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OCS - Ankle

QuestionAnswer
What ligaments cross the ankle joint? Anterior talofibular, Calcaneofibular, Posterior talofibular
What muscles control eccentric plantar flexion? Tib anterior, Extensor digitorum longus, Extensor digitorum brevis
What are the origin and insertion of extensor digitorum longus? O: Anterior lateral condyle of tibia, anterior shaft of fibula and superior ​3⁄4 of interosseous membrane I: Dorsal surface; middle and distal phalanges of lateral four digits
What are the characteristics of a grade I ankle sprain? -No loss of function -No ligamentous laxity (negative anterior drawer, negative talar tilt) -No point tenderness -Decreased motion of 5 degrees or less -swelling less than .5cm
What are the characteristics of a grade II ankle sprain? -Some loss of function -Positive anterior drawer -negative talar tilt (no calcaneofibular involvement) -point tenderness -decreased overall ROM of 5 to 10 degrees -swelling from .5-2.0 cm
What are characteristics of a grade III ankle sprain? -near total functional loss -positive anterior drawer and talar tilt -hemhorraging -extreme point tenderness -decreased motion greater than 10 degrees -swelling greater than 2.0cm
What are the Ottawa ankle rules? radiographs are indicated if the following are true: 1. tenderness along the tip of the posterior edge of distal lateral malleolus 2. tenderness along the medial malleolus and/or 3. an inability to bear weight for 4 steps.
What are the Ottawa rules for pain in midfoot? radiographs indicated if: 1. tenderness at base of 5th metatarsal 2. tenderness over the navicular 3. inability to bear weight for 4 steps
What are 4 tests for syndesmosis sprain? 1. Palpation 2. External rotation 3. Squeeze 4. Dorsiflexion-compression
What is the dorsiflexion compression test? Test for syndesmosis sprain - pt. is weight bearing in maximal DF and force then applied over both malleoli - if painful, may be a syndesmosis injury
What is the external rotation test for syndesmosis sprain? Pt. sitting with knee bent to 90 degrees. Maximally dorsiflex pt.'s foot, then apply external rotation force. Positive test if pain is felt anteriorly where syndesmosis is.
What are the origin and insertion of the fibularis longus? What are the origin and insertion of fibularis brevis? Longus: O: Head and proixmal two thirds of fibula I: Medial cuneiform at base of 1st metatarsal Brevis: O: Inferior two thirds of fibula I: Base of 5th metatarsal
What are the origin and insertion of the posterior tibialis? O: Tibia/fibula/interosseous membrane I: Navicular and medial cuneiform with slips to metatarsals 2-4
What is are the Tom, Dick and Nervous Harry muscles? Tendons of the: Tibialis Posterior (closest to medial malleolus) flexor Digitorum longus tibial Artery tibial Nerve flexor Hallucis longus (farthest from the medial malleolus)
How is the talar tilt test performed? What does it test for? Pt. sitting in 90 degrees of knee flexion. Examiner grasps distal tib/fib, second hand grasps calcaneus and moves it into inversion. Tests for laxity of calcaneofibular ligament.
What advice should patient with acute lateral ankle sprains be given concerning weight bearing and external supports? Progressive weight bearing, annd use external supports based on severity of injury/phase of healing (more severe injury = immobilization)
What should ice be used for post-acute lateral sprain? Reduce pain and need for mediation and improved weight bearing.
Should ultrasound be used for ankle sprains? Evidence is not good for it
Which muscle invert the foot? Tib anterior, tib posterior
What are the Bernese ankle rules? Used to determine if radiograph of ankle is needed after a sprain
What is the FAAM
What intrinsic factors lead to an overuse injury? Malalignment, muscle imbalances, inflexibility, weakness, instability (for example, high arches)
What extrinsic factors lead to an overuse injury? These are avoidable factors such as: -Poor technique -improper equipment -improper changes in duration/frequency of activity (most common
What are the differences between tendinitis, tendinosis, and tenosynovitis? -Tendinits = acute inflammation of the tendon -Tendinosis = chronic degeneration of the tendon -Tenosynovitis = inflammation of the tendon sheath
What 4 tendons in the ankle/foot are most subject to tendinopathy? -Achilles, posterior tib, peroneal brevis, peroneal longus
What is the difference between the terms tendinopathy, tendinitis, and tendinosis? Tendinopathy is a generic descriptor of pain, swelling, etc. around tendons arising from overuse. Tendinosis and tendinitis may be applied after histopathological examination.
What is tendinosis? Failure of cell matrix adaptation to trauma - imbalance between matrix degeneration and synthesis. Normal collagenous structure is lost replaced by amorphous mucinal material lacking parallel, longitudinal collagen architecture of healthy tendon.
How would you differentiate tendinosis from tendinitis? In tendinosis, no inflammatory response or inflammatory cells are present. More type collagen III than collagen type I.
How does tendinosis develop? Fatigued tendon from overuse loses its reparative ability with overuse - leads to cumulative microtrauma that weakens collagen cross -linking and impairs vasculature of the tendon.
What causes a spontaneous tendon rupture? It is likely end- state manifestation of degenerative process in tendon tissue
What intrinsic factors contribute to achilles tendon disorders? -hyper pronation of the foot -limited subtalar motion -leg length discrepancy -varus deformity of the forefoot -hindfoot inversion
What is forefoot varus? When the inside edge of the foot is higher up off of the ground than the outside of the foot with calcaneus in neutral (if you purposely varus your knee, your forefoot will varus too)
What is a classic history for development of achilles tendon injuries? Insidious, gradual increase in pain located 2-6 cm proximal to insertion and felt after exercise within days of a change in exercise regimen. Rest relieves pain, but return to activity reaggravates it.
How would you distinguish between lesions of the tendon and paratendon? Paratendonitis has crepitus, exquisite tenderness and swelling that doesn't move. Regular tendinopathy has no swelling or crepitus and has focal tender nodules that move as ankle is flexed/dorsiflexed.
What is the painful arc test? Test for tendinopathy (vs. paratendonitis). Pt. in prone and actively dorsiflexes and paraflexes. If you see a nodule moving, it is tendinopathy.
What are three important goals for treatment of achilles tendinopathy? 1. control pain 2. prevent degeneration 3. return to baseline activity
How much should someone with tendinopathy rest? Short course of rest because repair and remodelling of collagen is stimulated by loading of the tendon.
What is the gold stand for achilles tendon rehab? Eccentric exercise targeting muscle hypertrophy, speed, strength and endurance.
For whom is operative achilles treatment recommended? Pt.'s who do not respond adequately to 3-6 month couse of conservative treatment.
What are three distinct stages of posterior tibial dysfunction. 1. Pain and swelling along tendon 2. Unable to perform single heel raise. Collapsed medial arch, hindfoot valgus, subtalar eversion, forefoot abduction. Talonavicular joint can be reduced with foot in equinus 3. flatfoot, unable to single heel raise
What are the origin and insertion of the posterior tibialis O: Tibia and fibula I: Medial cuneiform and navicular
What kind of foot orthosis is recommended for flexible flat foot deformities such as those caused by PTTD? -UCBL brace, molded ankle foot brace, Marzano brace - something to prevent progressive valgus of hindfoot.
What is the definition of a stress fracture? Partial or complete bone fracture that results from repeated application of a stress lower than the stress required to fracture the bone in a single loading
Which part of the leg do most stress fracutres occur in? tibia>metatarsals and fibula
What types of stress fractures are most common in track athlete? Navicular
What types of stress fractures are most common in distance runners? Tibial stress fracture
What types fractures are most common in dancers Metatarsal fractures
What are the risk factors for developing a stress fracture? Hx of previous stress fx. Low bone density. Menstrual irregularity in women. Low calcium intake. High arches (for femoral and tibial stress fractures)
What is the typical presentation of a patient with a stress fracture? insidious onset of activity related pain that progressively worsens over time. Localized bony tenderness (most obvious sign).
What test can be used to confirm a femoral stress fx? Hop test
What is a critical stress fracture (as opposed to non-critical?) Require special attention due to higher rate of nonunion.
Which parts of the leg would a critical stress fracture occur in? Anterior tibia, medial malleolus, talus, navicular, fifth metatarsal and sesamoids
Which parts of the lower leg would a non-critical stress fracture occur in? Medial tibia, fibula and metatarsals 2, 3 and 4
What is the presentation of a Medial tibia stress fracture? Medial shin pain aggravated by exercise. Tenderness in posteromedial border of lower tibia. Rigid, high arch incapable of handling load, or excessive flat flood causing muscle fatigue.
What is the "dreaded black line"? Indicates nonunion of anterior tibial stress fx - due to bony resorption. Anterior cortex of tibia has poor vascularity and increased tension due to bowing of the tibia
What is the treatment program for an anterior tibial stress fracture? 4-6 monts of rest and immobilization, bone stimulation and surger.
What causes fibula stress fracture? Muscle traction and torsional forces (fibula has minimal role in weight bearing, so other forces not in play)
What is the treatment for fibular, medial malleolus, talus fractures and calcaneal fractures? 6-8 weeks of rest.
What types of metatarsal fractions require special consideration? 2nd and 5th metatarsal
What are the three types of 5th metatarsal fractures? 1. tuberosity avulsion fracture 2. Jones fracture (junction of metaphysis and diaphysis, base of 5th metatarsal) 3. diaphysial stress fracture
Which types of 5th metatarsal fractures are critical? Jones fracture and distal diaphysial fracture (prone to nonunion)
How would you treat a Jones or distal diaphyseal stress fracture? 6-10 weeks of non weight bearing rest or surgical fixation if proper healing doesn't occur or for those who need more rapid treatment - surgery with fixation screw.
What is the function of the sesamoid bones of the 1st MTP joint? Increase mechanical advantage of flexor hallusics brevis and stabilize first MTP joint in association with plantar plate capsule. Protect flexor hallucis longus tendon. Absorb weight bearing stress on medial forefoot.
What is the definition of Chronic exertional compartment syndrome? Reversible ischemia secondary to noncompliant osseofascial compartment that is unresponsive to expansion of muscle volume during exercise
What are symptoms of compartment syndrome? Recurrent leg discomfort experienced at a reproducible, well-defined distance or intensity of running. Tight, cramplike squeezing ache.
What are the causes of Compartment syndrome? Inelastic fascial sheath, increased skeletal muscle volume with exertion d/t blood flow and edema, muscle hypertrophy d/t exercise, dynamic contraction during gait. Maybe more common at beginning of running season d/t hypertrophy
What muscles are in the anterior compartment? EHL, EDL, Peroneus tertius, Anterior tib.
What nerve is in the anterior compartment? Deep peroneal nerve
What muscles are in the superficial posterior compartment? Gastroc/soleus/sural nerve
What muscles and nerves are in the deep posterior compartment FHL, FDL, Posterior tib, posterior tibial nerve
Which compartment is affected most often by compartment syndrome? anterior>deep posterior>lateral>superfiicial posterior
What are symptoms of anterior compartment syndrome? Weak ankle DF, weak toe extension, paresthesias on dorsum of the foot, numbness in first web space
What are symptoms of deep posterior compartment syndrome? weakness of toe flexion and foot inversion. Paresthesias on plantar aspect of foot
What are symtpoms of superficial posterior compartment syndrome? Dorsolateral parasthesia, plantar flexion weakness
What are symptoms of lateral compartment syndrome? anterolateral ssensory change, eversion weakness
How should you treat compartment syndrome conservatively? Conservative: relative rest (limiting activity to levels that avoids above minimal symptoms), anti -inflammatories, stretch, strengthen
How would you treat compartment syndrome surgically? if symtpoms last longer than 12 weeks, fasciotomy
What is a shin splint (medial tibial stress syndrome?) Diffuse tenderness over the posteromedial aspect of distal tibia
What are proposed etiologies of shin splints? Tendinopathy along tibial attachment of tib posterior or soleus, or possibly posterior compartment syndrome Could be caused by valgus of rear foot, excessive pronation and resulting increased eccentric contraction of soleus, post tib
What are possible intrinsic factors of shin splints knee varus, femoral anteversion, excessive Q angle, forefoot varus
What should treatment of shin splints include Relative rest, correction of recent transition in training. No hill running or uneven surfaces. Shoe wear to prevent rearfoot valgus and to prevent pronation. NSAIDS
What are risk factors for plantar fasciitis? Presence of limited ankle DF, high BMI in nonathletic individuals, running and work-related weight bearing activities, particularly under conditions with poor shock absorption
What is the windlass test? Passive dorsiflexion of great toe - if pain is produced
What is the tarsal tunnel test? Passive maximal dorsiflex and evert the foot - if tenderness over post tibial nerve, positive test
What is the best outcome measure to use for foot and ankle problems? FAAM (Foot and ankle ability measure)
What is recommended dosage for stretching calf muscles to relieve plantar fascia symptoms?
What kind of taping should be done for plantar fascia? How long will the effect last? Antipronation taping for up to 3 weeks pain reduction. Elastic therapeutic tape to gastroc/plantar fascia for short term (1 week) pain relief.
How should foot orthoses be used in the management of plantar fascia pain? Either pre fabricated or custom orthoses to support medial longitudinal arch and to cushion the heel for short term (2 weeks) to long term (1 year) periods, especially in those individuals who respond to anti pronation taping
How should night splints be used in the management of plantar fasciitis? Prescribe a 1-3 month program of night splints for patients who have pain with first step in the morning
What interventions are effective for treatment of plantar fascia? Stretching: plantar fascia/gastroc soleus. Manual therapy: Jt.mobs - posterior glide of talus. STM of plantar fascia, gastoc, soleus focusing on TrP. Anti pronation taping. Foot orthoses for medial arch and heel cushionng. Night splints for 1-3 month.
What is the presentation of a mallet toe?` DIP of usually the 2nd toe is in flexion contracture
What is the presentation of a hammer toe? MTP in extension, PIP in flexion
What is the presentation of a claw toe? MTP in extension, PIP and DIP in flexion
What part of the shoe is the midsole? Between the sole and the foot - it is the cushioned part
What part of the shoe is the upper? The fabric or the leather part
What does "last construction" refer to? How the upper is attached to the midsole
What is a "board lasted" shoe? Firm board with rigid platform for the foot - most stable, but least common in today's running shoes
What is a slip lasted shoe? The most flexible kind of shoe - simply wraps the fabric from the upper under the foot - if you take the insole out, you will a see a seam where the upper connects underneath the foot
What is the most flexible kind of last? Slip lasted shoe
What is a combination lasted shoe? Board lasted in rear foot and slip lasted in the front foot - allows for more rearfoot control, more flexibility in the front
What is a Strobel lasted shoe? The most common type in today's shoes - Thin sheet of EVA to which the last is stitched (less flexible than slip lasts but not as rigid as board lasts
What are the three type of last shapes?, Straight, curved and semi-curved
What is the benefit of a straight last? Heavier, provide more arch support
What is the benefit of a curved last? Light, less cumbersome than a straight last - used often in competitive runners
What is the benefit of a semi-curved last? More stable than curved, but less bulky than straight
What is the medial post? Found in motion control or stability shoes - piece of EVA under medial arch and/or rearfoot.
What is the benefit of a medial post? Controls pronation, does not cause supination (arch support)
What is a drawback of a medial post? Adds weight to shoe
What is the shank of a shoe? Stiffens shoe under the arch, near center of the foot, making shoe more resistant to torsion
What are the benefits of a shank? Assists the shoe in bending at the toes instead of under the arch as the foot naturally does when the heel lifts and weight transfers to the forefoot during gait
How much big toe extension is needed during normal gait ? 45-55 degrees
How much dorsiflexion is need for normal gait 15 degrees
What is a zone 1 metatarsal fracture Avulsion fracture - nonunion is ucommon
What is a zone 2 metatarsal fractures? Jones fracture - nonunion is common. Occurs at the metaphyseal, diaphyseal junction which a vascular "watershed" area of poor vascularity
What is zone 3 fracture? Proximal diaphyseal fracture - increased risk of nonunion
What is anterolateral impingement syndrome of the ankle? Entrapment of the hypertrophic soft tissue in the lateral gutter - tissue gets trapped between the talus and the medial malleolus - leads to chronic ankle pain. Common after inversion ankle sprain
What is the lateral gutter of the ankle? Area bounded by the anterolateral border of the talar dome, anterior border of the lateral malleolus and and the inferior margin of the anterior inferior tibiofibular ligament (AITFL)
What is the treatment for anterolateral impingement of the ankle Conserative treatment, then steroid injection or debridement.
What is the appropriate treatment for a fracture of the 4th phalange with 5 degrees of angulation and that does not involve the joint? Buddy tape the 4th to the 3rd phalanx with gauze in between
When is a person said to have lost protective sensation of the foot? When the patient is unable to feel a nylon filament with a 10 gram bending force
What are the signs and symptoms of PTTD? Too many toes sign, , inability to use the Posterio tib to turn heels inward with toe raising, in ability perform single heel raise.
What is tarsal tunnel syndrome? A complex of symtpoms caused by compression neuropathy of the tibial nerve or its branches
What are symptoms of tarsal tunnel syndrome? Parasthesias on plantar aspect of the foot, vague burning in the medial ankle
Created by: Dallin I