Common Foot & Ankle Sports Injuries Symptoms Related to Abnormal Foot Biomechanics & their Differential Diagnosis Daniel Pang BSc (Hon) P&O, Cped Certified Pedorthist (USA)
Only 10% of foot having structure with normal human biomechanics Lowell D. Lutter part II runner s knee injuries
Normal Gait : Heel -- Toe heel strike foot flat toe off
} Achilles tendon plantar fascia
Achilles Tendon Complex Gastrocnemius Soleus
Achilles Tendon Insertion Site : posterior middle 1/3 of calcaneus
Biomechanical Principle 1
pes planus pronated pes cavus A Pathomechanics heel deviation B
Achilles Tendon Injuries Anatomical Zone Achilles pain ( 足 跟 痛 ) posterior heel pain ( 後 跟 痛 )
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
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
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
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
Achilles Pain: Differential Diagnosis Tendinosis endogenous enzymes micro-tears, incomplete Rupture
Posterior Heel Pain: Differential Diagnosis Insertional Achilles Tendon Injuries: Richard Bouche s grid
Posterior Heel Pain: Differential Diagnosis Achilles Insertional Calcific Tendinosis pathologic degenerative calcification mirco-tears? surgical removal entire central row
Posterior Heel Pain: Differential Diagnosis Haglund s disease pump bump localized at superolateral of posterior heel exacerbated by shoe pressure Superolateral Box
Posterior Heel Pain: Differential Diagnosis Calcaneal Bursae 1. Retrocalcaneal Bursitis inflammation (effusion & warmth) surrounding Achilles attachment posterosuperior calcaneus border
Posterior Heel Pain: Differential Diagnosis Calcaneal Bursae 2. Retro-Achilles Bursitis inflammation (effusion & warmth) superficial area posterior to Achilles attachment Superficial subcutaneous
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
Posterior Heel Pain: Differential Diagnosis Sever s Disease
Plantar Fascia:Anatomy
Biomechanical Principle 2: Windlass Mechanism
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
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)
Plantar Fasciitis: Examination medial calcaneal tubercle arch pain
Plantar Heel Pain: Differential Diagnosis Calcaneal Stress Fracture Plantar Calcaneal Bursitis Fat Pad Atrophy Nerve Entrapment heel center
Nerves in Foot Sciatic Nerve Tibial Nerve Fibular Nerve Tibial Fibular
Tarsal Tunnel Tibial Nerve
Branches of Tibial Nerve Medial Calcaneal Nerve (MCN) Lateral Plantar Nerve (LPN) 1 st branch of LPN Medial Plantar Nerve (MPN)
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