What muscles lay in the first layer of the foot?
Abductor hallucis, flexor digitorum brevis, abductor digiti minimi
What muscles lay in the second layer of the foot?
Quadratus plantae, lumbricals (flexor digitorum longus and flexor hallucis longus pass through this layer)
What muscles lay in the third layer of the foot?
flexor hallucis brevis, adductor hallucis, flexordigit minimi brevis
What muscles lay in the fourth layer of the foot?
Plantar interossei and dorsal interossei (peroneus longus and tibilias posterior pass through this layer)
How much ROM is require for normal gait?
20-30 degrees of PF and 6-10 of DF
What is the windlass mechanism of the foot?
Toe DF produces supination and thereform creates a medial longitudinal arch
What are the four common arches of the normal foot?
Medial (formed by calcaneus, talus, navicular, & 3 cuneiforms) and lateral calcaneus, cuboid( metatarsals 4&5) longitudinal arch; proximal (navicular, three cunieforms, & cuboid) and distal (5 metatrasal) transverse
What is pes planus?
a foot that exhibits no longitudinal arch and an ankle that is everted (valgus); there is rigid (caused by tarsal coalition, verticle talus) and flexible
What is pes cavus?
high arch; may be related to muscle imbalances – toe walkers with tight tight tendo achilles and limited DF or neuromucular disease
What percentage of weight does the fibula bear?
Describe the function of the deltoid ligament?
prevents eversion and abd of the talus; higher potential to avulse secondary to strength
What are the lateral collateral ligaments of the foot?
ant talofibular, post talofibular, calcaneofibular; ATF most commonly sprained with inv injury with PF
Define Lisfranc's ligament:
tarsometatarsal spanning from the medial cuneiform to the base of the second metatarsal; can avulse
What is the spring ligament:
Calcaneonavicular ligament from the plantar aspect of the sustentaculum tali to the navicular; primary static stabilizer of the medial longitudinal arch
What is chopart's joint:
midtarsal joint: talonavicular and calcaneocuboid
How does a widening of the motise after a syndesmotic injury change the WB'ing surface of the ankle?
1 mm increase decrease the WB'ing surface by 40%; 3 mm >60%, 5mm ~80%; will increase likelihood of early degerative joint disease
What increases the risk for anterior talus impingement?
osteophytes, scar tissue, or overly compressed ORIF
What is the sinus tarsi?
opening between the talus and calcaneus
What are the contents of the tarsal tunnel?
Tom, Dick, And Very Nervous, Harry; T – posterior Tibial Tendon; D – Flexor Digitorum longus; ANV – posterior tibial artery, vein, and nerve; H – flexor hallucis longus
What are the 5 nerves that cross into and supply motor and sensory fibers to the foot?
1.) sural nerve (post lat) 2.) Superficial peroneal nerve (ant lat) 3.) deep peroneal nerve (ant) 4.) saphenous nerve (ant med) 5.) post tibial nerve (post med)
Define porta pedis
anatomic opening on the plantar surface of the foot that medial and lateral plantar nerve and compression of the plantar nerves
What structure is referred to as the “freshman's nerve”
plantaris tendon which attaches onto the medial aspect of the posterior calcaneus tuberosity
What is meant by an accessory bone of the foot?
An ossicle or bone that separates from the normal bone (most commonly caused by fracture or a secondary ossification center)
What is the function of the seasmoids?
transfer loads through the soft tissues to the metatarsal head and increase the lever arm of the flexor hallucis brevis to aid in push off
what effect does hallux valgus increase have on PF force at push off?
angle of 40 degrees decreases push off strength by 78%
How many muscles attach to the talus?
What is the difference between achilles tendonitis and tendonosis?
Tendonitis is an inflammatory process casued by overuse activities or a specific disease process; tendonosis is beyond the inflammatory stage where the tendon has failed to heal, with possible thickening of the tendon
Other differential Dx for achilles complex?
insertional tendinopathy and inflamed retrocalcaneal bursa
What treatments are there for achilles tendonitis and tendonosis?
Heel lifts, NSAIDs, eccentrics
Tyipcal patient with Achilles tendon rupture?
Over 40 and engages in physical activity or sport / weekend athlete, Hx of tendonitis, loss of flexibility
Describe the thompson test?
squeeze the calf to see if the foot PF's to R/O Achilles tendon rupture
Describe a typical protocol for an Achilles repair:
6-8 wks of casting/immobilization with Wb'ing at the discretion of the surgeon, pt progressed to a heel lift. Focus on progressive PF strength, DF stretching avoided until after 4 months post-op; recovery by 6 months of strength and ROM and running by 7 months, full activity by 10-12 months
Accelerated program for Achilles repair with stronger sutures:
Immobilization for 72 hours followed by early active ROM ex, posterior splint for 2 wks and then a hinged orthosis. 6 wks after surgery pt can FWB and PRE start, pre level activities by 4 months
Symptoms for tarsal tunnel:
pain in the area of the tarsal tunnel with possible complaints of paresthesia
What factors contribue to tarsal tunnel syndrome
pronation may cause compression of the tibial nerve, trauma – fx, sprain, or other soft tissue injury may cause swelling; RA
What objective tests are there for tarsal tunnel:
gait analysis, palpation of pulses, neuro exam, sensation, tinel sign, slump test, lower limb tension test
What is Posterior tibialis tendon dysfunciton?
progressive degeneration of the PTT causes aquired flatfoot deformity (collapse of the plantar arch)
What are the signs and symptoms of PTTD:
mild swelling and medial ankle pain with no deformity with mild weakness with painful heel raise but inability to invert; stage II progressive flattening or the arch with abducted midfoot, tendon ruptures or is functionally incompotent with a flexible foot, but unable to perform a heel raise; stage III the foot becomes fixed
Best Tx for PTTD?
Immobilization and rest to prevent excessive pronation and decrease demand on post tib; tape the arch or orthotics; calf stretching, progressive strengthening in pain free range, eccentrics, windshield wipe ex
What causes peroneal tendon subluxation?
passive DF of an everted foot; skiing or other sports
Differential Dx for posterior heel pain:
retrocalcaneal bursitis, haglund's deformity, Achilles tedonitis or tendonsis, calcification of the Achilles, referred pain
Differential Dx for plantar heel pain:
Plantar fascia, tibial nerve entrapment, fat pad atrophy, heel spur, stress fx, tarsal tunnel syndrome, systemic problems (gout), radiculopathy S1
What is plantar fasciitis:
Pain arising from the insertion of the plantar fascia characterized by progressive pain with WB'ing as well as pain with the first few steps upon rising from sitting
Best Tx for plantar heel pain?
Pt ed, tissue mobilization, joint mobilization, strengthening the muscles that support the arch, orthotics, taping
How can adverse neurodynamics cause plantar heel pain and why does neural mobilization help?
Local mechanical entrapment of the medial calcaneal branch of the tibial nerve or the abductor digiti minimi nerve; intraneural adhesion, compression, or scarring create a painful cycle; neural mobilizaiton potential can break adhesions and increase healing
Ottawa ankle rules warrant ankle x-rays when?
Bone tenderness in the posterior half of the lower 6 cm of the fibula or tibia or navicular or 5th met; Inability to bear wt immediately after or within 10 days of injury
Best guidelines for return to activities after an ankle sprain?
Full AROM and PROM, no limp, strength 90% equal, single leg hop & high jump & 30 yd zig zag 90% of uninvolved; ability to reach max cutting speed
Possible causes for chronic pain after an ankle sprain:
Tension neuropathy, anterior or lateral soft tissue impingement, or cuboid subluxation treated with manipulation
What is a syndesmotic ankle sprain?
injury of the Ant and post inferior tibiofibular ligaments and damage to the interosseous membrane; common MOI ER of the tibia on a planted foot
What are hallux rigidus and hallux limitus, what is the best Tx?
Loss of great toe ext with rigidus having arthritis; joint mobilization, seasmoid mobilizaion, strengthening of the MTP flexors; stiff soled shoe or metatarsal bar
ext of the MTPs tightens tissues on the plantar aspect elevating the arch; lost with pronation and may result in joint laxity of the mets, metarsalgia, and hallux valgus
What are hammer toes?
MTP ext with PIP flexion, callus formation on dorsum may be painful;
What are claw toes?
Ext of MTP with clawing of both the PIP and DIP
Most common site for a neuroma?
3rd and 4th metatarsals, patients complain of deep burning pain and may have paresthesia, pain is on the plantar aspect, relieved with rest; occurs from irritation of the intermetatarsal plantar digital nerve
What tests suggest a neuroma?
Mulder's sign (point pressure on the transverse arch) and squeeze test
What is a Jones fracture
Fracture of the 5th metatarsal, also notorious for nonunions
Weakness of what muscles have been associated with plantar fasciitis?
The calcaneonavicular “spring ligament” prevents excessive what?
DF of the navicular on the talar head
Causes of aquired flat foot deformity?
Gastroc-soleus tightness, tibialis posterior dysfunction, midfoot laxity, abduction of the forefoot, ER of the hindfoot, subluxation of the talus, traumatic deformities, ruptured plantar fascia, Charcot foot, neuromuscular imbalances
What injuries are runners with high arches more likely to encounter?
lateral ankle sprains and 5th metatarsal stress fracture)
Define following special test: Ant drawer test
performed in 10-20 PF with ant glide of the calcaneus to test for ATFL – pain or translation >3 mm on the involved side is +
Define following special test: Talar tilt
20 PF or 10 DF with the calcaneus moved passively into inv – tests for ATFL and CFL respectively
Define following special test: ER test
knee at 90 flexion and ankle at neutral, passively ER the foot and ankle – pain in the syndesmosis +
Define following special test: Squeeze test
squeeze the fibula and tibia just above the midpoint of the calf - + pain in the area of the syndesmosis
Define following special test: cotton test
stabilize the distal tibia and grasp the rear foot – if the talus translates in the ankle mortise possible syndesmotic injury +
Define following special test: fibula translation test
Stabilize the distal tibia while the other hand translates the lateral mallelous A-P and P-A - + pain is reproduced along the syndemosis
Define following special test: Thompson test
squeeze of the calf while patient is prone and knee flexed, it is to ensure the Achilles tendon is intact
Define following special test: Achilles tendon palpation
Pt prone and squeezing along the entire length of the Achilles while noting swelling and tenderness – reproduction of symptoms with palpation indicate Achilles tendinopathy
Define following special test: Royal London hospital test
prone, find most tender part of the Achiles, patient actively DF's and the same area is palpated – if the pt reports a decrease or absence of pain with the palpation in DF the Achilles tendinopathy is likely present
Define following special test: Arc sign
Prone, pt active PF and DF watching the area of max swelling – if the swelled region of the
Define following special test: Fibularis subluxation
prone and knee at 90, PF and DF then eversion against resistance - + subluxation or dislocation of the fibularis tendon
Define following special test: Coleman block test
observe patient standing on flat surface, and then with the lateral side of the foot only on a 1in step – observe the change in forefoot pronation; helps decide on flexible rearfoot varus vs rigid
Define following special test: Windlass test in WB'ing
Pt standing and passive ext of the first MTP until symptoms are reproduced or end range is felt; + pain along the plantar fascia = plantar fasciitis
Define following special test: Mulder click test
palpate a mass that is a possible neuroma and push it between the metatarsals, then squeeze the metatarsals together; + pain with a palpable click of the mass
Define following special test: Tinel sign
tap along the pathway of the posterior tibial nerve from distal to proximal from the medial longitudinal arch to above the medial malleolus; + symptoms reproduced for posterior tibial nerve involvement
Define following special test: Homan sign
passively DF the ankle; + pain in the calf for possible DVT but has poor relability
Most common cause for aquired flat foot deformity?
What is typically the MOI for a high (syndesmotic) ankle sprain
Rotation of the talus which gaps the distal tib-fib damaging the ligaments and possible the interosseus membrane
What are x-rays are helpful for determing a syndesmosis injury?
WB'ing DF and ER to gap to tib fib, but high false negatives
What are risk factors for lateral ankle sprains:
slower running, less cardiorespiratory fitness, decreased balance, less movement coordination, decreased DF ROM and strength, decreased reaction time of tib ant and gastroc
Common risk factors for plantar fasciitis:
time spent on feet during the day, decreased ROM for DF, and obesity
When is night splint use warrented in plantar fasciitis?
when symptoms are >6 months
MOI for lisfranc injury?
Low energy injury with sports or high energy injury with a MVA with a longitudinal force with the foot PF'ed
To screen for lisfranc injuries what are two suggested tests:
midfoot squeeze and hopping on a single leg 15x
What is sever disease
Childhood injury occuring with an unfused calcaneus with traction from the Achilles tendon resolves in 2wks to 2 months
osteochonrdorsis of the navicular in childhood
A pt presents with pain wrose in the morning or after sitting for long periods, pain with running, point tender pain on the Achilles with a thickened tendon; what is the most likley Dx?
What intrinsic factors may help with the prevention of Achilles tendinopathy?
limited DF, decreased PF strength, foot pronation
Is pain a contraindication for continuing an eccentric program?
grading an ankle sprain is a combination of what measurements:
laxity, point tenderness, swelling, function, and ability to bear weight; grade II able to bear weight, grade III unable to bear weight
Limited DF can occur due to altered movement across a series of what joints:
ltalocrural, subtalar, and tibiofibular
Current theory suggests passive lateral ankle instability will:
persist despite clinical care and the absence of pain (30%)
Fibularis tendinopathy typically occurs with what type of foot?
cavus or neutral
What is stage II PTTD:
Pain with palpation, flexible foot deformity, inability/weakness of PF
Someone with grade II PTTD would benefit most from what type of Tx:
custom ankle foot orthotic and strengthening to remodel the degenerative tendon
Long term outcome for PTTD is:
up to 70% may be symtpom free and not wearing a brace, but approximately 35% will have recurrent symptoms
Hallux rigidus stages:
Grade 0: 40-60 DF grade 1: 30-40 DF dorsal osteophytes and min joint changes; grade 2: 10-30 mild flattening of the MTP joint, sclerosis, dorsal, medial and lateral osteophytes; grade 4: pain throughout entire ROM
IF a patient presents with numbness but most like a plantar fasciitis what differential Dx should be considered?
Tarsal tunnel syndrome