Mid and Forefoot Injuries in Sports Medicine - PowerPoint Presentation

Slide1

Mid and Forefoot Injuries in Sports Medicine

Dr. Howard C H Chen

Athlete’s Care Sports Medicine CentresSlide2

Faculty/Presenter Disclosure

Faculty: Dr. Howard C. H. Chen

Relationships with commercial interests

Not Applicable

Relationships with commercial interests

This program has received NO in-kind support

Potential for conflict(s) of interest

Not applicable

Mitigating Potential Bias

All efforts have been made to present information in an equal and unbiased manner based on currently available dataSlide3

ObjectivesReview functional anatomy of the foot and arches

Discuss diagnosis and management of several common “not to be missed” foot injuries seen in sports medicine

Ottawa rules midfoot zone injuries related to inversion sprains

Transverse tarsal joint sprains

Lisfranc’s

sprains

1

st

MTPJ Flexor complex injuries/Turf toe

Metatarsal Stress fracturesSlide4

Anatomy of the FootSlide5

Anatomy of the FootSlide6

Roman Arches

Static load compression structuresSlide7

Dynamic Arches

Dynamic systems balance tension and compression

Kulripa

Bridge, Brisbane – largest tensegrity structure in the world

Damage from excessive tensile or compressive forcesSlide8

Arches of the FootSlide9

Dynamic Arch Supports

Dynamic adjustment of arch height/rigidity by Windlass mechanism PF/Triceps

surae

, FHL, FDL, peroneus longus and intrinsic foot muscles

Affects longitudinal and horizontal arches

Ground reaction force attenuation and adaptation to ground contour

Provide rigid lever for push-off

Windlass MechanismSlide10

Injuries

Traumatic

Ottawa Rules midfoot zone

Lisfranc

,

Chopart

tranverse

tarsal joint sprains

Cuboid Syndrome

1

st

MTPJ Flexor complex injuries

Stress Fractures

Navicular

Metatarsals

Sesamoids

Slide11

Ottawa Ankle RulesSlide12

MT5 FracturesSlide13

MT5 Fractures

Zone 1

Zone 2

Zone 3

Zone 4

Zone 5Slide14

MT5 Fractures

MT5 Metaphyseal Fractures

Zone 1 - Avulsion tuberosity

acute inversion injury - lateral band PF/peroneus brevis insertion

Zone 2 – Jones fracture

Inversion plantarflexion injury, overuse stress fracture

IA # MT 4-5 joint,

not exceeding distal border

MT5 Proximal

Diaphyseal

Fracture

Zone 3 - Proximal diaphysis stress fracture

vascular watershed with increased rate delayed/non-union

Zone 4 - Spiral fracture distal 1/3 shaft (

fouette

fracture)

Dancers lose balance in demi-pointe, roll over outer border

Undisplaced # WB rest, displaced # casting 6/52Slide15

MT5 Fractures

Imaging

X-rays helpful in Diagnosis and Prognosis, but maybe negative early in course

MRI can ID stress injury if x-rays negative

CT can confirm bony union prior to RTP in elite athletes

Management

(

Polzer

et al 2012 Injury )

Metaphyseal # (zone1-2) functional treatment

Diaphyseal

stress # acute

Tx

SLNWB cast x 6-8/52, early screw fixation +/- bone graftingSlide16

MT5 Fractures

Management

(

Mallee

et al SR 2015 BJSM)

Athletes MT5 # average RTP 14 weeks

RTP surgical 13.8 weeks vs non-surgical 19.2 weeks

(

Mologne

et al RCT 2005 Am J Sports med)

RCT Jones # SLNWB cast x 8 weeks vs IM screw + NWB x 2 weeks

Non-surgical 44% failure rate

Surgical 5% non-union, 32% discomfort resulting in 16% screw removal Slide17

Navicular Fractures

Epidemiology

Common in sports - sprinting, jumping or hurdling

Acute trauma vs overuse, training errors

14-35% of stress fractures, delayed

Dx

average 4 weeks

Usually middle 1/3 in relative avascular area

Increased risk of delayed or non-union

MOI not certain, ? compression as key stone of arch

↑ risk if ↓ dorsiflexion, excessive pronation and tarsal coalition requiring midfoot compensationSlide18

Navicular FracturesSlide19

Navicular Fractures

Clinical Features

Acute localized point tenderness and pain, with swelling and bruising, + x-rays



ortho

Stress # insidious, poorly localized midfoot ache with weight bearing and activity

Radiates medial longitudinal arch or dorsum foot

Improves with rest, non-

wt

bearing

Point tender “N-spot” 81% proximal, dorsal navicular

Requires high degree of clinical suspicion, so if +

ve

then stress # until proven otherwiseSlide20

Navicular Fractures

Imaging

Poor sensitivity X-rays navicular 33%, cuneiform and MT bases due to obliquity and orientation #, bone overlap

X-rays used to r/o other bony abnormalities such as tarsal coalition, DJD changes, accessory

ossicles

and tumours

MRI, bone scan (100%

sens

, poor spec and PPV) + CT

CT needs correct angling and 2mm thin slices from talus to navicular or may miss fractureSlide21

Navicular Fractures

Management

NWB rest cast/

castboot

6-8 weeks, or until non-tender, 80% successful return to sport rate

Clinical reassessment, as poor correlation CT/MRI with fracture healing

Screw fixation +/- bone graft if significant displacement/angulation, delayed or non-union

Elite athletes - RTP 16.4 weeks ORIF vs cast 21.7 weeks

Extensive rehabilitation – stiffness ankle, sub-

talar

, mid-tarsal joints

Myofascial

Tx

, progressive strengthening prior to impact activitySlide22

Cuboid Syndrome

Subluxation cuboid inferomedial resulting in pain with lateral WB

Common in excessive pronators, lateral instability and ballet dancers

MOI

Excessive peroneal longus traction

Plantarflexion and inversion ankle injury

Treatment

Manual manipulation

Taping, ankle brace Slide23

Cuboid SyndromeSlide24

Tansverse Tarsal Joint SprainsSlide25

Tansverse Tarsal Joint Sprains

Chopart’s

Joint –

talonavicular

, calcaneocuboid

Common in gymnasts, jumpers and football

Usually injury to calcaneocuboid or bifurcate ligaments (

calcaneonavicular

and calcaneocuboid ligaments)

Dorsal calcaneocuboid injury usually due to inversion injury

Bifurcate injury due to inversion injuries and forced

dorsi

/plantar flexion

Always do midfoot assessment with inversion injurySlide26

Tansverse Tarsal Joint Sprains

Clinical Features

Calcaneocuboid ligament

Pain lateral midfoot after inversion injury

Dorsolateral tenderness, swelling calcaneocuboid joint

Pain with stress inversion foot

Bifurcate ligament

May be associated with ant calcaneal process #

Lateral midfoot pain and swelling after inversion/DF/PF

Point tender ligaments and exacerbated by simultaneous supination/PFSlide27

Tansverse Tarsal Joint Sprains

Imaging and Management

X-rays, CT to r/o fracture

+/- MRI to confirm ligament injury

PT, taping, braces, orthotics, cast boot

If fracture

Non-displaced – cast x 4 weeks then brace

Displaced – referral to OrthopedicsSlide28

Lisfranc’s Joint Injuries

Complex spectrum of injuries

High energy leads to fracture/dislocations

 Ortho

Low energy injury second most common foot injury in athletes

Usually low velocity, indirect force

High degree of clinical suspicion required in all midfoot injuries, non-resolving ankle sprains

Very poor outcomes if missedSlide29

Lisfranc’s Joint Injuries

MT2 base keystone transverse tarsal arch

Low force

 damage weak dorsal

Lisfranc

ligament (C1M2)

Higher force  plantar

Lisfranc

ligament (C1M2,3) # MT or cuneiform, capsular rupture

MT may displace dorsally with loss of arch integrity

Widening 1

st

interspaceSlide30

Lisfranc’s Joint Injuries

Complex spectrum of injuries

MOI

Direct – uncommon, crush injury to TMTJ

Indirect – plantar ligaments stronger than dorsal ligaments, no D1-2 inter MT ligament

Longitudinal axial load plantar-flexed mild rotated foot - football, B-ball, running, dancing

Plantarflexed hindfoot, fall backward with forced forefoot abduction – equestrian, windsurfing with foot strapped in

Fall point of toesSlide31

Lisfranc’s Joint Injuries

Clinical Features

Significant midfoot pain and difficulty weight-bearing

↑ with forefoot loading – heel raises, push-off, sprinting

Midfoot tenderness medial dorsal TMTJ +/- swelling

Often delayed presentation as misdiagnosed as ankle sprain

Neurovascular exam for injury to dorsalis

pedis

A and deep peroneal NSlide32

Lisfranc’s Joint Injuries

Low Energy

Lisfranc

Sprain Classification,

Nunley

et al 2002 Am J Sport MedSlide33

Lisfranc’s Joint Injuries

Nunley

2002

Gr 1 – no diastasis

Gr 2 – 2-5 mm diastasis, no loss of arch height

Gr 3 - >5 mm

diastasis

and loss of arch heightSlide34

Lisfranc’s Joint Injuries

Imaging

X-rays bilateral WB AP and lateral, oblique

AP diastasis > 2mm D1-D2 MT bases, or > 1 mm asymmetry

Lateral MT2 base elevation vs cuneiform, or flattening of medial longitudinal arch asymmetry

Fleck sign – small avulsion fragment MT2 base or medial cuneiform

May reduce spontaneously with typical NWB x-rays despite severe tissue injury, 50% NWB views N

MRI sensitive for ligament tears

High correlation Gr 2,3 injury C1MT2,3 and true instabilitySlide35

Lisfranc’s Joint Injuries

Management

Grade 1 (no diastasis/instability)

NWB cast/

castboot

x 6 weeks

Orthotics to support MT2 base

PT ankle/foot ROM, mobilization

Grade 2-3 (+ instability)

Orthopedics – early percutaneous/ORIF better results

Delayed

Dx

/

Mgmt

results in poor outcome from chronic disability due to ligamentous instability, loss of arch and progressive DJD/OASlide36

Turf Toe

Sprain of the 1

st

MTPJ with injury to plantar capsule and ligament

MOI usually forced hyperextension/DF (85%), axial load, valgus stressSlide37

Turf ToeRisk Factors

Artificial turf

Pes

planus

or excessive

pronation

Limited ankle/1

st

MTPJ ROM

Soft flexible footwear

Clinical features

Aggravated by movement 1

st

MTPJ, WB, push-off

Tender plantar/medial, dorsal in higher grade injury

Pain with ↓PROM PF/DF

Increased glide if ligament injury+/- flexor tendon weaknessSlide38

Turf ToeClassification

Grade 1 – attenuation plantar structures, localized swelling, minimal bruising and pain, no laxity , symptomatic

Tx

, RTP as tolerated 1-4/52

Grade 2 – partial tear plantar structures with mild – mod laxity, walking boot +/- crutches, RTP 2-4/52, taping/orthoses

Grade 3 – plantar structures disrupted, significant swelling and bruising, weak flexion and frank instability, associated with plantar plate and FHL/FHB tendon injury Surgery if unstable with large capsular avulsion, retraction of

sesamoids

, loose body or

chondral

injurySlide39

Turf ToeSlide40

Turf ToeSlide41

Turf Toe

Imaging

Xrays

usually N, occasional fleck # with avulsion

Plantar plate injury assessed

lat

views with forced DF, +

ve

if no sesamoid excursion

MRI if grade 2-3 to assess degree of damage to structures

Significant delayed RTP, 3

rd

most behind knee/ankleSlide42

SesamoidsEmbedded in the 2 FHB tendons

30% bipartite

sesamoid

present

Functions

Protect FHL tendon

Weight bearing medial foot

Pulleys to increase mechanical advantage of flexors

Fracture, stress fracture, sprain sesamoid-MT articulation or bipartite sesamoid from excessive acute or repetitive load

Basketball, tennis and dancersSlide43

SesamoidsClinical features

Pain with forefoot WB, compensates with LWB

Local swelling and tenderness sesamoids

Pain and ↓ROM 1

st

MTPJ

Pain increase with resisted PF 1

st

MTPJ

Imaging and management

X-rays with axial sesamoid view

Bone scan and MRI often required to detect stress fractures and to differentiate between sprained bipartite sesamoid and fractureSlide44

Stress Fractures38% stress fractures in lower limbs

MT2 most common, always look for othersSlide45

Stress Fractures

Imaging

Poor sensitivity X-rays navicular, cuneiform and MT bases

If see one look for others

r/o other bony abnormalities such as tarsal coalition, DJD changes, accessory

ossicles

and tumours

MRI, bone scan + CT ( CT alone may miss in navicular stress fractures, needs correct angling and 2mm thin slices talus to navicular)Slide46

Stress Fractures

Clinical

Metatarsals very common, Most common MT2 neck

Excessive loading forefoot

Pronators

with dorsiflexed 1

st

ray and ↑ MT2 loading, Morton’s foot, ballet dancers

Progressively ↑ forefoot pain with activity and focal tenderness +/- swelling

Modified rest from WB activity x 4/52, +/-

aircast

Graduated return to activity when pain free with walkingSlide47

ConclusionsThe foot is a complex combination compression and tension arch structure that during the gait cycle, attenuates ground reaction forces, adapts to surface contours, and dynamically forms a rigid lever allowing for efficient transfer of propulsive forces for push-off.

Overload with excessive compression on the struts or tension on the cable supports, can result in injury to that component, but will also result in dysfunction in the foot-arch complex due to loss of the dynamic compression-tension equilibrium