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 ID: 131907
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Slide1
The Foot and Ankle Complex
Sarah Rayner
Extended Scope Practitioner PhysiotherapistSlide2
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 Slide3
Anatomy: AnkleSlide4
Anatomy : Foot
Hindfoot (posterior segment): talus and calcaneus
Midfoot (middle segment): navicular, cuboid and 3 cuneiforms
Forefoot (anterior segment): metatarsals and the phalangesSlide5
Examination: site of painSlide6
Examination: site of painSlide7
Examination: site of painSlide8
Anatomy: Surface marking practical
Talocrural
joint line
Medial
malleolus
Lateral
malleolus
Navicular
1
st
MTP joint
Achilles tendon
Tibialis posterior tendon
Anterior
talofibular
ligament
Calcaneofibular
ligament
Peroneus
longus
and
brevis
Plantarfascia
attachment to calcaneus
Midtarsal
joint lineSlide9
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
tiltSlide10
Ottawa Ankle RulesSlide11
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 procedureSlide12
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 insertionSlide13
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 releaseSlide14
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”)Slide15
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 therapySlide16
Conditions: Insertional Achilles Tendinopathy
Management
Initial conservative treatment as for non-insertional Achilles tendinopathy
Surgical debridementSlide17
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
SurgicalSlide18
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 arthroscopySlide19
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 raiseSlide20
Conditions: Tibialis Posterior Dysfunction Management
Conservative treatment
Rest
Orthotics and podiatry
Weight management
Surgical management
Hindfoot osteotomy with tendon transfer
Arthrodesis of the hindfootSlide21
Conditions: Hallux Rigidus
1
st
MTP Arthritis
Epidemiology:
Women > men
60% bilateral
Late adulthood
Etiology
:
Direct: trauma, fracture
Indirect: TMT hypermobility, flat 1
st
MTP joint, Long 1
st
MT,
pes
planus
, inflammatoryClinical Symptoms:
Limited 1
st
MTP movement
Pain on toe off
Pain with activity
Pain with
shoewear
Swelling
Limp: lateral foot WB, external rotation of hipSlide22
Conditions: Hallux Rigidus
Management:
Conservative
Footwear
Activity modification
Podiatry
Injections
Surgery
Cheilectomy
Osteotomy
Joint replacement
FusionSlide23
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 3
rd
and 2
nd
interdigital space
+
ve
Mulder’s test
Management:
Orthotics
Injection
Surgical removalSlide24
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)Slide25
Case Studies: Practical
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.
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.
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.
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.
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
.Slide26
Any Questions?
Thank you