Ankle and Foot

Clinical patterns

Foot Anatomy 
1. 2. 3.

Superficial layer Abductor HallucisHallucismedial plantar nerve Flexor digitorum brevis ² medial plantar nerve Abductor digiti minimi ² lateral plantar nerve



2nd Layer 
 

Tendon of the FHL Tendon of the FDL Quadratus plantae
‡ lateral plantar n. 

lumbricals 1st
‡ medial plantar n. ‡ lateral 3: lateral planar n.

 Flexor digiti minimi ‡ lateral plantar n. . 3rd Layer  Flexor hallucis brevis ‡ medial plantar n.  Adductor hallucis ‡ lateral plantar n.

 4th Layer  dorsal interossei ‡ abductors of the toes  plantar interossei ‡ adductors of the toes .

 4th Layer  dorsal interossei ‡ abductors of the toes .

Dorsum of foot .

Neural Anatomy .

. 6. 5. 3.clinical patterns of ankle and foot  Poorly localized bilateral foot pain ² interdigital neuralgia Posterior heel pain Superficial calcaneal bursitis (pump bumps) Retro calcaneal bursitis FHL tendinitis Insertional achilles tendinitis Peroneal tendinitis. 2. Sural nerve entrapment Os trigonum syndrome  1. 4.

 Plantar heel pain .

4.  1. 1. 2. 2. 3.cuboid arthropathy Recurrent cubido-4th metatarsal subluxation cubidoSinus tarsi syndrome . Medial heel pain Saphenous nerve lesions Medial calcaneal nerve lesions Lateral mid foot and hind foot pain Peroneus longus and brevis tendinitis Calcaneo .

hallux limitus. Lateralization of foot pain ² lateral foot pain when pathologies are at medial side of the foot Can be seen in hallux rigidus. painful medial strands of plantar fascia in PFascitis or result of excessive pronation secondary to PTTD  .

Medial Foot Pain .

talus post impingement syndrome referred pain from lumbar region  . Common causes PTTD FHL tendinopathy Lesser common medial calcaneal nerve tarsal tunnel syndrome stress fractures calcaneus.

Posterior tibialis tendon dysfunction  Dysfunction of the tibialis posterior tendon is a common condition and a common cause of acquired flatfoot deformity in adults older than 40 are most at risk  Women .

 Post tibialis is part of deep post compartment on proximal third of tibia and interosseous membrane insertion sites ± med cuneiform and navicular  Originates  Multiple .

5 cm excursion   . CN joint. and medial cunieform Posterior slip ± middle and lateral cuneiforms. cuboid and 2nd and 4th metatarsals Post tib tendon lies in the fibro ± osseous groove of med malleolus and has 1. Ant slip ± tuberosity of navicular.

mesotenon and synovial sheath vascular supply ± epitenon via periosteal vessels off medial plantar and dorsalis pedis  Distal . Proximal vascular supply ± post tibial artery.

Biomechanics  Posterior and medial to subtalar and ankle joint ± flexes the ankle. gastro continues the action Works with gastrosoleus to stabilize hind foot and invert the heel    . inverts mid foot and elevates the medial longitudinal arch through TN and CC joints Locks the subtalar joint during push off Most medial tendon & initiator of inversion.

before heel rise efficient progression of transverse tarsal joints from the unlocked to the locked position  Enables . Foot progresses from hind foot eversion at heel strike to hind foot inversion after mid stance.

post tibialis limits subtalar eversion by eccentric contraction  After . Subsequently gastro soleus acts on the calcaneus to invert the hind foot additionally. locking the transverse tarsal joints and allowing for efficient force transmission for gait HS.

locks transverse tarsal joints. resulting in a rigid lever phase ± accelerates subtalar supination and assists in heel lift inactive shortly after heel lift  Propulsive  Is . MS ± Allows for subtalar inversion.

etc  Inflammatory process ± degeneration due to synovitis  Impingement or constriction in tarsal canal  Zone of hypovascularity .Etiology of dysfunction  Trauma  Anatomic ± shallow groove. tight retinaculum.

 Medial ankle pain extending from post to medial malleolus towards the insertion of the tendon of the medial hind foot ± rare postinf to medial malleolus  Swelling  Tenderness .

a flattened longitudinal arch. and an abducted forefoot . Patients may also report a change in the shape of the foot or flattening of the foot  The foot develops a valgus heel (the heel rotates laterally when observed from behind).

 Single heel raise shows lack of inversion of hind foot ± MRI : highly specific and  Investigations sensitive USG ± 80% specific and 90% sensitive .

Johnson & Strom¶s classification  Stage 1 ± tendon length normal  Mild to moderate symptoms  Only aching along the med aspect of ankle exacerbated by training  Difficult to localize discomfort  Gradual onset  More easy to elicit if patient is asked to work out .

 Single heel raise ± in stage 1 dysfunction. patient either rises up incompletely or doesn¶t rise at all abnormal pattern may be present  Or  Treatment ± modification of activity. soft tissue mobilization. eccentric and concentric excs. initial inversion is weak. NSAID & orthotics .

hindfoot mobile  Pain present even at rest  Chronic history of months ± years  Localized pain along the length of tendon  Swelling and tenderness postinf to medial malleolus . Stage 2 ± tendon elongated .

windlass mechanism  Test for subtalar and ankle passive and active ROM. Single heel raise test significantly abnormal  Too may toes sign  Flattening of medial longitudinal arch. TA tightness .

ray shows prominent features  In AP view.forefoot abducted wrt hind viewfoot. navicular subluxes from the head of the talus. angle between the long head of talus & calcaneus increases  Lateral view ± sagging of long axis of TN joint and divergence of the long axis of the talus from calcaneus X .

tenodesis or tendon transfer . Treatment ± usually surgical with either shortening .

hind foot deformed and stiff  Never seen in active people  Degenerative changes present  Static supports of the foot are ruptured  Fixed flat foot . Stage 3 ± Tendon rupture.

most prominent feature  Treatment ± arthrodesis if pain is severe . Pain shifts to lateral aspect of hind foot as impingement develops  Deformity .

FHL tendinopathy  Secondary to overuse  Pain on toe off or forefoot weight bearing  May be associated with post impingement syndrome  Max pain over postmed aspect of calcaneus around sustentaculum tali  Aggravated by resisted flexion of great toe or stretching great toe into DF .

 Triggering may be present in some casescasesassociated with a snap or pop sound ± MRI/US  Investigation .

 1. 4. Treatment Ice Avoidance of activity FHL stretching + strengthening Soft tissue mobilization proximally in muscle belly Correction of subtalar hypomobility Control of excessive pronation during toe off with taping / orthosis Strengthen proximal components . 3. 5. 2. 7. 6.

Tarsal tunnel syndrome 
Compression

neuropathy of tibial nerve in tarsal tunnel where it winds around the medial malleolus ± 50% idiopathic trauma ( inversion injury) overuse (excessive pronation) 

Causes

 Indirect

trauma due to repetitive HS during running on hard surfaces, poor fitting shoes being transmitted through tarsal 

Forces

tunnel

relieved by rest  Aggravated  In some cases night pain may be present . great toe or medial aspect of the heel by activity. tingling. numbness along the plantar aspect of the foot. Poorly defined burning.

varicosities may be present  Tenderness  Tinel¶s in tarsal tunnel sign . Swelling. thickening.

corticosteroid injection in tarsal tunnel ± decompression  Surgical . referred pain from back  Conservative ± NSAID. plantar fasciitis. DDDD- medial or lateral plantar nerves.

Medial Calcaneal Nerve Entrapment  .

Lateral Ankle Pain .

 Common causes ± peroneal tendinopathy sinus tarsi syndrome  Less common causes ± impingement. AL. posterior recurrent dislocation of peroneal tendons stress fracture of talus referred pain .

Peroneal tendinopathy  1. 5. 3. 2. 4. Causes Excessive eversion of the foot Excessive pronation of the foot Secondary to tight ankle PF Excessive action of peroneals Inflammatory arthropathy .

3 main sites of tendinopathy  Posterior to lateral malleolus  At the peroneal trochlea  At the plantar surface of the cuboid .

relieved by rest Local tenderness. 1. 4. 3. 5. sometimes associated with swelling and crepitus Painful passive inversion and resisted eversion Calf tightness Excessive subtalar pronation or stiffness of subtalar or midtarsal joints . Clinical features Lateral ankle or heel pain. swelling which is aggravated by activity. 2.

mobilization of subtalar and midtarsal joints  Assess footwear .shows investigationcharacteristic features of tendinopathytendinopathyincreased signal and tendon thickening  Treatment ± pain relieving modalities. stretching. MRI recommended investigation. soft tissue mobilization.

resisted eversion in  Strengthening PF position . Lateral heel wedges or orthoses excs.

just anterior to fibular malleolus to postmed behind medial malleolus  .Sinus tarsi syndrome  Sinus tarsi is a conical shaped cavity located between antero sup surface of calcaneus and neck of the talus Opens laterally.

Contents ± Interosseous talocalcaneal ligament Cervical ligament Anterior portion of the subtalar joint capsule and synovium Posterior portion of the TCN joint capsule and synovium Medial. 2. 4. inferior and lateral roots of inferior extensor retinaculum Artery of tarsal tunnel . 5. 1. 6. 3.

ganglion cysts. entrapment of superficial peroneal nerve & exostosis associated with DJD .    Etiology First described by O¶Connor in 1949 He suggested that excessive post traumatic scarring of the superficial ligament floor was responsible for the symptoms Other causes ± hypertrophy of synovial membrane.

McCarthy 1985  This . Bartolomei. Etiology of sinus tarsi syndrome is thought to be associated with post traumatic complications following lateral ankle sprains is the case in 70% cases Bernstein.

 Other causes ± pes cavus. hypermobile pes planus and chronic STJ instability  Borrelli and Arenson (1987) described mechanism which may lead to sinus tarsi syndrome .

leading to increase in pronation into midstance to correct over supination  Ligaments . Due to increased laxity of interosseous and cervical ligaments there is increase in supination at heel strike respond to increased supination by initiating a feedback mechanism to fire the peroneal muscles.

 Due to decreased proprioceptor response of the ligaments. leading to decreased stability at propulsion . the mechanism is altered and peronii firing is diminished.

clinically represented by subtalar joint instability  Pain reproduced by forceful supination of forefoot .Clinical features  Pain over the lateral aspect of the foot. with increased tenderness over the sinus area  Rear foot instability.

 1. 2. 3. 4. and Borelli and Arenson. 1987. 4 clinical signs (Giorgini and Bernard . 1990. ) Pain over the lateral sinus tarsi opening which decreases with rest Perception of instability of the rear foot on uneven surfaces Complete relief if pain with injection on sinus tarsi Clinical and radiological studies are insignificant .

Diagnosis  Arthroscopic examination of the sinus tarsi and EMG of peronii show characteristic changes during gait  Injection of local anesthetic into the sinus tarsi is a common diagnostic tool used clinically .

 Direct palpation of sinus tarsi is not accurate .

Treatment  Relative  Ice  NSAID  Electrotherapeutic rest modalities  Subtalar joint mobilization  Proprioceptive and strength training  Biomechanical correction .

Antero lateral impingement  Cause ± ankle sprains involving anterolateral aspect of the ankle Inversion sprain promotes synovial thickening and exudation Meniscoid lesion develops in AL gutter Chondromalacia of lateral wall of the talus with an associated synovial reaction    .

 Pain at the anterior aspect of the lateral malleolus  An intermittent catching sensation in the ankle with a previous history of ankle sprain at antero inferior border of the fibula & AL surface of talus  Tenderness .

 Clinical assessment more reliable than MRI  Arthroscopic examination to confirm diagnosis  Corticosteroid injection and arthroscopic removal .

resulting in impingement of lateral process of the calcaneus on the PL corner of the talus ± lateral ankle pain of gradual  Symptoms onset  Worse by running and weight bearing .Stress fractures of talus  Develops secondary to excessive subtalar pronation and PF .

 Tenderness and swelling in the region of sinus tarsi  Isotopic bone scan and CT scan .

Anterior ankle pain .

Anterior impingement of ankle

Tibialis anterior tendinopathy 
Due

to overuse of ankle dorsiflexors secondary to restriction in joint range, occurring with stiff ankle swelling, stiffness in anterior ankle 

Pain, 

Aggravated

by activities like running, walking uphill or stairs

 Localizes

tenderness, swelling and occasionally crepitus along the tibialis anterior tendon 

Pain

on resisted DF and eccentric inversion and MRI may be used for diagnosis 

US

soft tissue mobilization and mobilization of the ankle of biomechanical problems with  Correction orthoses . Treatment ± eccentric strengthening .

Foot pain .

 Common causes ± plantar fasciitis and fat pad contusion  Lesser common ± calcaneal fractures. medial calcaneal nerve entrapment. lateral plantar nerve entrapment. tarsal tunnel syndrome. retro calcaneal bursitis .

Plantar fasciitis  Composed  Central of 3 segments . arising from plantar aspect of postero medial calcaneal tuberosity and inserts into toes to from the longitudinal arch . clinically most significant.

at its attachment to calcaneus  Due to collagen disarray in the absence of inflammatory cells . overuse condition of plantar fascia . Plantar fasciitis .

 Causes ± pes planus or pes cavus Results from activities requiring maximal PF and simultaneous DF of MTP Reduced DF increased risk factor Commonly associated with tightness in proximal myofascial structures    .

 Clinical features ± gradual onset  On medial aspect of heel  Worse in morning. decreases with activity  May last as ache post activity  Increase in pain as activity is recommenced  Progresses to pain with weight bearing  Other problems if associated biomechanical problems are present .

 Examination ± acute tenderness along the medial tuberosity of the calcaneus  May extend along the medial border of plantar fascia  Plantar fascia tightness may be present. stretching reproduces pain  Reduced supination increases strain on the fascia .

 US ± gold standard diagnostic investigation with swelling of plantar fascia the typical feature .

Treatment  Aviodance of aggravating activity  Cryotherapy after the activity  Strething of fascia. gastro-soleus gastro Taping ±  Extracorporeal Shock wave therapy  Strenghtening exercises  Footwear modification .

 Iontophoresis  Plantar fasciotomy .

Fat pad Contusion  Fat pad composed of elastic fibrous tissue septa acts as a shock absorber. protecting the calcaneus at heel strike  Cause ± may develop either acutely after a fall onto the heels or chronically as a result of excessive heel strike with poor heel cushioning or repetitive change in direction. sudden stops. starts .

 CF ± severe heel pain during weight bearing  Pain felt laterally in the heel due to pattern of heel strike  Tenderness in posterolateral heel  MRI reveals edematous changes in fat pad .

 Rest  Heel locking .

Calcaneal stress fractures .

Mid Foot pain .

ligaments and peroneus longus tendon  The .Cuboid Syndrome  Defined as a minor disruption or subluxation of the structural congruity of the calcaneo cuboid portion of the midtarsal joint disruption of cuboid¶s position irritates the surrounding joint capsule.

 Cuboid ± only bone in the foot that articulates with both tarsometatarsal and midtarsal joint  Only bone that links lateral column to the transverse plantar arch .

 Secured in the lateral column by calcaneocuboid . cuboideometatarsal and long plantar ligament more taut dorsomedially than plantar laterally rotates around a medially positioned  Ligaments  Joint axis . cuboidonavicular .

 Shape and position of cuboid is also influenced by the peroneus longus muscle tendon cuboid articulations provide accessory glide along with internal and external rotation  The .

DF + abduction with eversion  The  2nd . PF + adduction along with inversion movement pattern. The passive physiological motion of the lateral column consists of two patterns of movement 1st combined movement .

 Mid tarsal joint motion occurs around 2 axes which are dependent upon the position of subtalar joint midtarsal joint is fully pronated it is in locked position  When  When subtalar joint is pronated. forefoot is inverted and midtarsal joint is unlocked enabling the foot to adapt to uneven surfaces .

 With every degree of subtalar pronation there is exponential increase in the midtarsal joint instability .

improperly constructed orthoses. Etiology ± 2 mechanisms . PF n inversion ankle sprains and overuse syndrome factors ± uneven running terrain. inversion ankle injuries and pronated foot structures  Other .

 degree and direction of the force of the peroneus longus and the position of the subtalar joint act as a contributing factor a supinating subtalar joint during propulsion it acts as a dynamic stabilizer of the forefoot  In .

pronated cuboid as the rearfoot resupinates into propulsion . Pronated foot is naturally unstable . increasing the mechanical advantage of the peroneus longus  Mechanical advantage of peroneus longus is theoretically able to sublux the unstable.

 Pronated foot + plantar flexed lateral column may irritate the soft tissues due to excessive pressure on the lateral column congruency in the calcaneocuboid joint sprains of ankle  In  Inversion .

 Clinical presentation or rapid onset of pain directly over the cuboid  Gradual  Located  May radiate into plantar medial arch or distally along the 4th metatarsal .

 Pain during weight bearing or even non weight bearing during the propulsive phase may show inflammatory signs  Weakness  Examination .

 Sulcus if subluxation is severe forefoot valgus  Occasionally  Pain and point tenderness directly over the cuboid  Tenderness over EDB tendon at anterolateral surface of sinus tarsi and in the region of peroneal groove .

 Decreased  Pain ROM during passive inversion and active and resisted PF and eversion inversion resulting in pain along the peroneus longus ± diagnostic Subtonick. 1989  Resisted .

CT. Midtarsal  Midtarsal  Gait adduction test supination test evaluation and functional testing to make on X rays. MRI  Difficult .

 Differential diagnosis ± Jones fracture. fracture of anterior calcaneal process. lateral plantar nerve entrapment. sinus tarsi syndrome. Lisfranc¶s injuries etc . peroneal and EB tendonitis. tarsal coalition.

low dye arch taping. Treatment  Responds exceptionally well to conservative treatment method ± cuboid manipulation  Primary  Therapeutic modalities. exercise and taping .

 Manipulation ± cuboid whip or cuboid squeeze  Ice following manipulation  Low intensity pulsed US . increased to continuous US later .

 Stretching a tight peroneus longus and triceps surae . strengthening the intrinsic and extrinsic muscles of foot and proprioception training  Low dye taping can be used with or without cuboid padding to maintain cuboid position following manipulation .

.

Fore foot pain .

Turf toe  1st MTP joint sprain  Caused by jamming or hyperextension of the hallux at the MTP joint  Defined as an acute sprain of the plantar capsule and ligaments of the MTP joint of the great toe  Related to artficial turf. lightweight shoes. activities that require hyperextension of the toe .

Restricted ROM 3. Passive extension painful . Tender. More than 100 deg extension from neutarl position Signs and symptoms 1. swollen joint (plantar aspect) 2.

sesamoids. inflammation of sesamoids. FHL. FHB tendinitis and gout . DD ± fracture of the toe .

Modify footwear 5. Taping 4.Treatment 1. Reduce inflammation and edema 3. Mobilization of the MTP joint . Rest 2.

Hallux rigidus  Degenerative  Limited  Pain  Altered arthrosis of the 1st MTP joint ROM gait  Toe fixed in PF at times  Weight bearing on the lateral side .

5. 3. 4. 6. Etiology Osteochondritis dissecans of the 1st metatarsal head Trauma . 2. 1. single or overuse Primary OA Prominent long 1st metatarsal Abnormal gait Hypermobility of the 1st metatarsal segment .

footwear  Correct biomechanics  Mobilization . Treatment  Non operative ± US  Modify activities.

 Surgery ± debridement  Osteotomy  Arthroplasty  Arthrodesis .

Metatarsalgia  General term referring to pain in the metatarsals and MTP joints .

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