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Instructional Course Lecture 303

Instructional Course Lecture 303. Diagnoses and Treatment of Chronic Ankle Pain AAOS Annual Meeting 2012 San Francisco, California. David W. Boone, MD Raleigh Orthopaedic Clinic Raleigh, NC. My disclosure is in the Final Program Book and in the AAOS database.

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Instructional Course Lecture 303

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  1. Instructional Course Lecture 303 Diagnoses and Treatment of Chronic Ankle Pain AAOS Annual Meeting 2012 San Francisco, California David W. Boone, MD Raleigh Orthopaedic Clinic Raleigh, NC

  2. My disclosure is in the Final Program Book and in the AAOS database. I have no potential conflicts with this presentation. Diagnoses and Treatment of Chronic Ankle PainDavid W. Boone, Md

  3. Diagnoses and Treatment of Chronic Ankle Pain • Posterior Ankle Impingement • Flexor Hallucis Longus Tendonitis • Posterior Tibial Tendon Dysfunction • Achilles Tendinopathy and Retrocalcaneal Bursitis • Osteochondral Lesions of the Talar Dome

  4. Posterior Ankle ImpingementWhat is this? • Definition: posterior ankle pain due to plantar flexion of the foot • Differential Diagnosis: • bone related causes • os trigonum syndrome • soft tissue related causes • FHL pathology

  5. Posterior Ankle Impingement:Os Trigonum Syndrome • Anatomy • posterior process of talus • posteromedial process(tubercle) • posterolateral process(tubercle) Maquirriain J. J Am Acad Ortho Surg 2005;13(6):page 366.

  6. Posterior Ankle Impingement:Os Trigonum Syndrome • Anatomy • os trigonum • separate ossification center • incidence of 3-14% in adults; often bilateral • Stieda process formed when os trigonum fuses to talus Maquirriain J. J Am Acad Ortho Surg 2005;13(6):page 366.

  7. Posterior Ankle Impingement:Os Trigonum Syndrome • Etiology • acute trauma • Shepherd’s fracture • synchondrosis injury • overuse injury • repetitive plantar flexion activities Source: medscape.com

  8. OsTrigonum Syndrome:History and Clinical Presentation • pain with forced plantar flexion • most common in activities such as ballet, soccer, downhill running • consider in setting of frequent sprains • differentiate between posterolateral vs posteromedial pain • diagnosis can be difficult

  9. OsTrigonum Syndrome:Diagnosis • careful ankle palpation • forced plantar flexion test • dorsiflex ankle with hallux motion and palpate posteromedial for FHL involvement Hamilton WG. Surgical Correction of Posterior Ankle Pain in Athletes and Dancers. Advanced Reconstruction Foot and Ankle. Figure 2, Page 290.

  10. OsTrigonum Syndrome:Diagnostic Studies • plain radiographs • consider plantar flexed view • bone scan • CT scan • MRI Source: mskcases.com

  11. OsTrigonum Syndrome:Nonoperative Treatment • rest • avoid plantar flexion • ice • NSAIDs • diagnostic injection Source: buzzillions.com

  12. OsTrigonum Syndrome:Surgical Treatment • posterolateral approach • beware of sural nerve! • posteromedial approach • use with combined FHL tenosynovitis Hoppenfeld S. and deBoer P. Surgical Approaches in Orthopaedics. Third Edition. p. 628. Figure 12-25.

  13. OsTrigonum Syndrome:Postoperative Management • splint for 2 weeks with nonweightbearing • physical therapy at 2 weeks postop with weightbearing to tolerance • recovery can be prolonged and take up to 3-5 months

  14. OsTrigonum Syndrome:Minimally Invasive Surgical Options • subtalar arthroscopy • posterior ankle arthroscopy van Dijk CN, deLeeuw PAJ, Scholten PE. Hindfoot Endoscopy for Posterior Ankle Impingement. Surgical Technique. J Bone Joint Surg Am. 2009;91 Suppl 2(Part 2), p 288.

  15. OsTrigonum Syndrome:Minimally Invasive Surgery • Advantages • quicker recovery, less morbidity • Disadvantages • learning curve, special equipment needed

  16. Flexor Hallucis Longus Tendonitis • most commonly seen in ballet dancers(dancer’s tendonitis) • may be associated with painful os trigonum • differential diagnosis • posterior tibial tendonitis • tarsal tunnel syndrome • posterior deltoid sprain • osteochondral lesion posterior talus

  17. Flexor Hallucis Longus Tendonitis:Anatomy • originates from inf 2/3 of fibula • passes between tubercles of talus • goes inferior to sustentaculum tali • crosses superior to FDL(knot of Henry) • inserts into distal phalanx of hallux Sarrafian SK. Anatomy of the Foot and Ankle. Second Ed. p. 174, Figure 4-21.

  18. Flexor Hallucis Tendonitis:Anatomy • two synovial sheaths • proximal • distal • fibro-osseous tunnel • starts at level of talus • continues inferior to sustentaculum tali Sarrafian SK. Anatomy of the Foot and Ankle, Second Edition. p. 129, Figure 3-23.

  19. Flexor Hallucis Tendonitis:Tendon Function • major plantar flexor of hallux • allows controlled toe raise and descending downward • aids in stabilization of first mtp, midfoot, subtalar jts • plantar flexor and inverter of foot

  20. Flexor Hallucis Longus Tendonitis: • stenosis seen at three sites: • on entry to fibro-osseous tunnel • at knot of Henry • between sesamoids • tendon pathology: • hypertrophy/nodularity • mucoid degeneration • longitudinal tears • distal muscle entrapment

  21. Flexor Hallucis Longus Tendonitis:Clinical Presentation • posteromedial ankle pain • complaints of weakness on push off; en pointe position not possible • swelling • may report tearing sensation along medial ankle/arch

  22. Flexor Hallucis Longus Tendonitis:Physical Exam • careful posteromedial ankle palpation • look for tendon thickening, swelling • crepitus on hallux range of motion • pain on resisted hallux IP plantar flexion • passive hallux motion may be painless

  23. Flexor Hallucis Longus Tendonitis:Physical Exam • Tomassen’s sign: first mtp dorsiflexion lost with ankle dorsiflexion • hallux may plantar flex with ankle dorsiflexion due to scarring after trauma(i.e. pilon, calcaneal fx) • inability to actively plantar flex hallux with first mtp jt stabilized

  24. Flexor Hallucis Longus Tendonitis:Diagnostic Work Up • plain radiographs • MRI best to visualize FHL tendon • history and clinical exam most important diagnostic tools • other studies(bone scan, CT) to look for other causes of posterior ankle pain

  25. Flexor Hallucis Longus Tendonitis:Nonoperative Treatment • rest • activity modification • immobilization • change training technique • ice • nsaids • physical therapy • steroid injection not recommended

  26. Flexor Hallucis Longus Tendonitis:Surgical Treatment • posteromedial approach • debride/repair partial tears • release fibro-osseous sheath • release knot of Henry if pathology extends to that level Hoppenfeld S and deBoer P. Surgical Approaches in Orthopaedics. The Anatomic Approach. Third Edition. p. 626, Fig 12-22.

  27. Flexor Hallucis Longus Tendonitis:Postoperative Care • splint 7-14 days with nonweightbearing • start PT, weightbearing to tolerance • gradual return to activities • full return to activity could take 3-6 months

  28. Posterior Tibial Tendon Dysfunction(PTTD) • Anatomy • origin from posterior tibia, fibula, interosseous membrane • insertion consists of multiple bands • anterior insertion is to navicular tuberosity, inferior naviculocuneiform jt, inferior medial cuneiform • middle insertion is to 2nd and 3rd cuneiforms, cuboid, mets 2-4 • posterior insertion helps form acetab pedis

  29. Source: trifuel.com Source: anatomyfacts.com

  30. PTTD • Anatomy • Spring Ligament • Talonavicular Joint Capsule • Deltoid Ligament Sarrafian SK. Anatomy of the Foot and Ankle. Second Edition. p. 193. Figure 4-41.

  31. PTTDNormal Tendon Function • active during stance phase • limits heel eversion at heel strike • inverts heel and adducts forefoot to oppose peroneus brevis at toe off • inverted subtalar joint locks transverse tarsal joint

  32. PTTDAbnormal Tendon Function • peroneus brevis overpulls • hindfoot increasingly everts • forefoot abducts • gastrocsoleus muscle acts through midfoot • increasing stress applied to medial structures

  33. PTTDEtiology • degenerative rupture • obese, middle aged female • acute injury • inflammatory synovitis • rheumatoid arthritis, seronegativespondyloarthopathies Source: footankleinstitute.com

  34. PTTDClinical Presentation • History • medial ankle/foot pain • complain of collapsed arch • usually of insidious onset • feeling of fatigue with prolonged standing/walking • lateral impingement pain may develop late

  35. PTTDClinical Presentation • Physical Exam • flattened arch • pain along post tib tendon • check single limb heel rise • look for “too many toes” sign • check strength of post tib tendon • look for fixed vs flexible deformity • examine for equinus contracture

  36. PTTDDiagnostic Studies • Standing xrays • three views of foot with AP/mortise of ankle • Ultrasound • MRI

  37. PTTDStaging • Stage I: pain, swelling, no deformity • Stage II: flexible flat foot • Stage III: rigid flat foot • Stage IV: flat foot with ankle valgus

  38. PTTDNonoperative Treatment • rest • NSAIDs • phys therapy • bracing Source: podiatrytoday.com Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II Posterior Tibial Tendon Dysfunction Treated by a Structured Nonoperative Management Protocol: An Orthosis and Exercise Program. Foot Ankle Int. 2006;27(1):p. 3, Fig 1.

  39. PTTDSurgical Treatment • Stage I • tenosynovectomy • consider medial calcaneal osteotomy(mco) with increase in hindfoot valgus • immobilize 3-6 wks post-op

  40. PTTD: Surgical Treatment • Stage II • FDL transfer to midfoot • calcaneal osteotomy • medial displacement calc osteotomy(mco) • lateral column lengthening(lcl) • heel cord lengthening • forefoot osteotomy(Cotton osteotomy)/medial column fusion • arthroereisis

  41. PTTD: Surgical Treatment • Stage IIA-1: neutral forefoot • FDL trans, MCO • Stage IIA-2: persistent forefoot varus • add Cotton osteotomy(medial cuneiform plantar flexion osteotomy) • Stage IIB: forefoot abduction • add lcl to correct forefoot abduction • Stage IIC: unstable medial column contriubutes to fixed forefoot varus • consider medial column fusion

  42. PTTDSurgical Treatment for Stage IICotton Procedure Johnson JE. Plantarflexion Opening Wedge Cuneiform-1 Osteotomy for Correction of Fixed Forefoot Varus. Techniques in Foot and Ankle Surgery. 2004;3(1):p.5,6. Figs 4, 7.

  43. PTTDSurgical Treatment • Stage II postop care • 6 wksnonweightbearing with FDL transfer/mco • 8 wksnwb with lcl • 8-10 wksnwb with midfoot arthrodesis

  44. PTTDStage II Surgical Treatment

  45. PTTDSurgical Treatment • Stage II • arthroereisis • best used as adjunctive procedure in selected cases • significant incidence of need for removal due to pain Source: feetdoc.com Source: podiatrytoday.com

  46. PTTDSurgical Treatment • Stage III • triple arthrodesis • calcaneocuboid lengthening arthrodesis for forefoot abduction • may have to lengthen peroneal tendons

  47. PTTDSurgical Treatment • Stage IV • IV-A: treat as for stage II and add deltoid ligament reconstruction • IV-B: pantalar fusion, tibiotalocalcaneal fusion, triple arthrodesis with total ankle replacement are options Source: emedicine.medscape.com

  48. Achilles Tendinopathy and Retrocalcaneal Bursitis • Noninsertional Achilles Tendinopathy • Insertional Achilles Tendinopathy • Haglund’s deformity • retrocalcaneal bursitis • insertional Achilles tendon pain

  49. Achilles Tendinopathy and Retrocalcaneal Bursitis • Anatomy • arises from gastrocnemius and soleus • tendon fibers rotate 90 degrees as they approach calcaneus • tendon lacks true synovial sheath but is surrounded by a paratenon • retrocalcaneal bursa lies between tendon and posterior superior tuberosity of calcaneus

  50. Source: cits.tuftsmania.com

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