노인에서 뒤꿈치와 발목의 변형과 통증

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1 일산백병원재활의학과 족부클리닉, 소아휜다리클리닉 이홍재

2 1. 노인발목 / 뒤꿈치통증원인들 2. 치료방법들 3. 노인발목 / 뒤꿈치의변형 4. 치료방법들

3 Lateral ankle pain repetitive sprain & Anterolateral impingement Sinus tarsi SD Peroneal tendinopathy Talus Stress Fx

4 ATFL repitative sprain Anterolateral impingement Sinus tarsi SD

5 Medial ankle pain Tibialis posterior tendinopathy Tarsal tunnel SD FHL tendinopathy FDL tendinopathy

7 Posterior ankle pain Insertional achilles tendinopathy Retrocalcaneal bursitis Haglund s deformity (disease) Posterior ankle impingement SD

9 Anterior ankle pain Ankle jt arthritis :OA, inflammatory arthritis Traumatic synovitis after sprain Osteochondral lesion on talar dome Syndesmosis sprain Anterior impingement Charcot joint Tendinosynovitis: Tibialis anterior, EDL,...

11 Heel plantar pain Plantar fasciitis Heel pad contusion, atrophy Baxter s nerve impingement S1 radiculopathy, foraminal stenosis Hidden calcaneal Fracture

14 Heel pad Columns of Adipose tissues Separated by fibrous septae Shock absorbing

15 Sx Diffuse pain Painful at most of the Wt-bearing portion of the calcaneus P/Ex Not to radiate anteriorly Regardless of toe DF (fascia tension) Td on midpoint of heel pad Thin heel fat pad 호발 : eldly, obese patients, overuse in sports man, Hx of steroid inj on heel pad

16 Tx Heel silicon pad Foot orthosis with enough cushion (poron ) and deep heel cup Shoes with enough cushion 1. Heel pad c PORON 2. Dee heel cup tech

17 Plantar fascia A sheet of dense fibrous, collagenous connective tissue Relatively non-elastic Origin : plantar tuberosity of the calcaneus Insertion : deep short transverse ligaments of MT heads

18 T1-weighted sagittal image in a patient without heel pain. The normal plantar fascia (arrows) is thin demonstrates low signal intensity on all pulse sequences.

19 3 bands: central, medial, lateral m/c affected in central band Thickness : 3-4mm Functions Support for the longitudinal arch Dynamic shock absorption FDB

20 Sx Pain in first step in the morning After long time sitting Dissipate after several minutes In advanced cases, constant aching or throbbing pain 악화 : 맨발보행, 아치서포트없는신발착용

21 악화위험인자 1. Flat foot : overstretched fascia during overpronation 2. Pes cavus : sudden stretching of fascia at the quick start to run in rigid cavus foot 3. LLD : 체중부하를많이담당하는쪽 4. Femoral anterversion : leg int rotation more pronation of the foot

22 악화위험인자 5. Achilles tightness : Most important factor 1 STJ overpronation 2 early heel off fascia tension 증가

23 Physical findings Td on medial tubercle of the calcaneus or Proximal fascia Pain during Windlass test By big toe passive DF Esp, standing position

24 X ray : Heel spur 여부와는무관 Heel spur :15-25% in general population US: fascia thickness >4~5mm,, decreased echogenicity, perifascial effusion, hypervascularity ( in acute stage)

25 MRI : T1 : thickening and increased signal intensity within the plantar aponeurosis at the calcaneal attachment STIR : minimal edema is present deep to the calcaneal insertion EMG for R/o S1 radiculopathy STIR : Short T1 inversion recovery

26 T1-weighted sagittal image in a 50 year old female with mild, chronic heel pain reveals thickening and increased signal intensity within the plantar aponeurosis at the calcaneal attachment (arrow). A prominent calcaneal spur (arrowhead) is present.

27 1 st step NASIDs and PTx Padding, silicon heel cup OTC arch support c heel pad, 실내에서도쿠션슬리퍼착용 Stretching of calf muscle For 4-6 wks

28 2 nd Step Arch support to contol overpronation Medication + PTx + calf stretching Custom molded FO Enough heel cushion with deep heel cup tech Especially for overpronated foot controlling overpronation Night splints For 4~6 wks 1. Heel pad c PORON 2. Dee heel cup tech

29 3 rd Step continued 1 st and 2 nd step Tx Corticosteroid Inj 1 time Exact infiltration on the fascia under US guidance 1cc lidocaine +10~20mg Triam (or 1cc lido + 2mg limethason) Additional injection deep to fascia (b/w fascia and FDB tendon attachment site) Wait for 4~6 weeks

32 4 th Step ESWT 3~5 times, every week, Fasciotomy, nerve release 새로시도중인치료법들 Botulinum toxin injection Prolo Tx PRP

33 Onset :3 mon ago, aggravated 2 weeks ago Pain charac : first step pain, worse after walking Past Hx: 3 times steroid inj in local clinic under Dx of plantar fasciitis P/Ex : direct td on med calc tubercle, windlass test 시통증 (+) severe hyperkeratosis on heel Td on med heel soft tissue when pinching

36 Blind Injection 의문제점 1. 접근방법 2. 주사깊이

37 Ankle joint 특성 단위면적당받는체중이크다. 하지만, 다른관절에비해관절염의비율은낮다 1/9 of knee and hip arthritis Rolling jt 역할, 높은하중에서정합성보임 외상도흔히발생

38 관절연골두께 : 1~1.7mm 로제일얇음. 다른관절에비 해상대적으로일정한두께. Compressive modulus 는 제일높다. 관절의정합성이떨어질수록, 접촉면적이일부분에집중 퇴행성 발목관절연골은 tensile strength 가타관절에비해높고, 균질성이높아서 indentation 적다

39 원인 외상 : 관절연골의손상정도, 관절면의정확한정복여부가크게관여 비정상적인발목의생역학 퇴행성변화 염증성질환, 혈관절증, 감염 신경병증관절증 종양

40 Sx Pain on Wt bearing or motion 주로 anterior ankle pain Swelling, morning stiffness of ankle Warmth

41 Physical findings X ray CT and MRI

42 X ray asymmetric cartilage space loss subchondral sclerosis and cyst Osteophytosis, intra-articular loose body

43 Osteochondral Fracture

44 MRI : early detection Morphological changes of cartilage (thickness and signal) subchondal trabecular thickening, cyst subchondral BME, small osteophyte

46 Activity modification Wt control NSAIDs Corticosteroid injection 2 달정도의단기효과 3 달이상간격두고주사 Hyaluronic acid Intraarticular inj

47 Foot orthosis: 후족부의정렬회복, 특정관절면의자극을감소 Shoe modifications 발목과후족부의가동성을줄임 High top shoe with stiff midsole (extended steel shank) and Rocker bottom sole Proper wedge and SACH AFO or lace-up ankle support T-strap double-metal upright AFO PTB- AFO

48 for realigning of ankle jt and Wt redistribution Extra depth shoe + Custom molded foot othosis

50 Surgery Debridement and Distraction arthroplasty Corrective osteotomy Arthrodesis Arthroplasty Total ankle replacement

51 51

52 A triple arthrodesis consists of the surgical fusion of the talocalcaneal (TC), talonavicular (TN), and calcaneocuboid (CC) joints in the foot 52

53 53

54 54

56 Exostosis: Tibial spur & talar beak impingement spur normal

57 Tarsal tunnel b/w med Malleolus and post tubercle of talus, med aspect of calcaneus Covered by flexor retinaculum 지나가는구조물 : Posterior tibial nerve, artery, vein, Tendon of TP, FHL, FDL, 이터널내에서 PT nerve 가내, 외측가지로분지

59 Def. TP nerve 가족근관내에서눌려서나타나는여러가지증세들 원인 신경내부의원인 : 말초신경염, 말초혈관질환, 당뇨병성신경병증, 신경종, 신경초종 신경외부의원인 : 결절종, 지방종, 외상, 정맥류, tarsal coalition Unknown origin

60 Dx of TTS P/Ex : tinel sign?, mass?, distribution of abnormal sensory area? X ray: 뼈의이상유무 - coalition, bony spur, non union.. MRI : 깊은곳까지잘보임. US : mass, ganglion EMG: NCV of med and lat plantar nerve, needling on foot muscles

61 Tx Conservative 대부분의치료방법 Medication Steroid injection Anti depressants PT modalities Surgery 신중을기해야함. Mass 가확실히신경을누르는경우에만

62 Any ankle injury 와동반가능 증세 : ankle jt pain and swelling, LOM 원인 : 충분한휴식과치료없이다시운동복귀 초기에과도한체중부하

63 발생원인에대한요즘의견해 Mild form of sympathetic neuropathic pain Mild form of CRPS type 1 치료 Steroid IA injection Medications for neuropathic pain: Etravil, Gabapentin,.. Active ROM ex Slow progressive Wt bearing

65 1886 년 Chartcot & Marie 와영국의 Tooth 에의해처음으로기술 일차적으로운동신경을침범, 원위에서근위부로올라오는운동기능장애유발 진행성 발병율 : 일년에 1/2500 명 미국에서가장흔한 inherited neuropathy

68 Herediatary motorsensory neuropathy (HMSN) Inherited degenerative disorder in central and peripheral nervous system Muscle atrophy Loss of proprioception 발을가장먼저침범, 가장심하게침범

69 Pathology : Myelination 이상 Unknown : Gene mutation.

70 By Dyck et al., based on electrophysiologic properties and histopathology Type I ~ V Two main type HMSN 1 : primary peripheral demyelinating neuropathy HMSN 2 : primary peripheral axonal neuropathy

74 Stage 1: 건염, 건초염증세, no planovalgus deformity Stage 2: 건염, 건초염증세, planovalgus deformity (+), flexible Stage 3: planovalgus deformity (+), fixed Stage 4: fixed planovalgus deformity + valgus tilt of talus

75 PTTD stage 주간단하지석고붕대나보조신발그리고, 이후에재활운동 NSAIDs : 염증반응과통증감소 Foot orthosis

76 Stage 2 controlling longitudinal arch and heel valgus Foot orthosis AFO, Supramalleolar orthosis Shoe modification: extended medial counter or medial heel wedge For acute pain : immobilization

77 Stage 3 AFO, hinged Supramalleolar brace Fixed heel valgus 심하면보조기치료에반응이적다

78 Stage 4 Non-hinged AFO

79 - 비수술적치료로반응이없을때수술을고려 Stage 1 : 활액막절제술, 건감압술 Stage 2 : 활액막절제술, 건감압술및일차봉합 필요시건이전술 변형이있으면절골술과관절유합술고려 첨족이동반시, 후방근그룹연장술

80 Stage 3 보통, 관절유합술시행 Single, triple 첨족에대해후방근그룹연장술 stage 4 Ankle Mortise 내에 talus valgus deformity 있으므로 talocrural jt 를포함한수술 talar valgus without talocrural jt degenerative change 내측삼각인대봉합술, 내측전위종골절골술 talar valgus with talocrural jt Degenerative change 전거골관절유합술시행. 추가로전족근관절치환술이나과상절골술을삼중관절유합술과연계.

81 Hindfoot Common disorders in the eldly Degenerative Dz : Ankle arthritis P. fasciitis, heel pad atrophy Post-traumatic synovitis Deformities : CMT, PTTD

Microsoft PowerPoint - 발표자료(KSSiS 2016)

Microsoft PowerPoint - 발표자료(KSSiS 2016) Sang Jun Kim, MD, PhD Application of 3D Printing in the Orthotic Fields Hallux Valgus, Charcot Marie Tooth, ADL Kit, Foot Insole, Wrist Pain, Foot Drop Development of Automated Program for Ankle Foot Orthosis