Transcript Slide 1

The foot and ankle
Anatomy- bones
Anatomy- ligaments
Anatomy- tendons
Anatomy- tendons
Anatomy- syndesmosis &
capsule
The Ankle joint
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Hinge joint
Locomotion
Proprioception
Movements at this joint include
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Dorsiflexion
Plantarflexion
Eversion
Inversion
 Supination is a combination of plantarflexion,
inversion and forefoot adduction
 Pronation is a combination of dorsiflexion,
eversion and forefoot abduction
Movements of the ankle
Pronated, supinated or neutral
Patient walks in c/o ankle pain
 What is the mechanism of injury?
 What position was the foot in at time of injury?
 Most common is the inversion injury:
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Plantar flexed
Inverted
Adducted
 This can injure
 ATFL
 Anterolateral capsule
 Distal tibiofibular ligament
 Can cause a malleolar/ talar dome fracture/ medial
ankle pain through compression
Patient walks in c/o Ankle pain
 Was there any deformity after injury?
 Transitory locking indicating a loose body?
 Able to continue?
 Usually a grade 1 ankle sprain can continue with
running (painfully)
 A grade 2 ankle sprain can walk (painfully)
 A grade 3 ankle sprain cannot weightbear
 Staging the injury is important... Acute, subacute
or chronic. Is this acute on chronic?
 Does pain increase or decrease with activity?
 What does the patient do for work and leisure and
are there any contributing factors?
Patient walks in c/o Ankle pain
 Gait: have they walked/ limped in?
 Check for:
 Swelling- usually quick onset
 Bruising- can be delayed
 Numbness
 Pins and Needles
 Weakness: could this actually be an L4 nerve
root compression?
Ottawa Ankle rules
 Patient requires an ankle X-ray if:
 Bone tenderness along
the distal 6 cm of
the posterior edge of the tibia or tip
of the medial malleolus
 Bone tenderness along the distal
6 cm of the posterior edge of
the fibula or tip of the lateral
malleolus
 An inability to bear weight both
immediately and in the rooms for
four steps
Ottawa foot rules
 The patient requires a foot x-
ray if:
 Bone tenderness at the base
of the fifth metatarsal
 Bone tenderness at
the navicular bone
 An inability to bear weight
both immediately and in the
rooms for four steps
Assessment
 Assess in standing, ability to load through
joint, foot position. Always comparing sideside
 In lying check range of movement relative to
uninjured side.
 Palpate the painful area and surrounding soft
tissue and joints
Ligament tests
 ATFL- Anterior drawer test
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at 20° plantarflexion
Calcaneofibular ligamenttalar tilt at 90° into
adduction
Deltoid ligament- talar tilt
at 90° into abduction
Squeeze test- syndesmosis
injury
Thompson’s Test- Achilles
Other injuries to note
 Fractured calcaneum (a ‘Lovers’ or ‘Don Juan’
fracture!)- fall from height or occasionally with an
inversion injury.
 Fractured sub-talar surface can occur also. Check out
‘Sanders’ classification system.
 Sub-talar joint dislocation... Urgent relocation required
 Lis-Franc fracture-dislocation.
 Direct: crush injury
 Indirect: requires a longitudinal force sustained while the
foot is plantarflexed. A backward fall with the foot
entrapped, and a fall on the point of the toes is also a
common mechanism.
 Persistent midfoot pain for >5 days should raise suspicion
 Tenderness of the midfoot on palpation and pain on
eversion+abduction of forefoot while calcaneus is still
More injuries to note
 Navicular fracture: can be an avulsion, a
fracture of the body, or a stress fracture.
 Point tender over the ‘N’ spot.
 Pain with passive eversion and active inversion
 Very difficult to see on plain films
 Cuboid syndrome- subluxation of the cuboid...
Needs manipulation. Patient can’t walk
barefoot.
 Stress fractures: any bone, any age. Caused
by a spike in training or loading.
 Severe’s disease: growth plate enthesopathy
More still
 Hallux valgus: pain
can be unbearable,
need to see a
podiatrist.
 Morton’s neuroma:
pain in toes with
pins & needles and
numbness... Need
to see a podiatrist/
physio/ foot
surgeon.
Plantar fasciitis
 Patient complains of heel pain and/or pain through the arch
 Often chronic, and is not inflammatory so is actually a
fasciosis/ fasciopathy
 Not able to rise up on the balls of the feet from flat foot
 Risk factors include:
 Running and dancing
 Very high arches or very flat feet
 Poor shoe choices
 Obesity
 Poor dorsiflexion range
 Tight posterior fascial lines
 Patient MUST be referred for quality physiotherapy- at least
one session to teach how to self massage, stretches, foot
strengthening exercises, taping, shoe education.
Advice for a ‘mild’ sprained
ankle
 Get rid of the swelling
 Avoid running until pain-free hopping on one foot is
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possible
Walking (pain-free), cycling, cross-training and
stepping can be done to keep active, must ice
afterwards
Ankle braces should not be worn, not supportive
enough to prevent damage and offer ‘false’ sense of
security, while creating a biomechanical alteration
Proprioception exercises should be done prior to return
to sport
Theraband strengthening exercises are a good idea to
prevent future injuries.
Advice for ‘plantar fasciitis’
 Ice the area, sometimes using a frozen plastic
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bottle of water is useful to roll the foot (roll away
from the toes towards the heel)
Don’t walk around barefoot, supportive shoes
with good arch support can help relieve pain.
Avoid flat shoes like flip flops... ‘fitflops’ offer a
good alternative.
Stretching the soleus can help: stretch against a
doorframe.
Strengthening the foot through exercises with a
towel on the floor and theraband for the ankle.
Lose weight
Avoid exercising on hard surfaces