Foot and ankle treatment
Ankle Impingement
Ankle impingement syndrome is an inflammation in the anterior or posterior area of the ankle. It is produced by abnormal contact between the joint surfaces of the tibia and the talus or calcaneus which produces an inflammation of the synovial capsule. This results in osteophyte formation, (bone spurs). It is a very common injury in soccer players and dancers.
Anterior ankle impingement produces pain at the front of the ankle due to compression of the bone or soft tissue structures during activities of maximal dorsiflexion.
Posterior ankle impingement produces pain in the back of the ankle due to compression of the calcaneus and the tibia, when the foot and ankle are pointed maximally away from the body in a plantar flexion movement.
Treatment
- Conservative - Ice, NSAIDs, corticoid infiltration, PRP (Platelet-rich-plasma) or hyaluronic acid.
- Surgery -Arthroscopic or open surgery of the ankle joint to remove the osteophytes is performed when conservative treatment is unsuccessful. Progressive activity can begin ten days after surgery and return to normal sports after approximately three months.
Cartilage Injuries (Osteochondritis of the Talus)
This is an injury to the cartilage in the talus and underlying bone within the joint. The majority are in the posteromedial or anterolateral area and are a result of trauma. Pain is usually felt in the medial or lateral part of the ankle with periods of intermittent swelling, pseudo blockages, instability or repetitive sprains.
There are three levels of injuries: Grade I - fine cartilage but intact, Grade II - soft cartilage and Grade III - fissured cartilage.
Treatment
Treatment depends on the extent and associated injuries that generate instability to the knee.
Conservative treatment is performed in all cases as delaying surgery will not worsen the condition. This consists of immobilization with plaster and weight bearing after six to twelve weeks.
Surgery is either open or arthroscopic and can consist of:
- Microperforations - bone and fibrocartilage perforations to increase the vascularization of the area and help with the possible regeneration of the cartilage with fibroblasts.
- Removal of fragments, cleaning of the lesion, internal fixation of the fragments.
- Mosaicplasty - transplanting a piece of another joint of lesser load into the injured area.
- Autologous Chondrocyte implantation - a culture of the patient’s cells are processed in laboratory and the resulting collagen matrix is implanted into the injured area.
- Osteochondral allograft.
Tibial Plafond Fracture (Tibial Pilon)
This is a serious and complex joint fracture of the distal tibial weight-bearing surface. It is a high energy axial load injury with considerable damage to bone and soft tissue. Most are a due to trauma such as a car accident and will require surgery.
Treatment
As these are typically high energy injuries, treatment depends on the degree of soft tissue injury and accompanying fractured fragments. Most require surgery to restore the joint surface and to be able to carry out an early mobilization. This is a surgery of great technical complexity. Most patients require surgery to repair the joint surface damage and to recover mobility. This is a very technical surgery.
Malleolar Fractures
These fractures are the second most common fractures of the lower limb after the hip. They depend on the position of the ankle when the fracture occurs and are produced by torsion or rotation of the fifth talus within the tibioperoneal area. They are classified as Infrasyndesmotic (stable), Transyndesmotic (50% stable) or Suprasyndesmotic (100% unstable).
- Peroneal Malleolus Fractures
- Tibial Malleolus Fractures
- Posterior Malleolar Fracture (Volkmann fracture)
Treatment
Treatment can be conservative for stable non-dislocated fractures without cartilage injury. However surgery will be required for most fractures as they tend to be unstable and have associated ligament and soft tissue injuries.
Ankle sprain
This is a very frequent injury occurring when the ligaments supporting the ankle stretch beyond their limit and tear. The majority of cases affect the anterior talofibular ligament.
They range in severity depending on the damage to the anterior talo-peroneal and peroneal-calcaneal ligaments which can be stretched, partially ruptured or completely ruptured.
Treatment
- Treatment aims to reduce the edema, protect the ligament and restore function.
- Most sprains are minor injuries and can be treated with rest, ice, plaster and functional rehabilitation and orthosis. More severe sprains can lead to repeated sprains or chronic ankle pain if left untreated.
- Surgery is an uncommon treatment and is mostly used for athletes and patients still presenting chronic ankle instability after months of rehabilitation and non-surgical treatment.
Hallux Rigidus
“Stiff Big Toe” is a painful condition of the metatarsophalangeal (MTF) joint which causes dorsiflexion limitation. It is the most frequent osteoarthritis of the foot and can be caused by gout, trauma or an articular defect. The onset is usually insidious, with pain especially when walking.
Treatment
- Conservative - Initial conservative treatment consists of broad shoes with rigid soles to decrease the movement of the joint.
- Surgery - may be required depending on the severity of the condition. Surgery aims to improve and increase dorsiflexion.
- Metatarsophalangeal arthrodesis, where the bones are fused together, may be recommended for very serious cartilage damage.
Hallux Valgus
This is a common progressive forefoot deformity causing symptoms on the medial edge of the foot, the sole and the small toes. It produces bunions and is often due to ill-fitting shoes but it can also be caused by family disposition. Women are more affected than men due to use of narrower and high-heeled shoes.
Treatment
- Conservative treatment consists of adjusting footwear: using broad, soft footwear and cushioned soles
- Surgery is only indicated if there is pain with significant deformity or limitation of the use of footwear: bunionectomy, soft tissue realignment, osteotomies of the first metatarsal head and proximal phalangeal osteotomy.
Plantar Fascitis
Plantar fascitis is one of the most common causes of heel pain and occurs when the band of tissue that supports the arch of the foot becomes overly stressed developing micro-tears that cause inflammation. It is usually caused by repeated micro trauma in athletes, flat feet or a shortening of the Achilles tendon.
Treatment
In 90% of cases conditions improve within one year regardless of the treatment used.
Conservative treatment consists of physiotherapy, the use of night splints, supportive shoe inserts, steroid infiltrations and extracorporeal shock wave therapy (ESWT).
Surgery is performed if after a year of conservative treatment the symptoms still persist. This consists of a release of the plantar fascia by means of surgical decompression.
Achilles Tendon Injuries
This tendon is the largest of the body and links the muscles in your calf to the heel. It bears a lot of stress and pressure as it crosses two of the largest joints in the body and transmits forces of up to six to ten times the weight of the body during walking. Injuries are typically caused by anatomical predisposition, excessive exercise or sports activity with sudden dorsiflexion of the ankle and foot. The rupture may be incomplete and occur as a chronic injury. All can lead to tendonitis or rupture.
Treatment
- Conservative - Plaster for a minimum of eight weeks or functional treatment where after two weeks of immobilization the foot is placed in a CAM-Walker orthosis with early initiation of physiotherapy.
- Surgery - direct repair with tenography gives best results or minimally invasive techniques with percutaneous sutures allowing for a quicker return to activity, greater strength in plantar flexion and a lower rate of recurrence. Surgery is always recommended for chronic injuries.
Acute Achilles Tendinitis
This is an acutely inflamed Achilles tendon, paratenon or retrocalcaneal bursa usually due to microtrauma from strenuous exercise or overuse. It causes pain and edema and is common in athletes such as runners or tennis players.
Treatment
- Conservative - Rest, NSAIDs and physiotherapy. Corticosteroid infiltration should not be used as they can risk rupturing the tendon.
- Surgery - to release the paratenon if conservative treatment fails. It is usually recommended if pain persists for more than six months.
Chronic Achilles Tendinitis
This condition comes from chronic degenerative changes where the collagen fibers making up the tendon deteriorate. This is often the result of untreated tendinitis, producing a long-lasting pain that increases with activity.
Treatment
- Conservative - similar to that of Acute tendonitis.
- Surgery - resection of the injured portion of the tendon, removing the bursa, calcifications or exostosis and reinserting or repairing the tendon. In certain cases and depending on the patient’s age a tendon transfer of the flexor hallucis longus or lateral peroneus brevis is made.
Talus Fracture
The talus composes the bottom part of the ankle joint and is responsible for 90% of the mobility of the foot and ankle. Talus fractures usually result from high energy impact and many times require surgery to prevent future problems. Talus fractures are classified based on severity and dislocation.
Treatment
Non-surgical treatment options may be possible if the fracture is stable and not displaced. However, due to the high energy nature of these fractures, surgery is most often required.
Calcaneal Fracture
The talus composes the bottom part of the ankle joint and is responsible for 90% of the mobility of the foot and ankle. Talus fractures usually result from high energy impact and many times require surgery to prevent future problems. Talus fractures are classified based on severity and dislocation.
Treatment
Treatment can be both conservative or surgical, with most requiring surgery: open reduction, subtalar arthrodesis or deferred arthrodesis. Extra-articular fractures are generally treated conservatively.
Metatarsal Fracture
A metatarsal fracture is often a thin hairline crack to a metatarsal bone of the foot. Most are caused by direct trauma or sometimes indirectly by avulsion such as in the base of the 5th metatarsal, which is also the most frequent. These fractures can be classified as Avulsion styloid apophysis, Metaphyseal-diaphyseal union and stress fracture of the proximal diaphysis.
Treatment
Treatment can be both conservative or require surgery depending on if there is displacement or if the fracture is intra-articular. Bone grafting may be required in cases of pseudoarthrosis.
Lisfranc injury (Tarsometatarsal fracture-dislocation)
The Lisfranc joint is where the metatarsal and tarsal bones meet and the Lisfranc ligament gives stability to this joint.
A Lisfranc fracture-dislocation involves injury to bone and soft tissue in the tarsometatarsal joint and is most often due to torsion or high velocity trauma. In up to 20% of cases it is misdiagnosed or diagnosed late. Lisfranc injuries can be classified as: complete or psilateral, partial or divergent.
Treatment
Treatment for dislocations is surgical with closed reduction as early as possible or by open reduction and temporary fixation.