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MS3 Sports medicine workshop

MS3 Sports medicine workshop. Family Medicine Clerkship. Foot, Ankle and Lower Leg Problems. MS3 Family Medicine. Objectives. Define relevant anatomy, physiology, and radiographic features of the foot, ankle and lower leg

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MS3 Sports medicine workshop

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  1. MS3 Sports medicine workshop Family Medicine Clerkship

  2. Foot, Ankle and Lower Leg Problems MS3 Family Medicine

  3. Objectives • Define relevant anatomy, physiology, and radiographic features of the foot, ankle and lower leg • Recognize history, presenting signs and pertinent exam findings of common problems • Review treatment of common problems

  4. Tibia Fibula Talus Dome Neck Calcaneus Medial tubercle Anterior process Posterior process Ankle Bones

  5. Foot Bones

  6. What are these things? • Fractures • Sesamoids • Joint crystals • Phleboliths

  7. Lateral Ankle

  8. Medial Ankle“Tom, Dick and Harry”

  9. Anterior Ankle“Tom’s Hairy D!&#”

  10. Dorsal foot • Extensor tendons • Dorsal pedis artery • Digital nerves

  11. Posterior Leg and Ankle

  12. Plantar Foot • Plantar fascia • Longitudinal collagen fibers • Medial calcaneal tubercle • Proximal phalanges • Plantar nerves

  13. Midfoot Congruity • Tarsometatarsal Articulation (Lisfranc) • Transverse ligaments

  14. Physical Examination“MSK BIG-6” • Inspection • Palpation • Range of motion • Strength • Neurovascular • Special Tests

  15. Which foot is overpronated? • A • B • C • D D A B C

  16. Normal Ankle X-ray AP Lateral Mortise

  17. Normal Foot X-ray

  18. Acute Foot and Ankle Injuries • Bone • Ligament • Muscle Tendon • Nerve – Blood Vessels • Remember mechanism of injury!

  19. Case # 1 • 26 yo male with ankle pain • Landed on foot while playing basketball • Stopped playing • Lateral pain • Able to limp off court and into your office

  20. Case #1 History • Previous history: several prior sprains • Previous rehabilitation: minimal • Ankle protection: none recently • Ability to bear weight: yes • Neurovascular symptoms: no

  21. Case #1 Physical Exam • Inspection: • Able to walk • Swelling, slight bruising laterally • Palpation: TTP ant-distal to LatMall, but not on bone • ROM: decreased DF, PF, Inv, Ev • Strength: mild decrease • Neurovascular intact • Special Tests: • Drawer: normal • Talar tilt: normal

  22. Talar Tilt - ATFL/CFL

  23. Which of the following would indicate need for an x-ray? • Unable to bear weight • Tender over posterior lateral malleolus • Tender over posterior medial malleolus • Tender on navicular bone • Tender on 5th MT base • All of the above

  24. Ottawa Ankle RulesWhen to x-ray acute ankle sprains • Unable to bear weight • Tender over posterior lateral malleolus • Tender over posterior medial malleolus • Tender on navicular bone • Tender on 5th MT base

  25. Lateral Ankle Sprains • Grade 1 – Ligament stretch • Grade 2 – Ligament partial tear • Grade 3 – Ligament complete tear

  26. What is the treatment for a Grade 1-2 lateral ankle sprain? • RICE  rehab • RICE  brace  rehab • RICE  cast • Surgical repair of the ATFL

  27. Lateral Ankle Sprain • Treatment • PRICEMM: Protect, rest, ice, compress, elevate, Meds • Brace for 1-3 months during activity • Gradual ROM exercise • Physical Therapy • ROM • Strength • Proprioception

  28. Case #2 • 34 yo male football player • Right ankle rolled up under him during tackle • Walked off field • Unable to return to play

  29. Case #2 History • Previous history: neg • Previous rehabilitation: n/a • Ankle protection: none • Ability to bear weight: yes • Neurovascular symptoms: none

  30. Case #2 Physical Exam • Inspection: • Difficulty bearing weight • Mild swelling around ankle med/lat • Palp: TTP laterally, anteriorly, medially • ROM: full • Strength: mild decrease • Neurovascular intact • Special Tests: • Painful Tib-Fib Squeeze • Painful ankle external rotation

  31. High Ankle SprainAKA • Pain proximal to ankle • Painful ExtRot test • Painful squeeze test • ORDER xrays • Rule out mortise widening • Rule out fractured proximal fibula • Treatment: • Wide mortise: SURGERY • Normal xrays: cast 2-4 weeks >5mm

  32. Case 3 • 24 yo ROTC student c/o aching in medial calves during running for 6 weeks • Goes away w/ 1-2 days rest, but lasting longer with time • Training for marathon

  33. Examination • Normal appearing legs/ankles/feet • Palp: TTP diffusely medial tibial edges, distally • ROM: normal ankles (maybe tight heel) • Strength: normal • Neurovascular: normal • Special tests: • Fulcrum test normal

  34. What’s your diagnosis? • Compartment syndrome • Medial tibial stress syndrome • Stress fracture • Tibial sadness syndrome

  35. Etiology Muscle-bone junction traction injury Risk factors: ??? DDx Stress fracture Exertional compartment syndrome Treatment Cease painful activity Non-painful activity Physical therapy referral Ankle strength ex’s Heel stretches Orthotics Consider compression sleeve Medial Tibial Stress SyndromeAKA “shin splints”

  36. Case #4 • 45 yo Male with chronic, insidious posterior heel pain • Worse after volleyball or running • Pain for several months • Difficulty walking, but warms up

  37. Case #4 Differential Diagnosis • What lives in the back of the leg? • Calcaneus • Calf muscles • Gastrocnemius • Soleus • Achilles Tendon • Retrocalcaneal bursa

  38. Evaluation • Inspection: thickened Achilles tendon • Palpation: very tender Achilles w/ thickened nodularity • ROM: limited DF from tight heel cords, o/w normal at ankle • Strength: normal • Neurovascular: normal • Special Tests: • Negative Thompson test

  39. Achilles Tendinosis • Treatment • Reduce painful activities; alternate training activities • Physical Therapy modalities for acute pain control • Heel lift and BID heel cord stretches • Eccentric strengthening: • 90% success rate; takes time • Avoid steroid injection • Failures (>3 mos) • Refer to Sports Med

  40. 20 yo female kickboxing instructor Injured foot 2 days ago while kicking Walking painful, can’t jump or kick Whole foot hurts and is swollen Case 5

  41. Examination • Swelling in midfoot, some ecchymosis • Very TTP dorso-medial midfoot • ROM: ankle normal, toes decr. • Strength: decreased toes • Neurovascular: normal • Special Tests: • Midfoot stress test OUCH • Ankle ligaments stable

  42. Do You Need X-rays?

  43. WEIGHT-BEARING X-rays Non-weight bearing x-rays are normal

  44. Lisfranc Complex Injury • 20% are missed on initial presentation • Treatment • Casting 2-6 weeks if NO FRACTURES OR INSTABILITY • Surgery for fractures or instability • CT/MRI/Bone Scan

  45. Complications if Missed • Chronic pain • Arthritis • Inability to run or jump • Acute compartment syndrome

  46. Case 6 • 59 yo female with plantar heel pain • Worse with first steps when getting out of bed • Gradually improves but worsens by end of day • Related to wearing boots

  47. Examination • Valgus foot type (pronation, flatfoot) • TTP on sole at medial calcaneal tubercle • ROM: normal, but tight heel cords • Strength: normal • Neurovascular: normal • Special tests: neg

  48. Plantar fasciitis (fasciopathy) • Treatment • Cease painful activity • Pain meds acutely • Ice, cross-friction massage • Prefab orthoses • (Physical therapy) • Plantar fascia stretching • Heel cord stretching • Tension night splint • Steroid injection

  49. …before hands-on practice Questions?

  50. Anterior Drawer Test (ATFL)

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