Foot, Ankle and Lower Leg Problems

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Foot, Ankle and Lower Leg Problems

• MS3 Family Medicine

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Objectives

• Define relevant anatomy, physiology, and
  radiographic features of the foot, ankle and
  lower leg
• Recognize history, presenting signs and pertinent
  exam findings of common problems
• Review treatment of common problems

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Ankle Bones

• Tibia
• Fibula
• Talus
• Dome
• Neck
• Calcaneus
• Medial tubercle
• Anterior process
• Posterior process

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Foot Bones
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What are these things?

• Fractures
• Sesamoids
• Joint crystals
• Phleboliths

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Lateral Ankle
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Medial AnkleTom, Dick and Harry
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Anterior AnkleToms Hairy D!
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Dorsal foot

• Extensor tendons
• Dorsal pedis artery
• Digital nerves

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Posterior Leg and Ankle
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Plantar Foot

• Plantar fascia
• Longitudinal collagen fibers
• Medial calcaneal tubercle
• Proximal phalanges
• Plantar nerves

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Midfoot Congruity

• Tarsometatarsal Articulation (Lisfranc)
• Transverse ligaments

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Physical Examination

• Inspection
• Palpation
• Range of motion
• Strength
• Neurovascular
• Special Tests

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Which foot is overpronated?

• A
• B
• C
• D

D
B
A
C
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Normal Ankle X-ray
AP Lateral Mortise
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Normal Foot X-ray
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Acute Foot and Ankle Injuries

• Bone
• Ligament
• Muscle Tendon
• Nerve Blood Vessels
• Remember mechanism of injury!

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Case 1

• 26 yo male with ankle pain
• Landed on foot while playing basketball
• Stopped playing
• Lateral pain
• Able to limp off court and into your office

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Case 1 History

• Previous history several prior sprains
• Previous rehabilitation minimal
• Ankle protection none recently
• Ability to bear weight yes
• Neurovascular symptoms no

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Case 1 Physical Exam

• Inspection
• Able to walk
• Swelling, slight bruising laterally
• Palpation TTP ant-distal to LatMall, but not on
  bone
• ROM decreased DF, PF, Inv, Ev
• Strength mild decrease
• Neurovascular intact
• No instability on drawer or talar tilt test

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Which of the following would indicate need for an
x-ray?

• Unable to bear weight
• Tender over posterior lateral malleolus
• Tender over posterior medial malleolus
• Tender on navicular bone
• Tender on 5th MT base
• All of the above

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Ottawa Ankle RulesWhen to x-ray acute ankle
sprains

• Unable to bear weight
• Tender over posterior lateral malleolus
• Tender over posterior medial malleolus
• Tender on navicular bone
• Tender on 5th MT base

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Lateral Ankle Sprains

• Grade 1 Ligament stretch
• Grade 2 Ligament partial tear
• Grade 3 Ligament complete tear

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What is the treatment for a Grade 1-2 lateral
ankle sprain?

• RICE ? rehab
• RICE ? brace ? rehab
• RICE ? cast
• Surgical repair of the ATFL

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Lateral Ankle Sprain

• Treatment
• PRICEMM Protect, rest, ice, compress, elevate,
  Meds
• Brace for 1-3 months during activity
• Gradual ROM exercise
• Physical Therapy
• ROM
• Strength
• Proprioception

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Case 2

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

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Case 2 History

• Previous history neg
• Previous rehabilitation n/a
• Ankle protection none
• Ability to bear weight yes
• Neurovascular symptoms none

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Case 2 Physical Exam

• Inspection
• Difficulty bearing weight
• Mild swelling around ankle med/lat
• Palp TTP laterally, anteriorly, medially
• ROM full
• Strength mild decrease
• Neurovascular intact
• Tests
• Painful Tib-Fib Squeeze
• Painful ankle external rotation

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High Ankle SprainAKA

• Pain proximal to ankle
• Painful ExtRot test
• Painful squeeze test
• ORDER xrays
• Rule out mortise widening
• Rule out fractured proximal fibula
• Treatment
• Wide mortise SURGERY
• Normal xrays cast 2-4 weeks

gt5mm
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Case 3

• 24 yo ROTC student c/o aching in medial calves
  during running for 6 weeks
• Goes away in 1-2 days, but lasting longer with
  time
• Training for marathon

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Examination

• Normal appearing legs/ankles/feet
• Palp TTP diffusely medial tibial edges, distally
• ROM normal ankles (maybe tight heel)
• Strength normal
• Neurovascular normal
• Special tests normal

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Whats your diagnosis?

• Compartment syndrome
• Medial tibial stress syndrome
• Stress fracture
• Tibial sadness syndrome

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Medial Tibial Stress SyndromeAKA shin splints

• Etiology
• Muscle-bone junction traction injury
• Risk factors
• ???
• DDx
• Stress fracture
• Exertional compartment syndrome

• Treatment
• Cease painful activity
• Non-painful activity
• Physical therapy referral
• Ankle strength exs
• Heel stretches
• Orthotics
• Consider compression sleeve

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Case 4

• 45 yo Male with chronic, insidious right heel
  pain
• Worse after volleyball or running
• Pain and creaking over heel for past month
• Difficulty walking, but warms up

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Case 4 Differential Diagnosis

• What lives in the back of the leg?
• Calcaneus
• Calf muscles
• Gastrocnemius
• Soleus
• Achilles Tendon
• Retrocalcaneal bursa

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Achilles Tendinosis

• Evaluation
• Palpation with tender, thick Achilles Tendon
• /- crepitus
• Negative Thompson test
• Imaging?
• Treatment
• Avoid painful activities
• Heel lift
• Heel stretch, ice
• Eccentric strengthening
• Physical Therapy modalities
• Avoid injection

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Case 5

• 20 yo female kickboxing instructor
• Injured foot 2 days ago while kicking
• Persistent pain to walk, jump and kick
• Tapes her midfoot for class

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Examination

• Swelling in midfoot, some ecchymosis
• Very TTP dorso-medial midfoot
• ROM ankle normal, toes decr.
• Strength decreased toes
• Neurovascular normal
• Tests
• Midfoot stress test OUCH
• Ankle joints stable

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Do You Need X-rays?
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WEIGHT-BEARING X-rays
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Lisfranc Complex Injury

• 20 are missed on initial presentation
• Treatment
• Casting 2-6 weeks if NO FRACTURES OR INSTABILITY
• Surgery for fractures or instability
• CT/MRI/Bone Scan

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Complications if Missed

• Chronic pain
• Arthritis
• Inability to run or jump
• Acute compartment syndrome

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Case 6

• 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

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Examination

• Valgus foot type (pronation, flatfoot)
• TTP medial calcaneal tubercle and proximal
  midfoot
• ROM normal, but inflexible gastro-soleus
• Strength normal
• Neurovascular normal
• Special test neg

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Plantar fasciitis

• Treatment
• Cease painful activity
• Pain meds acutely
• Ice, cross-friction massage
• Arch suppts/heel cups
• (Physical therapy)
• Heel stretching
• /- tension night splint
• ? injection

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Questions?

• before hands-on practice

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Anterior Drawer Test (ATFL)
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Talar Tilt - ATFL/CFL
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Squeeze Test External Rotation Test
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Thompson Test Integrity of Achilles Tendon
is no movement
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Thompson Test for Achilles tendon rupture
POSITIVE
neg