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OCS Exam > Ankle and Foot > Flashcards

Ankle and Foot Flashcards

1
Q

What muscles lay in the first layer of the foot?

A

Abductor hallucis, flexor digitorum brevis, abductor digiti minimi

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2
Q

What muscles lay in the second layer of the foot?

A

Quadratus plantae, lumbricals (flexor digitorum longus and flexor hallucis longus pass through this layer)

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3
Q

What muscles lay in the third layer of the foot?

A

flexor hallucis brevis, adductor hallucis, flexordigit minimi brevis

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4
Q

What muscles lay in the fourth layer of the foot?

A

Plantar interossei and dorsal interossei (peroneus longus and tibilias posterior pass through this layer)

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5
Q

How much ROM is require for normal gait?

A

20-30 degrees of PF and 6-10 of DF

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6
Q

What is the windlass mechanism of the foot?

A

Toe DF produces supination and thereform creates a medial longitudinal arch

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7
Q

What are the four common arches of the normal foot?

A

Medial (formed by calcaneus, talus, navicular, & 3 cuneiforms) and lateral calcaneus, cuboid( metatarsals 4&5) longitudinal arch; proximal (navicular, three cunieforms, & cuboid) and distal (5 metatrasal) transverse

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8
Q

What is pes planus?

A

a foot that exhibits no longitudinal arch and an ankle that is everted (valgus); there is rigid (caused by tarsal coalition, verticle talus) and flexible

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9
Q

What is pes cavus?

A

high arch; may be related to muscle imbalances – toe walkers with tight tight tendo achilles and limited DF or neuromucular disease

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10
Q

What percentage of weight does the fibula bear?

A

12-17%

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11
Q

Describe the function of the deltoid ligament?

A

prevents eversion and abd of the talus; higher potential to avulse secondary to strength

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12
Q

What are the lateral collateral ligaments of the foot?

A

ant talofibular, post talofibular, calcaneofibular; ATF most commonly sprained with inv injury with PF

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13
Q

Define Lisfranc’s ligament:

A

tarsometatarsal spanning from the medial cuneiform to the base of the second metatarsal; can avulse

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14
Q

What is the spring ligament:

A

Calcaneonavicular ligament from the plantar aspect of the sustentaculum tali to the navicular; primary static stabilizer of the medial longitudinal arch

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15
Q

What is chopart’s joint:

A

midtarsal joint: talonavicular and calcaneocuboid

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16
Q

Lisfranc joint

A

tarsometatarsal joint

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17
Q

How does a widening of the motise after a syndesmotic injury change the WB’ing surface of the ankle?

A

1 mm increase decrease the WB’ing surface by 40%; 3 mm >60%, 5mm ~80%; will increase likelihood of early degerative joint disease

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18
Q

What increases the risk for anterior talus impingement?

A

osteophytes, scar tissue, or overly compressed ORIF

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19
Q

What is the sinus tarsi?

A

opening between the talus and calcaneus

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20
Q

What are the contents of the tarsal tunnel?

A

Tom, Dick, And Very Nervous, Harry; T – posterior Tibial Tendon; D – Flexor Digitorum longus; ANV – posterior tibial artery, vein, and nerve; H – flexor hallucis longus

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21
Q

What are the 5 nerves that cross into and supply motor and sensory fibers to the foot?

A

1.) sural nerve (post lat) 2.) Superficial peroneal nerve (ant lat) 3.) deep peroneal nerve (ant) 4.) saphenous nerve (ant med) 5.) post tibial nerve (post med)

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22
Q

Define porta pedis

A

anatomic opening on the plantar surface of the foot that medial and lateral plantar nerve and compression of the plantar nerves

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23
Q

What structure is referred to as the “freshman’s nerve”

A

plantaris tendon which attaches onto the medial aspect of the posterior calcaneus tuberosity

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24
Q

What is meant by an accessory bone of the foot?

A

An ossicle or bone that separates from the normal bone (most commonly caused by fracture or a secondary ossification center)

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25
Q

What is the function of the seasmoids?

A

transfer loads through the soft tissues to the metatarsal head and increase the lever arm of the flexor hallucis brevis to aid in push off

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26
Q

what effect does hallux valgus increase have on PF force at push off?

A

angle of 40 degrees decreases push off strength by 78%

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27
Q

How many muscles attach to the talus?

A

zero

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28
Q

What is the difference between achilles tendonitis and tendonosis?

A

Tendonitis is an inflammatory process casued by overuse activities or a specific disease process; tendonosis is beyond the inflammatory stage where the tendon has failed to heal, with possible thickening of the tendon

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29
Q

Other differential Dx for achilles complex?

A

insertional tendinopathy and inflamed retrocalcaneal bursa

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30
Q

What treatments are there for achilles tendonitis and tendonosis?

A

Heel lifts, NSAIDs, eccentrics

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31
Q

Tyipcal patient with Achilles tendon rupture?

A

Over 40 and engages in physical activity or sport / weekend athlete, Hx of tendonitis, loss of flexibility

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32
Q

Describe the thompson test?

A

squeeze the calf to see if the foot PF’s to R/O Achilles tendon rupture

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33
Q

Describe a typical protocol for an Achilles repair:

A

6-8 wks of casting/immobilization with Wb’ing at the discretion of the surgeon, pt progressed to a heel lift. Focus on progressive PF strength, DF stretching avoided until after 4 months post-op; recovery by 6 months of strength and ROM and running by 7 months, full activity by 10-12 months

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34
Q

Accelerated program for Achilles repair with stronger sutures:

A

Immobilization for 72 hours followed by early active ROM ex, posterior splint for 2 wks and then a hinged orthosis. 6 wks after surgery pt can FWB and PRE start, pre level activities by 4 months

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35
Q

Symptoms for tarsal tunnel:

A

pain in the area of the tarsal tunnel with possible complaints of paresthesia

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36
Q

What factors contribue to tarsal tunnel syndrome

A

pronation may cause compression of the tibial nerve, trauma – fx, sprain, or other soft tissue injury may cause swelling; RA

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37
Q

What objective tests are there for tarsal tunnel:

A

gait analysis, palpation of pulses, neuro exam, sensation, tinel sign, slump test, lower limb tension test

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38
Q

What is Posterior tibialis tendon dysfunciton?

A

progressive degeneration of the PTT causes aquired flatfoot deformity (collapse of the plantar arch)

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39
Q

What are the signs and symptoms of PTTD:

A

mild swelling and medial ankle pain with no deformity with mild weakness with painful heel raise but inability to invert; stage II progressive flattening or the arch with abducted midfoot, tendon ruptures or is functionally incompotent with a flexible foot, but unable to perform a heel raise; stage III the foot becomes fixed

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40
Q

Best Tx for PTTD?

A

Immobilization and rest to prevent excessive pronation and decrease demand on post tib; tape the arch or orthotics; calf stretching, progressive strengthening in pain free range, eccentrics, windshield wipe ex

41
Q

What causes peroneal tendon subluxation?

A

passive DF of an everted foot; skiing or other sports

42
Q

Differential Dx for posterior heel pain:

A

retrocalcaneal bursitis, haglund’s deformity, Achilles tedonitis or tendonsis, calcification of the Achilles, referred pain

43
Q

Differential Dx for plantar heel pain:

A

Plantar fascia, tibial nerve entrapment, fat pad atrophy, heel spur, stress fx, tarsal tunnel syndrome, systemic problems (gout), radiculopathy S1

44
Q

What is plantar fasciitis:

A

Pain arising from the insertion of the plantar fascia characterized by progressive pain with WB’ing as well as pain with the first few steps upon rising from sitting

45
Q

Best Tx for plantar heel pain?

A

Pt ed, tissue mobilization, joint mobilization, strengthening the muscles that support the arch, orthotics, taping

46
Q

How can adverse neurodynamics cause plantar heel pain and why does neural mobilization help?

A

Local mechanical entrapment of the medial calcaneal branch of the tibial nerve or the abductor digiti minimi nerve; intraneural adhesion, compression, or scarring create a painful cycle; neural mobilizaiton potential can break adhesions and increase healing

47
Q

Ottawa ankle rules warrant ankle x-rays when?

A

Bone tenderness in the posterior half of the lower 6 cm of the fibula or tibia or navicular or 5th met; Inability to bear wt immediately after or within 10 days of injury

48
Q

Best guidelines for return to activities after an ankle sprain?

A

Full AROM and PROM, no limp, strength 90% equal, single leg hop & high jump & 30 yd zig zag 90% of uninvolved; ability to reach max cutting speed

49
Q

Possible causes for chronic pain after an ankle sprain:

A

Tension neuropathy, anterior or lateral soft tissue impingement, or cuboid subluxation treated with manipulation

50
Q

What is a syndesmotic ankle sprain?

A

injury of the Ant and post inferior tibiofibular ligaments and damage to the interosseous membrane; common MOI ER of the tibia on a planted foot

51
Q

What are hallux rigidus and hallux limitus, what is the best Tx?

A

Loss of great toe ext with rigidus having arthritis; joint mobilization, seasmoid mobilizaion, strengthening of the MTP flexors; stiff soled shoe or metatarsal bar

52
Q

Windlass mechanism?

A

ext of the MTPs tightens tissues on the plantar aspect elevating the arch; lost with pronation and may result in joint laxity of the mets, metarsalgia, and hallux valgus

53
Q

What are hammer toes?

A

MTP ext with PIP flexion, callus formation on dorsum may be painful;

54
Q

What are claw toes?

A

Ext of MTP with clawing of both the PIP and DIP

55
Q

Most common site for a neuroma?

A

3rd and 4th metatarsals, patients complain of deep burning pain and may have paresthesia, pain is on the plantar aspect, relieved with rest; occurs from irritation of the intermetatarsal plantar digital nerve

56
Q

What tests suggest a neuroma?

A

Mulder’s sign (point pressure on the transverse arch) and squeeze test

57
Q

What is a Jones fracture

A

Fracture of the 5th metatarsal, also notorious for nonunions

58
Q

Weakness of what muscles have been associated with plantar fasciitis?

A

Toe flexors

59
Q

The calcaneonavicular “spring ligament” prevents excessive what?

A

DF of the navicular on the talar head

60
Q

Causes of aquired flat foot deformity?

A

Gastroc-soleus tightness, tibialis posterior dysfunction, midfoot laxity, abduction of the forefoot, ER of the hindfoot, subluxation of the talus, traumatic deformities, ruptured plantar fascia, Charcot foot, neuromuscular imbalances

61
Q

What injuries are runners with high arches more likely to encounter?

A

lateral ankle sprains and 5th metatarsal stress fracture)

62
Q

Define following special test: Ant drawer test

A

performed in 10-20 PF with ant glide of the calcaneus to test for ATFL – pain or translation >3 mm on the involved side is +

63
Q

Define following special test: Talar tilt

A

20 PF or 10 DF with the calcaneus moved passively into inv – tests for ATFL and CFL respectively

64
Q

Define following special test: ER test

A

knee at 90 flexion and ankle at neutral, passively ER the foot and ankle – pain in the syndesmosis +

65
Q

Define following special test: Squeeze test

A

squeeze the fibula and tibia just above the midpoint of the calf - + pain in the area of the syndesmosis

66
Q

Define following special test: cotton test

A

stabilize the distal tibia and grasp the rear foot – if the talus translates in the ankle mortise possible syndesmotic injury +

67
Q

Define following special test: fibula translation test

A

Stabilize the distal tibia while the other hand translates the lateral mallelous A-P and P-A - + pain is reproduced along the syndemosis

68
Q

Define following special test: Thompson test

A

squeeze of the calf while patient is prone and knee flexed, it is to ensure the Achilles tendon is intact

69
Q

Define following special test: Achilles tendon palpation

A

Pt prone and squeezing along the entire length of the Achilles while noting swelling and tenderness – reproduction of symptoms with palpation indicate Achilles tendinopathy

70
Q

Define following special test: Royal London hospital test

A

prone, find most tender part of the Achiles, patient actively DF’s and the same area is palpated – if the pt reports a decrease or absence of pain with the palpation in DF the Achilles tendinopathy is likely present

71
Q

Define following special test: Arc sign

A

Prone, pt active PF and DF watching the area of max swelling – if the swelled region of the

72
Q

Define following special test: Fibularis subluxation

A

prone and knee at 90, PF and DF then eversion against resistance - + subluxation or dislocation of the fibularis tendon

73
Q

Define following special test: Coleman block test

A

observe patient standing on flat surface, and then with the lateral side of the foot only on a 1in step – observe the change in forefoot pronation; helps decide on flexible rearfoot varus vs rigid

74
Q

Define following special test: Windlass test in WB’ing

A

Pt standing and passive ext of the first MTP until symptoms are reproduced or end range is felt; + pain along the plantar fascia = plantar fasciitis

75
Q

Define following special test: Mulder click test

A

palpate a mass that is a possible neuroma and push it between the metatarsals, then squeeze the metatarsals together; + pain with a palpable click of the mass

76
Q

Define following special test: Tinel sign

A

tap along the pathway of the posterior tibial nerve from distal to proximal from the medial longitudinal arch to above the medial malleolus; + symptoms reproduced for posterior tibial nerve involvement

77
Q

Define following special test: Homan sign

A

passively DF the ankle; + pain in the calf for possible DVT but has poor relability

78
Q

Most common cause for aquired flat foot deformity?

A

PTTD

79
Q

What is typically the MOI for a high (syndesmotic) ankle sprain

A

Rotation of the talus which gaps the distal tib-fib damaging the ligaments and possible the interosseus membrane

80
Q

What are x-rays are helpful for determing a syndesmosis injury?

A

WB’ing DF and ER to gap to tib fib, but high false negatives

81
Q

What are risk factors for lateral ankle sprains:

A

slower running, less cardiorespiratory fitness, decreased balance, less movement coordination, decreased DF ROM and strength, decreased reaction time of tib ant and gastroc

82
Q

Common risk factors for plantar fasciitis:

A

time spent on feet during the day, decreased ROM for DF, and obesity

83
Q

When is night splint use warrented in plantar fasciitis?

A

when symptoms are >6 months

84
Q

MOI for lisfranc injury?

A

Low energy injury with sports or high energy injury with a MVA with a longitudinal force with the foot PF’ed

85
Q

To screen for lisfranc injuries what are two suggested tests:

A

midfoot squeeze and hopping on a single leg 15x

86
Q

What is sever disease

A

Childhood injury occuring with an unfused calcaneus with traction from the Achilles tendon resolves in 2wks to 2 months

87
Q

Kohler disease

A

osteochonrdorsis of the navicular in childhood

88
Q

A pt presents with pain wrose in the morning or after sitting for long periods, pain with running, point tender pain on the Achilles with a thickened tendon; what is the most likley Dx?

A

Achilles tendinopathy

89
Q

What intrinsic factors may help with the prevention of Achilles tendinopathy?

A

limited DF, decreased PF strength, foot pronation

90
Q

Is pain a contraindication for continuing an eccentric program?

A

No

91
Q

grading an ankle sprain is a combination of what measurements:

A

laxity, point tenderness, swelling, function, and ability to bear weight; grade II able to bear weight, grade III unable to bear weight

92
Q

Limited DF can occur due to altered movement across a series of what joints:

A

ltalocrural, subtalar, and tibiofibular

93
Q

Current theory suggests passive lateral ankle instability will:

A

persist despite clinical care and the absence of pain (30%)

94
Q

Fibularis tendinopathy typically occurs with what type of foot?

A

cavus or neutral

95
Q

What is stage II PTTD:

A

Pain with palpation, flexible foot deformity, inability/weakness of PF

96
Q

Someone with grade II PTTD would benefit most from what type of Tx:

A

custom ankle foot orthotic and strengthening to remodel the degenerative tendon

97
Q

Long term outcome for PTTD is:

A

up to 70% may be symtpom free and not wearing a brace, but approximately 35% will have recurrent symptoms

98
Q

Hallux rigidus stages:

A

Grade 0: 40-60 DF grade 1: 30-40 DF dorsal osteophytes and min joint changes; grade 2: 10-30 mild flattening of the MTP joint, sclerosis, dorsal, medial and lateral osteophytes; grade 4: pain throughout entire ROM

99
Q

IF a patient presents with numbness but most like a plantar fasciitis what differential Dx should be considered?

A

Tarsal tunnel syndrome

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