Evaluation & Treatment of Disclaimer Ankle & Foot Pain in the Adult I, William T Crowe, have relevant financial relationships to be Patient© discussed, directly or indirectly, William T. Crowe referred to or illustrated with or without recognition within the RN-C, FNP, MSN, MBA presentation as follows:

– None

Objectives Anatomy - ankle Review anatomy of the ankle and foot Bony structures – Tibia Define elements of subjective history – Fibula – Talus

Discuss basic exam of the ankle and foot Sustains loads 3x Discuss current treatment regimens for body weight during common problems normal ADLs

Anatomy - foot Anatomy - foot Bony structures Bony structures – Tarsals – Tarsals Calcaneous – Metatarsals Talus – Phalanges Navicular

Cuneiform Cuboid – Metatarsals – Phalanges

1 Anatomy - ankle Anatomy - foot Connective tissue Connective tissue – Ligaments – Ligaments Anterior inferior tibiofibular Anterior talofibular Posterior talofibular Calcaneofibular Deltoid Syndesmosis

Anatomy Anatomy Tendons Tendons – Dorsal view – Medial view Achilles tendon Anterior tibial tendon Peroneus brevis Posterior tibial Peroneus longus tendon Peroneus tertius Achilles tendon Extensors

Anatomy Anatomy Passive stabilizers Active stabilizers – Ligaments – Major – Joint capsule Gastrocnemius and soleus Peroneals Posterior Tibialis – Minor anterior tibialis extensor digitorum flexor digitorum other intrinsic mucles

2 Anatomy Anatomy Planes of motion Normal ROM – Dorsiflexion & Plantarflexion – 0 - 10 degrees dorsiflexion – Inversion & eversion – 20 - 30 degrees plantar flexion – Circumduction (combination of above) – 35 - 45 degrees inversion (tarsal) – 15 - 25 degrees eversion (tarsal) – 5 – 20 degrees inversion (subtalar) – 5 – 15 degrees eversion (subtalar)

Subjective/History Location of pain - ankle Where does it Bony hurt? – Lateral malleolar fx – Medial malleolar fx – Osteoarthritis

Soft tissue – Ligamental sprain – Tendonitis/rupture

Location of pain - ankle Location of pain - ankle Lateral § Medial – Lateral malleolar fx – Medial malleolar fx Lateral distal – Deltoid ligamental sprain – Peroneus longus tear Posterior – Calcaneofibular ligamental sprain – Achilles bursitis/tendonitis/rupture Anterolateral – Haglund’s deformity – Anterior talofibular ligamental sprain Posteromedial Posterolateral – Posterior Tibial Tendonitis – Peroneus brevis tear Anterior – Posterior talofibular ligamental sprain – OA of Tibial-talar joint

3 Location of Pain - foot Subjective/History Calcaneal Where does it hurt? – Plantar fasciitis When did it start? Base of the 5th MT What happened? – Jones fx If injury, ROM? Intermetatarsal space Previous injury – Morton’s neuroma – Intermetatarsal ligamental sprain

Subjective/History Objective/Exam Severity – rest & activity Observation Instability – “can’t see, can’t treat” Alleviating/Aggravating factors Treatment to date Review of PMH/PSH/MEDS/DA

Objective/Exam Objective/Exam - ankle Observation Palpation – Swelling – Malleoli – Ecchymosis – Tendons – Deformity – Atrophy

4 Objective/Exam - foot Objective/Exam

Palpation Maneuvers – Tendons – ROM (active & passive) – Tarsal joints – Metatarsals – Phalanges

Objective/Exam - ankle Objective/Exam - ankle Maneuvers Maneuvers – Too many toes – Too many toes Posterior Tibial Tendon Dysfunction

Objective/Exam - ankle Objective/Exam - ankle Maneuvers Maneuvers – Drawer test – Talar tilt test Anterior Talofibular Calcaneofibular ligament ligament + if > 8mm Deltoid ligament movement

5 Objective/Exam - foot Objective/Studies Maneuvers Radiographs – Thompson’s test – CT scan Achilles tendon MRI

Objective - Studies Objective - Studies

Objective - Studies Objective - Studies

6 Ankle sprain Ankle Sprain Most common sports injury seen in OP Subjective clinics – “turning the ankle” during a fall or after landing Most frequent MS injury seen by PCP on an irregular surface ~25K have ankle sprain daily – Pain increases with weight-bearing – >23K seen daily for ankle injuries – Instability to ankle Can occur during sports or walking with ADLs 10-20% will develop chronic instability (pain persists >3m, may require Sx – ligamental reconstruction)

Ankle Sprain Ankle Sprain Objective Ottawa Ankle Rules – Localized pain/swelling over lateral aspect ANY pain in malleolar zone AND – Difficulty weight-bearing Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial – Limping malleolus OR – Drawer test +/- Bone tenderness along the distal 6 cm of the – Talar tilt test +/- posterior edge of the fibula or tip of the lateral malleolus OR An inability to weight-bear both immediately and in the emergency department for 4 steps

97% sensitivity, 99% predictive value

Ankle Sprain Peroneal Tendonitis

Treatment Tendons are repetitively overloaded MICE The subsequent inflammatory response Protected weight-bearing creates pain and discomfort. Physical Therapy NSAIDs Orthopedic referral (if elite athlete or pain > 3 months)

7 Peroneal Tendonitis Peroneal Tendonitis Subjective Objective – Pain to the – Pain on palp to the posterolateral ankle posterolateral ankle – May walk with limp – Walks with limp – Chronic pain – Swelling (+/-) to posterior LM – Dec sensory (+/-) – Muscle testing normal

Peroneal Tendonitis Achilles Tendinopathy

Treatment Most commonly occurs in runners who MICE have suddenly increased the intensity or NSAIDs duration of the runs Ankle bracing Weekend “warriors” Physical therapy Includes tendonitis, tears, and ruptures Avoid precipitating activities Refer to orthopedist

Achilles Tendinopathy Achilles Tendinopathy

Risk factors Subjective Sex/age - Most common in middle-aged males Mild ache in back of leg or above heel Physical problems - Naturally flat arch, obesity, Severe pain after prolonged running, climbing tight calf muscles stairs, or sprinting Training choices – running in worn-out shoes, Tenderness or stiffness, esp in morning cold v warm weather, running on hilly terrain Medical conditions – diabetes, HTN Medications - fluoroquinolones

8 Achilles Tendinopathy Achilles Tendinopathy

Objective Treatment POP ~ 2-4 cm proximal to insertion site MICE Calf squeeze (Thompson test) NSAIDs Ankle bracing (cast if necessary) Physical therapy Avoid precipitating activities Refer to orthopedist

Ankle Osteoarthritis Ankle Osteoarthritis Subjective Objective – Pain to the anterior ankle – POP of the anterolateral or anteromedial talar – Reduced ability to move, walk, or bear weight joint – Stiffness in the joint – Walk with limp – Swelling in the joint

Ankle Osteoarthritis Ankle Osteoarthritis Treatment – Conservative NSAIDs Cortisone injections Physical therapy – Surgical Arthroscopic debridement Ankle fusion Ankle replacement

9 Ankle fracture Ankle fracture Subjective Objective Immediate and severe pain to joint Immediate and severe pain to joint Swelling/bruising to joint Swelling/bruising to joint Inability to weight-bear on joint Inability to weight-bear on joint Deformity

Ankle Fracture Ankle injury Lateral malleolar Fibular

Ankle Fracture Medial malleolar Ankle Fracture/Dislocation

10 Foot Sprain Foot Sprain Types Causes – Midfoot (Lisfranc injury) – Midfoot (Lisfranc injury) – 1st MTP joint (“turf toe”) Direct – crush injury Indirect – sudden rotational force on a plantar flexed forefoot – 1st MTP joint (“turf toe”) Hyperextension of the great toe

Foot Sprain Foot Sprain Subjective – Foot pain – Foot swelling – Foot bruising – Foot stiffness – Difficulty in walking

Foot Sprain Foot Sprain Objective – Midfoot POP of midfoot Swelling to the midfoot Local bruising Inability to WB (+/-) – Turf toe Base of great toe swollen POP of 1st MTP joint

11 Foot Sprain/fx Foot Sprain

Treatment – Midfoot (mild) Boot walker MICE NSAIDs – Midfoot (unstable) Surgery – Turf toe MICE NSAIDs Splinting (hard-soled shoes)

Plantar Fasciitis Plantar Fasciosis

More properly known as plantar fasciosis Subjective – No real inflammation (no blood vessels), more – Burning, stabbing, or aching pain to heel or degenerative posterior sole, usually worse in the morning Affects ~ 2 million people annually – Increased knee pain, especially for runners Affects ~ 10% of people in their lifetime Associated with long periods of standing

Plantar Fasciosis Plantar Fasciosis

Objective – POP to heel or posterior sole – Walks with a limp

12 Plantar Fasciosis Foot Osteoarthritis Treatment Subjective – Rest – pain and stiffness of the affected foot – Massage therapy – swelling near the affected joint – Morning stretches – limited range of motion and difficulty walking – Night splints – NSAIDs – Cortisone injection

Foot Osteoarthritis Foot Osteoarthritis Objective – pain and stiffness of the affected foot – swelling near the affected joint – limited range of motion and difficulty walking – bony protrusions (spurs)

Foot Osteoarthritis Morton’s Neuroma Treatment Precise cause unknown – Conservative Women 10x more frequent than men NSAIDs Not a neuroma per se, more accurately a Shoe inserts/orthotics Physical therapy neurofibroma – Surgical Arthroscopy Joint fusion Joint replacement

13 Morton’s Neuroma Morton’s Neuroma Subjective Objective Pain to plantar aspect of forefoot, usually to Well localized tenderness between 2 MT heads 2nd or 3rd interspace 3rd interspace more frequently involved than the 2nd Pain inc with walking or tight-fitting shoes Rare – 1st and 4th. Pain dec with rest or walking barefoot Must differentiate between joint and interspace pain Sensory deficit rarely seen ~ 75%, symptoms reproduced by firmly palpating the web space

Morton’s Neuroma Jones Fracture Treatment AKA 5th MT base fracture – Conservative Occurs at the base of the 5th MT Wearing wide-box shoes Usually caused by a twisting motion of the Soft MT support placed in the shoe proximal to area of neuroma (~1/3 will respond to this alone) foot Steroid injection (CAUTION – occasional rupture of a collateral ligament) – Surgical Surgical excision (80% success, 60% decreased sensory either side of excision)

Jones Fracture Jones Fracture Subjective Objective Pain to base of foot or ankle Pain on palpation to base of foot or ankle Swelling to lateral foot Swelling to lateral foot Pain with or inability to weight-bear Pain with or inability to weight-bear

14 Jones fracture Jones fracture

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