Ankle Injuries Today’S Lecture Can Be Viewed at in Athletics the Following URL Address: We Most Likely Will Not Get Through All These Slides Today, Thomas W

Foot and Ankle Injuries Today’s lecture can be viewed at in Athletics the following URL address: We most likely will not get through all these slides today, Thomas W. Kaminski, PhD, ATC, http://sites.udel.edu/chshowever the presentation- atep/lectures/ is FNATA, FACSM, RFSA thorough and complete and will Professor make for an excellent study Director of Athletic Training Education guide for the BOC University of Delaware examination! Good Luck!

Learning A First State UD is located here! Fact! “All of life should be a Delaware is 96 miles learning experience, not long and varies from just for the trivial 9 to 35 miles in reasons but because by width. continuing the learning process, we are challenging our brain and therefore building brain circuitry” Arnold Scheibel

1 Athletic Training & Sports Laboratory Manual to accompany Health Care: The Journal for the Rehabilitation Techniques in Sports Medicine Practicing Clinician and Athletic Training 6th Edition

http://www.healio.co m/journals/atshc

https://www.healio.com/books/athletic- training/%7b927168ac-1da2-422c-b98e- ae9013d4e15b%7d/rehabilitation-techniques-for- sports-medicine-and-athletic-training-sixth-edition

Perhaps ATC’s Need to Incorporate this Into Their Assessment Scheme? Anatomical Review

Cyriax- “Diagnosis is only a matter of applying one’s anatomy”

2 Lower Extremity ~ Foot Lower Extremity ~ Foot

Clinical PEARL: Navicular Palpation Lower Extremity ~ Foot

• Palpated 2-3 cm anteroinferior to the medial malleolus • More prominent with foot adducted

3 Radiographically Viewed Articulations Ankle Joint (Medial View)

1. Fibula 2. Tibia 3. Ankle jointChallenge 4. Promontoryyourself of tibia to 5. Trochlear surface of talus 6. Talus identify the 7. Posterioranatomical tubercle of talus 8. Calcaneusstructures? 9. Sustentaculum tali 10. Tarsal tunnel 11. Navicular 12. Cuneiforms 13. Cuboid

The Ankle Mortise Major Lateral Ligaments

4 The Medial “Deltoid” Complex Ankle Syndesmosis

IOM = Interosseous membrane IOL = Interosseous ligament AITFL = Anterior inferior Tibiofibular Ligament PITFL = Posterior inferior Tibiofibular Ligament

The Subtalar Joint The Ligaments of the Subtalar Joint

5 WOW!

Compartments of the Leg

• Anterior Anterior Medial (Tibial Bone) Muscular Anatomy Lateral (Peroneal/Fibularis Region) Posterior Superficial Deep

6 Lower-Leg Compartment Lower Leg Musculature Contents Anterior Posterior

Tibialis Anterior Extensor Digitorum Longus

7 At what bony Can you tell landmark do they Posterior Compartment (S) bifurcate? Peroneals which one?

Plantaris

Posterior Compartment (S) Posterior Compartment (D)

TOM

Soleus DICK

8 Talocrural and Posterior Compartment (D) Subtalar Joint Motion

Talocrural Joint Subtalar Joint HARRY

Note we have excised the T&D

HAS ANYONE Selected Injuries Involving the SEEN FERRIS??? Can Ankle Region anyone name this voice?

Ben Stein!

Circa 1986

9 Ankle Sprain - Risk Factors Inversion/Lateral Sprains

• 85-95% of all ankle sprains – lateral malleolus extends further • medial acts as a fulcrum – weaker lateral ligs • MOI: – inversion (CF lig) – inv + pf (ATF/CF/TibFib ligs) • most common mechanism • R/O: – “push-off” fx’s of medial malleolus – other associated fx’s & nerve injury

Consequences of an Acute Ankle Sprain • Most commonly injured structures in 547 patients with soft tissue • Most common clinical injuries due to an acutely twisted presentations ankle – ATFL + CFL = 34% – Presented to emergency room or occupational medicine clinic – ATFL + CFL + PTFL = 31% – ATFL only = 16% – Other = 14% • “Injury” based on pain at site of structure – PTFL only = 2% – CFL only = 1% – Anterior Talofibular Lig. (83%) – Calcaneofibular Lig. (67%) • Most common primary diagnoses – Posterior Talofibular Lig. (34%) – Grade 1 sprain = 71% – Deltoid Lig. (32%) – Other = 15% – Ankle joint capsule (32%) – Grade 2 sprain = 10% – Dorsum of foot (20%) – Grade 3 sprain = 3% – Sinus tarsi (16%) – Syndesmotic sprain = 1% – Peroneals (15% – Bifurcate Lig. (8%) – Syndesmosis (6%) Fallet et al, J Foot Ankle Surg, 1998

10 Recommendations Recommendations from Five The purpose of this position statement is to (5) Different Categories present recommendations for certified athletic trainers and other allied health professionals • Diagnosis in the conservative management and • Treatment and Rehabilitation prevention of ankle sprains in athletes. Our recommendations will be reinforced by • Return-to-Play Considerations relevant scholarly evidence currently available • Prevention in peer-reviewed publications and graded • Special Considerations according to the Evidence Category Taxonomy (SORT) Evidence Based Scale.

Current State of AT Practice What is Evidence-Based Practice

Best Research

Clinical Experience

Patient Values

11 Evidence Categories Evidence Categories Made Simple SORT Taxonomy Level of SORT Grade Clinical Practice Evidence Recommendation

A Based on No brainer! You consistent and should be doing this good evidence in clinical practice B Based on Should probably inconsistent or include in our limited-quality clinical practice! evidence C Based on Flip a coin --- it is up consensus or to you to decide! usual practice

Clinical Diagnostic Assessment Clinical assessment of acute lateral ankle sprain injuries: consensus statement and recommendations of the International Ankle Consortium Authors: Delahunt E 1,2, Bleakley CM 3, Bossard DS 1,2, Caulfield BM 1,4, Docherty CL 5, Doherty C 4, Fourchet F 6, Fong DT 7, Hertel J 8, Hiller CE 9, Kaminski TW 10, McKeon PO 11, Refshauge KM 9, Remus A 4, Verhagen EA 12, Vicenzino BT 13, Wikstrom EA 14, Gribble PA 15

Eamonn Delahunt et al. Br J Sports Med doi:10.1136/bjsports-2017-098885

12 Helpful Resource Implementing the Position Statement Recommendations • Section I Risk and Risk Reduction of Ankle Sprains • Section II Diagnosis • Section III Treatment and Rehabilitation • Section IV Surgical Considerations https://www.nata.org/news- https://www.healio.com/books/athletic-training/%7b43034553-4c8b- 472d-98d2-aca4eefd4c48%7d/quick-questions-in-ankle-sprains- publications/pressroom/statements/position expert-advice-in-sports-medicine

Did This 2012 JAT Article Make You Stop and Think About Current Ankle Sprain Management?

13 An Interesting Take on an Old Practice

POLICE = Protection, Optimal Loading, Ice, Compression, and Elevation

BJSM 2016

14 The Future of Acute Ankle Sprain Footbeat in Action Treatment Intervention?

International Ankle Consortium Rehabilitation-Oriented ASsessmenT (ROAST)

• The International Ankle Consortium ROAST will help clinicians identify mechanical and/or sensorimotor impairments that are associated with chronic ankle instability (CAI). ROAST • This consensus statement from the International Ankle Consortium aims to be a key resource for clinicians who regularly assess individuals with acute lateral ankle sprain injuries.

15 OTTAWA ANKLE RULES OTTAWA ANKLE RULES • Developed to reduce the use of unnecessary radiographs in the diagnosis of acute foot and ankle injuries in emergency departments • Estimated only 15% of foot/ankle injuries presenting to emergency departments are fractures • Use of these diagnostic rules have significantly reduced unnecessary x-rays

Clinical PEARL: Ankle Instability Ottawa Ankle Rules Palpation Points

• Medial • Lateral

16 Hertel, J Athletic Training, 2002 Overview – Ankle Instability Chronic Ankle Instability • Inversion ankle sprains are a frequent orthopedic injury

Pathological • The majority of appropriately rehabilitated ankle sprains Arthro- Impaired Laxity Proprioception will do well . . . , but saying “they all do well” is a kinematic Impaired misnomer! Restrictions Neuromuscular Control Recurrent Mechanical Functional • Symptoms: Ankle Insufficiencies Insufficiencies – pain Sprain – feeling of giving way Degenerative Strength – swelling Deficits Changes Impaired – recurrent injury Synovial Postural Changes Control

Now This Takes Some Coordination! Ankle Instability (Mechanical) • Definition: – lateral ligament laxity (Freeman et al. - 1965) – joint motion that exceeds physiologic motion (Tropp - 1985) • Assessment Tools: – anterior drawer test – talar tilt – roentgenographic studies (Telos Stress)

A fancy name for x-ray!

17 LigMaster Stress with Musculoskeletal Telos Stress X-Ray Ultrasound Imaging

B A FIBULA

TALUS

A represents Talofibular Interval from MSUS image

Instrumented Ankle Arthrometry Ankle Instability (Functional)

• Definition: – disability to which patients refer when they say the foot tends to “give way” (Freeman et al. - 1965) – joint motion beyond voluntary control, but not necessarily exceeding physiologic ROM (Tropp - 1985)

18 Ankle Instability (Functional)

• Assessment Tools: – muscular strength • isometric • isokinetic – stabilometry – peroneal reaction times

Cumberland Ankle Instability Tool (CAIT) The Cumberland Ankle Instability Tool: A Report of Validity and Reliability Testing Claire E. Hiller, MAppSc, Kathryn M. Refshauge, PhD, Anita C. Bundy, ScD, Rob D. Herbert, PhD,Sharon L. Kilbreath, PhD Arch Phys Med Rehabil Vol 87, September 2006 • Designed to measure functional ankle instability • 9 questions related to subjects’ perception of ankle stability during various activities • Shown to be valid and reliable • How do you score? – Maximum score = 30 – Scores < 25 = ankle instability

19 Eversion/Medial Ankle Sprains Syndesmotic Ankle Sprains

• less common (5 - 15% • uncommon injury, the “high prevalence) ankle sprain” – strong deltoid complex • more disabling with prolonged recovery time – bony structure of ankle • MOI: mortise – forced df • talus located between • MOI: malleoli forces bones apart – damage to syndesmosis – eversion + df (ruptures (fibrous sheath) deltoid + tibfib ligs.) – forced rotation with a fixed foot • R/O associated fx’s • shape of the talus acts as a – rotation + eversion (fx 17% - 74% of ankle injuries fulcrum forcing the tibia and fibula apart fibular shaft + sprain of among young athletes! deltoid complex)

Syndesmotic Ankle Sprains Clinical PEARL: Syndesmosis Palpation • Sx: – point tenderness and swelling localized over the anterior + posterior tibiofibular ligaments – bilateral compression increases pain – walk on toes – inability to push off • Tx: – ICERS2 • immobilization usually for a period of 2-3 weeks – depends on the severity of mortise separation • Anterior Inferior • Interosseous • Posterior Inferior – NSAID’s Tibiofibular Membrane Tibiofibular Ligament Ligament

20 Ankle Fractures Radiological View

Radiograph showing widening of the tibiofibular Alecia Bell UD "clear space" WBB Player 11- (arrows) as a result 2014 of disruption of the syndesmosis. The clear space is normally less than 5 mm wide.

Tibial Plafond - the Did this really happen? Ankle Fractures articular surface of the distal end of the tibia.

• Ankle fractures are usually defined as single malleolar, bimalleolar, or trimalleolar

Trimalleolar involves med/lat and posterior tibial malleolus • Isolated fibular fractures are the most common type of fracture and, without displacement, usually requires 4-6 weeks to heal

21 Ankle Dislocation Posterior Malleolar Fracture • Ankle dislocation results from complete disruption of articular elements in the ankle • An isolated ankle dislocation without associated fracture is quite rare

Acute Ankle Dislocation

22 England’s Physiotherapist (Gary Achilles Tendon Injuries Lewin) Dislocates Ankle during • common tendon of the triceps surae (2 heads of 2014 World Cup --- Ughhhh! gastrocnemius & soleus) inserting into the calcaneus • receives its greatest stress during knee extension/ankle dorsiflexion Can you think of a MOI? • Tendinitis (aka tendonitis) – most common form of tendinitis seen in athletics – Et: • overuse – Sx: • crepitus (Landed on a water bottle celebrating a goal!) • inflammatory rxn

Triceps Surae Achilles Tendon Injuries • Tendinitis (con’t) – Tx: • cryotherapy • NSAID’s • heel lifts • decrease/modify activity • stretching/strengthening of gastroc/soleus • orthotics • gradual return to activity • Ruptures – 75% seen in males 30 - 40 yr. old who participate in intermittent activities Chauncey Billups NBA ---- https://www.youtube.com/watch?v=qGwnFAbDOZ8

23 Clinical PEARL: Achilles Tendon Injuries Gastrocnemius/Soleus Stretch • Ruptures (con’t) – Sites: • calcaneal insertion • 2-6 cm above insertion pt (poor vascularity) – most common site of injury • M-T junction – MOI: • forced pf during knee extension – common move during propulsion activities Side View of Ruptured Achilles' Tendon. Notice • sudden, forced df of an depression at site of rupture (red circle). Gastrocnemius Stretch Soleus Stretch already pf foot – return from a jumping https://www.instagram.c (Straight Knee) (Bent Knee) movement – most common om/p/BJqyDOphcnT/ mechanism

Achilles Tendon Injuries Achilles Tendon Rupture (Repaired!)

• Ruptures (con’t) – Factors Contributing to Ruptures • microtrauma/inflammation • dominant extremity ? • age • steroid usage – Signs/Sx: • painful, swollen calf • ecchymosis • palpable deformity • pf MMT = weakness – Tx • pf splint 10°-15°, NWB, transport, surgery

24 Os Trigonum Syndrome (Posterior Os Trigonum Syndrome

Ankle Impingement) • Sx: • Os Trigonum - D bone, posterior stylus of – painful & limited pf – pain on great toe flexion the talus • Dx Tests: – 7% of population has a free os trigonum (non- union) – bilateral x-rays (feet pf) • Path: – bone scans or MRI • Tx: – traction apophysitis during early childhood caused the separation – symptomatic therapy (conservative) • FHL irritates the bone as it passes by – surgical intervention in • PF motions impinge the posterior process some cases

Differential Diagnosis Distal Fibular Fracture

A Shepherd's fracture (avulsion fracture of the posterolateral process of talus), which is often difficult to differentiate radiographically from an os trigonum.

25 Proximal Tibia Fracture Foot Injuries

Every Athletic Trainer’s Arch Injuries Worst Nightmare • Longitudinal Arch – know anatomy – sprain - intertarsal ligaments – pes planus - flat foot – pes cavus – high arch • Transverse Arch – know anatomy – sprain - intertarsal ligaments • look for callosities under 2nd metatarsal head http://teachmeanatomy.info/l ower-limb/misc/foot-arches/

26 Morton’s Neuroma Morton’s Neuroma • Definition - a type of metatarsalgia (pain in the • Hx metatarsals) associated – complain of sprained transverse arch, sharp- with a localized shocklike pain during thickening (neuroma) at activity that is relieved the point where the medial when the shoe is removed, & lateral branches of the numbness in the 3rd & 4th plantar nerve join between toes the 3rd & 4th metatarsal • Tx heads – transverse arch pad – proper shoes – Sx – NSAID’s • pinpoint tenderness between 3rd & 4th metatarsal heads – RICE • decreased sensation in 3rd and 4th toes

Plantar Fascitis Clinical PEARL: • Definition - Plantar Fascia Palpation inflammation of the fascia covering the plantar aspect of the foot, most common • Passively extend hallux site is from the attachment off the • Palpate starting at the medial tubercle of the medial calcaneus tubercle of *Note – the long plantar ligament calcaneus is found laterally and connects to the cuboid is part of the plantar fascia

27 Turf Toe Turf Toe • Definition - • graded according to sx’s (I, II, III) – sprain of plantar capsuloligamentous complex of the great toe • Sx: • MOI: – inflammatory signs – hyperextension – ecchymosis – hyperflexion + valgus stress (uncommon!) – tenderness • Predisposing Factors: • Tx 2 – artificial turf – ICERS – flexible footwear • rigid foot insole • taping – pes planus • restricted activity – decreased ankle or MP joint motion • crutches NWB in severe cases

Lisfranc Injury Lisfranc Fracture • The injury is named after Jacques Lisfranc de St. Martin a French surgeon and gynecologist who described the injury in 1815. • Lisfranc Ligament – ligament between the 2nd metatarsal and the medial AP radiograph of the cuneiform (oblique fashion) forefoot. There is • MOI: homolateral Lisfranc – axial load of pf foot fracture-dislocation. • usually traumatic • Sx: – swelling & tenderness midfoot – ecchymosis late – pain on stress of 1st/2nd metatarsal bases

28 Lisfranc Injury Foot Fractures • Tx: • neck of talus (forced DF) – no flattening of long. arch • NWB cast 6 wks • calcaneus (crush injury/compression)

• walking cast 2 wks Open Reduction • avulsion of base of 5th metatarsal (strong and Internal – flattening of long. arch Fixation contraction of peroneus brevis) • ORIF • metatarsal fractures (direct trauma) • poor prognosis • Jones fracture (just distal to the base of the • 14.5 wks return to sports on average! 5th metatarsal)

5th Metatarsal Calcaneal Fracture Tuberosity Fracture • most common • “tennis fracture” Lateral • MOI: radiograph of – inversion force with pull by lateral plantar fascia the ankle. • Tx: There is a – undisplaced hatchet injury • wooden sole shoe to the • symptomatic care calcaneus. • union in 8 wks – > 2 mm displacement = ORIF

29 Jones Fractures 5th Metacarpal Fracture • 1902 Sir Robert Jones described 4 cases • Definition- – transverse fx @ the junction of the diaphysis and metaphysis • intraarticular fx (between 4th & 5th) • distal to base of 5th – @ a pt. between insertions of peroneus brevis & tertius • MOI: – pf ankle with a large adduction force to forefoot • Tx: – SLC for 6-8 wks. – ORIF in competitive athletes

Classification Scheme Jones Fracture

Lateral radiograph of the foot. A patient stepped off a curb and sustained a fracture of the proximal aspect of the fifth metatarsal.

30 Jones Fracture – UD Soccer Ouch – Sports Related Concusion?? Player Fall 2017

Neuropathies and Compartment Syndromes Definitions

• Neuropathy - any disorder affecting the nervous system. • Radiculopathy - disorder of the spinal nerve roots • Compartment Syndrome - condition in which increased intramuscular pressure in a confined anatomical space brought on by overactivity or trauma impedes blood flow and function of tissues within that space.

31 LE Neuropathies – Foot Lacinate LE Neuropathies – Foot mean rough • Tarsal Tunnel Syndromeedges!: • Tarsal Tunnel Syndrome: – Tunnel formed by the flexor – Uncommon in athletes retinaculum (lacinate ligament), medial wall of – Etiology: the calcaneus, posterior • Vascular compromise of talus, distal tibia and medial the nerve (sensory) malleolus • Direct compression – Structures include: neuropathy (sensory + • Posterior tibial nerve motor) • PT tendon – Abnormalities of the tunnel • FDL tendon – Extrinsic factors that • FH tendon compress • Posterior tibial artery & vein

Clinical PEARL: Tarsal Tunnel Palpation LE Neuropathies – Lower Leg

• Passively dorsiflex the • Entrapment of the ankle and extend the SPN: toes – Etiology: • Palpate between the • Facial impingement as medial malleolus and it exits the deep fascia Achilles tendon approx. 6 cm above the lateral malleolus • Tinel’s Sign – tapping • Chronic ankle sprains over the tarsal tunnel subject the nerve to recurrent stretching

32 Thank You LE Neuropathies – Lower Leg

• Sural Nerve Entrapment: – Secondary to 5th met Former VP Joe Joe Flacco – QB Baltimore Ravens fx’s Biden – Recurrent sprains (PF/inv) – Ganglions Bill Prentice – Principles – Extrinsic compression of Athletic Training (tight ski boot) Our Famous Former NJ Governor – Chris Christie Delawareans!

Review of the Wake Up! Clinical Foot and Ankle Assessment

33 Anterior Talofibular Ligament (ATF) Anterior Talofibular Ligament (ATF)

Anterior Talofibular Ligament (ATF) Calcaneofibular Ligament (CF)

34 Range of Motion Testing AROM

• AROM • Plantar Flexion • PROM • RROM Note that PF is – MMT two words!! – “Break Test”

AROM AROM

• Dorsiflexion • Inversion

35 AROM Weight Bearing AROM Plantar and Dorsiflexion • Eversion

Any UNF students in Weight Bearing AROM RROM the audience? Who is this? Inversion and Eversion • Plantar Flexion

36 RROM RROM

• Dorsiflexion • Inversion

RROM Show Me the Evidence!

• Eversion • Sensitivity – those people correctly identified by the test as having the condition of interest (Positive (+) Predictive Value)

• Specificity – those people BOC correctly identified as NOT having the condition of interest (Negative (-) Predictive Value)

37 Special Tests for Ligamentous Anterior Drawer Test and Capsular Laxity

Sensitivity 32% - 80%

Anterior Drawer Schematic Anterior Drawer Schematic

Anterior translation is > when the ankle is in 15° of plantar flexion

38 Anterior Drawer Test Talar Tilt (variation) (Inversion Stress)

Sensitivity 52%

Talar Tilt Schematic Talar Tilt

I (Eversion Stress) n v e r s i o n

E v e r s i o n

39 Ankle Syndesmosis Medial Subtalar-Glide Test

Used to assess laxity of the subtalar joint resulting from lateral ligament injury

Test is performed by translating the calcaneus medially on the talus in the transverse plane --- excessive laxity is a (+) test

Ankle Syndesmosis Risk Factors for Syndesmotic Ankle Sprains • Prospective cohort (USMA) study examining the causes of SAS and medial ankle sprains (11.8% of all ankle sprains) over a 4 yr. period • Gender – ♂ more medial sprains vs. ♀ – ♀ longer recovery time vs. ♂ • Sport – FB, soccer, team handball, basketball • Level of Competition – Intercollegiate > intramural • Body Mass Index (BMI) – > BMI is associated with more SAS and medial sprains

Athletic Training Research Laboratory

40 Mechanism of Injury Assessment Considerations – Ice Hockey Video • Evaluation usually involves: – Location and extent of pain – Anatomic palpation – Various stress tests – Differential diagnosis: • Medial (Deltoid) ligament involvement • Associated fractures of either the tibia or fibula • Lateral ankle sprain

Athletic Training Research Laboratory

Palpation Assessment of Pain • Evidence of swelling? – Severe swelling usually not • Patient complaints of present, if it is may take on a “rectangular” appearance! pain include: • Tenderness between fibula – Anteriorly between distal and tibia (AITFL and PITFL) fibula and tibia (AITFL) • Tenderness over the medial – Posteromedially at level of malleolus the ankle – Isolated syndesmotic – Pain with WB and ligamentous injury is rare, may have lesions of deltoid ligament “pushing-off” too – Some may complain of pain • Depends on evaluators ability extending proximally to find ligament/IM (interosseous membrane?) • Pain on palpation is the most • The “high ankle sprain”! frequent positive test – Alonso- JOSPT,1998 – Nussbaum, AJSM 2001