All right, I get the pleasure of starting this off. I think it's because they know that I talk so fast and we try to keep this on time here. So my task today is to discuss an overview of leg and ankle region. Again, as was mentioned, this is sort of an overview. I have a lot of questions in here. Most of these are taken from the self-assessment evaluation examinations by AOSSM, which are pretty similar to the qualifying exam questions. So here's my disclosures, which are available in your handout. I'd like to give a shout out to the people, as Dr. Gill had mentioned, this has been formulated over the years. These are two people that have presented this information prior to me. So our task in this next hour is to go through a bunch of principles in the leg, ankle, and foot to include some basic anatomy review, injuries to the bone and ligament, leg, chronic ankle injuries, and treatment protocols, and questions that assimilate some of this information. Now, again, all of this is review. Hopefully, there'll be some stuff in here that sparks your memories. Now, again, remember, I talk fast, so all of it is in your handout. All right, so basic anatomy. So as you remember, the ankle is a classic mortise configuration, a fairly constrained joint relying on the tibial plafond, medial and lateral malleolus to hold this constrained joint in place. Because of this constrainment, the articular surface of the tail of the done is very sensitive to any malalignments, secondary to the slight curve of the articular cartilage in nature, and it's a constrainment. Now, remember, the tail is shaped in a trapezoidal formation, such that the anterior aspect is a little bit wider than the posterior segment, so that when the ankle goes in dorsiflexion, you do get some fibular rotation, external rotation as the ankle goes in the dorsiflexion. Lateral ankle anatomy. So this is obviously something we see quite frequently with injuries to the lateral ankle with ankle sprains. The fibular collateral ligaments are the most common ones in this whole complex injured. Typically the anterior talofibular ligament is the weakest, which is the one up front. Next typically to be injured during an ankle sprain is a caneofibular ligament. And then less commonly but sometimes injured and the strongest is the posterior talofibular ligament. Now there are other lateral side ligaments that do get confused with this. Now part of the anterior aspect, the syndesmosis, is the anterior tibfib ligament, which is a primary stabilizer of the syndesmosis. Not to be confused, which does come up on questions and has been seen on MRI cut sections, is an accessory anterior inferior tibiofibular ligament, also known as a bassus ligament, which can also be related to ankle impingement. So again, tensioning or testing these can be ATFL in straight plantar flexion with anterior drawer and then testing in neutral or endorsoflexion, especially with a tilt test. Medial side. So the deltoid complex is a relatively complex structure that has superficial and deep components. The superficial components, which are more anterior, tibionavicular, tibiocalcaneal, and the superficial tibiotalar ligament. The deep, so the primary stabilizers mainly to medial, excuse me, lateral translation of the talus is related to the tibial mortis. Typically deep and integrated into the capsule, the deep tibiotalar ligament is the most important. As we get increased rotary instability to the ankle is typically when the deltoid injuries become more apparent. Now we have to remember that the attachments have very specific locations on the medial side of the ankle on the medial malleolus with an anterior and posterior colliculus. These anterior injuries are really related to some more superficial and less important ligaments that will relate to tailor tilt but not tailor subluxation. The deeper ligaments are related to injuries to the posterior aspect of the colliculus. So a higher transverse malleolus fracture will involve all the ligaments, whereas this anterior leaf fracture can sometimes just involve the superficial ligaments and not result in instability or medial instability translation of the ligaments. So again, superficial deltoid controls rotational aspect, and the deep controls the coronal plane or the medial translation or the medial clear space opening which you see on stress view. All right, overview of the medial side of the tendons. Obviously we have posterior tib tendon, flexor digitorum longus. In between this we have the neurovascular bundle, and then most posterior we have the flexor hallus longus. So lateral side, obviously the superficial of the proximal retinaculum is the most common in stabilizing the peroneals. Avulsion fractures can happen with the insertion of the peroneal brevis as well as the lateral band of the plantar fascia. Common zones have been described. More proximal zones above the articulated section is typically thought of as stress fractures. Jones fractures are within this articular zone where there is a high mobile, decreased mobile area that can go on to nonunion. And then obviously the more proximal segments are typically thought of as more avulsion type injuries. So this comes up quite often. Blood supply is an easy test question. It should be easily remembered. Basically the blood supply to the talus typically comes from the artery of the tarsal canal branch of the deltoid. Basics of the gait mechanics. So I'm just going to go very quickly through this. Just one slide. You're going to get this in much more detail from the next presenter. It's very complex and should be given a little bit more time to it. But basically it's a motion of ankle akin to a hinge joint. As the ankle and subtalar joint move in a complex motion, they are linked. In dorsiflexion, you find that the ankle tends to evert. And in plantarflexion, the ankle tends to invert. The Achilles insertion is typically a normal ankle. And this is important. It will come up in abnormal situations, but it's typically lateral to the midline. So patient history, especially as you're thinking about this in terms of test questions, which is why I bring this up, is really important. They give you information because it's important to the question or the point that they're trying to get to. Obviously, location, duration, mechanism, how the event happened, response to medications. As an example, cholesterol medications or statins can lead to heel pain. So a lot of this can come up. They give you the information. It's there for a reason. So obviously, on physical examination, the first thing is the swelling, the angulation, the alignment, which can lead to treatment, whether we're going to stage it or whether we need to get x-rays, palpation, localization of the tenderness, which they'll describe in the test question, what's their range of motion, reproducibility of the plane and stability is obviously important. Assessing Aquinas. Remember, when we do this in the clinic, certainly it can be presented on an exam like this to test this with the knee both extended and flexed as the gastroc becomes tensioned with the knee extended and less and more relaxed with the knee inflection because it attaches on the proximal aspect of the joint. Also remember that sometimes pulses can change when the knee goes into extension, which could relate to a popliteal entrapment type of scenario. Lower extremity alignment comes up well, and this is a relatively straightforward thing. Most of the time, if we have a situation where we have hind foot valgus or a cable varus foot, two-thirds of these patients will ultimately have some sort of neurological disorder, of which the most common is Charcot-Marie-Tooth. So if you end up having either an examination finding or a picture that has a cable varus foot, definitely consider these neurologic conditions. And like I said, Charcot-Marie-Tooth is the most commonly tested one. So that common x-ray is obviously a normal ankle AP mortise and a lateral x-ray. The things that are commonly measured are obviously the alignment of the joint, as it should be symmetric all the way around from the medial and the superior aspect, the tib-fib clear space, which should be around 5 millimeters, and then the tib-fib overlap, which is both related to the syndesmosis. So there are various angles which can be measured. This is just for your simple review. Some of these can relate to basically instability phenomena of the ankle that can be related to non-fractures or pure ligament disinjury, like an isolated deltoid ligament injury or a syndesmotic component. So on a lateral x-ray, on a true lateral x-ray, which we almost never get in clinic, at least in my clinic, you'll typically find some posterior aspect of the tibia to be available back here. We can often see some posterior fracture lines. You'll see the alignment of the deformity of the calcaneus with the subtalar joint and the talus. You can often see avulsion fractures anterior, and certainly looking at the articulation of the curvature of the dome of the talus to make sure it's congruent and without deformity. So calcaneus fractures comes up often, too. Bowler's angle is one of the criteria in which we can look at to see if there's been collapse or shortening, which often can indicate people for surgery. Other measurable factors that can be quoted are critical angle of gessane. Typically they will give you a Broden's view to look at the posterior fracture lines. When do you get an MRI? Stress fractures, if you want to look at anatomy, anomalies, synovitis, soft tissue masses, you want to evaluate ligaments, and don't forget infection. So anatomy and infection are important. This is actually, I've seen this with some of our basketball players, it does come up as a testable question. This is an MRI cross-section, T1, that looks at the extension of the soleus muscle, which is accessory soleus muscle belly. It's present in about 3% of patients. Distinct belly and medial to the Achilles tendon and more deep to it, accessory soleus, and often can cause a kind of compartment syndrome or pain, often seen in basketball players. CT scans obviously are best to evaluate fracture lines, cystic changes, infection involvement, and bony alignment. All right, now we're going to start with some questions. I go through these fairly quickly just to highlight. So primary strain to inversion when the ankle is positioned in plantar flexion is anterior talofibular ligament. You can see most of these are relatively straightforward. This is actually a question that was polled. So arrow identifies which of the following structures, accessory soleus. So there could be questions that are pure just anatomic recognition on MRI. High school football player treated by PCP, two months, chronic ankle pain, swelling, NSAIDs, activity modification, PT, normal exam except for swelling. What's the next appropriate stress? So obviously, the duration, the swelling, and otherwise normal examination at this point, MRI would be indicated. Thirty-five-year-old woman presents with evaluation of foot pain, five-month history, worsening plantar pain, numbness, tingling of the first three toes, exam, tenderness in the web space. More importantly, she has a positive Tonell's sign in the medial ankle. Her MRI shows these cystic changes along the neurovascular bundle, impinging that from her flexor hollis longus, exploratory surgery with excision of cystic mass to relieve her pressure. All right, switching gears, I told you we were going to go fast. So traumatic bone and ligament injuries, tibia shaft fractures, pylons, ankle fractures, syndesmosis injuries are all ones we're going to try to touch on. So no significant difference in your treatment thresholds for athletes as you would for a normal traumatic tibia shaft fracture that would normally come into your ER. IM nails are standard for mid-shaft fractures, but a reminder that casting still works for good alignment. Proximal distal plating, especially for distal segments, can do well. Beware of concomitant injury and the risk of compartment syndrome, which can come up. So this is an example of a patient of mine, so flag football with this basically nondisplaced tibia fracture, obviously doesn't need a nail, does well with casting and then transition to functional bracing, which also works for high-grade stress fractures, by the way. So this is another example of a Division I soccer goalie that sustained a well-aligned tibia shaft fracture, but this was treated with a nail, mainly because of his collegiate soccer status, but also to expedite his recovery process. Intrapylon fractures, principles of treatment, external fixation, swelling control for further deal with soft tissue injuries. This comes up all the time. We see it in the trauma literature. It's okay to stage these. The goal is to maintain and get it out to length very fast with external fixation and potentially plating of the fibula. Maintaining length of the fibula also helps with this articular repair. Metaphyseal grafting can often be the case, but stabilization is often on these exams. Ankle fractures, there are two most quoted classifications. The Weber, which looks at the position of the fracture line as it relates to the syndesmosis. So A is below, B is at, and C is above. This is, in theory, relates to stability, meaning stable to less stable ankle fractures and involvement of the syndesmosis. The Logge-Hansen is one that tries to assess basically the position of the ankle when the injury occurs to look at the structures that would be involved and can determine how to fix an ankle to restore stability. Basically two foot positions, supination, pronation, then direction of the force, which can be adduction or abduction, external rotation, dorsiflexion that results in supination adduction injuries, supination external rotation injuries, pronation, external rotation, and pronation abduction. Arthroscopy of the ankle. Arthroscopy is getting more push these days. It's expanding role for the treatment of interarticular injuries. There are a few studies that have come out now that I think it's well understood that the interarticular involvement may be more than we appreciate. So there has been studies that support arthroscopic evaluation of the ankles in the setting of ankle fractures may come up on the examination. Syndesmotic injuries can also come up. These can definitely happen without a fracture. Sometimes they come in as with a diagnosis of a quote unquote high ankle sprain, still having difficulty to ambulate. Sometimes they can have an extended recovery process. So look for a patient with increased pain, swelling. Stress x-rays are usually helpful. You can get intraoperative x-rays. And then fixation of these across the syndesmosis is typically the treatment with screws or there are other devices, all suture devices. Talus fractures. So this can happen within the body of the talus, the neck of the talus. It typically happens in a dorsiflexion axillary load. We can see it in football players, various sports related injuries. It's most common in motor vehicle accidents. Most common complication is not avascular necrosis, it is subtalar arthritis, which comes up quite frequently. Classifications are based on the location and displacement. So nondisplaced, subtalar displacement and subluxation, ankle and subtalar dislocation, or dislocation and subluxation, and the talon ovicular extrusion. So these are the risk of avascular necrosis with these based on the blood supply, which we discussed. Hawkins signs comes up. So this is an area of radiolucency, subchondral osteopenia that is associated on typically mortis or an AP x-ray that we usually see are anywhere from four to eight weeks post-injury. This is actually a good sign. This implies that the blood is getting there and there is an early resorption phenomenon. So the subchondral bone resorbs, which actually suggests that it's healing. So this is a good sign. So lateral ankle ligament injuries as we discuss the anatomy. These are obviously very common, acute inversion injuries. Look for people that have had prior sprain complaints. They typically have residual weakness in the peroneals and laxity. They're often tender anterior on the ATFL, distal to the fibula, CFL, and then sometimes even posterior. Look for the cavus foot, especially people with chronic ankle injuries. Most of them return to sport fairly quickly, but oftentimes they can have persistent pain. Gradation is fairly straightforward. Classically, we talk about one through three, meaning no ligamentous laxity, slight ligamentous laxity, and complete ligamentous rupture with a significant anterior translation as well as a tailored tilt or a medial translational drawer. Typically, ATFL is injured first, CFL a second, and as I said, with a rotational component or more significant component, the posterior lateral ankle ligament is injured. Anterior drawer is the most common way to assess this. As the more complex injury occurs with CFL involvement, you'll get more anterior shift on the drawer test as well as a tailored tilt when you pull down on the calcaneus and medialized calcaneus. You can feel this as well as visualize it on a stress exam. Acute management is, as we typically do, RICE, so compression, ice, elevation, and rest. There are new components that are being integrated into this. The Ottawa rules look at when to image these, so does every ankle sprain need an x-ray? There is a couple studies based on these in Ottawa, the Ottawa rules that look at whether or not to get this. Basically, if they have inability to bear weight or they have pain over the medial malleolus or lateral malleolus or the navicular or the fifth metatarsal, this is the indication to get x-rays. Two other things that have come up with the RICE treatment is protection. You can immobilize with these superficial braces, cast, or even a boot, but you want to initiate and facilitate early immobilization. Typically not narcotics, but it's some form of anti-inflammatory medication, localized application. Sometimes they'll need crutches, weight-bearing tolerates. You want to protect the ankle as the peroneals are really shut down at this point. You've got to reactivate them, but we still want to preserve ankle motion, so early range of motion is key. Strengthening exercises, the return to proprioceptive exercises is critical and often quoted as sport-specific drills as they become less symptomatic. These Ottawa rules are basically if they have any of these five positive findings, then the suggestion of these studies is to get x-rays for only these indications. Inability to bear weight initially or a presentation to the emergency room, in this case to your office. Tenderness to palpation of the posterior medial malleolus, posterior aspect of the lateral malleolus, not anterior where they almost always are. Tenderness to palpation over the base of the fifth metatarsal or over the navicular. So these are the zones that was published in the paper where they have tenderness to indicate getting x-rays or inability to bear weight. So they're fairly sensitive, the original publication. Subsequent studies have showed LEFS sensitivity, but they're fairly specific. Not perfect, but it comes up intermittently. But obviously, other indications are patients are unable to communicate with you for altered mental status, alcohol intoxication, or whatever. Always a good thing to get if you're worried about it. So 36-year-old speed skater, slips, ankle injury, no effusion, tender over the ATFL, so that's anterior. Radiographs show medial osteochondral defect, same as two years prior. What's the next step? So it's a chronic injury, chronic finding. He had no issues. It's acute injury with no effusion. College athlete has lower extremity injury that's being evaluated in the training room, which are the following, deferred radiographic injury. He just has distal anterior fibular tenderness, not an indication secondary to the auto classification. 13-year-old male presents to your clinic six months history of medial hind foot pain with sports activity, enjoys running, playing soccer, unable to because of pain in the foot, denies trauma, states increasing complaint of pain with walking, with sports, physical exam, no tenderness, but decreased range of motion on subtalar examination, which is the important part I highlighted here. No instability and otherwise functional. The images show coalition, which comes up fairly often. Given his pain and limitation, a surgical treatment takedown can be offered. Open reduction internal fixation is generally advocated for by malfractures. Recommendation is primarily based on biomechanical data that implies that abnormal distribution. So even a few millimeters of shifting or malalignment of the tibial-talar articulation can lead to progression of arthritis. Most common complication of tail and S fractures. This is easy. You've seen it already. It's not osteonecrosis. It's arthritis of subtalar joint. 53-year-old obese male presents with painless deformity of the anchor, denies trauma, but does note progressive loss of sensation over feet, radiographs displaced by malfracture, disorganized callus. So we know it's a chronic process. We know most likely it's an undiagnosed diabetic. So sometimes they can even be in this sort of format where they're not asking you about the fracture. They're asking you about the patient. 29-year-old male sustained tail and neck fracture with associated dislocation of the body from the subtalar and tibial-talar joints. Treated immediate open reduction to a fixation. 12 weeks later, there's a lucency. So we know that that's actually a good thing. So continued observation of protective weight bearing means that we did a good job and it's healing. 27-year-old female twisted her ankle and sustained a trimal fracture. It was determined to be a SE4. So this is off the Loggie Hansen classification. So whether it's worth memorizing that or not. Had surgery with open reduction and trimal fixation. One year later, complaints of pain, ankle range of motion. Radiographs revealed the development of DJD. What's the most likely etiology from this outcome? Occult fracture, articular cartilage injury at the time of initial trauma. Now, that doesn't mean that we could have fixed that with scope, but it just means that there is a process that happens during the event. 16-year-old male lacrosse sustained ankle injury during practice when his ankle is averted. Multiple swelling around the ankle, echemosis medial, tender distal malleolus, anterior lateral between tibia and fibula for about four centimeters proximal. Physical exam painful with external rotation. He is able to bear weight, but with minimal issues. But lateral movements cause some discomfort. X-rays are negative. Stress X-rays are normal. What's the best treatment? He's just got a high ankle sprain, higher level of involvement. 28-year-old hockey player, twist and fall, ankle injury, pain over the proximal aspect of his left leg, tenderness over the lateral side of his knee. So there's an indication right there, hockey, high skates, high external rotation moment, proximal pain. Radiographs show a proximal fibula fracture. It's subtle, but you can see even in this that he's got some medial clear space widening. So he actually has a syndesmotic injury without fracture around the ankle. 26-year-old male tennis player presents with a clinic for an evaluation of a, quote unquote, sprain of the ankle, reports catching and clicking of the ankle when he walks. Examination reveals tenderness over the anterior medial joint line of the ankle with an effusion. So catching, clicking, effusion, and tenderness on the medial side. So not surprisingly, the radiographs and MRI displaced osteochondral lesion of the talar dome on the medial side. What's the next appropriate management given his effusions and clicking? Remove the loose body and address the defect. 19-year-old male motocross racer presents emergency room after sustaining the injury. We'll see the images in a second. Grossly deformed lower extremity, significant swelling, no laceration, sensation intact, does have pulses, but he's got a displaced, shortened distal tibia, pylon fracture. So closed reduction with application of the ankle spaining to let the soft tissues recover before surgical intervention. All right, moving forward. So next we're going to talk about ligament injuries, myositis, osteocans, stress fractures, exertional compartment syndrome, popliteal entrapment syndrome, perineal nerve issues, and common tumors in the lower extremity. So quick basic science review. So collagen types. Remember, collagen 1 is typically associated with bone or ligament. Collagen type 2 is typically associated with articular cartilage, and cartilage type 3 is typically associated with fracture callus or healing process, typically in bone callus. Crosslinking does add strength to this collagen, and the elastin is typically 1% by volume and allows for length maintenance of collagen, meaning its overall elastic strength. Ligaments typically are considered unmineralized fibrocartilage. When it becomes mineralized, it becomes more of a bony process. Ligament avulsion injuries typically happens at the layer between the fibrocartilage layers. Strength of heel ligament diminishes due to less crosslinking, which can happen with age, and disorganization of the collagen orientation could be age-related or genetic-related. Muscle forces are created by myosin and actin interface. So there are two types of typically classically described muscle fibers distinctions. Type 1, which is the slow twitch, red, aerobic, metabolizing. They have more mitochondria because of this. They are for endurance athletes. Type 2, fast twitch, white, shorter, contracting, produces more lactic acid secondary to less oxygen usage, typically found more in the weightlifter or the sprinters. So this is something that I learned in residency. So toaster, type 1, anaerobic, slow twitch, enduring red. So it's a little way to kind of pneumatic to remind you of the two differences. This is the other way. So if you look at sort of a tension time curve, the short fibers are very high-tension, short-reacting. Type 1s are lower-tension, longer-reacting. So force is proportional to the cross-sectional area of the muscle belly, and velocity is really related to the proportion of the muscle fiber length, because the velocity is related to the displacement and the time it takes. So the overall length is important for that. Contusion. Contusions we see quite often. They're related to a direct blow, often in the thigh, hamstring, lateral compartment. West Point protocol, especially for thigh contusions, immobilized in a flexed, excuse me, a stretched position, meaning the leg flexed back, flexing the knee, dorsal flexion in the ankle, however it is, to elongate the muscle as best as possible. Early range of motion works better than casting, but you want to get the muscle fully elongated as best as possible, because it does form adhesions in the scar. Muscle strains can happen in direct force. Prevention with strengthening and obtaining maximum length with stretching consensus. No real consensus on the treatment of these mid-substance strains or contusions with NSAID steroids or even PRP. So as we see more and more people, there might see some test questions about what I call combative sports athletes. They often have thigh and leg contusions. They can have broken bones, tibia fractures. But part of their goal in their training or their combative sport is actually to kick each other in the thigh, posterior thigh, and anterior and posterior compartment of the leg. And oftentimes they can even induce compartment syndrome. He's a guy that actually won the match. He could barely walk, and if I stuck him, I guarantee you, he would be somewhere in an abnormal range. So myositis ossificans can happen quite often. Typically cortex is not involved. That's how we know it's not a bone tumor. It's within the mid-substance of the muscle belly. It can often be confused with osteocartilaginous lesions like osteochondromas. But again, the cortex part of the lesion is a cortex part of the lesion, meaning the osteochondromas have a cortex part to the lesion and can be malignant. Osteosarcomas are lesions that attach to the cortex also. So a free-floating ossified area will almost always be this. Mature ossificans can happen at the periphery. Osteosarcomas typically will happen in the center of this. Sometimes they can convert. Classically, in the thigh of the football athlete is what we think about, but can be elsewhere. Oftentimes, the proximal arm of the lacrosse player or hockey players, these guys are hitting each other with the stick. Again, the combative sports athlete. 40% without known trauma. They can happen idiopathically, or they just don't recall the trauma. 9% to 20% of thigh injuries are the typical location. If symptomatic, surgical removal is recommended only after they are metabolically stable, meaning they've matured. Oftentimes, we can get a bone scan to determine if they're still hot or cold. Cold meaning that they're fully matured. Stress fractures. Very common. Insidious onset of pain increases with duration and intensity of activity. Tibia is one of the most common locations, commonly associated with jumpers, distance runners, crossfitters, molecularized tenderness, periosteal reactions can be palpated. Sometimes they can be seen on x-rays. They most often can be seen on MRI before you can see the, quote unquote, dreaded black line that we see on x-rays. This is an example of an anterior tibia stress fracture, the dreaded black line example. Usually on the test questions, they're going to be fairly obvious with it. Risk factors, increase in training, distance, intensity, poor conditioning, hence the crossfitters, change in, meaning the early adopters of crossfitters, change in surface for the runners can often cause it. Beware of the metabolic stressors, so the female amenorrhea will come up when the test example, the female, classically the female triad. Medication usage, vitamin D deficiencies, thyroid, celiac disease is also another one that can be associated with this, secondary to mineral absorption abnormalities. Anterior cortex of the tibia, most common, secondary to its tension, side of the bone and poor vascularity. No consensus on treatments, therefore typically no questions on exactly how to treat it outside of potentially risk given on their symptoms. So an overlapping symptom is this shin splints or medial tibia stress syndrome, very common in runners. Or a surface change or a shoe change, periostitis, it's really at the origin of the anterior tibia periosteum as it connects with the medial superficial and deep compartment fascia. It's associated with pes plinus often, non-focal tenderness and non-focal on the imaging. Time limited, treat non-operatively, consider adjusting the cause, which can often be the foot position with orthotics or changing the shoe cushioning or surface. Exertional compartment syndrome, relatively uncommon, but I think it happens more common than we realize. Often happens in runners or running sport athletes, lacrosse players, soccer players, common. Compartment pressure measures are typically needed for actual diagnosis. What happens is you run them or stress them either in the field and then you striker them directly to measure the pressures in arresting an active and then a recovering, meaning active, meaning painful active, and then recovering pressures usually at one in three minutes. All four compartments can be involved, deep posterior, superficial posterior, many of the deep communicates with the foot, but not all involved in most cases. Most common is the anterior and lateral compartments. Surgical fasciotomies is the treatment, but recent studies suggesting that barefoot running may be effective. Jury's out on that. Diagnostic criteria, resting pressures greater than 15 millimeters. Again, this is all with the striker needle measurements. Activity one minute post exercise, greater than 30 minutes, and five minutes recovery, only down to 20 millimeters. Increased pressures, they often describe ischemic pain, which is this sort of dull, burning ache in their anterior leg. They can describe this slapping foot phenomenon where their anterior compartment kind of dials out and their anterior tibialis starts to functioning less. They get anterior and lateral pain most common. The superficial nerve is at risk. Oftentimes, they can have numbness at the anterior aspect of their foot, and during surgical release, this is the most common nerve at risk during the fasciotomies. This can cause overlapping symptoms with that. Popliteal artery entrapment syndrome, it is rare. Cause of same sort of thing, but this is more of a claudication type symptom. Exercise-induced pain in the young people, possibly due to repeated popliteal artery compression, leads to intimal fibrosis within the artery, which worsens the constellation. Exercise compartment pressures may be elevated to normal, so if they still have their symptoms but their pressures are all normal, this might be an indication to look at this. Oftentimes, they can have loss of pedipulses, as we talked about when they go into knee hyperextension when the gastrocs becomes tight. Also, don't forget about spontaneous DVT. This can also cause some overlapping symptoms. Consider duplex of the thigh and leg for swelling, non-trauma, tenderness along the midline post your leg. Oftentimes, they can be distal as well as proximal, and association with the knee scopes. So DVT, first-degree relatives, make sure that this can come up in the conversations. They are typically people at higher risk. They can often not be diagnosed with these hypercoagulable conditions, like antiphospholipsis syndrome or protein C or S deficiency. Sometimes they can have recent surgery or trauma, and even knee scopes can lead to DVTs. Let's not forget. So proximal tip-fib joint injury, typically a violent, twisting, flexed knee position. Proximal lateral leg pain, typically have a stable knee exam. Two patterns, they can actually have a subluxation of the tip-fib joint, or they can have actual dislocation of the tip-fib joint, with anterior lateral being the most common. Typically it can be treated closed. Leg tumors, none are common. Pain at rest or night, swelling without trauma. These are the various ones that have been described in the lower extremity. Osteochondroma, typically outside of the cortex, fibrous cortical defect, or NOF, inside the cortex, UBC, ABC, typically younger age group, osteosarcoma, typically around the knee, Ewing's, typically a younger age group, multiple myeloma, typically an older age group, osteosarcoma, typically mid-range with eroding cortex, and osteoid osteoma, I've actually seen this in my own practice, best seen on CT scans and its response to NSAIDs. So this is an example of a UBC in a fibula in a young patient of mine. This is an example of a 22-year-old with posterior knee pain for greater than two years, kept getting worked up for meniscus, pathology, but the meniscus were relatively normal and MRIs, no trauma, some pain at night, does correlate with activity or did not correlate specifically with changing with rest or activities, x-rays were negative, PCP obtained an MRI, and you kind of got lucky on this one cut, you sort of see this area and you see some adeno back there, and the CT scan was confirmatory and it was treated with radiofrequency ablation. Chronic ankle injuries, ankle instability, etiology, misalignment, and arthritis. So chronic instability, limb alignment is important, tibia varus, remember again the muscular confounders, muscle atrophy with Charcot-Marie-Tooth disease, assessment of foot shape, is cabal varus present, is cavus or varus present, and we use the Coleman block test to determine the flexibility or rigidity of the hind foot with certain deformities. Why? So rigid, rigid meaning non-mobile, especially with Coleman block tests or examination, cabal varus foot, these are typically the reasons that this can happen, tarsal correlations, post-traumatic arthrosis, Charcot-Marie-Tooth disease that can lead to fibrous tissue build-up and neuromuscular disorders. So Coleman block test, remember we place the heel and the lateral forefoot on the block and rest the first ray, let it drop off, if the heel moves to valgus position, it's flexible, if it remains in this original position, then it is rigid. Surgical indication for recurrent ankle instability, so recurrent ankle sprains, greater than six months of limitations and inability to return to activities, and failed PT. So treatment options, gold modification of the Brostrom, which is an anatomic ATFL repair augmented with the anterior extensor retinaculum brought up to do the repair, I'm sure most of you are familiar with this, typically a greater than 97% success rate, randomized clinical trial says that the anatomic is better than the non-anatomic ones where we looped the peroneal or brevis through. Tendon grafts for failures, typically for revision situations or people with ligamentous conditions, meaning collagen conditions, negatives, loss of motions, and the subtalar joint primarily are the most commonly quoted complications, the morbidity of the injury to the peroneal tendons with these accessory augmentations. Consider with hypermobility symptoms, obviously high BITEN scores, these accessory augmentations. Consider osteotomies, meaning the hind foot, to correct the cavus or release of coalitions. Ankle malalignment for reasonable preserved articular space, consider osteotomy, must ensure balance of the hind foot and ankle. Ankle arthritis, low prevalence in relation to the hip and the knee, but it is typically related to post-traumatic conditions. Recurrent ankle sprains could lead to it, but typically related to a history of fracture. Most likely, beware of tunnel vision and evaluate for other things that can cause this, like arthropathies, like hemochromatosis, hemophilia, and obviously RA, juvenile, and so forth. Indications for painful arthritis. Ankle fusion is still a treatment option, especially for the younger patient that has higher demands of the ankle, whether it's subtalar only or whether it's ankle or whether it's triple, acceptable for people after fusion to go back to biking, skiing, golf, cycling, and hiking. Arthrodesis, a typical position that you want to put the foot into is a neutral position of plantar flexion, slight five degrees of valgus, neutral to 10 degrees of external rotation. And you want to try to match the contralateral side, assuming this is in a normal position, which it often isn't, reduce, unless it's a traumatic condition, reduce translations whenever possible, and malalignments or malformations, like in the x-ray example, whenever possible. Automatic and open techniques have been reported. Certainly for the failed treatment, an older person or a severe arthritic condition, rheumatoid arthritis, the elderly or low-demand patient, ipsilateral hind foot arthritis, a compliant patient, and you have to sort of limit your sports participation or activity modifications in the setting with ankle arthroplasty. Okay, some more questions. A 24-year-old volleyball player has recurring ankle sprains, failed PT for greater than six months. Considering surgery, want to use her own tendon, what would be best? Obviously, modified Brostrom. 39-year-old, primary complaint, chronic ankle instability, failed non-operative management. Completely corrects with a Coleman block test. Optimum surgical care includes lateral ankle ligament reconstruction for first minute, and first minute tarsal dorsal osteotomy. Does have correction with the Coleman block test for chronic ankle instability. 10-year-old soccer player has foot pain and flat foot deformity. What are the most accurate physical exam tests to differentiate a flexible flat foot from a rigid flat foot? So sorry, yeah, Coleman block test. I highlighted the wrong one. 11-year-old female sustained an inversion sprain to her ankle 12 weeks ago and is unable to bear weight. Aledenia is present. Foot is purple hue and diffusely swollen. Bone scan shows increased uptake around the ankle, sub-talar joint, talonovicular cuboid joints. Treatment consideration is sympathetic nerve block and physical therapy. 18-year-old male presents with recurrent bilateral ankle instability. Symptoms slow to progress, denies problems of coordination, but easily fatigable when he types. Examination notable for bilateral cable varus feet, peroneal weakness. So here we go. So here's an electromyogram. So there's obviously a neurogenic condition at play here. Probably a shark on my tooth or chains. 35-year-old female, avid runner, complains of progressive worsening bilateral leg pain over the past six months. Reached a point she's unable to run, states that wearing quality shoes and stretches regularly. Medical exam, pain along the posterior medial distal half of the tibia. Normal knee exam, normal ankle exam, slight pronation of both feet, radiographs tibia normal. Bone scan reveals longitudinal uptake along the posterior medial surface of both tibia. So she's got medial tibia stress syndrome. So rest orthotics and calf stretching. All right, we're almost home. Achilles tendon tears. So we're going to talk about tendon problems. So Achilles tendon tears, tendinopathies, peroneal subluxation, peroneal tendon tears, and so forth. So tendinopathy calcification. So this is important. I always get confused by this. But tendinitis is basically rare. Most of these are tendinosis, which the people that present to us with painful constellation typically have a tendinosis. And this is, unfortunately, a histologic diagnosis that shows degeneration within the fibers and soft tissue or the collagens of the actual tendon. The periton can often get inflamed, which peritonitis can happen. Tendinosis with peritonitis is most common sympathetic or symptomatic tendinopathy. So these are the people that we typically are seeing. Partial tendon tears can occur and complete tendon tears can occur. So again, the periton is the surrounding neurovascular tissue around it. The endotions are basically the vesicles within the tendon itself. Achilles problems, ruptures. Obviously, we've seen these. Sudden, complete mechanical failure associated with floral quinones can be reported oftentimes with these kind of questions. I'll report them somewhere in the question. Average age, typically 35. Can have a history of ankle pain or prodromal symptoms or tendinosis. Rare to have a normal tendon at the time of surgery. Tendinosis, frequently asymptomatic. Paratendonitis, which is a chronic insertional. Or they can have proximal tenderness at the myotendinous junction. So obviously, the Thompson test is the classic test described. You can do this on a chair like this or in a prone position. But you want to assess the resting position of the ankle. Then you want to squeeze more proximal on the leg to incorporate both the gastroc and soleus complex. In which case, when you squeeze, you should see the muscle technically shorten and you'll see a reflexive response to the foot. If you do not see that, then there is a disconnect that implies a rupture within the tendon. So closed treatment is a reasonable option. You can cast or brace with early range of motion to prevent stiffness in the posterior capsule. There is no risk of infection in this, obviously. The risk of DVT is real with prolonged immobilization, especially of casting. Typically slower to initiate weight bearing. They can have a higher re-rupture rate. These have been re-looked at and assessed with more recent randomized clinical trials and may suggest that the re-rupture rates are probably more similar. There is an increased risk of infection when you do it open. There's a lower risk of re-rupture, potentially. Potentially more rapid rehab program, potentially. Early active range of motion in both the operative and non-operative cases is being more commonplace. Medial post-operative protocol really hasn't been identified, but more aggressive with early range of motion is being more accepted. Percutaneous techniques certainly decrease the risk of infection or wound healing issues, but do place the seronerve at risk. Remember, this is a power issue, so more aggressive in higher demand patients. OK, so open, typically done in a prone position. You can favor a medial approach just to get you away from the seronerve. Wound and nerve can be helpful for using the medial approach. Repair of the tendon and the tendon sheath is key. With the medial approach, you certainly have the risk of infection and wound healing. You can certainly do this percutaneous with reported injuries to the seronerve being upwards of 15% to 25% with percutaneous techniques. Again, this is a degenerative process and may or may not be painful. Oftentimes you can palpate increased swelling within the localized area of the tissue that is typically associated with the painful process. This is where the nodule is. Treatment is typically eccentric loading, so you're stretching it under tension. Done with physiotherapy, that's usually the first mode of treatment for any tendinopathies is eccentric loading, use of nitrate patches potentially. Adrenal tendinopathy, attritional condition or encephalopathy, meaning the attachment of the tendon directly to the bone, that conjunction or that junctional area. Bone spurs can often be present and lead to impingement within the tendon. It does have a broad plate of insertion on the posterior aspect of the calcaneus. Ossification within the tendon itself is common and can also be painful. Examination tendon is right at the insertion to the bone. Bony prominence can be sometimes felt and certainly visualized on x-ray. Most of these are treated non-operatively with stretching, modification of activity. Typically they're changing their activity levels, so you have to dial them back. NSAIDs, heel lift, you can lock them up with walking boots or casts. Stretching and eccentrics, again, the mainstay of the recovery process. You can also do percutaneous treatments like shock absorbing. Achilles heel pads are also to protect the posterior superficial structure. These are rarely recommended and can lead to tendon ruptures. Longitudinal tendon incisions, so for surgical treatment, concentrate on the most painful area. You want to excise and remove the entire degenerative part and any superficial intersubstance, bone calcifications, or underlying bony prominences. Reattach the tendon if you take it fully off, typically with suture anchors or bone tunnels. HL can be integrated as it's right there to augment the repair, especially if a large area of tendon has to be debrided. Prognosis, guarded, improve symptoms, but not a cure. Oftentimes it will come back, especially in the older person that has extensive tendinopathy. So oftentimes we'll see this bump, it's typically refers to as the Hoagland's deformity, can cause an impingement phenomenon that leads to either a chronic inflamed retrocancanial bursa or actual tendinosis within the tendon itself. So if you're going to treat these patients, the bony prominence, which is either the cause of the result or both, has to be removed. Insertional tendinopathies, decreased area of vascularity at this area, which leads to part of the problem. Tendon degenerates, you get tendinosis with that painful peritendinitis. Two to six centimeters proximal to the tendon insertion is an area of watershed where these problems can occur and the tendon usually ruptures. Less capacity to repair after repeated retraction overload secondary to the decreased vascularity is one theory why the ruptures happen in this area. So oftentimes with the peritendinitis, they'll have pain, swelling, warmth, crepitus, often runner's gradual onset. They can often have these bulbous areas that will move, meaning when the ankle dorsal flexor plantar flexor moves with the Achilles tendon. So oftentimes these respond well to rest, NSAIDs, stretching, and again, eccentrics come up, heel lifts to offload the power that the Achilles tendon has to see. Ionophoresis, and again, no steroid injections, no data on PRP or anything like that. Operative treatment, peritendinitis, longitudinal medial incision again for wound healing, release the adhesions, which often is present. Strip the thickened peritendin, post-operative immediate mobilization, get them moving quickly so that the adhesions and the scarring doesn't occur again. With intersubstance tendinosis also found, then you need to incise the inline with the fibers of the tendon. Book it open and debride the thickened peritendin in intersubstance lesion. Oftentimes in the tendon there is necrotic tissue which is incised and then the tendon is repaired and retubulized. Undiagnosed ruptures can often happen. Sometimes they can be, come in to you see chronic. They can, the tendon will heal, well at least scar tissue will form within the area, but it will tend to be in an elongated position which can affect power. They present with functional limitations, limp, oftentimes don't complain of pain. Functional limitations are often with walking up hills, walking up stairs and so forth. With these bigger defects, you can include the flexor hollosis longin as a transfer. FHL is the strongest ankle plantar flexor, so it works really well and it contracts in the access most closely approximates the Achilles tendon pull of force. You can go proximal into the muscle belly and do a VY myotendinous lengthening. In addition to a VY, or excuse me, in addition to a FHL transfer in really large defects, typically recommended greater than five centimeters. So the tendinopathy, this is an example of splitting the tendon. This is done in the brevis, is the most common area, especially on the lateral side of the ankle. This is excavated and then retubulized. Oftentimes you can see a small avulsion fracture, it's insertion on x-ray. Superficial repair of the perineal retinaculum is most important, especially in these situations. We often see this with instability of the perineal tendons as well. The superficial perineal retinaculum, which is more proximal, needs to be secured and repaired to prevent subluxation. This is an example of the tendinosis and a partial tear, commonly associated with patients with recurrent ankle sprains. Tears are commonly associated with perineal dislocations or subluxations. And this is often associated with attenuation of the superior perineal retinaculum. Posterior tib dysfunction, look for these, or the comments of the too many toes sign. It often presents with high input valgus. Radiographs usually show degenerative changes in tailored tip. The MRI will show changes in and around the tendons. Classifications are stages one through four, meaning less and more progressive with no structural changes, all the way down to fixed deformities with sub-tailor and ankle arthritis and deltoid insufficiency, these need fusions. So treatments based on the stages, typically non-operative all the way down to fusions and non-operative management, but repair of acute tears based on location. So 18-year-old high school basketball player being treated for Achilles tendonitis. What type of strengthening exercises do we do? Well, we know this one, eccentrics. 30-year-old sedentary male evaluated for increasing pain over the Achilles, denies any activity changes, chronic sinusitis with seasonal allergies, been giving Cipro, so here you go, here's your levofloxacin question. Family history of diabetes, so management of his early tenosynovitis discontinuation of the fluoroquinolone. 40-year-old female runner develops pain in the Achilles tendon, past four months, preventing her from running. It's episodic, worse when starting exercises, tried ibuprofen with little relief. Exam reveals palpable, painful thickening of the mid-portion of the Achilles tendon. Was the best treatment recommendation to return this patient to running exercises, PT and eccentrics. 35-year-old male sustains fall off climbing rock, notes immediate pain, deformity of ankle, diagnosed with bimal ankle fracture. Discuss surgical fixation, disruption of the medial posterior tib tendon is identified. Which of the following is the most appropriate intervention after identification of the posterior tibialis tendon disrupture? Acute repair of the posterior tib tendon at the time of surgical fixation. So this is a big one, so 50-year-old recreational tennis player, medial pain, weakness, symptoms three months, even after conservative treatment with NSAIDs, CAM walk or rest, and recent orthotics. Transient improvement with injection, tenderness and chronic swelling posterior to his medial mal. Mild flexible ankle deformity with a flat foot, ankle dorsiflexion, extension five degrees. So he's definitely got some range of motion, no residigy. He's got some tilts and some inflammation on MRI changes. So he's got earlier posterior tib dysfunction. At this point, he's got a tear, so posterior tib debridement and repair. All right, last section, close to it. Intraarticular issues, impingement, ankle pain with activity, mechanical blocked dorsiflexion, common in impact sports, gymnastics, basketball. Weight-bearing x-rays are critical in diagnosing these patients. To look at alignment, treatment, heel lift, non-steroidals, can do a diagnostic and potentially therapeutic corticosteroid injection and rest. Ankle impingement, surgical debridement in failed cases, oftentimes associated with what we discussed, that accessory. ATFL, the beset's ligament with anterior osteophyte often present along the distal tibia. Arthroscopic or open debridement in the gutters. Consider using fluoroscopy at this time to make sure you get enough debridement off the distal aspect of the tibia. Anterior lateral impingement, lesions most common. Most common complication in doing this surgery is a cutaneous nerve injury to the superficial perineal nerve, either with open dissection or with the scope. Ankle arthroscopy is effective at removing acute chondral loose bodies, synovial biopsies, and removal of painful synovitis or ankle impingement. They can also be used to treat osteochondral defects, typically with removing loose segments. The defects can then be debrided and drilling a microfracture is always your typical first line of treatment. There are other lines of treatment when these fail. So 26-year-old posterior medial tibial OCD, posterior lateral portal made during surgery. The portal is created through which anatomic structure? This is between the interval of the Achilles tendon and perineal longest tendon. 31-year-old hockey player, four years, left ankle pain, getting worse for the past few months, now interfering with activities. Initial injury, dorsiflexion, traumatic while snowboarding. MRI of the injury at that time showed a contusion. Now he's progressed to an active OCD with a subchondral cyst. So ankle arthroscopy, debridement with or without the marrow stimulation. 29, tennis player, multiple ankle sprains, anterior ankle pain, popping, locking despite PT, NSAIDs, MRI shows medial chronic OCD. Typically the medial sides are chronic. So next step is, again, arthroscopy and debrilling. So drilling is the first mainstay. 14, female dancer presents with ankle pain, persistent effusions, mechanical symptoms despite conservative management over several months. She again has flattening, collapse, and some anterior lateral OCD. So this is operative ankle arthroscopy as the selection for this. Counseling your patient for arthroscopy and loose body removal, what's the most appropriate thing to counsel them on is potential for a neurologic injury. All right, stress fractures in the ankle, pediatric injuries, and osteogonam. This is the last one. Stress fractures, relatively rare, typically overuse or metabolic issues, present with vague pain but limits activity. Gymnasts, skiers, runners, non-athletes, again, the workup is important and often comes into play, vitamin D deficiency. Initial x-rays, two to three weeks, MRI scan if they're not getting better, especially if they have pain over the navicular. Consider DEXA if it's a recurrent or multiple immobilization and limit the weight bearing for treatment. Pediatric ankles can have these triplane fractures, ankle instability, look for cavus or hind foot associated with these. Charcot-Marie-Tooth comes up commonly when pediatric patients come in with ankle pain or recurrent ankle sprains or difficulties. Look for weakness, intrinsic atrophy of the hand, and cavovarous deformity. So the triplane fractures occur along two planes, the tibia shaft and the physis. Different planes, so you see it on the AP and lateral, hence the triplane, often require surgical treatment. Painful osteogonam often comes up fairly commonly, source of posterior pain, common in the people with extreme dorsal flexion. Can happen with trauma, can happen more commonly attritionally with ballet dancers, and it's lateral to the flexor house as long as, but that can elicit pain. Rice therapy first, typical recommendation is injection. This can be both diagnostic and therapeutic. It's relatively straightforward, but can also be done with an ultrasound. Ballet dancer, chronic pain, osteogonam, relative to FHL, it is lateral. 23 year old, end point, which of the following most likely to cause her pain? Again, osteogonam. So we're running out of time here, so we'll kind of wrap it up. Stay on time, since I'm the first. Good luck.

leg and ankle region

anatomy

injuries

treatment protocols

ligament injuries

ankle instability

tendon problems

Achilles tendon tears

physical therapy