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Key Insights On Managing Injuries In Athletes
Injuries such as ankle sprains and conditions such as Achilles tendinopathy can sideline athletes for indefinite periods of time. In a discussion at the Western Foot and Ankle Conference, these panelists describe conservative and surgical treatment options, and special considerations in treating both pediatric and elite athletes.
Ankle sprains are common injuries in athletes and Lawrence Oloff, DPM, FACFAS, notes potential etiologies include regional tendon pathology, instability, ankle impingement, sinus tarsi syndrome, osteochondral defects, os trigonum syndrome and nerve syndromes. Methods of stabilizing the ankle include tenodesis, fasciodesis, primary ligament repair, the Brostrom procedure and arthroscopic surgery, according to Dr. Oloff.
For ankle sprains, Dr. Oloff suggests defining the extent of the injury, which determines the schedule of recovery. Specifically, for a high ankle sprain, he says options include surgery or immobilization with a slow, controlled recovery.
When patients present with peroneal tendon injuries, Dr. Oloff says clinical findings can include vague lateral ankle pain, swelling of the peroneal tendon sheath, pain with eversion, foot deformity, ankle instability and subluxing tendons. For a peroneal tendon tear without subluxation, he recommends debridement and tubularization for less extensive tears. In more severe cases, Dr. Oloff recommends resecting the damaged tendon and performing tenodesis of the proximal and distal segments to the peroneus longus. For a peroneal tear with subluxation, he says options include soft tissue reconstruction, tissue transfer, fibular groove deepening, a bone block and tendon rerouting. Specifically, Dr. Oloff notes Porter and colleagues found fibular groove deepening returned patients to sports within three months.1
For post-traumatic sinus tarsi syndrome, Dr. Oloff cites conservative treatment options including supportive orthoses, injections, non-steroidal anti-inflammatory drugs (NSAIDs), debridement, arthrodesis and implants. In recalcitrant cases, if magnetic resonance imaging (MRI) is positive, arthroscopic surgery is preferable, according to Dr. Oloff.
As for osteochondral injuries, treatment options are internal fixation, excision/debridement and marrow stimulation, chondral and osteochondral transplants, and orthobiologics, notes Dr. Oloff. He cites transplant devices including autologous chondrocyte implantation (Carticel, Genzyme), DeNovo NT Natural Tissue Graft (Zimmer) and BioCartilage (Arthrex).
Weighing Conservative Versus Surgical Treatment In Athletes
The best kind of surgery for an injured athlete is no surgery, asserts Lewis Freed, DPM. He cites several successful conservative treatments for athletes, also citing the efficacy of Tenex (Tenex Health) ultrasound debridement.
In a study of 35 patients, Dr. Freed notes Furia found extracorporeal shockwave therapy (ESWT) can effectively treat chronic insertional Achilles tendinopathy.2 Saxena and coworkers also found ESWT was effective in patients with Achilles tendinopathy in a study of 74 tendons in 60 patients.3
Conservative Achilles insertional calcific tendinosis treatments can include relative rest, physical therapy or eccentric exercises, notes Meagan Jennings, DPM. She says conservative treatment options for retrocalcaneal Achilles bursitis include topical analgesics, cryotherapy, NSAIDs, heel lifts, shoes with open backs or soft heel counters, U-shaped pads and corticosteroid injections in the bursa.
Are injectable therapies effective in the Achilles? In a review of nine studies involving a total of 213 Achilles tendons, Gross and colleagues found variable results on injectable treatments for non-insertional Achilles tendinosis and, in some cases, injections were no better than placebo.4 Dr. Freed says the reviewed interventions included platelet-rich plasma (PRP), autologous blood injection, sclerosing agents, protease inhibitors, hemodialysate, corticosteroids and prolotherapy. However, he notes that Gaweda and colleagues found that PRP improved the symptoms of Achilles tendinopathy in 14 patients.5
As for plantar fasciosis, Dr. Freed cites minimally invasive bipolar radiofrequency. Weil and colleagues related positive improvements in 10 patients with recalcitrant plantar fasciosis treated with percutaneous microtenotomy via a Topaz microdebrider.6 In addition, he says Lucas and colleagues found similar results in 111 patients with plantar fasciitis who received bipolar radiofrequency microtenotomy.7
Micronized dehydrated human amniotic/chorionic membrane (mDHACM) is an emerging treatment for plantar fasciitis, according to Dr. Freed. He cites a study of 45 patients by Zelen and colleagues who found that those who received mDHACM had improvement of plantar fasciitis symptoms starting one week after treatment.8
Case Studies In Treating Forefoot Pathology In The Athlete
When conservative treatments are not enough, surgery can provide athletes with an avenue back to competition. Michael Chin, DPM, presented several case studies of athletes who had surgery for forefoot injuries.
Case study 1. A soccer player presented with pain in the left great toe upon running, jumping and walking. He first experienced this pain two years prior during a slide tackle with another player. The pain had become worse and the patient rated it as 6 out of 10 on the Visual Analogue Scale (VAS). The objective exam revealed pain upon palpation of the first metatarsophalangeal joint (MPJ). Dr. Chin notes the patient was between stages 3 (established arthrosis) and stage 4 (ankylosis).
Dr. Chin performed a modified Valenti procedure due to the large osteophyte, multiple subchondral cystic lesions, the athlete’s age and his activity level. He also performed a joint salvage procedure. Postoperatively, the soccer player wore a controlled ankle motion (CAM) boot for three weeks and began passive range of motion on day four. Dr. Chin notes the surgery was successful and the patient was running on a weightless treadmill eight months after surgery.
Case study 2. A 37-year-old marathon runner presented with pain in the left foot. Dr. Chin notes the patient had run in two marathons that year and had run in Newton running shoes for six months. The patient had pain to palpation of the left plantar first MPJ and Dr. Chin diagnosed a tibial sesamoid fracture.
The patient wore a CAM boot and was non-weightbearing. Dr. Chin said the patient had ultrasound bone stimulation for 12 weeks and also took vitamin D supplements. Dr. Chin says the marathoner had pain with orthoses and a computed tomography (CT) scan showed no bridging of the tibial sesamoid. He performed a linear capsulotomy and noted the patient had a bursa under the first MPJ.
Case study 3. A 25-year-old runner, who was training for a marathon, presented with pain to the right ball of the foot as well as pain on the bottom and outer side of the foot. Dr. Chin noted excessive inversion and eversion at the ankle and subtalar joint bilaterally. He assessed her upper and lower extremity flexion, and noted a Beighton Score of 10/12. The X-ray was normal while the magnetic resonance imaging (MRI) showed an inflammatory response.
Dr. Chin performed a cortisone injection (Celestone Soluspan) of the third interspace. However, the patient returned in two weeks with worse pain and said the cortisone injection’s effect only lasted eight days. She rated her pain at 6/10 on the VAS. He notes an orthotic stabilized her hypermobility and reduced splaying of the forefoot. Three weeks later, the patient related neuroma pain of 3/10.
Dr. Chin performed nerve translocation. The patient wore a CAM boot and wore a surgical shoe while she slept. She transitioned to a gym shoe in four to six weeks and was running at 10 weeks postoperatively.
Treating Pediatric Sports Injuries
When treating injured child athletes, special considerations may be in order. Tim Dutra, DPM, cites the five Cs of treating pediatric sports injuries. These include conservative measures (protection, restricted activity, ice, compression and elevation), cross-training programs, control, compassion and compliance.
When treating youth, Dr. Dutra emphasizes the key differences in their social, physical and psychological levels. Kids have a special doctor-patient relationship and he notes parental consent and family influences are factors to consider in child athletes. Dr. Dutra notes one must obtain a history of injury and parents can sometimes involve themselves and "butt in” to the treatment discussion.
As part of a basic approach to treatment, Dr. Dutra notes that most injuries are due to overuse. With these injuries, he says one should always treat them conservatively if possible, saving surgery as a last resort. Dr. Dutra also stresses the importance of considering biomechanical and adherence issues.
Calcaneal apophysitis is very common and factors include high-impact sports, improper footwear or the sport surface, notes Dr. Dutra. He says the condition is generally self-limiting and treatment options include stretching of the Achilles or soleus, taping, orthoses, supportive shoes, or anti-inflammatory medication. In regard to stress fractures, Dr. Dutra recommends decreasing activity for three to six weeks, immobilization or cross-training.
Dr. Dutra also advises clinicians to consider the female athletic triad. As he notes, special factors with female athletes include eating disorders, altered menstrual function, amenorrhea and bone abnormalities.
When considering orthotic therapy in child athletes, Dr. Dutra says the goals are to alleviate structural disorders that can result in abnormal accommodations; protect the foot during any other treatments for injuries; and address rotational, muscular and functional abnormalities. He notes that abnormal foot position can result in complications. As the child’s foot is malleable while growing, Dr. Dutra says one must control and protect the foot.
When rehabilitating injured pediatric athletes, Dr. Dutra notes children may have short attention spans, feel invulnerable and may not feel rehab is important. He suggests keeping rehab short, simple and fun, and providing motivation to enhance kids’ performance. During rehabilitation, Dr. Dutra notes phase one is controlling pain and swelling, phase two is therapeutic exercise, phase three is an early return to activity and phase four is a full return. The guidelines for returning kids to play include ensuring injured areas are healed and can meet the sport’s demands, strength and endurance are near normal, and muscle flexibility and range of motion are normal, according to Dr. Dutra.
Special Considerations In Treating Injured Elite Athletes
When treating elite athletes, Dr. Oloff emphasizes the unusual pressures on athletes and high stakes for their recovery. He advises not going out on a limb when treating patients as agents will overprotect their clients. Those treating professional athletes should learn the sport and be able to interact as part of a medical team, according to Dr. Oloff.
Dr. Oloff notes athletes need a quick diagnosis and imaging. He says the athletic culture minimizes pain, and teammates and coaches often urge hurt athletes to go back on the field. He says degeneration occurs earlier in athletes and one should educate them on options and possible outcomes. If an athlete requires surgery, he notes minimally invasive surgery is the best approach.
Doug Richie Jr., DPM, FACFAS, suggests considering the emotional impact that cessation of running has on athletes. Dr. Richie says injured runners can experience emotions similar to the Kubler-Ross five stages of grief: denial, anger, bargaining, depression and acceptance.9 He says runners may deny that they have an injury and then become angry at those close to them, coaches, and doctors. The bargaining stage may take the form of runners wishing away their injuries and they may try to start running again. Dr. Richie says depressed athletes may become withdrawn. He notes that acceptance of the injury will facilitate the recovery process.
Dr. Richie notes that the majority of runners are not addicted to exercise and although some have withdrawal symptoms, the withdrawal is not due to addiction. If injury prevents athletes from training, he says some relate feelings of sluggishness, guilt and remorse, and others may worry about the loss of conditioning.
References
1. Porter D, McCarroll J, Knapp E, Torma J. Peroneal tendon subluxation in athletes: fibular groove deepening and retinacular reconstruction. Foot Ankle Int. 2005;26(6):436-41.
2. Furia J. High energy extracorporeal shockwave therapy as a treatment for insertional Achilles tendinitis. Am J Sports Med. 2006; 34(5):733–40.
3. Saxena A, Ramdath S Jr., O’Halloran P, et al. Extracorporeal pulsed activity sound waves for Achilles tendinitis. J Foot Ankle Surg. 2011; 50(3):315–19.
4. Gross CE, Hsu AR, Chahal J, Holmes GB Jr. Injectable treatments for noninsertional Achilles tendinosis: a systematic review. Foot Ankle Int. 2013; 34(5):619–28.
5. Gaweda K, Tarczynska M, Kryzanowski W. Treatment of Achilles tendinopathy with platelet-rich plasma. Int J Sports Med. 2010; 31(8):577–83.
6. Weil L Jr., Glover JP, Weil LS Sr. A new minimally invasive technique for treating plantar fasciosis using bipolar radiofrequency. Foot Ankle Spec. 2008; 1(1):13–18.
7. Lucas DE, Ekroth SR, Hyer CF. Intermediate term results of partial plantar fascia release with microtenotomy using bipolar radiofrequency microtenotomy. J Foot Ankle Surg. 2015; 54(2):179–82.
8. Zelen CM, Poka A, Andrews J. Prospective, randomized, blinded, comparative study of injectable micronized dehydrated amniotic/chorionic allograft for plantar fasciitis: a feasibility study. Foot Ankle Int. 2013; 34(10):1332–9.
9. Remy M. The Runner’s Field Manual. Rodale Books, Emmaus, PA, 2010, p. 184.
