10/20/2020

Objectives Michigan Center for Human Athletic Medicine and Performance • Understand clinical presentation, radiographic evaluation and Update On Sports Foot and Ankle Injuries management pearls and pitfalls:

– Ankle sprain or Inversion related injuries – Osteochondral Lesion of Talus – High Ankle Sprains – Lisfranc Injuries – Achilles Tendon Ruptures – Stress Fractures

David Walton MD Assistant Professor Orthopedic Surgery Division of Foot and Ankle University of Michigan 2 1 2

Low Ankle Sprain

History • Acute inversion plantar flexion injury • Previous ankle sprains? Inversion Injuries Physical examination • Tender anterolateral ankle (Anterior talofibular ligament) ATFL

3 4 3 4

Ankle Sprain Radiology Ankle Sprain Treatment

• Radiographs are Revised Ottawa Rules • Acute phase • Subacute Phase indicated • R.I.C.E. • Physical Therapy – According to Ottowa Rules • Immobilization – ROM • Bony Tenderness over Malleoli • Crutches PRN – Peroneal Strengthening • Inability to bear weight –Proprioception – Midfoot tenderness • Prophylactic bracing • MRI is not indicated acutely • 80-95% effective – ATFL tear is not indication for surgery

5 6 5 6

1 10/20/2020

Ankle Sprain Treatment When its not a just a sprain

• OPERATIVE TREATMENT • Occult fractures – Only for chronic instability – Sx > 6 months • Subtalar “sprain” • Failed appropriate rehab – Restore lateral ankle • Tarsal coalition ligament stability • ATFL and CFL • Occult Syndesmotic – Anatomic Repair – injury Brostrom • Peroneal pathology – Allograft reconstruction weave if fails

7 7 8

Fracture: Lateral Process of Talus Fracture: Talar Body

• “Ankle” pain +++ • Lateral “ankle” pain • Look at x-rays closely! Treatment • ORIF: large or displaced

9 10

Fracture: Anterior Process of Calcaneus

• Lateral hindfoot pain • Acute inversion injury • Tender to palpation anterior calc. • Bifurcate ligament

TREATMENT / PROGNOSIS • Displaced may require surgery, at least immobilize 4 weeks • Slower recovery • Moderately poorer prognosis

11 12

2 10/20/2020

Subtalar injury

• Difficult to diagnose • Very tender sinus tarsi • Often not much swelling • Irritable subtalar joint, especially inversion • Probably torn capsule and interosseus ligament Anterior process of calcaneus fracture injury • LONG recovery (a year, often)

13 14

Tarsal Coalition Peroneal Tendon Dislocation

• Fibrous vs. Bony • Lateral “ankle” pain • Can be between any • Tender: Posterior to malleoli tarsal bones • Can become chronic • Often previously asymptomatic Treatment • CT is sensitive • Ensure stable reduction • Can both predispose to ankle sprain as well as • Immobilization contribute to persistent • Functional rehab symptoms

Limited hindfoot motion on exam

15 16

Peroneal subluxation

17 18

3 10/20/2020

Peroneal Tendon Dislocation The bloody sock…

Recurrent Instability/Pain

• Surgical repair of Superior retinaculum • May require peroneal groove deepening

19 20

Peroneal Tendon Tear Peroneal Tear Treatment

• Split tears Common • Split tears treated • Peroneal Brevis Ruptures – Peroneus Brevis 85% conservatively  Surgical repair vs Longus 15% • R.I.C.E. tenodesis • Up to 40% prevalence in • Immobilization cadaveric studies • Physical Therapy • Ruptures rare • Peroneus Longus Treated like Ankle Sprain Ruptures  Rarely Surgical – Rarely Debridement or repair

21 22 21 22

Residual Pain after Ankle Sprain Osteochondral Lesions of Talus “OLT”

• 54% with ATFL injuries • 40% Osteochondral Lesions of the Talus • Different than Osteochondritis Dissecans “OCD” – Idiopathic with localized osteonecrosis of subchondral plate • OLT – Traumatic • Up to 50% of Ankle sprains • Up to 73% of Ankle fracture

23 24

4 10/20/2020

Pathogenesis Evaluation

• OLTs are comprised of • Exam both hyaline articular cartilage and its – Swelling underlying subchondral – Mechanical Symptoms bone. • Locking and Catching – Focal tenderness over • In traumatic lesions, Talar dome compressive and rotational forces crush the subchondral bone and crush/shear the cartilage.

25 26

Evaluation Imaging

• MRI indicated • Lateral • Medial • Weight Bearing Radiographs – Focal tenderness – tender over the –Often tender over the – Persistent effusion/Pain anterolateral joint posteromedial joint • Sublte lucency, shadow or fleck – Mechanical symptoms line with the ankle line with the ankle in in plantarflexion. dorsiflexion

27 28

MRI Imaging

• MRI is the most • CT scans sensitive diagnostic – Bony and subchondral test for OLTs anatomy • Useful to assess – Cysts associated ligament – Dimensions injuries. • CT can be useful for surgical planning

29 30

5 10/20/2020

Classification Treatment

Stable (non displaced) OLT

• Immobilization and no weight-bearing for approximately 6 weeks • Then WBAT in boot ~50-75% • Then progress out as tolerated

31 31 32

Operative Treatment Microfracture or Marrow Stimulation

Unstable (displaced) OLT OCD area (mm2) Failure • Primary repair of the OLT • Stimulation of < 100 mm2 5% fibrocartilage healing to fill the defect 100-150 mm2 19% • Transplantation of osteochondral tissue to > 150 mm2 80% fill the defect

Choi et al, Am J Sports Med, 2009

33 34

Algorithm Residual Pain after Ankle Sprain

• 54% with ATFL injuries • 40% Osteochondral Lesions of the Talus • 23% Syndesmotic Injuries • 4% anterior impingement soft tissue • 4% anterior impinging osteophytes • No fibrous bands detected with MRI • 25% OLTs missed by MRI • 17% distal tib-fib ligamament injuries missed by MRI

35 36

6 10/20/2020

High Ankle Sprain High Ankle Sprain

• Injury of Syndesmosis • Presentation – Lateral ankle pain proximal to joint line • Mechanism – Pain with external rotation – External rotation stress – Acute dorsiflexion – Pain with Tib-Fib – Severe ankle sprain compression – Stability Test

37 38 37 38

Radiography High Ankle Sprain Radiography High Ankle Sprain

• Weight bearing X-ray • X-ray – Syndesmotic Diastasis – Diastasis – Posterior Tibial Avulsion – Posterior Tibial Avulsion – Stress External Rotation – Stress External Rotation views views

• MRI highly sensitive • Bilateral CT scan

39 40 39 40

High Ankle Sprain Classification Bilateral CT scan

Grade Findings Treatment 1 No Diastasis on WB Xray, NWB then Functional Rehabilitation no instability, - Radiographic stress 2 No Diastasis on WB Xray Surgical Stabilization + radiographic stress > 2mm 3 Diastasis on WB Xray Surgical Stabilization

MRI

41 42 41 42

7 10/20/2020

High Ankle Sprain Non Op Recovery Recovery

• High Ankle Sprains – 2-3 times longer than “low ankle sprains” – Tailored to each individual • Personally – Use Hop test • 10 single limb hops w/o pain • Return to sport specific activities • If unable to bear weight at 5-7 days refer to Ortho

43 44 43 44

Surgical Management When to Order MRI with Inversion Injury

• Unstable injuries • Inability to bear weight in Boot >5 days • Mechanical symptoms – Catching and Locking • Lack of improvement after 4-6 weeks

45 46 45 46

Lisfranc Injuries

• High Energy – MVC and Polytrauma • Low Energy – Axial load on a plantarflexed foot Lisfranc Injuries

47 48 47 48

8 10/20/2020

Lisfranc Injuries Lisfranc Injuries

• Anatomy • Often missed (20%) – “Lisfranc ligament” • High index of suspicion w/ swollen midfoot • Betw medial cuneiform and base of 2nd MT • Plantar ecchymosis • Keystone and roman • Inability to bear weight arch configuration

49 50 49 50

Radiography Lisfranc Injury

• Bilateral Standing AP • Non Operative • Standing lateral and Management oblique – <1-2mm displacement • If can’t WB return in 2-3 – NWB 6 weeks days for repeat • Surgical • MRI sensitive for – Unstable on stress ligamentous injury (standing views) • CT for surgical planning – >2mm displacement – Intercuneiform instability

51 52 51 52

Surgical Treatment Lisfranc Prognosis

SEASON ENDING • Controversial – Depends quality of – Primary Fusion reduction and initial Displacement – Open reduction and CAREER internal fixation – Expect long rehab (> 1 yr) THREATENING – Midfoot pain/stiffness avg 1.3 yrs postop – 0-58% incidence of post- Delayed traumatic arthritis Treatment  significantly worse outcomes

53 54 53 54

9 10/20/2020

Achilles Tendon Rupture

HISTORY PHYSICAL EXAM • Acute injury • Swelling • Eccentric load – • Palpable gap Achilles Tendon Rupture casual athlete • Thompson Test • “kicked in back of leg”

55 55 56

Achilles Tendon Rupture Diagnosis ACHILLES TENDON RUPTURE DIAGNOSIS

• Resting Equinus • Thompson Test – Ruptured side less plantarflexion – No Passive Foot Plantarflexion when Squeeze Calf – Pathognomonic

58 57 58

Radiography Achilles Tendon Rupture Diagnosis

• Lateral ankle view • Mid portion most common – Eval for avulsion • There are no partial • Rare need for MRI ruptures • Dynamic Ultrasound –Functionally – Expand non op indications incompetent – Assess gap at neutral, 25° • Early Diagnosis is key and max plantarflex • IF CONCERNED  NWB in plantarflexion

59 60 59 60

10 10/20/2020

Achilles Rupture Treatment Functional Rehab

• Early Functional • Functional Rehab rehabilitation indicated if • Surgical Intervention – Acutely immobilized in plantarflexion >25 deg • Multiple high level studies – Acutely made Non Weight have shown equivalent bearing outcomes – WITHIN 48 Hours

61 62 61 62

Non Op Exceptions Treatment

• Collegiate or Professional Level Athlete Rerupture Strength Wound comp. Nerve Injury • Delayed presentation or Surgical 1% ~85% @240°/sec 12% 4% immobilization Early Functional 2.7% ~75% @240°/sec 0% 0% • Achilles Avulsion injuries Rehab • Patient Preference

Kadakia AR, Dekker RG II, Ho BS. Acute Achilles Tendon Ruptures. JAAOS - Journal of the American Academy of Orthopaedic Surgeons. 2017;25(1):23-31. doi:10.5435/JAAOS-D-15-00187.

Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. The Journal of Bone and Joint Surgery. 2012;94(23):2136-2143. doi:10.2106/JBJS.K.00917.

Willits K, Amendola A, Bryant D, et al. Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures. J Bone Joint Surg Am. 2010;92(17):2767-2775. doi:10.2106/JBJS.I.01401.

63 64 63 64

Stress Fractures

• Problem fractures – Navicular th Stress Fractures – 5 Metatarsal “Jones” – Medial malleolus

Initiate non weight bearing and EARLY REFERAL

65 65 66

11 10/20/2020

Radiography Navicular Stress Fx

• Radiographs may be • Etiology negative – Early – Overuse – Stress Reactions – Cavovarus foot – Subtle – Shoe mechanics • Advanced imaging indicated with bony point tenderness

67 67 68

Navicular Stress Fx Navicular Stress Fracture • History • Anatomy – Insidious onset of vague midfoot pain – Supplied by peripheral, – “Cramping” sensation medial and lateral vessels with a relative – Often a delay in diagnosis of up to 7 months central avascular region – Symptoms related to activity • Fracture line: • Examination – typically in the sagittal – May be tender over the navicular or medial longitudinal arch plane: central 1/3 or the central and lateral third – Symptoms exacerbated by hopping on foot in the equinus position – Proximal dorsal to distal plantar direction

69 70

MRI CT Scan

•MRI most sensitive • Can show stress reaction • Best for • Or fracture line – Evaluating fracture – Following to bony union • Fracture line is dark on T1 weighted images • Distinguishes – Incomplete from complete fracture – Acute versus nonunion • Helps preop planning for screw placement

71 72

12 10/20/2020

Incomplete vs. Complete Fracture Treatment

• Incomplete Stress Fractures • Nondisplaced fractures • Stress Injuries – Short leg cast – 6-8 weeks non-weight bearing – Use bone stimulator if available – Transition to walker boot – Repeat CT scan to document healing – Gradual resumption of activities with monitoring by a Incomplete Complete physical therapist or athletic trainer

73 74

th Surgical Treatment 5 Metatarsal Fractures Consider in Zones • Complete fracture • I = tuberosity • Displaced fracture • Established Nonunion • II = Jones • Failure of (metaphyseal- Casting/Immobilization diaphyseal) • III = diaphyseal

CONTROVERSIAL - ELITE ATHLETES

75 76

Jones Fracture Jones Fracture

Definition Zone II/III II • Best defined as a fracture of Fractures the metaphyseal-diaphyseal • Consider the same in junction regard to treatment • At or distal to the 4/5 • Both have guarded intermetatarsal articulation healing potential

III

77 78

13 10/20/2020

Vascular Water-shed Jones Fracture

Nonoperative Treatment – 4-6 weeks NWB cast – 4-6 weeks WB cast

79 80

Jones Fracture Jones Fracture

• RCT Nonop vs. Operative tx Nonoperative Treatment – Malone et al, AJSM 2005, 33-8 • Longer time to union – 38pts • Delayed union in 25- – Operative tx– 5% nonunion 50% • Avg time to union 6.9wks – Nonop tx– 8wks in NWB cast • 44% tx failures (28%nonunion/ 11% refractures) • Avg time to union 14.5 wks

81 82

Jones Fracture Jones Fracture

Treatment Operative goals • Operative indications • Expedite healing – Athlete • Quicker recovery; easier • Acute/stress fx rehab – Nonunion • Decrease refracture risk – Refracture – Cavovarus = lateral overload – Patient preference

83 84

14 10/20/2020

Medial Malleolar Stress Fx Medial Malleolar Stress Fx

• < 10% of foot and ankle • Predisposing stress fx factors • Most common 20-40 y/o – Genu varum • Almost exclusively in athletes – Tibia vara – Cavovarus – Impingement of talus on medial malleolus during ankle DF

85 86

Medial Malleolar Stress Fx Medial Malleolar Stress Fx

• Imaging • Imaging – Xrays positive in – Xrays positive in <50% <50% • Oblique or • Oblique or vertical fissure vertical fissure • Posteromedial • Posteromedial –MRI or bone –MRI or bone scan scan

87 88

Medial Malleolar Stress Fx Medial Malleolar Stress Fx

• Imaging • Treatment – Due to “tension” forces – CT highly difficult to heal recommended • Similar to anterior tib or once diagnosis femoral neck made – Cast prevents DF and stress induced by talus • Extent of fx line – NWB if established fx • May identify line cystic/lytic changes

89 90

15 10/20/2020

Medial Malleolar Stress Fx Medial Malleolar Stress Fx

• Treatment • Treatment – Typically – Surgery more recommend 4-6 reliable? weeks NWB and • Predictable reduction then 4-6 weeks WB of tension forces – Avg. healing time • 4.2 months to heal 6.7 months – Rapid rehab – Preferred for the elite athlete

91 92

Take Home Points

• “Low” Ankle sprain • “High” Ankle sprain – Torn ATFL not surgical – Tender proximal to ankle indication – Longer recovery – MRI rarely indicated – Early referral if unable to acutely Take Home Points bear weight 5-7 days – Advanced imaging if unable to WB after 5-7 days

93 94 93 94

Take Home Points Take Home Points

• Achilles Injury • Lisfranc • High Risk Stress Fractures • High Risk – There are no partial – Weight bearing imaging – Non op – Anterior Tibia Ruptures • Bilateral WB AP • MUST be NWB – 5th Metatarsal • FUNCTIONAL – Can save a pt from midfoot – Advanced imaging early – Navicular – If Concerned non weight fusion – Surgical Management bearing splinted in – Medial Malleolus • Peroneal Tendon plantarflexion AND early • Higher union rate • Low Risk referral – Split tear  physical • Faster return to Sport therapy – Calcaneus – Can save pt from operation – MRI for DxCT for Tx – Rupture  Referral – Cuboid – Other Metatarsal

95 96 95 96

16 10/20/2020

Thank You [email protected]

97 97

17