MOHAN LALMOHAN LALConsultant Orthopaedic & Foot/Ankle Consultant Orthopaedic & Foot/Ankle

SurgeonSurgeon

Surrey & Sussex NHS TrustSurrey & Sussex NHS Trust

Spire Gatwick Park HospitalSpire Gatwick Park Hospital

North Downs HospitalNorth Downs Hospital

FOOT & ANKLE

Presentation by Chandar Lal

FOOT AND ANKLE EXAMINATION

COMMON FOOT DISORDERS

ANKLE DISORDERS

TENDON DISORDERS

SUBCATEGORIESSUBCATEGORIES

FOOT & ANKLE FOOT & ANKLE EXAMINATIONEXAMINATION

General AspectsGeneral Aspects Gait: tiptoes/heel varus, heel walkingGait: tiptoes/heel varus, heel walking Shoe wear/orthoses Shoe wear/orthoses Expose to kneeExpose to knee Look, feel, moveLook, feel, move Neurovascular statusNeurovascular status Other medical conditions: RA, Gout, Other medical conditions: RA, Gout,

CNSCNS

LOOKLOOK

DeformityDeformity Arches: cavovarus, Arches: cavovarus,

planovalgusplanovalgus Hallux ValgusHallux Valgus Toes: hammer, mallet, clawToes: hammer, mallet, claw

Callosities represent Callosities represent pressure areaspressure areas

SwellingSwelling Bilateral (medical)Bilateral (medical) Unilateral (surgical)Unilateral (surgical)

FocalFocal LocalLocal

Lumps (heel, bunion, tailor’s bunion)ScarsUlcersColourTrophic changesNails

LOOK LOOK CONTD.CONTD.

PES PLANUS

CAVOVARUS

LOOK LOOK CONTD.CONTD.

FEELFEEL

TA, heel (Haglaund’s, plantar fasciitis)TA, heel (Haglaund’s, plantar fasciitis) Peroneal tendons, lateral ligament, 5Peroneal tendons, lateral ligament, 5thth MT MT

base, Tailor’s bunionbase, Tailor’s bunion Forefoot: Morton’s, MTPJ synovitis, 1Forefoot: Morton’s, MTPJ synovitis, 1stst MTPJ, MTPJ,

Freiberg’s, stress fractures, sesamoiditisFreiberg’s, stress fractures, sesamoiditis Midfoot: Kohler’s, acc. Navicular, OAMidfoot: Kohler’s, acc. Navicular, OA Ankle: OA, OCD, Tib. Post Tendon, tarsal Ankle: OA, OCD, Tib. Post Tendon, tarsal

tunneltunnel Temperature and pulsesTemperature and pulses Neurologic: sensation, motor, reflexesNeurologic: sensation, motor, reflexes

MOVEMOVE

AnkleAnkle Subtalar jointSubtalar joint MidfootMidfoot HalluxHallux ToesToes Specific TendonsSpecific Tendons

Hallux Valgus and RigidusHallux Valgus and Rigidus Lesser toe deformities Lesser toe deformities

Hammer toe Hammer toe Mallet toeMallet toe Claw toeClaw toe

Flat footFlat foot MetatarsalgiaMetatarsalgia

COMMON FOOT DISORDERS

Commonly seen in femalesCommonly seen in females

82% of women report having foot pain, while 82% of women report having foot pain, while 72% report one or more foot deformities. 72% report one or more foot deformities.

More than 7 out of 10 women develop a bunion, More than 7 out of 10 women develop a bunion, hammertoe, or other painful foot deformity. hammertoe, or other painful foot deformity.

Nine out of 10 women’s foot deformities can be Nine out of 10 women’s foot deformities can be attributed to tight shoes.attributed to tight shoes.

GENERAL PROFILE OF DEFORMITIES

HALLUX VALGUSHALLUX VALGUS

DefinitionDefinition Lateral deviation of great toeLateral deviation of great toe

AetiologyAetiology Familial Familial Inappropriate footwearInappropriate footwear FlatfeetFlatfeet Long first ray Long first ray Incongruous 1Incongruous 1stst MTP joint articular surface MTP joint articular surface Metatarsus primus varusMetatarsus primus varus Rheumatoid arthritis.Rheumatoid arthritis.

HV HV + Claw toes

HALLUX VALGUS HALLUX VALGUS CONTD.CONTD.

PathogenesisPathogenesis Complex deformity with angle between 1Complex deformity with angle between 1stst & &

22ndnd MT > 9 degrees and valgus angle at MTP MT > 9 degrees and valgus angle at MTP joint >20 degrees.joint >20 degrees.

Valgus posture of great toe causing hammer Valgus posture of great toe causing hammer toe like deformity of second toe.toe like deformity of second toe.

Splaying of forefoot causing bunion.Splaying of forefoot causing bunion. Incongruence causing osteoarthritis of 1Incongruence causing osteoarthritis of 1stst

MTP joint.MTP joint.

WHEN TO REFERWHEN TO REFER

SymptomsSymptoms Bunion painBunion pain Transfer metatarsalgiaTransfer metatarsalgia Significant deformity causing:Significant deformity causing:

22ndnd toe deformity toe deformity Shoe wear problemsShoe wear problems

Cosmesis – relative contraindication Cosmesis – relative contraindication

SIGNSSIGNS

Bunion and inflamed overlying bursa and Bunion and inflamed overlying bursa and skin skin

Valgus and pronation deformity of hallux.Valgus and pronation deformity of hallux. Painful callus on 2Painful callus on 2ndnd toe toe

Second toe is forced into hyperextension Second toe is forced into hyperextension by deviated great toe by deviated great toe

Transfer metatarsalgia/thickened skin Transfer metatarsalgia/thickened skin over MT heads.over MT heads.

Increased valgus angle at first MTP joint Increased valgus angle at first MTP joint Valgus angle at first MTP joint >20 Valgus angle at first MTP joint >20

degrees degrees Angle between 1Angle between 1stst & 2 & 2ndnd MT >9 degrees MT >9 degrees

MANAGEMENTMANAGEMENT

Entire foot must be assessed first.Entire foot must be assessed first.

X-ray of foot –Standing dorso plantar, oblique & X-ray of foot –Standing dorso plantar, oblique & axial sesamoid viewsaxial sesamoid views

Medial exostosis (bunion) Medial exostosis (bunion) Lateral displacement proximal phalanx Lateral displacement proximal phalanx Degenerative changes in 1Degenerative changes in 1stst MTP/IP Joint MTP/IP Joint Intermetatarsal & Hallux Valgus anglesIntermetatarsal & Hallux Valgus angles

ANGLES

TREATMENTTREATMENT

CONSERVATIVE TREATMENTCONSERVATIVE TREATMENTAim:Aim: Relieve pressure over painful bunion prominence Relieve pressure over painful bunion prominence

Properly fitted, low heeled stiff-soled shoes Properly fitted, low heeled stiff-soled shoes Wide, square shaped toe box Wide, square shaped toe box Toe portion stretched to accommodate bunion Toe portion stretched to accommodate bunion Extra-depth shoe to accommodates dorsiflexed Extra-depth shoe to accommodates dorsiflexed

second toe second toe Splint separates first and second toe Splint separates first and second toe Acute pain management Acute pain management

Rest Rest Apply moist heat Apply moist heat AnalgesicsAnalgesics

SURGICAL MANAGEMENTSURGICAL MANAGEMENT

Indications Indications Refractory to conservative management Refractory to conservative management Severe deformity or bunion painSevere deformity or bunion pain

Factors to be considered before surgeryFactors to be considered before surgery Valgus deviation of great toeValgus deviation of great toe Varus deviation of first metatarsalVarus deviation of first metatarsal Arthritis of MTP and IP jointArthritis of MTP and IP joint BunionBunion Metatarso-cuneiform joint instabilityMetatarso-cuneiform joint instability Vascularity & sensibilityVascularity & sensibility

Surgical Procedures Surgical Procedures Soft tissue surgery - rarely indicated in adolescent casesSoft tissue surgery - rarely indicated in adolescent casesBone/joint procedure remains the gold standardBone/joint procedure remains the gold standard

HALLUX RIGIDUS/DORSAL HALLUX RIGIDUS/DORSAL BUNIONBUNION

Painful limitation of motion at 1Painful limitation of motion at 1stst MTP joint MTP joint

Pathogenesis:Pathogenesis: synovitis, cartilage synovitis, cartilage destruction, osteophyte proliferation, destruction, osteophyte proliferation, subchondral cysts and sclerosissubchondral cysts and sclerosis

Clinical presentation:Clinical presentation: pain, limited pain, limited dorsiflexion and dorsal osteophyte, dorsal dorsiflexion and dorsal osteophyte, dorsal tendernesstenderness

Aetiology:Aetiology: Trauma, Repeated microtrauma, Trauma, Repeated microtrauma, osteochondritis dissicans and abnormally osteochondritis dissicans and abnormally long first metatarsallong first metatarsal

TREATMENTTREATMENT

Grade I: Mild osteophytes, joint space preservedGrade I: Mild osteophytes, joint space preserved NSAID, orthosis and injectionNSAID, orthosis and injection

Grade II: Moderate osteophyte formation, joint Grade II: Moderate osteophyte formation, joint space space narrowing & narrowing & subchondral sclerosissubchondral sclerosis Cheilectomy: eCheilectomy: excision of 20-35% of dorsal metatarsal head xcision of 20-35% of dorsal metatarsal head

aiming for up to 70aiming for up to 70ºº of dorsiflexion. of dorsiflexion.

Grade III: Severe arthritisGrade III: Severe arthritis Arthrodesis/joint replacementArthrodesis/joint replacement

LESSER TOE LESSER TOE DEFORMITIESDEFORMITIES

Hammer, Claw and MalletHammer, Claw and Mallet Association with HV, RA, DM and NM Association with HV, RA, DM and NM

disordersdisorders Pain, corns, ulcers, shoe wear difficultiesPain, corns, ulcers, shoe wear difficulties Flexible and fixedFlexible and fixed Conservative treatment: manipulation, corn Conservative treatment: manipulation, corn

pads, accommodative shoe wearpads, accommodative shoe wear Surgical treatment: tendon release and Surgical treatment: tendon release and

transfers for flexible deformities; fusion and transfers for flexible deformities; fusion and excision arthroplasties for fixed deformities.excision arthroplasties for fixed deformities.

FLAT FOOT/PES PLANUSFLAT FOOT/PES PLANUS

Flexible (99%) or Rigid (1%)Flexible (99%) or Rigid (1%) Distinguished by Jack test and tiptoeing Distinguished by Jack test and tiptoeing

Pathology - Loss of normal medial Pathology - Loss of normal medial longitudinal arch in combination with valgus longitudinal arch in combination with valgus posture of heel, mild subluxation of subtalar posture of heel, mild subluxation of subtalar joint & eversion of calcaneum joint & eversion of calcaneum

Arch develops till the age of 7-10 years so Arch develops till the age of 7-10 years so there is no treatment requiredthere is no treatment required

15-20% of adults have asymptomatic pes 15-20% of adults have asymptomatic pes planusplanus

TREATMENT OF FLEXIBLE PES TREATMENT OF FLEXIBLE PES PLANUSPLANUS

3-9 years: s3-9 years: symptomatic - arch supportymptomatic - arch support

10-14 years 10-14 years require investigationrequire investigation

Symptomatic patient - rule out Symptomatic patient - rule out accessory navicular or incomplete accessory navicular or incomplete tarsal coalition and treat accordingly.tarsal coalition and treat accordingly.

AdultsAdults with painful pes planus not with painful pes planus not responding to conservative responding to conservative management will benefit with surgerymanagement will benefit with surgery

RIGID PES PLANUSRIGID PES PLANUS

Aetiology:Aetiology: Congenital vertical talus & tarsal Congenital vertical talus & tarsal coalitioncoalition

Tarsal coalition:Tarsal coalition: calcaneo-navicular & calcaneo-navicular & talocalcaneal; can be bony, cartilagenous or talocalcaneal; can be bony, cartilagenous or fibrous.fibrous.

Symptoms:Symptoms: Foot pain, difficulty walking on Foot pain, difficulty walking on uneven surfaces, foot fatigue, peroneal spasmuneven surfaces, foot fatigue, peroneal spasm..

Treatment: Treatment: 4-6 weeks of cast immobilization; 4-6 weeks of cast immobilization; surgical treatment includes resection of surgical treatment includes resection of connecting bar & soft tissue interposition, connecting bar & soft tissue interposition, subtalar arthrodesis, triple arthrodesis.subtalar arthrodesis, triple arthrodesis.

METATARSALGIAMETATARSALGIA

Pressure from subluxed MTPJs with painful Pressure from subluxed MTPJs with painful callositiescallosities

Freiberg’s AVN (treatment: conservative Freiberg’s AVN (treatment: conservative and surgical)and surgical)

Stress FracturesStress Fractures Transfer from first metatarsal Transfer from first metatarsal

insufficiency/HVinsufficiency/HV SesamoiditisSesamoiditis Morton’sMorton’s

MORTON’S MORTON’S METATARSALGIAMETATARSALGIA

Commoner in middle-aged women; 85% Commoner in middle-aged women; 85% unilateralunilateral

Aetiology: trauma, ischaemia, entrapmentAetiology: trauma, ischaemia, entrapment Pathology: degenerative rather than a true Pathology: degenerative rather than a true

neuroma with perineural fibrosis and neuroma with perineural fibrosis and demyelination.demyelination.

Diagnosis: symptom of shooting/constant pain on Diagnosis: symptom of shooting/constant pain on walking, relieved by rest and removal of walking, relieved by rest and removal of footwear; clinical sign of third/second cleft footwear; clinical sign of third/second cleft tenderness and palpable click on metatarsal tenderness and palpable click on metatarsal squeeze test.squeeze test.

Treatment: orthoses, injection and excisionTreatment: orthoses, injection and excision

ANKLE DISORDERSANKLE DISORDERS

InstabilityInstability ImpingementImpingement Osteochondritis Dissecans of talusOsteochondritis Dissecans of talus ArthritisArthritis

PosttraumaticPosttraumatic InflammatoryInflammatory DegenerativeDegenerative

ANKLE INSTABILITYANKLE INSTABILITY

Repeated acute inversion Repeated acute inversion injuries/laxityinjuries/laxity

Presentation with pain and instabilityPresentation with pain and instability Diagnosis: tenderness, anterior drawDiagnosis: tenderness, anterior draw Imaging: stress X-rays, MRIImaging: stress X-rays, MRI TreatmentTreatment

Conservative - physiotherapy, splintsConservative - physiotherapy, splints Surgical – primary repair/reconstructive Surgical – primary repair/reconstructive

proceduresprocedures

ANKLE IMPINGEMENTANKLE IMPINGEMENT

Repeated sporting dorsiflexion injuriesRepeated sporting dorsiflexion injuries Presentation with anterior ankle painPresentation with anterior ankle pain Diagnosis: clinical anterior tenderness and Diagnosis: clinical anterior tenderness and

± anterior osteophytes on X-rays± anterior osteophytes on X-rays TreatmentTreatment

Conservative: Conservative: activity modification/NSAIDsactivity modification/NSAIDs Surgical: open/arthroscopic decompressionSurgical: open/arthroscopic decompression

OSTEOCHONDRITIS OSTEOCHONDRITIS DISSECANSDISSECANS

Posttraumatic in young patientsPosttraumatic in young patients Presentation with persistent pain and Presentation with persistent pain and

swelling with stiffnessswelling with stiffness Diagnosis: clinical tenderness, diffuse Diagnosis: clinical tenderness, diffuse

swellingswelling Imaging: X-rays and MRI scanImaging: X-rays and MRI scan Treatment: undisplaced lesions treated Treatment: undisplaced lesions treated

with rest and cast immobilisation; with rest and cast immobilisation; displaced lesions require arthroscopic displaced lesions require arthroscopic removal/drillingremoval/drilling

ANKLE ARTHRITISANKLE ARTHRITIS

Posttraumatic: rare in commonly Posttraumatic: rare in commonly injured joint; associated with displaced injured joint; associated with displaced intra-articular fractures and significant intra-articular fractures and significant lateral ligament complex injury.lateral ligament complex injury.

Inflammatory: RA in low-demand Inflammatory: RA in low-demand patientspatients

Degenerative: relatively uncommonDegenerative: relatively uncommon Presentation with pain, swelling, Presentation with pain, swelling,

stiffness, limited mobility, limping.stiffness, limited mobility, limping.

ANKLE ARTHRITIS ANKLE ARTHRITIS (CONTD.)(CONTD.)

Diagnosis: clinical swelling, tenderness, Diagnosis: clinical swelling, tenderness, ↓ROM↓ROM

Imaging: X-rays, bone scan to assess Imaging: X-rays, bone scan to assess surrounding jointssurrounding joints

TreatmentTreatment Conservative: NSAIDs, walking stick, weight Conservative: NSAIDs, walking stick, weight

reduction and activity modification.reduction and activity modification. Surgical: arthroscopic/open decompression; Surgical: arthroscopic/open decompression;

ankle arthrodesis (up to 25% non-union, 3 ankle arthrodesis (up to 25% non-union, 3 month casting); ankle replacement gives month casting); ankle replacement gives satisfactory mid-term results in properly satisfactory mid-term results in properly selected low-demand patients (long-term selected low-demand patients (long-term results?)results?)

ANKLE ARTHRITIS ANKLE ARTHRITIS (CONTD.)(CONTD.)

TENDON DISORDERSTENDON DISORDERS

Commonly affected tendons:Commonly affected tendons: Tibialis posteriorTibialis posterior Tibialis anteriorTibialis anterior Peroneus tendonsPeroneus tendons TendoachillisTendoachillis

TIBIALIS POSTERIOR TIBIALIS POSTERIOR TENDONTENDON

AnatomyAnatomy - posteromedial tendon, origin from - posteromedial tendon, origin from posterior surface of tibia & inserts on to the medial posterior surface of tibia & inserts on to the medial cuneiform cuneiform

FunctionFunction - plantar flexion, inversion, stabilizes - plantar flexion, inversion, stabilizes medial longitudinal archmedial longitudinal arch

Important tendon in foot, affection of which causes Important tendon in foot, affection of which causes more functional disability than TA rupturemore functional disability than TA rupture

AetiologyAetiology - - trauma, chronic flat foot, inflammatory trauma, chronic flat foot, inflammatory arthropathy, degenerative tendonopathy, arthropathy, degenerative tendonopathy, chronic chronic tenosynovitis, abnormal insertion, steroid use.tenosynovitis, abnormal insertion, steroid use.

DeformityDeformity - collapse of medial longitudinal arch, - collapse of medial longitudinal arch, hindfoot valgus, midfoot abduction, forefoot hindfoot valgus, midfoot abduction, forefoot pronationpronation

PATHOLOGY/PATHOLOGY/PRESENTATIONPRESENTATION

PRESENTATIONPRESENTATION Fatigue of foot with limited activity, medial and lateral Fatigue of foot with limited activity, medial and lateral

painpain Flat foot on weight bearingFlat foot on weight bearing Standing tip toe – heel will go into valgusStanding tip toe – heel will go into valgus Clinical examination confirms tenderness, Clinical examination confirms tenderness,

weak/ruptured tendon, hindfoot valgus (flexible/fixed) weak/ruptured tendon, hindfoot valgus (flexible/fixed) and a lack of heel varus on tiptoeingand a lack of heel varus on tiptoeing

Pathogenesis: tenosynovitis, incomplete tear, complete disruptionPathogenesis: tenosynovitis, incomplete tear, complete disruption Two groups of patients:Two groups of patients:

Younger patients with inflammatory arthropathy/traumatic rupture Younger patients with inflammatory arthropathy/traumatic rupture Older, typically female patients with degenerative tears Older, typically female patients with degenerative tears

MANAGEMENTMANAGEMENT

Imaging:Imaging: X-ray (degeneration), MRI X-ray (degeneration), MRI

Tenosynovitis - rest, NSAIDs, short leg Tenosynovitis - rest, NSAIDs, short leg walking cast, orthoses, steroid injection in walking cast, orthoses, steroid injection in tendon sheath, synovectomy.tendon sheath, synovectomy.

Incomplete tear - repair or augmentation Incomplete tear - repair or augmentation with either FDL or FHL.with either FDL or FHL.

Complete disruption – repair in traumatic Complete disruption – repair in traumatic young cases; tendon transfer with medial young cases; tendon transfer with medial calcaneal displacement osteotomy (mobile calcaneal displacement osteotomy (mobile hindfoot) and subtalar/triple arthrodesis hindfoot) and subtalar/triple arthrodesis (fixed hindfoot). (fixed hindfoot).

Satisfactory results in spite of prolonged Satisfactory results in spite of prolonged rehabilitationrehabilitation

TIBIALIS ANTERIORTIBIALIS ANTERIOR Anatomy:Anatomy:

Origin -Origin - lateral condyle of tibia, proximal 2/3 of lateral condyle of tibia, proximal 2/3 of lateral surface of tibia, interosseous membranelateral surface of tibia, interosseous membrane

Insertion -Insertion - base of first metatarsal and medial base of first metatarsal and medial plantar surface of 1st cuneiformplantar surface of 1st cuneiform

Action -Action - dorsiflexes and inverts foot dorsiflexes and inverts foot Disorders are common in athletes and old age Disorders are common in athletes and old age

groupgroup Diagnosis- weakness of dorsiflexion of foot, Diagnosis- weakness of dorsiflexion of foot,

pain, use of toe extensors for dorsiflexion of pain, use of toe extensors for dorsiflexion of foot.foot.

Treatment- steroid injection or synovectomy . Treatment- steroid injection or synovectomy . Tendon repair rarely required as deformity is Tendon repair rarely required as deformity is not functionally significant.not functionally significant.

PERONEAL TENDONSPERONEAL TENDONS

Anatomy:Anatomy:

Peroneus longus & brevis are posteolateral Peroneus longus & brevis are posteolateral tendons originating from fibula and interosseous tendons originating from fibula and interosseous membrane and are inserted at base of I & V MT membrane and are inserted at base of I & V MT respectively.respectively.

PERONEAL TENDONS PERONEAL TENDONS (CONTD.)(CONTD.)

Pathology:Pathology: TenosynovitisTenosynovitis - common in high arch foot - common in high arch foot

because of increase in excursion.because of increase in excursion. Sprain/ subluxationSprain/ subluxation - inversion ankle injuries. - inversion ankle injuries.

Symptoms:Symptoms: pain in the outer part of the pain in the outer part of the ankle or just behind the lateral malleolus. ankle or just behind the lateral malleolus. This pain commonly worsens with activity This pain commonly worsens with activity and eases with rest. and eases with rest.

Diagnosis:Diagnosis: Examination - tenderness/subluxationExamination - tenderness/subluxation X-rays to exclude fractureX-rays to exclude fracture MRIMRI

PERONEAL TENDONS PERONEAL TENDONS (CONTD.)(CONTD.)

TreatmentTreatment Non-surgicalNon-surgical

Rest, short-leg walking cast/brace, lateral Rest, short-leg walking cast/brace, lateral heel wedge, physical therapy, NSAIDs and heel wedge, physical therapy, NSAIDs and Cortisone injection Cortisone injection

SurgicalSurgical Tenosynovectomy and repair of split Tenosynovectomy and repair of split Stabilisation of dislocating tendons by Stabilisation of dislocating tendons by

groove deepening, peroneal retinaculum groove deepening, peroneal retinaculum reconstruction and bone block proceduresreconstruction and bone block procedures

ACHILLES ACHILLES TENDINITIS/TENDINOSISTENDINITIS/TENDINOSIS

Tendinosis - there will be clinical inflammation, but Tendinosis - there will be clinical inflammation, but objective pathologic evidence for cellular objective pathologic evidence for cellular inflammation is lacking inflammation is lacking

Tendinitis - there will be a peritendinous Tendinitis - there will be a peritendinous inflammationinflammation Seen in adults in their 30s and 40sSeen in adults in their 30s and 40s Most commonly affects runnersMost commonly affects runners Heel cord contracture can exacerbate symptoms Heel cord contracture can exacerbate symptoms

Two types:Two types: Non-insertionalNon-insertional

Occurs proximal to retrocalcaneal bursaOccurs proximal to retrocalcaneal bursa Generally responds well to non-operative treatmentGenerally responds well to non-operative treatment

InsertionalInsertional Tenderness is localized to calcaneal tendon insertion Tenderness is localized to calcaneal tendon insertion More difficult to treatMore difficult to treat

TREATMENTTREATMENT

ConservativeConservative Rest, ice, NSAIDs, physical therapy, orthoses Rest, ice, NSAIDs, physical therapy, orthoses

OperativeOperative Achilles tendon decompression Achilles tendon decompression andand

debridementdebridement if unrelieved by 6 months of  if unrelieved by 6 months of conservative measuresconservative measures

90% will have significant relief of symptoms; 90% will have significant relief of symptoms; 10% will have some symptom improvement10% will have some symptom improvement

Complete symptomatic cure not guaranteedComplete symptomatic cure not guaranteed

ACHILLES TENDON ACHILLES TENDON RUPTURERUPTURE

Common sporting incidence affecting the Common sporting incidence affecting the young to middle-agedyoung to middle-aged

Mechanism usually involves loading on a Mechanism usually involves loading on a dorsiflexed ankle with the knee extended dorsiflexed ankle with the knee extended (soleus and gastroc on maximal stretch) or (soleus and gastroc on maximal stretch) or repeated microtraumarepeated microtrauma

Consider systemic conditions such as gout Consider systemic conditions such as gout or hyperparathyroidism (esp. with pure or hyperparathyroidism (esp. with pure avulsion injury); previous avulsion injury); previous steroidsteroid injections injections

Disabling condition requires approx. 6 Disabling condition requires approx. 6 months to recover when treated adequatelymonths to recover when treated adequately

ACHILLES TENDON ACHILLES TENDON RUPTURE RUPTURE (CONTD.)(CONTD.)

Diagnosis (suspect in all ankle injury Diagnosis (suspect in all ankle injury cases):cases): Characteristic historyCharacteristic history Classical signs:Classical signs:

Local tenderness and gapLocal tenderness and gap Hyper-dorsiflexion at ankleHyper-dorsiflexion at ankle Thompson/Simmonds testThompson/Simmonds test

Imaging:Imaging: Ultrasound and MRI scan in doubtful casesUltrasound and MRI scan in doubtful cases

TREATMENTTREATMENT Non-operativeNon-operative treatment is indicated in older treatment is indicated in older

patients and minimally displaced ruptures and patients and minimally displaced ruptures and involves serial casting over 10-12 weeks involves serial casting over 10-12 weeks (complete equinus, mid equinus, neutral (complete equinus, mid equinus, neutral walking).walking).

OperativeOperative repair is indicated in younger patients repair is indicated in younger patients with clinically displaced ruptures, delayed with clinically displaced ruptures, delayed presentation (48-72 hours) and neglected presentation (48-72 hours) and neglected ruptures followed by similar casting regime.ruptures followed by similar casting regime.

Complications: Complications: wound healing and sural nerve wound healing and sural nerve injuryinjury

Consider DVT prophylaxisConsider DVT prophylaxis

NON-OPERATIVE VS. NON-OPERATIVE VS. OPERATIVEOPERATIVE

Return to the Return to the preinjury preinjury level of level of activityactivity

Patient Patient satisfactionsatisfaction

Re-Re-rupturerupture

Non-Non-operativeoperative

69%69% 66%66% Up to Up to 33%33%

OperativeOperative 83%83% 93%93% 2-3%2-3%

HEEL PAINHEEL PAIN Commonly caused by Commonly caused by

plantar fasciitis.plantar fasciitis. Heel spurs often Heel spurs often

associated. associated. Pain is worst on waking Pain is worst on waking

up. up. CausesCauses - obesity, - obesity,

excessive excessive walking/sporting activity, walking/sporting activity, tighttight plantar fascia & plantar fascia & flattening of the arch.flattening of the arch.

TreatmentTreatment – orthoses, – orthoses, physical therapy, physical therapy, injection, NSAIDs and injection, NSAIDs and (rarely) surgical release (rarely) surgical release in resistant cases.in resistant cases.

RETROCALCANEAL RETROCALCANEAL BURSITIS BURSITIS

Two bursae: rTwo bursae: retrocalcaneal (subtendinous) etrocalcaneal (subtendinous) bursa & subcutaneous calcaneal bursabursa & subcutaneous calcaneal bursa

CausesCauses Repetitive trauma from shoe wear and sports Repetitive trauma from shoe wear and sports Gout, RA and ankylosing spondyloarthropathiesGout, RA and ankylosing spondyloarthropathies Bursal impingement between the Achilles tendon Bursal impingement between the Achilles tendon

and an excessively prominent posterior-superior and an excessively prominent posterior-superior aspect of the calcaneus (Haglund deformity). aspect of the calcaneus (Haglund deformity).

Symptoms:Symptoms: pain, swelling, shoe wear pain, swelling, shoe wear difficultydifficulty

Signs:Signs: tenderness, lump, inflammation tenderness, lump, inflammation

MANAGEMENTMANAGEMENT Imaging:Imaging: X-rays for calcification and Haglund deformity. X-rays for calcification and Haglund deformity. Conservative:Conservative: physical therapy, appropriate shoe wear, physical therapy, appropriate shoe wear,

injection (risk of tendon rupture).injection (risk of tendon rupture). Surgical Intervention Surgical Intervention includes resection of Haglund includes resection of Haglund

deformity (removal of the calcaneal superoposterior deformity (removal of the calcaneal superoposterior prominence), excision of the painful bursa and debridement of prominence), excision of the painful bursa and debridement of tendon insertiontendon insertion

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