Lecture 3: Ankle and Foot Flashcards
What are the main ligaments of the ankle?
Anterior Talofibular Ligament
Calcaneofibular Ligament
Posterior Talofibular Ligament
Deltoid Ligament (medial)
In dorsiflexion which way does the talus slide and roll?
Slides posteriorly and rolls upwards
In plantarflexion which way does the talus slide and roll?
Slides anteriorly and rolls downwards
What movement occurs at the subtalar joint?
Pronation (eversion, abduction)
Supination (inversion, adduction)
What bones make up the subtalar joint?
Calcaneus and Talus
Common causes of plantar heel pain?
Plantar fasciopathy
Fat pad contusion (heel pain)
Common causes of acute lateral ankle sprain?
Lateral ligament sprain
- ATFL
- CFL
- PTFL
Common causes of Achilles region pain?
Midportion and Insertional Achilles Tendinopathy
Common causes of medial ankle pain?
Tibialis posterior tendinopathy
Flexor hallucis longus tendinopathy
What are some differential diagnoses for an acute ankle sprain?
Lisfranc, fracture, subtalar dislocation
Acute Ankle Sprain Diagnosis (Patient history, Observation, Palpation, AROM/PROM, MMT/IMT, Special test, Functional Testing)
Patient history: mechanism of injury, pain, swelling, limited ROM, difficulty weight bearing
Observation: observe for swelling (figure 8)
Palpation: tenderness/pain near ligament
AROM/PROM: limited ROM actively and passively
MMT/IMT: reduced, but limited by pain/swelling
Special test: anterior drawer test, talar tilt test
Functional Testing: single leg stance, gait, stairs
What test would you perform to confirm an acute ankle sprain?
Anterior drawer test
When would you use the Ottawa Ankle Rules
To predict which patients require X rays to exclude fracture
Normal ROM of the ankle
(PF, DF, Inv, Ev)
10-20 degrees dorsiflexion (DF)
40-55 degrees plantarflexion (PF)
30 degrees Inversion
18 degrees Eversion
Mechanisms of injury for ligament injuries
ATFL
CFL
PTFL
Deltoid:
Risk factors of plantar fasciopathy
Lifestyle: runners, military, dancers, sedentary
Elderly
High arc and excessive foot pronation
Overweight/obese
Plantar Fasciopathy Diagnosis (Patient history, Observation, Palpation, AROM/PROM, MMT/IMT, Special test, Functional Testing)
Patient history: Gradual onset heel pain. Typically worse in morning or after long periods of rest, improves with activity but worsens at end of day
- Aggravating factors: prolonged standing, walking or running especially on hard surfaces
- Alleviating factors: rest, stretching and sometimes ice
- ASx: Stiffness in heel or arch of foot, swelling and tenderness
Observation: flat feet or high arches, overpronation during gait can be present
Palpation: point tenderness at anteromedial aspect of calcaneal tubercle
AROM/PROM: active toe extension may provoke symptoms, normal ROM
MMT/IMT: normal or some weakness in intrinsic foot muscles
Special test: Pain during Windlass Test
Functional Testing: pain during heel raise test, pain in single leg stance
What is a special test for Plantar Fasciopathy
Windlass test
What are some differential diagnoses for Plantar fasciopathy?
Tarsal tunnel syndrome
Calcaneal Stress fracture
Neuropathies
Trauma
Achilles Tendinopathy Diagnosis (Patient history, Observation, Palpation, AROM/PROM, MMT/IMT, Special test, Functional Testing)
Patient history: Gradual onset of pain, often worsening with increased activity. Pain located 2-6cm above the calcaneal insertion. Morning stiffness, pain after periods of inactivity that may decrease with mild activity but worsens with vigorous use. Localised pain. History of overload. Pain presenting after activity (hours after or next day)
Questionnaires (PROMs): VISA-A
Observation: Swelling or thickening along the tendon, altered gait pattern to avoid pain
Palpation: tenderness on midportion of achilles, 2-6cm above insertion
AROM/PROM: pain reproduced with active movements
PAM: normal
MMT/IMT: weakness may be present in plantarflexion strength due to pain inhibition
Special test: Royal London Hospital Test, Arc Sign Test, Gap Palpation
Functional Testing: Difficulty with activities requiring forceful plantarflexion of the ankle, such as hopping, running or push offs
Differential diagnosis for Achilles tendinopathy
Rule out Achilles rupture (Thompson test) or calf strain
Plantar fasciopathy
Tarsal tunnel syndrome
Ankle OA
Deep vein thrombosis
What tests can be performed for Achilles Tendinopathy
Thomson Test (achilles rupture)
Royal London Hospital Test
Arc Sign Test
Gap Palpation test (rupture)
What is tarsal tunnel snd.
Compression of posterior tibial nerve through tarsal tunnel
What is in the Tarsal Tunnel? (Tom, Dick and Very Naughty Harry)
Tibialis posterior tendon
Flexor digitorum longus tendon
Posterior tibial artery & vein
Tibial nerve
Flexor hallucis longus tendon
Diagnosis of Tarsal Tunnel Syndrome
Patient history: Burning, tingling or a sensation of pins and needles in the foot and toes. Pain can also radiate up leg
o AF: activities that involve prolonged standing or walking, repetitive foot flexion
o ALF: Rest, foot elevation and non-weight bearing activities
o ASx: Numbness or weakness in foot, sometimes worsening at night
Questionnaires (PROMs): Foot and ankle ability measure, lower extremity functional scale
Observation: possible swelling in ankle area. Gait may be altered due to pain or numbness in foot
Palpation: Tenderness and pain along course of posterior tibial nerve
AROM/PROM: Active and passive ROM may reproduce symptoms of tingling or pain
PAM: Normal, but can produce tingling or pain
MMT/IMT: Weakness in toe flexion, particularly flexor hallucis longus and flexor digitorum longus, which are innervated by branches of the tibial nerve
Special test: Tinel’s Sign
Functional Testing: Standing, walking, decreased sensation may affect balance and proprioception
Special test for Tarsal Tunnel Syndrome
Tinel’s Sign
Tibialis Posterior Tendinopathy Diagnosis
- Medial ankle pain often arising from behind the medial malleolus and extending towards the medical midfoot to the insertion of the tendon at the navicular bone
- Common swelling in the later stages and is often diffuse around and below the medial malleolus
- Tenderness along the tendon is usual, most prominent posterior and inferior to the medial malleolus or at the insertion onto the navicular bone
- Resisted inversion will elicit pain and relative weakness comparted with the contralateral side
- A single heel raise test viewed from behind will reveal lack of inversion of the hindfoot, and if severe the patient may have difficulty performing a heel raise. In the normal ankle, the calcaneus moves into varus position during a single heel raise; in patients with tibialis posterior tendinopathy, this does not happen and the heel remains in the valgus position
- MRI has a sensitivity of 95%, a specificity of 100% and an accuracy of 96%
If there is an ATFL sprain, what will you feel in an anterior drawer test
Calcaneus will translate up the heel
What ligament sprain does anterior drawer test
ATFL
What ligament sprain does talar tilt test
ATFL, CFL and deltoid
What does the Matles test do? When is it positive?
Tests for Achilles rupture
Ruptured foot tends to remain dorsiflexed instead of plantarflexed
What is done in a Windlass test
Passive extension of 1st MTP
What test would you use to identify a syndesmosis injury?
Squeeze test
What is the mechanism of injury for a syndesmosis injury?
Dorsiflexion and Eversion
