Leg and Ankle Problems in Primary Care.

Transcription

1 Leg and Ankle Problems in Primary Care

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3 Leg and Ankle Presentations 4Trauma 4Pain

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5 Ankle Trauma 41. Twist and Fall--Fracture or Sprain 42. Patient hears/feels a pop--tendon or muscle injury

6 Ankle Trauma 1. Twist and Fall 4Common reason for clinic visits 4You have to exclude a fracture. 4Are there any short-cuts?

7 Ottawa Ankle Rules 4Stiel IG, et al. Ann Emerg Med 1992; 21: and JAMA 1993; 269: Bachman LM, et al. Brit Med J 2003; 326:

8 Rule out a Fracture 4Ottawa Ankle Rules Order an xray if there is tenderness at either posterior malleolus, 5th metatarsal base, navicular AND an inability to take 4 unassisted steps. 4When in doubt, recheck in one week or just get an xray.

9 Ottawa Ankle Rules

10 Ankle Landmarks

11 Example One 4Twisted ankle. 4Ottawa rules employed. 4Patient unable to walk unassisted. 4Tender at base of 5th metatarsal. 4XRs ordered: Foot AP/Lat/Oblique (non-weight bearing)

12 5th Metatarsal Fracture

13 5th Metatarsal Fracture 4Are they all the same? 4 Jones fracture diaphysis not metaphysis Usually a stress fracture NON weight bearing cast

14 Example Two Twisted ankle Ottawa rules employed 4Unable to walk unassisted. 4Tenderness at posterior edge of lateral malleolus. 4XRs: AP/Lat/Mortise or 3v ankle or ankle series

15 Lateral Malleolus Fracture

16 Lateral Malleolus Fractures 4Are they all the same? 4Medial side of ankle is just as tender 4XR shows widening of medial clear space 4Surgical ankle

17 Non-displaced lateral malleolus or 5th metatarsal base fractures TREATMENT WBAT in fracture boot or cast for 4-6 weeks, then PT referral to regain motion, strength, proprioception.

18 Example Three 4Twisted ankle 4Ottawa rules employed. 4Able to walk (poorly). 4Tenderness is in front of lateral malleolus. 4XRs NOT ordered.

19 Sprains 4 Rolled ankle. Inversion mechanism. 4ATFL commonly injured. 4Tenderness is anterior to malleolus. 4Grading System: Mild (localized lateral swelling) or Severe (diffuse swelling and tenderness).

20 Ankle Sprains 4Mild: ATFL only injured. 4Severe: ATFL + calcaneofibular ligament (CFL) +/- PTFL.

21 Sprains Treatment 4MILD 4RICE 4Crutches for a few days 4Functional splint 4Early weight bearing and ROM 43-7 days to recover

22 Sprains Treatment 4SEVERE 4Consider Fracture or Walking Boot 4Bear weight as tolerated 4ROM as pain allows 46 wks + to recover 4Surgery?

23 Sprains 4Treatment/Rehabilitation 4 After immobilization period start: RANGE OF MOTION WEIGHT BEARING TOE RISE EXERCISES

24 Ankle Sprains Recent Studies 4There are no minor sprains 4Early mobilization works best 4High MD visits; low PT visits 4Re-injury and residual symptoms are common

25 Recurrent Sprains 4Sometimes it is just bad luck. Usually the problem is inadequate rehabilitation. 4Persistent pain: usually inadequate rehab. Ankle can be stiff/swollen/weak. 4Other reasons: invertor/evertor imbalance weight transfer abnormal knee angles.

26 Other Sprains 4Deltoid: rare; medial side of ankle. Refer if medial clear space is widened. 4 High : syndesmosis sprain (connects tibia to fibula. Pain is in leg, worse with ext rot. 4Sinus tarsi syndrome: residual pain after sprain in soft spot. Responds to arch support, rehab, even injection.

27 The Terrell Owens Injury 4Maisonneuve: tear of deltoid (medial ligament), rupture of syndesmosis ligament, and high fracture of fibula.

28 Chips and Flakes 4Ligament avulsions 4 Old if smooth or rounded

29 Ankle Trauma 41. Twist and Fall 42. Felt a pop

30 Felt a Pop 4Posterior Ankle 4Gastrocnemius unit: high or low 4Always check with patient prone

31 Tendo-achilles Rupture 4Young to middle-aged patients 4Local tenderness/swelling. Can still walk. 4Diagnostic: palpable defect, abnormal resting position, Thompson test 4Refer

32 Tendoachilles Rupture Palpate the Tendon ProneRestingPosition

33 Medial Gastrocnemius Muscle Tear 4Pain is higher, mid to upper medial calf. 4Swelling can be mild to severe. Mimics DVT.

34 Medial Gastrocnemius Tear 4Treatment: 4Mild swelling and pain: ace, ice, crutches. Takes 1-3 weeks to return to activity. 4Severe swelling: posterior splint, NWB with crutches for 3-6 weeks. 4Never surgical ( like sewing wet Kleenex )

35 Leg or Ankle Pain 4As the reason for the clinic visit: 4Arthritis 4Overuse Of tendons Of bone Of muscle

36 Ankle Arthritis 4Rare. Usually history of injury/surgery 4Diffuse aching with weight bearing 4Decreased ROM 4XRAY is diagnostic 4Treat like any other arthritic joint but add contrast soaks, cushioned insoles, brace.

37 Overuse 4Achilles tendinitis 4Posterior tibial tendinitis

38 Achilles Tendinitis 4Usually related to significant increase or change in type of activity. 4Pain with push-off (if they can walk). 4Can be swelling, tenderness to palpation 4Takes weeks/months to resolve 4Heel lift +/- boot/cast. Soaks, NSAIDs. 4(can be prelude to rupture)

39 Achilles Tendinitis

40 Posterior Tibial Tendinitis 4 Acquired Flatfoot 4 Underdiagnosed/unrecognized 4Middle aged patient, medial ankle/foot pain 4Check for tenderness, swelling, arch, toe rise ability. 4Associated with hallux valgus, tight heelcord, sometimes knee pain. 4Treat with arch support and heel lift; sometimes needs casting; surgery can be needed.

41 Posterior Tibial Tendon

42 Posterior Tibial Tendinitis

43 Overuse of Bone 4Shin Splints: medial tibial stress syndrome Sore after stopping exercise Diffusely tender at medial edge of tibia Must stop aggravating activity

44 Overuse of Bone Stress Fracture 4Often young, woman, runner 4Sudden increases in duration/intensity 4Can have pain with walking, but much worse with running. 4Focal tenderness

45 Ankle Rehabilitation 4Swelling 4Stiffness 4Weakness 4Giving out

46 Swelling 4 It s going to look swollen for at least 3 months 4Elastic supports and Time

47 Stiffness 4 Let s compare the motion to the other ankle 4ROM doesn t return by itself. Selfstretching to start, formal PT prn. 4Some discomfort is normal and does not mean something is being damaged.

48 Weakness 4 Let s try the toe rise test together 4Easy demonstration of plantarflexor power. 4Patient won t walk or feel right until it returns. May take a month or two.

49 Giving out 4Usually a combination of weakness and loss of proprioception. 4After toe rise is regained, balance on toes of one foot and walk on tiptoes. 4This is needed to return to sports.

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