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MSK II > Ankle and Foot > Flashcards

Ankle and Foot Flashcards

1
Q

what are risk factors of an ankle sprain

A

previous ankle sprain
lack of external support
lack of warm-up
lack of coordination training
impaired dorsiflexion

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2
Q

what could be the cause of impaired dorsiflexion

A

shortened triceps surae (calf)
talar hypomobility
fibrotic capsule

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3
Q

why would the lateral foot be excessively loaded with limited dorsiflexion

A

talocrural joint does not reach CPP, stays supinated longer before pronating

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4
Q

what is the etiology of lateral sprains

A

excessive plantarflexion and inversion

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5
Q

what talocrural ligaments are most involved with lateral sprains

A

ATF
CF
PTF

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6
Q

what ligaments are the intraarticular ligaments of the ankle

A

interosseous talocalcaneal ligament

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7
Q

explain how the 5th metatarsal can be affected with lateral ankle sprain

A

excessive action of the peroneus brevis causes avulsion fracture of the 5th metatarsal

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8
Q

how can the medial malleolus be affected with lateral ankle sprain

A

medial malleolus fracture d/t excessive inversion

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9
Q

how can the cuboid be affected with lateral ankle sprains

A

excessive action of the peroneus longus

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10
Q

how can the tibia and fibula be affected with a lateral ankle sprains

A

fibula is anteriorly subluxated on tibia by reversal of muscle action of the peroneals

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11
Q

describe the symptoms common with lateral ankle sprains

A

sudden onset with trauma by “rolling ankle” and the foot turning inward

lateral ankle pain/swelling

limited and painful ROM, especially pointing for and turning inward

difficult and painful weight bearing

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12
Q

what would you expect to observe with a patient with a lateral ankle sprain

A

swelling and possible ecchymosis
antalgic and asymmetrical gait

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13
Q

what is used to determine if a patient has a lateral ankle sprain

A

ottawa and bernese ankle clinical decision rules

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14
Q

what would you expect to find in your scan with a lateral ankle sprain

A

ROM: limited and painful with PF and IV
RST: possibly weak and painful EV

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15
Q

what would you expect to find in your biomechanical test with a lateral ankle sprain for accessory motion

A

hypermobile ant talar glides
possible hypomobile cuboid from subluxation

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16
Q

what special tests would you expect to be positive with a lateral ankle sprain

A

talocrural: anterior drawer, reverse anterior drawer, CF with medial talar tilt, PTF

subtalar: anterior interosseuous, lateral

TTP over structures

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17
Q

what is the etiology of medial ankle sprains

A

excessive EV

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18
Q

what ligaments are involved with a medial ankle sprain

A

deltoid, posterior interosseous, medial calcaneal ligament

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19
Q

how is the bone affected with medial ankle sprains

A

avulsion fracture of medial malleolus

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20
Q

what muscles or tendons can be affected by medial ankle sprains

A

possible tibialis posterior strain and/or subluxation if flexor retinaculum is torn

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21
Q

how can the lateral malleolus be affected with medial ankle sprains

A

chipped lateral malleolus with too much eversion

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22
Q

what symptoms do you expect with a medial ankle sprain

A

sudden onset with trauma with ankle turning outward

medial ankle pain/swelling

limited and painful ROM, especially with turning outward

difficult and painful weight bearing

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23
Q

what would you expect to serve with medial ankle sprains

A

swelling and possible ecchymosis
antalgic and asymmetrical gait

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24
Q

what would you expect to find in your scan for a medial ankle sprain

A

ROM: primarily limited and painful EV
RST: possible weak and painful IV

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25
Q

what would you expect to find with accessory motion testing for a medial ankle sprain

A

potentially hypermobile calcaneal EV glides

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26
Q

what special tests would you expect to be positive with a medial ankle sprain

A

talocrural: anterior and reverse anterior drawer test

subtalar: medial calcaneal glide, posterior interossues, medial lig

TTP over involved structures

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27
Q

what is a syndesmotic sprain

A

high ankle sprain

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28
Q

what is the etiology for a syndesmotic sprain/high ankle sprain

A

primarily DF
excessive talar posterior glide with ER, possibly EV

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29
Q

list the ligaments in order that are most affected with a syndesmotic sprain

A

AITFL
interosseous membrane or syndesmosis
PITFL
deltoid ligaments

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30
Q

what bones can be affected with syndesmotic sprain

A

talar or distal tibia/fibular fracture

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31
Q

what symptoms do you expect with a syndesmotic sprain

A

sudden onset with trauma with ankle bent up
often anterior ankle pain/swelling
limited and painful ROM, especially bending ankle up
difficult and painful weight bearing

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32
Q

what would you expect to observe with a syndesmotic ankle sprain

A

swelling and possible ecchymosis
antalgic and asymmetrical gait

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33
Q

what would you expect to find during your scan with a syndesmotic sprain

A

ROM: primarily limited and painful DF and possibly EV
RST: possibly weak and painful, no real specific direction

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34
Q

what would you expect to find in your accessory motion testing of a syndesmotic sprain

A

likely hypermobile posterior talar glides

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35
Q

what special tests would you expect to be positive with a syndesmotic sprain

A

inferior TibFib - general: reverse posterior drawer, specific: fibular ant/post translation

single leg hop test

TTP over structures

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36
Q

what are the risk factors of chronic ankle instability

A

increased talar curvature
lack of external support
lack of coordination training following a prior sprain

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37
Q

what is the etiology of chronic ankle instability

A

past severe and/or recurrent sprains
80% reinjury following an IV sprain

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38
Q

what S&S would you expect with chronic ankle instability

A

decreased postural stability/proprioception and plantar sensation

altered mm activation patterns

aberrant joint motion

fibula is significantly more lateral from tibia (affected side is wider)

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39
Q

what modalities are beneficial with all sprains

A

cryotherapy benefits with pain/swelling

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40
Q

what modalities have weak evidence for ankle sprains

A

diathermy and LASER
electrotherapy
US should not be used with acute sprains
acupuncture

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41
Q

how is bracing used with ankle sprains

A

reduces risk and frequency but not severity with basketball

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42
Q

how does taping affect ankle sprains

A

mechanical support significantly decreases after 30 minutes of exercise

talar technique limits anterior glide

distal tib fib technique for high ankle sprains to limit separation and anterior distal fibualr glide

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43
Q

how is STM used with ankle sprains

A

lymphatic drainage for swelling

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44
Q

what is the purpose of JM with MET for ankle sprains

A

ROM, proprioception, tissue tolerances

AP talar mobes

hypo analgesic effect and subsequent increased ROM

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45
Q

what is the focus of MET for ankle sprains

A

tissue proliferation and stabilization

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46
Q

what is the positional/directional biases for a lateral ankle sprain, why

A

eversion and dorsiflexion

go away for the mechanism of injury first

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47
Q

what the positional/directional biases for a medial ankle sprain, why

A

inversion and plantarflexion

go away from the mechanism of injury first

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47
Q

what the positional/directional biases for a medial ankle sprain, why

A

inversion and plantarflexion

go away from the mechanism of injury first

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48
Q

what is the positional/directional biases for a high ankle sprain, why

A

plantarflexion

go away from the mechanism of injury first

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49
Q

why is it important to include balance and neuromuscular training with MET for ankle sprains

A

prevents reoccurrences

improved balance and inversion joint position sense

greater motor neuron excitability = makes inhibited muscles more excitable

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50
Q

what is the prognosis for return to play with a grade 1 ankle sprain

A

1-2 weeks

~7.2 days with track athletes = unidirectional motions

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51
Q

what is the prognosis for return to play with a grade 2 ankle sprain

A

2-6 weeks

~15 days with track athletes = unidirectional motions

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52
Q

what is the prognosis for return to play with a grade 3 ankle sprain

A

> 6 weeks

30-55 days with track athletes = unidirectional motions

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53
Q

t/f
early functional rehabilitation shows no difference when compared to immobilization with restoring early function

A

false

early functional rehabilitation appears superior to 6 weeks immobilization in restoring early function

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54
Q

what bones make up the lateral foot

A

4th and 5th rays and cuboid and calcaneus

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55
Q

what is the function of the lateral foot

A

shock absorption from heel strike to just before heel off

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56
Q

what bones make up the middle column of the foot

A

1st through 3rd rays and cuneiforms and talus

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57
Q

what is the functional ROM of ankle dorsiflexion during toe off with knee extended

A

10-15 degrees

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58
Q

what is the functional ROM of ankle dorsiflexion when walking down steps with the knee flexed

A

ascent: 15-25 degrees
descent: 20-35

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59
Q

what is the functional ROM of ankle plantarflexion for walking and stairs

A

15-30 degrees

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60
Q

what is the functional ROM of 1st MTP hyperextension at heel/toe off

A

65 degrees

61
Q

describe the subtalar joint neutral

A

talus centered in talocrural and on calcaneus
position the talus should be in

62
Q

t/f
the subtalar joint neutral is a common and widely taught measurement but is unreliable

A

true

63
Q

why is standing not a reliable way to measure the medial longitudinal arch

A

standing does not predict dynamic function

64
Q

what muscle primarily eccentrically controls plantarflexion

A

tibialis anterior

65
Q

what muscle primarily controls eversion during flat foot through heel off

A

tibialis posterior

66
Q

during which stage of the gait cycle are all foot arches maximally in a flattened position

A

when all metatarsal heads are in contact with the ground

midstance through heel off

67
Q

what position is the knee and hip in during midstance to heel off during the gait cycle

A

knee is maximally externally rotated

hip is maximally internal rotated and ext/hyperextended

68
Q

what happens at the 1st ray/MTP during heel off to toe off

A

1st ray bears most load of the foot

1st MTP maximally hyperextends and potential energy built through plantar fascia

69
Q

what happens to all structures during toe off to swing phase of gate

A

potential energy is released and opposing motions occur for propulsion

great toe flexes
ankle plantar flexes and talus IR
knee flexes and IR
hip flexes and ER

70
Q

what is excessive pronation

A

earlier, extended, and/or excessive combination of DF, EV, and abd

71
Q

what can cause excessive pronation

A

hypermobility/instability at TibFib or Talocrural
impaired LE control
adjacent joint hypomobility

72
Q

explain how adjacent joint hypomobility can lead to excessive pronation

A

limited talocrural DF = midfoot and forefoot excessively EV and abd

limited knee ext = excessive ankle DF

hip will not compensate because it internally rotates while the knee and talus externally rotates

73
Q

what can limited DF lead to

A

excessively loading lateral foot and staying in supination longer = ankle sprains are more common

compensatory and excessive knee extension

74
Q

what LQ conditions are associated with limited DF

A

foot: 1st MTP DJD, mortons, tarsal tunnel, plantar facitis, 5th MT stress fractures

leg/ankle: lateral ankle sprain, chilies tendinopathy, sever’s and MTSS

75
Q

what is the prevalence of achilles tendinopathy

A

most frequently reported overuse injury
recreational activities
training > competition
30-50 year olds
10-20% of runners

76
Q

what are the risk factors for achilles tendinopathy

A

reduced DF ROM that limits potential energy of achilles
limited calf flexibility that leads to tendinopathy origins
calf weakness
possible L4-S1 regional interdependence
male gender with family history
abnormal tendon structure and prior injury
older age
obesity
systemic disease with persistent inflammation and poor blood supply

77
Q

describe the pathomechanics of achilles tendinopathy

A

repetitive lengthening with compression from limited DF/excessive EV

lack of PE with limited DF = overworked

collagen fibril thinning/disorganization and fibroblast death

thickened bu weaker tendon

ineffective force transfer

impaired motor control

78
Q

what are the symptoms of achilles tendinopathy

A

gradual onset that limits WB

increased pain and stiffness with inactivity or severe activity

decreased pain with mild activity

79
Q

what would you expect to observe with achilles tendinopathy

A

achilles thickening
possible impaired LE control

80
Q

what would you expect to find in your scan for achilles tendinopathy

A

ROM: possible pain and limitation with DF
RST: possible pain with plantarflexion, hip and knee weakness

81
Q

what would you expect to find with accessory motion testing for achilles tendinopathy

A

possible talar hypomobility for DF

82
Q

what special tests would you expect to be positive with achilles tendinopathy

A

arc sign
royal london test
single leg heel raise
single leg hop test - less reps or pain vs uninvolved side
shortened gastroc

83
Q

what would you expect to find with palpation for achilles tendinopathy

A

TTP 2-6cm proximal to insertion
more medial achilles pain = plataris involved
achilles crepitus

84
Q

what should be included with achilles tendinopathy pt education

A

rest is not indicated
optimal stress is best with mild pain (3-5/10)
weight management
shoe wear

85
Q

what is the timeline and prognosis of achilles tendinopathy

A

8-12 weeks for dense connective tissue

80% progress with proper treatment and patient involvement

86
Q

what modalities could be useful when treating achilles tendinopathy

A

laser
ionto
shockwave therapy

87
Q

what is the effect of taping for achilles tendinopathy

A

foot taping can aid in shock absorption
can decrease rate of injury
overall, not clear evidence

88
Q

what is the effect of dry needling and STM for achilles tendinopathy

A

can help with pain and motion only with exercise

89
Q

what is the primary purpose of achilles tendinopathy

A

tendon proliferation and stabilization

90
Q

explain each phase of MET for achilles tendinopathy

A

isometric shortened - PF in shortened position
isotonic shortened - PF neutral to shortened
isotonic with lengthening - PF from DF position
isometric with EB - CC hip and, ER, ext
plyometrics

91
Q

give examples of the best mm actions to improve achilles tendinopathy

A

eccentrics
heavy, slow concentric, eccentrics
isometrics

92
Q

explain the ultimate parameters for achilles tendinopathy MET

A

3 sets 10-15 reps
3 sec phases of mm actions
heavy loads

93
Q

how long should MET continue to improve achilles tendinopathy

A

at least 2x/week for 6-12 weeks

once symptoms return to normal pain levels, repeat exercises

94
Q

what are the success rates for achilles tendinopathy

A

mostly normalized tendon structure and thickness
improved mechanical properties and cortical function
~12 weeks to recovery
80% full recovery within 3-6 months of progressive loading

95
Q

who is calcaneal apophysitis most common in

A

9-12-year-old males

96
Q

what are the risk factors for calcaneal apophysitis

A

long/year round spors
poor fitting shoes that lack cusion
training eros
shortened PFs
foot dysfunction

97
Q

what are the symptoms of calcaneal apophysitis

A

gradual onset of heel pain with overuse
bilateral in 60% cases
“pop” = possible avulsion

98
Q

what would you expect to observe with calcaneal apophysitis

A

poor shoe support/cusion
foot dysfunciton
impaired LE control

99
Q

what would you expect to find in the scan for calcaneal apophysitis

A

ROM: limited DF = greater tensile force on growth plate
RST: possible weak and painful PFs, weak DF

100
Q

what special tests would you expect to be positive with calcaneal apophysitis

A

squeeze test on heel
sever’s sign - pain with heel raise
m lengths - shortened gastroc

101
Q

what would you expect to find with palpation with calcaneal apophysitis

A

TTP over cal of calcaneus

102
Q

what should be included with patient education for calcaneal apophysitis

A

soreness rule
load management - rest days
movement cues for LE mechanics

103
Q

what ROM is limited with calcaneal apophysitis and should be improved with JM

A

dorsiflexion

104
Q

what muscle should be stretched with calcaneal apophysitis

A

hamstrings d/t facial connections with gastroc

105
Q

what orthotics could be helpful for patients with calcaneal apophysitis

A

arch support for excessive pronation
heel lift
gell heel cups with heel lift works best

106
Q

what MET should be performed for calcaneal apophysitis

what should be avoided during exercises

A

improve LE control

caution d/t mm and tendon attachment to growth plate to avoid greater overuse

107
Q

what is the prognosis ofr calcaneal apophysitis

A

most likely to resolve by 3 months, but can be recurrent/persistent problem

108
Q

what is the prevalence of achilles rupture

A

most common in men 20-50 years

109
Q

what is the etiology of an achilles rupture

A

typically during a sudden eccentric activity

110
Q

what symptoms would you expect with an achilles rupture

A

sudden onset of severe pain with trauma
sounds/feels like you’ve been shot in the calf
significant limitation in PF and weakness
unable to walk well if at all

111
Q

what would you expect to observe with an achilles rupture

A

ecchymosis and swelling
asymmetrical and antalgic gait at best - most likely unable to walk

112
Q

what would you find in the scan for achilles rupture

A

ROM: limited if any PF
RST: weak PF
special tests: (+) matle’s, thompson’s
palpation: gap in tendon

113
Q

t/f
early functional rehab and WB does not increase re-rupture vs cast immobilization for achilles rupture

A

true

114
Q

what is the prognosis of achilles rupture

A

many professional athletes dont return to prior levels
1/3 NBA and NFL don’t return at all

115
Q

t/f
plantar fascipathy is the most common foot condiiton

A

true

116
Q

what are the clear risk factors for plantar fasciopathy

A

increased PF ROM

high BMI

running

work related prolonged WBing with poor shock absorption

impaired 1 MTP extension that reduces PE of fascia

increased age

117
Q

what is the mechanical significance of the plantar fascia

A

assists with gait through windlass effect that is PE developed by normal foot and ankle motion

118
Q

what structures are involved with plantar fasciopathy

A

foot intrinsic muscles
heel fat pad innervated by tibial nerve
achilles tendon fibers
medial and lateral plantar nerves

119
Q

describe the correlation between plantar fasciopathy and bone spurring

A

bone spurs observed with and without condition

platar fascia thickening and fat pad thinning were better indicators

120
Q

what is the etiology/pathomechanics of plantar fasciopathy

A

tendinopathy origins
acute/solely inflammatory -21%
neoplastic - 25%
neither neoplastic or inflammatory - 54%

121
Q

what symptoms would you expect with plantar fasciopathy

A

gradual onset of heel pain after recent increased in WB activity

medial > central heel pain

122
Q

when would the pain be the worse with plantar fasciopathy

A

after a period of inactivity
worse at end of the day or after prolonged WB

123
Q

explain the effect on bone density during a growth spurt

A

done density decreased during a growth spurt and takes a while to return back to normal levels

124
Q

what is the prescription for bone stress injuries

A

graded unloading to ambulate without pain

gradual and progressive return to play activity while addressing risk factors and etiologies

125
Q

what is the etiology of compartment syndrome

A

blunt trauma
overuse

126
Q

what is the pathogenesis of compartment syndrome

A

increased swelling with limited fascial extensibility particularly compressing neurovascular structures in the anterior leg compartment

127
Q

describe the signs and symptoms of compartment syndrome

A

recent blunt trauma or overuse to anterior compartment

primarily cramping, burning, tingling

any lengthening or use of DFs adds to compression and pain

possible DF weakness

128
Q

what are the 6Ps for signs and symptoms of compartment syndrome

A

pain
palpable tenderness
pulselessness
pallor
paresthesias
paralysis

129
Q

what is a bi-malleolar ankle fracture

A

distal tibia and distal fibula fracture

130
Q

what is a tri-malleolar ankle fracture

A

tibia, fibula, and posterior tibial rim fracture

131
Q

what bone is most commonly fractured in the rearfoot

A

calcaneous

132
Q

what bone is most commonly fractured in the midfoot

A

navicular

133
Q

what area is most commonly fractured in the foot

A

forefoot

base of 5th MT

134
Q

what joint is most commonly affected by ARJC in the foot

A

1st MTP

135
Q

what is the etiology of ARJC at the 1st MTP

A

longer 1st ray
trauma
genetics

136
Q

what symptoms would you expect with ARJC at the 1st MTP

A

gradual onset
AM stiffness < 30 minutes
dorsal joint pain
antalgic/asymmetrical gait
pain increases when walking on incline

137
Q

what would you expect to observe with ARJC at the 1st MTP

A

hallux valgus with possible excessive pronation

claw tie = MTP hyperext and IP flx

hammer toe = MTP hyperext, PIP flx, DIP hyperext

mallet toe = neutral MTP and PIP with DIP flx

138
Q

what gait would you expect with ARJC at the 1st MTP

A

antalgic and asymmetrical gait

possible hip ER, vertical limp, vaulting d/t loss of motion at heel/toe off

excessive pronation

impaired LE control

139
Q

what ROM would you expect with ARJC at the 1st MTP

A

capsular pattern of restriction - loss of ext (hallux limitus/rigidus)

pain into CPP of ext

140
Q

how many degrees of motion is needed for hyperextension of MTP for normal gait

A

65 degrees

141
Q

besides ROM, what would you expect to find in the scan for ARJC at the 1st MTP

A

CM - consistent block
ST - compression and distraction (+) if symptomatic
AM - hypomobility of 1st MTP with DF and/or sesamoid bones

142
Q

what is the PT rx for ARJC at the 1st MTP

A

POLICED
proper footwear
AD
manual therapy
MET

143
Q

what is the improtance with footwear for ARJC at the 1st MTP

A

prevent hallux valgus
arch support
stiffer shoe with larger toe box
rocker bottom shoe

144
Q

what is the prognosis of injections for ARJC at the 1st MPT

A

fair quality of evidence to not use

145
Q

what is morton’s neuritis/-oma

A

compression of interdigital nerves

acute - inflammatory = neuritis
chronic - fibrous cyst = neuroma

146
Q

what is the etilogy of morton’s neuritis/-oma

A

excessive pronation
small toe boxes with/out high heels
limited 1st MTP extension shifts load onto lateral foot

147
Q

what are the pathomechanics of morton’s neuritis/-oma

A

excessive pronation leading to excessive inter-metatarsal compression

148
Q

what is tarsal tunnel syndrome

A

entrapment of tibial nerve at flexor retinaculum/medial malleolus

149
Q

what is the etiology/pathomechanics of tarsal tunnel syndrome

A

excessive pronation leading to excessive tension and compression of tibial nerve

150
Q

what is the nerve compression rx

A

POLICED - no C

JM/orthotics/MET to reduce compression by assisting with abnormal mechanics

MET used to create neural motion/flossing

MSK II (5 decks)

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