Foot and Ankle Management for the injured dancer - PowerPoint Presentation

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Foot and Ankle Management for the injured dancer

Presented by:Jonathan Reynolds, PT, PhD

1/30/19

1

22

nd

Annual Orthopaedic and Sports Medicine Conference Slide2

Diagnostic Excellence

Detailed historyThorough examinationRadiology dependenceThree major concerns:Posterior pain

Plantar foot painRecruitment/poor co-ordinationPracticumExamination

Treatment

1/30/192Slide3

Scenario 1:

Posterior Ankle Pain1/30/19

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Posterior Ankle Pain

Achilles tendinitisPosterior impingementTalocrural joint

Os TrigonumSteida’s

ProcessFHL TendinitisTalar stress fracture/OCDTalocrural malalignment

Anterior translationPosterior translation1/30/194Slide5

Achilles Tendinitis

Pain at:Anterior aspect (soleus) of Achilles tendonPathomechanics

Overuse (jumping, releve, running)Evaluation

Provocative tests:Heel raiseJumpSoleus stretch

MMT: Up on toesPROM: ankle DF Palpation: Tenderness at soleus aspect of ATCheck teno-periosteal junction at calcaneus1/30/19

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Differentiators:

Surface anatomy

Localization of pain

Range of ankle motion when symptoms are feltSlide6

Posterior Impingement

Pain at:Posterior TCJPathomechanics

Overuse (dance, high heels)Os TrigonumSteida’s

ProcessEvaluationProvocative tests:Heel raise – pain at EOR

MMT: Up on toesPROM: ankle PF Palpation: tenderness at TCJ – posterior capsule1/30/196

Hamilton, W.G.,

Clin

. Sports Med., 1988

Differentiators:

Pain on forced PF

Patients with PI will OVERUSE

gastroc

./soleus/AT to compensate → Achilles tendinitisSlide7

Posterior Impingement

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En

pointe

ReleveSlide8

Posterior Impingement

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Os

TrigonumSlide9

Posterior Impingement

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Ganglion Cyst

Talar

Stress FractureSlide10

Flexor Hallucis Longus Tendinitis

Pain at:Plantar MTPJ

Medial longitudinal archAntero-medial calcaneus (?PF)Retro-malleolar (medial)Pathomechanics

Forefoot varus → Ankle valgus Knee valgus↓Tissue complianceShortened use (ballet, high-heels)

Overuse (jumping, up on toes)EvaluationMMT: *1st MT plantarflexionPROM: *ankle DF with 1st MT DFPalpation: *tenderness along FHL1/30/19

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Differentiators:

Surface anatomy

MMT of 1

st

MT

Test-treat-re-testSlide11

Talar Stress Fracture and OCD

Pain at:Posterior TCJPathomechanics

Overuse (jumping, running)EvaluationProvocative tests:

Forced PFDownhill walkMMT: N/APROM: ankle PF

Palpation: Tenderness at:Posterior TCJ1/30/1911

Differentiator:

Catching during running and walkingSlide12

Talocrural Malalignment

Pain at:Retro-malleolarPosterior TCJ

PathomechanicsRepetitive decelerationEvaluationProvocative tests:

Forced PFPointeMMT: N/APROM: ankle PF

Palpation: N/AMixed: talus PA glide is:TherapeuticDiagnostic1/30/19

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Differentiators:

Negative MMT

+ forced PFSlide13

Normal Ankle Mechanics - Dorsiflexion

Talus – glides posteriorly, externally rotates and tilts laterallyFibula – supero-posterior glide, lateral translation

Proximal TFJ – Fibula moves anterolaterally and superiorly and rotates.Peroneus longus

– plantarflexes 1st rayPeroneals

(longus and brevis) – transfer weight from lateral to medial forefoot.1/30/1913

Denegar

and Miller, 2002)Slide14

Normal Ankle Mechanics - Plantarflexion

Talus – glides anteriorly, internally rotates and tilts mediallyFibula –

infero-anterior glide, medial translationProximal TFJ – Fibula glides Superoposteromedially with pronation, and

Inferoanterolaterally with supination.

1/30/1914Denegar and Miller, 2002Slide15

Scenario 2:Plantar Fasciitis

FHL TendinitisSesamoiditis

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Plantar Fasciitis

Pain at:Tenoperiostial junction (TPJ)Pathomechanics

Forefoot varus →PronationKnee valgus

Overload↓myofascial complianceTissue adaptationThickening

InflammationPain↑Water-binding capacityExaminationAlignment: HindfootForefootStanding posture:KneeFoot and anklePROM: Tight Achilles/gastroc

/soleus

Palpation: greatest at TPJ

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Flexor Hallucis Longus Tendinitis

Pain at:Plantar MTPJ

Medial longitudinal archAntero-medial calcaneus (?PF)Retro-malleolar (medial)Pathomechanics

Forefoot varus → Ankle valgus Knee valgus↓Tissue complianceShortened use (ballet, high-heels)

Overuse (jumping, up on toes)EvaluationMMT: *1st MT plantarflexionPROM: *ankle DF with 1st MT DFPalpation: *tenderness along FHL1/30/19

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Differentiators:

Surface anatomy

MMT of 1

st

MT

Test-treat-re-testSlide18

Sesamoiditis

Pain at:Plantar aspect of first rayPathomechanics

Forefoot varusKnee valgus

Tight/overactive hip adductorsWeak/inhibited hip abductors and external rotatorsPoor myofascial complianceShortened use (ballet, Irish dance high-heels)

Overuse (jumping, up on toes)EvaluationProvocative test:Heel raiseHoppingMMT: 1st MT plantarflexionPROM: ankle DF with 1st MT DFPalpation: *tenderness at sesamoids

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Differentiators:

Surface anatomy

Localized painSlide19

Scenario 3:Ankle instability

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Chronic Ankle Instability (CAI)

Alteration in TCJ arthrokinematics (Wilkstrom and Hubbard, 2010)

Reduced dorsi-flexion ROM (Drewes

et al 2009)Decreased postural control (Wilkstrom et al, 2009; Arnold et al, 2009; Munn et al, 2010)

Arthrogenic inhibition (McVey et al, 2005)Altered spinal reflex modulation patterns in soleus (Sefton et al, 2008)1/30/19

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Possible Causes

Greater Q-Angle in femalesLigament laxityPatella laxityGreater quadriceps:hamstring

strength ratioHormonal effects on ligament tensile strengthLanding techniquePoor shoe designTightness/↑ activation adductors

Weakness/inhibition or fatigue:Gluteus maximus and deep external rotatorsNeuromuscular activation lag (Chappel

et al, 2005)Impaired balance (Greig and Wilker-Johnson, 2007)Reduced coordination (Coventry et al, 2006) and proprioception1/30/19

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Foot and ankle Examination

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Examination

AlignmentFoot alignment

Quick Active TestsSquat

DoubleSingle

HopLungeRange of MotionDorsiflexionPlantarflexionPalpation

FHL

retromalleolar

, plantar,

retrofibular

Knot of Henry

Achilles – soleus component

Talocrural joint - posterior

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Differential Diagnosis Algorithm

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Posterior

Ankle

Pain

Heel

Raise

DF

PF

1

st

MTJ

PF MMT

Palpation

Treatment

Achilles (soleus)

XFM: Achilles

MFR: G&S

Ecc

. strength

FHL

Chief

Complaint

Peroneus Longus

XFM: FHL

MFR: FHL

Ecc

. strength

XFM: PL

MFR: P

Ecc

. strength

TCJ Capsule

PA Mobs

Windlass PNF

Balance

Plyometrics

XFM: TCJ caps

Balance

Plyometrics

No

Yes

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

No

No

Yes

Yes

Yes

Ankle

Ev

.+PF MMT

ISQ

Provocative TestsSlide25

Treatment

Joint mobilization (physiological and accessory) to:Restore joint mobility (DF)Improve functional stability

(Hoch and McKeon, 2011), and Relieve painSoft tissue treatments to:Fascia

Ligament/capsuleMuscleTendonPNF to ankle musculature to:

Inhibition: decreased motoneuron drive Facilitation: increased motoneuron driveProprioception:Wobble board, BOSU PerturbationsIntrinsic strengthening

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Deep Transverse Friction Massage

Tendons on a Stretch

Muscles relaxedStructures

AchillesFHLPeroneus longus

Posterior capsule1/30/1926Slide27

Soft Tissue Mobilization

Ligamentous mechanoreceptors → postural controlDeep transverse frictionsFascial manipulationImproved:

Mechanoreceptor activationFacilitation of spinal reflexesGreater tensile strength

Improved perfusion1/30/19

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Joint Mobilization

Talocrural PAProne

SupineSelf-applied

Talocrural APProne

SupineSelf-applied1/30/19

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TCJ mobilization (Maitland) improves DF ROM and SLS postural control

(Hoch and McKeon, 2011)Slide29

Joint Mobilization

DirectionGradeRhythmDose

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<60 degrees of active ROM: Accessory

=>60 degrees of active ROM: Physiological

Identify at least one Comparable Sign (CS)

I

II

II+

III

IVSlide30

Talo-Crural AP

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Patient

Supine, ankle neutral.

Therapist

Places right hand over dorsum of foot and left hand under calcaneus.

Mobilization

Applies distraction to the

talocrural

joint and applies AP pressure to the foot using the bed as a counter force

May use strap to apply long axis distraction

Grades I to IV

Repeat for 30 seconds, then check CSSlide31

Dynamic Stability from Proprioceptors

Fascia – Golgi end organs (90%), slow α-

mn firing rate, Paccinian and Pacinoform : rapid response to changes in pressure and vibration

Ruffini : slow response to pressure changeType III (unmyelinated

) and type IV (myelinated) free nerve endings: mechanoreceptorsLigament – Golgi end organ – function as anti-gravity mechanorepceptorsType III and IV free nerve endings: mechanoreceptorsMuscle – spindle - gamma afferent from intrafusal fibers: length, tension.

Tendon –

Golgi tendon organ:

respond to slow stretch by slowing the

α

-

mn

firing rate

Less than 10% of GT receptors found in tendon

Instability

Persistent faulty firing from receptors

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Proprioceptive Rehabilitation

PostureTandemSingle leg stanceSurface

Firm groundFoamBOSUWobble BoardPerturbations

Eyes closedHead turnArms to the sideWeight passing side-to-side

Arm sagittal circles with eye trackingWalking side-to-sideSimulation1/30/1932Slide33

Plyometrics

Reduced loadTotal GymPoolShuttleProgress to full load

Two feet to two feetOne foot to one footTwo feet to one foot

Two foot take off, single foot landing

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Plyometrics

1/30/1934Slide35

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Questions