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

11/21/2017 The Agony of the Foot: Top 5 Foot and Ankle Problems in Primary Care Daniel Thuillier, M.D. Assistant Professor of Clinical Orthopaedics University of California San Francisco Outline • Plantar Fasciitis • Achilles Tendonitis • Achilles Ruptures • Ankle Sprains – Lis Franc • Bunions 1

11/21/2017 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 Physical Examination/Studies • Inflammation of the plantar • +TTP at the plantar medial fascial insertion at the aspect of the calcaneus medial plantar aspect of the • Achilles/Gastrocnemius calcaneus tightness • May or may not have plantar calcaneal bone spur on xrays 2

11/21/2017 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 3

11/21/2017 Pathophysiology Exam/Imaging • Chronic Overuse Injury • +TTP in the achilles • Occurs in 2 places • Swelling of achilles in – Insertion midsubstance or insertion – Mid‐Substance • “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 4

11/21/2017 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 5

11/21/2017 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 6

11/21/2017 Initial Treatment • Plantarflexion in Splint (20‐30 degrees) • Alternatively, plantarflexion in CAM walker with heel lifts (2). 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 – “It’s what Kobe got” – Higher Rerupture Rate • Cons – Tension may not be restored as well – Cost – Higher complication rate • Especially wound problems 7

11/21/2017 • 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 8

11/21/2017 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 9

11/21/2017 Sprain vs Fracture? Sprain Fracture • Acute twisting Injury • Acute twisting Injury • Pain swelling at ankle • Pain Swelling at ankle • Bruising • Bruising • Difficulty with Weight • Difficulty with weight bearing bearing The only real way to tell is with imaging “High Ankle Sprain” - Syndesmosis History • 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 of ankle 10

11/21/2017 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 11

11/21/2017 Assessment • History – Painful walking – Pain in midfoot • Physical Examination • Midfoot Swelling • Midfoot Pain – Dorsal or plantar • Ecchymosis • MUST GET Appropriate IMAGING IF THESE ARE www.aofoundation.org PRESENT 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 12

11/21/2017 Pathoanatomy • Complex Deformity • Lateral Deviation First Toe, with Medial Deviation of Phalanx Treatment Conservative Surgical • Shoewear Modification • Usually reserved for those who fail conservative • Orthotics treatment • Bunion Sleeves • >100 different surgical • Bunion Pads procedures described • Gastroc Stretching • Results vary ‐ ~70‐85% improvement 13

11/21/2017 Thank You 14