Ankle Pathology Flashcards
Inversion Ankle Sprain
Represent 85% of ankle sprains Sequence of lateral ligament tears 1. ATFL 2. CFL 3. PTFL Grading of a Sprain -Grade I-ATFL(partial) -Grade II-ATFL(complete) and CFL (partial) Grade III-all 3 ligaments involved
Recurrent Ankle Sprains
•Possibly due to:
–Healing of ligaments in lengthened position
–Weakness of healed ligaments due to scar tissue
–Fibular muscle weakness
–Distal tibiofibular instability
–Hereditary hypermobility
–Loss of ankle proprioception
–Impingement in talofibular joint
–Undiagnosed associated problems such as cuboid subluxation or subtalar instability
Syndesmotic Ankle Sprain
*Also known as “high ankle sprain”
*damage to syndemosis between distal tibia and fibula
Mechanisms of Injury: widening of ankle mortise
–Forceful external rotation of foot
–Forceful eversion of talus
–Forceful dorsiflexion as anterior aspect of talar dome enters joint space
Syndesmotic Ankle Sprain
•Maisonneuve fracture
–Spiral fracture of the proximal fibula associated with high ankle sprain
–Requires knee radiographs with any suspected syndesmotic injury
Otawa Ankle Rules
Very sensitive not very specific
Good Screen
Good thing to do
will capture the majority of people with it
DO NOT TELL THEM IT IS BROKEN! GO GET AN XRAY
- Malleolar Zone
- Mid-Foot Zone
A Posterior Edge or tip of lateral malleolus 6cm
B Posterior edge or tip of medial malleolus 6cm
C Base of 5th Metatarsal
D Navicular - A series of ankle x ray film is required only if there is any pain in malleolar zone and any of these findings:
Bone Tenderness at A
Bone Tenderness at B
Inability to bear weight both immediately and in emergency department
A series of ankle x ray films is required only if there is any pain in mid-foot zone and any of these findings
Bone Tenderness at C
Bone Tenderness at D
Inability to bear weight both immediately and in emergency department
Foot Ankle Fractures
Unimalleolar Fracture
• Unimalleolar fracture – Most common fracture of ankle – 85% occur without damage to medial aspect of ankle joint and do not cause abnormal displacement of talus – Often seen in conjunction with other fractures
Foot Ankle Fractures
Bimalleolar Fracture
• Bimalleolar fracture – Result from severe pronation/abduction/ER rotational force – Shears lateral malleoli and avulses medial malleolus
Foot Ankle Fractures
Trimalleolar Fracture
• Trimalleolar fracture – Involves both malleoli and distal posterior aspect of tibia (posterior malleolus) – Usually requires ORIF
Foot Ankle Fractures
Jones Fracture
5th metatarsal fractures
- fracture of proximal fifth metatarsal names “Jones Fracture”
- Most common is avulsion fracture of tuberosity due to traction of fibularis brevis
- Poor blood supply results in high risk for delayed or non-union
Foot Ankle Fractures
Talar Dome Fracture
Most commmon chondral fracture
also known as osteochondritis dessecans, transchondral fracture or flake fracture
-presents with swelling, with walking, locking of the ankle and crepitus
-may be described as “sprained ankle that did not heal well”
BIG FLAG–CHRONIC INSTABILITY!
Foot Ankle Fractures
Pilon Fracture
Result of axial compression force
Tibia driven inferiorly into talus resulting in fracture to distal end of tibia
High velocity fracture
—-fall from height
—–MVA
—–Skiiing
Results in long-term morbidity in most cases
Foot/ Ankle Fractures
Major talar head neck or body fracture
Associated with high-energy mechanisms
50% involve talar neck
Usually involves axial load with foot in PF or excessive DF resulting in compression of talar head against anterior aspect of tibia
Foot/Ankle Stress Fractures
•Stress Fractures
–Involves a break developing after cyclical, submaximal loading
–Extrinsic factors include running on hard surfaces, improper running shoes, or sudden increase in training frequency/intensity
–Second and third metatarsals are most frequently stress fractured
Medial Tibial Stress Syndrome (MTSS)
*Shin Splints
•Also known as the non-descriptive generic term, “shin splints”
•Characterized by exercise-induced anterior and medial leg pain
•Involves periosteal irritation indicated by a diffuse linear uptake on a bone scan along length of tibia, localized to the fascial insertion of the medial soleus
•May be caused by overuse, weakness of TA, EDL, or EDB, excessive pronation, restricted DF, increasing training volume/intensity too quickly, or inadequate footwear
**not a stress fracture
pre-stress fracture
Tendinopathies
Tibialis Posterior
common in individuals with overpronation and who play running sports involving rapid directional changes
Tendinopathies
Tibialis Anterior
common in runners who participate in up or down hill training
Tendinopathies
Flexor Hallucis Longus
often confused with tibialis posterior tenosynovitis
common in pointe dancers and those who repeatedly push off of PF foot
Tendinopathies
Achilles
accounts for 5-15% of running injuries
Sever Disease (Calcaneal Apophysitis)
●Traction apophysitis at insertion of Achilles tendon
●Common cause of heel pain in athletically active children (tendon stronger than bone)
●61% of cases occur bilaterally
●Average age of onset is 8-13 y/o
●Etiologic factors: beginning new sport or season, foot pronation, tight gastroc/soleus complex; obesity
●Common in young gymnasts and dancers because due to repetitive jumping/landing from height
Iselin’s Disease
- Traction apophysitis of tuberosity of 5th metatarsal
- More commonly seen in athletically active older children and adolescents
- Patient usually involved in sports involving running, cutting, and jumping that may result in an inversion stress to the tuberosity
- Resisted eversion typically reproduces pain
Plantar Heel Pain…Plantar Fasciittis
1.Pain arising from insertion of plantar fascia, with or without a heel spur, commonly referred to as “plantar fisciitis”
2. Usually a chronic inflammatory process
3. Etiologic Factors
obesity
occupations involving prolonged standing or walking
acute injury such as stepping on a pebble or other hard object
decreased elasticity of heel pad
pes cavus or pes planus
Calf Stretches best treatment here
Haglund’s Deformity
●Abnormal prominence of the posterior superior lateral border of calcaneus
●Can be a spur or osteophyte acquired as a result of poorly fitting shoes in adolescent females, ice skaters, soccer players, and runners
●May be congenital
●Aggravates retrocalcaneal bursa and results in bursitis or Achilles tendinopathy
Mortin’s toe
2nd toe bigger than the 1st toe…extremes can cause pain in the metatarsal region…need foot doctor
Interdigital Neuroma—Morton’s Neuroma
most Common 3-4th metatarsals
●Not a true neuroma but rather a thickening of tissues around the nerve due to perineural fibrosis, fibrinoid degeneration, and endoneural fibrosis
●More common in females
●Caused by chronic compression of interdigital nerve or acute dorsiflexion injury to toes
●Symptoms aggravated with weight-bearing
●Shoes that are too narrow and compress foot are often a causative factor
Impingement
Anterior Ankle Impingement
○Can be bony or soft tissue related
○Presents as pain exacerbated by extreme dorsiflexion
○May be secondary to generalized synovitis or capsulitis developing after recurrent inversion ankle sprain or with repeated dorsiflexion activities
○Chronic impingement may be due to thickened and scarred joint capsule due to recurrent ankle sprains
Posterior Ankle Sprains
seen more in dacers
○Seen in sports requiring excessive PF that compresses posterior ankle structures
○May be associated with bony etiology, e.g. os trigonum
OS Trigonum
- accessory bone that develops posterior to talus
- present in 10% of population
- can cause impingement between posterior tibia and calcaneus with plantarfelxion
Compartment Syndrome
- Sudden or gradual increase in compartmental pressure
- May require emergency fasciotomy in cases of fractures/burns
- May require electice surgery in exertional cases (eg, runner’s)
Hallux Rigidus
•Decreased dorsiflexion of the first MTP joint with pain and swelling in posterior aspect of joint
•Adolescent Hallus Rigidus
–Consistent with an osteochondritis dissecans or localized articular disorder
•Adult Hallus Rigidus
–Due to generalized degenerative arthritis
Tarsal Tunnel Syndrome
•Tibial nerve entrapment in tunnel between flexor retinaculum and medial malleolus
•May be acute or insidious onset
•Internal factors:
–Accessory FDL muscle or other anatomical variations
•External factors:
–Excessive pronation which can tighten flexor retinaculum
Sinus Tarsi Syndrome
●Subtalar joint sprain with injury to the talocalcaneal interosseous ligament
●Mechanism of injury involves inversion sprain in PF position that injures both talocrural and subtalar joints
●Symptoms include feeling of hindfoot instability with walking on uneven ground
●Observation reveals swelling in sinus tarsi
●Painful with palpation and pronation
Cuboid Syndrome
- common but rarely diagnosed syndrome in which cuboid subluxes
- Generally result of overuse, increaseing body weight, training on uneven surfaces, or lateral ankle/foot sprain
- Presents with gradual onset of lateral midfoot pain localized near fourth and fifth metatarsals at posterior aspect of cuboid or calcaneocuboid joint
- Pain is reproduced in terminal stance at onset of heel rise
