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Heel and ankle problems

In the fourth of our six-part series, orthopaedic surgeon Mr Alex Watson outlines heel and ankle problems in three adult age groups

In the fourth of our six-part series, orthopaedic surgeon Mr Alex Watson outlines heel and ankle problems in three adult age groups

Most patients with heel or ankle problems present with pain or discomfort of variable intensity and duration, interfering with daily activities. For simplicity, accepting that there may be considerable overlap, these patients can be broadly divided into three groups:

• the young, fit adult

• the middle-aged, overweight adult

• the elderly.

The young, fit adult

As with all patients, it is essential to take a careful history. Most ‘sprained' ankles follow simple forced inversion injuries. If the problem is persistent instability, examination should elicit tenderness laterally and usually little else. These ‘sprains' are common and usually resolve with or without physiotherapy and support.

If the patient presents or re-presents with any persistent problem – or if they respond poorly to physiotherapy – consider weight-bearing X-rays of the foot and ankle. These may help to exclude missed fractures or rarer-type injuries such as fracture dislocations of the midfoot, stress fractures, bone cysts or tumours. Failure to respond to physiotherapy or expectant treatment should result in referral to a foot and ankle surgeon.

If the patient's main complaint is pain on weight bearing following a forced inversion injury, have a high suspicion of an osteochondral defect (OCD), usually of the talus. Examination may elicit ankle joint line tenderness with a small effusion, but may be normal.

Again, exclude missed fractures by X-ray, but only large or chronic OCDs are defined on X-ray – the investigation of choice is an MRI scan. Although few GPs will have direct access to MRI, the key point is that persistent ankle weight-bearing pain may be an OCD until proven otherwise. Early referral to a foot and ankle surgeon is appropriate as these injuries are usually amenable to arthroscopic debridement. In the absence of instability, physiotherapy could actually be detrimental until a working diagnosis has been made.

Heel pain is less common in this younger age group. All suspected Achilles tendon ruptures are usually managed by an orthopaedic surgeon via a direct A&E referral. Subacute or incomplete tears may present in a similar fashion to Achilles tendonitis and occasionally precede complete ruptures.

Achilles tendonitis and retrocalcaneal bursitis with or without a prominent calcaneal bone (the Haglands deformity) may respond well to non-operative measures such as ultrasound treatment, rest, anti-inflammatories and physiotherapy. Those who don't improve should be referred to a foot and ankle surgeon.

Middle-aged, overweight adult

Plantar fasciitis is common in this age group. Heel pain worst first thing in the morning, with a specific ‘trigger' point, is virtually pathognomic of plantar fasciitis. The mainstay of treatment is physiotherapy and the best techniques are stretching and strapping with thick elastoplast tape, heel cushions, ultrasound treatment and night splints. The patient needs to be motivated or the symptoms continue for a considerable length of time.

In the outpatient setting, injections of local anaesthetic with corticosteroid are painful and difficult. I advocate injections under full sedation or a quick general anaesthetic with image control in order to administer a large volume of local anaesthetic and steroid using a wide bore needle to ‘pepper' the insertion of the fascia at the calcaneum. These seem to work well but must be followed by physiotherapy, or else they are simple ‘quick fixes' that have no benefit in the long term.

Achilles tendinopathy of variable degree is also common in this age group. Examination often reveals a tender fusiform swelling above the insertion. This can be quite troublesome and difficult to treat. Patients rarely comply with a regime of strict rest and tend not to tolerate periods of plaster immobilisation leading to time off work.

A trial of physiotherapy with ultrasound treatment and anti-inflammatories is worthwhile, but a poor response warrants specialist referral with or without an MRI scan. MRI scans are far more informative than ultrasound scans, especially if surgical debridement, repair and augmentation by tendon transfer is being considered – therefore they are the surgeon's investigation of choice.

Do not be tempted to inject the Achilles tendon. This will only act as a ‘quick fix' and evidence suggests that repetitive injections weaken and may rupture the tendon.

Beware of the middle-aged female patient with non-specific aching in her feet and around her ankles. The early stage of tibialis posterior tendon insufficiency, which is amenable to medialising calcaneal osteotomy and tendon transfer surgery, is often overlooked.

The often distraught patient will present with a history of her medial instep or arch collapsing, inability to stand or initiate tip-toe stance, lateral impingement (pinching pain around lateral malleolus) and medial aching and tenderness along the pathway of tibialis posterior, especially at its insertion in the navicula in the medial longitudinal arch.

Although these patients benefit from immediate orthotic referral for medial instep insole arch supports, they should also be referred to a foot and ankle surgeon as there is an inevitable progression of the condition. Later stages of tibialis posterior insufficiency warrant ‘salvage' surgery as the subtalar joint becomes osteoarthritic and insoles are unhelpful.

The elderly

The elderly present with pain from degenerative changes within their ankle or subtalar joints. Clinically it can be difficult to establish which joint is the more arthritic. Arthritic changes will hinder walking distances and therefore interfere with daily activities.

Typically, stiffness follows periods of rest, and pain is worse at the end of the day after prolonged weight-bearing activity. There is often associated swelling and deformity. Plain weight-bearing X-rays are helpful – as are CT scans – in determining the degree of arthritic change in either or both joints.

If the patient wishes to consider surgical options, a referral to a foot and ankle surgeon should be made. The mainstay of surgical treatment is fusion of the affected joint, but some patients are suitable for ankle replacement surgery. But check this service is available locally.

Of course, not all elderly patients are fit or willing for major hindfoot surgery. Concurrent co-morbidity, or inability to comply or cope with post-operative instructions such as prolonged non-weight bearing, may rule out surgery. Such patients with pain and deformity benefit from custom-made shoes and boots to support their deformity, offloading prominent bony areas and spreading weight evenly to aid mobilisation.

Mr Alex Watson is a consultant trauma and orthopaedic surgeon with a sub-specialist interest in foot and ankle surgery – he is one of the London Orthopaedic Clinic partners and his NHS practice is at the Princess Alexandra Hospital in Harlow, Essex

The London Orthopaedic Clinic holds free monthly education sessions aimed at GPs, physiotherapists and allied health professionals. For more information about Brian Cohen and the clinic visit www.londonorthopaedic.com or call 0207 1861000. Details of the education programme and the clinic's after hours emergency service can also be found on the website.

Achilles tendonitis

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