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Foot and Ankle Injuries

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Foot and Ankle Injuries Today’s lecture can be viewed at Learning in Athletics the following URL address: We most likely will not get “All of life should be a through all these slides today, learning experience, not Thomas W. Kaminski, PhD, ATC, http://sites.udel.edu/chshowever the presentation- atep/lectures/is just for the trivial FNATA, FACSM, RFSA thorough and complete and will reasons but because by Professor make for an excellent study continuing the learning Director of Athletic Training Education guide for the BOC process, we are challenging our brain University of Delaware examination! Good Luck! and therefore building brain circuitry” Arnold Scheibel Athletic Training & Sports Laboratory Manual UD is located here! A First State to accompany Fact! Health Care: The Journal for the Rehabilitation Techniques in Sports Medicine Delaware is 96 miles Practicing Clinician and Athletic Training long and varies from th 9 to 35 miles in 6 Edition width. http://www.healio.com /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 Lower Extremity ~ Foot this Into Their Assessment Scheme? Anatomical Review Cyriax- “Diagnosis is only a matter of applying one’s anatomy” 1 Clinical PEARL: Lower Extremity ~ Foot Navicular Palpation Lower Extremity ~ Foot • Palpated 2-3 cm anteroinferior to the medial malleolus • More prominent with foot adducted Radiographically Viewed The Ankle Mortise 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. Posterior anatomicaltubercle of talus 8. Calcaneusstructures? 9. Sustentaculum tali 10. Tarsal tunnel 11. Navicular 12. Cuneiforms 13. Cuboid Major Lateral Ligaments The Medial “Deltoid” Complex Ankle Syndesmosis IOM = Interosseous membrane IOL = Interosseous ligament AITFL = Anterior inferior Tibiofibular Ligament PITFL = Posterior inferior Tibiofibular Ligament 2 The Subtalar Joint The Ligaments of the Subtalar Joint WOW! Compartments of the Leg • Anterior Anterior Medial (Tibial Bone) Muscular Anatomy Lateral (Peroneal/Fibularis Region) Posterior Superficial Deep Lower-Leg Compartment Lower Leg Musculature Tibialis Anterior Contents Anterior Posterior 3 At what bony Can you tell Extensor Digitorum Longus landmark do they Posterior Compartment (S) bifurcate? Peroneals which one? Plantaris Posterior Compartment (S) Posterior Compartment (D) Posterior Compartment (D) TOM HARRY Note we have excised the T&D Soleus DICK Talocrural and HAS ANYONE Selected Injuries Involving the Subtalar Joint Motion SEEN FERRIS??? Can Ankle Region anyone Talocrural Joint Subtalar Joint name this voice? Ben Stein! Circa 1986 4 Ankle Sprain - Risk Factors Inversion/Lateral Sprains Real-time Ankle Sprain Caught on Door Cam! • 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 Recommendations • Most commonly injured structures in 547 patients with soft tissue • Most common clinical The purpose of this position statement is to injuries due to an acutely twisted presentations ankle – ATFL + CFL = 34% – Presented to emergency room or present recommendations for certified athletic occupational medicine clinic – ATFL + CFL + PTFL = 31% – ATFL only = 16% trainers and other allied health professionals – Other = 14% • “Injury” based on pain at site of structure – PTFL only = 2% in the conservative management and – CFL only = 1% – Anterior Talofibular Lig. (83%) prevention of ankle sprains in athletes. Our – Calcaneofibular Lig. (67%) • Most common primary diagnoses – Posterior Talofibular Lig. (34%) – Grade 1 sprain = 71% recommendations will be reinforced by – Deltoid Lig. (32%) – Other = 15% – Ankle joint capsule (32%) – Grade 2 sprain = 10% relevant scholarly evidence currently available – Dorsum of foot (20%) – Grade 3 sprain = 3% – Sinus tarsi (16%) – Syndesmotic sprain = 1% in peer-reviewed publications and graded – Peroneals (15% – Bifurcate Lig. (8%) according to the Evidence Category Taxonomy – Syndesmosis (6%) Fallet et al, J Foot Ankle (SORT) Evidence Based Scale. Surg, 1998 Recommendations from Five Current State of AT Practice (5) Different Categories What is Evidence-Based Practice • Diagnosis • Treatment and Rehabilitation Best Research • Return-to-Play Considerations • Prevention Clinical Experience • Special Considerations Patient Values 5 Evidence Categories Evidence Categories Made Simple Implementing the Position SORT Taxonomy Level of SORT Grade Clinical Practice Statement Recommendations 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 https://www.nata.org/news- publications/pressroom/statements/position Clinical Diagnostic Assessment International Ankle Consortium Clinical assessment of acute lateral ankle Rehabilitation-Oriented ASsessmenT sprain injuries: consensus (ROAST) statement and recommendations of the International Ankle Consortium • The International Ankle Consortium ROAST will help Authors: clinicians identify mechanical and/or Delahunt E 1,2, Bleakley CM 3, Bossard DS 1,2, Caulfield BM 1,4, Docherty CL 5, sensorimotor impairments that are associated with Doherty C 4, Fourchet F 6, Fong DT 7, chronic ankle instability (CAI). Hertel J 8, Hiller CE 9, Kaminski TW 10, McKeon PO 11, Refshauge KM 9, Remus A 4, Verhagen EA 12, Vicenzino BT • This consensus statement from the International Ankle 13, Wikstrom EA 14, Gribble PA 15 Consortium aims to be a key resource for clinicians who regularly assess individuals with acute lateral ankle sprain injuries. Eamonn Delahunt et al. Br J Sports Med doi:10.1136/bjsports-2017-098885 Helpful Resource • Section I Risk and ROAST Risk Reduction of Ankle Sprains Infographic • Section II Diagnosis • Section III Treatment ROAST and Rehabilitation • Section IV Surgical Considerations https://www.healio.com/books/athletic-training/%7b43034553-4c8b- 472d-98d2-aca4eefd4c48%7d/quick-questions-in-ankle-sprains- expert-advice-in-sports-medicine 6 Did This 2012 JAT Article Make You Stop and Think About Current Ankle Sprain An Management? Interesting Take on an Old Practice POLICE = Protection, Optimal Loading, Ice, Compression, and Elevation An Even Newer Treatment Paradigm BJSM 2016 The Future of Acute Ankle Sprain Footbeat in Action Treatment Intervention? 7 The Anti-ICE Age via OTTAWA ANKLE RULES The Evolution of RICE ACTIVE recovery • Developed to reduce the use of unnecessary • Active recovery with non- radiographs in the diagnosis of acute foot fatiguing muscle activation, flushing out waste, and and ankle injuries in emergency What if RICE is wrong? delivering nourishment to the departments Newer evidence is target area suggesting that both ICE • Estimated only 15% of foot/ankle injuries and REST may actually delay recovery! Does this presenting to emergency departments are turn an ATC’s life into fractures peril? • Use of these diagnostic rules have significantly reduced unnecessary x-rays Athletic Training Research Laboratory OTTAWA ANKLE RULES Clinical PEARL: Ankle Instability Ottawa Ankle Rules Palpation Points • Medial • Lateral Updated CAI Model (Hertel & Corbett, JAT 2019) Overview – Ankle Instability Now This Takes Some Coordination! • Inversion ankle sprains are a frequent orthopedic injury • The majority of appropriately rehabilitated ankle sprains will do well . , but saying “they all do well” is a misnomer! • Symptoms: – pain – feeling of giving way – swelling – recurrent injury 8 Ankle Instability (Mechanical) LigMaster Stress with Musculoskeletal Telos Stress X-Ray Ultrasound Imaging • Definition: – lateral ligament laxity (Freeman et al. - 1965) – joint motion that exceeds physiologic motion B A (Tropp - 1985) FIBULA • Assessment Tools: TALUS – anterior drawer test A represents Talofibular – talar tilt Interval from MSUS – roentgenographic studies (Telos Stress) image A fancy name for x-ray! Instrumented Ankle Arthrometry Ankle Instability (Functional) Ankle Instability (Functional) • Assessment • Definition: Tools: – disability to which patients refer when they say the foot tends to “give way” (Freeman et al. - – muscular 1965) strength • isometric – joint motion beyond voluntary control, but not • isokinetic necessarily exceeding physiologic ROM (Tropp - 1985) – 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 9 Eversion/Medial Ankle Sprains Syndesmotic Ankle Sprains Syndesmotic Ankle Sprains • less common (5 - 15% • uncommon injury,
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