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

2. 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

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

4. 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?

5. 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”.

6. 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

8. 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

10. Lateral ligament/Inversion Strain

12. 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??

13. 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.

14. 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 ).

15. 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.

16. 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 ??

17. Osteochondral Lesion

18. 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.

20. 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.

21. 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.

22. 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

23. Matles Test and Simmonds Test

24. 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.

25. 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

26. 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

27. 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.

28. 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

29. 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

31. 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

32. 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

33. 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.

34. “ Too many toes sign”

35. 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

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

37. 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.

38. 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

39. 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

40. Lisfranc Injury

41. 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

45. Hallux Valgus/Rigidus

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

47. Heel Spur

48. 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.

49. 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

50. Haglund’s deformity

51. 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

52. 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