Management of foot and ankle disorders

9


Management of foot and ankle disorders





image Key words


Anatomy and biomechanics, classification, clinical practice framework, examination, interventions, motor control impairment, movement behaviour, movement impairment, therapeutic exercise, passive movement




Introduction


Foot and ankle problems are highly prevalent. Population-based studies indicate that between 18 and 63% of people report pain, aching, or stiffness in their feet ( Hill et al. 2008, Menz et al. 2010). Musculoskeletal foot and ankle problems are commonly seen in primary care consisting of 8% of all musculoskeletal consultations ( Menz et al. 2010). The role of manual therapy in the intervention of musculoskeletal foot and ankle disorders is well established ( Bronfort et al. 2010).


In contemporary manual therapy practice musculoskeletal foot and ankle disorders should be considered in a multifactorial bio-psychosocial framework ( Kangas et al. 2011). Therefore, the role of manual therapy extends far beyond manual techniques. Manual therapy practice should be a process involving the evaluation of the disorder and implementing an intervention based on evaluation. This process should consider the physical and the psychosocial dimensions of the disorder.



Anatomy and regions of the foot and ankle


The foot consists of 28 irregularly shaped bones, over 30 joints, 32 muscles and over 100 ligaments. All these structures have to work synchronously to fulfill the high requirements of the foot and ankle. The foot alternates in form and function between a flexible structure for shock-absorption during loading response and a rigid lever for propulsion during terminal stance of the gait cycle. Considerable forces act on the foot and ankle during normal daily activities. For example, a joint contact force for the talocrural joint (TCJ) can range from three to five times the body weight during the stance phase of gait ( Kleipool & Blankevoort 2010).


The foot can be divided into different regions based on anatomy, arches of the feet, functional regions and for examination and treatment purposes. Anatomically the foot can be divided into hindfoot, midfoot, and forefoot ( Fig. 9.1). The hindfoot consists of the talus and the calcaneus, the midfoot consists of the navicular, cuboid and cuneiform bones and the forefoot consists of the metatarsals (referred to as rays) and phalanges ( Hamill et al. 1995). Classically, the arches of the foot have been defined as medial longitudinal, lateral longitudinal and transverse. From a functional perspective, the arches can be divided into medial, central and lateral ( Fig. 9.2). The medial arch consists of the talus, calcaneus, navicular, medial cuneiform and the first metatarsal bones. The first metatarsal, medial cuneiform and the navicular bones form the first ray. The central arch consists of the intermediate and lateral cuneiforms and the second and the third metatarsal bones. The lateral arch consists of the calcaneus, cuboid and the fourth and the fifth metatarsal bones. The fifth metatarsal and cuboid bones form the fifth ray.



imageThe bones and arches of the foot





The medial and lateral arches are more flexible and are actively weight-bearing arches. Whereas, the central arch is more unyielding and passively contributes to the foot and ankle construct.


For manual examination and treatment it is convenient to divide the foot and ankle into the hindfoot and forefoot. The hindfoot consists of the distal tibiofibular joint, talocrural joint (TCJ), subtalar joint (STJ) and surrounding soft tissue structures. The forefoot consists of the midtarsal joint (MTJ), intertarsal joints, tarsometatarsal (TMT) joints, intermetatarsal spaces, metatarsophalangeal (MTP) joints, interphalangeal (IP) joints, and surrounding soft tissue structures.



Movements of the foot and ankle


Optimal function of the foot and ankle is based on the synchronization of the movements of individual joints. Single-joint movements occur in distinctively different directions ( Nester et al. 2001, Arndt et al. 2004, Tweed et al. 2008). However, in functional movements of the foot and ankle independent movements of single joints are seldom, if impossible. The actions of the joints are highly inter-related and an action at one single joint will influence the other joints. Moreover, movements are often combined or coupled between the joints. For example, in the ankle one-third of the inversion and eversion occurs in TCJ and two-thirds in STJ ( Kleipool & Blankevoort 2010).



Axes and planes of movements


In this text, the terms eversion and inversion (EV and INV, respectively) are used to describe movements around an anteroposterior axis of the foot. These movements take place in the frontal plane. Plantar flexion and dorsiflexion are used to describe movements around a transverse axis of the foot. These movements take place in the sagittal plane. Abduction and adduction are used to describe movements around a vertical axis of the foot. These movements take place in the transverse plane ( Arndt et al. 2004). The terms pronation and supination (Pron and Sup) are used to describe the triplanar motions of the subtalar joint (STJ) and midtarsal joint (MTJ). These movements are assumed to occur around an axis of the STJ and MTJ ( Nester et al. 2001, Arndt et al. 2004) These definitions are used throughout the text – apart from in the section on techniques. In the section on passive movement techniques, pronation and supination are used to describe the triplanar movement of the whole foot and ankle. The movement of the hindfoot around the vertical axis has been called ‘rotation’. This is to make it easier to separate the hindfoot and forefoot movements. Furthermore, the rotations of the hindfoot are so closely related to the rotations of the lower leg, that it is reasonable to maintain the same terminology in clinical practice. In the section on techniques, the movement directions are defined in Figure 9.4.



Movements of the single joints



Distal tibiofibular joint (syndesmosis)


The distal tibiofibular (syndesmosis) joint is formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis and are linked by the distal anterior tibiofibular ligament, the distal posterior tibiofibular ligament, the transverse ligament and the interosseous ligament ( Hermans et al. 2010). The main function of the distal tibiofibular syndesmosis is to provide stability for the ankle ( Norkus & Floyd 2001, Hermans et al. 2010). Stability of the distal tibiofibular syndesmosis is necessary for proper functioning of the ankle and lower extremity. Ankle sprain injury may result in widening of the ankle mortise due to increased length of the syndesmotic ligaments ( Hermans et al. 2010). This may be felt in passive mobility examination of the distal tibiofibular joint.


During ankle plantar flexion and dorsiflexion, some movement normally occurs at the distal tibiofibular joint. When the foot is moved from a plantar flexed position to a dorsiflexed position, the joint permits approximately 1 to 2 mm of widening at the mortise ( Norkus & Floyd 2001). Movement of the fibula occurs at the distal tibiofibular joint. While in the fibular groove of the tibia, the fibula rotates around its vertical axis when the ankle is plantar flexed and dorsiflexed. Lateral fibular rotation is approximately 3° to 5° with dorsiflexion, and medial rotation is 3° to 5° with plantar flexion ( Norkus & Floyd 2001).



Talocrural joint


The talocrural joint (TCJ) is formed between the articulation of the distal parts of the tibia and fibula with the talus. The TCJ may be considered to have a single axis of movement. When the TCJ is in a neutral position, the axis of the joint passes through the medial malleolus just below the lateral malleolus. Since the lateral malleolus lies more distally, the axis of the TCJ is angled 20°–30° in the frontal plane. Therefore, the dorsiflexion of the TCJ is coupled with abduction and plantar flexion is coupled with adduction ( Hamill et al. 1995). The normal range of motion of the TCJ in dorsiflexion is 20°–30°, and in plantar flexion 40°–50° ( Schuenke et al. 2006). However, there are individual variations: a professional ballet dancer would have difficulty managing with only average mobility, whereas another person with different requirements may have below average mobility without any problems.




Midtarsal joint


The midtarsal joint (MTJ) is capable of movement in all three cardinal body planes, either in isolation or in combination ( Nester et al. 2001, Tweed et al. 2008). The predominant motion plane of the MTJ varies between subjects; some subjects have a predominance of frontal plane motion, and others have a predominance of transverse plane motion ( Nester et al. 2001). In MTJ, eversion and inversion movements can be coupled in a different manner during the stance phase of gait. Between heel strike and forefoot loading, the MTJ can invert, adduct and dorsiflex, but it everts, abducts and plantar flexes after heel-off. This illustrates the complex and variable functional characteristics of the MTJ ( Nester et al. 2001). During the stance phase of gait, frontal plane movements of the MTJ occur in the opposite direction of the hindfoot ( Tweed et al. 2008).



Rays


The rays are formed in the longitudinal line of the foot. The tarsometatarsal joints are the main articulation of the rays. These joints are gliding planar joints and are numbered one to five ( Hamill et al. 1995). The intertarsal joint between the medial cuneiform and navicular bones may be included in the first ray. The axes of the first and fifth rays are oblique. In the first ray dorsiflexion is coupled with inversion and adduction, and conversely, plantar flexion is coupled with eversion and abduction. Whereas, in the fifth ray dorsiflexion is coupled with eversion and abduction, and plantar flexion is coupled with inversion and adduction ( Hamill et al. 1995). It is noteworthy, that the first and the fifth rays are the only rays that can be actively supported towards plantar flexion, i.e. on the ground.



The first metatarsophalangeal joint


There are five metatarsophalangeal (MTP) joints. However, the movements of the first MTP joint have a crucial role in the functioning of the foot and ankle. The movements of the first MTP joint are dorsiflexion and plantar flexion. The normal range of motion of the first MTP joint in dorsiflexion is 70°s, and in plantar flexion 45° ( Schuenke et al. 2006). During pre-swing of the gait the first MTP joint is dorsiflexed 55° ( Perry 1992). The motion of the first MTP joint is coupled with the movements of the first ray. Dorsiflexion of the first MTP joint is diminished as the first ray dorsiflexes ( Roukis et al. 1996). This means that the plantar flexion of the first ray is a prerequisite for the dorsiflexion of the first MTP joint in closed kinetic chain. This phenomenon is easy to prove in a clinical setting. Normally in the standing position dorsiflexion of the first MTP joint will result in plantar flexion of the first ray and rising of the longitudinal arch. Whereas if plantar flexion of the first ray does not occur it will limit the dorsiflexion of the first MTP joint.


The dorsiflexion of the MTP joints is related to an important function called the ‘windlass’ mechanism. This mechanism provides stability of the foot during propulsion and contributes to the efficient transfer of force during propulsion ( Herrmann 1995).



Musculoskeletal foot and ankle disorders



Typical medical diagnoses of the foot and ankle


Medical diagnosis aims to identify structural pathology and/or pathophysiological processes responsible for the disorder. Achilles tendinopathy, plantar fasciitis, hallux valgus and chronic ankle instability are typical medical diagnoses of musculoskeletal foot and ankle disorders. However, identifying pathological structures does not explain the mechanism leading to pathology. Plantar fasciitis is used as an example to describe the challenges of making specific structural diagnosis. Chronic ankle instability is used as an example to describe the multifactorial nature of foot and ankle disorders.



Plantar fasciitis


Plantar heel pain is a common disorder which is estimated to affect 10% of the general population at some time during their life ( Crawford & Thomson 2003). The exact etiology of plantar fasciitis is unknown in most cases. However, multiple risk factors have been associated with plantar fasciitis, particularly obesity, prolonged weight bearing, and limited ankle dorsiflexion ( De Vera Barredo et al. 2007).



Diagnosing plantar heel pain

Plantar fasciitis affects the hindfoot, specifically the insertion of the plantar aponeurosis at the medial calcaneal tubercle ( De Vera Barredo et al. 2007). In some cases, pain under the heel is diagnosed as a heel spur syndrome or plantar heel pain syndrome. Heel spur syndrome refers to the existence of plantar calcaneal spur. However, 50–55% of patients with heel pain do not have a calcaneal spur and 15–20% of non-painful heels manifest a spur ( Irving et al. 2006, De Vera Barredo et al. 2007). Therefore, the presence of structural pathology (i.e. calcaneal spur) does not correlate necessarily with pain.


Plantar heel pain syndrome is, as indicated by its name, a general definition for the location of pain, but it does not specify the structure of pain origin. Several different structures can be a source of pain under the heel. The plantar surface of the calcaneus serves as an insertion for several structures. Structures connected directly to the medial calcaneal tubercle, lateral calcaneal tubercle or adjacent to these tubercles include: short plantar ligament, long plantar ligament, plantar aponeurosis, m. flexor digitorum brevis (FDB), m. abductor halluces (AbdH), m. quadratus plantae (QP) and m. abductor digiti minimi (AbdDM) ( Acland 2010). Therefore, diagnosing plantar heel pain every time as plantar fasciitis is a simplification and can often misdirects the treatment. Identifying the specific source of the pain might be challenging and even in a case where it can be identified it does not explain the mechanism leading to pain. Considering the structures in the heel it is reasonable to argue that very different movement patterns of the foot and ankle may cause overloading and sensitization to one of these structures leading to plantar heel pain. For example, constant flexion of the toes during weight bearing can potentially cause irritation of FDB, QP, and AbdH muscle insertions. Constant loading of the lateral arch during weight bearing can potentially lead to overloading of short and long plantar ligaments and AbdDM muscle. Constant medial loading of the foot during weight bearing collapses the longitudinal arches of the foot potentially leading to overstretching of the plantar aponeurosis. All these loading patterns of the foot may become a mechanism resulting in plantar heel pain. Therefore, identifying the movement patterns of the foot and ankle that can potentially lead to overloading and sensitization of the structures is essential when planning and implementing the intervention. Obviously, all the above mentioned examples require different interventions. In addition to symptomatic structures interventions should target the underlying mechanisms that lead to or maintain the plantar heel pain.



Chronic ankle instability


Ankle ligament injuries are among the most common musculoskeletal injuries ( Pijnenburg et al. 2000, Beynnon et al. 2001, Kerkhoffs et al. 2007). Functional treatment has been recommended for the treatment of ankle ligament injuries since the early nineties ( Kannus & Renström 1991, Kaikkonen et al. 1996). The elements of functional treatment include: RICE (rest, ice, compression, elevation), protection of the injured ligament, early weight bearing and exercises ( Kaikkonen et al. 1996, Konradsen et al. 2002, van Rijn et al. 2010). However, despite functional treatment residual symptoms and disability are very common after inversion sprain ( Konradsen et al. 2002, van Rijn et al. 2010). After an acute ankle sprain 10–20% of people develop chronic ankle instability (CAI) ( de Vries et al. 2006). Two primary causes for CAI are mechanical ankle instability (MAI) and functional ankle instability (FAI) ( Hubbard et al. 2007). MAI is defined as ankle movement beyond the physiological limit of the ankle’s range of motion, whereas FAI is defined as the subjective feeling of ankle instability (‘giving way’) and/or recurrent symptomatic ankle sprains ( Tropp 2002). It is noteworthy that MAI means objectively measurable movement of the ankle and FAI is a person’s subjective symptoms and disability. MAI and FAI are often seen as dichotomous causes of chronic ankle instability. However, recent research has found relationships between MAI and FAI measures. For example, increased anterior laxity correlated with increased dorsiflexion strength and increased centre-of-pressure excursions ( Hubbard et al. 2007).



Chronic ankle instability and mobility of the ankle

Instability as a term refers to increased mobility. By definition, this is true in MAI when the physiological range of movement is tested passively. Objective assessment of mechanical ligamentous laxity is often carried out using the anterior drawer test and talar tilt test ( Hubbard et al. 2008). However, increased mechanical laxity in passive movement testing does not correlate with the functional mobility of the ankle. Similarly, in FAI the subjective feeling of instability, i.e. ‘giving way’, does not mean that functional mobility of the ankle is increased. Based on clinical evidence, patients with CAI often have movement impairments of the ankle. This feature of CAI is often missed. Contrarily to increased mobility, reduced ankle dorsiflexion range is known to predict future lateral ankle sprains ( de Noronha et al. 2006), whereas generalized joint hypermobility does not increase risk of injury in the ankle region ( Pacey et al. 2010).



Chronic ankle instability and pain

Pain is a common symptom related to ankle instability ( Kannus & Renström 1991, Konradsen et al. 2002, de Noronha et al. 2007).


Pain areas vary a lot after initial ankle injury and the pain area may change over time. The different pain areas are often related to the variety of structures that might be involved in inversion sprains, whereas the change of pain area is thought to indicate multi-tissue involvement ( Konradsen et al. 2002). The change of pain area over time may also be related to the person’s behaviour as caused by the injury. After initial injury people adopt, either consciously or instinctively, movement patterns to avoid pain. These movement patterns can be considered protective, that is, an adaptive mechanism to support healing process. However, if these movement patterns persist beyond normal tissue healing time they may become pain provocative, that is, maladaptive mechanisms, and result in ongoing pain. Depending on the movement pattern the person has adopted, different areas of the foot and ankle are predisposed to abnormal loading. This might be one explanation for the change of pain area over time after an ankle sprain.



Cognitive processes and injury


In acute injury, the escape from a harmful situation and the associated withdrawal behaviour promotes healing. In some individuals immediate withdrawal behaviours do not lead to the anticipated reduction of pain, which may be interpreted as a signal of continuous threat. Negative interpretation may not always reflect the real threat and catastrophic misinterpretations of benign physical sensations may occur. Catastrophic interpretations lead to fear reactions. Pain-related fear is likely to cause a cascade of psychological and physical events including hyper-vigilance, muscular reactivity, avoidance and guarding behaviours and physical disuse, which in turn are responsible for the persistencee of the pain problem ( Vlaeyen & Linton 2002). Pain-related fear of movement, or kinesiophobia, has been shown to contribute to disability in foot and ankle patients ( Lentz et al. 2010).


The contribution of physical factors, pain mechanisms and cognitive factors in CAI is individual and it is unlikely that the same functional treatment is beneficial for all patients with CAI. Therefore, identifying the individual group of factors that are maintaining the patient’s CAI is crucial to planning and implementing an appropriate intervention.



Chronic musculoskeletal foot and ankle disorders


Many foot and ankle pain disorders do not fit into existing medical diagnosis categories and, in many cases, even where pathoanatomical diagnosis can be made it does not explain the mechanism leading to the disorder. Examples given earlier in this chapter highlight the need to consider the multifactorial nature of musculoskeletal foot and ankle disorders. Chronic musculoskeletal disorders are particularly challenging as specific diagnosis is rarely achieved. The tendency for pain and disability to persist in the absence of obvious, ongoing primary peripheral pathology is challenging ( Zusman 2002). Therefore, further classification of chronic foot and ankle disorders is required. A new classification system for chronic musculoskeletal foot and ankle disorders has been proposed ( Kangas et al. 2011). This new approach is based on identifying the underlying mechanisms of the disorder. Within a multifactorial bio-psychosocial model, all factors that are maintaining the disorder should be considered. Without the identification of these mechanisms, the optimal intervention for the patient’s disorder cannot be determined ( Zusman 2002).


Chronic pain disorders may change motor control around the foot and ankle region and appear to result in monotonic movement and loading patterns, with specific parts of the foot and ankle loading unchangingly. Typically, these loading patterns present in a directional manner and are relatively independent of the movement task or activity the patient is performing ( Kangas et al. 2011).


Identifying the direction of impairment is the basis for identifying the mechanisms involved in movement and motor control-related disorders of the foot and ankle region and for planning and implementing a specific intervention ( Kangas et al. 2011).


Maladaptive motor control and movement impairments are considered underlying mechanisms for chronic foot and ankle disorders. Within these impairments, faulty movement patterns and coping strategies result in chronic abnormal tissue loading, pain, disability and distress. Different underlying pain mechanisms of motor control and movement impairments require further subclassification. These impairments can present with or without pathoanatomical findings ( O’Sullivan 2005).


In motor control impairments, lack of motor control results in monotonic loading patterns and pain in the foot and ankle. In movement impairments, movement is lost in the direction of pain provocation. In patients with motor control and/or movement impairments, the patient’s maladaptive movement behaviour is the underlying mechanism for the pain. An analysis of all potential factors affecting this movement behaviour should be based on a comprehensive subjective and physical examination and should aim to identify the underlying mechanisms maintaining the chronic foot and ankle disorders. Identifying this underlying mechanism also demands the integration of the proposed classification approach for foot and ankle disorders within a clinical reasoning process ( Kangas et al. 2011).



Psychosocial factors of pain and disability


The inclusion of psychosocial factors in the conceptual framework of pain theory helps to explain the limited association between organic pathology and pain severity ( Turk & Wilson 2010).


Avoidance behaviour may be reinforcing in the short term through the reduction of distress associated with noxious stimulation. If allowed to persist, it may become a maladaptive response leading to increased fear, limitation of activity, and other physical and psychological consequences that contribute to disability and persistence of pain ( Turk & Wilson 2010).


Catastrophic interpretations such as the belief that the presence of, or onset of, pain indicates pathology and therefore harm, are thought to contribute to the development of pain-related fear ( Turk & Wilson 2010).


A theoretical approach to the development of chronic pain and disability is the fear–avoidance model. This model is an attempt to highlight the importance of cognitive and behavioural factors in a chain of events linking the experience of pain to disability. The model stresses the role of catastrophic thinking following the pain experience and the consequent fear and hyper-vigilance. Avoidance behaviour features prominently, largely fuelled by the fear that activity will cause harm and will worsen the pain problem ( Boersma & Linton 2006).


Fear–avoidance beliefs, catastrophizing, and depression have been identified as important psychological variables in the development of a pain problem ( Boersma & Linton 2006).


The relationship between pain, catastrophizing, depression, fear–avoidance beliefs and function at the individual level is an integrated, interacting, and complex process ( Boersma & Linton 2006). Psychological variables might operate differently for different people. Therefore, to understand these processes within individuals, there has been a need to identify distinctive patterns of psychological factors ( Boersma & Linton 2006). A study by Boersma & Linton (2006) shows that distinct profiles of psychological functioning can be extracted and that these profiles are related to development of disability. Fear–avoidance, beliefs and catastrophizing were strongly related. These factors can be, but are not necessarily, accompanied with signs of depression. People in the subgroups ‘pain-related fear’, ‘pain-related fear + depressed mood’, and ‘depressed mood’ reported substantially more functional difficulties and pain and sick leave compared to ‘medium pain-related fear’ and ‘low risk’ subgroups.



Psychosocial factors and neurophysiological pain mechanisms


Pain processing is regulated by different mechanisms that modulate noxious information at the spinal level. This modulation is based on endogenous descending inhibitory and facilitatory pathways that reach the dorsal horn ( Weissman-Fogel et al. 2008). It has been proved that these inhibitory pathways are negatively influenced by catastrophizing ( Weissman-Fogel et al. 2008).


Growing evidence is showing that psychological processes have biological effects. For example, cognitive and affective processes within the construct of catastrophizing have been shown to exert an effect on the neuromuscular, cardiovascular, immune and neuroendocrine systems, and the activity in the pain neuromatrix within the brain ( Campbell & Edwards 2009). Studies have shown that higher levels of pain catastrophizing correlate with a lower pain threshold, lower pain tolerance, higher pain intensity and greater pain temporal summation ( Weissman-Fogel et al. 2008).



Psychosocial factors and musculoskeletal foot and ankle disorders


Pain-related fear of movement has been identified as a strong contributor to disability in the foot and ankle ( Lentz et al. 2010).


The treatment generally consists of concurrent patient education and encouragement to perform part of an activity of which they are fearful or an activity that is related to this specific fear. For example, a patient with ankle pain who will not attempt hopping for a distance because of fear of pain in the ankle might be encouraged to begin bouncing on a trampoline or to perform active plantar flexion while in one-leg stance. Once the patient indicates that the fear is reduced, the complexity and difficulty of the task can be progressed in a systematic fashion.


The risk factors and consequences of traumatic and non-traumatic lower limb pain are not the same. Traumatic lower limb pain is associated with practising vigorous exercise and a high level of physical fitness, while non-traumatic pain is correlated more with psychosomatic symptoms ( El-Metwally et al. 2006).


Greater numbers of depressive symptoms have been found to associate with greater impairment in lower extremity functioning ( McDermott et al. 2003).



Lifestyle factors and musculoskeletal foot and ankle disorders


Lifestyle factors, such as obesity, have been related to foot and ankle pain disorders ( Irving et al. 2006, Gaida et al. 2010). There is evidence of an association between increased body mass index and chronic plantar heel pain ( Irving et al. 2006). Achilles tendon pathology is associated with central fat distribution among men and with peripheral fat distribution among women ( Gaida et al. 2010).



Work-related factors and musculoskeletal foot and ankle disorders


Jobs that necessitate prolonged standing and walking activities are commonly associated with worker’s complaints of foot and ankle pain. The foot and ankle area has been identified as the most frequently affected body region among salespersons in department stores ( Pensri et al. 2010). Prolonged standing is associated with foot and ankle symptoms among salespersons ( Pensri et al. 2010). Furthermore, prolonged standing has been associated with the occurrence of chronic plantar heel pain ( Irving et al. 2006). Increased time spent walking is associated with foot and ankle disorders among assembly plant workers ( Werner et al. 2010).



Subjective examination


In the assessment of the foot and ankle disorders the physiotherapist needs to consider the multifactorial nature of the musculoskeletal disorders. Subjective examination forms a basis for the clinical reasoning process. Therefore, thorough subjective examination is required to consider all dimensions of the disorder.


The aim of the subjective examination is to gather information about the patient’s disorder from the patient’s perspective. Therefore, the communication style should reflect empathy, respect and understanding to create a confident atmosphere for the patient. A therapeutic relationship with the patient can be formed through mindful interviewing.


The patient’s story may reflect that psychosocial factors are contributing to their foot and ankle disorder. The role of these factors is individual. Therefore, it is reasonable to use standardized questionnaires to screen these factors. For example, the Örebro musculoskeletal pain questionnaire (ÖMPQ) can be used for screening for ‘yellow flags’. The Tampa scale of kinesiophobia (TSK) has been used to determine the influence of pain-related fear of movement on foot and ankle disability ( Lentz et al. 2010).


The subjective examination can be carried out in a structured manner or more informally. When the subjective examination is carried out in a structured manner it helps the physiotherapist to gather the most relevant information concerning the patient’s symptoms. A structured interview is suitable for obvious problems such as acute ankle sprain. Furthermore, some patients may find it easier to talk about their disorder when questioning is well organized. However, if the interview is too strictly organized a lot of information might be lost.


Therefore, the more informal interview has some advantages and it is more suitable, for example, in chronic foot and ankle disorders. It gives freedom to patient to explain their problem and how they experience it. The way patients describe their problem is often very informative because it includes information of factors influencing a patient’s pain and movement behaviour. For example, a patient might experience that the symptom itself is not the main problem, but the disability resulting from the symptom is the most disturbing problem. This disability might be maintained with maladaptive thoughts and beliefs. The challenge of an informal interview is to gather the relevant information that the patient possesses, but does not spontaneously reveal. This information can be obtained with reflective and follow-up questioning. The informal interview is best conducted by an experienced physiotherapist and it is not always suitable. As authorities, we have to be aware that our questioning is sometimes directing the patient’s attention and providing a structure for the patient to make observations about the problem. Therefore, our questioning should not reinforce the problem, but should be aiming towards recovery from the very beginning. The interview is the beginning of the management.


The following description of the subjective examination of the foot and ankle patient is in a structured format. Clinically, the same information can be gathered in any order. It is the physiotherapist’s responsibility to find the most confident way of accomplishing the patient’s interview.



Kind of disorder


The first question aims to establish what the patient’s main problem is. In other words, what brings the patient to physiotherapy and what is the patient seeking from physiotherapy? The answer to the first question is recorded in the patient’s own words on the body chart.


Information from ‘Question 1’ aids in the establishment of the kind of disorder. Many patients with musculoskeletal foot and ankle disorders will present with pain as the main problem. Other typical symptoms are stiffness, ankle sprains and ‘giving way’. However, it is noteworthy that some patients do not experience the symptom as a main problem, but disability, i.e. loss of function resulting in activity limitation. We should not assume that a symptom is the disability or that a symptom alone is causing the disability.


Hypotheses generation begins from the answer to ‘Question 1’. For example, a patient may reply to the first question: ‘I twisted my left ankle two weeks ago and it’s still swollen and painful when I walk’. This information immediately reveals the symptom area and possible local structural source of the symptoms. The answer includes information about the activity that provokes the symptoms. Early hypotheses of the pain mechanisms can be generated from this information. Furthermore, walking is the activity that is affected. The answer is also providing the first information about the injury mechanism and a stage of tissue healing. The physiotherapist may even generate an early hypothesis for treatment and a prognosis based on the answer to ‘Question 1’.


Four different clinical profiles are presented in this chapter. The first clinical profile is typical of a somatic source of symptoms. Somatic symptoms arise from a bone, ligament, joint or muscle. The second clinical profile is more related to chronic, local symptoms where the patient’s maladaptive behaviour maintains the disorder. In the third clinical profile typical features of radicular pain and neuropathy are represented. The fourth clinical profile represents foot and ankle disorder with central sensitization.



Symptom area(s)


The main question under symptom area is: where are the symptoms? In addition to location of the symptom(s), each symptom area is further defined according to quality, frequency and depth of the symptom(s).


Detailed topographical anatomy knowledge is required to align local symptoms with recognizable structures in the foot and ankle region. In the case of local foot and ankle symptom(s) where a patient can easily pinpoint the area, and describe the type of pain, a specific structural source may be hypothesized. Superficial pain is often related to soft tissue or neural structures, whereas deep pain is often related to articular structures. Symptoms that are consistently related to mechanical stimulus with the sensation most likely linked to stimulus intensity, indicate peripheral nociceptive pain. These local symptoms may be associated with stiffness. The presentation of stiffness is consistently related to movement direction(s) and it can be associated with or without pain.


In some cases local foot and ankle symptom(s) do not correspond with the course of any single anatomical structure and a patient may have difficulty in defining the symptom area exactly. Pain may be associated with other symptoms like a feeling of loss of control or stiffness. Furthermore, the patient may describe symptoms with other than physical qualities, for example, frustration, fear and anxiety. Symptoms are often related to loading of the foot and ankle, but the relationship between stimulus intensity and sensation may be inconsistent. Stiffness is related to pain or anticipation of pain. These local symptoms may indicate peripherally mediated pain associated with factors other than physical factorsrelated to central pain mechanisms.


Foot and ankle symptom(s) may originate from remote structures. A good knowledge of neuroanatomy is needed to differentiate between typical innervation areas of the nerves supplying thefoot and ankle region and somatic structures. For example, the pain around the medial forefoot may arise from the first MTP joint, constant loading of that region without specific structural findings or the L5 nerve root.


However, the neurogenic symptoms vary greatly depending on the local structure involved and the disorder. The symptoms differ depending on the pathophysiology related to the nerves. Radiculopathy, conduction block of the spinal nerve or its root, results in numbness or weakness. Radiculopathy alone does not cause pain. In radicular pain that arises as a result of irritation of the spinal nerve or its roots, pain is shooting and band-like. Radicular pain may occur with or without radiculopathy ( Bogduk 1997). In a neuropathy, symptoms related to sensory innervation include sensory loss, dysaesthesia and/or paraesthesia. Dysaesthesia includes symptoms like burning, pricking, tingling, cramping and throbbing. The most typical presentation of paraestheasia is spontaneous tingling that is often described as pins and needles. It is important to realize that numbness and increased sensitivity may be at the same site. The neuropathic process involving motor nerves will result in muscle wasting and weakness ( Bennett 2006). Foot and ankle symptoms relating to radicular pain or neuropathy are often spontaneous and/or variable, but independent from foot and ankle loading.


Sometimes a patient presents with widespread pain at the foot and ankle. The patient might describe the main symptom area as migrating and the type of pain as vague, worrying and severe. Pain is constant and variable, but loading makes it worse and most activities increase the symptoms. Pain may be associated with psychosocial factors relating to fear, catastrophizing and depression. These symptoms may indicate a dominant central pain mechanism.



Behaviour of the symptom(s)


The main question in behaviour of the symptom is: what makes the symptoms worse and/or better?


In the case of local foot and ankle symptom(s) with nociceptive pain, symptoms are provoked with activities involving foot and ankle loading and movements. Typical activities are standing, walking, running and jumping. Often pain is closely related to certain activities and the intensity of pain correlates with the amount of mechanical stress and vice versa – pain is often diminished by avoiding the particular activity. Among athletes and dancers foot and ankle pain may be provoked only during strenuous foot and ankle movements or during the great number of repetitions required in sports and dance. However, it is important to realize that mimicking movement patterns may be repeated during normal daily activities. In the acute stage of inflammation pain may be easily provoked, and it may linger after provocation.


In the case of local foot and ankle symptoms with peripherally mediated pain and associated psychosocial factors, symptoms are still provoked with activities of foot and ankle loading and movements. However, the intensity of pain does not necessarily correlate with the amount of mechanical stress. A patient may describe many activities with unequal mechanical stress that provoke the same pain. Analysing the activities the patient is describing may reveal that they all include the same movement direction of the foot and ankle. For example, the patient may say that walking down the stairs, the propulsion phase of walking and squatting are provoking the same pain. All these activities include dorsiflexion of the ankle and this may be the connecting movement component. Furthermore, the patient may discover that avoiding provoking activities does not resolve the disorder. This is often because of the difficulty in recognizing pain triggers or the impossibility of avoiding provoking the movement component during normal daily activities.


In radicular and neuropathic foot and ankle pain symptoms are inconsistently related to foot and ankle loading and movements apart from muscle weakness. Instead, radicular foot and ankle pain is often related to impairments and loading of the low back. In foot and ankle neuropathies symptoms are often spontaneous or the responses to movement stimulation are abnormal. In the 24-hour behaviour of symptoms, patients often complain of night pain. Changing positions or gentle moving like slow walking may diminish the symptoms.


In the case of widespread foot and ankle symptoms and dominant central sensitization, pain may be related to foot and ankle loading and movements, but the stimulus–response relationship is distorted. Response to different stimuli is unpredictable and inconsistent. Similarly, something that diminishes symptoms today may not ease them off tomorrow.



Behaviour of the patient according to the disorder


The main question in this phase of the subjective examination is: how does the patient manage with the problem? The aim of this question is to establish the patient’s coping strategies according to the disorder. This question is open and directs the attention to psychological effects of the disorder instead of concentrating only on the symptoms.


The patient may have a belief that pain always indicates pathology and therefore harm. This will often lead to avoidance of activities that provoke or that the patient expects to provoke the symptoms. Note, in particular, if the patient is describing activities which provoke the symptoms and if they is avoiding these activities. This may reflect catastrophic thinking and avoidance behaviour and result in disability and impaired physical performance.



History of the symptoms


The main questions at this stageare: when and how did the symptoms start?


In the case of local somatic foot and ankle symptoms with nociceptive pain, the onset of symptoms is often identifiable. The onset may be related to trauma or an event. In cases of trauma, the progression of symptoms is compared with expected tissue healing time. Multiple symptom areas within the same foot may indicate involvement of more than one structure. For example, after an inversion sprain a variety of structures might be injured.


Recognizable events are often related to so called ‘use categories’. ‘Use categories’ include: over-, mis-, dis-, ab-, new- and non-use. Patients are not always aware of these events and the beginning of the symptoms. Therefore, it is sometimes useful to ask: did you do something unusual when the symptoms started? Among athletes and dancers changes in training and choreography and training environment may play a crucial role in the onset of symptoms.


In the case of local foot and ankle symptoms with peripherally mediated pain and associated psychosocial factors, symptoms persist over the expected tissue healing time or without identified structural pathology. Typically, symptoms start either gradually without an identified event, or after a trauma, but the symptoms and disability do not correlate with the mechanism of injury. Sometimes a patient may recall an old, mild injury after which the foot and ankle has not been symptom free. The main line of thought here is that the relationship between present symptoms and disability cannot be explained by any single factor in the past.


The onset of radicular foot and ankle pain is often associated with the onset of low back pain and related movement impairment. The most common cause of radicular pain is disc herniation ( Bogduk 1997). Therefore, the progression of radicular foot and ankle pain often follows the course of low back pathology and associated symptoms.


The history of neuropathic foot and ankle pain is variable. Neuropathic pain can become apparent immediately following injury or be delayed for months or years. Sometimes neuropathic pain is triggered by a second injury at the same area.


Widespread foot and ankle symptoms with dominant central sensitization may develop after a trauma, surgery, immobilization or prolonged over-use.





Planning the physical examination


Planning the physical examination is a critical part of the clinical reasoning process. It is crucial for novice physiotherapists to plan the phases of of the physical examination; however, it is also important for experienced physiotherapists to do this, especially in cases where information from the subjective examination indicates a complex foot and ankle disorder. One phase of planning of the physical examination is expressing hypotheses in different categories. Information within these categories is changing through research. Therefore, it is important for all physiotherapists to update the planning process from time to time. This enables the application of new knowledge into the clinical reasoning process.


Planning the physical examination includes three phases: reflection on the subjective examination, expressing hypotheses and planning physical examination procedures.




Expressing hypotheses categories


Expressing hypotheses categories explicitly helps the physiotherapist to identify all the relevant factors related to the disorder. This helps the physiotherapist to direct the physical examination. In the foot and ankle region several hypotheses categories are required to direct the physical examination and the subsequent intervention. Each category has consequences for the examination process and treatment. These hypotheses categories are:




Nature of the disorder


The nature of the musculoskeletal foot and ankle disorder is multifactorial. The term disorder contains the physical and psychosocial factors related to disorder and their effects ( Elvey & O’Sullivan 2004). For example, inversion sprain of the ankle may result in the rupture of the anterior talofibular ligament (ATFL). This represents the pathology of the disorder. The physical effect of this is that the patient cannot do plantar flexion of the ankle because of the pain. Injury and resulting pain is always accompanied by psychosocial factors. Pain is psychologically processed and it will influence the patient’s behaviour. These effects are considered as psychological effects. Impairments of movement are consequences of physical and psychosocial factors related to the disorder. For an impairment of movement to be relevant it has to be in the context of the nature of the disorder.




Neurophysiological pain mechanisms


Pain mechanisms can be divided into peripheral and central mechanisms. This separation is somehow artificial, because different pain mechanisms are always overlapping. However, in a clinical situation it is convenient to think about the mechanism that is dominating in the patient’s disorder.


The peripheral pain mechanism can be further divided into the nociceptive pain mechanism and the peripheral neurogenic pain mechanism. These mechanisms are both related to pain states where the source of the symptom and/or pathophysiological processes can be identified. The third peripheral mechanism is peripherally mediated pain where the specific source of the symptoms is not always identified. Disorders with peripherally mediated pain are often associated with psychosocial factors.


The central pain mechanism can be further divided into two central subcategories. In the first subcategory psychosocial factors play a dominant role and a psychiatric disease can be diagnosed. In the other subcategory psychosocial factors do not play a dominant role, but the central nervous system is physiologically sensitized.


All these pain mechanisms require a different approach in the examination and treatment of the disorder. Pain mechanisms are explained in detail in Jones (2014), Blake & Beames (2014).





Intervention


Intervention is a term used to embrace manual therapy procedures of treatment and strategies of management. Treatment is regarded as specific intervention performed by the clinician. Management is intervention performed by the patient under the direction or by the prescription of the clinician ( Elvey & O’Sullivan 2004). Within this hypotheses category, hypotheses are generated relating to the need for treatment procedures and management strategies. For example, in motor control impairments of the foot and ankle, management strategies (i.e. exercise intervention) is the primary approach, whereas with movement impairments restoring normal physiological range of movement of the foot and ankle often requires specific treatment (i.e. mobilization or manipulation) before exercise intervention is initiated.




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Aug 28, 2016 | Posted by in RHEUMATOLOGY | Comments Off on Management of foot and ankle disorders

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