lecture 11: Foot and ankle problems Flashcards
Plantar Fascia Anatomy
- composed of 3 segments: central, medial and lateral
- the central ordinates from the medial tubercle on the plantar surface of the calcaneus
- travels toward the toes as a solid band of tissue dividing just prior to the MT heads into 5 slips
the central band in the foot
- very important
- starts at calcaneus, moves down towards the meta-tarsal heads
- gives us support and helps for “heel off” when we are starting to propel ourselves
windlass mechanism review
- when the toes are extended, the plantar fascia/arch is functionally shortened as it wraps around each MT head
- in this way, the plantar fascia functions “dynamically”, and affects arch height
- it is responsible for transferring the weight from the medial to the lateral side of the foot during the gait cycle, as well as arch support/dynamic shock absorption
what does the windlass mechanism review help us do
- move our foot from medial to lateral side of the end of our gait sections
- helps pronate and supinate
plantar fasciitis - the facts
- most common condition in the foot
(1 in 10 will report medial heel pain)
(usually on affects 1 foot (70%) with 30% having bilateral involvement) - brought about by overuse of excessive loading
- especially in those with atypical arches
(pes planus and pes Cavus)
when might plantar fasciitis occur in in people other than pronation?
1: with active people it may be due to changes in training (FITT), than over pronation
2: linked to BMI in less active or recently active people
plantar fasciitis - tissue level
1: overuse condition
2: changes in structure I.e. collagen disarray
3: non-inflammatory degenerative condition
4: this is a fasciOSIS
symptoms of plantar fascia
- gradual onset of pain
- sharp “stabbing pain” on first couple of steps in the morning or after long periods non-weightbearing
- pain generally improves after initial few steps but as condition progresses pain will worsen with prolonged activity (running, jumping, standing, etc)
signs of plantar fascia
- pes Planus or Pes Cavus (flat or high aches of feet)
- often decreased dorsiflexion ROM
- Tight Gastrocnemius or soleus
- poor joint mobility
- weakness of Tibialis posterior
- pain on palpation over again of PF and along its length
signs vs symptoms
symptoms: what someone says they feel, them telling you
signs: something that you can actually see or touch, you actually see or touch for yourself
shape of the foot (arch): over pronators and supinators
1: over pronators
- turn in too far
- have hard time mantaining arch
- trouble/slow with resupination
- may cause twist during propulsion
2: supinators
- usually people with super high arches, because their foot is not unlocking so when ti comes down it gets a pull through it which eventually breaks down
- decreased shock absorption and ability to adapt to the terrain
- due to lack of pronation
- force through the fascia to absorb shock
the role of pronation through the gait cycle
foot function: mobile adapter
foot structure: lowered arches, looser joints
Gait phase : just after heel strike to foot flat
the role of supination through the gait cycle
foot function: rigis lever
foot structure: heightened arches, tighter joints
gait phase: short period at heal strike and foot flat to toe off
tight posterior structures of the ankle
- anatomical connection between achilles tendon and plantar fascia
- if achilles tendon (or those structures attaching to it) is/are tight, then the plantar fascia may be pulled excessively tight
- tight plantar flexors will also affect dorsiflexion ROM and will affect motion throughout foot contact
heel spurs
- present in 80% of PF patients
- due to repeptivie microtrauma
- spur length is signficantly correlated with age, BMI, symptom duration, perceived pain
- may not be casually related to pain and may worsen on x ray after symptoms have resolved
why do heel spurs take a while to fully heal?
because it heels over night, but when the patient wakes up in the morning and steps everything tears again
- this then may lead to the body begins to lay down bone because the body can not heal the muscle (bone spur)
treatment for plantar fasciitis - initial pain control
- taping
-over pronators (calcaneal/low dye) acute < 10 days - orthotics - Over the counter vs Custom < 1 year
- night splints - for symptoms > 6 months
- you can use ice, however it is not for inflammation. it is just used to block the C fibers and help to control the pain
treatment for plantar fasciitis - fibroblastic/repair
- correct training errors!
- manual therapy/soft tissue work and exercise
-cavus foot- tight posterior muscles
- stretching (2-4 months)
- tight posterior muscles
- plantar fascia
treatment for plantar fasciitis - late repair/remodeling
- idealize strength through range
- add in power and agility component
- push-off, jumping, cutting etc
- decide on return to play taping, shoes and/or insole
Morten’s Neuroma - the facts
- the condition was initially described in 1876 by Thomas morton
- not a true neuroma
- this is a compressive neuropathy of the common plantar digital nerve of the 3rd webspace
- this nerve is thickest as it receives branches from medial plantar nerve and lateral plantar nerve
- nerve splits at the metatarsal (MT) head under ligament
transverse arch anatomy
- nerve bifurcates to give sensory to plantar aspect of foot.
- good transverse arch = more space for nerves
- decrease transverse arch means less space for nerves as bones drop causing inflammation from mechanical irritation
Morten’s neuroma - assessment findings (symptoms)
- pain/burning that radiates into the plantar aspect (the bottom of the foot) of the forefoot, usually 3rd webspace.
- toes
- occasionally the dorsal webspace
- made worse by forefoot weight-bearing
- dancing
- high heeled shoes
- may describe it as walking on a stone or pebble
- worse with narrow fitting footwear
Morten’s neuroma - assessment findings (signs)
- squeeze test, the examiner compresses the forefoot with his/her hand, while squeezing the webspace
- web space tenderness
- plantar percussion (Timel’s) test
- toe-tip numbness
Morten’s Neuroma- treatment
if acute and inflamed:
- police/peace &love
- refer for corticosteroid injuction
chronic or after acute phase: avoid high heeled, pointed or narrow shoes. (select shoes with a wide toe box). also avoid aggravating activities
morten’s neuroma - Treatment for correction of transverse flatfoot
- mobilization of foot-splaying to increase transverse arch position
- metatarsal pad
(graduated return to activity)
Morten’s Neuroma - last resort
Surgery
- but if you take the nerve out then you are loosing sensory to the bottom of your foot which can cause further issues
sesamoiditis - the facts
- two sesamoids beneath 1st MTP joint, to protect flexor halitus longus from being crushed
- transmit forced from ground to 1st MT head
- may be fractured, arthritic, but usually irritated or stress reaction
- estimated that 30% of seasamoid injuries are sesamoiditis
what is sesamoiditis mostly caused by
- often caused by repetitive stress and/or hyperextension of the great toe
- most common in dancing and basketball
sesamoiditis - symptoms
- patients reports pain under their great toe/forefoot when weight bearing (because you are putting pressure through the two bones)
- improved when not weight bearing
- worse with dorsiflexion of great toe
sesamoiditis - signs
- all the signs of the initial inflammation stage
- swelling, redness, pain with passive dorsiflexion of great toe
- pain and weakness with resisted plantar flexion of great toe
- pain with direct palpation of medial or lateral sesamoid
sesamoidities - treatment
- treatment of an
“ITIS” (red, hot, swollen, painful)
inflammatory/destructive phase
- POLICE/ Peace & love
- restrict activity to allow inflammation to subside
- metatarsal bar, dancers pad or orthotiics
prior to return to play for sesamoiditis treatment
- correct training errors/modify equipment (mostly like shoes)
- graded return to training
Turf toe - the facts
- can be one time or repeptive trauma (posterior roll-up MOI)
- forced hyperextension of the great toe (dorsiflexion > 100 degrees)
- causing tear of the plantar capsule and plantar ligaments of the great toe
- graded like other sprains (grading 1,2,3, looking for laxity and endpoint)
- predisposing factors are:
- playing on artificial turf
- soft flexible footwear
Turf toe - symptoms
- described a mechanism that includes hyper-dorsiflexion of the great toe
- reports pain swelling and at the first MTP joint (distal to sesamoids)
- worse with movement and weight-bearing
- may describe a weak “push-off”
turf - toe - signs
- visible, swelling, redness and or ecchymosis (bruising)
- pain with passive plantar and dorsiflexion of great toe, with limited ROM
- pain and weakness with resisted plantar flexion of great toe
- pain and laxity with dorsiplantar drawer test (slinging the toe up )
turf-toe - treatment phase 1: inflammatory/destructive phase, hot, painful, swollen
plan:
- POLICE/ peace & love (crutches and or tape to protect)
before the end of this stage:
- optimize healing environment
- palliate pain
- decrease swelling
turf toe - phase 2
repair/fibroblastic (pain, swelling subsides tissue healing)
- protect the tissue and idealize healing environment
- increase flow flow (heat)
before the end of this stage: - idealize ROM
- progress weight-beairng
- being gentle strengthening
turf-toe remodelling stage treatment
- functional training for return to play
- idealize strength through range
- add in power and agility component
- push-off, jumping, cutting etc
- decide on return to play taping, shoes and/or rigid insole
