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Foot and Ankle Injuries

Foot and Ankle Injuries. Brandon Mines, MD Emory Sports Medicine Center May 13 th , 2010. Objectives. Anatomy Injuries Treatment. Arches.

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Foot and Ankle Injuries

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  1. Foot and Ankle Injuries Brandon Mines, MD Emory Sports Medicine Center May 13th, 2010

  2. Objectives • Anatomy • Injuries • Treatment

  3. 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)

  4. high arch (pes cavus)

  5. flat feet (pes planus)

  6. hallux valgus

  7. Claw Toes

  8. 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 is reinforced laterally by the lateral lig. And medially by the deltoid (medial) lig. talus AP

  9. The Lateral Ligaments ant. talofibular lig. post. talofibular lig. calcaneofibular lig.

  10. The Deltoid Ligament

  11. Ankle Inspection • Position • Gait • Asymmetry • Muscle atrophy • Abnormal bone alignment • Swelling • Color change (bruising)

  12. Ankle Strength Testing • Dorsiflexion Anterior Tibialis • Plantar flexion Peroneal Tendons Gastroc & Soleus • Inversion Posterior Tibialis • Eversion Peroneal Tendons

  13. 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.

  14. LATERAL ANKLE SPRAIN • Patho-anatomy: • ATFL most commonly injured • Combination of ATFL and CFL is 2nd most common • Isolated PTFL injury is rare. ATFL PTFL CFL

  15. LATERAL ANKLE SPRAIN • Mechanism of Injury: Inversion, plantar flexion or internal rotation injury

  16. LATERAL ANKLE SPRAIN • Clinical Features: • Pain • Swelling • Limited ROM of ankle • Anterior Drawer test-Positive “Suction” test • Inversion stress test

  17. 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

  18. LATERAL ANKLE SPRAIN • Treatment: • RICE: Rest, Ice, Compression, Elevation. • Braces: Aircast, 3D boot, ASO- Pneumatic braces provide compression and rest together

  19. 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.

  20. 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.

  21. LATERAL ANKLE SPRAIN • Prevention: • Taping, bracing, high-top shoes, muscle strengthening and stretching with proprioceptive training help reduced incidence of ankle injuries.

  22. 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.

  23. High Ankle Sprain • Most significant force is external rotation AITF fails first Then interosseous ligament and finally interosseous membrane

  24. High Ankle Sprain • Mechanism • Foot fixed to ground • Mechanism • Ligaments rupture • Dorsiflexion • External rotation

  25. Continuum of injury: Minor stretch to a frank separation of the syndesmotic ligament. Interval between the tibia and fibula widens (diastasis)

  26. 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

  27. 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

  28. Maissoneuve injury

  29. Provocative Tests • Squeeze Test • Compression of tibia and fibula at mid-calf • Positive if causes pain

  30. 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

  31. MRI

  32. Treatment • Non-operative • No widening of the mortise • RICE • Brief course of non-weightbearing

  33. 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

  34. Frank Diastasis • Require anatomic reduction of the syndesmosis and internal fixation • Why is this important? • Risk of OA

  35. Lateral Ankle • Peroneal Tendons • Lateral compartment • Common sheath above malleolus • Fibro-osseous canal • Plantar flexion and eversion

  36. Peroneal Tendons • Tendonitis • Endurance sports • Shoe wear • Regimen • Surfaces

  37. Peroneal Tendons • Tendonitis • Aggravated with activity relieved with rest • Testing provokes pain • Swelling • Bulbous areas

  38. Peroneal Tendons • Tendonitis • Treatment • RICE • NSAIDS • Possible immobilization • Controlled rehabilitation • Stretching, strengthening, endurance

  39. 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

  40. 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

  41. Lisfranc ligament • Cuneiform-metatarsal • Intercuneiform Lisfranc joint complex

  42. Lisfranc Injuries • Non-Athletes • High-velocity force • Motor-vehicle accidents Curtis, Am J Sports Med 1993

  43. Lisfranc Injuries • Athletes • Low-velocity indirect force • Often axial longitudinal force • While foot was plantar flexed and slightly rotated

  44. Dorsal Displacement of 2nd Metatarsal

  45. 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

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