1. FOOT + ANKLE INJURIES
Shane York, DPM, FACFAS

2. Foot/Ankle Injuries Topics of Discussion Details of Each Injury
Soft Tissue Injuries
Sprains and Strains
Fractures / Dislocations
Overuse Injuries
CRPS
Review of Injury
Treatment Options
Course/Length of Treatment

3. Soft Tissue Injuries Puncture Wounds
Sharp or blunt penetration of skin
Introduction of pathogens
Tetanus and antibacterial coverage
Cultures required
May require irrigation and closure
If severe, surgical I+D
Offloading may be required

4. Soft Tissue Injuries Lacerations
Tetanus and Antibiotics
Method of closure
Skin seal/heal at 2-3 weeks (top vs. bottom)
Tx depends on depth (tendon, nerve, art-vein)
Deeper structure may require repair
Offloading may be required

7. Soft Tissue Injuries Foreign Body
Tetanus and Antibiotics
Imaging can be difficult
Removal: partial or complete
Attempt in office under local (Epi)
May require open removal and irrigation
Delayed closure if complex

8. Soft Tissue Injuries Nail Pathology
Ingrown Nail
(antibiotics vs. removal)

9. Soft Tissue Injuries Nail Pathology
Subungual Hematoma
-blunt trauma dorsum toe
-evacuation occasionally required
-surgical shoe
-antibiotics if associated with digital fracture (considered open fx)

10. Soft Tissue Injuries Skin Infections (Fungal)
-Fungal Nail Changes
-rarely work related
-oral antifungal or removal
-Tinea Pedis/Athletes Foot
-locations of infection
-topical and/or oral med tx

11. Soft Tissue Injuries Skin Infections (Bacterial)
Cellulitis and Abscess
Most often related to skin trauma
Oral vs. IV antibiotics
Severe cases require I+D
Culture all drainage (focus Ab coverage)
If abscess surgically opened, delay closure
Wound-Vac
Hematoma may become infected

15. Sprains and Strains Joints held together with ligaments
Involves trauma with force across joint
Ligaments stretched or torn
Tendons pulled beyond anatomic length
Varying degrees of tendon
injury sustained

16. Forefoot Sprains Typically involve Metatarsal Phalangeal Joints
Force against toes from side or ground
Produces stretch and/or tear of ligament
May involve Dislocation
Closed Reduction attempted / turf toe plate
If closed reduction fails→ Open Reduction
Open Reduction may require fixation

18. Lisfranc Sprains Metatarsals meet the midfoot Peak of arch(s)
Base of 2nd metatarsal articulation- Keystone
Most commonly missed ortho injury in ED
Usually involves subtle dislocation
MRI required to diagnose sprain
Cam Walker, orthotic, turf toe plate
Often required surgical ORIF

21. Ankle Sprains Major stabilization between foot and leg
Medial and Lateral involvement
Injury to ligament can range from simple stretch to frank tear
Most treated conservatively
(brace, boot, cast)
Surgery rarely indicated (repair vs. reconst)

22. ATF Ligament Sprain

23. Chronic Pain after Ankle Sprain
-Conservative tx fails
-MRI (bone bruising or cartilage damage)
Osteochondral Defect (OCD)

24. Sprain Ankle Osteochondral Defect of Talus

25. Syndesmotic Sprain

27. Fractures of Foot + Ankle
Wide range (digital fx to calcaneal fx)
Time for bone healing
Stabilization required
Callus formation
Bone stimulation
Displacement and
need for surgery

28. Digital Fracture Involve one of three toe bones
May require closed vs. open reduction
Surgical shoe or cam walker
Antibiotics given for nail plate trauma with fx
Open surgical reduction requires pin or screw

29. Metatarsal Fracture Treatment may depend on which metatarsal
Jones Fracture (5th Metatarsal)
If (-) Displacement
-Limited to no weight bearing 3-6 weeks
-Cam walker, cast, surgical shoe
-Monitor healing with radiographs

30. Metatarsal Fracture If (+) displacement Closed reduction difficult
Open reduction and fixation required
Plating, screw or pin fixation

32. Jones Fracture 5th Metatarsal Fracture
-statistically difficult to heal
-poor arterial supply to area
-increased need for non-weight bearing
-cast or cam walker
-bone stimulation frequently required
-surgical fixation and bone stimulation

33. Midfoot Fractures Cuboid Cuneiforms Navicular
-typically treated conservatively
-surgery required when joint involved
-casting or cam walker

34. Calcaneal Fracture High energy injury CT scan
Casting and NWB for non-displaced fx’s
Bone stimulation
Surgical ORIF
-Healing of lateral incision (high complication)
-Range of motion as soon as incision heals

35. Calcaneal Fracture

36. Ankle Fractures
Rotational force to medial and lateral ankle

37. Ankle Fractures Rotational force to medial and lateral ankle
Typically involve ligament injury

38. Ankle Fractures Rotational force to medial and lateral ankle
Typically involve ligament injury
Tibia, Fibula, Bi-Malleolar, Tri-Malleolar, Pilon

39. Ankle Fractures May involve Syndesmosis
(fibular fractures ABOVE ankle joint)

40. Ankle Fractures
May involve Syndesmosis
Closed reduction and splinting

41. Ankle Fractures May involve Syndesmosis
Closed reduction may be required
Definitive treatment depends on reduction

42. Ankle Fractures When reduction adequate and stable
-splint changed at 1 week to cast or boot
-NWB typically required
-bone healing requires approx 6 weeks

43. ORIF Ankle When reduction not adequate or unstable
Combination of plates and screws
Fixation may be required medial and lateral
Syndesmotic repair (may require removal)
RoM may start when incision heals

46. Syndesmotic Repair

47. Tightrope Repair

48. Pilon Fractures Tibial fracture involving joint surface
Poor prognosis (eventual arthrosis)
Often require initial external fixation
When edema reduced, final surgical fixation
Lengthy NWB required
Bone healing monitored closely

50. Dislocations
Occurs when the force of injury overpowers the strength of the ligament crossing a joint
Time to heal
Soft tissue stabilization (cast or boot)
When surgery needed
Methods of surgical stabilization

51. Tendon Tears Can begin as overuse Tear longitudinal
Small tear/rent propagates
Often where tendon changes course

52. Tendon Ruptures Most often diseased tendon
“normal tendons don’t rupture”

56. Overuse Injuries
Plantar Fasciitis
Stress Fractures
Neuroma
Tendonitis

57. Plantar Fasciitis/Heel Pain
Most common visit to Foot/Ankle specialist
Often called “Heel Spur”

58. Heel Pain / Plantar Fasciitis
Pain with first step in am
Mild pain reduction with activity
Pain after periods of rest
Often no history of trauma
Worse when barefoot
History of bone spur to the heel

59. Heel Pain / Plantar Fasciitis
Collapse of arch or increased pressure
Chronic pull of tissue at heel
Inflammation of band of tissue
Severe pain to the heel

60. Heel Pain Evaluation
X-Ray Examination
(role of heel spur)

61. Plantar Fasciitis Treatments
Supportive shoe gear
OTC arch supports
Heel Pad misconception
Anti-Inflammatory meds
Deep massage to heel
Night splint
Physical Therapy
*ASTYM-GRASTON*

62. Heel Pain Treatments Steroid Injection Aggressive PT RICE
Taping / Strapping
Custom Orthotics
Surgical Release (<5%)

63. Custom Orthotics Personalized device to fit in shoes
Correct abnormal or irregular forces
Restore proper foot function and balance
Excellent conservative approach
Rigid, Soft, Semi-Rigid
Address “CAUSE” of heel pain

64. Stress Fractures Stress Reaction→ Stress Fracture→ Fracture
Related to overuse
Abnormal stress on normal bone
Seen with Osteopenia/Osteoporosis
Difficult to view on Xrays initially
X-ray vs. MRI/Bone Scan
Treatment (boot, cast, turf toe)

65. Neuroma Inflammation of peripheral nerve
May occur at various locations in foot/ankle
Most often found in between metatarsal heads
Clinical diagnosis and imaging

66. Neuroma (Morton’s) Irritated nerve between heads of bone
Nerve swollen and damaged
Benign growth
Pain, burning, and tingling, or numbness between toes
May radiate to toes

68. Neuroma Treatment Anti-inflammatory medication Padding of insole
Custom orthotics
Cortisone injections
Sclerosing injections
Nerve resection / decompression
RFA

69. Tendonitis Related to overuse of a tendon
Inflammation develops in or around tendon
May relate to underlying foot structure
(ie: high arch and low arch)
-Treat by addressing foot deformity
-Bracing, Cam Walker

71. Blood Flow Restriction Training (BFRT)
Newer form of PT
Bodybuilders
Military-Large Universities
Cuffs used to occlude venous-arterial flow
Flow diminished to muscles
Baseline level determined
80% of baseline for treatment

72. BFRT
Low intensity resistance training with blood flow restriction leads to:
-Increase muscle size strength (20% 1RM)
-Safer than higher intensities

73. BFRT Mechanisms of Action -increased cellular swelling
-enhanced metabolic stress
-increased muscle recruitment

74. Foot/Ankle Use of BFRT -Achilles Tendon Rupture Repair
-Ankle Fracture Repair
Benefits:
Increase muscle- less load on limb
Early RoM
Ease of transition back to activities

75. Complex Regional Pain Syndrome
Injury may range from mild blunt trauma to severe open fracture/dislocation
RSD (Reflex Sympathetic Dystrophy)
Injury (varying degrees)
Pain (becomes chronic)
“Out of Proportion”
Autonomic Changes (skin, hair, swelling)
Osteoporosis, Contractures, Atrophy
Symptoms spin out of control
Diagnosis often missed or confused

76. Reason Behind Response
Painful Injury
Pain signal sent from foot to spinal cord (en route to brain)
Pain signal elicits “Fight or Flight Response”
Message back to foot (prepare to defend or run)
Fight or Flight response never calms!

77. Instead of nerve (red) causing muscle to contract (via reflex), the “Fight or Flight” nerves are activated and continue to fire

78. Typical Treatments for CRPS
Nerve Blocks (interrupt pain signal)
Pain Meds
Neuropathy Meds
Morphine Pump
Spinal Cord Stimulator

79. Concept of Management
Focus on stopping pain signal instead of treating symptoms
-free nerves from scar tissue (injury site)
-remove (excise) painful nerve

80. CRPS Treatment Course Diagnose Early! Difficult to monitor progress
Physical Therapy
Involve Pain Clinic

81. Thank You