Foot and Ankle Injuries

1. Foot and Ankle Injuries Howard J. McGowan, Maj, USAF, MC Sports Medicine Fellow USU Primary Care Sports Medicine Fellowship

2. Objectives • Review anatomy of Foot and Ankle • Discuss key history • Hands on exam • Discuss cases concerning common injuries of the Foot and Ankle

3. Anatomy

4. Anatomy

5. Anatomy

6. Anatomy

7. Anatomy

8. Anatomy

9. Anatomy

10. Anatomy

11. History • Onset • Duration • Activity/Mechanism • Swelling / Ecchymosis • Ambulation • Sound • Hx of previous injury

12. Exam

14. Cases

15. 25 yo male with foot pain Stepped in a hole on a road march Pain and swelling in midfoot dorsally Unable to bear weight Case 1

16. Case 1 • Refuses to bear weight • Mid foot grossly swollen and eccymotic • Tender to palpation along tarsometatarsal joints medially and laterally • Pain exacerbated by forefoot abduction and pronation • Neurovascularly intact

17. Case 1

18. Case 1Lisfranc Injury • Lisfranc injury • 1% of orthopedic trauma • 20% missed on initial presentation

19. Case 1Lisfranc Injury • Lisfranc joint • Stable axis of rotation • Keystone for plantar and dorsiflexion • Horizontal axis through second MT • Plantar flexion with an axial load provides stress to dorsally displace 2nd MT base

20. Case 2 • 32 yo female playing club rugby “jammed” her big toe • Was able to continue playing, but had pain exacerbated with push-off • Now with increased pain with ambulation

21. Case 2 • Antalgic gait • Walks on lateral aspect of her foot • Swelling around 1st MTP joint • Tender plantar aspect of 1st MTP joint • Pain exacerbated with dorsiflexion of great toe

22. Case 2Turf Toe • Turf toe • Forced hyperextension • Grades • I—minor swelling/eccymosis • II—partial tear of capsule • III—complete tear of capsule

23. Case 2Turf Toe • Ranked third in collegiate athletes after knee and ankle injuries • Forced hyperextension • Sometimes with varus or valgus stresses • Also with forced flexion

24. Case 3 • 21 yo female volleyball player presents with lateral ankle pain after landing on teammates foot • Ankle inverted

25. Case 3

26. Case 3

27. Case 3 • How good are the Ottawa Rules? • When originally published: • 100% sensitivity & 40% specificity for detecting malleolar fractures • Subsequent studies: • Lower sensitivity (93% to 95%) and specificity (6% to 11%) than originally thought • Not perfect, but still a good tool

28. Case 3Lateral Ankle Sprain • Estimated 1 million present to physicians with acute ankle injuries each year • Sprains account for 25% of all sports-related injuries and 75% of all ankle injuries • Lateral ankle ligaments are the most commonly injured structures in young athletes • More than 40% of ankle sprains have potential to cause chronic problems

29. Case 3Lateral Ankle Sprain • Presentation/Diagnosis • Lateral Pain • Weight Bearing • +/- Swelling • +/- Ecchymosis • Point tender over ATFL, CFL, PTFL • ? +talar tilt, +anterior drawer

30. Case 3

31. Case 4 • Pt is an 18 y/o football player who presents with an ankle sprain. • Pt has considerable swelling and demonstrates more tenderness proximal to the ATFL.

32. Case 4 • Patient unable to bear weight • Tender along deltoid ligament • Positive squeeze test • Positive external rotation test

33. Case 4

34. Case 4Syndesmotic Injury • Forced external rotation of the foot • Internal rotation of the tibia on a planted foot. • Common in soccer, skiing, motocross and football

35. Case 4 Maisonneuve

36. Case 4

37. Case 5 • USU secretary slipped on ice • Inverted ankle • Unable to bear weight • Tender at base of 5th MT

38. Case 5

39. Case 55TH Metatarsal Frx • The most commonly fractured metatarsal • These fractures may result from direct or indirect trauma. • Proximal fifth metatarsal fractures have been the subject of considerable debate and controversy.

40. Case 55TH Metatarsal Frx • The proximal fifth metatarsal consists of the tuberosity, base, and proximal shaft. • Tuberosity is the site of attachment of the peroneus brevis and lateral band of the plantar fascia. • The metaphyseal-diaphyseal junction is a vascular watershed • The metaphyseal-diaphyseal junction includes the joint between the base of the 4th and 5th metatarsals.

41. Case 6 • 22 yo female sprinter experiences pain when coming out of blocks • Able to bear weight, but painful • Ottawa negative • Initial x-rays were negative

42. Case 6 • Vague, aching pain • Dorsal foot, radiating along medial arch • Increase with activity and progress to post-activity

43. Case 6 • Normal ROM • Normal strength • Usually no swelling or ecchymosis • Localized pain with inverting-everting forefoot • Tender over dorsal navicular area • Pain with hopping, standing on toes

44. Case 6 • Navicular Stress Fracture • 0.7-2.4% of all stress fractures (1980) • More recent reports 14-35% • Track athletes at elite level – 59%

45. Case 7 • 45 yo male playing recreational basketball • Landed, “gunshot” calf • Minimal pain, but unable to bear weight or point toes

46. Case 7 • +calf pain • Antalgic gait • Difficulty with tiptoe walk • Visible and a palpable defect superior to calcaneus • Positive Thompson test

47. Case 7Achilles Rupture • Poorly conditioned 30-45 yo males (weekend warriors) • 1 per 1000 athlete-years • History of tendinitis/degenerative changes • Steroids? • Fluoroquinolones?

48. Conclusion • Review anatomy of Foot and Ankle • Discuss key history • Hands on exam • Discuss cases concerning common injuries of the Foot and Ankle

49. QUESTIONS