Foot Mechanics Chart Flashcards Preview

PHTH 7232 Ortho > Foot Mechanics Chart > Flashcards

Flashcards in Foot Mechanics Chart Deck (48):
1

Coupling mechanism-

Pronation= unlocked/loose packed position
Supination= locked/close packed position

2

Tibial Alignment

Tibial alignment

Typical 2-3deg varum

If you think about it when you're walking you transfer your weight over to the side and hive a tibia varus. Usually you have about a 4-7 deg varus angulation as you walk thats normal. That is why doing a lot of things single leg is so critical in your rehab, replicates gate cycle.

3

Clinical manifestations of pronation- (when you're watching your patient walk)

 

  • Forefoot- abduction (Main component of pronation)
  • Arch- depressing down
  • Mid-foot- pronated (we will measure these with longitudinal arch measurement, drop test, and phys' line)
  • Rearfoot or STJ(remember where pronation occurs)- eversion or calcaneal going into valgus (frontal plane component of the tri-plane motion of pronation)
  • Ankle- PF towards DF
    • when going from heel strike to forfoot loading going to the midstance phase of gate. You should be at the neutral position of the ankle at the 90 deg angle.
  • Tibia- IR
  • Patella- IR
  • LE- IR

3

Bergman's position

Birdmen's position- plantar flexion inversion how the  foot normally falls when relaxed. Also used in slipper casting for developing orthotics

3

Figure 8

 

  • pt in long sitting position start medially
  • Start at the anterior tib > navicular > plantar surface > cuboid groove > back to the anterior tib > distal to the medial malleolus > superior calcaneal dome > distal to the lateral malleolus
  • About 54 cm.
  • 7 mm is the minimal detectable change. If they haven't changed by 7 mm it is not enough to really be clinically important difference

3

Tests indicated if supspect a DVT (3)

 

  1. Circulatory tests-Buerger's test
  2. Homan's Test
  3. Well's CPR-DVT

4

Plantar Surfaces evaluation

Plantar Surfaces evaluation= dynamic pedograph (look at callus indicae weight bearing)

  • Pt. supine or long sitting on table (he said here where you would see the callouses for pronation and supination, but the recording skipped so I couldn't make it out)
  • you can look at the bottoms of the older models and see where it is wearing down
  • Should be on the posterior-lateral corner and goes along the lateral aspect, then goes to the center mid stance and then towards the first metatarsal as it is re-supinating. you can see this on the bottoms of shoes.

4

Mulder’s Sign

 

Mulder’s Sign (not that great best that we have)

Morton’s neuroma

  • Most commonly between 3 and 4
  • pt will present complaining of neurological symptoms into the toes.
  • Hand over the dorsum of the foot, squeeze everything together, push up with your finger from the plantar side between the 3rd and 4th toe
  • Compresses the neuroma Mulder's sign or squeeze test
  • you put your bottom hand between MTP of 3 and 4 the other hand squeezes over the dorsum of the foot pain over bottom of foot would be a positive of a Morton's neuroma
  • push with your finger first then squeeze

5

Haglund’s Deformities

 

Haglund’s Deformities-eccestosis usually soft tissue first then it goes on to cause boney response

  • usually occurs on Superior lateral dome of the calcaneus
  • can be caused by a lot of things old term Pump bumps (reaction to the back of pumps rubbing on heals)

5

Homan’s Text- DVT

Homan’s Text- DVT (not a good test but it's a good quick screening test well's cpr best way to ID a DVT)

  •  complaining of exquisite Pain in the back of the leg and usually have some swelling there and leg is Hard feeling and red
  • Dorsiflex and press in the center of the calf do it gently
  • If there is exquisite pain- DVT
  • Good to use as a screen for a post surgical patient
  • No research to back it also no research to prove that it can or has dislodge a DVT

6

Longitudinal Arch angle

  • Use a gonio axis is the navicular bisect first MTP with stationary arm and moveable arm to medial malleolus (measure the angle)
  • Between 100-130= low medial longitudinal arch (similar to a third degrees feiss’ line)
  • 130-150= (second degree Feiss’ line) Medium medial arch
  • 150-180= (1st degree of feiss' line)high medial arch

8

Knee Posture

 

Knee posture- you eyeball posture and keep all of the following possibilities in mind for future treatment. taking your time with this is one of the more critical things because it is all eyeballing.

  • Genu varum
  • Genu valgum
  • Knee flexion contracture
  • Knee recurvatum
  • Knee is the patella IR/ER  High low (alta baja)

9

4 Reasons you want the foot to pronate (Refered to as Dynamic Functions of the foot during Gate Cycle) (**** Know this***)

  1. Becomes a loose adapter at heel strike so it can accommodate to the terrain
  2. Shock absorber so all of the force is not transmitted up the body
  3. The pronation absorbs the transverse plane rotation (foot internally rotates but doesn’t slide on the ground into more IR)
  4. Foot needs to re-supinated to become a rigid lever for propulsive push off
    • really supination not pronation

9

Helbing’s Sign

 

  • observe again
  • Medial bowing in the achilles corelates with STJ pronation/calcaneal valgus

10

Circulatory- pulses

 

Posterior tib (primary blood supply)
Dorsalis Pedis is absent in 12-15% of people don't use as primary distal pulse. it is on the dorsum of the foot at the level of the navicular

11

Tests indicated if "Foot/LE pain" is present (3)

 

  1. NWB-STJ Neutral
  2. Midtarsal joint mobility
  3. NWB- forefoot position

12

Tibial Torsion

 

Tibial torsion (complicated not getting too bogged down now eye ball it)

  • Looking for tibial rotations
  • Normal is 13*-18* Q angle
  • If the tibial tuberosity in the center, lateral, or medial there are ways you can..(the recording skipped)

 

Measuring Q Angle (from physiopedia):

Position: Patient supine with knee extended. The therapist stands next to patient. (or can do in standing)

Application: When measuring ensure that the lower extremity is at a right angle to the line joining each ASIS. The foot should be placed in a neutral position relative to supination and pronation with the hip in neutral position relative to medial and lateral rotation. Draw a line from ASIS to the midpoint of patella and then from the midpoint of the patella to the tibial tubercle. The resultant angle formed by the crossing of these two lines is called the Q angle.

Positive sign: Normal Q angle score for females is between 13-18° with values greater than and lesser considered abnormal and may indicate the patient is at risk of developing chondramalacia patella, patella alta or mal tracking of the patella. http://www.physio-pedia.com/'Q'_Angle

 

From wheeless' textbook of orthopaedics:

q angle is increased by:
           - genu valgum
           - increased femoral anteversion
           - external tibial torsion
           - laterally positioned tibial tuberosity
           - tight lateral retinaculum
http://www.wheelessonline.com/ortho/q_angle_of_the_knee

12

Weight bearing leg lenght measures

Weight bearing leg length measurements this way the measurement can account for any genu varum/valgum etc. that is present in weight bearing. there are good studies supporting this using radiographs.

13

Foot biomechanics during the gait cylce (KNOW THIS******)

  • When you first hit the ground, the foot is in a supinated position in most cases. Can tell by looking at shoes as dynamic pedograph. Most shoes worn on post lat corner.
  • Instantaneously goes through neutral to pronation (25% of gait cycle)
  • Pronation is normal- shock absorber first 25% of stance phase (loosey goosey to absorb ground reaction forces)
  • Neutral (midstance phase)
  • Push off the foot needs to be a rigid lever so it re-supinated
  • Think of it as Close packed position, loose packed position, close packed

13

Passive mobility testing of the midtarsal joint

 

Passive mobility testing of the midtarsal joint (no good way to do this)(Mid foot)

  • Passive mobility testing
  • Stabilize the calcaneus and grab at the lisfranc area (right where the metatarsals attach to the tarsals) to the choparts area
  • Put the foot into adduction and abduction and see how much motion occurs
  • Totally qualitative (no objective measurements)

14

LE postural alignment “toes to the nose”

 

  • look at your partner from toes to waist today
  • Look from an anterior, posterior, and lateral view all strictly eye balling. There are different posture grids you can use but it is it is most always a posture technique.
  • If the person is standing with feet straight ahead it is not natural it indicates femeral anteversion internal tibial torsion or forefoot adductus.

15

Too Many Toes Sign

foot is externally rotates more, might be femoral retreversion, abduction, etc. this is usually related with forefoot pronation. too many toes sign.

17

Clinical manifestion- supination

 

  • Forefoot- adduction
  • Arch- eleveated
  • Midfoot- supinated
  • Rearfoot/STJ(STJ is the key joint remember)- inversion or calcaneal varus
  • Ankle- DF toward PF (at midstance phase everything is neutral)
  • Tibia- ER
  • Patella- ER
  • Lower extremity- ER

17

foot position: normal foot

Neutral foot- where everything is lined up in straight line

  • Patient is standing
  • Put one finger or thumb in the sinus tarsi lat aspect of talar dome and the thumb or finger (whichever is the opposite) underneath the medial malleoulus palpating dome of talus (anteriorly) you don't feel talor dome as easily as talor head
  • Have patient pronate and supinate starting big and then getting smaller and smaller until you cannot feel a bony prominence on either side that is by definition that patient's neutral position.
  • the therapist tells the patient when to stop
    • You will find that not everybodies neutral position is in the middle some are way out to one side or the other.

Clinical relevance- ideal position during the midstance phase of gait is neutral  (will get overuse issues if it deviates from that or varius compensations leading to pathologies)

19

Tests with "All" as the indication (21)

 

  1. LE Posture Exam
  2. Fick Angle
  3. Miserable malalignment syndrome 
  4. Hypertrophy-ABH
  5. Too many toes sign
  6. Keen's Sign
  7. Accessory Bones
  8. Knee alignment
  9. Tibia Varum
  10. Single leg stance position
  11. Tibial torsion
  12. WB-LLD
  13. Helbing's Sign
  14. Haglund's Deformities
  15. WB-Neutral foot
  16. WB-Pronated position
  17. WB-supinated position 
  18. Morton's foot
  19. NWB-Plantar surface for calluses 
  20. Bergman's position 
  21. Circulatory tests-pulses

20

Compensated vs uncompensated abnormal foot posture

Uncompensated or compensated (does the problem exist but the patient can compensate)

  • Uncompensated- patient cannot adjust for the deformity for some reason (classic ex= forefoot varus 80% of people do.)
  • Compensated- another joint compensates for the deficiency
    • Plantegrade position- when you stand your feet always try to go to the floor. we don't stand around with med side of foot sticking up in the air.
    • Classic Ex: Forefoot varus position (3 ways it gets foot to the ground)
      • 1. Drop the first metatarsal down
      • 2. Internally rotate the whole leg
      • 3. Pronate through the STJ (most common, when in doubt always blame STJ)
      • Treatment- forefoot post in an orthotic (bring ground up to foot )
      • Can't measure forefoot position in weight bearing has to be non weight bearing, can measure rearfoot.

21

Navicular drop test

 

  • Only be around last 20 years
  • Patient is standing neutral position first
  • better not to mark it skin moves to much Palapate the navicular and measure from the floor
  • Patient relaxes- palpate the navicular and measure to the floor
  • Measure with the patient’s foot in neutral and when the patient is relaxed (compensating)
    • Difference > than 10 mm= compensated pronated foot
    • Difference< 10mm= normal

23

Keen's Sign

 

Keen’s sign- are the ankles the same size yes? no?(sprains, distastasis, achilles, etc)

  • Asymmetry= Keen’s sign
  • Can document using the figure 8 measurement
  • could be non-traumatic or truamatic

25

1st ray mobility testing

 

  • 1st ray should be parallel to other rays
  • Plantar flexing the first ray could be a compensatory action so we have to assess it
  • take outside hand with 4 metatarsals inside hand over first metatarsal. Hold the foot like you’re eating a sandwich (a toe sandwich)
  • Outside hand is stationary inside hand is moving
  • Move up into dorsi flexion back to neutral and then down into plantar flexion (1st metatarsal)
    • the pasive mobility should be a 1:1 ratio ( some people say a finger's width in each direction don't worry about that)
    • 3 passive dorsiflexions, 3 passive plantarflexions
    • If the dorsiflexion is limited and the plantarflexion is increased, then it is indicative of a hypermobile plantar flexed 1st ray (compensation for a forefoot varus)
    • Pt could be normal hyper or hypo but hyper is most common

26

Fick angle

  • - 5-18* angle that is formed at the feet
  • Feet should be angled out, not straight forward
  • Have patient march and then stop to get true standing posture

28

Test for STJ/ rear foot position non weight bearing

  • check for rear foot first
  • (Not the same as goniometry for inversion and eversion. With gonio you would find 0 then have them invert measure then evert and measure and take the difference. This is not what we are doing in this test it is gonio.)
  • Static resting rear foot position- where the foot lays measured with a goniometer. this is pts starting 0 position
    • Usually in a few degrees of varus
  • Calcaneus, talus, and distal 1/3 of tibia(lower leg) need to be in a straight line
  • Patient is prone in a figure 4 position because usually a pts leg will ER this stops that from hapening. Don't let them cross their leg over have them put  the plantar surface of their foot on their knee stabilizing the leg
  • The patient's foot is off the edge of the table, and the therapist is at the end of the table. Make sure their foot is in line with the table if it is not move the leg around to get it into position.
  • your inside hand under anterior aspect of their leg thumb Palpate the head of the talus and index finger over the dome of the talus.
  • With your outside hand grab the metatarsals 4 and 5
    • Move the foot back and forth (inversion and eversion) really far and then move smaller to the point where you no longer feel the dome or head of the talus on either side or you feel them equally (this is subtalor neutral resting position.
  • Give slight dorsiflexion pressure with your outside hand(as much as you can without changing the position of the foot also stop when you feel resistance)
    • Trying to replicate the midstance phase of the gait cycle where everything is in line
    • the ankle should be at a 90 deg angle.
  • (Alternative way to figure out Neutral (measure STJ all the way through inversion and eversion and remember that inversion is 2/3 of the motion passively all the way to eversion and back off 1/3 or inversion and back of 2/3 of the motion)
    • First way is the better way to do it through your palpation
    • remember everything starts with the foot whether it is low back or hip.)
  • now look at forefoot it should be parallel the 5 metatarsals should be parallel to the table= neutral position
  • if big toe side is closer to the table that is a forefoot varus position
  • if lateral is toward the table that is forefoot valgus position

29

Look for miserable malalignment syndrome (in out in out)

 

  • Hip IR
  • Patella in the femoral trochlea so it’s internally rotated
  • External tibial torsion proximally
  • Distal tibia varum
  • STJ pronation
  • Think of it as in out in out

30

New Gait Terms

 

  1. Initial contact (may be the forefoot in a CP child)
  2. Loading response (analogous to foot flat)
  3. Mid-stance (body directly over the foot and everything is lined up)
  4. Terminal stance (moving forward)(called heel off toe off in classic terms)
  5. Preswing- right before toe off
  6. Initial swing
  7. Mid-swing
  8. Terminal swing

The initial swing mid swing and terminal swing are analogous to acceleration phase and deceleration phase in classic terms

31

Equinus Foot

 

Equinus Foot- when a patient lacks more than 10*  in dorsflexion

  • pt. in long sitting measure dorsiflexion make sure pt is in neutral position
  • palpate in sinus tarsi and dome of the talus to make sure they do not pronate, sometimes pt. will try to pronate so they can go further
  • problomateic because you need 10 deg minimum for normal dorsiflexion in gate, you need 20 deg for running.
  • STJ compensates for ankle and therefore person will be pronating
  • Measure dorsiflexion

32

Windlass Effects

 

pt standing

  • forcebly dorsiflex first phalange and the Medial longitudinal arch should raise up
  • When you dorsiflex the toe, the arch should elevate
  • Tightens the medial longitudinal arch and the plantar fascia
  • Someone that is a pronator loses the elevation of the arch/windlass affect
  • You can see the lack of windlass affect in people as they walk. When they toe off arch should raise up, and it won't if they pronate. All due to plantar fascia

33

Wells CPR- DVT

 

Do not have to know these just know that it is out there and we can go find it if we need it.

34

Thompson/Simmond's test

 

  • Usually happened from forcible push off pt will report they feel that someone shot them there usually very painful in the beginning
  • Check the achilles by using the gap test (run finger from attachment to the calcaneus and look for drop)
  • Achilles tendon rupture test
  • Squeeze the gastroc (pretty hard so you can see it), mechanically tightening and the foot will plantar flex (if the achilles is ruptured the foot will not move at all)
    • Qualifier- If the ankle deviates, it could be a partial tear of the achilles.  When the ankle deviates it deviates away from the side that was ruptured

36

Feiss’ Line test

 

  • Patient is in a weight bearing position make sure pt is relaxed and not weight bearing on one foot more than the other.
  • Pt is NOT standing in neutral for this test this is resting position. their compensated foot position
  • Draw a line that bisects the 1st MTP joint and the medial malleolus
  • palpate and find the Navicular tuberosity theoretically should be on that line theoretically feiss' line and "ideal foot" (supinated foot in davie's personal experience)
  • Draw a line parallel to the floor and divide the area into 3’s
  • 1st third (upper)= normal (first degree static pronated foot)
  • 2nd third(middle)= pronated
  • 3rd third(lower)= very pronated

37

Circulatory: Beurgers

 

Beurgers- don't have to worry about it commonly done for pdd.
elevate extremity and see how long it takes for blanching to return if pts have vascular response problems then this gets to be one of the better tests

38

Classic Gait Terms

 

2/3 of gait cycle is the stance phase (60-66%) depending on where you read

Where action occurs
Classic terms for stance phase

  1. Heel strike
  2. Foot flat
  3. Mid-stance (body is directly over the foot)
    • Neutral position of the foot- critical factor
    • Where prolonged pronation would occur if you deviate from neutral position and is why you use orthotics
  4. Heel off
  5. Toe off

Swing phase approx 1/3 of gate cycle

  • Acceleration phase
    1. Toe off
    2. Mid swing
  • Deceleration phase
    1. Mid swing
    2. Heel strike

40

Subluxating peroneal tendons

 

  • Patient is prone
  • Flex the knee to 90 deg
  • Planterflex and evert the foot
    • Resist that motion watch and or palpate what happens to the peroneal or fibularis tendons (should be like a 3+ MMT)
  • If they subluxate over the fibula the extensor retinaculum is loose if they don't it is normal

42

Accessory bones

Accessory bones- when looking at your partner look for any funny bumps.

  • Os trigonum(most important), os navicularis (over the navicular bone, second most important), os vesalianum (on the lateral side near the 5th styloid) there are about 20 of them.

43

Pronation is abnormal when: (know this!)

 

Pronation is abnormal when: (***Know This***)

  • Its excessive
  • Maintained in a pronated position for a prolonged period of time
    • (Excessive compensatory prolonged pronation)-Longer than 25% of the gait cycle. will cause problems in all of the joints all the way up to the lumbar area.

44

Measuring Forefoot position

 

  • Patient is in prone figure 8 for position 
  • Start with doing subtatalor/rear foot position in a neutral
  • Assess forefoot position relative to rearfoot- assess is it neutral varus or valgus?
  • grasp 4th and 5th met heads and dorsiflex
  •  draw a straight line parallel to table using a small gonio
    •   stationary arm is lined up with the table
    •   moveable arm  right under metatarsal heads.
    • Medial side closer to the table= forefoot varus (If the patient is standing the medial side elevated)
      • 80% of people have some forefoot varus
    • Lateral side closer to the table= forefoot valgus (if the patient is standing the lateral side elevated)
    • picture on power point has a tongue depressor showing this the forefoot position.
    • One of the most common compensations are pronation of subtalor joint or first ray compensations

45

Tests indicated if "foot pain" is present (9)

 

  1. Windlass effect
  2. Feiss' Line
  3. Navicular drop test
  4. Longitudinal arch angle
  5. 1st Ray mobility test
  6. Equinus foot
  7. NWB-STJ Neutral
  8. Midtarsal joint mobility
  9. NWB- forefoot position

46

Morton's Foot

  • Morton’s foot occurs in about 22% of indivisuals
  • 2nd toe and metatarsal longer (must be both) has never found a number of how much bigger
  • Palpate patient's metatarsal and phalange to assess length
  • Foot mechanics change
  • Normal great tow twice as long as other toes so you toe off on the great toe
  • Weight bearing comes off of the 2nd metatarsal instead of the first since it is longer
    • Stress fractures, hypermobility syndromes sprains at MTP joint
  • Morton’s extension orthotic forces weight bearing to no longer come off of second toe in gate cycle

47

Plantar fascia test

 

  • almost did this when we palpated
  • Dorsflex all of the toes as far as you can so that the plantar fascia is tight
  • starting from the medial calcaneal tubercle (where fascia originates) run finger along all of the bands/respective metatarsals (345 are harder to feel because the lat side is flat med side should be easier to feel)
  • if this hurts it confirms plantar fasciatis it will hurt as soon as you palpate the medial calcaneal tubercle it will also hurt when they stand.

48

Tinel’s sign

 

  • Tap on the posterior tib nerve between Tom, Dick, and Harry
  • Can use a reflex hammer
  • Look for tinglies into the foot
  • Tarsal tunnel syndrome flexer retinaculum puts pressure on the nerve if person pronates or posterior tib dysfunction usually
  • Dr. Glenn asked Dr. Davies if you should dorsiflex the foot for tinels. If you want to stretch tarsal tunnel you can evert STJ or dorsiflex toes but subtalor movement will tighten it the most. was his answer