Foot and Ankle Pain

Prof. Dr. Ece AYDOĞ

Physical Medicine and Rehabilitation

FUNCTIONAL ANATOMY AND BIOMECHANICS The ankle, or tibiotalar,

joint comprises the articulation between the foot (talus) and the lower leg (distal tibia and fibula).

Anatomic regions Forefoot; toes and

metatarsal bones; metatarsophalangeal (MTP) and interphalangeal joints

Midfoot; tarsometatarsal (TMT) joints connect the forefoot to the midfoot, which comprises the three cuneiform bones, the navicular, and the cuboid

Hindfoot; talus and calcaneus, talocalcaneal (subtalar), talonavicular, and calcaneocuboid articulations.

PHYSICAL EXAMINATION

Location of swelling Deformity;

Hallux valgus or bunion Hammer toes, Flatfoot deformity (characterized by hindfoot

valgus/forefoot abduction). Callosities Rheumatoid nodules Ulcerations Wear patterns: “A deformed foot can deform any good shoe; in fact, in

many cases the shoe is a literal showcase for certain disorders.”

Hallux Valgus

Gece Ateli

Flatfoot Deformity

Flatfoot Deformity

Rheumatoid nodules Diabetic ulcer

PHYSICAL EXAMINATION

Metatarsal heads and MTP joints palpation in patients with RA or nonarthritic metatarsalgia; tenderness, synovitis, and swelling.

Tenderness over the posterior aspect of calcaneus; Achilles tendinitis

Pain over the medial tubercle (palpable on the medial plantar surface); plantar fasciitis.

Tenderness over sinus tarsi of the hindfoot (located laterally, just anterior and distal to the tip of the fibula); talocalcaneal joint pathology

Tenderness over the anterior joint line usually correlates with ankle joint pathology.

Calcaneal medial tubercule (Plantar fasciitis)

Talocalcaneal yoint pathology

PHYSICAL EXAMINATION

Range of motion analysis: 10 to 20 degrees of

dorsiflexion 40 to 50 degrees of

plantar flexion.

Normal hindfoot inversion and eversion are each approximately 5 degrees.

COMMON CAUSES OF ANKLE PAIN

ANTERIOR AND CENTRAL ANKLE PAIN Spur and osteophyte formation

Arthritis (degenerative or inflammatory) Anterior tibial tendon tendinitis or tendinosis

Stress fractures

Osteochondral defect

POSTERIOR JOINT PAINAchilles tendon

in most instances, Achilles pain results from degenerative tendinosis, with or without an overlying tendinitis.

associated intratendinous spur formation is common

spur excision also frequently entails tendon débridement, reconstruction, and transfer.

Spur formation(Plantar calcaneal and achilles tendon)

Achilles tendon

protected by two distinct bursae.

more superficial bursa is immediately subcutaneous and becomes inflamed primarily with irritation from ill-fitting shoes with a tight counter (“pump bump”).

Achilles tendon

“retrocalcaneal” bursa is a larger structure that lies deep to the Achilles tendon. Inflammation of this structure often accompanies Achilles tendinitis/tendinosis.

It also may be irritated by an enlarged posterior superior calcaneal tuberosity, sometimes referred to as a Haglund's deformity.

MEDIAL ANKLE PAIN

Stress fracture

Arthritis

Inflammation or degeneration (or both) of the posteromedial flexor tendons, including the posterior tibial tendon and the flexor hallucis longus and flexor digitorum longus tendons

long-standing synovitis and dysfunction of posterior tibial tendon ultimately may lead to collapse of the arch and the development of an acquired flatfoot deformity.

MEDIAL ANKLE PAIN

Tarsal tunnel syndrome is another cause of posteromedial ankle pain. pain that radiates

into the plantar foot

percussion of the tarsal tunnel reproduces these symptoms (Tinel's sign).

LATERAL ANKLE PAIN

Stress fracture Arthritis Peroneal tendon pathology;

tenosynovitis

longitudinal “split” tears

chronic tendon instability

the tendons sublux over the posterolateral edge of the fibula, causing pain and attritional tearing

COMMON CAUSES OF FOOT PAIN

FOREFOOT PAIN The forefoot region is a common location of

foot pain.

Rheumatoid Arthritis

inflammation and progressive MTP synovitis eventually lead to capsular distention and destruction.

loss of collateral ligament stability and, finally, destruction of the articular cartilage and bone

FOREFOOT PAIN

Hallux valgus deformity or bunion; commonly encountered in patients with and without

inflammatory arthritis RA; 70% progression of this deformity may be accelerated

further by loss of support from the adjacent lesser MTP joints.

Hallux rigidus Degenerative arthritis Sesamoiditis Osteonecrosis Fracture

FOREFOOT PAIN

Claw toes Hammer toes Mallet toes Etiologies;

arthritis, trauma, nerve/muscle imbalance, and chronic use of shoes with inadequate toe boxes.

Instability; mechanical causes (long second metatarsal) inflammatory disease MTP joint subluxation

Claw toe

Mallet finger

FOREFOOT PAIN

Metatarsalgia Gastrocnemius contracture or tight Achilles tendon; the

forefoot is prematurely loaded during the stance phase of gait.

Hammer toes and mallet toes can result in downward pressure on the metatarsal heads, leading to metatarsalgia.

In elderly patients and patients with inflammatory arthritis, atrophy of the plantar fat pad of the forefoot also can result in metatarsalgia.

LATERAL FOREFOOT

Morton's neuroma: between the third and

fourth metatarsal heads

burning, aching, or shooting pain

symptoms are especially exacerbated with tight shoes

.

LATERAL FOREFOOT

Bunionette: angular deformity of

the fifth toe

pain over the lateral aspect of the fifth metatarsal head

MIDFOOT PAIN

Arthritis at the TMT joints most frequently the first TMT joint on the

medial side of the foot instability of the first TMT joint, repetitive

stress can lead to dorsiflexion of the first metatarsal

midfoot arthritis can lead to an abduction deformity of the foot, where the forefoot and metatarsals deviate outward.

MIDFOOT PAIN

lateral midfoot pain: peroneal tendinitis stress fracture of the fifth metatarsal

medial midfoot pain: accessory navicular bone osteonecrosis of the native navicular bone insertional posterior tibial tendinitis

HINDFOOT PAIN

joints of the hindfoot talonavicular talocalcaneal calcaneocuboid

degenerative and inflammatory arthritis RA; 21% to 29%

posterior tibial tendinitis and dysfunction Inflammation Degeneration Dysfunction

HEEL PAIN Plantar fasciitis;

inferior heel pain worse when first getting up in the morning or getting up after

sitting for a long time Achilles tendinosis;

posterior heel pain worse during or after exercise

Nerve entrapment; first branch of the lateral plantar nerve (Baxter's nerve) medial heel pain

Calcaneal stress fracture; medial and lateral pain Calcaneal stress fracture usually can be distinguished by a

positive “squeeze test,” with compression of both sides of the heel.

NONOPERATIVE TREATMENT

Medical management Nonsteroidal anti-inflammatory drugs

Steroids

Disease-modifying antirheumatic drugs

NONOPERATIVE TREATMENT

Shoewear modification deep, wide toe box firm heel counter soft heel

Well-constructed walking or jogging shoes usually provide sufficient room for mild-to-moderate deformities

NONOPERATIVE TREATMENT

Often it is necessary to prescribe a custom orthotic insert for patients with more moderate deformities

It is typically necessary to remove the insole of the shoe to make

room for the orthotic insert

Custom orthoses; rigid, semirigid, softer accommodative devices

Rigid and semirigid orthoses usually are used to correct supple deformities and should be used with caution in patients with arthritis

Most walking or jogging shoes suffice.

NONOPERATIVE TREATMENT

More commonly, these patients, especially if they have RA, benefit from accommodative orthoses (i.e., orthoses made of softer material that can be molded to “accommodate” a deformity)

Accommodative orthoses can be modified further by incorporating a “relief” under a deformity, further unloading it

When sending patients for orthoses, it is best to provide the

orthotist with a prescription that includes the patient's precise diagnosis (e.g., metatarsalgia) and the type of orthosis and any modifications desired (e.g., a “custom accommodative orthosis with a relief under the lesser metatarsal heads”).

Injections

Mixture of anesthetic and corticosteroid

Injection of a corticosteroid near or directly into a tendon can adversely affect the biomechanical properties of the tendon, ultimately leading to rupture

Avoid corticosteroid injections into the lesser MTPs when there is evidence of joint instability. Such injections can lead to further attenuation of the

joint capsule and result in frank joint dislocation.

OPERATIVE TREATMENT

If symptoms persist despite nonoperative management, surgical intervention should be considered Arthrodesis (joint fusion), Arthroplasty (joint replacement), Corrective osteotomy, Tendon débridement and transfer, Synovectomy (joint or tendon).