Ankle and Foot Flashcards
what are risk factors of an ankle sprain
previous ankle sprain
lack of external support
lack of warm-up
lack of coordination training
impaired dorsiflexion
what could be the cause of impaired dorsiflexion
shortened triceps surae (calf)
talar hypomobility
fibrotic capsule
why would the lateral foot be excessively loaded with limited dorsiflexion
talocrural joint does not reach CPP, stays supinated longer before pronating
what is the etiology of lateral sprains
excessive plantarflexion and inversion
what talocrural ligaments are most involved with lateral sprains
ATF
CF
PTF
what ligaments are the intraarticular ligaments of the ankle
interosseous talocalcaneal ligament
explain how the 5th metatarsal can be affected with lateral ankle sprain
excessive action of the peroneus brevis causes avulsion fracture of the 5th metatarsal
how can the medial malleolus be affected with lateral ankle sprain
medial malleolus fracture d/t excessive inversion
how can the cuboid be affected with lateral ankle sprains
excessive action of the peroneus longus
how can the tibia and fibula be affected with a lateral ankle sprains
fibula is anteriorly subluxated on tibia by reversal of muscle action of the peroneals
describe the symptoms common with lateral ankle sprains
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
what would you expect to observe with a patient with a lateral ankle sprain
swelling and possible ecchymosis
antalgic and asymmetrical gait
what is used to determine if a patient has a lateral ankle sprain
ottawa and bernese ankle clinical decision rules
what would you expect to find in your scan with a lateral ankle sprain
ROM: limited and painful with PF and IV
RST: possibly weak and painful EV
what would you expect to find in your biomechanical test with a lateral ankle sprain for accessory motion
hypermobile ant talar glides
possible hypomobile cuboid from subluxation
what special tests would you expect to be positive with a lateral ankle sprain
talocrural: anterior drawer, reverse anterior drawer, CF with medial talar tilt, PTF
subtalar: anterior interosseuous, lateral
TTP over structures
what is the etiology of medial ankle sprains
excessive EV
what ligaments are involved with a medial ankle sprain
deltoid, posterior interosseous, medial calcaneal ligament
how is the bone affected with medial ankle sprains
avulsion fracture of medial malleolus
what muscles or tendons can be affected by medial ankle sprains
possible tibialis posterior strain and/or subluxation if flexor retinaculum is torn
how can the lateral malleolus be affected with medial ankle sprains
chipped lateral malleolus with too much eversion
what symptoms do you expect with a medial ankle sprain
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
what would you expect to serve with medial ankle sprains
swelling and possible ecchymosis
antalgic and asymmetrical gait
what would you expect to find in your scan for a medial ankle sprain
ROM: primarily limited and painful EV
RST: possible weak and painful IV
what would you expect to find with accessory motion testing for a medial ankle sprain
potentially hypermobile calcaneal EV glides
what special tests would you expect to be positive with a medial ankle sprain
talocrural: anterior and reverse anterior drawer test
subtalar: medial calcaneal glide, posterior interossues, medial lig
TTP over involved structures
what is a syndesmotic sprain
high ankle sprain
what is the etiology for a syndesmotic sprain/high ankle sprain
primarily DF
excessive talar posterior glide with ER, possibly EV
list the ligaments in order that are most affected with a syndesmotic sprain
AITFL
interosseous membrane or syndesmosis
PITFL
deltoid ligaments
what bones can be affected with syndesmotic sprain
talar or distal tibia/fibular fracture
what symptoms do you expect with a syndesmotic sprain
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
what would you expect to observe with a syndesmotic ankle sprain
swelling and possible ecchymosis
antalgic and asymmetrical gait
what would you expect to find during your scan with a syndesmotic sprain
ROM: primarily limited and painful DF and possibly EV
RST: possibly weak and painful, no real specific direction
what would you expect to find in your accessory motion testing of a syndesmotic sprain
likely hypermobile posterior talar glides
what special tests would you expect to be positive with a syndesmotic sprain
inferior TibFib - general: reverse posterior drawer, specific: fibular ant/post translation
single leg hop test
TTP over structures
what are the risk factors of chronic ankle instability
increased talar curvature
lack of external support
lack of coordination training following a prior sprain
what is the etiology of chronic ankle instability
past severe and/or recurrent sprains
80% reinjury following an IV sprain
what S&S would you expect with chronic ankle instability
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)
what modalities are beneficial with all sprains
cryotherapy benefits with pain/swelling
what modalities have weak evidence for ankle sprains
diathermy and LASER
electrotherapy
US should not be used with acute sprains
acupuncture
how is bracing used with ankle sprains
reduces risk and frequency but not severity with basketball
how does taping affect ankle sprains
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
how is STM used with ankle sprains
lymphatic drainage for swelling
what is the purpose of JM with MET for ankle sprains
ROM, proprioception, tissue tolerances
AP talar mobes
hypo analgesic effect and subsequent increased ROM
what is the focus of MET for ankle sprains
tissue proliferation and stabilization
what is the positional/directional biases for a lateral ankle sprain, why
eversion and dorsiflexion
go away for the mechanism of injury first
what the positional/directional biases for a medial ankle sprain, why
inversion and plantarflexion
go away from the mechanism of injury first
what the positional/directional biases for a medial ankle sprain, why
inversion and plantarflexion
go away from the mechanism of injury first
what is the positional/directional biases for a high ankle sprain, why
plantarflexion
go away from the mechanism of injury first
why is it important to include balance and neuromuscular training with MET for ankle sprains
prevents reoccurrences
improved balance and inversion joint position sense
greater motor neuron excitability = makes inhibited muscles more excitable
what is the prognosis for return to play with a grade 1 ankle sprain
1-2 weeks
~7.2 days with track athletes = unidirectional motions
what is the prognosis for return to play with a grade 2 ankle sprain
2-6 weeks
~15 days with track athletes = unidirectional motions
what is the prognosis for return to play with a grade 3 ankle sprain
> 6 weeks
30-55 days with track athletes = unidirectional motions
t/f
early functional rehabilitation shows no difference when compared to immobilization with restoring early function
false
early functional rehabilitation appears superior to 6 weeks immobilization in restoring early function
what bones make up the lateral foot
4th and 5th rays and cuboid and calcaneus
what is the function of the lateral foot
shock absorption from heel strike to just before heel off
what bones make up the middle column of the foot
1st through 3rd rays and cuneiforms and talus
what is the functional ROM of ankle dorsiflexion during toe off with knee extended
10-15 degrees
what is the functional ROM of ankle dorsiflexion when walking down steps with the knee flexed
ascent: 15-25 degrees
descent: 20-35
what is the functional ROM of ankle plantarflexion for walking and stairs
15-30 degrees
what is the functional ROM of 1st MTP hyperextension at heel/toe off
65 degrees
describe the subtalar joint neutral
talus centered in talocrural and on calcaneus
position the talus should be in
t/f
the subtalar joint neutral is a common and widely taught measurement but is unreliable
true
why is standing not a reliable way to measure the medial longitudinal arch
standing does not predict dynamic function
what muscle primarily eccentrically controls plantarflexion
tibialis anterior
what muscle primarily controls eversion during flat foot through heel off
tibialis posterior
during which stage of the gait cycle are all foot arches maximally in a flattened position
when all metatarsal heads are in contact with the ground
midstance through heel off
what position is the knee and hip in during midstance to heel off during the gait cycle
knee is maximally externally rotated
hip is maximally internal rotated and ext/hyperextended
what happens at the 1st ray/MTP during heel off to toe off
1st ray bears most load of the foot
1st MTP maximally hyperextends and potential energy built through plantar fascia
what happens to all structures during toe off to swing phase of gate
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
what is excessive pronation
earlier, extended, and/or excessive combination of DF, EV, and abd
what can cause excessive pronation
hypermobility/instability at TibFib or Talocrural
impaired LE control
adjacent joint hypomobility
explain how adjacent joint hypomobility can lead to excessive pronation
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
what can limited DF lead to
excessively loading lateral foot and staying in supination longer = ankle sprains are more common
compensatory and excessive knee extension
what LQ conditions are associated with limited DF
foot: 1st MTP DJD, mortons, tarsal tunnel, plantar facitis, 5th MT stress fractures
leg/ankle: lateral ankle sprain, chilies tendinopathy, sever’s and MTSS
what is the prevalence of achilles tendinopathy
most frequently reported overuse injury
recreational activities
training > competition
30-50 year olds
10-20% of runners
what are the risk factors for achilles tendinopathy
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
describe the pathomechanics of achilles tendinopathy
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
what are the symptoms of achilles tendinopathy
gradual onset that limits WB
increased pain and stiffness with inactivity or severe activity
decreased pain with mild activity
what would you expect to observe with achilles tendinopathy
achilles thickening
possible impaired LE control
what would you expect to find in your scan for achilles tendinopathy
ROM: possible pain and limitation with DF
RST: possible pain with plantarflexion, hip and knee weakness
what would you expect to find with accessory motion testing for achilles tendinopathy
possible talar hypomobility for DF
what special tests would you expect to be positive with achilles tendinopathy
arc sign
royal london test
single leg heel raise
single leg hop test - less reps or pain vs uninvolved side
shortened gastroc
what would you expect to find with palpation for achilles tendinopathy
TTP 2-6cm proximal to insertion
more medial achilles pain = plataris involved
achilles crepitus
what should be included with achilles tendinopathy pt education
rest is not indicated
optimal stress is best with mild pain (3-5/10)
weight management
shoe wear
what is the timeline and prognosis of achilles tendinopathy
8-12 weeks for dense connective tissue
80% progress with proper treatment and patient involvement
what modalities could be useful when treating achilles tendinopathy
laser
ionto
shockwave therapy
what is the effect of taping for achilles tendinopathy
foot taping can aid in shock absorption
can decrease rate of injury
overall, not clear evidence
what is the effect of dry needling and STM for achilles tendinopathy
can help with pain and motion only with exercise
what is the primary purpose of achilles tendinopathy
tendon proliferation and stabilization
explain each phase of MET for achilles tendinopathy
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
give examples of the best mm actions to improve achilles tendinopathy
eccentrics
heavy, slow concentric, eccentrics
isometrics
explain the ultimate parameters for achilles tendinopathy MET
3 sets 10-15 reps
3 sec phases of mm actions
heavy loads
how long should MET continue to improve achilles tendinopathy
at least 2x/week for 6-12 weeks
once symptoms return to normal pain levels, repeat exercises
what are the success rates for achilles tendinopathy
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
who is calcaneal apophysitis most common in
9-12-year-old males
what are the risk factors for calcaneal apophysitis
long/year round spors
poor fitting shoes that lack cusion
training eros
shortened PFs
foot dysfunction
what are the symptoms of calcaneal apophysitis
gradual onset of heel pain with overuse
bilateral in 60% cases
“pop” = possible avulsion
what would you expect to observe with calcaneal apophysitis
poor shoe support/cusion
foot dysfunciton
impaired LE control
what would you expect to find in the scan for calcaneal apophysitis
ROM: limited DF = greater tensile force on growth plate
RST: possible weak and painful PFs, weak DF
what special tests would you expect to be positive with calcaneal apophysitis
squeeze test on heel
sever’s sign - pain with heel raise
m lengths - shortened gastroc
what would you expect to find with palpation with calcaneal apophysitis
TTP over cal of calcaneus
what should be included with patient education for calcaneal apophysitis
soreness rule
load management - rest days
movement cues for LE mechanics
what ROM is limited with calcaneal apophysitis and should be improved with JM
dorsiflexion
what muscle should be stretched with calcaneal apophysitis
hamstrings d/t facial connections with gastroc
what orthotics could be helpful for patients with calcaneal apophysitis
arch support for excessive pronation
heel lift
gell heel cups with heel lift works best
what MET should be performed for calcaneal apophysitis
what should be avoided during exercises
improve LE control
caution d/t mm and tendon attachment to growth plate to avoid greater overuse
what is the prognosis ofr calcaneal apophysitis
most likely to resolve by 3 months, but can be recurrent/persistent problem
what is the prevalence of achilles rupture
most common in men 20-50 years
what is the etiology of an achilles rupture
typically during a sudden eccentric activity
what symptoms would you expect with an achilles rupture
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
what would you expect to observe with an achilles rupture
ecchymosis and swelling
asymmetrical and antalgic gait at best - most likely unable to walk
what would you find in the scan for achilles rupture
ROM: limited if any PF
RST: weak PF
special tests: (+) matle’s, thompson’s
palpation: gap in tendon
t/f
early functional rehab and WB does not increase re-rupture vs cast immobilization for achilles rupture
true
what is the prognosis of achilles rupture
many professional athletes dont return to prior levels
1/3 NBA and NFL don’t return at all
t/f
plantar fascipathy is the most common foot condiiton
true
what are the clear risk factors for plantar fasciopathy
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
what is the mechanical significance of the plantar fascia
assists with gait through windlass effect that is PE developed by normal foot and ankle motion
what structures are involved with plantar fasciopathy
foot intrinsic muscles
heel fat pad innervated by tibial nerve
achilles tendon fibers
medial and lateral plantar nerves
describe the correlation between plantar fasciopathy and bone spurring
bone spurs observed with and without condition
platar fascia thickening and fat pad thinning were better indicators
what is the etiology/pathomechanics of plantar fasciopathy
tendinopathy origins
acute/solely inflammatory -21%
neoplastic - 25%
neither neoplastic or inflammatory - 54%
what symptoms would you expect with plantar fasciopathy
gradual onset of heel pain after recent increased in WB activity
medial > central heel pain
when would the pain be the worse with plantar fasciopathy
after a period of inactivity
worse at end of the day or after prolonged WB
explain the effect on bone density during a growth spurt
done density decreased during a growth spurt and takes a while to return back to normal levels
what is the prescription for bone stress injuries
graded unloading to ambulate without pain
gradual and progressive return to play activity while addressing risk factors and etiologies
what is the etiology of compartment syndrome
blunt trauma
overuse
what is the pathogenesis of compartment syndrome
increased swelling with limited fascial extensibility particularly compressing neurovascular structures in the anterior leg compartment
describe the signs and symptoms of compartment syndrome
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
what are the 6Ps for signs and symptoms of compartment syndrome
pain
palpable tenderness
pulselessness
pallor
paresthesias
paralysis
what is a bi-malleolar ankle fracture
distal tibia and distal fibula fracture
what is a tri-malleolar ankle fracture
tibia, fibula, and posterior tibial rim fracture
what bone is most commonly fractured in the rearfoot
calcaneous
what bone is most commonly fractured in the midfoot
navicular
what area is most commonly fractured in the foot
forefoot
base of 5th MT
what joint is most commonly affected by ARJC in the foot
1st MTP
what is the etiology of ARJC at the 1st MTP
longer 1st ray
trauma
genetics
what symptoms would you expect with ARJC at the 1st MTP
gradual onset
AM stiffness < 30 minutes
dorsal joint pain
antalgic/asymmetrical gait
pain increases when walking on incline
what would you expect to observe with ARJC at the 1st MTP
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
what gait would you expect with ARJC at the 1st MTP
antalgic and asymmetrical gait
possible hip ER, vertical limp, vaulting d/t loss of motion at heel/toe off
excessive pronation
impaired LE control
what ROM would you expect with ARJC at the 1st MTP
capsular pattern of restriction - loss of ext (hallux limitus/rigidus)
pain into CPP of ext
how many degrees of motion is needed for hyperextension of MTP for normal gait
65 degrees
besides ROM, what would you expect to find in the scan for ARJC at the 1st MTP
CM - consistent block
ST - compression and distraction (+) if symptomatic
AM - hypomobility of 1st MTP with DF and/or sesamoid bones
what is the PT rx for ARJC at the 1st MTP
POLICED
proper footwear
AD
manual therapy
MET
what is the improtance with footwear for ARJC at the 1st MTP
prevent hallux valgus
arch support
stiffer shoe with larger toe box
rocker bottom shoe
what is the prognosis of injections for ARJC at the 1st MPT
fair quality of evidence to not use
what is morton’s neuritis/-oma
compression of interdigital nerves
acute - inflammatory = neuritis
chronic - fibrous cyst = neuroma
what is the etilogy of morton’s neuritis/-oma
excessive pronation
small toe boxes with/out high heels
limited 1st MTP extension shifts load onto lateral foot
what are the pathomechanics of morton’s neuritis/-oma
excessive pronation leading to excessive inter-metatarsal compression
what is tarsal tunnel syndrome
entrapment of tibial nerve at flexor retinaculum/medial malleolus
what is the etiology/pathomechanics of tarsal tunnel syndrome
excessive pronation leading to excessive tension and compression of tibial nerve
what is the nerve compression rx
POLICED - no C
JM/orthotics/MET to reduce compression by assisting with abnormal mechanics
MET used to create neural motion/flossing
