The foot and the ankle Flashcards
Anatomy and function of the foot and ankle:
The foot and ankle are the focal points to which the body weight is transmitted in ambulation and they are well tailored to that function
Heel and toe pads act as ____ _____
Shock absorbers
Joints are capable of making _____ ____
Fine adjustments
Both a ____ and a ______ joint
stable and mobile
Lumbar, SI jt, hip and knee can all contribute to ___ and _____ issues
foot and ankle
Ankle movements:
Dorsiflexion
dorsum aspect of the foot moves cephallically (towards the head)
Plantarflexion
Plantar surface of the foot moves caudally
Inversion
Plantar aspect of the foot moves towards the midline of the body
Eversion
Plantar aspect of the foot moves away from the midline of the body
Supination
Inversion of the heel, adduction of the forefoot and plantarflexion at the subtalar joint
In which position is the foot most stable?
Supination
Pronation
Eversion of the heel, abduction of the forefoot and dorsiflexion of the subtalar jt
In which position is the foot and ankle absorbing the ground reaction force
Pronation
what type of joint is the Talcrural Jt
hinge jt, formed by the talus which rests between the sitar ends of the tibia and fibula
The loose pack position of the talocrural jt is
10 degrees of plantarflexion
The closed packed position of the talocrural jt is
full dorsiflexion
The capsular pattern of the talocrural jt is
Plantarflexion then dorsiflexion
What type of jt is the subtalar jt
is modified plane jt (gliding jt) and is made up of the articulation between the talus and then calcaneus
What is the closed pack position of the subtalar jt
supination (no mm attach to the talus and therefore the ligaments are what limit eversion and elastic recoil is what will bring it back into inversion)
1st step in the case history, Questions to ask in determining the MOI
Determine the meachanism of injury (MOI) which is key in helping you develop your testing hypothesis
- What position was the foot in? Inverted/Eversion? Plantarflexed/dorsiflexed?
- Was there an overuse scenario?
- Was the injured work or activity related?
- Can the patient recreate the MOI on their uninjured side?
- Consider the surface and footwear?
Questions to ask in relevance to pain
- Onset and duration (AM, PM, after activities, etc)
- Site and spread (Local, diffuse, radiating, etc)
- Behaviour and symptoms (severity, sharp, dull, numbness, noises, etc)
Flick angle
12-18 degree of toeing out
Feiss line
Apex (highest point) of medial malleolus, plantar aspect of first MTP and navicular tuberosity. These 3 points should create a straight line in NWB and WB. If in WB it drops then the arch would be first (1/3rd of the way), second (2/3rds of the way), or third degree (resting on the floor) flat foot
What side are rule outs done to? and how are they performed?
affected side to jts above and below, performed active free with over pressure
Fractures- how to assess
use a tuning fork or compression or tapping beginning distal to site and moving closer to suspected fracture
Ankle x-ray is necessary if any of the following are present
- Inability to bear weight of the affected side
- Bone tenderness along the posterior aspect of the distal 6cm of either the medial or lateral malleolus
- point tenderness at the proximal base of the 5th metatarsal
- Pt tenderness over the navicular bome
Active free testing- how is the patient seated? and what are we looking for?
Long seated, can be done BL simultaneously, looking for willingness to move and differences BL
Dorsiflexion, pain or limitation can be due to
20 DEGREE, A MINIMUM OF 10 DEGREE IS NEEDED FOR NORMAL AMBULATION
Injury to the prime movers (tib ant) and accessory dorsiflexors (extensor hallucis longus and EDL), Posterior structures (achilles tendon, gastrocs, soleus, posterior jt capsule and ligaments) being stretched
-Intra/extra capsular swelling
In plantarflexion during AF pain or limitation can be due to
50 degree, a minimum of 20-25 degree is needed for normal ambulation
Injury to the prime movers (gastrocs, and soleus)
Injury to the accessory movers (Tibialis posterior, peronerus longus/brevis)
anterior structures (anterior capsule, anterior talofibular ligament, anterior fibres of the deltoid ligament and dorsiflexors) being stretched
Intra and extra capsular swelling
In inversion during AF pain or limitation can be due to
Approx 5 degree
Injury to prime movers (Tib ant, tib post)
injury to accessory movers (Flexor hallucis longus, flexor digitorum longus, and extensor hallucis longus)
The lateral structures (anterior talofibular ligament, calcaneofibular ligament, peroneal mm) being stretched
swelling
In eversion during AF pain or limitation can be due to
Approx 5 degree (may vary greatly look for BL symmetry)
- Injury to the prime movers (peroneus longus/brevis)
- Injury to accessory movers (EDL)
- The medial structures (tibialis anterior/posterior, deltoid ligament) being stretched
- swelling
How is Passive relaxed performed by the therapist
Long seated, therapist grasps above and below the jt and provides the movement, and provides enough force during over pressure
Passive relaxed Dorsiflexion, pain or limitations of range due to and normal end feels
20 degrees
Tissue stretch end feel (achilles tendon and tricep surae)
Pain or limitation of range due to:
-injury to the posterior structures being stretched
-tight soleus, gastrocs, achilles tendon
-swelling
What is the normal end feel of Plantar flexion in PR
bony end feel (talus in mortise) or tissue stretch (ankle dorsiflexors)
What could the pain or limitation of range can be caused by in Plantar flexion PR
Injury to the anterior structures being stretched, injury to the anterior capsule, injury to the prime movers of dorsiflexion or the anterior talofibular ligament
What is the normal end feel of Inverson in PR
5 degree
Bony end feel or tissue stretch (hypermobile)
Pain or limitation of Inversion in PR due to
Injury to the lateral structures being stretched
Injury to the anterior talofinular ligament, calcaneofibular ligament, jt capsule, peroneals or extensor digitorum mm or tendons
What is the normal end feel of Eversion in Passive relaxed
5 degree
Bony end feel or tissue stretch (hypermobile)
Pain or limitation of range in Eversion during passive relaxed is due to
Injury to the medial structures being stretched
Injury to the deltoid ligament, tibialis anterior/posterior mm or tendons
during active resisted pain discomfort or weakness will be caused by injury to the prime movers or the _____ supplying them
nerves
Primary movers and primary nerve roots involved with Dorsiflexion during Active resisted
Tibialis anterior, primary nerve root is L4
What are the primary movers of plantar flexion
Gastrocs and soleus (tricep surae)
What primary nerve roots are involved with plantar flexion
S1 and S2
What are the primary movers of inversion
Tibialis anterior and tibialis posterior
What primary nerve roots are involved with the movement inversion
L4
What nerve root is involved with toe extension
L5
Muscle tests:
What mm are involved with the Dorsiflexors and what movements to test
muscles anterior to the malleoli
- Tib ant (Dorsiflexion and inversion)
- Extensor hallucis longus
- Extensor digitorum longus
Muscle tests for plantar flexors
(muscles posterior to the malleoli)
- Gastrocs: Plantar flexed with knee extended, gastrocs crosses the knee and plays a role in knee flexion and helps to prevent knee hyperextension.
- Soleus: Plantar flexed with knee flexed
with weakness in _____ there is a tendancy to hyperextend the knee
Gastrocnemius
Weakness in soleus will result in ankle _____ and is usually accompanies by knee flexion in standing
Soleus
Soleus strength may help compensate for weak quadriceps, hyperextending the knee
What action is performed with functional strength test
heel raise Flexor hallucis longus Flexor digitorum longus Tibialis posterior (PF and inversion)
Muscle tests for the everters
Peroneus longus/brevis, little plantar flexion and eversion
Muscle tests for the inverters
Tibialis anterior, resist DF and Inversion in long seated position
Tibialis posterior: Plantar flexion and inversion
ALSO: Extensor digitorum longus and brevis, extensor hallucis longus and brevis, flexor digitorum longus and brevis and flexor hallucis longus and brevis
Neurological tests
Myotomes: L4, L5,S1, S2
Dermatomes: L5, L4, S1
Reflexes: S1 achilles
Done high seated, put the achilles tendon on slight stretch, by passively dorsiflexion the ankle slightly. Tap the achilles tendon with the flat end of the reflex hammer repeat 7-10 times
Special tests:
what do talar tilts test for
Ankle stability, lateral ligaments: ATFL- anterior talofibular ligaments (most commonly injured ligament in the ankle) location is palpable in the sinus tarsi- injured by a combo movement- inversion and plantar flexion- ex. jumping, kicking a soccer ball
How to test for ATFL using talar tilts, and what is a positive outcome?
Passive plantar flexed and inversion, positive-pain along the ligament and its attachments or excessive ROM
testing for calcaneofibular ligament (CFL) using talar tilts
Passive inversion from a neutral position
What is a positive for CFL
pain along the ligament and its attachments or excessive ROM
Fan shaped ligament with a bundled attachment at the medial malleolus. The 4 ligaments are tibionavicular, tibiocalcaneal, anterior and posterior tibial talar. What is this ligament?
Medial deltoid ligaments
Excessive force causing ____ may cause micro tearing of the ligamentous fibres but most likely the medial malleolus will avulse
eversion
medial deltoid ligaments
Testing the posterior fibers of the medial deltoid ligament, using talar tilts, what is a positive testing?
Dorsiflexion and eversion, positive- pain along the ligament and its attachments or excessive ROM
Testing the middle fibers of the medial deltoid ligament using talar tilts and what is a positive?
Eversion from a neutral position, positive pain along the ligament and its attachments or excessive ROM
Testing the anterior fibers of the medial deltoid ligament using talar tilts, and what is a positive?
Plantar flexion and eversion, positive= pain along the ligament and its attachments or excessive ROM
What does the anterior drawer test?
Test the integrity of ATFL which should be taut in all positions (keeping the talus from moving forward from the tibia)
How to do the Anterior drawer test?
Grasp the calcaneous with one hand, with the clients sole resting on your forearm, the second hand stabalizes above the ankle joint which the first tractions (distracts) the ankle slightly and draws the clients foot forward anteriorly
Another way to do the anterior drawer test is
Grasp the calcaneous with one hand, with the clients sole resting on your forearm, the second hand stabalizes above the ankle joint. Have the ankle in 20 degrees of Plantar flexion and draw the talus forward in the mortise
Anterior drawer test positive
pain, tenderness and laxity and/or a clunk sometimes there may be a dimple or suction sign
What do wedge tests test
Test the integrity of the anterior inferior tibiofibular ligament
