foot and ankle
Help!
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| how many bones articulate in the foot for WB and ambulation? | 26
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| bones of the foot and ankle | Talus, calcaneus, navicular, cuboid, 3 cuneiforms, 5 metatarsals, 14 phalanges
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| joints of the foot and ankle | distal tibfib, talocrural, talocalcaneal
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| talocrural joint | mortise joint/ 'ankle' joint. Made up of the distal tib/fib and talus - Dorsi/Plantarflex
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| talocalcaneal joint motions | pronation and supination
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| how does the talus move in the talocalcaneal joint? | The head of the talus* of this joint moves opposite of the rest of the bones of the foot
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| loose pack position of the foot | pronated
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| how does talus and calcaneus move in pronation? | •Head of talus: adducts and plantarflexes
• Calcaneus: everts (valgus)
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| rigid position of the foot | supination
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| how does talus and calcaneus move in supination? | •Head of talus: abducts and dorsiflexes
•Calcaneus: inverts
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| midtarsal joint motions | In isolation, little movement; Together significant movement; Primary movement is slight gliding and rotation
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| midtarsal joints | Talocalcaneonavicular, Cuboideonavicular, Intercuneiform, Cuneocuboid, Calcaneocuboid
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| tarsal metatarsal joints are made up of what 3 bones | Cuboid, cuneiforms, and metatarsals
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| what joints make up the tarsal metatarsal joints? | •Metatarsalphalangeal joints: MTP
•Interphalangeal: PIPs, MIPs, and DIPs
•First Ray: First metatarsal and hallux
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| extrinsic mm of foot | Originate away from the foot and act on the foot
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| intrinsic mm of foot | Originate and insert on the foot, consist of 4 layers
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| intrinsic mm of foot function | Muscles of the sole of the foot and strengthen the arch
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| extrinsic mm of the foot | •Peroneus Longus and Brevis
•Extensor Hallux and Digitorum longus and Flexor hallux and digitorum
•Tibialis anterior and posterior
•Gastroc and Soleus
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| what action do foot intrinsic have? | ABD and ADD toes, flex toes, extend toes
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| medial collateral ligament (deltoid) | •Supports the medial ankle
• It is stronger than the lateral collateral
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| lateral collateral ligament | •supports the ankle laterally and is made up of the 3 major ligaments
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| 3 major ligaments that make up LCL | • anterior talofibular
• calcaneofibular
• posterior talofibular
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| spring ligament | •Supports the longitudinal arch (along with the post tib tendon).
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| what is ligaments is spring ligament made up of? | •Long and short plantar
•Plantar calcaneonavicular
•Plantar aponeurosis
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| arches of the foot | •Medial longitudinal
•Lateral longitudinal
•Transverse arch - medial to lateral
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| plantar fascia function | •Supports the sole of the foot
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| windlass effect | Arch elevates with dorsiflexion of great toe, helps propel motion of foot
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| how many degrees of great toe DF needed for windlass | 55-60
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| calcaneal fat pad function | accepts large force loads at heel strike and reduces the impact forces with weight bearing
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| what happen if calcaneal fat pad is injured? | becomes herniated and is quite painful and splayed
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| primary/congenital deformities | •Commonly seen with neurological conditions such as Cerebral palsy
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| secondary/biomechanical deformities | •Commonly seen in runners and other active individuals
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| talipes equinovarus | congenital clubfoot, or a secondary neuromuscular dysfunction
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| adducted forefoot | 'pigeon toes' must rule out internal rotation from the hip, can be secondary or primary
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| pes planus | Flat foot or fallen arches; Forefoot pronation and/or rearfoot valgus
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| pes cavus | •Abnormally high arch
•Usually seen with clawed/hammer toes
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| Forefoot Varus | (first ray is elevated compare to the fifth ray or supination) may be part of everted calcaneus or over pronated foot with weight bearing
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| rearfoot valgus | everted calcaneus and usually causes an over pronated foot in weight bearing. Pes Planus
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| forefoot valgus | (fifth ray is elevated compare to the first or pronation) usually is with a inverted calcaneus or over supinated foot with weight bearing
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| rearfoot varus | same as an inverted calcaneus and usually causes an over supinated foot in weight bearing. Pes Cavus
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| hallux valgus | Secondary condition usually asymptomatic, but may develop bunion
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| tx for hallux valgus | surgical intervention option, plus wide toe box shoe
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| hammer toes | extended MTP, flexed PIP, extended DIP
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| claw toes | •extended MTP, flexed PIP and DIP
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| mallet toes | flexed DIP
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| treatment for congenital foot deformities | •Treatment usually requires significant medical management
•Serial casting
•Surgery - fixative or stabilizing:
•Triple arthrodesis
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| triple arthrodesis | •Fusion of subtalar joint, talonavicular joint, and calcaneocuboid joint (also called hindfoot fusion)
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| what is triple arthrodesis used for? | correct deformity, eliminate instability.
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| when (age) is triple arthrodesis performed? | after growth is complete because future growth will be disturbed
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| treatment for secondary deformities | •Serial casting - to increase ROM
•Surgery- Arthrodesis, or pinning
•Joint excision for toe deformities
•Tendon transplant if muscle imbalance is contributor
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| goal of orthotic intervention | •stabilize flexible deformity, increase function, decrease pain or discomfort
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| orthotics can be ___ or ____ material | flexible, rigid
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| posting | material added to orthotic to maintain the anatomical alignment that has been built into the orthotic with casting.
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| what is posting used for? | Used for correction of forefoot valgus or varus and hind foot valgus or varus
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| rheumatoid arthritis | •Severe pain and deformity
•Stability issues as digression of ligaments occur
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| secondary OA of foot | very common secondary to previous injuries
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| what is common with osteoporosis of foot | stress fx
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| tx goals for degenerative conditions | •Decrease pain and inflammation
•Increase circulation
•Splinting/orthotics to relieve weight bearing stresses and protect joints from further damage
•Teach careful self inspection for open sores
•Change shoes
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| gout | Uric acid crystal deposition disorder with painful inflammation
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| treatment of gout | Diet, NSAIDS, Medication to stop uric acid production - Allopurinol, Surgical removal of osteophytes→ arthroplasty or arthrodesis if joint destruction has occurred
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| diabetic foot | Secondary conditions occur such as PVD, neuropathy, osteoporosis and infection
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| fractures of foot/ankle usually are ____ (simple/complex) because of the many bones and joints of the foot | complex
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| Pott's fracture | a severe twisting injury accompanied by ligament strain or avulsion, usually an external rotation
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| what motion causes pott's fx? | foot is planted and the body ERs above it, May involve a fall
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| how is unimalleolar pott's fx treated? (lateral malleolus- fibula) | •immobilize in walking cast
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| how is bimalleolar pott's fx treated? (both tibia and fibula) | •ORIF/Cast
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| trimalleolar potts fx | Includes two fractures on medial and lateral posterior tip of distal tibia and fracture of the fibular malleolus; Usually includes a dislocation
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| tx for trimalleolar pott's fx | ORIF/cast
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| Distal tib/fib fractures especially will affect the ankle joint due to _____ | malalignment
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| symptoms of distal tib/fib fx | Decreased ROM after immobilization, biomechanical change results in compensatory ankle/foot motions, OA results
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| tx of distal tib/fib fx | ORIF of displaced fractures is necessary, Closed reduction if the fracture is stable, Full body conditioning during immobilization
, Strengthening uninjured limb for crossover benefit, Progressive ROM, isometrics, cycling, proprioception, function
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| Long term sequelae of major ankle fracture includes: | pain, sensitivity to cold weather, swelling after standing, bluish discoloration after standing, joint doesn't "feel right" for many years, decreased agility, gastroc weakness and atrophy, slight limping
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| what causes calcaneal fx? | fall from a height; the calcaneus is mostly cancellous bone that will crush into many fragments; it may involve the articular surface of subtalar joint
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| complications of calcaneal fx | •Disability may be extreme due to complications
•Avascular necrosis - severe pain
•Significant degeneration of the articular cartilage in the subtalar joint - pain
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| tx for calcaneal fx | Treatment to follow physician's protocol; Strengthen peroneus longus; Gait retraining
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| most common areas for stress fx | tibia, metatarsals, navicular
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| what causes stress fx | •Repetitive motions or osteoporosis
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| symptoms of stress fx | deep pain
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| stress fx tx | •Usually heals after restricted activity for 1-3 months, return to activity must be guarded
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| tarsal tunnel syndrome | Impingement of the posterior tibial nerve that runs along with Tom, Dick and Harry
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| what does deltoid ligament protect? | tarsal tunnel area
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| tendons in tarsal tunnel | Tibialis Posterior Tendon, Flexor Digitorum Longus Tendon, Flexor Hallucis Longus Tendon (tom, dick, and harry)
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| symptoms of tarsal tunnel | Complaints of burning pain with paresthesia of the heel; Sometimes confused with plantar fasciitis
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| is medial or lateral ankle sprain more common? | 95% are lateral sprains with inversion sprain of the lateral collateral ligament
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| Complete rupture may be candidate for ____ | reconstruction
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| Loss of _____ occurs after an ankle sprain and the patient is 5x more likely to reinjure it than someone who never sprained | proprioception
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| acute phase ankle sprain tx | RICE, ankle-wrap(protect), NWB, electrical stimulation, AROM, isometrics
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| subacute phase ankle sprain tx | comprehensive rehabilitation: Full WB, taping, HS stretching, proprioception, strengthen, function
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| plantar fasciitis symptoms | presents as heel pain or arch pain
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| what causes plantar fasciitis | repetitive traction stress of the plantar fascia on the periosteum of the calcaneus or heel spur. Involves micro tears of fascia
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| plantar fasciitis tx | Proper orthotic intervention to alleviate tension on fascia and supportive shoes, Lodye taping, Analgesics, Anti-inflammatories, Stretching, Strengthening (foot, ankle- eccentric, posterior tibialis, hip), Joint mob, Fasciotomy if conservative fails
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| medial tibial stress syndrome (MTSS)/ shin splints | Overuse with pain distal tibia
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| what causes MTSS (shin splints) | excessive pronation of the foot that leads to internal rotation of the tibia and stress on the muscles and fascia of the tibia (especially posterior tibialis)
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| differential diagnostics for MTSS | Stress fracture, ischemia, compartment syndrome. Need imaging
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| tx for MTSS | RICE, taping, possible orthotics, modified activity
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| tendonitis is considered to be associated with | muscle weakness especially with eccentric contractions necessary for anti-gravity motions in ambulation/running
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| what can cause tendinitis | overpronation, and in the posterior tibialis tendon can eventually lead to rupture
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| what causes Achilles tendinopathy | overuse microtears
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| tx for Achilles tendonopathy | Rest, NSAIDS, heel lift, modalities, flexibility, eccentric strengthening
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| who is Achilles rupture most common in? | Men 30-50 yr, sudden contraction, degenerative changes
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| what antibiotic can cause spontaneous tendon rupute? | Levaquin, used for UTI and other bacterial infections. can cause spontaneous rupture of Achilles or patella tendon.
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| diagnostics for Achilles rupture | •(+) Thompson Test, imaging
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| Thompson Test | compression of the calf muscle while observing for plantar flexion to assess the stability of the Achilles tendon
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| is Achilles rupture initially painful? | no, may feel like someone hit them in the back of leg
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| tx for Achilles tendon rupture | Surgical and non surgical. Slow and variable depending on MD
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| metatarsalgia | pain in the lateral four metatarsal heads
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| what causes metatarsalgia | •result of altered biomechanics in WB and/or gait
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| tx for Morton's syndrome | Proper shoe ware, metatarsal pad or taping to provide a metatarsal arch, Surgery - successful in 83% cases
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| Morton's syndrome | metatarsalgia between 3rd MET head and 4th MET head, pinched nerve
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| what does anterior drawer test for ankle test? | anterior talofibular lig
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| what does talar tilt test? | calcaneofibular lig
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