the ankle Flashcards
1
Q
what are the bones that are in the forefoot
A
14 bones of the toes and 5 metatarsals
2
Q
what are the bones in the midfoot
A
navicular, cuboid and 3 cuneiform
3
Q
is the purpose of the midfoot
A
to be very stable and support the capstone of the arch of the foot
4
Q
what are the bones of the rearfoot
A
tibia, fibula, talus, and calcaneous
5
Q
what are the ligaments on the medial side of the foot called and what motion do they resist
A
ankles eversion and rotation of the tibia
6
Q
what are the ligaments on the lateral side of the ankle
A
- ATFL
- CFL
- PTFL
7
Q
what motion does the ATFL resist
A
inversion and planterflexion
8
Q
what motion does the CFL resist
A
resist inversion
9
Q
what motion does the PTFL resist
A
posterior motion of the talus
10
Q
what is the purpose of the retinaculum of the foot and how to distinguish it from the extensor digit
A
purpose is to hold everything in place
contract the extensor digitorum tendon to eliminate contractile pain
11
Q
what are the anterior muscles of the ankle
A
- TA
- ex hall longus
- ex digit longus
- peronenous tertius
12
Q
what are the lateral muscles of the ankle and foot
A
fib long and brev
13
Q
what are the posterior muscles of the ankle and foot
A
- TP
- flex digit long
- flex hall long
- gastroc
- soleus
- plantaris
14
Q
what is the most frequently injured part of the foot in athletes
A
lateral ankle sprain
15
Q
what lateral ankle ligament is the least elastic
A
ATFL
16
Q
what is the sequence of lateral ankle sprains
A
ATFL, Anterolateral capsule, distal tib-fib, CFL, posterior talo fib ligament, and PTFL
17
Q
what is osteochondritis of the talus
A
damage to the anterior lateral or poteriormedial domes of the talus due to a twisting injury
18
Q
characteristics of instability
A
damaged ligaments, axis of rotation is shifted, discribed as a cluck, pathological/abnormal or pts.
19
Q
characteristics of hypomobility
A
more “give” to the ligaments, axis of rotation increased but not shifted, discribed as a “click”
20
Q
what is the MOA of a lateral ankle sprain
A
inversion and PF
21
Q
what is a definition of a grade 1 lateral ankle sprain
A
less then 25% of the tissue is damaged, painful with a firm end feel
22
Q
what is the definition of a grade 2 lateral ankle sprain
A
25-99% of the tissue is damaged
- very painful with soft and spongy end feel
23
Q
what is the definition of a grade 3 lateral ankle sprain
A
100% of the tissue is damaged, not painful and no end feel
24
Q
west point grading system location of tenderness
A
1: ATFL
2: ATFL and CFL
3: ATFL, CFL and PTFL
25
west point grading system edema and ecchymosis
1: slight and local
2: moderate and local
3: significant and diffuse
26
west point grading system wt bearing
1: full or partial
2: difficult without crutches
3: impossible without significant pain
27
west point grading system ligament damage
1: stretched
2: partial tear
3: complete tear
28
west point grading system instability
1: none
2: none or slight
3: definite
29
what is the MOA of the high ankle sprain
DF and inversion with external rotation of the talus - the domes of the talus is wider anterior then posterior forcing apart the mortise
30
what are the ligaments that get damaged in an high ankle sprain
1) interosseous ligament
2) anterior inferior tibiofibular ligament
3) posterior inferior tibiofibular ligament
4) transverse ligament
- sometimes the deltoid ligaments can also be impacted in a servere high ankle sprain
31
what is the MOA of a medial ankle sprain
DF and eversion
32
what is the treatment for acute stage ankle sprain
1 day - 4 days ; RICE, decrease effusion, early protected movement, WBAT, ankle pumps
33
what is the treatment for subacute ankle sprain
(4-14 days) - balance training and open chain resistive training
34
what is the treatment for advanced healing ankle sprain
(2-4 weeks) - enhance proprioception and RTS
35
what are the ottawa rules for the ankle
pain in a the malleolar zone and one of the following:
1) tenderness at the lateral mall
2) tenderness at the medial mall
3) inability to wt bear
36
what is the MOI of chronic ankle instability
repeated acute sprains leading a a decrease in joint proprioception
37
what is the presentation of chronic ankle instability
pain and instability lasting longer then 12 mouths from the initial injury
38
what are the S/S of chronic ankle instability
- recurrent ankle sprains
- frequent episodes of the ankle "giving way"
- persistant s/s of pain, swelling, weakness, and diminished self-reported function
39
what are the quesionaires used to confirm chronic ankle instability
1) ankle instability index (5)
2) cumberland ankle instability (11)
3) identification of functional ankle instability (24)
40
what is the MOI for osteochondritis dissecans
twisting injury to the ankle that causes a fx to the joint surface
41
what is the subjective for osteochondritis dissecans
pain, swelling, and stiffness
42
what is the treatment of osteochondritis dissecans
undisplaced lesions are treated with RICE and immobilization; displaced lesion require arthroscopic removal and drilling
43
what is a type one osteochondritis dissecans of the talus grades
subcondral impaction: bone to bone
44
what is a type 2 osteochondritis dissecans of the talus grades
partly detached
45
what is a type 3 osteochondritis dissecans of the talus grades
non displaced free fragment
46
what is a type 4 osteochondritis dissecans of the talus grades
free fragment that has shifted out of place
47
what is the origin, insertion and action of the TP
o: posterior tibia
i: all the bones of the midfoot
a: PF and inversion ; stabilizes the medial longitudial arch
48
what is the orgin, insertion, and action of the fib brev
o:fibula and the interosseous membrane
i: base of the 5th
a: PF and eversion; provides stability
49
what is the origin, insertion, and action of the fib long
o: fibular and interosseous membrane
i: base of the 1st meta
a: PF and eversion; maintains balance
50
what are the 2 groups of patients that get tibialis posterior tendon issues
younger: patients with inflammatory arthropathy/ traumatic rupture
older: typically female pts with degenerative disorders
51
what is the subjective for posterior tibial tendonitis
- insideous onset of pain at one of the 3 locations
1) distal to the medial malleolus/ area of the navicular
2) proximal to the medial malleolus
3) at the location of the origin (shin splints)
- swelling to the medial ankle
52
what is the objective for TP tendonitis
- swelling and tenderness posterior and inferior to the medial malleolus, along the course of the posterior tib tendon, and to its insertion of the navicular
- medial arch is decreased or completely flattened
- heel shows increased valgus
- pain with resisted ankle PF and inversion
53
what is the treatment for tenosynovitis
RICE, short leg walking cast, orthoses, steroids, and synovectomy
54
what is the management for an incomplete tear of the TP
repair with wither the FDL or FHL
55
what is the management for a complete disruption of the TP
repair in traumatic young cases; tendon transfer with medial calcaneal displacement osteotomy (mobile hindfoot and subtalar triple arthrodesis ( fixed hind foot)
56
what is peroneal tenosynovitis common in
- high arch foot because of the increase in excursion or common inversion ankle injuries
57
what are the symptoms of peroneal tendonitis
pain just behind the lateral malleolus. pain worsens with activity and eases with rest
58
what are the treatment for peroneal tenonitis
- non surgical
rest, short leg walking cast, lateral heel wedge, NSAIDS, and cortisone injection
59
what population group is achilles tendinitis most common in
adults in their 30s and 40s most commonly runners
60
what are the 2 types of achilles tendinitis/ osis
1) noninsertional - occurs proximal to the retrocalcaneal bursa (generally responses well to non-operative tx
2) insertional- tenderness is located at the calcaneal tendon insertion (more difficult to treat)
61
what is the subjective of achilles tendonitis
- gradual onset of pain and swelling in the achilles tendon 2 to 3 cm proximal to the insertion of the tendon
- pain increases with activity
- some will present with pain and stiffness along the achilles tendon when rising in the morning or at the start of activity that improves as the activity progresses
62
what are the objective findings of achilles tendonitis
- tenderness and warmth to palpation along the tnedon
- decrease AROM and PROM DF
- gait deviations: premature toe of, ER
63
what is the treatments for achilles tendonitis
12 week eccentric strengthening and correction of LE asymmetries for insertional do floor level eccentric to decrease pain
64
treatment for type 1 achilles tendonitis
pain is experienced after activity; reduce pain by 25%
65
treatment for type 2 achilles tendonitis
pain that occurs both during and after activity but does not affect performance; reduce activity by 50%
66
treatment for type 3 achilles tendonitis
pain during and after activity that does impact performance; temporarily discontinue running
67
non-insertional achilles how long until symptoms start to improve
3-6 mo
- 70% RTS in 3 mo
68
what is the MOI of a achilles tendon rupture
loading on a DF ankle with knee extended, running backwards or repetitive microtrauma
69
what systemic conditions can contribute to causing achillies tendon rupture
hyperthyroidism, gout or previous steriod injection
70
what is the thompsons test
used to evaluate the integrity of the achillies tendon
positive with the absence of PF
71
non operative achillies tendon rupture tx
older pts with minimally displaced ruptures and involves serial casting over 10-12 weeks
72
operative achillies repair
indicated in younger pts with clinically displaced ruptures, delayed presentation (48-74 hours) followed by casting regime pt typically more satisfied if decide to do the operative treatment and lower risk of re-rupture
73
when can AROM be initiated in post op achillies tendon repair
6 weeks
74
when can pt discontinue functional brace post op achillies tendon repair
12 weeks
75
what is the subjective of planter fascitis
hx of pain and tenderness on the plantar medial aspect of the heel, esprecially when wt bearing in the morning or after a prolonged period of non wt bearing. typically worsens with the start of activity
76
what are the objective findings of planter fascitis
localized pain on palpation along the medial edge of the fascial or at the origin on the anterior edge of the calcaneus
77
px for planter fasciitis
90% who undergo conservative tx improve within 12 mo
78
what foot position is accociated with planter fasciitis
excessive pronation
79
what are the causes of retrocalcaneal bursitis
- repeative trauma from shoe wear and sports
- Gout, RA and ankylosing sondyloarthropathies
- bural impingement between the achillies tendon and an ecessively prominent poserior- superior aspect of the calcaneous
80
what are the subjective findings of retrocalcaneal bursitis
posterior ankle pain and pain with walking
81
what are the signs of retrocalcaneal bursitis
renderness, lump, and inflammation
82
what is the conservative managment for retrocalcaneal bursitis
PT, appropriate shoe wear,a nd injection
goals: reduce swelling and inflammation and achillies tendon stretching
83
what is the surgical intervation for retrocalcaneal bursitis
resection of haglund deformity (removal of the calcaneal superoposterior prominence), excision of the painful burse and debridement o the tendon insertion
84
Hallux valgus definition
lateral deviation of the great toe 1st MTP joint: proximal phalanx deviated laterally ( 9 and 20 degrees)
85
what is the etiology of hallux valgus
- familial
- inappropriate foot wear
- flat feet
- long first ray
- incongrouous 1st MTP joint articular surface
- metatarsus primus varus
- RA
86
what are the signs of hallux valgus
- bunion
- inflammed overlying bursa and skin
- valgus and pronation deformity of hallux
- painful callus and 2nd toe (2nd toe is forcesd into hyperextension and deviated great toe)
- transfer metatarsalgia and thichened skin over the Met heads
87
what is the conservative tx for hallux valgus
- releive pressure over the painful bunion prominence
- properlly fitted shoe with a wide toe box and low heels stiff soles
- spacers
- silicone bunion pad to alleviate direct pressure
88
post op bunionectomy week 0-2
RICE, AROM at hip and knee
89
post op bunionectomy week 2-6
ROM at non infused joints, heel touch WB in boot
90
post op bunionectomy week 6-10
ROM 1st and 2nd MTP joints , can sleep without boot
91
how to distinguish flexible or rigit pes planus
jack test and tiptoeing
92
flexible pes planus
disappreance of the internal longitudinal arch when wt bearing and reappearance when not wt bearing
93
postion the heel moves with doing the heel raise for a flexible planus foot
varus position
94
what is the etiology of a rigid pes plantus
congenital vertical talus and tarsal coalition
95
what is the tarsal coalition
calcaneo-navicular and talocalcaneal; can be bony, cartilagenous or fibrous
96
what is the symptoms fo rigid pes plantus
foot pain, difficulty walking on uneven surfaces, foot fatigue and peroneal spasm
97
what is the treatment for a rigid pes plantus
4-6 week cast immobilization
98
what metatarsals are most commonly injured in a metatarsal stress fx
the second and the 3rd
99
what is the MOI of a metatarsal stress fx
fx that develops after cyclical submaximal loading; running on hard surfaces,
100
what is the subjective for metatarsal stress fx
pain and swelling on wt bearing
hx o sudden increase in activity, change of running surface and prolonged walking
101
what is the objective of metatarsal stress fx
- swelling, ecchymosis and tenderness over the fx met head
- may not show on radiographs for 2-3 weeks
102
what is Morton's neuroma
mechanical entrapment neuropathy of the interdigital nerve; not a true nuropathy but rather a perineurial fibrosis of the common digital nerve as it passes between the met head
103
what are the subjective findings of mortons neuroma
- shooting and constant pain with walking
- relieved with rest and removal of footwear
- third and second cleft tenderness and palpable clikc on metatarsal squeeze test
- more common in women then men
104
what is the non operative treatment for mortons neuroma
metatarsal pad, orthoses injection and excision
- wear supportive shoes with a wide toe box (avoid pointed heels)
105
dorsal approach post op mortons neuroma
allows for immediate wt bearing and suture removal after 2 weeks
106
planter approach post op motons neuroma
delays wt bearing and suture removal at 4 weeks. transition to normal shoe by 3-4 weeks and RTS in 4-6 weeks
107
what is tarsal tunnel
entrapment neuropathy of the tibial nerve as it passes between the flexor retinaculum and the medial malleolus
108
subjective of tarsal tunnel
- acute or insidious
- poorly localized burning sensation or pain and paresthesia at the medial planter surface of the foot
- worse after activity and worse at the end of the day
109
objective of tarsal tunnel
- positive tinel sign
- pain with passive DF or eversion
- decreased 2 point discrimination on the planter aspect of the foot
- varus or valgus deformity of the heel
- weakness of the foot intrinsics with sustain PF of the toes
110
what is the tx for tarsal tunnel
steriod injections, othoses, strengthening of the foot intrinsics to restore the medial longitudinal arch
111
what is turf toe
- a sprain of the first MTP joint of the great toe
112
what is the MOI of turf toe
hyperextension and varus/valgus stress of the first MTP joint
113
what are the subjective findings of turf toe
- complaints of red, swollen, stiff first MTP joint
- joint may be tender on plantar and dorsal surface
- may have a limp and may be unable to run or jump
- hx of a single DF injury or multiple injuries to the great toe
114
what are the objective findings (grades) of turf toe
1: minor stretch injury to the soft tissue restraints with little pain, swelling, or disability
2: partial tear of the capsuloligaments structures with moderate pain, swelling, ecchymosis and disability
3: complete tear of the plantar plate with severe swelling, pain, ecchymosis and inability to wt bear normally
115
turf toe time line
grade 1: RTS as soon as symptoms allow
grade 2: 3-14 days of rest
grade 3: 6 weeks rest from sports
RTS: when toe can be DF to 90
116
what is cuboid syndrome
- disruption of the structural congruity of the calcaneo-cuboid joint complex
- cuboid is the keystone of the lateral column of the foot (concave cuboid rest of the convex navicular and lateral cuneiform)
- force of the fib longus with sudden inversion of the midfoot causes the cuboid to sublux medial and inferior
117
what is the subjective of the cuboid syndrome
midfoot pain or tightness with prolonged activity
118
what are the objective signs of cuboid syndrome
- persistant and localized pain over the cuboid following an inversion sprain
- pain with toe push off with walking
- inability to preform plyos
- pain radiating along the medial arch and length of the 4th met
- palpable prominence on the planter lateral aspect of the foot
- limited and painful DF, IN and EV localized to the CC joint
- painful dorsal glides of the cuboid
119
treatment for cuboid syndrome
- cuboid whip HVLAT (grade 5 mob in the dorsal and lateral direction)
- cuboid squeeze
- mob with movement
- intrinsic foot strengthening
