Foot & AnkleFoot & Ankle

Touro CollegeTouro College

April 19April 19thth, 2012, 2012

Adrian Miranda, PT, DPT, OCSAdrian Miranda, PT, DPT, OCS

ObjectivesObjectives

Understand the patho-biomechanics Understand the patho-biomechanics and how it relates to foot/ankle injuriesand how it relates to foot/ankle injuries

Understand the clinical concepts of the Understand the clinical concepts of the foot and ankle rehabilitationfoot and ankle rehabilitation

Review the literature on foot and ankle Review the literature on foot and ankle dysfunctions and treatmentdysfunctions and treatment

How to utilize the evidence and make How to utilize the evidence and make it relevant.it relevant.

Gain a better understanding of the Gain a better understanding of the concept of Regional Interdependenceconcept of Regional Interdependence

Foot & Ankle PainFoot & Ankle Pain

Anterior ImpingementAnterior Impingement Achilles TendonitisAchilles Tendonitis Posterior Tibialis Posterior Tibialis

Tendonitis/DysfunctionTendonitis/Dysfunction Ankle SprainsAnkle Sprains Peroneal TendonitisPeroneal Tendonitis

Question: But WHY?

AnatomyAnatomy

Know your foot & ankle anatomyKnow your foot & ankle anatomy

AnatomyAnatomy

But also know your GENERAL ANATOMYBut also know your GENERAL ANATOMY– Think about the hip, knee, ankleThink about the hip, knee, ankle– Ankle muscles, ankle joints, ankle ligs.Ankle muscles, ankle joints, ankle ligs.

Regional Regional InterdependenceInterdependence

““Seemingly unrelated Seemingly unrelated impairments in a remote impairments in a remote anatomical region may contribute anatomical region may contribute to, or be associated with, the to, or be associated with, the patient’s primary complaint.” patient’s primary complaint.”

Wainner RS, Whitman JM, Cleland JA, Flynn TW.Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007 Nov;37(11):658-60.

Anterior Anterior ImpingementImpingement

Anterior ImpingementAnterior Impingement

Can be bone/capsular or soft Can be bone/capsular or soft tissue approximationtissue approximation

Talus can have an anterior Talus can have an anterior displacementdisplacement

Scar tissue or thickened tendon Scar tissue or thickened tendon due to overusedue to overuse

Several possibilitiesSeveral possibilities

Anterior ImpingementAnterior Impingement

Typically reduced dorsiflexionTypically reduced dorsiflexion PainfulPainful Treatment Options:Treatment Options:

– Soft tissue to structures anterior to Soft tissue to structures anterior to talocrural jointtalocrural joint

– Posterior Glides of TalusPosterior Glides of Talus

Evidence: APEvidence: AP

Evidence: APEvidence: AP

Evidence: APEvidence: AP

Achilles Tendon Achilles Tendon InjuryInjury

Achilles InjuriesAchilles Injuries

Achilles is expending too much Achilles is expending too much energyenergy– ““physics”physics”– Gets too hot: leads to “–itis”Gets too hot: leads to “–itis”

Achilles meant to be powerful in Achilles meant to be powerful in the sagittal planethe sagittal plane

Check frontal plane regionsCheck frontal plane regions– i.e. (class?)i.e. (class?)

Evidence: ATEvidence: AT

Evidence: ATEvidence: AT

““The dancers with a history of The dancers with a history of achilles tendinopathy displayed achilles tendinopathy displayed greater peak hip adductiongreater peak hip adduction during during the braking phase and the braking phase and more knee more knee internalinternal rotationrotation during the push during the push off phase than a control group.”off phase than a control group.”

Posterior Tibialis Posterior Tibialis Tendon InjuryTendon Injury

Posterior Tibialis Posterior Tibialis Tendon InjuryTendon Injury ““Flat Foot”Flat Foot”

– Typically referred to as Typically referred to as overstretchedoverstretched

Anatomy and location of PTTAnatomy and location of PTT Orthotics?Orthotics? Again check frontal plane Again check frontal plane

Evidence: PTTEvidence: PTT

Evidence: PTTEvidence: PTT

Significant differences between PTTD Significant differences between PTTD group vs. Controlgroup vs. Control– Hip Abduction StrengthHip Abduction Strength– Hip Extension strengthHip Extension strength– Plantar Flexion strengthPlantar Flexion strength

““These findings suggest that pathology These findings suggest that pathology in the foot/ankle is accompanied by in the foot/ankle is accompanied by diminished performance of the hip diminished performance of the hip musculaturemusculature.”.”

Peroneal Tendon Peroneal Tendon InjuriesInjuries

Peroneal Tendon Peroneal Tendon InjuriesInjuries Consider path of peroneal tendonConsider path of peroneal tendon

– i.e. peroneus longusi.e. peroneus longus– Where does it course?Where does it course?

Overused Overused Irritated due to a mobility Irritated due to a mobility

dysfunctiondysfunction

Evidence: PTEvidence: PT

Evidence: PTEvidence: PT

50 year old female50 year old female 8 visits8 visits PainPain

– Baseline = 6Baseline = 6– Discharge = 0Discharge = 0

Lower Extremity Functional ScaleLower Extremity Functional Scale– Baseline = 51Baseline = 51– Discharge = 61Discharge = 61

Ankle SprainsAnkle Sprains

Ankle SprainsAnkle Sprains

Multi-factorialMulti-factorial TheoryTheory

– ATFL is strong, pulls the fibulaATFL is strong, pulls the fibula Cuboid involvementCuboid involvement Frontal plane weaknessFrontal plane weakness

– i.e. Hipi.e. Hip

Evidence: AIEvidence: AI

““Strength of the hip abductors Strength of the hip abductors was significantly weaker on the was significantly weaker on the involved side than on the involved side than on the uninvolved side.” uninvolved side.”

Evidence: AIEvidence: AI

Evidence: AIEvidence: AI 7 Patients7 Patients Cuboid Thrust ManipulationCuboid Thrust Manipulation All returned to pre injury level All returned to pre injury level

within 1 or 2 visits, with long term within 1 or 2 visits, with long term resolutionresolution

Evidence: AIEvidence: AI

Evidence: AIEvidence: AI

“ “These results lend support to the These results lend support to the hypothesis that a positional fault hypothesis that a positional fault occurs at the inferior tibiofibular occurs at the inferior tibiofibular joint in ankle sprain patients.”joint in ankle sprain patients.”

May have implications for treatment May have implications for treatment for a proportion of our patients.for a proportion of our patients.

VideosVideos

ConclusionConclusion

Importance of “Regional Importance of “Regional Interdependence”Interdependence”

Look at the bigger pictureLook at the bigger picture Search for the ‘cause of the cause’Search for the ‘cause of the cause’ Use your knowledge of anatomyUse your knowledge of anatomy

– Check for impairments, dysfunctions, Check for impairments, dysfunctions, imbalances, etc.imbalances, etc.

Examine > Treat > Re-ExamineExamine > Treat > Re-Examine

ReferencesReferences

WainnerWainner RS RS, , Whitman JMWhitman JM, , Cleland JACleland JA, , Flynn TWFlynn TW.. Regional interdependence: a musculoskeletal examination model whose time has come. Regional interdependence: a musculoskeletal examination model whose time has come. J J

OrthopOrthop Sports Phys Sports Phys TherTher.. 2007; 37:658-60. 2007; 37:658-60. Hensley CP, Hensley CP, KavchakKavchak AJ AJ. Novel use of a manual therapy technique and management of a . Novel use of a manual therapy technique and management of a

patient with peroneal tendinopathy: a case report. Man Ther. 2012 ;17:84-88.patient with peroneal tendinopathy: a case report. Man Ther. 2012 ;17:84-88. Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle sprains: a Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle sprains: a

case series. J Orthop Sports Phys Ther. 2005; 35:409-15.case series. J Orthop Sports Phys Ther. 2005; 35:409-15. Kulig K, Loudon JK, Popovich JM Jr, et al. Dancers with achilles tendinopathy demonstrate Kulig K, Loudon JK, Popovich JM Jr, et al. Dancers with achilles tendinopathy demonstrate

altered lower extremity takeoff kinematics. J Orthop Sports Phys Ther. 2011; 4: 606-13.altered lower extremity takeoff kinematics. J Orthop Sports Phys Ther. 2011; 4: 606-13. Kulig K, Popovich JM, Noceti-Dewit LM, et al. Women with posterior tibial tendon Kulig K, Popovich JM, Noceti-Dewit LM, et al. Women with posterior tibial tendon

dysfunction have diminished ankle and hip muscle performance. J Orthop Sports Phys Ther. dysfunction have diminished ankle and hip muscle performance. J Orthop Sports Phys Ther. 2011; 40: 687-94.2011; 40: 687-94.

Friel K, McLean N, Myers C, et al. Ipsilateral hip abductor weakness after inversion ankle Friel K, McLean N, Myers C, et al. Ipsilateral hip abductor weakness after inversion ankle sprain. J Athl Train. 2006; 41:74-8.sprain. J Athl Train. 2006; 41:74-8.

Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Man Ther. 2008; 13: 63-7.sprains. Man Ther. 2008; 13: 63-7.

Kavanagh J. Is there a positional fault at the inferior tibiofibular joint in patients with acute Kavanagh J. Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle sprains compared to normals? Man Ther. 1999; 4: 19-24.or chronic ankle sprains compared to normals? Man Ther. 1999; 4: 19-24.

Wikstrom EA, Hubbard TJ. Talar positional fault in persons with chronic ankle instability. Wikstrom EA, Hubbard TJ. Talar positional fault in persons with chronic ankle instability. Arch Phys Med Rehabil. 2010; 91: 1267-71.Arch Phys Med Rehabil. 2010; 91: 1267-71.

Landrum EL, Kelln CB, Parente WR, et al. Immediate Effects of Anterior-to-Posterior Landrum EL, Kelln CB, Parente WR, et al. Immediate Effects of Anterior-to-Posterior Talocrural Joint Mobilization after Prolonged Ankle Immobilization: A Preliminary Study. J Talocrural Joint Mobilization after Prolonged Ankle Immobilization: A Preliminary Study. J Man Manip Ther. 2008; 16: 100-5.Man Manip Ther. 2008; 16: 100-5.

Cleland JA, Abbott JH, Kidd MO, et al. Manual physical therapy and exercise versus Cleland JA, Abbott JH, Kidd MO, et al. Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther. 2009;39: 573-85.randomized clinical trial. J Orthop Sports Phys Ther. 2009;39: 573-85.

Thank You!Thank You!

DiscussionDiscussion Questions?Questions?