Ankle Pathology

Question 1

Inversion Ankle Sprain

Answer 1

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

Question 2

Recurrent Ankle Sprains

Answer 2

•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

Question 3

Syndesmotic Ankle Sprain

Answer 3

*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

Question 4

Syndesmotic Ankle Sprain

Answer 4

•Maisonneuve fracture
–Spiral fracture of the proximal fibula associated with high ankle sprain
–Requires knee radiographs with any suspected syndesmotic injury

Question 5

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

Answer 5

1. Malleolar Zone
2. 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
3. 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

Question 6

Foot Ankle Fractures

Unimalleolar Fracture

Answer 6

• 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

Question 7

Foot Ankle Fractures

Bimalleolar Fracture

Answer 7

• Bimalleolar fracture
– Result from severe
pronation/abduction/ER
rotational force
– Shears lateral malleoli and
avulses medial malleolus

Question 8

Foot Ankle Fractures

Trimalleolar Fracture

Answer 8

• Trimalleolar fracture
– Involves both malleoli and
distal posterior aspect of
tibia (posterior malleolus)
– Usually requires ORIF

Question 9

Foot Ankle Fractures

Jones Fracture

Answer 9

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

Question 10

Foot Ankle Fractures

Talar Dome Fracture

Answer 10

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!

Question 11

Foot Ankle Fractures

Pilon Fracture

Answer 11

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

Question 12

Foot/ Ankle Fractures

Major talar head neck or body fracture

Answer 12

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

Question 13

Foot/Ankle Stress Fractures

Answer 13

•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

Question 14

Medial Tibial Stress Syndrome (MTSS)

*Shin Splints

Answer 14

•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

Question 15

Tendinopathies

Tibialis Posterior

Answer 15

common in individuals with overpronation and who play running sports involving rapid directional changes

Question 16

Tendinopathies

Tibialis Anterior

Answer 16

common in runners who participate in up or down hill training

Question 17

Tendinopathies

Flexor Hallucis Longus

Answer 17

often confused with tibialis posterior tenosynovitis

common in pointe dancers and those who repeatedly push off of PF foot

Question 18

Tendinopathies

Achilles

Answer 18

accounts for 5-15% of running injuries

Question 19

Sever Disease (Calcaneal Apophysitis)

Answer 19

●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

Question 20

Iselin’s Disease

Answer 20

• 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

Question 21

Plantar Heel Pain…Plantar Fasciittis

Answer 21

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

Question 22

Haglund’s Deformity

Answer 22

●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

Question 23

Mortin’s toe

Answer 23

2nd toe bigger than the 1st toe…extremes can cause pain in the metatarsal region…need foot doctor

Question 24

Interdigital Neuroma—Morton’s Neuroma

most Common 3-4th metatarsals

Answer 24

●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

Question 25

Impingement

Anterior Ankle Impingement

Answer 25

○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

Question 26

Posterior Ankle Sprains

seen more in dacers

Answer 26

○Seen in sports requiring excessive PF that compresses posterior ankle structures
○May be associated with bony etiology, e.g. os trigonum

Question 27

OS Trigonum

Answer 27

• accessory bone that develops posterior to talus
• present in 10% of population
• can cause impingement between posterior tibia and calcaneus with plantarfelxion

Question 28

Compartment Syndrome

Answer 28

1. Sudden or gradual increase in compartmental pressure
2. May require emergency fasciotomy in cases of fractures/burns
3. May require electice surgery in exertional cases (eg, runner’s)

Question 29

Hallux Rigidus

Answer 29

•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

Question 30

Tarsal Tunnel Syndrome

Answer 30

•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

Question 31

Sinus Tarsi Syndrome

Answer 31

●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

Question 32

Cuboid Syndrome

Answer 32

1. common but rarely diagnosed syndrome in which cuboid subluxes
2. Generally result of overuse, increaseing body weight, training on uneven surfaces, or lateral ankle/foot sprain
3. Presents with gradual onset of lateral midfoot pain localized near fourth and fifth metatarsals at posterior aspect of cuboid or calcaneocuboid joint
4. Pain is reproduced in terminal stance at onset of heel rise