FOOT AND ANKLE PROBLEMS IN ATHLETES
Marlene DeMaio, MD Prof, Orthopaedic Surgery, Marshall University; VAMC
John J. Jasko, MD Asst Prof, Orthopaedic Surgery, Marshall University
ACMS Team Physician CourseSan AntonioFeb 2015
ANKLE ANATOMY
Seto, Foot and Ankle Anatomy, Slideshare
Syndesmosis
• Syndesmosis: – Ant. Inf. Tibiofibular ligament
– Post. Inf. Tibiofibular ligament
– Transverse ;biofibular ligament
– Interosseous membrane
SoN Tissue Injuries
• Sprains • Tendon strains and tears
Primemed.com.au
ANKLE SPRAINS • 27,000 per day in U.S. – 25% of all MSK injuries
• Most common sports injury – 25-‐50% of all sports injuries – >50% of all ankle injuries – #1 NCAA surveillance data and ballet, classical dance
– 45% of all basketball injuries
“It’s just a sprain.” • Not a benign injury – 75% athletes report recurrence – Up to 25% lead to chronic lateral ankle instability and/or pain
– Self assessed disability is high – Lost days of work, prac;ce, games • 10-‐15% of all ;me lost in football • 3-‐5 weeks lost • Even for lower grade injuries
“It’s just a sprain.” • Misdiagnosis, incomplete diagnosis – Bone • Fracture: Ankle, Talus, Maissoneuve, 5th metatarsal • Tarsal coali;on
– SoX ;ssue • Global laxity, Ehlers Danlos • Tendon injury: Peroneals, Achilles
– Nerve disorder • HNP, drop foot • Charcot Marie Tooth
DeMaio, Orthopedics 1992:87-‐96
Anatomy • Ligament = condensa;on of capsule
AITF
ATFL CFL
• ATF Ligament – Fails at 138N – Can undergo greater plas;c deforma;on than CFL
• CF Ligament – Cord like – Fails at 345N – Deep to peroneals – 105° b/t ATFL CFL Clanton T, et.al. Anatomic study of Lateral Ligaments.
Poster at AAOS 2014
Anatomy: Lateral Ligament Morphology
LIGAMENT WIDTH, mm LENGTH, mm ORIGIN INSERTION
ATF 5 12 Anterior border lateral malleolus
Neck of talus
CF 6 6-‐25 Fossa lateral malleolus, 10-‐45 deg angle
Lateral tubercle,
calcaneus post process
PTF 6 9 Post lat malleolus, post to CF ligament
Lateral tubercle, talus post process
Hollinshead, Textbook of Anatomy, 3rd ed, 1974: 423-‐488 Ruth, JBJS-‐Am, 1961 43: 229-‐239
Mechanism of Injury: Lateral Ankle Sprains
• Weight bearing • Low energy trauma • Example: 230 lb RB, terminal velocity of 22.2 X/sec, decelera;ng at 13.5 m/sec2 – Force on ankle: 7760N – Stress lateral ankle: 1264.4 lbs
– ATF fails at 138 N, CF at 345N
Guise, AJSM 1976 4: 1-‐6.
Lateral Ankle Sprains • Func;on and alignment changes with mo;on
• Primary inversion stabilizer – Plantarflexion: ATFL – Dorsiflexion: CFL
PF Neutral DF
Mechanism of Injury • Lateral ankle sprain: a cascade of injury – Supina;on/Inversion in Plantar-‐flexion or Neutral
• ATFL injured first (“essen;al lesion”) • CFL injured as ankle DF during con;nued inversion
– ATFL + CFL 30-‐60%
• PFL last to rupture in extreme inversion, DF
Lateral Ankle Sprain: Exam • Anterior drawer – Tests the ATFL – Slight plantarflexion – Translate anterior and slightly medial
• Talar Ult – Tests CFL – Neutral flexion – Inversion of hindfoot – Look for dimple
• Always compare to other side • Most sensi;ve at ;me 0, then day 7
Lateral Ankle Sprains: Grades Grade Injury Swelling Weight Bearing
I ATFL stretch, tear
Mild Mild limp, but can WB with brace
II ATFL and capsular tear + CFL
Moderate swelling and Bruising
Difficult
III AFTL, capsule, CFL tears
Severe swelling and bruising
Unable to bear weight
Note: Grade IV with avulsion fracture
Lateral Ankle Sprains
• Classifica;on: systems not comparable – AMA : Grades I-‐IV – Severity – Ligaments
• Single: ATF ligament and capsule
• Double: ATF and CF ligaments
• Triple: ATF, CF, and PTF ligaments
Imaging: X-‐ray IndicaUons • Onawa Rules • Inability to bear weight • Bony tenderness
AP, lateral, morUse
OXowa Rules
• Xrays are indicated to r/o fx if: – Presenta;on within 10 days of injury – Inability to bear weight at ;me of injury or at presenta;on
– Tenderness over then distal 6cm of malleoli, posterior aspect
– Tenderness over the base of the 5th metatarsal or navicular
Imaging: MRI IndicaUons • If isolated injury, f/u exam in 1-‐2 weeks • MRI if – Persistent significant swelling – Tenderness:
• Peroneals • Lateral talus • Anterior calcaneus
– Syndesmosis injury suspected
• R/o concomitant pathology
Lateral Ankle Sprains: Treatment • Isolated acute Grade I & II lateral ankle sprains – Universal consensus – Ini;al non-‐opera;ve treatment of
• Grade III – “Near” consensus – Some new evidence may change this
Lateral Ankle Sprains: Treatment
• Benign Neglect – Not appropriate – 75% recurrence rates – RR=2.3 for CAI without func;onal rehab
Lateral Ankle Sprains: Treatment • RICE: 24-‐48 hours
• Control pain • Limit swelling • Reduce hypoxic injury during acute inflamma;on
• Protect Ligaments, Stabilize the Joint – Trauma creates temporary instability – True healing takes >8 weeks – External support: Braces, cast, boot, tape
• FuncUonal RehabilitaUon – Neuromuscular and sport/task training
DeMaio, Orthopedics 1992 15:87-‐96 and 241-‐248
FuncUonal RehabilitaUon • AXer LAS pa;ents exhibit deficits in – Joint posi;on sense – Isometric strength in mul;ple planes of mo;on – Postural control on the involved and uninvolved limb • Posi;ve modified Rhomberg
– Abnormal EMG (Nitz AJSM 1985 13:177-‐182)
• Peroneal nerve, 86% Grade III • Tibial nerve, 83% Grade III
• Lack of neuromuscular retraining leads to recurrent injury, chronic problems – 2.3 x risk of recurrence
FuncUonal Rehab: Components • Early Joint mobilizaUon • Strengthening • Sensorimotor/balance – Wobble board – Trampoline
• Single/double leg Postural control • ConUnue external support
• Propriocep;ve feedback • Con;nued protec;on of ligaments
Meta-‐Analyses/Level 1 Evidence • FuncUonal Rehab > prolonged immobilizaUon – Faster return to sport, work – Fewer long term symptoms – Bener ROM
• Semi-‐rigid external support beXer than cast & Ace – S;rrup ≥ Lace up brace > tape > Elas;c wrap – SLC/boot useful in G3 (Lamb et al. Lancet 2009) • Short tem use (days) only
Meta-‐Analyses: Level 1 Evidence
• Petersen et al. Arch Ortho Trauma 2013 • Lamb,et al. Lancet 2009 • Beynnon et al. AJSM 2006 • Ardevol et al. KSSTA 2002 • Kerkhoffs et al. Cochrane 2002 • Kerkhoffs et al. Acta Ortho Scand. 2003
Taping
• Pros – Custom – Provides propriocep;ve feedback
– Lightweight, low bulk – May be useful when swelling prevents fitng of an orthosis
• Cons – Rapid loosening
• AXer 10 mins, 40% of strength lost
• 50% decrease in ROM aXer 2 1/2 -‐3 hrs
• 45-‐60 minutesàminimal effect
– Trained personnel – Expensive over the season – Variable effects on performance
DeMaio, Orthopedics 1992 15:87-‐96
Taping vs. Brace for Sports • Both shown to prevent ankle sprains – Braces overall more effec;ve – Braces cost less per season
• Much more effec;ve on athlete with h/o prior ankle sprain
“Marshall” Algorithm • Brace: S;rrup/ Lace up /Combo • Boot in G3 – To brace in few days
• TED hose • WBAT with crutches if limping – NWB A/PROM
• Func;onal Rehab
Return to Play
• Subjec;ve symptoms – Foot and Ankle Ability Measure (FAAM)
• Func;onal tests – Star Excursion Balance
• Simplfied to Y
– Single leg balance – Single leg heel to toe raises
• 60/minute
Ankle Sprains: Treatment • Func;onal rehab bener than immobiliza;on – Start with DF, eversion – Ac;ve resistance: isometric first
• Peroneals • Dorsiflexors • Evertors
• Role for acute surgical interven;on in selected cases?
Ankle Sprains: Treatment • Pinjenburg, et al. 2002 – RPT Level II – Acute repair vs. func;onal rehab – 317 pa;ents, 8 yr follow up – Surgery group fared bener
• Pain (16% vs. 25%) • Subjec;ve giving way (20% vs. 32%) • Recurrent sprains (22% vs. 34%) • Func;onal scores
“operaBve treatment for lateral ligament ruptures can be adopted in cases when higher funcBonal demands…such as sports at a compeBBve level… are required”
Ankle Sprains: Treatment • Pihlajamaki, et al. JBJS 2010 – Level 1, 14 yr follow-‐up – Male Finish military cadets, Grade III sprains – Acute repair vs. func;onal rehab – Lower risk of re-‐injury in surgery group (6% vs. 58%)
– Higher incidence of Mild OA (Grade 2) on MRI in surgery group (27% vs. 0%)
Paradigm ShiN?
• Early surgery for Acute ankle sprain? • Similar to 1st ;me shoulder disloca;ons? • Poten;al problems – Increased complica;ons – Higher costs – Availability of OR
• Secondary reconstruc;on of G3 injuries is possible even years out, outcomes similar to those of acute repairà More data needed
Chronic Lateral Ankle Instability • ~10-‐25%
• Func;onal instability – Impaired propriocep;on, neuromuscular control
• Mechanical instability – Pathologic laxity – Synovial changes – Chondral damage – Loose bodies
DeMaio, Orthopedics 1992 15:241-‐248
Chronic Lateral Ankle Sprain: Predisposing Factors
• Previous ankle sprain • Propriocep;on deficiency • Varus hindfoot (Cavus foot) • Ligamentous laxity – Collagen deficiency – Beighton’s Criteria
Chronic Lateral Ankle Instability • History – Pt c/o: Can’t trust ankle, Feeling of giving way, Ankle just gives out
– Mul;ple sprains – Con;nued subacute or chronic pain following sprain
• Pain signifies other pathology as well – Peroneal tendons – OCD or OA – Anterolateral guner impingement
Chronic Lateral Ankle Instability: Physical Exam
• More subtle findings than acute • Ligament laxity more easily noted – Less swelling – Less pain inhibi;on
• Careful palpa;on • Examine hindfoot alignment – Look for cavus – Peek-‐a-‐boo heel
Chronic Lateral Ankle Instability: Imaging
• Stress x-‐rays – Ques;onable value without Telos machine – Pain inhibi;on – No consensus on normal and pathological # – Must compare to “normal” side • But is that side normal? • >3 mm ant. Transla;on • >10 deg talar ;lt
– Adds a data point • Signs and symptoms more important
Chronic Lateral Ankle Instability: Imaging
• MRI – OXen done to rule out other pathology • OCDs • Peroneal tendons
– Surgical planning
Chronic Lateral Ankle Instability: Treatment
• FuncUonal & Neuromuscular Rehab – Esp. subjec;ve instability pa;ents
• Bracing/Taping – Get through season
• Surgical interven;on is indicated when func;onal rehab has failed and pt has chronic symptoms
Chronic Lateral Ankle Instability: Surgery
• Address all pathology – 93% intra-‐ar;cular path (Ferkel, Brostrum) – Always scope
– Consider Peroneal tendon pathology
Chronic Lateral Ankle Instability: OpUons for Surgery
• > 50 described procedures – 80% G/E results
• How to choose? – Quality of ;ssue – Degree of laxity – Revision?
Op;ons for surgery
Surgical Technique • Insufficient evidence exists to support any one specific surgical technique
• Non-‐anatomic/tenodesis procedures – Inferior outcomes – Tendency to over;ghten • Ankle, subtalar OA
– Sacrifice peroneals • Dynamic stabilizer
Anatomic Repair • Brostrom (1966)
• Brostrom-‐Gould (1980)
Pictures from: Baxter’s Foot and Ankle in Sport. Mosby, Inc. 2008
Bone Tunnels vs. Suture Anchors
• No difference in strength or s;ffness • Neither as strong as na;ve ATFL at T=Ø – 80N vs 160N
Waldrop, et al. Anatomic Suture Anchor Versus the Brostrom Technique for ATFL Repar. AJSM 2012
Outcomes: Pooled Data
• Brostrom/Modified Brostrom (500 cases) – 85-‐100% successful – Poor results in
• Heel varus • Inadequate rehab • Nerve injury • Pre-‐exis;ng arthri;s • Significant repeat sprains
Anatomic Reconstruc;on
Anatomic Reconstruc;on • As s;ff and strong as na;ve ATFL T=Ø
– Implica;on for Rehab – More technically demanding – Need for graX
• Indica;ons – Heavy athlete or laborer – Severe laxity – Weak or Deficient ;ssue precluding direct repair – Revision surgery
• Clanton, et al. Biomechanical Comparison of Anterior Talofibular Ligament ReconstrucUon Using Semitendinosus AllograNs With the Intact Ligament; Anterior Talofibular Ligament Ruptures, Part 2:. AJSM 2014
Approaches
Post-‐op Management
• Similar to acute sprain – Week 1 : Protect for 7-‐10 days – Week 2-‐5: WBAT boot; DF, PF, no inversion – Week 6: Brace; Func;onal Rehab – RTP 10-‐12 weeks
Post-‐op Management
• Accelerated Rehab vs. Delayed – No immobiliza;on vs. cast 4 weeks – Func;onal rehab started at 2 weeks
• Allowed progression as tolerated – Return to sport 5 weeks sooner – Equal outcomes at 2 years
Miyamoto, et al. Accelerated Versus TradiYonal RehabilitaYon AZer Anterior Talofibular Ligament ReconstrucYon for Chronic Lateral Instability of the Ankle in Athletes. AJSM 2014
Arthroscopic Brostrom
• “all-‐inside” anatomic repair • Anchors placed percutaneously • Biomechanically = to open • Short term f/u good
Anatomic Repair + Synthe;c Augment
Stronger than na;ve ATFL at T=Ø
Could allow earlier RTP
Eversion Ankle Sprains
• 5-‐15% of all ankle sprains • AKA: high ankle sprains, medial ankle sprains, deltoid ligament sprains
• Anatomic classifica;on – Tibiofibular syndesmosis – Deltoid ligament – Both
Roberts, Orthopedics 1995 18:299-‐304
Medial Ankle: Deltoid Ligament
• Major ligament complex
• Strongest of the ankle ligaments
Seto, Foot and Ankle Anatomy, Slideshare
Anatomy
Deltoid Ligament • Superficial
– Tibionavicular ligament – Anterior talocalcaneal ligament
– Posterior ;biotalar ligament
• Deep – Anterior ;biotalar ligament – Posterior ;biotalar ligament
Flexor reUnacula – Superficial – Deep
4 fibrosseous canals – Posterior ;bial tendon – Flexor hallucis longus – Posterior ;bial nerve – Posterior ;bial a & v
Olney in Reckling & Reckling, Orthopaedic Anatomy &Surgical Approaches, 1990: 421-‐481
Medial Ankle: Tendons
• Posterior ;bialis (inverter and plantar flexor)
• Flexor digitorum longus • Flexor hallucis longus
Seto, Foot and Ankle Anatomy, Slideshare
Mechanism of Injury
• External rota;on and or forced DF – Talus rotates laterally striking the fibula
• External rota;on with the foot pronated – Maissoneuve injury
BoyYm AJSM 1991 19:294 Lauge-‐Hansen Acta Chir Scand 1949 97:544
Injury ClassificaUon LIGAMENT INJURY STABLE UNSTABLE
Syndesmosis Incomplete disrup;on Complete disrup;on of deep and superficial AND Anterior ;biofibular por;on of the deltoid
Deltoid Incomplete tear Complete disrup;on of the superficial and deep fibers; may be associated with fracture
Deltoid and Anterior talofibular
Incompletle tear Complete tear
Eversion Ankle Injuries: H&P • History – Mechanism of injury – Pt c/o: medial pain, pain with weight bearing – Neurological symptoms
• Physical – Tenderness – Provoca;ve tests
• External Rota;on Stress Test: knee at 90°, foot in neutral • Squeeze Test: bimalleolar compression
– Neuro: combined deltoid and syndesmo;c injury • 86% peroneal nerve • 83% posterior ;bial nerve
Nitz, AJSM 1985 13:177-‐182
Eversion Ankle Injuries: Imaging
• X-‐rays – AP, lateral, mor;se
• Mor;se view: > 3mm medial clear space widening
– Stress views • DF and external rota;on • Abduc;on
• MRI
Eversion Ankle Injuries: Treatment
• RICE • Progressive mo;on • Strengthening: isometric first • Balance training and func;onal rehab • Orthoses – Taping not effec;ve Myburgh AJSM 1984 12:441-‐446
Tendons of the Lateral Ankle
• Peroneus brevis • Peroneus longus – Both serve as the major everters of the ankle
– Also serve as plantar flexors
Seto, Foot and Ankle Anatomy, Slideshare
Peroneal Tendon Injuries
• Strains • Tears – Complete – Par;al
• Isolated • Associated with – Ankle sprains – 5th MT fx – Talar OCD
Achilles Tendon Injuries
• Achilles – Greek chieXain – Dipped in the river Styx by his mother The;s.
– Killed in the Trojan War by an arrow striking his heel where is mother dunked him.
Achilles Tendon Anatomy
• 6 cm long, twists 90° laterally
• Tendon of the triceps surae, no tendon sheath – 2 heads of the gastroc – Soleus
• Nerve: ;bial n • Superficial posterior compartment
Achilles Tendon Anatomy
• Blood supply – Muscle and bony anachments
– Avascular zone 2-‐6cm proximal to inser;on • Site of tendinopathy and chronic tears
Achilles Tendon Joint EffecUve
PF Gastroc Crosses
knee & ankle
Knee extended
Soleus Crosses ankle
Ankle in PF & knee flexed
• FuncUon: transmit load from gastroc & soleus to calcaneus
• Forces – Walking
• 1962-‐2354N • 2-‐3x BW
– Running • 3924-‐5886N • 4-‐6x BW
DeMaio Orthopedics 1995 18:195-‐204
Achilles TendiniUs • Common in runners, dancers
• Risk factors – Exposure – Malalignment
• Cavus • Pes planovalgus
– Obesity – Fluoroquinolones – Inflammatory arthropathy
– Hyperlipoproteinemia (xanthoma)
• Classifica;on – Chronicity – Loca;on
• Inser;on • Muscle tendon jxn • Tendon
– Tendon condi;on • Microtear • Par;al tear • Complete tear
– Tissue involved
Achilles Histopathology
Puddu, AJSM 1976 4:145-‐150 Kvist, J Pathol 1987 19:1-‐11
Chart From Hartog, AAOS OKO, Midsubstance Achilles TendiniUs
Achilles TendiniUs: Diagnosis • History – Acute
• Pop, pain, inability to walk
– Chronic • Pain
– Running – Push off – On pointe
• Swelling • Bump or “squeaking” • Weakness with push off
– Acute on chronic
• DifferenUal Diagnosis – Muscle disorders
• Tear, medial head of the gastroc
• Soleus straing • Compartment syndrome
– Tarsal tunnel syndrome – Bony disorders
• Os trigonum • Sever’s disease • Haglund’s (pump bumps)
– Inflammatory arthropathies
Achilles TendiniUs: Diagnosis
• Pain: Acute or Chronic? – Localized – Arc of tenderness
• Nodules may change posi;on with DF and PF (moving with the tendon) • Tendon sheath pain does not change with the ROM
• ROM • Thompson test
Achilles TendiniUs: Imaging
• Xray – Normal – Dystrophic calcifica;on
• Ultrasound • MRI
Echometric
Treatment of Chronic Achilles TendiniUs
• Correct – Training -‐Flexibility – Strength & endurance -‐Footwear
• Protect the tendon – 3/8” heel liX – Night splint – Rest 7-‐10 days or cast/boot 1 month
• Local modali;es • Surgery: no response aXer 6-‐12 months, par;al tears
Treatment of Acute Achilles Tendon Tears
• Non-‐opera;ve vs. Opera;ve & Early Loading – Prospec;ve, Level 1, 100 pts – f/u at 3, 6, 12 months: sx, ac;vity, func;on, QOL – Primary outcome: Achilles Total Rupture Score – Results
• No significant difference: sx, ac;vity, QOL • Trend toward improved func;on with surgery • No reruptures in surgical group, 5 in non-‐surgical
Olsson, AJSM 2013 41:2867-‐2876
Treatment of Acute Achilles TendiniUs
• Surgery—Another Paradigm ShiX?
Treatment of Acute Achilles TendiniUs
• Surgery – Open reconstruc;on – Percutaneous repair
• Early weightbearing with ankle plan;grade – Not detrimental to outcome
– Shortens rehabilita;on – No effect on strength, muscle atrophy Mafulli AJSM 2003 31 692-‐700
Treatment of Acute Achilles Tendon Tears
• Effect of Loading aXer Repair, Meta-‐analysis – 9 studies: 6 RCT, 3 quasi RCT with 402 pts
• 6 early wt bearing & ROM, 3 early ROM only
– Results • Bener outcomes for early wt bearing and ROM • Similar rerupture rates, complica;ons • No advantage of delayed wt bearing
Huang AJSM 2014
Ankle Fractures
• Stable = Non-‐opera;ve management – Avulsion fractures – Intact syndesmosis – Intact ;biotalar joint
• Unstable = Surgery – Disrup;on of syndesmosis – Unstable ;biotalar joint
Talar Stability
• Mor;se stability = talar stability
• Anterior talus is wider than the posterior talus
FOOT INJURIES
ANATOMY
Fractures
• Forefoot – Sesamoid fractures – Stress fractures
• Midfoot – LisFranc fracture disloca;ons
– FiXh metatarsal fracture
• Hindfoot – Calcaneus fractures
Myerson, ICL 58, Chapt 56 2009:583-‐594
LisFranc Fracture DislocaUons
• OXen missed, up to 20% – About 30% associated with sports
• Spectrum of injury – Ligamentous, bony, both – Associated injury: compartment syndrome
• Mechanism: indirect trauma – Axial loading of the foot in PF
LisFranc Fracture DislocaUons
• History • Exam – Inability or pain w/ weight bearing – Medial ecchymosis – Midfoot tenderness – “Stress” tests
• Compression of midfoot • Dorsal and plantar transla;on of the 1rst MT
LisFranc Fracture DislocaUons
Prona;on abduc;on test Medial column squeeze test
Myerson, ICL 58, Chapt 56 2009:583-‐594
LisFranc Fracture DislocaUons: Imaging
• X-‐ray – AP, lateral, oblique (30 deg) • Fleck sign: avulsion from base of 2nd MT
• Nutcracker sign: cuboid fx w/ lateral column shortening
– Weight bearing comparison AP • Pain may limit FWB
• Fluoroscopy: spring test • CT scan • MRI Myerson, ICL 58, Chapt. 56 2009:583-‐594
LisFranc Fracture DislocaUons:
• Aggressive management and close follow up – Must prove the sprain
• <2mm diastasis, stable stress tests • 6 wks NWB
– Unstable midfoot, diastasis > 2mm • Early surgery with screw fixa;on • NWB 6-‐8 wks then progressive loading • Planned screw removal
Stress Fractures
• 2nd metatarsal – AKA march fracture – Loca;on
• 2nd MT: hallux valgus, Hallux rigidus, Morton’s foot • 3rd, 4th MT: most common sites
Stress Fractures
• 5th metatarsal – Loca;on
• I: proximal to tuberosity • II: into the 4-‐5 ar;cula;on • III: proximal metaphyseal-‐diaphyseal junc;on
– Treatment • Torg: 92% healed in NWB cast at a mean of 7 wks • DeLee: screw fixa;on, return at 6 wks
SoN Tissue Injuries
• Plantar Plate Injury • Plantar Fascii;s • Entrapment of the first branch of the lateral plantar nerve (of Baxter)
• Posterior Tibial Tendon Inflamma;on & Tears
Other Injuries and CondiUons
• Freiberg’s Infrac;on • Painful accessory navicular • Tarsal coali;on
• Inser;onal tendini;s of the ;bialis anterior
Freiberg’s Infrac;on
• AVN of the 2nd metatarsal head • Risk factors: Morton’s foot, trauma, surgery • Management – Modify footwear, ac;vi;es; treat pain – Surgery
• Microfracture; Debridement & dorsal wedge osteotomy • AllograX • Arthrodesis, arthroplasty