Ankle:

Sprain/Strain

• Cause/Pathophysiology

  • Stretch injury to any of the ankle ligaments (ATF, PTF, CF, Deltoid, A&P Tib/fib, syndesmosis), which can cause ligament failure

  • Ligament to corresponding mechanism

    • inversion - ATF, CF, PTF possible syndesmosis

    • eversion/ER - deltoid, syndesmosis

  • Syndesmosis involvement = "high ankle sprain" and can take longer to resolve

• History and symptoms

  • MOI

  • Pain

  • WB ability varies depending on severity

• Exam Findings

  • +/- antalgic gait

  • TTP over injured ligament

  • Swelling

  • +/- ROM or strength deficits

  • Pain and/or instability with, drawer tests, talar tilt test, Kleiger test

• Imaging

  • X-Ray 

    • AP, mortise view, lateral

    • should be done weight bearing​

    • usually negative, but may see mortise widening or talar lateralization if significant syndesmotic and deltoid ligament injury

• Treatment​

  • Conservative​

    • RICE​

    • brace

    • PT

    • NSAIDs

    • Short period of immobilization, NWB with crutches if unable to WB

      • "high ankle sprain" may require longer 

  • Surgery

    • severe injuries with mortise widening on X-Ray​

    • severe chronic instability

• Common ICD-10 codes​​

  • S93.499A

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Posterior Tibial Tendonitis/Dysfunction

• Cause/Pathophysiology

  • Tendonitis

    • Acute inflammation of the posterior tibial tendon​

    • Can occur after ankle injury

  • Dysfunction

    • Chronic failure of the posterior tibial tendon to maintain normal function​

    • Frequently associated with pet planus

• History and symptoms​

  • Complains of medial ankle pain

  • Worse with activity

• Exam Findings

  • TTP over tendon proximal and posterior to medial malleolus

  • Frequently planus foot 

  • +/- medial swelling

  • Pain with toe raise

• Imaging

  • X-Ray negative​

  • MRI

    • Appropriate if conservative treatment fails, to evaluate for tearing​

• Treatment​

  • Conservative​ options

    • NSAIDs​

    • Ice or contrast baths

    • Arch support (orthotics)

    • Ankle support

    • PT

  • Surgical referral if conservative options fail

• Common ICD-10 codes​

  • M76.829​

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Achilles Tendonitis/Tendonopathy

• Cause/Pathophysiology

  • Tendonitis

    • Acute inflammation of the tendon​

  • Tendonopathy

    • Chronic microtrauma to the tendon​

• History and symptoms

  • Atraumatic posterior ankle pain

  • Increased pain with push-off or stretch (stairs is a common complaint)

• Exam Findings

  • TTP in tendon substance or insertion

  • +/- swelling

  • Painful passive dorsiflexion

  • Pain +/- weakness with toe raise

• Imaging

  • X-Ray​

    • generally not necessary initially​

    • lateral may show posterior calcaneal enthesopathy

• Treatment​

  • Conservative​

    • NSAIDs​ or steroid taper

    • Ice

    • Heel lift

    • PT

    • Boot or cast for up to 6 weeks, if refractory to other conservative treatment

  • Surgery

    • option for failed conservative measures​

• Common ICD-10 codes​​

  • M76.60​

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Achilles Tendon Rupture

• Cause/Pathophysiology

  • Usually an eccentric load that supersedes tendon strength, causing failure 

  • May be preceded by chronic tendonopathy

• History and symptoms

  • Mechanism frequently involves trying to control a decent (coming down from a jump or stairs) or sudden forceful contraction (pushing off to sprint or jump)

  • Frequently described as "it felt like something hit the back of my leg"

  • Pain and difficulty WB or pushing off

• Exam Findings

  • May/may not be able to ambulate, but limited push-off if able t

  • Swelling

  • Tendon defect palpable and usually visible

  • Weak plantarflexion

  • + Thompson test

• Imaging

  • X-ray ​

    • evaluate for bony avulsion if defect is close to insertion​

  • IF diagnosis suspected, but not confirmed with exam MRI or US indicated

• Treatment​

  • Conservative​

    • Serial casting is traditional treatment​

    • Boot with serial wedges has recently shown to be effective

  • Surgical

    • Primary repair may be best choice for younger and active population​

• Common ICD-10 codes​​

  • S86.019A​

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Osteoarthritis of the Ankle

• Cause/Pathophysiology

  • Chronic or post-traumatic articular cartilage degeneration of the talocrural joint

• History and symptoms

  • Usually gradual progressively worsening ankle pain

  • Worse with weight bearing

• Exam Findings

  • TTP ankle joint space

  • +/- effusion

  • +/- deformity

  • +/- ROM deficit

• Imaging

  • X-Ray​ (AP, Lateral, Mortise weight-bearing views)

    • joint space narrowing​

    • subchondral sclerosis

    • +/- osteophyosis

    • +/- loose bodies

• Treatment​

  • Conservative options

    • NSAIDs​

    • Compression

    • Bracing

    • Cortisone injection​

    • Rocker bottom shoes

  • Surgery

    • Historically fusion​

    • Total ankle replacement is becoming more common

• Common ICD-10 codes​​

  • M19.079​

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FRACTURES

Lateral Malleolus

• Cause/Pathophysiology

  • Usually an excessive inversion or rotational mechanism to the point of bone failure

  • Several classification systems

• History and symptoms

  • Mechanism for injury

  • Pain 

  • May or may not be able to weight bear, depending on severity and individual pain tolerance

• Exam Findings

  • +/- deformity

  • swelling

  • TTP over lateral malleolus

  • +/- palpable crepitus

  • +/- ROM and strength deficits

• Imaging

  • X-Ray - AP, lateral, mortise, weight bearing views +/- stress view​

    • evaluate for fracture, displacement, and mortise widening​

• Treatment​

  • Conservative​

    • indicated for non to minimally displaced stable injuries (NO MORTISE WIDENING)​

    • Posterior splint with or without U-splint for initial visit, if referring or using a cast for definitive management

    • Short leg cast - after initial swelling subsides

    • Fracture boot

    • Stirrup brace for small avulsion type injuries below the joint line

    • WB status depends on fracture location (Below level of mortise - WBAT; At or above - Partial WB for 4 weeks)

  • Surgery 

    • unstable fractures ​- mortise widening

    • significant displacement

• Common ICD-10 codes​​

  • S82.66XA - ​non-displaced

  • S82.53XA - displd

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Medial Malleolus

• Cause/Pathophysiology

  • Usually rotational injury

  • Does not happen in isolation very often

  • Be sure to evaluate for proximal fibular tenderness as seemingly isolated medial malleolus fractures can also have associated proximal fibular fracture (Maisonneuve Fracture)

• History and symptoms

  • Mechanism for injury

  • Pain 

  • May or may not be able to weight bear, depending on severity and individual pain tolerance

• Exam Findings

  • +/- deformity

  • swelling

  • TTP over medial malleolus

  • +/- palpable crepitus

  • +/- ROM and strength deficits

• Imaging

  • X-Ray - AP, lateral, mortise, weight bearing views +/- stress view​

  • evaluate for fracture, displacement, and mortise widening​

• Treatment​

  • Conservative ​

    • non-displaced injuries​

    • Posterior splint with or without U-splint for initial visit, if referring or using a cast for definitive management

    • Short leg cast - after initial swelling subsides

    • NWB

  • Surgical ORIF

    • any displacement ​

• Common ICD-10 codes​​

  • S82.56XA - non-displaced​

  • S82.53XA - displaced

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Bimalleolar

• Cause/Pathophysiology

  • Inversion or eversion with rotation injury

  • Unstable injury

• History and symptoms

  • MOI

  • Complaint of pain

  • Inability to bear weight

• Exam Findings

  • Swelling

  • TTP over malleoli

  • +/- deformity

• Imaging

  • X-ray - AP, lateral, mortise​

    • may not be able to bear weight​

  • CT

    • may be helpful for surgical planning if severely comminuted or involves the weight-bearing surface of the tibia​

• Treatment​

  • Initially

    • SL posterior and stirrup splint​

    • NWB

  • Conservative treatment is not indicated, except in extenuating circumstances such as if patient at too for high risk surgery

  • Surgical ORIF​ 

• Common ICD-10 codes​

  • S82.846A - non displaced​

  • S82.843A - displaced

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Foot:

Plantar Fasciitis

• Cause/Pathophysiology

  • Acute Inflammation or chronic tendonosis-type condition of the plantar fascia, typically, at the calcaneal attachment

• History and symptoms

  • Complaints of pain on the bottom of the foot, particularly on the heel

  • Worse with first few steps after periods of rest

  • Generally pain improves at rest

• Exam Findings

  • TTP at plantar fascia attachment on calcaneus

  • +/- antalgic gait

  • +/- Achilles tightness

• Imaging

  • Not necessary initially, as diagnosis is clinical​

  • X-Ray if refractory to conservative treatment

    • may have calcaneal enthesopathy (spur)​

• Treatment​

  • Conservative​ options - 95% successful

    • Ice​

    • massage

    • NSAIDs

    • STRETCHING/PT

    • Heel cups

    • Orthotics

    • Compressive sleeves

    • Cortisone injection

• Common ICD-10 codes​​

  • M72.2​

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Midfoot Sprain

• Cause/Pathophysiology

  • Excessive stress on the foot that can be rotational (inversion or eversion) or hyper-dorsiflexion or plantar flexion​

  • Can involve any of the intertarsal or torso-metatarsal ligaments

  • LisFranc injury is a specific sprain injury that I have given its own section.  It is an important one not to miss.

• History and symptoms

  • MOI​

  • Pain​ worse with weight bearing

• Exam Findings

  • TTP over the midfoot​

  • +/- swelling

  • Pain with stress testing the mid foot

• Imaging

  • X-Ray​ - AP, lateral, oblique weight bearing views

    • evaluate for fracture, displacement, alignment, joint space widening​

• Treatment​

  • Conservative​

    • rigid soled shoe or fracture boot​

    • WBAT

    • RICE

    • NSAIDs

• Common ICD-10 codes​​

  • S93.609A​

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Lis Franc Injury 

• Cause/Pathophysiology

  • Direct trauma or significant rotational or hyperplantarflexion force to the foot​

  • Stretch or disruption of one or multiple tarso-metatarsal ligaments, causing dislocation, particularly the second metatarsal, middle cuneiform joint (Lis Franc joint)

  • Can be associated with fracture

• History and symptoms

  • MOI​

  • Pain with weight bearing​

  • May be unable to weight bear

• Exam Findings

  • Antalgic gait​, if able to weight bear

  • Midfoot swelling

  • Midfoot TTP, especially at Lis Franc joint

  • +/- ecchymosis

• Imaging

  • X-Rays - AP, lateral, oblique weight bearing ​

    • evaluate for fracture, Lis Franc joint widening (alignment of second metatarsal in relation to middle cuneiform), lateral dislocation of the forefoot ​

  • CT - standard for diagnosis and evaluation of suspected Lis Franc injury

  • MRI - better for evaluating the extent of ligament injury if no widening of the Lis Franc joint

• Treatment​

  • Conservative​

    • Sprains with no Lis Franc joint widening​

    • Posterior splint with or without U-splint for initial visit, if referring or using a cast for definitive management

    • Short leg cast (after initial swelling subsides) or boot

    • NWB

  • Surgical

    • Any unstable injury with displacement​ (widening between 1st and 2nd metatarsal at base)

• Common ICD-10 codes​​

  • S93.609A

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Osteoarthritis

• Cause/Pathophysiology

  • Chronic degeneration of the articular cartilage between any tarsal, metatarsal, or phalangeal joint​

• History and symptoms

  • Gradually worsening foot/toe pain​

  • Worse with standing and/or motion​

• Exam Findings

  • TTP of affected joint​

  • +/- stiffness

  • +/- swelling

  • +/- deformity, joint hypertrophy

• Imaging

  • X-Ray - AP, Lateral, Oblique​

  • joint space narrowing

  • osteophytosis

• Treatment​

  • Conservative options

    • NSAIDs​

    • ice/heat modalities

    • orthotics

    • rocker-bottom shoe

    • Cortisone injection - may require image guidance if midfoot

  • Varying surgical options depending on joint location, if conservative options fail

• Common ICD-10 codes​

  • M19.071​

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Hallux Valgus

• Cause/Pathophysiology

  • Big toe deviates laterally​ and can lead to first metatarsal head prominence medially (bunion)

  • Can be associated with footwear that is too narrow or pointed 

• History and symptoms

  • Gradually worsening deformity​

  • +/- pain​

  • Symptoms may be worse with narrower shoes

• Exam Findings

  • Valgus deformity or big toe​ (points outward)

  • +/- Prominent metatarsal head

  • +/- TTP

  • +/- decreased ROM

• Imaging

  • X-Ray - AP, lateral, oblique​

    • valgus deformity or big toe​

    • +/- degenerative changes of 1st MTPJ (joint space narrowing, flattening, osteophytosis)

• Treatment​

  • Conservative options

    • Footwear change - wide toe-box shoes​

    • bracing

    • ice/heat modalities, if painful

    • NSAIDs if painful

  • Surgical correction if conservative efforts fail to resolve symptoms

• Common ICD-10 codes​

  • M20.10​

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Hallux Rigidus (First MTPJ osteoarthritis)

• Cause/Pathophysiology

  • Degeneration of first MTPJ articular cartilage​​

• History and symptoms

  • Progressively worsening big toe pain and stiffness​

  • Worse with activity​

• Exam Findings

  • +/- dorsal hypertrophic deformity of the MPTJ​

  • MTPJ TTP

  • MTPJ decreased ROM

• Imaging

  • X-Ray - Big toe AP, lateral, oblique​

    • MTP joint space loss​

    • MTP osteophytosis

• Treatment​

  • Conservative ​

    • Footwear modifications - wide toe box, stiff soles or insert​

    • NSAIDs

    • Ice/heat modalities

    • Cortisone injection

  • Surgical if conservative efforts fail

    • Cheilectomy or fusion​

• Common ICD-10 codes​​

  • M20.20​

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Sever's Disease (Calcaneal Apophysitis)

• Cause/Pathophysiology

  • Repetitive stress causes inflammation/microtrauma of the calcaneal apophysis​

  • Active pediatric population, M>F, average age 9-11

  • Resolves completely when ossification center closes

• History and symptoms

  • Heel pain during or after activity​​

• Exam Findings

  • TTP on back of the heel​

  • +/- antalgic gait

• Imaging

  • X-Ray​

    • not necessary in initial work-up but can show sclerosis and/or fragmentation​ at the secondary ossification center

• Treatment​

  • Con​servative

    • ​Achilles stretching​​

    • Ice

    • NSAIDs

    • Heel cup/pad

    • Activity modification as needed

• Common ICD-10 codes​​

  • M92.60​

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Pes Planus (Flat foot)

• Cause/Pathophysiology

  • Congenital or acquired lack of medial longitudinal arch​

  • Arch can develop up until mid teens

  • Flexible Not a medical condition that needs to be corrected when bilateral or asymptomatic

• History and symptoms​​

  • Frequently will see due to parent concern​

• Exam Findings

  • Lack of medial longitudinal arch​

  • Check to see if arch develops when big toe is passively fully dorsiflexed (flexible flat foot), if not (rigid flat foot) there may be other pathology such as coalition

• Imaging

  • Generally not necessary in work-up​

  • X-Ray - (AP, lateral, oblique) if foot is painful, unilateral, or rigid on exam

• Treatment​

  • No treatment is indicated, necessary, or corrective for asymptomatic bilateral ​flexible pes planus

  • If other pathology is present, treat accordingly

• Common ICD-10 codes​

  • M21.40​

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Fractures:  

Metatarsal

• Cause/Pathophysiology

  • Acute trauma​

  • Chronic repetitive stresses

  • Fifth is most common

    • Avulsion​

    • Jones

    • Shaft

• History and symptoms

  • Acute pain after direct trauma or twist injury ​

  • Gradually worsening pain with activity​ - stress fractures

  • Pain worse with WB or activity

  • May not be able to weight bear, especially of acute

• Exam Findings

  • TTP over affected metatarsal​

  • Swelling with acute fx, may not have swelling with stress fx

  • Painful metatarsal squeeze

  • Pain with active eversion and/or passive inversion for 5th metatarsal base fractures

• Imaging

  • X-Ray - AP, lateral, oblique weight bearing​

    • evaluate for fracture, alignment, displacement, callous (stress fractures)​

    • Jones fracture is 1.5-3cm from the tip of the 5th metatarsal base tip

• Treatment - depends on which metatarsal and location of fracture​​

  • Conservative​

    • Most metatarsal fractures, including stress fracture ​(EXCEPT Jones, First metatarsal, intra-articular)

      • fracture shoe, boot, or cast​

      • Can weight bear when symptoms allow

    • Jones

      • Non-displaced​

      • Cast

      • NWB 6-8 weeks

      • Higher incidence of non-union

    • First Metatarsal or intra-articular 

      • Non-displaced​

      • Cast

      • NWB

  • Surgery

    • Viable option for primary treatment of non-displaced Jones fracture, especially in younger, active population​

    • Indicated for displaced Jones, first metatarsal fractures, nonunions, significantly displaced or severely angulated fractures

• Common ICD-10 code​​

  • S92.309A​

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Calcaneus

• Cause/Pathophysiology

  • Trauma​

  • Frequently, landing on feet from a height

  • Stress fracture

• History and symptoms

  • MOI​

  • Pain​

  • Usually unable to bear weight with traumatic injury

  • Stress fractures generally present as gradually worsening pain with weight-bearing

• Exam Findings

  • Swelling​

  • TTP over calcaneus

  • +/- ecchymosis

• Imaging

  • X-Ray - Axial and lateral calcaneus films​

    • evaluate for fracture, displacement, articular surface congruency ​

  • CT

    • Frequently helpful in determining articular surface involvement and significance of displacement or step-off​

    • surgical planning

  • MRI

    • most sensitive in diagnosing stress fracture​

• Treatment​

  • Conservative - non or minimally displaced​, no significant articular step-off

    • SL cast​

    • NWB 12 weeks

    • Stress fracture - boot or cast.  Weight bearing when symptoms allow.

  • Surgery - significant displacement, angulation or articular step-off

• Common ICD-10 codes​

  • S92.009 A - closed, B - open​

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Phalanx

• Cause/Pathophysiology

  • Trauma​

• History and symptoms

  • MOI​

  • Pain​

• Exam Findings

  • +/- deformity​

  • Swelling

  • TTP

  • Decreased ROM secondary to pain

• Imaging

  • X-Ray - AP, lateral, oblique​

• Treatment​

  • Reduction after digital block, if significantly displaced or angulated​

  • Most toe fractures do well conservatively treating with buddy taping and fracture shoe 

  • Significantly displaced, angulated, or intra-articular big toe fractures may need surgical fixation 

• Common ICD-10 codes​

  • S92.919 A - closed, B - open​

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