Foot and Ankle Flashcards
1
Q
Foot and Ankle Primary Care
Diagnosis, Treatment, and When to Refer
Inside Each Foot There Are
- 26 _____
- 33 _____
- 19 _____
- 10 ____ 107 ________
A
- 26 bones
- 33 joints
- 19 muscles
- 10 tendons 107 ligaments
2
Q
Foot Anatomy
A
3
Q
Nail Anatomy
A
4
Q
Diagnostic Tests for Foot, Ankle, Nail Abnormalities
(4)
A
Periodic Acid-Schiff (PAS) Reaction
Gomori Methenamine Silver (GMS) Stain
Fontana Masson Stain
PCR Assay (Molecular Genetic Testing)
5
Q
Periodic Acid-Schiff (PAS) Reaction
Best for (1)
Most often does as (1)
- How does this test work?
- Reacts with most but not all (2)
- Sensitivity?
A
Best for superficial skin/nail infections, which do not disclose abundant acute inflammation
Routine Exam
- Chemical reaction, whereby carbohydrates are oxidized to form aldehydes → Aldehydes react with Schiff reagent to produce a magenta color
- Reacts with most fungi and yeast, shows excellent fungal morphology
- High sensitivity (few false negatives), but rarely organism specific
6
Q
Gomori Methenamine Silver (GMS) Stain
Better for (1)
(1) Sensitivity when done with (1)
- How does it work?
- Stains most but not all (2)
- Sensitivity vs. morphology?
A
Better for Fungal Infections found in association with abscesses, better visualization of fungal infections in the deep tissues
High Sensitivity when done with PAS (but not organism specific)
- Stains carbohydrates (sugars), tissue is pre-treated with chromic acid, then silver is applied
- Stains most but not all fungi and yeast, may excel at staining degenerated organisms
- Offers high sensitivity, but poor morphology (target acquires a “dirty” granular appearance”
7
Q
Fontana Masson Stain
Best used for (1)
Adds what to sensitivity?
- Highlights _____ pigment in fungal organisms
- Large quantities of melanin pigment favors dematiaceous ____ (pigmented saprophytic mold)
- Deciphers _____ pigment from other pigments (hemosiderin)
A
Validates the presence of an underlying melanocytic process, e.g. benign matrical melanotic macule, nevus, or melanoma
Adds specificity (identifies dematiaceous fungi) and screens for pigmented lesions within nail matrix
- Highlights melanin pigment in fungal organisms
- Large quantities of melanin pigment favors dematiaceous fungi (pigmented saprophytic mold)
- Deciphers melanin pigment from other pigments (hemosiderin)
8
Q
PCR Assay (Molecular Genetic Testing)
What does this test do?
Sensitivity?
- If detected, g____ specific for the pathogens genus +/- species are sought
- Offers 2-3 day turn-around-time, rather than 28 days via c_____
- As a clinical lab test (such as bloodwork), molecular genetic studies are often paid for in-full by insurers
- Organism identification may be necessary for preauthorization of new topical nail antifungal products (indicated against Trichophyton Spp only)
- Augments the superior sensitivity of PAS/GMS, by providing high ______ (______ identification) for tar_____ patient therapy
A
Detects the genetic material of the pathologic fungi (dermatophytes, saprophytes, and/or yeasts)
Compared to culture, offers 25% higher sensitivity than culture overall, and twice its sensitivity when detecting dermatophytes
- If detected, genes specific for the pathogens genus +/- species are sought
- Offers 2-3 day turn-around-time, rather than 28 days via culture
- As a clinical lab test (such as bloodwork), molecular genetic studies are often paid for in-full by insurers
- Organism identification may be necessary for preauthorization of new topical nail antifungal products (indicated against Trichophyton Spp only)
- Augments the superior sensitivity of PAS/GMS, by providing high specificity (organism identification) for targeted patient therapy
9
Q
What condition is shown in this picture?
A
Onychomycosis
Onychomycosis is a fungal infection of the toenails or fingernails that may involve any component of the nail unit, including the matrix, bed, or plate. Onychomycosis can cause pain, discomfort, and disfigurement and may produce serious physical and occupational limitations, as well as reducing quality of life
10
Q
Mimics of Onychomycosis
What condition is shown in these pictures?
A
11
Q
Mimics of Onychomycosis
What condition does this picture show?
Symptoms
- p____ under nail
- l_____ nail
Cause
- pressure or imp____ to toenail
- bl_____ under nail causes discoloration
Intervention
- Acute dec______ if severe pain
- Leave it _____
A
Subungual Hematoma
Symptoms
- pain under nail
- loose nail
Cause
- pressure or impact to toenail
- bleeding under nail causes discoloration
Intervention
- Acute decompression if severe pain
- Leave it alone
12
Q
Antifungal Medications
A
13
Q
Warts
What type of Warts are shown in these pictures?
A
Verruca Plantaris (left pic)
Verruca Plantaris (Mosaic) (right pic)
14
Q
H&E Verruca
A
15
Q
Treatment for Warts
Topicals/Orals
- S____ Acid
- Candida injections
- Can____
- Ret_____ Creams
- 5-__
- Bleo_____ injections
- I______therapy
- Cim_____
A
- Salicylic Acid
- Candida injections
- Canthrone
- Retinoid Creams
- 5-FU
- Bleomycin injections
- Immunotherapy
- Cimetidine
16
Q
Treatment for Warts
Surgery/Modalities
- C____therapy
- Pulse D___ La___
- C____tage + Hyfercation
A
- Cryotherapy
- Pulse Dye Laser
- Curettage + Hyfercation
17
Q
Mimics of Verucca
What condition is shown in this picture?
Treatment
- De_______ (frequent)
- (1) with padding or orthoses
A
Intractable Plantar Keratosis (IPK)
Treatment
- Debridement (frequent)
- Offloading with padding or orthoses
IPK is caused by a “dropped metatarsal,” which happens when the metatarsal head drops to a lower level than the surrounding metatarsals and protrudes from the bottom of the foot. This results in more pressure being applied in this area and causes a thick callus to form.
18
Q
Inflammation of the fingers or toes in one or more of the three nail folds. Acute form is caused by polymicrobial infections after the protective nail barrier has been breached
A
Paronychia
19
Q
Paronychia Treatment
Acute
- __ ABX
- _______ ABX
- Home S____
- Surgical De_______
Chronic
- Phenol/Al____ Chemical Matrix______
- Sur___ Matrix_____
A
Acute
- PO ABX
- Topical ABX
- Home Soaks
- Surgical Decompression
Chronic
- Phenol/Alcohol Chemical Matrixectomy
- Surgical Matrixectomy
20
Q
Is an inflammation of the sesamoid bones in the ball of the foot and the tendons they are embedded in. It’s usually caused by overuse, especially by dancers, runners and athletes who frequently bear weight on the balls of their feet. It’s treated with rest and anti-inflammatory medication
Is a condition in which the ball of your foot becomes painful and inflamed. You might develop it if you participate in activities that involve running and jumping. There are other causes as well, including foot deformities and shoes that are too tight or too loose
A
Sesamoiditis
Metatarsalgia
21
Q
Sesamoiditis or Metatarsalgia
-
Symptoms
- P____
- Sw_____ at ball of foot
-
Causes
- Imp____ → Inf____
- Fr______ sesamoid
-
Intervention
- Rest or Off_____
- I__
- C_______
- E_____
- P____ control
A
-
Symptoms
- Pain
- Swelling at ball of foot
-
Causes
- Impact → Inflammation
- Fractured sesamoid
-
Intervention
- Rest or Offloading
- Ice
- Compression
- Elevation
- Pain control
22
Q
Puncture wound/Foreign Body
Foreign body may either still be present or just puncture wound
Intervention (1)
A
Call someone who has experience as situation may complicated
23
Q
Athletes foot, fungal skin infection
White, scaling plaques in a moccasin distribution
A
Tinea Pedis
24
Q
Tinea Pedis Treatment
- (1) for 2-4 weeks
- Add topical (1) if very itchy or pustular
A
- Topical antifungal cream, lotion or foam for 2-4 weeks
- Add topical steroid if very itchy or pustular
25
What condition is shown in these photos?
Treatment
* **Topical antifungal (1)\*** for 2-4 weeks
* Consider adding topical **(1)**for bacterial infection (**Rx (2)** 1% pledgets)
* **Topical antifungal _GEL_** for 2-4 weeks
* Consider adding **topical ABX** for bacterial infection (**Erythromycin or Clindamycin 1%** pledgets)
26
**A superficial infection of the skin caused by Corynebacterium minutissimum, a gram-positive, non-spore-forming bacillus.** The disorder typically presents as macerated, scaly plaques between the toes or erythematous to brown patches or thin plaques in intertriginous areas
Erythrasma/Corynebacteria
27
A **bony bump that forms on the MTPJ (metatarsophalangeal) joint at the base of the big toe**, caused by tight shoes, foot stress, arthritis
Hallux Valgus
28
Hallux Valgus Treatment
Conservative
* W\_\_\_\_ shoes
* P\_\_dings
* St\_\_\_ping
Surgical
* B\_\_\_\_\_ectomy
* O\_\_\_ctomy
* O\_\_\_\_tomy
* Fus\_\_\_
Conservative
* Wider shoes
* Paddings
* Strapping
Surgical
* Bunionectomy
* Ostectomy
* Osteotomy
* Fusion
29
Common type of arthritis that causes a “stiff big toe”
**Hallux Rigidus/Limitus ROM**
30
Hallux Rigidus/Limitus ROM Treatment
Conservative
* \_\_\_\_\_-bottom shoes
* Injections
* Orth\_\_\_\_\_
Surgical
* Ch\_\_\_\_ectomy
* Impl\_\_\_\_\_
* F\_\_\_\_\_\_
Conservative
* Rocker-bottom shoes
* Injections
* Orthotics
Surgical
* Cheilectomy
* Implants
* Fusion
31
Blisters
Symptoms
* P\_\_\_\_
Causes
* Fr\_\_\_\_\_
* Improper \_\_\_\_
Intervention
* a) leave \_\_\_\_\_
* b) clean it, ___ it, cover it
Symptoms
* Pain
Causes
* Friction
* Improper shoes
Intervention
* a) leave alone
* b) clean it, pop it, cover it
32
Foot Trauma
**5th metatarsal fracture (shaft or avulsion)**
**(2)**
* Symptomatic treatment (\_\_\_\_\_ bearing vs. ___ Weight Bearing)
* ____ walker or post-op shoe
**Jones Fracture**
**Stress Fractures**
* Symptomatic treatment (Weight bearing vs. Non Weight Bearing)
* Cam walker or post-op shoe
33
Jones Fracture
=
* Delayed or non-union significant complication
* Treat in c\_\_\_, (1) bearing 6 weeks
* O\_\_\_\_ for athlete or healthy active patient
**Fracture at Base of 5th metatarsal**
* Delayed or non-union significant complication
* Treat in cast, non-weight bearing 6 weeks
* ORIF for athlete or healthy active patient
34
Stress Fractures
* Rate of microfracture _____ rate of repair
* M\_\_\_\_\_\_\_\_, calcaneus, tibia, fibula
* Often not _____ on initial films (delayed approximately 2 weeks), positive bone scan
* Generally _____ tender on exam
* Rule out pathologic process
* Usually 2° sudden increase in activity
* Treatment (2)
35
Peroneal Tendon Injuries
## Footnote
**Tendon t\_\_\_**
**Tendon\_\_\_\_\_**
**Sub\_\_\_\_\_ peroneal tendons/Peroneus _____ Pathology**
**Tendon tears**
**Tendonitis**
**Subluxing peroneal tendons/Peroneus Brevis Pathology**
36
Ankle Sprains
Physical Exam
* P\_\_\_\_
* Lateral collateral ligaments of ankle
* Deep to ankle joint
* Lateral malleolus
* Compression of tibia and fibula
* Ed\_\_\_\_\_
* Ec\_\_\_\_\_\_\_\_\_
* Jump/Hop Test =
* Pain
* Lateral collateral ligaments of ankle
* Deep to ankle joint
* Lateral malleolus
* Compression of tibia and fibula
* Edema
* Ecchymosis
* Jump/Hop Test = *In this test,* ***the aim is to jump as far as possible on a single leg, without losing balance and landing firmly****. The distance is measured from the start line to the heel of the landing leg. The goal is to have a less than 10% difference in hop distance between the injured limb and uninjured limb*
37
Ankle Sprains DDx
**Diagnostics (1)**
Horse
* In\_\_\_\_\_\_ Ankle Sprain
* \_\_\_\_\_Tendon Sprain
Zebra
* Lateral Malleolus \_\_\_\_\_\_
* Osteochondral Injury =
* Syndesmotic Injury =
**Xray**
Horse
* Inversion Ankle Sprain
* Peroneal Tendon Sprain
Zebra
* Lateral Malleolus Fracture
* Osteochondral Injury = *An osteochondral defect refers to* ***a focal area of damage that involves both the cartilage and a piece of underlying bone***
* Syndesmotic Injury = *A syndesmotic ankle sprain is an injury to one or more of the ligaments comprising the distal tibiofibular syndesmosis; it is often referred to as a "high ankle sprain." Compared with the more common lateral ankle sprain, the high ankle sprain causes pain more proximally, just above the ankle joint, and is associated more often with significant morbidity.*
38
Ankle Rules for Radiography
An ankle x-ray is only required if
39
Treatment for Grade 1 Ankle Sprain
(1) + (1)
RICE + NSAIDs
40
Treatment for Grade II Ankle Sprains
(1) + (1)
(1)
(1) with brace or CAM boot
RICE + NSAIDs
Time
Immobilization (brace or CAM boot)
41
Treatment for Grade III Ankle Sprain
(1) + (1)
More (1)
(1) (CAM boot or plint)
**(1)**
RICE + NSAIDs
More time
Immobilization (CAM boot or splint)
**NWB**
42
(1)
**Repeated ankle sprains that lead to altered activity levels**
* ~30% of patients will develop CLAI after ____ ankle sprain
* (1): joint laxity anteriorly or laterally
* (1): sensorimotor or neuromuscular deficiency
Chronic Lateral Ankle Instability
* ~30% of patients will develop CLAI after first ankle sprain
* Mechanical: joint laxity anteriorly or laterally
* Functional: sensorimotor or neuromuscular deficiency
43
Ankle Stability Exam
(2)
Anterior Drawer
Talar TIlt
44
Chronic Lateral Ankle Instability Treatment
**Physical Therapy**
* Start ~\_\_ weeks after injury
* Str\_\_\_\_\_\_\_ exercises
* Pro\_\_\_\_\_\_\_ exercises
**Ankle Sprain Rehabilitation Exercises**
* _______ stretching
* Standing c\_\_\_\_ stretch
* Standing s\_\_\_\_\_ stretch
* Active (1)
* Resisted ankle \_\_\_\_\_\_\_\_\_
* Reisted ankle plantar \_\_\_\_\_\_\_
**Ankle \_\_\_\_ing and \_\_\_\_ing**
**Physical Therapy**
* Start ~3 weeks after injury
* Strengthening exercises
* Proprioception exercises
**Ankle Sprain Rehabilitation Exercises**
* Towel stretching
* Standing calf stretch
* Standing soleus stretch
* Active ROM
* Resisted ankle dorsiflexion
* Resisted ankle plantar flexion
**Ankle bracing and wrapping**
45
Chronic Lateral Ankle Instability When to Refer
* Any ______ or highly competitive individual
* h/o pr\_\_\_\_\_\_ ankle sprain
* Any _____ ankle sprain
* Any n\_\_\_\_\_\_\_ compromise
* Symptomatic after __ weeks
* Any athlete or highly competitive individual
* h/o previous ankle sprain
* Any high ankle sprain
* Any neurovascular compromise
* Symptomatic after 6 weeks
46
**Common problem when the posterior tibial tendon becomes inflamed or torn**
Posterior Tibial Tendon
47
Physical Exam Signs for Posterior Tibial Tendon
(2)
“Too Many Toes” Sign
Single Heel Rise
48
Imaging for Posterior Tibial Tendon
(2)
Xray
MRI
49
Posterior Tibial Tendon Dysfunction (PTTD) Grading
50
Posterior Tibial Tendon Dysfunction (PTTD) Treatment
* (1) + (1)
* \_\_\_\_loading
* Orth\_\_\_\_
* Custom Br\_\_\_\_\_
* S\_\_\_\_\_\_
* RICE + NSAIDs
* Offloading
* Orthotics
* Custom Bracing
* Surgery
51
Surgery for Posterior Tibial Tendon Dysfunction
(1)
The PTT connects to the navicular bone near the middle of the foot at the instep. In this surgery, your foot and ankle orthopaedic surgeon will remove the Flexor digitorum longus (FDL) tendon from its usual position and transfer it to the navicular bone. This helps support or replace the diseased PTT to improve function. The diseased PTT is cleaned up or removed to eliminate it as a source of pain.
FDL Tendon Transfer to PTT
52
Calcaneal Osteotomy with Lateral Column Lengthening and PTT Reconstruction
Describe this surgery?
A calcaneal osteotomy is a controlled break of the heel bone to correct a deformity of the foot and ankle
53
When to Refer for PTT
* C/O medial ankle p\_\_\_\_ and \_\_\_\_ness
* Inability to do single heel \_\_\_\_\_
* C/O medial ankle pain and weakness
* Inability to do single heel raises
54
Swelling and Pain at ball of foot with weightbearing
DDX
* \_\_\_\_\_
* Metatarsalgia
* Morton's Neuroma
* Stress Fracture
* Dermatologic
* Intractable Plantar keratosis
* Verucca
* \_\_\_\_\_\_
* Plantar Plate Tear
* Freiberg's Disease
* Inflammatory Arthritis
* Horse
* Metatarsalgia
* Morton's Neuroma
* Stress Fracture
* Dermatologic
* Intractable Plantar keratosis
* Verucca
* Zebra
* Plantar Plate Tear
* Freiberg's Disease
* Inflammatory Arthritis
55
Swelling and Pain at Ball of Foot with Weightbearing
Physical Exam
**Match each picture with each Condition**
* **Pain at plantar metatarsal heads =**
* **Elevated toe =**
* **Skin lesions plantar =**
* **Pain with foot lateral and interspace compression =**
* **Pain over dorsal metatarsal neck/shaft =**
* **Pain at plantar metatarsal heads (1st pic)**
* **Elevated toe (5th pic)**
* **Skin lesions plantar (2nd pic)**
* **Pain with foot lateral and interspace compression (4th pic)**
* **Pain over dorsal metatarsal neck/shaft (3rd pic)**
56
What Conditions are shown in these X-rays?
57
What conditions are shown in these images?
Morton's Neuroma
58
What condition does this image show?
Plantar Plate Tear
59
Metatarsalgia Treatment
* R\_\_\_\_ + N\_\_\_\_\_
* _____ Splint (top left pic)
* Custom \_\_\_\_\_\_(bottom left pic)
* ______ (right pic)
* RICE + NSAIDs
* Budin Splint (top left pic)
* Custom Orthotics (bottom left pic)
* Surgery (right pic)
60
Stress Fracture Treatment
(1) for 4-6 weeks
Return to ____ at 12 weeks
Offloading for 4-6 weeks
Return to sport at 12 weeks
61
Morton's Neuroma Treatment
* Activity/Shoe mod\_\_\_\_\_\_
* Custom \_\_\_\_\_\_
* N\_\_\_\_\_s + Rx (1)
* St\_\_\_\_\_ Injection
* Al\_\_\_\_\_ Sclerosing Injection
* Surgery: (1)
* Activity/Shoe modification
* Custom Orthotics
* NSAIDs + Gabapentin
* Steroid Injection
* Alcohol Sclerosing Injection
* Surgery: Neurectomy
62
Plantar Plate Tear Treatment
(2)
Strapping
Surgery
63
Plantar Pain DDx
* **Plantar (1)**
* Fat Pad \_\_\_\_\_\_
* Calcaneal Nerve \_\_\_\_\_\_
* Apo\_\_\_\_\_\_
* ______ Digiti Minimi Entrapment
* Calcaneal Burs\_\_\_\_\_
* Tarsal _____ Syndrome
* N\_\_\_\_pathies
* _____ Fracture
* R\_\_\_\_\_pathy
* Infectious
* Plantar Fascia T\_\_\_\_
* Tum\_\_\_
* Plantar Fib\_\_\_\_
* In\_\_\_\_\_\_ Arthropathies
* **Plantar Fasciitis**
* Fat Pad Atrophy
* Calcaneal Nerve Entrapment
* Apophysitis
* Abductor Digiti Minimi Entrapment
* Calcaneal Bursitis
* Tarsal Tunnel Syndrome
* Neuropathies
* Stress Fracture
* Radiculopathy
* Infectious
* Plantar Fascia Tear
* Tumor
* Plantar Fibroma
* Inflammatory Arthropathies
64
Plantar Fasciitis
Acute overuse injury with (**2)** distinct components
Both need to be addressed for successful outcomes
**MSK****: tight posterior muscle group**
**Inflammatory****: inflammation from _microtears_ of fascia**
65
(1)
The mechanics of the foot, II: the plantar aponeurosis and the arch
The Truss
*The plantar aponeurosis, also known as the plantar fascia, is* ***a strong layer of white fibrous tissue located beneath the skin on the sole of the foot****.*
66
(1)
Refers to the function of the anatomy on the base of the foot, specifically the plantar aponeurosis, sesamoid bones, plantar pads and the attachment of these structures under the MTPJ.
Windlass Mechanism
67
Pathomechanics of Plantar Fasciitis
* _____ works unopposed when sleeping or at rest → \_\_\_\_\_\_
* With _____ , the forefoot and hindfoot are opposed → _____ mechanism initiated → ______ of the fascia at its insertion causing \_\_\_\_\_\_\_\_
* Achilles works unopposed when sleeping or at rest → shortens
* With propulsion, the forefoot and hindfoot are opposed → Windlass mechanism initiated → microtearing of the fascia at its insertion causing inflammation
68
Overpronation
Excessive mobility → increase the level of stresses applied to the fascia → plantar fascial elongation → increased tissue stress
Overpronation
69
Imaging XR
Traction phenomenon on plantar fascia due to tightness → heel \_\_\_\_\_
Plantar heel spurs are a radiographic finding and DO ___ HURT. They are ___ the cause of fasciitis
Traction phenomenon on plantar fascia due to tightness → heel spur
Plantar heel spurs are a radiographic finding and DO NOT HURT. They are NOT the cause of fasciitis
70
PHASE I: Fasciitis Treatment
**Expectation is improvement \>\_\_\_% within __ weeks along all points of protocol**
**Expectation is improvement \>50% within 3 weeks along all points of protocol**
71
Home PT Stretches and Night Splint for Plantar Fasciitis
72
Custom Orthotics for Plantar Fasciitis
* Captures the foot in subtalar joint \_\_\_\_\_
* Directly reduces st\_\_\_\_ on fascia
* Elevates ____ → reduces Achilles effect on fascia
* Added cush\_\_\_\_\_\_ if heavy heel striker
73
Corticosteroid Injection
* Topical Refrigerant
* ____ chloride
* 2.5 cc steroid cocktail
* 1cc Marcaine 0.5%
* 1cc D\_\_\_\_\_\_ 4mg
* 0.5cc K\_\_\_\_\_ 40
* Approach \_\_\_\_\_\_
* Aim for plantar medial tubercle of calcaneus
* Wait __ minutes for response
**Conclusion**: steroid injection showed a clear benefit over placebo at __ weeks and this difference was maintained at __ weeks
* Topical Refrigerant
* Ethyl chloride
* 2.5 cc steroid cocktail
* 1cc Marcaine 0.5%
* 1cc Dexamethasone 4mg
* 0.5cc Kenalog 40
* Approach medially
* Aim for plantar medial tubercle of calcaneus
* Wait 5 minutes for response
**Conclusion**: steroid injection showed a clear benefit over placebo at 6 weeks and this difference was maintained at 12 weeks
74
Phase II: Fasciitis Treatment
**\_\_ weeks after initial visit with \_\_**
Expectation is improvement \>\_\_% within 3 weeks along all points of protocol
**3 weeks after initial visit with \<50% improvement in VAS (visual analog scale (pain scale))**
Expectation is improvement \>50% within 3 weeks along all points of protocol
75
Phase III Fasciitis Treatment
\_ weeks after initial visit with \<50% improvement in VAS
* Advanced Imaging: MRI, U/S, EMG/NCV
* MRI at least __ weeks after injection
* Lab tests: E\_\_\_, C\_\_, A\_\_, R\_, HLA B27
* Offloading: CAM \_\_\_\_, N\_ _ BK cast
6 weeks after initial visit with \<50% improvement in VAS
* Advanced Imaging: MRI, U/S, EMG/NCV
* MRI at least 6 weeks after injection
* Lab tests: ESR, CRP, ANA, RF, HLA B27
* Offloading: CAM boot, NWB BK cast
76
Phase IV: Fasciitis Treatment
(1) Findings of moderate to severe fasciitis
OR
Plantar Fasc\_\_\_\_\_
OR
Recalcitrant ____ pain x3 months with appropriate therapies
MRI Findings of moderate to severe fasciitis
OR
Plantar Fasciosis
OR
Recalcitrant heel pain x3 months with appropriate therapies
77
Definition of Platelet Rich Plasma
* A preparation of _____ concentrated in a limited volume of \_\_\_\_\_
* 3-5x increase in platelets and _____ factors per volume of plasma
* No significant information about platelet concentrations that is optimal for _____ of tissues
* A preparation of platelets concentrated in a limited volume of plasma
* 3-5x increase in platelets and growth factors per volume of plasma
* No significant information about platelet concentrations that is optimal for healing of tissues
78
PRP + Plantar Fasciosis
* ___ conservative tx or cortisone injection within __ days
* 7/9 pts ______ resolution of pain at 1 year
* 9/9 patients had improvement noted on diagnostic \_\_\_\_
* No conservative tx or cortisone injection within 90 days
* 7/9 pts complete resolution of pain at 1 year
* 9/9 patients had improvement noted on diagnostic U/S
79
Extracorporeal Shock Wave Theory for treatment of Chronic Plantar Fasciitis
* \_\_\_\_\_\_waves create a “new \_\_\_\_\_”
* Br\_\_\_\_ scar tissue
* F\_\_\_\_blast stimulation
* An\_\_\_\_\_\_ (?)
* 65-85% success rate in reported literature, however, not all studies show statistical improvement
* Soundwaves create a “new wound”
* Breaks scar tissue
* Fibroblast stimulation
* Analgesia (?)
* 65-85% success rate in reported literature, however, not all studies show statistical improvement
80
**Percutaneous Radiofrequency Microfasciotomy for the Treatment of Plantar Fasciosis**
Conclusions
* At 6 months, postoperative RFMF was _____ to open plantar fasciotomy in reducing the chronic pain of plantar fasciosis in more than 80% of the patients treated
* Reduced postoperative \_\_\_\_\_\_\_
* Faster return to ____ as compared with conventional surgery
* At 6 months, postoperative RFMF was equivalent to open plantar fasciotomy in reducing the chronic pain of plantar fasciosis in more than 80% of the patients treated
* Reduced postoperative complications
* Faster return to ADL as compared with conventional surgery
81
What treatment for plantar fasciitis is shown in these photos?
Tenex Microtenotomy and Debridement
82
Phase V: Plantar Fasciitis/osis
**When all else fails..Plantar (1)\***
* Risk of Open = ____ plantar nerve injury
* Risk of Endoscopic = lateral ____ overload, _____ nerve injury
**When all else fails..Plantar Fasciotomy\***
* Risk of Open = medial plantar nerve injury
* Risk of Endoscopic = lateral column overload, calcaneal nerve injury
83
Tendon Injuries
Acute
* Sudden crisis
* Predictable, but l\_\_\_thy resolution
* Usually midsubstance r\_\_\_\_\_ through aberrant tissues
* Direct sharp injury
Chronic
* Slow, insidious onset
* Implies antecedent sub-threshold str\_\_\_\_\_\_ damage
* A chronic disease that leads to cr\_\_\_\_ episodes of inf\_\_\_\_\_ and p\_\_\_\_
Acute
* Sudden crisis
* Predictable, but lengthy resolution
* Usually midsubstance ruptures through aberrant tissues
* Direct sharp injury
Chronic
* Slow, insidious onset
* Implies antecedent sub-threshold structural damage
* A chronic disease that leads to crisis episodes of inflammation and pain
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A chronic, non inflammatory disease with vascular and cellular changes that result in loss of the biomechanical and elastic properties of the tendon tissue
Tendinosis
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Why Use PRP for Tendinopathy
* Tendons have a ___ rate of healing after injury
* In vitro studies of tenocytes + PRP increased pro\_\_\_\_\_\_ and (1) secretion (VEGF, HGF)
* VEGF + HGF → ang\_\_\_\_\_\_ → tendon healing
* HGF is antifibrotic agent → reduce ____ formation
* Tendons have a low rate of healing after injury
* In vitro studies of tenocytes + PRP increased proliferation and GF secretion (VEGF, HGF)
* VEGF + HGF → angiogenesis → tendon healing
* HGF is antifibrotic agent → reduce scar formation
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Extracorporeal Shockwave Therapy for the Treatment of Achilles Tendinopathies
Is ESWT effective in tendinopathies?
Extracorporeal shockwave therapy **has been shown to be effective** in the treatment of chronic tendon pathology in the elbow, shoulder, and plantar fascia.
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Radiofrequency Coblation (Topaz) for chronic tendinosis
Bipolar RF micro\_\_\_\_\_\_ performed via “cold abl\_\_\_\_\_\_” of tissue
Bipolar RF microtenotomy performed via “cold ablation” of tissue
*This procedure is done by inserting a needle (or needles) through the skin to reach diseased tendons. The surgeon uses ultrasound to see the tissues and find the affected tendon(s). The needles are used to remove the diseased tissues. They also stimulate the surrounding healthy tissues to encourage the healing process.*
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Chronic Tendon Disease
What condition is shown in this picture?
**Achilles Tendinosis**
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Chronic Tendon Disease
What condition is shown in this picture?
**Plantar Fasciitis/Fasciosis**
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Can you combine Microtenotomy and PRP injections?
Is this combo effective?
Combination Therapy
* 51 patients had U/S-guided percutaneous needle tenotomy followed by a PRP injection
* Mean functional improvement 68%
* Worse-pain improvement 58%
* 83% satisfaction rat
