A Review Paper Foot and Ankle Injuries in American Football Andrew R. Hsu, MD, and Robert B. Anderson, MD size and speed, and improved reporting of injuries Abstract are also contributing to increasing injury rates. Physicians need to be aware of a variety The interaction between player cleats and the of foot and ankle injuries that commonly playing surface is a central issue of foot and ankle occur in American football, including turf injuries in football. Improved traction relates to toe, Jones fractures, Lisfranc injuries, performance, but increased subsequent torque on syndesmotic and deltoid disruption, and the lower extremity is associated with injury. While Achilles ruptures. These injuries are often lateral ankle sprains are the most common foot complex and require early individual and ankle injury experienced by football players,7 tailoring of treatment and rehabilitation numerous other injuries can occur, including turf protocols. Successful management and toe, Jones fractures, Lisfranc injuries, syndesmotic return to play requires early diagnosis, a disruption, deltoid complex avulsion, and Achilles thorough work-up, and prompt surgical ruptures. It is important for physicians to be able to intervention when warranted with metic- recognize, diagnose, and appropriately treat these ulous attention to restoration of normal injuries in players in order to expedite recovery, foot and ankle anatomy. Physicians restore function, and help prevent future injury should have a high suspicion for subtle in- and long-term sequelae. This review focuses on juries and variants that can occur via both updated treatment principles, surgical advances, and rehabilitation protocols for common football contact and noncontact mechanisms. foot and ankle injuries. Turf Toe Editor’s Note: For additional Figures, view this The term “turf toe” was first used in 1976 to refer to article on amjorthopedics.com. hyperextension injuries and plantar capsule-ligament sprains of the hallux metatarsophalangeal (MTP) oot and ankle injuries are common in Ameri- joint that can lead to progressive cock-up deformity.8 can football, with injury rates significantly in- While these injuries can occur on any surface and F creasing over the past decade.1-5 Epidemiolog- disrupt soft tissue balance with functional implica- ic studies of collegiate football players have shown tions, predisposing factors include increasing playing an annual incidence of foot and ankle injuries surface hardness and decreasing shoe stiffness. In ranging from 9% to 39%,3,6 with as many as 72% a classic scenario, the foot is fixed in equinus as an of all collegiate players presenting to the National axial load is placed on the back of the heel, resulting Football League (NFL) Combine with a history of in forced dorsiflexion of the hallux MTP joint.9 As the a foot or ankle injury and 13% undergoing surgical proximal phalanx extends, the sesamoids are drawn treatment.5 Player position influences the rate distally and the more dorsal portion of the meta- and type of foot and ankle injury. Offensive and tarsal head articular surface bears the majority of “skill position” players, including linemen, running the load, causing partial or complete tearing of the backs, and wide receivers, are particularly suscep- plantar plate with or without hallux MTP dislocation. tible to foot and ankle injuries due to high levels Osteochondral lesions of the MTP joint and sub- of force and torque placed on the distal extremity chondral edema of the metatarsal head can occur during running, cutting, and tackling. Shoe wear concurrently as the proximal phalanx impacts or changes, playing field conditions, increasing player shears across the metatarsal head articular surface. Authors’ Disclosure Statement: Dr. Hsu reports that he is a paid speaker/presenter for Arthrex. Dr. Anderson reports that he receives royalties from Ar- threx, DJ Orthopaedics, and Wright Medical Technology; is a paid consultant for Amniox, Wright Medical Technology, and Arthrex; and receives research support from Wright Medical Technology. 358 The American Journal of Orthopedics ® September/October 2016 www.amjorthopedics.com A. R. Hsu and R. B. Anderson Clinical examination should focus on hallux plantar plate to the proximal phalanx in a distal to swelling, alignment, and flexor hallucis longus proximal fashion and advancement of the medial (FHL) function along with vertical instability of the capsule. The plantar incision is made along the hallux MTP joint using a Lachman test. Radiographs lateral border of hallux MTP-sesamoid complex just should be evaluated for proximal migration of the lateral to the weight-bearing surface of the hallux sesamoids or diastasis (see Figures W1A-W1C and the plantar lateral cutaneous nerve is carefully on amjorthopedics.com). Forced hallux MTP dor- dissected and retracted out of the way. Sutures siflexion lateral view can help assess the distance are placed in a figure-of-eight fashion through the from the distal sesamoid to the base of the pha- plantar capsule and plantar plate starting lateral lanx. A small fleck of bone pulled off of the proximal to medial to reduce injury to the nerve. If the tear phalanx or distal sesamoid may indicate a capsular cannot be primarily repaired due to inadequate avulsion or disruption. Live fluoroscopy can be very healthy tissue, a plantar plate advancement can be helpful in diagnosing turf toe, as the physician can performed directly onto the base of the proximal assess the trailing motion of the sesamoids with phalanx using drill holes or suture anchors. Proper increasing dorsiflexion and evaluate instability in alignment and motion of the sesamoids should all planes. Magnetic resonance imaging (MRI) is be verified with fluoroscopy and compared to the useful for subtle capsular injuries and can also contralateral hallux (see Figures W3A, W3B on identify osseous and articular damage that may amjorthopedics.com). occur and FHL disruption (see Figures W2A, W2B It is important to recognize that not all turf toe on amjorthopedics.com). Nonoperative intervention injuries involve pure hyperextension on artificial focuses on rest, ice, compression, and elevation playing surfaces. In recent years, we have found (RICE) and nonsteroidal anti-inflammatory drugs an increasing rate of medial variant turf toe injuries (NSAIDs). The hallux is temporarily immobilized in in which a forceful valgus stress on the hallux a plantarflexed position using a short leg cast or leads to rupture of the medial collateral ligament, walking boot with toe spica or turf toe plate with medial or plantar-medial capsule, and/or abduc- tape for 2 to 3 weeks. tor halluces. Medial variant turf toe can lead Indications for surgical intervention include loss to progressive hallux valgus and a traumatic of push-off strength, gross MTP instability, proximal bunion with a significant loss of push-off migration of the sesamoids, and progressive hallux strength and difficulty with cutting ma- malalignment or clawing after immobilization. neuvers. Surgical treatment requires a Cases can involve one or a combination of the modified McBride bunionectomy with following: (1) large capsular avulsion with unstable adductor tenotomy and direct repair of MTP joint; (2) diastasis of bipartite sesamoid; (3) the medial soft tissue defect. diastasis of sesamoid fracture; (4) retraction of Postoperative management is just as sesamoid; (5) traumatic hallux valgus deformity; important as proper surgical technique (6) vertical instability (positive Lachman test); (7) for these injuries and involves a delicate loose body in MTP joint; or (8) chondral injury in balance between protecting the repair MTP joint. The goal of surgery is the restoration of and starting early range of motion (ROM). anatomy in order to restore normal function of the Patients are immobilized non-weight-bear- hallux MTP joint. ing (NWB) for 5 to 7 days maximum followed We have found that using dual medial and immediately with the initiation of passive hallux plantar incisions places less traction on the plantar plantarflexion to keep the sesamoids moving. Ac- medial cutaneous nerve, improves lateral expo- tive hallux plantarflexion is started at 4 weeks after sure, and provides better wound healing. The surgery with active dorsiflexion from 6 to 8 weeks. medial capsulotomy extends from the metatarsal Patients are transitioned to an accommodative shoe neck to the mid-phalanx to provide complete with stiff hallux insert 8 weeks postoperative with visualization of the sesamoid complex (Figures continued therapy focusing on hallux ROM. Running 1A-1F). The collateral ligaments are often torn is initiated at 12 weeks and return to play (RTP) is away from the metatarsal head during the initial typically allowed 4 months after surgery. dissection and the plantar plate tear is distal to the sesamoid complex. The soft tissue defect Jones Fractures in the plantar complex must be closed distal to Jones fractures are fractures of the 5th metatarsal the sesamoids followed by advancement of the at the metaphyseal-diaphyseal junction, where www.amjorthopedics.com September/October 2016 The American Journal of Orthopedics ® 359 Foot and Ankle Injuries in American Football there is a watershed area of decreased vascularity rates of 7% to 28%,11 and re-fracture rates of up between the intramedullary nutrient and metaphy- to 33% associated with nonoperative treatment.12 seal arteries. Current thought is that the rising rate Nonoperative management is usually not feasible