1. Questions The Mechanism of action for NSAIDs
A: Inhibits Cyclooxgynase enzyme (COX) preventing prostaglandin production.
B.Binds the mu and delta-opiod receptors
C: Activates the GABA beta receptor
D: blocking the fast voltage gated Sodium channels in cell membrane

2. Questions
What is the degree of intensity of immobilization from lowest to highest
A: CAM boot, Ace bandage, Air Cast/ Stirrups, Lace-up/Strapped Bracing
B: Lace-up/Strapped Bracing, Air Cast/Stirrups, CAM Boot, Ace Bandage
C: Ace Bandages, Air Cast/Stirrups, Lace-Up, Strapped Bracing, CAM Boot
D: CAM Boot, Air Cast Stirrups, Lace-Up Strapped Bracing, Ace Bandage

3. Questions The two ligaments commonly injured in Ankle Sprains are:
A: Deltoid ligament, Posterior talofibular ligament
B: Anterior talofibular ligament, Calcaneal Fibular Ligament
C: Deltoid ligament, Anterior Talofibular Ligament
D: Posterior Talofibular Ligament, Calcaneal Fibular Ligament

4. Questions What are risk factors for Plantar Fascittis?
A: Increased Activity
B: Obesity
C: Prolonged Standing
D: All of the Above

5. Common Rear Foot Problems
Darrell Ballinger DPM, ABPM

6. Conflicts of Interest
I have no conflicts of interest in regards to the presentation.

7. Goals Identify and evaluate common rear foot pathology
Develop strategies for conservative treatment of common rear foot pathology
Know your treatment tool kit!

8. Evaluation and Management
History
Mechanisms
Onset
Nature
Location
Duration
Course
Aggravating Factors

9. Evaluation and Management
Clinical Assessment
Vascular
Posterior and Dorsalis pedal pulses
Musculoskeletal
Range of Motion, pain with palpation, weakness, guarding, spasm
Neurological
Percussion of posterior tibial nerve, sural nerve

10. Evaluation and Management
Imaging
X-rays
Foot and ankle 3 views
Anterior-Posterior, Lateral, Medial Oblique
Ultrasound
MRI
CT Scan
Bone Scan

11. Treatment Tool Kit
It is important to get an accurate diagnosis through evaluation with the physical exam and imaging. This will help you with your treatment tool kit.
Oral anti-inflammatories
Topical anti-inflammatories, analgesics
Injection therapy
Mechanical Therapy

12. Oral Anti-Inflammatory Medications
NSAIDs
MOA: Inhibits Cyclooxgynase enzyme (COX) preventing prostaglandin production. Prostaglandins create inflammation and pain.
Side Effects: Stomach Ulcers, increased heart attack and stroke risks
Examples: Naproxen, Ibuprofen

13. Oral Anti-Inflammatory Medication
Steroids
MOA: Glucocorticoid receptor agonist. May involve decreasing the biosynthesis of prostaglandins and leukotrienes.
Side Effects: Weight gain with long term use, Increase blood glucose levels, edema to extremities, anxiety
Examples: Prednisone, Prednisolne

14. Topical Medications
Topical Medications can be used within a single gel or cream, or in combination
Topical Analgesics
Capsaicin, Lidocaine
Topical NSAIDs
Ketoprofin, Diclofenac
NDMA Receptor Agonist
Ketamine

15. Topical Medication

16. Injection Medications
Localized nerve blocks can help decrease acute pain
Bupivacaine
Binds to the intracellular portion of the voltage-gated sodium channels. It blocks the sodium influx into nerve cells effectively eliminating pain signals.
Onset: 2-15 minutes
Duration of action: 2-9 hr

17. Injection Therapy Corticosteroids
Reduces inflation by inhibiting the release of vasoactive kinnis and prostaglandins.
Examples
Dexamethasone
Kenalog

18. Mechanical Therapy
Immobilization can be a key tenant in treatment of common rear foot pathology
-Taping, Ace bandages, Air Casts stirrups , Light Weight Strapped Bracing/ Lace Up bracing, Full Immobilization (CAM Boot, Casting)
Physical therapy may be needed to assist in recovery for common rear foot pathology
Multiple modalities including stretching, strength training, electro stimulation, ultrasound therapy, etc.

19. Ankle Sprains
Ankle Sprains- Tearing or straining of ligmanents to the lateral ankle
Dx: Usually history and palpation of the anterior talofibular ligament, calcaneal fibular ligament
Range of Motion with pain on internal rotation

20. Ankle Sprains
Imaging
X-rays are used to rule out any fibular fractures
Ultrasound can be use to isolate torn ligaments
MRI may be used to indicate full ligament tears and any other ankle pathology

21. Ankle Sprain Grading Grade 1 Sprain Grade 2 Sprain Grade 3 Sprain Mild
Usually slight tenderness, swelling, and possible tears of the ligament
Grade 2 Sprain
Moderate to severe tenerness, edema, ecchymosis, and ligamentous laxity
Grade 3 Sprain
Severe pain, ecchymosis, heavy edema, ligamentus laxity

22. Initial Ankle Sprain Treatment
RICE
Rest, Ice, Compression, Elevation
Compression can included Ace Bandages, Unna’s Boot Therapy for Edema
Immobilizations: Three weeks with protected weight bearing
Medications
Typically NSAID therapy for 7-14 days
Can use steroid taper if NSAIDs are contraindicated
Topical NSAIDs

23. Immobilization
CAM BOOT
AIR CAST ANKLE STIRRUPS

24. Immobilization
Knee Roller
CRUTHCES
KNEE ROLLER

25. Ankle Sprain: Physical Therapy
Physical therapy for ankle sprains post initial therapy can help with ROM and strengthening the lower extremity

26. Achilles Tendonitis
Pain along the back of the ankle close to the heel. Usually see increased thickness of the tendon.
2 types
Insertional
Non-Insertional

27. Achilles Tendonitis
Insertional Tendonitis : Degeneration of the body of the Achilles tendon

28. Achilles Tendonitis
Insertional Achilles Tendonitis : Usually see a eminence to the posterior aspect of the heel

29. Achilles Tendonitis Diagnosis:
Usually history of current condition
PE: Includes Palpation of the Achilles tendon, ROM of the ankle joint in the sagittal plane.
Cause: Usually repetitive motion and increased stress to the tendon. Tight calf muscles and bone spurs can also cause issues.

30. Achilles Tendonitis Bone Spur

31. Achilles Tendonitis Imaging
X-rays are used to rule out any bone spurring
MRI may be used to indicate tendonopathy and any other ankle pathology

32. Achilles Tendonitis Treatment
RICE
Rest, Ice, Compression, Elevation
Compression can included bracing
Medications
Typically NSAID therapy for 7-14 days
Can use steroid taper if NSAIDs are contraindicated
Cortiocosteroid Injections
Not recommended due to risk of Achilles tendon rupture.
Orthotics with Heel Lifts

33. Achilles Tendonitis
BRACING

34. Calcaneal Apophysitis
Calcaneal Apophysitis also known as Sever’s Disease, is a common heel growth plate pain experienced by 8-14 year old children.

35. Calcaneal Apophysitis
Diagnosis:
Usually history of current condition
PE: Includes Palpation of the Achilles tendon insertion, with medial and lateral compression of the calcaneous, ROM of the ankle joint in the sagittal plane.
Cause: Usually repetitive motion and increased stress to the Achilles tendon. Tight calf muscles can also cause issues. Usually initiated by physical activity in sports.

36. Calcaneal Apophysitis
Imaging
X-rays are used to confirm the diagnosis

37. Calcaneal Apophysitis Treatment
RICE
Rest, Ice, Compression, Elevation
Compression can included bracing
Medications
Typically NSAID therapy for 7-14 days
Can use steroid taper if NSAIDs are contraindicated
Topical NSAIDs
Orthotics with Heel Lifts
Decrease Activity Levels in sports

38. Posterior Tibial Tendonitis
Posterior tibial tendonitis is inflammation along the posterior tibial tendon course.

39. Posterior Tibial Tendonitis
Diagnosis:
Usually history of current condition
PE: Includes Palpation of the posterior tibial tendon course, pain with eversion of the foot, decrease of the arch of the foot, mild edema to the medial aspect of the ankle, too many toes sign, unable to perform single limb heel raise
Cause: Usually repetitive motion and increased stress to the posterior tibial tendon, decreasing arch height

40. Posterior Tibial Tendonitis
Too Many Toes
Single Limb Heel Raise

41. Posterior Tibial Tendonitis
Imaging
X-rays are used to indicate the decrease of the arch height
MRI may be used to posterior tibial tendon tears and any other ankle pathology

42. Posterior Tibial Tendonitis
Treatments:
RICE
Rest, Ice, Compression, Elevation
Compression can included bracing
Medications
Typically NSAID therapy for 7-14 days
Can use steroid taper if NSAIDs are contraindicated
Topical NSAIDs
Cortiocosteroid Injection to the medial ankle joint, tarsal joint
Orthotics with arch supports
Physical Therapy

43. Peroneal Tendonitis
Peroneal tendonitis is inflammation along the peroneal tendon course

44. Peroneal Tendonitis Diagnosis:
Usually history of current condition
PE: Includes Palpation of the posterior tibial tendon course, pain with inversion of the foot distal to the fibular apex , mild edema to the lateral aspect of the ankle, tendons moving over the fibula
Cause: Usually repetitive motion with lateral movement and increased stress to the peroneal tendons

45. Peroneal Tendonitis Imaging
X-rays are used to indicate any ossicles within the tendon
Ultrasound may be used to indicate ossicles and peroneal tendon tears
MRI may be used to indicate any peroneal tendon tears and any other ankle pathology

46. Peroneal Tendonitis Treatments: RICE
Rest, Ice, Compression, Elevation
Compression: Immobilization CAM Boot
Medications
Typically NSAID therapy for 7-14 days
Can use steroid taper if NSAIDs are contraindicated
Topical NSAIDs
Cortiocosteroid Injection
Orthotics with arch supports
Physical Therapy

47. Ankle Osteoarthritis
Inflammation and degeneration of the ankle joint with pain to the medial and/or lateral aspects of the ankle joint.

48. Ankle Osteoarthritis Diagnosis: Cause: Injury, wear and tear, obesity
Usually history of current condition
PE: Includes Palpation of the medial and lateral aspect of the ankle, pain with ROM in the sagittal plain, crepitus with ROM
Cause: Injury, wear and tear, obesity

49. Ankle Osteoarthritis Imaging X-rays are used to indicate arthritis
CT scans can better visualize the ankle joint
MRI can visualize bone and soft tissue pathology within and around the ankle joint

50. Ankle Joint Osteoarthritis
Treatments:
Immobilization
Medications
Typically NSAID therapy for 7-14 days
Can use steroid taper if NSAIDs are contraindicated
Topical NSAIDs
Cortiocosteroid Injections to medial and lateral ankle gutters
Orthotics with arch supports
Physical Therapy

51. Ankle Osteoarthritis
Leather Ankle Gauntlet
Ankle Foot Orthosis

52. Plantar Fasciitis
Plantar Fasciitis is pain at the plantar aspect of the heel

53. Plantar Fasciitis Diagnosis:
Usually history of current condition- Hurts with the first steps of the day, pain is usually sharp
PE: Includes Palpation of the medial calcaneal tubercle, pain along the arch, pain is relieved by dorsiflexion of the foot
Cause: Injury, new activities in sports, obesity, tight calf muscles

54. Plantar Fasciitis Imaging
X-rays are used to evaluate the calcaneous for stress fracture
Ultrasound can visualize the soft tissue
MRI can visualize bone and soft tissue pathology within and around the plantar aspect of the foot

55. MRI: Plantar Fasciitis

56. Plantar Fasciitis Treatments: Immobilization Medications
Typically NSAID therapy for 7-14 days
Can use steroid taper if NSAIDs are contraindicated
Topical NSAIDs
Cortiocosteroid Injections to plantar fasciia
Orthotics with arch supports, Night Splints
Physical Therapy

57. Plantar Fasciitis Treatments: Night Splints & Orthotics

58. Plantar Fasciitis Steroid Injection
Plantar Approach
Medial approach

59. Goals 1. Appropriate diagnosis: History and Physical Examination
2. Know your tool kit: Oral, Topical, Injectable, Mechanical
3. When in doubt refer out.

60. Question 1 The Mechanism of action for NSAIDs
A: Inhibits Cyclooxgynase enzyme (COX) preventing prostaglandin production.
B.Binds the mu and delta-opiod receptors
C: Activates the GABA beta receptor
D: blocking the fast voltage gated Sodium channels in cell membrane

61. Question 2
What is the degree of intensity of immobilization from lowest to highest
A: CAM boot, Ace bandage, Air Cast/ Stirrups, Lace-up/Strapped Bracing
B: Lace-up/Strapped Bracing, Air Cast/Stirrups, CAM Boot, Ace Bandage
C: Ace Bandages, Air Cast/Stirrups, Lace-Up, Strapped Bracing, CAM Boot
D: CAM Boot, Air Cast Stirrups, Lace-Up Strapped Bracing, Ace Bandage

62. Question 3 The two ligaments commonly injured in Ankle Sprains are:
A: Deltoid ligament, Posterior talofibular ligament
B: Anterior talofibular ligament, Calcaneal Fibular Ligament
C: Deltoid ligament, Anterior Talofibular Ligament
D: Posterior Talofibular Ligament, Calcaneal Fibular Ligament

63. Question 4 What are risk factors for Plantar Fascittis?
A: Increased Activity
B: Obesity
C: Prolonged Standing
D: All of the Above

64. Thank You Questions, Comments, Concerns Darrell Ballinger DPM
Cell:
Office : 3359 Kemp Road Suite 210, Beavercreek, OH
Office Number:

65. References
Topical Medication JPEG:
Ankle Pain ROM JPEG:
Air Stirrup ankle Brace:

66. References
CAM Boot JPEG:
Knee Roller JPEG:

67. References
Crutches JPEG:
Achilles Tendonitis x3 Photos

68. References
Calcaneal Apophysitis X-ray:
Posterior Tibial Tendonitis: X3 Images
Ankle Arthritis:

69. References
AFO Image:
Leather Ankle Gauntlet