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Posterior ankle impingement is a cause of posterior ankle pain common in those who perform frequent plantarflexion activities. Three young patients presented with posterior ankle pain which was initially attributed to peroneal tendon subluxation. However, detailed physical exam and imaging confirmed the diagnosis of posterior ankle impingement as the actual cause of pain. The peroneal tendon subluxation was not causal but an unrelated co-incidental finding. After failed prolonged conservative management (rest, immobilization and physical therapy), the patients underwent posterior ankle arthroscopic debridement for the impingement resulting in return to prior sporting activity without limitation and no recurrence of pain at 19 months follow-up. Posterior ankle impingement diagnosis could be masked by co-incidental asymptomatic peroneal tendon subluxation in pediatric patients.

An osseous fragment at the distal tip of the medial malleolus in a skeletally immature individual may represent a secondary ossification center and should not always be interpreted as a fracture. In this case study of a young dance student presenting with bilateral medial ankle pain, we postulated that hindfoot valgus, in combination with extreme loads placed on the foot during ballet training, increased stresses at the medial malleolus and accessory physis. Our patient was treated conservatively for symptomatic secondary ossification of medial malleolus and she returned to dance class at 6 months.

Transient osteoporosis of the talus is an uncommon condition of unknown etiology that is characterized clinically by ankle pain without a history of trauma. We present a case of isolated transient bone marrow edema of the talus in a pediatric patient which is the youngest described in the literature.

Purpose: Osteochondral lesion of talus (OLT) is one of the common causes of ankle pain. This disorder is common in young athletes after ankle injury. There are various therapeutic options. One of the options is mosaic plasticizer. The purpose of this study was to investigate the effect of mosaicplasty on improvement of symptoms of patients with osteochondral lesions of talus. Methods: Nineteen patients with osteochondral lesions of talus participated in this study, who were treated with mosaicplasty. Before and after treatment, pain (visual analogue scale), function (American Orthopaedic Foot and Ankle Society), range of motion and radiographic signs were evaluated. Results: The results of this study showed that mosaicplasty could significantly reduce pain, increase function and improve radiographic symptoms. The range of motion increased after treatment, which was not significant. Conclusion: We can confirm the effect of mosaicplasty on the improvement of patients with osteochondral lesions of the ankle, suggesting it as a treatment option. Key words: Autografts; Talus; Osteochondral lesions

Background Posterior ankle impingement syndrome (PAIS) is a cause of ankle pain due to pinching of bony or soft tissue structures in the hindfoot. The diagnosis is primarily made based on detailed history and accurate clinical examination. The delay in its diagnosis has not yet been described in the pediatric and adolescent population. Aim To identify and characterize misdiagnosed cases of PAIS in pediatric and adolescent patients. Methods This descriptive prospective study at a tertiary children's hospital included patients ≤ 18 years who underwent posterior ankle arthroscopy after presenting with chronic posterior ankle pain after being diagnosed with PAIS. Collected data included: Demographics, prior diagnoses and treatments, providers seen, time to diagnosis from presentation, and prior imaging obtained. Visual Analogue Scale (VAS) for pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted at initial presentation and follow-up. Results 35 patients (46 ankles) with average age of 13 years had an average 19 mo (range 0-60 mo) delay in diagnosis from initial presentation. 25 (71%) patients had previously seen multiple medical providers and were given multiple other diagnoses. All 46 (100%) ankles had tenderness to palpation over the posterior ankle joint. Radiographs were reported normal in 31/42 (72%) exams. In 32 ankles who underwent MRI, the most common findings included os trigonum (47%)/Stieda process (47%). Conservative treatment had already been attempted in all patients. Ankle impingement pathology was confirmed during arthroscopy in 46 (100%) ankles. At an average follow-up of 13.1 mo, there was an improvement of VAS (pre-op 7.0 to post-op 1.2) and AOFAS scores (pre-op 65.1 to post-op 94). Conclusion This is the first study which shows that PAIS is a clinically misdiagnosed cause of posterior ankle pain in pediatric and adolescent population; an increased awareness about this diagnosis is needed amongst providers treating young patients.

Bone marrow edema (BME) is an imaging diagnosis defined by an abnormal accumulation of intraosseous interstitial fluid within a bone on magnetic resonance imaging (MRI) investigation. The aim of this study was to determine the prevalence of BME in patients with foot and/or ankle pain studied using MRI. This was a retrospective observational work on patient cases and controls studied through MRI of the foot and/or ankle at our Foot and Ankle Unit (FAU). An analytical statistical analysis and a multivariate analysis were performed to eliminate possible confounding factors. 1950 foot and/or ankle MRI cases were reviewed, of which 451 presented bone edema (23% prevalence). The average patient age was 51.8 (range, 7–87); the talus bone was most frequently affected: post-traumatic in 43.5% of cases, degenerative in 34.7% and there was no specific cause identified in 6.3% (these cases were termed ‘idiopathic’). With regards to risk factors, in the case of gender, the odds ratio (OR) of men suffering bone oedema was 1.5 times higher than that of women (P = 0.003); for immunosuppression the OR was 3.4 times higher (P = 0.001); while among those with a smoking habit it was 0.59 (P = 0.001), meaning that after ruling smoking out as a possible confounding factor, it was, in fact, revealed to be a protective factor. The prevalence of bone edema in MRI in patients with foot and/or ankle pain was 23%. The average patient was male, aged approximately 50, with traumatic or degenerative origin talus bone oedema. Level of Evidence: Level IV, revision observational study.

Objective The purpose of this case report is to describe the treatment of a 3-year-old plafond fracture that developed posttraumatic osteoarthritis in a patient with chronic left ankle pain. Clinical Features A 65-year-old woman presented with daily anterior, posterior, medial, and lateral left ankle pain. Her initial pain level was 7 of 10 on weight bearing. She had trouble working and walking. She was previously treated with a walking boot, crutches, exercises, nonsteroidal anti-inflammatory drugs, and a steroid injection. She consulted our office approximately 3 years post-injury, at which point her initial disability score was 55 of 104 on the Foot and Ankle Disability Index. Interventions and Outcome The patient was subsequently treated with low-level laser, kinesio taping, exercise, and toggle board manipulation of the ankle. After a total of 6 visits, she was able to return to work and was walking with marked reduction of pain. Her pain level was 1 of 10 on weight bearing 1.5 years after her last treatment. Conclusion In this case report, a patient presented with 3-year-old ankle pain with an original etiology of plafond fracture. Her pain and disability resolved with a combination of low-level laser, exercises, kinesio taping, and toggle board manipulation. Her disability score after 6 visits was 18 of 104 on the Foot and Ankle Disability Index. This is a possible treatment option for posttraumatic osteoarthritis secondary to plafond fractures.

Tibiofibular syndesmosis injury leads to ankle pain and dysfunction when ankle injuries are not treated properly. Despite several studies having been performed, many questions about diagnosis and treatment remain unanswered, especially in ankle syndesmosis injury with interosseous membrane injury. Therefore, the purpose of this study was to help guide best practice recommendations. This review explores the mechanism of injury, clinical features, diagnosis methods, and the treatment strategy for ankle syndesmosis injury with interosseous membrane injury to highlight the current evidence in terms of the controversies surrounding the management of these injuries. Radiological and CT examination are an important basis for diagnosing ankle syndesmosis injury. Physical examination combined with MRI to determine the damage to the interosseous membrane is significant in guiding the treatment of ankle syndesmosis injury with interosseous membrane injury. In the past, inserting syndesmosis screws was the gold standard for treating ankle syndesmosis injury. However, there were increasingly more controversies regarding loss of reduction and broken nails, so elastic fixation has become more popular in recent years. Anatomical reduction and effective fixation are the main aspects to be considered in the treatment of ankle syndesmosis injury with interosseous membrane injury and are the key to reducing postsurgery complications.

Achilles tendinopathy, both insertional and noninsertional, is a common cause of posterior ankle pain. Although the condition of most patients improves with simple conservative measures, a proportion will go on develop chronic symptoms. This study examines the outcomes of patients following extracorporeal shock wave therapy plus a home exercise program. This prospective case series study involves a total of 39 patients, with a mean follow-up duration of 163 (range 65 to 385) days. This has demonstrated significant benefits in pain, stiffness, and a range of measures of local and global function. Median (interquartile range [IQR]) values for average self-reported pain improved from 6.5 of 10 (IQR 5.0 to 7.8) at baseline to 3.5 of 10 (IQR 2.0 to 5.1) at 3 months and to 2.0 of 10 (IQR 0.6 to 4.8) at 6 months for patients with insertional Achilles tendinopathy. This compares to improvements from 7.0 of 10 (IQR 7.0 to 8.0) at baseline to 6.0 of 10 (IQR 5.6 to 6.8) at 3 months and to 6.0 of 10 (IQR 3.0 to 7.0) at 6 months for patients with noninsertional Achilles tendinopathy. Statistically significant improvements were seen in insertional tendinopathy across a range of outcome measures; however, these were less apparent for patients with noninsertional tendinopathy. Despite these figures, no significant differences were seen in the outcomes for patients with insertional and noninsertional tendinopathy. Despite the improvements seen in the aspects of pain and function, physical activity levels had not increased following the treatment.

Long-term studies have shown that 10% to 20% of patients continue to experience ankle pain years after tibial fracture, which causes poor functional results and dissatisfaction. The aim of this study was to show that there could be a talus injury in patients with a tibial shaft fracture and to reveal occult talus lesions with magnetic resonance imaging (MRI) examination. Fifty-two patients with a tibial shaft fracture, with closed epiphyses, not extending to the joint and with no problems in the application of MRI examination were included. All patients underwent intramedullary tibial nailing. Patients with a lesion detected on MRI were planned to be examined by MRI again at mean of 12 months later. Ankle function of the patients were evaluated with the American Orthopaedic Foot and Ankle Society, Freiburg, and Weber scoring systems at 3, 6, and 12 months postoperatively. At the first MRI, 22 (42.3%) patients with tibial shaft fracture were found to have talus lesions: 7 (13.5%) had osteochondritis dissecans, 12 (23.1%) had edema, and 3 (5.8%) had cysts. A second MRI was planned for patients with edema and osteochondritis dissecans at a mean of 12 months. Finally, at 12 months, MRI examinations revealed osteochondritis dissecans and edema in 9 (17.3%) and 8 (15.4%) patients, respectively. In the evaluations of the patients according to the ankle scoring systems, the scores of the patients with pathology determined in the talus were significantly worse statistically than those of patients with no pathology determined at 3, 6, and 12 months postoperatively. Atalus lesion accompanied the tibial shaft fracture at a rate of 37%. The talus injuries were seen especially with an indirect mechanism of trauma, in distal third fractures, in spiral fractures, and when the tibial fracture was accompanied by a lateral malleolar fracture. In the presence of findings indicating talus injury in cases of tibial shaft fracture, the talus should be evaluated with ankle MRI.

To assess prevalence of musculoskeletal disorders (MSDs) and possible work-related risk factors among physicians compared to dentists. A questionnaire-based cross-sectional comparative study among 131 physicians and 66 dentists in three hospitals in Beni Suef city. Data gathered from the questionnaires included: socio-demographic data, occupational risk factors, and musculoskeletal symptoms, following the Nordic Musculoskeletal Questionnaire (NMQ). Age ranged from 30 to 55 years, with a mean age of 35.2 ± 5 years among physicians. Smoking was significantly more frequent among physicians than dentists (22.9% vs 10.6% respectively). The mean for hours of physical exercise per week was 1.28 ± 2.46 for dentists compared to 1.16 ± 2.24 for physicians. Regular physical activity was performed by 22.9% of physicians and 22.7% of dentists. Most of the dentists (97%) reported prolonged standing,compared to 76.3% of physicians (P

Aim: The aim of this study was to investigate the diagnostic accuracy of high resolution ultrasonography for the assessment of painful ankle joint as compared with the clinical findings. Material and Methods: A prospective study was conducted on 136 patients having history of ankle pain and referred to the Department of Radiodiagnosis and Imaging for ultrasonography. Statistical analysis: Comparison of ultrasonography findings and clinical findings was done using McNemar Test. Results: 136 patients with 218 pathologies of the ankle joint were analyzed. Of these, 178 pathologies were clinically suspected, but 206 were diagnosed with ultrasonography. This difference was statistically significant (p value = 0.000). Conclusion: Ultrasonography is an excellent tool for evaluating patients with ankle pain, especially in cases of lateral ligament pathologies, tendinous pathologies, joint effusion, and miscellaneous pathologies. It can be used as the primary imaging investigation because it allows a rapid, dynamic, and cost-effective examination of the ankle joint. However, ultrasonography has limitations when using it to evaluate a suspected posterior talofibular ligament injury, marrow abnormalities, and deep seated pathologies, for which MRI should be incorporated for a diagnosis. Aim: The aim of this study was to investigate the diagnostic accuracy of high resolution ultrasonography for the assessment of painful ankle joint as compared with the clinical findings. Material and Methods: A prospective study was conducted on 136 patients having history of ankle pain and referred to the Department of Radiodiagnosis and Imaging for ultrasonography. Statistical analysis: Comparison of ultrasonography findings and clinical findings was done using McNemar Test. Results: 136 patients with 218 pathologies of the ankle joint were analyzed. Of these, 178 pathologies were clinically suspected, but 206 were diagnosed with ultrasonography. This difference was statistically significant (p value = 0.000). Conclusion: Ultrasonography is an excellent tool for evaluating patients with ankle pain, especially in cases of lateral ligament pathologies, tendinous pathologies, joint effusion, and miscellaneous pathologies. It can be used as the primary imaging investigation because it allows a rapid, dynamic, and cost-effective examination of the ankle joint. However, ultrasonography has limitations when using it to evaluate a suspected posterior talofibular ligament injury, marrow abnormalities, and deep seated pathologies, for which MRI should be incorporated for a diagnosis.

Introduction Various procedures have been used to treat osteochondral lesions of the talus. Among the new alternatives to treat these lesions, Autologous Matrix-Induced Chondrogenesis (AMIC®) has proven to provide satisfactory results through medium-term follow-up. The aim of this study is to report early post-operative clinical results of patients submitted to the AT-AMIC® technique and autologous bone graft, when necessary, for OLT’s at a eight-month minimum follow-up. Methods This is case series of 17 consecutive patients that were submitted to AT-AMIC®, between January of 2016 and April of 2017. Nine men and eight women, between 15 and 67 years were diagnosed with OLTs with the typical history of deep ankle pain and corresponding magnetic resonance imaging injury. Surgery was proposed only after failure of conservative treatment of at least 3 months. Patients answered the AOFAS score preoperatively and at the last follow-up, ranging from 8 to 20 months. Results Average size of OLTs were 1.16 cm2, with Raikin 4 location being the most common (71%). Calcaneal osteotomy was the most common associated procedure, with 18%. Average follow-up was 10.8 months. Average AOFAS before surgery was 46.4, increasing to 89.5 at the last follow-up. This difference was statistically significant with a p-value of Conclusion AT-AMIC® is a reliable and reproducible method of treatment for OLTs, reaching high clinical postoperative scores, with a very low rate of complications. Further comparative study is needed to prove its efficacy.

Background Talus osteochondral lesion is commonly associated with trauma, avascular necrosis or even genetic factors, but gouty tophus as a cause of Hepple stage V type talus osteochondral lesion is rare. Case presentation Here, we report a case of an 18-year-old man who complained of left medial deep ankle pain on ambulation. This young man had an extreme liking of sea food rich in purines and also sugar-sweetened drinks. He was diagnosed with a Hepple stage V type talus osteochondral lesion and was treated with medial malleolus osteotomy and an osteochondral graft. The talus osteochondral lesion was found to be a gouty tophus and was completely removed. Hypouricemic therapy was prescribed for 2 months, which allowed the patient to walk with a visual analogue score (VAS) score of 1. He was followed up for 12 months. Conclusions Young people with an extreme liking of sea food rich in purines and also sugar-sweetened drinks may be at a risk of developing gout. Acute onset of ankle atraumatic pain, swelling with a high level of serum uric acid and a talus osteochondral lesion with cyst formation should make physicians consider a diagnosis of gout.

Background Ankle sprains are one of the most common musculoskeletal injuries, accounting for up to 5% of all Emergency Department visits in the United Kingdom. Ankle injury may be associated with future ankle osteoarthritis. Up to 70% of ankle osteoarthritis cases may be associated with previous ankle injury. There is limited research regarding the association between ankle sprain and ankle osteoarthritis development. The current study aims to phenotype those who suffer significant ankle ligament injuries, identify potential risk factors for ankle injuries and subsequent poor recovery, examine why individuals may develop osteoarthritis, and what factors influence this chance. Methods In this multicentre cohort study participants were recruited from nine Emergency Departments and two Urgent Care Centres in the United Kingdom. Participants (aged 18–70 years old) were defined as those who had suffered an isolated acute ankle sprain, which was Ottawa Ankle Rules positive, but negative for a significant ankle fracture on x-ray. Age and sex matched controls were also recruited. The controls were individuals who had not suffered a significant ankle injury, including ankle pain, function affected for more than 7 days, or the ankle caused them to report to an Emergency Department. Data is collected through a series of seven questionnaires (at baseline, 3 months, 1 year, 3 years, 5 years, 10 years, and 15 years later). The questionnaires include four sections (demographic questions; index injury, and injury history questions; functional assessment questions; and quality of life questions) and are designed to collect detailed information about the individual, their injury, potential risk factors for ankle sprains and ankle osteoarthritis, plus their medical history and any medication consumed. Discussion The Significant Ankle Ligament Injury (SALI) study aims to add to the limited knowledge regarding which factors can predict ankle sprains, complaints, and osteoarthritis. This is important because despite ankle sprains being regarded as a benign injury that resolves quickly, residual symptoms are not uncommon months and years after the injury.

Objective Identify distinct trajectories of lack of knee confidence over an 8-year follow-up period and examine baseline factors associated with poor trajectories in persons with or at risk for knee osteoarthritis (OA). Methods The Osteoarthritis Initiative is a prospective cohort study of persons with or at high risk for knee OA. Confidence in the knees was assessed within the Knee Injury and Osteoarthritis Outcome Score instrument querying how much the individual is troubled by lack of confidence in his/her knee(s), rated as not-at-all (0), mildly (1), moderately (2), severely (3), and extremely (4) troubled, reported annually from baseline to 96 months. Lack of knee confidence was defined as a score ≥ 2. We used latent class models to identify subgroups that share similar underlying knee confidence trajectories over an 8-year period, and multivariable multinomial logistic regression models to examine baseline factors associated with poor trajectories. Results Among 4515 participants [mean age 61.2 years (SD 9.2), BMI 28.6 kg/m2 (4.8); 2640 (58.5%) women], four distinct knee confidence trajectories were identified: persistently good (65.6%); declining (9.1%); poor, improving (13.9%); and persistently poor (11.4%). Baseline predictors associated with persistently poor confidence (reference: persistently good) were younger age, male sex, higher BMI, depressive symptoms, more advanced radiographic disease, worse knee pain, weaker knee extensors, history of knee injury and surgery, and reported hip and/or ankle pain. Conclusion Findings suggest the dynamic nature of self-reported knee confidence and addressing modifiable factors (e.g., BMI, knee strength, depressive symptoms, lower limb pain) may improve its long-term course.

BACKGROUND Mosaicplasty osteochondral transplantation (MOT) has been proved a feasible choice for the treatment of talus osteochondral injury. It can reduce ankle pain and allow performance of daily living activities and elementary sports. However, there are very little data on the restoration of normal life with large lesions. Our investigation focused on assessing outcomes in patients with large lesions. MATERIAL AND METHODS The MOT operation was used, and the donor site was located at the lateral condyle of the femur. Clinical evaluation included the Berndt and Harty outcome question, Visual Analog Scale (VAS) pain score (during rest, walking and running), American Orthopedic Foot and ankle Association (AOFAS) score, International Knee Documentation Committee (IKDC) subjective knee evaluation form, and the Short Form 36 (SF-36). Twenty-four months after surgery, the graft binding was assessed by MRI using the magnetic resonance observation of cartilage repair tissue (MOCART) score. RESULTS We assessed 26 patients, including 14 males and 12 females. The average follow-up time was 33.9±5.2 months. The average lesion size was 173.1±23.5 mm². The average VAS score during rest improved from 4.62±0.85 preoperatively to 1.08±0.27 postoperatively (P

Osteoarticular tuberculosis (TB) of the ankle joint is rare, and there is a delay in diagnosis in most cases. All patients with the disease complained of swelling and pain in the affected ankle. Ankle TB is a disorder that can be simply misdiagnosed. The delay in diagnosis may range from months up to years. All patients in this series had already been diagnosed with ankle TB by the time they visited our hospital. The current case was reported in a middle-aged male nurse with ankle pain, ulcer, and limited range of movement. The classical clinical manifestations of TB were absent on free chest radiography. Ulcer biopsy showed TB infection with no lymph nodes. Nonspecific inflammation was initially treated, but, subsequently, anti-TB treatment was useful.

Introduction Ankle arthrodesis is one of the managements for a significantly unstable Charcot ankle. Some of the methods of internal fixation for ankle arthrodesis include the use of intramedullary nails, screws, and plates. Ankle arthrodesis using intramedullary nails has become more popular. However, studies evaluating the use of plate fixation, particularly double posterior lateral plating, are limited. We report the clinical and radiological outcomes of double posterior lateral plating ankle arthrodesis in three diabetic Charcot ankle patients. Presentation of case Three patients, aged 73, 67, and 65 years old, complained of ankle pain and with a history of type 2 diabetes mellitus. The physical examination revealed swelling and erythema without a sign of active infection. The radiological examination showed ankle deformity, and the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot scores were 5, 10, and 0, respectively. All patients were diagnosed with a diabetic Charcot ankle and underwent ankle arthrodesis using double posterior lateral plating. Four months and six months follow up revealed talus union, improved ankle deformity, and improved AOFAS Ankle-Hindfoot scores to 70, 76, and 73, respectively. Discussion Various methods of ankle arthrodesis are retrograde intramedullary nails, screws, and plates. In this report, we opt for plate fixation because it allows for stable internal fixation, adequate compression, high angular stability, and a lower irreversible deformation in osteoporotic bone. Conclusion Double posterior lateral plating ankle arthrodesis provided satisfactory clinical and radiological outcomes. This method can be an alternative for patients with Charcot ankle requiring ankle arthrodesis., Highlights • Double posterior lateral plating ankle arthrodesis is satisfactory. • This method can be an alternative for patients with Charcot ankle. • Plate fixation allows stable internal fixation and adequate compression.

Background Bone tumours of the talus are a rare cause of ankle pain. This study aims to provide additional clinical clarity regarding the presentation and management of a minimally researched topic. Methods Sixteen patients were diagnosed with bone tumour of the talus between 2002 and 2020 following referral for ankle pain. Symptoms, diagnosis, and management were retrospectively reviewed. Patients were actively followed up until consistently symptom-free and consenting to discharge (mean of 2.9 years). An open appointment was offered to all patients to reattend the unit if symptoms recurred. Results The most common diagnosis was osteoid osteoma/osteoblastoma (nine patients), chondroblastoma (four patients), a giant cell tumour of bone, a chondral lesion in Ollier's disease and a rare metastatic renal cancer case. The mean age of onset was 29 years. Thirteen patients experienced ankle pain without a clear precipitating cause. Night pain was less common in osteoid osteoma/osteoblastoma than usually observed in the literature. The mean delay in diagnosis was two years, often due to an incorrect diagnosis of soft tissue injury. Plain radiographs are insufficient to identify most lesions. Ten patients underwent computed tomography (CT)-guided radiofrequency ablation and five patients had open surgical curettage. Ollier's disease was managed with orthotics. The five cases of recurrence across four patients were managed operatively. Conclusions Patients are usually young and healthy with benign disease, but talus tumours can cause significant functional impairment. Unexplained ankle pain should be extensively examined and be further investigated with magnetic resonance imaging (MRI) and CT scanning to avoid missing these rare tumours.

Aim: To assess the efficacy of the electron modulation procedure (EMP) in reducing chronic musculoskeletal pain acutely over distinct anatomical areas. Materials & methods: We performed a retrospective analysis of 223 patients who received a single EMP treatment for various chronic musculoskeletal pain issues. Pain levels, recorded before and after receiving EMP, were analyzed at distinct anatomical musculoskeletal areas. Results & conclusion: The effect of the EMP treatments in reducing musculoskeletal pain was statistically significant at the 5% level. Those with hip/gluteal and ankle pain had the highest (92%) and lowest (58%) pain elimination rate, respectively. Statistical evidence supported the idea that EMP treatment can quickly reduce musculoskeletal pain. Distinct anatomical musculoskeletal areas responded differently to EMP treatment.

Shota Oda,1 Masashi Izumi,1,2 Shogo Takaya,1,2 Nobuaki Tadokoro,2 Koji Aso,2 Kristian Kjær Petersen,3 Masahiko Ikeuchi1,2 1Department of Rehabilitation Center, Kochi Medical School Hospital, Nankoku, Kochi, Japan; 2Department of Orthopedic Surgery, Kochi University, Nankoku, Kochi, Japan; 3Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, DenmarkCorrespondence: Masashi IzumiDepartment of Orthopedic Surgery, Kochi University, Oko-Cho Kohasu, Nankoku, Kochi, Japan, 783-8505 Tel +81-88-880-2386Fax +81-88-880-2388Email izumim@kochi-u.ac.jpPurpose: Clinically, arthrogenic muscle inhibition (AMI) has a negative impact on functional recovery in musculoskeletal disorders. One possible technique to relieve AMI is motor imagery, which is widely used in neurological rehabilitation to enhance motor neuron excitability. The purpose of this study was to verify the efficacy of visually-assisted motor imagery against AMI using a human experimental pain model.Methods: Ten healthy volunteers were included. Experimental ankle pain was induced by hypertonic saline infusion into unilateral Kager’s fat pad. Isotonic saline was used as control. Subjects were instructed to imagine while watching a movie in which repetitive motion of their own ankle or fingers was shown. H-reflex normalized by the motor response (H/M ratio) on soleus muscle, maximal voluntary contraction (MVC) force of ankle flexion, and contractile activities of the calf muscles during MVC were recorded at baseline, pre-intervention, post-intervention, and 10 minutes after the pain had subsided.Results: Hypertonic saline produced continuous and constant peri-ankle pain (VAS peak [median]= 6.7 [2.1– 8.4] cm) compared to isotonic saline (0 [0– 0.8] cm). In response to pain, there were significant decreases in the H/M ratio, MVC and contractile activities (P< 0.01), all of which were successfully reversed after the ankle motion imagery. In contrast, no significant changes were observed with the finger motion imagery.Conclusion: Visually-assisted motor imagery improved the pain-induced AMI. Motor imagery of the painful joint itself would efficiently work for relieving AMI. This investigation possibly shows the potential of a novel and versatile approach against AMI for patients with musculoskeletal pain.Keywords: arthrogenic muscle inhibition, experimental ankle pain model, visually-assisted motor imagery

Author(s): Besinger, Bart; Ryckman, Sydney | Abstract: Introduction: Septic malleolar bursitis is a rare cause of ankle pain and swelling. It has been described in certain occupational and recreational activities that involve tight-fitting boots, such as figure skating. Court-ordered electronic monitoring devices are often worn on the ankle. It is not known whether these devices are a risk factor for the development of malleolar bursitis.Case Report: We describe a 41-year-old male under house arrest with an electronic monitoring device on his right ankle who presented to our emergency department with several days of progressive pain and swelling over the medial malleolus. Point-of-care ultrasound revealed a thick-walled cystic structure consistent with medial malleolar bursitis. Bursal aspiration was performed. Fluid culture yielded Staphylococcus aureus.Discussion: Emergency physicians regularly see patients with ankle pain and swelling and must consider a comprehensive differential diagnosis. Septic malleolar bursitis is an uncommon but important cause of ankle pain and swelling that requires prompt diagnosis and intervention. Point-of-care ultrasonography may aid in the diagnosis. Additionally, emergency physicians should be aware of potential complications related to electronic monitoring devices.

BACKGROUND: Diagnosis and treatment of tendonitis/entrapment of the flexor hallucis longus (FHL) has been sporadically described in the evidence, primarily in the context of dancers and other athletes. Although various nonspecific nonoperative treatments have been described, it is not clear how often they achieve a satisfactory amount of symptom improvement. QUESTIONS/PURPOSES: The present study was designed to address the following questions regarding the nonoperative treatment of FHL tendonitis: (1) In a population of patients where the default management option for FHL tendonitis is a comprehensive nonsurgical approach, what proportion of patients thus treated opted not to have surgery? (2) What factors were associated with a patient's decision to undergo surgery after a period of nonsurgical management? METHODS: The 656 patients included were all those diagnosed with FHL tendonitis who were initially treated nonoperatively in the foot and ankle division between January 2009 and December 2018. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and final outcome were obtained from the electronic medical record. The primary outcome was the decision to have surgery due to unsatisfactory symptom improvement. We compared patients who opted for surgery with those who did not after nonoperative treatment with univariable and multivariable statistics using demographics, comorbidities, and clinical findings as potential risk factors, with p < 0.05. RESULTS: Forty-four percent (180 of 409) of patients decided to forgo surgery after the institution of a specific FHL stretching program. Surgery was more likely in patients with clinical hallux rigidus (OR 2.4 [95% CI 1.16 to 4.97]; p = 0.02) or posteromedial ankle pain (OR 1.78 [95% CI 1.12 to 2.83]; p = 0.01) and less likely in those who completed an FHL stretching program (OR 0.15 [95% CI 0.08 to 0.27]; p < 0.001). CONCLUSION: FHL tendonitis is more common than the previous evidence suggests and frequently occurs in nonathletes. Once it was diagnosed by detection of tenderness anywhere along the tendon, most frequently at the fibroosseous tunnel, nonoperative treatment focused on specific FHL stretching and immobilization in more severe cases reduced the symptoms to the extent that 44% of patients decided that surgery was unnecessary. The key to its diagnosis is awareness that this injury is possible because most patients treated in this study had been previously seen by orthopaedic providers who had not appreciated the presence of the condition, leading to a delay in diagnosis and treatment of more than a year in many patients. LEVEL OF EVIDENCE: Level III, therapeutic study.

ABSTRAC. Background : Hindfoot is frequently injured either duo to trauma, overuse or inflammatory processes. Different diagnoses unfortunately tend to have overlapping clinical signs and symptoms. So, clinicians tend to rely on imaging. Ultrasonography (US) has many benefits for evaluating hindfoot pain. Aim of the study: To review the prevalence of etiologies in patients with hindfoot pain by musculoskeletal ultrasound. Patient and methods: This study included one hundred (100) patients complaining of unilateral or bilateral hindfoot pain ranging in age from 16 to 65 years with no sex specification, excluding patients with chronic rheumatological inflammatory diseases, diabetes mellitus, major ankle trauma, previous foot surgery and any foot or lower limp deformity. All patients were subjected to careful history taking, clinical examination, laboratory investigations and X ray imaging for ankle and foot, giving provisional diagnosis; followed by real-time high resolution ultrasonography for the affected hind foot. Results: By high-resolution ultrasonography for the affected hindfoot of our patients, 181 different lesions were detected, tendon lesions were the commonest lesions detected, with 63 lesions (35%) followed by 59 lesions (32%) for joint & synovial lesions, 31(17%) for planter fascia lesions, 12(7%) for ligament lesions, 9(5%) for Bursal lesions and 7(4%) for subcutaneous lesions. Of these all lesions, 29 lesions (16%) were not clinically suspected. Conclusion: Ultrasonography is an ideal method for testing patients with hindfoot pain and are highly capable of identifying a wide variety of pathologies, some of which may not be clinically identified.

Introdução: A atividade de corrida requer um domínio técnico e físico adequado de forma a reduzir o risco de lesão e o aparecimento de dor. Dado o aumento exponencial de praticantes de corrida em Portugal, a presente investigação teve como objetivo caracterizar a prevalência de dor músculo esquelética em praticantes de corrida. Métodos: O presente estudo avaliou as características primárias (i.e. prática de corrida, intensidade e local da dor articular) e secundárias (i.e. sexo, idade, composição corporal e menopausa) da dor músculo esquelética de 387 participantes com idade ≥ 18 anos, através do questionário Knee Osteoarthritis Pre-Screening. A amostra foi subdividida em praticantes de corrida (GP) e não praticantes (GNP), e a análise estatística incluiu medidas de natureza descritiva, de relação entre variáveis através do teste Qui-quadrado, e de comparação entre grupos através do teste T-student e ANOVA. Resultados: 47,3% da amostra final afirmou ter dor articular, sendo que 47,5% são praticantes de corrida. Neste grupo a prevalência de dor crónica foi superior nos membros inferiores. Conclusão: A prevalência de dor no GP é superior nas articulações da coluna lombar, anca, joelho e tornozelo. Verificaram-se diferenças estatísticas na região da dor de acordo com o sexo. Running is one of the simplest, most natural and accessible physical recreation activities for health maintenance and disease prevention, and the number of participants has been increased in Portugal over the last years. The purpose of present investigation is estimate the prevalence of musculoskeletal pain in Portuguese runners. Methods: The present investigation studied the primary (running, intensity and location of joint pain) and secondary (sex, age, body composition and menopause) characteristics of musculoskeletal pain in 387 participants aged ≥ 18 years, using the Knee Osteoarthritis Pre-Screening. Sample was subdivided into runners (GP) and non-runners (GNP). Statistical analysis included measures of descriptive nature, Chi-square test was performed to examine the relationship through variables and T-student test and ANOVA to differences between groups. Results: 47,3% of the final sample has joint pain (47,5% are runners). The prevalence of chronic pain in runner was higher in lower limbs. Conclusions: The prevalence of chronic pain in runners is higher in the lumbar spine, hip, knee and ankle joints. There were statistical differences in pain region according to sex.

BackgroundLateral ankle sprains are common in indoor sports. High shoe–surface friction is considered a risk factor for non-contact lateral ankle sprains. Spraino is a novel low-friction patch that can be attached to the outside of sports shoes to minimise friction at the lateral edge, which could mitigate the risk of such injury. We aimed to determine preliminary effectiveness (incidence rate and severity) and safety (harms) of Spraino to prevent lateral ankle sprains among indoor sport athletes.MethodsIn this exploratory, parallel-group, two-arm pilot randomised controlled trial, 510 subelite indoor sport athletes with a previous lateral ankle sprain were randomly allocated (1:1) to Spraino or ‘do-as-usual’. Allocation was concealed and the trial was outcome assessor blinded. Match and training exposure, number of injuries and associated time loss were captured weekly via text messages. Information on harms, fear-of-injury and ankle pain was also documented.Results480 participants completed the trial. They reported a total of 151 lateral ankle sprains, of which 96 were categorised as non-contact, and 50 as severe. All outcomes favoured Spraino with incidence rate ratios of 0.87 (95% CI 0.62 to 1.23) for all lateral ankle sprains; 0.64 (95% CI 0.42 to 0.98) for non-contact lateral ankle sprains; and 0.47 (95% CI 0.25 to 0.88) for severe lateral ankle sprains. Time loss per injury was also lower in the Spraino group (1.8 vs 2.8 weeks, p=0.014). Six participants reported minor harms because of Spraino.ConclusionCompared with usual care, athletes allocated to Spraino had a lower risk of lateral ankle sprains and less time loss, with only few reported minor harms.Trial registration numberNCT03311490.

An isolated sustentaculum tali fracture is a rare manifestation of orthopedic injury involving the supporting bone of the middle calcaneal facet. Globally, the incidence is estimated to be less than 1% of all calcaneus fractures. We reported a 42-year-old man with persistent ankle pain and instability on the right foot following a week after a motorcycle accident. The Computed tomography evaluation showed an avulsion of the medial sustentaculum tali on the right calcaneus bone. An open reduction and internal fixation procedure was performed using two cannulated cancellous screws applied across the lateral wall through the sustentaculum bone medially. The subjective postoperative evaluation showed that the patient responded well and gradually returned to daily routine activities without pain and instability. Informed Patient Consent: The patient has already been assigned for informed consent and agreed to the publication of the case and clinical images for medical education purposes. Funding: None Conflict of Interests: None

Microinstability is an emerging concept among the possible causes of ankle symptoms and disability. Injury to the superior fascicle of the anterior talofibular ligament might play a key role in this condition. Microinstability of the ankle is considered as a low degree of mechanical lateral ankle instability. A mismatch between symptoms and imaging is very frequent once current imaging options lack sensitivity to identify this pathology which can latterly be confirmed arthroscopically. Moreover, there are also no reproducible objective findings on clinical examination which also contributes to its poor characterization.

Objective. To observe the characteristics of ankle pain and ankle joint muscle by microscope. Methods. In a sports university, 15 athletes above grade 2 were randomly selected as the experimental group, and 15 nonathletes were randomly selected as the control group. The experiment mainly included foot shape test, standard scaphoid height test, ankle range of motion test, ankle muscle emg test, and other experimental procedures. Medical microscopic image processing is a new technology developed in the past thirty years, which has brought great progress for mankind to understand and transform nature. Among them, the image processing and recognition of tumor cell microscopic images are one of the research focuses on the use of computers to process and recognize medical images. Results. In the test of ankle range of motion, when the angular velocity was the same as 60°/s, compared with the control group, the difference value of bilateral flexor peak moment in the experimental group was large, and the difference between the two groups was significant ( P < 0.05 ), with statistical significance. As the angular velocity dropped from 240°/s to 60°/s, 30 members of the experimental group and control group also experienced a decrease in the bilateral ankle isokyclic muscles, reflecting their lack of ankle strength. On the other hand, the muscle strength of the ankle joint in the experimental group was relatively small, and the difference between the two groups was significant ( P < 0.05 ). During the exercise, some members of the experimental group suffered from ankle pain, which resulted in insufficient strength of the muscles of the ankle joint, resulting in the interruption of the experiment. In the emg test of ankle muscles, the effective discharge values of preexcitation current of tibial anterior muscle before and after exercise were 104.6 ± 26.5 and 129.2 ± 38.1 , respectively, with significant difference and statistical significance. In the foot morphology test and the standard scaphoid height test, the difference between the two groups was not significant ( P > 0.05 ), and there was no statistical significance. Conclusion. Microscope based on athlete’s foot and ankle pain and ankle muscle characteristics to improve the accuracy of the observation, with the help of a microscope, you can see the details of a doctor are invisible to the naked eye and can record the relevant data in time in order to observe the late, for athlete’s foot and ankle pain relief and enhanced ankle muscles provide data support.

Objective: M-mode ultrasound imaging (US) reflects the motion of connective tissue within muscles. The objectives of this study were to evaluate inter-rater and intra-rater reliability of soleus muscle measurements between examiners with different levels of US experience in asymptomatic subjects and to investigate the level of soleus muscle isometric activity in two positions (knee extended and knee flexed at 30&deg, ). Methods: Thirty volunteers without a history of ankle pain were evaluated with US examinations of the soleus muscle. Each muscle was scanned independently by two evaluators. Muscle at rest thickness, maximal isometric contraction thickness, time and velocity measures were detailed and blinded to the other examiner. Results: Intra- and inter-rater reliability at rest, in maximal isometric contraction thickness, contraction time and contraction velocity measures for both positions (extended and flexed knee) were reported from good to excellent for all outcome measurements. The position with the knee extended reported a statistically significant increase in thickness after motion showing 1.33 &plusmn, 0.27 mm for measurements at rest thickness with knee extended versus 1.50 &plusmn, 0.29 mm for measurements at end thickness with the knee in flexed position (p = 0.001), as well as 1.31 &plusmn, 0.23 mm for rest thickness with the knee in flexed position measurements with respect to 1.34 &plusmn, 0.24 mm for maximal isometric contraction thickness with extended knee measurements (p = 0.058). Conclusions: This study found that intra- and inter-examiner reliability of M-mode ultrasound imaging of the soleus muscle was excellent in asymptomatic subjects and the soleus muscle activity was different between the position with the knee extended and the position with the knee flexed.

We present a unique case of chronic deltoid ligament disruption in a 34-year-old high-level military operator with a 12-month history of acute-onset medial ankle pain. Magnetic resonance imaging showed an isolated chronic disruption of the superficial and deep deltoid ligament. The patient was managed operatively with a semitendinosus allograft. No complications were observed during the intra- or perioperative periods. At 12-month follow-up, the patient reported near-complete pain resolution and was able to return to unrestricted active duty. Use of allograft ligamentous reconstruction of the deltoid ligament in a highly active soldier was successful, allowing return to unrestricted active duty.

Enthesitis is a cardinal feature of spondyloarthropathies. The Achilles insertion on the calcaneus is a commonly evaluated enthesis located at the hindfoot, generally resulting in hindfoot pain and possible tendon enlargement. For decades, diagnosis of enthesitis was based upon patient history of hindfoot or posterior ankle pain and clinical examination revealing tenderness and/or enlargement at the site of the tendon insertion. However, not all hindfoot or posterior ankle symptoms are related to enthesitis. Advanced imaging, including magnetic resonance imaging (MRI) and ultrasound (US), has allowed for more precise evaluation of hindfoot and posterior ankle conditions. Use of US in diagnosis has helped confirm some of these cases but also identified other conditions that may have otherwise been misclassified without use of advanced imaging diagnostics. Conditions that may result in hindfoot and posterior ankle symptoms related to the Achilles tendon include enthesitis (which can include retrocalcaneal bursitis and insertional tendonopathy), midportion tendonopathy, paratenonopathy, superficial calcaneal bursitis, calcaneal ossification (Haglund deformity), and calcific tendonopathy. With regard to classification of these conditions, much of the existing literature uses confusing nomenclature to describe conditions in this region of the body. Some terminology may imply inflammation when in fact there may be none. A more uniform approach to classifying these conditions based off anatomic location, symptoms, clinical findings, and histopathology is needed. There has been much debate regarding appropriate use of tendonitis when there is no true inflammation, calling instead for use of the terms tendinosis or tendonopathy. To date, there has not been clear examination of a similar overuse of the term enthesitis in conditions where there is no underlying inflammation, thus raising the need for more comprehensive taxonomy.

Introduction: Cryotherapy is a technique that involves the application of low temperatures in the treatment of acute injuries, with ice being the simplest and oldest therapeutic modality for this. Objective: To compare two different cold water immersion protocols (standard and intermittent) on the ankle region of healthy volunteers, we analyzed changes in static postural stability, threshold, and pain tolerance immediately after application. Method: This is a quasi-experimental study, controlled clinical trial, and non-probabilistic sampling. The total sample consisted of 40 male patients aged 18 to 30 years. Two different cold water immersion protocols (standard and intermittent) were compared for their effects on pain threshold, tolerance, and static postural stability. Results: There were no significant differences between the groups with regards to the stabilometric variables after the application of both protocols (p > 0.05). There was a significant difference in the threshold and tolerance of the two groups after the application of cold water immersion (p < 0.05); however, there were no significant differences between the groups (p > 0.05). Conclusion: Both cold water immersion protocols proved to be safe for static postural balance, without showing deficits in stabilometric variables. Regarding the analgesic effect, both were effective and significantly increased the threshold and tolerance of ankle pain after cryoimmersion, without any differences between groups. Thus, intermittent 10-minute cold water immersion is sufficient to generate the same analgesic effect as the standard 20-minute pattern, with no change in static postural stability. Resumo Introdução: A crioterapia é uma técnica que consiste na aplicação de temperaturas mais baixas, sendo o gelo, a modalidade terapêutica mais simples e antiga no tratamento de lesões agudas. Objetivo: Comparar dois protocolos diferentes de crioimersão (padrão e intermitente) sobre a região do tornozelo de voluntários saudáveis, analisando as alterações na estabilidade postural estática e no limiar e tolerância à dor, imediatamente após a aplicação. Método: Trata-se de um estudo de natureza quasi-experimental, do tipo ensaio clínico controlado, com amostragem não probabilística. A amostra total foi constituída de 40 indivíduos do sexo masculino com idade entre 18 e 30 anos, comparando dois protocolos diferentes de crioimersão (padrão e intermitente) e seus efeitos sobre o limiar e tolerância à dor, e estabilidade postural estática. Resultados: Não houve diferenças significativas em relação as variáveis estabilométricas após a aplicação de ambos os protocolos (p>0,05). Houve diferença significativa no limiar e tolerância dos dois grupos após a aplicação da crioimersão (p0,05). Conclusão: Os dois protocolos de crioimersão se mostraram seguros com relação ao equilíbrio postural estático, sem apresentar déficits nas variáveis estabilométricas. Com relação ao efeito analgésico, ambos foram eficazes, aumentando significativamente o limiar e a tolerância de dor no tornozelo após a crioimersão, sem que houvesse diferenças entre os grupos. Dessa forma, percebe-se que a crioimersão intermitente de 10 minutos é suficiente para gerar o mesmo efeito analgésico que a padrão de 20 minutos, sem alteração na estabilidade postural estática.

Background Injury or compression of a sensory nerve is an under-reported source of disabling pain in the lower limb. It is known that peripheral nerve microsurgeons can reconstruct and rewire injured nerves to relieve chronic pain but this option remains not completely understood and ignored by most orthopaedic surgeons, neurologists, and pain therapists. In this paper, we describe our experience with knee and ankle peripheral nerve surgery to improve the condition of patients suffering from chronic, posttraumatic lower limb pain. Patients and Methods Between 2015 and 2018, a retrospective investigation was performed including patients who underwent ankle and knee nerve surgery for posttraumatic chronic pain with at least 1 year of follow-up. Previous surgeries or type of trauma, pain location and characteristics, type of operation (reconstruction, decompression, or denervation), and number of nerves operated were listed. Selective neuropathy was confirmed by ultrasound-guided nerve blocks. Outcome was assessed combining the visual analogue scale (VAS) score at rest and during movement, functional indexes, drug use, and ability to work. Results A total of 34 patients (14 knee and 20 ankle) were included in this study. A statistically significant difference (p Conclusion Peripheral nerve microsurgery is a useful and minimally invasive tool to be added in the algorithm of treatment of chronic knee and ankle pain. Physicians should be trained to suspect a neuropathic origin of pain in absence of musculoskeletal signs of pathology, especially following trauma or surgeries.

Computerized dynamic posturography (CDP) is an objective technique for the evaluation of postural stability under static and dynamic conditions and perturbation. CDP is based on the inverted pendulum model that traces the interrelationship between the center of pressure and the center of gravity. CDP can be used to analyze the proportions of vision, proprioception, and vestibular sensation to maintain postural stability. The following characters define chronic ankle instability (CAI): persistent ankle pain, swelling, the feeling of "giving way," and self-reported disability. Postural stability and fibular muscle activation level in individuals with CAI decreased due to lateral ankle ligament complex injuries. Few studies have used CDP to explore the postural stability of individuals with CAI. Studies that investigate postural stability and related muscle activation by using synchronized CDP with surface electromyography are lacking. This CDP protocol includes a sensory organization test (SOT), a motor control test (MCT), and an adaption test (ADT), as well as tests that measure unilateral stance (US) and limit of stability (LOS). The surface electromyography system is synchronized with CDP to collect data on lower limb muscle activation during measurement. This protocol presents a novel approach for evaluating the coordination of the visual, somatosensory, and vestibular systems and related muscle activation to maintain postural stability. Moreover, it provides new insights into the neuromuscular control of individuals with CAI when coping with real complex environments.

Traumatic dislocation of the tibialis posterior tendon is one of the significantly rare conditions that we might deal with in the emergency department. Approximately only 50 cases have been reported in the literature, and, usually, this condition is misdiagnosed as an ankle sprain in acute settings. It might be neglected in case of improper clinical examination and imaging techniques. We present a case of a 39-year-old patient diagnosed with traumatic dislocation of the tibialis posterior tendon as a result of twisting injury after falling from a 1-meter jump height while playing basketball; the patient was clinically diagnosed primarily as a case of simple ankle sprain in the emergency department and treated conservatively with cold compression. The patient was seen in the clinic after five days with the same complaint, which was medial ankle pain without any improvement. Proper examination and imaging techniques lead us to the accurate diagnoses. The patient was managed surgically and had an excellent outcome postoperatively with a full range of motion of the ankle joint and full weight-bearing without any complaint. Tibialis posterior dislocation should be one of the possible differential diagnoses while dealing with any ankle injury even with unremarkable X-rays. History and physical examination, if conducted correctly, are the keys to making an accurate diagnosis. Therefore, we recommend a proper history-taking and precise physical examination with a high index of suspicion for any possible diagnoses. Early surgical intervention for such cases is the preferable method of treatment to avoid further complications and promote early functional recovery.

Posterior ankle pain is a common complaint, and the potential causative pathologic processes are diverse. The constellation of these numerous etiologies has been collectively referred to as posterior ankle impingement syndrome. The pain associated with posterior ankle impingement is caused by bony or soft tissue impingement of the posterior ankle while in terminal plantar flexion. This condition is most frequently encountered in athletes who participate in sports that involve forceful, or repetitive, ankle plantar flexion. This article discusses the associated pathology, diagnosis, conservative treatment, and surgical techniques associated with flexor hallucis longus and posterior ankle impingement syndrome.