foot and ankle 2022- part II physiotherapy.pptx

Rehabilitation

1. Mohammed Ali Sarhan Assistant professor of Orthopedics Physical Therapy Disorders and it’s Surgery South valley University

2. Assessment common Foot and Ankle Disorders from physical therapy point of view

3. Objectives Recognize the more prevalent foot and ankle- oriented pathologies seen in musculoskeletal practice Understand the etiology behind each of the pathologies Evaluate the treatment-oriented evidence behind each of the disease processes

4. Anatomy

5. Anatomy

6. Anatomy

7. Anatomy

8. Pathologies of the Foot and Ankle Tendinopathies Ankle Sprains Plantar Fasciitis Hallux Rigidus

9. Tendinopathies Achilles Tendinopathy Posterior Tibialis Dysfunction Flexor Hallucis Longus Peroneal Tendon

10. Achilles Tendinopathy Prevalence of 11-57% in runners compared to 2.9-4% of non-athletes with an odds ratio of 10.0 Annual incidence of 7- 9% in elite runners Increased incidence of Achilles injury as age increases

11. Achilles Tendonitis

12. Achilles Bursitis

13. Incidence 7/100,000 general population 12/100,000 in competitive athletes

14. E ti o logy Degenerative Process Achilles tendon undergoes morphologic and biomechanical changes with increasing age including: Decreased collagen diameter/density Decreased glycosaminoglycans and water content Increased nonreducible cross links Decreased tensile strength, linear stiffness, and ultimate load Decreased capacity for collagen synthesis Abnormal neovascularization which may be accompanied by an in-growth of nerve fascicles which may in part be responsible for the pain associated with Achilles tendinopathy Mechanical factors: Repetitive mechanical loads, excessive loads, contusions Structural factors: Morphologic, cellular, metabolic Fibrillar ruptures Cellular and matrix lesions Reactive tendinopathy Regeneration - adaptation Tendon dysrepair Optimized load Excessive load De g e n e r a ti v e t e n di n op a t h y Anatomical healing Clinical healing Ru p t u r e

15. Achilles Tendinopathy – Clinical Presentation Mean age 30-50 years Athletic – Running, Jumping Local tenderness of the Achilles 2-6cm proximal to its insertion Tendon thickening Decreased PF strength Decreased PF endurance Pain and stiffness after inactivity, lessens with activity and returns after activity Pain with eccentric DF (walking down stairs

16. Achilles Tendinopathy – Risk Factors Dorsiflexion ROM – Decreased (<11.5 degrees) increased risk by a factor of 3.5 Abnormal subtalar ROM Increased inversion ROM (>32.5 degrees) increased risk by a factor of 2.8 Decreases in total inversion/eversion ROM (<25 degrees) Decreased Plantar Flexion Strength Excessive pronation Hallux rigidis Intrinsic Factors

17. Training Errors – Increased mileage, intensity, hill training Footwear with insufficient rearfoot control, hard soles, or high heels Extrinsic Factors Achilles Tendinopathy – Risk Factors

18. Clinical Diagnosis Symptoms located to the midportion of the Achilles tendon and: Intermittent pain related to exercises or activity Stiffness upon weight bearing after prolonged immobility such as sleeping Achilles tendon tenderness

19. Achilles Tendinopathy – Differential Diagnosis Acute Achilles tendon rupture Partial tear of Achilles Retrocalcaneal bursitis Posterior ankle impingement Os trigonum syndrome Calcaneal stress fracture Posterior talar fracture Sural nerve Lumbar radiculopathy

20. Achilles Tendonitis Achilles Tear

21. Achilles Bursitis

22. Posterior Tibialis Dysfunction Often misdiagnosed as medial ankle sprain Tibialis posterior is the primary stabilizer of the medial longitudinal arch Can reach a prevalence of 10% in elderly ` women Estimated to affect nearly 5 million people in the US.

23. P a tho g enesis Age related tendon degeneration Fibrotic changes as a result of repeated microtrauma Abnormal forces arise from even mild flatfoot tenders , resulting in lifelong greater demands on the tibialis posterior than in a normal foot

24. Risk Factors Female > 40 years of age Flatfoot Hypertension Diabetes Steroid injection Obesity

25. Clinical Presentation Pain and swelling posterior to the medial malleolus Female > male Age > 40 Pain worse with weightbearing and with inversion and plantarflexion against resistance “Too many toes” sign Pain with single-leg toe raise Lacks normal heel varus when rising up on toes Ache after walking long distances

26. Stages of Posterior Tibial Tendinopathy Stage 1 Stage 2 Stage 3 Stage 4 Tendon pathology Deformity Tenosynovitis +/- degeneration Absent Degeneration + elongation Flexible pes planovalgus Degeneration + elongation Fixed pes planovalgus Medial +/- lateral pain Degeneration + elongation Fixed pes planovalgus Clinical findings Medial pain Mild pain with heel raise Mild weakness with hindfoot inversion Medial +/- lateral pain Too-many-toes sign Marked pain with heel raise +/- unable to perform Marked weakness with hindfoot inversion Too-many-toes sign Unable to perform heel raise Marked weakness with hindfoot inversion Medial +/- lateral pain Too-many-toes sign Unable to perform heel raise Marked weakness with hindfoot inversion Pain/crepitus with tibiotalur motion Nonope r a ti v e treatment Medial heel + sole wedge Period of immobilization Therapy Orthotic support (molded articulated AFO) Rigid AFO Rigid AFO Operative treatment T e n o s yn o v ec t o m y Repair FDL tendon transfer Calcaneal osteotomy Lateral column lengthening Heel cord lengthening Triple arthrodesis Ti b iotalo c al c a n eal arthrodesis Triple arthrodesis with total ankle arthroplasty (expiremental)

27. Diagnosis Medial pain or swelling behind the medial malleoli AND change in foot shape demonstrates a sensitivity of 100%

28. Differential Diagnosis Deltoid ligament sprain Flexor digitorum longus sprain Flexor hallucis longus injury Navicular stress fracture Tarsal Tunnel Syndrome

29. Tarsal Tunnel Syndrome Involves the motor and sensory branches of the tibial nerve (L4 to S3) as it travels underneath the flexor retinaculum

30. E ti o logy Can be a result of Posterior Tibial Tendon Dysfunction leading to hyperpronation in the mid-foot and resultant increased tension in the tibial nerve Space occupying lesion including ganglia, accessory muscles or tenosynovitis of adjacent flexors

31. Risk Factors Obesity Athletic Increased age Female Foot deformities Repeated ankle sprains

32. Clinical Presentation Local burning pain at the posteromedial heel Passive eversion elicits patient symptoms • +Tinel’s • +/- toe numbness • +/- toe clawing Worse with prolonged walking Flat foot Weakness in plantarflexion

33. Differential diagnosis Lumbar spine referral Fracture Plantar fasciitis Posterior tibial tendon dysfunction

34. Peroneal Tendon – Clinical Presentation Swelling not typically present Pain posterior or distal to lateral malleoli, around cuboid Varus hindfoot Forefoot varus Pain with terminal stance Unilateral heel rise painful Limited ankle DF Pain with passive DF and inversion Pain with resisted plantarflexion/eversion May have history of chronic lateral ankle pain and instability

35. Differential diagnosis Achilles tendinopathy High Ankle Sprain Sinus Tarsi syndrome Posterior ankle impingement Cuboid fracture Fibular fracture

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