Lecture 3: Ankle and Foot

Question 1

What are the main ligaments of the ankle?

Answer 1

Anterior Talofibular Ligament
Calcaneofibular Ligament
Posterior Talofibular Ligament
Deltoid Ligament (medial)

Question 2

In dorsiflexion which way does the talus slide and roll?

Answer 2

Slides posteriorly and rolls upwards

Question 3

In plantarflexion which way does the talus slide and roll?

Answer 3

Slides anteriorly and rolls downwards

Question 4

What movement occurs at the subtalar joint?

Answer 4

Pronation (eversion, abduction)

Supination (inversion, adduction)

Question 5

What bones make up the subtalar joint?

Answer 5

Calcaneus and Talus

Question 6

Common causes of plantar heel pain?

Answer 6

Plantar fasciopathy
Fat pad contusion (heel pain)

Question 7

Common causes of acute lateral ankle sprain?

Answer 7

Lateral ligament sprain
- ATFL
- CFL
- PTFL

Question 8

Common causes of Achilles region pain?

Answer 8

Midportion and Insertional Achilles Tendinopathy

Question 9

Common causes of medial ankle pain?

Answer 9

Tibialis posterior tendinopathy
Flexor hallucis longus tendinopathy

Question 10

What are some differential diagnoses for an acute ankle sprain?

Answer 10

Lisfranc, fracture, subtalar dislocation

Question 11

Acute Ankle Sprain Diagnosis (Patient history, Observation, Palpation, AROM/PROM, MMT/IMT, Special test, Functional Testing)

Answer 11

Patient history: mechanism of injury, pain, swelling, limited ROM, difficulty weight bearing

Observation: observe for swelling (figure 8)

Palpation: tenderness/pain near ligament

AROM/PROM: limited ROM actively and passively

MMT/IMT: reduced, but limited by pain/swelling

Special test: anterior drawer test, talar tilt test

Functional Testing: single leg stance, gait, stairs

Question 12

What test would you perform to confirm an acute ankle sprain?

Answer 12

Anterior drawer test

Question 13

When would you use the Ottawa Ankle Rules

Answer 13

To predict which patients require X rays to exclude fracture

Question 14

Normal ROM of the ankle
(PF, DF, Inv, Ev)

Answer 14

10-20 degrees dorsiflexion (DF)
40-55 degrees plantarflexion (PF)
30 degrees Inversion
18 degrees Eversion

Question 15

Mechanisms of injury for ligament injuries

Answer 15

ATFL
CFL
PTFL
Deltoid:

Question 16

Risk factors of plantar fasciopathy

Answer 16

Lifestyle: runners, military, dancers, sedentary
Elderly
High arc and excessive foot pronation
Overweight/obese

Question 17

Plantar Fasciopathy Diagnosis (Patient history, Observation, Palpation, AROM/PROM, MMT/IMT, Special test, Functional Testing)

Answer 17

Patient history: Gradual onset heel pain. Typically worse in morning or after long periods of rest, improves with activity but worsens at end of day
- Aggravating factors: prolonged standing, walking or running especially on hard surfaces
- Alleviating factors: rest, stretching and sometimes ice
- ASx: Stiffness in heel or arch of foot, swelling and tenderness

Observation: flat feet or high arches, overpronation during gait can be present

Palpation: point tenderness at anteromedial aspect of calcaneal tubercle

AROM/PROM: active toe extension may provoke symptoms, normal ROM

MMT/IMT: normal or some weakness in intrinsic foot muscles

Special test: Pain during Windlass Test

Functional Testing: pain during heel raise test, pain in single leg stance

Question 18

What is a special test for Plantar Fasciopathy

Answer 18

Windlass test

Question 19

What are some differential diagnoses for Plantar fasciopathy?

Answer 19

Tarsal tunnel syndrome
Calcaneal Stress fracture
Neuropathies
Trauma

Question 20

Achilles Tendinopathy Diagnosis (Patient history, Observation, Palpation, AROM/PROM, MMT/IMT, Special test, Functional Testing)

Answer 20

Patient history: Gradual onset of pain, often worsening with increased activity. Pain located 2-6cm above the calcaneal insertion. Morning stiffness, pain after periods of inactivity that may decrease with mild activity but worsens with vigorous use. Localised pain. History of overload. Pain presenting after activity (hours after or next day)

Questionnaires (PROMs): VISA-A

Observation: Swelling or thickening along the tendon, altered gait pattern to avoid pain

Palpation: tenderness on midportion of achilles, 2-6cm above insertion

AROM/PROM: pain reproduced with active movements

PAM: normal

MMT/IMT: weakness may be present in plantarflexion strength due to pain inhibition

Special test: Royal London Hospital Test, Arc Sign Test, Gap Palpation

Functional Testing: Difficulty with activities requiring forceful plantarflexion of the ankle, such as hopping, running or push offs

Question 21

Differential diagnosis for Achilles tendinopathy

Answer 21

Rule out Achilles rupture (Thompson test) or calf strain
Plantar fasciopathy
Tarsal tunnel syndrome
Ankle OA
Deep vein thrombosis

Question 22

What tests can be performed for Achilles Tendinopathy

Answer 22

Thomson Test (achilles rupture)
Royal London Hospital Test
Arc Sign Test
Gap Palpation test (rupture)

Question 23

What is tarsal tunnel snd.

Answer 23

Compression of posterior tibial nerve through tarsal tunnel

Question 24

What is in the Tarsal Tunnel? (Tom, Dick and Very Naughty Harry)

Answer 24

Tibialis posterior tendon
Flexor digitorum longus tendon
Posterior tibial artery & vein
Tibial nerve
Flexor hallucis longus tendon

Question 25

Diagnosis of Tarsal Tunnel Syndrome

Answer 25

Patient history: Burning, tingling or a sensation of pins and needles in the foot and toes. Pain can also radiate up leg o AF: activities that involve prolonged standing or walking, repetitive foot flexion o ALF: Rest, foot elevation and non-weight bearing activities o ASx: Numbness or weakness in foot, sometimes worsening at night Questionnaires (PROMs): Foot and ankle ability measure, lower extremity functional scale Observation: possible swelling in ankle area. Gait may be altered due to pain or numbness in foot Palpation: Tenderness and pain along course of posterior tibial nerve AROM/PROM: Active and passive ROM may reproduce symptoms of tingling or pain PAM: Normal, but can produce tingling or pain MMT/IMT: Weakness in toe flexion, particularly flexor hallucis longus and flexor digitorum longus, which are innervated by branches of the tibial nerve Special test: Tinel’s Sign Functional Testing: Standing, walking, decreased sensation may affect balance and proprioception

Question 26

Special test for Tarsal Tunnel Syndrome

Answer 26

Tinel's Sign

Question 27

Tibialis Posterior Tendinopathy Diagnosis

Answer 27

- Medial ankle pain often arising from behind the medial malleolus and extending towards the medical midfoot to the insertion of the tendon at the navicular bone - Common swelling in the later stages and is often diffuse around and below the medial malleolus - Tenderness along the tendon is usual, most prominent posterior and inferior to the medial malleolus or at the insertion onto the navicular bone - Resisted inversion will elicit pain and relative weakness comparted with the contralateral side - A single heel raise test viewed from behind will reveal lack of inversion of the hindfoot, and if severe the patient may have difficulty performing a heel raise. In the normal ankle, the calcaneus moves into varus position during a single heel raise; in patients with tibialis posterior tendinopathy, this does not happen and the heel remains in the valgus position - MRI has a sensitivity of 95%, a specificity of 100% and an accuracy of 96%

Question 28

If there is an ATFL sprain, what will you feel in an anterior drawer test

Answer 28

Calcaneus will translate up the heel

Question 29

What ligament sprain does anterior drawer test

Answer 29

ATFL

Question 30

What ligament sprain does talar tilt test

Answer 30

ATFL, CFL and deltoid

Question 31

What does the Matles test do? When is it positive?

Answer 31

Tests for Achilles rupture Ruptured foot tends to remain dorsiflexed instead of plantarflexed

Question 32

What is done in a Windlass test

Answer 32

Passive extension of 1st MTP

Question 33

What test would you use to identify a syndesmosis injury?

Answer 33

Squeeze test

Question 34

What is the mechanism of injury for a syndesmosis injury?

Answer 34

Dorsiflexion and Eversion