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MSK T3 > Lower Leg, Ankle & Foot > Flashcards

Lower Leg, Ankle & Foot Flashcards

1
Q

Bones of the ankle and foot consist of?

A

distal tibia & fibula, seven tarsals, & 14 phalanges

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2
Q

What are the 2 principle functions of The Leg, Ankle, and Foot?

A

Propulsion & Support

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3
Q

Lower leg, ankle, & foot have ability to ______________ different forces acting on body through contact with the ground - this is especially evident during _______.

A

• dissipate
• gait

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4
Q

• In foot & ankle, movement occurring at each
individual joint is ____________, but when combined, there is enough range of motion in all joints to allow for ____________________.

A

• minimal
• functional mobility

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5
Q

What is the Talocrural Joint (Ankle)?

A

• Articulation between distal tibia & fibula with
trochlea (dome) of talus.

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6
Q

What supports the Talocrural Joint (Ankle)?

A

It’s supported by thin joint capsule, ATFL, deltoid ligament, & calcaneofibular ligament

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7
Q

What is the available ROM of the Talocrural Joint (Ankle)?

A

• 0-20 degrees dorsiflexion (at least 10 degrees needed for normal gait)
• 0-50 degrees plantarflexion

*For optimal movement at talocrural joint, movement at proximal tibiofibular joint is needed as well. Assessment of this joint should be included when assessing ankle dysfunction

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8
Q

What is the Talocalcaneal Joint (Subtalar)?

A

Articulation between talus & calcaneus

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9
Q

What movement does the Talocalcaneal Joint (Subtalar) allow for?

A

5 deg of eversion & inversion

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10
Q

What are the 3 segments of the foot?

A

• Hindfoot
• Midfoot
• Forefoot

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11
Q

What is Hindfoot?

A

talus & calcaneus

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12
Q

What is Midfoot?

A

navicular, cuboid, cuneiforms

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13
Q

What is Forefoot?

A

metatarsals & phalanges

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14
Q

What is the normal range for the 1st MTP Joint?

A

between 70-90 degrees of extension

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15
Q

What is the range of the 1st MTP Joint needed for normal gait?

A

65 deg of extension needed for normal gait

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16
Q

What can cause pain & dysfunction in the foot & ankle?

A

Stiffness or subluxation of any of the joints in the foot & ankle.

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17
Q

What is the role of the arches in gait?

A

The arches absorb & return energy to the ground, acting as a primary component of gait.

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18
Q

What structures form the arches of the foot?

A

The arches are formed by the shape of interlocking bones, ligaments (spring ligament, long plantar ligament), the plantar fascia, & muscles.

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19
Q

Which muscles support the arches during ambulation?

A

Tibialis anterior, Tibialis posterior, & Peroneus longus, known as the “dynamic arch supporters.”

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20
Q

What can result from weakness or inhibition of the dynamic arch supporters?

A

Weakness or inhibition of these muscles can lead to overpronation of the arches during gait.

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21
Q

What is pronation in foot movement?

A

Pronation is a combination of dorsiflexion, eversion, & forefoot abduction, & is the loose-packed position of the foot.

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22
Q

What is supination in foot movement?

A

Supination is a combination of plantar flexion, inversion, & forefoot adduction, and is the close-packed or “rigid lever” position of the foot used to propel the body forward.

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23
Q

How does the foot function during the loading response of gait?

A

During loading, the heel strikes the ground in neutral or slight supination, & as the foot lowers, it pronates to conform to the ground & absorb impact forces.

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24
Q

What happens to the foot during mid-stance to terminal stance in gait?

A

The tibia rotates externally, initiating supination, bringing the foot into a close-packed position, which allows it to act as a rigid lever for propulsion.

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25
Q

What is the windlass mechanism?

A

The windlass mechanism tightens the plantar fascia during toe extension, helping to stabilize the foot in a rigid lever position for propulsion.

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26
Q

What is overpronation (aka flat foot, pes planus)?

A

Overpronation is an excessive flattening of the medial longitudinal arch during weight-bearing.

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27
Q

Is overpronation considered an injury?

A

No, overpronation itself is not considered an injury, but if left unaddressed, it can lead to repetitive strain injuries.

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28
Q

What are some injuries that can result from overpronation?

A

Injuries include plantar fasciitis, bunions, Achilles tendonitis, shin splints, compartment syndrome, meniscal or ligamentous injuries at the knees, patella femoral pain syndrome, hip pain, & strain to the discs, ligaments, & joints in the lower back.

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29
Q

Can overpronation be a response to an issue higher up the kinetic chain?

A

Yes, sometimes overpronation can be a response to problems higher up the chain, such as weak hip abductors.

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30
Q

What are the main contributing factors to overpronation?

A

The main factors include muscle imbalances or weakness of the dynamic arch supporters.

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31
Q

How can the dynamic arch supporters become weak?

A
  1. Wearing excessively supportive footwear or orthotics
  2. Overtraining
  3. Poor motor control of the leg/foot due to nerve root or peripheral nerve impairment.
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32
Q

What are some massage considerations for overpronation?

A
  1. Assess the cause through muscle & neurological testing
  2. Massage can relieve trigger points in the dynamic arch supporters (especially Tibialis posterior)
  3. Focus on strengthening exercises, gait retraining, & transitioning from overly supportive footwear.
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33
Q

What self-care recommendations can help with overpronation?

A
  1. Strengthen dynamic arch supporters
  2. Gait retraining
  3. Gradually transition from supportive footwear to less supportive options
  4. Walk barefoot as much as comfortably possible
  5. Ease up on intense training habits.
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34
Q

What is pes cavus (high instep, aka supinated foot)?

A

Pes cavus is an arch that does not fall flat upon weight-bearing.

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35
Q

What are possible causes of pes cavus?

A

The exact cause is unknown, but it is thought to be associated with neuromuscular conditions (e.g., Charcot-Marie-Tooth disease), congenital factors, or trauma such as fractures.

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36
Q

What impairments are commonly associated with pes cavus?

A
  • Imbalance/instability in the foot
  • Pain at the metatarsal heads
  • Frequent lateral ankle sprains
  • Hammertoes and claw toes
  • Pain with walking/standing
  • Overall foot pain
  • Stiffness in the lower leg/foot
  • Sesamoid pain
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37
Q

What are treatment options for pes cavus?

A
  • Petrissage to maintain mobility & decrease pain in the lower leg & foot
  • Joint play to maintain joint health/mobility & decrease pain
  • Referral for orthotics to increase foot surface contact
  • Surgery, if necessary
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38
Q

Why does the foot need to flatten (pronate) during gait?

A

The foot needs to flatten & mold to the ground to absorb forces from the ground during gait. If it doesn’t, this can impact joints further up the kinetic chain.

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39
Q

What are common sites for ankle sprains?

A
  1. Anterior talofibular ligament: usually sprained with a plantar flexion and inversion mechanism of injury (MOI)
  2. Calcaneofibular ligament: sprained with inversion MOI
  3. Deltoid ligament: sprained with eversion MOI
  4. Distal anterior tibiofibular sprain (high ankle sprain): happens with forced dorsiflexion, often with eversion
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40
Q

What tests are used to assess ankle sprains?

A
  1. Talar Tilt test: for anterior talofibular and calcaneofibular ligament sprains
  2. Deltoid ligament stress test: for deltoid ligament sprains
  3. Wedge test: for distal anterior tibiofibular (high ankle sprain)
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41
Q

What are the treatment goals during the acute phase of injury?

A
  • Manage inflammatory pain
  • Lymph drainage
  • Superficial fluid techniques
  • Cool hydrotherapy
  • Positioning for optimal - drainage
  • Low-grade joint play
  • K-taping
  • Manage spasm pain
  • Maintain ROM
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42
Q

What techniques are used to manage spasm pain in the acute phase of injury?

A
  1. Muscle approximation
  2. GTO (golgi tendon organ techniques), as long as tissues near the lesion site aren’t deformed
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43
Q

What self-care is recommended during the acute phase of injury?

A
  • RICE (Rest, Ice, Compression, Elevation)
  • Active free (AF) pain-free ROM exercises
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44
Q

What are the treatment goals during the subacute phase of injury?

A
  • Eliminate residual swelling
  • Normalize ROM
  • Eliminate residual spasm
  • Decrease tone/TrPs
  • Decrease fascial contracture
  • Encourage healthy scar tissue formation
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45
Q

What techniques are used during the subacute phase to eliminate residual spasm?

A

All spasm techniques, including petrissage to decrease tone & trigger points (TrPs).

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46
Q

What self-care is recommended during the subacute phase of injury?

A
  • Contrast hydrotherapy or heat
  • Passive stretching
  • Isometric exercises (muscle setting)
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47
Q

What are the treatment goals during the chronic phase of injury?

A
  • Improve function
  • Eliminate lingering TrPs and - high resting tone
  • Manage healthy scar tissue formation
  • Normalize strength
  • Normalize proprioception
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48
Q

What modalities can help improve strength & proprioception during the chronic phase?

A
  • Isotonic strengthening exercises
  • Electroacupuncture
  • K-taping (facilitation technique)
  • Proprioception exercises
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49
Q

What compensatory considerations should be made during the chronic phase?

A

Consider how the patient has been compensating during the rehabilitation process, & treat these compensatory areas as well. This can also be introduced in earlier stages.

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50
Q

What is Achilles Tendinopathy and its progression?

A

Typically begins with acute or chronic inflammation of the Achilles tendon, which may progress to degeneration (Achilles tendonosis) if unresolved, resulting in microscopic tears and scar tissue formation. In rare cases, it can lead to tendon rupture.

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51
Q

What causes Achilles Tendinopathy?

A

A sudden increase in repetitive activity involving the Achilles tendon can lead to micro-injury. Excessive pronation also increases the risk due to greater demands placed on the tendon.

52
Q

What are the common symptoms of Achilles Tendinopathy?

A
  • Pain (aching, stiffness, soreness) along the tendon
  • Morning pain or pain after rest that improves with motion but worsens with activity
  • Tenderness or intense pain when squeezing the tendon
  • Possible tendon enlargement and nodules with progression to degeneration
53
Q

What treatment approaches are used for acute Achilles tendonitis?

A
  • RICE (Rest, Ice, Compression, Elevation)
  • Lymphatic drainage
  • Reducing tone in the gastrocnemius and soleus to limit passive tension on the injured tissue
54
Q

What treatment strategies are recommended for chronic Achilles tendonitis?

A
  • Scar tissue management (heat, myofascial techniques, frictions, stretching)
  • Promoting tissue extensibility (heat, petrissage, stretching)
  • Therapeutic exercises to strengthen lower leg muscles, progressive loading of the tendon, & eccentric exercises
55
Q

What additional treatment considerations may be helpful for Achilles Tendinopathy?

A
  • Night splints to prevent contracture during sleep
  • Addressing flat foot presentation
  • Gait & running re-education
56
Q

What is Plantar Fasciopathy & where is it typically located?

A

Plantar Fasciopathy involves pain on the plantar surface of the foot, particularly in the medial calcaneus region. It may present with inflammation or not, similar to tendonopathy.

57
Q

What are the common causes of Plantar Fasciopathy?

A
  • Faulty foot posture
  • High arches that reduce shock absorption during gait
  • Overpronation during gait causing overstretching of the plantar fascia
  • Non-supportive footwear on hard surfaces
  • Obesity and pregnancy leading to overpronation
  • Tightness in the posterior compartment
  • Weakness of hip abductors
58
Q

What are the key symptoms of Plantar Fasciopathy?

A
  • Pain on the bottom of the heel and/or along the arch
  • Pain aggravated by standing or walking
  • Pain worsening over months
  • Morning pain or pain after sitting that improves with walking
  • Pain may subside but return after prolonged periods of standing
59
Q

What treatment approaches are effective for Plantar Fasciopathy?

A
  • Manage inflammation with cool hydrotherapy (e.g., rolling the foot on a frozen water bottle)
  • Use myofascial techniques, lengthening petrissage, & stretching if tightness in the posterior chain is present
  • Address overpronation issues by following the treatment notes for that condition
60
Q

What self-care strategies can help with Plantar Fasciopathy?

A
  • Rest to allow the plantar fascia to heal
  • Avoid going barefoot to reduce strain on the plantar fascia
  • Consider orthotics or a removable walking cast for support
  • Use night splints to prevent overnight contracture & reduce morning pain
61
Q

What is Hallux Valgus, also known as bunions?

A

It is a deformity of the first toe at the proximal phalanx that shifts the phalanx laterally toward the second toe. Over time, the flexor and extensor muscles shift laterally, worsening the deformity, and a painful bunion may form due to inflamed bursa and bone hypertrophy.

62
Q

What are the causes of Hallux Valgus (bunions)?

A

• Inherited faulty mechanical structure of the foot
• Wearing shoes that crowd the toes doesn’t directly cause bunions but can make them worse

63
Q

What are the common symptoms of Hallux Valgus?

A

• Pain and inflammation
• Burning or numb sensation
• Symptoms typically occur when wearing shoes that crowd the toes
• Long periods of walking or standing can aggravate symptoms

64
Q

What treatment considerations should be taken for Hallux Valgus?

A

• Foot massage: Feels good but won’t correct the bony misalignment
• Cool hydrotherapy: Helps minimize inflammation
• Footwear: Wear shoes with a wider toe box and avoid high heels
• Standing: Avoid standing for long periods of time
• Therapeutic exercise: Can correct muscle imbalances and improve foot posture, but it’s best to refer to physiotherapy
• Bunion night splints
• Surgery: Options include shaving the bony growth or fusing the 1st MTP in a neutral position (though this may have long-term complications with toe-off during gait)

65
Q

What is Morton’s Neuroma?

A

It is the irritation of a branch of the plantar nerve between the 3rd and 4th toes, leading to scar tissue formation around the nerve.

66
Q

Who is commonly affected by Morton’s Neuroma?

A

It is often found in individuals who wear shoes with a narrow toe box and is commonly associated with:
• Bunions
• Hammertoes
• Flat feet
• Morton’s toe (where the 2nd toe is longer than the 1st)
• Activities that cause repetitive irritation to the balls of the feet (e.g., running, court sports)

67
Q

What is a positive test for Morton’s Neuroma?

A

The Squeeze test is used to identify Morton’s Neuroma.

68
Q

What are the symptoms of Morton’s Neuroma?

A

• Pain, tingling, burning, or numbness in the affected toes
• A feeling that something is inside the ball of the foot
• A sensation that there is something in the shoe or that a sock is bunched up
• Symptoms tend to progressively worsen over time

69
Q

What are the treatment and self-care options for Morton’s Neuroma?

A

• Padding techniques: Provide support for the metatarsal arch, reducing pressure on the nerve.
• Orthotic devices: Offer support needed to decrease pressure and compression on the nerve.
• Footwear: Wear shoes with a wide toe box and avoid narrow-toed shoes or high heels (shoes with a slight heel may be helpful).
• Shockwave therapy
• Surgery: May be required in severe cases

70
Q

What are shin splints?

A

A non-specific term used to describe pain in the anteromedial or posteromedial tibia.

71
Q

What are the common causes of shin splints?

A

Pain/dysfunction may be due to:
• Periostitis
• Tibial stress fracture
• Exertional compartment syndrome

72
Q

Why is determining the location and characteristic of pain important for shin splints?

A

It is crucial in identifying the underlying cause of the pain.

73
Q

What is periostitis?

A

Inflammation of the periosteum, commonly felt at the attachment of muscles such as the soleus, tibialis posterior, and flexor digitorum.

74
Q

What are the causes of periostitis?

A

• Overuse due to overtraining
• Poor technique
• Running on hard or uneven surfaces
• Improper footwear

75
Q

What are the predisposing factors for shin splints?

A

• Poor biomechanics
• Excessive pronation is likely present

76
Q

How is pain from periostitis typically described?

A

Pain is usually reported as diffuse and occurring over the posterior tibia.

77
Q

Where is pain localized upon palpation for periostitis?

A

Pain is localized to the muscle attachment and often found a few centimeters in diameter, typically located about 2/3rds of the way down the tibia.

78
Q

What is the progression of pain in shin splints?

A

• Initially, pain is present only with activity and resolves with rest within minutes.
• As it worsens, pain starts earlier in the activity and takes longer to resolve.

79
Q

What are the treatment considerations for shin splints?

A

• Rest is key to allow tissue to heal.
• If acute signs and symptoms are present, all acute soft tissue injury modalities apply.
• For chronic cases, refer to chronic stage treatment considerations for Achilles tendonitis.
• Return to activity should be slow and gradual, working towards pain-free moderate training levels.
• Correct predisposing factors such as improper footwear and training on hard/uneven surfaces.
• Prescribe therapeutic exercise to strengthen affected muscles to avoid load transference to the periosteum.
• Address foot mechanics, such as overpronation.

80
Q

What is exertional compartment syndrome?

A

A condition that results from an increase in intracompartmental pressure in the compartments of the lower leg, primarily affecting the anterior or deep posterior compartment.

81
Q

How does exertional compartment syndrome occur?

A

It occurs due to repetitive (excessive) muscle contraction, which increases the demand for blood to the tissues.

82
Q

What happens when there is excessive blood perfusion in exertional compartment syndrome?

A

Excessive blood perfusion leads to increased intracompartmental pressure.

83
Q

What are the consequences of increased intracompartmental pressure in exertional compartment syndrome?

A

Increased pressure leads to ischemia and pain.

84
Q

How does exertional compartment syndrome differ from acute compartment syndrome?

A

Exertional compartment syndrome is related to exercise-induced increases in pressure, while acute compartment syndrome typically results from trauma or injury causing rapid pressure buildup.

85
Q

What is anterior compartment syndrome?

A

A condition characterized by pain specific to the anterior compartment of the leg.

86
Q

What are the symptoms of anterior compartment syndrome?

A

Symptoms include pain in the anterior compartment, possible paresthesia between the 1st and 2nd toes, and foot drop due to increased pressure.

87
Q

What is posterior compartment syndrome?

A

A condition characterized by pain specific to the deep posterior compartment of the leg.

88
Q

What are the symptoms of posterior compartment syndrome?

A

Symptoms include pain in the deep posterior compartment, possible paresthesia in the instep of the foot, and weakness in inversion, plantar flexion, and toe flexion due to pressure on the tibial nerve.

89
Q

How does pain typically manifest in posterior compartment syndrome?

A

Pain typically increases when the foot actively supinates and with passive dorsiflexion with eversion.

90
Q

What treatment considerations are recommended for compartment syndromes?

A

Treatments include creating slack in the compartment with heat, myofascial techniques, stretching, joint play, and interosseous release.

91
Q

How can patients help manage compartment syndrome symptoms before activities?

A

Patients should warm up properly to reduce rapid blood flow to the compartment and can perform self-massage techniques to the affected area before and after activity.

92
Q

What are the main nerves that supply the lower leg and foot?

A

The main nerves are the tibial nerve, superficial peroneal nerve, and deep peroneal nerve.

93
Q

Why is it important for nerves to move freely along their pathway?

A

Nerves need to move freely to effectively transfer motor and sensory information through the nervous system.

94
Q

What can happen if nerves in the lower leg and foot are not firing well or are entrapped?

A

Poor motor control, weakness, delayed healing, altered sensation, and pain can occur.

95
Q

What should be considered when assessing impaired nerve function in the lower leg and foot?

A

Determine if the nerves are being compressed or irritated locally or at their origin where they leave the spine.

96
Q

Where do the nerves that supply the lower leg and foot originate?

A

They originate in the low back.

97
Q

Why is it beneficial to examine the low back when treating lower leg and foot dysfunction?

A

The root cause of foot dysfunction could be stemming from the low back, as everything in the body is connected.

98
Q

What are common symptoms of Deep Vein Thrombosis (DVT)?

A

Local tightness and tenderness in the calf, constant pain regardless of activity, warmth and redness (which may be absent).

99
Q

What conditions can lead to Deep Vein Thrombosis?

A

Fractures, surgery, pregnancy, and prolonged bed rest, especially in the elderly.

100
Q

What is Homan’s sign, and what does a positive result indicate?

A

Homan’s sign is a test for DVT, and a positive result indicates potential deep vein thrombosis.

101
Q

What should you do if you suspect Deep Vein Thrombosis?

A

Refer the patient to a medical doctor (MD) immediately.

102
Q

What is a common complication of diabetes related to nerve function?

A

Diabetic neuropathy

103
Q

How does diabetes affect healing?

A

It can lead to delayed healing times.

104
Q

What are the key characteristics of a Tibial Stress Fracture?

A

Sharp pain localized to the fracture site, most commonly on the medial tibia, with a two to three week onset of symptoms.

105
Q

How does the pain from a Tibial Stress Fracture change with activity?

A

Initially, the pain worsens with activity and is relieved with rest; as it progresses, the pain becomes constant and worse with impact.

106
Q

Can someone “run through” the pain of a Tibial Stress Fracture?

A

No, the person is unable to run through the pain.

107
Q

What symptom may indicate a Tibial Stress Fracture that can occur at night?

A

Night pain.

108
Q

What should you do if you suspect a Tibial Stress Fracture?

A

Refer the patient to a medical doctor (MD).

109
Q

What happens to the body during normal gait when the heel lifts off the ground?

A

The body weight shifts forward on the foot, and the toes must extend, with the big toe playing a critical role in this action.

110
Q

Why is the big toe important in the push-off phase of gait?

A

The body weight shifts toward the medial forefoot, and the big toe needs to extend 65 degrees to accept the weight shift as the heel lifts.

111
Q

What happens if the big toe cannot extend 65 degrees during gait?

A

The forefoot cannot accept the weight shift, leading to faulty movement patterns in the foot, shin, and hip to compensate.

112
Q

How does walking with feet pointed out help when the big toe lacks extension?

A

It allows the body weight to roll off the inside edge of the foot, avoiding the inflexible big toe.

113
Q

How does walking with feet pointed out help when the big toe lacks extension?

A

It allows the body weight to roll off the inside edge of the foot, avoiding the inflexible big toe.

114
Q

What position do the femur and tibia maintain when walking with feet pointed out due to limited big toe extension?

A

The femur and tibia stay in an externally rotated position.

115
Q

Which muscles are held in a shortened position to maintain the externally rotated gait pattern?

A

Gluteus maximus, piriformis, and biceps femoris.

116
Q

What happens when the body weight is focused on the inside edge of the foot during gait?

A

The medial longitudinal arch collapses, causing over-pronation and leading to shortening of the peroneals and lateral calf muscles, and increased strain on the plantar fascia and medial shin muscles.

117
Q

Which muscles/tissues need attention with massage, stretching, and joint play when a client has limited big toe extension?

A

• Big toe flexors: Flexor hallicus longus and brevis
• Ankle everters: Peroneals and lateral calf (gastrocnemius & soleus)
• Hip external rotators: Biceps femoris, gluteus maximus, and piriformis
• Plantar fascia
• 1st MTP joint

118
Q

How should treatment be approached if the range of motion of the big toe cannot be changed due to bony changes like osteoarthritis?

A

Focus on maintaining the health of the compensating structures.

119
Q

What are Pes Cavus and Pes Planus?

A

Pes Cavus refers to a high arch, while Pes Planus refers to a flat foot. Both can present as structural or functional impairments.

120
Q

What is the difference between structural and functional high arch presentations?

A

• Structural High Arch: The high arch is maintained whether weight-bearing or not due to permanent structural (likely bony) changes.
• Functional High Arch: The arch can change when weight-bearing, and this can be normalized with massage and therapeutic exercise.

121
Q

What are the implications of a structural high arch on the body?

A

The inability of the foot to hold to the ground means that forces are distributed more forcefully through the body, potentially leading to problems further up the kinetic chain.

122
Q

How can massage be utilized for a structural high arch?

A

While massage can’t change the structural presentation, it can help manage symptoms and maintain the health of tissues further up the kinetic chain.

123
Q

What characterizes a functional flat foot?

A

The arch flattens when weight-bearing and reappears when non-weight-bearing. There are no bony changes, allowing for correction through massage and self-care, along with potential referral for orthotics.

124
Q

What is a structural flat foot?

A

A structural flat foot has a permanent lack of arch, regardless of weight-bearing status, similar to treatment considerations for a structural high arch.

125
Q

What key treatment planning concept is highlighted by these presentations?

A

Some patient presentations cannot be “fixed,” and treatment should emphasize managing symptoms and maintaining the health of compensating structures.

126
Q

What does a long-term maintenance treatment plan typically involve?

A

Regular appointments (e.g., once a week, twice a month, or once a month) over an extended period of time to manage symptoms and maintain health.

MSK T3 (5 decks)

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