Common Ankle Injuries- Dr Malini Basic Physical Exam

• Inspection: o Swelling, Ecchymosis, Deformity • Range of Motion: o Dorsiflexion, Plantarflexion o Inversion and Eversion • Strength • Palpation: o Medial and Lateral Malleolus o Base of 5th Metatarsal o Achilles Tendon o Midfoot o Proximal Fibula • Assess neurovascular status Normal Ankle Range of Motion 20° 40° Normal Ankle Range of Motion

Eversion Inversion

20° 30° Bones of Lateral Ankle

Tibia Fibula

Talus Navicular

Metatarsals

Calcaneus

Cuboid 5th Metatarsal Ankle Ligaments

Anterior Posterior Talofibular talofibular Ligament ligament

Calcaneofibular ligament Anterior Drawer • Tests integrity of anterior talofibular ligament

Emedicine.medscape.com Talar Tilt Test

• Tests integrity of anterior talofibular ligament and calcaneofibular ligament Ottawa Rules: When to Image

• Ottawa Ankle Rules: 98% sensitivity for fracture, decrease radiographs • Validated in ED and PCP Office • Do not apply rules if: o Age < 18 yo o Pregnancy o Multiple painful injuries o Compromised sensation

Case 1 • 35 year old woman sustained an ankle inversion injury while playing soccer. Able to bear weight after the injury and currently. Pain is localized to the lateral ankle. o No bony tenderness o Significant swelling of lateral ankle o Good end point on anterior drawer and talar tilt test o Tender over ATFL o Neurovascularly intact Diagnosis

Ankle Sprain of ATFL •Overview -ankle sprains -an injury to the ATFL and CFL and are the most common reason for missed athletic participation •treatment - includes a period of immobilization followed by physical therapy. -- Only when nonoperative treatment fails - surgical reconstruction indicated. •Ankle sprains consist of 1)high ankle sprain •syndesmosis injury •1-10% of all ankle sprains 2)low ankle sprain ATFL and CFL injury •>90% of all ankle sprains RISK FACTORS • patient-related -limited dorsiflexion, decreased proprioception, balance deficiency • environmental-related -indoor-court sports have the highest risk (basketball, volleyball)

•Pathophysiology • Mechanism of injury -Inversion type ankle injury on a plantarflexed foot -Recurrent ankle sprains can lead to functional instability Associated injuries/conditions include

•osteochondral defects •peroneal tendon injuries •deltoid ligament injury (isolated deltoid ligament injuries are very rare) •complex regional pain syndrome •fractures •5th metatarsal base •lateral or posterior process of the talus

Prognosis

•natural history -pain decreases rapidly during the first 2 weeks after injury -5-33% reports some pain at 1 year -increased risk of a sprain to ipsilateral and contralateral ankle

CLASSIFICATION

Classification of Low Ankle Sprains

Ligament disruption Ecchymosis and swelling Pain with weight bearing

Grade I none minimal normal

Grade II stretch without tear moderate mild

Grade III complete tear severe severe

Presentation:

Imaging • ER rotation stress view

•useful to diagnosis syndesmosis injury in high ankle sprain •look for asymmetric mortise widening •medial clear space widening > 4mm •tibiofibular clear space widening of 6 mm

•varus stress (talar tilt) view

•used to diagnose injury to CFL •measures ankle instability by looking at talar tilt •MRI • indications • consider MRI if pain persists for 6-8 weeks following sprain

• useful to evaluate • peroneal tendon pathology • osteochondral injury • syndesmotic injury Treatment Nonoperative

•RICE, elastic wrap to minimize swelling, followed by therapy •Indications

-Grade I, II, and III injuries •Technique

•initial immobilization •may require short period (approx. 1 week) of weight-bearing immobilization in a walking boot, aircast or walking cast, but early mobilization facilitates a better recovery

•grade III sprains may benefit from 10 days of casting and nonweightbearing Treatment Therapy

•early phase

•early functional rehabilitation begins with motion exercises and progresses to strengthening, proprioception, and activity-specific exercises

•strengthening phase •once swelling and pain have subsided and patient has ROM begin neuromuscular training with a focus on peroneal muscles strength and proprioception training

• •a functional brace that controls inversion and eversion is typically used during the strengthening period and used as prophylactic treatment during high-risk activities thereafter. Operative • anatomic reconstruction vs. tendon transfer with tenodesis

• indications • Grade I-III that continue to have pain and instability despite extensive nonoperative management • Grade I-III with a bony avulsion

• arthroscopy Surgical Technique •Gould modification of Brostrom anatomic reconstruction •procedure •an anatomic shortening and reinsertion of the ATFL and CFL •reinforced with inferior extensor retinaculum and distal fibular periosteum (Gould modification) •results •good to excellent results in 90% •consider arthroscopic evaluation prior to reconstruction for intra- articular evaluation

•Tendon transfer and tenodesis (Watson-Jones, Chrisman-Snook, Colville, Evans) •procedure •a nonanatomic reconstruction using a tendon transfer •technique •any malalignment must be corrected to achieve success during a lateral ligament reconstruction

•Coleman block testing used to distinguish between fixed and flexible hindfoot varus Return To Play

Classification Time to RTP

Grade I 1-2 weeks

Grade II 1-2 weeks

Grade III few weeks

High ankle (immobilization) several weeks Season High ankle (screw fixation) Prevention • Prevention techniques in athletes with prior sprains includes

• semirigid orthosis • evertor muscle (peroneals) strengthening • proprioception exercises • season long prevention program

Complications • Pain and instability Incidence • up to 30% continue to experience symptoms following and acute ankle sprain

• Risk factors • most common cause of chronic pain is a missed injury, including • missed fractures (anterior process of calcaneus, lateral or posterior process of the talus, 5th metatarsal) • osteochondral lesion • injuries to the peroneal tendons • injury to the syndesmosis • tarsal coalition • impingement syndromes Staging initially established for different treatment plans, but now regardless of staging all complete the same treatment plan- -functional rehabilitation. Management of Ankle Sprain

• Neuromuscular ankle training o Increased strength o Improved proprioception—balance exercises

• Air Splint initially (additional lateral stability) o Boot only if think more severe diagnosis on differential • Crutches for Pain—weight bearing as tolerated with heel to toe walking • RICE—Rest, Ice, Compression, Elevation • Emphasize early range of motion exercises o Write ABCs with foot Case 2

• 23 year old male with anterior ankle pain. Was playing intramural touch football yesterday and was pushed back by another player while his foot was planted. Able to bear weight since injury but with pain. o Minimal ankle swelling o Pain with bearing weight o Difficulty rising on toes o Limited dorsiflexion secondary to pain o Positive Squeeze Test o Neurovascularly intact Syndesmotic Injury • “High Ankle Sprain” of ligaments between tibia and fibula • Associated with rotational injury o Pushed back on planted foot

Interosseus Ligament

Anterior-Inferior Tibiofibular Ligament

Posterior-Inferior Tibiofibular Ligament Squeeze Test

• Compression of the mid tibia and fibula with reproduction of pain in the ankle o Indicates High Ankle Sprain—pain from syndesmotic injury

http://step.nl/enkelverzwikking-enkeldistorsie-inversietrauma-enkelbrace-propriocepsis Syndesmotic Injury Physical Exam: • Pain with External Rotation Test o Separates tibia from fibula • Tenderness between tibia and fibula • Positive Squeeze test • Limited dorsiflexion • Pain with weight bearing and rising up on their toes

Imaging: • X-Ray –Possible widening of the space between tibia and fibula Treatment of High Ankle Sprain

• Boot as needed—if severe pain • Functional Rehab o Strengthening, early ROM o Similar to ankle sprain • Takes twice as long to recover as compared to ankle sprain • Widening with fracture may require Ortho referral for surgical repair Do Not Miss…

• Maisonneuve Fracture: o Proximal Fibula Fracture that occurs with: • Avulsion fracture of medial malleolus • Rupture of deltoid ligament o Palpate proximal fibula on all ankle injuries High Ankle Sprain • INCIDENCE • 0.5% of all ankle sprains without fracture • 13% of all ankle fractures

• Known as syndesmostic injury MOI

•most commonly associated with external rotation injuries

•Pathoanatomy

•external rotation forces the talus to rotate laterally and push the fibula away from tibia

•may lead to

•increased compressive stresses seen by the tibia •increased likelihood of lateral subluxation of the distal fibula •incongruence of the ankle joint articulation Associated injuries

•osteochondral defects (15% to 25%) •peroneal tendon injuries (up to 25%) •Fractures

•5th metatarsal base •anterior process of calcaneus •lateral or posterior process of talus

•deltoid ligament injury •loose bodies Prognosis

• missed injuries may result in end-stage ankle arthritis • excellent functional outcomes if syndesmosis is anatomically reduced Ligaments

•distal tibiofibular syndesmosis includes

1)anterior-inferior tibiofibular ligaments (AITFL) •originates from anterolateral tubercle of tibia (Chaput's) •inserts on anterior tubercle of fibula (Wagstaffe’s)

2)posterior-inferior tibiofibular ligament (PITFL) •originates from posterior tubercle of tibia (Volkmann's) •inserts on posterior part of lateral malleolus •strongest component of syndesmosis

3)interosseous membrane

4)interosseous ligament (IOL) •distal continuation of the interosseous membrane •main restraint to proximal migration of the talus

5 )inferior transverse ligament (ITL) Presentation • Symptoms • anterolateral ankle pain proximal to AITFL • may have medial sided ankle tenderness/swelling • difficulty bearing weight • lateral ankle sprains are often able to bear weight Presentations Physical exam •palpation •syndesmosis tenderness •single best predictor for return to play •provocative tests

•squeeze test (Hopkin's) •compression of tibia and fibula at midcalf level causes pain at syndesmosis

•external rotation stress test •pain over syndesmosis is elicited with external rotation/dorsiflexion of the foot with knee and hip flexed to 90 degrees •anterior and posterior drawer force to the fibula with the tibia stabilized causes increased translation of the fibula and pain Radiographs

•recommended views •AP, lateral, mortise view of ankle •AP, lateral of entire tibia •may show fracture of proximal fibula •optional views •external rotation stress radiograph

•will help determine competence of deltoid ligament •contralateral ankle radiographs •may help clarify syndesmosis widening versus normal anatomic variant Imaging Findings: • decreased tibiofibular overlap • normal >6 mm on AP view • normal >1 mm on mortise view • increased medial clear space • normal less than or equal to 4 mm • increased tibiofibular clear space • normal <6 mm on both AP and mortise views CT • indications • clinical suspicion of syndesmotic injury with normal radiographs • useful post-operatively to assess reduction of syndesmosis after fixation • sensitivity and specificity • more sensitive than radiographs for detecting minor degrees of syndesmotic injury • MRIindications • clinical suspicion of syndesmotic injury with normal radiographs • sensitivity and specificity • highly sensitive and specific for detecting syndesmotic injury • Nonoperative • non-weight-bearing CAM boot or cast for 2 to 3 weeks • indications • syndesmotic sprain without diastasis or ankle instability • technique • delayed weight-bearing until pain free

• physical therapy program using a brace that limits external rotation

• outcomes • typically display a notoriously prolonged and highly variable recovery period • recovery may extend to twice that of standard ankle sprain •syndesmosis screw fixation •indications •syndesmotic sprain (without fracture) with instability on stress radiographs •syndesmotic sprain refractory to conservative treatment •syndesmotic injury with associated fracture that remains unstable after fixation of fracture •outcomes •excellent functional outcomes if syndesmosis is accurately reduced • •syndesmosis fixation with suture button •indications •same as for screw fixation •technique •fiberwire suture with two buttons tensioned around the syndesmosis •may be performed in addition to a screw •outcomes •early results promising with some showing earlier return to activity when compared to screw fixation •does not require removal

Case 3 • 65 year old woman who sustained an inversion injury of her ankle while stepping off a curb yesterday. Localizes pain to foot and lateral ankle. Unable to bear weight at the time of the injury, but can now. o Significant swelling of lateral ankle o TTP over the base of the 5th metatarsal o Neurovascularly Intact 5th Metatarsal Fracture

Strayer et al. Fractures of the proximal fifth metatarsal. Am Fam Physician. 1999 May 1;59(9):2516-2522. • Pathophysiology mechanism • depends on zone of injury • zone 1: hindfoot inversion • zone 2: forefoot adduction • zone 3: repetitive microtrauma Associated injuries • midfoot (Lisfranc injury)

• lateral ankle ligamentous complex • rule out associated foot deformities •Osteology and Insertions

•divided into tubercle (tuberosity), base, shaft, head and neck •peroneus brevis and lateral band of plantar fascia insert on base •peroneus tertius inserts on dorsal metadiaphysis

•Blood supply

•blood supply provided by metaphyseal vessels and diaphyseal nutrient artery •Zone 2 (Jones fx) represents a vascular watershed area, making these fracture prone to nonunion •Nonunion rates for Zone 2 injuries are as high as 15-30% Classification Class Description Zone 1▪ Proximal tubercle (rarely enters 5th tarsometatarsal joint) (pseudo Jones fx)▪ Due to long plantar ligament, lateral band of the plantar fascia, or contraction of the peroneus brevis

▪ Nonunions uncommon

Zone 2▪ Metaphyseal-diaphyseal junction (Jones fx)▪ Involves the 4th-5th metatarsal articulation ▪ Vascular watershed area

▪ Acute injury ▪ Increased risk of nonunion (15-30%)

Zone 3▪ Proximal diaphyseal fracture ▪ Distal to the 4th-5th metatarsal articulation ▪ Stress fracture in athletes ▪ Associated with cavovarus foot deformities or sensory neuropathies ▪ Increased risk of nonunion

• Symptoms • pain over lateral border of forefoot, especially with weight bearing • look for antecedent pain in setting of stress fracture • Physical Exam • manual palpation of area of concern • resisted foot eversion •Radiographs •AP, lateral and oblique foot images •CT •not routinely obtained •consider in setting of delayed healing or nonunion •MRI •not routinely obtained •consider in setting of delayed healing or nonunion Nonoperative •protected weight bearing in stiff soled shoe, boot or cast •indications •Zone 1 •technique •advance as tolerated by pain •early return to work but symptoms may persist for up to 6 months •non weight bearing short leg cast for 6-8 weeks •indications •Zone 2 (Jones fx) in recreational athlete •Zone 3 •technique •advance with signs of radiographic healing •Operative •intramedullary screw fixation •indications •zone 2 (Jones fx) in elite or competitive athletes •minimizes possibility of nonunion or prolonged restriction from activity •zone 3 fx with sclerosis/nonunion or in athletic individual •Nonunion •increased risk in Zone 2 (Jones fx) and Zone 3 due to vascular supply •smaller diameter screws (<4.5mm) associated with delayed union or nonunion •Failure of fixation •higher failure rate in •elite athletes •return to sports prior to radiographic union •fracture distraction or malreduction due to screw length •screws that are too long will straighten the curved metatarsal shaft or perforate the medial cort 5th Metatarsal Fractures

Avulsion Fracture: -No fracture line present in the space between 4th and 5th metatarsal= DIFFERENT from Jones fracture -Treatment: -Weight bearing as tolerated -Hard soled shoe -Rarely, surgical repair • If large, displaced intra-articular fragments 5th Metatarsal Fractures

• Jones Fracture: • The Don’t Miss Fracture o See in sprinters, jumpers o Watershed Region/Poor blood flow = Poor healing, risk of nonunion o Treatment: • Referral to Orthopedics or Podiatry • Splint in ER and make Non-weight bearing • Non-weight bearing with cast for 4-6 weeks followed by 4-6 weeks in walking boot • ~ 75% heal with non-operative treatment • If athlete, often orthopedic pinning required • 30-50% will re-fracture Jones Fracture X-Ray

http://radiopaedia.org/cases/jones-fracture-4 Case 6 • 37 year old male presents with slow onset of pain in his posterior heel. He is an avid runner and is currently training for a half marathon. Recently transitioned from running shoes to minimalist shoes because he wants to strengthen the muscles in his feet. o No swelling or ecchymosis o TTP over Achilles tendon o No bony TTP o Pain increased with dorsiflexion o Neurovascularly intact Achilles Tendinopathy

• Overuse injury of the Achilles tendon • Thickening and inflammation of the peritendinous tissue

• Risk Factors: o Increased activity (distance, speed, terrain) o Reduced recovery time o Change in footwear • Not as much type of footwear o Flat feet o Calf tightness Achilles Tendinopathy

Treatment: • Ice • Stretching

M Childress, A Beutler. Management of Chronic Tendon Injuries. Am Fam • Orthotics Physician. 2013 Apr 1;87(7):486-490. o Heel lift • Achilles Exercises o Initially with an extended knee o Quick rise, slow drop o Repeat with flexed knee • Physical Therapy Posterior Heel Pain • Achilles Rupture: o Sudden pain in heel o Primarily men 30-40 years old—weekend athletics o Cause is forceful dorsiflexion o Positive Thompson test • Diagnosis: Ultrasound • Treatment: Orthopedic Referral. Make NWB and splint. Debate between Plantarflexion Casting or Surgery

Thompson Thompson Negative Positive http://www.dgu-online.de/ Case 5

• 40 year old male sustained an inversion injury of his ankle while playing sand volleyball 2 weeks ago. Presents today with persistent pain in lateral lower ankle. Diagnosed with ankle sprain immediately after by his PCP and had normal X- Ray. o Had ecchymosis and pain inferior to lateral malleolus o No longer has ecchymosis or swelling o TTP inferior to lateral malleolus o Pain reproduced with resisted eversion Peroneal Tendon Injury

Peroneus longus: ● Proximal lateral fibula → plantar surface of the proximal 1st metatarsal ● Eversion and plantarflexion

Peroneus brevis: ● Lateral fibula → base of the 5th metatarsal ● Eversion Peroneal Tendon Injury Examination: • TTP of peroneal tendons as they pass posterior to the lateral malleolus • Pain with resisted eversion • Pain with passive inversion • Tendon snapping with resisted eversion and dorsiflexion Imaging: • Ultrasound Management: • Ice, rest, and NSAIDS • Walking boot for 2-4 weeks to allow for rest • Tendon dislocation/subluxation may require Ortho operative management Peroneal Tendon Subluxation • Peroneal tedon dislocation and repetitive subluxation from behind lateral malleolus • Mechanism -rapid dorsiflexion of an inverted foot inversion leading to rapid reflexive contraction of the PL and PB tendons -rapid contraction can also lead to injury to the superior peroneal retinaculum

Ogden Classification of Superior Peroneal Retinaculum (SPR) Tears

Grade 1 The SPR is partially elevated off of the fibula allowing for subluxation of both tendons

Grade 2 The SPR is separated from the cartilofibrous ridge of the lateral malleolus, allowing the tendons to sublux between the SPR and the cartilofibrous ridge

Grade 3 There is a cortical avulsion of the SPR off of the fibula, allowing the subluxed tendons to move underneath the cortical fragment

Grade 4 The SPR is torn from the calcaneous, not the fibula •

Presentation •History •patients often report they felt a pop with a dorsiflexion ankle injury •Symptoms •clicking, popping and feelings of instability or pain on the lateral aspect of the ankle •Physical exam •inspection •swelling posterior to the lateral malleolus •tenderness over the tendons •'pseudotumor' over the peroneal tendons •voluntary subluxation of the tendons +/- a popping sound Radiography

• recommended views • best recognized on an internal rotation view • findings • may see a cortical avulsion off the distal tip of the lateral malleolus (fleck sign, rim fracture) • needed to evaluate for varus hindfoot MRI • best evaluated with axial views of a slightly flexed ankle • can demonstrate anatomic anomalies leading to pathology • peroneus quartus muscle • low-lying peroneus brevis muscle belly

Treatment • Nonoperative • short leg cast immobilization and protected weight bearing for 6 weeks • indications • all acute injuries in nonprofessional athletes • technique • tendons must be reduced at the time of casting • outcomes • success rates for nonsurgical management are only marginally better than 50%. • Operative • acute repair of superior peroneal retinaculum and deepening of the fibular groove • indications • acute tendon dislocations in serious athletes who desire a quick return to a sport or active lifestyle • presence of a longitudinal tear • groove-deepening with soft tissue transfer and/or osteotomy

Case 6 • 40 year old female with month of burning pain of foot. Pain radiates into toes at times. Feels like there is a “rock in my shoe,” but there isn’t one. Pain is worse with running and narrow shoes. o Plantar TTP between 3rd and 4th metatarsal head o Neurovascularly intact Ankle Osteoathritis • Defined as osteoarthritis of the tibiotalar joint • Epidemiology • less common than OA of knee and hip • Pathophysiology • causes include • post-traumatic arthritis • most common etiology, accounting for greater than 2/3 of all ankle arthritis • primary osteoarthritis • accounts for less than 10% of all ankle arthritis • other etiologies include rheumatoid arthritis, osteonecrosis, neuropathic, septic, gout, and hemophiliac • Pathoanatomy • nonanatomic fracture healing alters the joint contact forces of the ankle and changes the load bearing mechanics of the ankle joint • loss of cartilage on the talar body and tibial plafond results in joint space narrowing, subchondral sclerosis and eburnation Takakura Classification Stage I Early sclerosis and osteophyte formation, no joint space narrowing

Stage II Narrowing of medial joint space (no subchondral bone contact)

Stage IIIA Obliteration of joint space at the medial malleolus, with subchondral bone contact

Obliteration of joint space over roof Stage IIIB of talar dome, with subchondral bone contact

Stage IV Obliteration of joint space with complete bone contact

• Symptoms • pain with weight bearing • loss of motion • Physical exam • joint effusion • pain with ROM testing, loss of ROM compared to the contralateral side • angular deformity may be present depending on the history of trauma • Radiographsrecommended views • weight bearing AP, lateral, and obliques

• radiographic findings include • loss of joint space • subchondral sclerosis and cysts • eburnation • possible angular deformity •Nonoperative •activity modification, bracing to immobilize the ankle, and NSAIDS •indications •indicated as first line of treatment in mild disease •single rocker sole shoe modification can improve gait and pain symptoms •Operative •surgical management •indications •indicated upon failure of conservative treatment in a patient with radiographic evidence of ankle arthritis Case 10

• 24 year old female runner training for a marathon with one month of heel pain. Initially, only had pain with running, now having pain with walking. o Pain increased with weight bearing o Tenderness over the medial-lateral calcaneus o Pain with calcaneal squeeze testing

www.medscape.com Imaging

• Start with Radiographs—Lateral and Heel X-ray • If X-Rays are normal and clinical suspicion remains high, consider CT or MRI

N Dobson, E Dobson, P Shromoff. Imaging Imaging Strategies for Diagnosing Calcaneal and Cuboid Stress Fractures. Clinics in Podiatric Medicine and Surgery, 2008-04-01, Volume 25 (2), 183-201. Management of Calcaneal Stress Fracture • Reduction in activity to pain free activity o If pain with walking, may need to be non-weight- bearing until pain free with walking o Slow progression back into activity, again reducing impact if pain returns o Addition of heel cushions or orthotics if needed o Assessment of calcium and vitamin D status

• Full healing usually takes 2-3 months Posterior Heel Pain • Haglund’s Syndrome (Retrocalcaneal Bursitis) o Insidious onset of pain in posterior heel o Due to swelling of bursa between Achilles and calcaneus o Better when barefoot or in open-backed shoes o Associated with Haglund’s deformity • Normal variant – posterolateral calcaneal prominence o Treatment: RICE, NSAID, heel cord stretching, PT

Achilles Tendon Subcutaneous Calcaneal Bursa

Retrocalcaneal bursa

T Tu, J Bytomski. Diagnosis of Heel Pain. Am Fam Physician. 2011 Oct 15;84(8):909-916. Case 11 • 35 year old woman sustained an inversion injury of her ankle while playing basketball. Came down on another players foot after jumping for a rebound o Diagnosed with ankle sprain o Persistent pain in the anterior ankle after 6 weeks o Intermittent ankle swelling o Feels ankle catching and locking Talar Osteochondral Defect • Ankle sprains with associated compressive forces (landing from a jump) • Often with inversion injury, but many after no trauma • Most commonly in the superomedial dome

• Symptoms/Exam: o Swelling, pain, catching and locking o TTP over Talus and not over ligament • Imaging: o X-Ray: May see on Mortis View o CT o MRI • Treatment: o Non-Op: Short Leg Cast and NWB x 6 weeks o Operative: Arthroscopy Talar Osteochondral Defect

Defect Management Articular Grade I cartilage injury Conservative only Articular Conservative cartilage injury Grade II (Joint motion w/out with underlying loading –bike) fracture Detached, but Grade Potentially not displaced III Surgical fragment Grade Displaced Surgical IV fragment Emedicine.medscape.com Berndt and Harty Radiographic Classification

Stage 1 • Small area of subchondral compression

Stage 2 • Partial fragment detachment.

Stage 3 • Complete fragment detachment but not displaced.

Stage 4 • Displaced fragment.

Case • 17yo ballet dancer presenting with increasing pain in her forefoot with dancing. No pain with walking. Pain improved some with a week of rest, but returned when she started dancing again. o Focal tenderness over the 2nd metatarsal DDx of Heel Pain

• Calcaneal stress fracture/traumatic fracture • Plantar fasciitis • Fat pad atrophy • Achilles tendinopathy • Achilles Bursitis (Haglund deformity) DDx Ankle Pain • Ankle Sprain • Syndesmotic injury (High Ankle Sprain) • 5th metatarsal fracture • Navicular fracture • Peroneal Tendon Injury • Fractures o Fibula o Tibia o Talus o Calcaneus • Achilles tendon injury Posterior Heel Pain • Sever’s disease—Calcaneal Apophysitis =Painful inflammation of calcaneal growth plate

o #1 cause of posterior heel pain in kids 9-14 years old o Increased pain with growth spurt—changing biomechanics o Risks: Microtrauma with running (soccer), decreased Achilles and Hamstring flexibility o Positive Sever’s Test: Heel pain aggravated by standing on tip toes o Improved with rest, heel lifts, stretching, ice, NSAIDs, out grow

Tenderness over normal appearing physis = apophysitis

Wheelessonline.com Resources

D Judd, D Kim. Foot Fractures Frequently Misdiagnosed as Ankle Sprains. Am Fam Physician. 2002 Sep 1;66(5):785-795. K Burroughs, C Reimer , K Fields. Lisfranc injury of the foot. Am Fam Physician 1998;58:121 Strayer et al. Fractures of the proximal fifth metatarsal. Am Fam Physician. 1999 May 1;59(9):2516-2522.. Timestra, Jeffrey. Update on Acute Ankle Sprains. Am Fam Physician. 2012 Jun 15;85(12):1170-1176. A Tallia, D Cardone. Diagnostic and Therapeutic Injection of the Ankle and Foot. Am Fam Physician. 2003 Oct 1;68(7):1356-1363. M Childress, A Beutler. Management of Chronic Tendon Injuries. Am Fam Physician. 2013 Apr 1;87(7):486-490. D Patel, M Roth, N Kapil. Stress Fractures: Diagnosis, Treatment, and Prevention. Am Fam Physician. 2011 Jan 1;83(1):39-46. M Simpson, T Howard. Tendinopathies of the Foot and Ankle. Am Fam Physician. 2009 Nov 15;80(10):1107-1114. D Judd, D Kim. Foot Fractures Frequently Misdiagnosed as Ankle Sprains. Am Fam Physician. 2002 Sep 1;66(5):785-795. J Goff, R Crawford. Diagnosis and Treatment of Plantar Fasciitis.. Am Fam Physician. 2011 Sep 15;84(6):676-682. P Tu, J Bytomski. Diagnosis of Heel Pain. Am Fam Physician. 2011 Oct 15;84(8):909-916. O’ Connor, Francis et al. ACSM’s Sports Medicine: A Comprehensive Review. Wolters Kluwer: China , 2012. Print. Brunkner, Peter; Khan, Karim; et al. Clinical Sports Medicine. McGraw-Hill: Australia, 2006. Print. Madden, Chris. Netter’s Sports Medicine. Saunders Elsiever. 2010. Thank you