Foot/Ankle Flashcards
plantar flexion/dorsiflexion
-sagittal plane rotation of one foot bone with respect to another
hindfoot/rearfoot varus
-inward angled hindfoot position in frontal plane
hindfoot/rearfoot valgus
-outward angled hindfoot position in frontal plane
forefoot varus
-inward angled forefoot in frontal plane
forefoot valgus
-outward angled forefoot in frontal plane
forefoot adductus
-inward angled forefoot in transverse plane
forefoot abductus
-outward angled forefoot in transverse plane
high arch
-higher than normal medial longitudinal arch
low arch
-lower than normal medial longitudinal arch
pes cavus
-foot posture that is characterized by a high arch and hindfoot varus
pes planus
-foot posture that is characterized by a low arch and hindfoot valgus
Ankle joint movements
- DF/PF
- sagittal
Subtalar (talocalcaneal)
- supination
- pronation
Supination
- frontal - inversion
- transverse - adduction
- sagittal - PF
Pronation
- frontal - eversion
- transverse - abduction
- sagittal - DF
Transverse tarsla joint (Choparts, talonavicular and calcaneocuboid)
- inversion/eversion - frontal
- adduction/abduction - transverse
- PF/DF - sagittal
Lisfranc joint (tarsal-metatarsal joint)
- inversion/eversion - frontal
- adduction/abduction - transverse
- PF/DF - sagittal
Forefoot
- inversion/eversion - frontal
- adduction/abduction - transverse
- PF/DF - sagittal
Bones in the foot
- 28
- 7 tarsals
- 5 MTs
- 14 phalanges
- 2 sesamoid
3 sections of foot
hindfoot (talus and calcaneous)
midfoot (tarsal bones - cuneiform, cuboid, navicular)
forefoot (metatarsals and phalanges)
Ankle mortise (ankle joint - talocrural)
-distal tibia and fibula and trochlea of talus
-hinge, uniaxial
SUPPORTING LIGAMENTS:
1) lateral - ATFL, calcaneofibular
2) posterior - talofibular
3) medial - deltoid
Subtalar
-talus (inferior facets) and calcaneous (superior facets)
-hinge (uniaxial)
SUPPORTING LIGAMENTS:
1) lateral - calcaneofibular
2) medial - deltoid
3) midline - interosseous talocalcaneal
Calcaneocuboid
-calcaneous (anterior) and cuboid (posterior)
-planar - non-axial
SUPPORTING LIGAMENTS:
long and short plantar
Talonavicular
-talus and navicular
-ball and socket, triaxial
SUPPORTING LIGAMENTS:
-plantar calcaneonavicular (spring)
Tarsometatarsal
-medial cuneiform and 2nd metatarsal
-planar, non-axial
SUPPORTING LIGAMENTS:
-dorsal, plantar, and lisfranc (interosseous)
1st MT
-proximal phalangeal and 1st MT
-bicondylar, biaxial
SUPPORTING LIGAMENTS:
1) sesamoid collateral
2) intersesamoid ligament
Lateral compartment muscles
-fibular muscles
Deep posterior compartment muscles
- though to play a major role in supinating the subtalar joint
- flexor hallucis longus
- flexor digitorum longus
- tibialis posterior
Anterior compartment muscles
- primarily DFs of ankle joint
- tib anterior
- fibularis tertius
- extensor digitorum longus
- extensor hallucis longus
Intrinsic foot muscles - medial compartment
- abductor hallucis
- flexor hallucis brevis
Intrinsic foot muscles - central compartment
- quadratus plantae
- flexor digitorum brevis
- adductor hallucis
- lumbricals
Intrinsic foot muscles - lateral compartment
- abductor digiti minimi
- flexor digit minimi
Intrinsic foot muscles - deep compartment
-dorsal and plantar interossei
Windlass mechanism
-plantar fascia plays key roll in supporting medial longitudinal arch
Releasing plantar fascia
- 52% increased load on long plantar ligament
- 94% increased load on plantar calcaenonavicular (spring) ligament
- likely to lead to failure of spring ligament
Rotation of tibia and ankle biomechanics
- translate through the talus because of the tight fit in the ankle mortise
- IR of tibia = lowers medial longitudinal arch
- ER of tibia = raises medial longitudinal arch
- BUT adding a foot orthoses to correct this may increase stress on the knee due to the hips being the major controller of the tibial movement
DF during gait
- at initial contact, foot is slightly dorsiflexed
- moves to neutral at foot flat (10-15% of stance)
- gradually moves into DF through mid and terminal stance peaking at 70-80% of stance
primary propulsion during gait
ankle plantarflexors
Subtalar movement during gait
- subtalar joint pronates at IC to foot flat
- rapidly supinates during terminal stance
What contributes to stabilizing the midfoot and raising the arch during terminal stance?
1) bony anatomy
2) ligamentous support
3) muscle action
Hallux DF during gait
- up to 60* during heel rise
- hallux stays in contact with teh ground during terminal stance and is an area of high pressure
Hallux and energy absorption
-absorbs a great amount of energy an dmay contribute to eccentric contraction of muscles in the 1st MTP joint
Acquired adult pes planus causes
1) gastroc/soleus tightness
2) tib posterior tendon dysfunction
3) midfoot laxity
4) abduction of forefoot
5) ER of hindfoot
6) subluxation of talus
7) traumatic deformities
8) ruptured plantar fascia
9) charcot foot
10) neuromuscular imablance
Functional problems with pes planus
- midfoot instability
- for forces to transfor from the achilles tendon to teh floor for push off, the midfoot must be a rigid lever
Pes planus altered kinematics
1) hindfoot eversion
2) forefoot abduction
3) forefoot DF
theorized to move the subtalar joint, talonavicular, and medial cuneiform 1st mt joints closer to end range –> leads to highe rilgament loading and dependence on muscle control
Causes of pes cavus
- much less common and less well understood than pes planus
1) neurmuscular problems in childhood and in the elderly
2) overactivity of tib posterior or tib anterior or both
3) ER of tibia
Pes cavus positional changes to foot
1) hindfoot = inverted
2) midfoot = inverted
3) forefoot = PF and adduction
Runners and pes cavus
- experience more ankle injuries (lateral ankel sprains)
- experience more bone injuries (5th met stress fractures)
Reasons why pes cavus is under diagnosed
1) lack of experience of clinicians
2) objective clinical measures are not clear
3) no accepted clinical sign
Recognition and assessment of pes cavus
1) observation
2) rOM
3) strength
4) coleman block test
peek a boo sign
-when you can see the medial heel when looking at the person from the front - may indicate pes cavus
Pes cavus + hallux
-increased MTP joint df and decreased pf
Pes planus + hallux
-decreased DF
Pes cavus + MTs
-prominent MT heads
pes planus + MTs
-higher level of hallux valgus and limitus
Pes cavus + toes
-increased incidence of claw and hammer toes
Pes planus + toes
N/A
pes cavus + radiographs
-increased talocalcaneal angle
pes planus + radiographs
-increased lateral talometatarsal angle
Pes cavus treatment
- directed at accomodating the rigid structure
- goal of shoe or orthotic is improve shock absorption and distribute pressure
- custom made orthotics were better than sham in recent study - for pain and resolution of symptoms
Foot posture index
- IDs a series of specific foot postures to rate
- quick and easy
- captures gross foot posture
- areas of measurement: talar head position, supralateral and infralateral malleolar curvature, calcaneal frontal plane position, prominence of talonavicular joint, congruence of medial arch, abduction/adduction of forefoot
Visual assessment of photos
- visual assessment of whether foot is flat, low arch, normal, high arch, cavus
- quick and easy
- captures gross foot posture
- reliability may be lower when applied to subtle foot postures
foot print analysis
- various methods are used to capture the imprint of the foot
- quick and easy
- various quantitative measures possible
- plantar soft tissue may cause errors
Navicular height
- measurement of the height of the navicular in various levels of WB (seated, 10%, standing, 50%)
- quick and easy
- palpation of navicular heigh is not always easy in patients with severe foot flat
dorsum height
- measurement of dorsum heigh in various levels of WB (seated, 10%, standing, 50%)
- quick
- requires a special jig or instrumentation system
Longitudinal arch angle
- measurement of angle between medial malleoli, navicular, and 1st MT head
- quick and easy
- palpation of navicular may be hard in pts with severe foot flat
foot line test
- measurements taken from an outline of foot print
- quick and easy
- information is related to medial position of navicular
Navicular drop
- measures height of navicular during seated and standing
- quick and easy
- palpation of navicular can be hard in pts w/ severe foot flat
- difference in navicular heigh greater than 10mm bw the 2 positions indicates + test
navicular drift
- measures the medial lateral displacement of navicular from subtalar neutral to relaxed in standing
- requires various positioning by pt
- palpation of subtalar neutral is not always consistent
hindfoot and forefoot position
- standing hindfoot valgus and prone forefoot varus/valgus
- requires various positioning by patient
- palpation of subtalar neutral is not always consistent
- studies vary in reliability estimates
Arch height index
- quantitative assessments of foot posture
- custom made device or digital caliper used to assess height of dorsum of foot
single leg balance testing
- can be used to evaluate athletes at risk for sprained ankles
- 18-39 = 43 seconds EO, 10 sec EC
- 40-49 = 40 sec EO, 7 sec EC
- 50-59 = 37 sec eo, 5 sec EC
- 60-69 = 26sec EO, 3 sec EC
- 70-79 = 15 sec EO, 2 sec EC
- 80-89 = 6 sec EO, 1 sec EC
Foot lift test
-counts teh number of foot lifts that occur over a 30 second interval
Star excursion balance test
-more dynamic and challenging
Heel raise test
- both bilatearl and unilateral
- endurance test
- healthy population = 25
Functional tests for return to sport
1) timed lateral step down
2) timed leap and catch hop sequence
3) single leg hop for distance
4) single leg timed hop
5) single leg triple hop for distance
6) crossover hop for distance endurance sequence
7) square hop test
8) lower extremity functional test (LEFT)
Side hop test
- participants hop laterally a distance of 30cm
- one rep is hopping 30 cm and back to starting locations
- pts asked to complete 10 reps as quick as possible
- SCORING: time it takes to complete 10 reps.
- FAILING: puts contralateral foot down, does not complete 30 cm, falls
6 meter crossover hop test
- 2 6 meter lines, 15 cm apart, placed on floor
- participant hops on 1 limb back and forth across the lines until he or she completes the 6 m distance as fast as possible
- SCORING: time it takes to complete 6 m distance
- FAILING: puts C/L foot down, does not clear lines, falls
Square hop test
- 40x40 box is marked on floor
- patient starts outside the square and hops in and out of each side of the box (4 hops in, 4 hops out)
- patient completes 5 cycles
- SCORING: time to complete hops
- FAILING: falls, misses line, places opposite foot down
Figure 8 hop test
- 5m course designated by cones
- pt hops on one limb 2 times around the course as fast as possible
- SCORING; time to complete 2 reps around cones
- FAILING: falls, mises a cone, places opposite foot down
Anterior drawer test
- ankle in 10-20* of PF
- gently pull the calcaneous anterior and assess the forward translation of talus
- result: laxity or tear of ATFL if pain is reproduced ant/inf to lateral malleolus or if forward translation is greater than 3mm on involved side
Talar tilt test
- ankle in 20* pf or ankle in 10* DF
- examiner passively moves calcaneous into max inversion
- PF position biases for assesment of ATFL
- DFL biases for assessment of CFL
- test may not be sensitive enough to distinguish between ATFL, CFL and ATFL-CFL injuries
- results: laxity or tear is suspected if pain is reproduced inferior to lateral malleolus, ankle inversion is 15* greater on impaired vs. unimpaired side, or empty end feel
DF-external rotation test
-knee 90* flexed, ankle in max DF, passively ER the involved foot/ankle
-result: pt reports anterolateral pain in area of syndesmosis, then + for high (syndesmotic) ankle sprain
Sens. 71%, Spec. 63%
Squeeze test
- pain in NWB position, squeeze fibula and tibia together just above midpoint of calf
- result; pain in area of syndesmosis, then + for high ankle sprain
sens. 26%, spec. 88%
Syndesmosis ligament palpation
-pt in supine or sitting - palpate anterior inferior tibofibular ligament and posterior inferior tibiofibular ligament
-result: TTP = high ankle sprain. the more proximal the TTP the more severe the injury
sens 92%, spec. 29%
Cotton test
-pt in supine or sitting, stabilize distal tibia and grasp rear foot. Attempt to move talus and calcaneous medial and lateral
-result: translation of talus in ankle mortise = syndesmotic instability
Spec 71%, sens 29%
Fibula translation test
-pt supine - stabilize distal tibia and move lateral malleolus ant/post
-result: pain reproduced along syndesmosis = +
Sens 64%, spec 57%
Thompson (calf squeeze) test
-patient prone, knee flexion to 90*, compress plantar flexors at middle third of posterior calf
-result: if achilles is intact, ankle should passively plantar flex. if no motion, achilles is completely or partially torn
sens 96%, spec 93%
Achilles tendon palpation
-pt prone, feet unsupported, gentley squeeze along length of achilles noting swelling and tenderness
-result: reproduction of symptoms with palpation = achilles tendinopathy.
Spec 81%, sens. 64%
Royal london hospital test
-pt prone, feet unsupported. ID and palpate most tender portion of achilles. Pt actively DFs affected ankle, again palpate the tender portion.
-results: if patient reports decrease or absence of pain w/ palpation in DF relative to PF position, then achilles tendinopathy is likely
Spec 86%, sens 54%
Arc sign
-pt in prone, feet unsupported, patient actively PF and DF. Examiner watches area of maximal swelling.
-result: if swollen region moves proximal and distal during active ankle AROM = tendinopathy
Spec 88%, sens 42%
Fibularis subluxation
- patient prone w/ knee flexed to 90*, pt actively PF and DF and then performs eversion against resistance. Monitor area posterior to lateral malleolus prior to testing and during testing for sublux of fibularis tendon
- result: sublux or dislocation of tnedon during test
Coleman block test
- observe psoition of calcaneous during stance with entire foot in contact w/ floor, then have pt stand with calcaneous and lateral side of foot (including 4th and 5th MTs) on 1 in step - assess if calcaneal position changed
- result: if calcaneou schanges from varus position to corrected position, then rear foot varus = flexible deformity - use orthotics to correct
- if no change in calcaneal position - orthotics should focus on correcting both forefoot and rear foot position
Windlass test in WB
-equal weight on both feet, pt stands on a step stool with entire foot supported except for toes. Examiner passively extends 1st MTP joint until symptom reproduction or end range DF of 1st MT
-result: (+) - reproducing symptoms along plantar fascia = plantar fasciitis
Spec 99%, sens 33%
Mulder click test
- grasp MTs with 1 hand and use thumb of other hand to palpate for neuroma or small mass between 2nd and 3rd or 3rd and 4th MTs. Push mass in between MT heads w/ thumb and then compress MT heads
- Result: if pt reports pain at same time examiner feels click, then mass is likely neuroma
Tinel sign
- foot and ankle in neutral, tap along pathway of posterior tibial nerve from proximal or from medial longitudinal arch above medial malleolus
- result: pt’s symptoms reproduced or are referred into foot, then involvement of posterior tibial nerve
Homan sign
- knee in extension, passively DF ankle
- result: pain in calf, then DVT.
- low sensitivity and specificity though
Radiographs
-mainstay of foot/ankle care for assessing WB foot posture
Lateral radiographs
- calcaneal pitch angle and 1st MT pitch angle
- talonavicular and naviculocuneiform and cuneiform-1st MT joint positions
- good alignment of mid tarsal joint = normal “s” shape
Bohler’s angle
- shape of articulating surface of calcaneous and is typically 20-40*
- line drawn from 1) most superior point of posterior calcaneous to the highest midpoint of calcaneous
2) highest midpoint of calcaneous to most superior point of anterior calcaneous - measured with lateral radiograph
- angle less than 20* indicates calcaneal fracture
Fowler- Philip angle
- lateral radiograph
- used to quantify calcaneal impingement
- BUT Chauveaux-Liet angle may be better
Chauveaux-Liet angle
- subtract the angle bw the posterosuperior surface of calcaneous and vertical pull of achilles tendon from calcaneal pitch
- person w/ insertional achilles tendinopathy will have a higher angle = greater impingement, than someone w/o
Transverse radiographs
-used to evaluate alignment of talus, navicular, medial cuneiform, and 1s tMT
US
- used to asses soft tissue changes
- effective in distinguishing bw tendinopathy and signs of inflammation
- dark regions (hypoechoic) indicate abnormal tendon structure or tendinopathy
- fluid around the tendon woudl indicate peritendonitis and adjacent pockets of fluid indicate bursitis
Collagen vs. water on US
- collagen is a strong reflector of high frequency and appears bright (hyperechoic)
- water appears dark (hypoechoic)
Hallux valgus - etiology
- irreversible foot deformity - lateral deviation of hallux and medial deviation of 1st MT leading to sublux of 1st MTP joint
- more common in women with lower BMI
- as hallux drifts, strength of medial collateral ligament weakens
- altered position causes incongruent loading
Hallux valgus epidemiology
- 23% of adults
- more common in those above 65
- genetic factor - >60% have family hx of deformity
Diagnosis of hallux valgus
- observed deviation of >15*
- severity is visually graded by magnitude of hallux angulation
Manchester scale
-examiner matches level of hallux valgus deofrmity to that of 4 photographs - none, mild, moderate, severe
Hammer toe and claw toe
- bnormal flexion of IP joints in 2nd through 5th phalanges
- hammer toe is IP flexion deformity
- 2nd toe is commonly involved
- claw toe = ip flexion and MTP ext - common in all toes
Mallet toe
- abnormal flexion of DIP
- can occur in isolation or with hammer toe deformity
- most frequently 2nd toe
- may be due to increased pressure w/ poorly fitted shoes
High (syndesmotic) ankle sprains
- rare in comparison to other LE injuries
- patients with high exposure to contact sports, most likely to have this
- involvement of anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, and syndemosis. Sometimes deltoid as well.
High ankle sprain - causes of pain
1) widening of ankle mortise
2) instability
3) increased width of trochlea of talus nateriorly
Diagnosis of high ankle sprain
1) pain out of proportion with injury (sn 65%, sp 79%)
2) pain felt in the shank or knee during injury (sn 50%, sp 70%)
high ankle sprain special tests
1) DF ER test
2) squeeze test
3) syndesmosis ligament palpation
4) cotton test
5) fibula translationt est
Diagnostic accuracy and reliability of these tests is not high, but clinicians should use multiple tests to rule in/out
Tibiofibular instability
- important to assess this
- this is best treated with cast immobilization or internal fixation
Clinical protocols for high ankle sprain
-bc they are rare are most likely based on expert oppinion
Stable high ankle sprains (grade I)
PT is recommended
- progress from protection to more weight bearing and sports specific tasks
- limit the amount of DF
- restrict strong PF contractions
Grade II/III high ankle sprain
- unstable
- significant gapping on stress radiographs
- immobilization or internal fixationr ecommended
Lateral ankle sprains - untreated
-leads to ankle instability
lateral ankle sprains and immobilization
-helps to return to function, but is not optimum for ligament healing
Ottawa ankle rules
If ANY of following are present:
1) bone tenderness in the malleolar zone - along medial and lateral malleoli, talar neck/head
2) bone tenderness specifically at:
- posterior edge or tip of lateral malleolus
- posterior edge or tip of medial malleolus
- base of 5th met
- navicular
3) inability to weight bear immediately following injury and during examination
LOW SPECIFICITY
Bernese ankle rules
POSITIVE IF ONE OF THESE CAUSES PAIN:
1) indirect fibular stress: compress fibula and tibia together approximately 10 cm proximally to fibular tip
2) direct medial malleolar stress: the thumb is pressed flat on medial malleolus
3) compression stress of mid foot and hind foot: one hand fixes calcaneous in a neutral position and other hand applies a sagitttal load on forefoot
Sn 100%, sp 915
Grade I lateral ankle sprain
- no loss of function, no ligamentous instability (negative ant drawer and talar tilt tests)
- little or no ech ymosis
- point tenderness
- decreased ankle motion of 5* or less
- swelling of 0.5cm or less
grade II ankle sprain
- some loss of function
- positive anterior drawer (anterior talofibular involvement)
- negative talar tilt test (no calcaneofibular involvement)
- echymosis
- swelling
- point tenderness
- decreased total ankle motion between 5-10*
- swelling between 0.5cm-2cm
grade III lateral ankle sprain
- near total loss of function
- positive anterior drawer and talar tilt test
- ecchymosis
- extreme point tenderness
- decreased total ankle motion > 10*
- swelling > 2.0cm
Supervised vs. unsupervised programs following lateral ankle sprain
Supervised result in:
1) less pain and instability at 8 weeks with no difference at long term follow up
2) greater gains in ankle strength and joint position sense , but worse postural control at 4 month follow up
3) inconclusive results regarding prevention of reinjury at 12 months
Manual therapy and lateral ankle sprain
- supported in literature
- studies recommend it for DF rom, positional faults of distal tibiofibula joint, and talus
Patients who are most likely to respond well to manual therapy after lateral ankle sprain
1) symptoms worse when standing
2) symptosm worse in evening
3) navicular drop >/+ 5.0mm
4) distal tibiofibular hypomobility
Bracing and lateral ankle sprains
- supported by literature
- semi-rigid bracing had the lowest reinjury prevalence
High risk for reinjury includes the following risk factors…
1) hx of previous ankle sprain
2) failure to use external supports
3) failure to warm up with static stretching and dynamic movement pre activity
4) lacking normal ankle DF range of movement
5) failure to participate in a balance and proprioceptive prevention program after previous injury
% of patients who will develop chronic ankle problems
20-40%
Chronic ankle instability classification
1) at least 1 lateral ankle sprain
2) at least 2 episodes of ankle “giving way” in last 6 months (a score on the cumberland ankle inventory of less than 25)
3) lower self-reported function on current scales
Mechanical ankle instability
- sometimes patients with chronic ankle instability develop this or it may occur independently (rarely)
- combo of anatomical factors and loss of ligament function create this form of ankle instability
Diagnosis of mechanical ankle instability
- ID’ing mechanical laxity and response to treatment
- stress radiographs with positive talar tilt of 7* and anterior displacement of 4mm
- decreased strength (half to full grade loss on mmt)
- decreased ROm
- anterior drawer test
Anterior impingement syndrome
- primarily occurs as a result of ankle trauma (typically lateral ankle sprain)
- 3% of sprains resulted in this
Diagnosis of anterior impingement syndrome
- anterior joint pain with forced DF
- c/o pain with squatting, stair climb, walking fast
Treatment of anterior impingement syndrome
- conservative
- improving DF w/o pain
- heel lift
Loose bodies and osteochondral lesions
-joint loose bodies and osteochondral defects are frequently reported after lateral ankle sprain
diagnosis of osteochondral defects
- not straightforward
- radiographs and other imaging may not detect cartilage damage
Treatment of osteochondral defects and loose bodies
-removal of loose bodies
Ankle osteoarthritis
- -not common
- affects 1-4% of population
- may be increasing due to higher number of elderly and vehicle trauma
Classifications of ankle oa
Type I: isolated ankle
Type II: ankle arthritis w/ intraartcicular varus or valgus
Type III: ankle arthritis with hindfoot deformity, tibial malunion, midfoot abductos/adductus, supinated midfoot, plantar flexed 1st ray
Type IV: I-III plus subtalar, calcaneocuboid, or talonavicular arthritis
Plantar fasciopathy
- overuse syndrome of plantar fascia
- heel spurs are associated (but little clinical significance)
- most commonly affects those age 45-64
Risk factors for plantar fasciopathy
1) obesity
2) decreased DF ROm
3) time spent during work day on feet
Strongest predictor of plantar fasciopathy
-limited ankle DF
Key diagnostic examination tests for patients with plantar fasciopathy
1) reported hx of medial plantar heel pain that is most severe w/ a) initial wb following inactivity, b) extended periods of WB activity
2) pain with palpation of calcaneal plantar fascia insertion
3) active and passive talocrural joint DF ROM
4) windless test
5) foot posture assesment
6) BMI
treatment of plantar fasciopathy
- EDUCATION
- taping
- orthotics
- stretching of gastroc/soleus and plantar fascia
- DF splints
- manual therapy in combo with other treatments
Tarsal coalition
- rare (1% of population with foot porblems)
- fibrous, cartilaginous, or osseus fusion of 2 or more bones in the midfoot and hindfoot
- most common deformities are calcaneonavicular and middle facet talocalcaneal
- adolescents (12-16)
- (B) involvement is common!
Treatment of tarsal coalition
- activity modification
- orthotics
- anti-inflammatories
Lisfranc injuries
- lisfranc ligament arises from medial 1st cuneiform and attaches to base of 2nd MT
- midfoto injuries as a result of high energy or low energy
clinical diagnosis of lisfranc injury
- deformity if complete rupture
- swelling and pain on medial side of foot w/o deformity
Stage I lisfrance
- with radiograph
- no change in separation between 1st and 2nd MT
- no loss of medial longitudinal arch hieght
Stage II lisfranc
- radiograph
- 1mm-5mm separation between 1st and 2nd metatarsals
- no loss of medial longitudinal arch height
Stage III lisfranc
- > 5mm of separation between 1st and 2nd MT
- losso f medial longitudinal arch height
Treatment of lisfranc injury
- depends on severity
- injuries with out instability can be treated with casting
- internal fixation needed if instability
Stage I listfranc treatemtn
- NWB with molded cast for 6 weeks
- painfree on cast removal, than custom orthosis and sport specific return to function
- if pain on cast removal, Wb afo prescribed
Sever’s disease
- calcaneal apophysitis
- self limiting condition
- occurs due to traction force of achilles pulling on bone fragment
- typically in boys in early part of accelerated growth spurt between age 6-8
- associated with high impact sports (running soccer)
- typically resolves in 2wks-2months
Diagnosis of sever’s disease
- young athlete having growth sport and complaining of intermittne tor constant heel pain that occurs with WB
- use of 1 leg heel standing test - sn 100%
- squeeze test - sn 97%
- combined sp of 100%
Treatment of sever’s disease
-rest, ice, heel lift, strengthening, stretching
Kohler’s disease
- uncommon
- osteochondrosis of navicular
- may be assosicated with osgood-schlatter or legg-calve-perthes
- self limiting
- excellent prognosis with no long term structural deformity
- children between 2 and 10
- more ocmmon in boys (4:1)
Etiology of kohler’s disease
- unknown
- proposed;
1) infection
2) inflammation
3) endocrine imbalance
4) nutritional factors
Diagnosis of kohler’s disease
- gradual onset
- swelling and erythema over dorsum of midfoot
- TTP navicular bone
- shifting weight onto lateral foot to relieve pressure
-imaging used to confirm
Treatment of kohler’s disease
- soft arch support
- avoid strenuous activity
Hallux rigidus
-stiff great toe caused by degenerative arthritis
of 1st MTP
-pain accompanies loss of motion
-females>males
-can also be caued by a runner who exposes 1st mtp to repeated hyperextension
Grade 0 hallux rigidus
- DF of 40-60* (10-20% loss compared to normal side)
- normal radiographic results
- no pain
Grade I hallux rigidus
- DF 30-40* (20-50% loss compared to normal side)
- dorsal osteophytes
- minimal to no other joint changes
grade II hallux rigidus
- DF of 10-30* (50-75% loss)
- mild flattening of mTP joint
- mild to moderate joint narrowing or scelorsis
- dorsal/lateral and/or medial ostephytes
Grade III hallux rigidus
- DF of less than 10* (75-100% loss)
- often less than 10* PF
- severe radiographic changes
- constant moderate to severe pain
- pain at the extremes of rom
grade IV hallux rigidus
-same as grade III, but pain throughout entire ROM
Treatment of hallux rigidus
- limit 1st mtp joint motion to decrease stress
- taping
- carbon footplates
- surgical intervention is common when stage becomes more limiting
Metatarsalgia
- pain in teh forefoot associated with stress over MT region
- common in 1st and 3rd MTP
morton neuroma
- perineural fibrosis and nerve degeneration
- common digital nerve bw 3rd and 4th MT
- 45-50yo women
- either foot may be affected, but rarely (B)
- pain is usually sharp and burning
- numbness is common
Proposed MOI for morton’s neuroma
- pes planus
- tight gastroc soleus
diagnosis of morton’s neuroma
- combines physical exam with imaging findings
- MRI is more common, but high frequency ultrasound is similar in sn and sp
physical exam s/s for morton’s neuroma
- pain and paresthesias with plantar pressure bw MT heads
- painful click reproduced with squeezing forefoot and pushing upward with thumb at site of nerve compression (mulder sign)
- relief with injection
Treatment of morton’s neuroma
- steroid injection (but lacks good evidence)
- 82% of patients who received steroid injection combined with footwear modifications improved compared to 63% of footwear modifications alone
- soft soled shoes and wide toe box can be helpful
- elevating MT heads on medial side of neuroma can help
Surgery for morton’s neuroma
- excision of plantar nerve
- surgical results are variable
- nerve regeneration can cause recurrence of symptoms
Noninsertional achilles tendinopathy
- one of most common overuse injuries
- 6 cm proximal to insertion
- shift to recognize sedentary patients also develoing the problem
- common among those age 41-60
Key risk factors for noninerstional achilles tendinopathy
- age
- obesity
- limited DF
- abnormal subtalar ROM
- decreased PF strength
- foot pronation
- abnormal tendon structure
- HTN
- high cholesterol
- diabetes
Clinical diagnostic tests for achilles tendon problems
- palpation
- royal london hospital test
- arc sign
- high specificity, low sensitivity
Treatment of non-insertional achilles tendinopathy
- education
- unloading (limiting ankle DF)
- reloading
- protection
- orthotics
- heel lift (but not well supported in literature)
- eccentric exercise
Eccentric loading protocol
- patient does (B) heel raise and lowers down on involved limb
- ROM cna be controlled by rising up from the floor or using a step
- load can be controlled by having pt assist with uninovlved limb, progressing to unassisted body weight or weighted back pack
- recommended dosage varies - 3 sets of 15 reps with knee flexed and bent 1x/day for 12 weeks in clinical trials
“do as tolerated” may be equally as sucessful as compared with encouraging pain supported by new RCT
Modalities for noninsertional achilles tendinopathy
-low level laser and ionto are both indicated with inflammation is there, but only have moderate evidence
Manual therapy and taping for noninsertional achilles tendinopathy
- low levels of support
- night splints not recommended
Prognosis of non-op treatmetn for non-insertional achilles tendinopathy
-good
Insertional achilles tendinopathy
- similar to non-insertional
- may also include bursitis, bon spurs, haglund’s deformity
- occurs at or near origin of achilles on calcaneous
- associated with less active and overweight
Type I Insertional achilles tendinopathy
-thickened tendon (6-8mm) with nonuniform intramural splits or foci of punctuate degeneration
Type II Insertional achilles tendinopathy
- thickening of tendon (more than 8 mm)
- uniform intramural degeneration involving less than 50% width of tendon
Type III Insertional achilles tendinopathy
- diffiuse thickening of tendon (more than 8 mm)
- uniform intramural degeneration involving more than 50% width of tendon
Treatment of Insertional achilles tendinopathy
- adaptations of eccentric program
- limiting range of movement to the floor (not past 0* DF) may be recommended during eccentrics
- poorer prognosis than those with non-insertional
Achilles tendon rupture
- people over age of 50
- greater number of older adults participating in sports
- achilles tendon rupture 3-4x more likely in men
- age 40-60
Diagnosing Achilles tendon rupture
- sudden pain
- inability to bear weight
- weakness of affected ankle
- postive thompson test (simonds squeeze test)
- decreased ankle PF
- presence of palpable gap
- increased passive ankle DF with gentle manipulation
Treatment of Achilles tendon rupture
- debate over operative vs. non-op
- both have similar rate of re-rupture (3-12%)
- similar incidence of DVT
- functional rehab results in earlier return to work and greater satisfaction
Bruman colleague protocol for Achilles tendon rupture
- recommends immediate full WB with ankle immobilized in PF
- at 3 weeks patients can move ankle through 0-30* PF
- at 7 weeks all orthoses and ROM restrictions are removed
Posterior tib dysfunction
- leading cause of flat foot deformity
- subjects over 40 yo
- high proprotion are female
- overweight
- progressive in nature
Diagnosis of Posterior tib dysfunction
- insidious onset of swelling and pain
- leads to acquired flat foot
Treatment of Posterior tib dysfunction
- bracing and orthotic strategies
- unload the tendon
- brace initially to maximize unloading and then transition to shoe orthotic
- most reviews recommend either off the shelf or custom that controls hindfoot eversion/inversion and supports medial longitudinal arch
Predictors of successful non-op care with Posterior tib dysfunction
-ability of patient to adapt to less aggressive orthotic device
Exercise for Posterior tib dysfunction
- patients may benefit from exercise
- eccentrics may help
- prevent muscle weakness, induce remodeling of tendon and cause hypertrophy of atrophied leg muscles
- if significant midfoot instability, may never recover ability to heel raise
Fibularis tendons
- commonly associated with lateral ankle sprain
- can result due to cavus foot
- cause = functional ankle instability trauma, ankle sprain, subluxation, insufficiency of retromalleolar groove, low lying fib brev muscle, pes cavus, or tears
Diagnosis of Fibularis tendons problems
- may occur from actue trauma or repetitive trauma
- pain with palpation, contraction, and stretching
- pain along posterior lateral region of the foot
- swelling/clicking
- pain with heel rise
Treatment Fibularis tendons
- casting and immobilizations do not improve stability of tendons
- surgery may be recommended
- current recs are based on expert opinion
Lauge-Hansen classfication
- ankle fractures
- based on injury mechanism and assists ortho surgeons in diagnosing the various soft tissue adn bone injuries involved
Weber classification
- ankle fracture
- typically based on lateral structures at ankle joint
Weber Type A
lateral malleoli injury distal to th etibial plafond
Weber type b
-at level of tibial plafond
Weber type c
fractures proximal to the tibial plafond
most severe - weber a, b or c?
B and C are most severe becuase they may involve the syndesmosis and malleolar tertius
-often require surgery
Treatment of ankle fracture
- early weight bearing post op has questionable benefits
- active exercises accelearate return to work and daily activities compared to immobilization
- early WB tends to accelerate return to work and daily activities
- active exercise combined with immediate weight bearing may be a safe option
General isolate fibula fracture rehab protocol
1 week - walking boot all times w/ crutches
2 week - WB with walking boot, removal of boot for ROM, stationary bike
3-5 week - strengthening, wean from boot to stirrup brace
6-12 weeks - stirrup brace worn with all activities
Bimalleolar fractures and syndesmosis injuries general guidelines
-same as fibula fracture, but weaned out of boot at 4-6 weeks and wore stirrup brace for 3 months post rehab
MT fractures
- 2% of all foot/ankle fractures
- high force required to fracture largest met so 1st met fx rare compared to II-V
Treatment of MT fractures
- immobilization if not displaced
- internal fixation if displaced
- majority are non-displaced
Calcaneal fractures
-small proportion of all foot/ankle fractures
Calcaneal fx MOI
-fall from significant height or motor vehicle accident
Treatment of calcaneal fractures
- controversy over internal fixation or nonop care being best
- complication rates after internal fixationa re high
- ORIF is currently advocated when fx are displaced >1mm
Medial tibial stress syndrome
- shin splints
- similar conditions that may underlie symptoms;
1) tibial stress fracture
2) periosteal injury
3) deep posterior compartment syndrome - associated with athletes that particiapte in intense, repetitive, WB activities
Symptoms and characteristics associated with medial tibial stress syndrome
- often bilateral
- distal 2/3 of posterior tibia
- female gender
- higher BMI
- below avg activity hx
- previous lower extremity injury
2 theories of cause for MTSS
1) periosteal modeling to reinforce the tibia at its narrowest diaphyseal cross section
2) inflammation of persioteum due to excessive traction on muscle fibers and fascia at their attachment site to medial distal tibia border
MTSS risk factors
- increased BMI
- greater navciular drop
limited ankle DF NOT listed as a risk factor
Treatment of MTSS
-rest for up to 4 months is key to allow tissue healing
-ice and NSAID injections
-NWB activities like swimming or biking to maintain fitness
-no studies were of sufficient rigor to recommend any specific treatment
-appropriate foot wear
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