Musculoskeletal Diseases and Disorders: Ankle and Foot

1. Musculoskeletal Diseases and Disorders: Ankle and Foot

2. Symbols • This is for your information only, • it won’t be used for the exam • important to know for exam

3. Ottawa Ankle Rules JAMA. 1993 Jul 28;270(4):453 www.mdcalc.com/ottawa_ankle.png

4. I. Fractures of the Ankle and Foot • Classification can be according to the stresses placed on the ankle • OR the anatomical structure that is fractured.

5. Ankle • Unimalleolar: involves either the medial or lateral malleolus. • Lateral malleolarfracture is more common • Generally involves the fibula.

6. Bimalleolar: involves both the medial and lateral malleolus -Medial malleolus is driven into the Calcaneus, lots of ligament damage.

7. Trimalleolar: involves both malleoli and the posterior tubercle of the distal tibia. 4. Complex: comminuted fracture of the distal tibia and fibula

8. Lauge-Hansen Classification System: Ankle Fractures • It uses 2 word descriptors. • First word describes the position of the foot • Second word describes the motion of the foot (talus) with respect to the leg.

9. Weber System • Examines the Syndesmosis or distal Tib/Fib joint • This will look at the stability of the mortise but does not look at other types of injuries associated with the fracture. • Good website for review of these systems and fractures: http://www.radiologyassistant.nl/en/4b6d817d8fade#

10. supination-adduction (Weber A) • supination-external rotation (Weber B) • stage 1: the anteroinferiortibiofibular ligament is torn or avulsed • stage 2: the talus displaces and fractures the fibula in an oblique or spiral fracture, starting at the joint. • stage 3: tear of the posteroinferiortibiofibular ligament or fracture posterior malleolus • stage 4: tear of the deltoid ligament or transverse fracture medial malleolus

11. pronation-abduction (Weber C) • pronation-external rotation (Weber C) • pronation-dorsiflexion (Weber C)

12. Foot • Hindfoot fractures: extra-articular or intra-articular • Calcaneus: Rowe Classification • Talus • Midfoot: isolated midfoot fractures are rare. Usually are an avulsion fracture of the navicular tuberosity if present • Navicular 3. Forefoot: displaced or non displaced fractures

13. Metatarsals The position of the fracture is important. a. First metatarsal: common along the medial base b. Second and third fracture along the distal diaphysis c. Fourth fractures along the middle to distal diaphysis d. Fifth fractures proximal near the junction of the diaphysis and metaphysis

14. Stress fractures Most common areas • Distal tibia • Metatarsal heads & bases • Cuboids Tibialstress fractures occur in upper two thirds of bone or at junction of middle and distal third. Fibula stress fracture occurs 5-7cm above the tip of the lateral malleolus Forces are repetitive in nature

15. Symptoms of a stress FX: • Forefoot pain • Or pain in the affected leg during or soon after a repeated load • Pain decreases with rest • Increases with activity

16. Signs: • Tenderness to palpation • Inability to weight bear without pain • X-ray will be negative initially • Bone scan will be positive

17. Treatment: Depends on where the stress fracture is located • will be partial weight bearing on crutches for 2-3 weeks • gradually return to activities, if occurs because of running • may get orthotics DD includes • shin splints, • Exertional compartment syndrome • tendinosus

18. Sesmoiditis • Trauma to the sesmoid bones located within the flexor hallucis brevis at its attachment to the base of the proximal phalanx of the hallux. • This can be a stress fracture, osteonecrosis, chondromalacia or OA of the bones as they slide over the articulation with the head of the first MT. www.footpainreliefstore.com/library/73399.htm

19. Weight bearing on the toes increases the stress across the bones. • Typically seen in jumping athletes, gymnasts, and dancers. • SX: localized tenderness over the bones, localized swelling and pain on WB that increases with hopping.

20. Systemic Disorders of the Ankle and Foot Osteoarthritis: rare as a primary systemic disease, more commonly a secondary disorder RA: symmetric involvement

21. Psoriatic arthritis: • Asymmetric multi-joint complaints • nail and joint changes with swelling of the digits producing a sausage shape of the fingers. • Commonly involves the small joints of the feet. • 20% will have musculoskeletal complaints prior to skin rashes

22. Reiter's Syndrome: • Inflammation of the insertion sites of tendons and ligaments • clinical triad of non-gonococcalurethritis, conjunctivitis, and arthritis. • achilles tendon commonly affected • sesamoiditis is also frequently seen FIGURE 4. Radiograph of the heel in a patient with Reiter's syndrome. The radiograph shows a periosteal reaction at the plantar fascia insertion (black arrow) and early erosion at the Achilles tendon insertion (white arrow) on the calcaneus. www.aafp.org/afp//AFPprinter/20040615/2853.html

23. Gout: Metabolic disorder with elevated serum uric acid and deposition of urate crystals in the joints, soft tissues and kidneys… Primary and secondary forms Primary: hyperuricemia in the absence of other disease Secondary: hyperuricemia resulting from another disease, history of leukemia, lymphoma, psoriasis, hemolytic disorders, those receiving chemotherapy. www.health.com/.../library/mdp/0,,zm6082,00.html

24. Risk Factors • Men > (10% women and if women are usually post-menopause) • peak period of time around age 50 • Alcohol consumption • chronic renal failure • Hypertension • hypothryroidism • hyperparathyroidism

25. Symptoms: exquisite joint pain, commonly occurs at night • Signs: location: usually first MTP, can also be instep, ankle, knee wrist, elbow, and fingers • Erythema, warmth and extreme tenderness and hypersensitivity, chills and fever may accompany

26. Phases: 1. acute 2. intercritical phase – lasts months to years 3. chronic

27. Musculoskeletal Dysfunctions of the Ankle and Foot Achilles Tendon Acute Tendinosis: retinaculur fascia which surrounds the tendon becomes irritated when the tendon is subjected to repetitive stress such as hiking or jogging. • The paratenon is usually first involved but with chronic cases, the tendon itself becomes inflamed. • Patients with overly pronated feet are at an increase risk for developing this. • 80% males more than females, 75% attributed to training errors

28. SX: Pain in the back of the heel and leg, pain worsens when Achilles is stretched or contracted • Signs: increase in symptoms with passive stretch, increase in symptoms with resisted Plantarflexion

29. Tendon Rupture MOI: • Forced dorsiflexion occurring suddenly in a plantar flexed foot • or an overuse injury with degeneration of the tendon • Usually occurs in the musculotendinous junction HX: often a male patient, • young 25 or less who sustains the injury during an athletic event, • notable snap in the back of the heel, • activities that cause a sudden “toe off” or landing after a jump

30. SX: pain • inability to walk on the foot • can't push off Signs: • + Thompson's test • weak active plantarflexion against resistance • palpable defect about 2-6 cm above the achilles insertion

31. RX: controversial, may or may not do surgery. If they do surgery, will place in a gravity equinus long leg cast for 4 weeks followed by a short cast for 4 weeks. Then a heel lift starting at 1 inch and decreasing by 1/4 inches over 4 weeks. Surgery: approximate the disrupted tendon followed by same treatment as noted above benefits of surgery are a slight increase in resistance to fatigue and a decreased rate of re-rupture

32. Posterior Tibialis Tendon • Tendonitis, tendinosis, 1,2,3 dg strains, or avulsion fracture of the tendon on the navicular • SX: pain along the course of the tendon just behind the medial malleolus

33. Signs: soft tissue edema along the tendon, unable to supinate actively, flatfoot deformity will evolve, active inversion against resistance is decreased, unable to stand on tip toes on affected side because of the pain • DD: tarsal tunnel syndrome

34. Tibialisanterior: generally tendonitis develops: pain in the dorsum of the foot, just under the extensor retinaculum. • Painful with dosiflexion. PeronealTendon: generally tendonitis develops: pain behind the lateral malleolus and at insertion into base of 5th metatarsal -more painful with eversion and inversion

35. Shin Splints Overuse syndrome, can refer to a number of different anatomical problems in the knee, leg, foot. Applied to pain along the tibia which could be lateral, medial or posteriomedial. Visible inflammation suggests myositis, periostitis, or a musculotendinous strain or tear. DD includes stress fractures, exertional compartment syndrome and tendinosus.

36. Shin Splints Cause is overuse SX: • Diffuse pain, medial 2/3 of tibial border • Gradual to sudden onset • Pain decreases with rest • Limited ROM can occur • Pain over the muscle compartment, located near the tibia • Pain may be referred to the foot or the knee • Movements that stretch or contract muscle will increase pain

37. Signs: • palpation over the affected muscle group and adjacent tibia will elicit tenderness • slight swelling and redness may be visible • end feel is empty or muscle spasm • x-rays normal • bone scan may show a periosteal uptake

38. Chronic Exertional Compartment Syndrome More difficult to diagnosis, not a surgical emergency As muscles are exercised, they increase their volume of blood flow, results in increase pressure within the compartment, which in turns actually causes an ischemic reaction into the muscle. Anterior compartment is the most common,

39. Compartments of the Lower Leg

40. HX of blunt trauma to soft tissues or a previous fracture to the area is common SX: • pain in the lower leg with running • or during repeated jumping activities • pain with fast walking • symptoms disappear with a few minutes rest • Blood supply gets cut off from them swelling up as stressed. • Skin will feel tight, as the muscle are outgrowing the skin.

41. Inert Tissue Dysfunctions of the Ankle and Foot Sprains: common injuries in sports, involves the lateral side of the ankle more frequently than the medial side

42. Lateral or inversion sprain: Stretching or tearing of the ligaments of the lateral side of the ankle. Most common ligaments injured (in order of increasing damage) are: • anterior talofibular ligament, • anterior capsule sprain, • calcaneofibular ligament, • posterior talofibular ligament, • then ligamentous tears, • fractures of the ankle begin to occur.

43. Sprains in the lateral ankle Staging of Ankle Sprains: Beynnon et al proposed the following staging: Grade I: no loss of function, no ligamentous instability (anterior drawer or talar tilt tests) little or no ecchymosis, and point tenderness Grade II: some loss of function, decreased motion, positive anterior drawer test, negative talar tilt test, ecchymosis, swelling and point tenderness Grade III: nearly total loss of function, a positive anterior drawer and talar tilt test, diffuse swelling and ecchymosis, extreme point tenderness Inability to weight bear and the presence of gross joint laxity places patients in a grade III

44. Fractures: begin at the lateral malleolus then move across to the medial malleolus as the severity of the ankle injury increases. • 20% of all athletes will develop functional instabilities and need surgery.

45. Eversion or medial ligament sprain: Less common than inversion sprains. Deltoid ligament is involved. Requires more force to sprain on the medial aspect Ligaments involved (in order of increasing damage) tibiocalcaneal ligament, tibionavicular ligament, tibiospring ligament, posterior tibiotalar ligament, then fractures of the bones occur.

46. Fractures: lower third of the fibula, avulsion fracture of the medial malleolus or bimalleolar fracture at or below the level of the tibia. Mechanism of injury is abduction, eversion and dorsiflexion force

47. Plantarflexion overstretch Uncommon strain anterior capsule sprain or tear, anterior talofibular ligament sprain, bifurcate ligament sprain, posterior talar impingement of the lateral posterior tubercle of the talus between the tibia and the calcaneus, midtarsal joint sprain

48. Plantar flexion and inversion most common mechanism for ankle sprains. anterior talofibular ligament, anterolateral capsule sprain, retinaculum may be included, anterior tibiofibular ligament may sprain

49. Forced Dorsiflexion • Talus moves into the mortise like a wedge, separates the fibula and tibia • Ligaments: anterior tibiofibular ligament sprain, achilles tendon strain, posterior talofibularligament sprain, calcaneofibular ligament sprain, posterior capsule sprain, anterior talar impingement • Fractures: fibula, neck of the talus with or without subtalar joint dislocation

50. Dorsiflexion and inversion: Ligaments: calcaneofibular ligament sprain or tear, posterior talofibular ligament sprain Fractures: lateral talar dome, osteochondral fractures