Quiz #10 Flashcards
what is the role of the ankle joint?
rigid lever and mobile adaptor
when the ankle is becoming a mobile adaptor, do the axes of the talonavicular jt become more parallel or cross?
the axes become more parallel
when the ankle is becoming a rigid lever, do the axes of the talonavicular jt become more parallel or cross?
the axes cross
what are the triplanar motions that make up pronation?
DF
eversion
abduction
what are the triplanar motions that make up supination?
PF
inversion
adduction
the pronation/supination contribution from the MTJ is ___ that of STJ
2x
what happens at the STJ in the CKC?
the talus moves on fixed WB calcaneous
WB IR/ER causes pro/sup
allows accomodation on uneven ground
does pronation or supination accompany tibial IR?
pronation
does pronation or supination accompany tibial ER?
supination
t/f: in the normal foot on the ground, calcaneal condyle on the ground and heads of the metatarsals on the ground are lying in the same plane, the rear foot is slightly inverted
true
what actions occur at the longitudinal axis of the MTJ?
inversion/eversion
what actions occur at the oblique axis of the MTJ?
DF/PF
abd/add
motion around the oblique axis of the MTJ is enhanced by putting the foot in what position?
abduction
t/f: pts may outtoeing w/ambulation to allow more pronation from unlocking the midtarsal jt’s oblique axis
true
what kind of jt is the tarsometatarsal jt?
plantar synovial jt
what are the jt surfaces of the tarsometatarsal jts?
bw the tarsal and respective metatarsal jts
what makes up the 1st ray of the foot?
1st cuneiform and 1st metatarsal
what is the most mobile ray of the foot?
the 1st ray
what makes up the 2nd ray of the foot?
2nd cuneiform and 2nd metatarsal
what is the most restricted ray of the foot?
the 2nd ray
what makes up the 3rd ray of the foot?
3rd cuneiform and 3rd metatarsal
what makes up the 4th and 5 rays of the foot?
cuboid and 4th and 5th metatarsals
how much 1st MTP ext is needed for normal gait? for running?
65 deg, 85 deg
t/f: when there is a reduction in ROM of the 1st MTP, it acts like decreased DF
true
what are some compensations for decreased 1st MTP/DF?
steppage gait
circumduction gait
out-toeing
what is hallux limitus?
not as much motion as it should have
what is hallux rigidus?
very stiff
what is the Windlass mechanism?
when the big toe is on the ground as you DF and it tightens up
what is the most injured lig in the body?
ant TF
what provides stability of the talocrural jt medially?
interosseous membrane
med collateral lig-deltoid lig
what provides stability of the talocrural jt laterally?
interosseous membrane
ant TF lig
calcaneofibular lig
post TF lig
lateral ankle sprains make up what % of ankle sprains?
85
how does a lat ankle sprain usually occur?
PF and inversion
the ATF lig is involved in what % of all ankle sprains?
60-70%
what % of ankle sprains involve the ATF and CF ligs?
20%
are more lig tears at the lat ankle mid-substance or avulsion injuries?
mid-substance
are mid-substance or avulsion injuries easier to treat? why?
avulsion injuries are easier to treat bc it’s easier to heal bone on bone than bone to lig
what causes a tib fib syndesmosis sprain (high ankle sprain)?
forced DF
what causes an ant capsule ankle sprain?
forced PF
what is a grade 1 lateral ankle sprain?
min edema, localized tenderness over ATF (12 days b4 return)
what is a grade 2 lateral ankle sprain?
localized edema, diffuse tenderness (2-6 weeks b4 return)
may use crutches for a few days
may have ecchymosis
what is a grade 3 lateral ankle sprain?
edema, ecchymosis (more than 6 wks b4 return)
only 25-60% symptoms free 1-4 yrs post injury
what are the s/s of lat ankle sprain?
edema and hematoma suggests rupture
TTP over ATF
(+) ant drawer
(+) talar tilt test
(+) squeeze test
(+) ER test
what is a (+) ant drawer test?
holding the tibia back and calcaneous forward creates p!
what is the talar tilt test?
mildly invert the foot (can also PF)
what is the squeeze test-?
squeeze the tibia and fibula together (high ankle sprain test)
mechanical instabilities and fxnal instabilities at the ankle can lead to what?
recurrent ankle sprains
when the rear foot is inverted is the there more or less pronation?
less pronation
is the foot a good or bad mobile adaptor inless pronation?
bad mobile adaptor
does a supination or pronated foot lead to lat ankle sprain?
supinated foot
what exercises can improve proprioceptive kinesthesia of the ankle?
ankle pumps with therabands (although not the best) and CKC strengthening for fxnal exercise
what are the interventions for for lat ankle sprains?
control edema
early, supported WB (taping, bracing)
proprioceptive training
OKC to CKC using non-dominent to dominant planes
multiplane fxnal training
plyometrics
sport-specific training
work towards offending plane of motion
why are med ankle sprains less likely than lat ankle sprains?
bc the med ankle has more robust support
t/f: there is a greater risk of an avulsion fx of the med mal with a med ankle fx
true
t/f: the approaches to treat lat vs med ankle sprains are different
false, they are similar
t/f: plantar fascitis is sometimes self limiting
true
what % of women with plantar fascitis are obese?
90%
what % of men with plantar fascitis are obese?
40%
what age does plantar fascitis usually occur at?
40-60 yo
what occupational factor leads to plantar fascitis?
prolonged standing/walking
what causes acute plantar fascitis?
something hits the arch of the foot hard
what factors affect anatomical plantar fascitis?
thickness and compressibility of heel pad
what are the biomechanical causes of plantar fascitis?
pes cavus, pes planus, overpronation, weak foot intrinsics, hallux rigidus/limitus
t/f: weak glut med/max can contribute to plantar fascitis
true
t/f: bad DF of the hallux can contribute to stress on the plantar fascia
true
t/f: plantar fascitis usually has an insidious onset
true
what are the s/s of plantar fascitis?
morning pain
15-30% BL
gastrocs tightness in 78% (trying to DF during gait but the gastrocs won’t let it)
TTp med calcaneal tubercle
p1 w/great toe ext
(+) Windlass test (p! with great toe ext)
presence of heel spurs
hallux abductor valgus (HAV): bunion from excessive pronation
what are the interventions for plantar fasciitis from most to least helpful?
low dye taping to support the arch
foot intrinsic PREs
stretching (gastrocs/plantar fascia)
TFM (transverse friction massage)
orthotics
high splints
great toe mobility
NSAIDS
US/phonophoresis
laser
extracorporeal shock wave therapy (adds mechanical influence)
injections
surgery
how many newtons of force can the Achilles tendon handle?
9000N
what is the strongest tendon in the body?
the Achilles tendon
what are the actions of Achilles tendon?
PF and inversion
what tendon controls DF, eversion, and pronation?
Achilles tendon
does the paratenon of the achilles tendon have a synovial sheath?
no, this affects it stealing process
where is the blood supply for the Achilles tendon?
paratenon and muscles vessels
what is nerve supply of the achilles tendon?
sural nerve
what is the most common overuse syndrome of the LE?
Achilles tendinopathy
what is the prevalence of Achilles tendinopathy?
57% in runners (2.9-4% of non-athletes)
what is the incidence of Achilles tendinopathy?
7/100,000 in general population
t/f: there is increased incidence of Achilles tendinopathy with increased age
true
what is the mean age in which Achilles tendinopathy occurs?
30-50 yo
what is usually the MOI in Achilles tendinopathy?
eccentric loading and overpronation
what actions can cause rupture of the Achilles tendon?
push off, sudden DF in WB, forceful DF
what is the difference bw insertional and noninsertional
insertional is closer to the enthesis
noninsertional is more in the midsubstance
is insertional or non insertional injuries easier to treat?
non insertional (mid-substance)
is midsubstance or calcaneal insertional injuries of the Achilles tendon more common?
mid-substance
are mid-substance injuries of the Achilles tendon more so the med or lat aspect of the midsubstance?
med aspect of the midsubstance
what are the morphological and biomechanical changes with aging that can lead to Achilles tendinopathy?
decreased collagen diameter/density
decreased GAGs and H2O
decreased tensile strength, linear stiffness, and ultimate load
t/f: Achilles tendinopathy is a degenerative process
true
t/f: there is a decreased collagen synthesis capacity with Achilles tendinopathy
true
what process may be responsible for the chronic pain associated with Achilles tendinopathy?
abnormal neovascularization accompanied by in-grwoth of nerve fasciles
Achilles tendinopathy may be associated with what deformity and disease?
Haglund’s deformity and Sever’s disease
what is the typical presentation for a pt with Achilles tendinopathy?
TTP Achilles 2-6 cm proximal to the insertion
tendon thickening
decreased PF strength
decreased PF endurance
p! and stiffness after inactivity that lessens with activity and returns post activity
p! with eccentric DF
Haglund’s deformity
(+) Thompson test
what is Haglund’s deformity?
a bump on the back of the heel from the stress of the achilles
bone spur
what is the Thompson test?
squeeze the calf to see if it elicits PF (no PF=positive test for Achilles rupture)
what imaging may be used to dx Achilles tendinopathy?
x-rays
what may be seen on imaging for Achilles tendinopathy?
Haglund’s deformity
os trigonum
calcaneal fx
retro calcaneal bursitis
post talar fx
what is os trigonum?
accessory bone sites on the back of the ankle near the heel
what is the treatment for midsubstance tendinopathy?
conservative care
correct biomechanical contributions
RICE in acute phase
TFM, stretching, eccentrics training in subacute phase
shoe w/o heel (zero drop shoes) may be used
addition of low energy extra-corporeal shockwave therapy
laser therapy (moderate evidence)
topical glyceryl trinitrate to reduce p! in acute/chronic cases (more evidence needed)
heel lifts early on and gradually reduced
manual therapy (TFM/STM)
taping
into (moderate evidence for low voltage driving in meds)
orthotics
high splints
US
t/f: eccentric training may decrease paratenon blood flow and preserve O2 saturation (cuts off excess blood flow to help with pain)
true
what are eccentrics for Achilles tendinopathy?
slow heel lowering (5-6”) that should cause p! but no more than 5/10
what are the interventions for insertional tendinopathy?
attempt eccentrics
extracorporeal shock wave therapy
no therapy is as effective with insertional tendinopathy as it is for midsubstance
about what % of Achilles ruptures are operated on?
70
are short term costs higher for operative or non-operative groups in Achilles tendinopathy?
operative group
are long term costs higher for operative or non-operative groups in Achilles tendinopathy?
similar in both
is long term satisfaction better in operative or non-operative groups in Achilles tendinopathy?
similar in both
are Achilles re-tear rates higher in operative or non-operative groups?
non-operative group
what are the risk factors for tibialis posterior tendinopathy?
female
> 40 years old
pes planus
HTN
diabetes
steroid injections
obesity
what are the symptoms of tibialis posterior tendinopathy?
navicular, prox to med mal, med shin
p! w/single leg heel raises
aches after long walk
p! w/PF and inversion
TTP
swelling post med ankle
what are the causes for tib post tendinopathy?
overpronation, change in direction, tight gastroc-soleus complex, weak tib ant
what do we treat in post tib tendinopathy?
inflammation, biomechanical contributions, and impairments
what is tarsal tunnel syndrome?
peripheral neuropathy of the tibial nerve bw the flexor retinaculum and med mal
involved the tibial nerve including the terminal branches, med/lat plantar nerves
there are increased symptoms of tarsal tunnel syndrome with what action?
prolonged walking
t/f: there can be toe numbness with tarsal tunnel syndrome
true
what is the test for tarsal tunnel syndrome?
tinel test
does overpronation or supination contribute to tarsal tunnel syndrome?
overpronation
what is the intervention for tarsal tunnel syndrome?
orthotic w/rearfoot control
proper footwear
PREs for inverters
injection
surgical release
are more males of females affected by morton’s neuroma?
females
what is morton’s neuroma?
compression of the interdigital nerve (usually bw metatarsals 3 and 4)
perineural fibrosis, demylenation, and endoneurial fibrosis leading to tenderness and decreased motion
what are the s/s of morton’s neuroma?
tender bw metatarsal heads on plantar foot
p! w/compression of the forefoot
(+) tinel test
(+) EMG/NCV
what are the interventions for morton’s neuroma?
wider shoes
orthotics w/metatarsal pad to help spread the metatarsals and reduce stress in the intermetatarsal space
NSAIDS
interspace injection
surgery (last resort)
what is hallux abductus valgus?
bunion results from valgus stresses of the 1st MTP and overpronation
1st metatarsal migrates med
1st prox phalynx migrates lat
toes crossed
usually biomechanical cause
what are the interventions for hallux abductus valgus?
conservative care (not often seen)
post–op (p! control, modalities for p!, ROM, manual therapy
what causes gaut
hyperuricemia
what is hyperuricemia?
elevated serum uric acid
causes deposition of urate crystals in jts, soft tissue, and kidneys
most common crystal-induced arthritis in the US
what is primary uricemia?
inherited
what is secondary uricemia?
acquired due to other metabolic problems
what is idiopathic uricemia?
other causes not classified under primary or secondary
t/f: gout is classified as arthritis
true
what is the most common inflammatory condition in middle aged men into the 5th decade?
gout
is gout more common in men or women?
men
when does gout typically become present?
after 20-30 years of hyperuricemia
is there an increased risk of gout with a family hx?
yes
t/f: fever and malaise may be present in gout
true
gout will have a similar clinical presentation to what other disease?
infectious arthritis
what are the associated factors of gout?
age
duration of hyperuricemia (longer time=increased risk)
genetics
heavy alcohol abuse
obesity
thiazide drugs
lead toxicity
shellfish (purine rich foods)
what is the presentation of a pt with gout?
acute, monoarticular arthritis
exquisite jt p! (comes on fast)
occurs suddenly at night
big toe involvement is common
erythema
warmth
hypersensitivity
presence of tophi (uric acid crystals that develop on the skin)
what are the interventions for gout?
meds (allopurinol)
NSAIDS
experimental uricase therapy
rest
reduced WB initially
education
monitored exercise program
what is Sever’s disease?
also called calcaneal apophysitis
irritation on the apophysitis of the calcaneous
overuse syndrome
what age group is commonly affected by Sever’s disease?
the skeletally immature (5-13 yo)
often young boys
what can cause Sever’s disease?
growth spurts
tight gastroc-soleus complex
repetitive jumping/landing (gymnasts/dancers)
Achilles pulls on growth plate of post heel
what % of Sever’s disease cases are BL?
60
what are the s/s of Sever’s disease?
CC: heel p! increased w/running or jumping
p! in post heel
how is Sever’s disease dxed?
radiographs (sclerosis or fragmentation of the apophysis is possible)
what is the treatment for Sever’s disease?
activity modification (dec duration, intensity, and frequency of activity)
calf/heel cord stretch if tight
heel cups/soft orthotics (softens blow of the heel)
NSAIDS
ice
short leg cast if symptoms aren’t getting better (recalcitrant symptoms)
how long does it typically take for Sever’s disease to resolve?
2-3 months, but can be longer or recurrent
t/f: Sever’s disease is often self-limiting
true
what may you have to teach a pt with Sever’s disease?
proper running techniques
what are some types of fxs at the ankle?
single malleolar
bimalleolar
trimalleolar
Pott’s fx
what is a trimalleolar fx?
lat and med mal and back of the tibia fxed
how are ankle fxs managed?
ROM, strengthening, and fxn based on impairment
what is a Jones fx?
avulsion of the base of the 5th metatarsal
sometimes overuse injury
how is a Jones fx managed?
surgical
conservative (boot)
PT (impairment based, control WB forces)
what is a Lisfranc fx?
midfoot injury
hyperDF of midfoot
fxs or torn ligs
single to multiple jts of midfoot affected
possible instability of the arch
how are Lisfranc fxs managed?
surgical (ORIF)
fusion (too much lig damage so jts have to be fused)
PT (impairment based)
what % of ppl will have LBP?
80
what is the single most common disability under 45 yo?
LBP
are females or males more affected by neck pain?
females
t/f: there is an increased incidence of neck pain in the populations over 50 yo
true
does LBP or neck pain experience smaller fxnal improvements?
neck pain
what are the characteristics of the cervical vertebrae
more transverse facet orientation
bifid spinous process
up/down glide
what is the up/down glide of the cervical spine with L rotation?
L downglide
R upglide
what are the characteristics of the thoracic vertebrae?
more frontal facet orientation
facets and demifacets with the ribs
what are the characteristics of the lumbar vertebrae?
more sagittal facet orientation
bigger vertebral bodies
what is the frontal jt of the spine?
synovial jt w/CLC and possibly menisci that directs and determines the quantity of motion in each plane
absorbs WB forces
has triple innervation
what is the triple innervation of the frontal jt of the spine?
ant. middle, and post pillar
what closes the cervical facets?
ext, rot, and SB toward
what opens the cervical facets?
flex, rot, and SB away
what closes the lumbar facets?
ext and SB toward, and rot away
what opens the lumbar facets?
flex and SB away, and rot toward
are sprains/strains in the spine opening or closing dysfxn?
can be either
if a pt has ext dysfxn, does the segment move worse in flex or ext?
ext
if a pt has an ext bias, do they prefer flex or ext?
ext
t/f: if one spinal segment tightens, adjacent segments may become hypermobile to compensate
true
what may lead to suspicions of a spinal sprain/strain?
h/o trauma
physical exam reveals transient neuro s/s, ROM deficits (potentially in capsular pattern), tissue texture, tension, tone changes
what would be the capsular pattern in spinal sprain/strain?
limits in SB w/rot equally limited ext throughout spine
what are the interventions for spinal sprain/strains?
address the cause
NSAIDS/relaxants
protection to gradual mobilization
jt and soft tissue mobilization
what is the prognosis for spinal sprains/strains?
90% resolved in 8 wks w/o impairments
what is the nucleus pulposus of the IV disc?
center of disc composed of hydrophilic proteoglycans
what is the inner non-fibrous annulus of the IV disc?
transition zone bw nucleus and annulus
what is the annulus fibrosis of the IV disc?
type 1 and 2 CT arranged in concentric rings (that don’t connect all the way around) from oblique to more vertical fiber direction
what is the cartilaginous end plate of the IV disc?
semi-permimeable structure allowing the influx and efflux of fluid
what is the neurovascular capsule of the IV disc?
perimeter of the disc only
t/f: only the outer ring of the IV discs are innervated?
true
t/f: a pt may not notice IV disc damage until the outer portion becomes involved
true
what are the fxns of the IV disc?
allows motion through deformation in all directions
limits motion (primarily rotation)
maintains diameter of the IVF (prevents nerve pinching)
transmits shock to vertebral bodies
what are the diurnal changes of the IV disc?
normal cycle of disc hydration which depends on segmental motion
how does the IV disc receive nutrition/get rid of wastes?
motion and redistribution of forces allows fluid to be pushed in and out
what age is most commonly affected by HNP (slipped disc)?
25-50 yo
do most ppl with a HNP have p!?
yes
what are the most common locations for HNP?
C5-6, L4-5, L5-S1
what is the most common site for HNP?
L5-S1
what are the stages of HNP?
prediscal
immediate
settled
chronic
what is the prediscal stage of HNP?
dull ache
what is the immediate stage of HNP?
sharp, local, no neuro s/s
what is the settled stage of HNP?
lat shift, neuro s/s, peripheralization w/repeated movement
t/f: as we age the IV discs lose hydration
true
what is peripheralization?
p! travels away from the source
what is centralization?
p! travels toward the source
do we want to see peripheralization or centralization?
centralization
what is lateral shifting?
the body is shifted away from the painful side (defined by the direction of the shoulder not the hip)
does the center or periphery of the IV disc breakdown first? why?
the center bc it has more collagen
t/f: some bulging of the disc is normal with compression
true
in flexion, the __ disc is pinched, fluid is pushed ___, and the nucleus is pushed __
ant, post, post
in extension, the __ disc is pinched, fluid is pushed ___, and the nucleus is pushed ___
post, ant, ant
is the following a bulging disc, herniated disc, or extruded disc?
outward pressure, disc is still contained
bulging disc
is the following a bulging disc, herniated disc, or extruded disc?
fluid is starting to flow out
herniated disc
is the following a bulging disc, herniated disc, or extruded disc?
more severe, could mean a portion of the disc has torn off and is irritating the nerve
extruded disc
what are physical exam findings with HNP?
neuro s/s, sx referral patterns, poor tolerance for flexion (or ext bias)
how is a HNP dxed?
MRI, CT, myelograms
what is a myelogram?
dye injected in subdural area of the spine and flows around w/CSF, take a radiograph to see if the dye flows where it’s supposed to (won’t fill space beyond herniation)
why are MRI findings for HNP not always very helpful?
many healthy individuals will have (+) MRI findings, so treat imairments not the test results
what are the interventions for HNP?
conservative care (PT)
NSAIDS, epidural injections
surgical intervention (microdiscectomy, laminectomy, fusion, replacement)
what is the prognosis for HNP?
80% better w/conservative care (PT)
reoccurance rate of 6%
favorable if the disc is reducible
what does a T1 weighted image show?
best to appreciate normal anatomy
fat cartilage, and muscles are white
fluid is dark
what does a T2 weighted image show?
best to appreciate pathology
fluid, acute hemorrhage, physiologic iron appear white
fluid is light
