Foot and Ankle 1 (test 4) Flashcards
Functional questionaires for ankle sprains
cumberland ankle instability tool
foot and ankle ability measure
LE functional scale
incidence/prevalence of ankle sprain
very frequent in sports
up to 1/4 people are unable to attend work for >1 wk
persistent symptoms in 30-72%
80% reinjury rate following inversion sprain
risk factors for ankle sprain
previous sprain
lack of external support
lack of warm up
lack of coordination training
impaired DF
what may cause impaired dorsiflexion
shortened triceps surae
talar hypomobility (decreased posterior glide or ER)
fibrosed capsule (universal hypo; limited distx compared to other side and all glides limited)
limited DF may cause escessive load where
lateral foot bc talocrural jt NOT reaching CPP and staying in supination longer before pronating
common etiology of ankle sprains
PF > inversion
most commonly torn ankle ligament
anterior talofibular
when is the calcaneofibular ligament often torn
primarily with pure IV
on slack with PF so not torn then
what are the 3 lateral talocrural ligaments
Anterior talofibular (ATF)
Calcaneofibular (CF)
Posterior talofibular (PTF)
what are the subtalar or talocalcaneal ligaments involved in lateral sprains
intraarticular = anterior interosseous
extraarticular = lateral attaches and runs parallel to CF ligament so they will likely be damaged together
what mechanism may strain the calcaneifibular ligament and the lateral talocalcaneal ligament (LCL)
Inversion and DF
what mechanism may strain the anterior talocalcaneal ligament
inversion and plantar flexion
how might the bone be involved with a lateral ankle sprain (and mechanism)
avulsion fx or lateral malleolus (ligament attachment)
avulsion fx of 5th MT (excess action of peroneus brevis)
medial malleolus fx (excess IV)
cuboid displacement (excessive action peroneus long.)
ant. subluxed fibula on tibia (reversed m action of peroneals)
what muscles/tendins may be involved with a lateral ankle sprain
possible peroneal strain and/or sublux if retinaculum is torn
symptoms of a lateral ankle sprain
sudden onset with trauma by “rolling ankle” and foot turning inward
lateral ankle P!/swelling
limited and painful ROM especially with pointing foot inward
difficulat and painful WBing
observation with a lateral ankle sprain
swelling with possible ecchymosis
antalgic/asymmetrical gait
what is the purpose of the Ottawa and Bernese ankle clinical decision rules
determine the need for a radiograph
ROM findings with a lateral ankle sprian
primarily limited in PF and IV
resisted test findings for a lateral ankle sprain
weak and painful EV
acessory motion findings for lateral sprain
likely hypermobile anterior talar glides due to ATF laxity
possibly hypomobile cuboid from sublux
special tests for a lateral ankle sprain
anterior and reverse anterior drawer
ATF = anterior lateral drawer and reverse anterior lateral drawer and anterior lateral talar palpation
CF = medial talar tilt
PTF
subtalar = anterior interosseous and lateral interosseous
TTP over involved structures
etiology of medial ankle sprains
excessive EV
structures that may be involved with a medial ankle sprain
deltoid lig (connect tibia to talus, calcaneus, and navicular + medial arch reinforcement)
dubtalar or talocalcaneal ligaments (intraarticular = post interosseous and extra = medial)
non-ligamentous structures that may also be involved with medial sprains
bone = avulsion fx of medial malleolus
epiphyseal plate of medial malleolus
possible post tib strain and/or sublux if flexor retinaculum is torn
symptoms of a medial ankle sprain
sudden onset with trauma + ankle turning out
medial ankle pain/swelling
limited/painful ROM, especially turning out
pain with WBing
what could you observe with a medial ankle sprain
swelling
possible ecchymosis
antalgic/asymmetrical gait
ROM and MMT findings with medial ankle sprain
ROM = primarily pain/limits with EV
MMT = possible weak/painful IV
accessory motion findings for medial sprain
potentially hypermobile calcaneal EV glides
special tests for a medial ankle sprain
talocrural
-general = anterior and reverse anterior drawer
-specific = medial lig tests for deltoid ligs
subtalar
-general = medial calcaneal glide
-specific = post interosseous and medial lig tests
what is a syndesmotic sprain
high ankle sprain
etiology of a syndesmotic sprain
primarily DF (bc talus is wider anterior than posterior)
excessive talar posterior glide with ER aka peeling mechanism
possibly EV
what ligaments are involved with a syndesmotic in order
1st = Anterior inferior tibio fibular ligament
2nd = interosseous membrane or syndesmosis
3rd = posterior inferior tibio fibular ligament
4th = deltoid ligaments
what bones may be involved with a high ankle sprain
talar or distal tib/fib fx
symptoms of syndesmotic sprain
sudden onset with trauma with ankle bent up
often anterior ankle pain or swelling
limited and painful ROM, especially with DF
pain with WBing
observation of a syndesmotic sprain
swelling
possible ecchymosis
antalgic/asymmetrical gait
ROM and MMT findings for high ankle sprain
ROM = limited and painful with DF and possibly EV
MMT = weak and painful; no specific direction
accessory motion findings for syndesmotic sprain
likely hypermobile post talar glides
special tests for syndesmotic sprain
inferior tib/fib lig
-general = reverse post drawer
-specific = fibular ant/post translation
possibly same as medial ankle sprain
single leg hop test (inability is most sensitive test for syndesmotic test)
what is chronic ankle instability
CAI
presence of functional or mechanical instability
risk factors for CAI
increased talar curvature
lack of external support
lack of cordination training following prior sprain
etiology of chronic ankle instability
past severe and or recurrent sprains
80% re-injury rate following IV sprain
S&S of CAI
acute S&S if aggravated; otherwise may be asymptomatic
S&S of hypermobility/instability plus:
-decreased postural stability and plantar sensation
-altered muscle activation patterns
-aberrant joint motion
-fibula is significantly more lateral from tibia
PT rx for sprains outside of MET/MT
90% success
brief immobilization period
modalities modtly conflicting evidence; cryotherapy good for pain/swelling/gait; US should NOT be used with acute
bracing/taping for protection/function
-bracing = reduced risk and frequency
-talar technique to limit anterior glide
-distal tib/fib technique for high ankle sprains; limits separation and anterior distal fibular glide
MT for sprains
STM including lymphatic drainage for swelling
JM with MET
-ROM/proprioception/tissue tolerance
-AP talar JM
-hypo analgesic effect and subsequent increased ROM
MET for sprains
goal = tissue proliferation and stabilization
positional/directional biases?
balance and neuromuscular training
-prevents reoccurance
-improved balance and inversion jt position sense and greater motor neuron excitability
prognosis for return to activity for grade I sprain
1-2 weeks
avg 7.2 days with track and field athletes
prognosis for return to activity for grade II sprain
2-6 weeks
avg 15 days with track and field athletes
prognosis for return to activity for grade IIIsprain
> 6 weeks
avg 30-55 days with track and field athletes
what is the MD Rx for CAI
CAI sx; “christman-snook procedure for mechanical ankle instability
drill holes in fibula and calcaneus
split portion of peroneus brevis tendon
tendon is inserted into drill holes and attached into itself
outcomes of CAI sx for sprains
no one procedure is better than another
early functional rehab appears superior to 6 weeks immobilization in restoring early function
what makes up the forefoot
metatarsals and phalanges
what makes up the midfoot
navicular, cuboid, and cuneiforms
2nd MT is a keystone in between the medial and lateral cuneiforms
what makes up the rearfoot
talus and calcaneus
what makes up the lateral foot or column and what is its functional purpose
4th and 5th rays and cuboid and calcaneus
functions more for shokc absorption from heel strike to just before heel off
strong ligaments are a storehouse of potential energy on the lateral longitudinal arch
what makes up the medial foot/column and its functional purpose
1dt ray thru the 3rd rays and the cuneiforms and talus
functions more for propulsion just before heel off to toe off
less ligament support vs lateral foot
how much DF occurs with knee extension and flexion and when does it occur in the gait cycle
knee extended = during heel/toe off; 10-15 deg
knee flex = during stairs; 15-25 during ascent; 20-35 during descent
how much PF is needed for stairs
15-30 deg for walking and stairs
how much MTP hyperext is needed at the first MTP
at least 65 deg at heel/toe off
what structures help maintain the arches of the foot
ligaments and aponeurosis = most support
shape of the bones and their relation to each other
muscles = only 15-25% of support so minimal ability to “strengthen” any abnormal arch flattening
what is subtalar neutral
talus is centered in talocrural andn on calcaneus
aka position talus should be in
best measurement of medial longitudinal arch
standing position = not predictable of dynamic fxn
measuring from video or 3D analysis is more reliable
how does the foot move during the gait cycle from heel strike to foot flat
supination with heel strike (PF, IV and ADD)
PF eccentrically controlled by tibialis anterior
how does the foot move from foot flat through heel off
DF, EV, ABD
eversion primary control is tibialis posterior
max ankle DF and talar ER with ABD of foot
how does the foot move from mid stance to heel off
all arches are maximally flattened when all MT heads contact the ground
knee ER and hip IR while both maximally extend/hyperextend (up to 10 deg)
how is potential energy built in the foot
foot ligaments
middle and posterior ankle ligaments
ankle PFs
interosseous membrane as tib/fib seperates with DF
knee and hip structures per prior lecture
what happens from heel off to toe off in terms of load bearing and potential energy
1st ray bears most of the load of the foot
1st MTP maximally hyperextends and PE is built through the plantar fascia tightening
what happens when PE is releases from toe off to swing
opposing motions occur for propulsion
great toe flexion
ankle PF and talus IR
knee flexes and IR
hip flexes and ER
what is excessive pronation
earlier, extended, and or excessive combo of DF, EV, and ABD
most common reason of excessive pronation related to hypermobility/instability
tib fib or talocrural hypermobility/instability (more common)
or
impaired LE control (top down influence)
less common mechanism for hypermobility related excessive pronation
subtalar or medial knee hypermobility
how can adj joint hypomobility cause excessive foot pronation
limited talocrural DF may lead to midfoot and forefoot excessive EV and ABD
limited knee ext may lead to excessive DF
hip wont compensate bc hip is IR where knee and talus are ER
what might limited DF lead to
excessive loading on lateral foot and staying in supination longer = more common for lateral sprains
compensatory/excess knee ext
LQ conditions associated with limited DF
1st MTP DJD
mortons
tarsal tunnel
plantar fascitis
5th MT stress fx
lateral ankle sprain
achilles tendinopathy
severs
MTSS
