Chapter 13: The ankle and foot Flashcards
____________ - are the focal points to which the total body weight is transmitted in ambulation, and they are well tailored to that function.
foot and ankle
The thick ______ and ______ pads perform as shock absorbers in the acts of walking and running,
heel
toe
In children, you may find the forefoot inclined medially on the hindfoot. This is called:
Forefoot adductus
Abnormal high medial longitudinal arch of the foot.
Pes Cavus
Absence of medial longitudinal arch of the foot.
Pes Planus
If the foot is a light pink when elevated but becomes red when lowered. It is known as:
Dependent rubor
Increase in the skin thickness. This condition most often manifests itself over the metatarsal heads.
Callosity
____________ - usually indicates a residual edema secondary to trauma like fractured ankle.
Unilateral swelling
_____________ - may be evidence of cardiac or lymphatic problems, or of pelvic obstruction to venous return.
Bilateral swelling
____________ - commonly occurs around the malleoli secondary to a sprain.
Local swelling
______________ - is secondary to massive trauma, and involves the entire foot, occasionally extending up the tibial shaft.
Generalized swelling
What is the position of the patient during palpation of foot and ankle?
patient is sitting on the edge of the examining table with his legs dangling free, while you sit on a stool facing him. Stabilize the foot and lower leg with one hand by holding the foot around the calcaneus.
_____________ - is the joint most frequently involved in gout and bunions.
metatarsophalangeal joint
The head of the first metatarsal bone and the metatarsophalangeal joint are palpable at the _____ of the foot.
ball
_______________ - forms from the junction of metatarsal and first cuneiform bone.
first metatarsocuneiform joint
____________ - projects distally nearly half an inch further than the other cuneiform bones. It articulates with the base of the first metatarsal in a simple plane joint, providing gliding movement.
first cuneiform bone
Proximally with the talar head, distally with the three cuneiforms, and laterally with the cuboid bone.
Navicular Tubercle
It is characterized by local tenderness and a limping gait, is sometimes found in children.
Aseptic necrosis of the navicular
True or False:
If the tubercle is too prominent, it may press against the medial counter of the shoe and become painful.
True
The medial side of the talar head is immediately proximal to the navicular. You can find it by inverting and everting the forefoot; the resultant motion between the talus and navicular is palpable.
Head of the Talus
.From the head of the talus, probe proximally until you come to the prominent to the distal end of the tibia. The malleolus embraces the medial aspect of the talus, adding bony stability to the ankle joint.
Medial Malleolus
How to locate Sustentaculum Tali?
Move plantarward approximately a finger’s breadth from the distal end of the malleolus until you find the sustentaculum tali
True or False:
The sustentaculum tali is small, and may not be palpable at all, but it has anatomic significance. Clinically, it supports the talus and serves as an attachment for the spring ligament; problems within this anatomic alignment may well lead to pes planus.
True
________________ - which is small and barely palpable, lies immediately posterior to the distal end of the medial malleolus. It is the point of insertion for the posterior aspect of the ankle’s medial collateral ligament
Medial Tubercle of the Talus
Fifth Metatarsal Bone; Fifth _______________ Joint. These are situated at the lateral side of the ball of the foot.
Metatarsophalangeal
_________ - Probe proximally along the lateral shaft of the fifth metatarsal to its flared base.
styloid process
Move proximally along the foot’s lateral border, which is subcutaneous and easily palpable .
Calcaneus
_____________ - lies on the calcaneus, distal to the lateral rnalleolus. The tubercle is a significant landmark because it separates the peroneus brevis and longus tendons at the point where they pass around the lateral calcaneus.
Peroneal tubercle
_____________ - located at the distal end of the fibula, extends further distally and is more posterior than the mediaimalleolus. Its configuration permits the ankle mortise to point 15° laterally, and its additional distal extension acts as a deterrent to eversion ankle sprains.
Lateral Malleolus
In inversion and plantar flexion of the foot . A small portion becomes palpable; a greater portion of its surface is palpable on its lateral side than on the medial side adjacent to the medial malleolus. Occasionally, a defect is palpable in the articulating surface of the dome.
Dome of the Talus
_____________- This joint lies immediately proximal to the talus. Since the anterior inferior tibiofibular ligament overlies this joint, clear palpation of the joint itself is impossible; however, you can feel a slight depression directly over it .
Inferior Tibiofibular Joint
__________ - The bare posterior third of the dome protrudes sharply from behind the ankle joint. As you move plantarward along the walls of the calcaneus, notice that the bone flares outward at its plantar base.
Dome of the Calcaneus
_____________ - lies on the medial plantar surface of the calcaneus. It is rather broad and large, and gives attachment to the abductor hallucis muscle medially and to the flexor digitorum brevis muscle and the plantar aponeurosis anteriorly.
medial tubercle
To examine, have the patient extend his leg with the sole of his foot facing you, and stabilize the lower limb by holding his leg posterior to the ankle joint.
Plantar Surface
What is the inflammation of sesamoid bones?
sesamoiditis
___________ - Move laterally and palpate each by placing your thumb upon the plantar surface and your index finger upon the dorsal surface. The transverse arch of the forefoot is located immediately behind.
Metatarsal Heads
The ___________ of the foot is located immediately behind the metatarsal heads.
transverse arch
Soft tissue palpation:
What is the bone included in Zone I ?
Head of the First Metatarsal Bone
____________ - is a deformity characterized by lateral deviation of the great toe. In many cases, the deviation is so excessive that it causes the big toe to overlap the second toe.
Hallux valgus
The first metatarsal shaft may be medially angulated. Also known as:
meta tarsus primus varus
The ____________ of the first metatarsal head is also a common site for gout.
medial aspect
Deposits of urate crystals in the tissues about the joints.
Tophi
What zone is the Navicular Tubercle and the Talar Head?
Zone H
The plantar portion of the talar head articulates with the ____________ and the anterior portion with the posterior aspect of the _________ . The talar head lacks bony support between these two articulations.
sustentaculum tali
navicular
In pes planus (flat feet), the talar head displaces _________ and _________ from under cover of the navicular and stretches the spring ligament and the tibialis posterior, resulting in the loss of the _____________ .
medially
plantarward
medial longitudinal arch
What is included in Zone III?
Medial Malleolus
The important soft tissue structures in the depression between posterior aspect of medial malleolus and the Achilles tendon. From anterior to posterior they are:
1) tibialis posterior tendon
2) flexor digitorum longus tendon
3) posterior tibial artery and tibial nerve
4) flexor hallucis longus tendon
This tendon is most prominent when the patient inverts and plantar flexes his foot. It is both palpable and visible where it passes immediately behind and inferior to the medial malleolus.
Tibialis Posterior Tendon
This muscle lies just behind the tibialis posterior tendon. To palpate it, have the patient flex his toes while you resist his motion.
Flexor Digitorum Longus Tendon
This tendon actually lies on the posterior aspect of the ankle joint, rather than around the medial malleolus. It runs along the posterior aspect of the tibia and grooves the posterior aspect of the talus between its medial and lateral tubercles as it crosses the ankle joint.
Flexor Hallucis Longus Tendon
_____________ - lies between the tendons of the flexor digitorum longus and the flexor hallucis longus musdes (Fig. 40). Its pulse is not always easy to find.
Posterior Tibial Artery
__________- is located immediately posterior and lateral to the posterior tibial artery, and follows the artery’s course into the foot. The nerve is difficult to palpate as an isolated structure, but, since it is the main nerve supply to the sole of the foot.
Tibial Nerve
___________ - is bound to the tibia by a ligament, creating a tarsal tunnel which, if it is too small or too tight, can cause neurovascular problems in the foot.
neurovascular bundle
______________ - is often visible immediately anterior to the medial malleolus. When veins in the upper extremity cannot be located, this vein is almost always an accessible site for intravenous infusion.
Long Saphenous Vein
What are three important tendons and one vessel that pass between the malleoli. From medial to lateral they are:
1) tibialis anterior tendon
2) extensor hallucis longus tendon
3) dorsal pedal artery
4) extensor digitorum longus tendon.
The tibialis anterior, the extensor hallucis Iongus, and the extensor digitorum longus muscles are the ____________ of the foot. If they are not functioning, the patient exhibits “drop-foot,” or steppage gait.
main dorsiflexors
This tendon is the most prominent, as well as the most medial, of the three tendons. It is also the strongest dorsiflexor and inverter of the foot, and its loss alone can result in a drop-foot.
Tibialis Anterior Tendon
This tendon is situated immediately lateral to the tibialis anterior tendon and becomes most prominent when the big toe is actively extended. It stands out immediately lateral to the tibialis anterior tendon at the level of the ankle joint.
Extensor Hallucis Longus Tendon
This tendon lies lateral to the extensor hallucis longus. Palpate it first where it crosses the ankle joint. Distal to the ankle, the tendon divides into four parts, each of which inserts into the dorsal base of the distal phalanx of the four lesser toes. The tendons become prominent for palpation when the toes are extended.
Extensor Digitorum Longus Tendon
____________ - lies between the extensor hallucis longus and the extensor digitorum longus tendons on the dorsum of the foot. It is absent approximately 12 to 15 percent of the time.
Dorsal Pedal Artery
In some instances, the pulse of the dorsal pedal artery may be reduced, usually as a result of ____________.
vascular disease
The tibialis anterior, the extensor hallucis longus, and the extensor digitorum longus muscles take origin from the _______________ on the leg’s anterolateral side, between the tibia and the fibula.
anterior compartment
There are three clinically important ligaments which comprise the lateral collateral ligaments of the ankle joint . From anterior to posterior they are:
1) anterior talofibular ligament
2) calcaneofibular ligament
3) posterior talofibular ligament.
What zone is the lateral Malleolus?
Zone V
This ligament has a high incidence of sprain because it is the first of the three lateral collateral ligaments to undergo stress when the ankle is inverted and plantar flexed. It runs from the anterior portion of the lateral malleolus to the lateral aspect of the talar neck.
Anterior Talofibular Ligament
______________ - stretches plantarward to its insertion into the lateral wall of the calcaneus. It actually attaches to a small tubercle on the calcaneus, slightly posterior to the peroneal tubercle.
Calcaneofibular Ligament
The loss of function of both Calcaneofibular Ligament and anterior talofibular ligament ligaments results in ____________ .
ankle instability
This ligament takes origin from the posterior edge of the lateral malleolus and passes posteriorly to the small lateral tubercle on the posterior aspect of the talus. It is stronger than the two other collateral ligaments.
Posterior Talofibular Ligament
What is the primary function of Posterior Talofibular Ligament?
its primary function is to prevent forward slippage of the fibula onto the talus.
These tendons pass immediately behind the lateral malleolus as they cross the ankle joint. The brevis is closer to the malleolus, grooving the bone as it passes, while the longus lies just posterior to the brevis.
Peroneus Longus and Brevis Tendons
What are the primary foot everters, and they assist in plantar flexion?
Peronei
__________ is commonly affected by ankle sprains. Its normal concavity may be filled with edema, and the course of the anterior talofibular ligament becomes tender from the anterior portion of the lateral malleolus to the talar neck.
Sinus Tarsi
What conditions causes Deep tenderness within the sinus tarsi?
some problem in the subtalar complex and is usually indicative of fracture, rheumatoid arthritis, or spastic foot syndrome.
When the patient extends his toes, the muscle belly of the extensor digitorum brevis bulges out of the sinus tarsi and is easily palpable. What is this muscle?
Extensor Digitorum Brevis Muscle
What zone is the Head of the Fifth Metatarsal?
Zone VII
Excessive friction or pressure upon this bursa can cause both bursitis and the development of an associated excrescence of bone over its lateral aspect with subsequent redness, swelling, and tenderness. This condition is known as:
“tailor’s bunion.”
What zone is the Calcaneus?
Zone VIII
This bursa lies between the anterior surface of the tendon of Achilles and the bare posterior superior angle of the calcaneus.
Retrocalcaneal Bursa
This bursa lies between the insertion of the Achilles tendon and the overlying skin.
Calcaneal Bursa
True or False:
The calcaneal bursa is more commonly enlarged, a condition usually due to oversized or tight shoes and particularly to high heels.
True
What zone is the Plantar surface of the foot?
Zone IX
The central bony prominence in the area of the hindfoot is the broad medial tubercle of the __________ . Most of the muscles of the plantar surface of the foot originate from this bone. Their origins are not palpable because of the thick pad of fat covering the bone.
calcaneus
_________ - a painful neuroma usually located between the 3rd and 4th metatarsal heads.
Morton’s neuroma
These strong bands of fascia originate at the medial tuberosity of the calcaneus, splay out over the sole, and insert into ligamentous structures near the metatarsal heads in the forefoot.
Plantar Aponeurosis (or Plantar Fascia)
What is the function of Plantar Aponeurosis?
The plantar aponeurosis covers all the soft tissue structures of the foot, and acts as a virtual tie-beam for the support of the medial longitudinal arch.
Palpate the plantar surface of the foot. It should feel smooth, nontender, and nonnodular. Point tenderness may indicate ___________ , while discrete palpable nodules in the fascia indicate ____________ . .
Plantar fascitis
Duputyren’s contracture
Nodules found on the skin of the sole (particularly on the ball of the foot) , which are more tender when pinched than when under direct pressure.
plantar warts
True or False:
Palpate the soft tissues between each of the metatarsal heads for tenderness and swelling.
True
True or False:
It is not uncommon to find painful neuromas in the space between the third and fourth metatarsal heads (Morton’s neuroma) . Callosities on the plantar surface, unlike warts, are tender to pressure but not to pinching.
True
What zone are the Toes?
Zone X
Normally, the toes lie _____ and ________on the floor as they bear weight. But there are several pathologic conditions indigenous to them.
flat
straight
Characterized by hyperextension of the metatarsophalangeal joints and flexion of the proximal and distal interphalangeal joints. The condition generally involves all of the toes and is often associated with pes cavils
Claw toes
_________ are typified by hyperextension of the metatarsophalangeal and distal interphalangeal joint and flexion of the proximal interphalangeal joint.
Hammer toes
_______ are soft due to the moisture between the toes. They should be palpated gently, for they are frequently tender
Corns
__________ are most often situated in areas of excessive pressure, such as on the dorsum of flexed interphalangeal joints, especially on the fifth toe. may be tender to direct pressure .
Hard corns
____________ - involve the medial and lateral aspects of the great toe. The anterior corners of the nail dig into the surrounding skin, causing swelling and infection of the adjacent soft tissue. The area of involvement feels warm and boggy and is tender to palpation
Ingrown Toenails
Movements of the foot and ankle almost in variably involve more than a single joint. The basic ankle and foot motions are:
1) Ankle Motion Dorsiflexion Plantar flexion
2) Subtalar Motion Inversion Eversion
3) Midtarsal Motion Forefoot adduction Forefoot abduction
4) Toe Motion Flexion Extension
Active Range of Motion: To test ___________ and ________, ask the patient to walk on his toes, to test dorsiflexion, instruct him to walk on his heels. To test inversion, have him walk on the lateral borders of his feet; to test eversion, instruct him to walk on the medial borders of his feet
plantar flexion
Toe motion
What is the Passive Range of Motion of the foot?
Ankle Dorsiflexion 20°
Ankle Plantar Flexion 50°
____________ and ___________ takes place between the talus and the tibia and fibula within the ankle mortise. A line drawn between the midpoints of the medial and lateral malleoli approximates the axis of ankle joint motion.
Dorsiflexion
plantar flexion
When the foot is plantar ________ , there is normally a slight degree of ___________ mobility between the malleoli.
flexed
lateral talar
These motions adjust the foot so that it can function on uneven surfaces. The motions take place primarily at the talocalcaneal, talonavicular, and calcanecuboid joints.
Subtalar inversion and eversion
True or False:
To test inversion and eversion, have the patient remain seated on the edge of the examining table and stabilize his tibia by holding it around its distal end. Then, gricalcaneus, and alternately invert and evert the heel.
True
A patient who has _____________ (secondary, perhaps, to a calcaneal fracture ex- ending to the subtalar joint) may complain of pain during this motion. There is a distinct and obvious difference between the subtalar motions of younger and older patients.
subtalar arthritis
The motions of forefoot adduction and abduction take place primarily at the __________ (the talonavicular and calcaneocuboid joints).
midtarsal joint
To test these motions, hold the patient’s foot at the calcaneus with one hand to stabilize the heel in the neutral position during the test, and move the forefoot medially and laterally with your free hand.
forefoot adduction and abduction
To test it, stabilize the patient’s foot and move his great toe through flexion and extension . Normal toe-off requires a minimum of 35° to 40° of extension.
First Metatarsophalangeal Joint
Passive range of motion: What is the degree of range of movement of Flexion and Extension?
Flexion 45°
Extension 70°-90°
______________ - can be functionally tested by having the patient walk on his heel, with his foot neither inverted or everted. The tendon should stand out clearly all the way to its insertion at the proximal end of the distal phalanx of the great toe.
extensor hallucis longus
This muscle is predominantly innervated by L4, but also receives some L5 innervation.
Tibialis Anterior
To test the muscle in function, ask the patient to walk on his heels with hisfeet inverted. The tendon of the muscle can be seen where it crosses the anteromedial portion of the ankle joint; it is quite prominent distally toward its insertion.
Tibialis Anterior
In this neurologic examination, first the dorsiflexors and then the plantar flexors will be tested, both from lateral to medial. As follows:
1) Tibialis Anterior deep peroneal nerve, L4, (L5)
2) Extensor Hallucis Longus deep peroneal nerve, L5
3) Extensor Digitorum Longus deep peroneal nerve, L5
The muscles of the foot fall into two main functional categories include:
the dorsiflexors and the plantar flexors.
