Transcript Small Group PPT 21.2.12 Foot Anklex

The Foot and Ankle
21.2.12
Mark Powers,PT,DPT,OCS
NxtGen Fellow-in-Training
[email protected]
Twitter: @PTSkeptic
Objectives
 Review anatomy/movements of the ankle/foot region
 Review pertinent tests/measures/observations for
patients with ankle/foot conditions
 Review common foot/ankle pathologies
 Discuss clinical utility of information within this
monograph
Functional Anatomy
 Commonly injured: high loads and repetitive loading
during daily activities
 A:5 Etiologic Variables
 Foot can act as rigid lever or flexible absorbing
structure
 Multiple important structures at risk for injury
Joint
Movements-Plane
Ankle
PF/DF-sagittal
Subtalar (talocalcaneal)
Supination
• Inversion-frontal
• Adduction-transvers
• PF-sagittal
Pronation
• Eversion-frontal
• Abd-transvers
• DF-sagittal
Talonavicular
Inversion/eversion-frontal
ADD/ABD-transvers
PF/DF-sagittal
Forefoot
INV/EV-frontal
ADD/ABD-transverse
PF/DF-sagittal
Anatomy
 28 bones total
 Forefoot (phalanges, metatarsals)
 Midfoot (cuneiforms, navicular, cuboid)
 Hindfoot (calcaneous, talus)
Talocrural joint
 Distal tibia and fibula with trochlea of talus (ankle mortise)
 Plantarflexion/Dorsiflexion
 Increased stability in DF due to shape of trochlea
 Ligamentous Support
 Anterior Talofibular (ATFL)
 Prevents anterior displacement of talus to ankle mortise
 Calcaneofibular (CFL)
 Inversion and adduction of calcaneus
 Posterior talofibular
 Taut in ER of talus on ankle mortise
Subtalar joint
 Superior boney facets of the calcaneus and inferior
facets on talus
 Ligamentous Support:
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CFL
Cervical ligaments
Parts of deltoid ligament (medial stability)
Interosseous talocalcaneal
Midfoot
 Articulates to hindfoot
 Calcaneocuboid joint
 Talonavicular joint
 Ligamentous Support
 Long and short plantar ligaments
 Spring ligament
 Spring ligament
 Prevents talar head from PFing, medial longitudinal arch
form lowering
 Involved in flat foot deformities
 Midfoot injuries frequently include ligaments stabilizing
2nd metatarsal and medial cuneiform bones
 Lisfranc ligament (prevents separations of 1st and 2nd
metatarsal)
Muscle
 Intrinsic and extrinsic muscles control foot movement
 Strength of muscle I proportional to its physiologic
cross sectional area
 Based off cross sectional area: triceps surae group
primary ankle plantarflexors
Lateral Compartment
 Fibularis longus/brevis
 Pronate subtalar joint
 Fibularis Longus
 PF of 1st metatarsal through its attachment to base of 1st
metatarsal and medial cuneiform bones
 Fibularis Brevis
 ABD of forefoot
 Pronator of subtalar joint
Deep Post Compartment
 FHL, FDL, Post Tib “tom, dick, harry”
 Posterior Tib
 Attaches to navicular and medial cuneiform-supports
medial longitudinal arch
 Supinates subtalar joint
Ant Compartment
 Dorsiflexors of ankle joint
 Tib Anterior, Fibularis tertius, EDL, EHL
 Tib Anterior
 Dorsiflexion/inversion
 Supination subtalar joint
Intrinsic Muscles
 PIP flex, MTP flex, ADD/ABD of MTP joints
 Arch support and propulsion during walking and
running
Compartment
Muscles
Medial
ABD hallucis, FHB
Central
Quadratus plantae muscle,
FDB, ADD hallucis, lumbricales
Lateral
ABD digiti mini, flexor digiti
mini brevis
Deep compartment
Dorsal and plantar interossei
Longitudinal Arch
 Hindfoot pronated=flexible foot
 Axes of talonavicular and calcaneocuboid joints are
parallel
 Hindfoot supinated=rigid lever
 Axes are not parallel
 Interaction of ligament and muscle forces maintains
bone positions
 Multiple foot disorders can affect it’s function
Windlass Mechanisms
 Plantar fascia plays key role in supporting medial
longitudinal arch via windlass mechanism
 Plantar fascia=maintains medial longitudinal arch
during movement
 Tension in plantar fascia directly related to DF of MTP
of toes
 Passive DF during gait cycle
 PF forces from calcaneal tendon is transferred to
forefoot through plantar fascia
Question Time
 Which muscle group is the primary driver behind
propulsion during gait?
A. Foot intrinsics
B. Plantarflexors (triceps surae group)
C. Evertors (fibularis longus/brevis)
D. Dorsiflexors (tibialis anterior)
 Answer B-Plantarflexors
Gait Biomechanics
 Initial contact: Slight DF, moves to neutral at 10-15% of
stance, DF through mid stance to terminal stance,
rapidly PF’s to toe off
 Plantarflexors primary muscles for propulsion/support
during gait
 80% of energy required for forward progression
 Soleus: decelerates tibia after foot flat (eccentric)
followed by triceps surae for push off
Subtalar Joint Mvt
 Moves 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 midfoot
 Initial contact: Tib Ant eccentrically controls foot to ground
and controls hindfoot in pronation
 Coactivation of medial+lateral: controls degree of supination
and pronation of subtalar joint, large role in maintaining
medial longitudinal arch
MLA + Gait
 Small/significant ROM during walking
 Rising of arch attributed to
 Boney anatomy, ligamentous support, muscle actions
 Arch raises during late stance phase when ankle power
is high
 Passive mechanisms (windlass effects) vs. muscle
 Further research required
Hallux Kinematics
 1st MTP: considerable ROM during walking and heel
rise
 Biomechanical Vital Signs-toe extension
 1st MTP DF’s >40 deg at terminal stance during heel
rise
 Eccentric contractions of FHL, FHB, ABD hallucis as 1st
MTP absorbs energy
Exam/Eval
 Rule out major medical
 Rule out spine, Rule out neurodynamics, rule in
peripheral joint
 Hypo vs. Hyper
 Regional Interdependent variables
 Remember: We’re the Movement Experts!
Subjective Exam
 Chief complaint, onset, behavior of symptoms, overall
assessment, PMH, patient goals
 Establishing foot position during injury may help guide
objective testing
 Self-report outcome measures
 LEFS, FAAM, VISA-A, CAIT, AII
Objective Exam
 Static Foot Posture
 Foot Posture Index
 Arch Height Index
 Navicular Drop Test
 Difference >10mm between 2 stance positions indicates
abnormal finding
 Lower Quarter Movement Screen!
Functional Testing
 Hop Tests
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Figure 8
Side-hop
6-meter crossover hop
Square hop
 Single Limb Balance Test
 Very good reliability with eyes open
 Star Excursion Balance Test
Age
Gender
EO
EC
18-39
Male
Female
43.5
43.2
8.5
10.2
40-49
Male
Female
40.4
40.1
7.4
7.3
50-59
Male
Female
36.0
38.1
5.0
4.5
60-69
Male
Female
25.1
28.7
2.5
3.1
70-79
Male
Female
11.3
18.3
2.2
1.9
80-89
Male
Female
7.4
5.6
1.4
1.3
Functional: Single HR
 Bilateral and unilateral heel raises to assess foot function
 Evaluate # of reps individual can perform
 Findings
 Athletes mean age of 24=39 heel rises
 Older adults 61-80=2-4 heel rises
 Kinematics
 Heel height
 Knee/trunk position
 Subtalar joint inversion/eversion
 First metatarsal PF/DF
 Pressure distribution
ROM
 Talocrural Joint: multiple positions (knee bent vs. knee
extended), WBing
 Subtalar joint neutral position
 Subtalar joint motion
 1st MTP joint (Extension!)
Joint Mobility
 Multiple joints throughout ankle foot
 Focus on end feel
 Osteokinematic/arthrokinematic relationship
Special Tests
 High number of special tests for foot/ankle complex
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External Rotation Test: syndesmotic injury
Thompson Test: Achilles integrity
Fibularis subluxation test
Mulder click test-neuroma
Unilateral heel raise-PTTD
Too many toes sign-PTTD
Common Foot
Problems
Pes Planus
 Incidental finding unless correlated with clinical
symptoms
 Extreme flat foot in runners associated with specific
injury types
 Manual Therapy/Regional Interdependent Variables
Short Foot
Hallux Valgus
 Lateral deviation of hallux/medial deviation 1st
metatarsal
 Diagnosis: deviation of hallux from 1st MTP >15
degrees
 Treatment
 Address pathomechanics of hallux valgus
 Early: Regain motion
 Later: Intrinsic strengthening, proprioception exercises,
functional strengthening
Foot/Ankle Problems
High Ankle Sprains
 High exposure to contact sports, skiing
 Rotation of talus gaps distal tibiofibular joint damaging
ligaments
 DF/ER of tibia on planted foot
 Treatment
 Progress from protective WBing to more WBing and
advance to sports-specific tasks
 Follow phases of healing (protection, subacute, sportsspecific training, return to play)
Lateral Ankle Sprain
 New studies suggest:
 Short period of immobilization may be recommended in
the future
 Trails of early surgical reconstruction of lateral ligament
complex may be investigated
 Possible risk factors
 Fatigue, 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?
A. Perform SLS testing to assess proprioception/balance ability and
pain provocation
B. Refer for imaging to rule out fracture
C. Continue with examination including ROM testing and joint
mobility testing
D. Perform thrust manipulation to proximal tib/fib joint and
reassessment pain levels for intersession change
 Answer B: rule out for imaging to rule out fracture
 Inability to weight is 1 criteria for Ottawa Ankle Rules
suggesting radiograph is recommended to rule out
fracture
 A:1 Medical hypothesis
Ottawa Ankle Rules
1. Bone tenderness in malleolar zone
2. Bone tenderness at:
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Posterior edge or tip of lateral malleolus
Posterior edge or tip of the medial malleolus
Base of fifth metatarsal
Navicular
3. Inability to weight bear immediately following the injury
and during examination
Grading
 Grade 1: no loss of function, no ligamentous instability,
little or no ecchymosis, point tenderness
 Grade 2: some loss of function, decreased motion, a +
ant drawer, negative talar tilt test, ecchymosis, swelling,
point tenderness
 Grade 3: nearly total loss of function, + ant drawer test
and talar tilt test, diffuse swelling and ecchymosis,
extreme point tenderness
Treatment
 Progression is based of grade of sprain
 Manual therapy
 Post talocrural glides for DF ROM
 Proximal tib/fib manipulation
 Motor Control/NMR Activities
 Higher level strengthening/balance activities
Anterior Impingement
Syndrome
 Repeated microtrauma at anterolateral talocrural line
may result in scar tissue formation
 Anterior joint pain with forced DF, pain with:
 Squatting, stair climbing, walking fast
 Treatment:
 Improve DF without pain
 Manual Therapy
Ankle OA
 Occurrence may be increasing due to higher number of
elderly individuals and MVA
 Posttraumatic (78%), secondary (13%), primary (9%)
 Osteochondral defect on talar dome-importance
prognostic factor for development of ankle osteoarthritis
 Treatment
 Cane, bracing, viscosupplementation, debridement
Hindfoot Problems
Plantar Fasciitis
 Overuse syndrome at origin of plantar fascia
 Repetitive loading of central band develops into a fasciosis
 Heel spurs may be present
 1/10 will experience plantar fasciitis
 Most common age 45-64
 Risk Factors
 Obesity
 Decreased DF ROM (strongest predictor)
 Time spend on feet at work
Diagnosis
 Pain with palpation of proximal plantar fascia insertion
 Active and passive talocrural joint DF ROM
 Tarsal tunnel syndrome test
 Windlass test
 Medial longitudinal arch angle
 Rule out neurodynamics: tibial nerve!
Treatment
 Manual therapy combined with other treatments shown
to be effective
 Variety of modalities and stretching vs. manual therapy
combined with therapies
 Manual therapy group=greater decreases in pain and
improvements in function
Midfoot Problems
Lisfranc Injuries
 Longitudinal forces applied to a plantarflexed ankle/foot
 Football linemen
 MVA
 Direct crush injuries
 Treatment depends on severity
 No stability: treat with casting or other forms of
immobilization
 Internal fixation for instability
Sever disease
 Calcaneal apophysitis
 Self limiting condition
 Traction force from Achilles tendon pulling on bone
fragment that is present before calcaneus fully ossifies
 Boys 6-8 yrs old
 Treatment
 Rest, ice, heel lift, stretching
 Most cases resolve completely 2wks-2 months
Forefoot Problems
Hallux Rigidus
 Degenerative arthritis of 1st MTP joint
 Lateral forefoot pain not uncommon due to load transfer
 Grade 0
 DF 40-60 deg, normal radiograph, no pain
 Grade 1
 DF 30-40 deg, dorsal osteophytes, min joint changes
 Grade 2
 DF 10-30 deg, mild flattening of MTP joint, joint narrowing,
osteophytes
 Grade 3
 DF <10 deg, severe radiographic changes, moderate to severe
pain, pain at extremes of ROM
 Grade 4
 Same criteria as grade 3 but pain throughout entire motion
Treatment
 Protect and remove irritating stress on joint
 Joint mobilizations
 Orthotics
 Surgical options
Tendinopathies and Ruptures
Insertional Achilles
Tendinopathy
 Retrocalcenal bursitis, subcutaneous bursitis, boney
spurs, Haglund deformity
 At or near insertion site on calcaneus
 Bursa and bone involvement
 Less active/overweight
 Diagnosis:
 Warmth, erythema, swelling, tenderness, crepitus
 Radiographs for boney abnormalities
Treatment
 Common eccentrics may not be appropriate for this
group due to low fitness levels
 Limit ROM to floor during heel lower to avoid
impingement on spurs
 Poorer prognosis than noninsertional Achilles
tendinopathy guide treatment by clinical presentation
Question Time!
 A 58 year old female presents to your clinic with referral
from physician for “plantar fasciitis, consider
ultrasound.” Patient presents medial foot/ankle pain
with insidious onset 5 months ago, has since
progressed to lateral aspect of foot. She reports
increased pain with climbing stairs and walking uphill,
as well as pushing heavier objects such as furniture
when she was rearranging her house. Considering the
information and images below, what is your main
consideration regarding pathology at this time?
A: Achilles Tendon Rupture
B: Plantar Fasciitis
C: Lateral ankle sprain
D: Posterior Tib Tendon Dysfunction
 D: Posterior Tib Tendon Dysfunction
Posterior Tib Tendon
 Common problem associated with flat foot
 Weakness with ankle inversion and forefoot adduction
 Lower muscle function may lead to increased loading
on key ligaments of causing flat foot posture
 Hypermobility, failure of boney stabilizing mechanisms
Stage Signs/Symptoms
Underlying Pathology
1
TTP
Swelling around tendon (distally)
Abnormal morphology of tendon
Pain with heel rise test
Tendon pathology with or
without synovitis
2
Same as stage 1
Flexible flat foot posture
Tendon pathology with or
without synovitis
Damage to soft tissue
supports
3
Same as stage 2, flat foot not flexible
Same as above with
development of joint
contractures
4
Same as stage 3, ankle OA
Same as above
Treatment
 Braces to unload tendon
 Exercise!
1. Induces remodeling of the tendon
2. Prevent weakness of leg muscles
3. Cause hypertrophy of atrophied leg muscles
Conclusion
 Rule out major medical, rule out spine, rule out
neurodynamics, rule in peripheral joint
 Observation will yield valuable information for
differential diagnosis in this region
 Focus on regional interdependent variables during
rehab-Look at hip!
 Manual therapy has a large role in rehabilitation with
these patients