1. Common Ankle and Foot Injuries
Richard V. Abdo, M.D.

2. Richard V. Abdo, M.D. College - Brown University (with Honors)
Medical School – SUNY Upstate (Syracuse), Cum Laude,
Orthopaedic Surgery Residency - Boston University,
The Lahey Clinic (Boston)
Orthopaedic Specialties present, offices in Clearwater
Reviewer for Foot and Ankle International , Reviewer for American Journal of Sports Medicine 1991-present

3. Plantar Fasciitis What is it?
Inflammation of the plantar fascia attachment to the heel bone (calcaneus). A traction (bone) spur may or may not be present. Entrapment of nerve may contribute to symptoms.
Calcaneus/heel bone
Heel/bone spur

4. Plantar Fasciitis
The low back pain of the foot

5. Plantar fascia – windlass mechanism
Windlass – a device for hauling or hoisting

6. Clinical Presentation
Plantar Fasciitis
Clinical Presentation
Pain and tenderness medial plantar heel
Worse on arising in the morning or after prolonged sitting
Increased with activities
X-rays – may show bone thickening or spur

7. Plantar Fasciitis Treatment Weight reduction
Activity modification, rest
Stretching exercises
NSAID’s, Ice
Heel cushions, orthotics
Nighttime splint
Cortisone injection
Physical therapy – ultrasound
Surgery - ~10% of patients

8. Platelet-Rich Plasma (PRP)
Platelets are small cells in the blood. They become activated at the site of injury or inflammation, and release beneficial proteins called growth factors.
PRP is obtained from a small amount of blood collected from the patient’s arm.

9. Platelet-Rich Plasma (PRP)
The blood goes through a rapid spinning process (centrifuge) that separates the platelet-rich plasma
PRP is injected at the site of injury or inflammation (e.g. plantar fasciitis)

10. Plantar Fasciitis Surgery Options Open release – invasive
Endoscopic plantar fascia release
Extracorporeal Shockwave Therapy (ESWT) – orthotripsy, noninvasive
Ankle
Incision
Arch
Bottom of heel

11. ESWT Heel Treatment/Orthotripsy
The Ossatron device provides a non-invasive alternative to open surgery with an estimated 75% success rate.

12. Retrocalcaneal (Heel) Bursitis and Insertional Achilles Tendinitis
What is it?
Inflammation of the bursa between the Achilles tendon and the heel bone (calcaneus). May be associated with insertional Achilles tendonitis and calcium deposits or spurs.
Spur

13. Retrocalcaneal (Heel) Bursitis
Clinical Presentation
Pain
Tenderness
Swelling
Warm to touch
X-rays – often calcium deposits or a spur
Pain
Swelling
Warm to touch

14. Retrocalcaneal (Heel) Bursitis
Treatment
Rest/activity modification
Ice, NSAID’s
Heel lift/cushion
Physical therapy
Injection
Cast boot
Surgery

15. Retrocalcaneal (Heel) Bursitis
Surgery
Preop Postop

16. Achilles Tendinitis (Tendinosis)
What is it?
Painful thickening and swelling 2-6 cm up from the back of the heel
Vascular watershed area
Overuse from repetitive microtrauma – runners, jumping sports
Extrinsic factors – change in training pattern, training on hard or uneven surfaces, poor footwear
Intrinsic factors – age, weight, flexibility, foot deformity
Degenerative (tendinosis), rather than inflammatory (tendinitis)

17. Achilles Tendinitis (Tendinosis)
Clinical Presentation
Pain and fusiform swelling at the heelcord
Tenderness upon squeezing the tendon
Worse with activity
Painful to push off while walking
Xrays usually negative
MRI not usually needed
Fusiform swelling
Heel

18. Achilles Tendinitis (Tendinosis)
Treatment
Activity modification
Heel cushions, heel lifts
PT, stretching, eccentric exercises
Ice
NSAID
Cast boot
Cortisone injection
Platelet rich plasma (PRP) injection

19. Achilles tendinitis (Tendinosis)
Surgery
Debride degenerative tendon fibers
Transfer tendon if needed

20. Stress Fractures What is it?
Microscopic failure of bone due to overuse microtrauma that overwhelms the normal bone repair process
Most common with repetitive impact activities – runners
History of new fitness activity, change in training program, poor footwear, hard running surface
Foot deformities and decreased flexibility increase risk of stress fracture

21. Clinical Presentation
Stress Fractures
Clinical Presentation
History of change in activity/fitness
Pain, swelling, and tenderness localized to the bone involved
Usually no distinct trauma
High risk stress fractures in area of poor blood supply: 5th metatarsal (Jones’ fx.), navicular, ankle medial malleolus)
Xrays – may be normal initially
Bone scan – sensitive, but not specific
MRI – preferred, sensitive and specific

22. Stress Fractures Treatment Rest, non-impact conditioning
Immobilization – cast boot, postop shoe
Limited or non-weight-bearing depending on location of fracture
Elevation and ice
Avoid NSAID’s
Physical therapy
High risk fractures – bone stimulator, surgery

23. Stress Fractures
Jones’ Fracture

24. Stress fractures
Medial Malleolus

25. Ankle Sprains What is it?
An injury that stretches, frays, and tears ligaments. Ligaments connect one bone to another, providing support and stability for a joint.

26. Clinical Presentation
Ankle Sprains
Clinical Presentation
Pain and tenderness
Swelling
Ecchymosis (black and blue)
Severity – mild, moderate, severe
X-rays – normal, occasionally a chip fx.
Tibia
Fibula
Talus

27. Ankle Sprains Treatment P – Protection (ankle splint) R – Rest I – Ice
C – Compression (ace wrap)
E – Elevation
Additonal – NSAID’s, physical therapy

28. Soft Tissue Impingement
probe
Anterolateral impingement syndrome
What is it?
1. ligament and synovial thickening
2. fibrosis
3. adhesions
Scar tissue

29. Soft Tissue Impingement
Clinical Presentation
History of ankle sprain(s)
Pain and tenderness over anterolateral corner of joint
Localized swelling
No instability
outside (lateral)
inside (medial)
Front of right ankle

30. Soft Tissue Impingement
Treatment
NSAID’s
Ankle splint
Physical therapy
Ice
Cortisone injection
Arthroscopic surgery debridement

31. Talus Osteochondral Lesion/Defect
What is it?
A fracture, bruise, or softening of a small segment of the talus cartilage and bone at the ankle joint. Usually located at the medial or lateral corner of the talar dome.
Medial talar dome lesion

32. Clinical Presentation
Talus OCD
Clinical Presentation
History of ankle sprains(s)
Pain, swelling, clicking
Sensation of instability
X-rays may be normal or underestimate the extent of the lesion
MRI scan
Xray

33. Talus OCD
MRI

34. Talus OCD Treatment Depends on location and stage/severity of lesion
Ankle splint
NSAID’s
Physical therapy
Cortisone injection
Surgery – arthroscopic debridement/drilling, bone/cartilage grafting.
Tibia
Talus

35. Talus OCD
Allograft procedure

36. Talus OCD
Allograft procedure

37. Talus OCD
Allograft procedure

38. Particulated Juvenile Cartilage Transplantation Denovo
Talus OCD
Particulated Juvenile Cartilage Transplantation Denovo

39. Particulated Juvenile Cartilage Transplantation Denovo
Talus OCD
Particulated Juvenile Cartilage Transplantation Denovo

41. Bone Impingement What is it?
Bone spurs that develop around the margin of the joint that create local inflammation and irritation.
“sports” spurs

42. Clinical Presentation
Bone Impingement
Clinical Presentation
Anterior – most common
Distal tibia and dorsal talus
Repetitive impact injury over a lifetime, particularly athletics
Tenderness, swelling
Decreased dorsiflexion
Bone spur

43. Bone Impingement Treatment NSAID’s Heel lift Ice Cortisone injection
Arthroscopic surgery - removal
Bone spur removed

44. Plantar Neuroma/Morton’s Neuroma
What is it?
Thickening, entrapment, fibrosis/scarring of the interdigital nerve between the metatarsal heads in the ball of the foot.

45. Plantar Neuroma/Morton’s Neuroma
Clinical Presentation
Burning, shooting pain localized to the plantar aspect of the affected interspace
3rd interspace > 2nd interspace
Worse wih activities or constrictive shoewear
Intermittent symptoms
Pain with palpation/pressure of interspace
X-rays - negative

46. Plantar Neuroma/Morton’s Neuroma
Treatment
Shoes – wide toe box
MT pad (and/or orthotic with MT pad)
Ice, NSAID’s
Injection
Surgery
MT pads

47. Plantar Neuroma/Morton’s Neuroma
Surgical Excision
neuroma

48. Other conditions Posterior tibial tendinitis Peroneal tendinitis
Flexor hallucis longus tendinitis (dancers)
Os trigonum syndrome (dancers)
Tarsal tunnel syndrome
Jogger’s foot (medial plantar nerve entrapment)
Sinus tarsi syndrome
Turf toe
Hallux rigidus

49. Thank You
Questions ?