LEG, ANKLE AND FOOT INJURIES Evaluation and

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
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Leg
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Ankle
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Acute ankle injury
Persistent ankle pain
Achilles injury
Foot
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Stress Fracture
MTSS
Compartment syndrome
Stress Fractures
Midfoot injury
Plantar fasciitis
Turf Toe
Pediatric Perspective
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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
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Medial Tibial Stress Syndrome
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“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
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Imaging
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Treatment
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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
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MRI or bone scan
Compartment testing
Consider lumbar radiculopathy
Tibia Stress Fracture
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A spontaneous fracture that is the result of the summation of stresses that
lead to failure of the bone.
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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
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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.
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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.
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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
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Exercise Induced Compartment Syndrome
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Reversible neurovascular compromise
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Symptoms
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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
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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
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At rest exam can be normal
Anterior
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Lateral
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Weakness of dorsiflexion or toe extension
Paresthesias over the dorsum of the foot
Weakness of ankle eversion
Paresthesias over the anterolateral aspect of leg
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Superficial Posterior
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Deep Posterior
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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
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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
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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
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Medial clear space
Lateral clear space
Tibiofibular clear space
Look for symmetry
Mortise View
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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
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Usually immobilized 6 weeks
Progress weight-bearing
Physical therapy
Return to sport 3-4 months
– May be up to 6 months
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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
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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
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Anterior talo-fibula ligament – ATFL
Calcaneo-fibula ligament – CFL
Posterior talo-fibula ligament – PTFL
Deltoid ligament
Syndesmosis
Ankle Sprain
• Inspection
– Deformity
– Swelling
– Ecchymosis
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Palpate for tender areas
Anterior draw
Talar tilt
Squeeze test
External rotation test
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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• X-Rays: AP, Lat, and
Oblique
• MRI, CT if uncertain
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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
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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.
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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
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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
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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
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Stretching, strengthening, and icing
Heel cups
Supportive shoes
Night splints
Walking boot
Corticosteroid injection, prp, prolo
Turf Toe
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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
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Pediatric Consideration
Open Physis
Sever’s Disease
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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
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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
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Tarsal Coalition
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Congenital abnormality
– Bony, cartilaginous, or fibrous fusion of two tarsal bones
– Calcaneonavicular is the most common followed by talocalcaneal
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•
Ankle and hind foot pain
Symptoms usually begin when coalition starts to ossify
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Diagnosis
– Calcaneonavicular – 8-12
– Talocalcaneal – 12-16
– Radiographs
– CT
– MRI
•
Treatment
– Arch supports, orthotics, walking boot
– Surgery when conservative measures fail
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•
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
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