The Foot & Ankle Flashcards
What are the components of the hindfoot?
talus & calcaneus
What are the components of the midfoot?
medial cuneiform, intermediate cuneiform, lateral cuneiform, navicular, cuboid
What are the components of the forefoot?
metatarsals (5) & phalanges (14)
What are the 2 primary ligaments that support the ankle joint laterally?
anterior talofibular ligament (ATFL) & calcaneofibular ligament
Which ankle movements are checked by the calcaneofibular ligament?
inversion & adduction of the calcaneus relative to the fibula
What motion is checked by the posterior talofibular ligament?
external rotation of the talus
What actions does the fibularis longus perform?
- subtalar pronation
- supports transverse arch of foot
- plantarflexion of 1st metatarsal
What actions does the fibularis brevis muscle perform?
- subtalar pronation
- forefoot abduction
What 3 muscles comprise the deep posterior compartment of the lower leg? Which is the strongest?
- flexor hallucis longus
- flexor digitorum longus
- tibialis posterior (strongest by a large margin)
What do the cross-sectional area and moment arm of the posterior tibialis tell us about its role in ankle movement?
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
What is the action of the muscles of the deep posterior compartment of the lower leg?
subtalar joint supination (also hypothesized to raise the medial arch & plantarflex the toes)
What are the 4 muscles of the anterior compartment of the lower leg?
1, tibialis anterior
- extensor digitorum longus
- extensor hallucis longus
- fibularis tertius
Explain why the talocrural joint is more stable in dorsiflexion and less stable in plantarflexion.
the trochlea of the talus is wider anterior than posterior, so it sits more snugly in the mortise (distal tibia/fibula) in dorsiflexion.
Describe the movements of the calcaneus and talus during supination and pronation. How do these movements affect the medial longitudinal arch?
- 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.
What are the two most important joints that contribute to the locking mechanism of the midfoot?
transverse tarsal joints (talonavicular & calcaneocuboid joints)
Describe the Windlass mechanism.
Extension (dorsiflexion) of the toes increases tension on the plantar fascia, which in turn supports the medial longitudinal arch.
What is the relationship between tibial rotation and arch height?
tibial ER results in an increase in the height of the medial longitudinal arch; IR results in a lower arch
How does the hip affect arch height? Is the tibial controlled by more proximal or distal forces/positions?
Tibial rotation affects arch height & is controlled more by proximal forces from the hip (femoral rotation) than distal foot/ankle positioning with orthoses.
What group of muscles are primarily responsible for propulsion and support during gait?
plantar flexors
During what phases of gait are the plantar flexors most active?
mid-stance to just prior to toe off
Describe the sagittal plane movement of the ankle during gait
- 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)
What is the role of the soleus during gait?
slows the tibia after foot flat
In older patients, what is the relationship between ankle strength and hip muscle activity during gait? How is this addressed clinically?
- 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
Describe the movement of the subtalar joint throughout the gait cycle.
- pronation/eversion from initial contact to foot flat (10%-15% of stance)
- rapidly supinates/inverts during terminal stance (peaks near 90% of stance)
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
What are the primary inverters of the foot & ankle?
tibialis anterior and tibialis posterior
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
What is the functional problem with an acquired flat foot?
midfoot instability (foot is too flexible at push-off)
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
Overactivity of which muscle(s) is thought to cause pes cavus (high arch)?
either tibialis posterior or tibialis anterior or both
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)
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
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)
List the 4 aspects of the chief complaint during the patient history portion of an ankle/foot evaluation
- pain (constant vs intermittent)
- location
- severity
- nature (aching, burning, sharp, tingling)
List the 5 aspects of the onset of symptoms during the patient history portion of an ankle/foot evaluation
- time since injury
- insidious
- traumatic
- gradual / acute
- training
List the 9 aspects of the behavior of symptoms during the patient history portion of an ankle/foot evaluation
Worse:
- activity (beginning vs end of day, increase training, etc)
- night pain?
- first step in morning?
- walking with/without shoes
- distance able to walk without pain
- functional tasks (stairs, squatting, running)
Better:
- rest
- activity?
- walking with/without shoes
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?
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)
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
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.
What are the two elements of the mechanism of ankle/foot injuries that should be ascertained during the patient history, if possible?
- foot position (dorsiflexion/plantar flexion)
2. the deforming force (inversion/eversion)
What are the 6 components of the Foot Posture Index (FPI-6)?
- talar head position
- supralateral and infralateral malleolar curvature
- calcaneal frontal plane position
- prominence of the talonavicular joint
- congruence of the medial longitudinal arch
- abduction/adduction of the forefoot on the rearfoot
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
What are the two take-aways from the current literature on arch height measurements?
- there is an association between foot posture and injury (pronation & hip, knee, or back pain)
- there is an association between foot posture and loading (high arch & incr vertical loading rate)
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 (+)
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
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)
What are the 4 balance tests suggested by the authors for foot/ankle injury examinations?
- Single-Leg Balance test
- Foot Lift test
- Star Excursion Balance test
- Heel Raise test
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
Should a bilateral or unilateral heel raise test be performed during an ankle/foot examination?
both
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
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
A low heel height during a Single Heel Raise test can indicate what 3 different issues?
- plantar flexor weakness / inability to lift one body weight
- shortening of plantar flexors
- midfoot instability / flat foot deformity
What are the 5 items to observe when a patient is performing the Single Heel Rise test?
- heel height
- knee & trunk position
- subtalar joint inversion/eversion
- 1st metatarsal dorsiflexion / plantar flexion
- pressure distribution under the forefoot
During the Single Heel Rise test, which observation(s) suggest weakness or fatigue?
lowering heel height and/or knee & trunk flexion compensations
During the Single Heel Rise test, which observation(s) suggests posterior tibialis weakness?
inability of hindfoot to invert and/or lateral forefoot weight-shift
During the Single Heel Rise test, which observation suggests midfoot instability?
1st metatarsal dorsiflexion
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
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
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
List the 8 tests in the control sequence of functional tests for return to sports evaluated by Haitz et al.
- Timed lateral step-down
- Timed leap & catch hop sequence
- Single-leg hop for distance
- Single-leg timed hop
- Single-leg triple hop for distance
- Crossover hop for distance endurance sequence
- Square hop test
- Lower Extremity Functional Test (LEFT)
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
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
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
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
What are three different positions in which you may want to measure ankle dorsiflexion?
- supine knee extended
- prone knee bent
- standing knee flexion
What two structures are being assessed with dorsiflexion ROM measurement?
- gastroc/soleus length
2. capsular tightness
What dorsiflexion ROM is considered to indicate “gastrocnemius tightness”?
less than 10°with knee extension (less than 5° is considered severe)
What does decreased ROM of the 1st metatarsal generally result in during gait?
lateral shift of the center of pressure through the forefoot
List the 2 special tests for ankle mobility described in the monograph.
- Anterior Drawer test
2. Talar Tilt test
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
What position should the ankle be in during the Talar Tilt test?
2 options:
- 20° plantar flexion (biases ATFL)
- 10° dorsiflexion (biases CFL)
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
List the 5 special tests for a High (Syndesmotic) Ankle Sprain described in the monograph.
- Dorsiflexion-External Rotation test
- Squeeze Test
- Syndesmosis Ligament Palpation
- Cotton test
- Fibula Translation test
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
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
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
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)
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
List the 4 special tests for Achilles Tendon injury described in the monograph.
- Thompson (Calf-squeeze) test
- Achilles Tendon Palpation
- Royal London Hospital test
- Arc Sign
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)
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
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
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
What 3 additional “other special tests” for the foot/ankle recommended by the monograph authors have significant evidential support?
- Windlass test in weight-bearing
- Tinel Sign
- Homan Sign
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)
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
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)
Infants are born with a flatfoot posture. By what age do we develop a “normal” footprint?
12-13 years old
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.”
List 4 situations in which an adult flexible flat foot posture might be clinically relevant.
- plantar fasciitis
- patellofemoral syndrome
- tibial stress fractures
- in runners specifically (may be linked to injury risk)
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?)
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
What is the relationship between Hallux Valgus and function?
contributes to impaired function (e.g. balance, gait) and increased risk of falls
Hallux Valgus is considered clinically present when the 1st MTP joint is at what angle?
15° or greater
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
In patients with a claw toe deformity, what 3 sites of increased pressure can develop painful corns?
- dorsum of the PIP joint
- plantar to nail bed
- plantar aspect of MTP
In patients with a flexible Hammer/Claw Toe deformity, what are the two main treatments performed? What other external factors can be accommodated?
- taping
- 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)
What is Mallet Toe?
abnormal flexion of DIP (most frequent at 2nd toe - poorly-fitting shoes?)
How should Mallet Toe be addressed in PT?
lengthened toe box or use of a “toe crest” to elevate the toe
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)
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)
What are the two mechanisms that are thought to contribute to pain after a High Ankle Sprain?
- widening of the ankle mortise & resultant decrease in effectiveness of plantar flexors / instability
- gapping of the distal tibiofibular joint during excessive dorsiflexion (trochlea of the talus pushes them apart)
What two subjective descriptions of pain at the time of injury might lead you to suspect a High Ankle Sprain?
- pain out of proportion to the apparent injury
2. pain felt in the shank or knee during injury
Which ankle movement(s) typically reproduce symptoms of a High Ankle Sprain?
- forced dorsiflexion
2. passive external rotation of the foot relative to the leg
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
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
Conservative management may be attempted in which grade(s) of High Ankle Sprain?
grade I (grades II and III need immobilization or internal fixation)