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Lower Extremity Evaluation Lecture > Foot & Toes > Flashcards

Foot & Toes Flashcards

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1
Q

What are the 2 functions of the foot?

A
  • “Loose bag of bones”
    ~ loading
    ~ unlock
    ~ pronation
  • “Rigid lever”
    ~ Unloading
    ~ lock
    ~ supination
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2
Q

Rear foot bones

A
  • Talus
  • Calcaneus
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3
Q

Mid foot bones

A
  • Navicular
  • Cuneiforms
    ~ Medial (1)
    ~ Intermediate (2)
    ~ Lateral (3)
  • Cuboid
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4
Q

Forefoot & toes

A
  • 5 metatarsals
  • 14 phalanges
    ~ proximal
    ~ middle
    ~ distal
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5
Q

How does Functional Loading relate to gravity?

A

Succumbing to gravity, absorbing force, deceleration

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6
Q

Functional Unloading in regards to gravity…

A

Overcoming gravity, generating force, acceleration

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7
Q

What kind of muscle contraction is occurring during Loading/Pronation?

A

Eccentric

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8
Q

What kind of muscle contraction is occurring during Unloading/Supination?

A

Concentric

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9
Q

When describing motions…

A

we are describing what the distal bone is doing relative to the proximal bone

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10
Q

Subtalar Joint

A
  • Articulation between talus & calcaneus
  • Calcaneus relative to talus
  • Classic movements: Inversion and Eversion
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11
Q

Loading; “Loose bag of bones”, Planes of Motion

A

STJ -
Frontal Plane: Eversion

Sagital Plane: Plantar Flexion —> Dorsiflexion

Transverse Plane: Abduction

MTJ -
Frontal Plane: Inversion

Sagital Plane: Dorsiflexion

Transverse Plane: Abduction

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12
Q

Unloading; “Rigid Lever”, Planes of Motion

A

STJ -
Frontal Plane: Inversion

Sagital Plane: Dorsiflexion —> Plantar Flexion

Transverse Plane: Adduction

MTJ -
Frontal Plane: Eversion

Sagital Plane: Plantar Flexion

Transverse Plane: Adduction

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13
Q

Midtarsal Joint

A
  • Joins the rear foot to the mid foot
  • 2 joints
    ~ Talonavicular: head of talus &
    navicular
    ~ Calcaneocuboid: calcaneus & cuboid
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14
Q

Relationship between the STJ & MTJ in regards to loading & unloading

A
  • Loading of the STJ (evert) causes the MTJ to unlock (“loose bag of bones”) & become hypermobile
  • Unloading of the STJ (invert) causes the MTJ to lock (“rigid lever”) & become hypomoble
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15
Q

Poor Pronator

A
  • STJ inverts instead of everts during loading
  • STJ doesn’t load well causing the MTJ to not load well
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16
Q

Poor Supinator

A
  • Excessive STJ eversion
  • STJ loads excessively and may cause the MTJ to load excessively
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17
Q

Plantar Fascia

A
  • Thick band of connective tissue
    ~ Originates from the medial calcaneal
    tubercle
    ~ Inserts into the plantar surface of all
    phalanges
  • Primary support for longitudinal arch
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18
Q

Plantar Fascia: Windlass Effect

A
  • Extension of the toes at MTP joint during the propulsive phase of gait (functional unloading)
  • Shortens the distance between the calcaneus and metatarsals to elevate the medial longitudinal arch and invert the calcaneus
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19
Q

Along with the windlass effect, what causes unloading to occur?

A

Concentric muscle contraction

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20
Q

Tarsometatarsal Joints, also known as…

A
  • Lisfranc’s joint
  • Joins the mid foot and the forefoot
    ~ Cuneiforms 1-3 & Cuboid
    ~ Metatarsal bones 1-5
  • Motions
    ~ Dorsal and plantar glide (up & down)
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21
Q

Intermetatarsal Joints

A
  • Proximal
    ~ Bases of the metatarsals
  • Distal
    ~ Heads of the metatarsals
  • Motions
    ~ Dorsal & plantar glide (up & down)
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22
Q

Metatarsophalangeal Joints

A
  • Joins the metatarsals & toes
  • Motions
    ~ Sagittal: flexion/extension
    ~ Frontal: Rotation
    ~ Transverse: abduction & adduction
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23
Q

Interphalangeal Joints

A
  • Joins phalanges to toes
  • 1 on the 1st digit (IP)
  • 2 on the 2nd-5th digit (DIP & PIP)
  • Motions
    ~ Flexion & extension
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24
Q

Intrinsic Muscles of the Foot

A
  • Very small muscles grouped into four layers
  • Superficial
  • Middle
  • Deep
  • Interosseous
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25
Superficial Muscle
Contains the primary toe abductors & secondary flexors
26
Middle Muscle
Contains the quadratus plantae which when contracted changes angle of pull for Flexor Digitorum Longus
27
Deep Muscle
Contains the secondary flexors of the 1st & 5th toes
28
Interosseous Muscle
Contains dorsal & plantar interossei
29
Extrinsic Muscles of the Foot
- Muscles that originate outside the foot in the lower leg and insert on the foot - Flexor Hallucis Longus - Flexor Digitorum Longus - Extensor Hallucis Longus - Extensor Digitorum Longus - Peroneus Tertiaus - Peroneus Brevis - Peroneus Longus - Tibialis Anterior - Tibialis Posterior
30
When describing the “action” of muscles…
you’re describing what the muscle does in space. - Artificial - Open chain: distal segment is not fixed - Less functional - Classic
31
When describing the “function” of muscles…
you’re describing what the muscles do when the foot is on the ground - Natural - Closed chain: distal segment is fixed - More functional
32
Foot Type: Pes Planus
- Decreased medial arch (pronation) - Everted heel - Abduction of forefoot
33
Foot Type: Pes Cavus
- Accentuated medial arch (supination) - Inverted heel - Adduction of forefoot
34
Test for Supple Pes Planus
- Tests the severity of arch angle - Positive Test (Supple) = Medial Arch disappears/is not present when standing, but reappears when on tippy toes - Negative Test (Rigid) = Medial Arch disappears/is not present when standing, but does not reappear when on tippy toes
35
Navicular Drop Test
- Measures starting and end point of navicular - Confirms pronated foot position - Positive = navicular drops more than 10 mm
36
During weight bearing inspection how should the patient be positioned anteriorly…
- Have them march in place - Ensure hip & trunk are not rotated: this can affect the entire kinetic chain ~ Toes should slightly be pointed out 12-18 degrees (Ficks’s angle): anything more or less is abnormal
37
Metatarsal Lengths
Index Plus (“Egyptian Foot”): 1st metatarsal longer than 2nd; most common Index Minus (Morton’s Toe or “Greek Foot”): 1st metatarsal shorter than 2nd; second most common Index Plus-Minus (“Squared Foot”): 1st metatarsal is equal to 2nd; least common
38
Toe Alignment Types
- Caused by shoes Claw Toes: Flexion contracture at PIP & DIP w/ hyperextension at MTP ↗️⤵️ Hammer Toes: Flexion contracture at PIP & hyperextension at MTP & DIP ➡️↘️ Mallet Toes: Flexion contracture at DIP ➡️⬇️
39
Hallux Abducto Valgus (“Bunion”)
- 1st toe is in valgus position - Caused by narrow shoes - MTP joint is enlarged & hypomible - Weight bears on medial side of foot - Limited Windlass & Flexion/Extension
40
During weight bearing inspection posteriorly, what kinds of things should be noticed…
- Calf Musculature ~ Girth ~ Contour - Achilles Tendon ~ Lateral ~ Medial ~ Deformity - Calcaneus ~ Inverted ~ Everted ~ Neutral ~ Shape > “pump bump”: bursitis
41
During weight bearing inspection lateraly, what kinds of things should be noticed…
- Lateral longitudinal arch - Toe Alignment - Skin abnormalities
42
During weight bearing inspection anteriorly, what kinds of things should be noticed…
- Arch ~ Pronated ~ Supinated
43
During non-weight bearing inspection how should the patient be positioned…
- Prone ~ Distal 1/3 leg off table ~ Figure 4 - Observe for skin abnormalities on sole
44
Transverse Metatarsal Arch
- Shaped by metatarsals & tarsals - Normally concave along inferior surface of metatarsals
45
Medial Longitudinal Arch
- Made up of calcaneus, talus, navicular, 1st cuneiform, & 1st metatarsal - Supported by calcaneonavicular ligament & plantar fascia - Supported by tibialis anterior, tibialis posterior, & flexor hallucis longus
46
Lateral Longitudinal Arch
- Made up of calcaneus, cuboid, & 5th metatarsal - Supported by plantar fascia - Supported by peroneus longus, peroneus brevis, & peroneus tertius
47
How would you know a foot is normal/neutral?
- Rearfoot (calcaneus) is in line with the lower leg (achilles & calf) - Forefoot (met heads) is parallel to rearfoot (calcaneus) - Forefoot (met heads) are in line to each other
48
Structural Deformity: Rearfoot Varus
- Rearfoot is inverted while STJ is neutral ↕️ ↙️ ———
49
Rearfoot Varus Compensation This compensation would make which muscles unhappy?
- STJ needs to EVERT in order to get the calcaneus neutral - Increases stress on structures that provide stability - Cause unhappy Tibialis Anterior & Tibialis Posterior muscles
50
Structural Deformity: Forefoot Varus
- Forefoot is inverted relative to Rearfoot while STJ is neutral ↕️ ⚫️ ⚫️ ⚫️ ⚫️ ⚫️ ↕️ ———
51
Structural Deformity: Dorsiflexed 1st Ray
- 1st met head is higher (dorsiflexed) than other 4 while STJ is neutral ↕️ ⚫️ ⚫️⚫️⚫️⚫️ ↕️ ————
52
Forefoot Varus & Dorsiflexed 1st Ray Compensation. This compensation would make which muscles unhappy?
- STJ needs to EVERT in order to get Forefoot & 1st ray in neutral - Increases stress on structures that provide stability - If calcaneus unable to evert, foot will be more rigid because the MTJ would have to evert to compensate for STJ - Cause unhappy Tibialis Anterior & Tibialis Posterior
53
Structural Deformity: Forefoot Valgus
- Forefoot is everted relative to Rearfoot while STJ is neutral ↕️ ⚫️ ⚫️ ⚫️ ⚫️ ⚫️ ↕️ ———
54
Structural Deformity: Plantarflexed 1st Ray
- 1st met head is lower (plantarflexed) than other 4 while STJ is neutral ↕️ ⚫️⚫️⚫️⚫️ ⚫️ ↕️ —————
55
Forefoot Valgus & Plantarflexed 1st Ray Compensation
- MTJ needs to INVERT in order to get lateral portion of Forefoot on the ground - OR - - STJ needs to INVERT/STAY INVERTED to to get lateral portion of Forefoot on the ground ~ Happens if there’s not enough MTJ motion ~ Foot isn’t a good shock absorber ~ Muscles become shortened & more prone to tendinitis - Increases stress on structures that provide stability
56
Why would someone take a pulse in the foot?
Dislocations can cause lack of blood flow to the foot
57
AROM Testing
- MTP Joint ~ Flexion: 35-45 degrees ~ Extension: 75-85 degrees - STJ ~ Inversion: 20 degrees ~ Eversion: 4-5 degrees
58
Neurological Assessment
- Lower Quarter Screen - Tinel’s Sign ~ Tibial Nerve palpitation ~ Increased or new neurological symptoms into heel & plantar aspect of foot
59
Normal/Neutral Foot: Rearfoot, Arch, & Forefoot positions
Rearfoot: Vertical Arch: Normal Forefoot: Straight
60
Pronated Foot: Rearfoot, Arch, & Forefoot positions
Rearfoot: Everted Arch: Flat Forefoot: Abducted
61
Supinated Foot: Rearfoot, Arch, & Forefoot positions
Rearfoot: Inverted Arch: High Forefoot: Adducted
62
What are the common signs & symptoms for a fracture?
- Loss of function - Deformity - Point tenderness
63
Intermetatarsal Joint Ligaments
- Proximal & Distal - Supported by Dorsal, Plantar, & Transverse Ligaments - Resists dorsal & plantar glide
64
Intermetatarsal Glide Test
- Positive test indicated by “pain” & increased glide compared to opposite foot
65
Metatarsalphalangeal & Interphalangeal Joint Ligaments
- Supported by collateral ligaments - Resists Varus (adduction) & Valgus (abduction)
66
MTP & IP (Valgus & Varus) Testing
- Positive test indicated by increased Varus or Valgus compared to opposite foot
67
Which way does Varus & Valgus stretch ligaments?
Varus: Laterally Valgus: Medially
68
Tarsometatarsal Joint Ligaments
- Supported by dorsal & plantar ligaments - Resists dorsal & plantar gliding
69
Tarsometatarsal Glide Test
- Positive test indicated by “pain” & increased glide compared to opposite foot
70
Talus Fracture
- Usually not a gross fracture, but instead a fragment or chip in the dome of Talus - Cause: ~ Forceful inversion, eversion, or rotation; forces dome of Talus into Ankle mortise (Tibia & Fibula) - Signs & Symptoms: ~ Pain when weight bearing ~ “Catching” or “snapping” ~ Tenderness with palpitation - Management: ~ Very important to pay attention to complaints ~ Difficult to find on X-Ray ~ Self limiting ~ No cast; can make it worse or stiff and can take to long to RTP
71
Sever’s Disease or Apophysitis of the Calcaneus
- Inflammation of the attachment of Achilles to Calcaneus - Common in children - Cause: ~ Excess stress or tension - Signs & Symptoms: ~ Pain just below attachment ~ Swelling over attachment - Management: ~ RICE ~ Stretching ~ Heel lift: causes plantarflexion (shortening of Achilles)
72
Apophy means…
Tendon attachment to bone
73
Retrocalcaneal Bursitis or “Pump Bump”
- Inflammation of bursa between Achilles and Calcaneus - Cause: ~ Pressure from heel counter of shoe ~ Tight calf/tendon ~ Excess friction - Signs & Symptoms: ~ Pain with activity & palpitation ~ Swelling - Management: ~ RICE ~ Stretching ~ Heel lift: reduces strain on tendon & bursa; distributes pressure of bursa ~ Donut heel pad ~ Change of shoes
74
Cuboid Subluxation
- Cuboid displaces in plantar direction - Cause: ~ Abnormal foot type that keeps foot pronated too long or too much ~ Trauma to lateral side of foot ~ Stairs - Signs & Symptoms: ~ Pain along 4th & 5th metatarsals & over Cuboid ~ Possible referred pain on heel: lateral or medial - Management: ~ Manipulation ~ Correct abnormal foot mechanics
75
Tarsal Tunnel Syndrome
- Tarsal tunnel is formed by the medial malleolus and flexor retinaculum - Contains: ~ Tibialis Posterior, Flexor Digitorum, & Flexor Hallucis Longus Tendons ~ Tibial artery, vein, & nerve - Cause: ~ Any event or condition that causes compression of structures (Tibial Nerve) inside tunnel > Mechanical > Inflammatory - Signs & Symptoms: ~ Pain & paresthesia into plantar side of foot - Management: ~ Control inflammation; prevent further inflammation ~ May need surgery to cut connective tissue to allow for more space for structures
76
Tinel’s Sign
- Tap behind malleolus - Positive test indicated by worsening pain or paresthesia
77
Lisfranc Injury
- Dorsal dislocation of the base of metatarsal ~ Typically seen in 1st or 2nd metatarsal ~ Fracture often occurs - Cause: ~ Hyper-planterflextion of Forefoot with axial load (foot on ball & force comes from top) - Management: ~ Identify & fixate bones ~ Casting may not be effective (foot stays in bad alignment) , but instead screws & plates will ~ Surgery may be best option
78
Arch Strains
- Strain of the INTRINSIC muscles of the foot - Cause: ~ Increased/excessive loading ~ Abnormal foot type - Signs & Symptoms: ~ Pain during weight bearing ~ Pain below Tibialis Posterior Tendon ~ Pain in metatarsal region - Management: ~ RICE ~ Arch Taping ~ Orthotic Device/Pad: can cause more pain in early stages
79
Plantar Fasciitis
- Inflammation of plantar fascia - Cause: ~ Change in footwear ~ Change in activity ~ Abnormal foot type ~ Leg length discrepancy: shorter legs needs to compensate causing poor mechanics affecting the kinetic chain ~ Calf tightness: pulls on plantar fascia - Signs & Symptoms: ~ Pain in anterior & medial heel ~ Pain in fascia ~ Increased pain in the morning or after long periods of sitting ~ Increased pain when toes & ankle are Dorsiflexed/extended - Management: ~ Identify cause and correct it ~ Shoe insert/pad for abnormal foot type ~ Add height to shoe for leg length discrepancies ~ Support & increased flexibility in calf
80
If a patient doesn’t display the common signs & symptoms of a fracture, you should follow the…
Ottawa Rules - Used to determine if a fracture is present or not and if a patient should be referred for an X-Ray - Areas to assess ~ Lateral & Medial Malleolus to 6cm proximally ~ Over Navicular ~ Base of 5th metatarsal ~ Inability to weight bear or take 4 steps
81
Jones Fracture
- Fracture to the base of 5th Metatarsal - Cause: ~ Forceful inversion ~ Direct blow - Signs & symptoms: ~ Swelling ~ Point tenderness ~ Complaints of lateral pain & ankle sprain: palpate 5th metatarsal - Management: ~ Refer ~ Fixate with screws & plates - Not every fracture to the 5th metatarsal is a Jones Fracture, it needs to be at the base
82
Sesamoiditis
- Inflammation is the Sesamoids of great toe - Cause: ~ Excessive loading ~ Repetitive hyperextension of great toe - Signs & symptoms ~ Pain under 1st metatarsal head ~ Compensation will occur by weight bearing on lateral side - Management: ~ RICE ~ Pads & supports to take stress off Sesamoids > needs to be placed behind Met heads to alleviate pressure
83
Turf Toe
- Sprain of 1st Metatarsal Phalangeal Joint - Cause: ~ Excess 1st MTP dorsiflexion/extension: (plantar side) more common ~ Excess 1st MTP plantarflexion/flexion: (dorsi side) - Signs & symptoms: ~ Pain ~ Swelling ~ Unable to properly push off during gait - Management: ~ RICE ~ Prevent excess movement (temporary) > Tape, Splint, & Heel Inserts • Limits motion affecting Windlass
84
Intermetatarsal (Interdigital) Neuroma
- Entrapment of the interdigital nerve between the met heads - Cause: ~ Morton’s Toe or foot: Valgus of 2nd toe ~ Foortwear ~ Foot mechanics - Signs & symptoms: ~ Pain & paresthesia on adjacent toes that may radiate up leg ~ Compression may reproduce pain and result in a click sound called Mulder’s Click (scar tissue)
85
Morton’s Neuroma
Nerve entrapment between 3rd & 4th metatarsals
86
Heel Spur
Bony outgrowth at medial Calcaneal Tubercle (exostosis) - Cause: ~ Excessive pulling of plantar fascia or Achilles
87
March Fracture
Stress fracture
88
Styloid Fracture of 5th Metatarsal
Avulsion fracture at peroneus brevis attachment

Lower Extremity Evaluation Lecture (8 decks)

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