Foot and Ankle care for primary care 60

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Foot and Ankle in the

Primary Care Setting

“Feets don’t fail me now”

John S. Early, M.D. Texas Orthopaedic Associates, L.L.P.

Dallas, Texas

The Role of the Foot / Ankle Complex

! To provide a stable, weight bearing platform for smooth weight transfer during single limb stance

Foot function in the Role of Ambulation

! Static component – Bones and Ligaments

! Dynamic component – Muscles

Anatomy of Foot Ankle Complex

! 28 Bones

! 30 articular surfaces

! 7 major motor units

Functional Issues

! Static Control – Bones and Ligaments – Mechanical integrity for

motor function – Static foot structure not

dependent on motor function

Anatomy: Ligamentous

Dorsolateral

Plantar

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Stability: Foot and Ankle

! Tripod balance of talus

! Smooth contours

! Motor control of major functioning joints

Stability Modelling

“3-legged” stool

Talus

•  Stability of stool depends on leg position

Foot Function

! Depends on: – Stable structure – Shock absorption – Adaptability to surface

contours ! Determination of Foot

function – Hindfoot – Midfoot – Forefoot

Hindfoot Motion

Hindfoot Mechanics

! Ankle joint controls stride length

! Pivot point for lever arm of foot

Hindfoot Motion

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Hindfoot Mechanics ! Calcaneal position: Controls gross forefoot

alignment

! Varus hindfoot restricts chopart motion ! Valgus hindfoot increases chopart motion

Midfoot Mechanics

! Rigid link –  Minimal joint motion within section

! Shock absorption –  Dissipates forces –  Strong ligaments

! No bony ground contact –  Distributes load

Forefoot Mechanics

! 6 weight bearing bones ! Varied mobility at Tarsometatarsal joints

–  Minimal motion at 2 and 3 –  1st ~ 2x greater than middle two –  4th & 5th ~3x greater than 1st

Columnar Approach

Lateral Column Medial column

Central Column

- Normal foot position depends on equal column lengths

Varus hindfoot: Lateral column long

Valgus hindfoot: Medial column long

Foot “Types”

! Weight bearing shape

! No relation to pathology

! No pain…. No problem

Role of Joint Motion

! Create a level platform for gait – Subtalar complex

! Allows foot to conform to ground

! Minimize energy expenditures – Ankle

! Allows transfer of weight to forefoot ! Advances point of contact from heel to toes ! Without ankle greater vertical rise of pelvis and

shorter stride

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Gait and the Foot

! “Normal Gait” –  Minimize energy use –  Minimize discomfort

! Important points –  Motor function Eccentric in

stance –  10° ankle dorsiflexion for

gait –  Use of ligamentous support

allows muscle rest

Functional Issues ! Dynamic Control

– Dependant on motor function

– Stability and mobility of joints

– Allow smooth progression of body weight to next foot ! The less vertical displacement of body mass the better

Motor Balance ! 7 motor units

–  Posttib muscles plantarflex

–  Pretibial muscles dorsiflex

! Dynamic stability dependent on antagonist pairs

! Strength disparity balanced by mechanical lever arm

Ankle dorsiflexors

! Eccentric work

! Concentric during swing

Ankle Plantarflexors

! Eccentric work

Foot Function: Simple Truths

! The muscles are designed to dissipate the load away from the ligaments that hold the bones together

! The ligaments and bones have a resting stability that is supposed to allow the muscles to rest occasionally

! Failure of one will lead to dysfunction of the other

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My Foot Hurts and I Can’t do Anything

Everything is a 10 when your foot hurts

Classifying Foot Pain for Medical Urgency

! “I can’t put weight on it” : Unstable injury ! “It hurts to stand” : stable injury hindfoot ! “It hurts to walk” : stable injury midfoot

forefoot ! “It Hurts when I exercise” : chronic instabilty ! “It hurts when run marathons or compete”

Clinical Evaluation

! Observe weight bearing function and position

! Test motor strength with patient’s body weight

! Carefully palpate the foot for pain location ! Move joints to assess pain and stability

Motor Testing

! Observe gait for symmetry / upper body sway

! Single limb stance: balance coordination

! Toe walk: extensor muscle function

! Heel walk: flexor muscle function

Examine the Foot

! Let foot hang to gravity – Best way to see deformity or assymetry – Gravity will allow muscles to relax – Gravity will many times help reduce fractures

or dislocations

Examine the foot

! Examine the “good foot” first – See what “normal” is; relax patient

! Observe deformity: – Supple or stiff? Does it change with weightbearing

! Observe skin

! Palpate all anatomical structures – Bones and tendons

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Corns and Callous

! Marker of high pressure

! Reaction of skin between bone and shoe

! Callous: broad tissue change

! Corn: deep, localized ! Analogous to splinter

Corns and Callous

! Treatment – Debride thick

tissue

! Daily pumice stone

! Daily skin softener – Alter plantar

pressure

Neuroma

! Damaged nerve –  Between metatarsal

heads –  Burning, stinging

pain –  Distinct area of pain

Neuroma Treatment

! Shoewear

! In shoe orthotics

! Steroid injection

! Transverse ligament release

! Neuroma excision

Neuroma vs Metatarsalgia ! Burning pain ! Pain in shoes ! Between metatarsals ! No toe instability

! Achy pain ! Pain barefoot ! Metatarsal head ! Toe instability

Metatarsalgia

! Local pressure overload

! Uneven metatarsal heads

! Tight heel cord

! Toe deformities

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Lesser toe Deformities ! PIP flexion ! Supple MTP joint

! MTP subluxation ! PIP and DIP flexion

Metatarsalgia

! Plantar plate instability

! Progressive deformity ! Raised toe ! Instability test

• Requires operative care

Combinations ! Crossover toes ! Hammer / mallet

Metatarsalgia Treatment

! Heel cord stretch

! In shoe orthotics

! Cushioned shoes

! Correction of toe deformities

Hallux Valgus 1st toe anatomy

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Hallux Rigidus Forefoot Treatment

! Motor / soft tissue driven deformities

! Nonoperative: Extra depth wide toed shoes

! Operative: – Bony realignment – Soft tissue realignment

HEEL PAIN

! Plantar Fasciitis: 90% ! Nerve Entrapment: 2% ! Soft Tissue Contusion: 8%

PLANTAR FASCIITIS

! Bow string of foot arch –  Supports arch shape

! Pain in am and after rest

! Worse with flat heels ! Tight Gastrocnemius ! No relation to

radiographic spur

Plantar Fasciitis

! 95% improve with non operative treatment ! Resolution can take 12 months ! Treatment consists of:

– Heel lift / cushion – gastrocnemius stretching – NSAIDS – Reassurance –  Ice massage

Gastrocnemius Tightness ! Found with knee

extension –  Loss of dorsiflexion

! Root of all evil in the foot –  Forefoot pain

! Metatarsalgia

–  Midfoot pain ! Posterior tibial dysfunction

–  Hindfoot pain ! Plantar fasciitis

Achilles Insertion

Gastrocnemius Origin

Soleus Origin

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Patient Evaluation ! Foot mobility

–  Subtalar mobility –  Achilles contracture

! gastrocnemius ! gastrosoleus

Gastrocnemius Tightness

! Technique –  Internal rotation of foot –  No pain in heel –  Knee extended –  Hold for 30 seconds –  5 or more times daily

Toe Fractures

! Usually isolated ! Usually stable ! Pain with weight ! Treatment

–  Correct deformity –  Buddy tape –  Hard sole shoe

! Up to 3 months recovery

Toe Fractures The exceptions

Metatarsal Fractures

! Acute Trauma ! Repetitive Trauma ! Dorsal pain with

weight ! Point tender ! Initial Radiograph

may be normal

Metatarsal Fracture

! Treatment – Hard sole shoe – Analgesics – Weightbearing as tolerated

! 8 -12 weeks recovery ! Achilles stretch if stress induced

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Stress Fractures

If tender on bone, treat As fracture till pain gone

7 days 4 weeks

Metatarsal Fractures Operative Care

First Metatarsal Multiple Metatarsals

Achilles Tendon Rupture

! Sudden movement ! Usually a pop felt ! Unable to walk

normally –  short step –  knee behind ankle

! No single heel lift

Achilles Tendon Rupture

! Asymmetric function ! Gravity check ! Thompson test

–  Foot over table –  Squeeze calf –  No movement foot –  Achilles

compromised

Achilles Tendon Treatment ! Immobilize immediately

– Keep tendon from retracting further

! Functional tx: nonoperative

! Operative tx: sew ends back together

! Successful treatment depends on tendon growing together – LONG RECOVERY

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“ANKLE SPRAINS” “ANKLE SPRAIN” ! Ankle ligament stretch

– Lateral ! Anterior talofibular ligament ! Calcaneal fibular ligament ! Syndesmosis ligament; High ankle

– Medial ! Deltoid ! Spring ligament

“ANKLE SPRAIN” ! Fracture

– Lateral Malleolus – Medial Malleolus – Talus

! Osteochondral lesion ! Lateral process ! Os Trigonum

– Calcaneus: anterior process

“ANKLE SPRAIN” ! Tendon Injury: tear or

subluxation – Medial side

! Tibialis Posterior – Lateral side

! Peroneus Brevis ! Peroneus Longus

“ANKLE SPRAIN” ! Anterior Lateral Pain

– Not on bone; in front

! Get an xray – Lateral and mortise view ankle – AP view of foot

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High Ankle Sprain

! On field evaluation – Location of pain

! Malleolar tip / syndesmosis

– Anterior drawer ?

– External rotation pain ! Ankle in neutral

Clinical Evaluation of Syndesmotic Injury

! A) Squeeze test

! B) External stress tests –  (shown) Keep knee

flexed to 90 degrees –  Standing version -

single limb stance with external rotation of body causes pain at syndesmosis

Clinical Evaluation

! Weight bearing stress

Ankle Sprain: Treatment In General

R - Rest I - Ice I - Immobilize C - Compress E - Elevate

Ankle Sprain: Treatment ! Can walk on ankle without instability

– Lace up brace and balance therapy

! Can Not bear weight – Cast in dorsiflexion 7-10 days – Allow weight bearing as comfort allows – Begin bracing and therapy when able to walk

Surgical Candidates ! Bony instability at exam ! Chronic joint laxity ! Failed Rehab ! Be sure no other pathology

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Joint Sprains: foot

! From stretch to complete dislocation

– Restore anatomical alignment

–  Immobilize non weight bearing till pain gone and able to bear weight (6 weeks)

– Balance therapy

Anatomy: Ligamentous

! Lisfranc ligament – Thickest of ligaments in midfoot – Lateral plantar base of medial

cuneiform – Plantar base of 2nd metatarsal – Rotates on its long axis

clockwise ! plantar from cuneiform to lateral

base metatarsal

Anatomy: Function

! Shock absorption mechanism for weight bearing

! joint motion at joints vary – 2nd tarsometatarsal stiffest – 1st and 3rd similar – 4th and 5th with 3 times the motion of

medial joints

Lisfranc: Mechanism of Injury

! Direct loading – Load parallel to joint

surfaces – Significant soft tissue

disruption ! Indirect loading

– Axial load along metatarsals

– Variable bony fracture involved

Lisfranc: Diagnosis

! Tender, swollen midfoot

! Pain with weight bearing

! Plantar ecchymosis

Lisfranc: Stress test No Stress Stress View

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Tendons about the ankle

! Treatment – Acute Injury / laceration

! Operative repair

– Chronic degeneration ! Bracing for stability ! Surgical reconstruction

– May require bony realignment if deformity present

Posterior Tibial Insufficiency ! Asymmetry in weight bearing foot position ! Unable to single heel rise ! Medial pain and swelling progressing to lateral

pain

Tibialis Posterior Insufficiency

•  Surgery: If Painful • Rigid deformity • Uncomfortable bracing • Patient activity level

Posterior Tibial Insufficiency ! Bracing

–  For supple deformity –  UCBL insert –  AFO

Peroneal Subluxation

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Diabetes and Feet

A Disaster Waiting to Happen

Diabetes

! Prevention is the key to foot preservation ! Constant education of patient necessary ! Diabetic neuropathy major complication

– unable to detect bone stress ! Diabetic vasculopathy major issue in

treatment – No blood flow… no healing

! A warm swollen foot without wound is foot fracture not infection

Diabetic Foot: Risk Factors

! Neuropathy

! Foot deformity

! Ulceration

! Infection

! Amputation

! Vasculopathy

! Amputation to viable level

Extra depth Wide Toed Shoes

! “Ugly Shoe” ! Provides extra room

for forefoot deformity ! Room for insert ! For low demand

patients ! For poor surgical

risk patients

Charcot Foot ! Bony instability ! Repetitive injury ! Warm, swollen

foot ! Bony

destruction ! Intact soft

tissue

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Charcot Arthropathy ! Ligamentous instability is not Charcot disease

but the start of the process

Charcot: Treatment

! Total Contact cast during active phase –  Change 1-3 weeks –  Initial non weight

bearing –  Continue till coalesence –  Attempt to minimize

deformity

! Surgical considerations –  Acute injury

! Ligamentous injury

–  Complications from deformity ! instability ! ulcer

Simple Treatment Truths

! With foot use: “IF IT HURTS…DON’T DO IT!” ! If it hurts to use immobilize it ! If a motor unit is tender, protect it

! Gait is all about bony stability and motor balance