11/21/2017

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The Agony of the Foot:

Daniel Thuillier, M.D.Assistant Professor of Clinical Orthopaedics

University of California San Francisco

Top 5 Foot and Ankle Problems in Primary Care

Outline

• Plantar Fasciitis

• Achilles Tendonitis

• Achilles Ruptures

• Ankle Sprains

– Lis Franc

• Bunions

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Plantar Fasciitis

• Population/Incidence 

– Men and Women of all ages

‐10% of Americans have some form of heel pain

‐1 Million medical visits Annually

• Symptoms

– Plantar Medial heel pain

– Often worse in morning

– Worse with Activity

Pathophysiology

• Inflammation of the plantar fascial insertion at the medial plantar aspect of the calcaneus

Physical Examination/Studies

• +TTP at the plantar medial aspect of the calcaneus

• Achilles/Gastrocnemius tightness

• May or may not have plantar calcaneal bone spur on xrays

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Treatment• Almost always Conservative

• May Take Many months to Resolve

• Achilles/Gastroc/Plantar fascial stretching

• Heel Cups

• OTC Arch Supports

• Night Splints

• CAM walker/Casting

• *Injections‐ do have increased rupture rate*

Achilles Tendonitis/Tendinopathy

• Incidence

– Men and women of all ages

– 24%‐50% of lifetime runners

• Symptoms

– Pain In Achilles Tendon with Activity

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Pathophysiology

• Chronic Overuse Injury

• Occurs in 2 places– Insertion

– Mid‐Substance

Exam/Imaging

• +TTP in the achilles

• Swelling of achilles in midsubstance or insertion

• “Pump Bump” – posterior calcaneal bone spur

Treatment

• Almost Always Conservative

– Ice, Rest, NSAIDS

– Heel Lift

– Dedicated Eccentric Stretching program

– Period of Immobilization (CAM walker, Cast)

– NO STEROID INJECTIONS

• Surgery Reserved for Failed Conservative Management

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Achilles Rupture

• Incidence– Men 30s/40s

– Athletes and weekend warriors

– 7/100,00 population

– ~10% prior achillessymptoms

• Symptoms– Relatively painless!!!

– “kicked in heel”

– Walk funny, limp, weak

Anatomy

• Achilles Tendon is the biggest tendon in the body and subjected to the highest loads

• Has a 90 degree twist

• Inserts broadly over the posterior calcaneus

• Watershed area 4‐6 cm proximal to the insertion 

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Clinical Examination

• Palpable Defect

• Decreased plantarflexion strength

• Decreased resting tone

• + Thompson’s Test (Calf Squeeze and no Plantarflexion)

• Clinical Examination was more sensitive than MRI in detecting acute rupture

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Initial Treatment

• Plantarflexion in Splint (20‐30 degrees)

• Alternatively, plantarflexion in CAM walker with heel lifts (2).

Surgery vs No Surgery

Surgery

• Pros– Get tension to proper degree

– Likely Lower rerupture rate

– Feel like you did something

– “It’s what Kobe got”

• Cons– Cost

– Higher complication rate

• Especially wound problems

Non Op Treatment

• Pros– Less complications

– No

• Cons– Higher Rerupture Rate

– Tension may not be restored as well

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• 12 month follow up

• Similar functional results

• Similar re‐rupture rate

Ankle Sprains• Men and Women of all

ages• ~600,000 Ankle

Sprains per year in the US

• 3-5% of all ED visits (UK)

• Symptoms– Pain in Ankle– Swelling– Difficulty with Weight

bearing

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Ankle Sprains

Pathophysiology• ATFL is the most common 

ligament injured– Resists Anterior translation of 

the talus

• CFL may be injured as well– Resists talar tilt

• Grading Sprain– 1‐3 – how much is torn

• Mortise is maintained no matter what the grade

Ankle Sprains

Treatment• 95% of ankle sprains are 

asymptomatic at 1 year no matter how they are treated

• Slightly better functional results with early rehabilitation

• Surgical Repair reserved for those with prolonged (>6 months) of symptoms of instability

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Sprain vs Fracture?

Sprain

• Acute twisting Injury

• Pain swelling at ankle

• Bruising

• Difficulty with Weight bearing

Fracture

• Acute twisting Injury

• Pain Swelling at ankle

• Bruising

• Difficulty with weight bearing

The only real way to tell is with imaging

History

“High Ankle Sprain” - Syndesmosis

• Pain out of proportion to injury

• Prolonged Recovery• Pain posterior to fibula• Pain up leg towards

knee• Difficulty with one leg

hop• Pain with dorsiflexion

of ankle

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Lis Franc Fracture/dislocation

Anatomy

• Lis Franc Joint runs between the tarsal and metatarsal bones

• Both Dorsal and plantar ligaments

• Plantar ligaments are stronger

• Strongest in between medial cuneiform and base of second metatarsal

• Same in Adults and Kids

www.aofoundation.org

Lis Franc Fracture/Dislocation

• Maybe direct or indirect, contact/no contact

• Axial Load to plantarflexed foot

www.aofoundation.org

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Assessment

• History– Painful walking

– Pain in midfoot

• Physical Examination

• Midfoot Swelling

• Midfoot Pain– Dorsal or plantar

• Ecchymosis

• MUST GET Appropriate IMAGING IF THESE ARE PRESENT

www.aofoundation.org

Bunion (Hallux Valgus)

• Population/Incidence

– 24% >60 yo

– Women 2‐4X men

– Strong family History

• Symptoms

– Pain in great toe, especially with shoewear

– Deformity of first toe

– Erythema, Swelling

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Pathoanatomy

• Complex Deformity

• Lateral Deviation First Toe, with Medial Deviation of Phalanx

Treatment

Conservative

• Shoewear Modification

• Orthotics

• Bunion Sleeves

• Bunion Pads

• Gastroc Stretching

Surgical

• Usually reserved for those who fail conservative treatment

• >100 different surgical procedures described

• Results vary ‐ ~70‐85% improvement

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Thank You