Foot & Ankle Pathologies

Ibrahim Altubasi, PT, PhD

University of Jordan
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
 STT
 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)
 STT:
 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, ESrest 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.
Anterior Compartment Syndrome
 Excessive
compartmental
pressure.
 May result in
neurovascular
compression.
 Anterior tibial artery,
deep peroneal nerve
Anterior Compartment Syndrome
 Mechanisms of Pathology
 Blunt trauma to anterior compartment
resulting in a large hematoma
 Fracture of the tibia
 Exercise induced edema
 Anterior Compartment Syndrome
 Signs and Symptoms
 Intense pain in anterior compartment region.
Hard and tender to palpation. Skin may be cooler
than normal over area due to poor circulation.
 edema and discoloration due to poor circulation
 Pain on passive plantar flexion
 Decreased sensation in web space between 1st
and 2nd toes
 Weak or absent dorsalis pedis pulse
 Weakness of muscles in anterior compartment
 Foot drop during gait if severe enough neurologic
involvement.
 Anterior Compartment Syndrome
 Treatment
 Rest, elevation, no
compressive garments
 Gentle massage to restore
circulation and remove
excess edema
 Fasciotomy in severe cases
of compression and
neurologic involvement
(Determined clinically by
insertion of Wick catheter:
>30 mm Hg pressure usually
indicative of immediate
fasciotomy. Normal pressure
is 8 mm Hg.)
Tarsal Tunnel Syndrome
 Entrapment
neuropathy of the
posterior tibial nerve
as it passes through
the tarsel tunnel.
Tarsal Tunnel Syndrome
 Mechanisms of Pathology
 Edema or space occupying lesion in the tarsal
tunnel.
 Tendonitis of muscles in tarsal tunnel
 fracture callous
 gout crystals
 deep varicose veins
 Tumors
 Aggravated by excessive pronation, as medial
tibial rotation and calcaneal eversion tighten the
flexor retinaculum
Tarsal Tunnel Syndrome
 Signs and Symptoms:
 Patient will complain of shooting, burning,
pain along plantar aspect of foot and heel
(distal distribution of tibial nerve)
 May complain of parasthesias and/or
impaired sensation on plantar aspect of
foot.
 Symptoms increase with activity and
decrease with rest.
 May have positive Tinel’s sign over tarsal
tunnel.
Tarsal Tunnel Syndrome
 Treatment:
 Treat inflammation if
tendonitis thought to
be a contributing factor
 Orthotic
considerations if
patient over-pronates.
 Possible surgical
release of flexor
retinaculum.
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
(BAPS, 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
Sinus Tarsi Syndrome
 Usually a secondary
complication of chronic
inversion sprain in patients who
also hyperpronate.
 Chronic pain and inflammation
of lateral aspect of sub-talar
joint (sinus tarsi).
 Lateral ligaments heal but
continue to have symptoms in
this region.
 STJ ligaments are lax
 With hyperpronation, talus
displaces into sinus tarsi region
resulting in irritation.
Sinus Tarsi Syndrome
 Signs and Symptoms:
 Point tenderness just anterior and inferior
to lateral malleolus.
 Patient is an over pronator
 Pain on ambulation which subsides with
rest.
 Treatment:
 Treat overpronation with low-dye taping
and/or orthotics.
 Steroid injections
 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 Tests

Presssure
above malleoli
results in
distraction of
distal. Tib-fib
joint

External Rotation Test T-F Compression Test

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 on weight bearing activities
 Parasthesias or impaired sensation in affected area.
Treatment:
 Wider shoes
 metatarsal pad to elevated transverse arch and separate
metatarsals
 Steroid injection
 Surgical Excision
“Turf Toe”
 Sprain of 1st MTP
 Hyperextension
combined with
compression
 Common in Football,
Soccer, Basketball
 Affect plantar capsule
and ligaments
“Turf Toe”: Grades of Severity
 Grade I: overstretch, some localized
tenderness, no significant swelling or loss
of motion. May continue to function at
normal levels
 Grade II: partial tear, moderate pain,
swelling, and echymosis. Some limping,
reduced motion. Unable to perform at
normal levels
 Grade III: Complete tear of capsule off the
met head. Severe pain, swelling,
echymosis, loss of motion. Unable to WB
on medial aspect of foot
“Turf Toe”: Long-term Problems
 Loss of 1st MTP motion (Hallux limitus)
 Hallux rigidus and OA
 Impaired push-off
 50% have symptoms 5 years later
“Turf Toe”: Treatment
 RICE
 Early Joint Mobility
 ↑ rigidity of shoe with
steel plate
 Taping or bracing on
return to play
 Should achieve 90
degrees of DF without
pain to return to
activity