Foot & Ankle Flashcards
What are the three components of supination?
Inversion, adduction and plantar flexion
What plane does inversion of the foot occur in?
Frontal
What plane does adduction of the foot occur in?
Transverse
What plane does plantar flexion of the foot occur in?
Sagittal
What are the three components of pronation?
Eversion, abduction and dorsiflexion
What plane does eversion of the foot occur in?
Frontal
What plane does abduction of the foot occur in?
Transverse
What plane does dorsiflexion of the foot occur in?
Sagittal
What is the Chopart joint?
Transverse tarsal - talonavicular and calcaneocuboid
What is the LisFranc joint?
Tarsal-metatarsal joints
cuneiforms and cuboids - metatarsals
What ligament prevents anterior displacement of the talus relative to the mortise?
ATFL
What ligament of the ankle is taut with inversion and adduction of the calcaneus relative to fibula?
CFL
What ligament is taut with ER of the talus relative to the ankle mortise?
Posterior talofibular ligament
What two ligaments work together to limit supination of the subtalar joint?
Calcaneofibular and cervical ligaments
Damage to this ligament can result in excessive supination of the subtalar joint?
Interosseous ligament
What bones constitute the midfoot?
Cuneiforms, navicular, cuboid
What ligament, with no attachment to the talus, prevents plantar flexion of the talus?
Calcaneonavicular or spring ligament
The Chopart joint joins which two parts of the foot?
Hind foot -> mid foot
The talonavicular joint is supported on the plantar surface by what ligament?
Spring or calcaneonavicular ligament
What bones create the transverse arch of the foot?
Intertarsal joints (cuneiforms, navicular, cuboid and navicular)
Which Lisfranc/tarsometatarsal joint is the most commonly injured joint?
2nd metatarsal with medial cuneiform - interosseous ligament
What muscle may have role in supporting transverse arch with an attachment at base of 1st metatarsal and medial cuneiform?
Fibularis longus
Which muscle is the largest in surface area and strength for supination of the subtalar joint?
Posterior tibialis - supporters -> flexor digitorum longus, flexor hallucis longus
Which muscle has larger moment arm for subtalar supination - anterior or posterior tibialis?
Posterior tib -
Anterior tib has 1/5 the moment arm
With size/shape of talocrural joint - which motion is joint more congruent?
Wider anteriorly than posteriorly -> more congruent in dorsiflexion
What movements occur in weight bearing supination in reference to calcaneus and talus?
Calcaneus ->inversion
Talus -> abduction and dorsiflexion (ER of tibfib)
What movements occur in weight bearing pronation in reference to calcaneus and talus?
Calcaneus ->eversion
Talus ->adduction and plantar flexion (IR of tibfib)
NWB supination is a combination of: (only calcaneal movement)
Inversion, adduction, plantar flexion
NWB pronation is a combination of: (only calcaneal movement)
Eversion, abduction and dorsiflexion
What ligament supports calcaneocuboid joint?
Long plantar ligament - one of strongest in body = minimal movement
Which joint is more mobile: talonavicular or calcaneocuboid?
Talonavicular
A loss of plantar fascial support inc the load on what two ligaments:
1) calcaneonavicular - spring
2) long plantar ligament (calcaneocuboid)
At IC of gait cycle: what position is the foot in?
Slight dorsiflexion
During gait cycle, when do plantar flexors start to become active? (what phase)
Late midstance -> pre-swing
What muscle decelerates tibia after flat foot/midstance?
Soleus
What motions does the subtalar joint move from and then to at IC to flat foot and then terminal stance?
Pronation (at IC/flat foot) to supination (terminal stance)
What muscle eccentrically lowers MLL at IC and during midstance phase?
Tibialias anterior
What muscle becomes eccentrically active before flat foot to control for pronation of the MLL?
Tibialis posterior
How many degrees of motion occur at the MLL with walking?
10 deg
What is normal ROM for great toe/hallux/MTP motion duriing pre-swing?
40-60 deg dorsiflexion
During running/sprinting, what percentage of moment energy is contributed by the digits/toes?
20-50%
When transferring energy from Achilles to and through the midfoot, what is more problematic: laxity of the midfoot or rigidity?
Laxity - excessive plantarflexion of talus results in subluxation of posterior facet of subtalar joint -> inc load on calcaneonavicular/spring ligament which can rupture
A variety of clinical conditions can contribute to excessive pronation(10 listed): what are examples?
Gastroc/soleus tightness PTT dysfunction midfoot laxity abduction of forefoot ER of hindfoot subluxation of alus traumatic deformities ruptured plantar fascia Charcot foot neuromuscular imbalance
Is there a strong correlation between static measurement of foot posture and foot kinematics?
Yes - McPoil found measurement of MLL statically and identical measure dynamically at midstance
What are believed to be causes of high arch/pes cavus?
Over activity of PTT or tib anterior or both - or ER of tibia with proximal control issue
What is the Coleman block test?
Identify foot posture with quiet, static standing and then have pt stand on 1” block with lateral foot and heel on block - does midfoot respond with rigidity or flexibility? (Looking at 1st-3rd metatarsals)
What is the peek a boo sign?
Observation of medial heel when looking at a person from the front due to excessive supination
What is the too many toes sign?
Observation of lateral toes (digits 3-5) when looking at a person from behind due to excessive pronation - PTT dysfunction
Which outcome measures are validated for ankle instability?
Cumberland Ankle Instability Tool (CAIT) and Ankle Instability Index (AII)
Which outcome measure looks at plantar fasciitis, Achilles tendinopathy, CAI?
Foot and ankle ability measure (FAAM)
What exam is a valid and reliable assessment tool for foot posture?
Foot posture index
What are generalized outcomes for the Foot Posture Index?
Neutral = 0
Highly pronated > +10
Highly supinated < -10
In runners with higher arches, what two injuries are more prominent?
Ankle sprains, bony injuries to 5th metatarsal
What is the expected average change in height in the Arch height index from NWB to WB?
10 mm or 13.4%
In the navicular drop test, what is the cutoff for abnormal findings?
Difference of 10 mm between NWB and WB
> 10 mm = risk factor for medial tibial stress syndrome
When assessing the heel raise, what might a lower height indicate in terms of dysfunction? (Normative = 55-65% of length of foot)
1) weakness - dec ability to plantar flex body weight
2) dec length of PFs
3) midfoot instability (flat foot deformity)
What is considered to be more severely tight in terms of dorsiflexion AROM? (less than…)
5 deg - average is 18 deg
With a tight first MTP joint, where is the center of pressure shifted during walking?
Laterally
Is MMT valid for plantar flexors?
No - need to do heel raise test
Name the special test: ankle in 10-20 deg of plantar flexion, gentle pull of calcaneus anteriorly and looking at amt of translation (positive outcome?)
Anterior drawer test - > 3 mm of translation or pain in region anterior/inferior to malleolus
(questionable reliability)
Name the special test: 20 deg of plantar flexion // 10 deg of dorsiflexion - apply maximal inversion (positive outcome?)
Talar tilt - plantar flexion looks more at ATFL // dorsiflexion looks more at CFL - but unable to distinguish which is injured - positive test is pain in region inferior to lateral malleolus, >15 deg or empty end feel
Name the special test: knee is flexed at 90 deg, flexion of ankle maximally in dorsiflexion and passive ER (positive outcome)
Dorsiflexion-ER test - positive is anterolateral pain in area of syndesmosis
Name the special test: squeeze fibula and tibia together (NWB) above midpoint of calf (positive outcome)
Squeeze test - positive test pain in area of syndesmosis (good specificity)
Name the special test: stabilize distal tibia and grasp rear foot, move talus and calcaneus medially/laterally (positive outcome)
Cotton test - positive test is translation of talus in mortise - syndesmotic injury
Name the special test: stabilize distal tibia and move lateral malleolus anterior to posterior (positive outcome)
Fibula translation test - positive is pain reproduced along syndesmosis
Name the special test: pt in prone, knee flexed to 90 deg, compress gastroc/soleus complex at middle third (positive outcome)
Thompson test - positive no associated ankle motion = Achilles tendon rupture - high sensitivity and specificity (90+)
Name the special test: pt in prone, palpation for most significant tender portion of Achilles, have pt actively dorsiflex ankle (positive outcome)
Royal London Hospital Test - positive test is repeated palpation of tender spot has decreased or absent pain in dorsiflexion = Achilles tendinopathy - highly specific
Name the special test: pt in prone, active pf/df with watching for area of maximal swelling (positive outcome)
Arc sign - positive is edema moves proximal to distal during motion = tendinopathy - high specificity
Name the special test: pt in prone, knee flexed to 90 deg - AROM for pf then df and follow with resisted eversion (positive test)
Fibularis subluxation - subluxation/dislocation of fibularis tendons - indicative of instability
Name the special test: observe foot/calcaneal position during stance -> have pt stnad with calcaneus and lateral foot (4/5) on one in step (positive outcome)
Coleman block test - looking at rigidity or flexibility of rear and forefoot deformity
Name the special test: pt standing with equal weight between feet, toes off edge of step -> passively extend 1st MTP until reproduction of sxs or end range df (positive outcome)
Winlass test - positive test reproduces sxs along plantar fascia - indicative of plantar fasciitis (high specificity)
Name the special test: palpate for mass between 2nd/3rd or 3rd/4th metatarsals - push mass between met head and then grasp around forefoot compressing heads together (positive outcome)
Mulder click test - pt experiences pain with pressing mass to plantar surface coupled with examiner feeling palpable click - mass is likely neuroma
Name the special test: foot/ankle in neutral position - tap along pathway of posterior tibial nerve (MLL to above medial malleolus) (positive outcome)
Tinels sign - pt sxs are reproduced at site of tapping or referred into foot
Name the special test: with the knee extended, passively dorsiflex the ankle (positive outcome)
Homan sign: pain in the calf may indicate DVT - LOW specificity and sensitivity
Are pitch angles in a radiograph high for supinated feet or pronated feet?
High in supinated feet - low in pronated feet
In an ultrasound, what do hypoechoic (dark) regions within the tendon indicate?
Abnormal tendon structure / tendinopathy
In an ultrasound, what does fluid around the tendon indicate?
Peritendinitis
In an ultrasound, what does fluid adjacent to the tendons indicate?
Bursitis
At what age do children develop normal footprints with set arch height?
12-13 y.o.
What is the most common cause for acquired flat foot in adults?
Tib posterior tendon dysfunction
Pes cavus foot deformity can be associated with two different conditions of the foot: (2)
1) Charcot foot
2) spastic neurological conditions
Pes cavus is associated with high rates of what common foot ailment:
Plantar fasciitis
Which foot deformity is characterized by lateral deviation of great toe corresponding to medial deviation of the 1st metatarsal (bunion)?
Hallux valgus
Does hallux valgus have a genetic component?
Yes - >60% have family hx
Is hallux valgus more common in women or men?
Women - 2-3x more
Women with lower BMI
Men with higher BMI
Does hallux valgus result in inc fall risk?
Yes
How is halux valgus defined:
> 15 deg of deviation of hallux from first metatarsal
What joint does a hammer toe affect?
IP flexion deformity - most commonly 2nd due to being longer
What joint does a claw toe affect?
Both IP flexion and MTP extension - typically all toes due to neuromuscular disorder
Is the extensor digitorum able to correct/extend the PIP joint with the MTP in neutral, flexed or extended positions?
Neutral and flexed - only if deformity is flexible; tenodesis of the extensors
What deformity is abnormal flexion of the DIP?
Mallet toe
What toe does mallet toe typically occur at?
2nd (poorly fitting shoes)
What are the main ligamentous supports of the distal tibiofibular joint?
Anterior inferior tibiofibular ligament - posterior inferior tibiofibular ligament - syndesmosis between tib/fib
What is the primary MOI for a high ankle sprain/
ER with dorsiflexion of tibia on planted foot
What are two indicators with syndesmotic special testing that may help confirm high ankle sprain?
1) pain out of proportion to the injury
2) pain at the knee or shank during injury
- also pain with forceful DF/passive ER
What grade syndesmosis injury requires immobilization or internal fixation?
Grade 2-3 - significant gapping, screw fixation 1-3 cm proximal to ankle
What percentage of pt’s have objective mechanical laxity after lateral ankle sprain?
30%
Ottawa ankle rules:
1) bone tenderness in malleolar zone along medial or lateral malleoli, talar neck/head
2) bone tenderness at posterior edge or tip of lateral malleolus / posterior edeg or tip of lateral malleolus - base of 5th metatarsal - navicular
3) inability to bear weight immediately following injury and during exam
What are the three Bernese rules added to the Ottawa ankle rules to inc specificity and dec false positives?
1) indirect fibular stress - compress fibula,tibia together approx 10 cm proximal to fibular tip
2) direct medial malleolar stress - thumb pressed flat on medial malloelus
3) compression stress on mid/hindfoot - stabilized calcaneus in neutral, apply sagittal load on forefoot to compress mid/hind foot
Typical characteristics of Grade I ankle sprain:
No loss of function, no ligamentous instability, little to no ecchymosis, less than 5 deg ROM loss, less than 0.5 cm selling
Typical characteristics of Grade II ankle sprain:
Some loss of function, positive anterior drawer/negative talar tilt, ecchymosis, swelling and point tenderness, dec ROM between 5-10 deg, swelling 0.5 cm to 2 cm
Typical characteristics of Grade III ankle sprain:
Near total loss of function, positive talar tilt and anterior drawer tests, ecchymosis, extreme point tenderness, decreased ROM >10 deg, swelling > 2 cm, loss of ability to bear weight
What are two factors are the current best evidence of indicators for reinjury with lateral ankle sprain?
1) exposure to court sports / indoor sports
2) poor balance
What is a good prognostic indicator for lateral ankle sprain?
Lack of WB pain with dorsiflexion
What is a negative prognostic indicator for lateral ankle sprain?
Limited dorsiflexion is factor for re-injury
What are 5 factors for high risk of reinjury with lateral ankle sprains?
1) hx of previous ankle sprain
2) failure to use external support
3) failure to warm up with static stretch/dynamic movement
4) lacking normal ankle DF
5) failure to participate in balance prevention program after injury
Do pts always demonstrate ankle joint laxity with side/side comparisons with injury?
No - functional ankle instability is used to distinguish lack of mechanical instability
Does joint laxity or mechanical instability after an ankle sprain contribute to development of Chronic Ankle Instability (CAI)?
No - contributes little - more a perceived instability due to sensorimotor theory (dec joint position sense, impaired sensory pathway)
What targeted manual therapy mobilization had immediate effect and maintained effect for 6 months with improved dynamic balance and perception of instability?
Specifically addressing dorsiflexion
Is clinical evaluation sensitive enough to detect ankle mechanical laxity?
May not be - may require stress radiographs; > 7 deg talar tilt - anterior displacement of 4 mm
Besides manual therapy, what else can be done to aid with anterior impingement?
Heel lift
When is OA of the ankle common?
Post-traumatically - 62% associated with fracture
What is a common prognostic factor leading to ankle OA?
Osteochondral defect of talar dome
Where is a heel spur common in plantar fasciopathy?
Medial calcaneal tubercle
What are factors for developing plantar fasciopathy?
Obesity
DM
decreased DF ** strongest predictor
Time spent on feet
What ROM for AROM dorsiflexion is 23x more likely to develop plantar fasciopathy?
0 deg or less
Does taping have a short term or long term improvement for plantar fasciopathy?
Short term
Which has greater improvement: pre-fab or custom orthotics for plantar fasciopathy?
Marginal improvement in custom compared to pre-fab -> cost?
What foot position may benefit more from custom foot orthoses for plantar fasciopathy?
Rigid and fixed flat foot deformity
True / false: The Achilles tendon is directly attached to the plantar fascia.
True - need neutral arch position to adequately stretch Achilles/PF combo
What proximal limitation in the hip contributes to the lowering of the MLL and thus plantar fasciopathy?
Limitations in ER
What has better outcomes in plantar fasciopathy: plantar fasciotomy or gastroc lengthening procedure?
Gastroc lengthening/recession -
Where is the sustentaculum tali located?
Inferior to and slightly anterior to the medial malleolus, where calcaneus articulates with talus
Where is the sinus tarsi located?
Slightly inferior and anterior to lateral malleolus, tunnel between calcaneus and talus.
Is a flat foot, neutral foot or supinated foot more likely to develop Sinus Tarsi Syndrome?
Flat foot due to compression of anatomy in the tunnel
Where is the Lis Franc ligament?
Medial aspect of first cuneiform attaching to base of second metatarsal
What injury is diagnosed based on the degree of separation between 1st and 2nd metatarsals?
Lis Franc injury
Stage 1 - no change in
separation; no loss MLL height
Stage 2 - 1-5 mm separation; no loss MLL height
Stage 3 - >5 mm separation; loss of MLL height
What disease is characterized by calcaneal apophysitis caused by inflammation of secondary calcaneal ossification open in childhood due to Achilles tendon traction on bone fragment?
Sever’s disease
Severe’s disease affects which gender more predominantly?
Boys > girls
Sever’s disease typically impacts children/adolescents playing what type of sports?
Higher impact (running, soccer)
Why would a growth spurt contribute to development of Sever’s disease?
Greater tension on Achilles tendon -> greater deg of traction on ossification center
What two special tests in combination are very specific (100%) in diagnosing Sever’s disease?
1) one leg heel raise
2) squeeze test: compress lateral sides of calcaneus just anterior and on either side of Achilles to reproduce pain
What disease is a rare and uncommon childhood disease consisting of osteochondrosis of the navicular bone?
Kohler’s disease
Typically, how long does it take the navicular to reconstitute itself with Kohler’s disease?
8 months - tx: soft arch support, activity modification - severe cases may require casting
What disease is characterized by disturbance in the dorsalis pedis or medial plantar artery supplying the navicular?
Kohler’s disease
What disease is classified by degenerative arthritis of the first MTP joint?
Hallux rigidus
Does hallux rigidus affect males or females more often?
Females
What is the grading system for Hallux Rigidus:
Grade 0: df 40-60, normal xray
Grade 1: 30-40 df, minimal joint change
Grade 2: 10-30 df, mild-mod joint narrowing, sclerosis
Grade 3: <10 df, < 10 pf, severe xray changes, constant pain
Grade 4: same as 3, but pain with any ROM
What metatarsals are the common sites for metatarsalgia?
1st and 3rd
What other anatomical feature is affected with 1st MTP metatarsalgia?
Sesamoid bones -> sesamoiditis
Where in the foot is the most common place to develop Morton’s neuroma?
Between 3rd-4th metatarsals - 3rd webspace
What may develop due to excessive dorsiflexion of the metatarsals as a result of flat foot deformity?
Morton’s neuroma
What is one of the most common overuse injuries in the foot in terms of tendinopathy?
Noninsertional Achilles tendinopathy
What is one of the most important factors in development of noninsertional Achilles tendinopahty?
Age - most common in 41-60 y.o.; also sedentary, obese
What technique with landing inc risk for noninsertional Achilles tendinopathy?
Forefoot landing / toe landing strategy
Does noninsertional Achilles tendinopathy have intermittent or constant sxs?
Intermittent - stiffness with NWB (sleeping)
What questionnaire is valid and reliable for Achilles tendinopathy?
VISA-A: Victorian Institute of Sports Assessment-Achilles
Does an athletic or non-athletic individual respond better to eccentric loading for Achilles tendinopathy?
Athletic - does have positive results either way - non-athletic is perform as tolerated, not through pain
What is the typical duration of sxs with noninsertional Achilles tendinopathy?
3-6 months; 40-65% report complete resolution within this time
What is the key characteristic of insertional Achilles tendinopathy?
Swelling within 2 cm of bony insertion
Which has a poorer prognosis; insertional or noninsertional Achilles tendinopathy?
Insertional - 50% success rate
Do bone spurs, Haglunds deformities impact long term outcome for insertional Achilles tendinopathy?
No - improve despite this involvement
What recommendation on eccentric heel lowering is recommended for those with Haglunds deformity / impingement of superior aspect of calcaneus?
Limiting the movement to 0 deg for lowering
At what age does the incidence of Achilles rupture increase?
> 50 y.o.
What gender is more greatly affected by Achilles tendon rupture?
Males, 3-4x greater
Do operative and non-operative approaches have similar rates of re-rupture and/or DVT?
Yes
Is research trending toward immediate WB or immobilization for Achilles tendon rupture (surgical or non-surgical route)?
Immediate WB -> earlier return to work, greater satisfaction
Brumann states immediate full WB with immobilization in plantar flexion
What is the leading cause of acquired flat foot deformity?
PTT dysfunction
Are males or females more greatly affected by PTT dysfunction?
Females (80%) - obesity /overweight is also key factor
What ligament is highly affected by PTT dysfunction?
Spring (calcaneonavicular) ligament
What three muscles work synergistically to contribute to subtalar inversion/supination?
Flexor hallucis longus, flexor digitorum, posterior tibialis
At what stage does PTT dysfunction become rigid?
Stage III
What distinguishes between Stage 1 and 2 for PTT?
Flat foot deformity - flexible
What are key exam findings distinguishing lateral ankle sprain from fibularis tendon subluxation?
Pain along lateral and posterior region of foot, 2-3 cm distal to lateral malleolus - occurs in cuboid tunnel or at insertion of base of 1st metatarsal
What is the most common treatment for fibularis muscle subluxation?
Due to anatomical incongruities - most often is surgical
Is osteoporosis a risk factor for ankle fractures?
No, but is factor in healing time
What is the golden time frame for recovery of strength, ROM, function for an ankle fracture?
6 months - after 6 months, varied and slow recovery
What is mallolar tertius?
The lateral and posterior aspect of the tibia
Which of the Weber ankle fractures are more severe?
B and C due to involvement of syndesmosis and malleolar tertius
What defines trimalleolar fracture?
Medial, lateral and malleolar tertius
What are negative prognostic factors affecting long term outcomes for ankle fractures (5)?
1) osteoporosis
2) skin problems
3) PVD
4) DM
5) age related comorbidities
Which metatarsal is the least commonly fractured metatarsal?
1st
Which metatarsal fracture has the propensity to not heal and result in non-union?
5th - Jone’s fracture
Which bone type does a stress fracture occur in?
Compact or cortical bone - slower healing than cancellous bone
What is the female athlete triad often associated with stress fractures?
Amenorrhea - osteoporosis - eating disorder
What are subjective factors important leading to diagnosis of stress fractures?
1) sharp inc in LE load/inc in training
2) walking on hard surfaces
3) pain at specific distance in run
4) focal tenderness along bone = key sign
What bone developing a stress fracture may have high risk for complication?
Navicular - found in sprinters, hurdlers, middle distance runners
Who is at greater risk for MTSS - males / females?
Females - esp higher BMI, below average activity, previous LE injury
What are key risk factors for MTSS?
Inc BMI, inc navicular drop, foot pronation, limited ankle df NOT a factor
