Foot and Ankle Theory

Question 1

List the traits of a tendinopathy (Achilles).

Answer 1

Non-inflammatory, rather a failed healing response.

i) degenerative changes in the tendon
ii) increased secreted ground substance proteins
iii) collagen deterioration
v) focal areas of fibroblast proliferation and vascularity

Question 2

Describe how a tendon changes in the context of tendinopathy.

Answer 2

i) Collagen fibres become looser and in dissarray
ii) tendon becomes thicker
iii) Higher concentration of Type II collagen fibres and proteoglycans (which trap water and contribute to swelling)

Question 3

Describe the typical presentation of an Achilles Tendinopathy.

Answer 3

i) pain especially in the mornings or after prolonged rest
ii) pain with activity
iii) Swelling and impaired function

Question 4

Describe Hallmark features of treatment for Achilles tendinopathy.

Answer 4

i) eccentric tendon strengthening (more effective in younger athletic population, more effect slow and heavy than high reps). Reduced amount of DF for insertional tendinopathy. Use externally times cues.
ii) isometrics for analgesia
iii) Manual therapy for joint restrictio and soft tissue work.
iv) stretching into DF
v) heel lifts, orthotics, night splints
vi) low evidence for LLLT, shockwave, corticosteroid injections
vii) some evidence for PRP
viii) rigid taping
ix) iontophoresis with dexamethasone

Question 5

Describe appropriate outcome measures for Achilles Tendinopathy

Answer 5

i) VISA-A
ii) LEFS
iii) Limb Symmetry Index
iv) hop test, heel raise endurance test

Question 6

List important areas to palpate to rule out fracture.

Answer 6

i) medial malleolus
ii) lateral malleolus
iii) 5th MT process
iv) navicular
v) lateral process of talus (combine inv and DF)
vi) posterior process of talus (lat tubercle from compression via extreme PF or avulsion via PTFL on forced inversion) (med tubercle rare on only from avulsion of last 3rd of deltoid lig on DF and pronation)
vii) anterior process of the calcaneus (compression w/ forced DF or avulsion via bifurcate ligament w/ forced PF and inv)

Question 7

Where would the sites of tenderness be for a talar osteochondral injury?

Answer 7

i) lateral dome anterior to lat malleolus

ii) medial dome posterior to med malleolus

Question 8

Describe the MOI and best test for a suspected ankle syndesmotic injury.

Answer 8

Forced DF and ER

i) squeeze test
ii) TOP syndesmotic ligaments

Question 9

What is a typical complaint in the case of cuboid subluxation following ankle inversion injury?

Answer 9

Pain in lateral foot on push off.

Question 10

Describe the mechanism of ankle impingement following lateral ankle sprain.

Answer 10

i) laxity of ATFL allow for anterior translation of talus during DF
ii) thickening/scarring of capsular tissue

Question 11

List the contents of the sinus tarsi.

Answer 11

i) fatty tissue
ii_ part of extensor retinaculum
iii) blood vessels
iv) cervical and interosseous ligaments
v) part of subtalar joint capsule
vi) lateral subtalar px w/ WBing
vii) nerve endings

Question 12

List risk factors for 1st MTP OA.

Answer 12

i) osteochondritis dessicans
ii) trauma
iii) hypermobile first ray
iv) gait deviations
v) narrow footware
vi) long metatarsal

Question 13

Desccribe the presentation of 1st MTP OA.

Answer 13

i) pain and swelling of 1st MTP
ii) plantarflexed forefoot and DF 1st ray relatively
iii) reduced MTP ext
iv) +ve grind test
vi) reduced toe flexion strength
vii) less push off toe ext in gait w/ pain in that phase

Question 14

Desccribe treatment components for 1st MTP OA.

Answer 14

i) plantar and dorsal glides for mobility/stretching
ii) joint trxn for pain relief
iii) strengthen 1st toe ABD, ADD, ext and flex
iv) TrPR and STR of foot and calf
v) orthotics
vi) gait training
v) surgery (arthrodesis, arthroplasty, debridement, osteotomy)

Question 15

Describe the presentation of Hallux valgus

Answer 15

i) valgus 1st phalanx
ii) attentuated weak medial collateral ligament
iii) weak lengthened ABD hallicis and short tonic ADD hallucis
iv) inefficient tib post/fib longus coupling causing prolonged pronation
vi) bunion formation
vii) lateral subluxation of FHB sesamoids and FHL tendon

Question 16

Describe the treatment for hallux valgus

Answer 16

i) strengthen FHL and ABDH
ii) lengthen EHL and ADD halluciss
iii) toe spacers/add bracing overnight
iv) orthotics
v) gait training
vi) manual medial and plantar glides to normalize med capsular mobility
v) joint trxn and STR
vi) sesamoid mobilisation
vii) surgery

Question 17

Describe the pathology of osteochondritis dessicans.

Answer 17

i) Idiopathic focal deterioration of subchondral bone leading to instability of the joint and displacement of djoint articular cartilage.. Precursor to arthritis. Primarily found in knee, ankle and elbow.

Question 18

Describe the presentation of osteochondritis dessicans of the elbow.

Answer 18

i) overuse of the joint WBing (primarily gymnasts,) occurs and the capitulum
ii) pain laterally on valgus stress test while other injuries give medial pain on valgus stress
iii) lateral elbow pain, pain on posterolateral joint
iv) weakness, popping, clicking
vi) edema

Question 19

Describe the presentation of osteochondritis dessicans of the knee.

Answer 19

i) May lock acutely
i) intermittent pain and edema - hemoarthrosis
ii) loose bodies
iii) responds to conservative Rx if fragment stable and pt juvenile

Question 20

Describe the pathology of plantar fasciiopathy

Answer 20

Acute or chronic inflammatory process in the early stages. Upon symptomatic threshold, degeneration and filed repair more the case than inflammation.

Question 21

Describe the objective findings of plantar fasciopathy.

Answer 21

i) reduced DF
ii) limited 1st MTP ext
iii) High BMI
iv) +ve Windlass test
v) TOP med calcaneal tubercle

Question 22

Describe the treatment of plantar fasciopathy.

Answer 22

i) STR and TPR of gastrocs/soleus and PF
ii) joint mobilisations of the foot/ankle as indicated
iii) Strengthen toe flexors, inversion and eversion
iii) balance training static and dynamic
iv) high load strength (PF and toes extension strength at 8-12 RM)
v) forefoot extension exercise
vi) stretching
vii) taping (navicular lift and calcaneal reposition)
vii) orthorics
viii) night splints (research controversial)
ix) footwer (rockerbottom shoe)
x) shockwave
xi_ corticosteroid injection
Surgery if fails..

80-90% resovle w/in 6-12mo of conservative treatment

Question 23

Describe the pathology of stress fractures.

Answer 23

When mechanical stresses causing osteoclast activity surpass the rate of bone remodeling or osteoblast activity resulting in a crack and propagation/poorly remodelled bone

i) increased stresses to normal bone causing microdamage to reach a certain threshold
ii) normal stresses over abnormal bone/bone metabolism (ie common in people w/ metabolic disorders or OP)

Question 24

What are the risk factors for stress fracture in runners?

Answer 24

i) increased navicular drop
ii) increased PF ROM
iii) increased hip ER ROM
iv) high BMI

Question 25

Describe the pathology of cuboid syndrome.

Answer 25

Subluxation of cuboid bone causing poor arthrokinematic and also impinging synovial folds and local ligaments. Likely related to fib longus everting the cuboid dorsal and medial movement) when the rest of the foot is supinating/inverting. Common after trauma (ie inversion sprain, sudden lateral movements/eversion repeated, severe overpronation.

Question 26

Desccribe the presentation of cuboid syndrome.

Answer 26

i) lateral ankle pain, may radiate.
ii) history of sprain
iii) pain in push off, hopping, lateral movements
iv) antalgic - esp in push off phase
v) may have dorsal sulcus sign
vi) resisted inv/ev reproduce pain
vii) +ve midtarsal adduction test
viii) +ve midtarsal supination test
ix) pain on plantar and/or dorsal glide of cuboid (may be hypermobile or hypomobile)

Question 27

Describe the treatment techniques for cuboid syndrome.

Answer 27

i) Cuboid whip (Gr V dorsal glide on whip into PF/inv)
ii) cuboid squeeze (maximal PF and flex foot while squeezing cuboid into DF)
iii) dorsal parallel thrust technique
iv) mitigate overpronation
v) cuboig glides
vii) taping for cuboid or MLA

Question 28

List the common causes of posterior heel pain.

Answer 28

i) Haglunds deformity
ii) Achilles tendinopathy
iii) retrocalcaneal bursitis
iv) sever’s disease (calcaneal aopohysitis in kids and teens)

Question 29

List common causes of medial and lteral ankle pain.

Answer 29

i) tib post tendinopathy
ii) FDL tendinopathy
iii) FHL tendinopathy

iv) peroneal tendinopathy

Question 30

List common differential diagnoses for plantar fasciitis.

Answer 30

i) fat pad atrophy (pain w/ prolonged standing, night pain, no morning difference)
ii) tarsal tunnel syndrome
iii) calcaneal stress fracture

Question 31

List the tests for tarsal tunnel syndrome.

Answer 31

i) Forced dorsiflexion/inversion (incr tenderness 10-15s)
ii) Tinel’s test
iii) Triple compression test (PF, inversion and pressure over TT for 30s)

Question 32

Describe some potential pathophysiological processes at proposed for MTSS.

Answer 32

i) traction forces on the periosteum from deep posterior compartment (tib post, FDL and soleus)
ii) metabolic bone changes and increased porosity at posteromedial border (repetitive bending causes invreased osteoclast activity and local osteopenia);

Question 33

Describe the risk factors for MTSS.

Answer 33

i) increased navicular drop
ii) increased hip ER ROM in flex
iii) female, high BMI
iv) incr PF ROM
v) incr subtalar ROM
vi) hyperpronation or supination
vii_ tightness in deep posterior muscle compartment
viii) increased subtalar ROM
ix_ reduce proprio

Question 34

Outline important education for pts w/ MTSS.

Answer 34

i) can take 90 days to run with minimal pain
ii) load reduction
iii) modalities (ice)
iv) full recovery can take 9-12mo if symptoms last >3mo

Question 35

Outline key treatment components for MTSS.

Answer 35

i) Graduated loading <10-20% increase per week
ii) Plantar flexion graduated strength/loading (isos eccentric and concentric)
iii) manual therapy and STR for restictions/abnormalities.

Outcome measure: MTSS score