Orthopedic surgeon Lan Chen, MD, FAAOS, presents a primer on ankle sprains, Achilles ruptures and acquired flatfoot, with straightforward physical exam tips, imaging recommendations, counsel on managing patients’ expectations, and guidance on when to choose surgery or refer for specialty care.
Thanks for the opportunity. Thio. Be here to give this talk. So today I'm gonna talk a little bit about some common acute and chronic injuries of the foot and ankle on their way. See them all the time in sports injuries. Eso have nothing to disclose. So today I'm going to talk a little bit about ankle sprains about. I'm going to talk about what things it could be going on when an ankle sprain just does not get better. On then Achilles tendon ruptures, which is very common and then also adult acquired flatfoot. So your patients who have kind of pets planus and flattened arches according to the N I H. About 40% of all athletic injuries are ankle sprain. So a lot that equates about 850,000 English screens per year and, you know, per month per week per day. Basically, every minute there is 1.6 single sprains, so lots of patients having these injuries. The most common mechanism of unequal spring is plantar flexion on Ben Inversion force on their foot, and post patients will often times say, I felt popping, tearing. Most of them are kind of running or they're kind of cutting and pivoting or they're kind of landing from a jump. And there's lots swelling that happens and lots of pain. And sometimes they have a lot of trouble just putting a little bit of weight on there. So I like to also talk about this concept of a finest athletes and ankle sprains. So what I mean by a finest athlete is basically that when we say finest in clinical quietness means, uh, plantar flexed ankles. So here you can see ballerina in her point shoes. Also, someone who's wearing high heels shoes but their ankles in sort of this maximum plant reflection. And the thing here is that when your ankle is in this position, it is inherently file mechanically unstable position. So if you think about your dancers or gymnasts, soccer players, basketball players kind of, you know, going for that shot their foot at some point in the motion is in. This plan reflects position, so it's kind of like already halfway there to an ankle sprain so these patients often times will sprain their ankle. It's important to also kind of look at the anatomy of the Taylor Dome, which is kind of the bone in the ankle, and this will also clarify the reason why a plan reflects ankle is the most unstable positions. If you look at this picture here at the top of the Taylor Dome is actually this top is a little shape, and so the front is a lot wider, so there's more surface area. So when the ankle is endorsee flex position, there's a lot of contact surface contact area in the front of the joints. It's very stable. But when the ankle suddenly goes into planter flexion, there's less contact area right here. Because most of that articulating surfaces in the back here and because there's less contact surface of the joint. That's the reason why plantar flex angle is much more unstable. So when we talk about an ankle sprain, I would like to emphasize there. There really are three joints. There is an ankle joint, which we all know about. There's a sub Taylor joint, which the joint just below the ankle. And then there's also this Sindhis, Moses and the Sindhis. Moses is the distal tibial, tabular like men tibial fibula joint. The answer. Uh, Taylor figure ligament is the most common Lee Injured Ligament, And this is where patients always always have pain. Uh, this ligament limits that anterior translation of the tailless in relation to the play font of the ankle. There's also the CFL, which the Cal Cane you'll figure ligament. And in more severe ankle sprains. This is sometimes injured as well. And then there's also the post scarier Taylor federal ligament. And this usually is never injured because patients usually don't complain that had pain. In fact, the ankle, they always say they have pain with a client or in the side of the equal. And then there's also the medial ligament, and so this is most commonly known as a deltoid. But I like this slide because it's not really just one ligament. It's actually the whole confluence of tissues. We call it the Deltoid ligament, but it's kind of this big ligament is complex and most of time a routine, low angle spraying patients are not gonna have a whole lot of pain in the medial side, but when they do have pain in the medial side, it's good to consider. Or maybe there's something else going on. So that was all essentially kind of a low angle spring. And then here isn't slide. That looks at this high ankle sprain, which is a Sindhis Moses spring on a high ankle sprain, is thes two ligaments. I've struggled here, so it's the anterior inferior tibial figure ligament. And also the post Yuria version. These air really important ligaments of ankle because essentially stabilizes the joint. If these ligaments were tourney, then this patient would actually need surgery. So the mechanism of high ankle sprain it's almost the opposite of a low angle spring. So in a low ankle sprains, remember I said, it's planner Flex and in inversion of the foot. But in the high ankle sprain is actually an external rotation of the foot and the the tailless. And that rotation really kind of tears apart these ligaments and really causes the ligaments to tear. Usually a high ankle sprains gonna involve ah, slower recovery and takes longer back to play patients who come in with an ankle sprain. Of course, they're gonna have lots of swelling, lots of tenderness. I like to ask them to tell me, where do you have pain? Usually, Um, they have so much pain that we're trying to touch them. You know, there's lots of guarding. They're very nervous. So asking them to point out where they have pain is a good way to start. I always dio a range of motion and again because they're so swollen with an acute injuries. Sometimes they can't do a full plan reflection, Dorsia flexion, but just want to make sure that yes, they can, you know, move to your satisfaction. And then you can also do these provocative tests of the interior door and Taylor tilt. I find that these air not helpful to do in the acute setting, not to mention that the patients not gonna let you do them because there are a lot of pain. So I usually save these tests as a secondary test that I would do maybe two weeks after, if I need to see the patient back. I always like to get three views of the ankle, and certainly you don't have to, but you know, when a patient comes in with big, puffy, swollen ankle, I could never really be sure that they don't have a fracture and they want to know. So I just get three views and if it's possible if they could be standing or even they can't stand. It's helpful if they just put their foot flat on the ground and shoot X rays, because when the foot is flat on the ground, you can see kind of standard views, and that could be really helpful in the acute setting. There is no role for a memory. I have lots of patients who come in who say, Well, how do you know I don't have a ligament injury or tear? And I tell them, Well, if you have an ankle sprain, by definition, that's a ligament injury or ligament here. But the good news is that most patients heal. And so in that acute setting, a not order a memory. Um, as we all know, ankle sprains, we treat them conservatively. So I really like putting patients in this tall black boot, Um, from biomechanics studies, you know that it's really important in the initial acute setting to kind of protect that angle from going into more inversion, because if you if you don't do that, it's going to cause that week Type three collagen that's trying to form to kind of a long gate. We also know that this collagen that is sorting that is trying to heal that by about three weeks, they actually starts to mature. And at this point, if you apply a little bit of controlled stress and motion on this area, it actually promotes proper college and orientation. And so, for these two reasons, my standard treatment for an acute ankle sprain is I put them in a boot for two weeks. Just arrest. Don't be ambitious. Just take it easy. Where the boot. And then after that, they start formal physical therapy, and it's really important. I tried toe emphasize that you're gonna do the boot, but the therapy is equally important. It's a lot of time stations like, Oh, I'll just do two weeks the food and then I should be OK, right? I don't need to spend any more time doing therapy, but I really try to emphasize the importance of going to therapy therapy. Um, it's also important because it helps toe break apart some of that scar tissue so that they don't end up getting something called our throw fibrosis. I see lots of patients who come in and they're two months from their ankle sprain and they're still wearing their boot and they're like, I think I got worse. Why am I not getting better? And half the reason is because, well, now they have so much scar tissue in the ankle and so much atrophy that it's almost fighting. Another battle tried to get them better so that initial treatment of therapy is very, very important. I also allow patients, I say, in about 4 to 6 weeks you'll probably be able to get back to most all activities, but it's important to act to manage your expectations. I tell them, just because I say you could do that does not mean it's going to be pain free. In fact, the first time you start getting on your bike or running or jogging, you're gonna have paint. And so expect that. And I would say that in general, if you have patients who have an ankle sprain, they are unable to tolerate physical therapy or get out of the boot In two weeks. That person is probably moving a little bit slower, and then I would consider doing a referral for that patient. So about 10 to 20% of patients fail this non operative treatment and continue tohave pain or recurrent instability. And so here's where we think about Okay, what else could it be? So one of the first things and pretty simple thing is that a patient could have a condition called the OSCE sub fibula, and this is essentially a avulsion fracture of the A T F L. So that's the most common ligament that's torn in the angle spring. And sometimes instead of the ligament, kind of just stretching or tearing, it actually pulls a part of the fibula. So you have this little kind of bony fragment that's there. And I would say most of time, no one ever feels anything. But sometimes this bony little fragment could be there and cause some impingement and rubbing within the joint. And so a lot of times, if a patient's having persistent pain, um, this is something we will look for on an X ray or a CT scan. Another condition that could sort of mass itself as an ankle sprain is lateral taylor process fracture, thes air called the borders fractures, and they're very, very subtle findings. So you can see on this X ray. All you see is Essentially, it's just this little crack right here. And when you get a C T scan, it literally looks like this where, you know, just on the X rays of self, you're like that. That can't be, you know something really bad, but then you get a C T. The C T always looks worse, and thes patients usually need surgery. So here we put three screws in there to fix it, because it is an articulating portion of the sub Taylor joint. Another, less serious problem that we can see is an anterior process fracture of the Cal cane IUs. And again, this is the same thing. It's avulsion fracture of this little beak on the front of their Cal cane IUs and be sometimes can be missed, but I find that radiologists pretty good to pick them up. But these can just be super annoying and because of persistent pain, And when we recognize this, sometimes we'll just respect it. If it's quite small, it's large enough we could put a screw in narrative. Fix it. Um, peroneal tendons are really common pathology that happened with ankle sprains. A swell So Paranal tendons are these tendons on the outer side of the ankle. And when you have a low ankle sprains, suddenly you know you have the sudden force that kind of pulls on these tendons, and they can cause a persistent lateral ankle pain. Sometimes patients or start saying Well, now I feel that's like popping or snapping sensation in my ankle. And then in patients who really have kind of tourney, they're written macula. You can literally see a gross subluxation like the tendon will sub, Let's say from posters the fibula, um, front of the fibula and oftentimes with lots of pain. Thes patients have completely normal X rays, but they have kind of localized pain along the tendon. Ultrasounds could be really helpful because you can use them in real time and have the patient circum duck and move their ankle and all different directions and actually visualized attendance moving and then certainly could get em ride to look at tears. When terrorists do occur, they're usually longitudinal tears, the most common and they do need to be repaired or fixed, and often times if there is snapping or dislocating of the attendants. We want to make sure that when we repair the tendon tears. We also repair the retina Oculus, which is really important. So these are just some clinical intra operative photos of a perennial bravest tendon terror. And so you can see this. This is sort of why you don't actually see, like, a tear, like you would think like a disruption attendant, these air sort of more longitudinal and then thes air kind of white fib. Roddick, start issue. So those air not normal tendon tissue. So we excise those and then we essentially so it up to burglarize it. And then here's a tissue. That's the retina. Kulum. So you can see here. Then we prepare the retina ocular because we wanna hold attendant and then an atomic location. We don't want the tendon to be snapping back and forth. Last thing that it could be is this osteo Condra region of the tail is this is pretty common. Most patients are most primary care. Doctors know about these, but essentially they're basically a fragmentation of the cartilage. And the underlying sub Condra bone within the tailors and they usually happen is basic is when the ankle, um, sprain happens is the tibial plateau bond and then the Taylor Dome just kind of hit each other, and, you know, it's like a bruise, but a deep bruise. The bone and most of time patients who have this condition will come in. They'll say it's been five or six months since my ankle sprain. I don't know what's wrong. All I can tell you that it just does not feel right. So it's just very vague, and you do some X rays and look very carefully and you can see here in this patient he has a O. C. D. The medial Taylor Dome. But it's very subtle finding. Sometimes it's much more subtle than this. So when you see this, we'll get a C T. And I'm right to confirm it. For myself, the C T is much more helpful because it tells me that this is a really large cystic defect. It's almost this big crater to really helps in terms of surgical planning. Most of these initially, when they're diagnosed, we would treat them conservatively so they get mobilized for about six weeks in the boot. You can cast them. I find it very difficult to convince the patient going to cast on Ben if they don't work. Then we do these Merrill stimulation procedures like a microfracture drilling. And then sometimes there's thes kind of artificial bio cartilage that can be put down to try to stimulate that healing on benefit that that doesn't work. Then we do. These open procedures sort of make a Aussie Academy of the Tibia to really get into the joint. And then you can do these oats procedures, which are essentially taking these plugs of bone. You can take them from the knee often times it could be Allah graft and then plug them into the Telus. And then sometimes, if that doesn't work, then you can do these cadaver Allah graphs where Kerry conceive. They essentially move this small corner of the tailless and fixed it. So that's it for the low ankle sprains. So I want to switch gears and talk about the Achilles tendon ruptures because they're really, really common. And I know you guys see ton of them, probably so. Achilles tendon ruptures really common and high impact athletes, right? People who play those types of sports, like soccer, basketball, tennis and then also recently learned that for steers you can if they're kind of going downhill and the accelerating very fastly, and they fall forward. They could really pull that tendon and claws and Achille structures. Well, most patients say, I just I heard a big pop and I thought I got kicked in the back of my leg or I literally thought someone took a baseball bat and hit me behind my leg and I look around behind me and there was nobody. So that's what all the patients say. They can walk, but they're really limping. And then initially they have lots of bruising, um, pain and swelling, but usually about a week or so later, the painfully goes away. So they're kind of like hobbling into your office, saying, I don't know, I can't really walk very well. I don't have a lot of pain, though, so those were kind of things. That Achilles tendon rupture patient's site. So for the anatomy of the Achilles tendon, um, approximately is the gas, rock and soul liest muscle, and then they condensed down to the fashion, which then becomes Achilles tendon, and then the tendon inserts onto the Cal Kenya's phone. The blood supply for the Achilles tendon comes partially from the proximal muscle which was the gas, rock and soul lius on, then distantly from this little piece of the Cal Kenya's. However, at the zone, about 2 to 6 centimeters proximal to the insertion of Achilles is this no man's land, where the blood vessels from the bone kind of get smaller and smaller, and then the blood vessels from above get smaller and smaller. So there's just not great blood supply there. And that's the reason why this is where just about all of the Achilles ruptures occur, about 2 to 6 centimeters about the insertion. So the most common test physical exam tests for Achilles tendon ruptures. This is Thompson test so which we all know about. So in the intact Achilles tendon, you squeeze the calf, you could see plan a reflection. But when the tendon is ruptured, you squeeze Cath, you see nothing. But I think one of the most underappreciated physical exam findings for Achilles tendon is literally just looking at their resting and quietness. So you don't even have the touch. The patient, you just have the patient get on the table, you put them prone, you hang their ankles off the table. And here in this picture, you can see the this side on the right. This is an intact Achilles. You can see there is a natural resting tone about 15 to 20 degrees on their left side, as puffy, swollen and then the ankle is in more neutral position. So it's not in this 20 degrees of resting tone. So just based on this alone, you can tell that this this side probably is the side that has Achilles rupture. So of course, you can also palpate a gap. But a lot of times patients have pain hard to really palpate it. But when I examine them, I really tried toe pushin because I want to know where it is if I'm gonna be fixing that. So just to some other clinical pictures of the actual gap that you can see here and then this is just demonstrating that when you have an Achilles structure, they can have you know, this excessive Dorsey flexion, right, Because attendant here is gone. I'm not suggesting that we do this during the exam, because when you do this, you kind of pulled attendants apart a little bit. But this is really just for demonstration purposes. Toe note that that this this is what happens when you have a killer structure. So in the urgent setting, I usually will have patients stop walking on it, become non weight bearing, and then I put them in planter flexion. So what? The toes pointing down? It doesn't matter if you use a boot. If you do use a boot, put some wedges and the heels of the forces the toes to turn down. Also, you could, you know, put them in a splint. This this is a cast. I don't recommend Cassie and I would say either a boot or a splint and then in the acute phase there, there is no need for M R I either, because usually these air, all based off of clinical diagnosis and I rarely get a memory to confirm a rupture because it's something that I can tell right away on exam. And then we like to fix these and repair these within the first 1 to 2 weeks. So sometimes I'll have patients, and they waited two weeks just to get the Emery's. By the time they come in to see me, it's three weeks going on four weeks. That's sort of on the longer end, so definitely like to get them a little bit sooner to fix. So in terms of options, um, surgery used to be pretty standard for most Achilles structures. But the last 5 to 10 years there's lots of studies, high level studies that have come out that basically say conservative treatment is a good option. But the bottom line is that right now there's no, um, consensus as to which one is better or than the other. But we do know a couple of different things. So one is that regardless of whether you have surgery or that's treated conservatively, it is a long recovery. So I tell patients it will take approximately a year for you to get back. Thio High impact activities So running tennis, soccer, all of those things about a year. Um, also, regardless of whether you have surgery, no surgery, most patients are in a boot for about three months because that's just how long takes a hell. And then the last thing that we all agree on is that surgery does decrease of the rupture rate. But the risk of surgery is wound healing. So most of time, when you have a pretty young, healthy person. Um, we generally do recommend surgery because it decreases three rupture rate. And then for relatively healthy young person, the wound healing aspect is not something we worry too much about, because usually they can heal. Ah, little bit, you know, easier. And it's only in patients were smokers or maybe have diabetes. Then we definitely worry about. They're going feeling So the last topic. I want to talk about this flatfoot. And I thought about whether or not to actually put this in here, and I decided to put it in here because I feel like when all of this see, you know until spring that doesn't get better or an Achilles rupture. Usually those are the ones you're going to refer, right? I mean, you're going to send them to the orthopedic surgeon or specialist or something. But when the patient comes in, there's like, Oh, I just I have flatfoot my whole life. It's something that, you know, kind of like most. I prefer this or not. I mean, is this something that everybody would see? And sometimes patients don't know, right, because they're like, Well, I sort of was born this way, and I had flat from my whole life, but I don't know, but I'm here to make the point that thes air patients that you want to refer because it does impact their treatment options later on. So the sooner I see these patients, I can counsel them on options. So post your tip tendon is one of the main stabilizers of the arson did foot. And so it's You don't want the medial portion of the foot and ankle, and patients who have tendonitis here will have pain. That's usually the most common first complaint, and they'll say they have swelling as well. And then they'll say, I used to be able to walk, you know, five miles. So now I can walk like a mile. And then I started having pain, and in the initial stages, they don't have any deformity. They just kind of have pain immediately, and they can't walk us much. But as that condition, progressives and their foot continues to kind of fall, and then attendance starts to degrade and sometimes even tear. You start seeing a lot more physical exam findings, so you see the forefoot actually start to rotate outwards. So that's abduction. The 4 ft. You start seeing this too many toes sign because their foots like, you know, rotating outward. You see a lot of little toes speaking out when you look from behind on Ben, you see this VALDAS position and their hind foot. And then in the late stages, patients will actually have paying the not on the medial side anymore. They actually have pain on the lateral side because the fibula is now hitting the Cal cane IUs on those two bones were just bumping into each other as you're walking, and that would be a late stage finding. So here's just some photographs of the, you know, picture of this side, which is normal. And then here's the too many toes sign of someone who has these fallen arches. We take an imprint of their foot in the office. You could see this big bump on the medial side. That's your arch, kind of that's actually there, Taylor, head pushing down into the floor again. Just some other pictures of this too many toe scene because there are just kind of falling and flattening out. And then on exam, I I try to have patients that do what we call a single and he'll rise. So they just kind of stand, uh, initially on both feet. And then I test them individually on one side versus the other, and I wanna be able to see that they're able to go up on their tiptoes. A lot of patients who cannot get on their tiptoes will have the tendon tear or even a tendon rupture. And then it's important to check the strength of the poster tibial tendon, which is this inversion strength. Eso That's something, uh, that's demonstrated in this picture. And then I also wanna help a the insertion attendant, which is in a vehicular. Oftentimes, patients with a flatfoot we'll have. We'll have this accessory navicular and not something that's congenital made, had it the whole life and often times they have pain, they're on. Then I get thes weight bearing X rays, the ankle, and then you concert. Seeing here is the tailors, and it's kind of pointing away away from the foot, and that is definitely not normal andan on the latter of you. You see this, um, sag here and I've drawn these two lines in a normal foot. These two lines should be Colin E. Er. They should just meet and the one long complete line. But in the patient who has a flatfoot where the arch is kind of sagging, thes two lines start to diverge. A memory is also really helpful, but it's not something that we necessarily need right away. It's really only helpful for surgery planning sometimes, and also just to confirm, you know, yes, this is the problem here and then here. Ah, lot of times I'll see patients who have had this for so long that the tenant, This is a stump of the like the distal stomp of the poster tip tendon. Because attendant has just completely torm eso. There's four different stages, supposed to To build tendency to stage one is kind of. They just have tendonitis. They do not have any deformity stage shoes when they actually do have some collapse of their art, and you can start to see this like kind of too many toe sign. But it's a flexible deformities, so I can correct them and kind of create that art in the office. Stage three is now. There had for so long that their sub Taylor joint is arthritic. I mean, you can't correct these patients. That just kind of stuff. That way on the stage four is taking this one step further is that they now have arthritis in their ankle. So it moved from pretty much, you know, the attendant, the tailor joint and now into the ankle. So we really want to kind of capture these patients and their cider stage one or two, which is the early stages, because once they get to stage three and four, there's not a whole lot of good surgical options. So the initial treatment when I see these patients in the stage one or two is I tell them rest, I get them a boot. I do physical therapy to try to get those tendons to be stronger. I also recommend using these orthotics, which are arch supports, and they really help Thio recreate the art in a normal person with no significant deformities other than just a flatfoot. I think that the, um, over the counter orthotic So our supports are just as good as the DNC custom ones, which can be really expensive. So once they get into stage three and four where they now have arthritis, and it's a fixed deformity. The only things you can really offer them are these Arizona braces, just kind of these big things and these FOS And so I would say, for patients who are really active. I mean, no one's going to be able to tolerate them. This is just not acceptable. They're not gonna wear this for the rest of their life. So that's why it's important to kind of catch them, whether in Stage one or Stage two, so we could do something we could, you know, do the physical therapy on then. Sometimes they even need surgery. So here's a surgical patient that we got in Stage two and why they needed surgery. The most important thing to recognize that the surgery, it's that is that it's joint sparing. So we're not fusing anything because it's a flexible deformity. You can recreate the art essentially, but if we let this patient go and they made it into Stage three or stage four and now they have arthritis, you can see the surgery options. Here is a fusion. The fusion is basically screws across all the joints. Nothing's moving, and so in terms of Activision's You wanna continue thio hiking and doing things. This definitely makes that function more difficult. And then the most important thing is that even after a fusion like this, you're much more likely to get adjacent joint arthritis. So it's not done yet. Yes, we fix your foot your flat foot. But you know, wait another five or 10 years, you'll have arthritis any other joints. So it's kind of just I'm getting no worse and worse and getting more and more. So that's why, for a flatfoot patients, it's really good to kind of catch some other in stage one and two. So that's my talk. This is our team. Ah, foot nickel orthopedic surgeons atyou CSF um, So my myself, Kristy Olsen and Dan Tolia were kind of the three that are seeing. I would say most of the patients a doctor, Coughlin's here not related, and the doctor man are seeing patients as well. But they really have been and funny go for many, many years or 20 plus years, and they sort of act as our mentors. So it's really nice compliment team where, you know we have access to a lot of Ah, senior orthopedic surgeons. Um, my Coughlin, Roger man used to be the president of the American Financial Society. So American Orthopedic Financial Society. So they have a lot to add on. Ben, just thank you for the opportunity. And here's my contact information is lost Summer for all information.