The Foot and
Ankle
Complex
SARAH RAYNER
EXTENDED SCOPE PRACTITIONER PHYSIOTHERAPIST
Anatomy

The ankle and foot is a complex structure
comprised of 28 bones (including 2 sesamoid
bones) and 55 articulations (including 30 synovial
joints), interconnected by ligaments and muscles

In addition to sustaining substantial forces, the
foot and ankle serve to convert the rotational
movements that occur with weight bearing
activities into sagittal, frontal, and transverse
movements
Anatomy: Ankle
Anatomy : Foot

Hindfoot (posterior
segment): talus and
calcaneus

Midfoot (middle
segment): navicular,
cuboid and 3
cuneiforms

Forefoot (anterior
segment): metatarsals
and the phalanges
Examination: site of pain
Examination: site of pain
Examination: site of pain
Anatomy: Surface marking
practical

Talocrural joint line

Medial malleolus

Lateral malleolus

Navicular

1st MTP joint

Achilles tendon

Tibialis posterior tendon

Anterior talofibular ligament

Calcaneofibular ligament

Peroneus longus and brevis

Plantarfascia attachment to calcaneus

Midtarsal joint line
Conditions: lateral
ligament injury
Acute inversion of ankle
 Usually occurs in sports requiring quick change of
direction especially if it takes place on uneven
surfaces such as grass.
 Also common in sports when a player has jumped
and lands on top of another players feet.
 Most common mechanism is Inversion coupled with
PF.
 ATFL injured first then CFL as ATFL is taut in PF
On Examination:
 Lateral ankle pain and swelling
 Pain on inversion combined with plantarflexion
 Tests: Anterior draw and talar tilt

Ottawa Ankle Rules
Conditions: lateral ligament
injury


Management

PRICE

Graded return to sport

May require Physiotherapy

Rate of recovery dependent on severity
Failure to resolve

Continued instability or possible OCD

Refer to CATTS / Orthopaedics

May require further investigations ? MRI

Surgical intervention (arthroscopy +/- stabilisation
procedure
Conditions: Plantarfasciitis

Insertional heel pain of the plantar fascia with or
without a heel spur.

Biomechanical abnormalities cause pathological
stress to the plantar soft tissues

Typical presentation:



Isolated heel pain on initiation of WB (on rising am or
after prolonged sitting/rest)
Predisposing factors:

High BMI

Tightness of TA

Inappropriate shoe wear
On Examination

Pain on palpation at plantar fascia insertion
Conditions: Plantarfasciitis
management


Initial self directed treatment (up to 6 weeks):

NSAID’s

Regular calf and plantar fascia stretches

Avoidance of flat shoes and barefoot walking

OTC arch supports and heel cushions

Ice

Weight loss

Limitation of extended physical activity

Consider steroid injection where appropriate
If failing to improve refer on to local CATTS/MSK service:

Custom orthotics (podiatry)

Night splints

Steroid injections

Immobilisation

Extracorpeal shockwave therapy

Surgical plantar fascia release
Conditions: Achilles
tendinopathy

Non-insertional:
Usually a degenerative mid substance lesion
 Often with neovascularisation and proliferation of
neural structures in the area which cause pain
 Often poor collagen structure, poor healing and no
inflammation on imaging


Insertional:
Change in microscpic structure with increased
Glycosaminoglycans
 Change in fibrillar structure giving swelling
 Tendinitis / tendinosis depends on degree of
inflammation
 Bursitis often associated with Haglund’s deformity
(“pump bumps”)

Conditions: Non-insertional
Achilles Tendinopathy


Presentation:

Most common in males but seen in all ages

Pain on Achilles loading (walking, running)

Can be debilitating

Fusiform swelling

Tightness of Gastrocnemius
Treatment:

Eccentric loading exercises

Stretches

Correct abnormal biomechanics

Physiotherapy / podiatry

Extracorpeal shockwave therapy
Conditions: Insertional
Achilles Tendinopathy

Management

Initial conservative treatment as for non-insertional
Achilles tendinopathy

Surgical debridement
Conditions: Achilles
Ruptures



Presentation:

Patients usually feel POP in Achilles area

POP may be heard

Usually occurs in the avascular area of the Achilles 5 – 10cm above
the insertion

Common in Badminton , Squash and football in that order

Usually occurs to the end of a game
On Examination:

+ve calf squeeze

Palpable dip
Management

Surgical
Conditions: Ankle
Impingement


Anterior bony impingement:

Pain usually over anterior ankle

Pain may be anterolateral

Osteophytes usually palpable and may be associated with loss of
ROM particularly dorsiflexion

Arthroscopy
Posterior Impingement

Os trigonum, Bony osteophytes

Adhesions, synovitis ; Multiple injuries or hypermobility (dancers)

FHL tendinitis

Subtalar impingement

If conservative treatment fails, posterior ankle arthroscopy
Conditions: Tibialis Posterior
Dysfunction

Common cause of acquired flatfoot in adults

Women over 40 most at risk

Presenting features:


Pain and swelling medial hindfoot

Change in foot shape reported
On Examination:

Valgus heel, flattened longitudinal arch and abducted
forefoot

Pain on resisted inversion and on palpation tibialis
posterior

Pain and dysfunction on single leg heel raise
Conditions: Tibialis Posterior
Dysfunction Management

Conservative treatment
 Rest
 Orthotics
 Weight

and podiatry
management
Surgical management
 Hindfoot
osteotomy with tendon transfer
 Arthrodesis
of the hindfoot
Conditions: Hallux Rigidus
1st MTP Arthritis
 Epidemiology:




Women > men

60% bilateral

Late adulthood
Etiology:

Direct: trauma, fracture

Indirect: TMT hypermobility, flat 1st MTP joint, Long 1st MT, pes planus,
inflammatory
Clinical Symptoms:

Limited 1st MTP movement

Pain on toe off

Pain with activity

Pain with shoewear

Swelling

Limp: lateral foot WB, external rotation of hip
Conditions: Hallux Rigidus

Management:


Conservative

Footwear

Activity modification

Podiatry

Injections
Surgery

Cheilectomy

Osteotomy

Joint replacement

Fusion
Conditions: Morton’s
Neuroma

Swelling of nerve and scar tissue arising
from compression of the interdigital nerve

Often pain radiating into the toes
accompanied by pins and needles

Pain increased by forefoot weight bearing
and with narrow fitting footwear

On Examination:


Interdigital pain commonly in the 3rd and 2nd
interdigital space

+ve Mulder’s test
Management:
•
Orthotics
•
Injection
•
Surgical removal
Examination: Summary
As always take a good history to guide your examination: site of
pain, overuse or trauma, swelling, WB status etc.
 Gait and function (heel raise, weight transfer, proprioception)
 Observations: in standing and sitting/lying


Swelling, heat, scars, bruising, circulation, deformity

Biomechanics (pronation/supination, abducted)
ROM
 Resisted testing
 Palpation
 Special Tests


Anterior draw rest

Talar tilt test

Squeeze test

Calf squeeze test (Thompson test)

Lateral squeeze test for Morton’s neuroma (Mulder’s click)
Case Studies: Practical
1.
Monica a 30-year-old medical receptionist presents with sore Achilles
tendons. Over the weekend she has done a 15-mile sponsored walk.
She is a bit annoyed because although she does not do any
significant walking she feels that she keeps herself very fit with her Latin
American dancing. She also bought an expensive pair of Nike trainers
especially for the walk.
2.
A 45-year-old lady complains of pain in her right heel. This started 3
weeks ago after she had spent the weekend helping her husband lay
some flags for a patio. She describes how it feels as if she has a small
ball bearing under her heel when walking.
3.
A 65-year-old man complains of gradually increasing pain in the ball
of his right foot over several months. He has had to curtail his ballroom
dancing and of late his walking is becoming restricted.
4.
A 13-year-old girl who enjoys ballet is finding increasing pain in her left
big toe with her dancing. She says her big toes are not straight
anymore.
5.
A 46-year-old farmer complains about his left ankle. Apparently a year
ago he had a "bad sprain" when he inverted the ankle as he was
trying to catch a sheep. He went to casualty and had an X-ray (NBI)
and came away with a tubigrip bandage. He was not followed up.
Since then he finds himself "going over" on the ankle on uneven
ground if he is not watching carefully where he puts his feet. The ankle
is frequently swollen following these episodes.
Any
Questions?
THANK YOU