So, let's talk about ankle and foot pain together,
another commonly seen musculoskeletal problem.
And we’ll start with the approach to
the patient with ankle and foot pain.
And it begins with looking at the acuity of pain.
Because ankle and foot,
I see patients, of course, with acute injuries,
lot of sprains and strains,
but also who have chronic and debilitating conditions.
And, of course, they have a precipitating event,
the most common being an
inversion injury of the ankle,
leading to a sprain.
You’re going to want to record that.
And that’s why getting a prior history
of injury is really important.
A previous history of sprains
begets more sprains.
Many patients might have conditions that more
chronic that relapse and remit over time,
and so therefore, getting
a prior history of injury.
And just how serious was it?
Did they recover from their ankle sprain
and was it always lax and never
quite recovered all the way?
What kind of activities can they do now?
So, a functional assessment is very, very important.
And then very importantly,
more so for my patients with chronic injuries,
what kind of footwear are they using?
Are they really protecting their foot and giving
it the padding and support that it needs to function?
So, let's start with something that I think is
going to be very germane to the USMLE exam,
and that’s the Ottawa ankle and foot rules.
These are specific rules to help rule
out fractures of the foot and ankle.
The nice thing is they are
just like a good screening test.
They’ve got a very high sensitivity.
They don't have the best specificity,
but what happens, therefore, is
that when they’re negative,
you can feel fairly reassured that
there is no x-ray needed.
So, the ankle rules start with the fact that the patient
cannot walk more than four steps after the injury.
So, they have to be able to
ambulate a little bit.
And here, what you’re really looking for is,
on exam, tenderness over the posterior edge
and/or the tip of both the
lateral and the medial malleolus.
Now, so the individuals who suffer an ankle injury,
but can walk immediately afterwards
and don't have those signs of
tenderness on the lateral medial malleoli
are therefore very unlikely
to have a risk of fracture,
and don't need x-rays.
And saving people x-rays saves them time,
saves them exposure to radiation.
For the foot, it’s similar.
They have to be able to
walk right after the injury.
The areas to check anatomically on your exam are the head of the fifth metatarsal, so that’s in the mid-foot lateral.
and then up just at the
very top of the foot,
over the navicular bone
in the midfoot as well.
No tenderness in those areas,
ability to walk after the injury,
no need for x-rays in those patients.
So, let's bring the Ottawa ankle and foot rules to life
to help understand the anatomic sites to
palpate before ruling out fracture.
And, whoa, is that a really good-looking foot?
Whoever’s foot this is is in the
wrong business if he is in medicine.
He should be a foot model.
Let's start showing the ankle areas for palpation.
So, that involves the lateral
and the medial malleolus from the tip,
about 6 cm up the
posterior bone of the tibia.
And so, the anterior side, not so much.
So, if there is tenderness up here, that's okay
because that is a site of
a lot of ankle sprains,
but it's really along the tip and
the posterior side laterally.
And the same thing medially.
Tip, lateral side, about that far up.
That's for the ankle.
For the foot itself,
the base of the fifth metatarsal
here, so way lateral,
and then over the navicular bone, about here.
If these areas are not tender,
you can feel comfortable that the patient
does not have a foot or ankle fracture,
and therefore, no x-ray is needed,
saving a lot of unnecessary x-rays.
Just mentioning some
other types of tendinopathies.
Posterior tibial tendon dysfunction,
that tendon tends to run
right under the foot,
but the pain tends be felt more medially.
It can be misdiagnosed as
a medial ankle sprain.
And left unattended,
it can promote flat foot over time.
the best way to draw it out is active eversion
with dorsiflexion against
resistance at the same time.
And we’ll talk more about this
other condition, Achilles tendinopathy,
but this oftentimes,
you'll find pain, maybe some
swelling over the tendon,
and it’s often above the
insertion of the calcaneus,
but you can get a tendinopathy that’s
closer to the calcaneus itself as well.
And it’s very much associated with
a change in the intensity of training.
So, those weekend warriors who get fired up
and go out and run 5 miles when
they haven’t run in a long time,
that's where you see cases
of Achilles tendinopathy.
Plantar fasciitis is one of the more common
foot problems that I see in my patients.
And this one is not related to feeling
pain at the end of an activity.
It's actually worst in the morning.
Those first steps can be really
painful over the plantar foot.
Similarly, after a prolonged sit.
A physical examination,
very important for these patients.
And you could see the percentages
of patients with plantar fasciitis
with particularly tenderness at
different points in the plantar fascia.
I think the main thing
that I would note is that
the tenderness is usually
more medial than lateral.
So, as you can see,
it’s 14% on the midfoot,
but right where that 42% is.
that's where I find most of my patients
with plantar fasciitis are most tender.
I think another thing that's
really important to note
about this condition is that if
the patient has typical symptoms
and they have the tenderness in the right areas,
very rarely do you need to
worry about imaging.
Many of these patients do have a calcaneal
spur on lateral imaging of the calcaneus,
but that's not actually related
to their fasciitis and the pain.
So, therefore, you can discard it.
You don't need to do
imaging on those patients.