Ankle Injuries

Ankle injuries fall into the same basic categories as

do all athletic injuries:

•Contusions
•Sprains
•Strains
•Fractures
85% of all ankle sprains involve some plantar flexion of the ankle and
inversion of the foot.

The remaining 15% consist of eversion mechanisms which are often the
result of an outside force such as being fallen on from the outside.
The syndesmosis ligament is often also injured
with an eversion force. If the tibia and fibula
spread on the talus, the ankle mortise is
disrupted and the ankle can become very
unstable. It is also not unusual to see an
associated fibula fracture with an eversion
mechanism. (see x-rays below) Assessment of a
syndesmosis sprain will be difficult for the
initial 24 to 48 hours. If the ankle is quite
swollen and edematous assessment of a
syndesmosis sprain may be difficult until the
pain and swelling have isolated to individual
areas or x-rays show some spreading of the
ankle mortise.
Ankle Ecchymosis
Maison - Neuve type fracture. 
Distal Fibula fracture with
associated medial deltoid ligament
disruption. This injury is frequently
the result of the foot being planted
with a valgus load applied to the
leg.
Notice the disruption of the medial
deltoid ligament and the widening
between the medial malleolus and
the talus. This is indicative of a
ruptured deltoid ligament.
Os Trigonum
This fracture requires surgical fixation of the fibula using a
screw and plate system. The plate should be removed prior
to return to competitive athletic activity as it will cause
stress areas in the bone at each end of the plate. Recovery
time (return to athletic activity) for a generally healthy
patient with this type of fracture will be in the 6 month
range.
Name the Injury
Talar Dome - AVN
Talar Dome - AVN
 

Ankle dislocation with no fractures. This takes a

high degree of trauma and force. In this case this
was generated as the result of a high flip off of a
trampoline and impact with the ground. The ankle
was in a plantar flexion and inverted position upon
impact. This was an open dislocation.
Negative Thompson Test
Positive Thompson Test
Achilles Tendon Tear and Repair
Foot Injuries
Plantar Fasciitis/Arch Strain

A. Mechanism of Injury
1. strain of plantar fascia-usually at medial insertion
into calcaneus
2. middle strip of plantar fascia sometimes involved
3. lateral strip almost never involved
B. Possible Responsible Factors
1. shoes
2. artificial turf
3. severe pronation
4. excessive weight
5. leg length discrepancy
6. tight bed sheets
Treatment

1. stretching, Achilles, plantar fascia (night splints)

2. strapping
3. shoe padding - medial heel wedge
-saddle pads
-arch supports
-lift type / padded heel pad
-heel lift for short leg
4. orthotics-rigid (for heavy lineman, need more support &
control)
-sports orthotics (lighter in weight with more flexibility for
backs and wide receivers)
5. Non Steroidal Anti Inflammatories
6. Steroid Injections - once weekly for 3 weeks
7. Surgical intervention - fasciotomy last resort, after 1 year
of conservative treatment
Chronic plantar fasciitis can lead to formation of heel
spurs. Plantar Fasciitis is the most common injury seen
among long distance runners. It is very painful and can
be chronic, extending over several years. The heel spur
does not cause the plantar fasciitis, the fasciitis causes
the heel spur.
Morton's Neuroma

A. Mechanism of Injury
1. direct or microtrauma to an interdigital nerve
2. 90% of neuromas involve the 3rd common digital
nerve approximately 10% involve the 2nd common
interdigital nerve - 3 & 4 metatarsals
B. Possible Responsible Factors
1. poorly cushioned and or tight shoes, high heels
2. pronation - nerve gets pinched between the heads of
the 3rd and 4th metatarsals and the base of the proximal
phalanx of the 3rd & 4th toes
3. hard surfaces
4. leg length discrepancy
Calcaneal Apophysitis (Severs Disease) (pump bumps)

A. Mechanism of Injury

1. direct or microtrauma to the growth center of the

posterior calcaneus

2. causes avascularity to the apophysis

3. Usually 8 - 12 year olds

B. Possible Responsible Factors

1. hard playing surfaces

2. shoes - poorly padded
- cleats
- poor support
3. cavus type foot
4. tight Achilles and or plantar fascia
C. Treatment

1. get out of cleats

2. shock absorbent heel pads
3. strapping - to help support
plantar fascia
4. orthotic or heel stabilizers
5. in resistant cases immobilization
for 4 - 6 weeks may be needed
Sesamoiditis/Sesamoid Fractures

Sesamoid fractures must be differentiated from a

normal bipartite sesamoid.

A. Mechanism of Injury

1. direct trauma to tibial (medial) sesamoid - most

common
2. direct trauma to fibular (lateral) sesamoid - rare
3. overuse - chronic microtrauma
B. Possible Responsible Factors

1. hard playing surfaces

2. hallux valgus - tibial sesamoid directly under mp joint
3. lack of cushioning in shoes

C. Structures involved

1. sesamoids
2. joint capsule
3. flexor brevis
4. plantar 1st metatarsal head
Treatment Sesamoiditis

1. shoe padding - transfer weight away from

sesamoid
2. super cushion inner soles
3. ice, elevation, compression
4. possible post-op shoe
5. steroid injection

Sesamoid fracture
1. cast for 3 weeks - BK
2. post-op shoe
Surgical excision of affected sesamoid in resistant cases very often will
not heal. If hallux valgus present should correct at time of surgery,
because weakening of flexor apparatus will increase deformity. This is a
last resort in most cases as it changes the bio mechanical forces on the
flexor tendons and if a single sesamoid is left in place, the weight
bearing mechanics of the foot are greatly altered.
Turf Toe

A. Mechanism of Injury

1. hyperextension (most common)

2. hyperflexion
3. valgus injury - usually from sudden acceleration

B. Possible Responsible Factors

1. artificial turf - no give, can be like playing on hard asphalt

2. shoes - too much forefoot flexion (no turf toe plate)
3. combination of turf & shoes
Specific Structures Involved

1. capsular & ligamentous structures

2. flexor apparatus

3. possibly sesamoids
D. Treatment
1. rest, ice, elevation, compression
2. possible immobilization and non weight bearing
3. shoe modifications - spring steel splint
4. activity is resumed within the limits of pain
Starting with flat foot walking, then normal gait, then jogging,
then straight ahead running at full speed, next running from
stance, last performing cutting maneuvers.
5. taping the toe to prevent injury from recurring
6. anti-inflammatories
7. surgery - for capsular repair in non responsive cases
Misc. Aggravations

A. Hallux Valgus (bunions)

1. Possible Responsible Factors
a. heredity
b. shoes - irritate but don't cause
c. pronation - accentuates
2. Specific Structures Involved
a. 1st MP - all structures
b. sesamoids
c. lst metatarsal - medial cuneiform joint
3. Treatment
a. accommodate in wider shoes
b. shoe stretching
c. surgical correction in off season if chronically
painful (may cause some limitation of joint
movement)
Hallux Limitus

1. Possible Responsible Factors

a. heredity
b. trauma to joint
c. foot type - plantar flexed 1st digit

2. Specific Structures Involved

a. 1st MP - degeneration of joint cartilage with
osteophytic limping of 1st metatarsal head and
base of proximal phalanx
b. sesamoids - in advanced cases
3. Treatment
a. rigid soled shoes which limit dorsiflexion
b. taping
c. injection with local and steroid when symptoms
acute
d. when condition becomes debilitating &
conservative measures fail then surgical
intervention is necessary - usually with placement
of plastic implant (will weaken push off)
Corns (digital clavi)
Calluses (tylomas)

1. Possible Responsible Factors

a. Cavus foot - toes hammer
- plantar flexion of forefoot causes excess pressure on
metatarsal heads
b. pronated foot - abnormal weight transfer
c. poor fitting shoes
Specific Structures Involved

a. interphalangeal joints of toes

b. extensor & flexor tendons
c. metatarsal heads

3. Treatment
a. deep & wide toe box
b. débride hyperkeratotic tissue regularly
c. Vaseline
d. padding - Spenco 2nd skin
- moleskin
Ingrown Nails

1. Possible Responsible Factors

a. improper cutting of nails
b. heredity
c. injury
d. tight shoes
2. Specific Structures Involved
a. tibial & fibular borders, usually hallux nails
b. nail groove
3. Treatment
a. packing cotton under affected border
b. wedge resection of affected border
c. partial radical nail procedure with matrix destruction (phenol
method)
Black Toe (Subungual Hematoma)

1. Possible Responsible Factors

a. shoes too tight

b. shoes too loose
c. low toe box
d. long 2nd toe
e. cleats
f. kicking
g. direct trauma
Specific Structures Involved

a. pedal nails
b. nail bed
c. distal phalanx - possible formation of subungual
exostosis
 3. Treatment
a. drain hematoma as soon as possible
b. if nail partially avulsed - remove nail completely &
débride the nail bed
- start soaks & topical antibiotics
c. if chronic, hypertrophied nail
- keep nail débrided back & thinned as much as possible
- complete avulsion of nail plate with destruction of
matrix
Plantar Verruca (Warts)

 1. Possible Responsible Factors

a. hyperhidrosis
b. abrasions to plantar surface of the foot
c. exposure to verruca virus
- showers- locker rooms - brothers & sisters
d. age - most commonly seen in teen years
Specific Structure Involved

a. skin - warts do not penetrate the basement membrane of

the skin
b. metatarsal heads and/or calcaneus- areas of most
pressure in weight bearing

 3. Treatment

 a. mechanical debridement prn.

b. topical acids
c. cryotherapy
d. surgical removal - does not leave scar
e. laser
Name the Injury
Rodeo Clown Foot
Foot Fractures
This is a ballerina type
fracture of the 5th
metatarsal.

The etiology involves and

avulsion of the proximal
tip of the 5th metatarsal
where the peroneus brevis
muscle tendon attaches.
Fracture of Styloid process of 5th metatarsal

A. Mechanism of injury

1. severe inversion ankle sprain causes peroneus

brevis tendon to pull away the base of the 5th
metatarsal (Ballerina fracture)
These X-Rays show a fracture of the proximal end of the 5th Metatarsal.
This fracture is commonly called a "Jones Fracture".
Direct trauma to base of 5th (Jones fracture)

A. Possible Responsible Factors

1. Cavus foot type

2. chronic ankle sprains
3. poor shoe and/or tape support

B. Specific structures involved

1. peroneus brevis tendon

2. styloid process 5th metatarsal base
Treatment

1. ice, elevation, compression and lift under 5th metatarsal

base
2. short leg walking brace
3. if severe avulsion of fragment, open reduction screw
fixation
Treatment of Jones Fractures includes several options.

Option 1 - immobilization of foot and ankle with non weight

bearing for a period of 1 month to 6 plus weeks and more time
may be required if the bone healing is delayed. The peroneus
brevis tendon attaches at the proximal end of the 5th Metatarsal
and treatment without ankle immobilization is not effective.
Every time the muscle contracts and pulls on the tendon, the
fracture site is disrupted. This type of fracture is known to form
a non union.
Option 2 - insertion of a intramedullary screw into the fracture to
compress the fragment and the bones back together. May or may
not be used with a bone graft. Many physicians will also opt to
use a bone growth stimulator on this fracture to insure that
healing occurs. Option 2 is certainly preferred in the authors
opinion since the fracture site is stabilized and the ends of the
fracture are approximated. The screw fixation allows for earlier
return to weight bearing and decreased immobilization time. (Dr.
Joe Milne, Dr. Steve Brotherton)
Ankle Evaluation

How did it happen? (etiology)

Previous history of injury to that area?

Sight evaluation

a) swelling?
b) deformities?
c) discoloration?
Palpation evaluation

examine ligaments

(1) medial: deltoid / anterior, medial, and posterior

portions

(2) lateral: Anterior talo-fib

Anterior drawer tests
should always be
performed with the
knee bent to eliminate
the Achilles and
Gastrocnemius
muscles from
providing any stability
to the ankle. A lateral
talar tilt test can be
conducted at the same
time.
Talar Tilt
Inversion Stress
Test
 Ottawa - Buffalo Modification for Ankle Exam
 

The incidence of ankle fractures in athletes involved in

controlled sports activities is relatively low. However, the
decision(s) on which ankles to study radiographically with x-
rays is not always easy. Not all ankle or foot injuries require
immediate x-rays. The allied health practitioner can determine
to a relatively accurate degree the need for futher study through
a good clinical exam and by following the Ottawa Ankle Rules
and with the use of the Buffalo Modification. (for more
information, consult the AJSM, Vol 26, No 2. 1998)

 
 
Research has shown that in a hospital based E.R. of every 6 ankles approved
for x-ray under the O.A.R. (Ottawa Ankle Rules), 5 have no radiographic
findings. Steill, I.G., JAMA, 269:1127-1132, 1993.
•Clinical ankle exam
If the patient needs x-rays, they will usually present with lateral fibular
malleolus pain in the distal 6 cm, medial tibial malleolus pain in the distal 6 cm
or pain to palpation over the proximal tip of the 5th metatarsal or the
Navicular.
The inability to bear weight may indicate a lesion to the dome of the Talus or
other associated trauma to the other structures of the ankle which may require
x-ray study.
Squeeze test - check malleolus (2)
Check tibia and fibula

7. Functional tests
a) walking - check gait
b) toe raises
1) both feet
2) one foot
c) jump and land on both feet and then on one foot

8. Refer to doctor for further evaluation and

possible x-ray
Refer to physician for further evaluation and possible x-ray

Non weight bearing x-rays

Weight bearing x-rays (syndesmosis spreading)

Stress x-rays for talar tilt and syndesmosis spreading

Other associated ankle and lower leg tests

Homan's Sign - patient is supine on the table, the knee is fully extended and the foot is
dorsi flexed. Reproduction of pain with localized edema is considered a positive test for
deep venous thrombophlebitis.
That’s All