Ankle & Foot Dysfunctions (Lecture 2) Flashcards
Where is the sesamoid bone?
Plantar surface of distal part of 1st Metatarsal
Explain the windlas effect?
With toe extension the plantar fascia is pulled taut (makes it more rigid and larger)
What happens to the medial longitudinal arch in great toe extension?
The fascia tightens and causes the metatarsal heads to be depressed and the longitudinal arch to rise (windlass effect)
* causes the metatarsal heads to drop down which increases the distance of the bottom of the metatarsal from the navicular - which in turn increases the angle between the two which creates a larger arch (do it yourself)
What does plantar fascitis feel like?
First few steps feel like a sharp pain in the heel and then the fascia starts to loosen up
KNOW: hindfoot excessive motion (going into excessive proantion / supination) may cause plantar fascitis
Excessive loading can cause this
Heel spur
reptitive loading
High BMI
Limited ankle DF (makes the foot cominsate w/ that. excessive motion)
Where does the plantar fascia insert?
Medial tuberical of the calcenous (where pain is often felt)
What time of day is plantar fascitits pain felt?
In the AM
KNOW: More likely to get plantar fascitis if they have pes cavus or pes planus (note this is basically the same as them having increased supination or pronation as stated before)
Why would someone w/ plantar fascitits have pain w/ toe extension?
Windlas effect
Because as the toes are put into extension the plantar fascia is stretched
which 2 muscles being tight could lead to plantar fascitits? Why?
Gastroc / Soleus
Decreases foot DF which leads to needing more mobility at the foot which irritates that plantar fascia
KNOW: someone w/ plantar fascitits might have decreased intrinsic foot muscle strength thats causing that plantar fascia to have to compinsate causing their pain
What phase of gait would someone w/ plantar fascitits avoid? Why?
What position of gait might be early?
Heel strike
because thats where the pain is coming from
may also have decreased stance time on that limb
They would also have early toe off because they don’t want to stretch that plantar fascia (so their weight wouldnt be forward yet and those toes come off before that plantar fascia is taut)
Does surgery work well for plantar fascitits pts?
No
(they do a plantar fascia release but it is often not effective)
What 4 things do we do to treat plantar fascitits?
1) Stretching –> however, we don’t actually change the tissue but we get those psycological effects (neurlogic response which reduces pain)
2) Massage
3) Shoe modification
4) Strengthening
can also do taping / dry needling
there is a strong link between plantar fascities and ____
posterior tibia tendinopathies (often dry needle here)
Achilies tendinopathy also affects
What is a midportion achilies tendinopathies?
Just distal to the mid portion of the gastric
What is insertional achillies tendonpathy?
2-6 cm proximal to the achilies insertion on the calcaneous
KNOW: A midportion achilies tendonopathy is going to be treated more like a muscular issue than a tendonis issus (muscleular loading mechancis)
A proximal tendonpathy is treated more like a tendon issue (tendon loading mechanis)
Where does the achillies tendon insert?
Posterior gastroc
Pt has posterior foot pain, what kind of tendonpathy is most likely
Achilies tendonpathy
pt is having medial foot pain. What tendonpathy am I thinking
posterior tibialis tendinopathy
Lateral foot pain caused by a tendinopathy is most likely
fibularis
Anterior foot pain linked to a tendinopathy is most likely
anterior tibialis (this is more shin splints / medial tibial stress syndome)
Who is most likely to get an achilles tendonopathy
athletic pop
Intrinsic factors that make a pt more likely to have an achillies tendonopathy
Decreased dorsiflexion
Adnormal subtalar ROM
* increased inversion
* Decreased total inversion/ecersion ROM
Decreased PF strength
Excessive rearfoot pronation
Hallux rigidus (big toe is stiff) - means they arent going to have great plyobility of metatarsals which means they won’t have foot push off which means the gastroc/soleus are what are going to be utilized = overuse
Extrinsic risk factors for achilles tendonpathy (2)
Training errors
Footwear w/ insufficient rearfoot control, hard soles or high heels (excessive plantar flexion = tighter gastroc/soleus
abnormal boney growth on the calcaneous from wearing high heels
haglunds deformation
KNOW: VISA-A / TENDINS-A = achilles specific questionaires
What age group is most likely to have an achilles tendonopathy?
30-50
NOTE: you can also get this younger. Normally basketball players that have that rapid DF/PF
* Running / jumping sports
* Normally happens in landing phase where the gastroc is having to slow the heel down from hitting the floor (going into DF and eccentrically lengthening gastroc/soleus)
KNOW: Continuous thickkening of the tendons will happen w/ over stress
What movement would not have as much strength w/ an achilies tendonpathy?
PF
Note: this movement will normally be very strong in most people due to it being a type 2 lever
Will also have decreased PF endurance
What happens to achilies tendonopathy after activity
What happens during actvity
After = stiffness
During = less stiffness
* movement makes it feel better
Would walking up or down stairs be worse for an achilles pt?
Down
Its eccentrically lengthening which causes the most stress on the tendon
Protocal for achilies:
* Increase strength and flexibility
* Decrease inflammation
* Normalize ROM
* Eccentric Loading
Protocal 2:
* Unlatearl heel raises w/ no concentric component (up with both down with 1)
* 3 sets of 15 reps 2x/day for 12 weeks (getting more into that endurance phase)
* For tendons healing takes a long time
Who normally gets achilles ruptures?
* Age
* active?
* sports?
Older 40-50
Usually sedentary adult
Sudden onset of increased activity “weekend warrior”
People make the common mistake of getting fit by playing sports instead of getting fit to play sports
Younger patients - usually an athletic or sports injury
What is the MOI for an achilles tendon rupture? (4)
Extra little stretch to a fully streched tendon
forced DF when ankle is related / unprepared (eccentric)
Forceful contraction of gastroc/soleus against resistance (concentric)
Direct trauma to tendon when its taut
Ruptured achilles
Which motion is weak (non existent) w/ an achilles tendon rupture
Lack of PF
Special test for achilies tendon rupture?
Positive thomson test
*squeeze the achilies and theres no motion at the foot (PF)
What do they use to reconstruct the achilies tendon?
Plantaris graft
How long do tenons take to fully heal?
8-12 weeks
Achilles rupture post OP
Tendons take 8-12 weeks to heal to it makes sense that were doing strenghtening at the 9-12week mark
Can achilies pts weight bear in phase 1?
No
In phase 1 of an achiles rupture what EX are we doing
Hip / knee OKC stregnthening
were also doing muscle setting (pushing ito either side of muscle) just to get the muscle moving (isometric)
Do we do scar mobilization in phase 1?
No
What happens in phase 2 of achilies rupture?
* Weight bearing?
* ROM?
* What motion do we avoid?
* Scar?
* Mobilizations
* cardio?
* Strengthening?
Partial weight bearing
Start wedge system here (to take off pressure) (do this until weight bearing as tolerated because addding wedges = shifting weight off that limb)
ROM - ALL MOTIONS EXCEPT AVOIDING DF PASSED 0
Scar mobilization
Foot / ankle mobilizations (grade 1 and 2)
Avoid using machines for mobilization
Bike
Hip/Knee/Core strengthening
Achilles rupture phase 3
Normalize gait pattern w/o wedges
WBAT/FWB
week 8 = shoot for FWB in boot
DF ROM no longer restricted, but continue to gently progress
No longer restrictions in DF
Ankle strengthening
For these phases we need to know for test:
* general time frames for weight bearing status
* General time frames for progression of ankle
* Know ROM resitrctions
* Know tendon heal times (8-12 wks)
Phase 4
Standing calf raise program
Standing ankle DF stretch on step
Stationary bike
Pool therapy (if inscision fully healed)
Phase 5 = advanced rehab (think plyo) might not be in clinic in this phase
