ankle and foot: common acute injuries. traumatic injuries to the ankle ankle sprains (25% of all...

Ankle and Foot:Ankle and Foot:Common Acute InjuriesCommon Acute Injuries

Traumatic Injuries to Traumatic Injuries to the Anklethe Ankle

• Ankle Sprains Ankle Sprains (25% of all Sports Injuries) (25% of all Sports Injuries) • Ankle FracturesAnkle Fractures• Achilles tendon ruptureAchilles tendon rupture

Traumatic Injuries to the Foot• 5th Metatarsal Fractures• Lisfranc Injuries

Bones & LigamentsBones & Ligaments

Bones & LigamentsBones & Ligaments

AnatomyAnatomy

AnatomyAnatomy

AnatomyAnatomy

AnatomyAnatomy

AnatomyAnatomy

AnatomyAnatomy

SUBTALAR JOINT:

Inversion and Eversion

Evaluation Evaluation HistoryHistory•Mechanism of injuryMechanism of injury•Location of painLocation of pain•Continued activity?Continued activity?•Weight bearing?Weight bearing?•Previous injuriesPrevious injuries•Prior treatmentPrior treatmentField vs Office EvaluationField vs Office Evaluation

Physical Physical ExaminationExamination•Inspection Inspection •PalpationPalpation•Range of motionRange of motion•Strength testing Strength testing •Special testsSpecial tests

Inspection: Inspection: Swelling, Ecchymosis, Swelling, Ecchymosis,

DeformityDeformity

PalpationPalpation

AXIOM OF SPORTS MEDICINE:

“Find out what is tender, then figure out what’s there.”

Knowing your anatomy is critical

ROM: ROM: dorsiflexion/plantarflexiondorsiflexion/plantarflexion• (Active & Passive) (Active & Passive)

ROM: Inversion/EversionROM: Inversion/Eversion

Special Tests

Anterior Drawer Test (ATFL)

Talar Tilt - ATFL/CFLTalar Tilt - ATFL/CFL

Syndesmosis

Injury

Squeeze Test

External Rotation Test

Squeeze Test External Rotation Test

Thompson’s TestIntegrity of Achilles Tendon

+

is

no

movement

Ankle RadiographsAnkle Radiographs

AP Lateral Mortise

Lateral Ankle SprainsLateral Ankle Sprains

• Inversion injuriesInversion injuries• Graded 1-3Graded 1-3

– 1: no ligament laxity1: no ligament laxity– 2: slight laxity2: slight laxity– 3: complete ligament rupture3: complete ligament rupture

• ATFL first ATFL first CFL second CFL second PTFL last PTFL last• ATFL 3ATFL 3rd-degrd-deg: + Anterior Drawer: + Anterior Drawer• ATFL & CFL 3ATFL & CFL 3rd-degrrd-degr: + AntDrawer & : + AntDrawer &

Talar TiltTalar Tilt

Do ankle sprains need x-Do ankle sprains need x-rays?rays?

• Ottowa Ankle Rules: if Ottowa Ankle Rules: if any any of the 5 of the 5 positive, get x-rayspositive, get x-rays– Inability to bear wt initially and in ERInability to bear wt initially and in ER– TTP over posterior Medial MalleolusTTP over posterior Medial Malleolus– TTP over posterior Lateral MalleolusTTP over posterior Lateral Malleolus– TTP over 5TTP over 5thth MT base MT base– TTP over Navicular boneTTP over Navicular bone

Ottawa Ankle Rules

**Or inability to bear weight

Ankle Sprain TreatmentAnkle Sprain Treatment• PRICEMPRICEM• NSAID short course may speed recoveryNSAID short course may speed recovery• Crutches prn, weight bearing as toleratedCrutches prn, weight bearing as tolerated• Protect ankle ligaments (brace)Protect ankle ligaments (brace)

– Consider cast/boot if severe painConsider cast/boot if severe pain• Early referral to Physical TherapyEarly referral to Physical Therapy

– Early ROMEarly ROM– Strength exercisesStrength exercises– Proprioception exercisesProprioception exercises– Sports-specific drillsSports-specific drills– Sports/DutySports/Duty

• Follow-up in 2 weeksFollow-up in 2 weeks

Ankle Sprain Tx BIG-Ankle Sprain Tx BIG-THREETHREE

• PROTECTION (BRACE)PROTECTION (BRACE)• STRENGTH EXERCISESTRENGTH EXERCISE• PRIPRIOCEPTION TRAININGPRIPRIOCEPTION TRAINING

Chronic Pain after Ankle Chronic Pain after Ankle SprainSprain

Inadequate Rehab ( Top 3)Slow RehabInstabilityTalar Dome OCDPeroneal Tendon InjurySynovial ImpingementComplex Regional Pain Syndrome

Subtalar Injury Tarsal CoalitionOsteoarthritisTarsal TunnelStress FractureInterosseous Membrane Injury

Refer to Sports Medicine

Tib-Fib Syndesmosis Tib-Fib Syndesmosis InjuriesInjuries

“High Ankle Sprains”“High Ankle Sprains”• If ANY widening of mortise, refer to OrthoIf ANY widening of mortise, refer to Ortho• If any fibular tenderness, r/o fx If any fibular tenderness, r/o fx

(Maisonneuve)(Maisonneuve)– Refer to OrthoRefer to Ortho

• If none of the above, (grades 1-2), If none of the above, (grades 1-2), IMMOBILIZE, CRUTCHESIMMOBILIZE, CRUTCHES– 2-4 weeks in cast2-4 weeks in cast– CAM boot until no pain walkingCAM boot until no pain walking– Refer to PhTh for good rehabRefer to PhTh for good rehab

Maisonneuve FractureMaisonneuve Fracture

Tib/Fib Clear Spaceshould be < 5mm

Medial Clear Spaceshould be < 5mm

Mortise View is important

If not….SCREW IT!

Ankle FracturesAnkle Fractures

Axioms in Ankle Axioms in Ankle FracturesFractures

• Nondisplaced avulsions of medial or Nondisplaced avulsions of medial or lateral malleolus: treat as grade 3 lateral malleolus: treat as grade 3 ankle sprainsankle sprains– +/- cast/boot, early mobilization+/- cast/boot, early mobilization

• Combinations of medial and lateral Combinations of medial and lateral fracture/sprain: UNSTABLE; refer to fracture/sprain: UNSTABLE; refer to OrthoOrtho

• Displaced >2mm: referDisplaced >2mm: refer• Mortise widening: referMortise widening: refer

Achilles Tendon RuptureAchilles Tendon Rupture

• Thompson Test positiveThompson Test positive• May have gap in tendonMay have gap in tendon• Ultrasound sensitive for tearUltrasound sensitive for tear

– Find Sports Med docFind Sports Med doc

Thompson Test for Achilles tendon rupture

negPOSITIVE

Ultrasound of Achilles Ultrasound of Achilles rupturerupture

Achilles Rupture Achilles Rupture TreatmentTreatment

• Treatment controversial; Treatment controversial; Refer to OrthoRefer to Ortho

• Surgical: better for young, Surgical: better for young, activeactive– Lower rate of re-ruptureLower rate of re-rupture– Higher wound complicationsHigher wound complications

• Casting: better for old, less Casting: better for old, less activeactive– Up to 40% re-ruptureUp to 40% re-rupture– Lower cost and wound Lower cost and wound

complicationscomplications

55thth Metatarsal Metatarsal FractureFracture•Avulsion of baseAvulsion of base

•Jones FractureJones Fracture–Metaphyseal-Diaphyseal Metaphyseal-Diaphyseal junction w/in 1.5cm of junction w/in 1.5cm of tuberosity tuberosity

•Midshaft FractureMidshaft Fracture•(stress fractures are (stress fractures are different)different)

55thth MT Base Avulsions MT Base Avulsions

• Treat similar to Treat similar to ankle sprainsankle sprains

• Bulky dressingBulky dressing• X-rays in 2-4 weeks X-rays in 2-4 weeks

to assure healingto assure healing• RTP 4-6 weeksRTP 4-6 weeks

• EXCEPTION: Refer EXCEPTION: Refer if fx is intra-if fx is intra-articulararticular

55thth MT MT Metaphysis/Diaphysis JxnMetaphysis/Diaphysis Jxn“Screw that Mr. Jones the “Screw that Mr. Jones the

Middle Man!”Middle Man!”• Screw fixation OR Screw fixation OR NWB short-leg NWB short-leg cast 6 weeks cast 6 weeks – Trend for faster Trend for faster

healing with Screwhealing with Screw• 8 wks vs 12 wks8 wks vs 12 wks

– Lower rate of Lower rate of NonunionNonunion• 20% vs 7%20% vs 7%

55thth MT Shaft Fracture MT Shaft Fracture

• Cast, hard-sole Cast, hard-sole shoe, bulky shoe, bulky dressings as dressings as neededneeded

• RTP in about 6 RTP in about 6 weeksweeks

LISFRANC

INJURY

Weight-bearing x-rays are MANDATORY

FleckSign

Lisfranc Complex Lisfranc Complex InjuryInjury

•Maintain High Index of Suspicion Maintain High Index of Suspicion •Stress the midfoot Lisfranc complexStress the midfoot Lisfranc complex•Consult Ortho if ANY fractures, ligamentous Consult Ortho if ANY fractures, ligamentous

instabilityinstability• If 1If 1stst-2-2ndnd MT space 2-5mm widening, may tx MT space 2-5mm widening, may tx

with castingwith casting• If only sprain: 6 weeks of castingIf only sprain: 6 weeks of casting

– 3 wks NWB, 3 wks SLWC3 wks NWB, 3 wks SLWC

ReviewReview•Ankle Sprain tx BIG-3?Ankle Sprain tx BIG-3?•Syndesmosis sprains: don’t miss Syndesmosis sprains: don’t miss

widened ______?widened ______?•5th Metatarsal Fx- screw that Mr. _____5th Metatarsal Fx- screw that Mr. _____•Midfoot pain: x-rays should be ___-___:Midfoot pain: x-rays should be ___-___:•Lisfranc sprains w/ fx or widening: ____Lisfranc sprains w/ fx or widening: ____•Lisfranc w/o instability: treat _______ly.Lisfranc w/o instability: treat _______ly.

ReviewReview

•Sports Medicine: find out Sports Medicine: find out where it hurts, then…..where it hurts, then…..