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Foot and Ankle Injuries and Pain PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Foot and Ankle Injuries and Pain” by Indranil ‘Neel’ Kushare, MD.

This medical PowerPoint presentation is about foot and ankle injuries and pain, common conditions that can affect people of all ages and activity levels. These injuries and conditions can be caused by a variety of factors, including sports injuries, overuse, trauma, or underlying medical conditions.

Some of the common foot and ankle injuries and pain conditions include:

Sprained ankle: This occurs when the ligaments that hold the ankle joint together are stretched or torn, usually due to a sudden twisting or rolling of the ankle.
Achilles tendonitis: This is an overuse injury that occurs when the Achilles tendon, which connects the calf muscles to the heel bone, becomes inflamed and painful.
Plantar fasciitis: This is a common condition that occurs when the plantar fascia, a thick band of tissue that runs along the bottom of the foot, becomes inflamed and painful.
Stress fractures: These are small cracks or fractures in the bones of the foot or ankle that are caused by repetitive stress or overuse.
Bunions: This is a bony bump that forms on the joint at the base of the big toe, causing pain and discomfort.
Gout: This is a type of arthritis that occurs when uric acid crystals build up in the joints, causing pain and inflammation.

Treatment for foot and ankle injuries and pain will depend on the specific condition and severity of the injury. Some treatments may include rest, ice, compression, and elevation (RICE), physical therapy, pain medication, or surgery. It is important to seek medical attention if you are experiencing foot or ankle pain, as early intervention can help prevent further damage and improve your chances of a full recovery.

Tags : Foot Injuries, ankle injuries, sports injuries, Sprained ankle, Achilles tendonitis, Plantar fasciitis, Stress fractures, Bunions, Gout, Orthopaedic Surgery, Orthopaedic Surgery PowerPoint presentation

Published on : Jun 23, 2023 | Views : 946 | Downloads : 2

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Slide 1-

Indranil ‘Neel’ Kushare, MD Pediatric Orthopedics and Sports Specialist Texas Children’s Hospital, The Woodlands Foot and Ankle Injuries and Pain
Slide 2-

Overview Ankle sprains Ankle fractures Ankle impingement ( and other differentials of foot and ankle pain)
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1 sprain per 10,000 per day Most common ligamentous injury Most common reason for missed athletic participation A stretch or tear of one or more ankle ligaments. Once the ligaments stretch beyond its natural range, a sprain will occur Ankle Sprain
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Can a 7 year old child sprain is ankle? Is it easier for an adult or child to sprain their ankle?
Slide 5-

Up for Debate! Pre adolescent children still have open growth plates which are the weakest part of their ankle…. Children do NOT sprain or tear their ligaments as easily as adults. The reason is that in children the weakest part of their bone anatomy is the growth plates (physis). The ligaments in children are stronger and so when they twist their ankles the bone usually separates
Slide 6-

Ankle is a Hinged Joint Mortise=
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90% caused by planter flexion with inversion – injure the ATFL Syndesmosis injury (high ankle sprain) more common with eversion and/or external rotation of ankle during injury
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Anatomy of Ankle – Ligaments Fibular collateral ligament consist of the following 3 structures. These are weaker than the medial ligaments, since the fibula also helps support the ankle Anterior talofibular ligament (ATFL) Calcaneofibular ligament (CF) Posterior talofibular ligament (PTFL) Deltoid Ligament – medial
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History How did injury occur? Mechanism of injury: inversion vs eversion of ankle Where you able to bear weight/walk afterwards? Any popping/snapping? Altered sensation? Throbbing? Pain? Medication use? Swelling? Any care performed already? Interventions?
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Physical Exam Inspect Skin – color, edema, ecchymosis, Palpate – over bony and ligamentous landmarks Assess Passive and Active Range of Motion Tests: Ambulate? Toe raises? Anterior Drawer Inversion/Eversion Internal/External rotation
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Anterior Drawer Test Secure the distal leg with one hand and apply an anterior pull on the heel with the foot held in gentle plantar flexion Positive if patient will have pain, anterior translation and/or “clunk” indicationsATFL injury/rupture
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Tests – To Asses for a High Ankle Sprain: Squeeze Test – in the absence of a fracture, mid-calf compression of tibia and fibula, causes pain at the syndesmosis.
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Radiographs Indications to obtain X-rays Inability to bear weight Medial or lateral point tenderness 5th metatarsal tenderness Navicular tenderness Not always necessary if there is no bone tenderness and patient is walking comfortably If on exam suspicious for additional fractures, obtain appropriate films (tib/fib, foot… etc) AP Lateral Mortise 3 views of ankle
Slide 16-

Normal Radiograph Findings of Closed vs Open Physis
Slide 17-

Additional Imaging MRI: helps evaluate ligament and syndesmotic injuries if needed Not predictive of instability Maybe used for high-level athlete to give better estimate of return to sport Not often used in typical ankle sprain May consider if pain persists 8 weeks after sprain
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Types of Ankle Sprains High Ankle Sprains – syndesmosis injury, 1-10% of all sprains, interossoeous membrane between the tibia and fibula is involved/injured Low Ankle Sprains – ATFL and CFL injury, > 90% of ankle sprains
Slide 19-

Classification of Low Ankle Sprains From Orthobullets.com/foot-and-ankle/7028/low-ankle-sprain
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Non-Operative TreatmentFor Grade I, II, III Sprains RICE (Rest, Ice, Compression, Elevate) Rest – Depending on severity, may require short period of weight bearing with immobilization ace wrap, aircast or walker boot (However, early mobilization facilitates better recovery) If a high ankle sprain and patient has instability on stress testing patient may be NWB in cast x 4 weeks, then walking cast/boot for 2-4 weeks Ice – first 72 hours most important Compression – Ace wrap or immobilization device Elevate – (Toes above nose) A functional ankle brace (lace up ankle brace) is often helpful during strengthening period and maybe during sport/activity thereafter
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Operative Management If associated tibia or fibula fracture Continued instability, despite extensive non-operative treatment
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Therapy Activities Once edema and pain have subsided and patient as full range of motion, may begin strengthening and proprioception rehab Passive and Active Range of Motion and Strengthening Therabands Proprioceptive Activities Balance – single leg stand, advance to with eyes closed Wobble Board Trampoline Lateral Shuffle Functional Progression back to sport/activities Earlier rehab allows for quicker return to activity/sport
Slide 23-

Long Term Estimated 10-30% incidence of functional instability… often related to incomplete or inadequate treatment and rehab If an ankle sprain is not recognized, and is not treated with the necessary attention and care, chronic problems of pain and instability may result
Slide 24-

Prevention The best way to prevent ankle sprains is to maintain good strength, muscle balance and flexibility Warm-up before doing exercises and vigorous activities Pay attention to walking, running or working surfaces Wear good shoes Pay attention to your body’s warning signs to slow down when you feel pain or fatigue
Slide 25-

Pediatric Ankle Fractures
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Epidemiology Physeal Injuries About the Ankle Constitute 10-25% of physeal injuries Most common between the ages of 10 – 15 Distal tibial epiphyseal fractures second only to those in the radius High risk of growth arrest
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Distal Tibial Physeal closureBegins in the midportion  medially and posteriorlylaterally
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Anatomy (cont’d) All major ligaments (except the interosseous) either insert or originate on the distal tibial or fibular epiphyses Ligaments are stronger than the physes
Slide 29-

Salter-Harris Dias and Tachdjian
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Surgical fixation if displaced or unstable
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Ankle Impingement ANTERIOR Pinching of structures at front of the ankle Associated with ankle sprains POSTERIOR Pinching of structures at back of the ankle
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Posterior Ankle Impingement ‘Under’ diagnosed cause of posterior ankle pain related to entrapment of soft tissue or osseous anatomical structures in the hindfoot Commonly presents in athletes in plantar flexion-predominant sports with chronic posterior ankle pain exacerbated by plantarflexion or activity E.g., ballet, gymnastics, soccer, running
Slide 33-

With Forceful Ankle Plantar Flexion “Nutcracker Effect” – to the Structures in the Posterior Ankle and Subtalar Joints
Slide 34-

Causes of Posterior Ankle Impingement Os Trigonum syndrome Stieda process Downsloping of the posterior tibia Fracture of the lateral tubercle of posterior process of talus Prominent superior calcaneus (Haglund deformity) Inflammatory SOFT tissue Ankle sprainavulsion fracture of posterior talofibular ligament2 impingement
Slide 35-

Soft Tissue Impingement – Don’t Underestimate! Posterior capsule and ligaments – inflamed, thickened and hypertrophied FHL sheath Accessory ligament, the posterior intermalleolar ligament (PIML)- identified it in 56% of cadaver specimens X-rays are often NORMAL!!
Slide 36-

Case 1 13 y.o. female, basketball player First seen by PCP: December 2014 First seen by specialist: December 2015 Number of years experiencing pain: TWO Number of X-rays: 3 Advanced Imaging: 1 MRI Specialties seen: Sports medicine (7 visits), physical therapy (15 visits) Diagnoses: Sever’s apophysitis, Achilles Tendonitis, calf tightness, hip weakness, calcaneus - old injury (Abnormal MRI)
Slide 37-

Case 2 14 y.o. female, gymnast First seen by PCP: November 2015 First seen by specialist: February 2016 Number of years experiencing pain: >1 Specialties seen: Next slide Number of X-rays: 8 Advanced Imaging: 2 MRI Diagnoses: Chronic regional pain syndrome, peroneal tendonitis, atrophy of R ankle, ankle sprain, sural nerve block for possible sural neuropathy vs peroneal brevis tendinopathy, stress reaction – Inability to cope
Slide 38-

Specialties Seen Orthopedics (5 different orthopedic surgeons) Sports medicine (2 visits) Physical therapy (15+ visits) Pain medicine (4 visits) – Sural nerve block – complete atrophy of skin, muscles and soft tissues around the sural nerve distribution Psychologist! (5 visits) Number of X-rays: 8 Advanced Imaging: 2 MRI Diagnoses: Chronic regional pain syndrome, peroneal tendonitis, atrophy of R ankle, ankle sprain, sural nerve block for possible sural neuropathy vs peroneal brevis tendinopathy, stress reaction – inability to cope
Slide 39-

Case 3 14 y.o. male, soccer player Side of injury: Right + Left First seen by specialist: December 2014 Number of years experiencing pain: TWO Specialties seen: Orthopedics (6 visits), sports medicine (2 visits), physical therapy (15+ visits) Number of X-rays: 7, Advanced Imaging: 3 MRI, 1 CT Diagnoses: Possible osteochondritis dissecans lesion, Chronic regional pain syndrome, ‘Deconditioned’ ankle, ankle sprain
Slide 40-

Case 4 8 y.o. subluxating peroneal tendons and ankle pain Scheduled for ‘groove deepening surgery’
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Similarities? Exquisite tenderness over the posterior ankle joint over talar process In front of the Achilles not Achilles tendinitis) Not on the Achilles insertion (not SEVERS DISEASE) Not laterally (no peroneal tendinopathy/ankle sprain) Joint pain posterior to lateral malleolus which correlates exactly to the site of pathology as seen in the MRI All patients had the exact same clinical finding:
Slide 42-

Similarities? For all patients, pain was completely relieved with rest Pain exacerbated by activity and young athletes could not continue sports activities X-ray imaging for read normal and MRI findings for all patients demonstrated the very similar findings Each patient had experienced pain for at least 1-2 years prior to being treated by an orthopaedic surgeon Each patient visited with a large number and variety of health specialists while seeking treatment for their various underlying conditions
Slide 43-

Os trigonum (7% normal population)
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Case 3 Bone marrow edema near the posterior ankle 44
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Treatment – Conservative Conservative treatment has been empirically recommended Efficacy has not been well documented Review of the literature suggests that little new information has been published in the past 3 decades
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Treatment – Conservative Steroid and local anesthetic injections are often employed to reduce inflammation and pain Hamilton would not inject because of the vicinity of the tibial nerve In Calder’s series of soccer players, all 28 patients had at least 1 injection (average 2; range 1–5) before surgery Marotta would not use steroid injections because of the risk of tendon rupture
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Treatment – Surgical Van Dijk, in 2000, two-portal minimally invasive arthroscopic treatment
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Steida Process with Osteotome 49
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Two ‘Poke Hole’ Incisions Before : Pain in the Os After: Pain in the Os, no more ! 50
Slide 51-

Take Home Points Posterior ankle impingement is an under-diagnosed / Misdiagnosed cause of chronic ankle pain common in young athletes especially in Houston area Pediatricians , Podiatrists, sports med docs, orthopedic surgeons, radiologists, PTs, ATCs, and anybody dealing with young athletes need to keep this diagnosis on their radar whenever they see a kid with posterior ankle pain Even if X-rays normal – don’t underestimate!
Slide 52-

Take Home Points Clinical exam + MRI = diagnostic Ankle arthroscopy – minimally invasive treatment to give excellent (almost dramatic) pain relief in this condition if no relief with conservative Rx Back to sports in 4-6 weeks !
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ALL 0/10 on VAS , AOFAS Scores 100/100 Case 2 Follow up: mother when asked how she is doing, at week 2 after ankle scope – “She is doing AWESOME! She has finally been cured” At 3 months:Participated in 2 meets and selected for state gymnastics 53
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54 Case 3
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