It's all about soft tissue injury and fracture of ankle and foot.

1. Fractures of Ankle & Foot
Dr. Dheeraj Lamba
Associate Professor & Head, Depth. of
Physiotherapy, Jimma University, Jimma
Email: dheeraj.lamba@gmail.com

3. INJURIES OF THE ANKLE
Anatomy of ankle joint
The ankle joint is formed by the talus
articulating in the mortise (a hole cut) formed
by the distal end of tibia and the malleolus.
Classification
The following are the types of violence which
can act on the ankle region and the fractures
are classified and named according to the
violence which cause them.

4. External rotation injuries.
Abduction injuries.
Adduction injuries.
Vertical compression injuries.
External rotation fractures
This is the commonest type of
fracture. The foot with the talus,
externally rotates in the ankle
mortise.

5. Abduction fracture at the ankle occurs,
when the foot is forcibly abducted on
the ankle or with the foot fixed on the
ground there is a blow or a weight
falling on the outer side of the leg.
Abduction Fracture
Adduction fracture
This is caused by forcible adduction
at the ankle level.

6. Pott’s fracture
First described by PERCIVAL POTT in
1765. This is caused by a combined
abduction external rotation
violence. It includes (a) Rupture of
medial ligament/ fracture medial
malleolus (b) Fracture of the lateral
malleolus (c) Lateral displacement
of the ankle.

7. Dupuytran’s Fracture
This again is due to abduction
external rotation violence. In a
typical case, there is (a) Fracture of
medial malleolus (b) Diastasis
(separation) of the inferior tibio
fibular syndesmosis and (c) a
fracture of distal fibula.

8. Vertical compression fractures
These are caused by a fall from a
height on the heels.
Type I : This may result in an anterior
marginal fracture of the articular end
of tibia with anterior displacement of
the talus.
Type II : This is a comminuted fracture
of the tibial articular surface with
upward displacement of the talus.

9. Conservative treatment
In isolated un displaced
Fracture of the lateral or medial
malleolus the foot is immobilized
first in a knee padded posterior
plaster slab. When the edema
subsides, a complete plaster cast is
applied and the patient allowed to
walk. The cast is kept for 4 to 6
weeks.

10. surgical reduction and screw
fixation is done.
In displaced fracture, manipulative
reduction under anesthesia is done
and plaster is applied. If
manipulation fails,

11. Surgical treatment
Bi malleolar fracture with
dislocation which are unstable after
manipulative reduction need open
reduction and screw fixation.
Fracture with tibio fibular diastasis
are often unstable after reduction.
They are best fixed by an additional
transverse screw fixing the lower
ends of the tibia and fibula.

13. Physiotherapy After Conservative
Treatment
Weight bearing is not allowed for 4-6 weeks. A
second plaster cast is then applied with the foot in
neutral position and the patient is allowed partial
weight bearing. Patients are encouraged to do
active toe exercise and quadriceps while in the
plaster. On the removal of the plaster, edema of
the leg and foot is prevented by elastocrepe
bandaging and active exercises are given to
mobilize the ankle and improve the muscle and
vasomotor tone in the leg.

14. Complications
It includes malunion, nonunion and
joint stiffness. Non-union is
common in medial malleolus
fracture when it has to be treated
by surgery. Malunion will later
result in osteoarthrosis.

15. FRACTURE IN FOOT

16. Fractures of foot bones
Bad treatment for foot injuries leading to stiff
and painful feet is a serious disability.
Fracture of Talus:
This is caused by fall on the foot with the
foot forced into dorsi flexion.
Fracture of Calcaneum:
This is the commonest tarsal bone to be
fractured. Injuries to the calcaneum are
caused by falling from a height and landing on
the foot.

17. Fracture of Metatarsals
Fractures of the metatarsals are
due to direct violence, the foot
being crushed by weights falling on
it. Crack fractures without
displacement are best treated by
strapping the foot and weight
bearing after few days.

18. Jones Fracture
Cause of Injury
• Fracture of metatarsal caused by inversion or high
velocity rotational forces
• Most common = base of 5th metatarsal
Sign of Injury
• Immediate swelling, pain over 5th metatarsal
• May feel a “pop”
• High nonunion rate and course of healing is
unpredictable
Care
• Generally requires 6-8 weeks non-weight bearing
with short leg cast if non-displaced
• If nonunion occurs, internal fixation may be
required

20. Metatarsal Stress Fractures
Cause of Injury
• 2nd metatarsal fracture (March fracture)
• Change in running pattern, mileage, hills, or hard
surfaces
• Often the result of structural deformities of the foot
or training errors (terrain, footwear, surfaces)
• Often associated with Morton’s toe
Signs of Injury
• Pain and tenderness along second metatarsal
• Pain with running and walking
• Continued pain/aching when non-weight bearing

21. Care
Determine cause of injury
Generally good success with modified
rest and training modifications (pool
running, stationary bike) for 2-4 weeks
Return to running should be gradual
over a 2-3 week period with
appropriate shoes (sport shoes).

22. Fracture of Phalanges
These fractures are treated by
strapping the injured toe to the
adjacent toe or toes for a period of
2-3 weeks. Displaced fractures
need manipulative reduction and
strapping.

23. Soft Tissue Injuries of Ankle &
Foot

24. Highly vulnerable area to variety of
injuries.
Injuries are best prevented by selecting
appropriate footwear, correcting
biomechanical structural deficiencies
through orthotics
Foot will adapt to training surfaces over
time
Must be aware of potential difficulties
associated with non-yielding and
absorbent training surfaces.

25. Plantar
Fascia

26. Plantar fasciitis
Plantar Fasciitis is a painful condition caused by
overuse of the plantar fascia or arch tendon of the
foot.
Clinical features
Heel pain, under the heel and usually on the inside, at
the origin of the attachment of the fascia.
Pain when pressing on the inside of the heel and
sometimes along the arch
Pain is usually worse first thing in the morning as the
fascia tightens up overnight. After a few minutes it
eases as the foot gets warmed up
As the condition becomes more severe the pain can
get worse throughout the day if activity continues.
Stretching the plantar fascia may be painful.

27. Rest for 3 days. Apply ice or cold
therapy to help reduce pain and
inflammation. Cold therapy (contrast
Bath) can be applied regularly until
symptoms have resolved.
Stretching with US, LLLT is an
important part of treatment and
prevention . Simply reducing pain and
inflammation alone is unlikely to result
in long term recovery.

28. The plantar fascia tightens up making
the origin at the heel more susceptible
to stress. Silicon heel can be beneficial.
A plantar fasciitis night splint, is an
excellent product which is worn
overnight and gently stretches the calf
muscles and plantar fascia preventing
it from tightening up overnight.

29. Applying “heel cup”
can also be effective
in giving relief from
s/sx

30. Retro calcaneal Bursitis
• Caused by inflammation of the bursa that lies
between the Achilles tendon and the
calcaneal.
• Symptoms and Signs: Swelling on both sides
of the heel cord.
• Management: RICE and NSAIDs. Routine
stretching of Achilles and use of ultrasound
can reduce inflammation.

32. Achilles Tendonitis
Definition: Inflammation of the achilles tendon
MOI: may be from a single incident but more
often from an accumulation of smaller stresses
S/Sx:
• Usually gradual onset of S/Sx
• Early on, pain occurs only during activity and
slowly progresses to pain all of the time
• Point tenderness over tendon
• Swelling may be present

34. Treatment
Rest, ice and NSAID’s
Gentle stretching of tendon
Heat before activity/Ice after
activity
Taping and/or heel lift
Ultrasound
LLLT, ECSWT

35. Medial Tibial Syndrome
• Def: Shin splints: a general term applied to a
variety of conditions that seasonally plague
many athletes
• MOI: factors that may lead to an increase
incidence of shin splints are:
–Biomechanical factors
–Change in intensity, duration, or frequency
of workouts
–Improper or worn footwear
–Change in surface
–Improper warm-up and cool-down
–Change in type of workout

36. S/Sx:
Grade I: pain after activity
Grade II: pain before and after activity
not affecting performance
Grade III: pain before, during and
after activity and affecting
performance
Grade IV: pain so sever that
performance is impossible

37. Tx: varies by individual
Constant heat (whirlpools and US)
with taping
NSAIDs
Ice massage before or after
Stretching of anterior and posterior
structures

38. Metatarsalgia
Metatarsalgia is a general term used to denote a painful foot
condition in the metatarsal region of the foot (the area just
before the toes, more commonly referred to as the ball-of-
the foot).
Cause:
Excessive pressure over a long period of time.
Improper footwear
Treatment:
The first step in treating metatarsalgia is to determine the
cause of the pain and managed accordingly. RICE, NSAIDs,
ultrasound, LLLT, tape and shoe modification.

39. Hallux rigidus
Hallux rigidus is a disorder of the joint located at the base
of the big toe. It causes pain and stiffness in the big toe,
and with time it gets increasingly harder to bend the toe.
"Hallux" refers to the big toe, while "rigidus" indicates
that the toe is rigid
Causes
Faulty function (biomechanics) and structural
abnormalities of the foot that can lead to osteoarthritis in
the big toe joint.
In some people, hallux rigidus runs in the family and is a
result of inheriting a foot type that is prone to
developing this condition.
In other cases, it is associated with overuse ,especially
among people engaged in activities or jobs that increase
the stress on the big toe, such as workers who often have
to stoop or squat.

40. Hallux rigidus can also result from an
injury even from stubbing your toe.
It may be caused by certain
inflammatory diseases, such as RA or
gout
Early signs and symptoms include
Pain and stiffness in the big toe during
use (walking, standing, bending, etc.)

41. As the disorder gets more serious,
additional symptoms may develop,
including:
Pain, even during rest
Difficulty wearing shoes because bone
spurs (overgrowths) develop. Wearing
high-heeled shoes can be particularly
difficult.

42. Dull pain in the hip, knee, or lower
back due to changes in the way you
walk
Limping, in severe cases
MANAGEMENT
Foot wear modification
Ultrasound therapy, night splint or
other modalities to relieve pain and
inflammation.

43. Pain and stiffness aggravated by
cold, damp weather
Difficulty with certain activities
(running, squatting)
Swelling and inflammation around
the joint

44. Bunionettes (Tailor’s Bunions)
• Etiology: Bunion occurs at the head of the first metatarsal. Often
caused by shoes. Bunionette the toe angulates toward the fourth
toe, causing an enlarged metatarsal head.
• In all bunions, both the flexor and extensor tendons are malaligned,
creating more angular stress on the joint.
• Symptoms/Signs: During formation there is tenderness, swelling,
and enlargement of the joint. Angulation of the toe progresses.
• Management: Early recognition and care can often prevent
increased irritation & deformity.
• Wear correctly fitting shoes
• Wear an appropriate fitting orthotic
• Place a sponge rubber doughnut pad over the 1st/5th
metatarsophalangeal joint
• Wear a tape splint along with a resilient wedge placed between the
great toe and 2nd toe.
• Engage in daily foot exercises. Ultimately, surgery may be necessary

45. Turf Toe

46. S/Sx: pain during push-off phase of
gait, active joint motion or manual
resistance. Pain when attempting
quick stops . Point tenderness over MP
joint, limited ROM
Tx: PRICE, NSAIDs, ultrasound, tape

47. Tarsal Tunnel Syndrome
• Symptoms and Signs: Complaints of pain and
paresthesia are typical, along the medial and
plantar aspects of the foot.
• Management: Anti-inflammatory drugs. UST,
nerve gliding exercises and mobilization
exercises.

48. Pes Planus Foot
• Pes planus is associated with excessive foot
pronation and may be caused by a number of
factors, including a structural forefoot varus
deformity, shoes that are too tight or trauma
that weakens supportive structures.
• Symptoms and Signs: Pain or a feeling of
weakness or fatigue in the medial longitudinal
arch.
• Management: Arch support with an orthotic.

49. Longitudinal Arch Strain
• Etiology: Caused by subjecting the musculature
of the foot to stress produced by repetitive
contact with hard surfaces. There is a flattening
or strain to the longitudinal arch.
• Symptoms/Signs: Pain is experienced only during
running or jumping. The pain usually appears just
below the posterior tibialis tendon.
• Management: PRICE followed by therapy, arch
taping and reduction of weight bearing along
with shoe modification.

51. Ankle Sprain
85% cases are due to inversion
– Deltoid ligament is stronger than the lateral
ligaments
• Anterior tibiotalar, tibiocalcaneal,
tibionavicular, and posterior tibiotalar
ligaments
– Lateral malleolus is longer than medial malleolus
– Axis of talo-crural joint
• In plantar flexion, ankle naturally inverts
• In dorsiflexion, ankle is very stable

52. Patho anatomy and Mechanisms of
Injury
• The most common mechanism of injury is a
combination of plantar flexion and inversion.
• The lateral stabilizing ligaments, which include the
anterior talofibular, calcaneofibular and posterior
talofibular ligaments.
• The anterior talofibular ligament is the most easily
injured.
• The posterior talofibular ligament is the strongest
of the lateral complex and is rarely injured in an
inversion sprain.

55. Grading
Grade I: anterior talofibular ligament (ATF)
Grade II: ATF plus calcaneofibular ligament
(CF)
Grade III: ATF plus CF plus posterior
talofibular ligament

57. Diagnosis
•History of trauma
•Swelling/discoloration
•Pain/tenderness
•Eversion restriction
•Anterior drawer test
for ankle
•X-ray

58. Special Tests
The anterior drawer test and the inversion stress
test
The anterior drawer test can
be used to assess the integrity
of the anterior talofibular
ligament.
The inversion stress test can be
used to assess the integrity of the
calcaneo fibular ligament.

59. Functional Rehabilitation
Prolonged immobilization of ankle sprains is a
common treatment error. Functional stress
stimulates the incorporation of stronger
replacement collagen.
The four components of rehabilitation are:
1. Range-of-motion rehabilitation
2. Progressive muscle-strengthening exercises
3. Proprioceptive training
4. Activity-specific training

60. RICE
Achilles tendon stretch
Isometric exercises to DF, PF, IR & ER
ROM exercises & later PRE

63. Morton’s Neuroma
• Etiology: Located between the 3rd & 4th
metatarsal heads where the nerve is the thickest.
With the collapse of the transverse arch of the
foot, it stretches metatarsal ligaments which then
compresses the digital nerves & vessels.
• Symptoms/signs: Burning paresthesia and pain in
the forefoot. Hyperextension of the toes can
increase the symptoms.
• Management: Bone scan often necessary. Use a
pad. Shoe selection with wider toe box would be
appropriate. Last resort is corticosteroid
injection.

65. Thanks