Foot Ankle Exam Gait Guarded antalgic steppage waddling

Foot & Ankle Exam ● Gait – Guarded, antalgic, steppage, waddling, NWB, PWB ● Skin – Temp, tropic changes, nails, ulcer, keratosis, hair growth ● Vascular – DP, PT, cap refil, edema, varicosities ● MSK – Ext/Flex/Eve/Inv, DTR, ROM, MS ● Neuro – Protective Sensation (Vib, monofiliment), DTR

Foot & Ankle Exam Normal Gait. Neurovascular status grossly intact. Protective Sensation intact. Dry Supple skin. There is no sign of infection. There is no edema. There is no erythema. There is no ecchymosis. There is no bony point tenderness. Rectus foot type. ROM of ankle is 20° df and 45° pf. STJ ROM is 30° inversion and 20° eversion. ROM of 1 st MTPJ is 70° df and 25° pf. MS is 5/5. There is no proximal tenderness. The calf is supple and nontender. There is no anterior draw. Radiographs 3 views weightbearing of the ankle show no acute fracture or degenerative changes.

Foot & Ankle Landmarks Ankle Joint Injection

Foot & Ankle Landmarks 1 st MTP Joint Injection EHL

Foot & Ankle Landmarks PT nerve block

Foot & Ankle Landmarks PT nerve block

Foot Intrinsics ● Stabilizers of the arch, digits, plantar fascia ● Tibial Nerve – Med, Lat plantar nerve, calcaneal branch ● Post Tib artery

Anterior Compartment ● Extensors ● Deep Fibular Nerve (L 4, L 5) ● Ant Tib artery

Posterior Compartment ● Flexors ● Tibial Nerve (L 4, L 5, S 1, S 2) ● Post Tib artery

Posterior Compartment ● Flexors ● Tibial Nerve (L 4, L 5, S 1, S 2) ● Ant Tib artery

Medial Ankle ● Flexors ● Tibial Nerve (L 4, L 5, S 1, S 2) ● Ant Tib artery

Medial Ankle ● Flexors ● Tibial Nerve (L 4, L 5, S 1, S 2) ● Ant Tib artery

Lateral Compartment ● Evertors ● Sup Fib Nerve (L 5, S 1, S 2) ● Peroneal artery and Post Tib perf

Lateral Ankle ● Flexors ● Tibial Nerve (L 4, L 5, S 1, S 2) ● Ant Tib artery

Cutaneous Innervation

Cutaneous Innervation

Neuro

Vascular

Plantar Fasciitis

Plantar Fasciitis ● RICE, NSAIDS ● Cushioned supportive Walking shoes ● Orthotics, night splint, bracing ● HEP, PT ● Injections, x 2, PRP ● Xrays, U/S, MRI ● Sx – Deformity corrction, fasciectomy (topaz)

Ankle Sprain ● Grade 1 – Stretch of ligament, able to wt bear ● Grade 2 – Partial Tear of ligament, PWB ● Grade 3 – Complete Tear, unable to wt bear ● ATFL ● CFL ● Deltoid ● AITFL (High ankle sprain)

Ankle Sprain ● G 1 – RICE, Early ROM, HEP ● 1 -3 ● G 2 – Add ankle brace with early D/C as tolerated, then PT ● 3 ● weeks - 6 weeks G 3 - Add NWB in cast or boot ● 6 weeks ● MRI ● Instability, osteochondral lesion, peroneal tendon tear, occult fx

Ankle Sprain 29 m, WC, left ankle inversion injury treated for 6 months with no improvement with RICE, NSAID, PT, HEP, cam boot, PWB crutches, injection. Complains of posterior lateral, and anterior lateral pain. + ant draw, + tender along peroneals ● ●MRI shows complete tear of ATFL and split tear of peroneus longus tendon. No OCD. ● Left ankle peroneal tendon repair and ATFL recon.

Ankle Sprain

Arthritis ● Ankle ● TMT ● 1 st MTPJ

Arthritis RICE, NSAIDS, cane, walker ●Walking shoes ●AFO bracing ●HEP, PT ●Injections, PRP, stem cell ●Xrays, CT, MRI ●Sx – Deformity correction, arthroscopy, ● fusion, joint replacement

Ankle Arthritis

TMT Arthritis

1 st MTPJ arthritis ● Hallux limitus, Hallux rigidus

1 st MTPJ Arthritis 45 m, WC injury in the past, c/o great toe joint pain stiffness, decreased ROM, has done treatments of PT, HEP, NSAIDs, orthotics, injections. ● ● Right 1 st MTPJ fusion

1 st MTPJ Arthritis

Achilles Tendonopathy ● Rupture ● Tendonosis ● Partial tears ● Enthesopathy, Bone spurs ● Bursitis

Achilles Tendonopathy ● RICE, NSAIDS, cane, walker ● Cushioned supportive Walking shoes ● Orthotics, AFO bracing ● HEP, PT ● Injections, PRP ● Xrays, U/S, MRI ● Sx – Repair, spur resection

Acute Rupture Achilles Tendon 45 m, 3 weeks ago playing basketball felt pop to back of Left ankle. Thought sprained ankle and would heal its on own. City. MD refereed to Community Rad for MRI. Works for Zoc. Doc. ● ● Primary Repair of Achilles tendon.

Acute Rupture Achilles Tendon

Posterior Calcaneal Heel Spur ● Bursitis, tendonosis, heel spur, partial tears ● RICE, bracing, PT, HEP, NSAIDs ● Injection into bursa

Posterior Heel Spur 34 m, WC, left ankle injury 1 year ago, c/o back of ankle pain. MRI shows partial tear of achilles tendon at insertion with associated bursitis, and bone spurs with in the tendon ● Left ankle achilles tendon repair with ostectomy and bone spure removal ●

Posterior Heel Spur

Posterior Heel Spur

Pes Planus Abducto Valgus Deformity ● Posterior Tibialis Tendon Dysfunction

Pes Planus Abducto Valgus Deformity Flat foot deformity ● 55 f with chronic pain and deformity to RT foot. ● Dx: ● Chronic pain ● Chronic plantar fasciitis ● Anterior Lateral Ankle impingement ● Chronic PT tendonitis/tendonosis ● Flat foot deformity ● Sinus Tarsi Syndrome ● Left PPAV (flat foot) reconstruction

Pes Planus Abducto Valgus Deformity Flat foot deformity

Pes Planus Abducto Valgus Deformity Flat foot deformity

Diabetic / Charcot Foot ● Skin – Dry/Keratosis, ulcers, infection Neuro – Neuropathy, decreased protective sensation (monofiliment, vib), decreased DTR ● ● Vasc – Decreased micro/macro vasculature ● MSK – Weak intrinsics, PPAV

Diabetic / Charcot Foot ● Dx: ●DM ●LE with complications neuropathy ●PVD ●G 1 ulcer ●Keratosis ●Fall Risk ●Osteoarthropathy ●Valgus ankle deformity

Diabetic / Charcot Foot

● Tarsal Tunnel Syndrome ● Neuroma ● Drop foot ● RSD/CRPS ● Coalition ● Lisfranc (Midfoot, TMT) Injury ● Metatarsalgia ● Hallux Valgus (Bunion) ● Hammer toe ● Sesamoiditis ● Turf Toe