Presented by:
Mary Lloyd Ireland
Professor
Dept. of Orthopaedic Surgery and Sports Medicine
University of Kentucky
Lexington KY
www.marylloydireland.com

0:00 Introducdion

0:24 A good History and Physical is Key

0:39 Foot: Pronated Hand

0:58 Function
•Propulsion
•Support
•Flexibility
•Rigidity
•Gait mechanics: ankle and foot motions

1:39 Ankle Axis
•Thus, with leg fixed and foot free
•Dorsiflexion results in outward deviation of the foot
•Plantarflexion results in inward deviation

2:30 Ankle Axis: Opposite with foot fixed
•With foot fixed, dorsiflexion / Plantarflexion results in rotation of the leg
•Dorsiflexion results in internal rotation
•Plantarflexion results in external rotation

3:38 Subtalar Joint
•Eversion and inversion of the subtalar joint are directly tied to internal and external rotation of the tibia

4:44 Windlass Mechanism
•Dorsiflexion of the proximal phalanges pulls the plantar aponeurosis over the metatarsal heads, resulting in depression of the metatarsal head and elevation of the longitudinal arch

5:02 During gait: coupled motion between ankle and subtalar joints
•First
•Tibial internal rotation
•Talar eversion
•Foot pronation
•Third
•Tibial external rotation
•Talar inversion
•Foot supination

8:08 Leg Movment

8:37 Ankle: Modified Hinge Joint
Bony configuration
•Mortise
•Circular Pretzel
Ligamentous stability
•ATF and CF laterally
•Deltoid superficial and deep medially
•Syndesmosis superiorly

9:18 With complete history and physical and appropriate imaging, the diagnosis should be made and be specific.9:34 Lateral Ankle Pain
•Sprain ATF and/or CF
•Sinus Tarsi Syndrome
•Subtalar Joint
•Arthrosis Fracture
•Cuboid Subluxation
•Peroneal Dysfunction

13:14 Summary of Findings From the National Collegiate Athletic Association Injury Surveillance System on Foot and Ankle Injury.

14:12 Basketball Injury Mechanism Video

14:47 EUA Gross instability, right ankle video

16:01 18 YO Female Gymnast
•Right ankle injury
•Landed awkwardly doing a back tuck
•Immediate pain and swelling, right ankle

16:10 Initial X-rays

16:41 Stress tests, L & R ankles

17:12 Dx lateral talus fracture displaced

17:33 Physical Exam of the Foot and Ankle Video

18:32 Lateral Ankle Pain Soft Tissue
Soft Tissue Mass
•Ganglion
Meniscoid of the Ankle
•Tomansen, Denmark 1982
Scar + Synovitis Gutter
•Ferkel’s Phenomenon, AJSM 1991
Distal Slip Anterior Tibiofibular Ligament
•Bassett’s Ligament, JBJS, 1990

19:13 14 YO Female
•Soccer athlete
•Left ankle
•Acute lateral talar dome fracture
•Documented by plain films and bone
•edema on MRI

19:16 Initial X-Rays

19:46 1 Month after Initial presentation

20:27 Talar Dome Fracture

20:45 Osteochondral Talar Lesions
Osteochondritis Dissecans
•Men 3 : 1 Women
•Medial : Lateral
•2 : 1
Etiologies
•Trauma
•Vascular
•Repetitive Loading

21:11 Mechanism of injury of medial border of the dome of the talus.
•Berndt, A.L. and Harty, M.: “Transchondral fractures of the talus” – JBJS 41 –A:988, 1959

22:08 Soft Tissue Lesion Location
•Ankle
•Anterolateral
•ATF or CF Sprain
•Peroneal Tendinitis
•Posteromedial
•PT or FHL Tendinitis
•Deltoid Sprain

24:32 Physical Exam of the Foot and Ankle Video

25:12 Think About Peroneal Tendon Involvement If:
•Recurrent Ankle Complaints
•Sprain Not Getting Better
•Pain, Swelling Higher in Peroneal Tendon Sheath

25:37 In Acute Ankle Sprain, Assess Peroneal Function

25:58 17 YO WM
High school Baseball/Football Player
C/O Repeated Inversion Ankle Sprains

26:14 Peroneal Tendon Subluxing Video

27:42 Physical Exam of the Foot and Ankle Video

28:50 19 YO basketball player Os vesalianum bilateral feet.

29:20 Os peroneum

29:33 Medial Ankle Pain
Differential Diagnosis
•Deltoid Sprain
•Medial Malleolus Fracture
•Tendinitis
•Posterior Tibialis
•Flexor Hallucis Longus
•Osteochondral
•Talus Fracture
•Osteochondritis Dissecans

30:25 Posterior Tibial Tendon Dysfunction Stages

31:12 "Too Many Toes" Sign

34:16 18 YO Freshman Div. I basketball athlete
•C/O mid-foot pain, L greather than R
•Started when she was running, playing in shoes mandated by her school
•History of “normal” periods

34:55 Navicular
•Initial x-rays

37:06 Posterior Ankle Pain
Differential Diagnosis
•FHL Tendinitis
•Posterior Process Talus Fracture (Shepherds 1982)
•Posterior Impingement
•Os Trigonum
•Achilles Tendon
•Overuse
•Tear, partial vs. complete

37:48 Bony Impingement of the Ankle
Motion & Contact Areas

38:09 Anterior Tibiotalar Impingement Syndrome "Footballers" Ankle

38:32 FHL Tendinitis
•“Dancers” Tendinitis

39:19 Witherspoon MOI Video

40:27 Thompson Test Video

41:15 Achilles Tendon Video

43:22 A good History and Physical is Key

44:05 Thank You

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