1. The Foot and Ankle Complex
Sarah Rayner
Extended Scope Practitioner Physiotherapist

2. Anatomy
The ankle and foot is a complex structure comprised of 28 bones (including 2 sesamoid bones) and 55 articulations (including 30 synovial joints), interconnected by ligaments and muscles
In addition to sustaining substantial forces, the foot and ankle serve to convert the rotational movements that occur with weight bearing activities into sagittal, frontal, and transverse movements

3. Anatomy: Ankle

4. Anatomy : Foot Hindfoot (posterior segment): talus and calcaneus
Midfoot (middle segment): navicular, cuboid and 3 cuneiforms
Forefoot (anterior segment): metatarsals and the phalanges

5. Examination: site of pain

6. Examination: site of pain

7. Examination: site of pain

8. Anatomy: Surface marking practical
Talocrural joint line
Medial malleolus
Lateral malleolus
Navicular
1st MTP joint
Achilles tendon
Tibialis posterior tendon
Anterior talofibular ligament
Calcaneofibular ligament
Peroneus longus and brevis
Plantarfascia attachment to calcaneus
Midtarsal joint line

9. Conditions: lateral ligament injury
Acute inversion of ankle
Usually occurs in sports requiring quick change of direction especially if it takes place on uneven surfaces such as grass.
Also common in sports when a player has jumped and lands on top of another players feet.
Most common mechanism is Inversion coupled with PF.
ATFL injured first then CFL as ATFL is taut in PF
On Examination:
Lateral ankle pain and swelling
Pain on inversion combined with plantarflexion
Tests: Anterior draw and talar tilt

10. Ottawa Ankle Rules

11. Conditions: lateral ligament injury
Management
PRICE
Graded return to sport
May require Physiotherapy
Rate of recovery dependent on severity
Failure to resolve
Continued instability or possible OCD
Refer to CATTS / Orthopaedics
May require further investigations ? MRI
Surgical intervention (arthroscopy +/- stabilisation procedure

12. Conditions: Plantarfasciitis
Insertional heel pain of the plantar fascia with or without a heel spur.
Biomechanical abnormalities cause pathological stress to the plantar soft tissues
Typical presentation:
Isolated heel pain on initiation of WB (on rising am or after prolonged sitting/rest)
Predisposing factors:
High BMI
Tightness of TA
Inappropriate shoe wear
On Examination
Pain on palpation at plantar fascia insertion

13. Conditions: Plantarfasciitis management
Initial self directed treatment (up to 6 weeks):
NSAID’s
Regular calf and plantar fascia stretches
Avoidance of flat shoes and barefoot walking
OTC arch supports and heel cushions
Ice
Weight loss
Limitation of extended physical activity
Consider steroid injection where appropriate
If failing to improve refer on to local CATTS/MSK service:
Custom orthotics (podiatry)
Night splints
Steroid injections
Immobilisation
Extracorpeal shockwave therapy
Surgical plantar fascia release

14. Conditions: Achilles tendinopathy
Non-insertional:
Usually a degenerative mid substance lesion
Often with neovascularisation and proliferation of neural structures in the area which cause pain
Often poor collagen structure, poor healing and no inflammation on imaging
Insertional:
Change in microscpic structure with increased Glycosaminoglycans
Change in fibrillar structure giving swelling
Tendinitis / tendinosis depends on degree of inflammation
Bursitis often associated with Haglund’s deformity (“pump bumps”)

15. Conditions: Non-insertional Achilles Tendinopathy
Presentation:
Most common in males but seen in all ages
Pain on Achilles loading (walking, running)
Can be debilitating
Fusiform swelling
Tightness of Gastrocnemius
Treatment:
Eccentric loading exercises
Stretches
Correct abnormal biomechanics
Physiotherapy / podiatry
Extracorpeal shockwave therapy

16. Conditions: Insertional Achilles Tendinopathy
Management
Initial conservative treatment as for non-insertional Achilles tendinopathy
Surgical debridement

17. Conditions: Achilles Ruptures
Presentation:
Patients usually feel POP in Achilles area
POP may be heard
Usually occurs in the avascular area of the Achilles 5 – 10cm above the insertion
Common in Badminton , Squash and football in that order
Usually occurs to the end of a game
On Examination:
+ve calf squeeze
Palpable dip
Management
Surgical

18. Conditions: Ankle Impingement
Anterior bony impingement:
Pain usually over anterior ankle
Pain may be anterolateral
Osteophytes usually palpable and may be associated with loss of ROM particularly dorsiflexion
Arthroscopy
Posterior Impingement
Os trigonum, Bony osteophytes
Adhesions, synovitis ; Multiple injuries or hypermobility (dancers)
FHL tendinitis
Subtalar impingement
If conservative treatment fails, posterior ankle arthroscopy

19. Conditions: Tibialis Posterior Dysfunction
Common cause of acquired flatfoot in adults
Women over 40 most at risk
Presenting features:
Pain and swelling medial hindfoot
Change in foot shape reported
On Examination:
Valgus heel, flattened longitudinal arch and abducted forefoot
Pain on resisted inversion and on palpation tibialis posterior
Pain and dysfunction on single leg heel raise

20. Conditions: Tibialis Posterior Dysfunction Management
Conservative treatment
Rest
Orthotics and podiatry
Weight management
Surgical management
Hindfoot osteotomy with tendon transfer
Arthrodesis of the hindfoot

21. Conditions: Hallux Rigidus
1st MTP Arthritis
Epidemiology:
Women > men
60% bilateral
Late adulthood
Etiology:
Direct: trauma, fracture
Indirect: TMT hypermobility, flat 1st MTP joint, Long 1st MT, pes planus, inflammatory
Clinical Symptoms:
Limited 1st MTP movement
Pain on toe off
Pain with activity
Pain with shoewear
Swelling
Limp: lateral foot WB, external rotation of hip

22. Conditions: Hallux Rigidus
Management:
Conservative
Footwear
Activity modification
Podiatry
Injections
Surgery
Cheilectomy
Osteotomy
Joint replacement
Fusion

23. Conditions: Morton’s Neuroma
Swelling of nerve and scar tissue arising from compression of the interdigital nerve
Often pain radiating into the toes accompanied by pins and needles
Pain increased by forefoot weight bearing and with narrow fitting footwear
On Examination:
Interdigital pain commonly in the 3rd and 2nd interdigital space
+ve Mulder’s test
Management:
Orthotics
Injection
Surgical removal

24. Examination: Summary
As always take a good history to guide your examination: site of pain, overuse or trauma, swelling, WB status etc.
Gait and function (heel raise, weight transfer, proprioception)
Observations: in standing and sitting/lying
Swelling, heat, scars, bruising, circulation, deformity
Biomechanics (pronation/supination, abducted)
ROM
Resisted testing
Palpation
Special Tests
Anterior draw rest
Talar tilt test
Squeeze test
Calf squeeze test (Thompson test)
Lateral squeeze test for Morton’s neuroma (Mulder’s click)

25. Case Studies: Practical
Monica a 30-year-old medical receptionist presents with sore Achilles tendons. Over the weekend she has done a 15-mile sponsored walk. She is a bit annoyed because although she does not do any significant walking she feels that she keeps herself very fit with her Latin American dancing. She also bought an expensive pair of Nike trainers especially for the walk.
A 45-year-old lady complains of pain in her right heel. This started 3 weeks ago after she had spent the weekend helping her husband lay some flags for a patio. She describes how it feels as if she has a small ball bearing under her heel when walking.
A 65-year-old man complains of gradually increasing pain in the ball of his right foot over several months. He has had to curtail his ballroom dancing and of late his walking is becoming restricted.
A 13-year-old girl who enjoys ballet is finding increasing pain in her left big toe with her dancing. She says her big toes are not straight anymore.
A 46-year-old farmer complains about his left ankle. Apparently a year ago he had a "bad sprain" when he inverted the ankle as he was trying to catch a sheep. He went to casualty and had an X-ray (NBI) and came away with a tubigrip bandage. He was not followed up. Since then he finds himself "going over" on the ankle on uneven ground if he is not watching carefully where he puts his feet. The ankle is frequently swollen following these episodes.

26. Any Questions?
Thank you