Faculty Bibliography

Ankle and foot problems are extremely common in the high-performance dance population. To adequately evaluate and treat these problems, the physician must possess knowledge of how the physical demands of dance affect the performer's body. A routine evaluation of the dancer, involving a team of orthopedists, dance instructors, and physical therapists familiar with dance mechanics, has been developed to facilitate recognition of the abnormal mechanics responsible for injury. This technique can be useful in prevention and early diagnosis of injury, thus minimizing lost performance time.

We present the radiographic results after flexor digitorum longus tendon transfer combined with a medial displacement calcaneal osteotomy for the treatment of posterior tibial tendon insufficiency. Eighteen patients with posterior tibial tendon insufficiency were reviewed from 12 to 26 months after surgery. The 15 women and 3 men had a mean age of 54 years (range, 38-72 years). The talar-first metatarsal and talonavicular coverage angles were measured before and after surgery on the anteroposterior weightbearing radiographs. The mean preoperative talar-first metatarsal and talonavicular coverage angles were 21 degrees (range, 3-45 degrees) and 34 degrees (range, 0-55 degrees), respectively. The mean postoperative values for these angles were 8.5 degrees (range, 0-35 degrees) and 21 degrees (range, -30-45 degrees), respectively. The mean talar-first metatarsal angle decreased from 21 degrees to 8.5 degrees, a mean improvement of 12.5 degrees, and the mean talonavicular coverage angle decreased from 34 degrees to 21 degrees, a mean improvement of 13 degrees. On the lateral weightbearing radiographs, the talar-first metatarsal angle and the distance from the medial cuneiform to the floor were measured before and after surgery. The mean preoperative values were -22 degrees (range, -10 to -40 degrees) and 9 mm (range, 1-19 mm), respectively. The mean postoperative values were -9 degrees (range, +5 to -25 degrees) and 16 mm (range, 10-28 mm), respectively. The mean talar-first metatarsal angle decreased from -22 to -9 degrees (a mean improvement of 13 degrees), and the distance from the medial cuneiform to the floor increased from 9 to 16 mm (a mean improvement of 7 mm). We conclude that the use of a combined medial displacement osteotomy of the calcaneus with a tendon transfer for treatment of posterior tibial tendon insufficiency may offset the inherent weakness of the flexor digitorum longus transfer by reducing the antagonistic deforming force of heel valgus.

Appropriate management for the diabetic patient with a fracture or sprain depends on recognition of "at-risk" factors. For patients with stable, minimally displaced injuries, conservative modalities (prolonged immobilization and non-weight-bearing) are sufficient. For patients with unstable or displaced fracture-dislocations, and whose general condition does not contraindicate surgery, open reduction and internal fixation, at times combined with external fixation, is recommended. Initial aggressive management can avoid or minimize the disastrous sequelae of a destructive neuroarthropathic process and can effect a biomechanically sound plantigrade, braceable, and shoeable lower extremity.

Anatomic variations in tibial nerve branches may help explain discrepancies between clinical examination and electrophysiologic tests as to the location of neuronal lesions. Dissection of 20 cadaveric feet (10 pair) along the course of the tibial nerve and its branches confirmed that it bifurcates within 2 cm of the medio-malleolar-calcaneal axis in 90% (18/20) and that it gives off frequent small branches with its accompanying vascular structures. Unlike other studies, however, we found that 60% had multiple calcaneal branches off the tibial nerve and that 20% evidenced previously undescribed accessory innervation to the abductor hallucis muscle from other than the medial plantar nerve.

Dance movements can be stressful to the body, and the required extreme positions may place physiologic structures at risk for acute, subacute, or chronic injury. The authors designed a screening program, conducted by a team of physical therapists, orthopedists, and dance instructors, to evaluate dancers for musculoskeletal problems and to make recommendations that would improve movement compensation, strength, endurance, and mobility.

The results following revision tarsal tunnel release in 12 patients (13 feet), including three men and nine women aged 28 to 66 years, are presented. The indication for surgery was incapacitating focal pain, associated with paresthesias and hyperesthesias, refractory to nonoperative treatment modalities. Electrodiagnostic studies were abnormal in nine and normal in four cases. Revision surgery was performed a mean 3.5 years (range 1-10 years) after the initial tarsal tunnel release. Epineurolysis was performed in nine of the 13 cases where the nerve was encased in a scar. An insufficient previous distal release was identified in nine of the 13 cases. Wound infection occurred in two patients, one of whom ultimately underwent a below the knee amputation. With the exception of this patient, all patients were evaluated a mean 31 months (range 12-59 months) after the revision surgery. Three groups of patients were identified based on similarities in presentation, intraoperative findings, and clinical outcome. The first group (four feet), characterized by encasement of the tibial nerve in scar and an adequate distal release at the previous tarsal tunnel surgery, did poorly. The second group (five feet), with both scarring of the tibial nerve and an inadequate prior distal release, had somewhat mixed results, but overall were improved. The final group (four feet), who had no significant tibial nerve scarring but had had an inadequate prior distal release, did well. Clinical history and physical examination were more helpful than electrodiagnostic studies in determining the extent and location of the tibial nerve irritation following previous tarsal tunnel release surgery.

Nerve entrapment, neuropathy, and nerve dysfunction in the legs, ankles, and feet of athletes are not uncommon conditions. Frequently, the conditions are overlooked as the more obvious musculoskeletal injury draws the physician's attention. Typically, with conservative treatment, including an occasional injection of local anesthetic with and without corticosteroid, resolution is achieved. Rarely, symptoms are severe and diffuse enough to require administration of a tricyclic antidepressant medication to decrease the nerve irritability. In cases that fail to respond to conservative treatment and have well-localized neurologic findings, surgery may be indicated. During surgery, the nerve should be minimally manipulated. The surrounding veins, arteries, and fat should be relatively undisturbed. Critical to understanding and treating these problems is a thorough knowledge of the peripheral neuroanatomy.

A local entrapment neuropathy has been proposed as one of the etiologies of heel pain, but it has never been documented by electrodiagnostic studies. Primary symptoms in patients suspected of having a neurologic basis for their heel pain include neuritic medial heel pain and radiation either proximally or distally. On physical examination, all patients in our series had reproduction of their symptomatology with palpation over the proximal aspect of the abductor hallucis and/or the origin of the plantar fascia from the medial tubercle of the calcaneus. Twenty-seven patients (20 women and seven men; average age 49) with these clinical characteristics were examined by electromyography and motor/sensory/mixed nerve conduction studies. Bilateral heel signs and symptoms were present in 11 patients. Ten of the patients had a significant history of back pain with referral to the legs. In 23 of the 38 symptomatic heels, abnormalities were identified in the lateral and/or the medial plantar nerves. The number of abnormal values per heel ranged from one to four, with a mean of 2.1. The most common finding was involvement of the medial nerve (57%). Thirty percent of the heels had isolated findings in the lateral plantar nerve and 13% had abnormalities in both plantar nerves. Two patients had electrophysiologic evidence of active S1 radiculopathy, with ipsilateral evidence of plantar nerve entrapment suggesting a "double crush" syndrome. The results of this study support the presence of abnormalities of plantar nerve function in a selected group of patients with neuritic heel pain.

Lower extremity problems, specifically in the feet and ankles, are common in dancers. This is not surprising considering the repetitive and acute stresses applied to lower limbs during this rigorous performing arts activity. When evaluating a dancer with lower extremity complaints, the nature of these demands must be appreciated. In addition to routine physical examination, static and dynamic biomechanical evaluation is paramount to analysis and treatment of leg, foot, and ankle conditions. Although a particular problem, such as painful bunion, may seem localized, it is often related to other factors, such as weak posterior tibial tendon, tight heel cords, or inadequate or forced turnout. It is incumbent on the physician to treat the specific area and, more importantly, to discover contributing factors that may be corrected by changes in technique or training. The physician caring for dancers should communicate with the instructor, physical therapist, or choreographer to facilitate the process. An overview of some common maladies and their characteristics findings are presented.

In brief "Shin splints" is a catchall term for any kind persistent exercise-related lower leg pain with no obvious cause. Such pain can originate from a number of conditions, such as medial tibial stress syndrome, stress fracture, compartment syndrome, vascular pathology, nerve entrapment, and others. A methodical work-up designed to detect problems in all anatomic structures from bone to skin will narrow the possibilities and lay the basis for appropriate treatment.