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.