Foot and Ankle

1. Foot and Ankle Rance L. McClain, D.O., FACOFP Associate Professor – FM Dept. KCUMB-COM

3. Learning Objectives • Review the diagnosis of the foot and ankle • Apply specific osteopathic testing to the diagnosis of the foot and ankle • Understand the application of osteopathic treatment to the foot and ankle

4. General • The foot and ankle is the focal point of total body weight, performing this function both when stationary and with gait • Adaptation to the terrain upon which a person stands and walks

5. General • Problems with the foot and ankle can arise from mechanical, pathological, vascular, or inflammatory origins • The foot is affected not only by local stresses, but also by systemic diseases • Approximately 40% of people have foot and ankle problems

6. Inspection - Ankle • Range of Motion • Plantar flexion: 50 degrees • Dorsiflexion 20 degrees • Excess motion can cause fibular dysfunction

8. Inspection - Ankle • Accessory motions of side-to-side glide, rotation, abduction, and adduction are also present depending on the position of the foot • Because the talus is wider anteriorly than posteriorly, the ankle is more mobile in plantarflexion than dorsiflexion

9. Inspection - Ankle • Ankle Mortis • Relationship of the medial and lateral malleoli causes the ankle articulation to be held in a position of 15 degrees of toeing out

11. Inspection - Ankle • Tibiofibular syndesmosis • Responsible for maintaining the width of the ankle mortise • If torn, the mortise can widen, and the talus becomes unstable

12. Inspection - Ankle • Soft Tissue & Edema • Medially located deltoid ligament • Laterally located anterior & posterior talofibular ligaments, as well as the calcaneofibular ligament • Anterior talofibular ligament is highly susceptible to injury • Lateral ankle edema inferior and anterior to the lateral malleolus

14. Inspection - Ankle • Unilateral swelling is usually trauma, while bilateral swelling is usually indicative of cardiovascular problems (CHF, venous insufficiency, etc.)

16. Inspection - Ankle • Vascular • Posterior tibial pulse • When you progress down to the inspection of the foot, you will also inspect the dorsal pedal pulse

17. Inspection - Foot • How many toes are present and are they deformed

18. Inspection - Foot • How does the foot contact the floor • Pressure points can develop calluses • Skin is usually thicker at the weight bearing areas at the heel, the lateral border, and the 1st and 5th metatarsal heads

19. Inspection - Foot • Can you slide your fingers under the medial arch of the foot

20. Inspection - Foot • Arches • Lateral longitudinal arch • Calcaneus, Cuboid, 4th & 5th Metatarsal bones • Low arch with limited mobility • Transmits weight and thrust to the ground • Medial longitudinal arch • Calcaneus, Talus, Navicular, Cuneiforms, and 1st-3rd Metatarsals • Higher arch, much more mobile. Sustained by the skeletal structures as well as the Plantar Fascia

21. Inspection - Foot • Inspect the arches with the patient sitting • Spastic flat foot will cause the foot to dorsiflex and evert, whereas a normal foot will plantar flex and invert

22. Inspection - Foot • Range of Motion • Calcaneal abduction and adduction at the subtalar articulation • Inversion and eversion are combination motions • Inversion is calcaneal adduction, navicular rotation, and glide on the talus • Eversion is produced by the opposite motions above

23. Inspection - Foot • Forefoot abduction and adduction • Pronation is the motion of the foot and ankle combining calcaneal abduction, forefoot abduction, subtalar- cuboid-navicular eversion, and ankle dorsiflexion • Supination consists of calcaneal adduction, subtalar-cuboid-navicular inversion, forefoot adduction, and ankle plantar flexion

25. Shoe Inspection • Alterations in structure and function will show in the wear and tear on shoes • Normal wear from heal strike to toe off gives a transverse crease

26. Shoe Inspection • Abnormal wear examples • Foot Drop (neurological damage) • Dorsiflexors are paralyzed • Toe scrapes in ambulation causes scuff marks on the toe box and the front part of the soles • Hallux Rigidus (no motion of the 1st MTP joint) • Does not allow normal toe off with gait, leading to an oblique crease in the shoes

29. Shoe Inspection • Flat Feet (Pes planus) • Tend to over pronate and increase wear on the soles of the shoe medially • High Arches (Pes cavus) • Tend to supinate and increase wear on the lateral aspects of the soles of the shoes

31. Lab/Treatment Section • Evaluation • Dorsiflexion/Plantarflexion • Subtalar Abduction/Adduction • Calcaneal Inversion/Eversion • Navicular (medial) & Cuboid (lateral) • Metatarsal motion • Phalanges motion

32. Lab/Treatment Section • Muscle Energy • Dorsiflexion/plantarflexion • Subtalar abduction/adduction • Calcaneal inversion/eversion

33. Lab/Treatment Section • Counterstrain • Calcaneal TP (plantar fasciitis) • Soft tissue treatment • Plantar fascia • Lymphatics • Effleurage & Pétrissage

34. Lab/Treatment Section • HVLA • Inversion/eversion calcaneus (ankle traction) • Subtalar thrust • Dorsal metatarsals treatment • Transtarsal thrust • Cuboid-Navicular treatment (Hiss whip)