Midterm Notes Flashcards
Open kinetic chain
When one end of a chain is free to move
In the lower extremity - when the foot is not in contact with the groung.
Open kinetic chain
Allows shared movement for close packed position and non-weight bearing stresses on articular surfaces
Open kinetic chain
Closed kinetic hain
Both ends of the chain are not free to move
When contact with the ground surface anchors the lower extremity, putting into action the subtalar joint, locking and unlocking mechanisms of the mid-foot across the trans-tarsal joint, load bearing of the arches, internal rotation of the tibia and glide of the fibula
Closed kinetic chian
Describe closed kinetic chain
Subtalar joint in action Locking and unlocking of mid-foot across trans-tarsal joint Load bearing of arches Internal rotation of tibia Glide of fibula
General foot/ankle info
26 bones
2 sesamoids
Work distal to proximal in ____ and proximal to distal in ____
Lower extremity
Upper extremity
Three major sections of the foot
Forefoot
Midfoot
Rearfoot/hindfoot
Forefoot
Metatarsals and phalanges - 5 rays
Midfoot
Navicular
Cuboid
Cuneiforms 1,2,3
Rearfoot/hindfoot
Calcaneus
Talus
Three arches of the foot
Lateral
Medial
Transverse
If keystone drops, so does
The arch
Lateral arch keystone
Cuboid
Medial arch keystone
Navicular
Transverse arch keystone
Second metatarsal head
Normal weight bearing and subsequent callus formation usually occurs at three sites
Calcaneus
1st and 5th metatarsal heads
Plantar surface of big toe
Calluses appear where
Constant friction
Abnormal weight bearing
Pes planus
Abnormal weight bearing occurs at
Calcaneus
2,3,4 metatarsal heads
Create forces which may lead to morton’s neuroma
Abnormal weight bearing
Patient may have pinch calluses on the lateral and/or medial edges of foot from
Hypersupination
Hyperpronation
Abnormal weight bearing
Pronation of the foot =
Abduction (external rotation) + eversion + dorsiflexion (anterior translation) - non weight bearing subtalar motion/calcaneal primary motion
Supination of the foot =
Adduction (internal rotation) + inversion + plantarflexion (posterior translation) - non weight bearing subtalar motion/calcaneal primary motion
There are no muscular attachments
Talus
If subluxated, the talus will block ___ due to altered weight distribution and the affect upon the locking and unlocking mechanisms of the foot and may lead to numerous foot complaints
Normal motion in the mortise (dorsiflexion)
Altered position of the talus that affects the ankle will cause
Whole body effects from tibia up
Altered position of talus may stress tibia/fibula interosseous ligament adding to or causing
Shin splint pain
Altered position of ____ may affect leg length
Talus
Altered motion of talus may affect ankle proprioception altering
Afferent signal
Components of a medial collapsing arch
Anterior talus
Inferior navicular and cuneiforms
Superior cuboid
Everted calcaneus
Possible spreading of metatarsal heads
Possible splay foot
Most common position of ankle injury
Plantarflexion/inversion
Open packed position/closed kinetic chain
Typically fracture or dislocation are caused by
Dorsiflexion/eversion
Closed packed position
May all relate back to the same underlying mechanical problem of a collapsing arch and hypo-tonicity in the muscularity of the lower leg
Interdigital neuritis (morton’s)
Plantar fascitis
Hallux valgus
Tarsal tunnel
An intact motor system can adapt via ____ and _____. The adaptations of the motor system are represented by ____
CNS control
Muscle system activity
Muscle imbalances
Primary shock absorbers for the spine
Foot and ankle
Foot and ankle conform to the ground surface for ___ and then become ___ for propulsion
Contact
Rigid lever
The foot and ankle conforming to the ground surface for contact and then becoming rigid lever for propulsion occurs via
Locking and unlocking process, which occurs at the trans-tarsal joint aka midtarsal joint
Trans-tarsal joint
Midtarsal joint
Talus/navicular and calcaneus/cuboid
Articulations between talus/navicular and calcaneus/cuboid are usually subluxated/misaligned in a
Mid-foot sprain or ankle injury
Classic area of investigation if the patient experiences pain in the mid foot upon weight bearing not associated with obvious edema or extreme point tenderness
Midtarsal joint
The function of the fibula during dorsiflexion above 90degrees will create
A palpable rising of the fibular head
The function of the fibula during dorsiflexion above 90degrees is essential for
Proper ankle function and stability
Fibular movement plantarflexion
Fibular head anterior, inferior, medial
Fibular head movement dorsiflexion
Posterior, superior, lateral
The best exercise for feet is
Walking in soft sand
Towel gathering may be substituted
Pt for exercise of feet
3 sets of 20 repetitions, 3 times per day
What can be substitued exercise for feet for walking in soft sand
Towel gathering
Cryotherapy and motion is easy to accomplish with the use of
A plastic soda bottle - 12 oz size
Fill 12 oz water bottle with water and freeze
Use anytime exercises are being done or when the foot is painful
Roll foot over frozen bottle for 3-5 minutes then perform the exercises
If the foot is painful, ____
Cryotherapy and motion
Ice between each set if foot is painful
If all attempts for the body to correct the foot problem have failed or if time is critical
Orthotics may be used
Understand the differences between custom and generic
Posting
Orthotics
A modified hinge joint at the connection of 2 long bones (levers)
Knee
Least stable joint in the lower extremity when the foot is in contact with the ground surface (closed kinetic chain)
Knee joint
Largest joint held together by soft tissue
Knee joint
Coupled motion of knee joint
Flexion with tibia on femur internal rotation
Extension with tibia on femus external rotation (screw home)
Quadriceps angle
ASIS - center of patella/tibial tuberosity - center of patella
Men <10 degrees
Women >10 degrees
20 degrees is unstalbe for all
Shin splints
Symptoms
Differential
Preventative
Rehabilitation
Pain behind the knee cap medial side while walking or running up hill or up steps usually associated with a weak vastus lateralis
Medial patellar tracking syndrome
Pain behind knee cap lateral side while walking or running down hills or down steps. Usually associated witha weak vastus medialis (VMO)
Excessive lateral patellar syndrome
For medial weakness exercise the joint during the last 15-20 degrees of
Knee extension
For lateral weakness, exercise should exclude
The last 15-20 degrees of knee extension
Taping and straps across patella tendon
May be hlepful
Impact at the fibular head may affect directly or indirectly
The common peroneal nerve
The fibular head is an insertion site for the
Biceps femoris
A slip of the IT band and the lateral collateral ligament with biceps femoris
Fibular head
Fibular mus have normal motion to allow
Normal biomechanics at knee and/or ankle
Semi-weight bearing sub-talar neutral casting
Orthotics
Fucntional orthotics
Accommodative orthotics
Generic
Normal foot
Functional orthotics requirements
Support the foot so that the subtalar joint will function around neutral position
Allow normal motions in the proper sequence and eliminate abnormal/compensatory motions
Conform to all contours of the foot that help function
Be comfortable within a 2 week period
Be capable of being adjusted
Accommodative orthotics
Any orthotic device that does not attempt to establish foot function around the neutral subtalar position (of restraicts motion from proper sequence)
Generic orthotics
The term used to indicate an off-the-shelf product
Aren’t specifically fitted to your feet and may or may not fit foot properly
Usually made at 4 degrees of varus correction
Normal foot
A foot that functions around neutral position and adapts well to terrain with normal shock absorption and goes through acceptable pronation and supination
Semi-weight bearing sub-talar neutral casting procedure
Adjust patient’s feet
Determine forefoot and rearfoot angles
For heel lifts use 1/2 of the measured difference but no more than 6mm inside the shoe
Place one foot on the unopened side of the foam
Place the other directly over the open foam impression box, making sure the knee is directly above the ankle
With your rearward hand, lift the foot into dorsiflexion at the 4-5 metatarsal heads to prepare for finding neutral position
Remove the rearward hand and grasp rear and side of the calcaneus to prevent any lateral movement.
Posting forefoot
Orthotic will generally have 4-6degrees of intrinsic forefoot varus angulation so you must subtract that anmount from your measurement. Do not post less than 3degrees. Max angle should not exceed 15-18degrees or it will not work in shoe
Rearfoot posting
Orthotic will have no rearfoot angulation. Therefore post one for one. Max positing is 5degrees
Determining sub-talar neutral
Adjust foot. 6-8 degree changes are not uncommon
Pt supine - place outside thumb on 4-5 metatarsal heads; place inside thumb and 1st finger into space on either side of talus; place foot into slight dorsiflexion and atttempt to place the foot in a position that is neither inverted nor everted, neither pronated or supinated. Attempt to equalize the holes where your fingers are located then measure angle off tibia
Pt prone - repeat process, measure forefoot angle. Normal is 0-6degree varus; check for functional hallus limitus (FHL)
Great toe dorsiflexion normal
70-90d
Great toe dorsiflexion under load normal is
35d
Family physicians are frequently called on to evalutae patients who have
Acute knee injuries
Each year, knee trauma is responsible for an estimated ____ visits to ER departments in the US
1.3 million
The anatomic characteristics of the knee, it’s exposure to external forces and the functional demands place on the joint may explain
The frequency of injury
Only ___ of patients with knee trauma have a fracture
6%
Standard texts imply that radiographs should be routinely obtained for every patient who
Presents with knee injury
Reasons for the unnecessary use of radiography include
Fear of lawsuits
Failure to obtain an adequate history
Expectations on the part of patients
Overuse of radiologic studies has become a significant ___ problem int he US
Economic
Fractures in the knee may occur in
The patella
Femoral condyles
Tibial plateua
Patellar fractures are divided into
Transverse Vertical Upper pole Lower pole Comminuted Osteochondral
The 2 main MOI’s of patellar fracture are
Direct trauma to the anterior aspect of the knee
A powerful contraction of the quadriceps muscle (transverse, upper pole and lower pole fractures)
____ are essential to assess traumatic patellar injury
Radiographs
In addition to AP, notch, andn lateral views, ___ and ___ views with the knee in 45d of flexion may be necessary to identify an osteochondral fragment
Merchant
Infrapatellar
Fractures of the femoral condyles involve the
Distal 9-15cm of the femur
Both the diaphyseal and metaphyseal regions may be involved . Fractures may also show
Intra-articular extension
Most condylar fractures occur as a result of
MVA’s
other causes besides MVA of condylar fractures are
Falling on a flexed knee or
Falling from a height
In young people, higher energy is necessary for a fracture to occur, therefore, more ____ is present
Soft tissue damage
In older patients with osteoporosis, less energy is needed to produce a fracture; therefore, less associated
Soft tissue damage is present
Fractures of the tibial plateau are important because of the
Weight-bearing areas
Fracturs of tibial plateaus may involve
Metaphysis
Epiphysis
Articular cartilage
MOI fracture of tibial plateau
Compression
Valgus force
Combination of both
The fractures involve the lateral plateau, medial plateau or both (bicondylar fractures)
Fractures of tibial plateau
The clinical decision rules created in ____ and ____ are the best known guidelines for appropriate use of radiographs in acute knee injuries
Ottawa
Pittsburgh
Ottawa knee rules
Age 55 or older Tenderness at head of fibula Isolated tenderness of patella Inability to flex knee to 90d Inability to walk four weight-bearing steps immediately after the injury andin the ER
Pittsburgh decision rules
Blunt trauma or a fall as MOI plus either of the following:
Age younger than 12 years or older than 50 years
Inability to walk four weight-bearing steps in the ER
Knees of 74% patients evaluated radiographically. ___ were found to have fractures
5.2%
Logistic regression analysis found fall or blunt trauma MOI knee had sensitivity or __ and specificity of ___ for the presence of knee fraction.
92%
57%
The prospective part of study for knee found combo of all 3 criteria was ___ sensitive and ___ specific for knee fracture
100%
79%
Pittsburgh decision rules were ___ sensitive and ___ specific for diagnosis of knee fractures
99%
60%
Ottawa knee rules were __ sensitive and ___specific
97%
27%
Ottawa ankle x-ray
Only required if there is pain in malleolar zone AND
Bone tenderness at posterior edge or tip of lateral malleolus OR
Bone tenderness at posterior edge or tip of medial malleolus OR
Inability to bear weight both immediately and in the ER
Foot x-ray ottawa only required if there is pain in the midfoot zone AND
Bone tenderness at base of 5th metatarsal OR
Bone tenderness at navicular OR
Inability to bear weight both immediately and in the ER
Ottawa for people
19 years and older
