KEYWORDS: ..Common cause of Ankle pain i. Ankle sprain(85%) (usually, inversion injury) ii. Fracture(<5%), including stress fractures : tibia, fibula, talus, calcaneus, fifth metatarsal iii. Peroneal tendonitis/subluxation/ dislocation iv. Arthritides : rheumatoid, degenerative joint disease, gout, pseudogout, ankylosing spondylitis, Reiter's syndrome, psoriatic v. Anterior/posterior impingement vi. Complex regional pain syndrome vii. Osteochondritis dissecans ▶ Ligaments of the ankle 1. Description of pain : - acute onset pain with no trauma? → stress fracture - Early morning stiffness? → arthritis - Pain with extreme dorsi-/ plantar flexion? → anterior/posterior impingement - Pain out of proportion to injury? Ankle pain Key questions Tibia Anterior talo-fibular Calcaneus Calcaneo-fibular ligament Fibula Posterior talo-fibular ligament - Vasomotor disturbances +/- edema? → complex regional pain synd. 2. Injury mechanism if injured 3. Previous foot or ankle injury? 4. Occupational or athletic history 5. Mechanical symptoms : popping or snapping? (peroneal tendon dysfunction) : locking or instability of ankle? (osteochondritis dissecans) 1. Anterior drawer test 2. Talar tilt test 3. Ankle AP/lat/oblique view if fracture suspected 4. CT/MRI : >80% sensitive and specific in detecting soft tissue damage 5. Bone scan for suspected stress fracture ..의사가 환자의 발을 잡고, 수동 족저굴곡(plantarflexion), 내번(inversion)을 할 때 외측부 통증이 증가하면 inversion injury (anterior talofibular ligament)의 손 상을 강력히 시사한다. ..Instability 정도가 손상 정도를 가장 잘 시사하며, 부종이나 통증이 심하다고 반드시 손상이 심각한 건 아니며 손상된 한 발로 체중부하를 하지 못할 때 심각한 손상을 고려해야 한다. 209 The Root of ambulatory care Key tests ▶ Drawing the calcaneus and talus anteriorly while stabilizing the tibia, 3~14mm indicates grade 2 sprain ; > 15mm indicates grade 3 sprain ▶ Stressing the ankle laterally (inversion) and medially (eversion) while stabilizing the patient’s leg, 5~10degree difference between ankles indicates grade 2 sprain ; > 10degree difference indicates grade 3 sprain .. → Key treatments Key treatment of Ankle sprain Ankle pain RICED 1. Rest from pain-producing activities 2. Ice for 20minutes several times a day while area is swollen 3. Compression with padding and a wrap 4. Elevation above level of heart to reduce edema 5. Drug : NSAIDs (e.g., Ibuprofen 400~800mg tid-qid & Acetaminophen 650mg every 4~6hours until edema and pain subside) Physical therapy(PT) aimed at improving motion, strength, flexibility and proprioception 분류 통증 전방전위검사 instability End point Grade 1 (+) (-) (+) 1~2주 정도 단순 압박붕대 혹은 테이핑 고정 Grade 2 (+) (+) (+) 3~4주 정도 functional splint Grade 3 (+/-) (+) (-) 4~6주 정도 석고 고정 Red flags signs-referral decisions (ankle sprain) - fractures of the foot and ankle - tears or subluxation of the peroneal tendons - nerve injury - a history of repeated giving way (chronic instability) - failure to improve in 6 weeks with apporopriate treatment 211 The Root of ambulatory care Medication Relative potency Onset Duration Hydrocortisone 1 Fast Short Prednisolone terbutate 4 Fast Intermediate Methylprednisolone acetate 4 Slow Intermediate Triamcinolone acetonide 5 Moderate Intermediate Triamcinolone hexacetonide 5 Moderate Intermediate Betamethasone 25 Fast Long Dose Anatomic site 5 to 10mg Phalangeal joints 20 to 30mg Wrist 20 to 30mg Elbow and ankle 40 to 80mg Shoulder, hip, or knee 참고 문헌 James R. Barrett : Ankle and Foot pain, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 988-991 이홍수 : 발목염좌, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1543-1548 양윤준 : 발목, 발 통증, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1182-1189 Walter B. Greene, M.D.(ed) : Ankle Sprain,in Essentials of Musculoskeletal Care. R osemont, American Academy of Orthopaedic Surgeons, 2001, P 422-424 Richard B. Birrer, M.D. : Ankle Injuries, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D.(ed). United States of America, The McGrwa-Hill Companies, Inc., 2005, P 24-30