Agenda . . .
-Plantar fasciitis / heel pain -Achilles tendinopathy Plantar fasciitis -Flatfoot -2nd MP synovitis -Morton’s neuroma
Plantar fasciitis
Old Definition: acquired inflammatory condition characterized by inflammation Inferior heel pain at the origin of the plantar fascia is not necessarily plantar fasciitis New Definition: “fasciosis” with degeneration, inelasticity, and Differential . . . microscopic tears
Plantar fasciitis Plantar fasciitis
Clinical presentation: Differential: - inferior heel pain with insidious onset - entrapment neuropathy - fat atrophy - first-step / morning pain - worsens as day progresses - tarsal tunnel - neoplasm - alleviated with rest - calcaneal stress fracture - plantar fibroma - plantar fascia rupture - Achilles Physical exam . . . Physical exam . . . Take home . . . Take home . . .
Plantar Nerve Lateral wall tenderness . . . calcaneal stress fx Fascia entrapment
Imaging . . . Plantar fasciitis - X-rays if sx’s > 6 weeks Non-operative Rx: - MRI if stress fx - Shoewear modification - Achilles / plantar fascia stretching - Night splint - NSAIDs
Plantar fascia specific stretching . . . Custom orthotics Take home . . .
- No better
Take home . . . Plantar fasciitis Other options: Take home . . .
- Walking cast/boot - Steroid injection (x 1) Refer for surgical evaluation if symptoms persists after - Shockwave 6 months of non-operative treatment
Surgical release for recalcitrant disease What about the heel spur?
Leave it alone
Achilles Tendinopathy
Definition: Tendinosis and/or peritendonitis
Achilles Tendinopathy Etiology: - Inelasticity - Hypovascularity - Overuse / Age - Fluoroquinolones - Constrictive shoes - Inflammatory arthropathy Achilles Tendonitis/osis Achilles Tendonitis/osis
Peritendinitis: inflammation involving peritendinous structures. In acute setting, symptoms typically last less than 2 weeks; in Insertional disease Non-insertional subacute setting, symptoms last 2 to 6 weeks; with chronic disease peritendinitis, symptoms are present 6 weeks or longer. Chronic peritendinitis may be associated with tendinosis.
Peritendinitis with tendinosis: inflammatory process involving peritendinous structures along with degeneration of tendon.
Tendinosis: typically an asymptomatic degeneration of tendon without concomitant inflammation caused by accumulated microtrauma, aging, or both. With tendinosis an interstitial rupture, partial rupture, or acute rupture may develop
Physical exam . . . Physical exam . . . Thompson test:
Take home . . .
No rupture
Ruptured
Imaging . . . Achilles Tendinopathy Clinical presentation: - posterior heel pain and swelling - ankle stiffness - posterior prominence
Differential: Acute rupture Posterior tibial tendon pathology Tarsal tunnel syndrome Posterior ankle impingement (os trigonum, etc.) Achilles Tendinopathy: Non-operative Treatment
Biomechanical measures - Eccentric stretching exercises The term “pump bump” is used - Immobilization - Night splint loosely but generally applies to a Haglund’s process or Local measures swelling associated with - Shoewear modification/stretching insertional Achilles - Gel sleeve tendonitis Biochemical measures -NSAIDs
Non-operative Treatment
-Eccentric stretching -Night splint -Heel lift (1/4”)
Surgical Treatment . . . Take home . . .
When considering steroid injections for Achilles tendonitis, … don’t Insertional Achilles tendinosis . . . Simple . . .
Complex . . . More substantial debridement and FHL transfer: Non-Insertional Tendinosis . . .
Adult acquired flatfoot Definitions 1. Pes planus 1. Pes planus 2. Pes planovalgus 2. Pes planovalgus 3. Adult acquired flatfoot 3. Adult acquired deformity flatfoot deformity 4. Posterior tibial tendon 4. Posterior tibial dysfunction (PTTD) 5. Foot pronation tendon dysfunction (PTTD) - Hindfoot valgus - Forefoot abduction Flatfoot: Potential Etiologies PTTD: Potential Etiologies
1. Posterior tibial tendon dysfunction (PTTD) 1. Hypovascularity 2. Arthritis 2. Obesity • Degenerative 3. Gastrocnemius contracture • Inflammatory 4. Trauma 3. Congenital deformity 5. Systemic inflammatory disease 4. Trauma 6. Systemic non-inflammatory disease 5. Gastrocnemius contracture
Posterior tibial tendon dysfunction: association with seronegative Etiology inflammatory disease
76 patients with PTTD Take home . . . 52 percent of patients with the adult acquired flatfoot secondary to PTTD Two Groups: had either diabetes mellitus, A – Young men (age ~ 39) with other sites of inflammation hypertension or obesity. B – Older patients (age ~ 64) with isolated PTTD ______Myerson MS, et al. Foot Ankle Int., 1989 Holmes GB and Mann RA, Foot Ankle Int., 1992
PTT dysfunction
Staging
Stage I No deformity Diagnosis Stage II Flexible asymmetric deformity Stage III Rigid deformity Stage IV Ankle valgus 1. Medial hindfoot symptoms Diagnosis 2. Medial lateral symptoms History • “Subfibular impingement” 1. History 3. Deformity 2. Physical • “fallen arches,”“pronation” examination 4. Arthritic symptoms 3. Radiographs • Start-up pain, polyarthralgia, 4. Advanced imaging morning stiffness 5. Systemic non-inflammatory disease
Physical Exam Gait analysis 1. Gait analysis 1. Overall alignment 2. Examination Standing 2. Midstance: • Alignment (foot is flat) • arch collapse • Medial foot swelling • valgus thrust of ankle/hindfoot 3. Examination Sitting • Range-of-motion 3. Antalgic gait • Strength testing • shortened stance phase • Neurovascular exam 4. Observe from front, • Palpation back, and side 4. Provocative maneuvers
Examination Standing
• Heel valgus • Abducted foot (“too many toes” sign) • Low arch
•Medial foot/ankle tenderness and swelling Heel valgus •Low arch Examination Sitting Take home . . .
• Medial Swelling • Palpation / Tenderness • Weak inversion • Neurovascular exam
Provocative Maneuvers Take home . . . Silfverskiold test:
1. Detect gastrocnemius contracture 2. Assess for Achilles vs gastrocnemius contracture
With attempted toe raise heel stays in valgus
Diagnosis
Silfverskiold Radiographs Test - must be weight-bearing - ankle and foot Diagnosis Diagnosis Radiographs
Ankle valgus … “Stage IV” PTTD
Diagnosis Diagnosis
Magnetic resonance Radiographs
- Highly sensitive Arthritis - Other structures - Costly - Necessary?
Diagnosis Diagnosis Computed Tomography Ultrasound - Arthritis - Coalition - Inexpensive - Potentially lucrative . . . Not commonly - Center/technician needed dependent . . . Probably note necessary My preferred treatment . . . Take home . . .
6 – 12 mo’s Non-operative Treatment
6 weeks
______Alvarez RG, et al. Foot and Ankle Int’l, 2006
My preferred treatment protocol . . . Stage I and II posterior tibial tendon dysfunction treated by a structured Other options: nonoperative management protocol: an 1. Cast orthosis and exercise program 2. AFO -47 consecutive patients 3. Arizona Brace -AFO/orthosis + physical therapy 4. Stirrup/Sports Brace -Mean f/u 4 months 5. Orthotics -83% patients with successful outcomes 6. Time -89% patients satisfied ______-11% required surgery Alvarez RG, et al. Foot and Ankle Int’l, 2006
Braces . . . Be aggressive . . .
Advantages Custom-fitted Low profile Maximal support
Disadvantages Procurement time Cost Orthotics
- Know your orthotist /podiatrist - “Wholesale” price ~ $100 Sports braces offer coronal support
Orthotics Orthotics
Materials: - Plastazote - Polypropylene - Graphite - Carbon fiber -Others
Physical Therapy
- Modalities and more . . . - Plantarflexion / inversion conditioning - Gastrocsoleus stretching - Peroneal stretching Operative Treatment - Mobilization -Hindfoot valgus -Forefoot varus -Medial ray elevation - Combine with supportive brace Many surgical options . . . But almost everyone gets . . .
FDL tendon transfer - Synovectomy / Debridement - Tendon transfer with calc osteotomy Rationale: Replaces/augments posterior tibial tendon - Lateral column lengthening Comment: Performed in most cases - Isolated hindfoot fusion - Triple arthrodesis - Cotton osteotomy - Arthroereisis - Strayer Medializing calcaneal osteotomy Rationale: Corrects heel valgus Converts Achilles vector from evertor to invertor
Calcaneal Slide
Toes . . .
Long 2nd met leads to joint weakness
2nd MTP Synovitis and Instability Physical exam . . . “Drawer test”
Take home . . .
Lesser MTP Instability “Budin” Splint: Initial Treatment Options (6-12 weeks)
- Taping - Splint - NSAIDs - Boot - Orthotics
Surgery: shortening metatarsal osteotomy Interdigital (Morton’s) Neuroma
Definition: an entrapment neuropathy of an interdigital nerve at the transverse metatarsal ligament Morton’s neuroma Possible Etiologies
- Increased mobility of nerve - Bursa formation - Thick ligament/nerve - Trauma
Morton’s Neuroma Take home . . .
Clinical presentation: Morton’s Neuroma - sharp/radiating plantar forefoot pain - worse with walking - bunched up sock Diagnosis - webspace numbness/paresthesias - webspace tenderness - Mulder’s click - insidious onset - Diagnostic lidocaine injection - usually progressive but can be intermittent - MRI or ultrasound
Morton’s Differential Diagnosis Take home . . . Metatarsal and MP joint disorders If the pathology isn’t in the - MTP synovitis/instability second or third webspace, - MP arthrosis it probably -Freiberg’s Infraction (osteonecrosis) isn’t a neuroma - Stress fracture - “Metatarsalgia” (metatarsal overload) Remember the“double crush phenomenon” in patients Proximal Neurogenic Pathology Degenerative disks, tarsal tunnel, neuropathy, etc with a Morton’s neuroma Morton’s neuroma Morton’s neuroma
Non-operative Rx: Non-operative Rx:
First Line Second Line - Wide shoes -NSAIDs - Steroid Injection - Orthotics with proximal metatarsal pad
Morton’s neuroma
Non-operative Rx:
Third Line
-Time - Surgery (refer after 3 months)
Missed injuries . . .
Lisfranc Injuries and Midfoot Sprains - Jacques Lisfranc - 1790 – 1847 - French surgeon - Napoleonic wars Numerous varieties . . . Lisfranc Injury
Subtle . . . Potentially leading to deformity . . .
Mechanism of Injury
Direct Injury Indirect Injury
- missed on up to 20% of initial radiographs . . . and arthritis Indirect Injury Indirect Injury
Twisting Axial load
- More common - Soft tissue injury less severe
If you remember one thing . . . AP Radiographs
Medial border of 2nd metatarsal Take home . . . and Medial border of middle cuneiform
. . . midfoot tenderness on physical exam ______Stein RE. Foot & Ankle, 1983
Oblique Radiographs
Medial border of 3rd/4th metatarsals
. . . CT scan ______helpful Stein RE. Foot & Ankle, 1983 Lisfranc Injury The Medial Column
…beware of the straight medial column Slight 1st TMT varus is normal
Treatment . . . Take home . . .
1. Weight-bearing x-rays 2. Rx usually surgical 3. Refer if not pain-free in 2-3 weeks …beware of the straight medial column
Midfoot Sprain . . . “Lisfranc light” Take home . . .
. . . midfoot tenderness on physical exam Missed injury . . . Strategies . . . Take home . . .
1. Weight-bearing x-rays 2. Magnetic Resonance 3. Refer if not pain-free in 2-3 weeks
Anterior Process of Calcaneus - Inversion of plantarflexed ankle - Bifurcate ligament
Anterior Process of Calcaneus Anterior Process of Calcaneus
Take home ...... physical exam . . . CT scan Achilles Rupture
History - Acute pain in back of ankle - Immediate difficulty with walking - Audible “pop” - “I turned around to see if someone had kicked me…”
Achilles Rupture
Physical Exam:
- Gait can be normal - Palpable gap - Diminished but not absent strength - Abnormal Thompson test . . .
Achilles Tendon Maisonneuve Fx - Thompson Test: Take home . . .
= Maisonneuve Fracture Exam . . . Clues: - Knee and ankle pain - Knee and ankle tenderness - Isolated posterior malleolus fracture - Isolated medial malleolus fracture - Shortening of talocrural angle
Take home . . .
Refer! 5th Metatarsal Take home . . .
-Zones I – III -Jones: Zone II or Zone II/III
Jones fracture . . . 5th Metatarsal Treatment - Zones I: WBAT in shoe / boot
- Zone II / Jones: NWB vs ORIF
- Zone III: NWB cast/boot
Take home . . . Take home . . .