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Lower Extremity Evaluation Lecture > Foot & Toes > Flashcards

Foot & Toes Flashcards

1
Q

What are the 2 functions of the foot?

A
  • “Loose bag of bones”
    ~ loading
    ~ unlock
    ~ pronation
  • “Rigid lever”
    ~ Unloading
    ~ lock
    ~ supination
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2
Q

Rear foot bones

A
  • Talus
  • Calcaneus
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3
Q

Mid foot bones

A
  • Navicular
  • Cuneiforms
    ~ Medial (1)
    ~ Intermediate (2)
    ~ Lateral (3)
  • Cuboid
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4
Q

Forefoot & toes

A
  • 5 metatarsals
  • 14 phalanges
    ~ proximal
    ~ middle
    ~ distal
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5
Q

How does Functional Loading relate to gravity?

A

Succumbing to gravity, absorbing force, deceleration

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6
Q

Functional Unloading in regards to gravity…

A

Overcoming gravity, generating force, acceleration

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7
Q

What kind of muscle contraction is occurring during Loading/Pronation?

A

Eccentric

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8
Q

What kind of muscle contraction is occurring during Unloading/Supination?

A

Concentric

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9
Q

When describing motions…

A

we are describing what the distal bone is doing relative to the proximal bone

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10
Q

Subtalar Joint

A
  • Articulation between talus & calcaneus
  • Calcaneus relative to talus
  • Classic movements: Inversion and Eversion
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11
Q

Loading; “Loose bag of bones”, Planes of Motion

A

STJ -
Frontal Plane: Eversion

Sagital Plane: Plantar Flexion —> Dorsiflexion

Transverse Plane: Abduction

MTJ -
Frontal Plane: Inversion

Sagital Plane: Dorsiflexion

Transverse Plane: Abduction

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12
Q

Unloading; “Rigid Lever”, Planes of Motion

A

STJ -
Frontal Plane: Inversion

Sagital Plane: Dorsiflexion —> Plantar Flexion

Transverse Plane: Adduction

MTJ -
Frontal Plane: Eversion

Sagital Plane: Plantar Flexion

Transverse Plane: Adduction

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13
Q

Midtarsal Joint

A
  • Joins the rear foot to the mid foot
  • 2 joints
    ~ Talonavicular: head of talus &
    navicular
    ~ Calcaneocuboid: calcaneus & cuboid
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14
Q

Relationship between the STJ & MTJ in regards to loading & unloading

A
  • Loading of the STJ (evert) causes the MTJ to unlock (“loose bag of bones”) & become hypermobile
  • Unloading of the STJ (invert) causes the MTJ to lock (“rigid lever”) & become hypomoble
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15
Q

Poor Pronator

A
  • STJ inverts instead of everts during loading
  • STJ doesn’t load well causing the MTJ to not load well
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16
Q

Poor Supinator

A
  • Excessive STJ eversion
  • STJ loads excessively and may cause the MTJ to load excessively
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17
Q

Plantar Fascia

A
  • Thick band of connective tissue
    ~ Originates from the medial calcaneal
    tubercle
    ~ Inserts into the plantar surface of all
    phalanges
  • Primary support for longitudinal arch
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18
Q

Plantar Fascia: Windlass Effect

A
  • Extension of the toes at MTP joint during the propulsive phase of gait (functional unloading)
  • Shortens the distance between the calcaneus and metatarsals to elevate the medial longitudinal arch and invert the calcaneus
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19
Q

Along with the windlass effect, what causes unloading to occur?

A

Concentric muscle contraction

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20
Q

Tarsometatarsal Joints, also known as…

A
  • Lisfranc’s joint
  • Joins the mid foot and the forefoot
    ~ Cuneiforms 1-3 & Cuboid
    ~ Metatarsal bones 1-5
  • Motions
    ~ Dorsal and plantar glide (up & down)
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21
Q

Intermetatarsal Joints

A
  • Proximal
    ~ Bases of the metatarsals
  • Distal
    ~ Heads of the metatarsals
  • Motions
    ~ Dorsal & plantar glide (up & down)
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22
Q

Metatarsophalangeal Joints

A
  • Joins the metatarsals & toes
  • Motions
    ~ Sagittal: flexion/extension
    ~ Frontal: Rotation
    ~ Transverse: abduction & adduction
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23
Q

Interphalangeal Joints

A
  • Joins phalanges to toes
  • 1 on the 1st digit (IP)
  • 2 on the 2nd-5th digit (DIP & PIP)
  • Motions
    ~ Flexion & extension
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24
Q

Intrinsic Muscles of the Foot

A
  • Very small muscles grouped into four layers
  • Superficial
  • Middle
  • Deep
  • Interosseous
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25
Q

Superficial Muscle

A

Contains the primary toe abductors & secondary flexors

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26
Q

Middle Muscle

A

Contains the quadratus plantae which when contracted changes angle of pull for Flexor Digitorum Longus

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27
Q

Deep Muscle

A

Contains the secondary flexors of the 1st & 5th toes

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28
Q

Interosseous Muscle

A

Contains dorsal & plantar interossei

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29
Q

Extrinsic Muscles of the Foot

A
  • Muscles that originate outside the foot in the lower leg and insert on the foot
  • Flexor Hallucis Longus
  • Flexor Digitorum Longus
  • Extensor Hallucis Longus
  • Extensor Digitorum Longus
  • Peroneus Tertiaus
  • Peroneus Brevis
  • Peroneus Longus
  • Tibialis Anterior
  • Tibialis Posterior
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30
Q

When describing the “action” of muscles…

A

you’re describing what the muscle does in space.

  • Artificial
  • Open chain: distal segment is not fixed
  • Less functional
  • Classic
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31
Q

When describing the “function” of muscles…

A

you’re describing what the muscles do when the foot is on the ground

  • Natural
  • Closed chain: distal segment is fixed
  • More functional
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32
Q

Foot Type: Pes Planus

A
  • Decreased medial arch (pronation)
  • Everted heel
  • Abduction of forefoot
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33
Q

Foot Type: Pes Cavus

A
  • Accentuated medial arch (supination)
  • Inverted heel
  • Adduction of forefoot
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34
Q

Test for Supple Pes Planus

A
  • Tests the severity of arch angle
  • Positive Test (Supple) = Medial Arch disappears/is not present when standing, but reappears when on tippy toes
  • Negative Test (Rigid) = Medial Arch disappears/is not present when standing, but does not reappear when on tippy toes
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35
Q

Navicular Drop Test

A
  • Measures starting and end point of navicular
  • Confirms pronated foot position
  • Positive = navicular drops more than 10 mm
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36
Q

During weight bearing inspection how should the patient be positioned anteriorly…

A
  • Have them march in place
  • Ensure hip & trunk are not rotated: this can affect the entire kinetic chain
    ~ Toes should slightly be pointed out
    12-18 degrees (Ficks’s angle):
    anything more or less is abnormal
37
Q

Metatarsal Lengths

A

Index Plus (“Egyptian Foot”): 1st metatarsal longer than 2nd; most common

Index Minus (Morton’s Toe or “Greek Foot”): 1st metatarsal shorter than 2nd; second most common

Index Plus-Minus (“Squared Foot”): 1st metatarsal is equal to 2nd; least common

38
Q

Toe Alignment Types

A
  • Caused by shoes

Claw Toes: Flexion contracture at PIP & DIP w/ hyperextension at MTP
↗️⤵️

Hammer Toes: Flexion contracture at PIP & hyperextension at MTP & DIP
➡️↘️

Mallet Toes: Flexion contracture at DIP
➡️⬇️

39
Q

Hallux Abducto Valgus (“Bunion”)

A
  • 1st toe is in valgus position
  • Caused by narrow shoes
  • MTP joint is enlarged & hypomible
  • Weight bears on medial side of foot
  • Limited Windlass & Flexion/Extension
40
Q

During weight bearing inspection posteriorly, what kinds of things should be noticed…

A
  • Calf Musculature
    ~ Girth
    ~ Contour
  • Achilles Tendon
    ~ Lateral
    ~ Medial
    ~ Deformity
  • Calcaneus
    ~ Inverted
    ~ Everted
    ~ Neutral
    ~ Shape
    > “pump bump”: bursitis
41
Q

During weight bearing inspection lateraly, what kinds of things should be noticed…

A
  • Lateral longitudinal arch
  • Toe Alignment
  • Skin abnormalities
42
Q

During weight bearing inspection anteriorly, what kinds of things should be noticed…

A
  • Arch
    ~ Pronated
    ~ Supinated
43
Q

During non-weight bearing inspection how should the patient be positioned…

A
  • Prone
    ~ Distal 1/3 leg off table
    ~ Figure 4
  • Observe for skin abnormalities on sole
44
Q

Transverse Metatarsal Arch

A
  • Shaped by metatarsals & tarsals
  • Normally concave along inferior surface of metatarsals
45
Q

Medial Longitudinal Arch

A
  • Made up of calcaneus, talus, navicular, 1st cuneiform, & 1st metatarsal
  • Supported by calcaneonavicular ligament & plantar fascia
  • Supported by tibialis anterior, tibialis posterior, & flexor hallucis longus
46
Q

Lateral Longitudinal Arch

A
  • Made up of calcaneus, cuboid, & 5th metatarsal
  • Supported by plantar fascia
  • Supported by peroneus longus, peroneus brevis, & peroneus tertius
47
Q

How would you know a foot is normal/neutral?

A
  • Rearfoot (calcaneus) is in line with the lower leg (achilles & calf)
  • Forefoot (met heads) is parallel to rearfoot (calcaneus)
  • Forefoot (met heads) are in line to each other
48
Q

Structural Deformity: Rearfoot Varus

A
  • Rearfoot is inverted while STJ is neutral
    ↕️
    ↙️
    ———
49
Q

Rearfoot Varus Compensation

This compensation would make which muscles unhappy?

A
  • STJ needs to EVERT in order to get the calcaneus neutral
  • Increases stress on structures that provide stability
  • Cause unhappy Tibialis Anterior & Tibialis Posterior muscles
50
Q

Structural Deformity: Forefoot Varus

A
  • Forefoot is inverted relative to Rearfoot while STJ is neutral
                                  ↕️
                    ⚫️
                          ⚫️
                                ⚫️
                                      ⚫️
                                            ⚫️
                              ↕️
                           ———
51
Q

Structural Deformity: Dorsiflexed 1st Ray

A
  • 1st met head is higher (dorsiflexed) than other 4 while STJ is neutral
    ↕️
    ⚫️
    ⚫️⚫️⚫️⚫️
    ↕️
    ————
52
Q

Forefoot Varus & Dorsiflexed 1st Ray Compensation.

This compensation would make which muscles unhappy?

A
  • STJ needs to EVERT in order to get Forefoot & 1st ray in neutral
  • Increases stress on structures that provide stability
  • If calcaneus unable to evert, foot will be more rigid because the MTJ would have to evert to compensate for STJ
  • Cause unhappy Tibialis Anterior & Tibialis Posterior
53
Q

Structural Deformity: Forefoot Valgus

A
  • Forefoot is everted relative to Rearfoot while STJ is neutral
                                  ↕️
                                        ⚫️
                                   ⚫️
                              ⚫️
                         ⚫️
                    ⚫️
                              ↕️
                           ———
54
Q

Structural Deformity: Plantarflexed 1st Ray

A
  • 1st met head is lower (plantarflexed) than other 4 while STJ is neutral
    ↕️
    ⚫️⚫️⚫️⚫️
    ⚫️
    ↕️
    —————
55
Q

Forefoot Valgus & Plantarflexed 1st Ray Compensation

A
  • MTJ needs to INVERT in order to get lateral portion of Forefoot on the ground
    - OR -
  • STJ needs to INVERT/STAY INVERTED to to get lateral portion of Forefoot on the ground
    ~ Happens if there’s not enough MTJ
    motion
    ~ Foot isn’t a good shock absorber
    ~ Muscles become shortened & more
    prone to tendinitis
  • Increases stress on structures that provide stability
56
Q

Why would someone take a pulse in the foot?

A

Dislocations can cause lack of blood flow to the foot

57
Q

AROM Testing

A
  • MTP Joint
    ~ Flexion: 35-45 degrees
    ~ Extension: 75-85 degrees
  • STJ
    ~ Inversion: 20 degrees
    ~ Eversion: 4-5 degrees
58
Q

Neurological Assessment

A
  • Lower Quarter Screen
  • Tinel’s Sign
    ~ Tibial Nerve palpitation
    ~ Increased or new neurological
    symptoms into heel & plantar aspect
    of foot
59
Q

Normal/Neutral Foot: Rearfoot, Arch, & Forefoot positions

A

Rearfoot: Vertical

Arch: Normal

Forefoot: Straight

60
Q

Pronated Foot: Rearfoot, Arch, & Forefoot positions

A

Rearfoot: Everted

Arch: Flat

Forefoot: Abducted

61
Q

Supinated Foot: Rearfoot, Arch, & Forefoot positions

A

Rearfoot: Inverted

Arch: High

Forefoot: Adducted

62
Q

What are the common signs & symptoms for a fracture?

A
  • Loss of function
  • Deformity
  • Point tenderness
63
Q

Intermetatarsal Joint Ligaments

A
  • Proximal & Distal
  • Supported by Dorsal, Plantar, & Transverse Ligaments
  • Resists dorsal & plantar glide
64
Q

Intermetatarsal Glide Test

A
  • Positive test indicated by “pain” & increased glide compared to opposite foot
65
Q

Metatarsalphalangeal & Interphalangeal Joint Ligaments

A
  • Supported by collateral ligaments
  • Resists Varus (adduction) & Valgus (abduction)
66
Q

MTP & IP (Valgus & Varus) Testing

A
  • Positive test indicated by increased Varus or Valgus compared to opposite foot
67
Q

Which way does Varus & Valgus stretch ligaments?

A

Varus: Laterally

Valgus: Medially

68
Q

Tarsometatarsal Joint Ligaments

A
  • Supported by dorsal & plantar ligaments
  • Resists dorsal & plantar gliding
69
Q

Tarsometatarsal Glide Test

A
  • Positive test indicated by “pain” & increased glide compared to opposite foot
70
Q

Talus Fracture

A
  • Usually not a gross fracture, but instead a fragment or chip in the dome of Talus
  • Cause:
    ~ Forceful inversion, eversion, or
    rotation; forces dome of Talus into
    Ankle mortise (Tibia & Fibula)
  • Signs & Symptoms:
    ~ Pain when weight bearing
    ~ “Catching” or “snapping”
    ~ Tenderness with palpitation
  • Management:
    ~ Very important to pay attention to
    complaints
    ~ Difficult to find on X-Ray
    ~ Self limiting
    ~ No cast; can make it worse or stiff and
    can take to long to RTP
71
Q

Sever’s Disease or Apophysitis of the Calcaneus

A
  • Inflammation of the attachment of Achilles to Calcaneus
  • Common in children
  • Cause:
    ~ Excess stress or tension
  • Signs & Symptoms:
    ~ Pain just below attachment
    ~ Swelling over attachment
  • Management:
    ~ RICE
    ~ Stretching
    ~ Heel lift: causes plantarflexion
    (shortening of Achilles)
72
Q

Apophy means…

A

Tendon attachment to bone

73
Q

Retrocalcaneal Bursitis or “Pump Bump”

A
  • Inflammation of bursa between Achilles and Calcaneus
  • Cause:
    ~ Pressure from heel counter of shoe
    ~ Tight calf/tendon
    ~ Excess friction
  • Signs & Symptoms:
    ~ Pain with activity & palpitation
    ~ Swelling
  • Management:
    ~ RICE
    ~ Stretching
    ~ Heel lift: reduces strain on tendon &
    bursa; distributes pressure of bursa
    ~ Donut heel pad
    ~ Change of shoes
74
Q

Cuboid Subluxation

A
  • Cuboid displaces in plantar direction
  • Cause:
    ~ Abnormal foot type that keeps foot
    pronated too long or too much
    ~ Trauma to lateral side of foot
    ~ Stairs
  • Signs & Symptoms:
    ~ Pain along 4th & 5th metatarsals &
    over Cuboid
    ~ Possible referred pain on heel: lateral
    or medial
  • Management:
    ~ Manipulation
    ~ Correct abnormal foot mechanics
75
Q

Tarsal Tunnel Syndrome

A
  • Tarsal tunnel is formed by the medial malleolus and flexor retinaculum
  • Contains:
    ~ Tibialis Posterior, Flexor Digitorum, &
    Flexor Hallucis Longus Tendons
    ~ Tibial artery, vein, & nerve
  • Cause:
    ~ Any event or condition that causes
    compression of structures (Tibial
    Nerve) inside tunnel
    > Mechanical
    > Inflammatory
  • Signs & Symptoms:
    ~ Pain & paresthesia into plantar side of
    foot
  • Management:
    ~ Control inflammation; prevent further
    inflammation
    ~ May need surgery to cut connective
    tissue to allow for more space for
    structures
76
Q

Tinel’s Sign

A
  • Tap behind malleolus
  • Positive test indicated by worsening pain or paresthesia
77
Q

Lisfranc Injury

A
  • Dorsal dislocation of the base of metatarsal
    ~ Typically seen in 1st or 2nd metatarsal
    ~ Fracture often occurs
  • Cause:
    ~ Hyper-planterflextion of Forefoot with
    axial load (foot on ball & force comes
    from top)
  • Management:
    ~ Identify & fixate bones
    ~ Casting may not be effective (foot
    stays in bad alignment) , but instead
    screws & plates will
    ~ Surgery may be best option
78
Q

Arch Strains

A
  • Strain of the INTRINSIC muscles of the foot
  • Cause:
    ~ Increased/excessive loading
    ~ Abnormal foot type
  • Signs & Symptoms:
    ~ Pain during weight bearing
    ~ Pain below Tibialis Posterior Tendon
    ~ Pain in metatarsal region
  • Management:
    ~ RICE
    ~ Arch Taping
    ~ Orthotic Device/Pad: can cause more
    pain in early stages
79
Q

Plantar Fasciitis

A
  • Inflammation of plantar fascia
  • Cause:
    ~ Change in footwear
    ~ Change in activity
    ~ Abnormal foot type
    ~ Leg length discrepancy: shorter legs
    needs to compensate causing poor
    mechanics affecting the kinetic chain
    ~ Calf tightness: pulls on plantar fascia
  • Signs & Symptoms:
    ~ Pain in anterior & medial heel
    ~ Pain in fascia
    ~ Increased pain in the morning or after
    long periods of sitting
    ~ Increased pain when toes & ankle are
    Dorsiflexed/extended
  • Management:
    ~ Identify cause and correct it
    ~ Shoe insert/pad for abnormal foot
    type
    ~ Add height to shoe for leg length
    discrepancies
    ~ Support & increased flexibility in calf
80
Q

If a patient doesn’t display the common signs & symptoms of a fracture, you should follow the…

A

Ottawa Rules
- Used to determine if a fracture is present or not and if a patient should be referred for an X-Ray

  • Areas to assess
    ~ Lateral & Medial Malleolus to 6cm
    proximally
    ~ Over Navicular
    ~ Base of 5th metatarsal
    ~ Inability to weight bear or take 4 steps
81
Q

Jones Fracture

A
  • Fracture to the base of 5th Metatarsal
  • Cause:
    ~ Forceful inversion
    ~ Direct blow
  • Signs & symptoms:
    ~ Swelling
    ~ Point tenderness
    ~ Complaints of lateral pain & ankle
    sprain: palpate 5th metatarsal
  • Management:
    ~ Refer
    ~ Fixate with screws & plates
  • Not every fracture to the 5th metatarsal is a Jones Fracture, it needs to be at the base
82
Q

Sesamoiditis

A
  • Inflammation is the Sesamoids of great toe
  • Cause:
    ~ Excessive loading
    ~ Repetitive hyperextension of great toe
  • Signs & symptoms
    ~ Pain under 1st metatarsal head
    ~ Compensation will occur by weight
    bearing on lateral side
  • Management:
    ~ RICE
    ~ Pads & supports to take stress off
    Sesamoids
    > needs to be placed behind Met
    heads to alleviate pressure
83
Q

Turf Toe

A
  • Sprain of 1st Metatarsal Phalangeal Joint
  • Cause:
    ~ Excess 1st MTP dorsiflexion/extension:
    (plantar side) more common
    ~ Excess 1st MTP plantarflexion/flexion:
    (dorsi side)
  • Signs & symptoms:
    ~ Pain
    ~ Swelling
    ~ Unable to properly push off during
    gait
  • Management:
    ~ RICE
    ~ Prevent excess movement (temporary)
    > Tape, Splint, & Heel Inserts
    • Limits motion affecting Windlass
84
Q

Intermetatarsal (Interdigital) Neuroma

A
  • Entrapment of the interdigital nerve between the met heads
  • Cause:
    ~ Morton’s Toe or foot: Valgus of 2nd
    toe
    ~ Foortwear
    ~ Foot mechanics
  • Signs & symptoms:
    ~ Pain & paresthesia on adjacent toes
    that may radiate up leg
    ~ Compression may reproduce pain and
    result in a click sound called Mulder’s
    Click (scar tissue)
85
Q

Morton’s Neuroma

A

Nerve entrapment between 3rd & 4th metatarsals

86
Q

Heel Spur

A

Bony outgrowth at medial Calcaneal Tubercle (exostosis)
- Cause:
~ Excessive pulling of plantar fascia or
Achilles

87
Q

March Fracture

A

Stress fracture

88
Q

Styloid Fracture of 5th Metatarsal

A

Avulsion fracture at peroneus brevis attachment

Lower Extremity Evaluation Lecture (8 decks)

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