1. Foot and Ankle Rance L. McClain, D.O., FACOFP Associate Professor – FM Dept. KCUMB-COM

3. Learning Objectives 1.Review the diagnosis of the foot and ankle 2.Apply specific osteopathic testing to the diagnosis of the foot and ankle 3.Understand the application of osteopathic treatment to the foot and ankle

4. General The foot and ankle is the focal point of total body weight, performing this function both when stationary and with gait Adaptation to the terrain upon which a person stands and walks

5. General Problems with the foot and ankle can arise from mechanical, pathological, vascular, or inflammatory origins The foot is affected not only by local stresses, but also by systemic diseases Approximately 40% of people have foot and ankle problems

6. Inspection - Ankle Range of Motion Plantar flexion: 50 degrees Dorsiflexion 20 degrees Excess motion can cause fibular dysfunction

8. Inspection - Ankle Accessory motions of side-to-side glide, rotation, abduction, and adduction are also present depending on the position of the foot Because the talus is wider anteriorly than posteriorly, the ankle is more mobile in plantarflexion than dorsiflexion

9. Inspection - Ankle Ankle Mortis –Relationship of the medial and lateral malleoli causes the ankle articulation to be held in a position of 15 degrees of toeing out

11. Inspection - Ankle Tibiofibular syndesmosis –Responsible for maintaining the width of the ankle mortise –If torn, the mortise can widen, and the talus becomes unstable

12. Inspection - Ankle Soft Tissue & Edema –Medially located deltoid ligament –Laterally located anterior & posterior talofibular ligaments, as well as the calcaneofibular ligament Anterior talofibular ligament is highly susceptible to injury Lateral ankle edema inferior and anterior to the lateral malleolus

14. Inspection - Ankle Unilateral swelling is usually trauma, while bilateral swelling is usually indicative of cardiovascular problems (CHF, venous insufficiency, etc.)

16. Inspection - Ankle Vascular Posterior tibial pulse When you progress down to the inspection of the foot, you will also inspect the dorsal pedal pulse

17. Inspection - Foot How many toes are present and are they deformed

18. Inspection - Foot How does the foot contact the floor –Pressure points can develop calluses –Skin is usually thicker at the weight bearing areas at the heel, the lateral border, and the 1 st and 5 th metatarsal heads

19. Inspection - Foot Can you slide your fingers under the medial arch of the foot

20. Inspection - Foot Arches –Lateral longitudinal arch Calcaneus, Cuboid, 4 th & 5 th Metatarsal bones Low arch with limited mobility Transmits weight and thrust to the ground –Medial longitudinal arch Calcaneus, Talus, Navicular, Cuneiforms, and 1 st - 3 rd Metatarsals Higher arch, much more mobile. Sustained by the skeletal structures as well as the Plantar Fascia

21. Inspection - Foot Inspect the arches with the patient sitting – Spastic flat foot will cause the foot to dorsiflex and evert, whereas a normal foot will plantar flex and invert

22. Inspection - Foot Range of Motion –Calcaneal abduction and adduction at the subtalar articulation –Inversion and eversion are combination motions Inversion is calcaneal adduction, navicular rotation, and glide on the talus Eversion is produced by the opposite motions above

23. Inspection - Foot Forefoot abduction and adduction Pronation is the motion of the foot and ankle combining calcaneal abduction, forefoot abduction, subtalar- cuboid- navicular eversion, and ankle dorsiflexion Supination consists of calcaneal adduction, subtalar-cuboid-navicular inversion, forefoot adduction, and ankle plantar flexion

25. Shoe Inspection Alterations in structure and function will show in the wear and tear on shoes Normal wear from heal strike to toe off gives a transverse crease

26. Shoe Inspection Abnormal wear examples Foot Drop (neurological damage) Dorsiflexors are paralyzed Toe scrapes in ambulation causes scuff marks on the toe box and the front part of the soles Hallux Rigidus (no motion of the 1 st MTP joint) Does not allow normal toe off with gait, leading to an oblique crease in the shoes

29. Shoe Inspection Flat Feet (Pes planus) –Tend to over pronate and increase wear on the soles of the shoe medially High Arches (Pes cavus) –Tend to supinate and increase wear on the lateral aspects of the soles of the shoes

31. Lab/Treatment Section Evaluation –Dorsiflexion/Plantarflexion –Subtalar Abduction/Adduction –Calcaneal Inversion/Eversion –Navicular (medial) & Cuboid (lateral) –Metatarsal motion –Phalanges motion

32. Lab/Treatment Section Muscle Energy –Dorsiflexion/plantarflexion –Subtalar abduction/adduction –Calcaneal inversion/eversion

33. Lab/Treatment Section Counterstrain –Calcaneal TP (plantar fasciitis) Soft tissue treatment –Plantar fascia Lymphatics –Effleurage & Pétrissage

34. Lab/Treatment Section HVLA –Inversion/eversion calcaneus (ankle traction) –Subtalar thrust –Dorsal metatarsals treatment –Transtarsal thrust –Cuboid-Navicular treatment (Hiss whip)