Lower Extremity: Foot
Metatarsal Fractures:
Epidemiology: Fractures of the metatarsals are a common fracture in the lower extremity. Patients tend to report getting their foot caught up in a flip flop or slipping.
Pathophysiology: The mechanism of injury depends on the zone of injury. Some associated structures that can be injured simultaneously are the Lis franc ligament and lateral ankle ligaments. Associated foot deformities include cavus foot and varus hindfoot. The metatarsals are analogous to the metacarpals of the hand.
Presentation: Patients will complain of pain over the lateral or dorsal border of the forefoot with weight bearing. If there is a prolonged history of vague forefoot pain, then a stress fracture may be the culprit. Physical examination in the setting of trauma may demonstrate bruising, swelling, and tenderness to palpation. In the setting of a stress fracture, tenderness to palpation is the most predictive test.
Diagnosis: Plain x-rays of the foot can demonstrate most foot fractures. MRI can be used when looking for a stress fracture or a more subtle fracture. CT scan can be used to evaluate the degree of a healed fracture or in the setting of delayed healing of a fracture.
Treatment: NonOperative Management consists of protected weight bearing in a CAM walker. Generally speaking, foot fractures will heal in 6 weeks. If this happens to be a stress fracture of the 5th Metatarsal, then healing may take up to 3 months. Operative Management of metacarpal fractures may be considerd for displaced fractures or in the setting of multiple metatarsal fractures. Plates and screws can be used. Percutaneous pins may be used. In the case of a 5th Metatarsal fracture, an intramedullary screw is a good option. Given the triangular shape of the 5th Metatarsal, there is a screw made by Acutrak which fits the geometry of the bone perfectly.
Plantar Fasciitis:
Epidemiology: There is no gender predilection for this entity. The general location of pain felt is at the posterior medial heel which is caused from an inflammation of the aponeurosis of the origin of the plantar fascia. Risk factors include obesity, decreased ankle dorsiflexion, and overuse in ill-fitting or worn out shoes. There is typically an event or episode that patients can recall as the beginning of their pain.
Pathophysiology: Chronic overuse leads to micro tears in the origin of the plantar fascia. The repetitive trauma leads to recurrent inflammation and periostitis. The plantar fascia is a thin layer of connective tissue which supports the arch of the foot.
Presentation: Patients will typically report very sharp heel pain usually worse with the first step of the day. They may have to walk on the ball of the foot initially. It can be worse by the end of the day and is commonly relieved with ambulation. Physical examination is exquisite pain with palpation of the origin of the plantar fascia on the plantar medial aspect of the posterior calcaneus. There is typically limitation in the ability to dorsiflex the foot secondary to tight Achilles tendon complex.
Diagnosis: Plain x-rays will sometimes be misleading because of the presence of a bone spur on the plantar aspect of the calcaneus in the region of the pain. Patients see this and believe that it is like a needle poking the tissue and this is the cause of the sharp pain. This is erroneous thinking because it is a Traction Spur in reality which originates from calcification of the origin of the plantar fascia. MRI may be used to identify a tear of the plantar fascia or in preoperative planning.
Treatment: NonOperative Management consists of shoe modification, icing, stretching, NSAIDs, avoidance of barefoot walking, foot orthotics and night splints. Steroid injection can be considered and usually performed by a podiatrist. There is evidence that shock wave treatment can be useful but is generally expensive and not covered by insurance. There is an ultrasonic device that can phagocytize, irrigate, and debride the damaged tissue. Operative Management consists of gastrocnemius lengthening or release of the plantar fascia. Occasionally, a release of the distal tarsal tunnel can provide relief in recalcitrant settings.
Lower Extremity: Ankle
Low Ankle Sprain:
Epidemiology: Ankle sprains are the most common reason for athletic participation. Ankle sprains are broken into two general types. The High Ankle Sprain is an injury to the syndesmosis and accounts for up to 10% of sprains. The Low Ankle Sprain accounts for approximately 90% or more of the sprains. Anatomy: The lateral ligaments of the ankle include: ATFL, CFL, and PTFL. The Anterior Talo Fibular Ligament (ATFL) is the most commonly involved ligament in low ankle sprains. The Calcaneo Fibular Ligament (CFL) is the second most common injured ankle ligament. The Posterior Talo Fibular Ligament is less commonly involved. Ligament sprains are broken down into 3 groups: Grade I, Grade II, and Grade III. Grade I injuries have minimal pain with weight bearing, minimal bruising and swelling and no ligamentous disruption. Grade II injuries have mild pain with weight bearing, moderate bruising and swelling and stretch injury to the ligament without tear. Grade III injuries have severe pain with weight bearing, severe bruising and swelling, and a complete tear of the ligaments. Injury to the medial ankle ligaments is much less common. The medial ankle ligaments are the Anterior Deltoid, Middle Deltoid, and Posterior Deltoid. Presentation: Patients will present with bruising, swelling, limited range of motion, and painful weight bearing. Some patients presents in a splint on crutches after a trip to the Emergency Room or Urgent Care Center. Imaging: Plain x-rays are indicated to rule out a fracture if patients have difficulty with weight bearing. In some situations, an MRI can be useful in determining the extent of damage that occurred to the patient. Things an MRI can determine is the degree of tear, presence of occult fracture, peroneal tendon pathology or osteochondral defect. Treatment: NonOperative Management consists of RICE: Rest, Ice, Compression, and Elevate. A short period of rest no longer than a week can help but early mobilization facilitates a better recovery. The mainstay of treatment is Physical Therapy. Once the swelling and pain have decreased to an acceptable level and range of motion has returned, then PT can be initiated. Therapists will work on neuromuscular training and proprioception. An Ankle Stabilizing Orthosis or ASO brace can be used to prevent repeat injuries. Early functional rehabilitation allows for the fastest return to play. Operative Management consists of ankle arthroscopy to debride impingement tissue which can cause recurrent ankle sprains. Acute repair of the ATFL and CFL can eliminate lateral instability if the tissues are robust enough. In a situation where the tissue is insufficient, an allograft reconstruction can be performed.
High Ankle Sprains:
Epidemiology: This is a much less common entity that low ankle sprain. It can occur in up to 13% of ankle fractures. Pathophysiology: It is most commonly associated with external rotation injuries. The external rotation forces the talus to rotate laterally and push the fibula away from the tibia. Associated injuries include the Weber C fibula fracture, peroneal tendon injuries, osteochondral defects, and deltoid ligament injury. Anatomy: The Anterior Inferior Tibiofibular ligament (AITFL), Posterior Inferior Tibiofibular Ligament (PITFL), Transverse Tibiofibular Ligament, Interosseous membrane, Interosseous Ligament, and the Inferior transverse Ligament are the structures which can be damaged. The function of these structures is to maintain the relationship between the tibia and fibula. They resist axial, rotational and translational forces. Presentation: Patients have difficulty with weight bearing with pain described as medial and lateral. On physical examination, patients will point to the syndesmosis as the point of maximal tenderness. Patients seem to have more bruising and swelling than with low ankle sprain. A dorsiflexion and external rotation stress will cause pain over the syndesmosis. Diagnosis: Plain x-rays can show a widening of the syndesmosis. An external rotation stress radiograph can be obtained but is painful for the patient. CT scan can be beneficial in evaluating the syndesmosis. MRI is very sensitive and specific for evaluating the soft tissues of the syndesmosis. Treatment: NonOperative Management consists of non weight bearing in a CAM walker for 2-3 weeks. This is indicated in a syndesmosis sprain without diastasis or ankle instability. Patients are maintained in the boot without weight bearing until pain-free then placed in an Ankle Brace. Recovery is variable but may be up to 3 months. Operative Management consists of reduction of the fibula with the tibia and closing down the widening. This can be accomplished with a device called a Tightrope or a simple screw. The advantage of the Tightrope is that it does not have to be removed and will allow for the physiologic motion of the syndesmosis once recovery is complete. A screw will either have to be removed or it will loosen or break. Total recovery is 3 months with no weight bearing in a CAM walker. Patients are encouraged to come out of the boot daily and begin Plantar Flexion and Dorsi Flexion exercises. They are to avoid inversion, eversion, and circumduction.
Fracture:
Epidemiology: Ankle fractures are one of the more common lower extremity fractures. The ankle is made up of three major bones (tibia, fibula, talus) which come together to make up the ankle joint. Anatomy: The distal end of the tibia is called the medial malleolus and can be fractured. The distal end of the fibula is called the lateral malleolus and can be fractured. Less commonly, the posterior lip of the distal end of the tibia is called the posterior malleolus and can be fractured. The lateral malleolus is the most commonly fractured. The combination fracture of the medial and lateral malleolus is called a Bimalleolar Ankle fracture. Finally the combination of the medial, lateral, and posterior malleolus is called a Trimalleolar Ankle fracture. Presentation: Patients present with ankle pain with difficulty or the inability to ambulate on the affected extremity. There is generally bruising and swelling about the ankle and foot. On physical examination, patients will have pain over the medial or/and the lateral malleolus. Range of Motion is limited or non-existent. Diagnosis: Plain x-rays of the ankle are very important. There are criteria that can be measured on the x-rays to help determine the course of treatment. The competency of the deltoid ligament must be determined. With stress radiographs, a medial clear space of greater than 5mm with external rotation applied in the dorsiflexed ankle is a strong predictor of a disrupted deltoid ligament. If there is a lateral talar shift that is greater than 3mm then surgery is a strong consideration. Rarely a CT scan or an MRI may be indicated for further information gathering. Treatment: NonOperative Management is the first line of treatment of a non-displaced or minimally displaced lateral malleolar fracture with no evidence of medial clear space widening or lateral talar translation. Operative Management is used when there is displacement of the lateral malleolus with medial clear space widening. If there is a medial malleolus component, then strong consideration of surgical intervention must be considered. The decision-making algorithm can become complex and should be discussed at length with the physician. Typical healing time is 6-8 weeks in healthy, non-smoking, non-Diabetic patients.
Achilles Tendonitis:
Epidemiology: The family of conditions include insertional Achilles tendonitis, Haglund Deformity, Retrocalcaneal Bursitis, and midsubstance Achilles Tendonitis. These entities occur in middle-aged and elderly patients with tightening of the Achilles Tendon. . Pathophysiology: The Achilles tendon can have midsubstance degeneration and/or proliferation of tissue causing a mass and pain. Repetitive stresses or trauma can lead to inflammation of the tendon or inflammation at the insertion site. Haglund Deformity is an enlarged process of the posterior calcaneus which can irritate the Retrocalcaneal bursae. Presentation: Patients present with posterior heel pain, swelling, and occasional stiffness. Shoe wear may be painful if there is direct contact with the inflamed area. Some patients will come in with backless shoes in an attempt to alleviate pressure and pain. There may be a progressive boney enlargement of the insertion site of the Achilles Tendon on the calcaneus. Physical examination will show pain with palpation of the mass at the mid to distal aspect of the Achilles tendon. There could be pain at the insertion site of the Achilles Tendon on the calcaneus. There could be pain with palpation of the Retrocalcaneal Bursae. Diagnosis: Plain x-rays can show some calcification of the distal Achilles at the insertion onto the calcaneus. A large Haglund Deformity may be present with visible soft tissue swelling. MRI is useful in determining the amount of degeneration within the tendon. Treatment: NonOperative Management consists of shoe modification and activity modification. Custom orthotics or a blue dot heel lift may be used to alleviate symptoms. Physical Therapy for stretching the Achilles and deep tissue cross friction treatment can be helpful. Avoidance of wearing a shoe with a stiff back such as a “pump” can be helpful. An injection into the Retrocalcaneal bursae can be considered but never into the insertion of the Achilles Tendon on the calcaneus. Operative Management is considered if non-operative management fails. The tendinosis within the tendon can be excised but care must be taken not to remove greater than 50% of tendon volume. If greater than 50% of the Achilles is involved and must be removed, then tendon augmentation or tendon transfer must be included. Consideration of excision of Retrocalcaneal bursae and/or excision of the Haglund Deformity can be helpful to alleviate pain but patients report this to be a very painful recovery.
Achilles Tendon Rupture:
Epidemiology: The incidence is 18 per 100,000 per year. This is most common in men ages 30-40 years old. They tend to be the “weekend warrior” type. There may be a history of Fluoroquinolone antibiotic use or steroid injection into the Achilles Tendon or at the insertion site of the Achilles Tendon. This injury may be missed in up to 25% of the cases. A high index of suspicion is a must. Pathoanatomy: The Achilles Tendon is the largest tendon in the body and is formed by the confluence of the soleus tendon and the medial and lateral head of the gastrocnemius tendons. The rupture typically occurs 4-6cm proximal to the insertion of the Achilles on the calcaneus. It is usually the result of a sudden forced plantar flexion or a violent dorsiflexion of the plantar flexed foot. Presentation: Patients usually report a sensation of a “pop” and occasionally the sound of a “pop”. It is not usual for a patient to tell me they felt like they heard a gunshot and then were unable to walk. The physical examination will generally show a palpable gap in the tendon. Patients will be unable to plantarflex the foot against resistance. The Thompson test is performed by squeezing the calf when the patient is in a prone position with the knee flexed to 90 degrees and the ankle is flexed to 90 degrees. A positive test is when the calf is squeezed and the foot does NOT plantarflex. Diagnosis: Plain x-rays are used to rule out any other pathology. Ultrasound can be used to image the Achilles tendon and will show a gap in the tendon with rupture is present. MRI is used to differentiate between a partial tear and to localize the level of the tear. MRI can also determine the degree of tendinosis present in the tendon. Treatment: NonOperative Management consists of placing the patient in a CAM walker and allowing full weight bearing. This may be painful after the initial injury and crutches can be used to alleviate the pain. Range Of Motion should be initiated at one month. Historically speaking, the understanding was that non-operatively treated Achilles tendon ruptures had an increased re-rupture rate and decreased plantar flexion strength. Newer studies show this not to be the case. I have successfully treated many patients non operatively in a CAM walker for 3 months. They returned to activity as tolerated following a course of Physical Therapy. Operative Management can be considered in high-functioning athletes. Recently, there has been some evidence that repairs augmented with Umbilical Cord can heal faster with decreased amounts of scar tissue. The biggest risk factor with surgical repair is wound breakdown. There is not much tissue between the skin and the Achilles Tendon and wound infections are common.