Commonly Missed Foot and Ankle Conditions David Miller, DPM AMG Podiatry
Lisfranc Injuries Wide spectrum of injuries High energy Subtle subluxation which could be easily missed injuries Men are 2-4x s as likely to sustain these injuries as women, average age mid 30 s Anatomic alignment is the goal, even if achieved, subjective patient outcomes rarely are normal.
Anatomy
Mechanism of Injury High energy- severely displaced fractures (MVA s) Less severe twisting injuries can result in more subtle sprains and subluxation Direct vs Indirect Injuries (plantarflexed foot)
Clinical Evaluation Have a high index of suspicion for subtle injuries as these can predispose to midfoot instability and chronic pain Xray exam: comparison, stress views, Wbing xray
Radiographic Evaluation Normal Abnormal
Radiographic Evaluation
Radiographic Evaluation Positive Findings
Stress views
Treatment Goal: painless, stable, plantargrade foot Nondisplaced/stable injuries can be treated nonsurgically: need serial xrays Displaced/unstable injuries: important to achieve and maintain anatomic reduction Clinical evidence justifies the need for aggressive treatment with ORIF Primarily ligamentous injuries have a worse prognosis
Syndesmotic Injuries High Ankle Sprain
Syndesmotic Sprains Diastasis occurs: refers to any loosening in the attachment of the fibula to the tibia at the inferior tibiofibular joint There does not need to be wide separation of the bones Diastasis may not be immediately apparent Incidence: occurs in as many as 25% of all ankle sprains.
AITF, PITF, ITFL Usually fail by external rotation but could have an element of abduction (failure of the medial deltoid ligament or medial malleolus Anatomy
Anatomy
Evaluation Clinical: swelling often times not very severe, many go undiagnosed and become apparent with slow healing Squeeze test: low reliability Cotton Test Negative Ant Drawer and Talar Tilt tests External rotation test
Clinical Evaluation
Radiologic Evaluation Medial clear space Tibiofibular clear space Overlap Stress radiographs CT/MRI s
Xray Evaluation
CT/MRI
Treatment Requires anatomic reduction Stable injuries are treated symptomatically but take double the time to return to play
Achilles Tendon Rupture Most common tendon rupture in the lower extremity Peak incidence in the 3 rd to 5 th decade of life Usually male Missed as often as 25% of the time Partial rupture can be missed easily
History and Exam Patient feels a pop Thompson s test (positive)
Exam
Treatment Surgery is treatment of choice Delayed repair is more difficult and results are typically better with surgery
Association with Antibiotics Fluoroquinolones are widely used- need to be aware of possible effect on tendon First reported in 1994 Signs of tendonitis can occur as early as 2-3 days after therapy Synergistic effect on the Achilles with age >60 years, use of corticosteroids, renal compromise
Bilateral Achilles Rupture
Association with Antibiotics Mechanism Still somewhat unclear Alter fibroblast metabolism Inhibits tenocyte migration (alters healing)
Capsulitis of the Second Toe Pain plantar to metatarsal head (usually 2 nd ) Pain with traction/drawer maneuver MP joint Sometimes associated with hammertoe contracture Sometimes associated with swelling Radiographs to rule out stress fracture
Capsulitis
Capsulitis
Capsulitis Treatment Shoes (low heel, thick soles) Metatarsal pads Arch supports/orthoses Physical Therapy modalities Local injection Surgical correction Hammertoe reduction Metatarsal osteotomy Flexor to extension tendon transfer
Capsulitis
Capsulitis Pre-op Post-op
Neuroma/Interdigital neuritis Pathoanatomy: nerve entrapment at distal aspect of the transverse MT ligament Rule out more proximal source Uncommon to have concurrent neuroma in adjacent interspace No characteristic x-ray findings and MRI is usually not necessary or diagnostic
Neuroma Caused by direct or microtrauma to an interdigital nerve 90% involve nerve between the 3-4 toes Shoes with poor cushion/tight shoes/high heels Pronation- pinching of the nerve between the bone Hard surfaces Paresthesias to involved toes Mulder's Click Pain with metatarsal compression
Treatment Neuroma Shock absorbent insoles Steroid injections Shoes with wide toe box Orthotics Surgery-neurectomy vs. neurolysis
Questions? Conclusion