MSK #8- Ankle and Foot Conditions Flashcards
Ligament Sprains: Where do most sprains occur?
- 95% on lateral side
- typically foot is plantarflexed and inverted at time of injury
Ligament Sprains: Risk factors for acute lateral sprain
- have Hx of previous ankle sprain
- do not use external support
- do not properly warm up before exercise or activities
- limited dorsiflexion
- do not engage in balance/proprioceptive activities where there was previous injury
Ligament Sprains: Risk factors for ankle instability
- have increased talar curvature
- not using external support
- did not engage in balance/proprioceptive activities where there was previous acute ankle sprain
Ligament Sprains: How many grades
3
Ligament Sprains: Grade 1
- no loss of function
- min tearing of ATFL
Ligament Sprains: Grade 2
- some loss of function
- partial disruption of ATFL and CFL
Ligament Sprains: Grade 3
- complete loss of function
- complete tear of ATFL and CFL
- partial tear of PTFL
Ligament Sprains: Diagnostic tests used
- MRI if necessary
Ligament Sprains: Special tests used
- anterior drawer test
- talar tilt test
Ligament Sprains: Meds used
- acetominophen for pain
- NSAIDs for pain and/or inflammation
Ligament Sprains: Modalities
- Cryotherapy: repeated intermittent application for pain and increasing ability for WB
- Diathermy: pulsating shortwave for reducing edema
- Estim: mod evidence for and against using it
- Low-Level Lasar Therapy: mod evidence for and against using it
- Ultrasound: No. Do NOT use it. Not even for like a second.
Ligament Sprains: self-report outcome measures
- LEFS
- FAAM
Ligament Sprains: Differential Diagnosis
- use Ottawa ankle rules (better sensitivity)
- use Bernese ankle rules
Ligament Sprains: Protected Motion and early WB
- advise use of external support to progressively WB on ankle
- Type of support and gait assistive device will depend on severity
- In severe injuries, semi-rigid bracing to below knee casting may be indicated
Ligament Sprains: Manual Therapy
- lymphatic drainage
- active and passive soft tissue and joint mobilizations
- anterior-to-posterior talar mobilization procedures
- all above completed w/in pain free ROM, to improve pain, reduce swelling, regain normal foot ankle mechanics, restore gait
- will progress to graded joint mobilizations and manips as needed to restore function
What is Achilles tendonosis/tendonopathy?
- degenerative condition of achilles tendon
- microtears of tendon
- tends to be overuse injury
- typically occurs in avascular zone of tendon
Achilles Tendonosis/Tendonopathy: special tests
- Royal London Hospital Test
- Positive Arc sign (high specificity)
- Thompson’s test (tests for rupture- so rule out and is a differential test?)
Achilles Tendonosis/Tendonopathy: Medications
- acetominophen
- NSAIDs
- corticosteroids
Achilles Tendonosis/Tendonopathy: Risk Factors
- abnormal DF ROM
- abnormal subtalar ROM
- decreased PF strength and flexibility
- increased foot pronation
- obesity
- hypertension
- hyperlipidemia
- diabetes
- training errors and/or faulty equipment (extrinsic factors)
Achilles Tendonosis/Tendonopathy: s/s
- localized pain
- feeling of stiffness at tendon after rest
- pain increases w/ activity
- muscle weakness
- swelling and thickening over tendon
- pain w/ single leg hop
Achilles Tendonosis/Tendonopathy: what to examine and
may reassess after interventions
- strength and ROM for PF, DF, and subtalar
- static arch height
- fore foot alignment
- pain w/ palpation
Achilles Tendonosis/Tendonopathy: exercise interventions
- strong evidence for eccentric exercise
- stretching to promote dorsiflexion ROM
Achilles Tendonosis/Tendonopathy: Modalities
- may use low-level laser for pain and stiffness
- iontophoresis w/ dexamethasone for pain
Achilles Tendonosis/Tendonopathy: Other interventions
- initially use RICE
- foot orthosis, possibly a heel lift and/or soft soled shoe
- manual therapy
- taping to reduce strain on Achilles tendon
***do not use heel lifts, and night splints are not that helpful especially when compared against eccentric exercise
Ankle/Foot fractures: what is a trimalleolar fracture
Fracture involving medial and lateral malleoli, and posterior tubercle of the distal tibia
***There is also a “uni” implicating one malleolus and “bi” implicating medial and lateral
Ankle/Foot fractures: Diagnostic tests used
plain film imaging
Ankle/Foot fractures: type of fracture occurring at the growth plate with highest complication rate
Type 3 and type 4 Salter Harris fractures
Ankle/Foot fractures: Medications
acetaminophen
NSAIDs
What is tarsal tunnel syndrome
entrapment of posterior tibial nerve or one of its branches w/in tarsal tunnel
Tarsal Tunnel Syndrome: cause
- over/excessive pronation
- overuse problems resulting in tendonitis of the long flexor and posterior tibialis tendon
- trauma may compromise space in the tarsal tunnel
Tarsal Tunnel Syndrome: symptoms
along medial ankle to the plantar surface of the foot
- pain
- numbness
- paresthsias
Tarsal Tunnel Syndrome: diagnostic tests
electrodiagnostic tests
Tarsal Tunnel Syndrome: special tests
Tinel’s sign at the tarsal tunnel
Tarsal Tunnel Syndrome: medications
- acetaminophen
- NSAIDs
- Neurontin for neuropathic pain
Tarsal Tunnel Syndrome: possible interventions
- foot orthoses to maintain neutral alignment of foot
- neurodynamic mobilization if abnormal neuro-tension
What is flexor hallucis tendonopathy
Identified as a tendonitis in the acute stage, or can be present as a chronic tendonosis. Commonly seen in ballet dancers
Flexor Hallucis Tendonopathy: medications
- Acetaminophen
- NSAIDs
- Corticosteroids
Flexor Hallucis Tendonopathy: treatment
refer to interventions for general bursitis, tendonitis, and tendonosis
What is Pes Cavus
- means hollow foot
- deformity observed includes an increased height of longitudinal arches, dropping of anterior arch, metatarsal heads lower than hindfoot, plantarflexion and splaying of forefoot, and claw toes
- function limited due to altered arthrokinematics, reducing ability to absorb forces
Pes Cavus: etiology
- genetics
- neurological disorders resulting in muscle imbalances
- contractures of soft tissue
Pes Cavus: diagnosis
made by clinical exam including thorough biomechanical lower quarter exam
Pes Cavus: possible interventions
- education emphasizing limitation on high impact sports such as running and ballet
- education for use of proper footwear
- fitting orthoses
What is Pes Planus
- means flat foot
- deformity observed may include reduction in height of medial longitudinal arch
- decreased ability of foot to provide a rigid lever for push-off during gait, due to altered biomechanics
Pes Planus: etiology
- genetics
- muscle weakness
- ligamentous laxity
- paralysis
- excessive pronation
- trauma
- disease such as RA
**pes planus is normal in infants and toddlers
Pes Planus: Diagnosis
made by clinical exam including thorough biomechanical lower quarter exam
Pes Planus: Interventions
- education for use of proper footwear
- fitting orthoses
How many types of Talipes Equinovarus aka Club Foot are there
2
Postural and Talipes Equinovarus
Talipes Equinovarus aka Club Foot: etiology
Postural: results from intrauterine malposition
Talipes Equinovarus: abnormal development of head and neck of the talus, due to genetics or neuromuscular disorders such as myelomeningocele
Talipes Equinovarus aka Club Foot: deformity observed
Postural: plantarflexed, adducted, and inverted
Talipes Equinovarus: 3 components
- PF at talocural joint
- inversion at subtalar, talocalcaneal, talonavicular, and calcaneocuboid joints
- supination at midtarsal joints
Talipes Equinovarus aka Club Foot: diagnosis
made by clinical exam including thorough biomechanical lower quarter exam
Talipes Equinovarus aka Club Foot: possible interventions
- manip followed by casting or splinting for postral condition
- talipes equinovarus requires surgical intervention followed by casting or splinting
What is Equinus foot
- deformity observed is plantarflexed foot
- compensation secondary to limited DF includes subtalar or midtarsal pronation
Equinus Foot: etiology
- congenital bone deformity
- neurological disorders such as CP, contracture of gastroc and/or soleus
- trauma
- inflammatory disease
Equinus Foot: diagnosis
made by clinical exam including thorough biomechanical lower quarter exam
Equinus Foot: possible interventions
- stretching shortened structures
- joint mobilizations
- strengthening intrinsic and extrinsic foot muscles
- orthotic management
What is Hallux Valgus
- a medial deviation of head of 1st metatarsal from midline of body
- metatarsal and base of proximal 1st phalanx move medially while distal phalanx then moves laterally
Hallux Valgus: etiology
- excessive pronation
- ligamentous laxity
- heredity
- weak muscles
- footwear that is too tight
Hallux Valgus: normal metatarsophalangeal angle
8-20 degrees
Hallux Valgus: diagnosis
made by clinical exam including thorough biomechanical lower quarter exam
Hallux Valgus: possible interventions
- early orthotic fitting
- pt. education
- later management requires surgery followed by flexibility and strengthening exercises and possible joint mobilizations
Metatarsalgia: etiologies
- Mechanical: tight triceps surae group and/or Achilles tendon, collapse of transverse arch, short 1st ray, pronation of forefoot
- Structural changes in transverse arch, possibly leading to vascular and/or neutral compromise in tissues of forefoot
- changes in footwear
Metatarsalgia: pt. report
complaint of pain at 1st and 2nd metatarsal heads after long periods of WB
Metatarsalgia: diagnosis
made by clinical exam including thorough biomechanical lower quarter exam
Metatarsalgia: meds
- acetaminophen
- NSAIDs
- Neurontin for neuropathic pain
Metatarsalgia: possible interventions
- correcting biomechanics w/ improving flexibility of triceps surae
- modalities for pain
- orthoses
pt. education on footwear
Metatarsus Adductus: etiology
- congenital
- muscle imbalance
- neuromuscular diseases such as polio
Metatarsus Adductus: the two types
rigid and flexible
Metatarsus Adductus: deformity observed
Rigid: medial subluxation of tarsometatarsal joints, hindfoot slightly valgus w/ navicular lateral to head of talus
Flexible: adduction of all 5 metatarsals at the tarsometatarsal joints
Metatarsus Adductus: diagnosis
made by clinical exam including thorough biomechanical lower quarter exam
Metatarsus Adductus: possible interventions
- strengthening
- orthoses
Charcot-Marie-Tooth Disease: what is it
- peroneal atrophy that affects motor and sensory nerves
- may begin in childhood or adulthood
- initially affects muscles in lower leg and foot but eventually progresses to muscles in hands and forearm
- slowly progressive disorder w/ varying degrees of involvement depending on genetics
Charcot-Marie-Tooth Disease: diagnosis
- electrodiagnostic tests
- made by clinical exam including thorough biomechanical lower quarter exam
Charcot-Marie-Tooth Disease: meds
- acetaminophen
- NSAIDs
- Neurontin for neuropathic pain
Charcot-Marie-Tooth Disease: possible interventions
- no specific treatment since it is an inherited disorder
- prevent contractures and skin breakdown
- pt ed and training for braces and ambulatory assistive devices
Rearfoot Valgus: etiology
abnormal mechanical alignment of the knee (genu valgum) or tibial valgus
Rearfoot Valgus: deformity observed
- eversion of calcaneus w/ neutral subtalar joint
- due to increased mobility of hindfoot, fewer MSK problems develop from this deformity than w/ rearfoot varus
Rearfoot Valgus: diagnosis
made by clinical exam including thorough biomechanical lower quarter exam
Rearfoot Valgus: POC
- orthotics
- pt. ed for footwear
- improve flexibility of shortened soft tissues
- regain alignment
Rearfoot Varus: etiology
- subtalar varus and calcaneal varus
- abnormal mechanical alignment of tibia
- shortened rearfoot soft tissues
- malunion of calcaneus
Rearfoot Varus: deformity
rigid inversion of calcaneus when subtalar joint is neutral
Rearfoot Varus: diagnosis
made by clinical exam including thorough biomechanical lower quarter exam
Rearfoot Varus: POC
- orthotics
- pt. ed for footwear
- improve flexibility of shortened soft tissues
- regain alignment
Forefoot Varus: etiology
congenital abnormal deviation of head and neck of talus
Forefoot Varus: deformity
inversion of forefoot when subtalar joint is in neutral
Forefoot Varus: diagnosis
made by clinical exam including thorough biomechanical lower quarter exam
Forefoot Varus: POC
- orthotics
- pt. ed for footwear
- improve flexibility of shortened soft tissues
- regain alignment
Forefoot Valgus: etiology
congenital abnormal deviation of head and neck of talus
Forefoot Valgus: deformity
eversion of forefoot when subtalar joint is in neutral
Forefoot Valgus: diagnosis
made by clinical exam including thorough biomechanical lower quarter exam
Forefoot Valgus: POC
- orthotics
- pt. ed for footwear
- improve flexibility of shortened soft tissues
- regain alignment
5 special tests for the ankle likely to be in exam
Ligamentous injury
- anterior drawer test
- talar tilt test
Misc
- Thompson
- Tibial Torsion
- Leg length discrepancy
Talk to me about the anterior drawer test
- Procedure: PT stabilizes distal tibia and fibula while other hand holds foot in 20 degrees of PF and draws talus forward in ankle mortise
- Positive test: excessive anterior translation of talus away from ankle mortise. May indicate ATFL sprain
Now talk to me about the talar tilt test
- Procedure: PT stabilizes distal tibia w/ one hand while grasping talus w/ other hand. Foot maintained in neutral position. PT tilts talus into abduction and adduction
- Positive test: excessive adduction may indicate CFL sprain
Thompson test. Go!
- Procedure: pt. prone w/ foot off edge of table. PT asks pt. to relax and then squeezes muscle belly of gastroc and soleus
- Positive test: absence of plantar flexion possibly indicating Achilles tendon rupture
What is the Tibial Torsion test
- Procedure: pt. positioned sitting w/ knees over edge of table. PT places thumb and index finger of one hand over medial and later malleolus. PT then measures acute angle from by the axes of knee and ankle
- Results: normal lateral rotation of tibia is 12-18 degrees
The True Leg length Discrepancy test. Go!
- Procedure: pt. supine w/ LE 15-20 cm apart and pelvis in balance w/ LEs. PT measures each LE from distal point of medial malleoli to ASIS
- Positive test: with bilateral comparison, discrepancy between LE is greater than 1 cm.
