ankle sprain imitators leslie a. michaud, m.d. steadman hawkins clinic of the carolinas primary care...
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Ankle Sprain Imitators
Leslie A. Michaud, M.D.Steadman Hawkins Clinic of the CarolinasPrimary Care Sports Medicine Fellow
Foot and ankle Statistics• 1982: NCAA develops the ISS (injury
surveillance system)• 2007 - 16 years of ISS data showed that ankle
sprains are the most common injury 14.9% of all injuries▫Compare to ACL 2.6%▫Concussion 5%
• 39.7% of high school injuries are foot and ankle
• 2004 - Olympic summer games Athens – 22% of injuries were ankle sprains
• 2002 - Olympic winter games Salt Lake City – 25% foot and ankle
• Collegiate basketball - higher rate of grade I ankle sprains in women than men
Tibia
Fibula
TalusLateral Malleolus
Medial Malleolus
Subtalar joint
Tibial Plafond
http://www.emedx.com/emedx/diagnosis_information/diagnosis_information_image_files/foot_ankle_images/ankle-xray-normal-2.jpg
Resists posterior displacement
Provides stabilization in plantarflexion
Stabilizes ankle and subtalar joint; especially during inversion
Evaluation of Foot and Ankle Injuries
• Identify and localize the injured bony and soft-tissue structures
• Determine MOI▫Clues regarding location and severity of injury▫Clues to potential concomitant injuries that
may be overlooked• More extensive evaluation in severe sprains
▫Arouse suspicion of fx or articular injury• 1% of ankle sprains are syndesmotic - more
common with eversion• Persistent symptoms 4-6 weeks despite
appropriate treatment
Imitators
•Osteochondral lesions of the talar dome
•Lateral process talar fractures
•Peroneal tendon subluxation and
dislocation
•Base of the 5th metatarsal (avulsion)
•Tarsal coalition
Osteochondral Lesions of the Talar Dome
• Injury to the cartilage and underlying bone
of the talus
•History of trauma in 98% of lateral dome
lesions
▫70% of medial dome lesions
•Trauma is often an inversion-type injury
• Initial radiographs often unremarkable
▫Seen best on mortise view
Osteochondral Lesion Presentation
•Persistent pain and swelling well after
injury
•Occasionally will have a slow onset
•+/- mechanical symptoms
▫Intraarticular process
Why do we need to catch an osteochondral lesion early?
• The fracture damages vascular supply to the
subchondral bone
• If treated early, capillaries can restore bloodflow
• If not, prolonged weight-bearing causes fibrous
tissue to accumulate which will block capillary
ingrowth
▫Leading to AVN and later DJD
Diagnosis and Treatment
•CT or MRI if radiographs negative and suspicion is high
•Conservative▫Rest and immobilization
•Surgical▫Drilling▫Debridement▫Excision of fragment▫Osteochondral graft
Lateral Talar Process Fractures
• “Snowboarder’s fracture”
• Often subtle presentation plain films
• Clinically resemble an inversion ankle sprain
• Tenderness 1 cm from the tip of the lateral malleolus at the lateral talus
Lateral Talar Process Fracture Facts
•24% of talar fractures are at the lateral
process
▫<1% of all ankle injuries are LTP fx
•15% are misdiagnosed as ankle sprains
▫Exam findings: “tenderness 1 cm inferior to
tip of lateral malleolus” mimic ATFL
• MOI: dorsiflexion + inversion + ER force
•More of an impact or crush injury
•Comminution
•More often than not have IA involvement
Evaluation and Treatment
•CT in all cases to determine intraarticular involvement and level of comminution
•Conservative▫Only for non-displaced▫SLNWB cast for 4 weeks▫Advance WB in boot for 2 additional weeks
•Operative▫Excision (fragments <1cm)▫ORIF (fragments >1cm)
Peroneal Tendon Instability
• Subluxation or dislocation
• Can be associated with chronic lateral ankle instability
▫ Functional
▫ Mechanical
▫ Previous injury
• Concern for degenerative tears of the peroneus brevis
tendon
• Persistent pain after Grade III sprains is commonly due
to incomplete rehab with too early RTP
▫ Peroneal strengthening
Superficial Peroneal Nerve
•Supplies lateral compartment muscles
•High incidence of neuropraxia
▫Grade II and III sprains
•Almost all resolve spontaneously with
time
History and Physical Exam
• Previous inversion injury
• Specific activities i.e. dancers
• Swelling and possibly ecchymosis (acute)
posterior to lateral malleolus
• Stress test
▫Resist dorsiflexion from the plantarflexed
position while the foot is in inversion
• Varus hindfoot
Treatment
• Conservative▫Acute injuries
Reduce tendon and SLWB cast for 6 weeks 50% success rate
▫Chronic PT
• Surgical▫Reattachment▫Deepen groove▫Reroute tendon▫Reconstruct retinaculum▫Bone block
Tarsal Coalition
•Congenital fusion of tarsal bones
▫Calcaneus to navicular most common
8-12 years old
▫Talus to calcaneus
12-15 years old
•Rigid flatfoot
•“Peroneal spastic flatfoot”
History and Physical Exam•Lateral ankle pain•Worse with activity•May radiate to calf•Inspect feet
▫Flat▫Hindfoot valgus▫No arch with toe raise
•Limited subtalar motion•Tight heel cords
Evaluation and Treatment•CT or MRI
▫Looking for other coalitions▫Determine size
•Conservative▫If asymptomatic – observation▫Symptomatic – orthotics or casting
•Surgical▫Resect coalition and interpose with fat
graft or EDB tendon▫Arthrodesis – not often used
Questions?
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the literature. Magn Reson Imaging Clin N Am 2003;11(2):311-321.6. Hosea TM, Carey CC, Harrer MF: The gender issue: Epidemiology of ankle injuries in
athletes who participate in basketball. Clin Orthop Relat Res 2000;372:45-497. Anderson RB, Hunt KJ, McCormick JJ. J Am Acad Orthop Surg 2010;18:546-5568. McCrory P, Bladin C: Fractures of the lateral process of the talus: A clinical review.
“Snowboarder’s ankle”. Clin J Sport Med 1996;6:124-128.9. Boon AJ, Smith J, Zobitz ME, Amrami KM: Snowboarder’s talus fracture: Mechanism of
injury. Am J Sports Med 2001;29:333-338.10. Weatherby, Brian. “Start Smart: What Every Practitioner Should Know About Treating
Foot and Ankle Pain.” Powerpoint presentation.11. DeLee and Drez's Orthopaedic Sports Medicine, 3rd ed. Copyright ©
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