Foot & Ankle Pathologies Quiz

Foot & Ankle Pathologies

• This presentation discusses various foot and ankle pathologies.

Shin Splints

• The pathology is believed to be periostitis.
• Tendon fibers pull away from bony insertion, causing inflammation and pain.
• Microscopic vasculitis and thickening of periosteum and cortical bone may occur.
• Shin splints can be categorized into antero-lateral and postero-medial types.

Shin Splints: Antero-lateral

• Involves anterior compartment muscles.
• Mechanisms: excessive eccentric forces to control plantar flexion (PF) at heel strike, especially on hard surfaces.
• Limited dorsiflexion (DF) causes effort by dorsiflexors for toe clearance during gait.
• Pain in the anterior lateral leg, worsening with activity and improving with rest.
• Gradual onset, related to overuse syndromes.
• Range of motion (ROM) testing: pain reproduced with DF combined with inversion (Inv) or eversion (EV), or PF combined with Inv or EV.

Shin Splints: Postero-medial

• Usually involves deep posterior compartment muscles, potentially including the soleus.
• Mechanisms: excessive eccentric activity to control excessive pronation.
• Pain in the posterior and medial leg, worsening with activity and improving with rest.
• Over-pronation, varus rearfoot and/or forefoot deformity (confirmed by navicular drop test).
• ROM testing: PF combined with Inv and DF combined with EV.

Shin Splints: General Treatment Guidelines

• Relative rest and anti-inflammatory measures.
• Stretching (if restricted).
• Eccentric strengthening of appropriate compartment muscles.
• Foot orthotics (if needed) to control pronation.
• Consider shock-absorbing shoes and playing surfaces.

Plantar Fasciitis (Heel Spur)

• Mechanisms:
  • Excessive foot pronation: overstretches the plantar fascia, causing irritation.
  • Pes cavus foot: reduced shock absorption during gait, leading to excessive force on the plantar fascia, causing irritation and inflammation.
  • Limited ankle dorsiflexion (DF): increased tension on the plantar fascia from MTP joints.
  • Limited DF of MTP joints: places excessive tension through the plantar fascia during gait.

Plantar Fasciitis (Heel Spur): Signs and Symptoms

• Pain on palpation of the calcaneal insertion of the plantar fascia.
• Severe pain on weight bearing after periods of rest or sleep, resolving temporarily with walking.
• Pain reappears after increased activity.
• Symptoms may be reproduced with passive extension of MTPs or resisted flexion of the toes.
• Patients may experience limited passive range of ankle DF and MTP DF.
• Pes cavus deformity or rearfoot/forefoot varus deformity may be present in individuals with excessive pronation.

Plantar Fasciitis (Heel Spur): Treatment

• Inflammation treatment: NSAIDs, ice, and rest from activities that reproduce symptoms.
• Stretching of ankle plantar fascia, toe flexors, and plantar fascia.
• Strengthening exercises for toe flexors and intrinsics.
• Deep friction massage of the plantar fascia.
• Orthotics to correct biomechanical dysfunctions.
• Heel cups or donut pads may provide temporary relief by reducing pressure.
• Resting dorsiflexion night splint.

Inversion Sprains

• Most common type of sprain.
• Mechanism: Involves plantar flexion (PF) and inversion (Inv).
• Typically involves anterior talo-fibular and calcaneo-fibular ligaments.
• Severe injury may also involve the posterior talo-fibular ligament.

Associated Pathologies

• Peroneal tendon injury.
• Fracture of the distal fibula or lateral malleolus.
• Fracture of the medial malleolus.
• Sinus Tarsi syndrome.

Signs and Symptoms for Inversion Sprain

• Tenderness to palpation of the lateral collateral ligaments.
• Swelling and possible discoloration (echymosis) in the lateral ankle and foot.
• Painful limitation of plantar flexion (PF) and inversion (Inv).
• Possible painful and weak resisted eversion.
• Positive anterior drawer and medial talar tilt tests.
• Antalgic gait, limping due to reduced weight bearing and limited ROM.

Non-operative Treatment of Inversion Sprains

• Initial period of immobilization (bracing).
• Treat initial inflammation and injury using RICE (Rest, Ice, Compression, Elevation).
• Early passive and active ROM within pain-free range of motion.
• Progress to ankle strengthening exercises (isometrics, theraband, PRE, weight bearing exercises), emphasizing ankle everters.
• Proprioceptive and coordination exercises (Perturbation, Agility training).
• Functional retraining activities.
• Protective bracing or taping upon return to activities.

Operative Treatment: Brostrom Repairs, With and Without Modification

• Indicated for chronic lateral ankle sprains and instability.

Brostrom Repair Post-op Rehab

• Splint for 10 to 14 days.
• Cam Walker for 4 weeks.
• Air Stirrup for 4 weeks.
• Initiate ROM and strengthening at 6 weeks.
• Return to full activity at 3 to 4 months.

Brostrom Repair with Modified Evans Tenodesis

• Same indications as Brostrom, plus need to stabilize the talus.
• Tenodesis of peroneus brevis tendon reduces excessive inversion of the subtalar joint.
• Rehabilitation similar to regular Brostrom.
• May take longer to restore peroneal strength and inversion ROM.

Eversion Sprain

• Mechanism: Forced excessive pronation or abduction of the planted foot.
• Typically involves the deltoid ligament, potentially the distal tib-fib interosseous membrane.
• Severe injury might involve an avulsion fracture of the calcaneal insertion of the deltoid ligament.
• Less common than inversion sprains due to the fibula's distal extension, which provides extra medial stability to the ankle.

Signs and Symptoms for Eversion Sprain

• Tenderness to palpation over the deltoid ligament, possibly the tibio-fibular ligament and interosseous membrane.
• Swelling and possible discoloration (echymosis) in the medial ankle and foot.
• Painful limitation of dorsiflexion (DF) and eversion (EV).
• Possible painful and weak resisted inversion.
• Positive anterior drawer and Kleiger tests.
• Antalgic gait, limping due to reduced weight bearing and limited ROM.

Non-operative Treatment of Eversion Sprain

• Similar principles to inversion sprains.
• May require an extended immobilization period if an avulsion fracture is present.
• Strengthening exercises should focus on ankle inverters.

Syndesmotic ("High Ankle") Sprains

• Involves the anterior distal tibiofibular ligament and the distal interosseous membrane.

High Ankle Sprain Mechanisms

• Mechanism: Forced external rotation of the foot combined with internal rotation of the leg (e.g., a lateral blow to the knee when the foot is fixed on the ground).

Signs and Symptoms

• Tenderness to palpation of the distal tib-fib region; possible minimal swelling.
• Patients avoid full dorsiflexion (DF) during gait to minimize stress on the distal tib-fib joint.
• May walk with a steppage gait.
• Passive full DF may reproduce symptoms.
• External rotation test is positive.
• Distal tib-fib compression test will reproduce pain.

High Ankle Sprain: Non-operative Treatment

• Key difference from other ankle rehab: prolonged protected weight bearing (WBAT) and return to sports.
• Patients may have no pain but aren't ready to return.
• WBAT period is approximately 4 weeks, then gradually advance to functional retraining activities until 8 weeks.
• External ankle support or brace is used for functional retraining and return to sports.

High Ankle Sprain: Operative Treatment

• Internal fixation of the distal tib-fib joint.
• Splint for 10–14 days.
• Protected weight-bearing (PWB) with Cam walker for 4–6 weeks.
• Screw removal after 3 months.

Morton's Neuroma

• Entrapment of the third common digital branch of the medial plantar nerve between the third and fourth metatarsal heads.
• Mechanisms: nerve compression and shear due to hypermobile metatarsals.
• Tight shoes can worsen the condition.

Morton's Neuroma: Signs and Symptoms

• Metatarsalgia of the third and fourth metatarsals is the most common complaint.
• Pain during weight-bearing activities.
• Paresthesias or impaired sensation in the affected area.

Morton's Neuroma: Treatment

• Wider shoes.
• Metatarsal pads to elevate the transverse arch and separate the metatarsals.
• Steroid injection.
• Surgical excision.