The Foot and Ankle 21.2.12 Mark Powers,PT,DPT,OCS NxtGen Fellow-in-Training [email protected] Twitter: @PTSkeptic.

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The Foot and Ankle21.2.12

Mark Powers,PT,DPT,OCSNxtGen [email protected]: @PTSkepticObjectivesReview anatomy/movements of the ankle/foot regionReview pertinent tests/measures/observations for patients with ankle/foot conditionsReview common foot/ankle pathologiesDiscuss clinical utility of information within this monograph

Functional AnatomyCommonly injured: high loads and repetitive loading during daily activitiesA:5 Etiologic VariablesFoot can act as rigid lever or flexible absorbing structureMultiple important structures at risk for injuryJointMovements-PlaneAnklePF/DF-sagittalSubtalar (talocalcaneal)SupinationInversion-frontalAdduction-transversPF-sagittalPronationEversion-frontalAbd-transversDF-sagittalTalonavicularInversion/eversion-frontalADD/ABD-transversPF/DF-sagittalForefootINV/EV-frontalADD/ABD-transversePF/DF-sagittalAnatomy28 bones totalForefoot (phalanges, metatarsals)Midfoot (cuneiforms, navicular, cuboid)Hindfoot (calcaneous, talus)

Talocrural jointDistal tibia and fibula with trochlea of talus (ankle mortise)Plantarflexion/DorsiflexionIncreased stability in DF due to shape of trochleaLigamentous SupportAnterior Talofibular (ATFL)Prevents anterior displacement of talus to ankle mortiseCalcaneofibular (CFL)Inversion and adduction of calcaneusPosterior talofibularTaut in ER of talus on ankle mortiseSubtalar jointSuperior boney facets of the calcaneus and inferior facets on talusLigamentous Support:CFLCervical ligamentsParts of deltoid ligament (medial stability)Interosseous talocalcaneal

MidfootArticulates to hindfootCalcaneocuboid jointTalonavicular jointLigamentous SupportLong and short plantar ligamentsSpring ligamentSpring ligamentPrevents talar head from PFing, medial longitudinal arch form loweringInvolved in flat foot deformitiesMidfoot injuries frequently include ligaments stabilizing 2nd metatarsal and medial cuneiform bonesLisfranc ligament (prevents separations of 1st and 2nd metatarsal)

MuscleIntrinsic and extrinsic muscles control foot movementStrength of muscle I proportional to its physiologic cross sectional areaBased off cross sectional area: triceps surae group primary ankle plantarflexors

Lateral CompartmentFibularis longus/brevisPronate subtalar jointFibularis LongusPF of 1st metatarsal through its attachment to base of 1st metatarsal and medial cuneiform bonesFibularis BrevisABD of forefootPronator of subtalar jointDeep Post CompartmentFHL, FDL, Post Tib tom, dick, harryPosterior TibAttaches to navicular and medial cuneiform-supports medial longitudinal archSupinates subtalar joint

Ant CompartmentDorsiflexors of ankle jointTib Anterior, Fibularis tertius, EDL, EHLTib AnteriorDorsiflexion/inversionSupination subtalar joint

Intrinsic MusclesPIP flex, MTP flex, ADD/ABD of MTP jointsArch support and propulsion during walking and runningCompartmentMusclesMedialABD hallucis, FHBCentralQuadratus plantae muscle, FDB, ADD hallucis, lumbricalesLateralABD digiti mini, flexor digiti mini brevisDeep compartmentDorsal and plantar interosseiLongitudinal ArchHindfoot pronated=flexible footAxes of talonavicular and calcaneocuboid joints are parallelHindfoot supinated=rigid leverAxes are not parallelInteraction of ligament and muscle forces maintains bone positionsMultiple foot disorders can affect its function

Windlass MechanismsPlantar fascia plays key role in supporting medial longitudinal arch via windlass mechanismPlantar fascia=maintains medial longitudinal arch during movementTension in plantar fascia directly related to DF of MTP of toesPassive DF during gait cyclePF forces from calcaneal tendon is transferred to forefoot through plantar fascia

Question TimeWhich muscle group is the primary driver behind propulsion during gait?Foot intrinsicsPlantarflexors (triceps surae group)Evertors (fibularis longus/brevis)Dorsiflexors (tibialis anterior)Answer B-Plantarflexors

Gait BiomechanicsInitial contact: Slight DF, moves to neutral at 10-15% of stance, DF through mid stance to terminal stance, rapidly PFs to toe offPlantarflexors primary muscles for propulsion/support during gait80% of energy required for forward progressionSoleus: decelerates tibia after foot flat (eccentric) followed by triceps surae for push offSubtalar Joint MvtMoves into pronation from initial contact to foot flat (10-15% of stance)Rapidly inverts/supinates during terminal stance (>50% stance). Late stance supination may assist with locking the midfootInitial contact: Tib Ant eccentrically controls foot to ground and controls hindfoot in pronationCoactivation of medial+lateral: controls degree of supination and pronation of subtalar joint, large role in maintaining medial longitudinal archMLA + GaitSmall/significant ROM during walkingRising of arch attributed toBoney anatomy, ligamentous support, muscle actionsArch raises during late stance phase when ankle power is highPassive mechanisms (windlass effects) vs. muscleFurther research requiredHallux Kinematics1st MTP: considerable ROM during walking and heel riseBiomechanical Vital Signs-toe extension1st MTP DFs >40 deg at terminal stance during heel riseEccentric contractions of FHL, FHB, ABD hallucis as 1st MTP absorbs energy

Exam/EvalRule out major medicalRule out spine, Rule out neurodynamics, rule in peripheral jointHypo vs. HyperRegional Interdependent variablesRemember: Were the Movement Experts!

Subjective ExamChief complaint, onset, behavior of symptoms, overall assessment, PMH, patient goalsEstablishing foot position during injury may help guide objective testingSelf-report outcome measuresLEFS, FAAM, VISA-A, CAIT, AII

Tell me your storyObjective ExamStatic Foot PostureFoot Posture IndexArch Height IndexNavicular Drop TestDifference >10mm between 2 stance positions indicates abnormal findingLower Quarter Movement Screen!

Functional TestingHop TestsFigure 8Side-hop6-meter crossover hopSquare hopSingle Limb Balance TestVery good reliability with eyes openStar Excursion Balance TestAgeGenderEOEC18-39MaleFemale43.543.28.510.240-49MaleFemale40.440.17.47.350-59MaleFemale36.038.15.04.560-69MaleFemale25.128.72.53.170-79MaleFemale11.318.32.21.980-89MaleFemale7.45.61.41.3Functional: Single HRBilateral and unilateral heel raises to assess foot functionEvaluate # of reps individual can performFindingsAthletes mean age of 24=39 heel risesOlder adults 61-80=2-4 heel risesKinematicsHeel heightKnee/trunk positionSubtalar joint inversion/eversionFirst metatarsal PF/DFPressure distributionROMTalocrural Joint: multiple positions (knee bent vs. knee extended), WBingSubtalar joint neutral positionSubtalar joint motion1st MTP joint (Extension!)Joint MobilityMultiple joints throughout ankle footFocus on end feelOsteokinematic/arthrokinematic relationship

Special TestsHigh number of special tests for foot/ankle complexExternal Rotation Test: syndesmotic injuryThompson Test: Achilles integrityFibularis subluxation testMulder click test-neuromaUnilateral heel raise-PTTDToo many toes sign-PTTDCommon Foot ProblemsPes PlanusIncidental finding unless correlated with clinical symptomsExtreme flat foot in runners associated with specific injury typesManual Therapy/Regional Interdependent Variables

Short Foot

Hallux ValgusLateral deviation of hallux/medial deviation 1st metatarsalDiagnosis: deviation of hallux from 1st MTP >15 degreesTreatmentAddress pathomechanics of hallux valgusEarly: Regain motionLater: Intrinsic strengthening, proprioception exercises, functional strengtheningFoot/Ankle Problems

High Ankle SprainsHigh exposure to contact sports, skiingRotation of talus gaps distal tibiofibular joint damaging ligamentsDF/ER of tibia on planted footTreatmentProgress from protective WBing to more WBing and advance to sports-specific tasksFollow phases of healing (protection, subacute, sports-specific training, return to play)

Lateral Ankle SprainNew studies suggest:Short period of immobilization may be recommended in the futureTrails of early surgical reconstruction of lateral ligament complex may be investigatedPossible risk factorsFatigue, balance, DF strength, coordination, positional and ROM variables

Medical screening! Rule out orthopedic medical!Question Time!A patient presents to your clinic via direct access 1 day s/p R ankle injury. Patient states she rolled her ankle on the way down after spiking a ball during a volleyball game. She presents with point tenderness over sinus tarsi, edema throughout ankle, ecchymosis in lateral ankle and lateral foot, and inability to bear weight on R LE. What is the next appropriate step in the clinical exam?Perform SLS testing to assess proprioception/balance ability and pain provocationRefer for imaging to rule out fractureContinue with examination including ROM testing and joint mobility testingPerform thrust manipulation to proximal tib/fib joint and reassessment pain levels for intersession change

Answer B: rule out for imaging to rule out fractureInability to weight is 1 criteria for Ottawa Ankle Rules suggesting radiograph is recommended to rule out fractureA:1 Medical hypothesisOttawa Ankle RulesBone tenderness in malleolar zoneBone tenderness at:Posterior edge or tip of lateral malleolusPosterior edge or tip of the medial malleolusBase of fifth metatarsalNavicularInability to weight bear immediately following the injury and during examinationGradingGrade 1: no loss of function, no ligamentous instability, little or no ecchymosis, point tendernessGrade 2: some loss of function, decreased motion, a + ant drawer, negative talar tilt test, ecchymosis, swelling, point tendernessGrade 3: nearly total loss of function, + ant drawer test and talar tilt test, diffuse swelling and ecchymosis, extreme point tendernessTreatmentProgression is based of grade of sprainManual therapyPost talocrural glides for DF ROMProximal tib/fib manipulationMotor Control/NMR ActivitiesHigher level strengthening/balance activitiesAnterior Impingement SyndromeRepeated microtrauma at anterolateral talocrural line may result in scar tissue formationAnterior joint pain with forced DF, pain with:Squatting, stair climbing, walking fastTreatment:Improve DF without painManual TherapyAnkle OAOccurrence may be increasing due to higher number of elderly individuals and MVAPosttraumatic (78%), secondary (13%), primary (9%)Osteochondral defect on talar dome-importance prognostic factor for development of ankle osteoarthritisTreatmentCane, bracing, viscosupplementation, debridement

Hindfoot Problems

Plantar FasciitisOveruse syndrome at origin of plantar fasciaRepetitive loading of central band develops into a fasciosisHeel spurs may be present1/10 will experience plantar fasciitisMost common age 45-64Risk FactorsObesityDecreased DF ROM (strongest predictor)Time spend on feet at work

DiagnosisPain with palpation of proximal plantar fascia insertionActive and passive talocrural joint DF ROMTarsal tunnel syndrome testWindlass testMedial longitudinal arch angleRule out neurodynamics: tibial nerve!TreatmentManual therapy combined with other treatments shown to be effectiveVariety of modalities and stretching vs. manual therapy combined with therapiesManual therapy group=greater decreases in pain and improvements in function

Midfoot Problems

Lisfranc InjuriesLongitudinal forces applied to a plantarflexed ankle/footFootball linemenMVADirect crush injuriesTreatment depends on severityNo stability: treat with casting or other forms of immobilizationInternal fixation for instabilitySever diseaseCalcaneal apophysitisSelf limiting conditionTraction force from Achilles tendon pulling on bone fragment that is present before calcaneus fully ossifiesBoys 6-8 yrs oldTreatmentRest, ice, heel lift, stretchingMost cases resolve completely 2wks-2 monthsForefoot Problems

Hallux RigidusDegenerative arthritis of 1st MTP jointLateral forefoot pain not uncommon due to load transferGrade 0DF 40-60 deg, normal radiograph, no painGrade 1DF 30-40 deg, dorsal osteophytes, min joint changesGrade 2DF 10-30 deg, mild flattening of MTP joint, joint narrowing, osteophytesGrade 3DF