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Foot and Ankle Injuries Overview Lateral Ankle Sprains Lateral by wulinqing

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                                                                                       statement or opinion of the faculty that may be helpful to others who face similar situations.

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                        Scott Flinn, M.D.                                              speaker or AAFP is prohibited without written consent of the AAFP.



                                                                                       FACULTY DISCLOSURE

                                                                                       The AAFP has selected all faculty appearing in this program. It is the policy of the AAFP that all CME planning
                                                                                       committees, faculty, authors, editors, and staff disclose relationships with commercial entities upon nomination or
      CME #085 Wednesday, 10:30-11:30 a.m. Location: Room 205                          invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified,
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       CME #086 Thursday, 3:00-4:00 p.m. Location: Room 205                            who agreed to an identified resolution process prior to their participation were involved in this CME activity.

        CME #087 Saturday, 7:30-8:30 a.m. Location: Room 205                           Scott D Flinn, MD, has disclosed a financial interest as an owner of stock in Merck.




                Learning Objectives/                                                                Foot and Ankle Injuries
                 Search References                                                                        Overview
•   Differentiate sprains from fractures in patients who present with ankle or       Lateral Ankle Sprain                                          Medial Ankle Sprains
    foot injuries through review of complete joint examination of the ankle, foot
    and toes.                                                                        • Ottawa rules                                                • Tarsal tunnel
•   Formulate diagnostic plans to evaluate the affected joint and order              • High Ankle sprains                                          • Tibialis Posterior tendon
    appropriate imaging tests as necessary.
•   Assess the skill level needed (or training required) to adequately brace or      • Fractures                                                   • OCD
    splint the foot or ankle.
                                                                                        – Fibula
                                                                                        – 5TH Met                                                  Heel pain
Cochrane
                                                                                        – Navicular                                                • Achilles tendonitis
Medline
                                                                                        – OCD/Talar Dome                                           • Achilles tendon rupture
                                                                                        – Lis Franc                                                • Plantar fascitis
                                                                                     • Soft Tissue                                                 • Calcaneal stress fracture
                                                                                        – Peroneal Tendon




            Lateral Ankle Sprains                                                   Lateral Ankle Sprains Epidemiology
                                                                                     Most Common Sports
• When to get an X-ray                                                                 Related Injury
• How to treat                                                                       • Estimated 2 million per
• What to watch out for                                                                year
     – Cold                                                                          • About 20% of all sports
                                                                                       injuries
     – Numb
                                                                                     • Basketball, Ice Skating,
     – Pain midfoot                                                                    Soccer most common
     – Pain syndesmosis                                                                sports
     – Pain proximal fibula                                                          • Sequalae – Decreased
                                                                                       ROM, chronic pain and
                                                                                       instability, DJD




                                                                                                                                                                                                                1
            Lateral Ankle Sprain                                                          Patient

 • Mechanism - Ankle Inversion                                   • 35 year old weekend warrior
 • Ligaments involved:                                             playing basketball
    – ATF Anterior Talofibular                                   • Came down on someone
    – CF Calcaneofibular                                           else’s foot
    – PTF Posterior Talofibular                                  • “Sprained” his ankle
    – Tibiofibular
                                                                 • What do you want to know?
    – Syndesmosis
       • “high ankle sprain”




    Pointers and pitfalls in lateral
                                                                     Lateral Ankle Sprain - Exam
            ankle sprains
                                                              • Weight Bearing
 Can they walk?                                                  – May be difficult initially but improves over
 • Helps tell if they need an they need an x-                      time
                                                              • Palpation of Bones:
   ray/ how disabling is the injury
                                                                 – Fibula all the way to the knee
 Have they hurt it before?                                       – Medial Malleolus
 • Previous known injuries/complications                         – Base of Fifth Metatarsal
                                                                 – Navicular
 Where does it hurt?
                                                                 – Lisfranc joint area
 • Make sure it is an ankle sprain and not                    • Soft Tissue:
   something else such as a Lisfranc injury or                   – Ligaments
   Maisonneuve fracture                                          – Tarsal Tunnel and peroneal tendons




   Ottowa Foot and Ankle Rules:
          X-ray or NOT                                             Ottawa Rules – Do they work?
Ankle Series                   Foot Series
• Inability to bear weight 4   • Inability to bear weight 4
                                                                 • High sensitivity - Systematic review of over
  steps immediately after        steps immediately after           15,000 patients, missed 0.3% (1 in 300).
  injury and in ER
                                 injury and in ER
• FIB - Bony TTP Distal                                          • Low specificity (but so does getting x-rays
  Post 6 CM                    • TTP Base 5th Met
• TIB - Bony TTP Distal
                                                                   on everyone)
                               • TTP Navicular
  Post 6 CM                                                      • Works for adults and children down to at
                               Also - LIS-FRANC injury
                                                                   least age 8




                                                                                                                  2
               How Bad is It Doc?                                                    Ankle Sprain Grading
• Graded I, II, III , with III being complete tear
• Sequalae and complications                                              Special Tests
  – Decreased ROM                                                         • Anterior Drawer
  – Pain                                                                  • Talar Tilt
  – Joint Instability
                                                                          • External Rotation – for
  – Osteo Chondral Defect (OCD)
                                                                            high ankle sprain
  – Degenerative Joint Disease (DJD)




               Anterior Drawer                                                         Anterior Drawer Test
                                                                          • Tests ATF integrity
                                                                          • Most reliable several
                                                                          weeks out
                                                                          • How to do
                                                                             –   Stabilize the tibia
                                                                             –   Grasp the heel
                                                                             –   Slight plantar flexion
                                                                             –   Apply force to anteriorly translate heel
                                                                             –   Compare to opposite side
                                                                          • If + drawer, pain, swelling, ecchymosis 96%
                                                                            sensitive, 86% specific for ATF tear
                                       Photos Courtesy Dr. Chip Walters




                                                                           What to Watch Out for in Lateral
                         Talar Tilt
                                                                                   Ankle Sprains
   • Tests for the integrity of CF                                        High Ankle sprains
     ligament
                                                                          Fractures
   • Best performed weeks out
   • More of historic interest
                                                                          • Fibula
   • Stabilize tibia, grasp heel,                                         • 5TH Met
     and invert ankle                                                     • Navicular
   • X-RAY diagnosis AP Ankle                                             • OCD/Talar Dome
     stress view positive if angle >
     11 degrees                                                           • Lisfranc
                                                                          Soft Tissue
                                                                          • Peroneal Tendon




                                                                                                                            3
Syndesmosis - High Ankle Sprain                              Syndesmosis Examination
                                                       ER – stabilize leg and
 • Tear in Tibio Fibular                                   grasp foot and ER
                                                       If mortise widens –
   ligament and up into                                surgery
   syndesmosis
                                                       Squeeze test - squeeze
 • May have instability of                             malleolae together
   joint and widening of
   mortise




                                                                                                    Photos Courtesy Dr. Chip Walters




                                                       Lateral Ankle Sprain Complications
                 Ankle X-ray
                                                             Distal Fibular Fractures
                           • Ankle is unforgiving if     • Distal Fibular fracture
                             malalignment                  with tenderness over
                           • Medial clear space no         deltoid – considered
                             more than 4mm                 unstable
                           • Symmetry in lateral and     • Non displaced stable
                             superior joint space          fx – weight bearing
                                                           cast or brace
                                                         • Displaced -
                                                           alignment crucial




     Proximal Fibular Fractures                             Lateral Ankle Sprain – 5th Met
                                                       Ottawa rules for Foot x-rays – palpate 5th
• Maisonneuve                                             met and navicular
                                                       • MOI - stepping off a curb, foot in
  fracture                                                equinus
                                                       3 BASIC TYPES
• Proximal fibula not                                  • Tuberosity avulsion fractures (pseudo
  the problem – need                                      Jones)
                                                           – peroneus brevis attachment
  to look at ankle joint                                   – through joint –not bad
• Often need surgery                                       – RX – Post op shoe or SLWC with
                                                             crutches advance WBAT up to 4-6
  as syndesmosis is                                          weeks
  torn and ankle                                       • Base or Jones fracture – more distal –
                                                          poor blood supply
  mortise integrity lost                                   – RX NWB 6 wks, SLC 6 wks
                                                       • Shaft Fracture




                                                                                                                                       4
                                      Ankle Sprain Complications -
 Lateral Ankle Sprain – Navicular
                                     Osteochondral Defects (OCD) of
             Fracture
                                            the Talar Dome
                                     • Fracture of Talar Dome, usually lateral
 • Navicular – medial location       • Usually ligament instability
 • Often missed on x-ray –           • Suspicious if ankle sprain does not heal like
   look especially on lateral          normal one
   view                              • Persistent pain
 • Similar to hand navicular         • Possible effusion and edema
 • Consider referral                 • X-RAY often negative
                                     • CT or MRI to Confirm




  Not a lateral Ankle Sprain –
                                             Foot X-ray evaluation
 Lisfranc Fracture/dislocations
                                    • 1ST met line up with
 • Lisfranc Joint – Lisfranc          1ST cuneiform, 2ND with
   was a surgeon in
   Napoleon's Army –                  2ND , 4TH with cuboid
   described the Tarsal
   Metatarsal joint                 • Base of second is the
 • Injuries sometimes missed          most common fracture
   when proper exam not               with midfoot sprain
   done.
 • MOI - Equinus                    • Lisfranc treatment –
 • Swelling in MIDFOOT                high risk – refer




                                                          Exam
   Peroneal Tendon Subluxation
                                     • TTP just distal to
• Tendons are superficial              distal fib
  to the joint capsule and           • Test – resisted
  is held in place by a                ER/dorsiflexion
  sheath                             • X-rays neg
• Torn sheath – tendons              • Rx – rehab,
                                       sometimes requires
  can slip out, snap over
                                       surgery
  lateral malleolus




                                                                                       5
            Snowboarder’s Ankle                         Types of snowboarders’
                                                               fractures
• Fracture of lateral process of Talus                                       • type 1 fracture chip
• MOI - ankle dorsiflexion (landing                                            fracture not into the
                                                                               talofibular joint.
  from an aerial maneuver or a jump)
                                                                             • type 2 fracture - single
• Not uncommon                                                                 large fragment extends
• Physicians should maintain a high                                            into the subtalar joint.
  index of suspicion - severe lateral                                        • type 3 fracture
  ankle sprain that doesn’t get better                                         comminuted
  with appropriate management                                                • may be difficult to see on
                                                                               a standard ankle x-ray
                                                                               series – may need CT or
                                                                               MRI




    Snowboarders ankle treatment                  Lateral Ankle Sprain Treatment
  • Treatment for a Type 1 and 2                  Initial - PRICEMM
    nondisplaced or minimally-                    • Protection - crutches if necessary immediately,
    displaced fracture (less than 2                  brace
    mm) - short-leg, partial-
    weightbearing cast or cam                     • Relative Rest
    walker for six weeks.                         • Ice – bag, massage
  • Patients with large displaced                 • Compression – ace or brace
    fractures and comminuted                      • Elevation
    fractures refer for eval for
    ORIF and/or excision of the                   • Medication – for pain
    fragments                                     • Modalities/PT




             EBCME - Protection                     EBCME – how much Protection
  • Cochrane review found that lace up or         Cochrane review found that functional treatment
    semi rigid supports are more effective than     was superior to casting / immobilization.
    tape or elastic bandages.                     Functional treatment consists of PRICE acutely,
                                                    exercises started within 48-72 hours, and
  • Return to sports or work was quicker with       endurance training , sport specific drills, and
    semirigid brace compared to the ace             sport specific training.
    bandage.                                      Acute Protection with braces, taping, or ace
  • The lace up brace was better at reducing        bandages is superior to casting
    persistent swelling compared to the other     Swelling was reduced, and return to work and
    methods.                                        sports was quicker with functional treatment




                                                                                                            6
             EBCME - Ice                                      EBCME - Meds
                                                 7 Randomized placebo controlled trials have
• Cryotherapy helps reduce edema, and
                                                   shown NSAIDs improved pain control,
  helps reduce pain and speeds recovery
                                                   improved function, decreased swelling,
  time.
                                                   and had a more rapid return to activity.
• Heat not recommended




        EBCME - Modalities                       Treatment of Ankle Sprains – Do
Cochrane review found no value in the use        they need referral for further care
 of ultrasound in the treatment of acute                 and/or surgery?
 ankle sprains.                                  Complicated sprains with fractures…often
                                                  need surgery or referral
                                                   – Unstable Fx
                                                   – Risk of nonunion
                                                   – Beyond your comfort level
                                                 What about the others?




       Treatment - Surgery                               EBCME – Prevention

• Cochrane database - Review of trials            Prevention –Cochrane review 14 trials with
  regarding chronic ankle instability due to       8,279 patients: semi-rigid braces during high
  sprains found no particular benefit for          risk activities can prevent sprains, and work
  treating conservative vs. surgical.              even better in those with previous ankle
                                                   sprains.
• If surgical reconstruction is done, early       Other supports – inconclusive
  functional rehab is superior to 6 weeks
                                                  Ankle disk training – probably useful, especially
  immobilization w.r.t. time to return to work     in those with previous ankle sprain
  and sports.




                                                                                                      7
    After the diagnosis, avoiding
    pitfalls, and initial PRICEMM,                                    Medial Ankle Sprain
               What next?
• Send to PT/ATC                                              • Anatomy
  EBCME showed:                                               • Ottawa rules
   – Speed return to activity (sports/job)
                                                              • Differential Dx
   – Prevent recurrence - rehab with
     proprioception, brace                                       • Tarsal Tunnel Syndrome
• What to do while awaiting PT                                   • Tibialis Posterior Tendon
   – Alphabet exercises
   – Toe raises
• Will review in hands on




    Bone and Ligament Anatomy                                   Medial Ankle – Soft Tissue
• Medial Malleolus
                                                          • Tom, Dick and Harry mm
• Deltoid Ligament                                           – Tibialis Posterior
                                                             – Flexor Digitorum
                                                               Longus
                                                             – Flexor Hallicus
                                                                Longus
                                                          • Posterior tibial nerve,
                                                            artery




                                                                 Med Ankle Sprain – Tarsal
  Medial Ankle Sprain Treatment
                                                                    Tunnel Syndrome
                                                            Hx
 • PRICEMM                       • Other considerations
                                                            • Impingement of Posterior
    • Protection - crutches if     – Differential dx          Tibial nerve
      necessary, brace             – Surgery                • Aching pain medial foot
    • Relative Rest                – Prevention             • Worse with weight
    • Ice – bag, massage                                      bearing
    • Compression – ace or                                  PE
      brace                                                 • Tinel’s
    • Elevation                                             • X-RAYS, EMG
    • Medication – for pain                                 • MRI – impingement
                                                              edema
    • Modalities/PT




                                                                                               8
    Tarsal Tunnel Syndrome - Rx                               Medial Ankle Pain –
                                                      Tibialis Posterior Tendon Rupture
•   NSAIDS                                            Hx
•   Orthotics                                         • Middle aged overweight
•   Relative rest with gradual return to activity       female
•   Consider steroid injection                        • Usually overuse injury
                                                        but can be acute
•   May need surgical release
                                                      • Causes loss of medial
                                                        arch support , flat foot,
                                                        overpronation




                                                              Tibialis Posterior Tendon
                          PE
                                                                        Rupture
                                                       Treatment
• TTP and swelling inferior to medial malleolus        • Consider surgical referral
• Chronic injury – view from behind – “too many          early as conservative Rx is
  toes”                                                  difficult
• Unable to rise on toes/ plantar flexion/ does not    • If chronic, consider short leg
  get nl heel inversion                                  cast or CAM walker for up to 4
• X-RAYS usually normal early                            weeks, progressing to AFO
                                                         with arch support
• MRI if insure
                                                       • Usually also need orthotics
• Progresses to acquired flexible flat foot, then
  rigid flat foot




    Complications of Ankle sprains -                                     Heel Pain
                 OCD
                                                       •   Achilles tendon
• REMEMBER , if NOT healing –                          •   Plantar fascia
  consider OCD and get CT or MRI                       •   Fat pad atrophy
                                                       •   Calcaneal stress fracture
                                                       •   Os trigonum




                                                                                          9
             Achilles Tendonitis                                        Achilles Tendonitis
   History                                                   Treatment – Mostly Modalities
   • Pain 4-6 cm from the insertion into the Calcaneus       • Relative Rest
   • Worse in am                                             • Achilles stretching – gastroc and soleus
   • Worse with exercise
                                                             • Correct over pronation
   PE
   • TTP along tendon
                                                                – Shoe selection
   • Tight heel cords                                           – Off the shelf inserts
   • X-rays neg                                                 – Custom Orthotics
   • MRI – may show                                          • ¼ inch cork or foam heel lift for 10-14 days
   inflammation or                                           • NO STERIOD INJECTION
   degenerative tissue
                                                             • Surgical RX rarely needed




        Achilles Tendon Rupture                                            Plantar Fascitis
                                                           • Hx- severe heel pain first
Tear at musculotendonous junction, about 4-5 cm above
  insertion                                                  step in morning
Hx                                                         • TTP at medial calcaneal
• Weekend warrior                                            tubercle
• Eccentric load
• Sudden pain/snap                                         • X-Ray – spur means
PE                                                           nothing clinically unless
• Palpable defect                                            acutely fractured
• Thompson Test
Rx
                                                           • Note – if bilateral – think
• Cast in equinuus vs. surgery. Functional outcome the       enthesopathy -Reiter’s
  same, quicker return to activity with surgery              syndrome.




        Plantar Fascitis Treatment
                                                         Steroid injection for PF
PRICEMM
• Protect with heel pad or cup                           Medial Approach
• Relative rest                                          25 GA 1 ½”needle
• Ice massage or roll cold can                           1 cc Kenalog 10mg/cc
• Meds- NSAIDs for pain, Injection
                                                         2 cc 1 % Lidocaine w/o epi, 2
• Modalities :
                                                         cc Marcaine
   • Achilles stretch
   • Night splint/ sock                                  Complication – fat pad
                                                         atrophy
   • Arch taping
   • Arch support
   • PT consult
• Casted orthotics
• Surgical RX last resort




                                                                                                              10
               Fat Pad Atrophy                              Stress Fracture of Calcaneus
• Complication of steroid injection                       • Acute fracture of Heel Spur – rare
• Necrosis of fat pad cushion on heel                     • Calcaneal Stress Fracture
                                                            – Gradually worsening heel pain
• Rx – very difficult
                                                            – May rapidly proceed to completed
                                                              fracture
                                                            – On exam – positive
                                                            squeeze test




    Radiology – Stress Fractures                                        Os Trigonum
• Plain films - X-rays often negative initially, repeat   • Accessory bone off posterior talus
  at two weeks
   – Some (perhaps up to 20%) NEVER positive
                                                          • Can get impinged in equinus
     on x-ray                                             • Usually responds to conservative Rx

• 4 x-ray findings of stress fracture
            Sclerosis
            Periosteal reaction
            Endosteal reaction
            Completed fracture




                                                                      ARMY Football
                     Summary
•   Complete and thorough exam                                  Helping NAVY Football
•   P-R-I-C-E-M-M for acute injury
•   AROM and support for acute injury                          Look Good for 115 years
•   Casting, taping, bracing for early return
•   Restore strength
•   Maintain/restore proprioception
•   Train for return to sport/work
•   If not improving like it should, think other
    conditions – OCD, Stress Fracture




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