Ankle & Foot Dysfunctions (Lecture 4) - Part 3 Flashcards
Explain what claw toes are
* MTP
* PIP
* DIP
Hyper extension of MTP (more than hammer toes)
Flexion of PIP
Flexion of DIP
Just like you’re clawing down
Explain what a hammer toe is
* MCP?
* PIP?
* DIP?
Extension of MTP
Flexion of PIP
Extension of DIP
What is hyperuricemia w/ difficulty with purine metabolism?
Gout
Uric acid crystals and calcium pyrofasfate acumulate around and inside of the joints
What is the pain typically like w/ gout?
Nawing sharp burning sensation (uric acid crystals form in the joints causing lots of pain)
* also form in the periarticular tissues
When is the pain worst with gout?
At night
Who gets gout more males or females?
Males
What age is most common to get gout?
40+
How long does it take gout to go away?
Lasts days to weeks
Is gout found more proximal or distal?
More distal (typically hands and feet)
Things that cause gout:
* Infection
* Diet (red meats)
* Emotions
* Cold
* Shellfish intolerance
* genetic predisposition
* alc
* obesity
* use of pharmacologic agents
What is this?
Gout
NOTE: it is often warm to the touch
What is this?
Gout
Note: its also warm to the touch
GOUT:
Hx: Pain in 1st MTP beginning @ night; am stuffness in chronic (much like arthritits)
Inspection: visible 1st MTP swelling, redness, joint deformity in chronic
SP: Warmth, edema
Decreased AROM/PROM due to swelling and pain
PROM: hypomobile in acute cases
PROM: Hypermobile in chronic cases (due to the joints becoming more lax)
Functional analysis: Decreased step length, speed, push off with 1st MTP
* push off creates lots of stress at the MTP joint
What is this?
* what is the name of the lesion here? (bone being eaten away)
Gout at first MTP
This is a punch out lesion (this is the bone being eaten away)
NOTE: theres also a narrowing of the joint space and swelling in the area
We can get this C shape deformity at 1st MTP w/ gout
* called a rate bite ersion
his is showing the uric acid accumulation / buildup / deposits
NOTE: in the early phases diet modification is quite helpful (avoid red meat / alc / cigars / shellfish)
we work on symptom management (calming it down) –> ROM / Wt bearing
What is this deformity? What other issue comes along w/ it?
Hallux valgus
Can lead to a medial bunion (bunion on big toe)
Would increased proantion or supination cause more hallux valgus?
* Would pes planus or pes cavus cause this more?
* What part of the foot being in pronation causes this?
Pronation (puts more pressure on that big toe)
Pes planus causes this more (more pressure on that big toe)
Forefoot pronation causes this
Joint laxity / heredity can also cause this
NOTE: this causes a bunion as well
This is hallux valgus
Proximal phalanx deviated laterally w/ respect to first metatarsal
You can see how this poking out of the 1st metatarsal creates that bonion
Notice the crossing toes
Is this hallux varus or valgus?
hallux valgus
medial prox
lateral distal
What surgery is done to correct bunions?
Bunionectomy
Typically involves
* Esostectomy - removal of medial prominence/medial aspext of 1st met head
OR
- Osteotomy - to realign metatarsals or proximal phalanx
When a bunionectomy is preformed what joint is hypomobile? because this joint is hypomobile what other joint become hypermobile to make up for this?
MTP joint is hypomobile
Tarsal metatarsal joint becomes hypermobile (also called lisfrank joint)
What motion is most limited w/ bunionectomy?
* which joint is this motion in?
* Which part of gait is most limited because of this?
* Since this motion is limited what glide is helpful?
MTP extension is very limited
= decreased push off
dorsal glide
Most common cause of a bonion?
Narrow shoes
KNOW: Things we do for a bonion: (biononectomy)
* Decrease swelling w/ ice
* massage
* muscle setting (isometrics)
* Scar mobilizations
KNOW: we can assume that MLA has not been properly stabilized w/ bunionectomy
* so strenghtening intrinisc foot muscles can help
Where is a tailors bunion?
Lateral
he called it a bonionet
KNOW: This is often seen in people that always sit criss-cross and that 5th met head is pusjed up against the floor
* can also be from tight shoes
KNOW: Metatarsal heads are more distal
When does turf toe normally occur?
* what joint is it at?
Weight bearing hyperextended 1st MTP
* feels like a jammed toe
In Turf Toe is the plantar or surace disrupted (at the first MTP Joint)
plantar surface
Disrupts the capsular ligament
* do w/ finger - can see that the plantar side is where the stress it
Turf Toe:
* often seen in sports (rapid accelration / deceleration)
* MTP pain
* Warmth, redness swelling
* ROM decreased because of pain
* Accessory: increased or decreased swelling or laxity endfeel
* Decreased great toe flexion strength or pain
* palpation: tender plantar aspect of MTP
* Function: Decreased push off during gait (because that needs hyper extension of MTP)
For turf toe we can do things to limit hyperextnsion (straining that plnatr capsular ligament)
Turf toe treatment
KNOW: Grade 3 turf toe is complete disruption
* puts them in a boot
* might need surgery
* 10-16 weeks return to play (so long because its a wt bearing ligament)
What is a trimalleolar fracture?
Both malleoli and one other structure
* could be posterior margin of tibia / taulus / soft tissue etc…
What is a potts fracture/dislocation?
Any dislocation and fracture of malleoli
What kind of fracture is this?
Spiral fracture
What kind of fracture is this?
This is transverse fracture
What kind of fracture is this?
What kind of fracture is this?
* What motion causes this fracture?
Jones fracture
* NOTE: it can be on the 4th or 5th proximal metatarsal
Typically an adduction injury (leading to inversion) during plantar flexion
* basically most of the pressure is on that latearl foot
* this could be a pivoting or cutting maneuver with most of the body wt on the 5th mtararsal hd
How old are jones fracture pts?
Younger (because they’re normally more athletic)
Where is pain felt w/ a jones fracture
Pain at the base of 5th metatarsal
* Edema
* Brusing
Screw fixation is typically common w/ a jones fracture
* Slow because its a wt bearing area
What causes a dancer fracture?
* where is it?
* What muscle causes it?
* What fascia causes it?
* What motion causes it?
Avulsion fx due to traction from fibularis brevis tendon or latearl band of the plantar fascia
Caused by foreful inversion and plantar flexion
* think about standing on your tippy toes (PF) and land off tippy toes and landing on the dorsal aspect of your foot (forcing inside of foot into inversion)
* This will pull on that tendon and cause that avulsion fx of the base of MT5
NOTE: Both a jones fracture and a dancer fracture are on the base of the 5th metatarsal. However, the Dancer fracture is proximal to the metatarsal tuberosity at the very distal end of the bone (Makes sense, this is the part that is avulsed)
Which injury is distal to the metatarsal tuberosity, jones fracture or dancer fracture?
Jones fracture is distal to the 5th metatarsal tuberosity
makes sense that dancers fracture is more proximal because this is the part that gets avulsed
which foot bone is most likely to be have a stress fracture?
Calcaneous
Where is a marchers fracture?
In the metatarsals (2,3,4)
* its a stress fracture
Who is more likely to get stress fractures in the foot - women or men?
Women
Biggest risk factor for stress fractures?
Caloric restriction
KNOW: Also
* Smaller bones in relation to body size
* Running / jumping sports
* repetititve stress
* new shoe wear
What is pain like for a stress fracture in the foot?
* Do they rememebr exactly what caused the fracture?
Normally localized
Insidious onset (because its just repetititve overloading so they dont really know when they did it)
* No specific event, just happens over time
* eaarly on, pain only while running
* can progress to pain w/ simple abulation
* reproduction focal point tenderness
What imaging do we do for an stress fracture
MRI more senstitive test early on showing bone marrow edema (use this)
Radiographic fingings typically show up after 2-8 weeks
What is a Lisfranc Injury?
* What causes it?
* What joint is it at?
* What bone is affected?
* MOI (direct and indirect)
*
Fracture or Fracture dislocation at tarsometatarsal joint
* Commonly involves 2nd metatarsal bone
MOI: Loaded hyperextension of toes; external rotation force combined w/ compression (dropping something) or indirect trauma (midfoot twisting getting caught on somthing)
Indirect trauma often caused by falling off a horse and foot getting stuck in saddle on the way down. Its a twist into extetneral rotation and extension of the toes which creates this dislocation fracture at the TMT
This is a lisfranc fracture
2nd metatarsal dislcoated dorasally
direction of force is into extension
swelling / brusing is present
pain in push off
Lisfranc fracture
NWB 6-8 wks (return to sports 6-8wks)
often requires surgical fixation
KNOW: OCD is normally within that taylor dome
Sprains = ligaments
Grade 1 sprain
* typically feel better within 1-2 weeks and usually do not seek treatment
*
What ligament in the foot/ankle is most commonly injuired
anterior talo fibularligament
second most common is calcaneofibular ligament
third is PTFL
Deltoid is not normally affected (this is on the medial side)
MOI is very important for identifying sprains
and sweeing the swelling
KNOW: w/ a sprain in the foot:
* decreased wb, decreased stance time and decreased push off on the affected side and shortened stride length
* decreased weight bearing = it hurts
The tibia and fibula are not being held together very well distally. What ligament is likely to blame?
anterior tibiafibular ligament
is the deltoid ligament medial or latearl?
Medial
Which kind of ankle sprain is the most common?
Latearl ankle sprain
* 11% of injuries within adolescents are due to this
* noramlly in sports (basketball or football)
An adolsencet female has a history of latearl ankle sprain. What is she likely to experience in adulthood?
Ankle instability
(50% of adolescents w/ chronic latearl ankle sprains have ankle instability going into adulthood)
* about 1/4 of them have ankle impingment
If you have a previous ankle sprains how much more likely are you to have another one in the next 6 months?
2.21 times more likely
* this is why rehab is so important - it decreases the chances of having another one
This is differintaiting what we should do w/ a chonric ankle sprain pt vs a new one
* also keep in mind their irritability
cont’d (ankle)
Lateral ankle sprain pts who might have success from manual therapy interventions: - would do good w/ a movement w/ mobilization / manipulation to this segment
CRPS for success: need 3 out of 4
* Symptoms worse w/ standing
* Symptoms worse in evening
* Navicular drop of > 5.0mm
* Distal tibiofibular joint hypomobility (stiff in that lateral ankle)
ankle shiz
ankle shiz
Ankle EX
Ankle surgery:
Cast / boot 2-6 wks of NWB
Followed by stirrup brace or CAM walking brace (contraolled ankle movement brace - making sure its nice and stable and limiting certain motions) several additional weeks
* AROM starts once in removable boot
* 6-12 weeks d/c immobilizer
* 3-6 months post op wear brace with intense activity
KNOW: Once your moving into that chronic rehab phase for ankle focus on wt bearing activity
* we want ankle strength to about 90% of contralateral side
KNOW: We always want to strength hip and knee along w/ ankle (we can also do core) / cardio
