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MM I > Ankle & Foot > Flashcards

Ankle & Foot Flashcards

1
Q

Which 3 intrinsic mm of the foot have the same proximal attachment as the plantar fascia?

A

Flexor digitorum brevis, abductor halluces, quadratus plantae medial head

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2
Q

What are common sxs of chronic plantar heel pain?

A

Most common site of pn/sxs at medial calcaneal tuberosity

Occasionally, pn/sxs in mid-portion

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3
Q

What conditions can CPHP be linked to?

A

RA, Reiter’s syndrome, psoriatic arthritis, ankylosing spondylitis, systemic lupus erythematosus (SLE)

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4
Q

What are risk factors for CPHP?

A
  • 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
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5
Q

What are key hx findings for CPHP?

A
  • 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
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6
Q

What are specific tests/measures for CPHP?

A
  • 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)
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7
Q

What are differential diagnoses for CPHP?

A
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8
Q

What is the goal for the 1st/protected phase of rehab for acute ankle sprains? (acute)

A

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
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9
Q

What is the goal for the 2nd/Progressive loading and sensorimotor training phase of rehab for ankle sprains? (post-acute)

A

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)

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10
Q

What is happening when we manipulate the subtalar joint?

A

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

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11
Q

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

A

MT + Ex

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12
Q

(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?

A

ECCENTRIC.

(3x/wk, 6 sessions, 5x10 reps, 2 min rest (300 reps total))

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13
Q

T of F: decreased hip ABD strength increases risk of sustaining lateral ankle sprain.

A

True.

When hip abd strength was < 33.8% of weight the prob of lateral ankle sprain increased from 11.9% to 26.7%

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14
Q

How can you increase the effectiveness of cryotherapy for ankle sprains?

A
  • Elevation
  • Compression
  • Exercise (ice + ex has greater effect on reducing swelling than heat)
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15
Q

Should US be used for the management of acute ankle sprains?

A

No. (based on STRONG evidence)

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16
Q

How long should you use cryotherapy for lateral ankle sprain?

A

10-15 min max (vasoconstriction effect)

> 15 –> vasoDILATION (no bueno)

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17
Q

For the Star Excursion Balance Test, decreased distances in which directions were predictive of ankle instability?

A

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

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18
Q

T of F: decreased DF ROM increases the odds of B ankle instability?

A

True. Restoring DF ROM = really important!

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19
Q

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 ?

A

Both MWM groups.

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20
Q

What are potential benefits of DN for ankle instability?

A
  • BB players: DN to fibularis longus & tib ant improved NM control and postural control
  • Improved strength & outcomes
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21
Q

T or F: MT may impart changes in balance and proprioception for pts with CAI?

A

True.

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22
Q

Review CPG for lateral ankle sprains (acute and CAI)

A
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23
Q

What tendon is the strongest dynamic support of the medial longitudinal arch (MLA)?

A

Tibialis Posterior tendon

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24
Q

Which mm are Tom Dick & Harry and where are their tendons located?

A

Tibialis posterior
flexor Digitorum longus
flexor Hallucis longus

Located at the medial ankle, wraps posterior and inferior around the medial malleolus

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25
Q

How can excessive strain of triceps surae (gastroc + soleus) affect tibialis posterior tendon?

A

Can lead to tendinosis and eventual rupture

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26
Q

How would someone with PTTD (posterior tib tendon dysfunction) present?

A

Flat foot, everted calcaneus, with heel raises: cannot raise high, ankle stays everted

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27
Q

What are rehab management options for PTTD?

A
  • 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)
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28
Q

Why are anti-inflammatory drugs controversial for the management of tendinopathy?

A

Acute phase: is blocking acute inflammatory response helpful?
Chronic phases: no inflammatory infiltrate present

*Most important reason to use: analgesic effect

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29
Q

What management option MUST you consider if in-shoe orthoses & footwear fail to address sxs and/or deformity caused by PTTD?

A

AFO (ankle foot orthoses)

30
Q

What are some muscle strengthening considerations for PTTD?

A

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

31
Q

What is a key element of tendon training?

A

Low load, high reps!!

32
Q

In the case of a pt with achilles tendinopathy, what pathologic changes occur within the tendon?

A
  • Neovascularity
  • Tenocyte proliferation w/ tendon thickening
  • Collagen fibril thinning & disorganization
  • Altered fluid mvmt
  • Fat deposition
33
Q

What are management options for a pt with Achilles tendinopathy?

A
  • 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)
34
Q

During the acute phase of achilles tendinopathy or when pt is in-season, should you prescribe concentric, eccentric, or isometric exercises?

A

Isometric!

35
Q

T or F: Pts with achilles tendinopathy SHOULD have pain when performing ecc calf training exercises?

A

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.

36
Q

What is an exercise protocol for achilles tendinopathy?

A

Roos’ Protocol (Eccentric exercise protocol)

37
Q

What is the Roos’ Protocol?

A

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)

38
Q

Kedia et al (2014) found that for INSERTIONAL achilles tendinopathy, conventional PT or ecc exercises had better outcomes?

A

Same outcomes!

(“Conventional PT” = gastroc stretching, HS stretching, heel lifts, night splints)

39
Q

For achilles tendinopathy, how does Heavy Slow Resistance (HSR) compare to Ecc exercises in terms of outcomes?

A

Positive outcomes for both!

Beyer et al (2015): HSR better pt satisfaction after 12 wks but not 52 wks.

40
Q

T or F: There is continuous connection between the paratenon of achilles tendon and the plantar fascia

A

True!

41
Q

What are management options for a patient with CPHP?

A
  • 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)
42
Q

For pts with CPHP, what time of day would you recommend plantar specific & calf stretching?

A

Prior to getting out of bed and taking first steps since stretching can greatly dec start-up pain.

43
Q

What are 3 steps/progressions of plantar fascia specific stretching for CPHP?

A
  1. Grasp ball of foot & DF 15-20x
  2. Extend toes & DF 15-20x
  3. Maintain stretched position from above & massage fascia
44
Q

Is there a difference in the degree of pain or function improvement between pre-fabricated and custom foot orthoses for someone with CPHP?

A

NO.

45
Q

For someone with CPHP, would you recommend long-term usage of a foot orthotic?

A

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.

46
Q

What have cadaveric studies found about the potential benefits of total contact foot orthotics?

A
  • Decrease pain on plantar fascia during static loading
  • Reduce collapse of MLA
  • Prevent elongation of foot secondary to pronation
47
Q

What are MT techniques for managing a pt with CPHP?

A
  • TC ant-post mob
  • Calcaneal lat glide
  • Subtalar jt distraction manip
48
Q

T of F: Intrinsic muscle weakness has been found to be assoc with plantar heel pain

A

True

49
Q

How can you strengthen foot intrinsics? (beneficial ex for CPHP)

A
  • 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)
50
Q

Outcome Assessments for Foot & Ankle

A

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)

51
Q

What are the SINSS?

A

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)

52
Q

What is the ankle lunge test MDC?

A

1.38 cm

53
Q

What are the Ottawa Ankle Rules?

A

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

54
Q

What is the MDC for figure 8 girth measurement?

A

9.6mm (~1cm)

55
Q

Special Tests for Lateral Ankle sprains

A
  • Anterior Drawer (ATFL)
  • Reverse Anterior Drawer (ATFL)
  • Talar Tilt test (CFL)
56
Q

Special tests for High ankle sprains (injury to inferior tib-fib lig)

A
  • Kleiger test (DF + ER)
  • Squeeze test
57
Q

What is an important thing to remember to do before performing the squeeze test for a suspected high ankle sprain?

A

Palpate along whole length of fibula

58
Q

Special tests for achilles tendon rupture

A
  • Thompson test (squeeze calf)
  • Gap test
  • Matles test (Increased resting DF test)
  • All 3 combined = 100% SEN
59
Q

Special tests for Tarsal Tunnel Syndrome

A
  • Foot Eversion Dorsiflexion test (w/ or w/o tapping)
60
Q

Specific exam procedures for metatarsalgia

A
  • Palpation of metatarsal heads (usu 2nd MT head, sometimes callus)
  • Pt report of discomfort in shoes w/ a heel
61
Q

Exam for Interdigital/Morton’s Neuroma

A
  • 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
62
Q

Special tests for achilles tendinopathy

A
  • PF endurance
  • Palpation of achilles tendon (including retrocalcaneal bursa - feel squishiness on either side of tendon))
  • Arc sign
63
Q

What position is joint play assessed in?

A

Loose pack (open pack) position

64
Q

In what position do you perform grade III/IV mobilizations to increase ROM

A

As close to pt’s restriction, depending on pt pain and guarding

65
Q

What mobilizations could you do for a pt with limited DF ROM?

A

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

66
Q

What are some exercises that inc DF ROM?

A
  • Step downs
  • Kneeling lunge
  • Ankle lunge test (minus the test)
67
Q

What mobs could you do for a pt with limited PF ROM?

A

TC jt P/A mob
Distal tib-fib P/A mob
TC jt distraction mob
Subtalar joint manip

68
Q

What are some exercises that increase PF ROM?

A

Heel raises, heel raises on a downward incline

69
Q

What is a mob you could do for a pt with limited eversion at the subtalar jt?

A

Subtalar jt medial-lateral glide

70
Q

What could you do for a pt with limited MTP jt ROM?

A
  • MTP distraction mob
  • MTP A/P and P/A glides (to improve flex: Dorsal/plantar, to improve ext: plantar/dorsal)

MM I (9 decks)

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