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Foot & Ankle Injuries and Treatment. Dr. John R. Sallade Physical Therapist Board Certified – Sports Medicine Fellow – Academy Applied Functional Science. Classes of Conditions. > Traumatic surgical intervention non surgical intervention Insidious onset Congenital.

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foot ankle injuries and treatment

Foot & Ankle Injuriesand Treatment

Dr. John R. Sallade

Physical Therapist

Board Certified – Sports Medicine

Fellow – Academy Applied Functional Science

classes of conditions
Classes of Conditions

> Traumatic surgical intervention

non surgical intervention

  • Insidious onset
  • Congenital
traumatic
Traumatic
  • Fractures Ankle

Mid foot

Forefoot

  • Tendon tears Achilles (plantaris)

Posterior Tibialis

Peroneal

  • Repair, ORIF +/- Immobilization, WB, PT
post operative complications
Post Operative Complications
  • Stiffness
  • Weakness
  • Decreased propioception
  • Decreased vascularity, edema
  • Infection
  • RSD CRIPS
  • DVT PE
non traumatic injuries insidious onset
“Non traumatic” InjuriesInsidious Onset
  • Tendinosis
  • Stress fractures
  • Bunions , Hallux Limitus
  • Hammer toes
  • Metatarsalgia
  • Neuromas
  • Plantar Fascitis
  • Compartment Syndrome
non traumatic injuries
“Non Traumatic” Injuries
  • Blisters
  • Callosities
  • Sub ungula hematomas
  • Arthritis
  • “pump bumps”
  • Apophositis
  • Sesmoiditis
  • Infections
tendinitis post tib achilles peroneal
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
treatment
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)

ankle sprains
Ankle Sprains
  • Account for 25% of all sports injuries
  • Lateral (ATF+CF)(85%)
  • Medial (Deltoid)>
  • “High” (Syndesmosis)>
  • Mid tarsal

Possible causes:

  • Cavus, poor proprioception, poor rehab, over weight and poorly conditioned
  • No significant male – female ratio
treatment24
Treatment
  • Surgery?
  • RICE
  • Progressive WB
  • Immobilization and Early mobilization
  • Closed Chain Exercise
  • Looking for a cause
causes
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
treatment28
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?
bunions
Bunions
  • Both medial (1st MTP) and lateral (5th)

In medial bunion:

  • Over pronated foot with abductus (toe out)
  • Tight heel cords
  • Forefoot varus
treatment33
Treatment
  • Treat the cause
  • Symptomatic relief with modalities
  • Heel cord stretching
  • Fore foot support via orthotic
  • Strengthening
  • When is surgery the best option?
stress fractures probable causes
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)
other risk factors for stress fractures
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
  • Amenorrhea>decrease 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
compartment syndrome
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.
symptoms and diagnosis
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
differential
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).
reflex sympathetic dystrophy chronic regional pain syndrome
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 stages—acute, dystrophic, and atrophic.
  • The acute stage occurs during the first 1–3 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.
advanced symptoms
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 3–6 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)
treatment50
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.
metatarsalgia
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
treatment53
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
inter metatarsal morton s neuroma
Inter Metatarsal (Morton’s) 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.
osteo arthritis
Osteo arthritis
  • condition characterized by the breakdown and eventual loss of cartilage in one or more joints (ankle>MTJ>1st MTP>ST)
  • 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
treatment60
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.

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