Ankle Sprain Imitators Leslie A. Michaud, M.D. Steadman Hawkins Clinic of the Carolinas Primary Care...
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![Page 1: Ankle Sprain Imitators Leslie A. Michaud, M.D. Steadman Hawkins Clinic of the Carolinas Primary Care Sports Medicine Fellow.](https://reader035.fdocuments.net/reader035/viewer/2022081513/551c42e45503467b488b4b9d/html5/thumbnails/1.jpg)
Ankle Sprain Imitators
Leslie A. Michaud, M.D.Steadman Hawkins Clinic of the CarolinasPrimary Care Sports Medicine Fellow
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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
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Tibia
Fibula
TalusLateral Malleolus
Medial Malleolus
Subtalar joint
Tibial Plafond
http://www.emedx.com/emedx/diagnosis_information/diagnosis_information_image_files/foot_ankle_images/ankle-xray-normal-2.jpg
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Resists posterior displacement
Provides stabilization in plantarflexion
Stabilizes ankle and subtalar joint; especially during inversion
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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
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Imitators
•Osteochondral lesions of the talar dome
•Lateral process talar fractures
•Peroneal tendon subluxation and
dislocation
•Base of the 5th metatarsal (avulsion)
•Tarsal coalition
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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
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Osteochondral Lesion Presentation
•Persistent pain and swelling well after
injury
•Occasionally will have a slow onset
•+/- mechanical symptoms
▫Intraarticular process
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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
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Diagnosis and Treatment
•CT or MRI if radiographs negative and suspicion is high
•Conservative▫Rest and immobilization
•Surgical▫Drilling▫Debridement▫Excision of fragment▫Osteochondral graft
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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
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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
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• MOI: dorsiflexion + inversion + ER force
•More of an impact or crush injury
•Comminution
•More often than not have IA involvement
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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)
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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
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Superficial Peroneal Nerve
•Supplies lateral compartment muscles
•High incidence of neuropraxia
▫Grade II and III sprains
•Almost all resolve spontaneously with
time
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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
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Treatment
• Conservative▫Acute injuries
Reduce tendon and SLWB cast for 6 weeks 50% success rate
▫Chronic PT
• Surgical▫Reattachment▫Deepen groove▫Reroute tendon▫Reconstruct retinaculum▫Bone block
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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”
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History and Physical Exam•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
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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
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Questions?
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Bibliography1. Dick R, Agel J, Marshall SW: National Collegiate Athletic Association Injury Surveillance
System commentaries:Introduction and methods. J Athl Train 2007;42(2):173-182.2. Hootman JM, Dick R, Agel J:Epidemiology of collegiate injuries for 15sports: Summary
and recommendations for injury prevention initiatives. J AthlTrain 2007;42(2):311-319.3. Borowski LA, Yard EE, Fields SK, Comstock RD: The epidemiology of US high school
basketball injuries, 2005-Am J Sports Med 2008;36(12):2328-2335.4. Badekas T, Papadakis SA, Vergados N,et al: Foot and ankle injuries during the Athens
2004 Olympic Games. J Foot Ankle Res 2009;2:9.5. Crim JR: Winter sports injuries: The 2002 Winter Olympics experience and a review of
the literature. Magn Reson Imaging Clin N Am 2003;11(2):311-321.6. Hosea TM, Carey CC, Harrer MF: The gender issue: Epidemiology of ankle injuries in
athletes who participate in basketball. Clin Orthop Relat Res 2000;372:45-497. Anderson RB, Hunt KJ, McCormick JJ. J Am Acad Orthop Surg 2010;18:546-5568. McCrory P, Bladin C: Fractures of the lateral process of the talus: A clinical review.
“Snowboarder’s ankle”. Clin J Sport Med 1996;6:124-128.9. Boon AJ, Smith J, Zobitz ME, Amrami KM: Snowboarder’s talus fracture: Mechanism of
injury. Am J Sports Med 2001;29:333-338.10. Weatherby, Brian. “Start Smart: What Every Practitioner Should Know About Treating
Foot and Ankle Pain.” Powerpoint presentation.11. DeLee and Drez's Orthopaedic Sports Medicine, 3rd ed. Copyright ©
2009 Saunders, An Imprint of Elsevier 12. Renstrom PA: Persistently painful sprained ankle. J Am Acad Orthop Surg
1994;2(5):270-280.13. Nitz AJ, Dobner JJ, Kersey D: Nerve injury and grades II and III ankle sprains. Am J
Sports Med 1985;13(3):177-182.