Breaking Down The Barriers to Orthopedic Foot & Ankle

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1 Breaking Down The Barriers to Orthopedic Foot & Ankle Common Conditions Treatable without a Referral Premjit Pete Deol, DO Orthopedic Foot & Ankle/ Trauma Panorama Orthopedics & Spine Center Golden, Colorado Disclosures No related disclosures Learning Objectives Treatment common foot & ankle disorders Comfortable in-office procedures When to refer to orthopedic specialist 1

2 Our Focus 1. Chronic Ankle Instability 2. The Calf & Related Pathology Achilles tendinitis Plantar Fasciitis Plantar Forefoot Pain 3. Atraumatic Ankle & Foot Pain The BAD Ankle Sprain Worse Than Average Pain Lateral >> Medial Worse with activity Inability to ambulate Prolonged recovery Never got all the way better ATFL >> CFL 2

3 Anterior Drawer Test (Ankle) Does Everyone Need An X-ray? Ottawa Rules Bony tenderness Inability to WB Unusual presentation Poor historian Stress x-rays useful Beware the High Ankle High ankle ligament (Syndesmosis) Greater than average swelling Tenderness above ankle joint Pain with stress Squeeze Test External Rotation Test 3

4 Avoid Early MRI Clinical diagnosis Rule out fracture Failure conservative measures 6-8 weeks post-injury Assess Talar OCDs and peroneal tears Treatment Goals (1) Joint Stability & Early Mobilization Prevent joint translating Boot vs. Bracing Sagittal ROM WB based upon pain 2-8 weeks Prado MP, et al. FAI 2014; 35 (3) Terada M, et al. J Athl Train 2013; 48 (5) Treatment Goals (2) Functional Recovery Improve strength & motion Peroneal strengthening Improve neuromuscular control Proprioception training Paizullin I, et al. Int J Risk Saf Med 2015; 27;1 Cain MS, et al. J Sports Rehab 2015; 26 Hale S, et al. JOSPT 2007; 37:6 4

5 Treatment Goals (3) Avoid Re-Injury Accumulative injury Maintain PT program at home Bracing as needed Uneven surfaces Situation of risk Houston MN, et al. Phys Ther Sport 2015; 16 (2) Barlow G, et al. Phys Ther Sport 2015; 16 (1) When All Else Fails Refer Chronic Ankle Instability Equivalent to ACL rupture Lack joint stability Surgical repair & scope Primary repair 85-90% success Return to full athletics/ professional sports White WJ, et al. Knee Surg Sports Trauma Arthro 2015 Brodsky AR, et al. FAI 2005; 26 (10) The Long-Term Consequence 5

6 Achilles Pain Heel Pain Forefoot Pain It s All From the Calf Gastrocnemius Soleus Fascial sleeve Achilles Plantar fascia The Common Link: Achilles Contracture Multiple etiologies Genetic predisposition Injury Natural aging process Continued plantarflexion posturing DiGiovanni CW, et al. JBJS-Am 2002; 84(6) 6

7 Biomechanics of Pain: Heel & Forefoot Heel Pain - Posterior Differential Diagnosis Achilles strain/ tendinitis Achilles partial tear Retro-calcaneal bursitis Calcaneal stress fracture Flexor tenosynovitis Peroneals PTT/ FDL/ FHL Heel Pain - Plantar Pain by location Plantar - Lateral - Medial Differential Diagnosis Plantar fasciitis Calcaneal stress fracture Tarsal Tunnel Syndrome Baxter s nerve Fat Pad Syndrome 7

8 Forefoot Pain Generalized Pad of the foot Increased pressure 2 o overload Focal 2 nd MTP joint Pre - Hammertoe Syndrome (plantar plate) IDN/ Morton s vs. Neuritis Stress fx The Dreaded Spur Reflects chronic process Traction spur Secondary phenomenon Does NOT require removal Failure of conservative care Mass effect X Treatment Approach Stretch, stretch, stretch Home based program 3-4 times / daily Maintenance program Physical Therapy Eccentric stretches Myofascial release Rolling Dry needling 8

9 Night Splint Offloading Options Metatarsal Bar/ Pad Reduces stress Distributes forces Shoes Reduces forefoot flexion pressure Stiff sole vs. Rocker bottom Plantar Fascia Injection Medial approach Direct laterally along insertion Prepare patients It HURTS! 1 cc Depo & 2 cc Lido plain 3-4 injections/ year/ area 9

10 Immobilization Reduces stress & strain Gradual resolution inflammation & pain Earlier transition to FWB Casting if all else fails Weight bearing Lengthening Procedures Surgical stretch Failure conservative care Pediatric origins CP/ spasticity Various surgical options Achilles +/- repair Plantar fascia Forefoot Atraumatic Painful Feet & Ankles 10

11 Non-Traumatic Diagnoses Gout Charcot Arthritis Infection Bursitis Tendinitis Gout Flares Gout Attack Most common 1 st MTP joint > Ankle > Knee Diet & genetic factors Serum levels uric acid unreliable 3 8 mg/dl Diagnostic aspiration crystal analysis X-rays limited early Bardin T. et al. Lancet 2010; 375(9711) 11

12 Management of Gout Medical NSAID vs oral prednisone Urate lowering therapy (<6 mg/dl) Supportive care Invasive options undefined Cortisone?? Serial aspiration?? Arthroscopic lavage?? Perez-Ruiz F. Rheum (Oxford) 2009; 48, Supl 2 Wang CC, et al. Arthroscopy 2009; 25(2) Charcot Arthropathy Atraumatic fractures & dislocations Neuropathic patients Multi-factorial etiology Unknown Classified: Midfoot > Hindfoot > Ankle C.R.O.W. Boot vs. TCC 12

13 Arthritis Most common Ankle / 1 st MTP joint / Midfoot Post-traumatic >> Primary OA or RA/Inflam. 13

14 Comfort Measures NSAIDS OTC Rx Steroids Consistent DAILY use 1-2 wks prior to failure Topical Oral intolerant vs. Allergic Glucosamine/ Chondroitin Khosla SK, et al. Foot Ankle Clin 2008; 13(3) When Unsure Immobilize! Weight bearing is problematic Progressive resolution inflammation & pain 2 o stress Earlier transition to FWB Casting if all else fails Weight bearing Ankle Injections Antero-Medial Tib Ant. / Med mal Antero-Lateral Fibula / EDL 1cc cortico. / 2cc anesthetic plain Max: 3 / joint / yr Abate M, et al. Clin Exp Rheum, 2012; 30(2) Lucas Y, et al. Orthop Trauma Surg Res, 2013; 99(5) 14

15 Referral Considerations Thank You 15

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