Commentary

In an earlier article, I addressed ankle ligament injuries. I plan on continuing with a series of articles that will address certain common ankle tendon injuries as well as some common foot injuries. The foot and ankle combination is incredibly complex, leaving the foot and ankle susceptible to significant damage in the event of a trauma. For instance, each foot has 26 bones, 33 joints and 100 tendons, muscles and ligaments. The injuries that can occur to these bones, joints, tendons, muscles and ligaments include fractures, cartilage injuries, dislocations, sprains, contusions and infections.

For purposes of cross-examination, the expert witnesses who will most commonly be addressing foot and ankle injuries are either an orthopedic specialist with a subspeciality in the foot and ankle or a podiatrist. It is important the plaintiffs attorney be aware of the differences between an orthopedic specialist who has a subspeciality in the foot and ankle and a podiatrist. The typical training of an orthopedic foot and ankle surgeon consists of four years of college, four years of allopathic or osteopathic medical school, one year surgical internship, five to six years of orthopedic training and an optional one-year fellowship in foot and ankle surgery.

Training for a podiatric foot and ankle surgeon consists of four years of college, four years of podiatric medical school and three to four years of a surgical residency. A podiatrist may also receive fellowship training. In terms of qualifications, the plaintiffs attorney should be able to cross-examine a podiatrist on his or her qualifications and the differences in training between a podiatrist and an orthopedist who specializes in foot and ankle injuries.

In terms of hierarchy, while it is always preferable to have an orthopedic surgeon with a subspeciality in foot and ankle over a podiatrist, a podiatrist will probably have more experience with the foot and ankle than a general orthopedist.

With respect to injuries to the foot and ankle, in my experience one of the most significant injuries that occurs post-trauma is something called an osteochondral defect. An osteochondral defect (also known as an osteochondral fracture, osteochondral lesion or intra-articular fracture) is an area of damaged cartilage found in a joint.

Concerning the combination of the foot and ankle, medical literature suggests that an osteochondral defect is most likely to occur in the ankle joint. It is present where an area of normally healthy cartilage has been damaged and is either partially/completely detached or has developed into an area with no cartilage present at all. The ankle joint itself is comprised of three bones: the tibia and fibula (longer bones) and the talus (connects to the calcaneus or heel bone).

Within the ankle joint itself, the talus bone is the most common location to find an osteochondral defect in the foot and ankle. From a damages standpoint, an osteochondral defect can be an even more devastating injury than a bone fracture, which usually heals well, or a ligamentous injury, which is often repairable by surgery.

The most common scenario causing an osteochondral defect is a twisting injury while walking or a twisting injury after falling from height.

In my practice, I encounter this injury most often with construction workers who are exposed to certain fall hazards on the worksite. Although conservative treatment may be attempted for an osteochondral defect, the significant pain, discomfort and lack of function results in a high percentage of cases requiring surgery. The surgery to perform an osteochondral defect repair can either be an arthroscopic procedure or an open procedure. Generally speaking, most surgeons will first attempt to repair the defect arthroscopically unless the defect is particularly large.

If the initial attempt at arthroscopic surgery fails, an open repair is usually the next step. While some repairs will enable the plaintiff to regain enough function to return to full-duty employment, many osteochondral defects are simply not repairable. It is extremely important for the plaintiffs attorney to focus on the potential future problems associated with an osteochondral defect, including the potential need for ankle fusion surgery or even ankle joint replacement surgery altogether.

Another significant injury commonly encountered is a peroneal tendon injury. A tendon is a band of tissue that connects a muscle to a bone. There are actually two peroneal tendons in the foot that run parallel to each other on the lateral side of the ankle (the outside part of the ankle with the bony prominence). One peroneal tendon attaches to the outer part of the midfoot, while the other tendon runs under the foot and attaches underneath. The main function of the peroneal tendons is to provide stability to the foot. If the peroneal tendons are not working properly, the foot and ankle will be particularly susceptible to sprain and strains.

From a personal injury standpoint, it is important to understand that the etiology of a peroneal tendon tear can be either acute or degenerative. Consequently, many defense medical examiners will not automatically concede that a peroneal tendon tear is post-traumatic.

The plaintiffs attorney should be aware that degenerative tears are usually associated with periodic or sporadic pain, weakness or instability in the ankle or an increase in the height of the arch. As a result, any time the plaintiff is claiming a post-traumatic peroneal tendon tear, as with most injuries, it is important to gather the pre-existing medical records.

If the plaintiff has made multiple visits to either his or her primary care physician or some other orthopedic specialist and never had these complaints of pain prior to the accident, it will tend to show it did not exist prior to the accident. In other words, a degenerative tear will generally result in symptoms. The lack of symptoms is proof there was no degenerative tear.  •