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Foot and Ankle Problems in the Endurance Athlete Brian A. Weatherby, MD Steadman-Hawkins Clinic of the Carolinas Assistant Professor Clinical Orthopaedic.

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Presentation on theme: "Foot and Ankle Problems in the Endurance Athlete Brian A. Weatherby, MD Steadman-Hawkins Clinic of the Carolinas Assistant Professor Clinical Orthopaedic."— Presentation transcript:

1 Foot and Ankle Problems in the Endurance Athlete Brian A. Weatherby, MD Steadman-Hawkins Clinic of the Carolinas Assistant Professor Clinical Orthopaedic Surgery University of South Carolina School of Medicine

2 DISCLOSURES NONE

3 Foot Problems Lesser MTP DisordersLesser MTP Disorders Great Toe DisordersGreat Toe Disorders Metatarsal Stress FractureMetatarsal Stress Fracture

4 Ankle Problems TendinopathyTendinopathy Achilles Achilles Posterior Tibial Posterior Tibial Peroneal Peroneal

5 Not this Endurance Athlete!

6 This Endurance Athlete!

7 Foot Problems Lesser MTP DisordersLesser MTP Disorders Metatarsalgia/MTP Synovitis/MTP Instability Metatarsalgia/MTP Synovitis/MTP Instability Interdigital neuroma Interdigital neuroma Great Toe DisordersGreat Toe Disorders Sesamoiditis Sesamoiditis Hallux Rigidus Hallux Rigidus Metatarsal Stress FractureMetatarsal Stress Fracture

8 Foot Problems Lesser MTP DisordersLesser MTP Disorders Metatarsalgia/MTP Synovitis/MTP Instability Metatarsalgia/MTP Synovitis/MTP Instability Interdigital Neuroma Interdigital Neuroma

9 Lesser MTP Pain Differential diagnosis extensive Mechanical Neurologic Idiopathic

10 Metatarsalgia Mechanical Shoewear Small toe box Short shoe

11 Metatarsalgia Mechanical MP instability Often associated with long 2 nd MT (Mortons Foot) –Especially in runner

12 Metatarsalgia Idiopathic Overuse syndromes (runners) Fat pad atrophy (aging)

13 Metatarsalgia MTP Synovitis MTP Instability MP Instability Chronic-Volar plate degeneration Wide spectrum of presentation Can be progressive

14 Lesser MTP Pain Neurologic Mortons Neuroma Mimic or be associated with synovitis Almost always 3 rd web space

15 Lesser MTP Pain Idiopathic Freibergs infraction 2>3 MT heads Occurs in adolescence but symptoms often in adult

16 Metatarsalgia Examination Isolated palpation of MT head Plantar keratosis Fat pad atrophy

17 MTP synovitis/MTP Instability MTP synovitis/MTP Instability Examination Deformity Hyperextension/Disloc ation Instability Lachmans Synovitis Plantarflexion stress

18 Mortons Neuroma Examination Palpate Inter-space (always) Squeeze Test (majority) Mulders Sign (30%)

19 Biomechanics Examination Check for Achilles contracture Increases forefoot pressures!

20 Lesser MTP Pain Diagnostic studies Radiographs –Subluxation –Dislocation –Degeneration –MT lengths

21 Treatment Metatarsalgia Activity Modification Cross Train-bike/swim Shoewear Changes Rocker bottom Heel Cord Stretching 10 minutes/day with body wt Custom Orthotics Rx Full length accomodative orthotic with MT pad to unload __ MT head(s)

22 Shoewear Neutral Stability combines cushioning and support Cavus (Supinator) Cushioning shock dispersion in its midsole and/or outsole design Planus (Pronator) Motion control medial support w/ dual density midsoles, roll bars, or foot bridges, thus slowing the rate of overpronation

23 Treatment Metatarsalgia Activity Modification Shoewear Changes Heel Cord Stretching 10 minutes/day with body wt Custom Orthotics Rx Full length accomodative orthotic with MT pad to unload __ MT head(s)

24 Treatment MTP Synovitis/MTP Instability Activity Mods/Shoe Δ/Achilles Buddy Taping Daily 8-10 wks Marble Pick-ups 50 x 3 days then 250 for 8-10 weeks Rx Strength NSAID 6-8 wks Orthotic w/ MT pad Temporary felt MT pad (Hapad) 6-8 wks

25 Treatment MTP Synovitis/MTP Instability MTP Injection Diagnostic &/or Therapeutic Longstanding/Refractory Must protect 4 wks in Budin splint

26 Treatment Mortons Neuroma Activity Mods Shoewear Changes Rx Strength NSAID 6-8 wks Custom Orthotic w/ MT pad Temporary Hapad Webspace Injection Diagnostic &/or Therapeutic Longstanding/Refractory Tape protection 4 wks

27 Summary Consider all possibilities Exhaust all non-operative modalities Surgical Tx warranted after minimum 16 + weeks conservative care

28 Great Toe Disorders Sesamoiditis Hallux Rigidus

29 First MTP Anatomy Tibial & Fibular Sesamoids FHL & FHB Plantar Plate Articular Surfaces MTP MT-sesamoid

30 Biomechanics Importance of great toe Analogous to patella Push-off phase of gait In athletics: Jumping Sprinting Spring board diving Control in ballet, tae kwon do

31 Biomechanics Normal gait Up to 50% body weight transmitted through great toe complex Great toe 2x lesser toes Jogging, running 2-3x body weight Running jump 8x body weight

32 Sesamoidtis Etiology Spectrum Acute (fall or forced DF) Fracture Sx bipartite sesamoid (tibial) Chronic (repetitive stress) Stress Fracture Sesamoiditis Osteochondritis Chondromalacia Osteonecrosis Exostosis IPK (tibial)

33 Sesamoid Disorders History Trauma, overuse, idiopathic Localized plantar 1 st MTP pain Sport/Stairs/High impact worse Δ in shoes/training/mechanics

34 Sesamoid Disorders Clinical Exam Specific TTP at tibial &/or fibular Swelling, warmth, erythema Plantar pain, +/- crepitus w/ motion IPK over tibial sesamoid

35 Sesamoid Disorders Radiographs Standing AP/bilateral Axial Oblique Marker over area TTP

36 Sesamoid Disorders Bone Scan Helpful when XR nml High false + Pinhole images to diff b/w sesamoids MRI Bone vs. soft tissue Assess bone viability, degeneration, tendon continuity CT Acute Frx Exostosis

37 SESAMOIDITIS Presentation Swelling and inflammation of peri-tendinous structures Overuse Pain on WB, TTP directly over Tibial Sesamoid XR normal, +/- flow T C bone scan, diffuse edema of sesamoid MRI Diagnosis of Exclusion

38 Sesamoid Fracture Presentation Acute Hyperextension injury Tibial sesamoid Transverse frx line, mid-waist Callus formation Association with MP dislocation CT to evaluate displacement

39 Bipartite Sesamoid Bipartite vs. Acute Fracture (Brown et al. CORR) Irregular & unequal fragment diastasis Callus formation Presence/absence on contralateral side

40 Sesamoid DJD Post-traumatic Iatrogenic s/p bunionectomy Chondromalacia Osteophytes Attritional rupture of abd/adductor H Valgus/Varus

41 Sesamoid Osteochondritis Etiology unknown Crush injury Stress Frx AVN Pain, fragmentation, cyst formation, flattening XR Δs may delay 6-12 mos Bone scan MRI

42 Bipartite Acute Frx Stress Frx Osteochondritis

43 Sesamoid IPK Tibial sesamoid Cavus, PF ray (diffuse) Sesamoid prominence (localized)

44 Treatment Acute Fracture ( 2mm diastasis) Heel Touch WB in toe spica cast x 2 weeks Wedge Shoe x 2-4 weeks Custom Orthotic there after Full length accomodative orthotic with area of relief for tibial/fibular sesamoid PT at 4-6 wks No running 3-4 mos

45

46 Treatment Sesamoditis/DJD/ Osteochondritis Activity Mods Shoewear Mods Remove cleat under 1 st MTP Rocker bottom shoe (Skecher) Rx NSAIDs 6-8 wks Custom Orthotic Wedge shoe until if symptoms RTP w/ FPP once asx x 3-4 wks & w/ orthotics

47 Treatment Cortisone Injection Longstanding/Refractory Flouro guided Results Highly Variable Surgical Tx Failure appropriate non-op tx 16 wks Displaced Frx

48 Hallux Rigidus

49 Second most common condition affecting the hallux MP joint Termed coined by Cotterill in 1888, after description by Davies-Colley in 1887

50 Hallux Rigidus Definition = stiffness of 1 st MTPJ Multiple names given: Hallux flexus/limitus Multiple etiologies considered Degenerative Traumatic (overuse/OCD/injury sequlae) Dorsal bunion (paralytic) Metatarsus primus elevatus

51 Hallux Rigidus Two groups: Adolescent Rigid swollen joint, painful DF Chondral lesion (traumatic) or OCD (atraumatic) Adult Degenerative destruction ? Overuse or traumatic etiology

52 Hallux Rigidus Presentation Dorsal prominence shoewear irritation Painful ROM (PF and DF, with push-off)

53 Hallux Rigidus Examination TTP over dorsal prominence Keratosis TTP over sesamoids – poorer prognosis 1 st MTP ROM Pain at extremes Pain at mid-range poorer prognosis Drawer exam

54 Hallux Rigidus Radiographs Varying Grades

55 Hallux Rigidus Radiographic worsening does NOT equate to clinical worsening

56 Hallux Rigidus Treatment Shoewear modifications Size Cushion prominences Orthotics Full length orthotic with TPE or carbon fiber Mortons extension under 1 st ray Taping Rx NSAIDs

57 Hallux Rigidus Treatment Steroid injection SELECTIVE Repeated injections will degenerative process

58 Hallux Rigidus Surgical Tx Adolescent/Young Athlete OCD lesion or chondral injury Arthroscopic debridement & microfracture

59 Hallux Rigidus Surgical Tx Adult Cheilectomy and Drilling of bare areas

60 Hallux Rigidus Surgical Tx Lengthy discussion with athlete Expectations Pain relief (majority) ? push-off power

61 Metatarsal Stress Fracture

62 Stress Fracture Definition Partial or complete fracture of a bone due to its inability to withstand nonviolent, rhythmic, repetitive subthreshold stress

63 Stress Fractures Pathophysiology Accumulation of microdamage to bone occurring with multiple subultimate failure strain loads & failure of body to initiate healing response. AAOS ICL 2004 Sub-threshold stress exceeds the bodys reparative ability Crack Initiation Propogation Final Frx

64 Stress Fractures Etiology Anatomy Foot Type & Alignment –Subtle Cavus –Long 2 nd MT –Leg Length Discrepancy Blood Supply –5 th MT base, middle MT neck

65 Stress Fractures Etiology Footwear Training Surface in intensity/distance or in training method Metabolic Hormone abnormality –Menstrual irregularity, oral contraceptives –Female Triad Calcium metabolism –Rickets: Vitamin D deficiency, renal tubular insufficiency, osteodystrophy, hypophosphatasia, Hyperparathyroidism

66 Stress Fractures History AWARENESS Wide spectrum of presentation pain with activity, pain with pressure (airplane) Vague, deep throbbing pain Alteration in stress/training +/- report of an actual single event Frx 2° continued loading Chronic fractures can have very subtle and unimpressive findings

67 Stress Fractures Physical Exam TTP over area Percussion/Tuning Fork Pain with one leg hopping Assess Foot Stucture

68 Foot Structure Neutral Cavus (Supinator) Planus (Pronator)

69 Foot Structure CAVUS Subtle Cavus Peek-a-boo heel (varus) PF 1 st ray Obvious Cavus

70 Foot Structure Cavus Related Conditions 5 th MT Stress Fracture Peroneal Tendon Pathology Chronic Ankle Instability

71 Orthotics Cavus Foot Pre-fab Donjoy Arch Rival Rx Full length orthotic w/ lateral forefoot posting and area of relief for 1st MT head, along w/ MT pad to unload __ MT head(s)

72 Stress Fractures Imaging Supports Clinical Suspicion Know Your Imaging XR lag behind or negative in 30-70% cases MRI & Bone Scan show reaction before fracture line is visable on CT

73 Stress Fractures XR Frx evident in 30-70%, better for cortical Pain onset bony avg.~ 21 days, may take 6 wks T c 99 sensitive w/in hrs Poor specificity MRI Sensitive & Specific CT Complete vs. Incomplete Frx

74 MT Stress Fractures Treatment- Stress Reaction (+ MRI/Bone Scan, - XR) 5 th MT NWB in Boot/Cast until NTTP When NT place in appropriate orthotic –Cavus foot Full length orthotic w/ lateral forefoot posting & area of relief for 1st MT head, to include TPE or carbon fiber baselayer –Nml foot Carbon fiber insert/Turf toe plate Modify activity 4-6 wks

75 MT Stress Fractures Treatment- Stress Reaction or Fracture 2/3/4 MTs WBAT Boot/Post op shoe 4-6 wks to carbon fiber/toe plate –After minimum 4 wks and NTTP Gradual return with FPP

76 MT Stress Fractures Treatment-Stress Frx (+ frx line or periosteal rxn on XR or CT) 5 th MT NWB cast 8 wks (+/- bone stimulator) If XR healing and NTTP Boot with progressive wt bearing 2-3 wks Then to carbon fiber/toe plate Gradual return with FPP wk Time to Union (bone stim 8-9 weeks) 30-50% RE-FRACTURE/NONUNION

77 Mologne et al., AJSM 2005 Cast vs. Screw, Level I Study 18 cast, 19 screw, 25 mos f/u 44% cast Tx Failure 6% screw Tx Failure Time to union/RTP Screw 7.5/8 wks Cast 14.5/15 wks MT Stress Fractures

78 5 th MT Fracture- Operative Indications Athlete Acute/stress fx Nonunion Re-fracture Cavovarus = lateral overload

79 MT Stress Fractures Operative Goals Expedite healing Quicker recovery; easier rehab Decrease re-fracture risk

80 Ankle Problems TendinopathyTendinopathy Achilles Achilles Posterior Tibial Posterior Tibial Peroneal Peroneal

81

82 Tendinopathy

83 Tendons: Basic Science *Aging results in increased stiffness due to inc. collagen cross-linking Decrease in tensile strength

84 Tendons: Basic Science Blood Supply 3 sources Musculotendinous junction Surrounding connective tissue Bone-tendon junction Zones of Hypovascularity Decreases with age and mechanical loading

85 Tendinopathy: Etiology Overuse injury (i.e. Degenerative Tendinopathy): Multifactorial: Repetitive microtrauma (fibril level) Load induced ischemia oxygen free radicals Local hypoxia tenocyte death Hyperthermic cell injury Most common histiopathologic finding in tendon rupture Biomechanics Cavus Peroneal Tendons Planus (Pronation) Achilles Tendon, Post Tib Tendon

86 Tendinopathy: Etiology Corticosteroids Flouroquinolones Autoimmune disorders, inflammatory arthropathies, infection Trauma

87 Tendon Healing Immobilization Decreases water and proteoglycan content Increases reducible crosslinks Results in tendon atrophy Mobilization Controlled stresses in proliferative and remodeling phases highly organized collagen, increased tenocyte DNA content and protein synthesis Increased tensile strength, cross-sectional area

88 Achilles Tendon Zone of hypovascularity 2- 6cm proximal to insertion Forces 8-10x body wt. in running

89 Achilles Tendon Insertional Tendinopathy Occurs in older, less athletic, overweight individuals Non-insertional Tendinopathy Occurs in more active athletes as a result of repetitive stess of jumping, pushing off and cutting activities

90 Achilles Tendon 1° CLINICAL DIAGNOSIS MRI Failure of Non-op Tx or Surgical planning

91

92 Achilles Tendon Treatment-Non-insertional Paratenonitis Activity Modification Cross training Swimming, Stationary Bike Rx NSAIDs and/or Medrol Dose Pack 0.25 inch heel lift Ice, Contrast baths Orthotics for overpronators Prevent whipping action on tendon Cam boot immobilization (if sxs > 6 wks)

93 Achilles Tendon Treatment-Non-insertional Paratenonitis Refractory Brisement injections

94 Achilles Tendon Treatment-Non-insertional Paratenonitis w/ Tendinosis Cam boot w/ 0.25 in heel lift Until no pain w/ ambulation shoe w/ lift PT Rx Eccentric Exercise Program, Iontophoresis, US, X-friction massage +/-Night Splint +/-Topical Nitro-Dur Patch 0.1mg/hr x 5-7 days

95 Achilles Tendon Treatment-Non-insertional Paratenonitis w/ Tendinosis Refractory Tx Options PRP Injection –Controversial!

96 Achilles Tendon Treatment-Non-insertional Paratenonitis w/ Tendinosis Surgical Treatment LAST RESORT!!! MUST fail 6 mos of non-operative tx Plethora of Surgical Procedures –Results 70-75% good to excellent –LESS than traditional orthopaedic procedures

97 Peroneal Tendons

98 Peroneal Tendon Tears Anatomic Predispositions Peroneus quartus Hypertrophied peroneal tubercle Os peroneum Low lying peroneus brevis Convex/Flat groove Cavo-varus foot

99 Peroneal Tendons Important Characteristics Pain Location Behind or distal to lateral malleolus PB- Distal to LM Base of 5 th PL- Over lateral calcaneus peroneal tubercle Pain Elicitation Passive PF & Inversion Resisted active DF & Everison –If pop/click elicited ? Tear or intra-sheath subluxation

100 Peroneal Tendons 1° CLINICAL DIAGNOSIS XR Standard foot views MRI Difficulty in diagnosis or Surgical planning Sensitivity 17%, Specificity 100% (Kijowski et al.)

101 Peroneal Tendons Non-operative Treatment RICE Cam boot or ASO until pain subsides Rx NSAIDs or Dose Pack PT Orthotics for Cavus foot Gradual Return with FPP

102 Peroneal Tendons Surgical Treatment Failure of non-operative treatment Procedure tailored to pathology Debridement +/- repair, possible groove deepening, excision p. quartus or p. brevis muscle belly, excision peroneal tubercle

103 Posterior Tib Tendon Anatomy Acute angulation of tendon Zone of hypovascularity Frey: starts cm distal to MM and extends to navicular insertion

104 Posterior Tib Tendon Important Characteristics Medial ankle pain TTP over course PTT Fullness over PTT Arch collapse Too many toes sign Inability to perform DSHR or SSHR

105 Posterior Tib Tendon AP/lateral weight bearing films of foot and/or ankle Talo-navicular sag Plantar flexion of Talus Collapse of midfoot Collapse of the talo-calcaneal angle MRI Difficulty in diagnosis or Surgical planning

106 Posterior Tib Tendon Non-operative Treatment RICE PT for Eccentric PTT program Rx NSAIDs or Dose Pack Protection If can do SSHR Orthotic w/ high trim line medially or Aircast Airlift PTTD brace If not Cam boot with arch support inside

107 Posterior Tib Tendon Operative Treatment Failure of 4-6 mos Non-op Tx Avoidance of bony procedures in athlete PT debridement +/- FDL t-fer Medializing calcaneal osteotomy at most

108


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