Foot and ankle Flashcards
hindfoot and forefoot varus and valgus
Varus = eversion/inversion Valgus = eversion/inversion
varus = inversion valgus = eversion
Finding subtalar neutral
pt in prone
make sure their limb is in neutral torsion
put them in neutral DF
middle finger and thumb anteriorly on talus
grab with your other hand on the 4th and 5th ray
move left and right until you feel talus equally under each finger
what are you looking at to find rearfoot angle at subtalar neutral?
you are looking at calcaneus in relation to the tibia
what is normal hindfoot and forefoot varus and valgus?
rearfoot varus
forefoot varus
what does “normal” rearfoot and forefoot varus lead to in gait
Varus means inversion, therefore
leads to more pronation during walking, because your foot needs to meet the ground
if you have severe varus in both hindfoot and forefoot thats going to lead to A TON of pronation
severe hindfoot and forefoot varus is going to lead to what motion at the foot during gait
excessive pronation! they have to get their foot to the ground
what if you have a severe mismatch of varus and valgus btwn hindfoot and forefoot?
every time you put your foot down there is a torsional effect on the midfoot which could cause irritation.
internal tibial torsion is going to cause the subtalar joint to what?
pronate!
what position is the patient in when measuring LAA (longitudinal arch angle)
standing!
as the angle gets more obtuse or acute in LAA, that signals that the arch is dropped
acute
what are the four points you mark to measure static rearfoot angle.
1) base of calcaneous
2) achilles tendon insertion
3) achilles at height of medial mal
4) 15 cm above mark 3
too many toe sign assesses for what related set of issues?
excessive pronation due to collapsed arch causing forefoot ABD
how do you perform the navicular drop test
pt is in sitting
find subtalar neutral
palpate navicular and measure from the ground to this point
have pt stand
measure again
> 5cm difference is signifcant
how many cm is significant for navicular drop test?
5 cm from sitting to standing
two main actions of the posterior tib
PF and inversion
where does posterior tib insert?
plantar surface of navicular, cuniforms and base of 1st and2nd met
if pt has pain right on the plantar surface of their medial arch what are you thinking?
insertional inflammation of posterior tib
posterior tib
origin
where it runs
insertion
origin: interosseous membrane btwn tib and fib posteriorly
tendon runs posterior to medial mal, wraps around
inserts: plantar surface of navicular, cuniforms and base of 1st and 2nd met
every time someone w/pes plantus takes a step, what is happening to the posterior tib muscle?
its being stretched out its full length and trying to work eccentrically.
Recipe for overuse!
over the counter vs custom inserts for pes planus?
over the counter is fine for most people.
if they have a severe deformity hen youd consider custom
if someone has notable rear foot and forefoot varus, what would you want to maybe recommend they use everday
orthotic in their shoe on the medial side to bring the floor to their foot!
pes planus or posterior tib overuse
if someone is overpronating, what other motion do you want to make sure you’re also looking at?
DF, lack of DF could cause someone to have to excessively pronate to get their foot to meet the ground
general purpose of orthotic
bring the floor to the foot to reduce stress
who might benefit more from an orthotic someone with a flexed or rigid deformity?
rigid! flexible you’d probably only want it temporarily
what are two pathoanatomic diagnoses that might benefit from an orthotic
posterior tib overuse
pes planus
name the three ways to assess DF motion in weight bearing
anterior lunge test
half kneel lunge test; SFMA
WBing DF w/ inclinometer
What is normal DF for anterior lunge test?
what is a significant difference side to side or one foot overtime
9-14 cm
someone who is taller is going to have more
2cm is significant difference
explain the half kneel lunge test; SFMA
they go in half lunge
keep heel on the ground
you put dowel at their knee
5 inch cut off is normal
Explain wt bearing DF w/ inclinometer
pt half kneels
DF as much as possible with heel still on ground
place inclinometer on tibia
what is normal DF in degrees?
20-25 (higher than this if you’re a runner)
how to assess subtalar motion
stabilize the talus, cup the calcaneus and twist to get supination and pronation
midfoot has what kind of axis
oblique
what would the limiting muscular structure be for hallux limitus?
flexor hallicus longus on the plantar aspect of the foot
define hallux limitis
limited mobility of the 1st MTP extension when 1st met head is LOADED, but NOT when unloaded
explain what the thompson test is and what it is for
testing for a complete rupture of the achilles tendon.
pt is in prone, relaxed, and you grab the calf looking for PF
highly specific
explain achilles tendon palpation test and what it is for
for achilles tendinitis
palpate their tendon in prone, if they have pain midtendon its positive test
explain royal london hospital test and what it is for
for achilles tendinopathy (more specific than just palpation)
pt is prone, you find the midpoint that is tender on their achilles
ask them to actively DF, and palpate the same spot that hurt before
a reduction in pain by 2/10 is a positive test for achilles tendinopathy
explain the Arc sign and what it is for
used in a pt that has achilles tendinopathy and you want to decide if its the tenon itself or the sheath
ask them to actively move in and out of DF and PF
if the point of swelling on the tendon moves, its the tendon itself
if the point of swelling does not move it is the sheath
achilles tendionpathy intervention big points
what are you doing
how many days
how many x a day
how many sets
how many reps
eccentric PF progressive program
6 days a week
2x a day
3 sets of 15
how to do you assess for high ankle sprain?
literally squeeze fib and tibia together (this stresses ankle syndesmoses) if this hurts this indicates high ankle sprain
what is the MOI for high ankle sprain
forced eversion/ER
how can you assess for lateral ankle sprain
talar tilt test: can look at ATFL, calcaneofibular and PTFL
explain how to test ATFL in talar tilt test
make sure pt is sitting with knees off the table
put them into PF (so the ligament is perpendicular to the motion you’re going to do)
Grab calcaenous
put them into inversion
explain how to test the calcaneofibular ligament as part of the talar tilt test
make sure pt is sitting with knees off the table
put them into neutral DF. stabilize the malleoli and bring foot into inversion and eversion
eversion: stresses the deltoid ligament
inversion: stersses calcaneofibular
explain how to test the PTFL as part of the talar tilt test
make sure pt is sitting with knees off the table
max DF
move them into eversion and inversion
are high grade manipulations indicated in low irritability ankle sprains
YES!
Describe the thrust distraction of talocrural
Good for what motion?
make sure their hip is IR
you’re wrapping their foot up, your palm on top of talus
thrusting towards you
good for DF
Anterior to posterior talocrural mobilization is good for what motion?
Df
posterior to anterior talocrural mob is good for what motion
PF
what direction does distal and proximal fibula go in wt bearing DF
proximal: anteriorly
distal: posteriorly
for all tibiofibular thrusts, which bone are you mobilizing?
fibula! Stabilize the tibia and move the fibula.
subtalar joint needs to be able to do what motion so the netire midfoot can unlock
evert
can do a distraction or a side tilt mob to get this
explain how to do a subtalar side tilt mobilization
pt is is sidlying
you’re working on bottom foot
lock the talus with one hand
moving the calcaneous with the other
explain what two joints are part of midtarsal motion and why they are so important
talonavicular
calcaneocuboid
when hindfoot is everted, the axis are parallel, allowing for flexible foot in midstance which is what we want
when hindfoot is inverted, the axis are opposed, so the midfoot becomes rigid.
true or false, as long as the ankle fracture is stable, it is appropriate to do a low grade mob on any ankle joint?
true!
what does the clinical prediction rule say about short term response to using mobs and maips on lateral ankle sprains
3/4 has best likelihood ratio/is the strongest predictor
what are the four predictors for the CPR for positive response to manual therapy post lateral ankle sprain
sx worse standing
sx worse in evening
navicular drop >5mm
distal tib fib hypomobile
how would you MMT the posterior tib?
have them seated, put them in inversion maybe a tiny bit of PF, do a make test with HHD
Take three and average it
normal DF ROM
15-25
you should see more with knee bent cause gastroc is out of the picture
normal PF ROM
40-50
Normal inversion ROM
~30
should be double eversion
Normal eversion ROM
~15
at what angle of LAA is the arch considered dropped?
90 degrees
best way to measure forefoot angle
put them in prone and use the table as an external horizontal to compare it to rearfoot angle
