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ABSTRACT: Most ankle injuries are straightforward ligamentous injuries. However, the clinical presentation of subtle fractures can be similar to that of ankle sprains, and these fractures are frequently missed on initial examination. Fractures of the talar dome may be medial or lateral, and they are usually the result of inversion injuries, although medial injuries may be atraumatic. Lateral talar process fractures are characterized by point tenderness over the lateral process. Posterior talar process fractures are often associated with tenderness to deep palpation anterior to the Achilles tendon over the posterolateral talus, and plantar flexion may exacerbate the pain. These fractures can often be managed nonsurgically with nonweight-bearing status and a short leg cast worn for approximately four weeks. Delays in treatment can result in long-term disability and surgery. Computed tomographic scans or magnetic resonance imaging may be required because these fractures are difficult to detect on plain films.
ABSTRACT: Joint and soft tissue injection of the ankle and foot region is a useful diagnostic and therapeutic tool for the family physician. This article reviews the injection procedure for the plantar fascia, ankle joint, tarsal tunnel, interdigital space, and first metatarsophalangeal joint. Indications for plantar fascia injection include degeneration secondary to repetitive use and traumatic injuries that are unresponsive to conservative treatment. Diagnostic aspiration or therapeutic injection of the ankle or first metatarsophalangeal joints can be performed for management of advanced osteoarthritis, rheumatoid arthritis, and other inflammatory arthritides such as gout, or synovitis or an arthrosis such as "turf toe." Persistent pain and disability resulting from tarsal tunnel syndrome, an analog of carpal tunnel syndrome of the wrist respond to local injection therapy. A painful interdigital space, such as that occurring in patients with Morton's neuroma, is commonly relieved with corticosteroid injection. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes.
Acute Ankle Sprain: An Update - Article
ABSTRACT: Acute ankle injury, a common musculoskeletal injury, can cause ankle sprains. Some evidence suggests that previous injuries or limited joint flexibility may contribute to ankle sprains. The initial assessment of an acute ankle injury should include questions about the timing and mechanism of the injury. The Ottawa Ankle and Foot Rules provide clinical guidelines for excluding a fracture in adults and children and determining if radiography is indicated at the time of injury. Reexamination three to five days after injury, when pain and swelling have improved, may help with the diagnosis. Therapy for ankle sprains focuses on controlling pain and swelling. PRICE (Protection, Rest, Ice, Compression, and Elevation) is a well-established protocol for the treatment of ankle injury. There is some evidence that applying ice and using nonsteroidal antiinflammatory drugs improves healing and speeds recovery. Functional rehabilitation (e.g., motion restoration and strengthening exercises) is preferred over immobilization. Superiority of surgical repair versus functional rehabilitation for severe lateral ligament rupture is controversial. Treatment using semirigid supports is superior to using elastic bandages. Support devices provide some protection against future ankle sprains, particularly in persons with a history of recurrent sprains. Ankle disk or proprioceptive neuromuscular facilitation exercise regimens also may be helpful, although the literature supporting this is limited.
ABSTRACT: Braces and splints can be useful for acute injuries, chronic conditions, and the prevention of injury. There is good evidence to support the use of some braces and splints; others are used because of subjective reports from patients, relatively low cost, and few adverse effects, despite limited data on their effectiveness. The unloader (valgus) knee brace is recommended for pain reduction in patients with osteoarthritis of the medial compartment of the knee. Use of the patellar brace for patellofemoral pain syndrome is neither recommended nor discouraged because good evidence for its effectiveness is lacking. A knee immobilizer may be used for a limited number of acute traumatic knee injuries. Functional ankle braces are recommended rather than immobilization for the treatment of acute ankle sprains, and semirigid ankle braces decrease the risk of future ankle sprains in patients with a history of ankle sprain. A neutral wrist splint worn full-time improves symptoms of carpal tunnel syndrome. Close follow-up after bracing or splinting is essential to ensure proper fit and use.
The Injured Ankle - Article
ABSTRACT: Ankle injuries are common presenting complaints in both emergency departments and family physicians' offices. Approximately 1 million ankle injuries occur annually in the United States; most of them are sprains resulting from inversion injuries. Treatment options differ according to the grade of injury--grade I and grade II sprains usually respond to rest and immobilization, while grade III sprains require casting or, possibly, surgery. A chronic "ankle" injury should prompt evaluation for other conditions, such as talar dome lesion. Most ankle injuries can be treated adequately in the family physician's office, although some of the more serious injuries should be referred to an orthopedic specialist for further evaluation.
Management of Ankle Sprains - Article
ABSTRACT: Without adequate care, acute ankle trauma can result in chronic joint instability. Use of a standardized protocol enhances the management of ankle sprains. In patients with grades I or II sprains, emphasis should be placed on accurate diagnosis, early use of RICE (rest, ice, compression and elevation), maintenance of range of motion and use of an ankle support. Sprains with complete ligament [corrected] tears (grade III) may require surgical intervention. Although early motion and mobility are recommended, ligamentous strength does not return until months after an ankle sprain.
Tendinopathies of the Foot and Ankle - Article
ABSTRACT: Because our understanding of tendinopathy has evolved in recent years, the condition is now considered a degenerative process; this affects the approach to treatment. Initial therapy should always involve relative rest and modification of physical activity, use of rehabilitative exercises, and evaluation of intrinsic and extrinsic causes of injury. The posterior tibial tendon is a dynamic arch stabilizer; injury to this tendon can cause a painful flat-footed deformity with hindfoot valgus and midfoot abduction (characterized by the too many toes sign). Treatment of posterior tibial tendinopathy is determined by its severity and can include immobilization, orthotics, physical therapy, or subspecialty referral. Because peroneal tendinopathy is often misdiagnosed, it can lead to chronic lateral ankle pain and instability and should be suspected in a patient with either of these symptoms. Treatment involves physical therapy and close monitoring for surgical indications. Achilles tendinopathy is often caused by overtraining, use of inappropriate training surfaces, and poor flexibility. It is characterized by pain in the Achilles tendon 4 to 6 cm above the point of insertion into the calcaneus. Evidence from clinical trials shows that eccentric strengthening of the calf muscle can help patients with Achilles tendinopathy. Flexor hallucis longus tendinopathy is most common among ballet dancers. Patients may complain of an insidious onset of pain in the posteromedial aspect of the ankle; treatment involves correcting physical training errors, focusing on body mechanics, and strengthening the body's core. Anterior tibial tendinopathy is rare, but is typically seen in patients older than 45 years. It causes weakness in dorsiflexion of the ankle; treatment involves short-term immobilization and physical therapy.
Evaluating the Patient with an Ankle or Foot Injury - Point-of-Care Guides