Dr Jimmy McLaren Introduction Anatomy amp DDx Hx and Exam Insidious Medial Ankle Medial Ankle Anatomy Bones MM talus calcaneus n avicular Ligaments Deltoid ligament Calcaneonavicular ID: 525727
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Slide1
Medial Ankle and Heel Pain
Dr Jimmy McLarenSlide2
Introduction
Anatomy & DDxHx and Exam
Insidious Medial AnkleSlide3
Medial Ankle Anatomy
Bones
– MM, talus, calcaneus,
n
avicular
Ligaments
Deltoid ligament
Calcaneonavicular
(Spring) ligament
Plantar Fascia, Fat Pad
Tendons
Tib
post
FDL
FHL
Tibial
Nerve Branches
Medial Calcaneal N
Posterior
Tibial
N - Medial Plantar N
-
Lateral Plantar NSlide4
Chronic Medial Ankle/Rearfoot
DDx
Tendons
-
Tib
Post
Tendinopathy
(common)
- FHL
Tendinopathy
Nerves
- Medial Calcaneal Nerve entrapment
- Tarsal Tunnel Syndrome
Bones
-
S
tress # -
Navicular
- Calcaneus
- Medial Malleolus
Plantar Fascia, Fat pad contusion
Posterior Impingement Syndrome
Referred pain
– Lumbar
CRPS Type 1Slide5
History
Previous injuryOveruse (eg
tib
post)
Sport: FHL
tendinopathy - ballet, high jump
Posterior impingement - dance, football
Radiation - to
navicular
(
tib
post),
- to arch (tibial tunnel syndrome)Parasthesia - tarsal tunnel syndromeSlide6
Examination
Biomechanical exam, KTW Functional - jump, hopLumbar Screen
Active - Ankle PF/DF,
Inv
/Eversion, 1
st MTP flex
Passive -
Subtalar
,
midtarasal
,
Resisted - inversion(TP), 1
st
toe flexion (FHL)Palpation - Ankle, Midtarsal joint, -
Tib
Post, FHL,
- MM,
Navicular
,
Calcaneal compression
Tinnel’s
-
compresses
tibial
nerve
Sensation
- pin prickSlide7
TENDINOPATHIESSlide8
Tibialis Posterior
Tendinopathy
Path - posterior to MM
Insert -
navicular
, cuboid,
- cuneiforms, 2-4MT, spring ligament
Fxn
- dynamic stabilizer medial long arch - invert STJ
Causes:
Overuse - Walk/run/jumping
Mechanics - Excessive ST pronation (
ecc
load)
Acute - ankle eversion sprain/#, avulsion
Inflam
- rheumatoid,
seronegative
arthopathySlide9
OE
Single heel raise pain/lack of inversionTender posterior+inferior to MM, towards
navicular
Resisted inversion painful
Swelling unusual – extensive/
seroneg
arthopathy
Grades
II -
pes
planus
,
III - rigid valgus hindfoot
STJ OA,
IV - deltoid ligament compromiseSlide10
Investigations
Treatment
Ice, eccentric exercises,
orthotic,
+/- NSAID if inflammatory
+/-
synovectomy
+/- reconstruction Slide11
FHL Tendinopathy
Anatomy
most posterior,
- b/w
lat+med
tubercles of talus
- b/w
sesamoid
, insert base distal
phalynx
Fxn
- big toe flexion, ankle
plantarflexion
Cause
-
Overuse - ballet/dance
- “Toe grip” shoes to big
- Tenosynovitis
Association with
Posterior Impingement
-
Large/displaced posterior process talus
-
Os
trigonumSlide12
FHL Tendinopathy
Hx
Pain behind MM, on toe-off or forefoot WB
OE
Pain resisted flexion,
passive
hallux extension
‘Triggering’
Excess inversion/eversion on toe off
Posterior impingement
Shoes size
Inv
+/-XR, MRI – assess associationsSlide13Slide14
FHL Tendinopathy
Rx
Ice
Activity Mod
– avoid en
pointe, hard floorsTape/
orthoses
– correct excess pronation
Well fitted shoes
Mobilise
- if STJ
hypomobile
FHL
strength/stretching, STW proximallySlide15
NERVES
Deep
peroneal
NSlide16
Tibial Nerve BranchesSlide17
Tibial Nerve Branches
1) Medial Calcaneal N
Pierce flexor retinaculum
Supply medial heel
Terminal Branches divides deep to flexor retinaculum
2)
Medial Plantar N
3)
Lateral Plantar NSlide18
Tibial Tarsal Syndrome
Intrinsic
Tendonopathy
/tenosynovitis
Varicose Veins
Ganglion
O
steophytes
lipoma
/tumor
Extrinsic
Anatomic -
tarsal coalition
- valgus
hindfoot
Shoes
Trauma:inversion
/#/post-op
Systemic inflammation
O
edema
Tibial
Nerve Compression
Identify Underlying Cause:
Idiopathic
50
%Slide19
Hx
Poorly defined burning/tingling/numbness plantar
foot
Agg
by activity, relieved by rest
But some worse in bed, relieved by moving foot
OE
V
algus
hindfoot
,
pes
planus, excess pronationThickenings/VV/ganglion/swellingTinnel’s
sign – reproduce pain, +/- fasciculation
Compression test (
PF
, invert, and
press)
Pain on passive eversion
+/-
parasthesia +/- intrinsic muscle wastingSlide20
Investigations
Clinical DiagnosisNCS
false negative 50%
inability
to predict which
respond to surgical decompression
XR
- tarsal coalition
MRI/USS
– mass /accessory muscleSlide21
Treatment
NonoperativeCorrect pronation: orthosis
/taping/foot wear
Neural glide
NSAID/
Iontophoresis / CSI
Surgical Decompression
failed conservative treatment &
+
ve
NCS
best results when
c
ompressing structure identified (cf traction neuritis poor response)Slide22
Medial Calcaneal Nerve Entrapment
Aka Baxter’s NerveBranch of
tibial
nerve at MM (or lateral
platar
N)pierce flexor retinaculum
medial heel sensation
Presentation
Burning
inferomedial
calcaneous
Tinnel’s
+
ve
Valgus
hindfoot
, excessive pronationSlide23
Medial Calcaneal Nerve Entrapment
InvestigationsDiagnostic LANCS – often false negative
Treatment
Change footwear
, p
ad
LA/CSI
Decompression of nerveSlide24
STRESS FRACTURES
General FeaturesAgg with activity
Absent / persists at a lower level at rest
If training continues, brought on with less intensity
History
Previous injury
Training load
Female
triad/REDS: Eating disorder,
menstruation
PMH – thyroid,
Meds –
glucocoticoidsSlide25
OE
Tenderness, +/-redness +/- swelling +/-
palpable periosteal thickening
Percussion of long bones
-> pain
at distant points
Biomechanics
:
LLD, excessive
pronation
, weakness,
stiffness
Investigations
XR +/- linear sclerosis
MRI T2
hyperintensity
Bone Scan – 100% sensitivity, but not specific
CT – cortical bone defectsSlide26
Medial Malleolus Stress Facture
vertical from jxn of tibial
plafond and MM
(may
arch obliquely from
distal tibial
metaphysis
)
Slide27
MM Stress Fracture Treatment
No fracture lineNWB until tenderness
resolves,
RTS 6/52
+
/- air braceFracture / cortical defect
Screw
(
Shelbourne
et
al)
(
Lempainen
)Biomechanics, orthosis, footwearSlide28
Navicular Stress #
#1 tarsal stress fractureNavicular impingement
reduced ankle DF
Middle 1/3
navicular
(relatively avascular)
Clinical
Usually
midfoot
pain
“N spot” tenderness – dorsal
prox
navicularSlide29
Navicular Stress #
TreatmentStable # - NWB cast, 6
-8 weeks
Unstable/distracted # - ScrewSlide30
Calcaneal Stress #
2nd most common tarsal stressy
Hx
Military, runners, jumpers, dancers
Technique –
overstriding
, heavy landing
Poor cushioning
OE
Localised
tenderness med or lateral posterior
calcaneous
Pain on calcaneal compressionSlide31
Upper
posterior margin / medial tuberosityTreatment
activity / short period NWB
Soft heel pad, orthotic, shoes
Technique –
overstriding
, heavy landingSlide32
SUMMARY
Plantar Fascia, Fat PadLigamentsTendonsBonesNerves
ReferredSlide33
Medial Ankle LigamentsSlide34
Deltoid Ligament
Superficial Layer
Crosses both ankle and
subtalar
jointsFans - Anterior
tibiotalar
(neck of talus)
-
Tibionavicular
-
Tibiocalcaneal
(
sustenaculum
tali) - Posterior tibiotalar
D
eep layer
Crosses only
ankle
joint
Inferior & posterior
MM
- medial+posteromedial talusprevents lateral displacement
& ER of
talus Slide35
Deltoid Ligament
O/EEversion test - with ankle
neutral
, evaluates superficial
layer
ER stress - evaluates syndesmosis
and deep layer
XR
– stress view with medial clear space widening
Associated clinical conditions
M
edial
malleolus fracture
Maisonneuve fracture
Variant
of
syndesmosis
sprain
Ruptured medial ligament, AITFL + IO membrane, proximal fibula fractureSlide36
Calcaneonavicular (Spring) Ligament
sustentaculum
tali
to
navicular
stabilize medial
longitudinal
arch &
talar
head
OE - flattened medial
longitudinal
arch
Clinical
conditions
Assoc
with
tibialis
posterior tendon dysfunction
Acute
spring ligament tear
forceful
landing on flat foot