A clinical review published by the American Osteopathic Association has issued a timely warning to the medical community: when you diagnose foot and ankle injuries, it makes sense to tread carefully.
According to the study, which was published by the journal of the AOA last month, the misdiagnosis of six common foot and ankle injuries – lateral talar process fractures, os trigonum injuries, Lisfranc injuries, turf toe, navicular stress fractures and syndesmotic injuries – often results in poor long-term patient outcomes, including arthritis and disability.
As the study points out, foot and ankle trauma is a very common and they can have severe long-term effects on the sufferer, with the potential to impact upon morbidity rates and long-term disability of elite athletes.
How is this so? It all lies in the diagnosis stage, where problems can be underestimated or missed completely. A lot of clinical diagnoses are described in the report as ‘vague and at times difficult to detect with plain radiographs’, and recommend that physicians adopt a ‘high level of suspicion’ to prevent injuries developing into long-term issues.
Let’s take a look at the six injuries discussed in the report:
Lateral talar process fractures
Otherwise known as ‘Snowboarder’s fracture’, this particular fracture is caused by axial loading with forced ankle dorsiflexion. Due to the nature of the injury, it can be frequently misdiagnosed as a severe ankle sprain, and treated as such. However, if left untreated, lateral talar process fractures have a high possibility of triggering subalar osteoarthritis, which can lead to severe pain and disability in later life.
Os trigonum injuries
The os trigonum is an accessory bone which sometimes develops behind the ankle bone when an area of bone refuses to fuse with the main area and develops on its own, occurring in five to ten percent of the population. Repetitive plantar flexion motion is the usual cause of injury, which means it can often be mistaken for an Achilles tendon or flexor hallucis longus injury. If left untreated, sufferers could be forced into compensating by rotating the hindfoot and ankle into a more comfortable position, which increases the risk of peroneal tendinitis, ankle sprains and sinus tarsi syndrome.
Otherwise known as the tarsometatarsal complex, the Lisfranc joint is the transition between the midfoot and the forefoot. The problem in diagnosis is that it appears to be very difficult to pin down with a simple radiograph.
A sprain to the ligaments around the joint of the big toe, a misdiagnosis of turf toe could result in long-term pain, stiffness, instability, deformity, and the development of joint arthritis.
Navicular stress fractures
A medial tarsal bone, the navicular can become fractured after being subjected to repeated submaximal stresses. As Dr Justin Lee, Consultant Radiologist at the Fortius Clinic, explains: “About a third of fractures are navicular stress fractures, common in ballet dancers and footballers, as well as sprinters. They are hugely undiagnosed and it often takes seven months between the injury and its correct diagnosis, plus about four months of treatment, as a result the player is out of their sport for about a year.”
The symptoms can be vague and non-specific which can also often lead to a misdiagnosis. An untreated navicular stress fracture can lead to chronic pain and disability in later life, as well as non-union of joints.
Syndesmotic injuries are common amongst the sporting community, particularly in contact sports. The ankle syndesmosis is composed of a multitude of ligamentous structures, including the posterior-inferior tibiofibular ligament, the anterior inferior tibiofibular ligament, and the transverse ligament. However, a bad diagnosis could point to a classic inversion ankle sprain.
The good news is that all of these ailments are relatively easy to remedy – some with RICE, some with a cast, and some with surgery – but left unchecked or misdiagnosed, they can become a problem in later life. At the Fortius Clinic, their imaging service is second to none and is available to all patients, whether top-flight athletes or non athletes suffering from long-term musculoskeletal conditions. Their consultant radiologists and expert radiographers have access to cutting-edge equipment, including X-ray, ultrasound and MRI scanners, to ensure a speedy and correct diagnosis.