Return to Athletic Activity After Foot andAnkle Surgery: A Preliminary Report onSelect Procedures

Amol Saxena, DPM

One hundred thirty-eight "athletic " patients from the author 's practice underwent retrospective reviewof their foot and ankle surgery that was performed from 1990 to 1997 to evaluate the time to return toactivity. Athletes were defined as follows : professional, varsity college and high schoo l, runners amassingmore than 25 miles per week, or those involved in regular competition. No recreational athletes wereincluded. Average follow -up for the group as a whole was 49.4 months, (range, 12-108 months).One hundred seventeen of the 138 patients were able to be contacted andlor had been evaluated bySeptember 1998. One hundred thirteen patients considered their surgery a success. All but two patientswere able to return to the desired level of performance. Twenty-three of the patients increased theiractivity level after surgery. Twenty-eight athletes underwent Achilles tendon-related surgery (averagefollow -up was 44.5 months). Runners undergoing peritenolyses had an average return to activity of 4.0weeks (range, 3-6 weeks). Patients undergoing Achilles procedure involving bone resection had anaverage return to activity of 13.8 weeks (range, 10-20 weeks). Forty-four bunionectomy procedureswere performed, includinq 31 first metatarsal osteotomies. The group 's average follow-up was 52.9months (range, 13-100 months), and average return to activity for the first metatarsal osteotomieswas 8.9 weeks. There were 48 rearfoot procedures. Lateral ankle stabilization procedures returned toactivity on an average of 10 weeks (range, 7- 16 weeks), while excised ossicles (as tibiale externum, ostrigonum) had an average return to activity of 9.1 weeks (range, 8-14 weeks). Seven neuroma patients(via dorsal approach) had a return to activity of 4.0 weeks (range, 2.5-6 weeks), sesamoidectomy 7.5weeks (range, 4-10 weeks), and Valenti arthroplasty of 6.5 weeks (range, 4-12 weeks), respectively.There were minimal complications. Two patients in the Achilles surgery group required revision surgery.One patient with a bunionectomy had postoperative hallux limitus. Eight patients had symptomaticscrews removed. (The Journal of Foot & Ankle Surgery 39(2):114-119, 2000)

Key words: athlete, foot and ankle surgery, sports med icine

Sport s medicine has become synonymous with returningan athlete to their desired sport as quickly as possible. Itis ap parent through the daily medi a that athletes undergosurge ry for various ailments in order to speed recovery andimprove performance. For instance, many athletes oftenundergo knee ar throscopy and Ach illes repair in order toretu rn to activity soo ner.

Surprising ly, review of recent literature from the past15 yea rs only reveal s a sparse number of articl es on theresult s of foo t and ankl e surgery on athletes (\ -10). Onegroup of authors describe their result s of plantar fasciasurgery which included 20 athletes which were amassedover what the authors adm it was a long period of time ( I ).Th e series of various auth ors ' surgical result s range from

Address correspondence 10: Amol Saxena. DPM. Department ofSports Medicine. Palo Alto Medical Foundation. 795 EI Camino Real.Palo Alto . CA 9430 I.

Received for publication August 13. 1998: accepted in revised formfor publication December 10. 1999.The Journal of Foot & Ankle Surgery 1067-2516/00/3902-0 114$4.00/0Copyright © 2000 by the Americ an Colleg e of Foot and Ankle Surgeons

114 THE JOURNAL OF FOOT & ANKLE SURGERY

4 to 25 cases (Table 1) (I, 2, 4-10). The actual results ofvar ious procedures and the definition ofan athlete are vague.Furthermore, the auth ors do not clarify the exact natu re ofreturn to activity. There are few textbooks that deal with theissue of foot and ankle surgery in athl etes as well.

Th e first purpose of this paper is to provide prel imi­nary data about the return to ac tivity (RTA) following footand ankle surge ry in athletes. Second, because previousliterature has not clea rly defined what an athl ete is.a proposed definition may help distinguish result s ofsurgery on athletes versus nonathl ete s. The result s may bedifferent due to the assumed different moti vation levelsof return ing to acti vity between the groups. It is hopedthat other authors will adopt these guidelines and usethem to help delin eate what proc edures and techniquesallow the athlete to return to the ir desired activity le vel.Because follow-up on so me types of procedures (such asAchill es tendon surgery) shows attrition ove r time . thisstudy is meant to be a prel imin ary report on a groupof athletes as a whole (2). Indi vidual procedures will be

TABLE 1 Other authors' results on surgery on athletic patients

Author

Snider et aI., 1983Murphyet aI., 1985Lutter, 1986Leach et aI., 1986Fitch et aI., 1989Schepsis et aI., 1991Leach et aI., 1992Khan et aI., 1992Hamilton et aI., 1993

Procedure

Plantar fasciotomyHeel neurolysisPlantar fasciotomyPlantar fasciotomyNavicular stress fracture graft/ORIFPlantar fasciotomyAchilles surgeryORIF navicular stress fracturesModified Brostrom ankle stabilization

Patients

9 athletes, 11 surgeries15 athletes4 athletes15 athletes15 athletes20 athletes9 runners, 12 tendons 2 revisions6 athletes25 dancers and recreational athletes

Comments

8/9 RTAAll successful50% very good relief14 RTA in 9 weeks12/15 RTA in 5-12 mos.

85% short-term (5 yr) success5/6 RTA in 3.8 mosAll successful RTA 8-12 weeks

RTA returned to activity; ORIF open reduction, internal fixation

critically reviewed in separate studies; however, somebasic concepts and concerns are addressed in this paper.This is meant to be an overview of appropriate time framesfor the patient to return to athletic activity after theyundergo a specific surgery. This paper is not meant toimply that the procedures the author performed are neces­sarily the only types recommended or available to athletes.

Materials and Methods

Athletes were defined as: professionals, varsity collegeand high school, runners amassing 25 or more miles/week,or aerobics or competitive sports enthusiasts partaking in6 or more hours/week. Recreational athletes who exerciseirregularly and "weekend warriors" were not included inthis study. Patients from the author's practice, who under­went surgery from 1990 to 1997 and were available forfollow-up examination were included in the study. Retro­spective chart review was performed, noting the procedure,duration, of follow-up and any complications. Note wastaken as to when the athlete was able to return to his or herdesired sport. This generally was a practice session, notcompetition. The author's general criteria for a runner, forinstance, allowed a 15- to 20-minute run to be attemptedif the athlete was able to walk briskly for 30-40 minuteswithout pain. Other parameters were to have the circumfer­ence of the operative calf within 5 mm of the nonoperativeside, and the range of motion within SO (dorsi- and plan­tarflexion), and hallux dorsiflexion greater than 25°.

All patients were examined clinically at I year postop­eratively and re-evaluated when possible subsequently. Aphone interview was conducted if the patient had not beenseen in the previous year and subjective assessment hadnot been recorded, and the patient was asked, "Do youhave any limitations from your surgery? Do you considerthe surgery a success?"

Results

One hundred thirty-eight patients were available forretrospective review: 68 males and 70 females. The

average age was 32.8 years (range, 12-70 years). Therewere 66 left foot/ankle surgeries and 62 rights. Ninepatients had bilateral surgery. There were II profes­sional/elite athletes, 18 high school athletes, and sixcollegiate athletes, respectively. Nine of the high schoolathletes went on to compete in college sports.

There were 28 Achilles surgeries on athletes, whichincluded four sub-4-minute milers. Average preoperativesymptoms ranged from 3 months to 13 years. Averagefollow-up postop for this group was 44.5 months. Peri­tenolyses was performed on eight runners (Table 2). Inthese patients, release and debridement of the paratenonwere performed. Only subcutaneous tissue and skin werereapproximated. The average return to activity of this typeof patient was 4.0 weeks (range, 3-6 weeks); this gener­ally was a 15- to 20-minute run. Average follow-up on theperitenolyses procedure was 47.7 months (range, 28-78months). Patients who had peritenolyses in conjunctionwith other procedures such as Haglund's retrocalcanealosteotomy were excluded from this group.

Four patients had peritenolyses with debridement ofthe Achilles tendon. This is similar to the peritenolysesprocedure in regard to the incisional approach and closure;however, a portion of mucinous degenerated Achillestendon was excised. The tendon was repaired with aside-to-side absorbable suture with a buried knot. Whena greater than 1 em defect was excised, nonabsorbablesuture was used. There were four patients in this groupwho had a range of return to activity of 6-15 weeks.

There were 17 Achilles-related procedures performedfor bony abnormalities: six for Achilles tendocalcinosis,and II for retrocalcaneal exostosislbursitis (Haglund'sdeformities). Approach for tendocalcinosis was a posteriorlazy-S as described by Saxena in 1995 (II). Lateral retro­calcaneal exostoses were excised with a lateral approach.Direct posterior midline incisions were made through theAchilles tendon for Achilles calcific tendinitis and poste­rior superior calcaneal exostosis. Soft-tissue anchors areused as necessary. All but one of the patients with a boneprocedure had soft-tissue anchors (ranging from one to

VOLUME 39, NUMBER 2, MARCH/APRIL 2000 115

TABLE 2 Current study

Procedure Patients RTA Comments

FlU 47.7 mos. (R = 28-78 mos.)FlU 35 mos. (R = 12-60 mos.)(whole group 44.46 mos.)(R = 12-96 mos.)FlU 52.9 mos. (R = 13-100 mos.)

FlU 63.8 mos. (R = 48-66 mos.)

FlU 71.5 mos. (R = 14-103 mos.)FlU 26-67 mos. (R = 13-78 mos.)Dorsal approach (R = 13-96 mos.)FlU 38.25 mos. (R = 25-44 mos.)

RTA 4.0 weeks (R = 3-6 weeks)RTA 9.75 weeks (R = 6-15 weeks)RTA 13.8 weeks (R = 10-20 weeks)

RTA 6.5 weeks (R = 4-12 weeks)Preop DF 7°Postop DF 34°RTA 7.4 weeks (R = 4-10 weeks)RTA 10.0 weeks (R = 7-16 weeks)RTA 4.0 weeks (R = 2.5-6 weeks)RTA 11.5 weeks (R = 8-13 weeks)

8 runners4 athletes17 athletes

3 tibial, 4 fibular7 athletes7 athletes4 athletes

10 Austin, 13 Hohmann, RTA 8.9 weeks (R = 7-12 weeks)8 Ludloff7 athletes

Achilles peritenolysesTendon debridementAchilles tendocalcinosis excision

& retrocalcaneal proceduresBunionectomy with osteotomy

Valenti arthroplasty

SesamoidectomiesMod. Brostrom ankle stabilizationMorton's neurectomyORIF navicular

RTA, return to activity; DF, dorsiflexion; FlU, follow-up; R, range; mas, months.

four). (Soft-tissue anchors were not developed at the timeof this one patient's surgery.)

One patient with Achilles tendocalcinosis developedectopic bone formation medially within the tendon 3 yearspostoperatively. which was excised 2 years later. Anotherpatient redeveloped retrocalcaneal bursitis, which wasreoperated 2 years postoperatively. One patient who had aretrocalcaneal exostosis and bursitis resected had previousAchilles tendocalcinosis excised elsewhere. Preoperatively,all but three of the 28 Achilles tendon surgery patientsutilized orthoses. All Achilles tendon patients had triedheel lifts preoperatively along with a minimum of 1 yearof conservative therapy. Nine patients utilized orthosespostoperati vely.

There were 44 bunionectomies, including 31 first meta­tarsal osteotomies. This latter group had an average returnto activity of 8.9 weeks (range, 4-12 weeks). (Bunionec­tomy patients without osteotomies had an average RTAof 5.5 weeks.) There were 10 Austin bunionectomies,13 Hohmann bunionectomies, eight Ludloff osteotomies,and a total of seven Akin osteotomies performed, two asan isolated procedure (the rest were combined with theother osteotomies). All but two patients had screw fixa­tion of their osteotomies. There were two cheilectomiesperformed for grade II (utilizing the I- IV scale) (13)hallux limitus with minimal intra-articular damage.

There were seven Valenti procedures (dorsal resectionof one-third of the metatarsal head and the opposingproximal phalanx) performed for grade III and IV halluxrigidus, which had a RTA of 6.5 weeks (range, 4-12weeks). However. if one excluded the individual whohad a concomitant Achilles calcinosis repair, the RTAfor this group was lowered to 5.5 weeks. Preoperativeaverage hallux dorsiflexion was 7°; postoperatively it was34°, (range, 2Y _50°). Average follow-up for the Valentiprocedures was 63.8 months (range, 48-66 months).

There were six athletes who underwent hallucial sesa­moidectomies (three of each tibial and four fibular) whose

RTA was 7.4 weeks (range. 4-10 weeks). Two fibularsesamoidectomies were performed from a plantar lateralapproach. The rest of the sesamoids were excised fromdorsolateral or dorsomedial approaches. No deviations ofthe hallux were noted.

Seven patients underwent Morton's neurectomies viadorsal approach and had a RTA of 4.0 weeks (range, 2.5-6weeks).

Seven patients with lateral ankle stabilizations had anaverage return to activity of 10 weeks (range, 8-16weeks). These patients had a modified Brostrom-typerepair. Six had soft-tissue anchors implanted. A modi­fied Olliers' (oblique anterolateral) incision was utilized.unless concomitant peroneal tendon repair needed to beperformed, in which case a posterolateral curvilinear inci­sion following the peroneal tendons was created (7).

Forty-eight rearfoot procedures were performed. TheRTA for excision of ossicles in this region (e.g., ostibiale externum, os trigonum, and loose bodies of theankle) had a RTA of 9.1 weeks (range, 8-12 weeks). Theseven athletes with open reduction and internal fixation of"Jones" and navicular fractures had a RTA of 11.3 weeks(range. 8-13 weeks).

For the group as a whole, there were no cases of infectionor reflex sympathetic dystrophy Eight patients requestedscrew removal. One patient with an Austin bunionectomyhad postoperative hallux limitus (hallux dorsiflexion of20°). Two patients had "decreased desired activity" I yearpostsurgery. One of these patients was able to train fora marathon at 3 years postop: however, his goal was tocompete in the Olympic trials in the 5000 meters.

Twenty-three patients were able to increase their acti­vity level after their surgery, including several runnerswho completed marathons and high school students whowent on to college competition. It is important to notethat several patients had reconstructive procedures suchas bunionectomies and were able to increase their perfor­mance/activity level postoperatively.

116 THE JOURNAL OF FOOT & ANKLE SURGERY

TABLE 3 Postoperative protocol for distal and midshaft first metatarsal osteotomy

1. Posterior splint immediately postop.2. 2-5 days later, nonweightbearing below-the-knee cast applied for 2-3 weeks.3. Stationary biking allowed when pain and swelling subsides (generally 2-5 days).4. Removable weightbearing below-the-knee cast boot applied 2-3 weeks postop5. Hallux and ankle ROM exercises (active) begun at 3 weeks postop.6. Swimming permitted at 4 weeks postop (no flip turns).7. Athletic shoe allowed at 5-7 weeks postop with physical therapy initiated, including

electrical and muscle stimulation, SAPS/proprioceptive training, and lower extremity reconditioning.

TABLE 4 Postoperative protocols for ankle ligament reconstruction and rearfoot ossicle removal

1. "U-Shaped" splint applied immediately postop.2. Nonweightbearing below-the-knee cast applied 2-5 days later.3. Stationary biking permitted as above.4. Below-the-knee cast boot applied 2-3 weeks postop and passive ROM begun.5. Active ROM of ankle begun at 4 weeks postop.6. Athletic shoe with lace-up ankle brace allowed at 5-6 weeks postop. Swimming/pool running allowed

now and physical therapy initiated as above.7. Ankle brace continued for daily activities until 3 months postop; however, use is encouraged for all "lateral"

motion sports for 3-6 months.

Of the 117 surgical patients who were able to becontacted via phone or office interview, 113 patientsconsidered their surgery a success. Two had revisionsurgery by the author and are now asymptomatic and theother is only 2 months postoperative. Two other patientswere classified as having decreased desired activity level,as noted above. Ten patients' activity levels had decreasedfor other reasons, such as high school graduation, and theywere no longer competing in their sport. Retirement fromtheir professional sport was another factor for some.

For the 11 professional/elite athletes, the average RTAwas 6.6 weeks (range, 3-15 weeks). The 18 high schoolathletes had an average of 8.4 weeks (range, 4-16 weeks).For the six college athletes, the average RTA was 9.7weeks (range, 4-14 weeks). No statistical analysis wasdone due to the small size of those groups.

There were 48 runners in the group, including four sub­4-minute milers, and their average weekly mileage was43.6 miles/week (range, 25-120). There were 17 soccerplayers, 10 triathletes, and eight each of basketball andfootball players. Additional athletes consisted of tennisplayers, dancers, aerobics instructors, and various othersports.

Discussion

The distinction between athlete and recreational athleteis vague and ambiguous. This paper sets rather arbitraryguidelines as to who or what is an athlete. There maybe debate over whether the guidelines are accurate orrealistic. It is hoped that others will look at their ownresults as well, using these guidelines since no others havebeen established and literature is lacking on the subject.

For instance, what is the difference between an athlete,a recreational athlete, and a competitive athlete? Theauthor uses strict parameters to differentiate these patients.The primary focus of this study was to see the resultsof the surgery on patients for whom athletic endeavorsare a focus of their daily life. Therefore, infrequent andrecreational exercisers were excluded.

Clearly the limitation of this study is that it merelyrepresents one practitioner's experience. However, byreviewing only one surgeon's results, variability of tech­nique is avoided. If other authors were to combine theirresults, there may not only be variability in technique andsurgical skill, but also preoperative and postoperative care,patient population, and so forth.

It would be interesting to compare the return to activitytime of "athletes" to "active" patients and sedentary indi­viduals. Even though the author follows similar post­operative protocols for most types of patients, he hasfound athletics tend to be more motivated to ice operatedlimbs and participate in physical therapy more often (12),For instance, professional athletes and others who hadaccess to a physical therapist or athletic trainer performedtherapy one to three times per day. This is much morefrequent than the typical patient who does therapy two tothree times per week. The typical postoperative protocolsare listed below (Tables 3-5). (The motivation level toreturn to desired activity level appears to be higher whencompared to the average patient population.)

Return to competition may be an area to research aswell. However, this does not appear to be as accurate of adetermining factor. Investigators found that the return tocompetition is highly variable, particularly when an athleteis injured during a season versus out of the season (2,

VOLUME 39, NUMBER 2, MARCH/APRIL 2000 117

TABLE 5 Postoperative protocol for Achilles surgery

1. Nonweightbearing below-the-knee posterior splint immediately postop.2. Continue posterior splint for 10 days if peritenolyses only is done; otherwise, nonvveightbearing below-the-knee

cast applied for 2-3 weeks for Achilles debridement, Haglund's and calcific tendinosis repair.3. Stationary biking permitted as above.4. Nonweightbearing may be continued up to 6 weeks postop if extensive repair of Achilles insertion is needed.5. Passive ROM and guarded weightbearing begun at 3 weeks. Active ROM begun at 4-5 weeks.6. Removable cast boot continued until 6-8 weeks postop unless calcific tendinitis repair; boot would be continued

for weightbearing until 10-12 weeks postop.7. Progression into formal physical therapy at 2 weeks (Peritenolyses), 6-8 weeks (Haglund's

and debridement), and 10-12 weeks (calcific tendinitis repair), respectively.

6, 8-10). There tends to be a rush to get the patientback to competition when in season. In addition, financialpressures, psychological factors, and so forth all play arole in returning an athlete to competition.

In general, removable/functional cast bracing is used forthe majority ofthe recuperative period. Patients undergoingthis type of protocol have to have strict instructions as totheir limitations. Nonweightbearing on a first metatarsalosteotomy may play a role in decreasing recovery time,hallux limitus, and other complications. One may surmisefrom the results of this study and the findings of minimalcomplications that these individuals tend to be healthyand compliant. Hamilton et al. reported no complicationsor revisions in their series of modified Brostrom repairs.Their series consisted of 15 professional dancers and 10"recreational" athletes. Their average return to activity issimilar to this study, ranging from 8 to 12 weeks (7).

The two patients who had decreased desired activitylevels had so for different reasons. One patient had aHaglund's resection and peritenolyses procedure. Becauseof the patient's equinus, it was felt that tenodesis of theAchilles tendon at a slightly lengthened position would bebeneficial. This patient had persistent Achilles tendinitisfor a year postoperatively at the "watershed" region, andgave up competitive running after a year of management.At follow-up 3 years later, he was able to train enough torun a marathon, but not do the speedwork for the 5000meters, his desired event.

Leach et al. reported on Achilles tendon surgery inrunners having an 85% success rate. Their group re­operated on two of their elite runners in their series (2).They felt that the results of Achilles tendon surgery maydeteriorate after 5 years. The peritenolyses group in thisstudy had a very high achievement level. One patient whohad bilateral procedures returned to running in 3 1/2 weeksand ran 100 miles a week by 2 months postoperatively. Heplaced second in the cross-country national championships5 months postoperatively. Another marathoner, under­going peritenolyses won the national marathon cham­pionship 21 months postoperatively. One national classrunner from Canada had each Achilles tendon operated on4 years apart he was able to get second at his country's

118 THE JOURNAL OF FOOT & ANKLE SURGERY

Olympic trials after each surgery. This patient had theshortest period of preoperative care (3 months); however,he felt that no progress was being made. After periodsof rest and physical therapy, he continued to redevelopperitendinous crepitus. As his time frame to train for theOlympic trials was narrow, he pursued surgery. All theother patients in the "Achilles" group had well over ayear of conservative treatment.

The second patient in this study with decreased desiredactivity level had a functional tarsal tunnel syndrome. Hewas felt to have a "double crush" phenomenon. Postopera­tively, however, when he assumed the typical forward leanof a speed skater, he still felt "wobbly" despite a clinicallystable ankle. Paresthesias in the medial arch had dimin­ished. The physiatrists and neurologists who evaluatedhim felt that a subclinical radiculopathy was occurringin the flexed skating position.

Lutter revealed that patients with localized heel pain,secondary to nerve entrapment, may have less than idealresults (5). One other patient in this series did have atarsal tunnel decompression. It is possible that this wassecondary to the valgus position of her foot plant withthe high jump. She had a full recovery and competed incollege as a neptathlete, which included the high jump.

Though plantar fasciitis is a common athletic injury,many have shown that the need for operation is small (6, 9,13). Lutter operated on four athletes over a 4-year period.In this current study, only one athlete underwent plantarfasciotomy. The author has operated on 23 patients over a9-year period for this condition. Some of the patients didnot fit the author's definition of "athletes," and thereforecould not be included in this study. In Snider's study ofplantar fascia release, eight of nine were able to returnto running and return to full training took an average4 1/2 months (9). In Leach et al. is study, 14 out of 15athletes returned to full athletic activity (6). Both studiesagain emphasize that very few patients need this type ofsurgery. Future study of endoscopic techniques on returnto activity and long-term results is warranted as well.

Some may question why a joint-destructive proceduresuch as the Valenti arthroplasty is performed on an athletewith hallux rigidus. One should note that in these patients,

the joints were already destroyed. Preoperatively, theirhallux dorsiflexion averaged 7°; postoperatively it aver­aged 34°. This procedure involved removing the dorsalone-third of the metatarsal head, including the osteo­chondral defects and the dorsal one-third of the base ofthe proximal phalanx. Because literature is lacking onoutcomes of first metatarsophalangeal fusions, implants,and reconstructive osteotomies for patients, particularlyathletes, with moderate to severe hallux rigidus, it isfelt that this was an acceptable procedure. Revisioninto a fusion or an implant may be needed for thesepatients in the future, but all the patients who wereable to be contacted (six out of seven) were very happywith their results and continued to have a high activitylevel (13).

The reader should be aware that return to activitygenerally involved running 15-20 minutes or a portionof a practice. In basketball, for instance, patients oftenwere shooting a basketball in their cast boot by 4 weeks(without either running or jumping) and able to maintaintheir technique. Generally, return to competition rangedfrom 2 weeks to several months, but, as noted above.this was highly variable. As was noted in other studies,some patients continued to improve 6 months to I yearpostoperatively (2, 3, 8, 9).

Future study of surgery on athletes is needed on largerpatient populations. Certain factors, such as nonweight­bearing on forefoot osteotomies, need to be studied aswell. A more detailed study with larger numbers of proce­dures and follow-up will be done in the future.

Conclusion

From the results of this study, it appears foot and anklesurgery may be able to be performed on athletes withoutrisk of curtailing their career. In fact, 23 out of 138 athletesevaluated were able to increase their activity levels. It ishoped that the guidelines for what constitutes an athletealong with the postoperative time frames of returning to

activity that are presented here will make patients and themedical profession aware of realistic expectations.

Acknowledgments

The author would like to acknowledge Drs. Fred Dehling,K. Gordon Campbell, John Grady, and John Durkin, Jr. forthe motivation in producing this paper.

References

t. Schepsis, A.. Leach, R., Gorzyea. J. Plantar fasciitis: surgical re­sults and review of the literature. Clin. Orthop. 266: 185-196. 1991.

2. Leach. R.. Schepsis, A.. Takai, H. Long-term results of surgicalmanagement of chilies tendinitis in runners. Clin. Orthop. 282:208-212. 1992.

3. Curtis. M.. Myerson, M.. Szura. B. Tarso-metatarsal joint injuriesin the athlete. Am. J. Sports Med. 21(4):497-502. 1993.

4. Murphy. P.. Baxter. D. Nerve entrapment of the foot and ankles inrunners. Chn. Sports Med. 4:753-762. 1985.

5. Lutter. L. Surgical decisions in athletes' subcalcaneal pain. Am. J.Sports Med. 14(6):481-485. 1986.

6. Leach. R.. Seavey. M.. Salter. D. Results of surgery in athletes withplantar fasciitis. Foot Ankle 7(3): 156- 161. 1986.

7. Hamilton. W.. Thompson. F.. Snow. S. The modified Brostrom forlateral ankle instability. Foot Ankle 14(1):1-7.1993.

8. Fitch. K.. Blackwell. J.• Gilmour. W. Operation for non-union ofstress fracture of the tarsal navicular. J. Bone Joint Surg. 71­B:105-110.1989.

9. Snider, M.. Clancy. W.. Mcbeath, A. Plantar fascia release forchronic plantar fasciitis in runners. Am. J. Sports Med. 11(4):215­219. 1983.

10. Khan. K., Fuller, P.. Brukner, P., Kearney. C, Burry, H. Outcomeof conservative and surgical management of navicular stress fracturein athletes: eighty-six cases proven with computerized tomography.Am. J. Sports Med. 20(6):657 -666. 1992.

II. Saxena, A. Surgery for chronic achilles problems. 1. Foot AnkleSurg. 34(2):294-300, 1995.

12. Saxena. A.. O'Brien. T. Post-operative physical therapy for podi­atric surgery. J. Am. Podiatr. Med. Assoc. 82(8):417-423, 1992.

13. Saxena. A., Bouche. R.. Campbell. K., Leach. R., McNerncy. 1..Weil. L. Grand rounds: sports medicine. J. Foot Ankle Surg.35(6):595-599. 1996.

VOLUME 39, NUMBER 2, MARCH/APRIL 2000 119