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Foot and Ankle Problems in Foot and Ankle Problems in the Endurance Athletethe Endurance Athlete
Brian A. Weatherby, MDBrian A. Weatherby, MD
Steadman-Hawkins Clinic of the CarolinasSteadman-Hawkins Clinic of the Carolinas
Assistant Professor Clinical Orthopaedic SurgeryAssistant Professor Clinical Orthopaedic Surgery
University of South Carolina School of MedicineUniversity of South Carolina School of Medicine
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DISCLOSURESDISCLOSURES
NONENONE
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Foot ProblemsFoot Problems
• Lesser MTP DisordersLesser MTP Disorders
• Great Toe DisordersGreat Toe Disorders
• Metatarsal Stress FractureMetatarsal Stress Fracture
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Ankle ProblemsAnkle Problems
• TendinopathyTendinopathy AchillesAchilles
Posterior TibialPosterior Tibial
PeronealPeroneal
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Not this Endurance Athlete!Not this Endurance Athlete!
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This Endurance Athlete!This Endurance Athlete!
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Foot ProblemsFoot Problems• Lesser MTP DisordersLesser MTP Disorders
Metatarsalgia/MTP Synovitis/MTP InstabilityMetatarsalgia/MTP Synovitis/MTP Instability Interdigital neuromaInterdigital neuroma
• Great Toe DisordersGreat Toe Disorders SesamoiditisSesamoiditis Hallux RigidusHallux Rigidus
• Metatarsal Stress FractureMetatarsal Stress Fracture
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Foot ProblemsFoot Problems
• Lesser MTP DisordersLesser MTP Disorders
Metatarsalgia/MTP Synovitis/MTP Metatarsalgia/MTP Synovitis/MTP InstabilityInstability
Interdigital NeuromaInterdigital Neuroma
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Lesser MTP PainLesser MTP Pain
• Differential diagnosis extensive Mechanical Neurologic Idiopathic
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MetatarsalgiaMetatarsalgia
• Mechanical Shoewear
• Small toe box• Short shoe
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MetatarsalgiaMetatarsalgia
• Mechanical MP instability
• Often associated with long 2nd MT (Morton’s Foot)
– Especially in runner
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MetatarsalgiaMetatarsalgia
• Idiopathic Overuse
syndromes (runners)
Fat pad atrophy (aging)
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MetatarsalgiaMetatarsalgiaMTP MTP SynovitisSynovitis MTP Instability MTP Instability
• MP Instability Chronic-Volar
plate degeneration • Wide spectrum
of presentation• Can be
progressive
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Lesser MTP PainLesser MTP Pain
• Neurologic Morton’s Neuroma
• Mimic or be associated with synovitis
• Almost always 3rd web space
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Lesser MTP PainLesser MTP Pain
• Idiopathic Freiberg’s infraction
• 2>3 MT heads
• Occurs in adolescence but symptoms often in adult
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MetatarsalgiaMetatarsalgia
• Examination Isolated palpation of
MT head
Plantar keratosis
Fat pad atrophy
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MTP synovitis/MTP MTP synovitis/MTP InstabilityInstability
• Examination Deformity
• Hyperextension/Dislocation
Instability
• Lachman’s Synovitis
• Plantarflexion stress
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Morton’s NeuromaMorton’s Neuroma
• Examination Palpate Inter-space
(always)
Squeeze Test (majority)
Mulder’s Sign (30%)
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BiomechanicsBiomechanics
• Examination• Check for Achilles
contracture Increases forefoot pressures!
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Lesser MTP PainLesser MTP Pain
• Diagnostic studies• Radiographs
–Subluxation
–Dislocation
–Degeneration
–MT lengths
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TreatmentTreatment• Metatarsalgia
Activity Modification• Cross Train-bike/swim
Shoewear Changes• Rocker bottom
Heel Cord Stretching• 10 minutes/day with body wt
Custom Orthotics• Rx Full length accomodative
orthotic with MT pad to unload __ MT head(s)
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Shoewear• Neutral
Stabilitycombines cushioning and support
• Cavus (Supinator) Cushioning shock dispersion
in its midsole and/or outsole design
• Planus (Pronator) Motion control medial
support w/ dual density midsoles, roll bars, or foot bridges, thus
slowing the rate of overpronation
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TreatmentTreatment
• Metatarsalgia Activity Modification Shoewear Changes Heel Cord Stretching
• 10 minutes/day with body wt Custom Orthotics
• Rx Full length accomodative orthotic with MT pad to unload __ MT head(s)
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TreatmentTreatment• MTP Synovitis/MTP Instability
Activity Mods/Shoe Δ/Achilles Buddy Taping
• Daily 8-10 wks Marble Pick-ups
• 50 x 3 days then 250 for 8-10 weeks
Rx Strength NSAID 6-8 wks Orthotic w/ MT pad
• Temporary felt MT pad (Hapad) 6-8 wks
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TreatmentTreatment• MTP Synovitis/MTP
Instability MTP Injection
• Diagnostic &/or Therapeutic• Longstanding/Refractory• Must protect 4 wks in Budin
splint
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TreatmentTreatment
• Morton’s Neuroma Activity Mods Shoewear Changes Rx Strength NSAID 6-8 wks Custom Orthotic w/ MT pad
• Temporary Hapad
Webspace Injection• Diagnostic &/or Therapeutic• Longstanding/Refractory• Tape protection 4 wks
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SummarySummary
• Consider all possibilities
• Exhaust all non-operative modalities
• Surgical Tx warranted after minimum 16 + weeks conservative care
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Great Toe Disorders
• Sesamoiditis
• Hallux Rigidus
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First MTP AnatomyFirst MTP Anatomy
• Tibial & Fibular Sesamoids
• FHL & FHB
• Plantar Plate
• Articular Surfaces MTP MT-sesamoid
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BiomechanicsBiomechanics
• Importance of great toe Analogous to patella Push-off phase of
gait In athletics:
• Jumping• Sprinting• Spring board diving• Control in ballet, tae
kwon do
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BiomechanicsBiomechanics
• Normal gait Up to 50% body weight
transmitted through great toe complex
Great toe 2x lesser toes
• Jogging, running 2-3x body weight
• Running jump 8x body weight
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SesamoidtisSesamoidtis• Etiology Spectrum
Acute (fall or forced DF)• Fracture• Sx bipartite sesamoid (tibial)
Chronic (repetitive stress)• Stress Fracture• Sesamoiditis• Osteochondritis• Chondromalacia• Osteonecrosis• Exostosis IPK (tibial)
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Sesamoid DisordersSesamoid Disorders• History
Trauma, overuse, idiopathic
Localized plantar 1st MTP pain
Sport/Stairs/High impact worse
Δ in shoes/training/mechanics
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Sesamoid DisordersSesamoid Disorders• Clinical Exam
Specific TTP at tibial &/or fibular
Swelling, warmth, erythema
Plantar pain, +/- crepitus w/ motion
IPK over tibial sesamoid
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Sesamoid DisordersSesamoid Disorders
• Radiographs Standing AP/bilateral Axial Oblique
Marker over area TTP
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Sesamoid DisordersSesamoid Disorders• Bone Scan
Helpful when XR nml High false + Pinhole images to diff
b/w sesamoids
• MRI Bone vs. soft tissue Assess bone viability,
degeneration, tendon continuity
• CT Acute Frx Exostosis
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SESAMOIDITISSESAMOIDITIS• Presentation
Swelling and inflammation of peri-tendinous structures
Overuse Pain on WB, TTP directly over Tibial Sesamoid XR normal, +/- ↑ flow TC bone
scan, diffuse edema of sesamoid MRI
Diagnosis of Exclusion
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Sesamoid FractureSesamoid Fracture
• Presentation Acute
• Hyperextension injury• Tibial sesamoid• Transverse frx line, mid-waist• Callus formation• Association with MP dislocation• CT to evaluate displacement
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Bipartite SesamoidBipartite Sesamoid
Bipartite vs. Acute Fracture (Brown et al. CORR)• Irregular & unequal
fragment diastasis• Callus formation• Presence/absence
on contralateral side
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Sesamoid DJDSesamoid DJD
• Post-traumatic
• Iatrogenic s/p bunionectomy
• Chondromalacia
• Osteophytes
• Attritional rupture of abd/adductor H Valgus/Varus
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Sesamoid OsteochondritisSesamoid Osteochondritis
• Etiology unknown Crush injury Stress Frx AVN
• Pain, fragmentation, cyst formation, flattening
• XR Δ’s may delay 6-12 mos Bone scan MRI
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Bipartite Acute Frx
Stress Frx Osteochondritis
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Sesamoid IPKSesamoid IPK
Tibial sesamoid Cavus, PF ray (diffuse) Sesamoid prominence (localized)
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Treatment
• Acute Fracture (≤ 2mm diastasis) Heel Touch WB in toe spica
cast x 2 weeks Wedge Shoe x 2-4 weeks Custom Orthotic there after
• Full length accomodative orthotic with area of relief for tibial/fibular sesamoid
PT at 4-6 wks No running 3-4 mos
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TreatmentTreatment• Sesamoditis/DJD/Osteochondritis
Activity Mods Shoewear Mods
• Remove cleat under 1st MTP• Rocker bottom shoe (Skecher)
Rx NSAID’s 6-8 wks Custom Orthotic
• Wedge shoe until if ↑ symptoms RTP w/ FPP once asx x 3-4 wks &
w/ orthotics
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TreatmentTreatment
• Cortisone Injection Longstanding/Refractory Flouro guided Results Highly Variable
• Surgical Tx Failure appropriate non-op
tx ≥ 16 wks Displaced Frx
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Hallux RigidusHallux Rigidus
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Hallux RigidusHallux Rigidus• Second most
common condition affecting the hallux MP joint
• Termed coined by Cotterill in 1888, after description by Davies-Colley in 1887
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Hallux RigidusHallux Rigidus
• Definition = stiffness of 1st MTPJ
• Multiple names given: Hallux flexus/limitus
• Multiple etiologies considered Degenerative Traumatic (overuse/OCD/injury
sequlae) Dorsal bunion (paralytic) Metatarsus primus elevatus
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Hallux RigidusHallux Rigidus• Two groups:
Adolescent• Rigid swollen joint, painful
DF• Chondral lesion
(traumatic) or OCD (atraumatic)
Adult• Degenerative destruction• ? Overuse or traumatic
etiology
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Hallux RigidusHallux Rigidus
• Presentation Dorsal
prominenceshoewear irritation
Painful ROM (PF and DF, with push-off)
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Hallux RigidusHallux Rigidus• Examination
TTP over dorsal prominence• Keratosis
TTP over sesamoids – poorer prognosis
1st MTP ROM• Pain at extremes• Pain at mid-range
poorer prognosis
Drawer exam
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Hallux RigidusHallux Rigidus
• Radiographs Varying Grades
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Hallux RigidusHallux Rigidus
• Radiographic worsening does NOT equate to clinical worsening
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Hallux RigidusHallux Rigidus
• Treatment Shoewear modifications
• Size• Cushion prominences
Orthotics• Full length orthotic with TPE or
carbon fiber Morton’s extension under 1st ray
Taping Rx NSAID’s
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Hallux RigidusHallux Rigidus
• Treatment Steroid injection
• SELECTIVE• Repeated injections will ↑ degenerative process
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Hallux RigidusHallux Rigidus
• Surgical Tx Adolescent/Young
Athlete• OCD lesion or chondral
injury Arthroscopic debridement & microfracture
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Hallux RigidusHallux Rigidus
• Surgical Tx Adult
• Cheilectomy and Drilling of bare areas
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Hallux RigidusHallux Rigidus
• Surgical Tx Lengthy
discussion with athlete
Expectations• Pain relief
(majority)• ? ↓ push-off
power
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Metatarsal Stress Metatarsal Stress FractureFracture
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Stress FractureStress Fracture
• Definition Partial or complete
fracture of a bone due to its inability to withstand nonviolent, rhythmic, repetitive subthreshold stress
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Stress FracturesStress Fractures
• Pathophysiology
“Accumulation of microdamage to bone occurring with multiple subultimate failure strain loads & failure of body to initiate healing response.” AAOS ICL 2004
“Sub-threshold stress exceeds the body’s reparative ability”
Crack Initiation Propogation Final Frx
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Stress FracturesStress Fractures
• Etiology Anatomy
• Foot Type & Alignment– Subtle Cavus– Long 2nd MT– Leg Length Discrepancy
• Blood Supply– 5th MT base, middle MT neck
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Stress FracturesStress Fractures• Etiology
Footwear Training Surface ↑ in intensity/distance or ∆ in training
method Metabolic
• Hormone abnormality– Menstrual irregularity, oral contraceptives– Female Triad
• Calcium metabolism– Rickets: Vitamin D deficiency, renal tubular
insufficiency, osteodystrophy, hypophosphatasia,
• Hyperparathyroidism
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Stress FracturesStress Fractures• History
AWARENESS• Wide spectrum of presentation
↑ pain with activity, ↑ pain with pressure ∆ (airplane)
Vague, deep “throbbing” pain Alteration in stress/training +/- report of an actual single event
• Frx 2° continued loading
Chronic fractures can have very subtle and unimpressive findings
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Stress FracturesStress Fractures• Physical Exam
TTP over area Percussion/Tuning Fork Pain with one leg hopping
Assess Foot Stucture
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Foot StructureFoot Structure
• Neutral
• Cavus (Supinator)
• Planus (Pronator)
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Foot StructureFoot Structure
• CAVUS Subtle Cavus
• Peek-a-boo heel (varus)
• PF 1st ray
Obvious Cavus
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Foot StructureFoot Structure
• Cavus Related Conditions
5th MT Stress Fracture
Peroneal Tendon Pathology
Chronic Ankle Instability
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OrthoticsOrthotics
• Cavus Foot Pre-fab
• Donjoy Arch Rival
Rx• Full length orthotic w/ lateral forefoot
posting and area of relief for 1st MT head, along w/ MT pad to unload __ MT head(s)
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Stress FracturesStress Fractures• Imaging
Supports Clinical Suspicion
Know Your Imaging• XR lag behind or negative in 30-70% cases• MRI & Bone Scan show reaction before
fracture line is visable on CT
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Stress FracturesStress Fractures
• XR Frx evident in 30-70%, better for
cortical Pain onset bony ∆ avg.~ 21
days, may take 6 wks
• Tc99 ↑ sensitive w/in 48-72 hrs Poor specificity
• MRI Sensitive & Specific
• CT Complete vs. Incomplete Frx
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MT Stress FracturesMT Stress Fractures• Treatment- Stress Reaction
(+ MRI/Bone Scan, - XR) 5th MT NWB in Boot/Cast
until NTTP• When NT place in appropriate
orthotic– Cavus foot Full length orthotic w/
lateral forefoot posting & area of relief for 1st MT head, to include TPE or carbon fiber baselayer
– Nml foot Carbon fiber insert/Turf toe plate
• Modify activity 4-6 wks
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MT Stress FracturesMT Stress Fractures
• Treatment- Stress Reaction or Fracture 2/3/4 MT’s WBAT
Boot/Post op shoe 4-6 wks• ∆ to carbon fiber/toe plate
– After minimum 4 wks and NTTP
• Gradual return with FPP
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MT Stress FracturesMT Stress Fractures• Treatment-Stress Frx (+ frx line or
periosteal rxn on XR or CT) 5th MT NWB cast 8 wks (+/- bone
stimulator)• If XR healing and NTTP Boot with progressive
wt bearing 2-3 wks• Then ∆ to carbon fiber/toe plate
• Gradual return with FPP
• 15-20 wk Time to Union (bone stim ↓ 8-9 weeks)
• 30-50% RE-FRACTURE/NONUNION
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• Mologne et al., AJSM 2005 Cast vs. Screw, Level I Study 18 cast, 19 screw, 25 mos f/u 44% cast Tx Failure 6% screw Tx Failure Time to union/RTP
• Screw 7.5/8 wks• Cast 14.5/15 wks
MT Stress FracturesMT Stress Fractures
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MT Stress FracturesMT Stress Fractures• 5th MT Fracture-
Operative Indications Athlete
• Acute/stress fx Nonunion Re-fracture Cavovarus = lateral
overload
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MT Stress FracturesMT Stress Fractures
• Operative Goals Expedite healing Quicker recovery;
easier rehab Decrease re-fracture
risk
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Ankle ProblemsAnkle Problems
• TendinopathyTendinopathy AchillesAchilles
Posterior TibialPosterior Tibial
PeronealPeroneal
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TendinopathyTendinopathy
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Tendons: Basic ScienceTendons: Basic Science
*Aging results in increased stiffness due to inc.collagen cross-linking Decrease in tensile strength
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Tendons: Basic ScienceTendons: Basic Science
• Blood Supply 3 sources
• Musculotendinous junction• Surrounding connective tissue• Bone-tendon junction
Zones of Hypovascularity Decreases with age and mechanical
loading
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Tendinopathy: EtiologyTendinopathy: Etiology• Overuse injury (i.e. Degenerative
Tendinopathy):
Multifactorial:• Repetitive microtrauma (fibril level)• Load induced ischemia oxygen free radicals• Local hypoxia tenocyte death• Hyperthermic cell injury
Most common histiopathologic finding in tendon rupture
• Biomechanics Cavus Peroneal Tendons Planus (Pronation) Achilles Tendon,
Post Tib Tendon
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Tendinopathy: EtiologyTendinopathy: Etiology
• Corticosteroids
• Flouroquinolones
• Autoimmune disorders, inflammatory arthropathies, infection
• Trauma
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Tendon HealingTendon Healing
• Immobilization Decreases water and proteoglycan content Increases reducible crosslinks Results in tendon atrophy
• Mobilization Controlled stresses in proliferative and
remodeling phases highly organized collagen, increased tenocyte DNA content and protein synthesis
Increased tensile strength, cross-sectional area
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Achilles TendonAchilles Tendon
• Zone of hypovascularity 2-6cm proximal to insertion
• Forces 8-10x body wt. in running
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Achilles TendonAchilles Tendon
• Insertional Tendinopathy Occurs in older, less athletic, overweight
individuals
• Non-insertional Tendinopathy Occurs in more active athletes as a result
of repetitive stess of jumping, pushing off and cutting activities
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Achilles TendonAchilles Tendon
• 1° CLINICAL DIAGNOSIS
• MRI Failure of Non-op Tx or Surgical planning
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Achilles TendonAchilles Tendon• Treatment-Non-insertional
Paratenonitis Activity Modification Cross training
• Swimming, Stationary Bike
Rx NSAID’s and/or Medrol Dose Pack 0.25 inch heel lift Ice, Contrast baths Orthotics for overpronators
• Prevent “whipping” action on tendon
Cam boot immobilization (if sx’s > 6 wks)
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Achilles TendonAchilles Tendon• Treatment-Non-insertional
Paratenonitis Refractory Brisement injections
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Achilles TendonAchilles Tendon• Treatment-Non-insertional Paratenonitis
w/ Tendinosis Cam boot w/ 0.25 in heel lift
• Until no pain w/ ambulation shoe w/ lift
PT Rx Eccentric Exercise Program, Iontophoresis, US, X-friction massage
+/-Night Splint +/-Topical Nitro-Dur Patch
• 0.1mg/hr x 5-7 days
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Achilles TendonAchilles Tendon• Treatment-Non-insertional
Paratenonitis w/ Tendinosis Refractory Tx Options
• PRP Injection– Controversial!
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Achilles TendonAchilles Tendon• Treatment-Non-insertional
Paratenonitis w/ Tendinosis Surgical Treatment LAST RESORT!!!
• MUST fail 6 mos of non-operative tx
• Plethora of Surgical Procedures– Results 70-75% good to excellent– LESS than traditional orthopaedic procedures
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Peroneal TendonsPeroneal Tendons
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Peroneal Tendon TearsPeroneal Tendon Tears• Anatomic
Predispositions Peroneus quartus Hypertrophied
peroneal tubercle Os peroneum Low lying peroneus
brevis Convex/Flat groove Cavo-varus foot
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Peroneal TendonsPeroneal Tendons• Important Characteristics
Pain Location• Behind or distal to lateral malleolus• PB- Distal to LM Base of 5th • PL- Over lateral calcaneus peroneal tubercle
Pain Elicitation• Passive PF & Inversion• Resisted active DF & Everison
– If pop/click elicited ? Tear or intra-sheath subluxation
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Peroneal TendonsPeroneal Tendons
• 1° CLINICAL DIAGNOSIS
• XR Standard foot views
• MRI Difficulty in diagnosis or Surgical planning Sensitivity 17%, Specificity
100% (Kijowski et al.)
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Peroneal TendonsPeroneal Tendons• Non-operative Treatment
RICE Cam boot or ASO until pain
subsides Rx NSAID’s or Dose Pack PT Orthotics for Cavus foot
Gradual Return with FPP
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Peroneal TendonsPeroneal Tendons
• Surgical Treatment Failure of non-operative treatment
Procedure tailored to pathology• Debridement +/- repair, possible groove
deepening, excision p. quartus or p. brevis muscle belly, excision peroneal tubercle
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Posterior Tib TendonPosterior Tib Tendon
• Anatomy Acute
angulation of tendon
• Zone of hypovascularity Frey: starts 1-
1.5 cm distal to MM and extends to navicular insertion
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Posterior Tib TendonPosterior Tib Tendon• Important Characteristics
Medial ankle pain• TTP over course PTT
Fullness over PTT Arch collapse “Too many toes” sign Inability to perform DSHR or
SSHR
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Posterior Tib TendonPosterior Tib Tendon• AP/lateral weight bearing
films of foot and/or ankle Talo-navicular “sag” Plantar flexion of Talus Collapse of midfoot Collapse of the talo-calcaneal
angle
• MRI Difficulty in diagnosis or Surgical planning
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Posterior Tib TendonPosterior Tib Tendon• Non-operative Treatment
RICE PT for Eccentric PTT
program Rx NSAID’s or Dose Pack Protection
• If can do SSHR Orthotic w/ high trim line medially or Aircast Airlift PTTD brace
• If not Cam boot with arch support inside
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Posterior Tib TendonPosterior Tib Tendon
• Operative Treatment Failure of 4-6 mos Non-op Tx
Avoidance of bony procedures in athlete• PT debridement +/- FDL t-fer• Medializing calcaneal osteotomy at most