3 s2.0 B9780323549424000257 Main

25
An International Perspective on
the Foot and Ankle in Sports
Lucas Furtado da Fonseca, Pedro Augusto Pontin,
Gustavo Damasio Magliocca, Gustavo Gonçalves Arliani,
Andrew Roney, Cesar de Cesar Netto
Gonzalo F. Bastías, Felipe Chaparro, Yuan Zhu, Xiangyang Xu, Carlos
Ramirez, Juan Kalb, Mostafa M. Abousayed, Ahmed Khedr, Amgad M.
Haleem, Rajiv Shah, Malhar Dave, Nikesh Shah, Alireza Mousavian,
Yasuhito Tanaka, Elias Hermida, Luis F. Hermida, Adriaan Van Zyl,
Ignatius Terblanche, Apisan Chinanuvathana, Jakrapong Orapin,
Apiporn Garnjanagoonchorn, Wisutthinee Thueakthong, Moosa Kazim,
Gabriel Khazen, Cesar Khazen
OUTLINE
Brazilian Foot and Ankle Injuries in Sports, 455 Kho Kho, 473
The Subtle Lisfranc Ligament Lesion, 455 Management, 474
Beach Toe Lesions, 456 The Athletic Foot and Ankle in Iran, 474
Posterior Ankle Impingement, 457 Mountain Tracking and Rock Climbing, 474
Loose Bodies of the Ankle Joint, 458 Chovgan, 475
Fifth Metatarsal Stress Fracture, 459 Wrestling, 475
Slaloming the Andes Mountains: Ski And Snowboard Inju- Pahlevaniv, 475
ries Of The Foot And Ankle In Chile, 460 Foot and Ankle Injuries Caused By Traditional Japanese
Introduction, 460 Martial Arts, 475
Equipment and Technical Considerations, 460 Judo, 476
Ankle Sprains and Fractures, 461 Sumo, 477
Snowboarder᾽s Fracture, 461 Kendo, 478
Morton᾽s Neuroma, 462 Foot and Ankle Injuries of Racetrack Jockeys in Mexico City,
Skier᾽s Toe, 462 479
Chilblains, 462 Introduction, 479
Chinese Traditional Concepts of Foot and Ankle Problems Mechanism of Injury (Box 25.1), 479
and Traditional Treatments, 463 Open Fractures, 480
Colombian Foot and Ankle Conditions in Sports, 465 Recovery Time on Bimalleolar Fractures, 480
Ankle Sprains and Ankle Impingement, 465 Protective Gear, 480
Achilles Tendon Lesions, 467 Summary, 481
Lisfranc Low-Grades Sprains, 468 Sports Injuries in South Africa, 481
An Egyptian Perspective on the Foot and Ankle in Sports, 468 Overload Injuries to the Second Metatarsal, 481
Osteochondral Lesions of the Talus, 468 Investigations, 482
Flexor Hallucis Longus Tendinitis/Posterior Ankle Impinge- A Perspective on the Foot and Ankle in Sports From Thai-
ment, 469 land, 483
Other Injuries, 469 Muay Thai, 483
An International Perspective on the Foot and Ankle in Sepak Takraw, 484
Sports: India, 472 Foot and Ankle Injuries in United Arab Emirates Sports, 486
Cricket, 472 Plantar Plate Rupture and Drum-Beat Dance in Venezuela, 488
Hockey, 473 Plantar Plate Rupture and Venezuelan Drum-Beat Dance, 489
Kabaddi, 473 Our Treatment Choice for Plantar Plate Rupture, 490
454
CHAPER 25 An International Perspective on the Foot and Ankle in Sports 455
BRAZILIAN FOOT AND ANKLE INJURIES IN Excellent results have been reported with nonoperative treat-
ment when less than 2 mm of diastasis occurs.9 However, a low
SPORTS tolerance for displacement should be accepted in elite players, as
Epidemiological studies on sport injuries occurring at the foot some recent studies have shown a trend that a surgical approach
and ankle are not consistent and lack uniformity in published results in an earlier return to play.8,10
outcomes in Brazil. Current literature on sports injuries in the The intraoperative finding of proximal extension of a
country indicates that soccer is the most frequently investigated Lisfranc injury into the intercuneiform area and naviculocune-
and the first source of injury.1 Research has shown that soccer iform joints is not uncommon. Small intercuneiform diastasis
players have a 1000-fold increased risk of injury compared to can be misdiagnosed and represents a less stable injury pattern
industrial workers.1 Approximately 15.3 million people in Brazil that demands adequate open reduction and internal fixation
play soccer, which represents 39.3% of all sports practiced in the (Figs. 25.2 and 25.3).
country.2 Barefoot sports such as beach soccer and beach volley-
ball have also been gaining participants due to Brazil’s advanced
placements in recent international tournaments.
Among sport injuries, after the thigh, the foot and ankle
are the most common locations for injury.3 In one epidemio-
logical study, severe ankle and foot problems occurred in 33%
of the 200 healthy soccer players over 2 years of prospective
observation.4 Direct player-to-player contact (32%) and over-
use (26%) are the most commonly cited mechanisms of injury.5
Of these, by far the most common injuries are sprains (80%)
(which includes foot sprains such as Lisfranc lesions), followed
by bruises (9%–49%) and tendon lesions (2%–23%). Fractures
are rare and account for only 1% of all ankle injuries in soccer.6
Except for Achilles tendinopathies, which are higher during the
preseason, most injuries occur during competition.5
Here, we briefly describe some of the most common inju-
ries that are seen in our clinics, including subtle Lisfranc injury,
sand-toe, posterior ankle impingement, and loose bodies of the
ankle joint.
The Subtle Lisfranc Ligament Lesion

In athletes, Lisfranc lesions are mostly the result of indirect trauma, Fig. 25.1 Subsequent weight-bearing x-ray after 1 week of rest demon-
occurring as plantar flexion or abduction injuries.7 Plantar flex- strates widening at Lisfranc joint.
ion injuries often occur when the player suffers a slide tackle and
an axial load is applied to a plantar flexed foot while the toes are
dorsiflexed through the metatarsophalangeal (MTP) joints. The
ligamentous complex at the tarsometatarsal (TMT) joints usually
fails dorsally as rotational forces are applied to the midfoot, with
resulting subtle joint subluxation or dislocations. Abduction pat-
tern injuries are also common in Brazil and occur when the fore-
foot is suddenly abducted relative to a fixed hindfoot, such as in
equestrian sports in which riders have their feet stuck in the stirrup
and may suddenly be thrown out of the saddle.
Early diagnosis of Lisfranc injuries is critical to allow for
appropriate treatment and a speedier return to play. Misdiagnosis
or maltreatment of these potentially career-ending injuries may
not only prolong return to competitive play but can also lead to
posttraumatic degenerative changes and pain that limit activity
and quality of life in the future. Patients with subtle Lisfranc com-
plex injuries may present with varied degrees of swelling through-
out the midfoot, though they reliably report pain with attempted
weight-bearing activity.8 Several tests are described, but a high
index of suspicion is paramount for diagnosing these injuries.
Radiographic studies are critical. If it is too painful for patients to
cooperate with adequate standing x-rays, a couple of days of rest Fig. 25.2 A professional goalkeeper (same as Fig. 25.1). Dorsal
or intra-articular local anesthetic can be administered (Fig. 25.1). approach for subtle Lisfranc injury.
456 SECTION 4 Unique and Exceptional Problems in Sports
Subtle Lisfranc lesions in athletes are not typically associated Our postoperative care consists of a below-knee nonweight-
with a severe degree of swelling. Therefore, in subtle lesion cases bearing boot used for 6 weeks. Foot and ankle range-of-motion
swelling would not limit the ability to proceed with surgery as (ROM) exercises are initiated at 3 weeks. At 2 months, patients
soon as feasible. The authors generally attempt to avoid pene- are allowed to wean out of the boot as tolerated. Plates and
trating cartilage surfaces at internal fixation up to 3 months after screws are routinely removed during the fourth month, and
injury. In cases where the initial diagnosis was missed, or treat- patients are permitted to fully weight bear on the limb.
ment is delayed for more than 6 weeks, open reduction of the
involved joints is required to remove the thickened scar tissue Beach Toe Lesions
between the joints, preventing a stable closed reduction. Dorsal Barefoot sports seem to have a surprisingly low number of inju-
bridging plates with or without a C1M2 screw may be a better ries, sometimes even lower than the rates for athletes wearing
option for high-impact athletes and contact players (Fig. 25.4). shoes and doing the same or similar activities. For instance, in
beach volleyball, injury rates have been found to be fourfold
lower during competition on the sand compared to indoors.11
Competing barefoot on a sand interface may pose a unique risk
for injury that is mainly exclusive to beach volleyball, known as
“sand toe.” The mechanism of this injury is a hyper-plantarflexion
sprain of the great toe, which usually occurs when the player steps
down unsteadily and shifts forward, catching the big toe in the
sand (Fig. 25.5). This stresses the dorsal capsule of the MTP joint.
This is essentially the opposite mechanism of injury of turf toe.12
Clinically, athletes present with tenderness at the dorsum of the
MTP joint capsule and pain in the same area with toe plantarflex-
ion, which is worse with passive stretching. Active dorsiflexion is
not as painful, and strength is typically intact.
Diagnosis is made clinically, but x-rays should rule out frac-
tures or avulsions. A magnetic resonance image (MRI) should
be reserved for severe lesions with likely extensor hallucis lon-
gus (EHL) weakness, when dorsiflexion strength does not get
better after 6 to 8 weeks.
Treatment starts with taping that is typically continued for
the remainder of the competitive season, or until the toe can
be plantarflexed passively and fully without pain. On the other
Fig. 25.3 A proximal intercuneiform lesion is appreciated with manual hand, rupture of the dorsal hood resulting in EHL sublux-
stress. ation may result in pain that is most pronounced with resisted
Fig. 25.4 Dorsal plating after extensive removal of thickened scar tis- Fig. 25.5 Mechanism of the sand toe injury‒hallux in hyperflexed into
sue. This patient presented 6 weeks after the trauma. the sand.
dorsiflexion and may need surgical repair. In a series of 12 symptoms by changing sports habits and wearing braces to limit
patients, the average player took 6 months to fully recover from plantarflexion.16
the injury.12 Beach volleyball players will probably benefit most Os trigonum is present in 8% to 13% of the general popula-
if they do some portion of their rehabilitation on an uneven tion and can impinge against the tibia and calcaneus, especially
sand surface, since this is the surface on which they will be in ballet dancers and soccer players.17 When symptoms cannot
returning to play. be relieved by conservative measures, athletes tend to compen-
In beach soccer, most injuries occur in the feet and toes sate the loss of plantarflexion by placing the foot in a suboptimal
(36.4%), followed by the Achilles tendon (18.2%).13 A specific position in order to diminish symptoms, which leads to further
clinical syndrome characterized by progressive pain and swell- injuries. Therefore, surgical treatment should not be delayed in
ing in the dominant (kicking side) hallux MTP or interpha- order to avoid other related lesions (Fig. 25.9).
langeal (IP) joints can lead to an osteochondral injury of the
hallux (Fig. 25.6). Hyperextension or hyperflexion with repet-
itive trauma of the hallux MTP or IP joints is the postulated
mechanism of injury. Radiographic evaluation can show a mar-
ginal, often sclerotic, bony fragment within the lateral or medial
aspect of the symptomatic MTP or IP joints. This fragment usu-
ally represents marginal osteonecrosis that can be confirmed
with MRI. When a symptomatic bony fragment is identified
within the MTP or IP joints of the hallux, simple excision has
been reported to predictably relieve symptoms.14
Posterior Ankle Impingement

Posterior ankle impingement syndrome (PAIS) is a clinical
disorder defined as a painful limitation of ankle ROM—more
specifically, forced plantarflexion—usually caused by repetitive
stress. Causes include neurovascular lesions that involve the
Stieda process, malunion fractures of the posterior malleolus or
talus, os trigonum syndrome, flexor hallucis longus stenosing
tendinitis (Figs. 25.7 and 25.8), osteochondral lesions (OCLs),
and retrocalcaneal bursitis.15
Among soccer players, PAIS symptoms arise more com-
monly when the soccer player sprints or hits the ball, which
results in forced plantarflexion of the ankle. Approximately 60% Fig. 25.7 Flexor halluces longus tendinitis caused by impinging effect
of conservatively treated athletes show improvement of their from Os Trigonum Syndrome.
Fig. 25.8 Flexor halluces longus is involved with extensive tenosynovi-

Fig. 25.6 Osteochondral injury of the hallux in beach soccer. tis, proximal to its tunnel.
We prefer to endoscopically treat these patients through two Loose Bodies of the Ankle Joint
para-Achilles portals previously described in the literature,18 Loose fragments of the ankle joint in athletes usually result from
because we believe faster return to play can be achieved. Return anterior bone impingement with fracture of the anterior osteo-
to play usually occurs around 40 days. Full weight bearing with phytes (Fig. 25.12). The mechanism of loose bodies is related
crutches is allowed immediately, and after 1 week can be done to recurrent ball impact or the repetitive hyper-dorsiflexion,
without crutches or a cane. Sports activity is resumed on their which occurs in high-impact sports, such as volleyball and run-
second postoperative week and field training with their respec- ning. The classic presentation is anterior ankle pain (especially
tive teams from week 4 thereon. with compression of the soft tissues against the anteromedial
When resecting the Os Trigonum, one should release all aspect of the ankle), restriction of dorsiflexion, and swelling.
bands involving the flexor halluces longus (FHL), since a con- When fracture of the osteophytes occurs, pain may go away and
stricting effect may arise from scar tissue there (Figs. 25.10 and loose bodies may deposit into lateral or medial gutters.
25.11).
OS trigonum
Fig. 25.11 After removal of the Os Trigonum and soft tissues, subtalar
surface and flexor halluces longus tunnel are well delineated. Care must
Fig. 25.9 Os Trigonum impinging against posterior subtalar and ankle
be taken not to over-resect bone tissue and damage healthy cartilage.
joints. Note the narrowing of the flexor halluces longus tunnel.
*
OS
Fig. 25.10 Os Trigonum (OS) being resected. Fibers bands around

flexor halluces longus are seen (*). Fig. 25.12 Loose body in the anterior compartment of the ankle.
Lateral ankle radiographs reveal osteophytes on the anterior supination as the most likely position for maximal strain on
tibia and talar neck (kissing osteophytes). The diagnostic value the fifth metatarsal base. Whether any prodromal symptoms
of an oblique radiograph in addition to a lateral radiograph has existed or not, the athletes report acute pain in the lateral foot
been shown. When the lateral radiograph was combined with at the metaphyseal-diaphyseal junction of the fifth metatarsal.
an oblique anteromedial radiograph, the sensitivity and speci- Commonly, the athlete is unable or lacks confidence to continue
ficity of the method were high.19 MRI is useful to rule out any full play.21
associated soft tissue lesions (Fig. 25.13). Fifth metatarsal stress fractures typically involve the proxi-
We have a low threshold to maintain athletes in conservative mal to mid diaphysis, characteristically occurring more distal
treatment. Arthroscopy is usually indicated when diagnosis is than a traumatic base of fifth metatarsal tuberosity avulsion
confirmed. Results of ankle arthroscopic soft-tissue debridement fracture.
and osteophyte resection are good, satisfaction is high (94% to Physical examination confirms mild to moderate swelling
98%), and the rate of major complications is as low as 1%.20 localized to the lateral midfoot and sharp tenderness at the base
Postoperatively, the ankle is immobilized with a bandage, of the fifth metatarsal. It is important to examine the athlete,
and partial weight bearing is applied for 3 to 5 days. Full weight both sitting and standing, to assess the full lower leg align-
bearing is allowed 5 days after surgery, and postoperative reha- ment, especially the hindfoot and midfoot alignment. Cavus
bilitation is started. Athletes usually return to complete activity midfoot or varus hindfoot can be present but is not uniform.
after 4 weeks. More recent studies have demonstrated an everted rearfoot and
inverted forefoot alignment were associated with fifth metatar-
Fifth Metatarsal Stress Fracture sal stress fractures.23
Fifth metatarsal stress fractures account for less than 2% of Weight-bearing anteroposterior (AP), lateral, and oblique
metatarsal fractures in college football players, but can be a radiographic imaging of the involved foot is mandatory.
source of significant temporary disability and loss of playing Additional specialty imaging, such as a bone scan, MRI, or com-
time.21 puted tomography (CT), is used in unique circumstances.24
Athletes typically report an acute episode of lateral foot pain Radiographic and MRI findings of fifth metatarsal stress
that, in some cases, follows a 1- to 2-month prodromal history fractures include features of both diaphyseal (cortical-predom-
of a lateral foot “ache.” They also often report mild to moderate inant) and metaphyseal (trabecular-predominant) stress frac-
pain with ambulation but intense, sharp pain at the base of the tures given its location at the junction of the metaphysis and
fifth metatarsal with attempts to run, jump, cut on the involved diaphysis. Initial radiographic findings include periosteal reac-
foot, roll up on the lateral side, or land on the lateral side of the tion, with the degree of intramedullary sclerosis increasing in
foot.22 healing and chronic fractures. Important prognostic findings
The mechanism of injury is rarely from a direct blow or include the presence of a plantar gap at the fracture site, which
crush injury that may occur in actions such as a pileup. Some is associated with poorer healing. MRI demonstrates periosteal
have described the position of 30 degrees to 50 degrees of foot and intramedullary edema, with a cortical fracture line evident
in higher-grade injuries.24
Significant medical workup for athletes with Jones fractures
is not routinely needed. However, vitamin D deficiency, low cal-
cium intake, and general nutritional evaluation are helpful in
athletes at all levels. Vitamin D deficiency has been shown to
occur in up to 50% of Division I athletes and is noted in some
studies to be higher in African American populations.25
In the female athlete, a history of menstrual cycle irregular-
ity should be investigated, as low estrogen and other hormonal
imbalances may lead to a higher risk of delayed unions or non-
unions. Dual-energy x-ray absorptiometry (DEXA) scan eval-
uation is reserved for the athlete with multiple stress fractures
or recurring nonunions, as well as the middle-aged and older
athlete. Newer-technology DEXA scanning allows for a more
detailed evaluation of trabecular bone abnormalities despite
normal, generalized bone.26
Fractures of the proximal fifth metatarsal that occur in the
proximal diaphysis (greater than 1.5 cm from the tuberosity)
have an increased risk of poor healing, which is believed to be
due, at least partially, to the relative lack of blood supply of the
proximal diaphysis. In contrast to the metaphysis, which is sup-
plied by a rich network of metaphyseal arteries, the proximal
Fig. 25.13 Professional volleyball player with loose fragments of kiss- diaphysis is supplied by a sole nutrient artery, which may be dis-
ing osteophytes. rupted in proximal diaphyseal fractures.
In a recent review of the literature, it is described that oper-

ative treatment of fifth metatarsal stress fractures results in a
smaller number of delayed unions or nonunions, compared to
conservative treatment. Also, the goals of early surgical manage-
ment are to minimize the risk of nonunion and recurring frac-
ture, and to decrease the time to return to sport. Foot anatomy
must be taken into consideration, and additional procedures
such as the lateralizing calcaneal osteotomy for a cavovarus foot
should be considered.
Internal fixation with a solid stainless-steel IM screw has
become the procedure of choice.24 The patient is kept nonweight
bearing for 3 weeks; then partial weight bearing is allowed with a
removable boot, and stationary bicycle and pool therapy is initi-
ated. Transition to full weight bearing begins at 5 weeks. In general,
Fig. 25.14 Slalom at La Parva, Chile.
return to activity is allowed 2 months after surgery, depending on
the resolution of pain and radiographic evidence of healing.
SLALOMING THE ANDES MOUNTAINS: SKI

AND SNOWBOARD INJURIES OF THE FOOT
AND ANKLE IN CHILE
Introduction
The Andes Mountains is the world᾽s longest mountain range
extending from north to south for 4498 miles across seven coun-
tries: Venezuela, Colombia, Ecuador, Peru, Bolivia, Argentina,
and Chile. The chain has an average height of 12,000 feet and a
width of 149 miles, giving shape to the landscape and scenery of
most of western South America.
Providing a stunning backdrop to almost the entire Chilean
territory, the Andes mountains contribute with approximately
3000 miles of natural border running down from the arid
Atacama Desert to the Glaciers of the Patagonia. The above,
added to the narrowness of Chile᾽s geography, makes the moun-
tains accessible from almost every point of the country and
usually can be planned as a day trip from almost every major
city. This unique feature facilitated since the 1930s the develop-
ment of numerous ski areas and world-class resorts throughout Fig. 25.15 Chilean Olympic skier Henrik Von Appen during downhill
the central and south regions, being the firsts of their kind in competition.
South America and making Chile nowadays an internationally
renowned winter sports destination (Fig. 25.14). Foot and ankle injuries are far less frequent in these disci-
Skiing and snowboarding are the most popular activities plines. Nevertheless, there are several sport-specific injuries in
during the regular winter season that runs usually from May this category presenting unique characteristics that physicians
until October. These sports have been growing in popularity in charge of these winter sports athletes must consider for pre-
among the Chilean population during the last 20 years, as they vention and adequate treatment.
are more accessible and are no longer perceived as elite activ-
ities. Professional skiing has also seen great advances in the Equipment and Technical Considerations
current decade with consistent World Cup and Olympic partic- The basic modern skiing equipment considers the use of a boot-
ipation (Fig. 25.15). binding-ski system. This spring-actuated mechanism attaches
Injuries affecting skiers and snowboarders have been widely the boot to the ski in a fixed position until the bindings are
described.27-32 The most common injuries in skiers involve the released in response to torsional and upward forces (Fig. 25.16).
knee, specifically the anterior cruciate ligament and medial Release is determined by the spring tensions in two adjust-
collateral ligament, with a prevalence reported between 27% able toe and heel pieces.34 A significant decrease in foot and
and 33% of all injuries.28,30 On the other hand, snowboarders ankle injuries during downhill skiing has been evidenced after
usually sustain upper extremity injuries especially involving the 1970s due mainly to the breakthrough of better-designed
the wrist and shoulder, corresponding to almost 20% of all and -engineered ski boots and binding systems, transmitting
injuries.30,33 the torque forces more proximally in the lower limb.32,35 These
advances also included improved materials for harder boot is a soft “pack-type” boot, with a nonreleasable strap bind-
shells and weight/height-specific bindings that optimize the ing. Although less popular, hybrid and hard ski boots are
detaching process following falls and twisting forces. also used with either releasable or nonreleasable bindings.
However, the current popularity of snowboarding has Kirkpatrick and collaborators compared snowboarding inju-
meant an increase in foot and ankle injuries due to the use ries of the foot and ankle in relation to the type of boot used
of softer boots that allow better control and maneuverability (soft, hybrid, or hard) and found no significant correlation
(Fig. 25.17). In line with this trend, there are several stud- between boot type and overall injury rate. Nevertheless, in
ies showing that 12% to 38% of snowboarding lesions are their study, hard boots appeared to be protective for ankle
ankle-related, in comparison to only 1.7% to 6% of all ski- fractures not involving the lateral process of the talus (LPT).10
ing injuries.29,30,36 Several different types of boot-binding
combinations exist nowadays, but the most commonly used Ankle Sprains and Fractures
Ankle sprains and fractures are the most prevalent injuries of
the foot and ankle segment reported both in skiers and snow-
boarders.28,30,33 Differential diagnosis is crucial in patients sus-
taining an ankle sprain in this context, especially because there
are similar clinical findings on fractures of the LPT or peroneal
tendon injuries that can be easily misdiagnosed.
The most frequent mechanism of fractures of the lower leg
and ankle usually involves a fall in skiers, while a greater propor-
tion of snowboarders has jump-related injuries.37 Concerning
the level of injury, skiers present most commonly with oblique
or spiral distal tibial fractures at the edge of the skiing boot, or
“Boot-Top-Fractures.” On the other hand, malleolar fractures
are more common among snowboarders, with isolated fibula
fractures almost exclusively seen in this discipline. Ishimaru and
colleagues reported that most ankle fractures in snowboarders
were supination-external rotation type II injuries as described
by the Lauge and Hansen classification.38
Pilon fractures are common in the context of vertical impact
and axial load, especially in skiers landing from a high-altitude
jump. Energy tends to dissipate when the athlete lands on a
slope and then continues in a downhill direction. In cases where
the landing is effected on a flat surface, the energy is not capable
of dissipating, and this can result in a tibial plafond injury.33
Fig. 25.16 Boot-binding-ski system.
Management of these injuries is no different from lesions
occurring outside of the ski/snowboard context. Emphasis
should be on rehabilitation and complete healing of the fracture
site with a period of at least 12 weeks following open reduction
and internal fixation before returning to practice.
Snowboarder᾽s Fracture
Fractures of the LPT are a specific type of injury that was rarely
seen before the snowboard era but has become more prevalent
mimicking snowboarding popularity, which has contributed
to its current name, “Snowboarder´s fracture.”39 Kirkpatrick
in his series reported a talar fracture incidence of 17% within
all snowboarding injuries around the foot and ankle. LPT
fractures were particularly high, accounting for almost 95%
of these injuries.36
The LPT is a wedge-shaped prominence that comprises the most
lateral aspect of the talar body, being part of the talofibular and sub-
talar joints and serving for various ligamentous attachments.
Even though the mechanism of injury is controversial, the
most common accepted explanation for LPT fractures is an axial
impaction in dorsiflexion with the hindfoot in inversion and in
an externally rotated position. This axial impaction is typically
Fig. 25.17 Snowboarding soft boot. seen after landing from a height in snowboard jumping.39,40
In 1965, Hawkins described three types of LPT fractures41,42: may be indicated. Common complications include chronic
Type I, Simple (42%): Extends from the talofibular articular sur- pain, nonunion, ankle instability, and subtalar arthritis.40
face and the posterior subtalar facet.
Type II, Comminuted (34%): Involves both articular surfaces Morton᾽s Neuroma
and the entire lateral process. Erroneously classified as a neuroma, this entity is one of the
Type III, Chip (24%): Normally compromising only the subtalar most common causes of metatarsalgia. Morton᾽s neuroma is
joint, variable size. an entrapment neuropathy causing an interdigital neuralgia
Clinical presentation resembles an ankle sprain and may secondary to perineural fibrosis.45 This condition is frequent
result in pain and disability if not recognized and treated, espe- in skiers, in relation to narrow hard boots producing increased
cially because up to 41% of LPT are missed on initial presen- pressure on the forefoot. This leads to traction of the interdig-
tation.43 Typically, there will be local ecchymosis, edema, and ital nerves, which subsequently produces perineural fibrosis.
tenderness to perifibular palpation, with variable weight-bear- Other factors influencing the condition is repetitive trauma and
ing ability. ROM can be limited by pain, though deformity is stresses over the MTP joints producing swelling of underlying
usually not seen in these kind of injuries. metatarsal bursa and causing greater compression of the inter-
Imaging study includes x-rays to rule out other more prevalent digital nerve against the intermetatarsal ligament.46
injuries such as ankle fractures. LPT fractures can be identified Clinical features include pain and tingling at the involved web
more clearly on the Mortise view. However, there is a general space. Numbness may be present. Patients often describe a shoot-
agreement that the best diagnostic accuracy is obtained with ing electrical sensation during or after skiing that usually alleviates
CT-Scan, allowing classification of the type of fracture and assess- by taking the boot off. Ultrasound and MRI examination have been
ment of articular involvement, thus guiding the treatment plan.36 described to confirm the diagnosis.47 However, clinical findings
Treatment of LPT fractures is guided by the topographi- still have the highest accuracy for Morton᾽s neuroma diagnosis.48
cal Hawkins classification and the amount of displacement Conservative treatment options include ski boot modifica-
involved. Valderrabano proposed a treatment algorithm based tions, inserts to reduce pressure beneath the metatarsal heads,
on their series of 20 cases.44 Large displaced fragments (type I) or lidocaine/steroid injections. Surgical excision is indicated
should be surgically treated in order to restore articular congru- with persistent symptoms and has been shown to have between
ity and diminish long-term morbidity (Fig. 25.18). For nondis- 70% to 85% success in literature.45
placed fragments, a nonsurgical approach can be made but with
a higher risk of future morbidity. For type II and III, treatment Skier᾽s Toe
depends on the amount of displacement; nonoperative man- Skier᾽s toe or subungual hematoma is produced by excessive
agement if no displacement is seen, and surgical debridement compression of the toes against a narrow boot or by a repeti-
if there is any displacement. In general, this approach appears tive trauma of the affected toe secondary to a loose boot. The
to be reasonable and is accepted by the vast majority of authors. most affected toe is the hallux, and patients usually complain
Outcomes for type I fractures treated operatively, regardless of progressive pain due the increased pressure produced by the
of the method of fixation, are fairly good. Perera and colleagues hematoma on the nail bed.
reported that 88% of their patients presented mild or no symp- Another factor related to skier᾽s toe is improper skiing tech-
toms during follow-up. On the other hand, up to 38% of the nique. Sitting back on the skis forces the toes against the roof
patients treated conservatively persist with moderate or severe of the boot, while maintaining forward pressure on the shins
symptoms.42 Poor prognosis has to be expected if diagnosis diminishes this pressure on the toes. Long toenails also act as
is missed initially, which is a common reason for nonsurgical a lever, increasing pressure on the respective toes. We recom-
treatment. For patients with continued pain and morbidity, mend keeping toenails short when skiing or snowboarding in
depending on the type of fracture, excision or articular fusion order to avoid this complication.
Treatment of the subungual hematoma includes conserva-
tive measures such as applying ice and nonsteroid antiinflam-
matory drugs (NSAIDs). In cases of persistent pain or complete
involvement of the nail bed, aseptic fenestration of the nail to
drain the hematoma is indicated.
Chilblains
Chilblains, or pernio, is an injury that develops with prolonged
exposure (1 to 5 hours) to frigid or near-freezing temperature.
This condition appears as erythematous, well-defined, and ten-
der papules typically on the hands or feet of susceptible skiers
and snowboarders.
Treatment involves removing wet clothes or constrictive
boots, gentle washing and drying of the area, and covering the
Fig. 25.18 Fracture of the lateral process of the talus (black arrow). skin with dry and loose clothing. Nifedipine may decrease pain
Hawkins type I. and accelerate resolutions of symptoms.49
CHINESE TRADITIONAL CONCEPTS OF FOOT

AND ANKLE PROBLEMS AND TRADITIONAL
TREATMENTS
There are many traditional sports and performances that are
still popular in China at present, such as shuttlecock kicking
(Figs. 25.19 and 25.20), flipping in various Chinese local operas
(Figs. 25.21 and 25.22), and the Chinese martial art “wushu,”
which is also called Kung Fu (Figs. 25.23 and 25.24). Usually,
the Chinese do traditional sports for health purposes and
Fig. 25.22 Flipping is a maneuver in Chinese martial art “Wushu.”
Fig. 25.19 Shuttlecock kicking is a popular sport in China.
Fig. 25.23 Chinese martial art “Wushu.”
Fig. 25.20 Shuttlecock kicking performance is technically demanding.
Fig. 25.21 Flipping is often performed in many kinds of traditional Chi-

nese local operas. Fig. 25.24 Some kinds of “Wushu” are less competitive.
personal fulfillment. Thus there are infrequent opportunities acupuncture, and massage, accompanied by functional exer-
for the traditional Chinese sports to be competitive. However, cises, are the treatments for subacute injury.
it is not unusual to see foot and ankle injuries caused by these Acupuncture and massage are important components of
traditional sports in clinic. Soft-tissue injuries are much more restoring balance to the person’s vital energy channels, which
common than a real fracture. form the basis behind traditional Chinese medicine. The chan-
The most common reason for the shuttlecock players suffer- nels are a system of conduits throughout the body that carry and
ing a foot or ankle injury is players performing a trick. When distribute “Qi,” which can be considered as vital energy. Disease
there is uneven ground, there is more likely to be an accident. is present when the flow of vital energy through the channels is
Ankle sprain occurs and may lead to chronic ankle instability disrupted. This may occur when the integrity of the channels
several years later. Furthermore, injury may occur as a result of themselves is damaged by a sprain. The Chinese describe this
increasing body weight or decreasing strength of the ligament. as a disease of “Bi,” or pain, caused by a localized disruption to
Flipping is often performed in many kinds of traditional local the flow of “Qi.”
Chinese operas. This maneuver is more skillful and always per- The traditional Chinese explanation for soft-tissue injury is
formed by professional actors. Since the calf contracts suddenly that the channel running through the damaged tissue has been
and strongly when doing this, Achilles tendon injury (partial or physically disrupted, resulting in local pain, a disease of “Bi.”
complete rupture) may occur. Chronic injury is seen in Chinese To treat the pain, the integrity of the channel and the flow of
wushu players when they continue to practice wushu exercises vital energy through the channel must be restored. This can be
for decades after a primary injury. achieved by the selective use of points on the damaged channel,
There are many different kinds of foot and ankle injuries thereby restoring the flow of “Qi” and relieving the pain.
caused by these traditional Chinese sports and performances, The foot plantar surface is an important place for the body
including ankle sprain, fifth metatarsal avulsion fracture, because there are many points of channels, which represent
Achilles tendon rupture, diastasis of syndesmosis, MTP joint many internal organs. Therefore foot massage not only treats
capsular injury, instability of the ankle, and medial and lateral the injury of foot but also can treat diseases anywhere in the
malleolus fracture. body. In China, foot massage is looked on as a good method for
Many Chinese believe in traditional treatment and tradi- preventing and treating diseases and is popular throughout the
tional medicine when they have foot and ankle problems. There whole country.
are some special, traditional treatments for soft-tissue injuries Foot massage is used to stimulate the points of the channels
of the ankle joint in China that have a long history. These treat- that can activate the gates of the body, which are opened and
ments include acupuncture, Chinese herb ointment, poultices, closed to adjust circulation in the channels. Foot massage has
foot massage, and so on (Figs. 25.25 through 25.28). four functions: it can enhance the blood circulation, so as to
Chinese herb ointment and sometimes a semirigid splint accelerate the metabolism of the body1; it can regulate the ner-
made of bark are the usual management modalities for vous system; because there are many nerves endings in the foot,
soft-tissue injury in the early stage. Chinese herb ointment one can stimulate the reflex zone of the foot to regulate the cor-
can decrease the swelling effectively and quickly. Poultices, responding tissues and organs2; it can mobilize “Qi,” moisture,
and blood and promote proper function of the muscles, nerves,
vessels, glands, and organs3; and it brings the efficacy of release
and relaxation.4
Chinese traditional treatments for acute foot and ankle
injury are similar to modern treatments in some aspects,
such as rest, relieving the pain, and diminishing the swelling.
Fig. 25.25 Chinese herb ointment. Fig. 25.26 Acupuncture treatment at the foot.
Fig. 25.27 The points on the foot reflect the organs of the body.
is a widespread activity throughout the country, and profes-

sional dancing has a special place in some regions of the coun-
try. Athletic activities including 5, 10, 21, and 42 km racing
competitions, and cycling in two modalities (mountain biking
and road biking) is also very popular sports sometimes asso-
ciated with foot and ankle conditions. Since Colombia has no
seasons, these sports and recreational activities can be practiced
year-round, leading to frequent overuse syndromes.
Related to soccer, the most frequent injuries are ankle sprains
and anterior ankle impingement. Soccer is played on turf, which
can be soft in the rainy season and hard in the dry season. The
uneven grounds are also related to the frequency of ankle
sprains. Indoor soccer played on synthetic turf has also a very
high frequency of ankle sprains, due to shear forces on ankle
Fig. 25.28 Foot massage. and knee joints. Radiological evaluation of regular soccer play-
ers shows frequently medial, lateral, and anterior osteophytes
The treatments of acupuncture and foot massage are helpful associated with the repetitive trauma to the ankle. In recent lit-
to the patients during rehabilitation. Nowadays, the mod- erature, the origin of the tibial and talar osteophytes is related
ern treatment and rehabilitation methods have been widely to ankle instability or repetitive trauma at or near the joint line.
accepted and used throughout the country. The traditional Thus, these are called osteophytes and not enthesophytes. The
method and modern method supplement each other. traction theory is no longer valid as cited by Johannes et al.50,51
COLOMBIAN FOOT AND ANKLE CONDITIONS Ankle Sprains and Ankle Impingement
Patients with a history of frequent soccer games in the past
IN SPORTS present with multiple sprains and painful episodes after games.
Colombia has a varied geography and a variety of sports and They may have had an initial severe sprain that received med-
recreational activities. The most popular sport is soccer, which ical attention with adequate management. However, after
A B
C
Fig. 25.29 A, Preop x-rays. B, 7 months postop. C, 2 years postop.
ongoing sprains, patients do not search for medical attention immobilization period sent to physiotherapy. We put great
until symptoms evolve either with instability or limitation in value in a thorough rehabilitation program looking for a total
motion and impingement symptoms. In cases of ankle ante- restoration of full eversion strength, Achilles tendon flexibility,
rior impingement on physical exam, patients may complain and proprioception. Most of these patients get back to regular
of ankle reduced dorsiflexion compared to the contralateral sports after 6 to 8 weeks, and only those who continue having
side. Palpation on the anterior ankle joint can elicit pain, giving-way symptoms and recurrent pain are treated surgically
and depending on the size of the osteophyte, these can often with the open Bröstrom-Gould procedure.
be palpated. Stability testing of the ankle is carried out, and Other patients who have an instability sensation in more
sometimes instability findings can be associated. Patients must chronic cases can have an anterior impingement syndrome,
also be tested for peroneal tendon pathology and subtalar which affects their proprioceptive condition. In these cases,
symptoms, which are to be ruled out. Eversion strength and the surgical procedure is focused on the resection of the ante-
gastrocsoleus muscle contracture are also evaluated. rior osteophytes of the tibia and the dorsum of the talar neck.
Antero-posterior, lateral, and mortise standing comparative This procedure is preferably performed either with a 40-mm
views are taken in routine fashion (Fig. 25.29), and if a small arthroscope or with a mini-open technique. The joint is
osteophyte is seen, an additional van Dijk᾽s view is taken52 inspected first with a thorough complete ankle joint evaluation,
(Fig. 25.30). Only if any other instability-generating factor is with special attention to the medial and lateral gutters and at
suspected will a CT or MRI be ordered. the horizontal joint line. Temporary distraction of the ankle is
The ankle sprains are managed initially with the rest, ice, performed for inspection. The main procedure is performed
compression, elevation (RICE) protocol and after a short without traction, and we proceed to resect the osteophytes
Fig. 25.31 Rupture gap in Achilles tendon.
Fig. 25.30 Van Dijk᾽s view.

Achilles Tendon Lesions
Achilles tendon ruptures are increasing and causing morbidity
on both sides (tibia and talus). The extent of the resection is in our young population. These young adults are more involved
checked under fluoroscopy. Careful resection of the inflamed in indoor and outdoor soccer without a physical training pro-
synovial tissue of the anterior joint space is also performed. gram, which renders more lesions than in the professional
These patients are operated as outpatients under peripheral players.58 High frequency of games throughout the week (3–4
nerve block and sedation. Postoperatively they are immobilized times) generate overuse syndromes that predispose to tendi-
with a soft dressing and 48 hours bed rest and elevation. Weight nopathy and tendon ruptures.59 These lesions can be caused by
bearing is allowed after 2 days to tolerance, and sutures are either indirect or direct trauma to the tendon. Patients can pres-
removed after 12 to 15 days. A rehabilitation protocol centered ent with some prodromal symptoms before the acute rupture.
on dorsiflexion recovery, strength, and proprioception is begun Occasionally our patients have had previous visits with paraten-
at that time. donitis or paratendonitis with tendinosis that were not treated
On follow-up, we have experienced what the literature adequately.60
describes as recurrence of the osteophytes in a large percent- These patients come in to the emergency room with an acute
age of our cases,53,54 but less than a third of those patients have onset of pain and a sudden snapping or popping sensation at the
recurring symptoms. If instability persists, the recurrence is Achilles tendon during sports activity. On occasions, a previous
greater (see Fig. 25.30). history of Achilles tendon pain can be obtained from the patient.
Our main problems with surgical treatment of ankle instabil- On physical exam the patient walks with a limp and variable
ity, are neuropathic pain with superficial peroneal nerve lesion, edema around the rupture site. A positive Thompson test and a
arthrofibrosis, and medial or residual lateral instability.55,56 The palpable gap are typical of a complete rupture (Fig. 25.31). The
multimodal pain management or in combination with nerve plantar flexion strength can be diminished. In cases of doubt
blocks with the aid of ultrasound and open neurolysis are the we order an ultrasound or an MRI, but these are not routinely
common approaches to this clinical entity. Arthrofibrosis is not performed.
frequent after open or arthroscopic ligament reconstruction. If If the rupture is a palpable gap within 7 cm of the postero-
there is a mild to moderate case, physical therapy has been ben- superior calcaneal tuberosity with a positive Thompson test,
eficial. Uncommonly there are severe cases of arthrofibrosis that we proceed to perform a minimal incision repair within the
may require open debridement. first 10 days. If the rupture does not have a clear gap, but a
The residual instability of ankle is described more often in positive Thompson test, an ultrasound or an MRI is ordered
the recent literature, and the medial component of this pathol- to define the type of rupture to plan the surgical approach.
ogy has had more focus in the last years. We are focusing on this The mini-invasive technique has a lower complication rate
clinical problem and see it with a more prevalent frequency in with respect to the soft-tissue complications in simple rup-
our clinical practice. When rupture of the deltoid ligament in tures (horizontal), but in massive and irregular tears, an open
an acute setting is present, a repair of the ligament is performed. reparative technique is preferred.
In acute or chronic spring ligament ruptures, and an MRI with
positive findings, our choice is a repair with suture anchors in Surgical Technique
acute settings or debridement of scar tissue and direct repair in The patient is positioned prone with both legs prepped for
the chronic lesions.57 comparison of foot position at final tendon repair (Fig. 25.32).
the Achilles insertion, fixed with anchor sutures or biotenodesis

screws.62 We have used this transfer tendon technique in more
than 80 patients with solid results at this time.
Lisfranc Low-Grades Sprains

In other activities performed in Colombia, like dancing, cycling,
or horseback riding, trauma to the foot and ankle can involve
torsional forces that generate these sprains and have a relative
high incidence and are not properly diagnosed in local emer-
gency rooms. Sometimes these lesions are detected in patients
in a late form with residual pain and problems at their midfoot.
Persistent pain after 4 to 6 weeks of injury, with edema present
at the TMT point of first and second rays, with initial ecchymo-
sis described on the first visit at the emergency room, can be
indicative of severe ligament or soft-tissue damage.
Clinical findings, AP, lateral, and oblique standing bilateral
views can sometimes be sufficient to view subtle differences
of both feet to make the diagnosis. The fleck sign, which indi-
cates Lisfranc’s avulsion fracture, must also be considered.
Fig. 25.32 Positive Thompson test. CT scan or MRI can be indicated in cases of doubt, but they
are usually not ordered in a routine fashion. The open reduc-
tion and internal solid fixation are mandatory in all displaced
fracture-dislocations.63-67
For low-grades lesions and symptomatic sprains, we use the
Nunley and Vertullo68 classification, with good and excellent
results in the 89% of our patients with surgical treatment in
grade II and III lesions with transarticular screws or the endo
button technique.
AN EGYPTIAN PERSPECTIVE ON THE FOOT

AND ANKLE IN SPORTS
In Egypt, soccer is the most common sport practiced both on
professional and recreational levels. People of all age groups play
soccer, and it is currently played on different terrains includ-
ing turf mostly, but also sand and concrete. An array of foot
and ankle injuries has been associated with soccer, including
but not limited to ankle sprains, Achilles tendon ruptures, turf
toes, FHL tendinitis, Lisfranc injuries, ankle impingement, and
OCLs of the talus. Other popular sports include squash, wres-
Fig. 25.33 Tension after surgical reconstruction of Achilles. tling, and martial arts. Recently, cycling and marathon running
have gained popularity and attracted a good proportion of the
A 4-cm skin incision is performed horizontally 1 cm above the youth population.
gap, and careful incision of the paratenon is also performed. One thing to mention is the delayed presentation of many of
The stumps are localized and pulled through the incision, and our patients. This is partly due to limited access to health care at
a commercial tendon repair kit is used to perform the repair on some areas. Moreover, patients tend to ignore their complaints
both sides of the ruptured tendon. Three strands of reinforced and try natural remedies and alternative medicine long before
nonabsorbable suture are knotted with the foot in a similar or they seek medical advice. This reflects on the chronicity of the
slightly more plantar-flexed ankle position as the contralateral case and therefore decision-making and available options to
limb (Fig. 25.33). Suture of the paratenon and skin incision are treat such problems.
performed. A bulky dressing with the foot in plantar flexion and We here report on our experience with management of
a posterior splint is applied for 12 days nonweight bearing. On some of the aforementioned injuries and our preferred surgical
day 12, the sutures are removed and a walker boot with a 40-mm techniques.
heel lift is applied with permission for progressive weight bear-
ing. Physiotherapy with the Mendelbaum protocol is started.61 Osteochondral Lesions of the Talus
For all chronic lesions, either partial or complete, with more It is estimated to occur in 2%–6% of ankle sprains; however,
than three months evolution, we use the FHL transfer deep to more than 80% of lesions are missed or diagnosed in a delayed
fashion.69 Many factors have to be considered when discussing Flexor Hallucis Longus Tendinitis/Posterior Ankle
surgical management of these injuries. These can be classified Impingement
into patient factors (age, body mass index [BMI], activity level, FHL tendinitis is a chronic overuse disease common among
and comorbidities) and lesion factors (size, containment, ballet dancers but can also affect soccer players due to repet-
condition of surrounding cartilage and subchondral bone). itive plantarflexion maneuvers. Symptoms and physical exam
Treatment strategies can generally be grouped into two major can mimic posterior ankle impingement.75 Both conditions
categories: can coexist and are sometimes considered as spectrums of the
1) Reconstruction techniques: fixation or reattachment of OCLs same pathology. Conservative management can be successful
and autograft or allograft osteochondral transplantation in up to 64% of cases with immobilization.76,77 Surgical treat-
2) Repair techniques or marrow-stimulation techniques: ment consists of surgical release/tenosynovectomy, which can
microfracture and drilling (with or without biologic aug- be done both open and arthroscopically. We now prefer doing
mentation), autologous or allogeneic cell implantation arthroscopic release to avoid the invasive open approach, which
While we have performed many of these options, our results carries higher risks of postoperative adhesions and increased
have been inconsistent and not fully satisfactory. This is in line morbidity. As previously described by van Dijk et al,78 poste-
with data showing no superiority of one cartilage repair tech- rior arthroscopy is performed with the patient in prone position
nique over others.70,71 We recommend performing microf- with utilization of a thigh tourniquet and 30-degree 4.0-mm
racture for lesions <10 mm2. Lesions larger then 10 mm2 are arthroscope. Two main portals are established; a posterolateral
treated with either microfracture supplemented with biological and posteromedial portal. The posterolateral portal is estab-
augmentation (bone marrow aspirate concentrate [BMAC] or lished first 1 cm proximal to the tip of the lateral malleolus just
platelet-rich plasma [PRP]) or osteochondral autologous trans- lateral (5 mm) to the Achilles tendon. Subsequently the pos-
plantation (OATs) with allografts reserved for critically sized teromedial portal is performed just medial to the Achilles ten-
lesions that are not amenable to autografts. don at the same level as the posterolateral portal. A motorized
Recently, the senior author (AH) reported on the use of shaver is used to perform synovectomy and resection of soft
culture-expanded bone marrow–derived mesenchymal stem tissues between the talus and Achilles tendon, starting laterally
cells (MSCs) in treatment of large OCLs of the femoral con- until the FHL is visualized. The FHL serves as a “lighthouse” to
dyle. Their preliminary results were promising, and they this approach, and visualizing it is the key to the procedure. The
noted improvement in patient outcomes and MRIs.72 We sub- FHL is located typically about 1–2 cm proximal to the subta-
sequently decided to use the same technique with OCLs of lar joint. Identifying the tendon can be aided by passive motion
the talus. We started using second-generation bone marrow of the big toe. Extreme caution is warranted to avoid injury to
MSC implantation, which entailed culture-expanded MSCs, the neurovascular bundle located just medial to the FHL ten-
implanted on platelet-rich fibrin glue (PR-FG) scaffold. This don. In the presence of a symptomatic os trigonum, it can be
mixture was injected via all-arthroscopic technique into the excised via a combination of shaver and punches. At this point,
base of critical-sized OCLs, and patients were made non- the tendon is inspected for any pathology. In patients with
weight bearing for 6 weeks postoperatively (Fig. 25.34). We FHL tenosynovitis (Fig. 25.35A), the tendon can be entrapped
reported on a small case series of 16 patients treated with this underneath its sheath, which is then incised and subsequently
technique with an average size of OCL of 3.74 cm2 ± 1.12 and excised with a shaver (Fig. 25.35B). The entirety of the tendon is
mean follow-up of 18 months. Briefly, autologous bone mar- then examined to ensure absence of tears and smooth gliding of
row aspirate was acquired from patients in a first-stage pro- the tendon (Fig. 25.35C), including the most distal part within
cedure. This was transferred to the Tissue Engineering Unit its fibro-osseous tunnel (arrow in Fig. 25.35C). We believe ade-
at the Department of Biochemistry, Cairo University College quate portal placement is a must to be able to perform adequate
of Medicine, where MSCs were isolated and culture expanded FHL decompression. Inadvertent distal placement of the portals
for a minimum of five passages. The plasma was processed to makes this procedure extremely difficult, especially in the face
create PR-FG. In a second-stage all-arthroscopic procedure, of an os trigonum that can block access if not approached from
the base of the defect was curetted to a stable healthy rim of a “higher” portal. This higher portal also allows relative ease of
cartilage and underlying bleeding subchondral bone. Defects access into the FHL fibro-osseous tunnel.
deeper than 8 mm were grafted with autologous calcaneal bone
graft.73 The culture-expanded MSCs were then mixed with the Other Injuries
autologous PR-FG and injected in the base of the defect after Management of these injuries usually follows the general tech-
establishing dry arthroscopy. The mixture was let to clot and niques practiced worldwide. Ankle sprains are mostly treated
ankle ROM was tested under arthroscopy for stability of the conservatively. Patients with ankle instability are treated with
implant. Immobilization for 2 weeks was followed by active Brostrom-Gould repair when sufficient local tissue is available.
and passive ROM exercise while maintaining nonweight-bear- Insufficient local tissue has prompted us to use anatomic recon-
ing status for 6 weeks, followed by progressive weight bear- struction with gracilis autograft fixed with biotenodesis screws
ing. Our study showed improvement in postoperative AOFAS at the fibula and talus. More recently, we have been using the
scores compared to preoperatively, but this improvement did fibertape construct (Internal Brace, Arthrex, Naples, FL) for
not reach statistical significance.74 augmentation of repair in cases of insufficient tissues. Our
A B
C D
E
Fig. 25.34 Talar osteochondral defect (OCD) treated with mesenchymal stem cells (MSCs)/platelet-rich fibrin
glue (PR-FG) mixture. A, Medial talar dome OCD measuring 7 mm x 8 mm. B, OCD after debridement to a
stable rim and healthy bleeding subchondral bone. C, Establishing dry arthroscopy before implantation of the
MSC/Fibrin glue mixture. D, Injection of the MSCs/PR-FG from the dual barrel syringe arthroscopically into the
base of the defect. E, The mixture is set level with the surrounding cartilage and left to dry for 7 minutes after
which the construct’s stability is verified by ranging the ankle under arthroscopic visualization.
short-term experience has yielded comparable results to the provided for the health care sector. Moreover, there has been a
standard Brostrom-Gould reconstruction without augmenta- shift in paradigm lately in light of recent literature79,80 toward
tion while allowing an accelerated postoperative recovery due nonsurgical treatment with accelerated functional rehabili-
to the restraining effect of the fiber tape. tation protocols.81 This is gaining more popularity given the
Acute Achilles ruptures are treated via open repair using reduced expense and equivalent functional results of such treat-
Krackow technique. We started utilizing percutaneous tech- ment algorithm. Surgical repair, however, remains the preferred
niques more often recently but have not noticed a difference in method in professional and high-demand athletes due to stud-
outcomes with the latter. The price of the percutaneous kit is a ies showing slight increased difference in push-off during run-
limiting factor in its wide use in Egypt due to limited resources ning and jumping.82
FHL FHL
T
T
C C
A B
FHL
C
Fig. 25.35 Arthroscopic images of a 23-year-old soccer player who presented with severe posterior ankle
pain and exacerbation of symptoms with hallux dorsiflexion. MRI confirmed extensive FHL tenosynovitis
(C = calcaneus, T = talus, FHL = flexor halluces longus). A, Arthroscopic image demonstrating significant
tenosynovitis of FHL tendon with the tendon enclosed in hypertrophied inflamed synovium. B, Image after
FHL tenosynovectomy and debridement revealing properly oriented tendon fibers free of tears. C, FHL ten-
don was traced all the way down in its tunnel to ensure complete excision of tenosynovitis and exclusion of
tears in the tendon proper (arrow = fibro-osseous tunnel).
AN INTERNATIONAL PERSPECTIVE ON THE formats of this game have evolved to attract more and more
spectators from every age group. Such aggressive and attractive
FOOT AND ANKLE IN SPORTS: INDIA formats have increased viewership at the cost of increased rate
India is a big country with a huge, diverse population. Four of injuries to players. While the game has limited contact inju-
very commonly played sports in India are cricket, field hockey, ries, activities like bowling, fielding, throwing, diving, catching,
kabaddi, and khokho. Though hockey is a national sport, cricket and running lead to impaction and overuse injuries. Projectile
is ‘The religion’ in India and outnumbers every other sport injuries to any part of players’ body can occur by a hard-thrown
played in India.83 In today’s competitive world, no sports are heavy cricket ball in spite of protective gear.
immune from sporting injuries. The tendency of the body to In 2016, an international consensus statement on injury sur-
over perform against its capabilities is the key reason for most veillance in cricket was introduced. Countries like Australia,
of the sporting injuries. External factors like playing environ- England, South Africa, the West Indies, and India have all con-
ment, playing surfaces, lack of proper training, and poor protec- tributed data. Today the subcontinent has become the hub of
tive equipment are other important causes of sports injuries.84 cricket, but very limited data is published from these countries.
Internal factors like strength and endurance plus anatomical With fewer publications on cricketing injuries, very few pub-
abnormalities also can be responsible for sports injuries.84 lications have focused on the foot and ankle.83 Incidences of
In India, varying formats of these key sports are noticed. cricket injuries, in general, are found to be increasing because
A large number of children, adolescent, and adults play these of a greater number of games being played with decreasing rest
sports on streets on a daily basis for recreation. Street sports out- periods between games. The act of bowling and fielding (41.3%)
number competitive sports played on playing grounds. Street accounts for the highest number of injuries, with hamstring
sports are characterized by poor playing environment, poor sprain being the most common injury. Based on the mode of
surfaces, lack of training, and lack of protection (Fig. 25.36).85 onset, Dhillon et al. classified cricket injuries as acute (64%–
Presumably, the rate of injuries must be very high, but data to 76%), acute on chronic (16%–22.8%), and chronic (8%–22%).83
support this are lacking. Next in count are school-level sports, Younger players under the age of 22 sustain more chronic over-
again with poor documentation of injury and treatment. Studies use injuries than do older players. Stretch et al. in his study men-
have focused mainly on injuries at a competitive level. The main tioned that lower limb injuries (48%) rate highest in numbers
objectives of studies are to analyze reasons for injuries and to followed by back injuries (22.8%), upper limb injuries (23.3%),
suggest preventive actions. No studies have specifically focused and neck injuries (4.1%). Hamstring and quadriceps sprains
on management aspects of foot and ankle injuries. With these form the most common lower limb injuries.86
inherent odds, we present sports foot and ankle injuries with its Studies have reported that 11% of injuries affecting fast
management modalities. bowlers involve the foot and ankle.83,86 In general, the forefoot
is more prone to acute injuries while the hindfoot is more prone
Cricket to chronic overuse injuries. Acute-onset foot and ankle injuries
Cricket is a globally popular sport being played in 105 coun- in cricket are hematomas, contusions, ankle ligament injuries,
tries. It is the second most popular spectator sport after football syndesmotic and midfoot sprains, Lisfranc injuries, and turf-toe
in the world. Cricket is played on an oval ground with a rect- injuries. Sudden-onset aggressive impact can lead to foot and
angular pitch with 11 players on each team. Activities done by ankle fractures. Acute-and chronic-onset foot and ankle inju-
a player involve batting, bowling, fielding, and wicket-keeping. ries result from overuse coupled with poor training and preex-
Though cricket is a noncontact sport played with ball and bat, isting unrecognized anatomical abnormalities. Posterior ankle
it requires physical fitness, skill, and strategy. Recently many impingement is one such common overuse injury in fast bowl-
ers. Modern lowcut boots with harder surfaces aggravate this
problem. Other problems include plantar fasciitis, tendoachilles
tendonitis, medial tibial stress syndrome, flexor hallucis ten-
donitis, peroneal tenosynovitis, intra-articular loose bodies,
ankle synovitis, and os trigonum disorders.
In an unpublished study the authors conducted foot and
ankle evaluations of 400 cricket players from district-level
cricket associations with interesting observations. We noticed
that more than 50% of cricketers had undiagnosed anatomi-
cal abnormalities in form of pes planus, accessory bones, and
pes cavus. Foot postures were found to be different among fast
bowlers (pronated) and spinners (supinated). More than 20% of
cricketers had a poor bowling posture resulting in easy fatigue,
loss of accuracy, and injuries in turn. In all cases coaches and
parents were unaware of such anatomical as well as postural
abnormalities in players. We even noticed a lack of knowledge
Fig. 25.36 Street sport (kabaddi) being played by children in a poor envi- about selection and evaluation of footwear among players and
ronment without the use of protective gear. coaches.
Hockey Inflammation of Achilles tendon due to overuse results in ten-

Field hockey is the second most popular sport in the world after donitis. One of the rare injuries documented by the correspond-
soccer and is played in more than 132 countries around the ing author was habitual medial dislocation of the first MTP joint
world. Though it is the national sport of India, it is more popu- (Fig. 25.38).
lar in northern Indian states. Prabhu et al. and Dhillon et al. in
their studies noted that the overall rate of injuries in field hockey Kho Kho
is around 6 per 1000 athlete exposuress with lower limbs being Kho kho is one of the most ancient and traditional games and
the most frequently injured site (51%).83,87 Out of all lower is a modification of a “Run Chase.” In the game, the player runs
limb injuries in hockey, ankle sprains are the most common around two poles chasing the opponent to touch him or her and
(14% to 19%). Improper footwear plus rapid rotational move- send the opponent out of the game (Fig. 25.39). It requires not
ments are the key factors responsible for higher rates of ankle only fast running but also sudden strategic stopping to inter-
sprains in hockey. Overuse injuries to the ankles and feet are change runners. Thus, it is a game of strength, speed, stamina,
also very common (18% to 32% of all hockey injuries). Typical and skill. The game develops endurance and intellectual capa-
examples of these injuries in hockey include tibial stress syn- bilities. The game also develops sportsmanship, team building,
drome, Achilles tendonitis, plantar fasciitis, and stress fractures. and obedience among players. Participation is highest among
Females are more prone to overuse injuries than males. Rarely schoolchildren (69%) followed by college (50%) and university
foot and ankle injuries do also result from direct injuries like (34%) students. Thus, in India the participation level decreases
being struck by the hockey stick or ball. These injuries range as the education qualification increases. In a study of 503 kho
from minor contusions to serious compound fractures. kho injury cases, Jayati Sen reported that knee (14%) and back
(13%) injuries were the most common form of injuries.88 Ankle
Kabaddi (11%) and foot (10%) injuries were next in line, with males being
Kabaddi is the most ancient sport played in urban as well as more prone to ankle and foot injuries than their female coun-
rural areas of India. It is a type of contact sport that is very sim- terparts. Ankle injuries comprise ankle sprains due to distortion
ple, inexpensive, and easy to organize. A player has to raid the followed by a concussion. Toe injuries are also common due to
opponent’s court to tag members of the opposite team while twisting and falls. Fractures of the foot and ankle do occur due
continuously chanting the word ‘Kabaddi’ and holding his
breath, while on the side of the opposition, they act as a team, to
prevent any kind of tagging of their team member (Fig. 25.37).
Because of its inherent nature of heavy contact in the form of
tackling each other with aggression, kabaddi is an injury-prone
game. Large pulling and pushing forces to the lower body result
in injuries like ligament and tendon sprains and tears in the
ankle and foot. Direct collision with other players also results
in ankle and foot injuries. Injuries also occur due to falls on the
hard or uneven ground. Hell and Schonle mentioned in their
study that ankle injuries form 55% of all injuries due to collision
with opponents.85 Ankle sprains are the most common injury
and occur due to sudden twisting while running or jumping. Fig. 25.37 Game of kabaddi being played at a competitive level.
Fig. 25.38 MRI pictures of a professional kabaddi player who injured lateral capsule-ligamentous structures
resulting in recurrent dislocation of the first metatarsophalangeal joint.
to falling to the ground or due to a violent collision. Common open reduction internal fixation (ORIF) rather than pri-
reasons for injuries in kho kho are lack of use of protective gear, mary fusion. Use of k-wires over screws for Lisfranc injuries
poor playing grounds, and poor training. is still common, while spanning plates are used at a few cen-
ters. Fractures, hematomas, and contusions are managed on
Management their merits as per standard AO (Arbeitsgemeinschaft fur
Foot and ankle orthopedics has yet to develop as a specialty in Osteosynthesefragen – German for Association for the Study of
India. Sports medicine is slightly better positioned. Available Internal Fixation) principles like elsewhere in the world.
data on foot and ankle sporting injuries is only from injuries Overuse injuries like tendonitis and fasciitis are primarily treated
happening at competitive level. Interestingly in India, the num- by team physiotherapists with rest, NSAIDs, and physiotherapy,
ber of games played at competitive level is much lower than failing which, qualified sports medicine specialists get involved.
games played at street level for recreation. There are no studies The most common diagnostic modality is MRI. Treatment is in the
focused on injuries happening in street-level sports. School- and form of rest, activity modifications, orthotics, and bracing. Modern
college-level sports do have data of injuries but are very scanty therapies like extracorporeal shock wave therapy, radiofrequency
because of lack of precise record keeping. No registry of sports ablation, and PRP injections are utilized by a few centers without
injuries has yet been created for any sport to date. Naturally, any published data on results. Stress fractures are quite commonly
the data we get represent just the tip of the iceberg. Street-level missed. Once diagnosed, they are treated with rest, orthotics, and
injuries presumably are being managed by home remedies like physiotherapy. Posterior ankle impingement is managed with open
local applications or by bonesetters with remedies in the form of surgery at most of the centers as hindfoot endoscopy is evolving.
manipulation plus local applications. Complications like cellu- Ankle joint issues like synovitis and impingement are treated with
litis, abscess, and stiffness follow such unscientific management ankle arthroscopy at many centers.
and are ultimately dealt with by qualified orthopedic surgeons. Improved record keeping and precise documentation of
Many of the street injury cases are also managed by family phy- sports injuries at every level are the need of the day in develop-
sicians. Neglected cases are quite common due to being ignored ing countries like India.
by player or coach in order to play out the season. At compet-
itive level, due to a handful of foot and ankle and sports medi-
cine specialists in India, foot and ankle sports injuries are being
THE ATHLETIC FOOT AND ANKLE IN IRAN
treated either by coaches and physiotherapists or by generalists. Iran is a vast country in the Middle East with high mountains,
Acute ankle sprains are treated with modalities like RICE green areas, dense jungles, deserts, and seasides. Four full sea-
supported with NSAIDS. Long-term plaster immobilization sons are experienced in Iran with all types of weather in any
is also practiced, unlike the recent trends noticed in the west- time of year. There are different ethnic groups living in this
ern world. There is no trend to acutely repair torn ligaments. country with different habits and sports preferences.
Pain and persistent disablement are very common after ankle All categories of sport are available in Iran, but ball games
sprains. A huge number of unresolved ankle sprain cases, in like football and volleyball are considered the most popular
fact, are missed injuries like peripheral talar process fractures, sports. Wrestling, rock climbing, and martial arts are other pop-
high ankle sprains, osteochondral injuries of talus, etc. In a ular activities. Most uniquely, Zurkhaneh (a form of martial arts
study of 482 foot and ankle injuries, the corresponding author and gymnastics) and Chovgan (a horse-riding team sport) are
reported missed injuries with ankle sprains being second high- traditional Iranian sports.
est after Lisfranc injuries.89 Chronic lateral ligament injuries
are being managed with Brostrom Gould reconstruction of the Mountain Tracking and Rock Climbing
lateral ligament. At some centers in India, arthroscopy-assisted These are popular sports in Iran and recently have changed with
lateral ligament reconstruction is also practiced. modern techniques (Fig. 25.40). This sport is part of real living
Lisfranc injuries are often misdiagnosed as midfoot sprains. in some western mountain areas.
Documented Lisfranc injuries are managed commonly with Rock climbing can be potentially risky for acute foot and ankle
injuries (Fig. 25.41). Although there are several reports, empha-
sizing safety of the legs, ankles, and feet as long as guidelines are
followed, up to 50% of acute injuries occur in lower extremi-
ties. These injuries increase in mountain tracking, especially in
the form of an acute ankle sprain and fractures of the calcaneus
and talus. The most common injuries occur in nonprofessionals
during the winter. Some of the injuries are related to flexible shoes
that may lead to hallux valgus or hallux rigidus over time. Most
climbers prefer to use rigid boots with better support in foot and
ankle on uneven ground. Still they may induce some overuse
injuries like subungual hematoma. Professional rock climbers use
specific shoes that are asymmetric and have forefoot turn-downs.
These shoes reduce pressure and injury on toes, although they are
Fig. 25.39 Game of kho kho being played at a competitive level. not suitable for long-distance walking.90-92
Chovgan and twisting motions, making it very strenuous on the foot.

Chovgan is a horse-riding team sport. Historically it has been Although there is also trauma from direct contact, overall injury
considered an aristocratic game done by kings in the first mil- is not common in this sport. Most injuries including ankle
lennium CE, and most injuries occur to the elbow and head, yet sprain, Achilles tendinosis, and peritendinitis, which occur
there are a few reports of leg and ankle injuries. during competition season.93,94
Wrestling Pahlevaniv
Wrestling is considered the most popular traditional sport of Pahlevaniv (bastani or zurkhganeh) is a unique traditional mar-
Iran especially in northern areas, with few variations (Figs. tial art of Iran, which is infused with ethical and moral rules. All
25.42 and 25.43). In this sport there are lots of pushing, cutting, parts of this sport are rigorous and include wrestling, whirling,
club exercises, and calisthenics synchronized with a special style
of music incorporating bells, drums, and chanting. This sport
is performed barefoot in a ceremony with a unique engraved
suit. Part of the activity consists of different kinds of running,
hopping, leaping, short jumping, and fast spinning.95,96 (Figs.
25.44 and 25.45)
FOOT AND ANKLE INJURIES CAUSED BY

TRADITIONAL JAPANESE MARTIAL ARTS
In Japan, there are many forms of traditional martial arts that
are still actively practiced today. This chapter explains in detail
Fig. 25.40 Mountain tracking has always been associated with foot

injuries; people usually use stiff boots that help them with long-distance
journeys but are not ideal for rock climbing.
Fig. 25.42 Wrestling with chookhe is one of popular traditional kinds of

wrestling. It was played in special ceremonies.
Fig. 25.41 Rock climbing as a growing sport; note the specific turn- Fig. 25.43 Wrestling with chookke is associated with increased risk of
down shoes that reduce pressure on forefoot and toenails. foot and ankle sprains.
foot and ankle injuries associated with the three most popular
martial arts: judo, sumo, and kendo. Although the origin of
these martial arts is not known, the earliest known mention of
their basic forms is found in Japanese documents written during
the eighth century. In the last half of the nineteenth century, the
modern rules for these martial arts were established, and peo-
ple began to practice them as sports. Because these martial arts
are practiced barefoot, there is a high incidence of ankle and
foot injuries among their practitioners. However, because play-
ing surfaces and styles of competition differ markedly among
these three martial arts, they are associated with different foot
injuries.
Judo
Fig. 25.44 Zurkhaneh federation with Pahlevani. The picture shows a
special form of spinning. This activity can produce acute and chronic
Because judo is an Olympic sport, the number of people who
high ankle sprains. practice judo is increasing worldwide. A judo contest is a fight
Tibia
Fibula
A B C
D E F
Fig. 25.45 High ankle sprain in an athlete from repetetive twisting activity. A and B, preoperative radiograph
shows no problem. C, Arthroscopy was performed because of persistent pain on anterior inferior tibiofibular
ligament (AITFL) and syndesmosis. There was a positive arthroscopic cotton test with marked synovitis. The
3-mm shaver is easily passed into syndesmosis space, indicative of instability. D and E, early postoperative.
F, Four months after operation the syndesmotic screw was removed.
between two contestants who wear judo suits and fight on Sumo
tatami (straw) mats. The first contestant to score a full point Sumo is a sport in which two wrestlers fight on a round ring
(“ippon”) wins. A contestant can score a full point by throw- that is made of packed earth and has a diameter of about 4 m.
ing the opponent on his or her back, holding the opponent for Sumo wrestlers wear nothing but a loincloth belt. In each bout,
30 seconds, or making the opponent concede. Injuries almost two wrestlers initially face each other from behind two parallel
always are caused by throwing moves. Many judo injuries occur lines at the center of the ring. Once the bout begins, they collide
in the lower extremities, particularly at the knees, ankles, and violently, like guards and tackles in American football. The loser
feet. Because mild foot injuries are so common, those who sus- is the first wrestler to touch the ring with any part of the body
tain them rarely seek treatment at a medical institution. other than the bottom of the feet or the first wrestler to go out
The most common foot injury is ankle sprain; about half of of the ring. Sumo wrestlers try to push each other out of the
all judo practitioners suffer an ankle sprain at some point (Fig. ring, and heavy body weight confers an advantage in this push-
25.46). Severe inversion sprains typically are accompanied by ing. Consequently, sumo wrestlers intentionally try to achieve
osteochondral fracture of the talar dome. Also, ankle instability and maintain a heavy body weight. Although the most common
persists in many cases, and many people who practice judo for clinical problem associated with sumo is lumbar pain, injuries
a long period develop osteoarthritis of the ankle. Also, when a in the lower extremities account for more than half of all inju-
strong external force is applied, a malleolar fracture occurs, but ries associated with sumo.
plafond fractures and talar fractures are rare. Ankle and foot injuries account for about 15% of all sumo-
The incidence of toe injury is high among judo practitioners. related injuries. It might seem that this is a low percentage for a
Turf-toe is a well-known injury associated with sports played sport that is practiced barefoot. The reason for this low percent-
on turf, such as American football. Most cases of turf-toe are age is the manner in which sumo wrestlers move, by shuffling
caused by excessive dorsiflexion of the great toe. When a foot their feet instead of lifting their feet off the ground (Fig. 25.48).
sweep is attempted in judo, the sweeping foot is in the equino- In sumo, the friction between the ground and the soles of the
varus position and is swung horizontally. If the sweeping foot feet is important in keeping a wrestler in position. If either foot
gets caught in the seams of the tatami mats or on the opponent’s comes off the ground for even a short time, the wrestler easily
foot, the MTP joint of the great toe is excessively plantarflexed can be pushed out of the ring. Thus, shuffling helps to prevent
(Fig. 25.47). Although this generally causes sprain without a a wrestler from being pushed out of the ring. During shuffling,
fracture, severe bending can cause a chip fracture. This type of the knees are bent in the valgus position, the lower legs are
toe injury is sufficiently unique to judo to merit its own name abducted, and the feet are pronated. As a result, sumo training
(perhaps “tatami toe”). If accompanied by osteochondral dam- strengthens the peroneal muscles, thus lowering the incidence
age to the MTP joint of the great toe, osteoarthritis can lead to of inversion sprain. Furthermore, even if a sprain occurs, it usu-
hallux rigidus. Although toe injuries most often affect the great ally does not cause persistent ankle instability.
toe, sometimes they can affect the lesser toe. Foot shuffling and squatting with knees spread apart are the
basic movements of sumo, and during these movements the
ankles are dorsally flexed. Thus, in competition, the ankle often
Fig. 25.46 Many judo injuries occur in the lower extremities. During

‘‘Ohsoto-gari,’’ a throwing technique, the foot and ankle assume an
equinovarus position. Inversion sprain can occur in the foot when Fig. 25.47 The great toe is easily plantarflexed (arrow) (‘‘tatami toe’’).
defensing (arrow). Tatami (straw) mats typically are used as a floor covering in judo.
is dorsally flexed (Fig. 25.49). Furthermore, when a wrestler a foot in the equinovarus position is swept sideways. However,
braces against being pushed out of the ring, the ankles are in lacerations of the skin on the plantar side of the first MTP joint
excessive dorsiflexion. On the anterior surface of the ankle, the are very common. Some sumo wrestlers prevent such lacera-
tibia often collides with the neck of the talus, causing impinge- tions by taping their toes or wearing Japanese thick-soled socks
ment exostosis. Because this condition exists in most sumo (“tabi”) (see Fig. 25.48).
wrestlers, and not many sumo wrestlers have ankle instability,
its onset must involve collision. Kendo
Because sumo wrestlers are heavy and collisions are violent, Japanese swords are the symbol of the Samurai culture. Unlike
there is a high incidence of bone fracture around the ankle. Western swords, Japanese swords are held using both hands.
Pronation-external rotation-type malleolar fracture is com- Kendo is a sport modeled after samurai sword fighting, using
mon because the lower leg is abducted and the foot is pronated, bamboo swords resembling Samurai swords. Practitioners wear
unlike the case in sports that are played with a ball. However, protective pads on the face (“men”), belly (“do”), and forearm
despite their severity, rehabilitation of such injuries is faster (“kote”). A point is scored when a bamboo sword cleanly hits
than for soft-tissue injury. one of the protective pads. A kendo practitioner holds a bam-
Severe toe injuries are less common than severe ankle inju- boo sword using both hands, with the right hand in front of the
ries. Unlike judo, sumo does not involve many moves in which left hand, somewhat like a right-handed baseball player holding
a bat. The two competitors face each other so that the tips of
their bamboo swords are lightly touching (Fig. 25.50). Right-
and left-handed practitioners take the same stance. The right
foot is placed in front, while the left foot stays back. Competitors
put their weight on the front half of each foot and slightly lift the
heels so that they can move very quickly.
Kendo is generally a safe sport, with a low incidence of frac-
ture, but mild toe injuries are quite common. Beginners often
complain of heel pain. Because kendo is practiced barefoot on
a wooden floor, there is great impact on the feet during kendo
moves. About 40% of kendo practitioners develop hemoglo-
binuria because red blood cells in the skin and subcutaneous
tissue of the sole are destroyed by the impact of the heel hit-
ting the floor. Some kendo practitioners develop a condition
called “black heel,” which is characterized by ecchymosis on
the sole of the feet. Usually, heel pads are used to treat this
condition.
Fig. 25.48 Exercise of shuffling. Keeping the feet on the ground

improves stability in this sport, which revolves around collisions and
pushing. The knees are bent in the valgus position, the lower legs are
abducted, and the feet are pronated. The playing surface is packed
earth. Sumo wrestlers tape their toes and wear ‘‘tabi’’ to prevent lacer-
ations on the soles of their feet.
Fig. 25.50 A starting posture of kendo is demonstrated. Note that the

Fig. 25.49 The ankles often are dorsally flexed in a bout. The incidence sport is practiced barefoot on a wooden floor. The right leg is in front of
of anterior ankle impingement exostoses is high in sumo wrestlers. the left. Weight is kept on the forefoot.
In kendo, the most common severe injury is rupture of the height between 1.62–1.64 m (5.3 ft) and can reach a speed of 60
Achilles tendon. This injury almost always occurs in the left leg, to 70 km/hour (37–43 mph).97 Jockeys have special equipment
because of the positions of the legs in the kendo stance (Fig. to protect them from trauma (riding helmet and special vests
25.51). During kendo moves, a great amount of force is applied for impact absorption), but there are still some parts of their
to the left leg. When the body pushes forward, the triceps muscle body exposed, such as their pelvis and lower limbs. Jockeys’
of the calf is tensed, and the Achilles tendon can rupture if there injuries during horse races have been published in the United
is a delay in plantarflexion of the ankle. In most sports, rupture States and Australia.98,99 These injuries include jockeys’ head or
of the Achilles tendon is rare among young people, but among neck (18.8%), the leg (15.5%), foot/ankle (10.7%), back (10.7%),
kendo practitioners, this injury is somewhat common in high arm/hand (11.0%), and shoulder (9.6%).
school students. This supports the theory that a great amount Jockeys’ lifestyle and nutrition status are a very important
of force is applied to the Achilles tendon in the left leg when the factor of vulnerability for this kind of injuries. Apart from the
body pushes forward in kendo. Rupture of the Achilles tendon risk of riding a high-speed racing horse in competition, these
is rare among beginners but is more common among skilled patients typically have an unbalanced diet. Occasionally they
practitioners. Most of those who sustain this injury chose to ingest alcohol, use diuretics, and have sauna sessions in order to
undergo surgery, and rehabilitation takes 6 to 12 months. maintain a low weight before races. All of this has been reported
to increase fracture risk.100
FOOT AND ANKLE INJURIES OF RACETRACK There are lots of minor to moderate injuries that are attended
JOCKEYS IN MEXICO CITY on the site of the accident or the racetrack emergency room,
such as minor head and limbs contusions and minor skin abra-
Introduction sions. Mild to moderate injuries that are treated at the hospital
Throughout the world since the time of the ancient Greeks, emergency room include lacerations and trauma involving the
horse races have been popular.97 Since the opening of the neck, wrist, knee, and ankle. Severe trauma is always treated on
Mexico City Racetrack, Hipòdromo de las Americas, in 1943, an inpatient basis in the hospital.
this sport has drawn public interest in Mexico. Although much Medical records of jockeys treated for orthopedics and
is known about the sport nationally, little has been written on trauma purposes since 1978 were reviewed identifying 1333
foot and ankle injuries of race track jockeys. This is a retrospec- cases that had musculoskeletal treatment.
tive review of 30 years of foot and ankle injuries as chronicled by The top cause of hospital admittance was upper extremity
their designated trauma orthopaedic surgeon. injury (52.36%) (Table 25.1). Of this, clavicle and wrist fractures
Every season (from January to October every year) the active were the most frequent.
jockey population is 24 to 30. These athletes typically have a Lower limb was second with 31.58% and a total of 421 patients.
petite physique with a weight between 42 kg (92.5lb) and 54 Starting in July 1978 until December 2014 (with a pause
kg (119.05 lb) and a height that ranges from 1.31 m (4.2ft) to between 1996 and 2001 while the racetrack was closed, 399
1.65 m (5.4 ft), while the thoroughbred horses they ride have a patients were admitted to the hospital for surgical treatment
because of foot and ankle injuries. (Table 25.2)
Mechanism of Injury (Box 25.1)

During preparation for the race, the horse is taken for saddle
placement, placing the jockeys at risk for a crush injury due to
being stepped on by the horse. Usually the jockey or the trainer
are vulnerable to a soft-tissue crush injury or a metatarsal fracture.
We had 18 feet with one to four metatarsal fractures that needed
reduction with internal fixation with K-wires or plates/screws.
TABLE 25.1 Injuries That Required Hospital

Admittance
Injuries that required
hospital admittance Cases
Upper Limb 52.36% 698
Lower Limb 31.58% 421
Pelvis 0.60% 8
Head Trauma 4.80% 64
Cervical/Lumbar Spine 9.52% 127
Fig. 25.51 An offense hit on a face guard (‘‘men’’). The right leg goes Multiple Costal Fractures 0.30% 4
forward during a lunge. Excessive force is loaded on the left Achilles Abdominal Trauma 0.80% 11
tendon during the sport. The incidence of Achilles tendon injuries is high Total 1333
relative to the other martial arts.
A very specific area where foot and ankle injuries presented was Of course, the youth, low BMI, and nonchronic condition
the departure gate. This happens because whenever the gates are play a very important role in this recovery time.
suddenly opened, the horse jumps forward and the jockey’s foot
in the saddle stirrup locks within the gate, experiencing a violent Protective Gear
external rotation inducing a bimalleolar fracture. This occurred Apart from riding helmet, goggles, and rigid vest, further
in 22 cases. In our review, the most common mechanism was the improvement in this and new equipment has been advised in
jockey falling from or with the horse during a race. When a horse order to lower the incidence of fractures in jockeys.97 Foot and
falls while running, limb fractures are sustained, but due to the ankle protection is controversial. While racing, the jockey’s
speed and weight of the animal, sudden death may occur.99 An ankle must have 110–115 grades of dorsiflexion, so a more rigid
uneven surface on the racetrack could lead to a horse stumbling, or complex boot that could provide more protection definitely
a front limb fracture, and rear limbs collapsing. Since the jockey is would diminish this ROM and potentially the performance.
projected forward, the upper limbs sustain direct trauma.
This is why clavicle and wrist fractures were the most fre-
quent fractures in the 1333 patients in our study. Whenever a
jockey is down, other running horses can trample the athlete,
resulting in spine, pelvis, and/or abdominal trauma.
Open Fractures
There were 23 open fractures in this review. All of these were
treated with surgical irrigation and debridement before open
reduction internal fixation (ORIF). These cases are treated with
triple antibiotics: metronidazole, penicillin, and gentamycin,
given the contamination from the dirt and fecal matter.
Recovery Time on Bimalleolar Fractures

Jockeys, as with other elite athletes, have the determination to
quickly return to work.
All 201 patients were treated with regular ORIF with medial
screws, lateral plate, and screws as well as syndesmotic fixation
as needed. Typically, following the surgery, there was no weight
bearing until the sixth week. Syndesmotic screws were removed
between weeks 3 and 4. After this they started aggressive physi-
cal therapy (Figs. 25.52 through 25.55).
All of these patients returned to horse racing between week Fig. 25.52 Antero-posterior view of a preoperative distal tibial and fibu-
lar malleolus fracture.
9 and 12 postoperatively.
TABLE 25.2 Type of Foot and Ankle Injury

Type of Foot and Ankle Injury Feet/Ankles
Bimalleolar Ankle Fracture 201 50%
Unimalleolar Ankle Fracture 101 25.3%
Trimalleolar Ankle Fracture 25 6.2%
Distal Tibia Fracture 22 5.5%
Metatarsal/Phalanx Fractures 18 4.5%
Pilon Fracture 15 3.7%
Lisfranc Fracture/dislocation 13 3.2%
Syndesmotic Injury w/o Fracture 4 1%
Total 399
BOX 25.1 Mechanism of Injury

1. Falling from the horse while racing
2. Foot/ankle locking in the departure gate
3. Standing horse stepping on foot
4. Running horse stepping on foot
Fig. 25.53 Lateral view of a preoperative distal tibial and fibular malle-
olus fracture.
SPORTS INJURIES IN SOUTH AFRICA

Overload Injuries to the Second Metatarsal
South Africa is a country blessed with wonderful weather, so
most South Africans love their sporting and outdoor activities.
Golf, tennis, rugby, football, watersports, cycling, and running
are very popular, and sport-related injuries are thus very com-
mon. These include ankle sprains, Achilles’ tendon problems,
stress fractures, Lisfranc injuries, impingement syndromes, and
so forth.
People of all ages participate in running, and we are famous
for our ultra-marathon races, especially the Two Oceans
marathon (56 km) and the Comrades marathon (89 km).
Thousands of people line up at the start of the Comrades mar-
athon every year (23,818 participants in 2018). Few sportsmen
are as fanatic and passionate about their sport as the ultra-dis-
tance runner. The mean age of participants in this grueling
event is around 40 with the age range varying from 20 years
old to octogenarians.
This presents a special group of injuries to the sports physi-
Fig. 25.54 Antero-posterior view of an open reduction internal fixation cians and foot and ankle surgeons, namely injuries associated
(ORIF) of distal tibial and fibular malleolus fracture treated with plate and with forefoot pain due to overloading of the second metatarsal.
screws to distal tibia and fibular malleolus. Stress fracture of the second metatarsal is a common diagnosis,
but we want to highlight overload injuries of the second MTP
joint in this selected group of patients.
As in nonathletes, it is more common in women and usu-
ally unilateral. It initially presents with forefoot pain and
swelling only when running and then later progresses to pain
with daily activities. Deformities in the sagittal and coronal
plane develop later in the progression of the disease. Often
it is possible to find a biomechanical reason for the develop-
ment of this overload other than a long rigid second metatar-
sal (Morton foot), which should be addressed in treatment.
Surgical treatment of the symptoms and not the cause will
end in recurrence of the injury, including instability and
associated deformities.
Patho-anatomy that causes overloading of the forefoot
includes the following:
• Hypermobile first ray
• Abnormally long second metatarsal/Short first metatarsal
• Metatarsal primus elevates
• Hallux valgus
• Short gastro-soleus complex
This results in synovitis that causes the capsuloligamentous struc-
tures of the MTP joint to become stretched, leading to instability.
Fig. 25.55 Lateral view of an open reduction internal fixation (ORIF) of This can progress to attenuation of plantar plate and extension of the
distal tibial and fibular malleolus fracture treated with plate and screws
to distal tibia and fibular malleolus.
MTP joint (sagittal component) and an associated crossover defor-
mity (coronal component). Progression of instability can lead to dor-
sal dislocation of MTP joint, predisposing to hammer toe deformity.
Summary Overload injury can also present with different patho-anat-
Injuries to the musculoskeletal system are frequent in jockeys. omy including cartilage injury and synovitis.
They range from contusions and simple trauma to limb frac-
tures, head trauma, spine injuries, or death. Bimalleolar ankle Case report
fractures, Lisfranc injuries, and metatarsal fractures are com- Thirty-nine-year-old healthy female marathon runner with
mon. Open fractures are also frequent, requiring immediate a 15-month history of right forefoot pain and swelling.
treatment with triple antibiotics and aggressive debridement Diagnosed with a stress fracture of the second metatarsal and
and stabilization. treated with orthotics, twice with cortisone infiltration, a boot
Fig. 25.56 Cartilage was deficient centrally and was debrided and

drilled.
Fig. 25.58 Swelling, crepitus, and tenderness of the second metatarso-

phalangeal. The joint is stable.
On examination, it is easy to localize the pain to the sec-

ond MP joint, and there is usually obvious swelling present
on the dorsal aspect of this joint. The joint must be tested for
instability with the drawer test and compared to the other
foot. Tightness of the Achilles’ tendon should be excluded and
the Silfverskiold test performed. We always examine the first
ray for instability and alignment and exclude other reasons
for pain in the area like sesamoid pain, stress fracture, and
Morton’s neuroma.
Investigations
Plain standing radiographs are routinely performed. With
Fig. 25.57 X-ray showing a dysplastic first metatarsophalangeal joint
the high accuracy of clinical examination for most diagnoses
with a short proximal phalanx.
including plantar plate injury, MRI is reserved for cases when
brace, and ultimately 7 months of cessation of running. On the diagnosis and treatment plan cannot be established from the
physical exam there was swelling, crepitus, and tenderness of clinical findings or to exclude other pathology, e.g., OCLs.
the second MTP. The joint was stable (Fig. 25.56). Evaluation of Treatment should include:
the alignment and mobility of the rest of the foot and ankle was • Adaptation of shoewear as necessary (running and daily shoes)
normal. There was no gastrocnemius tightness. X-rays demon- • Orthotics—Medial arch supports with metatarsal pads
strated a shorter right first metatarsal. MRI revealed synovitis • Modification of mileage and cross training
of the second MTP (Fig. 25.57). Patient was treated with a Weil • NSAIDs
osteotomy to shorten the second metatarsal 2 mm. A double
cut was made to elevate the metatarsal. The cartilage was defi- Case report
cient centrally and was debrided and drilled (Fig. 25.58). A 44-year-old female marathon runner had gradual onset of pain
Mechanical pain associated with running will be the main in the left forefoot with running. Her usual distance for train-
initial complaint. A sudden increase in distance could be the ing was 100 km/week. She was treated elsewhere for a neuroma
initiating factor in this overuse injury. In obtaining a history with cortisone infiltration and physiotherapy. On physical exam
from these patients, it is important to inquire about previous she was noted to have a tight gastrocnemius, moderate hallux
surgery, i.e., previous Bunion surgery, with resultant shortening valgus, synovitis second metatarsal phalangeal joint, and slight
or elevation of the first ray. Complaints of swelling of the MTP valgus deviation of the first and second toes. X-rays revealed a
joint indicating synovitis of the MTP joint are common. Most dysplastic first MTP joint with a short proximal phalanx (Fig.
patients would have visited a sports physician and received cor- 25.59). Treatment began with shoewear modifications, rest, and
tisone injections into the MTP joint with the possible worsen- orthotics. Once symptoms subsided, she gradually built up her
ing of any deformities. A change of shoewear or worn-out shoes distances but stayed limited to training distances of 20–30 km/
might also contribute to the injury. week. She also began swimming for alternative exercise.
A PERSPECTIVE ON THE FOOT AND ANKLE IN

SPORTS FROM THAILAND
In Thailand, there are different kinds of unique cultural games
and sports that have implications in foot and ankle injury. Muay
Thai and Sepak Takraw are two that will be the focus of this
section.
Muay Thai
Muay Thai, an ancient traditional martial art of Thailand, has
been developed with the concept of using the body as a weapon
in close-range person-to-person combat. It is also referred to
the “Art of the Eight Limbs” because of its use of punches, kicks,
and elbow and knee strikes as opposed to other martial arts
such as Judo and Taekwondo in which only punches and kicks
are used. This is the reason why Muay Thai is widely regarded
as a devastating martial art, with a knockout rate ranging from
28% to 56% in all professional fights.
More than half (55.4%) of Muay Thai boxers reported an
injury in their most recent fight. The lower extremities (51%)
were the most commonly injured body region during fights.101
Fig. 25.59 MRI showing synovitis of the second metatarsophalangeal. Most of the reported injuries were soft-tissue injuries contrib-
uting to at least 80–90% of all injuries. The severity of these
We do not support injecting the joint with cortisone, as we soft-tissue injuries were usually lower on the injury severity
have seen disastrous results with it, especially if it allows the scale.102 Injury prevalence is also associated with fight experi-
patient to continue with running and participating in races. This ence level, use of protective equipment, level of competition,
includes deterioration of the stabilizing structures around the and previous injury history.101-103
joint and progress of intra-articular pathology. As this problem Even though Muay Thai is a type of kickboxing, it has a
is sometimes a critical injury preventing the athlete from con- distinctive kicking style. The kicks in Muay Thai have been
tinuing with running ultra-distance races, a change in approach divided into two types. The first is the front kick (Fig. 25.60)
and even sporting activity should be considered. using the forefoot, especially the first metatarsal head, to
Surgical treatment options differ from patient to patient. It is hit the target. The second is the side kick (see Fig. 25.60),
important to treat not only the joint problem (synovitis/cartilage in which the shin is used as a weapon to attack the target.
injury/instability) but also the underlying mechanical overload Because of these distinctive kicking styles, the most com-
of the MTP joint. This includes different metatarsal osteotomies, mon injury in Muay Thai is contusion of the shin. However,
stabilizing and aligning the first ray and gastrocnemius slides. because Muay Thai boxers can use their elbows and knees to
As mentioned above, these (e.g., gastrocnemius slide) may affect protect themselves from attack, if the kicks miss the target,
the patient’s ability to participate in running sports. When there there is a chance of hyperextension ankle injury or soft-tissue
is MTP instability, a plantar plate repair is performed through a injury of the dorsal portion of the foot. Thus, the rate of foot
dorsal approach. A Weil osteotomy is recommended for access to and ankle injuries in the well-trained Muay Thai boxers is
the plate and to alter the length and height slightly. Finally, any fewer when compared to other types of kickboxing. Regarding
IP deformity is addressed as indicated. When the plantar plate the prevalence of shin contusion, use of shin guards is recom-
is irreparable owing to insufficient tissue, a flexor-to-extensor mended (Fig. 25.61) for all Muay Thai beginners.
transfer is performed. More commonly a Cobb II type procedure There are unique types of attacks called Kon Muay, advanced
is performed. In this technique the extensor digitorum longus tactics to take down the opponent. Some of these Kon Muay
(EDL) is released distally and routed through a drill hole in the tactics (Fig. 25.62) can result in improper landings, causing
neck of the metatarsal or sutured to the plantar plate. sprains. Moreover, Muay Thai allows the boxers to sweep under
Postoperatively patients are allowed weight bearing in a rigid the legs of their opponents by using the dorsum of the foot and
shank postoperative shoe for 6 weeks. anterior aspect of ankle. With these types of attacks, twisted
The operated toe is strapped in a plantarflexed position ankles and Achilles tendon injuries are common.
for 6/52. Active and passive ROM exercises begin at 6 weeks. Vaseenon et al.104 found that the most common foot and
Patients may advance to normal shoewear at this stage. ankle problem in Muay Thai boxers was callosity over high con-
Above-discussed patient group can be very demanding, as tact zones (77.5% forefoot, 16.3% malleoli, 3.1% midfoot, and
they are exremely passionate about their sport. Diagnosis is 3.1% heel), followed by gastrocnemius contracture, toe defor-
usually relatively straightforward. Unfortunately conservative mities, and heel pain. The causes of these common problems are
and surgical treatment can be challenging for the patient and barefoot training with tiptoe dancing and use of the forefoot as
the surgeon. a pivot point when kicking.
Fig. 25.60 The front kick (left) and the side kick (right).
In 1833, the Thai sport association introduced the volley-

ball-like style net and held the first contest. By the 1940s, the
first set of formalized rules were introduced, and the game took
the official name of Sepak Takraw with the International Sepak
Takraw Federation (ISTAF) governing the sport worldwide.
Like the volleyball game, the Sepak Takraw players are allowed
a maximum of three contacts with the ball to get it over the net.
Unlike volleyball, the players are allowed to use their legs, head,
and trunk to contact the ball but are prohibited from having any
contact with their arms or hands.
There are three basic player positions in this sport. These
consist of the server, Tekong (Back), feeder (setter), and kicker
(striker). Each particular position carries a particular risk for a
specific type of injury. The kicker position carries the highest risk
of foot and ankle injury, as they also function as a blocker and
striker near the net, their kicks consisting of a somersault-like
kick (Fig. 25.63). The server and the feeder have a lower chance of
injury, but their injuries are specific to their positions. The feeder
needs to reach the ball before it contacts the floor and try to feed
the ball back to the kicker to make the score, therefore they have
Fig. 25.61 Shin guards. a higher chance of tripping while chasing the ball. For the server,
when they serve by hitting the ball hard and they miss, they can
end up landing badly and may experience a foot or ankle sprain.
In the past, the grapefruit-sized balls were handwoven from
Sepak Takraw bamboo or rattan, but most modern ones are made of rattan or
Sepak Takraw is a game originating from Southeast Asia. The synthetic material with weights between 170–180 grams under
word “Sepak” is from the Malaysian language that means “kick” ISTAF regulations (Fig. 25.64). These balls are different from
and “Takraw” originates from the Thai language, meaning “rat- the balls used in volleyball, soccer, and rugby. There is no air
tan ball.” In the fifteenth century, the game rules varied slightly in the balls, making them stiffer with less bounce. As a result,
in different parts of Southeast Asia. Traditionally, Thai people it requires more energy from the players in order to propel the
formerly played this game by standing in a circle and used their ball across the court. When more energy is used, especially if
feet to pass the ball back and forth between them, which was the player is not properly trained in technique, there is a higher
called “Circle Sepak Takraw.” risk of uncontrolled landing when kicking.
Fig. 25.62 Kon Muay tactics.
As the ball does not recoil from the player’s foot, when kick-
ing, it is necessary to have a large contact area with it in order
to have more control. This has led to the requirement of special
shoes. Most Sepak Takraw players choose to use a local brand of
canvas shoes (Fig. 25.65) that have minimal outer sole in order
to maximize the contact surface to the longitudinal arch of the
foot during kicks. These canvas shoes are made of a thin cloth so
the ball can be felt while kicking, with a low, smooth outer sole
that is crafted from a particular type of rubber with high friction
and proper weight. With proper weight on these shoes, they can
create more momentum as well as increased control, which is
necessary because the ball is small and difficult to control.
The disadvantages to these types of shoes do exist. As the
insole is a flat surface, there is no support to the arch of the
foot, which can lead to plantar fasciitis. The lack of support from
Fig. 25.63 Summersault-like kick. the insole will also result in excessive pressure in certain parts
Fig. 25.64 Ball.
(42/58, 72%), but only 15% of the time do the players seek med-
ical attention for their sprains. The players are treated conserva-
tively and take less than 2 weeks off to recover. Residual laxity
in the ankle is found in 20% (20/58) of the players, but usually it
does not affect the player’s ability to play as their muscles in the
lower leg area are well trained and they are able to compensate.
We also noted common problems including callus formation
in 64% (37/58), gastrocnemius tightness (20/58, 34%), hamstring
tightness (16/58, 28%), plantar fasciitis (8/58, 14%), Achilles ten-
dinitis (3/58, 5%), stress fracture on the tibia (1/58), and turf-
toes (1/58). If improper stretching techniques are implemented,
strains and tightness can easily occur at the Achilles tendon, ham-
strings, adductor muscles, and iliotibial (IT) band. All this can
be corrected by proper stretching, which is emphasized in this
sport. If proper time is allocated for stretching, strengthening,
Fig. 25.65 A local-brand canvas shoe. and reconditioning then injuries are rare.
of the foot that are not accommodated, resulting in increased FOOT AND ANKLE INJURIES IN UNITED ARAB
callus formation in the forefoot. Moreover, with a certain type
of stiffer rubber, a great deal of force will transfer through the
EMIRATES SPORTS
first MTP joint and hallucal-sesamoid complex making these The United Arab Emirates (UAE) has a desert climate and is
structures vulnerable to injury during landing and pivoting on situated directly on the Arabian Gulf. This unique geography
the forefoot. These shoes also have no ankle support and lack a lends itself to a truly wide variety of sporting activities among
flared heel, so the ankle will be easily twisted and sprained. the residents. Water sports such as water skiing, wakeboarding,
In 58 professional Sepak Takraw national team players, we and kite surfing are hugely popular. Other sports such as soc-
found the most common injury in this sport is ankle sprain cer, rugby, tennis, and squash are commonplace. In the desert,
Fig. 25.66 A unique sport in the United Arab Emirates is hunting prey
with falcons. The sandals keep the foot high off the ground to prevent
entry of pebbles. They are discarded when running in soft sand.
sand boarding and motor sports command the winter months.

Most of the common injuries seen elsewhere are encountered
but with some unique scenarios.
Certain niche sports are found in the UAE. For example,
falcons are trained to hunt prey. This involves long periods of
bonding and progressive conditioning of the predator bird.
To accomplish this, the owner often has to run rapidly to tend
A
to his falcon, and in the soft sand this is better accomplished
barefoot. Sandals typically are worn (Fig. 25.66) to keep the
foot high off the ground to prevent entry of pebbles but are dis-
carded when running in soft sand. Still, minor stub and barb
injuries are common. Because the terrain underfoot is soft,
the barbs or other objects have little force for any penetration.
When training the falcons on the harder desert plain, one wears
enclosed shoes (Figs. 25.67 and 25.68) to prevent the entry of
foreign objects. Also, ankle sprains (mostly lateral) tend to be
relatively minor on the sand because the surface is not firm and
thus is very forgiving during inversion.
Arabs have a long tradition with horses. In the UAE, horse
racing (speed and marathon) and polo are two sports in which
injuries are relatively common. Most tend to be in the upper
extremities from falls, but foot and ankle injuries also occur. The
prolonged “heel down” position in the saddle can lead to impinge- B
ment syndromes of the anterior chamber of the ankle, requiring Fig. 25.67 On the harder desert plain, A, the hunter seen here with the
removal of any kissing osteophytes or soft tissues. Because these falcon uses B, enclosed shoes.
are mostly symptomatic early in their development, arthroscopic
debridement is very successful, with arthrotomy rarely being with walker-type removable braces allows rapid return to riding.
required. Minor crush injuries of the foot and ankle occur as the Occasionally, more severe problems such as Lisfranc injuries and
horses collide during play, but serious crush injuries from hooves subluxations or dislocations of the talocrural joint occur. When
are surprisingly uncommon in the UAE. This could possibly be surgical reconstruction is warranted, rigid internal fixation is
from the combination of a high standard of horsemanship and used, possibly including the repair of a deltoid ligament avulsion
well-trained thoroughbreds that are used in the sport. and concomitant syndesmosis stabilization (Fig. 25.70).
Motocross has its share of injuries because dirt bikes are rid- Long-distance bike riding is now becoming popular in the
den in the sand at high speeds. Riders are required to wear body UAE. A relatively common problem seen in these cyclists is
armor and protective footwear (Fig. 25.69). However, unlike Morton’s neuroma. This happens despite appropriate shoewear
hard dirt terrain that causes a violent plantarflexion force of and possibly results from a combination of the high heat and
short duration, sand produces a more moderate force of longer humidity causing edema of the foot. Conservative care with
duration. This leads to sprains of the anterior structures, with metatarsal pads and a wider toe box to accommodate the fore-
relatively frequent anterior capsular tears. Conservative care foot is very successful.
A C
Fig. 25.68 Another example of A, the falcon trainer with B, typical shoewear used for C, hard desert terrain.
Tendinopathies in the UAE are now increasingly diagnosed rituals, rhythm, songs, and instruments. There are usually seven
by ultrasound and treated with biologics. Platelet-rich plasma, different types of drums playing the beat.
mostly leukocyte-poor PRP, is the most common medium To celebrate Saint John on June 24, parishioners perform
employed. Success rates are similar to those in the published their rituals and dance the drum-beat for 3 days in many coastal
literature to date. Needle electrical stimulation (EIN or EPTE) town central squares or beach areas, although the dance has
is also used but less frequently. For Achilles tendon ruptures, the become so popular that it is performed all year long and all
trend is toward functional brace treatment instead of surgery. around the country.
The decision on the ground here is guided by dynamic diagnos- The dance is performed by a male and female couple sur-
tic ultrasound, looking for approach of the torn tendon ends rounded by drummers, singers, and spectators in a circle who
with passive ankle plantar flexion. In the UAE, we emphasize sing and cheer at the same time. The male dances around the
rapid rehabilitation and return to sports. Fast-track programs female pretending to trap her with sudden movements, and
and hydrotherapy for management of foot and ankle injuries the female pretends to ignore the male dancer turning her
provide an early start to the recovery process, with weight bear- back to him while he tries to face her again; it can become very
ing as soon as safely possible. Rapid progression to strengthen- fast, a bit aggressive and sensual at the same time. The male is
ing and proprioceptive feedback exercises has been beneficial to replaced after a short time by another male dancer who jumps
returning the player quickly to his or her sport. suddenly between the couple; the female remains longer and
can dance with many different males in the same song.
PLANTAR PLATE RUPTURE AND DRUM-BEAT The main characteristic of the Venezuelan drum-beat dance
is that the dancer’s rear foot has to remain in a forced MTP
DANCE IN VENEZUELA joint dorsiflexion position for long periods, exerting pressure
Drum-beat dance has become a very popular musical genre in in this area when the body position suddenly changes during
Venezuela for the last 200 years. It is strongly related to vener- the dance, which is mostly performed barefoot in sandy areas.
ation of saints Peter and John, and part of the African slaves’ This rear foot stance makes the dancer susceptible to forefoot
musical heritage. This dance is mainly from the country’s cen- problems, mainly metatarsalgia, toes deformities, and acute or
tral coast, and depending on the area, it may differ in dance chronic plantar plate rupture (Fig. 25.71).
Plantar Plate Rupture and Venezuelan Drum-Beat

Dance
Metatarsophalangeal plantar plate rupture can occur in an acute
or chronic setting.
Acute plantar plate rupture is an infrequent condition. The
patient reports having felt a sudden crepitation and pain in the
plantar plate area during the event, progressive second MTP
B
Fig. 25.69 A popular winter sport is motocross. The rider wears body
armor and protective footwear to minimize injury. A, The rider here is
preparing to land on a dune following a jump. B, The rider cuts across
the soft and at times unstable sand and is susceptible to ankle and leg Fig. 25.71 There are mainly seven different types of drums playing the
trauma. beat.
A B
Fig. 25.70 A, This syndesmotic injury was noted on a stress view of the ankle. B, Two syndesmotic screws
close the tibiofibular space and suture anchors stabilize the deltoid tear.
joint dorsiflexion days after the injury with swelling and even
hematoma around the area.
Metatarsophalangeal instability and chronic plantar plate
rupture can be present in drum-beat dancers, mainly in more
frequent dancers. Most patients with this condition, refer
plantar or dorsal gradual pain onset in the effected joint and
progressive long-standing MTP dorsiflexion, with coronal or
sagittal deviation.105-108 Depending on the clinical progression,
patients may have positive drawer test or discomfort with the
exam. Drum-beat dancers normally have clinical deformities of
grades 0, I, or II and very rarely grades III or IV according to the
Nery et al. staging system (Table 25.3).109 Fig. 25.72 In acute plantar plate rupture, progressive second metatar-
sophalangeal joint dorsiflexion is observed days after the injury.
Our Treatment Choice for Plantar Plate Rupture
Acute Plantar Plate Rupture
In acute plantar plate rupture we suggest repairing the plantar
plate acutely, by a plantar incision.110 The MTP joint is approached
directly after the flexor digitorum longus is retracted laterally (as
shown in the image), and the plantar plate is reinserted to the base
of the first phalanx with 2.0-mm suture anchors. Postoperatively
the injured joint in held in slight plantar flexion by strapping for
2 weeks and active or passive joint dorsiflexion is avoided for the
next 2 weeks, protecting the foot in a postop shoe for the first 4
postop weeks (Figs. 25.72 through 25.75).
Since these are normally acute injuries in balanced forefoot,
there is no need to alter the forefoot biomechanics with meta-
tarsal osteotomies or invade healthy joints to access and repair
the acutely ruptured plantar plate.
We operated on seven patients with acute plantar plate
rupture using the previously described technique, three were
TABLE 25.3 Clinical Staging System for

Lesser Toes MTP Joints Instability
Fig. 25.73 In acute plantar plate rupture we perform the plate repair
Grade Alignment Physical Exam through a plantar incision, the metatarsophalangeal joint is approached
directly after the flexor digitorum longus is retracted laterally.
0 Prodromal phase: no Thickening or swelling of the
deformity MTP joint MTP joint.
alignment Reduction of the toe purchase
Negative drawer test
I Mild deformity: toe MTP joint pain, swelling of the
elevation + web space MTP joint.
widening + medial Loss of toe purchase
deviation Mild positive drawer less than
50% subluxable
II Moderate deformity: toe MTP joint pain, reduction of
elevation + medial or swelling. No toe purchase
dorsomedial deviation Moderate positive drawer: more
than 50% subluxable
III Severe deformity: toe Joint and toe pain, little swelling.
elevation + medial No toe purchase
deviation toe overlap. Severe positive drawer: dislocatable
Flexible hammertoe MTP joint
IV Very severe deformity: Joint and toe pain, little or no
dorsomedial or dorsal swelling. No toe purchase
Cross over toe. Fixed Dislocated MTP
hammertoe.
From Nery C, Coughlin MJ, Baumfeld D, Mann T. Lesser metatarso-
phalangeal joint instability: prospective evaluation and repair of plantar Fig. 25.74 Plantar plate is reinserted to the base of the first phalanx
plate and capsular insufficiency. Foot Ankle Int. 2012;33(4):301–311. with 2.0-mm suture anchors.
Fig. 25.75 Plantar plate is refreshed and reinserted to the base of the Fig. 25.76 Plantar plate is reinserted to the base of the first phalanx
first phalanx with 2.0-mm suture anchors. with 2.0-mm suture anchors forcing slight plantar flexion.
recreational male drum-beat dancers after a prolonged dance

round in sandy areas. The other four patients, two were
injured after playing beach racquet, one sliding into second
base while playing baseball, and the last one after a strong
golf swing.
After surgery three patients reported slight discomfort and
edema in the plantar plate area that lasted over 3 months and
eventually disappeared. One patient had transient plantar neu-
ritis for 2 months. No patient had any skin issues or complica-
tions from the plantar approach.
Instability and Chronic Plantar Plate Rupture

In clinical grade 0, with no deformity (or slight dorsiflexion)
and moderate joint pain increased with drawer test, treatment
consisted of strapping the MTP joint in slight plantar flexion
for 4 to 6 weeks.111 Twelve of 16 patients with grade 0 improved
their symptoms and did not develop deformity after 1 year (4
patients were drum-beat dancers). The other four patients did
not improve and toe dorsiflexion increased—they were treated
as grade I.107
Grade I patients presented with mild toe elevation and Fig. 25.77 Chronic plantar plate reconstruction is performed through a
medial deviation, grade II patients have a moderate defor- dorsal approach and Weil osteotomy.
mity with toe elevation and medial or dorsomedial devia-
tion, both grades with discomfort and positive drawer test.
We performed surgery in 24 patients grades I and II (five the 17 patients had edema and discomfort in the plantar plate
patients were drum-beat dancers). In 17 of 24 patients, sur- area that lasted over a year in most of the patients, and 7 of
gery consisted of plantar plate reconstruction using a dorsal 17 patients ended with mild to moderate floating toes. In the
approach,112-114 Weil osteotomy and lateral capsule reefing other group, 7 of 24 patients, treated only with Girdlestone
or extensor digitorum brevis (EDB) transfer. In 8 of the 17 Taylor flexor to extensor transfer and lateral capsule reefing
patients, Girdlestone Taylor flexor to extensor transfer was or EDB transfer, there were no plantar plate discomfort after
added to address flexible hammer toe.115 We found that 9 of 3 months and no floating toes (Figs. 25.76 through 25.78).
Fig. 25.78 After chronic plantar plate reconstruction is performed, Weil Fig. 25.80 We consider plantar plate repair and Weil osteotomy in
osteotomy is fixed in position. patients diagnosed of plantar plate rupture grade I or II, with long central
metatarsals, second and third toes divergence, plantar hyperqueratosis,
and metatarsalgia.
Fig. 25.81 According to Nery´s Clinical staging system for lesser toes
Fig. 25.79 Light to moderate floating toe is a common complication metatarsophalangeal joints instability (Nery et al, FAI 2012, vol 33-4),
after Weil osteotomy. right foot is grade III and left foot grade II.
For these reasons, our treatment choice is the Girdlestone Our treatment choice for grade III and IV is similar, but
Taylor flexor to extensor transfer with lateral capsule reefing116 without plantar plate reconstruction, since the tissue quality
or EDB transfer to treat grade I and II plantar plate rupture. We is not optimal to heal at this grade. We may also add in some
consider performing the plantar plate repair and Weil osteotomy of the patients a DuVries first proximal interphalangeal joint
in patients diagnosed with plantar plate rupture grade I or II, fusion for fixed hammer toes and EDB transfer (Figs. 25.81
with long central metatarsals, second and third toes divergence, and 25.82).
plantar hyperkeratosis, and metatarsalgia (Figs. 25.79 and 25.80).
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25

The Subtle Lisfranc Ligament Lesion

Posterior Ankle Impingement

Fig. 25.8 Flexor halluces longus is involved with extensive tenosynovi-

Fig. 25.10 Os Trigonum (OS) being resected. Fibers bands around

In a recent review of the literature, it is described that oper-

SLALOMING THE ANDES MOUNTAINS: SKI

CHINESE TRADITIONAL CONCEPTS OF FOOT

Fig. 25.22 Flipping is a maneuver in Chinese martial art “Wushu.”

Fig. 25.19 Shuttlecock kicking is a popular sport in China.

Fig. 25.23 Chinese martial art “Wushu.”

Fig. 25.20 Shuttlecock kicking performance is technically demanding.

Fig. 25.21 Flipping is often performed in many kinds of traditional Chi-

is a widespread activity throughout the country, and profes-

Fig. 25.31 Rupture gap in Achilles tendon.

Fig. 25.30 Van Dijk᾽s view.

the Achilles insertion, fixed with anchor sutures or biotenodesis

Lisfranc Low-Grades Sprains

AN EGYPTIAN PERSPECTIVE ON THE FOOT

Hockey Inflammation of Achilles tendon due to overuse results in ten-

Chovgan and twisting motions, making it very strenuous on the foot.

FOOT AND ANKLE INJURIES CAUSED BY

Fig. 25.40 Mountain tracking has always been associated with foot

Fig. 25.42 Wrestling with chookhe is one of popular traditional kinds of

Fig. 25.46 Many judo injuries occur in the lower extremities. During

Fig. 25.48 Exercise of shuffling. Keeping the feet on the ground

Fig. 25.50 A starting posture of kendo is demonstrated. Note that the

Mechanism of Injury (Box 25.1)

TABLE 25.1 Injuries That Required Hospital

Recovery Time on Bimalleolar Fractures

TABLE 25.2 Type of Foot and Ankle Injury

BOX 25.1 Mechanism of Injury

SPORTS INJURIES IN SOUTH AFRICA

Fig. 25.56 Cartilage was deficient centrally and was debrided and

Fig. 25.58 Swelling, crepitus, and tenderness of the second metatarso-

On examination, it is easy to localize the pain to the sec-

A PERSPECTIVE ON THE FOOT AND ANKLE IN

In 1833, the Thai sport association introduced the volley-

Fig. 25.62 Kon Muay tactics.

sand boarding and motor sports command the winter months.

Plantar Plate Rupture and Venezuelan Drum-Beat

TABLE 25.3 Clinical Staging System for

recreational male drum-beat dancers after a prolonged dance

Instability and Chronic Plantar Plate Rupture

13. Mina H, Faezeh Z, Leila Z. Incidence and mechanisms of inju-

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