Foot & Ankle Injuries and Treatment

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Foot Ankle Injuriesand Treatment

• Dr. John R. Sallade
• Physical Therapist
• Board Certified Sports Medicine
• Fellow Academy Applied Functional Science

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Classes of Conditions

• gt Traumatic surgical intervention
• non surgical intervention
• Insidious onset
• Congenital

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Traumatic

• Fractures Ankle
• Mid foot
• Forefoot
• Tendon tears Achilles (plantaris)
• Posterior Tibialis
• Peroneal
• Repair, ORIF /- Immobilization, WB, PT

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Osseous Anatomy
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Osseous Anatomy
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ORIF
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ORIF
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ORIF
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OREF (Hoffman)
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Immobilization
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Repair MRI
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Immobilization
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Post Operative Complications

• Stiffness
• Weakness
• Decreased propioception
• Decreased vascularity, edema
• Infection
• RSD CRIPS
• DVT PE

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Non traumatic InjuriesInsidious Onset

• Tendinosis
• Stress fractures
• Bunions , Hallux Limitus
• Hammer toes
• Metatarsalgia
• Neuromas
• Plantar Fascitis
• Compartment Syndrome

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Non Traumatic Injuries

• Blisters
• Callosities
• Sub ungula hematomas
• Arthritis
• pump bumps
• Apophositis
• Sesmoiditis
• Infections

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Peroneal Tendons
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Medial Tendons
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Tendinitis(post. tib., achilles, peroneal)

• Usually insidious in onset
• Pain with WB stretch or contraction
• Improves with light activity
• Latent inflammatory response
• TTP, warm
• Labs and Radiography not helpful

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Treatment

• Relative rest
• Ice 15
• Anti inflamatories dosage and duration
• PT - Find the biomechanical cause
• modalities, stretching, strengthening (hip
  partner), transverse friction massage,
  biomechanical control (shoes, inserts, lifts or
  orthotics)

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Ankle Sprains

• Account for 25 of all sports injuries
• Lateral (ATFCF)(85)
• Medial (Deltoid)gt
• High (Syndesmosis)gt
• Mid tarsal
• Possible causes
• Cavus, poor proprioception, poor rehab, over
  weight and poorly conditioned
• No significant male female ratio

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Ankle Ligaments
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High Ankle sprain
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Midtarsal Sprain
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Treatment

• Surgery?
• RICE
• Progressive WB
• Immobilization and Early mobilization
• Closed Chain Exercise
• Looking for a cause

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Closed chain Exercise
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Plantar Fascitis
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Causes

• Unlocked midtarsal joint at push off phase of
  gait causing stretch to fascia
• Variety of foot types
• Tight heelcords for level of function
• Tight great toe flexors or fascia
• Weakness in control of pronation
• Training errors, shoes

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Treatment

• No correlation to heel spurs
• Differentiate from tarsal tunnel
• Treat the cause
• Stretch tight heel cords and FHL
• Support unstable biomechanics orthotics, taping
  or arch strapping
• Night splints, morning/first step routine
• Analgesic modalities, injections? Surgery?

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Treatment for Plantar Fascitis
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Treatment for plantar fascitis
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Bunions(Hallux Valgus)
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Bunions

• Both medial (1st MTP) and lateral (5th)
• In medial bunion
• Over pronated foot with abductus (toe out)
• Tight heel cords
• Forefoot varus

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Treatment

• Treat the cause
• Symptomatic relief with modalities
• Heel cord stretching
• Fore foot support via orthotic
• Strengthening
• When is surgery the best option?

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Treatmentstretching orthotics
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Stress Fractures Micro FracturesMost common
sites metatarsals
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Tibia
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Calcaneal
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Calcaneal
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Femur
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Stress FracturesProbable Causes

• Increasing the amount or intensity of an activity
  too quickly (most common)
• Hard or uneven running surface
• Improper or old shoes
• Untreated biomechanical imbalances
• Biomechanical limitations of motion (subtalar and
  midtarsal joints)

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Other Risk Factors forStress Fractures

• Risk Factors
• Female, short, thin and caucasian
• Certain sports, especially involving plyometric
  loading
• Distance running
• Gymnastics
• Dance
• Basketball and Tennis
• Amenorrheagtdecrease hormone support
• Poor diet- low in calcium and high in acidity
• Osteopenia (Reduced bone thickness or density)
• Poor muscle strength or flexibility
• Overweight or underweight

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Compartment Syndrome

• Compartment syndrome is a painful condition that
  occurs when pressure within the muscles builds to
  dangerous levels. This pressure can decrease
  blood flow, which prevents nourishment and oxygen
  from reaching nerve and muscle cells.
• Compartment syndrome can be either acute or
  chronic.
• Acute compartment syndrome is a medical
  emergency. It is usually caused by a severe
  injury. Without treatment, it can lead to
  permanent muscle damage.
• Chronic compartment syndrome, also known as
  exertional compartment syndrome, is usually not a
  medical emergency. It is most often caused by
  athletic exertion.
• Compartments are groupings of muscles, nerves,
  and blood vessels in your arms and legs. Covering
  these tissues is a tough membrane called a
  fascia. The role of the fascia is to keep the
  tissues in place, and, therefore, the fascia does
  not stretch or expand easily.

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Compartment Syndrome
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Symptoms and Diagnosis

• Chronic (Exert ional) Compartment Syndrome
• Chronic compartment syndrome causes pain or
  cramping during exercise. This pain subsides when
  activity stops. It most often occurs in the leg.
• Symptoms may also include
• Numbness
• Difficulty moving the foot
• Visible muscle bulging

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Differential

• Chronic (Exertional) Compartment Syndrome
• To diagnose chronic compartment syndrome, other
  conditions that could also cause pain in the
  lower leg should be ruled out. Tendonitis can be
  ruled out but history and physical exam
  (palpation, passive and resistive tests) . To
  rules out stress fractures, an x-ray, bone scan
  or CT scan can be used depending on the duration
  and location of the injury.
• To confirm chronic compartment syndrome, pressure
  tests of the compartment before and after
  exercise must be performed .
• Treatment may involve a combination of rest,
  activity modification, change of shoes and
  orthotics and PT or in more involve cases surgery
  (fasciotomy).

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Testing Fasciotomy
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Reflex Sympathetic DystrophyChronic Regional
Pain Syndrome

• Hyper reactivity of the sympathetic nervous
  system causing sustained fight and flight
  response.
• The symptoms of RSD/CRPS often progress in three
  stagesacute, dystrophic, and atrophic.
• The acute stage occurs during the first 13
  months (usually after injury to bone or nerve,
  surgery and/or immobilization of an extremity)
  and may include burning pain (not proportionate
  to the degree of injury), swelling, increased
  sensitivity to touch, increased hair and nail
  growth in the affected region, joint pain, and
  color and temperature changes.

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Advanced Symptoms

• The dystrophic stage may involve constant pain
  and swelling. The affected limb may feel cool to
  the touch and appear bluish in color. Muscle
  stiffness, wasting of the muscles (atrophy), and
  early bone loss (osteoporosis) also may occur.
  This stage usually develops 36 months after
  onset of the disorder.
• During the atrophic stage, the skin becomes cool
  and shiny, increased muscle stiffness and
  weakness occur, and symptoms may spread to
  another limb.
• Characteristic signs and symptoms of sympathetic
  nervous system involvement include the following
• Burning pain
• Extreme sensitivity to touch
• Skin color changes (red or bluish)
• Skin temperature changes (hot or cold)

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RSD appearance
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Treatment

• Treatment
• The goals of RSD/CRPS treatment are to control
  pain and promote as much mobilization of the
  affected limb as possible without increasing
  symptoms. Treatment must be individualized and
  will often combine medications, physical therapy,
  nerve blocks (ganglion blocks with alpha
  adrenergic antagonist), and psychosocial support.
  Sympathectomy can be helpful in recalcitrant
  cases.
• Early detection and intervention is paramount.

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Metatarsalgia

• Inflammation of the heads of one or more
  metatarsal heads (periostitis)
• Caused by uneven loading of forefoot during
  propulsion
• Caused by forefoot imbalance or deformity

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Metatarsalgia
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Treatment

• Rest, ice and NSAIAs
• Shoe, cushioned insoles
• Callous reduction (egg)
• Biomechanical exam to determine extent of
  forefoot imbalance and prescription of custom
  orthotic with FF balancing and relief cut outs

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Treatment
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Inter Metatarsal (Mortons) Neuroma

• Enlarged, fibrotic and benign interdigital nerves
• Most commonly between the third and forth
  metatarsals
• Brought on by shearing between metatarsals
• Aggravated by narrow shoes and forefoot imbalance
• Treatments include special shoes or inserts,
  NSAIAs and/or cortisone injections, but surgical
  removal of the growth is sometimes necessary.

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Neuromas
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Treatment
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Osteo arthritis

• condition characterized by the breakdown and
  eventual loss of cartilage in one or more joints
  (anklegtMTJgt1st MTPgtST)
• degenerative arthritis, reflecting its nature to
  develop as part of the aging process
• Pain and stiffness in the joint, swelling in or
  near the joint, difficulty walking or bending the
  joint

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Radiography
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Treatment

• Proper footwear
• Medications to relieve pain and swelling (NSAIA,
  analgesic, glucosamine)
• Education on activity modification
• Weight loss
• PT -heat/cold therapy, E Stim., US, exercises to
  improve range of motion and strength, insoles or
  custom orthotics
• Injections and in some cases surgery.
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