Chronic Ankle Pain

1. Chronic Ankle Pain Sharese M. White, MD LCDR MC USN

2. Thank you’s for some slides: • Kevin deWeber, MD, FAAFP, FACSM • AAOS Instructional Course Lecture • JBJS Volume 92-A, Number 10, August 18, 2010

3. Anatomy

4. Anatomy

5. Anatomy

6. Anatomy

7. Anatomy

8. ANKLE JOINT ROM • Dorsiflexion • Plantarflexion • Exam – check both active and passive

9. SUBTALAR JOINT: Inversion and Eversion

10. ROM: Inversion/Eversion

11. Anterior Drawer Test (ATFL)

12. Talar Tilt - ATFL/CFL

13. Syndesmosis Injury Squeeze Test External Rotation Test

14. Ankle Radiographs AP Lateral Mortise

15. Lateral Ankle Sprains • Inversion injuries • Graded 1-3 • 1: no ligament laxity • 2: slight laxity • 3: complete ligament rupture • ATFL first  CFL second  PTFL last • ATFL 3rd-deg: + Anterior Drawer • ATFL & CFL 3rd-degr: + AntDrawer & Talar Tilt

16. Chronic Pain after Ankle Sprain/Injury Inadequate Rehab Instability TalarDome OCD PeronealTendon Injury Anterior Impingement PTT dysfunction FHL tendonitis Sinus Tarsi Syndrome Osteoarthritis Tarsal Tunnel Occult Fracture CRPS Achilles tendonitis

17. Where is the pain? • Anterior • Lateral • Posterior • Medial

18. Anterior Ankle Pain • Anterior ankle impingement • osseous or soft tissue • Osteophyte • Synovial tissue • Ligamentous tissue • “walking uphill” • Painful limited passive dorsiflexion • Tx – small heel lift, NSAIDs, ice, PT • Surgery for refractory cases

19. Anterior Ankle Pain • Osteochondraltalar lesions • Anterior pain • effusion • Acute – anterolateral • fractures • Chronic – posteromedial • Recurrent ankle sprains • Treatment – depends on stage • STRONGLY RECOMMEND ORTHOPEDIC CONSULTATION

20. Anterior Ankle Pain • Nerve entrapment • Deep peroneal nerve • Branches into medial motor and lateral sensory branch 1cm proximal to joint line • Compressed by extensor retinaculum and EHB • Tx: • Steroid injection around nerve • Surgical release

21. Lateral Ankle Pain • Chronic instability • Usually painless unless underlying lesion • OCD, peroneal tendon, loose bodies, etc. • Tx – physical therapy, proprioceptive training • Surgery for refractive cases

22. Lateral Ankle Pain • Peroneal tendon injury • Tears • Subluxation • Peroneusquartus • 20% of population • Increased risk of synovitis • Retromalleolar pain • Look for hindfootvarus • Eversion testing • Tx – cast; surgery

23. Lateral Ankle Pain • Sinus Tarsi Syndrome • Diagnosis of exclusion • Injection relieves pain • X-rays are normal • MRI – nonspecific inflammation • Tx • Steroid injection (US guided best) • operative debridement

24. Lateral Ankle Pain • Occult fractures • Lateral talar process • Eversion moment on dorsiflexed axially loaded foot • Anterior calcaneal process • Inversion of plantarflexed ankle • Tx – depends on size of fragment • Surgery for fragment >1 cm and >2 mm displacement

25. Posterior Ankle Pain • Posterior ankle impingement • Enlarged posterolateraltalar tubercle – Steida process • Os trigonum • Repeated plantarflexion • Tx – immobilization followed by physical therapy • Surgery for refractory cases • excision of ostrigonum • decompression of posterior talar process

26. Posterior Ankle Pain • Achilles tendinitis • Paratenonitis • Noninsertionaltendinosis • Insertionaltendinosisand retrocalcaneal bursitis • Shoe wear, activity • Tx • Acute paratenonitis: relative rest • Midsubstancetendinopathy: eccentric rehab 3-6 mos • ? Dextrose prolotherapy • Insertionaltendinopathy: nothing works very well • surgery after six months of conservative management • NO STEROID INJECTIONS!!!

27. Medial Ankle Pain • Tarsal Tunnel Syndrome • Symptomatic entrapment of tibial nerve within the tunnel • Rule out space occupying lesion • Paresthesias on percussion (Tinel’s) • Dorsiflexion and eversion (Phalen’s) • Tx • Conservative: orthotics, steroid injection (US-guided) • Surgery for refractory cases

28. Medial Ankle Pain • Posterior Tibial Tendon Dysfunction • Begins with inflammation, ends with dysfunction • “too many toes” sign • Single leg heel rise - fails • Tx – conservative (3 months)– boot/Arizona brace/cast • Surgery for refractory cases • NO STEROID INJECTIONS

29. Posteromedial Ankle Pain • Flexor HallucisLongus Tendonitis • Pain w/ passive toe motion • Cause: Repetitive push-off activities • Tx – rest/activity modification • Surgery for refractive cases • NO STEROID INJECTIONS!!!

30. Review Time! • Question Text:A 36 year old female recreational soccer player presents with insidious onset of left posterior heel pain and a limp. She is wearing flip flops because shoes make the pain worse. Examination reveals swelling and erythema of the posterior heel. There is no palpable defect in the Achilles tendon and a Thompson test is negative. The most likely diagnosis is:Possible Answers:A. Stress fracture of the calcaneusB. Plantar fasciitisC. Achilles tendon avulsionD. Sural neuritisE. Retrocalcaneal bursitis

31. Review Time! • Correct Answer: ECritique:Retrocalcaneal bursitis (also called Haglund’s syndrome) is associated with overuse and presents with pain behind the calcaneus. Examination reveals swelling and erythema of the posterior heel. A prominence, called a “pump bump” may be noticeable. Retrocalcaneal bursitis is associated with pain and tenderness anterior to the Achilles tendon, along the medial and lateral aspects of the posterior calcaneus. Plantar flexion of the foot and/or squeezing the bursa from side to side reproduces the patient’s complaint.A stress fracture of the calcaneus produces mid-calcaneal bony tenderness and occurs with acute overuse. The symptoms of plantar fasciitis include tenderness and pain underneath (plantar surface), rather than behind the heel. A pop is generally heard and felt along with a palpable defect in the tendon and a positive Thompson test with an Achilles tendon avulsion injury. Sural neuritis is rare and the result of direct trauma. A positive percussion sign over the nerve lateral to the Achilles tendon is diagnostic of sural neuritis.References:1. Snider, R. K. (1997). Essentials of musculoskeletal care. USA: American Academy of Orthopaedic Surgeons.

32. More Review Time! • Question Text: • A 22 year old dancer presents to clinic with pain over the posterior aspect of her ankle. On exam she is tender to palpation over the posteromedial ankle. • Provocative testing with compression over the posteromedial ankle with dorsiflexion of the great toe reproduces the pain. What is the most likely diagnosis? • Possible Answers: • A. Flexor hallucislongussynovitis • B. Os trigonum syndrome • C. Halluxrigidus • D. Posterior tibial tendonitis • E. Peroneal tendonitis

33. Even MORE Review Time! • Correct Answer: A • Critique: • Tenosynovitis of the flexor hallucislongus (FHL) is most commonly descried in classical ballet dancers. It is the hyperflexed position of the ankle that causes • compression of the tendon as it passes posterior to the subtalar joint complex. This most commonly presents as pain in the posterior medial ankle. On physical • exam there is tenderness to palpation over the musculotendonous junction of the FHL. Pain can also by elicited by forced dorsiflexion of the ankle and first MTP • joint simultaneously. Conservative treatment includes rest, anti-inflammatories, and physical therapy modalities. This should include specific FHL stretching • exercises. In cases of recalcitrant pain, surgical decompression is warranted. • References: 1. Michelson J, Dunn L. Tenosynovitis of the flexor hallucislongus: a clinical study of the spectrum of presentation and treatement. Foot Ankle Int, • 2005;26(4):291-303. • 2. Gould N. Stenosingtenosynovitisofteh flexor hallucislongus tendon at the great toe. Foot Ankle, 1981;2:46-48. • 3. Hedrick, W; Mcryde, A. Posterior ankle impingement. Foot Ankle Int,1994;15:2-8