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  EQUESTRIAN INJURIES OF THE FOOT &ANKLE
 
 Written by
Dr. Darryl J. Martins DPM, FACFAS
 
[dropcap]H[/dropcap]orse riding is a popular sport throughout the world both recreationally and professionally. As with every sport, injuries develop; some minor- others serious. Current literature shows head injuries are the most prevalent (24%) with upper extremity second (17%) and third lower extremity (15%) (1,2). Most injuries are related from direct falls from the horse (2). This article is not intended to educate or train riders on proper techniques but to discuss common injuries and recognition. For prevention and guidance on technique in riding and transitions, please refer to the master perfumer Jean Paul Guerlain (3,4) in Desert Mirage.  Horse riding is a dangerous sport with horses weighing up to 500 kg, traveling as fast as 65 km/hr, and with the saddle roughly 2 m from the ground (5). Horse-related traumas are common in children and can cause severe injuries resulting in death and long-term disability (6). Interestingly, the most common population to get injured are women between the ages of 16-30 (2). Modern riding boots are usually knee high and made of leather. They are classically low heeled, even though historically the high heel is supposed to have been invented for riding boots to prevent the boot from slipping out of the stirrup (7). Most injuries occur when the foot is within the stirrup and undergoes trauma when the horse falls directly on the foot/ankle causing a crush injury.  The second type of injury is when the foot is entrapped in the stirrup and the midfoot/ankle rotates. These traumatic events cause several types of fractures and ruptures which include, lisfranc fractures, dislocation, ankle injuries, and foot fractures.
 
ANKLE FRACTURES
Ankle fractures are common injuries as they can occur due to the direct fall of a horse on a foot and also from stirrup entrapment. The concern with ankle fractures is they are not always this obvious (as we see in the photos on the following page) which require surgery. Some will develop ligament injuries and cause chronic dull ache and swelling. Those type of injuries that involve the syndesmotic ligament, which is attached between the tibia and fibula, require surgery to assist in healing. This injury over time will cause rapid degeneration of the ankle joint with progressive painful arthritis. A basic ankle sprain with the foot entrapped in the stirrup can cause cartilage damage of the joint. Once again, ignoring symptoms like: locking, cracking, loss of instability, or lack of improvement over time can develop into a chronic arthritic joint. But unlike the knee and hip, ankle replacements are still in the developmental stages with good outcomes for patients over 65 and with a sedentary lifestyle.  Unfortunately, riders do not fit into this category and would be required to stop their sport to undergo a successful replacement.
2_3_Ankle Fx Xrays
 
 
 
 
 
 
 
 
 CRUSHING INJURIES
4_open toe fx
These injuries are by far the most difficult to treat in the acute setting as many disasters can develop. Direct injuries of a horse hoof are painful and require immediate treatment.  Photo four below illustrates the power and weight of an adult horse. This patient unfortunately was not wearing protective shoes and developed an open fracture requiring surgery to reconstruct his first and second toes.  Luckily his toe was saved but he lost his nail and will have some loss of proprioception. These open type fractures require hospitalization, surgery within eight hours and require several surgeries for infection control and Patients, at times, present with fractures in multiple locations. The patient in photo five developed nutcracker fractures of the cuboid and associated other complex midfoot injuries. These types of injuries require a detailed examination with CT scan of the foot and ankle as missed fracture from conventional x-rays will be clear.  Further, these injuries have a risk of a compartment syndrome which is an increase in internal pressure from swelling and bleeding. These are emergent cases and require emergency surgery to reduce risk of gangrene. This patient was taken to surgery within four hours and required screws and plates to repair her fracture. These injuries take 6-8 weeks to heal and frequently develop post traumatic arthritis.
 Most injuries are directly related to foot vs. stirrup entrapment. If a rider was thrown from his horse and the foot is caught in the stirrup, the rider is dragged by the horse. In this situation, the rider could not remove his foot from the stirrup during falling, and the outside branch of the stirrup created a fulcrum effect with longitudinal bending of the foot (7). This rider in photo six was thrown off his horse and suffered a dislocation of the subtalar joint and fracture of multiple bones. This patient required surgery to reduce his dislocation. Unfortunately these fracture/dislocations are painful and most are reduced in the Emergency Room by a skilled physician.
  Some injuries involve just isolated metatarsal fracture. These injuries are very delayed in healing. Patients for the most part will choose to “walk it  off” and believe to “give it time”. This attitude in my experience is seen mostly with male riders. We get to see them two to three months later as the injury never heals and requires surgery to address the non-union (non-healing bone). Unfortunately with this type of surgery it requires over three months to heal and the patient be non-weight bearing with the use of crutches. Pain, aching, swelling and tenderness is not usual four weeks after an equestrian related incident.
5_6_Nutcracker_Subtalar
 
 
 
 
 
 
 MIDFOOT FRACTURE
 Since the time of Napoleon, the most foot injury recognized to be specific to equestrian injuries has been called the Lisfranc injury of the foot (7).  Not only is this a devastating injury to have but can be challenging to repair as perfect anatomic re-alignment must be obtained each and every time. In the past, this trauma often resulted in an amputation of the fore-foot at a specific level called the Lisfranc joint, after the French surgeon who first noticed the pattern of this injury. Today these injuries are re-constructed but most obtain post traumatic arthritis which often requires additional surgery. Today’s new adjunctive treatments help patients ambulate relatively pain free without need of a fusion of the midfoot joints.
7_5thMetFx 
 
 
 
 
 
 
 
In conclusion, equestrian sport is often consistent with a trauma of the foot which is forced abduction of the forefoot. The two etiologies that lead to specific injuries are: falling from the horse and if the rider’s foot is hung up in the stirrup. The resulting injuries are frequently misjudged and underestimated with respect to their potential consequences for global foot function. If injured either acutely or chronically, a foot and ankle surgeon knowledgeable in equestrian related injuries is recommended that will perform a detailed comprehensive examination and who is also a skilled and experienced surgeon.
 8_OpenReduction
 
 
 
 
 
 
 
 
 
 
 
 
 
Reference:
1. Waller, A. et al; Jockey injuries in the USA.
JAMA, March 8, 2000 Vol 28, 10. Pages 1326-1328.
2. Hasler, R, et al; Protective and risk factors in amateur
equestrians and description of injury patterns: A
retrospective data analysis and a case – control survey.
Journal of Trauma Management & Outcomes
2011, 5:4
3. Guerlain, J. (2013, August) Transitions. Desert
Mirage. Page 12-13.
4. Guerlain J. (2012, October) World championship
dressage rider & carriage driver. Desert Mirage, page
16-17.
5. Temes RT, et al; Head, face and neck trauma
from large animal injury in New Mexico. J Trauma
43:492— 495, 1997.
6. Ghosh A, et al. Horse-related injuries in pediatric
patients. J Pediatr Surg 35:1766 —1770, 2000.
7. The Importance of Proper Shoe Gear and Safety
Stirrups in the Prevention of Equestrian Foot Injuries;
THE JOURNAL OF FOOT & ANKLE SURGERY
Vol 46, 1, Jan/ Feb 2007. Pages 32-39.
 
 martins
 
 
 
 
 
Dr. Darryl J. Martins DPM, FACFAS
Board Certified Foot & Ankle Surgeon
Dr. Martins is a Fellow of the American College of
Foot &Ankle Surgeons practicing in Michigan. He
specializes in trauma, reconstructive foot and ankle
surgery, revisional surgery and arthroscopic procedures.
For questions or comments, please email
Dr. Martins at the following address:
darryljmartins@michiganpodiatry.com