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

12/10/2016 1

Foot and Ankle Exam

Anthony Luke MD, MPH, CAQ (Sport Med) UCSF Sports Medicine ABC’s of MSK Care December 10, 2016

Disclosure

• Founder, RunSafe™, RaceSafe™
• Founder, SportZPeak Inc.
• Sanofi, Investigator initiated grant

Outline

• Anatomy of the Ankle
• Anatomy of the Foot
• Common ankle problems
• Common foot problems
• Examination of the foot and ankle

Ankle Joint

Hinge Joint

• Tibiofibular joint
• Talotibial joint
• Talofibular joint
• Talocalcaneal joint
• Talonavicular joint
• Calcaneocuboid joint

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Ankle Movements

Mortise

• Dorsiflexion, plantarflexion

Subtalar joint

• Inversion eversion
• Moves like an angled hinge

Ankle Ligaments

Lateral Collateral Complex

• Anterior talofibular lig.
• Calcaneofibular lig.
• Posterior talofibular lig.

Medial Ligament Complex

• Deltoid ligament
• Superficial and deep ligaments

Ankle Ligaments

Sinus tarsi / Subtalar joint

• Interosseous talocalcaneal ligament

Tibiofibular joint

• Anterior and posterior tibiofibular ligaments,

intraosseous membrane

Muscles

Posteromedial

• “

“ “ “Tom, Dick And Not Harry” ” ” ”

• Posterior Tibialis, Flexor

Digitorum, Tibial Artery,Tibial Nerve, Flexor Hallucis Longus

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Muscles

Lateral

• Peroneus Longus, Brevis, Tertius

Superior

• Anterior tibialis, extensors

Posterior

• Achilles Tendon

Anatomy of The Foot

• Hindfoot
• Chopart’

’ ’ ’s Joint

• Midfoot
• Lisfranc’

’ ’ ’s Joint

• Forefoot

Acute Ankle Injuries

Mechanism of injury

• Inversion (Supination)
• Eversion (Pronation)
• Axial load
• Muscle rupture

Position of foot

• Dorsiflexed or plantarflexed

Ankle Sprains

• Inversion, plantarflexion is most common

injury

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Associated Injuries

• Subtalar joint sprain
• Sinus tarsi syndrome
• Osteochondral talus

injury

• Lateral talar process

fracture

• Posterior impingement

(os trigonum)

• Posterior tibial tendon

strain

• Peroneal tendon

subluxation

• Fracture at the base
• f the fifth metatarsal
• Jones fracture
• Syndesmotic sprain
• Salter fracture (fibula)
• Ankle fractures

Ottawa Ankle Rules

• Inability to weight bear immediately and in the

emergency / office (4 steps)

• Bone tenderness at the posterior edge of the

medial or lateral malleolus (Obtain Ankle Series)

• Bone tenderness over the navicular or base of

the fifth metatarsal (Obtain Foot Series)

• Sens 97%, Spec 31-63%, NPV 99%, PPV <20%

(Am J Emerg Med 1998; 16: 564-67)

Grading Ankle Sprains

• Grade 1 = mild stretch with no instability
• Grade 2 = mild laxity with a good end point

(ATFL usually torn but CFL and PTFL intact)

• Grade 3 = laxity poor end point (ATFL and CFL

usually torn)

Treatment of Ankle Sprains

Acute

• Ice, Compression, Elevation
• Rest or modified activities
• Crutches PRN
• Bracing (Grade 2 and 3)
• Physical Therapy
• Early Motion is essential

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Prognosis

• Grade 1 – 2 to 4 weeks
• Grade 2 – 4 to 6 weeks
• Grade 3 – 6 to 12 weeks
• More than 12 weeks – consider associated

injuries causing chronic ankle pain

Foot issues

• Morton’s Neuroma
• Bunions
• Hallux Rigidus
• 2nd metatarsalgia
• Plantar fasciitis

MRI Plantar Fasciitis Plantar Fasciitis Injection

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

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Plantar Fascia Injection #2

• Alternative

Technique: Injection approach through the medial heel border posterior to the point

• f heel tenderness
• Avoid inferior

approach

Plantar Fascia Injection

• Post injection:
• Check pre and post injection pain levels with walking and

palpation (injection can be diagnostic)

• Lidocaine effect should be immediate and the steroid effect

will occur in 24 hours

• Continue other treatments (i.e. stretching, NSAIDS,

footwear, +/- nightsplint, etc.)

• Decrease physical activity for 5-10 days after injection

Plantar Fascia Injection

• Complications
• Bleeding, Infection
• Plantar fascia

rupture

• Fat pad atrophy

Posterior Tibilialis (PT) Dysfunction

• Main dynamic stabilizer of

the hindfoot to prevent Heel EVERSION

• Hyperpronation
• Tendon dislocation or

rupture (partial vs Complete tears) can cause flatfoot deformity

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PT Dysfunction

Presentation

• Usually women > 40 y.o.
• Weakness with inversion
• “

“ “ “Too many toes sign” ” ” ”

• Unable to plantarflex – Single limb heel

rise test

PT Dysfunction Subtalar neutral Orthotics

• Material

(polypropylene, cork, rigid plastic)

• Length (3/4 or full)
• Lift
• Posting (forefoot,

midfoot, rearfoot)

Courtesy of Alicia Knee, DPM, UCSF

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Screening Orthotics

Courtesy of Alicia Knee, DPM, UCSF