Download Foot and Ankle - The Kansas Association of Osteopathic

Foot and Ankle
Rance L. McClain, D.O., FACOFP
Associate Professor – FM Dept.
KCUMB-COM
Learning Objectives
1. Review the diagnosis of the foot and
ankle
2. Apply specific osteopathic testing to the
diagnosis of the foot and ankle
3. Understand the application of osteopathic
treatment to the foot and ankle
General
•
•
The foot and ankle is the focal point of
total body weight, performing this
function both when stationary and with
gait
Adaptation to the terrain upon which a
person stands and walks
General
• Problems with the foot and ankle can arise
from mechanical, pathological, vascular, or
inflammatory origins
• The foot is affected not only by local
stresses, but also by systemic diseases
• Approximately 40% of people have foot and
ankle problems
Inspection - Ankle
•
Range of Motion
•
•
Plantar flexion: 50 degrees
Dorsiflexion 20 degrees
•
Excess motion can cause fibular dysfunction
Inspection - Ankle
• Accessory motions of side-to-side glide,
rotation, abduction, and adduction are also
present depending on the position of the foot
• Because the talus is wider anteriorly than
posteriorly, the ankle is more mobile in
plantarflexion than dorsiflexion
Inspection - Ankle
•
Ankle Mortis
–
Relationship of the medial and lateral
malleoli causes the ankle articulation to be
held in a position of 15 degrees of toeing out
Inspection - Ankle
• Tibiofibular syndesmosis
– Responsible for maintaining the width of the
ankle mortise
– If torn, the mortise can widen, and the talus
becomes unstable
Inspection - Ankle
•
Soft Tissue & Edema
–
–
Medially located deltoid ligament
Laterally located anterior & posterior
talofibular ligaments, as well as the
calcaneofibular ligament
•
•
Anterior talofibular ligament is highly susceptible
to injury
Lateral ankle edema inferior and anterior to the
lateral malleolus
Inspection - Ankle
•
Unilateral swelling is usually trauma,
while bilateral swelling is usually
indicative of cardiovascular problems
(CHF, venous insufficiency, etc.)
Inspection - Ankle
•
Vascular
•
•
Posterior tibial pulse
When you progress down to the inspection of
the foot, you will also inspect the dorsal
pedal pulse
Inspection - Foot
•
How many toes are present and are they
deformed
Inspection - Foot
• How does the foot contact the floor
– Pressure points can develop calluses
– Skin is usually thicker at the weight bearing
areas at the heel, the lateral border, and the 1st
and 5th metatarsal heads
Inspection - Foot
• Can you slide your fingers under the medial
arch of the foot
Inspection - Foot
• Arches
– Lateral longitudinal arch
• Calcaneus, Cuboid, 4th & 5th Metatarsal bones
• Low arch with limited mobility
• Transmits weight and thrust to the ground
– Medial longitudinal arch
• Calcaneus, Talus, Navicular, Cuneiforms, and 1st3rd Metatarsals
• Higher arch, much more mobile. Sustained by the
skeletal structures as well as the Plantar Fascia
Inspection - Foot
• Inspect the arches with the patient sitting
– Spastic flat foot will cause the foot to dorsiflex
and evert, whereas a normal foot will plantar
flex and invert
Inspection - Foot
•
Range of Motion
–
–
Calcaneal abduction and adduction at the
subtalar articulation
Inversion and eversion are combination
motions
•
•
Inversion is calcaneal adduction, navicular
rotation, and glide on the talus
Eversion is produced by the opposite motions
above
Inspection - Foot
•
•
•
Forefoot abduction and adduction
Pronation is the motion of the foot and
ankle combining calcaneal abduction,
forefoot abduction, subtalar- cuboidnavicular eversion, and ankle dorsiflexion
Supination consists of calcaneal
adduction, subtalar-cuboid-navicular
inversion, forefoot adduction, and ankle
plantar flexion
Shoe Inspection
•
•
Alterations in structure and function will
show in the wear and tear on shoes
Normal wear from heal strike to toe off
gives a transverse crease
Shoe Inspection
•
Abnormal wear examples
•
Foot Drop (neurological damage)
•
•
•
Dorsiflexors are paralyzed
Toe scrapes in ambulation causes scuff marks on
the toe box and the front part of the soles
Hallux Rigidus (no motion of the 1st MTP
joint)
•
Does not allow normal toe off with gait, leading
to an oblique crease in the shoes
Shoe Inspection
• Flat Feet (Pes planus)
– Tend to over pronate and increase wear on the
soles of the shoe medially
• High Arches (Pes cavus)
– Tend to supinate and increase wear on the
lateral aspects of the soles of the shoes
Lab/Treatment Section
• Evaluation
– Dorsiflexion/Plantarflexion
– Subtalar Abduction/Adduction
– Calcaneal Inversion/Eversion
– Navicular (medial) & Cuboid (lateral)
– Metatarsal motion
– Phalanges motion
Lab/Treatment Section
• Muscle Energy
– Dorsiflexion/plantarflexion
– Subtalar abduction/adduction
– Calcaneal inversion/eversion
Lab/Treatment Section
• Counterstrain
– Calcaneal TP (plantar fasciitis)
• Soft tissue treatment
– Plantar fascia
• Lymphatics
– Effleurage & Pétrissage
Lab/Treatment Section
• HVLA
–
–
–
–
–
Inversion/eversion calcaneus (ankle traction)
Subtalar thrust
Dorsal metatarsals treatment
Transtarsal thrust
Cuboid-Navicular treatment (Hiss whip)