ACMS Team Physician CourseSan AntonioFeb 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, prac;ce, 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 coali;on – 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 plas;c 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 X/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 • Func;on and alignment changes with mo;on 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 (“essen;al lesion”) • CFL injured as ankle DF during con;nued 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 sensi;ve 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 • Onawa Rules • Inability to bear weight AP, lateral, MorUse • 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 IndicaUons • 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 – Ini;al 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 func;onal 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 • FuncUonal RehabilitaUon – Neuromuscular and sport/task training DeMaio, Orthopedics 1992 15:87-96 and 241-248 FuncUonal RehabilitaUon • AXer LAS paents exhibit deficits in – Joint posi;on sense – Isometric strength in mul;ple planes of mo;on – Postural control on the involved and uninvolved limb • Posi;ve 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 FuncUonal Rehab: CoMponents • Early Joint mobilizaon • Strengthening • Sensorimotor/balance – Wobble board – Trampoline • Single/double leg Postural control • Connue external support • Propriocep;ve feedback • Con;nued protec;on of ligaments Meta-Analyses/Level 1 Evidence • FuncUonal Rehab > prolonged iMMobiliZaUon – Faster return to sport, work – Fewer long term symptoms – Bener ROM • SeMi-rigid external support beXer than cast & Ace – S;rrup ≥ Lace up brace > tape > Elas;c 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 • AXer 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 effec;ve – Braces cost less per season • Much more effec;ve on athlete with h/o prior ankle sprain “Marshall” AlgorithM • Brace: S;rrup/ Lace up /Combo • Boot in G3 – To brace in few days • TED hose • WBAT with crutches if limping – NWB A/PROM • Func;onal Rehab Return to Play • Subjec;ve symptoms – Foot and Ankle Ability Measure (FAAM) • Func;onal tests – Star Excursion Balance • Simplfied to Y – Single leg balance – Single leg heel to toe raises • 60/minute Ankle Sprains: TreatMent • Func;onal rehab bener than immobilizaon – Start with DF, eversion – Ac;ve resistance: isometric first • Peroneals • Dorsiflexors • Evertors • Role for acute surgical interven;on in selected cases? Ankle Sprains: TreatMent • Pinjenburg, et al. 2002 – RPT Level II – Acute repair vs. func;onal rehab – 317 paents, 8 yr follow up – Surgery group fared bener • Pain (16% vs. 25%) • Subjec;ve giving way (20% vs. 32%) • Recurrent sprains (22% vs. 34%) • Func;onal scores “operaBve treatment for lateral ligament ruptures can be adopted in cases when higher funcBonal demands…such as sports at a compeBBve 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. func;onal 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 ShiN? • Early surgery for Acute ankle sprain? • Similar to 1st ;me shoulder dislocaons? • Poten;al problems – Increased complicaons – Higher costs – Availability of OR • Secondary reconstruc;on of G3 injuries is possible even years out, outcomes similar to those of acute repairà More data needed Chronic Lateral Ankle Instability • ~10-25% • Func;onal 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 • Propriocep;on 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 – Mul;ple sprains – Connued subacute or chronic pain following sprain • Pain signifies other pathology as well – Peroneal tendons – OCD or OA – Anterolateral guner impingement Chronic Lateral Ankle Instability: Physical Exam • More subtle findings than acute • Ligament laxity more easily noted – Less swelling – Less pain inhibi;on • Careful palpaon • Examine hindfoot alignment – Look for cavus – Peek-a-boo heel Chronic Lateral Ankle Instability: Imaging • Stress x-rays – Ques;onable value without Telos machine – Pain inhibi;on – 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