1. Diagnosing and Treating Acute and Chronic Pathology of the Foot and Ankle.
Todd Derksen DPM, FACFAS
Orthopedic and Sports Institute of the Fox Valley

2. Today’s Objectives Review the major anatomy of the foot and ankle.
Discuss relevant tendon injuries and treatment options
Discuss common sprains and fractures with treatment options
Discuss ankle arthritis with specific focus on total ankle replacement

3. Bones of the Foot 26 bones in the foot 33 joints in the foot
Plus 2 constant sesamoids
Tibia and fibula
Over 20 described accessory bones
33 joints in the foot
Divided into 3 parts
Hindfoot
Midfoot
Forefoot
Talus hardest bone in the body

4. Ligaments of the Foot and Ankle
Over 100 ligaments in each foot

5. Muscles and Tendons of the Foot
9 extrinsic and 20 intrinsic muscles

6. Shoes
These radiographs help demonstrate why shoes, especially unsensible ones can irritate our feet and while this may be an extreme example since not everyone is wearing 4 inch heels but it does help get the point across. A lower tech way to do this would be to trace your foot on a piece of paper and then remove the insole from you shoe and see if they overlap anywhere, the insole should completely obscure the foot tracing.

7. Again just another view of a foot in an unsensible shoe, from this view it is easy to see how these shoes change the biomechanics of the the foot and put abnormal stresses on parts of the foot and ankle

9. Achilles Tendon Injuries
Chronic
Tendonitis
Tendinosis
Acute
Rupture
Named in greek mythology trojan war hero, mother dipped him in the river styx as a baby to make him immortal, his only weakness was his heels where she held him when she dipped him in the river was eventually killed by a poison arrow to the heel.

10. Anatomy of Posterior Heel
Achilles tendon
Posterior calcaneus posterior tuberosity superior prominence
Retrocalcaneal bursa
Adventitial bursa

11. Insertional Tendonitis
Tenderness posterior heel
Swelling
Bony prominence

12. Confirming Diagnosis of Insertional Tendonitis
X-ray
MRI
Frequently not needed

13. Achilles Tendinosis Chronic pain with activity
Fusiform enlargement 4- 8cm above heel

14. Confirming Diagnosis of Tendinosis
MRI
Diagnostic ultrasound
Operator dependant

15. Nonsurgical Treatment of Tendonitis and Tendinosis
Activity modification
NSAIDs
Heel lift (1/4 - 3/8 inch)
Achilles stretching
Night time AFO
Immobilization
Physical therapy
Eccentric strengthening

16. Surgical Treatment of Insertional Tendonitis and Tendinosis
Debride tendon
Possible achilles lengthening
Excise
Bony prominence
Calcification

17. Achilles Tendon Rupture
Acute injury
Palpable dell
Lack of plantarflexion w/ Thompson test
Thompson test

18. Achilles Tendon Rupture
Acute injury
Surgical repair
Wound healing complications
Cast immobilization
Increased rerupture rate

19. Ankle Inversion Injuries
Lateral Ankle Sprain
Syndesmosis Injury (high ankle sprain)
Peroneal Tendon Injury
Talar Osteochondral Injuries
Ankle Fracture
5th Metatarsal Fracture

20. Ankle Sprains Tender over involved ligaments Antalgic gait
Significant swelling
Stability tests – more important in chronic setting.

21. Anterior Drawer Test

22. Talar Tilt
Stress views

23. Treatment of Ankle Sprains
Control Inflammation
RICE
NSAIDs
Restore normal function
PT for motion, strength and balance
Surgery for chronic instability

24. Peroneal Tendon Injuries
Acute
Usually inversion injury
Rupture
Retinacular injury w/ subluxation
Chronic
Tendonitis/tendinosis
Fibular groove insufficiency

25. Peroneal Tendon Subluxation
Acute or Chronic generally same treatment
Diagnosis usually clinical
Subluxation occurs w/ eversion against resistance
Immobilization followed by physical therapy
If pain persists then surgery

26. Peroneal Tendonitis/Tendinosis
Initial treatment
NSAIDs
Physical therapy
MRI
Helps differentiate
Surgical treatment
Repair of split tear
Excision w/ tenodesis
Acute rupture is extremely rare and treated w/ surgical repair

27. Ottowa Foot and Ankle Rules
Tenderness in distal 6 cm of the tibia or fibula
Inability to take four steps at time of injury and upon presentation
Foot
Tenderness to navicular tuberosity or 5th metatarsal base
The rules have been found to have a very low rate of false negatives. Evidence in systematic reviews supports the Ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and mid-foot most common w inversion injuries. The instrument has a sensitivity of 99% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30-40%. [2]

28. Ankle Fractures Cast immobilization Surgical ORIF
Less than 2mm displacement
Surgical ORIF
Greater than 2mm displacement
Early ROM

29. Ankle Fractures

30. Syndesmosis Injuries “High” Ankle Sprains

31. High Ankle Sprains Injury to the syndesmosis External rotation force
Turf sports particularly susceptible
Complain of pain with push off and difficulty with ankle dorsiflexion
Exam
Squeeze test- compression of tib/fib at mid calf
Pain on palpation of distal tib/fib ligament
External rotation stress test
Significantly less swelling and ecchymosis than accompanies lateral sprains

32. High Ankle Sprains AP, Mortise, and Lateral views Stress views
Medial clear space < 4mm

33. High Ankle Sprain Treatment
Without fracture or gross radiographic evidence of syndesmotic widening can be treated nonoperatively
Temporary stabilization with short leg cast or brace to decrease acute symptoms
Aggressive rehab program for motion, strengthening and proprioception
Time for return to activity is longer than inversion ankle sprain

34. 5th Metatarsal Fracture
Jones fracture – proximal metaphysis fracture
Poor healing due to blood supply, high nonunion rate
Must be treated NWB w/ crutches or surgery

35. 5th Metatarsal Fracture
Avulsion fracture or shaft fracture
WBAT in CAM boot
Surgery is only needed if there is displacement of the fracture

36. Posterior Tibial Tendon
Stabilization of foot
Inversion of subtalar joint
Adduction of forefoot
Ankle plantarflexion

37. Pathophysiology of PTT Dysfunction (PTTD)
High loads
Poor blood supply
Multiple insertion
Shear within tendon
Systemic conditions

38. Spectrum of PTTD Tendonitis Interstitial tearing Complete tear
Elongation
Complete tear
Deformity
Degenerative changes

39. Symptoms of PTTD Pain Swelling Deformity Posterior medial
Worse with activity
Weakness “tiredness”
Swelling
Deformity
Flatfoot

40. Signs of PTTD Tenderness and swelling Deformity Weakness
Along course of tendon
Posterior and inferior to malleolus
Deformity
Flatfoot: Too many toe sign
Hindfoot valgus
Weakness
Single heel raise

44. Confirming Diagnosis Plain x-ray Ultrasound MRI Must be weight bearing
Operator dependant
MRI
Study of choice

45. AP X-ray in PTTD Increased TC angle Lateral subluxation talonavicular
Lost second MT bisection of TC angle

46. Lateral X-ray in PTTD Increased talocalcaneal (TC) angle
Sagging midfoot talonavicular navicular cuneiform medial MT cuneiform
Increase talocalcancal overlap

47. Stages PTT Dysfunction
Stage I
Pain,swelling & weakness w/o deformity
Stage II
Same as I, but with flexible flatfoot deformity
Stage III
Rigid flatfoot deformity
Stage IV
Rigid flatfoot w/ valgus ankle deformity as well

48. Nonsurgical Treatment Goals for PTTD
Symptom reduction
Stress reduction
Support arch
Improve hindfoot alignment
Prevent progressive deformity
NSAIDs
Immobilization
Medial heel wedge
Orthosis
UCBL
AFO

49. Surgical Treatment for PTTD
Calcaneal osteotomy
Neck lengthening
Medializing osteotomy
PTT repair
Possible FDL transfer
Cuneiform osteotomy
Arthrodesis
STJ
TNJ
Triple

50. Ankle Arthritis
Post traumatic most common
Rheumatoid arthritis

51. Treatment of Arthritis
Non-surgical care
Physical Therapy
Activity modification
Medication
Braces
Injections
Cortisone
Viscosupplementation
Surgical Care
Arthroscopy
Joint replacement surgery
Arthrodesis

52. Injections Cortisone Viscosupplementation (hyaluronan)
Strong anti-inflammatory
Limit of 3-4/year
Viscosupplementation (hyaluronan)
Only approved for the knee
Augments synovial fluid
Synvisc (3 injections)
Hyalgan/Supartz (5 injections)
Pomegranate fruit extract inhibits MMP (Matrix metalloprotienases) which are active in cartilage turnover.
Surgical management Used when non-operative treatments have failed to provide adequate relief

53. Ankle Fusion Good pain relief Younger patient Loss of motion
Late arthritis in foot
Gold standard

54. Ankle Replacement Older patients Rheumatoid patients Lasts 15-20 years…

55. Fusion vs Replacement Fusion Replacement Gold standard Young patients
Correct deformity
Transfer arthritis
Replacement
The new standard
Preserves motion
Wears out
Can not correct major deformity
Requires ligament integrity
k fusions, 4k replacements, k fusions 10k TAA

56. References Netter F. Atlas of Human Anatomy. 1989.
Coughlin M, Mann R, Saltzman C. Surgery of the Foot and Ankle
Banks A, Downey M, Martin D, Miller S. McGlamry’s Comprehensive Textbook of Foot and Ankle Ed
Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR (April 1992). "A study to develop clinical decision rules for the use of radiography in acute ankle injuries". Ann Emerg Med. 21 (4): 384–90.

57. Thank You