Update on the management of common foot and ankle conditions

1. Foot and Ankle Session
Cameron Bulluss, Rob Dingle, Peter Enks, Pierre
Buchholz, Gavin Jackson – Advanced Physiotherapy
and Injury Prevention
www.advancedphysio.com.au

2. 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

3. Imaging

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

5. Ottawa Ankle and Foot Rules

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

7. 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

8. Grades of Injury – Muscle/Ligament
Ligament
 Grade 1 Pathology = microscopic tearing (strain)
Clinical = Tenderness but no ligament laxity
MRI = normal ligament thickness but increased periligamentous
signal
 Grade 2 Pathology = partial tear
Clinical = some ligamentous laxity but firm end-point
MRI = ligament thickening +- partial discontinuity, increased signal
 Grade 3 Pathology = complete tear
Clinical = increased ligament laxity and no indentifiable end point
MRI = complete ligament discontinuity + oedema and
haemorrhage

9. Anatomy of the Foot and Ankle
Bones and Articulations
Inferior tibiofibular joint
Talocrural joint
Subtalar joint
Transverse tarsal (Choparts)
Intertarsal joints
Tarsometatarsal joint (Lisfranc)

10. Anatomy of the Foot and Ankle

11. Anatomy of the Foot and Ankle
Ligaments

12. Anatomy of the Foot and Ankle
Ligaments

13. 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

14. Case Study 1
 Probable diagnosis?
 Clinical tests to confirm
diagnosis?
 Further imaging required?

15. Case Study No 1
 Lateral ligament sprain

16. 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

17. 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

18. Conservative vs Surgical For Grade 3
Lateral Ligament Tears
 Rehab 87% excellent or good outcomes
 Surgery 60% excellent or good outcomes (Kaikkonen 1996)

19. 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

20. Complications Following Major Lateral
Ligament Tear
Location of osteochondral Study of 30 patients with
lesions 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.

21. ANKLE TAPING DEMONSTRATION
 Also show walking boot, dorsiwedge splint
 Discuss management high versus low grade injuries

22. Case Study 2
 Soccer Player twisted ankle  Possible diagnosis?
(external rotation).  Clinical tests to confirm
Presented unable to diagnosis?
weightbear with swelling  Further imaging required?
anterior ankle joint. ED
series x-rays – patient told
no fracture. Reports no
swelling lateral ankle but
swelling anteriorally

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

24. 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

25. MRI Syndesmotic Ligaments

26. Inferior Tibiofibular Diastasis (should not exceed 5.5mm
also look for jt space medial malleolus

27. 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

28. Case Study 3
 51 year old female presents  Probable diagnosis?
with heel pain that she has  Clinical tests to confirm
had for several months. It is diagnosis?
worse in the morning,  Further imaging required?
particularly with her first
step.

29. Case Study 3 - Plantar Fasciitis
 Management options
 Most common foot
problem  Plantar fascia stretches
 Heel cord stretches
 Biomechanics
 Night splint
 Pathology
 Orthotics
 ?Heel spur (FDB)  Tape
 Time frame to recover
 ?referral on
 Imaging?
 Clinical tests

30. 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?

31. Case Study 4
Acquired Pes Planus

32. 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

33. Rupture or Severe attenuation of Tibialis
Posterior

34. Acquired Adult Flat foot
 Referral on?
 Clinical tests
 Management
 Likely time frame to recover?
 Likelyhood of poor outcome?

35. Case Study 5
 39 year old woman  Probable diagnosis?
presents with pain over the  Clinical tests to confirm
mid achilles tendon diagnosis?
following commencing  Further imaging required?
boot camp training.
 Referral on?
Impossible to run
comfortably now, but is  Likely time frame to
able to walk except up hills recover?
 Likelyhood of poor
outcome?

36. Case Study 5 Achilles Tendinopathy
 Apart from disorders of the tendon sheath there are no
inflammatory changes in most tendon pathologies (excluding
tendon sheath)
 Alfredson’s accidental discovery

37. 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

38. Tendon Facts
 Most tendon pathologies we see in the non-athletic
population are degenerative tendinopathies
 Most athletic tendinopathies are insertional

39. 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

40. Tendon Facts
 Degenerative tendon pathology is reversible
sometimes (Alfredson, Cook 2005,Silbernagle 2008)

41. 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)

42. 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

43. 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
don’t 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,

44. Case Study 6
 15 year old boy, falls out of a  Probable diagnosis?
roof at work and lands on  Clinical tests to confirm
foot. Fracture to distal tibia diagnosis?
and fibula treated by cast  Further imaging required?
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 .

45. Lisfranc Injury
 Although not common early management is crucial to long
term outcome
 Referral on?
 Likely time frame to recover?
 Likelyhood of poor outcome?

47. 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)

48. 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

49. Metatarsal Fracture and Instability
Secondary to Lisfranc ligament tear

50. 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.

51. Diagnositic Algorithm for Forefoot Pain

52. 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

53. Gaitscan

54. Gaitscan
 Indications for orthotics