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BAXTER’S THE FOOT AND ANKLE IN SPORT ISBN: 978-0-323-02358-0

Copyright # 2008, 1995 by Mosby, Inc., an affiliate of Elsevier Inc.

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Notice

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary or
appropriate. Readers are advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindications. It is the
responsibility of the practitioner, relying on their own experience and knowledge of the patient, to
make diagnoses, to determine dosages and the best treatment for each individual patient, and to take
all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the
Authors assume any liability for any injury and/or damage to persons or property arising out of or
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The Publisher

Library of Congress Cataloging-in-Publication Data

Baxter’s the foot and ankle in sport / [edited by] David A. Porter, Lew C. Schon.—2nd ed.
p. ; cm.
Rev. ed. of: The foot and ankle in sport / edited by Donald E. Baxter. c1995.
ISBN 978-0-323-02358-0
1. Foot—Wounds and injuries. 2. Ankle—Wounds and injuries. 3. Foot—Abnormalities.
4. Ankle—Abnormalities. 5. Sports injuries. I. Baxter, Donald E. II. Porter, David A.,
1959- III. Schon, Lew. IV. Title: Foot and ankle in sport.
[DNLM: 1. Ankle Injuries. 2. Foot Injuries. 3. Ankle—abnormalities. 4. Foot
Deformities. 5. Sports Medicine—methods. WE 880 B355 2007]
RD563.F638 2007
617.50 85044 dc22
2007022810

Acquisitions Editor: Emily Christie

Editorial Assistant: Faith Brody
Project Manager: David Saltzberg
Design Direction: Lou Forgione

Printed in USA
Last digit is the print number: 9 8 7 6 5 4 3 2 1
......................................... CONTRIBUTORS

Abrao M. Altman, MD Michael W. Bowman, MD, FACS

Professor, Orthopaedics Clinical Assistant Professor
Santa Cecilia University Department of Orthopaedic Surgery
Orthopaedic Surgeon University of Pittsburgh
Casa de Saude de Santos Consultant, Pittsburgh Steelers Football Club
Santos, Brazil Pittsburgh, Pennsylvania
Robert B. Anderson, MD W. Grant Braly, MD
Chief, Foot and Ankle Service Clinical Professor, Foot and Ankle Fellowship
Department of Orthopaedics Foundation for Orthopaedic Athletic
Carolinas Medical Center and Reconstruction Research
Charlotte, North Carolina Department of Orthopaedic Surgery
University of Texas Health Science Center at Houston
Erin Richard Barill, PT, ATC
Clinical Assistant Professor
Director of Rehabilitation
Department of Orthopaedic Surgery
Indianapolis Colts
Baylor College of Medicine
Indianapolis, Indiana
Active Staff, Orthopaedic Surgery
Donald E. Baxter, MD Texas Orthopaedic Hospital
Former Clinical Professor of Orthopaedic Surgery Houston, Texas
Head of Foot and Ankle Surgery
Peter Brukner, MBBS, FACSP
Director of Foot and Ankle Fellowship Programs
Associate Professor in Sports Medicine
Baylor College of Medicine
Centre for Health, Exercise and Sports Medicine
University of Texas Medical School
University of Melbourne
Houston, Texas
Melbourne, Australia
Christoph Becher, MD
Thomas O. Clanton, MD
Center for Knee and Foot Surgery/Sports Trauma
Professor and Chairman
ATOS Clinic Center
Department of Orthopaedic Surgery
Heidelberg, Germany
The University of Texas Health and Science Center
Kim L. Bennell, BAppSci (physio), PhD at Houston
Professor Team Physician, Rice University
Centre for Health, Exercise and Sports Medicine Team Orthopaedist, Houston Texans
University of Melbourne Team Physician, Houston Rockets
School of Physiotherapy Houston, Texas
Melbourne, Australia
J.A. Colombier, MD
Gregory C. Berlet, MD, FRCSC Foot and Ankle Surgery
Chief, Section of Foot and Ankle Clinique de l’Union
Department of Orthopaedics Toulouse, France
The Ohio State University
Fellowship Director
Orthopaedic Foot and Ankle Center
Columbus, Ohio

v
...........
 Contributors

Michael J. Coughlin, MD Kevin B. Gebke, MD

Director, Idaho Foot and Ankle Fellowship Assistant Professor of Clinical Family Medicine
Boise, Idaho Primary Care Sports Medicine Fellowship Director
Clinical Professor, Department of Orthopaedic Surgery IU Center for Sports Medicine
and Rehabilitation Family Medicine
Oregon Health Science University Indiana University
Portland, Oregon Indianapolis, Indiana
Private Practice of Orthopaedic Surgery
Sandro Giannini, MD
St. Alphonsus Regional Medical Center
Professor
Boise, Idaho
Orthopaedics
Past President, American Orthopaedic Foot and Ankle
Bologna University
Society
Chief of VI Department
P.A.J. DeLeeuw, PhD Istituti Ortopedici Rizzoli
Fellow Bologna, Italy
Department of Orthopaedics
John S. Gould, MD
Academic Medical Centre
Professor of Surgery
University of Amsterdam
Division of Orthopaedic Surgery
Amsterdam, The Netherlands
University of Alabama at Birmingham
A. Lee Dellon, MD Chief of Medical Staff
Professor of Plastic Surgery and Neurosurgery UAB Highlands Hospital
The Johns Hopkins University Birmingham
Baltimore, Maryland Clinical Professor
Clinical Professor of Plastic Surgery, Neurosurgery and Orthopaedic Surgery
Anatomy University of South Alabama
University of Arizona Mobile, Alabama
Tucson, Arizona
J. Speight Grimes, MD
Director, the Dellon Institutes for Peripheral Nerve
Assistant Professor
Surgery
Orthopedic Surgery
Jonathan C. Dick, MB, BCh, BAO, LRCP & SI Texas Tech University Health Sciences Center
Associate Lecturer Lubbock, Texas
School of Medicine
Florian W. Gruber, MD
University of Queensland
Resident
Brisbane, Australia
1st Orthopaedic Department
Peter H. Edwards, Jr., MD Orthopedic Clinic Gersthof
Senior Attending Vienna, Austria
Orthopaedic Surgery
William G. Hamilton, BSE, MD
Ohio Orthopedic Center of Excellence
Senior Attending
Columbus, Ohio
Orthopaedic Surgery
David G. Ford, C. Ped St. Luke’s Roosevelt Hospital
Board Certified Pedorthist Assistant Attending Orthopaedic Surgeon
Orthopaedic Sports Medicine The Hospital for Special Surgery
Birmingham, Alabama Clinical Professor of Orthopaedic Surgery
College of Physicians & Surgeons
Carol Frey, MD
Columbia University
Fellowship Co-Director
New York, New York
Foot & Ankle
West Coast Orthopedic & Sports Medicine Foundation Travis W. Hanson, MD
Manhattan Beach, California Foot and Ankle Surgery & General Orthopaedics
KSF Orthopaedic Center
Houston, Texas

vi
...........
 Contributors

Christopher W. Hodgkins, MD Rover Krips, MD, PhD

Orthopaedic Fellow Department of Orthopaedic Surgery
Foot and Ankle Surgery Academic Medical Center
Hospital for Special Surgery University of Amsterdam
New York, New York Amsterdam
Afdelind Orthopaedie
Hong-Geun Jung, MD, PhD
Diaconessenhuis Leiden
Associate Professor
Leiden, The Netherlands
Attending Staff Surgeon
Department of Orthopedic Surgery, Foot and Ankle Kyung-Tai Lee, MD
Service Professor, Chief
Konkuk University School of Medicine Foot and Ankle Service
Seoul, South Korea Department of Orthopedics
Eulji University Hospital
Jon Karlsson, MD, PhD
Seoul, South Korea
Professor of Orthopaedics and Sports Traumatology
Department of Orthopaedics Thomas H. Lee, MD
Sahlgrenska University Hospital Assistant Clinical Professor
Goeteborg, Sweden Department of Orthopaedics
The Ohio State University
Moosa Kazim, MD, FRCS (C)
Columbus, Ohio
Director, Department of Sports Medicine
Orthosports Medical Center Nicola Maffulli, MD, PhD, FRCS
Dubai, United Arab Emirates Sports Med, Ltd.
The London Independent Hospital
John G. Kennedy, MD, FRCS (Ortho)
London
Assistant Professor of Orthopaedic Surgery
Professor of Trauma and Orthopaedic Surgery
Cornell University
University of Keele School of Medicine
Ithaca
University Hospital of North Staffordshire
Attending Surgeon
Stoke-on-Trent, United Kingdom
Foot and Ankle in Sports
Hospital for Special Surgery Ansar Mahmood, MB, ChB, MRCS
New York, New York Specialist Registrar in Trauma & Orthopaedic Surgery
University of Keele School of Medicine
Cesar Khazen, MD
Registrar in Trauma & Orthopaedics
Foot and Ankle Surgeon
Queens Hospital Burton
Department of Orthopaedic Surgery
Burton-upon-Trent, United Kingdom
Hospital de Clinicas Caracas
Caracas, Venezuela Roger A. Mann, MD
Associate Clinical Professor
Gabriel Khazen, MD
Orthopaedic Surgery
Foot and Ankle Surgeon
University of California School of Medicine
Department of Orthopaedic Surgery
San Francisco
Hospital de Clinicas Caracas
Director
Caracas, Venezuela
Foot and Ankle Fellowship
Daniel E. Kraft, MD Oakland, California
Assistant Clinical Professor
John V. Marymont, MD
Pediatrics
Associate Professor
Indiana University
Chief, Foot & Ankle Section
Methodist Sports Medicine Clinic
Baylor College of Medicine
Indianapolis, Indiana
Staff Physician
Methodist Hospital
Houston, Texas

vii
...........
 Contributors

Peter B. Maurus, MD Glenn B. Pfeffer, MD

Orthopaedic Surgeon, Foot and Ankle Surgery Director, Foot and Ankle Center
Mercy Hospital Cedars-Sinai Medical Center
Steindler Orthopedic Clinic Los Angeles, California
Iowa City, Iowa
Terrence Philbin, DO
William C. McGarvey, MD Assistant Clinical Professor
Associate Professor Department of Orthopaedics
Director of Foot and Ankle Surgery The Ohio State University
Department of Orthopaedic Surgery Medical Director of Foot and Ankle Orthopaedics
University of Texas-Houston Health Science Center Grant Hospital
Houston, Texas Columbus, Ohio
Eyal Melamed, MD David A. Porter, MD, PhD
Foot and Ankle Service Voluntary Clinical Associate Faculty
Department of Orthopaedics B Orthopaedics, Indiana University
Rambam Medical Center Indianapolis
Foot and Ankle Clinic Adjunct Clinical Associate Professor of
Kelalit HMO Polyclinic Health, Kinesiology and Leisure Studies
Kiriat Bialik Foot and Ankle Consultant
Haifa, Israel Purdue University
Secretary, Israeli Foot and Ankle Society West Layfayette
Foot and Ankle Consultant
Larry L. Nguyen, MD
Indianapolis Colts
Orthopaedic Surgeon
Indianapolis
Physician
Foot and Ankle Consultant
OrthoArkansas, P.A.
Co-Director Department of Research and Education
Little Rock, Arkansas
Methodist Sports Medicine – The Orthopedic
James A. Nunley, MD Specialists
J. Leonard Professor and Chief of the Division of Indianapolis, Indiana
Orthopaedics
Anthony S. Rhorer, MD
Department of Surgery
Director, Orthopaedic Trauma
Duke University
Scottsdale Healthcare
Durham, North Carolina
President
Padraic R. Obma, MD Sonoran Orthopaedic Trauma Surgeons
Resident, Orthopaedic Surgery Scottsdale, Arizona
Indiana University School of Medicine
Gregory A. Rowdon, MD
Indianapolis, Indiana
Team Physician
Yong-Wook Park, MD, PhD Purdue University
Professor of Orthopaedics West Lafayette, Indiana
Hangang Sacred Heart Hospital
G. James Sammarco, MD
Seoul
Volunteer Professor
Professor of Orthopaedics
Orthopaedic Surgery
Chunchon Sacred Heart Hospital
University of Cincinnati
Chunchon
Cincinnati SportsMedicine and Orthopaedic Center
Supervisor of Orthopaedics
Cincinnati, Ohio
The Armed Forces Medical Command
Yangju, South Korea V.J. Sammarco, MD
Co-Director Foot and Ankle Fellowship
Mihir M. Patel, MD
University of Cincinnati
Fellow, Foot and Ankle Service
Cincinnati SportsMedicine and Orthopaedic Center
Department of Orthopaedic Surgery
Cincinnati, Ohio
The Hospital for Special Surgery
New York, New York

viii
...........
 Contributors

Melanie Sanders, MD Roman A. Sibel, MD

Leesburg, Virginia Fellow, Foot and Ankle
Department of Orthopaedics
Mikael Sansone, MD
The Hospital for Special Surgery
Resident, Department of Orthopaedics
New York, New York
Sahlgrens University Hospital
Gothenburg, Sweden Yasuhito Tanaka, MD
Assistant Professor
Scott T. Sauer, MD
Department of Orthopaedic Surgery
Clinical Instructor
Nara Medical University
Department of Orthopaedic Surgery
Kashihara, Japan
Georgetown University School of Medicine
Washington, DC David D. Taylor, MD
Sports Medicine Fellow
Terence S. Saxby, FRACS (Ortho)
Methodist Sports Medicine
Consultant Orthopaedic Surgeon
Indianapolis, Indiana
Brisbane Foot and Ankle Center
Brisbane, Australia Hajo Thermann, MD, PhD
Professor, Trauma Department
Robert C. Schenck, Jr., MD
Hannover Medical School
Professor and Chairman
Hannover
Department of Orthopaedic Surgery
Center for Knee and Foot Surgery/Sports Trauma
University of New Mexico School of Medicine
ATOS Clinic Center
Albuquerque, New Mexico
Heidelberg, Germany
Lew C. Schon, MD Craig Ives Title, MD
Assistant Professor Department of Orthopaedics
Department of Orthopaedic Surgery Lenox Hill Hospital
The Johns Hopkins University New York, New York
Baltimore
Clinical Associate Professor of Orthopaedic Surgery C. Niek van Dijk, MD, PhD
Department of Orthopaedic Surgery Head
Georgetown University Medical Center Department of Orthopedic Surgery
Washington, DC Academic Medical Center
Director of Foot and Ankle Services Amsterdam, The Netherlands
Department of Orthopaedic Surgery Francesca Vannini, MD
The Union Memorial Hospital Department of Orthopaedic Surgery
Baltimore Bologna University
Active Staff, Part Time Consultant, VI Department
Department of Orthopaedic Surgery Istituti Ortopedici Rizzoli
The Johns Hopkins Medical Institutions Bologna, Italy
Baltimore, Maryland
Sergio Vianna, MD
Scott B. Shawen, MD, MAJ(P), MC Chief, Section of Foot and Ankle Surgery
Assistant Professor Instituto Nacional de Traumato-Ortopedia
Surgery Rio de Janeiro, Brazil
Uniformed Services University of the Health Sciences
Veronica Vianna, MD
Bethesda, Maryland
Member, Section of Foot and Ankle Surgery
Director, Orthopaedic Foot & Ankle Surgery
Instituto Nacional de Traumato-Ortopedia
Orthopaedics & Rehabilitation
Rio de Janeiro, Brazil
Walter Reed Army Medical Center
Washington, DC Xu Xiangyang, MD
Staff Orthopaedic Surgeon Professor
Surgery Department of Orthopaedics
Kimbrough Ambulatory Care Center Shanghai Jiaotong University Medical College
Fort Meade, Maryland Ruijin Hospital
Shanghai, China

ix
...........
 Contributors

Zhu Yuan, MM Chaim Zinman, MD

Attending Doctor The Bruce Rappaport Faculty of Medicine
Department of Orthopaedics Technion-Israel, Institute of Technology
Ruijin Hospital Chairman, Department of Orthopaedics B
Shanghai Rambam Medical Center
Jiaotong University Haifa, Israel
Shanghai Orthopaedics Institute
Shanghai, China Jerett Zipin, DO
Attending
Mohammed S. Zafar, BSc, MBBS, MRCS Sports Medicine
Specialist Registrar in Trauma and Orthopaedic Surgery Health Care Partners
University of Keele School of Medicine Pasadena, California
Staffordshire
University Hospitals
Birmingham
Selly Oak Hospital
Birmingham, United Kingdom

x
...........
......................................... P R E F A C E

The original volume of The Foot and Ankle in Sport by treatment. The chapter on the subtalar joint has been
Don Baxter has become a widespread authority on the expanded and the ever elusive topic of subtalar instability
diagnosis and treatment of athletic injuries to the foot has been addressed and hopefully clarified. We have
and ankle. It is an ominous task to improve on this text. added a chapter on new advances in the treatment of
In fact, our attempt with the second edition is to update the foot and ankle. We have tried to focus more on the
the already authoritative text and provide the same rehabilitation needs in the chapter on Unique Problems
authoritative resource today. in Sports and Dance. We have also added a new chapter
We have decided to keep the basic format with sec- on the principles of rehabilition for the foot and ankle.
tions on Athletic Evaluation, Sports Syndromes, Ana- The advancements in treatment for athletic injuries to
tomic Disorders, Unique Problems in Sports and the foot and ankle have continued to explode. We have
Dance and a section on shoewear, orthoses, and rehabil- therefore updated each chapter to keep the clinician at
itation. We hope you have enjoyed this approach and the forefront of this exciting field. We have tried to keep
find it helpful to your treatment of athletes and sports the length similar so as to be an easy access for all health
enthusiasts. care providers. The field of sports medicine of the foot
We have memorialized the chapter provided by and ankle has become global in its scope, therefore the
the late Ken Johnson, MD, by having one of his former reader will note a more international flavor to the
fellows compile this chapter. We have expanded the chap- authorship of this edition.
ter on trauma to focus on the treatment of ankle fractures We hope you enjoy this edition of the foot and ankle
(both acute and stress), midfoot ligamentous injuries and in sport. We have enjoyed working with our contributor
occult fractures of the foot and ankle. We have included friends and colleagues in the field of foot and ankle
a chapter on the problematic stress fractures also. The sports medicine. We have also enjoyed thinking of our
section on ankle injuries has been focused more closely readers and their needs and interests. We hope this edi-
on ankle instability, ankle sprains, and their updated tion meets all your interests, needs, and expectations.

xi
...........
........................................... C H A P T E R 1

Assessment and treatment of the elite athlete:

helpful hints and pertinent pearls
Donald Baxter and Lew Schon

......................
CHAPTER CONTENTS

#1. Look at the big picture 3 #12. Plan twice, cut once 12
#2. ‘‘Conservative treatment was exhausted’’ may #13. A stealthlike incursion should leave ne’er a trace 13
mean only that the athlete and medical team
were exhausted 4 #14. Minimize surgery and maximize recovery 15

#3. Conservative care may not conserve resources 5 #15. Identify injuries that are at high risk for failure 15

#4. Patience and relative rest are virtues 6 #16. A little instability can go a long way: keep both
eyes open 16
#5. Think about the nerves 7
#17. When is it okay to ‘‘spare the rod and spoil the
#6. The tarsal coalition can be the great masquerader 10 athlete’’? 18
#7. Timing should never be underrated 10 #18. Work backward in establishing a return to sport
protocol 18
#8. Location, location, location 10
#19. Everyone loves a winner 21
#9. Despite #8, it is better to be lucky than good 11
#20. It is better to have no publicity than bad publicity 21
#10. A quick fix may buy time 11
Conclusion 25
#11. Sometimes it is better to go for the base hit 11

Although this textbook contains sections on specific addition, other general sports activities should be noted,
entities, there are broader themes that must be consid- such as details about the gear; the surfaces; the opponents,
ered. The authors have compiled a list of their favorite teammates, and partners (dance); and the sporting envi-
pearls and highlighted them with case presentations. ronment. Training factors should be documented, espe-
The list is by no means profound or comprehensive, cially the duration, intensity, and frequency of events, as
but like a mantra recited during meditation, it still can well as the warm up and cool down. Motivational drives
be a source of inspiration or focus. These points cut and the way that the condition is perceived relative to
across many situations and can facilitate the assessment future ambitions are enlightening. Nutritional issues,
and care of the elite athlete. general health, medical history, medications, vitamins
and supplements, and prior surgeries or traumas often
may be revealing.
#1. LOOK AT THE BIG PICTURE
The physical examination should be performed ac-
cordingly, taking both wide and focused perspectives
The proper history and physical examination is com- and juxtaposing the examination with static and dynamic
pleted by keeping the big picture in mind and obtaining appraisals. The athlete should be observed during normal
contributory static and dynamic factors that affect standing, walking, and sitting, as well as running or
the athlete. This approach includes appreciating the performing the particular maneuvers of the sport or dance.
patient’s experience with the condition or injury; the The musculoskeletal system, especially the lower extremi-
character of the symptoms; the duration and onset of ties, warrants evaluation, because any one area can affect
the problem; aggravating and ameliorating factors; and the foot and ankle and the clinician may find clues that
a description of the specific offending activity. In are useful to determining a diagnosis and treatment. The
 CHAPTER 1  Assessment and treatment of the elite athlete: helpful hints and pertinent pearls

synthesis of these protean elements can be challenging but second toe. After a slow start to the season and requisite
carries a high reward for observing the human body at its reassurance, the pitcher won 22 games using a simple
finest physical performance. device (Fig. 1-1).
Another Major League Baseball player had ankle and
hindfoot symptoms that were felt to limit his hitting.
The ankle and hindfoot examination was unremarkable,
#2. ‘‘CONSERVATIVE TREATMENT WAS
with good stability, alignment, and strength. An exami-
EXHAUSTED’’ MAY MEAN ONLY THAT
nation of the whole musculoskeletal system brought to
THE ATHLETE AND MEDICAL TEAM
light an obvious genu varus, which resulted in varus of
WERE EXHAUSTED
the ankle and the subtalar joint. When watching him
simulate his swing, we noted that his ankle would subtly
In treating the elite athlete, as with treating any athlete invert. By placing an off-the-shelf lateral wedge into
or patient, there is an evaluation process that must the shoe, the player was able to get a better stance and
include conservative consideration of all options before more stability while batting and was able to increase
invasive treatment may be instituted. The orthopaedic his batting average significantly, winning the major
foot and ankle and or sports medicine subspecialist must league batting title (Fig. 1-2).
know the condition, its etiology, and its natural course. A professional quarterback asked for the opinion of
Timing relative to the disease state and the activity three foot and ankle subspecialists. His ruptured
requirements is critical and must influence the approach. Achilles tendon had been repaired one season before
Operative treatment might be considered with the elite the examination. The repair had stretched out and did
athlete, whereas conservative treatment would be used not allow adequate push-off. After careful discussion
with the high school athlete and nonathlete having the by the three orthopaedists who saw the quarterback
same problem. Although simple and complex nonsurgi- simultaneously, it was decided to treat the elongated
cal techniques exist for every orthopaedic malady, do and weak tendon conservatively with an ankle-foot
not assume that the solution was applied appropriately orthosis (AFO). This AFO was made with a plantar
or completely for the elite athlete. Often, a thorough assist by using an anterior tibial stop for the AFO
evaluation of the dynamic and static conditions that (Fig. 1-3). The Hall of Fame quarter back played three
contribute to the problem has not been synthesized to
design a customized, multitiered approach best suited
to the individual. As with surgery, there are ‘‘tricks and
moves’’ that can render the standard treatment into
a tour de force cure. Often the effort, including reas-
sessments and tweaking of the protocol, can be more
laborious and frustrating than an operative endeavor.
Finally, despite good intentions, it must be remembered
that nonoperative treatment carries risks and can be con-
sidered a waste of valuable time and resources. It is the
norm for multiple opinions to be offered regarding
treatment of elite athletes, and it is preferable for every-
one involved, including the team physician, agent, and
so forth, to agree with the treatment recommended by
the clinician.
With that said, the following cases illustrate straight-
forward and unglamorous conservative interventions that
carried little risk but made a major, beneficial impact.
A Major League Baseball player presented with
a chronic, overuse strain of his left great toe. He was
a left-handed pitcher, and the left great toe was being
subluxed into a lateral valgus position during push-off.
The problem was diagnosed as a form of a turf-toe,
more specifically a sprain of the medial sesamoidal pha-
langeal ligament and the medial head of the flexor hallu-
cis brevis tendon. After talking to the trainer, agent, Figure 1-1 Hallux valgus toe spacer is a useful means of
team doctor, and orthotist, we designed and custom conservative treatment for a metatarsophalangeal (MTP) cap-
made a spacer to fit between the great toe and the sular or ligamentous injury.
4
...........
 #3. Conservative care may not conserve resources

#3. CONSERVATIVE CARE MAY NOT

CONSERVE RESOURCES

Many stress fractures of the talus and other bones seen

on magnetic resonance imaging (MRI) have healed after
months of treatment but without surgery. Occasionally
these fractures can become long, drawn-out, chronic
affairs. The cost of a prolonged convalescence can be
overwhelming to the athlete and the team. With this
potential for a long recovery, it is typical to use a bone
stimulator, despite uncertainty that one truly is needed.
Thus whereas the cost may be prohibitive in the nonelite
athlete population, it can be justified for the elite
performer.
An example of the economic impact of the conserva-
tive option is provided. A 2-mm, displaced supination-
eversion II fibular fracture occurred in a top-level
National Hockey League player immediately preseason
(Fig. 1-5, A through C). He had no deltoid or syndes-
motic tenderness. There were concerns about potential
hardware prominence interfering with the skate if an
open reduction internal fixation (ORIF) were per-
formed. This would delay return to play until after the
Figure 1-2 Several views of wedged heel shock absorbers, hardware was removed. Given the nature of this injury
Anti-Shox by Apex (Teaneck, NJ). to heal quickly and uneventfully, it was decided to treat
the ankle fracture without surgery. The ankle was placed
more seasons with a similar brace and never had addi- in a cast and the player was kept nonweight bearing for 6
tional surgery to the Achilles tendon. weeks, then given a removable, off-the-shelf, boot brace.
A top-level and highly paid National Basketball Asso- He resumed conditioning and ankle strengthening pro-
ciation (NBA) star sustained within 1 year three sequen- gressively with low-impact activity and then subse-
tial injuries to his Achilles tendon that were diagnosed as quently began skating. At 3 months, he still had
partial tears. Following each injury, addressed by brief tenderness, focal edema, and warmth, and could not
bouts of conservative treatment (physical therapy [PT], skate aggressively or confidently enough to perform
nonsteroidal anti-inflammatory drugs [NSAIDs], and choppy sprints or to make quick stops and precision
rest), he was aggressively encouraged to continue to play turns. He also was concerned about getting checked
despite persistent pain, swelling, and dysfunction. His and sustaining a complete fracture. The x-ray and com-
third injury during the playoffs was the most incapacitat- puted tomography (CT) scan (Fig. 1-5, D) performed
ing, both physically and emotionally. He lost faith in his at 3 months showed approximately 20% healing along
doctors, whom he felt had allowed him to be reinjured the proximal posterior aspect. All parties were frustrated,
by trivializing his trauma as insignificant. Much to the and the team suffered without his talent. Treatments
frustration of the team management, doctors, and fans, discussed included operative and nonoperative modal-
he decided to wait for complete resolution of the swelling, ities. Among all parties—trainers, manager, team doctor,
pain, and weakness before resuming play and missed and the patient—it was agreed that we perform shock
numerous games. Further opinions were sought to bring wave treatment of the delayed union with the Sonocur
the situation to resolution. The nonsurgical solution that extracorporeal machine (which requires no local or gen-
we initiated satisfied all parties and permitted return with eral anesthetic), begin an EBI bone stimulator (EBI,
protection. A flexible plastic molded poster shell AFO, Parsippany, NJ), and fabricate a custom-molded, plastic
fabricated for each game (to avoid sudden and potentially AFO that could be worn in a sneaker. The patient
catastrophic fatigue failure of the device), reduced the continued to advance in his low-impact skating and
strain on the Achilles tendon while allowing somewhat nonskating workout, using the brace and bone stimula-
restricted and controlled mobility. With the device, he tor when not conditioning. By two additional months,
returned to play after a 6-month hiatus and experienced the fracture had progressed to 60% healing and the
progressive restoration of confidence while the injury symptoms had abated to allow return to aggressive
continued to heal (Fig. 1-4). skating during the playoffs (Fig. 1-5, E and F).
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 CHAPTER 1  Assessment and treatment of the elite athlete: helpful hints and pertinent pearls

Figure 1-3 The Toeoff splint made of carbon graphite (Camp Scandinavia, Helsingborg, Sweden). The Toeoff is
an AFO with an anterior tibial shell connected to a foot plate. The brace is open posteriorly.

an Achilles stretching protocol, orthotic devices, and

#4. PATIENCE AND RELATIVE REST
a night splint, the fascia finally healed and he recovered.
ARE VIRTUES
It was a year filled with many office visits and requests
for a quick fix. Great runners and elite athletes often
A world record holder in the 100 meters had plantar fas- find it difficult to be patient. No one knows when or
ciitis and could not compete for 12 months. He cross if the condition will resolve. On our side is the knowl-
trained with water running, biking, and lower impact edge that most cases of plantar fasciitis (more than
activities to stay in shape. Ultimately, with the use of 90%) respond to conservative modalities by 12 months.
6
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 #5. Think about the nerves

The risk of an unusual complication following plantar

#5. THINK ABOUT THE NERVES
fascia release and the loss of spring and push-off in this
sprinter were outweighed by the benefits of a potentially
faster recovery, given the demands of his sport. Of Many patients with a deep posterior compartment syn-
course, 20/20 hindsight is everything. drome have pain at one specific area. This pain usually

Figure 1-4 AFO for Achilles tendinitis. (Courtesy of John Rheinstein CPO, New York, NY and Otto Bock
Healthcare, Minneapolis, MN.)

Figure 1-5 (A-C) Lateral, mortise, and anteroposterior (AP) radiograph of the initial supination-eversion severity
rating II fracture in this professional hockey player.
(continued)
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 CHAPTER 1  Assessment and treatment of the elite athlete: helpful hints and pertinent pearls

Figure 1-5 cont’d. (D) The player was still symptomatic and a sagittal computed tomography (CT) scan at
3 months shows insufficient bridging of the fracture site. (E) Lateral x-ray at 5 months.

is isolated to the lower edge of the gastrocnemius on the syndrome. Occasionally, a specific nerve conduction test
medial side of the leg. With a history of chronic pain in and electromyogram (EMG) can pick up a delay of the
this compartment and a negative scan, exercise compart- tibial nerve in the leg. However, because the nerve
ment testing to rule out exertional compartment syn- entrapment is a functional entrapment from a hypertro-
drome is recommended. On occasion, despite normal phied muscle and a squeezing effect on the nerve, the
pressures, a local fascial release has been performed nerve conduction is not always positive. The symptoms
at the lower gastrocnemius, releasing what we have may result from a compressed tibial nerve, rather than
considered to be an isolated high tarsal tunnel from lack of oxygen to leg muscles.
8
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 #5. Think about the nerves

Figure 1-5 cont’d. (F) Sagittal CT scan at 5 months shows bridging of >60%.

We have treated several elite athletes, particularly permit the cramping to subside and the leg pain to
track runners, who have presented with a cramping-type resolve.
sensation in the posterior calf in the midline area. After Similarly, an athlete with what appears to be lateral
a full evaluation of standard posterior calf pain (deep exertional compartment syndrome may be suffering
venous thrombosis [DVT], exertional compartment from superficial peroneal nerve entrapment. This may
syndrome, muscle tear, and so forth), we have attributed present with normal compartment pressures. One
the pain to a sural nerve fascial constriction. Releasing should be aware that this condition may occur because
fascia around the sural nerve in this isolated area may of an unstable ankle. In the latter cases, not only does
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 CHAPTER 1  Assessment and treatment of the elite athlete: helpful hints and pertinent pearls

a superficial peroneal nerve have to be released, but the affected nerve, proximal to the transverse metatarsal
unstable ankle must be repaired as well. There are ana- ligament.
tomic variations of this nerve, and it may lie within the
lateral or anterior compartments or both.
The jogger’s foot is more common than most physi- #6. THE TARSAL COALITION CAN BE
cians realize. The medial plantar nerve may become THE GREAT MASQUERADER
entrapped at an isolated area at the knot of Henry.
Abnormal range of motion may lead to a squeezing
When treating the younger, promising, future elite ath-
effect by the hypertrophied abductor hallucis muscle.
letes, remember to consider the possibility of a tarsal
A minimal incision releases the medial plantar nerve;
coalition. Unlike the descriptions in the literature that
because it is relatively deep, care must be taken to avoid
portray the peroneal spastic flat foot, the tarsal coalitions
damage.
in athletic individuals present as chronic ankle sprains;
The anterior tarsal tunnel syndrome also is fascinating
chronic calcaneal, navicular or talus stress fractures; pos-
because the deep peroneal nerve may be irritated for sev-
terior tibial tendinitis; tarsal tunnel syndrome; sinus tarsi
eral reasons. It can be compressed because of a func-
syndrome; peroneal tendinitis; ankle impingement; or
tional instability of the ankle or the talonavicular joint.
even Achilles tendinitis. They rarely have peroneal spas-
The treatment includes a minimal release by cutting
ticity and typically do not have deformities. Often, sub-
the inferior edge of the retinaculum and then carefully
talar motion will be restricted but may not be eliminated.
removing dorsal bone from the talus or navicular bone
The x-rays may not show the coalition because they may
(Fig. 1-6). The lateral branch of the deep peroneal nerve
be incomplete, fibrous, or cartilaginous. MRI, CT scan,
may be compressed by the fascia of the extensor brevis
and/or technetium (Tc) bone scan may be needed to
muscle, causing a sinus tarsi pain. This is an often-over-
identify the site and extent of the coalition (Fig. 1-7).
looked cause of the sinus tarsi syndrome. In this situa-
tion, the nerve should be released where it is focally
tender, typically dorsal and medial to the sinus tarsi
itself. The fascia of the extensor brevis muscle can be #7. TIMING SHOULD NEVER BE
the causative structure, but the physician always must UNDERRATED
evaluate for ankle instability, as well. We do not recom-
mend transecting this nerve branch as a means of reduc-
ing the pain. Some of the hardest injuries to treat include the non-
Interdigital nerves are either entrapped and cut by displaced navicular stress fracture, the nondisplaced
the edge of the transverse metatarsal ligament or bul- medial-malleolar stress fracture, the nondisplaced Lis-
bous from chronic compression and scarring of the franc strain, and the high ankle sprain. With many of these
nerve. If the entrapment is treated before the nerve injuries, bone stimulators, cast immobilization or brac-
ing, rest, careful PT, and, occasionally, well-placed percu-
becomes ‘‘scarred and bulbous,’’ then a simple release
taneous screws are invaluable. Yet the most influential
of the intermetatarsal ligament may be considered.
factor is time. Insufficiency in this latter element may lead
If the nerve is bulbous, we prefer to remove the
to more complicated problems, such as displaced frac-
tures or dislocations, and a need for complex surgery.

#8. LOCATION, LOCATION, LOCATION

A stress fracture of the navicular or medial malleolus

generally is more ominous than a middle-lower one-
third junction fibula stress fracture. Although the former
stress fractures are more likely to preclude athletics, cer-
tain stress fractures, such as the latter, can be managed
less aggressively.
A world record-holding, female, middle distance run-
ner presented with a fibular stress fracture 4 cm above
Figure 1-6 Lateral radiograph of a dorsal osteophyte on na- ankle joint. She had excellent strength; good hip, knee,
viculum caused a deep peroneal neuralgia. leg, and ankle biomechanics; and no ankle instability

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 #11. Sometimes it is better to go for the base hit

Figure 1-7 Coronal magnetic resonance imaging (MRI) of a medial subtalar facet tarsal coalition in a young
dancer with hindfoot pain. She was referred for evaluation of insertional Achilles tendinitis. She had tender-
ness medially along the posterior tibial tendon, laterally in the sinus tarsi, and posteriorly by the retrocalcaneal
bursa. Following resection of the coalition, all three zones of tenderness resolved.

medially or laterally. She had some forefoot supination surgical trauma while reinforcing the weakened bone.
that was felt to cause a valgus moment at her ankle while The odds were not in our favor, but luck was. After
she was striding. After careful analysis of her condition, the season, two small screws and a bone graft were used
it was agreed that she could, with use of a semirigid in the navicular, preventing reoccurrence in a 5-year
orthotic, run one race that she and her trainer felt was professional basketball career (Fig. 1-8).
essential for her preparation for the World Champion-
ships. The plan was that, following this event, she would
then do easy training for two and a half weeks before her
#10. A QUICK FIX MAY BUY TIME
next big race. During the event, not only were the
symptoms controlled but she had the greatest race of Unlike the aforementioned case, an NCAA college bas-
her career, winning the world championship as her East- ketball center presented with a nonhealing proximal
ern European challenger fell, chasing her at the finish. second metatarsal fracture (about 1.5 cm distal to the
metatarsocuneiform [MTC] joint) several weeks before
the beginning of the season. The decision was made to
#9. DESPITE #8, IT IS BETTER TO place a screw across the fracture percutaneously and drill
BE LUCKY THAN GOOD the nonunion site. Eight weeks later, the center was able
to return to play. At the end of the season, the symp-
toms were escalating to the preseason level. After the
One National Collegiate Athletic Association (NCAA) season, the fracture underwent open bone grafting and
center for a Final Four basketball team sustained a non- insertion of a larger screw, and full recovery was permit-
displaced navicular fracture. The athlete used both ted during the off season (Fig. 1-9).
a high-intensity ultrasound machine and a bone stimula-
tor for a month before gradually resuming play with an
arch support. Two months after the injury, he played
#11. SOMETIMES IT IS BETTER TO GO
in the National Championship game without advancing
FOR THE BASE HIT
to a complete fracture. This was a risky choice; a better
option would have been to fix the fracture percutane- A middle distance runner was felt to have first tarsome-
ously without open grafting, in order to minimize the tatarsal (TMT) instability with hallux valgus, second
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 CHAPTER 1  Assessment and treatment of the elite athlete: helpful hints and pertinent pearls

Figure 1-8 (A) Centrally located navicular stress fracture seen on the anteroposterior (AP) x-ray (arrow).
(B) Sagittal magnetic resonance imaging (MRI) demonstrates edema in the naviculum.

metatarsophalangeal (MTP) subluxation, and lesser two Olympics and set an American record on the roads
metatarsal overload. A Lapidus procedure with MTC (Fig. 1-10).
fusion was recommended to correct the deformity.
Because most of the symptoms were at the bunion and
the runner could not take off more than 8 to 12 weeks,
#12. PLAN TWICE, CUT ONCE
a chevron bunionectomy was performed, ignoring the
first TMT instability. The runner did have a recurrence Treatments should be reviewed and rereviewed and
10 years later, but that was after he had participated in should stand up to scrutiny readily provided by the
12
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 #13. A stealthlike incursion should leave ne’er a trace

Figure 1-8 cont’d. (C and D) Two small screws were inserted from the medial pole.

athlete, family, coach, trainer, and agent. Similarly, it does permit concerted preoperative appraisal. Any
when devising a surgical plan, it always is useful to ‘‘wasted’’ time often will be recouped intraoperatively
review all the other alternatives for one’s own benefit, or postoperatively.
even though one may have a preferred treatment that
has worked well in the past. One should think about
how the plan or the alternatives will affect any associa-
#13. A STEALTHLIKE INCURSION SHOULD
ted conditions, the rehabilitation, return to sport,
LEAVE NE’ER A TRACE
and lifelong function beyond sports. Even though
the exercise of mapping out the screw placement or Our philosophy with the elite athlete is to restore the
osteotomy is tedious or may be considered remedial, anatomic structure with the least surgery possible and
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 CHAPTER 1  Assessment and treatment of the elite athlete: helpful hints and pertinent pearls

Figure 1-9 (A) An anteroposterior (AP) x-ray reveals the second metatarsal stress fracture in this basketball
player that became symptomatic just before the season. (B-D) Magnetic resonance imaging (MRI) demon-
strates the proximal fracture. (E) Intraoperative fluoroscan shows the insertion of the screw in a minimally
traumatic fashion that permitted him to start the season. Toward the end of a relatively asymptomatic season, his
symptoms increased and he underwent open bone grafting and insertion of a larger screw. Full recovery occurred
in the off season.

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 #15. Identify injuries that are at high risk for failure

#14. MINIMIZE SURGERY AND MAXIMIZE

RECOVERY

A pole vaulter missed the pit, landing on his foot in

abducted fashion. This led to the development of a spring
ligament/deltoid complex detachment. Ecchymosis and
tenderness were noted medially anterior to the medial
malleolus. The foot assumed an abducted posture with
bulging around the talonavicular joint. The posterior tib-
ial tendon had excellent strength with full inversion
power 45 degrees past the midline against resistance. An
MRI showed changes in the spring ligament. Intervention
with an anatomic and secure repair was critical to the pole
vaulter’s future career. The reconstruction was accom-
plished through a 4-cm incision (Fig. 1-11). After the torn
spring ligament was exposed at its navicular insertion, the
edges and thinned portions were debrided. The proximal
medial aspect of the pole of the navicular was roughened,
establishing a cancellous bleeding surface through which
an osseous suture anchor was placed, thereby avoiding
Figure 1-10 Preoperative x-ray of an elite runner with inadvertent talonavicular joint penetration. A splint was
hallux valgus and second metatarsophalangeal (MTP) joint applied following surgery. This was replaced by a brace
instability who ultimately had a chevron bunionectomy that was worn for 16 weeks. A heel lift was used for 6 to
instead of a Lapidus and second MTP joint procedure, as 8 weeks subsequently. Rehabilitation succeeded in per-
recommended elsewhere. mitting this athlete to resume his career and to set the
American pole vault record on his repaired foot.

#15. IDENTIFY INJURIES THAT ARE AT HIGH

RISK FOR FAILURE
then use a functional recovery. When surgery is per-
formed, the tissues should be minimally disturbed.
One should know where to go, not dissect widely, avoid Stress fractures of the medial malleolus, especially ver-
disrupting soft tissue planes, save neurovascular struc- tical type stress fractures, need a vertical repair, not a
tures, do the repair, and take care on the way out. Post-
operative management should allow rehabilitation
without compromising the integrity of the reconstruc-
tion. Initially a half-cast or U-splint and posterior splint
are used, followed by removable bracing with early
range of motion. This is especially important with
Achilles tears. One gifted sprinter ruptured his Achilles
tendon in the finals of the Olympic 100 meters. With a
minimal incision and limited exposure, the Achilles was
sutured. The anterior fat pad was reapposed, and the
paratenon was repaired. Early plantarflexion range of
motion was instituted postoperatively. The sprinter was
kept in equinus for 1 month in a plantarflexed brace.
Walking without the brace was permitted by 10 weeks.
Progressive impact activities were permitted with careful
monitoring by an excellent trainer/therapist. The Figure 1-11 Spring ligament repair. The torn spring ligament
sprinter was running aggressively by 9 months, and, by is seen after the posterior tibial tendon sheath is opened.
1 year, full-out sprinting was comfortable. The sprinter The triangular open arrow demonstrates the posterior tibial
came back in 18 months and ran the fastest 60-m indoor tendon, the solid arrow points to the naviculum, and the open
race of the year despite this potentially career-ending arrow shows the talonavicular ligament and spring ligament.
injury. The inset displays the ligament being held by forceps.
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 CHAPTER 1  Assessment and treatment of the elite athlete: helpful hints and pertinent pearls

horizontal repair. If a horizontal typical medial malleolar An NBA guard had a vertical stress fracture with a
screw is used in a vertical stress fracture of the medial medial malleolar screw and bone graft. The fracture
malleolus, the stresses are not adequately removed to healed; however, the following year, an additional frac-
allow healing, making it possible for the fracture to recur ture occurred in the same area and had to be fixed with
and the screw to break. For that reason, a buttress plate a buttress plate and bone graft (Fig. 1-14). Following
on the medial malleolus should be used to relieve the treatment, the NBA guard has been able to play for
vertical stresses (Fig. 1-12). 3 years with no further problems, playing 30 out of
One sprinter with an injured ankle and a medial mal- 48 minutes in each game. Functional problems with
leolar stress fracture was treated with nonweight-bearing biomechanical stresses need repair, eliminating those
activity and with conservative care for 2 months. His stresses that caused the injury.
ankle healed, and he went on to have a 15-year career,
including an Olympic appearance 12 years later, and
no further stress fractures occurred (Fig. 1-13). Other
#16. A LITTLE INSTABILITY CAN GO A LONG
athletes have had these vertical fractures, particularly
WAY: KEEP BOTH EYES OPEN
those with some genu varus or heel varus. There is an
inordinate amount of stress placed through the medial
malleolus, and conservative care will not suffice. In these Some joints are susceptible to ligamentous damage that
vertical fractures, extending above the articular cartilage, can present with occult instability and therefore are
the stress fracture should be curetted and small local often overlooked. Nearly all physicians can identify lat-
bone graft should be injected; then a medial buttress eral ankle ligamentous injuries, but what about the
plate should be used to remove the vertical stresses. spring ligament, the anterior deltoid, the Lisfranc liga-
ment, or instability of the MTP joint’s plantar plate?
A turf-toe injury of the great toe is a diagnosis that may
represent many anatomic problems. The standard great
toe strain, a first- or second-degree turf-toe, often can
be treated by using rigid plate inserts in the shoe and tap-
ing the great toe. If there is a complete rupture or third-
degree turf-toe type injury, there may be complete separa-
tion of the sesamoids from the proximal phalanx with rup-
ture of the sesamoidal phalangeal ligament(s); or there
may be a complete rupture of the adductor or abductor
tendon from the base of the proximal phalanx of the great
toe with or without collateral ligament injury, causing
marked laxity of the first metatarsal phalangeal joint.
There can be diastasis of a bipartite sesamoid or disruption
of the flexor hallucal brevis tendons from the sesamoids.
In these cases, performing bilateral anterior draw maneu-
ver and checking flexor hallucis longus (FHL) and flexor
hallucis brevis (FHB) function may reveal the deficit. Fur-
ther testing with a varus or valgus stress also is helpful, as
well. X-rays and MRIs can show irregular position of the
sesamoids with ligament and/or tendon rupture. These
instabilities can result in problems cutting, pivoting,
running, and jumping. Long term, if unaddressed, the
joint subjected to nonphysiologic shear stresses will
suffer degenerative changes. If recognized early, the condi-
tion can be repaired and the cycle of deterioration
halted. Although the rehabilitation period is 6 to 9
months, return to top performance is possible (Fig. 1-15).
The plantar plate injury in the lesser MTP joints also
Figure 1-12 This medial malleolar stress fracture was unrec- can be a ‘‘small’’ problem with grave consequences if
ognized and went on to complete fracture. Notice the medial the joint subluxates or, even worse, dislocates. This is
talar osteophyte. The fracture was fixed with horizontally particularly true when there is a long second metatarsal.
placed compression screws and an Ace Depuy (Warsaw, IN) Again, early recognition with the anterior draw test and
fibular plate. varus/valgus stresses is paramount. Although further
16
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 #16. A little instability can go a long way: keep both eyes open

Figure 1-13 The magnetic resonance imaging (MRI) showed this medial malleolar stress fracture that healed
following conservative treatment.

subluxation of the second metatarsophalangeal joint

may be prevented by initially treating a plantar plate
strain of the metatarsal phalangeal joint (including plan-
tarflexion stretching of the extensor tendon by use of a
metatarsal pad and toe taping), surgical repair may be
warranted. Once the plantar plate stretches out signifi-
cantly, either acutely or chronically, surgery must be
considered (Fig. 1-16). In this case, a second MTP dis-
location and hallux valgus were treated with a Chevron-
Akin osteotomy and open reduction of the dislocation.
The second MTP joint was stabilized with a 0.62 pin,
which was left in place for 3 weeks. In the patient with
a long second metatarsal and unstable MTP joint, we
do an oblique osteotomy to shorten the metatarsal
(Fig. 1-17).
Why do some fibular stress fractures and high ankle
sprains lead to diastasis of the ankle joint, whereas other
fractures of the fibula do not? (Fig. 1-18). At times,
incompetence of the anterior deltoid ligament or spring
ligament is to blame. When rotary ankle injury occurs
with or without fibula fracture, one should check for
tenderness in the anterior deltoid (Fig. 1-19). If there
is excessive swelling and tenderness over the anterior
deltoid or spring ligament, a repair should be considered Figure 1-14 (A) The x-ray shows a medial malleolar stress
in the high-performance athlete. If the anterior deltoid fracture.
ligament is torn from the medial malleolus or off the (continued)
17
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 CHAPTER 1  Assessment and treatment of the elite athlete: helpful hints and pertinent pearls

Figure 1-14 cont’d. (B) After fixation with a single screw, the fracture ultimately failed and the complete fracture
was treated with bone graft and medial malleolar plating with a Synthes tibial plate.

the medial malleolus or the navicular to repair the torn

anterior deltoid. If there is some question about
whether the diastasis needs support, a diastasis screw
should be used after the anterior deltoid has been fixed.

#17. WHEN IS IT OKAY TO ‘‘SPARE THE

ROD AND SPOIL THE ATHLETE’’?

Midtibial chronic stress fractures with the ‘‘dreaded

black line’’ usually respond to drilling without the need
for bone grafting (Fig. 1-20). We have success with bal-
let dancers with a minimal drilling of the isolated tibial
stress fracture under x-ray control. Dancers have gone
on to long careers without reoccurrence of the stress
Figure 1-15 Sagittal magnetic resonance imaging (MRI) fractures once this tibial stress fracture heals from
demonstrates the rupture of the plantar plate (solid arrow
isolated drilling. It is imperative for the ballet dancer
shows retracted sesamoid; open arrow points to intact flexor
hallucis longus [FHL] tendon, which is directly plantar to the
or the athlete to avoid torque for 2 to 3 months before
rupture of the sesamoid phalangeal ligament). or after the drilling process so that the stress fracture
does not lead to a complete catastrophic fracture.

navicular attachment, the ankle is allowed to rotate out

of the ankle mortise. Unfortunately, if a diastasis screw
is placed across the tibiofibular joint, the talus will con-
#18. WORK BACKWARD IN ESTABLISHING
tinue to sublux forward in the ankle mortise. In severe
A RETURN TO SPORT PROTOCOL
injuries of the ankle in which there is a lateral malleolar
fracture and a diastasis, consider repairing the injury by One should realize that designing an appropriate return
plating the distal fibula and putting anchors in either to the sports program requires not only an appreciation
18
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 #18. Work backward in establishing a return to sport protocol

Figure 1-16 In this case, a second metatarsophalangeal (MTP) dislocation and hallux valgus was treated
by open reduction and pinning of the second in conjunction with a Chevron-Akin osteotomy. The joint was
stabilized with a 0.62 pin across the MTP joint that was left in place for 3 weeks. 19
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 CHAPTER 1  Assessment and treatment of the elite athlete: helpful hints and pertinent pearls

Figure 1-17 (A and B) This ultra-marathon runner had been

treated conservatively for a progressively more symptomatic
second hammertoe, second metatarsophalangeal (MTP)
subluxation, and hallux valgus. (C) Return to running was
10 weeks with this distal chevron osteotomy coupled with a
distal second metatarsal oblique osteotomy and proximal
interphalangel fusion.

20
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 #20. It is better to have no publicity than bad publicity

elliptical trainer. At 6 weeks postoperatively, an Airsport

or lace-up ankle brace is applied, allowing for more
mobility. Dancing at the barre is permitted but relevé
beyond the 40-degree plantarflexed position must be
avoided so as not to stretch the repair. At 10 to 12
weeks, the relevé restrictions are gradually lifted, but full
pointe should not be achieved until 14 weeks. Once full
range of motion permits completion of the barre exer-
cises without pain or swelling, the dancer may begin
center work. The dancer should initially avoid pirou-
ettes, large jumps, or leaps. As soon as the dancer mas-
ters the smaller jumps and rapid weight shift from side
to side, he or she can advance to performing faster
movement combinations that incorporate the pirouettes
and jumps, ideally by 18 weeks. To reach the target
release date, the dancer should be able to handle a full
class and rehearsal by 20 weeks. During rehabilitation,
the trainer, teacher, and/or orthopaedist must continu-
ously assess the dancer’s signs and symptoms to ensure
that the reconstruction is not undone as these new
stresses are introduced.
Figure 1-18 Fibula stress fractures need to be evaluated
for medial ankle ligamentous instability and occult syndes-
motic instability. Although pain can be the best guide, stress
views and a magnetic resonance imaging (MRI) may be #19. EVERYONE LOVES A WINNER
helpful.
The easy cases that require little worry and intervention
are a pleasure to recap and ponder. The challenge is to
of the competition or performance schedule but an stay engaged with the ones that are not following the
assessment of the timing and requirements of a recondi- typical pathway. One should be prepared to get addi-
tioning program. The clinician should learn from the tional advice. At the least, the clinician should step back,
athlete, trainer, and coach what milestones and compe- clear the mind of any assumptions, and acquire new or
tencies are achieved in the typical preseason routine revisit old information about the case. This process of
and how long they take to be mastered. Next, knowing providing oneself with a second opinion generally is pro-
the magnitude of the injury and requisite recovery to ductive and will allow the less successful recoveries to
nonathletic baseline, one should anticipate the tasks switch to the winning category.
and time for reestablishing the athletic baseline. Along
the way, the clinician should determine what testing or
standards will be used to permit safe advancement to
#20. IT IS BETTER TO HAVE NO PUBLICITY
the next level of activity.
A good example is a ballet dancer with chronic ankle
THAN BAD PUBLICITY
instability who undergoes a lateral ligament reconstruc-
tion. To return to high-level dance, he or she must It is the athlete’s business to converse with the public
achieve not only full range of motion, strength, stability, through the media. The clinician must respect the
and proprioception but also endurance. In our basic wishes of the patient and his or her team for confidenti-
protocol, the athlete is off the foot and in a posterior ality. These days it is the law. The clinician’s glory will
splint for 10 to 14 days after surgery. Then a boot brace come in a quieter manner long after the fans have lost
is applied and the athlete is allowed to be fully weight intense interest as the athlete manages to return without
bearing. During this time, a strengthening program is a relapse or reinjury through the season. One should let
initiated and the ankle can be put through a range of the agents, athletes, and team handle the press. In ad-
motion from maximum dorsiflexion to 30 to 40 degrees dition, a worse situation is the negative press associ-
of plantarflexion, avoiding any inversion. Cardiovascular ated with failure or a complication, whether or not the
workout can be achieved using an exercise bike or physician was responsible.

21
...........
 CHAPTER 1  Assessment and treatment of the elite athlete: helpful hints and pertinent pearls

Figure 1-19 (A) This is an athlete whose magnetic resonance imaging (MRI) demonstrated a fibula stress frac-
ture (open arrow);
(continued)

22
...........
 #20. It is better to have no publicity than bad publicity

Figure 1-19 cont’d. (B) Regular arrow shows fracture. There also is edema of the talus dome laterally, deltoid
signal abnormalities, and changes in the anterior tibial fibular ligaments (open arrow shows the syndesmotic
injury).
(continued)

23
...........
 CHAPTER 1  Assessment and treatment of the elite athlete: helpful hints and pertinent pearls

Figure 1-19 cont’d. (C) The coronal MRI views demonstrate the syndesmotic injury (regular and open arrows).

24
...........
 Conclusion

by issues, trainers, coaches, agents, team physicians,

owners, and other consultants who influence the inter-
action. The big picture is visualized so that the static
and dynamic factors can be assessed. Odd condi-
tions present with uncharacteristic symptoms, and stan-
dard conditions may manifest in peculiar ways. The
physician should think profoundly to determine the
diagnosis and then create a customized treatment algo-
rithm that incorporates conservative and surgical modal-
ities. One should provide honest and evidence-based
opinions.
The timing obviously is important. Being cost con-
scious is laudable, but the cost of a conservative or sur-
gical treatment sometimes is dwarfed by the cost of
missed games and bad seasons. If an operation is
warranted, it should be well conceived, striving for a
biomechanically logical and anatomically sound recon-
struction with limited surgical trauma. Postoperative
rehabilitation and return to sport or dance should be
mapped and reassessed along the way to avoid a setback.
Communication should flow to the patient and his or
Figure 1-20 The white arrow delineates the ‘‘dreaded black her immediate family and should involve the trainers,
line’’ of the established tibial stress fracture. therapists, coaches, and agents as permitted by Health
Insurance Portability and Accountability Act (HIPAA).
The media should be directed to contact the player
or his or her designee. Most importantly, one should
CONCLUSION keep an open and creative mind, work hard, treat people
with dignity, and enjoy the journey. Once the athlete,
The elite athlete presents a wide variety of challenges the trainer, and the agent see positive outcomes,
that require a keen knowledge of anatomy, biome- other cases will follow and the physician will slowly
chanics, physiology of healing, and psychology to inter- develop a good reputation for being a doctor who treats
pret. Usually the physician and athlete are surrounded winners.

25
...........
Exploring the Variety of Random
Documents with Different Content
 294 OLIVER TWIST. It might oe that her tears relieved her,
or that she fell the full hopelessness of her condition ; but she
turned back ; and hurrying with nearly as great rapidity in the
contrary direction- partly to recover lost time, and partly to keep
pace with the violent current of her own thoughts : soon reached
the dwelling where she had left the house-breaker. If she betrayed
any agitation, when she presented herself, to Mr. Sikes, he did not
observe it ; for merely inquiring if she had brought the money, and
receiving a reply in the af* firmative, he uttered a growl of
satisfaction, and replacing his head upon the pillow, resumed the
slumbers which her arrival had interrupted. It was fortunate for her
that the possession of money occasioned him so much employment
next day in the way of eating and drinking ; and withal had so
beneficial an effect in smoothing down the asperities of his temper ;
that he had neither time nor inclination to be very critical upon her
behavior and deportment. That she had all the abstracted and
nervous manner of one who is on the eve of some bold and
hazardous step, which it has required no common struggle to resolve
upon, would have been obvious to the lynx-eyed Fagin, vAio would
most probably have taken the alarm at once ; but Mr. Sikes lacking
the niceties of discrimination, and being troubled with no more
subtle misgivings than those which resolve themselves into a dogged
roughness of behavior towards everybody ; and being, furthermore
in an unusually amiable condition, as has been already observed ;
saw nothing unusual in her demeanor, and indeed, troubled himself
so little about Jier, that, had her agitation been far more jJerceptible
than it was, it would have been very unlikely to have awakened his
suspicions. As that day closed in, the girl's excitement increased ;
and when night came on, and she sat by, watching until the
housebreaker should drink himself asleep, there was an unusual
paleness in her cheek, and a fire in her eye, that even Sikes
observed with astonishment. Mr. Sikes being weak from the fever,
was lying in bed, taking hot water with his gin to render it less
inflammatory ; and had pushed his glass towards Nancy to be
replenished for the third or fourth time, when these symptoms first
struck him. " Why, burn my body ! " said the man, raising himself on
his hands, as he stared the girl in the face. " You look lika a coipse
come to life again. What's the matter ? "
 OLIVER TWIST. 295 " Matter !" replied the girl. "Nothing.
What do you look at me so hard for } " " What foolery is this .'' "
demanded Sikes, grasping her by the arm, and shaking her roiigly. "
What is it ? What do you mean t What are you thinking of t " " Of
many things, Bill," replied the girl, shivering, and as she did so,
pressing her hands upon her eyes. " But, Lord I What odds in
that.'*" The tone of forced gayety in which the last words were
spoken, seemed to produce a deeper impression on Sikes than the
wild and rigid look which had preceded them. '' I tell you wot it is,"
said Sikes ; " if you haven't caught *lie iever, and got it comin' on,
now, there's something more •iian usual in the v^-ind, and
something dangerous too. You're 'Ot a-going to . No, damme ! you
wouldn't do that ! " " Do what ? " asked the girl. " There ain't," said
Sikes, fixing his eyes upon the girl, and nuttering the words to
himself; "there ain't a stauncheraearted girl going, or I'd have cut
her throat three months ago. She's got the fever coming on ; that's
it." Fortifying himself with this assurance, Sikes drained the glass to
the bottom, and then, wdth many grumbling oaths, called for his
physic. The girl jumped up, with great alacrity ; poured it quickly
out, but with her back towards him ; and held the vessel to his lips,
while he drank off the con-tents. " Now," said the robber, " come
and sit aside of me, and put on your own face ; or I'll alter it so, that
you won't know it again when you do want it." The girl obeyed.
Sikes, locking her hand in his, fell back upon the pillow : turning his
eyes upon her face. They closed ; opened again ; closed once more
; again opened. He shifted his position restlessly ; and, after dozing
again^ and again, for two or three minutes, and as often springing
up with a look of terror, and gazing vacantly about him, was
suddenly stricken, as it were, while in the very attitude of rising,,
into a deep and heavy sleep. The grasp of his hand relaxed ; the
upraised arm fell languidly by his side ; and ha lay like one in a
profound trance. " The laudanum has taken effect at la'^t,'
murmured the girl, as she rose from the bedside. " I may be too
late, evec now." She hastily dressed herself in her bonnet and shawl
: look
 596 OLIVER TWIST. ing fearfully round, from time to time,
as if, deapite the sleeping draught she expected every moment to
feel the pressure of Sikes's heavy hand upon her shoulder ; then
stooping softly over the bed, she kissed the robber's lips ; and then
opening and closing the room-door with noiseless touch, hurried
from the house. A watchman was crying half-past nine, down a dark
passage through which she had to pass, in gaining the main
thoroughfare. " Has it long gone the half hour ? " asked the girl. *'
It'll strike the hour in another quarter," said the man, raising his
lantern to her face. " And I cannot get there in less than an hour or
more." muttered Nancy, brushing swiftly past him, and gliding
rapidly down the street. Many of the shops v/ere already closing in
the back lanes and avenues through which she tracked her Vv^ay, in
making from Spitalfields towards the West-End of London. The clock
struck ten, increasing her impatience. She tore along the narrow
pavement : elbowing the passengers, from side to side ; and darting
almost under the horses' heads, crossed crowded streets, where
clusters of people were eagerly watching their •opportunity to do the
like. " The woman is mad ! " said the people, turning to look after
her as she rushed away. Vv hen she reached the more wealthy
quarter of the town, the streets were comparatively deserted; and
here her headlong progress excited a still greater curiosity in the
stragglers whom she hurried past. Some quickened their pace
behind, as though to see whither she was hastening at such an
unusual rate ; and a few made head upon her, and looked back,
surprised at her undiminished speed ; but they feU off one by one ;
and when she neared her place of destination, she was alone. It was
a family hotel in a quiet but handsome street near Hyde Park. As the
brilliant light of the lamp which burnt before its door, guided her to
the spot, the clock struck eleven. She had loitered for a few paces as
though irresolute, and maVdng up her mind to advance ; but the
sound determined her and she stepped into the hall. The porter's'
seat was vacant. She looked round with an air of incerti* tude, and
advanced towards the stairs. " Now, young woman .' " said a
smartly-dressed fem2.1e.
 OLIVER TWIST. 297 looking out from a door behind her,
"what do you want here ? " " A lady who Is stopping in this house,"
answered the girl. " A lady ! " was the reply, accompanied with a
scornful look. " What lady ? " " Miss Maylie,'' said Nancy. The young
woman, who haa by this time, noted her appearance, replied only by
a look of virtuous disdain ; and summoned a man to answer her. To
him, Nancy repeated her request. " What name am I to say ? "
asked the waiter. " It's of no use saying any," replied Nancy. " Nor
business ? " said the man. " No, nor that neither," rejoined the girl. "
I must see the lady." " Come ! " said the man, pushing her towards
the door, " None of this. Take yourself off." " I shall be carried out, if
I go ! " said the girl violently ; ^' and I can make that a job that two
of you won't like to do. Isn't, there anybody here," she said, looking
round, " that will -see a simple message carried for a poor wretch
like me ? " This appeal produced an effect on a good-tempered-
faced man-cook, who with some of the other servants was looking
on, and who stepped forward to interfere. " Take it up for her, Joe ;
can't you ? " said this person. " What's the good ? " replied the man.
" You don't suppose the young lady will see such as her ; do you ? "
This allusion to Nancy's doubtful character, raised a vast quantity of
chaste wrath in the bosoms of four housemaids, who remarked, with
great fervor that the creature was a dis grace to her sex ; and
strongly advocated her being thrown, ruthlessly, into the kennel. "
Do what you like with me," said the girl, turning to the men again ; "
but do what I ask you first, and I ask you to .give this message for
God Almighty's sake." The soft-hearted cook added his intercession,
and the result was that the man who had first appeared undertook
its delivery. " What's it to be ? " said the man, with one foot on the
stairs. " That a young woman earnestly asks to speak to Miss Maylie
alone," said Nancy ; " and that if the lady will only
 298 OLIVER TWIST. hear the first word she has to say, she
will know whether tQ hear her business, or to have her turned out of
doors as an. impostor." " I say," said the man, you're coming it
strong ! " " You give the message," said the girl firmly ; " and let me
hear the answer," The man ran up stairs. Nancy remained, pale and
almost breathless, listening with quivering lip to the very audible
expressions of scorn, of which the chaste housemaids were very
prolific ; and of which they became still more so, when the man
returned, and said the young woman was to walk up stairs. " It's no
good being proper in this world," said the first housemaid. " Brass
can do better than the gold what has stood the fire," said the
second. The third contented herself with wondering " what ladies
was made of ; " and the fourth took the first in a quartette of "
Shameful ! " with which the Dianas concluded. Regardless of all this
: for she had weightier matters at heart . Nancy followed the man,
w^th trembling limbs, to a small antechamber, lighted by a lamp
from the ceiling. Here he left her, and retired. CHAPTER XL. A
STRANGE INTERVIEW, WHICH IS A SEQUEL TO THE LAST
CHAPTER. The girl's life had been squandered in the streets, and
among the most noisome of the stews and dens of London,, but
there was something of the woman's original nature left in her still ;
and when she heard a light step approaching the door opposite to
that by which she had entered, and thought of the wide contrast
which the small room would in another moment contain, she felt
burdened with the sense of her own deep shame, and shrunk as
though she could scarcely bear the presence of her with whom she
had sought this interview. But struggling with these better feelings
was pride, — the vice of the lowest and most debased creatures no
less than
 OLIVER TWIST. 299 of the high and self-assured. The
miserable companion of thieves and ruffians, the fallen outcast of
low haunts, the associate of the scourings of the jails and hulks,
living within the shadow of the gallows itself, — even this degraded
being felt too proud to betray a feeble gleam of the womanly feeling
which she thought a weakness, but which alone connected her with
that humanity, of which her wasting life had obliterated so many,
many traces when a very child. She raised her eyes sufficiently to
observe that the figure which presented itself was that of a slight
and beautiful girl ; then, bending them on the ground, she tossed
her head with affected carelessness as she said : " It's a hard matter
to get to see you, lady. If I had taken offence, and gone away, as
many would have done, you'd have been sorry for it one day, and
not without reason either.'^ " I am very sorry if any one has
behaved harshly to you,'' replied Rose. " Do not think of that. Tell me
why you wished to see me. I am the person you inquired for." The
kind tone of this answer, the sweet voice, the gentle manner, the
absence of any accent of haughtiness or displeasure, took the girl
completely by surprise, and she burst, into tears. " Oh, lady, lady ! "
she said, clasping her hands passionately before her face, " if there
was more like you, there would be fewer like me, there would —
there would ! " " Sit down," said Rose, earnestly. " If you are in
poverty or affliction I shall be truly glad to relieve you if I can, — I
shall indeed. Sit down." " Let m^ stand, lady," 5aid the girl, still
weeping, " and do not speak to me so kindly till you know me better.
It is growing late. Is — is — that door shut? " " Yes," said Rose,
recoiling a few steps, as if to be nearer assistance in case she should
require it. " Why 1 " " Because," said the girl, " I am about to put my
life, and the lives of others in your hands. I am the girl that dragged
little Oliver back to old Fagin's, on the night he went out from the
house in Pentonville." " You ! " said Rose Maylie. " I, lady ! " replied
the girl. " I am the infamous creature you have heard of, that lives
among the thieves, and that never from the first moment I can
recollect my eyes and senses opening on London streets have known
any better life, or kinder words than they have given me, so help me
God I
 300 OLIVER TWIST. Do not mind shrinking openly fiom me,
lady. I am younger than you would think, to looJc at me, but I am
well used to it. The poorest women fall back, as I make my way
along the crowded pavement." " What dreadful things are these ? "
said R.ose, involuntarily falling from her strange companion. " Thank
Heaven upon your knees, dear lady," cried the girl, " that you had
friends to care for and keep you in your childhood, and that you
were never in the midst of cold and hunger, and riot and
drunkenness, and — and — something worse than all — as I have
been from my cradle. I may use the word, for the alley and the
gutter were mine, as they will be my death-bed." " I pity you ! " said
Rose, in a broken voice. " It wrings my heart to hear you ! " "
Heaven bless you for your goodness ! " rejoined the girl. "If you
knew what I am sometimes, you would pity me, indeed. But I have
stolen away from those who would surely murder me, if they knew I
had been here, to tell you what I have overheard. Do you know a
man named Monks ? " " No," said Rose. " He knows you," replied
the girl ; " and knew you were here, for it was by hearing him tell
the place that I found you out." " I never heard the name," said
Rose. " Then he goes by some other amongst us," rejoined the girl,
" which I more than thought before. Some time ago, and soon after
Oliver was put into your house on the night of the robbery, I —
suspecting this man — listened to a conversation held between him
and Fagin in the dark. I found out, from what I heard, that Monks —
the man I asked you about, you know — " " Yes," said Rose, " I
understand." " — That Monks," pursued the girl, "had seen him
accidentally with two of our boys on the day we first lost him, and
had known him directly to be the same child that he was watching
for, though I couldn't make out why. A bargain was struck with
Fagin, that if Oliver was got back he should have a certain sum ; and
he was to have more for making him a thief, which this Monks
wanted for some purpose of his ^wn." " For what purpose ? " asked
Rose. " He caught sight of my shadow on the wall as I listened,
 OLIVER TWIST. 301 In the hope of finding out," said the
girl ; " and there are not many people besides me that could have
got out of their way in time to escape discovery. But I did : and I
saw him no more till last night." " And what occurred then ? " " I'll
tell you, lady. Last night he came again. Again they went up stairs,
and I, wrapping myself up so that my shadow should not betray me,
again listened at the dcor. The first words I heard ]\Ionks say were
these : ' So the only proofs of the boy's identity lie at the bottom of
the river, and the old hag that received them from the mother is
rotting in her coffin.' They laughed, and talked of his success in
doing this ; and ]\Ionks, talking on about the boy, and getting very
wild, said that though he had got the young devil's money safely
now, he'd rather have had it the other way ; for, what a game it
would have been to have brought down the boast of the father's
will, by driving him through every jail in town, and then hauling him
up for some capital felony which Fagin could easily manage, after
having made a good profit of him besides." " What is all this 1 " said
Rose. " The truth, lady, though it comes from m^y lips," replied the
girl. " Then, he said, Vv'ith oaths common enough in my ears, but
strange to yours, that if he could gratify his hatred by taking the
boy's life without bringing his own neck in danger, he would ; but, as
he couldn't, he'd be upon the watch to meet him at every turn in life
; and if he took advantage of his birth and history, he might harm
him yet. * In short, Fagin,' he says, ' Jew as you are, you never laid
such snares as I'll contrive for mv vouns: brother, Oliver.'" " His
brother ! " exclaimed Rose. " Those were his words," said Nancy,
glancing uneasily round, as she had scarcely ceased to do, since she
began to speak, for a vision of Sikes haunted her perpetually. " And
more. When he spoke of you and the other lady, and said it seemed
contrived by Heaven, or the devil, against him, that Oliver should
come into your hands, he laughed, and said there was some comfort
in that too, for how many thousands and hundreds of thousands of
pounds would you not give if you had them, to know who your two-
legged spaniel was." " You do not mean," said Rose, turning very
pale, " to tell me that this was said in earnest ? " " He spoke in hard
and angrry earnest, if a man ever did,**
 302 OLIVER TWIST. replied the girl, shaking her head. *•
He is an earnest mafl when his hatred is up. I know many who do
worse things ; but I'd rather listen to them all a dozen times, than to
that Monks once. It is growing late, and I have to reach home
without suspicion of having been on such an errand as this. I must
get back quickly." " But what can I do .'* " said Rose. " To what use
can I turn this communication without you ? Back ! Why do you wish
to return to companions you paint in such terrible colors ? If you
repeat this information to a gentleman whom I can summon in an
instant from the next room, you can be •consigned to some place of
safety without half an hour's -delay." " I wish to go back," said the
girl. "I must go back, because — how can I tell such things to an
innocent lady like you ? — because among the men I have told you
of, there is one : the most desperate among them all : that I can't
leave ; no, not even to be saved from the life I am leading now." "
Your having interfered in this dear boy's behalf before," said Rose ; "
your coming here, at so great a risk, to tell me what you have heard
; your manner, which convinces me 'Of the truth of what you say ;
your evident contrition, and sense of shame ; all lead me to believe
that you might be yet reclaimed. Oh ! " said the earnest girl, folding
her hands as the tears coursed down her face, "do not turn a deaf
ear to the entreaties of one of your own sex ; the first — the first, I
do believe, who ever appealed to you in the voice of pity and
compassion. Do hear my words, and let me save you yet, for better
things." " Lady," cried the girl sinking on her knees, " dear, sweet,
angel lady, you arc the first that ever blessed me with siich words as
these, and if I had heard them years ago, they might have turned
me from a life of sin and sorrow ; but it is too late, it is too late ! " "
It is never too late," said Rose, " for penitence and •atonement," " It
is," cried the girl, writhing in the agony of her mind, " I cannot leave
him now ? I could not be his death." "Why should you be ? " asked
Rose. " Nothing could save him," cried the girl. " If I told others
what I have told you, and led to their being taken, he would be sure
to die. He is the boldest, and has been so cruel . "
 OLIVER TWIST. 30^ " Is it possible," cried Rose, *' that for
such a man as thisr you can resign every future hope, and the
certainty of immfr diate rescue ? It is madness." " I don't know what
it is," answered the girl; "I onl* know that it is so, and not with me
alone, but with hundreds of others as bad and wretched as myself. I
must go back Whether it is God's wrath for the wrong I have done, I
do no\ know ; but I am drawn back to him through every suffering
and ill usage; and I should be, I believe, if I knew that } was to die
by his hand at last." " What am I to do ? " said Rose. " I should not
let you depart from me thus." " You should, lady, and I know you
will," rejoined the girl, rising. " You will not stop my going because I
have trusted in your goodness, and forced no promise from you, as I
might have done." " Of what use, then, is the communication you
have made ?* said Rose. " This mystery must be investigated, or
how will its disclosure to me, benefit Oliver, whom you are anxious
to serve ? " " You must have some kind gentleman about you that
wil> hear it as a secret, and advise you what to do," rejoined the
girl. " But where can I find you again when it is necessary ? " asked
Rose. " I do not seek to know where these dreadful people live, but
where will you be walking or passing at any settled period from this
time ? " " Will you promise me that you will have my secret strictly
kept, and come alone, or with the only other person that knows it ;
and that I shall not be watched or followed?" asked the girl. " I
promise you solemnly," answered Rose. " Every Sunday night, from
eleven until the clock strikes" twelve," said the girl without
hesitation, " I will walk on London Bridge if I am alive." " Stay
another mioment," interposed Rose, as the girl moved hurriedly
towards the door. " Think once again on your own condition, and the
opportunity you have of escaping. from it. You have a claim on me:
not only as the voluntary bearer of this intelligence, but as a woman
lost almost beyond redemption. W^ill you return to this gang of
robbers, and to* this man, when a word can save you ? What
fascination is it that can take you back, and make you cling to
wickedness and
 3^4 OLIVER TWIST. misery ? Oh ! is there no chord in your
heart that I can touch ! Is theie nothing left, to which I can appeal
against this terrible infatuation ! " " When ladies as young, and
good, and beautiful as you aie,'' replied the girl steadily, "give away
your hearts, love will carry }ou all lengths — even such as you, who
have home, friends, other admirers, everything to fill them. When
such as I, who have no certain roof but the coffm-lid, and no friend
in sickness or death but the hospital nurse, set our rotten hearts on
any man, and let him fill the place that has been a blank through all
our wretched lives, who can hope to cure us ? Pity us, lady — pity us
for having only one feeling of the woman left, and for having that
turned, by a heavy judgment, from a comfort and a pride, into a
new means of violence and suffering," " You will," said Rose, after a
pause, " take some money from me, which m.ay enable you to live
without dishonesty — at all events until we meet again ?" " Not a
penny," replied the girl, waving her hand. " Do not close your heart
against all my efforts to help you," said Rose, stepping gently
forward " I wish to serve you indeed." " You would serve me best,
lady," replied the girl, wringing her hands, "if you could take my life
at once ; for I have felt more grief to think of what I am, to night,
than I ever did before, and it would be something not to die in the
hell in which I have lived. God bless you, sweet lady, and send as
much happiness on your head as I have brought shame on mine ! "
Thus speaking, and sobbing aloud the unhappy creature turned
away ; while Rose Maylie. overpowered by this extraordinary
interview, which had more the semblance of a rapid dream than an
actual occurrence, sank into a chair, and en' 'eavored to collect her
wandering thoughts.
 OLIVER TWIST, 305 CHAPTER XLT. CONTAINING FRESH
DISCOVERIES, AND SHOWING THAT SURPRISES, LIKE
MISFORTUNES, SELDOxM COME ALONE. Her situation was, indeed,
one of no common trial and difficulty. While she felt the most eager
and burning desire to penetrate the mystery in which Oliver's history
was enveloped, she could not but hold sacred the confidence which
the miserable woman with whom she had just conversed, had
reposed in her, as a young and guileless girl. Her words and manner
had touched Rose Maylie's heart ; and mingled with her love for her
young charge, and scarcely less intense in its truth and fervor, was
her fond wish to win the outcast back to repentance and hope. They
purposed remaining in London only three days, prior to departing for
some weeks to a distant part of the coast. It was now midnight of
the first day. What course of action, could she determine upon,
whicli could be adopted in eightand-forty hours ? Or how could she
postpone the journey without exciting suspicion 1 Mr. Losberne was
with them, and would be for the next two days ; but Rose was too
well acquainted with the excellent gentleman's impetuosity, and
foresaw too clearly the wrath with which, in the first explosion of his
indignation he would regard the instrument of Oliver's re-capture, to
trust him with the secret, when her representations in the girl's
behalf could be seconded by no experienced person. These were all
reasons for the greatest caution and most circumspect behavior in
communicating it to Mrs. Maylie, whose first impulse would infallibly
be to hold a conference with the worthy doctor on the subject. As to
resorting to any legal adviser, even if she had known how to do so, it
was scarcely to be thought of, for the same reasons. Once the
thous^ht occurred to her of seekins: assistance from Harry ; but this
awakened the recollection of their last parting, and it seemed
unworthy of her to call him back, when — the tears rose to her eyes
as she pursued this train of reflection — he might have by this time
learnt to forget her, and to be happier away. Disturbed by these
different reflecticns : inclining now ta
 3o6 OLIVER TIVIST. one course and then to another, and
again recoiling from all, as each successive consideration presented
itself to her mind : Rose passed a sleepless and anxious night. After
more communing with herself next day, she arrived at the desperate
conclusive of consulting Harry. " If it be painful to him," she thought,
" to come back here, how painful it will be to me ! But perhaps he
will not come ; he may write, or he may come himself, and
studiously abstain from meeting me — he did when he went away. I
hardly thought he would ; but it was better for us both." And here
Rose dropped the pen, and turned away, as though the very paper
which was to be her messenger should not see her weep. She had
taken up the same pen, and laid it down again fifty times, and had
considered and reconsidered the first line of her letter without
writing the first word, when Oliver, who had been walking in the
streets, with Mr. Giles, for a bodyguard, entered the room in such
breathless haste and violent agitation, as seemed to betoken some
new cause of alarmi. " What makes 3'ou look so flurried .'' " asked
Rose, advancing to meet him. " I hardly know how ; I feel as if I
should be choked,'^ replied the boy. '' Oh dear ! To think that I
should see him at last, and you should be able to know that I have
told you all the truth ! " " I never thought 3^ou had told us anything
but the truth,'* said Rose, soothing him. " But what is this .'* — of
whom da you speak ? " " I have seen the gentleman," replied Oliver,
scarcely able \o articulate, " the gentleman who was so good to me
— Mr» Brownlow, that we have so often talked about." " Where "i "
asked Rose. " Getting out of a coach," replied Oliver, shedding tears
of delight, " and going into a house. I didn't speak to him — I
couldn't speak to him, for he didn't see me, and I trembled so, that I
was not able to go up to him. But Giles asked, for me, whether he
lived there, and they said he did. Look here," said Oliver, opening a
scrap of paper, " here it is ; here's where he lives — I'm going there
directly ! Oh, dear me, dear me ! What shall I do when I come to
see him and hear him. speak again ! " With her attention not a little
distracted by fiese, and a great many other incoherent exclamations
of joy, Rose read
 OLIVER TWIST. 307 the address, which was Craven Street,
in the Strand. She very soon determined upon turning the discovery
to account. " Quick ! " she said. " Tell them to fetch a hackney-
coach, and be ready to go with me. I will take you there directly,
without a minute's loss of time. I will only tell my aunt that we are
going out for an hour, and be ready as soon as you are. " Oliver
needed no prompting to despatch, and in little more than five
minutes they were on their way to Craven Street. When they arrived
there. Rose left Oliver in the coach, under pretence of preparing the
old gentleman to receive him ; and sending up her card by the
servant, requested to see Mr. Brownlow on very pressing business.
The servant soon returned, to beg that she would walk up stairs ;
and following him into an upper room, Miss Maylie was presented to
an eldeily gentleman of benevolent appearance, in a bottle-green
coat. At no great distance from whom, was seated another old
gentleman, in nankeen breeches and gaiters ; who did not look
particularly benevolent, and who was sitting with his hands clasped
on the top of a thick stick, and his chin propped thereupon. " Dear
me," said the gentleman, in the bottle-green coat, hastily rising with
great politeness. " I beg your pardon, young lady. I imagined it was
som.e importunate person who — I beg you will excuse me. Be
seated, pray. " "Mr. Brownlow, I believe, sir?" said Rose, glancing
from the other gentleman to the one who had spoken. " That is my
name," said the old gentleman. " This is my friend, Mr. Grimwig.
Grimwig, will you leave us for a few minutes ? " " I believe,"
interposed Miss Maylie, " that at this period of our interview I need
not give that gentleman the trouble of ^ going away. If I am
correctly informed, he is cognizant of the business on which I wish
to speak to you." Mr. Brownlow inclined his head. Mr. Grimwig, who
had made one very stiff bow, and risen from his chair, made another
very stiff bow, and dropped into it again. " I shall surprise you very
much, I have no doubt," said Rose, naturally embarrassed ; "but you
once showed great benevolence and goodness to a very dear young
friend of mine, and I am sure you will take an interest in hearing of
him again." " Indeed ! " said Mr. Brownlow.
 3oS OLIVER TWIST, " Oliver Twist you knew him as,"
replied Rose. The words no sooner escaped her lips, than Mr.
Grimwi^ who had been affecting to dip into a large book that lay on
the table, upset it with a great crash, and falling back in his chair,
discharged from his features every expression but one of
unmitigated wonder, and indulged in a' prolonged and vacant stare ;
then, as if ashamed of having betrayed so much emotion, he jerked
himself, as it were, by a convulsion into his former attitude, and
looking out straight before him emitted a long deep whistle, which
seemed, at last, not to be discharged on empty air, but to die away
in the innermost recesses of his stomach. Mr. Brownlow wasno less
surprised, although his astonishment was not expressed in the same
eccentric manner. He drew his chair nearer to Miss Maylie's, and
said, " Do me the favor, my dear young lady, to leave entirely out of
the question that goodness and benevolence of which you speak,
and of which nobody else knows anything ; and if you have it in your
pov/er to produce any evidence which v/ill alter the unfavorable
opinion I was once induced to entertain of that poor child, in
Heaven's name put me in possession of it." " A bad one ! I'll eat my
head if he is not a bad one," growled Mr. Grimwig, speaking by some
ventriloquial power, without moving a muscle of his face. " He is a
child of a noble nature and a warm heart," said Rose, coloring ; "
and that Power which has thought fit to try him beyond his years,
has planted in his breast affections and feelings which would do
honor to many who have numbered his days six times over." " I'm
only sixty-one," said Mr. Grimwig, with the same rigid face. " And, as
the devil's in it if this Oliver is not twelve years old at least, I don't
see the application of that remark." " Do not heed my friend, Miss
Maylie," said Mr. Brown' low ; " he does not mean what he says."
"Yes, he does," growled Mr. Grimwig. " No, he does not," said Mr.
Brownlow, obviously rising in wrath as he spoke. " He'll eat his head,
if he doesn't," growled Mr. Grimwig. " He would deserve to have it
knocked off, if he does," said Mr. Brownlow. " And he'd uncommonly
like to see any man offer to
 OLIVER TlVISr, 309 do it, ^' responded Mr. Grimwig,
knocking his stick upon the floor. Having gone thus far, the two old
gentlemen severally took snuff, and afterwards shook hands,
according to their invariable custom. *^' Now, Miss Maylie," said Mr.
Brownlow, " to return to ithe subject in which your humanity is so
much interested. IWill you let me knov/ what intelligence you have
of this poor child : allowing me to premise that I exhausted every
means in my power of discovering him, and that since I have been
absent from this country, my first impression that he had imposed
upon me, and had been persuaded by his former associates to rob
me, has been considerably shaken." Rose, who had had time to
collect her thoughts, at once related, in a few natural words, all that
had befallen Oliver since he left ]\Ir. Brownlow's house ; reserving
Nancy's information for that gentleman's private ear, and concluding
with the assurance that his only sorrow^, for some months past,
had been the not being able to meet with his former benefactor and
friend. " Thank God ! " said the old gentleman. " This is great
happiness to me, great happiness. But you have not told me where
he is now. Miss Maylie. You must pardon my finding fault with you,
— but why not have brought him ? " " He is waiting in a coach at the
door," replied Rose. *• At this door ! " cried the old gentleman. With
v/hich he hurried out of the room, down the stairs, up the coach-
steps, and into the coach, v/ithout another word. When the room-
door closed behind him, ]\Ir. Grimwig lifted up his head, and
converting one of the hind legs of his chair into a pivot, described
three distinct circles with the assistance of his stick and the table :
sitting in it all the time. After performing this evolution, he rose and
limped as fast as he could up and down the room at least a dozen
times, and then stopping suddenly before Rose, kissed her without
the slightest preface. " Hush ! " he said, as the young lady rose in
some alarm at this unusual proceeding. " Don't be afraid. I'm old
enough to be your grandfather. You're a sweet girl. I like you. Here
they are ! " In fact, as he threw himself at one dexterous dive into
his former seat, Mr. Brownlow returned, accompanied by Oliver,
whom Mr. Grimwig received very graciously ; and it" the
 3IO OLIVER TWIST. gratification of that moment had been
the only reward for all her anxiety and care in Oliver's behalf, Rose
Maylie would have been well repaid. " There is somebody else who
should not be forgotten by the bye," said Mr. Brownlow, ringing the
bell. " Send Mrs. Bedvv^in here, if you please." The old housekeeper
answered the summons with all dis-^ patch ; and dropping a curtsey
at the door, waited for orders. I " Why, you get blinder every day,
Bedwin," said Mr. Brownlow, rather testily. " Well, that I do, sir,"
replied the old lady. " People'seyes, at my time of life, don't improve
with age, sir." " I could have told you that," rejoined Mr. Brownlow ;
" but put on your glasses, and see if you can't find out what you
were ivanted for, will you ? " The old lady began to rummage in her
pocket for her spectacles. But Oliver's patience was not proof against
this new trial ; and yielding to his first impulse, he sprang into her
arms. " God be good to me ! " cried the old lady, embracing him ; "
it is my innocent boy ! " " My dear old nurse ! " cried Oliver. " He
would come back — I knew he would," said the old lady, holding him
in her arms. '^ How well he looks, and how like a gentleman's son
he is dressed again ! Where have you been, this long, long while ?
Ah ! the same sweet face, but not so pale ; the same soft eye, but
not so sad. I have never forgotten them or his quiet smile, but have
seen them every day, side by side with those of my own dear
children, dead and gone since I was a lightsome young creature."
Running on thus, and now holding Oliver from her to mark how he
had grown, now clasping him to her and passing her fingers fondly
through his hair, the good soul laughed and wept upon his neck by
turns. Leaving her and Oliver to compare notes at leisure, Mr,
Brownlow led the way into another room ; and there, heard from
Rose a full narration of her interview with Nancy, which occasioned
him no little surprise and perplexity. Rose also explained her reasons
for not confiding in her friend Mr. Losberne in the first instance. The
old gentleman considered that she had acted prudently, and readily
undertook to hold solemn conference with the worthy doctor himself.
To afford him an early opportunity for the execution of this design, it
 OLIVER TWIST. 3 IT was arranged that he should call at
the hotel at eight o'clock that evening, and that in the meantime
Mrs. Maylie should be cautiously informed of all that had occurred.
These preliminaries adjusted, Rose and Oliver returned home. Rose
had by no means overrated the measure of the good doctor's wrath.
Nancy's history was no sooner unfolded to him, than he poured forth
a shower of mingled threats and execrations ; threatened to make
her the first victim of the combined ingenuity of Messrs. Blathers and
Duff ; and actually put on his hat preparatory to sallying forth to
obtain the assistance of those worthies. And, doubtless, he would, in
this first outbreak, have carried the intention into effect without a
moment's consideration of the consequences, if he had not been
restrained, in part, by corresponding violence on the side of Mr.
Brownlow, who was himself of an irascible temperament, and partly
by such arguments and representations as seemed best calculated
to dissuade him from his hot-brained purpose. " Then what the devil
is to be done t " said the impetuous doctor, when they had rejoined
the two ladies. " Are we to pass a vote of thanks to all these
vagabonds, male and female, and beg them to accept a hundred
pounds, or so, apiece, as a trifling mark of our esteem, and some
slight acknowledgment of their kindness to Oliver ? " " Not exactly
that," rejoined Mr. Brownlow, laughing : ^'' but we must proceed
gently and with great care." " Gentleness and care," exclaimed the
doctor. " I'd send them one and all to " " Never mind where,"
interposed Mr. Brownlow. " But reflect whether sending them
anywhere is likely to attain the object we have in view." " What
object?" asked the doctor. " Simply, the discovery of Oliver's
parentage, and regaining for him the inheritance of which, if this
story be true, he has been fraudulently deprived." " Ah ! " said Mr.
Losberne, cooling himself with his pocket-handkerchief ; " I almost
forgot that." " You see," pursued Mr. Brownlow ; " placing this poor
girl entirely out of the question, and supposing it were possible to
bring these scoundrels to justice without compromising her safety,
what good should we bring about ? " " Hanging a few of them at
least, in all probability," sug' -gested the doctor, " and transporting
the rest."
 312 OLIVER TWIST, *' Very good," replied Mr. Brownlow
smiling ; " but no doubt thevwill brin.'x that about for themselves in
the fulness of time, and if we step in to forestall them, it seems to
me that we shall be performing a very Quixotic act, in direct
opposition to our own interest — or at least to Oliver's, v/hich is the
same thing." " How ? " inquired the doctor. " Thus. It is quite clear
that we shall have extreme diffi' culty in getting to the bottom of this
mystery, unless we can bring this man. Monks, upon his knees. That
can only be done by stratagem, and by catching him when he is not
surrounded by these people. For, suppose he were apprehended, we
have no proof against him. He is not even (so far as we know, or as
the facts appear to us) concerned with the gang in any of their
robberies. If he were not discharged, it is very unlikely that he could
receive any further punishment than being committed to prison as a
rogue and vagabond ;. and of course ever afterwards his mouth
would be so obstinately closed that he might as well, for our
purpose, be deaf^ dumb, blind, and an idiot." " Then," said the
doctor impetuously, " I put it to ycu again, whether you think it
reasonable that this promise ta the girl should be considered
binding; a promise made with the best and kindest intentions, but
really " " Do not discuss the point, my dear young lady, pray," said
Mr. Brownlow^ interrupting Rose as she was about ta speak. " The
promise shall be kept. I don't think it will, in the slightest degree,
interfere with our proceedings. But, before we can reso! ve upon any
precise course of action, it will be necessary to see the girl ; to
ascertain from her whether she will point out this Monks, on the
understanding that he is to be dealt with by us, and not by the law ;
or, if she will not, or cannot do that, to procure from her such an
account of his haunts and descrip^jtion of his person, as will enable
us to identify him. She cannot be seen until next Sunday night ; this
is Tuesday. I would suggest that in the meantime, we remain
perfectly quiet, and keep these matters secret even from Oliver
himself." Although Mr, Losberne received with man}'' wTy faces a
proposal involving a delay of live whole days, he was fain to admit
that no better course occurred to him just then ; and as both Rose
and Mrs. Maylie sided very strongly with Mr. Brownr low, that
gentleman's proposition was carried unanimously.
 OLIVER TWIST. Z'^Z " I should like." he said, " to call in
the aid of my friend Grimwig. He is a strange creature, but a shrewd
one, and might prove of material assistance to us; I should say that
he was bred a lawyer, and quitted the Bar in disgust because he had
only one brief and a motion of course, in twenty years, though
whether that is a recommendation or not, you must determine for
yourselves." " I have no objection to your calling in your friend if I
m^)^ call in mine," said the doctor. " We must put it to the vote,"
replied Mr. Brov/nlow, " who may he be ? " " That lady's son, and
this young lady's — very old friend," said the doctor, motioning
towards Mrs. Maylie, and concluding with an expressive glance at
her niece. Rose blushed deeply, but she did not make any audible
objection to this motion (possibly she felt in a hopeless minorit},') ;
and Harry Maylie and Mr. Grimwig were accordingly added to the
committee. " We stay in town, of course," said Mrs. Maylie, "while
there remains the slightest prospect of prosecuting this inquiry with
a chance of success. I will spare neither trouble nor expense in
behalf of the object in which we are all so deeply interested, and I
am content to remain here, if it be for twelve months, so long as you
assure me that any hope remains." " Good ! " rejoined jMr.
Brownlow. " And as I see on the faces about me, a disposition to
inquire how it happened, that I was not in the w'ay to corroborate
Oliver's tale, and had so suddenly left the kingdom, let me stipulate
that I shall be asked no questions until such time as I may deem it
expedient to forestall them by telling my own story. Believe me, I
make this request with good reason, for I might otherwise excite
hopes destined never to be realized, and only increase difficulties
and disappointments already quite numerous enough. Come !
Supper has been announced, and young Oliver, who is all alone in
the next room, will have begun to think, by this time, that we have
wearied of his company, and entered into some dark conspiracy to
thrust him forth upon the world." With these w'ords, the old
gentleman gave his hand to Mrs. Maylie, and escorted her into the
supper-room. Mr. Losberne followed, leading Rose ; and the council
was for the present, effectually broken up.
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