Foot & Ankle InjuriesFoot & Ankle Injuriesand Treatmentand Treatment

Dr. John R. SalladeDr. John R. SalladePhysical TherapistPhysical Therapist

Board Certified – Sports MedicineBoard Certified – Sports MedicineFellow – Academy Applied Functional ScienceFellow – Academy Applied Functional Science

Classes of ConditionsClasses of Conditions

> Traumatic surgical intervention> Traumatic surgical intervention

non surgical interventionnon surgical intervention

Insidious onsetInsidious onset

CongenitalCongenital

TraumaticTraumatic

Fractures Ankle Fractures Ankle

Mid footMid foot

ForefootForefootTendon tears Achilles (plantaris)Tendon tears Achilles (plantaris)

Posterior TibialisPosterior Tibialis

PeronealPeronealRepair, ORIF +/- Immobilization, WB, PTRepair, ORIF +/- Immobilization, WB, PT

Osseous AnatomyOsseous Anatomy

Osseous AnatomyOsseous Anatomy

ORIFORIF

ORIFORIF

ORIFORIF

OREF (Hoffman)OREF (Hoffman)

ImmobilizationImmobilization

Repair MRIRepair MRI

ImmobilizationImmobilization

Post Operative Post Operative ComplicationsComplications

StiffnessStiffness WeaknessWeakness Decreased propioceptionDecreased propioception Decreased vascularity, edemaDecreased vascularity, edema

InfectionInfection RSD CRIPSRSD CRIPS DVT PEDVT PE

““Non traumatic” InjuriesNon traumatic” InjuriesInsidious OnsetInsidious Onset

TendinosisTendinosis Stress fracturesStress fractures Bunions , Hallux LimitusBunions , Hallux Limitus Hammer toesHammer toes MetatarsalgiaMetatarsalgia NeuromasNeuromas Plantar Fascitis Plantar Fascitis Compartment SyndromeCompartment Syndrome

““Non Traumatic” InjuriesNon Traumatic” Injuries

BlistersBlisters Callosities Callosities Sub ungula hematomasSub ungula hematomas Arthritis Arthritis ““pump bumps”pump bumps” ApophositisApophositis SesmoiditisSesmoiditis InfectionsInfections

Peroneal TendonsPeroneal Tendons

Medial TendonsMedial Tendons

TendinitisTendinitis(post. tib., achilles, peroneal)(post. tib., achilles, peroneal)

Usually insidious in onsetUsually insidious in onset Pain with WB – stretch or contractionPain with WB – stretch or contraction Improves with light activityImproves with light activity Latent inflammatory responseLatent inflammatory response TTP, warmTTP, warm Labs and Radiography not helpfulLabs and Radiography not helpful

TreatmentTreatment

Relative restRelative rest Ice – 15Ice – 15 Anti inflamatories – dosage and durationAnti inflamatories – dosage and duration PT - Find the biomechanical causePT - Find the biomechanical cause

modalities, stretching, strengthening (hip modalities, stretching, strengthening (hip partner), transverse friction massage, partner), transverse friction massage,

biomechanical control (shoes, biomechanical control (shoes, inserts, inserts, lifts or orthotics)lifts or orthotics)

Ankle SprainsAnkle Sprains

Account for 25% of all sports injuriesAccount for 25% of all sports injuries Lateral (ATF+CF)(85%)Lateral (ATF+CF)(85%) Medial (Deltoid)>Medial (Deltoid)> ““High” (Syndesmosis)>High” (Syndesmosis)> Mid tarsalMid tarsalPossible causes:Possible causes: Cavus, poor proprioception, poor rehab, over Cavus, poor proprioception, poor rehab, over

weight and poorly conditionedweight and poorly conditioned No significant male – female ratioNo significant male – female ratio

Ankle LigamentsAnkle Ligaments

““High” Ankle sprainHigh” Ankle sprain

Midtarsal SprainMidtarsal Sprain

TreatmentTreatment

Surgery?Surgery? RICERICE Progressive WBProgressive WB Immobilization and Early mobilizationImmobilization and Early mobilization Closed Chain ExerciseClosed Chain Exercise Looking for a causeLooking for a cause

Closed chain ExerciseClosed chain Exercise

Plantar FascitisPlantar Fascitis

CausesCauses

Unlocked midtarsal joint at push off phase Unlocked midtarsal joint at push off phase of gait causing stretch to fasciaof gait causing stretch to fascia

Variety of foot typesVariety of foot types Tight heelcords for level of functionTight heelcords for level of function Tight great toe flexors or fasciaTight great toe flexors or fascia Weakness in control of pronationWeakness in control of pronation Training errors, shoesTraining errors, shoes

TreatmentTreatment

No correlation to heel spurs No correlation to heel spurs Differentiate from tarsal tunnelDifferentiate from tarsal tunnel Treat the cause:Treat the cause: Stretch tight heel cords and FHLStretch tight heel cords and FHL Support unstable biomechanics – Support unstable biomechanics –

orthotics, taping or arch strapping orthotics, taping or arch strapping Night splints, morning/first step routineNight splints, morning/first step routine Analgesic modalities, injections? Surgery?Analgesic modalities, injections? Surgery?

Treatment for Plantar FascitisTreatment for Plantar Fascitis

Treatment for plantar fascitisTreatment for plantar fascitis

BunionsBunions(Hallux Valgus)(Hallux Valgus)

BunionsBunions

Both medial (1Both medial (1stst MTP) and lateral (5 MTP) and lateral (5thth))

In medial bunion:In medial bunion: Over pronated foot with abductus (toe out)Over pronated foot with abductus (toe out) Tight heel cords Tight heel cords Forefoot varusForefoot varus

TreatmentTreatment

Treat the causeTreat the cause Symptomatic relief with modalitiesSymptomatic relief with modalities Heel cord stretching Heel cord stretching Fore foot support via orthoticFore foot support via orthotic StrengtheningStrengthening When is surgery the best option?When is surgery the best option?

TreatmentTreatmentstretching orthoticsstretching orthotics

Stress Fractures – Micro FracturesStress Fractures – Micro FracturesMost common sites: metatarsalsMost common sites: metatarsals

TibiaTibia

CalcanealCalcaneal

CalcanealCalcaneal

FemurFemur

Stress FracturesStress FracturesProbable CausesProbable Causes

Increasing the amount or intensity of an Increasing the amount or intensity of an activity too quickly (most common)activity too quickly (most common)

Hard or uneven running surfaceHard or uneven running surface Improper or old shoesImproper or old shoes Untreated biomechanical imbalances Untreated biomechanical imbalances Biomechanical limitations of motion Biomechanical limitations of motion

(subtalar and midtarsal joints)(subtalar and midtarsal joints)

Other Risk Factors forOther Risk Factors forStress FracturesStress Fractures

Risk FactorsRisk Factors

Female, short, thin and caucasianFemale, short, thin and caucasian Certain sports, especially involving plyometric loading: Certain sports, especially involving plyometric loading:

Distance runningDistance running GymnasticsGymnastics DanceDance Basketball and TennisBasketball and Tennis

AmenorrheaAmenorrhea>decrease hormone support>decrease hormone support Poor diet- low in calcium and high in acidityPoor diet- low in calcium and high in acidity Osteopenia (Reduced bone thickness or density)Osteopenia (Reduced bone thickness or density) Poor muscle strength or flexibilityPoor muscle strength or flexibility Overweight or underweightOverweight or underweight

Compartment SyndromeCompartment Syndrome Compartment syndrome is a painful condition that occurs when Compartment syndrome is a painful condition that occurs when

pressure within the muscles builds to dangerous levels. This pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells.oxygen from reaching nerve and muscle cells.

Compartment syndrome can be either acute or chronic. Compartment syndrome can be either acute or chronic. Acute compartment syndrome is a medical emergency. It is usually Acute compartment syndrome is a medical emergency. It is usually

caused by a severe injury. Without treatment, it can lead to caused by a severe injury. Without treatment, it can lead to permanent muscle damage.permanent muscle damage.

Chronic compartment syndrome, also known as exertional Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion.most often caused by athletic exertion.

Compartments are groupings of muscles, nerves, and blood vessels Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane in your arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.and, therefore, the fascia does not stretch or expand easily.

Compartment SyndromeCompartment Syndrome

Symptoms and DiagnosisSymptoms and Diagnosis

Chronic (Exert ional) Compartment Chronic (Exert ional) Compartment SyndromeSyndrome

Chronic compartment syndrome causes pain or Chronic compartment syndrome causes pain or cramping during exercise. This pain subsides cramping during exercise. This pain subsides when activity stops. It most often occurs in the when activity stops. It most often occurs in the leg.leg.

Symptoms may also include:Symptoms may also include: Numbness Numbness Difficulty moving the foot Difficulty moving the foot Visible muscle bulging Visible muscle bulging

DifferentialDifferential

Chronic (Exertional) Compartment SyndromeChronic (Exertional) Compartment Syndrome To diagnose chronic compartment syndrome, other To diagnose chronic compartment syndrome, other

conditions that could also cause pain in the lower leg conditions that could also cause pain in the lower leg should be ruled out. Tendonitis can be ruled out but should be ruled out. Tendonitis can be ruled out but history and physical exam (palpation, passive and history and physical exam (palpation, passive and resistive tests) . To rules out stress fractures, an x-ray, resistive tests) . To rules out stress fractures, an x-ray, bone scan or CT scan can be used depending on the bone scan or CT scan can be used depending on the duration and location of the injury.duration and location of the injury.

To confirm chronic compartment syndrome, pressure To confirm chronic compartment syndrome, pressure tests of the compartment before and after exercise must tests of the compartment before and after exercise must be performed .be performed .

Treatment may involve a combination of rest, activity Treatment may involve a combination of rest, activity modification, change of shoes and orthotics and PT or in modification, change of shoes and orthotics and PT or in more involve cases surgery (fasciotomy).more involve cases surgery (fasciotomy).

Testing Fasciotomy Testing Fasciotomy

Reflex Sympathetic DystrophyReflex Sympathetic DystrophyChronic Regional Pain SyndromeChronic Regional Pain Syndrome

Hyper reactivity of the sympathetic nervous system Hyper reactivity of the sympathetic nervous system causing sustained “fight and flight” response. causing sustained “fight and flight” response.

The symptoms of RSD/CRPS often progress in three The symptoms of RSD/CRPS often progress in three stages—acute, dystrophic, and atrophic.stages—acute, dystrophic, and atrophic.

The The acuteacute stage occurs during the first 1–3 months stage occurs during the first 1–3 months (usually after injury to bone or nerve, surgery and/or (usually after injury to bone or nerve, surgery and/or immobilization of an extremity) and may include burning immobilization of an extremity) and may include burning pain (not proportionate to the degree of injury), swelling, pain (not proportionate to the degree of injury), swelling, increased sensitivity to touch, increased hair and nail increased sensitivity to touch, increased hair and nail growth in the affected region, joint pain, and color and growth in the affected region, joint pain, and color and temperature changes.temperature changes.

Advanced SymptomsAdvanced Symptoms

The The dystrophicdystrophic stage may involve constant pain and swelling. The stage may involve constant pain and swelling. The affected limb may feel cool to the touch and appear bluish in color. affected limb may feel cool to the touch and appear bluish in color. Muscle stiffness, wasting of the muscles (atrophy), and early bone Muscle stiffness, wasting of the muscles (atrophy), and early bone loss (osteoporosis) also may occur. This stage usually develops 3–6 loss (osteoporosis) also may occur. This stage usually develops 3–6 months after onset of the disorder.months after onset of the disorder.

During the During the atrophicatrophic stage, the skin becomes cool and shiny, stage, the skin becomes cool and shiny, increased muscle stiffness and weakness occur, and symptoms increased muscle stiffness and weakness occur, and symptoms may spread to another limb. may spread to another limb.

Characteristic signs and symptoms of Characteristic signs and symptoms of sympathetic nervous sympathetic nervous systemsystem involvement include the following: involvement include the following:

Burning pain Burning pain Extreme sensitivity to touch Extreme sensitivity to touch Skin color changes (red or bluish) Skin color changes (red or bluish) Skin temperature changes (hot or cold) Skin temperature changes (hot or cold)

RSD appearanceRSD appearance

TreatmentTreatment

Treatment Treatment The goals of RSD/CRPS treatment are to control The goals of RSD/CRPS treatment are to control

pain and promote as much mobilization of the pain and promote as much mobilization of the affected limb as possible without increasing affected limb as possible without increasing symptoms. Treatment must be symptoms. Treatment must be individualized individualized and willand will often combine medications, physical often combine medications, physical therapy, nerve blocks (ganglion blocks with therapy, nerve blocks (ganglion blocks with alpha adrenergic antagonist), and psychosocial alpha adrenergic antagonist), and psychosocial support. Sympathectomy can be helpful in support. Sympathectomy can be helpful in recalcitrant cases.recalcitrant cases.

Early detection and intervention is paramount.Early detection and intervention is paramount.

MetatarsalgiaMetatarsalgia

Inflammation of the heads of one or more Inflammation of the heads of one or more metatarsal heads (periostitis)metatarsal heads (periostitis)

Caused by uneven loading of forefoot Caused by uneven loading of forefoot during propulsionduring propulsion

Caused by forefoot imbalance or deformityCaused by forefoot imbalance or deformity

MetatarsalgiaMetatarsalgia

TreatmentTreatment

Rest, ice and NSAIAsRest, ice and NSAIAs Shoe, cushioned insoles Shoe, cushioned insoles Callous reduction (egg)Callous reduction (egg) Biomechanical exam to determine extent Biomechanical exam to determine extent

of forefoot imbalance and prescription of of forefoot imbalance and prescription of custom orthotic with FF balancing and custom orthotic with FF balancing and relief cut outsrelief cut outs

TreatmentTreatment

Inter Metatarsal (Morton’s) Inter Metatarsal (Morton’s) NeuromaNeuroma

Enlarged, fibrotic and benign interdigital nervesEnlarged, fibrotic and benign interdigital nerves Most commonly between the third and forth Most commonly between the third and forth

metatarsalsmetatarsals Brought on by shearing between metatarsalsBrought on by shearing between metatarsals Aggravated by narrow shoes and forefoot Aggravated by narrow shoes and forefoot

imbalanceimbalance Treatments include special shoes or inserts, Treatments include special shoes or inserts,

NSAIAs and/or cortisone injections, but surgical NSAIAs and/or cortisone injections, but surgical removal of the growth is sometimes necessary.removal of the growth is sometimes necessary.

NeuromasNeuromas

TreatmentTreatment

Osteo arthritisOsteo arthritis

condition characterized by the breakdown condition characterized by the breakdown and eventual loss of cartilage in one or and eventual loss of cartilage in one or more joints (ankle>MTJ>1more joints (ankle>MTJ>1stst MTP>ST) MTP>ST)

degenerative arthritis, reflecting its nature degenerative arthritis, reflecting its nature to develop as part of the aging process to develop as part of the aging process

Pain and stiffness in the joint, swelling in Pain and stiffness in the joint, swelling in or near the joint, difficulty walking or or near the joint, difficulty walking or bending the joint bending the joint

RadiographyRadiography

TreatmentTreatment

Proper footwear Proper footwear Medications to relieve pain and swelling (NSAIA, Medications to relieve pain and swelling (NSAIA,

analgesic, glucosamine) analgesic, glucosamine) Education on activity modificationEducation on activity modification Weight lossWeight loss PT -heat/cold therapy, E Stim., US, exercises to improve PT -heat/cold therapy, E Stim., US, exercises to improve

range of motion and strength, insoles or custom orthoticsrange of motion and strength, insoles or custom orthotics Injections and in some cases surgery. Injections and in some cases surgery.

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