Foot, Shoes, and Orthotic Interventions Flashcards
Initial Contact
Eccentric anterior tib/long toe extensors, concentric quad, eccentric hamstrings, glut maximus eccentric activity
What controls decent of the foot during loading response?
pretibial regulates ankle PF, Quads regulated knee flexion eccentrically
What prevents hip flexion?
Gluts, hamstring and adductor magnus prevent hip flexion via eccentric actions. Highest ground force reactions seen at this stage
What controls tibial advancement during mid stance?
Eccentric soleus and gastroc (lesser degree)
What decreases late midstance?
Glut max decreases in late mid stance due to vertical alignment of pelvis over the femur.
What is in highest demand during terminal stance?
body weight vector approaches MTP’s, Highest demands on the triceps surae (eccentrically) due to large dorsiflexion moment at ankle
Foot clearance during initial swing:
Concentric pretibial muscle activity for foot clearance. Short head of biceps femoris flexes knee concentrically
What assists with hip and knee flexion during initial swing?
iliacus advances hip to 20 d of flexio. Gacilis and Sartorius assist hip and knee flexion concentrically
Disorders of the Hindfoot
Achillies Tendinosis Sever’s Disease Retrocalcaneal Bursitis Peroneal Tendinosis Ankle OA/Subtalar Joint arthritis Ankle Impingement Tarsal Tunnel Syndrome
Tendinosis
mucoid degeneration of Achilles Tendon
degenerationwithdepositofmyelinandlecithininthecells.
Active DF and PF is painful +/-‐ painful arc
Paratendinopathy
inflammation of the paratendon (membrane that surrounds the tendon or fascial plate (insertional point
Achilles Tendinopathy
Graston Technique modified
Eccentrics
Stretch – multidirectional
ICE with Stretch
Exerises for mid portion achilles tendinopathy:
Responds to eccentrics with ankle in plantarflexion and dropping into extreme dorsiflexion – three sets of 15
What do insertional achilles tendinopathy need to avoid?
extreme DF
Severe’s Disease
a traction apophysitis to the insertion of the Achilles tendon
boys 7-15
Cause of severe’s disease”
shear stresses applied to the unossified apophysis.
Whee is pain with Severe’s Disease?
Pain in posterior heel that is worse With activity and weight bearing
Pain on squeezing posterior calcaneus near growth plate
Treatment and Orthotics for Sever’s Disease
Heel Cups Heel Lifts Orthoses with Medial Longitudinal Arch (MLA) and medial Posting Taping Rest Stretching Achilles
Retrocalcaneal Bursitis
Describe by location of pain and swelling May exist as a constellation of symptoms May exist with Achilles tendinopathy Often associated with Haglund’s Radiographs help with location
Assessment of Retrocalcanel Bursitis
Passive dorsiflexion may be painful
Two finger pinch test anterior to achilles
MRI and Ultrasound form gold standard to determine soft tissue swelling.
Haglund’s Deformity
Presents as a constellation of symptoms
Painful soft tissue swelling at Achilles tendon
Describes as an enlarged area of Post lateral calcaneus
bony deformity
Haglund’s Syndrome
includes pathology of Achilles tendon and the Achilles bursa
Posterior Impingement of Ankle
Caused by overuse or trauma
Dancers have overuse
Trauma cause forced pf with running/soccer Plantar flexed and then impact. Os trigonum (accessory bone in the ankle) will cause pain.
Bony spurs
Slightly displaced os Trigonum (Accessory Talus), hypertrophy of post talus or loose body
Assessment of Posterior Impingement of Ankle
Complaints of pain in posterior lateral ankle
Pain increased with passive plantarflexion
Pain increased with repeat active plantarflexion
Posterior lateral pain on palpation
Morning stiffness
These people are on their toes a lot. Mobilizing the patient into plantar flexion is always painful
Physical Therapy for Posterior Impingement
Treat hypomobility at Talocrural joint Talocrural mobilization- distraction Talocrural manipulation-‐ distraction Talar glides posterior – for df Mulligans mobs with movement for df Maitland physiological mobs – subtalar,TC Active stretching of the ankle Active movements of the anterior compartment in conjunction with stretch of the posterior compartment: Shuffle Gait/moon walk gait exercise
When is preoneus longus active during gait?
Active through midstance to late stance
Decelerates speed and amount of supination at STJ
Helps the midfoot and forefoot relatively pronates
Disorders of the Midfoot
Arthritis of the Midfoot and Lisfranc
Plantar Fasciitis
Cuboid Syndrome
PTTD
What is Lisfrance associate with?
rheumatology
Rheumatoid or Osteoarthritis
Lisfrance injury:
Associated with Sporting Injury or axial load
May occur with foot structure and indirect injury
Pronation and abduction or dorsiflexion with abduction elicits pain
Plantar fasciitis
Pain with first step in the am or after a period of inactivity
Relieved by activity until stress increase
Pain on palpation at medial calcaneal tubercle
Pain usually unilateral
No burning or numbness
Baxter’s Nerve Entrapment
Pain not as bad with first step but worsens as day progresses
burning or numbness present
Thought to be about 20% heel pain
Present in athletes
Pain may be present at rest
Abductor digiti minimi muscle weakness can be present
Facial attachment of plantar fascia?
Abductor Hallucis and Abductor Minimi
Plantar Fascia communicates with paratendon of Achilles Tendon at periosteum
Tarsal Tunnel Syndrome
Related to foot type
Tarsal tunnel: canal formed between medial malleolus and flexor retinaculum
Shooting pain in the foot, with numbness, tingling or burning
Nerve affected with tarsal tunnel syndrome:
Medial Calcaneal Nerve (branch of tibial nerve)
Nerve to Abductor Digiti Minimus
What foot deformities is tarsal tunnel syndrome associated with?
Association with pronation, mechanical stretch with arthritis, Ligamentous injury, trauma and obesity
Tarsal Tunnel vs Plantar Fascitis
Tarsal Tunnel pain without weight bearing
Pain at night-‐ pain described as burning
No pain on palpation of plantar fascia
Pain on triple compression test with plantarflexion and eversion and compression of Tibial nerve.
Toe abductors and intrinsic muscles of feet weak with advanced cases
Physical Therapy Treatment for TTS
Stretching of calf
Tibial nerve mobilization
Treatment of subtalar and midtarsal and hallux
Strengthening post Tib and peroneus longus
Where is pain felt with fat pad syndrome?
Pain is felt in the center of heel or perimeter
Pain is felt with deep palpation or squeezing
Pain is worse with weight bearing
Tarsal Coalition
A union between two or more tarsal bones May be osseous or ligamentous Can exist with or without pes planovalgus Really flat feet Ridged foot
Causes of cuboid syndrome:
forceful eversion of the cuboid while the calcaneus is inverted, with resultant disruption of CC joint congruity
Associated with Sprain commonly in sports
Pain with cuboid syndrome:
Antalgic
Weakness with resistance of eversion
Pain on palpation of cuboid
Pain on movement into supination or adduction
Who often has cuboid syndrome?
Ballet due to repeative jumps with pronation
Cuboid Syndrome Assessment
History of pain and overuse into plantar flexion and inversion
Pain with weight bearing, jumping and running
Special tests-‐ squeezing the midtarsal joint with superior to inferior pressure
Forced abduction and pronation of the midfoot
Functional movements with cuboid syndrome:
Antalgic gait during push off
Antalgic gait during side to side motion
Hopping increases symptoms
Rest decreases symptoms
Contraindications to Cuboid Whip
Bone Disease Gout Acute injury with bruising and swelling Neural injury Vascular injury And most importantly -‐ Neoplastic Disease
Disorders of the Forefoot
Bunions (HAV) Hallux Limitus and Rigidus SesamoidiEs Metatarsalgia Turf Toe in sports
Bunions
Hallux Abducto Valgus is associated with change in the Abductor Hallucis thickness
Significant differences in Dorsal Plantar (DP)
Exercise for Bunions
Muscle Activity for Abductor Hallucis with short foot and toe spread
TSO (Toe Spread Out)has a greater activation
Both exercises should be incorporated into program
MOI for turf toe:
Foot loaded axially with fixed equinus and toe extension
heel is always elevated
Turf Toe Evaluation
Pain distal to sesamoids Evaluate dorsoplantar drawer test Active flexion and extension Resisted flexion and extension for disruption of FHL or FHB Test migration of sesamoids
Morton’s extension
A rigidMorton’s extensionis essentially a continuation of the polypropylene or graphite shell of the orthosis beyond the first metatarsophalangeal joint (MPJ), extending to the tip of the toe.
Grade I turf toe:
attenuation of plantar structures
localized swelling
minimial ecchymosis
Treatment of Grade I turf toe
symptomatic
return to play as tolerated
Grade II turf toe
partial tear of plantar structures
moderate swelling
restricted motion due to pain
Treatment of Grade II turf toe
walking boot
crutches prn
return to play: up to 2 weeks may need taping upon return
Grade III turf toe
complete disruption of plantar structures
significant swelling/ecchymosis
hallux flexion weakness
frank instability of hallux MTP
Treatment of Grade III turf toe
long term immobilization or surgery
10-16 weeks return to play
Hallux limitus ROM:
< 45 in open chain
Hallux rigidus ROM:
<10 degrees
Normal ROM first MTP:
45-65
Orthosis for Hallux Rigidus
Unload the 1st ray with cut out
Reverse Morton’s extension
Kinetic Wedge
Placement of metatarsal bars?
start with them 1/16 of a inch proximally. The patient may not feel relief for a week so educate your patients about the need to continue to wear the pad or bar
Tailors Bunion or Bunionette
Exostosis or inflammation of the 5th metatarsal base
