lecture 47 parekh sports f&a
TRANSCRIPT
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Foot and Ankle Sports
Selene G. Parekh, MD, MBAAssociate Professor of Surgery
Partner, North Carolina Orthopaedic ClinicDepartment of Orthopaedic Surgery
Adjunct Faculty Fuqua Business SchoolDuke University
Durham, NC919.471.9622
http://seleneparekhmd.comTwitter: @seleneparekhmd
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Ankle Problems in the Athlete
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Athletic Injuries
• Participation in organized/recreational sports continues to increase
• Injuries can be debilitating
• Recognition, prompt treatment and rehabilitation • Prevent long term disability
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Athletic Injuries
• 59% of adults participate in exercise
• 11% jog
• 25% run ≥ 2 miles/day
• 800 footstrikes/mile
• Impact 3-8 x body wt
• Running injuries vary between 37%-57%
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Athletic Injuries
• Risk Factors• Intrinsic
• Individual’s physical and personality traits
• Extrinsic• Training techniques
• Weekly running mileage greater than 40 miles
• Playing surfaces• Equipment
• Break-away bases
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Athletic Injuries
• Etiologic Factors• Biomechanical abnml
• Flexibility
• Strength
• Footwear & orthoses
• Playing surfaces
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Athletic Injuries: Etiology
• Biomechanical abnormalities
• Pelvic obliquity only predictor of injury
• <10% running injuries are due to biomechanical problems
• 70-80% runners treated with orthoses improve
• Need to wean use
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Athletic Injuries: Etiology
• Flexibility• Prevention
• Tight Achilles• Decreased DF
HV, turf toe, midfoot strain, ankle sprain, Achilles tendinitis, calf strain
• Decr. MTP ROM• HR dancers predispose to injury
• Hypermobility• Posterior ankle pain
• Pathologic laxity• Recurrent ankle sprain
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Athletic Injuries: Etiology
• Strength• Weakness injury
• >10% difference in extremity strength puts player at risk
• Soccer & volleyball players risk for injury and recurrence due to weakness
• Restore normal strength ratio though isotonic and isokinetic strengthening
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Athletic Injuries: Etiology
• Footwear and orthoses• Improper fit
• Tight/loose, neurapraxia• Load cushioning
• Reduced calcaneal stress fx in military recruits• Loss of sensory feedback
• Torque• Cleating ankle injuries• Too much, too little traction
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Athletic Injuries: Etiology
• Playing Surfaces• Concrete, synthetic track• Grass vs. artificial turf
• Role not completely defined
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Chronic Leg Pain
• Concurrent with foot/ankle complaints• Differential
• Chronic compartment syndrome• Medial tibial stress syndrome• Stress fractures• Muscle strain/tendinitis• Nerve entrapment• Vascular disease• Fascial herniation• Radiculopathy
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Chronic Leg Pain
• Incidence• 150 patients
• 33% chronic compartment syndrome• 25% stress fx• 14% muscle strain, 13% medial tibial stress
syndrome• 10% nerve entrapment, 4% venous disease
• Shin splints• Periostitis
• 10-15% all running injuries
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Exercise-Induced Compartment Syndrome
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Exercise-Induced Compartment Syndrome
• Incidence• Unclear
• 70% runners, 20% ball and puck• Clinical Features
• Pain predictable after certain distance, duration, speed
• Aching, cramping, stabbing, fullness• Neurologic symptoms
• Anterior, deep posterior compartments
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Exercise-Induced Compartment Syndrome
• Diagnosis• Clinical
• Rest: Minimal tenderness • Exercise to provoke sx• Muscle herniation 20-60% pts• DPN/SPN
• Radiologic• Stress fx• Occult tumor• Bone scan• MRI
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Exercise-Induced Compartment Syndrome
• Criteria for Diagnosis• Pressure measurements
• Resting, post-exercise measurements
• Secondary• Pressure >15mmHg pre-exercise• Pressure >30mmHg 1 min post-exercise• Pressure >15mmHg 5-10 min post-exercise
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Exercise-Induced Compartment Syndrome
• Conservative treatment• Dependent on athletes goals• Activity modification• Rest gradual increase in exercise• Ice, NSAID’s• Insoles, orthoses
• Surgical treatment• Fasciotomies
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Exercise-Induced Compartment Syndrome
• Results• Good with proper patient and techniques• 80-95% excellent results• 20% decrease in strength
• Complications• Swelling• Hematoma• Infection• Herniation• Nerve entrapment• Recurrence
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Stress Fractures: Tibia & Fibula
• Abnormal repetitive loads causing imbalance of resorption over formation
• Running > basketball > soccer > skating > aerobics > ballet
• Athletes with decreased mineral content • Amenorrheic females
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Stress Fractures: Tibia & Fibula
• Clinical features• Recent change in routine• Insidious, localized tenderness, swelling
• Diagnosis• X-ray initially negative
• (2-3 weeks) radiodense haze, periosteal rxn• Transverse cortical lucency• Bone scan
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Stress Fractures: Tibia & Fibula
• Conservative Treatment• Rest, cessation of activity• NWB PWB to WBAT
• As symptoms allow• Swimming, pool running, cycling
• Resume competition full motion, strength, minimal tenderness
• Surgical Treatment• Excision, bone grafting• PEMF bone stimulation• Intramedullary fixation
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Gastrocnemius-Soleus Strain
• Common injury• Racquet sports, basketball, running, skiing• Plantaris tear
• Clinical Features• Sudden knee extension while crouched w/ ankle DF• Sudden sharp pain
• Difficulty with toe-off
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Gastrocnemius-Soleus Strain
• Treatment• Casting/immobilization
• RICE
• WBAT• Active dorsiflexion• Gentle passive stretching more functional
recovery
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Nerve Entrapment Syndromes
• Superficial Peroneal Nerve• Neuritic pain, burning, tingling, radiation• Tenderness over area of compression• R/o compartment syndrome, double-crush• Tx
• Injections, modalities, thermogesic creams, neuroactive medications, shoe modifications
• Surgical nerve release, fasciotomy
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Popliteal Artery Entrapment Syndrome
• Rare, mimics pain chronic compartment syndrome• Recognition important as may lead to amputation
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Popliteal Artery Entrapment Syndrome
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Popliteal Artery Entrapment Syndrome
• Clinical• Cramping pain, intermittent claudication
• 67% bilaterality
• Pulses diminished or absent• Knee hyperextended, ankle dorsiflexed
• Knee warm, foot cool• Ischemia, thrombosis; palpable mass
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Popliteal Artery Entrapment Syndrome
• Diagnostics• Provocative testing (treadmill) absent pulses• Doppler, U/S flow, aneurysm• Biplanar arteriography after exercise
• Deviation, occlusion, dilatation
• Treatment• Release• Bypass grafting
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Venous Disease
• Effort thrombosis• Pain, edema, distended veins, discoloration• Venography• Tx: anticoagulation heparin, coumadin
• Thrombophlebitis• Immobilization after injury• Air travel• Dehydration• Oral contraceptives• Alcohol/drug use
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Delayed-Onset Muscle Soreness
• Unaccustomed to activity
• Eccentric muscle contraction microinjury, subcellular level• Inability to generate maximal force
• Pain, fatigue• Loss of performance 24-48hrs• Resolve 5-7 days
• Tx• Symptomatic treatment
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Medial Ankle Sprains
• Rare, associated with lateral, bony injuries
• 2 portions:• Superficial deltoid• Deep deltoid
DeepSuperficial
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Medial Ankle Sprains
• Biomechanics of deltoid• Prohibits abduction
• Secondary restraint against anterior translation ankle
• Deep deltoid • Greatest restraint lateral translation (after fibula)• Highest load to failure
• Valgus tilt superficial & deep rupture
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Medial Ankle Sprains
• Clinical Evaluation• Lateral injury, fracture, syndesmotic injury• Abduction, eversion• Other injuries
• Maisonneuve, FDL, PTT, FHL, tibial & saph n
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• Radiographs• Assoc fx, AP stress valgus tilt, normal with
incomplete injury• MRI
Medial Ankle Sprains
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• Conservative Treatment• Dependent upon associated injuries• Walking cast, boot 6-8wks• Functional treatment
• Surgical treatment• Inability to reduce medial clear space• Direct repair
• Suture, suture anchors
• Stirrup brace 6 months after surgery
Medial Ankle Sprains
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Sinus Tarsi Syndrome
• Related to subtalar instability
• Nebulous condition w/ pain in lateral ankle & sinus tarsi
• Pathologic anatomy not clearly defined• Scarring or degenerative changes to soft tissues
within sinus tarsi• Loss of nerve function loss of proprioception
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Sinus Tarsi Syndrome
• Diagnosis• Clinical Evaluation
• Pain lateral ankle, sinus tarsi• Prior inversion injury• Instability rare
• Radiologic Evaluation• X-rays- normal• Subtalar arthrography
• Absence of microrecesses, interdigitation• MRI
• Fibrosis, fluid collections
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Sinus Tarsi Syndrome
• Conservative treatment• Injection
• Surgical treatment• Exploratory, sx may persist• Resect fibrofatty tissue & extensions from IER• Subtalar arthroscopy
• Results• 96 cases; 69% excellent, 25% good, 6% failures
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Os Trigonum/Posterior Impingement
• First Described Rosenmuller
• First Described as Fx Shepherd 1822
• Asymptomatic• Separate
Ossification Center• Age 8-11• Incidence 1.7 - 7%
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Os Trigonum/Posterior Impingement
• No side predominence• Vary in size• Normal anatomic variation
• Mild extension• Thumb shaped projection - 1 cm (Stieda’s
Process)
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Os Trigonum/Posterior Impingement
• Symptoms• Pain with PF• Young Athlete/Dancer
• Spectrum• Acute – Fx• Gradual - FHL Tendinitis
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Os Trigonum/Posterior Impingement
• Conservative• Immobilization• NSAID
• Surgical – Excision
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Prone Ankle Scope
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Evaluation
• 54% of talar dome
• Os trigonum
• Haglund’s
• Achilles insertion site
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Foot Problems in the Athlete
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Goals & Objectives
• Specific problems• Midfoot
• Forefoot
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Os Peroneum
• Ossification• Complete• Less than complete• Multipartite
• Location• Lateral border calc & plantar lateral cuboid
• Useful marker for ruptured PL
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Painful Os Peroneum Syndrome (POS) & PL Disruption
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POPS/Peroneus Long. Tendonitis/Tear
• Conservative treatment• Cast immobilization (20% success)• Physical therapy
• Surgical treatment• Os peroneum excision/tendon repair• Peroneal tenodesis
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Forefoot Sprains
•First MTP joint/ “turf toe”
•Etiology•Hard artificial surface, flexible shoes•True incidence not defined, but many reports indicate a fairly common entity
•Functional disability•Push-off impaired•Compromised forward drive and running•More missed games & practices than other injuries
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Forefoot Sprains
• Mechanisms of injury• Hyperextension of the MTP joint
• Foot dorsiflexed, forefoot fixed, heel raised• Joint capsule tears, compression injury to the dorsal articular
surface with extremes of dorsiflexion
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Forefoot Sprains
• Etiologic factors• Shoe-surface interface
• Flexible shoes
• Hardness of surface• Loss of resiliency with time
• Enhanced friction• Fixes foot allows extremes of motion
• Excessive DF• In those with limited DF
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Forefoot Sprains
• Radiographs• R/o fx, avulsions, impaction• Other methods usually not necessary
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Forefoot Sprains
• Conservative treatment• RICE, NSAID’s• Taping, boot• Increase stiffness in shoe
• Custom molded insert/Morton’s extension
• Rehab once decrease in sx allows
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Forefoot Sprains
• Surgical treatment• Rarely necessary
• Instability• Loose bodies, osteochondral injury• Ligamentous disruption• Sesamoid retraction
• Repair plantar plate, FHB, long flexor transfer
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Metatarsal Stress Fractures
• Etiology• Injury to opposite limp
increased stress to normal limb
• Muscle fatigue increase in loading
• Hard surfaces, poorly cushioned shoes, heavy heel strike
• Rigid cavus feet decrease shock absorption of the midfoot increase stress on MT’s
• Hypermobile first ray or long 2nd MT
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Stress Fractures
• High index of suspicion • Focal tenderness • Min/no swelling• X-rays nl < 3-4 wks • Bone scan, MRI, & CT scans
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Treatment
• Activity modifications• Non-impact sports• Avoid casting if possible
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Treatment
• Shoe modifications• Rigid cavus foot
• Flexible, cushioned arch support• Hyperpronation/hypermobile 1st ray
• Soft medial arch support• Long 2nd MT
• MT pad
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RE ECT
the ankle
the foot