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
2
Q
Shank
A
Tibia/fibula
3
Q
Hindfoot
A
Talus and calcaneous
4
Q
Hindfoot pronation is coupled with shank or tib/fib (ER/IR)
A
IR (medial rotation)
5
Q
Hindfoot supination is coupled with shank or tib/fib (ER/IR)
A
ER (lateral rotation)
Think “SUP-ER”
6
Q
Primary ligaments of the subtalar jt
A
Cervical and interosseous talocalcaneal ligaments
7
Q
TC and ST jts have oblique axes that result in a functional hinge called what?
A
Mitered hinge
8
Q
Midfoot
A
Navicular, cuboid, 3 cuneiforms
9
Q
Midtarsal (Chopart) jt complex (2 parts)
A
1) Medial talonavicular jt
2) Lateral calcaneocuboid jt (CCJ)
10
Q
What midfoot motion occurs around the longitudinal axis?
A
Inversion and eversion
11
Q
What midfoot motion occurs around the transverse axis
A
Combined PF/add and DF/abd
12
Q
Forefoot
A
Metatarsals distally
13
Q
Medial forefoot includes?
A
1st MT and great toe
14
Q
Lateral forefoot includes
A
2nd-5th MT and toes
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
16
Q
Innervation of anterior compartment of the lower leg muscles
A
Deep fibular nerve
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
18
Q
Muscles of the lateral compartment of the lower leg
A
Fibularis longus and brevis
19
Q
Innervation of lateral compartment of the lower leg muscles
A
Superficial fibular nerve
20
Q
Afferent input provided by what lateral compartment muscle (lower leg) is more important vs ligaments/capsule for balance?
A
Fibularis longus
21
Q
Primary evertor of the hindfoot
A
Fibularis brevis
22
Q
Muscles of the posterior compartment of the lower leg
A
Gastrocnemius and soleus (together = triceps surae), tibialis posterior, flexor digitorum longus (FDL)
23
Q
Innervation of posterior compartment of the lower leg muscles
A
Tibial nerve
24
Q
Gastrocs and soleus together are known as what?
A
Triceps Surae
25
How does the triceps surae stabilize the midfoot?
Working together with intrinsic muscles the triceps surae tensions the plantar fascia through the windlass mechanism
26
Plantar intrinsic foot muscles are innervated by what nerve(s)?
Medial and lateral plantar nerves
27
Dorsal intrinsic foot muscles are innervated by what nerve(s)?
Deep fibular nerve
28
Dorsal intrinsic foot muscles
Extensor digitorum brevis, extensor hallucis brevis, dorsal interossei
29
Plantar intrinsic foot muscles: 1st layer
1) Abductor hallucis
2) Flexor digitorum brevis
3) Abductor digiti minimi
30
Plantar intrinsic foot muscles: 2nd layer
1) Quadratus Plantus
2) Lumbricals
31
Plantar intrinsic foot muscles: 3rd layer
1) Adductor hallucis
2) Flexor hallucis brevis
3) Flexor digiti minimi
32
Plantar intrinsic foot muscles: 4th layer
1) Interossei muscles (3 total)
33
Mnemonic for muscles innervated by the medial plantar nerve
LAFF muscles
L: Lumbrical (1st)
A: Abductor hallucis
F: Flexor digitorum brevis
F: Flexor hallucis brevis
34
ST joint closed packed position
Supination
35
ST joint open packed position
Pronation
36
In those with diabetes, what level of monofilament should be used?
5.07 (10g) monofilament to screen for protective sensation on plantar surface of foot
37
DF ROM should be assessed in knee extension and knee flexion of what degree?
20° flexion
38
What is the NORM for SL HR?
25+ reps
39
T/F: Tibiopedial DF ROM measured in WB is thought to better represent ankle DF ROM vs NWB
True, typically measured using the weight bearing lunge test (WBLT)
40
Foot posture index (FPI-6):
-Range of scores
- + = ?
- = ?
-12 to +12
+ "Positive" = Pronation (think PP)
- = supination
41
FPI-6 normal score
0 to +4
42
Clinical measurement techniques for foot alignment
1) FPI-6 (best!)
2) Navicular drop
3) Navicular drift
4) Static arch index
5) Medial longitudinal arch angle
6) Dynamic arch index
43
Navicular drop (WB)
Standing, position foot in STJ neutral position, then relax foot and measure difference
Neutral: 6-8mm (mixed)
Pronated: >9-10mm (mixed)
Supinated: <5mm
44
Balance Error Scoring System (BESS)
Ways to assess SL balance
Start in narrow stance -> SLS -> tandem stance
THEN do the same thing on AIREX
45
Single Limb Balance Test (SLBT)
Variation of the BESS, counts errors while performing SLS w/ eyes closed, firm surface
Normal: 2-3 errors
46
T/F: SLBT is predictive of tx success for pt's with chronic ankle instability (CAI)
True
47
Step-down vs SL squat for assessment of foot and ankle pathologies
Step-down is better because ankle motion is greater emphasized
48
Validated patient reported outcome measures for foot/ankle pathologies
1) PROMIS
2) Foot And Ankle Measure (FAAM)
3) LEFS
Fear-avoidance: use the Tampa scale of kinesiophobia or fear-avoidance beliefs questionnaire
49
Classification of abnormal PRONATED foot posture:
- FPI score
- Midfoot (hyper/hypomobility)
- Decreased muscle strength
- Rotated LE position
FPI: >4
MidFt: HYPERmobile
MMT: Post tib
Rot: Medially rotated LE
50
Classification of abnormal SUPINATED foot posture:
- FPI score
- Midfoot (hyper/hypomobility)
- Decreased muscle strength
- Rotated LE position
FPI: <0
MidFt: HYPOmobile
MMT: Fib long/brevis
Rot: Laterally rotated LE
51
Manual therapy for abnormal PRONATED foot posture
Navicular whip, Navicular PA glides, STjoint medial glide
52
Manual therapy for abnormal SUPINATED foot posture
Cuboid whip, Cuboid PA, Navicular AP, STJoint lateral glide
53
Most commonly affected ligament in inversion sprains?
And how common is that single ligament injured in isolation?
ATF
Rarely (9%) isolated
54
Athletes with CAI have persistent decreased nerve conduction velocities in what nerve?
Superficial fibular nerve
55
Risk factors for lateral ankle sprains
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
56
What bone contusion is common with inversion sprains?
Talus contusions (44-50% all inversion sprains)
57
What % of lateral ankle sprains will turn into CAI in 1 year?
40%
58
Contemporary operational definition of CAI
At least 1 ankle sprain who have has perceived or episodic "giving way" that persists >1yr, causes resultant activity limitation
59
Prognostic risk factors for development of CAI
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
60
What 2 nerve injuries are common with inversion sprains?
Tibial nerve and superficial fibular nerve (83-85% in grade III sprains)
61
Ottawa ankle rules ->
Ankle X-ray is only required if:
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
62
Ottawa ankle rules ->
Foot X-ray is only required if:
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
63
T/F: Bilateral neuromotor deficits are common following ankle sprain
True, makes it hard to have "true baseline" on opposite limb
64
Assessment of single leg balance should use norms based on (opposite limb, population-reference norms)
Population reference norms > opposite limb (due to bilat deficits)
65
Use of plantar massage in CAI
Beneficial for CAI, used in sensory ankle rehab, can improve SLS and ADL/sports
Stimulates plantar cutaneous receptors and enhances afferent sensory information
66
Is exercise indicated for lateral ankle sprain and CAI
Yes (A evidence)
67
What intervention (ther-ex) has the largest effect for improving DF ROM in lateral ankle sprains?
Static stretching (triceps surae stretching)
68
What type of sport has a higher risk factor for lateral ankle sprain: field sport vs court sport
Court sport
69
What special tests are indicated in diagnosing acute lateral ankle sprain?
1) Reverse
anterolateral drawer test
2) Anterolateral talar palpation
IN ADDITION to
3) Traditional anterior drawer test
Grade B evidence to use special tests
70
Diagnosis and classification of CAI
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
71
Is bracing suggested for prevention of lateral ankle injury, and/or after acute lateral ankle sprain injury, and/or for CAI?
ALL of the above
A level for prevention and acute management
B level evidence for CAI
72
Is manual therapy indicated for lateral ankle sprains?
- Acute
- CAI
Grade A for both
73
Are balance/proprioceptive interventions good at preventing ankle sprains (1st time)?
No
74
MOI for medial ankle sprains
Pronation w/ eversion/lateral rotation
75
Maisonneuve fracture
Fracture of the fibula ALONG with widened/unstable ankle mortise
76
Medial ankle sprain: males vs female
More common in males
77
Return to sport criteria for medial ankle sprains
Full/pain-free ROM, strength ≥80%, able to run/cut without pain or instability
Continue to use bracing
78
Special tests for medial ankle sprain
Ant drawer w/ lat rotation, lateral talar tilt, and Kleiger test (used for high ankle sprains)
79
When is MRI indicated in lateral ankle sprains?
If XR negative, but ankle instability, impingement, osteochondral lesions, or tendon injuries are suspected
80
When is XR indicated in ankle pain (negative Ottawa)?
When symptoms persist >6wks
81
MOI for syndesmotic sprain
IR of leg on fixed/DFlexed ankle
82
Syndesmotic sprains are commonly associated with (lateral/medial) ankle sprains?
Medial ankle sprains
83
Special tests for syndesmotic sprains
Kleiger test (lateral rotation w/ DF)
Squeeze test
Another study cluster:
1) TTP
2) + stress test
3) Hematoma
84
T/F: Exam of acute high ankle sprain may be inconclusive and re-exam in 3-5 days may be necessary?
True
85
Surgical vs non-surgical management of high ankle sprains:
Grade I
Grade II
Grade III
Grades I & II = non-surgical
Grade III = surgical
86
Stabilization of high-ankle sprain techniques:
Suture button vs Bioabsorbable screws
Suture button is typically quicker rehab but can have high rate of complications (wounds)
87
Evidence for PRP in high ankle sprains
2 small studies showed some improvement, still evolving
88
Recommended period of immobilization or altered WB post-high ankle sprain
Up to 2 wks, typically a gradual progression to FWB by day 6
89
What is the most common type of achilles tendinopathy?
Midportion
90
Use of fluoroquinolone can increase risk for what condition?
Achilles tendinopathy
91
What interventions can prevent Achilles tendinopathy in active individuals?
Shock absorbing insoles and participation in a proprioceptive training program
92
Are foot posture and activity level related to risk factor for achilles tendinopathy?
No
93
Special tests for achilles tendinopathy
TTP, Royal London Hospital test, and positive arc sign
C level evidence
94
Haglund deformity
Bony growth on calcaneous where your Achilles tendon attaches
95
Symptoms of achilles tendinopathy
Gradual onset, localized pain and stiffness (following rest and typically improves w/ light activity), may have thickening or nodule at painful site, swelling
96
If neurogenic symptoms are found when assessing for achilles tendinopathy, suspect what nerve involvement?
Sural nerve
97
Outcomes scores to use in achilles tendinopathy
- VISA-A: to assess pain and stiffness
And either:
- FAAM
or
- LEFS
Grade A evidence!!
98
Tx of achilles tendinopathy:
Heavy-load/slow-speed
VS
Eccentric
Both show improvements, high satisfaction rate @1yr for heavy-load/slow speed
99
Tx of achilles tendinopathy:
Concentric
VS
Eccentric strengthening
Eccentric > Concentric exercise, general ther-ex, extracorporeal shock wave therapy
100
Tx of achilles tendinopathy:
Frequency of tx (2x vs 7x/wk)
Same
101
Tx of achilles tendinopathy:
Intensity (tolerance vs protocol)
Same
102
Tx of achilles tendinopathy:
Iontophoresis with dexamethasone
Grade B - for acute cases
103
Tx of achilles tendinopathy:
Stretching
Grade C evidence for triceps surae tightness
104
Tx of achilles tendinopathy:
Education re rest
Complete rest is not necessary
B level evidence
105
Tx of achilles tendinopathy:
NSAIDs and cortisone injections
Pain relief short-term, no benefit long-term
106
Sever disease
aka Calcaneal apophysitis
Most common heel pain in children /adolescents
Pediatric overuse
107
Common demographics for severs disease
Young, athletic or overweight, growth spurt, recent increase in activity
Often related to new participation in running and jumping sports
108
Symptoms of Sever's disease
Decreased ankle DF ROM, tight calves, TTP to distal calcaneous, pain w/ PROM ankle DF
109
Good way to decipher between achilles tendinopathy vs Sever's disease
- Age (achilles tendinopathy is 40-50's, Severes is young)
- Calcaneal squeeze test (+ severs, - achilles)
110
Special tests for Sever's disease
One-leg heel standing, calcaneal squeeze test, pain w/ palpation
All tests have HIGH sensitivity = good at ruling out
111
Healing time-frame for Sever's
2wks-2 months
Usually self-limiting
112
Is imaging indicated in suspected severs disease?
No
113
Tx for sever disease
Education on activity mod, calf stretching, heel cup
114
Key findings with plantar fasciopathy
TTP: medial calcaneous tubercle, + Windlass, decreased ankle DF A/PROM, abnormal foot posture (very pronated or very supinated)
115
T/F: Rotating through different pairs of shoes during the work week can help manage symptoms of plantar fasciitis?
True
116
Achilles tendinopathy: Score on VISA-A that means a good score that could indicate d/c with HEP
80% = good and could progress independently
117
T/F: Acute achilles tendinopathy patients can be instructed to resume sports but keep pain ≤5/10 pain level?
False, can do with chronic injuries NOT acute
Also note the 5/10 pain can occur during, after, and the next day
118
(Forefoot/hindfoot) strike during running causes less load on achilles tendon
Hindfoot = less load
Also tell runners to shorten their stride
119
Management of load on achilles tendon while running: short vs long stride
Short = less load on achilles
120
Progressive collapsing foot deformity (PCFD)
Adult acquired flatfoot deformity (AAFD)
Leading cause of flatfoot
Due to post tib dysfunction
121
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?
Transverse tarsal jts, supination
122
+ too many toes sign
2+ toes showing laterally
123
Exam findings for AAFD/PCFD
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
Intervention for AAFD/PCFD
Begin with: NSAIDs, immobilization (3-8wks in boot -> AFO), activity modification
Progress to:
Short foot exercises, stretching, post tib strengthening, continued orthosis use
125
Medial tibial stress syndrom
aka Shin splints
Posteromedial tibial pain
Thought to be caused by a combo of periosteal traction and repetitive bony overload
126
Prevention of MTSS
No known program BUT:
Shock-absorbing, neoprene, or semi-rigid orthosis MAY help prevent MTSS
127
Clinical diagnosis of MTSS (3)
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
Symptoms of chronic exertional compartment syndrome
Cramping/burning in post leg, exercise-related numbness or tingling
129
Tx of MTSS
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
Contents of the tarsal tunnel (from anterior to posterior)
"Tom, Dick, And Nervous Harry"
- Posterior Tibialis
- FDL tendon
- Post tibial artery/vein
- Tibial nerve
- FHL tendon
131
Tarsal tunnel syndrome:
Proximal vs distal
Proximal: tibial nerve entrapped in tarsal tunnel
Distal: compression after tibial nerve has branched, may include 1-3 branches
132
Jogger's foot
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
Baxter neuropathy
Entrapment of the lateral plantar nerve
Common in runners, gymnasts, dancers
Medial plantar heel pain WITHOUT sensory disturbances
+ Tinel and Trepman
134
Symptoms of proximal tarsal tunnel syndrome
- 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
Special tests recommended for proximal tarsal tunnel syndrome
Tinel, DF/EV test, Trapman test (PF/EV)
Tinel + Trapman = 93.8% ruling IN (specificity)
DF/EV tests is very sensitive
136
Joggers foot vs baxters neuropathy
- Nerve
- Deficits
Joggers: medial plantar nerve entrapment
- PAIN + SENSORY issues
Baxters: lateral plantar nerve entrapment
- PAIN w/ first steps that doesn't increase w/ activity
137
Diagnosis of Baxter's neuropathy should include
Initial dx based on hx and exam, THEN confirmed w/ electrodiagnostic studies (possible digiti minimi muscle weakness)
138
Differentiation of Baxter's nerve entrapment vs plantar fasciitis
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
Tx of proximal tarsal tunnel syndrome
Limited evidence
NSAIDs, activity mod, night-splinting, immobilization, PT (strengthening/stretching), corticosteroids (short-term relief), keep foot in neutral (taping or orthosis)
140
Tx of distal tarsal tunnel syndrome
Limited evidence
Injections, footwear modification, modification or removal of rigid orthosis, NSAIDs, rest, ice, PT, taping
141
Most common coalitions in the foot
Calcaneonavicular (CNC)
Talocalcaneal Coalition (TCC)
142
Coalitions in the foot typically are (unilat/bilat)
Bilateral 50-80% of the time
143
Exam findings with tarsal coalitions
- 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
Adolescent that c/o pain in foot w/ activity, fibularis spasms, decreased ROM
Think tarsal coalition
145
How to differentiate between tarsal coalition and flexible flat foot deformity
Reducible pes planus combined w/ WNL ROM = flat foot deformity
146
Tx for tarsal coalition
Focus on reducing fibularis spasms and pain
Rest, orthotics, immobilization (3-6wks in boot), NSAIDs, PT if ankle instability
147
T/F: A forceful fibularis longus contraction during inversion sprain can sublux the cuboid
True, plantar/medial subluxation
148
Symptoms of cuboid syndrome
- 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
Risk factors of cuboid syndrome
Increased BMI, hx of lateral ankle sprain, abnormal foot posture (FPI-6)
150
"Feels like there is a rock in my shoe"
Think cuboid syndrome
151
2 diagnostic tests for cuboid syndrome (not validated)
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
Jones fracture
Fracture of the fifth metatarsal bone
153
Interventions for cuboid syndrome
- 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
Insertion of fibularis longus
1st MT and medial cuneiform
155
Insertion of fibularis brevis
5th MT
156
Fibularis longus works in combo with what muscle to stabilize the mid-tarsal joint?
Tibialis posterior
157
Avascular zones of the fibularis longus tendon
Where it turns around the lateral malleoli and cuboid
158
If swelling and TTP to fibularis tendons are seen in absence of increased activity/trauma, suspect what conditions?
RA or seronegative arthropathy
159
Special test for assessment of fibularis brevis tears
Fibularis tunnel compression test (pressure over tunnel, DF/EV)
160
Lisfranc articulation
Between tarsals and metatarsals
161
Lisfranc injuries occur most frequently where?
@2nd metatarsal
162
Lisfranc ligament connects which 2 structures?
2nd MT and medial cuneiform
163
Lisfranc MOI
Ankle/foot supination on axially loaded forefoot
"Fall over a a fixed forefoot"
Common in horseback riders, windsurfers, and football
164
(Eversion/inversion) sprains are associated with lisfranc injuries
Inversion
165
Exam findings with lisfranc injuries
- Diffuse pain & swelling
- Limited WB
- "Pop" @injury
- Difficulty with push-off
Gap sign, ecchymosis, painful passive mobility testing, PPT
166
Gap sign
Observed separation between the great and second toes = lisfranc injury
167
Fleck sign on XR
Small avulsion fragment from either: med cuneiform OR 2nd MT base
168
Hallux limitus and rigidus
Hypomobility of 1st MTP (limitus) can turn into auto-fusion (rigidus)
Pain, swelling, osteophytes on the dorsal aspect of the jt
169
Hallux limitus and rigidus MOI
Trauma or injury to 1st MTP jt (turf toe) or surgery
170
Special test for hallux limitus and rigidus
1) Paper grip test
2) Windlass test
3) Axial grind test
171
Staging of hallux rigidus (0-4)
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
Pseudo hallux rigidus
1st MTP ROM limited in DF but NOT in PF
D/T: tenosynovitis of FHL
173
Interventions for hallux limitus/rigidus
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
Orthotics that help with hallux limitus/rigidus pain
1st ray cut-out, Morton extension, 2nd-5th forefoot posting
175
Hallux abducto-valgus (HAV)
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
Compensated bunion
Mild deformity, NO 1st MTP sublux, NO sesamoid sublux
177
Decompensated bunion
Mod/severe deformity, hallux valgus angle >25°, intermetatarsal angle >15°, lat sesamoid sublux, incongruency of 1st MTP
178
Exam findings of hallux abducto-valgus (HAV)
Pronation, laxity w jt mobs, decreased triceps surae flexibility, TTP to jt
179
Scale to evaluate severity of HAV
Manchester scale (4 images)
180
Normal angle of the hallux valgus
Abnormal angles (mild, moderate, severe)
<15° = normal
15-20° = mild
20-40° = moderate
>40° = severe
181
Tx for bunions
Manual therapy + exercise
ALSO footwear modifications, silicone toe separator, orthosis or taping
Address toe and ankle ROM and strength deficits
182
Turf toe
Great toe extends (typically w/ foot planted) = damage to plantar aspect of the jt
183
Turf toe is usually (short-lived/chronic)
50% becomes chronic
184
Grades of turf toe (3)
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
Turf toe: proximal migration of sesamoids is suggestive of what?
Capsular disruption (grade III injury)
TTP distal to sesamoids = suggest injury to plantar plate
186
Tx for turf toe
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
Return to sport after grade III turf toe criteria
Delayed for 2-6wks
- Great toe ext to at least 60°
- Pain-free HR
188
Primary metatarsalgia cause
Rising from innate abnormalities in the patient’s anatomy leading to overload of the affected metatarsal
189
Secondary metatarsalgia cause
Caused by systemic conditions such as arthritis of the MTP joint (i.e. mortons neuroma)
190
Iatrogenic metatarsalgia cause
Can occur after (failed) reconstructive surgery
191
Freiberg disease/infraction
Osteonecrosis of the metatarsal heads
192
T/F: metatarsalgia is the most common cause of foot pain in middle-aged women
True
193
Exam findings of metatarsalgia
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
Key of rehab for metatarsalgia
Restoration of natural arches and foot stability
195
Interventions for metatarsalgia
Orthosis (redistributes plantar pressures/reduces pain), metatarsal pad (just prox to MTP), rocker bars, taping (2nd toe in slight PF), stiff soled shoe
196
Evidence for manual therapy in tx of metatarsalgia
Limited
Initially can use dorsal MTP jt capsule stretches and calf stretching - can be helpful
Also STM for tendon gliding
197
Evidence for exercise in management of metatarsalgia
Limited
Focus on optimizing biomechanics of the foot/ankle
Short-foot and toe flexor strengthening MAY improve forefoot pressure
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Interdigital neuroma
aka Morton Neuroma
- benign enlargement
- mechanical entrapment neuropathy of interdigital nerve
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Most common location of Morton neuroma
Between 3rd-4th MT heads
- Medial plantar nerve (3rd common digital branch)
2nd branch is next most common
200
Primary risk factors for development of interdigital neuroma
- Foot type and abnormal mechanics d/t narrow shoes
- Training techniques/overuse
- Gait
Also: female, runners, dancers
201
Signs of interdigital neuroma
- 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)
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Exam findings for interdigital neuroma
- 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
Special tests for interdigital neuroma
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
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
True
205
Imaging to rule IN interdigital neuroma
US or MRI
206
Management of interdigital neuroma
Education, activity mod, NSAIDs, shoe mods (rocker-bottom shoes, wide toe box, custom orthosis, MT head unloading w/ MT pad)
207
Use of manual therapy for tx of interdigital neuroma
Limited studies, one used cuboid whip and grade IV mid-foot mobs
208
Use of steroid injections in management of interdigital neuroma
Widely used and shown to be helpful for pain management
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Hallux sesamoid syndrome
Pain in the ball of the foot
- Nonspecific description of pathologies, anatomical anomalies, or adaptive changes of the sesamoid bones
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Sesamoiditis
Pain in WB, with palpation, or with PROM ext of 1st MTP jt
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Which sesamoid bone in the foot is larger? Which one is more likely to sustain a stress fx?
Both medial
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What muscle does the sesamoid bones in the foot lie within
FHB
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What 2 muscles other than FHBrevis attach to the sesamoids?
Adductor and abductor hallucis
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Key exam findings with sesamoiditis
Forefoot swelling, TTP, decreased 1st MTP ext, decreased MMT FHL and FHB, impaired 1st ray and/or 1st MTP jt
215
Tx for sesamoiditis
Taping, shoe mod, orthosis, manual jt mobs, exercise (strengthening FHL), stretching (FHL, dorsal MTP capsules, triceps surae)
216
Use of corticosteroids in sesamoiditis
Not indicated
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Knot of Henry
Where the FHL tendon goes UNDER The FDL tendon
218
Key findings for FHL tendinopathy
- 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
Demographics for FHL tendinopathy
Tennis players, ballerinas, those who move into extreme equinus positions
220
If undergoing a surgical tenolysis of the FHL tendon, what is an important possible complication?
Damage to the medial branch of the tibial nerve
221
Tx of FHL tendinopathy
Stretching, exercise, manual tx, taping (stab sub-talar jt and arch)
222
Who is at risk of a LE stress fx?
Sudden inappropriate increase in activity, athletes (runners), and military
223
Most common stress fx?
#1 = Tibia
NOTE: 2nd-3rd metatarsals are also common
224
Risk factors for stress fx's
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
Tx for low risk stress fx's
Activity modification, normal WB
226
Tx for high risk stress fx's
Restrictive WB, partial immobilization, may progress to surgery if issues
227
Recommended rest time for stress fractures (diagnosed via MRI) grades 1-4
1) 3wks
2) 3-6wks
3) 12-16wks
4) 16+
228
First imaging of choice for suspect stress fx's
XR
229
If XR are - for fx, but exam is consistent with a stress fracture at a LOW risk site, what is your next action?
Treated w/ activity mod and correction of risk factors for 2-3wks
230
When is MRI appropriate for stress fracture diagnosis
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
Low risk fx sites in LE
Post/med distal tibia, 2nd-3rd MT, calcaneus, and fibula
232
Return to sport after stress fx
After pain-free for 10-14 days:
10% increase in training intensity per/wk
233
