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Chronic Leg Pain

Introduction Orthopaedic surgeons continue to see an increase in the incidence of sports-related injuries with much of the population becoming active in more strenuous activity. Nonspecific complaints of pain in the foot, ankle, calf, or shin are often reported, with shin pain as the most common presentation. Evaluation of leg pain requires not only knowledge of the anatomy and biomechanics of the lower extremity but also…

Bunions in the Elite Athlete: The Philosophy and Principles

Introduction Sports medicine physicians treat many problems. One important area is the foot and ankle, with bunions being a common complaint. What do you do when an athlete comes to your office and says “My great toe hurts and has developed a prominence”? This chapter is not an explanation of bunions and all the various treatments. You can review those treatments in other textbooks and articles.…

Great-Toe Disorders

Introduction Injuries to the hallux metatarsophalangeal (MTP) joint are not uncommon, particularly in the running athlete, and may result in chronic pain and deformity. Causes of hallux injuries range from soft-tissue disruption to overuse and degeneration. Trainers and physicians may fail to recognize the potential dysfunction of these injuries, thus providing inadequate care and protection from further injury. Long-term sequelae of even isolated soft-tissue injury include…

Lesser Toe Disorders

Metatarsalgia in the athlete can be a debilitating disorder that can lead to loss of function. Forefoot disorders encompass lesser toe abnormalities such as claw toes, hammertoes, mallet toes, and hard and soft corns. More proximally, problems can include intractable plantar keratosis (IPK), bunionettes, neuromas, and metatarsophalangeal (MTP) joint capsulitis and instability. For the athlete, repetitive activities can lead to repeated stress reactions in soft tissues,…

Foot and Ankle Endoscopy

Introduction In the last decade, minimal invasive management of multiple foot and ankle pathologies has been proposed, seeking to reduce the postoperative complications that occur in patients classically treated with open surgical management. Arthroscopy and endoscopy has emerged as a powerful minimally invasive tool for intra- and extra-articular pathologies in foot and ankle. As a diagnostic tool, it has been utilized to evaluate articular osteochondral lesions,…

Diagnostic and Operative Ankle and Subtalar Joint Arthroscopy

History of the Technique Arthroscopy has revolutionized the practice of orthopedic surgery since the mid-1970s. After a long history of sporadic attempts at arthroscopy, technologic breakthroughs in Japan and several surgical pioneers in North America launched widespread interest in percutaneous joint surgery. In 1939, Tagaki was the first to introduce systematic arthroscopic assessment of the ankle in the literature. More than 30 years later, Watanabe published…

Disorders of the Subtalar Joint, Including Subtalar Sprains and Tarsal Coalitions

Introduction Pathology in the subtalar joint can be debilitating, is challenging to diagnose, and can lead to significant lost time for the athlete. In addition to acute bony or cartilage injuries, instability, ligamentous strain, and congenital coalition may all play a role in generating subtalar pain. Subtalar instability as an isolated phenomenon or in conjunction with lateral ankle ligament instability is often subtle and is frequently…

Osteochondral Lesions of the Ankle and Occult Fractures of the Foot and Ankle

Introduction Fractures of the foot and ankle are a common occurrence in the athletic population. Sometimes fractures may not be obvious on x-rays, and one must be on the lookout for occult fractures. Ankle fractures are approximately 7% of all sport-related fractures, and as high as 11% in National Football League (NFL) players evaluated at the combine. Disability due to foot and ankle stress fractures is…

Ankle Sprains, Ankle Instability, and Syndesmosis Injuries

Introduction Epidemiology Despite attempts to reduce the incidence of ankle sprain injuries worldwide, ankle sprains continue to account for a large proportion of sport-related injuries as reported consistently in epidemiological studies. In the US population in general, the incidence of ankle sprains was reported to be 2.15 per 1000 person-years with the peak incidence in ages 15–19 (7.2 per 1000 person-years). Almost 50% of those ankle…

Nonsurgical Treatment of Acute and Chronic Ankle Instability

Introduction Ankle sprains are common injuries in the athletic population, with an estimated 85% involving the lateral ligament complex. The lateral ligament complex consists of the anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), and the calcaneofibular ligament (CFL). Cumulative data from a systematic review and meta-analysis estimated the incidence of ankle sprains at 12 per 1000 exposures based on the highest-quality studies reviewed, with athletes…

Dermatologic, Infectious, and Nail Disorders

Introduction The majority of sports and fitness activities place extraordinary stresses on the feet. In addition to the potential for musculoskeletal injury, the sport participant’s foot is at risk for a number of dermatologic and infectious conditions that range from incidental to potentially disabling. Direct pressure from shoe or surface, sheer stresses from running/jumping/cutting activity, and the increase in moisture from perspiration are predisposing factors to…

Arthritic, Metabolic, and Vascular Disorders

Introduction Foot and ankle problems are common complaints to the physician who cares for athletes. Most of these complaints can be attributed directly to the athlete’s training and competition with their sport. However, athletes are not immune from disease. Most of these athletes will present to the sports medicine physician assuming their complaints are related to their participation, and many will try to explain their complaints…

Functional Nerve Disorders and Plantar Heel Pain

Acknowledgment Dr. Porter would like to acknowledge the assistance in manuscript preparation from Anoka Padubidri, MD, orthopedic resident, Indiana University; and Madison Walrod and Nicole Heffern, students, Butler University. Introduction Tarsal tunnel syndrome (TTS) is classified as a focal compressive neuropathy of the posterior tibial nerve (PTN) or one of its associated branches individually or collectively within the tarsal tunnel. The tarsal tunnel is a fibro-osseous…

Posterior Tibialis Tendon Injury in the Athlete

Introduction The tibialis posterior muscle and its tendon (PTT) play a vital role in most athletic activities. The tibialis posterior is the strongest inverter of the foot, it locks the triple joint during gait progression facilitating a rigid lever of push-off, and provides both power for acceleration and control for deceleration. Due to these important and repetitive roles, acute and chronic injury to the PTT are…

Achilles Tendon Disorders Including Tendinopathies and Ruptures

Introduction The Achilles tendon is formed by a coalescence of fibers from the gastrocnemius and soleus muscles. This complex spans both the knee and ankle joints, making it more susceptible to injury than muscles that span a single joint. The Achilles tendon is notably susceptible to injury with concomitant knee extension and ankle dorsiflexion. The medial and lateral heads of the gastrocnemius originate from the medial…

Rupture of the Anterior Tibial and Peroneal Tendons

Rupture of the Anterior Tibial Tendon Anatomy The anatomy of the tendon makes it susceptible to degenerative rupture due to attrition under the extensor retinaculum. The healthy tendon passes under the medial compartment of the transverse and cruciate crural ligament, and inserts onto the medial cuneiform dorsally and medially, with an extension of the attachment to the more inferomedial aspect of the first tarsometatarsal joint and…

Midfoot Fractures and Dislocations

Introduction Injuries to the foot are common in the athletic population, accounting for approximately 16% of all sports injuries. Trauma to the tarsometatarsal (TMT) joints is the second most common injury pattern, second only to metatarsophalangeal (MTP) joint injuries. The Lisfranc joint complex is the most commonly involved in injuries to the midfoot due to the limited static and dynamic stability of this region. Stress fractures,…

Ankle and Midfoot Fractures and Dislocations

Introduction Fractures and dislocations of the foot are among the most common injuries in the musculoskeletal system. Sports-related lower limb fractures and dislocation are less frequent than those of the upper limb, but they are particularly problematic for athletes because they often result in significant periods of non-weight rehabilitation. The disability and time away from sports resulting from these injuries warrant close attention to diagnosis and…

Problematic Stress Fractures of the Foot and Ankle

Pearls 1. Subtle, unexplained pain in the foot or ankle in an athlete can be a stress fracture. 2. Stress fractures of the medial malleolus may be associated with pathologic varus coming from the knee, ankle, or hindfoot. If surgery is warranted, the underlying biomechanics leading to the stress fracture need to be addressed. 3. Navicular stress fractures can occur in both the competitive and recreational…