rheumatology

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ANKLEFOOT

• Dr. TAREK NASRALA
• AL AZHAR UNIVERSTY

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Your Guide to Treating Foot Pain
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Walking is the 2nd most common conscious function
of our body next to breathing.
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A person takes between 5,000 to 10,000 steps a
day, depending on their activity level.
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When your feet hurt you are reminded with every
step taken.
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Eliminating foot pain is a challenge.
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Its pretty easy to rest your back, shoulder,
arm, wrist or hand.
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But to tell someone to stay off their foot,
thats not so easy.
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Ankle and Foot Joints

• Complex
• 26 bones
• 30 joints
• gt 20 muscles
• Simplification
• Tarsals
• Extrinsic muscles only
• 9 joints

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Ankle and Foot Joint Bones

• Tibia
• Fibula
• Talus
• Calcaneus
• Tarsals (5)
• Metatarsals (5)
• Proximal phalanges (5)
• Middle phalanges (4)
• Distal phalanges (5)

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Calcaneus
Talus
Tibia
Tarsals
Fibula
Metatarsals
Interosseus membrane
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Proximal phalanges
Middle phalanges
Distal phalanges
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Ankle and Foot Joints

• Talocrural joint (ankle)
• Uniaxial hinge
• Subtalar joint
• Gliding/nonaxial
• Transverse tarsal joints
• Gliding/nonaxial
• Intertarsal joints
• Gliding/nonaxial
• Tarsometatarsal joints
• Gliding/nonaxial

• Metatarsophalangeal joints
• Biaxial ball and socket
• Proximal interphalangeal joints
• Little toes Uniaxial hinge
• Distal interphalangeal joints
• Little toes Uniaxial hinge
• Interphalangeal joint
• Big toe Uniaxial hinge

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Talocrural joint
Plantar/dorsiflexion Sagittal, ML axis
Subtalar joint
Eversion/inversion Frontal plane AP axis
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Transverse tarsal joints
Intertarsal joints
Tarsometatarsal joints
Metatarsophalangeal joints
Proximal interphalangeal joints
Distal interphalangeal joints
Interphalangeal joint
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• Behind the trochlea is a posterior process with a
  medial and a lateral tubercle separated by a
  groove for the tendon of flexor hallucis longus.
• Exceptionally, the lateral of these tubercles
  forms an independent bone called os trigonum or
  "accessory talus".

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Plantar Fascia
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Movements

• When the body is in the erect position, the foot
  is at right angles to the leg
• dorsiflexion consists in the approximation of the
  dorsum of the foot to the front of the leg, while
  in extension the heel is drawn up and the toes
  pointed downward
• The range of movement varies in different
  individuals from about 50 to 90

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Ankle and Foot Joint Movements

• Flexion/Extension
• Talocrural joint (plantar/dorsiflexion)
• Proximal interphalangeal joints
• Distal interphalangeal joints
• Interphalangeal joint
• Metatarsophalangeal joints (Biaxial BS)
• Inversion/Eversion
• Subtalar joint
• Transverse tarsal joints
• Abduction/Adduction/Circumduction
• Metatarsophalangeal joints (Biaxial BS)

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Arches of the Foot
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Basic Anatomy of the Foot and Ankle

• Three Arches enable us to absorb forces
• Transverse Arch
• Medial Longitudinal
• Arch
• Lateral Longitudinal
• Arch

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The Three Arches

• Transverse Arch
• Goes across the width of the foot
• Comprised of the cuneiforms (all three), the
  cuboid, and the base of the fifth metatarsal.

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The Three Arches

• Medial longitudinal arch
• The highest and most important arch in the foot.
• Goes the length of the foot on the medial side.
• Comprised of the calcaneus, talus, navicular,
  cuneiforms and the first three metatarsals.

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The Three Arches

• Lateral longitudinal arch
• The arch next to the medial one that is flatter
  and lower.
• Goes the length of the foot on the lateral side.
• Comprised of the calcaneus, talus, cuboid, and
  the forth and fifth metatarsals.

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Ligaments

• Medial Side
• Deltoid Ligament- support ligament
• on medial side of
• foot.
• Spring Ligament-
• AKA the Plantar Calcaneonavicular ligament.

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Ligaments

• Lateral Side
• ATF-Anterior Talofibular Ligament
• CF-Calcaneofibular Ligament
• PTF-Posterior Talofibular Ligament

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Assessing the Lower Leg and Ankle

• History
• Past history
• Mechanism of injury
• When does it hurt?
• Type of, quality of, duration of pain?
• Sounds or feelings?
• How long were you disabled?
• Swelling?
• Previous treatments?

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• Observations
• Postural deviations?
• Genu valgum or varum?
• Is there difficulty with walking?
• Deformities, asymmetries or swelling?
• Color and texture of skin, heat, redness?
• Patient in obvious pain?
• Is range of motion normal?
• Palpation
• Begin with bony landmarks and progress to soft
  tissue
• Attempt to locate areas of deformity, swelling
  and localized tenderness

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EXAM Inspection. Palpation. Movements. Special
tests.
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INSPECTION 1- ERECT POSITION. 2-SUPINE POSITION.
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INSPECTION OF THE PATIENTS GAIT
Evaluation of the walking cycle
GAIT ANALYSIS
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• Gait cycle

Toe off
Foot flat
Heel strike
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Biomechanics of Normal Gait

• 2 phases stance or support phase swing or
  recovery phase
• Stance initial contact at heel strike and ends
  at toe off
• Swing time immediately after toe off, leg moved
  from behind body to a position in front of body
  in preparation of heel strike

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Foot at stance phase

• Shock absorber to impact forces at heel strike
  and adapt to uneven surface
• At push off functions as rigid lever to transmit
  explosive force
• Lateral aspect of calcaneus with subtalar joint
  in supination to forefoot contact on medial
  surface of foot and subtalar joint pronation
• Pronation distributes forces to many structures

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• Foot begins to re-supinate and returns subtalar
  joint to neutrally 70 to 90 of support phase
• Foot becomes rigid and stable to allow greater
  amount of force at push off

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Trendelenburg gait
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Tip-toe walking
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Foot drop walking
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Spastic gait
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Intoeing/Out toeng gait
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Antalgic gait
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SPECIAL PATHOLOGIES
INTOING GAIT
-Internal femoral torsion exaggerated
anteversion.
-Internal tibial torsion.
-Forefoot adduction.
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Inspection in standing position
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POSTERIOR HEEL STANDING
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FOOT SHAPE
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ALL THE TOES SHOULD BE IN GROUND CONTACT IN
W.B.(stability of the foot on the ground)
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INSPECTION of the L.L
Any asymmetry of length, rotational problem, or
mal alignment of the lower limbs.
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INSPECTION
- Deformity, swelling, skin changes, muscle
wasting, asymmetry of length, abnormal position.
INSPECT ALL ARROUND
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INSPECTION
PLANTAR SKIN
callosity
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Palpation Bone and joints Soft tissues
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Anatomical landmarks
-Medial malleolus, lateral malleolus, Achilles
tendon, calcaneal tuberosity, peroneal tendon,
tibialis posterior tendon, tibialis anterior
tendon, plantar fascia, base of 5th metatarsal,
1st MP joint, metatarsal heads..etc
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Ankle Landmarks
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PALPATION Tenderness, swelling, deformity.
Knowing the anatomy
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MOVEMENTS
Ankle -dorsiflection -plantarflection.
Subtalar -inversion -eversion.
Midtarsal -pronation -supination
Tarso-metatarsals move the metatarsals one by
one.
Toes
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Ankle movements
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SUBTALAR
MOVEMENT
MOVE THE HEEL Inversion---eversion
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Midtarsal supination?
Move the metatarsals one by one
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MOVEMENTS
IMPORTANCE OF THE BIG TOE (running, jumping)
Problem of hallux rigidus
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EXAMINATION OF THE SHOES
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Special tests
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Test for the ATFL

• The anterior draw tests the ATFL
• Test should be done with the ankle in 10o-20o
  plantar flexion
• Low loads

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• Percussion and compression tests
• Used when fracture is suspected
• Percussion test is a blow to the tibia, fibula or
  heel to create vibratory force that resonates
  w/in fracture causing pain
• Compression test involves compression of tibia
  and fibula either above or below site of concern
• Thompson test
• Squeeze calf muscle, while foot is extended off
  table to test the integrity of the Achilles
  tendon
• Positive tests results in no movement in the foot
• Homans test
• Test for deep vein thrombophlebitis
• With knee extended and foot off table, ankle is
  moved into dorsiflexion
• Pain in calf is a positive sign and should be
  referred

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Compression Test
Percussion Test
Homans Test
Thompson Test
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• Ankle Stability Tests
• Anterior drawer test
• Used to determine damage to anterior talofibular
  ligament primarily and other lateral ligament
  secondarily
• A positive test occurs when foot slides forward
  and/or makes a clunking sound as it reaches the
  end point
• Talar tilt test
• Performed to determine extent of inversion or
  eversion injuries
• With foot at 90 degrees calcaneus is inverted and
  excessive motion indicates injury to
  calcaneofibular ligament and possibly the
  anterior and posterior talofibular ligaments
• If the calcaneus is everted, the deltoid ligament
  is tested

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Talar Tilt Test
Anterior Drawer Test
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Talar Tilt Test
Bump Test
Anterior Drawer Test
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• Kleigers test
• Used primarily to determine extent of damage to
  the deltoid ligament and may be used to evaluate
  distal ankle syndesmosis, anterior/posterior
  tibiofibular ligaments and the interosseus
  membrane
• With lower leg stabilized, foot is rotated
  laterally to stress the deltoid
• Medial Subtalar Glide Test
• Performed to determine presence of excessive
  medial translation of the calcaneus on the talus
• Talus is stabilized in subtalar neutral, while
  other hand glides the calcaneus, medially
• A positive test presents with excessive movement,
  indicating injury to the lateral ligaments

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Medial Subtalar Glide Test
Kleigers Test
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• Tinels Sign
• Tap over posterior tibial nerve
• Positive test tingling distal to area
• Indicates presence of tarsal tunnel syndrome

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• Mortons Test
• Transverse pressure applied to heads of
  metatarsals
• Positive test pain in forefoot
• Indicate presence of neuroma or metatarsalgia

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• Neurological Assessment
• Reflexes
• Tendon reflexes should elicit a response
• Achilles reflex should be assessed for the foot
• Sensation
• Cutaneous distribution of nerves must be tested
• Sensation can be tested by running hands over all
  surfaces of foot and ankle

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• Functional Tests
• While weight bearing the following should be
  performed
• Walk on toes (plantar flexion)
• Walk on heels (dorsiflexion)
• Hops on injured ankle
• Start and stop running
• Change direction rapidly
• Run figure eights

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• Medial Tibial Stress Syndrome (Shin Splints)
• Cause of Injury
• Pain in anterior portion of shin
• Stress fractures, muscle strains, chronic
  anterior compartment syndrome, periosteum
  irritation
• Caused by repetitive microtrauma
• Weak muscles, improper footwear, training errors,
  varus foot, tight heel cord, hypermobile or
  pronated feet and even forefoot supination can
  contribute to MTSS
• May also involve, stress fractures or exertional
  compartment syndrome

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• Shin Splints (continued)
• Signs of Injury
• Diffuse pain about distomedial aspect of lower
  leg
• As condition worsens ambulation may be painful,
  morning pain and stiffness may also increase
• Can progress to stress fracture if not treated
• Care
• Physician referral for X-rays and bone scan
• Activity modification
• Correction of abnormal biomechanics
• Ice massage to reduce pain and inflammation
• Flexibility program for gastroc-soleus complex
• Arch taping and orthotics

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• Shin Contusion
• Cause of Injury
• Direct blow to lower leg (impacting periosteum
  anteriorly)
• Signs of Injury
• Intense pain, rapidly forming hematoma w/ jelly
  like consistency
• Increased warmth
• Care
• RICE, NSAIDs and analgesics as needed
• Maintaining compression for hematoma (which may
  need to aspirated)
• Fit with doughnut pad and orthoplast shell for
  protection

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• Compartment Syndrome
• Cause of Injury
• Rare acute traumatic syndrome due to direct blow
  or excessive exercise
• May be classified as acute, acute exertional or
  chronic
• Signs of Injury
• Excessive swelling compresses muscles, blood
  supply and nerves
• Deep aching pain and tightness is experienced
• Weakness with foot and toe extension and
  occasionally numbness in dorsal region of foot

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Figure 15-20
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• Care
• If severe acute or chronic case, may present as
  medical emergency that requires surgery to reduce
  pressure or release fascia
• NSAIDs and analgesics as needed Avoid use of
  compression wrap increased pressure
• Surgical release is generally used in recurrent
  conditions
• May require 2-4 month recovery (post surgery)
• Conservative management requires activity
  modification, icing and stretching
• Surgery is required if conservative management
  fails
• Return to activity after surgery , light
  activity,10 days later

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• Achilles Tendonitis
• Cause of Injury
• Inflammatory condition involving tendon, sheath
  or paratenon
• Tendon is overloaded due to extensive stress
• Presents with gradual onset and worsens with
  continued use
• Decreased flexibility exacerbates condition
• Signs of Injury
• Generalized pain and stiffness, localized
  proximal to calcaneal insertion, warmth and
  painful with palpation, as well as thickened
• May progress to morning stiffness

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Achilles Tendinitis

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Achilles Tendinopathy
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Imaging
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• Care
• Resistant to quick resolution due to slow healing
  nature of tendon
• Must reduce stress on tendon, address structural
  faults (orthotics, mechanics, flexibility)
• Aggressive stretching and use of heel lift may be
  beneficial
• Use of anti-inflammatory medications is suggested

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• Achilles Tendon Rupture
• Cause
• Occurs w/ sudden stop and go forceful plantar
  flexion w/ knee moving into full extension
• Commonly seen in athletes gt 30 years old
• Generally has history of chronic inflammation
• Signs of Injury
• Sudden snap (kick in the leg) w/ immediate pain
  which rapidly subsides
• Point tenderness, swelling, discoloration
  decreased ROM
• Obvious indentation and positive Thompson test

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Figure 15-20
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Tendoachilles Rupture

• Palpate the Tendon ProneRestingPosition

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• Care
• Usual management involves surgical repair for
  serious injuries
• Non-operative treatment consists of, NSAIDs,
  analgesics, and a non-weight bearing cast for 6
  weeks to allow for proper tendon healing
• Must work to regain normal range of motion
  followed by gradual and progressive strengthening
  program

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Retrocalcaneal Bursitis (Pump Bump)

• Etiology
• Caused by inflammation of bursa beneath Achilles
  tendon
• Result of pressure and rubbing of shoe heel
  counter
• Chronic condition that develops over time
• May take extensive time to resolve
• Exostosis may also develop

• Signs and Symptoms
• Pain with palpation superior and anterior to
  Achilles insertion
• Swelling on both sides of the heel cord

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Retrocalcaneal Bursitis (Pump Bump) cont.

• Management
• RICE and NSAIDs used as needed
• Ultrasound can reduce inflammation
• Routine stretching of Achilles
• Heel lifts to reduce stress
• Donut pad to reduce pressure
• Possibly invest in larger shoes with wider heel
  contours

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• Leg Cramps and Spasms
• (sudden, violent, involuntary contraction, either
  clonic (intermittent) or tonic (sustained)
• Etiology
• Difficult to determine fatigue, loss of fluids,
  electrolyte imbalance, inadequate reciprocal
  muscle coordination
• Signs and Symptoms
• Cramping with pain and contraction of calf muscle
• Management
• Try to help athlete relax to relieve cramp
• Firm grasp of cramping muscle with gentle
  stretching will relieve acute spasm
• Ice will also aid in reducing spasm
• If recurrent may be fatigue or water/electrolyte
  imbalance

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• Gastrocnemius Strain
• Etiology
• Susceptible to strain near musculotendinous
  attachment
• Caused by quick start or stop, jumping
• Signs and Symptoms
• Depending on grade, variable amount of swelling,
  pain, muscle disability
• May feel like being hit in leg with a stick
• Edema, point tenderness and functional loss of
  strength
• Management
• RICE, NSAIDs and analgesics as needed
• Grade 1 should apply gentle stretch after cooling
• Weight bearing as tolerated heel wedge to reduce
  calf stretching while walking
• Gradual rehab program should be instituted

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• Stress Fracture of Tibia or Fibula
• Etiology
• Common overuse condition, particularly in those
  with structural and biomechanical insufficiencies
• Runners tends to develop in lower third of leg,
  dancers middle third
• Often occur in unconditioned, non-experienced
  individuals
• Often training errors are involved
• Component of female athlete triad
• Signs and Symptoms
• Pain more intense after exercise than before
• Point tenderness difficult to discern bone and
  soft tissue pain
• Bone scan results (stress fracture vs.
  periostitis)

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Pes planus common 20
-GAIT UGLY.
-INSPECTION STANDING HEEL, ARCH, FOREFOOT.
-LIGAMENT LAXITY
-MOVE THE HEEL AND THE 1ST METATARSAL.
-EXAMIN THE TENDO ACHILLES
-May be asymptomatic
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Pes cavus High arch Varus
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TARSAL COALSION
Painful stiff flat foot Usually bilateral, can be
unilateral
-Stiff subtalar.
MORE COMMONcalcaneo-navicular and subtalar.
-Request CT scan
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Plantar Fasciitis

• Plantar fascia
• Dense, broad band of connective tissue attaching
  proximal and medially on the calcaneus and fans
  out over the plantar aspect of the foot
• Works in maintaining stability of the foot and
  bracing the longitudinal arch
• Plantar Fasciitis
• Catch all term used for pain in proximal arch
  and heel
• Common in athletes and nonathletes
• Attributed to heel spurs, plantar fascia
  irritation, and bursitis

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Plantar Fasciitis cont.

• Etiology
• Increased tension and stress on fascia
• Particularly during push off of running phase
• Change from rigid supportive footwear to flexible
  footwear
• Running on soft surfaces while wearing shoes with
  poor support
• Poor running technique
• Leg length discrepancy, excessive pronation,
  inflexible longitudinal arch, or tight
  gastroc-soleus complex

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Plantar Fasciitis cont.

• Signs and Symptoms
• Pain in anterior medial heel and along medial
  longitudinal arch
• Increased pain in morning
• Plantar fascia loosens after first few steps thus
  decreasing pain
• Increased pain with forefoot dorsiflexion

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Plantar Fasciitis cont.

• Management
• Extended treatment (8-12 weeks)
• Orthotic therapy is very useful
• Soft orthotic with deep heel cup
• Simple arch taping
• Night splint to stretch plantar fascia
• Vigorous heel cord stretching
• Exercises that increase great toe dorsiflexion
• NSAIDs and occasionally steroidal injection

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Longitudinal Arch Strain

• Etiology
• Early season injury due to increased stress on
  arch
• Flattening of foot during midsupport phase
  causing strain on arch
• May appear suddenly or develop slowly

• Sign and Symptoms
• Pain with running and jumping
• Pain below posterior tibialis tendon accompanied
  by swelling
• May also be associated with sprained
  calcaneonavicular ligament and flexor hallucis
  longus strain

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Longitudinal Arch Strain cont.

• Management
• Immediate care is RICE
• Reduction of weight bearing
• Weight bearing must be pain free
• Arch taping may be used to allow pain free walking

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Apophysitis of the Calcaneus(Severs Disease)

• Etiology
• Traction injury at apophysis of calcaneus
• Where Achilles tendon attaches to calcaneous

• Signs and Symptoms
• Pain occurs at posterior heel below Achilles
  attachment
• Pain occurs during vigorous activity
• Pain ceases following activity

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Apophysitis of the Calcaneus

• (Severs Disease) cont.
• Management
• Best treated with ice, rest, stretching and
  NSAIDs
• Heel lift could also relieve some stress

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Heel Contusion

• Etiology
• Caused by sudden starts, stops or changes of
  direction
• Irritation of fat pad
• Pain often on the lateral aspect due to heel
  strike pattern

• Sign and Symptoms
• Severe pain in heel
• Unable to withstand stress of weight bearing
• Often warmth and redness over the tender area

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Heel Contusion cont.

• Management
• Reduce weight bearing for 24 hours
• RICE and NSAIDs
• Resume activity with heel cup or doughnut pad
  after pain has subsided
• Wear shock absorbent shoes

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Bunion (Hallux Valgus Deformity)

• Etiology
• Exostosis of 1st metatarsal head
• Associated with
• Forefoot varus
• Wearing shoes that are too narrow or too short
• Wearing shoes with pointed toes
• Bursa becomes inflamed and thickens
• Enlarges the joint and causes lateral
  malalignment of the great toe
• Bunionette (Tailors bunion)
• Impacts 5th metatarsophalangeal joint
• Causes medial displacement of 5th toe

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Bunion (Hallux Valgus Deformity) cont.

• Signs and Symptoms
• Initially
• Tenderness
• Swelling
• Enlargement of joint
• As inflammation continues
• Angulation of the joint increases
• Painful ambulation
• Tendinitis in great toe flexors may develop

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Bunion (Hallux Valgus Deformity) cont.

• Management
• Early recognition and care is critical
• Wear correct fitting shoes
• Orthotics may be used
• Padding over 1st metatarsal head with a tape
  splint between 1st and 2nd toe may be
  used
• Exercises for flexor and extensor muscles
• Bunionectomy may be necessary

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Hallux valgus
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Sesamoiditis

• Etiology
• Caused by repetitive hyperextension of the great
  toe
• Results in inflammation

• Signs and Symptoms
• Pain under great to
• Especially during push off
• Palpable tenderness under first metatarsal head

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Sesamoiditis cont.

• Management
• Orthotics that include metatarsal pads, arch
  supports, and metatarsal bars
• Decrease activity to allow inflammation to
  subside

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Mortons Toe

• Signs and Symptoms
• Possible stress fracture
• Pain during and after activity with possible
  point tenderness
• Positive bone scan
• Callus development under 2nd metatarsal head

• Etiology
• Abnormally short 1st metatarsal (great toe)
• 2nd toe looks longer
• More weight bearing occurs on 2nd toe as a result
  and can impact gait
• Stress fracture could develop

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Mortons Toe cont.

• Management
• If no signs and symptoms dont fix what isnt
  broken
• If associated with structural forefoot varus,
  orthotics with a medial wedge would be helpful

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Hallux Rigidus

• Etiology
• Development of bone spurs on dorsal aspect of
  first metatarsophalangeal joint
• Results in impingement
• Loss of active and passive dorsiflexion
• Degenerative arthritic process involving
  articular cartilage and synovitis
• If restricted, compensation occurs with foot
  rolling laterally

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Hallux rigidus O.A 1st MPJ
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Hallux Rigidus cont.

• Signs and Symptoms
• Forced dorsiflexion causes pain
• Walking becomes awkward due to weight bearing on
  lateral aspect of foot
• Management
• Stiffer shoe with large toe box
• Orthotics to increase rigidity of forefoot region
  within the shoe
• NSAIDs
• Surgery may be requires
• Osteotomy to remove mechanical obstructions in
  effort to return to normal functioning

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Hammer Toe, Mallet Toe, or Claw Toe

• Etiology
• Hammer toe
• Flexion contracture of the PIP joint, which can
  become fixed
• Mallet toe
• Flexion contracture of the DIP joint, which can
  become fixed
• Claw toe
• Flexion contracture of the DIP joint with
  hyperextension at the MP joint
• All may be caused by wearing short shoes over an
  extended period of time

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Hammer Toe, Mallet Toe, or Claw Toe cont.

• Signs and Symptoms
• The MP, DIP, and PIP can all become fixed
• Swelling
• Pain
• Callus formation
• Occasionally infection

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Hammer Toe, Mallet Toe, or Claw Toe cont.

• Management
• Wear shoes with more room for toes
• Use padding and taping to prevent irritation
• Shave calluses
• Once the contracture becomes fixed, surgery will
  be required to correct

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Overlapping Toes

• Etiology
• May be congenital
• May be caused by wearing shoes that are too narrow

• Signs and Symptoms
• Outward projection of great toe articulation
• Drop in longitudinal arch

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Overlapping Toes cont.

• Management
• Hammer toe surgery is the only cure
• Some modalities, such as whirlpool baths can
  assist in alleviating inflammation
• Taping may prevent some of the contractual
  tension within the sports shoe

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Metatarsalgia

• Signs and Symptoms
• Pain in ball of foot
• In the area of the 2nd and 3rd metatarsal heads
• Flattened transverse arch
• Depressing 2nd, 3rd, and 4th metatarsal bones

• Etiology
• Decreased flexibility of gastroc-soleus complex
• Typically emphasizes toe off phase during gait
• Fallen metatarsal arch
• Pes Cavus

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Metatarsalgia cont.

• Management
• Orthotics that elevate the depressed metatarsal
  heads and/or medial aspect of calcaneus may be
  used
• Remove excessive callus build-up
• Stretching of heel cord
• Strengthening exercises for the intrinsic foot
  muscles

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Metatarsal Arch Strain

• Etiology
• Fallen metatarsal arch
• Pes Cavus
• Excessive pronation

• Signs and Symptoms
• Pain or cramping in metatarsal region
• Point tenderness
• Weakness
• Positive Mortons test

• Management
• - Pad to elevate metatarsals just behind ball of
  foot

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Mortons Neuroma

• Etiology
• Thickening of nerve sheath of the common plantar
  nerve where it divides into digital branches
• Commonly occurs between 3rd and 4th metatarsal
  heads where medial and lateral plantar nerves
  come together
• Also irritated by collapse of transverse arch of
  foot
• Places transverse metatarsal ligaments under
  stretch, compressing digital nerves and vessels
• Excessive pronation can be a predisposing factor

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Mortons Neuroma cont.

• Signs and Symptoms
• Burning paresthesia in forefoot
• Severe intermittent pain in forefoot
• Pain relieved with non-weight bearing
• Toe hyperextension increases symptoms

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Mortons Neuroma cont.

• Management
• Must rule out stress fracture
• Teardrop pad can be placed between metatarsal
  heads to increase space
• Decreases pressure on neuroma
• Shoes with wider toe box would be appropriate
• Surgical excision may be required

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Subungual Hematoma

• Etiology
• Direct pressure
• Dropping an object on toe
• Kicking another object
• Repetitive shear forces on toenail

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Subungual Hematoma cont.

• Signs of Injury
• Accumulation of blood underneath toenail
• Likely to produce extreme pain
• May result in loss of toe nail
• Management
• RICE immediately
• Reduces pain and swelling
• Relieve pressure within 12-24 hours
• Lance or drill nail
• Must be sterile to prevent infection

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Metatarsalgia
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Tarsal Tunnel Syndrome

• Tunnel behind medial malleolus
• Osseous floor
• Roof composed of flexor retinaculum
• Etiology
• Any condition that compromises tibialis
  posterior, flexor hallucis longus, flexor
  digitorum, and tibial nerve, artery, or vein
• May result from previous fracture, tenosynovitis,
  acute trauma, or excessive pronation

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Tarsal Tunnel Syndrome cont.

• Signs and Symptoms
• Pain and paresthesia along medial and plantar
  aspect of foot
• Motor weakness and atrophy may result
• Increased pain at night
• Positive Tinels Sign
• Management
• NSAIDs and anti-inflammatory modalities
• Orthotics
• Possibly surgery if condition is recurrent

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Foot Rehabilitation

• General Body Conditioning
• A period of non-weight bearing is common,
  therefore alternative means of conditioning must
  be introduced
• Pool running
• Upper body ergometer
• General strengthening and flexibility should be
  included as allowed by injury

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Foot Rehabilitation

• Progression to Weight Bearing
• If unable to walk without a limp, crutch or cane
  walking should be utilized
• Poor gait mechanics will impact other joints
  within the kinetic chain
• Could result in additional injuries
• Progress to full weight bearing as soon as
  tolerable

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Foot Rehabilitation

• Joint Mobilizations
• Can be very useful in normalizing joint motions

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Foot Rehabilitation

• Flexibility
• Must maintain or re-establish normal flexibility
  of the foot
• Full range of motion is critical for normal
  function
• Stretching of the plantar fascia and Achilles
  tendon is very important

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Foot Rehabilitation

• Strengthening
• Writing alphabet
• Picking up objects
• Ankle circumduction
• Gripping and spreading toes
• Towel gathering
• Towel Scoop

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Foot Rehabilitation

• Neuromuscular Control
• Critical to re-establish because it is the single
  most important element dictating movement
• Muscular weakness, proprioceptive deficits, and
  ROM deficits challenge the athletes ability to
  maintain center of gravity without losing balance

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Foot Rehabilitation

• Neuromuscular Control cont.
• Must be able to adapt to changing surfaces
• Involves highly integrative and dynamic process
  that utilizes multiple neurological
  pathways
• Proprioception and kinesthesia is essential in
  athletics

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Figure 15-4
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• Neuromuscular Control Training
• Can be enhanced by training in controlled
  activities on uneven surfaces or a balance board

Figure 15-5 6
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• Taping and Bracing
• Ideal to have athlete return w/out taping and
  bracing
• Common practice to use tape and brace initially
  to enhance stabilization
• Must be sure it does not interfere with overall
  motor performance
• Functional Progressions
• Severe injuries require more detailed plan
• Typical progression initiated w/ partial weight
  bearing until full weight bearing occurs w/out a
  limp
• Running can begin when ambulation is pain free
  (transition from pool - even surface - changes of
  speed and direction)

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• Return to Activity
• Must have complete range of motion and at least
  80-90 of pre-injury strength before return to
  sport
• If full practice is tolerated w/out insult,
  athlete can return to competition
• Must involve gradual progression of functional
  activities, slowly increasing stress on injured
  structure
• Specific sports dictate specific drills

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• Footwear
• Can be an important factor in reducing injury
• Shoes should not be used in activities they were
  not made for
• Preventive Taping and Orthoses
• Tape can provide some prophylactic protection
• However, improperly applied tape can disrupt
  normal biomechanical function and cause injury
• Lace-up braces have even been found to be
  effective in controlling ankle motion

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Appropriate Footwear

• Select a rigid shoe for pronators
• Select a flexible shoe with additional cushioning
  for supinators
• Other considerations
• Midsole design controls motion along medial
  aspect of foot
• Heel counters controls motion in rearfoot
• Outsole contour and composition
• Lacing systems
• Forefoot wedges

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Foot Hygiene

• Keep toenails trimmed correctly
• Shave down excessive calluses
• Keep feet clean
• Wear clean socks and shoes that fit correclty
• Keep feet as dry as possible
• Prevents development of athletes foot

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