Common Foot & Ankle Sports Injuries

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1 Common Foot & Ankle Sports Injuries Symptoms Related to Abnormal Foot Biomechanics & their Differential Diagnosis Daniel Pang BSc (Hon) P&O, Cped Certified Pedorthist (USA)

2 Only 10% of foot having structure with normal human biomechanics Lowell D. Lutter part II runner s knee injuries

3 Normal Gait : Heel -- Toe heel strike foot flat toe off

4 } Achilles tendon plantar fascia

5 Achilles Tendon Complex Gastrocnemius Soleus

6 Achilles Tendon Insertion Site : posterior middle 1/3 of calcaneus

7 Biomechanical Principle 1

8 pes planus pronated pes cavus A Pathomechanics heel deviation B

9 Achilles Tendon Injuries Anatomical Zone Achilles pain ( 足 跟 痛 ) posterior heel pain ( 後 跟 痛 )

10 Achilles Pain: Differential Diagnosis Achilles Paratenonitis ( 腱 鞘 炎 ) encapsulating structure a loose fatty, aerolar network of tissue (Not a true synovial sheath) paratenon for vascular supply for normal gliding

11 Achilles Pain: Differential Diagnosis Achilles Paratenonitis ( 腱 鞘 炎 ) Avascular area 2 to 6 cm proximal to insertion site Effusion, warmth, swelling, pain pain not move with ankle motion watershed area

12 Achilles Pain: Differential Diagnosis Achilles Paratenonitis If untreated Adhesive Tendinopathy fibrosis: adhesion between paratenon & Achilles tendon chronic inflammation of paratenon + reduced motion, fibrillation, creptus, yellowing? surgical intervention

13 Achilles Pain: Differential Diagnosis Adhesive Tendinopathy Achilles Tendinosis advanced chronic (not truly inflammatory) condition i.e pathologic degeneration of collagen fibers including calcification painful arc sign -- pain moves with ankle motion surgical repair If untreated

14 Achilles Pain: Differential Diagnosis Tendinosis endogenous enzymes micro-tears, incomplete Rupture

15 Posterior Heel Pain: Differential Diagnosis Insertional Achilles Tendon Injuries: Richard Bouche s grid

16 Posterior Heel Pain: Differential Diagnosis Achilles Insertional Calcific Tendinosis pathologic degenerative calcification mirco-tears? surgical removal entire central row

17 Posterior Heel Pain: Differential Diagnosis Haglund s disease pump bump localized at superolateral of posterior heel exacerbated by shoe pressure Superolateral Box

18 Posterior Heel Pain: Differential Diagnosis Calcaneal Bursae 1. Retrocalcaneal Bursitis inflammation (effusion & warmth) surrounding Achilles attachment posterosuperior calcaneus border

19 Posterior Heel Pain: Differential Diagnosis Calcaneal Bursae 2. Retro-Achilles Bursitis inflammation (effusion & warmth) superficial area posterior to Achilles attachment Superficial subcutaneous

20 Posterior Heel Pain: Differential Diagnosis Distal Achilles Tendo-fasciitis Inflammation of deep connective tissue between Achilles tendon and plantar fascia across lower boxes posterior plantar of calcaneus

21 Posterior Heel Pain: Differential Diagnosis Sever s Disease

22 Plantar Fascia:Anatomy

23 Biomechanical Principle 2: Windlass Mechanism

24 Pathomechanics -- low efficiency Propulsion coherency of subtalar joint motion flexibility of mid-tarsal joints ROM of 1 st MPJ lever elasticity of plantar fascia integrity of sesamoid pulley

25 Plantar Fasciitis : signs & symptoms Pain Pattern : Post-static Dyskinesia morning pain resting pain worse with prolonged weight bearing (better with rest, non-weight) No night pain No sensory disturbance (e.g. tingling, numbness, paraesthesiae, burning, sharp shooting, electric shock-like, radiating)

26 Plantar Fasciitis: Examination medial calcaneal tubercle arch pain

27 Plantar Heel Pain: Differential Diagnosis Calcaneal Stress Fracture Plantar Calcaneal Bursitis Fat Pad Atrophy Nerve Entrapment heel center

28 Nerves in Foot Sciatic Nerve Tibial Nerve Fibular Nerve Tibial Fibular

29 Tarsal Tunnel Tibial Nerve

30 Branches of Tibial Nerve Medial Calcaneal Nerve (MCN) Lateral Plantar Nerve (LPN) 1 st branch of LPN Medial Plantar Nerve (MPN)

31 Medial Calcaneal Nerve (MCN) Diagnotic Palpation: superficial pain at medial anterior part of heel fat & abductor hallucis muscle distally radiating pain minimal pain over plantar fascia origin fat pad abductor hallucis muscle

HEEL PAIN. Differential diagnosis. 1. Insertional Plantar fascitis. 2. Enthesis. 3. Heel pad atrophy. 4. Tarsal tunnel syndrome

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