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OCS - Current Concepts of Ortho PT > Ankle/Foot > Flashcards

Ankle/Foot Flashcards

1
Q

7 segments of the foot

A

1) Shank
2) Hindfoot
3) Lat/med midfoot
4) Lat/med forefoot
5) Hallux

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2
Q

Shank

A

Tibia/fibula

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3
Q

Hindfoot

A

Talus and calcaneous

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4
Q

Hindfoot pronation is coupled with shank or tib/fib (ER/IR)

A

IR (medial rotation)

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5
Q

Hindfoot supination is coupled with shank or tib/fib (ER/IR)

A

ER (lateral rotation)

Think “SUP-ER”

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6
Q

Primary ligaments of the subtalar jt

A

Cervical and interosseous talocalcaneal ligaments

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7
Q

TC and ST jts have oblique axes that result in a functional hinge called what?

A

Mitered hinge

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8
Q

Midfoot

A

Navicular, cuboid, 3 cuneiforms

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9
Q

Midtarsal (Chopart) jt complex (2 parts)

A

1) Medial talonavicular jt
2) Lateral calcaneocuboid jt (CCJ)

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10
Q

What midfoot motion occurs around the longitudinal axis?

A

Inversion and eversion

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11
Q

What midfoot motion occurs around the transverse axis

A

Combined PF/add and DF/abd

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12
Q

Forefoot

A

Metatarsals distally

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13
Q

Medial forefoot includes?

A

1st MT and great toe

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14
Q

Lateral forefoot includes

A

2nd-5th MT and toes

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15
Q

Muscles of the anterior compartment of the lower leg

A

1) Tibialis anterior
2) Extensor hallucis longus (EHL)
3) Extensor digitorum longus (EDL)
4) Fibularis tertius

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16
Q

Innervation of anterior compartment of the lower leg muscles

A

Deep fibular nerve

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17
Q

T/F: Anterior lower leg muscles play a role with the soleus? And if so, what do they do?

A

Modulate soleus muscle tone during walking

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18
Q

Muscles of the lateral compartment of the lower leg

A

Fibularis longus and brevis

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19
Q

Innervation of lateral compartment of the lower leg muscles

A

Superficial fibular nerve

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20
Q

Afferent input provided by what lateral compartment muscle (lower leg) is more important vs ligaments/capsule for balance?

A

Fibularis longus

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21
Q

Primary evertor of the hindfoot

A

Fibularis brevis

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22
Q

Muscles of the posterior compartment of the lower leg

A

Gastrocnemius and soleus (together = triceps surae), tibialis posterior, flexor digitorum longus (FDL)

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23
Q

Innervation of posterior compartment of the lower leg muscles

A

Tibial nerve

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24
Q

Gastrocs and soleus together are known as what?

A

Triceps Surae

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25
Q

How does the triceps surae stabilize the midfoot?

A

Working together with intrinsic muscles the triceps surae tensions the plantar fascia through the windlass mechanism

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26
Q

Plantar intrinsic foot muscles are innervated by what nerve(s)?

A

Medial and lateral plantar nerves

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27
Q

Dorsal intrinsic foot muscles are innervated by what nerve(s)?

A

Deep fibular nerve

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28
Q

Dorsal intrinsic foot muscles

A

Extensor digitorum brevis, extensor hallucis brevis, dorsal interossei

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29
Q

Plantar intrinsic foot muscles: 1st layer

A

1) Abductor hallucis
2) Flexor digitorum brevis
3) Abductor digiti minimi

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30
Q

Plantar intrinsic foot muscles: 2nd layer

A

1) Quadratus Plantus
2) Lumbricals

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31
Q

Plantar intrinsic foot muscles: 3rd layer

A

1) Adductor hallucis
2) Flexor hallucis brevis
3) Flexor digiti minimi

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32
Q

Plantar intrinsic foot muscles: 4th layer

A

1) Interossei muscles (3 total)

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33
Q

Mnemonic for muscles innervated by the medial plantar nerve

A

LAFF muscles

L: Lumbrical (1st)
A: Abductor hallucis
F: Flexor digitorum brevis
F: Flexor hallucis brevis

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34
Q

ST joint closed packed position

A

Supination

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35
Q

ST joint open packed position

A

Pronation

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36
Q

In those with diabetes, what level of monofilament should be used?

A

5.07 (10g) monofilament to screen for protective sensation on plantar surface of foot

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37
Q

DF ROM should be assessed in knee extension and knee flexion of what degree?

A

20° flexion

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38
Q

What is the NORM for SL HR?

A

25+ reps

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39
Q

T/F: Tibiopedial DF ROM measured in WB is thought to better represent ankle DF ROM vs NWB

A

True, typically measured using the weight bearing lunge test (WBLT)

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40
Q

Foot posture index (FPI-6):
-Range of scores
- + = ?
- = ?

A

-12 to +12

+ “Positive” = Pronation (think PP)
- = supination

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41
Q

FPI-6 normal score

A

0 to +4

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42
Q

Clinical measurement techniques for foot alignment

A

1) FPI-6 (best!)
2) Navicular drop
3) Navicular drift
4) Static arch index
5) Medial longitudinal arch angle
6) Dynamic arch index

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43
Q

Navicular drop (WB)

A

Standing, position foot in STJ neutral position, then relax foot and measure difference

Neutral: 6-8mm (mixed)
Pronated: >9-10mm (mixed)
Supinated: <5mm

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44
Q

Balance Error Scoring System (BESS)

A

Ways to assess SL balance

Start in narrow stance -> SLS -> tandem stance
THEN do the same thing on AIREX

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45
Q

Single Limb Balance Test (SLBT)

A

Variation of the BESS, counts errors while performing SLS w/ eyes closed, firm surface

Normal: 2-3 errors

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46
Q

T/F: SLBT is predictive of tx success for pt’s with chronic ankle instability (CAI)

A

True

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47
Q

Step-down vs SL squat for assessment of foot and ankle pathologies

A

Step-down is better because ankle motion is greater emphasized

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48
Q

Validated patient reported outcome measures for foot/ankle pathologies

A

1) PROMIS
2) Foot And Ankle Measure (FAAM)
3) LEFS

Fear-avoidance: use the Tampa scale of kinesiophobia or fear-avoidance beliefs questionnaire

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49
Q

Classification of abnormal PRONATED foot posture:
- FPI score
- Midfoot (hyper/hypomobility)
- Decreased muscle strength
- Rotated LE position

A

FPI: >4
MidFt: HYPERmobile
MMT: Post tib
Rot: Medially rotated LE

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50
Q

Classification of abnormal SUPINATED foot posture:
- FPI score
- Midfoot (hyper/hypomobility)
- Decreased muscle strength
- Rotated LE position

A

FPI: <0
MidFt: HYPOmobile
MMT: Fib long/brevis
Rot: Laterally rotated LE

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51
Q

Manual therapy for abnormal PRONATED foot posture

A

Navicular whip, Navicular PA glides, STjoint medial glide

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52
Q

Manual therapy for abnormal SUPINATED foot posture

A

Cuboid whip, Cuboid PA, Navicular AP, STJoint lateral glide

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53
Q

Most commonly affected ligament in inversion sprains?

And how common is that single ligament injured in isolation?

A

ATF

Rarely (9%) isolated

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54
Q

Athletes with CAI have persistent decreased nerve conduction velocities in what nerve?

A

Superficial fibular nerve

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55
Q

Risk factors for lateral ankle sprains

A

Female, younger age, occupation, and type of sport

Another study:
High BMI, decreased/slow eccentric INV strength, increased/fast concentric PF strength, earlier reaction time of the fib brevis muscle, impaired passive jt position sense = significant predictors of injury

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56
Q

What bone contusion is common with inversion sprains?

A

Talus contusions (44-50% all inversion sprains)

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57
Q

What % of lateral ankle sprains will turn into CAI in 1 year?

A

40%

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58
Q

Contemporary operational definition of CAI

A

At least 1 ankle sprain who have has perceived or episodic “giving way” that persists >1yr, causes resultant activity limitation

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59
Q

Prognostic risk factors for development of CAI

A

Inability to perform: 1) SL drop landing 2) Drop vertical jump (2wks post injury)

(6 months post injury)
3) decreased FAAM scores on ADLs
4) Decreased sagittal plane motion (hip/knee/ankle)
5) Decreased SEBT post reach

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60
Q

What 2 nerve injuries are common with inversion sprains?

A

Tibial nerve and superficial fibular nerve (83-85% in grade III sprains)

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61
Q

Ottawa ankle rules ->
Ankle X-ray is only required if:

A

1) There is any pain in the malleolar zone;

AND

2) Any one of the following:
- TTP distal 6 cm of the post edge of the tibia or tip of the medial malleolus
- TTP distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
- Inability to bear weight both immediately and in the emergency department for 4 steps

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62
Q

Ottawa ankle rules ->
Foot X-ray is only required if:

A

1) There is any pain in the midfoot zone;

AND

2) Any of the following:
- TTP @base of 5th metatarsal
- TTP @navicular
- Inability to bear weight both immediately and in the emergency department for 4 steps

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63
Q

T/F: Bilateral neuromotor deficits are common following ankle sprain

A

True, makes it hard to have “true baseline” on opposite limb

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64
Q

Assessment of single leg balance should use norms based on (opposite limb, population-reference norms)

A

Population reference norms > opposite limb (due to bilat deficits)

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65
Q

Use of plantar massage in CAI

A

Beneficial for CAI, used in sensory ankle rehab, can improve SLS and ADL/sports

Stimulates plantar cutaneous receptors and enhances afferent sensory information

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66
Q

Is exercise indicated for lateral ankle sprain and CAI

A

Yes (A evidence)

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67
Q

What intervention (ther-ex) has the largest effect for improving DF ROM in lateral ankle sprains?

A

Static stretching (triceps surae stretching)

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68
Q

What type of sport has a higher risk factor for lateral ankle sprain: field sport vs court sport

A

Court sport

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69
Q

What special tests are indicated in diagnosing acute lateral ankle sprain?

A

1) Reverse
anterolateral drawer test
2) Anterolateral talar palpation
IN ADDITION to
3) Traditional anterior drawer test

Grade B evidence to use special tests

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70
Q

Diagnosis and classification of CAI

A

1) Cumberland Ankle Instability Tool (≤24 = CAI)
OR
2) Identification of Functional Ankle Instability (≥11 = CAI)

ALSO
Battery
of functional performance tests

B level evidence

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71
Q

Is bracing suggested for prevention of lateral ankle injury, and/or after acute lateral ankle sprain injury, and/or for CAI?

A

ALL of the above

A level for prevention and acute management

B level evidence for CAI

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72
Q

Is manual therapy indicated for lateral ankle sprains?
- Acute
- CAI

A

Grade A for both

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73
Q

Are balance/proprioceptive interventions good at preventing ankle sprains (1st time)?

A

No

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74
Q

MOI for medial ankle sprains

A

Pronation w/ eversion/lateral rotation

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75
Q

Maisonneuve fracture

A

Fracture of the fibula ALONG with widened/unstable ankle mortise

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76
Q

Medial ankle sprain: males vs female

A

More common in males

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77
Q

Return to sport criteria for medial ankle sprains

A

Full/pain-free ROM, strength ≥80%, able to run/cut without pain or instability

Continue to use bracing

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78
Q

Special tests for medial ankle sprain

A

Ant drawer w/ lat rotation, lateral talar tilt, and Kleiger test (used for high ankle sprains)

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79
Q

When is MRI indicated in lateral ankle sprains?

A

If XR negative, but ankle instability, impingement, osteochondral lesions, or tendon injuries are suspected

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80
Q

When is XR indicated in ankle pain (negative Ottawa)?

A

When symptoms persist >6wks

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81
Q

MOI for syndesmotic sprain

A

IR of leg on fixed/DFlexed ankle

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82
Q

Syndesmotic sprains are commonly associated with (lateral/medial) ankle sprains?

A

Medial ankle sprains

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83
Q

Special tests for syndesmotic sprains

A

Kleiger test (lateral rotation w/ DF)
Squeeze test

Another study cluster:
1) TTP
2) + stress test
3) Hematoma

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84
Q

T/F: Exam of acute high ankle sprain may be inconclusive and re-exam in 3-5 days may be necessary?

A

True

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85
Q

Surgical vs non-surgical management of high ankle sprains:
Grade I
Grade II
Grade III

A

Grades I & II = non-surgical

Grade III = surgical

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86
Q

Stabilization of high-ankle sprain techniques:
Suture button vs Bioabsorbable screws

A

Suture button is typically quicker rehab but can have high rate of complications (wounds)

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87
Q

Evidence for PRP in high ankle sprains

A

2 small studies showed some improvement, still evolving

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88
Q

Recommended period of immobilization or altered WB post-high ankle sprain

A

Up to 2 wks, typically a gradual progression to FWB by day 6

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89
Q

What is the most common type of achilles tendinopathy?

A

Midportion

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90
Q

Use of fluoroquinolone can increase risk for what condition?

A

Achilles tendinopathy

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91
Q

What interventions can prevent Achilles tendinopathy in active individuals?

A

Shock absorbing insoles and participation in a proprioceptive training program

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92
Q

Are foot posture and activity level related to risk factor for achilles tendinopathy?

A

No

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93
Q

Special tests for achilles tendinopathy

A

TTP, Royal London Hospital test, and positive arc sign

C level evidence

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94
Q

Haglund deformity

A

Bony growth on calcaneous where your Achilles tendon attaches

95
Q

Symptoms of achilles tendinopathy

A

Gradual onset, localized pain and stiffness (following rest and typically improves w/ light activity), may have thickening or nodule at painful site, swelling

96
Q

If neurogenic symptoms are found when assessing for achilles tendinopathy, suspect what nerve involvement?

A

Sural nerve

97
Q

Outcomes scores to use in achilles tendinopathy

A
  • VISA-A: to assess pain and stiffness

And either:
- FAAM
or
- LEFS

Grade A evidence!!

98
Q

Tx of achilles tendinopathy:
Heavy-load/slow-speed
VS
Eccentric

A

Both show improvements, high satisfaction rate @1yr for heavy-load/slow speed

99
Q

Tx of achilles tendinopathy:
Concentric
VS
Eccentric strengthening

A

Eccentric > Concentric exercise, general ther-ex, extracorporeal shock wave therapy

100
Q

Tx of achilles tendinopathy:
Frequency of tx (2x vs 7x/wk)

101
Q

Tx of achilles tendinopathy:
Intensity (tolerance vs protocol)

102
Q

Tx of achilles tendinopathy:
Iontophoresis with dexamethasone

A

Grade B - for acute cases

103
Q

Tx of achilles tendinopathy:
Stretching

A

Grade C evidence for triceps surae tightness

104
Q

Tx of achilles tendinopathy:
Education re rest

A

Complete rest is not necessary

B level evidence

105
Q

Tx of achilles tendinopathy:
NSAIDs and cortisone injections

A

Pain relief short-term, no benefit long-term

106
Q

Sever disease

A

aka Calcaneal apophysitis

Most common heel pain in children /adolescents

Pediatric overuse

107
Q

Common demographics for severs disease

A

Young, athletic or overweight, growth spurt, recent increase in activity

Often related to new participation in running and jumping sports

108
Q

Symptoms of Sever’s disease

A

Decreased ankle DF ROM, tight calves, TTP to distal calcaneous, pain w/ PROM ankle DF

109
Q

Good way to decipher between achilles tendinopathy vs Sever’s disease

A
  • Age (achilles tendinopathy is 40-50’s, Severes is young)
  • Calcaneal squeeze test (+ severs, - achilles)
110
Q

Special tests for Sever’s disease

A

One-leg heel standing, calcaneal squeeze test, pain w/ palpation

All tests have HIGH sensitivity = good at ruling out

111
Q

Healing time-frame for Sever’s

A

2wks-2 months

Usually self-limiting

112
Q

Is imaging indicated in suspected severs disease?

113
Q

Tx for sever disease

A

Education on activity mod, calf stretching, heel cup

114
Q

Key findings with plantar fasciopathy

A

TTP: medial calcaneous tubercle, + Windlass, decreased ankle DF A/PROM, abnormal foot posture (very pronated or very supinated)

115
Q

T/F: Rotating through different pairs of shoes during the work week can help manage symptoms of plantar fasciitis?

116
Q

Achilles tendinopathy: Score on VISA-A that means a good score that could indicate d/c with HEP

A

80% = good and could progress independently

117
Q

T/F: Acute achilles tendinopathy patients can be instructed to resume sports but keep pain ≤5/10 pain level?

A

False, can do with chronic injuries NOT acute

Also note the 5/10 pain can occur during, after, and the next day

118
Q

(Forefoot/hindfoot) strike during running causes less load on achilles tendon

A

Hindfoot = less load

Also tell runners to shorten their stride

119
Q

Management of load on achilles tendon while running: short vs long stride

A

Short = less load on achilles

120
Q

Progressive collapsing foot deformity (PCFD)

A

Adult acquired flatfoot deformity (AAFD)

Leading cause of flatfoot

Due to post tib dysfunction

121
Q

Insufficiency of the post tib can lead to decreased ability to lock which joints into (pronation/supination) to create a rigid level for push-off during gait?

A

Transverse tarsal jts, supination

122
Q

+ too many toes sign

A

2+ toes showing laterally

123
Q

Exam findings for AAFD/PCFD

A

Slow, insidious onset, pain along post tib tendon (absent could be rupture), pain w/ weight bearing, may have sinus tarsi pain d/t impingment

ROM deficits, abnormal HR test, gait dysfunction,

124
Q

Intervention for AAFD/PCFD

A

Begin with: NSAIDs, immobilization (3-8wks in boot -> AFO), activity modification

Progress to:
Short foot exercises, stretching, post tib strengthening, continued orthosis use

125
Q

Medial tibial stress syndrom

A

aka Shin splints

Posteromedial tibial pain

Thought to be caused by a combo of periosteal traction and repetitive bony overload

126
Q

Prevention of MTSS

A

No known program BUT:

Shock-absorbing, neoprene, or semi-rigid orthosis MAY help prevent MTSS

127
Q

Clinical diagnosis of MTSS (3)

A

1) TTP distal 2/3rds medial tibia that is worse w/ activity and better w/ rest

2) TTP of at least 5 consecutive CM of posteromedial tibia

3) Other serious pathology is ruled out

128
Q

Symptoms of chronic exertional compartment syndrome

A

Cramping/burning in post leg, exercise-related numbness or tingling

129
Q

Tx of MTSS

A

Relative rest, graded return to PLOF, education about disorder of inadequate load management

NOTE: can have some pain (up to 2/10) w/ activity

130
Q

Contents of the tarsal tunnel (from anterior to posterior)

A

“Tom, Dick, And Nervous Harry”

  • Posterior Tibialis
  • FDL tendon
  • Post tibial artery/vein
  • Tibial nerve
  • FHL tendon
131
Q

Tarsal tunnel syndrome:
Proximal vs distal

A

Proximal: tibial nerve entrapped in tarsal tunnel

Distal: compression after tibial nerve has branched, may include 1-3 branches

132
Q

Jogger’s foot

A

Entrapment of the medial plantar nerve

Heel pain in long-distance runners

Pain w/ HR or eversion of the foot, common to have flat feet

133
Q

Baxter neuropathy

A

Entrapment of the lateral plantar nerve

Common in runners, gymnasts, dancers

Medial plantar heel pain WITHOUT sensory disturbances

+ Tinel and Trepman

134
Q

Symptoms of proximal tarsal tunnel syndrome

A
  • Poorly localized neurogenic complaints (shooting, burning, cramping, hyperesthesias, paresthesias)
  • Possible atrophy/weakness
  • Symptoms worsen as day progresses especially with walking/standing/running
  • Symptoms ease w/ rest but can have NIGHT PAIN
  • TTP
135
Q

Special tests recommended for proximal tarsal tunnel syndrome

A

Tinel, DF/EV test, Trapman test (PF/EV)

Tinel + Trapman = 93.8% ruling IN (specificity)

DF/EV tests is very sensitive

136
Q

Joggers foot vs baxters neuropathy
- Nerve
- Deficits

A

Joggers: medial plantar nerve entrapment
- PAIN + SENSORY issues

Baxters: lateral plantar nerve entrapment
- PAIN w/ first steps that doesn’t increase w/ activity

137
Q

Diagnosis of Baxter’s neuropathy should include

A

Initial dx based on hx and exam, THEN confirmed w/ electrodiagnostic studies (possible digiti minimi muscle weakness)

138
Q

Differentiation of Baxter’s nerve entrapment vs plantar fasciitis

A

Palpation: Medial calcanous (Bax), plantar fascia insertion (PF)

Pain behavior: Worsen w/ activity (Bax), get better w/ more steps (PF)

Ankle motion: Pain w/ ev/abd of ankle (Bax), DF (PF)

139
Q

Tx of proximal tarsal tunnel syndrome

A

Limited evidence

NSAIDs, activity mod, night-splinting, immobilization, PT (strengthening/stretching), corticosteroids (short-term relief), keep foot in neutral (taping or orthosis)

140
Q

Tx of distal tarsal tunnel syndrome

A

Limited evidence

Injections, footwear modification, modification or removal of rigid orthosis, NSAIDs, rest, ice, PT, taping

141
Q

Most common coalitions in the foot

A

Calcaneonavicular (CNC)

Talocalcaneal Coalition (TCC)

142
Q

Coalitions in the foot typically are (unilat/bilat)

A

Bilateral 50-80% of the time

143
Q

Exam findings with tarsal coalitions

A
  • HR test (no inv)
  • Positive Hubscher maneuver (or Jack’s test)
  • Medial long. arch sitting = standing
  • Pronated foot and everted calcaneous (rigid)
  • TTP over site of coaliation
  • Fibularis muscle spasms
144
Q

Adolescent that c/o pain in foot w/ activity, fibularis spasms, decreased ROM

A

Think tarsal coalition

145
Q

How to differentiate between tarsal coalition and flexible flat foot deformity

A

Reducible pes planus combined w/ WNL ROM = flat foot deformity

146
Q

Tx for tarsal coalition

A

Focus on reducing fibularis spasms and pain

Rest, orthotics, immobilization (3-6wks in boot), NSAIDs, PT if ankle instability

147
Q

T/F: A forceful fibularis longus contraction during inversion sprain can sublux the cuboid

A

True, plantar/medial subluxation

148
Q

Symptoms of cuboid syndrome

A
  • Lateral mid-foot pain
  • Decreased cuboid mobility (dorsilateral)
  • Dropped 4th metatarsal head w callus
  • TTP cuboid
  • Pain w/ mid-foot mobility testing
  • Antalgic gait
  • Painful and weak fibularis longus
  • Difficulty w/ HR, SL hops
149
Q

Risk factors of cuboid syndrome

A

Increased BMI, hx of lateral ankle sprain, abnormal foot posture (FPI-6)

150
Q

“Feels like there is a rock in my shoe”

A

Think cuboid syndrome

151
Q

2 diagnostic tests for cuboid syndrome (not validated)

A

1) Mid-tarsal adduction test

2) Mid-tarsal supination test

NOTE: these tests should only be used IN COMBO with pt hx and exam findings

152
Q

Jones fracture

A

Fracture of the fifth metatarsal bone

153
Q

Interventions for cuboid syndrome

A
  • Cuboid whip (pretty much only intervention w/ research)
  • Taping or orthotics post-mobs
  • Can mob 4th-5th metatarsals into PF may help restore lateral arch
  • Progressive functional WB exercises
154
Q

Insertion of fibularis longus

A

1st MT and medial cuneiform

155
Q

Insertion of fibularis brevis

156
Q

Fibularis longus works in combo with what muscle to stabilize the mid-tarsal joint?

A

Tibialis posterior

157
Q

Avascular zones of the fibularis longus tendon

A

Where it turns around the lateral malleoli and cuboid

158
Q

If swelling and TTP to fibularis tendons are seen in absence of increased activity/trauma, suspect what conditions?

A

RA or seronegative arthropathy

159
Q

Special test for assessment of fibularis brevis tears

A

Fibularis tunnel compression test (pressure over tunnel, DF/EV)

160
Q

Lisfranc articulation

A

Between tarsals and metatarsals

161
Q

Lisfranc injuries occur most frequently where?

A

@2nd metatarsal

162
Q

Lisfranc ligament connects which 2 structures?

A

2nd MT and medial cuneiform

163
Q

Lisfranc MOI

A

Ankle/foot supination on axially loaded forefoot

“Fall over a a fixed forefoot”

Common in horseback riders, windsurfers, and football

164
Q

(Eversion/inversion) sprains are associated with lisfranc injuries

165
Q

Exam findings with lisfranc injuries

A
  • Diffuse pain & swelling
  • Limited WB
  • “Pop” @injury
  • Difficulty with push-off

Gap sign, ecchymosis, painful passive mobility testing, PPT

166
Q

Gap sign

A

Observed separation between the great and second toes = lisfranc injury

167
Q

Fleck sign on XR

A

Small avulsion fragment from either: med cuneiform OR 2nd MT base

168
Q

Hallux limitus and rigidus

A

Hypomobility of 1st MTP (limitus) can turn into auto-fusion (rigidus)

Pain, swelling, osteophytes on the dorsal aspect of the jt

169
Q

Hallux limitus and rigidus MOI

A

Trauma or injury to 1st MTP jt (turf toe) or surgery

170
Q

Special test for hallux limitus and rigidus

A

1) Paper grip test
2) Windlass test
3) Axial grind test

171
Q

Staging of hallux rigidus (0-4)

A

0 = 40-60°, no pain
1 = 30-40°, osteophytes
2 = 10-30°, mild/mod jt space narrowing
3 = <10°, severe XR, mod/severe pain
4 = Siff, loose bodies or osteochondritis dessecans

172
Q

Pseudo hallux rigidus

A

1st MTP ROM limited in DF but NOT in PF

D/T: tenosynovitis of FHL

173
Q

Interventions for hallux limitus/rigidus

A

Initial tx:
Shoe mods, rest, NSAIDs, hyaluronic acid injections (for lubrication)

Long-term:
Stretching, ROM, functional exercise, manual therapy, footwear/activity modification, taping/orthosis

NOTE: overall research is limited

Manual + functional exercise = good in short-term

Manual sesamoid mobs + stretching = increased toe ROM

174
Q

Orthotics that help with hallux limitus/rigidus pain

A

1st ray cut-out, Morton extension, 2nd-5th forefoot posting

175
Q

Hallux abducto-valgus (HAV)

A

aka Bunions

Medial deviation: 1st MT
Lateral deviation: 1st hallux

Repetitive valus loading of the hallux, weakening MEDIAL capsule and causing contractures of LATERAL jt capsule and adductor tendons

176
Q

Compensated bunion

A

Mild deformity, NO 1st MTP sublux, NO sesamoid sublux

177
Q

Decompensated bunion

A

Mod/severe deformity, hallux valgus angle >25°, intermetatarsal angle >15°, lat sesamoid sublux, incongruency of 1st MTP

178
Q

Exam findings of hallux abducto-valgus (HAV)

A

Pronation, laxity w jt mobs, decreased triceps surae flexibility, TTP to jt

179
Q

Scale to evaluate severity of HAV

A

Manchester scale (4 images)

180
Q

Normal angle of the hallux valgus

Abnormal angles (mild, moderate, severe)

A

<15° = normal

15-20° = mild
20-40° = moderate
>40° = severe

181
Q

Tx for bunions

A

Manual therapy + exercise
ALSO footwear modifications, silicone toe separator, orthosis or taping

Address toe and ankle ROM and strength deficits

182
Q

Turf toe

A

Great toe extends (typically w/ foot planted) = damage to plantar aspect of the jt

183
Q

Turf toe is usually (short-lived/chronic)

A

50% becomes chronic

184
Q

Grades of turf toe (3)

A

Grade I: minimal swelling, NO ecchymosis, continue playing

Grade II: Partial tears, TTP, mod swelling/ecchymosis, limited ROM d/t pain

Grade III: complete tear of plantar plate off MT heads, severe swelling/ROM deficits/ecchymosis, unable to WB

185
Q

Turf toe: proximal migration of sesamoids is suggestive of what?

A

Capsular disruption (grade III injury)

TTP distal to sesamoids = suggest injury to plantar plate

186
Q

Tx for turf toe

A

PT (ROM, manual), rest, ice, compression, NSAIDs

Grade I & II: see above, grade II may need 2wks off

Grade III: No sports 2-6wks, pain management and immobilization in PF

187
Q

Return to sport after grade III turf toe criteria

A

Delayed for 2-6wks

  • Great toe ext to at least 60°
  • Pain-free HR
188
Q

Primary metatarsalgia cause

A

Rising from innate abnormalities in the patient’s anatomy leading to overload of the affected metatarsal

189
Q

Secondary metatarsalgia cause

A

Caused by systemic conditions such as arthritis of the MTP joint (i.e. mortons neuroma)

190
Q

Iatrogenic metatarsalgia cause

A

Can occur after (failed) reconstructive surgery

191
Q

Freiberg disease/infraction

A

Osteonecrosis of the metatarsal heads

192
Q

T/F: metatarsalgia is the most common cause of foot pain in middle-aged women

193
Q

Exam findings of metatarsalgia

A

Gradual onset diffuse pain in forefoot, worse w/ activity or barefoot walking, calluses, and/or hyperext of 1st IP jt, MTP jt instability (dorsoplantar drawer (lachmans) test), gait changes

194
Q

Key of rehab for metatarsalgia

A

Restoration of natural arches and foot stability

195
Q

Interventions for metatarsalgia

A

Orthosis (redistributes plantar pressures/reduces pain), metatarsal pad (just prox to MTP), rocker bars, taping (2nd toe in slight PF), stiff soled shoe

196
Q

Evidence for manual therapy in tx of metatarsalgia

A

Limited

Initially can use dorsal MTP jt capsule stretches and calf stretching - can be helpful
Also STM for tendon gliding

197
Q

Evidence for exercise in management of metatarsalgia

A

Limited

Focus on optimizing biomechanics of the foot/ankle

Short-foot and toe flexor strengthening MAY improve forefoot pressure

198
Q

Interdigital neuroma

A

aka Morton Neuroma
- benign enlargement
- mechanical entrapment neuropathy of interdigital nerve

199
Q

Most common location of Morton neuroma

A

Between 3rd-4th MT heads
- Medial plantar nerve (3rd common digital branch)

2nd branch is next most common

200
Q

Primary risk factors for development of interdigital neuroma

A
  • Foot type and abnormal mechanics d/t narrow shoes
  • Training techniques/overuse
  • Gait

Also: female, runners, dancers

201
Q

Signs of interdigital neuroma

A
  • Insidious onset of pain in plantar forefoot
  • Sharp/shooting/burning pain (worse during or after activity, better w/ rest)
  • Cramping
  • Numbness/tingling in toes
  • Feels like walking on lump

Can be dull ache
ALSO can have pain @ rest or at night (venous stasis/engorgement)

202
Q

Exam findings for interdigital neuroma

A
  • TTP in affected web space (plantar and between MT’s)
  • Pain w/ manual compression of transverse arch
  • Pain w/ ext of MTP
  • Sensory changes in affected web space
  • Visual separation of toes/MT’s (indicating instability)
  • Weakness of intrinsics
203
Q

Special tests for interdigital neuroma

A

1) Mulder maneuver (forefoot squeeze and push on interspace)

2) Plantar percussion test (aka Tinel, tapping along course of nerve)

3) Modified digital nerve stretch test (extend all MTP’s in combo w/ DF and EV)

204
Q

T/F: Pain relief following an injection of anesthetic just prox to MT head and plantar to the inter-metatarsal ligament is diagnostic interdigital neuroma

205
Q

Imaging to rule IN interdigital neuroma

206
Q

Management of interdigital neuroma

A

Education, activity mod, NSAIDs, shoe mods (rocker-bottom shoes, wide toe box, custom orthosis, MT head unloading w/ MT pad)

207
Q

Use of manual therapy for tx of interdigital neuroma

A

Limited studies, one used cuboid whip and grade IV mid-foot mobs

208
Q

Use of steroid injections in management of interdigital neuroma

A

Widely used and shown to be helpful for pain management

209
Q

Hallux sesamoid syndrome

A

Pain in the ball of the foot
- Nonspecific description of pathologies, anatomical anomalies, or adaptive changes of the sesamoid bones

210
Q

Sesamoiditis

A

Pain in WB, with palpation, or with PROM ext of 1st MTP jt

211
Q

Which sesamoid bone in the foot is larger? Which one is more likely to sustain a stress fx?

A

Both medial

212
Q

What muscle does the sesamoid bones in the foot lie within

213
Q

What 2 muscles other than FHBrevis attach to the sesamoids?

A

Adductor and abductor hallucis

214
Q

Key exam findings with sesamoiditis

A

Forefoot swelling, TTP, decreased 1st MTP ext, decreased MMT FHL and FHB, impaired 1st ray and/or 1st MTP jt

215
Q

Tx for sesamoiditis

A

Taping, shoe mod, orthosis, manual jt mobs, exercise (strengthening FHL), stretching (FHL, dorsal MTP capsules, triceps surae)

216
Q

Use of corticosteroids in sesamoiditis

A

Not indicated

217
Q

Knot of Henry

A

Where the FHL tendon goes UNDER The FDL tendon

218
Q

Key findings for FHL tendinopathy

A
  • Crepitus with FHL palpation and testing
  • Pseudo hallux rigidus
  • FHL stretch test (+ for MTP pain or 1st MTP ext <20°)
  • FHL resistance for pain (+ if no pain w/ ankle PF)

C/O: pain behind med malleoli/subtalar jt region and/or medial arch, mild swelling and TTP @knot of Henry/between sesamoids

219
Q

Demographics for FHL tendinopathy

A

Tennis players, ballerinas, those who move into extreme equinus positions

220
Q

If undergoing a surgical tenolysis of the FHL tendon, what is an important possible complication?

A

Damage to the medial branch of the tibial nerve

221
Q

Tx of FHL tendinopathy

A

Stretching, exercise, manual tx, taping (stab sub-talar jt and arch)

222
Q

Who is at risk of a LE stress fx?

A

Sudden inappropriate increase in activity, athletes (runners), and military

223
Q

Most common stress fx?

A

1 = Tibia

NOTE: 2nd-3rd metatarsals are also common

224
Q

Risk factors for stress fx’s

A

Intrinsic:
LLD, abnormal supination & pronation (supination higher), poor pre-participation condition, older age, female, caucasian, poor bone density, hormonal/menstrual abnormalities, low calorie/fat diet, inadequate sleep pattern, collagen diseases

Extrinsic:
Shoes, training surface, intensity of training, environment

225
Q

Tx for low risk stress fx’s

A

Activity modification, normal WB

226
Q

Tx for high risk stress fx’s

A

Restrictive WB, partial immobilization, may progress to surgery if issues

227
Q

Recommended rest time for stress fractures (diagnosed via MRI) grades 1-4

A

1) 3wks
2) 3-6wks
3) 12-16wks
4) 16+

228
Q

First imaging of choice for suspect stress fx’s

229
Q

If XR are - for fx, but exam is consistent with a stress fracture at a LOW risk site, what is your next action?

A

Treated w/ activity mod and correction of risk factors for 2-3wks

230
Q

When is MRI appropriate for stress fracture diagnosis

A

High-level athletes, high risk site (navicular, 5th MT, med malleoli, sesamoids, and talus)

OR if symptoms persist after 3wks of tx in those with potential stress fx at LOW risk site.

231
Q

Low risk fx sites in LE

A

Post/med distal tibia, 2nd-3rd MT, calcaneus, and fibula

232
Q

Return to sport after stress fx

A

After pain-free for 10-14 days:
10% increase in training intensity per/wk

OCS - Current Concepts of Ortho PT (12 decks)

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