VOL. 98-B, No. 10, OCTOBER 2016 1299 SPECIALTY UPDATE Management of sports injuries of the foot and ankle AN UPDATE. C. C. Hong, C. J. Pearce, M. S. Ballal, J. D. F. Calder From Jurong Health, NTFGH Hospital, Singapore C. C. Hong, MBBS, MRCS(Ed), MMED(ORTHO), Senior Resident National University Hospital, 5 Lower Kent Ridge Road, 119074, Singapore. C. J. Pearce, FRCS (Tr&Orth). MFSEM, Consultant Orthopaedic Surgeon Jurong Health, NTFGH Hospital, 609606, Singapore. M. S. Ballal, MBBS, MRCSEd, FRCSEd (Tr&Orth), Foot & Ankle Fellow J. D. F. Calder, MD, FRCS (Tr&Orth), FFSEM, Consultant Orthopaedic Surgeon Fortius Clinic, 17 Fitzhardinge Street, London W1H 6EQ, UK. Correspondence should be sent to Mr C. C. Hong; e-mail: [email protected] ©2016 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.98B10. 37896 $2.00 Bone Joint J 2016;98-B:1299–1311. Received 14 January 2016; Accepted after revision 5 July 2016 Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration. In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:1299–1311. This is a follow-up review on sports injuries of the foot. The initial article dealt with injuries to the ankle; 1 the current article will deal with injuries to the foot. Lisfranc injuries Return to play: up to 92% of patients with a Lisfranc injury will return to their pre-injury level of sporting activities two years after the injury. 2 The time taken to return to training has been reported to be between 18 and 24 weeks and to return to competition between 21 and 31 weeks. 3 The Lisfranc joint is named after the French surgeon, Jacques Lisfranc de St. Martin (1790 to 1847) who described an amputation through the level of the tarsometatarsal joints (TMTJs) in 1815. 4 The Lisfranc or TMTJ complex forms the foundation of the transverse and longitudinal arches of the foot and plays a vital role in the stability of the midfoot. This stability is main- tained by both the bony and ligamentous struc- tures. 5,6 The bony anatomy of the base of the second metatarsal is crucial as it forms the key- stone of the transverse arch and is recessed by an average of 8 mm proximal to the medial cuneiform and 4 mm proximal to the lateral cuneiform in the coronal plane, making a very stable arrangement (until it is disrupted). 7 There is no intermetatarsal ligament between the first and second metatarsals as there is between the second to fifth metatarsals. Instead there are the three ‘Lisfranc ligaments’ (dorsal, plantar and interosseous) from the medial cuneiform to the base of the second metatarsal. 5,6 Solan et al 8 examined the strength of these ligaments and concluded that the interosseous Lisfranc ligament was the strongest followed by the plantar and then the much weaker dorsal ligament. Lisfranc injuries may be purely ligamentous, osseous or a combination of both. They may be associated with high energy trauma such as a fall from height, industrial accidents and pol- ytrauma or low energy injuries. 9-12 Sports related Lisfranc injuries are increasingly being recognised and it has been reported that up to one third are now sports related. 12 There may be direct or indirect trauma. Direct trauma is usually caused by crush injuries and is often accompanied by significant soft-tissue dam- age. 13,14 Indirect trauma occurs more com- monly in sports injuries, 15 which mostly occur as a result of an excessive twisting force or an axial force to the plantar flexed foot. 15 Subtle injuries can be difficult to diagnose, and 20% of Lisfranc injuries are missed on initial radio- graphs, which can lead to long-term morbidity and lawsuits. 16-18 A high index for suspicion is therefore required. Pain and swelling out of proportion to the radiographic appearances may alert the physician and the plantar ecchy- mosis sign has been reported to be the most reliable sign of a significant midfoot injury (Fig. 1). 19 Initial radiographs may not show displacement and if the diagnosis is suspected weight-bearing radiographs, if the patient is able to tolerate them, should be requested (anteroposterior (AP) of both feet, oblique and lateral). 20 Diastasis of more than 2 mm between the medial cuneiform and the base of the second metatarsal indicates a Lisfranc liga- ment injury and instability. 21 The presence of a
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