11/23/2010 Foot and A Taste of Foot and Ankle Injuries in Ankle Injuries in Athletes Athletes Robert C. Palumbo, M.D. Robert C. Palumbo, M.D. OAA Orthopaedic Specialists OAA Orthopaedic Specialists Sports Medicine Institute Foundation Sports Medicine Institute Foundation The Problem Foot and Ankle Sports Injuries History 300,000 lbs of stress per mile of running Sport Position at injury is centered on heel and then disapated Surface Noise to the rest of the foot Shoes Pain location Custom/Prefab Orthosis Swelling Onset Time out of Sports Foot and Ankle Sports Injuries Foot and Ankle Sports Injuries Physical Exam Imaging AP/Lat/Obliques Gait Auscultation Callus Distribution Range of Motion Tangenital Views Shoe Wear Percussion Orthosis wear Pulses Weight Bearing Views Palpation Sensory Exam CT/MRI Naviculcuboid coalition 1 11/23/2010 Foot and Ankle Sports Injuries Metatarsalgia Therapy R.I.C.E. Early Gentle Motion Common overuse injury Crushed ice best Whirlpool/Ultrasound described as pain in the forefoot that is associated Ice Massage Tilt Board with increased stress over Compression-Jones Strengthening the metatarsal head region Wrap Stretching!!! Crutches Often referred to as a symptom, rather than as a specific disease. Metatarsalgia Sesamoiditis SIGNS Common causes of Metatarsalgia Local Tenderness Sesamoiditis Interdigital neuroma (also known as Morton neuroma) Pain with Hyperextenion Avascular necrosis (Frieberg’s Infarction) Rare Swelling Metatarsophalangeal Synovitis Inflammatory arthritis Synovitis/Inflammation from Repetitive Trauma Sesamoid Fracture Sesamoiditis Mechanism Incidence Stress Fracture Acute Fall from height (Ballet) Any age Hyperext. Of MTP (football) Tibial or Fibular Sesamoid Chronic-Stress Fracture(Runners) Osteochondritis Osteochondritis Female, 20’s lateral Sesamoid Kilman, F+A,3:220 1983 2 11/23/2010 Sesamoid Fracture Sesamoid Fracture X-RAY Acute AP/Lat/Oblique Presentation Reverse Oblique May mimic Turf Toe Tangential Views Bone Scan Treatment Depends on amount of Diastasis Sesamoid Fracture Sesamoid Fracture Acute Chronic Diastasis >2mm Treatment Bony Fixation U or J pad Soft tissue repair Firm Soled Shoes Diastasis < 2mm NWB 3 weeks if severe SLC 3-6 weeks Steel shank insole Prevent Hyperextension Sesamoid Fracture Sesamoid Fracture Surgical Treatment Excision of Fragment-Complications Displaced Fracture Migration of Hallux 10% Non-Disp Fx Not Resp to cast Immob. or shoe Persistent Pain 41-50% inserts x 12 wks Stiffness 33% Unrelieved Sesamoiditis/Bursitis Weakness 60% Osteomyelitis Richardson, F + A 7:29, 1987 Mann AOFAS 1985 3 11/23/2010 Sesamoid Fracture Turf Toe Late Repair Mechanism •Seventeen Patients Acute •Treated with Curretage and Bone Grafting Hyperextension of first MTP •Post-op SLC for Six Weeks Direct blow to heel with toe planted in dorsiflexion •Mean Follow-up 33 months Football Lineman •15/17 Asymtomatic return to all Pre Injury Activities Chronic •14/15 Healed by Tomography at 12 weeks Repetitive valgus stress Runner’s (Especially Cross-country) Anderson/McBryde AOFAS March 1991 Turf Toe Turf Toe Anatomy Treatment MTP Capsule No role for injections Articular Cartilage RICE, Shoe Mod. And Taping Great Toe Flexors If can’t jog w/in 3 wks. Sesamoids Consider Abductor Hallicus open treatment Plantar Nerves Late repair works Bones Coker, J Ark.Med Soc. 74:309 1978 Morton's Neuroma Morton’s Neuroma “Click" which is known as Mulder's sign Symptoms There may be tenderness in the interspace Classically described as a burning pain in the forefoot Rule out similar or concurrent problems can also be felt as an aching or shooting pain in the Tenderness at one of the metatarsal bones can suggest forefoot an overstress reaction (pre-stress fracture or stress fracture) in the bone. Pain may occur in the middle of a run or at the end of a long run An ultrasound scan can confirm the diagnosis and is a less expensive and at this time, at least as sensitive a test If your shoes are quite tight or the neuroma is very large, as an MRI the pain may be present even when walking An x-ray does not show neuromas, but can be useful to Occasionally a sensation of numbness is felt in addition "rule out" other causes of the pain. to the pain or even before the pain appears. 4 11/23/2010 Morton’s Neuroma Morton’s Neuroma Cause Contributing Factors An enlargement of the sheath Pronation of the foot can cause the metatarsal heads to of an intermetatarsal nerve in rotate slightly and pinch the nerve running between the the foot metatarsal heads Most Common –The third Chronic pinching can make the nerve sheath enlarge. intermetatarsal space As it enlarges it than becomes more squeezed and The second interspace increasingly troublesome. being the next most Tight shoes, shoes with little room for the forefoot, common location. pointy toeboxes can all make this problem more painful. Walking barefoot may also be painful, since the foot may be functioning in an over-pronated position. Morton’s Neuroma Morton’s Neuroma Orthotics – esp. for the Pronator Self-Treatment Injection of Steroid and Local Anesthetic Wear wide toe box shoes Occasionally injection of other substances to "ablate" the neuroma. Don't lace the forefoot part of your shoe too tight Surgical Removal of Neuroma Tips Make sure your feet are in supportive shoes that do not squeeze your forefoot Wear shoes designed with a roomy toebox. Wear shoes that have good forefoot cushioning. Use sport specific shoes. Fit your shoes with the socks that you plan to wear during aerobics activity. Freiberg's Infraction Frieberg’s Infarction AKA Avascular Necrosis, Osteonecrosis, Osteochondrosis Relatively uncommon General considerations Painful collapse of the head of the 2nd metatarsal Named “infraction” because it was originally thought May affect 3rd metatarsal head as well secondary to trauma Women to men by 5:1 Exact cause remains uncertain but thought to be one of the osteochondroses in adolescents Possibly because of shoes, i.e. stresses placed on Osteochondroses are diseases that usually affect the toe by high-heeled shoes epiphyses of growing bones resulting in necrosis most Length of second metatarsal thought to be a likely on a vascular basis, although the exact factor by some mechanism is not known In others, Freiberg's may be due to a combination of Usually adolescents trauma, and vascular insults Almost always unilateral 5 11/23/2010 Freiberg's Infarction Frieberg’s Infarction Imaging findings Clinical findings Early signs are sclerosis of 2nd Local pain, activity-related MT head and widening of joint space Tenderness Later there is fragmentation Stiffness and limp and collapse End result is flattening of head May produce “loose body” Freiberg's Infarction Frieberg’s Infraction Treatment Medical Surgical Complications Immobilization and avoidance of weight- Premature closure of growth plate bearing to rest the joint Loose bodies Surgical Secondary osteoarthritis Various osteotomies, bone grafts, excision of the head, joint replacement have each been used alone or in combinations Midfoot Injuries Tarsometatarsal Sprains Considerable Disability Midfoot Dislocation Diagnosis Tarso-metatarsal Sprains Pain/Swelling over TMT Joint Metatarsal Fractures Flattening of Longitudinal Arch Metatarsal and Tarsal Stress Fractures Standing X-ray 6 11/23/2010 Base of 5th MT Fracture Tarsometatarsal Sprains Location Nondisplaced Tuberosity Avulsion Fracture Immobilize in NWB SLC for Eight weeks Mechanism - Inversion Heals Clinically-3 wks Orthotic Arch Support Radiograghically-6 wks Displaced Reduction and internal fixation Metaphyseal/Disphyseal ( Jones Fracture ) Mechanism – Supination Delayed union/non-union is common Metatarsal Stress Fx Jones Fracture SIGNS AND SYMPTOMS Natural History Fracture of Proximal diaphysis interrupts Recent Change in Distance intraosseous Blood Supply No relation to ht, wt., age Creates Zone of Relative Avascularity Tender on bone, not interspace Significant Delayed Union X-rays pos. at 3 -6 wks. Significant Refracture Bone scan is diagnostic Kavanaugh JBJS 60:776 1978 Smith F + A 13:143 1992 Jones Fracture Jones Fracture Treatment Presentation Type I Type I Acute Fracture, No IM Sclerosis NWB Cast Type II Type II Delayed Union, IM Sclerosis Non-Athlete treat Conservatively Type III Athlete treat w/ Curretage/Bone Grafting Non-union, Complete Obliteration of Type III Medullary Canal by Sclerotic Bone Curretage/Bone Grafting Torg JBJS 66:209 1984 Torg JBJS 66:209 1984 7 11/23/2010 Jones Fracture Typical Jones Stress Fracture IM Fixation POD#10 WBAT Cast Boot Healed Clinically in 6 weeks Return to Athletics in 6 weeks Healed Radiographically by 13 weeks Ankle Sprains Ankle Sprain Associated Injuries Prevention Patients with Previous Ankle Injury 2.3 Osteochondritis Dissicans Times Greater Risk of Future Injury Distal Tib/Fib Disruption than uninjured Patient Anterior Process of Talus Fx After 10 weeks of Proprioception Lateral Process of Talus Fx Training, Risk Decreases to that of the Uninjured Patient Fibula, Tibia Fx Ekstrand F + A 11:41-44 1991 Ankle Sprains Ankle Sprains Treatment Treatment Much Debate – At one year, no difference between Function Bracing and Cast immobilization in Ankle Stability Taping or symptoms during activity. Casting Bracing Functional Bracing allowed Significantly Earlier Return