Common Ankle and Foot Injuries Richard V. Abdo, M.D

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


• Pain

• Tenderness

• Swelling

• Warm to touch

• X-rays – often calcium deposits or a spur

Pain

Swelling

Warm to touch


Treatment• Rest/activity modification

• Ice, NSAID’s

• Heel lift/cushion

• Physical therapy

• Injection

• Cast boot

• Surgery


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)



• 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


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


• 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


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


Treatment• NSAID’s

• Ankle splint


• 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



• 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


• 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


• 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.


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


Treatment• Shoes – wide

toe box

• MT pad (and/or orthotic with MT pad)

• Ice, NSAID’s

• Injection

• Surgery MT pads


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 ?

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Common Ankle and Foot Injuries Richard V. Abdo, M.D