2/1/2018
THESE FEET WON’T KARRIE LYNN CROSBY, WALK! WHAT’S NEXT? MPAS, PA-C
OBJECTIVE
DISCUSS DIAGNOSIS AND TREATMENT OF COMMON FOOT AND ANKLE PROBLEMS
PLANTAR FASCIITIS
1 2/1/2018
PLANTAR FASCIITIS
DIAGNOSIS/HISTORY: .FIRST STEP OR AM PAIN .RECENT SHOE GEAR CHANGE .STAND FOR LONG PERIODS OF TIME .WHAT TYPE OF FLOORING DO THEY HAVE OR STAND ON? .BAREFOOT .PLANTAR FASCIA PAIN ON PALPATION, TIGHT GASTROCS .NO OTHER DIAGNOSIS SUPPORTED ON XRAYS
PLANTAR FASCIITIS
TREATMENT: . AVOID GOING BAREFOOT . SHOE GEAR CHANGE . DON’T WEAR SAME PAIR OF SHOES MORE THEN 1 DAY . DON’T WEAR SHOES FOR MORE THEN 500 MILES . WONDERZORB HEEL PADS (CUSTOM ACCOMMODATIVE ORTHOTICS) . ICING . MASSAGE PLANTAR FASCIA BEFORE GETTING OUT OF BED
PLANTAR FASCIITIS
TREATMENT CONTINUED… .GASTROC/SOLEUS STRETCHING .TOPICAL NSAIDS .ORAL NSAIDS .STEROID DOSEPACK .BOOT (NIGHT SPLINTS) .SURGERY- GASTROC SLIDE, TOPAZ PROCEDURE
2 2/1/2018
PLANTAR FASCIITIS
HAGLUND’S DEFORMITY
ACHILLES TENDONITIS
DIAGNOSIS/HISTORY: . OVERUSE . CONCENTRIC EXERCISES LIKE TOE RAISES OR SIMILAR . SHOES THAT HAVE A SEAM OR SHARP HEEL COUNTER . TIGHT GASTROCS . BODY MECHANICS . XRAYS- CALCIFICATIONS IN ACHILLES OR HAGLUND’S DEFORMITY
. IF TEAR IS SUSPECT ORDER MRI . THOMPSON TESTING
3 2/1/2018
ACHILLES TENDONITIS
TREATMENT: .BOOT OR SHOE WITH HEEL LIFT, REST .ICING .PHYSICAL THERAPY (GASTROC/SOLEUS STRETCH) ECCENTRIC STRETCHING .ULTRASOUND .SHOE GEAR MODIFICATION .NEVER INJECT WITH STEROIDS- RISK OF ACHILLES RUPTURE
GASTROCNEMIUS
ACHILLES TENDONITIS
TREATMENT CONTINUED… .ORAL &/0R TOPICAL NSAIDS, ORAL STEROIDS .WARN ABOUT RECURRANCE OF PAIN AND RESTARTING BEHAVIOR MODIFICATIONS EARLY .SURGERY- GASTROC SLIDE, TOPAZ PROCEDURE, ACHILLES TENDON REPAIR
4 2/1/2018
MORTON’S FOOT TYPE
METATARSALGIA
DIAGNOSIS/HISTORY: .PLANTAR METATARSAL PAIN .OVERUSE, ACTIVITIES THAT PUT AREA UNDER STRESS .POOR SHOE GEAR OR POOR FIT .NO SIGN OF FRACTURE ON PLAIN FILMS .PREVIOUS STEROID INJECTION AROUND THE REGION
IF THE SHOE FITS, WEAR IT
5 2/1/2018
METATARSALGIA
TREATMENT: . APPROPRIATE FIT/TYPE OF SHOES . ACTIVITY MODIFICATION (SIT ON STOOL OR BUCKET INSTEAD OF SQUAT) . AVOID SHOES WITHOUT BACK . ORTHOTIC WITH HAYPAD BELOW POINT OF PAIN TO ELEVATE MT HEAD . ORAL AND/OR TOPICAL NSAIDS . NEVER INJECT DUE TO RISK OF HAMMER TOE FORMATION/EROSION OF FAT PAD . CUSTOM ACCOMMODATIVE ORTHOTICS
METATARSALGIA
STRESS FRACTURE
DIAGNOSIS: .PAIN ON PALPATION DORSUM OF BONE IN FOOT .SWELLING .RECENT SHOE GEAR CHANGE .CHANGE IN WORK OUT REGIMEN .FRAGILITY OF HEALTH, NUTRITION .XRAYS MAY OR MAY NOT SHOW FRACTURE ON INITIAL FILMS
6 2/1/2018
STRESS FRACTURE
TREATMENT: .REST .SHOE GEAR CHANGE .BOOT, NON WEIGHT BEARING .?NEED FOR BONE DENSITY &/OR VIT D SCREENING .CUSTOM ACCOMMODATIVE ORTHOTICS
STRESS FRACTURE
SEDENTARY- THINK DVT RISK
7 2/1/2018
DVT RISK REDUCTION
ASA 325 MG TWICE DAILY ELIQUIS 2.5 MG TWICE DAILY XARELTO 10 MG DAILY LOVENOX 40 MG SC DAILY KNEE SCOOTER PROMOTES MORE MOBILITY
MORTON’S NEUROMA
DIAGNOSIS: .PAIN BETWEEN THE 2ND-3RD OR 3RD-4TH WEBSPACE, PLANTAR ASPECT . SYMPTOMS CAN IMPROVE WHEN BAREFOOT .MULDER’S CLICK .XRAYS RULE OUT OTHER CAUSES OF PAIN .CHRONIC PAIN WITH NEUROPATHIC DESCRIPTION OF PAIN (BURNING, TINGLING, NUMBING)
MORTON’S NEUROMA
TREATMENT: .SHOE GEAR/ACTIVITY MODIFICATIONS .CUSTOM ACCOMMODATIVE ORTHOTICS .ORAL ANELGESICS .SURGICAL EXCISION .AVOID INJECTING- CAN CONTRIBUTE TO HAMMER TOE OR FAT PAD EROSION.
8 2/1/2018
MORTON’S NEUROMA
Mulder’s Click Excised Neuroma
HALLUX VALGUS
HALLUX VALGUS
DIAGNOSIS: . PAIN AND DEFORMITY OF GREAT TOE . XRAYS RULE OUT OTHER REASON FOR PAIN OR DEFORMITY TREATMENT: . SHOE GEAR MODIFICATION- WIDE TOE BOX, STRETCH SHOE . BUNION PAD . ORAL ANALGESICS . LIMITATION IN ADL’S OR TRUE INTERFERANCE IN DAY TO DAY LIFE- CONSIDER SURGERY . SURGERY IS NOT FOR COSMETIC CORRECTION OR SO PATIENT CAN WEAR THEIR FAVORITE SHOES AGAIN
9 2/1/2018
HALLUX VALGUS
HAMMER TOES
HAMMER TOES
DIAGNOSIS: . PAIN AND DEFORMITY OF TOE . XRAYS RULE OUT OTHER CAUSE OF DEFORMITY TREATMENT: . SHOE GEAR MODIFICATION . ORAL ANALGESICS . WRAP, CUSHION, OR STRAIGHTENER . CAUTION IN PATIENTS WITH NEUROPATHY OR CIRCULATORY ISSUES . SURGERY . ?AMPUTATION
10 2/1/2018
HAMMER TOES
HAMMER TOES
HAMMER TOES
11 2/1/2018
HYPERMOBILITY SYNDROME
ANKLE SPRAIN WITH POSSIBLE OCCULT FRACTURE
DIAGNOSIS: .MECHANISM OF INJURY/TRAUMA .PAIN ALONG TIBIA OR FIBULA .SWELLING .ECCHYMOSIS .MAY OR MAY NOT BE ABLE TO BEAR WEIGHT .PLAIN FILMS MAY OR MAY NOT SHOW INITIAL FRACTURE
ANKLE SPRAIN
TREATMENT: .BOOT- WEIGHT BEAR OR NON WEIGHT BEAR? .RICE- REST, ICE, COMPRESSION, ELEVATION . ELEVATE ABOVE THE LEVEL OF THE HEART .RECHECK IN 7-10 DAYS WITH REPEAT FILMS .PROLONGED OR WORSENING SYMPTOMS? CONSIDER MRI TO RULE OUT OSTEOCHONDRAL LESION, TENDON TEAR OR OTHER PATHOLOGY.
12 2/1/2018
ANKLE SPRAIN
FOLLOW UP XRAYS DO NOT SHOW FRACTURE . TRANSITION TO ASO BRACE AND WEAN OUT OF ASO AS PROPRIOCEPTION AND STRENGTH IMPROVE
. CONSIDER SUPERVISED PHYSICAL THERAPY VERSUS HOME EXERCISE PROGRAM WITH PHASE I,II, III EXERCISES WITH THERABAND
ANKLE SPRAIN
FOLLOW UP XRAYS SHOW NON SURGICAL FRACTURE . REMAIN NON WEIGHT BEARING IN BOOT X 4 TOTAL WEEKS . IF F/U SHOWS CLINICAL AND RADIOGRAPHIC SIGNS OF HEALING, PROGRESS TO WBAT IN BOOT X 4 WEEKS . REPEAT FILMS AT 8 WEEKS. TRANSITION TO ASO AND WEAN OUT OF ASO. . CONSIDER SUPERVISED PT CONSULT VERSUS HEP
SYNDESMOSIS TEAR
CONSIDER SYNDESMOSIS TEAR, ESPECIALLY WITH LOW ENERGY ROTATIONAL INJURY TO ANKLE MAKE SURE PLAIN FILMS ARE WEIGHT BEARING OR STRESS (EXTERNAL ROTATION) PAIN ANTERIOR OR LATERAL SQUEEZE TEST- COMPRESSION OF CALF ELLICITS PAIN
13 2/1/2018
SYNDESMOSIS TEAR
CONSIDER MRI IF PLAIN FILMS ARE EQUIVOCAL
SURGERY IF TEAR IS DIAGNOSED
DELTOID TEAR MAY ALSO BE PRESENT- PAIN MEDIALLY
SYNDESMOSIS TEAR
QUESTIONS ?
14