Ankle Flashcards
mob direction to improve DF
mobilize talus posteriorly
mob direction to improve DF
mobilize talus anteriorly
mob direction to improve DF/ pronation of the transverse tarsals
dorsal glide
mob direction to improve DP/ supination of the transverse tarsals
plantar glide
In OKC, what foot positions make up pronation
Talocrual joint: DF
Subtalar joint: Eversion, Abduction, DF
Transverse tarsal joint
Forefoot: DF, Abduction
In CKC, what foot positions make up supination
Talocrual joint: PF
Subtalar joint: Inversion, Adduction
Transverse tarsal joint: Inc, Add, PF
Forefoot:: PF
Forefoot valgus is what type of deformity
Pes Cavus
Supinated foot structure
increased knee varus
Forefoot varus is what type of deformity
Pes Planus
pronated foot structure
increased knee valgus
FPI scoring
Positive = pronated
score 0-5+ is normal
What does the deep fibular N innervate (Sensory and motor)
Anterior compartment: tibialis anterior , extensor digitorum, EHL
web space of toes 1-2
What does the Superficail fibular N innervate (Sensory and motor)
Lateral compartment fibularis longus and brevis
Lower half of lateral leg and foot dorsum (except for first Webb space)
what provides sensation to the upper 2/3 of the lateral leg
Lateral sural cutaneous N
A level recommendations for heel pain/ Plantar fasciitis
Manual therapy for pain and function can use mobs and STM, Self stretching via intermittent holds, and taping for short term relief, Orthosis especially if taping helps- can be short-term relief up to 1 year to support medial and long arch. Night splints especially for pain with first steps, but have to be work for 1-3 months
high ankle sprain region and specific tests
Syndesmosis, ER test known as Klieger test is specific. When + we can rule it in. Squeeze test is anotehr test.
Brace recomendations following lateral ankle sprian
Recd’s for: Prevention especailyl for those with high risks, prevention of recurrent sprains after intial event with the use of thera-ex and balance, and for acute and post acute care in order to progressivly WB ASAP
For severe injureis immoblize foot for up to 10 days
A level recs for acute and post acute interventions following ankle sprain
MT: lymph drainage, joint mobs, WITH thera-ex
Thera-ex: protective AROM, restore balance and nero-re-ed. To be done at clinic AND home
C level recs for acute and post acute interventions following ankle sprain
intermittent ice, NSAIDS for pain and swellign
A level recs for CAI
Thera-act and ex: proprioceptive neuromuscular dynamic postural stability for increased function Manual Therapy: including mobilization and manipulation port increase dorsiflexion and dynamic balance\
Acute lateral ankle sprain risk factors
Previous injury, female sex, weakness of hip abductors/extensors, poor balance performance, poor hopping test performance, court sport participation
chronic lateral ankle sprain risk factors
not using prophylactic brace, not participating in exercise program, high BMI, poor functional performance, sport participation
MCID for FAAM-sport and ADL. LEFS MCID
FAAM-ADL 8%
FAAM-SPORT / LEFS 9% (poitns for LEFS)
what should you rule out or be sus of with a medial ankle sprain?
Maisionneuve Fx: proxmal fibular fx and distal TC instability simillar to syndemsmotic injury
If there’s pain at the fibular, refer out for imaging
LAteral ankle sprain tests
reverse anteriro droawer with a posterios force on teh tib while the heel is fixed on the table
cuboid syndrome, what injury may also present with this?
lateral midfoot pain due a a postionsl faulty. Subux may happen due to forcefull pull of fibularis longus. May over 2ndary to lateral ankle sprain. Rul eup with Fibularis pain, weakness and increased mobility in region
Lisfranc injury, where is the lisfranc ligament, how to test for this
Fx location between tarsals and metatarals
ligament over the medial cuneiform and 2nd MT
Most common injured is 2nd and 1st MT. MOI is supination and axial loading. Tests: Gao sign, increased space btwn 1/2nd toes. Fleck sign for avulsion of ligament. CHECK PULSES, sensation of 1st webspace due to deep fibular N,.
Thompson test
good specificty
Distinguish fibularis tear form and subluxing
Increased strain from PF and EV therefore painful with MMT. Need imaging to see if torn. Tears are from acute MOI such as LAI. Chronic injuries and from CAI adn tendon subluxign and may affect retinacul and lead to clicking.
Achilles tendon apathy
increased thickening of tissue, (+) Arc sign, Royal London hospital test (decrease pain dorsiflexion). Treted with load and pain monitoring, Ionto, stretching
Posterior tibialis dysfunction also known as PCFD
Obese, middle aged woman, posterior tib tenderness, too many toes sign
Sever’s disease
Active or overweight children 8- 15 years old. Will present with limited dorsiflexion pain with palpation distal to Achilles insertion and pain with passive dorsiflexion. Tests: calcaneus quiz test, pain with one he’ll stand. Treated with stretching orthoses heel cup wedge plantar flexion strengthening. Concern of growth plate issue also known as calcaneal apophysitis
calcaneal stress fracture
Similar to Seivers disease but does not improve. Bone stress injury does not = a stress fracture line, changes must be seen on imaging. Recommendation to have bone scan for diagnosis.
Retrocalcaneal bursitis
No tendon thickening seen. Will present like insertional Achilles tendinopathy with palpable painful bursitis
Os-Trigonum syndrome
Ossicle usually fuses with Talus at early development. If not fused, overuse or trauma can lead to impingement. Will have posterior talus pain and pain at end range plantar flexion due to pinching. Rule out Achilles tendinitis or Sever’s disease with PROM dorsiflexion. Should not have posterior calcaneus tenderness or Achilles tenderness. Also known as posterior impingement syndrome. Fragment will be seen on imaging over posterior talus.
Medial tibial syndrome
Will have pain at distal 2/3 of medial tibia and have worsened pain with activity improved with rest. Pain should be 5 consecutive cm along medial tibia. Caused by bony overload, traction forces over fascia and perhaps strong plantar flexors or posterior tibialis. Treatment should include load management with pain monitoring <2/10
tarsal tunnel syndrome
Entrapment of tibial nerve. Symptoms are poorly localized and will reflect site of entrapment. Location of Tom Dick and Harry over medial malleolus. Worse at night with weight-bearing and walking/standing.
Types of tarsal tunnel syndrome
Distal entrapment = Jogger’s foot.
Baxters neuropathy
Joggers foot
medial arch and toes 1,2,3 are painful or have dysesthesia. Positive Tinel’s sign symptoms with dorsiflexion eversion and MTP extension
Baxters neuropathy
Chronic medial heel pain. Will have burning and chronic history. Think tibial nerve and rule out plantar fasciitis- Will get better with activity instead of a neuropathy that will not to get better with activity.
Morton neuroma and most common location
Usually between 3/4 digits. Second most common 2nd/3rd toes. 10 times more common in female dancers. Will present as sharp shooting burning cramping doll ache sensation and walking on lump
How is fat pad battery different counter fasciitis
Plantar fasciitis/optehy or heel pain Will get better and then worse with activity and have pain with the first step. Positive windlass test. Will respond well to treatment such as improving ROM due to decreased dorsiflexion, taping, orthoses night splints ionto/phonophoresis and laser.
Fat pad atrophy will be most likely due to corticosteroid injections. Rule out with negative wind last test no plantar flexion tenderness and rule in with a heel cushion
How long will a G1 ankle sprain need to recover
2 -10 day recovery due to micro tearing of ATFL
Ottawa ankle rules
Ankle: Pain in malleolar zone PLUS poster edge or tip of medial/malleolus tenderness within distal 6 cm and ability to weight bear immediately and in emergency department
Foot: Tenderness at mid foot PLUS pain at navicular, base of fifth, and ability to weight bear immediately and in emergency department
fracture tests have goos sensitivity
How long will a G3 ankle sprain need to recover
30-90 days . Unstable, ligamentous tear involvement of anterior capsule. Difficulty weight-bearing, may be unable to wheat beer after injury. Accompanied with fracture so make sure the screen. Moderate to severe joint instability.
How long will a G2 ankle sprain need to recover
10–30 days. Moderate functional loss due to partial tearing. Initial pain may be well controlled, diffuse swelling that limits activity. Partial weight-bearing trouble to walking mild moderate joint instability. ATFL and CFL disturbance
Expectations for return to play following syndesmotic ankle sprain
Grade 3 ankle sprain or high ankle sprain will require > 6 months recovery. Too conservative of weight-bearing restrictions prolong recovery for grade 1/2 . Protected weight-bearing for grade 3 is ideal, immobilize high ankle sprains. No indications for ultrasound or laser use, neuro-re-ed instead. Return to sport with brace indicated – lace up. Dorsiflexion expectations 30° at tibial shaft or 9 to 10 cm LWBT test
chronic ankle instability underline pathology/ impairment
Mechanical instability versus functional instability.
Mechanical instability: Implies mechanical changes to biomechanics degenerative changes and laxity. Functional instability: Result of neural control and strength posture deficits.
Persistent weakness giving away pain instability and self-reported disability= CAI. Greeted with a discharge of injury prevention program to avoid the second and third episodes, increased self management with multimodal approach is recommended
patho anatomic features of plantar heel pain/plantar fasciitis
Increased plantar fascia thickness, increased compression of properties at heel pad, neovascularity, fat disposition, overproduction of nitric acid with a tissue apoptosis. pad and tenocyte proliferation. Pain related to fear avoidance activity is greatest contributor to disability
imaging for plantar fasciitis
Not required however can be performed to differentiate from Achilles tendinitis can be differentiated from fat pad abnormalities. Plantar fascia thickness and heel pain ARE related and thickening be seen on ultrasound. Bone spurs not related to PF
Plantar fasciitis presentation
- Plantar medial heel pain with first steps, worse with prolonged weight-bearing to.
2.Heal pain onset with new weight-bearing demands. 3. Pain at proximal plantar flexor insertion - Windlass test performed in weight-bearing
- Negative tarsal tunnel test
- Decrease active and passive range of motion TC mobility
- abnormal FPI score, both extremes ares seen
8.. Increased BMI and non-athletic patient
outcomes can be used for the foot and ankle.
FAAM, HSAQ, FFI,
But, FAAM and LEFS are simple to use. Increase score is increased function for patient.
MCID for LEFS 9
what are CDE & F level recommendations for plantar fasciitis
C phonophoresis, low-level razor, rocker shoe. No ultrasound
D Iontophoresis
E Weight loss management
F: expert opinion neuromotor control balance eccentric pronation training, intrinsic foot control, dry needling, extracorporeal shockwave, steroid injections due to adverse effects
Fibularis longus
inserts on plantar surface of metatarsal plantar surface of 1 and 2 , 1st dorsal interosseous and lateral side of cuneiform.
Allows for first raised ability. Works with tibialis posterior or metatarsal stabilizing sling. Innervated by superficial peroneal nerve. Eversion and plantar flexion of first MT
Plantar fasciitis risk factors
decreased dorsiflexion, increased BMI, running, work related standing wiyh poor shock absorption.
Is increased tendon thickness correlated with patient outcomes. What does ?
No.
Instead, genetic factors such as neuronal phenotype cause abnormal collagen production or nerve infiltration and tendon causing hyper sensitivity
What contributes to inefficient loading of tendon with midportion Achilles tendinitis
Overload due to tensile loading and shearing. Tenocytes and neovascularity lead to thickening of tendon. Tendon becomes weaker due to collegen thinning and disorganization. Increase in non-collageniac and fibrocartilage matrix with fat disposition leads to less efficient loading
Mid portion Achilles tendinopathy risk factors
Older age, hypertension, increased cholesterol, abnormal subtalar ROM, abnormal foot mechanics, abnormal dorsiflexion, decreased PF strength deficits, antibiotic use, rigid orthotics, DM, lipidemia, obesity, systemic disease
Achilles tendinopathy diagnosis
- Gradual onset of pain 2–6 cm proximal to insertion
- tenderness over tendon.
- Arc Sign: identify most swollen area with active movement with swelling at tendon.
- Royal London hospital test: Palpate most tender area, if decreased active DF and decreased pain with active Achilles stretch then positive
which systemic diseases also have insertional pain at Achilles tendon
Ankylosing spondylitis, rheumatoid arthritis, psoriatic arthritis
tibial stress fracture
Most common location for stress fracture. Risks include: women, military, running 25 miles a week. Will present with anterior tibia tenderness, edema pain with tuning fork. MRI equals gold standard. Managed with activity modification and weight-bearing. Prognosis is worse if treatment is delayed
DVT screening with Wells CPR
Active cancer
Immobilization or cast disability.
Bedridden at least three days.
Tenderness over venous system.
Entire lower extremity swelling.
Greater than 3 cm calf swelling.
Pitting edema.
Non-varicose superficial veins.
Alternative diagnosis -2 points.
Over three equals 75%
peripheral arterial disease signs
Claudication, cramp tight feeling of tiredness, achiness. Relieved with rest. Objectivly check skin and pulses
ABI 1-1.4 is normal
.8-.9 is moderate
.4 is severe
Lumbar stenosis.
Improved symptoms with a flexion, worsened with extension. Bilateral symptoms, leg pain will be worse than back pain. Pain with walking and standing and relief with sitting. Will be over 48 years old. Test with two stage treadmill test or bike test. PAD symptoms will get worse with these tests due to exertion and stenosis will respond well to flexion
What does a post do in orthotic design
A post is a wedge.
Post reduces motion and frontal plane and therefore addresses subtalar motion.
What is the primary corrective component for calcaneus inclination
Adjust rear foot
Tarsal coalition
Osseous or fibrous connection between two tarsal bones usually navicular calcaneus or talus calcaneus. Will have ridgid flat arches with x-rays to diagnose. Interventions include orthotics to address hindfoot due to compromise of sub talar motion. Low dye taping to support medial arch. Immobilized for 3 to 6 weeks in ortho boot
Salter- Harris I fracture
SCFE at hip is example
Fracture through physis
Peroneus brevis
Plantar flexion and Main Everter
The peroneus brevis originates from the lower two-thirds of the lateral fibula and inserts on the proximal fifth metatarsal
Who will benefit from soft foot orthosis
Insensate feet, fixed deformities with bony prominences. Will provide cushion and protection with shock absorption. Unable to feel at least 10 mm of pressure with seams Weinstein filament = insensate
Who will benefit from ridgid foot orthosis
Chains with control flexible deformities. Decreased motion. Not for fat pad atrophy. Mid or forefoot arthritis flexible deformities
Who will benefit from semi rigid orthoses.
Most common and offer shock absorption/protection. Weight redistribution and support control for flexible deformities. Hope offload high pressure areas of plantar surface. Patient with diabetes with heel and forefoot plantar pressure points
what type of modification would you make for an orthoses based on Varus deformity
Medial post
what type of modification would you make for an orthoses based on Valgus deformity
Lateral post
who would benefit from an Arizona brace
Will correct hindfoot Dalgas scene with posterior tib dysfunction
Who will benefit from hinged AFO
Foot drop
a patient with subtalar arthritis will benefit from what type of brace
Will need to limit inversion and Iverson with hinged AFO or SMO supramalleolar orthoses
A patient with Midfoot arthritis will benefit from what type of brace
Will need to stabilize transversed her soul and tarsometatarsal joint. UCBLRAFO device. Will benefit from rocker or double rocker soled shoes
what is leriche syndrome
Decreased femoral pulse and thigh muscle wasting indicates iliac artery occlusive disease. Location of pain may indicate level of obstruction thigh or butt
Turf toe injury
Hyperextension injury of first MTP resulting in plantar plate injury. Will disrupt sesamoids tracking.
turf toe grades
Grade 1: stretching of plantar plate with some swelling. Return to play as tolerated
Grade 2: partial tear with moderate swelling. Restricted motion due to pain. Treat with crutches as needed and returned to play in two weeks taping in plantarflexed position
Grade 3: complete disruption. Significant swelling in flexion weakness with instability will occur. Immobilization or surgery is required. Anticipated RTP 10–16 weeks. Will require 50 to 60° pain-free MTP passive dorsiflexion before running or plyometrics
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