Foot and ankle exam/alignment

Question 1

What joints make up the rearfoot

Answer 1

• distal tibiofibular
• talocrural
• subtalor

Question 2

What joints of the foot make up the mid foot

Answer 2

• mid tarsal joint
• talonavicular
• calcaneocuboid
• intertarsal

Question 3

What joints make up the forefoot

Answer 3

• Tarsometatarsal
• inter metatarsal
• metatarsalphalangeal (MTP)
• Interphalangeal

Question 4

Medial Ankle ligament

Answer 4

Deltoid ligament

• tibiotalar anterior
• Posterior tibiotalar
• tibionavicular
• tibiocalcaneal

Plantar calcaneonavicular Ligament (spring)

Question 5

Lateral ankle ligaments

Answer 5

• Anterior and posterior tibia-fibular ligament
• calcaneofibular
• short plantar ligament
• long plantar ligament

Question 6

Open chain cardinal (single) plane motions of the foot and ankle

Answer 6

• Transverse plane: adduction/abduction
• Frontal plane: inversion/eversion
• sagittal plane: dorsiflexion/plantarflexion

Question 7

Triplanar motion of the foot/ankle

Answer 7

• motions of the foot occur in lane that pass through all 3 cardinal planes
• open chain pronation: combination of eversion, DF and abduction
• Open chain supination: combination of inversion, plantar flexion, and adduction

Question 8

Talocrural open chain joint motion

Answer 8

• axis = med to lateral thu malleoli
• DF
• PF

Question 9

Arthrokinematics in open chain of the talocrural joint

Answer 9

• roll and glide opposite

Question 10

Subtalar joint

Answer 10

• talus with calcaneous
• Eversion/inversion
• inversion to eversion = 2:1
• axis = posterior, lateral down thru navicular
• medial/lateral arc glides

Question 11

Midtarsal joint axis

Answer 11

1. longitudinal axis: follows subtalar, eversion and inversion
2. oblique axis of motion: PF+ adduction +inversion = supination and DF + abduction + eversion = pronation (open chain)

Question 12

1TMT and 1st ray of the foot
VS
2nd TMT and 2nd ray

Answer 12

1. most mobile
2. most stable (lisfranc=fracture of this making it unstable)

Question 13

How to move the forefoot on midfoot

Answer 13

• lateral rotation of metatarsal (DF/inversion)
• medial rotation of the metatarsal (PF/eversion)

Question 14

TMT mobilizations

Answer 14

• distraction
• rotation
• DF glides
• PF glides

Question 15

Arches of the foot
- quiet standing
- walking/running

Answer 15

• passive support for quiet standing
• need to add dynamic support of muscles during walking/running

Question 16

Medial longitudinal arch anatomical support

Answer 16

• Tibialis anterior/posterior supports the arch
• plantar calcaneonavicular (spring)
• sustentaculum tali supports the talus on the medial side
• plantar fascia
• navicular = keystone
• these get overworked with flat feet

Question 17

Lateral longitudinal arch

Answer 17

• short and long plantar ligament
• peroneus longus, brevis tendon
• cuboid is keystone

Question 18

Transverse arch

What supports this

Answer 18

• Anterior tibialis/posterior tibialis
• peroneus longus
• bony support = cuneiforms, cuboid

Question 19

Closed chain pronation and up kinetic chain during gait

Answer 19

• Gait: loading response to foot flat
• accommodation, absorbs ground reaction forces
• Calcaneus: everts
• talus: adducts and PF
• Leg/tibia: internally rotates
• knee: flexes

Question 20

Closed chain supination and up the kinetic chain/gait

Answer 20

• gait: midstance to terminal stance/push off
• supination: stability
• calcaneus: inverts
• talus: abducts and DF
• leg: externally rotates
• knee: extends

Question 21

Supinated foot/high arch/pes caves

Answer 21

• stability
• supinated at heel strike and midstance to push off
• rigid foot = ligaments taut, joints hypomobile
• lacks shock absorption:
• foot to surface contact is minimized
• increase ground reaction force at heel, 1st/5th met heads
• increase chance of skin breakdown with desensitized feet
• more prone to inversion ankle sprains and stress fx
• makes leg functionally longer

Question 22

Pronated foot/low arch/flat feet/ples planus

Answer 22

• loading response to foot flat
• flexible foot, ligaments lax, joints hypermobile
• flattening of medial longitudinal arch
• foot to surface contact is maximized
• accommodation to uneven surfaces
• Makes leg functionally shorter
• over pronation undesirable
• tenosynovitis: posterior tib, FHL, FD, anterior tib
• plantar fasciitis
• tarsal tunnel syndrome

Question 23

pronation effect up kinetic chain

Answer 23

• IR of tibia
• genu valgus at knee
• increase tensile stress on MCL
• increase compression on lateral femoral/tibial condyles
• patella can track laterally
• IR at hip and ER weakened/lengthened
• shortened leg = stress on spine
• lower iliac crest on that side
• lumbar side bend to opposite

Question 24

Plantar fasciitis

Answer 24

• inflammation of the plantar fascia (runs from calcaneal tubercle to met heads)
• heel spur may or may not be present on Xray
• Worsen with WB
• tightens with sleeping(go into PF) - worse with initial WB
• occurs in over pronators/poor arches
• fatigued/overworked extrinsic and intrinsic muscles
• may also occur in supinated foot due to tightness of Plantar fascia
• responds well to orthotic or low dye tapping

Question 25

tarsal tunnel syndrome

Answer 25

- inflammation of posterior tibial nerve - flexor retinaculum tight, small space - tenosynovitis of posterior tibialis, FDL, FHL - seen in over pronators - overuse fatigue extrinsic and intrinsic muscules - poor arches

Question 26

Signs and symptoms of tarsal tunnel

Answer 26

- paresthesia of plantar aspect of foot - may lead to weakness of intrinsics –> claw toe - responds well to orthotic, low dye taping - medial plantar n. = great toe - lateral plantar n. = 2nd toe and laterally

Question 27

MTP joints - requirements for gait

Answer 27

- extension required during push off - need 45-55 Toe extension for normal walking - compensation = ER at hip - evaluate 1st MTP position and mobility

Question 28

Hallux Rigidus

Answer 28

- lack of great toe extension - results in pain and limited push off - compensation = ER at hip - this sets them up for excessive pronation - look for callus in medial aspect of great toe MTP

Question 29

Hallux Valgus deformity

Answer 29

- bunion - lateral deviation. of 1st proximal phalanx - medial deviation of 1st metatarsal - sublux. 1st MTP joint on X-ray - capsule, MCL, bursa, thickened/inflammed - excessive bone forms (exostosis/bunion pain) - gait - Hip ER compensation

Question 30

Claw toes

Answer 30

- hyperextended MTPs - flexion of IPs - loss of interossei/lumbricales - can be result of Tarsal tunnel syndrome with posterior tibial n. compression)

Question 31

Hammer toe

Answer 31

- hyperextension MTP - flex PIP - common at 2nd toe - muscle imbalance, heredity, poor fitting shoes

Question 32

Mallet toe

Answer 32

- can't actively extend DIP - rupture of extensor insertion into distal phalanx - MOI - stub toe - contracture of DIP joint

Question 33

Lateral tibial torsion signs

Answer 33

- too many toes - normal 15º ER - position of medial and lateral malleoli in regards to the femoral condyles