Foot & Ankle Pathologies PDF

Foot & Ankle Pathologies Mohammad Yabroudi, PT, PhD Jordan University of Science and Technology Shin Splints Pathology believed to be periostitis Tendon fibers pull away from bony insertion, resulting in inflammation and pain. May have microscopic vasculitis and thicken...

Foot & Ankle Pathologies Mohammad Yabroudi, PT, PhD Jordan University of Science and Technology Shin Splints Pathology believed to be periostitis Tendon fibers pull away from bony insertion, resulting in inflammation and pain. May have microscopic vasculitis and thickening of periosteum and cortical bone in region Can be classified as antero-lateral and postero- medial shin splints Shin Splints: Antero-lateral Involves anterior compartment muscles Mechanisms: Excesssive eccentric forces to control PF at heel strike (particularly if function on hard surface) Limited DF causes ↑ effort by DFs for toe clearance during gait Shin Splints: Antero-lateral Pain in anterior lateral leg, worse with activity, usually improves with rest Usually gradual onset related to overuse syndromes ROM testing AROM/RROM: pain reproduced with DF combined with Inv or DF combined with EV PROM: pain reproduced with PF combined with EV or PF combined with Inv Shin Splints: Postero-medial Usually involves deep posterior compartment, may involve soleus as well Mechanisms: Excessive eccentric activity to control excessive pronation Shin Spints: Postero-medial Pain in posterior and medial leg, worse with activity, better with rest Over-pronation: varus rearfoot and/or forefoot deformity (Bennet, et al, JOSPT, 2001: navicular drop test) ROM testing AROM/RROM: PF combined with Inv PROM: DF combined with EV Shin Splints: General Treatment Guidelines ▪ Relative Rest/Anti-inflammatory ▪ Stretching if motions are restricted ▪ Eccentric strengthening of appropriate compartment muscles ▪ Foot orthotics to control pronation if needed ▪ Consider shock absorbing shoes, playing surface, etc.  Plantar Fasciitis (Heel Spur) Mechanisms: Excessive foot pronation: Over stretches the plantar fascia resulting in irritation. Pes Cavus foot: Limited pronation during gait results in reduced shock absorption. Plantar fascia has to absorb excessive amounts of force, may result in irritation and inflammation. Limited Ankle DF: May require more DF from MTP joints which would place excessive tension on the plantar fascia Limited DF of MTP joints would place excessive tension through plantar fascia during gait.  Plantar Fasciitis (Heel Spur) Signs and Symptoms: Pain on palpation of calcaneal insertion of plantar fascia. Typically complain of severe pain on weight bearing after period of rest or sleep, resolves temporarily as patient walks. (probably stiffness) Pain then re-appears after increased activity. Symptoms may be reproduced with passive extension of the MTPs or resisted flexion of the toes. Patient may have limited passive range of ankle DF and MTP DF Pes Cavus deformity or RF/FF varus deformity may be present with excessive pronators.  Plantar Fasciitis (Heel Spur) Treatment: Inflammation: NSAIDS, ice, ES, rest from activities that reproduce symptoms. Stretching of ankle PFs, toe flexors, and plantar fascia (DiGiovanni, 2003) Strengthening of toe flexors and intrinsics Deep friction massage to Plantar fascia Orthotics to correct biomechanical dysfunctions Heel cups or Donut pads are often prescribed but don’t usually have much success. They don’t control the biomechanical dysfunctions. They may, however, give temporary relief by helping with shock absorption and relieving pressure over the inflammed area. Resting dorsiflexion night splint. Inversion Sprains Most common type of sprain. Mechanism involves PF/Inv Typically involves anterior talo-fibular ligament and calcaneo-fibular ligament. Severe injury may also involve the posterior talo- fibular ligament. Associated Pathologies Peroneal Tendon Injury Fracture of distal fibula or lateral malleolus Fracture of medial malleolus Sinus Tarsi Syndrome Signs and Symptoms for Inversion Sprain ▪ Tenderness to palpation of lateral collateral ligaments. ▪ Swelling and possibly discoloration (echymosis) in lateral ankle and foot. ▪ Painful limitation of PF/Inv. ▪ Possible painful and weak resisted eversion. ▪ Positive anterior drawer and medial talar tilt tests. ▪ Antalgic gait, limping due to  wt bearing and limited ROM. Non-operative Treatment of Inversion Sprains Initial period of immobilization. Bracing. Treat initial inflammation and injury with RICE (Rest, Ice, Compression, Elevation) Early passive and active ROM in pain-free range of motion Progress to ankle strengthening exercise. Begin with isometrics, progress to theraband, PRE, weight bearing strength exercises. Major emphasis on ankle everters. Proprioceptive and coordination exercises (Perturbation, Agility training) Functional re-training activities. Protective bracing or taping on 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 10 to 14 days Cam Walker 4 weeks Air Stirrup 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 talus Tenodesis of peroneus brevis tendon reduces excessive inversion of the subtalar joint Rehab similar to regular Brostrom May have longer time to restore peroneal strength and inversion ROM may be a little harder to get back  Eversion Sprain Mechanism: Forced excessive pronation or excessive abduction of planted foot if lateral leg receives external blow. Typically involves deltoid ligament, may also involve distal tib-fib interosseous membrane. Severe injury may involve avulsion fracture of calcaneal insertion of deltoid ligament. Not as common as inversion sprains because distal fibula extends below joint line, providing extra medial stability to ankle. Signs and Symptoms for Eversion Sprain Tenderness to palpation over deltoid ligament, also possibly tibio-fibular ligament and interosseous membrane. Swelling and possibly discoloration (echymosis) in medial ankle and foot. Painful limitation of DF/Ev. Possible painful and week resisted inverters. Positive anterior drawer and Kleiger tests. Antalgic gait, limping due to  wt bearing and limited ROM. Non-operative Treatment of Eversion Sprain Same principles as Inversion sprain. May have extended immobilization period if avulsion fracture is present. Strengthening will emphasize ankle inverters. Syndesmotic (“High Ankle”) Sprains ▪ Involves anterior distal tib-fib ligament and distal interroseus membrane High Ankle Sprain Mechanisms Mechanism: Forced external rotation of the foot, combined with internal rotation of the leg. Example might be when foot is fixed on ground, a lateral blow to the knee forces the tibia into internal rotation and simultaneously, the ground reaction force results in an external rotation force on the foot.  Signs and Symptoms Tenderness to palpation of distal tib-fib region Swelling may be minimal at times, which may mislead the examiner into thinking there is no severe injury. Patients will avoid full DF during gait to minimize stress on distal tib-fib joint. May walk with steppage gait (Not allowing normal DF range) Passive full DF may reproduce symptoms External rotation test will be positive (with foot in neutral DF, knee flexed to 90, examiner externally rotates foot) Distal Tib-fib compression test will reproduce pain. High Ankle Sprain: Non-operative Treatment Key difference from other ankle rehab is prolonged protected weight bearing time and return to sports. Patients will have no pain, but they are not ready to return. Protected weight bearing (WBAT) should be approximately 4 weeks, and delay advancing to functional retraining activities until 8 weeks. Then gradual return to activity. External ankle support or brace is used for functional retraining and return to sports. High Ankle Sprain: Operative Treatment Internal fixation of distal tib-fib joint Splint for 10 to 14 days PWB in Cam walker for 4 to 6 weeks Screw removal after 3 months  Morton’s Neuroma Entrapment of 3rd common digital branch of medial plantar nerve between metatarsal head 3 and 4. Mechanisms: Compression of nerve due to compression and shear of hypermobile metatarsals. Tight shoes may aggravate the condition. Morton’s Neuroma Signs and Symptoms: Metatarsalgia of 3 and 4 most common complaint Pain in weight bearing activities Parasthesias or impaired sensation in the affected area. Treatment: Wider shoes Metatarsal pad to elevated transverse arch and separate metatarsals Steroid injection Surgical Excision