Foot & Ankle Injuries

Kylee Phillips, MD, MBA

Clinical Instructor of Emergency Medicine
Team Physician University of Michigan Athletics
University of Michigan

October 19, 2016

 Basic Physical Exam
• Inspection:
o Swelling, Ecchymosis, Deformity
• Range of Motion:
o Dorsiflexion, Plantarflexion
o Inversion and Eversion
• Strength
• Palpation:
o Medial and Lateral Malleolus
o Base of 5th Metatarsal
o Achilles Tendon
o Midfoot
o Proximal Fibula
• Assess neurovascular status
Normal Ankle Range of
Motion
20° 40°

http://www.dshs.wa.gov/
 Normal Ankle Range of
Motion

Eversion Inversion

20° 30°
http://www.dshs.wa.gov/
Bones of Lateral Ankle
Tibia
Fibula

Talus
Navicular

Metatarsals

Calcaneus

Cuboid 5th Metatarsal

 Ankle Ligaments

Anterior
Posterior Talofibular
talofibular Ligament
ligament

Calcaneofibular
ligament
 Anterior Drawer
• Tests integrity of anterior talofibular ligament

Emedicine.medscape.com
 Talar Tilt Test
• Tests integrity of anterior talofibular ligament and
calcaneofibular ligament

Emedicine.medscape.com
 Ottawa Rules: When to Image
• Ottawa Ankle Rules: 98% sensitivity
for fracture, decrease radiographs
• Validated in ED and PCP Office
• Do not apply rules if:
o Age < 18 yo
o Pregnancy
o Multiple painful
injuries
o Compromised
sensation

http://www.mdcalc.com/ottawa-ankle-rules/
 Case 1
• 35 year old woman sustained
an ankle inversion injury while
playing soccer. Able to bear
weight after the injury and
currently. Pain is localized to
the lateral ankle.
o No bony tenderness
o Significant swelling of lateral ankle
o Good end point on anterior drawer and
talar tilt test
o TTP over ATFL
o Neurovascularly intact
 Diagnosis
Ankle Sprain of ATFL
 Staging initially established for different treatment plans, but
now regardless of staging all complete the same treatment plan-
-functional rehabilitation.
Management of Ankle Sprain
• Neuromuscular ankle training
o Increased strength
o Improved proprioception—balance exercises

• Air Splint initially (additional lateral stability)

o Boot only if think more severe diagnosis on differential
• Crutches for Pain—weight bearing as tolerated with
heel to toe walking
• RICE—Rest, Ice, Compression, Elevation
• Emphasize early range of motion exercises
o Write ABCs with foot
 Case 2
• 23 year old male with anterior ankle pain. Was
playing intramural touch football yesterday and
was pushed back by another player while his foot
was planted. Able to bear weight since injury but
with pain.
o Minimal ankle swelling
o Pain with bearing weight
o Difficulty rising on toes
o Limited dorsiflexion secondary
to pain
o Positive Squeeze Test
o Neurovascularly intact
 Syndesmotic Injury
• “High Ankle Sprain” of ligaments
between tibia and fibula
• Associated with rotational injury
o Pushed back on planted foot

Interosseus
Ligament

Anterior-Inferior
Tibiofibular
Ligament

Posterior-Inferior
Tibiofibular
Ligament
 Squeeze Test
• Compression of the mid tibia and fibula with
reproduction of pain in the ankle
o Indicates High Ankle Sprain—pain from
syndesmotic injury

http://step.nl/enkelverzwikking-enkeldistorsie-inversietrauma-enkelbrace-proprioce
 Syndesmotic Injury
Physical Exam:
• Pain with External Rotation Test
o Separates tibia from fibula
• Tenderness between tibia and fibula
• Positive Squeeze test
• Limited dorsiflexion
• Pain with weight bearing and rising up on their toes

Imaging:
• X-Ray –Possible widening of the space between tibia
and fibula
 Treatment of High Ankle
Sprain
• Boot as needed—if severe pain
• Functional Rehab
o Strengthening, early ROM
o Similar to ankle sprain
• Takes twice as long to recover as compared
to ankle sprain
• Widening with fracture may require Ortho
referral for surgical repair
 Do Not Miss…
• Maisonneuve Fracture:
o Proximal Fibula Fracture
that occurs with:
• Avulsion fracture of
medial malleolus
• Rupture of deltoid
ligament
o Palpate proximal fibula
on all ankle injuries

http://www.radiologyassistant.nl/en/p50335f3cb7dc9/ankle-
special-fracture-cases.html
 Case 3
• 65 year old woman who
sustained an inversion injury of
her ankle while stepping off a
curb yesterday. Localizes pain to
foot and lateral ankle. Unable to
bear weight at the time of the
injury, but can now.
o Significant swelling of lateral ankle
o TTP over the base of the 5th
metatarsal
o Neurovascularly Intact
5th Metatarsal Fracture

Strayer et al. Fractures of the proximal fifth metatarsal. Am Fam Physician. 1999 May 1;59(9):2516-2522.
 5th Metatarsal Fractures

Avulsion Fracture:
-No fracture line present in the space between 4th
and 5th metatarsal= DIFFERENT from Jones fracture
-Treatment:
-Weight bearing as tolerated
-Hard soled shoe
-Rarely, surgical repair
• If large, displaced intra-articular fragments
 5 th Metatarsal Fractures
• Jones Fracture:
• The Don’t Miss Fracture
o See in sprinters, jumpers
o Watershed Region/Poor blood flow
= Poor healing, risk of nonunion
o Treatment:
• Referral to Orthopedics or Podiatry
• Splint in ER and make Non-weight bearing
• Non-weight bearing with cast for 4-6 weeks
followed by 4-6 weeks in walking boot
• ~ 75% heal with non-operative treatment
• If athlete, often orthopedic pinning required
• 30-50% will re-fracture
 Jones Fracture X-Ray

http://radiopaedia.org/cases/jones-fracture-4
 Case 4
• 27 year old male lacrosse player presents
after an ankle injury. Occurred yesterday
when his foot was caught in a divot in the
field and he fell forward. Seen in an
Urgent Care yesterday with normal ankle
X-Ray. Discharged with walking boot and
crutches.
o Significant swelling and ecchymosis of
the midfoot
o Neurovascularly intact
o Tenderness over tarsometatarsal joints
o Pain with weight-bearing and unable to
stand on tiptoes

K Burroughs, C Reimer , K Fields. Lisfranc injury of the foot. Am Fam Physician 1998;58:121
 Lisfranc Injury
• Lisfranc Ligament:
Base of 2nd Medial
Metatarsal Cuneiform

-Injury causes separation of the

base of the 1st and 2nd metatarsals
leading to forefoot instability
 Lisfranc Injury
• Injury is referred to as a Lisfranc if there is
any disruption of the tarsometatarsal joint
complex
o Injury can range from sprain of the Lisfranc ligament to
dislocation (due to ligament tear) to fracture

• Why is this area of the foot prone to injury?

o Transverse ligaments connect the bases of the four
lateral metatarsals
• No transverse ligament exists between the 1st and 2nd
metatarsal bases
o Minimal support = increased risk of injury
Imaging
• X-Ray—Weight-bearing: AP and
lateral, +/- oblique
• -Tell radiology what diagnosis you
are concerned about

• Lisfranc Injury XR Evaluation:

o Look for widening of space
between 1st and 2nd metatarsal
o Look for fracture at base of 2nd
metatarsal
o XR findings very subtle. If have
midfoot pain and negative XR,
still possibly a Lisfranc and
needs follow up
http://orthoinfo.aaos.org/topic.cfm?topic=A00162
 Lisfranc Injury
• Weight Bearing View:
Widening > 2mm between 1st and 2nd metatarsal bases
Indicates at least ligamentous injury present

http://orthoinfo.aaos.org/
 Lisfranc Injury
• Fleck Sign: Avulsion off base of 2nd
metatarsal. Represents rupture of Lisfranc
Ligament

http://orthoinfo.aaos.org
 Lisfranc Treatment
• Clinical Diagnosis:
Midfoot pain (Tarsometarsal pain) + Injury + Pain
with Weight Bearing = Lisfranc

o Get weight bearing XR

• Treatment:
o Prompt Orthopedic referral and follow up
o Boot or splint and make non-weight bearing
o Treatment usually almost always surgical

• Diagnose early as delayed treatment causes:

o Chronic pain
o Foot dysfunction and arthritis
 Case 5
• 42 year old woman presents with persistent
heel pain for the last several month. No injury
to the area. Pain is worse in the morning and
improves throughout the day. Increased pain
with activity.
o Tenderness at the base of the calcaneus
o Neurovascularly intact
o No swelling or ecchymosis
 Plantar Fasciitis
=Overuse injury of the plantar fascia
Risk Factors:
• Flat foot (pes planus)
• High arch (pes cavus)

Plantar Aponeurosis
• Leg length discrepancy
• Tightness of Achilles tendon and intrinsic
foot muscles
• Obesity (BMI > 30)
• Sedentary lifestyle
• Prolonged standing/walking at work
• Excessive running
• Poor arch support shoes
 Heel Spur?
Calcaneal spurs
are a SIGN of
the problem,
not the source
of the pain!

Timestra, Jeffrey. Update on Acute Ankle Sprains. Am Fam Physician. 2012 Jun 15;85(12):1170-
1176.

Calcaneal Enthesophyte

Plantar Fascia
 Plantar Fasciitis
Diagnosis:
- History and Physical
Treatment:
• Foot Strengthening
o Pick up pencils or marbles with toes
• Calf/Achilles stretching
• Icing
• Massage
• Arch supports
• Weight loss
• Avoidance of unsupportive shoes, barefoot walking
• NSAIDs
 Case 6
• 37 year old male presents with slow onset of pain
in his posterior heel. He is an avid runner and is
currently training for a half marathon. Recently
transitioned from running shoes to minimalist
shoes because he wants to strengthen the
muscles in his feet.
o No swelling or ecchymosis
o TTP over Achilles tendon
o No bony TTP
o Pain increased with dorsiflexion
o Neurovascularly intact
 Achilles Tendinopathy
• Overuse injury of the Achilles tendon
• Thickening and inflammation of the
peritendinous tissue

• Risk Factors:
o Increased activity (distance, speed, terrain)
o Reduced recovery time
o Change in footwear
• Not as much type of footwear
o Flat feet
o Calf tightness
 Achilles Tendinopathy

Treatment:
• Ice
• Stretching
• Orthotics M Childress, A Beutler. Management of Chronic Tendon Injuries. Am Fam
Physician. 2013 Apr 1;87(7):486-490.

o Heel lift
• Achilles Exercises
o Initially with an extended knee
o Quick rise, slow drop
o Repeat with flexed knee
• Physical Therapy
 Posterior Heel Pain
• Achilles Rupture:
o Sudden pain in heel
o Primarily men 30-40 years old—weekend athletics
o Cause is forceful dorsiflexion
o Positive Thompson test
• Diagnosis: Ultrasound
• Treatment: Orthopedic Referral.
Make NWB and splint. Debate
between Plantarflexion Casting or
Surgery
Thompson Thompson
Negative Positive
http://www.dgu-online.de/
 Case 7
• 18 year old male presents with left great toe pain
that occurred while playing football this morning.
Was pushing off on turf when toe jammed and
developed sudden pain. Pain increases with
running.
o Neurovascularly intact
o Swelling at 1st toe MTP
o TTP at plantar aspect of 1st toe MTP
o Weakness of great toe compared
to contralateral great toe
o Increased pain with hyperextension
of the 1st MTP
 Turf Toe
• Sprain of the first metatarsophalangeal joint
o Caused by forced hyperflexion of the MTP
o See in football linemen
• Diagnosis: Clinical
• Imaging: XR usually normal—use to rule out fracture
• Treatment: Rest, Ice, NSAIDs, taping, stiff shoe/orthotic,
Foot and Ankle follow-up
 Case 8
• 40 year old female with month of burning
pain of foot. Pain radiates into toes at times.
Feels like there is a “rock in my shoe,” but
there isn’t one. Pain is worse with running
and narrow shoes.
o Plantar TTP between 3rd and 4th metatarsal head
o Neurovascularly intact
 Morton’s Neuroma
• Impingement/Compressive Neuropathy of Interdigital
Nerves as they divide at metatarsal head
• Chronic Irritation (compression, tension) of nerves as
they transverse metatarsal ligament
• More common in women (9:1)
• Pain radiating into toes
• Parasthesias in 40%
• Plantar TTP at metatarsal joint
• Most common between
between 3rd and 4th metatarsal head
 Morton’s Neuroma
• Positive Mulder’s Sign: Squeezing the
forefoot from lateral to medial while
palpating web space and feel click

• Imaging: X-Ray normal, Ultrasound

• Treatment: STOP wearing high heels,

wide toe box shoes, NSAIDs, steroid
injections
• Surgical excision if chronic and not
improved with conservative
treatment
A Case Outside of the Box…
 Case 9
• 24 year old female presents with right knee
pain. Was playing intramural soccer yesterday
when another player grazed the outside of her
knee. Pain developed on medial knee after the
game. She has been able to bear weight since
the injury. No popping or locking of the knee.
o Inspection: Mild Knee Effusion
o ROM: Full passive and active extension/flexion
o Strength: 5/5 knee flexion and extension
o Neurovascularly intact
o Palpation: No bony TTP, mild TTP over MCL
o Special Testing: No laxity with varus or valgus stress,
negative Lachman, negative Anterior and Posterior
Drawer, negative McMurray and able to squat
without pain
 MCL Sprain
• MCL Sprain—Grade 1
o Mild TTP over MCL
o Force to lateral knee
o No laxity
o Normal ROM
o Mild severity

• Knee Immobilizer?
 Knee Immobilizer
• Indications For Use:
o Instability of Knee
• Multiple ligaments
• If this diagnosis is made, should be consulting Ortho
o Fracture
o Patella Dislocation
o Extensor Mechanism Injuries= Ortho Consult
• Patellar Tendon
• Quadriceps Tendon
o Bucket Handle Meniscus Tears
• Unable to fully extend
o Extreme Pain
• Consider if you are missing something
• Should arrange follow-up prior to discharge
o +/- ACL Tear
• BRIEF rest period—then early ROM and pre-op PT
 Knee Immobilizer
• NOT Indications For Use:
o Osteoarthritis with Effusion
o Unsure of knee injury
• Should be pretty confident why it is being
provided
o “Internal Derangement of Knee”
o Knee Sprain
• LCL or MCL
 Knee Immobilizer
• Reasonable to provide Knee Immobilizer for acute
knee rest and to decrease inflammation after injury

• Problem is the patient wears knee immobilizer

continuously until follows up
o Days to Weeks to Never Following Up
o Significant decreased ROM, weakness, atrophy and
stiffness develop
• Patient education is key—take it off frequently, ROM, early
follow-up

• Most Orthopedic Surgeons will not operate until

effusion resolves and many will start “prehab” PT
prior to surgery to improve strength
o Aids in post-op recovery
o Improved outcomes
 AAFP Guidelines
• Complete immobilization of the knee for an
extended period is generally contraindicated
because of the prolonged stiffness, muscle atrophy,
and chronic pain that result
• Indications for the use of a knee immobilizer include
the acute (or presurgical) management of:
o Quadriceps rupture
o Patellar tendon rupture
o Medial collateral ligament rupture
o Patellar fracture or dislocation
o Limited number of other acute traumatic knee injuries
Questions?
 Resources
D Judd, D Kim. Foot Fractures Frequently Misdiagnosed as Ankle Sprains. Am Fam
Physician. 2002 Sep 1;66(5):785-795.
K Burroughs, C Reimer , K Fields. Lisfranc injury of the foot. Am Fam Physician 1998;58:121
Strayer et al. Fractures of the proximal fifth metatarsal. Am Fam Physician. 1999 May 1;59(9):2516-2522..
Timestra, Jeffrey. Update on Acute Ankle Sprains. Am Fam Physician. 2012 Jun 15;85(12):1170-1176.
A Tallia, D Cardone. Diagnostic and Therapeutic Injection of the Ankle and Foot. Am Fam
Physician. 2003 Oct 1;68(7):1356-1363.
M Childress, A Beutler. Management of Chronic Tendon Injuries. Am Fam Physician. 2013 Apr 1;87(7):486-490.
D Patel, M Roth, N Kapil. Stress Fractures: Diagnosis, Treatment, and Prevention. Am Fam
Physician. 2011 Jan 1;83(1):39-46.
M Simpson, T Howard. Tendinopathies of the Foot and Ankle. Am Fam Physician. 2009 Nov 15;80(10):1107-1114.
D Judd, D Kim. Foot Fractures Frequently Misdiagnosed as Ankle Sprains. Am Fam
Physician. 2002 Sep 1;66(5):785-795.
J Goff, R Crawford. Diagnosis and Treatment of Plantar Fasciitis.. Am Fam Physician. 2011 Sep 15;84(6):676-682.
P Tu, J Bytomski. Diagnosis of Heel Pain. Am Fam Physician. 2011 Oct 15;84(8):909-916.
O’ Connor, Francis et al. ACSM’s Sports Medicine: A Comprehensive Review. Wolters Kluwer: China , 2012. Print.
Brunkner, Peter; Khan, Karim; et al. Clinical Sports Medicine. McGraw-Hill: Australia, 2006. Print.
Madden, Chris. Netter’s Sports Medicine. Saunders Elsiever. 2010.
 Case 5
• 40 year old male sustained an inversion injury of
his ankle while playing sand volleyball 2 weeks
ago. Presents today with persistent pain in
lateral lower ankle. Diagnosed with ankle sprain
immediately after by his PCP and had normal X-
Ray.
o Had ecchymosis and pain inferior to lateral
malleolus
o No longer has ecchymosis or swelling
o TTP inferior to lateral malleolus
o Pain reproduced with resisted eversion
 Peroneal Tendon Injury
Peroneus longus:
● Proximal lateral fibula  plantar
surface of the proximal 1st metatarsal
● Eversion and plantarflexion

Peroneus brevis:
● Lateral fibula  base of the 5th metatarsal
● Eversion
 Peroneal Tendon Injury
Examination:
• TTP of peroneal tendons as they pass posterior to the lateral
malleolus
• Pain with resisted eversion
• Pain with passive inversion
• Tendon snapping with resisted eversion and dorsiflexion
Imaging:
• Ultrasound
Management:
• Ice, rest, and NSAIDS
• Walking boot for 2-4 weeks to allow for rest
• Tendon dislocation/subluxation may require Ortho operative
management
 Case 6
• 40 year old female with month of burning
pain of foot. Pain radiates into toes at times.
Feels like there is a “rock in my shoe,” but
there isn’t one. Pain is worse with running
and narrow shoes.
o Plantar TTP between 3rd and 4th metatarsal head
o Neurovascularly intact
 Morton’s Neuroma
• Impingement/Compressive Neuropathy of Interdigital
Nerves as they divide at metatarsal head
• Chronic Irritation (compression, tension) of nerves as
they transverse metatarsal ligament
• More common in women (9:1)
• Pain radiating into toes
• Parasthesias in 40%
• Plantar TTP at metatarsal joint
• Most common between
between 3rd and 4th metatarsal head
 Morton’s Neuroma
• Positive Mulder’s Sign: Squeezing the
forefoot from lateral to medial while
palpating web space and feel click

• Imaging: X-Ray normal, Ultrasound

• Treatment: STOP wearing high heels,

wide toe box shoes, NSAIDs, steroid
injections
• Surgical excision if chronic and not
improved with conservative
treatment
 Case 10
• 24 year old female runner training for a marathon with
one month of heel pain. Initially, only had pain with
running, now having pain with walking.
o Pain increased with weight bearing
o Tenderness over the medial-lateral calcaneus
o Pain with calcaneal squeeze testing

www.medscape.com
 Imaging
• Start with Radiographs—Lateral and Heel X-ray
• If X-Rays are normal and clinical suspicion remains
high, consider CT or MRI

N Dobson, E Dobson, P Shromoff. Imaging Imaging Strategies for Diagnosing Calcaneal and Cuboid Stress Fractures. Clinics in Podiatric
Medicine and Surgery, 2008-04-01, Volume 25 (2), 183-201.
 Management of Calcaneal
Stress Fracture
• Reduction in activity to pain free activity
o If pain with walking, may need to be non-weight-
bearing until pain free with walking
o Slow progression back into activity, again reducing
impact if pain returns
o Addition of heel cushions or orthotics if needed
o Assessment of calcium and vitamin D status

• Full healing usually takes 2-3 months

 Posterior Heel Pain
• Haglund’s Syndrome (Retrocalcaneal Bursitis)
o Insidious onset of pain in posterior heel
o Due to swelling of bursa between Achilles and calcaneus
o Better when barefoot or in open-backed shoes
o Associated with Haglund’s deformity
• Normal variant – posterolateral calcaneal prominence
o Treatment: RICE, NSAID, heel cord stretching, PT

Achilles
Tendon
Subcutaneous
Calcaneal Bursa

Retrocalcaneal bursa
T Tu, J Bytomski. Diagnosis of Heel Pain. Am Fam
 Case 11
• 35 year old woman sustained an inversion injury of
her ankle while playing basketball. Came down on
another players foot after jumping for a rebound
o Diagnosed with ankle sprain
o Persistent pain in the anterior ankle after 6 weeks
o Intermittent ankle swelling
o Feels ankle catching and locking
 Talar Osteochondral
Defect
• Ankle sprains with associated compressive forces
(landing from a jump)
• Often with inversion injury, but many after no trauma
• Most commonly in the superomedial dome

• Symptoms/Exam:
o Swelling, pain, catching and locking
o TTP over Talus and not over ligament
• Imaging:
o X-Ray: May see on Mortis View
o CT
o MRI
• Treatment:
o Non-Op: Short Leg Cast and NWB x 6 weeks
o Operative: Arthroscopy D Judd, D Kim. Foot Fractures Frequently Misdiagnosed as Ankle Sprains.
Am Fam Physician. 2002 Sep 1;66(5):785-795.
 Talar Osteochondral
Defect
Defect Management
Articular
Grade I cartilage injury Conservative
only
Articular
Conservative
cartilage injury
Grade II (Joint motion w/out
with underlying
loading –bike)
fracture
Detached, but
Grade Potentially
not displaced
III Surgical
fragment
Grade Displaced
Surgical
IV fragment
Emedicine.medscape.com
 Case
• 17yo ballet dancer presenting with
increasing pain in her forefoot with dancing.
No pain with walking. Pain improved some
with a week of rest, but returned when she
started dancing again.
o Focal tenderness over the 2nd metatarsal
 Metatarsal Stress
Fractures
• Risk Factors
o High arches
o Repetitive impact activity (running, marching,
dancing)

• Avoidance of painful weight-bearing

o Non-weight-bearing with crutches if pain with walking

• Slow return to normal activity when pain free

with walking and to palpation over the stress
injury
o May need orthoses to help prevent future injury
 DDx of Heel Pain
• Calcaneal stress fracture/traumatic fracture
• Plantar fasciitis
• Fat pad atrophy
• Achilles tendinopathy
• Achilles Bursitis (Haglund deformity)
 DDx Ankle Pain
• Ankle Sprain
• Syndesmotic injury (High Ankle Sprain)
• 5th metatarsal fracture
• Navicular fracture
• Peroneal Tendon Injury
• Fractures
o Fibula
o Tibia
o Talus
o Calcaneus

• Achilles tendon injury

 Posterior Heel Pain
• Sever’s disease—Calcaneal Apophysitis
=Painful inflammation of calcaneal growth plate

o #1 cause of posterior heel pain in kids 9-14 years old

o Increased pain with growth spurt—changing biomechanics
o Risks: Microtrauma with running (soccer), decreased Achilles and
Hamstring flexibility
o Positive Sever’s Test: Heel pain aggravated by standing on tip toes
o Improved with rest, heel lifts, stretching, ice, NSAIDs, out grow

Tenderness over
normal appearing
physis = apophysitis

Wheelessonline.com
 Plantar Fascia Injection

Risks:
• Painful procedure
• High Complications
• Problem returns if cause not addressed
• Plantar fascia rupture
• Fat pad atrophy A Tallia, D Cardone. Diagnostic and Therapeutic Injection of the
Ankle and Foot. Am Fam Physician. 2003 Oct 1;68(7):1356-1363.
• Skin hypopigmentation