Foot/Ankle Flashcards
Ottawa Rules (better to R/O fx)
Ankle: TTP at malleolus, unable to WB
Foot: TTP at base of 5th or navicular, unable to WB
Orthotics
No evidence for LBP, can be helpful for PFPS with other modalities
Orthotics for Plantar Fasciitis
Prefab better than custom, short term> long term
Hallux valgus
Surgery > orthotics
Pes Cavus
Custom orthotics OK
Ankle sprain grading
Grade 1 - no loss of function, 10 degrees total motion loss (more laxity is classified as 3B vs. 3A)
West point ankle scale
TTP Proximal > 4 cm to syndesmosis suggest high-ankle sprain (grade III),
Ankle sprain recovery
Grade 1: 1-2 weeks
Grade 2: 2-3 weeks
Grade 3A: 4-5 weeks
Grade 3B: 7-8 weeks
*3B sprain takes almost twice as long to heal as grade 3!
Risk factors for lateral ankle sprain
H/O ankle sprain Improper warm-up No external support Impaired DF ROM Don't participate in balance/NM training
Ankle outcome measures
FAAM + LEFS (8-9 MCID @ 1 month)
No evidence for Hop tests
Girth Assessment
Figure-8 (around base of 5th, achilles, dorsum and below malleoli)
Special Tests
Anterior Drawer + TTP at ATFL + lateral hemorrhage is used to R/O rupture of ligament
Talar Tilt (not great) used for CFL ligament
Star excursion (
Modalities
Strong evidence to use ice intermittently after injury to decrease pain and increase WB
Acute ankle sprain treatment
MTT and progressive loading, sensory motor training
Bracing
lace-up brace dec. sprains by 2-3x
Ankle + nerve injury
Common concomitant N injury to fibular/tibial nerve with grade III ankle sprain
To improve DF ROM
A-P talar mobilization
MWM
Ankle mortise HVLA
CPR for HVLA to ankle after a sprain (3+/4)
Symptoms worse with standing
worse in evening
navicular drop > 5 mm
Distal Tib-Fib hypomobility
Chronic ankle instability
Everter weakness
Proprioceptive training
More effective if H/O sprains present
Achilles tendinopathy
Vascularity is greatest in the muscle-tendon junction, worst at mid-tendon which is where pathology usually occurs (followed by the bone insertion).
Achilles is innervated by sural nerve
Stiffness and pain worse initially, gets better and then worsens (pain throughout activity once chronic).
Dec. strength with unilateral heel raise (normal = 1 rep/ 2 sec)
(+)Arc sign swelling moves with PF/DF
Royal London test (TTP dec. with ankle DF, worse with PF)
Thompson test (calf squeeze to assess for tendon rupture if no PF occurs)
Best Imaging U/S and MRI
Younger patients (age 33 mean) do better with conservative treatment than older patients (mean age 48)
Treatment for achilles tendinopathy
Eccentric loading is most effective but can also use iontophoresis with dexamethasone or low level laser. Stretching and night splints are weak,
3x15 BID x 12 weeks is exercise Rx (better combined with air heel brace when not exercising)
Foot pain DDx
AM pain = plantar fasciitis (Windlass test to R/I)
Big toe hyperextension = turf toe
Insidious swelling at 1st MTP = gout
numbness/tingling = tarsal tunnel vs. Morton’s neuroma (3rd/4th tarsals)
Mid heel pain which is worse barefoot and better with taping of the heel = fat pad atrophy
Plantar Fasciitis
Heel Pain worse in AM and after prolonged walking, patients with impaired DF ROM and increased BMI are at highest risk
TTP at medial arch/Prox. attachment of the PF
Usually resolves in 13-14 months (normal clinical course)
Tx:Night splints, Pre Fab orthotics, Stretching of the PF 2-3x per day (3 minutes total), dexamethasone or acetic acid delivered with iontophoresis has moderate evidence.
Taping - short term relief (anti-pronation)
MTT - short term relief (1-4 months)
weak evidence for footwear, laser and weight loss Ed.
Tarsal Tunnel Syndrome
Weak Toe Flexion
+ Tinel’s
Pain and numbness at arch (burning in the arch)
worse with running and/or prolonged activity
Effects the posterior Tibial Nerve and caused by overpronation or collapsed arch (tarsal coalition?)
Tx:arch supports, mobilization of the mid-foot, strengthening the foot intrinsics
DDx for foot Nerve pathology
S1 radiculopathy will effect the gastroc/soleus
common peroneal neuropathy will present with a drop foot
Morton’s neuroma will effect the 3rd common digital nerve (best treated with neurolysis)
Post. Tib tendonosis
(+)Too many toes sign
Pain with resisted inversion
Weak heel raise
Tx: supportive orthotics with eccentric strengthening
1st MTP
Traumatic - turf toe
Microtrauma - sesamoid stress fx
Chronic - arthrosis, gout, hallux rigidus, hallux valgus
Assess ankle DF (usually impaired with 1st MTP pathology)
Mulder’s sign
Squeeze the MTs and press with the thumb were nerve lesion is suspected (use for Morton’s neuroma)
Freiberg’s disease
Collapse of the articular surface of 2nd metatarsal
Gait symptoms
Heel Strike - cavus foot, congenital deformity, tight achilles
Midstance - ankle mobility deficit (DF)
Toe-off - Hammer-toe, metatarsalgia
Primary metatarsalgia
painful at midstance, treated with MT bars that reduce pressure or injections
Mallet toe
DIP flexion with PIP and MTP neutral (more common in women)
