Download Foot and Ankle Problems

Foot and Ankle Problems
To treat or Refer????
CDP Events on Foot/Ankle
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Fantastic events at respected institutions
( e.g. RNOH Stanmore, Wellington, Lister)
Bright confident young surgeons!
State of the art imaging and technology
Advancing surgical approaches
Really pushing the boundaries!!
Seemingly limitless supply of healthy patients
My impressions of all this CPD
• Is there nothing that these bright young
surgeons can’t
• Resect?
• Suture?
• Realign?
• Graft?
• Replace?
Reflections????
• My intention is not to undermine the excellent
surgical advances that are happening.
• But which patients are suitable for surgery?
• What happens to the patients after the
surgeon has finished with them?
• What about the long and sometimes painful
rehabilitation process?
Where does Osteopathy fit?
• Referring to the relevant Osteopathic Practice
Standards
• A5 “You must work in partnership with the
patient to find the best treatment for them”.
• B3 “You must recognise and work within your
limits of competence”.
• D1 “You must consider the contribution of other
healthcare professionals in patient care”.
Welcome to my world!
• Where patients are often not very fit/healthy to
start with.
• Where they are at the mercy of the overworked
NHS.
• Where the GP is not remotely interested in their
problem if it is not life threatening.
• Where money ( or lack of it ) matters!
• Where accessing the latest advances is limited
Aims of this session
• To meander through some common foot and
ankle problems ( Hopefully with some lively
interaction from the audience! Please
interrupt as necessary!)
• Revisit some common pitfalls in diagnosis
• Consider criteria for referral
• Revisit some surgical options
Lateral ligament/Inversion Strain
Lateral ligament/Inversion strain
• Acute injury ( less than 6 weeks)
Osteopathic management?
Suggestions??? What can we do?
• Chronic lingering problems
If painful 6-10 weeks after injury consider
Is ankle painful, unstable or both??
Guidelines for management
• Recurring Instability
Try rehabilitation first ( suggestions?) and surgery as
a last resort
• Chronic Pain
Consider misdiagnosis/fracture. If 6 weeks plus
consider MRI
• Instability and Pain
Refer for MRI to establish why there is pain before
rehab.
Surgical Options
• Suture of lateral ligaments
• Tightening of Peroneal tendon ( especially for
overweight patients or those with
ligamentous laxity).
• Surgery followed by cast splint for 4 weeks
( absolutely no Inversion/eversion ).
Complications to watch out for
Osteochondral Lesion
10% of patients suffer this after an inversion strain
• The Talus shears against the tibia causing swelling
on the Medial aspect of the foot
• A flap of articular cartilage occurs
• Movement of the ankle pumps synovial fluid into
the flap
• Cyst forms in the articular cartilage.
Surgical treatment
• Remove the flap of cartilage if displaced
• Micro fracturing to encourage fibrocartilage
growth
• NB fibro cartilage is not the same structure as
articular cartilage- much softer. Predisposes
patient to early OA ??
Osteochondral Lesion
Syndesmosis injury
• Tear/strain of the anterior part of tib-fib
ligament.
• Common in football and skiing.
• Very slow to heal after what appears to be a
straightforward ankle injury.
• Clinically it is tender to palpate higher up from
the lateral ligaments
• External rotation of the foot on the tibia is
painful.
Management options
• Stress X rays of the ankle may show splaying
of the tibia and fibular on weight bearing.
• If mild conservative treatment with crutches
splints and immobilisation.
• If severe surgically the tibia and fibula can be
pinned to stabilise.
Acute Achilles Tendon Rupture
• Typically acute presentation during sport or
activity or chronic pain after a low impact
injury.
• Patient often feels like they have been slapped
on the leg during activity.
• NB The long flexors alone may be sufficient for
the patient to do a heel raise so this is not a
reliable test for rupture.
Helpful diagnostic tests
• Simmonds/Thomson Test ( calf squeeze test)
• Patient prone feet hanging over end of plinth
• Squeezing a normal calf should cause plantar
flexion of the foot
• In positive Simmonds test foot remains in
dorsiflexion
• Matles Test
• Patient prone with knee flexed to 90 degrees
• In positive test foot will hang in dorsiflexion
Matles Test and Simmonds Test
Other clinical signs
• Swelling and tenderness over tendon
• Palpable gap in tendon often 2-6 cm up from
the insertion.
• Referral for ultrasound imaging indicated if
tests are positive to assess apposition of the
tendon.
• Surgeons are only interested in seeing patients
with positive Simmonds Test.
Surgical options
• Surgery preferred in younger active sporty
patients
• Open repair medially to avoid Sural Nerve
damage.
• Percutaneous repair with smaller incisionquicker to heal but more chance of Sural
Nerve damage.
• Conservative treatment in older patients
• Boot /cast blocking dorsiflexion
Achilles Tendinopathy
• Common in sporty patients , dancers, jumping
• Associated with poor training routines/footwear
• Poor flexibility
• High foot arches or flat feet
• More common in patients with AS or psoriatic
arthritis
• Prolonged use of certain antibiotics can result in
tendinopathy
Clinical Features
• Repetitive micro trauma to the tendon results
in pain swelling and stiffness.
• Typical pattern worse first thing in the
morning
• Painful at start of exercise easier during a run
and painful afterwards
• Tender and swelling over the area.
Management Ideas?
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Conservative treatment
Rest, Ice, ultrasound, NSAIDS
Orthotics?
Steroid injections? Ultrasound guided to
avoid potential rupture?
• Shock Wave therapy
• Surgical removal of nodules/adhesions
• Incision of tendon to promote new growth
Tarsal Tunnel Syndrome
• Compression of the Tibial Nerve as it passes
under the flexor retinaculum
• Contents of the tarsal tunnel are:
FDL, FHL, Tib. Post, Tibial Nerve/ Artery.
• In the tunnel the nerve splits into the
calcaneal branch and medial and lateral
plantar nerves
• Compression can occur in flat feet, ganglions
cysts, synovitis etc
Clinical features
• Peripheral nerve compression i.e.
• Swelling, Numbness, Tingling, burning pain
medial aspect of the foot and toes 1,2, and 3.
• Tinel’s test positive
• Investigations can include nerve conduction
test or MRI or Ultrasound depending on
suspected cause of compression
Tibialis Posterior Dysfunction
• Tibialis posterior main function is to support
the medial arch.
• Failure of the tendon causes progressive
collapsing of the medial foot and tilting of the
heel outwards.
• Acute cases from high impact sports
• Chronic cases risk factors are flat feet, over 40
obese, diabetes
Symptoms of Tibialis Posterior
Dysfunction
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Pain/swelling on the medial aspect of the foot
Pain worse on activity even on walking
Progressive flattening of the foot
Pain on the lateral aspect of the foot due to
compression of the lateral ankle and subtalar
joint.
“ Too many toes sign”
Clinical features
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Tenderness pain and swelling medially
Flat foot deformity with an everted foot
“Too many toes sign” on weight bearing
Unable to do a single heel raise
• May want to use MRI, ultrasound, imaging to
• Check state of tendon and grade of injury
Management options
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Conservative
Low impact exercise/eccentric stretching
Ice, NSAIDS
Orthotics
Splints
Surgical options – 90 % have a scarf osteotomy
Surgical options
• These vary according to grade of injury
• In a flexible foot with an inflamed tendon stripping cleaning ( tenosynovectomy)
• In case of rupture -tendon transfer
• In a more rigid foot -osteotomy
• If arthritis is present - arthrodesis
• All these procedures have long rehab time up
to 1 year.
Lisfranc Tarso-Metatarsal Injury
• Injury where the metatarsals are displaced
from the cuneiforms. ( Lisfranc joint)
• Common in snowboarders, windsurfing , horse
riding where bindings are strapped across the
foot
• Also common in crush injuries, objects falling
onto foot.
• Also rotation injuries on a plantar flexed foot
Clinical Features
• Foot usually balloons up immediately after
injury with bruising medially and inferior ( sole
of foot).
• Medial Arch collapses
• Swelling is persistent
• Often missed at A & E as non weight bearing
X-Rays are often normal
• Weight bearing X rays will show gaping
between 1st and 2nd met and cuneiforms
Lisfranc Injury
Inferior Heel Pain
• Differential diagnoses to consider
• Stress fracture in elderly – medial pain especially
on cupping the heel side to side
• Sero -negative rheumatological conditions
• Tarsal Tunnel Syndrome
• S1 referred pain
• Plantar fasciitis. Swelling with fasciitis and night
pain. No swelling with fasciosis. Acute pain may
be rupture
• Fat Pad Atrophy
Hallux Valgus/Rigidus
Treatment options
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Manipulation
Orthotics
Arthrodesis
Cheilectomy - Remove bone to allow
dorsiflexion of the toe
• Joint replacements – New and unreliable
Heel Spur
Heel Spur
• Essentially a calcium deposit on the
calcaneum often associated with plantar
fasciitis.
• Common in sports with repeated micro trauma eg jumping, running, causing
periosteal traction on the fascial attachment.
• Also associated with obesity, diabetes,
prolonged standing, poor footwear.
Clinical Features
• Local heel pain on weight bearing – like a pin
/needle digging into the foot
• Associated inflammation in the soft tissues
• Diagnosis via X Ray
• Treatment options include
• Orthotics, NSAIDS, Cortisone
• Plantar fascia release and or spur removal
Haglund’s deformity
Haglund’s Deformity
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Also known as “ Pump Bump”
Leads to Retro calcaneal Bursitis
Often a congenitally altered calcaneum
Associated with altered gait- walking on lateral
aspect of the foot
• Pain and swelling over the achilles insertion
• Aggravated by shoes rubbing/trainers
• Pain redness and lump over the calcaneum
Management
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Conservative Treatment
NSAIDS, Ice.
orthotics, heel lifts, change shoes
Surgical options are
Debridement of the Achilles Tendon
Removal of the retro calcaneal bursa
Excision of the Haglund’s deformity