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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. . 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 D e e p P l a n t 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/gradu al onset – Point tenderness – Swelling • Treatment – Altered participation – Non-weight bearing LISFRANC (TarsalMetatarsal) 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