg cast for 6 weeks, whereas a fracture with large fragments should undergo open reduction with internal fixation.
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Ankle sprains and instability
These injuries are common in athletes and most often involve the anterior talofibular ligament (ATFL) and occasionally the calcaneofibular ligament (CFL). The posterior talofibular ligament (PTFL) is rarely involved. Surgical treatment is reserved for recurrent, symptomatic ankle instability with excessive tilt and a positive anterior drawer on examination/stress radiographs that have not responded to orthoses and peroneal strengthening/proprioceptive exercises over an extended period.
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Ankle arthroscopy
Indications: treatment of osteochondral fractures ankle, chronic pain and anterior-exo collision consequence sprain, remove exostosis of anterior astragaloknimiaias hinge, purification traumatic synovitis, removal triangle ossicles (Os trigonum).