Common Ankle and Foot Injuries Richard V. Abdo, M.D.

Richard V. Abdo, M.D. College - Brown University (with Honors) Medical School – SUNY Upstate (Syracuse), Cum Laude, 1978-1982 Orthopaedic Surgery Residency - Boston University, 1983-1987 The Lahey Clinic (Boston) - 1987-1994 Orthopaedic Specialties - 1994-present, offices in Clearwater Reviewer for Foot and Ankle International 1989-2015, Reviewer for American Journal of Sports Medicine 1991-present

Plantar Fasciitis What is it? Inflammation of the plantar fascia attachment to the heel bone (calcaneus). A traction (bone) spur may or may not be present. Entrapment of nerve may contribute to symptoms. Calcaneus/heel bone Heel/bone spur

Plantar Fasciitis The low back pain of the foot

Plantar fascia – windlass mechanism Windlass – a device for hauling or hoisting

Clinical Presentation Plantar Fasciitis Clinical Presentation Pain and tenderness medial plantar heel Worse on arising in the morning or after prolonged sitting Increased with activities X-rays – may show bone thickening or spur

Plantar Fasciitis Treatment Weight reduction Activity modification, rest Stretching exercises NSAID’s, Ice Heel cushions, orthotics Nighttime splint Cortisone injection Physical therapy – ultrasound Surgery - ~10% of patients

Platelet-Rich Plasma (PRP) Platelets are small cells in the blood. They become activated at the site of injury or inflammation, and release beneficial proteins called growth factors. PRP is obtained from a small amount of blood collected from the patient’s arm.

Platelet-Rich Plasma (PRP) The blood goes through a rapid spinning process (centrifuge) that separates the platelet-rich plasma PRP is injected at the site of injury or inflammation (e.g. plantar fasciitis)

Plantar Fasciitis Surgery Options Open release – invasive Endoscopic plantar fascia release Extracorporeal Shockwave Therapy (ESWT) – orthotripsy, noninvasive Ankle Incision Arch Bottom of heel

ESWT Heel Treatment/Orthotripsy The Ossatron device provides a non-invasive alternative to open surgery with an estimated 75% success rate.

Retrocalcaneal (Heel) Bursitis and Insertional Achilles Tendinitis What is it? Inflammation of the bursa between the Achilles tendon and the heel bone (calcaneus). May be associated with insertional Achilles tendonitis and calcium deposits or spurs. Spur

Retrocalcaneal (Heel) Bursitis Clinical Presentation Pain Tenderness Swelling Warm to touch X-rays – often calcium deposits or a spur Pain Swelling Warm to touch

Retrocalcaneal (Heel) Bursitis Treatment Rest/activity modification Ice, NSAID’s Heel lift/cushion Physical therapy Injection Cast boot Surgery

Retrocalcaneal (Heel) Bursitis Surgery Preop Postop

Achilles Tendinitis (Tendinosis) What is it? Painful thickening and swelling 2-6 cm up from the back of the heel Vascular watershed area Overuse from repetitive microtrauma – runners, jumping sports Extrinsic factors – change in training pattern, training on hard or uneven surfaces, poor footwear Intrinsic factors – age, weight, flexibility, foot deformity Degenerative (tendinosis), rather than inflammatory (tendinitis)

Achilles Tendinitis (Tendinosis) Clinical Presentation Pain and fusiform swelling at the heelcord Tenderness upon squeezing the tendon Worse with activity Painful to push off while walking Xrays usually negative MRI not usually needed Fusiform swelling Heel

Achilles Tendinitis (Tendinosis) Treatment Activity modification Heel cushions, heel lifts PT, stretching, eccentric exercises Ice NSAID Cast boot Cortisone injection Platelet rich plasma (PRP) injection

Achilles tendinitis (Tendinosis) Surgery Debride degenerative tendon fibers Transfer tendon if needed

Stress Fractures What is it? Microscopic failure of bone due to overuse microtrauma that overwhelms the normal bone repair process Most common with repetitive impact activities – runners History of new fitness activity, change in training program, poor footwear, hard running surface Foot deformities and decreased flexibility increase risk of stress fracture

Clinical Presentation Stress Fractures Clinical Presentation History of change in activity/fitness Pain, swelling, and tenderness localized to the bone involved Usually no distinct trauma High risk stress fractures in area of poor blood supply: 5th metatarsal (Jones’ fx.), navicular, ankle medial malleolus) Xrays – may be normal initially Bone scan – sensitive, but not specific MRI – preferred, sensitive and specific

Stress Fractures Treatment Rest, non-impact conditioning Immobilization – cast boot, postop shoe Limited or non-weight-bearing depending on location of fracture Elevation and ice Avoid NSAID’s Physical therapy High risk fractures – bone stimulator, surgery

Stress Fractures Jones’ Fracture

Stress fractures Medial Malleolus

Ankle Sprains What is it? An injury that stretches, frays, and tears ligaments. Ligaments connect one bone to another, providing support and stability for a joint.

Clinical Presentation Ankle Sprains Clinical Presentation Pain and tenderness Swelling Ecchymosis (black and blue) Severity – mild, moderate, severe X-rays – normal, occasionally a chip fx. Tibia Fibula Talus

Ankle Sprains Treatment P – Protection (ankle splint) R – Rest I – Ice C – Compression (ace wrap) E – Elevation Additonal – NSAID’s, physical therapy

Soft Tissue Impingement probe Anterolateral impingement syndrome What is it? 1. ligament and synovial thickening 2. fibrosis 3. adhesions Scar tissue

Soft Tissue Impingement Clinical Presentation History of ankle sprain(s) Pain and tenderness over anterolateral corner of joint Localized swelling No instability outside (lateral) inside (medial) Front of right ankle

Soft Tissue Impingement Treatment NSAID’s Ankle splint Physical therapy Ice Cortisone injection Arthroscopic surgery debridement

Talus Osteochondral Lesion/Defect What is it? A fracture, bruise, or softening of a small segment of the talus cartilage and bone at the ankle joint. Usually located at the medial or lateral corner of the talar dome. Medial talar dome lesion

Clinical Presentation Talus OCD Clinical Presentation History of ankle sprains(s) Pain, swelling, clicking Sensation of instability X-rays may be normal or underestimate the extent of the lesion MRI scan Xray

Talus OCD MRI

Talus OCD Treatment Depends on location and stage/severity of lesion Ankle splint NSAID’s Physical therapy Cortisone injection Surgery – arthroscopic debridement/drilling, bone/cartilage grafting. Tibia Talus

Talus OCD Allograft procedure

Talus OCD Allograft procedure

Talus OCD Allograft procedure

Particulated Juvenile Cartilage Transplantation Denovo Talus OCD Particulated Juvenile Cartilage Transplantation Denovo

Particulated Juvenile Cartilage Transplantation Denovo Talus OCD Particulated Juvenile Cartilage Transplantation Denovo

Bone Impingement What is it? Bone spurs that develop around the margin of the joint that create local inflammation and irritation. “sports” spurs

Clinical Presentation Bone Impingement Clinical Presentation Anterior – most common Distal tibia and dorsal talus Repetitive impact injury over a lifetime, particularly athletics Tenderness, swelling Decreased dorsiflexion Bone spur

Bone Impingement Treatment NSAID’s Heel lift Ice Cortisone injection Arthroscopic surgery - removal Bone spur removed

Plantar Neuroma/Morton’s Neuroma What is it? Thickening, entrapment, fibrosis/scarring of the interdigital nerve between the metatarsal heads in the ball of the foot.

Plantar Neuroma/Morton’s Neuroma Clinical Presentation Burning, shooting pain localized to the plantar aspect of the affected interspace 3rd interspace > 2nd interspace Worse wih activities or constrictive shoewear Intermittent symptoms Pain with palpation/pressure of interspace X-rays - negative

Plantar Neuroma/Morton’s Neuroma Treatment Shoes – wide toe box MT pad (and/or orthotic with MT pad) Ice, NSAID’s Injection Surgery MT pads

Plantar Neuroma/Morton’s Neuroma Surgical Excision neuroma

Other conditions Posterior tibial tendinitis Peroneal tendinitis Flexor hallucis longus tendinitis (dancers) Os trigonum syndrome (dancers) Tarsal tunnel syndrome Jogger’s foot (medial plantar nerve entrapment) Sinus tarsi syndrome Turf toe Hallux rigidus

Thank You Questions ?