25 Lateral Soft Tissue Injuries of the Ankle(student copy)(1).pdf

Lateral Soft Tissue Injuries of the Ankle z Jarrod Smith, DPM FACFAS Assistant Professor z Learning Objectives § Demonstrate the knowledge of lateral ankle anatomy and function. § Demonstrate the knowledge of associated biomechanics and anatomic varianc...

Lateral Soft Tissue Injuries of the Ankle z Jarrod Smith, DPM FACFAS Assistant Professor z Learning Objectives § Demonstrate the knowledge of lateral ankle anatomy and function. § Demonstrate the knowledge of associated biomechanics and anatomic variances of lateral ankle pathology. § Demonstrate the knowledge of the clinical evaluation of ankle instability. § Demonstrate the knowledge of the radiographic findings associated with lateral ankle injuries and ankle instability. § Demonstrate the knowledge of treatment options for acute and chronic lateral ankle injuries. z Ankle Injuries § Among the most common injuries presenting to primary care providers and emergency departments. § Approximately 2 million ankle sprains occur in the USA annually. § Ankle sprains can result in significant time lost to disability. § Repeated sprains can result in chronic ankle instability, degenerative joint changes, and chronic pain. Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Anatomy: Lateral Ankle Ligaments § Anterior talofibular ligament (ATFL) § Most common injured ankle ligament. § Ligament is intracapsular (intra-articular). § Prevents anterior translation of the talus. § Considered the primary stabilizer of the ankle § Ligament is tight in plantarflexed inversion and loose in dorsiflexed eversion. Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Anatomy: Lateral Ankle Ligaments § Calcaneofibular ligament (CFL) § Second most common injured ankle ligament § Ligament is extracapsular (extra-articular) § Resists ankle and subtalar inversion § Peroneal tendons reside superficial to the CFL § Crosses the ankle and subtalar joint § Ligament is tight in dorsiflexed inversion Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Anatomy: Lateral Ankle Ligaments § Posterior talofibular ligament (PTFL) § Strongest and least common injured ankle ligament. § Injury usually involves ankle fractures and/or dislocations § Ligament is intracapsular (intra-articular). § Ligament is tight in dorsiflexed inversion. § Prevents posterior translation of the talus. Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Anatomy: Lateral Ankle Ligaments Netter, Frank H. 509. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019. z Anatomy: Lateral Ankle Ligaments Netter, Frank H. 507. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019. z Anatomy: Syndesmosis § Distal tibiofibular ligament complex § Anterior Inferior tibiofibular ligament (AITFL) § Posterior Inferior tibiofibular ligament (PITFL) § Transverse tibiofibular ligament § Deep component of the PITFL § Interosseous Tibiofibular ligament (membrane) § Spans the length of the tibia and fibula § Injury occurs with forced dorsiflexion and eversion Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Anatomy: Syndesmosis Netter, Frank H. 505. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019. z Anatomy: Syndesmosis Netter, Frank H. 505. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019. z Anatomy: Syndesmosis Netter, Frank H. 507. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019. z Anatomy: Deltoid Ligament § Superficial structures: § Tibionavicular § Tibiocalcaneal § Superficial posterior tibiotalar § Deep structures: § Anterior Tibiotalar § Deep Posterior Tibiotalar § Complete rupture is rare à Medial malleolus avulsion fracture Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Anatomy: Deltoid Ligament Netter, Frank H. 509. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019. z Acute Ankle Sprains § Lateral ankle sprains comprise as much as 85% of ankle sprains § Syndesmotic sprains occur in as much as 10% of lateral ankle sprains § Deltoid ankle sprains comprise as much as 15% of ankle sprains Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Ankle Sprain Classification § Grade 1 (Mild) § Stretching of the affected ligament(s) § Pain on palpation § Mild edema § No instability on examination § No loss of function/motion Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Acute Ankle Sprain Classification § Grade 2 (Moderate) § Incomplete tearing of the affected ligament(s) § Pain on palpation § Moderate edema § Ecchymosis § Mild/moderate instability on examination § Some loss of function § Moderate pain with weight bearing Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Acute Ankle Sprain Classification § Grade 3 (Severe) § Complete tearing of the affected ligament(s) § Pain on palpation § Diffuse edema § Diffuse ecchymosis § Significant instability on examination § Significant loss of function § Inability to bear weight Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Acute Ankle Sprains z The Ottawa Ankle Rules § Demonstrated that more than 95% of patients with ankle injuries had radiographs, but 85% were negative for fracture. § An estimated 500,000,000 is spent annually on ankle radiographs in Canada and the United States (1994) § Use of these rules decreased ankle radiographs by 28% and foot radiographs by 14%. Stiell I. Ottawa ankle rules. Canadian family physician. 1996;42:478. z The Ottawa Ankle Rules § A) Palpate the posterior border of the fibula from the distal tip of the lateral malleolus to the area 6 cm proximal. § B) Palpate the posterior border of the tibia from the distal tip of the medial malleolus to the area 6 cm proximal. § C) Palpate the base of the 5th metatarsal. § D) Palpate the navicular from the dorsal aspect to the tuberosity. Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the ottawa ankle rules. Jama. 1994;271(11):827-832. z The Ottawa Ankle Rules § A and B § Pain on palpation = 3 views of the ankle § Inability to bear weight immediately after injury or in the ED = 3 views of the ankle § C and D § Pain on palpation = 3 views of the foot § Inability to bear weight immediately after injury or in the ED = 3 views of the foot Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the ottawa ankle rules. Jama. 1994;271(11):827-832. z Stiell I. Ottawa ankle rules. Canadian family physician. 1996;42:478. z Acute Ankle Sprains § Clinical examination – 15 step proximal to distal evaluation § 1 – Palpate proximal fibula to r/o Maisonneuve fracture § 2 – Evaluate syndesmosis with external rotation and proximal squeeze (medial to lateral) § 3 – Palpate the medial malleolus § 4 – Palpate the Deltoid ligament § 5 – Palpate the posterior tibial tendon Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Ankle Sprains § Clinical examination – 15 step proximal to distal evaluation § 6 – Palpate the lateral malleolus § 7 – Palpate the ATFL à anterior drawer test § 8 – Palpate the CFL à talar tilt § 9 – Palpate PTFL § 10 – Palpate the peroneal tendons and evaluate for subluxation Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Ankle Sprains § Clinical examination – 15 step proximal to distal evaluation § 11 – Palpate the anterior talus with foot plantarflexed à OCD § 12 – Palpate the Achilles tendon § 13 – Palpate the calcaneal wall and anterior process § 14 – Palpate the dorsal navicular and tuberosity § 15 – Palpate the 5th metatarsal base Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Lateral Ankle Sprains § External rotation § Clinical test to evaluate for syndesmotic injury § Stabilize the leg § Grasp the forefoot § Externally rotate the foot § Compare to the contralateral side Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Lateral Ankle Sprains § Fibular squeeze (proximal squeeze) § Clinical test to evaluate for syndesmotic injury § Compress the tibia and fibula together which stresses the syndesmosis by splaying the tibia and fibula distal to compression § Positive with pain at syndesmosis Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Lateral Ankle Sprains § Fibular squeeze (proximal squeeze) § Clinical test to evaluate for syndesmotic injury Compress § Compress the tibia and fibula together which stresses the syndesmosis by splaying the Splay tibia and fibula distal to compression § Positive with pain at syndesmosis Netter, Frank H. 505. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019. z Acute Lateral Ankle Sprains § Anterior drawer § Clinical test to evaluate the ATFL § Lock the anterior leg § Cup the heel § Attempt to translate the foot anteriorly § Compare to the contralateral side Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Lateral Ankle Sprains § Anterior drawer § Clinical test to evaluate the ATFL § Lock the anterior leg § Cup the heel § Attempt to translate the foot anteriorly § Compare to the contralateral side Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Lateral Ankle Sprains § Anterior drawer § Clinical test to evaluate the ATFL § Lock the anterior leg § Cup the heel § Attempt to translate the foot anteriorly § Compare to the contralateral side Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Lateral Ankle Sprains § Talar Tilt § Clinical test to evaluate the CFL § Lock the medial leg § Cup the heel § Invert the calcaneus § Compare to the contralateral side Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Lateral Ankle Sprains § Talar Tilt § Clinical test to evaluate the CFL § Lock the medial leg § Cup the heel § Invert the calcaneus § Compare to the contralateral side Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Lateral Ankle Sprains § Talar Tilt § Clinical test to evaluate the CFL § Lock the medial leg § Cup the heel § Invert the calcaneus § Compare to the contralateral side Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Radiographic Evaluation for Syndesmotic Injuries § Three most common methods § Mortise View § Medial clear space § Medial clear space = superior clear space § Space > 6mm = likely rupture https://www.startradiology.com/internships/general-surgery/ankle/x-ankle/index.html z Radiographic Evaluation for Syndesmotic Injuries § Three most common methods § Mortise View § Medial clear space § Medial clear space = superior clear space § Space > 6mm = likely rupture Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Radiographic Evaluation for Syndesmotic Injuries § Three most common methods § AP View § Tibiofibular overlap § Less than 10 mm increases likelihood of rupture Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Radiographic Evaluation for Syndesmotic Injuries § Three most common methods § AP View § Tibiofibular clear space § Measured 1 cm superior to the tibial plafond § > 5 mm = increased likelihood of rupture Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Lateral Ankle Sprains § Diagnosis is made by physical examination § Further imaging may be necessary depending on physical exam findings § Radiographs § Suspected fractures § Ottawa rules/15 step examination § Stress radiographs § MRI § Suspected peroneal pathology § Suspected osteochondral defect § Confirmation of injury if severe Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Acute Lateral Ankle Sprains § Ligament healing time § 6 weeks to 3 months depending on grade of injury and patient § Conservative treatment is successful up to 90% of the time § Functional rehabilitation is not curative for grade 3 syndesmotic injuries § Surgical reduction and stabilization is required Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Treatment of Acute Lateral Ankle Sprains § PRICE § Protection from further injury (restrict inversion) § Air cast (stirrup splint)??? Allows dorsiflexion and plantarflexion § Controlled Ankle Motion (CAM) Boot/Short Leg Walking (SLW) Boot § WB Cast § NWB Cast § Rest § Ice § 20 minutes on 20 minutes off § Elevation Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Treatment of Acute Lateral Ankle Sprains § PRICEMMMS § Protection, Rest, Ice, Compression, Elevation § Medications à NSAIDs to reduce pain & swelling § Modalities à Electrical stimulation, ultrasound, contrast baths § Mobilization à Controversial § Many advocate for active dorsiflexion and plantarflexion to commence on day of injury to decrease edema. § Does this make sense in a grade 3 ATFL sprain? § Strengthening à rehabilitation of the peroneal tendons Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Treatment of Acute Lateral Ankle Sprains § Early Mobilization § The vast majority of what you read and hear involving ankle sprains will include “early mobilization” § I personally do not institute early mobilization which includes plantarflexion (I am in the minority) § Refer to the previous anatomy material § What happens the ATFL in plantarflexion? § What if it is torn? Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Treatment of Acute Lateral Ankle Sprains § Close-Packed Position § The joint position in which articulating bones have their maximum area of contact with each other. § It is in this position that joint stability is greatest. § Foot 90 degrees to the leg to max dorsiflexion. § Open-Packed Position § The joint position in which articulating bones have their least area of contact with each other. § It is the position in which joint instability is greatest. § Foot plantarflexed 10 degrees to the leg to max plantarflexion. z Treatment of Acute Lateral Ankle Sprains § I keep my acute ankle sprain patients in the close-packed position for 3 weeks followed by physical therapy. § If in a CAM boot, I allow them to unstrap the foot and perform active dorsiflexion. § Plantarflexion will create a gap between the ends of ruptured ligaments. z Treatment of Acute Lateral Ankle Sprains § Grade III Syndesmotic injuries § Immobilization followed by physical therapy is contraindicated!!! § Surgical reduction and stabilization is required § Unless patient is not a surgical candidate. z Treatment of Acute Lateral Ankle Sprains § Grade III Syndesmotic injuries Hardy, Mark A., Hild, Gina A. Chapter 50: Acute Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Chronic Ankle Instability § Acute ankle sprains can lead to chronic ankle instability § Biomechanical causes: § Pathologic laxity § Recurrent ankle sprains § Connective soft tissue disorder Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Chronic Ankle Instability § Acute ankle sprains can lead to chronic ankle instability § Biomechanical causes: § Anatomic variance § Rearfoot/calcaneal varus § Forefoot valgus § Plantarflexed first ray Camasta, Craig A. Cass, Andrea D. Chapter 42: Pes Cavus Surgery. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Chronic Ankle Instability § Acute ankle sprains can lead to chronic ankle instability § Functional causes § Proprioceptive abnormalities § Loss of neuromuscular control § Strength deficits Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Treatment of Chronic Ankle Instability § Conservative Treatment § Neuromuscular training à exercises to increase strength and balance § Wobble board § Hop to stabilization § Single limb stance § Taping/bracing Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Treatment of Chronic Ankle Instability § Surgical Treatment § Direct repair § Brostrom Schnirring-Judge, Molly. Perlman, Michael D. Chapter 35: Chronic Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Third Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Treatment of Chronic Ankle Instability § Surgical Treatment § Direct repair § Brostrom-Gould § 60% increase in strength Schnirring-Judge, Molly. Perlman, Michael D. Chapter 35: Chronic Ankle Conditions. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Third Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. z Treatment of Chronic Ankle Instability § Surgical Treatment § Indirect Repair (Historical) § A – Watson-Jones § B – Evans § C – Chrisman-Snook § Sacrifice the PB Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. z Treatment of Chronic Ankle Instability § Surgical Treatment § Indirect Repair (Contemporary) § Autograft § split PL free graft (Dockery) § Allografts § Fresh-frozen PL § Synthetics § Arthrex Internal Brace Evans RD, Feller SR, Heath NS. Review of the Dockery procedure for lateral ankle instability. a seven-year retrospective analysis. Journal of the american podiatric medical association. 1998;88(6):279-284. z Treatment of Chronic Ankle Instability § Post Operative Course § NWB for 2 – 4 weeks (Splint then cast once edema is controlled) § Walking cast/CAM boot for 2 – 4 weeks § Physical therapy at 6 – 8 weeks § Running – 3 months at the earliest z Peroneal Tendon Pathology § Peroneal tendinitis § Peroneal tendon tears/ruptures § Peroneal subluxation/dislocation § Painful Os Peroneum z Peroneal Tendon Anatomy § The peroneal tendons reside in the lateral compartment of the leg. § The longus and brevis share a common tendon sheath until reaching the side wall of the calcaneus. § They course around the ankle within the retro-malleolar groove. § The peroneal tendons are held in place by the superior peroneal retinaculum. § The myotendinous junction of the PB should be proximal to the superior retinaculum z Peroneal Tendon Anatomy § The common sheath splits at the peroneal tubercle. § Peroneus Brevis runs superior § Peroneus Longus runs inferior § The PB tendon inserts on the styloid process. § The PL tendon courses around the cuboid (within the cuboid groove) and inserts on the base of the 1st metatarsal cuneiform joint. § The os peroneum is a variant sesamoid bone. § Located within the PL tendon at the cuboid notch z Peroneal Tendon Anatomy Netter, Frank H. 514. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019. z Peroneal Tendon Anatomy Netter, Frank H. 510. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019. z Peroneal Tendon Anatomy Netter, Frank H. 519. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019. z Peroneal Tendon Pathology § Often occur after acute ankle sprains § Rarely is an isolated finding § Low lying PB muscle belly § Presence of a peroneus quartus § Hypertrophic peroneal tubercle § Laxity or rupture of the SPR § Hypertrophic os peroneum z Peroneal Tendon Pathology § Biomechanical causes: § Rearfoot varus § Forefoot valgus § Plantarflexed first ray z Peroneal Tendon Pathology § Physical Examination § Pain on palpation § Posterior fibula à Both PB and PL § Calcaneal side wall à Peroneal tubercle § 5th metatarsal base à PB insertion § Cuboid notch à PL tendon, os peroneum, § Muscle strength testing à eversion § Clicking/popping or dislocation with ankle circumduction z Peroneal Tendon Pathology § Physical Examination § Evaluation of ankle stability § Anterior drawer § Talar tilt § Stance Evaluation § RCSP § Coleman block test z Peroneal Tendon Pathology § Imaging § Radiographs § Os peroneum § Fibular fleck fracture § avulsion fragment of the SPR z Peroneal Tendon Pathology § Imaging § MRI – § Most utilized modality § Tenosynovitis § Tendon tears/SPR tears § Low lying PB muscle belly § Be cognizant of false positives § magic angle z Peroneal Tendon Pathology § Conservative care: § Immobilization § Cast, CAM boot, ankle brace § NSAIDs § Ice § Valgus wedge/lateral lift § In shoe § Addition to orthotics z Peroneal Tendon Pathology § Surgical Treatment § Tenosynovectomy § Repair of tendon tear § Tears are usually longitudinal § Excision of low lying muscle belly § Excision of peroneus quartus § Resection of hypertrophic peroneal tubercle § Resection of os peroneum Hutchinson B. Chapter 38: repair of Peroneal Subluxation. Master Techniques in Podiatric Surgery: The Foot & Ankle. Philadelphia, PA: Lippincott Williams & Wilkins, 2005. z Peroneal Tendon Pathology § Surgical Treatment § Repair of superior retinaculum § Direct repair § Retro-malleolar groove deepening § Fibular bone block § Peroneal longus to brevis tenodesis (Peroneal stop) § Severe PL tendinopathy or rupture § Attenuation following resection of os peroneum Hutchinson B. Chapter 38: repair of Peroneal Subluxation. Master Techniques in Podiatric Surgery: The Foot & Ankle. Philadelphia, PA: Lippincott Williams & Wilkins, 2005. z Peroneal Tendon Pathology § Surgical Treatment § Repair of superior retinaculum § Direct repair § Retro-malleolar groove deepening § Fibular bone block § Peroneal longus to brevis tenodesis (Peroneal stop) § Severe PL tendinopathy or rupture § Attenuation following resection of os peroneum Hutchinson B. Chapter 38: repair of Peroneal Subluxation. Master Techniques in Podiatric Surgery: The Foot & Ankle. Philadelphia, PA: Lippincott Williams & Wilkins, 2005. z Peroneal Tendon Pathology § Surgical Treatment § Repair of superior retinaculum § Direct repair § Retro-malleolar groove deepening § Fibular bone block § Peroneal longus to brevis tenodesis (Peroneal stop) § Severe PL tendinopathy or rupture § Attenuation following resection of os peroneum Hutchinson B. Chapter 38: repair of Peroneal Subluxation. Master Techniques in Podiatric Surgery: The Foot & Ankle. Philadelphia, PA: Lippincott Williams & Wilkins, 2005. z Peroneal Tendon Pathology § Surgical Treatment § Always evaluate for biomechanical causes of peroneal pathology § Chronic ankle instability à Direct/Indirect repair § Calcaneal varus à Consider a Dwyer osteotomy § Plantarflexed first ray à Dorsiflexory osteotomy or peroneal stop z Case #1 § 23 year old female presents following an acute left ankle sprain 3 days ago § She rolled her ankle while running § Reports her foot “tipped inward” on the edge of the sidewalk § Does not recall any severe ankle sprains in the past § No prior symptoms of instability or ankle pain § Pain is 8/10 with WB and 4/10 at rest § She can walk, but it is difficult and painful § She has been icing, using an ACE wrap, and using crutches z Case #1 § Vascular Exam § DP and PT pulses are palpable at 2/4 bilaterally § Diffuse edema present at the lateral left ankle z Case #1 § Dermatological Exam § Diffuse ecchymosis at her lateral ankle § No other abnormal findings are noted z Case #1 § Neurological Exam § Sensation is intact bilaterally § No deficits are appreciated z Case #1 § Musculoskeletal Exam § ROM § WNL on the right § Mildly limited due to edema and pain on the left § Muscle strength § 4/5 with eversion on the left § Remaining groups are 5/5 z Case #1 § Musculoskeletal Exam § No pain present at the proximal fibula § External rotation and proximal squeeze negative for pain § No pain at the medial malleolus § No pain at the deltoid ligament § No pain at the posterior tibial tendon z Case #1 § Musculoskeletal Exam § No pain at the lateral malleolus § Pain on palpation of the ATFL. Positive anterior drawer on the left (negative on the right) § No pain at the CFL. Talar tilt is negative on the left and right § No pain at the PTFL § No pain at the peroneal tendons. No subluxation with circumduction z Case #1 § Musculoskeletal Exam § No pain on palpation of the anterior joint line § No pain or palpable defect at the Achilles tendon § No pain at the calcaneal sidewall/anterior process § No pain at the navicular § No pain at 5th metatarsal base z Case #1 § Diagnosis? § Treatment? § Likelihood of a positive outcome? z References, Recommended Reading, & Resources § Chang TJ. Master Techniques in Podiatric Surgery: The Foot and Ankle. Philadelphia: Lippincott Williams & Wilkins; 2005 § Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar;98(2):313-29. § Evans RD, Feller SR, Heath NS. Review of the Dockery procedure for lateral ankle instability. a seven-year retrospective analysis. Journal of the american podiatric medical association. 1998;88(6):279-284. § McGlamry’s Comprehensive Textbook of Foot & Ankle Surgery. 3rd Ed. Chapter 35. § McGlamry’s Comprehensive Textbook of Foot & Ankle Surgery. 4th Ed. Chapters 50 & 77 § Nichols, Aimee A. Chapter 62: Radiographic Analysis of Ankle Ligamentous Injuries. The Podiatry Institute Update 2003. § http://www.podiatryinstitute.com/pdfs/Update_2003/2003_62.pdf § https://www.startradiology.com/internships/general-surgery/ankle/x-ankle/index.html § Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the Ottawa ankle rules. Jama. 1994;271(11):827-832. § Stiell I. Ottawa ankle rules. Canadian family physician. 1996;42:478. z Copyright Notice: § This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws.