Gerald Weniger, MEd, MPAS, ATC, PA-C · MORTON’S NEUROMA • narrow toe box • 2nd& 3rdweb spaces • metatarsal compression test LISFRANC INJURIES • rare, but frequently missed

Gerald Weniger, MEd, MPAS, ATC, PA-C

Director, Physician Assistant ProgramAssociate Professor, Health Professions Department

James Madison University

WHY DO WE CARE?• foot and ankle susceptible to both acute injury

and overuse syndromes

• foot/ankle dysfunction = disability, altered gait

• ~25% of all sports injuries occur at the foot/ankle

• medially (big, thick, strong)• deltoid ligament

• laterally – three distinct ligaments (puny, weak)• anterior talofibular ligament (ATF)• posterior talofibular ligament (PTF)• calcaneofibular ligament (CF)

• ankle “mortise”• anterior tibiofibular ligament

• posterior tibiofibular ligament

• interosseous membrane

• Ankle• dorsiflexion & plantarflexion• inversion & eversion

• Foot• internal (medial) rotation• external (lateral) rotation

• entrapment/compression of interdigital nerve

• 2nd and 3rd web spaces most common• causes: running, ballet, high heels, narrow toe box shoes

• burning, stinging pain

• incidence: females > males

• worse with WB• numbness/tingling into toes

• history

• exam• specific tenderness on area between metatarsals

• imaging• X-rays are no help• ultrasound/MRI show most, not all• surgical visualization

• metatarsal compression test

• conservative treatment• wide shoes, no heels• metatarsal pads• corticosteroid injections

• surgical treatment• neuroma excision

• tarsometatarsal (Lisfranc) joint complex• injuries here are not common, but frequently missed• legal liability

• tarsometatarsal (Lisfranc) joint complex• dorsal ligament is most important

Images from UpToDate © 2019

• tarsometatarsal (Lisfranc) joint complex• mechanism of injury: trauma

• MVCs• falls• athletics


• tarsometatarsal (Lisfranc) joint complex• terminology can be confusing:• Lisfranc fracture• Lisfranc dislocation• Lisfranc “injury”


• History• MOI (mechanism of injury)• pain & swelling at TMT joint• worse w/ weight bearing (often cannot walk)

• Exam• point tenderness at TMT joint• swelling & ecchymosis• ↓ ROM• ↓ strength

• Imaging• X-rays: three views (AP, lateral, oblique)• often misread as “normal”• findings can be quite subtle

On AP View: medial borders of 2nd MT and middle cuneiform

• Imaging• X-rays: three views (AP, lateral, oblique)• often misread as “normal”• findings can be quite subtle

On Oblique View: medial borders of 4th MT and cuboid

• Imaging• 50% of athletes with midfoot injuries have normal

non-weight bearing radiographs• Order weight bearing X-rays on single cassette

• Imaging• But wait!!

• Multiple studies demonstrate: even properly performed weight-bearing radiographs have limited specificity and sensitivity for detecting TMT injuries

• Order a CT or MRI

• Imaging• Example of a CT

• Classification system?

• Acute Treatment• immobilize (splint or CAM walker)• non-weight bearing: crutches• referral to Orthopedics

• Long-term Treatmenta) non-operative: immobilize 6-10 weeks, then physical therapyb) operative: open reduction, internal fixation (ORIF)

• at risk with running, jumping, and sudden acceleration or deceleration

• Incidence• General population: 0.01%

(80% of these are during recreational sports)

• Competitive athletes: 8.3%• sprinters: 18%• decathletes & soccer: 17%• T&F jumpers: 12%• basketball: 12%

• ↑ recreational sport participation = ↑ rate of tendon ruptures

• peak age: 30 to 40 years (male & female)• this might be when degenerative changes & high

stress from sports coincide

• rupture 4-5x more common in men

• glucocorticoids• oral systemic steroids and/or local steroid injections

increase risk of rupture

• fluoroquinolones• incidence of rupture is rare: 12 per 100,000 (0.012%)• but, risk is 3x during first 90 days of taking for 1st time

• “water shed” area• poor blood supply: 2 - 6 cm above the insertion point• most ruptures occur here

• History• sudden pivoting or rapid acceleration/deceleration

• struck violently in the back of ankle??• “got kicked from behind”• “someone shot me”• “hit by a 2x4”

• feel and hear a loud “pop”

• sharp pain, then less pain

• Exam• straightforward, but don’t be fooled!

• Achilles tendon easily identified & palpated• Palpate for tenderness and for defect

• Exam• straightforward, but don’t be fooled!

• UTD: “sizable minority of patients with complete tendon rupture are able to ambulate”• many are able to actively plantarflex too• How?

• Exam• Thompson (calf squeeze) Test• 96% sensitivity, 93% specificity• therefore, more reliable than a patient’s inability

to walk or plantarflex

• Imaging• typically not needed, Achilles tendon rupture may

be diagnosed solely on clinical exam• ultrasound enables rapid confirmation at bedside• 100% sensitivity, 83% specificity

• Imaging• Magnetic Resonance Imaging (MRI)• if clinical exam uncertain• if ultrasound unavailable

• Acute Treatment• immobilize (splint or CAM walker)• heel lift• non-weight bearing: crutches• referral to Orthopedics (1-2 days)

• Long-term Treatmenta) non-operative: immobilize 6-8 weeks with heel liftb) operative: repair vs. reconstruction

• among the most common injuries in primary care and emergency departments

• most are sustained during athletics

• risks:• females > males• children/teenagers > adults• indoor court sports > outdoor• natural grass > artificial turf• defensive player > offensive player

• Classification

Type Mechanism of InjuryLateral Ankle Sprain Ankle InversionMedial Ankle Sprain Ankle EversionSyndesmosis Sprain

(“high ankle” sprain)Externally Rotated Foot

• Classification

Type Mechanism of InjuryLateral Ankle Sprain Ankle Inversion


• Classification

Type Mechanism of InjuryMedial Ankle Sprain Ankle Eversion


• Classification

Type Mechanism of InjurySyndesmosis Sprain



• Classification

Type Mechanism of InjurySyndesmosis Sprain


• History• mechanism of injury• inversion or eversion?• did foot get turned out (laterally)?

• able to bear weight? If not, more suspicious of fracture

• prior ankle sprains?

• Exam• swelling/ecchymosis

• palpation (obvious):• bony areas: distal tibia/fibula, foot• soft tissue: ligaments, tendons

• palpation (don’t forget):• dome of talus• areas for “Ottawa Ankle Rules”

• Exam - Ottawa Ankle Rules

• Exam - Ottawa Ankle Rules

• X-rays only if:• bony tenderness at one of these spots

OR• inability to take 4 complete steps both immediately & in ED

• Exam• active & passive ROM limited (pain)• strength/resistive ROM limited (pain)

• Exam – Special Tests

Type Mechanism of Injury

Lateral Ankle Sprain Ankle Inversion

Medial Ankle Sprain Ankle Eversion

Syndesmosis Sprain(“high ankle” sprain)

Externally Rotated Foot


Type Mechanism of Injury Special Test

Lateral Ankle Sprain Ankle Inversion Inversion Stress TestAnterior Drawer

Medial Ankle Sprain Ankle Eversion Eversion Stress Test


Externally Rotated Foot Kleiger’s Test



Lateral Ankle Sprain Ankle Inversion Inversion Stress TestAnterior Drawer



Medial Ankle Sprain Ankle Eversion Eversion Stress Test

• Exam – Special TestsType Mechanism of Injury Special Test


Externally Rotated Foot Kleiger’s Test


• Grading System(s)• grade I: stretched ligament• grade II: partially torn ligament• grade III: fully torn (ruptured) ligament

• Secondarily, for lateral ankle sprains:• which ligament(s) are torn?


• Remember:• ankle effusion typically not notable• localized soft tissue swelling only

• degree of ecchymosis does not correlate with degree of injury

• Imaging• Ankle X-rays (AP, oblique, lateral) if concern for:• malleolar fracture• talar dome fracture• syndesmosis diastasis

• Foot X-rays (AP, oblique, lateral) if concern for:• associated foot fracture (navicular, cuboid, base of 5th MT)

• Imaging• MRI has no role in acute injury setting• can be considered if still pain after 6-8 weeks of

standard care…• …MRI can show talar dome defects and/or

syndesmosis injuries

• Acute Treatment• Rest: limited WB (crutches) until walk normally• Ice: for 2-3 days until inflammatory phase over• Compression: ACE wrap ↓ hydrostatic pressure• Elevation: above the heart

• Acute Treatment• NSAIDS• none is more superior than another• no study directly compares acetaminophen to NSAIDS

• Acute Treatment• Immobilization• grade I should not need• grades II and III, likely do• no harm if patient desires it


• Long-term Treatment• therapeutic exercises are the key to recovery• stretching/ROM, strengthening

• Long-term Treatment• therapeutic exercises are the key to recovery• formal PT vs. home exercise program• helps prevent chronic instability• return to full WB as tolerated

Special Tests

Metatarsal Compression Test Morton’s Neuroma

Thompson Test Achilles Rupture

Inversion Stress TestAnterior Drawer Test Inversion (Lateral) Ankle Sprain

Eversion Stress Test Eversion (Medial) Ankle Sprain

Kleiger’s Test Syndesmosis (“High”) Ankle Sprain

MORTON’S NEUROMA • narrow toe box• 2nd & 3rd web spaces• metatarsal compression test

LISFRANC INJURIES • rare, but frequently missed = legal liability• tarsometatarsal joint complex• often cannot weight bear• subtle X-ray findings• must refer to Orthopedics

ACHILLES RUPTURE • most occur in athletes or with recreational sports• most common in males, ages 30 – 40• surprise at suddenness of injury• Thompson test• must refer to Orthopedics quickly

ANKLE SPRAINS • most are lateral ankle sprains• “Ottawa Ankle Rules”• amount of ecchymosis does not correlate to degree of injury• Kleiger’s test for high ankle (syndesmosis)• therapeutic exercise is key to recovery

1. Beutler, A. and Taylor, C. Tarsometatarsal (Lisfranc) joint complex injuries. In: UpToDate, Eiff, P. and Asplund, CA. (Ed), UpToDate, Waltham, MA, 2019

2. Buchbinder, R. Plantar fasciitis. In: UpToDate, Issac, Z. (Ed), UpToDate, Waltham, MA, 2019

3. Maughan, KL. Ankle sprain. In: UpToDate, Eiff, P. and O’Connor, FG. (Ed), UpToDate, Waltham, MA, 2019

4. Maughan, KL. and Boggess, BR. Achilles tendinopathy and tendon rupture. In: UpToDate, Fields, KB (Ed), UpToDate, Waltham, MA, 2019

5. Miller, MD. and Thompson, SR. Miller’s review of orthopaedics. 6th ed. Philadelphia, PA: Elsevier; 2012.

6. Rynders, SD, Hart JA. Orthopedics for physician assistants. Philadelphia, PA: Elsevier; 2013.

7. Toy, EC., Rosenbaum, AJ., Roberts, TT., and Dines, JS. Case files: Orthopedic surgery. New York, NY: McGraw-Hill Education; 2013.

Documents

Gerald Weniger, MEd, MPAS, ATC, PA-C · MORTON’S NEUROMA • narrow toe box • 2nd& 3rdweb spaces • metatarsal compression test LISFRANC INJURIES • rare, but frequently missed