Ankle and FootAnkle and Foot

Clinical patternsClinical patterns

Foot Anatomy Foot Anatomy

Superficial layerSuperficial layer

1.1. Abductor Hallucis- Abductor Hallucis- medial plantar nervemedial plantar nerve

2.2. Flexor digitorum Flexor digitorum brevis – medial brevis – medial plantar nerveplantar nerve

3.3. Abductor digiti minimi Abductor digiti minimi – lateral plantar nerve– lateral plantar nerve

2nd Layer2nd Layer Tendon of the FHLTendon of the FHL Tendon of the FDLTendon of the FDL Quadratus plantaeQuadratus plantae

• lateral plantar n.lateral plantar n. lumbricals 1stlumbricals 1st

• medial plantar n.medial plantar n.• lateral 3: lateral lateral 3: lateral

planar n.planar n.

3rd Layer3rd Layer Flexor hallucis Flexor hallucis

brevisbrevis• medial plantar n.medial plantar n.

Adductor hallucisAdductor hallucis• lateral plantar n.lateral plantar n.

Flexor digiti minimiFlexor digiti minimi• lateral plantar n.lateral plantar n.

4th Layer4th Layer dorsal interosseidorsal interossei

• abductors of the abductors of the toestoes

plantar interosseiplantar interossei• adductors of the adductors of the

toestoes

4th Layer4th Layer dorsal interosseidorsal interossei

• abductors of the abductors of the toestoes

Dorsum of footDorsum of foot

Neural AnatomyNeural Anatomy

clinical patterns of ankle and clinical patterns of ankle and footfoot

Poorly localized bilateral foot pain – Poorly localized bilateral foot pain – interdigital neuralgiainterdigital neuralgia

Posterior heel painPosterior heel pain1.1. Superficial calcaneal bursitis (pump bumps)Superficial calcaneal bursitis (pump bumps)2.2. Retro calcaneal bursitisRetro calcaneal bursitis3.3. FHL tendinitisFHL tendinitis4.4. Insertional achilles tendinitisInsertional achilles tendinitis5.5. Peroneal tendinitis, Sural nerve entrapmentPeroneal tendinitis, Sural nerve entrapment6.6. Os trigonum syndromeOs trigonum syndrome

Plantar heel painPlantar heel pain

Medial heel pain Medial heel pain 1.1. Saphenous nerve lesionsSaphenous nerve lesions2.2. Medial calcaneal nerve lesionsMedial calcaneal nerve lesions

Lateral mid foot and hind foot painLateral mid foot and hind foot pain1.1. Peroneus longus and brevis tendinitisPeroneus longus and brevis tendinitis2.2. Calcaneo - cuboid arthropathyCalcaneo - cuboid arthropathy3.3. Recurrent cubido-4Recurrent cubido-4thth metatarsal metatarsal

subluxationsubluxation4.4. Sinus tarsi syndromeSinus tarsi syndrome

Lateralization of foot pain – lateral foot Lateralization of foot pain – lateral foot pain when pathologies are at medial side pain when pathologies are at medial side of the footof the foot

Can be seen in hallux rigidus, hallux Can be seen in hallux rigidus, hallux limitus, painful medial strands of plantar limitus, painful medial strands of plantar fascia in PFascitis or result of excessive fascia in PFascitis or result of excessive pronation secondary to PTTDpronation secondary to PTTD

Medial Foot PainMedial Foot Pain

Common causes Common causes PTTDPTTD FHL tendinopathyFHL tendinopathy

Lesser commonLesser common medial calcaneal nerve medial calcaneal nerve tarsal tunnel syndrometarsal tunnel syndrome stress fractures calcaneus, talusstress fractures calcaneus, talus post impingement syndrome post impingement syndrome referred pain from lumbar regionreferred pain from lumbar region

Posterior tibialis tendon Posterior tibialis tendon dysfunctiondysfunction

Dysfunction of the tibialis posterior tendon is a common condition and a common cause of acquired flatfoot deformity in adults

Women older than 40 are most at risk

Post tibialis is part of deep post Post tibialis is part of deep post compartmentcompartment

Originates on proximal third of tibia and Originates on proximal third of tibia and interosseous membraneinterosseous membrane

Multiple insertion sites – med cuneiform Multiple insertion sites – med cuneiform and navicularand navicular

Ant slip – tuberosity of navicular, CN joint, and Ant slip – tuberosity of navicular, CN joint, and medial cunieformmedial cunieform

Posterior slip – middle and lateral cuneiforms, Posterior slip – middle and lateral cuneiforms, cuboid and 2cuboid and 2ndnd and 4 and 4thth metatarsals metatarsals

Post tib tendon lies in the fibro – osseous Post tib tendon lies in the fibro – osseous groove of med malleolus and has 1.5 cm groove of med malleolus and has 1.5 cm excursionexcursion

Proximal vascular supply – post tibial Proximal vascular supply – post tibial artery, mesotenon and synovial sheathartery, mesotenon and synovial sheath

Distal vascular supply – epitenon via Distal vascular supply – epitenon via periosteal vessels off medial plantar and periosteal vessels off medial plantar and dorsalis pedisdorsalis pedis

Biomechanics Biomechanics Posterior and medial to subtalar and ankle joint Posterior and medial to subtalar and ankle joint

– flexes the ankle, inverts mid foot and elevates – flexes the ankle, inverts mid foot and elevates the medial longitudinal arch through TN and CC the medial longitudinal arch through TN and CC jointsjoints

Locks the subtalar joint during push offLocks the subtalar joint during push off

Most medial tendon & initiator of inversion; Most medial tendon & initiator of inversion; gastro continues the actiongastro continues the action

Works with gastrosoleus to stabilize hind foot Works with gastrosoleus to stabilize hind foot and invert the heeland invert the heel

Foot progresses from hind foot eversion at Foot progresses from hind foot eversion at heel strike to hind foot inversion after mid heel strike to hind foot inversion after mid stance, before heel risestance, before heel rise

Enables efficient progression of transverse Enables efficient progression of transverse tarsal joints from the unlocked to the tarsal joints from the unlocked to the locked positionlocked position

Subsequently gastro soleus acts on the Subsequently gastro soleus acts on the calcaneus to invert the hind foot calcaneus to invert the hind foot additionally, locking the transverse tarsal additionally, locking the transverse tarsal joints and allowing for efficient force joints and allowing for efficient force transmission for gaittransmission for gait

After HS, post tibialis limits subtalar After HS, post tibialis limits subtalar eversion by eccentric contractioneversion by eccentric contraction

MS – Allows for subtalar inversion, locks MS – Allows for subtalar inversion, locks transverse tarsal joints, resulting in a rigid transverse tarsal joints, resulting in a rigid leverlever

Propulsive phase – accelerates subtalar Propulsive phase – accelerates subtalar supination and assists in heel liftsupination and assists in heel lift

Is inactive shortly after heel liftIs inactive shortly after heel lift

Etiology of dysfunctionEtiology of dysfunction

Trauma Trauma Anatomic – shallow groove, tight Anatomic – shallow groove, tight

retinaculum, etcretinaculum, etc Inflammatory process – degeneration due Inflammatory process – degeneration due

to synovitisto synovitis Impingement or constriction in tarsal canalImpingement or constriction in tarsal canal Zone of hypovascularityZone of hypovascularity

Medial ankle pain extending from post to medial malleolus towards the insertion of the tendon

Swelling of the medial hind foot – rare

Tenderness postinf to medial malleolus

Patients may also report a change in the shape of the foot or flattening of the foot

The foot develops a valgus heel (the heel rotates laterally when observed from behind), a flattened longitudinal arch, and an abducted forefoot

Single heel raise shows lack of inversion Single heel raise shows lack of inversion of hind foot of hind foot

Investigations – MRI : highly specific and Investigations – MRI : highly specific and sensitive sensitive

USG – 80% specific and 90% sensitiveUSG – 80% specific and 90% sensitive

Johnson & Strom’s classificationJohnson & Strom’s classification

Stage 1 – tendon length normalStage 1 – tendon length normal Mild to moderate symptomsMild to moderate symptoms Only aching along the med aspect of ankle Only aching along the med aspect of ankle

exacerbated by trainingexacerbated by training Difficult to localize discomfortDifficult to localize discomfort Gradual onsetGradual onset More easy to elicit if patient is asked to More easy to elicit if patient is asked to

work outwork out

Single heel raise – in stage 1 dysfunction, Single heel raise – in stage 1 dysfunction, initial inversion is weak, patient either rises initial inversion is weak, patient either rises up incompletely or doesn’t rise at allup incompletely or doesn’t rise at all

Or abnormal pattern may be presentOr abnormal pattern may be present

Treatment – modification of activity, Treatment – modification of activity, eccentric and concentric excs, soft tissue eccentric and concentric excs, soft tissue mobilization, NSAID & orthoticsmobilization, NSAID & orthotics

Stage 2 – tendon elongated , hindfoot Stage 2 – tendon elongated , hindfoot mobilemobile

Pain present even at restPain present even at rest Chronic history of months – yearsChronic history of months – years Localized pain along the length of tendonLocalized pain along the length of tendon Swelling and tenderness postinf to medial Swelling and tenderness postinf to medial

malleolusmalleolus

Single heel raise test significantly Single heel raise test significantly abnormalabnormal

Too may toes signToo may toes sign Flattening of medial longitudinal arch, Flattening of medial longitudinal arch,

windlass mechanismwindlass mechanism Test for subtalar and ankle passive and Test for subtalar and ankle passive and

active ROM, TA tightnessactive ROM, TA tightness

X ray shows prominent featuresX ray shows prominent features In AP view- forefoot abducted wrt hind In AP view- forefoot abducted wrt hind

foot, navicular subluxes from the head of foot, navicular subluxes from the head of the talus, angle between the long head of the talus, angle between the long head of talus & calcaneus increases talus & calcaneus increases

Lateral view – sagging of long axis of TN Lateral view – sagging of long axis of TN joint and divergence of the long axis of the joint and divergence of the long axis of the talus from calcaneustalus from calcaneus

Treatment – usually surgical with either Treatment – usually surgical with either shortening , tenodesis or tendon transfershortening , tenodesis or tendon transfer

Stage 3 – Tendon rupture, hind foot Stage 3 – Tendon rupture, hind foot deformed and stiffdeformed and stiff

Never seen in active peopleNever seen in active people Degenerative changes presentDegenerative changes present Static supports of the foot are rupturedStatic supports of the foot are ruptured Fixed flat foot Fixed flat foot

Pain shifts to lateral aspect of hind foot as Pain shifts to lateral aspect of hind foot as impingement developsimpingement develops

Deformity ; most prominent featureDeformity ; most prominent feature Treatment – arthrodesis if pain is severeTreatment – arthrodesis if pain is severe

FHL tendinopathyFHL tendinopathy

Secondary to overuseSecondary to overuse Pain on toe off or forefoot weight bearingPain on toe off or forefoot weight bearing May be associated with post impingement May be associated with post impingement

syndromesyndrome Max pain over postmed aspect of Max pain over postmed aspect of

calcaneus around sustentaculum talicalcaneus around sustentaculum tali Aggravated by resisted flexion of great toe Aggravated by resisted flexion of great toe

or stretching great toe into DFor stretching great toe into DF

Triggering may be present in some cases- Triggering may be present in some cases- associated with a snap or pop soundassociated with a snap or pop sound

Investigation – MRI/USInvestigation – MRI/US

Treatment Treatment

1.1. IceIce

2.2. Avoidance of activityAvoidance of activity

3.3. FHL stretching + strengthening FHL stretching + strengthening

4.4. Soft tissue mobilization proximally in Soft tissue mobilization proximally in muscle bellymuscle belly

5.5. Correction of subtalar hypomobilityCorrection of subtalar hypomobility

6.6. Control of excessive pronation during toe Control of excessive pronation during toe off with taping / orthosisoff with taping / orthosis

7.7. Strengthen proximal componentsStrengthen proximal components

Tarsal tunnel syndromeTarsal tunnel syndrome

Compression neuropathy of tibial nerve in Compression neuropathy of tibial nerve in tarsal tunnel where it winds around the tarsal tunnel where it winds around the medial malleolusmedial malleolus

Causes – 50% idiopathicCauses – 50% idiopathic

trauma ( inversion injury)trauma ( inversion injury)

overuse (excessive pronation)overuse (excessive pronation)

Indirect trauma due to repetitive HS during Indirect trauma due to repetitive HS during running on hard surfaces, poor fitting running on hard surfaces, poor fitting shoesshoes

Forces being transmitted through tarsal Forces being transmitted through tarsal tunneltunnel

Poorly defined burning, tingling, numbness Poorly defined burning, tingling, numbness along the plantar aspect of the foot, great along the plantar aspect of the foot, great toe or medial aspect of the heeltoe or medial aspect of the heel

Aggravated by activity, relieved by restAggravated by activity, relieved by rest

In some cases night pain may be presentIn some cases night pain may be present

Swelling, thickening, varicosities may be Swelling, thickening, varicosities may be presentpresent

Tenderness in tarsal tunnelTenderness in tarsal tunnel

Tinel’s sign Tinel’s sign

DD- medial or lateral plantar nerves, DD- medial or lateral plantar nerves, plantar fasciitis, referred pain from backplantar fasciitis, referred pain from back

Conservative – NSAID, corticosteroid Conservative – NSAID, corticosteroid injection in tarsal tunnelinjection in tarsal tunnel

Surgical – decompression Surgical – decompression

Medial Calcaneal Nerve Medial Calcaneal Nerve EntrapmentEntrapment

Lateral Ankle PainLateral Ankle Pain

Common causes – peroneal tendinopathyCommon causes – peroneal tendinopathy sinus tarsi syndromesinus tarsi syndrome

Less common causes – impingement; AL, Less common causes – impingement; AL, posteriorposterior

recurrent dislocation of peroneal tendonsrecurrent dislocation of peroneal tendons stress fracture of talusstress fracture of talus referred pain referred pain

Peroneal tendinopathyPeroneal tendinopathy

Causes Causes

1.1. Excessive eversion of the footExcessive eversion of the foot

2.2. Excessive pronation of the footExcessive pronation of the foot

3.3. Secondary to tight ankle PFSecondary to tight ankle PF

4.4. Excessive action of peronealsExcessive action of peroneals

5.5. Inflammatory arthropathyInflammatory arthropathy

3 main sites of tendinopathy3 main sites of tendinopathy Posterior to lateral malleolusPosterior to lateral malleolus At the peroneal trochleaAt the peroneal trochlea At the plantar surface of the cuboidAt the plantar surface of the cuboid

Clinical features Clinical features

1.1. Lateral ankle or heel pain, swelling which is Lateral ankle or heel pain, swelling which is aggravated by activity, relieved by restaggravated by activity, relieved by rest

2.2. Local tenderness, sometimes associated with Local tenderness, sometimes associated with swelling and crepitusswelling and crepitus

3.3. Painful passive inversion and resisted eversionPainful passive inversion and resisted eversion

4.4. Calf tightnessCalf tightness

5.5. Excessive subtalar pronation or stiffness of Excessive subtalar pronation or stiffness of subtalar or midtarsal jointssubtalar or midtarsal joints

MRI recommended investigation- shows MRI recommended investigation- shows characteristic features of tendinopathy- characteristic features of tendinopathy- increased signal and tendon thickeningincreased signal and tendon thickening

Treatment – pain relieving modalities, soft Treatment – pain relieving modalities, soft tissue mobilization, stretching, mobilization tissue mobilization, stretching, mobilization of subtalar and midtarsal jointsof subtalar and midtarsal joints

Assess footwearAssess footwear

Lateral heel wedges or orthoses Lateral heel wedges or orthoses

Strengthening excs, resisted eversion in Strengthening excs, resisted eversion in PF positionPF position

Sinus tarsi syndromeSinus tarsi syndrome

Sinus tarsi is a conical Sinus tarsi is a conical shaped cavity located shaped cavity located between antero sup between antero sup surface of calcaneus and surface of calcaneus and neck of the talusneck of the talus

Opens laterally, just Opens laterally, just anterior to fibular anterior to fibular malleolus to postmed malleolus to postmed behind medial malleolusbehind medial malleolus

Contents – Contents – 1.1. Interosseous talocalcaneal ligamentInterosseous talocalcaneal ligament2.2. Cervical ligamentCervical ligament3.3. Anterior portion of the subtalar joint capsule Anterior portion of the subtalar joint capsule

and synoviumand synovium4.4. Posterior portion of the TCN joint capsule and Posterior portion of the TCN joint capsule and

synoviumsynovium5.5. Medial, inferior and lateral roots of inferior Medial, inferior and lateral roots of inferior

extensor retinaculumextensor retinaculum6.6. Artery of tarsal tunnelArtery of tarsal tunnel

Etiology Etiology First described by O’Connor in 1949First described by O’Connor in 1949 He suggested that excessive post traumatic He suggested that excessive post traumatic

scarring of the superficial ligament floor was scarring of the superficial ligament floor was responsible for the symptomsresponsible for the symptoms

Other causes – hypertrophy of synovial Other causes – hypertrophy of synovial membrane, ganglion cysts, entrapment of membrane, ganglion cysts, entrapment of superficial peroneal nerve & exostosis superficial peroneal nerve & exostosis associated with DJDassociated with DJD

Etiology of sinus tarsi syndrome is thought Etiology of sinus tarsi syndrome is thought to be associated with post traumatic to be associated with post traumatic complications following lateral ankle complications following lateral ankle sprainssprains

This is the case in 70% cases This is the case in 70% cases

Bernstein, Bartolomei, McCarthy 1985 Bernstein, Bartolomei, McCarthy 1985

Other causes – pes cavus, hypermobile Other causes – pes cavus, hypermobile pes planus and chronic STJ instabilitypes planus and chronic STJ instability

Borrelli and Arenson (1987) described Borrelli and Arenson (1987) described mechanism which may lead to sinus tarsi mechanism which may lead to sinus tarsi syndromesyndrome

Due to increased laxity of interosseous Due to increased laxity of interosseous and cervical ligaments there is increase in and cervical ligaments there is increase in supination at heel strikesupination at heel strike

Ligaments respond to increased Ligaments respond to increased supination by initiating a feedback supination by initiating a feedback mechanism to fire the peroneal muscles, mechanism to fire the peroneal muscles, leading to increase in pronation into leading to increase in pronation into midstance to correct over supinationmidstance to correct over supination

Due to decreased proprioceptor response Due to decreased proprioceptor response of the ligaments, the mechanism is altered of the ligaments, the mechanism is altered and peronii firing is diminished, leading to and peronii firing is diminished, leading to decreased stability at propulsiondecreased stability at propulsion

Clinical featuresClinical features

Pain over the lateral aspect of the foot, Pain over the lateral aspect of the foot, with increased tenderness over the sinus with increased tenderness over the sinus areaarea

Rear foot instability, clinically represented Rear foot instability, clinically represented by subtalar joint instabilityby subtalar joint instability

Pain reproduced by forceful supination of Pain reproduced by forceful supination of forefootforefoot

4 clinical signs (Giorgini and Bernard , 1990, 4 clinical signs (Giorgini and Bernard , 1990, and Borelli and Arenson, 1987, )and Borelli and Arenson, 1987, )

1.1. Pain over the lateral sinus tarsi opening which Pain over the lateral sinus tarsi opening which decreases with restdecreases with rest

2.2. Perception of instability of the rear foot on Perception of instability of the rear foot on uneven surfacesuneven surfaces

3.3. Complete relief if pain with injection on sinus Complete relief if pain with injection on sinus tarsitarsi

4.4. Clinical and radiological studies are Clinical and radiological studies are insignificant insignificant

Diagnosis Diagnosis

Arthroscopic examination of the sinus tarsi Arthroscopic examination of the sinus tarsi and EMG of peronii show characteristic and EMG of peronii show characteristic changes during gaitchanges during gait

Injection of local anesthetic into the sinus Injection of local anesthetic into the sinus tarsi is a common diagnostic tool used tarsi is a common diagnostic tool used clinicallyclinically

Direct palpation of sinus tarsi is not Direct palpation of sinus tarsi is not accurateaccurate

Treatment Treatment

Relative restRelative rest IceIce NSAIDNSAID Electrotherapeutic modalitiesElectrotherapeutic modalities Subtalar joint mobilizationSubtalar joint mobilization Proprioceptive and strength trainingProprioceptive and strength training Biomechanical correctionBiomechanical correction

Antero lateral impingement Antero lateral impingement

Cause – ankle sprains involving anterolateral Cause – ankle sprains involving anterolateral aspect of the ankleaspect of the ankle

Inversion sprain promotes synovial thickening Inversion sprain promotes synovial thickening and exudationand exudation

Meniscoid lesion develops in AL gutterMeniscoid lesion develops in AL gutter

Chondromalacia of lateral wall of the talus with Chondromalacia of lateral wall of the talus with an associated synovial reactionan associated synovial reaction

Pain at the anterior aspect of the lateral Pain at the anterior aspect of the lateral malleolus malleolus

An intermittent catching sensation in the An intermittent catching sensation in the ankle with a previous history of ankle ankle with a previous history of ankle sprainsprain

Tenderness at antero inferior border of the Tenderness at antero inferior border of the fibula & AL surface of talusfibula & AL surface of talus

Clinical assessment more reliable than Clinical assessment more reliable than MRI MRI

Arthroscopic examination to confirm Arthroscopic examination to confirm diagnosisdiagnosis

Corticosteroid injection and arthroscopic Corticosteroid injection and arthroscopic removalremoval

Stress fractures of talus Stress fractures of talus

Develops secondary to excessive subtalar Develops secondary to excessive subtalar pronation and PF , resulting in pronation and PF , resulting in impingement of lateral process of the impingement of lateral process of the calcaneus on the PL corner of the taluscalcaneus on the PL corner of the talus

Symptoms – lateral ankle pain of gradual Symptoms – lateral ankle pain of gradual onsetonset

Worse by running and weight bearingWorse by running and weight bearing

Tenderness and swelling in the region of Tenderness and swelling in the region of sinus tarsisinus tarsi

Isotopic bone scan and CT scanIsotopic bone scan and CT scan

Anterior ankle painAnterior ankle pain

Anterior impingement of ankleAnterior impingement of ankle

Tibialis anterior tendinopathyTibialis anterior tendinopathy

Due to overuse of ankle dorsiflexors Due to overuse of ankle dorsiflexors secondary to restriction in joint range, secondary to restriction in joint range, occurring with stiff ankleoccurring with stiff ankle

Pain, swelling, stiffness in anterior anklePain, swelling, stiffness in anterior ankle

Aggravated by activities like running, Aggravated by activities like running, walking uphill or stairswalking uphill or stairs

Localizes tenderness, swelling and Localizes tenderness, swelling and occasionally crepitus along the tibialis occasionally crepitus along the tibialis anterior tendonanterior tendon

Pain on resisted DF and eccentric Pain on resisted DF and eccentric inversioninversion

US and MRI may be used for diagnosisUS and MRI may be used for diagnosis

Treatment – eccentric strengthening , soft Treatment – eccentric strengthening , soft tissue mobilization and mobilization of the tissue mobilization and mobilization of the ankle ankle

Correction of biomechanical problems with Correction of biomechanical problems with orthosesorthoses

Foot pain Foot pain

Common causes – plantar fasciitis and fat Common causes – plantar fasciitis and fat pad contusionpad contusion

Lesser common – calcaneal fractures, Lesser common – calcaneal fractures, medial calcaneal nerve entrapment, lateral medial calcaneal nerve entrapment, lateral plantar nerve entrapment, tarsal tunnel plantar nerve entrapment, tarsal tunnel syndrome, retro calcaneal bursitissyndrome, retro calcaneal bursitis

Plantar fasciitis Plantar fasciitis

Composed of 3 segmentsComposed of 3 segments

Central , clinically most significant, arising Central , clinically most significant, arising from plantar aspect of postero medial from plantar aspect of postero medial calcaneal tuberosity and inserts into toes calcaneal tuberosity and inserts into toes to from the longitudinal archto from the longitudinal arch

Plantar fasciitis , overuse condition of Plantar fasciitis , overuse condition of plantar fascia , at its attachment to plantar fascia , at its attachment to calcaneuscalcaneus

Due to collagen disarray in the absence of Due to collagen disarray in the absence of inflammatory cellsinflammatory cells

Causes – pes planus or pes cavusCauses – pes planus or pes cavus

Results from activities requiring maximal PF and Results from activities requiring maximal PF and simultaneous DF of MTP simultaneous DF of MTP

Reduced DF increased risk factorReduced DF increased risk factor

Commonly associated with tightness in proximal Commonly associated with tightness in proximal myofascial structures myofascial structures

Clinical features – gradual onsetClinical features – gradual onset On medial aspect of heelOn medial aspect of heel Worse in morning, decreases with activityWorse in morning, decreases with activity May last as ache post activityMay last as ache post activity Increase in pain as activity is Increase in pain as activity is

recommencedrecommenced Progresses to pain with weight bearingProgresses to pain with weight bearing Other problems if associated Other problems if associated

biomechanical problems are presentbiomechanical problems are present

Examination – acute tenderness along the Examination – acute tenderness along the medial tuberosity of the calcaneusmedial tuberosity of the calcaneus

May extend along the medial border of May extend along the medial border of plantar fasciaplantar fascia

Plantar fascia tightness may be present, Plantar fascia tightness may be present, stretching reproduces painstretching reproduces pain

Reduced supination increases strain on Reduced supination increases strain on the fasciathe fascia

US – gold standard diagnostic US – gold standard diagnostic investigation with swelling of plantar fascia investigation with swelling of plantar fascia the typical featurethe typical feature

Treatment Treatment Aviodance of aggravating activityAviodance of aggravating activity Cryotherapy after the activityCryotherapy after the activity Strething of fascia, gastro-soleusStrething of fascia, gastro-soleus Taping – Taping – Extracorporeal Shock wave therapyExtracorporeal Shock wave therapy Strenghtening exercisesStrenghtening exercises Footwear modificationFootwear modification

Iontophoresis Iontophoresis Plantar fasciotomyPlantar fasciotomy

Fat pad Contusion Fat pad Contusion

Fat pad composed of elastic fibrous tissue Fat pad composed of elastic fibrous tissue septa acts as a shock absorber, protecting septa acts as a shock absorber, protecting the calcaneus at heel strikethe calcaneus at heel strike

Cause – may develop either acutely after Cause – may develop either acutely after a fall onto the heels or chronically as a a fall onto the heels or chronically as a result of excessive heel strike with poor result of excessive heel strike with poor heel cushioning or repetitive change in heel cushioning or repetitive change in direction, sudden stops, startsdirection, sudden stops, starts

CF – severe heel pain during weight CF – severe heel pain during weight bearing bearing

Pain felt laterally in the heel due to pattern Pain felt laterally in the heel due to pattern of heel strikeof heel strike

Tenderness in posterolateral heel Tenderness in posterolateral heel MRI reveals edematous changes in fat MRI reveals edematous changes in fat

pad pad

Rest Rest Heel lockingHeel locking

Calcaneal stress fracturesCalcaneal stress fractures

Mid Foot painMid Foot pain

Cuboid SyndromeCuboid Syndrome

Defined as a minor disruption or Defined as a minor disruption or subluxation of the structural congruity of subluxation of the structural congruity of the calcaneo cuboid portion of the the calcaneo cuboid portion of the midtarsal jointmidtarsal joint

The disruption of cuboid’s position irritates The disruption of cuboid’s position irritates the surrounding joint capsule, ligaments the surrounding joint capsule, ligaments and peroneus longus tendon and peroneus longus tendon

Cuboid – only bone in the foot that Cuboid – only bone in the foot that articulates with both tarsometatarsal and articulates with both tarsometatarsal and midtarsal jointmidtarsal joint

Only bone that links lateral column to the Only bone that links lateral column to the transverse plantar archtransverse plantar arch

Secured in the lateral column by Secured in the lateral column by calcaneocuboid , cuboidonavicular , calcaneocuboid , cuboidonavicular , cuboideometatarsal and long plantar cuboideometatarsal and long plantar ligamentligament

Ligaments more taut dorsomedially than Ligaments more taut dorsomedially than plantar laterallyplantar laterally

Joint rotates around a medially positioned Joint rotates around a medially positioned axisaxis

Shape and position of cuboid is also Shape and position of cuboid is also influenced by the peroneus longus muscle influenced by the peroneus longus muscle tendontendon

The cuboid articulations provide accessory The cuboid articulations provide accessory glide along with internal and external glide along with internal and external rotationrotation

The passive physiological motion of the The passive physiological motion of the lateral column consists of two patterns of lateral column consists of two patterns of movement movement

The 1The 1stst combined movement , PF + combined movement , PF + adduction along with inversionadduction along with inversion

22ndnd movement pattern, DF + abduction with movement pattern, DF + abduction with eversioneversion

Mid tarsal joint motion occurs around 2 Mid tarsal joint motion occurs around 2 axes which are dependent upon the axes which are dependent upon the position of subtalar jointposition of subtalar joint

When midtarsal joint is fully pronated it is When midtarsal joint is fully pronated it is in locked positionin locked position

When subtalar joint is pronated, forefoot is When subtalar joint is pronated, forefoot is inverted and midtarsal joint is unlocked inverted and midtarsal joint is unlocked enabling the foot to adapt to uneven enabling the foot to adapt to uneven surfacessurfaces

With every degree of subtalar pronation With every degree of subtalar pronation there is exponential increase in the there is exponential increase in the midtarsal joint instabilitymidtarsal joint instability

Etiology – 2 mechanisms ; PF n inversion Etiology – 2 mechanisms ; PF n inversion ankle sprains and overuse syndromeankle sprains and overuse syndrome

Other factors – uneven running terrain, Other factors – uneven running terrain, improperly constructed orthoses, inversion improperly constructed orthoses, inversion ankle injuries and pronated foot structuresankle injuries and pronated foot structures

degree and direction of the force of the degree and direction of the force of the peroneus longus and the position of the peroneus longus and the position of the subtalar joint act as a contributing factor subtalar joint act as a contributing factor

In a supinating subtalar joint during In a supinating subtalar joint during propulsion it acts as a dynamic stabilizer propulsion it acts as a dynamic stabilizer of the forefootof the forefoot

Pronated foot is naturally unstable , Pronated foot is naturally unstable , increasing the mechanical advantage of increasing the mechanical advantage of the peroneus longusthe peroneus longus

Mechanical advantage of peroneus longus Mechanical advantage of peroneus longus is theoretically able to sublux the unstable, is theoretically able to sublux the unstable, pronated cuboid as the rearfoot pronated cuboid as the rearfoot resupinates into propulsionresupinates into propulsion

Pronated foot + plantar flexed lateral Pronated foot + plantar flexed lateral columncolumn may irritate the soft tissues due to may irritate the soft tissues due to excessive pressure on the lateral columnexcessive pressure on the lateral column

In congruency in the calcaneocuboid jointIn congruency in the calcaneocuboid joint

Inversion sprains of ankleInversion sprains of ankle

Clinical presentation Clinical presentation

Gradual or rapid onset of pain Gradual or rapid onset of pain

Located directly over the cuboid Located directly over the cuboid

May radiate into plantar medial arch or May radiate into plantar medial arch or distally along the 4distally along the 4thth metatarsal metatarsal

Pain during weight bearing or even non Pain during weight bearing or even non weight bearingweight bearing

Weakness during the propulsive phaseWeakness during the propulsive phase

Examination may show inflammatory signsExamination may show inflammatory signs

Sulcus if subluxation is severeSulcus if subluxation is severe

Occasionally forefoot valgusOccasionally forefoot valgus

Pain and point tenderness directly over the Pain and point tenderness directly over the cuboidcuboid

Tenderness over EDB tendon at Tenderness over EDB tendon at anterolateral surface of sinus tarsi and in anterolateral surface of sinus tarsi and in the region of peroneal groovethe region of peroneal groove

Decreased ROMDecreased ROM

Pain during passive inversion and active Pain during passive inversion and active and resisted PF and eversionand resisted PF and eversion

Resisted inversion resulting in pain along Resisted inversion resulting in pain along the peroneus longus – diagnosticthe peroneus longus – diagnostic

Subtonick, 1989 Subtonick, 1989

Midtarsal adduction testMidtarsal adduction test

Midtarsal supination test Midtarsal supination test

Gait evaluation and functional testingGait evaluation and functional testing

Difficult to make on X rays, CT, MRIDifficult to make on X rays, CT, MRI

Differential diagnosis – Jones fracture, Differential diagnosis – Jones fracture, fracture of anterior calcaneal process, fracture of anterior calcaneal process, tarsal coalition, peroneal and EB tarsal coalition, peroneal and EB tendonitis, sinus tarsi syndrome, lateral tendonitis, sinus tarsi syndrome, lateral plantar nerve entrapment, Lisfranc’s plantar nerve entrapment, Lisfranc’s injuries etcinjuries etc

TreatmentTreatment

Responds exceptionally well to Responds exceptionally well to conservative treatmentconservative treatment

Primary method – cuboid manipulationPrimary method – cuboid manipulation

Therapeutic modalities, low dye arch Therapeutic modalities, low dye arch taping, exercise and tapingtaping, exercise and taping

Manipulation – Manipulation – cuboid whipcuboid whip or or cuboid cuboid squeezesqueeze

Ice following manipulationIce following manipulation

Low intensity pulsed US , increased to Low intensity pulsed US , increased to continuous US later continuous US later

Stretching a tight peroneus longus and Stretching a tight peroneus longus and triceps surae , strengthening the intrinsic triceps surae , strengthening the intrinsic and extrinsic muscles of foot and and extrinsic muscles of foot and proprioception trainingproprioception training

Low dye taping can be used with or Low dye taping can be used with or without cuboid padding to maintain cuboid without cuboid padding to maintain cuboid position following manipulationposition following manipulation

Fore foot pain Fore foot pain

Turf toeTurf toe

11stst MTP joint sprain MTP joint sprain Caused by jamming or hyperextension of Caused by jamming or hyperextension of

the hallux at the MTP jointthe hallux at the MTP joint Defined as an acute sprain of the plantar Defined as an acute sprain of the plantar

capsule and ligaments of the MTP joint of capsule and ligaments of the MTP joint of the great toethe great toe

Related to artficial turf, lightweight shoes, Related to artficial turf, lightweight shoes, activities that require hyperextension of activities that require hyperextension of the toe the toe

More than 100 deg extension from More than 100 deg extension from neutarl positionneutarl position

Signs and symptoms Signs and symptoms

1.1. Tender, swollen joint (plantar aspect) Tender, swollen joint (plantar aspect)

2.2. Restricted ROMRestricted ROM

3.3. Passive extension painfulPassive extension painful

DD – fracture of the toe , sesamoids, DD – fracture of the toe , sesamoids, inflammation of sesamoids, FHL, FHB inflammation of sesamoids, FHL, FHB tendinitis and gouttendinitis and gout

Treatment Treatment

1.1. Rest Rest

2.2. Reduce inflammation and edemaReduce inflammation and edema

3.3. Taping Taping

4.4. Modify footwearModify footwear

5.5. Mobilization of the MTP jointMobilization of the MTP joint

Hallux rigidus Hallux rigidus

Degenerative arthrosis of the 1Degenerative arthrosis of the 1stst MTP joint MTP joint Limited ROMLimited ROM PainPain Altered gaitAltered gait Toe fixed in PF at timesToe fixed in PF at times Weight bearing on the lateral sideWeight bearing on the lateral side

Etiology Etiology

1.1. Osteochondritis dissecans of the 1Osteochondritis dissecans of the 1stst metatarsal metatarsal head head

2.2. Trauma ; single or overuse Trauma ; single or overuse

3.3. Primary OA Primary OA

4.4. Prominent long 1Prominent long 1stst metatarsal metatarsal

5.5. Abnormal gaitAbnormal gait

6.6. Hypermobility of the 1Hypermobility of the 1stst metatarsal segment metatarsal segment

Treatment Treatment Non operative – USNon operative – US Modify activities, footwearModify activities, footwear Correct biomechanicsCorrect biomechanics Mobilization Mobilization

Surgery – debridementSurgery – debridement Osteotomy Osteotomy ArthroplastyArthroplasty Arthrodesis Arthrodesis

Metatarsalgia Metatarsalgia

General term referring to pain in the General term referring to pain in the metatarsals and MTP jointsmetatarsals and MTP joints