Mechanics of the Foot and Ankle Flashcards Preview

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Flashcards in Mechanics of the Foot and Ankle Deck (63)
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1

What is the tibiotalar joint stabilized by?

 

  1. Joint stabilized by capsule,
  2. deltoid ligament,
  3. anterior talofibular (ATFL-always tear first!),
  4. calcaneofibular (CFL)
  5. posterior talofibular (PTFL) ligaments
     

2

What are the subunits of the deltoid ligament?  What injury usually occurs here?


•Comprised of: tibionavicular, anterior and posterior tibiotalar, and tibiocalcaneal ligaments
 


•Usually bone injury (fracture) occurs before this ligament is damaged.
 

3

Describe the lateral ligaments of the tibiotalar joint


•The ATFL (always tear first in inversion sprain)
•Attaches to the lateral malleolus & to the neck & lateral articular facet of the talus
•The Calcaneofibular
•Attaches to the lateral malleolus & to the tubercle of the lateral surface of the calcaneus
•The PTFL
•Attaches to the lateral malleolus & to the lateral tubercle of the post process of the talus
 

4

What are the major motions of the ankle?


•Plantar flexion (to 50 degrees)
•Performed by gastrocnemius & soleus (major players)
•Performed by plantaris (if you have one!), tibialis post, flexor hallucis longus & flexor digitorum longus  (minor players)
•Dorsiflexion (to 20 degrees)
•Performed by tibialis anterior (major player)
•Performed by extensor digitorum longus & extensor hallucis longus (minor players)
 

5

When is the ankle most stable?

In dorsiflexion

6

Accessory ankle motions?


•Side-to-side glide, rotation, abduction and adduction only if the joint is plantar flexed.
 

7

Major motions of the subtalar joint?


•Major motions are calcaneal ABDuction (valgus) & ADDuction (varus) in relationship to a fixed talus
•So the heel deviates in and out
 

8

The talus articulates with the...

The calcaneus articulates with the...

Navicular

cuboid

9

Motion of the hind foot is the combined motions of the...


• Talocalcaneal (subtalar), Talonavicular, and Calcaneocuboid
 

10

Motions of the hind foot?

Inversion and eversion

11

Where is the midfoot?


•Between Transverse Tarsal joint and Tarsometatarsal joint
 

12

Motions of the midfoot?

Pronation and supination

13

Describe pronation

Pronation= Eversion + Dorsiflexion + ABduction (calcaneus & foot)

14

Describe supination

Supination= Inversion + Plantar flexion + ADduction (calcaneus & foot)

15

Motion of the tarsometatarsal joints?


•flexion & extension
 

16

Motions of the intermetatarsal joints?

sliding

17

MTP movements?

Flexion, extension, abduction, and adduction.

Also slide, rotate and can provide long axis traction

18

Movements of IP's

Flex and extend

19

What are the longitudinal arches?

Lateral and medial

20

Describe the lateral arch.  What is it built for?


•Weight bearing & elastic
•Firm osseous structure
•Made up of calcaneus, cuboid, 4th& 5th Mets
•Limited mobility
•Built to transmit weight & thrust to the ground
 

21

Describe the medial arch.  What is it's primary purpose?


•More mobile & higher than the lateral arch
•Made of (calcaneus), talus, navicular, the cuneiforms and 1-3Mets
•Controlled by plantar ligament, plantar fascia, tibialis post, FDL, FHL & intrinsic muscles of the foot
•Does not have firm osseous support
•Changes to adapt to terrain
 

22

The medial arch helps to control...

gait

23

What is a high medial arch caused by?


•Caused by ADduction of foot and a varus calcaneus
 

24

What causes a dropped medial arch?


•Caused by ABduction of foot and a valgus calcaneus & dorsiflexion of the ankle
•Extreme pronation!!!
 

25

What does the foot musculature do with regard to the arch?

What do they not do?

They help control it for balance and gait.  

 

Do not support the arch.

26

What are the three transverse arches?

Anterior

Posterior

Tarsal

27

Describe the anterior transverse arch


•Made of the metatarsal heads
•Transmits weight to the ground
•Flattens with weight bearing
 

28

What comprises the posterior transverse arch?

metatarsal bases

29

Describe the tarsal arch


•Made of navicular, cuboid and cuneiforms
•Assists in flexability of the foot as well as rotation
 

30

What arch is involved in flat feet?

Transverse tarsal arch
•Decrease of loss of this arch is pesplanus (flat feet)
 

31

How do you evaluate the foot and ankle?


•Observe
•Have the patient stand
•Have the patient walk
•Evaluate the foot, ankle (and knee, and hip, and pelvis, and…)
•In general, when evaluating an orthopedic injury, you examine 1-3 joint(s) up and down from the injured joint
 

32

What are we looking for when evaluating the foot and ankle?

  1. •Edema
  2. •Swelling
  3. •Discoloration
  4. •Callus
  5. •Corns
  6. •How the weight is distributed on each foot
  7. •Position of the toes (in/out)
  8. •Arch (medial) height
  9. •Position of Achillies tendon
  10. •Deformities of the bones themselves
     

33

Corns and calluses reveal?

The alteration of force directionality in the anatomy.

34

What is this condition?

Hammer toes

35

What is this called?

Claw Toes

36

Describe hammer toes


•Hammer toes have a flexion deformity of the PIP & an extension deformity of the DIP
 

Hammers need naile - if can see nail, hammer toe.

37

Describe claw toes


•Claw toes have flexion deformities of the PIP & DIP joints
 

38

What is this?

Bunion

39

What is a bunion?


•A bunion is the medial deviation of the 1st Metatarsal with lateral deviation of the proximal phalanx of the hallux (great toe)
 

40

What are normal ROM for dorsi and plantar flexion?

Dorsi - 20 degrees

Platar - 50 degrees

41

How does one test motion of the foot?


•Dorsiflexion & plantar flexion
•Have patient actively do it 1st
•Then passively move the foot
•Invert the foot slightly
•Place into plantar and dorsi flexion
 

42

How does one test motion of the lateral malleolus?


•Lateral malleolus
•Patient supine. 
•Grab the lateral malleolus between your thumb and index finger and wiggle it anteriorly and posteriorly. 
•Named for the direction of freer motion.  
 

43

How do you motion test the subtalar joint?


•Subtalar ABDuction & ADDuction
•Occurs at subtalar, talonavicular and calcaneocuboid joints
•The patient actively moves the foot first
•Then the doctor passively moves the foot in ABDuction & ADDuction
 

44

Normal ROM for adduction and abduction of subtalar?

ADDuction - 20 degrees

ABDuction - 10 degrees

45

How do you test the motion of the calcaneal inversion-eversion? NL ROM?


•The patient actively moves the foot first
•Then the doctor passively moves the foot by gripping the calcaneus in one hand and locking the talus by gripping the forefoot with the other.  Then invert and evert the foot
•Inversion/eversion 5 degrees of motion
 

46

How do you test the motion of the 1rst metatarsal?

NL ROM in flexion and extension?


•1st Metatarsal
•Grasp and lock the 1st cuneiform
•Rotate the bone to check for freedom of motion
•Have patient actively flex and extend the joint. Doc then passively moves the the hallux into flexion and extension to check the motion
•Flexion 45 degrees
•Extension 70-90 degrees
 

47

Describe the gait phases


1.Stance phase
    1.heel strike
    2.Foot rolls to lateral edge
    3.Weight should roll back to ant transverse arch
    4.The great toe should push (toe) off


2.Swing phase
 

48

Describe the acute inversion ankle sprain.


•Very common injury


•Ligaments involved 
     •Anterior talofibular (ATFL)
          •Always tears first
     •Calcaneofibular
     •Posterior talofibular (rare—generally seen with fracture-       dislocation)
 

49

Describe a grade 1 sprain


•Grade 1-microtears with the ligament
•Swelling and disability but no instability (no laxity)
 

50

Describe a grade 2 sprain


•Grade 2-partial tear of the ligament
•Severe swelling over the ankle, mild instability, antalgic gait, mild ligamentous laxity, laxity is noted with a good end point, decreased ROM
 

51

Describe a grade 3 sprain


•marked loss of function and complete instability, no endpoint noted on provocative testing
 

52

What is the MOI for an acute inversion ankle sprain?


•Inversion and plantar flexion
•Generally by stepping on an uneven surface (ie.  landing on someone else’s foot after rebounding a basketball)
 

53

SSX of acute inversion ankle sprain?


•Swelling
•Eccymosis
•TTP depending on degree of injury
•Decreased ROM
•Antalgic  gait
•Poor lower extremity propreoception
         •Assessed with one leg standing test
 

54

What tests are we to use to determine if X-ray is needed?

Anterior Drawer test - Assesses ATF only

Talar Tilt test - Assesses the ATF and calcaneofibular ligaments


•Always check the arches of the foot after a sprain.  IF the arch is acutely flat; this may indicate tear of tibialis posterior tendon (a stabilizer of the foot)
 

55

Timeframe for repair of tibialis posterior tendon?

14 days

56

Ottawa ankle rules may be used for all patients but...

Those under age 18

57

How does one perform the Talar tilt test?


•Pt is sitting with legs dangling off table
•Doc inverts the calcaneus
•If the talus gaps or rocks in the ankle mortise, the ATF & calcaneofibular ligaments are torn and the test is positive
 

58

How is the anterior drawer test done?


•Pt is sitting with legs dangling off table
•Foot is in a few degrees of plantar flexion
•Doc grabs front of tibia with the other hand cupping the calcaneus
•Gently pull the calcaneus anterior as you push the tibia posterior
•If normal the talus will not move on the tibia
•If abnormal the talus slides anteriorly—this is a positive test 
 

59

Describe the effects of a sprain on the body.

 

  1. •The ankle inverts
  2. •The fibular head moves posterior, the lateral malleolus moves anterior
  3. •This could impinge the common peroneal nerve and cause a foot drop
  4. •The tibia externally rotates
  5. •The femur internally rotates
  6. •Ipsilateral anterior innominate
  7. •Anterior torsion of the sacrum facing the side of the ankle sprain
  8. •So for a right ankle sprain, a Right on Right sacral torsion
  9. •L5 will rotate opposite of the sacrum
     

60

How does one treat grade one and two tears?


•Conservative treatment
•PRICE (protection, rest ice, compression, elevation)
•NO NSAIDs!
•Other pain medication
•Crutches if needed
•OMT
(Stem cell injections someday?)

61

What is the problem with NSAIDs?

Stop inflammatory cascade.  Which is the first step in the healing cascade.  Prevention initiates progress towards chronic disfunction.

 

 

62

Describe physical therapy protocols for the acute ankle sprain


•Start once acute inflammation is over (within 48-72 hours)
•Continue ankle proprioception exercises (one leg standing, wobble board) for a full 10 weeks to prevent recurrent sprains
(Draw all letters of alphabet)

63

What is the return to play criterion for an acute ankle sprain?


•Full painless ROM
•Strength 90% compared to uninjured side
•Able to tolerate gym, work or sport specific activity without increasing pain