Lecture 6 Flashcards
Heel pain differential (posterior or plantar os calcis)
- Achilles insertional tendinopathy
- Retrocalcaneal bursitis
- Haglund’s Syndrome
- Os trigonum syndrome
- FHL tendinopathy or tenosyvitis
Achilles insertional tendinopathy often accompanied by
- Calcification (spur) at tendon attachment
Haglund’s Syndrome
- Enlarged posterior superior margin of calcaneus
- Can impinge upon retrocalcaneal bursa and Achilles tendon
Os trigonum syndrome
- Presence of os trigonum usually not painful
- Usually triggered by an ankle injury
- Repeated plantarflexion causes ossicle to become impinged
- Posterior ankle impingement
- The connective tissue connection between the ossicle and talus is damaged
FHL tendinopathy or tenosynovitis
- Not common
- Seen in dancers
Other possible heel pain diagnoses
- Plantar fasciitis (inferior heel)
- Calcaneal stress fracture
- Calcaneus fracture
- Tarsal tunnel syndrome
- Other arthropathies
- Infection
Calcaneal apophysitis (Sever’s Disease)
- Overuse/overload injury to the posterior apophysis (posterior growth plate)
- Xrays can rule out other conditions
- Secondary center is usually fragmented (not always)
- Diagnosis is clinical
- Treated conservatively
Calcaneal apophysitis (Sever’s Disease) causes
- Achilles tendon (traction apophysitis)
- Mechanical compression
Calcaneal apophysis ossification
- Secondary center appears mostly btwn ages 6-9 (almost always appears by age 11)
- Fuses btwn 12-18 (most fused by 15)
Calcaneal apophysitis (Sever’s Disease) symptoms
- Pain localized to posterior/plantar heel
- Elicited during weightbearing
Calcaneal apophysitis (Sever’s Disease) most commonly seen in
- Children and adolescents during growth
- Especially ages 9-13 who are active in sports
- Boys > girls
- Both heels commonly affected
Haglund’s deformity (pump bump, Mulholland deformity)
- Bony enlargement of the back of the heel (posterior superior calcaneus)
- Soft tissue surrounding (Achilles, bursa) can become irritated leading to Haglund’s syndrome
Haglund’s Syndrome symptoms
- Retrocalcaneal pain
- Abnormal protuberance of the posterosuperior border
- Retrocalcaneal bursitis and swelling
- Achilles tendinosis
- Pumps or shoes with rigid shoe backs aggravate the enlargement (shoes with a hard back)
Haglund’s Syndrome clinical appearance
- Can be difficult to distinguish Haglund’s syndrome from other causes of hindfoot pain
- Prominent calcaneal posterosuperior protuberance
- Usually on the lateral side
- Swelling and inflammation
Haglund’s Syndrome predisposing factors
- Wearing tight, stiff shoes
- Pes cavus
- Forefoot varus
- Tight Achilles
- Walking on lateral side of foot
Haglund’s Syndrome usually affects
- Middle-aged individuals
- F > M
- Often bilateral
Conservative treatment of Haglund’s Syndrome
- Shoe modification
- Orthotics: heel pads and lifts
- PT: Achilles stretching, anti-inflammatories, ice
- Local injections (bursa)
Surgical treatment of Haglund’s Syndrome
- Removal of bony enlargement (calcaneal osteotomy)
AP view x-ray
- Foot positioned in dorsiflexion
- Toes toward ceiling
Mortise view x-ray
- AP with foot internally rotated ~ 15-20ᵒ
- Brings malleoli parallel to each other
- Allow visualization of mortise (tibial plafond, malleoli, talar dome, clear space)
- Allows assessment of distal tib/fib syndesmosis
Lateral view x-ray
- Calcaneus/talus profile
Tibiofibular overlap
- Overlap of fibula and anterior tubercle of tibia (anterior aspect of fibular notch of tibia)
- Overlap should be at least ≥ 6mm on AP, ≥ 1mm on mortise view
Tibiofibular clear space
- Distance between medial border of fibula and lateral border of posterior tubercle (posterior aspect of fibular notch of tibia)
- <6mm on both AP and Mortise view
Medial clear space
- Between lateral border of medial malleolus and medial border of talus
<4mm on AP - Should be equal to superior clear space on mortise view
Stress x-rays
- Positioned for mortise view and then the foot is stressed into external rotation
Conservative treatment of ankle sprain
- Pressure, rest, ice, compression, stabilization
- Non-weight-bearing immobilization
- Progressed to functional brace and physiotherapy
Syndesmotic ankle sprains
- Less common than lateral ankle sprains (1-18% of all ankle sprains)
- Athletic population incidence increases up to 12-32%
- More difficult to diagnose and usually require longer recovery periods vs. lateral ankle sprain
Uncorrected unstable injuries can lead to
- Chronic instability
- Degenerative OA
Common causes of syndesmotic ankle sprains
- External rotation of a planted foot (rotation of talus widens ankle mortise)
- Pivoting internally on an externally rotated foot
- Valgus load to the leg with planted foot
- Lateral blow to ankle in external rotation
Foot position (pronation vs supination) and deforming force (abduction,adduction, internal or external) rotation can influence other tissues that are damaged
- Deltoid ligament (syndesmosis injury + deltoid rupture usually causes instability)
- Malleoli and fibular fractures
- Very common to have frxs and other ligamentous injuries, need all 3 x-ray views
- Advanced imaging can be very helpful
Usually the 1st ligament to tear
- Anterior inferior tibiofibular ligament
Maisonneuve fracture
- Combination of proximal 1/3 of fibula and unstable ankle injury (widening of ankle mortise)
- Usually involves ligament injuries and/or frx
Ligament injuries and fractures often associated with Maisonneuve fracture
- Distal tib/fib syndesmosis
- Deltoid ligament
- Medial malleolus frx
Ankle stability depends on
- Congruency of bone: ankle mortise
- Joints and ligaments
- Joint capsule
Deltoid ligament resists
- Eversion, lateral translation, and external rotation of talus
Distal tib/fib syndesmosis
prevents
- Separation of tibia and fibula
- Talar wedging
Interosseous border of tibia (lateral border) ends as
- The fibular notch
Anterior tubercle of tibia (Chaput’s tubercle)
- Large tubercle that projects laterally
- Overlaps the fibula (supramalleolar shaft)
- Posterior tubercle of tibia (Volkmann’s tubercle) is smaller
Anterior inferior tibiofibular ligament
- Multiple bands that form a trapezoidal shaped ligament
Anterior inferior tibiofibular ligament attachments
- Medially to Chaput’s tubercle on distal anterolateral tibia (anterior fibular notch of tibia)
- Courses distolaterally to anterior border of fibula/lateral malleolus (Wagstaffe’s tubercle)
- Distal fascicle is known as Bassett ligament
Posterior inferior tibiofibular ligament attachments
- Trapezoidal shaped
- Distolateral margin of posterior fibular notch on tibia (Volkmann tubercle) and posterior malleolus of tibia
- Courses distolaterally to attach to posterior lateral malleolus
Chaput’s, Wagstaffe’s, and Volkmann’s tubercles
- Can be sites of avulsion fractures
Fibular notch is also known as
- Incisura fibularis tibiae (fibular incisure of tibia)
Inferior transverse tibiofibular ligament
- Deep inferior fibers of PIFL
- Deepens posterior ankle mortise
Inferior transverse tibiofibular ligament attachments
- Posterior inferior fibular notch
- Superior aspect of fibular fossa
Interosseous tibiofibular ligament
- Lower margin of interosseous membrane
- Spring-like function allows slight separation during dorsiflexion
Interosseous membrane and deltoid ligament
- Also support the syndesmotic joint
Synovial recess
- Extends from from tibiotalar to interosseous ligament
Synovial lined plica
- Extends proximally from tibiotalar joint into distal tib/fib joint
Synovial recess and fold (fringe)
- Interposed between tibia and fibula
- Contains adipose and fibrous tissue, nerves, vessels
Synovial recess and fold (fringe) movements
- Retracts between tib/fib during dorsiflexion
- Descends during plantarflexion
Synovial recess and fold (fringe) function
- Believed to aid in synovial fluid distribution and protection of dital tib/fib edges
- Possible source of pain in ankle impingement
