Foot and Ankle Seminar

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Foot and Ankle Seminar

• Jim Clover, MED, ATC

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Foot Anatomy Review

• Bony Anatomy
• Talus
• Calcaneus
• Tarsals
• 5 bones
• Metatarsals
• 5 bones
• Phalanges
• 14 bones

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Foot Anatomy
Figure Three
Figure Two
Figure One
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Foot Biomechanics

• Transverse Arch (A)
• Medial Longitudinal Arch (B)
• Lateral Longitudinal Arch (C)

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Lower Leg Anatomy

• Bony
• Tibia
• Fibula

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Lower Leg Anatomy

• Musculature
• Anterior
• Tibialis Anterior
• Medial
• Tibialis Posterior
• Extensor Digitorum Longus
• Extensor Hallicus Longus
• Lateral
• Peroneals
• Posterior
• Gastrocnemius
• Soleous

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Lower Leg Anatomy

• Other Structures
• Joints
• Ligament
• Cartilage

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Foot / Ankle Anatomy

• Nerve Supply
• Blood Supply

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Foot Biomechanics Normal Gait

• Two phases
• Stance or support phase which starts at initial
  heel strike and ends at toe-off
• Swing or recovery which represents time from
  toe-off to heel strike
• Foot serves as shock absorber at heel strike and
  adapts to uneven surface during stance
• At push-off foot serves as rigid lever to provide
  propulsive force
• Initial heel strike while running involves
  contact on lateral aspect of foot with subtalar
  joint in supination

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Foot Biomechanics Normal Gait

• 80 of distance runners follow heel strike
  pattern
• Sprinters tend to be forefoot strikers
• With initial contact there is obligatory external
  rotation of the tibia with subtalar supination
• As loading occurs, foot and subtalar joint
  pronates and tibia internally rotates (transverse
  plane rotation at the knee)
• Pronation allows for unlocking of midfoot and
  shock absorption
• Also provides for even distribution of forces
  throughout the foot
• Subtalar joint will remain in pronation for
  55-85 of stance phase
• occurring maximally as center of gravity passes
  over base of support
• As foot moves to toe-off, foot supinates, causing
  midtarsal lock and lever formation in order to
  produce greater force

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Foot Biomechanics Pronation Supination

• Excessive or prolonged pronation or supination
  can contribute to overuse injuries
• Have them walk in water and see what happens

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Foot Biomechanics Pronation Supination
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Foot Biomechanics Excessive Pronation

• Excessive Prontation
• Major cause of stress injuries due to overload of
  structures during extensive stance phase or into
  propulsive phase

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Foot Biomechanics Excessive Supination

• Excessive Supination
• Limits internal rotation and can lead to
  inversion sprains, tibial stress syndrome,
  peroneal tendinitis, IT-Band friction syndrome
  and bursitis

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Foot Evaluation (History)

• Generic history questions
• 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?
• Questions specific to the foot
• Location of pain - heel, foot, toes, arches?
• Training surfaces or changes in footwear?
• Changes in training, volume or type?
• Does footwear increase discomfort?

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Foot Evaluation (Observation)

• Observations
• Does athlete favor a foot, limp, or is unable to
  bear weight?
• Shoe Wear Patterns
• Over pronators tend to wear out shoe under 2nd
  metatarsal
• Athletes often mistakenly perceive wear on the
  outside edge of the heel as being the result of
  over-pronation
• Wear on the lateral border of the shoe is a sign
  of excessive supination
• Heel counter and forefoot should also be examined

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Foot Evaluation (Palpation)

• Bony Palpation
• Medial calcaneus

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Foot Evaluation (Palpation)

• Soft Tissue
• Deltoid ligament
• Medial longitudinal arch
• Plantar fascia
• Transverse arch

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Foot Evaluation (Special Testing)

• Manual Muscle Testing
• Toe Flexion
• Toe Extension

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Foot Evaluation (Special Testing)

• Tinels Sign
• Tapping over posterior tibial nerve producing
  tingling distal to area
• Numbness paresthesia may indicate presence of
  tarsal tunnel syndrome
• Mortons Test
• Transverse pressure applied to heads of
  metatarsals causing pain in forefoot
• Positive sign may indicate neuroma or
  metatarsalgia

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Foot Evaluation (Special Testing)
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Foot Common Injuries

• Tarsal Region
• Fractures (Calcaneus, Talus, Etc.)
• Stress Fractures
• Subluxations

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Foot Common Injuries

• Metatarsal Region
• Strains
• Fractures (Jones) / Stress Fractures
• Bunion
• Neuroma

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Ankle Evaluation (History)

• Generic History questions
• 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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• Severity of sprains is graded (1-3)
• With inversion sprains the foot is forcefully
  inverted or occurs when the foot comes into
  contact w/ uneven surfaces

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• Grade 1 Inversion Ankle Sprain
• Etiology (how it happens) Mechanism
• Occurs with inversion plantar flexion and
  adduction
• Causes stretching of the anterior talofibular
  ligament (ATFL)
• Signs and Symptoms
• Mild pain and disability weight bearing is
  minimally impaired point tenderness over
  ligaments and no laxity
• Management/Treatment/Rehabilitation
• PRICE for 1-2 days limited weight bearing
  initially and then aggressive rehab
• Tape may provide some additional support
• Return to activity in 1 -10 days

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• Grade 2 Inversion Ankle Sprain
• Etiology (how it happens) Mechanism
• Moderate inversion force causing great deal of
  disability with many days of lost time
• Signs and Symptoms
• Ligaments have an end point
• Feel or hear pop or snap moderate pain w/
  difficulty bearing weight tenderness and edema
• Positive talar tilt and anterior drawer tests
• Possible tearing of the anterior talofibular and
  calcaneofibular ligaments
• Management/Treatment/Rehabilitation t
• PRICE for at least first 72 hours X-ray exam to
  rule out fx crutches 5-10 days, progressing to
  weight bearing

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• Management (continued)
• Will require protective immobilization but begin
  ROM exercises early to aid in maintenance of
  motion and proprioception
• Taping will provide support during early stages
  of walking and running
• Long term disability will include chronic
  instability with injury recurrence potentially
  leading to joint degeneration
• Must continue to engage in rehab to prevent
  against re-injury

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• Grade 3 Inversion Ankle Sprain
• Etiology / Mechanism
• Relatively uncommon but is extremely disabling
• Caused by significant force (inversion) resulting
  in spontaneous subluxation and reduction
• Causes damage to the anterior/posterior
  talofibular and calcaneofibular ligaments as well
  as the capsule
• Signs and Symptoms
• Severe pain, swelling, discoloration
• Unable to bear weight
• Positive talar tilt and anterior drawer (no end
  point

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Injury Prevention

• Strength training allows the supporting
  musculature to stabilize where ligaments may no
  longer be capable of holding the original tension
  between bones of the joint. This will also help
  prevent reinjury.

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• Management
• PRICE, X-ray (physician may apply dorsiflexion
  splint for 3-6 weeks)
• Crutches are provided after cast removal
• Isometrics in cast ROM, PRE and balance exercise
  once out
• Surgery may be warranted to stabilize ankle due
  to increased laxity and instability

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Dislocation
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Ankle Evaluation (Observation)

• Observations
• 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?

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Ankle Evaluation (Palpation)

• Bony Anatomy
• Soft Tissue Anatomy

• Soft Tissue Anatomy

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Ankle Evaluation (Special Testing)

• Fracture Tests
• Tap / Percussion / Bump
• Active / Passive Range of Motion (R.O.M.)
• Manual Muscle Testing
• Check all motions of the Foot and Ankle
• Joint Stability Tests
• Anterior Drawer
• Special Pathology Tests
• Thompson Test

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Ankle Evaluation (Special Tests)
Fracture Test
Compression Test
Percussion Test
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Ankle Evaluation (Special Tests)

• 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

Anterior Drawer Test
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Ankle Evaluation (Special Tests)

• Talar tilt test (ATF,CF,PTF)
• 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

Talar Tilt Test
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Ankle Injury bad
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Ankle Evaluation (Special Tests)

• Other Special Tests
• Thompsons 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

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Ankle Evaluation (Special Tests)

• 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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Foot Rehabilitation

• Three simple keys
• Range of Motion
• Needed to increase motion and return to function
  as quickly as prudent and possible
• Strength
• Needed to deter further problems or protect the
  area of injury from further injury
• Functionality
• Needed to return the student-athlete or patient
  to normal daily activities within reason.

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Foot Rehabilitation

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

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Foot Rehabilitation

• Range of Motion
• Joints
• Joint Mobilization
• BAPS Board / Disc
• Functionality of foot
• Plantar Fascia
• Towel pulls
• Cotton ball movement
• Gastroc / Soleus Stretching

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Joint Mobilizations

• Can help normalize joint motion

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Foot Rehabilitation

• Strengthening
• Towel Pulls
• Cotton Ball Pick-up
• Thera-band Exercises
• Dorsiflexion, Plantar Flexion, Inversion,
  Eversion
• Isometric Exercises
• Dorsiflexion, Plantar Flexion, Inversion,
  Eversion
• PNF Diagonals / D1 and D2 Patterns
• Proprioception
• Dyna-Disc / Wobble Boards / Couch Cushions / Etc.

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Foot Rehabilitation

• Towel Exercises

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Foot Rehabilitation

• Rehab plans are focusing more on closed kinetic
  chain activities
• Exercises should incorporate walking, running,
  jumping in multiple planes and on multiple
  surfaces

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• Neuromuscular Control Training
• Can be enhanced by training in controlled
  activities
• Uneven surfaces, BAPS boards, rocker boards, or
  Dynadiscs can also be utilized to challenge
  athlete

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Foot Rehabilitation

• Weight Bearing
• If unable to walk without a limp, crutch or can
  walking may be introduced
• Poor gait mechanics will impact other joints
  within the kinetic chain
• Progressing to full weight bearing as soon as
  tolerable is suggested

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Foot Rehabilitation

• General Body Conditioning
• Because a period of non-weight bearing is common,
  substitute means of conditioning must be
  introduced
• Pool running upper body ergometer
• General strengthening and flexibility as allowed
  by injury

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Ankle Rehabilitation

• General Body Conditioning
• Must be maintained with non-weight bearing
  activities
• Weight Bearing
• Non-weight bearing vs. partial weight bearing
• Protection and faster healing
• Partial weight bearing helps to limit muscle
  atrophy, proprioceptive loss, circulatory stasis
  and tendinitis
• Protected motion facilitates collagen alignment
  and stronger healing

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Ankle Rehabilitation

• Joint Mobilizations
• Movement of an injured joint can be improved with
  manual mobilization techniques
• Flexibility
• During early stages inversion and eversion should
  be limited
• Plantar flexion and dorsiflexion should be
  encouraged
• With decreased discomfort inversion and eversion
  exercises should be initiated
• BAPS board progression

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Ankle Rehabilitation

• Strengthening
• Isometrics (4 directions) early during rehab
  phase
• With increased healing, aggressive nature of
  strengthening should increase (isotonic exercises
• Pain should serve as the guideline for
  progression
• Tubing exercises allows for concentric and
  eccentric exercises

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Ankle Rehabilitation
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Ankle Rehabilitation
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Ankle Rehabilitation

• 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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Ankle Rehabilitation
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Tape vs. Brace

• Why choose one over another
• Taping may be more time consuming over brace
• Braces may or may not allow more support over
  tape
• Tape allows more functional movement and often
  feels more stable
• Tape will loosen with time
• Braces will often loosen with time
• It really is based on the quality of the brace
  vs. the ability of the person to tape. Both have
  advantages and disadvantages.

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Ankle Rehabilitation

• 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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Injury prevention

• Tight Achilles tendons can predispose someone to
  injuring the ankle. Tendonitis, plantar
  fasciitis, and other disorders may occur due to a
  tight Achilles tendon.

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Injury Prevention

• Footwear is something often overlooked but
  improper footwear can predispose someone with a
  foot condition such as pes planus (flat feet) to
  be more prone to having problems with their feet
  and ankles.

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The Ankle

• What are the 4 bone in the Ankle?
• What are the 2 muscles in the posterior of the
  aspect of the Tibia?
• What is the one muscle on the anterior of the
  Tibia?
• If you have a patient that has a possible Stress
  Fracture what is and how would you explain it to
  your patient?

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The Ankle

• What is the difference between a fracture and a
  broken bone?
• What is a Sprain?
• What is a Strain?
• What is an Isometric Contraction?
• What is an Isotonic Contraction?

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The Ankle

• What is the difference between a 1st, 2nd and 3rd
  degree sprain?
• What is P.R. I.C.E.C.?
• What are the exercises you would have someone do
  in Phase One of rehab.?
• What would you have them do in Phase Two?
• Phase Three