The Foot & Ankle Flashcards
1
Q
What are the components of the hindfoot?
A
talus & calcaneus
2
Q
What are the components of the midfoot?
A
medial cuneiform, intermediate cuneiform, lateral cuneiform, navicular, cuboid
3
Q
What are the components of the forefoot?
A
metatarsals (5) & phalanges (14)
4
Q
What are the 2 primary ligaments that support the ankle joint laterally?
A
anterior talofibular ligament (ATFL) & calcaneofibular ligament
5
Q
Which ankle movements are checked by the calcaneofibular ligament?
A
inversion & adduction of the calcaneus relative to the fibula
6
Q
What motion is checked by the posterior talofibular ligament?
A
external rotation of the talus
7
Q
What actions does the fibularis longus perform?
A
- subtalar pronation
- supports transverse arch of foot
- plantarflexion of 1st metatarsal
8
Q
What actions does the fibularis brevis muscle perform?
A
- subtalar pronation
- forefoot abduction
9
Q
What 3 muscles comprise the deep posterior compartment of the lower leg? Which is the strongest?
A
- flexor hallucis longus
- flexor digitorum longus
- tibialis posterior (strongest by a large margin)
10
Q
What do the cross-sectional area and moment arm of the posterior tibialis tell us about its role in ankle movement?
A
larger moment arm & higher cross-sectional area compared to the other deep posterior compartment muscles suggest that it is the dominant supinator of the subtalar joint
11
Q
What is the action of the muscles of the deep posterior compartment of the lower leg?
A
subtalar joint supination (also hypothesized to raise the medial arch & plantarflex the toes)
12
Q
What are the 4 muscles of the anterior compartment of the lower leg?
A
1, tibialis anterior
- extensor digitorum longus
- extensor hallucis longus
- fibularis tertius
13
Q
Explain why the talocrural joint is more stable in dorsiflexion and less stable in plantarflexion.
A
the trochlea of the talus is wider anterior than posterior, so it sits more snugly in the mortise (distal tibia/fibula) in dorsiflexion.
14
Q
Describe the movements of the calcaneus and talus during supination and pronation. How do these movements affect the medial longitudinal arch?
A
- Supination: calcaneus inverts (frontal plane), while talus abducts (transverse) & dorsiflexes (sagittal); medial longitudinal arch rises
- Pronation: calcaneus everts (frontal), while talus adducts (transverse) & plantarflexes (sagittal); medial longitudinal arch lowers.
15
Q
What are the two most important joints that contribute to the locking mechanism of the midfoot?
A
transverse tarsal joints (talonavicular & calcaneocuboid joints)
16
Q
Describe the Windlass mechanism.
A
Extension (dorsiflexion) of the toes increases tension on the plantar fascia, which in turn supports the medial longitudinal arch.
17
Q
What is the relationship between tibial rotation and arch height?
A
tibial ER results in an increase in the height of the medial longitudinal arch; IR results in a lower arch
18
Q
How does the hip affect arch height? Is the tibial controlled by more proximal or distal forces/positions?
A
Tibial rotation affects arch height & is controlled more by proximal forces from the hip (femoral rotation) than distal foot/ankle positioning with orthoses.
19
Q
What group of muscles are primarily responsible for propulsion and support during gait?
A
plantar flexors
20
Q
During what phases of gait are the plantar flexors most active?
A
mid-stance to just prior to toe off
21
Q
Describe the sagittal plane movement of the ankle during gait
A
- slight dorsiflexion at initial contact
- moves to neutral at foot flat (in first 10%-15% of stance phase)
- gradually moves into dorsiflexion (peaking at 70%-80% of stance phase)
- rapidly plantar flexes to toe off (pre-swing)
22
Q
What is the role of the soleus during gait?
A
slows the tibia after foot flat
23
Q
In older patients, what is the relationship between ankle strength and hip muscle activity during gait? How is this addressed clinically?
A
- Elderly patients tend to have decreased plantar flexor strength & diminished push-off, so they tend to rely on a hip pull-off contribution during walking.
- Cueing patients to increase their ankle push-off during gait lowers hip flexor and extensor activity during gait
24
Q
Describe the movement of the subtalar joint throughout the gait cycle.
A
- pronation/eversion from initial contact to foot flat (10%-15% of stance)
- rapidly supinates/inverts during terminal stance (peaks near 90% of stance)
25
During a normal gait cycle, the subtalar joint rapidly supinates in terminal stance, peaking at 90% of stance. What is the current theoretical explanation for this?
supination of the calcaneus helps the mid-foot (talonavicular and calcaneocuboid joints) lock into place and stabilize the foot as a rigid lever
26
What are the primary inverters of the foot & ankle?
tibialis anterior and tibialis posterior
27
What is the role of co-contraction of lateral and medial compartment muscles of the ankle in gait?
During stance phase, the tibialis anterior and posterior (medial) co-contract with the fibularis longus (lateral) to stabilize the subtalar joint and likely maintain the medial longitudinal arch
28
What is the functional problem with an acquired flat foot?
midfoot instability (foot is too flexible at push-off)
29
What is the most commonly affected ligament in an adult-acquired flat foot deformity? Which nearby ligamentous structures are largely unaffected?
plantar calcaneonavicular (spring) ligament; plantar fascia and long/short plantar ligaments are no different than healthy subjects
30
Overactivity of which muscle(s) is thought to cause pes cavus (high arch)?
either tibialis posterior or tibialis anterior or both
31
According to Williams et al, what is the relationship between high arches and injury risk in runners? What are some precautions to take in interpreting this kind of data?
runners with pes cavus experienced more lateral ankle sprains and fifth metatarsal stress fractures than those with pes planus;
- high arches aren't defined well (higher than average vs calcaneal inversion)
32
What is the "peek a boo" sign?
criteria for classifying a patient with subtle pes cavus foot type; when viewing a patient from the front, the medial heel can be seen
33
What is the functional problem with a pes cavus foot? How is this addressed with footwear/orthotics?
too rigid; the foot can't accommodate changes in terrain or absorb shock as well; shoes and orthotics can help improve shock absorption and/or distribute pressure under the foot evenly (custom orthotics may be better than off-the-shelf for pes cavus)
34
List the 4 aspects of the chief complaint during the patient history portion of an ankle/foot evaluation
1. pain (constant vs intermittent)
2. location
3. severity
4. nature (aching, burning, sharp, tingling)
35
List the 5 aspects of the onset of symptoms during the patient history portion of an ankle/foot evaluation
1. time since injury
2. insidious
3. traumatic
4. gradual / acute
5. training
36
List the 9 aspects of the behavior of symptoms during the patient history portion of an ankle/foot evaluation
Worse:
1. activity (beginning vs end of day, increase training, etc)
2. night pain?
3. first step in morning?
4. walking with/without shoes
5. distance able to walk without pain
6. functional tasks (stairs, squatting, running)
Better:
7. rest
8. activity?
9. walking with/without shoes
37
What information should be obtained from an "overall assessment" during the patient history portion of an ankle/foot evaluation
are symptoms getting better/worse or staying the same?
38
What information should be obtained regarding the patient's past medical history during a foot/ankle evaluation?
history of previous injury (e.g. ankle sprains, foot pain, etc)
39
What types of foot/ankle injuries are associated with the following subjective pain descriptions:
- tingling/burning
- sharp
- aching
- pain with clicking / giving way
- tingling/burning: nerve impingement
- sharp: acute injury
- aching: chronic pain
- pain with clicking / giving way: dislocated tendon
40
How useful are the location and nature of pain in assessing foot/ankle injuries?
Location and nature of pain are especially helpful in foot/ankle injuries, because many of the injured structures are superficial and can be palpated during the examination.
41
What are the two elements of the mechanism of ankle/foot injuries that should be ascertained during the patient history, if possible?
1. foot position (dorsiflexion/plantar flexion)
| 2. the deforming force (inversion/eversion)
42
What are the 6 components of the Foot Posture Index (FPI-6)?
1. talar head position
2. supralateral and infralateral malleolar curvature
3. calcaneal frontal plane position
4. prominence of the talonavicular joint
5. congruence of the medial longitudinal arch
6. abduction/adduction of the forefoot on the rearfoot
43
In a sample of 200 health subjects, what was the average arch height change from nonweight-bearing to standing?
10mm or 13.4% decrease in arch height
44
What are the two take-aways from the current literature on arch height measurements?
1. there is an association between foot posture and injury (pronation & hip, knee, or back pain)
2. there is an association between foot posture and loading (high arch & incr vertical loading rate)
45
Describe the Navicular Drop test.
- pt is placed in subtalar neutral & height of navicular is measured on a card
- pt then relaxes foot posture to quiet standing & heigh is remeasured
- difference of more than 10 mm is (+)
46
What is the current state of the evidence on the relationship between the Navicular Drop test and injury risk?
conflicting
- meta-analysis shows a navicular drop greater than 10 mm is a risk factor for medial tibial stress syndrome
- some studies suggest a relationship with patellofemoral problems, but not running injuries
47
Describe the Foot Lift Test.
identical to Single-Leg Balance Test, but the number of foot lifts in 30 seconds is counted (nonweight-bearing limb touching down counts as an error)
48
What are the 4 balance tests suggested by the authors for foot/ankle injury examinations?
1. Single-Leg Balance test
2. Foot Lift test
3. Star Excursion Balance test
4. Heel Raise test
49
In patients with chronic ankle instability, what are the current interpretations of the components of the Star Excursion Balance test (anterior & posterior medial/lateral)?
- in patients with chronic ankle instability, anterior reach is limited by (1) dorsiflexion ROM and (2) plantar cutaneous sensation
- posterior medial & lateral reach are limited by (1) eversion strength and (2) balance
50
Should a bilateral or unilateral heel raise test be performed during an ankle/foot examination?
both
51
What is the average reference value for a Single Heel Rise test for a patient in their 20s-40s?
20-25 reps, though athletes may be up to 40 reps
52
Is heel height during the Single Heel Raise test a useful metric for Achilles tendon ruptures? For Achilles tendinopathy?
- for Achilles tendon ruptures, single leg heel height of less than 2 cm is sensitive to deficits and improvements, but not for tendonopathy
53
A low heel height during a Single Heel Raise test can indicate what 3 different issues?
1. plantar flexor weakness / inability to lift one body weight
2. shortening of plantar flexors
3. midfoot instability / flat foot deformity
54
What are the 5 items to observe when a patient is performing the Single Heel Rise test?
1. heel height
2. knee & trunk position
3. subtalar joint inversion/eversion
4. 1st metatarsal dorsiflexion / plantar flexion
5. pressure distribution under the forefoot
55
During the Single Heel Rise test, which observation(s) suggest weakness or fatigue?
lowering heel height and/or knee & trunk flexion compensations
56
During the Single Heel Rise test, which observation(s) suggests posterior tibialis weakness?
inability of hindfoot to invert and/or lateral forefoot weight-shift
57
During the Single Heel Rise test, which observation suggests midfoot instability?
1st metatarsal dorsiflexion
58
During the Single Heel Rise test, what does a lateral weight shift through the forefoot suggest? Which 3 muscles are most likely involved?
uneven pressure distribution / lateral weight-shift suggests weakness of arch muscles: posterior tibialis, flexor hallucis longus, fibularis longus
59
Describe the Single Heel Rise test.
- single-leg standing on flat surface or 10° incline
- patient is facing wall with fingertip pressure
- "perform as many heel raises as you can"
- 1-2 reps per second (can use metronome)
- heel height and repetitions are most common quantitative assessment
60
How reliable is gait assessment during the foot/ankle examination?
moderately; gets more accurate when you video record / slow it down or if the deformity is greater; subtle things like subtalar motion may not be readily observable
61
List the 8 tests in the control sequence of functional tests for return to sports evaluated by Haitz et al.
1. Timed lateral step-down
2. Timed leap & catch hop sequence
3. Single-leg hop for distance
4. Single-leg timed hop
5. Single-leg triple hop for distance
6. Crossover hop for distance endurance sequence
7. Square hop test
8. Lower Extremity Functional Test (LEFT)
62
Describe the Side Hop Test.
hop laterally 30 cm & back to starting point; patient performs 10 reps as quickly as possible without letting the contralateral foot touch the ground; compare time side-to-side
63
Describe the 6-meter Crossover Hop test.
two 6m-long lines, 15cm apart; patient hops on one leg back & forth to either side of the lines as fast as possible; compare time side-to-side
64
Describe the Square Hop test.
40x40 box on the floor with tape; patient hops in/out each side for 5 cycles (20 hops in, 20 hops out); time is compared side-to-side
65
Describe the Figure-of-8 Hop test.
two cones 5m apart; patient hops on one leg for 2 figure 8 laps around the cones; time is compared side-to-side
66
What are three different positions in which you may want to measure ankle dorsiflexion?
1. supine knee extended
2. prone knee bent
3. standing knee flexion
67
What two structures are being assessed with dorsiflexion ROM measurement?
1. gastroc/soleus length
| 2. capsular tightness
68
What dorsiflexion ROM is considered to indicate "gastrocnemius tightness"?
less than 10°with knee extension (less than 5° is considered severe)
69
What does decreased ROM of the 1st metatarsal generally result in during gait?
lateral shift of the center of pressure through the forefoot
70
List the 2 special tests for ankle mobility described in the monograph.
1. Anterior Drawer test
| 2. Talar Tilt test
71
What position should the ankle be in during the Anterior Drawer test? What does a positive test suggest?
10°-20° of plantar flexion
(+) test (3mm more than uninvolved side) suggests ATFL laxity or tear
72
What position should the ankle be in during the Talar Tilt test?
2 options:
- 20° plantar flexion (biases ATFL)
- 10° dorsiflexion (biases CFL)
73
What is considered a (+) Talar Tilt test? What does a positive test suggest?
(+) if...
- pain below level of lateral malleolus
- inversion is 15° greater than uninvolved side (double ligament injury)
- empty end-feel
(+) indicates laxity or tear of either the ATFL and/or CFL
74
List the 5 special tests for a High (Syndesmotic) Ankle Sprain described in the monograph.
1. Dorsiflexion-External Rotation test
2. Squeeze Test
3. Syndesmosis Ligament Palpation
4. Cotton test
5. Fibula Translation test
75
Describe the Dorsiflexion-External Rotation test. What does a positive test indicate?
- knee in 90° flexion
- ankle in max dorsiflexion
- passively externally rotation foot/ankle
- (+) if patient reports anterolateral upper ankle / lower leg pain
(+) test is moderately reliable for detecting syndesmosis injury, but sensitivity is better
76
Describe the Squeeze test. What does a positive test indicate?
- patient in nonweight-bearing
- manually squeeze fibula and tibia together, just about midpoint of calf
(+) test suggests syndesmosis injury
77
Describe the Syndesmosis Ligament Palpation test. What does a positive test indicate?
- patient sitting or supine
- palpate anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, and proximally between tibia and fibula
(+) test isn't very reliable for syndesmosis injury, but sensitivity is good
78
Describe the Cotton test. What does a positive test indicate?
- patient supine or sitting
- lightly stabilize distal tibia
- grasping rear foot, move talus & calcaneus medially & laterally
(+) test suggests syndesmotic instability / injury (sensitivity is low, though)
79
Describe the Fibula Translation test. What does a positive test indicate?
- patient supine
- stabilize distal tibia
- move lateral malleolus anterior & posterior
(+) moderate specificity/sensitivity for syndesmosis injury
80
List the 4 special tests for Achilles Tendon injury described in the monograph.
1. Thompson (Calf-squeeze) test
2. Achilles Tendon Palpation
3. Royal London Hospital test
4. Arc Sign
81
Describe the Thompson (Calf-squeeze) test. What does a positive test indicate?
- patient prone, knee flexed to 90°
- compress plantar flexors at middle 3rd of calf
- (+) if no ankle motion
(+) test highly specific for Achilles tendon partial/complete tear (high sensitivity, too)
82
Describe the Achilles Tendon Palpation test. What does a positive test indicate?
- patient prone, feet off table
- squeeze along entire length of Achilles tendon
- note areas of swelling
(+) pain reproduction highly specific for Achilles tendinopathy
83
Describe the Royal London Hospital test. What does a positive test indicate?
- patient prone, feet off table
- palpate most tender part of Achilles tendon
- patient actively dorsiflexes & the area is palpated again
- (+) if patient reports less tenderness in active dorsiflexion
(+) test highly specific for Achilles tendinopathy
84
Describe the Arc Sign test. What does a positive test indicate?
- patient prone, feet off table
- active plantar flexion / dorsiflexion
- observe area of maximal swelling
- (+) if swollen area of tendon moves during active ankle ROM
(+) test is highly specific for Achilles tendinopathy
85
What 3 additional "other special tests" for the foot/ankle recommended by the monograph authors have significant evidential support?
1. Windlass test in weight-bearing
2. Tinel Sign
3. Homan Sign
86
Describe the Windlass test in weight-bearing. What does a positive test suggest?
- patient stands with both feet on step stool, toes off the edge
- passive extension of 1st MTP
(+) test reproducing symptoms is highly specific for plantar fasciitis (sensitivity is poor, though)
87
Describe the Tinel Sign test. What does a positive test suggest?
- foot and ankle in neutral
- tap pathway of posterior tibial nerve (medial malleolus to arch of foot)
(+) symptom reproduction indicates involvement of the posterior tibial nerve
88
Describe the Homan Sign test. What does a positive test suggest?
- knee in extension
- passive dorsiflexion
(+) pain in calf suggests a DVT (but sensitivity is low, so don't rely on this test alone)
89
Infants are born with a flatfoot posture. By what age do we develop a "normal" footprint?
12-13 years old
90
What is the clinical relevance of a flexible flat foot posture if the patient is asymptomatic?
flexible flat foot is an incidental finding unless directly correlated to a clinical syndrome. "In general, congenital flexible flat foot is not a specific clinical condition."
91
List 4 situations in which an adult flexible flat foot posture might be clinically relevant.
1. plantar fasciitis
2. patellofemoral syndrome
3. tibial stress fractures
4. in runners specifically (may be linked to injury risk)
92
What is thought to be the most common cause of Adult-acquired Flat Foot? What are other potential causes?
tibialis posterior tendon dysfunction (TPTD) is most common cause; other causes include tight heel cord, spring ligament damage, midfoot/rearfoot arthritis (contributing factors?)
93
What is the clinical relevance of a Pes Cavus (high arch) foot posture if the patient is asymptomatic?
Pes Cavus in adults is usually an incidental finding unless directly correlated to a clinical syndrome
94
What is the relationship between Hallux Valgus and function?
contributes to impaired function (e.g. balance, gait) and increased risk of falls
95
Hallux Valgus is considered clinically present when the 1st MTP joint is at what angle?
15° or greater
96
What should physical therapy treatment following Hallux Valgus surgery consist of?
- 6 weeks
- address ROM, swelling, and massage of scar tissue early in treatment
- progress to strengthening, gait, and proprioceptive exercse later
97
In patients with a claw toe deformity, what 3 sites of increased pressure can develop painful corns?
1. dorsum of the PIP joint
2. plantar to nail bed
3. plantar aspect of MTP
98
In patients with a flexible Hammer/Claw Toe deformity, what are the two main treatments performed? What other external factors can be accommodated?
1. taping
2. manipulation of MTP joint into flexion (helps Extensor Digitorum Longus extend the PIP joints)
Modifications to shoes (larger toe box, padding to decrease pressure of areas that can develop corns)
99
What is Mallet Toe?
abnormal flexion of DIP (most frequent at 2nd toe - poorly-fitting shoes?)
100
How should Mallet Toe be addressed in PT?
lengthened toe box or use of a "toe crest" to elevate the toe
101
What are the main ligaments involved in a High Ankle Sprain?
anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, syndesmosis between tibia and fibula (deltoid ligament may also be involved)
102
What is the primary mechanism of a High Ankle Sprain?
dorsiflexion of the ankle and external rotation of the tibia on a planted foot (sometimes excessive inversion and dorsiflexion)
103
What are the two mechanisms that are thought to contribute to pain after a High Ankle Sprain?
1. widening of the ankle mortise & resultant decrease in effectiveness of plantar flexors / instability
2. gapping of the distal tibiofibular joint during excessive dorsiflexion (trochlea of the talus pushes them apart)
104
What two subjective descriptions of pain at the time of injury might lead you to suspect a High Ankle Sprain?
1. pain out of proportion to the apparent injury
| 2. pain felt in the shank or knee during injury
105
Which ankle movement(s) typically reproduce symptoms of a High Ankle Sprain?
1. forced dorsiflexion
| 2. passive external rotation of the foot relative to the leg
106
In the treatment of a High Ankle Sprain, why is determining the presence of distal tibiofibular joint instability such an important element of the decision-making process?
patients with tibiofibular joint instability are likely best treated with cast immobilization or internal fixation
107
In the early phases of High Ankle Sprain rehab, which activities and positions should be restricted or controlled in order to manage pain?
- limit degree of dorsiflexion
- restrict strong plantar flexion contraction
- control weight-bearing
108
Conservative management may be attempted in which grade(s) of High Ankle Sprain?
grade I (grades II and III need immobilization or internal fixation)
109
What population(s) are at highest risk for a Lateral Ankle Sprain?
females between the ages of 10-40 playing indoor or court sports
110
What is the first priority when assessing a suspected Lateral Ankle Sprain?
rule out fracture (occurs in 10%-15% of cases)
111
Describe the Ottawa Ankle Rules.
x-ray if...
1. bone tenderness in the malleolar zone (along the medial and lateral malleoli, talar neck/head)
2. tenderness at: posterior edge / tip of lateral or medial malleolus, base of 5th metatarsal, or navicular
3. inability to bear weight immediately following the injury and during examination
112
Describe the Bernese Ankle Rules. What advantage may these rules have over the Ottawa Ankle Rules?
x-ray if...
1. pain with fibula/tibia compression 10 cm proximal to fibular tip
2. pain with direct medial malleolus pressure
3. pain with compression stress of the midfoot and hindfoot (one hand holds the calcaneus in neutral & the other applies a sagittal load on the forefoot)
may be more specific (less false positives) than the Ottawa Ankle Rules
113
Describe 6 characteristics of a Grade I Lateral Ankle Sprain.
- no loss of function
- no ligamentous instability (negative Anterior Drawer & Talar Tilt tests)
- little to no bruising
- point tenderness
- decreased ankle motion of 5° or less
- swelling of 0.5 cm or less
114
Describe 7 characteristics of a Grade II Lateral Ankle Sprain.
- some loss of function
- positive Anterior Drawer test
- negative Talar Tilt test
- bruising
- swelling
- point tenderness
decreased ankle motion between 5°-10°
- swelling between 0.5 cm and 2.0 cm
115
Describe 7 characteristics of a Grade III Lateral Ankle Sprain.
- near total loss of function
- positive Anterior Drawer test
- positive Talar Tilt test
- bruising
- extreme point tenderness
- decreased ankle motion greater than 10°
- swelling greater than 2.0 cm
116
What is the average timeframe for recovery from a Grade I Lateral Ankle Sprain?
5-9 days
117
What is the average timeframe for recovery from a Grade III Lateral Ankle Sprain?
31-55 days
118
What % of patients with a Lateral Ankle Sprain will reinjure in the next year? What % continue to experience instability?
29% reinjure in 12 months; 50% continue to experience reinjury
119
Whitman et al suggest that patients with a Lateral Ankle Sprain are more likely to respond to manual therapy if what 4 criteria are present?
1. symptoms are worse with standing
2. symptoms are worse in the evening
3. navicular drop of 5.0 mm or more
4. distal tibiofibular hypomobility
120
What is the current state of the evidence regarding bracing and supports for the prevention of ankle sprains / reinjury?
if the patient is able to wear a semi-rigid ankle brace without affecting his/her performance, they can be an effective strategy to prevent reinjury.
121
According to a current clinical practice guidelines, what are 5 indicators of a high risk of ankle sprain / injury?
1. history of previous ankle sprain
2. failure to use external support
3. failure to warm up
4. lacking normal ankle dorsiflexion ROM
5. failure to participate in balance/proprioceptive training after a previous injury
122
What is important to note about lateral ankle sprains and early mobilization / return to play?
Studies highlight that early mobilization, although effective in returning patients to function may not be optimum for ligament healing (lots of people re-injure)
123
Why do Lateral Ankle Sprains tend to be chronic?
ATFL healing is poor & likely does not heal at a "normal" length, creating laxity that persists after the sprain
124
What is the most commonly treated condition that occurs after a Latera Ankle Sprain?
Chronic Ankle Instability
125
What 3 criteria define Chronic Ankle Instability?
1. at least one lateral ankle sprain
2. at least 2 episodes of ankle "giving way"
3. lower self-reported function on current scales (e.g. the ADL and Sport Scale of the FAAM)
126
Give 3 differences in function & activity between people with Chronic Ankle Instability and those without.
- lower step count
- less moderate to vigorous physical activity
- lower scores on self-reported outcomes (Sport section of FAAM)
127
What is the relationship between joint laxity / mechanical instability after an ankle sprain & the development of Chronic Ankle Instability?
Although included in some models of CAI, joint laxity or mechanical instability after an ankle sprain appears to contribute little to the development of CAI.
128
Since there is a tenuous relationship between mechanical instability and Chronic Ankle Instability, what are more reliable indicators of CAI?
- perceived instability
| - recurrent sprains
129
What evidence supports the central nervous system mechanism behind the development of Chronic Ankle Instability?
- fibularis longus corticospinal excitability via transcranial stimulation was greater in controls than in those with CAI. (low excitability of the motor cortex for fib. longus, decreased muscle force production)
130
What are the 2 most discriminating balance tests to diagnose Chronic Ankle Instability? What are the cut-off scores for each?
1. Foot Lift test ≥ 3
| 2. Time in Balance test < 26 seconds
131
What is the best functional test for diagnosing Chronic Ankle Instability? What is the cut-off score?
Side Hop test - ≥ 13 seconds for 10 repetitions
132
During the Side Hop test, how far apart should the lines be?
40 cm (15.75 inches)
133
Describe the 5 exercises included in the Chronic Ankle Instability Training Program listed in the monograph.
1. Hop to Stabilization
2. Hop to Stabilization & Reach
3. Hop to Stabilization Box Drill
4. Progressive SLS
5. Progressive SLS with eyes closed
134
What is the relationship between manual therapy and Chronic Ankle Instability?
effective only in those with a ROM restriction (weight-bearing posterior talar glide 10 x 2 sets resulted in increased dorsiflexion in weight-bearing & on drop landing, improved dynamic balance, and patient-reports perception of instability)
135
Describe Anterior Impingement Syndrome of the Ankle.
Condition characterized by pain with forced dorsiflexion (squatting, stairs, walking fast) that often results from ankle sprains / instability. Can be bony impingement or soft tissue as a result of microtrauma along the anterolateral talocrural joint line.
136
In addition to joint mobilization, what other treatment may be useful for a patient with Anterior Impingement Syndrome of the Ankle?
heel lift to decrease dorsiflexion during functional tasks
137
What is the cause of most cases of Ankle Osteoarthritis?
posttraumatic arthritis (78%)
138
Why is it surprising that Ankle Osteoarthritis is relatively rare?
The articular surface area is small & the loads at the ankle joint are high
139
What items in the patient history might raise the likelihood that Osteoarthritis is the source of ankle pain?
a history of ankle fracture (malleolar, tibial, talar) or repeated ankle sprains
140
What is the main treatment for Ankle Osteoarthritis?
surgery (total ankle replacement or ankle arthrodesis)
141
What types of footwear modifications may be useful for patients with Ankle Osteoarthritis?
- rocker sole
- solid ankle cushioned heel
- articulated hindfoot orthosis
142
Why is plantar fasciitis now referred to as Plantar Fasciopathy? How does this affect treatment for the condition?
Similar to studies of tendinopathy, closer examination of the plantar fascia removed at surgery reveal no markers of inflammation. The lack of inflammatory cells coupled with imaging studies that show enlargement of the plantar fascia suggest a fasciosis (i.e. degeneration, so care is shifting away from use of antiinflammatories and toward treatments that facilitate tissue remodeling.
143
How common is Plantar Fasciopathy?
1 in 10 people will experience fasciopathy (2 million patient visits in the U.S. every year)
144
What is the most common age range for Plantar Fasciopathy?
45-65 years old
145
What are the 3 main factors in the development of Plantar Fasciopathy? Which is the strongest predictor?
1. obesity
2. decreased dorsiflexion ROM (strongest predictor)
3. time spent during the work day on feet
146
List 6 items/tests during the evaluation/examination that indicate Plantar Fasciopathy.
1. history of medial plantar heel pain that is most severe with (1) initial weight-bearing following prolonged inactivity, and (2) extended periods of weight-bearing activity
2. pain with palpation of the calcaneal plantar fascia insertion
3. active/passive dorsiflexion ROM
4. Windlass test
5. foot posture assessment (Foot Posture Index)
6. BMI
147
What hindfoot motion should be reduced/controlled in patients with Plantar Fasciopathy?
eversion (leads to flat foot posture)
148
How long should a dorsiflexion night splint be worn in patients with Plantar Fasciopathy?
1-3 months
149
A limitation in what hip motion may contribute to Plantar Fasciopathy pain?
limited hip ER may limit ER throughout the lower extremity and resultant lowering of the medial arch.
150
How long does Plantar Fasciopathy generally last?
80% experience significant improvements within 10 months
151
What is the current state of the evidence regarding modalities like iontophoresis, ultrasound, and e-stim in the treatment of Plantar Fasciopathy?
do not provide any demonstrable benefit (PF is not an inflammatory disorder)
152
What other structural change commonly occurs with Plantar Fasciopathy?
bony heel spurs
153
What condition is gastrocnemius recession surgery used to treat? How effective is the procedure?
used to treat plantar fasciopathy by lengthening the medial gastrocnemius & therefore reducing the load on the midfoot and forefoot (95% success rate in mostly/completely resolving symptoms)
154
What is a tarsal coalition?
a fibrous, cartilaginous, or osseous fusion of two or more bones in the midfoot / hindfoot.
155
What are the 2 most common sites of tarsal coalitions?
calcaneonavicular & middle facet talocalcaneal coalition
156
What rare condition presents similarly to an ankle sprain that results in subtalar hypomobility?
tarsal coalition
157
When do most tarsal coalitions become symptomatic & why?
in adolescents (between 12-16); tarsal coalition ossifies and begins to restrict subtalar joint motion
158
List 6 items in the typical clinical presentation of someone with a tarsal coalition?
1. family history of TC
2. repeated ankle sprains
3. vague hindfoot pain (worse with activity, better with rest)
4. tenderness over sinus tarsi (for calcaneonavicular coalition) or sustentaculum tali (for middle facet talocalcaneal
coalition)
5. hindfoot valgus
6. limited subtalar movements
159
How is the sinus tarsi palpated?
Starting from the anterior surface of the lateral malleolus and moving anteriorly and medially, the finger falls into a depression.
160
How is the sustentaculum tali palpated?
Just inferior to the lowest tip of the medial malleolus, the finger runs over a ridge
161
What is the Lisfranc Ligament?
thick ligament that arises from the medial border of the 1st cuneiform & attaches to the base of the 2nd metatarsal
162
What 2 tests are recommended by Reid et al for screening patients with midfoot pain for Lisfranc injury?
1. Midfoot Squeeze test
| 2. Single-Leg Hop test
163
What is Sever's Disease?
Calcaneal apophysitis caused by inflammation of the secondary calcaneal ossification that is open in childhood.
164
What is thought to cause Sever's Disease?
traction force from the Achilles tendon pulling on the bone fragment present before the calcaneus fully ossifies
165
What's the difference between apophysitis & epiphysitis?
Apophysitis occurs when a tuberosity is stressed in traction, whereas epiphysitis is a compression or shear injury
166
How long does Sever's Disease typically last?
2 weeks to 2 months
167
Describe the typical patient with Sever's Disease.
young athlete who is having a growth spurt and who complains of intermittent or continuous heel pain that occurs with weight-bearing shortly after he/she begins a new sport or season
168
Contrast the use of imaging vs clinical testing in the detection of Sever's Disease.
- radiographs may not be very helpful
| - combination of one-leg heel standing (pain while standing) & squeeze test have near 100% specificity
169
List 7 conditions that can cause heel pain in children.
1. Sever's Disease
2. Plantar Fasciopathy
3. Achilles tendinopathy
4. Retrocalcaneal Bursitis
5. Calcaneal Stress Fracture
6. Tarsal Coalition
7. Tarsal Tunnel Syndrome
170
Which ankle/foot condition is similar to Osgood-Schlatter or Legg-Calve-Perthes disease in etiology?
Kohler's Disease
171
What is Kohler's Disease?
ischemia/necrosis of the Navicular bone (it is one of the last to ossify & it is subject to a lot of compressive stress during weight-bearing though the arch)
172
List 4 clinical signs of Kohler's Disease.
1. gradual onset
2. swelling and erythema over dorsum of midfoot
3. tenderness of navicular
4. shifting weight to lateral foot to relieve arch pressure
173
Contrast orthoses used to treat Sever's vs. Kohler's Disease.
```
Sever's = heel lift
Kohler's = soft arch support
```
174
List 3 forefoot problems described in the monograph.
1. Hallux Rigidus
2. Metatarsalgia / Sesamoiditis
3. Morton Neuroma
175
What is Hallux Rigidus?
1st MTP joint degenerative arthritis characterized by stiffness and pain
176
In addition to 1st MTP joint pain, what other area of the foot might also be painful in patients with Hallux Rigidus & why?
Lateral forefoot pain is common as load is transferred away from the painful 1st MTP
177
List the most important interventions to treat Hallux Rigidus.
1. taping of toe to limit motion (early phases for pain control)
2. distraction and extension joint mobilization
3. stiff-soled, deep toe box shoes
178
What type of shoes are best for patients with Hallux Rigidus?
stiff-soled, with a deep toe box; rocker bottoms & low-heeled shoes can also be useful
179
What is a cheilectomy?
common procedure used to treat Hallux Rigidus; removal of bone spurs or the lip of bone that forms as a result of arthritis.
180
How do you tell the difference between metatarsalgia and a neuroma?
metatarsalgia = pain/tenderness over the MTP joints (1st & 3rd are most common); neuroma = pain/tenderness in interdigital space
181
Which MTP joints are the most commonly painful in a patient with metatarsalgia?
1st & 3rd
182
Where does sesamoiditis occur in the foot?
1st MTP joint
183
What is the definition of sesamoiditis?
conditions involving the sesamoids that is characterized by avascular changes or inflammation without radiologic evidence of fracture.
184
List 4 alternate causes of forefoot pain & tenderness that present similarly to metatarsalgia.
1. interdigital neuroma
2. sesamoiditis
3. stress fractures
4. arthritic changes
185
What is the primary goal in treating metatarsalgia conservatively?
reduce load on the forefoot (nonweight-bearing may be recommended in the acute phase)
186
What is the relationship between midfoot/forefoot overload conditions and gastrocnemius lengthening/resection surgery?
grade B level evidence supports gastroc surgery to reduce fore/midfoot pain in adults
187
What is the most common surgical option for metatarsalgia of the 1st MTP?
sesamoidectomy
188
What is the current state of the evidence regarding sesamoidectomy and it's impact on pain & function?
Mixed bag. One study reports 90% of patients returned to normal, but another reports a high percentage (~50%) still had pain.
189
What is a Morton Neuroma?
perineural fibrosis & nerve degeneration of the common digital nerve (usually between the 3rd & 4th metatarsals / 3rd webspace)
190
What is the most common demographic to suffer from a Morton Neuroma?
women between the ages of 45-50
191
What is the theorized mechanism behind the development of a Morton Neuroma?
stress & irritation to the nerve tissue due to excessive toe dorsiflexion (pes planus and tight gastrocnemius may contribute)
192
What is Mulder's Sign?
test for Morton Neuroma; clinician squeezes the forefoot & pushes upward with the thumb at the site of suspected nerve compression; painful click is a (+) test
193
What types of footwear modifications may be useful for patients with a Morton's Neuroma?
soft-soled shoes with wide toe box, felt or gel pad to elevate the metatarsal head on the medial side of the neuroma
194
What is the current evidence on surgical excision for the treatment of a Morton's Neuroma?
Mixed bag, but generally 75%-96% good to excellent relief of symptoms
195
What role does tissue inflammation play in tendonopathy?
considered a tendinosis associated with degeneration rather than inflammation of the tendon; however, the origin of the pain in tendinopathy can come from inflammation of surrounding soft tissues, the peritendon, or perhaps neurogenic mediators that supply the tendon
196
What is the focus of physical therapy treatment of lower extremity tendinopathies?
altering tendon loading through education / bracing & causing remodeling of the tendinosis through exercise instead of anti-inflammatory treatment approaches
197
What is the most common age range for the development of Achilles Tendinopathy?
41-60
198
What is the relationship between obesity and Achilles Tendinopathy?
more research is needed, but analyses find obese people are 2.6x-6.6x more likely to have Achilles Tendinopathy
199
List 6 "intrinsic" risk factors in the development of Achilles tendon problems.
1. limited dorsiflexion ROM
2. abnormal (increased or decreased) subtalar ROM
3. foot pronation
4. decreased plantar flexor strength
5. abnormal tendon structure
6. co-morbidities (obesity, hypertension, increased cholesterol, diabetes)
200
What is the theorized relationship between high blood cholesterol levels and the development of Achilles Tendinopathy?
It's thought that a buildup of cholesterol triggers a low level of ongoing inflammation that affects your tendons, causing pain and susceptibility to injury.
201
List 4 "extrinsic" risk factors in the development of Achilles tendon problems.
mostly training/technique errors:
1. abnormal proximal movements strategies
2. excessive running mileage
3. progressing mileage too quickly
4. toe-landing strategy (in volleyball players)
202
What is the most common location of insertional Achilles Tendinopathy?
6 cm proximal to the insertion
203
Which type of Achilles Tendinopathy is more common: insertional or noninsertional?
noninsertional
204
Describe the general sensitivity and specificity of clinical tests for noninsertional Achilles Tendinopathy.
(Re: palpation, Royal London Hospital test, Arc Sign)
In general these tests have high specificity, but only moderate sensitivity. In other words, the tests are good at correctly identifying people who do not have tendinopathy, but are relatively poor at correctly identifying people who have a tendinopathy.
205
What are the first 3
| keys to diagnosing Achilles tendon problems?
1. identify location of injury
2. determine if inflammation is present (will not move with ROM testing)
3. determine if a rupture is present
206
List 10 conditions that may be confused with Achilles tendinopathies/tears.
1. Plantar Fasciopathy
2. Tarsal Tunnel Syndrome
3. Sural Nerve Neuroma
4. Tumor
5. Infection
6. Systemic Inflammatory Disease (e.g. RA)
7. Retrocalcaneal Bursitis
8. Posterior Ankle Impingement
9. Os Trigonum Syndrome
10. Achilles Tendon Ossification
207
Describe Os Trigonum Syndrome.
Embryologically, the body of the talus and the posterior talar process are separate ossification centers. Between the 7th and the 13th year of life, the posterior talar process appears as a separate ossicle: the os trigonum. When an os trigonum is present, this accessory ossicle together with surrounding soft tissues can become wedged between the tibia, talus and calcaneus. This can lead to inflammation of the involved structures & posterior ankle pain.
208
Describe the 4 elements of a conceptual guideline for treating lower extremity tendinopathies.
1. education
2. unloading
3. reloading
4. protection
209
Education is the first element in the conceptual guideline for treating lower extremity tendinopathies. What should the education component focus on?
extrinsic factors (training errors related to sport, work modification)
210
Unloading is the second element in the conceptual guideline for treating lower extremity tendinopathies. How should Achilles Tendinopathies specifically be unloaded?
- orthotics
- heel lift
- reduce forefoot loading (alterations in movement strategies and/or adaptations to work tasks)
- although cessation from sports or work may sometimes be necessary, altering movement strategies may allow patients to return to sports/work quickly and result in longer-lasting benefits
211
What compensations do patients with Achilles Tendinopathy commonly make when performing home exercises like weight-bearing stretches and eccentric calf strengthening?
1. compensatory motion at the rearfoot (subtalar eversion)
| 2. compensatory motion at the midfoot (flattening of the arch)
212
Describe an eccentric training protocol for treating Achilles Tendinopathy.
- Bilateral heel raise with bilateral eccentric lower
- Progressing to step (incr DF ROM)
- Progress to unilateral eccentric on involved side
- Add weight / backpack
- recommended dosage varies, but 3x15 both with knee flexed and knee extended, once per day for 12 weeks is what is used in clinical trials
- traditionally, patients are encouraged to exercise to the point of pain, but recent RCT suggests that "do-as-tolerated" works just as well
213
```
Summarize the current state of the evidence regarding:
- low-level laser
- iontophoresis
- manual therapy
- taping
and
- night splints
for the treatment of Achilles Tendinopathy
```
- low-level laser & iontophoresis (indicated for inflammatory conditions) have moderate evidence
- manual therapy & taping have low levels of support
- night splints are not recommended
214
What is the general prognosis for conservative management of noninsertional Achilles Tendinopathy?
```
generally good (40%-65% resolution by 5 years), but many will not be able to resume their prior level of physical performance without symptoms (25%-50% ultimately choose surgery)
- most people improve with 3-6 months of treatment
```
215
What are the 3 most common clinical findings associated with intertional Achilles Tendinopathy?
1. swelling within 2 cm of the bony insertion of the Achilles tendon
2. tenderness to pressure
3. stiffness
216
What is the relationship between a patient's fitness level and the type of Achilles Tendinopathy they develop?
Noninsertional: more common to athletes / overloading
| - Insertional: more common to people with relatively lower fitness level
217
What is a Haglund's deformity & how does it affect exercise prescription?
- prominent superior aspect of the calcaneus commonly associated with insertional Achilles Tendinopathy
- process impinges on the tendon & surrounding innervated soft tissues like the bursa and paratenon during dorsiflexion
- patients can still perform calf raises to remodel tissue, but ROM should be limited to 0° dorsiflexion (to the floor)
218
What is a paratenon?
fatty/synovial material (loose connective tissue) between a tendon and its sheath
219
What is the difference in prognosis between insertional and noninsertional Achilles Tendinopathy?
insertional has a poorer prognosis (only 53% satisfied with non-operative treatment)
220
What is the relationship between imaging findings and patient prognosis in those with insertional Achilles Tendinopathy?
less tendon involvement in MRI is associated with better long-term outcome (duh), but patients can improve despite bony spurs, Haglund's deformity, and bursa involvement.
221
How has the incidence of Achilles Tendon ruptures changed over the past decade?
increasing incidence, possibly attributed to a greater number of older adults participating in sports and/or increasing incidence of metabolic and chronic diseases (which are associated with tendon rupture)
222
What is the most likely demographic to suffer an Achilles Tendon Rupture?
40-60 year old men (men are 3-4x more likely to rupture)
223
Compare and contrast surgical vs. conservative management of an Achilles Tendon Rupture.
- in both cases, early full weight-bearing with the ankle immobilized in plantar flexion & ankle mobilization are recommended
- post-op: 0°-30° of plantarflexion is allowed at 3 weeks; orthoses and ROM restrictions are removed at 7 weeks
- conservative: 10-16 weeks with the orthosis
224
What is the leading cause of flat foot deformity?
Posterior Tibial Tendon Dysfunction (PTTD)
225
Why is early treatment of Posterior Tibial Tendon Dysfunction important?
PTTD is progressive in nature as the tendon function decays
226
Describe the use of orthotics and bracing in treating patients with Posterior Tibial Tendon Dysfunction.
- to unload the tendon, braces that anchor support proximally to the tibia are theoretically more effective than orthotics
- followed by transition to an in-shoe orthotic (off-the-shelf or custom) to control hindfoot eversion/inversion and support the arch
227
Compare and contrast solid vs hinged AFO for the treatment of Posterior Tibial Tendon Dysfunction.
Solid may be better for severe deformities & compromised plantar flexor function (as a result of midfoot instability), but hinge is preferred because it doesn't limit plantarflexion & helps to prevent the development of PF weakness
228
What is the natural history of Posterior Tibial Tendon Dysfunction?
ongoing degenerative condition with intermittent episodes
229
Fibularis Tendinosis is sometimes associated with which foot posture?
Cavus or supinated foot posture (subtalar inversion)
230
What ankle condition is commonly confused with a lateral ankle sprain or missed when someone has a lateral ankle sprain?
acute onset of fibularis tendinopathy
231
List 6 potential clinical signs of Fibularis Tendinopathy.
1. pain along the posterior lateral region of the foot
2. swelling
3. clicking
4. visible tendon subluxation
5. subtalar eversion weakness
6. pain with heel rise tasks
232
How do you distinguish a lateral ankle sprain from fibularis tendinopathy?
location of pain (postero-lateral ankle) and weakness of subtalar eversion = tendinopathy
233
What special test is used to detect subluxation of the fibularis tendons?
resisted ankle dorsiflexion and subtalar eversion (dorsiflexion draws tendons around the lateral malleolus & eversion forces the tendons laterally if the superior fibular retinaculum is damaged)
234
What is the role of casting and other forms of immobilization for patients with Fibularis Tendon subluxation?
immobilization does not improve stability of the tendons (surgery is recommended when subluxation is present)
235
How common are ankle/foot fractures? What is the most common type?
Very common: ~25% of all fractures; ankle fracture is the most common type: ~10% of all fractures
236
What is the current evidence on return to sport following bimalleolar/trimalleolar fracture?
only 27.3% of patients returned to sport & 18% could not play at all
237
What is the prognosis following surgical treatment of ankle fractures?
functional recovery is expected, but the extent varies; 6 months post-op,
238
What is the relationship between ankle ROM and outcomes following immobilization for ankle fractures?
marked restriction in ankle & subtalar ROM is anticipated, but it is not always present; the prognostic value of limited dorsiflexion is only weakly associated with outcomes
239
What local muscles are most at risk for atrophy during ankle immobilization due to a fracture?
- gastrocnemius (lateral more than medial)
- soleus
- tibialis anterior
240
To what extent do leg muscles atrophy when the ankle is immobilized due to a fracture?
15%-30% muscle atrophy post-immobilization
241
How does ankle immobilization due to fracture affect plantar flexor strength?
30%-40% force/torque production of uninvolved side at removal of stabilization
242
What is the long-term effect of an ankle fracture on balance?
at 1 year, single-limb balance is poor
243
List 3 performance-based tests that should be performed post ankle fracture?
1. gait speed
2. timed stair ascent/descent
3. hop tests
244
What is a Jones Fracture?
avulsion of the base of the 5th metatarsal due to strong contraction of the fibularis brevis (twisting injuries)
245
Contrast typical healing of Jones Fractures vs stress fractures
Jones Fractures are avulsions that typically heal with 6-8 weeks of immobilization; 5th metatarsal stress or traumatic fractures have a propensity for poor healing and non-union
246
What are the 2 most common MOI for Calcaneal Fractures
fall from a significant height or motor vehicle accident
247
What type of fracture most commonly occurs in the calcaneus?
comminuted fracture, frequently separating the calcaneus into medial and lateral fragments
248
If a patient sustains a calcaneal fracture, how might they present clinically upon visual inspection?
If anatomical alignment of the fragments is not achieved during reduction, the lateral fragment may give the appearance of an everted hindfoot
249
How does a Calcaneal Fracture affect the fibularis tendons?
frequently, the lateral wall of calcaneus is fractured, leading to bulging and friction on the fibularis tendons
250
Contrast remodeling of cortical vs cancellous bone & to the resultant impact on the development of stress fractures
most stress fractures occur in cortical (compact) bone rather than cancellous; remodeling of cortical bone is slower than cancellous; when training loads are induced faster than the bone can remodel, this can lead to weakening & eventual fracture
251
Why are runners and military recruits two groups that have high rates of stress fractures?
they both tend to rapidly increase training loads
252
What is an "insufficiency" fracture & what populations are most likely to sustain one?
stress fracture not induced by increased training load, but by impaired bone remodeling or low bone mineral density; patients with osteoporosis & with the female athlete triad
253
What is the Female Athlete Triad?
1. disordered eating
2. amenorrhea
3. osteoporosis
254
What phase of running gait has been implicated as a factor for developing a stress fracture?
increased rate of loading at initial contact
255
Running shoes should be replaced after logging how many miles?
300-500 miles
256
Running with what two excessive motions is associated with tibial stress fracture?
excessive hip adduction & rearfoot eversion
257
What imaging modality is most useful for detecting stress fractures?
MRI (radiography frequently don't show a stress fracture)
258
What is the relationship between limited dorsiflexion ROM and the development of Medial Tibial Stress Syndrome?
limited ankle dorsiflexion has not been identified as a risk factor (supports the idea that stretching is not effective in the prevention of MTSS)
259
A recent meta-analysis identified which two risk factors as the greatest predictors of developing Medial Tibial Stress Syndrome?
increased BMI and navicular drop (indicating foot pronation)
260
What other conditions may be occurring in parallel with Medial Tibial Stress Syndrome?
Tibial Stress Fracture and/or Deep Posterior Compartment Syndrome
261
How is a stress fracture differentiated from MTSS?
stress fracture is more focal
262
Pain & paresthesia consistent with what compression of which nerve indicate Compartment Syndrome?
Tibial Nerve
263
Contrast symptom behavior of MTSS vs Compartment Syndrome.
MTSS pain occurs during exercise and only occurs at rest when severe. Compartment Syndrome pain persists after activity
264
What is the gold standard test for Compartment Syndrome?
pressure in the deep posterior compartment
265
Describe elements of conservative treatment for Medial Tibial Stress Syndrome.
1. relative rest for up to 4 months
2. ice
3. NSAIDs
4. nonweight-bearing activities (swimming, biking, etc)
5. footwear modifications (shock absorption, limit pronation)
266
Describe the stage and assumed underlying pathology of Posterior Tibial Tendon Dysfunction that presents clinically as:
- tenderness to palpation
- swelling around tendon (distal to medial malleoli)
- abnormal morphology of tendon
- pain with heel rise test
Stage I; tendon pathology with or without synovitis
267
Describe the stage and assumed underlying pathology of Posterior Tibial Tendon Dysfunction that presents clinically as:
- tenderness
- swelling
- abnormal morphology
- pain with heel rise
- flexible flat foot posture
Stage II; tendon pathology with or without synovitis, damage to spring ligament or other soft tissue supports to the foot (hypermobility of talonavicular joint)
268
Describe the stage and assumed underlying pathology of Posterior Tibial Tendon Dysfunction that presents clinically as:
- tenderness
- swelling
- abnormal morphology
- pain with heel rise
- inflexible flat foot posture
Stage III; tendon pathology with or without synovitis, damage to spring ligament (may also include deltoid ligament, and/or talonavicular hypermobility), development of joint contractures
269
Describe the stage and assumed underlying pathology of Posterior Tibial Tendon Dysfunction that presents clinically as:
- tenderness
- swelling
- abnormal morphology
- pain with heel rise
- inflexible flat foot posture
- ankle osteoarthritis
Stage IV; tendon pathology with or without synovitis, damage to spring ligament (may also include deltoid ligament, and/or talonavicular hypermobility), development of joint contractures
270
Lin et al followed 30 patients with Posterior Tibial Tendon Dysfunction that received 15 months of brace wear (cast followed by orthosis). 8.6 years after initial treatment, what were the long-term outcomes that they discovered?
approximately 70% of patients were symptom-free & not wearing a brace, but 35% had episodes of reoccurrence that caused them to wear the brace a second time
271
Contrast the sensitivity and specificity of the Ottawa Ankle Rules. What does this mean clinically?
excellent sensitivity (~100%), but poor specificity (7.8%); negative result = no fracture, but positive result doesn't necessarily mean a fracture is present.
