Transcript Slide 1
The foot and ankle
Anatomy- bones
Anatomy- ligaments
Anatomy- tendons
Anatomy- tendons
Anatomy- syndesmosis &
capsule
The Ankle joint
Hinge joint
Locomotion
Proprioception
Movements at this joint include
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:
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
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
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
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