Foot and Ankle Regional Diagnosis

Plantar Fascitis is common in?

Sports or activités that involve running and long-distance walking. It can be in athletic or non-athletic populations.

Plantar Fascitis Risk Factors

Prolonged WB, Overuse, Rapid change in exercise, Inappropriate footwear and decreased DF ROM → increased Plantarfascities

PF Test

Windlass PF Test, DF ankle and GT for + pain reproduction

Where is pain in plantar facities?

Pinpoint (calcaneal tubercle) or diffuse over plantar fascia

WHAT IS THE BEST SIGN OF PF?

First couple of steps in the morning are ass, once warmed-up, they decrease in pain

What motions could elect PF pain?

DF and great toe extension

If you have a high longitudinal arch, what could occur?

Overpronation and overstretched fascia

What do you not want to do with PF?

Overstretch the fascia

Strong evidence for PF treatment

Manual therapy: Mobilizing talocrual, subtler, rear foot, mid foot and forefoot

Gastroc Stretching and PF stretching: Make sure Great toe isn't in extension

Arch taping (rigid or elastic): Orthotic candidate, very good in short term (3 weeks) for arch support

Night splints (1-3 months): Due to pain with first steps in morning

Moderate evidence for PF treatment

TherEx + neuromuscular re-ed

Low-level laser

Weak evidence for PF treatment

Iontophoresis (dexamethasone or acetic acid)

What drug increases PF rupture?

Corticosteroids

What is the tibialis posterior responsible for?

Locks subtalar joint out as a rigid lever

Posterior Tibialis Tendinopathy/Insufficiency

Due to excessive pronation and limited talocrual motion leading to failure

Posterior tibialis tendinopathy Clinical Findings

Can't do unilateral heel raise and PF/INV is weak, point tender or "boggy" along tendon insertion, and may have tenosynovitis

Where do Posterior Tibialis Tendiniopathy hurt?

Pain over medial arch

Which ankle joint is most underevaluated?

Subtalar

Posterior Tibialis Tendinopathy Treatment

Boot for 3-8 weeks, after boot will be fitted for an orthotic. Treat hypo mobility and strength deficits, starting in seating and progress to standing.

What are some important things to consider in therapy for posterior tibialis patients?

Talocrual and subtalar mobility, along with soleus stretching

Tarsal Tunnel Syndrome

Compression of posterior tibial nerve in the tarsal tunnel. Patient may talk about pain or burning, decreased sensation and weakened toe flexors.

Will have decreased sensation in medial or lateral plantar nerves, or both

What are the tarsal tunnel DD?

PF and post-tib insufficiency

Tarsal tunnel Testing

Positive Tinel's at tarsal tunnel (most common in extensor retinaculum = tibial nerve or M/L plantar nerves)

EMG: ~90% accurate in confirmed cases (gold standard)

What are the "Shin splints" diagnoses under MTSS?

Stress fx, myostatis, periostitis, tendinitis, compartment syndrome, Fasciitis, and ischemic disorders

Medial Tibial Stress syndrome doesn't include what 3 diagnoses from shin splints?

Stress fx, compartment syndrome and ischemic disorders.

Exertional Compartment Syndrome

Increased pressure in anterior, lateral or posterior compartment. Presents as tightness, cramping, burning, and pain during exertion that resolves with rest. May have paresthesia, weakness, drop foot.

When does exertional compartment syndrome resolve?

10-20 mins after activity or running. If it progresses, could be at rest

Exertional Compartment Syndrome Testing

Catheters with pressure during run pre/post. Can rule in if pain is reproduced and is relived by rest

Does exertional compartment syndrome need surgery?

Yes, especially if there's rapid onset and swelling. If elective, it would be to release or fasicotomy.

Conservative treatment for Compartment Syndrome

STS, joint mobs, gait retraining

MTSS

Involves periostitis (inflammation of the tibial periosteum)

Caused by traction from tibialis posterior, soleus, or FDL on medial tibial border

Early stage overuse injury (repetitive traction)

May lead to stress fx if untreated

MTSS is the classic “medial shin splint”

Medial Tibial Stress Syndrome Factors

Tightness in gastroc and decreased talocrual mobility. Weakness in glute abductors and external rotators (medial collapse and overpronation)

What population that gets MTSS and tibial stress fx a lot?

Military Cadets

MTSS Sx

Dull ache over posterior medial tibia, may have tenderness to palpation to distal middle of tibia

What exacerbates MTSS?

Volume increase due to overloading, hopping, and pain w passive DF/resisted PF.

Tibial Stress Fracture

Progression from MTSS or independent from repetitive loading (micro trauma), due to bone remodeling that fails to keep up with loading. Will be tender to palpation along the length of the tibia

Females have a higher risk than males for Tibial stress fractures, T or F?

T

Females have additional risk factors of stress fx due to?

Female Athlete Triad (Nutrition, Osteoporosis and Amenorrhea)

Tibial Stress Fx Diagnosing

Bone Scan (Dexa gold standard)

X-Ray (Done first, however, need to repeat 2-3 weeks after due to stress fx not showing up till 14 days after injury)

Populations who have increased risk of stress fx?

Military recruits, long distance runners, high school to college transitions, and increased mileage

If you're in athletics, what's your treatment team?

Multidisciplinary, including nutrition which is important

Tibial Stress FX Treatment

Rest, boot, activity mod, crutches or knee scooter. Work on impairments whether its tightness or weakness

Which point of the Achilles is avascular ?

Midpoint 2-6cm from the achilles to the calcaneal insertion. This area is more vulnerable to degeneration and injury

Achillies tendon Anatomy

No synovial sheath → covered by paratenon (vascularized fatty tissue)

Blood supply:

Musculotendinous junction

Mid-tendon

Insertion

Achilles Tendinopathy is the most common?

Most common foot/posteiror pain pathology

What difference between tendinosis and paratenonitis?

Tendinosis: Degenerative thickening, not inflammatory (Lump will move with PF/DF, could be pain-free and asymptomatic, occurs in older ages, and chronic phases)

Paratenonitis: Inflammation of paratenon (palpation to nodule or bump, more severe in younger age, may have crepitus, BUMP WILL STAY IN PLACE)

Achillies Tendinosis could lead too?

Achillies Tendon Rupture

Factors that increase in paratenonitis injuries?

Training overload

Poor footwear

Pronation/tight gastroc-soleus (limits DF and decreased talocrual mobility)

Uneven/loose terrain

Sudden return to training

Weak PF and limited DF can lead too?

Achilles Tendinopathy and rupture

Achilles Tendinopathy Disorders

Paratenonitis: Inflammation of the peritendinous structures

Tendinosis: Asymptomatic degeneration of the tendon without inflammation regional focal loss of the tendon

Paratendonitis with Tendonosis: Inflammation of peritendounous structures along with intratendeonous degeneration

Insertional Tendinosis: Inflammatory process within tendinous insertion of Achilles

Tendonosis would show ___ on imaging?

Absent of darkness on tendon

How do you identify paratenonitis?

MRI, MSK US

Treatment of Acute Paratenonitis

Boot for 3-6 weeks

Look at mobility for subtalar and talocrual joint and rear foot inversion/eversion

Modify intensity and surface of running

Gentle stretching of gastroc and soleus

Arch taping, orthotics, and heel lift due to limited DF

Why shouldn't you do eccentrics for the until pain free after 2-3 weeks for acute paratenonitis?

Due to inflammation around the achillies (paratenon)

Treatment of Chronic Paratenonitis

ECCENTRICS + Pain Monitoring

Eccentric training in chronic achillies tendinopathy is good for what part of the achillies?

Mid-portion not insertional

Alfredson protocol for achilles tendinopathy

Two eccentric movements:

Gastrocnemius eccentric heel drop (Knee straight) and Soleus eccentric heel drop (Knee bent)

3 sets of 15 reps per exercise

Twice daily

7 days per week

Total: 180 reps/day

Slow, controlled eccentric lowering (2-3 sec)

NO concentric lifting with injured leg

Instead: Use the uninvolved leg or hands to return to start position

12-week program

But it should be ≤4/10 and not worsen over time

Alfredson Protocol Mechanism of Action

Promotes:

Collagen reorganization

Tendon thickening

Neovascularization regression

Additional Achilles Tendinopathy Treatment

Heavy load, slow speed:

Seated leg press, knee ext and sitting heel raises

Week 1 (3x15) and week 9-12 (4x6)

Phase 1 (Week 1-2) Silbernogel Protocol

Goal: Start exercise and understand pain monitoring

Exercises: Circulation exercise and two-legged heel raises (3x15), one-legged heel raises (3x10) and sitting heel raises (3x10) and eccentric heel lowering (3x10)

Phase 2 (week3-5) Silbernogel Protocol

Goal: Start Strengthening

Exercises: Two-legged heel raises on step (3x15), One-legged heel raise on step (3x10),Sitting toe raises (3x15), Eccentric heel lowering off edge of step (3x10)Quick rebounding (3x20)

Phase 3 (week 6-12) Silbernogel Protocol

Goal: Heavier strength, RTS

Exercises: One-legged heel raise on step with added weight (3x15), Sitting toe raises(3x15)Eccentric heel-lowering on step with weight (3x15), Quick rebounding (3x20) Plyometrics training

Phase 4 (3-6 months) Silbernogel protocol

Goal: Maintenance

Exercises: One-legged heel raises on step with weight (3x15), Eccentric heel raises withweight (3x15),Quick rebounding (3x20)

Silbernogel Protocol should not be done with?

Pain, inflammation, or acute paratenonitis

Achilles Tendon Complete Rupture

Tends to occur in middle aged patients and those without pre-existing complaints

Achilles Tendon Partial Rupture

Tend to occur in well trained athletes, and usually involve the lateral aspect of the tendon

Achilles Tendon Rupture MOI

Push Off of WB foot with knee extension, sudden violent DF contraction of PF foot (eccentric)

Where do most achilles tears occur in?

2-6cm from calcaneal insertion "water shed area of reduced vascularity)

Achilles Rupture RF

Middle age, Male, High BMI, fluoroquinolone and corticosteroids

Management of Achilles Tendon Partial Ruptures

Immobilize, knee scooter or crutches

Management of Achilles Tendon Full Ruptures

End to end approximation surgery with a DONJOY ROM walker

DonJoy ROM Walker Weening Post Rupture (0-2 weeks)

WBAT in boot with heel wedges (typically 2-3 wedges = ~30° PF)

NO DF past neutral allowed

DonJoy ROM walker post rupture (2-4 weeks) + treatment

30 deg PF to unrestricted, DF to -30 deg, + strengthening of quad + HS + Hip early on

DonJoy ROM walker post rupture (4-6 weeks) + treatment

NWB, unrestricted PF to -10 deg DF, +isometrics in EV/IV

DonJoy ROM Walker post rupture (6-8 weeks) + treatment

WBAT in boot to out of boot, max PF and 10deg DF, + talocrual mobility + gentle stretching/strengthening + Gait training

What is important once out of the boot?

Heel lifts (allows tibial advancement and great toe mobility

Achilles Post rupture 8-12 weeks treatment

Exercise bike, ankle ROM, sitting heel-rise, standing heel rise, gait training, balance exercises, leg press, leg ext and leg curl

Achilles Post-rupture 12-16 weeks treatment

Walking on mattress, steps, standing heel raises at end range of PF with 1 leg

Increase weight on prior exercises

Achilles Post rupture week 16-20 treatment

Quick rebounding heel raises from week 18, heel rise in stairs, slide jumps, 2 legged jumps

Achilles Post rupture week 20-24 treatment

Jog, slide jumps forward and week 24 onward RTS

Haglund's Deformity

Bony enlargement of the posterior aspect of the calcaneus

"Pump bump"

Haglud's Deformity MOI

High arches, tight triceps sure musculature and supinator due to high shoes or heels

Treatment of Haglud's Deformity

Shoe Mod, talocrucal joint mobs, and gastroc/soleus stretching

Sever's Disease

Calcaneal apophysitis (insertion), most common cause of heel pain in adolescents. Similar to PF, but tender on posterior calcaneus near insertion and bottom of the foot

Sever's Disease Occurrence

Only skeletally immature, adolescent males, either active or high BMI + active.

Other factors include tight gastroc/soleus, talcrural hypo mobility

Sever's Disease treatment

Manage pain, reduce load, heel lift, calf stretches and strength building exercises.

Can be flared up with rapid growth

Calcaneal Stress Fx Populations

Common in athletes and runners with overuse history, or history of high impact activities. Can also be elder women with osteoporosis and overuse

Calcaneal Stress fx is more diffuse than?

PF, due to calcaneal fat pads decrease which impact the bone more

Calcaneal Stress Fx Special tests

Dexa: Gold standard + Positive Heel thump + calcaneal squeeze test

Retrocalcaneal Bursitis

Inflammation of the bursa between the Achilles tendon and the calcaneus, caused by compression from structures during DF

Retrocalcenal Symptoms

Pain anterior to achilles tendon and athletes training uphill.

Usually pain at insertion site, and diagnosed by exclusion. Tight gastroc, soleus and hypo mobility may be at play

How do you test for retrocalcaneal bursitis?

+ Two-finger squeeze test

1st MTP Sprain (Turf Toe) MOI

Forced MTP DF or hyperdorsiflexion

Flexible footwear could cause this as well

Turf Toe Sx

1st MTP Joint swelling, ecchymosis, tenderness to palpation, Pain with MTP extension and limited MTP extension, and Ian with joint loading (late stance-push off)

What test may be positive with Turf Toe?

Windlass Test

Turf Toe Treatment

DF strengthening of toe/ankle in isolation, taping (resist ext) useful but fails quickly, right turf toe inserts, talocrural jt mobs, and surgery is possible due to damaged joint capsule

Hallux Limitus/Rigidus

Less than 60 deg of great toe extension, will see toe out gait as compensation

Hallux Limitus/Rigidus Treatment

Mobility, stretching and joint mobs (traction of MTP, dorsal/plantar glides)

*JOINT MOBS ARE HUGE

Hallux Valgus

Progresses to bunion, which is swollen bursa sac and hypertrophy of 1st MTP joint

Hallux Valgus treatment

Wide toe box, foot intrinsic strength, toe splints, abd/add strength of the toes, shoe modification, bunionectomy

Bunionectomy is more for?

Aesthetics