Foot and Ankle Flashcards
What is the function of the ankle/foot?
Stability:
stable base of support for WB, act as a rigid level for effective push-off during gait
Mobility:
dampening rotations from proximal joints, flexible enough to absorb shock, foot conform to terrain
How many bones in the foot/ankle?
How many joint components?
28, 25
What are the components of the forefoot?
metatarsals, phalanges
What are the components of the midfoot?
navicular, cuboid, cunieforms
What are the components of the hind/rearfoot?
talus, calcaneus
What motion(s) occurs at the talocrural joint?
dorsiflexion/plantarflexion, Inversion/eversion, Abduction/Adduction, Pronation/Supination
Ankle DF/PF occurs in what plane and around what axis?
sagittal plane @ coronal axis
What is the approximate normal ROM for DF? PF?
20 degrees, 50 degrees
Ankle IV/EV occurs in what plane around what axis?
frontal plane @ AP axis
_ = plantar surface toward midline
= plantar surface away from midline
inversion, eversion
Calcaneal ABD/ADD occurs in what plane and around what axis?
transverse plane @ vertical axis
_ = distal segment toward the midline _ = distal segment away from midline
ADD, ABD
Ankle Supination/Pronation occurs at what joint and around what axis?
subtalar joint @ combination of axes
What combination of movements occur during open chain supination? close chain?
calcaneus PF, IV, and ADD
ER tib/fib, Talar ABD and DF, calcaneal IV
What combination of movements occur during open chain pronation? close chain?
calcaneus DF, EV, and ABD
IR tib/fib, talar ADD and PF, calcaneal EV
“Raise the arch of the foot” is another way of saying close chain pronation or supination?
supination
Calcaneal varus = distal segment _ midline.
Calcaneal valgus = distal segment _ midline.
toward, away from
What are the components of the proximal tibiofibular joint?
fibular head and fibular articulating facet of tibia
What motions occur at the proximal tibiofibular joint?
sup/inf fibular gliding, fibular rotation (small magnitude both)
What type of joint is the distal tibiofibular joint?
syndesmosis/fibrous union
What are the components of the distal tibiofibular joint?
distal fibula and fibular notch of tibia
What are the ligaments of the distal tibiofibular joint that restrict motion and stabilize the mortise?
A/P tibiofibular
A/P tibiofibular ligaments are usually _ than ankle lateral collateral or distal fibula.
stronger
True/False: motion at the TFJ generally indicates injury.
true
What type of joint is the talocrural joint?
synovial, modified saddle/hinge
uniaxial, oblique hinge
What are the components of the TC joint?
mortise (tibial medial mallelous and inferior = roof; fibular lateral malleolus) and tenon (trochlea talus - projection shaped for insertion into mortise)
Which of the following is not true for the TC joint?
a. talue/tenon and mortis is wider anteriorly
b. no muscular attachments
c. adequate blood supply
d. risk for delayed or non-union fracture
c - has limited blood supply causing D
What is the meaning behind TC coupling?
axis shifts slightly with motion - change transverse plane motion of the LE into frontal plane motion of the foot
lower leg rotation initiates mvmt of the talus which causes simultaneous motion in all 3 joints
Regarding TC coupling for left leg CKC:
Leg _ rotation -> _ gliding of talus -> foot pronation
Leg _rotation -> _ gliding of talus -> foot supination
internal, inward
external, upward
For the TC joint, what motion is closed packed? open packed?
DF, PF
For the closed pack position of the TC joint, fill in the blanks,
Position of _ congruency and joint compression
Ligaments and capsule are _
more _ position.
greatest, taut, stable
Describe the capsular pattern of the TC joint.
PF limited more so than DF
In what position would joint mobilization be best?
PF because joint play is greatest
Which of the following is true for the deltoid ligament?
a. resists inversion
b. weak tensile strength
c. resists side to side motion or rotation of mortise upon talus
d. resists adduction of calcaneus
c is true.
a - resists EV
b - great tensile strength
d - resists abduction of calcaneus
What are the components of the deltoid ligament?
tibionavicular ligament, tibiocalcaneal ligament, posterior tibiotalar ligament, anterior tibiotalar ligament
_ sprains are rare (5-10% of all sprains).
EV
due to deltoid ligament strength and distal extension of fibula
Eversion sprains are at high risk of what other condition occuring?
bony trauma - medial malleolus, fibula
What are the bands of the lateral collateral ligament of the TC joint?
anterior talofibular, posterior talofibular, calcaneofibular
The LCL of the TC joint counters what motions?
varus/IV stresses or lateral ankle joint distraction
True/False: The LCL of the TC joint is weaker and more commonly injured than the deltoid ligament.
true - IV sprains are 85% of all ankle sprains
Between the ATFL and PTFL which is weakest and most commonly injured and which is strongest and least frequently injured?
ATFL, PTFL
What type of joint is the subtalar joint?
functional synovial joint
What are the components of the subtalar joint?
talus and calcaneus
What forces does the subtalar joint dampen?
rotational
Talar ADD component of pronation causes _ of the superimposed tibia/fibula.
IR
Subtalar joint maintained in WBing, pronation imposes IR force on leg that can affect what other regions?
knee and hip
Hip joint _ may be related to medially facing patellae and patient’s knee pain.
IR
Describe the closed-packed position of the subtalar joint.
supination - ligamentous tension draws together or “locks” Talocalcaneal joint surfaces - critical for stability: foot becomes rigid level
Describe the open packed position of the subtalar joint.
midway between sup/pro and 10 degrees talar PF - pronation critical for mobility, shock absorption and dampening BW-imposed rotational forces
Describe the capsular pattern of the subtalar joint.
varus limited more than valgus
What is the transverse tarsal joint?
separates hindfoot and midfoot, moves in concert with subtalar joint
What ligament supports the talonavicular joint?
spring ligament (Plantar calcaneonavicular)
What arch does the spring ligament support?
medial longitudinal arch
what type of joint is the talonavicular joint?
ball and socket
What supports the calcaneocuboid joint and the lateral longitudinal arch?
long plantar ligament
What paired motions does the transverse tarsal joint increase?
sup/pro range of subtalar joint
What does the transverse tarsal joint compensate for?
hindfoot positioning - theoretically enables forefoot to remain flat on ground regardless of hindfoot pro/sup
Transverse tarsal joint activity: early to mid stance of gait:
During level surface stance, subtalar and TT joints each _.
enabling foot to absorb .
Subtalar and transverse tarsal _ absorb shock during early stance.
TT then to ensure contact between lateral border of foot and ground.
“Counter movement” enables normal WB thru forefoot while rearfoot absorbs tibial _.
pronate
BW
prontation
supinates
IR
Transverse tarsal joint activity: late stance of gait:
Subtalar and TT _ increase stability of stance limb.
Bony surfaces congruent and joints locked in closed pack position.
Locking of joints enables _ to forefoot as foot becomes rigid level for push off.
supination, weight transfer
What effect on subtalar joint does pes planus have?
excessive pronation at subtalar joint can depress navicular which prevents transverse tarsal joint from reversing or supinating to absorb excessive rearfoot pronation - prevents transverse tarsal “counter movement” that would otherwise enable normal WB thru forefoot
What type of joint are the tarsometatarsal joints?
plane synovial
What forms the tarsometatarsal joint?
distal tarsals and bases of metatarsals
What is another name for the tarsometatarsal joint?
Lisfranc’s joint
What is the funciton of the tarsometatarsal joint?
augment transverse tarsal joint function
position metatarsals and phalanges
maintain forefoot contact with ground: rotate to adjust forefoot positioning when transverse tarsal joint cannot fully compensate rearfoot positioning
What is the functional unit formed by the metatarsal and associated cuneiforms?
rays (1-3)
Describe the function of rays 1-3.
1 and 2: IV/EXT and EV/Flex
3: extend and flex
(2 least mobile - most stable, 1 and 3 - very little motion)
Describe rays 4 and 5.
consist of metatarsal
evert/extend and invert/flex
more motion than 1-3
What type of joint are the metatarsalpharyngeal joints?
condyloid synovial
What motions occur about the metatarsalpharyngeal joints?
Extension: body passes over foot during late stance phase
Flexion: return to neutral from extension
Abd/Add (little bit): grasping, absorb some of force on MTs as they undergo pro/sup twist at TMT joints
What are the functions of the sesamoid bones in the foot?
anatomic pulleys for FHB, protect the tendon from WB trauma, which passes thru tunnel formed by sesamoids and intersesamoidal ligament joining their plantar surfaces
What arch is the inclination between the calcaneus and 1st MT?
medial longitudinal
What is the fibrous tissue extending from calcaneus to plantar plated at MTP joint then to proximal phalanges to support arches?
plantar aponeurosis/fascia
What does the plantar aponeurosis increase foot stability during?
MTP extension in push off (Windlass effect)
Describe pes planus.
pronated or flat foot
decreased or absent medial longitudinal arch
talus depresses navicular and minimizes potential for transverse tarsal counter rotation to offset subtalar pronation
Describe pes cavus.
supinated or high arches foot
What are the potential effects of pes planus?
overly mobile/flexible foot, foot may require muscular contraction during stance, possibly decreased push off during gait (foot not a rigid lever), increased tibial internal rotation (increased Q angle at knee, potentially altered patellar tracking), excessive mobility may stress ligaments, tendons, and muscles that control motion of rear foot, increased magnitude and rate of pronation
Effects of pes cavus.
increased medial long arch height, subtalar and transverse tarsal joints excessively supinated, rearfoot varus, potential ER stress on leg, rigid or flexible, less effective shock absorption capability, increased loading of lateral structures
What are some pes planus related injuries?
plantar fasciitis, knee pain, patellar tendinitis, stress fractures (2nd/3rd MTs)
What are some pes cavus related injuries?
plantar fasciitis, ankle INV sprains, ITBS, Stress fractures (5th MT)
Describe the diabetic foot.
infection, ulceration, or destruction of deep tissues associated with neurological abnormalities and various degrees of peripheral vascular diseases in lower limb
What percentage of non-traumatic lower limb amputation is because of diabetes?
40-60%`
What percentage of diabetic related foot amputation are preceded by foot ulcer?
85%
What ratio of ulcers in diabetics are precipitated by trauma?
4/5
What is the prevalence of foot ulcers in diabetics?
4-10%
True/False: History and careful foot exam are mandatory to diagnose neuropathy.
true!!!
Up to what percentage of patients with type 2 diabetes have significant neuropathy and are at risk of foot ulcer?
50%
What are two major risk factors for ulcer?
sensorimotor and peripheral sympathetic neuropathy
What historical symptom is evident of PVD?
claudication (calf pain after waling a specific distance) that is relieved by rest
What do you do in the exam for PVD?
palpate the foot for temperature, palpate the dorsalis pedis pulse and if absent, the posterior tibial pulse
What is another common s/sx of PVD?
reactive hyperemia (leg turns bright red when going from an elevated position to declining back to the ground)
Describe the monofilament for pressure sensation/pinprick sense test.
place a 10g nylon Semmes-Weinstein monofilament at a right angle to the skin, apply pressure until the monofilament buckles, inability to perceive the 10g of force applied by the monofilament is assoc w. clinically significant large fibre neuropathy and an increased risk of ulceration
What is stage one of the ulcer development?
callus formation
What is stage two of ulcer development?
subcutaneous hemorrhage
What is stage three of ulcer development?
breakdown of skin
What is stage four of ulcer development?
deep foot infection with osteomyelitis
What is charcot foot?
neurogenic arthropathy that affects the joints in the foot - rapidly progressive degenerative arthritis that results from damaged nerves (neuropathy)
pain perception, motor function, and proprioception of the foot are severely impaired
loss of motor and sensory nerve functions allow minor traumas to go undetected and untreated, leading to laxity, dislocations, bone erosion, cartilage damage, and deformity of the foot
What is the most common cause of charcot foot?
diabetes
What percentage of people with diabetes develop peripheral nerve damage that can lead to Charcot foot?
60-70%
When does onset of charcot foot occur?
after pt has been diabetic 15-20 years, usually at the age of 50 or older
What is the tx for charcot foot?
total contact casting done by professional. cast provides moist environment to promote healing
What are the 5 pillars to prevent foot problems in diabetes?
identification of high risk pt, regular inspection and exam of foot and footwear, education of pt/family/and HCPs, appropriate footwear, tx of non-ulcerative pathology
What are the reasons for orthotics?
prevent or correct deformities, assist with the use of weak limb to allow maximal functional independence, protect against injury of a weak or malaligned joint, maintain proper alignment of joints, inhibit muscle tone, and facilitate motion
What are these abbrevations for orthotics?
FO. KO. HO. AFO. KAFO. HKAFO.
foot orthosis, knee orthosis, hip orthosis, ankle foot orthosis, knee ankle foot orthosis, hip knee ankle foot orthosis
What is the “definition” of a foot orthosis?
a semi-rigid or rigid insert worn inside a shoe that can correct foot alignment, provide support, and may also be used to relieve pain
What is the ultimate goal of foot orthoses?
improve functional activity tolerance
Describe the foot orthoses mechanism in terms of biomechanical changes.
provide structural support that mat alter the position of the foot, ankle, and/or LE
Describe the foot orthoses mechanism in terms of shock attenuation.
orthotics help the body to better tolerate the forces that occur in WB activities
Describe the foot orthoses mechanism in terms of neurosensory input.
input to NMS can be altered by foot orthotics by perhaps changing muscle activation, mvmt patterns, or providing a comfortable position for the foot
What are the conclusions for the use of orthotics for local foot pain?
custom foot orthoses are effective for painful pes cavus, rear foot pain in RA, foot pain in Juvenile Idiopathic Arthritis. non-custom foot orthoses appear just as effective for JIA, plantar fasciitis, or MTP joint pain in RA
plantar heel pain:
medium term - moderate evidence reducing pain but no improvement in function; short term and long term - very low quality evidence that orthotics do not reproduce pain or improve function
What are the conclusions about using orthotics for injury prevention and overuse injuries?
they were found to be effective in reducing overall injuries and stress fractures, but not with preventing soft tissue injuries.
shock-absorbing insoles were not effective for preventing injuries.
use of foot orthoses to prevent 1st LE overuse incident
difficult to support or refute use if already have overuse condition.
no difference between custom and pre-fabricated orthoses
What are the conclusions about using anterior knee pain in adults?
contoured foot orthoses compared to flat orthoses caused greater reduction in knee pain at 6 weeks but not at 1 year f/u
long-term outcomes were not significant between foot orthoses vs PT
while foot orthoses may provide short-term knee pain relief, the benefit may be marginal
What should be the patient progression thru the HCS?
self care management -> conservative care -> surgery
What are indication for surgery?
pain, loss of function, instability
What are common soft tissue repairs procedures?
achilles tendon repair, tarsal tunnel release
What are common stabilization procedures and arthroplasties?
lateral stabilization, lis franc fusion, ankle fusion or replacement, 1sst MTP replacement
What are common general surgical repairs done on the foot?
osteochonddral grafting of the talus, hallux valgus repair
When is the lateral ankle least stable for lateral ankle sprain?
least stable in “loose-packed” position: PF with IV. progresison of severity from ATFL to CFL to PTFL
Why are medial ankle sprains less common?
decreased eversion ROM and bony architecture
Describe a grade 1 ankle sprain.
mild symptoms, likely kept playing initially, microscopic tearing of ATFL, no functional loss or instability
recovery time: 2-10 days
usually self treatable
Describe a grade II ankle sprain.
moderate functional loss, changed gait
involves ATFL and CFL
may have initially “walked it off”, diffuse swelling and tenderness. recovery time: 10-30 days
*most commonly seen in PT
Describe a grade III ankle sprain.
unstable, multi-ligamentous sprain. anterior capsule involvement. unable to fully WB. diffuse edema/tenderness. frequent concomitant fx. recovery time: 30-90 days - often go to ER then ortho then PT
Debate tearing type among the 3 ankle sprain grades.
Gi: microscopic, G2: partial, G3: complete rupture
Debate swelling type among the 3 ankle sprain grades.
G1 - minimal, G2 - mod/severe, G3 - severe
Debate joint instability among the 3 ankle sprain grades.
G1 - none, G2 - mild/mod, G3 - mod/severe
Debate WB status among the 3 snkle sprain grades.
G1 - fully/partial, G2 - partial/unable, G3 - unable
What test can be utilized to test for ATFL?
anterior drawer - anterior displacement of calcaneus w/ talus on tibia or laxity or pain
What test can be utilized for CFL?
talar tilt test
What sinister complications that can occur due to ankle sprains?
superficial peroneal/fibular nerve involvement; bony: base of 5th MT, spiral fx of fibula, lateral malleoli, navicular
What test indicates a medial ankle sprain?
positive eversion (talar tilt) test
Describe a syndesmotic sprain.
high ankle - injury to anterior tibiofibular ligament and/or syndesmosis, MOI: HDF, rot + PF. recovery is > 6 mos, often surgical candidate
What are the 3 special tests for syndesmotic ankle sprain?
syndesmotic squeeze, ER stress test, fibular translation test
What is the acute management for
RICE, initial pain and edema control, use crtuches to control gimpy gait, early immobilization and REDUCED WBing
When is immobilization for ankle sprain generally indicated?
G3 injuries as well as syndesmotic injuries.
leads to protracted recovery in G1 and G2 injuries.
Protected WB ideal immediately post-injury
According to Whitman et al, 2009, what was found regarding manual therapy and ankle sprains?
thrust and non-thrust techniques may improve pain and function following acute ankle sprain
According to Van der Wees et al, 2006, what was found regarding TE and ankle sprains?
exercise therapy reduced risk of recurrent ankle sprains and functional instability
What can happen if ankle sprain patient’s neuromuscular re-education is not progressed beyond simple tasks (like standing on one foot flat on ground)?
can lead to Chronic Ankle Instability
What is CAI?
characterized by residual symptoms that include feelings of giving way and instability as well as repeated ankle sprains, persistent weakness, pain during activity, and self-reported disability.
two primary components: mechanical instability (ligamentous, etc) and functional instability (NMS control, stength deficits, deficient postural control)
Describe how Closed Chain DF can help to prevent reinjury.
injury most commonly in this chain so likely to be reinjured in this chain
test: 38 degree tibial shaft ankle, 9-10 cm knee to wall
What did Hale et all 2007, have to say about factors contributing to CAI?
not a result on one factor (ligament, muscle weakness, diminished proprioception, or postural control deficits. but rather assoc w all these factors as well as altered arthrokinematics and joint structure at the TC joint when compared to subjects without CAI
What did Kaminski et all, 2003 have to say about prevention of injury?
clinicians should implement a multi-intervention injury-prevention program lasting at least 3 mo that focuses on balance and NMS control to reduce the risk of ankle injury - athletes with hx of ankle injury may benefit more
