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 1
12/11/2015 Achilles Tendonitis/Tendinopathy • Incidence Pathophysiology Physical Examination/Studies – Men and women of all • Inflammation of the plantar • +TTP at the plantar medial ages fascial insertion at the aspect of the calcaneus – 24%-50% of lifetime • Achilles/Gastrocnemius medial plantar aspect of the calcaneus runners tightness • Symptoms • May or may not have – Pain In Achilles Tendon plantar calcaneal bone spur 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* 2
12/11/2015 Treatment Anatomy • Achilles Tendon is the • Almost Always Conservative biggest tendon in the – Ice, Rest, NSAIDS body and subjected to – Heel Lift the highest loads – Dedicated Eccentric Stretching • Has a 90 degree twist program • Inserts broadly over the – Period of Immobilization (CAM posterior calcaneus walker, Cast) • Watershed area 4-6 cm – NO STEROID INJECTIONS proximal to the • Surgery Reserved for Failed insertion Conservative Management Achilles Rupture Clinical Examination • Incidence – Men 30s/40s – Athletes and weekend warriors – 7/100,00 population • Palpable Defect – ~10% prior achilles • Decreased plantarflexion strength symptoms • Symptoms • Decreased resting tone – Relatively painless!!! • + Thompson’s Test (Calf Squeeze and no – “kicked in heel” Plantarflexion) – Walk funny, limp, weak 3
12/11/2015 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 4
12/11/2015 Ankle Sprains Ankle Sprains • Men and Women of all Treatment ages • ~600,000 Ankle • 95% of ankle sprains are Sprains per year in the asymptomatic at 1 year no US matter how they are treated • Slightly better functional • 3-5% of all ED visits results with early (UK) 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 • • Acute twisting Injury • Acute twisting Injury ATFL is the most common ligament injured • Pain swelling at ankle • Pain Swelling at ankle – Resists Anterior translation of • Bruising • Bruising the talus • 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 The only real way to tell is with imaging • Mortise is maintained no matter what the grade 5
12/11/2015 Lis Franc Fracture/Dislocation “High Ankle Sprain” - Syndesmosis History • Maybe direct or • Pain out of proportion indirect, contact/no to injury contact • Prolonged Recovery • Axial Load to • Pain posterior to fibula plantarflexed foot • Pain up leg towards knee • Difficulty with one leg hop • Pain with dorsiflexion of ankle www.aofoundation.org Lis Franc Fracture/dislocation Assessment • History Anatomy – Painful walking • Lis Franc Joint runs between – Pain in midfoot the tarsal and metatarsal • Physical Examination bones • Midfoot Swelling • Both Dorsal and plantar • Midfoot Pain ligaments • – Dorsal or plantar Plantar ligaments are stronger • • Ecchymosis Strongest in between medial 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 6
12/11/2015 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 • >100 different surgical • Symptoms • Bunion Pads procedures described – Pain in great toe, • Gastroc Stretching • Results vary - ~70-85% especially with shoewear improvement – Deformity of first toe – Erythema, Swelling Pathoanatomy Thank You • Complex Deformity • Lateral Deviation First Toe, with Medial Deviation of Phalanx 7
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