Forced Plantar Flexion Research Articles

Posterior Ankle Pain After Ankle Sprain: Bony and Soft Tissue Impingement and Flexor Hallucis Longus (FHL) Tenosynovitis

The proper diagnosis of posterior ankle pain after ankle sprains is often missed. This can occur as an overuse injury or as a result of acute trauma in patients performing repetitive forced plantar flexion sports. An understanding of various causes of posterior ankle impingement, both bony and soft tissue, is critical to make the proper diagnosis and provide appropriate treatment. Nonoperative treatment should be considered as the initial treatment for the posterior ankle pathology. Surgical intervention is indicated if pain persists despite nonsurgical treatment, particularly for athletes or dancers who want to continue to train and perform their sport. Surgery can be performed using an open or arthroscopic approach. Level of Evidence Level V—expert opinion. See Instructions for Authors for a complete description of levels of evidence.

Surgical Treatment of Medial Gastrocnemius Tear

Medial gastrocnemius tears typically occur with forced dorsiflexion while the knee is extended. Myotendinous injuries occur most commonly, which are almost always treated without surgery. If a tendinous injury or avulsion occurs, nonoperative treatment should first be attempted. However, in patients where forceful plantar flexion is required for their desired activities or occupation, surgical fixation is an important treatment option. Postoperative bracing should be used to protect the repair with a graduated therapy progression, including range of motion followed by strengthening and return to activities. This technical note describes the technique for a safe and reliable medial gastrocnemius tendinous repair using two suture anchors.

Outcomes of a 2-Portal Endoscopic Technique for Osseous Lesions Resulting in Posterior Ankle Impingement Syndrome

Posterior ankle impingement syndrome is common in sporting populations and encompasses a range of disorders that cause posterior ankle pain during maximal forced plantarflexion. The aim of this study was to evaluate the short- and medium- to long-term outcomes of 2-portal endoscopic surgery for osseous lesions causing posterior ankle impingement syndrome. This was a retrospective case series analysis of all patients who underwent 2-portal endoscopic surgery at a single institution between 2005 and 2016. Visual analogue scales and selected components of the Short Form of the Revised Foot Function Index were used to assess ankle function, with the median follow-up time being 4.8 years. Of the 52 patients, 49 (94%) were able to return to their previous sport/physical activity, with the mean time taken being 5.8 months. At the completion of follow-up, the mean pain score during exercise had improved from 7.5 to 0.9 points. The mean work and sporting function scores also improved, from 5.9 to 9.6 points and 2.9 to 8.8 points, respectively. The mean score of the Short Form of the Revised Foot Function Index also improved by 77.7 points, from 84.4 to 6.7 at the completion of follow-up. There were no postoperative infections or any other major complications. This study provides strong supporting evidence for the use of hindfoot endoscopy in the treatment of posterior ankle impingement syndrome in athletes.

The Reliability of Kager's Triangle in Detecting Acute Achilles Tendon Ruptures

The Achilles tendon is a common site of anatomical injury among athletes and those participating in recreational sporting activities. Acute Achilles tendon ruptures are often misdiagnosed as a sprained ankle and are more common in the male population. Mechanism of injury is often a noncontact injury, resulting from sudden forced plantar flexion or violent dorsiflexion in a plantar flexed foot. Delays in diagnosis and treatment may complicate the clinical outcome. Because findings may be subtle on history and physical examination, the use of readily available adjunctive studies is important for practitioners. One method is the analysis of Kager's triangle on lateral ankle radiographs. Obscuration of Kager's triangle has been described as a radiographic indicator of Achilles tendon rupture, but the sensitivity and specificity of this finding have been poorly reported. [Orthopedics. 2020; 43(2): e91-e94.].

Lower Extremity Pain - Field Hockey

Lower Leg Pain – Field Hockey HISTORY: A 20-year-old collegiate field hockey player 1 year, 2 months out from bilateral anterior/lateral/deep posterior compartment fasciotomies for chronic exertional compartment syndrome, recurrence of pain along her bilateral medial legs and medial/plantar foot numbness. Worsening over previous 6 months. Pain is daily, constant. Had MRI/MRA arterial duplex performed at onset of symptoms and was told it was negative. No improvement with neuropathic pain medication, physical therapy, hydrodissection. PHYSICAL EXAMINATION: Examination revealed healed surgical incisions. Mild scar hypertrophy along medial incisions with moderate tenderness to palpation. Full knee/ankle ROM. Pain reproduced with resisted ankle plantar flexion after 30 seconds, numbness along medial/plantar aspect of foot in tibial nerve distribution. Easily palpable dorsalis pedis/posterior tibialis pulses. DIFFERENTIAL DIAGNOSIS: 1. Recurrent chronic exertional compartment syndrome 2. Saphenous nerve compression neuropathy 3. Popliteal Artery Entrapment Syndrome TEST AND RESULTS: 1. Repeating compartment pressure testing: normal compartment pressures 2. EMG/NCS: normal without evidence of compression neuropathy 3. MRA (PRISMA 3T) study: forced plantarflexion demonstrates bilateral compression of the popliteal arteries at the popliteal fossa between the medial and lateral heads of the gastrocnemius muscle. FINAL/WORKING DIAGNOSIS: Popliteal Artery Entrapment Syndrome TREATMENT AND OUTCOMES: 1. Referred to plastic surgery colleagues. 2. Underwent bilateral popliteal artery releases 1 year, 8 months after index surgery. 3. Improvement of both pain and numbness along medial aspect of foot. 4. Last seen at 3 months post-operatively. Full, painless ROM. No pain with resisted plantarflexion. Normal sensation. Anticipate return to sport over the next 6 weeks.

Anatomical Popliteal Artery Entrapment Syndrome Caused by an Aberrant Plantaris Muscle.

Purpose:We report on cases of anatomical popliteal artery entrapment syndrome (PAES) caused by an aberrant plantaris muscle and highlight the involvement of this muscle in PAES.Materials and Methods:Seven symptomatic PAES legs in six patients treated at The Division of Vascular Surgery, Asan Medical Center, Seoul, Korea, between 1995 and 2011 were included in this study. We retrospectively analyzed patient records, magnetic resonance imaging (MRI) and/or computed tomography (CT) scans of the knee joint, Doppler pressure studies, CT angiographies, and conventional femoral arteriographies.Results:Five males and one female patient with a median age of 32 (18–53) years old were enrolled in the study. All patients complained of intermittent claudication of the affected leg. All aberrant plantaris muscles were higher and more medially located than normal plantaris muscles, causing occlusion of the popliteal artery upon forced plantar flexion of the ankle. For arterial lesions, five occlusions of the popliteal artery and two patent popliteal arteries with positive provocation were noted. As for treatment, myotomy of the aberrant plantaris muscle was done for two non-occlusive PAES legs. For occlusive PAES legs, one thrombectomy, one saphenous vein graft interposition of the popliteal artery followed by myotomy, and two below-knee femoro-popliteal bypasses were performed. The median follow-up period was 88 (7–148) months.Conclusion:An aberrant plantaris muscle can cause anatomical PAES. Classification or diagnosis of PAES should be based on axial studies using CT scans or MRI using various reconstruction methods. Treatment, including myotomy of the plantaris muscle, should be individualized.

Missed isolated posterior malleolar fractures.

The aim of this study was to evaluate the injury mechanism and clinical and radiological results of the patients with isolated posterior malleolar fracture. Seven patients (5 male, 2 female; mean age: 32 years; range: 23-40) with a missed isolated posterior malleolar fracture were included in the study. All patients had initially been examined for an ankle sprain in the emergency room, where the initial plain radiographs did not show any abnormality. Due to the long lasting symptoms all patients underwent an MRI scan by the 3rd week which revealed a posterior malleolar fracture. Patients were treated with an ankle brace for 3 weeks. All patients were followed up for 1 year. Bone healing and degenerative changes were evaluated with plain Radiographs, including a 50° external rotation lateral. Clinical outcome was evaluated with American Orthopedic Foot and Ankle Society ankle hindfoot scale. Fracture healing was seen in 6 of the 7 patients by the 6th week. There was no radiographic healing by 6th month in the remaining patient. Mean AOFAS ankle hindfoot scores at the beginning of the treatment and at 3rd month were 20 (11-31) and 86 (43-96), respectively. There was no instability or degenerative changes at one-year follow-up. Isolated posterior malleolar fracture should be kept in mind in patients who present with pain at the posterior part of the ankle following a forced plantar flexion and/or axial compression injury. A 50° external rotation lateral radiograph can be useful in detecting the fracture.

(iii) Lateral ankle instability

Abstract Ankle sprains are the most common sports-related injury and are caused by forced plantar flexion and inversion. Most involve the lateral ligamentous complex and recover with conservative management, but 20% go on to develop biomechanical or functional instability. This article focuses on clinical symptoms, signs, conservative and surgical management of acute lateral ankle sprains and lateral ankle instability.

Síndrome do impacto posterior do tornozelo: um diagnóstico que deve ser lembrado pelo reumatologista. Relato de dois casos

The ankle is a common site of painful symptoms in athletes and nonathletes. Posterior ankle pain can be the end result of several pathologies, and a diagnostic challenge for rheumatologists. The posterior ankle impingement syndrome, also known as os trigonum syndrome and posterior tibiotalar compression syndrome, is a clinical disorder characterized by acute or chronic posterior ankle pain triggered by forced plantar flexion, which causes chronic repetitive microtrauma. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but there are other causes, such as tenosynovitis of the flexor hallucis longus, ankle osteochondritis, subtalar joint disease, and fracture. Diagnosis is based on clinical history and physical examination, and complemented by findings on plain radiography (RX), ultrasound (US), scintigraphy, computed tomography (CT), and magnetic resonance imaging (MRI). It is worth noting that RX has low cost and good sensitivity, US can provide guidance to therapeutic infiltrations, and MRI allows the assessment of surrounding soft tissues.

Ictal extension (dorsiflexion) of the toes in a patient with temporal lobe epilepsy: A new ictal lateralizing sign

Neurologists have analyzed the clinical behaviors that occur during seizures for many years. Several ictal behaviors have been defined in temporal lobe epilepsy (TLE). Ictal behaviors are especially important in the evaluation of candidates for epilepsy surgery. We propose a new ictal lateralizing sign originating from the nondominant hemisphere: extension (dorsiflexion) of the toes (Babinski's, Chaddock's, and Moniz’ signs). Our patient is a 16-year-old woman. Her epileptogenic foci were localized to the right neocortical temporal region after noninvasive presurgical investigations. Cranial MRI revealed a right insular lesion compatible with focal cortical dysplasia or cortical tumor. We observed progressive movement of the left leg and, when the patient touched the lateral aspect of the foot to the bed, dorsiflexion of the great toe (Babinski's sign). In other seizures, the patient started a progressive movement of the left leg, rubbing the external border of the left foot on the bed and provoking dorsiflexion of the great toe (Chaddock's sign). The Brissaud reflex component was also observed when the movement was accompanied by internal rotation of the leg and recruitment of the tensor fascia lata, making dorsiflexion more likely to be a reflex response and not voluntary. We also observed forceful passive plantar flexion at the ankle in association with dorsiflexion of the great toe (Moniz’ sign). All of these signs were contralateral to ictal seizure onset and to the cerebral epileptogenic lesion. These signs may occur as a result of ictal activation of a specific brain region in this hemisphere.

Les ruptures du tendon du muscle tibial antérieur

In sports medicine, tears of the tibialis anterior are exceptional. We describe our experience with one case. Two types of injury can be observed: true tears involving the main body of the muscle under the pulley or the more distal portion at the insertion and fissurations. These injuries usually occur in a context of longstanding tenosynovitis or tendinopathy and are generally observed in runners. The mechanism requires stretching with the foot in forced plantar flexion and external rotation (fall backward with forefoot blocked). The diagnosis is clinical. Complementary explorations, excepting plain X-rays to search for a distal detachment from the bone, are not indispensable. In sports medicine, surgical treatment is required for full thickness tears. A plasty is usually performed with the third toe extensor. Recovery is long and progressive. In our experience, corticosteroid injections do not provoke these tears but can be useful for more rapid recovery in the athlete. After an injection, we immobilize the ankle for three weeks in a walking cast in order to “limit” the motivated athlete.

Bilateral functional popliteal artery entrapment in a young athlete

Popliteal artery entrapment syndrome is a frequent cause of intermittent claudication in young patients. We present a case of a bilateral functional entrapment, where static imaging did not demonstrate the occlusion until the patient's feet were placed in forced plantar flexion. A high index of clinical suspicion and dynamic tests with provocative manoeuvres are needed to diagnose this condition.

Electroacupuncture-induced analgesia in a rat model of ankle sprain pain is mediated by spinal α-adrenoceptors

In a previous study, we showed that electroacupuncture (EA) applied to the SI-6 point on the contralateral forelimb produces long-lasting and powerful analgesia in pain caused by ankle sprain in a rat model. To investigate the underlying mechanism of EA analgesia, the present study tested the effects of various antagonists on known endogenous analgesic systems in this model. Ankle sprain was induced in anesthetized rats by overextending their right ankle with repeated forceful plantar flexion and inversion of the foot. When rats developed pain behaviors (a reduction in weight-bearing of the affected hind limb), EA was applied to the SI-6 point on the contralateral forelimb for 30min under halothane anesthesia. EA significantly improved the weight-bearing capacity of the affected hind limb for 2h, suggesting an analgesic effect. The α-adrenoceptor antagonist phentolamine (2mg/kg, i.p. or 30μg, i.t.) completely blocked the EA-induced analgesia, whereas naloxone (1mg/kg, i.p.) failed to block the effect. These results suggest that EA-induced analgesia is mediated by α-adrenoceptor mechanisms. Further experiments showed that intrathecal administration of yohimbine, an α2-adrenergic antagonist, reduced the EA-induced analgesia in a dose-dependent manner, whereas terazosin, an α1-adrenergic antagonist, did not produce any effect. These data suggest that the analgesic effect of EA in ankle sprain pain is, at least in part, mediated by spinal α2-adrenoceptor mechanisms.

Stress-Dependent and Stress-Independent Gene Expression after Muscle Contraction

PURPOSE: The purpose of this study was to define the relationship between muscle mechanical conditions and gene expression in rat skeletal muscle by varying stress and contraction mode. Eccentric and isometric contractions at different frequencies were used to independently vary mechanical stress (force/PCSA) from contraction mode (eccentric vs. isometric). The goal was to determine whether muscle tissue simply responds to mechanical stress, contraction mode, or a combination of the two. METHODS: The experimental model used was stimulation of the rat dorsiflexors in vivo, via a peroneal nerve cuff electrode (n=25), activating them at high or low frequencies (150 Hz or 40 Hz) either eccentrically or isometric ally. This experimental design yielded four experimental groups. Eccentric contractions were induced by forced plantarflexion of the ankle. Muscle physiological, immunohistochemical and gene expression changes were then measured 24 hours after the exercise bout. Gene expression was measured for each muscle using quantitative PCR. Specific primer pairs were designed to amplify myostatin, MyoD, myogenin, MLP (also referred to as CRP3), CARP, Arpp/Ankrd2 and embryonic MHC. RESULTS: Peak stress was the best predictor of muscle injury, independent of contraction mode (i.e., eccentric or isometric),. When peak stresses were matched, no physiologic or immunohistochemical differences were detected between isometric and eccentric contractions. This indicated that structurally and physiologically, stress affected the muscle independent of mode. In contrast, the expression of certain myogenic regulatory and MARP genes (myoD, myogenin, MLP, and CARP) depended both on peak muscle stress achieved during contraction and contraction mode while Arpp/Ankrd2 was dramatically upregulated only by eccentric contractions, but not by isometric contractions. Conclusions: These data demonstrate that, structurally and physiologically, the stress imposed upon a muscle determines the magnitude of injury, represented either by peak tetanic tension or altered immunohistochemical staining. In contrast, several muscle-specific genes (myoD, myogenin, MLP, and CARP) were sensitive both to muscle contractile stress and contraction mode while another (Arpp/Ankrd2) was sensitive only to contraction mode. The gene expression results thus indicate biological sensitivity that is not apparent at the functional level. The data also suggest that the Arpp/Ankrd2 gene may be a sensor of eccentric contractions.

Demonstration of entrapment in a totally occluded popliteal artery-a case report

AbstractA case of intermittent claudication in a young male patient with short segment occlusion of popliteal artery is presented. Entrapment of the artery was recognised during attempted angioplasty by demonstration of extrinsic impression on the inflated balloon during forced plantar flexion. The importance of identifying this condition for definitive surgical management is stressed.

Arthroscopic Excision of the Talar Stieda’s Process

Abstract One of the causes of posterior ankle pain is posterior impingement syndrome. When the talar lateral process is long, in which case it is called Stieda’s process, it may be impinged between the tibia and calcaneus. We report the case of a 19-year-old patient who complained of posterior ankle pain and was diagnosed with posterior impingement of Stieda’s process. He failed to respond to conservative treatment and thus underwent arthroscopic excision. The ankle was approached through standard posterior lateral and trans-Achilles portals. A 4.5-mm diameter 30° arthroscope was used. Soft tissues around the talus were cleared with the help of a motorized shaver; after this, the posterior aspect of the subtalar joint could be visualized. The Stieda’s process was seen to impinge between the tibia and the calcaneus in forced plantar flexion. The talar process was removed with a burr until the impingement disappeared. The patient returned to contact sports 8 weeks after surgery. Arthroscopic excision of the lateral process of the talus can be accomplished easily and return to sports is achieved in a relatively short time.

Atrapamiento de la arteria poplítea: Comunicación de un caso

Popliteal artery entrampment is a rare condition, occurring in young subjects, that causes ischemia of the extremity. The anatomical background is the compression or occlussion of the popliteal artery caused by forced plantar or dorsal flexion. We report a 32 year-old sportsman who presented with gangrene of the right first toe and a history of three months of progressive claudication. The Ankle-Brachial index and pulse volume curve registries showed a severe ischemia below the knee. Angiography showed a medial deviation of the popliteal artery associated to stenosis and aneurysm formation. A CT scan of the contralateral artery was normal. The patient was operated using a posterior approach, performing a reverse saphenous vein bypass graft and excising the popliteal artery. The postoperative period was uneventful.

Mosaicplasty with Autogenous Talar Autograft for Osteochondral Lesions of the Talus after Failed Primary Arthroscopic Management

Background There have been limited data in the literature reporting the results of osteochondral autografting for osteochondral lesions of the talus that have failed arthroscopic treatment. Hypothesis Osteochondral autografting can produce significant clinical improvement and a high rate of healing of osteochondral defects of the talus that have failed arthroscopic treatment. Study Design Cohort study; Level of evidence, 4. Methods Between 1998 and 2003, 35 patients (18 men, 17 women) with osteochondral talar lesions for which arthroscopic excision, curettage, and drilling had failed, underwent mosaicplasty with an osteochondral graft harvested from the ipsilateral talar articular facet. A malleolar osteotomy or a tibial wedge osteotomy was used for central or posterior lesions that could not otherwise be reached. The mean age of the patients was 30.9 years, and the mean follow-up was 48.9 months. Results The American Orthopaedic Foot and Ankle Society Ankle Hindfoot scale score in patients without osteotomy rose by 39 points (P =. 0001); with malleolar osteotomy, by 30.1 points (P =. 017); with tibial wedge osteotomy, by 34.9 points (P =. 0002); and with the posterolateral approach, by 32 points. The Wilcoxon test revealed a significant difference between patients without and with osteotomy (P =. 027) and between patients with malleolar and tibial wedge osteotomies (P =. 046). There were no patients with nonunion or malunion in the osteotomy groups. The score values corresponded with the subjective patient evaluation. The Spearman coefficient of correlation was. 89. Conclusion Osteochondral autografting with tibial wedge osteotomy is a good alternative to malleolar osteotomy in osteochondral talar lesions that have failed arthroscopic treatment and that cannot be reached in spite of a forced plantar flexion of the ankle. Patients with small osteochondral lesions accessible through an anterior approach without additional osteotomy have the best prognostic factors.

Posterior Ankle Impingement Syndrome

Posterior ankle impingement syndrome is a clinical disorder characterized by posterior ankle pain that occurs in forced plantar flexion. The pain may be acute as a result of trauma or chronic from repetitive stress. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but it also may result from flexor hallucis longus tenosynovitis, ankle osteochondritis, subtalar joint disease, and fracture. Patients usually report chronic or recurrent posterior ankle pain caused or exacerbated by forced plantar flexion or push-off maneuvers, such as may occur during dancing, kicking, or downhill running. Diagnosis of posterior ankle impingement syndrome is based primarily on clinical history and physical examination. Radiography, scintigraphy, computed tomography, and magnetic resonance imaging depict associated bone and soft-tissue abnormalities. Symptoms typically improve with nonsurgical management, but surgery may be required in refractory cases.

Posterior Impingement of the Ankle Caused by Anomalous Muscles

P osterior impingement of the ankle results from the compression of the talus and surrounding soft tissue between the tibia and the calcaneus and has been likened to a “nut in a nutcracker.”1 It is produced by repetitive or forced plantar flexion of the foot and has been described in female ballet dancers, athletes, and in nonathletes after an ankle sprain1-4. Patients have pain in the posterolateral or posteromedial aspect of the ankle with activity, particularly plantar flexion. Often there is tenderness medial or lateral to the Achilles tendon, and soft-tissue thickening may be palpated. A positive posterior impingement test consists of reproduction of the symptoms with forced plantar flexion of the ankle2. The diagnosis is made on the basis of the history and physical examination of the patient and the clinical judgment of the surgeon and is supported if the symptoms are temporarily relieved by an injection of a local anesthetic and steroid into the region of the posterior process of the talus through a posterolateral approach2. Structures implicated in the etiology of posterior impingement of the ankle include an os trigonum5, an enlarged lateral process of the talus2, an enlarged posterior process of the calcaneus1, the posterior intermalleolar ligament6, soft-tissue impingement7, a gouty os trigonum8, loose bodies, ganglia, calcified inflammatory tissue, and a low-lying flexor hallucis longus muscle belly1,2. The surgical resection of symptomatic structures can be a successful treatment even in the high-level athlete2. Anomalous muscles about the ankle have been documented since the nineteenth century9-11. The peroneus quartus has been reported most frequently, and studies involving anatomical dissection of cadavera have shown that the prevalence …