UPDATE: Aidan Rich, an Australian physiotherapist, pointed out to me on Twitter than Alfredson himself now advocates a minor surgical procedure that basically involves scraping the tendon. He found that the heel. Injury Series: Flat eccentric heel drops for insertional Achilles tendonitis. Ankle Arthrodesis Results. Lose 70% sagittal plane ROM. Disadvantages of Arthrodesis. Non union rates up to 12%. Poor mobility over uneven surfaces. Need for shoe modification. Hey, this is Sock Doc. And today I’m going to talk about plantar fasciitis, a common problem that many people have, pain in their foot, pain in the heel. Typically, it’s worse as you get up in the morning and step down out. El objetivo de este art Foot And Ankle. Foot And Ankle. Achilles Tendon. Achilles Tendon Rupture. Gastrocnemius tendon 1. Paratenonitis. - inflammation of paratenon. Paratenonitis with tendinosis. Tendinosis. - intratendinous degeneration due to atrophy. Rupture Site. 1. Poor women's shoe- wear. B. Bony protuberance of Os Calcis - Haglund's Deformity / Pump bump- Patrick Haglund, 1. Swedish orthopaedic surgeon - prominence of posterosuperior & lateral calcaneus- causes impingement & mechanical abrasion of T achilles at insertion. C. Retrocalcaneal Bursitis- retrocalcaneal bursa lies between tendon & posterior surface of calcaneum- normal lubricating structure- may become inflamed. DDx insertional- seronegative enteropathy- gout- corticosteroids- oral fluoroquinolones- hyperlipidaemia- DISH. Pathology. Peritendinitis- inflammation limited to paratenon. Tendinosis- tendon thickened- focal areas of degeneration- increased type 3 collagen- may be partial tear. Clinical Features. Non Insertional. Presentation- pain 2- 6 cm proximal to insertion- usually worse in morning & post exercise- may present with tendon rupture. Findings- localised tenderness- tendon may be palpably thickened- pain with DF and PF- DF may be limited. Insertional. Presentation- pain at bone- tendon interface- worse after exercise. Findings- localised tenderness & thickening- bony lump- DF may be limited. Note: Some younger patients may present only with pump bump / Haglund's- no tendonitis- just problems with foot wear. X- ray. Haglund's Deformity- may be calcification of bone- tendon interface with spur in insertional tendonitis- can define with Pavlow lines / Fowler's angle. Pavlov - lateral weight bearing x- ray- draw parallel pitch lines- defines Haglund's deformity to be removed (above second line)Fowler's angle Normal < 7. Open. - gold standard. B. Arthroscopic. - 8 Vs 1. Intraarticular Technique Dual incision reciprocal flat- cut technique. Incision. - over distal fibular, curved forward over ST joint. Superficial dissection. Fibula osteotomy / excise distal fibula. Deep dissection. - expose talar neck anteriorly. NV bundles with retractors. Distal tibial cut. Make a separate antero- medial incision. T anterior, protect saphenous nerve and vein. Talar dome cut. - place foot in desired position. DF. - make a parallel cut to distal tibia. Stimulate bleeding bony surfaces. Position foot. - ER 5 – 1. Fixation. - medial tibia down to talus. Options for fibular. NWB 6/5. 2 in cast. PWB in moon boot further 6/5. Double time if diabetic. Supination- Adduction. Stage 1: Transverse fracture of lateral malleolus at or below the level of anterior talo- fibular ligament (Weber B). Stage 2: Vertical fracture of medial malleolus (often a marginal impaction at medial edge of plafond)B. Pronation- Abduction (Less than 5% of ankle fractures). Stage 1: Rupture of the deltoid ligament or transverse fracture of the medial malleolus. Stage 2: Rupture of the anterior and posterior inferior tibiotalofibular ligaments or bony avulsion. Stage 3: Proximal fibula fracture (often butterfly)D. Pronation- External Rotation. Stage 1: Rupture of the deltoid ligament or transverse fracture of the medial malleolus. Stage 2: Rupture of the anterior inferior tibiotalofibular ligaments or bony avulsion. Stage 3: Spiral/Oblique fracture of the fibula above the level of the syndesmosis. Stage 4: Rupture of the posterior inferior tibiofibular ligament or fracture of the posterior malleolus. X- ray assessment. AP, lateral and mortise. Mortise. Technique. AP projection. - should be symmetrical clear space around talus. Bassett's Lesion. Pathology. Primary injury to AITFL. DF. - normally thin and above level of ankle joint. Diagnosis. Difficult to diagnose. Management. - arthroscopy and debride. Anterolateral capsule. Can lead to ankle OA over time. Swelling over anterolateral ankle. Giving way with inversion. Chronic pain is unusual with isolated chronic instability. Tender & swelling over involved ligaments. ATFL. - inferior to lateral malleolus for CFL. Limited dorsiflexion. Calf atrophy (especially peroneal). ATFL Instability. Chrisman & Snook. Reconstructs ATFL + CFL. STJ. - preserves 1/2 PB. Good results in 9. PB in 2 leaving 1/2 attached to 5th MT base. AP direction. - drill calcaneus with small tunnel inferior to fibula. PB / PL or to PB anterior to fibula. B. CORR 2. 00. 4. AOFAS score 9. 1. C. Watson- Jones. Attempt to recreate ATFL with PB tenodesis. PB tendon as proximally as possible. LM. - limits STJ motion. D. Colville. Anatomic reconstruction CFL and ATFL. PB left attached distally. STJ movement. Os Trigonum FHL Impingement. Posterior Ankle Impingement. Repetitive plantar flexion. FHL stenosing tenosynovitis. Soft tissue mass. Secondary centre of ossification of talus. FHL. - 2- 7% of normal feet. PF. - can cause FHL tenosynovitis. Pain with forced plantarflexion. Pain with resisted FHL. FHL. - posterior tibia bone oedema. US guided HCLA. - good results reported. Options. 1. Ankle Fracture. Weber A 4%- Weber C 3. Displaced large posterior malleolar. Any OA develops in first 2 years. Talus Injury. Talar Dome OCD. Talar neck malunion. Other. Inflammatory OA. Hemochromatosis. Ankle OA much lower than hip or knee. Thin cartilage 1 mm. Joint highly congruent. Tibio- talar contact stresses- 1mm shift causes 4. Clinically. Pain. Stiff Ankle Joint. Useful to define small anterior osteophytes. Solid Ankle Foot Cushion (SACH) + rocker bottom sole. HCLA / Hyaluronic acid Injections. Operative Options. Articular distraction with external fixator. Technique. - apply for 4/1. Sustenacular Fragment- constant- supero- medial - attached to talus by deltoid lig. Superolateral fragment- thalamic fragment- lateral fragment of posterior facet. Lateral wall fragment. Tuberosity fragment- posterior heel. Examination. EMSTLumbar spine- log roll- injury in 1. Other heel- 1. 0% bilateral. Foot- compartment syndrome. Effects- loss heel height- increased heel width- varus heel. X- ray Views. Lateral- Bohler's angle- crucial angle Guisane. Harris axial views- 4. Oblique view- CCJBroden's view- visualise posterior facet- IR foot 4. Axial- parallel to bottom of foot- information regarding CCJ & sustentaculum. Coronal plane- perpendicular to posterior facet- information regarding posterior facet and number of fragments +- sustentaculum / heel shape / position peroneal & FHL tendons. Rodger Atkins AOA 2. Salvage arthrodesis very difficult. Always better to attempt reconstruction initially even if just to make arthrodesis easier. Alternative is Primary Arthrodesis. Pain free functional foot that can fit in a shoe. Primary STJ arthrodesis. Salvage / STJ arthrodesis. Issues. 1. Restore posterior facet with screws. Restore calcaneum height and Bohler's by reducing tuberosity fragment. Pull out of varus. Disease Factors - Active infection (consider staged) - Stage I Eichenholtz - Insufficient soft tissue coverage - Insufficient bone stock. Patient Factors - Uncontrolled DM or malnutrition - Nonreconstructable PVD - Non- compliant Technique. Preoperative- cast / TCC till Stage III- optimise HBA1c and nutrition. Intraoperative- longitudinal incisions with full thickness flaps under no tension- meticulous soft tissue handling- resect bone to correct deformity- strongest fixation device possible ; often augmented- if using hindfoot nail ensure > 2. T Achilles lengthening- alternative: fine wire fixation if active infection Postoperative- TCC - 3/1. NWB ; 1/1. 2 PWB; 1/1. WBAT- Lifelong AFO- Periodic 6/1. Results- Lowery FAI 2. Total Contact Cast. TCC’s heal ulcers by reducing pressure. Works best if closely applied & moulded to leg. Protection from trauma. Reduce pressure over ulcers. Redistributes pressure over a greater weight bearing surface. Indications. 1. Medial. ABDH & FHB 2. Central / Calcaneal compartment. FDB. - deep: ADDH / F accessorius. Lateral. - FDM & Ab. DDM4. Interosseous. The calcaneal compartment communicateswith the deep post compartment of the leg through the medial retro- malleolar space. Two dorsal longitudinal incisions. MT. - lateral aspect of the 4th MT. One 6- cm medial incision. MM. - distally along the sole. ABDH & 1st MT interval. DPC or split- thickness skin grafting at 5 days. Non Treated Compartment Syndrome. FDL tethering. DDx / Posterior leg compartment syndrome / FDL involvement. PF of ankle. - FDL muscle & deep post compartment of leg are involved. Diabetic Foot. Background. Diabetic Foot Pathophysiology 1. Immunopathy Neuropathy. Most important aetiologic factor in foot disease. Due to . - metabolic (glycosylation of nerves). A. Diabetic Foot Ulceration (DFU). DM admissions. 5. BKA or AKA). 5. 0% coexisting vascular disease. DFU 2. Diabetic Foot Infection Microbiology. Acute & Mild Infections. S Aureus, Strep. - Up to 3. DFU hospitalized patients MRSA. Chronic & Severe. G + Cocci (Staph; Group B Strep). G - (E Coli; Pseudomonas). Anaerobes –in ischaemic Limbs; Eg Bacteriodes Fragilis. Workup of Diabetic Foot Diabetic Foot History. Ulceration. - episodes of infection. Diabetic Control. Examination. Look. Feel. - pulses / capillary refill. Charcot)Move. - anterior and lateral compartment mm power (for balancing transfers) Special Tests. Silfverskiold Test (need for TAL) Diabetic Amputations. DM > 1. 0 years. Considerations. - soft tissue envelope. Charcot collapse. Achilles tendon, knee, toe. Selection of Level. Aim is to preserve foot. BKA leads to contralateral BKA in 1/2 in 5 years. Biologic Amputation Level'. Cover with IV Abs 1. No sharp corners on bone. Long plantar flap if available. Delay Weight bearing and prosthesis. Try & leave base proximal phalanx. If complete toe amputation. Hallux. - must stabilise sesamoids or they retract & expose base MT2nd toe. MTPJ. Most useful for 1st or 5th ray. P brevis). Transmetatarsal amputation. A. ABI. - use doppler US & BP cuff. BP at ankle & arm. ABI = Ankle / Brachial. Normal Range. . 9 – 1. Measurement in DM. PVD. - <. 7 severe PVD2. Transcutaneous O2 Measurement (Tc. PO2). Measured by electrode placed on warmed foot. Hg = unlikely to heal. Toe Blood Pressure. Achilles Tendonitis Exercises . An eccentric muscle contraction is one where the muscle gets longer as it contracts rather than shortening. Alfredson created an achilles rehabilitation program based on eccentric exercises but made three innovations: If the achilles pain gets worse this is not necessarily a bad thing. It could just be part of the normal healing process. Heel drop exercises should be performed both with the leg straight and bent. A total of 1. 80 repetitions should be done every day for 1. This is a lot more than most achilles rehab programs would advocate.**Download your 1. Gastrocnemius heel drop. The patient begins by standing with one foot on a step and the heel raised up. Slowly lower the heel down keeping the leg straight until the foot is parallel to the ground but no further. The push up to the starting position using the uninjured leg to assist and repeat. Perform 3 x 1. 5 repetitions twice a day. This is maintained every day for 1. The exercise should be moderately painful. Over time the pain in the achilles may get worse before it gets better but as soon as 2 x 1. This can be done by wearing a weighted vest or rucksack to increase the weight or load through the achilles tendon. Soleus heel drop. The patient stands with one leg on a step the as with the gastrocnemius heel drop except this time the knee of the leg being exercised is bent to 4. The heel is raised up high and then slowly lowered to the horizontal position but no further. Return to the starting position up on the toes with the heel high by using the uninjured leg. Perform 3 sets of 1. Again, the exercise should be moderately painful and the pain may get worse before it gets better. Exercises should be continued until they are not painful then increase the load until moderate pain or discomfort is experienced once more. This routine should be done every day for 1. How does it work? If the two exercises are done strictly this should total 1. In the short term exercise increases tendon volume and stimulates collagen production. The tensile strength of the tendon will increase over time making it more able to cope with the loads expected of it in day to day activities and sport. Eccentric exercise where the muscle gets longer as it contracts may be more beneficial than the usual concentric exercise because of the repeated stretching of the muscle tendon unit. Eccentric exercises also allow for more force to be transmitted through the tendon. Stretching exercises. Stretching is an important part of the treatment and rehabilitation of achilles tendinitis. Stretching tight or shortened calf muscles may reduce the strain on the achilles tendon and enable the muscle to work more effectively. Gastrocnemius stretch. Place the leg to be stretched behind and lean forward, ensuring the heel is kept in contact with the floor at all times. Hold the stretch for 2. This can be repeated several times a day and should not be painful. A stretch should be felt at the back of the lower leg. If not then move the back leg further back. A more advanced version of a calf stretch is to use a step and drop the heel down off it. Soleus stretch. To stretch the soleus muscle the back leg should be bent. Place the leg to be stretched behind and lean against a wall keeping the heel down. A stretch should be felt lower down nearer the ankle at the back of the leg. If this stretch is not felt then a more advanced version is to place the forefoot of the front leg against the wall with the heel on the floor and push the from knee towards the wall. Stretching on a step. This stretch can be performed to further the stretch on the calf muscles and achilles. Stand on a step with the toes on the step and the heels off the back. Carefully lower the heels down below the level of the step until you feel a stretch - make sure you have something to hold on to! Hold for 1. 5- 2. This should be performed with the knee straight and then repeated with the knee bent to make sure you are stretching both muscles. You should feel a gentle stretch. Be careful not to over- do this one.
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