Primary Care Orthopaedics Conference The Foot Panelcmetracker.net/EH/Files/EventMaterials/18026/FOOT...

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Primary Care Orthopaedics ConferenceThe Foot Panel

Sheree Christian, PTXan Courville, MDBoni Jo Silbernagel, DPMK ji S d h MDKenji Sudoh, MDLaura Trombino, MDMichael Watson, CPO

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Case 1:

A 3-year-old healthy female is brought into the clinic by her mother for concerns of flat feet. She has no functional issues and does not complain of pain. She walks on the medial aspect of the ankle.

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Case 1

• 3-year-old female brought into the office by her parentsparents

• Concern for flat feet and walking on the medial side of ankle

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History

• No complaints of pain

P d t f NSVD t d li• Product of NSVD vertex delivery

• Normal developmental milestones

• Walking independently at 12 months

• No functional problems (runs, jumps, and climbs)

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Physical Examination

• Spine—straight, no scoliosis or kyphosis

N l di li h i t h• No sacral dimpling or hairy patches

• Hips and knee full range of motion (FROM)

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• Spine—straight, no scoliosis or kyphosis

N l di li h i t h• No sacral dimpling or hairy patches

• Hips and knee full range of motion (FROM)

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Foot and Ankle Alignment

• Pes planus

Mild hi df t kl l• Mild hindfoot ankle valgus

• Ankle range of motion (ROM) is full

• Dorsiflexion 20 degrees, plantarflexion full

• Excellent subtalar motion

• Heel goes from vagus to varusg g

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Foot and Ankle Alignment

• Pes planus

Mild hi df t kl l• Mild hindfoot ankle valgus

• Ankle range of motion (ROM) is full

• Dorsiflexion 20 degrees, plantarflexion full

• Excellent subtalar motion

• Heel goes from vagus to varusg g

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Evaluating Flat Feet in Children

• Flexible versus nonflexible

• Painful versus non painful

Sullivan, J A et al Journal of AAOS, 7:1:44-53

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Natural History

• Studies from countries where most people don’t wear shoeswear shoes

• Patients with flexible flat feet are generally asymptomatic as adults

Rao et al, J Bone Joint Surg Br 1992, 74:525-27

Sachithananadam, V. J Bone Joint Surg Br 1995;77:254-257

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Key Elements of Exam

• Arch developed until age 5

F tt ti i h• Fatty tissue in arch

• Tip-toe reconstitutes arch

• Walks on toes, heels, inner, and outer border of feet

• Arch when on toes

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Best Prospective Study

• Wenger et al.

C t l• Control group

• Corrective shoes

• Helfet heel cups

• UCBL

No statistical difference in arch at 3-year follow-up.

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Treatment

• Observation

S ft th ti• Soft orthotic

• Molded orthotic

• Heelcord tight– Stretching

– Casting

– Lengthening

– Surgery—rarely indicated

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Case 2:

A 10 ld i l t ith i f l i htA 10-year-old girl presents with a painful right foot and ankle. She has multiple episodes of giving way during her favorite sport, soccer. No noted swelling. Limited subtalar motion on exam.

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Case 2

• Ten-year-old girl presents with painful right foot and ankleand ankle

• Favorite sport is soccer

• Multiple episodes of ankle giving way

• No swelling noted at ankle

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Examination

• Gait—antalgic

F t iti hi df t i li ht l• Foot position—hindfoot in slight valgus

• Patient can walk on toes and heels

• Does not develop good arch formation when walking on toes

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Examination (continued)

• Heel does not go into varus with walking on toes

N kl i t bilit• No ankle instability

• Ankle range of motion (ROM) normal

• Subtalar joint limited

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Tarsal Coalition

• Incidence probably 1 in 1000 but not known definitivelydefinitively

• Most common

– Calcaneonavicular

– Talocalcaneal

– Others possible

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Examination

• Pes planovalgus

Li it d bt l ti• Limited subtalar motion

• Everted—pain with inversion

• Generally presents

• Calcaneonavicular—preteen

• Talocalcaneal—later teens

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Imaging

• Radiographs

B t f l i l• Best for calcaneonavicular

• Standing AP lateral and oblique

• 45-degree oblique important

– Bony coalition—synostosis

– Cartilaginous—synchondrosisg y

– Fibrous

– Syndesmosis

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Imaging

• Radiographs

B t f l i l• Best for calcaneonavicular

• Standing AP lateral and oblique

• 45-degree oblique important

– Bony coalition—synostosis

– Cartilaginous—synchondrosisg y

– Fibrous

– Syndesmosis

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Further Imaging

• Talocalcaneal difficult to diagnose

Will ti h i l i• Will sometimes show up on axial view

• CT scan best

• MRI sometimes helpful

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Further Imaging



• CT scan best


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Further Imaging



• CT scan best


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Treatment

• Conservative

O th ti• Orthotics

• Casting

• Activity modification

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Foot Orthosis

• Support medial longitudinal (M-L) arch

R d bt l j i t ti d t• Reduce subtalar joint motion and stresses

• Reduce midtarsal joint motion

• Provide hindfoot control

W txt 1

Downey, M. Vol.24, Issue 10, Oct. 2011, Keys to Treating Tarsal Conditions Podiatry TodayVu, Louis, Feb 9, 2010, Tarsal Coalition Treatment &Management, Medscape

UCBL

• University of California Biomechanics Lab

I d di l l it di l (M L) t l• Increased medial longitudinal (M-L) control

• Increased control of calcaneus

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Surgical Treatment

• Calcaneonavicular

E i i f b ith i t iti f t– Excision of bar with interposition fat or extensor digitorum brevis

– Generally good results—80%

Gonzalez et al J Bone Joint Surg 72:71-77

Mosca V. AAOS Instructional Course Lectures 1996;45:347-354

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Surgical Treatment

• Talocalcaneal—usually middle facet

C id if l th 50% f j i t• Consider if less than 50% of joint

• Excision with interposition of fat

• Results not as predictable

• Osteotomies

• Fusion

McCormack, T J Pediatr Orthop 1997;17:13-15

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Case 3:

A 12-year-old boy presents with concerns for flat feet It seems to be getting orse o er time Hefeet. It seems to be getting worse over time. He also notes intermittent arch pain with activity. The family recalls the patient being a toe-walker until age 5. He has tried shelf inserts without relief. He did not go out for sports this year because of his symptoms.because of his symptoms.

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Case 3

• 15-year-old boy presents with what the family feels is progressive flatfootfeels is progressive flatfoot

• Intermittent pain with activities in arch

• History remarkable for patient being toe-walker until age 5

• Tried off-the-shelf orthotics without relief

• Patient has significantly decreased activities

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• Spine straight with anomalies

• Mild to moderate external tibial torsionMild to moderate external tibial torsion

• Gait: toe heel to foot flat with some midfoot break

• Patient can walk on toes and hindfoot goes from valgus to varus on toes

Ankle ROM• Ankle ROM– Plantarflexion full

– Dorsiflexion limited to -5 degrees at subtalar neutral

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Pes Planovalgus

• Stretching

Ph i l th• Physical therapy

• Orthotics

• Casts

• Botox

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Pes Planovalgus

• Stretching

Ph i l th• Physical therapy

• Orthotics

• Casts

• Botox

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Foot Orthosis

• Support medial longitudinal (M-L) arch

R d bt l j i t ti d t• Reduce subtalar joint motion and stresses

• Reduce midtarsal joint motion


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Off the Shelf vs. Custom

• Cost

A il bilit• Availability

• Pressure = Force/Area (P=F/A)

• Correct placement of support

• Break-in schedule

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UCBL


I d di l l it di l (M L) t l• Increased medial longitudinal (M-L) control


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Custom Night Splint

• Cast in corrected position

Hi h t i li• High trimlines

• Maintain range of motion (ROM)

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Treatment Options Pediatric Flexible Flatfoot

• Heel cord stretching• Pelvic stability exercises• Shoe wear instruction• Temporary inserts (Powerstep or

accommodative)

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• Heel cord stretching• Pelvic stability exercises• Pelvic stability exercises• Shoe wear instruction• Temporary inserts (Powerstep or

accommodative)

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• Heel cord stretchingg• Pelvic stability exercises• Shoe wear instruction• Temporary inserts (Powerstep or

accommodative)

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Surgical Treatment

• Gastrocnemius lengthening

C l l t t• Calcaneal osteotomy

• Sliding varus

• Lengthening osteotomy with bone graft

• Cuneiform open-wedge osteotomy with bone graft

• Possible peroneus brevis lengthening

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Surgical Treatment



• Sliding varus




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Surgical Treatment



• Sliding varus




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Surgical Treatment



• Sliding varus




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Case 4:

A 16-year-old female presents with a history of recurrent ankle sprains. She injured her leftrecurrent ankle sprains. She injured her left ankle 4 months ago during basketball. X-rays were negative. She wants to run track, but her medial ankle and arch bother her when she runs. She had gone to PT once and tried orthotics, but the orthotics hurt her arch. Last year, she had to sit out due to knee pain.

ARS txt 4

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16 Year Old with Ongoing Ankle Pain

• 16-year-old female with a history of recurrent ankle sprainsp

• She injured her left ankle 4 months ago during basketball

• X-rays were negative• She wants to run track, but her medial ankle and

arch bother her when she runs. She has gone t PT d t i d th ti b t th th tito PT once and tried orthotics, but the orthotics hurt her arch. Last year, she had to sit out due to knee pain.

KS txt 1

Differential Diagnosis

• Posterior tibial tendon strain• Anterior tibial tendon strain• Anterior tibial tendon strain• Flexor hallucis longus strain• Os navicula• Spring ligament sprain• Stress fracture

Pl t f i l i j• Plantar facial injury• Deltoid ligament injury

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Exam

• Tender medial ankle

P t i t ll l• Posterior to malleolus

• Medial foot tenderness

• Gait:

– Pes planus

– Over pronationp

• Step down

• Internal rotation of femur

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Exam




• Gait:

– Pes planus

– Over pronation

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p

• Step down


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Exam




• Gait: – Pes planus

– Over pronation

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• Step down


Exam




• Gait: – Pes planus

– Over pronation

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• Step down


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Imaging

• X-ray

MRI• MRI

• CT

• Ultrasound

KS txt 7

Diagnosis

• Os NaviculareA N i l i S d– Accessory Navicularis Syndrome

– Os Tibiale Externum

– Accessory Navicular Ossicle

• 3 Types

KS txt 8

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Treatment

• Orthotics• Physical therapy• Physical therapy• Activity modification• NSAIDs• Ice• Brace

T• Tape• Surgery

KS txt 9

Off the Shelf vs. Custom

• Total contact: P = F/A (Pressure = Force/Area)

O ti h i ht/ ti d l t• Optimum height/correction and placement

• Break-in schedule

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Foot Orthosis

• Support/raise medial longitudinal (M-L) arch

R d bt l d idt l j i t ti• Reduce subtalar and midtarsal joint motion


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UCBL


I d M L t l• Increased M-L control


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Treatment Options High School Athlete—Sports Injury

A. Acute/Subacute treatmentM d liti /G t• Modalities/Graston

• Taping• Shoe wear review (sports specific)• Temporary inserts• Bracing

B Core stabilization exercisesB. Core stabilization exercisesC. Sports specific exercise retraining

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Case 5:

Your patient is a 39-year-old female with long-standing medial foot pain that is worse withstanding medial foot pain that is worse with activity:– Pes planovalgus deformity

– Able to double-stance heel rise, unable to single-stance heel rise

– Normal reconstitution of heel varus on toesNormal reconstitution of heel varus on toes

– Pain with resisted inversion along posterior tibial tendon.

ARS - 5

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Progressive Flat Foot

39-year-old female with long-standing history of• 39-year-old female with long-standing history of left foot pain

• RN, works standing on feet

• Complains of pain along medial aspect of left hindfoot and medial malleolus, worse with standing and activitystanding and activity

BJS txt 2

Physical Exam

5’7” tall and 205 lbs

Pl l d f it ith t di Planovalgus deformity with standing

Externally rotates foot during ambulation

Tender to palpation from insertion of PTT to medial malleolus and along spring ligament

BJS txt 3

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Physical Exam

• More normal appearing arch when sitting

C ll f h i t l l f t h• Collapse of arch into planovalgus foot when standing

BJS txt 4

Physical Exam


Pl l f t h t di• Planovalgus foot when standing

BJS txt 5

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Physical Exam



BJS txt 6

Physical Exam: Appearance



BJS txt 7

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Physical Exam: Heel Angle

• Posterior examination of patient’s heels

BJS txt 8


• Line depicting normal 7 degrees of valgus

BJS txt 9

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• Second line depicting this patient’s hindfoot alignmentalignment– Angle between axis of tibia and posterior axis of

calcaneus

BJS txt 10

Physical Exam: Posterior Standing Observations

• Asymmetric heel valgus

F f t bd ti• Forefoot abduction

• From incompetent medial support structures (spring ligament, deltoid ligament, talonavicular joint capsule)

• “too many toes” sign

• Ability to single limb heel rise

• Painful heel rise

BJS txt 11

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Physical Exam: Double-stance Hindfoot Raise

• Important to distinguish between flexible and rigid hindfoot valgus to select appropriate treatment

• Flexible valgus hindfoot corrects to varus with double-stance hindfoot raise

BJS txt 12

Physical Exam: Silverskjold Test

• Reduce subtalar and talonavicular joints prior to measurementmeasurement

• Ankle dorsiflexion with knee extended and knee bent

• Tightness only in extension from gastrocnemius contracture

Ti ht b th i t i d fl i f• Tightness both in extension and flexion from Achilles tendon contracture

BJS txt 13

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Physical Exam: Forefoot Varus

• Check for fixed forefoot varus with hindfoot reducedreduced

BJS txt 14

Imaging Studies – 3/7/11

• 40% uncovering talar head on AP xray

“ i ” ith fl tt i f l l it h l• “c sign” with flattening of calcaneal pitch angle on lateral xray

• No early arthritic changes

BJS txt 15

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Imaging Studies – 3/7/11

• Valgus angulation of ankle on AP ankle x-ray

Hi df t l hi df t li t i• Hindfoot valgus on hindfoot alignment view

• No ankle joint space narrowing or osteophytes

BJS txt 16

Impression

BJS txt 17

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Treatment Options

BJS txt 18

Conservative Options

Cast

W lki b t• Walking boots

• Functional shoe gear

• Modified Low dye foot strapping

• NSAIDS

BJS txt 19

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Conservative Options

• F-scan/gait analysisSt l f th ti /b i d i– Style of orthotic/bracing device

– Materials of products

• Physical therapy– Stretching

– Strengthening

BJS txt 20

Treatment Options30 to 40-Year-Old Bunion Patient

Subacute/Chronic Treatment 1 Symptom presentation:1. Symptom presentation:

• Posterior tibialis tendonitis• Plantar Fasciitis• Flexor Hallucis Longus

tendonitis

2. Symptomatic Treatment2. Symptomatic Treatment• Modalities• Graston• Taping

SC-9

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3. Temporary Support

Treatment Options30 to 40-Year-Old Bunion Patient

• Powerstep inserts with posting• Motion control shoe wear• Rocker bottom shoe wear

4 Stretching/Strengthening4. Stretching/Strengthening

SC-10

Articulated Ankle Foot Orthosis

• Ankle-foot orthosis (AFO) with joints

S th it l• Smoother gait cycle

• May facilitate muscle activation

Lake, Trexler, and Barringer, 1999 Vol. 11, Num. 1, Posterior Tibial Tendo Dysfunction: A Review of Pain and Activity Levels of Twenty-one Patients, Journal of Prosthetics and Orthotics

Groner, C. , Dec. 2010, AFO Choices for PTTD Grow Clearer, Journal of Foot and Ankle Research

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Surgical Options

1 M di li i l l t t1. Medializing calcaneal osteotomy

2. Resection of degenerative posterior tibial tendon

3. FDL transfer

4. Gastrocnemius recession

XC txt 1

Medial Incision

• Medial incision

Id tifi ti t i tibi l t d• Identification posterior tibial tendon

• Resection of diseased portion of PT tendon

• FDL identification and transfer into navicular

• Repair of spring ligament

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FDL Transfer

• Attaching FDL to navicular in place of posterior tibial tendontibial tendon

XC txt 3

Calcaneal Osteotomy

• Additional lateral calcaneus incision

L bli t t f l• Long oblique osteotomy of calcaneus

• Fixation with one or two screws

XC txt 4

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Follow-up

• Patients NWB x6-8 weeks for bone and tendon healinghealing

• Physical therapy to start around 4-6 weeks for ROM and strengthening

• Boot or cast for 3 months total

• Wearing regular shoes at 3 months if minimal i i f tpain in foot

XC txt 5

Adult Acquired Flatfoot Deformity

• Posterior tibial tendon dysfunction = most common cause of adult acquired flatfootcommon cause of adult acquired flatfoot deformity

• 10-25% incidence

• Most asymptomatic, medial foot/ankle discomfort

U ll iddl d• Usually middle aged women

• Progressive deformity– Collapse medial arch

– Hindfoot valgus

– Abduction hindfootXC txt 6

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Case 6:

Your patient is a 61-year-old female with bilateral increasing pain and progressive collapse of archincreasing pain and progressive collapse of arch for several years. She is currently able to ambulate only very short distances. Physical exam reveals severe planovalgus deformities, unable to heel rise, and fixed deformities that are not correctable.

XC txt 7A

Case 6:

Your patient is a 61-year-old female with bilateral increasing pain and progressive collapse of archincreasing pain and progressive collapse of arch for several years. She is currently able to ambulate only very short distances. Physical exam reveals severe planovalgus deformities, unable to heel rise, and fixed deformities that are not correctable.

XC txt 7B

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History and Physical

• 61-year-old female with increasing pain and deformity bilateral feet for several yearsdeformity bilateral feet for several years

• Progressive collapse arch, crepitus with walking, severe pain

• Pain worse with activity

XC txt 8

Physical Exam

• PE: 5’1” 220 lbs

Bil t l l l d f iti R L• Bilateral severe planovalgus deformities R>L

• Unable walk

• Unable heel rise

• Pain along PT tendon bilaterally and lateral at distal fibula

XC txt 9

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Physical Exam

• Hindfoot deformities stiff and not correctable

I d fl ibilit f f f t d idf t• Increased flexibility of forefoot and midfoot

• ROM talonavicular joint there is audible and palpable clunk

• Gastrocnemius tightness

• Weakness of posterior tibial tendon

XC txt 10

Radiographs Preoperatively

• Subluxation of talonavicular and subtalar joints on AP and lateral radiographson AP and lateral radiographs

• Irregular calcaneocuboid joint

• Talus no longer in line with 1st MT

• Negative calcaneal pitch angle

XC txt 11

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Radiographs Preoperatively

• Hindfoot valgus

P ti ll l fib l• Proportionally long fibula

• Medial prominence

XC txt 12

Impression

XC txt 13

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Conservative Treatment Options

• Activity modification and rest

S l ti i j ti• Selective injections

• AFO or Arizona braces

XC txt 14

Solid Ankle Foot Orthosis

• AFO without joints

• Increased ankle stability in all planes

• Preservation of bony and ligamentous structures

Olszewski, H., Nov 2011, Evidence-based Orthotic Management of PTTD, Journal of Foot and Ankle Research

Houk, H., et all, Nov 2009, Kinematics of PTTD Dictate Management, Journal of Foot and Ankle Research

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Rocker Bottom Shoe

• Simulate lost motion

D k l t• Decrease peak plantar pressures

• Address bilaterally to prevent LLD

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Surgical Options: Selective Fusions

• Clear joints of remaining cartilage

R li f t d f iti• Realign foot deformities

• Hold joints in place with compression screws

• Triple arthrodesis– Talonavicular

– Subtalar

– Calcaneocuboid

XC txt 15

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Pre-operative Photos

XC txt 16

Pre-operative Photos

XC txt 17

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Post-operative Care

• 2 months non-weight bearing

3 th i t b t• 3 months in cast or boot

• At 3 months, minimal pain and wearing normal shoes

XC txt 18

3-Month Follow-Up

XC txt 19

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Outcomes Triple Arthrodesis

• 5-10% nonunion

• 90 96% patients satisfied with surgery• 90-96% patients satisfied with surgery

• One-third walk with limp following surgery

• Three-fourths have progressive arthritis in surrounding joints, however many asymptomatic or mild pain

Double arthrodesis for PTTD. CORR 365:74-80, 1999

Triple arthrodesis in adults with non-paralytic disease: A minimum ten-year follow-up study. Smith RW, Shen W, DeWitt S, Reischl S. JBJS 86-A:2707-13, 2004

Triple arthrodesis. Fortia PT and Walling AK. CORR 365:91-99, 1999

XC txt 20

Treatment of PTT DysfunctionDependent Upon Stages

• Early stages, flexible

First treated conservative (rest ice NSAID’s PT– First treated conservative (rest, ice, NSAID s, PT, orthotics)

– Foot reconstruction and tendon transfers if conservative treatment fails

• Later stages, rigid

– Bracing cortisone injections activity modification– Bracing, cortisone injections, activity modification

– Hindfoot arthrodesis/ fusion

– Joints to be fused determined by deformity and severity of arthritis

XC txt 21

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ReferencesKrause F, Bosshard A, Lehmann O, Weber M. Shell brace for stage II posterior tibial tendon

insufficiency. Foot Ankle Int 2008;29(11):1095-1100.

Augustin JF, Lin SS, Berberian WS, Johnson JE. Nonoperative treatment of adult acquired flat foot withthe Arizona brace Foot Ankle Clin 2003;8(3):491 502the Arizona brace. Foot Ankle Clin 2003;8(3):491-502.

Lin JL, Balbas J, Richardson EG. Results of non-surgical treatment of stage II posterior tibial tendondysfunction: a 7-10 year follow-up. Foot Ankle Int 2008;29(8):781-786.

Kulig K, Reischl SF, Pomrantz AB, et al. Nonsurgical management of posterior tibial tendon dysfunctionwith orthoses and resistive exercise: a randomized controlled trial. Phys Ther 2009;89(1):26-37.

Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treatedby a structured non-operative management protocol: an orthosis and exercise program. Foot AnkleInt 2006;27(1):2-8.

Lester JJ, Todd WF. Abnormal Biomechanics of Flatfoot Deformities and Related Theories ofBiomechanical Development. Clinic in Podiatric Medicine and Surgery - Vol. 6, No. 3, July 1989.

Van Boerum DH, Sangeorzan. Foot Ankle Clin N Am 8 (2003) 419-430.

References (Continued)

Treatment of stage II PTTD with FDL tendon transfer and calcaneal osteotomy. Myerson MS, Badekas A, Schon LC. FAI, 25:445-450, 2004.

Double arthrodesis for PTTD. CORR 365:74-80, 1999

Triple arthrodesis in adults with non-paralytic disease: A minimum ten-year follow-up study. Smith RW, Shen W, DeWitt S, Reischl S. JBJS 86-A:2707-13, 2004

Triple arthrodesis. Fortia PT and Walling AK. CORR 365:91-99, 1999

Downey, M. Vol.24, Issue 10, Oct. 2011, Keys to Treating Tarsal Conditions Podiatry Today

Vu, Louis, Feb 9, 2010, Tarsal Coalition Treatment & Management, Medscape

Lake, Trexler, and Barringer, 1999 Vol. 11, Num. 1, Posterior Tibial Tendo Dysfunction: A Review of Pain and Activity Levels of Twenty-one Patients, Journal of Prosthetics and Orthotics

61

Groner, C. , Dec. 2010, AFO Choices for PTTD Grow Clearer, Journal of Foot and Ankle Research


Olszewski, H., Nov 2011, Evidence-based Orthotic Management of PTTD, Journal of Foot and Ankle Research

Houk, H., et all, Nov 2009, Kinematics of PTTD Dictate Management, Journal of Foot and Ankle Research

http://www.lowerextremityreview.com

Kawartha Regional Orthopedic Specialists (http://www.kros.ca/UCBL.php)

Shoe Modification and the Use of Orthoses in the Treatment of Foot and Ankle PathologyShoe Modification and the Use of Orthoses in the Treatment of Foot and Ankle PathologyDennis J. Janisse and Erick Janisse , J Am Acad Orthop Surg March 2008 ; 16:152-158.

http://www.wheatonbrace.com

http://www.orthopedicinserts.org


http://www.actionbp.com

http://www.podiatrytoday.com

http://www.orthoticshop.com

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