Foot & Ankle

Question 1

Cerebral palsy: Foot

1. What are the foot deformities seen in CP?

Answer 1

Equinus
Hallux Valgus
Equinocavovarus
Equinoplanovalgus

Question 2

CMT

What are the foot deformities seen in CMT and what contributes to them?

Answer 2

Claw toes

Hindfoot varus

Plantarflexed 1st ray

Question 3

Hallux Valgus

What is modified McBride procedure?
Indication?

Question 4

Biomechanics

Describe the Windlass mechanism.

Question 5

Biomechanics

1. Draw gait cycle.
2. Describe gait:
   a) Antalgic gait.
   b) Steppage gait
   c) Calcaneus gait

Answer 5

2. Gait
   a) Antalgic gait: Shortened, single-leg stance phase (SSS)
   b) Steppage gait: Increased knee and hip flexion during swing phase to ensure toe clear the floor.
   c) Calcaneus gait: increased ankle dorsiflexion during heel strike

Question 6

Deformities

Equinus
1. What are the muscles involved that gives rise to this deformity?
2. What test to determine cause?

Answer 6

1. Muscle imbalances
   Strong muscle - gastroc-soleus complex
   Weak muscle - dorsiflexors
2. Special test
   Silfverskiöld test
   * improved ankle dorsiflexion with knee flexed = gastrocnemius tightness
   * equivalent ankle dorsiflexion with knee flexion and extension= achilles tightness

Question 7

Deformities

Cavus
1. What are the muscles involved that gives rise to this deformity?
2. What test to determine cause?

Answer 7

1. Strong musc: Plantar fascia, intrinsics
   Weak musc: Dorsiflexors

Question 8

Deformities

Varus
1. What are the muscles involved that gives rise to this deformity?
2. What test to determine cause?

Question 8

Deformities
Flat foot
1. What are the muscles involved that gives rise to this deformity?
2. What test to determine cause?

Question 8

Deformities

Supination
1. What are the muscles involved that gives rise to this deformity?
2. What test to determine cause?

Question 8

Deformities
Equinovarus
1. What are the muscles involved that gives rise to this deformity?
2. What test to determine cause?

Question 9

Deformities
Equinovalgus
1. What are the muscles involved that gives rise to this deformity?
2. What test to determine cause?

Question 10

Deformities
Calcaneovalgus
1. What are the muscles involved that gives rise to this deformity?
2. What test to determine cause?

Question 11

Deformities

Name simple deformities of the foot

Name complex deformities of the foot

Question 12

How to approach Charcot arthropathy?

Answer 12

Charcot neuroarthropathy is a chronic systemic and progressive disease that generates pathological changes in the
musculoskeletal system that results in collaspe, fracture, joint destruction involving the foot and ankle.

2 Pathophysiological cause have been theorise to be a cause of CN.
Neurotraumatic theory
- repititive microtrauma in an extremity that has loss its protective sensation causes an upregulated inflammatory cascade that
results in collaspe and joint destruction.

Neurovascular theory
-alteration in the sympathtetic nervous system, increase blood flow to the affected extremity through vascular shunting,
causing bone resorption and osteopenia and subsequently fracture.

The dysregulated inflammatory and autonomic neuropathy results in fragility and instability of bones, joints, ligaments.
If continued weight bearing, the unstable pedal is unable to withstand the physiological forces of gait.
it can cause fractures, dislocation,collaspe which further accentuates the dysregulated inflammatory cascade.

During the acute phase
features
Erythematous, swollen, warmth
Warmth is 3.3 C more than unaffected side,
Elevation test is also positive where there is disappearance of erythema upon elevating the affected imb for approx 10 minutes (versus osteomyelitis)

Eichenholtz has divided into stages of disease
0 prodromal: erythematous, swollen, warmth, normal xray, MRI & bone scan positive.
1 fragmentation: erythematous, swollen, warmth, xray: fragmentation, osteopenia, fracture, dislocation
2 coalescence: reduced signs, xray:coalescence of bones, sclerosis, resorption.
3 consolidation: absence of signs, xray: consolidation, sclerosis, remodelling, fusion, deformity.

CN can also be classifisied based on location of involvement- Brodsky’s
Type 1- tarsometatarsal joint, naviculocuneiform joint
Type 2- subtalar, talonavicular, calcaneocuboid joint
Type 3A-tibiotalar
3B- calcaneal tuberosity
4 - combine
5- forefoot only

Management

Acute CN
- managed conservative
Options
1) Bisphosphonates
IV Pamidronate, 3 doses, 3-4 monthly
to shorten the acute phase for eg usually 0 to 3 is 18 months, so shorten from 18 months to 12 months

2) Orthosis
Stage 1
- Offloading during fragmentation phase
- Use TCC to redistribute plantar pressure
Mechanism of TCC
* by transferring about 30% of the load directly to cast wall
* greater proportionate load sharing by the heel
* removal of load bearing surface from metatarsal heads because of cavity created by the soft foam covering th forefoot.
- non-weightbearing until inflammation resolves
- weekly change of cast, weekly check of soft tissues of the foot
- serial XRs to look for evidence of healing

stage 2
- Can allow protected weight-bearing while awaiting re-modelling
- Can use metal stirrups
- CAM (controlled action motion) walker, CROW (Charcot Restraint Orthotic Walker) to stabilise varus / valgus ankle instability

Stage 3
- Custom shoes- total contact insoles
- Can consider surgery for OM, deformity correction

Principle of surgery for CN foot
1. Superconstruct- fixation/fusion may extend beyond the zone of involvementof CN
2. Double fixation - nail and plate
3. Double immobilisation lenght eg 12 weeks instead of 6 weeks.
4. need to make sure patient manages diabetes.

Aim of surgery
- to enable patient to have a stable, plantigrade, painless and shoeable foot.
- to remove any infected bone
- to remove any bony prominence (exostectomy) that causes plantar pressure, increasing risk of recurrent ulcer.
- to correct deformity via bony procedures.
- to reduce force transmission across the midfoot - contracted gastroc release

Implant:
No ulcer, no infection - can use locking plate osteosynthesis/ midfoot fusion bolt to achieve fusion
If ulcer, infected - use external ring fixators.
Bone graft to increase rate of fusion.

Question 13

Framework for Lisfranc injury.

Answer 13

1. Lisfranc

• Clinical features - MOI,symptoms
• Examination findings, provocative test
• Radiographic features - of instability, of subtle type
• Classification (Myerson enough)
• Conservative - indication, method.
• Surgery
  fixation vs fusion (indications)
  how to perform ORIF- approach
  screw fixation principles
  how to manage open Lisfranc
• Complications from getting a Lisfranc - compartment syndrome - from severe soft tissue, from ruptured dorsalis pedis artery
• Complications of Rx- missed/non-operative, operative

Source: AO, orthobullet
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9301181/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3111796/

Question 14

Extra elements that can be asked in Lisfranc

Answer 14

Need clarification
1. Screw used in Lisfranc- positional or lag screw?
AO
for ORIF purposes
- medial to middle cuneiform is Lag Screw
- base of 2nd MTB to middle cuneiform is positional screw

for arthrodesis
- base of 2nd MTB to middle cuneiform is lag screw

another option for arthrodesis- plate, need to

**2)When to remove screw? should it be removed?

3) Options if too comminuted fracture for screw?
Other options
T plate, invert it, place across 2nd MTB to middle cuneiform, can also use it fix watever fracture at base of 2nd MTB

AO
- Plate with or without lag screw (reconstructible complete articular fracture where the articular component is amenable to lag screw fixation)
- Locking plate with or without lag screw (reconstructible complete articular fracture in osteoporotic bone or in cases where a lag screw cannot be inserted)
- Primary arthrodesis of length stable and primary arthrodesis of length unstable fractures (non-reconstructible articular fracture)

How to perform fusion?
-entry point is
1. cartilage is removed from both the surfaces to expose the subchondral bone.
2.a bridge plate/transarticular lag screws across the joint to achieve primary arthrodesis until union has occurred.

Question 15

Do we need to ROI after ORIF of Lisfrance?

Answer 15

From literature
Retaining metalwork in the long term could cause the tarsometatarsal joints to be stiff, as such simulating fusion and resulting in altered biomechanics of the midfoot.

The potential but unproven purported benefits of metalwork removal include optimization of midfoot biomechanics and function, reduced pain,
lower risk of broken metalwork, and easier secondary surgery in the event of developing painful posttraumatic osteoarthritis.

The disadvantages of routine metalwork removal include risks of surgery such as deep peroneal nerve injury,a second anaesthesia, further time off work,
rehabilitation delays, increased health care costs, and potentially no subjective benefit to the patient.

Conclusion:
The current study demonstrates similar functional outcomes comparing routine removal of metalwork vs planned retention following fixation for a Lisfranc injury.
Overall, the strength of evidence to recommend routine removal of metalwork is low.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9558891/

Question 16

Calcaneal fracture

Answer 16

Calcaneal fracture
1. Definition
- Is a fracture of tarsal bone of hindfoot
- With mechanism of injury of
* axial loading from trauma- fall
* strong concentric contraction of tricep surae with forced dorsiflexion in bone with poor quality/osteoporosis
* stress fracture from increased physical activity

2. Categorize- can be divided into
   * intra-articular ( primary # line- superomedial & superolateral fragment, secondary # line – extend from intra-articular aspect)
   * Extra-articular (calcaneal tuberosity, anterior process #)
3. MOI- Commonly associated with other injuries if MOI is axial loading such as – fall from height, high velocity injury.
   Eg: Vertebral spine #
   Femur #
   Tibia plateau #
   Tibial plafond #
   Talar neck #
   Contralateral calcaneum
   Therefore, these injuries also need to be ruled out
4. Classification:

a) Extra vs intra-articular #
Extra is 25%: avulsion injury of anterior process, sustentaculum tali (bifurcate ligament), calcaneal tuberosity (Achilles tendon avulsion)
Intra is 75%: Essex-Lopresti
Tongue-type
Joint depression
* Used this when primary # line runs obliquely through posterior facet and forms 2 fragments.
* Secondary line runs from the posterior facet, either exiting behind the posterior facet (Joint depression) or exiting posteriorly towards the tuberosity (Tongue type)
Sanders classification
Is based on number of articular fragments seen on coronal CT
At the widest point of posterior facet
Type 1: Non-displaced posterior facet (regardless of the no of # pieces/lines)
Type 2: 1 line, 2 fragments
Type 3: 2 lines: 3 fragments
Type 4: comminuted with > 3 lines, 4 or more fragments
A-lateral 3rd (outside)
B-central 3rd
C-medial 3rd (involved next to sustentaculum tali)

5. Clinical features:- pain, hind foot swelling, ecchymosis, shortened widen heel, varus heel, blisters, skin tenting, open wound, loss of heel cord continuity
6. Complications with this fracture
   - Compartment syndrome
   - Skin tenting leading to an open fracture – fracture avulsion Achiles tendon

Question 17

Indications of non-operative treatment of calcaneum fractures?

Answer 17

a) Non-operative
Indication:
NWB for 6 weeks – Calcaneal stress fractures
NWB for 10-12 weeks
- Small extra-articular # < 1 cm, intact Achilles tendon, <2 mm displacement
- Sanders Type 1 nondisplaced
- Near normal Bohler angles
- Anterior process # with < 25% of calcaneocuboid joint
- Patients with comorbidities leading to poor outcome if surgical (smoker, DM, PVD)
- Minimally displace tuberosity # (< 1cm)

Question 18

How to manage Beak-type calcaneum fractures?

Answer 18

1) Closed reduction with percutaneous pinning/ srew fixation
Indication:
* Avulsion fracture of calcaneal tuberosity
– Need immediate urgent reduction & fixation (< 24 hours) to prevent skin tenting from bone to cause skin necrosis which need subsequent flap coverage (soft tissue sparing and joint reduction achieved at same time)
* Minimally displaced tongue-type #
* Large extra-articular fractures
* Patients with PVD or severe soft tissue compromise
* Open contaminated fracture

Method:
Reduction:
1) Make a small posterior incision near dorsal tuberosity of calcaneum.
2) The dorsal tuberosity and fractue can be visualized.
3) Place a large pointed reduction clamp through the incision with 1 arm on the top of tuberosity, another 1 arm through the heel pad.
4) Carefully closing the clamp, with foot plantarflexion, the fracture ends are reapproximated and reduced.
5) Quality of reduction confirmed under II. Approximating fragments should lead to an anatomically reduced subtalar joint, not just approximating the fragments.

Fixation:
- Use lag screws; 2-3 cortical screws, can add washer if osteoporotic.
- Placed perpendicular to fracture line
- From posterosuperior tuberosity
- Directed inferior & distal, aim anterior to weight bearing portion of tuberosity, must purchase far cortex (bicortical) but not penetrating through.
6) Wash and close subcut-skin
7) Immobilise: if too swollen, place in below knee back slab that maintains ankle in neutral position. Put in cast in neutral, as it acts as a tension band to protect the lag screws.
8) Post op care: elevate, NWB for 6-12 weeks, Xrays in Lateral and Axial view at 6,12, 26 weeks.

Question 19

Describe extensile lateral approach to the calcaneum for fixation.

Answer 19

-is known as the Extended lateral approach
- most commonly used for complex, intra-articular with severe displacements.
- once soft tissue condition is favourable as evidence by wrinkling sign & dried up blisters.
- be aware that the planned flap is watershed, soft tissue handling should be meticulous.

1) Supine, radiolucent table, well padded tournique at thigh, II with good Lateral and Axial views.
2) Time out. Correct patient, operation, site.
3) Clean and drape above the knee.
4) Skin incision for vertical limb - midway between fibular and Achilles tendon, horizontal limb placed in line with the base of 5th metatarsal at junction of glabourous and non-glabourous skin. These limbs will meet at a corner, where skin handling is meticulously careful.
5. Incisions at and near the corner is made directly to the bone, to raise a full thickness flap through subperiosteal elevation from lateral calcaneal wall. Avoid undermining edges.
6. Take note of the sural nerve, lateral calcaneal artery and peroneal tendons which are within the flap, not exposed, but do not over retract this flap.
7. Divide retinaculum & detach the fibulocalcneal & talocalcaneal ligaments from bone to raise flap upwards to expose the subtalar joint.
8. Once at subtalar joint, capsulotomy is performed.
9. Remove fracture hematoma and irrigate.
Place retraction K-wires into lateral process of talus and fibular to assist with retraction of flap.
10. Reduction and fixation performed.
11. Careful soft tissue closure, tension free especially at distal corner of incision. Use interrupted Allgower-Donati stitch to close skin. Skin edges should just a apposed, not strangulated.
12. Dress with soft dressing, dont tighten bandage, places on well padded back slab, elevate, cryocuff, careful observation of wound, may need longer antibiotics, optimise other wound healing factors- wound healing problems very common 15%

https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/calcaneous/approach/extended-lateral-approach-to-the-calcaneus

Question 20

Describe the minimally invasive approach to the calcaneum for fixation.

Answer 20

Indication:
- simpler intra-articular calcaneal #

Features:
- minimally invasive
- Also from the lateral side of foot.
- subfibular
- need to look for the sural nerve

1) a small oblique incision is made at the lateral aspect, over the sinus tarsi, slightly above the angle of Gissane.
2) Subcutaneous layer is incised to obtained a fasciocutaneous flap.
3) Identify the peroneal retinaculum with its content & sural nerve, incise the reticulum.
4) Place retractors to mobilse and protect tendons and sural nerve inferiorly
5) Dissection continues until subtalar joint is reached. small incision is made at this joint to allow the surgeon to have direct vision of the subtalar joint
6) Manipulation and reduction of the main fragments is carried out percutaneously, but the joint fragments can be manipulated directly through the approach.
7) Definite fixation is achieved with percutaneous screws or bolts, an intramedullary nail with locking screws, or a small plate that is sled in through the approach and tunnelled beneath the peroneal tendons.
8) Reduced, check ii, acceptable. Accurate anatomical reduction of subtalar joint is essential.
9) Wound closure.

Benefits
- can obtain adequate reduction
- can slide in a plate to stabilise
-reduced rate of soft tissue complications.

https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/calcaneous/approach/sinus-tarsi-approach-to-the-calcaneus#wound-closure

Question 21

How to reduce comminuted pieces in calcaneal fracture in ORIF?

Answer 21

i) The drawing demonstrates typical positions of the five standard fragments that need reduction.
ii) The surgical tactic that will be used identifies a step-by-step process for the reduction maneuver.
iii) Generally, one begins by identifying the “constant” fragment, i.e. the sustentacular fragment (4), which remains attached to the talus and does not displace.
iv) The reconstruction of the os calcis builds on this stable fragment and therefore one begins the reconstruction anteriorly and medially with this fragment
v) and works simultaneously on the posterior (2) and lateral (3) articular fragments.
vi) To achieve this, it is often necessary to apply traction to fragement 2 which helps to restore the three dimensional shape of the os calcis.
vii) Once these are in place, one closes the lateral wall like a door, which is the final step of the reconstruction.
viii) Fragments are maintained temporarily with K-wires.
ix) The final step is the fixation.

Question 22

Explain the gait cycle

Question 23

Acquired Adult Flat Feet

Answer 23

Adult flat foot
- Most common cause is PTTD (Posterior Tibial Tendon Insufficiency)
- Normal function of PTT for the foot during gait cycle is to
i) Foot flat: Provide primary dynamic support for medial arch of the foot, elevates this arch
ii) Transition to toe off:
- Fires after foot flat to generate heel rise
- Inverts hindfoot
- Then locks the transverse tarsal joint
- To obtain a rigid stable foot lever arm for toe off.
- Shifts the Achilles line of pull more medially to allow it to become primary invertor of subtalar joint.
iii) Next heel strike
- Decelerates subtalar joint pronation via eccentric contraction.

• When attenuation of PTT, this leads to a spectrum of
• Medial longitudinal arch collapse  medial sided foot pain, cant do single heel raise test
• Hindfoot valgus  weakened PTT
• Forefoot ABDuction at talonavicular joint lateral-sided ankle pain
• Midfoot OA
• Causes can be degeneration (of PTT) or traumatic (ankle fractures caused by pronation and ER).

Question 24

Classification of PTTD.

Answer 24

Classification- Johnson & Strom
4 stages
STAGE I - No deformity
- No deformity (normal foot)
- Tenosynovitis along PTT (pain and swelling)
- Can do single heel raise
- NORMAL Xray
STAGE 2 – Flexible
2a
- Got flat foot deformity
- Flexible hindfoot valgus
- Normal forefoot
- Got mild sinus tarsi pain
- Cannot do SHR
- ARCH COLLASPE xray
2b
- Got flat foot deformity
- Flexible hindfoot valgus
- ABDucted forefoot, > 40% talonavicular undercoverage, too many toes sign
- Got mild sinus tarsi pain
- Cannot do SHR
- ARCH COLLASPE xray

2c
- Got flat foot deformity
- Flexible hindfoot valgus
- Supinated forefoot, > 40% talonavicular undercoverage, too many toes sign
- Got mild sinus tarsi pain
- Cannot do SHR
- ARCH COLLASPE xray

STAGE 3
- Got flat foot deformity
- Rigid forefoot
- Rigid hindfoot
- Got severe sinus tarsi pain
- Cannot do SHR
- ARCH COLLASPE + SUBTALAR arthritis xray

STAGE 4
- Got flat foot deformity
- Rigid forefoot
- Rigid hindfoot
- Got severe sinus tarsi pain + ankle pain
- Cannot do SHR
- ARCH COLLASPE + SUBTALAR arthritis + TALAR TILT xray

Question 25

Differential diagnosis of adult PES PLANUS

Answer 25

1. Tendon  PTTI – traumatic, degeneration
2. Ligament  Spring ligament incompetence, is primary static stabilizer of Talonavicular joint.
3. Bone  midfoot pathology – OA midfoot, Charcot arthropathy, Chronic Lisfranc injury

Question 26

Management of PTTI

Answer 26

Management
- Depends on stages & foot deformities

Stage 1
i) Non-op
a) Immobilisation in walking cast/boots – 6 weeks
b) Orthotic prescribed (custom molded shoe orthotics) – medial heel wedge, medial column post for arch support, medial forefoot post if varus present
c) Physiotherapy once asymptomatic – PTT strengthening, proprioception, ROM

ii) OP
- Tenosynovectomy, if non-op fails

Stage 2
i) Non-op
a) AFO
b) Orthotic prescribed (Custom molded total contact rigid orthosis)- more to accommodate existing deformities developed
c) Physiotherapy once asymptomatic – PTT strengthening, proprioception, ROM

ii) OP
a) FDL transfer to navicular
b) Additional procedures as needed
* Gastroc contracture  gastric recession
* Hindfoot valgus medial slide/displacement calcaneal osteotomy (MDCO)
* Forefoot ABD  Lateral column lengthening (Evan’s opening wedge)
* Fixed forefoot supination (varus)  cotton osteotomy (dorsal opening wedge osteotomy of medial cuneiform- to plantarflex the 1st ray

c) Assess midfoot/medial column for stability
* Stable – cotton osteotomy
* Unstable (plantarsagging noted)- medial column fusion, based on the point of collapse, ie isolated NC fusion, isolated 1st TMT fusion, combined NC and 1st TMT fusion
d) Assess hindfoot – based on talar uncovering
< 40% = MDCO, > 40% =MDCO + lateral column lengthening

Generally
2a: FDL transfer + MDCO
2b:FDL transfer + MDCO + lateral column lengthening
2c: stable – cotton, unstable- medial column fusion

Stage 3
i) Non-op- similar to above
ii) OP
a) Triple arthrodesis: talonavicular, calcaneocuboidal, subtalar
+/- medial column stabilization
+/- TAL if equinus contracture

Stage 4
Op
i) Ankle valgus passively CORRECTABLE – triple arthrodesis + ligament reconstruction

ii) Ankle valgus RIGID – tibiotalocalcaneal (TTC) arthrodesis

Question 27

Why soft tissue procedures uses FDL?

Answer 27

FDL is transferred to augment function of PTT
i) Origin of FDL and PTT are adjacent to each other, they have the same line of pull
ii) are in phase muscle/synergistic
iii) FDL strength matches peroneus brevis (the antagonist to action of PTT)
iv) FDL is expandable
Prerequisite
- Must have adequate subtalar motion (> 15 degrees of motion)
- Must have supple forefoot supination/varus deformity

Contraindication
- Inadequate subtalar motion (> 15 degrees of motion), transverse talar motion
- Fixed forefoot supination/varus deformity
- Obesity
- Symptomatic OA (subtalar, tibiotalar, talonavicular, calcaneocuboidal)

Question 28

How to perform FDL transfer?

Answer 28

1. Incision made behind medial malleolus and directed distally towards the base of 1st metatarsal.
2. Tibialis posterior tendon sheath is opened up
3. Excise non-viable tendon
4. Locate the FDL.
   The FDL tendon crosses superficially over the FHL in the plantar midfoot at the knot of Henry, which is usually located over the navicular and medial cuneiform in most patients, and deep to ABDuctor hallucis.
5. Release FDL at the Knot of Henry, as distally as possible, under direct vision.
6. Drill 2-5 mm hole at navicular tuberosity.
7. Pass the harvested FDL in a plantar to dorsal and then suture back to itself and periosteum, whilst ankle in plantarflexion and inversion.
8. Can do Pulvertave weaving technique or secure with interference screw.
9. Additional
   - optional to tenodese remaining distal FDL to FHL to preserve small toe function
   -Can do imbrication of spring ligament is this is attenuated.

https://radsource.us/tendon-intersection-syndromes/

Question 29

Evaluating an adult with FLAT FOOT

Answer 29

Evaluating an adult with FLAT FOOT
1. Stand the patient, expose adequately to midthigh
2. Set the patellar facing forward
LOOK- start from forefoot, midfoot, hindfoot
(Front)
- Scars
- Callosities
- Skin changes – erythema, pigmented skin, cracking, fissure, fungus, dystrophic nails
- Deformities of toes
- Medial arch loss – put your fingers through
- Dorsal midfoot prominences
- Leg: trophic changes
(Side)
- Confirm loss of loss of medial arch
- Scars
- Swellings at malleoli region
- Dorsal midfoot prominences
(Back)
- Hindfoot valgus
- Too many toe sign (forefoot ABD)
- Forefoot supination/varus
- Leg: calf muscle atrophy

Gait- get patient to walk x 1 ROUND only
Heel raise – get patient to face the bed, hold the bed if feel unstable, perform bilateral heel raise 1st
* Observe for reconstitution of medial arch + hindfoot valgus becoming varus/ neutral.

• Get patient to do single heel raise – for the affected leg only
  Lie patient down
  FEEL
• Ask patient where is painful- medial midfoot pain
• Rule out other causes first
• Palpate along plantar fascia – Plantar fasciitis
• Palpate heel – fat pad atrophy
• Palpate calcaneal tuberosity – Achilles tendinitis, Haglund deformity’s bump, retrocalcaneal bursitis
• Palpate lateral ankle – ATFL, CFL, PTFL, SUBFIBULAR region
• Palpate ankle joint line
• Palpate midfoot- for bump, crepitations, instability
• Then come back to medial side, palplate at Navicular, follow proximally to behind the medial malleolus – pathway pain indicative of PTT problem
  MOVE
  1. How is PTT status – inflamed or weakness?
• Passively stretch PTT – EVERT-plantarflex
• Ask patient to actively – INVERT-plantarflex, ask if got pain, point where? – usage of PTT causing pain
• Ask patient to resist – assess power
• If in supine, CANNOT DO  MRC < 3, always palpate PTT to feel contraction, compare with Normal side.

2. How is the SUPPLENESS of joint – Supple or rigid?
   - Active ROM by patient
   * Tibiotalar -dorsiflex (20-30), plantarflex (35-45)
   * Subtalar – (23° inversion − 12° eversion)
   * Adduction, Abduction – Add (35), ABD (25)

• Hindfoot valgus- correctable to neutral? – passively do
• Forefoot ABD correctable to neutral?- passively do

3. Any INSTABILITY?
   - Midfoot instability – ballotment
4. Any DEGENERATION?
   - Grinding test- tibiotalar, subtalar
5. Any DONOR?
   - Test donor FDL function- ask to catch tissue paper with lesser toes
6. Is the patient NEUROLOGICALLY intact
   Neurovascular assessment
   * Dorsiflexion
   * Plantarflexion
   * DPA, PTA