Week 13 Ankle/Foot Common Conditions Flashcards
1
Q
Pes Planus (Flat foot)
Common Symptoms
A
- usually incidental unless correlated with a clinical syndrome
- may be due to subluxation of talus, traumatic deformities, ruptured plantar fascia, Charcot foot, neuromuscular imbalances `
2
Q
Pes Planus (Flat foot)
Exam findings
A
- Gastroc/soleus tightness
- post tibial tendon dysfunction
- Midfoot laxity/instability ( can no longer act as a strong lever during push off)
- ABD of forefoot
- ER of hindfoot
3
Q
Pes Cavus (High Arch)
Common Symptoms
A
- less common
- may be due to neuromuscular problem
- anything beyond 1 SD of the mean foot posture measure
4
Q
Pes Cavus (High Arch)
Exam Findings
A
- inverted hindfoot and midfoot
- Forefoot in PF and ADD
- High medial arch during weight bearing and inverted calcaneus
(+) navicular drop
(+)Too many toe signs
5
Q
Pes Cavus (High Arch)
Interventions
A
Accommodate the rigid foot
- orthotics: shock absorption/distribution of pressure
6
Q
Hallux Valgus (Bunions)
Common Symptoms
A
- pain at 1st metatarsal with walking
- pain with standing
- parasthesia in 1st metatarsal
- joint redness and pain
- difficulty finding shoes with proper fit
- inability to wear stiff shoes
- more common in woman
- contributing factors: pes planus, xs pronation, genu valgus, limited DF , arthritis, LLD, neuro conditions
7
Q
Hallux Valgus (Bunions)
Exam findings
A
- valgus deviation of great toe (lateral)
- varus (medial) deviation of 1st metatarsal
- > 15 degrees of deviation of hallux from 1st MTP
- hypomobility of 2nd PIP
- callus and blister formation around bunion (bump on medial side of great toe)
Altered gait and mechanical issues of forefoot
8
Q
Hallux Valgus (Bunions)
Intervention
A
- correct forces acting on 1st MTP
- strength
- stretch
- splinting
- orthotics
- toe spacers
- address inflammation
9
Q
Hammer Toe
A
Only 1-2 toes does not typically include MTP extension
- A hammertoe is curled due to a bend in the middle joint of the toe.
10
Q
Claw Toe
A
- Includes extension of MTP, flexion of all IP’s and often all toes, generally neuromuscular
- metatarsalgia (pain in ball of foot)
- corns due to increased pressure at dorsum of PIP, plantar to nail bed ( flex of PIP/DIP), dorsum of MTP (extension deformity of MTP)
11
Q
Mallet Toe
A
Abnormal flexion of DIP
- may be isolated or 2 degrees to hammer toes
- most frequent at 2nd toe
- corns may develop plantar to nail bed
12
Q
High Ankle Sprain
Common Symptoms
A
- Syndesmotic sprain(tib/fib)
MOI= ankle DF and ER of tibia on a planted foot also xs DF or Inversion
13
Q
High Ankle Sprain
Exam Findings
A
- pain due to= tib-fib loss of stability/ gapping with DF due to increased width of talar trochlea
- Syndesmosis tenderness (over ATFL)
- Unable to single leg hop (best indicator)
(+) squeeze/ER (kleiger)
14
Q
High Ankle Sprain
Intervention Phase 1
A
protection
- allow for healing and decrease inflammation
- immobilize
- AD to normalize gait
-PRICE
- pain free ROM
- Progress when pain/edema is controlled and normal gait
15
Q
High Ankle Sprain
Intervention Phase 2
A
- restore normal ROM
- Improve strength
- NM control
- Joint mobs/stretching
- progress when able to jog/hop
subacute
16
Q
High Ankle Sprain
Intervention Phase 3
A
sport specific training
- Aggressive strength
- NM training
- Agility
17
Q
Lateral ankle Sprain
Common Symptoms
A
- ligaments involve: ATFL/CFL/PTFL
- H/o previous ankle sprain
- no use of external support, proper warm up, balance/proprioceptive training
- Lack of normal DF
MOI= Pf with inversion
18
Q
Lateral Ankle Sprain
Exam Findings
A
- Men= increase talar tilt
- Woman = increased calcaneal eversion, increased tibial varum, participation in high risk sports
Sprain Vs. Fx (ottawa rule)
1. inability to bear weight ( can’t take more than 4 steps)
2. Medial/lateral malleolus point tenderness
3. 5MT base tenderness
4. Navicular tenderness
19
Q
Lateral Ankle Sprain Intervention
A
- Phase 1= max protection
- Phase 2= weeks 1-2 progressive ROM and early strengthening
- Phase 3 weeks 2-3 progressive strengthening
- Weeks 3-6 advanced strengthening and return to sports
20
Q
Recurrent Sprains/Chronic Instability
Common Symptoms
A
Functional Ankle Instability
- recurrent ankle sprains with absence of objective joint instability
- Due to mm weakness, altered mm recruitment patterns, decreased ankle ROM, balance problems, joint proprioception
Mechanical Ankle Instability
- recurrent ankle sprains with evidence of ankle ligament laxity
- Due to loss of ligament function leading to decreased strength, decreased ROM
- may loose bodies, chondral defects, anterior scar tissue
21
Q
Recurrent Sprains/Chronic Instability
Exam Findings
A
- difficulty running on uneven surfaces, cutting/jumping, feeling of giving way, recurrent pain and swelling tenderness, weakness
(+) anterior drawer/talar tilt
22
Q
Recurrent Sprains/Chronic Instability
Interventions
A
- balance exercises
- ankle supports
- taping
23
Q
Anterior Impingement Syndrome
Common Symptoms
A
- anterior ankle pain worse with extreme DF
- pain with squatting, climbing stairs, fast walking
- may be caused by repeated microtrauma along anterior talocrural joint line, leading to scar tissue formation, and the synovitis or capsulitis of the CTR of the Tib-Fib joint capsule becomes impinged
24
Q
Anterior Impingement Syndrome
Exam Findings
A
- decreased DF
- Pain with forced DF
- TTP anterior ankle
- No swelling
25
Anterior Impingement Syndrome
Interventions
- activity modification
- cryotherapy
- NSAIDs
- Stretch AT and strengthen DF
- manual Therapy to increase DF
- Surgery if conservative fails
26
OA
Common Symptoms
MOI= h/o recurrent ankle sprains or fx
1. Type 1= isolated ankle arthritis
2. Type 2= OA with intraarticular varus or valgus deformity or tight heel cord, or both
3. Type 3 = OA with hindfoot deformity, tibia malunion, midfoot abducts or adducts, supinated midfoot, PF 1st ray
4. Type 4= Types 1-3 + subtalar, calcaneal cuboid or talonavicular arthritis
27
OA
Exam Findings
- decreased ROM
- Ankle weakness
- Impaired balance
- varus/valgus hindfoot deformity
28
OA
Interventions
Conservative:
- cane (decrease load)
- bracing/shoe inserts (rocker sole and SACH)
- Viscosupplementation
Surgery:
- Debridement
- Allograft transplantation
- Distraction arthroplasty
- Total ankle replacement/arthrodesis
29
Plantar Fasciitis
Common Symptoms
- gradual onset
- pain with 1st step in the morning
- Pain in the medial heel
- Pain in calf/toes
- worse with increased activity or after sitting
- Treat more like an osis
-Strongly influenced by activity rather than foot posture
10 month clinical course
30
Plantar Fasciitis
Exam Findings
- TTP medial calcaneal tubercle
- slight swelling
- Achilles tightness
- Decreased DF ROM
- (+) windlass test
Predictors:
- age 45-64
- overweight
- bilateral DF limitations
- Occupation or activity that requires prolonged standing
31
Plantar Fasciitis
Interventions
- taping
- education
- orthotics
- Stretching G-S, AT, Plantar fascia
- splints
- Manual Therapy
- Modalities
32
Lisfranc Injuries
Common Symptoms
MOI=longitudinal forces or axial load applied to a PF ankle and foot, direct crush
-thick ligament arising from medial aspect of 1st cuneiform and attaches to base of 2nd metatarsal
1. Stage 1= no change in separation between 1st and 2nd metatarsal , no loss of medial longitudinal arch height
2. Stage 2= 1mm-5mm separation no loss of arch
3. Stage 3 = >5mm separation, with loss of arch
33
Lisfranc Injuries
Exam Findings
- depending on severity there is a spectrum of deformity, swelling, and medial foot pain
(+) midfoot squeeze
34
Lisfranc Injuries
Interventions
1. Stage 1 Injuries:
- immobilize x 6 weeks
- if pain free, orthosis with return to function
- if pain , weight bearing AFO for additional 4 weeks
2. Stage 2 and 3 Injuries:
- ORIF
- NWB x8 weeks
- PWB to FWB in 8-12 weeks
- Custom medial arch support
- differentiate between instability and sprain, instability usually requires surgery
35
Sever Disease
Common Symptoms
MOI= traction force that AT pulling on the bone fragment before the calcaneus ossifies fully, overuse and microtrauma during sports that require repetitive loading ( running/soccer), overweight
- Calcaneal apophysitis
- inflammation of the 2 degree calcaneal ossification that is open in childhood
- Mainly boys 6-8 y.o
36
Sever Disease
Exam findings
- more common in pes cavus vs. pes planus
-intermittent or continuous heel pain with weight bearing shortly after beginning new sport or season
- may have malalignment
- may have reduced flexibility in AT, plantar fascia, posterior tib, and peroneal tendons
(+) squeeze test
37
Sever Disease
Interventions
- rest
- ice
- heel lift
- shoe inserts
- stretch G-S and plantar fascia
- Avoid barefoot walking
- typically resolves in 2-4 weeks
38
Hallux Rigidus/Limits
Common Symptoms
- degenerative arthritis of 1st MTP (higher incidence in females)
- lateral foot pain
- stiffness
- intermittent to constant pain
- H/o injury to 1st MTP
- pain when walking (push off) or running up hills
- tingling or numbness (compression of cutaneous nerves)
39
Hallux Rigidus/Limits
Exam Findings
- limited 1st MTP DF
- TTP1st MTP ( dorsal and lateral)
- antalgic gait/compensated gait
40
Hallux Rigidus/Limits
Interventions
- taping 1st MTP to limit motion
- joint mobs: distraction, extension
- Foot wear mods: deep or wide toe box, stiff shoes with rocker bottoms, steel shank
- in shoe orthotics that limit MTP movement
- Surgery: removal of bone spurs (goal is to achieve 70 degrees of extension)
41
Morton's Neuroma
Common Symptom's
- Fibrosis and nerve degeneration of the common digital nerve, usually between 3rd and 4th metatarsals
- mainly in women 45-50 y.o
- sharp and burning intermitted pain and paresthesia with plantar pressure on the met heads, click with forefoot squeeze and push upward at site of compression
- develops as a result of stress and irritation to nerve
- worse with prolonged running, squatting, aggravated with narrow toe box and high heels
42
Morton's Neuroma
Exam Findings
- rarely bilateral
- may present with pes planus
- may present with tight G-S
- DF of metatarsals
(+) morton's
43
Morton's Neuroma
Interventions
- steroid injection
- soft soled shoes with wide toe boxes
- elevated met head on medial side of neuroma to prevent compression
44
Sesamoiditis
Common Symptoms
MOI= mechanical overload, trauma, repetitive high impact sports
- Avascular changes or inflammation of the sesamoids
- most often at medial/plantar at tibial sesamoid
- Exacerbated by weight bearing activities
- At flexor hallucis brevis
45
Sesamoiditis
Exam Findings
- Predisposing factors: pes cavus, PF 1st ray, ankle equinas
- pain, tenderness and swelling under the sesamoid aggravated by movement of the great toe
46
Sesamoiditis
Interventions
Conservative
- elevate proximally, unload, restrict forefoot loading
- Taping
- NSAIDs
- low heeled shoes with soft support proximal to met heads
- cortisone injections
Surgical
- sesamoidectomy
47
Achille's tendinopathy
Common Symptoms
- overuse and overloading can lead to microtears and inflammation
- May also include retrocalcaneal bursitis and or bone spurs (insertional AT--> poorer prognosis)
- occurs at origin of AT and is associated with bursa and bone involvement
- sedentary and overweight
48
Achille's Tendinopathy
Exam Findings
- pain, increased temp, redness, swelling (2cm of insertion) tenderness, crepitus
- non insertional ( away from insertion point)
49
Achille's Tendinopathy
Interventions
- Eccentric training (G-S)
- Load the AT to promote remodeling
50
Achille's Rupture
Common Symptoms
- most often occur during sport activities in males 30-50 y.o
- Sudden pain, inability to bear weight, weakness, especially in PF
51
Achille's Rupture
Exam Findings
(+) Thompson
- decreased ankle PF strength
- palpable gap (defect loss of contour)
- increased ankle DF with gentle manipulation
52
Achille's Rupture
Interventions
- surgical
-Nonsurgical if acute( weakly recommended)
53
Posterior Tibial Tendon Dysfunction
Common Symptoms
- Insidious onset
-Swelling
- Pain with standing, walking, running, stair climbing
- Commonly associated with flat foot
- Spring ligament may be injured
54
Posterior Tibial Tendon Dysfunction
Exam findings
- pain and weakness on MMT PF/Inversion
- TTP along tendon at navicular and med malleolus
- Unable to perform heel raise
- G-S tightness
- medial longitudinal arch height lowering
- Decreased navicular height (midfoot instability)
- hindfoot eversion
- abnormal gait
(+) too many toe sign
55
Posterior Tibial Tendon Dysfunction
Interventions
- bracing
- orthotics (custom hinged AFO)
- exercise (concentric and eccentric)
- Bilateral heel raises
56
Medial Tibial Stress Syndrome (Shin Splints)
Common Symptoms
- Associated with athletes who participate in intense, repetitive weight bearing activities
- Tibial periosteum inflammation, secondary to bony weakness and local stress
- Often bilateral and commonly located at distal 2/3rd of tib
57
Medial Tibial Stress Syndrome (Shin Splints)
Exam findings
- intrinsic risk factors: may have weakness of tib anterior, EDL, or EDB, poor biomechanics (xs or abnormal pronation), restricted ankle DF
- pain during or after exercise, may last hours or days (diffuse 5cm pain at posteromedial border)
- TTP
- Risk factors: female, high BMI, sedentary, previous LE injury
58
Medial Tibial Stress Syndrome (Shin Splints)
Interventions
- rest/ice/NSAIDs
- low load exercises
- activity modification
- strengthening (G-S, Core, foot inverison/eversion)
- Footwear mods
- Address proximal impairments
59
Nerve Entrapment Injuries
Deep Peroneal N. L4-S2
MOI= blunt trauma
Location of Entrapment
- anterior compartment of the lower leg
- extensor retinaculum (anterior tarsal syndrome)
Signs/Symptoms
- motor loss, high steppage gait, and inability to control ankle movement
- sensory loss and possible pain referral in a small triangle area between the first and second toes
- pain with plantar flexion
60
Nerve Entrapment Injuries
Superficial Peroneal Nerve L4-S2
MOI= ankle inversion
Location of Entrapment= near the head of fibula and lateral foot
Signs/symptoms
- loss of foot eversion and ankle stability
- sensory lateral side of the leg and dorsum of the foot
- symptoms increase with plantar flexion and inversion of the foot
61
Nerve Entrapment Injuries
Tibial Nerve L4-S3
MOI= knee trauma, bow or dislocation or ankle sprain
Location of Entrapment=
- popliteal fossa
- tarsal tunnel: swelling from sprains
- deltoid ligament
- calcaneonavicular ligament (spring ligament)
- deep fascia of the abductor hallucis and the quadratus plantae
Risk Factors= valgus deformity
Signs/Symptoms= symptoms vary depending on location of nerve entrapment
62
Nerve Entrapment Injuries
Tibial Nerve L4-S3 entrapment at Popliteal Fossa
- inability to plantar flex and invert the foot
- inability to flex abduct or adduct the toes
- sensory loss on sole of the foot, lateral surface of the heel and plantar surfaces of the toes
63
Nerve Entrapment Injuries
Tibial Nerve L4-S3 Entrapment at the Tarsal Tunnel and Deltoid Ligament
- pain and paresthesia's on the sole of the foot and medial side of the ankle distal to the medial malleolus
- motor weakness in the terminal branches of the lateral and medial plantar nerve
- Worse after activity, end of the day
- can be similar to plantar fasciitis
64
Nerve Entrapment Injuries
Tibial Nerve L4-S3 Entrapment at the Calcaneonavicular Ligament:
- pain and paresthesias on the medial plantar nerve
- arching in the arch
- burning pain in the heel
- altered sensation on the sole of the foot behind the hallux
65
Nerve Entrapment Injuries
Tibial Nerve L4-S3 ENtrapment at the Deep Fascia of the Abductor Hallucis and Quadratus Plantae:
- pain and paresthesias on the lateral nerve
- dull and aching pain on the heel
