MS3 Family Medicine - ASOPcastingworkshop.com/images/DL_Leg_Ankle_Foot_Problems.pdf · Define relevant anatomy, physiology, and radiographic features of the foot, ankle and lower

MS3 Family Medicine

Define relevant anatomy, physiology, and radiographic features of the foot, ankle and lower leg

Recognize history, presenting signs and pertinent exam findings of common problems

Review treatment of common problems

Tibia

Fibula

Talus

Dome

Neck

Calcaneus

Medial tubercle

Anterior process

Posterior process

1. Fractures

2. Sesamoids

3. Joint crystals

4. Phleboliths

Extensor tendons

Dorsal pedis artery

Digital nerves

Plantar fascia

Longitudinal collagen fibers

Medial calcaneal tubercle

Proximal phalanges

Plantar nerves

Tarsometatarsal Articulation (Lisfranc)

Transverse ligaments

Inspection

Palpation

Range of motion

Strength

Neurovascular

Special Tests

D

C B A

AP Lateral Mortise

Bone

Ligament

Muscle Tendon

Nerve – Blood Vessels

Remember mechanism of injury!

26 yo male with ankle pain

Landed on foot while playing basketball

Stopped playing

Lateral pain

Able to limp off court and into your office

Previous history: several prior sprains

Previous rehabilitation: minimal

Ankle protection: none recently

Ability to bear weight: yes

Neurovascular symptoms: no

Inspection: Able to walk Swelling, slight bruising laterally

Palpation: TTP ant-distal to LatMall, but not on bone

ROM: decreased DF, PF, Inv, Ev Strength: mild decrease Neurovascular intact Special Tests:

(A/P)Drawer: normal Talar tilt: normal

1. Unable to bear weight

2. Tender over posterior lateral malleolus

3. Tender over posterior medial malleolus

4. Tender on navicular bone

5. Tender on 5th MT base

6. All of the above

1. Unable to bear weight

2. Tender over posterior lateral malleolus

3. Tender over posterior medial malleolus

4. Tender on navicular bone

5. Tender on 5th MT base

Grade 1 – Ligament stretch

Grade 2 – Ligament partial tear

Grade 3 – Ligament complete tear

1. RICE rehab

2. RICE brace rehab

3. RICE cast

4. Surgical repair of the ATFL

Treatment

PRICEMM: Protect, rest, ice, compress, elevate, Meds

Brace for 1-3 months during activity

Gradual ROM exercise

Physical Therapy

ROM

Strength

Proprioception

34 yo male football player

Right ankle rolled up under him during tackle

Walked off field

Unable to return to play

Previous history: neg

Previous rehabilitation: n/a

Ankle protection: none

Ability to bear weight: yes

Neurovascular symptoms: none

Inspection: Difficulty bearing weight

Mild swelling around ankle med/lat

Palp: TTP laterally, anteriorly, medially

ROM: full

Strength: mild decrease

Neurovascular intact

Special Tests: Painful Tib-Fib Squeeze

Painful ankle external rotation

Pain proximal to ankle

Painful ExtRot test

Painful squeeze test

ORDER xrays

Rule out mortise widening

Rule out fractured proximal fibula

Treatment:

Wide mortise: SURGERY

Normal xrays: cast 2-4 weeks

>5mm

24 yo ROTC student c/o aching in medial calves during running for 6 weeks

Goes away w/ 1-2 days rest, but lasting longer with time

Training for marathon

Normal appearing legs/ankles/feet

Palp: TTP diffusely medial tibial edges, distally

ROM: normal ankles (maybe tight heel)

Strength: normal

Neurovascular: normal

Special tests:

Fulcrum test normal

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1. Compartment syndrome

2. Medial tibial stress syndrome

3. Stress fracture

4. Tibial sadness syndrome

Etiology Muscle-bone junction

traction injury

Risk factors: ???

DDx Stress fracture

Exertional compartment syndrome

Treatment Cease painful activity

Non-painful activity

Physical therapy referral

Ankle strength ex’s

Heel stretches

Orthotics

Consider compression sleeve

45 yo Male with chronic, insidious posterior heel pain

Worse after volleyball or running

Pain for several months

Difficulty walking, but warms up

What lives in the back of the leg?

Calcaneus

Calf muscles

Gastrocnemius

Soleus

Achilles Tendon

Retrocalcaneal bursa

Evaluation

Inspection: thickened Achilles tendon

Palpation: very tender Achilles w/ thickened nodularity

ROM: limited DF from tight heel cords, o/w normal at ankle

Strength: normal

Neurovascular: normal

Special Tests:

Negative Thompson test for ruptured achilles tendon

Treatment

Reduce painful activities; alternate training activities

Physical Therapy modalities for acute pain control

Heel lift and BID heel cord stretches

Eccentric strengthening:

90% success rate; takes time

Avoid steroid injection

Failures (>3 mos)

Refer to Sports Med

20 yo female kickboxing instructor

Injured foot 2 days ago while kicking

Walking painful, can’t jump or kick

Whole foot hurts and is swollen

Swelling in midfoot, some ecchymosis

Very TTP dorso-medial midfoot

ROM: ankle normal, toes decr.

Strength: decreased toes

Neurovascular: normal

Special Tests:

Midfoot stress test OUCH

Ankle ligaments stable

Non-weight bearing

x-rays are normal

20% are missed on initial presentation

Treatment

Casting 2-6 weeks if NO FRACTURES OR INSTABILITY

Surgery for fractures or instability

CT/MRI/Bone Scan

Chronic pain

Arthritis

Inability to run or jump

Acute compartment syndrome

59 yo female with plantar heel pain

Worse with first steps when getting out of bed

Gradually improves but worsens by end of day

Related to wearing boots

Valgus foot type (pronation, flatfoot)

TTP on sole at medial calcaneal tubercle

ROM: normal, but tight heel cords

Strength: normal

Neurovascular: normal

Special tests: neg

Treatment

Cease painful activity

Pain meds acutely

Ice, cross-friction massage

Prefab orthoses

(Physical therapy)

Plantar fascia stretching

Heel cord stretching

Tension night splint

Steroid injection

…before hands-on practice

Anterior Drawer Test (ATFL)

Squeeze Test External Rotation Test

Thompson Test Integrity of Achilles Tendon

+

is

no

movement

Thompson Test

for Achilles

tendon rupture

neg POSITIVE