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Foot, Ankle and Lower Leg Problems

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Rest, stretch, ice, cross-friction massage. Eccentric strengthening ... Felt like he was hit with a ball. Trouble with toe raise. Medial Gastrocnemius Strain ... – PowerPoint PPT presentation

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Title: Foot, Ankle and Lower Leg Problems


1
Foot, Ankle and Lower Leg Problems
  • Scott W. Pyne, M.D.
  • CDR, MC, USN
  • United States Naval Academy

2
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

3
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

6
Lateral Ankle
  • Lateral Malleolus Distal Fibula
  • Tibiofibular Ligaments
  • Syndesmosis
  • Anterior Talofibular Ligament
  • Calcaneofibular Ligament
  • Posterior Talofibular Ligament
  • Peroneus Brevis
  • Peroneus Longus

7
Anterior Ankle
  • Tibialis Anterior Tendon
  • Extensor Hallicus Longus
  • Anterior tibiofibular ligament

8
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

9
Medial ankle
10
Posterior Ankle
  • Calcaneus
  • Achilles Tendon
  • Gastrocnemius
  • Soleus
  • Posterior tibiofibular ligament

11
Plantar Foot
  • Plantar fascia
  • Longitudinally oriented collagen fibers
  • Medial calcaneal tubercle
  • Proximal phalanges

12
Dorsal foot
  • Extensor tendons
  • Dorsal pedis artery
  • Digital nerves

13
Midfoot Congruity
  • Tarsometatarsal Articulation
  • First and second metatarsal with medial and
    intermediate cuneiform
  • Lisfranc ligament
  • Transverse ligaments

14
Which foot is overpronated?
D
  • A
  • B
  • C
  • D

A
B
C
Q
15
A Word About Imaging
  • Ottawa Ankle Rules
  • X-rays
  • Stress views
  • Bone Scan
  • CT
  • MRI

16
Normal Ankle X-ray
17
Normal Foot X-ray
18
Acute Foot and Ankle Injuries
  • Bone
  • Ligament
  • Muscle Tendon
  • Nerve Blood Vessels
  • Remember mechanism of injury!

19
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

20
Case 1 History
  • Previous history
  • Previous rehabilitation
  • Ankle protection
  • Ability to bear weight
  • Neurovascular symptoms

21
Case 1 Physical Exam
  • Able to walk
  • Swelling Laterally
  • Tender laterally, but not bone
  • Slight bruising
  • Neurovascular intact
  • No instability

22
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
23
Case 2
  • 34 yo male football player
  • Right ankle rolled up under him during tackle
  • Walked off field
  • Unable to return to play

24
Case 2 History
  • Previous history
  • Previous rehabilitation
  • Ankle protection
  • Ability to bear weight
  • Neurovascular symptoms

25
Case 2 Physical Exam
  • Difficulty bearing weight
  • Swelling throughout
  • Tender laterally, anteriorly, medially
  • Neurovascular intact
  • Painful Tib-Fib Squeeze

26
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

27
Lateral Ankle Sprain
  • Evaluation
  • Image as necessary
  • Functional Assessment
  • Treatment
  • Protect, rest, ice, compress, elevate
  • Brace
  • Movement
  • Physical Therapy ROM, strength, proprioception

28
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 …

29
Case 3 Physical Exam
  • Difficulty bearing weight
  • Swelling throughout
  • Tender laterally, anteriorly, medially
  • Neurovascular intact
  • Painful tib-fib squeeze

30
Danis-Weber Classification
31
Ankle Fracture
  • Evaluation
  • Neurovascular
  • Mortise and proximal fibula
  • Treatment
  • Bulky splint
  • Protect, elevate
  • Referral

32
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
33
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

34
Case 4 Differential Diagnosis
  • What lives in the back of the leg
  • Calcaneus unlikely
  • Calf muscle
  • Gastrocnemius
  • Soleus
  • Achilles Tendon

35
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

36
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

37
Case 5 Differential Diagnosis
  • What lives on the lateral ankle?
  • Bone
  • Lateral malleolus
  • Talus
  • Ligaments
  • Tendons
  • Peroneus brevis
  • Peroneus longus

38
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

39
Case 6
  • Football player tackled
  • Entire stadium heard a loud crack
  • Defense immediately calling trainers
  • Never had this happen before

40
Case 6 Physical Exam
  • Painful distal leg
  • Resistant to any movement
  • Something doesnt look right
  • Deformity
  • Swelling

41
Tibia Fibula fracture
  • Evaluation
  • Neurovascular status
  • X-ray
  • Treatment
  • Bulky splint
  • Protect and elevate
  • Referral

42
Chronic Ankle Injuries
  • Remember functional anatomy
  • Previous Injury
  • How long ago?
  • Treatment?
  • Previous problem or limitations?
  • What is different?
  • Reason for the visit today?

43
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

44
Case 7 Physical Exam
  • Normal gait
  • Minimal swelling laterally
  • No bruising
  • Normal strength
  • Neurovascular intact
  • Poor proprioception

45
Case 7 Differential Diagnosis
  • What lives laterally?
  • Bone
  • Lateral malleolus
  • Talus
  • Ligaments
  • Tendons
  • What will help?

46
Case 7 Diagnosis
  • Chronic ligament injury
  • Positive anterior drawer
  • What can we do?
  • Strengthen
  • Brace
  • Operate
  • How to decide?

47
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

48
Case 8 Differential Diagnosis
  • This one is different
  • Global ankle problem
  • Possible Causes
  • Bone
  • Infection
  • Crystal deposition

49
Case 8
  • Evaluation
  • X-ray
  • Blood Work
  • Aspiration
  • Treatment options
  • Good luck
  • Activity modification
  • Medications
  • Corticosteroid injection
  • Surgery

50
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

51
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

52
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

53
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

54
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

55
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

56
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

57
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

58
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

59
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

60
What is the word starting with p that means
cold?
  • Polarthermic
  • Poikilothermia
  • Poikilodactyly
  • Poi

Q
61
Chronic Exertional Compartment Syndrome
  • Evaluation
  • Differentiate leg pain
  • Pressure measurement
  • Treatment
  • Conservative
  • Surgical fasciotomy

62
Tibial Stress Fracture
  • X-ray
  • No finding
  • Periosteal reaction
  • Dreaded black line
  • Bone Scan
  • MRI

63
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

64
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

65
Mortons Neuroma
  • Interdigital nerve chronic stress
  • Treatment
  • New shoes
  • Wider toe box
  • Metatarsal pads
  • Injection

66
Metatarsal Stress Fracture
67
Questions?
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