Foot and Ankle - Muscles, Tendons, Compartment Syndrome, and Turf Toe

Lecture 13

How is Posterior Tibialis tendon dysfunction differentiated from muscle atrophy?

tendinopathy is DISTAL to the medial malleolus, atrophy is PROXIMAL to the medial malleolus

What other impairments accompany Posterior Tibialis tendon dysfunction?

• ST joint inversion

• forefoot adduction

• plantar flexion

• weak BIL hip and ankle performance

What were the findings of the Alvarez 2019 study?

SL HR performance does not return for all pts

What are the goals of PTTD treatment?

1. minimize disability during episodes

2. attempt to slow progress of foot deformity

What are the main aspects of PTTD treatment?

1. symptoms are often chronic with intermittent episodes

2. greater chronicity associated with surgery

3. weight loss may be indicated if achievable

4. high reps of PREs of post tib, tib ant, tricep surae, and fibularis - CCOPT

5. initially brace, the progress to orthotic

   1. OTC AFO can work, does not have to be expensive or custom

What are the risk factors for Plantar Fasciitis?

• limited ankle DF

• high BMI in non-athletic individuals

• middle-age

• prolonged occupational/recreational setting

• running

• weak intrinsic foot muscles

What signs during evaluation point to Plantar Fasciitis?

• heel pain onset with recent increase in WB

• pain with initial or prolonged WB

• TTP at plantar fascia insertion

• limited talocrural AROM and PROM

• + tarsal tunnel syndrome test

• + windlass test

• abnormal foot posture (higher score = pronated, lower score = supinated)

Is US recommended for tx of Plantar Fasciitis?

no

Which modalities should be used for tx of Plantar Fasciitis?

• iontophoresis with dexamethasone

• low- or high-level laser

Which forms of manual therapy are indicated for tx of Plantar Fasciitis?

• TC joint posterior glide

• ST joint lateral glide

• A-P glides of 1t TMT

• subtalar joint distraction manip

• mixed evidence for dry needling

• STM

How should stretching be utilized in the tx of Plantar Fasciitis?

• calf muscle and fascia stretching:

  • short term pain management

  • sustained (3 mins) or intermittent (20s) 2-3x per day

  • no preference for Achilles stretching vs PF stretching

**keep in mind that tighter areas will be affected the most by forces, which can lead to overuse-type injuries like PF

Describe the evidence for taping as an intervention for Plantar Fasciitis.

• strong evidence for pain reduction at 1 week

• no evidence for speeding up recovery

• taping + stretching = pretty good

Describe how orthotics and footwear can be used in the tx of Plantar Fasciitis.

Orthotics:

• CPG says “should use”

• support medial longitudinal arch & cushion the heel

• reduce pain and improve function up to 1 year (best up to 3 months)

• very good for those who respond well to antipronation techniques

Footwear:

• rocker-bottom shoe

• rotate out shoes during the work week to preserve their insoles

Describe how Night Splints can be used to treat Plantar Fasciitis.

• 1-3 month program should be used

• consistent 1st step for morning pain

• type of splint does not matter but anterior type may be more comfortable sleeping

Should NSAIDs or corticosteroids be used for tx of Plantar Fasciitis?

NSAIDs: no evidence

Corticosteroids: benefits do not outweigh risk for harm

Oral Steroids: less risk than corticosteroids

**steroids may be harmful for diabetic pts

Describe surgical intervention for Plantar Fasciitis.

• 90-95% of pts respond to conservative tx

• 2 types of surgery: open vs endoscopic

  • fascia release with nerve decompression

  • AKA distal tarsal decompression

  • gastroc recession

  • recovery: 6-12 weeks

What complications can arise from surgical treatment of Plantar Fasciitis?

• flat foot deformity

• nerve injury

• symptoms persist

• infection

• scar tissue may form

Describe the cutaneous nerve distribution of the sole of the foot.

Sural Nerve: lateral border of calcaneus

Lateral Plantar: lateral border of foot

Medial Plantar: most of the sole, save for the little toe

Saphenous: high part of arch

Medial Calcaneal: heel

Should shockwave be used to treat Plantar Fasciitis? If so, at what point in the rehab timeline?

it can be used, best evidence is for about 6 months of conservative tx

Should ESWT (shockwave) be used to treat Plantar Fasciitis?

CPG says it is not more effective than stretching + ultrasound

What findings will be evident during imaging for Turf Toe?

• swelling

• small periarticular joint avulsions

• intra-articular loose bodies

• sesamoid fx or migration

What is the treatment for Turf Toe?

• RICE

• no taping

• gentle ROM and WB

• may require casting/boot

• surgery may be indicated only with an associated condition

What is Turf Toe?

tendon avulsion from 1st MTP

How does grade of turf toe affect RTS timeline?

1. attenuation: RTS as tolerated

2. partial tear: RTS may take up to 2 weeks, may still need taping

3. complete disruption: 6-10 weeks depending on sport and position

What is a Bunionectomy?

osteotomy to correct medial deviation of first toe

• some surgeons may ask fo PT post-op

What shoud PTs consider when treating a patient post-bunionectomy?

• pain

• swelling

• decreased ROM

• inability to don footwear

• gait patterns should not change significantly

**some pts still do not use big toe for push-off even post-op

What is recommended for PT tx of post-operative bunionectomy?

• no loading for 4 weeks

• self PROM begins day 2 post-op

• program should be 1x/week for 45min for 4-6 weeks

• elevation of LE

• lymphatic drainage

• muscle pump (ankle pumps)

• cold therapy

• manual therapy

• STM and scar mobs

• proprioceptive training, strengthening, gait training, all progress over next 4 weeks

**rehab is very, very painful, surgery should only be recommended when function is severely impaired

What things are included in the treatment of Medial Tibial Stress Syndrome?

• strength and endurance of soleus

• control over-pronation

• shock absorption improvement through proper footwear, biomechanics, and insoles

• cross-trianing

• relative rest for 4 months

• cold therapy and NSAIDs

• eccentrics

• address proximal impairments

• decrease stride length by 10%

Which muscles can be affected by “shin splints?”

anterior tibialis and posterior tibialis

What diagnoses needs to be ruled out before beginning tx for MTSS?

Chronic Exertional Compartment Syndrome (CECS)

• ruled out through absence of cramping/burning, and absence of numbness and tingling

• condition still responds well to rest and activity modification

• significant swelling or erythema of leg would point to severe condition

Stress Fx

• TTP

• swelling, erythema

If left untreated, what can CECS turn into?

• drop foot

• sever complications

• acute compartment syndrome is associated with traumatic MOI

• risk of DVT, rule out with Doppler!

What is the tx for Tibial Stress Fx?

• proper nutrition

• gradual return to activity

• protected WB and rest

What is the most sensitive imaging that can diagnose Tibial Stress Fx?

MRI

Describe the tx for Tarsal Tunnel Syndrome.

• control pronation

• nerve glides

• NSAIDs

What is the tx for Flexor Hallucis tendinopathy?

• common in dancers

• figure out if it is tendinosis or tendinopathy

• treat accordingly

Which tissues respond best to which medications?

	PRP/Prolo	BMAC	Anesthetics	Steroid	Hyaluronic
Articular	ü	ü	ü		ü
Tendon	ü	ü		Not within tendon	ü
Bursa	ü		ü	ü
Ligaments	ü	ü		Not within tendon
OA	ü	ü