Foot and Ankle pain and injury

Cartilage lesion

These injuries most commonly occur as the result of a distortion of the foot during supination, typically affecting the medial compartment and resulting in persistent pain and functional limitation. Patients (often professional athletes) report numerous ankle sprains, persistence of pain, limited range of movement and swelling. Varus-valgus and drawer tests can have very positive results in these cases. X-rays are not sufficiently accurate to use in these cases, MRI’s give a better picture of osteochondral fractures as well as any displaced fragments. Treatments for these injuries vary depending on the severity of the lesion. As long as a 4th level lesion is not found (a lesion with a displaced fragment which can only be dealt with surgically) a conservative rehabilitation-based treatment can begin.

Cartilage lesion surgery

Cartilage lesions are often observed as the result of wear on the knee joint through repetitive movements, although they are equally common as the result of a sports injury. Treatment here can be conservative, or surgical in more severe cases. Either way, we can effectively treat this type of knee injury using our own conservative rehabilitation process, or through planning a specialised post-surgical rehabilitation programme.

Fracture or lesion of Lisfranc joint

This is a rare and difficult to diagnose injury involving the tarsometatarsal joint (also known as the Lisfranc joint). These injuries can arise through both direct and indirect mechanisms. A classic example of a direct trauma comes from a lateral or medial kick to the middle of the foot, something which often goes unnoticed or underestimated by the recipient. Indirect traumas include falls and awkward placement of the forefoot. Symptoms are characterised by a localised, intense pain in the midfoot which is then exacerbated along the Lisfranc joint line during compression. Around 20% of x-rays of Lisfranc dislocations return negative results, however CT scans are very effective at highlighting lesions which point to this kind of injury. Typically, patients suffering from these kinds of injuries who do not experience any instability are still given a brace for 4-6 weeks, after which remission of symptoms tends to begin. Physiotherapy is used to reduce pain and inflammation and a programme of rehabilitation is planned to help reinforce the intra-rotator ankle muscles and improve the cavus position along the plantar arch. When dealing with unstable lesions, surgical treatment is most likely required, consisting of percutaneous suspension using wires or screws, followed by immobilisation with a brace or cast. Subsequent rehabilitation techniques after the cast has been removed follow the same principles as when dealing with stable lesions.

Fractured metatarsal

Fractures to the fourth and fifth metatarsal are the most common, and typically do not require surgery. Patients usually present themselves in pain, following a sprain or after a fall or jump. Motorcycle or car accidents are also frequently responsible for these kinds of injuries. Common courses of treatment involve immobilising the foot with a cast for around 30 days, after which significant muscle atrophy in the leg will be evident. Again, X-rays are extremely important for diagnosis. Once the Case Manager has verified that the fracture has consolidated, and the heads of the bones are correctly juxtapositioned, rehabilitation can begin. The rehabilitation programme will start with very light load and progress steadily until crutches are no longer needed. Before rehabilitation on the field can begin, the patient must have a full range of motion, fluidity, proprioception and good muscular strength in the lower limb. If osteosynthesis techniques have been used, the rehabilitation programme does not change significantly, however loading exercises may begin sooner, decreasing the overall length of the process.

Morton’s Neuroma is often attributed to swelling in the plantar nerve branches that run between the second and third, and third and fourth metatarsals. Compression of these nerves between metatarsal heads can be caused by microtraumas resulting from the use of inappropriate footwear (narrow shoes in particular). Patients usually present with a sudden onset of pain, often likened to an electric shock. Numbness is also frequently present in the two affected toes. The diagnosis is essentially clinical, but can be confirmed through an ultrasound, or an MRI scan. Initial treatment is conservative, but in severe cases where surgical intervention is necessary the neuroma is removed.

Malleolar fractures

These type of injuries can be caused by a wide range of occurrences, including car accidents, sports injuries and even accidents around the home or workplace. These injuries will normally require a cast or brace be used to immobilise the joint for 30-40 days. After this period, the ankle will be extremely rigid in all planes (flexion-extension, and inversion-eversion) and muscle hypotrophy will be evident. If you have experienced this kind of injury and come to us for your rehabilitation, it is very important that you bring any X-rays of the area with you, in particular those taken after the cast has been removed. These X-rays inform your doctor of whether or not your malleoli are in line – if they are not, successful rehabilitation becomes impossible. Rehabilitation of these kinds of injuries can take a long time. Physical and pharmacological strategies will be used to reduce pain and swelling and manual lymph drainage is often required. Further on in the process, proprioceptive exercises will be introduced alongside load progression to help strengthen the muscles around the ankle. In-pool rehabilitation is very effective when treating these kinds of injuries as it allows the patient to re-develop their gait with minimal loading. These injuries can be especially disruptive to a patient’s life due to the immobilisation of the leg. We try to help our patients achieve the basics needed for them to go back to living a normal life (helping them to drive, walk without crutches, and eventually return to sport or their usual activities).

Malleolar fracture surgery

These are the most common fractures of the inferior limb: they involve the internal and external malleolus, sometimes adjoined by ankle ligament lesions. Fracture involving two malleoli and the posterior part of tibia is defined trimalleolar fracture. Probably you suffered from a trauma subsequent to a car crash, a sports trauma or an accidental fall. According to the different type of fracture, there are various surgical treatments to undergo. Numerous synthetic bone substitutes are used as well as an external fixators. You will be able to start a rehabilitation period after some time of mobilisation with a plaster or fixator. It is important for you to know that the rehabilitation suggested for this type of pathology is a long-term one and challenging, requiring on average 4 months achieving a discreet recovery of the functionality and 8 months recovering the agonistic sports activity. Generally, the synthetic bone substitutes are removed a year after surgery. Rehabilitation after the removal of these synthetic bone substitutes will take almost one month.

Achilles tendon rupture

Plantar fasciitis is a disorder relating to the fibrous connective tissue structures originating from the calcaneal tuberosity and inserting into the metatarsal heads. During the stance phase of step and run movements, the plantar fascia is stretched significantly, causing a great deal of stress around the insertion on the medial tubercle of the calcaneus. Over time, calcification can occur along the length of this band that produces a typical radiological heel spur. The presence of these kinds of spurs is not necessarily linked with the presence of pain - heel spurs are often found by chance during X-rays for other injuries that have not caused the patient any pain, whilst some patients experience very painful plantar fasciitis in the absence of a heel spur. This condition is common amongst athletes involved in running, dancing, tennis and basketball, especially if they have increased their load too quickly during training. It may also present itself in older individuals who have started wearing flat shoes, those who are overweight, people required to wear unsuitable shoes for work reasons and those with irregularities in their arches (flat feet, hard soles and those with a tendency to hyper-pronate). Generally speaking, this condition tends to be chronic as it is often overlooked or neglected by sufferers for several months whilst it worsens. Symptoms usually consist of severe pain during the first steps of the day which gradually improve after some movement, before flaring up again later on. Swelling may also be present around the affected area. It is not uncommon for patients to experience deficits in strength and extensibility of the calf muscles. X-rays, ultrasound and possibly electromyography scans are useful in establishing a diagnosis. Electromyography is especially useful if there is any numbness or paralysis due to associated nerve compression. In the short term, the patient must stop all sporting activity (with the exception of swimming and cycling) and attempt to reduce the effect of predisposing factors (avoid wearing inappropriate footwear, or losing weight for example). Using insoles may help correct any abnormalities in the plantar arch. Shockwave therapy can be very effective at reducing inflammation in these conditions.

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