Victor Valderrabano

Posterior Tibial Tendon Lesions and Insufficiency

The rate of occurrence of Posterior Tibial Tendon (PTT) injuries and insufficiency in sports is not yet clear based on the available literature. However, literature review may point to a link between some sports with specific lesions such as PTT dislocation, PTT tear, and PTT Insufficiency (PTTI) stage I or II. High index of suspicion is needed to diagnose and treat those lesions to prevent their progression to advanced stages.

Anterior Tibial Tendon Lesion

Ruptures of the anterior tibial tendon are quite rare but unfortunately still often missed. Most cases are caused by a degenerative process and only a small number of cases is caused by direct trauma or laceration. The main symptoms of an anterior tibial tendon rupture are swelling, mild pain, a weakened dorsiflexion, equinovalgus foot deformity and as an end-stage even a complete drop foot. However, in most cases the specific history in combination with the physical examination will lead to the diagnosis of anterior tibial tendon rupture. The treatment is dependent on several factors as aetiology, period of time to the onset of symptoms, age and level of activity. Surgical treatment is performed in selected cases, as described in the article, and a direct reinsertion or end-to-end suture of the tendon should be performed when possible. In difficult cases with delayed diagnosis, or initially misdiagnosed cases, a gracilis autologous tendon graft with tunnel-fixation to the medial cuneiform might be necessary to restore physiological biomechanics and gait patterns.

Sports and Osteoarthritis

Recent literature proves a distinct correlation between sporting activity and the development of osteoarthritis (OA). In a disease affecting millions of people worldwide this is an important and ever growing field of interest. Sports has the potential to be a positive but also negative impact factor in OA development, depending on the intensity and the level of professionalism of sporting activity. Due to the importance of muscular stability in the development of OA this is also a reasonable approach for the treatment of already established OA in the elderly.

Plantar Fasciitis in Sport

Plantar fasciitis is a common musculoskeletal condition among sport-active people. Careful history taking and appropriate clinical examination is essential to exclude other causes of plantar heel pain. Following a step-wise approach is recommended in plantar fasciitis treatment, as it is usually self-limiting condition. Inadequate response to non-operative treatment and persistence of symptoms more than 6 months may warrant surgical intervention. Provision of health instructions to athletes would help in prevention of plantar fasciitis. Athletes should watch for their training mistakes and should maintain good muscular strength and balance.

Chronic Ankle Osteochondral and Chondral Lesions

Osteochondral and chondral lesions of the talus are commonly found following sport related trauma to the ankle joint. Conservative treatment frequently fails, and most patients undergo surgery. Several surgical treatment techniques are available, showing good short and mid-term clinical and radiological results.

Morton’s Neuroma in Sports

Morton’s neuroma is a common cause of metatarsalgia which characterized by enlargement of interdigital nerve possibly due to nerve entrapment. Morton’s neuroma is usually common among middle age population with female gender predominance. Diagnosis of Morton’s neuroma is essentially clinical. Imaging modalities may help to delineate and localize the nerve lesion. Prone position foot MRI is associated with higher visibility of Morton’s neuroma. Identification of Morton’s neuroma, as a cause of metatarsalgia, tends to be missed by clinicians. Hence, high index of suspicion should be invested for this purpose. Proper footwear awareness should be emphasized among athletes. The cross-training shoes are discouraged for long distance running. Local steroid injection may provide temporary relief. Ultrasound-guided injection can improve the localization of injection. Neurectomy of the thickened nerve is considered the standard surgical treatment to date. Majority of surgeons prefer dorsal approach for first-time excision of Morton’s neuroma despite of its limited exposure reserving the plantar approach to the revision cases. Plantar surgical approach provides direct anatomical access and allows wide exploration of the area of neuroma. Recurrent neuroma is a major concern after neurectomy. Deep burial of nerve stump within the intermetatarsal soft tissues might minimize the risk of recurrent neuroma formation.

Acute Ankle Osteochondral and Chondral Lesions

Acute chondral or osteochondral lesions of the ankle joint are typically co entities of ankle sprains and ankle fractures. The exact inicidence is not clear, however clinical and radiological studies suggest that this entity is more common then assumed and probably frequently missed in an acute trauma situation. The initial clinical examination and conventioanl radiographs are often inconclusive. In a severe ankle injury, CT scans and MRI are useful diagnostic tools to assess chondral or osteochondral injury. If diagnosed, surgical treatment consists of either debridment and bone marrow stimulation, or refixation. Return to sports depends on additional injury to the joint as well as patients and sports specific condition.