Division of Foot and Ankle Common Foot & Reconstruction Ankle Injuries • Adam T. Groth, MD • Kevin P. Martin, DO • Timothy Miller, MD Adam T. Groth, MD • Julie Swain, APRN-CNP Associate Professor Chief, Division of Foot & Ankle Reconstruction • OSU Podiatry Jameson Crane Sports Medicine Institute Department of Orthopaedics • OSU Sports Medicine Family Medicine The Ohio State University Wexner Medical Center • OSU PM&R • OSU Physical Therapy Acknowledgement Foot & Ankle Center of Excellence • Professor Emeritus Ian J. Alexander • Comprehensive care for all adult foot and ankle Disclosures problems: • None • Sports injuries / Sprains / Cartilage disorders • Arthritis / Degenerative conditions • Deformities • Trauma / Fractures • Bunions / Hammertoes • Whatever is causing your pain 1 Common Problems of the Acute Ankle Sprain Foot & Ankle • Exceedingly common • Acute ankle sprains • 10-40% of civilian athletic injuries annually • Significant time lost to injury • Late pain after ankle sprains / associated injuries • 1 inversion event per 10,000 people per day • Stress fractures • 23,000 to 30,000 ankle injuries per day in U.S. • 10% or ER visits in U.S. • Achilles tendon ruptures • Plantar fasciitis • 45% of all basketball injuries • Bunions • 31% of collegiate football injuries • 20% of soccer injuries • Ankle arthritis • Leading cause of time loss in NFL • Most common cause of acute injury in volleyball The Ankle Sprain Anatomy and Biomechanics • Mainstay of treatment is functional rehabilitation • 80% make a full recovery with conservative treatment • 20-30% may be symptomatic 3 months after surgery • Associated injuries may result in continued pain and dysfunction Calcaneofibular Anterior Talofibular (CFL) • Repeat sprains or inadequate rehabilitation may (ATFL) result in chronic lateral instability in 20% 2 Mechanism Diagnosis • Position of instability: • History of injury plantarflexion and inversion • Mechanism of injury • Talus is more narrow – Forces involved posteriorly – Direction of foot deviation • Failure occurs in predictable order • Prior episodes and frequency • Anterolateral capsule • ATFL (involved in 85%) • Immediate ability to weight bear • Restraint to inversion in PF • CFL (also injured in 20-40%) • Restraint to inversion in neutral or dorsiflexion • PTFL rarely injured Examination of the Foot & Ankle Examination of the Foot & Ankle •Examination • Examination – special tests • Be systematic (knee to toe) • Anterior drawer • Inspection / gait • Squeeze test – Ecchymosis and swelling • External rotation stress test – Localize tenderness » Soft tissue vs bony – Ambulatory capacity – Neurovascular exam – Range of motion 3 Anterior Drawer Are RADIOGRAPHS indicated? • Ottawa rules • Allow the leg to hang •ANKLE X-rays freely with foot plantarflexed 25° • Posterior tenderness distal 6 cm of tibia or • Stabilize the tibia with 1 fibula hand and grasp the heel • Malleolar tip tenderness with the other. • Both immediate inability to WB and not able • Pull foot anteriorly, “Sulcus sign” anterior to fibula allowing it to rotate to walk more than 4 steps in ED internally (around the deltoid) as it translates. • Incompetent ATFL => Excessive anterior translation relative to other side * Acute laxity does not correlate with development of late symptoms = does not always require surgery Are RADIOGRAPHS indicated? MRI • Ottawa rules • Not required in the ACUTE setting •FOOT X-rays • Considered for the patient with chronic pain (>6 • Navicular tenderness weeks) after ankle sprain • 5th metatarsal base tenderness • Useful for assessing concomitant pathology • Both immediate inability to WB and not able • 90% accuracy for ATFL and CFL tears to walk more than 4 steps in ED • Does not give an absolute indication for surgery 4 Clinical Classification Grade I Grade II Grade III • Mild Sprain Edema, Localized, Localized, Diffuse, slight moderate significant • Able to walk without limp ecchymosis • Minimal swelling or point tenderness Full or Difficult Impossible partial without • Pain with reproduction of mechanism of injury Weight bearing without crutches significant • Moderate Sprain pain • Walking with a limp Ligament Ligament Partial tear Complete tear • Localized swelling with point tenderness pathology stretch (ATFL) (ATFL + CFL) • Unable to rise on toes or hop on injured ankle Instability testing None None or slight Definite • Severe Sprain (anterior drawer) • Prefers crutches and has difficulty bearing weight Time to return to 11 days 2-6 weeks 4-26 weeks sport • Diffuse tenderness and swelling • Mainstay of treatment is nonoperative Treatment – Acute Ankle Sprain management, even in the athletic population • P.R.I.C.E • Protection • Rest • Ice • Compression • Elevation • Progressive weightbearing as tolerated • Early range of motion • Physical Therapy – functional ankle rehabilitation 5 Treatment – Acute Ankle Sprain Treatment – Acute Ankle Sprain • Bracing • Bracing • Protection from inversion to prevent weaker type III • Semi-rigid ankle support: shorter time collagen elongation to return to work & sport, less • 3 weeks collagen starts to mature, controlled stress on the ligament promotes proper collagen symptomatic instability at short-term orientation follow-up Grade 3 • Functional Rehabilitation Grade 1 & 2 • Ankle motion, stretching and strengthening will avoid harmful effects of immobilization on muscle, joint cartilage, and bone • Full return to activities between 4-8 weeks The Ankle Sprain The Ankle Sprain • Functional Rehabilitation • Achieve full ROM • Peroneal tendon strengthening and • Grade I and II good to excellent proprioception • Gradual progression of weightbearing and return to play • Grade III a little more controversial • Supervised PT has better outcome with regard to strength and proprioception in the short term • Reinjury rates and long term functional results similar to home therapy plans 6 Acute Sprain Chronic Instability Operative Indications for Lateral Ankle Reconstruction • 10-20% risk after ankle sprain • Two types • Continued pain and instability despite extensive • Mechanical non-operative management • Abnormal clinical laxity • pathologic hypermobility of the tibiotalar joint • Must rule out and/or treat other pathology • Sign • Functional • Subjective instability • unreliable ankle, no demonstrable radiographic signs of instability • Symptom Surgical Management of Return to Play after Lateral Lateral Ankle Instability Ligament Reconstruction • Anatomic reconstruction • Outcomes of athletes after Brostrom • Modified Brostrom lateral ligament • 58% returned to preinjury level reconstruction • 16% competing at a lower level • Allograft lateral ligament reconstruction • 26% discontinued sport but still active • (Maffulli et al, AJSM 2013) 7 Rehab and Recovery after Clinically significant late Reconstruction pain after ankle sprain • Phase I – ROM • Clinically significant pain >6 weeks after injury • Phase II – Endurance without recurrent injury or instability • Phase III – Strength • Phase IV – Power • Consider pathology that may be in conjunction with an ankle sprain or consider a • Phase V – Return to Sport Testing and Physician different diagnosis Clearance • Achieve 90% of contralateral limb strength • Soft tissue lesions • Bone / articular lesions Soft Tissue Lesions Soft Tissue Lesions • Anterolateral soft tissue impingement • Peroneal tendon tear • Complaint: focal anterolateral pain, worse with • Complaint: focal lateral pain, worse dorsiflexion and cutting maneuvers with eversion • Exam: swelling, focal lateral • Exam: focal anterolateral ankle tenderness tenderness, pain with eversion • Treatment: steroid injection; arthroscopic debridement 8 Soft Tissue Lesions Soft Tissue Lesions • Peroneal tendon tear • Peroneal tendon subluxation • Treatment: NSAID/immobilization, lateral heel wedge, • Complaint: pain and snapping of tendons over fibula surgical debridement or repair if no response • Exam: swelling, focal ttp posterior to distal fibula, dislocation of tendons with resisted eversion Soft Tissue Lesions Soft Tissue Lesions • Peroneal tendon subluxation • Sinus tarsi syndrome • Treatment: fibular groove deepening and retinacular reconstruction • Complaint: pain and swelling lateral hindfoot, exacerbated on uneven surfaces • Exam: swelling, focal ttp anterior to distal fibula • Treatment: NSAID/immobilization, steroid injection, arthroscopic debridement 9 Syndesmotic Injury – High Soft Tissue Lesions Ankle Sprain • Syndesmotic injury • Collision sports, 10% of all ankle sprains • Complaint: pain in distal leg and ankle with • Mechanism: external rotation cutting/twisting • Direct force posterior calf of downed player with • Exam: external rotation stress test; squeeze test foot externally rotated • Xrays/MRI/US: • External rotation force on knee while foot firmly planted • Stress xrays: disruption or widening of syndesmosis Syndesmotic injury - Treatment Soft Tissue Lesions • Grade I and II: • Superficial peroneal neuropraxia • RICE, PT, ankle brace or – intermediate branch taping • Grade III: • Acute- ORIF • Complaint: anterolateral pain / burning / (screws/Tightrope) numbness • Chronic- arthroscopic • Exam: focal ttp, + tinels, decreased debridement + fixation sensation dorsolateral foot • Longer time to return to play • Treatment: neurontin / lidoderm patch / and more residual symptoms desensitization than simple ankle sprain • Neurolysis vs. transection 10 Bone / Articular Lesions Bone / Articular Lesions • Juxta-articular fractures • Juxta-articular fracture • Anterior