Common Foot and Ankle Sports Injuries
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
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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
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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
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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.
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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
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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
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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
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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 to Natural Walking and Resumption of Rehab Sports 90% do well with any conservative RX Reasonable to wait and treat fractures
Konradsen F + A 12:69 1991
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Ankle sprains Ankle Sprains Rehabilitation Treatment
Walk> Jog >Run >Steps 90% do well with any conservative >Turns>Jumps treatment Reasonable to wait and treat failures Return to Dance when: later Proprioception and Strength normal Able to perform Jumps and Turns There is some tread to consider earlier surgical stabilization in the elite dancer
Ankle Sprains Ankle Sprains Syndesmosis Injuries Syndesmosis Injuries
Diagnosis Compared to Lateral Ankle Injury Hx of External Rotation Tenderness over Ant Tibiofib, More Games Missed Sydesmosis or Post Tibiofib Received More Treatments Usually Less Swelling than Lateral Sprains Missed More Practices + External Rotation Test + Syndesmosis Squeeze Test
Boytim AJSM 19(3):294 1991 Boytim AJSM 19(3):294 1991
Ankle Sprains Meniscoid Lesion Chronic Pain Treatment Meniscoid Lesion (Anteriolateral All Treated with Arthroscopic debridement Hypertrophic Synovitis) Path showed Chronic Synovitis 15 Exc., 11 Good, 4 Fair ,1 Poor 31 Patients >2months of rehab Anteriolateral Pain and tenderness MRI most useful screening test (But only 25% accurate)
Ferkel AJSM 19(5) 440 1991
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Osteochondral Injuries Anterior Scarring of the Talar Dome
PosterioMedial less often has a history of trauma
Anteriolateral More often associated with trauma Often with a Inversion injury
Berndt + Harty JBJS 41A:997,1959
Osteochondral Injuries Osteochondral Injuries of the Talar Dome of the Talar Dome PosterioMedial Usually graded Stage I - IV Larger, Deeper Can be Developmental
Anteriolateral Smaller, Flakelike Mostly Trauma Related
Treatment I –II: Non-Op III Med :Trial of Non-OP III Lateral, All IV : Surgery Fixation for acute with bone attached Debridement,Curratage and Microfracture for Chronic lesions or those without attached bone Canale JBJS 62A p.97 ,1980
Osteochondral Injuries Osteochondral Injuries of the Talar Dome of the Talar Dome
All lesions excised followed by drilling Few Lesions unite long term without or abrasion surgical treatment Average followup – 18 months 86% excellent or good Degenerative changes (+/- Symptoms) present in 50%
Van Buecken AJSM 17(3) 350 1989
Canale JBJS 62A p.97 ,1980
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Osteochondral Injuries Tendon Disorders of the Talar Dome
Very Common Achilles Tendon disorders most common <12 yo, prior to physeal closure Peroneal and Posterior Tendon disorder also common Non-displaced – Immobilize Tendonitis/Tendonosis/Paratendonitis/Tenosyovitis/Partial Displaced – Consider fixation or Tears/Complete tears excision All can happen independently, or concurrently
Direct Trauma/Overuse/ Collagen disorders/Inflammatory conditions Stone & Guhl AANA Boston 1992
Common Disorders Anatomy
Gastrocnemius Musculo-tendonous Junction Tears Triceps Surae Achilles Tendonitis Soleus muscle Non insertional Gastrocnemius Insertional Crosses 2 joints Achilles tendon Tears Largest and strongest tendon in the body Partial “Watershed” blood supply proximal to insertion Complete This area most susceptible
Gastrocnemius Muculotendonous Biomechanics Junction Tear
Up to 8X Body weight while running Presentation Sudden “Pop” in calf Medial gastrocnemius by far the largest component as per EMG studies History of sudden movement or Stop +/- Prodromal “tightness” or Because soleus doesn’t cross knee, subject to early tenderness disuse atrophy w/ under training and immobilization Difficulty bearing weight /push-off
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Gastrocnemius Muculotendonous Medial Gastrocnemius Musculotendonous Junction Tear Junction Tear
Diagnosis Treatment Point Tenderness Always conservative +/- Palatable Defect Immobilize 1-2 weeks if severe Negative Thompson’s Test Protected weight-bearing in Cam Normal Galiazzi Pasteur Walker Heel Lift Return to Full Activity 2-4 months Must have full painfree range of motion and full strength
Achilles Tendonitis Achilles Tendonitis
Common in Ballet Dancers Pain on grand plie’ Pain on grand plie’
Swelling, tenderness, occasional Swelling, tenderness, nodule occasional nodule Ribbons, elastic or back of dance shoe may rub against Ribbons, elastic or back of inflamed tissue dance shoe may rub against inflammed tissue Repetitively explosive activities Repetitive toe-off activities
Achilles Tendonitis Non-Insertional Achilles Paratendonitis
Saline/Lidocaine Injections may be helpful in 4 Pathologic Stages cases of Para tendonitis Used to separate Paratendon from tendon Paratendonitis Severe Acute Case of Tendonitis Paratendonitis with Tendonosis Immobilization 10 – 14 days Tendonosis No!!!!??? Steroid Injection Reports of several complete ruptures following intratendonious Tendonitis cortisone injections Studies show no positive effect on degenerative changes or tendonopathy
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Achilles Paratendonitis Achilles Paratendonitis/Tendonitis
Release Sheath from Musculotendonous junction to Post-Op Management Achilles insertion Paratendonitis Adhesions should be released posterior, medially and Immobilize only for would healing laterally but NOT Interiorly, to avoid injury to blood supply Tendonitis +/- Venting of the tendon to encourage in-growth of new Depends on extent of debridement blood vessels Simple debridement – Immobilize 2 weeks Turndown/Augmentation – Immobilize 5 to 7 weeks
Achilles Paratendonitis
Release Sheath from musculotendonous junction to Achilles insertion Adhesions should be released posteriorly, medially and laterally but NOT Anteriorly, to avoid injury to blood supply
+/- Venting of the tendon to encourage ingrowth of new blood vessels
Achilles Tendonitis Achilles Tendonitis Non-Insertional
Etiology Non-operative Treatment in Majority of Cases Watershed of Blood Supply Rest Repeated Micro- Trauma Heel Lift Training Disorders NSAIDs Ie. Sudden increase of Orthotic treatment training intensity Modalities ( U/S , Phono , Ionto , Deep Massage) Hindfoot Malalignment Stretching Overpronation 56% Poor Triceps Surae flexiblity Return to dance when pain-free for 10 days
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Achilles Tendonitis Achilles Tendonitis Surgical Results Surgical Results
Paratendon Release Paratendon Release 89% Good/Excellent 89% Good/Excellent
Tendon Debridement and side to side Tendon Debridement and side to side 67 to 75% Good/Excellent 67 to 75% Good/Excellent
16% Reoperation in 5 years 16% Reoperation in 5 years
Schepsis and Leach AJSM 1994 Nelen AJSM 1989 Nelen AJSM 1989 Schepsis and Leach AJSM 1994
Achilles Tendonitis Achilles Tendonitis Post-Op Management Surgical Treatment Diseased area should be completely excised Stretching and Strengthening after Remaining tendon repaired side to side immobilization Palpate remainder of tendon to assure no non- adjacient involvement After tendon Reconstruction If more than 50% of the cross-sectional area is Jog 8 – 12 Weeks excised, consider augmentation with: Full recovery 5 – 6 months Plantarus graft Gastroc Turndown Flexor Tendon Transfer
Investigational Treatments for Tendonopathies and Fasciopathies Prolotherapy ("Proliferative Injection Therapy“)
Injection of an irritant solution into the area where connective tissue has been weakened or damaged through injury or strain Many solutions are used, including Dextrose, Lidocaine (a commonly used local anesthetic), Phenol (an alcohol), Glycerine, or Cod Liver Oil extract The Injected solution causes the body to heal itself through the process of inflammation and repair. In the case of weakened or torn connective tissue, induced inflammation and release of growth factor at the site of injury may result in a 30-40% strengthening of the attachment points Extracorporeal Shock Wave Therapy (ESWT)
Application of high-intensity acoustic radiation Microtrauma of the repeated shock wave to the affected area creates neo- vascularization into the area which promotes tissue healing. Platelet Rich Plasma Therapy (PRP)
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Platelet Rich Plasma Therapy Achilles Tendonitis
Post-Op Management
Stretching and Strengthening after immobilization
After tendon Reconstruction Jog 8 – 12 Weeks Full recovery 5 – 6 months
Achilles Insertional Tendonitis Insertional Achilles Tendonitis “Different Animal” Usually Older population McGarvey WC, Palumbo RC,et al Pathology at the Achilles insertion Foot Ankle Int. 2002 Jan;23(1):19-25 Associated often with a Haglund’s Deformity 22 heels in 21 patients Treated with central splint Treatment 90% Conservative Debridement tendon bursa and Haglunds process Prolonged attempt Post-op
10% Surgical 20/22 returned to work or normal activities Debride fibrotic / Calcific Debris Only 13 of 22 were pain free Remove Boney Impingement and resect inflamed, scarred bursa 3 patients required reop
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Achilles Tendon Rupture Achilles Tendon Rupture
Most Common 2 to 6 in proximal to insertion Exam 22% missed originally by Primary Care physicians Positive Thompson’s Test Loss of normal Galiazzi posture Presentation Palpatable Defect – if seen early “Pop” Acute but not dramatic pain Edema and ecchymosis often follow late Complaints of instability
Achilles Tendon Achilles Tendon Rupture Partial Rupture Treatment
10 – 50% of Tendon – Conservative Treatment In the Athlete/Dancer, surgery is the >50% = Likely complete Rupture Treat as complete only option other than retirement Palpative Defect Neg Thompsons Principles of Surgical repair Treatment Surgery Effective if no response to 6 months of conservative treatment Avoid Excessive Tension Should come to Full Dorsiflexion in OR Most Patients return to Pre-Injury Status Use Flaps, Grafts,ect. To make up Gap
Skeoch AJSM 9(1) 1981 p.20
Achilles Tendon Rupture Achilles Tendon Rupture
Functional Non-op Treatment Ultrasound proved <10mm btw tendon ends at 20 deg Functional Non-op Treatment plantar flexion Cam walker brace w/ 3cm heel lift Authors now recommend PT started at 3 weeks Results 1) Repeat U/S 2 to 5 days after original 6.4% re-rupture 2) 3 cm heel lift 6 to 8 weeks 73.5% good/excellent complete return to activities 3) 1 cm lift in shoe for 3 months 9% satisfactory 17.5% poor –pain, tendon lengthening, decreased strength, decreased calf size Hufner et al: Foot Ankle Int. 2006 Hufner et al: Foot Ankle Int. 2006 Mar;27(3):167-71 Mar;27(3):167-71
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Achilles Tendon Rupture Chronic Achilles Tendon Tear
New Trend in Post-op Care
Functional Treatment Early Weight-Bearing Dorsiflexion Block Orthosis
Carter Amer J Sports Med 20:459-462 1992
Chronic Achilles Tendon Tear
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Tendon Disorders in Runners Peroneal Tendon Disorders Tendonitis, Subluxation and Tears Peroneal Tendon disorders Often Traumatic, Inversion injury Pain Presents laterally and the dancer may also complain of weakness and Instability
Pain at Demi- and Grand Plie’
Posterior Tibialis Disorders Sense of snapping consistent with subluxing tendon Often attritional Orthotic Devices can be very helpful
Peroneal Tendon Disorders Peroneal Tendon Subluxation Tendonitis, Subluxation and Tears
Treatment Treatment – Acute Injury Avoidance of Releve’ NSAIDs Stirrup Brace Immobilize 6 weeks in well molded Short Physical Therapy Modalities leg Cast
If pain persists MRI or Exploration Good reults in 50% Debridement and/or Repair Poor results in 50% Reason some recommend immediate surgery
Peroneal Tendon Disorders Tendonitis and Tears Peroneal Tendon Subluxation Treatment
“Bankart Lesion” Detachment of Periosteum Tendons Dislocate into False Pouch
Anatomic Repair Reattach Periosteum thru Drillholes
Das De JBJS 67(B):585 1985
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Peroneal Tendon Subluxation Peroneal Tendon Subluxation
Lateral Treatment Deepens Groove, maintains gliding surface
Posterior Anterior 9 Patients, 10 Ankles
All Patients reported excellent results
Medial Zoeliner JBJS 61-A(2) 292 1979
“ False” Peroneus Quadratus Peroneal Tendon Subluxation
Peroneus Quadratus Congenital abnormality Extra Tendon “Fills” Retinaculum Can Mimic Subluxation and Tendonitis
Treatment Surgical Debridement
Peroneus Brevis Abnormality Extensor Tendonitis
• Pain or pointing of foot on Relevé • Clinically- • Pain with passive plantar flexion • Crepitus if severe
• Rx- • Rest, occasional • immobilization
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Flexor Hallucis Longus Stenosing Tenosynovitis “Dancer’s Tendonitis”
Tendon under maximal tension in demi-pointe
Triggering of the Big Toe with stenosing tenosynovitis at the fibrous steath in the posterior ankle
Stenosis can occur at the Knot of Henry and at the MTP joint (mimics Hallux Rigidus)
Flexor Hallucis Longus Stenosing Tenosynovitis “Dancer’s Tendonitis Posterior Impingement of the Ankle
Treatment Painful Os Trigonum Relative Rest Large Trigonal NSAIDs Process Physical Therapy with modalities Stress Fracture can NEVER INJECT occur Lateral Instability Surgery to release the tight sheath May notice assymetry of pointe’ and releve’
Posterior Impingement of the Ankle Anterior Ankle Impingement Not as common in dancers
Needs to be differentiated from FHL STS Presents at Plie’ Anterior osteophyte on Talar neck and/or Test FHL in Dorsiflexion would not hurt if pain Anterior Tibia was due to Posterior impingement
Passive Plantarflexion should hurt with Posterior impingement, not FHL STSD
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Anterior Ankle Impingement Plantar Aponeurosis
Arises predominately from the medial calcaneal
Treatment tubercle NSAIDs Inserts distally through multiple slips into plantar Heel Lift plates , flexor sheaths, proximal phalanges and Surgery- Arthroscopic skin Debridement
Plantar Fasciitis Plantar Fascia Rupture
Plantar Heel Pain Trauma 6 million cases / year 2 billion dollar cost /year Cortisone injection
300,000 lbs of stress per square mile of Attrition running centered on heel
Proximal Plantar Fasciitis Proximal Plantar Fasciitis
Often associated with seronegative arthritrides Microtrauma to the plantar Diagnosis fascia attachment with Usually clinical attempted repair and Heel pain at anteriomedial calcaneal tubercle chronic inflammation Bone scan positive 60% of cases MRI fairly specific
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Proximal Plantar Fasciitis Proximal Plantar Fasciitis Custom Orthotics?
Initial Conservative Care
Activity and Shoe Stretching plus a prefabricated insert is modification more effective than stretching plus a custom Stretching Program orthotic Orthotic Device NSAIDs Pfeffer,GB et al 1999 Night Splint
Proximal Plantar Fasciitis Proximal Plantar Fasciitis
Efficacy of Cortisone Injection Open Plantar Fasciotomy 41% still improve at 5 months 71% Good and excellent results at 8 year F/U
Focused Ultrasound Treatments (ESWT) Endoscopic Plantar Fascia Release Effective, not often reimbursed 89% with effective pain relief 71% returned to unrestricted sports Prolotherapy Ogilvie-Harris,DJ 2000
Endoscopic Plantar Fascia Release Nerve Entrapments • Most Common- Complications • Superficial peroneal nerve as it exits fascia Inadequate release • Must be aware of Nerve injury “Double Crush” concurrent HNP Lateral column pain Metatarsalgia • Rx • Injections, NSAID, Elevation • Surgical release with fasciectomy
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Entrapment of the First Branch of the Nerve Entrapments Lateral Plantar Nerve • Most Common- Often missed • Superficial peroneal nerve as it exits fascia Not addressed with endoscopic release • Must be aware of “Double Crush” concurrent HNP Release yields 83% complete resolution • Rx • Injections, NSAID, Baxter,DE 1992 Elevation • Surgical release with fasciotomy
Nerve Entrapments Stress Fractures
Mechanism of injury
Repetitive loads Wolfe’s law Remodeling of bone results from stresses placed on it Osteoclastic activity outstrips osteoblastic activity
Stress Fractures Stress Fractures
Presentation Diagnosic Imaging Insidious onset, often after a change in training Xrays activities 2/3 may initially be Negative Localized pain ½ may remain negative Progressive worsening Bone Scan st 1 – Pain after activities May take 2 to 3 weeks to become positive 2nd - Pain during activities Asymptomatic foci noted in up to ½ of those athletes with positive foci 3rd – Pain limiting activities
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Stress Fractures Stress Fractures
Special Consideration - The Female Athlete Treatment Principles
Oligomenorrhea Low Body Fat Unload area from repetitive stress Low Estrogen Maintain Conditioning May all contribute to higher risk of stress fractures
Estrogen containing BCP’s have been advocated by some
Metatarsal Stress Fracture Stress Fractures Treatment Tarsal Navicular Stress Elastoplast strapping Fracture Stiff soled shoe Fracture usually in sagital plane in middle 1/3 (Limited MT pad X 6 weeks vascular supply) CT Scan/MRI – usually Occ. Cast treatment diagnostic
REST Treatment If no sclerotic margins seen- NWB Cast 6-8 weeks If Sclerosis seen – ORIF with bone graft
Stress Fractures Navicular Stress Fractures
Tarsal Navicular Stress Fracture 21 cases in 19 patients Sagital mid 1/3 fx Fracture usually in sagital plane in middle 1/3 (Limited vascular supply) Complete or proximal/distal cortex CT Scan/MRI – usually diagnostic Most respond to immobilization
Treatment occ. ORIF If no sclerotic margins seen- NWB Cast 6-8 weeks If Sclerosis seen – ORIF with bone graft
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Stress Fractures Stress Fractures Interosseous Talar Stress Fracture
May mimic sinus tarsi syndrome Os Calcis Xrays rarely helpful MRI usually diagnostic Important to PROLONGED REST necessary differentiate from other sources of heel pain Pain localized to tuberosity Usually rapid healing due to cancellous bone
Stress Fractures Stress Fractures Medial Malleolus
Medial Malleolus Pain directly over the Malleolus Associated with effusion
RX Immobilize/Unload ORIF
Stress Fractures
Fibula
Most common 4 to 7 cm above the tip of the lateral malleolus Typical presentation Thank You Usually return to full activities within 6 weeks
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