Medical Foundations of Workers’ Compensation Conditions of the Feet Objective: This section will introduce the student to basic medical terms, familiarize them with common diagnoses, and review treatment options relating to conditions of the feet. The Foot Common Injuries Achilles Bursitis or Tendinitis Heel Spurs Forefoot (Sesamoid, Phalanges) Fracture Metatarsal Bone Fracture Midfoot (Cuboid, Cuneiform, Navicular) Fracture Plantar Fasciitis Sprains and Strains Tests and Treatments Excision of Bone Spur Excision of Morton's Neuroma 1 Medical Foundations of Workers’ Compensation Conditions of the Feet The Foot The foot is a complex structure made up of 26 bones, 33 joints, 107 ligaments, and 19 muscles and tendons. All of them deserve focused attention and care. Foot Skeletal Structure 2 The disarticulated bones of the left foot, from above. (The talus and calcaneus remain articulated) 1 Calcaneus 2 Talus 3 Navicular 4 Medial cuneiform 5 Intermediate cuneiform 6 Lateral cuneiform 7 Cuboid 8 First metatarsal 9 Second metatarsal 10 Third metatarsal 11 Fourth metatarsal 12 Fifth metatarsal 13 Proximal phalanx of great toe 14 Distal phalanx of great toe 15 Proximal phalanx of second toe 16 Middle phalanx of second toe 17 Distal phalanx of second toe Bones of the tarsus, the back part of the foot Talus Calcaneus Navicular bone Cuboid bone Medial, intermediate and lateral cuneiform bones Bones of the metatarsus, the forepart of the foot First to fifth metatarsal bones (numbered from the medial side) Bones of the toes or digits Phalanges -- a proximal and a distal phalanx for the great toe; proximal, middle and distal phalanges for the second to fifth toes Sesamoid bones Two always present in the tendons of flexor hallucis brevis Origin and meaning of some terms associated with the foot: Tibia: Latin for a flute or pipe; the shin bone has a fanciful resemblance to this wind instrument. Fibula: Latin for a pin or skewer; the long thin bone of the leg. Adjective fibular or peroneal, which is from the Greek for pin. Tarsus: Greek for a wicker frame; the basic framework for the back of the foot. 3 Metatarsus: Greek for beyond the tarsus; the forepart of the foot. Talus (astragalus): Latin (Greek) for one of a set of dice; viewed from above the main part of the talus has a rather square appearance. Calcaneus: from the Greek for heel; the heel bone. Navicular (scaphoid): Latin (Greek) for boat-shaped; the navicular bone roughly resembles a saucer-shaped coracle. Cuboid: Greek for cube-shaped. Cuneiform: Latin for wedge-shaped. Phalanx: Greek for a row of soldiers; a row of bones in the toes. Plural phalanges. Sesamoid: Greek for shaped like a sesame seed. Digitus: Latin for finger or toe. Digiti and digitorum are the genitive singular and genitive plural -- of the toe(s). Hallux: Latin for the great toe. Hallucis is the genitive singular -- of the great toe. Dorsum: Latin for back; the upper surface of the foot. Adjective dorsal. Plantar: adjective from planta, Latin for the sole of the foot. Common Injuries Achilles Bursitis or Tendinitis Definition Achilles bursitis is a painful and inflammatory condition affecting either the tendon (tendinitis) that joins the heel bone to the calf muscle (Achilles tendon) or the small sacs (bursae) that surround that tendon. Tendons are fibrous tissues connecting muscles to bones or other structures. Bursae are small sacs or pouches found over most bony prominences. They provide cushioning and protect tendons and ligaments from wear by producing a lubricating synovial fluid that reduces the effects of friction and impact. Risk The Achilles tendon serves to raise and lower the heel during movement such as walking, running, and jumping. Repetitive forces on this tendon and its bursae from these types of activities can cause either of these inflammatory conditions. Changes in the tendon due to aging may also make the tendon more prone to inflammation. Individuals at a higher risk for developing this condition include manual laborers and athletes who participate in running or jumping activities. Wearing ill-fitting shoes may also contribute to the development of tendinitis. 4 Those with a familial high cholesterol condition called familial hyperlipidemia type II have a higher risk of getting tendinitis. Some individuals with this type of cholesterol abnormality may develop fat-like deposits (xanthomas) in tendons that result in Achilles tendinitis. Incidence and Prevalence The exact incidence and prevalence of Achilles bursitis or tendinitis is not reported, but this condition is common in active, middle-aged individuals. Diagnosis History With either Achilles tendinitis or bursitis, individuals generally report heel or calf pain that is made worse by activity, although there may be pain while the individual is at rest. The area overlying the inflammation may be tender and swollen. Other reported signs include swelling around the joint and palpable grating (crepitus) when flexing and extending the foot. The individual may also report pain associated with occupational tasks and sports activities or a history of trauma to this area. Physical Exam With tendinitis, physical examination usually reveals swelling and tenderness. Mobility (ankle extension, especially bending the foot up) may be limited because of pain. An examination of the individual's shoes may provide information with regard to the individual's gait or running pattern. Cases of Achilles bursitis usually involve swelling on both sides of the tendon, with the individual experiencing pain upon extension of the ankle. Tests No diagnostic tests are usually required for Achilles tendinitis, although plain film x-rays of the joint and surrounding area may be taken. Diagnostic ultrasound may also be useful in examining the area, particularly if the tendon is viewed during contraction. When the physician is not sure if the tendon is intact, MRI may be performed to identify tears, partial tears, inflammation, or tumors. In cases of suspected Achilles bursitis, joint or synovial fluid may be removed through suction with a needle (aspiration) and examined microscopically. This fluid will be cultured to help the physician diagnose whether bursitis is from infection or inflammation. Treatment The goal of treatment is to relieve pain, reduce inflammation, and rest the joint. Specific recommendations depend on the cause of the injury. Treatment may consist of a heel lift, application of ice, and protective pressure wraps to the area. The individuals should also decrease or modify the repetitive activity to allow the tendon to heal properly and prevent symptom recurrence. Nonsteroidal anti-inflammatory drugs (NSAIDs) are useful in relieving pain and inflammation. Severe cases of Achilles tendinitis may be treated by immobilizing the muscle and tendon using a brace, cane, or crutch and, in severe cases, by casting of the foot and ankle. Following a recovery period, the individual may receive physical therapy and instruction in stretching exercises. 5 In cases of Achilles bursitis, the joint should be elevated and gentle compression applied, such as an elastic bandage. Some cases may require one or more injections of corticosteroids into the bursa to relieve inflammation, although most experts consider cortisone injection anywhere near the Achilles tendon as contraindicated since it may predispose Achilles tendon rupture. In rare cases in which tendinitis persists and does not respond to non-surgical treatment, removal of unhealthy tissue (débridement) of the Achilles tendon may be suggested. The ankle is then placed in a cast until healing takes place (about 6 to 8 weeks). Once the cast is removed, the individual begins physical therapy to restore strength and mobility of the ankle and lower leg. Prognosis In general, Achilles tendinitis resolves completely following a period of rest, use of anti- inflammatory medications, and splinting or casting if necessary. Acute bursitis may progress to chronic or long-term bursitis and result in limitations of ankle or foot range of motion. Surgical debridement of the tendon generally has a good outcome but carries common surgical risks. Specialists Orthopedic (Orthopaedic) Surgeon Podiatrist Physical Therapist Rheumatologist Rehabilitation An important step in the rehabilitation of Achilles bursitis or tendinitis is to modify any risk factors that are associated with the occurrence of this condition, including poor ankle flexibility, biomechanical abnormalities of the lower limb, and training errors in sports activities such as practicing on a hard running surface or wearing worn out shoes. Achilles bursitis is an inflammation of the retrocalcaneal bursa. Achilles tendinitis can affect the tendon itself, the overlying sheath, or both. The initial goal of the rehabilitation is to decrease pain and inflammation. Later, the aim is to restore function and prevent reoccurrence of the condition. Initially, it is recommended to follow the PRICE principle (protection, rest, ice, compression, elevation). Modification of activities should always be part of the initial treatment. A soft heel pad in the individual's shoe can reduce pressure on the Achilles tendon and the bursa. As soon as pain and inflammation are reduced, the individual should be instructed in a home program of stretching and strengthening exercises. Heat and cold may be used for pain management. Injection of steroids into the surrounding tendon tissue remains controversial. Although injection may provide pain relief, it weakens the Achilles tendon, increasing