Foot and Ankle Problems To treat or Refer????

CDP Events on Foot/Ankle Fantastic events at respected institutions ( e.g. RNOH Stanmore, Wellington, Lister) Bright confident young surgeons! State of the art imaging and technology Advancing surgical approaches Really pushing the boundaries!! Seemingly limitless supply of healthy patients

My impressions of all this CPD Is there nothing that these bright young surgeons can’t Resect? Suture? Realign? Graft? Replace?

Reflections???? My intention is not to undermine the excellent surgical advances that are happening. But which patients are suitable for surgery? What happens to the patients after the surgeon has finished with them? What about the long and sometimes painful rehabilitation process?

Where does Osteopathy fit? Referring to the relevant Osteopathic Practice Standards A5 “You must work in partnership with the patient to find the best treatment for them”. B3 “You must recognise and work within your limits of competence”. D1 “You must consider the contribution of other healthcare professionals in patient care”.

Welcome to my world! Where patients are often not very fit/healthy to start with. Where they are at the mercy of the overworked NHS. Where the GP is not remotely interested in their problem if it is not life threatening. Where money ( or lack of it ) matters! Where accessing the latest advances is limited

Aims of this session To meander through some common foot and ankle problems ( Hopefully with some lively interaction from the audience! Please interrupt as necessary!) Revisit some common pitfalls in diagnosis Consider criteria for referral Revisit some surgical options

Lateral ligament/Inversion Strain

Lateral ligament/Inversion strain Acute injury ( less than 6 weeks) Osteopathic management? Suggestions??? What can we do? Chronic lingering problems If painful 6-10 weeks after injury consider Is ankle painful, unstable or both??

Guidelines for management Recurring Instability Try rehabilitation first ( suggestions?) and surgery as a last resort Chronic Pain Consider misdiagnosis/fracture. If 6 weeks plus consider MRI Instability and Pain Refer for MRI to establish why there is pain before rehab.

Surgical Options Suture of lateral ligaments Tightening of Peroneal tendon ( especially for overweight patients or those with ligamentous laxity). Surgery followed by cast splint for 4 weeks ( absolutely no Inversion/eversion ).

Complications to watch out for Osteochondral Lesion 10% of patients suffer this after an inversion strain The Talus shears against the tibia causing swelling on the Medial aspect of the foot A flap of articular cartilage occurs Movement of the ankle pumps synovial fluid into the flap Cyst forms in the articular cartilage.

Surgical treatment Remove the flap of cartilage if displaced Micro fracturing to encourage fibrocartilage growth NB fibro cartilage is not the same structure as articular cartilage- much softer. Predisposes patient to early OA ??

Osteochondral Lesion

Syndesmosis injury Tear/strain of the anterior part of tib-fib ligament. Common in football and skiing. Very slow to heal after what appears to be a straightforward ankle injury. Clinically it is tender to palpate higher up from the lateral ligaments External rotation of the foot on the tibia is painful.

Management options Stress X rays of the ankle may show splaying of the tibia and fibular on weight bearing. If mild conservative treatment with crutches splints and immobilisation. If severe surgically the tibia and fibula can be pinned to stabilise.

Acute Achilles Tendon Rupture Typically acute presentation during sport or activity or chronic pain after a low impact injury. Patient often feels like they have been slapped on the leg during activity. NB The long flexors alone may be sufficient for the patient to do a heel raise so this is not a reliable test for rupture.

Helpful diagnostic tests Simmonds/Thomson Test ( calf squeeze test) Patient prone feet hanging over end of plinth Squeezing a normal calf should cause plantar flexion of the foot In positive Simmonds test foot remains in dorsiflexion Matles Test Patient prone with knee flexed to 90 degrees In positive test foot will hang in dorsiflexion

Matles Test and Simmonds Test

Other clinical signs Swelling and tenderness over tendon Palpable gap in tendon often 2-6 cm up from the insertion. Referral for ultrasound imaging indicated if tests are positive to assess apposition of the tendon. Surgeons are only interested in seeing patients with positive Simmonds Test.

Surgical options Surgery preferred in younger active sporty patients Open repair medially to avoid Sural Nerve damage. Percutaneous repair with smaller incision- quicker to heal but more chance of Sural Nerve damage. Conservative treatment in older patients Boot /cast blocking dorsiflexion

Achilles Tendinopathy Common in sporty patients , dancers, jumping Associated with poor training routines/footwear Poor flexibility High foot arches or flat feet More common in patients with AS or psoriatic arthritis Prolonged use of certain antibiotics can result in tendinopathy

Clinical Features Repetitive micro trauma to the tendon results in pain swelling and stiffness. Typical pattern worse first thing in the morning Painful at start of exercise easier during a run and painful afterwards Tender and swelling over the area.

Management Ideas? Conservative treatment Rest, Ice, ultrasound, NSAIDS Orthotics? Steroid injections? Ultrasound guided to avoid potential rupture? Shock Wave therapy Surgical removal of nodules/adhesions Incision of tendon to promote new growth

Tarsal Tunnel Syndrome Compression of the Tibial Nerve as it passes under the flexor retinaculum Contents of the tarsal tunnel are: FDL, FHL, Tib. Post, Tibial Nerve/ Artery. In the tunnel the nerve splits into the calcaneal branch and medial and lateral plantar nerves Compression can occur in flat feet, ganglions cysts, synovitis etc

Clinical features Peripheral nerve compression i.e. Swelling, Numbness, Tingling, burning pain medial aspect of the foot and toes 1,2, and 3. Tinel’s test positive Investigations can include nerve conduction test or MRI or Ultrasound depending on suspected cause of compression

Tibialis Posterior Dysfunction Tibialis posterior main function is to support the medial arch. Failure of the tendon causes progressive collapsing of the medial foot and tilting of the heel outwards. Acute cases from high impact sports Chronic cases risk factors are flat feet, over 40 obese, diabetes

Symptoms of Tibialis Posterior Dysfunction Pain/swelling on the medial aspect of the foot Pain worse on activity even on walking Progressive flattening of the foot Pain on the lateral aspect of the foot due to compression of the lateral ankle and subtalar joint.

“ Too many toes sign”

Clinical features Tenderness pain and swelling medially Flat foot deformity with an everted foot “Too many toes sign” on weight bearing Unable to do a single heel raise May want to use MRI, ultrasound, imaging to Check state of tendon and grade of injury

Management options Conservative Low impact exercise/eccentric stretching Ice, NSAIDS Orthotics Splints Surgical options – 90 % have a scarf osteotomy

Surgical options These vary according to grade of injury In a flexible foot with an inflamed tendon -stripping cleaning ( tenosynovectomy) In case of rupture -tendon transfer In a more rigid foot -osteotomy If arthritis is present - arthrodesis All these procedures have long rehab time up to 1 year.

Lisfranc Tarso-Metatarsal Injury Injury where the metatarsals are displaced from the cuneiforms. ( Lisfranc joint) Common in snowboarders, windsurfing , horse riding where bindings are strapped across the foot Also common in crush injuries, objects falling onto foot. Also rotation injuries on a plantar flexed foot

Clinical Features Foot usually balloons up immediately after injury with bruising medially and inferior ( sole of foot). Medial Arch collapses Swelling is persistent Often missed at A & E as non weight bearing X-Rays are often normal Weight bearing X rays will show gaping between 1st and 2nd met and cuneiforms

Lisfranc Injury

Inferior Heel Pain Differential diagnoses to consider Stress fracture in elderly – medial pain especially on cupping the heel side to side Sero -negative rheumatological conditions Tarsal Tunnel Syndrome S1 referred pain Plantar fasciitis. Swelling with fasciitis and night pain. No swelling with fasciosis. Acute pain may be rupture Fat Pad Atrophy

Hallux Valgus/Rigidus

Treatment options Manipulation Orthotics Arthrodesis Cheilectomy - Remove bone to allow dorsiflexion of the toe Joint replacements – New and unreliable

Heel Spur

Heel Spur Essentially a calcium deposit on the calcaneum often associated with plantar fasciitis. Common in sports with repeated micro -trauma eg jumping, running, causing periosteal traction on the fascial attachment. Also associated with obesity, diabetes, prolonged standing, poor footwear.

Clinical Features Local heel pain on weight bearing – like a pin /needle digging into the foot Associated inflammation in the soft tissues Diagnosis via X Ray Treatment options include Orthotics, NSAIDS, Cortisone Plantar fascia release and or spur removal

Haglund’s deformity

Haglund’s Deformity Also known as “ Pump Bump” Leads to Retro calcaneal Bursitis Often a congenitally altered calcaneum Associated with altered gait- walking on lateral aspect of the foot Pain and swelling over the achilles insertion Aggravated by shoes rubbing/trainers Pain redness and lump over the calcaneum

Management Conservative Treatment NSAIDS, Ice. orthotics, heel lifts, change shoes Surgical options are Debridement of the Achilles Tendon Removal of the retro calcaneal bursa Excision of the Haglund’s deformity