1/14/2015

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A. Holly Johnson, M.D. Massachusetts General Hospital

Harvard Medical School

Boston, MA

USA

I have no potential conflicts with this talk

Epidemiology

>2 million ankle sprains

every year in US

40-45% of sports

injuries are ankle

injuries

85% inversion sprains

Anatomy

Lateral ligaments

ATFL

CFL

PTFL

Medial ligaments

Deltoid

Syndesmosis

AITFL, PITFL, transverse, interosseous membrane

Classification

Grade I Grade II Grade III

Initial Evaluation

Palpate the ankle and

the foot!

Bones

Ligaments

Tendons

Attempt gentle ROM

X-rays ankle +/- foot –

WB if possible

Can’t walk

Suspicious tenderness

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Initial Treatment

RICE

NWB vs WBAT Ankle supports Functional

Rehabilitation

Recovery Phases Phase 1 (1-2 weeks)

Protect the ankle, reducing swelling

Phase 2 (1-2 weeks, when WB) Restore ROM, strength,

flexibility

Phase 3 (weeks to months) Gradual return to

running, elliptical, swimming, sport

RICE

PT – gait, strength,

PT – proprioception, prepare for return to sport, then cutting, plyo, sport specific activ

Prognosis Grade I: 8 days, Grade II: >2 weeks, Grade III: >6

weeks

40% of ankle sprains with have symptoms for at least 6 months

15-30% will have persistent ankle symptoms

19% recurrent inversion sprains

4% experience pain at rest

Inadequate Rehab

Review of 21 trials showed superior results functional rehab vs. immobilization (Arch Orthop Trauma Surg. 2001)

Inadequate rehab

perpetuates residual inflammation

postural stability deficits

Don’t Miss it…

Ankle Sprain Impersonators

Syndesmotic Injury

“High ankle sprain”

External rotation injury

Squeeze & external rotation test

Stable: rest, PT

Recovery 2x longer

Unstable: surgery

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Peroneal Tendon Pathology

Tears

Tenosynovitis

Subluxation

Peroneal Tendon Pathology

Diagnosis

Pain to palpation

Crepitation

Instability to resisted eversion or circumduction of ankle

Imaging: xrays, MRI

Peroneal Tendon Pathology

Treatment

Rest

Lateral heel wedges

Bracing

NSAIDS

Cold therapy

PT

Surgery ▪ Debridement of synovitis,

repair tear, repair tunnel

Undetected Trauma

FRACTURES:

Lateral process of talus

Anterior process of calcaneus

Cuboid

Fifth metatarsal

5th Metatarsal Fractures Most common foot

fracture

3 types

Seen on foot x-ray (may be missed on ankle x-ray)

5th Metatarsal Fractures

Base (“Avulsion”)

Shaft (“Dancer’s)

Displacement varies

Boot/hard soled shoe x6 weeks, then as symptoms dictate

Rarely surgical

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5th MT – “Jones” Fracture

(metaphyseal-diaphyseal)

Associated with high nonunion rate

Treatment

Cast and nonweightbearing

Surgery may be indicated

Lis Franc Ligament Injuries

Tarsometatarsal Joints

High energy or low energy

High index of suspicion

At least 20% missed on initial eval

Lis Franc Injury Direct

Indirect Axial loading of plantar flexed foot

Severe abduction

Lis Franc

Physical exam

Variable degree of swelling

Pain with weight bearing

Midfoot tenderness

Pain with forced pronation and abduction

**Plantar midarch ecchymosis

Lis Franc

Radiographs

AP, lateral and oblique views are mandatory

Weight bearing films if possible

Comparison films are very helpful

“Fleck sign”

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Lis Franc

Surgery indicated for any displacement

Persistent pain and arthritis not infrequent

Potentially Catastrophic Misses

Jones

Lis Franc

Ankle Fracture

Talus Fracture

**Heavy consequences

to patient and provider **

The Sprain that won’t get better

Ongoing pain and

swelling p/ 3 mos

Ankle feels unstable

Catching and Locking

Refer (Consider MRI)

Bone Contusion

Ongoing pain and

swelling

Edema seen on MRI

(X-rays negative)

May take 6 months to

feel better

(Image)

Ankle Impingement

Seen after initial phase

Anterolateral/Anteromedial

Chronic inflammation - adhesions, hypertrophied synovium, ligament injury

Anterior

Anterior tibia & talar neck osteophytes

Ankle Impingement

Posterior:

Inflammation of synovium

Osseous injury (os trigonum, lateral tib tubercle)

FHL tenosynovitis

1/14/2015

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Osteochondritis Dissecans(OCD)

Most commonly a result of a trauma – OLT talus

Reported to occur in 2-6% of ankle sprains

Most asymptomatic

Medial lesions most common

Osteochondral Lesions of the Talus (OLT)

Swelling, stiffness, Clicking or locking +/- instability Joint line tenderness?

Imaging

3 WB views ankle

MRI - cartilage

CT- bone

OLTs - Treatment

Conservative ▪ Immobilization

▪ Physical therapy

Surgery (3 principles) ▪ Loose-body removal, +/-

fibrocartilage growth stimulation (microfracture)

▪ Securing OLTs to talar dome

▪ Hyaline cartilage growth stimulation with autograft (OATS), allograft, or cell culture

Ankle Instability

Functional Subjective sense of

ankle giving out Diminished

proprioception of the ankle

Mechanical Incompetent

ligament restraints Frequent inversion

sprains, also on even surface

Long term consequences to ankle joint

Ankle Instability

Anterior Drawer

1o restraint: ATFL

Perform with ankle @ 10o PF

> 8mm forward shift( > 3mm to contralateral side)

Ankle Instability

Talar Tilt

1o restraint: CFL (ATFL)

Perform with ankle @ 10o PF

> 9o tilt (twice the angle of the contralateral side)

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Ankle Instability

Treatment

PT

Bracing

Shoewear mod/orthosis

Surgery

▪ Ligament repair

▪ Tendon reconstruction

Review

Comprehensive examination

Obtain WB radiographs Adjuvant imaging

MRI, CT, stress radiographs

Consider trial of conservative management & PT

Counsel patient on appropriate expectations

When to refer…..

Severe joint line tenderness & effusion

Failed conservative therapy

Unclear diagnosis

Thank you

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