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Background: Metatarsalgia and plantar plate tears are characterized by forefoot pain and toe deformity in severe cases. Conservative management may slow progression of symptoms; however, definitive treatment often requires operative intervention. The purpose of this observational study was to evaluate the combination of plantar condylectomy and surgical imbrication of the plantar plate to the metatarsal neck to repair grade 0 plantar plate injuries. Methods: We retrospectively identified 22 patients with metatarsalgia and low-grade plantar plate lesions (grade 0), operated between 2018 and 2021, who underwent operative repair involving plantar metatarsal condylectomy and proximal surgical imbrication of the plantar plate to the metatarsal neck. Fourteen patients underwent concomitant hallux valgus correction. Data collection was performed preoperatively and postoperatively and included Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores. Paired Wilcoxon signed-rank tests compared PROMIS PF and PI scores at patients’ preoperative, 6-9-week, 3-4-month, 5-6-month, and ≥9-month follow-up evaluations ( P

Background: There continues to be controversy regarding treatment options for Achilles tendon ruptures (ATR). The aim of our study is to compare outcomes between operatively and nonoperatively managed Achilles ruptures in young adults (age 18-30 years), which has not been previously evaluated. Methods: At a single institution, all patients aged 18-30 years at time of injury who underwent treatment for an acute ATR from 2014 to 2021 were evaluated. Medical records were reviewed to collect demographics, dates of injury and treatment, smoking status, body mass index (BMI), Charlson Comorbidity Index (CCI), rate of deep venous thrombosis (DVT) after treatment, and rate of rerupture. Patients then completed Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) questionnaires. Mann-Whitney nonparametric testing was used to evaluate for any statistical differences in PROMIS scores. Results: Sixty-six operative patients qualified and 28 (42%) participated. Thirty-seven nonoperative patients qualified and 14 (38%) participated. All patients had a CCI of 0. One patient in the operative cohort and 2 in the nonoperative reported active smoking. In the operative and nonoperative cohorts, respectively, the average age was 24.4 and 27.8 years; average BMI 26.5 (SD = 4.8) and 27.3 (SD = 4.3, P = .52); DVT rates 4 (6.1%) and 2 (5.4%); and rerupture rates 2 (3.0%) and 1 (2.7%), respectively. PROMIS scores did not differ in the operative and nonoperative groups: PROMIS PF mean of 60.4 (SD = 9.8) and 62.9 (SD = 9.1), respectively ( P = .33); as well as PROMIS PI mean of 44.6 (SD = 5.9) and 43.9 (SD = 6.5), respectively ( P = .59). Conclusion: This study should be interpreted with the understanding that we had a considerable loss to follow-up rate. In the study cohort, we found that young adults with ATR may be considered for either operative or nonoperative management. Rates of DVT, rates of rerupture, and PROMIS scores were not dissimilar between the 2 cohorts. Level of Evidence: Level III, retrospective cohort study.

Background: Lateral talar subluxation (LTS) was introduced as a measurement tool for evaluating isolated Weber B ankle fractures, with LTS >4 mm on gravity stress (GS) radiographs possibly indicating need for surgery. This study reviews LTS measurements in nonoperatively managed isolated Weber B fibula fractures to further investigate the validity of this previously stated cutoff. Methods: The senior authors previously reported outcomes of a novel algorithm for nonoperative management of isolated Weber B ankle fractures. Outcome scores reported include American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, Olerud-Molander (OMA), Foot and Ankle Ability Measure for activities of daily living (FAAM/ADL), and visual analog scale (VAS) scores. All patients achieved union of their fracture. LTS was measured on GS radiographs of both injured and contralateral uninjured extremities. Results: Forty-two patients were included with minimum 1-year follow-up. Average age was 49 years (range 19-72). Mean measurements on injury GS radiographs were as follows: medial clear space (MCS) 4.45 mm (SD = 0.93), superior clear space (SCS) 3.46 mm (SD = 0.70), and LTS 2.33 mm (SD = 1.57, range 0-4.7 mm), with 35 (83.3%) patients having injury LTS ≤4 mm. Mean measurements on contralateral (uninjured) GS radiographs were as follows: MCS 3.39 mm (SD = 0.63), SCS 3.15 mm (SD = 0.50), and LTS 1.30 mm (SD = 1.28, range 0-4.8 mm). There was no statistically significant difference in all outcome measures based on amount of LTS (4 mm). Conclusion: Most patients had injury LTS ≤4 mm, although those with LTS >4 mm had excellent outcome scores. LTS measurements on normal ankles reveal a large range. LTS may be a useful adjunct in evaluating isolated Weber B ankle fractures but the 4-mm cutoff may not be entirely reliable. Further studies are required to validate LTS as a decision-making tool. Level of Evidence: Level IV, case series.

Background: Though ubiquitously used in orthopaedic trauma, lower extremity splints may have associated iatrogenic risk of morbidity. Although clinicians pad bony prominences to minimize skin pressure, the effect of joint position on skin pressure and, more specifically, changing joint position, is understudied. The purpose of this biomechanical study is to determine the effect of various short-leg splint application techniques on anterior ankle surface pressure in the development of iatrogenic skin pressure ulcers. Methods: Various constructs of lower extremity, short-leg splints were applied to 3 healthy subjects (6 limbs total) with an underlying pressure transducer (Tekscan I-Scan system) on the skin surface centered on the tibialis anterior tendon at the level of the ankle. All subjects underwent anterior ankle surface pressure assessment when padding was applied in maximum plantar flexion and neutral position for conventional short-leg splints application in clinically relevant patient scenarios. Percentage change from initial contact pressure centered on the tibialis anterior with cast padding were calculated. Results: The percentage change in anterior ankle contact pressure when padding was applied in maximum plantar flexion (PF) and then definitively placed in neutral was increased at least 2-fold without the addition of plaster in lower extremity short-leg splints. Removing anterior ankle padding following final splint application in neutral reduced contact forces at the anterior ankle 46% and 59% in splints applied in maximum PF and neutral ankle position, respectively. Conclusion: The present study is the first of its kind to underscore and quantify clinically relevant technical pearls that can be useful in reducing risk of iatrogenic risk of skin breakdown at the anterior ankle when placing short-leg splints, mainly, that it is imperative to apply padding in the intended final splint position and to remove anterior ankle padding following splint application when able. Level of Evidence: Level IV, biomechanical study with clear hypothesis.

Category: Lesser Toes Introduction/Purpose: Lesser toe metatarsophalangeal (MTP) instability is implicated in common forefoot pain and deformities. The plantar plate is a major stabilizing structure of the MTP joint with instability frequently occurring after a tear or attenuation of this structure. Previous studies have demonstrated that the blood supply to the proximal plantar plate comes from both the metatarsal and the plantar fascia. Commonly, a McGlamry elevator is used to strip the plantar plate from the plantar surface of the metatarsal to improve exposure of the MTP joint. The vascular consequence of stripping the plantar plate from the metatarsal is not yet well understood. The purpose of this study is to quantify the relative contribution of blood supply to the proximal plantar plate from the metatarsal and plantar fascia. Methods: Twelve fresh-frozen human adult cadaver lower extremity specimens were utilized for this study, resulting in 35 lesser MTP joints that were studied. All specimens were between the ages of 18 and 65 years and had no history of diabetes, peripheral vascular disease, or connective tissue disorders. Specimens with a history of trauma to the foot or ankle, prior foot or ankle surgery, or evidence of clinical deformity of less toes upon inspection were excluded. The specimens were prepared as described previously in Finney et al. The anterior and posterior tibial arteries were perfused with a barium solution and counterstained with phosphomolybdic acid. The second through fourth MTP joints of 12 feet were imaged with nano-computed tomography (nano- CT) at 14-micron resolution. Reconstructed 3D and 2D CT images were utilized for analysis of the volume of vasculature along the metatarsal pedicle and plantar fascia of the proximal plantar plate. Results: Based on nano-CT imaging, the plantar plate specimen demonstrated microvascular infiltration at the proximal attachments of the metatarsal neck, interosseous muscles, periosteum, and plantar fascia (Figure 1). An average of 63.5% of the vascular supply to the proximal portion of the plantar plate entered from the metatarsal pedicle in 35 lesser toe specimens analyzed. The remaining 36.5% of the vascular supply entered from the plantar fascia. The second toes, third toes, and fourth toes had an average of 64.7%, 59.0%, and 67.1% of vasculature supply from the metatarsal pedicle, respectively. The average volume of vasculature from the metatarsal pedicle to the proximal plantar plate was 0.38 mm 3 , while the average volume of vasculature from the plantar fascia to the proximal plantar plate was 0.19 mm 3 . Conclusion: The vascular supply of the proximal plantar plate is supplied from both the metatarsal pedicle and plantar fascia. Using the McGlamry elevator for exposure of the MTP joint disrupts the dominant tributary for proximal plantar plate perfusion.

Category: Trauma; Ankle Introduction/Purpose: Lower extremity splints are commonly used in orthopaedic care throughout emergency departments, operating rooms, and outpatient clinics. Although the mainstay of ankle immobilization, they have been associated with ulcers due to high contact pressures over bony prominences and the anterior ankle. High contact pressures may occur in the anterior ankle when splint padding is applied while the ankle is in a plantarflexed position and subsequently dorsiflexed as the plaster or fiberglass hardens. The purpose of this study is to measure contact pressures in the anterior ankle when cast padding is applied in a plantarflexed position and subsequently dorsiflexed. We hypothesized, that the removal of padding over the anterior ankle following dorsiflexion would result in reduced anterior ankle contact pressures. Methods: Short leg posterior U-splints were applied to the right lower extremity in two healthy volunteers with an underlying pressure transducer [Tekscan I-Scan system (Tekscan Inc, South Boston, MA, USA)] on the skin surface centered over the tibialis anterior tendon. Anterior ankle surface pressures were measured when the padding was applied in maximum plantar flexion and dorsiflexed to neutral position as measured by a goniometer. This was then repeated in the same subjects but prior to dorsiflexion, a 3cm x 3cm square of padding was removed over the pressure transducer prior to dorsiflexion. Percent change from initial contact pressure centered on the tibialis anterior with either Webril (Covidien/Medtronic, Dublin, Ireland), or Specialist Cotton Blend Cast Padding (BSN Medical, Charlotte, NC, USA) was calculated. Results: There were 2 limbs analyzed for presentation of this pilot data. The percent change in anterior ankle contact pressure when padding was applied in plantar flexion and then placed in neutral was an average increase of 264% with just padding and 238% with padding and plaster. [TP1] Subsequently, the removal of padding from the anterior ankle resulted in an average decrease of 126% of[TP2] the increased pressure relative to baseline measurements (Figure 1). The reduction in contact force with the removal of Webril was greater than Specialist. Conclusion: In this pilot data, we report increases in anterior ankle contact pressures when splint padding is applied in plantar flexion and re-positioned into neutral. However, removal of anterior ankle padding reduces pressure over the anterior ankle and may reduce the risk of iatrogenic splint related ulcers in this area. Additionally, this technique may elicit varying reductions in anterior ankle pressure depending on the type of cast padding utilized. This data, though preliminary, underscores the importance of avoiding excess padding over the anterior ankle during splint application.

Category: Ankle; Trauma; Other Introduction/Purpose: Though ubiquitously utilized in orthopaedic trauma, lower extremity splints are not without their associated iatrogenic risk of morbidity. In fact, improper splinting not only necessitates replacement, but splint-related soft tissue complications are the second most common iatrogenic cause for referral to plastic surgery. Improper splinting techniques include inadequate molding of plaster/fiberglass splints, inadequate padding over bony prominences, excessive compressive forces from elastic bandages applied too aggressively, and/or pressure areas created by applying padding and casting material in varying joint positions. While clinicians commonly pad bony prominences to minimize skin pressure, the effect of joint position on skin pressure and, more specifically, changing joint position, is understudied. The purpose of this study is to evaluate anterior ankle skin pressure secondary to joint position change during splinting. Methods: Following ethics approval by our institutional review board, various constructs of lower extremity, short-leg splints were applied to two healthy subjects (2 limbs total in this preliminary data set) with an underlying pressure transducer (Tekscan I- Scan system (Tekscan Inc, South Boston, MA, USA) on the skin surface centered on the anterior ankle on the tibialis anterior tendon. All subjects underwent anterior ankle surface pressure assessment when padding was applied in maximum plantar flexion and neutral position for conventional short leg splints application. Percent change from initial contact pressure centered on the tibialis anterior with either Webril (Covidien/Medtronic, Dublin, Ireland), or Specialist Cotton Blend Cast Padding (BSN Medical, Charlotte, NC, USA) were calculated. Neutral position of the foot/ankle will be confirmed with goniometer. Results: There were 2 limbs total that were analyzed for the presentation of pilot data for this study. The percent change in anterior ankle contact pressure when padding was applied in maximum plantarflexion (PF) and then placed in neutral was increased at least two-fold without the addition of plaster and subsequently with the addition of plaster in lower extremity short leg splints (Figure 1). Conclusion: In this pilot data, we report significant increases in anterior ankle contact pressures when splint padding is applied in plantar-flexion and re-positioned into neutral during splint application which may precipitate iatrogenic pressure ulcers in patients sustaining foot/ankle trauma. This data, though preliminary, underscores the importance in proper splinting techniques for all clinicians that manage lower extremity trauma (eg, orthopaedic surgery, emergency medicine, urgent care, etc).

Category: Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Persistent metatarsalgia refractory to non-operative therapy with accompanying plantar plate injury represents a common and challenging treatment problem. In previous studies, radiofrequency shrinkage has been used for the treatment of MTP joint instability secondary to low-grade plantar plate lesions.1 In the shoulder, this technique shows histological evidence of modest regenerative capacity but is also associated with several chronic sequelae including capsular stretching, nerve damage, recurrent instability, adhesive capsulitis, and thermally-induced chondrolysis.2-6 The purpose of this observational study was to examine the efficacy of surgical imbrication of the plantar plate to the metatarsal neck as a novel, cost-effective approach to repair Grade 0-1 plantar plate injuries. We sought to characterize patient-reported and radiographic outcomes in patients undergoing this procedure. Methods: Patients from a single fellowship-trained orthopaedic surgeon (1/2017 - 12/2020) were screened by electronic medical record review. Inclusion criteria were age >18 years, a pre-operatively measured Patient-Reported Outcomes Measurement Information System (PROMIS) score, a Grade 0 or 1 plantar plate tear discovered at time of surgery, and repair via surgical imbrication to the metatarsal neck. PROMIS Physical Function and Pain Interference scores were obtained from 14 enrolled patients (median age was 55 years; range: 40-69; 12 female) post-operatively at 6-9 weeks, 3 months, 6 months, and 1-2 years. Basic demographic information and pertinent medical information were also obtained. Three fellowship-trained orthopaedic surgeons independently reviewed radiographs to assess reduction of the metatarsophalangeal joint, and joints were graded as reduced, subluxated, or dislocated. Wilcoxon signed-rank tests compared pre- and post-operative PROMIS scores. Changes in PROMIS scores were compared to numerical and categorical patient characteristics via univariate linear regressions and Mann- Whitney U-tests, respectively. Results: Median postoperative times to most recent PROMIS score and radiographs were respectively 13.0 months (95% confidence interval: 10.0-21.4) and 7.6 months (2.9-10.0). Median preoperative and most recent Physical Function scores were 39.5 (35-50) and 52.5 (41-62), respectively (p=0.003), and median Pain Interference scores changed from 61.0 (56-68) to 53.5 (39- 58) (p=0.002) ( Fig. 1 ). Changes in PROMIS scores showed no association with BMI, age, preoperative opioid use, wound complications, concomitant dislocation, fibromyalgia, or mood disorder (p>0.10). Preoperatively, 9 second MTP joints were concentrically reduced, and 5 were subluxated (n=14). At 6 weeks post-operation, 13 joints remained reduced (n=14). At most recent measurement, all (n=10) joints were reduced (4 patients missing data). 9 of 14 patients underwent concomitant correction of hallux valgus at time of surgery. Conclusion: Patients with Grade 0-1 plantar plate injuries improved significantly in radiographic parameters and patient reported outcome scores following surgical imbrication of the plantar plate to the metatarsal neck. This procedure represents a novel, alternative approach that is both efficacious and cost-effective. Our work contributes valuable surgical outcomes data to a limited knowledgebase regarding pathophysiology and management for low-grade plantar plate lesions in MTP joint instability. Future work will involve larger, prospective studies to better understand outcomes of and indications for this approach.

Category: Trauma; Other Introduction/Purpose: Disuse osteopenia develops in individuals with decrease lower limb use especially after injury necessitating non-weightbearing, hospitalization or both. However, the nature of this change is not well characterized and, therefore, cannot be appropriately addressed. Conventional CT produces a reliable evaluation of bone quality as Hounsfield Units (HU) and offers the opportunity to longitudinally study bone density in activity-altered patients. The purpose of this study is to estimate the degree of osteopenia in non-weightbearing hospitalized patients and to identify patient-related factors associated with this loss. Methods: Initial screening criteria included patients who presented to the emergency department between January 1, 2010 to August 1, 2020; baseline lower extremity orthopaedic trauma evaluated by CT. Further criteria included CT imaging capturing the ipsilateral hip at the time of admission; a second CT scan, for any indication (eg, small bowel obstruction, diverticulitis, etc) that include that same hip; strict non-weightbearing in between scans. Exclusion criteria included change in weightbearing status and CT imaging changes that would not allow eBMD analysis (eg, intervention). Estimated BMD (eBMD) was measured at baseline and and at the secondary time point via HU approximation 12mm inferior to superior aspect of femoral neck on axial CT. The change in eBMD was calculated as a proxy for disuse osteopenia and the relationship between relative bone loss (as a nominal rate of osteopenia, eBMD loss/time) and patient-specific factors was explored. Results: Of 200,000 patients who received CT evaluation including their hip during the targeted timeframe, seventeen patients met our inclusion and exclusion criteria. There was an average of 7.3 days (median = 6 days; mode = 4 days; interquartile range: 4 - 8.5 days) between CT scans. The average rate of disuse osteopenia in the cohort was a net average decrease of 7.5 +- 5.8 HU/day. To place in a standardized clinical context, this change is estimated to correlate linearly with respect to change in DEXA BMD T-Score and may be clinically relevant when HU approach values

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc injuries are thought to contribute to debilitating outcomes in polytrauma patients. Due to the relative rarity of Lisfranc injuries, consistent long-term follow-up is a challenge and clinical outcomes are difficult to assess in this patient population. As a result, there exists a need for further investigation into patient-related clinical outcomes after Lisfranc injury. The purpose of this study was to collect long-term clinical outcome data following Lisfranc injuries using PROMIS Physical Function (PROMIS-PF) and Visual Analogue Scale-Foot and Ankle (VAS-FA). Methods: A chart review was performed to identify all patients who had surgical treatment of an acute Lisfranc injury at our institution from 2005 to 2014. Of forty-five patients identified, we were able to recruit nineteen for a follow-up clinic visit consisting of a physical exam, administration of questionnaires addressing pain and medication usage, radiographs, and completion of outcome surveys including PROMIS-Physical Function and Visual Analogue Scale-Foot and Ankle. Results: There were 14 female and 5 male patients enrolled in the study with a mean time of 6.25 years from the time of injury. Within this cohort, the mean PROMIS-PF score was 52.4+-8.2 and the mean VAS-Foot and Ankle Score was 76.6+-22.3. The risk factors of age, gender, BMI, smoking status, depression, and time from injury showed no statistically significant association with PROMIS-PF or VAS-FA scores using p

Background: There remains a paucity of data regarding long-term patient-reported outcomes following Lisfranc injuries. We sought to collect long-term clinical outcome data following Lisfranc injuries using PROMIS Physical Function (PROMIS-PF) and visual analog scale–foot and ankle (VAS-FA). Methods: A chart review was performed to identify all patients who had surgical treatment of an acute Lisfranc injury at our institution from 2005 to 2014. Of the 45 patients identified, we were able to recruit 19 for a follow-up clinic visit consisting of physical examination, administration of questionnaires addressing pain and medication usage, radiographs, and completion of outcome surveys including PROMIS-Physical Function and visual analog scale–foot and ankle. Results: There were 14 female and 5 male patients enrolled in the study with a mean time of 6.25 years from the time of injury. Within this cohort, the mean PROMIS-PF score was 52.4±8.2 and the mean VAS–foot and ankle score was 76.6±22.3. Conclusion: We report satisfactory long-term patient-reported outcomes using PROMIS-PF and VAS-FA. Level of Evidence: Level III, retrospective cohort study.

Level of Evidence: Level IV, case series.

Category: Lesser Toes Introduction/Purpose: Recent surgical techniques have focused on anatomic repair of lesser toe metatarsophalangeal (MTP) plantar plate tears. MTP instability has been implicated in a number of common toe deformities as well as metatarsalgia. Recently, a study demonstrated that the microvasculature of the normal plantar plate is densest at the proximal and distal attachments. The purpose of this study was to compare the intact plantar plate microvasculature network to the microvasculature network of plantar plates in the presence of toe deformity using similar perfusion and nano-CT imaging methods. Methods: Eight fresh frozen human cadaveric lower extremities with lesser toe deformities including hammertoe or crossover toe were perfused using a barium solution. The soft tissues of each foot were counterstained with phosphomolybdic acid (PMA). Then using nano-CT imaging the second through fourth toe metatarsophalangeal joints of 8 feet were imaged. These images were then reconstructed, plantar plate tears were identified, and eleven toes remained. The plantar plate microvasculature for these eleven toes was analyzed and calculation of vascular density along the plantar plate was performed. Using ANOVA analysis this experimental group was compared to a control group of 35 toes from cadaveric feet without deformity and the vascular density compared between quartiles of plantar plate length proximal to distal. Results: Demonstrated in Figure 1, of the torn plantar plates the average percent vascular density (vascular volume/tissue volume) in the first quartile of length (proximal to distal) is 0.365 (SD 0.058) compared to 0.281 (SD 0.036) for intact plantar plates; in the second quartile it is 0.300 (SD 0.044) vs 0.175 (SD 0.025); third quartile it is 0.326 (SD 0.051) vs 0.117 (SD 0.015); and fourth (most distal) quartile is 0.600 (SD 0.183) vs 0.319 (SD 0.082) respectively. Using ANOVA testing all differences were found to be significant to p

Category: Sports; Midfoot/Forefoot; Trauma Introduction/Purpose: Return-to-play (RTP) rates of National Football League (NFL) athletes following surgical intervention for numerous foot and ankle injuries has been reported. To our knowledge, no studies have reported on RTP rates of NFL athletes after non-operative and operative treatment of high-grade turf toe injuries. The purpose of this study was to evaluate the RTP rates in NFL athletes who sustained high-grade turf to injuries. We hypothesized that NFL athletes requiring operative intervention for high-grade turf toe injuries would have lower RTP rates and longer recoveries than athletes treated non- operatively. Additionally, we hypothesized that regardless of treatment, NFL athletes would demonstrate equal productivity following RTP. Methods: Publicly available NFL injury data was reviewed to identify athletes who sustained high-grade turf toe injuries, as indicated by surgical intervention or missed playing time of 2 weeks or more. Athletes were excluded if RTP was prevented for reasons unrelated to the injury. Demographic and performance data was obtained including a player’s injury, date of injury, date of surgery, RTP, time to RTP, number and percentage of games played, and performance. Results: 53 NFL athletes were identified with high-grade turf toe injuries that met inclusion criteria. 28 of these athletes were treated non-operatively and 25 were treated with surgery. The overall RTP rate was 91%. Athletes who were treated non- operatively had a RTP rate of 100% while athletes who underwent surgery had a RTP rate of 80% (P = 0.011). The mean time to RTP for all athletes was 140.9+-111.9 days. The mean time to RTP for non-operatively treated patients was 75.8+-99.0 days, compared with 221.4+-81.6 days for operatively treated athletes (P = 0.002). In skill position athletes who achieved RTP, 78% treated non-operatively were able to return to their prior level of performance compared to only 27% for athletes treated surgically (P = 0.032). Conclusion: There is a significant difference in return to play following surgical versus non-operative management of high-grade turf toe injuries, with only 80% of athletes achieving return to play after surgery. No athletes were able to return the same season as surgery and the mean time to RTP following initiation of treatment was significantly shorter for players who underwent non- operative management. Postoperative performance was also significantly worse in players who underwent surgical intervention compared to non-operative management. This study provides important prognostic information to high level athletes in regards to recovery following high-grade turf toe injuries

Category: Ankle Introduction/Purpose: The opioid epidemic has been defined by over-prescribing by practitioners and increasing misuse, abuse, and diversion of opioids by patients. Orthopedic surgeons are the fourth largest prescriber of opioid medications and have a unique opportunity to play a prominent role in the solution. Many perceived barriers to such a solution have now been eliminated. For example, it has been demonstrated that neither the amount nor duration of opioid prescription correlates with patient satisfaction. To address this epidemic, it is important to first understand rates of new persistent opioid use following specific injuries and to identify patient-specific risk factors. In this study, we evaluated new persistent opioid use following nonoperatively treated ankle sprains, one of the most common orthopaedic injuries seen in any healthcare system. Methods: A widely accepted insurance claims database was used to identify patients who underwent nonoperative treatment of an ankle sprain between January 2008 and December 2016. None had an opioid prescription filled in the period of 12 months to 7 days prior to treatment (defined as “opioid naïve”). We evaluated peri-treatment and post-treatment opioid prescription fulfillment to analyze prescribing patterns and continuation of opioid use. The primary outcome, new persistent opioid use, was defined as opioid prescription fulfillment between 91 and 180 days after treatment. Logistic regression analysis was used to evaluate the effect of patient factors, including age, gender, median household income, tobacco use, mental health and pain disorders, and medical comorbidities on the likelihood of new persistent use. Results: 42,445 patients were identified who underwent nonoperative treatment of an ankle sprain and received an opioid prescription. The overall rate of new persistent opioid used following nonoperative treatment of ankle sprains was 9.3%. Rates of continued opioid use were significantly increased among patients who received an opioid dose prescribed in the peri-treatment period that was in the top 25th percentile of total oral morphine equivalents. In addition, patient-specific factors which were associated with new persistent opioid use included female gender, tobacco use, certain mental health disorders, comorbid conditions, and pre-existing arthritis. Patient factors associated with lower rates of new persistent opioid use included higher level education and median household income of $100,000 or more. Conclusion: Chronic opioid use is a major problem, even in the setting of relatively minor musculoskeletal injuries. Defining the problem and understanding contributing factors to this epidemic are paramount to developing a solution. Ankle sprains represent an orthopaedic injury which does not warrant opioid use for pain control. In this series, an alarming number of patients who sustained an ankle sprain were treated with an opioid medication, and 9.3% of these patients continued opioid use after three months. Understanding the risk factors associated with this problem provides a foundation upon which to address this sometimes lethal, public health problem.