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Ankle Sprain Imitators Leslie A. Michaud, M.D. Steadman Hawkins Clinic of the Carolinas Primary Care Sports Medicine Fellow.

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Presentation on theme: "Ankle Sprain Imitators Leslie A. Michaud, M.D. Steadman Hawkins Clinic of the Carolinas Primary Care Sports Medicine Fellow."— Presentation transcript:

1 Ankle Sprain Imitators Leslie A. Michaud, M.D. Steadman Hawkins Clinic of the Carolinas Primary Care Sports Medicine Fellow

2 Foot and ankle Statistics 1982: NCAA develops the ISS (injury surveillance system) 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 Olympic summer games Athens – 22% of injuries were ankle sprains Olympic winter games Salt Lake City – 25% foot and ankle Collegiate basketball - higher rate of grade I ankle sprains in women than men

3 Tibia Fibula Talus Lateral Malleolus Medial Malleolus Subtalar joint Tibial Plafond ge_files/foot_ankle_images/ankle-xray-normal-2.jpg

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5 Resists posterior displacement Provides stabilization in plantarflexion Stabilizes ankle and subtalar joint; especially during inversion

6 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

7 Imitators Osteochondral lesions of the talar dome Lateral process talar fractures Peroneal tendon subluxation and dislocation Base of the 5 th metatarsal (avulsion) Tarsal coalition

8 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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10 Osteochondral Lesion Presentation Persistent pain and swelling well after injury Occasionally will have a slow onset +/- mechanical symptoms ▫Intraarticular process

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12 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

13 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

14 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

15 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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17 MOI: dorsiflexion + inversion + ER force More of an impact or crush injury Comminution More often than not have IA involvement

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19 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)

20 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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22 Superficial Peroneal Nerve Supplies lateral compartment muscles High incidence of neuropraxia ▫Grade II and III sprains Almost all resolve spontaneously with time

23 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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25 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

26 Tarsal Coalition Congenital fusion of tarsal bones ▫Calcaneus to navicular most common  8-12 years old ▫Talus to calcaneus  years old Rigid flatfoot “Peroneal spastic flatfoot”

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28 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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30 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

31 Questions?

32 Bibliography 1.Dick R, Agel J, Marshall SW: National Collegiate Athletic Association Injury Surveillance System commentaries:Introduction and methods. J Athl Train 2007;42(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): Borowski LA, Yard EE, Fields SK, Comstock RD: The epidemiology of US high school basketball injuries, 2005-Am J Sports Med 2008;36(12): 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): 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: Anderson RB, Hunt KJ, McCormick JJ. J Am Acad Orthop Surg 2010;18: McCrory P, Bladin C: Fractures of the lateral process of the talus: A clinical review. “Snowboarder’s ankle”. Clin J Sport Med 1996;6: Boon AJ, Smith J, Zobitz ME, Amrami KM: Snowboarder’s talus fracture: Mechanism of injury. Am J Sports Med 2001;29: 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 Elsevier2009 Saunders, An Imprint of Elsevier 12.Renstrom PA: Persistently painful sprained ankle. J Am Acad Orthop Surg 1994;2(5): Nitz AJ, Dobner JJ, Kersey D: Nerve injury and grades II and III ankle sprains. Am J Sports Med 1985;13(3):


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