Foot and Ankle Flashcards
1
Q
Overuse/degenerative injuries are typically due to
A
- poor footwear
- training errors
- biomechanical faults
2
Q
excessive supination
A
- hypomobility
- poor shock absorber
- poor at absorbing limb rotation
- may lead to stress up the chain
3
Q
treatment for excessive supination
A
- joint mobs
- stretching
- cushioned shoes/inserts for shock absorption
4
Q
excessive pronation
A
- hypermobile foot
- increased stress to soft tissues due to stretching and flattening arch
- absorbed limb rotation too quickly can lead to stresses up the chain
- decreased ability to become a rigid lever during push off
5
Q
treatment for excessive pronation
A
- strengthening
- arch taping/orthotics
- motion controlling shoes
6
Q
What is tarsal tunnel syndrome
A
- entrapment of tibial n as it passes under flexor retinaculum in the posterior tarsal tunnel (contains Tom, Dick, and Harry)
7
Q
signs and symptoms of tarsal tunnel syndrome
A
- pain, burning, throbbing, paresthesias on plantar aspect of foot
- increased symptoms with WB (excessive pronation)
- tinel’s sign at post tarsal tunnel
- weakness of foot intrinsics
- sensory deficits possible
8
Q
etiology of tarsal tunnel syndrome
A
- tenosynovitis/teninopathies of PT, FDL, FHL
- ankle sprain
- excessive/uncontrolled pronation
- previous fractures
9
Q
interventions for tarsal tunnel syndrome
A
- based on etiology
- stretch gastric and soleus
- arch supports
- strengthen intrinsics, PT, AT
- neural mobilizations
- address tendinopathies
- surgical release
10
Q
What is Morton’s neuroma?
A
- plantar digital nerve comes entrapped between metatarsal heads
- typically 3rd and 4th
11
Q
etiology of Mortons neuroma
A
- F>M
- 25-50 yo
- overuse or biomechanical abnormalities
- poor shoe fit/style (high heels, small toe box)
12
Q
Signs and symptoms of Morton’s Neuroma
A
- burning and/or throbbing sensation at MT heads that usually shoots into toes
- may have dorsal pain or pain radiating proximally into foot
- worse with walking/running
- Mortons test (squeeze MT heads together)
13
Q
Interventions for Morton’s Neuroma
A
- neural mobs
- joint jobs of MT heads and MT joints
- forefoot strengthening into flexion
- footwear adjustments/changes –> wide toe box
- nerve block, injections, surgery
14
Q
signs and symptoms of common fibular nerve compression/injury
A
- DF, EV, toe ext weakness
- foot drop and/or foot slap
- decreased sensation of ant leg and dorsal of foot/sides of toes
15
Q
Interventiosn for common fibular n compression/injury
A
- nerve mobs
- joint mobilizations of superior tib-fib joint
- soft tissue mobs of fibularis mm
- support if needed (AFO)
16
Q
Charcot Marie Tooth diagnosis
A
- first noticed due to foot deformities
- fatigue, pain, loss of balance
- nerve conduction tests/genetic testing
17
Q
Charcot Marie Tooth treatment
A
- no definitive treatment
- usually, progression steadies on its own
- stretching, strengthening, endurance
- contracture management, bracing, AD
- pain reduction/ management
18
Q
What is hallux valgus
A
- medial deviation of MT head; lateral deviation of proximal phalanx
- normal angle: 15 degrees
- pathological: >20
“bunion”
19
Q
hallux valgus etiology
A
- excessive pronation
- limited MTP extension during heel-toe off
- lax ligamentous structures
- weak musculature
- shoe wear
20
Q
hallux valgus conservative management
A
- joint mobs/stretching/strengthening
- correct biomechanics/arch supports
- shoe wear
21
Q
hallux valgus surgical management
A
- bunionectomy
- osteotomy
22
Q
Hammer toes
A
- MTP extension
- PIP flexion
23
Q
claw toes
A
- MTP hyperextension
- DIP and PIP flexion
24
Q
mallet toes
A
- flexion deformity of distal IP
25
interventions for toe deformities - conservative
- joint mobs/ stretching
- intrinsic strengthening
- orthotics/ shoe alteration
26
interventions for toe deformities - surgical
- bony corrections
- osteotomy
- bunionectomy
27
fibular fracture
- may cause injury to inferior tibiofibular joint
- may require surgical fixation if syndesmosis widening is more than 5 mm
28
malleolar fractures
- 85% involved isolated malleolus without displacement
- evidence supports god to excellent results with non surgical approach
- immobilization 6-7 weeks
29
bimalleolar fractures
- lateral malleolus fracture with either medial Mal fracture or rupture of deltoid ligament
- ORIF
- NWB/PWB 4-6 weeks
30
trimalleolar fractures
- bimalleolar fracture plus fracture of posterior lip of tibia
- ORIF with posterior fixation if large posterior fragments are present
31
extra-articular calcaneal fracture
- avulsion of achilles
- anterior process
(hyperdosiflexion injury)
32
intra-articular calcaneal fractures
- usually due to large compressive force
- fall from height
- requires surgical intervention
33
Talus fractures
- most are considered intra-articular bc most of talus is covered by articular cartilage
- most common: talar neck due to hyper-dorsiflexion at TC joint
- poor blood supply --> avascular necrosis common in talus
34
navicular tuberosity fracture
- PF/INV injury
- immobilize in supinated position
- possible surgery
35
navicular body fracture
- direct trauma
36
stress fracture of navicular
dorsomedial pain
37
cuboid fractures
- avulsion fractures commonly associated with PF/INV injuries
- frequently occur with lateral MT fractures
38
Cuneiform fractures
typically due to direct trauma
39
what is a Lisfranc Fracture
- disruption of 2nd TMT joint usually due to sudden twisting
40
presentation of LisFranc Fracture
- significant pain; inability to WB
- bruising (top or bottom of foot), swelling
41
treatment of LisFranc fracture
- NWB in cast/boot for 6 weeks
- RICE
- surgery
42
MT fractures
- displaced: need reduction
- non-displaced: #2-5 treated with tape immobilization; #1 NWB for 2 weeks then progressive WB
43
Phalangeal fractures
- primary cause is direct trauma - stubbing toe
- "nightwalker fractures"
- Rx: tape immobilization and protected weight bearing
44
general PT interventions for fracture
- in subacute phase
- progressive, protected WBing/gait training as instructed by MD
- ROM
- strengthening
- balance/proprioception
- joint mobs as cleared by MD
45
Intervention for shin splints
- relative rest
- address cause --> educate, training adjustments, biomechanical faults
- cushioned inserts/shoes
- gradual return to activity
46
Risk factors for shin spints/anterior medial tibial stress syndrome
- F>M
- increased body weight
- increased mm stiffness
- greater rear foot eversion during during running
- increased hip ER in flex
- previous running injury
47
Heel spur signs and symptoms
- local heel pain/plantar pain
- pain after activity, better with rest, worsens with in creased WBing
- may have excessive supination or pronation
48
PT intervention for heel spurs
- joint mobs and stretching if hypo mobility is present
- orthotics and footwear changes to reduce stress on plantar fascia
- heel insert/cushion
- strengthening if hyper mobility is present
49
Grade I ankle sprain - pathology
- mild stretch
- no instability
- single ligament (usually ATFL)
50
Grade I ankle sprain - signs and symptoms
- no hemorrhage
- minimal swelling
- point tenderness
- (-) ant drawer
- no varus laxity
51
Grade I ankle sprain - disability/ participation restrictions
- little/no limp
- minimal to no functional loss
- difficulty hopping
- recovery 2-10 days
52
Grade II ankle sprain - pathology
- large spectrum of injury
- mild-mod instability
- complete tear of ATFL OR partial tear of ATFL and CFL
53
Grade II ankle sprain - signs and symptoms
- localized swelling
- (+) anterior drawer
- no varus laxity
54
Grade II ankle sprain - disability/participation restrictions
- limp with walking
- unable to toe raise
- unable to hop
- unable to run
- Recovery: 10-30 days
55
Grade III ankle sprain - pathology
- significant instability
- complete tear: ATFL, CFL, anterior capsule
56
Grade III ankle sprain - signs and symptoms
- diffuse swelling
- early hemorrhage
- (+) ant drawer
- (+) varus laxity
57
Grade III ankle sprain - disability/participation restrictions
- unable to FWB
- significant pain inhibition
- initial loss of ROM (almost complete)
- recovery: 30-60 days
58
Management of Grade I and II ankle sprains
- depends on severity
- RICE 2-3 days for swelling
- strengthening and balance training
- proprioception
- external trading or taping may be required for high level activities
59
Management of Grade III sprains
- early mobilization and activity vs immobilization
- if immobilized, place in neutral or slight DF
- used for approx 3 weeks
- should allow WBing
60
Plantar fasciitis etiology
- Traumatic: sudden excessive pronation or direct pressure/contusion of plantar longitudinal arch surface
- mechanical/overuse
61
plantar fasciitis history/exam findings
- plantar (medial) heel pain --> most noticeable w/ initial steps after period of inability; worse following prolonged WBing
- recent change in activity (increased WBing)
- tenderness with palpation over medial plantar heel
- excessive pronation or supination
- + Windlass
- (-) Tarsal tunnel
- limited DF A/PROM
- possible heel spur
62
plantar fasciitis CPG - outcome measures
- use outcome measures such as Foot and Ankle Ability Measure, Foot Function Index, and others (LEFS, Foot health status questionnaire)
(I)
63
plantar fasciitis CPG - Interventions
- Manual Therapy (joint and tissue mobilization)
- Stretching - should use fascia specific and gastroc-soleus stretching
- Taping - should use taping (1-3 weeks); use foot orthoses to support medial longitudinal arch and cushion the heel (2 weeks to 1 yr); should prescribe night splints (1-3 mo)
64
Achilles tendonopathy etiology
- most prevalent in 40-59 age group
- risk factors: increased body weight, other systemic diseases, previous injury, decreased mm strength and flexility, family history
65
Ankle ligament sprains CPG - outcome measure
- use valid/reliable measures: PROMIS physical function and pain interference, Food and Ankle ability measure, lower extremity functional scale
- utilize at baseline and at least 1 follow up
(I)
66
Ankle ligament sprains CPG - physical impairment measures
- include objective measures of ankle swelling, ROM, talar transition and inversion, and single leg balance
- specifically include: WBing lunge test, static SLB on firm surface with eyes closed, dynamic balance (Star balance extrusion test)
(I)
67
Ankle ligament sprains CPG - Acute lateral ankle sprain intervention
- for primary prevention, should prescribe prophylactic bracing, particularly with risk factors
- for secondary prevention, should prescribe prophylactic bracing and use proprioception/balance training
- should advise patient on external support and progressive WBing
- for severe injustices, may immobilize for up to 10 days post
- should implement structures Therex program that includes protective AROM, stretching, neuromuscular training, post re-ed and balance training, both in the clinic and at home
- should use manual therapy in conjunction with exercise to reduce swelling, improve mobility, and normalize gait
- should NOT use ultrasound
68
Ankle ligament sprain CPG - chronic ankle instability interventions
- should prescribe proprioceptive and neuromuscular therapeutic exercise to improve dynamic postural stability and patient perceived stability
- should use manual therapy (mobs, manips, mobs with movement) to improve WBing DF and dynamic balance in short term
69
Achilles tendonopathy CPG - outcome and physical performance measure
- use the Victorian Institute of Sport Assessment-Achilles (VISA-A) t assess pain and stiffness (I)
- Use the foot and ankle ability measure or LEFS to assess activity and participation (I)
- include hope tests and heel raise endurance tests (II)
70
Achilles tendonopathy CPG - interventions
- use mechanical loading (eccentric or heavy-load, slow velocity) exercise to decrease pain and increased function (I)
- educate relative rest is not indicated (II)
- dexamethasone iontophoresis to decrease pain and improve function (II)
71
signs and symptoms of Achilles tendonopathy
- located pain (2-6 cm from insertion) and perceived stiffness following inactivity
- "warm up" phenomenon --> lessens with acute activity; may increase with prolonged activity
- selective tissue testing confirms pain with resisted testing, pain with stretching
- tender to palpation
- (+) London royal hospital test; arc sign
- excessive pronation
72
achilles tendon rupture signs and symptoms
- described as like being "kicked" or "shot" in the calf
- pain and swelling
- severe weakness and gait deviations due to limited/absent push off
- (+) thompson test
73
Achilles tendon rupture conservation management w/ early mobilization
- typically < 2 weeks immobilization at 20 degrees PF
- typically WBAT w/ hinged CAM boot
- progress to 0 degrees DF w/ in CAM boot
- may use 1-1.5 cm heel lift (B) after D/C from boot
- 6-8 weeks pain free ambulation w/o AD
74
achilles tendon rupture surgical repair
- immobilized 2 weeks
- Not > 10 deg DF by 8 weeks
- Symmetrical DF by 12 week
- limited and protected WB for 4 weeks then WBAT
75
flexor hallucis tendonopathy is commonly seen in
ballet performers
76
Pes Cavus (hollow foot) etiology
- numerous etiologies to include genetic predisposition, neurological disorders resulting in muscle imbalances, and contracture of soft tissue
77
deformity observed in pes cavus
- increased height of longitudinal arches, dropping of anterior arch, MT heads lower than hindfood, plantar flexion, and splaying of forefoot, and claw toes
78
PT goals, outcomes, and interventions for pes cavus
pt education emphasizing limitation of high impact sports, use of proper footwear, and fitting for orthoses
79
equinus etiology
- can include congenital bone deformity, neurological disorders such as CP, contracture of gastroc and/or soleus mm, trauma, or inflammatory disease
80
deformity observed in equinus
plantar flexed foot
81
compensation from equinus deformity
- limited dorsiflexion results in compensation of subtalar joint pronation and mid tarsal joint pronation
82
equinus deformity PT goals, outcomes, intervention
- flexility exercises of shortened structures within foot, joint mobilization to joint restrictions identified in examination, strengthening to intrinsic and extrinsic foot muscles, and orthotic management
83
etiologies of metatarsaliga
- mechanical: tight triceps sure group and/or achilles tendon, collapse of transverse arch, short first ray, pronation of forefoot
- structural changes in transverse arch, possible leading to vascular and/or neural compromise in tissues in forefoot
- changes in footwear
84
complaints frequently heard in matatarsalgia
- pain at first and second metatarsal heads after long periods of weight bearing
85
PT interventions, goals, outcomes for metatarsalgia
- correction of biomechanical abnormality (improving flexility of triceps surae), and modalities to decreased pain
- prescription and/or creation of orthoses
- pt education on foot wear
86
etiology of rear foot valgus
- abnormal mechanical alignment of the knee (genu valgum) or tibial valgus
87
deformity observed in rear foot valgus
- eversion of calcaneus with a neutral subtalar joint
88
do more muscular skeletal problems develop with rear foot valgus or varus?
- rearfoot varus
- due to increased mobility of hindfoot
89
PT goals for rear foot valgus
- regaining proper mechanical alignment
- improving flexibility of shortened soft tissues
- orthotic fitting and patient ed regarding foot wear selection
90
etiology of rear foot varus
- congenital abnormal deviation of head and neck of talus
91
deformity observed in rear foot varus
inversion of forefoot when subtalar joint is in neutral
92
PT goals, interventions, outcomes for rear foot varus
- regaining proper mechanical alignment
- improving flexibility of shortened soft tissues
- orthotic fitting and patient ed regarding foot wear selection
93
what is forefoot varus
- forefoot is in inverted position relative to the calcanea bisection due to lack of derotation of the talus
94
compensated forefoot varus
STJ and mid foot pronation
95
uncompensated forefoot varus
- anterior midfoot
- excessive forces and ankle or knee
96
what is forefoot valgus
forefoot is in an everted position relative to the calcaneal bisection due to excessive rotation of the talus
97
where will compensation occur for forefoot valgus deformity
compensation will occur through rearfoot
- will be supinated during mid stance
98
toes concave/convex rule
concave moving on convex
99
MTP joint abd/add concave/convex rule
concave on convex
100
subtalar concave/convex
concave on convex
101
talocrural concave/convex rule
convex on concave
102
TC joint OPP/CPP
OPP: mid inv/eversion and 10 degrees PF
CPP: full DF
103
subtalar joint OPP/CPP
OPP: midway between extremes
CPP: full inversion
104
mid tarsal joint OPP/CPP
OPP: Midway between extremes
CPP: full supination
105
TMT joint OPP/CPP
OPP: midway between supination and pronation
CPP: full supination
106
MTP OPP/CPP
OPP: neural (10 degrees ext)
CPP: full ext
107
IP joint OPP/CPP
OPP: flight flexion
CPP: full extension
108
talocrural joint capsular pattern
PF > DF
109
mid tarsal joint capsular pattern
supination > pronation
110
1st MTP capsular pattern
ext > flex
111
MTP II-V capsular pattern
variable --> tends toward flexion restrictions
112
IP capsular pattern
tends towards extension restrictions
113
ankle normal supination/pronation
sup: 45-60
pro: 15-30
114
ankle normal PF/DF
PF: 50
DF: 20
115
2nd -5th MTP normal flex/ext
flex: 40
ext: 40
116
1st MTP normal flex/ext
flex: 45
ext: 70
117
1st IP normal flex/ext
flex: 90
ext: 0
118
2nd-5th PIP normal flex/ext
flex: 35
ext: 0
119
2nd - 5th DIP normal flex/ext
flex: 60
ext: 30
120
