The Foot and Ankle ComplexSARAH RAYNEREXTENDED 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 PFOn 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 and podiatry Weight 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: Practical1. 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