Ankle & Foot Dysfunctions (Lecture 3) - Part 2 Flashcards
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Which Arch does the posterior tibialis help to support?
Why would posterior tibalis weakness affect the plantar fascia
Medial longitudinal arch
So if this muscle was weak we could have a collapse of that medial longitudinal arch
Because the plantar fascia and the posterior tibialis both support the medial longitudinal arch. If the posterior tibialis is weakened the plantar fascia will have to work harder to hold that medial longitudinal arch in place - which will apply more stress on that plantar fascia
* Sometimes we work on treating plantar fascitis by strenghtening posterior tibalis - a stronger posterior tibialis will support that medial longitudinal arch more which will take some of the stress off of the plantar fascia
Tibialis posterior
* Origin
* Insertion
* Action
* Innervation
Tibialis posterior: (runs through sustentaculum tali)
* Origin: Interosseous membrane; posterior surface of tibia inferior to soleal line; posterior surface of fibula
* Insertion: Tuberosity of navicular, cuneiform, cuboid, and sustentaculum tali of calcaneus; bases of 2nd, 3rd, and 4th metatarsals (this is all on the inferior foot)
* Innervation: Tibial nerve
* Action: Plantarflexes ankle joint; inverts foot; maintains medial longitudinal arch
What typiclly causes dysfunction of tibialis posterior? (2)
* risk factors (4)
Repeated microtrauma (think people on feet all day long) (most common pathology cause) - think factor workers or mailmen who are on their feet all day long
Also correlated w/ flatfootedeness because this tendon wold need to work harder to support the medial longitudinal arch (pes planes)
* stretches it out more as well
Risk factors:
* female
* 40+
* Steriod injection (in the tendon itself)
* Obesity
Is full rest normally best for a tendon?
NO! active rest is typically best
* So don’t put it in a cast right away for tendon pathologies
KNOW: Braces are often good during play but don’t wear it all the time
* When you put them in an AFO it tells the tendons/muscles they dont have to work that harder - something else is supporting them
Where is pain and swelling typically located for posterior tibialis tendonopathy?
Posterior to medial malleolus
Which active activities bring on posterior tibialis pain?
What passive activities bring on pain?
Plantar flexion and inversion
* NOTE: we do reisted provocation for tendons not MMTs
DF / Eversion (stretch the tendon)
For most tendonopathhies what test do we do to see if the tendon is whats causing the problem?
resisted provocation test
* NOTE: this is NOT a MMT - this is very quick and testing that tension on the tendon (less about muscle strength and more about tensing the tendon)
* “Does activitity of the muscle bring on my symptoms - not how strong the m is” - and seeing if that brings on the pts pain
* NOTE: you need to make sure you’re doing that resisted provocation in the same way the m would concentrically contract
What does too many toes sign test for? what movement causes it?
Tests for posterior tibialis tendinopathy
To much external rotation
KNOW: Medial ankle sprain = deltoid ligament = very rare
* might be a differential diagnosis for posterior tibialis tendonpathy (both run in the same area at medial ankle)
* HOWEVER - since its a ligament they won’t have pain w/ resisted motion and posterior tibialis tendonpathy will
* Rare to have a deltoid ligment pathology
Peroneal tendinopathy = fibularis tendinopathy
Whats muscles (2) cause fibularis tendinopathies?
Fibularis longus / Brevis
Do peroneal tendinopathies run anterior or posterior to the fibular head? is it medial or lateral
Where is pain w/ tendinopathies?
Posterior and lateral to the malleoli
Pain is normally just posterior / latearl to latearl malleoli
Fibularis longus:
* Origin
* Insertion
* Action
* Innervation
Fibularis longus:
* Origin: Head and superior two thirds of lateral surface of fibula
* Insertion: Base of 1st metatarsal and medial cuneiform (on plantar side – threads through sustentaculum tali)
* Innervation: Superficial fibular nerve
* Action: Everts subtalar joint and weakly plantarflexes ankle joint
Fibularis brevis
* Origin
* Insertion
* Action
* Innvervation
Fibularis Brevis: (deep to longus)
* Origin: Inferior two thirds of lateral surface of fibula
* Insertion: Dorsal surface of tuberosity on lateral side of base of 5th metatarsal (its essentially on the base)
* Innervation: Superficial fibular nerve
* Action: Everts subtalar joint and weakly plantarflexes ankle joint
What actions cause a fibularis tendinopathy to be flared up (active and passive)
PF / Eversion = active
DF / inversion = passive stretch
The fibularis longus / brevis stop the ankle from doing what two motions?
Knowing those two motions if this pt had these muscles being unstable where would the instability be?
Inversion / DF (that would be stretching the tendon) (this is how they stablize the ankle)
So lateral ankle sprainers - their everters might be over active / over working and thats whats causing the fibularlris longus / brevis tendinopathy (eversion would stretch its tendon [pull it taut causing pain])
* remember fibularis longus / brevis are constently trying to pull it into eversion to keep it form inverting (but if inverters are to strong it wont be able to keep up and pulled taut)
KNOW: Ankle tendonpathies: do these
* Location (get good palpation - know where muscle bellies and tendons run) - know where muscle bellys become tendon (def be proximal to make sure you’re palpating m bellys if thats what you’re looking for)
* resisted provocation testing
* Passive stretch (passive motion testing)
Which part of stance would be painful for someone w/ a fibularis tendinopathy? (2 movements)
Pain w/ terminal stance
this is because they are going into plantar flexion
* and its rolling from inversion into eversion and these muscles do eversion so if they have an issue this motion will hurt
NOTE: the stuff below is for an acute phase
Tendinopathies: Police:
* Protect
* Optimal loading (loading principles)
* Rest (active rest)
* Ice
* Compress
* Elevate
If its healing respect it
If its pissed off calm it down
This is for acute stages
If its extremely acute and their ankle has 0 stability their might be an AFO used
Acute stage = isometrics (submax prolonged (think 30-60 seconds))
Joint mobilization grade 1 / 2
Soft tissue for pain inhibition / edema management
PROM (manual therapy)
* just shy of pain
Manual reistance (this is actaully an isometrics)
* can do this in a shortened position or a lengthened position
* Shorter position = less muscle stress = tension on m not as high - in acute phases do this one as an isometric
What is medial tibial stress syndrome?
Shin splints
Why is medial tibial stress syndrome medial?
Because the anterior tibialis is medial on the tibia and when it pulls thats where the pain is
What two things happening to the anterior tibialis cause medial tibial stres syndrome?
* whats the other bad thing that can happen
How does this cause periosteitits (look at the same of the word)
Fatigue
Quick change in demands (think weekend warrior)
However - it might even be a stress fracture of the tibia (think repetitive loading / weekend warrior / new shoes / new training redgemine)
The repetitive pulling of the anterior tibialis might cause periosteitits - inflammation of the lining of the bone
KNOW: Compartment syndrome is a differential diagnosis for medial tibial stress syndrome
Irritation of interosseous memebrane can come along w/ shin splints
KNOW: shin splints can be in two places
* Anterior tibial stress syndrome = along the anterior lateral aspects of the prox 2/3 tibia
* Posterior medial tibial stress syndrome = posterior medial portion of the tibia
May include:
* Stress fx of tibia
* Periosteitis
* compartment syndrome (differntial diagnosis)
* Irritation of interosseous membrane
Muscle fatigue or intensity/duration change my bring on shin splints (in either location)
What is the most common cause of anterior shin splints?
What are 3 more things that could cause anterior shin splints?
What are 2 ways to bring on pain
Overuse of anterior tibalis (note its not normally weak - just overused)
1) Tight gastroc-soleus - not allowing for proper DF (which means anterior tibialis would have to work harder) - NOTE: L4 nerve root pathology could also cause weakened DF (Know myotomes / dermatomes)
2) Weak anterior tibialis (rare) - swelling my present as weakness
3) Excessive reer foot pronation - might put anterior tib in a bad spot for active activation (overuse)
Pain w/ active DF
Pain w/ ant tib stretch (PF)
Another name for posterior shin splints?
What tendinopathies often cause these?
Posterior tibial stress syndrome
Posterior tibialis tendinopathies
* NOTE: the difference between a posterioral tendinopathy and posterior shin splints is shin splints being an acute repetitive motion that is truely in that inflammatory state - but the differentiation between the two is minimal
What 3 things cause posterior shin splints?
* what passive and active thing bring on pain?
1) Tight gastroc muscle
2) Weak of inflammaed posterior tib muscle (most likely this)
3) Increased rearfoot pronation (because post tib is stretching)
Pain w/ passive pronation to end range w/ OP (stretching post tib)
Active supination against resistance (concentric post tib)
What would the #1 education for someone w/ shin splints be?
We know repetitive overloading most likely brough it on. So activity modification (cutting back on activity) would probs be the education
* We want to do active rest (stop shy of pain / symptoms)
* When you start feeling the front of the leg getting tired thats when its time to take a break
NOTE: Soft tissue work does pretty well with this (can move out matabolites from the system –> get lactic acid out of m)
Can also do strenghtening if weakness is really whats bringing it on
tibialis posterior
* origin
* Insertion
* Action
* Innvercation
Tibialis posterior: (runs through sustentaculum tali)
* Origin: Interosseous membrane; posterior surface of tibia inferior to soleal line; posterior surface of fibula
* Insertion: Tuberosity of navicular, cuneiform, cuboid, and sustentaculum tali of calcaneus; bases of 2nd, 3rd, and 4th metatarsals (this is all on the inferior foot)
* Innervation: Tibial nerve
* Action: Plantarflexes ankle joint; inverts foot; maintains medial longitudinal arch
Why would you not do eccentric training w/ shin splints?
Because if its eccentrically activated you’re really pulling on that bone
Would we noramlly strenghtening muscles when we have shin splints?
Most likely not because this pathology is not due to weak muscles (most of the time)
* These people are normally active individuals - their muscles are still strong - it just needs time to calm down
We would do soft tissue work (clearing metabolites) / activity modification education
Compartment syndrome = red flag
Compartment syndrome: Reversible ischemia secondary to a noncompliant osseofascial compartment that is unresponsive to the expansion of muscle volume that occurs w/ EX
* Meaning - those compartments in the LE have fasciles surrounding those compartments (and there are muscles / other stuff in these compartments)
* Some ty pe of repetitive trauma / blunt force trauma creates swelling. that swelling stays inside the fasicle compartment and doesnt have a chance to escape / doesnt get recycled back into the system - so swelling continues to build up without a way to disapate
* You then get this compartment syndrome (feels very tight)
What often also happens is that increased exertion / demand / increased BF / edema that happens w/ EX is not able to escape and compartment syndrome can be brough on
* this is how repetitive overuse is brought on
What is the most common kind of compartment syndrome in the LE?
Anterior compartment syndrome
What muscles are in the anterior compartment of the LE (most common compartment for compartment syndrome)
* what nerves
* what arteries
* what veins
Tibialis anterior m
Extensior hallucis longus m
Extension digitorum longus m
Peroneus tertius m
Deep peronal n
Anterior tibial artery / vein
Compartment syndrome etiology:
* Enclosure of comaprtment contentsin an inelastic fasical sheath
* Increased volume of the skeletal muscle w/ exertion due to blood flow and edema
* Muscle hypertrophy as a response to EX
What is the presentation for compartment syndrome? (anterior compartment syndrome)
* when does the pain come on?
* What does the pain feel like?
* How long after the activity do symptoms start to go away?
* What two movements hurt?
* Where are paresthesias found?
* What other area is likely numb?
* Do they have pitting edema?
recurrent episodes of leg discomfort experienced at a given distance or intensity or running (think leg tightness coming on)
* NOTE: this is swelling that is like a balloon that is about to bust - very tight w/o rebound - very sensitive (no pitting edema)
Pain described as a tight, cramolike, or squeezing ache over a specific compartment of the leg.
Relief of symptoms following cessation of activity (~10 minutes)
* In the non emergent setting
Weakness of DF or toe extension (anterior tib / extensor digitorum are both in the anterior compartment)
* KNOW: Weakness of muscles is normally not due to actual muscular changes but swelling /pain in the area which (muscle spindles?)
* The nerve going to these muscles also might be compressed - which would make the muscles weaker
Paresthesias over dorsum of foot
* The nerve is trapped in the compartment and being compressed which can lead to this
Numbness in 1st webspace
* Deep fibular n
**Differential diagnosis table **
* NOTE: pulse is occluded w/ compartment due to the pressing - posterior tib / dorsal pedal pulse are occuluded - great way to rule in / out compartment syndrome from the rest
Pain at rest is a great way to differeintiate shin splints from stress fractures
Also note that fractures have a pinpoint pain while shin splints do not
Warm up for compartment syndrome makes it worse because were increasing BF to the area
Warm up for shin splints might decrease the pain
NOTE: All 3 are due to repetitive trauma - so MOI will not help us differeintiate
*
What happens w/ tarsal tunnel syndrome?
* where is it felt?
Posterior tibial n entrapment
felt on medial foot
What 3 things go through the tarsal tunnel?
What ligament covers the top of the tarsal tunnel?
Tibialis posterior
Flexor digitorum Longus
Posterior tibial nerve
Flexor hallicus long
(Tom, Dick, Nervous Harry)
Flexor retinaculum
** Which tendon pathology leads to this altered movement that causes tarsal tunnel syndrome? Why? What nerve is affected?**
Which tendons being swollen can causes compression of tibialis posterior n (NOTE: compression of this nerve is what causes tarsal tunnel syndrome)
What space ocyping lesion can cause this
Posterior tibial tendon dusfinction leading to hyperpronation in the mid foot can result in increased tension in posterior tibial n(Posterior tib not acting strong enough causing eversion (pronation) allows the posterior tib n to be stretched causing symptoms)
* Its actions are platar flexion / inversion
* So if it can’t do its job we fall into excessve eversion (pronation)
* this pronation stress the flexor retinaculum which can swell and put pressure on the posterior tibial n which is carap tunnel syndrome
Tenosynovitits (thickening of the sheaths) of T,D,H can compress the N
* repetitive streching from hyprepronation can cause these sheaths to thicken
* repetitive trauma can also cause this
Some type of space occupying lesion can also cause this (think ganglion cyst)
Which 2 nerves is the sural n made up of?
* where does it provide innervation
Common fibular n and tibial n
lateral foot and latearl lower leg
Sural n pathway
Runs between between heads of gastroc down latearl side of leg from peroneal tendon sheath to latearl tuberosity of 5th toe
(betweenheads of the gastroc, down lateral leg and foot)
KNOW: sural n worsents w/ activity (because its being stretched)
* it will present w/ tenderness/numbness on the posterior / latearl leg / foot
Often caused by a ganglion cyst pushing on it
What 3 nerves cause sensation loss on the bottom of the feet?
Which of these 3 nerves is most often affected? Why?
Medial plantar n
Latearl plantar n
Calcaneal n
KNOW: Posteriorlatearl heel sensation = sural n
Posteriomedial nerve sensation = calcaneal nerve
Of the medial / latearl plantar n and the calcneal n which one is most commonly affected? Why?
* 2 things do this
medialplantar n most often affected
This is due to entrapment at the abductor hallucis muscle
Can also be affected due to overpornation stretching that medial side (which is where the medial plantar n runs)
* medial nerves are strained w/ hyperpronation (because its basically the same thing as eversion)
Where do the calcanealand medial and latearl plantar nerves come from?
Posterior tibial n
If you wanted to stress the medial plantar nerve how would you do it? (3)
Note: they run all the way to the toes:
Toe extension
DF
Eversion (because it starts medial and the lateral one runs latearl)
What is a mortons Neuroma?
Thickening of the tissue around the nerve due to fibrosis (it will cause nervey symptoms down the foot)
Its some disruption / pressure on the nerve
* compression hurts because its squeezing together the MT and the nerve runs between them
Normally happens between the second and third, and third and forth toes
What activity would we do w/ someone who has mortons neuroma? (7)
MT splaying into either extension or flexion (spreading them apart instead of compressing)
Modify footwear (wider shoe base)
Massage
Nsaids
metatarsal pad - this dispurses the wt around that area
surgery
steriod injection
What kind of deformity is this? What causes it?
Hallxus valgus deformity
RA causes this (which will also cause tendon rupture)
RA will cause little nodulates at the at the joints
* NOTE: It doesnt affect just the joint but also the surround tissue / joint capsule
What typically causes DJD (OA) of the ankle?
Post traumatic (some traumatic event prior in life caused it)
Notice how close the joint surfaces are
What is this?
Total ankle arthoplasty
* Losts of complications compared to other joint replacements (unstable joint)
NOTE: this is a new surgery - they used to just fuse the ankle (because when it doesnt move it doesnt hurt)
Benefits of TAA
* Pain relief
* Deformity correction
* Resoted stability or mobility (because pain is gone)
* Improved muscle strength and endurance
* Improved ambulation
AVN of what causes someone to need a total ankle?
Talus
they replace the mortis joint and the talus component
Absoulte contraindications for TAA (6)
Active or chronic ankle infection
Osteoporosis of the tibia (because you have to drill the new mortis into it)
AVN of the tibia (decreased BF which is really bad for healing)
Peripheral neuropathy (numbness / tingling of the joint)
Impaired vascular supply
Long term corticosteriod use (decreased bone density)
Realtive Total ankle contraindications (5)
* You can do them somtimes
Malalingnment
**Instability (SO YOU WOULDNT DO IT ON SOMEONE WHO IS ALREADY UNSTABLE [HINTS THE LIGAMENTS THING FROM EARLIER])
**
Tobacoo (slow healing)
Obesity (more load / slower healing / if they are sedentary they wont do surgery)
High demand activity
