Ankle and Foot Problems

1
Ankle and Foot Problems

• Baylor College of Medicine
• Anoop Agrawal, M.D.

2
Review of Ankle Anatomy

• Name the ligaments on the lateral aspect of the
  ankle.
• ant talofibular (ATFL), calcaneofibular (CFL),
  and post talofibular (PTFL)

3
Review of Ankle anatomy

• Name the ligaments on the medial aspect of the
  ankle.
• deltoid ligament

4
Case One

• A 30 yo white male presents with complaint of
  having twisted his right ankle yesterday. The
  ankle has been painful and swollen. He has been
  limping and unable to bear weight since the
  accident. Exam shows swelling with point
  tenderness over the lateral malleolus. How would
  you manage this case? Would you get an x-ray? If
  so, what would you order?

5
Ankle Sprains

• Classification based on location and grade
• Location
• Lateral
• Medial
• Syndesmostic (high ankle sprain)

6
Lateral Ankle Sprain

• Most common type
• Which ligament is always involved in this type of
  sprain?
• ant talofibular ligament (ATFL) - mechanism due
  to inversion and plantarflexion
• Stronger forces of injury may also involve the
  CFL. The CFL rarely is injured in isolation.

7
When to x-ray the ankle?

• Ottawa ankle rules serve as guidelines for when
  to x-ray.
• Developed by urgent care department in Ottawa,
  Canada.
• Numerous studies demonstrate Ottawa rules have a
  near 100 sensitivity and reduce the number of
  unnecessary x-rays by 30-40.
• A recent study showed 98.5 sensitivity in
  children 6 years and older.

Dowling S, Spooner CH, Liang Y, et al. Accuracy
of Ottawa ankle rules to exclude fractures of the
ankle and midfoot in children A meta-analysis.
Acad Emerg Med 200916(4)277-287
8
Ottawa Ankle Rules
1. Is there pain in the malleolar or mid-foot
zone?
2. If yes, then if one additional finding order
x-ray of affected area
9
Case One

• Would you have ordered the x-ray on this patient?
• What would you order?
• Yes. AP, lateral and mortise ankle films. Do not
  need foot films.

10
Medial Ankle Sprain

• Uncommon injury due to the strength of the
  deltoid ligament
• Forced eversion can damage the deltoid, but more
  commonly results in an avulsion fracture of the
  medial malleolus because of the deltoids
  strength.

11
Syndesmotic Sprain(High Ankle Sprain)

• One more ligament to KNOW...actually two more
• ant and post tibiofibular ligaments (syndesmosis
  ligaments)
• Occurs with dorsiflexsion and/or eversion, often
  times with concomitant lateral force to the knee
• What exam maneuver is performed to assess for
  this sprain?

Squeeze Test
12
Syndesmotic Sprain

• Anterior tibiofibular ligament
• Posterior tibiofibular not pictured
• Positive Squeeze test on exam

13
Ankle Sprains Grade

• Three Classifications of Grades
• Grade I partial tear of ligament, no functional
  impairment, not frequently seen in the office
• Grade II incomplete tear of ligament with mild
  to moderate functional impairment, pain with
  weight bearing
• Grade III complete tear and loss of integrity of
  ligament, usually unable to bear weight
• Time for healing is not always proportional to
  grade.

14
Treatment

• RICE - rest, ice, compression, elevation
• NSAIDS
• Functional Rehabilitation vs. Immobilization - In
  grade I and II, all studies have found rehab to
  be superior to immobilization in every aspect.
• For grade III - controversial, but a few studies
  support early functional rehab
• Splints and braces - semi-rigid device allowing
  for plantar and dorsiflexion with
  stabilization/prevention of inversion/eversion

15
Rehab Program

• Functional Rehab begins on the day of the injury.
• There are four progressive phases
• Range of Motion - start immediately
• Achilles Tendon stretch
• Write upper case alphabet with great toe
• Perform each three to five times a day

16
Orthopedics Referral

• Reasons for referral
• Fracture
• Dislocation or subluxation
• Syndesmosis injury
• Tendon rupture
• Wound penetrating into the joint
• Uncertain diagnosis
• Neurovascular compromise requires emergent care

17
Case two

• A 46 yo female presents with complaints of
  burning pain in her right foot. Exam reveals
  tenderness on palpation between the third and
  fourth metatarsal heads.
• What is the differential?

18
Case two

• Differential
• Mortons Neuroma
• metatarsal stress fracture
• synovitis
• fat pad atrophy
• avascular necrosis

19
Mortons Neuroma

• entrapment of the common digital nerves at the
  base of 3rd and 4th toe.
• frequently described as walking on a pebble
• Exacerbated by wearing narrow toe box shoes (i.e.
  high heels)
• Predominant in women - FM ratio 81
• Tx change footwear, metatarsal padding, steroid
  injection. NSAIDS of little help.

20
Case three

• A 60 yo male, with hx of DM, HTN complains of
  pain at the first metatarsal phalangeal joint.
  Exam reveals a large knobby deformity on the
  medial aspect of MTP joint, mildly swollen and
  erythematous, without warmth. Also of note, the
  patient has a thick and calloused area over the
  heel.
• What is the differential?
• Why is the callus of concern in this patient?

21
Case three

• Differential
• hallux valgus (bunions)
• gout
• septic arthritis

22
Bunions

• Hallux valgus deformities are prone to
  inflammation/bursitis and osteoarthritis
• Management with NSAIDS, looser fitting footwear
• Calluses and corns (concentrated areas of
  hyperkeratosis) pose a threat for tissue
  breakdown and ulceration of skin beneath these
  areas in diabetics.
• Refer to podiatrist for debridement

23
References

• Maughan, KL. Ankle Sprain. Up To Date, 2006.
• Paige NM, Nouvong A. The top 10 things foot and
  ankle specialists wish every primary care
  physician knew. Mayo Clinical Proceedings.
  200681(6)818-822.
• Pfeffer, GB. Foot and Ankle. Essentials of
  Musculoskeletal Care, Greene, WB (2nd Ed).
  American Academy of Orthopaedic Surgeons,
  Rosemont, IL, 2001.
• Wolfe, MW, et al. Management of Ankle Sprains.
  American Family Physician 631 Jan 1, 2001.

24
Questions?