Leg and Ankle Problems in Primary Care: Briant W. Smith, MD Orthopedic Surgery TPMG

Leg and Ankle Problems in
Primary Care
Briant W. Smith, MD
Orthopedic Surgery
TPMG
Leg and Ankle Presentations
 Trauma
 Pain
Ankle Trauma
 1. Twist and Fall--Fracture or Sprain
 2. Patient hears/feels a pop--tendon or

muscle injury
Ankle Trauma
1. Twist and Fall
 Common reason for clinic visits

 You have to exclude a fracture.
 Are there any short-cuts?
Ottawa Ankle Rules
 Stiel IG, et al. Ann Emerg Med 1992;

21:384-390 and JAMA 1993; 269:1127-32.
 Bachman LM, et al. Brit Med J 2003; 326:

417-428.
Rule out a Fracture
 Ottawa Ankle Rules
– Order an xray if there is tenderness at either
posterior malleolus, 5th metatarsal base,
navicular AND an inability to take 4 unassisted
steps.
 When in doubt, recheck in one week or just
get an xray.
Ottawa Ankle Rules
Ankle Landmarks
Example One
 Twisted ankle.
 Ottawa rules employed.
 Patient unable to walk unassisted.
 Tender at base of 5th metatarsal.
 XRs ordered: Foot AP/Lat/Oblique
(non-weight bearing)
5th Metatarsal Fracture
5th Metatarsal Fracture
 Are they all the same?
 “Jones” fracture
– diaphysis not metaphysis
– Usually a stress fracture
– NON weight bearing cast
Example Two
Twisted ankle
Ottawa rules employed
 Unable to walk unassisted.
 Tenderness at posterior edge of lateral
malleolus.
 XRs: AP/Lat/Mortise or ‘3v ankle’ or
‘ankle series’
Lateral Malleolus Fracture
Lateral Malleolus Fractures
 Are they all the same?
 Medial side of ankle

is just as tender
 XR shows widening of
medial clear space
 Surgical ankle
Non-displaced lateral malleolus
or 5th metatarsal base fractures
TREATMENT
WBAT in fracture boot or cast for 4-6 weeks,

then
PT referral to regain motion, strength,
proprioception.
Example Three
 Twisted ankle
 Ottawa rules employed.
 Able to walk (poorly).
 Tenderness is in front of lateral malleolus.
 XRs NOT ordered.
Sprains
 ‘Rolled ankle’. Inversion mechanism.
 ATFL commonly injured.
 Tenderness is anterior to
malleolus.
 Grading System:
– Mild (localized lateral swelling) or
– Severe (diffuse swelling and tenderness).
Ankle Sprains
 Mild: ATFL only injured.
 Severe: ATFL + calcaneofibular ligament

(CFL) +/- PTFL.
Sprains
Treatment
 MILD
 RICE
 Crutches for a few days
 Functional splint
 Early weight bearing
and ROM
 3-7 days to recover
Sprains
Treatment
 SEVERE
 Consider Fracture or Walking Boot
 Bear weight as tolerated
 ROM as pain allows
 6 wks + to recover
 Surgery?
Sprains
 Treatment/Rehabilitation
 After immobilization period start:
– RANGE OF MOTION
– WEIGHT BEARING
– TOE RISE EXERCISES
Ankle Sprains
Recent Studies
 There are no ‘minor’ sprains

 Early mobilization works best
 High MD visits; low PT visits
 Re-injury and residual symptoms are
common
Recurrent Sprains
 Sometimes it is just bad luck. Usually the
problem is inadequate rehabilitation.
 Persistent pain: usually inadequate rehab.
Ankle can be stiff/swollen/weak.
 Other reasons:
– invertor/evertor imbalance
– weight transfer
– abnormal knee angles.
Other Sprains
 Deltoid: rare; medial side of ankle. Refer if
medial clear space is widened.
 “High”: syndesmosis sprain (connects tibia
to fibula. Pain is in leg, worse with ext rot.
 Sinus tarsi syndrome: residual pain after
sprain in ‘soft spot’. Responds to arch
support, rehab, even injection.
The ‘Terrell Owens’ Injury
 Maisonneuve: tear of
deltoid (medial ligament),
rupture of syndesmosis
ligament, and high
fracture of fibula.
Chips and Flakes
 Ligament
avulsions
 “Old” if smooth
or rounded
Ankle Trauma
 1. Twist and Fall
 2. Felt a ‘pop’
Felt a Pop
 Posterior Ankle
 Gastrocnemius unit:
high or low
 Always check with
patient prone
Tendo-achilles Rupture
 Young to middle-aged patients
 Local tenderness/swelling. Can still walk.
 Diagnostic: palpable defect,
abnormal resting position,
Thompson test
 Refer
Tendoachilles Rupture
Palpate the Tendon ProneRestingPosition
Medial Gastrocnemius Muscle
Tear
 Pain is higher, mid to upper medial calf.
 Swelling can be
mild to severe.
Mimics DVT.
Medial Gastrocnemius Tear
 Treatment:
 Mild swelling and pain: ace, ice, crutches.
Takes 1-3 weeks to return to activity.
 Severe swelling: posterior splint, NWB
with crutches for 3-6 weeks.
 Never surgical (‘like sewing wet Kleenex’)
Leg or Ankle Pain
As the reason for the clinic visit:
Arthritis
Overuse
– Of tendons
– Of bone
– Of muscle
Ankle Arthritis
 Rare. Usually history of injury/surgery
 Diffuse aching with weight
bearing
 Decreased ROM
 XRAY is diagnostic
 Treat like any other arthritic joint but add
contrast soaks, cushioned insoles, brace.
Overuse
 Achilles tendinitis
 Posterior tibial tendinitis

Achilles Tendinitis
 Usually related to significant increase or
change in type of activity.
 Pain with push-off (if they can walk).
 Can be swelling, tenderness to palpation
 Takes weeks/months to resolve
 Heel lift +/- boot/cast. Soaks, NSAIDs.
 (can be prelude to rupture)
Achilles Tendinitis
Posterior Tibial Tendinitis
 ‘Acquired Flatfoot’
 Underdiagnosed/unrecognized
 Middle aged patient, medial ankle/foot pain
 Check for tenderness, swelling, arch, toe rise
ability.
 Associated with hallux valgus, tight heelcord,
sometimes knee pain.
 Treat with arch support and heel lift; sometimes
needs casting; surgery can be needed.
Posterior Tibial Tendon
Posterior Tibial Tendinitis
Overuse of Bone
 Shin Splints: medial tibial stress syndrome
– Sore after stopping
exercise
– Diffusely tender at
medial edge of tibia
– Must stop aggravating
activity
Overuse of Bone
Stress Fracture
 Often young, woman, runner
 Sudden increases in
duration/intensity
 Can have pain with
walking, but much
worse with running.
 Focal tenderness
Ankle Rehabilitation
 Swelling
 Stiffness
 Weakness
 Giving out
Swelling
 “It’s going to look swollen for at least 3

months”
 Elastic supports and Time
Stiffness
 “Let’s compare the motion to the other
ankle”
 ROM doesn’t return by itself. Self-
stretching to start, formal PT prn.
 Some discomfort is normal and does not
mean something is being damaged.
Weakness
 “Let’s try the toe rise test together”
 Easy demonstration of plantarflexor power.
 Patient won’t walk or feel right until it
returns. May take a month or two.
Giving out
 Usually a combination of weakness and loss
of proprioception.
 After toe rise is regained, balance on toes of
one foot and walk on tiptoes.
 This is needed to return to sports.

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Leg and Ankle Problems in

 1. Twist and Fall--Fracture or Sprain

 2. Patient hears/feels a pop--tendon or

 Common reason for clinic visits

 Stiel IG, et al. Ann Emerg Med 1992;

 Bachman LM, et al. Brit Med J 2003; 326:

 Medial side of ankle

WBAT in fracture boot or cast for 4-6 weeks,

 Mild: ATFL only injured.

 Severe: ATFL + calcaneofibular ligament

 There are no ‘minor’ sprains

 1. Twist and Fall

 Posterior tibial tendinitis

 “It’s going to look swollen for at least 3

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