Ankle & Foot Assessment and Rehab PDF

Ankle & Foot Assessment and Rehab Dr. Amjad Shallan PT, PhD Anatomy  Visual Inspection Hammer toe = hyperextension of MTP & DIP with PIP flexion of toes 2, 3, 4, 5; associated with hallux valgus; pain is worse with shoes on; corns present Hallux valgus = 1st MTP >20° valgus angle; 1st & 2nd to...

Ankle & Foot Assessment and Rehab Dr. Amjad Shallan PT, PhD Anatomy  Visual Inspection Hammer toe = hyperextension of MTP & DIP with PIP flexion of toes 2, 3, 4, 5; associated with hallux valgus; pain is worse with shoes on; corns present Hallux valgus = 1st MTP >20° valgus angle; 1st & 2nd toe overlap Visual Inspection Visual Inspection Visual Inspection Palpation  Muscle Strength Inversion: Posterior tibialis tendon Eversion: Peroneus longus, brevis, tertius Plantar flex (longus) Dorsiflex (brevis, tertius) Dorsiflexion Tibialis anterior muscle Extensor digitorum longus Strength/Neuro  Differential Diagnosis Turf Toe Hallux Valgus Causes: Extreme hyperextension of great toe Causes: RA, poor fitting footwear, flat feet in CKC position resulting in sprain of plantar Pain, swelling, great toe valgus >15° capsule & LCL of 1st MTP ↓ ROM of great toe & hammer 2nd toe X-ray helpful Pain with toe extension Need to r/o RA Impairment of push-off, antalgic gait Ecchymosis & swelling of 1st MTP joint (–) X-ray Need to r/o sesamoid & metatarsal head fx  Differential Diagnosis Morton’s Neuroma Plantarfascitis ❑ Thickening of interdigital nerve ❑ subject to inflammation secondary to repetitive stress, poorly cushioned footwear, hard surfaces, ↑ pronation, obesity ❑ Secondary to high heel shoes, excessive pronation, high arch, lateral compression of forefoot. Morning pain that ↓ with activity, nodules are palpable over proximomedial border of plantar fascia Throbbing/burning into plantar aspect of 3rd & 4th MT Pain with dorsiflexion & toe extension heads; feels like a pebble is in the shoe ↓ Dorsiflexion due to tight gastroc Callus under involved rays Weak foot intrinsics ↑ Pain with WB, (+) Morton’s test Sensation & reflexes WNL Weak intrinsic muscles (–) EMG; x-ray may show calcaneal spur but there is no correlation EMG = unreliable between a bone spur & pain of plantarfascitis Need to r/o stress fx (MRI with contrast)  Differential Diagnosis Achilles Tendonitis Lateral Sprain ❑ Causes: running hills (up = stretch & down = eccentric stress), Rich blood supply = significant swelling within 2 hours poor footwear, excess pronation (↑ rotational forces) TTP over involved ligaments, ecchymosis that drains distal Localized tenderness 2–6 cm proximal to Achilles insertion Varying levels of instability (grade 1–3) Early morning stiffness, antalgic gait; pain climbing stairs (+) Tests: Talar tilt & anterior drawer (presence of a dimple just inferior to the tip of the lateral malleolus) Tendon thickening & crepitus with AROM (–) X-ray for fracture but stress film may show ↑ joint space Palpable Achilles nodule Arthrography is only accurate within 24 hours ↓ Ankle dorsiflexion with knee extended MRI to r/o tendon defect & DVT Pain Location And Possible Diagnoses Lateral ankle sprain Rehab  Achilles Tendinopathy Rehab Plantar Fasciitis Rehab  The intervention for hallux valgus is conservative in mild to moderate cases. The intervention for the bunion includes wider shoes and orthotics. Achilles stretching should be used in cases of Achilles contracture. Hallux Valgus A simple toe spacer can be used between the first and second toes, Rehab and a silicone bunion pad placed over the bunion may be helpful in alleviating direct pressure on the prominence. In cases of pes planus associated with hallux valgus, a medial longitudinal arch support with Morton extension under the first MTP joint may also alleviate symptoms.  The intervention initially entails avoiding the offending activity, cross- training in lower-impact sports, and modification of footwear. A switch to wider, more accommodating shoes with soft soles and better shock absorption will often improve symptoms. A metatarsal pad, such as an adhesive-backed felt pad, placed proximal to MORTON the symptomatic interspace is helpful. The metatarsal pad can also be incorporated into a custom-made full-length NEUROMA semirigid orthotic. Rehab A trial of nonsteroidal anti-inflammatory drugs is indicated in an attempt to decrease inflammation around the interdigital nerve. A trial of vitamin B6 has been used successfully in the treatment of carpal tunnel syndrome and may also be useful in the treatment of interdigital neuritis. ❑ Prognosis If symptoms persist or recur, surgical excision of the neuroma or division of the transverse metatarsal ligament is indicated.  ▪ The initial intervention for turf toe is rest, ice, a compressive dressing, and elevation. ▪ A nonsteroidal anti-inflammatory medication is often recommended. ▪ The toe should be taped to limit dorsiflexion with multiple loops of tape placed over the dorsal aspect of the hallucal proximal phalanx and criss-crossed under the ball of the foot plantarly, or a forefoot steel plate can be used. ▪ PROM and progressive resistance exercises are begun as soon as symptoms allow. TURF TOE ▪ Patients with grade I sprains are usually allowed to return to sports as soon as symptoms allow, sometimes immediately. Rehab ▪ Patients with grade II sprains usually require 3 to 14 days rest from athletic training. ▪ Grade III sprains usually require crutches for a few days and up to 6 weeks rest from sports participation. ▪ A return to sports training too early after injury could result in prolonged disability. ▪ Return to play is indicated when the toe can be dorsiflexed 90 degrees. ❑ Prognosis ▪ Turf toe typically develops into a chronic injury, and long-term results include decreased first MTP joint motion, impaired push-off, and hallux rigidus. ▪ Fifty percent of athletes will have persistent symptoms 5 years later. Thank You