What stabilizes the tibiotalar joint?
Capsule Deltoid Ligament Anterior Tibiofibular Ligament (ATFL - Always Tears First Ligament) Calcaneofibular Ligament- CFL Posterior Talofibular Ligament - PTFL
What does the tibia articulate with, distally?
Talus - fits concave surface of tibia
What surface is the deltoid ligament on?
Medial
What does the deltoid ligament attach to?
Medial malleolus
Tuberosity of navicular
Sustentaculum tali of calcaneus
Medial tubercle of talus
What ligaments make up the deltoid ligament?
Tibionavicular
Anterior tiobiotalar
Posterior tibiotalar
Tibiocalcaneal ligaments
What usually happens before deltoid ligament is ruptured?
Bony injury - fracture
What does the anterior tibiofibular ligament attach to?
lateral malleolus
neck and lateral articular facet of the talus
What does the calcaneofibular ligament attach to?
lateral malleolus
tubercle of lateral surface of calcaneus
What does the posterior talofibular ligament attach to?
lateral malleolus
lateral tubercle of the posterior process of talus
What are the major motions of the ankle?
Plantar flexion - up to 50 degrees
Dorisflexion - up to 20 degrees
What are the minor motions of the ankle?
side-to-side glide
rotation
abduction
adduction - only if joint is plantar flexed
Where is the ankle most stable?
dorsiflexion
What muscles mediate plantar flexion of the ankle?
Mostly:
gastrocnemius
soleus
Also: plantaris tibialis posterior flexor hallucis longus flexor digitorum longus
What muscles mediate dorsiflexion of the ankle?
Mostly:
tibialis anterior
Also:
extensor digitorum longus
extensor hallucis longus
What glide of the talus do you get with plantar flexion?
Anterior
What glide of the talus do you get with dorsiflexion?
Posterior
What does the talus sit on?
The calcaneus
How many talocalcaneal articulations are there?
2 - concave convex articulations
What are the major calcaneal motions?
Abduction - valgus
Adduction - varus
both in relation to a fixed talus
What does the talus articulate with?
Other than the calcaneus, navicular
What else does the calcaneus articulate with?
Cuboid
What mediates motion of the hindfoot?
Combined motions of these joints:
Talocalcaneal/subtalar
talonavicular
calcaneocuboid
What joints are changed with inversion of the hindfoot?
Medial rotation of calcaneus and navicular bones
Cuboid rotates down on calcaneus
What does inversion do to the arch of the foot?
Increases the height
Accented by plantar flexion
What muscles are used in inversion of the foot?
tibialis anterior and posterior
What joints are changed with eversion of the hindfoot?
Lateral rotation of calcaneus
Lateral rotation of navicular
Cuboid rotates upward on calcaneus
What does eversion do to the arch of the foot?
Decreases height of median arch
What muscles do eversion of the foot?
Fibularis longus and brevis
What region of the foot is the midfoot?
Between transverse tarsal joint and tarsometatarsal joint
What motions dictate pronation?
Eversion
Dorsiflexion
Abduction - calcaneus and foot
What motions dictate supination?
Inversion
plantar flexion
Adduction - calcaneus and foot
What region of the foot is the forefoot?
Anterior to tarsometatarsal joints
What are the primary motions of the tarsometatarsal joints?
Flexion and extension
What are the primary motions of the metatarsals and phalanges?
Adduction and abduction
What are the primary motions of the intermetatarsal joints?
Sliding
What are the primary motions of the metatarsalphalange joints?
Flexion
Extension
Abduction
Adduction
Also:
slide
rotation
long axis traction
What is the major motion of the IP joints?
Flex and extend
What are some characteristics of the lateral arch?
Weight bearing elastic firm osseous structure limited mobility transmits weight and thrust to ground
What bones make up the lateral arch?
calcaneus
cuboid
4th and 5th metatarsal
What bones make up the medial arch?
calcaneus talus navicular cuneiforms 1-3 metatarsals
What makes the medial arch different from the lateral arch?
More mobile and higher
doesn’t have firm osseous support
changes to adapt to changes in terrain
Helps control gait!
What ligaments stabilize the medial arch?
plantar ligament plantar fascia tibialis posterior FDL FHL intinsic mm of the foot
Muscles don’t stabilize this arch, they control it for balance and gait
Which arch controls gait?
Medial arch
muscles don’t support this arch, they control it for balance and gait
What causes a high medial arch?
Supination - more rare
Adduction of the foot
varus calcaneus
What causes a dropped medial arch?
Pronation - pretty common
Abduction of the foot
valgus calcaneus
dorsiflexion of the ankle - extreme pronation
What 3 arches make up the transverse arches?
Anterior transverse arch
Posterior transverse arch
Tarsal arch
What are the components and functions of the anterior transverse arch?
Made up of metatarsal heads
Transmits weight to the ground
- flattens with weight bearing
What are the components of the posterior transverse arch?
metatarsal bases
What are the components and functions of the tarsal arch?
Navicular
Cuboid
Cuneiforms
Assists in flexibility of the foot as well as rotation
What causes flat feet?
pesplanus is caused by a decrease in that tarsal arch
How do you evaluate the foot and ankle?
Have patient stand, walk, evaluate joints of lower half of body - at least 1-3 up or down
Observe statically - sitting, standing
Observe motion testing and dynamically
What are we looking for when evaluating the feet and ankles?
Edema Swelling Discoloration Callus Corns Weight distribution on each foot Position of toes - in or out? Arch height Position of achilles tendon Bony deformities
What is the deformity of hammertoes?
flexion deformity of PIP
extension deformity of DIP
What is the deformity of claw toes
flexion deformities of PIP and DIPs
What is a bunion?
Medial deviation of the 1st metatarsal with lateral deviation of proximal phalanx of the hallux
MTP can be swollen, tender, erythematous
Correlated with Morton’s toe, ballerina
When you palpate the foot, what are you palpating for?
Tenderness and swelling
Bony landmarks
Explain motion testing of the foot and ankle.
Dorsiflexion & plantar flexion
Have patient actively do it first
Then passively move the foot
- Invert the foot slightly
- Place into plantar and dorsi flexion
What is the normal ROM for plantar and dorsiflexion?
Normal ROM
Dorsi- 20 degrees
Plantar- 50 degrees
How do you do motion testing for the 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.
How do you do motion testing for the talus?
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
What is the normal ROM for the talus?
ADDuction 20 degrees
ABDuction 10 degrees
How do you do motion testing for the subtalar/calcaneal joint?
Calcaneal (subtalar) inversion-eversion
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
What is normal ROM for the calcaneal/subtalar joint?
Inversion/eversion 5 degrees of motion
Explain motion testing for cuboid, navicular, and cuneiforms.
Cuboid, navicular, cuneiforms
Grasp the bone between your thumb and index finger
Move (wiggle) it plantar and dorsally (and the other planes)
Note which way the individual bones move better
Explain motion testing for the 5th metatarsal.
5th metatarsal
Lock out the cuboid by grasping it
Grasp the 5th MT and wiggle it dorsally and plantar
Note degrees of motion
To check the rotation of this (or any) MT, grasp the one next to it to lock it out
Explain motion testing for the 1st metatarsal.
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
What is the normal ROM for the 1st metatarsal?
Flexion 45 degrees
Extension 70-90 degrees
Explain motion testing for the phalanges.
Have the pt actively flex and extend phalanges
Doc then passively moves the phalanges, with a bit of traction, into flexion, extension, rotation, adduction and abduction, noting any restrictions
Explain the stance phase of gait.
Stance phase
- heel strike
- Foot rolls to lateral edge
- Weight should roll back to ant transverse arch
- The great toe should push (toe) off
Swing phase
What are the ligaments involved with an acute inversion ankle sprain?
Anterior talofibular ligament - Always Tears First Calcaneofibular Posterior talofibular - rare, usu seen with fracture-dislocation
What is a grade 1 acute inversion ankle sprain?
Grade 1-microtears with the ligament
Swelling and disability but no instability (no laxity)
What is a grade 2 acute inversion ankle 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
What is a grade 3 acute inversion ankle sprain?
Grade 3-complete tear
marked loss of function and complete instability, no endpoint noted on provocative testing
What is the mechanism of injury for acute inversion ankle sprains?
Inversion and plantar flexion
Generally by stepping on an uneven surface (ie. landing on someone else’s foot after rebounding a basketball)
What are the symptoms of an acute inversion ankle sprain?
Swelling Ecchymosis TTP depending on degree of injury Decreased ROM Antalgic gait - abnormal gait to avoid pain Poor lower extremity proprioception Assessed with one leg standing test
What do you do if you have a negative x-ray with an acute inversion ankle sprain?
Negative x-ray
X-ray determination is based on the Ottawa ankle rules
What diagnostic tests do you perform after an acute inversion ankle sprain?
+anterior drawer test (in 2nd and 3rd degree tears only)
Assesses ATF only
+Talar tilt test
Assesses the ATF & 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)
What imaging do you order after an acute inversion ankle sprain?
Order MRI
If Tib Post tendon is torn—it must be surgically corrected within 14 days for optimal outcome to prevent degeneration of the foot
Explain the anterior drawer test.
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
Explain 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
What are the effects of an inversion ankle sprain on the body?
The ankle inverts
The fibular head moves posterior, the lateral malleolus moves anterior
This could impinge the common peroneal nerve and cause a foot drop
The tibia externally rotates
The femur internally rotates
Ipsilateral anterior innominate
Anterior torsion of the sacrum facing the side of the ankle sprain
So for a right ankle sprain, a Right on Right sacral torsion
L5 will rotate opposite of the sacrum
What is the treatment for grade 1 and 2 tears of an acute ankle sprain?
Grade 1 & 2 tears Conservative treatment PRICE (protection, rest ice, compression, elevation) NO NSAIDs! Other pain medication Crutches if needed OMT
What is the treatment for grade 3 tears with an acute ankle sprain?
Grade 3 tears require PRICES
The S stands for surgery
What is physical therapy for an acute ankle sprain?
Physical therapy
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
What is return to play criteria 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
Explain counterstrain of the foot/ankle.
Find the tender point
Establish a pain scale (10/10)
Reduce the tender point by placing the patient in a position of maximal comfort (at least 70% better for boards) (3/10)
Hold this position for 90
seconds
Continue to monitor the point (gently) throughout the entire treatment
Slowly, PASSIVELY return the patient to neutral
The patient should not help at all!!!
Re-assess the tender point