Common%Work%Related%Foot% and%ankle%problems Dr. George H. Theodore Massachusetts General Hospital Harvard Medical School Foot and Ankle Consultant Boston Red Sox New England Patriots Boston Bruins
Work%Related%Foot%and%Ankle% Problems! Bureau of Labor Statistics 2014! Nonfatal occupational injuries 112, 900 foot/ankle cases 10.4%/10,000 workers! 9% arm/wrist 18 median days from work! 16 back/neck Other! Return to work 1.5 x greater for men than women! 600 million paid in claims
Ankle%Sprains! Most common work injury! 25,000 per day in USA! $1,211 average ER visit cost! Most heal uneventfully! Types! Grade 1-stretch of ligament! Grade 2-partial tearing of ligament! Grade 3-complete tear of ligament! Mechanism! Inversion! 90% sprains! Low ankle sprain! Injures lateral ligaments! Eversion! 10% sprains! High ankle sprain! Injures syndesmosis
Ankle%sprains! Evaluation! Physical examination! Deformity! Tenderness! Difficulty weight-bearing! Radiographs! Ottawa guidelines! Exclude fracture Treatment! Individualize treatment! RICE! Immobilization! Grade 1: ace wrap! Grade 2: stirrup! Grade 3: walking boot! Physical therapy! Cortisone injection
Ankle%Sprains! Return to work Grade 1 (mild)! 2-4 weeks Grade 2 (moderate)! 4-6 weeks Factors influencing return to work! cartilage or tendon injury! Nerve damage! Poor balance
Ankle%Sprains! Grade 3 (severe) Persistent symptoms! 3 months! Pain, instability Advanced studies! MRI scan, stress test Surgery! Ankle arthroscopy! Repair of ligaments! Repair any associated injuries (cartilage)
Question%1 A 35 year old male warehouse worker slips on a wet floor and injures his ankle. Which answer is incorrect? A. The most common mechanism of injury is an inversion injury B. He may require a brace to help him walk C. Xrays may be helpful to exclude a fracture D. He should have immediate surgery to fix a torn ligament Answer D
Achilles%Tendon%Disorders tear tendonitis tendinosis Retrocalcaneal bursitis
Achilles%Tendon%Disorders! Tendonitis Inflammation of tendon sheath Overuse injury! Tendinosis Intrinsic degeneration Older patients with comorbidities Sheath swelling tendon thickened
Achilles%Tendon%Disorders! Treatment Modification of activities Heel lift Walking boot Physical therapy Surgery! Prognosis! Tendon debridement! Tendon transfer (FHL) Achilles tendonitis! RTW 6 weeks to 3 months Achilles tendinosis! RTW 3-6 months
Achilles%Tendon%Disorders! Acute rupture Profile! Middle aged males! Sudden pain! Eccentric contraction Physical examination! Positive thompson s test! Defect in the tendon Radiology! MRI! ultrasound
Achilles%Tendon%Disorders! Treatment nonop versus surgery! Surgery costs 3.7 x nonop! 1 year outcomes similar Criteria Trend toward less strength with push-off after nonop! Occupational demands! Overall health! Re-rupture vs. infection! Return to work Light: 2-3 months Moderate: 4-6 months Heavy: 6-9 months Ability to single heel rise
Question%2! A 50 year old female recently changed her job description which entails frequent use of stairs. She has gradually developed pain in her Achilles tendon area. There is no deformity in the tendon. Which answer is correct? A. She has likely ruptured her Achilles tendon and needs surgery B. She has a positive Thompson s test on physical examination C. She should have a PRP injection as first treatment D. She has Achilles tendonitis, and should limit stair-climbing Answer D
Plantar%Fasciitis! Most common cause of heel pain Affects 2 million Americans / year Females more than males Peak age: 40-60 No correlation with a heel spur 80% resolve within 12 months Most cases not work-related but an acute work-related force on foot may lead to fasciitis! $200 million spent annually! Independent risk factors Ankle DF < 0 degrees BMI > 30 Occupations or activities with prolonged weight-bearing
Plantar%Fasciitis Thickened fascia! Pathoanatomy Microtear in fascia Primarily degenerative Calcaneal edema! Presentation Pain with first steps in the morning and after rising from the seated position! Evaluation Proximal plantar heel Usually involves one foot Exclude other causes
Plantar%Fasciitis! Treatment Level one up to 2 months! NSAID s 30% to 70% success No study has proven its effectiveness alone! OTC orthosis or cushioned heel insert Used to correct pronation, off-load fascia No difference between custom and OTC! Stretching program 25% to 50% effective Plantar stretch preferred! Treatment Level two - up to 4 months! Cortisone injection Limited evidence of effectiveness Complications: rupture and pad atrophy! Night splint/walking cast No convincing evidence in literature! Physical therapy Formal therapy with ultrasound, estim, and laser supported for short term benefit
Plantar%Fasciitis! Treatment Level three! Alternative treatments PRP Prolotherapy Tenex! Surgery fasciotomy! Extracorporeal shockwave treatment (ESWT) Use of sound waves to treat fasciitis by microinjury to tissue 70% success No consensus on effectiveness
Question%3! A 60 year old female works as a cashier with frequent standing. She recently developed heel pain without an injury. X-rays are normal. Pain is worse with the first steps in the morning and after rising from the seated position. Which answer is correct? A. She likely has broken her heel B. This is a work-related injury C. She should begin a stretching program, wear well padded shoes, and take NSIAD s D. She should undergo a cortisone injection as the first treatment Answer C
Crush%injuries! Common workplace injury Statistics (1998-2009)! Prevalence 0.33/10,000! Average hospital stay 4.97 days! Average cost $13,514 Complex injury pattern! Various structure are injured! Skin, tendons, muscles, bones, nerves, blood vessels! Open wounds Dirty environments
Crush%injuries! Complications Infection-skin loss! Antibiotics! Skin grafting Nerve damage! Loss of sensation and movement! CRPS Fractures! Nonunions! Traumatic arthropathy Impairment! amputation
Fractures! Ankle Most need referral Types! Unimalleolar! Bimalleolar! Trimalleolar Surgical fixation! Unstable injuries! Loss of reduction of ankle joint mortise! Complicatons! Traumatic arthropathy! RTW: up to 6 months
Fractures! Foot fractures Phalanx! Most nonop-buddy tape Metatarsal! Non-displaced: cast! Displaced: surgery Calcaneus! Serious injuries! Usually from a fall Roofers landscapers! High incidence of arthritis! can result in fusion! Residual impairment
Nerve%Damage! Nerve injuries CRPS I! Not a specific nerve injury, aka RSD CRPS II! Defined nerve injury Superficial peroneal nerve Early diagnosis! Symptoms, signs, testing Treatment! Physical therapy! Bracing to prevent contractures! Pain service treatment Neuropathic medication, LSB, SCS! Costs Median 8 year cost: $436, 679
Question%4! A 35 year old male sustains a crush injury to the right foot. Initial xrays were negative. One month later, he is experiencing severe foot pain, swelling, altered sensation, and discoloration of the foot. The next step may include? A. Assure him that this is normal and return to full work duty work B. Arrange consultation with a neurologist and pain specialist for evolving CRPS C. Recommend oxycontin in increasing doses until pain is controlled D. Administer growth factor injections in the foot to promote healing Answer B
Common%Work%Related%Foot% and%ankle%problems! Observation Proper diagnosis is important for outcome Maintain function of injured worker Intervene early for adverse outcomes Communicate effectively with team members Develop effective preventive measures
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