1. Hinge joint that also incorporates both gliding and rolling, which are essential to its kinematics

2. See Chapter 2, Anatomy, for a thorough discussion of knee anatomy.

3. Ligaments

4. Medial structures of the knee (three layers) (Table 4-1; Figure 4-2)

5. Lateral structures of the knee (three layers) (Table 4-2; see Figure 4-2)

6. Menisci

7. Joint relationships

1. Ligamentous biomechanics: The role of the ligaments of the knee is to provide passive restraints against abnormal motion (Table 4-3).

2. Structural properties of ligaments: The tensile strength of a ligament, or maximal stress that a ligament can sustain before failure, has been characterized for all knee ligaments. However, it is important to consider age, ligament orientation, preparation of the specimen, and other factors before determining which graft to use.

3. Kinematics: The motion of the knee joint and interplay of ligaments have been described as a four-bar cruciate linkage system (Figure 4-5).

4. Meniscal biomechanics:

5. Patellofemoral joint:

1. Complete history of the injury

2. Clarification of mechanism of injury

3. Patient’s age

4. Important key historical points (Table 4-4)

1. Key examination points are shown in Table 4-5.

2. Examination performed with the patient under anesthesia may be helpful in some cases.

1. KT-1000 and KT-2000 Knee Ligament Arthrometers (MEDmetric, San Diego, California) are the devices most commonly used for standardized laxity measurement.

1. Standard radiographs:

2. Stress radiographs: These are useful for evaluating injuries to the femoral physis (to differentiate from MCL injury) and are becoming the “gold standard” in diagnosing and quantifying PCL injury. They can also be used to evaluate LCL and PLC injuries.

3. Nuclear imaging: Technetium-99m bone scans are useful in diagnosing stress fractures, early degenerative joint disease, and complex regional pain syndrome.

4. Magnetic resonance imaging (MRI): This has become the imaging modality of choice for diagnosis of ligament injuries, meniscal disease, avascular necrosis, spontaneous osteonecrosis of the knee, and articular cartilage defects and has replaced the use of arthrography. On coronal MRI sequences, meniscal root tears are seen as a band of low-signal fibrocartilage. Occult fractures of the knee can be identified by a double fluid-fluid layer, which signifies lipohemarthrosis.

5. Magnetic resonance arthrography: Intraarticular magnetic resonance arthrography is the most accurate imaging method for confirming the diagnosis of repeated meniscal tears after repair.

6. Computed tomography (CT): CT has been replaced largely by MRI, but it is still useful in the evaluation of bony tumors, patellar tilt, and fractures. CT has been advocated as a tool to assist in operative planning for patellar realignment by allowing measurement of the tibial tuberosity–trochlear groove (TT-TG) distance; authors recommend distal realignment procedures for a TT-TG distance exceeding 20 mm. MRI can also be used to measure TT-TG distance.

7. Arthrography: This technique was useful historically for the diagnosis of MCL tears and has been supplanted by MRI. However, it can be useful when MRI is not available or tolerated by the patient, and it can be combined with CT.

8. Tomography: Tomograms are preferred to CT in the evaluation of tibial plateau fractures at some medical centers.

9. Ultrasonography: This technique is useful for detecting soft tissue lesions about the knee, including patellar tendinitis, hematomas, and extensor mechanism ruptures, in some centers. Ultrasonography has begun to be used to evaluate meniscal tears but is not as sensitive as MRI.

1. Most accurately administered with the knee in extension; a lateral entry point that is in the middle to upper portion of the patella is used

1. The “gold standard” for the diagnosis of knee disease

2. The benefits of arthroscopic over open techniques include smaller incisions, less morbidity, improved visualization, and decreased recovery time.

1. Standard portals

2. Accessory portals, sometimes helpful for visualizing the posterior horns of the menisci and PCL

3. Less commonly used portals

1. Each knee arthroscopy should include an evaluation of the suprapatellar pouch; patellofemoral joint and tracking; medial and lateral gutters; medial compartment, including the medial meniscus and the articular surface; the lateral compartment, including the lateral meniscus and the articular surface; and the intercondylar notch to visualize the ACL and PCL.

2. The posteromedial corner can be best visualized with a 70-degree arthroscope placed through the notch (modified Gillquist view) or a posteromedial portal.

1. The most common arthroscopic complication is iatrogenic articular cartilage damage.

2. Additional complications include instrument breakage, hemarthrosis, infection, and neurovascular injury, especially injury to the infrapatellar branches of the saphenous nerve.

1. Overview

2. Treatment

1. Occur primarily in conjunction with horizontal cleavage tears of the lateral meniscus (Figure 4-14)

2. Operative treatment consisting of arthroscopic partial meniscectomy and decompression through the tear (sometimes including “needling” of the cyst) has been shown to be effective.

3. En bloc excision is no longer favored for most meniscal cysts.

4. Popliteal (Baker) cysts are commonly related to meniscal disorders and usually resolve with treatment of the primary disorder.

1. Can be classified as (I) incomplete, (II) complete, or (III) the Wrisberg variant (Figure 4-15).

2. Patients may develop mechanical symptoms, or “popping,” with the knee in extension.

3. Plain radiographs may demonstrate a widened joint space, squaring of the lateral femoral condyle, cupping of the lateral tibial plateau, and a hypoplastic lateral intercondylar spine.

4. Appearance of a contiguous lateral meniscus on three consecutive sagittal images on MRI is diagnostic; MRI may also demonstrate associated tears. Treatment includes partial meniscectomy (saucerization) for tears, meniscal repair for peripheral detachments (Wrisberg variant), and simple observation for discoid menisci without tears.

1. Remains controversial but may be indicated for young patients who have had near-total meniscectomy (especially lateral meniscectomy) and who have early symptomatic chondrosis

2. Relative contraindications include diffuse grades III and IV chondral lesions, so-called kissing lesions (chondral lesions adjacent to each other on the femur and tibia), advanced age of patient, and joint space narrowing.

3. ACL deficiency, as well as limb alignment, must be addressed to increase the success rates of meniscal transplantation.

4. Graft size accurate to within 5% of the native meniscus is crucial for success.

5. Pain relief is the most consistent benefit; most studies have short-term to 5-year data available.

6. Three-phase bone scans can be used diagnostically in patients who fit inclusion criteria to help determine whether they are good surgical candidates. Allograft tissue needs to be appropriately sized and is typically harvested with a sterile technique, appropriately screened, and frozen.

7. Techniques for implantation include the use of individual bone plugs for the anterior and posterior horns and the use of a bone bridge, especially laterally.

8. Collagen meniscal implantation has yielded promising initial results for irreparable medial meniscal tears with new meniscus-like matrix formation, in comparison with partial meniscectomy. However, long-term results, especially by independent sources, have not been reported.

1. Introduction

2. History and physical examination

3. Treatment

4. Surgical technique

5. Partial ACL tears

6. Postoperative rehabilitation

7. Complications

1. History

2. Physical examination and classification

3. Imaging

4. Treatment

1. MCL injury

2. LCL injury

1. History

2. Treatment

1. History and physical examination

2. Treatment

1. Introduction

2. Diagnosis

3. Treatment and prognosis

1. Overview

2. Treatment

1. Diffuse chondral damage is usually not considered “sports medicine,” but treatment modalities include medications, nutritional supplements such as glucosamine with chondroitin sulfate, hyaluronic acid injections, arthroscopic débridement, osteotomies, and arthroplasty. These treatment modalities are addressed in detail in Chapter 5, Adult Reconstruction.

1. Atraumatic osteonecrosis is similar to idiopathic osteonecrosis of the hip. Risk factors are similar to those of the hip and are common in elderly women.

2. Spontaneous osteonecrosis of the knee is thought to represent a subchondral insufficiency fracture and is typically a self-limiting condition. This condition can follow knee arthroscopy in middle-aged women. It should be treated with limited weight bearing until it resolves.

3. One hypothesis for the cause of spontaneous osteonecrosis of the knee involves a meniscal root tear.

1. Affected patients may present with pain and swelling and may have a palpable mass.

2. MRI demonstrates intraarticular nodular masses of low signal intensity on T1- and T2-weighted images.

3. There are nodular and diffuse types.

1. This proliferative disease of the synovium is associated with cartilaginous metaplasia, which results in multiple intraarticular loose bodies.

1. Synovial folds that are embryologic remnants

2. They are occasionally pathologic, particularly the medial patellar plica, which can cause abrasion of the medial femoral condyle and sometimes responds to arthroscopic excision (Figure 4-26).

1. Anterior knee pain is classified based on etiologic factors (Box 4-1). The term chondromalacia should be replaced with a specific diagnosis that is based on this classification.

1. Includes fractures of the patella (discussed in Chapter 11, Trauma) and tendon injuries (Figure 4-27).

2. Tendon ruptures

3. Repetitive trauma: overuse injuries

1. Patellofemoral arthritis

2. Anterior fat pad syndrome (Hoffa disease)

3. Complex regional pain syndrome (formerly known as reflex sympathetic dystrophy)

1. Lateral patellar facet compression syndrome

2. Patellar instability

1. Articular damage and changes to the patella have traditionally been referred to as idiopathic chondromalacia patellae; however, this term has fallen into disfavor.

2. Treatment is usually symptomatic, and physical therapy is emphasized heavily.

3. Débridement procedures are of questionable benefit.

4. The Outerbridge classification system is still in common use today (Figure 4-29).

1. Most often involve Salter-Harris II fractures of the distal femoral physis

2. Pain, swelling, and an inability to ambulate are common.

3. Stress radiographs and/or MRI may be necessary to make the diagnosis.

4. Open reduction and internal fixation are indicated for displaced Salter-Harris II, III and IV fractures and Salter-Harris I that cannot be adequately reduced.

5. It is important to counsel the parents that knee physeal injuries, and particularly distal femoral physeal injuries, may have a worse prognosis than other physeal fractures.

1. Classification: Avulsion fractures of the intercondylar eminence of the tibia are described as types I through IV.

2. Types I and II avulsion fractures are usually amenable to closed treatment.

3. Types III and IV fractures, and types I and II fractures for which closed treatment fails, are amenable to open or arthroscopic reduction and fixation of the fragment.

4. The medial or lateral menisci may become trapped beneath the bony fragment and thus prevent reduction if not addressed. Medial meniscal entrapment is more common in the Kocher et al series (2003).

1. Classification: Ogden modification of the Watson-Jones classification

2. Treatment: Displaced (>5 mm) type 2 and 3 fractures necessitate open reduction with internal fixation. Postoperative care includes immobilization in extension for approximately 6 weeks.

1. Treatment: ACL injury in skeletally immature athletes has received increased attention; the incidence is probably increasing because more children participate in athletics, and the condition is more often diagnosed because of increasing awareness.

1. This condition is present in such disorders as Osgood-Schlatter disease and Sinding-Larsen-Johansson disease.

2. Usually treated symptomatically, with immobilization as needed.

3. Procedures such as ossicle excision are occasionally indicated for refractory cases (Figure 4-30).

1. Direct trauma to this area can occur in contact sports.

2. An avulsion of the iliac apophysis should be confirmed or ruled out in adolescent athletes.

3. Treatment consists of ice, compression, pain control, and placing the affected leg on maximal stretch.

4. Corticosteroid injections have occasionally been advocated.

5. Additional padding is indicated after the acute phase.

1. An avulsion fracture of the lesser trochanter, traumatic phlebitis, thrombosis, athletic pubalgia, or femoral neuropathy must be confirmed or ruled out before supportive treatment is initiated.

1. This can result in hemorrhage and late myositis ossificans.

2. Acute management includes cold compression and overnight immobilization in 120 degrees of flexion.

3. Close monitoring for compartment syndrome is indicated in the acute phase.

1. This common injury is often the result of sudden stretch on the musculotendinous junction during sprinting.

2. It can occur anywhere in the posterior thigh.

3. Treatment is supportive, followed by stretching and strengthening.

4. To prevent recurrence, return to play should be delayed until strength is approximately 90% that of the opposite side.

1. Common in sports such as soccer, these injuries must be differentiated from subtle hernias.

2. Injury to the muscles of the abdominal wall or adductor longus produce anterior pelvis or groin pain, or both, without the classic physical findings of a true inguinal hernia.

3. Can result from acute trauma or microtrauma associated with overuse of the affected muscle.

4. Confirm or rule out other causes of pain with radiography, bone scan, or MRI, or a combination of these.

5. Treat nonoperatively for 6 to 8 weeks with rest and therapy.

6. Repair or reinforcement of the anterior abdominal wall is indicated after conservative measures have failed and after other causes have been excluded.

7. Decompression of the genital branch of the genitofemoral nerve is also favored by some authors in patients presenting with athletic pubalgia.

1. Acute injuries are usually located more distally on the thigh, but chronic injuries are usually nearer the muscle origin.

2. Pain is elicited with resisted hip flexion or extension.

3. Treatment includes ice and stretching/strengthening exercises.

1. Occurs frequently in female runners and is associated with training on banked surfaces

2. Treatment includes oral anti-inflammatory drugs, stretching, and rest.

3. Corticosteroid injections are occasionally advocated.

1. A cause of anterior hip pain in athletes and often associated with mechanical irritation of the iliopsoas tendon

2. Also a cause of “snapping” or “clicking” symptoms associated with hip pain

1. Caused by direct trauma or prolonged sitting and hard to distinguish from hamstring injuries

1. This nerve can be constricted by hypertrophied abdominal muscles as a result of intensive training.

2. Hyperextension of the hip may exacerbate the pain that patients experience, and hyperesthesia symptoms are common. Surgical release is occasionally necessary.

1. Can lead to chronic medial thigh pain, especially in athletes with well-developed hip adductor muscles (e.g., skaters)

2. Nerve conduction studies are helpful for establishing the diagnosis.

3. Treatment is usually supportive.

1. Can lead to meralgia paresthetica, a painful condition

2. Tight belts and prolonged hip flexion may exacerbate symptoms.

3. Release of compressive devices, postural exercises, and NSAIDs are usually curative.

1. Can occur anywhere along the course of the nerve, but the two most common locations are at the level of the ischial tuberosity and by the piriformis muscle, known as piriformis syndrome

1. A history of overuse, an insidious onset of pain, and localized tenderness and swelling are typical.

2. Stress fractures occur via propagation of a crack.

3. Bone scan can be diagnostic, even with normal plain radiographs.

4. MRI is the most specific test for detecting stress fractures.

5. Treatment includes protected weight bearing, rest, cross-training, analgesics, and therapeutic modalities.

6. There are several especially problematic stress fractures:

1. Can occur in athletes, especially cross-country skiers (skier’s hip)

2. Release bindings have reduced the incidence of these injuries.

1. Traumatic hip subluxation can disrupt the arterial blood supply to the hip and result in avascular necrosis.

2. Early recognition of these injuries, which are seen in football players, is essential.

3. With posterior subluxation or dislocation, one study revealed a 25% incidence of avascular necrosis.

4. Obturator oblique radiographs (to determine the presence of an avulsion injury) and MRI are recommended.

5. Such imaging should be followed by aspiration of the hip if a large hemarthrosis is present, 6 weeks of minimal weight bearing, and a repeat MRI.

6. With atraumatic injuries, other causative factors (alcohol, catabolic steroids, and decompression sickness) should be sought.

1. Repetitive trauma can cause an inflammation of the symphysis.

2. It occurs frequently in soccer players, hockey players, and runners.

3. Conservative management is usually curative.

1. Because more than 10% of all musculoskeletal tumors occur in the hip and pelvis, they must be suspected in cases of unexplained pain.

1. Often result from trauma or diseases such as synovial chondromatosis

2. Should be removed, either in an open procedure or arthroscopically, to prevent third-body wear

1. Often a cause of mechanical hip pain manifesting with vague symptoms

2. Magnetic resonance arthrography has greater than 90% sensitivity and is often used for diagnosis, but arthroscopy is the “gold standard” test (Figure 4-31).

3. The incidence of labral tears is highest in patients with acetabular dysplasia.

4. Underlying hip disease should be addressed in addition to the labral tear for the best results.

5. Arthroscopic labral débridement has yielded good short-term and midterm results.

6. Labral repair may yield better results than débridement, according to emerging data on new techniques.

1. Articular surface injury is often a cause of mechanical hip pain.

2. Microfracture is effective in the treatment of focal lesions.

1. Associated with mechanical hip pain as the ruptured ligament catches within the joint after a hip dislocation.

2. Débridement is often necessary.

3. The viability of the femoral head is not in jeopardy with a ruptured ligamentum teres.

1. Abnormal contact between proximal femur and acetabulum that leads to chondral damage and symptoms.

1. Cam, pincer, and a combination of cam and pincer

1. Acetabular retroversion; an old slipped capital femoral epiphysis; a nonspherical head; decreased femoral offset or decreased head/neck ratio; overhang of the anterosuperior acetabular rim; protrusio; and a retroverted femoral neck (after fracture).

1. Groin or hip pain in association with limitation in ROM, especially in flexion, can be a symptom.

2. Patients generally have more passive external rotation than internal rotation.

3. A positive result of an anterior impingement test is the reproduction of symptoms with passive flexion, adduction, and internal rotation.

1. Plain radiographs should include anteroposterior pelvis and true lateral views with hip in 15 degrees of internal rotation.

2. CT or MRI can give additional information about femoral-acetabular mismatch and chondral or labral lesions.

3. The false profile view (faux profil) was originally described by Lequesne to assist in the diagnosis of early osteoarthritis and developmental dysplasia of the hip. It is obtained by having the patient stand next to a vertical radiograph cassette. The hip of interest is closest to the cassette. The ipsilateral foot is parallel to the cassette also. The pelvis is rotated 25 degrees backward (the back of the patient is at a 65-degree angle with the cassette).

1. Treatment options include open or arthroscopic procedures to trim the femoral head and neck or acetabular rim; periacetabular osteotomy; femoral osteotomy; a combinations of these procedures with labral débridement; and repair.

2. Total hip arthroplasty is reserved for patients with significant arthritic changes.

1. Condition in which the iliotibial band abruptly catches on the greater trochanter or the iliopsoas impinges on the hip capsule.

2. The iliotibial condition (external snapping hip) is more common in women with wide pelvises and prominent trochanters and can be exacerbated by running on banked surfaces.

3. The snapping may be reproduced with passive hip flexion from an adducted position.

4. Stretching and strengthening exercises, modalities such as ultrasonography, and occasionally surgical release may relieve the snapping.

5. This condition must be differentiated from the less common snapping iliopsoas tendon (internal snapping hip), which can be diagnosed with extension and internal rotation of the hip from a flexed and externally rotated position.

6. Dynamic ultrasonography, arthrography, and bursography may also be helpful in determining the diagnosis.

1. As techniques improve, so do the indications. Hip arthroscopy is currently effective for the treatment of loose bodies, labral tears, chondral injuries, femoroacetabular impingement, avascular necrosis, synovial disease, ruptured ligamentum teres, impinging osteophytes, and unexplained mechanical symptoms.

1. Hip arthroscopy is typically performed with the patient in the supine or lateral position with approximately 50 lb (22.7 kg) of traction and a well-padded perineal post.

1. Three portals are commonly used for instrumentation: one on each side of the greater trochanter and an additional anterior portal (Figure 4-32).

1. Three compartments are described:

1. Complications, which are rare, are associated with traction injuries, iatrogenic chondral injuries, and neurovascular injury caused by aberrant portal placement.

2. The anterior portal puts the lateral femoral cutaneous nerve at risk.

3. The anterolateral portal is associated with injury to the superior gluteal nerve.

4. The posterolateral portal places the sciatic nerve at risk, particularly when the hip is externally rotated.

1. When compressed at the Hunter canal or in the proximal leg, the saphenous nerve can cause painful symptoms inferior and medial to the knee.

1. The common peroneal nerve can be compressed behind the fibula or injured by a direct blow to this area.

2. The superficial peroneal nerve can be entrapped about 12 cm proximal to the tip of the lateral malleolus, where it exits the fascia of the anterolateral leg, as a result of inversion injuries.

3. Superficial peroneal nerve entrapment manifests with numbness and tingling over the dorsum of the foot that worsens with plantar flexion and inversion of the foot.

4. The deep peroneal nerve can be compressed by the inferior extensor retinaculum, which leads to anterior tarsal tunnel syndrome and sometimes necessitates release of this retinaculum.

1. Compression of the tibial nerve under the flexor retinaculum behind the medial malleolus may result in tarsal tunnel syndrome. Electromyography or nerve conduction evaluation is helpful, and surgical release is sometimes indicated.

2. Distal entrapment of the first branch of the lateral plantar nerve (Baxter nerve) (to the adductor digiti quinti), between the fascia of the abductor hallucis and the medial side of the quadratus plantae, has also been described.

1. Occurs at the point where the flexor digitorum longus and flexor hallucis longus cross (knot of Henry)

2. Most commonly caused by external compression from orthoses

3. Commonly called jogger’s foot, this condition usually responds to conservative measures

4. Orthotics can exacerbate symptoms and should thus be avoided.

1. Can occur anywhere along the course of the nerve, but the nerve is most vulnerable 12 to 15 mm distal to the tip of the fibula as the foot rests in equinus position

2. Surgical release is usually effective.

1. Commonly called a Morton neuroma

2. Entrapment can occur during the push-off phase during running in athletes and with the demi-pointe position in dancers.

3. It usually occurs between the third and fourth metatarsals plantar to the transverse metatarsal ligament and responds to surgical resection if conservative measures fail.

1. Nicknamed tennis leg because of its common association with tennis

2. Much more common than rupture of the plantaris tendon

3. Supportive treatment is indicated.

1. Subluxation and dislocation

2. Tenosynovitis

3. Longitudinal tears of the peroneal tendons (especially the peroneus brevis tendon)

1. This injury often occurs in older athletes.

2. Patients complain of midarch foot pain, with difficulty pushing off.

3. Débridement of partial ruptures and flexor digitorum longus transfer for chronic injuries are recommended.

1. Rupture of this tendon is uncommon but has been reported in elderly athletes.

2. Repair is recommended.

1. Tendinitis and tendinosis

2. Rupture

1. Pressures higher than 20 mm Hg 5 minutes after exercise, absolute values higher than 15 mm Hg during rest, or pressures higher than 30 mm Hg 1 minute after exercise can help establish the diagnosis.

1. Patients present with intermittent claudication, including intermittent calf pain, cramping, coolness, and, at times, paresthesias into the foot.

2. Provocative clinical tests for the syndrome of popliteal artery entrapment include obliteration of pedal pulses by active plantar flexion or passive dorsiflexion of the ankle as detected by Doppler recordings.

3. Treatment is release and recession of the medial head of the gastrocnemius.

1. Common in athletes who have undergone a change in their training routines and in female endurance athletes (examiner must ask about the menstrual history).

2. Usually responds to rest and activity modification

3. Recalcitrant fractures may necessitate operative fixation.

1. Fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal in an athlete.

2. Early intramedullary screw fixation allows for earlier healing and an earlier return to conditioning activities.

3. A screw with a minimal diameter of 4 mm should be used (Figure 4-37).

4. Returning to sports activity before radiographic union increases the risk of nonunion.

1. Inflammation of the plantar fascia, usually in the central to medial subcalcaneal region, is common in runners.

2. Plantar fasciitis is associated with a tight heel cord on physical examination.

3. Rest, orthoses, stretching, NSAIDs, and local steroid injections are helpful.

4. Partial plantar fasciotomy is occasionally necessary, but recovery can be protracted.

5. Refractory cases may be treated with extracorporeal shock wave therapy.

1. Can cause impingement with plantar flexion of the foot, especially in ballet dancers

2. Treatment may include local anesthetic injection and other supportive measures.

3. Surgical excision of the offending bone with or without release of the flexor hallucis longus is occasionally necessary, and arthroscopic techniques have been described.

1. Common in athletes and most often involve the anterior talofibular ligament and occasionally involve the calcaneofibular ligament

2. The posterior talofibular ligament is rarely involved.

3. The Ottawa ankle rules (Stiell et al, 1995) indicate that radiographs are required only in patients with tenderness at the distal (especially posterior) tibia or fibula, tenderness at the base of the fifth metatarsal or navicular, and an inability to bear weight.

4. Surgical treatment is reserved for recurrent, symptomatic ankle instability with excessive tilt and a positive finding of the anterior drawer test on examination or on stress radiographs that have not responded to orthoses and peroneal strengthening and proprioceptive exercises over an extended period.

5. Anatomic procedures (modified Broström procedure) are usually successful.

6. Involvement of the subtalar joint necessitates tendon rerouting procedures that include this joint.

7. Patients with “high” ankle sprains involving the syndesmosis require recovery periods almost twice as long as those for patients with common ankle sprains.

1. Severe dorsiflexion of the metatarsophalangeal joint of the great toe (injuring the plantar plate) can result in tenderness, stiffness, and swelling of the toe.

2. Treatment includes physical therapy, ice, and taping in plantar flexion.

3. If symptoms persist, a stress fracture of the proximal phalanx should be ruled out with a bone scan or MRI.

4. Chronic turf toe can result in hallux rigidus.

1. Fracture of the lateral process of the talus (Figure 4-38).

2. The injury involves the leading leg on the board.

3. CT can help confirm the diagnosis.

4. Fracture with small fragments (<2 mm) can be treated in a short leg cast for 6 weeks, whereas a fracture with large fragments should should be treated with open reduction with internal fixation.

1. Soft tissue or bony conditions leading to decreased ROM, chronic pain around the ankle, or both

1. Include treatment of osteochondral injuries of the talus, débridement of post-traumatic synovitis, anterolateral impingement secondary to chronic pain from an ankle sprain, removal of anterior tibiotalar spurring, os trigonum excision, and cartilage débridement in conjunction with ankle fusions.

2. Osteochondral injuries of the talus

3. Lateral lesions are usually traumatic, shallow, and anterior, whereas medial lesions are atraumatic, deeper, and posterior.

4. The modification to the Berndt and Harty classification scheme (Figure 4-39) by Loomer and coworkers (1993) is helpful in the management of these osteochondral lesions of the talus.

1. Supine positioning with the leg over a well-padded bolster and an external traction device are currently popular.

2. Meticulous attention to portal placement is required because the most common complication of ankle arthroscopy is nerve injury.

3. Five portals—anteromedial, anterolateral, posterolateral, posteromedial, and anterocentral—have been suggested (Figure 4-40), but most surgeons avoid both the posteromedial portal (because of the risk to the posterior tibial artery and tibial nerve) and the anterocentral portal (because of the risk to the dorsalis pedis and deep peroneal nerve).

4. The “nick and spread” method is advocated for the anterolateral portal (superficial peroneal nerve) and the anteromedial portal (saphenous vein).