Introduction Functional Anatomy & Physical Exam Of Foot and Ankle Kim Jin-su,MD.PhD su,md.phd. Assistant Professor Sports Physician Incidence & terminology Anatomy & Physical Exam (Related to the Sports medicine) 1. Calf, shin pain, Achilles pain 2. Foot pain 3. Acute ankle injuries, Ankle pain Foot & Ankle Injury Foot & Ankle Injury 종목저자위치원인 15% 태권도 Siana et al 발등손상, 13/364 막기동작에팔꿈치부딪혀서 씨름 아킬레스건염, 염좌 농구 Mckay 발목손상 45% 점프후착지 축구 Larsen 킥하는발목, 35/1000 점프, 킥, 그라운드상태 럭비 Ekstrand 17-19%, 발목손상태클, 깔릴때 야구 Robert 16%, 족부손상슬라이딩시 High Risk Ballet Basketball Dance Ice skating Mountaineering Running Skateboarding Snowboarding Soccer Adapted from Sports Injuries. Accident Facts. Report of the National Safety Council, 1990, p 88; and from Table 26-1 in Clanton TO: Athletic injuries to the soft tissues of the foot and ankle. In Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, 7th ed. St. Louis, Mosby, 1999. Risk Sports for Foot and Ankle Injury Medium Risk Aerobics Baseball Football Gymnastics Ice hockey Lacrosse Racquetball, squash Roller skating Rugby Tennis Volleyball Water-skiing Low Risk Archery Boating Bowing Cycling Equestrian Fishing Golf Parachuting Rodeo Skiing Weight training Wrestling 1
Foot & Ankle Terminology Abduction Adduction Pronation & Supination ( 회내 : 회외 ) Heel varus, ankle inversion, forefoot adduction 예외 ~ 무지 (Hallux); Varus( 내반 ) / Valgus( 외반 ) P/E Video :http://youtu.be/klb0vh8y7ng Foot and Ankle injury : part I Acute ankle injury Sprain Associated injury Chronic ankle injury 2
Acute Ankle Injuries Lateral ligament injury Acute sprain Ankle sprain Lateral ligament injury Grade III >15mm ATF, CF complete rupture Problem ankle: Fracture around ankle Impingement tendon problem, atypical sprain 외측인대 (lateral ligament complex) 외측인대 (lateral ligament complex) 1. 전거비인대 ATF (anterior talofibular ligament) 2. 거종인대 CF (calcaneofibular ligament) 4 1 3. 후거비인대 PTF (posterior talofibular ligament) 4. 전하방경비간인대 AITF (anterior inferior tibiofibular ligament 5. 이분이대 (bifurcate ligament) 6. 족근동 (sinus tarsi, cervical ligament) 2 6 5 3 2 8 6. 비골근 (peroneal tendon) 8. 신전지대 (extensor retinaculum) Drawer test Antero lateral rotary instability > Anterior drawer test + Suction sign + 3
Clinical oriented classification Jackson et al, CORR, 1974 Grade I Grade II Grade III Severity State Symptom Instability Mild 거의늘어남이없음 Moderate 어느정도늘어남 (Firm end point) Severe 끝이견고성없이느슨한상태 Intraligamentous tear Incomplete tear Complete rupture Minimal swelling pain, tenderness Considerable swelling, pain, tenderness, LOM Marked swelling pain, tenderness, LOM Need assistance Minimal Functional instability Mild moderate instability Marked instability Marked Swelling, pain Deltoid injury Syndesmotic injury Avulsion fracture OLT etc. Fracture, combined injury Ottawa ankle rules : take Radiographic evaluation Complex fracture (Bimalleolar fracture) Displacement: >2mm Mortise widening Syndesmotic injury Post fx > 25% MRI findings : Sprain Confirmed : Grade I, II sprain Most common cause of Chronic ankle pain : insufficient rehabilitation & pain control. Grade III; > 6weeks rehab 특수한상황을제외하고는수술을하지않는다. 4
Associated injury and DDx Medial ankle sprain High ankle sprain OSF OLT OSM ANS Peroneal functional weakness (functional instability) Peroneal tendon injury Peroneal subluxation Ant. impingement Post. impingement Sinus tarsi syndrome Subtalar instability Tarsal coalition Calcaneal alignment OA Ganglion CRPS Injuries rate: 1-18% of all ankle sprains Physical Exam Reliable test t External rotation test Not always Cotton test Squeeze test Frick test Interosseous ligament Syndesmosis diastasis MRI(helpful), Arthroscopy(confirm) 4. Anterior inferior tibio-fibular ligament Deltoid ligament ( 삼각인대, 내측측부인대 ) Thickest and longest Diagnosis : medial lig injury 빈도 : 2 ~ 45.3% Superficial Deltoid Prohibit abduction Deep Deltoid Resist ER when DF Deltoid (Tibionavicular) lig. related to eversion and rotary instability Stress view Diagnosis: CT guide 5
Mechanism : Synd + Medial Grade III Severe ER, Abduction Complete disruption of the medial ligaments Extensive disruption of syndesmosis Acompanished by fracture (maisonneuve) Overtly unstable Tender point X-ray MRI Sono Acute Deltoid rupture Chronicity Bony Problem (DDx) Acute lateral sprain Chronic : 20% Acute medial sprain Chronic : 8% (MCAI) Syndesmotic injury: Grade II, III Operative risk < Morbidity of CSI Ankle OA, Chronic intractable pain Rehab : double up Possible chronic pain 뼈조각 뼈조각제거술 골절 고정술 OSF OSM(OST) ANS AIS PIS Os peroneum APC Os subfibulare (OSF): 비골하부골 Os subtibiale (submalleolae) Avulsion fracture Secondary ossifciation center Not united Bone scan, MRI Bone scan, MRI OST OSM ~35% 6
Anterior Impingement syndrome (AIS) Radiologic evaluation X-ray: Anterior spur 전방골극 McDermott grading categories Preop. Postop. CT, MRI, Bone scan 24/M Soccer player m/c, Ballet dancer Diagnosis 삼각골 (Os trigonum) : Shepherd s fracture 발목통증. 전방, 전내측 Hyper Dorsiflexion Hyper Plantarflexion 통증 Posterior impingement syndrome(pis) Malleolar fracture ( 내과, 외과골절 ) 2mm Displace ment 발레, 축구 Sx : Trigonal fx FHL tenosynovitis PIS, Loose bodies 7
Lateral malleolar fracture PER injury MM fracture, syndesmotic injury, talar fracture, chondral injury Careful! Neurovascular damage N/V Splinting Icing No traction, just align Cartilage OLT: osteochondral lesion of talus Pain, swelling, catching, locking. LOM MRI, *Bone scan. Grading of Osteochondral Fracture of the Talar dome IIa III IV : IIa, III, IV : Arthroscopic microfracture 8
Foot and Ankle injury : part II 주상골 (Navicular), 부주상골 (Accessory navicular) Bone Ossicles Stress fracture Tendon Peroneus AchillesA Calf Other ds 발안쪽 Accessary Navicular Syndrome Painful Accessory Navicular ( 부주상골 ) Os Tibiale Externum Radiologic finding Posterior tibialis tendon Cartilagenous connection P/Ex. : direct tenderness Navicualr tuberosity bulging inversion power decreased MM Anterior process fracture of calcaneus Fracture Around Foot Stress fracture Lower extremity weight-bearing bones : more common : tibia(49.1%) > tarsal bone(25.3%) > 1.Bifurcate ligament avulsion fx, 2. Compression fracture Inversion Midfoot sprain Bifurcate ligament : Y-shaped lig CNL, CCL metatarsals (8.8%) Repetitive Stress, compression 9
Tibial stress fracture, DDx: shin splint > 6 month March fracture, 2 nd MT Running Jumping 군인 Conservative Tx 5 th MT base stress fracture 5 th MT base stress fracture Modified Tension Band Wiring : all Surgical results of 5th metatarsal stress fracture using modified tension band wiring. Knee Surg Sports Traumatol Arthrosc. 2011 Union : CT check!! Navicular stress fracture 주상골스트레스골절 Complications Nonunion : Bone graft 10
Navicular stress fx : ORIF with bone graft Vs Conservative Tx : debate Lisfrac injury Injury mechanism Thick: dorsal, plantar intermetatarsal, tarsointermetatarsal ligament 1 st MT 1 st Cuneiform 1 st Cuneiform -2 nd MT Weak Lisfrac lig. Coalition ( 골융합증 ) : CT, MRI Dx Tendon 건 Achilles tendon ( 아킬레스건 ) Peroneal tendon ( 비골건 ) Flexor Hallucis Longus ( 장족무지굴곡근 ) Extensor hallucis longus ( 장족무지신전근 ) 통증 Plantar fascia ( 족저근막 ) m/c Talo-calcaneal coalition 11
Achilles tendon Midportion Achilles tendinopathy 달리기선수 : 일반인에비해아킬레스건파열의위험도는 15 배높고, 단순건병증의위험도도 30 배가넘는다. Achilles tendinopathy :midportion Achilles bursa Retrocalcaneal bursa Achilles Insertional bursitis Paratenon, peritenon Insertional achilles tendinopathy Haglund deformity Insertional achilles tendinopathy Calcific tendinitis, apophysitis Sever s ds: Children, adolescent P/E : Victorian Institute of Sport Assessment, VISA-A 아침에일어나면, 아킬레스강직을느낍니까? 낮에준비운동후스트레칭을하면통증이있습니까? 평지 30분걷고, 2시간내에통증이있습니까? 정상보폭으로계단내려갈때아픕니까? 평지에서 10번뛰꿈치들기하는중혹은직후통증이있습니까? 한발로뛰기를통증없이몇회할수있습니까? 얼마나오랫동안운동이가능합니까? Predisposing factors 운동을한횟수 운동강도의증가 ( 거리, 속도, 경사도등 ) 훈련세션사이회복기의감소 훈련장바닥의변화 신발의변화 [ 낮은힐스파이크 (lower heeled spike), 힐탭 (heel tab) 이있는신발등 ] 회내과다 ( 발가락들림기에발을재-회외시키기위하여비복근- 가자미근복합체에과도한부하가걸린다 ) 장딴지근력약화 근육의유연성저하 ( 긴장된장딴지근등 ) 관절가동범위 ( 제한된족배굴곡 ) 12
Diagnosis : Achilles Rupture Palpable defect : dimpling. Dimpling Diagnosis : Ease, no neglect! No single heel rise, Simmond s test Thomson squeeze test Thompson test / heel rising test Open repair VS Conservative Rerupture rate OP : rerupture risk 27% 낮음 infection, fibrosis risk 11% 증가 Complications 34 % surgery VS 2.7 % non-op Tx Peroneal tendon anatomy Functional ankle Instability Peroneal tendinopathy Most important Muscle group In Rehab Inf. Surface of cuboid bone Lat. Surface of 1 st MT Most common lateral overuse injury : pronation, 무용, 농구, 배구 13
Degeneration, longitudinal splitting : Tubulization Peroneal subluxation( 비골근탈구 ) WB 갑자기빠지면서아프고, 힘이빠진다. Dislocation Sudden DF Violent reflex contraction Peroneal subluxation Skillful neglect Intra-sheath subluxation of peroneal tendon Snapping Retinacular repair Shin pain, 정강이통증 Common in runner = Shin splint Clinical perspective Bone stress reaction Vascular compromise Inflammation Compartment syndrome Nerve entrapment Role of biomechanics Rigid cavus ( 요족 ) : 충격흡수력 Excessive pronated feet ( 평발 ) Stretched TP FHL Soleus. Heel strike : resisted to pronation Heel strike : resisted to pronation Eccentric contraction Toe off : convert to supinated foot for rigid locker. Concentric contraction Stress riser (traction c proximal m. attachment site) 14
Gait cycle Calf pain Gastrocnemius, 비복근 Soleus, 가자미근 Acceleration Contusion DDx Vascular causes Neuromyofascial casues Clamp Fatigue Heat condition Heel pain (syndrome) Proximal plantar fasciitis (overuse) Fat pad contusion Stress fracture Lateral plantar n. entrapment Apophysitis Bone marrow edema Sero-negative connective tissue disease Plantar fascia 콜라겐의정렬손실변화, no inflammation 족저근막염, plantar fasciitis. 15
Flexor Hallucis Longus (FHL) 장족무지굴곡근 Extensor hallucis longus (EHL) 장족무지신전근 태권도 : direct trauma ; rupture Tenosynovitis. Tenosynovitis : 너무흔하다 Metatarsalgia DDx Cavus Flat feet Callus Neuromuscular OA Deformity Sesamoid Shoes problem Hallux Valgus ( 무지외반증 ) Bunion pain 발가락통증. Joplin's neuritis 안쪽통증 Freiberg s disease 2 nd MT head AVN (avascular necrosis) OA, LOM Morton s Neuroma Inter digital n. entrapment Narrow shoes 16
Sesamoiditis Tuft toe Sesmoid 기능 장무지굴근 (fl exor hallucis longus) 의건보호 전족부의내측부의대부분의체중부하흡수 무지의내재근구조물의역학적기능향상 대략 30% 의사람에서양분된 (bipartite) 내, 외측종자골이관찰된다. High arch Stress Ingrowing nail, 내향성발톱 Subungal hematoma, sports toe Grade First antibiotics Protection Partial nail excision with matrixetomy Nail avulsion Contusion No removal Distal nail end deform nail lip hypertrophy Clubbed nail New nail grow outward P/E Video : 정리 Fast exam with precise pointing : 26 point or Exam: http://youtu.be/0hxlqqq_qz4 17