Sports Injuries of the Foot and Ankle Dominic Nielsen. Parkside Hospital Ashtead Hospital St George s

Transcription

1 Sports Injuries of the Foot and Ankle Dominic Nielsen Parkside Hospital Ashtead Hospital St George s

2 Themes Ankle instability Ankle impingement Stress fractures 5 th MT fractures Peroneal subluxation

3 Ankle instability Common Sports injury Often worse initial injury than appreciated

4 Ankle instability Lateral most common ATFL CFL

5 Ankle instability Remember the syndesmosis High ankle sprain

6 Ankle instability Excessive supination of the rearfoot about an externally rotated leg ATFL injured first then CFL CFL has higher load to failure than ATFL (Attarian) Grade 1 Ligament stretch Grade 2 ATFL torn, CFL intact Grade 3 ATFL and CFL torn (Chapman 1975)

7 Ankle Instability Key anatomic considerations ATFL is weakest CFL is 3.5 x as strong, PTFL is strongest Deep deltoid ligament is crucial Syndesmotic ligaments may be injured with soft tissue injury

8 Ankle instability subtalar joint GRF acts through COP to act as everter and dorsiflexor

9 Ankle instability Gauffin Knee and Ankle Kinesiology and Joint Instability 1991 Everters cannot withstand lever arm >3-4cm

10 Ankle instability - shoes Why is this (hopefully) lady at risk of spraining their ankle?

11 Ankle instability - shoes

12 Ankle instability usually a combination Mechanical stability Functional stability PAINLESS PAINFUL

13 Ankle instability - causes Pathologic laxity Biomechanical - Equinus, hindfoot varus Pain - intra-articular lesions Loss of proprioceptive control

14 Ankle instability - examination Localise areas of tenderness/swelling Examine subtalar joint Examine TA and Gastrocnemius Impingement tests (Molloy) Anterior drawer Inversion stress testing Syndesmotic squeeze test

15 Impingement test Indicative of anterolateral soft tissue impingement lesion (synovitis)

16 Anterior drawer test To test anterior subluxation ATFL function Hanging or fixed Foot in 10 degrees plantarflexion 2mm normal / 5mm pathologic

17 Syndesmotic test Indicative of syndesmotic injury Pilling s test

18 MRI The main indication for MRI is to identify any other pathology This test looks for functional instability

19 Treatment considerations Conservative treatment 3-6 months improve functional instability Is the ankle painful? If so MRI Proprioception Neuromuscular control Postural control Strength Is the ankle unstable? If so screening? Deal with pain 1 st -> Arthroscopy Surgical reconstruction Anatomic/non-anatomic?

20 Surgery Non-anatomic and anatomic repair Evans, Watson-Jones are non-anatomic Brostrom/Gould is anatomic Contemporary option is anatomic Non-anatomic reserved for revision surgery Excellent results 80% (Karlsson et al 1988)

21 Surgery Gould Modification reinforcement with inferior extensor retinaculum

22 Key points Most patients have an element of functional instability If painful then you must treat pain first Screening can identify mechanical instability MRI for functional instability (pain) Arthroscopy for pain (75% will not need reconstruction) Then proceed with reconstruction if needed

23 Ankle Impingement Footballer s ankle Morris 1943 Anterior ankle pain with forced dorsiflexion Scranton 1992 open vs arthroscopic resection, improved results

24 Anterior impingement Meniscoid lesion Glassman 1950 Seen after 3% of ankle sprains (Umans 2002) Positive impingement test (Molloy s test) Responsive to intra-articular LA Arthroscopy indicated after 6 months conservative treatment (Ogilvie-Harris 1997) 90% excellent results with resection (Kim 2002)

25 Syndesmotic impingement Due to High ankle sprains Rarer injury, amenable to arthroscopic debridement (Pritsch 1993) Tenderness along syndesmosis

26 Osteochondral injuries Microfracture Current standard Poor prognosis related with subchondral cyst formation (Hepple 1999) New developments MACI

27 Stress fractures Failure of bone due to repeated mechanical stress Lack initial displacement Often not on early XR Repeat if clinical suspicion

28 Stress fractures

29 Stress fractures Most common in metatarsals Happen elsewhere Navicular common in athletes 30 year old runner 6/12 significant pain in midfoot

30 Stress fracture

31 Stress fracture

32 Stress fracture

33 Stress fracture Majority unite uneventfully PROVIDED load is reduced

34 Jones fracture 5 th metatarsal base fracture very common Prognosis depends on zone of injury

35 Jones fracture 5 th metatarsal base fracture very common Prognosis depends on zone of injury

36 Jones fracture Relative avascular zone In between forces applied Higher chance non union Lower threshold for early surgery

37 Jones fracture Relative avascular zone In between forces applied Higher chance non union Lower threshold for early surgery

38 Jones fracture Stabilise fracture Early weight bearing Earlier return to function

39 Jones fracture Stabilise fracture Early weight bearing Earlier return to function

40 Peroneal Subluxation Pain and clicking on lateral side Visible tendon sliding over fibula Common in skiers Land from small height on uneven snow

41 Peroneal subluxation Test with circumduction or resisted eversion MRI to look for tendon splits and fibula anatomy

42 Repair any splits

43 Reconstruction Consider bony augmentation

44 Rehabilitation 6 weeks in a plaster Active rehab thereafter

45 Thank you