Ankle & Foot Flashcards
Which 3 intrinsic mm of the foot have the same proximal attachment as the plantar fascia?
Flexor digitorum brevis, abductor halluces, quadratus plantae medial head
What are common sxs of chronic plantar heel pain?
Most common site of pn/sxs at medial calcaneal tuberosity
Occasionally, pn/sxs in mid-portion
What conditions can CPHP be linked to?
RA, Reiter’s syndrome, psoriatic arthritis, ankylosing spondylitis, systemic lupus erythematosus (SLE)
What are risk factors for CPHP?
- Mod assoc w/ BMI in non-athletic pop
- Mod assoc w/: inc age, dec ankle DF, dec 1st MTP ext,, prolonged standing, running
- Weak assoc w/: fat pad atrophy & abnormal FPI score
What are key hx findings for CPHP?
- Insidious onset of pn w/ WBing after period of non-WBing
- Start-up pain: most noticeable w/ 1st step in morning or after inactivity
- Pn often dec w/ activity
- May or may not have antalgic gait (may WB on lateral border of foot)
- Hx may indicate recent change in level of activity
- Sharp, localized pn at medial calcaneal tuberosity (anteromedial aspect of calc)
- Paresthesia = uncommon
What are specific tests/measures for CPHP?
- LEFS and FAAM
- Palpation: medial calc tuberosity
- Active talocrural (ankle) jt ROM (test w/ knee ext - gastroc, test w/ knee flexed - soleus)
- Windlass test (low sensitivity)
What are differential diagnoses for CPHP?
What is the goal for the 1st/protected phase of rehab for acute ankle sprains? (acute)
Control pain and edema/swelling
- MT = effective for improving outcomes, dec pn, restoring mobility
- Normalize gait patterns
- Ther ex should include balance training
- Hip strengthening as appropriate
What is the goal for the 2nd/Progressive loading and sensorimotor training phase of rehab for ankle sprains? (post-acute)
Address instability, weakness, intermittent edema, ROM limitations (safe to work DF early on!)
-Functional WBing activities, progress to single limb (and unstable surfaces), progress to perturbations (UE & LE)
-Sports activity training: cutting, jumping, 1 leg single hip for distance, 1 leg triple hip for distance, etc)
What is happening when we manipulate the subtalar joint?
Neurophysiological effects. A study found that it can modify the pattern of load support at the foot & it exerts proprioceptive effects (Lopez-Rodriguez, 2007) Manips can also have effects on soft tissue structures
Which group made statistically sig improvements in FAAM, LEFS, and Pain at 4 wks and 6 mo post inv ankle sprain: 1) MT + Ex or 2) HEP
MT + Ex
(Collado 2010) For pts post lateral ankle sprain, with pain-free active eversion and passive inversion, did ECCENTRIC or CONCENTRIC bias exercise restore normal fibularis strength?
ECCENTRIC.
(3x/wk, 6 sessions, 5x10 reps, 2 min rest (300 reps total))
T of F: decreased hip ABD strength increases risk of sustaining lateral ankle sprain.
True.
When hip abd strength was < 33.8% of weight the prob of lateral ankle sprain increased from 11.9% to 26.7%
How can you increase the effectiveness of cryotherapy for ankle sprains?
- Elevation
- Compression
- Exercise (ice + ex has greater effect on reducing swelling than heat)
Should US be used for the management of acute ankle sprains?
No. (based on STRONG evidence)
How long should you use cryotherapy for lateral ankle sprain?
10-15 min max (vasoconstriction effect)
> 15 –> vasoDILATION (no bueno)
For the Star Excursion Balance Test, decreased distances in which directions were predictive of ankle instability?
Anterior & Posterior Medial
Notes:
- Dec ant reach >4 cm = 2.5x more likely to sustain LE injury
- Post-Med distance of 77.5% or less of leg length = 4x more likely to sustain ankle sprain
T of F: decreased DF ROM increases the odds of B ankle instability?
True. Restoring DF ROM = really important!
In a study by Vicenzino (2006), which groups resulted in improvements with posterior talar glide and DF ROM for pts with recurrent ankle sprains: no tx, WB MWM, Non-WB MWM ?
Both MWM groups.
What are potential benefits of DN for ankle instability?
- BB players: DN to fibularis longus & tib ant improved NM control and postural control
- Improved strength & outcomes
T or F: MT may impart changes in balance and proprioception for pts with CAI?
True.
Review CPG for lateral ankle sprains (acute and CAI)
What tendon is the strongest dynamic support of the medial longitudinal arch (MLA)?
Tibialis Posterior tendon
Which mm are Tom Dick & Harry and where are their tendons located?
Tibialis posterior
flexor Digitorum longus
flexor Hallucis longus
Located at the medial ankle, wraps posterior and inferior around the medial malleolus
How can excessive strain of triceps surae (gastroc + soleus) affect tibialis posterior tendon?
Can lead to tendinosis and eventual rupture
How would someone with PTTD (posterior tib tendon dysfunction) present?
Flat foot, everted calcaneus, with heel raises: cannot raise high, ankle stays everted
What are rehab management options for PTTD?
- Anti-inflammatory drugs….controversial
- Cryotherapy (to reduce inflammation if tenosynovitis - BUT, could be contraindicated if tendinosis bc linked to vascular insufficiency)
- Orthotics & Footwear (supports medial arch to dec stress on tendon)
- Weight loss (obesity can lead to abnormal pronation which is a predisposing factor of PTTD)
- If lim DF ROM, stretching of gastroc + sol when acute sxs reside (MUST support arch or else post tib will be overworked)
-Strengthening of anterior tib/ fibularis/ post tib/ gastroc (low load, high reps)
Why are anti-inflammatory drugs controversial for the management of tendinopathy?
Acute phase: is blocking acute inflammatory response helpful?
Chronic phases: no inflammatory infiltrate present
*Most important reason to use: analgesic effect
What management option MUST you consider if in-shoe orthoses & footwear fail to address sxs and/or deformity caused by PTTD?
AFO (ankle foot orthoses)
What are some muscle strengthening considerations for PTTD?
For post tib:
- begin once pn, tenderness, and swelling subside
- Theraband (ecc and conc) foot add exercises
- If pt has pes planus, need orthoses/footwear when performing exercises
- Heel raises: focus on ecc (like Achilles tendinopathy protocol)
Strengthen peri-ankle mm: tib ant, toe extensors, fib longus/brevis
What is a key element of tendon training?
Low load, high reps!!
In the case of a pt with achilles tendinopathy, what pathologic changes occur within the tendon?
- Neovascularity
- Tenocyte proliferation w/ tendon thickening
- Collagen fibril thinning & disorganization
- Altered fluid mvmt
- Fat deposition
What are management options for a pt with Achilles tendinopathy?
- Modification of training (active rest…stationary bike, running in deep pool etc)
- Soft tissue mobilization
- Calf & LE strengthening (prox hip)
- Calf stretching (w/ arch support!)
- Foot orthotics ?? (if excessive rearfoot mvmt)
- Isometric ex (during acute phase OR in-season)
- Ecc calf training (limit concentric)
- MT of TC jt and subtalar jt (expert opinion)
During the acute phase of achilles tendinopathy or when pt is in-season, should you prescribe concentric, eccentric, or isometric exercises?
Isometric!
T or F: Pts with achilles tendinopathy SHOULD have pain when performing ecc calf training exercises?
TRUE! The load should be inc until pn is present (~4-5/10 pn pain scale). If pain doesn’t dec within 1 hour, modify.
What is an exercise protocol for achilles tendinopathy?
Roos’ Protocol (Eccentric exercise protocol)
What is the Roos’ Protocol?
Eccentric exercise protocol for achilles tendinopathy
Gist: 3x15 w/ knee bent & straight, 2x/day, 12 wks
1st week (STRAIGHT knee only):
- 1-2 (1x15)
- 3-4 (2x15)
- 5-7 (3x15)
- Note: heel only comes to GROUND, not below edge of step! (can go below horizontal in later stages)
Kedia et al (2014) found that for INSERTIONAL achilles tendinopathy, conventional PT or ecc exercises had better outcomes?
Same outcomes!
(“Conventional PT” = gastroc stretching, HS stretching, heel lifts, night splints)
For achilles tendinopathy, how does Heavy Slow Resistance (HSR) compare to Ecc exercises in terms of outcomes?
Positive outcomes for both!
Beyer et al (2015): HSR better pt satisfaction after 12 wks but not 52 wks.
T or F: There is continuous connection between the paratenon of achilles tendon and the plantar fascia
True!
What are management options for a patient with CPHP?
- Plantar fascia specific & calf stretching (short term 2-4 mo pain relief and inc calf flexibility)
- Foot orthotics (short-term 3 mo pain relief)
- Iontophoresis: Dexamethasone 0.4% or acetic acid 5% (for “itis” stage) - short term pn relief (2-4 mo)
- Manual therapy (jt and STM)
- Night splints (sxs > 6 mo) - use for 1-3 mo
- DN gastroc and soleus (mod-low evidence)
For pts with CPHP, what time of day would you recommend plantar specific & calf stretching?
Prior to getting out of bed and taking first steps since stretching can greatly dec start-up pain.
What are 3 steps/progressions of plantar fascia specific stretching for CPHP?
- Grasp ball of foot & DF 15-20x
- Extend toes & DF 15-20x
- Maintain stretched position from above & massage fascia
Is there a difference in the degree of pain or function improvement between pre-fabricated and custom foot orthoses for someone with CPHP?
NO.
For someone with CPHP, would you recommend long-term usage of a foot orthotic?
There is no evidence to support the use of orthotic for long term (>1 yr) pain or function improvement. But they CAN provide SHORT-term (3 mo) pain relief.
What have cadaveric studies found about the potential benefits of total contact foot orthotics?
- Decrease pain on plantar fascia during static loading
- Reduce collapse of MLA
- Prevent elongation of foot secondary to pronation
What are MT techniques for managing a pt with CPHP?
- TC ant-post mob
- Calcaneal lat glide
- Subtalar jt distraction manip
T of F: Intrinsic muscle weakness has been found to be assoc with plantar heel pain
True
How can you strengthen foot intrinsics? (beneficial ex for CPHP)
- Short foot exercise (bring head of 1st MTP toward heel w/o flexing toes) (3x5)
- TB toe curling
- DL and SL standing (SL has > intrinsic activation)
Outcome Assessments for Foot & Ankle
Foot & Ankle Ability Measure (FAAM)
- MCID: 8 (ADL), 9 (Sports)
LEFS (Lower extremity functional scale)
- MCID: 9 pts
PROMIS CAT
FABQ (fear avoidance beliefs questionnaire)
TSK (tampa scale of kinesiophobia)
What are the SINSS?
Severity - intensity of sxs
Irritability - ease in which sxs are produced & time it takes to dec
Nature - type & extent/degree of injury/condition
Stage - acute, post-acute, chronic
Stability - how are sxs changing (better, same, worse)
What is the ankle lunge test MDC?
1.38 cm
What are the Ottawa Ankle Rules?
Clinical Prediction Rule to determine when to order X-rays
If bone tenderness at any of the below:
- post edge or tip of lat malleolus
- post edge or tip of med malleolus
- base of 5th met
- navicular bone
- cannot bear weight 4 steps immediately after injury or during exm
What is the MDC for figure 8 girth measurement?
9.6mm (~1cm)
Special Tests for Lateral Ankle sprains
- Anterior Drawer (ATFL)
- Reverse Anterior Drawer (ATFL)
- Talar Tilt test (CFL)
Special tests for High ankle sprains (injury to inferior tib-fib lig)
- Kleiger test (DF + ER)
- Squeeze test
What is an important thing to remember to do before performing the squeeze test for a suspected high ankle sprain?
Palpate along whole length of fibula
Special tests for achilles tendon rupture
- Thompson test (squeeze calf)
- Gap test
- Matles test (Increased resting DF test)
- All 3 combined = 100% SEN
Special tests for Tarsal Tunnel Syndrome
- Foot Eversion Dorsiflexion test (w/ or w/o tapping)
Specific exam procedures for metatarsalgia
- Palpation of metatarsal heads (usu 2nd MT head, sometimes callus)
- Pt report of discomfort in shoes w/ a heel
Exam for Interdigital/Morton’s Neuroma
- Palpation of interdigital space (btwn heads of MTs)
- if reproduction of sxs (burning, tingling, feels like sock is wrinkled, or stepping on pebble)
- Report of discomfort with shoes w/ tight toe box
Special tests for achilles tendinopathy
- PF endurance
- Palpation of achilles tendon (including retrocalcaneal bursa - feel squishiness on either side of tendon))
- Arc sign
What position is joint play assessed in?
Loose pack (open pack) position
In what position do you perform grade III/IV mobilizations to increase ROM
As close to pt’s restriction, depending on pt pain and guarding
What mobilizations could you do for a pt with limited DF ROM?
TC jt A/P mob, grade III/IV
Distal tib-fib A/P mob, grade III/IV
TC jt distraction mob (for DF and general mobility)
TN jt mob (for DF and general mobility)
Subtalar jt manip
What are some exercises that inc DF ROM?
- Step downs
- Kneeling lunge
- Ankle lunge test (minus the test)
What mobs could you do for a pt with limited PF ROM?
TC jt P/A mob
Distal tib-fib P/A mob
TC jt distraction mob
Subtalar joint manip
What are some exercises that increase PF ROM?
Heel raises, heel raises on a downward incline
What is a mob you could do for a pt with limited eversion at the subtalar jt?
Subtalar jt medial-lateral glide
What could you do for a pt with limited MTP jt ROM?
- MTP distraction mob
- MTP A/P and P/A glides (to improve flex: Dorsal/plantar, to improve ext: plantar/dorsal)
