Perioperative Considerations in Athletic Patients

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Clinical Summary

• Patient-Centered Preoperative Evaluation

  • Assess overall activity level and ADLs, tailoring expectations for return to play.

  • Athletic patients often overtrain and need structured guidance to avoid premature return.

  • Sports psychology and mental resilience are crucial—mental preparedness improves outcomes.

  • Engage the patient’s support system (coaches, trainers, family) to align goals and reinforce compliance.

• Preoperative Testing & Imaging

  • Routine labs (CBC, BMP) standard; add CK levels when risk of exercise-induced muscle breakdown or compartment syndrome suspected.

  • Prefer MRI + CT for athletes to evaluate both soft tissue (Achilles, ligaments) and osseous integrity (avulsion, fracture detail).

• Intraoperative Strategies

  • Ankle fractures: consider ankle arthroscopy prior to fixation to evaluate ligaments (ATFL, syndesmotic complex) and intra-articular pathology.

  • Achilles injuries: despite percutaneous systems, open exploration or arthroscopic visualization ensures complete assessment of tendon quality.

  • Direct visualization helps optimize repair durability and expedite safe return to sport.

• Postoperative Protocols

  • Accelerated mobilization: initiate weight-bearing and PT as early as feasible to enhance circulation, reduce anticoagulant need, and expedite return.

  • Sports-focused physical therapy: essential for accountability, structured rehab, and aligning with athlete mentality.

  • Early structured home program (logs, reps, accountability) reinforces compliance.

  • Use of non-narcotic analgesics (newer options beyond opioids) paired with regional blocks reduces narcotic dependency.

  • Emphasize elevation and edema control for pain management and recovery optimization.

• Nutritional Considerations

  • Collaboration with nutritionists to ensure adequate protein and collagen support for healing.

  • Monitor diet trends (vegan, vegetarian, carnivore) to avoid deficiencies impacting recovery.

  • Prevent muscle mass loss during downtime with structured nutrition and supplementation.

• Return-to-Play and Prevention

  • Gradual progression: cast/boot → CAM boot → shoe/cleats/skates, tailored to sport-specific demands.

  • Evaluate and optimize athletic footwear and gear postoperatively.

  • Consider custom orthotics, AFOs, or braces to prevent reinjury and enhance stability.

  • Strong focus on prevention and long-term protection to extend athletic performance.

• Key Clinical Pearls

  • Listen to the athlete—they know their bodies but require cautious guidance to prevent overexertion.

  • Recovery involves the athlete, family, coaches, and trainers; effective communication is central to success.

  • For young athletes, recognize the impact of NIL (Name, Image, Likeness) opportunities—safe, timely return may directly affect career trajectory.

Transcript

Welcome back to Podiatry Today Podcasts where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. Today we are so excited to have Dr. Nicholas Butler with us and to be producing this podcast episode in partnership with the American Society of Podiatric Surgeons. He's here to talk to us today about perioperative considerations when treating those more athletic, more active patients. So we're really excited to dive right into this with him. I'll turn it over to him really quickly, just to give a quick intro to who he is, where he practices and his interest in this topic.

Hello, everyone. Thanks for joining us today in this exciting topic. I'm Dr. Nicholas Butler. I practice currently in Cleveland, Ohio. I am an Assistant Professor in the division of Clinical Science and Surgery department at Kent State University College of Podiatry Medicine. I'm an Ohio graduate as well. I graduated from Kent State as well in 2015. Did my surgical residency out on the East Coast, got away from Ohio. I'm originally from Michigan as well. So I got away from the Midwest, went East Coast to Jefferson Health,  New Jersey with Kennedy Health originally it was, and did three years there. I stayed out there for a while and then came back to Cleveland, Ohio where my wife is from to practice medicine and also teach at the school. I'm also in private practice at Erie Foot and Ankle, which is in Beechwood, Ohio, in private practice as well. And I have affiliations with UH University hospitals here as well, where I do one day of wound care as well. And it's a great aspect to be able to work with students, to be able to work in private practice, to be able to work with athletes as well, all from, you know, more competitive little kids all the way up and adults and even some professional athletes. So it's an honor to be able to see a little bit of it all.

Well, thank you for that. And let's dive right into it. When it comes to treating athletic patients, many podiatrists are already well aware that this patient population does require a more focused or targeted approach. Starting with the preoperative period, what do you think are some important things to keep in mind for surgeons looking towards surgery for these patients?

When it comes down to it, I tell my patients and also tell my students right now and also fellow surgeons that want some advice if they want to take it from me, is you have to look at the patient as a whole. What's their activity they live in, their ADLs? It's the same thing when we do any of our regular patients as well, what is their thing? But the difference is with these high performance athletes is how fast can they get back to the field? That's all they care about more than anything. And the thing about these patients, they are more willing to do the physical therapy, to do the training, and sometimes they wanna over train. So that's something that you have to take into consideration is to slow them down enough because they are the patients that are gonna listen and do exactly what you say, versus some other patients might be a little relaxed and not wanna go to if you're right away or do physical therapy at home, these patients are gonna push themselves.

So, you know, periodically it's setting the expectations for these patients. And when it comes to these athletic patients, we have to start thinking it's not just, you know, when we think of high school athletes or middle school athletes or college or pro athletes, you know, we're starting to see a huge resurgence right now, specifically with injuries with pickleball. So even our elderly patients that are becoming more athletic as well, we've got to start considering these patients and their perioperative modalities are a little bit different than our younger athletic patients. But the number one thing I always do is set their expectations and, you know, perioperatively, you know, preoperatively, I really have to worry about these patients is overstressing themselves and strain yourself, you know, trying to get back to their sport quicker than they should. So that's one thing that is set an expectation. And at the end of the day, you know, sports psychology is a huge ask looking at the psyche and mental toughness and seeing what they need to do, make sure they stay on top of their plays and everything as well, because injuries take a little bit longer for some people and being mentally strong and having a great mental aspect going into surgery outcomes tend to do better as well.

Do you have any communication pearls or things that you found effective in conveying this to your very athletic patients prior to surgery?

Yeah. For a lot of my patients, you know, my athletic patients, I like to talk to them and say, can you give me your coach's contact? I think that's the number one thing that, you know, I try to go a little bit above and beyond for that is to talk to their coach and their trainers. So these are the people that are seeing them every single day. And then of course, you know, their parents, even if they're they're an adult athletes, they still talk to their parents, give their advice for them. So I always like to communicate with their family members, but specifically their coach and their trainer to see what their goals are for the season and to relieve the expectations of what is actually gonna happen and when they're actually gonna be able to get back out there. But I think the number one communication and how to relate is to talk to their coaches and their trainers. And usually that kind of bridges the gap from what they're hearing in the office from me versus what they're hearing from their coach. 'Cause if you don't make the communication, the bridge, and reach out to them, a lot of times they're going to kind of blow it off or go find a different doctor or find somebody else that will get them back on the field, quote, unquote, back on the field, but they just wanna hear something that they wanna hear. At the end of the day, I understand for me being, you know, a college athlete myself, playing football in college, you know, I've had a couple injuries, I had a turf toe injury, and then I had a couple concussions that ACL injury. And my main thing was getting back on the field as quick as I can. And I didn't want to listen to the doctor or really hear anything. But when the coach communicated this with me, when my trainer communicated with me, that they spoke to the doctor and all this, it hit home a little bit more. So I think that's one of the things that I like to do is communicate with their family members, their coach specifically in their trainer. and that kind of bridges the gap of information when it comes to this type of patient clientele. 

What about any preoperative testing or evaluations? Is there anything that you find is more unique to the athletic population?

Yes, when it comes to athletic population, you're gonna get your normal labs. But for me, when it comes These athletes, it's not as much, you know, the pre -operative labs as much forthem. It's more of your actual imaging modality. It's more important when it comes to these athletes, specifically, a lot of times for some of these athletes, we might just, you know, for non -athletes, we might just get a CT scan, but for a lot of these athletes, I like to get an MRI and a CT. I know some people think it's a little overkill. If you think it's more of a soft tissue injury or Achilles injury, such as Achilles rupture, I still get a CT scan. This makes sure it's nothing more with that insertion, specifically if any bone got pulled off. So for me, the modality is more important than the actual testing 'cause most of these patients are healthy. But I still do one test. I've started to order a little bit more. I do check the CK level as well, but I normally wouldn't do it at all.

Main thing is to really check if you're really having some type of exercise-induced issues from muscle breakdown as well. Otherwise than that, the rest of the labs are gonna be my normal CBC with Diff and their BMP. But I also add on, for me personally, I add on the CK level to check as well for any muscle breakdown more than usual, just to rule out that could be exercise and do compartment syndrome to kind of leave me down that road just in case if something else is going on. But otherwise than that, most of the labs are going to be general standard labs, but that's the one little caveat that I've learned to do. You know, I've caught a couple times, you know, for that, I've caught a couple exercise and do compartment syndrome in patients keeping complaining about pain as well. So that's something I do do as well for most of my athletes now.

What about the intraoperative phase? Are there any tips or pros that you have that you've found especially helpful with your active patients?

Yeah, the one thing about interop, especially when it comes to, it all depends on what type of injury it is. If it's more of a, you know, a calcaneal injury or a lot of ..., we see a lot of Achilles. And then of course, a lot of lateral ankle instability, sprains, tears. And then of course, you do see a lot of the twisting and torsion injuries, such as causing these different ankle fractures that can help with these athletes. When it comes down to that, specifically when I look at it, when it comes to an ankle fracture, one thing that I've been doing more lately is not just relying off of just the MRI or getting a CT. CT, now I've done almost majority of all my ankle fractures, specifically with sports injuries, ankle fracture, doing an ankle scope prior to fixing the ankle fracture to visualize and actually be able to see your ligaments, your lateral ligaments, your medial ligaments, and also looking at your anterior talo fibular ligament, your syndesmotic injuries, looking at that and seeing what's actually getting caught in there. That's something I'm a little more aggressive with, with these kids or even still be able to let that ligament move. So that's something I'm doing interoperably a little bit more is actually taking a look and physically looking in it with a scope or if it's an Achilles. I know everyone loves the, you know, different companies that have percutaneous Achilles, you know, systems that can help, you know, stop the healing, excuse me, promote the healing and quicker recovery. I still think it's best to physically open them up sometimes and look in there. And if you don't feel comfortable physically opening up or you want to do the percutaneous, don't harm in getting the scope and look in there and physically look at the ligament and see what needs to be done. You know, we've seen these athletes, these professional athletes that come back to me as Achilles and they're coming back quicker. And that's the one thing that these patients want to do is come back quicker. But the best case in theirs for this patient is to open it up, see what's going on, look at it, observe everything, and you can get these patients back on their feet a little bit quicker.

Well speaking of getting them back on their feet, what about the postoperative phase? I know there's so much to discuss here, but have you found any productive pathways or clinical steps that have really had an impact for your athletic patients?

Yes, for my athletic patients, I think I'm a little more aggressive. I'm more aggressive with most of my surgical patients and sometimes that too much aggression, too aggressiveness can cause some, you know, setbacks with possibly surgical complications or dehiscence. But my main thing when it comes down to it is, postoperatively, the sooner I can get some weight bearing, the sooner I can get them out of bed the faster I'm, you know, don't shoot the messenger, but I'm a little more like to get them up and moving a little bit quicker than most people. And the thing is for that, for me as a two -fold, I can get them off of any anticoagulants a lot quicker. The more we can move it and get it pumping, a lot of times I don't even prescribe a lot of anticoagulants, you know, after these, some of these cases, I know some people don't think I'm a little crazy for not doing that, but I think the sooner you can get them walking, the sooner you can get them pumping, the sooner you can get them physical therapy, the better.

You know, I send them home right away with physical therapy instructions that they're going to do right away. They're going to go to formal physical therapy within two to three days postop to really get them going. That is huge for them is physical therapy, working with physical therapy, finding somebody in your area that you're really close with and somebody that understands athletes. I think that's number one thing that people have to realize, you can't listen to any physical therapist. Don't get me wrong, a lot of general physical therapists are great, but a sports related, you know, sports medicine, physical therapist understands these patients a little bit better, especially their mentality. And you also have to talk with a lot of these, especially when I work with college athletes, speaking with their trainer and their team docs and their team to even see, hey, do they have a physical therapist that they have on campus that they prefer than to see it? And that's the thing is giving them these exercises, giving them a home and having them log what they're doing, keeping journals and keeping them accountability. That's the main thing, keeping your patient accountable, keeping the athlete accountable. They're used to structure, they're used to, you know, telling and what to do and when to do it, and they're going to do it, giving them reps like, "Hey, we're doing three sets of this." They understand that. They've already used it at being in a weight room and being in a condition, no one plays, they understand that. So for them, for me, postoperatively is getting up there as soon as I can.

And if I can walk them day one, and I feel comfortable in my structural concept, let's get them walking from day one. I don't want them sprinting or anything, but to get them up and walking, get them off any anticoagulants as quick as they can, and get them off the pain medication as quick as they can. I think that's the huge aspect. You know, I think a huge thing that has changed my practice real recently, to be honest, and in the last, like, I would say three months has been a new medication out there, the non-narcotic medication, specifically made for bunionectomies, but also has been great for other orthopedics surgeries as well. I think that's a great avenue versus going to these patients that are on these narcotics, such as, you know, we know the heavy hitters of, you know, vicodin and percocets, getting them off of these "oxies" and getting them on a non-narcotic and give them a good block before and get them off it real quick. I think that's been an unbelievable thing for our profession as a whole. And then also, you know, elevation, elevation, elevation, you know, edema control is huge for these patients when it comes to pain, athletes, and getting them back as quick as we can.

Do you ever work with your athletic patients from a nutritional perspective, maybe bring somebody in and there. I'm thinking about RED-S syndrome or other types of nutritional deficiencies in athletes that may not be following their training advice or might be overtraining things like that that you mentioned before. Is that ever a part of your postop course?

Yes. Nutrition is a huge part of my postop course for not just my athletic patients, I'm specifically, because I do, I also do a wound care day as well. My wound care patients as well, when it comes down to it, we learn in school, we've learned from our residencies that, you know, how important protein is, how important collagen is, and nutrition is a huge aspect for these patients, you know. And I think that's a huge aspect for it, especially because even when I speak to the coaches, and a lot of times a lot of these teams already have nutritionists that they have on board or the patients do and speaking to them and their diet. Diets have changed significantly since I can even remember for myself as a kid from what we think as an athlete, from people going more vegan based diet, more vegetarian diet, some people do the carnivore diet, it varies so much. And you have to look at aspects to it, you know, what they can eat, what they can't eat, what they believe in as well. But I think, you know, getting a nutritionist involved is huge for these athletes, especially when it comes to the postop healing aspect of it. The number one thing for me is making sure that they're getting enough source of protein, eating a little bit more protein, taking protein powders, shakes, but not overdoing it. But that's one thing that's a huge aspect for healing. And for, you know, the thing that I worry about these athletes is, you know, if they're off it too much, are you going to lose that muscle mass? And especially to get back out there for some of these physical sports, you know, specifically what we're going to now, we're getting into football season again, and even, you know, the other football season as well, getting into those, these physical athletes for that and getting closer to that. And then eventually we'll get into, you know, volleyball, lacrosse, softball season, you know, this muscle mass is one thing to get to worry about them losing and trying to prevent that as much as we can.

Great. Is there anything else that you'd like to add so that our audience can round out their updated knowledge on perioperative considerations for our active patients?

Yeah, I think the number one thing that I want anyone to take away from this is, first, listen to the patient. They know their bodies better than even we do. Yes, we know the science, we know the anatomy, but the patient knows their body. They've been training their whole life for this, so they understand their injury. So listen to them, and if they feel like they can do a little bit more, maybe listen to them for a little bit, but also, you know, be hesitant not to put to overdo it. And I think second, you know, is talking to the coaches, talking to the family that need to take away from that and and bringing and making it a whole family affair and making it a whole coaches affair. It's just not them going through his injury and going through surgeries. It's the whole family. And for a lot of these patients nowadays, especially these young high school going to college, NIL is huge, you know, for them to be able to make a living. And this might be their big shot. So take a serious, you know, when they're when they need to get back on their feet, take a serious to help them get back as quick as you can for them at the safest as well when it comes down to it. And then also when it comes to the postop, for me, again, take away getting weight -bearing as quick as you can, make that transition from the CAM boot. If you're a cast person from a cast or soft splint to a CAM boot, to possibly back into a shoe, and taking consideration, have them bring in their tennis shoes, their cleats, their skates, if they're hockey player, and really evaluate what they are wearing. And if you can, prevention, prevention, prevention, after this injury, if you need to do a custom insert, orthotic, AFO, there's lots of different great braces out there. There's great braces that go on outside of cleats, some that go on inside of cleats, different things that athletes are wearing to help them protect your ankles, protect your feet, protect your legs, you know, that's a huge aspect of it. You know, we, a lot of people neglect their feet and their ankles until you get an injury like this. So these are all things that take into consideration. And when is it, and when is it, do you need to send them to rehab? And that's the thing. Sometimes you, they can't do it alone by themselves at home physical therapy or rehab. Sometimes you have to send the rehab and get them back in this field on the field or on the ice or on the court as quick as you can.

Well, thank you so much, Dr. Butler, for sharing all that with us today and thank you to your audience for joining us. You can find this episode and all others of Podiatry Today podcasts on podiatrytoday.com and your favorite podcast platforms.

Published in partnership with the American Society of Podiatric Surgeons