Transcript Foot / Ankle Injuries and Treatment

Foot & Ankle Injuries
and Treatment
Dr. John R. Sallade
Physical Therapist
Board Certified – Sports Medicine
Fellow – Academy Applied Functional Science
Classes of Conditions
> Traumatic surgical intervention
non surgical intervention
Insidious onset
Congenital
Traumatic
Fractures Ankle
Mid foot
Forefoot
Tendon tears Achilles (plantaris)
Posterior Tibialis
Peroneal
Repair, ORIF +/- Immobilization, WB, PT
Osseous Anatomy
Osseous Anatomy
ORIF
ORIF
ORIF
OREF (Hoffman)
Immobilization
Repair
MRI
Immobilization
Post Operative
Complications
 Stiffness
 Weakness
 Decreased propioception
 Decreased vascularity, edema
 Infection
 RSD CRIPS
 DVT PE
“Non traumatic” Injuries
Insidious Onset
 Tendinosis
 Stress fractures
 Bunions , Hallux Limitus
 Hammer toes
 Metatarsalgia
 Neuromas
 Plantar Fascitis
 Compartment Syndrome
“Non Traumatic” Injuries
 Blisters
 Callosities
 Sub ungula hematomas
 Arthritis
 “pump bumps”
 Apophositis
 Sesmoiditis
 Infections
Peroneal Tendons
Medial Tendons
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
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)
Ankle Sprains
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Account for 25% of all sports injuries
Lateral (ATF+CF)(85%)
Medial (Deltoid)>
“High” (Syndesmosis)>
Mid tarsal
Possible causes:
 Cavus, poor proprioception, poor rehab, over
weight and poorly conditioned
 No significant male – female ratio
Ankle Ligaments
“High” Ankle sprain
Midtarsal Sprain
Treatment
 Surgery?
 RICE
 Progressive WB
 Immobilization and Early mobilization
 Closed Chain Exercise
 Looking for a cause
Closed chain Exercise
Plantar Fascitis
Causes
 Unlocked midtarsal joint at push off phase
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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
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?
Treatment for Plantar Fascitis
Treatment for plantar fascitis
Bunions
(Hallux Valgus)
Bunions
 Both medial (1st MTP) and lateral (5th)
In medial bunion:
 Over pronated foot with abductus (toe out)
 Tight heel cords
 Forefoot varus
Treatment
 Treat the cause
 Symptomatic relief with modalities
 Heel cord stretching
 Fore foot support via orthotic
 Strengthening
 When is surgery the best option?
Treatment
stretching
orthotics
Stress Fractures – Micro Fractures
Most common sites: metatarsals
Tibia
Calcaneal
Calcaneal
Femur
Stress Fractures
Probable Causes
 Increasing the amount or intensity of an
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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)
Other Risk Factors for
Stress Fractures
Risk Factors
 Female, short, thin and caucasian
 Certain sports, especially involving plyometric loading:
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Distance running
Gymnastics
Dance
Basketball and Tennis
Amenorrhea>decrease 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
Compartment Syndrome
 Compartment syndrome is a painful condition that occurs when
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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.
Compartment Syndrome
Symptoms and Diagnosis
 Chronic (Exert ional) Compartment
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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
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).
Testing
Fasciotomy
Reflex Sympathetic Dystrophy
Chronic 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
stages—acute, dystrophic, and atrophic.
 The acute stage occurs during the first 1–3 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.
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 3–6
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)
RSD appearance
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.
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
Metatarsalgia
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
Treatment
Inter Metatarsal (Morton’s)
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.
Neuromas
Treatment
Osteo arthritis
 condition characterized by the breakdown
and eventual loss of cartilage in one or
more joints (ankle>MTJ>1st MTP>ST)
 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
Radiography
Treatment
 Proper footwear
 Medications to relieve pain and swelling (NSAIA,
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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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