12/11/2015

Outline The Agony of the Foot: • Plantar Fasciitis • Achilles Tendonitis Top 5 Foot and Ankle Problems in Primary • Achilles Ruptures Care • Ankle Sprains – Lis Franc • Bunions Daniel Thuillier, M.D. Assistant Professor of Clinical Orthopaedics University of California San Francisco

Disclosure Plantar Fasciitis

• I have nothing to disclose • Population/Incidence – Men and Women of all ages -10% of Americans have some form of heel pain -1 Million medical visits Annually • Symptoms – Plantar Medial heel pain – Often worse in morning – Worse with Activity

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Achilles Tendonitis/Tendinopathy

Pathophysiology Physical Examination/Studies • Incidence • Inflammation of the plantar • +TTP at the plantar medial – Men and women of all fascial insertion at the aspect of the calcaneus ages medial plantar aspect of the • Achilles/Gastrocnemius – 24%-50% of lifetime calcaneus tightness runners • May or may not have • Symptoms plantar calcaneal bone spur – Pain In Achilles Tendon on xrays with Activity

Treatment Pathophysiology Exam/Imaging • Almost always Conservative • Chronic Overuse Injury • +TTP in the achilles • May Take Many months to • Occurs in 2 places • Swelling of achilles in Resolve – Insertion midsubstance or insertion • Achilles/Gastroc/Plantar – Mid-Substance • “Pump Bump” – posterior fascial stretching calcaneal bone spur • Heel Cups • OTC Arch Supports • Night Splints • CAM walker/Casting • *Injections- do have increased rupture rate*

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Treatment Anatomy

• Almost Always Conservative • Achilles Tendon is the – Ice, Rest, NSAIDS biggest tendon in the body and subjected to – Heel Lift the highest loads – Dedicated Eccentric Stretching • program Has a 90 degree twist – Period of Immobilization (CAM • Inserts broadly over the walker, Cast) posterior calcaneus – NO STEROID INJECTIONS • Watershed area 4-6 cm • Surgery Reserved for Failed proximal to the insertion Conservative Management

Achilles Rupture Clinical Examination

• Incidence – Men 30s/40s – Athletes and weekend warriors – 7/100,00 population – ~10% prior achilles • Palpable Defect symptoms • Decreased plantarflexion strength • Symptoms • Decreased resting tone – Relatively painless!!! • + Thompson’s Test (Calf Squeeze and no – “kicked in heel” Plantarflexion) – Walk funny, limp, weak

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Surgery vs No Surgery

Surgery Non Op Treatment • Pros • Pros – Get tension to proper degree – Less complications – Likely Lower rerupture rate – No – Feel like you did something • Cons • Clinical Examination was more sensitive than MRI – “It’s what Kobe got” – Higher Rerupture Rate in detecting acute rupture • Cons – Tension may not be restored – Cost as well – Higher complication rate • Especially wound problems

Initial Treatment

• Plantarflexion in Splint (20-30 degrees) • 12 month follow up • Alternatively, plantarflexion in CAM walker • Similar functional results with heel lifts (2). • Similar re-rupture rate

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Ankle Sprains Ankle Sprains • Men and Women of all ages Treatment • ~600,000 Ankle • 95% of ankle sprains are Sprains per year in the asymptomatic at 1 year no US matter how they are treated • 3-5% of all ED visits • Slightly better functional (UK) results with early rehabilitation • Symptoms • Surgical Repair reserved for – Pain in Ankle those with prolonged (>6 – Swelling months) of symptoms of – Difficulty with Weight instability bearing

Ankle Sprains Sprain vs Fracture?

Pathophysiology Sprain Fracture • ATFL is the most common • Acute twisting Injury • Acute twisting Injury ligament injured – Resists Anterior translation of • Pain swelling at ankle • Pain Swelling at ankle the talus • Bruising • Bruising • CFL may be injured as well • Difficulty with Weight • Difficulty with weight Resists talar tilt – bearing bearing • Grading Sprain – 1-3 – how much is torn

• Mortise is maintained no The only real way to tell is with imaging matter what the grade

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“High Ankle Sprain” - Syndesmosis Lis Franc Fracture/Dislocation History • Maybe direct or • Pain out of proportion to injury indirect, contact/no contact • Prolonged Recovery • Pain posterior to fibula • Axial Load to • Pain up leg towards plantarflexed foot knee • Difficulty with one leg hop • Pain with dorsiflexion of ankle www.aofoundation.org

Lis Franc Fracture/dislocation Assessment

Anatomy • History – Painful walking • Lis Franc Joint runs between – Pain in midfoot the tarsal and metatarsal bones • Physical Examination • Both Dorsal and plantar • Midfoot Swelling ligaments • Midfoot Pain • Plantar ligaments are stronger – Dorsal or plantar • Strongest in between medial • Ecchymosis cuneiform and base of second • MUST GET Appropriate metatarsal IMAGING IF THESE ARE • www.aofoundation.org Same in Adults and Kids PRESENT

www.aofoundation.org

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Bunion (Hallux Valgus) Treatment

• Population/Incidence Conservative Surgical – 24% >60 yo • Shoewear Modification • Usually reserved for those – Women 2-4X men • Orthotics who fail conservative – Strong family History • Bunion Sleeves treatment • • Symptoms • Bunion Pads >100 different surgical procedures described – Pain in great toe, • Gastroc Stretching • especially with shoewear Results vary - ~70-85% improvement – Deformity of first toe – Erythema, Swelling

Pathoanatomy Thank You

• Complex Deformity • Lateral Deviation First Toe, with Medial Deviation of Phalanx

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