LEG, ANKLE AND FOOT INJURIES Evaluation and Treatment of Leg, Ankle and Foot Injuries Jeff Roberts, MD, CAQSM 159 Leg, Ankle, and Foot Injuries in Athletes Jeff Roberts MD CAQSM Objectives • Leg – – – • Ankle – – – • Acute ankle injury Persistent ankle pain Achilles injury Foot – – – – • Stress Fracture MTSS Compartment syndrome Stress Fractures Midfoot injury Plantar fasciitis Turf Toe Pediatric Perspective – – – – Sever’s Iselin’s Tarsal coalition Traction apophysitis of the navicular Leg Pain • Differential Diagnosis – Medial tibial stress syndrome (MTSS) – “shin splints” – Tibia stress fracture – Exercise induced compartment syndrome 160 1 Medial Tibial Stress Syndrome • • • “Shin Splint” – dull ache over the posterior, medial, distal third of the tibia with activity Tendinopathy or periosteal reaction along the attachment sites of the tibialis posterior or soleus Exam • Imaging • Treatment – – – – – – – • Tenderness over the medial distal third of the tibia Neurovascular exam - normal Radiographs – normal MRI – used when concerned about associated stress fracture Stretching – gastroc, Soleus, and tibialis posterior Strengthening – concentric and eccentric – tibialis posterior, soleus, tibialis anterior, FH, FDL Antipronator orthotics Persistent symptoms – – – MRI or bone scan Compartment testing Consider lumbar radiculopathy Tibia Stress Fracture • A spontaneous fracture that is the result of the summation of stresses that lead to failure of the bone. • • • • • Progressively worsening pain in the proximal or middle third of the tibia Common in distance runners Recent transition in training Patients often have symptoms for months but continue to train Exam • Imaging – Fatigue fractures: Normal bone – Insufficiency fractures: Abnormal bone – Focal tenderness – Tuning fork test – X-ray – often normal – MRI – bone marrow edema and/or fracture line – Bone scan – increased uptake Tibial Stress Fracture • Posteromedial cortex – compression side –Low risk • Middle-third anterior cortex fractures are described as the "dreaded black line” –High risk –At risk of progressing to acute transverse fractures of the tibia Harmon, K. Lower Extremity Stress Fractures. Clin J Sport Med 2003;13:358-364. 161 2 Tibial Stress Fracture • Treatment: • Proximal- or distal-third (compression type) – Crutches until walking is pain-free – Return to running after 8 weeks of rest » Slowly increase training intensity and mileage » Response to therapy is highly individual » Pain recurrence should prompt a return to whatever level of activity can be performed pain-free Harmon, K. Lower Extremity Stress Fractures. Clin J Sport Med 2003;13:358-364. Bracing • Casts • Boots • Aircast stirrup Pneumatic Bracing: Tibial Stress Fracture Early mobilization with the support of a pneumatic brace may accelerate a return to training activity. Rome K. Handoll HH. Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev. 2005 Apr 18;(2): 1-50. 162 3 Rehab: Tibial Stress Fracture Protocol Week 1 Days 1. Walk 1 mile at a quick pace. Bike/Swim/Elliptical 20-30 minutes. Bodyweight squats 3x10, RBE#1 2. Walk 1 mile at a quick pace, RBE#2 3. Walk 300 yards, jog 100 yards, walk 300 yards, jog 100 yards, walk 300 yards, jog 100 yards, walk 300 yards, jog 100 yards, walk 100 yards. Bike/ Swim/ Elliptical 20-30 minutes. Bodyweight squats 3x10. 4. OFF 5. Walk 200 yards, jog 200 yards, walk 200 yards, jog 200 yards, walk 200 yards, jog 200 yards, walk 400 yards. 6. Walk 400 yards, jog 400 yards, walk 400 yards, jog 400 yards, walk 100 yards. Bike/ Swim/ Elliptical 20-30 minutes, RBE#3. 7. Walk 400 yards, jog 800 yards, walk 400 yards, Bodyweight squats 3x10. Week 2 Days 1. Walk 200 yards, jog 1200 yards, walk 400 yards. Bike/Swim/Elliptical 25-35 minutes. Bodyweight squats 3x10. RBE#1 2. Walk 100 yards, jog 1 mile, walk 100 yards. Single leg extensions 3x8 ___lbs, 4-way hip machine 3x8 ___lbs (Abduction, Adduction), Single leg hamstring curls 3x8 ___lbs. 3. Jog 300 yards, run 100 yards, jog 300 yards, run 100 yards, jog 300 yards, run 100 yards, jog 300 yards, run 100 yards, jog 100 yards. Bike/Swim/Elliptical 25-35 minutes. Bodyweight squats 3x15, RBE #3. 4. OFF 5. Jog 200 yards, run 200 yards, jog 200 yards, run 200 yards, jog 200 yards, run 200 yards, jog 400 yards. Single leg extensions 3x8 ___lbs, 4- way hip machine 3x8 __lbs, Single leg hamstring curls 3x8 __lbs. 6. Jog 400 yards, run 400 yards, jog 400 yards, run 400 yards, jog 100 yards. Bike/Swim/Elliptical 25-35 minutes. Bodyweight squats 3x15. 7. Jog 400 yards, run 800 yards, jog 400 yards. RBE#2 Week 3 Days 1. Jog 600 yards, run1200 yards, walk 400 yards. Bike/Swim/Elliptical 30-40 minutes. Bodyweight squats 3x15. RBE#2. 2. Jog 400 yards, run 1 mile, jog 200 yards. Single leg extensions 3x8 __lbs, 4 way hip machine (adduction, abduction, flexion, extension) 3x8 __lbs, Single leg hamstring curls 3x8 __lbs. 3. Jog 400 yards, run 1 mile, jog 200 yards, walk 400 yards, Bodyweight squats 3x20. RBE#1. 4. Run 50 yards at 50% speed x2, then at 75% speed x2, and finally at 100 % speed x2, 1 minute rest between change in speeds. Run 100 yards x2 with 1 minute rest. Bike/Swim/Elliptical 30-40 minutes. 3/10/06 5/24/06 163 4 Exercise Induced Compartment Syndrome • Reversible neurovascular compromise • Symptoms – – – – – – • Recurrent leg discomfort with exercise Pain is cramping, tight, or squeezing ache Occurs at the same time frame Increased with duration of exercise and intensity Improvement with rest Four major compartments of the lower leg – each contains a nerve – – – – • Restrictive fascial compartments that are noncompliant to increased muscle volume associated with exercise Anterior (45%) – deep peroneal nerve Lateral (40%) – superficial peroneal nerve Superficial posterior (10%) – sural nerve Deep posterior (5%) – posterior tibial nerve Exam – – At rest exam can be normal Anterior – Lateral • • • • Weakness of dorsiflexion or toe extension Paresthesias over the dorsum of the foot Weakness of ankle eversion Paresthesias over the anterolateral aspect of leg – Superficial Posterior – Deep Posterior • • • • Weakness of plantar flexion Hypesthesia of the dorsolateral foot Weakness of toe flexion and foot inversion Parasthesia of the plantar aspect of the foot Exercise Induced Compartment Syndrome • Diagnosis – Compartment testing • Pre-exercise ≥ 5 mm-Hg • 1 minute post-exercise ≥ 30 mm-Hg • 5 minute post-exercise ≥ 20 mm-Hg • Treatment – Nonoperative • • • • • Relative rest Avoiding level of exercise that triggers symptoms Antiinflammatories Stretching and strengthening Orthotics – Operative • Fasciotomy Acute Ankle Injury To x-ray or not to x-ray, that is the question 164 5 Ottawa Ankle Rules An ankle x-ray is required only if there is any pain in malleolar zone and any of these findings: bone tenderness at A bone tenderness at B Inability to weight bear both immediately and in the clinic. A foot x-ray is required if there is any pain in the midfoot zone and any of these findings: bone tenderness at C bone tenderness at D Inability to weight bear both immediately and in the clinic. Radiographic Anatomy of the Ankle • AP, Lat, Mortise views – Mortise • 10-15o internal rotation • • • • Medial clear space Lateral clear space Tibiofibular clear space Look for symmetry Mortise View 165 6 Malleolus Fractures • Usually external rotation mechanism – Variable injury patterns – Medial or lateral or both – Concomitant ligament damage typical – ATFL, anterior tibiofibular, deltoid Malleolus Fractures • Displaced Fractures – ORIF – Even 1-2 mm of mortise displacement can shift contact pressures of the ankle joint • Non-displaced fractures – Or closed reduction • May be treated conservatively Medial Malleolus Fracture Care • • • • Usually immobilized 6 weeks Progress weight-bearing Physical therapy Return to sport 3-4 months – May be up to 6 months 166 7 Lateral Malleolus Fractures • Most common fracture of the ankle • Inversion or external rotation mechanism • PE – TTP lateral malleolus – Concomitant ankle sprain • Imaging- Ottawa rules, suspicion • Danis-Weber classification – A below mortise – B spiral fracture at mortise – C above mortise Treatment • Danis-Weber A – Short leg cast 4 weeks – Change to boot for 2 weeks • Radiographic healing • Clinically improved • Start physical therapy at 5-6 weeks – Refer if no evidence of healing after 8 weeks Treatment • Danis-Weber B and C – Refer – Also bimalleolar or trimalleolar fx – Check medial ankle 167 8 Maisonneuve Fractures • External rotation injury with fracture of the proximal 1/3 of the fibula • Medial ankle pain – Deltoid ligament sprain – Syndesmotic injury • Refer – ORIF Ankle Sprains • • • • • Anterior talo-fibula ligament – ATFL Calcaneo-fibula ligament – CFL Posterior talo-fibula ligament – PTFL Deltoid ligament Syndesmosis Ankle Sprain • Inspection – Deformity – Swelling – Ecchymosis • • • • • Palpate for tender areas Anterior draw Talar tilt Squeeze test External rotation test 168 9 Treatment Progression • ABC exercises to Theraband exercises • Stretching program • Proprioceptive re-training • Sport specific drills – Run 20 yds, zig-zag – Hop on one leg 20 times – Balance 169 10 Persistent Ankle Pain • Commonly missed fracture – FLOAT • Tibialis posterior tendon • Peroneal tendon Osteochondral Defects • Can be acute or repetitive microtrauma • Most common areas are anterolateral or posteromedial talar dome • May get locking or clicking sensation if loose body present • May see on x-ray but often negative – MRI definitive imaging of lesion • Usually surgical intervention needed Osteochondral Defect 170 11 Lateral Process of the Talus Fractures • “Snowboarder’s fracture” • Less than 1% of ankle fractures in general population • 32% of fractures in ankles of snowboarders – 15% of all ankle injuries in snowboarding • Clinical presentation is similar to lateral ankle sprain • Mechanism is controversial – Severe dorsiflexion with hindfoot inversion • Landing an aerial maneuver Talus Anatomy and Fracture Types Imaging • Can be seen on mortise and lateral views – X-ray can often be negative • CT scan definitive modality 171 12 Management • Type 1 and non-displaced type 2 – NWB short leg cast 4-6 weeks • Progress walking boot and PT • Displaced type 2 and all type 3 – Closed reduction with casting (type 2) or ORIF if reduction unsuccessful – Subtalar joint stiffness often an issue – Bony overgrowth can occur as well – Can have long-term disability • Recommend orthopedic management Achilles • Tendinopathy • Rupture – Common in jumping athletes – Tenderness at the insertion of the achilles – Pain with plantar flexion – Treatment • • • • NSAIDs Stretching Eccentric exercises ?PRP, prolo, nitro – Pop and pain in the posterior ankle – Palpable defect – Weakness with plantar flexion – Thomas test – Referral to Ortho Foot Pain 172 13 Metatarsal Stress Fracture • Most common Î Second “March Fracture” and Third • Increasing pain with activity • Localized tenderness • X-ray often negative • MRI for definitive diagnosis • Walking boot for 6-8 weeks followed by gradual return to activity Ottawa Ankle Rules An ankle x-ray is required only if there is any pain in malleolar zone and any of these findings: bone tenderness at A bone tenderness at B Inability to weight bear both immediately and in the clinic. A foot x-ray is required if there is any pain in the midfoot zone and any of these findings: bone tenderness at C bone tenderness at D Inability to weight bear both immediately and in the clinic. 5th Metatarsal Fractures • 1- Tuberosity avulsion fractures – Dancer’s fracture • 2- Jones fractures – communicate with the 4-5 intermetatarsal joint • 3- Stress Fracture – distal to the 4-5 intermetatarsal joint Lawrence SJ, Botte M: Jones' fractures and related fractures of the proximal fifth metatarsal. Foot and Ankle 14(6):360, 1993. 173 14 Blood Supply of the 5th Metatarsal • Vascular Anatomy • 25% Non-union rate (even with NWB) 5th metatarsal nutrient artery Smith J, Arnoczky SP, Hersh A: Intraosseous blood supply of the fifth metatarsal: Implications for proximal fracture healing. Foot and Ankle 13(3):144, 1992 Dancer’s Fracture • Inversion injury • TTP base 5th metatarsal • Plantar aponeurosis pull • Treatment – Boot, progress WB as tolerated – May wean in 4-6 weeks – RTP 8 weeks – PT Dancer’s Fracture 174 15 5th Metatarsal Stress Fracture • Proximal diaphysis just distal to intermetatarsal ligaments • Increasing incidence in athletes, esp. basketball players • Prodromal symptoms • Increased risk of delayed union, nonunion and refracture with nonoperative treatment Treatment • Early stress fx – NWB 6wks – Protected weight bearing 6wks – Risk of delayed union and non-union • ORIF – Percutaneous screw fixation – 4.5 - 7.0 mm fullythreaded cortical screw Jones Fracture • Term often misused • Originally described by Sir Robert Jones in 1902 – Transverse fx at area between diaphysis and metaphysis • Area between insertion of peroneus brevis and peroneus tertius • Can also have acute fracture on chronic stress injury • Mechanism – Plantar-flexion and adduction force 175 16 Jones Fracture Jones Fracture Treatment • Conservative – Non-weight bearing immobilization • Short leg cast • 8-12 weeks • Progress to boot after 8 weeks if evidence of healing • ORIF – Displaced – In-season athlete – Patient decision Navicular Stress Fracture • Incidence: Uncommon when first described but incidence increasing – 14% in some studies. • Etiology: repetitive stress and poor blood supply • Running most common, but can occur in all patients active in sports 176 17 Navicular Stress Fracture Diagnosis • Vague arch pain with midfoot tenderness – “N-spot” • Delay in diagnosis common • Activity-specific incidence of navicular stress fractures – Track and field 59% – Football • • • X-Rays: AP, Lat, and Oblique • MRI, CT if uncertain – – – – – – – Australian 19% American 1% Soccer 1% Basketball 10% Field hockey 2% Racquet sports 2% Ballet 1% Gymnastics 1% Cricket 1% Navicular Stress Fracture • “N” spot tenderness – Nickel-sized area at proximal, dorsal navicular bone – Tender in 81% of patients with navicular stress fractures Source: Medscape.com Source: Medscape.com Navicular Stress Fracture – Delay in Diagnosis • Average delay in diagnosis – 4 to 7 months • Proposed reasons – Symptoms often disappear with a few days of rest – Overlooked by physicians because of vague nature of symptoms – Talonavicular joint innervated by medial plantar nerve • Radiate along medial arch, occasionally distally – Initial radiographs often normal 177 18 Navicular Stress Fracture Diagnosis • MRI – Good for early detection – high sensitivity – Occasionally good definition of fracture pattern Source: JA Nunley, MD personal files Navicular Stress Fracture • CT Scan – Gold standard for defining the fracture pattern (location, completeness, displacement, and direction) Source: JA Nunley, MD personal files Navicular Stress Fracture Treatment • Incomplete Fracture (Type I and Type II –Non-weight bearing cast until healed (variable time) • Complete fracture (Type III) or nonunion –ORIF with screws perpendicular to fracture plane with or without bone graft Torg J et al. Management of Tarsal Navicular Stress Fractures: Conservative Versus Surgical Treatment: A Meta-Analysis. Am J Sports Med 2010 38: 1048. Sexena A, Fullem B, Torg J. Letter to the Editor Am J sports Med 2010 38 NP3. Harmon, K. LowerExtremity Stress Fractures. Clin J Sport Med 2003;13:358-364. 178 19 Lisfranc Injuries • Jacques Lisfranc – Surgeon in Napoleon’s army – Could amputate a foot in under one minute – Described injuries between forefoot and midfoot in calvary riders falling off horse • Mechanism – Toe dorsiflexion, ankle plantarflexion axial load Lisfranc Injury • PE – TTP proximal 1st metatarsal • “Shuck” test • Twist forefoot • Look for compartment syndrome • Radiographs – AP WEIGHTBEARING views • Bilateral for comparison Lisfranc Radiographs and Bone Scans • Bone scan also helpful in diagnosis – Sensitive – Lower cost compared to MRI 179 20 Treatment • Nondisplaced – Immobilization 6 weeks • Non-weight bearing cast • Consider referral • RTP 12-16 weeks • Displaced (>2mm) – ORIF • RTP 4-6 months – Consider ORIF in athletes Plantar Fasciitis • • • • • • Overuse injury at the insertion to the calcaneus Associated with pes planus and pronation Older athletes Heel pain and stiffness that is worse in the morning Point tenderness at the insertion on the calcaneus Diagnosis – Clinical – X-ray • Treatment – – – – – – Stretching, strengthening, and icing Heel cups Supportive shoes Night splints Walking boot Corticosteroid injection, prp, prolo Turf Toe • • • • Dorsiflexion of the 1st MTP joint Injury to joint and plantar plate complex Common on artificial surfaces Typically stable sprains – Lachman test • Diagnosis – X-ray to r/o fracture – MRI to evaluate plantar plate • Treatment – Ice and analgesics – Taping – Rigid insole 180 21 Pediatric Consideration Open Physis Sever’s Disease • • • • • Traction apophysitis of the calcaneus 2nd most common apophysitis after Osgood-Schlatter Usually between age 10-13 Unilateral or bilateral heel pain with running or jumping Exam – Hyperpronation and pes planus – Calf and hamstring flexibility – Tenderness at the posterior calcaneus • Radiographs usually not indicated – Fragmentation of the calcaneal apophysis • Treatment – – – – Limit running and jumping Heel raise in the shoe Ice after activities Calf and hamstring stretching program Iselin’s Disease • Traction apophysitis of the base of the 5th metatarsal – Insertion of peroneus brevis • Tenderness at the base of the 5th metatarsal • Pain with passive foot inversion and resisted eversion • Treatment – Rest – Ankle taping or bracing – Stretching and strengthening program of the peroneal muscles 181 22 Tarsal Coalition • Congenital abnormality – Bony, cartilaginous, or fibrous fusion of two tarsal bones – Calcaneonavicular is the most common followed by talocalcaneal • • Ankle and hind foot pain Symptoms usually begin when coalition starts to ossify • Diagnosis – Calcaneonavicular – 8-12 – Talocalcaneal – 12-16 – Radiographs – CT – MRI • Treatment – Arch supports, orthotics, walking boot – Surgery when conservative measures fail • • Often missed Arthritic changes in the tarsal joints Traction Apophysitis of the Navicular • Insertion of tibialis posterior tendon • Medial foot pain • Pain with passive foot eversion and resisted inversion • Associated with pes planus and hyperpronation • Orthotics to unload tibialis posterior • Stretching and strengthening of the tibialis posterior Thank You 182 23
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