Gp lecture foot_ankle_sept_2010

Cameron Bulluss, Rob Dingle, Peter Enks, Pierre Buchholz, Gavin Jackson – Advanced Physiotherapy

and Injury Preventionwww.advancedphysio.com.au

Foot and Ankle Session

PreliminariesUseful Resources and Acknowledgements1. Atlas of Imaging in Sports Medicine (2nd ed.). Jock Anderson and

John W Read 2. Clinical Sports Medicine. Bruckner and Khan3. American Academy of Orthopedic Surgeons Website.

www.aaos.org 4. Advanced Physiotherapy and Injury Prevention Website

www.advancedphysio.com.au, notes will be on website (show)Acknowledgements – Isobel Green, Jess FidlerIntroduce ColleaguesPurpose of these talks: educate, meet, value addWho we treat

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Presentation Notes

Useful Resources 1. Atlas of Imaging in Sports Medicine (2nd ed.). Jock Anderson and John W Read 2. Clinical Sports Medicine. Bruckner and Khan 3. American Academy of Orthopedic Surgeons Website. www.aaos.org 4. Advanced Physiotherapy and Injury Prevention Website www.advancedphysio.com.au

http://www.advancedphysio.com.au/�

Imaging

When to Image If it affects management Diagnosis is uncertain Demanding patient To assist with determining prognosis Red flags Orange flags Failed treatment

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Presentation Notes

Basic Imaging Principles (Anderson and Read) “It is the clinical assessment coupled with a knowledge coupled with an knowledge of relevant anatomy and the pathological process that is the cornerstone of effective management. Paradoxically as imaging technology becomes more sophisticated the importance of clinical judgement in determining the relevance of any reported findings actually increases. Studies have shown that sub-clinical pathology is present in a large proportion of asymptomatic individuals. It is vitally important to provide a request form to the radiologist that offers a short guiding differential diagnosis or asks specific questions that the radiologist is expected to answer. “

Ottawa Ankle and Foot Rules

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Presentation Notes

Ottawa rules for x-ray of knee, ankle and foot An ankle x-ray is required only if there is any pain in malleolar zone and any of these findings: bone tenderness at A bone tenderness at B inability to weight bear both immediately and in the casualty department. A foot x-ray is required if there is any pain in the midfoot zone and any of these findings: bone tenderness at C bone tenderness at D inability to weight bear both immediately and in the casualty department. Ankle injuries are extremely common but many features on history and physical examination are unreliable�The combined Ottawa ankle and foot rules have a sensitivity of 97.8% and a specificity of 31.5%, giving a negative likelihood ratio of 0.07; this will yield a post-test probability of about 1% for fracture of the ankle if test results are negative (not requiring x ray)�Treatment for ligament injuries should include dynamic splinting and RICE (rest, ice, compression, and elevation)�Rule out a complete tear of the ligaments by doing drawer testing of the ankle before discharging the patient or at the first follow-up visit

Red Flags > 50 year old Systemic symptoms Significant morning stiffness Known risk factors Past history or family history Noctural pain

Orange Flags Disability disproportionate to mechanism Failure to respond to conservative management Multiple opinions Anxious patient Education Significant trauma (fall over 1 metre) IV drug use Cord or cauda equina signs History of use of oral corticosteroids

Grades of Injury – Muscle/LigamentLigament

Grade 1 Pathology = microscopic tearing (strain)Clinical = Tenderness but no ligament laxityMRI = normal ligament thickness but increased periligamentoussignal

Grade 2 Pathology = partial tearClinical = some ligamentous laxity but firm end-pointMRI = ligament thickening +- partial discontinuity, increased signal

Grade 3 Pathology = complete tearClinical = increased ligament laxity and no indentifiable end pointMRI = complete ligament discontinuity + oedema and

haemorrhage

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Presentation Notes

The MRI grading system for articular cartilage abnormalities is as follows: (Anderson and Read) Grade 0 = normal Grade 1 = swelling or softening with signal increased or decreased Grade 2 = superficial fibrillations or irregularities, loss of thickness less than 50% Grade 3 = deep fibrillation or ulceration with loss of thickness Grade 4 = Exposure of subchondral bone with associated marrow oedema Ligament Grade 1 Pathology = microscopic tearing (strain) Clinical = Tenderness but no ligament laxity MRI = normal ligament thickness but increased periligamentous signal Grade 2Pathology = partial tear Clinical = some ligamentous laxity but firm end-point MRI = ligament thickening +- partial discontinuity, increased signal Grade 3Pathology = complete tear Clinical = increased ligament laxity and no indentifiable end point MRI = complete ligament discontinuity + oedema and haemorrhage Muscle Injuries that involve muscle bellies or musculotendinous junctions are best evaluated by MRI. The grading system for muscle tears is as follows Grade 1 Pathology = microscopic tearing, heals without defect Clinical = pain and tenderness with no loss of function MRI = increased signal, no fibre discontinuity, perifascial hyperintensity Grade 2 Pathology = partial tear Clinical = often inseperable from grade 1 tears, some loss of function MRI = increased signal, some fibres torn Grade 3 Pathology = complete tear Clinical = complete or near complete loss of function MRI = complete muscle discontinuity, retracted tear margin, haematoma Ref. Anderson 2008

Anatomy of the Foot and AnkleBones and Articulations

Inferior tibiofibular jointTalocrural joint Subtalar jointTransverse tarsal (Choparts)Intertarsal jointsTarsometatarsal joint (Lisfranc)

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Presentation Notes

The foot has 26 bones, but it also has four layers of muscles and tendons, joints, veins, arteries, nerves and fatty tissue. It is very important to remember that a force severe enough to break a bone will damage some of these other tissues as well. Injury causes swelling and bleeding which eventually forms scar tissue. During the healing process, this scar tissue can bind together the muscles and tendons which normally glide over one another. How well the foot functions after a fracture depends on how well both bone and soft tissue heal. Has transverse and longitudinal bony arches that are given static support by ligaments and dynamic support by muscles and tendons. Anatomically the foot can be divided into 3 sections (hindfoot, midfoot and forefoot) and these divisions are used here. The hindfoot consists of the talus and calcaneus and subtalar joint. The talonavicular and calcaneocuboid articulations divide the hindfoot from the midfoot and combine to form the transverse or Chopart joints. It allows some pivoting movements of the forefoot on the hindfoot and flattening of the arch. The midfoot comprises the 5 tarsal bones, these being the 3 cunieforms, the navicular and the cuboid. The tarsometatarsal joints divide the midfoot from the forefoot. The tarsometatarsal joint (also called Lisfranc’s joint) is between the distal tarsal bones, (the three cuneiforms and the cuboid) and the metatarsals. Its complex anatomy allows for a little movement of the longitudinal arch of the foot and a bit more movement at the outer border of the foot. Distally the forefoot comprises the metatarsals and phalanges. Biomechanically, these three sections interact, with the subtalar complex involved in hind and midfoot function, and the hindfoot and midfoot functioning together through a 3 column structure. The first metatarsals and the medial cuneiform form the medial column, the 2nd and 3rd cuneiforms and the corresponding cuneiforms form the middle column. The lateral column is formed by the cuboid and the 4th and 5th metatarsals. The ankle joint between the end of the tibia and the talus. 80-90% of plantarflexion and dorsiflexion occurs at this joint. A small amount of inversion and eversion is possible here. The subtalar joint is between the talus and the calcaneus. It allows side to side movement so that you can stand on the side of a sloping surface. . The tarsometatarsal joint (also called Lisfranc’s joint) is between the distal tarsal bones, (the three cuneiforms and the cuboid) and the metatarsals. Its complex anatomy allows for a little movement of the longitudinal arch of the foot and a bit more movement at the outer border of the foot Dislocation of this joint is a serious injury often associated with fracture of the metatarsals and/or cuneiform bones. Metatarsophalangeal (MTP) joints. There are five of these. These joints are between the heads of the metatarsals and the proximal phalanges. They allow flexion and extension of the toes. When you stand on tiptoe the MTP joints are extended and you are bearing weight on the toes and the joints. Interphalangeal joints. These nine joints are located between the phalanges (toe bones) and allow the toes to curl. Loss of this function is not usually a severe handicap.

Anatomy of the Foot and Ankle

Anatomy of the Foot and AnkleLigaments

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Presentation Notes

THE ANKLE The ankle is a hinge joint creating a stable linkage between the body and foot. It is bound medially and laterally by collateral ligaments and internally by the syndesmotic ligaments. Below the ankle is subtalar joint whose main function is to absorb transverse plane rotation of the lower extremity during stance phase. A syndesmosis is a joint where the rough edges of two bones are held together by thick connective ligaments. Only a few joints in the body are syndesmosis joints. The connection of the lower leg bones, the talus , is a syndesmosis. The ankle syndesmosis is held together by three main ligaments. 1. The ligament crossing just above the front of the ankle and connecting the tibia to the fibula is called the anterior inferior tibiofibular ligament (AITFL). 2. The posterior fibular ligaments attach across the back of the tibia and fibula. These ligaments include the posterior inferior tibiofibular ligament (PITFL) and the transverse ligament. 3. The interosseous ligament lies between the tibia and fibula. The function of this group of ligaments is to hold these bones together and so provide a stable junction between the lower leg and the ankle. An ankle syndesmosis injury involves a sprain of one or more of the ligaments that support the ankle syndesmosis. A sprain stretches or tears the ligaments. The ligament is weakened by the injury. How much it is weakened depends on the degree of the sprain.

Anatomy of the Foot and AnkleLigaments

Case Study 1 42 year old coal-miner, twisted ankle felt pop, swelled

immediately and unable to weight-bear, ED x-rays reported as normal, placed in backslab at hospital, told to RICE and presented to you 2 days post injury

Case Study 1

Probable diagnosis? Clinical tests to confirm

diagnosis? Further imaging required?

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Presentation Notes

Effects of balance training in prevention of ankle sprains Verhagen E, Van Der Beek A, Twisk J, et al. The effect of a proprioceptive balance board training program for the prevention of ankle sprains. The American Journal of Sports Medicine, 2004 32:1385. 1. Ankle injuries are one of the most prevalent injuries in sports today. Balance training is an effective way to prevent further ankle injuries and should be implemented to help these patients reduce the risk of further ankle injuries. 2. For athletes, implementing balance training may also help to prevent days lost due to injury. � Level of Evidence: Level 1b. This is a randomized controlled study. The large sample size (over 1,000 athletes) strengthens the evidence. � Clinical Question: Is balance training a more effective method of treatment for prevention of all types of ankle sprains than a treatment plan with no balance training? � Study: The purpose of this study was to evaluate the effect of a proprioceptive balance board training program on athletes to see if it helps to reduce and/or prevent ankle sprains. The study looked at male and female volleyball athletes due to the high risk of ankle sprains associated with the sport. The subjects came from 116 male and female volleyball teams (N=1127). The coaches were informed of the study and asked to note participation level of each athlete in everyday workouts and exercises and to note injuries and outside activities that hampered each athlete from completing at full level in any activities such as practices or games. In addition to looking at adherence to the study protocol, these logs were used to calculate exposure to opportunities for ankle sprains. � The Study Patients: A total of 1127 male and female volleyball players from 116 teams from four geographical regions from the Netherlands agreed to participate in the study. The teams were kept together within their geographical regions as well so each athlete would train in the same altitude and conditions they were used to. The regions were randomly assigned to either the control group or experimental group. � Control Group: The control group consisted of 50 teams and 486 players. The control group documented duration of workout and injuries when they happened throughout the season. They participated as normal in their sport with no further help or guidance from the investigators. � Experimental Group: The experimental group consisted of 66 teams totaling 641 players. The intervention teams had four prescribed exercises to focus on each week. The four exercises included one exercise without any material, one exercise with a ball only, one exercise with a balance board only, and one exercise with a ball and balance board. Each team had five balance boards and participated in fourteen exercises off and on the boards. The program increased with intensity and difficulty throughout the season. The season and program lasted for 36 weeks. � The Evidence: Some of the main findings in the intervention group showed there was a lower incidence of acute lateral ankle injuries than the control group. They reported narrow 95% confidence intervals (CIs) (below), some of which indicate statistical significance. The cox regression analysis showed that the incidence of ankle sprains was lower for the intervention group than the control group with a significance level of P < 0.5. Comments: The study provides moderate evidence for balance board training to prevent ankle injuries. The large number of subjects that participated helps to strengthen the evidence. One of the main problems is the participants were all from the Netherlands. This can hurt the external validity. The investigators do a follow up on the athletes in both groups that developed overuse knee problems. The intervention group had an incidence of overuse injury of 0.8 while the control group had an incidence of overuse injury of 0.5 A combination of volleyball with a balance training program caused overuse on the knees of the intervention group. The investigators document the teams that dropped out and the reasons they dropped out. This helps aid the study because it shows they did not use partial data but only used complete data from participants. Balance training not only reduces the risk of ankle sprains but it also reduces injury incidences and acute injury incidence.

Case Study No 1

Lateral ligament sprain

Lateral Ligament Sprain (16 -21% of all athletic injuries)

- Biomechanics of injury- Clinical Tests (ant. Drawer,

palpation, inversion, KTW)- Time frame to recover- Likleyhood of poor prognosis- ? Refer on

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Presentation Notes

Lateral Ligaments – consist of the ATFL, CFL AND PTFL Injuries to the lateral ligaments account fo 16-21% of all athletic injuries (Mangwani, J Chronic Lateral Instability: review of anatomy, biomechanics, pathology and treatment) The ATFL provides the primary restraint to ankle inversion in plantarflexion and also resists anterolateral translation of the talus in the mortise. It is an intra-articular band comprising two fascicles. It becomes taut in plantarflexion. The CFL is extra capsular and is taut in dorsiflexion and inversion and with continuing inversion is the next ligament to rupture after the ATFL. The PTFL acts as a constraint against posterior displacement of the talus within the mortise as well as external rotation of the talus. It is the strongest of the lateral ligaments and is rarely injured. Prognosis Most lateral ligament injuries have a good prognosis. At 6-12 weeks post injury complete tears show evidence of a repairing ligament with no evidence of laxity. However a laxity of the ankle may occur in 10-20 percent of cases and infrequently a varus pattern of degenerative osteoarthropathy can develop related to chronic instability.

Management of Lateral Ligament Sprains - conservative RICE Place ligament in shortened position Boot, brace, tape

Short period of reduced weight bearing Then progressive exercise based rehabilitation

focusing on regaining movement, balance, strength and proprioception

2-6 weeks to recover 80% recover structurally Strap or brace for season

Conservative vs Surgical For Grade 3 Lateral Ligament Tears Rehab 87% excellent or good outcomes Surgery 60% excellent or good outcomes (Kaikkonen 1996)

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Reference. Kaikkonen A, Kannus P, Jarvinen M Surgery versus functional treatment in lateral ligament tears. A prospective study. Clin Orthop 1996; 326 194-202 Prognosis Most ankle injuries settle without significant complication. At 6-12 weeks post injury complete tears show evidence of a repairing ligament with no evidence of laxity Anderson 2008). However a laxity of the ankle may occur in 10-20 percent of cases and infrequently a varus pattern of degenerative osteoarthropathy can develop related to chronic instability.

Treatment of Choice for Lateral Ligament Sprain

(BRITISH MEDICAL JOURNAL VOLUME 282/ 21 1981)Early functional treatment with a short period of protection via boot, brace or tape followed by series of exercises designed to gradually restore range of motion, strength, proprioception

The Journal of Bone and Joint Surgery VOL. 73-A, NO. 2, FEBRUARY 1991 Summary. After a critical review of these twelve studies, it is not difficult to select functional treatment as the treatment of choice for acute complete tears of the lateral ligaments of the ankle

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Presentation Notes

BRITISH MEDICAL JOURNAL VOLUME 282 21 FEBRUARY 1981 S C BROOKS, B T POTTER, J B RAINEY Treatment for partial tears of the lateral ligament of the ankle: a prospective trial Abstract There is debate about the most appropriate form of treatment for partial tears of the lateral ligament of the ankle, which are common after inversion injuries. A prospective trial of four forms of treatment was carried out. The forms of treatment used were: no treatment with only a minimal bandage, Tubigrip support, immobilisation in plaster-of-Paris, and physiotherapy. The end point was taken when the patient returned to work or had a low score on an objective clinical scale. Early mobilisation, with or without physiotherapy, was found to offer the most rapid return to functional activity. Patients who had had their ankle immobilised in plaster-of-Paris required more days off work and longer attendance at afollow-up clinic. Inversion injuries are common and cause absence from work and discomfort for the patient. These findings suggest that mobilisation with physiotherapy, althoughNot practical for all patients, is the most satisfactory course of treatment. TREATMENT FOR ACUTE TEARS OF THE LATERAL LIGAMENTS OF THE ANKLE The Journal of Bone and Joint Surgery VOL. 73-A, NO. 2, FEBRUARY 1991 Summary After a critical review of these twelve studies, it is not difficult to select functional treatment as the treatment of choice for acute complete tears of the lateral ligaments of the ankle. Functional treatment includes only a short period of protection by tape, bandage, or a brace, and allows early weight-bearing. Range-of-motion exercises, as well as neuromuscular training of the ankle, should begin early. This program clearly provides the quickest recovery to a full range of motion and return to work and physical activity. It does not, however, compromise the bate mechanical stability of the ankle more than the other treatments, and it does not produce more bate symptoms (giving-way, pain, swelling, stiffness, or muscular weakness) than operation and immobilization in a cast or a cast alone. In addition, functional treatment seems to be virtually free from complications, while after the other methods of treatment, especial by operation, serious complications sometimes occur.

Complications Following Major Lateral Ligament TearLocation of osteochondrallesions

Study of 30 patients with grade 3 lateral ligament tears

The arthroscopic findings in these were

chondral lesions in 20 patients,

traumatic synovitis in 19, adhesions in nine and a

partial rupture of the deltoid ligament in one.

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Presentation Notes

After a severe ankle sprain the incidence of residual complaints, particularly on the medial side of the joint, is high. We studied a consecutive series of 30 patients who had operative repair of acute ruptures of lateral ligaments. During operation, arthroscopy revealed a fresh injury to the articular cartilage in 20 ankles, in 19 at the tip and/or anterior distal part of the medial malleolus as well as on the opposite medial facet of the talus. In six patients, a loose piece of articular cartilage was found. We conclude that in patients with a rupture of one or more of the lateral ankle ligaments after an inversion injury, an impingement occurs between the medial malleolus and the medial facet of the talus. Patients with a lesion of the lateral ankle ligament caused by a high-velocity injury (a faulty landing during jumping or running) had a higher incidence of macroscopic cartilage damage (p < 0.01), medially-located pressure pain (p = 0.06) and medially-located complaints at one-year follow-up (p = 0.02) than those with a low-velocity injury (a stumble). MEDIAL ANKLE PAIN AFTER LATERAL LIGAMENT RUPTURE C. N. VAN DIJK, P. M. M. BOSSUYT, R. K. MARTI The Journal of Bone and Joint Surgery VOL. 78-B, NO. 4, JULY 1996

ANKLE TAPING DEMONSTRATION Also show walking boot, dorsiwedge splint Discuss management high versus low grade injuries

Case Study 2 Soccer Player twisted ankle

(external rotation). Presented unable to weightbear with swelling anterior ankle joint. ED series x-rays – patient told no fracture. Reports no swelling lateral ankle but swelling anteriorally

Possible diagnosis? Clinical tests to confirm


Case Study 2 Injury to inferior tibiofibular ligaments (high ankle sprain)

Injuries to the Inferior tibiofibular ligaments (syndesmotic ligaments) 3-10% of ankle sprainsBiomechanics of injury, patient presentation, clinical testing

(ext rot, squeeze), investigations, show primal dvd

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Presentation Notes

Injury to the Distal Tibiofibular Syndesmosis It is important these are recognised early. If chronic instability occurs it can lead to rapid osteoarthropathy of the ankle. The inferior tibiofibular ligament complex consists of - The anterior tibiofibular ligament - The posterior tibiofibular ligament - The inferior interosseus ligaments Biomechanics of Injury Usually external rotation on a dorsiflexed foot. An internal rotation of the tibia on a fixed plantarflexed foot is another mechanism. Imaging of tibiofibular syndesmosis injuries. Plain films Will detect a reported 64% of these reflecting the fact that not all are unstable and that not all unstable ones demonstrate malalignment on stressed plain films. Changes in alignment due to ligamentous injury. Widening of the medial clear space occurs due to disruption of the distal tibiofibular syndesmosis as well as the deep fibres of the deltoid ligament. The most reliable finding is widening of the distal tibiofibular syndesmosis which is a width greater than 5.5 mm and is measured from the medial border of the fibula to the vertical sclerotic line representing the base of the fibular notch of the tibia. MRI - Is the method of choice for examination of these injuries.

MRI Syndesmotic Ligaments

Inferior Tibiofibular Diastasis (should not exceed 5.5mm also look for jt space medial malleolus

Management of Syndesmosis Injuries AITFL – MRI and surgical referral if high grade

tear/instability PITFL – does not cause diastasis and treated as per a typical

sprain

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Presentation Notes

The AITFL is one components of the ankle syndesmosis. High grades of injury can result in widening (diastasis) of the mortise and is often associated with fractures.

Case Study 3 51 year old female presents

with heel pain that she has had for several months. It is worse in the morning, particularly with her first step.



Case Study 3 - Plantar Fasciitis Most common foot

problem Biomechanics Pathology ?Heel spur (FDB) Time frame to recover ?referral on Imaging? Clinical tests

Management options Plantar fascia stretches Heel cord stretches Night splint Orthotics Tape

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Presentation Notes

PLANTAR fasciitis is the most common cause of plantar heel pain. In the US it is estimated that two million patients receive treatment for plantar fasciitis each year, comprising 1% of all visits to orthopaedic surgeons. It is estimated that 10% of persons may experience plantar heel pain at some time. The peak age of incidence in the general population is 40-60. Plantar fasciitis is considered a self-limiting condition. Symptoms resolve in 80-90% of cases within 10 months. Anatomy The plantar fascia is a fibrous aponeurosis that originates from the plantar tuberosity of the calcaneus and fans out distally to divide into five digital bands at the metatarsophalangeal joints. Each band inserts into the base of the proximal phalanx of each toe. The thick plantar fat pad protects and cushions the origin and insertion of the plantar fascia. Cadaveric dissections have demonstrated that plantar heel spurs, when they are present, are located within the origin of the flexor digitorum brevis rather than within the plantar fascia itself. About 50% of patients with heel pain will have heel spurs. It now widely accepted that heel spurs can occur with plantar fasciitis, but they are not the cause. Aetiology The word fasciitis implies an inflammatory process. Histological evidence demonstrates degenerative changes with fibroblastic proliferation and limited inflammatory tissue. These changes are more consistent with a degenerative process without inflammation, likely to be secondary to mechanical overload or repetitive micro-trauma at the origin of the plantar fascia. Diagnosis History Patients typically report a gradual onset of pain. The pain is often located in the plantar heel area but may sometimes occur along the medial arch. The pain is worse with the first few steps in the morning or after a period of sitting. It tends to improve after a few minutes of walking.It is worse at the end of the day. Bilateral plantar fasciitis can occur in up to 30% of cases. Bilateral plantar heel pain, in conjunction with joint pain or pain at tendon or ligament insertion, may suggest a systemic rheumatological condition such as ankylosing spondylitis. Severe constant pain or nocturnal pain may be related to a different condition, and further investigation is required (eg, to exclude tumour, infection or stress fracture). Physical examination Tenderness is localised to the medial tubercle of the calcaneus (figure 17). This serves as the origin of the plantar fascia. The rest of the plantar fascia is tender in cases of distal plantar fasciitis. The distal plantar fascia is best palpated after passive dorsiflexion of the toes, as this manoeuvre places the plantar fascia under tension. Differential diagnosis Tarsal tunnel syndrome is associated with tenderness and a positive Tinel sign (pain and radiation of nerve pain in the distribution of the nerve) when the nerve is tapped with the index finger over the site of nerve compression. L5-S1 radiculopathy is associated with pain that radiates down the leg. There is often associated motor weakness, with an area of numbness in the S1 distribution. In peripheral neuropathy, patients frequently report more generalised foot and heel pain. The numbness or pain is in a non-anatomical distribution (that is, stocking distribution). Calcaneal stress fractures present with diffuse pain and swelling of the foot. The ‘squeeze test’ involves medial and lateral compression of the calcaneus. This manoeuvre causes pain. Heel fat pad atrophy is associated with pain that is worse when walking barefoot and with prolonged standing and walking activities. The pain is improved by wearing shoes with a supportive sole and avoiding bare feet, especially on hard surfaces. Imaging Imaging does not usually play a role in the diagnosis of plantar fasciitis. Plain radiography may be helpful in ruling out other pathology such as bone tumours. Bone scan has 86% specificity when used to diagnose plantar fasciitis. Bone scan can exclude a calcaneal stress fracture. Ultrasound and MRI may be helpful in excluding a plantar fascia tear. Non-surgical treatment A wide variety of management strategies has been developed to treat plantar fasciitis. Non-surgical treatment is the mainstay of treatment. There is considerable debate regarding the optimal management of plantar fasciitis. NSAIDs To date, no studies have specifically examined the effectiveness of this treatment alone. A recent prospective, double-blind, randomised controlled study comparing the pain and disability scores between a group treated with celecoxib and a placebo group showed a trend toward improved pain relief in the NSAID group, but there was no statistically significant difference between the two groups.1 Orthoses/inserts Commonly used orthoses include prefabricated silicon or rubber heel cups, prefabricated arch supports, felt pads and custom arch supports. The 2008 Cochrane review of custom-made foot orthoses for the treatment of foot pain reported that for people diagnosed with plantar fasciitis, custom orthotics: • Are more effective than sham orthotics for improving function, but not for reducing foot pain, after three and 12 months. • Are not more effective than night splints but do increase the effectiveness of a standard intervention of night splints for reducing foot pain or improving function, after six weeks or three months. • Are not more effective than non custom orthotics for reducing foot pain or improving function, after 2-3 months or 12 months. • Do not increase the effectiveness of a standard intervention of Achilles tendon and plantar fascia stretching or night splints for reducing foot pain, after 6-8 weeks. • Are less effective than a combined treatment of manipulation, mobilisation and stretching for reducing foot pain after two weeks, but not after 1- 2 months.2 Physiotherapy A stretching program has traditionally been the primary treatment modality for patients with plantar fasciitis. It is not known whether an Achilles tendon stretching program or a plantar- fascia-specific stretching program is more effective. In a prospective study comparing these two protocols, DiGiovanni et al. reported that the heel pain was eliminated or improved at eight weeks in 52% of patients treated with the plantar- fascia-specific stretching program, versus 22% performing the Achilles tendon stretching program.3 However, the two-year follow-up study reported no difference between the two groups. Night splints The use of night splints has been postulated to help alleviate initial morning pain by preventing contracture of the plantar fascia and gastrocnemius-soleus complex. Absence of plantar heel pain on arising from bed in the morning is considered a direct benefit of nocturnal splinting. Overall the body of evidence regarding the use of night splints supports a grade B recommendation (treatment supported by fair evidence consistent with level III or IV studies) for the use of this modality in the management of plantar fasciitis. Night splints can be purchased from physiotherapists.

Case Study 4 62 year old woman,

presents with medial foot and ankle pain of insidious onset. Claims that she notices the arch of her foot has gradually collapsed over the last few years

Probable diagnosis?

Case Study 4 Acquired Pes Planus

Acquired Adult Flat Foot - Causes Uncoupling of tarsal bone Tibialis posterior tendinopathy Osteoarthrits of midtarsal joint Lisfranc Injuries Insufficiency of Plantar fascia, spring ligament, deltoid (medial) ligament

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Presentation Notes

Tibialis Posterior - Anatomy:� - origin: lateral part of posterior surface of tibia, medial 2/3 of fibula, interosseous membrane, intermuscular septa and deep fascia;� - mid course:� - it runs in the deep post compartment and passes posterior posterior to the medial malleolus;� - here it changes direction from a verticle to horizontal direction;� - it is held in position behind the medial malleolus by the flexor retinaculum;� - insertion:� - major tendon insertion passes to tuberosity of navicular;� - posterior tendon slips pass to sustenaculum tali of calcaneus, plantar surface of all 3 cuneforms, cuboid and to base of 2nd, 3rd, and 4th metatarsals;� - nerve supply: tibial: L5, S1;� - action:� - inverts and plantar flexion of the foot at the ankle;� - medial ankle stabilizer;� - synergists: FHL, FDL Acquired Adult Flatfoot Causes Tibialis Posterior Dysfunction Stage 1 Stage 1 disease is characterisedby pain, swelling and tenderness of the posterior tibial tendon along the medial aspect of the foot and ankle. The length of the tendon is normal, so there is no clinical or radiographic deformity. The tendonitis may be associated with mild degeneration. There may be mild weakness of the tendon. Stage 2 In stage 2 there is elongation and disruption of the posterior tibial tendon. Deformity is present with loss of the medial longitudinal arch, forefoot abduction and hindfoot valgus. The patient is unable to perform, or has difficulty performing, a single-heel-raise test. The subtalar joint remains flexible. Stage 3 In stage 3 the deformity is more severe and the hindfoot is not flexible. The patient complains of lateral ankle pain. This is due to lateral impingement from the fixed hindfoot valgus deformity. This stage may be accompanied by degenerative arthritis of the hindfoot, as seen on radiographs. Stage 4 In stage 4 there is valgus deformity and arthritis of the ankle. Lisfranc Injuries The Lisfranc ligament is a large band of plantar collagenous tissue that spans the articulation of the medial cuneiform and the second metatarsal base. While transverse ligaments connect the bases of the lateral four metatarsals, no transverse ligament exists between the first and second metatarsal bases. The joint capsule and dorsal ligaments form the only minimal support on the dorsal surface of the Lisfranc joint. The bony architecture of this joint, specifically the "keystone" wedging of the second metatarsal into the cuneiform, forms the focal point that supports the entire tarsometatarsal articulation.2 This anatomy establishes a "weak link" that, with stress, is prone to injury. The anatomic complexity at the Lisfranc joint complex leads to multiple injury patterns.6 Sprains are the most common injury, with the midfoot sprain being the least severe injury. The severity of the sprain usually depends on the energy absorbed at the time of injury. Most tarsometatarsal ligament injuries are grade I (pain at the joint, with minimal swelling and no instability) or grade II (increased pain and swelling at the joint, with mild laxity but no instability). The more severe grade III sprain represents complete ligamentous disruption and may represent fracture-dislocation.9 Several further classifications of true fracture-dislocations are used,10 but they do not predict prognosis. TARSOMETATARSAL fracture dislocation is an infrequent but serious injury. The incidence of tarsometatarsal fracture dislocation is low, being one in 55,000 people per year, accounting for 0.2% of all fractures. Tarsometatarsal fracture dislocations are often referred to as Lisfranc injuries. The reported low incidence may be related to misdiagnosis, as the findings on radiographs may be subtle. About 20% of Lisfranc injuries are wrongly diagnosed. Diagnosis may be difficult and a high index of suspicion is required. Early diagnosis and prompt appropriate treatment with anatomical reduction is necessary to obtain good functional results. These injuries have the potential to cause chronic disability, with the development of post-traumatic midfoot arthritis if the diagnosis is delayed or the injury is not treated appropriately. Mechanism of injury The exact mechanism of injury is often difficult to identify. The two basic mechanisms are either direct or indirect. In direct injuries, there is a crushing force on the dorsum of the foot such as from a heavy weight or the foot being crushed by a car. Indirect trauma usually involves some form of twisting force on the midfoot such as in rugby or falling off a horse with the foot in the stirrup. Diagnosis History A high index of suspicion is required in any injury to the midfoot in which there is gross swelling and pain that causes difficulty in weight bearing. There is usually a history of a direct crush injury or an indirect twisting injury to the midfoot. Physical examination There is usually marked swelling of the foot . Lisfranc injuries are often associated with localised ecchymosis beneath the medial arch. Imaging Anteroposterior, oblique and lateral radiographs of the foot are recommended. Weight-bearing radiographs are generally not possible in the acute setting because of pain. On the anteroposterior view the medial border of the second metatarsal forms a continuous line with the medial border of the middle cuneiform. If there is a step, this would indicate a disruption to the Lisfranc ligament. The intermetatarsal space between the bases of the first and second metatarsals should be evaluated for the presence of a small bony avulsion fragment (fleck sign). This fleck represents an avulsion fracture of the second metatarsal attachment of the Lisfranc ligament and is pathognomonic of this injury (figure 15). If clinical suspicion is high and the plain radiographs do not provide a positive diagnosis, an MRI scan is required. MRI provides clear delineation of the ligamentous structures. Treatment It is imperative for an early diagnosis of the injury to be followed by prompt treatment. Precise anatomical reduction is required for optimal results. There is direct correlation between achieving an accurate reduction and a satisfactory clinical outcome. Non-operative treatment for stable injuries only If no displacement is seen on non-weight-bearing radiographs and on the CT scan and there is MRI evidence of Lisfranc ligament disruption, examination under anaesthetic may be required to assess the stability of the injury. If the weight-bearing X-rays (in this instance weight-bearing X-rays serve as stress radiographs) do not show any displacement, the injury may be treated with a short-leg non-weight-bearing cast or by non-weight bearing in a boot for six weeks, depending on the compliance of the patient. This should be followed by a further six weeks in a walking cast or walker boot. These stable injuries generally result in significant morbidity, with a prolonged period of gradual resolution of pain and occasionally permanent mild symptomatology. Surgery Open reduction and internal fixation is required for all displaced tarsometatarsal fracture dislocation injuries. Accurate and stable reduction is paramount to obtaining a good functional result Poor functional results are seen in those whose diagnosis was delayed or those whose injury was not treated appropriately. After surgery patients should not bear weight for 6-12 weeks, depending on the complexity

Rupture or Severe attenuation of Tibialis Posterior

Acquired Adult Flat foot Referral on? Clinical tests Management Likely time frame to recover? Likelyhood of poor outcome?

Case Study 5 39 year old woman

presents with pain over the mid achilles tendon following commencing boot camp training. Impossible to run comfortably now, but is able to walk except up hills


diagnosis? Further imaging required? Referral on? Likely time frame to

recover? Likelyhood of poor

outcome?

Case Study 5 Achilles Tendinopathy Apart from disorders of the tendon sheath there are no

inflammatory changes in most tendon pathologies (excluding tendon sheath)

Alfredson’s accidental discovery

Tendon Facts Types of tendon Pathology (Cook and Purdham BMJ 2008)normal, proliferative failed healingdegenerativeruptureTendon sheathInsertional and non-insertional tendinopathies

These pathologies can co-exist

Tendon Facts Most tendon pathologies we see in the non-athletic

population are degenerative tendinopathies Most athletic tendinopathies are insertional

Aeitiology Genetic factors (more type 3 collagen, blood group O,) Hypermobility Higher incidence in diabetics Increased with increasing age Related to waist girth (BMI>30 3times greater likelyhood of

rotator cuff surgery) - ? Effect of cytokinines, lipids on tendon health

Hormonal (positive effects from HRT) Seronegative and metabolic disorders

Tendon FactsDegenerative tendon pathology is reversible

sometimes (Alfredson, Cook 2005,Silbernagle 2008)

Presenter

Presentation Notes

Alfredson’s model of eccentric training involves no concentric loading and emphasises the need for patients to complete the exercise protocol despite pain in the tendon. If patients experience no tendon pain doing this programme, the load should be increased until the exercises provoke pain. Good short-term and long-term clinical results have been reported. This 12-week programme is effective whenthe other conventional treatments (rest, NSAIDs, change of shoes, orthoses, physical therapy and ordinary training programmes) have failed and is successful in approximately 90% of those with mid-tendon pain and pathology. Insertional Achilles tendon pain is not as responsive, and good clinical results are achieved in approximately 30% of tendons. A follow-up study (mean 3.8 years later) of patients treated with eccentric training indicated the majority of the patients were satisfied and back to previous tendon-loading activity level. Interestingly, the tendon thickness had decreased significantly, and ultrasonographically the tendon structure looked more normal.39 The same 12-week programme resulted in a decrease in tendon volume assessed with MRI, as well as a decrease in tendon signal intensity by 23%.

What Works Best Best evidence is for slow resistance exercises that have an

eccentric component and this can be enhanced with the application of a GTN patch Achilles – painfree 49% (78% with patch) (Murrell 2007) Achilles -Mid substance 90 %, Insertional 30%

significant improvement with eccentric program (Alfredson2008)

Why Does Exercise Work Produces new collagen (but can take 100 days) Destruction of neovessels and nerves Normalisation of cells Reduces thickness of tendon Implications for impingement

Implications for Management If patient presents with acute overload a period of rest is

important If pain in a sedentary person or is chronic we can embark

immediately on a resistance exercise program If there is a bursae associated with the tendon then ultrasound is

worthwhile and if the bursae is inflamed consider an injection If the tendinopathy is insertional and you are prescribing exercises

don’t allow the tendon to stretch Many of the traditional programs are not appropriate Expect 6 -12 months in many cases ?GTN patches and other measures such as autologous blood,

polidocinol,

Case Study 6 15 year old boy, falls out of a

roof at work and lands on foot. Fracture to distal tibia and fibula treated by cast immobilisation for 8 weeks. After 6 weeks of physio and exercises ankle movement is good but complains of persistent forefoot pain. He reports that he is unable to rise up on to his toes, xrayseries of foot at initial incident show no fracture .



Lisfranc Injury Although not common early management is crucial to long

term outcome Referral on? Likely time frame to recover? Likelyhood of poor outcome?

Presenter

Presentation Notes

The tarsometatarsal joint (also called Lisfranc’s joint) is between the distal tarsal bones, (the three cuneiforms and the cuboid) and the metatarsals. Its complex anatomy allows for a little movement of the longitudinal arch of the foot and a bit more movement at the outer border of the foot Dislocation of this joint is a serious injury often associated with fracture of the metatarsals and/or cuneiform bones.

Low Velocity Lisfranc Ligament Injuries 2 predominant mechansims Forced hyperplantarflexion with fixed midfoot Typically involves a strap (windsurfers, equestrian, wakeboarders etc) Foot gets stuck in strap and patient has fallen backwards

Weightbearing on forefoot, axial loading Contact sports where a player may fall on another players heel when

forefoot weightbearing. Landing on the forefoot with force (landing from jump, parachuting)

Lisfranc Ligament Injury Clinical Echymosis Swelling Often unable to weight-bear Pain on passive inversion and eversion of forefoot X-Rays often normal or reported as normal MRI best test Higher grade injuries need urgent orthopaedic referral

Metatarsal Fracture and Instability Secondary to Lisfranc ligament tear

Metatarsalgia The term metatarsalgia is often used to describe pain in the

distal forefoot, but does not define a specific diagnosis or indicate a particular mode of treatment.

Diagnositic Algorithm for Forefoot Pain

Assessment Upright

Standing look at shoes, wear patterns, symmetry, muscle wasting, erythema, scarring, arch height, toe position, knees, general posture, single leg heel raise

Walking normally, heels, toes, Weightbearing dorsiflexion and calf length

Supine Neurological (webspace b/t 1st, 2nd toes deep peroneal nerve) Vascular (dorsalis pedis, posterior tibial pulses, capilliary refill great toe) Palpate collateral ligaments, joint lines (ant and post), TDH, peroneals, plantar fascia,

sustentaculum tali, navicular, base of 5th met, dome of talus, individual bones Active and passive movements (ankle, subtalar, transverse tarsal, midtarsal,

tarsometatarsal, forefoot, toes) Resisted muscle tests Special tests eg posterior impingement, syndesmotic ligaments, anterior drawer

Prone Achilles tendon Stress tests for ATFL and Syndesmosis

Presenter

Presentation Notes

The examination should commence with inspection of the patient’s shoes for any sign of asymetrical wear or the presence of an orthotic. Expose the whole lower leg and foot. Upright Gait should be assessed, ask the patient to walk and observe for the normal symetrical heel to toe gait. Look for any excessive flattening of the arch. Look for a high stepping gait (foot drop, equinovarus), antalgic gait (ankle, hindfoot or midfoot pain) and short propulsive phase (forefoot pain). Observe for muscle wasting. Observe this from the front/back and from side to side. Functional ankle dorsiflexion can be assessed by checking the knee to wall measurement (normal = 10 cm), calf length in standing. Functional plantarflexion can be assessed by asking the patient to rise up onto the balls of both feet, then to lower with one foot. Importantly a flattened arch should return to normal on the toes and the heel should invert. Semi Supine Neurovascular The dorsalis pedis and posterior tibial pulses can be palpated and recapilliarisation of the big toe (3 seconds = normal) can assist with assessing arterial supply. The dorsalis pedis can be located approimately 1cm medial to navicular/ehl tendon Sensation should be tested via light touch across dermatomes and via palpation of the webspace between the first and second toes (deep peroneal nerve). It has been noted in large studies of healthy individuals, the dorsalis pedis, posterior tibial and femoral pulses are not palpable 8.1%, 2.9% and 1.0% of the time respectively (McGee, 1998). Achilles tendon reflex can be tested. Palpation can include the lateral and medial ligaments, anterior and posterior joint lines, the sustentaculum tali, the sinus tarsi, the syndesmosis and dome of talus, the tibialis posterior tendon and accompanying tendons (flexor hallicus longus, and flexor digitorum longus), peroneal tendons the plantar fascia insertion and plantar fascia and individual bones and articulations. Active movement of plantarflexion, dorsiflexion, inversion and eversion should be tested. These movements should also be tested passively and the examiner should also test isolated passive movement at the subtalar joint (inversion and eversion), transverse tarsal joints, midtarsal joints and tarsometatarsal joints. Movement of the toes should be assessed. Active and Passive Movement in more detail ANKLE Active ask the patient to lift foot up (dorsiflex) and down (plantarflex) Passive -Dorsiflexion = Put one hand on the heel with the same forearm supporting the foot. The other hand supports the tibia. Dorsiflex the ankle by lifting the forearm under the foot. (Normal = 55 degrees) Plantarflexion = As in below: (Normal = 15 degrees) SUBTALAR Hold the calcaneus with one hand and the talar head/neck with the thumb & index finger of the other hand. Apply varus and valgus stress with the hand on the calcaneus feeling for movement of the talus (at extremes of subtalar motion) with the other hand. Holding talus rather than the tibia isolates subtalar from ankle motion. (Normal = 5 degrees in each direction) The subtalar joint can also be examined with the patient prone & the foot off the end of the couch. MIDTARSAL (Talo-navicular & Calcaneo-cuboid joints) Hold the calcaneus with one hand and move the forefoot medially & laterally with the other hand = adduction (20 degrees) & abduction (10 degrees). This movement cannot be seen, but can be felt. TARSOMETATARSAL Active motion is zero, but test the joints for stability (by pushing each joint up & down) FIRST METATARSOPHALANGEAL JOINT Normal ROM = 70-90 degrees DF; 45 degrees PF. Normal toe-off requires 35-40 degrees DF. Resisted Movements Dorsiflexion EHL Toes Tibialis posterior In prone The Achilles tendon can be assessed by squeezing the calf. Stress tests of the anterior talofibular ligament and syndesmosis are done in this position.

Gaitscan

Gaitscan Indications for orthotics

Gp lecture foot_ankle_sept_2010

Health & Medicine

Transcript of Gp lecture foot_ankle_sept_2010