Ankle and Foot Injuries in Pediatric and Adult Athletes

Ankle instability in pediatric and adolescent patients diagnosed with lateral malleolus avulsion fracture: Analysis of clinical and functional outcomes of ligament injury repair surgery

BACKGROUND

Some children and adolescents can develop persistent pain and instability following inversion injuries of the ankle. In these cases, imaging exams could reveal small bone fragments distal to the lateral malleolus. For these patients, regular conservative treatment may not be successful, requiring additional management, which can include surgical treatment. This study aimed to present the short-to-midterm functional and clinical outcomes of a series of 12 pediatric and adolescent patients who underwent ligament repair surgery due to chronic instability associated with the presence of osseous components in the lateral ligaments.

METHODS

A review of 12 patients treated with surgical ligament reconstruction of the ankle was evaluated. Clinical and functional evaluations were based on comparing the Visual Analogue Scale (VAS), AOFAS ankle-hindfoot score, and residual symptoms before and after the surgical intervention.

RESULTS

Before the reconstructive approach, the mean VAS was 2.41 and the mean AOFAS score was 74.16. After the procedure, the standard VAS declined to zero, and the AOFAS score was 100 in all patients. The mean follow-up was 6.33 months.

CONCLUSION

The surgical approach in children and adolescents with symptomatic ankle instability due to the presence of osseous fragments after an initial inversion trauma provided adequate clinical and functional results at short-to-midterm follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A Review of Pediatric Heel Pain

The objective of this review article is to provide orthopaedic surgeons and general practitioners a reference and guidance for the evaluation and workup of heel pain in pediatric patients. The authors performed a comprehensive literature search to review the etiologies and management of heel pain in patients <18 years of age. Relevant studies in Medline/PubMed and EMBASE were searched from inception to March 3, 2022 using medical subject headings and text words without limitations on language or study type. The initial search utilized the following Boolean operators: (children) AND (heel pain); (pediatric) AND (heel pain). Heel pain in the pediatric population is usually a benign condition. Sever's apophysitis is the most common etiology of heel pain in pediatric patients. Most causes of heel pain in the pediatric population do not require imaging or extensive workup. However, providers must maintain a high index of suspicion for symptoms that could indicate a more severe pathology.

Treatment of paediatric Lisfranc injuries: A systematic review and introduction of a novel treatment algorithm

BACKGROUND

Pediatric Lisfranc injuries (PLI) are rare injuries that have few studies published about their occurrence and treatment in pediatric population. Due to this lack of information, the diagnostic criteria and surgical or non-surgical methods for treatment have not been clearly established within the pediatric orthopedic literature. The objective of this study was to review the published literature related to treatment options and develop a concise stepwise treatment algorithm for pediatric patients presenting with Lisfranc injuries.

METHODS

A systematic literature review was conducted using PubMed to find studies discussing the treatment of PLI with reported long-term outcomes. Data collection accounted for the mechanism of injury, diagnostic imaging modality used, injury type, fracture classification using the Myerson system, treatment method used, and postoperative complications.

RESULTS

An initial PubMed search revealed 290 articles, but only 10 studies fulfilled the criteria for in-depth review. A total of 114 patients were included in this review from the selected case reports and case series studies. Primary treatment methods were as follows: 44% (50/114) with open reduction internal fixation (ORIF) using Kirschner wires (K-wires) and/or screws, 3% (3/114) with closed reduction percutaneous fixation (CRPF), 4% (4/114) with suture-button constructs, 20% (23/114) with cast immobilization, and 29% (33/114) were described as not requiring reduction.

CONCLUSION

There were two main limitations to this study. First, there are few published studies with longitudinal outcomes of PLI treatment. Second, some case series did not disclose which procedure a patient with post-treatment complications underwent. Therefore, an overall statistical analysis of success and failure rates with associated complications of each procedure could not be conducted. In conclusion, we found that a stepwise approach to evaluating conservative and surgical treatment options based on the presentation of the PLI should be utilized to optimize long-term outcomes.

DTI and MTR Measures of Nerve Fiber Integrity in Pediatric Patients With Ankle Injury

Acute peripheral nerve injury can lead to chronic neuropathic pain. Having a standardized, non-invasive method to evaluate pathological changes in a nerve following nerve injury would help with diagnostic and therapeutic assessments or interventions. The accurate evaluation of nerve fiber integrity after injury may provide insight into the extent of pathology and a patient's level of self-reported pain. The aim of this investigation was to evaluate the extent to which peripheral nerve integrity could be evaluated in an acute ankle injury cohort and how markers of nerve fiber integrity correlate with self-reported pain levels in afferent nerves. We recruited 39 pediatric participants with clinically defined neuropathic pain within 3 months of an ankle injury and 16 healthy controls. Participants underwent peripheral nerve MRI using diffusion tensor (DTI) and magnetization transfer imaging (MTI) of their injured and non-injured ankles. The imaging window was focused on the branching point of the sciatic nerve into the tibial and fibular division. Each participant completed the Pain Detection Questionnaire (PDQ). Findings demonstrated group differences in DTI and MTI in the sciatic, tibial and fibular nerve in the injured ankle relative to healthy control and contralateral non-injured nerve fibers. Only AD and RD from the injured fibular nerve correlated with PDQ scores which coincides with the inversion-dominant nature of this particular ankle injuruy cohort. Exploratory analyses highlight the potential remodeling stages of nerve injury from neuropathic pain. Future research should emphasize sub-acute time frames of injury to capture post-injury inflammation and nerve fiber recovery.

Sever's Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations

Sever's disease is an underreported prevalent pediatric condition that causes heel pain in children worldwide. It is often described as an overuse injury that can present with either unilateral or bilateral heel pain. Even though the exact mechanism of injury is unknown, it is often thought it involves repetitive stress and pressure on the calcaneal growth plate. Diagnosing Sever's disease mainly relies on a thorough clinical investigation and physical examination, with a positive squeeze test usually sufficient to establish diagnosis. Nevertheless, radiographic imaging can help exclude other differential diagnoses. Therapeutic options of Sever's disease are mostly conservative, and these include rest, physical therapy, kinesiotherapy, and orthoses. Educating parents and coaches on the symptomatology and presentation of Sever's disease is pivotal for the establishment of efficient preventive interventions and earlier diagnoses. This study presents a case of a pediatric patient with Sever's disease and offers medical insight into the diagnostic, clinical, pathologic, and therapeutic characteristics of this condition, in light of the current existing literature.

Imaging of Sports-related Injuries of the Lower Extremity in Pediatric Patients

With increasing participation and intensity of training in youth sports in the United States, the incidence of sports-related injuries is increasing, and the types of injuries are shifting. In this article, the authors review sports injuries of the lower extremity, including both acute and overuse injuries, that are common in or specific to the pediatric population. Common traumatic injuries that occur in individuals of all ages (eg, tears of the acetabular labrum and anterior cruciate ligament) are not addressed, although these occur routinely in pediatric sports. However, some injuries that occur almost exclusively in high-level athletes (eg, athletic pubalgia) are reviewed to increase awareness and understanding of these entities among pediatric radiologists who may not be familiar with them and thus may not look for them. Injuries are described according to their location (ie, hip, knee, or foot and ankle) and pathologic process (eg, apophysitis, osteochondritis dissecans). Examples of abnormalities and normal variants of the anatomy that are often misdiagnosed are provided. The injuries reviewed represent a common and growing subset of pathologic processes about which all pediatric and musculoskeletal radiologists should be knowledgeable. Understanding physeal injury is especially important because missed diagnoses can lead to premature physeal closure and osteoarthritis. ^©RSNA, 2016.

Treatment outcomes of adolescents with Iselin's apophysitis

This study assessed the presentations and outcomes of patients treated for Iselin's apophysitis. A total of 27 patients with Iselin's apophysitis were retrospectively analyzed for presentation, treatment, and clinical outcome. The mean age of presentation was 11.5 years (range: 9.2-15 years). All patients played sports, and their symptomatic severity and acuity varied. Treatments included rest, footwear modification, use of a controlled ankle movement boot, and use of a post-op shoe. Treatment lasted for an average of 24 days (range: 14-33 days), and the average time to return to play was 38 days (range: 14-53 days). All cases healed, with three reinjuries and no nonunions. Six cases were initially misdiagnosed as a fracture or tendonitis, indicating the need for further education on the diagnosis and natural history of Iselin's apophysitis.

Acute fractures of the pediatric foot and ankle

BACKGROUND

Injuries around the foot and ankle are challenging. There is a paucity of literature, outside that of specialist orthopedic journals, that focuses on this subject in the pediatric population.

DATA SOURCES

In this review, we outline pediatric foot and ankle fractures in an anatomically oriented manner from the current literature. Our aim is to aid the emergency department doctor to manage these challenging injuries more effectively in the acute setting.

RESULTS

These injuries require a detailed history and examination to aid the diagnosis. Often, plain radiographs are sufficient, but more complex injuries require the use of magnetic resonance imaging. Treatment is dependent on the proximity to skeletal maturity and the degree of displacement of fracture. Children have a marked ability to remodel after fractures and therefore mainstay treatment is immobilization by a cast or splint. Operative fixation, although uncommon in this population, may be necessary with adolescents, certain unstable injuries or in cases with displaced articular surface. In the setting of severe foot trauma, skin compromise and compartment syndrome of the foot must be excluded.

CONCLUSION

The integrity of the physis, articular surface and soft tissues are all equally important in treating these injuries.

Foot pain in the child and adolescent

There are multiple causes of pediatric foot and ankle pain. Although conservative measures are appropriate for initial management, patients with refractory pain should be given consideration for further intervention. This review highlights some of the most common causes of foot and ankle pain in the child, with specific attention to demographics, etiologies, diagnostic workup, and treatment options.

Swedish translation and validation of a web-based questionnaire for registration of overuse problems

The main aim of this study was to translate the Oslo Sport Trauma Research Center (OSTRC) Overuse Injury Questionnaire into Swedish. The validity and applicability of the questionnaire for studying overuse injuries among Swedish handball, volleyball, tennis, and orienteering top athletes were also examined. The back-translation method was used for translation. An expert committee further developed it for use in a study of injuries in handball, orienteering, tennis, and volleyball. A 10-week pretest was then conducted on 43 athletes, average age 21 (18-31) from these sports, during which time the athletes completed the modified OSTRC questionnaire on a weekly basis. In the 10th week, four additional questions were added in order to examine the questionnaire's content validity. No major disagreement was found in the translation. The athletes perceived the web-based questionnaire to be smooth and easy to complete, accurately capturing overuse injuries. However, suggestions were made to add questions relating to the hip for orienteerers and to the hand/fingers for handball players. The average prevalence of overuse injuries for all athletes, in any anatomical area was 22% (95% confidence interval 20-25). Construct validity appeared to be high, and we therefore suggest that the questionnaire may be used when studying overuse injuries in different sports.

Prevalence of joint-related pain in the extremities and spine in five groups of top athletes

PURPOSE

Joint-related pain conditions from the spine and extremities are common among top athletes. The frequency of back pain has, however, been studied in more detail, and the frequency of low-back pain in top athletes in different high-load sports has been reported to be as high as 85%. Sport-related pain from different joints in the extremities is, however, infrequently reported on in the literature.

METHODS

Seventy-five male athletes, i.e. divers, weight-lifters, wrestlers, orienteers and ice-hockey players and 12 non-athletes (control group) were included in the study. A specific self-assessed pain-oriented questionnaire related to the cervical, thoracic and lumbar spine, as well as the various joints, i.e. shoulders, elbows, wrists, hips, knees and ankles, was filled out by the athletes and the non-athletes.

RESULTS

The overall frequency of pain reported by the athletes during the last week/last year was as follows; cervical spine 35/55%; thoracic spine 22/33%; lumbar spine 50/68%; shoulder 10/21%; elbow 7/7%; wrist 7/8%; hip 15/23%; knee 22/44%; and ankle 11/25%. The corresponding values for non-athletes were cervical spine 9/36%; thoracic spine 17/33%; lumbar spine 36/50%; shoulder 0/9%; elbow 9/0%; wrist 0/0%; hip 9/16%; knee 10/9%; and ankle 0/0%. A higher percentage of athletes reported pain in almost all joint regions, but there were no statistically significant differences (n.s.), with the exception of the knees (P = 0.05). Over the last year, athletes reporting the highest pain frequency in the lumbar spine were ice-hockey players and, in the cervical spine, wrestlers and ice-hockey players. The highest levels of knee pain were found among wrestlers and ice-hockey players, whereas the highest levels for wrist pain were found among divers, hip pain among weight-lifters, orienteers and divers and ankle pain among orienteers. For the thoracic spine, shoulder and elbow regions, only minor differences were found.

CONCLUSION

There was no statistically significant difference in prevalence of pain in the neck, spine and joints between top athletes in different sports or between athletes and non-athletes. However, pain in one spinal region was correlated to reported pain in other regions of the spine. Moreover, pain in the spine was also correlated to pain in the shoulders, hips and knees.

Aspects of treatment for posterior heel pain in young athletes

Posterior heel pain occurs in young athletes involved in running and jumping. Due to the pain, the child often limits his/her physical activity level, with a possible negative effect on health and well-being. Although numerous research studies have examined the cause and treatment of heel and Achilles tendon pain in adults, there are no randomized clinical trials on treatment in children and adolescents. Therefore, there is limited evidence for how to treat young athletes with this type of complaint. The purpose of this review was to analyze critically and summarize the literature in regards to the cause and treatment of posterior heel pain in young athletes. The various diagnoses and clinical presentations relating to posterior heel and Achilles tendon pain are discussed. The theory and mechanism behind various recommended treatment strategies are also reviewed in the context of use in the young athlete. In summary, it is important to perform a thorough evaluation of each young athlete with heel pain to determine the appropriate diagnosis and to treat the deficits found and allow for a gradual progression to training. However, the recommendations at this time are based on clinical experience and a few retrospective studies, so further well designed prospective studies with validated outcome measures are urgently needed for the young athlete.

Review for the generalist: evaluation of pediatric foot and ankle pain

Foot and ankle pain is common in children and adolescents. Problems are usually related to skeletal maturity and are fairly specific to the age of the child. Evaluation and management is challenging and requires a thorough history and physical exam, and understanding of the pediatric skeleton. This article will review common causes of foot and ankle pain in the pediatric population.

Asymmetry of the active nonweightbearing foot and ankle range of motion for dorsiflexion-plantar flexion and its coupled movements in adults

Asymmetries in ankle range of motion (ROM) have been reported, but often the uninvolved limb is used as a reference in clinical practice. The study wanted to quantify the intraindividual asymmetries in dorsi-plantar flexion foot and ankle ROM and its coupled foot movements. Active triplanar nonweightbearing ROM of the foot and ankle was recorded in young healthy adults (30 male volunteers, mean age 22.8 years; 35 female volunteers, mean age 23.8 years) using an optoelectronic set-up. The sagittal plane movement (mean ROM female subjects right side 71.3 degrees, left side 71.4 degrees, P > 0.05; mean ROM male subjects right side 69 degrees , left side 68.9 degrees, P > 0.05; sex difference, P < 0.001) was coupled with frontal (mean ROM female subjects right side 16.6 degrees, left side 14.8 degrees, P > 0.05; male subjects right side 17 degrees, left side 15.3 degrees; P > 0.05; no sex difference) and horizontal (mean ROM female subjects right side 19.6 degrees, left side 18.8 degrees, P < 0.001; male subjects right side 17.6 degrees, left side 16.2 degrees, P < 0.001; sex < 0.001) plane motions. Individual fluctuating asymmetries up to 15 degrees (principal movement), and up to 29 degrees (associated movements) were measured. Overall, 20% of female and 34% of male subjects had principal plane asymmetries >5 degrees, and 50% of the subjects had asymmetries >5 degrees in the associated movements. In young adults, individual asymmetries in ankle joint complex dorsi-plantar flexion should be taken into account when using the uninvolved, contralateral limb as a reference for clinical examination.