Prof. Dr. Ece AYDOĞ Physical Medicine and Rehabilitation Foot and Ankle Pain Prof. Dr. Ece AYDOĞ Physical Medicine and Rehabilitation

FUNCTIONAL ANATOMY AND BIOMECHANICS The ankle, or tibiotalar, joint comprises the articulation between the foot (talus) and the lower leg (distal tibia and fibula).

Anatomic regions Forefoot; toes and metatarsal bones; metatarsophalangeal (MTP) and interphalangeal joints Midfoot; tarsometatarsal (TMT) joints connect the forefoot to the midfoot, which comprises the three cuneiform bones, the navicular, and the cuboid Hindfoot; talus and calcaneus, talocalcaneal (subtalar), talonavicular, and calcaneocuboid articulations.

PHYSICAL EXAMINATION Hallux valgus or bunion Hammer toes, Location of swelling Deformity; Hallux valgus or bunion Hammer toes, Flatfoot deformity (characterized by hindfoot valgus/forefoot abduction). Callosities Rheumatoid nodules Ulcerations Wear patterns: “A deformed foot can deform any good shoe; in fact, in many cases the shoe is a literal showcase for certain disorders.”

Hallux Valgus Gece Ateli

Flatfoot Deformity

Flatfoot Deformity

Rheumatoid nodules Diabetic ulcer

PHYSICAL EXAMINATION Metatarsal heads and MTP joints palpation in patients with RA or nonarthritic metatarsalgia; tenderness, synovitis, and swelling. Tenderness over the posterior aspect of calcaneus; Achilles tendinitis Pain over the medial tubercle (palpable on the medial plantar surface); plantar fasciitis. Tenderness over sinus tarsi of the hindfoot (located laterally, just anterior and distal to the tip of the fibula); talocalcaneal joint pathology Tenderness over the anterior joint line usually correlates with ankle joint pathology.

Calcaneal medial tubercule (Plantar fasciitis) Talocalcaneal yoint pathology

PHYSICAL EXAMINATION Range of motion analysis: 10 to 20 degrees of dorsiflexion 40 to 50 degrees of plantar flexion.

Normal hindfoot inversion and eversion are each approximately 5 degrees.

COMMON CAUSES OF ANKLE PAIN ANTERIOR AND CENTRAL ANKLE PAIN Spur and osteophyte formation Arthritis (degenerative or inflammatory) Anterior tibial tendon tendinitis or tendinosis Stress fractures Osteochondral defect Talar stress fracture Osteochondral defect

POSTERIOR JOINT PAIN Achilles tendon in most instances, Achilles pain results from degenerative tendinosis, with or without an overlying tendinitis. associated intratendinous spur formation is common spur excision also frequently entails tendon débridement, reconstruction, and transfer.

Spur formation (Plantar calcaneal and achilles tendon)

Achilles tendon protected by two distinct bursae. more superficial bursa is immediately subcutaneous and becomes inflamed primarily with irritation from ill-fitting shoes with a tight counter (“pump bump”).

Achilles tendon “retrocalcaneal” bursa is a larger structure that lies deep to the Achilles tendon. Inflammation of this structure often accompanies Achilles tendinitis/tendinosis. It also may be irritated by an enlarged posterior superior calcaneal tuberosity, sometimes referred to as a Haglund's deformity.

MEDIAL ANKLE PAIN Stress fracture Arthritis Inflammation or degeneration (or both) of the posteromedial flexor tendons, including the posterior tibial tendon and the flexor hallucis longus and flexor digitorum longus tendons long-standing synovitis and dysfunction of posterior tibial tendon ultimately may lead to collapse of the arch and the development of an acquired flatfoot deformity.

MEDIAL ANKLE PAIN Tarsal tunnel syndrome is another cause of posteromedial ankle pain. pain that radiates into the plantar foot percussion of the tarsal tunnel reproduces these symptoms (Tinel's sign).

LATERAL ANKLE PAIN Stress fracture Arthritis Peroneal tendon pathology; tenosynovitis longitudinal “split” tears chronic tendon instability the tendons sublux over the posterolateral edge of the fibula, causing pain and attritional tearing

COMMON CAUSES OF FOOT PAIN FOREFOOT PAIN The forefoot region is a common location of foot pain.

Rheumatoid Arthritis inflammation and progressive MTP synovitis eventually lead to capsular distention and destruction. loss of collateral ligament stability and, finally, destruction of the articular cartilage and bone

FOREFOOT PAIN Hallux valgus deformity or bunion; Hallux rigidus commonly encountered in patients with and without inflammatory arthritis RA; 70% progression of this deformity may be accelerated further by loss of support from the adjacent lesser MTP joints. Hallux rigidus Degenerative arthritis Sesamoiditis Osteonecrosis Fracture

FOREFOOT PAIN Claw toes Hammer toes Mallet toes Etiologies; arthritis, trauma, nerve/muscle imbalance, and chronic use of shoes with inadequate toe boxes. Instability; mechanical causes (long second metatarsal) inflammatory disease MTP joint subluxation

Claw toe Mallet finger

FOREFOOT PAIN Metatarsalgia Gastrocnemius contracture or tight Achilles tendon; the forefoot is prematurely loaded during the stance phase of gait. Hammer toes and mallet toes can result in downward pressure on the metatarsal heads, leading to metatarsalgia. In elderly patients and patients with inflammatory arthritis, atrophy of the plantar fat pad of the forefoot also can result in metatarsalgia.

LATERAL FOREFOOT Morton's neuroma: . between the third and fourth metatarsal heads burning, aching, or shooting pain symptoms are especially exacerbated with tight shoes .

LATERAL FOREFOOT Bunionette: angular deformity of the fifth toe pain over the lateral aspect of the fifth metatarsal head

MIDFOOT PAIN Arthritis at the TMT joints most frequently the first TMT joint on the medial side of the foot instability of the first TMT joint, repetitive stress can lead to dorsiflexion of the first metatarsal midfoot arthritis can lead to an abduction deformity of the foot, where the forefoot and metatarsals deviate outward.

MIDFOOT PAIN lateral midfoot pain: peroneal tendinitis stress fracture of the fifth metatarsal medial midfoot pain: accessory navicular bone osteonecrosis of the native navicular bone insertional posterior tibial tendinitis

HINDFOOT PAIN joints of the hindfoot talonavicular talocalcaneal calcaneocuboid degenerative and inflammatory arthritis RA; 21% to 29% posterior tibial tendinitis and dysfunction Inflammation Degeneration Dysfunction

HEEL PAIN Plantar fasciitis; inferior heel pain worse when first getting up in the morning or getting up after sitting for a long time Achilles tendinosis; posterior heel pain worse during or after exercise Nerve entrapment; first branch of the lateral plantar nerve (Baxter's nerve) medial heel pain Calcaneal stress fracture; medial and lateral pain Calcaneal stress fracture usually can be distinguished by a positive “squeeze test,” with compression of both sides of the heel.

NONOPERATIVE TREATMENT Medical management Nonsteroidal anti-inflammatory drugs Steroids Disease-modifying antirheumatic drugs

NONOPERATIVE TREATMENT Shoewear modification deep, wide toe box firm heel counter soft heel Well-constructed walking or jogging shoes usually provide sufficient room for mild-to-moderate deformities

NONOPERATIVE TREATMENT Often it is necessary to prescribe a custom orthotic insert for patients with more moderate deformities It is typically necessary to remove the insole of the shoe to make room for the orthotic insert Custom orthoses; rigid, semirigid, softer accommodative devices Rigid and semirigid orthoses usually are used to correct supple deformities and should be used with caution in patients with arthritis Most walking or jogging shoes suffice.

Ski boot insert

NONOPERATIVE TREATMENT More commonly, these patients, especially if they have RA, benefit from accommodative orthoses (i.e., orthoses made of softer material that can be molded to “accommodate” a deformity) Accommodative orthoses can be modified further by incorporating a “relief” under a deformity, further unloading it When sending patients for orthoses, it is best to provide the orthotist with a prescription that includes the patient's precise diagnosis (e.g., metatarsalgia) and the type of orthosis and any modifications desired (e.g., a “custom accommodative orthosis with a relief under the lesser metatarsal heads”).

Injections Mixture of anesthetic and corticosteroid Injection of a corticosteroid near or directly into a tendon can adversely affect the biomechanical properties of the tendon, ultimately leading to rupture Avoid corticosteroid injections into the lesser MTPs when there is evidence of joint instability. Such injections can lead to further attenuation of the joint capsule and result in frank joint dislocation.

OPERATIVE TREATMENT If symptoms persist despite nonoperative management, surgical intervention should be considered Arthrodesis (joint fusion), Arthroplasty (joint replacement), Corrective osteotomy, Tendon débridement and transfer, Synovectomy (joint or tendon).