The Agony of the Foot: Top 5 Foot and Ankle Problems in Primary - - PDF document

11/21/2017 1

The Agony of the Foot:

Daniel Thuillier, M.D.

Assistant Professor of Clinical Orthopaedics University of California San Francisco

Top 5 Foot and Ankle Problems in Primary Care

Outline

• Plantar Fasciitis
• Achilles Tendonitis
• Achilles Ruptures
• Ankle Sprains

– Lis Franc

• Bunions

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Plantar Fasciitis

• 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 Pathophysiology

• Inflammation of the plantar

fascial insertion at the medial plantar aspect of the calcaneus Physical Examination/Studies

• +TTP at the plantar medial

aspect of the calcaneus

• Achilles/Gastrocnemius

tightness

• May or may not have

plantar calcaneal bone spur

• n xrays

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Treatment

• Almost always Conservative
• May Take Many months to

Resolve

• Achilles/Gastroc/Plantar

fascial stretching

• Heel Cups
• OTC Arch Supports
• Night Splints
• CAM walker/Casting
• *Injections‐ do have

increased rupture rate*

Achilles Tendonitis/Tendinopathy

• Incidence

– Men and women of all ages – 24%‐50% of lifetime runners

• Symptoms

– Pain In Achilles Tendon with Activity

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Pathophysiology

• Chronic Overuse Injury
• Occurs in 2 places

– Insertion – Mid‐Substance

Exam/Imaging

• +TTP in the achilles
• Swelling of achilles in

midsubstance or insertion

• “Pump Bump” – posterior

calcaneal bone spur

Treatment

• Almost Always Conservative

– Ice, Rest, NSAIDS – Heel Lift – Dedicated Eccentric Stretching program – Period of Immobilization (CAM walker, Cast) – NO STEROID INJECTIONS

• Surgery Reserved for Failed

Conservative Management

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Achilles Rupture

• Incidence

– Men 30s/40s – Athletes and weekend warriors – 7/100,00 population – ~10% prior achilles symptoms

• Symptoms

– Relatively painless!!! – “kicked in heel” – Walk funny, limp, weak

Anatomy

• Achilles Tendon is the

biggest tendon in the body and subjected to the highest loads

• Has a 90 degree twist
• Inserts broadly over the

posterior calcaneus

• Watershed area 4‐6 cm

proximal to the insertion

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Clinical Examination

• Palpable Defect
• Decreased plantarflexion strength
• Decreased resting tone
• + Thompson’s Test (Calf Squeeze and no

Plantarflexion)

• Clinical Examination was more sensitive than MRI

in detecting acute rupture

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Initial Treatment

• Plantarflexion in Splint (20‐30 degrees)
• Alternatively, plantarflexion in CAM walker

with heel lifts (2).

Surgery vs No Surgery

Surgery

• Pros

– Get tension to proper degree – Likely Lower rerupture rate – Feel like you did something – “It’s what Kobe got”

• Cons

– Cost – Higher complication rate

• Especially wound problems

Non Op Treatment

• Pros

– Less complications – No

• Cons

– Higher Rerupture Rate – Tension may not be restored as well

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• 12 month follow up
• Similar functional results
• Similar re‐rupture rate

Ankle Sprains

• Men and Women of all

ages

• ~600,000 Ankle

Sprains per year in the US

• 3-5% of all ED visits

(UK)

• Symptoms

– Pain in Ankle – Swelling – Difficulty with Weight bearing

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Ankle Sprains

Pathophysiology

• ATFL is the most common

ligament injured

– Resists Anterior translation of the talus

• CFL may be injured as well

– Resists talar tilt

• Grading Sprain

– 1‐3 – how much is torn

• Mortise is maintained no

matter what the grade

Ankle Sprains

Treatment

• 95% of ankle sprains are

asymptomatic at 1 year no matter how they are treated

• Slightly better functional

results with early rehabilitation

• Surgical Repair reserved for

those with prolonged (>6 months) of symptoms of instability

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Sprain vs Fracture?

Sprain

• Acute twisting Injury
• Pain swelling at ankle
• Bruising
• Difficulty with Weight

bearing Fracture

• Acute twisting Injury
• Pain Swelling at ankle
• Bruising
• Difficulty with weight

bearing

The only real way to tell is with imaging

History

“High Ankle Sprain” - Syndesmosis

• Pain out of proportion

to injury

• Prolonged Recovery
• Pain posterior to fibula
• Pain up leg towards

knee

• Difficulty with one leg

hop

• Pain with dorsiflexion
• f ankle

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Lis Franc Fracture/dislocation

Anatomy

• Lis Franc Joint runs between

the tarsal and metatarsal bones

• Both Dorsal and plantar

ligaments

• Plantar ligaments are stronger
• Strongest in between medial

cuneiform and base of second metatarsal

• Same in Adults and Kids

www.aofoundation.org

Lis Franc Fracture/Dislocation

• Maybe direct or

indirect, contact/no contact

• Axial Load to

plantarflexed foot

www.aofoundation.org

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Assessment

• History

– Painful walking – Pain in midfoot

• Physical Examination
• Midfoot Swelling
• Midfoot Pain

– Dorsal or plantar

• Ecchymosis
• MUST GET Appropriate

IMAGING IF THESE ARE PRESENT

www.aofoundation.org

Bunion (Hallux Valgus)

• Population/Incidence

– 24% >60 yo – Women 2‐4X men – Strong family History

• Symptoms

– Pain in great toe, especially with shoewear – Deformity of first toe – Erythema, Swelling

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Pathoanatomy

• Complex Deformity
• Lateral Deviation

First Toe, with Medial Deviation of Phalanx

Treatment

Conservative

• Shoewear Modification
• Orthotics
• Bunion Sleeves
• Bunion Pads
• Gastroc Stretching

Surgical

• Usually reserved for those

who fail conservative treatment

• >100 different surgical

procedures described

• Results vary ‐ ~70‐85%

improvement

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Thank You