4. Objectives
• Recognize the more prevalent foot and ankle- oriented
pathologies seen in musculoskeletal practice
• Understand the etiology behind each of the
pathologies
• Evaluate the treatment-oriented evidence behind
each of the disease processes
11. Achilles Tendinopathy
• Prevalence of 11-57% in
runners compared to 2.9-
4% of non-athletes with
an odds ratio of 10.0
• Annual incidence of 7-
9% in elite runners
• Increased incidence of
Achilles injury as age
increases
16. Etiology
• Degenerative Process
• Achilles tendon undergoes
morphologic and biomechanical
changes with increasing age
including:
– Decreased collagen diameter/density
– Decreased glycosaminoglycans and
water content
– Increased nonreducible cross links
– Decreased tensile strength, linear
stiffness, and ultimate load
• Decreased capacity for collagen synthesis
• Abnormal neovascularization which may be accompanied by an in-
growth of nerve fascicles which may in part be responsible for the
pain associated with Achilles tendinopathy
Mechanical factors: Repetitive
mechanicalloads, excessive loads,
contusions
Structural factors:
Morphologic,cellular,
metabolic
Fibrillar ruptures
Cellular and matrix lesions
Reactive tendinopathy
Regeneration - adaptation Tendon dysrepair
Optimized load Excessive load
Degenerative
tendinopathy
Anatomical healing
Clinicalhealing Rupture
17. Achilles Tendinopathy – Clinical
Presentation
• Mean age 30-50 years
• Athletic
– Running, Jumping
• Local tenderness of the Achilles 2-6cm proximal
to its insertion
• Tendon thickening
• Decreased PF strength
• Decreased PF endurance
• Pain and stiffness after inactivity, lessens with activity and
returns after activity
• Pain with eccentric DF (walking down stairs
18. Achilles Tendinopathy – Risk Factors
• Dorsiflexion ROM
–Decreased (<11.5 degrees)
increased risk by a factor of 3.5
• Abnormal subtalar ROM
–Increased inversion ROM (>32.5 degrees) increased
risk by a factor of 2.8
–Decreases in total inversion/eversion ROM (<25
degrees)
• Decreased Plantar Flexion Strength
• Excessive pronation
• Hallux rigidis
Intrinsic Factors
19. • Training Errors
–Increased mileage, intensity, hill training
• Footwear with insufficient rearfoot control, hard
soles, or high heels
Extrinsic Factors
Achilles Tendinopathy – Risk Factors
20. Clinical Diagnosis
• Symptoms located to the midportion of the
Achilles tendon and:
–Intermittent pain related to exercises or activity
–Stiffness upon weight bearing after prolonged
immobility such as sleeping
–Achilles tendon tenderness
24. Posterior Tibialis Dysfunction
• Often misdiagnosed as medial ankle sprain
• Tibialis posterior is the primary stabilizer of
the medial longitudinal arch
• Can reach a prevalence of 10% in elderly`
women
• Estimated to affect nearly 5 million people in
the US.
25. Pathogenesis
• Age related tendon degeneration
• Fibrotic changes as a result of repeated
microtrauma
• Abnormal forces arise from even mild flatfoot
tenders, resulting in lifelong greater demands on the
tibialis posterior than in a normal foot
26. Risk Factors
• Female
• > 40 years of age
• Flatfoot
• Hypertension
• Diabetes
• Steroid injection
• Obesity
27. Clinical Presentation
• Pain and swelling posterior to
the medial malleolus
• Female > male
• Age > 40
• Pain worse with weightbearing
and with inversion and
plantarflexion against resistance
• “Too many toes” sign
• Pain with single-leg toe raise
• Lacks normal heel varus when
rising up on toes
• Ache after walking long
distances
28. Stages of Posterior Tibial Tendinopathy
Stage 1 Stage 2 Stage 3 Stage 4
Tendonpathology
Deformity
Tenosynovitis+/-
degeneration
Absent
Degeneration+
elongation
Flexible pes
planovalgus
Degeneration+
elongation
Fixed pes planovalgus
Medial +/- lateralpain
Degeneration+
elongation
Fixed pes planovalgus
Clinical findings Medial pain
Mild pain with heelraise
Mild weakness with
hindfoot inversion
Medial +/-lateral
pain
Too-many-toes sign
Marked pain with heel
raise +/-unable to
perform
Marked weakness
with hindfoot
inversion
Too-many-toes sign
Unable to performheel
raise
Marked weakness with
hindfoot inversion
Medial +/- lateral pain
Too-many-toes sign
Unable to performheel
raise
Marked weakness with
hindfoot inversion
Pain/crepitus with
tibiotalur motion
Nonoperative
treatment
Medial heel +sole
wedge
Period of immobilization
Therapy
Orthotic support
(molded articulated
AFO)
Rigid AFO Rigid AFO
Operative treatment Tenosynovectomy
Repair
FDL tendon transfer
Calcaneal osteotomy
Lateral column
lengthening
Heel cord lengthening
Triple arthrodesis Tibiotalocalcaneal
arthrodesis
Triple arthrodesis with
total ankle arthroplasty
(expiremental)
29. Diagnosis
• Medial pain or swelling
behind the medial
malleoli AND change in
foot shape demonstrates
a sensitivity of 100%
31. Tarsal Tunnel Syndrome
• Involves the motor and
sensory branches of
the tibial nerve (L4 to
S3) as it travels
underneath the flexor
retinaculum
32. Etiology
• Can be a result of Posterior Tibial Tendon
Dysfunction leading to hyperpronation in the
mid-foot and resultant increased tension in
the tibial nerve
• Space occupying lesion including ganglia,
accessory muscles or tenosynovitis of adjacent
flexors
36. Peroneal Tendon – Clinical Presentation
• Swelling not typically present
• Pain posterior or distal to lateral
malleoli, around cuboid
• Varus hindfoot
• Forefoot varus
• Pain with terminal stance
• Unilateral heel rise painful
• Limited ankle DF
• Pain with passive DF and
inversion
• Pain with resisted
plantarflexion/eversion
• May have history of chronic
lateral ankle pain and instability
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