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
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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
(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
