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FOOT AND ANKLE INJURIES IN ATHLETES
BY- SUNIL
CPRS, JMI
drsuniljmi@gmail.com
 Foot and ankle injuries are very common among
athletes.
 Increased competition means professional athletes
and dedicate...
Mobile Joints of the foot and ankle:
Ankle joint
Sub-talar joint
Talo-navicular joint
Metatarso-phalangeal (MTP) joints.
POTT'S FRACTURE
• A fracture affecting one or more of the malleoli
(lateral, medial, posterior) is known as a Pott's fract...
 The management of Pott's fractures requires
restoration of the normal anatomy between the
superior surface of the talus ...
Osteochondral lesions of the talar dome
 It is not uncommon for osteochondral fractures of the talar
dome to occur in ass...
 The patient often gives a history of progressing well
following a sprain but then developing symptoms of
increasing pain...
 Chronic grade I and II lesions should be treated
conservatively.
 The patient should avoid activities that cause pain a...
Evalsion fracture of the base of the 5th
metatarsal
 Inversion injury may result in an
evalsion fracture of the base of
t...
 Fracture of the base of the
fifth metatarsal may be
treated conservatively with
immobilization for pain
relief followed ...
Calcaneal stress fractures
 Calcaneal stress
fractures22 are the second
most common tarsal stress
fracture.
 They occur ...
Clinical features
 Patients give a history of insidious onset of heel
pain that is aggravated by weight- bearing
activiti...
Investigations
 Plain X-ray may show a typical sclerotic
appearance on the lateral X-ray, parallel to the
posterior margi...
Treatment
 Treatment involves a reduction in activity and for
those with marked pain a short period ofnon-
weightbearing ...
Stress fracture of the navicular
 Stress fractures of the
navicular are among the most
common stress fractures Seen
in th...
Cause
 A comhination of overuse and training errors plays
a significant role in the development of navicular
stress fract...
Clinical features
 The onset of symptoms is usually insidious, consisting
of a poorly localized midfoot ache associated w...
Stress fractures of the metatarsals
 Stress fractures of the metatarsals in most series
have been shown to be the second ...
Clinical features
 The patient with a metatarsal stress fracture
complain of forefoot pain aggravated by activity
such as...
Investigation
 X-rays reveal a radiolucent line or periosteal
thickening if the fracture has been present for a few
weeks...
Treatment
 The management of most stress fractures is straightforward, involving
rest from weight-bearing aggravating act...
TARSAL TUNNEL SYNDROME
 Tarsal tunnel syndrome occurs as a result of
entraptment of the posterior tibial nerve in the
tar...
Causes
In approximately 50% of cases the cause of tarsal tunnel
syndrome is idiopathic . It may also occur as a result of ...
Clinical features
 Poorly defined burning, tingling or numb sensation on the
plantar aspect of the foot, often radiating ...
 A ganglion or cyst may be palpable in the tendon
sheaths around the medial ankle.
 Tenderness in the region of the tars...
Treatment
• Conservative treatment should be attempted in those
with either an idiopathic or biomechanical cause.
•Treatme...
PERONEAL TENDINOPATHY
 The most common overuse injury causing lateral ankle pain is peroneal
tendinopathy.
 The peroneus...
Causes
Peroneal tendinopathy may occur as a result of
an acute ankle inversion injury or secondary to an overuse injury.
C...
 It has been suggested that peroneal tendinopathy may be due
to the excessive pulley action of, and abrupt change in
dire...
 local tenderness over the peroneal tendons on
examination, sometimes associated with swelling
and crepitus (a true parat...
 Treatment
 Treatment initially involves settling the pain with rest from
aggravating activities, analgesic medication i...
SINUS TARSI SYNDROME
 The sinus tarsi is a small osseous canal running from an opening anterior and
interior to the later...
Causes
 Although injury to the sinus tarsi may result from chronic overuse
secondary to poor biomechanics (especially exc...
Clinical features
The symptoms of sinus tarsi syndrome include:
• pain which may be poorly localized but is most often cen...
TREATMENT
 Conservative management includes relative rest, ice.
 NSAID and electrotherapeutic modalities. Mobilization o...
MORTON’S NEUROMA
 The most common presentation of an interdigital (Morton's) neuroma is pain
located between the third an...
Anatomy and Pathophysiology
 The "classic" Morton neuroma is a lesion of the common
digital nerve that supplies the third...
Diagnosis-
 The diagnosis of a Morton neuroma is clinical. There are no useful
radiographic or electrodiagnostic tests.
...
HALLUX RIGIDUS
 The term hallux rigidus describes a limited arthrosis
of the first MTP joint. The first MTP joint and the...
 Hallux rigidus is an arthritic condition limited to the dorsal
aspect of the first MTP joint. Also known as a dorsal bun...
CLASSIFICATION
METATARSALGIA
 Metatarsalgia describes an assortment of
conditions that cause plantar pain in the
forefoot.
 Metatarsalg...
 Inflammatory arthritis, trauma, or neuromuscular disorders can
cause imbalances of flexion and extension forces around t...
It is common in following factors:
• Pesplantaris
• Pescavus
• Muscular weakness in the toe flexors due to
inactivity or i...
Treatment
1. Painful stage: warm water bath, contrast bath
TENS, ultrasonic, diapulse or hot packs.
2. When associated wit...
FLEXOR HALLUCIS LONGUS
TENDINOPATHY
 The flexor hallucis longus tendon flexes the big toe
and assists in plantarflexion o...
Causes
 Flexor hallucis longus tendinopathy may occur secondary to
overuse, a stenosing tenosynovitis, pseudocyst or tend...
Clinical features
 Pain on toe-off or forefoot weight-bearing(e.g. rising in ballet), maximal
over the posteromedial aspe...
TARSAL COALITION
 Management may require orthotic therapy.
Surgical excision with severe symptoms or after
failure of conservative therapy...
THANK YOU
 CONTACT OR EMAIL AT
 drsuniljmi@gmail.com
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
Ankle injuries by sunil
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common injuries of foot and ankle in sports and common during activity, overview of foot and ankle injuries.

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  1. 1. FOOT AND ANKLE INJURIES IN ATHLETES BY- SUNIL CPRS, JMI drsuniljmi@gmail.com
  2. 2.  Foot and ankle injuries are very common among athletes.  Increased competition means professional athletes and dedicated amateur athletes push themselves to their limits, so there are more foot and ankle injuries than ever.
  3. 3. Mobile Joints of the foot and ankle: Ankle joint Sub-talar joint Talo-navicular joint Metatarso-phalangeal (MTP) joints.
  4. 4. POTT'S FRACTURE • A fracture affecting one or more of the malleoli (lateral, medial, posterior) is known as a Pott's fracture. • It can be difficult to distinguish a fracture from a moderate-to- severe ligament sprain as both condilions may result from similar mechanisms of injury and cause severe pain and inability to weight- bear. • Careful and gentle palpation can generally localize the greatest site of tenderness to either the malleoli (fracture) or just distal to the ligament attachment (sprain).
  5. 5.  The management of Pott's fractures requires restoration of the normal anatomy between the superior surface of the talus and the ankle mortise (inferior margin of the tibia and fibula).  If this relationship has been disrupted, internal fixation is almost always required.
  6. 6. Osteochondral lesions of the talar dome  It is not uncommon for osteochondral fractures of the talar dome to occur in association with ankle sprains, particularly when there is a compressive component to the inversion injury, such as when landing from a jump.  The talar dome is compressed by the tibial plafond, causing damage to the osteochondral surface the lesions occur most commonly in the superome dial corner of the talar dome, less commonly on the superolateral part.
  7. 7.  The patient often gives a history of progressing well following a sprain but then developing symptoms of increasing pain and swelling, stiffness and perhaps catching locking as activity is increased.  Reduced range of motion is often a prominent symptom.  Examination with the patient's foot plantarflexed at 45degree to rotate the talus out of the ankle mortise reveal tenderness of the dome of the talus.
  8. 8.  Chronic grade I and II lesions should be treated conservatively.  The patient should avoid activities that cause pain and be encouraged to pedal an exercise bicycle with low resistance.  If there is pain, or symptoms of clicking, locking or giving persist beyond two to three months of this conservative management, ankle arthroscopy is indicated.  A grade IIa, III or IV lesion also requires arthroscopic.
  9. 9. Evalsion fracture of the base of the 5th metatarsal  Inversion injury may result in an evalsion fracture of the base of the 5th metatarsal.  This fracture result from evalsion of the peroneus brevis tendon from its attachment to the base of the 5th metatarsal.  X-rays should be examined closely. Avulsion frature is characterized by its involvement of the joint surface of the base of the fifth metatarsal.
  10. 10.  Fracture of the base of the fifth metatarsal may be treated conservatively with immobilization for pain relief followed after one to two weeks by protected mobilization and rehabilitation.
  11. 11. Calcaneal stress fractures  Calcaneal stress fractures22 are the second most common tarsal stress fracture.  They occur most commonly at two main sites: the upper posterior margin of the os calcis or adjacent to the medial tuberosity, at the point where calcaneal spurs occur. occur in runners, ballet dancers and jumpers
  12. 12. Clinical features  Patients give a history of insidious onset of heel pain that is aggravated by weight- bearing activities,especially running.  Examination reveals localized tenderness over the medial or lateral aspects of the posterior calcaneus and pain that is produced by squeezing the posterior aspect of the calcaneus from both sides Simultaneously.
  13. 13. Investigations  Plain X-ray may show a typical sclerotic appearance on the lateral X-ray, parallel to the posterior margin of the calcaneus
  14. 14. Treatment  Treatment involves a reduction in activity and for those with marked pain a short period ofnon- weightbearing may be required. Once pain-free, a program of gradually increased weight-bearing can occur.  Stretching of the calf muscles and plantar fascia, and joint mobilization are important for long-term recovery.  Soft heel pads, in conjunction with orthoses if required, are recommended.
  15. 15. Stress fracture of the navicular  Stress fractures of the navicular are among the most common stress fractures Seen in the athlete, especially in sports that involve sprinting, jumping or hurdling.  The stress fracture commonly occurs in the mi dle third of the navicular bone, a relatively avascular region of the bone.
  16. 16. Cause  A comhination of overuse and training errors plays a significant role in the development of navicular stress fractures.  Although the exact cause ofa navicular stress fracture is not known, it is believed that impingement of the navicular bone occurs between the proximal and distal tarsal bones when the muscles exert compressing and bending forces.
  17. 17. Clinical features  The onset of symptoms is usually insidious, consisting of a poorly localized midfoot ache associated with activity.  The pain typically radiates along the medial aspect of the longitudinal arch or the dorsum of the foot.  The symptoms abate rapidly with rest.
  18. 18. Stress fractures of the metatarsals  Stress fractures of the metatarsals in most series have been shown to be the second most common stress fracture, second to the tibia.  The most common metatarsal stress fracture is at the neck of the second metatarsal.  This occurs in the pronating foot, when the first ray is dorsiflexed, resulting in the second metatarsal being subjected to greater load.
  19. 19. Clinical features  The patient with a metatarsal stress fracture complain of forefoot pain aggravated by activity such as turning or dancing.  The pain is not severe initially but gradually worsens with activity.
  20. 20. Investigation  X-rays reveal a radiolucent line or periosteal thickening if the fracture has been present for a few weeks .  If the X- ray is negative, an isotopic  bone scan or MRI may confirm the diagnosis.
  21. 21. Treatment  The management of most stress fractures is straightforward, involving rest from weight-bearing aggravating activities for approximatly four weeks.  If the patient is required to be on his or her feet excessively, the use of an air cast may be required for one to two weeks until pain settles.  The athlete Should be allowed to recommence activity when he or she does not experience pain when walking and there is no local tenderness at the fracture site.  A graduated exercise program should be instituted to return the athlete to full training and competition.
  22. 22. TARSAL TUNNEL SYNDROME  Tarsal tunnel syndrome occurs as a result of entraptment of the posterior tibial nerve in the tarsal tunnel where the nerve winds around the medial malleolus.  It may also involve only one of its terminal branches distal to the tarsal tunnel.
  23. 23. Causes In approximately 50% of cases the cause of tarsal tunnel syndrome is idiopathic . It may also occur as a result of trauma (e.g. inversion injury to the ankle or overuse associated with excessive pronation. Other less common causes include: • Ganglion  Talonavicular coalition  Varicose veins  Synovial cyst  Lipoma  Accesory muscle- flexor digitorum accessories longus  Tenosynovitis  Fracture of the distal tibia or calcaneus.
  24. 24. Clinical features  Poorly defined burning, tingling or numb sensation on the plantar aspect of the foot, often radiating into the toes.  Pain is usually aggravated by activity and releived by rest.  In some patients the symptoms are worse in bed at night and relieved by getting up and moving or massaging the foot.  Swellings, varicosities or thickenings may be found on examination around the medial ankle or heel.
  25. 25.  A ganglion or cyst may be palpable in the tendon sheaths around the medial ankle.  Tenderness in the region of the tarsal tunnel is common.  Tapping over the posterior tibial nerve ( Tinel's sign) may elicit the patient's pain and occasionally cause fasciculations but this 'classic' sign is not commonly seen.  There may be altered sensation along the arch of the foot.
  26. 26. Treatment • Conservative treatment should be attempted in those with either an idiopathic or biomechanical cause. •Treatment with NSAID and, if required an injection of a corticosteroid agenr into tarsal tunnel may be helpful. If excessive pronation is present, an orthosis should be utilised. •Surgical treatment is required if there is mechanical pressure on the nerve. A decompression of the posterior tibial nerve and its branches should be performed, but only after both the diagnosis and the site of nerve entraptment have been confirmed.
  27. 27. PERONEAL TENDINOPATHY  The most common overuse injury causing lateral ankle pain is peroneal tendinopathy.  The peroneus longus and peroneus brevis tendons cross the ankle joint within a fibro-osseous tunnel, posterior the lateral malleolus.  The peroneus brevis tendon insert into the tuberosity on the lateral aspect of the of the fifth metatarsal. The peroneus longus tendon passes under the plantar surface of the foot to insert into the lateral side of the base of the first metal and medial cuneiform.  The peroneal tendons share a common tendon sheath proximal to the distal tip of the fibula, after which they have their own sheaths.  The peroneal muscles serve as ankle flexors in addition to being the primary evertors of the ankle.
  28. 28. Causes Peroneal tendinopathy may occur as a result of an acute ankle inversion injury or secondary to an overuse injury. Common causes of an overuse injury are: • Excessive eversion of the foot, such as occurs when running on slopes or on cambered surfaces. • Excessive pronation of the foot. • Secondary to tight ankle plantarflexors (most commonly soleus) resulting in excessive load on lateral muscles. • Excessive action on the peroneals (e.g. dancing, football, volleyball).
  29. 29.  It has been suggested that peroneal tendinopathy may be due to the excessive pulley action of, and abrupt change in direction of, the peroneal tendons at the lateral malleolus.  There are three main sites of peroneal tendinopathy: 1. posterior to the lateral malleolus 2. at the peroneal trochlea 3. at the plantar surface of the cuboid. Clinical features The athlete commonly presents with:  lateral ankle or heel pain and swelling which is aggravated by activity and relieved by rest
  30. 30.  local tenderness over the peroneal tendons on examination, sometimes associated with swelling and crepitus (a true paratenonitis) • painful passive inversion and resisted eversion, although in some cases eccentric contraction may be required to reproduce the pain  a possible associated calf muscle tightness  excessive subtalar pronation or stiffness of the subtalar or midtarsal joints.
  31. 31.  Treatment  Treatment initially involves settling the pain with rest from aggravating activities, analgesic medication if needed and soft tissue therapy.  Stretching in conjunction with mobilization of the subtalar and midtarsal joints may be helpful. Footwear should be assessed and the use of lateral heel wedges or orthoses may be required to correct biomechanical abnormalities.  Strengthening exercises should include resisted eversion (e.g. rubber tubing, rotagym), especially in plantarflexion as this position maximally engages the peroneal muscles.  In severe cases, surgery may be required, which may involve a synovectomy, tendon debridement or repair
  32. 32. SINUS TARSI SYNDROME  The sinus tarsi is a small osseous canal running from an opening anterior and interior to the lateral malleolus in a posteromedial direction to a point posterior to the medial malleolus.  The interosseus ligament occupies the sinus tarsi and divides it into an anterior portion, which is part of the talocalcaneonavicular joint, and a posterior part, which represents the subtalar joint.  It is lined by a synovial membrane and in addition to ligament it contains small blood vessels, fat and connective tissue.
  33. 33. Causes  Although injury to the sinus tarsi may result from chronic overuse secondary to poor biomechanics (especially excessive pronation), approximately 70%of all patients with sinus tarsi syndrome have single or repeated inversion injury to the ankle may also occur after repeated forced eversion of the ankle, such as high jump take off.  The sinus tarsi contains abundant synovial tissue that is prone to synovitis and inflammation when injured. An influx of inflammatory cells may result in the development of a low-grade inflammatory synovitis.  Other causes of sinus tarsi syndrome may include chronic inflammation in conditions such as gout, inflammatory arthropathies and osteoarthritis.
  34. 34. Clinical features The symptoms of sinus tarsi syndrome include: • pain which may be poorly localized but is most often centered just anterior to the lateral malleolus • pain that is often more severe in the morning and may diminish with exercise • pain that may be exacerbated by running on curve in the direction of the affected anklepatientmayalso complain of ankle and foot stiffness, a feeling of instability of the hind f and occasionally of weakness • difficulty walking on uneven ground • full range of pain-free ankle movement on examination but the subtalar joint may be stiff. • pain on forced passive eversion of the subtal joint; forced passive inversion may also be painful due to damage to the subtalar Iigam • tenderness of the lateral aspect of the ankle a“ the opening of the sinus tarsi and occasionall also over the anterior talofibular ligament; th may be minor localized swelling.
  35. 35. TREATMENT  Conservative management includes relative rest, ice.  NSAID and electrotherapeutic modalities. Mobilization of the subtalar joint is essential. Rehabilitation involves proprioception and strenght to the anterior talofibular ligament may promote synovial thickening and exudation.
  36. 36. MORTON’S NEUROMA  The most common presentation of an interdigital (Morton's) neuroma is pain located between the third and the fourth metatarsal heads (in the third interspace) that radiates into the third and fourth toes.  Patients often describe this as a burning pain that intermittently "moves around." Usually, the pain is exacerbated by tight-fitting and/or high- heeled shoes or increased activity on the foot. The pain is often relieved by removing the shoe and rubbing the forefoot. Occasionally, these symptoms occur in the second interspace with radiation into the second and third toes. Seldom do neuromas occur in both interspaces simultaneously.
  37. 37. Anatomy and Pathophysiology  The "classic" Morton neuroma is a lesion of the common digital nerve that supplies the third and fourth toes. This is not a true neuroma, but rather an irritated perineural fibrosis where the nerve passes plantar to the transverse metatarsal ligament.  It has been speculated that because the common digital nerve to the third interspace has branches from the medial and lateral plantar nerves (and thus increased thickness) that this accounts for the third interspace being the one most commonly involved.
  38. 38. Diagnosis-  The diagnosis of a Morton neuroma is clinical. There are no useful radiographic or electrodiagnostic tests.  Serial examinations may be necessary to establish the correct diagnosis. Examination-  Direct palpation and palpation with a stripping motion of the interspace will usually reproduce the patient's pain. This maneuver, called "Mulder's sign,“ often reproducing the third (or second) interspace. The examiner places the index finger and thumb proximal to the metatarsal heads in the interspace, and while pushing firmly into the interspace, "strips" distally to the end of the interspace, often feeling a click or pop that elicits pain (Mulder's click) a clicking or popping sensation and pain.
  39. 39. HALLUX RIGIDUS  The term hallux rigidus describes a limited arthrosis of the first MTP joint. The first MTP joint and the great toe (hallux) provide significant weight transfer from the foot to the ground as well as active push-off. An intact first MTP joint implies a complete and pain-free ROM,and full intrinsic and extrinsic motor strength.
  40. 40.  Hallux rigidus is an arthritic condition limited to the dorsal aspect of the first MTP joint. Also known as a dorsal bunion or hallux limitus, the condition is most commonly idiopathic (but may be associated with posttraumatic OCD of the metatarsal head) and is characterized by an extensive dorsal osteophyte and dorsal third cartilage damage and loss. An associated synovitis may further aggravate the limited and painful ROM.  A foot with increased first ray ROM and increased pronation may be predisposed to the condition.  Excessive flexibility of the shoe forefoot increases the potential for hyperdorsiflexion of the hallux MTP joint  For this reason, this type of shoewear should be avoided.
  41. 41. CLASSIFICATION
  42. 42. METATARSALGIA  Metatarsalgia describes an assortment of conditions that cause plantar pain in the forefoot.  Metatarsalgia is best characterized by pain under the metatarsal heads exacerbated by weight-bearing. The fatty cushion of the forefoot is a highly specialized tissue.  When weight is applied, hydrostatic pressure builds within the compartments, dampening and dispersing forces on the plantar skin. This mechanism acts as a cushion, protecting the area from potentially damaging focal concentrations in pressure arising.
  43. 43.  Inflammatory arthritis, trauma, or neuromuscular disorders can cause imbalances of flexion and extension forces around the small joints of the toes.  Toe deformity is a consequence of this imbalance. Hyperextension at the MTP joint is a common component of these deformities and draws the fatty cushion of the forefoot distally and dorsally with the proximal phalanx . When this occurs, the weight transferred through the metatarsal heads is applied to the thinner proximal skin without the intervening fatty cushion.
  44. 44. It is common in following factors: • Pesplantaris • Pescavus • Muscular weakness in the toe flexors due to inactivity or immobilization • Wearing high heels • Tightness of plantar aponeurosis
  45. 45. Treatment 1. Painful stage: warm water bath, contrast bath TENS, ultrasonic, diapulse or hot packs. 2. When associated with swelling : suitable cryotherapy with leg in elevation. 3. Speedy ankle and toe movements to reduce oedema and to improve circulation. 4. Faradism under pressure (elastic bandage) with leg in elevation. 5. Faradic foot bath synchronised with voluntary intrinsic exercise. 6. Gradual re-education of walking with appropriate shoe wedge, pad or metatarsal bar.
  46. 46. FLEXOR HALLUCIS LONGUS TENDINOPATHY  The flexor hallucis longus tendon flexes the big toe and assists in plantarflexion of the ankle.  It passes posterior to the medial malleolus, and runs between the two sesamoid bones to insert into the base of the distal phalanx of the big toe.
  47. 47. Causes  Flexor hallucis longus tendinopathy may occur secondary to overuse, a stenosing tenosynovitis, pseudocyst or tendon tear.  A common cause is overuse in a ballet dancer, as dancers repetitively go from flat foot stance to the en pointe position, when extreme plantarflexion is required.  Wearing shoes that are too big and require the athlete to 'toe- grip' may also result in flexor hallucis longus tendinopathy.
  48. 48. Clinical features  Pain on toe-off or forefoot weight-bearing(e.g. rising in ballet), maximal over the posteromedial aspect of the calcaneus around the sustentaculum tali.  Pain may be aggravated by resisted flexion of the first toe or stretch into full dorsiflexion of the hallux.  In more severe cases, there may be 'triggering‘ of the first toe, both with rising onto the balls of the foot (e.g. in ballet) and in lowering from this position. Triggering occurs when the foot is placed in plantarflexion and the athlete, unable to flex the hallux, but then with forcible active contraction of the flexor halluds longus, is able to extend the interphalangeal or metatarsophalangeal joints of the toe.  A snap or pop occurs in the posteromedial aspect of the ankle when this happens. Subsequent passive flexion or extension of the interphalangeal joint produces a painless snap posterior to the medial malleolus.
  49. 49. TARSAL COALITION
  50. 50.  Management may require orthotic therapy. Surgical excision with severe symptoms or after failure of conservative therapy. The cartilaginous bar may recur after surgery.
  51. 51. THANK YOU  CONTACT OR EMAIL AT  drsuniljmi@gmail.com
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common injuries of foot and ankle in sports and common during activity, overview of foot and ankle injuries.

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