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Diagnosing and Treating Acute and Chronic Pathology of the Foot and Ankle.
Todd Derksen DPM, FACFAS Orthopedic and Sports Institute of the Fox Valley
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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
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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
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Ligaments of the Foot and Ankle
Over 100 ligaments in each foot
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Muscles and Tendons of the Foot
9 extrinsic and 20 intrinsic muscles
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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.
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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
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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.
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Anatomy of Posterior Heel
Achilles tendon Posterior calcaneus posterior tuberosity superior prominence Retrocalcaneal bursa Adventitial bursa
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Insertional Tendonitis
Tenderness posterior heel Swelling Bony prominence
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Confirming Diagnosis of Insertional Tendonitis
X-ray MRI Frequently not needed
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Achilles Tendinosis Chronic pain with activity
Fusiform enlargement 4- 8cm above heel
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Confirming Diagnosis of Tendinosis
MRI Diagnostic ultrasound Operator dependant
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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
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Surgical Treatment of Insertional Tendonitis and Tendinosis
Debride tendon Possible achilles lengthening Excise Bony prominence Calcification
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Achilles Tendon Rupture
Acute injury Palpable dell Lack of plantarflexion w/ Thompson test Thompson test
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Achilles Tendon Rupture
Acute injury Surgical repair Wound healing complications Cast immobilization Increased rerupture rate
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Ankle Inversion Injuries
Lateral Ankle Sprain Syndesmosis Injury (high ankle sprain) Peroneal Tendon Injury Talar Osteochondral Injuries Ankle Fracture 5th Metatarsal Fracture
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Ankle Sprains Tender over involved ligaments Antalgic gait
Significant swelling Stability tests – more important in chronic setting.
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Anterior Drawer Test
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Talar Tilt Stress views
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Treatment of Ankle Sprains
Control Inflammation RICE NSAIDs Restore normal function PT for motion, strength and balance Surgery for chronic instability
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Peroneal Tendon Injuries
Acute Usually inversion injury Rupture Retinacular injury w/ subluxation Chronic Tendonitis/tendinosis Fibular groove insufficiency
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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
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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
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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]
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Ankle Fractures Cast immobilization Surgical ORIF
Less than 2mm displacement Surgical ORIF Greater than 2mm displacement Early ROM
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Ankle Fractures
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Syndesmosis Injuries “High” Ankle Sprains
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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
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High Ankle Sprains AP, Mortise, and Lateral views Stress views
Medial clear space < 4mm
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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
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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
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5th Metatarsal Fracture
Avulsion fracture or shaft fracture WBAT in CAM boot Surgery is only needed if there is displacement of the fracture
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Posterior Tibial Tendon
Stabilization of foot Inversion of subtalar joint Adduction of forefoot Ankle plantarflexion
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Pathophysiology of PTT Dysfunction (PTTD)
High loads Poor blood supply Multiple insertion Shear within tendon Systemic conditions
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Spectrum of PTTD Tendonitis Interstitial tearing Complete tear
Elongation Complete tear Deformity Degenerative changes
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Symptoms of PTTD Pain Swelling Deformity Posterior medial
Worse with activity Weakness “tiredness” Swelling Deformity Flatfoot
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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
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Confirming Diagnosis Plain x-ray Ultrasound MRI Must be weight bearing
Operator dependant MRI Study of choice
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AP X-ray in PTTD Increased TC angle Lateral subluxation talonavicular
Lost second MT bisection of TC angle
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Lateral X-ray in PTTD Increased talocalcaneal (TC) angle
Sagging midfoot talonavicular navicular cuneiform medial MT cuneiform Increase talocalcancal overlap
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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
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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
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Surgical Treatment for PTTD
Calcaneal osteotomy Neck lengthening Medializing osteotomy PTT repair Possible FDL transfer Cuneiform osteotomy Arthrodesis STJ TNJ Triple
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Ankle Arthritis Post traumatic most common Rheumatoid arthritis
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Treatment of Arthritis
Non-surgical care Physical Therapy Activity modification Medication Braces Injections Cortisone Viscosupplementation Surgical Care Arthroscopy Joint replacement surgery Arthrodesis
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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
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Ankle Fusion Good pain relief Younger patient Loss of motion
Late arthritis in foot Gold standard
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Ankle Replacement Older patients Rheumatoid patients Lasts 15-20 years
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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
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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.
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Thank You
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