Foot, Ankle and Lower Leg Problems

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Foot, Ankle and Lower Leg Problems

• Scott W. Pyne, M.D.
• CDR, MC, USN
• United States Naval Academy

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Objectives

• Define relevant anatomy, physiology, and
  radiographic features of the foot, ankle and
  lower leg
• Recognize history, presenting signs and pertinent
  exam findings
• Demonstrate common rehabilitative exercises
• Demonstrate proper injection techniques,
  indications and contraindications

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Ankle Bones

• Tibia
• Fibula
• Talus
• Dome
• Neck
• Calcaneus
• Medial tubercle
• Anterior process
• Posterior process

4
What are these things?

• Fractures
• Sesamoids
• Gout crystals
• Tendon calcification

Q
5
Foot Bones

• Calcaneus
• Talus
• Navicular
• Cuboid
• Cuneiform
• Medial, Intermediate, Lateral
• Metatarsals
• Phalanges
• Sesamoids

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Lateral Ankle

• Lateral Malleolus Distal Fibula
• Tibiofibular Ligaments
• Syndesmosis
• Anterior Talofibular Ligament
• Calcaneofibular Ligament
• Posterior Talofibular Ligament
• Peroneus Brevis
• Peroneus Longus

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Anterior Ankle

• Tibialis Anterior Tendon
• Extensor Hallicus Longus
• Anterior tibiofibular ligament

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Medial Ankle

• Medial Malleolus Distal Tibia
• Deltoid Ligament
• Tibialis Posterior Tendon
• Flexor Digitorum Longus Tendon
• Posterior Tibial Artery
• Posterior Tibial Vein
• Tibial Nerve
• Flexor Hallicus Longus

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Medial ankle
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Posterior Ankle

• Calcaneus
• Achilles Tendon
• Gastrocnemius
• Soleus
• Posterior tibiofibular ligament

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Plantar Foot

• Plantar fascia
• Longitudinally oriented collagen fibers
• Medial calcaneal tubercle
• Proximal phalanges

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Dorsal foot

• Extensor tendons
• Dorsal pedis artery
• Digital nerves

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Midfoot Congruity

• Tarsometatarsal Articulation
• First and second metatarsal with medial and
  intermediate cuneiform
• Lisfranc ligament
• Transverse ligaments

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Which foot is overpronated?
D

• A
• B
• C
• D

A
B
C
Q
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A Word About Imaging

• Ottawa Ankle Rules
• X-rays
• Stress views
• Bone Scan
• CT
• MRI

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Normal Ankle X-ray
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Normal Foot X-ray
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Acute Foot and Ankle Injuries

• Bone
• Ligament
• Muscle Tendon
• Nerve Blood Vessels
• Remember mechanism of injury!

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Case 1

• 34 yo male with ankle pain
• Landed on foot while playing basketball
• Stopped playing
• Lateral pain
• Able to limp off court and into your office

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Case 1 History

• Previous history
• Previous rehabilitation
• Ankle protection
• Ability to bear weight
• Neurovascular symptoms

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Case 1 Physical Exam

• Able to walk
• Swelling Laterally
• Tender laterally, but not bone
• Slight bruising
• Neurovascular intact
• No instability

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How do you treat this?

• Cast and crutch for 3 weeks
• Orthopedic referral
• Early range of motion,
  protect and gradually
  advance activity
• MRI will guide treatment

Q
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Case 2

• 34 yo male football player
• Right ankle rolled up under him during tackle
• Walked off field
• Unable to return to play

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Case 2 History

• Previous history
• Previous rehabilitation
• Ankle protection
• Ability to bear weight
• Neurovascular symptoms

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Case 2 Physical Exam

• Difficulty bearing weight
• Swelling throughout
• Tender laterally, anteriorly, medially
• Neurovascular intact
• Painful Tib-Fib Squeeze

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Lateral Ankle Sprains

• Grade 1 Ligament stretch
• Grade 2 Ligament partial tear
• Grade 3 Ligament complete tear
• High Ankle Sprain
• Involvement of syndesmosis
• All structures keeping tibial and fibula together

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Lateral Ankle Sprain

• Evaluation
• Image as necessary
• Functional Assessment
• Treatment
• Protect, rest, ice, compress, elevate
• Brace
• Movement
• Physical Therapy ROM, strength, proprioception

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Case 3 History

• 33 yo Football Player
• Ankle twisted up under him
• Heard a pop
• Unable to bear weight
• Thinks something bad happened
• Blamed the quarterback, the coach, the city

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Case 3 Physical Exam

• Difficulty bearing weight
• Swelling throughout
• Tender laterally, anteriorly, medially
• Neurovascular intact
• Painful tib-fib squeeze

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Danis-Weber Classification
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Ankle Fracture

• Evaluation
• Neurovascular
• Mortise and proximal fibula
• Treatment
• Bulky splint
• Protect, elevate
• Referral

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Who is Maissoneuve?

• One of Napoleon's surgeons
• He runs a spa in Maui
• Described proximal fibular fracture with
  ankle external rotation
• Described causative mechanism in
  Mortons metatarsalgia

Q
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Case 4

• 45 yo Male with right heel pain
• Exercises daily run, basketball, volleyball
• Worse after volleyball game
• Pain and creaking over heel for past month
• Difficulty walking, but warms up

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Case 4 Differential Diagnosis

• What lives in the back of the leg
• Calcaneus unlikely
• Calf muscle
• Gastrocnemius
• Soleus
• Achilles Tendon

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Achilles Tendinosis

• Evaluation
• Palpation with tender Achilles Tendon
• Associated crepitus
• Imaging?
• Treatment
• Rest, stretch, ice, cross-friction massage
• Eccentric strengthening
• Physical Therapy modalities
• Avoid injection

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Case 5

• 19 yo female with lateral ankle pain 2 days after
  her first marathon
• No swelling or bruising
• Worse with running and stairs
• No previous sx and no pain with marathon

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Case 5 Differential Diagnosis

• What lives on the lateral ankle?
• Bone
• Lateral malleolus
• Talus
• Ligaments
• Tendons
• Peroneus brevis
• Peroneus longus

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Peroneal Tendonitis

• Evaluation
• Tender to palpation along tendons
• Increased with resisted eversion
• No bony tenderness
• Imaging?
• Treatment
• Protect, Rest, Ice, Time, Physical Therapy
• Prevention
• Foot analysis, gradual training, footwear

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Case 6

• Football player tackled
• Entire stadium heard a loud crack
• Defense immediately calling trainers
• Never had this happen before

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Case 6 Physical Exam

• Painful distal leg
• Resistant to any movement
• Something doesnt look right
• Deformity
• Swelling

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Tibia Fibula fracture

• Evaluation
• Neurovascular status
• X-ray
• Treatment
• Bulky splint
• Protect and elevate
• Referral

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Chronic Ankle Injuries

• Remember functional anatomy
• Previous Injury
• How long ago?
• Treatment?
• Previous problem or limitations?
• What is different?
• Reason for the visit today?

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Case 7

• 20 yo basketball player
• Rolls ankle all the time
• Rehabilitation with physical therapy a few times
• Stopped when he could play again
• Wears brace

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Case 7 Physical Exam

• Normal gait
• Minimal swelling laterally
• No bruising
• Normal strength
• Neurovascular intact
• Poor proprioception

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Case 7 Differential Diagnosis

• What lives laterally?
• Bone
• Lateral malleolus
• Talus
• Ligaments
• Tendons
• What will help?

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Case 7 Diagnosis

• Chronic ligament injury
• Positive anterior drawer
• What can we do?
• Strengthen
• Brace
• Operate
• How to decide?

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Case 8

• 65 yo male with right ankle pain.
• Gradually worsening over past year
• No fever, chills or recent trauma
• No instability
• Long history bilateral ankle injuries
• History of Gout

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Case 8 Differential Diagnosis

• This one is different
• Global ankle problem
• Possible Causes
• Bone
• Infection
• Crystal deposition

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Case 8

• Evaluation
• X-ray
• Blood Work
• Aspiration
• Treatment options
• Good luck
• Activity modification
• Medications
• Corticosteroid injection
• Surgery

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Case 9

• 20 yo female kickboxing instructor
• Injured foot 2 months ago while landing
• Persistent pain to run, jump and kick
• Tapes her midfoot for class

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Lisfranc Ligament Complex

• Evaluation
• Painful midfoot stress
• Mild swelling
• Weight-bearing X-ray
• 2nd MT/intermediate cuneiform
• CT/MRI/Bone Scan
• Treatment
• Casting for mild
• Surgery for advanced

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Case 10

• 59 yo female with right heel pain
• Worse with first steps when getting out of bed
• Gradually improves but worsens by end of day
• Related to wearing boots

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Case 10

• Evaluation
• Point tender medial calcaneal tubercle
• Increased with passive great toe extension
• Valgus foot type
• Treatment
• Ice, stretch, cross-friction massage
• Night splint, orthotics
• Physical therapy
• Corticosteroid injection

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How Bad Does This Hurt

• Not at all
• Like a Bee Sting
• Grumpy face on visual pain scale
• Ill have another baby before I do this again

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Case 11

• 48 yo male with right leg pain after playing
  tennis
• Medial calf pain
• Felt like he was hit with a ball
• Trouble with toe raise

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Medial Gastrocnemius Strain

• Evaluation
• Swelling and ecchymosis medial gastroc
• No palpable muscle defect
• Achilles intact
• Imaging?
• Treatment
• Protect, ice, stretch
• NSAIDs?
• Protected return to activities

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Case 12 History

• 38 yo active duty airman with 10 year history of
  bilateral lower leg pain
• Diagnosed with shin splints and stress fractures
• No pain at rest
• Pain 10 minutes into exercise

• Pain resolves 10 minutes after exercise
• Unable to drive standard transmission for 10-15
  minutes after exercise
• Associated dorsal foot numbness and leg tightness

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Case 12 Physical

• Pre-exercise
• Normal gait and appearance
• TTP posterior medial tibia bilaterally
• No calf tenderness
• Neurovascular intact
• Normal strength

• Post-exercise
• Foot drop gait
• TTP posterior medial tibia bilaterally
• Calf pain
• Decreased dorsal foot sensation
• 4/5 strength ankle and 1st toe extension

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Lower Leg Pain

• Medial Tibial Stress Syndrome
• Shin splint
• Isolated medial tibial pain
• Normal X-rays
• Stress fracture
• Bone injury
• Varying degrees of injury
• X-ray, bone scan, MRI

• Chronic Exertional Compartment Syndrome
• Tight compartments
• Anterior, lateral, superficial posterior and deep
  posterior
• Associated nerve and vascular compromise
• Ps
• Pulseless, palor, paresthesia, pain, paralysis

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What is the word starting with p that means
cold?

• Polarthermic
• Poikilothermia
• Poikilodactyly
• Poi

Q
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Chronic Exertional Compartment Syndrome

• Evaluation
• Differentiate leg pain
• Pressure measurement
• Treatment
• Conservative
• Surgical fasciotomy

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Tibial Stress Fracture

• X-ray
• No finding
• Periosteal reaction
• Dreaded black line
• Bone Scan
• MRI

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Unlucky Case 13

• 19yo female student
• New running program
• Shooting foot pain
• Pebble sensation
• No history of injury
• Associated toe numbness with pedicure
• Works as a waitress

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Case 13 Physical Exam

• Normal appearing foot
• FROM, Motor intact
• Decreased sensation 3rd webspace
• Non-tender metatarsal heads and shaft
• Squeeze her metatarsal heads
• Mulders sign palpable click
• Reproduce shooting pain

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Mortons Neuroma

• Interdigital nerve chronic stress
• Treatment
• New shoes
• Wider toe box
• Metatarsal pads
• Injection

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Metatarsal Stress Fracture
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Questions?