The Ankle and Foot Flashcards
What bones make up the talocrural joint?
- Distal fibula
- Tibia
- Talus
What bones make up the midfoot?
- Navicular
- Cuboid
- 3 cuneiform
What bones make up the forefoot?
- Metatarsals
- Phalanges
What ligaments supports the medial ankle?
- Deltoid ligament
- Plantar calcaneonavicular ligament (spring)
- Plantar aponeurosis
What ligaments support the lateral aspect of the ankle?
- Anterior talofibular
- Calcaneofibular
- Bifurcate ligament
- Posterior talofibular ligament
- Dorsal calcaneocuboid ligament
- Short plantar ligament
- Long plantar ligament
What muscles cross the anterior aspect of the ankle?
- Anterior tibialis
- Extensor hallicus longus
- Extensor digitorum longus
- Peroneus tertius
What muscles are found in the lateral compartment of the ankle?
- Peroneus longus
- Peroneus brevis
What muscles are in the posterior compartment of the leg?
- Gastronemius
- Soleus
- Plantaris
What muscles are found in the deep compartment of the shank?
- Posterior tibialis
- Flexor hallucis longus
- Flexor digitorum longus
What is the action of the posterior tibialis?
- Plantar flexion and inversion
What are the 3 functions for the talocrural/ subtalar/ mid-tarsal joints?
- Shock absorption
- Absorb lower extremity rotary forces
- Provide lever for effect propulsion
What are the 3 components of open chain pronation?
- Calcaneal Eversion
- Talar Abduction
- Talar Dorsiflexion
What are the 3 components of open chain supination
- Calcaneal Inversion
- Talar Adduction
- Talar Plantar flexion
What occurs at the talocrural joint during pronation?
- Mostly dorsiflexion
- Some eversion and abduction
What occurs at the talocrural joint during supination?
- Mostly plantar flexion
- Some inversion and adduction
What are the 3 components of closed chain pronation at the subtalar joint?
- Calcaneal eversion
- Talar adduction and dorsiflexion
What occurs at the medial longitudinal arch during closed chain pronation?
Lowers
What occurs at the tib/fib joint during closed chain pronation?
IR of the tib/fib
What are the 3 components of closed chain supination at the subtalar joint?
- Calcaneal inversion
- Talar abduction and plantar flexion
What occurs at the medial longitudinal arch during closed chain supination?
- Elevates
What occurs at the tib/fib during closed chain supination?
- ER of the tib-fib
What does the function of the mid-tarsal joint depend on in closed chain pronation and supination?
- Subtalar joint mechanics
What is the effect subtalar pronation on the mid tarsal joint?
- Mobility
What is the effect subtalar supination on the mid tarsal joint?
- Stability
What joints are involved int he initial phase of gait?
- Talocrural
- Subtalar
What is the position of the TC and ST joint during the initial phase of gait?
TC: 0 degrees dorsiflexion
ST: Supination
What is the overall position of the ankle in the initial phase of gait?
Plantar flexion
What muscles are active in the initial phase of gait? What types of contractions?
TCJ: Isometric dorsiflexors
ST: Isometric everters
What is the ROM of the TCJ and STJ during the loading response of gait?
TCJ: Flexes from 0 - 15 degrees plantar flexion
STJ: Begins pronation
What is the position of the ankle during loading response?
- Plantar flexion with some valgus movement
What muscles are active during the loading response of gait? What type of contraction?
TCJ: Eccentric dorsiflexors
STJ: Eccentric inverters
What is the ROM of the TCJ and STJ during the midstance phase of gait?
TCJ: 10 degrees dorsiflexion
STJ: Begins supination
What is the overall position of the ankle during the midstance phase of gait?
- Moving to dorsiflexion with a valgus to varus movement
What muscles are active during the midstance phase of gait? What types of contraction?
TCJ: Eccentric plantar-flexors
STJ: Eccentric into concentric inverters
What is the ROM of the TCJ and STJ during terminal stance?
TCJ:15 degrees dorsiflexion
STJ: Supinating
What is the position of the ankle during the terminal stance of gait?
TCJ: Dorsiflexion
STJ: Varus
What muscles are active during the terminal stance of gait? What type of contraction?
TCJ: Eccentric into concentric plantar flexors
STJ: Isometric Everters
Which muscle group eccentrically contracts to prevent pronation?
- Everters
How is alignment of the ankle assessed?
- From the subtalar neutral position
(neither supinated nor pronated) - Assess rearfoot and forefoot
Describe alignment of the tibia, foot, and ankle in the sagittal plane.
- Plumb line slightly anterior to midline through knee and malleolus
- Navicular tubercle should rest in a line from the medial malleolus to the the point of the MTP joint that rests on the floor
Describe alignment of the tibia, foot, and ankle in the frontal plane.
- Distal 3rd of tibia is in sagittal plane
- Great toe not deviated toward midline of foot
- Toes are not hyperextended
Describe uncompensated forefoot varus.
- Hind foot in normal alignment
- Forefoot raised off floor
What supports are being stretched in forefoot varus? What is the effect?
- Plantar fascitis
- Posterior tibialis
- LE is internally rotated
What is the compensation for forefoot varus?
- Pronation
Describe forefoot valgus.
- Lateral forefoot raised off the ground
What is the compensation for forefoot valgus?
Excessive supination.
What is the structural effect of excessive supination, what 3 effects does this have on the function of the joint, and what are the 2 clinical implications?
- Rigid lever
- Less shock absorption
- Lateral forces increased
- Lateral stability decreased
- More at risk for ankle sprains
- More at risk for stress fractures
What are the 8 components of the history and examination of an ankle impairment?
- History
- Inspection
- Palpation
- Clearing tests
- A/P/R ROM
- Joint integrity/ mobility
- Neurological examination
What 4 components should be assessed during the history portion of a patient with an ankle injury?
- Mechanism of injury
- Onset
- What increases/ decreases symptoms
- Self-report measures
What 5 things should be assessed during inspection of the ankle?
- Postural alignment
- Scars
- Wounds
- Calluses
- Swelling
What 3 things should be assessed during palpation of the ankle?
- Tenderness
- Temperature
- Tissue density/ adherence
What joints should be cleared when assessing the ankle?
- Lumbar spine
- Hip
- Knee
What 3 tests should be used when assessing neurological impairment of the ankle?
- Reflexes
- Sensation
- Myotomes
List 8 functional tasks for the ankle from easy to hard .
- Gait
- Double/ Single limb heel raise
- Double limb squat
- Double/ single limb balance
- Step-down tasks
- Star Excursion balance test
- Hop testing
- Agility testing
Describe the 5 compensatory movements that may occur during the lateral step-down test.
- Arm strategy (removal of hand from waist)
- Trunk alignment (leaning in any direction)
- Pelvis plane (loss of horizontal plane)
- Knee position (tibial tuberosity medial to second toe or border of foot)
- Steady stance *step down on untested limb foot wavers side to side
What functional test is especially good for assessing patients with chronic ankle instability?
Star excursion balance test.
Which side is medial and which side is lateral in the start excursion balance test?
Medial is ipsilateral open chain limb
Lateral is contralateral the open chain limb
What are the 8 positions of SEBT?
- Anterior
- Anteromedial/ lateral
- Posterior
- Posteriomedial/lateral
- Medial
- Lateral
Which 3 components are representative of all 8 tests in SEBT?
- Anteromedial
- Medial
- Posteromedial
Which single component is representative of all components of the SEBT?
- Posteromedial
What 7 ROM and muscle lengths should be assessed in a patient with an ankle impairment?
- Hip and Knee ROM
- Calcaneal inversion/ eversion ROM
- Midtarsal ROM
- Hallux dorsiflexion ORM
- Ankle dorsiflexion and plantar flexion ROM with knee flexed and extended
- First ray position and mobility
- 1st through 5th ray mobility
What sense is important to restoring balance of the ankle?
Proprioception
What 3 methods can be used in ankle balance treatment in the clinic?
- Balance machine
- Balance board
- External pertubations
What are 2 exercise progressions for balance at home?
- Balance on one leg with eyes open, progress to door frame with eyes closed
- Stand on one leg on a pillow or couch cushion with eyes open; progress to eyes closed
What are 3 exercises to work the intrinsic muscles of the foot?
- Flex proximal MTP before IPs
- Draw towel under foot or pick up marbles
- Use therabands to resist proximal MTP joint flexion
What are 2 extrinic foot muscle exercises?
- Resisted talocrural plantar flexion with slow eccentric return to talocrural dorsiflexed position
- Close chained exercises (heel rises)
What are 6 treatments for pain of the ankle?
- Exercise in pain free range
- Soft tissue immobilization
- Cryotherapy
- NMES/ TENS
- Exercise neighboring regions
- Pateient ed about discomfort
What types of excessive movements are the most common?
- Pronation
- Supination
What is the basis for the development of exercises for posture and movement?
- Using components of gait
What is the goal of posture and movement exercises?
- Control motions into and out of static positions at various speeds.
What 4 examples of posture and movement exercises?
- Static weight shifting on bathroom scale
- Forward and backward stepping
- Circular weight- shifting drill
- Funcitonal drills (such as: retrowalking, sidestepping, etc.)
How are hypo and hyper mobile segments on the ankle treated?
- Hypermobile segment protected with (taping, bracing, casting, or footwear)
- Hypomobile segments mobilized with manual therapy or mobility exercises
- Dynamic stabilization exercise initiated at the hypermobile segment
How is talocrural joint dorsiflexion restored (3-step process)?
- Joint mobilization
- TJC dorsiflexion ROM with talar joint in neutral or slightly supinated
- Step- down training to facilitate eccentric dorsiflexion
What is the 2 step progression of subtalar joint supination or pronation mobility restoration?
- Full active/ active assisted supination/ pronation performed
- Progress to functional training of mobility in appropriate phase of gait cycle
What are 5 causes of plantar fascitis?
- Excessive pronation
- Obesity
- Malalignment
- Decreased dorsiflexion ROM
- Prolonged time on feet
What are 2 signs or symptoms of plantar fascitis?
- Pain in medial heel
- Pain on 1st steps in am and after rest
What are 4 methods of pain control and tissue extensibility for plantar fascitis?
- NSAIDS
- US
- Iontophoresis
- Deep tissue massage
What 4 pieces of equipment can be used to help correct the alignment of the ankle?
- Taping
- Orthoses
- Night splints
- Modified footwear
If patient has plantar fascitis and is pronated, what is the 5 step progression?
- Mobilize talocrural joint
- Address LE malalignment
- Stretch gastroc, soleus, PF
- Strengthen tib anterior, and extensor digitorum
- Initiate functional and proprioceptive activities.
Are electrophysiological agents and exercise, or manual therapy and exercise preferred for heel pain?
Manual therapy and therex.
What tendon is affected in excessive subtalar joint pronation and results in flat foot deformity?
- Posterior tibial tendon dysfunction
What action will a patient with posterior tibial tendon dysfunction be unable to perform?
Inversion with a heel raise
What What is the 5 step treatment progression for a patient with posterior tibial tendon dysfunction?
- NWB short leg casting may be necessary if there is a tear for 4 - 6 weeks
- Medicaiton/ modalities for inflammation
- Arch strapping to control end-range pronation
- Pain-free, low-intensity, high-repetition open kinetic chain plantar flexion
- Proprioception, strength, coordination
What type of injury is an achilles tendinosis?
- Overuse pathology of Achilles tendon
What are the two types of ahilles tendinosis? Which has a worse prognosis?
- Insertional (worse)
- Non-insertional (at musculotendinous junction)
What are 2 signs and symptoms of achilles tendinosis? Who typically presents with this impairment?
- Runners and jumpers at risk due to training errors
- Tender to palpation 2 - 6 cm above insertion
- Palpable defects
What factors correlate to indications of surgery in achilles tendinosis?
- Age and duration of symptoms
What is the 5 strep treatment progression of achilles tendinosis?
- Address acute symptoms with
- Restore TCJ mobility and biomechanical faults
- Stretching
- Strengthening exercises following inflammation recovery
- Eccentric training
How can the acute symptoms of achilles tendinosis be addressed? (4 methods)
- Low level laser therapy
- Iontophoresis
- Heel lifts
- Night splints
How can the mechanical faults of achilles tendinosis be addressed?
- taping
- orthoses
Describe the specific training protocol for achilles tendinosis.
- 3 X 15 bent/straight leg unilateral eccentric calf raise 2X/ day
What changes can help resolve nerve disorders at the ankle?
- Shoe changes
- Orthotics
- Alignment cahnges
- Mobility
- Movement pattern exercises
What should be assessed when neurological problems arise at the ankle?
- The spine
- The hip
What 2 nerves are typically affected at the ankle?
- Tibial nerve
- Peroneal nerve
What 3 ligaments account for 70 - 80 % of ligament sprains?
- Anterior talofibular ligmament
- Calcaneal fibular ligament
- Posterior talofibular ligament
What are the 3 degrees of grade III sprains at the ankle?
1st: Complete rupture of ATFL
2nd: Complete rupture of ATFL and CFL
3rd: Complete rupture of ATFL, CFL< and PTFL with a dislocation
What is the treatment for a mild grade I or II ankle sprain?
Protect Rest Ice Compress Elevate
What device may be required in severe grade I or II sprains?
- Crutches
What exercise is indicated following grade I - II sprain?
- Open chain kinetic inversion ROM
When do patients typically reinjure a ligamen sprain?
At 3 - 6 weeks when they start feeling better
How long will a patient require external support in a grade 3 sprain?
6 - 8 weeks.
What is a high ankle sprain?
Syndesmotic ankle sprain
What are the 2 signs and symptoms of a high ankle sprain?
- MOI of ER and/or dorsiflexion on a fixed foot
- + ER or squeeze test
Which ligament is disrupted in a high ankle sprain?
- Distal tibiofibular
What are the 2 treatments for high ankle sprains?
- Same as lateral ankle sprains, but 2 - 3 x longer
- Reduce lower leg ER stress
What is turf toe?
Hyperextension sprain of the 1st mtp due to flexible footwear
How long does it take for the patient to return to sport following turf toe?
- Several weeks to months
What is the treatment for turf toe?
- RICE
- Rigid toe insert
- ROM
What are the 4 typical mechanisms of injury of ankle fractures?
- Supination, adduction injury
- Supination, ER injury
- Pronation, abduction injury
- Pronation, ER unjury
What is the typical treatment of ankle fractures post op?
- Edema massage, scar mobilization, edema reduction
- AROM in mid-range, low intensity/ high reps
- ROM exercise as function improves
- Make sure patient is following through with precautions from surgeon
What is the rule for obtaining an imaging series for the ankle?
- Pain in malleolar zone
AND
Bone pain on posterior edge or tip of medial or lateral malleolus
OR
Can’t bear weight immediately and in clinic
What is the rule for obtaining an imaging series for the foot?
Pain in the midfoot zone
AND/OR
Bone pain in bose of 5th MT or navicular
AND/OR
Can’t bear weight immediately and in clinic
What are the 6 anatomic impairments of the foot and ankle?
- Forefoot varus/ valgus
- Hindfoot varus/ valgus
- Hallux valgus
- Pes planus/ cavus
- Hammer toe
- Claw toe
What are the 4 basic adjunctive interventions for the ankle?
- Adhesive strapping
- Wedges and pads
- Biomechanical foot orthotics
- Heel and full sole lifts
