Dr. Daniel Thuillier presents "Best Foot Forward: Common Foot and Ankle Injuries in Adolescent Athletes" at the UCSF Pediatric Musculoskeletal and Sports Medicine Conference 2023 in Berkeley, CA.
All right. It is my pleasure to introduce our next speaker, Doctor Daniel Tuli. Uh, he's a foot and ankle orthopedic surgeon here at U CS F. He earned his medi medical degree and completed a residency in orthopedic surgery at U CS F as well. He completed a fellowship in foot and ankle surgery at Harbor View Medical Center, part of the University of Washington Health Care System. His interests include ankle stability, post traumatic ankle arthritis and ankle replacement surgery. He's a bay area native kudos to you. Thank you and currently serves as team physician for the Oakland Roots, those people. Uh Thank you all. I appreciate the opportunity to talk. Uh I love following an Olympian. It's great. Um So today we're gonna appreciate Ronda's talk, talking about kind of the chronic stress injuries which are incredibly important, can be really challenging. Treat. My job will be to talk a little bit more about the acute injuries and hopefully providing a framework for how you can think about them and kind of what to do when to refer. You know, the ones that you should worry about. The ones that will generally be ok. Um I do not have any disclosures for this talk. Unfortunately. Um So we're gonna talk about incidents, anatomy, ankle sprains, high, ankle sprains, ankle fractures, facial fractures. And if I'm talking really fast, we'll get to Liz Franks just because I like to include them. So in thinking about ankle injuries, the incidence is incredibly high. There's about 600,000 ankle sprains per year in the US. There's about 2.95 for every 10,000 athletic exposures in high school. Um The greatest incidence is in women's and men's basketball, women's about 5.4, men's is about 5.1. Um And just for reference, this is about 10 times the rate of AC L injuries. So I'm not saying this talk is more important than doctor Pandy is. But you know, um and as with so many things, uh the rate is really increasing uh according to our N A T A data, um ankle fractures are the most common injury to be taken to the O R by an orthopedic surgeon. So though, though they're far less common, um they can be really serious. I mean, it's about 100 and 87 per 100,000 person years. Um So my wife is giving me a hard time for the slide because I included in almost all my talk. So I apologize if you've seen it before. Anyway, this is a mortis. So anyone who does woodwork, this is a mortis joint, you can see here, uh on the right side and the ankle is thought of to be as a mortis. The ankle is really a highly congruent joint which is really resistant to cartilage injury. Um until that congruence is interrupted. So in our normal circumstances, very low rate of arthritis, other problems. But with injuries, these small shifts in the ta can really, really have devastating consequences for long term health of the ankle in terms of pain and function. Uh We know this from some really kind of classic study. This is a classic study in our orthopedic literature which showed that a one millimeter shift in the tail changes the joint forces by about 40%. And this has actually been replicated in more recent studies. Um That kind of show this is from Thorson more recently, still not that recent, but more recently, um has really demonstrated this is really true and we see this. So this is uh not my patient, but this is a woman, young woman who had this fracture. This is a high fibula fracture with the sys injury. We'll talk a lot about that in a bit. This is her initial post surgery film. I don't have her injury films. Unfortunately, here you can see broken screw as often happens with Sys Moses, um they remove that screw thinking that's gonna be helpful. Um You know, here she is following along, they removed the hard on the outside because she continued to up the pain. Um, again, going back, revised the sys because I was worried that it wasn't quite where it needed to be, um, revised it again, moving along. You see, this ankle is just now going in. So this is a 19 year old with this injury and then five years later, she's got endstage arthritis. So this can progress really, really quickly. Um, if these aren't treated properly and well. Um, so what are the contributors to a concurrent joint? Well, the bones are a big contributor, the later Ollis, the meum my and the poster malis note, there's no anterior malleoli and that'll be important later. Um And the ligaments and for stability of the ankle joint itself, the big ligaments are the deltoid ligament immediately and the SSIs ligaments laterally that help hold the fibula onto. Um the tibia here is uh a beautiful dissection that was done um by a group in Spain, I believe. Um looking at the parts of the sys and you can see the ligaments here and their bony attachments note that those sys ligaments are just above the joint and what we'll talk about quite a bit next. The A T F L and the C F L, the common sprain ones are actually below the joint. Um So that's what we're gonna get into. Now, ankle sprains, I would bet almost there, almost there. One, the vast majority of people here have sprained their ankle at some point in their life, especially if you've played any kind of sport. Um They are incredibly common. The A T F L is the most common ligament injured. It resists anti translation of the Taylor. So it doesn't function in pro holding that mortis together. And so when you're standing, even if your A T F L and your C F L are completely out, the joint will be well aligned and the cartilage will find its uh corresponding spot on the other side. And that is really kind of crucial for how we think about these injuries. Um The A T F L is most common, the C F L which does tailor tilt um and really resists E version when you're at a neutral position is the most commonly injured and we often will grade these injuries as 1 to 31 being kind of a minor spray and three being a complete tear. But because of how the mortis is still intact and the ankle is still stable, um Even when these are completely torn, um the grating doesn't have as much of a big deal as it will for say, the sys Mois later on, this also makes a big difference for how we treat these and how we think about these because what we know is that 95% of ankle sprains are asymptomatic no matter what you do. So you can put him in a cast, you can do nothing, you can put him in a boot, you can put him in a splint, you can let him walk right away, you can take him off for weeks, but one year is a really, really long time. And so we like to look at it for our literature. We look at one in two years and say this is great. But you know, anyone who's waiting one year to get back into activity is not happy. Um So we usually recommend limited early mobilization. I usually recommend the can boot for one week if they even need it and trying to get them out after one week, three weeks. Really max because what we find, what I've found in my own practice is the longer they stay in the boot, the longer they stay in the boot. And so getting them out and getting them moving early really can be helpful and we really see slightly better early results um with early rehabilitation. So for a lot of my young athletes, I'm getting them into physical therapy, getting them into their athletic trainers, making sure they're checking in with their athletic trainers, um basically right away to kind of get them going. Um And because this is generally stable and the vast majority of these will heal, even the grade threes, even those complete tears, most of those will heal and be functional. Surgical repair is really reserved for those um with prolonged symptoms greater than six months. Um So again, to hype on that rehab protocol, swelling control cam walker, early range of motion, perennial and poster tib strengthening and a gradual return to to activity as symptoms allow that time frame can be really variable. And this can be the frustration sometimes in treating these. Whereas some young athletes will get back within a day, two days a week, some will take 2 to 3 months to get back and that is still normal and still generally able to get back. So this requires a lot of, I don't wanna say hand holding, but a lot of coaching and a lot of encouragement that yes, it is still normal to have a prolonged recovery from some of these um because they can't take longer. And so there can be a decent amount of variability when things are just not getting better. Um That's where surgery comes into play. Um And this is an incredibly common surgery just because the numbers are so high. So even if you have only one or 2% of these bad sprains who ever need surgery because the number of sprains are so high, this is still the most common surgery I do in my practice. The tried and true is what we call a modified Brostrom Gould. What it really is is a augmented repair of the ligaments where you are still using the patient's own tissue to bring back, implicate the tissue and provide that stability that is needed. So that shift is not happening in the in that frontal plane. Um This works very well. You're talking overall 90% results of getting people back to sport and that's usually getting people back to sport in about 3 to 4 months with full recovery and strength. Usually by six for patients who have uh really bad tears and especially patients who are and those other collagen vascular diseases that are have ligaments that may not be amenable to a really strong repair. That's where we reserve the ligament reconstruction. You can see it looks very similar to what you can consider to be an AC L and it is, it's really similar in a lot of ways. We usually use Allegra and not autographed reason for that is really donor site, pain and problems. Um The autograph works really well. We don't thankfully see the rupture rate. Uh the rupture rate for all of these is really low. Um And then you're not taking something else that's gonna be weak. You're not taking hamstring or quad or something else that you then have to rehab. In addition, um there's nothing I would like less than to take someone with ankle pain and also give them knee pain. Um All right. So what about high ankle sprains or syndesmosis injuries? And these can be really, really tricky. Um They can be tricky to diagnose and they can be tricky to treat ankle sprains. A lot of people get a good sense and the nice part is like we said kind of no matter what you do, most of them get better. But there are certainly things you can do to kind of help that process for high ankle sprains. So when we think about the Sindiso, the sys Moses is really composed of three ligaments, the A I T F L, the P I T F L and then the inner Aus liga, there's some even additional breakdowns within that you, you can make. But thinking about it as three ligaments is crucial. Um tearing just one of these won't be enough in order to really get a true sys disruption to where it's no longer gonna be functional. You have to tear all three and you have to tear about five centimeters of the inner Aus. The neo goes all the way up between the tib fib. And so, um it thankfully can hold, even if the A I T F L or the P I T F L have injured, usually there's enough stability there. Um We don't think about that joint moving very much, but it does, the fibula actually has some very subtle movements. The talus is a conical bone and so the front of the talus is wider than the back. And so as the talus moves up and you do flex, the wider portion of the talus will come into um the joint that is good because it's an inherently very stable position. As you can imagine, most of these sprains are happening with a planner flexed position. And that's when the thinner uh less wide portion of the tail is in the back is within that within the mortis. And to help accommodate this, the fibula will actually move and rotate very, very slightly. It's very small movements, but they are movements that can be helpful. Um So in planter reflection, it will migrate dola, it'll translate an inter media in rotate slightly. And in dole it migrates approximately translates poster media actually rotates again to help allow the uh tail into that position. And then remember the function of the synesis, it really helps maintain the congruity of the tibia taylor joint by maintaining the position of the lateral malleolus. So if this is disrupted, it can be really problematic because that mortis is gone just like that uh image I was showing that 19 year old and the disruption of the sys, this can be a real, real problem. So how do you diagnose a sprain when we think about this? And we're calling a synesis sprain. What I'm really meaning is uh injury without full tearing to where the mortis is disrupted. So if the mortis is congruent on our imaging, it's a sprain. So basically, if the is remaining in place, we'll list it as a sprain. And if it's truly disrupted though, that's another big problem. So another one, not a adolescent. Unfortunately, I don't have a, thankfully, I don't have any adolescents with tragic stories to show for this one. Um So this is a 23 year old who was playing basketball, twisting injury originally seen outside. And um the original imaging was a little am ambivalent. Um got in Clark's raise, um showed a little widening of the media clear space here and was diagnosed with deltoid Spain was told to be weight bearing is tolerated and to come back in a month, he continued to have a lot of pain, ended up seeing me when he changed insurances. Um I looked at this and was very concerned because my biggest concern here, of course, the mortis is knocking and you can see here where he's got that big shift that mortis is actually shifted out laterally. Um So this is a particular injury that can be a little bit rare and often gets missed for this exact reason. The initial inlex rays don't show where the fracture is here. So you can see here he's got this high fibula fracture. This is what is known as a mason new fracture. Um And this is really problematic because this shows a basically a full disruption of the sys Mois with the injury, uh energy exiting proximately. And you can see, not only if we look back here, you can imagine he has a syndesmosis injury. He also has a deltoid injury. So both his deltoid and his syndesmosis are injury here. He has a fibula fracture, but that fibular fracture is doesn't matter, but we care about are the ligaments that are holding that joint in place. So for this reason, this became surgery, um, this isn't one you can rehab and get back. This is one you really need to make sure those ligaments heal. And so the surgery we do for this that uh made famous, um And many other people have had since uh are this tight rope surgery? I've kind of switched away from screws and gone to tight ropes for nuanced reasons, don't time to get into. But um they have been good and effective. Um The biggest key here is to maintain that mortis um and actually saw this guy recently and he's back playing basketball and he's really quite happy and so, um thankfully worked out well. Um All right. So what about non disruption, the high ankle sprains and these are where it gets trickier. Obviously, those are pretty obvious x-rays and there's a really obvious path to take here. Um Ankle sprains, you want to think about pain out of proportion of the injury, prolonged recovery, pain poster to the fibula, obviously, pain that goes up the leg, the A T F L and C F L we know are kind of below the joint, these are higher injuries, um pain with dors reflection in the ankle. And why is that important? Remember that the Dorff reflection ankle is bringing the wider part of the taus up in and it will actually push on the fibula. So as you push on the fibula, if your sys moses is strained, that will cause pain. Um And this is more typically caused by the door inflection and external rotation, not exclusively. But you can see here as you're bringing it up and you're pulling that foot out to the side, it can strain those ligaments. And so you see this injury here on for one of my gunners, but um this is uh a very common mechanism. When you see this, you can still, you can still get this with your typical kind of planner reflection and inversion too though. So don't think that it's completely um separate diagnosing this again can be a little bit tricky. And so there's a number of physical exam maneuvers you can do the most common and probably the best one is what's called the squeeze test listed here in b all the squeeze test does is you're actually squeezing the tibia and the fibula approximately to the ankle joint. And a positive test is when they have pain that shoots down into their ankle. Um This is fairly sensitive but not very specific. I also as a result of that, we do multiple um the Dorsa flexion extra rotation test, which is kind of listed here in a again, what you're doing is Dorsa flexing the foot having externally rotate. And what you're trying to do there again is straining that sys moses. Um And then this uh test in c where you're having them kind of cross over to the side and doing the same thing. Your doors are flexing extra and rotating them. I will often have these people try to do single leg. He Rs in clinic as well. All of that to kind of get an idea of how that feels. And one thing you can do with a single leg, he, which I've done is you can get if you have athletic tape, um you can have them do the singing heel rise to see how they feel and then you can really above their malleoli tape them really tightly and have them do it and see if it feels better. And that can sometimes be uh helpful for you. Um The difficulty with that is you have to tape them pretty tight. Um So it can be helpful if they're getting back on the field sometimes too. However, usually have to tape them really tight and it can be problematic. So again, all these combination, you know, the tenderness squeeze test really specific, not terribly sensitive, tenderness, sensitive, not specific. So I will use a combination. I'm not doing one thing and relying on it. I'm doing three or four tests and trying to get um an idea of what to do. Uh rehabbing these high ankle sprains, everything just kind of takes longer. So you're still doing swollen control. Usually I do a cam walker if I really suspect ain osmosis injury, I will have them in the cam walker longer. Usually on 3 to 6 weeks, 3 to 6 weeks, I will have them do an active, active range of motion immediately. But again, perennial and postive strengthening and stabilization. Um these typically will have a more delayed return to activity than your uh just straightforward ankle sprains. All right. So moving on to ankle fractures, again, incredibly common and an incredible variation, they usually will involve both bones and ligaments because these are usually twisting injuries. And remember that it's both the bones and the ligaments that are really crucial for providing the stability of the ankle joint. And so while we look and we see the bones, we always have to be thinking about those ligaments that are um providing that stability or helping provide that stability. Um It's all right. So how do you know if it's stable versus unstable? Well, the same thing, right? You get strained or uh stress x-rays and see if that tali is shifting or not. So stable will have no shift to the talus. It's usually kind of either the media or the latter mali only and the ligaments, the deltoid and the sys are intact for the unstable, the tay list will shift. These are usually bialo or or trime fractures and a combination of bone and ligamentous injuries. So, the deltoid and the sys moses as we saw earlier and that makes a new fracture. It's a high fibula fracture. So just the fibula but two ligaments out and those two ligaments out provide an unstable scenario. Um The only way to truly assess stability is with radiographs. Um You wanna just make sure that, that, that mortis really should be pretty similar all the way around there is of course, an an atomic variability though. Um And that can sometimes be a little bit tough if things look a little weird. Um You can, if you're able sometimes get the other side. Unfortunately, insurance sometimes pushes back on that, but you gotta do what you gotta do to best treat your patients sometimes. Um One common thing that we'll get is what's known as a gravity stress for you. Most emergency departments and um uh radiology, um technicians will know how to do this, which is just kind of hanging the foot over the side. And what you're doing is allowing that kind of external rotation. What we're really looking for here is again that deltoid and that medial clear space to see if that opens up. Um a deltoid ligament that's torn will cause an unstable scenario. An unstable scenario is not good as we talked about earlier. I think I've heard on that enough. Um So for stable fractures with no tailor shift, the gravity stress views standing x-rays or manual stress testing. Um If those are fine, even though there's broken bones and maybe injured ligaments, these can generally be treated non operatively where you can usually let them weight bear right away again because they're stable. It usually means a boot, sometimes a walking cast. Um for a period of time, usually 4 to 6 weeks until um they're able to have enough stability again and healing within the initial bones to then get back to kind of more normal activity for unstable fractures. When the mortis is unstable, that's not a situation you wanna leave alone and allow to its own designs because these sometimes will heal. But if they heal in a bad position, as we said, one millimeter shift in the tail, um can lead to devastating consequences. Um So these typically need surgery. Um We do not typically address this, the ligaments directly. Usually, what we're doing is fixing the bones and allowing the ligaments to heal themselves. The de ligament and the sys, as long as the bones are lined up well, will heal themselves with um good regularity and good reliability. All right. So what about for our younger adolescents? Because there's a wrinkle that always gets played in and that's the feces, right? So the as we've talked about is where endochondral indri ossification is occurring. It may represent a weak point with the ligaments now being stronger um than the bone is. And so the same type of mechanisms in our patients with closed feces with open feces may cause different patterns. Um The tibial physis is the second or third, most injured Feiss depending on which what you're looking at. So it is quite common and all spal injuries have the potential for growth arrest. Um And I think I, oh it's the next slide I apologize. So not gonna harp on Salter Harris fractures, but you can really see any injury pattern going through the feces. Um The added wrinkle here always is you have to think about ligaments. You have to think about the malleoli that are protecting the stability of the joint. And then you also have to think about the and so you have an additional wrinkle ci closure in the ankle goes through a little bit of an interesting pattern where it starts centrally and spirals immediately and then comes back laterally. Um The age of closure for girls is usually 12 to 16 and boys is 14 to 19. But obviously, there can be some variability um within that as a result of this kind of unique way that the tibia closes. You can create some unique transitional fractures and transitional fractures are fractures that are happening during phyo closure where you're gonna have part of the bone that is the P vice is closed and part of it is open. Um One of the most common ones that we're seeing in the ankle is what's called a low fracture. Um And the low fracture happens that is the last part of the distal tibia um to uh solidify and that A I T F L is a very nice and stout ligament. And so as a result of this, it will actually pull off um a piece of bone there. Obviously, we can see here, you have two things to deal with. One the that's interrupted in the joint itself in our uh transitional fractures because the is already closing. We worry a lot less about the and a lot more about the joint because as we can see the growth is usually there. But depending on what this is displaced or not, this can really represent an unstable um action. Another really kind of common when we talk about is this trine fracture. Again, similar type of pattern. This is where you get this kind of complex pattern uh weaving through, you can see where here the joint is stepped off, you know, the growth plate is off again, more concerning about the joint. So you get these kind of unique patterns within these ankle injuries. And they're important to kind of recognize that that Feiss provides yet another kind of wrinkle in the stability mix because of its, you know, relative weak bone relative to the ligaments that can be really stout. Um So in terms of treatment of these distal vial fractures, one, the first treatment goal is restore the feces to the atomic position, restore the articular service to an atomic position, restore stability of the mortis as an adult, prevent growth arrest or especially for people that have, you know, three or four more years of growth left and then again, prevent that post traumatic arthritis. So, for the non displaced and the stable ones, you can treat in a cast, um for the displaced and the unstable, they usually need surgery. All right. So sometimes this is obvious. But what about the kind of less obvious ones? Um And then when do I need imaging, which always often comes up? So when we talk about sprains versus fractures again, spraying you have acute twisting injury pains, one at the ankle bruising difficulty with weight bearing fractures, acute twisting injury pains, one the ankle bruising difficulty with weight bearing. The only real way to tell is with imaging. Um But as my wife will say he was an A trainer, you can't always get imaging. Dan can't always get imaging and I say you need imaging. Um So, you know, social medicine in uh Canada. Um I'm sure you guys have heard this. So the auto ankle rules, the auto ankle rules are a good framework to think about, right? Um So what are they basically pay any over any bony prominence or difficulty with weight bearing? They should get an x-ray. Um When you think about sprains, remember that the A T F L, you can't really palpate the C F L because the C F L is below the perennial, but you can palpate the A T F L. So pain that's directly in the anterior part of the fibula oftentimes will be the sprain pain, poster pain, going up, pain over the navicular. We talked about a little bit about navicular stress fractures base of the fifth. These are all ones for whom uh people should get imaging. And when you look at the auto ankle rules, they'll say, oh, we didn't miss or had very few missing of significant injuries. But there are things that get missed, what get missed, lateral process, the tail will get missed, anti process of the calcaneus will get missed. And these are ones for whom, if they get missed and aren't kind of treated properly can lead to long term problems. You large O C L s will get missed. Um And these are sometimes ones where if it's large enough can be amenable to early surgery. It's another complicated topic, no time to go into, but that's where the imaging is there. Obviously, it depending on where you are, depending on where you practice. These are the choices we all have to make about who needs them, especially if you're in a resource limited environment. But when at all possible, it can be really helpful. And the Ottawa ankle rules have been validated um in uh people with open feces and in kids again, showing these quote unquote significant injuries, but I love how they considered significant injuries greater than three millimeters when I've been harping this whole talk that greater than one milli millimeter is a problem. And so, you know, yeah, I know an or surgeon but if you can't get imaging. Um So what about the, the classic difficult one, these non displaced salter one type injuries versus a sprain? You know, how do you diagnose these in difference? And the answer is uh it's hard uh for lack of a better term. So again, pain that's lateral or posterior, then you would worry more about that injury to the feces. Um pain that's anterior and more distal A T F L and the C F L actually are distal to the feces a little bit. Um Then you would worry more and think, yeah, maybe it's a sprain. Um This used to be, I think a little more prescient because we really wanted to treat these with the cast. But there's at least some uh newer data that shows even a functional brace or a boot, these non displaced um salter hairs type ones do just fine. And so that may make it less of an issue where you can just kind of immobilize them for a short period of time. Um regardless, all right, I have yet to talk about really C T S or MRI S. Um And that's because most of these you can diagnose without having to go there, but there is a time for advanced imaging for sure. Um And you should consider it if for any unclear suspicious x-rays. And honestly, if you have fracture lines that are going into the joint you probably should get one. You can see where that trip plan can be a little tough, but the latter really shows the step off. Um And sometimes you'll have patients who just have unexplained symptoms, you know, will be going on. They'll have a sprain. Usually for me, a sprain that has pain lasting beyond eight weeks with initial normal x-rays, I'm getting an MRI again to look for O C L S, you know, other things that might be continuing to give them problem and obviously, there just comes a time when your suspicion is just high. Um and your imaging is not there and that can be helpful. And so, you know, as we all see patients over time that subconscious pattern recognition kicks in sometimes and you wanna say something here is just a little not right. And so sometimes you just gotta do that. Um So in summary, ankle injuries are incredibly common, I'm sure we, most of us have seen them and a lot of us have had them. Um ankle sprains are obviously much more common than fractures. Um ankle sprains do do better with earlier rehab. So try not to just lock them up and say come back later, um try to give them a program or get them into physical therapy, quickly, get them to see their athletic trainers, get them going. Um Imaging is usually the only way to truly distinguish brains from fractures. Uh So if you are concerned try to get imaging. A injury about the ankles are very common and you really do need imaging to kind of understand if it's displaced, is it stable where it is? And what's going on? Maintain the Feiss in the morning mortis is a real key to a stable and functional ankle and one that will last a long time. A lot of these injuries, despite how bad they might look initially, if you can get the feces back, if you can get the mortis stable, uh, it'll be a good ankle for a long, long time. All right. Thank you. And as always, go roots.