Foot and Ankle Seminar

1. Foot and Ankle Seminar Jim Clover, MED, ATC

2. Foot Anatomy Review • Bony Anatomy • Talus • Calcaneus • Tarsals • 5 bones • Metatarsals • 5 bones • Phalanges • 14 bones

3. Foot Anatomy Figure Two Figure Three Figure One

4. Foot Biomechanics • Transverse Arch (A) • Medial Longitudinal Arch (B) • Lateral Longitudinal Arch (C)

5. Lower Leg Anatomy • Bony • Tibia • Fibula

6. Lower Leg Anatomy • Musculature • Anterior • Tibialis Anterior • Medial • Tibialis Posterior • Extensor Digitorum Longus • Extensor Hallicus Longus • Lateral • Peroneals • Posterior • Gastrocnemius • Soleous

7. Lower Leg Anatomy • Other Structures • Joints • Ligament • Cartilage

8. Foot / Ankle Anatomy • Nerve Supply • Blood Supply

9. Foot Biomechanics – Normal Gait • Two phases: • Stance or support phase which starts at initial heel strike and ends at toe-off • Swing or recovery which represents time from toe-off to heel strike • Foot serves as shock absorber at heel strike and adapts to uneven surface during stance • At push-off foot serves as rigid lever to provide propulsive force • Initial heel strike while running involves contact on lateral aspect of foot with subtalar joint in supination

10. Foot Biomechanics – Normal Gait • 80% of distance runners follow heel strike pattern • Sprinters tend to be forefoot strikers • With initial contact there is obligatory external rotation of the tibia with subtalar supination • As loading occurs, foot and subtalar joint pronates and tibia internally rotates (transverse plane rotation at the knee) • Pronation allows for unlocking of midfoot and shock absorption • Also provides for even distribution of forces throughout the foot • Subtalar joint will remain in pronation for 55-85% of stance phase • occurring maximally as center of gravity passes over base of support • As foot moves to toe-off, foot supinates, causing midtarsal lock and lever formation in order to produce greater force

14. Foot Biomechanics – Pronation & Supination • Excessive or prolonged pronation or supination can contribute to overuse injuries • Have them walk in water and see what happens

15. Foot Biomechanics – Pronation & Supination

16. Foot Biomechanics – Excessive Pronation • Excessive Prontation • Major cause of stress injuries due to overload of structures during extensive stance phase or into propulsive phase

17. Foot Biomechanics – Excessive Supination • Excessive Supination • Limits internal rotation and can lead to inversion sprains, tibial stress syndrome, peroneal tendinitis, IT-Band friction syndrome and bursitis

19. Foot Evaluation (History) • Generic history questions • Past history • Mechanism of injury • When does it hurt? • Type of, quality of, duration of pain? • Sounds or feelings? • How long were you disabled? • Swelling? • Previous treatments? • Questions specific to the foot • Location of pain - heel, foot, toes, arches? • Training surfaces or changes in footwear? • Changes in training, volume or type? • Does footwear increase discomfort?

20. Foot Evaluation (Observation) • Observations • Does athlete favor a foot, limp, or is unable to bear weight? • Shoe Wear Patterns • Over pronators tend to wear out shoe under 2nd metatarsal • Athletes often mistakenly perceive wear on the outside edge of the heel as being the result of over-pronation • Wear on the lateral border of the shoe is a sign of excessive supination • Heel counter and forefoot should also be examined

21. Bony Palpation Medial calcaneus Foot Evaluation (Palpation)

22. Soft Tissue Deltoid ligament Medial longitudinal arch Plantar fascia Transverse arch Foot Evaluation (Palpation)

23. Foot Evaluation (Special Testing) • Manual Muscle Testing • Toe Flexion • Toe Extension

24. Foot Evaluation (Special Testing) • Tinel’s Sign • Tapping over posterior tibial nerve producing tingling distal to area • Numbness & paresthesia may indicate presence of tarsal tunnel syndrome • Morton’s Test • Transverse pressure applied to heads of metatarsals causing pain in forefoot • Positive sign may indicate neuroma or metatarsalgia

25. Foot Evaluation (Special Testing)

26. Foot Common Injuries • Tarsal Region • Fractures (Calcaneus, Talus, Etc.) • Stress Fractures • Subluxations

27. Foot Common Injuries • Metatarsal Region • Strains • Fractures (Jones’) / Stress Fractures • Bunion • Neuroma

28. Ankle Evaluation (History) • Generic History questions • Past history • Mechanism of injury • When does it hurt? • Type of, quality of, duration of pain? • Sounds or feelings? • How long were you disabled? • Swelling? • Previous treatments?

29. Severity of sprains is graded (1-3) • With inversion sprains the foot is forcefully inverted or occurs when the foot comes into contact w/ uneven surfaces

30. Grade 1 Inversion Ankle Sprain Etiology (how it happens) Mechanism • Occurs with inversion plantar flexion and adduction • Causes stretching of the anterior talofibular ligament (ATFL) • Signs and Symptoms • Mild pain and disability; weight bearing is minimally impaired; point tenderness over ligaments and no laxity • Management/Treatment/Rehabilitation • PRICE for 1-2 days; limited weight bearing initially and then aggressive rehab • Tape may provide some additional support • Return to activity in 1 -10 days

31. Grade 2 Inversion Ankle Sprain • Etiology (how it happens) Mechanism • Moderate inversion force causing great deal of disability with many days of lost time • Signs and Symptoms • Ligaments have an “end” point • Feel or hear pop or snap; moderate pain w/ difficulty bearing weight; tenderness and edema • Positive talar tilt and anterior drawer tests • Possible tearing of the anterior talofibular and calcaneofibular ligaments • Management/Treatment/Rehabilitation t • PRICE for at least first 72 hours; X-ray exam to rule out fx; crutches 5-10 days, progressing to weight bearing

32. Management (continued) • Will require protective immobilization but begin ROM exercises early to aid in maintenance of motion and proprioception • Taping will provide support during early stages of walking and running • Long term disability will include chronic instability with injury recurrence potentially leading to joint degeneration • Must continue to engage in rehab to prevent against re-injury

33. Grade 3 Inversion Ankle Sprain • Etiology / Mechanism • Relatively uncommon but is extremely disabling • Caused by significant force (inversion) resulting in spontaneous subluxation and reduction • Causes damage to the anterior/posterior talofibular and calcaneofibular ligaments as well as the capsule • Signs and Symptoms • Severe pain, swelling, discoloration • Unable to bear weight • Positive talar tilt and anterior drawer (no “end” point

36. Injury Prevention • Strength training allows the supporting musculature to stabilize where ligaments may no longer be capable of holding the original tension between bones of the joint. This will also help prevent reinjury.

37. Management • PRICE, X-ray (physician may apply dorsiflexion splint for 3-6 weeks) • Crutches are provided after cast removal • Isometrics in cast; ROM, PRE and balance exercise once out • Surgery may be warranted to stabilize ankle due to increased laxity and instability

38. Dislocation

39. Ankle Evaluation (Observation) • Observations • Is there difficulty with walking? • Deformities, asymmetries or swelling? • Color and texture of skin, heat, redness? • Patient in obvious pain? • Is range of motion normal?

40. Bony Anatomy Soft Tissue Anatomy Soft Tissue Anatomy Ankle Evaluation (Palpation)

41. Ankle Evaluation (Special Testing) • Fracture Tests • Tap / Percussion / Bump • Active / Passive Range of Motion (R.O.M.) • Manual Muscle Testing • Check all motions of the Foot and Ankle • Joint Stability Tests • Anterior Drawer • Special Pathology Tests • Thompson Test

42. Ankle Evaluation (Special Tests) Fracture Test Compression Test Percussion Test

43. Ankle Evaluation (Special Tests) • Ankle Stability Tests • Anterior drawer test • Used to determine damage to anterior talofibular ligament primarily and other lateral ligament secondarily • A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point Anterior Drawer Test

44. Ankle Evaluation (Special Tests) • Talar tilt test (ATF,CF,PTF) • Performed to determine extent of inversion or eversion injuries • With foot at 90 degrees calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments • If the calcaneus is everted, the deltoid ligament is tested Talar Tilt Test

45. Ankle Injury “bad”

46. Ankle Evaluation (Special Tests) • Other Special Tests • Thompson’s Test • Squeeze calf muscle, while foot is extended off table to test the integrity of the Achilles tendon • Positive tests results in no movement in the foot

47. Ankle Evaluation (Special Tests) • Homan’s test • Test for deep vein thrombophlebitis • With knee extended and foot off table, ankle is moved into dorsiflexion • Pain in calf is a positive sign and should be referred

48. Foot Rehabilitation • Three simple keys • Range of Motion • Needed to increase motion and return to function as quickly as prudent and possible • Strength • Needed to deter further problems or protect the area of injury from further injury • Functionality • Needed to return the student-athlete or patient to normal daily activities within reason.

49. Foot Rehabilitation • Flexibility • Must maintain or re-establish normal flexibility of the foot • Full range of motion is critical • Stretching of the plantar fascia and Achilles is very important for a number of conditions

50. Foot Rehabilitation • Range of Motion • Joints • Joint Mobilization • BAPS Board / Disc • Functionality of foot • Plantar Fascia • Towel pulls • Cotton ball movement • Gastroc / Soleus Stretching