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Hindfoot and ankle problems

 

Jump to plantar fasciitis / achilles tendonitis / anterior ankle impingement / ankle arthritis / ankle sprains and instability /

Plantar fasciitis

 

The plantar fascia runs from the medial calcaneal tubercle to the metatarsals and acts to maintain the arch of the foot and absorb shock. Plantar fasciitis results from inflammation and microtears of the insertion of the fascia into the calcaneum. It is a common problem, particularly in the presence of obesity, cavus foot, achilles contracture and repetitive loading. It is normally self-limiting but may take up to two years to resolve. 

Symptoms

  • Pain on plantar-medial aspect of heel.
  • Worse after rest, classically for the first few steps in the morning.

Signs

  • Focal tenderness on plantar medial aspect of heel.
  • Assess for high arch (cavus).
  • Check for tight achilles or gastrocnemius contracture.
  • Check sensation in the sole of the foot (tarsal tunnel syndrome or entrapment of branches of the tibial nerve, may mimic plantar fasciitis).
  • Diffuse heel tenderness may indicate calcaneal stress fracture.

Treatment

  • Stretching of plantar fascia and tight calf muscles is key treatment. Eccentric stretches are best, achieved by doing heel dips on a step. Exercises must be done for 20 minutes, twice a day.
  • Rolling the foot over a frozen plastic water bottle may offer pain relief.
  • Silicone heel cups and well padded shoes.
  • Avoid running or repetitive impact.
  • Steroid injection may be helpful:
  • To inject in clinic use a green needle, 40mg kenalog in 2ml marcaine. Insert the needle at 45˚ to skin at point of maximum tenderness and advance to bone. Withdraw 1mm, aspirate and inject slowly. More than three injections in 12 months risks plantar fascia rupture and heel fat pad atrophy. If one injection has failed, refer for injection under GA.

Investigations

  • Normally, diagnosis is clinical and no imaging is needed.
  • There is often confusion regarding heel spurs seen on x-ray.
  • Heel spurring is a sign of plantar fasciitis, not a cause.

Referral?

  • Most cases are successfully treated with physiotherapy although may take months or years to resolve. The majority of resistant cases are due to lack of compliance with physiotherapy. 
  • The patient must have seen a physiotherapist, do their exercises regularly, be wearing heel cups and be of healthy weight before referral.
  • Steroid injection is best performed under GA as the periosteum can be injected – if one injection in clinic has failed, refer for further GA injection.
  • Plantar fascia release or calf muscle lengthening may be performed in resistant cases, but 40% will not benefit from surgery.

 

 

 

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Achilles tendonitis

A common problem in middle-age. Described as insertional or non-insertional depending on the site of tenderness. Microtears result in areas of painful scar tissue within or around the achilles tendon.

Symptoms

  • Pain and swelling in the achilles tendon.
  • Worse first thing in the morning or after a period of rest.

Signs

  • Tenderness and swelling;
  • Bony lump at the back of the heel, called a Haglund deformity.
  • It is vital to exclude rupture of the achilles.
  • Perform Simmond’s test – kneel the patient on a chair and squeeze the calf. Normally the foot should plantarflex. Absence of movement may indicate rupture – refer the patient to A&E for plaster cast and urgent fracture clinic appointment.

Investigations

  • Ultrasound is more sensitive, specific and cheaper than MRI.
  • Weightbearing lateral ankle x-ray will demonstrate intratendinous calcification or Haglund deformity.

Treatment 

  • Physiotherapy is key, especially eccentric stretches by doing heel-dips on a step.
  • A heel-raise wedge may take tension off the tendon and reduce pain.
  • Steroid injection is contraindicated as it may precipitate tendon rupture.

Referral?

  • Cases resistant to physiotherapy should be referred for consideration of tendon debridement.
  • This usually requires 2-6 weeks in cast.
  • Extensive debridement may require tendon transfer to reconstruct the achilles.

 

 

 

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Anterior ankle impingement

A common problem known as ‘footballer’s ankle’. Repetitive extreme plantar flexion results in traction spurs forming at the front of the ankle. Often seen in men in their forties who were keen footballers in their youth.

Symptoms

  • Pain at the front of the ankle, particularly on dorsiflexion or walking up stairs.

Signs

  • Tenderness along the anterior joint line of the ankle.
  • Range of movement may be restricted.
  • Bone spurs may be palpable.
  • Positive impingement sign:
  • Impingement test: pain when the ankle is brought into dorsiflexion with the examiner’s thumb on the joint line.

Investigations

  • Weightbearing AP and lateral ankle X-ray will demonstrate osteophytes on the anterior tibia and often also on the talar neck.
  • MRI is helpful to exclude a talar osteochondral defect or generalised osteoarthritis.

Treatment

  • Activity modification.
  • Analgesia.
  • Consider steroid injection into the ankle.

Referral?

  • Most cases respond well to arthroscopic debridement in which the bone spurs are removed from the front of the ankle joint.
  • Arthroscopy also allows evaluation of the rest of the joint, including the presence of talar osteochondral defects.
  • Patients are usually treated as a day case under GA, are fully weightbearing afterwards and require 2-4 weeks off work.

 

 

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Ankle arthritis

Arthritis of the ankle may be due to inflammatory arthropathy, primary osteoarthritis or as a result of previous injury.

Symptoms

  • Pain, swelling and reduced range of movement.
  • In severe cases the ankle may drift into varus or valgus.

Signs

  • Tenderness around the ankle joint.
  • Reduced range of movement.
  • Inspect the hindfoot from behind to assess varus/valgus malalignment.

Investigations

  • Weightbearing AP and lateral ankle x-rays.

Treatment

  • Analgesia.
  • Glucosamine (1500mg od) has been proven to help in OA of the knee, so may be helpful in ankle OA, although there is no evidence for this.
  • Weight loss.
  • Physiotherapy to improve and maintain range of movement.
  • Walking boot or ankle brace.
  • Steroid injection:
  • Palpate the ‘soft-spot’ along the anterior joint line, medial to the tibialis anterior tendon, approximately 1cm proximal and lateral to the tip of the medial malleolus; using a blue needle angled 20˚ towards midline and proximal, inject 40mg kenalog in 10ml marcaine. 

Referral?

  • When conservative Treatment has failed, the two surgical options are ankle fusion or total ankle replacement.
  • The former can usually be performed arthroscopically and eliminates all movement at the ankle. This reduces stride length and patients will be unable to run, but is very effective at alleviating pain. There is some concern about subsequent development of midfoot arthritis after an ankle fusion.
  • Ankle replacement has a higher complication rate but is a good option in low-demand, older patients without significant deformity.

 

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Ankle sprains and instability

The lateral ligaments (principally the ATFL – anterior talofibular ligament) may be torn following inversion of the ankle. Although painful for up to three months, 95% will make a full recovery. A few patients will experience ongoing problems due to pain or instability.

Symptoms

Acutely: pain, swelling and bruising over anterior border of distal fibula.

Chronically: pain or instability. 

Signs

Acutely: 

  • Reduced range of movement, tenderness and swelling.

Chronically:

  • Tenderness over anterior joint line suggests osteochondral defect.
  • Pain behind fibula or weakness of eversion suggests peroneal tendon tear.
  • Instability, demonstrated by anterior drawer test:
    • Hold tibia firmly around anterior ankle, grasp heel and pull forwards. Excessive anterior translation compared to the uninjured side indicates ligament tear.

Investigations

  • Weightbearing AP and lateral ankle x-ray will demonstrate avulsion fractures or large osteochondral defects of the talus.
  • MRI will demonstrate ATFL tears and tendon pathology, but if performed within three months of injury has a high false-positive rate.

Treatment

  • Acute – rest, ice and elevation.
  • Chronic – physiotherapy to restore range of movement and improve proprioception.
  • Ankle braces and elasticated bandages may improve confidence and proprioception.

Referral?

  • Failure to recover after three months should prompt referral.
  • Ligaments can be reconstructed with a Brostrom procedure, which requires six weeks in plaster.

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