The Foot and Ankle Flashcards
What land mark serves as the point of reference when referring to medial/lateral and abduction/adduction relative to the foot?
2nd ray
What three motions make up the triplanar motion of PRONATION around the longitudinal axis of the foot?
- Dorsiflexion
- Abduction
- Eversion
What three motions make up the triplanar motion of SUPINATION around the longitudinal axis of the foot?
- Plantarflexion
- Adduction
- Inversion
What landmark serves as the end of the dorsal surface of the leg and the beginning of the dorsal surface of the foot?
Subtalar Joint
What are 3 serious diagnoses that can affect the foot and ankle?
- Traumatic/Stress Fractures
- Bone tumors
- Post op: sepsis, DVT
What are the Ottowa Ankle Rules when there is pain in the malleolar zone?
- Tenderness at Posterior edge or tip of lateral mallelolus (6cm)
- Inability to WB both immediately and in emergency department
What are the Ottowa Ankle Rules when there is pain in the mifoot zone?
- Bone tenderness at base of fifth metatarsal
- Bone tenderness at navicular
- Inability to WB both immediately and in emergency department
What 3 criteria warrant referring a patient for a X-ray after a lateral ankle sprain?
- Reports pain in the area of the lateral malleolus
- Unable to weight bear immediately after the injury and in the ‘emergency room’ (in this case, your clinic)
- Tenderness at the posterior edge or tip of lateral malleolus
What 8 things should be examined at the ankle/foot in addition to ROM/Strength, Sensation etc.?
- Presence of skin breakdown
- Presence of corns/calluses
- Presence of excessive dryness/moisture
- Effusion/Edema
- Color changes in foot/toenails
- Shoe wear
- Assess for pes planus (flat feet) vs pes cavus (high arch)
- Gait Analysis
What is hammer toe? What can this cause?
- A flexion contracture of the PIP or DIP joint of the toe due to a capsular restriction
- Causes pain on pressure areas caused by the altered alignment
What is claw toe? What can cause this?
- An extension contracture of the MTP joint accompanied by a flexion contracture of the IP joints due to pes cavus alignment creating a windlass effect
- Causes pain on pressure areas caused by the altered alignment
What is the treatment for claw toe?
- Instruct patient to purchase shoe with high toe box
2. Stretch out toes and plantar fascia
What is Morton’s toe?
A condition where the second toe is longer than the 1st toe, adversely affecting push off during gait
What is Hallux Valgus/Abductus? What can this cause?
- An alignment impairment of the 1st MTP joint in which the MT joint is positioned farther toward the midline of the body than what is considered normal
- Causes pain in the MTP joint, or pain on pressure areas caused by the altered alignment
How is Hallux valgus/abductus treated?
Alleviate the pressure off of the metatarsal head using a metatarsal head pad
What is metatarsalgia? What can this cause?
- Pain in the first and/or second metatarsal head after long periods of weight bearing
- Caused by hyperpronation, collapse of the transverse arch of the foot, or a tight Achilles’ tendon
What is tarsal coalition? What is the result of this condition?
- A congenital condition in which any two tarsal bones are fused together
- Result of this condition is usually a rigid flat foot
What 3 signs/symptoms make up the lateral ankle sprain cluster?
Combination of all 3 at 5 days post injury:
- Positive Anterior Drawer Test
- Tenderness over ATFL
- Presence of ecchymosis
What is the biggest predictor of having an ankle sprain?
Having had a prior ankle sprain in the past
What is the typical mechanism of injury for lateral ankle sprains?
Plantarflexion and inversion
What ligament is most commonly injured with a lateral ankle sprain? 2nd most commonly injured?
- ATFL is most commonly injured
2. CFL is 2nd most commonly injured
What percent of ankle sprains seen in the ER are referred for PT?
Less than 5%
What are 3 treatment considerations for lateral ankle sprain?
- PRICE (elevation for 48+ hours)
- Manual therapy: mobilization/thrust manipulation to improve dorsiflexion ROM and mobility of the talus, and to decrease pain
- Exercise for stretching, strengthening and proprioception
Where will pain be present in a high ankle/syndesmotic sprain? What population are these sprains common in? MOI?
- Occurs rarely when compared with lateral ankle sprains
- Characterized by pain at the mortise
- More common in athletes (football, hockey, skiing)
- Mechanism of injury: ankle DF and tibial ER on the talus with foot planted on the ground
How should high ankle/syndesmotic sprains evaluated? What is needed to confirm this diagnosis?
- Evaluate by looking for the presence of distal tibial-fibular hypermobility
- Stress radiographs are needed to confirm
What are 3 ways high ankle/syndesmotic sprains treated?
- Cast immobilization or ORIF
- Initially, limit weight bearing and movement into dorsiflexion
- Then treat the same as any condition involving inflammation and/or immobilization
What are 8 diagnostic criteria for plantar fasciitis?
- Plantar medial heel pain, most noticeable with initial steps after a period of inactivity but also worse following prolonged WB
- Heel pain precipitated by a recent increase in WB activity
- Pain with palpation of the calcaneal insertion of the plantar fascia
- Positive Windlass Test
- Negative tarsal tunnel syndrome (compression of the tibial nerve behind the medial malleolus) tests
- Limited active and passive talocrural joint DF ROM
- Abnormal Foot Posture Index score (to determine if the foot is excessively supinated or pronated)
- High body mass index in nonathletic individuals
What are 9 treatment options for plantar fasciitis?
- Manual therapy to treat relevant LE joint mobility and calf flexibility impairment, and decrease pain
- Stretching of the gastrocsoleus/plantar fascia
- Anti-pronation taping/kinesiotape to the gastroc-soleus and plantar fascia
- Orthotics to support the medial arch/heel cushion
- Night splinting for 1–3 months if pt. has pain with first step upon arising from sleep
- Laser, phonophoresis with ketoprofen gel
- Recommend wearing a rocker bottom shoe with a foot orthosis, and wearing different shoes if standing for long periods of time
- Address weight loss if overweight
- Strengthening exercises that control pronation and attenuate forces during WB activities.
What is another name for a stress fracture?
Hairline fracture
What are 3 areas stress fractures commonly occur?
- Metatarsals
- Tibia
- Fibula
______ fracture is a stress fracture that takes place at the metatarsals.
March Fracture
What typically causes stress fractures?
Caused by overuse or by biomechanical factors
What are 2 ways stress fractures are diagnosed?
- Diagnosed by a bone scan or MRI
2. Point tenderness at the location of the fracture
What is the problem with using x-rays to diagnose stress fractures?
Fracture line does not show up on X-ray until about 10 days after the fracture occurred
What is Morton’s Neuroma? What is the common cause?
- Entrapment of the deep peroneal nerve between the metatarsal shafts
- It is usually caused by wearing shoes that are too tight or from wearing heels.
***Wearing heels causes the foot to move forward in the shoe, compressing the metatarsal shafts against one another
What test is used to diagnose Morton’s Neuroma and tarsal tunnel syndrome? What is considered a positive test?
- Tinel’s sign: Diagnosed by tapping on the nerve at the site of the lesion
- Positive test: Patient experiences tingling distal to the tapping
What is tarsal tunnel syndrome?
Entrapment of the posterior tibial nerve at the medial malleolus
_________ syndrome is another name for posterior shin splints.
Medial tibial stress syndrome
What is medial tibial stress syndrome/posterior shin splints? Cause?
- Tendinopathy of the soleus, tibialis posterior, and/or other posterior compartment muscles,
- Caused by excessive pronation
How is medial tibial stress syndrome/posterior shin splints diagnosed?
- Diagnosed by reproducing symptoms when palpating the proximal attachment of the tendon (medial shin)
- Performing resisted isometric testing to appropriate musculature
- Passively stretching the appropriate musculature
What 3 ways is medial tibial stress syndrome/posterior shin splints treated?
- Strengthen the tibialis posterior (low speed, high load)
- Provide arch support and cushioning to the foot
- Educate re: activity level
______ syndrome is also known as anterior shin splints.
Anterior tibial stress syndrome
What is Anterior Shin Splints/Anterior Tibial Stress Syndrome?
A tendinopathy of the tibialis anterior and/or other anterior compartment muscles
What 3 ways is Anterior Shin Splints/Anterior Tibial Stress Syndrome diagnosed?
- Diagnosed by reproducing symptoms when palpating the proximal attachment of the tendon (lateral shin)
- Performing resisted isometric testing to appropriate musculature
- Passively stretching the appropriate musculature
What 2 diagnoses can also be responsible for symptoms associated with Anterior Shin Splints/Anterior Tibial Stress Syndrome?
- Stress fracture
2. Compartment Syndrome
What are 3 possible treatments for Anterior Shin Splints/Anterior Tibial Stress Syndrome?
- Strengthen the tibialis anterior (low speed, high load)
- Correct hyperpronation if present and provide cushioning to the foot
- Educate re: activity level
What is Achilles tendinopathy?
Tendinopathy of the gastrocsoleus muscle
How is Achillies tendinopathy diagnosed?
- Reproducing symptoms when palpating the tendon 2. Performing resisted isometric testing to
- Passively stretching the gastrocsoleus
What special test is used to diagnose an Achilles tendon tear?
Thompson’s Test
What is bursitis? What 2 bursae are most commonly affected?
- An inflammation of the bursa
- Usually of the calcaneal bursa, which lies on top of the Achilles tendon
- The retrocalcaneal bursa, which lies underneath the Achilles tendon
What symptom does bursitis often elicit?
Often elicits a painful response above the heel with resisted isometric testing
(which is a false positive finding, because bursa are not contractile tissue)
What 3 joints in the foot are often affected by OA?
- Talocrural Joint
- 1st Metatarsophalangeal Joint = Hallux Rigidus
- Interphalangeal Joints
What 7 impairments are commonly associated with LE immobilization?
- Pain
- Activity and Participation Limitations
- Swelling
- Gait impairments
- Decreased range of motion
- Decreased accessory motion
- Decreased strength
What is hyperpronation?
- When the “normal” foot is in midstance, it moves slightly beyond subtalar neutral in the direction of pronation.
- A foot that hyperpronates moves more than slightly beyond subtalar neutral in the direction of pronation during mid stance.
What 6 conditions can occur as a result of hyperpronation?
- Pain at the 1st/2nd metatarsal heads
- Hallux Valgus, which often causes the pt. to have pain at the 1st/2nd MTP joints
- Plantar Fasciitis
- Pain at the navicular tuberosity
- Shin Splints
- Knee pain, which is often due to PFPS
What are 6 common reasons for hyperpronation?
- Forefoot varus
- Rearfoot varus
- Midfoot ligament laxity
- Congenital Flat Feet
- Tightness in the gastrocsoleus
- Leg length discrepancy
How does forefoot varus contribute to hyperpronation? How is the presence of this condition determined?
- The foot will tend to pronate in an attempt to get as much of the surface of the forefoot in contact with the ground.
- The presence of this condition is determined with subtalar neutral testing.
How does rearfoot varus contribute to hyperpronation? How is the presence of this condition determined?
- The foot will tend to pronate in an attempt to get as much of the surface of the rearfoot in contact with the ground, assuming that there is enough range of motion in the subtalar joint to allow this to happen.
- The presence of this condition is determined with subtalar neutral testing.
How does midfoot ligament laxity contribute to hyperpronation? How is the presence of this condition determined?
- The foot will tend to pronate in weight bearing because the ligaments are not able to support the longitudinal arch of the foot. 2. The presence of this condition is determined by examining the location of the navicular tuberosity in relation to Feiss’s line in weight bearing and in non‑weight bearing, and navicular height in subtalar neutral and normal stance.
How do congenital flat feet contribute to hyperpronation? How is the presence of this condition determined?
- the longitudinal arch of the foot is congenitally absent. 2. The presence of this condition is determined by examining the location of the navicular tuberosity in relation to Feiss’s Line in WB and in non-WB, and navicular height in subtalar neutral and normal stance.
How does tightness in the gastrocsoleus contribute to hyperpronation? How is the presence of this condition determined?
If when the foot is on the ground and the intended motion is DF, and DF cannot occur because of tightness in the gastrocsoleus, the motion will come from one of the other components of the triplanar motion.
The foot will therefore tend to go into eversion and abduction (i.e.: pronation) to compensate for a lack of DF.
This is a common occurrence during the mid-stance to terminal stance stages of the stance phase of gait.
The presence of gastrocsoleus tightness is determined with range of motion testing into DF.
How does leg length discrepancy contribute to hyperpronation?
The shorter leg will bear more weight, increasing the pronatory forces on the shorter leg.
What is one treatment option for problems with foot alignment?
Foot orthotics
