Primary Care of the Ankle and Foot. Christian T. Royer, MD Baylor University Medical Center Foot and Ankle Surgery

Transcription

1 Primary Care of the Ankle and Foot Christian T. Royer, MD Baylor University Medical Center Foot and Ankle Surgery

2 Outline Plantar Fasciitis Metatarsalgia Morton s Neuroma Ankle Sprains and Sequelae Achilles Tendonitis/Rupture Diabetic Footcare Issues Fractures

3 The fibrous ligament that runs from the heel to the base of the toes. It runs directly underneath the skin and fat. Helps maintain the arch of the foot. Plantar Fascia

4 Plantar Fascial Connection The fascia is one piece of tissue that extends around the heel bone (calcaneus) into the Achilles tendon and calf muscle.

5 Plantar Fasciitis Is inflammation and tearing of the fascial tissue near its insertion into the heel bone. This can cause significant pain and disability

6 Symptoms Heel can be puffy Pain can be sharp, dull, throbbing, burning Pain usually gradual onset in nature Severity can increase over timepain in the heel worst when getting up out of bed. Warms up as day goes on but will worsen standing on feet during the day. Bad when getting up from sitting or driving.

7 Can be pinpoint where the fascia attaches to the calcanues. Most common. Can be extended over the entire plantar fascia. Called DIFFUSE plantar fasciitis. Less Common Pain Location

8 Plantar Fasciitis

9 Cause of Plantar Fasciitis Most common etiology is a tight calf muscle and achilles tendon. Causes microscopic tearing of the fascia as the foot dorsiflexes with the tight calf.

10 Predispostion Women more than men Obesity Job which requires standing or walking on hard surfaces for a long period of time Walking or running for exercise

11 Types of feet Plantar Fasciitis can occur in high arched and flatfeet

12 heel spur syndrome or stone bruise This is NOT a bony problem, it is a soft tissue problem

13 Treatment: First Line Stretching exercises for the calf and fascia Ice to the heel 20 minutes per night Gel heel cushions in all shoes NO BAREFEET on hard surfaces NSAIDS (aleve, advil, motrin)

14 Stretching exercises Must do them 2-4 times/day Must be consistent and persistant

15 Gel heel cushions Over the counter available

16 Do you need custom insoles? Good studies show that most people will get better with stretching excercises alone. Truly custom made insoles can help in recalcitrant cases but most cost in the range of $300-$400 Save for last resort

17 Night Splints Now I m tired and my heel hurts Most people will not wear them after the first night

18 Length of time Takes a long time to get better 6-12 months if not unusual People often get frustrated and quit the exercises that will make them better.

19 Second Line of Treatment Injections of cortisone Very painful but can help, not first line Formal Physical Therapy Helps with range of motion Modalities to decrease pain Massage Ultrasound iontophoresis

20 Third Line of Treatment Boots Casts Crutches to minimize weightbearing

21 Extracorporeal Shockwave Therapy (ESWT) Pulsed ultrasound to restimulate the healing process Approved by the FDA Most insurances WILL NOT cover it, consider it experimental Costs between $ out of pocket Results vary based on study

22 Surgery of the plantar fascia Partial Plantar Fasciotomy Cutting a portion of the plantar fascia to release the tension Results are not very good

23 Plantar Fasciitis Take Home Message Prevent it by keeping calf muscle stretched Good Cushioned shoes NO BAREFEET If you get it, persistance is the key to getting better

24 Metatarsalgia Local pressure overload Uneven metatarsal heads Tight heel cord Toe deformities

25 Lesser toe Deformities Can Cause Metatarsalgia PIP flexion Supple MTP joint MTP subluxation PIP and DIP flexion

26 Metatarsalgia Plantar plate instability Progressive deformity Beginning of a hammer toe? Raised toe Dorsal pain at joint Synovitis Instability test

27 Metatarsalgia Treatment Heel cord stretch Acutely: Post op shoe for four weeks In shoe orthotics Cushioned shoes Correction of toe deformities NO HIGH HEELS

28 Metatarsalgia Operative Treatment Motor / soft tissue driven deformities Operative: Bony realignment Soft tissue realignment Amputation Shorter, simpler recovery No functional difference

29 Neuroma Damaged nerve Between metatarsal heads Burning, stinging pain Distinct area of pain

30 Neuroma vs Metatarsalgia Burning pain Pain in shoes Between metatarsals No toe instability Achy pain Pain barefoot Metatarsal head Toe instability

31 Neuroma Treatment Shoewear In shoe orthotics Steroid injection Transverse ligament release Neuroma excision

32 Ankle Sprains One of the most common injuries in all of sports. Most common in basketball and soccer Multiple types of sprains based on the mechanism of injury. 1) step on someone s foot 2) trip off of curb 3) step in a hole 4) forced bending whenbeing tackled

33 DEFINITION An ankle sprain is: TEARING OF THE LIGAMENTS AROUND THE ANKLE

34 Ankle Ligaments 3 on the outside of the ankle 1 big one on the inside 1 that connects the tibia and fibula (the high ankle sprain

35 Lateral Sprains: Inversion Injury Grading Grade I: mild pain, able to walk. Ice the ankle keep playing after taping/bracing Grade II: Moderate Pain, able to walk gingerly R.I.C.E., walking boot, cruthes for assistance, no playing likely 1-2 weeks Grade III: Intense Pain, unable to bear weight R.I.C.E, boot or cast for 4 weeks, minimal weightbearing for 2 weeks then may advance, almost always need PT to safely regain function and prevent further injury

36 Eversion Injury: The deltoid ligament Often an injury while turning on a planted foot or force from a tackle. Can be graded similar to the Inversion injury Much less common but can be associated with a massionueve injury this is severe and often requires surgery Treatement is often the same as inversion assuming no associated injuries

37 Immobilization Options Boots, casts, stabilization braces

38 Testing Kids Is pain over the bone or ligaments? Beware of Growth plate injuries in kids!! Physical Exam: Careful palpation over the ligaments Anterior Drawer testing test tightness Squeeze Test/External Rotation Test: Syndesmotic Injury (high ankle sprain) Can the patient bear weight?

39 Radiography Xrays: 3 views of the ankle: AP, Lateral, Mortise

40 Stress Radiographs

41 Other Tests MRI a water-gram Very good for looking a ligaments, tendons and subltle injury to the bone CT scan three dimensional Xray These are typically done for: 1) injuries that don t heal in the expected time 2) concern for associated injuries 3) NOT DONE FOR ROUTINE ANKLE SPRAINS

42 Treatment Great Variation: R.I.C.E. Grade I-II: Aircast Stirrup, ASO, Walking Boot, protected weightbearing, Start early ankle ROM, PT if necessary Grade III: Cast Immobilization/Boot, Nonweightbearing period (2-4 weeks) then advance like I-II Primary Repair VERY CONTROVERSIAL Not Typically Accepted Treatment

43 Ankle Stability Exercise program: Balance, strengthening and range of motion work on all the muscles, especially those that keep your foot from turning in out. These aren t typically strengthened in a routine gym workout The peroneal muscles and posterior tibial muscle.

44 Ankle Sprains that don t get better!! What s going on? 1) Chronic Ankle Instability 2) Peroneal Tendon Injuries 3) Cartilage Injury in the Ankle

45 Chronic Ankle Instability Functional Ankle Instability: Recurrent Ankle Sprains Inability to run on uneven surfaces Difficulty jumping or cutting Persistent Lateral Ankle Instability Can occur in up to 20% of patients Neidermann 1981, Brostrom 1966

46 Treatment: Conservative Conservative: Physical Therapy with concentration on strengthening, proprioception 2x/week for 6 weeks Ankle stability bracing Augmentation of activity levels FAILURE: Refer

47 Repaired Lateral Ligaments

48 Peroneal Tendons: Tears and Subluxation Major tendons of lateral ankle Pronators and everters of the foot Lateral compartment of the foot Tendons lie in the sulcus of the fibula but 18-28%f have flattened or convex sulcus

49 Physical Examination Peroneal Compression Test Move foot from plantarflexed inverted to dorsiflexed everted with pain May get triggering or clicking Possible active subluxation of tendons out of the fibular groove

50 Split Brevis

51 Treatment: Conservative ICE (20-30 min/day) NSAIDS PT ASO bracing Potential casting/walking boot to relieve acute inflammation (4-8 weeks)

52 Cartilage Injury of the Ankle Osteochondral Defect/Osteochondritis Dissecans (OCD) 4% of osteochondral lesions in joints Traumatic Fracture vs. idiopathic/traumatic necrosis

53 Continued pain with motion and activity in ankle Unexplained swelling Catching of the ankle Locking Symptoms

54 Treatment If Asymptomatic simply watch it Symptoms: 1) Ankle arthroscopy to clean the joint and remove the fragment with drilling of the talus to induce healing 2) still painful arthroscopy AGAIN! 3) cartilage transplant OATS procedure this is a salvage procedure 4) cartilage harvest and re-tranplant: results not better than simple arthroscopy and debridement

55 Long Term Expectations After OCD Injury Early Arthritis Potentially persistent pain Need for further surgery Use of ankle brace when active permenantly Potentially CAREER ENDING May need to give up impact exercises!! See Amare Stoudamire

56 Syndemotic Assessment Diastasis of the Ankle Mortise on XRAY Increase Medial Clear Space greater than 4mm on mortise view. Must attempt weightbearing radiographs Stress Radiographs or examination under anesthesia may be necessary. (Terrell Owens) Positive Squeeze Test on Examination

57 Treatment: Deltoid Isolated If isolated Injury - cast for 4 weeks nonweightbearing Advance to boot and walking at 4 weeks Physical Therapy at 4 weeks RARELY: need surgical repair if continued instability after conservative treatment

58 Syndesmotic Injury: The High Ankle Sprain Injury to the Tibiofibular Ligaments Hold the ankle together

59 Treatment If no displacement or instability on exam (RARE): may treat non-weightbearing in cast or boot for 4 weeks then protected weightbearing in boot May advance to ankle stability brace around weeks Return to sports after PT at weeks MORE COMMONLY NEEDS SURGERY

60 Syndesmosis Surgery

61 Achillies Tendonitis Inflammation around and in the tendon Overuse injury Pain tends to be worse with increased running Onset usually slow overtime

62 Achilles Tendonitis MRI

63 Achilles Tendinitis Treatment REST, REST, REST Time is very variable from several weeks to several months Ice to the tendon 20 minutes twice a day Course of anti-inflammatories STRETCH THE CALF Immobilize for period of time, Boot x 4-8 weeks Possibly crutches

64 Achilles Tendinitis Treatment Stretching Exercises 2 3 times per day Stretch before every workout to help prevent its reoccurence SURGERY: If conservative treatment doesn t work, debride the tendon of scarred tissue and repair. No running for 3 months.

65 Achilles Rupture I was kicked in the leg, I felt a pop Thickest Strongest tendon in the body See 8 times body weight Can accept up to 7000N of force Poorly vascularized 2 to 6cm above insertion Absence of true synovial sheath, paratenon is prone to inflammatory changes Most ruptures occur without prodromal symptoms

66 Achilles Rupture II Average age years old Most are men in third to fifth decade of life participating in recreational activities

67 Achilles: Treatment Surgical: Benefit: decreased rerupture rate, 0-5%, increased strength Risks: soft tissue complications Nonsurgical: Benefit: no surgical risks Risk: Higher rerupture rate, above 10% in most studies, loss of power and strength

68 Outpatient Surgery Suture end to end Problems with wound healing can be higher in this area Splint in equinus post-op Operative

69 Rehabilitation Much variation, WB vs. Nonweightbearing Week 1-2: - post op splint NWB Week 3-6: post op equinus cast Week 6: WB in boot, start PT Week 8-12 advance out of boot Goal single leg toe raise by 12 weeks

70 Diabetes and Feet A Disaster Waiting to Happen

71 Diabetes Prevention is the key to foot preservation Constant education of patient necessary Diabetic neuropathy major complication unable to detect bone stress Diabetic vasculopathy major issue in treatment No blood flow no healing

72 Diabetic Foot: Risk Factors Neuropathy Foot deformity Vasculopathy Amputation to viable level Ulceration Infection Amputation

73 Patient Evaluation Sensation: Semme - Weinstein Monofilament Vascular Status: pressure > 40 mm Hg locally

74 Patient Evaluation Body Chemistry Total albumin > 3.5 Total Lymphocyte > 1500 Alpha-hydroxyhemeglobin < 8.5% Mechanical Integrity Skin condition Joint Mobility Weight bearing foot position

75 Preventative Care Patient Education Nail and Skin care Shoe Selection

76 Preventative Care Sensation intact: Yearly followup and normal shoewear Sensation absent: Biannual followup and soft insoles Deformity present: Quarterly followup and custom shoes Ulcerative history: Followup every 2 months and custom shoes

77 Charcot: Treatment Total Contact cast during active phase Change 1-3 weeks Initial non weight bearing Continue till coalesence Attempt to minimize deformity Surgical considerations Acute injury Ligamentous injury Complications from deformity instability ulcer

78 Total Contact Cast Carefully constructed short leg cast Thin layer padding First layer of fiberglass molded to contours of foot Ankle in neutral Bulk up mold to withstand patient abuse Must cover or enclose toes

79 Charcot: Treatment Phase III Assess foot stability Extra depth wide-toed shoes Accommodative inserts Closely moniter skin for changes Callous erythema

80 SUPPORTIVE INSERTS Soft to semirigid Used for supple feet to support normal contours Decrease impact loads

81 SUPPORTIVE INSERTS Posts - Wedges medial/lateral hindfoot /forefoot

82 SMAFO RESTRICTIVE

83 AFO RESTRICTIVE

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85 Charcot Foot Bony destruction Repetitive injury Warm, swollen foot Bony destruction Intact soft tissue

86 Infection vs Charcot Draining sinus No Glucose control Edema stays with elevation High C-reactive protein Indium scan and 3 phase bone scan positive MRI for abscess Skin Intact Glocose controlled Edema down with elevation Nml C-reactive protein

87 Infection vs Charcot Surgical Debridement Prolonged casting Amputation Limited activity Accommodative shoewear Surgical reconstruction Accommodative shoewear

88 Summary Many common problems can be managed without surgery Careful examination is required to NOT miss serious injuries Constant vigilance need for diabetic feet

89 TRAUMA Toe Fractures Metatarsal Fractures Lisfranc Fractures

90 Foot Trauma Get weight bearing radiographs!! Accentuates bony and ligamentous instability Important factor in deciding treatment Decreases cost reshoot weight bearing films for accurate diagnosis.

91 Toe Fractures Usually isolated Usually stable Pain with weight Treatment Correct deformity Buddy tape Hard sole shoe Up to 3 months recovery

92 Toe Fractures The exceptions

93 Metatarsal Fractures Acute Trauma Repetitive Trauma Dorsal pain with weight Point tender Initial Radiograph may be normal

94 Metatarsal Fracture Treatment Hard sole shoe Analgesics Weightbearing as tolerated 8-12 weeks recovery Achilles stretch if stress induced

95 Metatarsal Fractures Operative Care First Metatarsal Multiple Metatarsals

96 Lisfranc Fracture-Dislocations Tearing of the Major Midfoot Ligament May be associated with fractures of the foot Can be chronically painful in varying degree despite surgery Best results correlate with best reduction (& least joint damage) Occult, milder versions in athletes Lisfranc ligament Medial cuneiform to base of 2 nd metatarsal

97 Lisfranc Anatomy Tarsometatarsal joint line Recessed 2nd metatarsal 2nd metatarsal aligns with middle cuneiform 4th metatarsal aligns with cuboid Stability depends on integrity of ligaments

98 Mechanism - Low Energy Sports Injuries Fall from ground height Typically: Twisting and axial loading of fixed plantarflexed foot (FOOTBALL) Forced plantarflexion of a fixed forefoot

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100 Can get CT or MRI MR better for subtle ligamentous injury

101 Lisfranc Fracture Treatment ORIF is standard of care, except for completely non-displaced VERY RARE Screws or pins under skin x 4 months Typically non-weightbearing for 10 weeks then progress. PT for 6 weeks Remove screws at four months Return to sports at five to six months

102 Lisfranc Outcomes Outcome correlates with anantomic reduction!! Ligamentous injury does more poorly than bony injury generally. Sangeorzan, 2000 Development of midfoot DJD Persistent pain Persistent swelling Shoe modification with orthotics Activity/Work modification Can be CAREER THREATENING

103 Thank You