Gp lecture foot_ankle_sept_2010


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Update on the management of common foot and ankle conditions

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Gp lecture foot_ankle_sept_2010

  1. 1. Foot and Ankle Session Cameron Bulluss, Rob Dingle, Peter Enks, Pierre Buchholz, Gavin Jackson – Advanced Physiotherapy and Injury Prevention
  2. 2. Preliminaries Useful Resources and Acknowledgements 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. 4. Advanced Physiotherapy and Injury Prevention Website, notes will be on website (show)  Acknowledgements – Isobel Green, Jess Fidler  Introduce Colleagues  Purpose of these talks: educate, meet, value add  Who we treat
  3. 3. Imaging
  4. 4. When to Image  If it affects management  Diagnosis is uncertain  Demanding patient  To assist with determining prognosis  Red flags  Orange flags  Failed treatment
  5. 5. Ottawa Ankle and Foot Rules
  6. 6. Red Flags  > 50 year old  Systemic symptoms  Significant morning stiffness  Known risk factors  Past history or family history  Noctural pain
  7. 7. 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
  8. 8. Grades of Injury – Muscle/Ligament Ligament  Grade 1 Pathology = microscopic tearing (strain) Clinical = Tenderness but no ligament laxity MRI = normal ligament thickness but increased periligamentous signal  Grade 2 Pathology = partial tear Clinical = some ligamentous laxity but firm end-point MRI = ligament thickening +- partial discontinuity, increased signal  Grade 3 Pathology = complete tear Clinical = increased ligament laxity and no indentifiable end point MRI = complete ligament discontinuity + oedema and haemorrhage
  9. 9. Anatomy of the Foot and Ankle Bones and Articulations Inferior tibiofibular joint Talocrural joint Subtalar joint Transverse tarsal (Choparts) Intertarsal joints Tarsometatarsal joint (Lisfranc)
  10. 10. Anatomy of the Foot and Ankle
  11. 11. Anatomy of the Foot and Ankle Ligaments
  12. 12. Anatomy of the Foot and Ankle Ligaments
  13. 13. 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
  14. 14. Case Study 1  Probable diagnosis?  Clinical tests to confirm diagnosis?  Further imaging required?
  15. 15. Case Study No 1  Lateral ligament sprain
  16. 16. 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
  17. 17. 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
  18. 18. Conservative vs Surgical For Grade 3 Lateral Ligament Tears  Rehab 87% excellent or good outcomes  Surgery 60% excellent or good outcomes (Kaikkonen 1996)
  19. 19. 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
  20. 20. Complications Following Major Lateral Ligament Tear Location of osteochondral Study of 30 patients with lesions 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.
  21. 21. ANKLE TAPING DEMONSTRATION  Also show walking boot, dorsiwedge splint  Discuss management high versus low grade injuries
  22. 22. Case Study 2  Soccer Player twisted ankle  Possible diagnosis? (external rotation).  Clinical tests to confirm Presented unable to diagnosis? weightbear with swelling  Further imaging required? anterior ankle joint. ED series x-rays – patient told no fracture. Reports no swelling lateral ankle but swelling anteriorally
  23. 23. Case Study 2  Injury to inferior tibiofibular ligaments (high ankle sprain)
  24. 24. Injuries to the Inferior tibiofibular ligaments (syndesmotic ligaments) 3-10% of ankle sprains Biomechanics of injury, patient presentation, clinical testing (ext rot, squeeze), investigations, show primal dvd
  25. 25. MRI Syndesmotic Ligaments
  26. 26. Inferior Tibiofibular Diastasis (should not exceed 5.5mm also look for jt space medial malleolus
  27. 27. 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
  28. 28. Case Study 3  51 year old female presents  Probable diagnosis? with heel pain that she has  Clinical tests to confirm had for several months. It is diagnosis? worse in the morning,  Further imaging required? particularly with her first step.
  29. 29. Case Study 3 - Plantar Fasciitis  Management options  Most common foot problem  Plantar fascia stretches  Heel cord stretches  Biomechanics  Night splint  Pathology  Orthotics  ?Heel spur (FDB)  Tape  Time frame to recover  ?referral on  Imaging?  Clinical tests
  30. 30. 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?
  31. 31. Case Study 4 Acquired Pes Planus
  32. 32. 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
  33. 33. Rupture or Severe attenuation of Tibialis Posterior
  34. 34. Acquired Adult Flat foot  Referral on?  Clinical tests  Management  Likely time frame to recover?  Likelyhood of poor outcome?
  35. 35. Case Study 5  39 year old woman  Probable diagnosis? presents with pain over the  Clinical tests to confirm mid achilles tendon diagnosis? following commencing  Further imaging required? boot camp training.  Referral on? Impossible to run comfortably now, but is  Likely time frame to able to walk except up hills recover?  Likelyhood of poor outcome?
  36. 36. 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
  37. 37. Tendon Facts  Types of tendon Pathology (Cook and Purdham BMJ 2008) normal, proliferative failed healing degenerative rupture Tendon sheath Insertional and non-insertional tendinopathies  These pathologies can co-exist
  38. 38. Tendon Facts  Most tendon pathologies we see in the non-athletic population are degenerative tendinopathies  Most athletic tendinopathies are insertional
  39. 39. 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
  40. 40. Tendon Facts  Degenerative tendon pathology is reversible sometimes (Alfredson, Cook 2005,Silbernagle 2008)
  41. 41. 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 (Alfredson 2008)
  42. 42. 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
  43. 43. 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,
  44. 44. Case Study 6  15 year old boy, falls out of a  Probable diagnosis? roof at work and lands on  Clinical tests to confirm foot. Fracture to distal tibia diagnosis? and fibula treated by cast  Further imaging required? 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, xray series of foot at initial incident show no fracture .
  45. 45. Lisfranc Injury  Although not common early management is crucial to long term outcome  Referral on?  Likely time frame to recover?  Likelyhood of poor outcome?
  46. 46. 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)
  47. 47. 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
  48. 48. Metatarsal Fracture and Instability Secondary to Lisfranc ligament tear
  49. 49. 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.
  50. 50. Diagnositic Algorithm for Forefoot Pain
  51. 51. 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
  52. 52. Gaitscan
  53. 53. Gaitscan  Indications for orthotics