Management

Management

Management Overview

  • Always follow general principles:
    • Rest, Ice, Compression, Elevation (first 48-72 hours)
    • Avoid Heat, Alcohol, Reinjury and Massage (for first 48-72 hours)
    • Most injuries allow weight bearing as tolerated (consider crutches)
    • Arrange followup for reassessment once the acute symptoms have subsided
  • Consider more significant injury if:
  • “pop” or “crack” – likely to be ligament rupture +/- avulsion
  • Avulsion injuries from foot bones, particularly from navicular, while they might appear small, may have significant long term consequences

 

 

Inferior Tibiofibular Joint

Injury

  • Can sublux anteriorly or posteriorly.
  • Anterior subluxations can be caused by an inversion injury of the ankle (or direct contact)
  • Posterior subluxation is often cumulative due to over-flattening of the foot (or direct contact)
  • Often injured in association with other ligaments

Management

  • If subluxed, may need to reduce
  • Usually managed with taping to minimise movement of joint (direction dependent on mechanism of injury)
  • If chronic subluxation / dislocation occurs, surgical reconstruction may be necessary
  • As usually occurs in conjunction with other injuries, these must also be managed.

 

 

Medial Collateral (Deltoid) Ligament

Injury

  • Not as commonly injured
  • Mechanism of injury is usually eversion or severe trauma in any direction
  • Deltoid ligament is very strong – chance of avulsion # or worse

Findings

  • On range of motion, usually painful into dorsiflexion and eversion.
  • Tenderness located over the medial ligament (!)

Grading

  • Graded I-III depending on severity and laxity (on talar tilt)
    • Grade I = pain with NO laxity
    • Grade II = MILD laxity
    • Grade III = SIGNIFICANT laxity
    • * Complete Rupture may mean no pain after initial injury = no nerve fibres to hurt!

Management

  • Grade I / II (ie pain with no or mild laxity)
    • Mx conservatively – possibly taping
  • Grade III (significant laxity +/- pain)
    • May be worth considering short period in backslab (or ankle brace) particularly if resting posture is plantarflexion / eversion to keep the ligaments in a shortened position
    • Even complete rupture should be initially managed conservatively.
    • Surgical reconstruction is used when conservative management has failed, with persistent instability despite rehabilitation

 

 

Lateral Collateral Ligament

Injury

  • Very common (much more common than MCL sprain)
  • Usually the result of an “inversion” injury as a result of change of direction, uneven surfaces or standing on someone’s foot
  • May also involve straining of the peroneal muscles (“everters” of the ankle) or avulsion of the 5th MT base where peroneus brevis attaches

Grading

  • Graded I-III depending on severity and laxity (on talar tilt)
    • Grade I = pain with NO laxity
    • Grade II = MILD laxity
    • Grade III = SIGNIFICANT laxity
      * Complete Rupture may mean no pain after initial injury = no nerve fibres to hurt!

Management

  • Grade I / II (ie pain with no or mild laxity)
    • Mx conservatively – possibly taping
  • Grade III (significant laxity +/- pain)
    • May be worth considering short period in backslab (or ankle brace) particularly if resting posture is plantarflexion / eversion to keep the ligaments in a shortened position
    • Even complete rupture should be initially managed conservatively.
    • Surgical reconstruction is used when conservative management has failed, with persistent instability despite rehabilitation
  • Taping
 

 

 

Peroneal Tendons

Peroneal Tendon Avulsion
Injury

  • Mechanism is usually an inversion injury
  • May be associated with a ‘pop’ or ‘crack’

Findings

  • Weakness +/- pain on resisted eversion
  • Localised tenderness over 5th MT base (peroneus brevis)

Management

  • Minor = as per severe ankle sprain – short period in backslab / ankle sprain
  • Significant = surgical intervention
  • If completely unable to evert the foot and there is NO local tenderness, consider common peroneal nerve palsy which is not uncommon in severe ankle sprains
  • Failed conservative Mx requires surgical intervention.

 

 

Tendinopathy

  • Tendinopathy involves a process of mucoid degeneration with neovessels (presence of neurovascular structures within the tendon) which is also known as “tendinosis” (tendon degeneration without inflammation).
  • Tendinopathy is usually the result of an inability to recover adequately from the load placed on the structure, which may be caused by or excessive activity (especially if a sudden increase in load) or biomechanical error such as:
    • Inappropriate footwear (poor shock attenuation)
    • Unforgiving running surfaces
    • Poor lower limb mechanics (eg increased force required to supinate the foot)
  • In the foot and ankle, the achilles tendon, peroneal tendons and supinators of the foot (tibialis posterior, flexor hallucis longus and flexor digitorum longus) are most commonly affected.

Grading

  • Tendinopathy is categorised into stages:
    • Stage 1 – Pain only after activity
    • Stage 2 – Mild symptoms until warmed up, then pain after activity
    • Stage 3 – Pain that doesn’t warm up; continually sore

Management

  • Correction of biomechanical irregularities
  • Eccentric exercise program
  • Relative rest
  • Recalcitrant cases may need additional Mx options – NO patches, sclerosing agents, autologous blood have allbeen used with additional effect; surgery is reserved for cases not responding to conservative Mx

Overuse Paediatric

Calcaneal Apophysitis / Sever’s “Disease”

  • The paediatric equivalent of achilles tendinopathy is overuse at the bony interface, which is called Sever’s “Disease” or calcaneal apophysitis.
  • Aside from the factors listed under tendinopathy, the child might have recently had a growth spurt and be particularly tight in the lower limb musculature, in particular the calves

Findings

  • Generally only mild (if any) swelling
  • Pain on loading the achilles tendon particularly when the ankle is dorsiflexed (such as in running or jumping)
  • Patient may have a palpable tender lump over the calcaneal tubercle
  • X-ray may show fragmentation of the calcaneal tubercle

 

 

Grading

  • Grading is as per tendinopathy:
    • Stage 1 – Pain only after activity
    • Stage 2 – Mild symptoms until warmed up, then     pain after activity
    • Stage 3 – Pain that doesn’t warm up – continually sore

Management

  • Correction of biomechanical irregularities
  • Eccentric exercise program
  • Relative rest and cautioning regarding potential for avulsion fracture if does not manage

Tendon and Muscle Injuries

Achilles Tendon Tear / Rupture

  • Failure can occur in the Achilles tendon, usually with 2-4 cm of the calcaneal attachment point, or the calf which is usually at the musculotendinous junction
  • The patient is usually in middle age
  • Typically, the patient moves to push off to run or jump and feels as though someone has either kicked or shot them in the back of the leg

Findings

  • As with muscle strains, pain will be on stretch (dorsiflexion) and contraction of the calf
  • There will be localised tenderness over the achilles tendon and in substantial tears, a palpable defect
  • If the patient cannot generate significant plantarflexion force and has a positive Thompson / Simmonds test (+/- palpable defect) then they have likely ruptured their Achilles tendon
  • Confirmation may be required on ultrasound if clinical examination is not conclusive

Management

  • Substantial tears or rupture require surgical repair for best outcome
  • Small tears may be managed conservatively in an equinas splint and as per muscle injury

Calf Tear / Rupture

Findings

  • Pain will be on stretch (dorsiflexion) and contraction of the calf
  • There will be localised tenderness over (usually) the musculotendinous junction of the calf (usually the medial portion)
  • It is unusual to do so, but it is possible to rupture the calf. If the patient cannot generate significant plantarflexion force and has a positive Thompson / Simmonds test (+/- palpable defect) then they have likely ruptured their calf. Unlike tendon however, muscle has a better capacity to heal and this does not change initial management.

Management

  • Equinus splint or heel wedges in shoe to shorten calf and prevent stretch (initially)
  • Progressive strengthening and stretching program

Sinus Tarsi Syndrome

  • The sinus tarsi is a space in the tarsal bones which has the interosseous talocalcaneal ligament at its floor.
  • This ligament is the most commonly ruptured ligament in an inversion injury (not the ATFL)
  • Persistent pain in this region is usually caused by damage of this ligament from an inversion injury (80%), or pressure on this region from excessive pronation (20%)

Findings

  • Tenderness over the sinus tarsi
  • May have lateral ligament laxity
  • Pain with inversion
  • Local anaesthetic injection often used to diagnose

Management

  • Correction of biomechanical irregularities
  • Relative rest
  • Recalcitrant cases may need additional Mx options – corticosteroid injection or potentially even surgery

 

 

Tarsal Tunnel Syndrome

  • Tarsal tunnel syndrome, also known as posterior tibial neuralgia, is a painful foot condition in which the tibial nerve is impinged and compressed as it travels through the tarsal tunnel.
  • This tunnel is formed inferior to the medial malleolus by the flexor retinaculum and the adjacent tarsal bones
  • The posterior tibial artery, tibial nerve, and tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus travel in a bundle along this pathway. In the tunnel, the nerve splits into three different paths. The calcaneal nerve continues to the heel, while the medial and lateral plantar nervescontinue on to the bottom of the foot.

Cause

  • Inflammation or swelling can occur within this tunnel for a number of reasons.
    • The flexor retinaculum is largely inflexible so any pathology which takes up space will cause compression on the nerve (or vessels) within the tunnel
    • This could include benign tumors or cysts, bone spurs, inflammation of the tendon sheath (eg from overuse), ganglions, or swelling from a broken or sprained ankle.
    • Varicose veins (that may or may not be visible) can also cause compression of the nerve

Symptoms

  • Patients complain typically of numbness in the foot, radiating to the big toe and the first 3 toes, pain, burning, cramping or electrical sensations, and tingling over the base of the foot and the heel.
  • Symptoms will vary depending on the level of entrapment.
  • If the entrapment is high, the entire foot can be affected as varying branches of the tibial nerve can become involved.
  • Ankle pain is also present in patients who have high level entrapments.

Findings

  • Tinel’s sign positive (tapping on the tibial nerve reproduces patient’s symptoms)
  • May be some tenderness over the tendons in this region (tenosynovitis may be a cause of tarsal tunnel syndrome).
  • May also have altered sensation over the foot and potentially even intrinsic motor loss / wasting as in carpal tunnel (depending on which nerve is affected and the severity).

Management

  • Avoidance of aggravating activities
  • Correction of biomechanical errors
  • NSAIDs
  • Corticosteroid injection
  • Recalcitrant cases may require surgery

Morton’s Neuroma

  • Morton’s neuroma is a benign neuroma of an intermetatarsal plantar nerve, most commonly of the third and fourth intermetatarsal spaces but can be of adjacent nerves as well.
  • This problem is characterised by numbness and pain between the toes, which is exacerbated by tight shoes and relieved by removing footwear.

Cause

  • The pain is caused by pressure on the enlarged section of nerve where it passes between the metatarsal heads, and is squeezed between them

Symptoms

  • Pain on weight bearing between the affected toes, frequently after only a short time
  • Burning, numbness and paresthesia  may also be experienced.

Findings

  • Direct pressure between the metatarsal heads will replicate the symptoms, as will compression of the forefoot between the finger and thumb so as to compress the transverse arch of the foot (Mulder’s Sign)
  • Often there is a palpable lump, however this may not always be obvious
  • Imaging may be required if it will change management

Management

  • Donut padding to prevent contact of the neuroma on the shoe can be quite effective
  • Surgery may be required

 

 

Stress Fractures

  • Just as soft tissues begin to fail with repeated overload, bones can also fail to cope with stress
  • A “Stress Reaction” is where the bony is not recovering adequately, but there is no actual fracture
  • A “Stress Fracture” implies that the damage has been extensive enough to permit the bone to actually break (whether this is seen on plain x-ray or not; bone scan / CT or MRI may be required to show this)
  • In the foot, stress fractures are common. In particular, the calcaneus, navicular and the metatarsals are the most commonly affected. Stress fractures of the metatarsal heads are known as “March” fractures as they are common in newly recruited soldiers who begin their training (sudden increase in load).

Cause

  • Biomechanical errors (eg increased resistance required to actively supinate to foot)
  • Overweight
  • Overtraining (or relative overtraining), especially if there is a sudden change in activity or mechanics
  • Inappropriate footwear
  • Metabolic disorders

Symptoms

  • Patients complain typically of pain in the region of interest which is worse with prolonged weightbearing, walking, running or jumping.

Findings

  • Local tenderness over the involved structures
  • Swelling is not always present
  • Plain x-ray may not show stress fractures and further imaging (bone scan, CT, MRI) may be required if this will potentially change management (or to confirm diagnosis)

Management

  • Avoidance of aggravating activities
  • Correction of biomechanical errors including orthotic therapy or taping
  • Appropriate footwear
  • REST!! This may include a period of non-weightbearing until symptoms improve and a gradual return to activity once this is possible.

 

 

Plantar Foot Pain

  • There are many structures on the plantar aspect of the foot which can be injured and responsible for pain and dysfunction
  • Generally, most of these structures have at least some role in active supination of the foot, maintenance of the normal arches or preventing excessive pronation
  • Overload of these structures can lead to pain both acutely and on a chronic basis

Cause

  • Biomechanical errors (eg increased resistance required to actively supinate to foot)
  • Overweight
  • Overtraining (or relative overtraining)
  • Inappropriate footwear
  • Excessive overload of the tissue leads to micro and potentially macro damage.
  • Commonly involved structures include the plantar fascia, flexor digitorum brevis, spring ligament and the tendons of flexor hallucis longis and tibialis posterior.

Symptoms

  • Patients complain typically of a sharp pain in the sole of the foot that is more marked on the first few steps in the morning, or if they have been sitting for a length of time.
  • Pain is often related to prolonged weightbearing, particularly on unforgiving surfaces

Findings

  • Local tenderness over the involved structures, which more typically would involve the flexor digitorum brevis and plantar fascia.
  • The presence of a “heel spur” on x-ray is not necessarily evidence of pathology as many people (as we age) have these in the absence of symptoms.
  • Initially this was thought to evolve from continual traction on the medial calcaneal tubercle by the plantar fascia, however more recent work suggests that the calcification is actually within the tendon of the flexor digitorum brevis and may not even contact the calcaneus.
  • Current theory is of a tendinopathic type pathology of the FDB, with mucoid degeneration visible on ultrasound  or MRI

Management

  • Avoidance of aggravating activities
  • Correction of biomechanical errors including orthotic therapy or taping
  • Appropriate footwear
  • NSAIDs
  • Corticosteroid injection (although, as with other tendinopathy, at biopsy there are no / few inflammatory cells present – the process is thought to be degenerative, so this is being challenged)
  • Recalcitrant cases may require surgery to excise the diseased tissue (not to remove the “spur”)
  • Low dye taping