Disclaimer. Evaluation & Treatment of Ankle & Foot Pain in the Adult Patient. Objectives. Anatomy - ankle. Anatomy - foot.

Transcription

1 Evaluation & Treatment of Ankle & Foot Pain in the Adult Patient William T. Crowe RN-C, FNP, MSN, MBA Disclaimer! I, William T Crowe, have relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation as follows: None Objectives! Review anatomy of the ankle and foot! Define elements of subjective history! Bony structures Tibia Fibula Talus Anatomy - ankle! Discuss basic exam of the ankle and foot! Discuss current treatment regimens for common problems Sustains loads 3x body weight during normal ADLs! Bony structures Tarsals! Calcaneous! Talus! Navicular! Cuneiform! Cuboid Metatarsals Phalanges Anatomy - foot! Bony structures Tarsals Metatarsals Phalanges Anatomy - foot 1

2 ! Connective tissue Ligaments! Anterior inferior tibiofibular! Anterior talofibular! Posterior talofibular! Calcaneofibular! Deltoid! Syndesmosis Anatomy - ankle! Connective tissue Ligaments Anatomy - foot! Tendons Dorsal view! Achilles tendon! Peroneus brevis! Peroneus longus! Peroneus tertius! Extensors Anatomy! Tendons Medial view! Anterior tibial tendon! Posterior tibial tendon! Achilles tendon Anatomy! Passive stabilizers Ligaments Joint capsule Anatomy Anatomy! Active stabilizers Major! Gastrocnemius and soleus! Peroneals! Posterior Tibialis Minor! anterior tibialis! extensor digitorum! flexor digitorum! other intrinsic mucles 2

3 Anatomy! Planes of motion Dorsiflexion & Plantarflexion Inversion & eversion Circumduction (combination of above) Anatomy! Normal ROM 0-10 degrees dorsiflexion degrees plantar flexion degrees inversion (tarsal) degrees eversion (tarsal) 5 20 degrees inversion (subtalar) 5 15 degrees eversion (subtalar)! Where does it hurt? Subjective/History Location of pain - ankle! Bony Lateral malleolar fx Medial malleolar fx Osteoarthritis! Soft tissue Ligamental sprain Tendonitis/rupture Location of pain - ankle! Lateral Lateral malleolar fx! Lateral distal Peroneus longus tear Calcaneofibular ligamental sprain! Anterolateral Anterior talofibular ligamental sprain! Posterolateral Peroneus brevis tear Posterior talofibular ligamental sprain Location of pain - ankle Medial Medial malleolar fx Deltoid ligamental sprain! Posterior Achilles bursitis/tendonitis/rupture Haglund s deformity! Posteromedial Posterior Tibial Tendonitis! Anterior OA of Tibial-talar joint 3

4 Location of Pain - foot! Calcaneal Plantar fasciitis! Base of the 5 th MT Jones fx! Intermetatarsal space Morton s neuroma Intermetatarsal ligamental sprain Subjective/History! Where does it hurt?! When did it start?! What happened?! If injury, ROM?! Previous injury Subjective/History! Severity rest & activity! Instability! Alleviating/Aggravating factors to date! Review of PMH/PSH/MEDS/DA Objective/Exam! Observation can t see, can t treat! Observation Swelling Ecchymosis Deformity Atrophy Objective/Exam! Palpation Malleoli Tendons Objective/Exam - ankle 4

5 ! Palpation Tendons Tarsal joints Metatarsals Phalanges Objective/Exam - foot Objective/Exam! Maneuvers ROM (active & passive) Objective/Exam - ankle! Maneuvers Too many toes Objective/Exam - ankle! Maneuvers Too many toes! Posterior Tibial Tendon Dysfunction Objective/Exam - ankle! Maneuvers Drawer test! Anterior Talofibular ligament! + if > 8mm movement Objective/Exam - ankle! Maneuvers Talar tilt test! Calcaneofibular ligament! Deltoid ligament 5

6 Objective/Exam - foot! Maneuvers Thompson s test Achilles tendon! Radiographs! CT scan! MRI Objective/Studies Objective - Studies Objective - Studies Objective - Studies Objective - Studies 6

7 Ankle sprain! Most common sports injury seen in OP clinics! Most frequent MS injury seen by PCP! ~25K have ankle sprain daily >23K seen daily for ankle injuries! Can occur during sports or walking with ADLs! 10-20% will develop chronic instability (pain persists >3m, may require Sx ligamental reconstruction) Ankle Sprain turning the ankle during a fall or after landing on an irregular surface Pain increases with weight-bearing Instability to ankle Ankle Sprain Localized pain/swelling over lateral aspect Difficulty weight-bearing Limping Drawer test +/- Talar tilt test +/- Ankle Sprain! Ottawa Ankle Rules! ANY pain in malleolar zone AND! Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus OR! Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus OR! An inability to weight-bear both immediately and in the emergency department for 4 steps 97% sensitivity, 99% predictive value Ankle Sprain! MICE! Protected weight-bearing! Physical Therapy! NSAIDs! Orthopedic referral (if elite athlete or pain > 3 months) Peroneal Tendonitis! Tendons are repetitively overloaded! The subsequent inflammatory response creates pain and discomfort. 7

8 Peroneal Tendonitis Pain to the posterolateral ankle May walk with limp Chronic pain Peroneal Tendonitis Pain on palp to the posterolateral ankle Walks with limp Swelling (+/-) to posterior LM Dec sensory (+/-) Muscle testing normal Peroneal Tendonitis! MICE! NSAIDs! Ankle bracing! Physical therapy! Avoid precipitating activities! Refer to orthopedist Achilles Tendinopathy! Most commonly occurs in runners who have suddenly increased the intensity or duration of the runs! Weekend warriors! Includes tendonitis, tears, and ruptures Achilles Tendinopathy! Risk factors! Sex/age - Most common in middle-aged males! Physical problems - Naturally flat arch, obesity, tight calf muscles! Training choices running in worn-out shoes, cold v warm weather, running on hilly terrain! Medical conditions diabetes, HTN! Medications - fluoroquinolones Achilles Tendinopathy! Mild ache in back of leg or above heel! Severe pain after prolonged running, climbing stairs, or sprinting! Tenderness or stiffness, esp in morning 8

9 Achilles Tendinopathy! POP ~ 2-4 cm proximal to insertion site! Calf squeeze (Thompson test) Achilles Tendinopathy! MICE! NSAIDs! Ankle bracing (cast if necessary)! Physical therapy! Avoid precipitating activities! Refer to orthopedist Ankle Osteoarthritis Pain to the anterior ankle Reduced ability to move, walk, or bear weight Stiffness in the joint Swelling in the joint Ankle Osteoarthritis POP of the anterolateral or anteromedial talar joint Walk with limp Ankle Osteoarthritis Ankle Osteoarthritis Conservative! NSAIDs! Cortisone injections! Physical therapy Surgical! Arthroscopic debridement! Ankle fusion! Ankle replacement 9

10 Ankle fracture! Immediate and severe pain to joint! Swelling/bruising to joint! Inability to weight-bear on joint Ankle fracture! Immediate and severe pain to joint! Swelling/bruising to joint! Inability to weight-bear on joint! Deformity Ankle Fracture Lateral malleolar Ankle injury Fibular Ankle Fracture Medial malleolar Ankle Fracture/Dislocation 10

11 Foot Sprain! Types Midfoot (Lisfranc injury) 1 st MTP joint ( turf toe ) Foot Sprain! Causes Midfoot (Lisfranc injury)! Direct crush injury! Indirect sudden rotational force on a plantar flexed forefoot 1 st MTP joint ( turf toe )! Hyperextension of the great toe Foot Sprain Foot pain Foot swelling Foot bruising Foot stiffness Difficulty in walking Foot Sprain Foot Sprain Midfoot! POP of midfoot! Swelling to the midfoot! Local bruising! Inability to WB (+/-) Turf toe! Base of great toe swollen! POP of 1 st MTP joint Foot Sprain 11

12 Foot Sprain/fx Foot Sprain Midfoot (mild)! Boot walker! MICE! NSAIDs Midfoot (unstable)! Surgery Turf toe! MICE! NSAIDs! Splinting (hard-soled shoes) Plantar Fasciitis! More properly known as plantar fasciosis No real inflammation (no blood vessels), more degenerative! Affects ~ 2 million people annually! Affects ~ 10% of people in their lifetime! Associated with long periods of standing Plantar Fasciosis Burning, stabbing, or aching pain to heel or posterior sole, usually worse in the morning Increased knee pain, especially for runners Plantar Fasciosis Plantar Fasciosis POP to heel or posterior sole Walks with a limp 12

13 Plantar Fasciosis Rest Massage therapy Morning stretches Night splints NSAIDs Cortisone injection Foot Osteoarthritis pain and stiffness of the affected foot swelling near the affected joint limited range of motion and difficulty walking Foot Osteoarthritis pain and stiffness of the affected foot swelling near the affected joint limited range of motion and difficulty walking bony protrusions (spurs) Foot Osteoarthritis Foot Osteoarthritis Conservative! NSAIDs! Shoe inserts/orthotics! Physical therapy Surgical! Arthroscopy! Joint fusion! Joint replacement Morton s Neuroma! Precise cause unknown! Women 10x more frequent than men! Not a neuroma per se, more accurately a neurofibroma 13

14 Morton s Neuroma! Pain to plantar aspect of forefoot, usually to 2 nd or 3 rd interspace! Pain inc with walking or tight-fitting shoes! Pain dec with rest or walking barefoot Morton s Neuroma! Well localized tenderness between 2 MT heads! 3 rd interspace more frequently involved than the 2 nd! Rare 1 st and 4 th.! Must differentiate between joint and interspace pain! Sensory deficit rarely seen! ~ 75%, symptoms reproduced by firmly palpating the web space Morton s Neuroma Conservative! Wearing wide-box shoes! Soft MT support placed in the shoe proximal to area of neuroma (~1/3 will respond to this alone)! Steroid injection (CAUTION occasional rupture of a collateral ligament) Surgical! Surgical excision (80% success, 60% decreased sensory either side of excision) Jones Fracture! AKA 5 th MT base fracture! Occurs at the base of the 5 th MT! Usually caused by a twisting motion of the foot Jones Fracture! Pain to base of foot or ankle! Swelling to lateral foot! Pain with or inability to weight-bear Jones Fracture! Pain on palpation to base of foot or ankle! Swelling to lateral foot! Pain with or inability to weight-bear 14

15 Jones fracture Jones fracture 15