1. Leg and Ankle Problems in Primary Care Briant W. Smith, MD Orthopedic Surgery TPMG

3. Leg and Ankle Presentations 4 Trauma 4 Pain

5. Ankle Trauma 4 1. Twist and Fall--Fracture or Sprain 4 2. Patient hears/feels a pop--tendon or muscle injury

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

7. Ottawa Ankle Rules 4 Stiel IG, et al. Ann Emerg Med 1992; 21:384-390 and JAMA 1993; 269:1127-32. 4 Bachman LM, et al. Brit Med J 2003; 326: 417-428.

8. Rule out a Fracture 4 Ottawa 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. 4 When in doubt, recheck in one week or just get an xray.

9. Ottawa Ankle Rules

10. Ankle Landmarks

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

12. 5th Metatarsal Fracture

13. 4 Are 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 4 Unable to walk unassisted. 4 Tenderness at posterior edge of lateral malleolus. 4 XRs: AP/Lat/Mortise or ‘3v ankle’ or ‘ankle series’

15. Lateral Malleolus Fracture

16. Lateral Malleolus Fractures 4 Are they all the same? 4 Medial side of ankle is just as tender 4 XR shows widening of medial clear space 4 Surgical 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 4 Twisted ankle 4 Ottawa rules employed. 4 Able to walk (poorly). 4 Tenderness is in front of lateral malleolus. 4 XRs NOT ordered.

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

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

21. Sprains Treatment 4 MILD 4 RICE 4 Crutches for a few days 4 Functional splint 4 Early weight bearing and ROM 4 3-7 days to recover

22. Sprains Treatment 4 SEVERE 4 Consider Fracture or Walking Boot 4 Bear weight as tolerated 4 ROM as pain allows 4 6 wks + to recover 4 Surgery?

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

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

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

26. Other Sprains 4 Deltoid: 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. 4 Sinus tarsi syndrome: residual pain after sprain in ‘soft spot’. Responds to arch support, rehab, even injection.

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

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

29. Ankle Trauma 4 1. Twist and Fall 4 2. Felt a ‘pop’

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

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

32. Tendoachilles Rupture Palpate the TendonProneRestingPosition

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

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

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

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

37. Overuse 4 Achilles tendinitis 4 Posterior tibial tendinitis

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

39. Achilles Tendinitis

40. Posterior Tibial Tendinitis 4 ‘Acquired Flatfoot’ 4 Underdiagnosed/unrecognized 4 Middle aged patient, medial ankle/foot pain 4 Check for tenderness, swelling, arch, toe rise ability. 4 Associated with hallux valgus, tight heelcord, sometimes knee pain. 4 Treat 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 4 Shin 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 4 Often young, woman, runner 4 Sudden increases in duration/intensity 4 Can have pain with walking, but much worse with running. 4 Focal tenderness

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

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

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

48. Weakness 4 “Let’s try the toe rise test together” 4 Easy demonstration of plantarflexor power. 4 Patient won’t walk or feel right until it returns. May take a month or two.

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