Foot and Ankle Exam Founder, SportZPeak Inc. Sanofi, Investigator - PowerPoint PPT Presentation

12/10/2016 Disclosure • Founder, RunSafe™, RaceSafe™ Foot and Ankle Exam • Founder, SportZPeak Inc. • Sanofi, Investigator initiated grant Anthony Luke MD, MPH, CAQ (Sport Med) ABC ’ s of MSK Care UCSF Sports Medicine December 10, 2016 Outline Ankle Joint Hinge Joint • Anatomy of the Ankle • Tibiofibular joint • Anatomy of the Foot • Talotibial joint • Common ankle problems • Talofibular joint • Common foot problems • Talocalcaneal joint • Examination of the foot and ankle • Talonavicular joint • Calcaneocuboid joint 1

12/10/2016 Ankle Movements Ankle Ligaments Mortise Lateral Collateral Complex • Dorsiflexion, plantarflexion • Anterior talofibular lig. • Calcaneofibular lig. Subtalar joint • Posterior talofibular lig. • Inversion eversion Medial Ligament Complex • Moves like an angled hinge • Deltoid ligament • Superficial and deep ligaments Ankle Ligaments Muscles “ “ “ “ Tom, Dick And Not Sinus tarsi / Subtalar joint Posteromedial Harry ” ” ” ” • Interosseous talocalcaneal ligament • Tibiofibular joint Posterior Tibialis, Flexor • • Anterior and posterior tibiofibular ligaments, Digitorum, Tibial intraosseous membrane Artery,Tibial Nerve, Flexor Hallucis Longus 2

12/10/2016 Muscles Anatomy of The Foot Lateral • Chopart ’ ’ s Joint ’ ’ • Peroneus Longus, Brevis, Tertius • Hindfoot Superior • Lisfranc ’ ’ ’ ’ s Joint • Anterior tibialis, extensors • Midfoot Posterior • Achilles Tendon • Forefoot Acute Ankle Injuries Ankle Sprains Mechanism of injury • Inversion, plantarflexion is most common injury • Inversion (Supination) • Eversion (Pronation) • Axial load • Muscle rupture Position of foot • Dorsiflexed or plantarflexed 3

12/10/2016 Associated Injuries Ottawa Ankle Rules • Subtalar joint sprain • Peroneal tendon • Inability to weight bear immediately and in the emergency / office (4 steps) subluxation • Sinus tarsi syndrome • Bone tenderness at the posterior edge of the • Fracture at the base • Osteochondral talus medial or lateral malleolus (Obtain Ankle Series) of the fifth metatarsal injury • Bone tenderness over the navicular or base of • Jones fracture • Lateral talar process the fifth metatarsal (Obtain Foot Series) fracture • Syndesmotic sprain • Sens 97%, Spec 31-63%, NPV 99%, PPV <20% • Posterior impingement • Salter fracture (fibula) (Am J Emerg Med 1998; 16: 564-67) (os trigonum) • Ankle fractures • Posterior tibial tendon strain Grading Ankle Sprains Treatment of Ankle Sprains • Grade 1 = mild stretch with no instability Acute • Ice, Compression, Elevation • Grade 2 = mild laxity with a good end point • Rest or modified activities (ATFL usually torn but CFL and PTFL intact) • Crutches PRN • Bracing (Grade 2 and 3) • Grade 3 = laxity poor end point (ATFL and CFL • Physical Therapy usually torn) • Early Motion is essential 4

12/10/2016 Prognosis Foot issues • Grade 1 – 2 to 4 weeks • Morton’s Neuroma • Grade 2 – 4 to 6 weeks • Bunions • Grade 3 – 6 to 12 weeks • Hallux Rigidus • 2 nd metatarsalgia • More than 12 weeks – consider associated • Plantar fasciitis injuries causing chronic ankle pain Plantar Fasciitis Injection MRI Plantar Fasciitis Patient Supine Landmarks: • Medial tubercle of the calcaneus (insertion of plantar fascia into the calcaneus) is usually the point of maximal tenderness • Go 2 cm distal to the most tender point then aim needle toward tender point 5

12/10/2016 Plantar Fascia Injection #2 Plantar Fascia Injection • Post injection: • Alternative Technique: Injection • Check pre and post injection pain levels with walking and palpation (injection can be diagnostic) approach through the medial heel border • Lidocaine effect should be immediate and the steroid effect posterior to the point will occur in 24 hours of heel tenderness • Continue other treatments (i.e. stretching, NSAIDS, footwear, +/- nightsplint, etc.) • Avoid inferior • Decrease physical activity for 5-10 days after injection approach Plantar Fascia Injection Posterior Tibilialis (PT) Dysfunction • Main dynamic stabilizer of • Complications the hindfoot to prevent Heel EVERSION • Bleeding, Infection • Plantar fascia • Hyperpronation rupture • Tendon dislocation or • Fat pad atrophy rupture (partial vs Complete tears) can cause flatfoot deformity 6

12/10/2016 PT Dysfunction PT Dysfunction Presentation • Usually women > 40 y.o. • “ “ “ Too many toes sign ” “ ” ” ” • Weakness with inversion • Unable to plantarflex – Single limb heel rise test Subtalar neutral Orthotics • Material (polypropylene, cork, rigid plastic) • Length (3/4 or full) • Lift • Posting (forefoot, midfoot, rearfoot) Courtesy of Alicia Knee, DPM, UCSF 7

12/10/2016 Screening Orthotics Courtesy of Alicia Knee, DPM, UCSF 8