Ankle and Foot Pain: Management

by Charles Vega, MD

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    00:01 Talking about management now for ankle sprains in particular, one of the keys, and I think this could come up on your examination, would be early mobilization with range of motion exercises.

    00:12 Of course, ice is important.

    00:14 Compression.

    00:15 We know that a more serious brace, either an Air-Stirrup or a lace-up brace provides superior results to just wearing an elastic compression sleeve alone.

    00:25 So, that’s something to consider.

    00:27 For ankle sprains in particular, acetaminophen is about as effective as NSAIDs and probably safer.

    00:33 And then, certainly think about physiotherapy, particularly for that patient with a second or even third ankle sprain.

    00:39 They definitely need to start working on preventing the next episode of ankle sprain because it’s most likely to come.

    00:46 Therefore, some muscle strengthening and stretching as well.

    00:52 In those other conditions, talking about management, Achilles tendinitis, workouts that involve hills – so going up hills, using stairs or interval workouts where they take a rest and they go again makes that tendinitis worse.

    01:05 So, those should be avoided.

    01:07 For physical therapy, strengthening of the calf musculature is important to help strengthen and protect that Achilles tendon.

    01:15 For peroneal tendinitis, which also produces something of a more lateral type of ankle pain, there’s evidence that lateral heel wedges and ankle taping don't necessarily help healing.

    01:27 But a strong commitment to physical therapy, with range of motion and strengthening, can help these patients.

    01:33 And then eventually, some of these patients might actually need surgical repair as well.

    01:39 And so, let's look at plantar fasciitis.

    01:42 The good news is, as common as it is, most patients do fine with just conservative treatment only.

    01:48 So, that includes stretching on a routine basis.

    01:50 I recommend it at least twice a day.

    01:52 Deep myofascial massage to work out that stretching and inflammation.

    01:58 Analgesics can be effective for the short term.

    02:01 And then using an ice massage is helpful as well.

    02:05 In terms of next steps of therapy for plantar fasciitis, I often will recommend just simple orthotics to try to take some of the pressure off the plantar fascia.

    02:16 Doesn't have to be something custom, at least at first for straightforward cases.

    02:21 I recommend over-the-counter because they are so much cheaper.

    02:24 And still highly effective.

    02:26 For those patients who break through, that 10% who don't do well in conservative therapy, it’s time to consider injection therapy.

    02:32 It’s usually fanned out over three anatomical sites in the plantar fascia.

    02:37 It is superior in research to be better than dry needling or just lidocaine by itself.

    02:44 There is some risk, though, with these injections of plantar fascia rupture, which is a devastating condition.

    02:50 And I should mention here as well that you never inject the Achilles tendinitis because of the risk of rupture of the Achilles tendon.

    02:58 And then finally, for severe cases of plantar fasciitis, think about extracorporeal shockwave therapy and some of these patients need to go to surgery as well.

    03:09 So, with that, I’d say that we have a bunch of different conditions that can affect the foot and ankle.

    03:15 A good examination and a history as to where the location of that pain is and how much it affects our function is key.

    03:24 Ottawa ankle rules for avoiding unnecessary use of x-ray also key.

    03:29 And therapy tends to involve conservative treatment for the majority of these conditions at first.

    03:35 But think about getting physical therapy involved probably sooner rather later for these conditions as well, particularly if there's a chance for recurrence.

    03:42 Thanks very much.

    About the Lecture

    The lecture Ankle and Foot Pain: Management by Charles Vega, MD is from the course Acute Care.

    Included Quiz Questions

    1. Stretching exercises
    2. X-ray
    3. Prescribe orthotics
    4. Injection of triamcinolone
    5. Opiates
    1. Eccentric calf strengthening
    2. Rest
    3. Surgical repair
    4. Injection of triamcinolone
    5. Lateral heel wedges
    1. X-ray of ankle
    2. Surgery referral
    3. Early mobilization
    4. Ankle brace
    5. Ultrasound of ankle

    Author of lecture Ankle and Foot Pain: Management

     Charles Vega, MD

    Charles Vega, MD

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