Foot and Ankle Injuries and Pain

Indranil ‘Neel’ Kushare, MD

Pediatric Orthopedics and Sports Specialist
Texas Children’s Hospital,
The Woodlands
Overview
1. Ankle sprains
2. Ankle fractures
3. Ankle impingement ( and other
differentials of foot and ankle pain)
Ankle A stretch or tear of one or more ankle
ligaments. Once the ligaments stretch
Sprain beyond its natural range, a sprain will occur

• 1 sprain per 10,000 per day

• Most common ligamentous injury
• Most common reason for missed athletic participation
• Can a 7 year old child sprain is ankle?

• Is it easier for an adult or child to sprain their ankle?

Up for Debate!
• Pre adolescent children still have open growth plates
which are the weakest part of their ankle….
• Children do NOT sprain or tear their ligaments as
easily as adults. The reason is that in children the
weakest part of their bone anatomy is the growth
plates (physis). The ligaments in children are stronger
and so when they twist their ankles the bone usually
separates
Ankle is a Hinged Joint
Mortise=
• 90% caused by planter flexion with inversion –
injure the ATFL

• Syndesmosis injury (high ankle sprain) more

common with eversion and/or external rotation
of ankle during injury
Anatomy of Ankle – Ligaments
Fibular collateral ligament consist of the following
3 structures. These are weaker than the medial ligaments,
since the fibula also helps support the ankle
• Anterior talofibular ligament (ATFL)
• Calcaneofibular ligament (CF)
• Posterior talofibular ligament (PTFL)

• Deltoid Ligament – medial

History
• How did injury occur? Mechanism of injury: inversion vs eversion of ankle
• Where you able to bear weight/walk afterwards?
• Any popping/snapping?
• Altered sensation?
• Throbbing?
• Pain? Medication use?
• Swelling?
• Any care performed already? Interventions?
Physical Exam
• Inspect Skin – color, edema, ecchymosis,
• Palpate – over bony and ligamentous landmarks
• Assess Passive and Active Range of Motion
• Tests:
– Ambulate? Toe raises?
– Anterior Drawer
– Inversion/Eversion
– Internal/External rotation
Anterior Drawer Test

• Secure the distal leg with one hand and apply an anterior pull on the heel
with the foot held in gentle plantar flexion

• Positive if patient will have pain, anterior translation and/or “clunk” indications
ATFL injury/rupture
Tests – To Asses for a High Ankle Sprain:

Squeeze Test – in the

absence of a fracture,
mid-calf compression of
tibia and fibula, causes
pain at the syndesmosis.
Radiographs
Indications to obtain X-rays
3
• AP
• Inability to bear weight views • Lateral
• Medial or lateral point of ankle • Mortise
tenderness
• 5th metatarsal tenderness • If on exam suspicious for additional
fractures, obtain appropriate films
• Navicular tenderness (tib/fib, foot… etc)
– Not always necessary if there
is no bone tenderness and
patient is walking comfortably
Normal Radiograph
Findings of Closed vs Open Physis
Additional Imaging
MRI: helps evaluate ligament and syndesmotic injuries if
needed
• Not predictive of instability
• Maybe used for high-level athlete to give better
estimate of return to sport
• Not often used in typical ankle sprain
• May consider if pain persists 8 weeks after sprain
Types of Ankle Sprains
High Ankle Sprains – syndesmosis injury, 1-
10% of all sprains, interossoeous membrane
between the tibia and fibula is involved/injured

Low Ankle Sprains – ATFL and CFL injury,

> 90% of ankle sprains
Classification of Low Ankle Sprains
Ecchymosis Pain with
Ligament disruption
and Edema Weight Bearing

Grade 1 None Minimal Normal

Grade 2 Stretch without tear Moderate Mild

Grade 3 Complete tear Severe Severe

From Orthobullets.com/foot-and-ankle/7028/low-ankle-sprain
Non-Operative Treatment
For Grade I, II, III Sprains

RICE (Rest, Ice, Compression, Elevate)

Rest – Depending on severity, may require short period of

weight bearing with immobilization ace wrap, aircast or walker
boot (However, early mobilization facilitates better recovery)
If a high ankle sprain and patient has instability on stress
testing patient may be NWB in cast x 4 weeks, then walking A functional ankle brace
cast/boot for 2-4 weeks (lace up ankle brace)
Ice – first 72 hours most important is often helpful during
strengthening period
Compression – Ace wrap or immobilization device and maybe during
Elevate – (Toes above nose) sport/activity thereafter
Operative Management
• If associated tibia or fibula fracture

• Continued instability, despite extensive

non-operative treatment
Therapy Activities
Once edema and pain have subsided and patient as full range
of motion, may begin strengthening and proprioception rehab
• Passive and Active Range of Motion and Strengthening
• Therabands
• Proprioceptive Activities
• Balance – single leg stand, advance to with eyes closed
• Wobble Board
• Trampoline
• Lateral Shuffle
• Functional Progression back to sport/activities
– Earlier rehab allows for quicker return to activity/sport
Long Term
• Estimated 10-30% incidence of functional
instability… often related to incomplete or
inadequate treatment and rehab
• If an ankle sprain is not recognized, and is
not treated with the necessary attention
and care, chronic problems of pain and
instability may result
Prevention
• The best way to prevent ankle sprains is to maintain
good strength, muscle balance and flexibility
• Warm-up before doing exercises and vigorous activities
• Pay attention to walking, running or working surfaces
• Wear good shoes
• Pay attention to your body’s warning signs to slow down
when you feel pain or fatigue
Pediatric Ankle Fractures
Epidemiology
Physeal Injuries About the Ankle
• Constitute 10-25% of physeal injuries
• Most common between the ages of 10 – 15
• Distal tibial epiphyseal fractures second only to
those in the radius
• High risk of growth arrest
Distal Tibial Physeal closure
Begins in the midportion  medially and posteriorlylaterally
Anatomy (cont’d)
All major ligaments (except the
interosseous) either insert or
originate on the distal tibial or
fibular epiphyses

Ligaments are stronger

than the physes
Salter-Harris
Dias and Tachdjian
Surgical fixation if displaced or unstable
Ankle Impingement
ANTERIOR POSTERIOR
• Pinching of structures Pinching of structures
at front of the ankle at back of the ankle
• Associated with
ankle sprains
Posterior Ankle Impingement
• ‘Under’ diagnosed cause of posterior ankle pain
related to entrapment of soft tissue or osseous
anatomical structures in the hindfoot
• Commonly presents in athletes in plantar flexion-
predominant sports with chronic posterior ankle
pain exacerbated by plantarflexion or activity
– E.g., ballet, gymnastics, soccer, running
With Forceful Ankle
Plantar Flexion
“Nutcracker Effect” –
to the Structures in
the Posterior Ankle
and Subtalar Joints
Causes of Posterior Ankle Impingement
A.Os Trigonum syndrome
B.Stieda process
C.Downsloping of the posterior tibia
D.Fracture of the lateral tubercle of
posterior process of talus
E.Prominent superior calcaneus
(Haglund deformity)
F.Inflammatory SOFT tissue
G.Ankle sprainavulsion fracture of
posterior talofibular ligament
2 impingement
Soft Tissue Impingement –
Don’t Underestimate!
• Posterior capsule and ligaments –
inflamed, thickened and hypertrophied
• FHL sheath X-rays are
• Accessory ligament, the posterior often NORMAL!!
intermalleolar ligament (PIML)-
identified it in 56% of cadaver specimens
Case 1
• 13 y.o. female, basketball player
• First seen by PCP: December 2014
• First seen by specialist: December 2015
• Number of years experiencing pain: TWO
• Number of X-rays: 3 Advanced Imaging: 1 MRI
• Specialties seen:
Sports medicine (7 visits), physical therapy (15 visits)
• Diagnoses: Sever’s apophysitis, Achilles Tendonitis,
calf tightness, hip weakness, calcaneus - old injury (Abnormal MRI)
Case 2
• 14 y.o. female, gymnast
• First seen by PCP: November 2015
• First seen by specialist: February 2016
• Number of years experiencing pain: >1
• Specialties seen: Next slide
• Number of X-rays: 8 Advanced Imaging: 2 MRI
• Diagnoses: Chronic regional pain syndrome, peroneal tendonitis, atrophy
of R ankle, ankle sprain, sural nerve block for possible sural neuropathy
vs peroneal brevis tendinopathy, stress reaction – Inability to cope
Specialties Seen
Orthopedics (5 different orthopedic surgeons)
Sports medicine (2 visits)
Physical therapy (15+ visits)
Pain medicine (4 visits) – Sural nerve block – complete atrophy of skin, muscles and soft
tissues around the sural nerve distribution
Psychologist! (5 visits)
Number of X-rays: 8 Advanced Imaging: 2 MRI
Diagnoses: Chronic regional pain syndrome, peroneal tendonitis, atrophy
of R ankle, ankle sprain, sural nerve block for possible sural neuropathy vs peroneal
brevis tendinopathy, stress reaction – inability to cope
Case 3
• 14 y.o. male, soccer player
• Side of injury: Right + Left
• First seen by specialist: December 2014
• Number of years experiencing pain: TWO
• Specialties seen: Orthopedics (6 visits), sports medicine
(2 visits), physical therapy (15+ visits)
• Number of X-rays: 7, Advanced Imaging: 3 MRI, 1 CT
• Diagnoses: Possible osteochondritis dissecans lesion, Chronic regional
pain syndrome, ‘Deconditioned’ ankle, ankle sprain
Case 4

• 8 y.o. subluxating peroneal tendons and

ankle pain

• Scheduled for ‘groove deepening surgery’

Similarities?

All patients had the exact same clinical finding: Joint pain
posterior to
Exquisite tenderness over the posterior ankle joint lateral malleolus
which correlates
over talar process exactly to
• In front of the Achilles not Achilles tendinitis) the site of
pathology as
• Not on the Achilles insertion (not SEVERS DISEASE) seen in the MRI
• Not laterally (no peroneal tendinopathy/ankle sprain)
Similarities?
• For all patients, pain was completely relieved with rest
• Pain exacerbated by activity and young athletes
could not continue sports activities
• X-ray imaging for read normal and MRI findings for all patients
demonstrated the very similar findings
• Each patient had experienced pain for at least 1-2 years
prior to being treated by an orthopaedic surgeon
• Each patient visited with a large number and variety of health
specialists while seeking treatment for their various underlying conditions
Os trigonum (7% normal population)
Case 3

Bone marrow edema

near the posterior ankle

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Treatment – Conservative
• Conservative treatment has been empirically
recommended
• Efficacy has not been well documented
• Review of the literature suggests that little new
information has been published in the past
3 decades
Treatment – Conservative
• Steroid and local anesthetic injections are often employed
to reduce inflammation and pain
• Hamilton would not inject because of the vicinity of
the tibial nerve
• In Calder’s series of soccer players, all 28 patients
had at least 1 injection (average 2; range 1–5)
before surgery
• Marotta would not use steroid injections because of the
risk of tendon rupture
Treatment – Surgical
• Van Dijk, in 2000, two-portal minimally
invasive arthroscopic treatment
Steida Process with Osteotome

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Two ‘Poke Hole’ Incisions

Before : Pain in the Os After: Pain in the Os, no more !

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Take Home Points
• Posterior ankle impingement is an under-diagnosed /
Misdiagnosed cause of chronic ankle pain common in
young athletes especially in Houston area
• Pediatricians , Podiatrists, sports med docs, orthopedic
surgeons, radiologists, PTs, ATCs, and anybody dealing
with young athletes need to keep this diagnosis on their
radar whenever they see a kid with posterior ankle pain
• Even if X-rays normal – don’t underestimate!
Take Home Points
• Clinical exam + MRI = diagnostic
• Ankle arthroscopy – minimally invasive treatment to give
excellent (almost dramatic) pain relief in this condition if no
relief with conservative Rx
• Back to sports in 4-6 weeks !
ALL 0/10 on VAS , AOFAS Scores 100/100

Case 2
Follow up: mother
when asked how she
is doing, at week At 3 months:
2 after ankle scope – Participated in 2 meets
“She is doing AWESOME! and selected for
She has finally been cured” state gymnastics

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Case 3

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