Mechanics of the Foot and Ankle Flashcards
1
Q
What stabilizes the tibiotalar joint?
A
Capsule Deltoid Ligament Anterior Tibiofibular Ligament (ATFL - Always Tears First Ligament) Calcaneofibular Ligament- CFL Posterior Talofibular Ligament - PTFL
2
Q
What does the tibia articulate with, distally?
A
Talus - fits concave surface of tibia
3
Q
What surface is the deltoid ligament on?
A
Medial
4
Q
What does the deltoid ligament attach to?
A
Medial malleolus
Tuberosity of navicular
Sustentaculum tali of calcaneus
Medial tubercle of talus
5
Q
What ligaments make up the deltoid ligament?
A
Tibionavicular
Anterior tiobiotalar
Posterior tibiotalar
Tibiocalcaneal ligaments
6
Q
What usually happens before deltoid ligament is ruptured?
A
Bony injury - fracture
7
Q
What does the anterior tibiofibular ligament attach to?
A
lateral malleolus
neck and lateral articular facet of the talus
8
Q
What does the calcaneofibular ligament attach to?
A
lateral malleolus
tubercle of lateral surface of calcaneus
9
Q
What does the posterior talofibular ligament attach to?
A
lateral malleolus
lateral tubercle of the posterior process of talus
10
Q
What are the major motions of the ankle?
A
Plantar flexion - up to 50 degrees
Dorisflexion - up to 20 degrees
11
Q
What are the minor motions of the ankle?
A
side-to-side glide
rotation
abduction
adduction - only if joint is plantar flexed
12
Q
Where is the ankle most stable?
A
dorsiflexion
13
Q
What muscles mediate plantar flexion of the ankle?
A
Mostly:
gastrocnemius
soleus
Also: plantaris tibialis posterior flexor hallucis longus flexor digitorum longus
14
Q
What muscles mediate dorsiflexion of the ankle?
A
Mostly:
tibialis anterior
Also:
extensor digitorum longus
extensor hallucis longus
15
Q
What glide of the talus do you get with plantar flexion?
A
Anterior
16
Q
What glide of the talus do you get with dorsiflexion?
A
Posterior
17
Q
What does the talus sit on?
A
The calcaneus
18
Q
How many talocalcaneal articulations are there?
A
2 - concave convex articulations
19
Q
What are the major calcaneal motions?
A
Abduction - valgus
Adduction - varus
both in relation to a fixed talus
20
Q
What does the talus articulate with?
A
Other than the calcaneus, navicular
21
Q
What else does the calcaneus articulate with?
A
Cuboid
22
Q
What mediates motion of the hindfoot?
A
Combined motions of these joints:
Talocalcaneal/subtalar
talonavicular
calcaneocuboid
23
Q
What joints are changed with inversion of the hindfoot?
A
Medial rotation of calcaneus and navicular bones
Cuboid rotates down on calcaneus
24
Q
What does inversion do to the arch of the foot?
A
Increases the height
Accented by plantar flexion
25
What muscles are used in inversion of the foot?
tibialis anterior and posterior
26
What joints are changed with eversion of the hindfoot?
Lateral rotation of calcaneus
Lateral rotation of navicular
Cuboid rotates upward on calcaneus
27
What does eversion do to the arch of the foot?
Decreases height of median arch
28
What muscles do eversion of the foot?
Fibularis longus and brevis
29
What region of the foot is the midfoot?
Between transverse tarsal joint and tarsometatarsal joint
30
What motions dictate pronation?
Eversion
Dorsiflexion
Abduction - calcaneus and foot
31
What motions dictate supination?
Inversion
plantar flexion
Adduction - calcaneus and foot
32
What region of the foot is the forefoot?
Anterior to tarsometatarsal joints
33
What are the primary motions of the tarsometatarsal joints?
Flexion and extension
34
What are the primary motions of the metatarsals and phalanges?
Adduction and abduction
35
What are the primary motions of the intermetatarsal joints?
Sliding
36
What are the primary motions of the metatarsalphalange joints?
Flexion
Extension
Abduction
Adduction
Also:
slide
rotation
long axis traction
37
What is the major motion of the IP joints?
Flex and extend
38
What are some characteristics of the lateral arch?
```
Weight bearing
elastic
firm osseous structure
limited mobility
transmits weight and thrust to ground
```
39
What bones make up the lateral arch?
calcaneus
cuboid
4th and 5th metatarsal
40
What bones make up the medial arch?
```
calcaneus
talus
navicular
cuneiforms
1-3 metatarsals
```
41
What makes the medial arch different from the lateral arch?
More mobile and higher
doesn't have firm osseous support
changes to adapt to changes in terrain
Helps control gait!
42
What ligaments stabilize the medial arch?
```
plantar ligament
plantar fascia
tibialis posterior
FDL
FHL
intinsic mm of the foot
```
Muscles don't stabilize this arch, they control it for balance and gait
43
Which arch controls gait?
Medial arch
| muscles don't support this arch, they control it for balance and gait
44
What causes a high medial arch?
Supination - more rare
Adduction of the foot
varus calcaneus
45
What causes a dropped medial arch?
Pronation - pretty common
Abduction of the foot
valgus calcaneus
dorsiflexion of the ankle - extreme pronation
46
What 3 arches make up the transverse arches?
Anterior transverse arch
Posterior transverse arch
Tarsal arch
47
What are the components and functions of the anterior transverse arch?
Made up of metatarsal heads
Transmits weight to the ground
- flattens with weight bearing
48
What are the components of the posterior transverse arch?
metatarsal bases
49
What are the components and functions of the tarsal arch?
Navicular
Cuboid
Cuneiforms
Assists in flexibility of the foot as well as rotation
50
What causes flat feet?
pesplanus is caused by a decrease in that tarsal arch
51
How do you evaluate the foot and ankle?
Have patient stand, walk, evaluate joints of lower half of body - at least 1-3 up or down
Observe statically - sitting, standing
Observe motion testing and dynamically
52
What are we looking for when evaluating the feet and ankles?
```
Edema
Swelling
Discoloration
Callus
Corns
Weight distribution on each foot
Position of toes - in or out?
Arch height
Position of achilles tendon
Bony deformities
```
53
What is the deformity of hammertoes?
flexion deformity of PIP
| extension deformity of DIP
54
What is the deformity of claw toes
flexion deformities of PIP and DIPs
55
What is a bunion?
Medial deviation of the 1st metatarsal with lateral deviation of proximal phalanx of the hallux
MTP can be swollen, tender, erythematous
Correlated with Morton's toe, ballerina
56
When you palpate the foot, what are you palpating for?
Tenderness and swelling
| Bony landmarks
57
Explain motion testing of the foot and ankle.
Dorsiflexion & plantar flexion
Have patient actively do it first
Then passively move the foot
- Invert the foot slightly
- Place into plantar and dorsi flexion
58
What is the normal ROM for plantar and dorsiflexion?
Normal ROM
Dorsi- 20 degrees
Plantar- 50 degrees
59
How do you do motion testing for the lateral malleolus?
Patient supine.
Grab the lateral malleolus between your thumb and index finger and wiggle it anteriorly and posteriorly.
Named for the direction of freer motion.
60
How do you do motion testing for the talus?
Subtalar ABDuction & ADDuction
Occurs at subtalar, talonavicular and calcaneocuboid joints
The patient actively moves the foot first
Then the doctor passively moves the foot in ABDuction & ADDuction
61
What is the normal ROM for the talus?
ADDuction 20 degrees
| ABDuction 10 degrees
62
How do you do motion testing for the subtalar/calcaneal joint?
Calcaneal (subtalar) inversion-eversion
The patient actively moves the foot first
Then the doctor passively moves the foot by gripping the calcaneus in one hand and locking the talus by gripping the forefoot with the other. Then invert and evert the foot
63
What is normal ROM for the calcaneal/subtalar joint?
Inversion/eversion 5 degrees of motion
64
Explain motion testing for cuboid, navicular, and cuneiforms.
Cuboid, navicular, cuneiforms
Grasp the bone between your thumb and index finger
Move (wiggle) it plantar and dorsally (and the other planes)
Note which way the individual bones move better
65
Explain motion testing for the 5th metatarsal.
5th metatarsal
Lock out the cuboid by grasping it
Grasp the 5th MT and wiggle it dorsally and plantar
Note degrees of motion
To check the rotation of this (or any) MT, grasp the one next to it to lock it out
66
Explain motion testing for the 1st metatarsal.
1st Metatarsal
Grasp and lock the 1st cuneiform
Rotate the bone to check for freedom of motion
Have patient actively flex and extend the joint. Doc then passively moves the the hallux into flexion and extension to check the motion
67
What is the normal ROM for the 1st metatarsal?
Flexion 45 degrees
| Extension 70-90 degrees
68
Explain motion testing for the phalanges.
Have the pt actively flex and extend phalanges
Doc then passively moves the phalanges, with a bit of traction, into flexion, extension, rotation, adduction and abduction, noting any restrictions
69
Explain the stance phase of gait.
Stance phase
1. heel strike
2. Foot rolls to lateral edge
3. Weight should roll back to ant transverse arch
4. The great toe should push (toe) off
Swing phase
70
What are the ligaments involved with an acute inversion ankle sprain?
```
Anterior talofibular ligament
- Always Tears First
Calcaneofibular
Posterior talofibular
- rare, usu seen with fracture-dislocation
```
71
What is a grade 1 acute inversion ankle sprain?
Grade 1-microtears with the ligament
| Swelling and disability but no instability (no laxity)
72
What is a grade 2 acute inversion ankle sprain?
Grade 2-partial tear of the ligament
Severe swelling over the ankle, mild instability, antalgic gait, mild ligamentous laxity, laxity is noted with a good end point, decreased ROM
73
What is a grade 3 acute inversion ankle sprain?
Grade 3-complete tear
| marked loss of function and complete instability, no endpoint noted on provocative testing
74
What is the mechanism of injury for acute inversion ankle sprains?
Inversion and plantar flexion
Generally by stepping on an uneven surface (ie. landing on someone else’s foot after rebounding a basketball)
75
What are the symptoms of an acute inversion ankle sprain?
```
Swelling
Ecchymosis
TTP depending on degree of injury
Decreased ROM
Antalgic gait - abnormal gait to avoid pain
Poor lower extremity proprioception
Assessed with one leg standing test
```
76
What do you do if you have a negative x-ray with an acute inversion ankle sprain?
Negative x-ray
| X-ray determination is based on the Ottawa ankle rules
77
What diagnostic tests do you perform after an acute inversion ankle sprain?
+anterior drawer test (in 2nd and 3rd degree tears only)
Assesses ATF only
+Talar tilt test
Assesses the ATF & calcaneofibular ligaments
Always check the arches of the foot after a sprain. IF the arch is acutely flat; this may indicate tear of tibialis posterior tendon (a stabilizer of the foot)
78
What imaging do you order after an acute inversion ankle sprain?
Order MRI
If Tib Post tendon is torn—it must be surgically corrected within 14 days for optimal outcome to prevent degeneration of the foot
79
Explain the anterior drawer test.
Pt is sitting with legs dangling off table
Foot is in a few degrees of plantar flexion
Doc grabs front of tibia with the other hand cupping the calcaneus
Gently pull the calcaneus anterior as you push the tibia posterior
If normal the talus will not move on the tibia
If abnormal the talus slides anteriorly—this is a positive test
80
Explain the talar tilt test.
Pt is sitting with legs dangling off table
Doc inverts the calcaneus
If the talus gaps or rocks in the ankle mortise, the ATF & calcaneofibular ligaments are torn and the test is positive
81
What are the effects of an inversion ankle sprain on the body?
The ankle inverts
The fibular head moves posterior, the lateral malleolus moves anterior
This could impinge the common peroneal nerve and cause a foot drop
The tibia externally rotates
The femur internally rotates
Ipsilateral anterior innominate
Anterior torsion of the sacrum facing the side of the ankle sprain
So for a right ankle sprain, a Right on Right sacral torsion
L5 will rotate opposite of the sacrum
82
What is the treatment for grade 1 and 2 tears of an acute ankle sprain?
```
Grade 1 & 2 tears
Conservative treatment
PRICE (protection, rest ice, compression, elevation)
NO NSAIDs!
Other pain medication
Crutches if needed
OMT
```
83
What is the treatment for grade 3 tears with an acute ankle sprain?
Grade 3 tears require PRICES
| The S stands for surgery
84
What is physical therapy for an acute ankle sprain?
Physical therapy
Start once acute inflammation is over (within 48-72 hours)
Continue ankle proprioception exercises (one leg standing, wobble board) for a full 10 weeks to prevent recurrent sprains
85
What is return to play criteria for an acute ankle sprain?
Full painless ROM
Strength 90% compared to uninjured side
Able to tolerate gym, work or sport specific activity without increasing pain
86
Explain counterstrain of the foot/ankle.
Find the tender point
Establish a pain scale (10/10)
Reduce the tender point by placing the patient in a position of maximal comfort (at least 70% better for boards) (3/10)
Hold this position for 90
seconds
Continue to monitor the point (gently) throughout the entire treatment
Slowly, PASSIVELY return the patient to neutral
The patient should not help at all!!!
Re-assess the tender point
