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Foot & Ankle Injuries and Treatment Dr. John R. Sallade Physical Therapist Board Certified – Sports Medicine Fellow – Academy Applied Functional Science.

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Presentation on theme: "Foot & Ankle Injuries and Treatment Dr. John R. Sallade Physical Therapist Board Certified – Sports Medicine Fellow – Academy Applied Functional Science."— Presentation transcript:

1 Foot & Ankle Injuries and Treatment Dr. John R. Sallade Physical Therapist Board Certified – Sports Medicine Fellow – Academy Applied Functional Science

2 Classes of Conditions > Traumatic surgical intervention non surgical intervention non surgical intervention Insidious onset Insidious onset Congenital Congenital

3 Traumatic Fractures Ankle Fractures Ankle Mid foot Mid foot Forefoot Forefoot Tendon tears Achilles (plantaris) Tendon tears Achilles (plantaris) Posterior Tibialis Posterior Tibialis Peroneal Peroneal Repair, ORIF +/- Immobilization, WB, PT Repair, ORIF +/- Immobilization, WB, PT

4 Osseous Anatomy

5

6 ORIF

7 ORIF

8 ORIF

9 OREF (Hoffman)

10 Immobilization

11 Repair MRI

12 Immobilization

13 Post Operative Complications Stiffness Stiffness Weakness Weakness Decreased propioception Decreased propioception Decreased vascularity, edema Decreased vascularity, edema Infection Infection RSD CRIPS RSD CRIPS DVT PE DVT PE

14 Non traumatic Injuries Insidious Onset Tendinosis Tendinosis Stress fractures Stress fractures Bunions, Hallux Limitus Bunions, Hallux Limitus Hammer toes Hammer toes Metatarsalgia Metatarsalgia Neuromas Neuromas Plantar Fascitis Plantar Fascitis Compartment Syndrome Compartment Syndrome

15 Non Traumatic Injuries Blisters Blisters Callosities Callosities Sub ungula hematomas Sub ungula hematomas Arthritis Arthritis pump bumps pump bumps Apophositis Apophositis Sesmoiditis Sesmoiditis Infections Infections

16 Peroneal Tendons

17 Medial Tendons

18 Tendinitis (post. tib., achilles, peroneal) Usually insidious in onset Usually insidious in onset Pain with WB – stretch or contraction Pain with WB – stretch or contraction Improves with light activity Improves with light activity Latent inflammatory response Latent inflammatory response TTP, warm TTP, warm Labs and Radiography not helpful Labs and Radiography not helpful

19 Treatment Relative rest Relative rest Ice – 15 Ice – 15 Anti inflamatories – dosage and duration Anti inflamatories – dosage and duration PT - Find the biomechanical cause PT - Find the biomechanical cause modalities, stretching, strengthening (hip partner), transverse friction massage, biomechanical control (shoes, inserts, lifts or orthotics) modalities, stretching, strengthening (hip partner), transverse friction massage, biomechanical control (shoes, inserts, lifts or orthotics)

20 Ankle Sprains Account for 25% of all sports injuries Account for 25% of all sports injuries Lateral (ATF+CF)(85%) Lateral (ATF+CF)(85%) Medial (Deltoid)> Medial (Deltoid)> High (Syndesmosis)> High (Syndesmosis)> Mid tarsal Mid tarsal Possible causes: Cavus, poor proprioception, poor rehab, over weight and poorly conditioned Cavus, poor proprioception, poor rehab, over weight and poorly conditioned No significant male – female ratio No significant male – female ratio

21 Ankle Ligaments

22 High Ankle sprain

23 Midtarsal Sprain

24 Treatment Surgery? Surgery? RICE RICE Progressive WB Progressive WB Immobilization and Early mobilization Immobilization and Early mobilization Closed Chain Exercise Closed Chain Exercise Looking for a cause Looking for a cause

25 Closed chain Exercise

26 Plantar Fascitis

27 Causes Unlocked midtarsal joint at push off phase of gait causing stretch to fascia Unlocked midtarsal joint at push off phase of gait causing stretch to fascia Variety of foot types Variety of foot types Tight heelcords for level of function Tight heelcords for level of function Tight great toe flexors or fascia Tight great toe flexors or fascia Weakness in control of pronation Weakness in control of pronation Training errors, shoes Training errors, shoes

28 Treatment No correlation to heel spurs No correlation to heel spurs Differentiate from tarsal tunnel Differentiate from tarsal tunnel Treat the cause: Treat the cause: Stretch tight heel cords and FHL Stretch tight heel cords and FHL Support unstable biomechanics – orthotics, taping or arch strapping Support unstable biomechanics – orthotics, taping or arch strapping Night splints, morning/first step routine Night splints, morning/first step routine Analgesic modalities, injections? Surgery? Analgesic modalities, injections? Surgery?

29 Treatment for Plantar Fascitis

30 Treatment for plantar fascitis

31 Bunions (Hallux Valgus)

32 Bunions Both medial (1 st MTP) and lateral (5 th ) Both medial (1 st MTP) and lateral (5 th ) In medial bunion: In medial bunion: Over pronated foot with abductus (toe out) Over pronated foot with abductus (toe out) Tight heel cords Tight heel cords Forefoot varus Forefoot varus

33 Treatment Treat the cause Treat the cause Symptomatic relief with modalities Symptomatic relief with modalities Heel cord stretching Heel cord stretching Fore foot support via orthotic Fore foot support via orthotic Strengthening Strengthening When is surgery the best option? When is surgery the best option?

34 Treatment stretching orthotics

35 Stress Fractures – Micro Fractures Most common sites: metatarsals

36 Tibia

37 Calcaneal

38 Calcaneal

39 Femur

40 Stress Fractures Probable Causes Increasing the amount or intensity of an activity too quickly (most common) Increasing the amount or intensity of an activity too quickly (most common) Hard or uneven running surface Hard or uneven running surface Improper or old shoes Improper or old shoes Untreated biomechanical imbalances Untreated biomechanical imbalances Biomechanical limitations of motion (subtalar and midtarsal joints) Biomechanical limitations of motion (subtalar and midtarsal joints)

41 Other Risk Factors for Stress Fractures Risk Factors Female, short, thin and caucasian Female, short, thin and caucasian Certain sports, especially involving plyometric loading: Certain sports, especially involving plyometric loading: Distance running Distance running Gymnastics Gymnastics Dance Dance Basketball and Tennis Basketball and Tennis Amenorrhea>decrease hormone support Amenorrhea>decrease hormone support Amenorrhea Poor diet- low in calcium and high in acidity Poor diet- low in calcium and high in acidity Osteopenia (Reduced bone thickness or density) Osteopenia (Reduced bone thickness or density) Poor muscle strength or flexibility Poor muscle strength or flexibility Overweight or underweight Overweight or underweight

42 Compartment Syndrome Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells. Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells. Compartment syndrome can be either acute or chronic. Compartment syndrome can be either acute or chronic. Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury. Without treatment, it can lead to permanent muscle damage. Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury. Without treatment, it can lead to permanent muscle damage. Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion. Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion. Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily. Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.

43 Compartment Syndrome

44 Symptoms and Diagnosis Chronic (Exert ional) Compartment Syndrome Chronic (Exert ional) Compartment Syndrome Chronic compartment syndrome causes pain or cramping during exercise. This pain subsides when activity stops. It most often occurs in the leg. Chronic compartment syndrome causes pain or cramping during exercise. This pain subsides when activity stops. It most often occurs in the leg. Symptoms may also include: Symptoms may also include: Numbness Numbness Difficulty moving the foot Difficulty moving the foot Visible muscle bulging Visible muscle bulging

45 Differential Chronic (Exertional) Compartment Syndrome Chronic (Exertional) Compartment Syndrome To diagnose chronic compartment syndrome, other conditions that could also cause pain in the lower leg should be ruled out. Tendonitis can be ruled out but history and physical exam (palpation, passive and resistive tests). To rules out stress fractures, an x-ray, bone scan or CT scan can be used depending on the duration and location of the injury. To diagnose chronic compartment syndrome, other conditions that could also cause pain in the lower leg should be ruled out. Tendonitis can be ruled out but history and physical exam (palpation, passive and resistive tests). To rules out stress fractures, an x-ray, bone scan or CT scan can be used depending on the duration and location of the injury. To confirm chronic compartment syndrome, pressure tests of the compartment before and after exercise must be performed. To confirm chronic compartment syndrome, pressure tests of the compartment before and after exercise must be performed. Treatment may involve a combination of rest, activity modification, change of shoes and orthotics and PT or in more involve cases surgery (fasciotomy). Treatment may involve a combination of rest, activity modification, change of shoes and orthotics and PT or in more involve cases surgery (fasciotomy).

46 Testing Fasciotomy

47 Reflex Sympathetic Dystrophy Chronic Regional Pain Syndrome Hyper reactivity of the sympathetic nervous system causing sustained fight and flight response. Hyper reactivity of the sympathetic nervous system causing sustained fight and flight response. The symptoms of RSD/CRPS often progress in three stagesacute, dystrophic, and atrophic. The symptoms of RSD/CRPS often progress in three stagesacute, dystrophic, and atrophic. The acute stage occurs during the first 1–3 months (usually after injury to bone or nerve, surgery and/or immobilization of an extremity) and may include burning pain (not proportionate to the degree of injury), swelling, increased sensitivity to touch, increased hair and nail growth in the affected region, joint pain, and color and temperature changes. The acute stage occurs during the first 1–3 months (usually after injury to bone or nerve, surgery and/or immobilization of an extremity) and may include burning pain (not proportionate to the degree of injury), swelling, increased sensitivity to touch, increased hair and nail growth in the affected region, joint pain, and color and temperature changes.

48 Advanced Symptoms The dystrophic stage may involve constant pain and swelling. The affected limb may feel cool to the touch and appear bluish in color. Muscle stiffness, wasting of the muscles (atrophy), and early bone loss (osteoporosis) also may occur. This stage usually develops 3–6 months after onset of the disorder. During the atrophic stage, the skin becomes cool and shiny, increased muscle stiffness and weakness occur, and symptoms may spread to another limb. During the atrophic stage, the skin becomes cool and shiny, increased muscle stiffness and weakness occur, and symptoms may spread to another limb. Characteristic signs and symptoms of sympathetic nervous system involvement include the following: Characteristic signs and symptoms of sympathetic nervous system involvement include the following: Burning pain Burning pain Extreme sensitivity to touch Extreme sensitivity to touch Skin color changes (red or bluish) Skin color changes (red or bluish) Skin temperature changes (hot or cold) Skin temperature changes (hot or cold)

49 RSD appearance

50 Treatment Treatment Treatment The goals of RSD/CRPS treatment are to control pain and promote as much mobilization of the affected limb as possible without increasing symptoms. Treatment must be individualized and will often combine medications, physical therapy, nerve blocks (ganglion blocks with alpha adrenergic antagonist), and psychosocial support. Sympathectomy can be helpful in recalcitrant cases. The goals of RSD/CRPS treatment are to control pain and promote as much mobilization of the affected limb as possible without increasing symptoms. Treatment must be individualized and will often combine medications, physical therapy, nerve blocks (ganglion blocks with alpha adrenergic antagonist), and psychosocial support. Sympathectomy can be helpful in recalcitrant cases. Early detection and intervention is paramount. Early detection and intervention is paramount.

51 Metatarsalgia Inflammation of the heads of one or more metatarsal heads (periostitis) Inflammation of the heads of one or more metatarsal heads (periostitis) Caused by uneven loading of forefoot during propulsion Caused by uneven loading of forefoot during propulsion Caused by forefoot imbalance or deformity Caused by forefoot imbalance or deformity

52 Metatarsalgia

53 Treatment Rest, ice and NSAIAs Rest, ice and NSAIAs Shoe, cushioned insoles Shoe, cushioned insoles Callous reduction (egg) Callous reduction (egg) Biomechanical exam to determine extent of forefoot imbalance and prescription of custom orthotic with FF balancing and relief cut outs Biomechanical exam to determine extent of forefoot imbalance and prescription of custom orthotic with FF balancing and relief cut outs

54 Treatment

55 Inter Metatarsal (Mortons) Neuroma Enlarged, fibrotic and benign interdigital nerves Enlarged, fibrotic and benign interdigital nerves Most commonly between the third and forth metatarsals Most commonly between the third and forth metatarsals Brought on by shearing between metatarsals Brought on by shearing between metatarsals Aggravated by narrow shoes and forefoot imbalance Aggravated by narrow shoes and forefoot imbalance Treatments include special shoes or inserts, NSAIAs and/or cortisone injections, but surgical removal of the growth is sometimes necessary. Treatments include special shoes or inserts, NSAIAs and/or cortisone injections, but surgical removal of the growth is sometimes necessary.

56 Neuromas

57 Treatment

58 Osteo arthritis condition characterized by the breakdown and eventual loss of cartilage in one or more joints (ankle>MTJ>1 st MTP>ST) condition characterized by the breakdown and eventual loss of cartilage in one or more joints (ankle>MTJ>1 st MTP>ST) degenerative arthritis, reflecting its nature to develop as part of the aging process degenerative arthritis, reflecting its nature to develop as part of the aging process Pain and stiffness in the joint, swelling in or near the joint, difficulty walking or bending the joint Pain and stiffness in the joint, swelling in or near the joint, difficulty walking or bending the joint

59 Radiography

60 Treatment Proper footwear Proper footwear Medications to relieve pain and swelling (NSAIA, analgesic, glucosamine) Medications to relieve pain and swelling (NSAIA, analgesic, glucosamine) Education on activity modification Education on activity modification Weight loss Weight loss PT -heat/cold therapy, E Stim., US, exercises to improve range of motion and strength, insoles or custom orthotics PT -heat/cold therapy, E Stim., US, exercises to improve range of motion and strength, insoles or custom orthotics Injections and in some cases surgery. Injections and in some cases surgery. Read more: 2.html#ixzz0i40DeAAZ 2.html#ixzz0i40DeAAZhttp://www.automailer.com/tws/TopicOA- 2.html#ixzz0i40DeAAZ


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