Foot and Ankle Flashcards
Describe the ligaments of the foot.
Ligaments between all phalanges, can have sprains between all
Describe the ankle ligaments on the medial side.
- Ligament on inside of ankle is deltoid ligament: medial side (covers majority of inside of ankle)
- Medial side of ankle is stronger
Describe the ankle ligaments on the lateral side.
- Anterior talofibular ligament (anterior, connects talus and fibula)
- Calcaneofibular ligament (connect calcaneus and fibula)
- Posterior talofibular ligament (posterior, connects talus and fibula)
Describe the ankle ligament on the anterior side.
- Anterior inferior tibularfibular ligament
What are the 3 types of muscles in the foot?
- DAB muscles
- PAD muscles
- Muscles at lower leg that insert at foot
What are DAB muscles?
dorsal abductors (top of foot, move toes apart from each other)
What are PAD muscles?
plantar adductors (bottom of foot, bring toes in together) (ex. Toe cramps)
What is flat feet called?
pes planus foot
pes planus foot is the product of ______ _______.
excessive pronation (bottom of feet are falling flat in arch)
What are the causes of pes planus?
- Can be born with it
- Comes along with several other conditions (ex. Down syndrome)
- Can get this from spraining your ankles a lot (weakens ligament that holds arch up)
- Can get it from wearing really tight shoes (tight shoes = ligaments don’t have to work as hard, too weak to hold it up)
- Overweight (weight bearing on arch)
What are the signs and symptoms of pes planus?
- Pain in arch (ache)
- Pain in medial side of ankle
- Weak feet
- Feet tire quickly on arch/inside
- Can lead to bunions (bulge bone out to the side to hold weight)
- Knees cave in, inside of knees are weak
- Hips cave in, hips aren’t sitting right
How do we manage pes planus?
- No pain = do nothing
- insoles/orthotics
- Can be taped
What is pes cavus?
- high arch foot
What are the causes of pes cavus?
- generally born with it
- rare
- common in runners
How can we tell if someone has pes cavus?
Look at imprint of foot when wet (only see heel, ball, and toes, nothing connecting)
What are the signs and symptoms of pes cavus?
- Can have no symptoms
- Can have pain and tightness in bottom of foot
- Hammertoes (toes bunch up)
- Calluses on top of toes, heels, ball of foot
How do we manage pes cavus?
- No pain/discomfort = do nothing
- Try to loosen structures at bottom of feet
- Roll out feet with golf ball
- Stretch out bottom of feet
What is the plantar fascia?
- runs bottom of feet, starts bottom of feet, fans out to all toes
- Shock absorption/support for bottom of feet
- Attached to achilles tendon and calf muscles
What is plantar fasciitis?
inflammation of the plantar fascia
How does pes cavus relate to plantar fasciitis?
plantar fascia is already tight (works harder because it has to spread out farther and rebound farther)
What makes you more likely to have plantar fasciitis?
- Tends to be more common in runners (more shock to the bottom of the feet, higher impact, more often)
- Tend to have it more often if you wear unsupported footwear (no cushion for feet)
- Tight achilles tendon or calf muscles means tight plantar fascia
Describe the progression of signs and symptoms for plantar fasciitis.
- Burning pain on the bottom of their feet
- Starts with being sore only after activity
- Progresses to bothering them during activity (generally last part of activity)
- Progresses to bothering them from the beginning of activity
- Progresses to hurting them all the time (regardless of weight bearing or not)
What is the tell tale sign of plantar fasciitis?
- first two or three steps in the morning feel like their feet are on fire
- then it loosens up
- then at end of activity it hurts again (plantar fascia is shortened/tightened overnight, then first steps stretch it out)
How do we manage plantar fasciitis?
- roll/stretch bottom of feet
- Roll with golf ball, frozen water bottles
- Ultrasound
- Massage
- Heat feet/stretch before activity
- Ice feet/stretch after activity
How do we assess plantar fasciitis?
- Palpate plantar fascia
- Feels tight, painful when you touch it
What is the most common injury in the bottom?
inversion ankle sprains
What happens in inversion ankle sprains?
- bottom of the foot goes in
- sprains ligaments on the outside of the ankle
What ligaments do you hurt in an inversion ankle sprain?
- anterior talofibular ligament
- calcaneofibular ligament
- posterior talofibular ligament
- grades apply to each individual ligament (can have
different grades on each from same injury)
Which ligaments are typically injured in a grade 1 inversion ankle sprain? What happens to these ligaments?
- Predominantly anterior talofibular and calcaneofibular ligaments
- stretching of a ligament
What are the signs and symptoms of a grade 1 inversion ankle sprain?
- Mild pain
- Mild inflammation
- No bruising
- No deformity
- Tender over whichever ligament has been damaged
- No laxity (movement between the bones), but special test will be painful
How do we manage a grade 1 inversion ankle sprain?
- Control their pain, inflammation
- Ice
- Compression
- Should not need to limp (full function of all structures in ankle), but may limp due to pain
- Make sure they are walking properly
Which ligaments are typically injured in a grade 2 inversion ankle sprain? What happens to these ligaments?
- More common in anterior talofibular and calcaneofibular
- some tearing of fibres
What are the signs and symptoms of a grade 2 inversion ankle sprain?
- More pain
- More inflammation
- Bruising
- Limping
- Special test: pain and laxity (more movement out of joint than you should)
How do we manage a grade 2 inversion ankle sprain?
- Need some sort of protection: taping, bracing etc.
- RICE
- Anti inflammatory
- Need strengthening of joint and of supporting muscles and structures
- Tubing (pulling inside or outside)
- Calf raises
Which ligaments are typically injured in a grade 3 inversion ankle sprain? What happens to these ligaments?
- At least one of the three ligaments is torn completely (usually either the anterior talofibular or calcaneofibular ligament)
- Can have avulsion fracture
What are the signs and symptoms of a grade 3 inversion ankle sprain?
- Lots of pain
- Lots of swelling
- Lots of bruising
- Lots of laxity
- No function
- Limping
How do we manage a grade 3 inversion ankle sprain?
- Need brace or boot
- May not be weight bearing
- Protect area more
- Need to deal with swelling, pain, bruising
- Strengthen joint
Why are eversion ankle sprains more rare than inversion ankle sprains?
ligaments on the inside are stronger
Describe a grade 1 eversion ankle sprain.
- Pain, some swelling, no bruising
- Stretched ligament
- No laxity
- Make sure they are walking properly
- Generally don’t need extra protection
Describe a grade 2 eversion ankle sprain.
- Tear
- More swelling, more pain
- Limping
Describe a grade 3 eversion ankle sprain.
- Complete tear of some part of the ligament
- Lots of swelling, bruising
- Limping
What is sprained in a high ankle sprain?
- anterior inferior tibularfibular ligament
- holds together tibia and fibula
- sprain means they spread apart with every step
What is typically the MOI of a high ankle sprain?
rotation movement
What are the signs and symptoms of a high ankle sprain?
- Very painful to walk, regardless of degree (nothing else holds them together)
- Swelling sits higher up their leg, but lots of swelling would spread into feet
- More pain (every step hurts)
How do we manage a high ankle sprain?
- Taped or braced, even if it is a first degree
- Longer heal (8-12 week), even if it is a first degree
What are the 2 ankle stability tests?
- anterior drawer test
- talar tilt test
What are the 2 tests for high ankle sprains?
- squeeze test
- external rotation test
Describe the anterior drawer test.
- Specific to deltoid ligament and 3 ligaments on outside
- Regular inversion or eversion ankle sprain
- Pulling and pushing shin and heel in opposite directions
Describe the talar tilt test.
- Specific to calcaneofibular ligament and deltoid ligament
- Tilting the heel back and forth
Describe the squeeze test.
- anterior inferior tibularfibular ligament
- squeeze tibia and fibula together
Describe the external rotation test.
- anterior inferior tibularfibular ligament
- Rotate ankle out to the side, force tibia and fibula apart
=
fracture
Name 3 ways that ankle fractures and dislocations can occur.
- Compression load down
- Twist
- Sprain
What bones can be fractured/dislocated? Which is most common?
- Talus
- Lateral malleolus
- Medial malleolus
- no bone is more common than another
What types of fractures are most common in the ankle?
- crush type fracture
- avulsion fracture
- straight longitudinal fracture
Why are spiral fractures rare in the ankle?
spiral force will cause dislocations
In what position is the ankle strongest vs dislocations and in what position is the ankle the weakest?
- Foot in dorsi flexion means talus and tibia and fibula is tight and stable
- Pointed toes means talus and fibula is loose, this is the easiest way to dislocate ankle
What are the signs and symptoms of ankle fractures/dislocations?
- Redness
- Heat
- Bruising
- Grinding
- Popping
- Cracking
- Usually see deformity (divots or bulges)
How do we manage ankle fractures/dislocations?
- No distal pulse = EMS
- Need to go to the hospital
- Don’t need special test if it is obvious
- Support ankle as best as you can in the position it is in
- Generally immobilize the person, will almost never cast (boot)
How do you check for a distal pulse?
- Pulse on bottom of foot closest to toes
- Pulse on top of foot
- Squish toes, if it turns white, see if it turns back to red
Describe rehab for ankle fractures/dislocations.
- Probably in boot for 2 weeks non weight bearing
- RICE
- Electrotherapy
- Do not do ultrasound (sound wave enters tissues and causes them to vibrate,
anyone with a fracture or dislocation will feel this as an electric sensation) - Then need stress on it, still generally in boot for 4 weeks or until they are comfortable walking
Why are fractures more severe in the lower leg than in the ankle?
- Only 2 bones
- Veins and arteries and nerves in lower leg
- Generally jagged fractures, blood vessels are close to bones
- Muscles in lower leg are in compartments, swelling has nowhere to go = further damage
Where do fractures generally happen in the lower leg?
middle area of the shaft
What are the signs and symptoms of lower leg fractures?
- Painful
- Can be open or closed
- Jagged (increase likelihood of being open)
- Swelling
- Bruising
What is the special test for lower leg fractures?
- compression test
- Don’t do this if it is obvious
- Squeeze tibia and fibula together
- Pain is positive indication
How will they immobilize a lower leg fracture?
- If this fracture is below halfway, they may be able to be in a long boot (immobilize whole tibia)
- If fracture is above halfway, their knee needs to be immobilized. Will be in a long leg cast, or in zimmer splint
How long will the leg be immobilized with a lower leg fracture?
- Long term immobilization (at least 4-6 weeks)
- Less time if it is fibula (3-4 weeks)
- More time for tibia (4-6 weeks)
Describe the rehab for a lower leg fracture.
- Regain ROM at ankle and knee
- Watch for atrophy
- Lots of calf raises, foot exercises
How does achilles tendonitis occur?
- overuse injury
- most common injury in achilles
- MOI: too much calf raise type movement (running, jumping etc.)
- MOI: calf raise type movement while pushing on achilles (shoes, strapping etc.)
What are the signs and symptoms of achilles tendonitis?
- Swollen right at the structure
- warm/hot right at the tendon
- Might have redness
- Will NOT have bruising
- Grinding sensation, feels like it catches (crepitus)
What is the special test for achilles tendonitis? How is it performed?
- thompson test
- physically palpate tendon for grinding sensation
What are the 4 stages of signs of achilles tendonitis?
- Stage 1: only painful after activity
- Stage 2: starting to get sore during activity, but doesn’t impede performance much. Painful during and after, feels better next day
- Stage 3: hurts during whole activity, starts to impede performance (harder to run, jump, limping)
- Stage 4: physically impossible to do activity, just walking around hurts
People generally don’t seek help for achilles tendonitis until stage ___.
3
What is achilles tendinosus?
achilles tendon is breaking down, no way to reverse it
How do we manage achilles tendonitis?
- Rest (activity modification)
- Tape, strap to provide support to the structure that is damaged
- Strengthen tendon without further damage
- Calf raises
How does an acute achilles strain occur?
- 1 time mechanism injury (not overuse)
- MOI: too much stretch
- MOI: trying to push off explosively when already in stretch
- covers 1st and 2nd degree
What are the signs and symptoms of a first degree achilles strain?
- Mild swelling
- Mild pain
- Mild heat
- Mild redness
- No deformity
- Can walk, but painful
What are the signs and symptoms of a second degree achilles strain?
- Some tearing
- Moderate swelling
- Moderate heat
- Moderate redness
- Bruising on either side and down in the heel
- No deformity
- Very painful to walk, probably limping
How do we manage a first degree achilles strain?
- Taping
- Strapping
- 2 weeks
How do we manage a second degree achilles strain?
- May be in a boot for 1-2 weeks
- Stabilize so that they do not further tear the tendon
- 90 degree boot = no active movement
What is the MOI of a acute achilles rupture?
Explosive movement when already in the stretch position
What are the signs and symptoms of a achilles rupture?
- Lots of swelling, redness, bruising
- Will have deformity (divot)
- Feels like they got shot in ankle, then no pain
- Lacking ability in foot
What is the special test for an achilles rupture?
- thompson test
- contract gastrocnemius, testing if foot moves
- not able to control foot drop
How is an achilles rupture managed with surgery?
- Immediate
- Stitched together
- Immobilized for 3-4 weeks
- Tend to do surgery on athletes
How is an achilles rupture managed without surgery?
- In a boot, with heel raised up
- Gradually try to get them back to 90 degrees every 2 weeks
Describe the timeframe for a achilles rupture.
- Season ending injury
- Walking in boot approx 6-8 weeks
What is a common misconception around achilles ruptures?
you are not more likely to rupture if you have had achilles tendonitis or achilles strains
What are shin splints called?
medial tibial stress syndrome
What are the prime causes of shin splints?
- muscles in back of leg is stronger, they are pulling away from medial side of tibia
- Arches: Muscles in lower leg has to work harder to support arch = increase load in muscle = pain in muscle up the tibia
How can we palpate shin splints?
Muscle feels thick on medial side of tibia (local inflammation)
What can shin splints lead to?
stress fractures
What are the signs and symptoms of shin splints?
- Pain in medial side of tibia (very specific)
- Palpable inflammation
- Can visibly see if severe
- Hot to touch
- Red
- No bruising
- 4 stages
How do we manage shin splints?
- Rest (modified activity: take out as many things as possible that aggravate
injuries while letting them do something) - Laser
- Current
- Ultrasound
- Ice after activities
What do we need to remember when sizing crutches?
- Not meant to be leaned on armpits
- At least 3-4 fingers between armpit and crutch
- Start with height guideline
- Need slight bend in elbow
- Size to line in wrist
- Crutch base is meant to land 2 inches outside of toes and 6 inches in front of toes