Common Ankle and Foot Injuries
Richard V. Abdo, M.D.
Richard V. Abdo, M.D.
• College - Brown University (with Honors)• Medical School – SUNY Upstate (Syracuse),
Cum Laude, 1978-1982• Orthopaedic Surgery Residency - Boston
University, 1983-1987• The Lahey Clinic (Boston) - 1987-1994• Orthopaedic Specialties - 1994-present, offices in
Clearwater • Reviewer for Foot and Ankle International 1989-
2015, Reviewer for American Journal of Sports Medicine 1991-present
Plantar FasciitisWhat is it?
Inflammation of the plantar fascia attachment to the heel bone (calcaneus). A traction (bone) spur may or may not be present. Entrapment of nerve may contribute to symptoms.
Calcaneus/heel bone
Heel/bone spur
Plantar Fasciitis
The low back pain of the foot
Plantar fascia – windlass mechanism
Windlass – a device for hauling or hoisting
Plantar Fasciitis
Clinical Presentation
• Pain and tenderness medial plantar heel
• Worse on arising in the morning or after prolonged sitting
• Increased with activities• X-rays – may show
bone thickening or spur
Plantar Fasciitis
Treatment• Weight reduction • Activity modification, rest• Stretching exercises• NSAID’s, Ice• Heel cushions, orthotics• Nighttime splint• Cortisone injection• Physical therapy –
ultrasound• Surgery - ~10% of patients
Platelet-Rich Plasma (PRP)• Platelets are small cells in the blood. They
become activated at the site of injury or inflammation, and release beneficial proteins called growth factors.
• PRP is obtained from a small amount of blood collected from the patient’s arm.
Platelet-Rich Plasma (PRP)
•The blood goes through a rapid spinning process (centrifuge) that separates the platelet-rich plasma
•PRP is injected at the site of injury or inflammation (e.g. plantar fasciitis)
Plantar Fasciitis
Surgery Options
• Open release – invasive
• Endoscopic plantar fascia release
• Extracorporeal Shockwave Therapy (ESWT) – orthotripsy, noninvasive
Ankle
Bottom of heel
Arch
Incision
The Ossatron device provides a non-invasive alternative to open surgery with an estimated 75% success rate.
ESWT Heel Treatment/Orthotripsy
Retrocalcaneal (Heel) Bursitis and Insertional Achilles Tendinitis
What is it?
Inflammation of the bursa between the Achilles tendon and the heel bone (calcaneus). May be associated with insertional Achilles tendonitis and calcium deposits or spurs.
Spur
Retrocalcaneal (Heel) Bursitis
Clinical Presentation
• Pain
• Tenderness
• Swelling
• Warm to touch
• X-rays – often calcium deposits or a spur
Pain
Swelling
Warm to touch
Retrocalcaneal (Heel) Bursitis
Treatment• Rest/activity modification
• Ice, NSAID’s
• Heel lift/cushion
• Physical therapy
• Injection
• Cast boot
• Surgery
Retrocalcaneal (Heel) Bursitis
Surgery
Preop Postop
Achilles Tendinitis (Tendinosis)
What is it?• Painful thickening and swelling 2-6
cm up from the back of the heel• Vascular watershed area• Overuse from repetitive
microtrauma – runners, jumping sports
• Extrinsic factors – change in training pattern, training on hard or uneven surfaces, poor footwear
• Intrinsic factors – age, weight, flexibility, foot deformity
• Degenerative (tendinosis), rather than inflammatory (tendinitis)
Achilles Tendinitis (Tendinosis)
Clinical Presentation
• Pain and fusiform swelling at the heelcord
• Tenderness upon squeezing the tendon
• Worse with activity• Painful to push off
while walking• Xrays usually negative• MRI not usually needed Heel
Fusiform swelling
Achilles Tendinitis (Tendinosis)
Treatment
• Activity modification• Heel cushions, heel lifts• PT, stretching, eccentric
exercises• Ice• NSAID• Cast boot• Cortisone injection• Platelet rich plasma
(PRP) injection
Achilles tendinitis (Tendinosis)
Surgery
• Debride degenerative tendon fibers
• Transfer tendon if needed
Stress Fractures
What is it?• Microscopic failure of bone
due to overuse microtrauma that overwhelms the normal bone repair process
• Most common with repetitive impact activities – runners
• History of new fitness activity, change in training program, poor footwear, hard running surface
• Foot deformities and decreased flexibility increase risk of stress fracture
Stress Fractures
Clinical Presentation• History of change in
activity/fitness• Pain, swelling, and tenderness
localized to the bone involved• Usually no distinct trauma• High risk stress fractures in area
of poor blood supply: 5th metatarsal (Jones’ fx.), navicular, ankle medial malleolus)
• Xrays – may be normal initially• Bone scan – sensitive, but not
specific• MRI – preferred, sensitive and
specific
Stress FracturesTreatment
• Rest, non-impact conditioning
• Immobilization – cast boot, postop shoe
• Limited or non-weight-bearing depending on location of fracture
• Elevation and ice• Avoid NSAID’s• Physical therapy• High risk fractures –
bone stimulator, surgery
Stress FracturesJones’ Fracture
Stress fracturesMedial Malleolus
Ankle Sprains
What is it?
An injury that stretches, frays, and tears ligaments. Ligaments connect one bone to another, providing support and stability for a joint.
Ankle Sprains
Clinical Presentation
• Pain and tenderness
• Swelling
• Ecchymosis (black and blue)
• Severity – mild, moderate, severe
• X-rays – normal, occasionally a chip fx.
Tibia
Fibula
Talus
Ankle Sprains
Treatment
P – Protection (ankle splint)
R – Rest
I – Ice
C – Compression (ace wrap)
E – Elevation
Additonal – NSAID’s, physical therapy
Soft Tissue Impingement
• Anterolateral impingement syndrome
• What is it?
1. ligament and synovial thickening
2. fibrosis
3. adhesions Scar tissue
probe
Soft Tissue Impingement
Clinical Presentation• History of ankle
sprain(s)
• Pain and tenderness over anterolateral corner of joint
• Localized swelling
• No instability
inside (medial)
outside (lateral)
Front of right ankle
Soft Tissue Impingement
Treatment• NSAID’s
• Ankle splint
• Physical therapy
• Ice
• Cortisone injection
• Arthroscopic surgery debridement
Talus Osteochondral Lesion/Defect
What is it?
A fracture, bruise, or softening of a small segment of the talus cartilage and bone at the ankle joint. Usually located at the medial or lateral corner of the talar dome.
Medial talar dome lesion
Talus OCD
Clinical Presentation• History of ankle
sprains(s)
• Pain, swelling, clicking
• Sensation of instability
• X-rays may be normal or underestimate the extent of the lesion
• MRI scan
Xray
Talus OCDMRI
Talus OCD
Treatment• Depends on location and
stage/severity of lesion
• Ankle splint
• NSAID’s
• Physical therapy
• Cortisone injection
• Surgery – arthroscopic debridement/drilling, bone/cartilage grafting.
Tibia
Talus
Talus OCD
Allograft procedure
Talus OCD
Allograft procedure
Talus OCDAllograft procedure
Talus OCDParticulated Juvenile Cartilage Transplantation
Denovo
Talus OCDParticulated Juvenile Cartilage Transplantation
Denovo
Bone Impingement
What is it?
Bone spurs that develop around the margin of the joint that create local inflammation and irritation.
“sports” spurs
Bone Impingement
Clinical Presentation
• Anterior – most common
• Distal tibia and dorsal talus
• Repetitive impact injury over a lifetime, particularly athletics
• Tenderness, swelling
• Decreased dorsiflexion Bone spur
Bone Impingement
Treatment• NSAID’s
• Heel lift
• Ice
• Cortisone injection
• Arthroscopic surgery - removal
Bone spur removed
Plantar Neuroma/Morton’s Neuroma
What is it?
Thickening, entrapment, fibrosis/scarring of the interdigital nerve between the metatarsal heads in the ball of the foot.
Plantar Neuroma/Morton’s Neuroma
Clinical Presentation• Burning, shooting pain localized to the
plantar aspect of the affected interspace
• 3rd interspace > 2nd interspace
• Worse wih activities or constrictive shoewear
• Intermittent symptoms
• Pain with palpation/pressure of interspace
• X-rays - negative
Plantar Neuroma/Morton’s Neuroma
Treatment• Shoes – wide
toe box
• MT pad (and/or orthotic with MT pad)
• Ice, NSAID’s
• Injection
• Surgery MT pads
Plantar Neuroma/Morton’s Neuroma
Surgical Excision
neuroma
Other conditions
• Posterior tibial tendinitis• Peroneal tendinitis• Flexor hallucis longus tendinitis
(dancers)• Os trigonum syndrome (dancers)• Tarsal tunnel syndrome• Jogger’s foot (medial plantar nerve
entrapment)• Sinus tarsi syndrome• Turf toe• Hallux rigidus
Thank You
Questions ?