The foot and ankle

Anatomy- bones

Anatomy- ligaments

Anatomy- tendons

Anatomy- syndesmosis & capsule

The Ankle joint Hinge joint Locomotion Proprioception Movements at this joint include Dorsiflexion Plantarflexion Eversion Inversion Supination is a combination of plantarflexion, inversion and forefoot adduction Pronation is a combination of dorsiflexion, eversion and forefoot abduction

Movements of the ankle

Pronated, supinated or neutral

Patient walks in c/o ankle pain What is the mechanism of injury? What position was the foot in at time of injury? Most common is the inversion injury: Plantar flexed Inverted Adducted This can injure ATFL Anterolateral capsule Distal tibiofibular ligament Can cause a malleolar/ talar dome fracture/ medial ankle pain through compression

Patient walks in c/o Ankle pain Was there any deformity after injury? Transitory locking indicating a loose body? Able to continue? Usually a grade 1 ankle sprain can continue with running (painfully) A grade 2 ankle sprain can walk (painfully) A grade 3 ankle sprain cannot weightbear Staging the injury is important... Acute, subacute or chronic. Is this acute on chronic? Does pain increase or decrease with activity? What does the patient do for work and leisure and are there any contributing factors?

Patient walks in c/o Ankle pain Gait: have they walked/ limped in? Check for: Swelling- usually quick onset Bruising- can be delayed Numbness Pins and Needles Weakness: could this actually be an L4 nerve root compression?

Ottawa Ankle rules Patient requires an ankle X-ray if: Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus An inability to bear weight both immediately and in the rooms for four steps

Ottawa foot rules The patient requires a foot x- ray if: Bone tenderness at the base of the fifth metatarsal Bone tenderness at the navicular bone An inability to bear weight both immediately and in the rooms for four steps

Assessment Assess in standing, ability to load through joint, foot position. Always comparing side- side In lying check range of movement relative to uninjured side. Palpate the painful area and surrounding soft tissue and joints

Ligament tests ATFL- Anterior drawer test at 20° plantarflexion Calcaneofibular ligament- talar tilt at 90° into adduction Deltoid ligament- talar tilt at 90° into abduction Squeeze test- syndesmosis injury Thompson’s Test- Achilles

Other injuries to note Fractured calcaneum (a ‘Lovers’ or ‘Don Juan’ fracture!)- fall from height or occasionally with an inversion injury. Fractured sub-talar surface can occur also. Check out ‘Sanders’ classification system. Sub-talar joint dislocation... Urgent relocation required Lis-Franc fracture-dislocation. Direct: crush injury Indirect: requires a longitudinal force sustained while the foot is plantarflexed. A backward fall with the foot entrapped, and a fall on the point of the toes is also a common mechanism. Persistent midfoot pain for >5 days should raise suspicion Tenderness of the midfoot on palpation and pain on eversion+abduction of forefoot while calcaneus is still

More injuries to note Navicular fracture: can be an avulsion, a fracture of the body, or a stress fracture. Point tender over the ‘N’ spot. Pain with passive eversion and active inversion Very difficult to see on plain films Cuboid syndrome- subluxation of the cuboid... Needs manipulation. Patient can’t walk barefoot. Stress fractures: any bone, any age. Caused by a spike in training or loading. Severe’s disease: growth plate enthesopathy

More still Hallux valgus: pain can be unbearable, need to see a podiatrist. Morton’s neuroma: pain in toes with pins & needles and numbness... Need to see a podiatrist/ physio/ foot surgeon.

Plantar fasciitis Patient complains of heel pain and/or pain through the arch Often chronic, and is not inflammatory so is actually a fasciosis/ fasciopathy Not able to rise up on the balls of the feet from flat foot Risk factors include: Running and dancing Very high arches or very flat feet Poor shoe choices Obesity Poor dorsiflexion range Tight posterior fascial lines Patient MUST be referred for quality physiotherapy- at least one session to teach how to self massage, stretches, foot strengthening exercises, taping, shoe education.

Advice for a ‘mild’ sprained ankle Get rid of the swelling Avoid running until pain-free hopping on one foot is possible Walking (pain-free), cycling, cross-training and stepping can be done to keep active, must ice afterwards Ankle braces should not be worn, not supportive enough to prevent damage and offer ‘false’ sense of security, while creating a biomechanical alteration Proprioception exercises should be done prior to return to sport Theraband strengthening exercises are a good idea to prevent future injuries.

Advice for ‘plantar fasciitis’ Ice the area, sometimes using a frozen plastic bottle of water is useful to roll the foot (roll away from the toes towards the heel) Don’t walk around barefoot, supportive shoes with good arch support can help relieve pain. Avoid flat shoes like flip flops... ‘fitflops’ offer a good alternative. Stretching the soleus can help: stretch against a doorframe. Strengthening the foot through exercises with a towel on the floor and theraband for the ankle. Lose weight Avoid exercising on hard surfaces