The Foot and Ankle Complex
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Transcript The Foot and Ankle Complex
The Foot and
Ankle
Complex
SARAH RAYNER
EXTENDED SCOPE PRACTITIONER PHYSIOTHERAPIST
Anatomy
The ankle and foot is a complex structure
comprised of 28 bones (including 2 sesamoid
bones) and 55 articulations (including 30 synovial
joints), interconnected by ligaments and muscles
In addition to sustaining substantial forces, the
foot and ankle serve to convert the rotational
movements that occur with weight bearing
activities into sagittal, frontal, and transverse
movements
Anatomy: Ankle
Anatomy : Foot
Hindfoot (posterior
segment): talus and
calcaneus
Midfoot (middle
segment): navicular,
cuboid and 3
cuneiforms
Forefoot (anterior
segment): metatarsals
and the phalanges
Examination: site of pain
Examination: site of pain
Examination: site of pain
Anatomy: Surface marking
practical
Talocrural joint line
Medial malleolus
Lateral malleolus
Navicular
1st MTP joint
Achilles tendon
Tibialis posterior tendon
Anterior talofibular ligament
Calcaneofibular ligament
Peroneus longus and brevis
Plantarfascia attachment to calcaneus
Midtarsal joint line
Conditions: lateral
ligament injury
Acute inversion of ankle
Usually occurs in sports requiring quick change of
direction especially if it takes place on uneven
surfaces such as grass.
Also common in sports when a player has jumped
and lands on top of another players feet.
Most common mechanism is Inversion coupled with
PF.
ATFL injured first then CFL as ATFL is taut in PF
On Examination:
Lateral ankle pain and swelling
Pain on inversion combined with plantarflexion
Tests: Anterior draw and talar tilt
Ottawa Ankle Rules
Conditions: lateral ligament
injury
Management
PRICE
Graded return to sport
May require Physiotherapy
Rate of recovery dependent on severity
Failure to resolve
Continued instability or possible OCD
Refer to CATTS / Orthopaedics
May require further investigations ? MRI
Surgical intervention (arthroscopy +/- stabilisation
procedure
Conditions: Plantarfasciitis
Insertional heel pain of the plantar fascia with or
without a heel spur.
Biomechanical abnormalities cause pathological
stress to the plantar soft tissues
Typical presentation:
Isolated heel pain on initiation of WB (on rising am or
after prolonged sitting/rest)
Predisposing factors:
High BMI
Tightness of TA
Inappropriate shoe wear
On Examination
Pain on palpation at plantar fascia insertion
Conditions: Plantarfasciitis
management
Initial self directed treatment (up to 6 weeks):
NSAID’s
Regular calf and plantar fascia stretches
Avoidance of flat shoes and barefoot walking
OTC arch supports and heel cushions
Ice
Weight loss
Limitation of extended physical activity
Consider steroid injection where appropriate
If failing to improve refer on to local CATTS/MSK service:
Custom orthotics (podiatry)
Night splints
Steroid injections
Immobilisation
Extracorpeal shockwave therapy
Surgical plantar fascia release
Conditions: Achilles
tendinopathy
Non-insertional:
Usually a degenerative mid substance lesion
Often with neovascularisation and proliferation of
neural structures in the area which cause pain
Often poor collagen structure, poor healing and no
inflammation on imaging
Insertional:
Change in microscpic structure with increased
Glycosaminoglycans
Change in fibrillar structure giving swelling
Tendinitis / tendinosis depends on degree of
inflammation
Bursitis often associated with Haglund’s deformity
(“pump bumps”)
Conditions: Non-insertional
Achilles Tendinopathy
Presentation:
Most common in males but seen in all ages
Pain on Achilles loading (walking, running)
Can be debilitating
Fusiform swelling
Tightness of Gastrocnemius
Treatment:
Eccentric loading exercises
Stretches
Correct abnormal biomechanics
Physiotherapy / podiatry
Extracorpeal shockwave therapy
Conditions: Insertional
Achilles Tendinopathy
Management
Initial conservative treatment as for non-insertional
Achilles tendinopathy
Surgical debridement
Conditions: Achilles
Ruptures
Presentation:
Patients usually feel POP in Achilles area
POP may be heard
Usually occurs in the avascular area of the Achilles 5 – 10cm above
the insertion
Common in Badminton , Squash and football in that order
Usually occurs to the end of a game
On Examination:
+ve calf squeeze
Palpable dip
Management
Surgical
Conditions: Ankle
Impingement
Anterior bony impingement:
Pain usually over anterior ankle
Pain may be anterolateral
Osteophytes usually palpable and may be associated with loss of
ROM particularly dorsiflexion
Arthroscopy
Posterior Impingement
Os trigonum, Bony osteophytes
Adhesions, synovitis ; Multiple injuries or hypermobility (dancers)
FHL tendinitis
Subtalar impingement
If conservative treatment fails, posterior ankle arthroscopy
Conditions: Tibialis Posterior
Dysfunction
Common cause of acquired flatfoot in adults
Women over 40 most at risk
Presenting features:
Pain and swelling medial hindfoot
Change in foot shape reported
On Examination:
Valgus heel, flattened longitudinal arch and abducted
forefoot
Pain on resisted inversion and on palpation tibialis
posterior
Pain and dysfunction on single leg heel raise
Conditions: Tibialis Posterior
Dysfunction Management
Conservative treatment
Rest
Orthotics
Weight
and podiatry
management
Surgical management
Hindfoot
osteotomy with tendon transfer
Arthrodesis
of the hindfoot
Conditions: Hallux Rigidus
1st MTP Arthritis
Epidemiology:
Women > men
60% bilateral
Late adulthood
Etiology:
Direct: trauma, fracture
Indirect: TMT hypermobility, flat 1st MTP joint, Long 1st MT, pes planus,
inflammatory
Clinical Symptoms:
Limited 1st MTP movement
Pain on toe off
Pain with activity
Pain with shoewear
Swelling
Limp: lateral foot WB, external rotation of hip
Conditions: Hallux Rigidus
Management:
Conservative
Footwear
Activity modification
Podiatry
Injections
Surgery
Cheilectomy
Osteotomy
Joint replacement
Fusion
Conditions: Morton’s
Neuroma
Swelling of nerve and scar tissue arising
from compression of the interdigital nerve
Often pain radiating into the toes
accompanied by pins and needles
Pain increased by forefoot weight bearing
and with narrow fitting footwear
On Examination:
Interdigital pain commonly in the 3rd and 2nd
interdigital space
+ve Mulder’s test
Management:
•
Orthotics
•
Injection
•
Surgical removal
Examination: Summary
As always take a good history to guide your examination: site of
pain, overuse or trauma, swelling, WB status etc.
Gait and function (heel raise, weight transfer, proprioception)
Observations: in standing and sitting/lying
Swelling, heat, scars, bruising, circulation, deformity
Biomechanics (pronation/supination, abducted)
ROM
Resisted testing
Palpation
Special Tests
Anterior draw rest
Talar tilt test
Squeeze test
Calf squeeze test (Thompson test)
Lateral squeeze test for Morton’s neuroma (Mulder’s click)
Case Studies: Practical
1.
Monica a 30-year-old medical receptionist presents with sore Achilles
tendons. Over the weekend she has done a 15-mile sponsored walk.
She is a bit annoyed because although she does not do any
significant walking she feels that she keeps herself very fit with her Latin
American dancing. She also bought an expensive pair of Nike trainers
especially for the walk.
2.
A 45-year-old lady complains of pain in her right heel. This started 3
weeks ago after she had spent the weekend helping her husband lay
some flags for a patio. She describes how it feels as if she has a small
ball bearing under her heel when walking.
3.
A 65-year-old man complains of gradually increasing pain in the ball
of his right foot over several months. He has had to curtail his ballroom
dancing and of late his walking is becoming restricted.
4.
A 13-year-old girl who enjoys ballet is finding increasing pain in her left
big toe with her dancing. She says her big toes are not straight
anymore.
5.
A 46-year-old farmer complains about his left ankle. Apparently a year
ago he had a "bad sprain" when he inverted the ankle as he was
trying to catch a sheep. He went to casualty and had an X-ray (NBI)
and came away with a tubigrip bandage. He was not followed up.
Since then he finds himself "going over" on the ankle on uneven
ground if he is not watching carefully where he puts his feet. The ankle
is frequently swollen following these episodes.
Any
Questions?
THANK YOU