Foot and Ankle Sprains

Question 1

Inspection of the foot/ankle

Answer 1

• appearance
• gait (watch come in without them knowing!)
• overall alignment of LE
• alignment of foot and ankle

Question 2

Vascular exam of foot/ankle

Answer 2

• dorsalis pedis pulse
• posterior tibial pulse
• cap refill

Question 3

Sensory exam of foot/ankle

Answer 3

• light vs. deep pressure touch
• light: Semmes-Weinstein filament
• peripheral nerve distribution vs. nerve root level (Clowers prefers peripheral for his foot exams)

Question 4

Motor exam of foot/ankle

Answer 4

• ankle dorsiflexion/plantar-flexion
• Hind-foot eversion/inversion
• Great toe and lesser toe flexion and extension

Question 5

Palpation of foot/ankle

Answer 5

manual map of entire foot and ankle - this is what Clowers spends the majority of his exam doing

Question 6

Special tests of foot/ankle

Answer 6

• stability
• Achilles
• at your discretion

Question 7

What is the best radiographic imaging of foot and the ankle

Answer 7

• weight bearing
• 3 views of foot (AP, oblique, lateral)
• 2 views of ankle (AP and oblique)
  Xray is usually sufficient, MRI/CT only after xray

Question 8

what stress radiographs may be helpful in certain situations

Answer 8

• External rotation stress
• varus/anterior drawer
• pronation/abduction

Question 9

What are the 4 main sprains of the foot and ankle

Answer 9

Ankel
- lateral ligaments
- syndesmosis
- deltoid 
Midfoot

Question 10

What usually causes an acute lateral sprain?

Answer 10

inversion that results in abrupt stretching or fractional lengthening of the ATFL and/or CFL

Question 11

What are the three ligaments in the lateral ligamentous complex and what is their main role

Answer 11

• ATFL
• CFL
• PTFL (minor)
  Static stabilizers (the seatbelt)

Question 12

What is the anatomic purpose of the ATFL

Answer 12

• mostly resists anterior translation of talus

- resists inversion

Question 13

What is the anatomic purpose of the CFL

Answer 13

resists inversion, varus stress

Question 14

Lateral ankle sprain

- clinical exam findings

Answer 14

• swelling
• bruising
• lateral tenderness/pain MC, can be elsewhere in foot too

Question 15

Lateral ankle sprain

- imaging

Answer 15

plain radiographs

Question 16

What other potential injury can occur with lateral ankle sprain?

Answer 16

• peroneal tendon
• lateral process of talus
• anterior process of calcaneus
• cuboid/fibular contusion
• osteochondral defect

Question 17

Lateral ankle sprain initial management

Answer 17

1 mitigate inflammatory response:

• immobilization
• cryotherapy
• limit weight-bearing
• NSAIDs

Question 18

Lateral ankle sprain, when transition from both to brace?

Answer 18

When weightbearing in boot without pain

Question 19

What formal therapy is needed for lateral ankle sprains?

Answer 19

• passive motion
• strengthening
• proprioception (once regained can resume athletic activities)
• PT

Question 20

After how many weeks of no progression is it time to pursue advanced imaging?

Answer 20

6 weeks

Question 21

Deltoid ligament injury

• how common?
• how treat?

Answer 21

• Much less common than lateral sprains
• Usually occur in conjunction with ankle fx/other injuries
• Tx usually conservative, similar to lateral sprain
• Immobilization and limited WB followed by functional rehab and bracing
• Heal very well

Question 22

Deltoid ligament

- describe

Answer 22

• primary static restraint to valgus instability of tibio-talar joint
• four components
• two functional components - superficial and deep (primary portion)

Question 23

Deltoid ligament injury

- commonly associated with what

Answer 23

• low E rotational ankle fractures

Question 24

Tibia-Fibular syndesmosis

Answer 24

• joint formed between distal tibia and fibula
• Strong ligament complex: interosseous ligament, AITFL, PITFL, interior transverse
• runs to the knee
• takes a lot of force to injure

Question 25

What is anatomical purpose of tibia-fibular syndesmosis

Answer 25

allows for accommodation of variable width of the taller body with varying angles of flexion - allows talus to move up and down in ankle as foot dorsi- and plantar- flexes

Question 26

What is a syndesmosis injury called?

Answer 26

high ankle sprain

Question 27

What generally causes injury to syndesmosis? What is often seen in conjunction with this injury?

Answer 27

- eversion or external rotation | - bony injuries or other ligament injuries

Question 28

What are the three grades of syndesmosis instability?

Answer 28

Grade I: stable radiographically, conservative tx Grade II: unstable on stress radiograph Grade III: diastasis on non-weightbearing radiograph

Question 29

How to treat stable syndesmosis injuries

Answer 29

- conservative - non-weightbearing and immobilization for 4-6 weeks - then advance weight bearing and rehab - return to play slower than lateral ankle sprain

Question 30

How to treat unstable syndesmosis injuries

Answer 30

- operative repair if bony injuries present - screw fixation - suture button fixation

Question 31

Lisfranc Injury | - describe

Answer 31

- Ligament on bottom of foot from median cuneiform to second metatarsal base - injury usually from hyper-extension moment of midfoot - easily missed. Bilateral comparison really helpful

Question 32

Lisfranc injury | - clinical exam

Answer 32

- presentation similar to ankle sprains | - look for plantar ecchymosis

Question 33

Lisfranc Injury | - radiographic eval

Answer 33

- Weightbearing image if possible | - pronation/abduction stress view

Question 34

Lisfranc Injury | - stable injury tx

Answer 34

- conservative - boot immobilization - limited weight bearing

Question 35

Lisfranc Injury | - unstable injury tx

Answer 35

- operative reduction and fixation | - chronic instability can lead to degenerative change