Transcript Ankle Sprain Imitators

Ankle Sprain Imitators
Leslie A. Michaud, M.D.
Steadman Hawkins Clinic of the Carolinas
Primary 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
Tibial Plafond
Lateral
Malleolus
Medial
Malleolus
Talus
Subtalar joint
http://www.emedx.com/emedx/diagnosis_information/diagnosis_information_ima
ge_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
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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
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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
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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?
Bibliography
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