foot and ankle - residents

					    Brandon Mines, MD
Emory Sports Medicine Center
       May 13th, 2010
Objectives
 Anatomy
 Injuries
 Treatment
        Arches


The foot has both
longitudinal and transerves
arches. The longitudinal
arch is composed of medial
and lateral parts. The medial
part of the longitudinal arch is
obvious when the normal
living foot is examined from
the medial aspect.



                                       lateral medial
                                   longitudinal arch(es)
 high arch
(pes cavus)
  flat feet
(pes planus)
hallux valgus
Claw Toes
fibula
                       ankle (talocrural)
                       joint
              tibia
                       The ankle joint is a hinge-
                       type, synovial joint
                       located between the distal
                       ends of the tibia and fibula
                       and the superior part of the
                       talus. The main movements
                       of this joint are
                       dorsiflexion and plantar
                       flexion. The joint capsule
         AP    talus   is reinforced laterally by the
                       lateral lig. And medially by
                       the deltoid (medial) lig.
                             The Lateral Ligaments


                             ant. talofibular lig.

post.
talofibular lig.




                   calcaneofibular lig.
The Deltoid Ligament
Ankle Inspection
 Position
    Gait
 Asymmetry
    Muscle atrophy
    Abnormal bone alignment
 Swelling
 Color change (bruising)
Ankle Strength Testing
 Dorsiflexion      Anterior Tibialis
 Plantar flexion   Peroneal Tendons
                    Gastroc & Soleus
 Inversion         Posterior Tibialis
 Eversion          Peroneal Tendons
LATERAL ANKLE SPRAIN

              Acute Lateral Ankle
               Sprains
                23,000 injuries a day in
                 the U.S.
                7-10% of E.R. visits
                Most common athletic
                 injury- about 45% of
                 basketball and 32% of
                 soccer injuries.
LATERAL ANKLE SPRAIN
 Patho-anatomy:
                                    ATFL
                            PTFL
 ATFL most commonly
  injured
                              CFL
 Combination of ATFL
  and CFL is 2nd most
  common
 Isolated PTFL injury is
  rare.
LATERAL ANKLE SPRAIN
 Mechanism of Injury:
 Inversion, plantar
 flexion or internal
 rotation injury
LATERAL ANKLE SPRAIN
 Clinical Features:
 Pain
 Swelling
 Limited ROM of ankle
 Anterior Drawer test-
  Positive “Suction” test
 Inversion stress test
LATERAL ANKLE SPRAIN
 Classification:
  Clinical Grading:
  Grade 1: Intra-ligamentous tear with no
           instability
  Grade 2: Incomplete tear, with mild to
           moderate instability
  Grade 3: Complete tear, with frank instability
LATERAL ANKLE SPRAIN
 Treatment:


RICE: Rest, Ice, Compression, Elevation.
Braces: Aircast, 3D boot, ASO- Pneumatic braces
 provide compression and rest together
LATERAL ANKLE SPRAIN
 Treatment:
Early protected weight bearing in Brace or Boot is
 encouraged.

Physical therapy has very important role, in achieving
 strength and ROM, and early return to sports.
LATERAL ANKLE SPRAIN
 Prognosis: About 30-35% of patients treated for acute
 injuries, may complain of chronic pain, swelling and
 recurrent sprains and instability.
Early treatment with immobilization, followed by
 programmed rehabilitation prevent chronic
 symptoms.
LATERAL ANKLE SPRAIN
 Prevention:
Taping, bracing, high-top shoes, muscle strengthening
 and stretching with proprioceptive training help
 reduced incidence of ankle injuries.
High Ankle Sprains
 One of the most difficult
  athletic injuries to treat
 Causes persistent
  disability in athletes
 Longer wait period in
  return to play and poor
  satisfaction.
       High Ankle Sprain
 Most significant force is
  external rotation
   AITF fails first
   Then interosseous ligament
     and finally interosseous
     membrane
High Ankle Sprain
 Mechanism
   Foot fixed to
    ground
 Mechanism
   Ligaments
    rupture
   Dorsiflexion
   External rotation
Continuum of injury:
 Minor stretch to a frank
 separation of the
 syndesmotic ligament.
 Interval between the
 tibia and fibula widens
 (diastasis)
Examination
 Pain directly over the anterior syndesmosis
 Pain and swelling are more precisely localized than with
  the more common lateral ankle sprain
 Minimal tenderness occurs over ATFL and calcaneofibular
  ligaments
 Severe swelling often absent
 Delayed ecchymosis proximal to ankle joint often present
 If abduction component
  is involved, pain and
  swelling should be
  expected over deltoid or
  medial malleolus
 Knee must also be
  examined to rule out
  Maissoneuve injury
Maissoneuve injury
Provocative Tests
 Squeeze Test
    Compression of tibia
     and fibula at mid-calf


• Positive if causes pain
 External rotation test
    Knee is kept at 90º
    Leg is stabilized with
     one hand and foot is
     externally rotated with
     the other
    Positive test is
     associated with pain at
     the syndesmosis
    Most reliable – highest
     interpreter correlation
MRI
Treatment
 Non-operative
   No widening of the
    mortise

   RICE


   Brief course of non-
    weightbearing
Treatment
 ROM/Strengthening


 Ankle braces or taping
 may be helpful to
 prevent external rotation
 forces while the
 syndesmosis is healing

 Longer rehab than
 lateral sprain
 Frank Diastasis
   Require anatomic reduction
    of the syndesmosis and
    internal fixation
   Why is this important?
       Risk of OA
                 Lateral Ankle
 Peroneal Tendons
    Lateral compartment
    Common sheath above malleolus
    Fibro-osseous canal
    Plantar flexion and eversion
Peroneal Tendons
  Tendonitis
      Endurance sports
      Shoe wear
      Regimen
      Surfaces
             Peroneal Tendons

 Tendonitis
    Aggravated with activity
     relieved with rest
    Testing provokes pain
    Swelling
    Bulbous areas
Peroneal Tendons

                    Tendonitis
                       Treatment
                          RICE
                          NSAIDS
                          Possible immobilization
                          Controlled rehabilitation
                          Stretching,
                           strengthening, endurance
Peroneal Tendons
 Tears
    Pain over sheath or along tendon course
    Resisted eversion
    Treatment for mild tears similar to tendonitis but
     includes bracing to prevent inversion
    If symptoms persist then further work-up and possible
     surgery needed
Peroneal Tendons
 Dislocations
   Occurs with dorsiflexed and everted ankle with
    simultaneous contraction of peroneal muscles
   Swelling and pain over lateral ankle
   “Snapping”
   Feeling of instability
Lisfranc ligament

      Cuneiform-       Lisfranc joint
                          complex
       metatarsal
      Intercuneiform
Lisfranc Injuries
  Non-Athletes
    High-velocity force
    Motor-vehicle accidents




                               Curtis, Am J Sports Med 1993
Lisfranc Injuries
  Athletes
     Low-velocity indirect
      force
     Often axial longitudinal
      force
     While foot was plantar
      flexed and slightly
      rotated
Dorsal Displacement of
   2nd Metatarsal
Clinical presentation
 Midfoot pain
 Specific event not always recallable
 Swelling in the midfoot-region and tenderness
 Inability to bear weight
 Persistent pain over 5 days after the initial injury




      Curtis, Am J Sports Med 1993; Mullen, Clin Sports Med 2004
Pronation-
Abduction-
Test


 Limited to the early
 and acute phase
 of the injury.

                        Curtis, Am J Sports Med 1993
Diagnostic Algorithm
               Nonweightbearing Radiograph



      If diagnosis not possible

                 Comparative Weightbearing



      If diagnosis not possible

                                  MRI
Nonweightbearing radiograph
MRI with intact Lisfranc ligament
  Dorsal (A) and plantar (B) components of the Lisfranc ligament




                      Potter, Foot Ankle Int; 1998, Preidler, AJR 1999
MRI with complete tear
 Complete rupture of the dorsal (A) and the plantar (B) components of
  the Lisfranc ligament




                                         Potter, Foot Ankle Int, 1998
Stage I – Lisfranc ligament sprain




•Unfit for sports
•Pain at Lisfranc joint line
•Non-displaced weight bearing x-rays

                                       Nunley, Am J Sports Med 2002
Stage II – Ruptured Lisfranc ligament




•Diastase of 1 to 5 mm on an ap weight bearing x-ray
•No evidence of a loss of midfoot arch height
                                           Nunley, Am J Sports Med 2002
Treatment Stage I injuries
 Cast for 4 to 6 weeks
   Short leg walking cast
   Short leg orthotic
   Non-weight-bearing cast
 Afterwards progressive ambulation and
  rehabilitation
 If symptoms persist weight-bearing x-rays to check
  stability and evidence of delayed separation


          Mantas, Clin Sports Med 1994; Curtis, Am J Sports Med 1993
                                      Nunley, Am J Sports Med 2002
Treatment Stage II injuries
 No conclusive data in literature to favor either
  operative or non operative treatment
   Non weight bearing cast for 6 weeks (Faciszewski 1990)
   Open reduction and internal fixation (Nunley 2002)




            Faciszewski, JBJS-A 1990; Nunley, Am J Sports Med 2002
Internal Fixation – K-Wires
  Minimal soft tissue
   trauma
  Sometimes problems
   to hold anatomical
   reduction
Internal fixation – AO-Screws
Calcaneal Apophysitis
(Sever’s Disease)
 Most common cause of heel pain in children
   Soccer and running: male
   Soccer and gymnastics: females


 Etiology
   Combination of repetitive forces
     Impact
     Traction
Calcaneal apophysitis
 Age:
    Girls 11 - 13
    Boys 12 – 14
 Heel pain exacerbated with running
 PE: Pain with lateral and medial compression of the
 calcaneus
   Decrease dorsi-flexion
Calcaneal apophysitis
 X-Rays: Not indicated.
   Increased density: not specific
Calcaneal apophysitis
 Tx
   Improve flexibility
   Foot orthotics
   Heal lifts
          Short term remedy
   Immobilization
          Severe cases
5th   Metatarsal Apophysitis
 Base of the fifth metatarsal at insertion of
  peroneal brevis
 Age 12-15, Fusion at 17 –18 years of age
 Pain on the lateral side of the foot
   Running, jumping, cutting, and inversion stresses
   +/- H/O preceding trauma

5th   Metatarsal Apophysitis
 PE
    Swelling
    Localized pain
    Pain with resisted
     eversion
Avulsion Fracture   5th MT Apophysitis
5th    Metatarsal Apophysitis
 Tx
   Rest
   Cryotherapy
   Stretching
   Orthotics
Achilles Tendinitis
 Overuse injury
 Mean age 24-30
 Up to 18% of running injuries
    Male-34 miles/wk
    Females-24 miles/wk
Achilles Tendinitis
 Predisposing factors
    Intrinsic (anatomic)
        Forefoot varus
        Hindfoot valgus
        Pes planus
        Poor gastroc/soleus flexibility
Achilles Tendinitis
 Predisposing factors
    Extrinsic (environment)
       Training changes
       Training surfaces
       Insufficient footwear
Achilles Tendinitis
               Clinical presentation

 History                    PE:
   Pain
                               Alignment
   Tendonosis
                               Shoe wear
   Swelling
                               Tenderness (local?)
   Warmth
                               Edema
   Crepitus
                               Thompson’s test
   Thickening
   Nodular
Treatment
 Non surgical
   Rest, decrease mileage
   NSAIDS, ICE
   Heel lift (1/4-3/8”)
       <2 wks (shortening)
   Ultrasound
   Strengthening/stretching (eccentric/concentric)
   No steroids
   PRP
Treatment
 Surgical
    After 3-6 months of conservative treatment
    Mechanisms
       Relieve pressure
       Lyse adhesions
       Remove necrotic areas, inflammed bursa, bone exostosis

				
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