17/10/2017. Foot and Ankle

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Tibialis Tendon tendinopathy Stress Fracture Ligamentous tearing Turf Toe Osteochondral Defect of the Talar Dome Plantar

into 5 sections extending to each toe Functions to prevent eversion during heel rise Arises predominantly from the medial

1 17/10/2017 Alicia M. Yochum RN, DC, DACBR, RMSK Foot and Ankle Plantar Fasciitis Hallux Valgus Deformity Achilles Tendinosis Posterior Tibialis Tendon tendinopathy Stress Fracture Ligamentous tearing Turf Toe Osteochondral Defect of the Talar Dome Plantar Fascia (Aponeurosis) Thin Ligament directly beneath the skin Absorbs the shock placed on the foot when walking Divides into 5 sections extending to each toe Functions to prevent eversion during heel rise Arises predominantly from the medial calcaneal tubercle Central Band: Implicated in plantar fasciitis Medial Band: Very thin Lateral Band: Attaches to the base of the 5th metatarsal Absent in 12% of the population The Pathomechanics of Plantar Fasciitis Sports Medicine 1

Plantar Fasciitis Mechanical overload altered load Micro tears Degeneration of collagen Uncommon to see traumatic rupture Imaging features Edema in the

$2482062110# Advanced Imaging Computed Tomography Best for bony anatomy fractures Magnetic Resonance Imaging Physiologic imaging most sensitive T1: Good at$ evaluating bony anatomy Fat is white T2: Good at evaluating fluid/pathology WATER is white WWII (Water is white on T2) Diagnostic Ultrasound Good soft

evaluating bony anatomy Fat is white T2: Good at evaluating fluid/pathology WATER is white WWII (Water is white on T2) Diagnostic Ultrasound Good soft

2 Plantar Fasciitis Mechanical overload altered load Micro tears Degeneration of collagen Uncommon to see traumatic rupture Imaging features Edema in the tissues deep to the fascia Edema within the fascia Bone marrow edema at the insertion Thickened fascia Hypermia (ultrasound) Calcaneal Enthesopathy/spur 25% in asymptomatic patients Calcaneal Enthesopathy Remember inflammatory arthritis Reactive Advanced Imaging Computed Tomography Best for bony anatomy fractures Magnetic Resonance Imaging Physiologic imaging most sensitive T1: Good at evaluating bony anatomy Fat is white T2: Good at evaluating fluid/pathology WATER is white WWII (Water is white on T2) Diagnostic Ultrasound Good soft tissue resolution and can evaluate blood flow Allows for movement/orthopedic tests during the exam Limited at evaluating articular/internal joint structures Very limited in the spine 2

3 T1 T2 Edema in the Adjacent Soft tissues Edema and Thickening of the Fascia 3

4 Hallux Valgus Deformity Angle Normal 5 10 Tibial Sesamoid Position Should be medial to the line Lateral deviation of the sesamoid Crista Seen with position 4 and up Central prominence on the 1 st MT head Other terms Hallux Limitus reduced 1 st MTP dorsiflexion Hallux Rigidus results from structural or functional restriction of motion (end stage of limitus) 4

5 Normal: 5 10 Case Courtesy of Logan University Grade 4 Achilles Tendinosis Thickened tendon Fluid within the fibers May have some partial thickness tearing 5

6 Achilles Tendinopathy Ultrasound Achilles Tendinopathy Ultrasound 6

7 Achilles Tendon Rupture Fluid is black on Ultrasound 7

$March fracture 3 rd 5 th Near peroneus$

8 Stress Fracture Repetitive Injury Stress response X Ray: Periosteal Reaction Callus formation Sign of attempt at healing MRI: Bone marrow edema Present even BEFORE it Fractures Location Metatarsal 2 nd Metatarsal: March fracture 3 rd 5 th Near peroneus brevis insertion Case Courtesy of Jamie Bedle DC, DACBR 8

One Month Later Ligamentous Grading Grade 1 Sprain Ligament injured

Disorganization of fibers Grade 3 Sprain Full thickness tearing May have

restraint to ankle inversion Injury as patient moves into plantar

Ligament (CFL) Stabilizes both the ankle joint and the subtalar jt

tear in inversion ankle injuries Both are torn in approx.

9 One Month Later Ligamentous Grading Grade 1 Sprain Ligament injured without disorganization of fibers Grade 2 Sprain Partial thickness tear Disorganization of fibers Grade 3 Sprain Full thickness tearing May have instability Ligaments Anterior Talofibular Ligament (ATFL) Primary restraint to ankle inversion Injury as patient moves into plantar flexion and inversion Most common ligament to tear Calcaneofibular Ligament (CFL) Stabilizes both the ankle joint and the subtalar jt Injury as ankle is inverted and dorsiflexed 2 nd most common ligament to tear in inversion ankle injuries Both are torn in approx. 20% Anterior Inferior Syndesmotic Ligament Injured in a HIGH ANKLE sprain Can be very unstable and require surgery 9

10 ATFL Anterior Inferior Syndesmotic Ligament 10

11 Posterior Tibialis Tendon Common site of pain in patients who pronate excessively Posterior Tibialis Tendon Interstitial Tear Tenosynovitis 11

12 Turf Toe Plantar plate injury Sesamoids embedded in a plate of connective tissue Hyperextension FHL FHL 12

13 Osteochondral Defect History of trauma in 85% Location Posteromedial Inversion, plantar flexion, external rotation Deeper lesion Slightly more common than lateral Anterolateral Inversion, dorsiflexion Shallower Osteochondral Defect Talar Dome Osteochondral Defect Talar Dome 13

14 Osteoarthritis Post trauma? 14

15 Talar Avascular Necrosis Sclerosis Collapse Case courtesy of Dr Ahmed Abd Rabou, Radiopaedia.org, rid: Thank You! 15

Review relevant anatomy of the foot and ankle. Learn the approach to examining the foot and ankle

Objectives Review relevant anatomy of the foot and ankle Learn the approach to examining the foot and ankle Learn the basics of diagnosis and treatment of ankle sprains Overview of other common causes