We're gonna talk about how do you
approach a problem in the foot and ankle
from an osteopathic
This is gonna be heavy on anatomy,
heavy on learning the spaces,
the attachments and the muscle functions
of the foot as well as the joint motions.
We'll talk about different tests you can do and
also have separate videos for those tests.
And we'll talk a little bit about ankle sprains
as the most common issue noted in the ankle.
So when you want to examine the ankle, you want to
inspect one joint above, one joint below.
You want to make sure the motion of the ankle,
the function of the ankle is smooth and fluid.
You want to make sure that the foot and the ankle
during the weight bearing phase of walking,
are fluid as well because that's where an injury
may occur, a fall may occur or other issues.
You also want to look for skin
changes, changes in color
and changes that may
signal other issues.
And you want to look for any
swelling or signs of trauma.
So let's start with the
anatomy of the foot.
When you look at the foot and
you look at the medial aspect,
one of the bones that we're gonna be
very focused on is the navicular bone.
We don't want to miss a fracture and
it often feels like an ankle sprain
but the navicular
bone can be broken
The navicular bone articulates
with 5 other bones.
It has three cuneiforms and a
cuboid bone all attaching it.
So, we are gonna touch it, make sure we feel
it and understand the motion that you can induce.
We also worry about a septic necrosis of the
navicular bone occuring, especially in children.
So the navicular and the
head of the talus will touch.
The talar head is immediately proximal
to the navicular bone, closer to the body
And these are the bones that are gonna cause
inversion and eversion of the forefoot.
So it's gonna create motion in the foot
that's gonna happen only in that bone.
It's not gonna be a great motion
but it is very important motion.
We're gonna talk a little about the medial
malleolus, the inside of the ankle that sticks out.
It's part of the talus connection, it creates
the ankle mortise and it comes from the tibia.
So it's an important bone.
Under that bone you're gonna have the
sustentaculum tali,which is a space.
It is difficult to
palpate, it's there,
It will support the talus and serve as
an attachment for the spring ligament.
So these are important areas to be
aware of because there is motion
that's gonna be occuring in this area as well,
and you may have some swelling and tenderness.
The 5th metatarsal bone and the
5th metatarsophalangeal joint
are important areas to explore, to examine, to touch,
to make sure enough there isn't any tenderness
It's also a frequently broken area.
It's the lateral side of the ball of the foot towards
the back of it and it's along the lateral side
of the fifth metatarsal and the styloid
process there can often be palpated
And if you palpate it too
much, it is somewhat tender.
When you look at the lateral aspect of the foot,
there are muscles there that are gonna cause the
eversion as well with the peroneous
brevis, one that you can feel
and is important to look out
when you're doing the exam.
There's a groove located just behind the cuboid
bone that's created by the peroneus longus
and peroneus brevis that you want to feel and
examine because the motion is going to be causing
in the foot and allowing the foot to
plantarflex, to push down into the ground.
The sinus tarsi area is just
anterior to the lateral malleolus.
So if you go to the lateral malleolus, the little
bone out cropping on the outside and anteriorly,
you'll see the sinus tarsi region,
This is a soft tissue depression
between the bones and is also
where the extensor digitorum
muscle will go and there's an overlying
fat pad that can be touched as well.
The dome of the talus is
also an important bone.
It can be felt in inverting and plantarflexing
the foot, and helps with motion,
will be very tender at times
if the motion is abnormal
and it could be palpated
more laterally than medially.
So the dome of the talus is an
important area to be aware of.
The medial tubercle of the calcaneus
is something you hold on to a lot
when you're doing manipulation,
you use it to stabilize the foot.
It's on the medial plantar
surface of the calcaneus
and it gives you a good grip
in stabilizing the foot.
There are a lot of muscle attachment
here particularly at ABductors.
The abductor hallucis muscle comes medially
and the flexor digitorium brevis muscle
will also attach and you'll have the
plantar aponeurosis that may cause
plantar fasciatis may pull the arch
and it's something we'll talk about
in just a few minutes when
we talk about the arches.
And this is also important
because when you walk, this is
where heel strke occurs and the
first touch of the ground is,
and you may notice tenderness or
early contraction of the toes.
So these are just things that all
come together you should be aware of.
When you look at the plantar surface, you'll
also notice there are some sesamoid bones
Sesamoid bones are small round bones that
are embedded in a ligament or in a fascia.
You'll find sesamoid
by the first metatarsal, the base on
the first toe just under the big toe.
You'll have at least two sesamoid bones within the
flexor hallucis brevis tendon which help with motion
and also allows for some distribution
of the body weight when you're walking
by displacing the force amongst more than
just that one area so you don't develop more
osteoarthritis or risk breaking
something or having overuse injuries.
We talk about arches, we talk about the
medial and lateral longitudinal arches and the
the anterior metatarsal arch creating
the biggest portion of the foot arch
that allows you to walk comfortably gives you a
sponginess to your walk and gives you comfort
You can also think of the posterior
metatarsal arch which is smaller
and the tarsal arch which
also is in existence.
When we look at soft tissue landmarks,
the navicular tubercle and the talar head
are important because while
they lack boney support,
they do support some of the muscles by
attaching, by being a tendon attachment
and giving you the spring ligament
and the sustentaculum tali area
So it is just an
important part to notice.
When people have flat feet, the navicular
tubercle will displace medially and plantarward.
So you're gonna have the foot
bent upward toward the body.
The deltoid ligament is a medial
ligament, It is a very strong ligament
made up of multiple pieces and this is one
that can be torn during an ankle sprain
It has the tibialis posterior tendon running through it
and the flexor digitorum tendon
running just behind it as well.
It's important to be aware of the deltoid ligament
because you're gonna palpate a lot of these
You're gonna learn what the normal size
is, what the normal distribution is
and when you feel a piece of it
gone, or a piece of it pulled off,
you know there's gonna
be an ankle sprain.
The flexor hallucis longest
tendon is also another one.
It's right behind
the ankle joint.
The ankle mortise is the tibia, the fibula coming
together form a very strong hinge joint of the foot
and the flexus hallucis longus which
moves the toe is going to be behind it
and you can't palpate it because
it's deep to the other muscles.
The posterior tibial
muscle and the tibial nerve
are also in the back portion of the foot between
the tendons and the flexor digitorum longus
and flexor hallucis longus muscle.
And these are the ones
inducing movement to the foot
With the neuromuscular bundle
bound by the tarsal tunnel.
So it's gonna be deeper
and somewhat protected.
The anterior talofibular
ligament is the lateral ligament,
it is frequently
sprained or strained.
It's part of 3 ligament that are that attaching
the tibia to the foot and calcaneofibular
and the posterior talofibular
ligament are the other two.
The posterior talofibular ligament is a
pretty strong one and usually not torn.
It's usually anterior talofib and
pieces of the calcaneo fibular ligaments
Other soft tissue landmarks to be aware of
are the proneus longus and brevis tendons
and these are gonna be seen on
the dorsal aspect of the foot.
They go just behind the lateral malleolus
and they're primarily foot everters
and they sometimes assist in plantarflexion
as well, pushing the foot down.
This is something you can also snap on
occasion and you're gonna hear people
and what sometimes sounds
like a click or a pop
but it's just a snapping tendon when
it goes over a tuberousity, a little
outcropping of bone that
the tendon can snap over.
The sinus tarsi is another soft tissue
landmark on the top of the tarsal bone.
It's affected by ankle sprains in
that some of the swelling goes there,
some of the pain and the difficulty
in walking arises from there.
There's a deep tenderness when you palpate
it and they can sometimes confuse people
into thinking that maybe a break because
if you look at the Ottawa ankle rules,
if you have tenderness within 6 inches up
of the malleolus, you need to get an x-ray
This may confuse you of the swelling
that extends down and into this area.
The calcaneus again, the large bone in
the back with achilles tendon inserts
and the gastrocnemius will assist
with motion, very strong tendon,
can pop or snap with severe pressure or can
be cut but it is easily reattached surgically
When that does happen, you'll notice a
positive Thompson's test which is when you
squeeze the gastrocnemius
and the foot doesn't move,
will tell you there's been an
interruption in the gastrocnemius tendon.
I just want to mention the retrocalcaneal bursa
because bursas are important at easing motion.
This is the area between the anterior
surface of the achilles tendon
and the superior angle
of the calcaneous.
and then there's the calcaneal
bursa, another bursa which
follows the insertion of the
achilles tendon over that region.