Tendinopathies of the Foot and Ankle.

Tendinopathies of the foot and ankle, including posterior tibial, peroneal, and tibialis anterior, are commonly overlooked by primary care physicians. The posterior tibial tendon is the main dynamic stabilizing muscle of the medial longitudinal arch. Patients who have posterior tibial tendinopathy present with medial ankle pain, pes planovalgus deformity, and a positive too many toes sign. Nonoperative treatment options include support for the medial longitudinal arch and physical therapy focusing on eccentric exercises. Surgical treatment is considered for patients who do not respond to nonoperative treatments after three to six months and is based on the specific stage of tendinopathy. Peroneal tendon disorders are commonly mistaken for or occur concomitantly with lateral ankle sprains. Varus hindfoot is a known risk factor for peroneal tendinopathy. Treatments include immobilization, laterally posted orthotics, and physical therapy for progressive tendon loading. Tibialis anterior tendinopathy presents as anterior ankle and medial midfoot pain and can be diagnosed with a positive tibialis anterior passive stretch test. Initial treatment includes immobilization followed by physical therapy. Surgical debridement can be considered if nonoperative treatment is ineffective.

Nonoperative Treatment of Patellar Instability.

The treatment of patellar instability is challenging and typically begins with nonoperative methods. Clinical decisions are made on an individual basis and may vary according to a number of factors. First-time patellar dislocations most commonly occur during sports participation. Initial evaluation, including patient history, physical examination, and appropriate imaging, determines care. Although nonoperative treatment consists primarily of regressive immobilization and physical therapy, there is little evidence to support particular protocols for either. Factors that may contraindicate nonoperative treatment include osteochondral lesions and recurrent instability. In these cases, surgery is considered. Reported recurrence rates after nonoperative treatment of acute patellar dislocation are 15% to 44%. Well-designed studies are needed to determine not only the outcomes of nonoperative versus surgical treatment of patellar instability but also the risk factors that may predict poor outcomes in either group.

Ankle Morel-Lavallée lesion in a recreational racquetball player.

Unilateral ankle swelling is a relatively common presenting complaint among athletes and non-athletes. Due to its broad differential diagnosis, a comprehensive evaluation beginning with history and physical examination are recommended. Imaging including plain radiography, ultrasound (US), and magnetic resonance imaging (MRI) are preferred modalities. Aspiration of a local fluctuating mass may help with the diagnosis and management of some of these conditions. Morel-Lavallée lesion (MLL) is a rare condition consisting of a closed degloving injury caused by forces of pressure and shear stress between the subcutaneous tissue and the superficial fascia or bone. Most commonly MLL is found over the greater trochanter and sacrum, but in rare cases can be found in other regions of the body. In most cases concurrent severe injury mechanisms like motor vehicle accidents are present. MLL due to sports injuries are rare. Depending on the stage and type of MLL, therapeutic strategies may vary from compression wraps and aspiration to surgical evacuation. We present a case of a 65-year-old gentleman with ankle MLL with no known history of a major trauma as a result of playing racquetball 6 weeks earlier. Physical examination revealed a transilluminating lesion in the lateral aspect of his left ankle which was successfully treated with one time aspiration of a serosanguinous fluid. We propose less aggressive methods for management of low-impact sports-related MLL.

Morel-Lavallée Lesion in Sports.

Posttraumatic soft tissue swelling is a relatively common presenting complaint among athletes. Due to its broad differential diagnosis, a comprehensive evaluation beginning with history and physical examination are recommended. Imaging including radiography, ultrasound, and magnetic resonance imaging (MRI) are preferred modalities. Aspiration of a fluid collection, preferably under ultrasound guidance, may help with the diagnosis and management of some of these conditions. Morel-Lavallée lesion (MLL) is an uncommon condition consisting of a closed degloving injury caused by forces that create pressure and shear stress between the subcutaneous tissue and the superficial fascia or bone. Most commonly, MLL is found over the greater trochanter and sacrum, but in rare cases can be found in other regions of the body. In most cases, concurrent severe injury mechanisms are present. Sports-related MLL are rare and underreported. Depending on the stage and type of MLL, therapeutic strategies may vary from compression wraps and aspiration to surgical evacuation.