foot and ankle Flashcards
Grade 1 ankle sprain
no loss of function, no laxity (-) tests, Loss of 5 degrees total ROM, swelling .5cm or less
Grade 2 ankle sprain
Some loss of function, Positive Ant drawer test (ATFL), (-) talar tilt, no CCFL, 5-10 degree loss of ROM, swelling > .5 cm but less than 2 cm
Grade 3 ankle sprain
Near total loss of function, (+) ATFL and CCFL, ROM loss > 10deg, edema > 2cm,
Lateral ankle sprain (ligament rupture) cluster
- pain with palpation to ATFL
- (+) anterior drawer
- lateral edema
Ankle sprain A recommendations
Obj: take measures: edema, DF ROM, ant/post translation, SLS
- outcome measures FAAM (foot ankle assessment meaesure) and LEFS
Intervention: protected WB early
Acute: therex, mobs, prorgessive loading/sensorimotor training, manips, NWB and WB MWM to improve ankle DF
Tx: ice, and NOT using US - all A recommendations
Pain in AM
- think plantar fasciitis or fat pad
Acute hyperextension of 1st MTP
think turf toe
Insidious onset of pain and swelling in 1st MTP
think gout
Numbness and tingling
think tarsal tunnel syndrome or mortons neuroma
Best outcome measure
FAAM (foot and ankle ability measure) - best
others: LEFS, foot function index FFI
Fat pad atrophy
differential vs Plantar fasciitis
- location of pain different- pain in middle of heel vs front of heel (PF)
- pain worse with walking barefoot (need to differentiate vs first steps in AM- PF)
- palpation- compare size to contralateral fat pad
Tx: footwear (cushioned heel for runners), heel cup, changing to a mid/forefoot strike
Plantar Fasciitis treatment clinical guidelines
A- manual therapy, stretching, taping, orthotics
- manual therapy- joint and of tissue mobs
- taping- anti pronation and gastroc/sol taping
- stretching- gastroc/sol, and PF
- orthotics- supporting medial longitudinal arch (works best for people who respond positively to anti pronation taping)
US and dry needling not recommended
Mortons Neuroma
- 3rd common digital nerve impingement
- buring pain in plant 3rd web space
- pain and parasthesias in toes can occur
- “wrinkled socks sensation”
(+) mulders sign- metatarsal squeeze test
(+) digital nerve stretch test- ankle in DF, passively stretch toes on both sides to stretch digital nerve
Metatarsalgia
Inflammation under base of MTP’s
Tx: met pad, orthotics to distribute forces, shoe modification, injection
Mallet toe
- DIP flexion, IP ext
- associated with tight shoes, no real causitive reasons
- can be caused by inflammatory arthiritis, trauma, sequela of hammer toe repair
Tx: toe sleeves (elevates toes to decrease pressure)
Hammer toe
- IP flexion, DIP ext
- older population, narrow shoes; can happen to just one or two toes
Tx: foam to midfoot to offload pressure - splints to improve ROM restrictions (if flexible)
- if rigid and symptomaic, surgery indicated
Claw toe
DIP, PIP flexion, MTP hyperextension
- USUALLY NEUROLOGICAL DISORDER, affecting all toes; associated with cavus foot, tight achilles, and intrinsic muscular imbalances
Tx: foam to midfoot to offload pressure
- splints to improve ROM restrictions
deltoid ligament
involved in overpronation injuries, associated with flat foot deformity
midfoot bones
TMT (lisfranc) or CC, Talonavicular (chopart)
spring ligament
Important in preventing flat feet- plantar calcaneonavicular ligament
limits the talus from plantarflexing (which is alsso naviuclar dorsiflexing closed chain), thus supporting the medial longitudinal arch from lowering
tib posterior
largest cross sectional area and larger moment arm for muscles of supination= dominant supinator of foot
- important for raising medial longitudinal arch
calcaneocuboid joint
- supported by long plantar ligament- one of the strongest ligaments in the body- more stable, less movement than talonavicular jt
- long plantar ligament supports longitudinal arch
Flat foot positioning
forefoot abduction and dorsiflexion and rearfoot valgus
peek a boo sign
- you see the medial calcaneous while looking at a person fro the front ( indicative of subtle pes cavus)
Pes cavus tx
- high arches can lead to 5th MTP stress fx and lateral ankle sprains due to positioning
- foot tends to be more structural deformity( can have achilles tightness)
- tx looks to accommodate the rigid strucutre that has difficulty accommodating to terrain for shock absorption
Arch Height index
measure in NWB to 50% WB
- average change is 10 mm or 13.4 % of arch height
Navicular drop test
measure navicular height standing in subtalar neutral
measure navicular height in regular standing, measure difference by marks of a card
- difference of > 10mm indicates (+) test
royal london hospital test
tests for achilles tendonopathy
- palpate along most tender point of achilles
- have pt dorsiflex
- palpate area again. (+) test if less pain with palpation with foot dorisflexed
coleman block test
- tests for rigid rearfoot
- observe calcaneal position in standing
- have pt stand on a box with 4th and 5th mets on, and rest of foot off
- observe position of calcaneous
- if they go from varus to neutral position, flexible deformity and orthotics may work
- if no change, ,its a rigid deformity and orthotics wont make a difference
tinnels sign
at medial malleoli- testing for posterior tibial nerve impingement
mulders sign
metatarsal squeeze- looking for metatarsal neuroma
predictive signs of recurrent ankle sprain
- poor balance
- high exposure (to activities that caused i.e. basketball player going back to basketball)
- laxity tends to persist after a sprain, even after symptoms decrease indicating poor healing of ligaments
CPR:
- hx of ankle sprain
- lack of full DF
- no balance training in rehab
- no use of external supports
- inadequate dynamic warm up prior to activity
plantar fasciitis treatement
- patient education
- taping A
- stretching (PF and gastroc/sol) A
- orthotics A- prefab
- night splints ( to decrease pain first few steps in AM)
Tarsal coalition
fusion of tarsals
- usually calcaneonavicular and talocalcaneal
- can resitrict subtalar joint motion and cause micro fracturing –> pain (in hindfoot)
- imitates lateral ankle sprain symptoms, can lead to more sprains due to lack of subtalar ROM
-
Lisfranc injury
- stirrup injury
- damage to TMT joint- specifically lisfranc ligament which connects 2nd MTP to 1st cuneiform
- MOI: usually a horizontal force to a plantarflexed ankle
- tests: squeeze test of midfoot, single leg hop test
tx: cast, immobilization if stable, if not, need ORIF
Severs disesase
- calcaneal apophysitis
- self limiting inflammatory process of an avlused bone usually from childhood
- can be due to overuse and microtrauma during sports
- pt usually young athlete going through growth spurt c/o heel pain after starting a new sport
special tests: squeeze test (calcaneous) single leg hop
Tx: work on tightness, fix biomechanical issues. RICE, heel lifts, heel cups
Kohlers disease
” AVN of the navicular”
- osteochondrosis (developmental derangement of normal bone growth) of navicular
Tx: either arch support (mild symptoms) , short cast (mod-severe symptoms)
- usually self limiting, surgery rarely indicated but can do arthrodesis of calcaneocuboid and talonavicular joints
Metatarsalgia
Pain in forefoot associated with stress under base of MTP - most commonly 1st and 3rd
- absense of pain in interdigit space (more mortons neuroma)
Tx: conservative- NWB, offloading, orthotics (met pad)
Mortons Neuroma
digital nerve irritation- (+) mulder sign
- sharp neural pain,
- usually digit space bw 3rd and 4th
- neuroma develops due to biomechanical changes (lack of ankle DF –> increased reliance on digit ext)
Tx: injection tends to help, shoe modification, offloading, biomehcanicsal corrections
Hallux Rigidus
- lack of hallux ext ROM due to pain or thickening with inflammation to first MTP synovium.
Tx: primary: DECREASE motion by taping to decrease pain. typically ext is painful position
- corrrect biomechanical faults such as limtied DF, tightness in calves which may lead to excessive hallux ext
non insertional achilles tendonopathy
6 cm proximal to tendon insertion
- occurs more in athletes
- prognosis good, with eccentric training program
- may be due to overtraining
insertional achilles tendonopathy
- occurs more in fat people, sedentary
- limit DF with eccentrics due to postential posterior ankle impingement (haglunds deformity) - can be due to more bony changes
haglunds deformity
bony enlargement posteriolaterally near calcaneous
Achilles tendon rupture
- (+) thompsons squeeze test
- PF weakness,
- palpable gap
- increase passive ankle DF
Order of operations for suspected DVT
get d-dimer lab (99% sensitive)- if (+), get compressive US. If (-), can r/o
How old for Ottowa ankle to be applied to child?
16 years old
when are orthotics contraindicated for plantar fasciitis?
1 year, no evidence to support efficacy > 1 year of symptoms
Tests for achilles tendinitis
US or MRI. equally good
Special tests for achilles tendinitis
- royal london hospital test
- achilles palpation test ( 2-6 cm proximal to heel)
- decreased PF strength/endurance vs contra
- arc sign where area of palpated swelling moves with DF and PF
Achilles tendinitis treatment
A: eccentric loading
B: laser, Ionto
C: stretching
Plantar Fasciitis CPG
- (+) windlass (-) tarsal tunnel - limited ankle DF pain with first steps in AM BMI > 25 heel pain after increase in activity
Posterior tib tendinosis
Tests: too many toes sign, fallen arch
Tx: orthotics AND eccentric strengthening
Sx: will also have pain with resisted inversion
