Derbyshire Sports Injuries Clinic presents

1. Derbyshire Sports Injuries Clinic presents The foot and ankle

2. Anatomy- bones

3. Anatomy- ligaments

4. Anatomy- tendons

5. Anatomy- tendons

6. Anatomy- syndesmosis & capsule

7. The Ankle joint • Hinge joint • Locomotion • Proprioception • Movements at this joint include • Dorsiflexion • Plantarflexion • Eversion • Inversion • Supination is a combination of plantarflexion, inversion and forefoot adduction • Pronation is a combination of dorsiflexion, eversion and forefoot abduction

8. Movements of the ankle

9. Pronated, supinated or neutral

10. Patient walks in c/o ankle pain • What is the mechanism of injury? • What position was the foot in at time of injury? • Most common is the inversion injury: • Plantar flexed • Inverted • Adducted • This can injure • ATFL • Anterolateral capsule • Distal tibiofibular ligament • Can cause a malleolar/ talar dome fracture/ medial ankle pain through compression

11. Patient walks in c/o Ankle pain • Was there any deformity after injury? • Transitory locking indicating a loose body? • Able to continue? • Usually a grade 1 ankle sprain can continue with running (painfully) • A grade 2 ankle sprain can walk (painfully) • A grade 3 ankle sprain cannot weightbear • Staging the injury is important... Acute, subacute or chronic. Is this acute on chronic? • Does pain increase or decrease with activity? • What does the patient do for work and leisure and are there any contributing factors?

12. Patient walks in c/o Ankle pain • Gait: have they walked/ limped in? • Check for: • Swelling- usually quick onset • Bruising- can be delayed • Numbness • Pins and Needles • Weakness: could this actually be an L4 nerve root compression?

13. Ottawa Ankle rules • Patient requires an ankle X-ray if: • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus • An inability to bear weight both immediately and in the rooms for four steps

14. Ottawa foot rules • The patient requires a foot x-ray if: • Bone tenderness at the base of the fifth metatarsal • Bone tenderness at the navicular bone • An inability to bear weight both immediately and in the rooms for four steps

15. Assessment • Assess in standing, ability to load through joint, foot position. Always comparing side-side • In lying check range of movement relative to uninjured side. • Palpate the painful area and surrounding soft tissue and joints

16. Ligament tests • ATFL- Anterior drawer test at 20° plantarflexion • Calcaneofibular ligament- talar tilt at 90° into adduction • Deltoid ligament- talar tilt at 90° into abduction • Squeeze test- syndesmosis injury • Thompson’s Test- Achilles

17. Other injuries to note • Fractured calcaneum (a ‘Lovers’ or ‘Don Juan’ fracture!)- fall from height or occasionally with an inversion injury. • Fractured sub-talar surface can occur also. Check out ‘Sanders’ classification system. • Sub-talar joint dislocation... Urgent relocation required • Lis-Franc fracture-dislocation. • Direct: crush injury • Indirect: requires a longitudinal force sustained while the foot is plantarflexed. A backward fall with the foot entrapped, and a fall on the point of the toes is also a common mechanism. • Persistent midfoot pain for >5 days should raise suspicion • Tenderness of the midfoot on palpation and pain on eversion+abduction of forefoot while calcaneus is still

18. More injuries to note • Navicular fracture: can be an avulsion, a fracture of the body, or a stress fracture. • Point tender over the ‘N’ spot. • Pain with passive eversion and active inversion • Very difficult to see on plain films • Cuboid syndrome- subluxation of the cuboid... Needs manipulation. Patient can’t walk barefoot. • Stress fractures: any bone, any age. Caused by a spike in training or loading. • Severe’s disease: growth plate enthesopathy

19. More still • Halluxvalgus: pain can be unbearable, need to see a podiatrist. • Morton’s neuroma: pain in toes with pins & needles and numbness... Need to see a podiatrist/ physio/ foot surgeon.

20. Plantar fasciitis • Patient complains of heel pain and/or pain through the arch • Often chronic, and is not inflammatory so is actually a fasciosis/ fasciopathy • Not able to rise up on the balls of the feet from flat foot • Risk factors include: • Running and dancing • Very high arches or very flat feet • Poor shoe choices • Obesity • Poor dorsiflexion range • Tight posterior fascial lines • Patient MUST be referred for quality physiotherapy- at least one session to teach how to self massage, stretches, foot strengthening exercises, taping, shoe education.

21. Advice for a ‘mild’ sprained ankle • Get rid of the swelling • Avoid running until pain-free hopping on one foot is possible • Walking (pain-free), cycling, cross-training and stepping can be done to keep active, must ice afterwards • Ankle braces should not be worn, not supportive enough to prevent damage and offer ‘false’ sense of security, while creating a biomechanical alteration • Proprioception exercises should be done prior to return to sport • Theraband strengthening exercises are a good idea to prevent future injuries.

22. Advice for ‘plantar fasciitis’ • Ice the area, sometimes using a frozen plastic bottle of water is useful to roll the foot (roll away from the toes towards the heel) • Don’t walk around barefoot, supportive shoes with good arch support can help relieve pain. • Avoid flat shoes like flip flops... ‘fitflops’ offer a good alternative. • Stretching the soleus can help: stretch against a doorframe. • Strengthening the foot through exercises with a towel on the floor and theraband for the ankle. • Lose weight • Avoid exercising on hard surfaces