Foot and Ankle Injuries

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Foot and Ankle Injuries

• Howard J. McGowan, Maj, USAF, MC
• Sports Medicine Fellow
• USU Primary Care Sports Medicine Fellowship

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Objectives

• Review anatomy of Foot and Ankle
• Discuss key history
• Hands on exam
• Discuss cases concerning common injuries of the
  Foot and Ankle

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Anatomy
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Anatomy
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Anatomy
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Anatomy
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Anatomy
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Anatomy
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Anatomy
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Anatomy
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History

• Onset
• Duration
• Activity/Mechanism
• Swelling / Ecchymosis
• Ambulation
• Sound
• Hx of previous injury

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Exam
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(No Transcript)
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Cases
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Case 1

• 25 yo male with foot pain
• Stepped in a hole on a road march
• Pain and swelling in midfoot dorsally
• Unable to bear weight

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Case 1

• Refuses to bear weight
• Mid foot grossly swollen and eccymotic
• Tender to palpation along tarsometatarsal joints
  medially and laterally
• Pain exacerbated by forefoot abduction and
  pronation
• Neurovascularly intact

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Case 1
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Case 1Lisfranc Injury

• Lisfranc injury
• 1 of orthopedic trauma
• 20 missed on initial presentation

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Case 1Lisfranc Injury

• Lisfranc joint
• Stable axis of rotation
• Keystone for plantar and dorsiflexion
• Horizontal axis through second MT
• Plantar flexion with an axial load provides
  stress to dorsally displace 2nd MT base

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Case 2

• 32 yo female playing club rugby jammed her big
  toe
• Was able to continue playing, but had pain
  exacerbated with push-off
• Now with increased pain with ambulation

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Case 2

• Antalgic gait
• Walks on lateral aspect of her foot
• Swelling around 1st MTP joint
• Tender plantar aspect of 1st MTP joint
• Pain exacerbated with dorsiflexion of great toe

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Case 2Turf Toe

• Turf toe
• Forced hyperextension
• Grades
• Iminor swelling/eccymosis
• IIpartial tear of capsule
• IIIcomplete tear of capsule

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Case 2Turf Toe

• Ranked third in collegiate athletes after knee
  and ankle injuries
• Forced hyperextension
• Sometimes with varus or valgus stresses
• Also with forced flexion

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Case 3

• 21 yo female volleyball player presents with
  lateral ankle pain after landing on teammates
  foot
• Ankle inverted

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Case 3
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Case 3
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Case 3

• How good are the Ottawa Rules?
• When originally published
• 100 sensitivity 40 specificity for detecting
  malleolar fractures
• Subsequent studies
• Lower sensitivity (93 to 95) and specificity
  (6 to 11) than originally thought
• Not perfect, but still a good tool

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Case 3Lateral Ankle Sprain

• Estimated 1 million present to physicians with
  acute ankle injuries each year
• Sprains account for 25 of all sports-related
  injuries and 75 of all ankle injuries
• Lateral ankle ligaments are the most commonly
  injured structures in young athletes
• More than 40 of ankle sprains have potential to
  cause chronic problems

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Case 3Lateral Ankle Sprain

• Presentation/Diagnosis
• Lateral Pain
• Weight Bearing
• /- Swelling
• /- Ecchymosis
• Point tender over ATFL, CFL, PTFL
• ? talar tilt, anterior drawer

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Case 3
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Case 4

• Pt is an 18 y/o football player who presents with
  an ankle sprain.
• Pt has considerable swelling and demonstrates
  more tenderness proximal to the ATFL.

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Case 4

• Patient unable to bear weight
• Tender along deltoid ligament
• Positive squeeze test
• Positive external rotation test

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Case 4
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Case 4Syndesmotic Injury

• Forced external rotation of the foot
• Internal rotation of the tibia on a planted foot.
• Common in soccer, skiing, motocross and football

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Case 4
Maisonneuve
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Case 4
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Case 5

• USU secretary slipped on ice
• Inverted ankle
• Unable to bear weight
• Tender at base of 5th MT

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Case 5
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Case 55TH Metatarsal Frx

• The most commonly fractured metatarsal
• These fractures may result from direct or
  indirect trauma.
• Proximal fifth metatarsal fractures have been the
  subject of considerable debate and controversy.

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Case 55TH Metatarsal Frx

• The proximal fifth metatarsal consists of the
  tuberosity, base, and proximal shaft.
• Tuberosity is the site of attachment of the
  peroneus brevis and lateral band of the plantar
  fascia.
• The metaphyseal-diaphyseal junction is a vascular
  watershed
• The metaphyseal-diaphyseal junction includes the
  joint between the base of the 4th and 5th
  metatarsals.

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Case 6

• 22 yo female sprinter experiences pain when
  coming out of blocks
• Able to bear weight, but painful
• Ottawa negative
• Initial x-rays were negative

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Case 6

• Vague, aching pain
• Dorsal foot, radiating along medial arch
• Increase with activity and progress to
  post-activity

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Case 6

• Normal ROM
• Normal strength
• Usually no swelling or ecchymosis
• Localized pain with inverting-everting forefoot
• Tender over dorsal navicular area
• Pain with hopping, standing on toes

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Case 6

• Navicular Stress Fracture
• 0.7-2.4 of all stress fractures (1980)
• More recent reports 14-35
• Track athletes at elite level 59

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Case 7

• 45 yo male playing recreational basketball
• Landed, gunshot calf
• Minimal pain, but unable to bear weight or point
  toes

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Case 7

• calf pain
• Antalgic gait
• Difficulty with tiptoe walk
• Visible and a palpable defect superior to
  calcaneus
• Positive Thompson test

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Case 7Achilles Rupture

• Poorly conditioned 30-45 yo males (weekend
  warriors)
• 1 per 1000 athlete-years
• History of tendinitis/degenerative changes
• Steroids?
• Fluoroquinolones?

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Conclusion

• Review anatomy of Foot and Ankle
• Discuss key history
• Hands on exam
• Discuss cases concerning common injuries of the
  Foot and Ankle

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• QUESTIONS