ankle and foot module 7

Question 1

What is the MOI for capsular restriction?

Answer 1

post ankle immobilization: develops over time due to lack of movement through range

Question 2

how do patients with a capsular restriction present?

Answer 2

capsular pattern presents during A/PROM assessment
complaint of stiffness

Question 3

what is the definition of a capsular pattern?

Answer 3

a series of limitations of joint movement when the joint capsule is limiting structure… occurring only in synovial joints that are controlled by muscles and not in joints that depend primarily on ligamentous stability

Question 4

what is the common restriction pattern at the talocrural joint?

Answer 4

PF is limited greater than DF

Question 5

what is the common restriction patter at the subtalar joint?

Answer 5

limited varus/valgus PROM translation

Question 6

what is the common restriction pattern at the transverse tarsal joint?

Answer 6

DF > PF > Add > medial rotation

Question 7

what is the common restriction patter at the 1st MTP joint?

Answer 7

extension is limited greater than flexion

Question 8

what is hallux abducto-valgus (HAV)?

Answer 8

inflamed and eventually thickened bursa inferior to MTP
tendinitis may develop in the flexor tendons of the great toe, with bunions, flexor and extensor tendons are misaligned creating more angular stress on the joint.

Question 9

what deformities do we see because of HAV?

Answer 9

flattened transverse arch and a pronated foot

Question 10

what are some signs and symptoms of HAV?

Answer 10

in the beginning of bunion formation there is tenderness swelling and enlargement of the joint
poorly fitting shoes increase the irritation and pain- as the inflammation continues, angulation of the toe progresses eventually leading to painful ambulation

Question 11

what are some is hallux limitus?

Answer 11

stiff big toe or rigid first ray
arthritic degeneration of great toe
progression to bone spurs at first MTP joint
limited MTP joint mobility
bump or callus on MTP joint
altered mechanics during push-off phase of gait

Question 12

what are some signs and symptoms of hallux limitus?

Answer 12

limited motion of MTP joint; decreased DF
pain, redness around joint
callus bunion on top of toe
feeling of hard-end during joint motion may indicate bone spur

Question 13

what are some functional implications of hallux limitus?

Answer 13

pain with standing
pain in first metatarsal with walking
inability to wear high-heeled shoes that create extension at big toe
altered gait pattern and mechanical issues of the forefoot; increased supination and ER of foot for clearance; forefoot abduction with lateral whip

Question 14

what are some differential diagnoses for hallux limitus?

Answer 14

hallux valgus
gout
osteochondrotic lesion of the 1st metatarsal head
sesamoiditis, turf toe
osteochondritis dissecans
metatarsalgia
metatarsal stress fracture
plantar fasciitis: patient may initially have more pain at medial arch due to altered mechanics

Question 15

what is the treatment for Hallux deformities?

Answer 15

orthotics designed to reduce biomechanical forces leading to deformity
surgical realignment with bony osteotomy, debridement of joint, fusion of joints

Question 16

what do are lesser toe deformities?

Answer 16

hammer toe
claw toe
mallet toe

Question 17

what do lesser toe deformities result in?

Answer 17

corns, calluses, phalangeal joint pathology

Question 18

what is the MOI for tarsal tunnel syndrome?

Answer 18

insidious, runners, RA

Question 19

what are the signs and symptoms for tarsal tunnel syndrome?

Answer 19

difficulty localizing pain, diffuse burning, worse at night or when rest at the end of the day

Question 20

what is tarsal tunnel syndrome?

Answer 20

compression of the posterior tibial nerve occurs proximally and therefore the whole foot can be affected. after the nerve passes distal to the tarsal tunnel one branch (calcaneal) continues to the heel, the other two (medial and lateral plantar nerves) continue on to the bottom of the foot

Question 21

what is the MOI for distal tarsal tunnel syndrome?

Answer 21

> 9 months history of plantar fascia type pain that does not respond to typical treatment

Question 22

what are the signs and symptoms for distal tarsal tunnel syndrome?

Answer 22

pain at medial calcaneal tubercle (similar to plantar fasciitis), decreased sensation at lateral heel

Question 23

what are some special tests for distal tarsal syndrome?

Answer 23

unable to abduct the 5th digit
altered sensation
+ tinnels sign at baxters nerve = 1st branch off the lateral plantar nerve

Question 24

what population do we typically see distal tarsal tunnel syndrome in?

Answer 24

40-50 year olds, long distance runners

Question 25

what is the treatment for distal tarsal tunnel syndrome?

Answer 25

plantar fascia stretch, NSAIDs, orthodic (cupped heel with a relief channel for the nerve), no steoid injections

Question 26

What is metatarsalgia (Morton’s neuroma)?

Answer 26

Growth of scar tissue from chronic irritation of compression Most common area is between the third and fourth toes, but also can be in between the second and third toes Involved a thickening of the tissues (neuroma) around one of the intermetatarsal plantar nerves

Question 27

What is the MOI for metatarsalgia (Morton’s neuroma)?

Answer 27

Wearing high heels Rock climbers with repetitive forefoot pressure Higher risk for individuals with bunions and flat feet

Question 28

What are some signs and symptoms for metatarsalgia (Morton’s neuroma)?

Answer 28

Burning pain in the ball of the foot Numbness and tingling in the toes, especially between the third and fourth toes Difficulty wearing/finding shoes, especially pointed ones Limited motion of the MTP joint

Question 29

What are some functional implications for metatarsalgia (Morton’s neuroma)?

Answer 29

Pain with standing Pain with ambulation at the toe Inability to wear regular shoes Need to wear larger shoes with a larger toe box Alteration of gait pattern and mechanical issues of the forefoot

Question 30

Is the sural nerve sensory or motor?

Answer 30

Sensory

Question 31

Where does the sural nerve cross?

Answer 31

Crosses the Achilles tendon form proximal-medial to distal-lateral. There exists a hot zone around a lateral border of the Achilles tendon approximately 9-12 cm proximal to the insertion of Achilles

Question 32

If someone is experiencing pain on the outer border of their distal calf, lateral heel/foot what could it be?

Answer 32

The sural nerve

Question 33

Where is pain for the deep fibular nerve?

Answer 33

Dorsal foot, pain/1st web space

Question 34

Where is pain for the superficial fibular nerve?

Answer 34

Lateral lower leg, lateral border of foot

Question 35

Where should we examine for peripheral nerve injuries?

Answer 35

Clear lumbar spine Pain with palpación of entrapment + tinsels sign with tapping of nerve at entrapment Pain with stretch, adverse neural tension Quality of pain will often be burning

Question 36

How do we conservatively treat peripheral nerve injuries?

Answer 36

Conservative treatment consists of orthotics, heel pads etc, cortisone injection, relative rest

Question 37

How do we surgically treat peripheral nerve injuries?

Answer 37

Attempt to eliminate offending tissue

Question 38

What are foot conditions related to diabetes mellitus?

Answer 38

Concurrent neurological and circulatory involvement Sensory loss Motor weakness leading to toe deformities, pes cavus foot type Plantar metatarsal fat pads migrate distally, no longer protecting the met heads

Question 39

How commonly do foot ulcers from excessive pressure develop?

Answer 39

Accounting for 20% of all diabetic hospitalizations and 5-70% of all non traumatic and amputations performed annually

Question 40

What is Charcot joint?

Answer 40

Aka neuropathic joint Refers to a progressive degenerative joint disorder when the patient has peripheral neuropathy and impaired proprioception. Most commonly occurs in the foot

Question 41

What are some treatments of diabetic foot ulcers?

Answer 41

Prevent tissue ulceration through patient education Protect plantar surface with full contact soft orthotics, accommodative padding Custom shoes if necessary Wound care

Question 42

What are some signs of Charcot foot of tarsal bones?

Answer 42

A red, hot, swollen foot (without a foot ulcer) and increased skin temperature in the affected foot (compared with the other foot). Care need to be coordinated with physician

Question 43

Why do patients with Charcot foot in the tarsal bones “offload”?

Answer 43

Helps prevent inflammation and stops the condition form getting worse and prevents deformity

Question 44

What is a treatment for Charcot foot of the tarsal bones?

Answer 44

Protected weight-bearing (walking in a walking boot)- in later stages can prevent complications from the existing deformity and avoid new deformities

Question 45

What is another treatment for Charcot foot of the tarsal bones?

Answer 45

Serial casting- stabilizes 8-12 weeks. Crutches, knee walker or a wheelchair are sued to avoid putting any weight on the affected foot. The cast is changed several times as the swelling in the foot goes down. The casting continues until the redness, swelling, and heat are resolved