gerald weniger, med, mpas, atc, pa-c · morton’s neuroma • narrow toe box • 2nd& 3rdweb...
TRANSCRIPT
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Gerald Weniger, MEd, MPAS, ATC, PA-C
Director, Physician Assistant ProgramAssociate Professor, Health Professions Department
James Madison University
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WHY DO WE CARE?• foot and ankle susceptible to both acute injury
and overuse syndromes
• foot/ankle dysfunction = disability, altered gait
• ~25% of all sports injuries occur at the foot/ankle
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• medially (big, thick, strong)• deltoid ligament
• laterally – three distinct ligaments (puny, weak)• anterior talofibular ligament (ATF)• posterior talofibular ligament (PTF)• calcaneofibular ligament (CF)
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• ankle “mortise”• anterior tibiofibular ligament
• posterior tibiofibular ligament
• interosseous membrane
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• Ankle• dorsiflexion & plantarflexion• inversion & eversion
• Foot• internal (medial) rotation• external (lateral) rotation
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• entrapment/compression of interdigital nerve
• 2nd and 3rd web spaces most common• causes: running, ballet, high heels, narrow toe box shoes
• burning, stinging pain
• incidence: females > males
• worse with WB• numbness/tingling into toes
• history
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• exam• specific tenderness on area between metatarsals
• imaging• X-rays are no help• ultrasound/MRI show most, not all• surgical visualization
• metatarsal compression test
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• conservative treatment• wide shoes, no heels• metatarsal pads• corticosteroid injections
• surgical treatment• neuroma excision
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• tarsometatarsal (Lisfranc) joint complex• injuries here are not common, but frequently missed• legal liability
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• tarsometatarsal (Lisfranc) joint complex• dorsal ligament is most important
Images from UpToDate © 2019
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• tarsometatarsal (Lisfranc) joint complex• mechanism of injury: trauma
• MVCs• falls• athletics
Images from UpToDate © 2019
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• tarsometatarsal (Lisfranc) joint complex• terminology can be confusing:• Lisfranc fracture• Lisfranc dislocation• Lisfranc “injury”
Images from UpToDate © 2019
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• History• MOI (mechanism of injury)• pain & swelling at TMT joint• worse w/ weight bearing (often cannot walk)
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• Exam• point tenderness at TMT joint• swelling & ecchymosis• ↓ ROM• ↓ strength
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• Imaging• X-rays: three views (AP, lateral, oblique)• often misread as “normal”• findings can be quite subtle
On AP View: medial borders of 2nd MT and middle cuneiform
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• Imaging• X-rays: three views (AP, lateral, oblique)• often misread as “normal”• findings can be quite subtle
On Oblique View: medial borders of 4th MT and cuboid
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• Imaging• 50% of athletes with midfoot injuries have normal
non-weight bearing radiographs• Order weight bearing X-rays on single cassette
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• Imaging• But wait!!
• Multiple studies demonstrate: even properly performed weight-bearing radiographs have limited specificity and sensitivity for detecting TMT injuries
• Order a CT or MRI
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• Imaging• Example of a CT
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• Classification system?
• Acute Treatment• immobilize (splint or CAM walker)• non-weight bearing: crutches• referral to Orthopedics
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• Long-term Treatmenta) non-operative: immobilize 6-10 weeks, then physical therapyb) operative: open reduction, internal fixation (ORIF)
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• at risk with running, jumping, and sudden acceleration or deceleration
• Incidence• General population: 0.01%
(80% of these are during recreational sports)
• Competitive athletes: 8.3%• sprinters: 18%• decathletes & soccer: 17%• T&F jumpers: 12%• basketball: 12%
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• ↑ recreational sport participation = ↑ rate of tendon ruptures
• peak age: 30 to 40 years (male & female)• this might be when degenerative changes & high
stress from sports coincide
• rupture 4-5x more common in men
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• glucocorticoids• oral systemic steroids and/or local steroid injections
increase risk of rupture
• fluoroquinolones• incidence of rupture is rare: 12 per 100,000 (0.012%)• but, risk is 3x during first 90 days of taking for 1st time
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• “water shed” area• poor blood supply: 2 - 6 cm above the insertion point• most ruptures occur here
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• History• sudden pivoting or rapid acceleration/deceleration
• struck violently in the back of ankle??• “got kicked from behind”• “someone shot me”• “hit by a 2x4”
• feel and hear a loud “pop”
• sharp pain, then less pain
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• Exam• straightforward, but don’t be fooled!
• Achilles tendon easily identified & palpated• Palpate for tenderness and for defect
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• Exam• straightforward, but don’t be fooled!
• UTD: “sizable minority of patients with complete tendon rupture are able to ambulate”• many are able to actively plantarflex too• How?
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• Exam• Thompson (calf squeeze) Test• 96% sensitivity, 93% specificity• therefore, more reliable than a patient’s inability
to walk or plantarflex
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• Imaging• typically not needed, Achilles tendon rupture may
be diagnosed solely on clinical exam• ultrasound enables rapid confirmation at bedside• 100% sensitivity, 83% specificity
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• Imaging• Magnetic Resonance Imaging (MRI)• if clinical exam uncertain• if ultrasound unavailable
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• Acute Treatment• immobilize (splint or CAM walker)• heel lift• non-weight bearing: crutches• referral to Orthopedics (1-2 days)
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• Long-term Treatmenta) non-operative: immobilize 6-8 weeks with heel liftb) operative: repair vs. reconstruction
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• among the most common injuries in primary care and emergency departments
• most are sustained during athletics
• risks:• females > males• children/teenagers > adults• indoor court sports > outdoor• natural grass > artificial turf• defensive player > offensive player
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• Classification
Type Mechanism of InjuryLateral Ankle Sprain Ankle InversionMedial Ankle Sprain Ankle EversionSyndesmosis Sprain
(“high ankle” sprain)Externally Rotated Foot
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• Classification
Type Mechanism of InjuryLateral Ankle Sprain Ankle Inversion
Images from UpToDate © 2019
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• Classification
Type Mechanism of InjuryMedial Ankle Sprain Ankle Eversion
Images from UpToDate © 2019
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• Classification
Type Mechanism of InjurySyndesmosis Sprain
(“high ankle” sprain)Externally Rotated Foot
Images from UpToDate © 2019
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• Classification
Type Mechanism of InjurySyndesmosis Sprain
(“high ankle” sprain)Externally Rotated Foot
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• History• mechanism of injury• inversion or eversion?• did foot get turned out (laterally)?
• able to bear weight? If not, more suspicious of fracture
• prior ankle sprains?
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• Exam• swelling/ecchymosis
• palpation (obvious):• bony areas: distal tibia/fibula, foot• soft tissue: ligaments, tendons
• palpation (don’t forget):• dome of talus• areas for “Ottawa Ankle Rules”
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• Exam - Ottawa Ankle Rules
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• Exam - Ottawa Ankle Rules
• X-rays only if:• bony tenderness at one of these spots
OR• inability to take 4 complete steps both immediately & in ED
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• Exam• active & passive ROM limited (pain)• strength/resistive ROM limited (pain)
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• Exam – Special Tests
Type Mechanism of Injury
Lateral Ankle Sprain Ankle Inversion
Medial Ankle Sprain Ankle Eversion
Syndesmosis Sprain(“high ankle” sprain)
Externally Rotated Foot
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• Exam – Special Tests
Type Mechanism of Injury Special Test
Lateral Ankle Sprain Ankle Inversion Inversion Stress TestAnterior Drawer
Medial Ankle Sprain Ankle Eversion Eversion Stress Test
Syndesmosis Sprain(“high ankle” sprain)
Externally Rotated Foot Kleiger’s Test
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• Exam – Special Tests
Type Mechanism of Injury Special Test
Lateral Ankle Sprain Ankle Inversion Inversion Stress TestAnterior Drawer
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• Exam – Special Tests
Type Mechanism of Injury Special Test
Medial Ankle Sprain Ankle Eversion Eversion Stress Test
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• Exam – Special TestsType Mechanism of Injury Special Test
Syndesmosis Sprain(“high ankle” sprain)
Externally Rotated Foot Kleiger’s Test
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• Grading System(s)• grade I: stretched ligament• grade II: partially torn ligament• grade III: fully torn (ruptured) ligament
• Secondarily, for lateral ankle sprains:• which ligament(s) are torn?
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• Remember:• ankle effusion typically not notable• localized soft tissue swelling only
• degree of ecchymosis does not correlate with degree of injury
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• Imaging• Ankle X-rays (AP, oblique, lateral) if concern for:• malleolar fracture• talar dome fracture• syndesmosis diastasis
• Foot X-rays (AP, oblique, lateral) if concern for:• associated foot fracture (navicular, cuboid, base of 5th MT)
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• Imaging• MRI has no role in acute injury setting• can be considered if still pain after 6-8 weeks of
standard care…• …MRI can show talar dome defects and/or
syndesmosis injuries
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• Acute Treatment• Rest: limited WB (crutches) until walk normally• Ice: for 2-3 days until inflammatory phase over• Compression: ACE wrap ↓ hydrostatic pressure• Elevation: above the heart
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• Acute Treatment• NSAIDS• none is more superior than another• no study directly compares acetaminophen to NSAIDS
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• Acute Treatment• Immobilization• grade I should not need• grades II and III, likely do• no harm if patient desires it
Images from UpToDate © 2019
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• Long-term Treatment• therapeutic exercises are the key to recovery• stretching/ROM, strengthening
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• Long-term Treatment• therapeutic exercises are the key to recovery• formal PT vs. home exercise program• helps prevent chronic instability• return to full WB as tolerated
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Special Tests
Metatarsal Compression Test Morton’s Neuroma
Thompson Test Achilles Rupture
Inversion Stress TestAnterior Drawer Test Inversion (Lateral) Ankle Sprain
Eversion Stress Test Eversion (Medial) Ankle Sprain
Kleiger’s Test Syndesmosis (“High”) Ankle Sprain
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MORTON’S NEUROMA • narrow toe box• 2nd & 3rd web spaces• metatarsal compression test
LISFRANC INJURIES • rare, but frequently missed = legal liability• tarsometatarsal joint complex• often cannot weight bear• subtle X-ray findings• must refer to Orthopedics
ACHILLES RUPTURE • most occur in athletes or with recreational sports• most common in males, ages 30 – 40• surprise at suddenness of injury• Thompson test• must refer to Orthopedics quickly
ANKLE SPRAINS • most are lateral ankle sprains• “Ottawa Ankle Rules”• amount of ecchymosis does not correlate to degree of injury• Kleiger’s test for high ankle (syndesmosis)• therapeutic exercise is key to recovery
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1. Beutler, A. and Taylor, C. Tarsometatarsal (Lisfranc) joint complex injuries. In: UpToDate, Eiff, P. and Asplund, CA. (Ed), UpToDate, Waltham, MA, 2019
2. Buchbinder, R. Plantar fasciitis. In: UpToDate, Issac, Z. (Ed), UpToDate, Waltham, MA, 2019
3. Maughan, KL. Ankle sprain. In: UpToDate, Eiff, P. and O’Connor, FG. (Ed), UpToDate, Waltham, MA, 2019
4. Maughan, KL. and Boggess, BR. Achilles tendinopathy and tendon rupture. In: UpToDate, Fields, KB (Ed), UpToDate, Waltham, MA, 2019
5. Miller, MD. and Thompson, SR. Miller’s review of orthopaedics. 6th ed. Philadelphia, PA: Elsevier; 2012.
6. Rynders, SD, Hart JA. Orthopedics for physician assistants. Philadelphia, PA: Elsevier; 2013.
7. Toy, EC., Rosenbaum, AJ., Roberts, TT., and Dines, JS. Case files: Orthopedic surgery. New York, NY: McGraw-Hill Education; 2013.