orthopaedic foot and ankle injuries and treatment - … tendinopathies, turf toe, and occult...

$: Orthopaedic Foot and Ankle Injuries and Treatment - … tendinopathies, Turf toe, and occult fractures$
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Foot Pain: A Guide to Commonly Missed Foot/Ankle Complaints

Lloyd Barker, PAC, ATC, MBA/HCM

Mayo Clinic

January 25, 2014

Objectives

At the conclusion of this session, the participant will be able to:

Identify the early and late clinical presentation of commonly missed foot and ankle musculoskeletal conditions

Evaluate radiographic findings of Lisfranc injuries, tendinopathies, Turf toe, and occult fractures

Formulate a treatment plan including

conservative management versus referral for surgical intervention

Areas of emphasis

Lisfranc injuries 20% mis-diagnosed in ED on initial presentation

Posterior Tibial Tendon dysfunction (PTTD) 3.3% prevalence rate in women over 40

Achilles Tendinopathies ~10% of patients who sustain an Achilles tendon rupture had preexisting

Achilles tendon problems

Turf toe 50% incidence persistent symptoms at 1st MTP five years after injury

Occult fractures

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Foot Anatomy

Ankle Anatomy

Lisfranc Injury

Jacques Lisfranc (1790-1847), a field surgeon in Napoleon’s army in Russia.

Fracture/dislocation of

1st/2nd TMT joint Mechanism of Injury

Twisting of forefoot Axial load Crush

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Lisfranc Injury

Stability

Roman arch – keystone 5 metatarsals with the

2nd metatarsal acting as a keystone.

Lisfranc Injury Diagnosis

Foot sprain Dislocation Fracture Obvious versus subtle findings

History is very important! Acute versus chronic presentation Direct versus indirect 20% of injuries mis-diagnosed or overlooked

High energy versus low energy injury

High- MVA, fall from height Low- Stepping off curb, stepping into hole

Lisfranc Injury - Indirect

Axial load applied to plantarflexed foot forefoot hyperplantarflexes, weak dorsal ligaments rupture plantar

aspect of metatarsal base fractures or plantar capsule ruptures along MT bases to displace dorsally.

-Anderson, MD (2005) Sports Medicine of the Foot and Ankle

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Lisfranc Injury

Lisfranc Injury

Signs & Symptoms

Midfoot pain when bearing weight

Point tenderness over Lisfranc joint

Swelling/deformity in midfoot

Plantar flexion and rotation of forefoot painful

Lisfranc Injury Radiographs

AP - Medial margin 2nd metatarsal and middle cuneiform alignment

Lateral - Dorsal margin 1st/2nd metatarsal

and cuneiforms alignment

Oblique - Base of 4th metatarsal and

cuboid alignment

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Lisfranc Injury

AP view

Lateral view

Oblique view

Lisfranc Injury

Treatment (Early Recognition Important)

Goal – Stable anatomic foot

Conservative – Cast immobilization, orthotics

Surgical

Acute Injury with displacement

Neurovascular compromise/Compartment Syndrome

Case Study

66 yo female walking out of store when her right foot slipped off the sidewalk curb. Had immediate pain in foot. Saw her PCP who ordered initial x-rays of ankle, which were negative for fracture. Sent to Orthopaedics for persistent foot/ankle pain.

Foot x-rays ordered and show the following:

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Case Study

A. Fracture sesamoid

B. Fracture metatarsal

C. Lisfranc sprain

D. Lisfranc dislocation

Case Study

Case Study

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Case Study

Case Study

Case Study

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Case Study

Case Study

Case Study

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Case Study

Lisfranc Injury

Treatment Non-weight bearing cast

Walking boot (WB as tolerated)

Athletic shoewear with custom orthotics

Patience! Recovery time up to one year!

Tendinopathy

Posterior Tibial Tendon (PTT)

Achilles Tendon

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Posterior Tibial Tendon

Females -75% Age- over 50 years Caucasians – 95% or more Underlying disease process


Function Adducts the forefoot Inverts the heel

Acute Rupture v Tendinitis

Chronic Tendonosis v PTT dysfunction


History

Injury / Precipitating event

↓ walking tolerance

Misdiagnosed as ankle sprain, cellulitis, DVT

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PHYSICAL EXAM

Point tenderness along course of tendon, palpable deficit if ruptured

Pain, weakness, and/or inability to do heel rise manuever

“Too many toes sign”


“Too many toes sign”

Posterior Tibial Tendon Dysfunction Stages

Stage I Tenosynovitis without deformity

Stage II Damage to tendon; flexible forefoot

Stage III Rigid hindfoot valgus

Stage IV Ankle valgus

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Normal Tendon

Stress Age related degeneration

Abnormal Tendon Abnormal Tendon

Tendinitis Tendonosis

Mechanical Failure

PTTD

Planovalgus deformity

Partial Tear

Complete Tear

Obesity

Inflammatory disease

Acute trauma

Steroids

Acute Chronic


Early Symptoms

Medial ankle pain/swelling

Muscle weakness Thickened tendon +/- heel rise test

Late Symptoms

Lateral ankle pain/swelling

Deformity Sinus tarsi pain + heel rise test

Heel rise test

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Case Study 55 yo female with history of IDDM, peripheral

neuropathy, and RA presents c/o right foot/ankle pain. She describes dull achy pain for the past month. She thinks she sprained her ankle but never had it evaluated. After initial exam, which radiograph exam should be ordered:

A. Foot radiographs

B. Ankle radiographs

C. MRI lower leg

D. CT lower leg

Radiographs Sagging of talonavicular, naviculocuneiform,

or cuneiform first metatarsal joint


MRI exam

Fluid in sheath (tendinitis v. tendonosis)

Abnormal signal

Partial tear

Absent

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Treatment Acute

NSAIDs

Immobilization

Physical Therapy / Activity Modification

Chronic

Orthosis

Surgery



33 patients w/average follow-up 8.6 yrs.

Stage II PTTD with use of Double Upright Ankle Foot Orthosis (DUAFO).

Results 60.6% (20) satisfied

33.3% (11) Satisfied with minor reservations

3% (1) Partially satisfied

3% (1) Unsatisfied

Results of non-surgical treatment of stage II posterior tibial tendon dysfunction: a 7- to 10-year followup. Lin, JL., Balbas, J., Richardson, EG. Foot Ankle Int. 2008, Aug;29(8), 781-6.


Operative Treatment

Tenolysis

Tendon transfer

Tendon transfer +

“X” to restore alignment

Arthrodesis

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Surgical correction (Subtalar)

Achilles Tendon

Common insertion of Gastrocnemius/Soleus

Function – Plantarflexes ankle/foot

Acute

Tendinitis

Rupture

Chronic

Tendinosis

Insertional enthesitis

Achilles Tendon

History

Precipitating event(s)

Misdiagnosed as ankle sprain

Physical Exam

Point tenderness and/or palpable defect

Positive Thompson test

Radiographs

Plain x-rays

MRI

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Achilles Tendon

X-Rays MRI

Insertional Enthesitis

Achilles Tendon

Treatment Acute

Immobilization Surgical repair Therapy

Chronic Immobilization Heel lifts Surgical repair

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Turf Toe

Acute injury to 1st metatarsophalangeal (MTP) joint

First described by Bowers & Martin in 1976.

U. of West Virginia, 5.4 injuries/year.

Conclusion: “Turf toe, though not a serious injury, is significantly disabling functionally to warrant attempts at its prevention.”

Turf Toe

Stages Grade I

Attenuation plantar structures, min ecchymosis, local swelling

Grade II Partial tear plantar structures, moderate swelling, ↓ ROM

Grade III Complete disruption plantar structures, weakness, 1st MTP

instability

Turf Toe

Radiographs Fracture

Sesamoids position

MRI Evaluate plantar

capsular structures

Evaluate joint surface

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Turf Toe Treatment

RICE/Therapy

Taping for activity

Carbon Fiber insert

NSAIDs

Stiff soled shoes

Gradual return to activity

Hallux Rigidus

Repetitive stress at 1st MTP joint

Cartilage Damage Misalignment, “wear & tear”

Genetics

Trauma Single v. repetitive episodes

Hallux Rigidus (Early)

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Hallux Rigidus (Late)

Hallux Rigidus Treatment

Conservative

Shoewear

Stiff, rocker bottom, wide toe box, external metatarsal bar

Carbon fiber plate insert

Activity Modification

NSAIDs

Cortisone injection

Surgical

Cheilectomy v. Arthrodesis

Occult fractures

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Occult fractures

26 yo female with left forefoot pain after wearing high heels and walking for several days at a trade show the previous month

Pain better in flats and athletic shoes

No obvious swelling/ecchymosis/

deformity

Occult fractures

Avid runner 4-5 miles/day on treadmill

Able to run w/minimal pain except uphill which increases pain

No specific point tenderness on foot exam

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Occult fractures

21 yo female with new onset pain in hindfoot after running on treadmill

No twisting injury or trauma

Pain initially with running only, now present with normal ambulation

Pt. notices minimal swelling with no ecchymosis

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Occult fractures

Occult fractures

18 yo male skateboarder who came off of board attemping to jump down 10 steps.

Inability to walk due to midfoot pain.

Swelling & point tenderness dorsal midfoot.

Occult fractures

Placed in removable cast/boot

NWB

CT scan

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Occult fractures

59 yo female twisted ankle coming down stairs.

Thought she had “sprained her ankle”.

Unable to fully weightbear.

Pain lateral foot/ankle area.

Occult fractures

Treatment

Protective immobilization (4-6 wks)

NWB » PWB » WBAT

Transition to athletic shoewear

Orthotics (?)

Activity modification

Re-evaluate

Take home points

Lisfranc injuries often overlooked

Posterior tibial tendon injury often misdiagnosed as medial ankle sprain

When in doubt, immobilize and refer

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orthopaedic foot and ankle injuries and treatment - … tendinopathies, turf toe, and occult...

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