MSK2 Week 8 Flashcards
1
Q
Arthroplasty
A
Prosthesis
2
Q
Accelerated rehab for Achilles’ tendon repair
A
Better outcomes
3
Q
Tarsal tunnel syndrome
A
Posterior tibial nerve (or med/lat plantar nerve) entrapment as it passes posterior to medial malleolus Causes: Trauma Excessive pronation/pes planus Tight laced shoes Local edema/inflammation Space occupying lesion (ie tumor)
4
Q
PHP (plantar heel pain)
Objective exam common findings
A
Pain with palpation of plantar fascia Insertion Limited DF ROM Higher BMI in non-athletes Positive windlass test Negative tarsal tunnel test Positive impaired neurodynamics
Assumes cleared up through lumbar spine
US thickness >4mm at calcaneal attachment
5
Q
Symptoms begin 10 min into exercise and resolve 30 min after exercise
Sensory or motor loss
Elevated anterior compartment pressures
A
Exertional compartment syndrome
Tissue Origin: muscle and fascia
6
Q
2 primary components of CAI
A
Mechanical instability (pathologic instability, impaired arthrokinematics, and degenerative joint changes)
Functional instability (altered neuromuscular control, strength deficits, deficient postural control)
7
Q
Category 3 red flag
A
Require further physical testing and differential analysis
8
Q
PF
A
Ankle or talocrural joint
Sagittal ply
Coronal axis
~50*
9
Q
Moderate talipes equinovarus intervention
A
Weekly application of plaster casts for ~6 weeks
Denis Brown splinting with feet fixed to brace and progressively turned outward into Valgus for 12 weeks
Use of Denis Brown splint day and night for 3 months, in static position after initial 12 weeks
Straight last or outflare shoes/boots for day wear until 3 years
Semi-rigid orthodics to maintain soft tissue position and length
10
Q
Grade I lateral ankle sprain
A
Mild symptoms Microscopic tearing of ATFL (anterior talofibular ligament) No functional loss or instability Recovery time: 2-10 days Rarely seen in PT: self treat
11
Q
Shin pain : treatment
A
RICE Flexibility program for GS complex Retrain and strengthen inhibited musculature Restore CKC DF Improve intrinsic foot strength Short term: low-dye taping Running evaluation and retraining Address associated trigger points Footwear change if necessary
12
Q
Talar chondral repair
A
Chondral defects of talar dome
Requires donor tissue- usually from less weight-bearing of knee (OATS)
Rehab considerations: tissue/osteotomy healing; ROM
13
Q
Lis Franc Stabilization
A
Tarsometatarsal joints
Fusion- decreased chance of 2nd surgery
Vs
ORIF
6 weeks immobilization
Orthodics not bad idea for support post-op
Slowly regain ROM, flexibility, normalize gait, and improve proprioception and gait.
~6 mo return to sport
14
Q
Vague, diffuse pain along middle-distal tibia
Worse at beginning of exercise, decreased during training
A
Medial tibial stress syndrome
Tissue Origin: periosteum
15
Q
West Point Sprain Grading
Grade II
A
Partial tearing
Moderate/severe swelling
Mild/Moderate joint instability
Partial/Unable WB
16
Q
Inflammation/infection red flags
A
Osteomyelitis Septic arthritis Cellulitis Gout Ingrown toenail
17
Q
The talocrural joint has a _____.
The tenon is ___
A
Mortise (rectangular cavity)
Tenon (projection shaped for Insertion into mortise) is Trochlea talus
18
Q
Causes of MTSS (medial tibial stress syndrome
A
Improper footwear Muscle weakness Poor running mechanics Improper training Tight gastrocs Weak tibialis anterior/posterior Hypermobile or pronated feet Excessive supination
19
Q
Hallux Valgus
A
1% adults in US
Incidence increases with age:
3% under 30, 9% 31-60, 16% > 60 yo
Female to male 2:1 to 4:1
20
Q
Achilles’ tendon rupture
A
Chronic degeneration due to inflammation
Forceful, sudden contraction
Audible pop: “who did that?”
Risk factors: cortisone injection; 30-40 year old male
Palpable and/or visual defect Gait changes: unable to push off Swelling and ecchymosis Can PF 2ndary to 2ndary muscles, albeit weak \+ Thompson test Most treated surgically
21
Q
Tibialis Anterior Tendinopathy
A
Presentation very similar to MTSS
Overuse due to training or faulty mechanics
Differential diag:
Reproduced w/ resisted testing
Palpation
L4 myotome issue (DF, eversion)
22
Q
Talocrural capsular pattern
A
PF limited more than DF
23
Q
Subtalar supination: closed chain
A
ER of tibia and fibula
Talar abduction and DF
Calcaneal inversion
24
Q
Midfoot is made up of
A
Navicular, cuboid, cuneiforms
25
Inversion sprain
Stress greatest in _____
_____ rotatory instability
Combined INV/PF
| Anterolateral rotatory instability
26
Tarsometatarsal joint function
Augment transverse tarsal joint function
Position metatarsals and phalanges
Maintain forefoot contact with ground: rotate to adjust forefoot positioning when transverse tarsal joint cannot fully compensate for rearfoot positioning
27
Bones of hindfoot
Talus
| Calcaneus
28
Posterior tibialis dysfunction
Pain, inflammation along posterior tibialis tendon and sheath - May show anywhere along tendon to plantar aspect of foot
Can have pain with weight bearing, which may ease through day
Gait, push-off deficits
Decreased posterior tibialis length with testing
29
Achilles tendonitis
Inflammation of Achilles’ tendon
Overuse/overload
Gradual onset
Decreased flexibility exacerbates
30
Category 1 red flag
Requires immediate medical attention
31
Severe talipes equinovarus intervention
Surgical treatment if non-surgical methods fail
Meticulous soft tissue release of tendons and joint contractions
Post-op the non-op methods are resumed
Semi-rigid orthodics to maintain soft tissue length
32
Charcot foot
Neurogenic arthropathy that affects the joints in the foot.
Rapidly progressive degenerative arthritis that results from neuropathy
Pain perception, motor function and proprioception of foot are severely impaired
Loss of these motor and sensory nerve functions allow minor traumas to go undetected/untreated- leading to laxity, dislocations, bone erosion, cartilage damage and deformity of foot.
33
Lateral ankle sprain
Least stable in loose packed position: PF with inversion
| Progression of severity from ATFL to CFL to PTFL
34
Hallux rigidus/limitus
Degenerative Arthrosis 1st MTP
2nd most common great toe disorder
Effects 1/45 over age 50
Most common great toe injury to great toe in athletes
Limited evidence for conservative management
35
Ankle injury prevention programs are effective at reducing the risk of ankle injuries by ___% in soccer players
40%
36
Metatarsalpharengeal joints are ____ joints.
| Motions:
Condyloid synovial
Extension: body passes over foot during late stance of gait
Flexion: return to neutral from extension
ABD/ADD: grasping; absorb some force on metatarsals as they undergo pronation/supination twist at TMT joints
37
Syndesmotic “High” ankle sprains
Rarest sprain
Injury to anterior tibiofibular ligament and/or syndesmosis
Hyper-dorsiflexion
Rotation and PF
Recovery >6 mo
Often surgical candidate
Special test: syndesmotic squeeze, ER stress test, fibular translation test
38
Pressure sensation exam for diabetic
10 g nylon Senses-Weinstein monofilament at a right angle to the skin
Apply pressure until monofilament buckles.
Inability to perceive the 10g of force applied by the monofilament is associated with clinically significant large fiber neuropathy and increased risk of ulceration
39
FO were found to be effective in reducing overall _____, but not ___
Reduce overall injuries and stress fractures
| But NOT with preventing soft tissue injuries
40
Differential diagnosis of PHP
Systemic conditions- incl neuropathy and inflammatory arthritis
Fat pad syndrome- age related or trauma induced degeneration of fat pad
Tarsal tunnel syndrome- compression and/or stretching of posterior tibial nerve (Tinels and DF/EV tests)
Calcaneal stress fracture- overuse vs insufficiency
Posterior tibialis dysfunction
41
Ankle arthrodesis and arthroplasty rehab considerations
Longer recovery after fusion
Risk of nearby joint OA after fusion
NWB: 2-8 weeks
Arthroplasty rehab progression faster than fusion : 4-6 mo respectively
42
The ___ Ray is the least mobile
2nd
43
Talar ____ component of pronation causes ____ of superimposed __
Talar Adduction
| Causes IR tibia/fibula
44
CAI prevention
Closed chain DF
38* tibial shaft angle
9-10 cm knee to wall
Athletes: at least 3 month multi intervention focusing on balance and neuromuscular control
45
Inversion grade I/II ankle sprain MT/exercise intervention
```
MT:
Proximal and distal tibial/fibular mobilizations
Mobilize with movement
Posterior glide talocrural
Rear foot distraction
Eversion mobilization
Exercise:
Achilles stretch 3x30 sec (2x day)
Ankle alphabet (2x day)
Self mobilization TC and ST 3x30 reps
Maintain activity as tolerated
Ice and elevation
```
46
The deltoid ligament has ___ strength. It is comprised of the ___ ligaments
```
Great tensile strength
Tibionavicular ligament
Tibiocalcaneal ligament
Anterior tibiotalar ligament
Posterior tibiotalar ligament
```
47
Assessment for PVD (peripheral vascular disease) in diabetic assessment
History: claudication (calf pain after walking a specific distance) relieved by rest. However this is uncommon in people with diabetes due to concomitant neuropathy
Exam: palpate foot for temp (cool in PVD)
Palpate dorsalis pedis pulse, and if absent the posterior tibial pulse
Reactive hyperemia (leg turns bright red when going from elevated position to declining back to ground)
48
L4 myotome
DF
| eversion
49
Talocrural coupling axis
Axis shifts slightly with motion
| Transverse plane motion of lower extremity changed into frontal plane motion of the foot.
50
For patients with chronic ankle instability and limited DF, using talocrural thrust manipulation is superior to DF mobilization with movement
True or false?
False
51
FO can be used to prevent
1st incident of overuse injury
52
Tibialis Posterior tenonopathy etiology and exam
tibialis posterior is an anti-pronatory muscle
Pain with AROM and/or MMT
Repetitive stress
Pes planus, hypermobile feet
Irritation at insertion on navicular or behind medial malleoli
Look at resting and dynamic foot posture
53
Mobility functions of foot
Dampening rotations from proximal joints
Flexible enough to absorb shock
Foot conform to terrain
54
Tibialis Anterior tendonopathy presentation
```
Will look similar to MTSS
MMT testing should provoke
Palpation key
Be sure to screen lumbar
Gait and running analysis key
```
55
Deltoid ligament strongly resists
Eversion
| Side to side movement or rotation of mortise on talus
56
Effects (potential) of pes planus
Overly mobile or flexible foot
Foot may require contraction during stance
Possible decreased push off during gait (foot not a rigid lever during push off)
Increased tibial IR; increased Q angle at knee; potentially altered patellar tracking
Excessive mobility may stress ligaments, tendons, and muscles that control motion of rear foot
Increased magnitude and rate of pronation
57
The lateral collateral ligament (ankle) is comprised of __ ligaments. The ____.
3 separate bands/ligaments
Anterior talofibular ligament
Posterior talofibukar ligament
Calcaneofibular ligament
58
Forefoot made up of
Metatarsals and phalanges
59
Sources of foot stability
Wedge shaped mid-tarsal bones
Inclination of calcaneus and 1st MT (med longitudinal arch)
Ligamentous support (incl plantar aponeurosis)
Intrinsic foot muscles
60
High arch
Cushioning; less effective shock absorption capability
| > 0.3862
61
VINDICATES
```
Vascular
Inflammatory/infection
Neoplasm
Degenerative
Intoxication
Congenital
Autoimmune/Allergic
Trauma
Endocrine
pSychological
```
62
Category 2 red flag
Require subjective questioning and precautionary exam and treatment procedures
63
The subtalar joint dampens ____ and ___ contact with ____.
Dampens rotational forces
| Maintain foot contact with supporting surface
64
Plantar heel pain, prevalence and presentation
Pain arises from insertion of plants fascia with or without heel spur.
10%
Presentation:
Progressive pain with WB
Especially 1st steps in am
Presenting body athletic and non-athletic populations
Rarely a case of inflammation
65
Grade III lateral ankle sprain
```
Unstable, multi-ligamentous sprain
Anterior capsule involvement
Unable to fully WB
Diffuse edema/tenderness
Frequent concomitant fracture
Recovery time: 30-90 days
Typically managed by ortho first
```
66
Stages of ulcer development
1. Callus formation
2. Subcutaneous hemorrhage
3. Breakdown of skin
4. Deep foot infection with osteomyelitis
67
DF
Ankle or talocrural joint
Sagittal plane
coronal axis
~20*
68
Eversion of foot
Frontal plane
AP axis
Plantar surface away from midline
~10*
69
____ is most common cause of Charcot foot. ___% of people with this develop peripheral nerve damage that can lead to Charcot foot.
Onset usually age ____ , patient has been __ for ___ years
Diabetes
60-70%
50 years old or older
Has been diabetic for 15-20 years
70
Achilles tendonosis treatment
IASTM
Stretching
No NSAIDs, no ice
```
Eccentric training:
3 sets of 15 eccentric heel drops
2x daily
12 weeks
It should hurt more when done (+2~3)
```
71
Foot has ___ bones and ___ joints
28 bones
| 25 joints
72
Ray
Functional unit formed by:
(1st-3rd)metatarsal and associated cuneiforms
(4th-5th rays) metatarsals
73
The 1st and 2nd rays ...
Invert/extend and evert/flex
74
MT for ankle sprains
| Precautions and red flags
Acute: avoid increased pain
Severe, grade III sprain
Fracture and syndesmotic injury; Ottawa ankle rules
Screen for associated injuries
75
Syndesmotic/High ankle pain usually caused by
External rotation
| Or forced DF
76
Sesamoids
2 pea sized bones maintained by ligamentous masses in grooves along plantar aspect of 1st MT
Anatomic pulley for flexor hallucis brevis
Protect FHB tendon from WB trauma, which passes through tunnel formed by sesamoids and intersesmoidal ligament joining their plantar surface
77
Talocrural closed/open pack
Closed pack: DF
| Open pack: PF
78
Calcaneal Varus
Distal segment toward midline
79
The lateral collateral ligament (ankle) counters:
Varus/inversion stresses or
| Lateral ankle joint distraction
80
Plantar heel pain and FO
| Short, medium and long term research
Short and long term: very low quality evidence..DO NOT reduce pain or improve function
Medium-term: moderate evidence FO more effective than sham FO in reducing pain- but no improvement in function
81
Hip joint ____ May be related to medially facing ____ and patients ___ pain
Hip joint IR May be related to
| Medially facing patellae and patient’s Knee pain
82
Transverse tarsal joint separates ___ from ___
Hindfoot from rearfoot
83
Immobilization after lateral ankle sprain
May be indicated in Grade III injuries as well as syndesmotic injuries
Leads to protracted recovery in grade I and II injuries
Protected WB ideal immediately post-injury
84
Chronic ankle instability (CAI)
Characterized by residual symptoms that include feelings of giving away and instability as well as repeated ankle sprains, persistent weakness, pain during activity, and self-reported disability
85
For grade I/II ankle sprain, ___ and ___ are both effective; however ____ better
Manual therapy + exercise
Home exercise program
Manual therapy + exercise more effective
86
Closed chain talocrural coupling
Leg internally rotates, talus glides inward, foot pronation
Leg externally rotates, talus glides upward, foot supination
87
Ultrasound, laser therapy and electro therapy have ____ acute ankle injuries.
____ recommended for return to sport
No effect treating acute ankle injuries
| Lace-up or semi-rigid brace recommended for return to sport
88
Functions of transverse tarsal joint
Transitional link between hindfoot and forefoot
Increases supination/pronation range of subtalar joint
Compensates (within forefoot) for hindfoot positioning
Theoretically enables forefoot to remain flat on ground regardless of hindfoot pronation/supination
89
Talar tilt test tests
CFL or deltoid ligament
90
Morton’s Neuroma
Pain and paresthesia in interdigital space (typically 2-3 or 3-4) with fibrous entrapment of interdigital Nerve
Conservative management: decompression vs footwear modification, metatarsal pads, MT mobilization, IASTM
Surgical excision if don’t improve (but often return after surgery)
91
Transverse tarsal joint activity: late stance of gait
Subtalar and transverse tarsal supination increase stability of stance limb
Bony surface congruent and joints locked in closed-pack position
Locking if joints enable weight transfer to forefoot as foot becomes rigid lever for push off
92
Medial/Eversion sprain
```
Less common due to decreased eversion ROM and bony architecture
5-10% of all ankle sprains
Strong deltoid ligament
Potential for mortise instability
Medial malleolar fracture
```
```
Localized pain over deltoid
Positive eversion (talar tilt) Test
```
93
Achilles’ tendon repair recovery time
boot in PF for 2 weeks, potential for full WB
Limited DF to 0 first 3 weeks
Week 7 wean out of boot, ROM progressed as tolerated
6-9 month recovery
Return to sport 1 year
94
Ankle ligament CPG
| Progressive loading/Sensorimotor training phase
MT: graded mobilization/manipulation, mobilization with movement
EX: reinforce MT, functional retraining, strength and balance
95
Pain with running, point tenderness, “dreaded black line” on lateral X-ray
Tibial or fibular stress fracture
96
Vascular red flags
```
Acute compartment syndrome
DVT
Aneurysm
PVD
Necrosis
Thrombophlebitis
```
97
Subtalar pronation: open chain
Calcaneus moves on fixed talus/leg
Calcaneus DF, everts, abducts
98
Deltoid ligament
Eversion sprains are ____, ___% of all sprains.
High risk of bony trauma to ____ with eversion sprains.
Rare
5-10% of all sprains
Medial malleolus and fibula
99
Fat pad syndrome
```
Generally degenerates > 40 yrs, after injury or recurrent stress
Reduced cushioning
Hard training surfaces
PT management may include:
Activity modification
Doughnuts, heel cups or pads
Cushioned footwear
Ice
```
100
West Point Sprain Grading
| Grade III
Complete rupture
Severe swelling
Moderate/Severe joint instability
Unable to WB
101
Talocrural coupling
Lower leg rotation initiates movement of talus which causes simultaneous motion in all 3 joints.
102
Worse with lumbar tension position (sitting)
Lumbar radiculopathy
103
Hallux abductovalgus
Medial deviation of 1st metatarsal head in relation to center of body
Types:
Adolescent: familial and may require surgical intervention. Often assoc with hyperpronation of rearfoot
Degenerative: DJD of 1st MT head and base of proximal phalanx
104
Lateral stabilization surgery
```
When indicated surgical outcomes good
Brostrom technique, popular, reroutes peroneals
Immobilize 2 weeks in eversion
Consider bracing 1st 3 months
No inversion ROM for 6 weeks
3-6 month recovery
```
105
The talocrural joint is a ____ ____ joint.
Synovial, modified saddle of hinge
106
Common sequelea
```
Nerve: superficial peroneal/fibular nerve involvement
Bony:
Based of5th MT
Spiral fracture of fibula
Lateral malleoli
Navicular
```
107
This joint is “the most congruent joint in the body” with a close fit throughout ROM.
Talocrural joint
108
Stability functions of foot
Stable BOS for WB
| Act as rigid lever for effective push-off during gait
109
4 predictor variables for MT and exercise interventions for inversion ankle sprain
Symptoms worse when standing
Symptoms worse in evening
Navicular drop > 5mm
Distal tibiofibular joint hypomobility
110
Custom FO are effective for
Painful pes cavus
Rear foot pain in RA
Foot pain in juvenile idiopathic arthritis (JIA)
111
Cuboid syndrome presentation
Pain during gait; reduced push-off
Localized pain and tenderness
Pain with passive physiological and accessory motion testing
May or may not show up on imaging.
Differentiate other causes: accessory ossicles, peroneal tendon dysfunction
112
Heel spur present in ___% symptomatic and ___% asymptomatic plantar heel pain.
89% symptomatic
| 39% asymptomatic
113
Lateral ankle reconstruction
| Week 6
Begin proprioceptive/balance activities
Slide board
Hopping (side to side, front to back, diagonal)
Mini-tramp jogging
Ankle eversion (complete rehab if peroneals essential l)
114
Tarsometatarsal joints are ____ joints, formed by ___ and ____.
AKA _____
Planar synovial joints
Distal tarsals and bases of metatarsals
Lisfranc’s joint
115
1st MTP arthrodesis and arthroplasty
Arthrodesis: good at reducing pain and avoiding revises. Not good bc lose ROM
10* DF, 15* abduction
Choice of several methods for arthroplasty or re-surfacing. Goal is to maintain ROM and function but none of them are ideal.
Rehab:
Early NWB to allow healing
Gait training while avoiding stressing healing tissues
116
Lateral ankle reconstruction
| Weeks 8-12
Return to sport/dancing
| Can only return if peroneal strength is normal and symmetric with uninvolved limb
117
The transverse tarsal joint acts with the ___ joint
Subtalar joint
118
Talonavicular joint is a ____ joint. It Is enhanced by the ____ which functions to ____.
Ball-socket joint
Enhanced by spring ligament (plantar calcaneonavicular ligament) which
Supports the joint and the medial longitudinal arch
119
Mild talipes equinovarus intervention
Initiation of treatment within 1st few day of life with gentle passive correction of the deformities
Maintenance of correction for a long period and supervision of child until end of growth period
120
Achilles’ tendon repair indications
Rupture
Young, active
Not musculotendinous junction - these heal well without surgery
121
Supinates or high arch foot
Pes cavus
122
Chronic exertional compartment syndrome etiology and exam
Typically anterior
2 year history prior to diag
Common in runners and soccer players
Muscle herniation can be palpated in 40-60%
Neurologic weakness and numbness in respective compartment
Pain comes at predictable periods
Test with Wick catheter before and after treadmill test
Treatment: consider transition to forefoot running
123
Causes of medial tibial stress syndrome (MTSS)
```
Inappropriate footwear
Muscle weakness
Poor running mechanics
Improper training (hard surfaces, poor dosage)
Tight gastrocnemius
Weak tibialis anterior and posterior
Hypermobile or pronated feet
Excessive supination
```
124
Diabetic foot neuropathy
Motor: limited joint mobility, postural and coordination deviation
Sensory: decreased protective sensation
Lead to foot deformities, shear and stress pressure...
Lead to callus and contribute to injury and ulcers
Autonomic: diminished sweating, altered blood flow regulation, microvascular dysfunction
Lead to skin fissuring and cracking...ulcer
125
Calcaneal Valgus
Distal segment away from midline
126
The middle tibiofibular joint is ____. It ___.
Interosseous membrane
| Supports proximal and distal joints
127
Calcaneal stress fracture
Sudden or gradual onset pain
Typically associated with increase in load > normal bone capacity. Falls/impact
Pain with all weight bearing activities
Exam: pain with...
Calcaneal palpation along medial/lateral aspect
Calcaneal squeeze, percussion
128
Hallux abductovalgus interventions
```
Strengthen intrinsic muscles
Manual therapy of foot and ankle
Modify footwear
Custom orthodics
Splinting
```
129
PHP (plantar heel pain) potential underlying factors
Pes planus with subsequent overstretch of fascia
Rigid, cavus foot with tight fascia
Sudden increase in frequency, intensity, duration of activity (esp hill or speed work for runners)
Calcaneal spur may develop due to chronic pull of fascia on calcaneus
130
Anterior drawer tests
ATFL
| Anterior talofibular ligament
131
Lateral ankle reconstruction
| Week 4
Remove walking boot at 4-6 weeks
Use air splint for protection from weeks 6-8 weeks
Start gentle ROM ankle exercises
Isometric peroneal strengthening
Avoid adduction/abduction of ankle until 6 weeks
Start stationary bike and light swimming
132
Pes planus
Flexible flat feet (arch disappears when WB)
Excessive pronation at subtalar joint can depress navicular
Depressed navicular prevents transverse tarsal joint from reversing or supinating to absorb excessive tear foot pronation
Prevents transverse tarsal “counter movement” that would otherwise enable normal WB through forefoot.
133
Cuboid syndrome intervention
Manipulation (black snake whip)
134
Subtalar joint closed pack
Closed: supination
Locks talocalcaneal joint surfaces
Foot becomes “rigid lever”
135
The distal tibiofibular joint is a ___ joint, between ___ and ___.
It’s ligaments (___) function ___
Syndesmosis/fibrous union
Distal fibula and fibular notch PF tibia
Anterior and posterior tibfib ligaments restrict motion and stabilize mortise
136
Arch height and related injuries: Planus
Plantar fasciitis
Knee pain
Patellar tendinitis
Stress fractures (2nd/3rd MTs)
137
Ottawa ankle rules
Pain in malleolar or midfoot area, and any 1 of the following:
Inability to WB both immediately after injury and in ER for 4 steps
Bone tenderness: distal 6 cm of posterior edge of tibia or tip of medial malleolus
Bone tenderness: distal 6 cm of posterior edge of fibula or tip of lateral malleolus
Bone tenderness: base of 5th metatarsal or navicular
138
Vague, diffuse pain along anterolateral tibia, worse at beginning of exercise
Decreases during training
Anterior tibial stress syndrome
| Tissue Origin: periosteum
139
Arthrodesis
Bone glue/grafts and screws
| “Fusion”
140
Functional segments of foot
Forefoot
Midfoot
Hind/rearfoot
141
Grade II lateral ankle sprain
```
Moderate functional loss
Involves ATFL (anterior talofibular ligament) and CFL (calcaneofibular ligament)
May have initially “walked it off”
Diffuse swelling/tenderness
Recovery time: 10-30 days
Commonly managed in PT
```
142
PHP (plantar heel pain) “grade A” interventions
Manual therapy
Stretching
Target: plantar fascia, gastroc/soleus
Short term relief
Taping
Antipronation (low-dye)
Short term benefit (~48 hrs)
May benefit early in care to ease pain/restore function
Foot orthoses- potentially useful to those who respond favorably to taping
Night splints- 1-3 mo for those w/consistent 1st step pain
143
Pronated or flat foot.
Decreased or absent medial longitudinal arch
Talus depresses navicular and minimizes potential for transverse tarsal counter rotation to offset subtalar pronation
Pes planus
144
PHP interventions (non grade A)
Physical agents
Therapeutic exercise
Trigger point dry needling
145
Achilles tendonosis
```
Chronic in nature
Hypovascular zone 2-6cm from Insertion
May present crepitus
Often lack of CKC DF
Thickening of Achilles’ tendon
Tight, painful gastroc/soleus with TPs
Painful resisted PF
```
Anti-inflammatories don’t work
146
Post-op hallux Valgus priorities
Bone healing
Great toe extension
Gait training
Neuromuscular re-education
147
The 4th and 5th rays
Evert/extend and invert/flex
148
Subtalar supination: open chain
calcaneus moves on fixed talus/leg
Calcaneus PF, inverts, adducts
149
There are ___ Tibiofibular joints: _____.
3
Proximal
Middle/interosseous
Distal
150
Tib-fib posterior support muscles
Posterior tibialis
| Popliteus
151
The ___ joint of the transverse tarsal joint, is more restrictive motion, and the ___ ligament functions to ____
Calcaneocuboid joint
| Long plantar ligament supports the lateral longitudinal arch
152
Indications for ankle/foot surgery
Pain
Loss of function
Instability
153
Bones of midfoot
Tarsals: cuneiforms 1-3, cuboid, navicular
154
Tarsal tunnel syndrome etiology and exam
Aka: posterior tibial neuritis
Lesion to posterior tibial nerve in flexor retinaculum : entrapment or traction; behind medial malleoli
Analogous to carpal tunnel syndrome
Indirect trauma: running on hard surfaces, or poor fitting shoes; overpronation
```
Localized swelling (sometimes)
Medial ankle and heel pain
Positive sensory loss to medial heel
+ Tinel’s sign
Possible adverse neural tension
```
155
The ____ joint has a risk for delayed or nonunion fracture.
Talocrural joint
156
Subtalar pronation: closed chain
IR of tibia and fibula
Talar adduction and PF
Calcaneal eversion
157
Acute lateral ankle sprain testing
Anterior drawer: tests for ATFL - better diagnostic accuracy 5 days post-injury compared to 2 days post-injury
Talar Tilt Test
158
The talocrural joint is wider ____.
| It is a ___ joint, with ___ muscular attachment.
Anteriorly
Uniaxial Oblique hinge joint
No muscular attachments
159
Subtalar capsular pattern
Varus limited more than Valgus
160
5 pillars: prevent foot problems in diabetes
1. Identify high risk patient
2. Regular inspection/examination of foot and footwear
3. Education of patient, family and health providers
4. Appropriate footwear
5. Treatment of non ulcerative pathology
161
Calcaneal apophysitis - Sever’s disease, signs/symptoms and management
```
Antalgic gait- heel pain during walking/running
Swelling
Localized pain/tenderness
+ AROM/PROM test for tight Achilles
(Children)
```
Initial- restrict DF by elevating heel
Will resolve when apophysis closes
Modification of activity level
Non-irritating stretching if GS complex
162
The transverse tarsal joint is comprised of the
Talonavicular joint and
Calcaneocuboid joint
Midtarsal joint - Chopart joint
163
Cuboid syndrome
| location, mechanism, prevalence
```
Pain plantar region of cuboid
Mechanism: forceful contraction of peroneus longus with plantar subluxation
Prevalence:
Dancers 17% of foot/ankle injuries
Athletes 4% of foot injuries
Lateral ankle sprains 7%
```
164
Shock-absorbing insoles ...
Not effective for prevention of any injuries
165
Inversion of foot
Frontal plane
AP axis
Plantar surface moves toward midline
~20*
166
Tarsal tunnel syndrome exam
Burning, N/T in medial ankle and/or plantar foot
Plantar foot paresthesia
(+) Tinnels to Posterior tibial Nerve w/ simultaneous DF/EV and toe extension
MMT changes (rare)
Max passive ankle EV/DF and MTP/IP extension held 5-10 sec
167
Subtalar joint is a ____ joint with ___ motions ____.
Functional synovial joint
Triplanar motions
Posterior, (then tarsal canal) middle, and anterior articulations.
168
Calcaneal abduction
Transverse plane
Vertical axis
Distal segment away from midline of body
169
Tarsal tunnel release surgery indications
Tarsal tunnel syndrome
Increased motor nerve latency on EMG
Early diagnosis
Identifiable lesion
170
Subtalar joint
| Plane, axis, type, normal, capsular pattern
```
Plane: frontal plane
Axis: sagittal axis
Joint type: gliding synovial
Movement: inversion and eversion
Normal range: 20* and 10* respectively
Capsular pattern: increased limitation of inversion, eventual fixation into full eversion
```
171
____ FO compared to ___ FO caused greater reduction in ___ pain a 6 weeks, but not 1 year f/u
Contoured
Flat
Knee pain
172
Infection, ulceration or destruction of deep tissues associated with neurological abnormalities and various degrees of peripheral vascular diseases in the lower limb
Diabetic foot
173
Tarsal tunnel release post-op
```
3 weeks immobilization, NWB
Tissue mobility (incision, mobilization, gentle nerve guides)
Progression into DF, and start gait training and functional re-training
```
174
Diabetic neuropathy
History and careful foot exam mandatory to diag neuropathy
Up to 50% of patients with type 2 diabetes have significant neuropathy and are at risk of foot ulcer
Sensorimotor and peripheral sympathetic neuropathy are major risk factors for ulcer
175
The 3rd Ray...
Extends and flexes
176
Low arch
Motion control; excessive mobility in foot
| < 0.3058
177
The proximal tibiofibular joint is ___, and comprised of the ___ and ___.
Motions:
Synovial
Fibular head and fibular articulating facet of tibia
Motions: superior and inferior gliding, fibular rotation
178
Non-custom FO appear just as effective (as custom) for
JIA (juveniles idiopathic arthritis)
Plantar fasciitis
MTP pain in RA
179
Plantar aponeurosis extends from____ to ____, then via ___ to ___.
Calcaneus to plantar plates at MTP joints, via plantar plates to proximal phalanges
180
Pes cavus
Increased medial longitudinal arch height
Subtalar and transverse tarsal joints excessively supinates
Rearfoot varus
Potential ER stress on leg
Rigid or flexible
181
Diabetic foot...
___% of all non-traumatic lower limb amputation
___% of diabetic related foot amputation are preceded by foot ulcer
__ our of ___ ulcers in diabetics are precipitated by trauma
___% prevalence of foot ulcers in diabetics
40-60% of all non-trauma lower limb amputations
85% preceded by ulcer
4 out of 5 precipitated by trauma
4-10% prevalence of foot ulcers in diabetics
182
Rigid pes cavus
Increased loading on lateral structures
| Less effective shock absorption capacity
183
Endocrine red flags
Diabetes
Gout
Vitamin D deficiency
184
Ankle ligament CPG
| Acute/Protected Stage
Manual therapy for lymph drainage, edema reduction, pain-free soft tissue and joint mobilizations.
Exercise: reinforce MT; appropriate for stage and goals
185
The at-risk foot
Deformities s/b accommodated in properly fitting footwear
Clawed toes need wide, deep, soft toe box to reduce pressure on dorsum of toes. Extra depth shoes to protect apices of toes
Prominent metatarsal heads: extra depth stock shoe with cushioning insole
Callus: most important pre-ulcerative lesion. S/b regularly and sufficiently removed by trained pro with a scalpel
Dry skin/fissure: treat with emollient, reduce fissure margins with scalpel
186
Arch height and related injuries: Cavus
Plantar fasciitis
Ankle INV sprains
ITBS
Stress fractures (5th MT)
187
Subtalar joint maintained in WB, pronation imposes ___ force of leg that can affect ___
IR force
| Knee and hip
188
Subtalar joint open pack
Midway between pronation and supination, and 10* talar PF
189
The ___ is typically stronger than the ankle lateral collaterals or distal fibula
Distal tibiofibular joint
190
Medial tibial stress syndrome
Inflammatory, traction event on tibial aspect of leg: common in runners
Tightness/tenderness, throbbing along tibial crest that comes on with activity and settles with rest
More accurately named: medial tibial traction periostitis or medial tibial periostitis
191
Lateral ankle reconstruction Days 0-7
Ankle in neutral DF in walking boot and WBAT in boot with crutches
Elevate and use cryotherapy often
Wean crutches at days 7-10 to walking boot only WBAT
192
Talipes Equinovarus
Aka “clubfoot”
Incidence: 2 per 1,000; and boys 2:1
Populations: cerebral palsy, cerebral vascular accidents and children (congenital)
Posterior and medial muscles are unduly short. Caps of affected joints become thick and contracted on concave side of deformity.
Soft tissue contracture become progressively resistant to correction as weeks go by before/after birth
2* changes in shape of actively growing bones and involved joints
Frequently associated with internal tibial rotation
193
FO mechanisms
Biomechanical change
Shock attenuation
Neurosensory input
194
PHP (plantar heel pain) risk factors
```
Limited ankle DF
Runners with PHP had either < 5* DF, or side-side difference of 10* or more
If 0* or less DF (high high odds ratio)
Prolonged standing during the day
Associated with poor shock absorption
BMI > 30
```
195
West Point Sprain Grading System
| Grade I
Microscopic tearing
Minimal swelling
No joint instability
Full/partial WB
196
Increases foot stability during MTP extension in push off
Plantar aponeurosis
| Windlass effect
197
Calcaneal adduction
Transverse plane
Vertical axis
Distal segment toward midline of body
198
Peroneal tendonopathy etiology and exam
Occurs in sulcus behind lateral malleoli or at cuboid
Overuse or friction
Often after inversion sprain
Can rupture at retinaculum, leading to peroneal subluxation
199
Hindfoot made up of
Talus
| Calcaneus
200
Anterior shin pain
Medial tibial stress syndrome
Tendonopathies: tibialis anterior, tibialis posterior, peroneals
Exertional compartment syndrome
201
____ sprains are 85% of all ankle sprains.
The ____ is weakest and most commonly injured.
The ____ is strongest and least frequently injured
Weakest: ATFL (ant talo-fib)
Strongest: PTFL (post talo-fib)
202
Transverse tarsal joint activity: early to mid stance phase of gait
During level surface stance, subtalar and transverse tarsal joints each pronate
Enables foot to absorb BW
Subtalar and transverse tarsal pronation absorb shock during early stance
Transverse tarsal then supinates to ensure contact between lateral border of foot and ground
“Counter movement” enables normal WB through forefoot while rearfoot absorbs tibial IR.
203
The ___ is weaker and more commonly injured than the deltoid ligament
Lateral collateral ligament
204
Calcaneal apophysitis
Sever’s disease
Commonly seen in skeletally immature
Direct trauma (repetitive heel strike during WB activities)
Repetitive traction through Achilles’ tendon
Inflammation of apophysis of calcaneus
Apophysis May fragment
