Ankle and Foot

Ottawa ankle rules

• pain in malleolar zone AND any of the following

  • bone tenderness at the distal 6 cm or tip of lateral malleolus

  • bone tenderness at the distal 6 cm or tip of medial malleolus

  • inability to bear weight both immediately and in the ED

Ottawa foot rules

• pain in midfoot zone AND any of the following

  • bone tenderness at the base of the 5th met

  • bone tenderness at the navicular bone

  • inability to bear weight both immediately and in the ED for 4 steps

what is the MDC for the sports FAAM?

12 pts

what is the MDC for the ADL FAAM?

6 pts

what is the MCID for the FAAM?

8-9 pts

what does a higher score indicate on the FAAM?

more function

Should we recommend the use of prophylactic bracing to reduce the risk of a first-time lateral ankle sprain for those with risk factors or prevent subsequent ankle sprains?

yes

what are risk factors for a lateral ankle sprain?

• high risk sports

  • basketball

  • soccer

• high BMI

• poor DF

• poor balance

does bracing make your ankle weaker?

no

special tests for acute lateral ankle sprain

• anterior drawer test

• talar tilt test

• reverse anterolateral drawer test

grade 1 sprain

stretching, small tears

grade 2 sprain

larger, but incomplete tear

grade 3 sprain

complete tear

pt position for anterior drawer test

• sitting or supine

• 20 degrees PF

pt position for talar tilt test

• foot remains DF

• inversion stress added by adducting rear foot

pt position for reverse anterolateral drawer test

• 10-15 degrees PF

• foot in slight wt bearing position

MOI for syndesmotic injury

• DF with ER

• cutting sports particularly with cleats

special tests for syndesmosis injuries

• DF ER stress test

• syndesmosis squeeze test

another name for DF ER stress test

Kleiger’s test

landmarks for figure 8 test

• start midway between tib anterior and lateral malleolus

• medially to just distal to the navicular tuberosity

• tape across arch to just proximal 5th met

• cross tib ant around ankle just distal to medial malleolus

• over Achilles and back to start

what ther-ex should be included in rehab for lateral ankle sprain?

• protected AROM

• stretching exercises

• neuromuscular training

• postural re-education

• balance training

is manual therapy beneficial for primary outcomes of self-reported or injury recurrence?

unclear

ankle sprain commonly leads to what?

decreased DF ROM

what should we do for chronic ankle instability?

• foot, ankle, knee, and hip rehab

• proprioceptive and neuromuscular ther-ex

• manual therapy

immediately after a lateral ankle sprain what should we do?

• restore ankle CKC DF

• tubigrip/taping/bracing

• balance

• as soon as wt bearing, start performance drills walking

• test and restore hip strength

benefit of tubigrip

control swelling and increase proprioceptive input

when on unstable surfaces, the body uses proprioceptive from what joint?

hip

if wanting to challenge ankle strategy, what type of surface should we use?

firm surface

after an ACL reconstruction, which strategy does the body switch to?

ankle

how to challenge ankle strategy?

• barefoot

• turf

• velcro

• any stable surface with increased sensory input

anterior ankle impingement

spurring on lip of talus or neck of talus

anterior-lateral ankle impingement

build-up of synovitis and/or scar tissue secondary to trauma

posterior ankle impingement

• Os Trigonum

• common among athletes such as ballet dances

  • frequent ankle sprains and repeated PF

• painful passive PF

sinus tarsus syndrome

• pain deep in sinus tarsus

• worse with impact and pronation

• may be d/t osteophytes, nerve entrapments, or soft tissue impingement

what is the sinus tarsi?

• space between the talus and calcaneus

• filled with connective and adipose tissue

• richly innervated with mechanoreceptors and free nerve endings

important function of sinus tarsi

proprioception

what should we address with sinus tarsus syndrome?

• CKC DF

  • use manual therapy as indicated

• try heel lift and/or orthotic

  • to control pronation

supination vs. supinated vs. supinating

• supination

  • normal

  • part of gait cycle

• supinated

  • refers to static foot postition

  • high arch

• supinating

  • could be abnormal if excessive

pronation vs. pronated vs. pronating

• pronation

  • part of gait cycle

  • normal

• pronated

  • refers to static foot position

  • flat foot

• pronating

  • could be abnormal if excessive

what motions make up pronation?

• ankle DF

• subtalar joint eversion

• midfoot ABD

purpose of pronation

shock attenuation and terrain adaptation

what does overpronating cause?

• results in IR of LE d/t tibial/talar coupling with resulting torque proximally

• results in less stable lever at heel off

  • foot is not supinated so less effect Windlass mechanism

  • less efficient gait

• shortens limb

• lengthens foot

what does normal gait look like at subtalar joint?

subtalar movement transitions from supination at heel strike to pronation at foot flat to resupination at heel off

what all allows for a stable midfoot/forefoot lever at push-off?

• re-supination

• Windlass mechanism of plantar fascia

• CKC hip ER

what is normal navicular drop?

5-10 mm

what amount of navicular drop is considered over-supinating?

0-5 mm

what amount of navicular drop is considered over-pronating?

10-15 mm

what amount of navicular drop is considered substantial over-pronating?

>15 mm

what is the problem with over-supinating?

less force absorption

how does your body compensate for lack of CKC DF in gait?

ER of foot and advances tibia by pronating

timeline for tendinitis

2-4 weeks

timeline for tendinopathy

>6 weeks

According to Dr. Katie Whetstone, what is the best “medicine” for tendinopathies?

moderate loading exercises consisting of eccentric, concentric, and isometric exercises

benefits of isometric exercises

• analgesic effect for 45 min to 1 hour

• gives a window to reload the tissues

what are not recommended for tendinopathies as they may cause further degradation of the tissue?

• complete rest

• NSAIDs

• corticosteroid injections

risk factors for non-insertional tendinopathy

• middle age

• weekend athlete

• missed step

how often should we load the Achilles tendon for tendinopathy?

at least 3x/week

flow of exercises for Achilles tendinopathy

interventions not recommended for Achilles tendinopathy

• manual therapy

• DN

  • unless pain is keeping them from doing activity

• low-level laser therapy

• therapeutic US

should you use heel lifts for midportion Achilles tendinopathy?

yes, to temporarily reduce ankle DF during activity

what is Haglund deformity?

• chronic irritation results in chemical erosion/calcium formation

special test for Achilles tendon rupture

• Thompsom test

• Matles test

pt position for Thompson test

prone with knee extended

pt position for Matles test

prone with knees at 90 degrees

what is peak incidence of plantar fasciitis?

45-65 years old

risk factors of plantar fasciitis

• limited DF

• increased BMI

• standing for long periods of time

how do pts describe plantar fasciitis?

pain, sharpened with first walking in the morning or after long period of rest, but also worse following prolonged weight bearing

when are orthotics best for plantar fasciitis?

when combined with other treatments

how long should pts wear night splints for plantar fasciitis?

1 to 3 months

what should the orthotics for plantar fasciitis include?

• support for medial longitudinal arch

• cushion the heel in individuals

techniques we should use for plantar fasciitis

• manual therapy

• plantar fasciitis and gastroc/soleus stretching

• foot taping

what is a good home stretch for plantar fasciitis?

figure 4 position with passive great toe extension

what should be the first line of treatment for plantar fasciits?

• eccentric calf loading (Alfredson protocol)

  • with towel roll under great toe

• stretching

what area if TTP with medial tibial stress syndrome?

• tenderness 5-10 cm proximal to medial malleolus

• may be tender proximally along muscle belly

what measures of navicular drop are more prone to medial tibial stress syndrome?

• 0-5 mm

• >10 mm

MOI of medial tibial stress syndrome

• compensatory pronation?

• poor plyometric and shock absorbing ability

what is compartment syndrome?

condition in which increased compartment pressure within a confined space, comprises the circulation and potentially viability of the tissues within that space

acute compartment syndrome

• from trauma

• very painful

• medical emergency

exercise induced compartment syndrome

• commonly seen in distance runners

• no pain in the first 10-15 mins of their run

• as they continue, have increased cramping and pain

purpose of fibularis longus/brevis

• foot ABD

• ankle PF

• subtalar eversion

• stabilizes foot (brings 1st met toward the ground)

increased risk of fibularis longus/brevis tendonitis

• cutting maneuvers to medial side

• “early season” deconditioned forefoot sports

  • basketball

  • racquet sports

  • dance

treatment of fibularis longus/brevis tendonitis

• modalities

• progressive strengthening/balance (OKC to CKC)

• brace/wedge

• slide board

purpose of the tibialis posterior

• primary dynamic stabilizer of the medial longitudinal arch

• inverter of the midfoot

stage 1 on posterior tibialis tendon dysfunction

medial ankle pain and swelling

stage 2 posterior tibialis tendon dysfunction

• weak inversion

• poor heel raise

• rearfoot valgus

• forefoot ABD

stage 3 posterior tibialis tendon dysfunction

deformity is fixed

orthotics/bracing for posterior tibialis tendon dysfunction

• early recognition leading to protective support

  • corrective shoes/insoles

  • custom, high edged foot orthotics

  • hinged SMO (frontal plane control)

  • Arizona brace

ther-ex for pre-treatment phase for PTTD

• “sole-to-sole” exercise

  • 25 reps per set

• start with 4 sets

• build up to 12 sets

• then toward 300 consecutive reps per day over the course of 2 weeks

ther-ex for phase 1 PTTD

• theraband resisted:

  • DF

  • inversion

  • eversion

• build up to 200 reps per day

ther-ex for phase 2 of PTTD

• double leg heel rises

  • progressing to single leg

  • build up to 50 reps

• toe ambulation

  • working towards 100 yards

• Achilles stretch

  • if muscular tightness is limiting full DF

ther-ex for phase 3 PTTD

progress of phase 2 activities toward target repetitions and distances

what is a sign of PTTD?

rearfoot inversion with heel raise

what is tarsal tunnel syndrome?

• compression of posterior tibial n. or one of it’s branches

  • medial calcaneal n. to the heel

  • medial and lateral plantar n. to the sole of the foot and toes

• burning, numbness, tingling, pain to medial heel and lateral forefoot

special test for tarsal tunnel syndrome

Tinel’s

treatment of tarsal tunnel

• correct rearfoot eversion

• pad course of nerves

causes/risk factors of tarsal tunnel syndrome

• space occupying lesions

• repetitive stress

• tendon hypertrophy

• BMI

• RA

• traumatic fxs

• dislocation

• female

• repeated ligament sprains

• hyperpronation

what is anterior tarsal tunnel?

• deep peroneal nerve compression on the dorsal side of foot

  • inferior extensor retinaculum

• causes sensation loss at webpace of 1st and 2nd toes

causes of anterior tarsal tunnel

• recurrent sprains

• shoes/ski boots too tight

• sit up with feet anchored

what is Sever’s disease?

calcaneal apophysitis

risk factors of Sever’s disease

• seen in early teens

• associated with a rapid growth spurt and running sports

  • soccer

  • basketball

  • gymnastics

  • track

• boys twice as often as girls