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Foot and Ankle Pain
Prof. Dr. Ece AYDOĞ
Physical Medicine and Rehabilitation
FUNCTIONAL ANATOMY AND
BIOMECHANICS
 The ankle, or tibiotalar,
joint comprises the
articulation between the
foot (talus) and the
lower leg (distal tibia
and fibula).
Anatomic regions



Forefoot; toes and
metatarsal bones;
metatarsophalangeal (MTP)
and interphalangeal joints
Midfoot; tarsometatarsal
(TMT) joints connect the
forefoot to the midfoot,
which comprises the three
cuneiform bones, the
navicular, and the cuboid
Hindfoot; talus and
calcaneus, talocalcaneal
(subtalar), talonavicular,
and calcaneocuboid
articulations.
PHYSICAL EXAMINATION
 Location of swelling
 Deformity;
Hallux valgus or bunion
 Hammer toes,
 Flatfoot deformity (characterized by hindfoot
valgus/forefoot abduction).
 Callosities
 Rheumatoid nodules
 Ulcerations
 Wear patterns:
“A deformed foot can deform any good shoe; in fact, in
many cases the shoe is a literal showcase for certain
disorders.”

Hallux Valgus
Gece Ateli
Flatfoot Deformity
Flatfoot Deformity
 Rheumatoid nodules
 Diabetic ulcer
PHYSICAL EXAMINATION
 Metatarsal heads and MTP joints palpation in patients with RA
or nonarthritic metatarsalgia; tenderness, synovitis, and
swelling.
 Tenderness over the posterior aspect of calcaneus; Achilles
tendinitis
 Pain over the medial tubercle (palpable on the medial plantar
surface); plantar fasciitis.
 Tenderness over sinus tarsi of the hindfoot (located laterally,
just anterior and distal to the tip of the fibula); talocalcaneal joint
pathology
 Tenderness over the anterior joint line usually correlates with
ankle joint pathology.
 Calcaneal medial
tubercule (Plantar
fasciitis)
 Talocalcaneal yoint
pathology
PHYSICAL EXAMINATION
 Range of motion
analysis:


10 to 20 degrees of
dorsiflexion
40 to 50 degrees of
plantar flexion.

Normal hindfoot
inversion and eversion
are each
approximately 5
degrees.
COMMON CAUSES OF ANKLE PAIN
ANTERIOR AND CENTRAL ANKLE PAIN
 Spur and osteophyte formation
 Arthritis (degenerative or inflammatory)

 Anterior tibial tendon tendinitis or tendinosis
 Stress fractures
 Osteochondral defect
POSTERIOR JOINT PAIN
Achilles tendon

in most instances, Achilles
pain results from
degenerative tendinosis,
with or without an overlying
tendinitis.

associated intratendinous
spur formation is common

spur excision also frequently
entails tendon débridement,
reconstruction, and transfer.
Spur formation
(Plantar calcaneal and achilles tendon)
Achilles tendon

protected by two distinct
bursae.

more superficial bursa is
immediately
subcutaneous and
becomes inflamed
primarily with irritation
from ill-fitting shoes with
a tight counter (“pump
bump”).
Achilles tendon
“retrocalcaneal” bursa is a
larger structure that lies
deep to the Achilles
tendon. Inflammation of
this structure often
accompanies Achilles
tendinitis/tendinosis.

It also may be irritated by
an enlarged posterior
superior calcaneal
tuberosity, sometimes
referred to as a
Haglund's deformity.
MEDIAL ANKLE PAIN
 Stress fracture
 Arthritis
 Inflammation or degeneration (or both) of the posteromedial
flexor tendons, including the posterior tibial tendon and the
flexor hallucis longus and flexor digitorum longus tendons

long-standing synovitis and dysfunction of posterior tibial
tendon ultimately may lead to collapse of the arch and the
development of an acquired flatfoot deformity.
MEDIAL ANKLE PAIN
 Tarsal tunnel syndrome
is another cause of
posteromedial ankle
pain.
 pain that radiates
into the plantar foot

percussion of the
tarsal tunnel
reproduces these
symptoms (Tinel's
sign).
LATERAL ANKLE PAIN
 Stress fracture
 Arthritis
 Peroneal tendon pathology;
 tenosynovitis

longitudinal “split” tears

chronic tendon instability

the tendons sublux over the posterolateral edge of the
fibula, causing pain and attritional tearing
COMMON CAUSES OF FOOT PAIN
FOREFOOT PAIN
 The forefoot region is a common location of
foot pain.
Rheumatoid Arthritis


inflammation and
progressive MTP
synovitis eventually
lead to capsular
distention and
destruction.
loss of collateral
ligament stability and,
finally, destruction of
the articular cartilage
and bone
FOREFOOT PAIN
 Hallux valgus deformity or bunion;
 commonly encountered in patients with and without
inflammatory arthritis
 RA; 70%
 progression of this deformity may be accelerated
further by loss of support from the adjacent lesser MTP
joints.
 Hallux rigidus
 Degenerative arthritis
 Sesamoiditis
 Osteonecrosis
 Fracture
FOREFOOT PAIN




Claw toes
Hammer toes
Mallet toes
Etiologies;
 arthritis,
 trauma,
 nerve/muscle imbalance,
 and chronic use of shoes with inadequate toe boxes.
 Instability;
 mechanical causes (long second metatarsal)
 inflammatory disease
 MTP joint subluxation
 Claw toe

Mallet finger
FOREFOOT PAIN
Metatarsalgia
 Gastrocnemius contracture or tight Achilles tendon;
the forefoot is prematurely loaded during the stance
phase of gait.
 Hammer toes and mallet toes can result in downward
pressure on the metatarsal heads, leading to
metatarsalgia.
 In elderly patients and patients with inflammatory
arthritis, atrophy of the plantar fat pad of the forefoot
also can result in metatarsalgia.
LATERAL FOREFOOT
Morton's neuroma:
.

between the third and
fourth metatarsal
heads

burning, aching, or
shooting pain

symptoms are
especially exacerbated
with tight shoes
LATERAL FOREFOOT
Bunionette:

angular deformity of
the fifth toe

pain over the lateral
aspect of the fifth
metatarsal head
MIDFOOT PAIN
 Arthritis at the TMT joints


most frequently the first TMT joint on the
medial side of the foot
instability of the first TMT joint, repetitive
stress can lead to dorsiflexion of the first
metatarsal
 midfoot arthritis can lead to an abduction
deformity of the foot, where the forefoot and
metatarsals deviate outward.
MIDFOOT PAIN
 lateral midfoot pain:


peroneal tendinitis
stress fracture of the fifth metatarsal
 medial midfoot pain:



accessory navicular bone
osteonecrosis of the native navicular bone
insertional posterior tibial tendinitis
HINDFOOT PAIN
 joints of the hindfoot
 talonavicular
 talocalcaneal
 calcaneocuboid
 degenerative and inflammatory arthritis
 RA; 21% to 29%
 posterior tibial tendinitis and dysfunction
 Inflammation
 Degeneration
 Dysfunction
HEEL PAIN
 Plantar fasciitis;
inferior heel pain
 worse when first getting up in the morning or getting up after
sitting for a long time
 Achilles tendinosis;
 posterior heel pain
 worse during or after exercise
 Nerve entrapment;
 first branch of the lateral plantar nerve (Baxter's nerve)
 medial heel pain
 Calcaneal stress fracture;
 medial and lateral pain
 Calcaneal stress fracture usually can be distinguished by a
positive “squeeze test,” with compression of both sides of
the heel.

NONOPERATIVE TREATMENT
 Medical management

Nonsteroidal anti-inflammatory drugs

Steroids

Disease-modifying antirheumatic drugs
NONOPERATIVE TREATMENT
 Shoewear modification



deep, wide toe box
firm heel counter
soft heel
 Well-constructed walking or jogging shoes
usually provide sufficient room for mild-tomoderate deformities
NONOPERATIVE TREATMENT
 Often it is necessary to prescribe a custom orthotic insert for
patients with more moderate deformities
 It is typically necessary to remove the insole of the shoe to make
room for the orthotic insert
 Custom orthoses;



rigid,
semirigid,
softer accommodative devices

 Rigid and semirigid orthoses usually are used to correct supple
deformities and should be used with caution in patients with
arthritis
 Most walking or jogging shoes suffice.
NONOPERATIVE TREATMENT
 More commonly, these patients, especially if they have RA,
benefit from accommodative orthoses (i.e., orthoses made of
softer material that can be molded to “accommodate” a
deformity)
 Accommodative orthoses can be modified further by
incorporating a “relief” under a deformity, further unloading it

 When sending patients for orthoses, it is best to provide the
orthotist with a prescription that includes the patient's precise
diagnosis (e.g., metatarsalgia) and the type of orthosis and any
modifications desired (e.g., a “custom accommodative orthosis
with a relief under the lesser metatarsal heads”).
Injections
 Mixture of anesthetic and corticosteroid
 Injection of a corticosteroid near or directly into a
tendon can adversely affect the biomechanical
properties of the tendon, ultimately leading to rupture
 Avoid corticosteroid injections into the lesser MTPs
when there is evidence of joint instability.

Such injections can lead to further attenuation of the
joint capsule and result in frank joint dislocation.
OPERATIVE TREATMENT
 If symptoms persist despite nonoperative
management, surgical intervention should be
considered





Arthrodesis (joint fusion),
Arthroplasty (joint replacement),
Corrective osteotomy,
Tendon débridement and transfer,
Synovectomy (joint or tendon).