Random MSK Questions Flashcards
How many axes make up the Midtarsal joint
2
Longitudinal axis and Oblique axis
however It has been argued that the Midtarsal joint moves around multiple axes
The Midtarsal joint is made up of what Joints
Talonavicular and Calcaneocuboid joints
What are the alternative names given to the Midtarsal joint
Transverse Tarsal Joint and Choparts joint
During Pronation the axes of the Midtarsal joint are locked?
TRUE OR FALSE
False
During Pronation the axes of the Midtarsal Joint (Talonavicular and Calcaneocuboid) are parallel, this unlocks the joint and makes it hypermobile for shock absorption
The axes of the Midtarsal joints are locked during Supination?
TRUE OR FALSE
True
During Supination the axes are not parallel and the joint becomes locked for force transmission into the ground during push off and propulsion.
How many degrees of Dorsiflexion is needed at the ankle to facilitate normal walking?
At least 10 degrees of Dorsiflexion is needed during the stance phase of Gait contributing to forward body movement and normal walking
What is the normal ROM of the Ankle
45 to 65 degrees
The Pre Tibial (Extensor) muscles are concentrically contracting during Pre Swing phase of the gait cycle?
TRUE OR FALSE
False
They eccentrically contract to control the rate of plantar flexion preventing the foot from slapping onto the ground
What is the normal ratio of movement, inversion relative to eversion of the subtalar joint?
2:1
The subtalar joint allows for twice as much inversion relative to eversion
What is the normal ROM of the 1st Ray
10mm dorsiflexion and 10mm plantarflexion
Overall excursion = 20mm
Which bones make up your 1st ray
Medial cuneiform and 1st Metatarsal
A Lisfranc injury can result in midfoot subluxation?
TRUE OR FALSE
True
The Lisfranc ligament maintains the stability of your Medial cuneiform to your 2nd Metatarsal base.
What kind of joint is the 1st MTPJ
The 1st MTPJ is a Ginglymoarthroidal joint. It allows a gliding and hinge motion
What is Hallux Rigidus
The progressive structural restriction of Sagittal plane ROM at the 1st MTPJ
Hallux dorsiflexion sub 10 degrees in open chain
Which bone is considered the Keystone of the Lisfranc joint complex?
The 2nd Metatarsal is considered the Keystone of the Lisfranc joint complex.
The 2nd Metatarsal bone is recessed within a mortise created between the 3 surrounding cuneiform bones.
There are connecting ligaments between the bases of all the Metatarsals?
TRUE OR FALSE
False the are connective ligament between the bases of the Lateral four Metatarsals but there is no connecting ligament between the 1st and 2nd Met’s.
Define HAV deformity
Medial deviation of the 1st Metatarsal and Lateral deviation of hallux
What is the most common cause of HAV deformity
1st Ray instability
Describe the open chain function of the Windlass mechanism 5
Hallux Dorsiflexes
Plantar aponeurosis becomes tensioned
First ray plantar flexes
Medial Longitudinal arch raises
Foot shortens
What is the maximal point of tenderness in Plantar Fasciopathy
Medial calcaneal tuberosity
What is the visual scale used to grade HAV
Manchester scale
What is the purpose of the Lisfranc joint
Maintains the stability of the medial cuneiform to your 2nd metatarsal
During walking why would a delayed windlass mechanism be attributed to rearfoot pronation
One of the functions of the Windlass is to Assist in resupination of subtalar joint (STJ) during propulsive phase of walking.
Therefore if the windlass is delayed there is nothing to support the midfoot and resupinate the foot as the heel comes off the ground
What is the only Intrinsic Muscle on the Dorsal aspect of the foot
Extensor Digitorum Brevis
Detail the Characteristics of Extensor Digitorum Brevis
Extensor Digitorum Brevis
Origin - Superolateral surface of the Calcaneus
Insertion - Extensor Digitorum Longus Tendons of Digit 2-5
Innervation - Deep Fibular Nerve
Action - Toe Extension at Distal IP Joints digit 2-5
What is a forefoot Supinatus
Flexible Forefoot Varus (Forefoot is inverted relative to the rearfoot in subtalar Neutral)
What is Adult Aquired Flat Foot
PPV
Complex pathology defined as collapse of the medial longitudinal arch with progressive valgus deformity of the foot and ankle.
Described as Pes PlanoValgus
What is Posterior Tibial Tendon Dysfunction
Progressive Tedinopathy of the PPosterior Tibial Tendon and the leading cause of Adult Acquired Flat Foot. It can cause plantar foot pain and Medial Longitudinal arch dysfunction.
The foot becomes more pronated
Describe the function of the Posterior Tibial Tendon during the various stages of the stance phase
Initial Contact = fires eccentrically to stabalise the hindfoot from valgus and decelrates midfoot pronation
Midstance = Initiates inversion of the Subtalar Joint increasing foot rigidity for toe off through concentric contraction
Adducts and plantarflexes the navicular onthe talar headpreventing medial arch collapse
Inserts into the plantar ligaments increaseing tension and pulling the cuboid medially
What is the main role of the Posterior Tibials 4
Plantar flexion of the ankle
Inversion of the foot
Elevate Medial longitudinal arch
Reduce the speed of pronation and assit with supination
What are the management options for PPTD
Offloading of the tendon via multiple methods
Rehabilitation of the tendon and correction of any
noted resultant foot deformity
Increased arch
Rearfoot Varus posting
What diagnostic procedures could be used for PTTD
Too many toes sign
Single leg heel raise
First metatarsal rise sign
Plantar flexion and inversion of the foot against resistance
Mobility of TN and CC joints
Weightbearing X-Rays
List some of the possible differential diagnosis for PTTD 8
Tarsal coalition
Inflammatory arthritis
Charcot arthropathy
Neuromuscular disease
Traumatic disruption of midfoot ligaments
Achilles Tendinopathy
Spring Ligament Injury
Limb Length Discrepancy (One foot more pronated)
Describe the scoring system of the Foot Posture index
Pronated postures are given a positive value, the higher the value the more pronated.
Supinated features are given a negative value, the more negative the value the more supinated.
Describe the mechanism of the Stretch Shorten Cycle
- Eccentirc Loading Causes Lengthening of the Muscle
- Brief Isometric Period Stores Enegry
- Rapid Concetric Contraction Returns Stored Enegry
Provide efficient enregy return used at all stages of gait but mainly HEEL LIFT
Describe the mode of action of the reverse windlass mechanism
Leg Internally Rotates
Calcaneum Everts
Medial Longitudinal Arch Lowers
1st Metatarsal / Metatarsals Dorsiflex
Foot Elongates
Describe the cause of Acquired Pes Planus
Caused by Reduced MLA stability or Increased load
Dysfunction of the Post Tib is the main factor reducing arch stability
Post Tib stabalises the foot plantar flexing and inverting the foot elevating the MLA and locking the Midtarsal joint
What is the difference between flexible flat foot and rigid flat foot
Flexible flat foot (flexible FF): The longitudinal arches of the foot are present on heel elevation (tiptoe standing) and non-bearing but disappear with full weight bearing on the foot.
Rigid flat foot: The longitudinal arches of the foot are absent in both heel elevation (tiptoe standing) and weight bearing
What treatment options are available for Pes Planus
Stretching exercises = Lengthening of the Achilles and calf, as a tight Achilles tendon will further pronate the foot. Hamstrings and adductors, as contracture can result in increased internal limb rotation.
Strengthen intrinsic foot muscles
Orthoses: These usually contain a varus posting or skive to correct calcaneal valgus deformity, and an
arch support.
What pathologies are associated with Pes Planus
- Tibialis Posterior Tendon Dysfunction (PTTD) (because hyper-pronation elongates this tendon).
- Hallux Valgus.
- Metatarsalgia.
- Plantar Fasciopathy.
- Knee pain: Medial Knee Osteoarthritis and Patello-Femoral Pain
Which bones make up the medial longitudinal arch of the foot
medial 3 metatarsals
seasmoids
three cuneiforms
Navicular
talus
Calcaneus
Which bones make up the lateral longitudinal arch of the foot
4th 5th metatarsals
Cuboid
Calcaneus
Which bones make up the transverse arch of the foot
Bases of all 5 metatarsals
cuboid
Intermeditate and lateral cuneiforms
In closed chain kinetics what kinetic movements take place in the over pronated foot (feet in contact with ground)
Calcaneal eversion
Adduction and plantarflexion of talus
Medial rotation of talus
Medial rotation of tibia and fibula
Valgus at knee
Medial rotation of femur
Anterior tilting of pelvis
In closed chain kinetics what kinetic movements take place in an over supinated foot
Calcaneal inversion
Abduction and dorsiflexion of talus
Lateral rotation of talus
Lateral rotation of tibia and fibula
Varus at knee
Lateral rotation of femur
Posterior tilting of pelvis
Describe the structural and musclar imbalances which generate pes cavus
Pes Cavus is an abnormal increase in the MLA of the foor (does not correct upon weight bearing)
Structurally = Forefoot Plantarflexion (equinus)
Muscle imbalance = Peroneous Longus and Post Tib overpower Tib Ant and Peroneous Brevis which Plantarflexes the First Ray and pronates forefoot
Subtalar Joint supinates to bring Lateral Forefoot to the ground causing Hindfoot Varus
Exstensor Hallucis Longus dorsiflexes the foot shortening the plantar fascia and causing Cavus Deformity
What callus patterns are common with Pes Cavus
The foot tries to maintain three point conatct
1st Met head
5th Met Head
Lateral border Styloid proccess
Describe what Reverse Mortons extension is and what pathologies it could be used for
Pad which extends from Distal lateral midfoot and ends just distal of the toes 2-5.
Function:
Plantarflexes 1st Met head relative to lesser toes
Increase 1st MTP ROM
Clinical Use:
Functional Hallux Limitus
Planatr flexed 1st Ray
Seasmoiditis
Describe what a Mortons extension is and what Pathologies it could be used for
Extension Pad that runs from Medial distal portion of the insole and ends distal to the toes (Hallux)
Function:
Imobolizes 1st MTPJ decreaseing dorsiflexion force at 1st MTPJ and IPJ
Clinical Use:
Hallux rigidus or 1st MTPJ osteoarthiritus
HAV (RIGID)
What is Rearfoot Medial/Varus Post and what pathologies should it be used for
Firm Material placed medially to the rearfoot to icrease supinatory forces
Inverts the heel at Heel strike
Clinical Use:
Overpronatied Subtalar Joint
Pes Planus/ Pronated foot type
Tib Post pathologies
Sinus Tarsi Syndrome (compression of the tunnel between Calcanues and the Talus Lateral)
What is a Rearfoot Valgus Post and what pathologies can it be used for
Firm posting place tot the lateral rearfoot which Increase Orothotic Reaction Forces Lateral to STJ causing Pronation
Clinical use:
Oversupination of Subtalar joint
Flexible Pes Cavus
Medial Knee OA
Peroneal Tendon Pathologies
What is forefoot Lateral posting and what pathologies can it be used for
Firm material applied to Lateral forefoot of orthotic to increase pronatory force under the forefoot. Placed under 5th met head tapering toward the 1st.
Clinical Use:
Provide ORF Laterla to the MTJ/STJ
Rigid Forefoot Valgus
Plantar Fasciopathy
Peroneal Tendinopathies
What is forefoot Varus/Medial posting and what pathologies can it be used for
Firm material placed medially to forefoot Orthotic device to increase
supinatory ORF under the forefoot.
Placed under the 1st Met and tapers toward the 5th
Clinical use:
Rigid forefoot varus to stabilize 1st ray.
Restrict 1st MTPJ ROM
PTTD
Rigid Flatfoot deformity
What is a Heel Spur/Horse Shoe Pad and what pathologies can it be used for
A curved pad that supports the borders of the heel with a central recess
Clinical Use:
Calcaneal Burstitis
Plantar Heel Spur
Fat Pad Syndrome
What clinical signs of Osteoarthirits to be noted on an x- ray
Joint space narrowing
Subchondral Sclerosis
Subchondral Cycts
Osteophytes
Joint malposition
Describe what Plantar Fasciopathy is
Collagen degenration of the plantar fascia from the origin (Calcaneal tuberosity of the heel)
It is charecterised by medail heel pain that worsens upon weight bearing
Detail the foot posture index
Talar Head palpation
Malleolur curvature
Calcaneal inversion/eversion
Talo-Navicular Congruence
Medial arch height
Forefoot ab/adduction
What tests can be conducted for the Talocrural joint
Talar Tilt Test injury
* Patient seated edge of the couch
* Proximally stabalise the leg left hand (grasp around back of ankle achillies area) Grasp the calcaneum with one hand around the heel and invert the ankle. Laxity would indicate posotive test (excessive inversion)
* FOOT PLANTARFLEXED AND INVERTED (Tests for ATFL)
* FOOT NEUTRAL AND INVERTED (Test for CFL)
* FOOT DORSIFLEXED AND INVERTED (Test PTFL)
Anterior Draw Test
* Patient supine
* Grasp calcaneum with one hand and tibia with other hand – Ankle Plantarflexed 15 degrees.
* Pull firmly anterior on the calcaneum whilst maintaining tibia position.
* Test for ATFL Laxity
External Rotation Test (Kiegler Test)
* Grasp calcaneum and talus in one hand. Ankle maximally dorsiflexed.
* Hold tibia stable with other hand.
* Externally rotate foot relative to leg.
* +ve if reproduction of symptoms in anterior lateral aspect of ankle
What effects on Gait would could limited Ankle ROM have
Early heel Lift (Bouncy Gait)
Externally rotated foot
Internally rotate and use the 5th met head to progress
Knee hyperextension
Hypersupinate / or pronate
What is the normal range of motion of the Hallux Dorsiflexion and Platarflexion
Dorsiflexion = 70 - 90 degrees
Plantarflexion = 45 degrees
What is the significance of the 1st ray when talking about hallux dorsiflexion
1st ray (Medial Cuneiform 1st Metatarsal) must plantar flex to allow the Hallux to dorsiflex increasing the MLA height and inverting the rearfoot due to tension on the PA
What are the risk factors for Planatr Fasciopathy
Age - Age related decrease in elasticity
Body weight - Increased bodyweight
Lifestyle - More active more risk of PF injurys
Biomechanical dysfunction
Genetics
What are the stages of the Manchester scale
Stage 1 = Unstable 1st Ray
Stage 2 = Lateral shifting of the Hallux
Stage 3 = Subluxation, apropulsive gait and widening of the forefoot
Stage 4 = Complete Dislocation of the 1st MTPJ
From a radiongraphic perspective Hallux Valgus is present when the Hallux abducto Valgus angle is greater than what 5, 10, 12, 15 Degrees
Greater than 15 degrees would suggest Hallux Valgus (Lateral devation of the Hallux and Medial Deviation of the 1st Metatarsal
What are the risk factors associated with tendon injury 6
Age
Sex
Medication
Smoking
Nutrition
Genetics
What are the Basic Gait deviations
Appropulsive
Propulsive
Antalgic
Ataxic
Trendelenburg gait
Detail the Tendon adaption cycle
Collagen degradation occurs after excercise = 0-24hr
Net collagen synthesis begins to repair tendon = 24-72 hr
Collagen synthesis remains upto sevreal days post excercise
Why is uncompensated rearfoot varus often associated with ankle pain
· Uncompensated rearfoot varus will strike the floor more laterally.
· Increase in inversion ground reaction force applied to rearfoot.
· Increased tissue stress applied to lateral ankle complex.
· Increased tissue stress results in physiological tissue lengthening from Elastic to Plastic Deformation.
Describe the observational effects on gait seen in individuals with limited ankle plantarflexion
· Increased loading response period.
· Increased period of initial contact.
· Poor stability of the midfoot at midstance.
· Increased 3rd Rocker use at toe-off.
· Early heel contact of the contralateral limb.
What is the propsoed purpose of the windlass mechanism?
· 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
Define Mallet Toe
MTP joint Neutral
PIP Joint Neutral
Which of these is a diagnostic test for PTTD
Lunge Test
Squat Test
Resisted eversion of the ankle
Resisted inversion of the ankle
Laterl Hops
Resisted Inversion of the ankle
Maximal tenderness in Plantar Calcaneal Enthesopathy can be palpated where:
Medial Calcaneal Tuberosity
Which of the following antibiotic groups has shown a relationship with tendinopathies?
Quinoline
Macrolide
Penecillin
Sulphonamides
Tetracyclines
Quinoline
Which of the following is true of a patient who is “excessively supinating”?
Subtalar joint is supinated on heel strike
Subtalar joint is pronating at inital swing
Midtarsal joint is locked at Forefoot loading
Midtarsal joint is locked at Midstance
Midtarsal joint is unlocked at Heel Lift
Midtarsal Joint is Locked at forefoot loading
Plantar fasciopathy is more common in which demographic?
Women
Obese
Military recruits
Define rearfoot Valgus
Rearfoot that is everted relative to the floor in subtalar joint neutral
When in the Gait Cycle is the Stretch-Shorten Cycle most engaged
Heel lift
Contracture of triceps surae can cause what patholgogy
a) Exstensor Substitution
b) Flexor Substitution
c) Flexor Stabilization
d) Exstensor Stabilization
Extensor substitution
Tricep surae are used to flex the calf therefore if they are contracted they limit the ability of the ankle to dorsi flex so the extensor muscles over compensate
Which structural foot deformity is associated with the best shock attenuation?
Forefoot Varus
Uncompenstaed rearfoot valgus
compensated rearfoot varus
Partially compensated forefoot varus
uncompensated forefoot varus
compensated rearfoot varus
Explain the Digital Lachman Test and explain what pathology it can be used as a diagnostic test for:
Its a draw test
Stabalise the Metatarsal head with one hand and grasp the proximal phalanx of the associated digit with the other. Dorsally translocated the proximal phalanx
Looking for instability, pain or subluxation of the mtpj
Used to diagnose Plantar plate injury
Which of the following are common differential diagnoses of Plantar Fasciopathy based on the anatomical location of symptoms?
Baxters Neuritis
Kagers Fat pad pannicuilits
Sural nerve entrapment
Heuters Neuroma
Quadratus Plantae Hypertrophy
Quadratus Plantae Hypertrophy
Baxters Neuritis
What is a Rearfoot Varus Deformity defined as in subtalar joint neutral?
A rearfoot that is inverted relative to the floor.
What are the stages of the coughlin scale for Hallux limitus/rigidus
Grade 0: No pain
Grade 1: Dorsiflexion 30-40°, dorsal osteophytes
Grade 2:Dorsiflexion 10-30°, joint narrowing or sclerosis, osteophytes
Grade 3: Dorsiflexion less than 10°, constant moderate to severe pain at extremities
Grade 4: Stiff joint, severe changes with loose bodies and osteochondritis dissecans
What are the common mechanical factors predisposing to neuroma of the 3rd/4th Intermetatarsal space?
Conjoined Nerve
Neural Ischaemia
Area of Forefoot Hypermobiltiy
What is the primary variation in symptoms of insertional versus midportion Achilles Tendinopathy?
· Midportion Achilles Tendinopathy will demonstrate pain at end-range dorsiflexion.
· Insertional Achilles Tendinopathy will not demonstrate pain at end-range dorsiflexion.
Which pathology os associated with Haglunds deformity
Haglunds deformity is a boney prominence formed at the posterior of the Calcaneas and is associated with Superficial Calcaneal Burstitus
What are the clinical features of Superficail Calcaneal Burstitus and what are differential diagnpsis
- Inflamed tender Central lateral heel
- Hypertrophy of tissue
Differential diagnosis:
* Insertional Achillies Tendinopathy
What is Insertional Achillies Tedinopathy
Where is pain felt
What type of Pain
Management 3
Inflamation and pain at the insertion point of the Achillies Tendon at the Calcaneus
Diffuse pain posterior calcaneus
Management
RICE
Cortico steriod injections
Heel raise
Describe Hallux Limitus
What is aim of treatment
management options
Non Osseus reduced ROM of 1st MTPJ in Sagital Plane
Treatment aims to improve range of motion aid Windlass
Orthotics = 1st ray cut out, Cluffy Wedge
Exercise = Peroneous longus strengthening, Tib Post strengthening
Footwear = Flexible forefoot, forefoot rocker
Give a brief overview os Sagital Plane Theory
Sagittal Plane Theory
For motion to occur smoothly and efficiently within the Sagittal Plane, movement passes through 3 pivotal points :
Plantar Calcaneus - Rocker bottom side of plantar calcaneus
Ankle - 10 degree dorsiflexion of the Tibia on the Talus prior to heel off
Metatarsophalangeal Joint - 65 degree dorsiflexion considered the minimum to be needed at the MTPJ
Restriction in the movement specific to propulsion during gait in any one of these sites will affect the other joints and require compensation.
Give an overview of Root theory of Foot function
Based on a series of Static measurements to predict kinematic foot function
In order for the foot to be normal, The Subtalar Joint (STJ) should be in a neutral position and the Midtarsal joint should be fully locked.
Any deviation from this alignment is considered to be abnormal and should therefore display some form of mechanical dysfunction
Detail what Plantar Fasciopathy is
Cause
Diagnosis
- Collagen degridation of the Plantar Fascia
- Overuse injury
Diagnosis: - Pain upon palpation medial calc tuberacle
- Pain with passive dorsiflexion of foot and toes i.e posotive windlass
What is uncompensated rearfoot varus
No STJ motion available, and the heel is inverted to the floor with no compensatory motion
What is partially compensated rearfoot varus
The STJ can evert but the calcaneus remains somewhat inverted when the STJ is fully pronated.
What is a fully compensated Fully compensated rearfoot varus
In STJ neutral Rearfoot position is in Varus (inverted)
In RCSP moves to a Valgus (everted) position.
What is the clinical significance of Forefoot Varus
- Highly pronated foot throughout the whole gait cycle
- Because the medial side of the foot is elevated at initial contact the subtalar joint has to pronate to bring it down
- Planus foot type , can be rigid or flexible
- Tibialis Posterior can be overload as it has to work harder to resist excessive pronation and stabalize the foot
What is the clinical significance of Forefoot Valgus
Medium to high arch with lowering on Weightbearing
Lateral compartment overload,
Tailor’sBunion, HAV and Hallux Limitus.
What is the clinical significance of Rearfoot Varus
Abnormal excessive duration of pronation of the STJ on heel strike , continuing until the calcaneus is perpendicular to ground (causing mid foot collapse).
internal leg rotation during loading
STJ still pronated during propulsion, Tib post overload
What is the clinical significance of Rearfoot Valgus
Lateral ankle impingement, External rotation at heel strike, low shock attenuation , Haglunds deformity.
Why does inadequate shock absorption occur in patients with partial or uncompensated rear foot varus?
In rearfoot varus, the heel strikes the ground in an inverted position, and without adequate compensatory pronation.
There is no Subtalar Joint pronation to compensate for inverted rearfoot.
Midtarsal joint will be maximally pronated and locked.
The shock of heel strike is not absorbed as efficiently because the ground reaction force is not optimally aligned with the anatomical structures designed to handle it.
Why does Haglund’s Deformity occur in patients with rear foot varus
Inversion of the rearfoot often leads to abnormal pressure and friction at the attachment of the Achilles tendon Posterior Calcaneus which is where Haglunds Deformity occurs
