Return to Play and Functional Outcomes Following Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-Analysis.

Return to play (RTP) and functional outcomes are critical to treatment success for acute Achilles tendon rupture (AATR). This systematic review and meta-analysis explored treatment superiority essential in optimal treatment selection concerning individual patients and their expectations regarding RTP and functional outcomes. This study was in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. The included studies were assessed regarding the level and quality of evidence. Fixed-effects models were employed for I2 < 25% and random-effects models for I2 ≥ 25%. The RTP rate meta-analysis of surgical vs conservative treatment revealed no significant difference. This was similar to the subgroup analysis of open repair and conservative treatment. The RTP rate and Achilles Tendon Total Rupture Score (ATRS) meta-analysis of open repair + earlier rehabilitation (ER) vs + later rehabilitation (LR) also revealed no significant differences. The mean time to RTP meta-analysis of open repair + ER vs + LR showed that open repair + ER was significantly favored (-4.19 weeks; p = .002). The ATRS meta-analysis of conservative treatment with ER vs with LR revealed no significant difference. This meta-analysis has revealed that the RTP rates following treatment of AATR are high. Therefore, the decision for surgical vs conservative treatment or open repair + ER vs + LR for AATR should not be selected based on the expectation of RTP. However, open repair + ER can be advocated over + LR for reduced mean time to RTP.

Long-term follow-up of equine incisor endodontic treatments using an orthograde technique.

OBJECTIVE: This retrospective clinical study was performed to determine the suitability and success rate of endodontic treatment of equine incisors presenting with apical and periapical disease. ANIMALS: All horses presented to a referral equine dental clinic between March 2013 and December 2019 specifically selected as candidates suitable for endodontic treatment were included in this study. METHODS: Initial clinical and radiographic presentation of incisor disorder cases suitable for endodontic treatment were recorded (88 incisors) and follow-up examination for long-term viability (8 months to 5 years) was performed in cases involving 32 incisors in total. RESULTS: A total of 68 horses with 88 incisors were included in this study for endodontic restorative treatment. Different dental materials were used, with a temporary 3-layered technique using calcium hydroxide apically and temporary cement and resin composite occlusally most commonly used at the first treatment. Complete obturation with resin composite was performed in 48% of the cases requiring second treatments (50 incisors). Follow-up examination involving 32 incisors showed that successful endodontic treatment was achieved in 75% of the teeth treated. CLINICAL RELEVANCE: Endodontic treatment of diseased incisors is a viable option in equid patients with a success rate comparable to humans in practice. The use of flowable resin composite as an obturation material has been shown to be successful at either the second treatment or in carefully selected patients at the first treatment.

Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute achilles tendon ruptures: a systematic review of overlapping meta-analyses.

PURPOSE: To systematically review and evaluate the current meta-analyses for the treatment of acute Achilles tendon rupture (AATR). This study can provide clinicians with a clear overview of the current literature to aid clinical decision-making and the optimal formulation of treatment plans for AATR. METHODS: Two independent reviewers searched PubMed and Embase on June 2, 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Assessment of evidence was twofold: level of evidence (LoE) and quality of evidence (QoE). LoE was evaluated using published criteria by The Journal of Bone and Joint Surgery and the QoE by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) scale. Pooled complication rates were highlighted for significance in favour of one treatment arm or no significance. RESULTS: There were 34 meta-analyses that met the eligibility criteria, with 28 studies of LoE 1, and the mean QoE was 9.8 ± 1.2. Significantly lower re-rupture rates were reported with surgical (2.3-5%) versus conservative treatment (3.9-13%), but conservative treatment was favoured in terms of lower complication rates. The re-rupture rates were not significantly different between percutaneous repair or minimally invasive surgery (MIS) compared to open repair, but MIS was favoured in terms of lower complication rates (7.5-10.4%). When comparing rehabilitation protocols following open repair (four studies), conservative treatment (nine studies), or combined (three studies), there was no significant difference in terms of re-rupture or obvious advantage in terms of lower complication rates between early versus later rehabilitation. CONCLUSION: This systematic review found that surgical treatment was significantly favoured over conservative treatment for re-rupture, but conservative treatment had lower complication rates other than re-rupture, notably for infections and sural nerve injury. Open repair had similar re-rupture rates to MIS, but lower complication rates; however, the rate of sural nerve injuries was lower in open repair. When comparing earlier versus later rehabilitation, there was no difference in re-rupture rates or obvious advantage in complications between open repair, conservative treatment, or when combined. The findings of this study will allow clinicians to effectively counsel their patients on the postoperative outcomes and complications associated with different treatment approaches for AATR. LEVEL OF EVIDENCE: IV.

Limited evidence of adjuvant biologics with bone marrow stimulation for the treatment of osteochondral lesion of the talus: a systematic review.

PURPOSE: To evaluate the complication rates, continuous functional outcome scores, and return to play data following bone marrow stimulation (BMS) versus biologics ± BMS for the treatment of osteochondral lesion of the talus (OLT). METHODS: A systematic review was performed. The PubMed and Embase databases were searched using specific search terms and eligibility criteria according to the PRISMA guidelines. The level of evidence was assessed using published criteria by The Journal of Bone & Joint Surgery, and the quality of evidence using the Modified Coleman Methodology Score. Continuous variables were presented as mean ± standard deviation and categorical variables as frequencies (percentages). RESULTS: BMS versus BMS + hyaluronic acid (HA): no complications in either treatment arm were reported. The mean American Orthopaedic Foot and Ankle Society score was 43.5 to 67.3 points and 44.0 to 72.4 points, respectively. The mean 10 mm Visual Analogue Scale pain score was 7.7 to 3.8 points and 7.5 to 2.5 points, respectively. BMS versus BMS + concentrated bone marrow aspirate (CBMA): the pooled overall complication rate was 17/64 (26.6%) versus 11/71 (15.5%), respectively (non-significant). The pool revision rate was 15/64 (23.4%) versus 6/71 (8.5%), respectively (p = 0.016). There has been a notable poor reporting of complication rates for the use of ADSC and PRP as adjuvant biological therapies to BMS for the treatment of OLT. CONCLUSION: There was an overall limited comparative clinical evidence of adjuvant biologics with BMS versus BMS alone for the treatment of OLT. BMS + HA and BMS + CBMA can provide superior outcomes, albeit the currently limited evidence. Further studies are warranted to establish the true clinical superiority of the various biologics ± BMS versus BMS alone. These studies must also compare the various biologics against one another to determine, if any, the optimal biologic for OLT. Clinicians should counsel patients accordingly on these findings as required. LEVEL OF EVIDENCE: Level III.

Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held. RESULTS: A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement). CONCLUSION: These consensus statements may assist clinicians in the management of these difficult clinical pathologies. LEVEL OF EVIDENCE: Level V, mechanism-based reasoning.

Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates.

BACKGROUND: An acute Achilles tendon rupture (AATR) is a common injury. The controversy that has surrounded the optimal treatment options for AATRs warrants an updated meta-analysis that is comprehensive, accounts for loss to follow-up, and utilizes the now greater number of available studies for data pooling. PURPOSE: To meta-analyze the rates of all complications after the treatment of AATRs with a "best-case scenario" and "worst-case scenario" analysis for rerupture rates that assumes that all patients lost to follow-up did not or did experience a rerupture, respectively. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 1. METHODS: Two authors performed a systematic review of the PubMed and Embase databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on February 17, 2020. The included studies were assessed in terms of the level of evidence, quality of evidence, and quality of the literature. A meta-analysis by fixed-effects models was performed if heterogeneity was low (I2 < 25%) and by random-effects models if heterogeneity was moderate to high (I2≥ 25%). RESULTS: Surgical treatment was significantly favored over nonsurgical treatment for reruptures. Nonsurgical treatment was significantly favored over surgical treatment for complications other than reruptures, notably infections. Minimally invasive surgery was significantly favored over open repair for complications other than reruptures (no difference for reruptures), in particular for minor complications. CONCLUSION: This meta-analysis demonstrated that surgical treatment was superior to nonsurgical treatment in terms of reruptures. However, the number needed to treat analysis produced nonmeaningful values for all treatment options, except for surgical versus nonsurgical treatment and minimally invasive surgery versus open repair. No single treatment option was revealed to be profoundly favorable with respect to every complication. The results of this meta-analysis can guide clinicians and patients in their treatment decisions that should be made jointly and on a case-by-case basis.

Long-Term Follow-Up of Restorations of Equine Cheek Teeth Infundibula (2006-2017).

BACKGROUND: Caries of the infundibula of equine cheek teeth can lead to significant dental disease including increased attritional wear, pulpar and apical disease, secondary sinusitis, and dental fracture. Restorations of cavities of equine cheek teeth infundibula have been performed since 1889. Recent advances in dental materials, instrumentation, and techniques have facilitated the use of dental restoration techniques by equine veterinary practitioners. No studies to date have demonstrated the safety or efficacy of restorations of equine cheek teeth infundibula. OBJECTIVES: To assess the long-term results of restorations of equine cheek teeth affected by infundibular caries, to report on the safety of the procedure, and to give guidelines for future restorative therapies. STUDY DESIGN: Retrospective analysis of results of clinical and oroscopic examination of horses that underwent infundibular restoration procedures between 2006 and 2017. METHODS: A total of 223 infundibula in 185 maxillary cheek teeth in 92 horses were restored using a variety of dental materials including glass ionomer cement, flowable and compactible resin composites. The time between restoration and re-examination was recorded along with findings of clinical signs in the interim, restorative material loss, and any further pathological changes of the teeth including caries progression, fracture, or apical disease. Follow-up examinations were performed over two study periods 2006-2012 and in 2017. RESULTS: Over the full study period, 99% of treated horses available for follow-up examinations had no adverse clinical signs or developed any abnormalities of restored teeth observable on oroscopic examination. Of horses re-examined, 83% of restorations were shown to have minimal or no loss of the restoration material, with occlusal surface wear visibly comparable to other adjacent maxillary teeth. Statistical analysis showed success of the procedure was related to the restorative material used, the restoration technique, and the caries grade present at the time of restoration (grade 3 is more successful than grade 2). MAIN LIMITATIONS: There are no case controls in this study and therefore it is not clear if restoration of equine infundibula is a consistently beneficial procedure, or at which grade of caries progression restorations should be performed for optimum benefit. The procedures were not re-examined at consistent regular times creating some difficulties in standardizing results. Re-examinations of treated horses did not consistently include radiography or computed tomography and therefore some apical changes may have occurred in treated teeth without visual oroscopic or external clinical signs. CONCLUSION: Restoration of equine infundibula using materials developed for human dentistry including flowable resin composites is a safe and long-lasting procedure and appears to prevent the development of further pathological changes including apical infection and dental fracture.

Correlation Between Gastrocnemius Tightness and Heel Pain Severity in Plantar Fasciitis.

BACKGROUND: It is known that there is an association between gastrocnemius tightness and plantar fasciitis, but this has never been quantified. The purpose of the study was to determine the correlation between gastrocnemius tightness and the severity of heel pain in plantar fasciitis. METHODS: Thirty-three patients were prescribed physiotherapist-directed gastrocnemius stretching exercises, a Strassburg Sock or night splint, and silicone heel insoles as required. Outcome measures included (1) gastrocnemius tightness, (2) 100-mm visual analog scale (VAS) for pain on the first steps in the morning, and (3) 100-mm VAS for the worst pain felt during the previous week. Gastrocnemius tightness was measured by the difference in maximal ankle dorsiflexion between knee bent and straight with a goniometer. RESULTS: The mean gastrocnemius tightness was 22 degrees at baseline compared with 9 degrees at the final follow-up (P < .01). A reduction in VAS for pain on the first steps in the morning and VAS for the worst pain felt during the previous week from baseline to final follow-up was observed (P < .01). Correlation analysis of 105 data points between gastrocnemius tightness and VAS for pain on the first steps in the morning was R = 0.757 (P < .001), and between gastrocnemius tightness and VAS for the worst pain felt during the previous week was R = 0.781 (P < .001). CONCLUSION: The study observed a strong, statistically significant correlation between gastrocnemius tightness and the severity of heel pain in plantar fasciitis. LEVEL OF EVIDENCE: Level IV, case series.

Diagnosis: History, Physical Examination, Imaging, and Arthroscopy: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Diagnosis: History, Physical Examination, Imaging, and Arthroscopy" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus: 51 - 74%; strong consensus: 75 - 99%; unanimous: 100%. RESULTS: A total of 12 statements on the diagnosis of cartilage injuries of the ankle reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support and 10 reached strong consensus (greater than 75% agreement). All statements reached at least 86% agreement. CONCLUSIONS: This international consensus derived from leaders in the field will assist clinicians in the diagnosis of cartilage injuries of the ankle.

Barriers and enablers to proper diabetic foot care amongst community dwellers in an Asian population: a qualitative study.

BACKGROUND: Diabetic foot complications are common within Asian populations. They arise due to poor diabetic control and foot care. In this study, we aimed to identify the causes for proper and improper diabetic foot care. METHODS: A qualitative study consisting of key informant interviews with 17 healthcare professionals, including doctors and various allied health workers, was conducted. Participants included had at least five years of caring for diabetic foot patients either in public institutions or private clinics. Data collected was analyzed via thematic analysis. RESULTS: Diabetic patients were generally observed to have a mixture of proper and improper information and beliefs which eventually resulted in the extent of proper foot care. Factors which influenced the extent of proper and improper state of information and beliefs were classified into predisposing and precipitating factors. Predisposing factors were further categorised into modifiable factors (e.g., education level, socioeconomic status, social support) and non-modifiable factors (e.g., age, presence and severity of co-morbidities restricting ability to selfcare, past experiences). Precipitating factors were categorized into patient factors (e.g., degree of reception of information, presence of psychological barriers), provider factors (presence and degree of multi-disciplinary approach to care, presence of administrative inconveniences) and disease factors (presence of diabetic sensory neuropathy, complexity of disease process). CONCLUSIONS: The extent of proper foot care amongst diabetic patients is influenced by numerous predisposing and precipitating factors. Further studies can look at further development of the described structure as well as quantitatively defining the various components and factors which make up the described system.

Rehabilitation after anatomical ankle ligament repair or reconstruction.

The selection, implementation of and adherence to a post-operative regimen are all essential in order to achieve the best outcomes after ankle ligament surgery. The purpose of this paper is to present a best-evidence approach to this, with grounding in basic science and a consensus opinion from the members of the ESSKA-AFAS Ankle Instability Group. Basic science and clinical evidence surrounding tissue healing after surgical repair or reconstruction of the ligaments as well as around the re-establishment of sensorimotor control are reviewed. A consensus opinion based on this evidence as to the recommended rehabilitation protocol after ankle ligament surgery was then obtained from the members of the ESSKA-AFAS Ankle Instability Group. Rehabilitation recommendations are presented for the initial post-operative period, the early recovery phase and a goal-orientated late rehabilitation and return-to-sport phase. This paper presents practical, evidenced-based guidelines for rehabilitation and return to activity after lateral ankle ligament surgery.

Non-insertional Achilles tendinopathy.

Non-insertional Achilles tendinopathy is a degenerative condition characterised by pain on activity.Eccentric stretching is the most effective treatment.Surgical treatment is reserved for recalcitrant cases.Minimally-invasive and tendinoscopic treatments are showing promising results. Cite this article: Pearce CJ, Tan A. Non-insertional Achilles tendinopathy. EFORT Open Rev 2016;1:383-390. DOI: 10.1302/2058-5241.1.160024.

Histological evaluation of calcaneal tuberosity cartilage--A proposed donor site for osteochondral autologous transplant for talar dome osteochondral lesions.

BACKGROUND: Osteochondral Autologous Transplant (OATs) as a treatment option for Osteochondral lesions (OCLs) of the talar dome frequently uses the distal femur as the donor site which is associated with donor site morbidity in up to 50%. Some studies have described the presence of hyaline cartilage in the posterior superior calcaneal tuberosity. The aim of this study was to evaluate the posterior superior calcaneal tuberosity to determine if it can be a suitable donor site for OATs of the talus METHODS: In this cadaveric study, we histologically evaluated 12 osteochondral plugs taken from the posterior superior calcaneal tuberosity and compared them to 12 osteochondral plugs taken from the talar dome. RESULTS: In the talar dome group, all samples had evidence of hyaline cartilage with varying degrees of GAG staining. The average hyaline cartilage thickness in the samples was 1.33 mm. There was no evidence of fibrocartilage, fibrous tissue or fatty tissue in this group. In contrast, the Calcaneal tuberosity samples had no evidence of hyaline cartilage. Fibrocartilage was noted in 3 samples only. CONCLUSIONS: We believe that the structural differences between the talus and calcanium grafts render the posterior superior clancaneal tuberosity an unsuitable donor site for OATs in the treatment of OCL of the talus.

Management of syndesmosis injuries in the elite athlete.

This article reviews the basics and evidence base thus far on syndesmosis injuries, focusing on its management in the elite sporting population. A syndesmosis injury or "high ankle sprain" is a significant injury, especially in the elite athlete. Among all ankle sprains, the syndesmotic injury is most predictive of persistent symptoms in the athletic population. Late diagnosis of unstable syndesmosis injuries leads to a poor outcome and delayed return to sports. A high index of suspicion and an understanding of the mechanism of injury is required to ensure an early diagnosis. Incomplete/inaccurate reduction leads to a poor outcome.

The effect of population heterogeneities upon spread of infection.

It has often been observed that population heterogeneities can lead to outbreaks of infection being less frequent and less severe than homogeneous population models would suggest. We address this issue by comparing a model incorporating various forms of heterogeneity with a homogenised model matched according to the value of the basic reproduction number [Formula: see text]. We mainly focus upon heterogeneity in individuals' infectivity and susceptibility, though with some allowance also for heterogeneous patterns of mixing. The measures of infectious spread we consider are (i) the probability of a major outbreak; (ii) the mean outbreak size; (iii) the mean endemic prevalence level; and (iv) the persistence time. For each measure, we establish conditions under which heterogeneity leads to a reduction in infectious spread. We also demonstrate that if such conditions are not satisfied, the reverse may occur. As well as comparison with a homogeneous population, we investigate comparisons between two heterogeneous populations of differing degrees of heterogeneity. All of our results are derived under the assumption that the susceptible population is sufficiently large.

Synthetic osteochondral grafting of ankle osteochondral lesions.

BACKGROUND: The treatment of osteochondral lesions, especially those with a cystic component or those that have failed the standard arthroscopic procedures can be challenging. Synthetic grafts have several potential advantages over other second line treatments including the fact that only one operation is required and no other joint is violated. METHOD: We report the results of the first series of synthetic grafts used in the treatment of osteochondral lesions of the ankle with a minimum of one year follow up. RESULTS: There was significant improvement in the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot and Ankle Osteoarthritis Scale (AOS) scores and all patients were satisfied with the results of surgery. Magnetic Resonance Imaging (MRI) scans at one year have demonstrated resolution of the bony cysts and surrounding bone marrow oedema but, worryingly, continued to show high signal on the T2 weighted images within the plugs themselves. Qualitative T2 mapping has suggested a fibrous rather than hyaline appearance of the cartilage portions of the plugs. CONCLUSIONS: The clinical results have been encouraging but more patients and longer follow up are required before firm conclusions can be drawn.

Achilles tendinoscopy and plantaris tendon release and division in the treatment of non-insertional Achilles tendinopathy.

BACKGROUND: The mainstay of treatment for non-insertional Achilles tendinopathy is non-operative, however a proportion of patients will fail conservative measures. We describe the results of Achilles tendinoscopy with plantaris tendon release in patients who have failed first line conservative treatment for at least 6 months. METHODS: A consecutive series of 11 patients with a minimum of 2 years follow up. RESULTS: The mean AOFAS scores significantly improved from 68 pre-op to 92 post op (p=0.0002) as did the AOS scores for both pain (28% pre-op to 8% post op (p=0.0004)) and disability (38% pre-op to 10% post op (p=0.0005). The mean SF-36 scores also improved but were not statistically significant (pre-op 76, post op 87 (p=0.059). There were no complications. 8 of the 11 patients were satisfied, the other 3 somewhat satisfied. CONCLUSIONS: The results of Achilles tendinoscopy and division of the plantaris tendon are encouraging but further studies are required to compare it to other treatments. It is minimally invasive and low risk so should not affect the ability to perform a formal open procedure if unsuccessful.

Metatarsalgia: proximal metatarsal osteotomies.

Metatarsalgia is a blanket term to describe pain in the forefoot that may have many different etiologies and contributory factors. A careful history, examination, and appropriate imaging are required to make an accurate diagnosis and treat the patient appropriately. Metatarsalgia is a common condition and is more common in women. Many nonsurgical treatments can be implemented as a first line but if these fail then surgery may be undertaken. There are several different lesser metatarsal osteotomies described with little published evidence to recommend one over another, leaving the decision as to which one to use largely to surgeon choice. The surgeon, however, must decide, by using a combination of clinical examination and imaging, whether the desired effect of the osteotomy is to shorten or elevate the metatarsal head or both. Whichever method is employed it is important to maintain or restore the metatarsal cascade to keep even pressure under the lesser metatarsal heads and prevent transfer lesions. Proximal osteotomies are more powerful than distal ones but often that can mean that they are more technically demanding. Many early descriptions of osteotomy techniques did not include any fixation but the results in terms of union and relief of symptoms as well as the prevention of transfer pain appear to be better with fixation. More research is required comparing the different osteotomy techniques to ascertain which can most reliably resolve patients' symptoms with the lowest complication rate.

The epidemiology of foot injuries in professional rugby union players.

BACKGROUND: Foot injuries represent a small but important proportion of injuries to professional rugby union players. There are no detailed epidemiological studies regarding these injuries. The aim of this study was to describe the epidemiology of foot injuries sustained by a cohort of professional rugby union players and identify areas that may be targeted for injury prevention in the future. METHODS: Medical personnel prospectively recorded injuries in professional Premiership rugby union players in England over four seasons. Injuries to the foot were identified and the time away from training and playing was reported. RESULTS: A total of 147 foot injuries were sustained resulting in 3542 days of absence in total. Acute events accounted for 73% of all foot injuries, with chronic, mostly overuse conditions, accounting for 25% (undiagnosed 2%). Chronic conditions led to proportionately more time away from training and playing (p=<0.001). Specifically, stress fractures in the foot accounted for 8% of the total foot injuries but 22% of the absence. Navicular stress fractures had the longest recovery time with the mean return to training and match play of 188 days. CONCLUSION: In collision sports such as rugby, some injuries may be inevitable but clinicians should always be seeking ways to minimise their occurrence and impact. This study revealed a high proportion of morbidity associated with chronic and overuse foot injuries in these professional athletes. With greater attention paid to risk factors, some of these injuries, and importantly, recurrent injuries may be avoided.