9/22/15

The Role of the Foot / Ankle Foot and Ankle Complex

in the To provide a Primary Care Setting stable, weight bearing platform for “Feets don’t fail me now” smooth weight transfer during single limb John S. Early, M.D. Texas Orthopaedic Associates, L.L.P. stance Dallas, Texas

Foot function in the Role of Anatomy of Foot Ankle Ambulation Complex Static component – Bones and Ligaments 28 Bones

Dynamic component – Muscles 30 articular surfaces

7 major motor units

Functional Issues Anatomy: Ligamentous

Plantar Static Control Dorsolateral – Bones and Ligaments – Mechanical integrity for motor function – Static foot structure not dependent on motor function

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Stability: Foot and Ankle Stability Modelling

Tripod balance of “3-legged” stool talus • Stability of stool depends on leg position

Smooth contours

Motor control of major functioning joints Talus

Foot Function Hindfoot Motion

Depends on: – Stable structure – Shock absorption – Adaptability to surface contours Determination of Foot function – Hindfoot – Midfoot – Forefoot

Hindfoot Mechanics Hindfoot Motion

Ankle joint controls stride length

Pivot point for lever arm of foot

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Hindfoot Mechanics Midfoot Mechanics Calcaneal position: Controls gross forefoot alignment Rigid link – Minimal joint motion within section Shock absorption – Dissipates forces – Strong ligaments No bony ground contact – Distributes load

Varus hindfoot restricts chopart motion Valgus hindfoot increases chopart motion

Columnar Approach Forefoot Mechanics - Normal foot position depends on equal 6 weight bearing bones column lengths Varied mobility at Tarsometatarsal joints – Minimal motion at 2 and 3 – 1st ~ 2x greater than middle two Lateral Column Medial column – 4th & 5th ~3x greater than 1st Varus hindfoot: Valgus hindfoot: Lateral column long Medial column long

Central Column

Role of Joint Motion Foot “Types” Create a level platform for gait Weight bearing shape – Subtalar complex Allows foot to conform to ground No relation to Minimize energy expenditures pathology – Ankle Allows transfer of weight to forefoot No pain…. No problem Advances point of contact from heel to toes Without ankle greater vertical rise of pelvis and shorter stride

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Functional Issues Gait and the Foot Dynamic Control “Normal Gait” – Dependant on motor function – Minimize energy use – Minimize discomfort – Stability and mobility of joints Important points – Motor function Eccentric in stance – 10° ankle dorsiflexion for gait – Allow smooth progression of body weight to next – Use of ligamentous support foot allows muscle rest The less vertical displacement of body mass the better

Motor Balance Ankle dorsiflexors 7 motor units – Posttib muscles plantarflex Eccentric – Pretibial muscles dorsiflex work

Dynamic stability dependent on Concentric antagonist pairs during swing

Strength disparity balanced by mechanical lever arm

Ankle Plantarflexors Foot Function: Simple Truths

Eccentric work The muscles are designed to dissipate the load away from the ligaments that hold the bones together

The ligaments and bones have a resting stability that is supposed to allow the muscles to rest occasionally Failure of one will lead to dysfunction of the other

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Classifying Foot Pain for Medical Urgency My Foot Hurts and I Can’t do “I can’t put weight on it” : Unstable injury “It hurts to stand” : stable injury hindfoot Anything “It hurts to walk” : stable injury midfoot forefoot Everything is a 10 when your “It Hurts when I exercise” : chronic instabilty foot hurts “It hurts when run marathons or compete”

Clinical Evaluation Motor Testing

Observe weight bearing function and Observe gait for symmetry / upper body position sway Test motor strength with patient’s body weight Single limb stance: balance coordination Carefully palpate the foot for pain location Toe walk: extensor muscle function Move joints to assess pain and stability Heel walk: flexor muscle function

Examine the Foot Examine the foot

Let foot hang to gravity Examine the “good foot” first – Best way to see deformity or assymetry – See what “normal” is; relax patient – Gravity will allow muscles to relax Observe deformity: – Gravity will many times help reduce fractures – Supple or stiff? Does it change with weightbearing or dislocations Observe skin

Palpate all anatomical structures – Bones and tendons

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Corns and Callous Corns and Callous

Marker of high Treatment pressure – Debride thick Reaction of skin between bone and tissue shoe Daily pumice stone Callous: broad tissue change Daily skin softener Corn: deep, localized – Alter plantar Analogous to splinter pressure

Neuroma Neuroma Treatment

Damaged nerve Shoewear – Between metatarsal heads In shoe orthotics – Burning, stinging pain Steroid injection – Distinct area of pain Transverse ligament release

Neuroma excision

Neuroma vs Metatarsalgia Metatarsalgia Burning pain Achy pain Pain in shoes Pain barefoot Local pressure overload Between metatarsals Metatarsal head No toe instability Toe instability Uneven metatarsal heads

Tight heel cord

Toe deformities

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Lesser toe Deformities Metatarsalgia PIP flexion MTP subluxation Supple MTP joint PIP and DIP flexion Plantar plate instability Progressive deformity Raised toe Instability test

• Requires operative care

Combinations Metatarsalgia Treatment Crossover toes Hammer / mallet Heel cord stretch

In shoe orthotics

Cushioned shoes

Correction of toe deformities

Hallux Valgus 1st toe anatomy

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Hallux Rigidus Forefoot Treatment

Motor / soft tissue driven deformities

Nonoperative: Extra depth wide toed shoes

Operative: – Bony realignment – Soft tissue realignment

HEEL PAIN PLANTAR FASCIITIS

Plantar Fasciitis: 90% Bow string of foot arch – Supports arch shape Nerve Entrapment: 2% Pain in am and after rest Soft Tissue Contusion: 8% Worse with flat heels Tight Gastrocnemius No relation to radiographic spur

Plantar Fasciitis Gastrocnemius Tightness Gastrocnemius Found with knee Origin 95% improve with non operative treatment extension Resolution can take 12 months – Loss of dorsiflexion Soleus Treatment consists of: Origin – Heel lift / cushion Root of all evil in the foot – gastrocnemius stretching – Forefoot pain Metatarsalgia – NSAIDS Achilles – Midfoot pain Insertion – Reassurance Posterior tibial dysfunction – Ice massage – Hindfoot pain Plantar fasciitis

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Gastrocnemius Tightness Patient Evaluation Foot mobility – Subtalar mobility Technique – Achilles contracture – Internal rotation of foot gastrocnemius – No pain in heel gastrosoleus – Knee extended – Hold for 30 seconds – 5 or more times daily

Toe Fractures Toe Fractures The exceptions

Usually isolated Usually stable Pain with weight Treatment – Correct deformity – Buddy tape – Hard sole shoe Up to 3 months recovery

Metatarsal Fracture Metatarsal Fractures Treatment Acute Trauma – Hard sole shoe Repetitive Trauma – Analgesics Dorsal pain with – Weightbearing as tolerated weight Point tender 8 -12 weeks recovery Initial Radiograph Achilles stretch if stress induced may be normal

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Stress Fractures Metatarsal Fractures Operative Care First Metatarsal Multiple Metatarsals If tender on bone, treat As fracture till pain gone

7 days 4 weeks

Achilles Tendon Rupture Achilles Tendon Rupture

Sudden movement Asymmetric function Usually a pop felt Gravity check Unable to walk Thompson test normally – Foot over table – short step – Squeeze calf – knee behind ankle – No movement foot No single heel lift – Achilles compromised

Achilles Tendon Treatment

Immobilize immediately – Keep tendon from retracting further

Functional tx: nonoperative

Operative tx: sew ends back together

Successful treatment depends on tendon growing together – LONG RECOVERY

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“ANKLE SPRAINS” “ANKLE SPRAIN”

Ankle ligament stretch – Lateral Anterior talofibular ligament Calcaneal fibular ligament Syndesmosis ligament; High ankle – Medial Deltoid Spring ligament

“ANKLE SPRAIN” “ANKLE SPRAIN”

Fracture Tendon Injury: tear or – Lateral Malleolus subluxation – Medial Malleolus – Medial side – Talus Tibialis Posterior Osteochondral lesion – Lateral side Lateral process Peroneus Brevis Os Trigonum Peroneus Longus – Calcaneus: anterior process

“ANKLE SPRAIN”

Anterior Lateral Pain – Not on bone; in front Get an xray – Lateral and mortise view ankle – AP view of foot

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Clinical Evaluation of High Ankle Sprain Syndesmotic Injury On field evaluation A) Squeeze test – Location of pain Malleolar tip / syndesmosis B) External stress tests – Anterior drawer ? – (shown) Keep knee flexed to 90 degrees – Standing version - – External rotation pain single limb stance with Ankle in neutral external rotation of body causes pain at syndesmosis

Clinical Evaluation Ankle Sprain: Treatment Weight bearing stress In General R - Rest I - Ice I - Immobilize C - Compress E - Elevate

Ankle Sprain: Treatment Surgical Candidates

Can walk on ankle without instability Bony instability at exam – Lace up brace and balance therapy Chronic joint laxity Can Not bear weight Failed Rehab – Cast in dorsiflexion 7-10 days – Allow weight bearing as comfort allows Be sure no other pathology – Begin bracing and therapy when able to walk

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Joint Sprains: foot Anatomy: Ligamentous

From stretch to complete dislocation Lisfranc ligament – Thickest of ligaments in midfoot – Restore anatomical alignment – Lateral plantar base of medial cuneiform – Immobilize non weight bearing till pain gone and able to bear weight (6 weeks) – Plantar base of 2nd metatarsal – Rotates on its long axis – Balance therapy clockwise plantar from cuneiform to lateral base metatarsal

Anatomy: Function Lisfranc: Mechanism of Injury

Shock absorption mechanism for weight Direct loading bearing – Load parallel to joint joint motion at joints vary surfaces – Significant soft tissue – 2nd tarsometatarsal stiffest disruption – 1st and 3rd similar Indirect loading – 4th and 5th with 3 times the motion of – Axial load along medial joints metatarsals – Variable bony fracture involved

Lisfranc: Diagnosis Lisfranc: Stress test

No Stress Stress View Tender, swollen midfoot

Pain with weight bearing

Plantar ecchymosis

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Tendons about the ankle Posterior Tibial Insufficiency

Asymmetry in weight bearing foot position Treatment Unable to single heel rise – Acute Injury / laceration Medial pain and swelling progressing to lateral Operative repair pain – Chronic degeneration Bracing for stability Surgical reconstruction – May require bony realignment if deformity present

Tibialis Posterior Insufficiency

Posterior Tibial Insufficiency Bracing – For supple deformity – UCBL insert – AFO

Peroneal • Surgery: If Painful Subluxation • Rigid deformity • Uncomfortable bracing • Patient activity level

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Diabetes and Feet

A Disaster Waiting to Happen

Diabetes Diabetic Foot: Risk Factors

Prevention is the key to foot preservation Neuropathy Vasculopathy Constant education of patient necessary Diabetic neuropathy major complication Foot deformity Amputation to – unable to detect bone stress viable level Diabetic vasculopathy major issue in Ulceration treatment – No blood flow… no healing Infection A warm swollen foot without wound is foot fracture not infection Amputation

Charcot Foot Extra depth Wide Toed Shoes Bony instability “Ugly Shoe” Provides extra room Repetitive injury for forefoot deformity Warm, swollen Room for insert foot For low demand patients Bony For poor surgical destruction risk patients Intact soft tissue

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Charcot Arthropathy Charcot: Treatment Ligamentous instability is not Charcot disease but the start of the process Total Contact cast Surgical during active phase considerations – Change 1-3 weeks – Acute injury – Initial non weight Ligamentous injury bearing – Complications from – Continue till coalesence deformity – Attempt to minimize instability deformity ulcer

Simple Treatment Truths

With foot use: “IF IT HURTS…DON’T DO IT!” If it hurts to use immobilize it If a motor unit is tender, protect it

Gait is all about bony stability and motor balance

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