Foot/ankle Flashcards
1
Q
talocrural joint
A
distal fibula
tibia
talus
2
Q
midfoot
A
navicular
cuboid
3 cuneiforms
3
Q
forefoot
A
5 metatarsals
phalanges
4
Q
medial ligaments
A
deltoid ligament
5
Q
lateral ligaments
A
anterior talofibular lig
calcaneofibular lig
posterior talofibular lig
6
Q
anterior muscles
A
anterior tibialis
extensor hallucis longus
extensor digitorum longus
peroneus tertius
7
Q
anterior open chain actions
A
dorsiflexion/inversion
extension of phalanges
everts foot
8
Q
lateral muscles
A
peroneus longus and brevis
EVERSION
9
Q
posterior muscles
A
gastrocnemius
soleus
plantaris
DEEP:
post tibialis
flexor hallucis longus
flexor digitorum longus
10
Q
posterior open chain action
A
plantar flexion
PF and inversion
flexion of phalanges
11
Q
talocrural/subtalar/midtarsal joint functions
A
- shock absorption
- absorb LE rotary forces
- provide lever for effective propulsion
12
Q
pronation
A
eversion
abduction
dorsiflexion
13
Q
supination
A
inversion
adduction
plantar flexion
14
Q
talocrural
A
Pronates (DF most dominant with eversion and abduction)
Supinates (dominated most by plantar flexion with inversion and adduction)
15
Q
subtalar
A
closed chain pronation (calcaneus everts, talus adducts and dorsiflexes)
*medial longitudinal arch lowers and IR of tibfib
Closed chain supination (calcaneus inverts, talus abducts and PFs)
*med longitudinal arch elevates and ER of tibfib
16
Q
midtarsal joint (MTJ)
A
depends on subtalar joint biomechanics
subtalar pronation: promotes mobility in MTJ and forefoot
Subtalar supination: promotes stability in MTJ and forefoot
17
Q
kinetics and kinematics of gait cycle
A
slide 14
18
Q
alignment
A
- must be assessed from subtalar neutral position (neither pronated nor supinated)
- subtalar jt assessed in both prone and WBing positions
- forefoot and rearfoot alignment are evaluated separately
19
Q
ideal rearfoot alignment
A
the plumb line bisects the calcaneus and talus
20
Q
alignment of tibia, foot and ankle in the sagittal plane
A
- plumbline alignment is slightly anterior to midline through knee and lateral malleolus
- navicular tubercle, line from medial malleolus to where MTP jt of great toe rests on floor
21
Q
alignment of tibia, foot and ankle in the frontal plane
A
- distal 1/3 of tibia is in sagittal plane
- great toe is not deviated toward midline of foot
- toes are not hyperextended
22
Q
forefoot varus
A
excess forefoot mobility –> supporting structures strained –> LE IR
compensation= excessive pronation
23
Q
forefoot valgus
A
rigid lever –> less shock absorption –> lateral forces increased –> lateral stability decreased
compensation= excessive supination
24
Q
history and exam
A
history inspection palpation clearing tests joint integrity & mobility neurological functional tests
25
history
```
MOI
onset
increase/decrease symptoms
VAS
self report measures
```
26
inspection
```
postural alignment (NWB/WB)
scars
wound
calluses
swelling
```
27
palpation
tenderness
temp
tissue density/adherence
28
clearing tests
lumbar spine
hip
knee
29
ROM
Active
Passive
resisted
30
joint integrity and mobility
special tests and accessory motions
31
neurological
reflexes
sensation
myotomes
32
functional tests
```
gait
double/single limb heel raise
double limb squat
double/single limb balance
step down tasks
SEBT-star excursion balance test
hop testing
agility testing
```
33
lateral step down test
arm strategy:
-removal of hand off waist
trunk alignment
-leaning in any direction
pelvis plane
-loss of horizontal plane
knee position
- tibial tuberosity medial to 2nd toe
- tibial tuberosity medial to border of foot
steady stance
-step down on untested limb or foot wavers side to side
* each tab is scored as -1
* also used in knee instability
34
star excursion balance test (SEBT)
performed on individuals with and w/out chronic ankle instability (CAI)
- posteromedial component highly representative of all 8 components of the test in limbs with and without CAI
- anteromedial, medial and posteromedial reach tasks be used clinically to test for functional deficits related to CAI in lieu of all 8 tasks. (also used for knee instability)
35
ROM and muscle length
*examination of the knee, hip, ankle and spine are essential!!
- hip and knee ROM & muscle length
- calcaneal inversion and eversion ROM
- midtarsal joint supination and pronation ROM
- 1st ray position & mobility
- hallux dorsiflexion ROM
- 1st-5th ray mobility
- ankle dorsiflexion and plantar flexion ROM with knee flexed and extended
36
therapeutic intervention for balance impairment
- restoration requires positional sense (proprioception)
| - balance macine, balance board, external perturbation
37
balance home exercises
- balancing on 1 leg with eyes open --> closed in door frame
| - standing on 1 leg on a pillow or couch cushion with eyes open --> closed
38
therapeutic exercise for intrinsic muscles
- pt flexes at proximal MTP jt before distal MTP jt
- draw towel under foot, pick up marbles
- using resistance bands to resist proximal MTP joint flexion (long sit)
**great for post-op its that are limited for a few weeks. working intrinsics helps to maintain strength and mobility as much as possible
39
therapeutic exercise for extrinsic muscles
- resisted talocrural plantar flexion with slow eccentric return to talocrural dorsiflexed position.
- closed chain exercises (double leg heel rises, etc.)
40
pain
- exercise initiated in pain free range
- soft tissue mobilization
- cryotherapy
- NMES/TENS
- exercise of neighboring regions!
- patient education
41
posture and movement impairment
- excessive pronation and supination are most commong
- exercises developed from components of gait: while assessing strength/mobility deficits
- goal is to control motions in/out of static positions at varying speeds
- static weight shifting on bathroom scale
- circular weight shifting drill
- functional drills (retrowalking, sidestepping, etc)
42
acute phase hyper/hypo mobility
- hypermobile segment should be protected (taping, bracing, casting, footwear, etc)
- adjacent hypomobile segments should be mobilized with manual therapy or mobility exercise
- dynamic stabilization exercise should be initiated at the hypermobile segment.
43
talocrural dorsiflexion
joint mobilization--> TCJ dorsiflexion ROM (soleus stretch w/ talar joint in neutral or slightly supinated position--> step down training to facilitate eccentric control of dorsiflexion
44
subtalar joint
- full active/active assisted supination can be performed
- pronation mobility active/active assisted
- progressions involve functional training of new mobility in appropriate phase of gait cycle
45
plantar fasciitis
overuse caused by excessive pronation, obesity (BMI>30), malalignment, decreased dorsiflexion ROM, prolonged time on feet
S&S: pain medial heel, 1st steps in AM, and after rest
46
plantar fasciitis treatment
- decrease pain and inflammation, reduce tissue stress, restore muscle strength
- NSAIS, US, iontophoresis, deep tissue massage- for pain & tissue extensibility
- taping, orthoses, night splint, modified footwear to reduce tissue stress
**treat all LE biomechanical impairments!
if pronated:
- mobilize TCJ
- address all LE malalignment!
- stretch gastroc, soleus and PF
- strengthen tibialis anterior and extensor digitorum
- initiate functions and proprioceptive activities
47
plantar heel pain study: agents & exercise vs. manual therapy & exercise
electrophysiological agents & exercise (EPAX): US, ionto, dexa, stretching, intrinsic stretching, ice, HEP (3x/day)
manual therapy & exercise (MTEX): agressive soft tissue mob for 5 min & rearfoot eversion mobs. MT approach to hip, knee, ankle and foot. HEP (self eversion mob, self-soft tissue mob, stretching)
**MTEX favored
48
posterior tibial tendon dysfunction
usually excessive subtalar joint pronation and result in acquired flatfoot deformity.
S&S: TTP to tendon, resisted inv & pflx, PRONATION, absent inversion w/ heel raise
49
post tibial tendon dysfunction treatment
- NWB short leg casting may be necessary for 4-6 wks (pts w/ partial tears)
- meds and modalities for inflammation
- arch strapping to control end range pronation
- pain-free, low intensity, high rep open kinetic chain plantar flexion
- proprioception, strength, coordination
**big time pronators. eccentrically trying to stop rolling in
50
achilles tendinosis
=overuse pathology of achilles tendon (insertional vs. non)
S&S: runners and jumpers (training errors),
- NON INSERTIONAL: TTP 2-6 cm above insertion, palpable defects
- INSERTIONAL: lower, slower prognosis
51
achilles tendinosis treatment
-address acute symptoms (low level laser therapy, into, heel lift, night splint)
-restore TCJ mobility and biomechanical faults (taping, orthoses)
-stretching is essential after TCJ mobility is restored
-strengthening exercises following inflammation recovery
-eccentric training *** promotes correct orientation of collagen fibers (fewer motor units but produce more force.
(Alfredson: 3 x 15 bent/straight leg unilateral calf raise 2x/day)
52
achilles tendinosis prognosis
favorable for acute to subchronic; surgery increased with age and duration of symptoms
53
functional nerve disorders
-assessment should include spine and hip involvement
nerve involvement may result in shoe changes, orthotics, alteration of impairments in alignment, mobility, and movement pattern exercises
affected nerves include:
- tibial nerve (tarsal tunnel syndrome): where wraps around post tibialis
- peroneal nerve
54
ligament sprains
70-80%involve anterior talofibular ligamanet (ATFL), calcaneal fibular ligament (CFL), posterior talofibular ligament (PTFL)
55
grade 3 ligament sprains
are further classified:
1st degree: complete rupture of ATFL
2nd: complete rupture of ATFL and CFL
3rd: dislocation in which ATFL, CFL, and PTFL are ruptured.
*pain and improvement in DF
56
ligament sprain treatment
grade 1-2, 1st 4 days: P R I C E
severe grade 1/2 may need crutches in early stage.
open kinetic chain inversion ROM as tolerated
progress as pain and swelling are controllled and WBing tolerance increases
grade 3 rehab similar.
pt ed:
- many reinjure at 3-6 wks
- external support ofr 6-8 wks
57
syndesmotic ankle sprain
=high ankle sprain; disruption of distal tibiofemoral ligaments
diastasis=mortise widening
58
S&S of syndesmotic ankle sprain
MOI: ER and/or DF on fixed foot
+ ER stress test or squeeze test
59
syndesmotic ankle sprain treatment
reduce lower leg ER stres
lateral ankle sprain- 2-3x longer
60
turf toe
hyperextension sprain of the 1st MTP usually due to flexible footwear
mild-mod-severe injury may take from several weeks to months to return to sport
treatment= RICE, rigid shoe insert, ROM
**difficult healing bc need to walk
61
ankle fractures
- supination adduction injury
- supination ER injury
- pronated abduction injury
- pronated ER injury
62
ankle fracture tx:
- edema massage, scar mobilization, edema reduction
- AROM begins mid range, low intensity/high reps
- as function normalizes, ROM exercise is generally more tolerable
63
Ottawa ankle rules
pain in malleolar zone AND
-bone pain in posterior edge or tip of med or lat malleolus
AND/OR
-can't bear weight immediately and in clinic
64
Ottowa foot rules
pain in midfoot zone AND
-bone pain in base of 5th MT or navicular
AND/OR
-can't bear weight immediately and in clinic
65
anatomic impairments
forefoot varus/valgus
hindfoot varus/valgus
hallux valgus
pes planus/cavus
hammer toe
claw toe
66
adjunctive interventions
adhesive strapping
wedges and pads
biomechnical foot orthotics
heel and full sole lifts
67
3 main joints of foot/ankle
TCL
ST
MTL
subdivided into calcaneocuboid and talonavicular
68
extrinsic muscles
anterior groups: DF
lateral groups: evert
posterior groups: PF
69
functions of foot during gait:
shock absorption
surface adaptation
propulsion
70
common physiologic impairments
include loss of mobility, force, torque, balance, impaired balance, posture
