Foot and Ankle Injuries

HuP: 268 Lower Extremity

Foot Anatomy

• Superficial Layer– Abductor Hallicus

• Medial plantar nerve

– Flexor digitorm brevis• Medial plantar n.

– Abductor digiti minimi• lateral plantar n.

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Foot Anatomy

• 2nd Layer– Tendon of the FHL– Tendon of the FDL– Quadratus plantae

• lateral plantar n.

– lumbricals 1st• medial plantar n.• lateral 3: lateral planar n.

Foot Anatomy

• 3rd Layer– Flexor hallicus brevis

• medial plantar n.

– Adductor haliucs• lateral plantar n.

– Flexor digiti minimi• lateral plantar n.

Foot Anatomy

• 4th Layer– dorsal interossei

• abductors of the toes

– plantar interossei• adductors of the toes

Foot Anatomy

•4th Layer

–dorsal interossei

•abductors of the toes

• Dorsum – Extensor ditigorum brevis– Extensor hallicus brevis

Foot Neural Anatomy

Deep Plantar

Ligaments - between every joint

• 1. Spring ligament (calcaneonavicular) supports the medial longitudinal arch

• 2. Plantar facia - runs from the heel to the toe. Originates on the medial tubercle of the calcaneous, and attaches to the metatarsal heads. Band of thick fibers acts somewhat like arch.

Plantar Faciitis• Etiology:

– Repetitive stress (traction) during weight bearing and/or push off

– predisposing factors: rigid pes cavus, shortened achilles tendon, hypermobile forefoot

• Pathology:– Microtrauma/inflammation at the insertion of the

plantar fascia into the calcaneous with w/out bony exostosis formation (calcaneal spur)

Plantar Facitis Cont.

– Signs & Symptoms• History: repetitive stress, morning pain• Walking “toe-out”• Swelling• Localized pain and tenderness during passive

hyperextension of MP joints• Point tender at calcaneal insertion (calcaneal

spur)• Positive test for tightness of achilles (DF)

Plantar Facitis Cont.

– Treatment:• Stretching (achilles, plantar facia)• US (Mechanical)• Orthotics (?)

– Participation to tolerance

Heel Spur

Tarsal Tunnel Syndrome

• Etiology:– Indirect trauma: repetitive heel strike during

running on hard surfaces, poor fitting shoes– Forces transmitted to tarsal tunnel

• Pathology:– Compression of the posterior tibial nerve in

the posteriomedial compartment of the ankle

Tarsal Tunnel Syndrome

• Signs & Symptoms– Localized swelling– Pain medial ankle and

heel– Positive sensory test

(Medial heel)– Positive motor test

(planar flexion of the ankle, flexion of the toes)

– Positive Tinel sign

Tarsal Tunnel Syndrome Cont.

• Treatment:– Antiinflammatory (US, ice(may be

sensitive)– Non-weight bearing/ or altered participation– Orthotics - if indicated– Decompression - surgical if indicated

Ankle Synovitis• Etiology:

– Indirect trauma: repetitive heel strike during running on hard surfaces, poor fitting shoes

– Secondary to primary injury

• Pathology:– Inflammation of

synovium

Ankle Synovitis Cont.• Signs & Symptoms

– Swelling– Diffuse Pain– May present as other ankle injuries - chronic

• Treatment:– Antiinflmmatory (US, ice(may be sensitive)– Non-weight bearing/ or altered participation– Orthotics - if indicated– Surgical if indicated

Fractures of the Metatarsals

• Etiology:– Direct Trauma (foot stepped on)– Rotatory forces acting on the forefoot

(inversion/PF)– Avulsion (5th met head - Jones fracture)

• Pathology:– Transverse/Spiral-oblique fx of met shaft– avulsion of the head of 5th– fracture of base 5th

Fractures of the Metatarsals

• Signs & Symptoms– Localized

pain/tenderness– Localized swelling– Crepitus

• Treatment:– Non-weightbearing– May be placed in boot

March Fracture

• Etiology– Repetitive stress (running, jumping, ballet)

• Pathology– Stress fracture of the neck or shaft (most

common of the metatarsal)• usually 2nd, 3rd, or 4th

March Fracture Cont.

• Signs & Symptoms– Metetarsalgia/

gradual onset– Point tenderness– Swelling

• Treatment– Altered participation– Non-weight bearing

   

LISFRANC (Tarsal-

Metatarsal) FRACTURE

DISLOCATION

Morton’s Neuroma– Etiology:

• Direct trauma (stretching of plantar structures during hyperextension of the MP joint (sprint starts, recovery from jump)

• Tight shoes, lateral compression of met heads and interdigital nerves

– Pathology:• Localized thickening (neuroma) at the junction of the

third and of the medial plantar nerve and communicating branch of the lateral plantar n. between 3rd and 4th (most commonly resulting in chronic neuritis)

Morton’s Neuroma Cont.– Signs & Symptoms

• “cramp-like pain during running

• Tingling/numbness in lateral third and medial 4th toes

• pain relief on removal of shoe and/or pressure

• point tenderness• callus• positive compression test

may have (clicking)• positive sensory test

Morton’s Neuroma Cont.• Treatment:

– Relieve pressure• orthotics• Ha-Pad

– May be surgical

• Friebergs Disease: Osteochondritis of head 2nd met. Head– Similar etiology– Signs & Symptoms similar to Morton’s neuroma

minus neurological symptoms

Interdigital Neuroma

Cuboid Syndrome• Etiology: Repetitive stresses particularly

in “stance to push-off phase” jumping

• Pathology: disputed– subluxation/dislocation of cuboid– subluxation/dislocation peroneus longus

Cuboid Syndrome Cont.

• Signs & Symptoms– pain in stance phase– point tender plantar surface of cuboid– crepitus

• Treatment:– Cuboid Bump– Foot Snap– Acutely - antinflam.– Chronic - Heat modalities

Calcaneal Apophysitis (Sever’s Disease)

• Etiology:– Direct trauma (repetitive heel strike during

running , recovery, jumping– Repetitive traction through achilles tendon

• Pathology– Inflammation of the Apophysitis of the os

calcis with w/out fragmentation of the Apophysitis

Calcaneal Apophysitis Cont.

• Signs & Symptoms– Antalgic gait - heel pain during running/walking– swelling– localized pain/tenderness– positive active/passive ROM test for tight achilles

tendon

• Calcaneal Extosis: need to differentiate between Apophysitis

Fractures of Calcaneous

• Etiology:– Violent crushing forces (forceful heel strike

on hard playing surface– avulsion of achilles tendon– Miscellaneous direct trauma

• Pathology– Crush fracture intraarticular (subtalar joint– Crush fractures

Fractures of the Calcaneous Cont.

• Signs and symptoms– severe heel pain/antalgic gait (toe gait)– Localized tenderness– Swelling

Retrocalcaneal/Retroachilles Bursitis

• Etiology:– Repetitive dorsiflexion/plantar flexion of the ankle

with friction/traction exerted through the achilles tendon

– Direct pressure

• Pathology:– Inflammation of the retrocalcaneal and/or

retroachilles bursa– This may be with w/out callus formation “pump

bump”

Retrocalcaneal/Retroachilles Bursitis

• Signs & Symptoms– Localized swelling– tenderness– positive active/passive ROM tests for pain

positive

Fat Pad Contusion/Lacertation

• Etiology: Direct Trauma

• Pathology: Contusion or lacertation of fat pad between calcaneous and hard surface

• Signs and Symptoms:– Swelling, discoloration– Point tenderness– pain with heel strike– Anatalgic gait

Fat Pad Contusion/Lacertaion Cont.

• Treatment:– Ice– May need to alter participation– Heel cup/taping

Talus Fracture and OCD

Talus Fracture and OCD

Talus Fracture and OCD

Ankle Anatomy

• . Muscles -• Gastroc - plantarflexion• Soleus - plantarflexion• Anterior Tibialis - Dorsiflexion• Medial - Posterior tibialis, Flexor digitorum

Longus Hallux longus (Plantarflexion/inversion)• Lateral - Peroneals (Dorsiflexion/eversion)

Ankle Anatomy

• Ligamentous Anatomy– Deltoid Ligament– Anterior Talo-Fibular Ligament– Calcaneofibular Ligament– Posterior Talo-Fibular Ligament– Ant/Post Tib-Fib

Sprains

– Inversion Sprain - Supination and inversion (stepping off a curb)

• 1st degree - mild swelling discomfort not necessarily disability anterior talo-fibular ligament

• 2nd degree - Some dysfunction, some joint laxity and increased swelling

– Inversion test– Anterior Drawer - shift talus forward– Stress X-ray - Physician may do this for the angle

between the talus and tib/fib

Sprains

• 3rd degree - Greater laxity, more often involves PTF

• ** If in doubt of the severity and gait is compromised put the individual on crutches, and RICE

Eversion Sprain - Disruption of The Deltoid ligament, eversion

and pronation

• Treat the same as Inversion Sprain

• If excessive eversion may fracture the fibula (lateral Maleoli)

Rotation Sprain- Hyperflexion (Dorsiflexion) - Disruption of

Tib-Fib

• 1. Land in hyperflexion (jump off something)

• 2. Rotation and plantarflexion

• 3. Test - Compression/distraction

• 4. Takes longer to heal because every time the individual steps the tib-fib ligament is re-irritated.

Avulsion Fracture - Ligament pulls off a piece of bone Instead of disrupting the

ligament.• 5th Metatarsal styloid fracture (Jones

Fracture)

• Peroneal tendon of the peroneus brevis pulls of a piece of the 5th metatarsal.– Mechanism - step on– accompanied with inversion sprain– Treatment - casted/immobilized

Subluxing peroneals– Peroneals pop back and forth over the

peroneal tubercle– Mechanism

• acute• chronic - due to shallow peroneal tubercle

– Signs/symptoms - popping and pain on eversion

– Treatment - conservative strengthen peroneals– Surgical - not often

Achilles Rupture• Mechanism - acute over stretch (3rd degree

strain) or due to hit (3rd degree contusion)• Signs and Symptoms - Complain "kick in

calf" ,Ball under the knee, not particularly painful

• Treatment - 72 hours until it starts to degenerate and more difficult to surgically reattach

• Thompson test

Ankle Dislocation - Talus comes out of the mortise,

• Mechanism - same as ankle sprains

• Signs and Symptoms - Deformity

• Treatment - Closed reduction by physician, sometimes surgical

Talar Dome Fractures

• Etiology: Hyperdorsiflexion, Direct Trauma, Rotational forces

• Pathology:– Fracture Talar Dome

• Signs & Symptoms– Swelling, may seem excessive– point tenderness– positive tap test

Talar Dome Fractures– Treatment:

• Referral• Non-weightbearing

– Osteochondritis dissecans of the Talar Dome• Etiology - original trauma• Pathology - degeneration• Signs & Symptoms:

– Point tenderness– Swelling (may be intermittent– Pain - diffuse, dull, achy– Weight bearing and pain with activity

• Treatment: Surgical

Tibialis Posterior Strain/Tendonitis

• Etiology:– Repetitive Stress, pes planus, hyperflexible

forefoot

• Pathology:– Overuse of Tibialis Posterior, on stretch in

pes planus

Tibialis Posterior Strain/Tendonitis

– Signs & Symptoms• Pain during walking/running• pain on active inversion/PF, passive eversion• swelling• point tenderness

– Treatment:• Antinflammatories (US, ice,meds)• Stretching/strengthening• Orthotics - when indicated• Taping/bracing and proper shoes• limited px when indicated

Muscle Strains

• No limit to type of muscle strain that can be experiences

• More Common– Flexor Hallux Longus/Brevis– Extensor digitorum brevis