Saul G. Trevino

A Prospective Study of Ankle Injury Risk Factors

Many factors are thought to cause ankle ligament in juries. The purpose of this study was to examine injury risk factors prospectively and determine if an abnor mality in any one or a combination of factors identifies an individual, or an ankle, at risk for subsequent inver sion ankle injury. We examined 145 college-aged ath letes before the athletic season and measured gener alized joint laxity, anatomic foot and ankle alignment, ankle ligament stability, and isokinetic strength. These athletes were monitored throughout the season. Fifteen athletes incurred inversion ankle injuries. Statistical analyses were performed using both within-group (un injured versus injured groups) data and within-subject (injured versus uninjured ankles) data. No significant differences were found between the injured (N = 15) and uninjured (N = 130) groups in any of the param eters measured. However, the eversion-to-inversion strength ratio was significantly greater for the injured group compared with the uninjured group. Analysis of the within-subject data demonstrated that plantar flex ion strength and the ratio of dorsiflexion to plantar flex ion strength was significantly different for the injured ankle compared with the contralateral uninjured ankle. Individuals with a muscle strength imbalance as meas ured by an elevated eversion-to-inversion ratio exhib ited a higher incidence of inversion ankle sprains. Ankles with greater plantar flexion strength and a smaller dorsiflexion-to-plantar flexion ratio also had a higher incidence of inversion ankle sprains.

Fortnightly review: Plantar fasciitis

Plantar fasciitis is the most common cause of inferior heel pain (fig 1). Its aetiology is poorly understood by many, which has led to a confusion in terminology.1 It is said to affect patients between the ages of 8 and 80, but is most common in middle aged women and younger, predominantly male, runners.2 Fig 1 Causes of inferior heel pain The role of the doctor in the management of plantar fasciitis is to make an appropriate diagnosis and to allow enough time for the condition to run its course, with the aid of supportive measures. If treatment is begun soon after the onset of symptoms, most patients can be cured within six weeks.3 This article is based largely on our experience and recent concepts that have changed our management of inferior heel pain. Reviews written by experts have been supplemented by selected original articles cited in Medline between 1976 and 1995 and published in high quality journals. We used the following keywords for the Medline search: plantar fasciitis, inferior heel pain, heel spur, calcaneodynia. The plantar fascia is a strong band of white glistening fibres which has an important function in maintaining the medial longitudinal arch: spontaneous rupture or surgical division of the plantar fascia will lead to a flat foot.4 5 The plantar fascia arises predominantly from the medial calcaneal tuberosity on the undersurface of the calcaneus, and its main structure fans out to be inserted through several slips into the plantar plates of the metatarso-phalangeal joints, the bases of the proximal phalanges of the toes and the flexor tendon sheaths. Just after heel strike during the first half of the stance phase of the gait cycle, the tibia turns inward and the foot pronates to allow flattening of the foot. This stretches the plantar fascia. …

The effects of rotation on radiographic evaluation of the tibiofibular syndesmosis.

Radiographs of 12 normal cadaveric lower extremities were prepared with each extremity in seven increments of axial rotation, ranging from 5° of external rotation to 25° of internal rotation. The tibiofibular clear space, the tibiofibular overlap, the width of the tibia and fibula, and the medial clear space were measured on each film. The width of the tibiofibular clear space (syndesmosis A) averaged 3.9±0.9 mm (range, 2 to 5.5 mm), but did not change significantly with rotation. Its size was independent of the size of tibia and fibula. All other measurements changed dramatically with rotation. In our specimens, a true mortise view of the ankle joint was obtained by internally rotating the extremity an average of 13.6±0.7° (range, 12.0° to 17.0°). Based on our results the width of the tibiofibular clear space on the anterior-posterior view is the most reliable parameter for detecting widening of the syndesmosis on plain radiographs. However, due to its variability among different individuals, comparison views of the contralateral extremity are warranted for confirmation of clinical suspicion of syndesmosis disruption.

Partial Achilles Tendon Ruptures Associated with Fluoroquinolone Antibiotics: A Case Report and Literature Review

Fluoroquinolone antibiotics (such as ciprofloxacin, pefloxacin, ofloxacin, norfloxacin, temafloxacin, etc.) have recently been implicated in the etiology of Achilles tendinitis and subsequent tendon rupture. We report on a patient with bilateral partial Achilles tendon ruptures associated with ciprofloxacin therapy and present a review of the current literature on this increasingly recognized complication. Treatment with fluoroquinolones should be discontinued at the first sign of tendon inflammation so as to reduce the risk of subsequent rupture. Magnetic resonance imaging is useful in distinguishing between Achilles tendinitis and partial tendon rupture.

Biomechanical Consequences of Sequential Plantar Fascia Release

Plantar fascia release has long been a mainstay in the surgical treatment of persistent heel pain, although its effects on the biomechanics of the foot are not well understood. With the use of cadaver specimens and digitized computer programs, the changes in the medial and lateral columns of the foot and in the transverse arch were evaluated after sequential sectioning of the plantar fascia. Complete release of the plantar fascia caused a severe drop in the medial and lateral columns of the foot, compared with release of only the medial third. Equinus rotation of the calcaneus and a drop in the cuboid indicate that strain of the plantar calcaneocuboid joint capsule and ligament is a likely cause of lateral midfoot pain after complete plantar fascia release.

Tibiotalocalcaneal Arthrodesis: Anatomic and Technical Considerations

In the first of this two-part cadaver investigation, we inserted a specially designed, pointed device (simulating a 12-mm nail) in an antegrade fashion in each of eight fresh-frozen cadaver tibial specimens; the tibial isthmus was used as a centralizing guide. The exit point was noted, and the specimen was dissected to identify the structures at risk. In all specimens, we found that the device placed the lateral plantar artery and nerve at risk (average minimal distance from device to structure, 0 mm) and that damage to the flexor hallucis brevis and plantar fascia occurred. In addition, in six of the eight specimens, the device skewered or skived the flexor hallucis longus tendon. We also noted that in each specimen the exit point was the sustentaculum tali, not the body of the calcaneus as expected. Thus, there was less calcaneal bone-to-rod interface for stability, and distal locking would be less effective in the lateral-to-medial direction because of the lack of medial bone stock. On the basis of the results of the first portion of the study, we investigated an alternative approach to retrograde tibial nailing to reduce the risk of injury to the plantar and medial structures of the foot. We performed a medial malleolar resection, medially displaced the talus, inserted the device in an antegrade fashion, and dissected the specimens to analyze the structures at risk. We found that malleolar resection and medial translation of the distal extremity an average of 9.3 mm (range, 7–11 mm) increased the average minimal distance from the tip of the device to the neurovascular bundle to 18.4 mm (range, 14–32 mm). We also found that there was no damage to the flexor hallucis longus and that all eight specimens demonstrated bony contact completely surrounding the nail device within the tuberosity portion of the calcaneus (assessed by postoperative radiographs). The results of this study suggest that malleolar resection and medial translation of the distal extremity before retrograde nailing of the tibia may reduce the risk of vital structure injury and enhance the rigidity of the fixation.

The effects of early mobilization in the healing of achilles tendon repair

Twenty-four male New Zealand rabbits underwent suture repair of a tenotomy of the left achilles tendon. The rabbits were randomized into two groups of 12 animals; in group (A), the ankle was immobilized by pinning for 35 days, while in the group (B), the ankle was immobilized for only 14 days followed by active mobilization. Following sacrifice at 35 days postoperatively, the retrieved tendons were evaluated by biomechanical testing and histologic examination. Approximately 50% of stretching occurred in the first four days; average overall elongation was 9.5±1.0 mm and 12.7±1.5 mm (p = 0.102) and average stiffness recovery was 67.4±2.0% and 82.9±1.9% (p = 0.0004) for groups A and B respectively. Histologically both groups demonstrated traces of disorganized neo-collagen fibers at the repair site as early as the fourth day with subsequent appearance of more mature collagen. The results obtained from our study favor early mobilization of the repaired tendon, which seems to restore the functional properties of the tendons more rapidly than continuous immobilization of an identical surgical repair.

Evaluation of results of endoscopic gastrocnemius recession

Background: Gastrocnemius recession is traditionally done as an open procedure. The aim of this retrospective study was to evaluate the safety and efficacy of gastrocnemius recession performed endoscopically. Methods: The procedure was done in 28 patients (17 men and 11 women), ranging in age from 16 to 72 years (average 47.57, SD 13.86) between January, 2001, and September, 2003. In three patients, the procedure was done bilaterally. Followup ranged from 4 to 36 months (average 22.00, SD 11.84). The procedure was done through a single medial or lateral portal using the 3M Agee Carpal Tunnel Release System (Micro Aire Surgical Instruments, Charlottesville, VA). Results: The initial incision for portal entry was at the wrong level in two of 31 procedures (6.5%), requiring a second incision. The recession could not be accomplished in one of 31 procedures (3.2%), so an open technique was used to complete transection of the gastrocnemius aponeurosis. One patient had a superficial wound infection (3.2%). There was no incidence of sural nerve or Achilles tendon damage. Analysis of results from a modified Olerud and Molander score using a paired student t-test revealed statistically significant improvement (p ≤ 0.05) in pain, stiffness, swelling, and overall average score after the procedure. Conclusion: The results of endoscopic gastrocnemius recession using the Agee Carpal Tunnel Release System have been encouraging, with limited morbidity. The technique proved both feasible and safe in this study.

Test-Retest Reliability of Ankle Injury Risk Factors

Ligamentous instability, ankle muscle weakness, foot ankle alignment, and generalized joint laxity may be predisposing factors for ankle ligament injuries. The purpose of this study was to examine the reliability of these risk factors before and after the season in healthy individuals and to determine if any significant differ ences developed during the athletic season (range, 12 to 16 weeks). Twenty-one healthy college-aged ath letes were tested for generalized joint laxity, anatomic alignment of the foot and ankle, ligamentous stability, and isokinetic strength of the ankle muscles. This study showed that generalized joint laxity, ankle ligamentous stability, and ankle strength measurements demon strated high correlation coefficients (r > 0.75). The high correlation coefficients suggested reliable measures. Some of the range of motion measurements had lower correlation coefficients, which suggested more variabil ity in these measurements. After establishing the reli ability in 24 of the 28 measurements with standardized methods, further work is underway to evaluate the role of these factors in inversion ankle sprains.

Calcaneocuboid stability: a clinical and anatomic study.

Injuries to the midtarsal joints are relatively uncommon and often unrecognized entities. Acute and chronic instability patterns to the calcaneocuboid joint can occur from such injuries. No previous determinations of normal calcaneocuboid laxity have been reported. Utilizing a previously described technique, stress radiographs were performed in human cadaveric specimens following serial sectioning of the ligamentous supports of the calcaneocuboid joint. Significant differences in calcaneocuboid gap and angle occurred between unstressed and stressed conditions. Cadaveric specimen testing determined that the dorsal and plantar calcaneocuboid ligaments both provide significant contributions to joint stability. Prior to defining pathologic states of joint laxity, normal ranges of stability must be determined. By more clearly defining normal stability of the calcaneocuboid joint and its ligamentous contributions, greater insight into the diagnosis and treatment of calcaneocuboid instability can be obtained.