Medial Ankle and Heel Pain Excluding plantar fascia Dr Jimmy McLaren

Introduction Anatomy & DDx Hx and Exam Insidious Medial Ankle

Medial Ankle Anatomy Bones – MM, talus, calcaneus, navicular Ligaments Deltoid ligament Calcaneonavicular (Spring) ligament  Plantar Fascia, Fat Pad Tendons Tib post FDL FHL Tibial Nerve Branches Medial Calcaneal N Posterior Tibial N - Medial Plantar N - Lateral Plantar N

Chronic Medial Ankle/Rearfoot DDx Tendons - Tib Post Tendinopathy (common) - FHL Tendinopathy Nerves - Medial Calcaneal Nerve entrapment - Tarsal Tunnel Syndrome Bones - Stress # - Navicular - Calcaneus - Medial Malleolus Plantar Fascia, Fat pad contusion Posterior Impingement Syndrome Referred pain – Lumbar CRPS Type 1

History Previous injury Overuse (eg tib post) Sport: FHL tendinopathy - ballet, high jump Posterior impingement - dance, football Radiation - to navicular (tib post), - to arch (tibial tunnel syndrome) Parasthesia - tarsal tunnel syndrome

Examination Biomechanical exam, KTW Functional - jump, hop Lumbar Screen Active - Ankle PF/DF, Inv/Eversion, 1st MTP flex Passive - Subtalar, midtarasal, Resisted - inversion(TP), 1st toe flexion (FHL) Palpation - Ankle, Midtarsal joint, - Tib Post, FHL, - MM, Navicular, Calcaneal compression Tinnel’s - compresses tibial nerve Sensation - pin prick

TENDINOPATHIES Tib post: Insertion- navicular, cuboid, cuneiforms, 2-4MT, spring ligament FDL FHL: Most posterior when deep to felxor retiinaculum, b/w lat+med tubercles of talus, b/w sesamoid, insert base distal phalynx

Tibialis Posterior Tendinopathy Path - posterior to MM Insert - navicular, cuboid, - cuneiforms, 2-4MT, spring ligament Fxn - dynamic stabilizer medial long arch - invert STJ Causes: Overuse - Walk/run/jumping Mechanics - Excessive ST pronation (ecc load) Acute - ankle eversion sprain/#, avulsion Inflam - rheumatoid, seronegative arthopathy

OE Single heel raise pain/lack of inversion Tender posterior+inferior to MM, towards navicular Resisted inversion painful Swelling unusual – extensive/seroneg arthopathy Grades II - pes planus, III - rigid valgus hindfoot STJ OA, IV - deltoid ligament compromise

Ice, eccentric exercises, orthotic, +/- NSAID if inflammatory Investigations Treatment Ice, eccentric exercises, orthotic, +/- NSAID if inflammatory +/- synovectomy +/- reconstruction XR – pes planus, MRI - Axial view, right ankle T2 fat suppressed. Oedema around Tib post, reactive boney oedema

FHL Tendinopathy Anatomy most posterior, - b/w lat+med tubercles of talus - b/w sesamoid, insert base distal phalynx Fxn - big toe flexion, ankle plantarflexion Cause - Overuse - ballet/dance - “Toe grip” shoes to big - Tenosynovitis Association with Posterior Impingement - Large/displaced posterior process talus - Os trigonum Origin – distal 2/3 fibula and IO membrane Association – Posterior Impingement. FHL tendon lies in firbosseous tunnel b/w medial and lateral tubrercles pof the posterior process of the talus.

FHL Tendinopathy Hx Pain behind MM, on toe-off or forefoot WB OE Pain resisted flexion, passive hallux extension ‘Triggering’ Excess inversion/eversion on toe off Posterior impingement Shoes size Inv +/-XR, MRI – assess associations Painful audible crepitation due to thickened/scarred tendon catching on fibroosseous tunnel

MRI - Axial view, right ankle T2 fat suppressed MRI - Axial view, right ankle T2 fat suppressed. FHL with synovitis, behind the talus XR – indirectly looking for posterior impingement association

FHL Tendinopathy Rx Ice Activity Mod – avoid en pointe, hard floors Tape/orthoses – correct excess pronation Well fitted shoes Mobilise - if STJ hypomobile FHL strength/stretching, STW proximally

NERVES Deep peroneal N

Tibial Nerve Branches Branches 1) Medial Calcaneal N - Pierce flexor reitinaculum Divides deep to flexor retinaculum Terminal braches divide under flexor retinaculum 2) Medial Plantar 3)Lateral Plantar N

Tibial Nerve Branches 1) Medial Calcaneal N Pierce flexor retinaculum Supply medial heel Terminal Branches divides deep to flexor retinaculum 2) Medial Plantar N 3)Lateral Plantar N

Tibial Tarsal Syndrome Tibial Nerve Compression Identify Underlying Cause: Idiopathic 50% Intrinsic Extrinsic Tendonopathy/tenosynovitis Varicose Veins Ganglion Osteophytes lipoma/tumor Anatomic - tarsal coalition - valgus hindfoot Shoes Trauma:inversion/#/post-op Systemic inflammation Oedema

Poorly defined burning/tingling/numbness plantar foot Hx Poorly defined burning/tingling/numbness plantar foot Agg by activity, relieved by rest But some worse in bed, relieved by moving foot OE Valgus hindfoot, pes planus, excess pronation Thickenings/VV/ganglion/swelling Tinnel’s sign – reproduce pain, +/- fasciculation Compression test (PF, invert, and press) Pain on passive eversion +/-parasthesia +/- intrinsic muscle wasting

Investigations Clinical Diagnosis NCS false negative 50% inability to predict which respond to surgical decompression XR - tarsal coalition MRI/USS – mass /accessory muscle

Treatment Nonoperative Correct pronation: orthosis/taping/foot wear Neural glide NSAID/Iontophoresis / CSI Surgical Decompression failed conservative treatment & +ve NCS best results when compressing structure identified (cf traction neuritis poor response)

Medial Calcaneal Nerve Entrapment Aka Baxter’s Nerve Branch of tibial nerve at MM (or lateral platar N) pierce flexor retinaculum medial heel sensation Presentation Burning inferomedial calcaneous Tinnel’s +ve Valgus hindfoot, excessive pronation

Medial Calcaneal Nerve Entrapment Investigations Diagnostic LA NCS – often false negative Treatment Change footwear, pad LA/CSI Decompression of nerve

STRESS FRACTURES General Features Agg with activity Absent / persists at a lower level at rest If training continues, brought on with less intensity History Previous injury Training load Female triad/REDS: Eating disorder, menstruation PMH – thyroid, Meds – glucocoticoids

OE Tenderness, +/-redness +/- swelling +/- palpable periosteal thickening Percussion of long bones -> pain at distant points Biomechanics: LLD, excessive pronation, weakness, stiffness Investigations XR +/- linear sclerosis MRI T2 hyperintensity Bone Scan – 100% sensitivity, but not specific CT – cortical bone defects

Medial Malleolus Stress Facture vertical from jxn of tibial plafond and MM (may arch obliquely from distal tibial metaphysis)  Coronal view, T2 imaging, Increased signal, Peri-osteal reaction,

MM Stress Fracture Treatment No fracture line NWB until tenderness resolves, RTS 6/52 +/- air brace Fracture / cortical defect Screw (Shelbourne et al) (Lempainen) Biomechanics, orthosis, footwear

Navicular Stress # #1 tarsal stress fracture Navicular impingement reduced ankle DF Middle 1/3 navicular (relatively avascular) Clinical Usually midfoot pain “N spot” tenderness – dorsal prox navicular Stress # until proven otherwise

Navicular Stress # Treatment Stable # - NWB cast, 6-8 weeks T1 weighted axial MRI and CT (axial image and coronal) CT – poor positioning can miss them. Get thin 2mm slices from distal talus to distal navicular Treatment Stable # - NWB cast, 6-8 weeks Unstable/distracted # - Screw

Calcaneal Stress # 2nd most common tarsal stressy Hx Military, runners, jumpers, dancers Technique – overstriding, heavy landing Poor cushioning OE Localised tenderness med or lateral posterior calcaneous Pain on calcaneal compression

Upper posterior margin / medial tuberosity Treatment activity / short period NWB Soft heel pad, orthotic, shoes Technique – overstriding, heavy landing XR - sclerosis

SUMMARY Plantar Fascia, Fat Pad Ligaments Tendons Bones Nerves Referred

Medial Ankle Ligaments Focus on Deltoid ligament Superficial Ligament – 4 parts as above(start from bottom up), cross both ankle and subtalar joint Deep Ligament – cross only ankle joint, MM to talus

Deltoid Ligament Superficial Layer Crosses both ankle and subtalar joints Fans - Anterior tibiotalar (neck of talus) - Tibionavicular - Tibiocalcaneal (sustenaculum tali) - Posterior tibiotalar Deep layer Crosses only ankle joint Inferior & posterior MM - medial+posteromedial talus prevents lateral displacement & ER of talus  Skip

Deltoid Ligament O/E Eversion test - with ankle neutral, evaluates superficial layer ER stress - evaluates syndesmosis and deep layer XR – stress view with medial clear space widening Associated clinical conditions Medial malleolus fracture Maisonneuve fracture Variant of syndesmosis sprain Ruptured medial ligament, AITFL + IO membrane, proximal fibula fracture

Calcaneonavicular (Spring) Ligament sustentaculum tali to  navicular  stabilize medial longitudinal arch & talar head OE - flattened medial longitudinal arch Clinical conditions Assoc with tibialis posterior tendon dysfunction Acute spring ligament tear forceful landing on flat foot