Outline. The Agony of the Foot: Disclosure. Plantar Fasciitis. Top 5 Foot and Ankle Problems in Primary Care. Daniel Thuillier, M.D.

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1 The Agony of the Foot: Top 5 Foot and Ankle Problems in Primary Care Daniel Thuillier, M.D. Assistant Professor of Clinical Orthopaedics University of California San Francisco Plantar Fasciitis Achilles Tendonitis Achilles Ruptures Ankle Sprains Lis Franc Bunions Outline Disclosure I have nothing to disclose Plantar Fasciitis Population/Incidence Men and Women of all ages -10% of Americans have some form of heel pain -1 Million medical visits Annually Plantar Medial heel pain Often worse in morning Worse with Activity 1

2 Achilles Tendonitis/Tendinopathy Pathophysiology Inflammation of the plantar fascial insertion at the medial plantar aspect of the calcaneus Physical Examination/Studies +TTP at the plantar medial aspect of the calcaneus Achilles/Gastrocnemius tightness May or may not have plantar calcaneal bone spur on xrays Incidence Men and women of all ages 24%-50% of lifetime runners Pain In Achilles Tendon with Activity Almost always Conservative May Take Many months to Resolve Achilles/Gastroc/Plantar fascial stretching Heel Cups OTC Arch Supports Night Splints CAM walker/casting *Injections- do have increased rupture rate* Pathophysiology Chronic Overuse Injury Occurs in 2 places Insertion Mid-Substance Exam/Imaging +TTP in the achilles Swelling of achilles in midsubstance or insertion Pump Bump posterior calcaneal bone spur 2

3 Almost Always Conservative Ice, Rest, NSAIDS Heel Lift Dedicated Eccentric Stretching program Period of Immobilization (CAM walker, Cast) NO STEROID INJECTIONS Surgery Reserved for Failed Conservative Management Achilles Tendon is the biggest tendon in the body and subjected to the highest loads Has a 90 degree twist Inserts broadly over the posterior calcaneus Watershed area 4-6 cm proximal to the insertion Anatomy Incidence Men 30s/40s Athletes and weekend warriors 7/100,00 population ~10% prior achilles symptoms Relatively painless!!! kicked in heel Walk funny, limp, weak Achilles Rupture Clinical Examination Palpable Defect Decreased plantarflexion strength Decreased resting tone + Thompson s Test (Calf Squeeze and no Plantarflexion) 3

4 Surgery vs No Surgery Clinical Examination was more sensitive than MRI in detecting acute rupture Surgery Pros Get tension to proper degree Likely Lower rerupture rate Feel like you did something It s what Kobe got Cons Cost Higher complication rate Especially wound problems Non Op Pros Less complications No Cons Higher Rerupture Rate Tension may not be restored as well Initial Plantarflexion in Splint (20-30 degrees) Alternatively, plantarflexion in CAM walker with heel lifts (2). 12 month follow up Similar functional results Similar re-rupture rate 4

5 Men and Women of all ages ~600,000 Ankle Sprains per year in the US 3-5% of all ED visits (UK) Pain in Ankle Swelling Difficulty with Weight bearing Ankle Sprains Ankle Sprains 95% of ankle sprains are asymptomatic at 1 year no matter how they are treated Slightly better functional results with early rehabilitation Surgical Repair reserved for those with prolonged (>6 months) of symptoms of instability Ankle Sprains Sprain vs Fracture? Pathophysiology ATFL is the most common ligament injured Resists Anterior translation of the talus CFL may be injured as well Resists talar tilt Grading Sprain 1-3 how much is torn Sprain Acute twisting Injury Pain swelling at ankle Bruising Difficulty with Weight bearing Fracture Acute twisting Injury Pain Swelling at ankle Bruising Difficulty with weight bearing Mortise is maintained no matter what the grade The only real way to tell is with imaging 5

6 High Ankle Sprain - Syndesmosis History Pain out of proportion to injury Prolonged Recovery Pain posterior to fibula Pain up leg towards knee Difficulty with one leg hop Pain with dorsiflexion of ankle Lis Franc Fracture/Dislocation Maybe direct or indirect, contact/no contact Axial Load to plantarflexed foot Lis Franc Fracture/dislocation Assessment Anatomy Lis Franc Joint runs between the tarsal and metatarsal bones Both Dorsal and plantar ligaments Plantar ligaments are stronger Strongest in between medial cuneiform and base of second metatarsal Same in Adults and Kids History Painful walking Pain in midfoot Physical Examination Midfoot Swelling Midfoot Pain Dorsal or plantar Ecchymosis MUST GET Appropriate IMAGING IF THESE ARE PRESENT 6

7 Bunion (Hallux Valgus) Population/Incidence 24% >60 yo Women 2-4X men Strong family History Pain in great toe, especially with shoewear Deformity of first toe Erythema, Swelling Conservative Shoewear Modification Orthotics Bunion Sleeves Bunion Pads Gastroc Stretching Surgical Usually reserved for those who fail conservative treatment >100 different surgical procedures described Results vary - ~70-85% improvement Pathoanatomy Thank You Complex Deformity Lateral Deviation First Toe, with Medial Deviation of Phalanx 7

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