Foot and Ankle Session

Cameron Bulluss, Rob Dingle, Peter Enks, Pierre

Buchholz, Gavin Jackson Advanced Physiotherapy
and Injury Prevention
www.advancedphysio.com.au

Preliminaries
Useful Resources and Acknowledgements
1. Atlas of Imaging in Sports Medicine (2nd ed.). Jock Anderson and
John W Read
2. Clinical Sports Medicine. Bruckner and Khan
3. American Academy of Orthopedic Surgeons Website.
www.aaos.org
4. Advanced Physiotherapy and Injury Prevention Website
www.advancedphysio.com.au, notes will be on website (show)
Acknowledgements Isobel Green, Jess Fidler
Introduce Colleagues
Purpose of these talks: educate, meet, value add
Who we treat

Imaging

When to Image
If it affects management
Diagnosis is uncertain
Demanding patient
To assist with determining prognosis
Red flags
Orange flags
Failed treatment

Ottawa Ankle and Foot Rules

Red Flags
> 50 year old
Systemic symptoms
Significant morning stiffness
Known risk factors
Past history or family history
Noctural pain

Orange Flags
Disability disproportionate to mechanism
Failure to respond to conservative management
Multiple opinions
Anxious patient
Education
Significant trauma (fall over 1 metre)
IV drug use
Cord or cauda equina signs
History of use of oral corticosteroids

Grades of Injury Muscle/Ligament

Ligament
Grade 1

Grade 2

Grade 3

Pathology = microscopic tearing (strain)

Clinical = Tenderness but no ligament laxity
MRI = normal ligament thickness but increased periligamentous
signal
Pathology = partial tear
Clinical = some ligamentous laxity but firm end-point
MRI = ligament thickening +- partial discontinuity, increased signal
Pathology = complete tear
Clinical = increased ligament laxity and no indentifiable end point
MRI = complete ligament discontinuity + oedema and
haemorrhage

Anatomy of the Foot and Ankle

Bones and Articulations
Inferior tibiofibular joint
Talocrural joint
Subtalar joint
Transverse tarsal (Choparts)
Intertarsal joints
Tarsometatarsal joint (Lisfranc)

Anatomy of the Foot and Ankle

Anatomy of the Foot and Ankle

Ligaments

Anatomy of the Foot and Ankle

Ligaments

Case Study 1
42 year old coal-miner, twisted ankle felt pop, swelled

immediately and unable to weight-bear, ED x-rays reported

as normal, placed in backslab at hospital, told to RICE and
presented to you 2 days post injury

Case Study 1
Probable diagnosis?
Clinical tests to confirm

diagnosis?
Further imaging required?

Case Study No 1
Lateral ligament sprain

Lateral Ligament Sprain (16 -21% of all

athletic injuries)
- Biomechanics of injury
- Clinical Tests (ant. Drawer,

palpation, inversion, KTW)

- Time frame to recover
- Likleyhood of poor prognosis
- ? Refer on

Management of Lateral Ligament

Sprains - conservative
RICE
Place ligament in shortened position
Boot, brace, tape

Short period of reduced weight bearing

Then progressive exercise based rehabilitation

focusing on regaining movement, balance, strength and

proprioception
2-6 weeks to recover
80% recover structurally
Strap or brace for season

Conservative vs Surgical For Grade 3

Lateral Ligament Tears
Rehab 87% excellent or good outcomes
Surgery 60% excellent or good outcomes (Kaikkonen 1996)

Treatment of Choice for Lateral

Ligament Sprain
(BRITISH MEDICAL JOURNAL VOLUME 282/ 21 1981)Early functional treatment

with a short period of protection via boot, brace or tape followed by series of exercises
designed to gradually restore range of motion, strength, proprioception

The Journal of Bone and Joint Surgery VOL. 73-A, NO. 2, FEBRUARY 1991 Summary.

After a critical review of these twelve studies, it is not difficult to select functional
treatment as the treatment of choice for acute complete tears of the lateral ligaments of
the ankle

Complications Following Major Lateral

Ligament Tear
Location of osteochondral
lesions

Study of 30 patients with

grade 3 lateral ligament tears

The arthroscopic findings

in these were
chondral lesions in 20
patients,
traumatic synovitis in 19,
adhesions in nine and a
partial rupture of the
deltoid ligament in one.

ANKLE TAPING DEMONSTRATION

Also show walking boot, dorsiwedge splint
Discuss management high versus low grade injuries

Case Study 2
Soccer Player twisted ankle

(external rotation).
Presented unable to
weightbear with swelling
anterior ankle joint. ED
series x-rays patient told
no fracture. Reports no
swelling lateral ankle but
swelling anteriorally

Possible diagnosis?
Clinical tests to confirm

diagnosis?
Further imaging required?

Case Study 2
Injury to inferior tibiofibular ligaments (high ankle sprain)

Injuries to the Inferior tibiofibular ligaments

(syndesmotic ligaments) 3-10% of ankle sprains
Biomechanics of injury, patient presentation, clinical testing
(ext rot, squeeze), investigations, show primal dvd

MRI Syndesmotic Ligaments

Inferior Tibiofibular Diastasis (should not exceed 5.5mm

also look for jt space medial malleolus

Management of Syndesmosis Injuries

AITFL MRI and surgical referral if high grade

tear/instability
PITFL does not cause diastasis and treated as per a typical
sprain

Case Study 3
51 year old female presents

with heel pain that she has

had for several months. It is
worse in the morning,
particularly with her first
step.

Probable diagnosis?
Clinical tests to confirm

diagnosis?
Further imaging required?

Case Study 3 - Plantar Fasciitis

Most common foot

problem
Biomechanics
Pathology
?Heel spur (FDB)
Time frame to recover
?referral on
Imaging?
Clinical tests

Management options

Plantar fascia stretches

Heel cord stretches
Night splint
Orthotics
Tape

Case Study 4
62 year old woman,

presents with medial foot

and ankle pain of insidious
onset. Claims that she
notices the arch of her foot
has gradually collapsed
over the last few years
Probable diagnosis?

Case Study 4
Acquired Pes Planus

Acquired Adult Flat Foot - Causes

Uncoupling of tarsal bone
Tibialis posterior tendinopathy
Osteoarthrits of midtarsal joint
Lisfranc Injuries
Insufficiency of
Plantar fascia, spring ligament, deltoid (medial) ligament

Rupture or Severe attenuation of Tibialis

Posterior

Acquired Adult Flat foot

Referral on?
Clinical tests
Management
Likely time frame to recover?
Likelyhood of poor outcome?

Case Study 5
39 year old woman

presents with pain over the

mid achilles tendon
following commencing
boot camp training.
Impossible to run
comfortably now, but is
able to walk except up hills

Probable diagnosis?
Clinical tests to confirm

diagnosis?
Further imaging required?
Referral on?
Likely time frame to
recover?
Likelyhood of poor
outcome?

Case Study 5 Achilles Tendinopathy

Apart from disorders of the tendon sheath there are no

inflammatory changes in most tendon pathologies (excluding

tendon sheath)
Alfredsons accidental discovery

Tendon Facts
Types of tendon Pathology (Cook and Purdham BMJ 2008)
normal,
proliferative
failed healing
degenerative
rupture
Tendon sheath
Insertional and non-insertional tendinopathies

These pathologies can co-exist

Tendon Facts
Most tendon pathologies we see in the non-athletic

population are degenerative tendinopathies

Most athletic tendinopathies are insertional

Aeitiology
Genetic factors (more type 3 collagen, blood group O,)
Hypermobility
Higher incidence in diabetics
Increased with increasing age
Related to waist girth (BMI>30 3times greater likelyhood of

rotator cuff surgery) - ? Effect of cytokinines, lipids on tendon

health
Hormonal (positive effects from HRT)
Seronegative and metabolic disorders

Tendon Facts
Degenerative tendon pathology is reversible

sometimes (Alfredson, Cook 2005,Silbernagle 2008)

What Works Best

Best evidence is for slow resistance exercises that have an

eccentric component and this can be enhanced with the

application of a GTN patch

Achilles painfree 49% (78% with patch) (Murrell 2007)

Achilles -Mid substance 90 %, Insertional 30%

significant improvement with eccentric program (Alfredson

2008)

Why Does Exercise Work

Produces new collagen (but can take 100 days)
Destruction of neovessels and nerves
Normalisation of cells
Reduces thickness of tendon
Implications for impingement

Implications for Management

If patient presents with acute overload a period of rest is

important
If pain in a sedentary person or is chronic we can embark
immediately on a resistance exercise program
If there is a bursae associated with the tendon then ultrasound is
worthwhile and if the bursae is inflamed consider an injection
If the tendinopathy is insertional and you are prescribing exercises
dont allow the tendon to stretch
Many of the traditional programs are not appropriate
Expect 6 -12 months in many cases
?GTN patches and other measures such as autologous blood,
polidocinol,

Case Study 6
15 year old boy, falls out of a

roof at work and lands on

foot. Fracture to distal tibia
and fibula treated by cast
immobilisation for 8 weeks.
After 6 weeks of physio and
exercises ankle movement is
good but complains of
persistent forefoot pain. He
reports that he is unable to
rise up on to his toes, xray
series of foot at initial
incident show no fracture .

Probable diagnosis?
Clinical tests to confirm

diagnosis?
Further imaging required?

Lisfranc Injury
Although not common early management is crucial to long

term outcome
Referral on?
Likely time frame to recover?
Likelyhood of poor outcome?

Low Velocity Lisfranc Ligament Injuries

2 predominant mechansims
Forced hyperplantarflexion with fixed midfoot
Typically involves a strap (windsurfers, equestrian, wakeboarders etc)
Foot gets stuck in strap and patient has fallen backwards
Weightbearing on forefoot, axial loading
Contact sports where a player may fall on another players heel when
forefoot weightbearing.
Landing on the forefoot with force (landing from jump, parachuting)

Lisfranc Ligament Injury Clinical

Echymosis
Swelling
Often unable to weight-bear
Pain on passive inversion and eversion of forefoot
X-Rays often normal or reported as normal
MRI best test
Higher grade injuries need urgent orthopaedic referral

Metatarsal Fracture and Instability

Secondary to Lisfranc ligament tear

Metatarsalgia
The term metatarsalgia is often used to describe pain in the

distal forefoot, but does not define a specific diagnosis or

indicate a particular mode of treatment.

Diagnositic Algorithm for Forefoot Pain

Assessment
Upright

Standing look at shoes, wear patterns, symmetry, muscle wasting, erythema, scarring,

arch height, toe position, knees, general posture, single leg heel raise
Walking normally, heels, toes,
Weightbearing dorsiflexion and calf length
Supine

Neurological (webspace b/t 1st, 2nd toes deep peroneal nerve)

Vascular (dorsalis pedis, posterior tibial pulses, capilliary refill great toe)
Palpate collateral ligaments, joint lines (ant and post), TDH, peroneals, plantar fascia,

sustentaculum tali, navicular, base of 5th met, dome of talus, individual bones
Active and passive movements (ankle, subtalar, transverse tarsal, midtarsal,
tarsometatarsal, forefoot, toes)
Resisted muscle tests
Special tests eg posterior impingement, syndesmotic ligaments, anterior drawer
Prone

Achilles tendon
Stress tests for ATFL and Syndesmosis

Gaitscan

Gaitscan
Indications for orthotics