ACMS Team Physician CourseSan AntonioFeb 2015 FOOT AND ANKLE PROBLEMS IN ATHLETES

Marlene DeMaio, MD Prof, Orthopaedic Surgery, Marshall University; VAMC John J. Jasko, MD Asst Prof, Orthopaedic Surgery, Marshall University

ANKLE ANATOMY

Seto, Foot and Ankle Anatomy, Slideshare Syndesmosis

• Syndesmosis: – Ant. Inf. Tibiofibular ligament – Post. Inf. Tibiofibular ligament – Transverse biofibular ligament – Interosseous membrane So Tissue Injuries

• Sprains • Tendon strains and tears

Primemed.com.au ANKLE SPRAINS • 27,000 per day in U.S. – 25% of all MSK injuries

• Most common sports injury – 25-50% of all sports injuries – >50% of all ankle injuries – #1 NCAA surveillance data and ballet, classical dance – 45% of all basketball injuries “It’s just a sprain.” • Not a benign injury – 75% athletes report recurrence – Up to 25% lead to chronic lateral ankle instability and/or pain – Self assessed disability is high – Lost days of work, pracce, games • 10-15% of all me lost in football • 3-5 weeks lost • Even for lower grade injuries “It’s just a sprain.” • Misdiagnosis, incomplete diagnosis – Bone • Fracture: Ankle, Talus, Maissoneuve, 5th metatarsal • Tarsal coalion – So ssue • Global laxity, Ehlers Danlos • Tendon injury: Peroneals, Achilles – Nerve disorder • HNP, drop foot • Charcot Marie Tooth

DeMaio, Orthopedics 1992:87-96 Anatomy • Ligament = condensaon of • ATF Ligament capsule – Fails at 138N AITF – Can undergo greater CFL ATFL plasc deformaon than CFL • CF Ligament – Cord like – Fails at 345N – Deep to peroneals

Clanton T, et.al. Anatomic study of Lateral Ligaments. – 105° b/t ATFL CFL Poster at AAOS 2014 Anatomy: Lateral Ligament Morphology

LIGAMENT WIDTH, mm LENGTH, mm ORIGIN INSERTION

Anterior Neck of talus ATF 5 12 border lateral malleolus

Fossa lateral Lateral CF 6 6-25 malleolus, tubercle, 10-45 deg calcaneus post angle process Post lat Lateral PTF 6 9 malleolus, post tubercle, talus to CF ligament post process

Hollinshead, Textbook of Anatomy, 3rd ed, 1974: 423-488 Ruth, JBJS-Am, 1961 43: 229-239 Mechanism of Injury: Lateral Ankle Sprains • Weight bearing • Low energy trauma • Example: 230 lb RB, terminal velocity of 22.2 /sec, decelerang at 13.5 m/sec2 – Force on ankle: 7760N – Stress lateral ankle: 1264.4 lbs

– ATF fails at 138 N, CF at 345N

Guise, AJSM 1976 4: 1-6. Lateral Ankle Sprains • Funcon and alignment changes with moon

PF Neutral DF

• Primary inversion stabilizer – Plantarflexion: ATFL – Dorsiflexion: CFL Mechanism of Injury • Lateral ankle sprain: a cascade of injury – Supinaon/Inversion in Plantar-flexion or Neutral

• ATFL injured first (“essenal lesion”) • CFL injured as ankle DF during connued inversion – ATFL + CFL 30-60% • PFL last to rupture in extreme inversion, DF

Lateral Ankle Sprain: Exam • Anterior drawer – Tests the ATFL – Slight plantarflexion – Translate anterior and slightly medial • Talar lt – Tests CFL – Neutral flexion – Inversion of hindfoot – Look for dimple

• Always compare to other side • Most sensive at me 0, then day 7 Lateral Ankle Sprains: Grades Grade Injury Swelling Weight Bearing I ATFL stretch, Mild Mild limp, but tear can WB with brace II ATFL and Moderate Difficult capsular tear + swelling and CFL Bruising

III AFTL, capsule, Severe swelling Unable to bear CFL tears and bruising weight

Note: Grade IV with avulsion fracture Lateral Ankle Sprains

• Classificaon: systems not comparable – AMA : Grades I-IV – Severity – Ligaments • Single: ATF ligament and capsule • Double: ATF and CF ligaments • Triple: ATF, CF, and PTF ligaments Imaging: X-ray Indicaons • Oawa Rules • Inability to bear weight AP, lateral, morse • Bony tenderness

Oowa Rules

• Xrays are indicated to r/o fx if: – Presentaon within 10 days of injury – Inability to bear weight at me of injury or at presentaon – Tenderness over then distal 6cm of malleoli, posterior aspect – Tenderness over the base of the 5th metatarsal or navicular

Imaging: MRI Indicaons • If isolated injury, f/u exam in 1-2 weeks • MRI if – Persistent significant swelling – Tenderness: • Peroneals • Lateral talus • Anterior calcaneus – Syndesmosis injury suspected

• R/o concomitant pathology Lateral Ankle Sprains: Treatment • Isolated acute Grade I & II lateral ankle sprains – Universal consensus – Inial non-operave treatment of • Grade III – “Near” consensus – Some new evidence may change this Lateral Ankle Sprains: Treatment

• Benign Neglect – Not appropriate – 75% recurrence rates – RR=2.3 for CAI without funconal rehab Lateral Ankle Sprains: Treatment • RICE: 24-48 hours • Control pain • Limit swelling • Reduce hypoxic injury during acute inflammaon • Protect Ligaments, Stabilize the Joint – Trauma creates temporary instability – True healing takes >8 weeks – External support: Braces, cast, boot, tape • Funconal Rehabilitaon – Neuromuscular and sport/task training DeMaio, Orthopedics 1992 15:87-96 and 241-248

Funconal Rehabilitaon • Aer LAS paents exhibit deficits in – Joint posion sense – Isometric strength in mulple planes of moon – Postural control on the involved and uninvolved limb • Posive modified Rhomberg – Abnormal EMG (Nitz AJSM 1985 13:177-182) • Peroneal nerve, 86% Grade III • Tibial nerve, 83% Grade III • Lack of neuromuscular retraining leads to recurrent injury, chronic problems – 2.3 x risk of recurrence Funconal Rehab: Components • Early Joint mobilizaon • Strengthening • Sensorimotor/balance – Wobble board – Trampoline • Single/double leg Postural control • Connue external support • Propriocepve feedback • Connued protecon of ligaments Meta-Analyses/Level 1 Evidence • Funconal Rehab > prolonged immobilizaon – Faster return to sport, work – Fewer long term symptoms – Beer ROM • Semi-rigid external support beer than cast & Ace – Srrup ≥ Lace up brace > tape > Elasc wrap – SLC/boot useful in G3 (Lamb et al. Lancet 2009) • Short tem use (days) only Meta-Analyses: Level 1 Evidence

• Petersen et al. Arch Ortho Trauma 2013 • Lamb,et al. Lancet 2009 • Beynnon et al. AJSM 2006 • Ardevol et al. KSSTA 2002 • Kerkhoffs et al. Cochrane 2002 • Kerkhoffs et al. Acta Ortho Scand. 2003 Taping

• Pros • Cons – Custom – Rapid loosening – Provides propriocepve • Aer 10 mins, 40% of strength feedback lost • 50% decrease in ROM aer 2 1/2 – Lightweight, low bulk -3 hrs – May be useful when • 45-60 minutesàminimal effect swelling prevents fing – Trained personnel of an orthosis – Expensive over the season – Variable effects on performance DeMaio, Orthopedics 1992 15:87-96

Taping vs. Brace for Sports • Both shown to prevent ankle sprains – Braces overall more effecve – Braces cost less per season • Much more effecve on athlete with h/o prior ankle sprain “Marshall” Algorithm • Brace: Srrup/ Lace up /Combo • Boot in G3 – To brace in few days • TED hose • WBAT with crutches if limping – NWB A/PROM • Funconal Rehab Return to Play

• Subjecve symptoms – Foot and Ankle Ability Measure (FAAM) • Funconal tests – Star Excursion Balance • Simplfied to Y – Single leg balance – Single leg heel to toe raises • 60/minute Ankle Sprains: Treatment • Funconal rehab beer than immobilizaon – Start with DF, eversion – Acve resistance: isometric first • Peroneals • Dorsiflexors • Evertors

• Role for acute surgical intervenon in selected cases? Ankle Sprains: Treatment

• Pinjenburg, et al. 2002 – RPT Level II – Acute repair vs. funconal rehab – 317 paents, 8 yr follow up – Surgery group fared beer • Pain (16% vs. 25%) • Subjecve giving way (20% vs. 32%) • Recurrent sprains (22% vs. 34%) • Funconal scores

“operave treatment for lateral ligament ruptures can be adopted in cases when higher funconal demands…such as sports at a compeve level… are required” Ankle Sprains: Treatment • Pihlajamaki, et al. JBJS 2010 – Level 1, 14 yr follow-up – Male Finish military cadets, Grade III sprains – Acute repair vs. funconal rehab – Lower risk of re-injury in surgery group (6% vs. 58%) – Higher incidence of Mild OA (Grade 2) on MRI in surgery group (27% vs. 0%) Paradigm Shi?

• Early surgery for Acute ankle sprain? • Similar to 1st me shoulder dislocaons? • Potenal problems – Increased complicaons – Higher costs – Availability of OR

• Secondary reconstrucon of G3 injuries is possible even years out, outcomes similar to those of acute repairà More data needed Chronic Lateral Ankle Instability • ~10-25%

• Funconal instability – Impaired propriocepon, neuromuscular control • Mechanical instability – Pathologic laxity – Synovial changes – Chondral damage – Loose bodies DeMaio, Orthopedics 1992 15:241-248 Chronic Lateral Ankle Sprain: Predisposing Factors

• Previous ankle sprain • Propriocepon deficiency • Varus hindfoot (Cavus foot) • Ligamentous laxity – Collagen deficiency – Beighton’s Criteria Chronic Lateral Ankle Instability • History – Pt c/o: Can’t trust ankle, Feeling of giving way, Ankle just gives out – Mulple sprains – Connued subacute or chronic pain following sprain

• Pain signifies other pathology as well – Peroneal tendons – OCD or OA – Anterolateral guer impingement Chronic Lateral Ankle Instability: Physical Exam • More subtle findings than acute • Ligament laxity more easily noted – Less swelling – Less pain inhibion • Careful palpaon • Examine hindfoot alignment – Look for cavus – Peek-a-boo heel Chronic Lateral Ankle Instability: Imaging • Stress x-rays – Quesonable value without Telos machine – Pain inhibion – No consensus on normal and pathological # – Must compare to “normal” side • But is that side normal? • >3 mm ant. Translaon • >10 deg talar lt – Adds a data point • Signs and symptoms more important

Chronic Lateral Ankle Instability: Imaging

• MRI – Oen done to rule out other pathology • OCDs • Peroneal tendons – Surgical planning Chronic Lateral Ankle Instability: Treatment • Funconal & Neuromuscular Rehab – Esp. subjecve instability paents • Bracing/Taping – Get through season

• Surgical intervenon is indicated when funconal rehab has failed and pt has chronic symptoms Chronic Lateral Ankle Instability: Surgery

• Address all pathology – 93% intra-arcular path (Ferkel, Brostrum) – Always scope

– Consider Peroneal tendon pathology Chronic Lateral Ankle Instability: Opons for Surgery • > 50 described procedures – 80% G/E results

• How to choose? – Quality of ssue – Degree of laxity – Revision? Opons for surgery Surgical Technique • Insufficient evidence exists to support any one specific surgical technique • Non-anatomic/tenodesis procedures – Inferior outcomes – Tendency to overghten • Ankle, subtalar OA – Sacrifice peroneals • Dynamic stabilizer Anatomic Repair • Brostrom (1966)

• Brostrom-Gould (1980)

Pictures from: Baxter’s Foot and Ankle in Sport. Mosby, Inc. 2008 Bone Tunnels vs. Suture Anchors

• No difference in strength or sffness • Neither as strong as nave ATFL at T=Ø – 80N vs 160N

Waldrop, et al. Anatomic Suture Anchor Versus the Brostrom Technique for ATFL Repar. AJSM 2012

Outcomes: Pooled Data

• Brostrom/Modified Brostrom (500 cases) – 85-100% successful – Poor results in • Heel varus • Inadequate rehab • Nerve injury • Pre-exisng arthris • Significant repeat sprains Anatomic Reconstrucon Anatomic Reconstrucon • As sff and strong as nave ATFL T=Ø – Implicaon for Rehab – More technically demanding – Need for gra

• Indicaons – Heavy athlete or laborer – Severe laxity – Weak or Deficient ssue precluding direct repair – Revision surgery

• Clanton, et al. Biomechanical Comparison of Anterior Talofibular Ligament Reconstrucon Using Semitendinosus Allogras With the Intact Ligament; Anterior Talofibular Ligament Ruptures, Part 2:. AJSM 2014

Approaches Post-op Management

• Similar to acute sprain – Week 1 : Protect for 7-10 days – Week 2-5: WBAT boot; DF, PF, no inversion – Week 6: Brace; Funconal Rehab – RTP 10-12 weeks Post-op Management

• Accelerated Rehab vs. Delayed – No immobilizaon vs. cast 4 weeks – Funconal rehab started at 2 weeks • Allowed progression as tolerated – Return to sport 5 weeks sooner – Equal outcomes at 2 years

Miyamoto, et al. Accelerated Versus Tradional Rehabilitaon Aer Anterior Talofibular Ligament Reconstrucon for Chronic Lateral Instability of the Ankle in Athletes. AJSM 2014 Arthroscopic Brostrom

• “all-inside” anatomic repair • Anchors placed percutaneously • Biomechanically = to open • Short term f/u good Anatomic Repair + Synthec Augment

Stronger than nave ATFL at T=Ø

Could allow earlier RTP Eversion Ankle Sprains

• 5-15% of all ankle sprains • AKA: high ankle sprains, medial ankle sprains, deltoid ligament sprains • Anatomic classificaon – Tibiofibular syndesmosis – Deltoid ligament – Both Roberts, Orthopedics 1995 18:299-304 Medial Ankle: Deltoid Ligament

• Major ligament complex • Strongest of the ankle ligaments

Seto, Foot and Ankle Anatomy, Slideshare Anatomy

Deltoid Ligament Flexor renacula • Superficial – Superficial – Tibionavicular ligament – Deep – Anterior talocalcaneal 4 fibrosseous canals ligament – Posterior bial tendon – Posterior biotalar – Flexor hallucis longus ligament – Posterior bial nerve • Deep – Posterior bial a & v – Anterior biotalar ligament Olney in Reckling & Reckling, – Posterior biotalar Orthopaedic Anatomy &Surgical ligament Approaches, 1990: 421-481

Medial Ankle: Tendons

• Posterior bialis (inverter and plantar flexor) • Flexor digitorum longus • Flexor hallucis longus

Seto, Foot and Ankle Anatomy, Slideshare Mechanism of Injury

• External rotaon and or forced DF – Talus rotates laterally striking the fibula

• External rotaon with the foot pronated – Maissoneuve injury Boym AJSM 1991 19:294 Lauge-Hansen Acta Chir Scand 1949 97:544 Injury Classificaon

LIGAMENT INJURY STABLE UNSTABLE Syndesmosis Incomplete disrupon Complete disrupon of deep and superficial AND Anterior biofibular poron of the deltoid Deltoid Incomplete tear Complete disrupon of the superficial and deep fibers; may be associated with fracture Deltoid and Anterior Incompletle tear Complete tear talofibular Eversion Ankle Injuries: H&P • History – Mechanism of injury – Pt c/o: medial pain, pain with weight bearing – Neurological symptoms • Physical – Tenderness – Provocave tests • External Rotaon Stress Test: knee at 90°, foot in neutral • Squeeze Test: bimalleolar compression – Neuro: combined deltoid and syndesmoc injury • 86% peroneal nerve • 83% posterior bial nerve Nitz, AJSM 1985 13:177-182 Eversion Ankle Injuries: Imaging

• X-rays – AP, lateral, morse • Morse view: > 3mm medial clear space widening – Stress views • DF and external rotaon • Abducon

• MRI Eversion Ankle Injuries: Treatment

• RICE • Progressive moon • Strengthening: isometric first • Balance training and funconal rehab • Orthoses – Taping not effecve Myburgh AJSM 1984 12:441-446 Tendons of the Lateral Ankle

• Peroneus brevis • Peroneus longus – Both serve as the major everters of the ankle – Also serve as plantar flexors

Seto, Foot and Ankle Anatomy, Slideshare Peroneal Tendon Injuries

• Strains • Tears – Complete – Paral

• Isolated • Associated with – Ankle sprains – 5th MT fx – Talar OCD Achilles Tendon Injuries

• Achilles – Greek chieain – Dipped in the river Styx by his mother Thes. – Killed in the Trojan War by an arrow striking his heel where is mother dunked him. Achilles Tendon Anatomy

• 6 cm long, twists 90° laterally • Tendon of the triceps surae, no tendon sheath – 2 heads of the gastroc – Soleus • Nerve: bial n • Superficial posterior compartment Achilles Tendon Anatomy

• Blood supply – Muscle and bony aachments – Avascular zone 2-6cm proximal to inseron • Site of tendinopathy and chronic tears Achilles Tendon

Joint Effecve • Funcon: transmit load PF from gastroc & soleus Gastroc Crosses Knee to calcaneus knee & extended ankle • Forces – Soleus Crosses Ankle in Walking ankle PF & • 1962-2354N knee • 2-3x BW flexed – Running • 3924-5886N • 4-6x BW DeMaio Orthopedics 1995 18:195-204 Achilles Tendinis • Common in runners, • Classificaon dancers – Chronicity • Risk factors – Locaon – Exposure • Inseron • Muscle tendon jxn – Malalignment • Tendon • Cavus – • Pes planovalgus Tendon condion • Microtear – Obesity • Paral tear – Fluoroquinolones • Complete tear – Inflammatory – Tissue involved arthropathy – Hyperlipoproteinemia (xanthoma) Achilles Histopathology

Chart From Hartog, AAOS OKO, Midsubstance Achilles Tendinis Puddu, AJSM 1976 4:145-150 Kvist, J Pathol 1987 19:1-11 Achilles Tendinis: Diagnosis • History • Differenal Diagnosis – Acute – Muscle disorders • Pop, pain, inability to • Tear, medial head of the walk gastroc – Chronic • Soleus straing • Pain • Compartment syndrome – Running – Tarsal tunnel syndrome – Push off – Bony disorders – On pointe • Os trigonum • Swelling • Sever’s disease • Bump or “squeaking” • Haglund’s (pump bumps) • Weakness with push off – Inflammatory – Acute on chronic arthropathies Achilles Tendinis: Diagnosis

• Pain: Acute or Chronic? – Localized – Arc of tenderness • Nodules may change posion with DF and PF (moving with the tendon) • Tendon sheath pain does not change with the ROM • ROM • Thompson test Achilles Tendinis: Imaging

• Xray – Normal – Dystrophic calcificaon • Ultrasound • MRI

Echometric Treatment of Chronic Achilles Tendinis • Correct – Training -Flexibility – Strength & endurance -Footwear • Protect the tendon – 3/8” heel li – Night splint – Rest 7-10 days or cast/boot 1 month • Local modalies • Surgery: no response aer 6-12 months, paral tears Treatment of Acute Achilles Tendon Tears • Non-operave vs. Operave & Early Loading – Prospecve, Level 1, 100 pts – f/u at 3, 6, 12 months: sx, acvity, funcon, QOL – Primary outcome: Achilles Total Rupture Score – Results • No significant difference: sx, acvity, QOL • Trend toward improved funcon with surgery • No reruptures in surgical group, 5 in non-surgical

Olsson, AJSM 2013 41:2867-2876 Treatment of Acute Achilles Tendinis • Surgery—Another Paradigm Shi? Treatment of Acute Achilles Tendinis • Surgery – Open reconstrucon – Percutaneous repair

• Early weightbearing with ankle plangrade – Not detrimental to outcome – Shortens rehabilitaon – No effect on strength, muscle atrophy Mafulli AJSM 2003 31 692-700 Treatment of Acute Achilles Tendon Tears

• Effect of Loading aer Repair, Meta-analysis – 9 studies: 6 RCT, 3 quasi RCT with 402 pts • 6 early wt bearing & ROM, 3 early ROM only – Results • Beer outcomes for early wt bearing and ROM • Similar rerupture rates, complicaons • No advantage of delayed wt bearing Huang AJSM 2014

Ankle Fractures

• Stable = Non-operave management – Avulsion fractures – Intact syndesmosis – Intact biotalar joint • Unstable = Surgery – Disrupon of syndesmosis – Unstable biotalar joint Talar Stability

• Morse stability = talar stability

• Anterior talus is wider than the posterior talus

FOOT INJURIES ANATOMY Fractures

• Forefoot – Sesamoid fractures – Stress fractures • Midfoot – LisFranc fracture dislocaons – Fih metatarsal fracture • Hindfoot – Calcaneus fractures Myerson, ICL 58, Chapt 56 2009:583-594 LisFranc Fracture Dislocaons

• Oen missed, up to 20% – About 30% associated with sports • Spectrum of injury – Ligamentous, bony, both – Associated injury: compartment syndrome • Mechanism: indirect trauma – Axial loading of the foot in PF LisFranc Fracture Dislocaons

• History • Exam – Inability or pain w/ weight bearing – Medial ecchymosis – Midfoot tenderness – “Stress” tests • Compression of midfoot • Dorsal and plantar translaon of the 1rst MT LisFranc Fracture Dislocaons

Pronaon abducon test Medial column squeeze test Myerson, ICL 58, Chapt 56 2009:583-594 LisFranc Fracture Dislocaons: Imaging • X-ray – AP, lateral, oblique (30 deg) • Fleck sign: avulsion from base of 2nd MT • Nutcracker sign: cuboid fx w/ lateral column shortening – Weight bearing comparison AP • Pain may limit FWB • Fluoroscopy: spring test • CT scan • MRI Myerson, ICL 58, Chapt. 56 2009:583-594 LisFranc Fracture Dislocaons:

• Aggressive management and close follow up – Must prove the sprain • <2mm diastasis, stable stress tests • 6 wks NWB – Unstable midfoot, diastasis > 2mm • Early surgery with screw fixaon • NWB 6-8 wks then progressive loading • Planned screw removal

Stress Fractures

• 2nd metatarsal – AKA march fracture – Locaon • 2nd MT: hallux valgus, Hallux rigidus, Morton’s foot • 3rd, 4th MT: most common sites Stress Fractures

• 5th metatarsal – Locaon • I: proximal to tuberosity • II: into the 4-5 arculaon • III: proximal metaphyseal-diaphyseal juncon – Treatment • Torg: 92% healed in NWB cast at a mean of 7 wks • DeLee: screw fixaon, return at 6 wks So Tissue Injuries

• Plantar Plate Injury • Plantar Fasciis • Entrapment of the first branch of the lateral plantar nerve (of Baxter) • Posterior Tibial Tendon Inflammaon & Tears Other Injuries and Condions

• Freiberg’s Infracon • Painful accessory navicular • Tarsal coalion

• Inseronal tendinis of the bialis anterior Freiberg’s Infracon

• AVN of the 2nd metatarsal head • Risk factors: Morton’s foot, trauma, surgery • Management – Modify footwear, acvies; treat pain – Surgery • Microfracture; Debridement & dorsal wedge osteotomy • Allogra • Arthrodesis, arthroplasty