Foot Pain: A Guide to Commonly
Missed Foot/Ankle Complaints
Lloyd Barker, PAC, ATC, MBA/HCM
Mayo Clinic
January 25, 2014
Objectives

At the conclusion of this session, the participant
will be able to:
 Identify the early and late clinical presentation
of commonly missed foot and ankle
musculoskeletal conditions
 Evaluate radiographic findings of Lisfranc
injuries, tendinopathies, Turf toe, and occult
fractures
 Formulate a treatment plan including
conservative management versus referral for
surgical intervention
Areas of emphasis

Lisfranc injuries


Posterior Tibial Tendon dysfunction (PTTD)


~10% of patients who sustain an Achilles tendon rupture had preexisting
Achilles tendon problems
Turf toe


3.3% prevalence rate in women over 40
Achilles Tendinopathies


20% mis-diagnosed in ED on initial presentation
50% incidence persistent symptoms at 1st MTP five years after injury
Occult fractures
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Foot Anatomy
Ankle Anatomy
Lisfranc Injury

Jacques Lisfranc (17901847), a field surgeon in
Napoleon’s army in Russia.

Fracture/dislocation of
1st/2nd TMT joint

Mechanism of Injury



Twisting of forefoot
Axial load
Crush
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Lisfranc Injury
Stability


Roman arch – keystone
5 metatarsals with the
2nd metatarsal acting as
a keystone.
Lisfranc Injury



Diagnosis
 Foot sprain
 Dislocation
 Fracture
 Obvious versus subtle findings
History is very important!
 Acute versus chronic presentation
 Direct versus indirect
 20% of injuries mis-diagnosed or overlooked
High energy versus low energy injury
 High- MVA, fall from height
 Low- Stepping off curb, stepping into hole
Lisfranc Injury - Indirect
Axial load applied to
plantarflexed foot
forefoot
hyperplantarflexes, weak dorsal
ligaments rupture
plantar
aspect of metatarsal base
fractures or plantar capsule
ruptures along MT bases to
displace dorsally.
-Anderson, MD (2005) Sports Medicine of the
Foot and Ankle
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Lisfranc Injury
Lisfranc Injury

Signs & Symptoms
Midfoot pain when bearing weight
 Point tenderness over Lisfranc joint
 Swelling/deformity in midfoot
 Plantar flexion and rotation of forefoot
painful

Lisfranc Injury Radiographs

AP - Medial margin 2nd metatarsal and
middle cuneiform alignment

Lateral - Dorsal margin 1st/2nd metatarsal
and cuneiforms alignment

Oblique - Base of 4th metatarsal and
cuboid alignment
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Lisfranc Injury
Lateral view
AP view
Oblique view
Lisfranc Injury

Treatment



(Early Recognition Important)
Goal – Stable anatomic foot
Conservative – Cast immobilization, orthotics
Surgical
 Acute Injury with displacement
 Neurovascular compromise/Compartment
Syndrome
Case Study


66 yo female walking out of store when
her right foot slipped off the sidewalk
curb. Had immediate pain in foot. Saw
her PCP who ordered initial x-rays of
ankle, which were negative for fracture.
Sent to Orthopaedics for persistent
foot/ankle pain.
Foot x-rays ordered and show the
following:
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Case Study
A. Fracture sesamoid
B. Fracture metatarsal
C. Lisfranc sprain
D. Lisfranc dislocation
Case Study
Case Study
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Case Study
Case Study
Case Study
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Case Study
Case Study
Case Study
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Case Study
Lisfranc Injury

Treatment
Non-weight bearing cast
Walking boot (WB as tolerated)
 Athletic shoewear with custom orthotics
 Patience! Recovery time up to one year!


Tendinopathy
Posterior Tibial Tendon (PTT)
 Achilles Tendon

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Posterior Tibial Tendon




Females -75%
Age- over 50 years
Caucasians – 95% or more
Underlying disease process
Posterior Tibial Tendon

Function


Adducts the forefoot
Inverts the heel

Acute

Chronic


Rupture v Tendinitis
Tendonosis v PTT dysfunction
Posterior Tibial Tendon

History
 Injury / Precipitating
event
 ↓ walking tolerance
 Misdiagnosed as ankle
sprain, cellulitis, DVT
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Posterior Tibial Tendon
PHYSICAL EXAM
Point tenderness along course of tendon,
palpable deficit if ruptured
 Pain, weakness, and/or inability to do
heel rise manuever
 “Too many toes sign”

Posterior Tibial Tendon
“Too many toes sign”
Posterior Tibial Tendon
Dysfunction Stages
Stage I

Tenosynovitis without deformity
Stage II

Damage to tendon; flexible forefoot
Stage III

Rigid hindfoot valgus
Stage IV

Ankle valgus
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Normal Tendon
Chronic
Acute
Stress
Age related degeneration
Abnormal Tendon
Tendinitis
Abnormal Tendon
Obesity
Inflammatory disease
Acute trauma
Steroids
Tendonosis
Partial Tear
Mechanical Failure
Complete Tear
PTTD
Planovalgus deformity
Posterior Tibial Tendon
Early Symptoms




Medial ankle
pain/swelling
Muscle weakness
Thickened tendon
+/- heel rise test
Late Symptoms




Lateral ankle
pain/swelling
Deformity
Sinus tarsi pain
+ heel rise test
Heel rise test
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Case Study

55 yo female with history of IDDM, peripheral
neuropathy, and RA presents c/o right foot/ankle
pain. She describes dull achy pain for the past
month. She thinks she sprained her ankle but never
had it evaluated. After initial exam, which radiograph
exam should be ordered:
A.
B.
C.
D.
Foot radiographs
Ankle radiographs
MRI lower leg
CT lower leg
Radiographs
Sagging of talonavicular, naviculocuneiform,
or cuneiform first metatarsal joint
Posterior Tibial Tendon
 MRI
exam
 Fluid
in sheath
(tendinitis v.
tendonosis)
 Abnormal signal
 Partial tear
 Absent
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Posterior Tibial Tendon
Treatment
Acute
 NSAIDs
 Immobilization
 Physical Therapy / Activity Modification
Chronic
 Orthosis
 Surgery


Posterior Tibial Tendon
Results of non-surgical treatment of stage II posterior tibial tendon dysfunction:
a 7- to 10-year followup. Lin, JL., Balbas, J., Richardson, EG. Foot Ankle Int.
2008, Aug;29(8), 781-6.



33 patients w/average
follow-up 8.6 yrs.
Stage II PTTD with use
of Double Upright Ankle
Foot Orthosis (DUAFO).
Results




60.6% (20) satisfied
33.3% (11) Satisfied with
minor reservations
3% (1) Partially satisfied
3% (1) Unsatisfied
Posterior Tibial Tendon

Operative Treatment




Tenolysis
Tendon transfer
Tendon transfer +
“X” to restore
alignment
Arthrodesis
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Surgical correction (Subtalar)
Achilles Tendon




Common insertion of Gastrocnemius/Soleus
Function – Plantarflexes ankle/foot
Acute
 Tendinitis
 Rupture
Chronic
 Tendinosis
 Insertional enthesitis
Achilles Tendon

History



Physical Exam



Precipitating event(s)
Misdiagnosed as ankle sprain
Point tenderness and/or palpable defect
Positive Thompson test
Radiographs


Plain x-rays
MRI
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Achilles Tendon

X-Rays

MRI
Insertional Enthesitis
Achilles Tendon

Treatment


Acute
 Immobilization
 Surgical repair
 Therapy
Chronic
 Immobilization
 Heel lifts
 Surgical repair
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Turf Toe


Acute injury to 1st metatarsophalangeal (MTP) joint
First described by Bowers & Martin in 1976.
 U. of West Virginia, 5.4 injuries/year.
 Conclusion: “Turf toe, though not a serious
injury, is significantly disabling functionally to
warrant attempts at its prevention.”
Turf Toe
Stages

Grade I

Attenuation plantar structures, min ecchymosis, local
swelling

Grade II

Grade III


Partial tear plantar structures, moderate swelling, ↓ ROM
Complete disruption plantar structures, weakness, 1st MTP
instability
Turf Toe

Radiographs



Fracture
Sesamoids position
MRI


Evaluate plantar
capsular structures
Evaluate joint surface
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Turf Toe
Treatment
RICE/Therapy
 Taping for activity
 Carbon Fiber insert
 NSAIDs
 Stiff soled shoes
 Gradual return to
activity

Hallux Rigidus
 Repetitive
stress at 1st MTP
joint
 Cartilage Damage
 Misalignment,
“wear & tear”
 Genetics
 Trauma
 Single
v. repetitive episodes
Hallux Rigidus (Early)
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Hallux Rigidus (Late)
Hallux Rigidus Treatment

Conservative

Shoewear






Stiff, rocker bottom, wide
toe box, external metatarsal
bar
Carbon fiber plate insert
Activity Modification
NSAIDs
Cortisone injection
Surgical

Cheilectomy v.
Arthrodesis
Occult fractures
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Occult fractures



26 yo female with left
forefoot pain after
wearing high heels and
walking for several
days at a trade show
the previous month
Pain better in flats and
athletic shoes
No obvious
swelling/ecchymosis/
deformity
Occult fractures



Avid runner 4-5
miles/day on treadmill
Able to run w/minimal
pain except uphill
which increases pain
No specific point
tenderness on foot
exam
1
4
2
5
3
6
Occult fractures




21 yo female with new
onset pain in hindfoot
after running on
treadmill
No twisting injury or
trauma
Pain initially with
running only, now
present with normal
ambulation
Pt. notices minimal
swelling with no
ecchymosis
20
Occult fractures
Occult fractures



18 yo male
skateboarder who
came off of board
attemping to jump
down 10 steps.
Inability to walk
due to midfoot
pain.
Swelling & point
tenderness dorsal
midfoot.
Occult fractures



Placed in
removable
cast/boot
NWB
CT scan
21
Occult fractures




59 yo female
twisted ankle
coming down
stairs.
Thought she had
“sprained her
ankle”.
Unable to fully
weightbear.
Pain lateral
foot/ankle area.
Occult fractures

Treatment






Protective immobilization (4-6 wks)
NWB » PWB » WBAT
Transition to athletic shoewear
Orthotics (?)
Activity modification
Re-evaluate
Take home points



Lisfranc injuries often overlooked
Posterior tibial tendon injury often
misdiagnosed as medial ankle sprain
When in doubt, immobilize and refer
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