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517 Ortho > Ankle/Foot > Flashcards

Ankle/Foot Flashcards

1
Q

How many bones in the ankle/foot? How many articulations?

A

28 bones, 55 articulations

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2
Q

Forces through ankle joint while walking and running

A

walking: 120% BW
running: 275% BW

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3
Q

weight distribution in foot while walking, %

A

60% rearfoot
28% met heads

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4
Q

rearfoot bones

A

tib/fib, talus, calcaneus

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5
Q

midfoot bones

A

cuboid, cuneiforms, navicular

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6
Q

forefoot bones

A

metatarsals, toe bones

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7
Q

hypermobility vs instability

A

hypermobile has more motion than is typical due to laxity in ligaments; it is not always pathological
instabillity means the joint moves off its axis, issue with supporting tissues; “clunk”

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8
Q

ankle sprain - most common type?

A

85% are lateral ankle sprains
most commonly ATFL involved 60-70%
then CFL then PTFL

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9
Q

What directions tension each lateral ligament?

A

CFL: DF/neutral + inv
ATFL: PF/inv
PTFL: DF

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10
Q

grades of ankle sprain

A

1: less than 25%, painful, microtears, stable, some swelling
2: 25-75%, laxity and pain with movement
3: 75% to full tear, no pain with movement

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10
Q

high ankle sprain involved structures and MOA
Recovery?

A

syndesmosis torn as well as AITFL, PITFL, transverse
often in high contact sports
caused in DF/inv, dome of talus separates tib/fib
recovery takes twice as long!

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11
Q

medial ankle sprain MOI

A

excess ev/DF
strong ligament, so less common

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12
Q

ottawa ankle/foot rules

A

bony tenderness at lat malleolus
bony tenderness at med malleolus
bony tenderness at navicular
bony tenderness at base of 5th metatarsals
inability to weight bear

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13
Q

significance of ottawa ankle/foot

A

pt needs xray if they are showing any of the ottawa findings
pt safety, PT liability to prevent displacing a potential Fx

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14
Q

Treatment of ankle sprain: acute phase

A

1-3 days; protection!
reduced swelling, early pain free motion, supported WBAT, prevent reinjury
RICE
ankle pumps

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15
Q

Treatment of ankle sprain: subacute stage

A

4-14 days post
dynamic balance
proprioceptive ther ex
open chain resistance
bike

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16
Q

treatment of ankle sprain: advanced healing

A

restore normal AROM, normalize gait w/o AD
FWB in fxal activity
enhance proprioception

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17
Q

phases of ankle sprain treatment

A

1: protect, immobilize/stabilzie, NWM, RICE
2: low level strength/balance, PWB
3: advanced balance, SL, walking
4: jog, sport specific training

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18
Q

What obj/subj signs differentiate Grade 1 vs 2 ankle sprains?

A

edema - increased in 2
ligament integrity - decreased on special tests in 2
WB status - 2 will be PWB/NWB
location of tenderness

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19
Q

Which ligament is often damaged first in an inversion ankle sprain?

A

ATFL
stretched in inv/PF

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20
Q

Chronic ankle instability (CAI)

A

frequent ankle sprains, chronic ankle weakness and giving out over 12+ months
presents as pain, instability, swelling, decreased function
tenderness, + ant. drawer

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21
Q

CAI treatment

A

conservative - PT, splints
balance and strength training
surgical repair or reconstruction

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22
Q

What % of ankle sprains become chronic?

A

30%

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23
Q

CAI diagnostic criteria

A

Hx of 1+ traumatic ankle sprain
Hx of ankle instability, recurrent ankle sprains
- confirmed with validated questionnaire
impaired level of disability

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24
Q

osteochondritis dissecans of the talus

MOI, symptoms

A

injury of the anterolateral/posteromedial talus due to torsional stress/impact
twisting injury to the ankle causing a talar Fx
clinical tenderness, diffuse swelling, persistant pain/stiffness

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25
Q

regression of osteochondritis dissecans

A

area has lack of blood flow at articular cartilage, repeated stress degrades area over time
subchondral impaction -> partly detached fragment -> non displaced free fragment -> fragment with 180 shift

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26
Q

osteochondritis dissecans treatment

A

nondisplaced: rest, cast to immobilize
displaced: arthroscopic removal/drilling

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27
Q

posterior tibialis tendonitis

A

pain at: distal to medial malleolus over navicular; proximal to medial malleolus; at origin/insertion
findings: swelling tenderness around med malleolus
flattened medial arch
heel valgus
painful PF/inv

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28
Q

Posterior tibialis tendonitis management

A

xray/MRI
tenosynovitis - rest/NSAIDs, short walking boot/orthotic, steroid injection, synovectomy
incomplete tear - repair/augmentation
complete tear - repair w possible fixation of hindfoot

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29
Q

peroneal tenosynovitis

A

pain behind lateral malleolus, worse with activity and better with rest
diagnose w xray to exclude FX, MRI, tenderness/tendon subluxation
more common in high arches due to increased excursion

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30
Q

peroneal tenosynovitis treatment

A

conservative - rest, walking boot, lateral heel wedge, NDAIDs, cortisone, PT
surgical - tenosynovectomy, repair, stabilize dislocating tendon by deepening groove, retinaculum reconstruction

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31
Q

Achilles tendinitis/osis

A

insertional at calcaneus or non insertional superior to insertion
most common in 30s-40s and runners
gradual onset
worse w activity
pain stiffness worse in morning/start of activity and improves
obj: tenderness/warmth
decreased DF
antalgic gait, early heel off, leg in ER

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32
Q

tendonitis vs tendinosis

A

osis - clinical inflammation, lack of cellular inflammation
itis.- peritendinous inflammation

33
Q

Achilles tendinitis treatment

A

conservative: rest, ice, NSAIDs, orthotics, 12 wk eccentric calf strengthening, correct LE asymmetries, stretching
surgical: decompression/debridement, not a guarantee of symptom cure

34
Q

types of Achilles tendinitis/severity

A

1: pain after activity - reduce activity 25%
2: pain during/after activity not affecting performance - reduce activity 50%
3: pain during/after activity affecting performance - discontinue running temp.

35
Q

Should insertional Achilles tendinitis complete full range or floor level eccentrics?

A

floor level, to reduce stress on insertion as compared to dropping heel off step

36
Q

timeline of achilles tendinopathy

A

3-6 mo for significant improvement with first symptom improvement with morning stiffness

37
Q

Acceptable pain levels when working with tendinitis

A

<4/10 during activity
subjective, alter number as needed for low-mod pain levels

38
Q

Where will a pt report tenderness w posterior tibialis tendinits

A

distal to med malleolus over navicular
proximal to med malleolus
at origin/medial shin splints or insertion in foot

39
Q

Achilles tendon rupture

A

MOI: DF + knee extension, microtrauma, eccentric loading
increased risk w/ gout, hyperparathyroidism, steroid injections
timeline: 6-8 mo

40
Q

thompson’s test

A

achilles tendon integrity
pt in prone, leg over edge of table, squeeze calf
+: absence of slight PF

41
Q

achilles tendon rupture treatment

A

non operative - minimally displaced ruptures or older pts would not get surgery
serial casting 10-12 weeks
surgical - younger pt, displaced rupture

42
Q

complications of achilles tendon rupture repair

A

wound healing
sural nerve injury
DVT

43
Q

success of achilles tendon treatment

A

non operative - lower return to prev activity level, lower satisfaction, and higher reinjury
surgical - 83% return to activity level, 93% satisfaction, 2-3% re rupture

44
Q

general progression of post op Achilles tendon rupture

A

0-4 weeks: NWB, crutches
compression, splint, boot
4 weeks: TTWB to WBAT, walking boot/CAM to limit DF, immobilize addt 2-4 weeks
6-8 weeks: allow DF beyonf neutral, AROM exercise in brace, FWB w/ brace, transition to heel lift
12+ weeks: discontinue brace, FWB w/o lift

45
Q

Evidence for interventions for Achilles tendon rupture

A

mechanical loading/exercise/eccentrics
iontophoresis to decrease pain and increase function
some evidence for stretching PFs

46
Q

plantar fasciitis

A

heel pain, worst upon waking
subj: Hx of pain on medial arch, worse with activity
obj: tenderness along medial fascia, origin at calcaneous
firm pressure

47
Q

causes of plantar fasciitis

A

obesity
excess walking
sports
tight plantar fascia
flattened arch
excess pronation

48
Q

plantar fasciitis treatment

A

orthotic, injection, NSAIDs, surgical release (poor outcomes)
PT: foot intrinsics, support arch w towel in exercise, stretching PFs/DFs, balance, resisted ankle AROM

49
Q

plantar fascia prognosis

A

90% who do conservative treatment improve in 12 mo

50
Q

evidence for interventions - plantar fasciitis

A

A - manual therapy, stretching, taping, foot orthoses, night splints
B - diagnosis/assessment

51
Q

retrocalcaneal bursitis

A

aka haglund’s deformity
tenderness/enlarged calcaneal lump due to inflammation

52
Q

causes of retrocalcaneal bursitis

A

repetitive trauma - shoes and sports
gout, RA, ankylosing spondyloarthopathy
bursal impingement w achilles tendon

53
Q

treatment for retrocalcaneal bursitis

A

conservative: shoe wear, injection (risky)
PT: achilles tendon stretching, reduce inflam
surgery: resect deformity, excise bursa, debride tendon insertion

54
Q

Hallux valgus

A

bunions - lateral deviation of great toe causing bony growth on 1st metatarsal
MTP joint angle > 20 degrees
painful callus on 2nd toe
lack DF

55
Q

causes of hallux valgus

A

familial
inappropriate shoes
flat feet - abducts toes
long first ray
MTP joint surface incongruous
metatarsus primus varus - 1st ray rotated away from 2nd
RA

56
Q

hallux valgus treatment

A

conservative: low heel/stiff shoes w wide toe box
splints, toe spacers
bunion pad to reduce pressure
rest/heat/analgesics
surgical: only for severe deformity or pain
bunionectomy

57
Q

progression of post op bunionectomy protocol

A

0-2: NWB w crutches, safe ADLs w AD, hip/knee AROM, rest/elevate
2-6: ankle/toe AROM, boot on except exercises, heel WB short distances
6-10: full WB w boot, ankle ROM, hip/knee strength, scar massage, joint mob unfused joints

58
Q

pes planus

A

flat foot - 99% flexible, 1% rigid
medial arch disappears in weight bearing, reappears when non weightbearing

59
Q

jack test

A

hallux hyperextension should create medial arch in flexible pes planus, won’t in rigid

60
Q

heel rise

A

pt raises heel, flexible pes planus heel will move into varus

61
Q

rigid pes planus cause/symptoms

A

congenital vertical talus, no subtalar motion, stays pronates bc bone/scar tissue/fusion
foot pain, hard to walk on uneven surface, fatigue, peroneal spasm

62
Q

rigid pes planus treatment

A

control symptoms
immobilization 4-6 weeks once irritated
surgical treatment

63
Q

metatarsal stress Fx

A

overuse, cyclical submaximal loading
caused by shoes, hard surface, increase in running distance
most often 2nd/3rd MT
pain/swelling in WB, Hx of change in activity/shoes/surface
ecchymosis

64
Q

Will stress Fxs show up on xrays?

A

Not while acute, too hairline to detect
they will show up as healing area of more white bone on subsequent xrays

65
Q

Morton’s neuroma

A

nerve entrapment of interdigital nerve
caused by trauma, ischemia, entrapment
shooting/constant pain w WB, rest/no shoes help
female > men
most common btwn 3rd/4th

66
Q

metatarsal squeeze test

A

+ tenderness/click on squeeze of MTPs

67
Q

Morton’s neuroma treatment

A

conservative - metatarsal pad, orthotic, injection, excision
wide toe box/no heels
surgical - dorsal or plantar approach

68
Q

dorsal vs plantar approch morton’s neuroma

A

dorsal allows immediate WB, sutures removed after 2 weeks
plantar delays WB 2 weeks, transition to normal shoe 3-4 weeks, return to sport 4-6 weeks

69
Q

Tarsal Tunnel

A

tibial nerve entrapment in flexor retinaculum and medial malleolus
burning/pain/paresthesia medial plantar surfacce of foot
worse after activity
+ tinel’s sign
painful DF/ev
decreased 2 pt discrim plantar aspect
heel varus/valgus
weak foot intrinsics

70
Q

tarsal tunnel treatment

A

injections, orthotics, foot intrinsic exercises to restore medial arch

71
Q

turf toe

A

sprain of 1st MTP
hyperextension, varus/valgus stress on MTP
1st MTP inflammation, tender, limp, unable to run, Hx or DF injury or great toe injury
need at least 70 degrees DF at 1st toe to avoid overstretching

72
Q

grades of turf toe injury

A

sprain grades
1: minor stretch, little swelling/pain/disability, return as symptoms improve
2: partial tear, mod pain/bruising/disability, 3-14 days rest
3: complete tear of plantar plate w severe swelling/pain/bruising, unable to WB, 6 weeks rest, crutches

73
Q

turf toe treatment

A

RICE, NSAIDs, tape to limit toe DF
return to sport when toe can DF 90
1: tape toe to 2nd, stiff shoes
2: brace/boot, weeks of rest
3: surgery if Fx, cartilage damage, tendon teat, excess joint movement causing subluxation

74
Q

cuboid syndrome

A

disrupts congruence of calcaneal/cuboid joint
uncommon w lateral ankle sprain
lacks valid/reliable tests
ligament injury
poor function of the cuboid reduces mechanical advantage of the peroneals

75
Q

s/s of cuboid syndrome

A

persistnet local pain over cuboid following lateral ankle sprain
painful toe off
painful plyometrics
medial arch/4th metatarsal pain
palpable prominence
limited/painful DF/inv/ev at joint
painful mobs of cuboid - ligament

76
Q

cuboid syndrome treatment

A

cuboid whip (grade 5)
cuboid squeeze
mobs w movement
retrain foot intrinsics and kinetic chain as applicable
NM/proprioceptive control
peroneal/gastroc stretching

77
Q

3 feet types and shoe types

A

flat: stability shoes
normal: neutral
high arch: cushion

78
Q

Lateral Ankle Sprain CPG Components

A

A: prevention/bracing those at risk/those who have had 1st ankle sprain; AD and immobilization for acute sprain; PT/HEP; should NOT use ultrasound; manual therapy like drainage, MWM, STM, joint mob, to reduce pain/swelling
B: brace usage for return to work schedule and activity. limitation
C: preventative balance training for those w/o LAS; ice; diathermy; low level laser; NSAIDs
D: mode of HEP mixed evidence (paper/app/etc); electrotherapy; accupuncture

79
Q

CAI CPG Components

A

A: NRED/proprioceptive to retrain postural stability; manual to improve DF
B: bracing alone should not be used, supplement; combined treatment
C: dry needling
E: motivational interviewing/psych

517 Ortho (8 decks)

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