12/14/2018 Outline The Agony of the Foot 2018: • 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 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 1
12/14/2018 Treatment • Almost always Conservative • May Take Many months to Pathophysiology Physical Examination/Studies Resolve • Inflammation of the plantar • +TTP at the plantar medial • Achilles/Gastroc/Plantar fascial insertion at the aspect of the calcaneus fascial stretching medial plantar aspect of the • Achilles/Gastrocnemius • Heel Cups calcaneus tightness • OTC Arch Supports • May or may not have • Night Splints plantar calcaneal bone spur on xrays • CAM walker/Casting • *Injections- do have increased rupture rate* Achilles Tendonitis/Tendinopathy “I can tell you if you’re listening out there, if you have PLANTAR FASCIITIS, • Incidence stay away from surgery,’’ – Men and women of all Kerr told reporters. “I can ages say that from the bottom of – 2-10% of general my heart. Rehab, rehab, population rehab. Don’t let anyone get – 24%-50% of lifetime in there.” runners • Symptoms Surgical Results are very mixed – Pain In Achilles Tendon with Activity 2
12/14/2018 Treatment Pathophysiology Exam/Imaging • Chronic Overuse Injury • +TTP in the achilles • Almost Always Conservative • Occurs in 2 places • Swelling of achilles in – Ice, Rest, NSAIDS – Insertion midsubstance or insertion – Heel Lift – Mid-Substance • “Pump Bump” – posterior – Dedicated Eccentric Stretching calcaneal bone spur program – Period of Immobilization (CAM walker, Cast) – NO STEROID INJECTIONS • Surgery Reserved for Failed Conservative Management – Potentially more effective in insertional disease Achilles Rupture Anatomy • Incidence • Achilles Tendon is the – Men 30s/40s biggest tendon in the body and subjected to – Athletes and weekend the highest loads warriors – 7/100,000 population • Has a 90 degree twist – ~10% prior achilles • Inserts broadly over the symptoms posterior calcaneus • Symptoms • Watershed area 4-6 cm – Relatively painless!!! proximal to the – “kicked in heel” insertion – Walk funny, limp, weak 3
12/14/2018 Clinical Examination • Palpable Defect • Clinical Examination was more sensitive than MRI • Decreased plantarflexion strength in detecting acute rupture • Decreased resting tone • + Thompson’s Test (Calf Squeeze and no Plantarflexion) Surgery vs No Surgery Surgery Non Op Treatment • Pros • Pros Initial Treatment – Get tension to proper degree – Less complications – Likely Lower rerupture rate – No – Feel like you did something • Cons • Plantarflexion in Splint (20-30 degrees) – Slightly better – Higher Rerupture Rate – “It’s what Richard Sherman • Alternatively, plantarflexion in CAM walker – Tension may not be restored got” • Cons as well with heel lifts (2). – Cost – Higher complication rate • Especially wound problems 4
12/14/2018 Ankle Sprains • Men and Women of all ages • ~600,000 Ankle Sprains per year in the US • 3-5% of all ED visits • 12 month follow up (UK) • Symptoms • Similar functional results – Pain in Ankle • Similar re-rupture rate – Swelling – Difficulty with Weight bearing Ankle Sprains Ankle Sprains Pathophysiology Treatment • 95% of ankle sprains are • ATFL is the most common asymptomatic at 1 year no ligament injured matter how they are treated – Resists Anterior translation of • Recommend limiting early the talus immobilization (CAM boot 1-3 • CFL may be injured as well weeks max) – Resists talar tilt • Slightly better functional • Grading Sprain results with early rehabilitation – 1-3 – how much is torn • Surgical Repair reserved for those with prolonged (>6 • Mortise is maintained no months) of symptoms of matter what the grade instability 5
12/14/2018 Sprain vs Fracture? “High Ankle Sprain” - Syndesmosis History Sprain Fracture • Pain out of proportion to injury • Acute twisting Injury • Acute twisting Injury • Pain swelling at ankle • Pain Swelling at ankle • Prolonged Recovery • Bruising • Bruising • Pain posterior to fibula • Difficulty with Weight • Difficulty with weight • Pain up leg towards bearing bearing knee • Difficulty with one leg hop • Pain with dorsiflexion of ankle Ottawa Ankle Rules Things missed in Ottawa Ankle Rules • Anterior Process calcaneus fractures • Lateral Process Talus • If at all concerned, get Fractures an xray • Osteochondral Lesions of the Talus and loose bodies • Neuropathics!!!! 6
12/14/2018 Lisfranc Fracture/dislocation Lisfranc Fracture/Dislocation • Maybe direct or Anatomy indirect, contact/no • Lisfranc Joint runs between contact the tarsal and metatarsal bones • Axial Load to • Both Dorsal and plantar plantarflexed foot ligaments • Plantar ligaments are stronger • Strongest in between medial cuneiform and base of second metatarsal • Same in Adults and Kids www.aofoundation.org www.aofoundation.org Assessment Bunion (Hallux Valgus) • History • Population/Incidence – Painful walking – Pain in midfoot – 24% >60 yo • Physical Examination – Women 2-4X men • Midfoot Swelling – Strong family History • Midfoot Pain • Symptoms – Dorsal or plantar • Ecchymosis – Pain in great toe, • MUST GET Appropriate especially with shoewear IMAGING IF THESE ARE – Deformity of first toe PRESENT (Weight bearing – Erythema, Swelling foot xrays) www.aofoundation.org 7
12/14/2018 Pathoanatomy Treatment Conservative Surgical • Complex Deformity • Shoewear Modification • Usually reserved for those • Lateral Deviation • Orthotics who fail non-operative First Toe, with treatment • Bunion Sleeves Medial Deviation of • >100 different surgical • Bunion Pads Phalanx procedures described • Gastroc Stretching – Different recovery periods • Results vary - ~70-85% improvement • LONG recovery With Surgery, We’re able to make a bad toe good, but really tough to make a good toe great Thank You 8
Recommend
More recommend
