REIDER PART 211

Chapter 7 Lower Leg, Foot, and Ankle 271

7-1 • When the Patient Complains of Ankle Pain

If There is a History of Trauma or a Specific Injury: Major diagnostic possibiuties include:

• Fracture

• Posttraumatic osteoarthritis

• Sprain

• Loose body

• Instability

• Osteochondral defect

• Avascular necrosis (talus)

Ask patient to describe original injury episode

• Able to bear weight right away?

• Significant swelling after injury?

• If relevant, from what height was the fali?

If There was No Specific Injury Event Major diagnostic possibiuties include:

• Osteoarthritis

• Chronić instability

• Osteochondritis dissecans

• Idiopathic osteochondral defect

• Os trigonum

• Sinus tarsi syndrome

• Tarsal tunnel syndrome

• Tendinitis/tendinopathy

- Peroneal tendons

- Posterior tibial tendon

• Idiopathic avascular necrosis

-Talus

- Navicular (Kohler's)

Ask the Patient to Describe Characteristics of the Pain Location of pain

• Exacerbating activities (i.e., weight bearing)

• Aggravating shoe

• Associated weakness

• Associated numbness or tingling

• Pain with weight bearing—arthritis/fracture

• Pain with athletic activities

- Decreased with bracing—instability/sprain

• Intermittent pain—loose body?

• Associated neurologie symptoms

- Numbness

- Paresthesias

Relevant Physical Examination

General

Inspection

• Swelling

• Skin changes

• Deformity

• Gait evaluation

Palpation

Malleoli, Talus, Posterior Tibial Tendon, Joint Linę,

Tendon/Ligament Insertions

Strength

• lnversion

• Eversion

• Dorsiflexion

Ligamentous evaluation

• Eversion—deltoid ligament

• lnversion—calcaneofibular ligament

• Anterior drawer—anterior talofibular ligament

Neurovascular examination Relevant maneuvers—as below Fracture Swelling

Localized tenderness over malleoli Crepitus

Inability to weight bear common Posttraumatic osteoarthritis

Stiffness, decreased ankle motion Crepitus

Look for posttraumatic deformity Sprain Swelling

Localized tenderness over injured ligament Anterior drawer maneuver—anterior talofibular ligament rupture

Increased inversion (painful)—calcaneofibular ligament rupture

Tenderness of syndesmosis—syndesmosis injury

NSTABILITY

Anterior drawer test—ATFL injury lnversion stress test—CFL injury

Os TRIGONUM

Painful forceful plantar flexion Tenderness at posterior talus

Sinus tarsi syndrome

Heel rise to evaluate posterior tibial tendon Reproduce symptomatic lateral impaction with forced hindfoot valgus

Tarsal tunnel syndrome

• Dorsiflexion-eversion test—pain/numbness/tingling suggestive of tarsal tunnel syndrome

occur. Thus, any situation that causes the syndesmosis to scar or to ossify in a contracted configuration also limits dorsiflexion. This situation commonly arises following sprain or fracture, especially if the ankle has been immo-bilized in a plantar flexed position.

Finally, impingement of tissue anteriorly may also limit dorsiflexion. Following an ankle sprain, pinching of anterior soft tissues, such as ffagments of damaged liga-ments or tongues of inflamed synovium, may occasionally cause such a syndrome to develop. If anterior impingement is present, passively forcing the ankle into maximal dorsiflexion with a quick sharp movement may elicit pain localized at the site of the soft tissue impingement (see Fig. 7-36B). Anterior ankle impingement may also be due to the accretion of osteophytes on the anterior rim of the tibial plafond and the neck of the talus. Such osteophytes are common among athletes in jumping sports, such as yolleyball and basketball, and in ballet dancers.