Feet First. Michael K. Cooper, DO FACOFP Family Practice/OMM St John Clinic - Claremore OOA 2018 Annual Convention

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1 Feet First Michael K. Cooper, DO FACOFP Family Practice/OMM St John Clinic - Claremore OOA 2018 Annual Convention

2 Disclaimer I have no conflict of interest. I am not on any pharmaceutical company payroll or speaker bureau.

3 ACOFP Resources 1. iphone/ipad/android resources: A) OMT B) DO Reflex 2. Publication: Somatic Dysfunction in Family Practice 2nd ed., 2014

4 Learning Objectives Understand basic foot mechanics Understand how foot dysfunction affects the rest of the body Learn how to code for OMT procedures. Review techniques to improve foot pain and motion.

5 The foot and ankle play an essential role in the maintenance of balance, transmission of loads and orientation and adaptation of the foot to ground contours.

7 The forces on the foot can be 5 times body weight during walking and 15 times body weight during running.

8 Most patients with foot problems present with pain as a chief complaint. They also may describe a sensation of ankle instability, recurrent ankle sprains and paresthesias.

9 This is why foot treatment is important.

10 Basic Anatomy

11 The foot has 2(3) functional arches: Longitudinal Medial Lateral Transverse

12 Longitudinal Arch Divided into medial and lateral components - bony lateral arch calcaneus, cuboid and 4 th and 5 th metatarsals - bony medial arch talus, navicular, cuneiforms and the first 3 metatarsals

13 Longitudinal Arch Supported by the tibialis posterior muscle with tendon attachments to the navicular, 1 st cuneiform, and the base of the 2 nd, 3 rd and 4 th metatarsals

14 Transverse Arch Composed of cuboid, navicular, cuneiforms, and the proximal end of the metatarsals. Supported by the peroneus longus muscle inferiorly and the tibialis anterior which attaches to the medial and undersurface of the first cuneiform and proximal first metatarsal

15 Transverse Arch

16 Functions of the foot arches Support and divide weight equally between the calcaneus and the metatarsal heads Propel the body when walking or running assisting the gastrocnemius and soleus Shock absorber Adapt to changes on an uneven surface

17 Plantar Ligaments and Fasciae Plantar aponeurosis extends from the calcaneus to the phalanges and encompasses the sesamoid bones under the great toe. Functional demand causes chronic stress on the structure. Irritation caused by either excessive pronation or a high arched cavus foot may result in plantar foot pain or plantar fasciitis. With time calcium was laid down along the lines of stress leading to heel spurs.

18 The size of the spur does not necessarily correlate with pain intensity.

19 Long plantar ligament Long plantar ligament runs from the calcaneus to the lateral 3 metatarsals. It forms a tunnel for the passage of the peroneus longus muscle as the tendon passes under the foot to the first cuneiform and first metatarsal.

20 Short Plantar Ligament Short plantar ligament lies medial to the longitudinal arch. It attaches between the calcaneus and the proximal end of the cuboid.

21 The Spring Ligament The Spring ligament (calcaneonavicular) runs from the sustentaculum tali of the calcaneus to the navicular. The spring ligament strengthens the medial longitudinal arch.

22 Transverse Tarsal Joint The transverse tarsal joint contains the talonavicular and calcaneocuboid articulations. These are separate joints act together as a functional unit. The transverse tarsal joint has a greatest influence during the stance phase of walking

23 Transverse Tarsal Joint Contains the talonavicular and calcaneocuboid joints. These two joints function as a unit. The load bearing of this joint is 4 times body weight in the stance phase. Normal range of motion is 20 degrees of flexion and 40 degrees of extension. At least 10 degrees of dorsiflexion is needed for normal gait.

24 Transverse tarsal joint

25 Tarsal Somatic Dysfunction Relatively common These bones may even sublux in middle and long-distance runners. Somatic dysfunction of the tarsal bones can be diagnosed with a combination of tenderness and increased tissue tension over the plantar surface of each of these bones Osteopathic manipulative treatment is effective treatment. Some patients may require orthotics to modify any predisposing biomechanical factor

27 Case Study John W. is a 35-year-old male presenting with bilateral foot pain. The pain started approximately 6 months ago and has progressively worsened. He states that he has intense pain when first getting out of bed in the morning. The pain does get somewhat better by the time he reaches his kitchen to make coffee in the morning. The pain increases throughout the day while he is at work. He is employed in a local industrial plant where he must stand most of the day at work. He has tried multiple brands of footwear hoping to relieve his pain. John has had a 30 pound weight gain over the last 6 months. He blames his lack of exercise for the weight gain.

28 Case study- continued Physical examination: -BP: 142/87, pulse: 78, respirations: 16 -Height: 150 cm, weight: 95.5 kg -Alert, oriented, frustrated HRRR, LCTAB OSTEOPATHIC EXAM: Cervical: Chronic tissue texture changes with muscle tightness Slight limitation in all end points of motion C3-C6: SRRL Ribs: Good excursion with respiration Thoracic: Chronic tissue texture changes at T2-T8 levels bilaterally T2-T8: SLRR Lumbar: Decreased range of motion with muscle tightness L5 is uncompensated Sacrum: In neutral-no torsion or unilateral lesion noted Lower extremities: Bilateral tibialis anterior tenderness Plantar tenderness over the calcaneus bilaterally.

29 Case Study-continued Tightness and tenderness the plantar surface of both feet. Poor range of motion the lateral portion of the longitudinal arch bilaterally. Cuboid immobile bilaterally.

your patient s diagnosis People who pronate tend to wear out the

30 Don t forget to check the shoes! Looking at a well worn pair of shoes may give you great insight into your patient s diagnosis People who pronate tend to wear out the medial side of the sole where as the people who supinate tend to wear out the lateral side of the sole first.

31 Case study-continued Osteopathic manipulative therapy was used to correct dysfunctions in each foot, each leg and the spinal column. The patient reported some relief of pain. The patient was instructed on proper footwear and daily exercises.

32 Farriers also must choose from multiple shoes.

33 Don t forget the inserts!

34 A good stiff soled shoe or boot with adequate cushioning works best-especially during the acute pain phase. The use of cushioned inserts, preferably without an arch, is best for most patients.

35 Stretching And Strengthening Exercises

36 Other Aids

37 Case Study - Continued Diagnosis: 1) Plantar fasciitis 2) Somatic Dysfunction, cervical 3) Somatic Dysfunction, thoracic 4) Somatic Dysfunction, lumbar 5) Somatic Dysfunction, lower extremity Coding: Office visit: (Don t forget to add the modifier so that both the office visit and the OMT will be covered by insurance.) Procedure code: (OMT 3-4 areas) You must include in your office note: Osteopathic manipulative therapy using HVLA, soft tissue and Still techniques were performed on the cervical, thoracic, lumbar and lower extremity areas with good result.

38 Question# What do you need to document in order to get both the office visit and treatment reimbursed? a) Modifier -25 added to your office visit level code. b) Documentation of areas treated. c) A statement about result of the treatment. d) All the above.

39 Techniques (Still) Cooper s principles of OMM If it won t move but should, make it move. If it moves too much (hypermobile), strengthen the surrounding muscles. Splint only if necessary.

40 Tibialis Anterior Originates from the proximal fibular head and lateral proximal tibia. Distal tendon crosses the bottom of the foot then turns inferior around the medial aspect of the foot. Inserts on the medial cuneiform and proximal first metatarsal. Acts to dorsiflex and invert the foot.

41 Tibialis Anterior

42 Tibialis anterior dysfunction Patient presenting with complaints of shin splints or plantar pain. Tenderness over the origin of the muscle Both active and passive decreased plantar flexion. May also cause a restriction in pronation. Weakness of this muscle can contribute to foot drop.

43 Treatment of tibialis anterior Patient is supine Sensing finger is on the origin of tibial anterior superior Operating hand grasps the foot and places it in supination and dorsiflexion While introducing compression, bring the foot into plantar flexion and pronation. Release compression and return the foot to neutral. Retest.

44 Peroneus longus Originates just lateral to tibialis anterior Distal tendon Runs behind the lateral malleolus Passes on the lateral side of the calcaneus Continues on the underside of the foot Inserts into the base of the first metatarsal and medial cuneiform

45 Peroneus longus

46 Peroneus longus dysfunction Patient presents with either lateral knee pain and/or plantar foot pain Tenderness over the muscle origin - anterolateral proximal fibula Dysfunction causes a restriction in plantar flexion (and possibly supination) Can contribute to foot drop

47 Treatment of peroneus longus Patient is supine Sensing finger is on the anterolateral superior fibula Operating hand grasps the foot and places it in external rotation and dorsiflexion While introducing compression, bring the foot into plantar flexion and supination Release compression and return the foot to neutral. Retest.

48 Talus The most dorsal bone in the foot Provides the load bearing joint surface Primary motion is dorsiflexion and plantar flexion The talus is the keystone to the longitudinal arch

49 Diagnosis of talar dysfunction Diagnosis is made when the ankle dorsiflexion or plantar flexion is limited. An anterior (flexed) talus will be more prominent at the ankle mortise (moved superior with the patient supine). A posterior (dorsiflexed) restricts plantar flexion (feels more posterior with supine patient).

50 Treatment of a plantar flexed talus Place one hand of the forefoot and with the other hand grasp the calcaneus. Plantar flex the patient s foot. Introduce compression vectored to the talus. Dorsiflex the patient s foot. Release compression and return the foot to normal. Retest.

51 Treatment of a dorsiflexed talus Place one hand of the forefoot and with the other hand grasp the calcaneus. Dorsiflex the patient s foot. Introduce compression vectored to the talus. Plantarflex the patient s foot. Release compression and return the foot to normal. Retest.

52 Naviculus Anterior to the talus and posterior to the 3 cuneiforms

53 Diagnosis of navicular dysfunction A dropped navicular is diagnosed by tenderness over the medial plantar fascia and a palpably inferior medial aspect of the navicular. The navicular resists lateral movement of the distal foot. The naviculus is rotated in a plantar-medial direction relative to the talus.

54 Treatment of the naviculus Distal foot grasped distal to the naviculus Sensing thumb placed over the lateral surface of the naviculus Rotate and plantar flex the distal foot to produce relaxation of tissue over the naviculus Introduce compression (or traction) and rotate the forefoot outward. Release the compression and return the foot to neutral. Retest.

55 Calcaneus Articulates with the talus and cuboid Strongly bound to the naviculus by the spring ligament Normal motion is external and internal rotation -opposite to the naviculus The axis of rotation is on the superior surface

56 Diagnosis of calcaneus dysfunction Related to ankle involved sprains Usually involves restriction in supination or pronation Ease may demonstrate hypermobility May not be tenderness over the calcaneus but rather the collateral ligaments

57 Treatment of an inverted calcaneus Foot distal naviculus held in one hand with the other hand grasps the calcaneus The foot is rotated inward on the long axis of the foot producing relaxation over the calcaneus Introduce traction and rotate the foot outwardly Release traction and retest

58 Cuneiforms The range of motion of the three cuneiforms is limited as the act as the keystone to the longitudinal arch They can slip downward producing plantar pain. This is the most common type of cuneiform dysfunction.

59 Treatment of cuneiform dysfunction Place a sensing finger on the inferior surface of the affected cuneiform The operating hand grasps the metatarsal bone distal to the affected cuneiform Dorsiflex the metatarsal to produce relaxation over the cuneiform With the operating hand introduce traction or compression Bring the metatarsal inferiorly maintaining compression Release force and return to neutral. Retest.

60 References Van Buskirk, R, The Still Technique Manual, 2nd ed, 2006 Somatic Dysfunction in Family Practice, 2nd ed 2014

The Lower Limb VII: The Ankle & Foot. Anatomy RHS 241 Lecture 7 Dr. Einas Al-Eisa

The Lower Limb VII: The Ankle & Foot Anatomy RHS 241 Lecture 7 Dr. Einas Al-Eisa Ankle joint Synovial, hinge joint Allow movement of the foot in the sagittal plane only (1 degree of freedom): dorsiflexion: