Ankle and Foot

Clinical patterns
Foot Anatomy
 Superficial layer
1. Abductor Hallucis-
medial plantar nerve
2. Flexor digitorum brevis
– medial plantar nerve
3. Abductor digiti minimi –
lateral plantar nerve
 2nd Layer
 Tendon of the FHL
 Tendon of the FDL
 Quadratus plantae
• lateral plantar n.
 lumbricals 1st
• medial plantar n.
• lateral 3: lateral
planar n.
 3rd Layer
 Flexor hallucis brevis
• medial plantar n.
 Adductor hallucis
• lateral plantar n.
 Flexor digiti minimi
• lateral plantar n.
 4th Layer
 dorsal interossei
• abductors of the toes
 plantar interossei
• adductors of the toes
 4th Layer
 dorsal interossei
• abductors of the toes
Dorsum of foot
Neural Anatomy
clinical patterns of ankle and foot
 Poorly localized bilateral foot pain –
interdigital neuralgia

 Posterior heel pain

1. Superficial calcaneal bursitis (pump bumps)
2. Retro calcaneal bursitis
3. FHL tendinitis
4. Insertional achilles tendinitis
5. Peroneal tendinitis, Sural nerve entrapment
6. Os trigonum syndrome
 Plantar heel pain
 Medial heel pain
1. Saphenous nerve lesions
2. Medial calcaneal nerve lesions

 Lateral mid foot and hind foot pain

1. Peroneus longus and brevis tendinitis
2. Calcaneo - cuboid arthropathy
3. Recurrent cubido-4th metatarsal subluxation
4. Sinus tarsi syndrome
 Lateralization of foot pain – lateral foot pain
when pathologies are at medial side of the
foot

 Can be seen in hallux rigidus, hallux limitus,

painful medial strands of plantar fascia in
PFascitis or result of excessive pronation
secondary to PTTD
Medial Foot Pain
 Common causes
PTTD
FHL tendinopathy

 Lesser common
medial calcaneal nerve
tarsal tunnel syndrome
stress fractures calcaneus, talus
post impingement syndrome
referred pain from lumbar region
 Posterior tibialis tendon
dysfunction
 Dysfunctionof the tibialis posterior tendon
is a common condition and a common
cause of acquired flatfoot deformity in
adults

 Women older than 40 are most at risk

 Post tibialis is part of deep post
compartment

 Originates on proximal third of tibia and

interosseous membrane

 Multiple insertion sites – med cuneiform

and navicular
 Ant slip – tuberosity of navicular, CN joint, and
medial cunieform

 Posterior slip – middle and lateral cuneiforms,

cuboid and 2nd and 4th metatarsals

 Post tib tendon lies in the fibro – osseous

groove of med malleolus and has 1.5 cm
excursion
 Proximal vascular supply – post tibial
artery, mesotenon and synovial sheath

 Distal vascular supply – epitenon via

periosteal vessels off medial plantar and
dorsalis pedis
 Biomechanics
 Posterior and medial to subtalar and ankle joint
– flexes the ankle, inverts mid foot and elevates
the medial longitudinal arch through TN and CC
joints

 Locks the subtalar joint during push off

 Most medial tendon & initiator of inversion;

gastro continues the action
 Works with gastrosoleus to stabilize hind foot
and invert the heel
 Foot progresses from hind foot eversion at
heel strike to hind foot inversion after mid
stance, before heel rise

 Enables efficient progression of transverse

tarsal joints from the unlocked to the
locked position
 Subsequently gastro soleus acts on the
calcaneus to invert the hind foot
additionally, locking the transverse tarsal
joints and allowing for efficient force
transmission for gait

 After HS, post tibialis limits subtalar

eversion by eccentric contraction
 MS – Allows for subtalar inversion, locks
transverse tarsal joints, resulting in a rigid
lever

 Propulsive phase – accelerates subtalar

supination and assists in heel lift

 Is inactive shortly after heel lift

 Etiology of dysfunction
 Trauma
 Anatomic – shallow groove, tight
retinaculum, etc
 Inflammatory process – degeneration due
to synovitis
 Impingement or constriction in tarsal canal
 Zone of hypovascularity
 Medialankle pain extending from post to
medial malleolus towards the insertion of
the tendon

 Swelling of the medial hind foot – rare

 Tenderness postinf to medial malleolus

 Patients
may also report a change in the
shape of the foot or flattening of the foot

 The foot develops a valgus heel (the heel

rotates laterally when observed from
behind), a flattened longitudinal arch, and
an abducted forefoot
 Single heel raise shows lack of inversion
of hind foot

 Investigations – MRI : highly specific and

sensitive
USG – 80% specific and 90% sensitive
Johnson & Strom’s classification
 Stage 1 – tendon length normal
 Mild to moderate symptoms
 Only aching along the med aspect of ankle
exacerbated by training
 Difficult to localize discomfort
 Gradual onset
 More easy to elicit if patient is asked to
work out
 Single heel raise – in stage 1 dysfunction,
initial inversion is weak, patient either rises
up incompletely or doesn’t rise at all

 Or abnormal pattern may be present

 Treatment – modification of activity,

eccentric and concentric excs, soft tissue
mobilization, NSAID & orthotics
 Stage 2 – tendon elongated , hindfoot
mobile
 Pain present even at rest
 Chronic history of months – years
 Localized pain along the length of tendon
 Swelling and tenderness postinf to medial
malleolus
 Single heel raise test significantly
abnormal
 Too may toes sign
 Flattening of medial longitudinal arch,
windlass mechanism
 Test for subtalar and ankle passive and
active ROM, TA tightness
 X ray shows prominent features
 In AP view- forefoot abducted wrt hind
foot, navicular subluxes from the head of
the talus, angle between the long head of
talus & calcaneus increases
 Lateral view – sagging of long axis of TN
joint and divergence of the long axis of the
talus from calcaneus
 Treatment – usually surgical with either
shortening , tenodesis or tendon transfer
 Stage 3 – Tendon rupture, hind foot
deformed and stiff
 Never seen in active people
 Degenerative changes present
 Static supports of the foot are ruptured
 Fixed flat foot
 Pain shifts to lateral aspect of hind foot as
impingement develops
 Deformity ; most prominent feature
 Treatment – arthrodesis if pain is severe
 FHL tendinopathy
 Secondary to overuse
 Pain on toe off or forefoot weight bearing
 May be associated with post impingement
syndrome
 Max pain over postmed aspect of
calcaneus around sustentaculum tali
 Aggravated by resisted flexion of great toe
or stretching great toe into DF
 Triggering may be present in some cases-
associated with a snap or pop sound

 Investigation – MRI/US
 Treatment
1. Ice
2. Avoidance of activity
3. FHL stretching + strengthening
4. Soft tissue mobilization proximally in
muscle belly
5. Correction of subtalar hypomobility
6. Control of excessive pronation during toe
off with taping / orthosis
7. Strengthen proximal components
 Tarsal tunnel syndrome
 Compression neuropathy of tibial nerve in
tarsal tunnel where it winds around the
medial malleolus

 Causes – 50% idiopathic

trauma ( inversion injury)
overuse (excessive pronation)
 Indirect trauma due to repetitive HS during
running on hard surfaces, poor fitting
shoes

 Forces being transmitted through tarsal

tunnel
 Poorly defined burning, tingling, numbness
along the plantar aspect of the foot, great
toe or medial aspect of the heel

 Aggravated by activity, relieved by rest

 In some cases night pain may be present

 Swelling, thickening, varicosities may be
present

 Tenderness in tarsal tunnel

 Tinel’s sign
 DD- medial or lateral plantar nerves,
plantar fasciitis, referred pain from back

 Conservative – NSAID, corticosteroid

injection in tarsal tunnel

 Surgical – decompression
 Medial Calcaneal Nerve
Entrapment

Lateral Ankle Pain
 Common causes – peroneal tendinopathy
sinus tarsi syndrome

 Less common causes – impingement; AL,

posterior
recurrent dislocation of peroneal tendons
stress fracture of talus
referred pain
 Peroneal tendinopathy
 Causes
1. Excessive eversion of the foot
2. Excessive pronation of the foot
3. Secondary to tight ankle PF
4. Excessive action of peroneals
5. Inflammatory arthropathy
 3 main sites of tendinopathy
 Posterior to lateral malleolus
 At the peroneal trochlea
 At the plantar surface of the cuboid
 Clinical features
1. Lateral ankle or heel pain, swelling which is
aggravated by activity, relieved by rest
2. Local tenderness, sometimes associated with
swelling and crepitus
3. Painful passive inversion and resisted eversion
4. Calf tightness
5. Excessive subtalar pronation or stiffness of
subtalar or midtarsal joints
 MRI recommended investigation- shows
characteristic features of tendinopathy-
increased signal and tendon thickening

 Treatment – pain relieving modalities, soft

tissue mobilization, stretching, mobilization
of subtalar and midtarsal joints
 Assess footwear
 Lateral heel wedges or orthoses

 Strengthening excs, resisted eversion in

PF position
 Sinus tarsi syndrome
 Sinus tarsi is a conical
shaped cavity located
between antero sup
surface of calcaneus and
neck of the talus

 Opens laterally, just

anterior to fibular
malleolus to postmed
behind medial malleolus
 Contents –
1. Interosseous talocalcaneal ligament
2. Cervical ligament
3. Anterior portion of the subtalar joint capsule
and synovium
4. Posterior portion of the TCN joint capsule and
synovium
5. Medial, inferior and lateral roots of inferior
extensor retinaculum
6. Artery of tarsal tunnel
 Etiology
 First described by O’Connor in 1949
 He suggested that excessive post traumatic
scarring of the superficial ligament floor was
responsible for the symptoms
 Other causes – hypertrophy of synovial
membrane, ganglion cysts, entrapment of
superficial peroneal nerve & exostosis
associated with DJD
 Etiology of sinus tarsi syndrome is thought
to be associated with post traumatic
complications following lateral ankle
sprains

 This is the case in 70% cases

Bernstein, Bartolomei, McCarthy 1985
 Other causes – pes cavus, hypermobile
pes planus and chronic STJ instability

 Borrelli and Arenson (1987) described

mechanism which may lead to sinus tarsi
syndrome
 Due to increased laxity of interosseous
and cervical ligaments there is increase in
supination at heel strike

 Ligaments respond to increased

supination by initiating a feedback
mechanism to fire the peroneal muscles,
leading to increase in pronation into
midstance to correct over supination
 Due to decreased proprioceptor response
of the ligaments, the mechanism is altered
and peronii firing is diminished, leading to
decreased stability at propulsion
 Clinical features
 Pain over the lateral aspect of the foot,
with increased tenderness over the sinus
area
 Rear foot instability, clinically represented
by subtalar joint instability
 Pain reproduced by forceful supination of
forefoot
 4 clinical signs (Giorgini and Bernard , 1990,
and Borelli and Arenson, 1987, )
1. Pain over the lateral sinus tarsi opening which
decreases with rest
2. Perception of instability of the rear foot on
uneven surfaces
3. Complete relief if pain with injection on sinus
tarsi
4. Clinical and radiological studies are
insignificant
 Diagnosis
 Arthroscopic examination of the sinus tarsi
and EMG of peronii show characteristic
changes during gait

 Injection of local anesthetic

into the sinus
tarsi is a common diagnostic tool used
clinically
 Direct palpation of sinus tarsi is not
accurate
 Treatment
 Relative rest
 Ice
 NSAID
 Electrotherapeutic modalities
 Subtalar joint mobilization
 Proprioceptive and strength training
 Biomechanical correction
 Antero lateral impingement
 Cause – ankle sprains involving anterolateral
aspect of the ankle

 Inversion sprain promotes synovial thickening

and exudation

 Meniscoid lesion develops in AL gutter

 Chondromalacia of lateral wall of the talus with

an associated synovial reaction
 Pain at the anterior aspect of the lateral
malleolus

 An intermittent catching sensation in the

ankle with a previous history of ankle
sprain

 Tenderness at antero inferior border of the

fibula & AL surface of talus
 Clinical assessment more reliable than
MRI

 Arthroscopic examination to confirm

diagnosis

 Corticosteroid injection and arthroscopic

removal
 Stress fractures of talus
 Develops secondary to excessive subtalar
pronation and PF , resulting in
impingement of lateral process of the
calcaneus on the PL corner of the talus

 Symptoms – lateral ankle pain of gradual

onset

 Worse by running and weight bearing

 Tenderness and swelling in the region of
sinus tarsi

 Isotopic bone scan and CT scan

Anterior ankle pain
Anterior impingement of ankle
 Tibialis anterior tendinopathy
 Due to overuse of ankle dorsiflexors
secondary to restriction in joint range,
occurring with stiff ankle

 Pain, swelling, stiffness in anterior ankle

 Aggravated by activities like running,

walking uphill or stairs
 Localizes tenderness, swelling and
occasionally crepitus along the tibialis
anterior tendon

 Pain on resisted DF and eccentric

inversion

 US and MRI may be used for diagnosis

 Treatment – eccentric strengthening , soft
tissue mobilization and mobilization of the
ankle

 Correction of biomechanical problems with

orthoses
Foot pain
 Common causes – plantar fasciitis and fat
pad contusion

 Lesser common – calcaneal fractures,

medial calcaneal nerve entrapment, lateral
plantar nerve entrapment, tarsal tunnel
syndrome, retro calcaneal bursitis
 Plantar fasciitis
 Composed of 3 segments

 Central , clinically most significant, arising

from plantar aspect of postero medial
calcaneal tuberosity and inserts into toes
to from the longitudinal arch
 Plantar fasciitis , overuse condition of
plantar fascia , at its attachment to
calcaneus

 Due to collagen disarray in the absence of

inflammatory cells
 Causes – pes planus or pes cavus

 Results from activities requiring maximal PF and

simultaneous DF of MTP

 Reduced DF increased risk factor

 Commonly associated with tightness in proximal

myofascial structures
 Clinical features – gradual onset
 On medial aspect of heel
 Worse in morning, decreases with activity
 May last as ache post activity
 Increase in pain as activity is
recommenced
 Progresses to pain with weight bearing
 Other problems if associated
biomechanical problems are present
 Examination – acute tenderness along the
medial tuberosity of the calcaneus
 May extend along the medial border of
plantar fascia
 Plantar fascia tightness may be present,
stretching reproduces pain
 Reduced supination increases strain on
the fascia
 US – gold standard diagnostic
investigation with swelling of plantar fascia
the typical feature
Treatment
 Aviodance of aggravating activity
 Cryotherapy after the activity
 Strething of fascia, gastro-soleus
 Taping –
 Extracorporeal Shock wave therapy
 Strenghtening exercises
 Footwear modification
 Iontophoresis
 Plantar fasciotomy
 Fat pad Contusion
 Fat pad composed of elastic fibrous tissue
septa acts as a shock absorber, protecting
the calcaneus at heel strike

 Cause – may develop either acutely after

a fall onto the heels or chronically as a
result of excessive heel strike with poor
heel cushioning or repetitive change in
direction, sudden stops, starts
 CF – severe heel pain during weight
bearing
 Pain felt laterally in the heel due to pattern
of heel strike

 Tenderness in posterolateral heel

 MRI reveals edematous changes in fat
pad
 Rest
 Heel locking
Calcaneal stress fractures
Mid Foot pain
 Cuboid Syndrome
 Defined as a minor disruption or
subluxation of the structural congruity of
the calcaneo cuboid portion of the
midtarsal joint

 The disruption of cuboid’s position irritates

the surrounding joint capsule, ligaments
and peroneus longus tendon
 Cuboid – only bone in the foot that
articulates with both tarsometatarsal and
midtarsal joint

 Only bone that links lateral column to the

transverse plantar arch
 Secured in the lateral column by
calcaneocuboid , cuboidonavicular ,
cuboideometatarsal and long plantar
ligament

 Ligaments more taut dorsomedially than

plantar laterally

 Joint rotates around a medially positioned

axis
 Shape and position of cuboid is also
influenced by the peroneus longus muscle
tendon

 The cuboid articulations provide accessory

glide along with internal and external
rotation
 The passive physiological motion of the
lateral column consists of two patterns of
movement

 The 1stcombined movement , PF +

adduction along with inversion

 2ndmovement pattern, DF + abduction with

eversion
 Mid tarsal joint motion occurs around 2
axes which are dependent upon the
position of subtalar joint

 When midtarsal joint is fully pronated it is

in locked position

 When subtalar joint is pronated, forefoot is

inverted and midtarsal joint is unlocked
enabling the foot to adapt to uneven
surfaces
 With every degree of subtalar pronation
there is exponential increase in the
midtarsal joint instability
 Etiology – 2 mechanisms ; PF n inversion
ankle sprains and overuse syndrome

 Other factors – uneven running terrain,

improperly constructed orthoses, inversion
ankle injuries and pronated foot structures
 degree and direction of the force of the
peroneus longus and the position of the
subtalar joint act as a contributing factor

 In a supinating subtalar joint during

propulsion it acts as a dynamic stabilizer
of the forefoot
 Pronated foot is naturally unstable ,
increasing the mechanical advantage of
the peroneus longus

 Mechanical advantage of peroneus longus

is theoretically able to sublux the unstable,
pronated cuboid as the rearfoot
resupinates into propulsion
 Pronated foot + plantar flexed lateral
column may irritate the soft tissues due to
excessive pressure on the lateral column

 In congruency in the calcaneocuboid joint

 Inversion sprains of ankle

 Clinical presentation

 Gradual or rapid onset of pain

 Located directly over the cuboid

 May radiate into plantar medial arch or

distally along the 4th metatarsal
 Pain during weight bearing or even non
weight bearing

 Weakness during the propulsive phase

 Examination may show inflammatory signs

 Sulcus if subluxation is severe

 Occasionally forefoot valgus

 Pain and point tenderness directly over the

cuboid

 Tenderness over EDB tendon at

anterolateral surface of sinus tarsi and in
the region of peroneal groove
 Decreased ROM

 Pain during passive inversion and active

and resisted PF and eversion

 Resisted inversion resulting in pain along

the peroneus longus – diagnostic
Subtonick, 1989
 Midtarsal adduction test

 Midtarsal supination test

 Gait evaluation and functional testing

 Difficult to make on X rays, CT, MRI

 Differential diagnosis – Jones fracture,
fracture of anterior calcaneal process,
tarsal coalition, peroneal and EB
tendonitis, sinus tarsi syndrome, lateral
plantar nerve entrapment, Lisfranc’s
injuries etc
 Treatment

 Responds exceptionally well to

conservative treatment

 Primary method – cuboid manipulation

 Therapeutic modalities, low dye arch

taping, exercise and taping
 Manipulation – cuboid whip or cuboid
squeeze

 Ice following manipulation

 Low intensity pulsed US , increased to

continuous US later
 Stretching a tight peroneus longus and
triceps surae , strengthening the intrinsic
and extrinsic muscles of foot and
proprioception training

 Low dye taping can be used with or

without cuboid padding to maintain cuboid
position following manipulation
Fore foot pain
 Turf toe
 1stMTP joint sprain
 Caused by jamming or hyperextension of
the hallux at the MTP joint
 Defined as an acute sprain of the plantar
capsule and ligaments of the MTP joint of
the great toe
 Related to artficial turf, lightweight shoes,
activities that require hyperextension of
the toe
 More than 100 deg extension from
neutarl position

Signs and symptoms

1. Tender, swollen joint (plantar aspect)
2. Restricted ROM
3. Passive extension painful
 DD – fracture of the toe , sesamoids,
inflammation of sesamoids, FHL, FHB
tendinitis and gout
Treatment
1. Rest
2. Reduce inflammation and edema
3. Taping
4. Modify footwear
5. Mobilization of the MTP joint
 Hallux rigidus
 Degenerative arthrosis of the 1st MTP joint
 Limited ROM
 Pain
 Altered gait
 Toe fixed inPF at times
 Weight bearing on the lateral side
 Etiology
1. Osteochondritis dissecans of the 1st metatarsal
head
2. Trauma ; single or overuse
3. Primary OA
4. Prominent long 1st metatarsal
5. Abnormal gait
6. Hypermobility of the 1st metatarsal segment
 Treatment
 Non operative – US
 Modify activities, footwear
 Correct biomechanics
 Mobilization
 Surgery – debridement
 Osteotomy
 Arthroplasty
 Arthrodesis
 Metatarsalgia
 General term referring to pain in the
metatarsals and MTP joints