Joba Chamberlain, pitcher for the New York Yankees, suffered from a serious open ankle dislocation on Thursday and underwent surgery for the injury.  After recovering from Tommy John last June, this will be another big setback for this young pitcher.    

ANATOMY

The ankle is made up of three bones: the fibula (on the outer part of the ankle), the tibia (on the inner part of the ankle), and the talus (on the central part of the ankle).  Between the tibia and fibula, at the level of the ankle joint, is a ligament which holds these one together, called the syndesmosis.  

In an ankle dislocation, the talus comes out of the “socket”.  When coming out of the joint, the skin may or may not rip open.  If the skin opens, this is known as an open dislocation.  If the skin does not rip open, then it is known as a closed dislocation. 

When the ankle dislocates, any of the bony structures can fracture/break or the tendons around the ankle tear.  Finally, the ankle joint or the subtalar joint (the joint beneath the ankle that allows the foot to move in and out) can be damaged.

CAUSES

An ankle dislocation can occur whenever the ankle is twisted to its maximum point.  Rarely, can this happen with bad ankle sprains.  More often, the athlete turns or twists the ankle with a fall, motor vehicle accident, or jumping activity.

SYMPTOMS

Individuals who dislocate the ankle will have pain, swelling, loss of motion, and bruising.  A lump or bump will be seen around the ankle.  If the skin breaks open, the ankle bone may be seen.   

WHEN TO SEEK MEDICAL CARE

If you suspect that you are suffering from a dislocated ankle, you should seek medical attention immediately.  A physical exam and x-rays are usually performed. A CT or MRI scan at times may be needed.  The ankle will need to be placed back into the alignment. 

TREATMENT

Ankle dislocations that are closed can often times be put back in place, or reduced, without surgery.  If there is no associated break of a bone or tendon injury, the leg is kept in a cast for a few weeks to allow the soft tissue to scar in and stabilize.  Then a lot of physical therapy is needed to work on the range of motion and strength.

If an ankle fracture is open, the athlete must go to the operating room so that the wound can be washed out.  The joint is put back in place and any broken bones, if present are fixed.  Depending on how large the skin laceration is, infection is a serious and real risk.  Again, the leg is kept in a cast for a few weeks to allow the soft tissue to scar in and stabilize.  Any bones that may be broken will take 6-8 weeks to heal before the athlete can walk on the leg.  Once the cast is off, a lot of physical therapy is needed to work on the range of motion and strength.

OUTCOMES

Ankle dislocations can be career ending for an athlete, especially if there are associated injuries.  Pain, loss of motion, and loss of strength can be long term issues that do not allow the athlete to return to competitive sports.   

RETURN TO ACTIVITIES

From the current reports, it is unclear if Chamberlain has any associated injuries.  This is a serious injury.  If Chamberlain is able to return to the pitching mound, it will be late in the season this year. 

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.d

Patriot's tight end, Rob Gronkowski, suffered from a high ankle sprain.  How effective will he be in the Super Bowl?  

Ankle sprains are very common injuries.  In the US alone, approximately 25,000 ankle sprains occur every day.  Not all of these individuals seek medical care.  Most walk it off and resume life with little or no consequences.  The question is when should you be concerned that you have a serious ankle sprain or something worse and see a doctor.   I will get to this question later in the blog.

ANATOMY

Most people sprain their ankle with an inversion type injury.  This is where the foot rolls in and the ankle rolls out.  This stretches and may tear the ligaments on the outer part of the ankle.  Outer ligaments of the ankle are always injured in the common ankle sprain.

However, in severe cases, the ligaments on the inner part of the ankle (medial ankle sprain) or between the ankle bones (high ankle sprain) can be injured.  The medial sprain will be a topic for future blogs.

A high ankle sprain occurs when the ankle rolls out to the point where the ligaments between the fibula (outer leg bone) and the tibia (inner leg bone) tear.  This ligament structure is known as the syndesmosis.   This can be a stable or unstable injury.  If the ligament is stretched or strained, the ankle is usually stable and does not require surgery.  If the ligament is fully torn, the ankle is unstable.  This injury pattern requires surgery.

Below is an xray of an individual with an unstable syndesmosis tear.

SYMPTOMS

When an individual has a high ankle sprain, walking and jumping on the injured ankle is difficult.  One may experience pain, swelling, bruising, weakness and even a black and blue mark.  Usually people have some level of pain with motion of the ankle.  Rest, ice, elevation, an ace wrap and antiinflammatories can help relieve some of these symptoms.  But if you suspect a high ankle sprain, you should see a physician sooner than later.

TREATMENTS

Initially, after a high ankle sprain, rest, ice, elevation, an ace wrap and antiinflammatories can help relieve some of these symptoms.  If xrays suggest a stable high ankle sprain, the patient is placed in a boot or short leg cast.  The individual is nonweightbearing (not allowed to placed any weight on the injured ankle) for 4 to 6 weeks.

If the syndesmosis is torn, surgery is needed.  In the operation, the tibia and fibula are put back in their proper position and held in place with screws or a device called a tightrope (see xrays).  These patients are not allowed to put weight on the ankle for 3 months.  

In either injury pattern, physical therapy is necessary to help regain range of motion and strength of the ankle.  Physical therapy has been shown in the medical literature to be very beneficial in preventing what is known as “chronic ankle pain”.  Some physicians may want you to use an ankle brace for a short period of time, while others may not want you to use one at all.  Rarely is surgery needed.

OUTCOMES

Most individuals with high ankle sprains are able to return to their lifestyles and activities after 6 to 8 weeks and a lot of therapy.  Being the Super Bowl, Gronkowski will play.  The question is how effective will be.  Just as Ben Roethlisberger's level of play decreased with this injury, it is likely that Gronkowski's will suffer as well.  Cutting, pushing off defenders, and blocking will all be problematic for him.  

VIDEO/ANIMATIONS

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.

New Jersey Nets Center, Brook Lopez has a Jones fracture.  When will he return to this already shortened season?

ANATOMY

The metatarsal are a series of bones in the foot that lead to the toes.  There are five metatarsal in each foot, correlating to the five toes.  The fifth metatarsal interacts with the fifth or pinky toe.  This bone is particularly important, as breaks at the base of this bone can be difficult to heal. 

To understand breaks of the fifth metatarsal, one needs to know the type of break present.  The breaks at the base of the fifth metatarsal are divided into three types:

Type 1 – an avulsion break off the base of the fifth metatarsal. This break usually heals with little problem. 

Type 2 (also known as a Jones Fracture) – a break of the base of the 5^th metatarsal that goes into the area where the 4^th and 5^th metatarsal interact with one another.  This fracture is difficult to treat, as the blood supply to this area of the 5^th metatarsal is poor. 

Type 3 (also known as a Dancer’s fracture) – a break of the long shaft of the 5^th metatarsal.

CAUSES

Fractures of the base of the 5^th metatarsal occur when the ankle is twisted in inversion, or the ankle rolls outward.  Extra pressure is placed on the base of the 5^th metatarsal, causing it to break.

SYMPTOMS

A person who breaks their 5^th metatarsal may have pain at the base of the bone, with swelling pain, and possible difficulty with walking.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have a 5^th metatarsal fracture, you should see an orthopaedic surgeon.  They will require a thorough physical exam and x-rays will be needed to determine where the break is located.

TREATMENT

Treatment varies depending on the location of the 5^th metatarsal fracture and the type of break present.

Type 1 – an avulsion break off the base of the fifth metatarsal. This break usually heals with little problem. It usually requires a boot and walking cast for 4 weeks.

Type 2 (also known as a Jones Fracture) – a break of the base of the 5^th metatarsal that goes into the area where the 4^th and 5^th metatarsal interact with one another.  This fracture is difficult to treat, as the blood supply to this area of the 5^th metatarsal is poor.  The break can be treated with a cast or surgery. For those patients who decide to have a cast, they may be non-weight bearing on the injured leg for 12 or more weeks.  There is approximately a 20% non healing rate of this fracture, when treated without surgery.  With surgery, the patient is usually allowed to wear protective boots or insoles and walk 4 weeks following surgery.  In surgery, a screw or plate with screws can be used to span the break and hold the pieces together.

Type 3 (also known as a Dancer’s fracture) – a break of the long shaft of the 5^th metatarsal, This break can be treated in a non-weight bearing cast for approximately 6-8 weeks.  It requires surgery if it has moved out of place, or is not positioned correctly.

OUTCOMES

Most patients with 5^th metatarsal fractures are able to return to play.  For type 1 and 3 breaks, return to competitive sports may take 3-4 months.  For type 2 breaks, return to competitive play occurs 6-8 weeks after the surgery.

RETURN TO ACTIVITIES

Depending on the type of fracture Lopez has sustained, he should be back to football in 6-8 weeks.

VIDEO/ANIMATIONS

A live surgical video can be seen at: http://www.youtube.com/NCOCatDuke

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Cowboys DeMarco Murray was hurt in tonights game against the Giants.  He has an ankle fracture and a high ankle sprain.  He was immediately taken out of the game.  What does this mean for his season?   

ANATOMY

The ankle is made up of three bones: the fibula (on the outer part of the ankle), the tibia (on the inner part of the ankle), and the talus (on the central part of the ankle).  Between the tibia and fibula, at the level of the ankle joint, is a ligament which holds these one together, called the syndesmosis.  

Any of these structures can be injured in an ankle fracture/break.  Typically, the fibula is fractured.  At the same time, the tibia can be broken and/or the syndesmosis can be torn. 

CAUSES

The ankle can break with any type of trauma that causes excessive energy to go through the ankle.  The energy can break 1, 2, or more bones.  Typically, the ankle breaks with a twisting mechanism, when the ankle "rolls", or if one trips and falls.  Occasionally, a direct blow to the ankle or the heel can break the ankle.

SYMPTOMS

A person who breaks their ankle usually experiences immediate pain and swelling.  A pop or crack may be heard or felt.  The ankle will get black and blue.  Often times, the person will not be able to walk on the broken ankle.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have an ankle fracture, you should seek medical attention within hours of the injury. A thorough physical exam and xrays will be needed to find out if you have an ankle fracture and the type of fracture you may have.

TREATMENT

Treatment varies depending on the severity of the ankle fracture.  If the fibula has broken, but has not shifted, a non-weight bearing cast may be worn for 8-10 weeks.  If the fibula is fractured and shifted out of place or the tibia is fractured or the syndesmosis is torn, then surgery may be necessary.  In the operating room, an orthopaedic surgeon will usually place a plate and screws in the fibula, screws or a plate in the medial malleolus part of the tibia, and/or screws or a similar device across the syndesmosis.  This allows for the broken bones and ligament to be held in place while the bones and/or ligament heals.  If the syndesmosis is torn, the patient is not allowed to put weight on the foot and ankle for 3 months.  If the syndesmosis is not torn, then the patient is not allowed to put weight on the foot and ankle for approximately 6-10 weeks.  

Below are representations of a type of ankle fracture where the fibula and the syndesmosis were torn and needed to be repaired.

OUTCOMES

Most patients with ankle fractures are able to return to their pre-injury activities with little or no difficulties.  However, there are some long-term implications of this injury.  First, about 30% of the time a "pot-hole" can develop in the ankle at the time of the injury.  This can lead to long-term pain.  Second, the cartilage is damaged at the time of injury.  This causes the development of post-traumatic arthritis in the ankle at a faster rate than an ankle that has never been broken.  Third, many patients will have stiffness and loss of motion following the injury.  Finally, extensive physical therapy is required to regain as much motion and strength in the ankle.

RETURN TO ACTIVITIES

Depending on the type of ankle fracture that Murray has, he will be out of football for at least 8 weeks.  If his syndesmosis is also torn, he will be out for 12 weeks.

VIDEO/ANIMATIONS

Dr. P

 ----------------------------------------------------------------------------------------------All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Sunday, during the win over the Tampa Bay Buccaneers, the Houston Texan quarterback, Matt Schaub, injured his foot.  Today it was discovered that he sustained a Lisfranc injury.  What is the Lisfranc injury and why will Schaub be out for the entire remaining season?

Prince Amukamara, rookie cornerback of the New York Giants, broke his left foot on Saturday.  The bone that he fractured is the fifth metatarsals.  Reports state that he will require surgery.  Will it be possible for him to be back this season?

ANATOMY

The metatarsal are a series of bones in the foot that lead to the toes.  There are five metatarsal in each foot, correlating to the five toes.  The fifth metatarsal interacts with the fifth or pinky toe.  This bone is particularly important, as breaks at the base of this bone can be difficult to heal. 

To understand breaks of the fifth metatarsal, one needs to know the type of break present.  The breaks at the base of the fifth metatarsal are divided into three types:

Type 1 – an avulsion break off the base of the fifth metatarsal. This break usually heals with little problem. 

Type 2 (also known as a Jones Fracture) – a break of the base of the 5^th metatarsal that goes into the area where the 4^th and 5^th metatarsal interact with one another.  This fracture is difficult to treat, as the blood supply to this area of the 5^th metatarsal is poor. 

Type 3 (also known as a Dancer’s fracture) – a break of the long shaft of the 5^th metatarsal.

CAUSES

Fractures of the base of the 5^th metatarsal occur when the ankle is twisted in inversion, or the ankle rolls outward.  Extra pressure is placed on the base of the 5^th metatarsal, causing it to break.

SYMPTOMS

A person who breaks their 5^th metatarsal may have pain at the base of the bone, with swelling pain, and possible difficulty with walking.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have a 5^th metatarsal fracture, you should see an orthopaedic surgeon.  They will require a thorough physical exam and x-rays will be needed to determine where the break is located.

TREATMENT

Treatment varies depending on the location of the 5^th metatarsal fracture and the type of break present.

Type 1 – an avulsion break off the base of the fifth metatarsal. This break usually heals with little problem. It usually requires a boot and walking cast for 4 weeks.

Type 2 (also known as a Jones Fracture) – a break of the base of the 5^th metatarsal that goes into the area where the 4^th and 5^th metatarsal interact with one another.  This fracture is difficult to treat, as the blood supply to this area of the 5^th metatarsal is poor.  The break can be treated with a cast or surgery. For those patients who decide to have a cast, they may be non-weight bearing on the injured leg for 12 or more weeks.  There is approximately a 20% non healing rate of this fracture, when treated without surgery.  With surgery, the patient is usually allowed to wear protective boots or insoles and walk 4 weeks following surgery.  In surgery, a screw or plate with screws can be used to span the break and hold the pieces together.

Type 3 (also known as a Dancer’s fracture) – a break of the long shaft of the 5^th metatarsal, This break can be treated in a non-weight bearing cast for approximately 6-8 weeks.  It requires surgery if it has moved out of place, or is not positioned correctly.

OUTCOMES

Most patients 5^th metatarsal fractures are able to return to play.  For type 1 and 3 breaks, return to competitive sports may take 3-4 months.  For type 2 breaks, return to competitive play occurs 6-8 weeks after the surgery.

RETURN TO ACTIVITIES

Depending on the type of femur fracture Price has sustained, he should be back to football in 2-3 months.

VIDEO/ANIMATIONS

A live surgical video can be seen at: http://www.youtube.com/NCOCatDuke

Animated video can be seen below:

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Tony Parker, guard of the San Antonio Spurs, suffered from a calf strain on his left leg against Memphis.  What is a calf strain?

ANATOMY

The calf muscle, also known as the gastrocsoleus complex (GSC), runs from the top of the knee to the back of the heel bone.  It begins as two muscles bellies (the gastrocnemius muscle and the soleus muscle) and then merges to become one tendon – the Achilles tendon.  The Achilles tendon is the largest tendon in the human body.

The GSC is in charge of pointing the ankle towards the floor (plantarflexion), as you would do when pushing on a gas pedal.  The complex also functions to give you push off strength.

CAUSES

The GSC complex can be injured with direct trauma, sudden changes in direction when running, or pushing up on a plantarflexed ankle.

SYMPTOMS

There are different grades of muscle strains:

Grade I – the tearing is microscopic with stretching of the fibers.  Bleeding occurs in the muscle. These injuries associated with a twinge of pain.  Athletes may be able to return to play, but the soreness last for 3-5 days.

Grade II – the tearing is more severe. More bleeding occurs in the muscle.  There is a sharper pain in the back portion of the leg.  There is usually pain with walking and with plantarflexion. The soreness and tightness last for 7-10 days.

Grade III – this is a complete tear of the muscle.  There is sudden, intense pain in the calf.    The athlete is unable to plantarflex the ankle.  The entire muscle or tendon may be torn.  Athletes can be out of competitive play for 3-6 weeks.

TREATMENTS

Treatment is based on the severity of the injury.  Rest, ice, compression, and elevation (RICE) begin immediately.  Cold/ice therapy is applied first to minimize the bleeding and swelling in the calf.  Anti-inflammatories can help with the pain and inflammation.  A compression sleeve, sock, or stocking can help with the swelling. Physical therapy, with massage, ultrasound, stretching and strengthening exercises is essential.  Surgery is rarely needed, unless the tendon has torn.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have symptoms concerning for a calf strain, you should seek medical attention within a few days.

RETURN TO ACTIVITIES/OUTCOMES

The timing for a return to play depends on the severity of the strain:

Grade I – Athletes may be able to return to play, but the soreness last for 3-5 days.

Grade II – The soreness and tightness last for 7-10 days.

Grade III –  Athletes can be out of competitive play for 3-6 weeks.

VIDEO/ANIMATION

To watch a surgical video of Achilles tendon repairs, go to:http://www.youtube.com/NCOCatDuke#p/u/5/rD3aI_7EneA

Based on reports on his injury, Parker will likely be back to action within 4 weeks.

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics.

Reports are that Serena Williams  injured her right foot at a restaurant, sustaining a cut to the top her foot. She will need surgery and will miss the next few tournaments.
  ANATOMY




A cut to the top of the foot, particularly at the junction of the foot and ankle, can be very concerning.  In this area, vital structures can be damaged, including: nerves, blood vessels, tendons, ligaments, and muscles.  An injury two tendons, the anterior tibial tendon and the extensor hallucis longus, or an injury to the artery, are particularly worrisome.  The anterior tibial tendon (ATT) runs from the front, inner part of the shin to the foot. It helps the foot to move up and in (a motion known as inversion).  The extensor hallucis longus (EHL) runs from the front of the shin bone to the big toe. It helps to move the big toe up.  The artery on the top of the foot is one of two major arteries that provides blood supply to the foot.  Injury to this structure is bloody, but no devastating.

CAUSES

A cut to the top of the foot is usually due to a sharp piece of glass, metal, or plastic falling on the foot.  Depending on the size, weight, and depth of the injury. any of the structures on the top of the foot can be injured. 
SYMPTOMS

All cuts will lead to some amount of pain, swelling, and bleeding.  One may notice a loss of the ability to raise the lesser or big toes to the ceiling or the inability to move the ankle upwards.  This is concerning for a tear or laceration of a tendon.

WHEN TO SEEK MEDICAL CARE

If you think you may have cut a tendon, ligament, nerve, or blood vessel, you should seek medical attention within a few hours to days.

TREATMENT

The treatment for a cut on the top of the foot depends on the depth of the cut and other structures involved with the cut.  If the cut has not gone deep enough to injure any other structures, an athlete is usually kept out of play for a week or so with local wound care.  If deeper, an a tendon such as the EHL or ATT is cut, then conservative care or surgery may be needed.

Conservative care would include a non-weight bearing cast for 6 weeks, where the toes or ankle is casted in an upward position.  This will allow the two ends of the torn tendon to be close enough together to heal.

In the competitive athlete or someone who has pain or loss of function even after a cast, surgery is needed.  The surgery involves the repair of the torn tendon.  The ends of the tendon are found and sewn end-to-end.  The patient is usually made non-weight bearing in a cast for 8 weeks. Intensive physical therapy is then needed.

OUTCOMES AND RETURN TO ACTIVITIES

If the cut is superficial, the wound will heal with little long-term issues.  These players are back to competitive sports within 1-2 weeks.  If a tendon is torn, the athlete is not allowed to return to play for 8 to 12 weeks.  Physical therapy is needed to rehabilitate the tendon and restore range of motion and strength to the tendon.


In the next few days, we will learn more about Serena's surgery, the injury, and when she will be returning to tennis.  Early reports suggest that she will be ready to play in the US Open on August 30, 2010.

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.