1. Foot and Ankle Session
Cameron Bulluss, Rob Dingle, Peter Enks, Pierre
Buchholz, Gavin Jackson – Advanced Physiotherapy
and Injury Prevention
www.advancedphysio.com.au
2. Preliminaries
Useful Resources and Acknowledgements
1. Atlas of Imaging in Sports Medicine (2nd ed.). Jock Anderson and
John W Read
2. Clinical Sports Medicine. Bruckner and Khan
3. American Academy of Orthopedic Surgeons Website.
www.aaos.org
4. Advanced Physiotherapy and Injury Prevention Website
www.advancedphysio.com.au, notes will be on website (show)
Acknowledgements – Isobel Green, Jess Fidler
Introduce Colleagues
Purpose of these talks: educate, meet, value add
Who we treat
4. When to Image
If it affects management
Diagnosis is uncertain
Demanding patient
To assist with determining prognosis
Red flags
Orange flags
Failed treatment
6. Red Flags
> 50 year old
Systemic symptoms
Significant morning stiffness
Known risk factors
Past history or family history
Noctural pain
7. Orange Flags
Disability disproportionate to mechanism
Failure to respond to conservative management
Multiple opinions
Anxious patient
Education
Significant trauma (fall over 1 metre)
IV drug use
Cord or cauda equina signs
History of use of oral corticosteroids
8. Grades of Injury – Muscle/Ligament
Ligament
Grade 1 Pathology = microscopic tearing (strain)
Clinical = Tenderness but no ligament laxity
MRI = normal ligament thickness but increased periligamentous
signal
Grade 2 Pathology = partial tear
Clinical = some ligamentous laxity but firm end-point
MRI = ligament thickening +- partial discontinuity, increased signal
Grade 3 Pathology = complete tear
Clinical = increased ligament laxity and no indentifiable end point
MRI = complete ligament discontinuity + oedema and
haemorrhage
9. Anatomy of the Foot and Ankle
Bones and Articulations
Inferior tibiofibular joint
Talocrural joint
Subtalar joint
Transverse tarsal (Choparts)
Intertarsal joints
Tarsometatarsal joint (Lisfranc)
13. Case Study 1
42 year old coal-miner, twisted ankle felt pop, swelled
immediately and unable to weight-bear, ED x-rays reported
as normal, placed in backslab at hospital, told to RICE and
presented to you 2 days post injury
14. Case Study 1
Probable diagnosis?
Clinical tests to confirm
diagnosis?
Further imaging required?
16. Lateral Ligament Sprain (16 -21% of all
athletic injuries)
- Biomechanics of injury
- Clinical Tests (ant. Drawer,
palpation, inversion, KTW)
- Time frame to recover
- Likleyhood of poor prognosis
- ? Refer on
17. Management of Lateral Ligament
Sprains - conservative
RICE
Place ligament in shortened position
Boot, brace, tape
Short period of reduced weight bearing
Then progressive exercise based rehabilitation
focusing on regaining movement, balance, strength and
proprioception
2-6 weeks to recover
80% recover structurally
Strap or brace for season
18. Conservative vs Surgical For Grade 3
Lateral Ligament Tears
Rehab 87% excellent or good outcomes
Surgery 60% excellent or good outcomes (Kaikkonen 1996)
19. Treatment of Choice for Lateral
Ligament Sprain
(BRITISH MEDICAL JOURNAL VOLUME 282/ 21 1981)Early functional treatment
with a short period of protection via boot, brace or tape followed by series of exercises
designed to gradually restore range of motion, strength, proprioception
The Journal of Bone and Joint Surgery VOL. 73-A, NO. 2, FEBRUARY 1991 Summary.
After a critical review of these twelve studies, it is not difficult to select functional
treatment as the treatment of choice for acute complete tears of the lateral ligaments of
the ankle
20. Complications Following Major Lateral
Ligament Tear
Location of osteochondral Study of 30 patients with
lesions grade 3 lateral ligament tears
The arthroscopic findings
in these were
chondral lesions in 20
patients,
traumatic synovitis in 19,
adhesions in nine and a
partial rupture of the
deltoid ligament in one.
21. ANKLE TAPING DEMONSTRATION
Also show walking boot, dorsiwedge splint
Discuss management high versus low grade injuries
22. Case Study 2
Soccer Player twisted ankle Possible diagnosis?
(external rotation). Clinical tests to confirm
Presented unable to diagnosis?
weightbear with swelling Further imaging required?
anterior ankle joint. ED
series x-rays – patient told
no fracture. Reports no
swelling lateral ankle but
swelling anteriorally
23. Case Study 2
Injury to inferior tibiofibular ligaments (high ankle sprain)
24. Injuries to the Inferior tibiofibular ligaments
(syndesmotic ligaments) 3-10% of ankle sprains
Biomechanics of injury, patient presentation, clinical testing
(ext rot, squeeze), investigations, show primal dvd
27. Management of Syndesmosis Injuries
AITFL – MRI and surgical referral if high grade
tear/instability
PITFL – does not cause diastasis and treated as per a typical
sprain
28. Case Study 3
51 year old female presents Probable diagnosis?
with heel pain that she has Clinical tests to confirm
had for several months. It is diagnosis?
worse in the morning, Further imaging required?
particularly with her first
step.
29. Case Study 3 - Plantar Fasciitis
Management options
Most common foot
problem Plantar fascia stretches
Heel cord stretches
Biomechanics
Night splint
Pathology
Orthotics
?Heel spur (FDB) Tape
Time frame to recover
?referral on
Imaging?
Clinical tests
30. Case Study 4
62 year old woman,
presents with medial foot
and ankle pain of insidious
onset. Claims that she
notices the arch of her foot
has gradually collapsed
over the last few years
Probable diagnosis?
34. Acquired Adult Flat foot
Referral on?
Clinical tests
Management
Likely time frame to recover?
Likelyhood of poor outcome?
35. Case Study 5
39 year old woman Probable diagnosis?
presents with pain over the Clinical tests to confirm
mid achilles tendon diagnosis?
following commencing Further imaging required?
boot camp training.
Referral on?
Impossible to run
comfortably now, but is Likely time frame to
able to walk except up hills recover?
Likelyhood of poor
outcome?
36. Case Study 5 Achilles Tendinopathy
Apart from disorders of the tendon sheath there are no
inflammatory changes in most tendon pathologies (excluding
tendon sheath)
Alfredson’s accidental discovery
37. Tendon Facts
Types of tendon Pathology (Cook and Purdham BMJ 2008)
normal,
proliferative
failed healing
degenerative
rupture
Tendon sheath
Insertional and non-insertional tendinopathies
These pathologies can co-exist
38. Tendon Facts
Most tendon pathologies we see in the non-athletic
population are degenerative tendinopathies
Most athletic tendinopathies are insertional
39. Aeitiology
Genetic factors (more type 3 collagen, blood group O,)
Hypermobility
Higher incidence in diabetics
Increased with increasing age
Related to waist girth (BMI>30 3times greater likelyhood of
rotator cuff surgery) - ? Effect of cytokinines, lipids on tendon
health
Hormonal (positive effects from HRT)
Seronegative and metabolic disorders
40. Tendon Facts
Degenerative tendon pathology is reversible
sometimes (Alfredson, Cook 2005,Silbernagle 2008)
41. What Works Best
Best evidence is for slow resistance exercises that have an
eccentric component and this can be enhanced with the
application of a GTN patch
Achilles – painfree 49% (78% with patch) (Murrell 2007)
Achilles -Mid substance 90 %, Insertional 30%
significant improvement with eccentric program (Alfredson
2008)
42. Why Does Exercise Work
Produces new collagen (but can take 100 days)
Destruction of neovessels and nerves
Normalisation of cells
Reduces thickness of tendon
Implications for impingement
43. Implications for Management
If patient presents with acute overload a period of rest is
important
If pain in a sedentary person or is chronic we can embark
immediately on a resistance exercise program
If there is a bursae associated with the tendon then ultrasound is
worthwhile and if the bursae is inflamed consider an injection
If the tendinopathy is insertional and you are prescribing exercises
don’t allow the tendon to stretch
Many of the traditional programs are not appropriate
Expect 6 -12 months in many cases
?GTN patches and other measures such as autologous blood,
polidocinol,
44. Case Study 6
15 year old boy, falls out of a Probable diagnosis?
roof at work and lands on Clinical tests to confirm
foot. Fracture to distal tibia diagnosis?
and fibula treated by cast Further imaging required?
immobilisation for 8 weeks.
After 6 weeks of physio and
exercises ankle movement is
good but complains of
persistent forefoot pain. He
reports that he is unable to
rise up on to his toes, xray
series of foot at initial
incident show no fracture .
45. Lisfranc Injury
Although not common early management is crucial to long
term outcome
Referral on?
Likely time frame to recover?
Likelyhood of poor outcome?
46.
47. Low Velocity Lisfranc Ligament Injuries
2 predominant mechansims
Forced hyperplantarflexion with fixed midfoot
Typically involves a strap (windsurfers, equestrian, wakeboarders etc)
Foot gets stuck in strap and patient has fallen backwards
Weightbearing on forefoot, axial loading
Contact sports where a player may fall on another players heel when
forefoot weightbearing.
Landing on the forefoot with force (landing from jump, parachuting)
48. Lisfranc Ligament Injury Clinical
Echymosis
Swelling
Often unable to weight-bear
Pain on passive inversion and eversion of forefoot
X-Rays often normal or reported as normal
MRI best test
Higher grade injuries need urgent orthopaedic referral
50. Metatarsalgia
The term metatarsalgia is often used to describe pain in the
distal forefoot, but does not define a specific diagnosis or
indicate a particular mode of treatment.