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Foot & Ankle Injuries and Treatment

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

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Title: Foot & Ankle Injuries and Treatment


1
Foot Ankle Injuriesand Treatment
  • Dr. John R. Sallade
  • Physical Therapist
  • Board Certified Sports Medicine
  • Fellow Academy Applied Functional Science

2
Classes of Conditions
  • gt Traumatic surgical intervention
  • non surgical intervention
  • Insidious onset
  • Congenital

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

4
Osseous Anatomy
5
Osseous Anatomy
6
ORIF
7
ORIF
8
ORIF
9
OREF (Hoffman)
10
Immobilization
11
Repair MRI
12
Immobilization
13
Post Operative Complications
  • Stiffness
  • Weakness
  • Decreased propioception
  • Decreased vascularity, edema
  • Infection
  • RSD CRIPS
  • DVT PE

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

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

16
Peroneal Tendons
17
Medial Tendons
18
Tendinitis(post. tib., achilles, peroneal)
  • Usually insidious in onset
  • Pain with WB stretch or contraction
  • Improves with light activity
  • Latent inflammatory response
  • TTP, warm
  • Labs and Radiography not helpful

19
Treatment
  • Relative rest
  • Ice 15
  • Anti inflamatories dosage and duration
  • PT - Find the biomechanical cause
  • 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
  • Lateral (ATFCF)(85)
  • Medial (Deltoid)gt
  • High (Syndesmosis)gt
  • Mid tarsal
  • Possible causes
  • Cavus, poor proprioception, poor rehab, over
    weight and poorly conditioned
  • No significant male female ratio

21
Ankle Ligaments
22
High Ankle sprain
23
Midtarsal Sprain
24
Treatment
  • Surgery?
  • RICE
  • Progressive WB
  • Immobilization and Early mobilization
  • Closed Chain Exercise
  • 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
  • Variety of foot types
  • Tight heelcords for level of function
  • Tight great toe flexors or fascia
  • Weakness in control of pronation
  • Training errors, shoes

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

29
Treatment for Plantar Fascitis
30
Treatment for plantar fascitis
31
Bunions(Hallux Valgus)
32
Bunions
  • Both medial (1st MTP) and lateral (5th)
  • In medial bunion
  • Over pronated foot with abductus (toe out)
  • Tight heel cords
  • Forefoot varus

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

34
Treatmentstretching orthotics
35
Stress Fractures Micro FracturesMost common
sites metatarsals
36
Tibia
37
Calcaneal
38
Calcaneal
39
Femur
40
Stress FracturesProbable Causes
  • Increasing the amount or intensity of an activity
    too quickly (most common)
  • Hard or uneven running surface
  • Improper or old shoes
  • Untreated biomechanical imbalances
  • Biomechanical limitations of motion (subtalar and
    midtarsal joints)

41
Other Risk Factors forStress Fractures
  • Risk Factors
  • Female, short, thin and caucasian
  • Certain sports, especially involving plyometric
    loading
  • Distance running
  • Gymnastics
  • Dance
  • Basketball and Tennis
  • Amenorrheagtdecrease hormone support
  • Poor diet- low in calcium and high in acidity
  • Osteopenia (Reduced bone thickness or density)
  • Poor muscle strength or flexibility
  • 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 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.
  • 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.

43
Compartment Syndrome
44
Symptoms and Diagnosis
  • 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.
  • Symptoms may also include
  • Numbness
  • Difficulty moving the foot
  • Visible muscle bulging

45
Differential
  • 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 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).

46
Testing Fasciotomy
47
Reflex Sympathetic DystrophyChronic Regional
Pain Syndrome
  • 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 acute stage occurs during the first 13
    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 36 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.
  • Characteristic signs and symptoms of sympathetic
    nervous system involvement include the following
  • Burning pain
  • Extreme sensitivity to touch
  • Skin color changes (red or bluish)
  • Skin temperature changes (hot or cold)

49
RSD appearance
50
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.
  • Early detection and intervention is paramount.

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

52
Metatarsalgia
53
Treatment
  • Rest, ice and NSAIAs
  • Shoe, cushioned insoles
  • Callous reduction (egg)
  • 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
  • Most commonly between the third and forth
    metatarsals
  • Brought on by shearing between metatarsals
  • 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.

56
Neuromas
57
Treatment
58
Osteo arthritis
  • condition characterized by the breakdown and
    eventual loss of cartilage in one or more joints
    (anklegtMTJgt1st MTPgtST)
  • 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

59
Radiography
60
Treatment
  • Proper footwear
  • Medications to relieve pain and swelling (NSAIA,
    analgesic, glucosamine)
  • Education on activity modification
  • Weight loss
  • 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.
  • Read more http//www.automailer.com/tws/TopicOA-
    2.htmlixzz0i40DeAAZ
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