Abstract
Injuries to the foot and ankle are commonly encountered, especially among athletes, and can lead to morbidity if not managed appropriately. Health care professionals must have a firm understanding of injury anatomy, diagnoses, and management. This article provides a review of lateral talus process fractures, os trigonum injuries, Lisfranc injuries, turf toe, navicular stress fractures, and syndesmotic injuries.
Keywords: ankle injury, foot injury, sports medicine
Foot and ankle trauma accounts for more than 3 million emergency department visits annually in the United States.1 These injuries can be a clinically significant source of morbidity and long-term disability in elite athletes, as well as in the general population. Thus, emergency department physicians, primary care physicians, sports medicine physicians, orthopedic surgeons, and athletic trainers must be familiar with these conditions to prevent missed diagnoses or mismanagement.
In this article, we discuss common sports-related foot and ankle injuries, including lateral talar process fractures, os trigonum injuries, Lisfranc injuries, turf toe, navicular stress fractures, and syndesmotic injuries. Prompt diagnosis and management of these conditions is important to avoid long-term sequelae.
Lateral Talar Process Fractures
Commonly known as the snowboarder’s fracture, lateral talar process fractures have increased in frequency since 1943 because of the rising popularity of snowboarding.2 The mechanism of injury is not fully defined but is thought to be axial loading with forced ankle dorsiflexion and possibly additional inversion or external rotation forces.3 Because physicians may have difficulty detecting this fracture on plain radiographs and patients present with lateral ankle pain and swelling, these injuries are frequently misdiagnosed as severe ankle sprains.4 Untreated lateral talar process fractures have a high likelihood for development of subtalar osteoarthritis.2 Therefore, these fractures can cause severe pain and disability years after injury.
Anatomy
The talus has 2 processes, lateral and posterior, that project from its body. The lateral process is a broad-based, wedge-shaped prominence with an articular surface dorsolaterally for the fibula and inferomedially for the anterior aspect of the posterior facet of the calcaneus. The lateral talocalcaneal ligament originates from its tip.4-6 The posterior process is lateral to the groove for the flexor hallucis longus. If not completely fused, this ossicle is frequently referred to as the os trigonum.
Diagnosis
Clinically, patients exhibit pain and symptoms similar to purely ligamentous inversion ankle sprains,3 which include marked swelling and pain over the lateral ankle. Point tenderness is often elicited over the lateral process of the talus, anterior and inferior to the tip of the lateral malleolus.4 Patients often have extreme difficulty with range of motion of the ankle in all planes because of pain. Also, weight bearing can be difficult even with the assistance of a controlled ankle motion boot.
Initial management should include orthogonal views of plain radiographs; however, the injury is often missed by this modality. Particularly on the lateral view, overlap of the malleoli and the sustentaculum tali can make detection of the fracture extremely difficult.5 Lateral talar process fractures are best seen on the mortise view, especially with the foot in slight plantar flexion.6 Computed tomography is considered the criterion standard for diagnosing these injuries. This modality can also be helpful in accurately measuring fragments, as well as assessing displacement, comminution, and fracture pattern.
Management
Management is dictated by the size of the fracture fragment, displacement, comminution, associated injuries, and joint congruity. Fracture fragments smaller than 1 cm with less than 2 mm of displacement can be treated nonoperatively.5 Nonoperative management usually consists of cast immobilization with non–weight-bearing precautions for 4 to 6 weeks.4 Physical therapy may be necessary after immobilization to restore range of motion of the ankle and subtalar joints.5
Operative management is indicated for fractures with displacement of more than 2 mm, greater than 1 cm in size, or notable comminution.5 Options are open reduction internal fixation, arthroscopic fixation, and excision of the fracture fragment.2,4 Up to 1 cm of the lateral process of the talus can be excised without residual ankle instability.5 The lateral talocalcaneal ligament becomes incompetent with excision; however, this change does not affect clinical outcomes.7
Os Trigonum Injuries
The os trigonum is an accessory bone located at the posterolateral aspect of the talus in approximately 5% to 10% of the global population.8 Injuries to this structure are usually caused by repetitive plantar flexion motion of the ankle or acute trauma, which result in an avulsion injury of the posterior talofibular ligament, fracture of the Stieda process or os trigonum, or cartilaginous synchondrosis disruption.8 Dancers and athletes who participate in kicking sports are particularly susceptible to these injuries because their feet are in a forced plantar flexed position.9 These injuries are often confused with Achilles tendon and flexor hallucis longus injuries because of the proximity of the os trigonum to these structures. If these conditions are undiagnosed, athletes compensate by rotating the hindfoot and ankle into a varus position, leading to other conditions such as peroneal tendinitis, recurrent ankle sprains, and sinus tarsi syndrome.9,10
Anatomy
The os trigonum is of variable size and shape (eg, round, oval, triangular) and is located posterior to the talus and lateral to the flexor hallucis longus tendon. The os trigonum is formed when there is failure of fusion of a secondary ossification center of the lateral tubercle or a stress fracture of the Stieda process, an elongated lateral tubercle of the talus.9,11
Diagnosis
Patients describe pain in the posterior aspect of the ankle, particularly while plantar flexing. Tenderness to palpation is usually elicited between the Achilles and peroneal tendons. Other common symptoms are stiffness and swelling behind the ankle, especially with forced plantar flexion and when wearing high heels.9
Typically, physical examination and plain radiographs are sufficient for diagnosis. Radiographs often detect fractures of the os trigonum or Stieda process.9 To evaluate for impingement in dancers, a lateral weight-bearing view of the ankle in the demi-pointe position should be obtained.10 However, even if there is no bony contact between the os trigonum and the talus, impingement cannot be ruled out owing to a cartilaginous layer overlying the os trigonum.9
Although magnetic resonance (MR) imaging is often not necessary, it can confirm the diagnosis and rule out other causes, such as Achilles tendinosis or fracture of the posterior process of the talus. Bone marrow edema of the os trigonum and inflammation may be present in the flexor hallucis longus tendon sheath, as well as surrounding the os trigonum.12
Management
Conservative management consisting of activity modification, nonsteroidal anti-inflammatory drugs, ice, immobilization, and rest should be trialed initially. Cortisone injections guided by ultrasonography or fluoroscopy can confirm the diagnosis and relieve pain but are often not longlasting.9 If a patient’s symptoms do not improve after 3 to 6 months of conservative management, operative management consists of surgical excision of the os trigonum, which can be performed through an open or arthroscopic technique.8
Lisfranc Injuries
Injuries to the Lisfranc joint, also known as the tarsometatarsal complex, may involve the bases of the 5 metatarsals, their articulations with the 4 distal tarsal bones, and the Lisfranc ligament. Approximately one-third of these injuries are subtle and low energy, commonly caused by excessive plantar flexion and abduction forces with associated longitudinal force applied to the forefoot.13 In athletes, misdiagnosis or maltreatment may prolong return to competitive play and can lead to posttraumatic arthritis and chronic pain that limits activity and quality of life in the future.14 Therefore, physicians must have a high index of suspicion for these injuries to limit long-term disability.13
Anatomy
The Lisfranc joint is the transition between the midfoot and the forefoot. This joint consists of 3 articulations, including the 3 cuneiform-metatarsal articulations and the 2 cuboid-metatarsal articulations of the fourth and fifth rays. The distal articular surfaces of the cuneiforms and the cuboid provide for the transverse arch of the foot. The metatarsals comprise the distal half of the longitudinal arch. The interosseous Lisfranc ligament spans from the medial cuneiform to the base of the second metatarsal on the plantar surface.15 This joint is inherently stable with minimal motion owing to its recessed position, “roman arch” stability, and the multiple ligamentous restraints.13
Diagnosis
Patients may present with a relatively benign history of injury, examination, and radiographic studies or a high-energy mechanism with obvious radiographic abnormalities. Patients with subtle Lisfranc complex injuries often have varied degrees of swelling throughout the midfoot and reliably report pain with attempted weight-bearing activity.14 Patients may exhibit tenderness to palpation in the midfoot and classic plantar ecchymosis, which suggests ligamentous injury or fracture.13
Plain radiographs may not show any abnormalities; however, weight-bearing anteroposterior (30°) and lateral radiographs should be obtained in all patients with presumed Lisfranc injuries.14 Findings are often subtle; therefore, physicians must evaluate radiographs carefully for misalignment. The normal anteroposterior radiograph should demonstrate alignment of the medial border of the second metatarsal with the medial side of the middle cuneiform. The 30° oblique view shows the alignment of the medial border of the second metatarsal with the middle cuneiform and the medial border of the fourth metatarsal base with the medial border of the cuboid. On the lateral view, the dorsal and plantar aspects of the metatarsals should correspond with the cuneiform and cuboid.13 If any doubt remains, obtaining radiographs of the contralateral foot may assist with diagnosis.
Computed tomography and MR imaging may also be used. A computed tomographic scan is useful to aid detection and delineation of fracture patterns.13 Magnetic resonance imaging can demonstrate ruptures or sprains of the Lisfranc ligament, which may lead to instability.16
Management
Nonoperative management is limited to injuries with normal anatomy on radiographs that do not exhibit instability. Conservative management consists of rest, ice, elevation, and, most importantly, immobilization. Patients are given a walking cast or controlled ankle motion boot and are permitted to bear weight as comfort allows.13 Although these patients are permitted to bear weight, they may have difficulty doing so because of pain.
Surgical management is indicated for any injury with displacement seen on weight-bearing radiographs or non–weight-bearing, as this injury is indicative of instability. Instability is defined as a greater than 2-mm shift in normal joint position. An open or percutaneous approach with internal fixation is usually necessary because of the difficult reduction and residual deformity with closed reduction and casting.5 Anatomic reduction should be considered because of the midfoot tarsometatarsal joints’ poor tolerance for malalignment.13 Primary arthrodesis of the Lisfranc region of the foot is another option. Whether 1 of these 2 procedures results in better outcomes than the other is a controversial topic, and current management will depend on the physician.5
Turf Toe
A common condition among athletes,17 turf toe involves a spectrum of injury to the structures on the plantar aspect of the first metatarsophalangeal joint. Most injuries are caused by a combination of a hyperdorsiflexion force and axial load on the metatarsophalangeal joint with the foot fixed in equinus. This type of injury is often a result of contact with another player or a playing surface. If misdiagnosed and mismanaged, this injury could result in long-term sequelae, such as persistent pain, weakness in push-off, stiffness, deformity, and development of joint arthritis.17
Anatomy
The first metatarsophalangeal joint has limited inherent stability because of the shallow articulation between the convex metatarsal head and concave base of the proximal phalanx articular surface. Stability is attributed to the complex attachments of the joint capsule and the ligamentous structures surrounding it.17 The sesamoid bones, which are closely connected to the fibrous layer of the joint capsule, also provide stability, and their function is to increase the power of plantar flexion of the first ray by increasing the moment of the intrinsic flexors.18
Diagnosis
Clinical presentation depends on the severity of the injury. Patients typically present with difficulty bearing weight and tenderness to palpation of the first metatarsophalangeal joint in a low-grade injury. All structures, including the collateral ligaments, sesamoids, plantar plate, and dorsal capsule, should be palpated. Instability and deformity may develop with more severe injuries. Instability is assessed by performing the varus or valgus stress test and the dorsoplantar drawer test of the metatarsophalangeal joint. Patients often have ecchymosis and edema in the area as well.17
Anteroposterior, lateral, and axial sesamoid radiographs with the patient bearing weight are important in the initial evaluation of the injury. In cases of severe injury, obtaining radiographs with the patient bearing weight may not be possible. Lateral and medial 40° oblique views allow visualization of the lateral and medial sesamoids, respectively. Dorsiflexion lateral stress views can be useful to show movement of the sesamoids, indicating instability.17 Magnetic resonance imaging can be used to evaluate the extent of plantar plate disruption, as well as the integrity of surrounding structures, including the flexor hallucis longus and the articular surface of the joint.18
Management
Initially, patients may be treated with conservative measures such as rest and ice. Taping the toe simultaneously compresses and immobilizes the joint, thus reducing pain. Patients may gradually progress toward weight bearing as pain allows.17
Operative management is recommended for large capsular avulsions, unstable joints, diastasis or distraction of the sesamoids, vertical instability, intra-articular loose bodies, chondral injury, and failed conservative management.17 Operative techniques often consist of a plantar plate or capsular repair. When sesamoid fracture is present, open reduction internal fixation is an option, as well as partial excision of the sesamoid. Caution must be used when excising the sesamoid because of the risk of iatrogenic hallux varus or valgus18 after removal of the fibular or tibial sesamoid, respectively.
Navicular Stress Fractures
As a result of microscopic trauma sustained when the bone is subjected to repeated submaximal stresses, navicular stress fractures can occur.19 Physicians must have a high index of suspicion, especially in patients who participate in high-impact and explosive athletic activities because of the vague and nonspecific symptoms of dorsal foot pain. These stress fractures usually occur during the foot-strike phase of running, especially in the equinus foot, when compression forces are generated from distal to proximal across the medial and lateral aspects of the navicular via the first and second metatarsocuneiform joints.20 Late identification can be associated with chronic pain and disability, and it may predispose the joints to nonunion.19
Anatomy
The navicular is a medial tarsal bone with a concave proximal articular surface that articulates with the talus. Distally, its convex surface articulates with the first to third cuneiforms. The only muscle attachment is the tibialis posterior, which inserts on its tuberosity proximally and medially.21 The blood supply to the navicular is an important component of its anatomy. The medial tarsal branches of the dorsalis pedis are the main blood supply, and the lateral tarsal branches supply a portion of the dorsal navicular.22 However, the central one-third of the navicular body, which is the zone of maximum shear stress, is devoid of direct blood supply in some people; thus, the navicular is a watershed area, making healing difficult.20 This central area with its tenuous blood supply is predisposed to poor healing and nonunion.
Diagnosis
Patients typically present with poorly localized midfoot pain aggravated by physical stress and relieved by rest.19 Usually, minimal associated swelling or deformity are present. Focal tenderness to palpation is often elicited over the dorsal aspect of the navicular.20
Plain radiographs often do not show obvious causes. Weeks may pass before fracture lines become evident. Therefore, physicians must have a high index of suspicion for this injury and, if suspected, an MR image should be obtained20 to demonstrate marrow edema in the area of the stress fracture.23
Management
Optimal management is controversial because of the prolonged immobilization and limitation of activity necessary when these injuries are managed conservatively.19,20 Nonoperative management is indicated for patients with nondisplaced and incomplete fractures. Strict immobilization with casting and instructions for the patient to not bear weight until healing is complete yields excellent outcomes.20 Operative management with percutaneous or open reduction with internal fixation is often performed in elite athletes who desire quicker return to activity.19 In nondisplaced fractures without sclerosis, surgeons should consider percutaneous fixation; however, in displaced or sclerotic fractures, open reduction with bone grafting is indicated.24
Syndesmotic Injuries
Injuries to the syndesmosis are common in sports in which high-torque cutting, jumping forces, and high-speed collisions can occur or the terrain is artificial or uneven. The mechanism is typically associated with external rotation and pronation or dorsiflexion of the ankle. Injuries can be purely ligamentous (also known as high ankle sprains) or more commonly associated with fractures of the tibia or fibula.25 Proper and timely management is important because these injuries may result in substantial missed time from athletic activity, they may potentially require surgical stabilization, and they are associated with long-term ankle dysfunction.26 Physicians must distinguish syndesmotic injury from classic inversion ankle sprains caused by ankle instability due to long-term morbidity associated with improperly treated syndesmotic injuries.27
Anatomy
The ankle syndesmosis is an inherently stable articulation composed of multiple ligamentous structures, including the anterior-inferior tibiofibular ligament the posterior-inferior tibiofibular ligament, the interosseous ligament, and the transverse ligament that connect the distal tibia to the fibula.25 The posterior-inferior tibiofibular ligament is considered the most integral ligament in this complex. The fibula rests within the incisura of the tibia, a concave triangular groove.28
Diagnosis
Clinically, pain is often diffuse but can be located anterolaterally and posteromedially about the ankle joint, as well as proximally throughout the leg. On examination, swelling and ecchymosis are often present, as well as tenderness of the syndesmosis. Provocative tests that have been described include the squeeze test, the radiographic external rotation stress test, the intraoperative cotton test, fibular translation, and cross-leg tests.25
Plain radiographs should be obtained, including anteroposterior, mortise, and lateral views. Full-length tibia or fibula radiographic imaging should also be ordered to assess the proximal fibula for fracture, indicating a Maisonneuve injury. In certain circumstances, physicians may have difficulty assessing purely ligamentous injuries without fracture on plain radiographs unless stress view radiographic imaging is performed; therefore, if syndesmotic injury is suspected, stress views should be obtained.25
Although ultrasonography is reported to have high reliability in diagnosing syndesmotic injury, it is very operator-dependent.29 Magnetic resonance imaging is useful for acute injuries because of its signal changes, and it also helps to rule out associated abnormalities.30 Athletes may require an examination with anesthesia or arthroscopic evaluation before an appropriate course of management can be determined.25
Management
Nonoperative management is indicated in stable injuries. Rest, ice, and elevation are helpful to diminish swelling after the initial trauma. Immobilization with a controlled ankle motion boot is recommended. Progression to weight bearing, functional exercises, and proprioceptive exercises can be made within the first week.25
Unstable injuries require operative fixation. No true consensus exists regarding the operative stabilization of the syndesmosis. Surgical techniques are highly surgeon-dependent and include screw fixation alone or suture button implants with or without arthroscopic reduction assistance. Associated fractures of the tibia and fibula, if present, should be treated with open reduction and internal fixation. The syndesmosis can be stabilized with screws or a suture button device, depending on surgeon preference.25
Conclusion
Appropriate diagnosis and management of common injuries of the foot and ankle are necessary to avoid long-term morbidity and disability. Clinical symptoms are often vague and at times difficult to detect with plain radiographs; therefore, physicians’ index of suspicion should remain high for all of the aforementioned conditions. When in doubt, further imaging should be obtained or referral to an orthopedic surgeon should be given to avoid long-term sequelae.
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