NMS 3: Foot/Ankle Flashcards by Gabriel Zeigler

Hindfoot

-Talus & Calcaneus

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Midfoot

-Navicular & Cuboid

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Forefoot

Metatarsals, 3 cuneiforms & phalanges

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Arches in the Foot

-Medial Longitudinal Arch
-Lateral Longitudinal Arch
-Anterior Transverse Arch

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Pes Planus

Flat Foot
-Loss of medial longitudinal arch
-Dropped arch
-Eversion of calcaneus
-Prominent Talus
-Inner shoe breakdown
-Uneven heel wear
Foot flares->Knee rotates->Pelvis Tilts->Shoulder drops

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Pes Cavus

Exaggerated Arch
-High instep

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Medial Longitudinal Arch

-Navicular is crucial in maintaining the arch
-Tibialis ant and post
-Peroneus longus
-Abductor hallucis longus
-Various Ligaments: Spring Ligament

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What muscles contibute to calcaneal inversion during gait

Gastrocnemius and soleus

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Hallux Valgus

Bunion
-1st MTP becomes valgus (great toe rotates/shifts laterally)
-Pain over the 1st MTP
-Treatment: Restore normal motion/adjust, add spacer, use of orthotics/supportive shoe, “toe crunches”
-If all else fails->Surgery

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Haglund’s Deformity

“Pump Bump”
-Abnormal prominence of the posterolateral surface of the calcaneus
-Other conditions: Gout, RA, calcific tendonitis…

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Hammer Toes

-Flexion contracture of the PIP, usually the 2nd toe
-Often BL and symmetrical

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Claw Toes

Hyperextension at the MTP and flexion of both PIP and DIP joints
-May be secondary to a cavus foot

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Mallet Toe

Flexion defomity of toe

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Morton’s Foot/Toe

-Congenitally short 1st MTP

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Ankle Sprain

-Most common foot/ankle injury
-Can also have hip, knee or LBP
-85-95% are inversion ankle sprains (5% are eversion)
-Other related conditions: Avascular necrosis, osteochondral fragment, 5th metatarsal shaft or styloid process fracture…

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Key examination findings: Ankle Sprain

-Associated edema
-Postural/gait alterations
-ROM alterations
-Orthopedic tests may be positive
-Possible fracture
-Resisted motions may be painful or weak

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Ankle Sprain Tests

-Anterior Drawer
-Inversoin Stress
-Eversion Stress: Deltoid Ligament
-Squeeze Test

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Inversion Sprains

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Grade I Ankle Sprain

-No laxity/instability
-Recovery 2-10 days

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Grade II Ankle Sprain

Mild to moderate laxity/stability
-Recovery 10-20 days

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Grade III Ankle Sprain

-Significant instability
-Recovery 30-90 days
-Diffuse swelling, more hemorrhage
-Unable to bear weight fully, initially almost complete loss of ROM

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Ankle Sprain-Treatment

-RICE
-Weight bearing (avoid with moderate/severe sprains)
-Adjustments as per clinical findings
-ROM
-Taping
-Exercise: Strengthen dorsiflexors
-Stretch: Calf Muscles

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Plantar Fasciitis

-Overload injury of the plantar fascia
-Insidious onset of pain at the medial heel
-Pain in the morning
-“Stepping on broken glass”
-Other potential ddx: Tarsal tunnel syndrome, sacral radiculopathy
-May reveal heel spur

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Contributing factors of: Plantar facitisi

-Middle-aged/older
-Diabetes
-Overweight
-Limited dorsiflexion
-Overuse

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Treatment: Plantar faciitis

-Taping -Gradual stretching -Myofascial release: Graston, tennis ball, frozen golf ball, taping -Tennis ball -Ultrasound -Adjustments -Orthotics for pronation

Tarsal Tunnel Syndrome

-Pain & burning, numbness, pressure or parasthesia of: Medial plantar nerve, calcaneal branches… -Prolonged standing, walking or running may be aggravating -May refer to the popliteal region -Other DDx: Anterior Tarsal Tunnel syndrome, saphenous nerve syndrome, posterior tibialis tendinitis

TTS: Causes

-Overweight -Poor shoes -Overuse -Pregnancy -Systemic disease -Excessive subtalar pronation

TTS: Treatment

-Joint playt -PRICE -Stretching

Anterior Tarsal Tunnel Syndrome

Numbness and tingling across the top of the foot

Saphenous Nerve Syndrome

Pain, numbness, loss of feeling in the medial knee; Can be burning

Morton’s Neuroma

-Perineurofibrosis of the interdigital nerve -3-4th metatarsal (Most common)/4th-5th metatarsal (Least common) -Sharp, burning pain at the base of the toes -Hyperthesia in the web* -DDx: Stress fracture, tarsal tunnel syndrome…

Cuboid syndrome

Subluxation of the cuboid bone plantarward

Achilles Tendon Overuse Injuries

-Chronic or acute pain the back of the heel -Chronic: Intermittent pain/usually during or after activities -Acute: Sudden pain in the hell after a “push-off” movement

Achilles: Key findings

Inability to perform hell raise maneuver -Rupture: Positive Thompson’s Test -Repetitive microtrauma -

Turf Toe

Hyperextension injury of the first toe -Plantar capsule is sprained -Treatment: Stabilization

Shin Splints

-Anterior: tibialis anterior, EHL, EDL -Posterior: tibialis posterior… -Treatment: Joint manipulation, release tight tissues via myofascial release, decrease activity, footwear, nutrition, sensorimotor training, orthotics

Metatarsalgia

-Pain on bottom of foot -Dropped metatarsal heads -Ortho/Neuro: Morton’s test, Strunsky’s Sign, and Metatarsal Tap -Treatment: Footwear, metatarsal pad, adjust foot

High Ankle Spain

-Ankle Syndesmosis Injury

Lower Extremity Compartment Syndrome

-Acute: Severe blow to lower leg; Swelling in fascia compartment, neurological dysfunction, stiff muscles, muscle necrosis if left untreated -Chronic: Overuse, lasts weeks to months, runners, pain in anterior/lateral components -Treatment: Stop activity, PRICE, light massage to drain

Lisfranc Ligamental injury

-Midfoot swelling and tenderness -Plantar ecchymosis -Gait -Bruising on the bottom of the foot

Tendon Rupture and Antibiotics

-Fluoroquinolone: Levaquin -Triples risk among users

Patient presents with focal heel and plantar pain. Upon viewing xrays, heel spur wear discovered. What is your DDX? a. Plantarfascitis b. Ankle sprain c. Metatarsalgia

a. Plantarfascitis

Which sprains are the most common? a. Plantarflexion b. Inversion c. Dorsiflexion d. Eversion

b. Inversion

Which of the following is the most common missed diagnosis with individuals with an inversion injury? a. Compression fracture of calcaneus. b. Osteochondral fractures of talar dome. c. Osteochondral fracture of lateral navicular d. Osteochondral fractures of medial navicular.

b. Osteochondral fractures of talar dome.

Sesmoiditis of the big toe is caused by the direct trauma or overpull from which muscle? a. Adductor hallucis b. Flexor hallucis longus c. Flexor hallucis brevis d. Abductor Hallucis

c. Flexor hallucis brevis

Which of the following is associated with pes planus? a. Bunions question b. Pain over 1st MTP c. High instep d. Calcaneus in valgus

d. Calcaneus in valgus

Which of the following are true regarding plantar fasciitis? a. May show up on radiographs b. Heel spurs are the cause of plantar fascitis c. Pain onset is at lateral heel d. Tenderness at the navicular tubercle

a. May show up on radiographs

Another name for Metatarsus Primus Atavicus is? a. Hammer toes question b. Claw toes c. Mallet toes d. Mortons Foot

d. Mortons Foot

Which disease has a morning symptom likened to stepping on broken glass? a. Pes Cavus b. Achilles Tendon Rupture c. Plantar Fascitis

c. Plantar Fascitis

If you had a collapsed medial longitudinal arch what tarsal bone would you most likely have a problem with? a. Cuboid b. Navicular c. Talus d. Pisiform

b. Navicular

All of the following conditions can be initially present as bursitis in Haglunds Deformity area EXECPT? a. RA b. Osteomyelitis c. Gout d. Microtrauma

d. Microtrauma

What is the analog of Carpal Tunnel Syndrome in the foot? a. Tarsal Tunnel Syndrome b. Os trigonum syndrome c. Crural Tunnel syndrome

a. Tarsal Tunnel Syndrome

Inspecting a patients foot you notice a slight indentation over the dorsal, lateral midfoot. Patient has plantarward cuboid subluxation causing pain when patient is active. What is your DX? a. Navicular syndrome b. Congenital loss of cuboid c. Broken Heart d. Cuboid Syndrome

d. Cuboid Syndrome

Which of these ligaments would most likely NOT be affected in an ankle eversion sprain? a. Anterior tibiotalar b. Tibiocalcaneal c. Tibionavicular d. All would be affected e. Posterior tibiotalar

d. All would be affected

Patient complains that her feet are ugly. Upon inspection, the doctor notices flexion of the PIP and DIP in the 2nd and 3rd toes with corn formations on the PIPs of both toes. What is you DX? a. Gout b. Claw Toe c. Mallet Toe d. Hammer Toe

d. Hammer Toe

Tarsal Tunnel Syndrome affects the 3rd toe via which nerve? a. Medial plantar nerve b. Lateral plantar nerve c. Calcaneal branch of tibial nerve d. Anterior femoral

a. Medial plantar nerve

Plantar fasciitis has these classic findings EXCEPT? a. Caused by either pronation or supination question b. Associated with pes planus c. Pain worse when getting out of bed in the morning d. Pain and tenderness found in the middle of the heel

d. Pain and tenderness found in the middle of the heel

All of the following are DDXs for Mortons Neuroma EXCEPT? a. Metatarsalgia question b. Stress fx c. Sesmoiditis d. Spondyloarthropathies

d. Spondyloarthropathies

Grade II ankle sprains generally have a recovery time of? a. 20 or more days question b. 5 to 10 days c. 2 to 5 days d. 10 to 20 days

d. 10 to 20 days

Which of the following is not associated with Mortons Neuroma? a. Visible swelling of the neuroma question b. Sharp, burning pain at the bases of the toes occasionally worse at night c. Ingrown toenail d. Perineurofibrosis of an interdigital nerve

c. Ingrown toenail

Hallux Valgus is common in which population? a. Middle-aged women b. Elderly men c. Middle-aged men d. Young children

a. Middle-aged women

A patient presents with an absent medial longitudinal arch what structures is NOT associated with maintaining this arch? a. Tibialis anterior & posterior b. Proper hindfoot, midfoot, and forefoot positioning c. Spring ligament d. Flexor digitorum longus

d. Flexor digitorum longus

Mortons Neuroma is most common between which metatarsal heads? A. 4-5th metatarsal heads question b. 2-3rd metatarsal heads c. 1-2nd metatarsal heads d. 3-4th metatarsal heads

d. 3-4th metatarsal heads

Patient is diagnosed with a high ankle sprain what joint is injured? a. Pulling of the Plantar Fascia question b. Fracturing of the keystone of the foot, the Navicular c. Gubernaculum d. Ripping of the Interossessous membrane between the fibula and tibia

d. Ripping of the Interossessous membrane between the fibula and tibia

Which of the following is NOT associated with acute Achilles tendon pain? a. Immediate weakness and swelling question b. Sudden pain in heel after a push off c. Intermittent pain in posterior heel post-activities d. Audible pop with movement

c. Intermittent pain in posterior heel post-activities

Haglunds Deformity is common among what specific group of people? a. Contact sport athletes b. High heel wearers c. Long distance runners d. Mechanics

b. High heel wearers

What ligament is typically injured on Eversion sprains? a. Posterior Talofibular Ligament question b. Patellar ligament c. Deltoid Ligament d. Coracoclavicular ligament

c. Deltoid Ligament

An entrapment neuropathy with progressive degeneration and deposition of amorphous deposits on nerve fibers and occurs commonly on the plantar surface by the intermetatarsal ligament is known as? a. Talar ostephytes b. Metatarsalgia c. Plantar fascitiitis

b. Metatarsalgia

Patient presents with a limp while walking and is unable to run. Anterior drawer test was positive, and the talar tilt was negative. What Grade is the patients sprain? a. Grade I b. Grade IV c. Grade III d. Grade II

d. Grade II

What condition would have anterior leg pain involving the lower and middle 3rd of the tibia with the tibialis anterior, extensor hallicus longus and digitorum longus sore to the touch? a. Tibial fracture b. Shin splits c. Humeral fracture d. Tarsalgia

b. Shin splits

Patient presents with pain on bottom aspect of foot and has a positive Mortons Test and Strunskys Sign. Upon observation, you noticed calluses at the metatarsal heads. What is your DDX? a. Plantarfascitis b. Phutenaz disease c. Metatarsalgia d. Ruptured achillies tendon

c. Metatarsalgia

All of the following are true regarding hammer toes EXCEPT? a. Often is occurs bilaterally question b. Can occur due to wearing small shoes c. The DIP may be in flexion, extension or hyperflexion. d. Usually involves the 2nd toe

c. The DIP may be in flexion, extension or hyperflexion.

In grade III ankle sprain, what test(s) are positive for instability? a. Talar Tilt b. Both A & B c. Anterior Drawer

b. Both A & B

Sinus Tarsi is located where compared to which malleolus? a. posterior; lateral b. anterior; lateral c. posterior; medial d. anterior; medial

b. anterior; lateral

Hallux rigidus is the condition? a. Analogous to Hallux valgus b. Commonly associated with a bunion

b. Commonly associated with a bunion

If I sprained my ankle and had a positive Inversion stress test, what ligament would have I most likely injured? a. Calcaneofibular Ligament b. Deltoid Ligament c. Anterior Cruciate Ligament d. Tib/Fib syndesmosis

a. Calcaneofibular Ligament

Which of the following are is a common history associated with Metatarsalgia? a. Non-weight bearing activities question b. Pain on dorsum of foot c. Related to hammer toes d. Underweight individuals

c. Related to hammer toes

Patient complains of ankle and calf pain saying, it felt like someone had kicked him.Patient has lost the ability to plantarflex and the patient has a noticeable lump at the mid-calf area. What is your ddx? a. Just received graston from a burly man b. Achilles tendon rupture c. Malleolar fracture

b. Achilles tendon rupture

The 1st MTP of Hallux Valgus rotates and shifts ______ forming a bunion by causing shear forces in the _______ when wearing shoes? a. Laterally, PIP b. Medially, subcutaneous tissue c. Laterally, subcutaneous tissue d. Dorsally, toe nail

c. Laterally, subcutaneous tissue

Which of the following orthopedic tests does NOT test for metatarsalgia? a. Metatarsal Tap question b. Strunky Sign c. Thompson Test d. Morton Test

c. Thompson Test

Jogger presents in your office complaining pain in posterior leg near the calcaneus. You notice unilateral swelling on the lower 3rd of the Achilles tendon and it feels warm and inflamed. The jogger said he ran 5 times a week. What is your ddx? a. Tarsal Tunnel syndrome b. Decapatation c. Achilles Tendonitis d. Calcaneal fracture

c. Achilles Tendonitis

What nerves are involved in Tarsal Tunnel Syndrome? a. All the nerves listed b. Medial Plantar Nerve c. Lateral Plantar Nerve d. Calcaneal nerve branches

a. All the nerves listed

Patient present with inability to bear weight and has diffuse swelling around the ankle. The anterior drawer test is positive and the talar tilt is positive. What is the patients sprain? a. Grade I b. GradeII c. Grade IV d. Grade III

d. Grade III

Paralysis of this muscle can cause foot drop in a patient? a. Extensor hallucis longus question b. Tibialis anterior c. Peroneus Longus d. Peroneus tertius

b. Tibialis anterior

Which of the following examination findings would be expected with a Mortons neuroma? a. Localized tenderness between metatarsal bases b. Positive Morton Sign c. Most often, hyperesthesia in web between affected metatarsals d. No visible swelling

b. Positive Morton Sign

Gout is associated with what type of disorder? a. Inflammatory b. Metabolic c. Psoriatic d. Degenerative

b. Metabolic

Which best describes the injury that occurs with turf toe? a. Hyperflexion injury of 1st toe b. Hyperextension injury of 1st toe c. Fracture of 1st toe d. Subluxation of tarso-metametarsal joint

b. Hyperextension injury of 1st toe

Which of following is NOT true about inversion ankle sprains? a. Most common type of ankle sprain question b. Tight Achilles tendon is a contributing factor to an inversion sprain c. The deltoid ligament is the most common ligament injured d. Weak peroneal muscles contribute to laxity of the joint

c. The deltoid ligament is the most common ligament injured

Doctor performs Thompson test, a positive sign would indicate? A. Achilles tendon rupture b. High ankle sprain c. Posterior tibial nerve rupture d. Calf or leg pain indicating thromboplebitis

A. Achilles tendon rupture

A patient presents with knock knees and muscle fatigue of the posterior tibial muscles. Upon stationary inspection you notice the patient has pronated heels, tibial torsion, flat feet and too many toes when viewed from behind. What is your primary Select one: a. Pes Planus b. Pes Cavus c. Lederhose Disease d. Tibial Tendonitis

a. Pes Planus

What would be a poor confirmation test following a positive Thompson test? A. Hoffa B. Diagnostic imaging C. Homan D. Achilles tap

C. Homan

What motion should the doctor move the foot into during the eversion stress test?

Eversion

What side of the ankle should be up while performing Tinel foot sign

Medial

What would be a positive Thompson test?

no movement of the foot

‘The inversion stress tests which two ligaments?

Calcaneofibular Anterior talofibular

Morton’s test is performed with patient?

Seated or supine with toes up on table

Where should the doctor tap to test Tinel foot sign?

Posterior tibial nerve

What is another name for the eversion stress test?

Keliger

Choose the test that deals with the deltoid ligament? A. Keliger B. Yerguson C. Kilroy D. C5 MSR

A. Keliger

The Dr raises the patients leg this many degrees during Homan sign? A. 35 B. 45 C. 15 D. 30

B. 45

What region of the foot is evaluated with Morton Test? A. Metatarsal bases B. Mid foot C. Phalanges D. Metatarsal heads

D. Metatarsal heads

What does Tinel foot sign test for? A. Metatarsalgia B. Fracture C. Tarsal tunnel syndrome D. Achilles tendon rupture

C. Tarsal tunnel syndrome

What is a common cause of metatarsalgia that gives a positive Morton test? A. Leg length inequality B. Birth defect C. Ill-fitting or tight shoes D. Athletic injury

C. Ill-fitting or tight shoes

After finding a positive Thompson test, what is the next logical step? A. Adjust the talus B. Determine the exact location of injury. C. Adjust the calcaneus D. Call 911

B. Determine the exact location of injury.

What do you use to tap the metatarsal heads? A. Fist B. Bat C. Relfex hammer D. Finger

C. Relfex hammer

Pain upon tapping the metatarsals in indicative of what? A. Hammer toe B. Morton neuroma c. Sprained ankle D. Metatarsalgia

D. Metatarsalgia

In Morton test, what is being evaluated? A. Metatarsalgia only B. Metatarsalgia and neuroma C. Neuroma only D. Metatarsalgia and potential fracture

B. Metatarsalgia and neuroma

Which test assesses the fracture of the calcaneous? A. Homan B. Keen C. Helping D. Hoffa

D. Hoffa

If Morton test is positive what confirmation procedures can be done? A strunsky test B. Anterior drawer test C. Squeeze test D. Keens sign

A strunsky test

The anterior drawer test evaluates the: A. Collateral ligaments of the ankle B deltoid ligament C. Anterior talofibular ligament D. Posterior talofibular ligament

C. Anterior talofibular ligament

This test tests for metarsalgia? A. Metatarsal tap B. Anterior Drawer C. Keliger D. Tinel

A. Metatarsal tap

What does Thompson test focus on?

Achilles tendon rupture

When performing the squeeze test, the patient should be? A. Supine only B. Seated only C. Seated or supine D. Standing only

C. Seated or supine

While performing Tinel foot sign, the dr. Should strike between the medial malleolus and…? A. Retinacular ligament B. Navicular tubercle C. Cuboid D. First metatarsal head

A. Retinacular ligament