MSK Exam questions Flashcards
What would be the effects of limited ankle dorsiflexion
Limited ankle D/F will inhibt the forward progression of the body
Early Heel Lift (Bouncy Gait)
Externally rotated foot
Low gear push off Internally rotate and use the 5th met head to progress
Knee hyperextension
Which ligaments would you expect to be injured during a Lateral ankle sprain
Anterior Talofibular Ligament
Posterior Talofibular ligament
Calcaneofibular ligament
Which structural foot shape is an ankle injury most associated with and why
Uncompensated Rearfoot Varus
Rearfoot Varus = Rearfoot inverted relative to floor during subtalar neutral
Uncompensated Rearfoot Varus is when there is no additional subatlar joint pronation to compensate for inverted rearfoot
Midtarsal is locked so cannot pronate to bring medial border of the foot down meaning the lateral border will bear all the weight.
What are the signs and symptomns of an Uncompensated Rearfoot Varus
Callus along the lateral border Styloid
Tailors Bunion (bunion 5th met)
Lateral ankle injurys
What is a Flexor Substitution
When the flexors FHL and FDL Substitute for a weak Tricep Surae
Results in flexing of the toes
What is Extensor Substitution
EDL gains mechanical advantage over Lumbricals
Causing Contracture at MTPJ
Resulting in the toes retracting during the swing phase of GAIT.
Causes Hammertoe
How would stage 1 Hallux Abducto Valgus present
Weakness of Abductor hallucis
Hallux instability in closed chain
Unstable 1st Ray
Detail the FPI Scoring system
Negative = Supinated
Neutral = 1,2,3,4
Pronated = 5,6,7,8,9,10
Which of the following would be an appropriate Orthotic addition for Functional Hallux Limitus? Explain your answer
Mortons extension
Valgus forefoot post
Revers mortons extension
Lateral heel skive
Cuboid Pad
Reverse Mortons Extension
If Hallux limitus is consided functional the RE aims to increase 1st MTPJ ROM
Which Structural deformity is associated with the best shock attenuation
Compensated Rearfoot Varus
The full compensation of subtalr pronation aids in the gradual controlled loading of the foot from the lateral border to the medial border evenly distributing ground reaction forces
Individuals with Hallux Abducto-Valgus (HAV) would likely display which gait deviation?
Apropulsive
What are the determinants of gait
1.Pelvic rotation
2.Pelvic tilt
3.Knee flexion in stance phase
4.Foot mechanisms
5.Knee mechanisms
6.Lateral displacement of the pelvis
s
The Digital Lachman Test can be used as a diagnostic test for what?
Plantar Plate dysfunction
What is Baxters Neuritis
Baxters Nerve entrapment (Calcaneal nerve) becomes trapped betwen 2 muscles in the inner foot.
The nerve runs along the bottom of the heel which is why it can comonly be differential diagnosise for Plantar fasciopathy
Branch of Tibial Nerve arising from the Tarsal Tunnel (area Posterior to the Medial Malleoules)
Which of the following are accepted theories of digital deformity
Flexor Substitution Theory
Flexor Stabalisatin Theory
Sagital Plane Theory
Exstensor Substitution Theory
Flexor Substitution Theory
Flexor Stabalisatin Theory
Exstensor Substitution Theory
List the common treatments suitable for a Lateral ankle Injury
Orthoses – heel raises
Stretch gastroc and posterior muscle groups
Rocker bottom shoes
Eccentric exercises
Mobilization of the ankle
Post injury soft tissue work on ligaments
Which test would assist in identifying a tibiofibular syndesmotic injury.
External Rotation Test (Kleiglers test)
Patient seated end of the bed ankle relaxed
Grasp the front of the Shin to stabalise
Dorsiflex the ankle and externally rotate foot
Posotive test = Pain reproduced around the Tib/Finb syndesmosis area (Front lower shin)
What would you expect to observe in the 1st MTPJ of a foot with HAV?
Hallux Limitus/Rigidus (Reduced Dorsiflexion AND Plantarflexion),
Overlying
Erythema to 1st MTPJ
Dorsal Osteophytic Lipping
Callosity and or Medial Callus to interphalangeal joint
Possible abductory flick
Functional Hallux Limitus can be indicated by:
Dorsal Orinentation of the Hallux Toenail
Callus under the Hallux
Callus sub 2nd and 3rd MTPJ
What are the common mechanical factors predisposing to neuroma of the 3rd/4th Intermetatarsal space?
Conjoined nerve
Forefoot Hypermobility
Neural Ischeamia
- Outline the open chain observations of the windlass mechanism (5 Marks).
Hallux Dorsiflexion
1st Metatarsal Plantarflexion
Medial longitudinal arch raises
Foot shortens
Rearfoot inverts
- Describe the observational effects on gait seen in individuals with limited ankle plantarflexion (5 Marks).
- Increased loading response period.
- Increased period of initial contact.
- Increased 3rd Rocker use at toe-off
- Poor stability of the midfoot at midstance.
- Early heel contact of the contralateral limb.
- What is the primary variation in symptoms of insertional versus midportion Achilles Tendinopathy? (1 Mark)
· Midportion Achilles Tendinopathy will demonstrate pain at end-range dorsiflexion.
Or
· Insertional Achilles Tendinopathy will not demonstrate pain at end-range dorsiflexion.
- Outline the proposed purposes of the windlass mechanism (5 Marks).
· Serves to support the medial and lateral longitudinal arch in a higher arched position (i.e. increases the dorsiflexion stiffness of the medial and lateral forefoot)
· Assists in resupination of subtalar joint (STJ) during propulsive phase of walking
· Assists the deep posterior compartment muscles by limiting STJ pronation
· Assists the plantar intrinsic muscles in preventing longitudinal arch flattening
· Reduces tensile forces in plantar ligaments
· Prevents excessive interosseous compression forces on dorsal aspects of midfoot joints
· Prevents excessive dorsiflexion bending moments on the metatarsals
· Passively maintains digital purchase and stabilizes proximal phalanx of digits within sagittal plane
· Reduces ground reaction force on metatarsal heads during late midstance and propulsion
· Helps to absorb and release elastic strain energy during running and jumping activities
Outline the aetiology of Morton Neuroma
Restrictive Foootwear
Tricep surae Contracture
Prediliction for women
Prediliction for pronated foot type
Define Hammer toe
MTPJ Extension
PIPJ Flexion
DIPJ Extension
Define Claw Toe
MTPJ Extension
PIPJ Flexion
DIPJ Flexion
Define Mallet Toe
MTPJ Neutral
PIPJ Neutral
DIPJ Flexion
What are the signs and symptomns of PTTD
Pain and swelling along the medial ankle excaserbated by activity
Medial longitudinal arch collapse
Sinus Tarsi Syndrome
Inability to perform unilateral heel raise ( Calcanel inversion upon ascent)
A pronated foot type would display what Subtalar Joint Axis
Medially deviated Subtalar Joint axis
This is due to the GRF being lateral to the Subtalar joint axis causimg a pronatory moment
The further the lateral positiong of the GRF creates a longer lever arm increasing the toruque that promotes pronation.
Which of the following is NOT true of hallux ridgius?
a) Dorsiflexion less than 10 degrees
b) Assisted by use of a Morton’s Extension
c) Assisted by Fleible Footwear
d) Commonly cause by 1st MTPJ Osteoarthritis
C.
Hallux Rigidus would require immobilisation of the 1st MTPJ so therefore it would not be assited by flexible footwear
- What is the normal range of dorsiflexion of the 1st Metatarsophalangeal Joint (MTPJ)?
a) 15 degrees
b) 30 degrees
c) 45 degrees
d) 60 degrees
D.
- Which muscle primarily assists supination of the foot out of midstance?
a) Tibialis Posterior
b) Gluteus Medius
c) Sartorius
d) Extensor Hallucis Longus
When it contracts, it pulls the foot into inversion and plantarflexion (supination)
The tibialis posterior assists in moving the foot into this supinated position, ensuring a stable and rigid lever for propulsion.
- In Subtalar Neutral, a Rearfoot Valgus Deformity is defined as?
a) A rearfoot that is dorsiflexed at the ankle
b) A rearfoot that is inverted relative to the floor
c) A rearfoot that is everted relative to the floor
d) A rearfoot that is inverted relative to the forefoot
C.
What is a Medial Heel skive and what pathology might it be used for
Medial Heel Skive controls Pronation by increasing Supination moment at Subtalar Joint
Clinical Use:
* PTTD
* Flexible Flat Foot
* Excesivley Pronated Feet
- Which lesser digtial deformity is defined as a Neutral Metatarsophalangeal Joint (MTPJ), Neutral Proximal Interphalangeal Joint (IPJ) and Flexion at the Distal IPJ.
a) Turf Toe
b) Mallet Toe
c) Hammer Toe
d) Claw Toe
B.
Mallet to is defined as
MTPJ Neutral
PIPJ Neutral
DIPJ Flexion
What positon should the Midtarsal Joint (MTJ) be in at heel strike?
a) Locked
b) Unlocked
c) Flexible
d) Pronated
A.
The locked position of the MTJ contributes to this stability. When the MTJ is locked, it provides a rigid structure necessary for the foot to effectively act as a lever to support body weight and stabilize the lower extremity.
As per the Thompson and Hamilton (1987) grading system for plantar plate/ injuries, a digit in which the base of the proximal phalanx can be dislocated would be:
a) Stage 0
b) Stage 1
c) Stage 2
d) Stage 3
C.
Stage 0 - No dorsal translocation of the proximal phalanx. NO TRANSLOCATION
Stage 1 - No dislocation but may show Phalanx subluxation . NO DISLOCATION
Stage 2 - The base of the phalanx can be dislocated. DISLOCATION
Stage 3 - The phalanx base is in a fixed dislocated position. FIXED DISLOCATION
- Describe in brief the Mechanism of the Stretch-Shorten Cycle (3 Marks).
I. Eccentirc Loading Causes Lengthening of the Muscle
II. Brief Isometric Period Stores Enegry
III. Rapid Concetric Contraction Returns Stored Enegry
IV. Designed for Maximal Power Output With Minimal Energy Consumption
V. Energy Conservation
VI. Provides a Spring type mechanism
- Describe mode of action the Reverse Windlass Mechanism occuring from heel strike (5 Marks).
I. Leg Internally Rotates
II. Rearfoot / Calcaneum Everts / Moves into Valgus Position
III. Medial Longitudinal Arch Lowers
IV. 1st Metatarsal / Metatarsals Dorsiflex/s
V. Foot Elongates
VI. Plantar Fascia Tension Increases
VII. Plantar Fascia Unwinds From Metatarsal Head/s Fulcrum
VIII. Hallux / Lesser Digits Plantarflex/s
What are the three phases of Ligament injury
Heamorage with inflamattion
Matrix and cellular proliferation
Remodelling and maturation
What are Ligament injury treatment aims?
Prevent abnormal scar tissue, joint stiffness and muscle weakness
Restore proprioceptive effect
Pain relief through joint mobility
What ligament might be preventing Ankle dorsiflexion
Anterior Talofibular ligament
Someone with limited ankle dorsiflexion would display which of the following
1. Naturally adducted foot
2. Naturally abducted foot
Explain your answer
2.Naturally abducted foot
Compensation for limited dorsiflexion is to outwardly rotate the foot (abduction) Abductory flick
If an individual has Oestoarthirits of the posterior facet of the Subtalar joint what limited mpoveemtn might we observe, Explain why?
Dorsi flexion and Plantar flexion
Posterior facet of the subtalar joint is responsible for Dorsi Flexion and Plantar Flexion
Anterior Facet = abduction adduction
Intermediate Facet = inversion eversion
Somebody with a medially deviated Subtalar Joint axis will display which Rearfoot position
a. Rearfoot Varus
b. Rearfoot Valgus
Explain your answer
B. Rearfoot Valgus
When GRF is lateral to the subtalar joint axis it causes pronatory moment
In a medially devaiated STJ Ground reaction forces would be lateral to the STJ Axis causing the foot to pronate and the rearfoot to assume a Valgus position
Somebody with a Laterally deviated STJ will display which Rearfoot position?
a. Raerfoot valgus
b. Rearfoot Varus
b. Rearfoot Varus
When Ground Reaction Force is Medial to the STJ axis, a STJ Supinatory moment will be produced.
In a Laterally deviated STJ Axis the GRF is medial to the STJ causing the foot to supinate and the reafoot to assume a Varus position
Why is someone with a Laterally deviated Subtalar Joint Axis more prone to Lateral ankle sprains
GRF will be Medial to the STJ Axis causing the foot to invert/Supinate and making them more prone to lateral ankle injurys.
The supinated foot is less able to adapt to uneven surface
Lateral ankle ligaments Anterior/Posterior Talofibular and CalcaneofIbular are under more stress in the inverted position
Stress on these structures can cause ligament damage, collagen degridation
Inelastic fibres are stretched through, too great a range of motion to failure point.
What is a forefoot supinatus?
Flexible inverted forefoot relative to the rearfoot
Which of these is not an accepted theory of function?
The Neutral Position of the Subtalar Joint / 8 Biomechanical Criteria for “Normalcy”
Sagittal Plane Facilitation Theory.
Tissue Stress Theory
Subtalar Rotation Equilibrium
Trendelenberg Theory
Neuromechanical Theory / Preferred Motion Pathway
Trendelenberg Theory
Explain Sagital Plane Theory
For motion to occur smoothly in the Sagital plane in has to occur through in 3 pivotal sites: Heel, ankle, MTP Joint Rocker
Any blockage of movement in Sagital Plane will lead to dysfunction in ithe intrinsic joints of the foot and lower limb e.g. (Windlass, High gear low gear)
This dysfunction will lead to compensatory movement:
* Apropulsive Gait with delayed heel lift -
* Vertical toe off
* loading of Lateral Column
* propulsion with the foot in abduction or
adduction
* Flexed Body position
Apply Sagital plane Theory to Hallux Limitus
Dysfunction of MTPJ in Sagital Plane
- The next proximal joint to allow Sagital Plane motion is Midtarsal
- Midtarsal joint collapse/pronates casing delayed Heel Lift
- Vertical Toe off
- Weight fails to shift medially Leading to loaidng of the Lateral column
- Body follows the path of least resistance due to Hallux limitus causing hip to externally rotate
- Knee, Hip and Lumbar Flexion occur
Explain the determinants of Gait
Pelvic Rotation = Pelvis rotates 4 degrees forward on the swing side and 4 backwards on the stance limb decreasing vertical displacment of center of gravuty
Pelvic Tilt = Pelvis drops 5 degrees on the side opposite to that of weight bearing limb during midstance
Knee flexion (after heel strike in stance phase) = at heel strike the knee is fully extended and at foot flat the knee is flexed 15-20 degrees; this absorbs shock and helps minimizes the displacement of the center of gravity
Foot mechanisms (foot and ankle motion) = at heel strike the foot is dorsiflexed and the center of rotation of the ankle is elevated. At foot flat the foot plantarflexes and the center of rotation on the ankle is lowered. At push off the heel lifts from the floor and the center of rotation of the ankle raises again
Knee mechanisms = at heel strike, when the center of rotation of the ankle is high, the knee joint begins to flex. During midstance when the ankle center is low the knee joint flexes a second time. The effects of this relationship between the motions of the foot, ankle, and knee is to smooth the pathway of the center of gravity
Lateral displacement of the pelvis – the center of gravity must shift over the stance foot to provide balance, otherwise the person will fall over the unsupported limb.
List all the Foot/Ankle pathologies that occur at the Medial ankle
- Flexor Hallucis Longus Tendinopathy - often misdiagnosed as Posterior Tibial Tendon dysfunction
- Posterior Tibial Tendon Dysfunction - Inflamed Tendon inner ankle
- Flexor Digitorum Longus Tendinopathy
- Tarsal Tunnel syndrome - a nerve irritation that can cause inner ankle and foot pain
- Deltoid Ligament Sprain - web of ligaments spanning the inner ankle joint
- Mueller Weiss syndrome - condition affecting navicular bone
- Medial Malleolous Fracture
List all the Foot/Ankle pathologies that occur at the Lateral ankle
- Lateral ligament sprain (CFL, ATFL,PTFL)
- Sinus Tarsi Syndrome -
- Peroneal Tendinopathy - inflammed degerneration of peroneal tendons due to overuse trauma or biomechanical deficit (Peroneus Longus, Brevis, Tertuis)
- Lateral Malleoluor fracture - fracture of the lower aspect of the fibula
List all the Foot/Ankle pathologies that occur at the Forefoot
- Hallux Rigidus / Limitus / HAV
- Plantar Plate Dysfunction/ Rupture - Stabalises MTPJ joints
- Metatarsalgia - MTPJ pain
- Mortons Neuroma
- Hammer Toe/ Mallet Toe / Claw Toe / Turf Toe
List all the Foot/Ankle pathologies that occur at the Plantar foot
- Fat pad Contusion
- Baxters Neuritus
- Plantar Fascitis
List all the Foot/Ankle pathologies that occur at the Posterior Heel
- Plantaris Tendinopathy
- Achillies Tedinopathy
- Retro Calcaneal Bursitus
- Sub Cutaneous Bursitus
- Haglunds Deformity
- Sural Neuropathy
List all the Foot/Ankle pathologies that occur at the Midfoot
Inner Midfoot
* Navicular Fracture
* Midfoot Arthritis - arthritis of the tarsal bones in the midfoot
Outer Midfoot
* Sinus Tarsi Syndrome
* Tarsal Coalition - congenital condition that involves the attachment of two tarsal bones from birth
* Cuboid Syndrome - irritation or subluxation of the cuboid bone
Top Of Midfoot
* Exstensor Tedinopathy
* Cuneiform Frcature
* Superficial Peronaeal Nerve Entrapment
Detail the orthotic prescription appropriate for achillies tedinopathy and how do they work
Heel Raise
Heel lift attenuate reduce impact forces at heel strike
Heel Raise reduces Plantar flexion of the ankle joint and shortens the muscle-tendon unit, thereby decreasing the load in the Achilles tendon during gait.
What is Flexor Stabalization theory
Muscle imbalance
Midtarsal unlocked causing unstable forefoot during toe off
Midtarsal pronates past midstance
As a result Flexors fire for longer to stabalize forfoot overpoweing interosseuos muscles
This leads to hammering clawing + adducto Varus 5th
What is the Foot Edge test, what does it test for?
Assement of the digits and Reverse Wndlass Mechanism
* Standing on the edge of a stool at the MTPJ level and
allowing the digits to hang over the edge.
* In a positive reverse windlass, the proximal phalanges
go into plantarflexion.
* If the proximal phalanges are in the same position on the
‘footstool edge test’ as to relaxed stance, this shows
a non-functioning reverse windlass mechanism.
