Week 8 finished Flashcards
Case info:
Laura is a 43 year-old mother of 4 who works long hours on her feet as a theatre nurse. Laura decided recently that the long hours were taking a toll on her and preventing her from supporting her kids through their high school exams so she cut her work back to three days per week.
Laura says she used to be quite active but for the last five or six years her work schedule has limited her ability to do any regular exercise, she thought working less was a good excuse to re-join the gym and get back into shape. She is about 15kg overweight but otherwise healthy.
Laura presents to your clinic with left heel and plantar pain. She says she had something similar years ago but it went away after seeing a podiatrist who taped her foot. She notes that the pain is particularly severe each morning on rising and also occurs toward the end of, and after her nursing shifts. She thinks the problem began after jogging on the treadmill six weeks ago.
- Review the bones of the foot and ankle and their relationships to one another.
Tarsals:
- Talus
- Calcaneus
- Cuboid
- Navicular
- 3 x cuneiforms
Metatarsals x 5
2 x sesamoid bones
14 x phalanges
- List the major ligaments supporting the talocrural and subtalar joints.
Medial Collateral (Deltoid) Ligament
- Fan-shaped ligament arising from the tibial malleolus and attaching to the navicular (anteriorly), talus and calcaneus (posteriorly & inferiorly).
- It limits medial distraction
Lateral Collateral Ligament
- Composed of the anterior (weakest) and posterior (strongest) talofibular ligaments and the calcaneofibular ligament.
- Inferior extensor retinaculum and superior peroneal retinaculum contribute to stability. Generally weaker and more prone to injury than the deltoid ligament.
- What movements are available at the talocrural and subtalar joints? What is the most stable position for each joint?
Talocrural joint:
- Dorsiflexion and plantar flexion across an oblique axis through the 2 malleoli and the body of the talus. This means that the movement at this joint actually occurs across 3 planes.
- Inclined laterally 10 degrees to horizontal
- Rotated laterally 20-30 degrees to coronal.
Most stable position is in Dorsiflexion.
Subtalar joint:
- Pronation and supination across an oblique axis so that movement occurs over all 3 planes.
- Supination = calcaneal adduction, inversion and plantar flexion.
- Pronation = calcaneal abduction, eversion and dorsiflexion
Most stable position is Supination as ligamentous tension draws the joint surfaces together
What is the normal ROM of the talocrural joint?
20 degrees DF
30-50 degrees PF
- What is the major function of the mid- or transverse- tarsal joints?
It allows independent movement of the forefoot and rear foot and allows the foot to change according to the terrain.
What is the transverse tarsal joint made of?
The talcalcaneaonavicular joint and the calcaneocuboid joint.
- Define the following conditions which affect the digits:
a. Metatarsalgia
Is pain at the metatarsal heads often associated with weight gain, pes planus and poor intrinsic muscle use preventing toe weight bearing and increasing metatarsal head weight bearing.
- Define the following conditions which affect the digits:
b. March fracture
- Stress fracture of the metatarsals (usually 2nd or 3rd) typically associated with excessive walking.
- Tender lump in the neck of the met. Predisposed by calf tightness.
- Define the following conditions which affect the digits:
c. Frieberg’s disease
Is avascular necrosis of met head
- Define the following conditions which affect the digits:
d. Morton’s neuroma
- Usually affects women around 40-50.
- An enlargement of the plantar digital nerves – usually between 3rd and 4th digits.
- The enlargement gets compressed between the ground and the transverse metatarsal ligaments and is irritated.
- Define the following conditions which affect the digits:
e. Sesamoiditis
Inflammation of the sesamoid bone
- Define the following conditions which affect the digits:
f. Hammer toe
- Associated with metatarsophalangeal extension and fixed PIP flexion – usually accepted but some undergo surgery.
- Imbalance of flex/ext associated with weakness of the interossei and lumbricals.
- Define the following conditions which affect the digits:
g. Hallux valgus
- Commonest deformity of foot – associated with shoes (not seen in people who’ve never worn shoes) especially high heels.
- May consist of metatarsal splaying with valgus hallux causing crowding of other toes and likely bunion – often leads to OA.
- Also associated with pes planus.
- Define the following conditions which affect the digits:
h. Hallux rigidus
Pain on walking, unable to extend toe, decreased stride length
- What is the relationship of pes planus to all of these conditions? https://open.spotify.com/track/1Je1IMUlBXcx1Fz0WE7oPT
- Pes Planus (flat foot) = poor arches -> lack of support and distribution of forces.
- Increases weight distribution towards the medial side of the foot -> predisposing one to metatarsalgia, sesamoiditis and March fracture, etc
- Flattened foot -> broader -> shoes are tighter-> predispose one to Hallux Valgus and even Rigidus
- Trigger points in extensor digitorum longus and tibialis anterior can cause toe and foot pain. Which conditions do these mimic?
The pain can feel as though its originating from the joint when in fact its originating from tibialis anterior.
This pain is often falsely attributed to arthritis, “turf toe” or gout. (trigger points that mimic gout and actual gout can commonly coexist).
- List the structures passing under the flexor retinaculum. What is tarsal tunnel syndrome?
The flexor retinaculum creates the tarsal tunnel posterior and inferior to the medial malleolus. It encloses:
- the tendons of the flexors of the ankle and foot
- posterior tibial artery and vein
- posterior tibial nerve
TOM DICK AND VERY NAUGHT HARRY (ANT TO POST)
Tarsal tunnel syndrome is analogous with carpal tunnel syndrome.
- involves heel pain from compression of the tibial nerve often by inflamed flexor tendons.
- The pain is often worse at night and patient may get up and stamp foot, walk or twist foot.
- List the tarsals forming the transverse arch and the medial longitudinal arch. Which tarsal is the key in each arch?
TRANSVERSE ARCH: Best visualised at the level of the anterior row of the tarsal bones.
Formed by:
- the metatarsal bases
- cuboid
- 3 cuneiforms
** the medial cuneiform is the keystone of the arch.
MEDIAL LONGITUDINAL ARCH: Formed by: - the calcaneus - the talus - the navicular - the three cuneiforms - the first 3 metatarsal bones ** talus forms the keystone of the arch.
- List the dynamic and static supports of each of the plantar arches.
TRANSVERSE ARCH:
- Tibialis anterior: originates in the upper two-thirds of the lateral surface of the tibia and interosseous margins, and inserts into the medial cuneiform and medial and plantar surfaces of the first metatarsal.
- Peroneus Longus: head and proximal 1/3 of the lateral surface of the fibula and crosses the plantar surface of the foot to attach to the lateral sides of the medial cuneiform and 1st metatarsal base.
GENERAL LONGITUDINAL ARCH:
- Flexor digitorum longus: arises from the posterior surface of the body of the tibia and inserts into the bases of the last phalanges of the second, third, fourth, and fifth toes.
- Flexor hallucis longus: arises from the inferior two-thirds of the posterior surface of the body of the fibula and inserts into the base of the last phalanx of the great toe.
- Peroneus Longus: head and proximal 1/3 of the lateral surface of the fibula and crosses the plantar surface of the foot to attach to the lateral sides of the medial cuneiform and 1st metatarsal base.
MEDIAL LONGITUDINAL ARCH:
- Plantar calcaneonavicular ligament (spring ligament) is the main ligamentous support - anterior margin of the sustentaculum tali of the calcaneus to the plantar surface of the navicular.
- Tibialis posterior - Runs posterior to the medial malleolus and inserts on the navicular, cuneiforms, cuboid and bases of 2nd to 4th metatarsals.
LATERAL LONGITUDINAL ARCH:
Long plantar ligament supports the lateral aspect of the longitudinal ligament.
- What is policeman’s heel?
Policeman’s heel refers to tenderness under the calcaneous in the location of the fibro-fatty tissue. If this tissue degenerates or spreads out its cushioning affect is reduced and inflammation or contusion of the underlying calcaneous may ensue. Can be differentiated from plantar fasciitis as stretching the plantar surface does not aggravate policeman’s heel.
- Describe the anatomy of the Achilles (calcaneal) tendon.
- Begins as a continuation of the gastroc aponeurosis about halfway down the calf.
- Fibres are joined by the soleus, Soleus inserts medial and gastrocs inserts laterally on calcaneus.
- Insertion of gastroc soleus and plantaris
- Inserts on posterior surface of the calcaneous.
- Myofascially continuous with plantar fascia
- Fibres wrap around each other and assist recoil. (Typically the fibres wind 90 degrees so the gastroc ends up attaching more laterally – wind up to store energy.)
On questioning, you find that Laura works on concrete and lino flooring and generally wears ballet flats under her booties at work. She has tried massaging and icing her feet but this provides only temporary relief.
Clinical application
xx
- List the causes of heel pain.
- Planatar fasciitis
- Calcaneal bursitis
- Fat pad iritiation
- Gout
- L5 disc herniation (causing S1 radiculopathy)
- Tarsal tunnel syndrome
- Entrapment of the lateral plantar nerve
- Rupture of the plantar fascia
- Calcaneal stress fracture
- Achilles tendonitis (tear, rupture, inflammation, soleus rupture will refer pain down the posterior aspect of the calcaneus.
- Bone bruises
- Haglund’s deformity (bony growth at the back of
the heel) - Sever’s disease (Growth plate closes around 11,
consider up to age of 15) - Soft-tissue sarcoma of the foot (rare)
- Stress fractures of the heel.
- Infection
