Syndesmosis injuries occur when there is a disruption of the distal attachment of the tibia and fibula. These injuries occur commonly (up to 18% of ankle sprains), and the incidence increases in the setting of athletic activity. Recognition of these injuries is key to preventing long-term morbidity. Diagnosis and treatment of these injuries requires a thorough understanding of the normal anatomy and the role it plays in the stability of the ankle. A complete history and physical examination is of paramount importance. Patients usually experience an external rotation mechanism of injury. Key physical exam features include detailed documentation about areas of focal tenderness (syndesmosis and deltoid) and provocative maneuvers such as the external rotation stress test. Imaging workup in all cases should consist of radiographs with the physiologic stress of weight bearing. If these images are inconclusive, then further imaging with external rotation stress testing or magnetic resonance imaging are warranted. Nonoperative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. This consists of stabilizing the syndesmosis with either trans-syndesmotic screw or tightrope fixation. In the setting of a concomitant Weber B or C fracture, the fibula is anatomically reduced and stabilized with a standard plate and screw construct. Proximal fibular fractures, as seen in the Maisonneuve fracture pattern, are not repaired operatively. Recent interest is moving toward repair of the deltoid ligament, which may provide increased stability, especially in rehabilitation protocols that involve early weight bearing. Rehabilitation is focused on allowing patients to return to their pre-injury activities as quickly and safely as possible. Protocols initially focus on controlling swelling and recovery from surgery. The protocols then progress to restoration of motion, early protected weight bearing, restoration of strength, and eventually a functional progression back to desired activities.

Background: We report data on the largest cohort to date of patients who sustained a ligamentous Lisfranc injury during sport. To date, the prevalence of concurrent intercuneiform ligament injuries in the competitive athlete with subtle Lisfranc instability has not been reported. Methods: Eighty-two patients (64 males, 18 females) sustained an unstable Lisfranc injury (49 left, 33 right) and met inclusion criteria. Injuries were classified as traditional dislocation (TRAD, first to second TMT ligament tear), medial column dislocation (MCD, second TMT, and medial-middle cuneiform ligament tear), or proximal extension dislocation (PE, first, second, and medial-middle cuneiform ligament tear) and the injury pattern confirmed at surgery. All athletes underwent open reduction with internal fixation (ORIF) of each unstable midfoot segment. Fisher exact tests and 2-tailed t tests were used to analyze statistical significance according to injury pattern, sport, gender difference, hindfoot angle alignment, and injured side ( P < .05). Results: Average age of athletes was 21.0 ± 5.3 years old (range 12-40), and return to sports was 7.5 ± 2.1 months. Injury distribution was as follows: TRAD (n = 40), MCD (n = 17), and PE (n = 23). MCD trended toward a longer return to sport (8.4 ± 3.3 months, P = .074). Football was the most common sport at time of injury (n = 48). Wakeboard athletes (n = 5) were older (31.4 ± 3.2, P = .0002), and MCD tears were more prevalent among them ( P = .061). Basketball (n = 13) players were significantly younger (19.1 ± 2.5 years, P = .028) and returned to sports quicker (5.2 ± 0.7, P = .0002). Return to sport data indicated a typical population for athletes with Lisfranc injury in these sports. Conclusion: Proximal extension disruption (intercuneiform ligament tear) occurred in 50% of these low-energy Lisfranc athletic injuries. MCD and PE may be more prevalent than previously understood. This is the first study to document the extent, pattern, and prevalence of associated intercuneiform ligament tears in the competitive athlete with a low-energy subtle, unstable Lisfranc injury. Level of Evidence: Level IV, retrospective case series.

Level III, cohort study.

In athletes, conservative treatment of proximal fourth metatarsal stress fractures can result in deconditioning, delayed return to sport, disability, and recurrence of the fracture. Although nonoperative care has been advocated for such an injury, internal fixation can provide more rapid and reliable healing in athletes. However, until now, bone grafting with or without dorsal plate fixation was the only surgical option. We have developed a means of inserting a 4.5-mm cannulated intramedullary screw as a safe approach that can promote complete healing and timely return to sport. This fixation shows healing similar to intramedullary screw fixation of the fifth metatarsal Jones fracture. We term this the ''fourth metatarsal 'Jones' fracture'' and treat it in a similar manner as the fifth. The senior author has treated 8 athletes surgically with this approach for chronic nonunion of fourth metatarsal stress fractures. Clinical and radiographic assessments up to 10 years after surgery show 100% healing without fourth tarsometatarsal joint degeneration. Subjective reporting indicates 100% healing in as little as 6 weeks. No postoperative complications (screw failure, persistent sclerosis, refractures, or arthritis at the tarsometatarsal joint) have occurred. This technique results in reliable, effective, fast healing of chronic fourth metatarsal stress fracture sites in competitive athletes. However, the technique is technically demanding.The concept of a stress fracture was first described by the Prussian military physician, Breithaupt, in 1855. 1 Since then, numerous studies have highlighted the relatively high incidence of stress fractures in competitive athletes and others who undergo rigorous training, such as military recruits at boot camps.Stress fractures of the metatarsals are the second most common type of fracture that athletes sustain, 2 accounting for approximately 10% of all overuse injuries. 3 Some reports say this is as high as 28%. 4 Athletes who repeatedly perform high levels of running and jumping activities are particularly predisposed to metatarsal stress fractures, as the injury is associated with a marked increase in loading forces applied to the foot. 5 Despite this, the frequency with which such fractures occur is not well documented. 5 Chuckpaiwong et al 2 reported that 10% to 20% of all stress fractures in athletes are metatarsal fractures, which corroborates earlier studies. [6][7][8][9] Although all stress fractures are precipitated by excessive force or strain without adequate rest periods, the etiology for fourth metatarsal stress fractures remains unclear. 10-12 Studies have documented numerous factors that may predispose an athlete to stress fractures, 5,10,11 but the primary cause seems to be related to muscle fatigue transmitting excessive forces to the underlying bone. 10 Strength gains in bone (bone remodeling) lag behind strength gains in muscle. 13 Regional vascularity may also contribute to the pathomechanics, as the fourth metatarsal's nutrient artery is compressed during weigh...

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