MSK Exam questions

Question 1

What would be the effects of limited ankle dorsiflexion

Answer 1

Limited ankle D/F will inhibt the forward progression of the body

Early Heel Lift (Bouncy Gait)
Externally rotated foot
Low gear push off Internally rotate and use the 5th met head to progress
Knee hyperextension

Question 2

Which ligaments would you expect to be injured during a Lateral ankle sprain

Answer 2

Anterior Talofibular Ligament
Posterior Talofibular ligament
Calcaneofibular ligament

Question 3

Which structural foot shape is an ankle injury most associated with and why

Answer 3

Uncompensated Rearfoot Varus

Rearfoot Varus = Rearfoot inverted relative to floor during subtalar neutral

Uncompensated Rearfoot Varus is when there is no additional subatlar joint pronation to compensate for inverted rearfoot

Midtarsal is locked so cannot pronate to bring medial border of the foot down meaning the lateral border will bear all the weight.

Question 4

What are the signs and symptomns of an Uncompensated Rearfoot Varus

Answer 4

Callus along the lateral border Styloid
Tailors Bunion (bunion 5th met)
Lateral ankle injurys

Question 5

What is a Flexor Substitution

Answer 5

When the flexors FHL and FDL Substitute for a weak Tricep Surae

Results in flexing of the toes

Question 6

What is Extensor Substitution

Answer 6

EDL gains mechanical advantage over Lumbricals
Causing Contracture at MTPJ

Resulting in the toes retracting during the swing phase of GAIT.

Causes Hammertoe

Question 7

How would stage 1 Hallux Abducto Valgus present

Answer 7

Weakness of Abductor hallucis
Hallux instability in closed chain
Unstable 1st Ray

Question 8

Detail the FPI Scoring system

Answer 8

Negative = Supinated

Neutral = 1,2,3,4

Pronated = 5,6,7,8,9,10

Question 9

Which of the following would be an appropriate Orthotic addition for Functional Hallux Limitus? Explain your answer

Mortons extension
Valgus forefoot post
Revers mortons extension
Lateral heel skive
Cuboid Pad

Answer 9

Reverse Mortons Extension

If Hallux limitus is consided functional the RE aims to increase 1st MTPJ ROM

Question 10

Which Structural deformity is associated with the best shock attenuation

Answer 10

Compensated Rearfoot Varus

The full compensation of subtalr pronation aids in the gradual controlled loading of the foot from the lateral border to the medial border evenly distributing ground reaction forces

Question 11

Individuals with Hallux Abducto-Valgus (HAV) would likely display which gait deviation?

Answer 11

Apropulsive

Question 12

What are the determinants of gait

Answer 12

1.Pelvic rotation
2.Pelvic tilt
3.Knee flexion in stance phase
4.Foot mechanisms
5.Knee mechanisms
6.Lateral displacement of the pelvis

Question 13

s

The Digital Lachman Test can be used as a diagnostic test for what?

Answer 13

Plantar Plate dysfunction

Question 14

What is Baxters Neuritis

Answer 14

Baxters Nerve entrapment (Calcaneal nerve) becomes trapped betwen 2 muscles in the inner foot.

The nerve runs along the bottom of the heel which is why it can comonly be differential diagnosise for Plantar fasciopathy

Branch of Tibial Nerve arising from the Tarsal Tunnel (area Posterior to the Medial Malleoules)

Question 15

Which of the following are accepted theories of digital deformity

Flexor Substitution Theory
Flexor Stabalisatin Theory
Sagital Plane Theory
Exstensor Substitution Theory

Answer 15

Flexor Substitution Theory
Flexor Stabalisatin Theory
Exstensor Substitution Theory

Question 16

List the common treatments suitable for a Lateral ankle Injury

Answer 16

Orthoses – heel raises
Stretch gastroc and posterior muscle groups
Rocker bottom shoes
Eccentric exercises
Mobilization of the ankle
Post injury soft tissue work on ligaments

Question 17

Which test would assist in identifying a tibiofibular syndesmotic injury.

Answer 17

External Rotation Test (Kleiglers test)

Patient seated end of the bed ankle relaxed
Grasp the front of the Shin to stabalise
Dorsiflex the ankle and externally rotate foot
Posotive test = Pain reproduced around the Tib/Finb syndesmosis area (Front lower shin)

Question 18

What would you expect to observe in the 1st MTPJ of a foot with HAV?

Answer 18

Hallux Limitus/Rigidus (Reduced Dorsiflexion AND Plantarflexion),
Overlying
Erythema to 1st MTPJ
Dorsal Osteophytic Lipping
Callosity and or Medial Callus to interphalangeal joint
Possible abductory flick

Question 19

Functional Hallux Limitus can be indicated by:

Answer 19

Dorsal Orinentation of the Hallux Toenail

Callus under the Hallux

Callus sub 2nd and 3rd MTPJ

Question 20

What are the common mechanical factors predisposing to neuroma of the 3rd/4th Intermetatarsal space?

Answer 20

Conjoined nerve

Forefoot Hypermobility

Neural Ischeamia

Question 21

2. Outline the open chain observations of the windlass mechanism (5 Marks).

Answer 21

Hallux Dorsiflexion
1st Metatarsal Plantarflexion
Medial longitudinal arch raises
Foot shortens
Rearfoot inverts

Question 22

3. Describe the observational effects on gait seen in individuals with limited ankle plantarflexion (5 Marks).

Answer 22

• Increased loading response period.
• Increased period of initial contact.
• Increased 3rd Rocker use at toe-off
• Poor stability of the midfoot at midstance.
• Early heel contact of the contralateral limb.

Question 23

4. What is the primary variation in symptoms of insertional versus midportion Achilles Tendinopathy? (1 Mark)

Answer 23

· Midportion Achilles Tendinopathy will demonstrate pain at end-range dorsiflexion.

Or

· Insertional Achilles Tendinopathy will not demonstrate pain at end-range dorsiflexion.

Question 24

5. Outline the proposed purposes of the windlass mechanism (5 Marks).

Answer 24

· Serves to support the medial and lateral longitudinal arch in a higher arched position (i.e. increases the dorsiflexion stiffness of the medial and lateral forefoot)

· Assists in resupination of subtalar joint (STJ) during propulsive phase of walking

· Assists the deep posterior compartment muscles by limiting STJ pronation

· Assists the plantar intrinsic muscles in preventing longitudinal arch flattening

· Reduces tensile forces in plantar ligaments

· Prevents excessive interosseous compression forces on dorsal aspects of midfoot joints

· Prevents excessive dorsiflexion bending moments on the metatarsals

· Passively maintains digital purchase and stabilizes proximal phalanx of digits within sagittal plane

· Reduces ground reaction force on metatarsal heads during late midstance and propulsion

· Helps to absorb and release elastic strain energy during running and jumping activities

Question 25

Outline the aetiology of Morton Neuroma

Answer 25

Restrictive Foootwear Tricep surae Contracture Prediliction for women Prediliction for pronated foot type

Question 26

Define Hammer toe

Answer 26

MTPJ Extension PIPJ Flexion DIPJ Extension

Question 27

Define Claw Toe

Answer 27

MTPJ Extension PIPJ Flexion DIPJ Flexion

Question 28

Define Mallet Toe

Answer 28

MTPJ Neutral PIPJ Neutral DIPJ Flexion

Question 29

What are the signs and symptomns of PTTD

Answer 29

Pain and swelling along the medial ankle excaserbated by activity Medial longitudinal arch collapse Sinus Tarsi Syndrome Inability to perform unilateral heel raise ( Calcanel inversion upon ascent)

Question 30

A pronated foot type would display what Subtalar Joint Axis

Answer 30

Medially deviated Subtalar Joint axis This is due to the GRF being lateral to the Subtalar joint axis causimg a pronatory moment The further the lateral positiong of the GRF creates a longer lever arm increasing the toruque that promotes pronation.

Question 31

Which of the following is NOT true of hallux ridgius? a) Dorsiflexion less than 10 degrees b) Assisted by use of a Morton’s Extension c) Assisted by Fleible Footwear d) Commonly cause by 1st MTPJ Osteoarthritis

Answer 31

C. Hallux Rigidus would require immobilisation of the 1st MTPJ so therefore it would not be assited by flexible footwear

Question 32

2. What is the normal range of dorsiflexion of the 1st Metatarsophalangeal Joint (MTPJ)? a) 15 degrees b) 30 degrees c) 45 degrees d) 60 degrees

Answer 32

D.

Question 33

3. Which muscle primarily assists supination of the foot out of midstance? a) Tibialis Posterior b) Gluteus Medius c) Sartorius d) Extensor Hallucis Longus

Answer 33

When it contracts, it pulls the foot into inversion and plantarflexion (supination) The tibialis posterior assists in moving the foot into this supinated position, ensuring a stable and rigid lever for propulsion.

Question 34

4. In Subtalar Neutral, a Rearfoot Valgus Deformity is defined as? a) A rearfoot that is dorsiflexed at the ankle b) A rearfoot that is inverted relative to the floor c) A rearfoot that is everted relative to the floor d) A rearfoot that is inverted relative to the forefoot

Answer 34

C.

Question 35

What is a Medial Heel skive and what pathology might it be used for

Answer 35

Medial Heel Skive controls Pronation by increasing Supination moment at Subtalar Joint Clinical Use: * PTTD * Flexible Flat Foot * Excesivley Pronated Feet

Question 36

6. Which lesser digtial deformity is defined as a Neutral Metatarsophalangeal Joint (MTPJ), Neutral Proximal Interphalangeal Joint (IPJ) and Flexion at the Distal IPJ. a) Turf Toe b) Mallet Toe c) Hammer Toe d) Claw Toe

Answer 36

B. Mallet to is defined as MTPJ Neutral PIPJ Neutral DIPJ Flexion

Question 37

What positon should the Midtarsal Joint (MTJ) be in at heel strike? a) Locked b) Unlocked c) Flexible d) Pronated

Answer 37

A. The locked position of the MTJ contributes to this stability. When the MTJ is locked, it provides a rigid structure necessary for the foot to effectively act as a lever to support body weight and stabilize the lower extremity.

Question 38

As per the Thompson and Hamilton (1987) grading system for plantar plate/ injuries, a digit in which the base of the proximal phalanx can be dislocated would be: a) Stage 0 b) Stage 1 c) Stage 2 d) Stage 3

Answer 38

C. Stage 0 - No dorsal translocation of the proximal phalanx. NO TRANSLOCATION Stage 1 - No dislocation but may show Phalanx subluxation . NO DISLOCATION Stage 2 - The base of the phalanx can be dislocated. DISLOCATION Stage 3 - The phalanx base is in a fixed dislocated position. FIXED DISLOCATION

Question 39

1. Describe in brief the Mechanism of the Stretch-Shorten Cycle (3 Marks).

Answer 39

I. Eccentirc Loading Causes Lengthening of the Muscle II. Brief Isometric Period Stores Enegry III. Rapid Concetric Contraction Returns Stored Enegry IV. Designed for Maximal Power Output With Minimal Energy Consumption V. Energy Conservation VI. Provides a Spring type mechanism

Question 40

2. Describe mode of action the Reverse Windlass Mechanism occuring from heel strike (5 Marks).

Answer 40

I. Leg Internally Rotates II. Rearfoot / Calcaneum Everts / Moves into Valgus Position III. Medial Longitudinal Arch Lowers IV. 1st Metatarsal / Metatarsals Dorsiflex/s V. Foot Elongates VI. Plantar Fascia Tension Increases VII. Plantar Fascia Unwinds From Metatarsal Head/s Fulcrum VIII. Hallux / Lesser Digits Plantarflex/s

Question 41

What are the three phases of Ligament injury

Answer 41

Heamorage with inflamattion Matrix and cellular proliferation Remodelling and maturation

Question 42

What are Ligament injury treatment aims?

Answer 42

Prevent abnormal scar tissue, joint stiffness and muscle weakness Restore proprioceptive effect Pain relief through joint mobility

Question 43

What ligament might be preventing Ankle dorsiflexion

Answer 43

Anterior Talofibular ligament

Question 44

Someone with limited ankle dorsiflexion would display which of the following 1. Naturally adducted foot 2. Naturally abducted foot Explain your answer

Answer 44

2.Naturally abducted foot Compensation for limited dorsiflexion is to outwardly rotate the foot (abduction) Abductory flick

Question 45

If an individual has Oestoarthirits of the posterior facet of the Subtalar joint what limited mpoveemtn might we observe, Explain why?

Answer 45

Dorsi flexion and Plantar flexion Posterior facet of the subtalar joint is responsible for Dorsi Flexion and Plantar Flexion Anterior Facet = abduction adduction Intermediate Facet = inversion eversion

Question 46

Somebody with a medially deviated Subtalar Joint axis will display which Rearfoot position a. Rearfoot Varus b. Rearfoot Valgus Explain your answer

Answer 46

B. Rearfoot Valgus When GRF is lateral to the subtalar joint axis it causes pronatory moment In a medially devaiated STJ Ground reaction forces would be lateral to the STJ Axis causing the foot to pronate and the rearfoot to assume a Valgus position

Question 47

Somebody with a Laterally deviated STJ will display which Rearfoot position? a. Raerfoot valgus b. Rearfoot Varus

Answer 47

b. Rearfoot Varus When Ground Reaction Force is Medial to the STJ axis, a STJ Supinatory moment will be produced. In a Laterally deviated STJ Axis the GRF is medial to the STJ causing the foot to supinate and the reafoot to assume a Varus position

Question 48

Why is someone with a Laterally deviated Subtalar Joint Axis more prone to Lateral ankle sprains

Answer 48

GRF will be Medial to the STJ Axis causing the foot to invert/Supinate and making them more prone to lateral ankle injurys. The supinated foot is less able to adapt to uneven surface Lateral ankle ligaments Anterior/Posterior Talofibular and CalcaneofIbular are under more stress in the inverted position Stress on these structures can cause ligament damage, collagen degridation Inelastic fibres are stretched through, too great a range of motion to failure point.

Question 49

What is a forefoot supinatus?

Answer 49

Flexible inverted forefoot relative to the rearfoot

Question 50

Which of these is not an accepted theory of function? The Neutral Position of the Subtalar Joint / 8 Biomechanical Criteria for “Normalcy” Sagittal Plane Facilitation Theory. Tissue Stress Theory Subtalar Rotation Equilibrium Trendelenberg Theory Neuromechanical Theory / Preferred Motion Pathway

Answer 50

Trendelenberg Theory

Question 51

Explain Sagital Plane Theory

Answer 51

For motion to occur smoothly in the Sagital plane in has to occur through in 3 pivotal sites: **Heel, ankle, MTP Joint Rocker** Any blockage of movement in Sagital Plane will lead to dysfunction in ithe intrinsic joints of the foot and lower limb e.g. (Windlass, High gear low gear) This dysfunction will lead to compensatory movement: * Apropulsive Gait with delayed heel lift - * Vertical toe off * loading of Lateral Column * propulsion with the foot in abduction or adduction * Flexed Body position

Question 52

Apply Sagital plane Theory to Hallux Limitus

Answer 52

Dysfunction of MTPJ in Sagital Plane * The next proximal joint to allow Sagital Plane motion is Midtarsal * Midtarsal joint collapse/pronates casing delayed Heel Lift * Vertical Toe off * Weight fails to shift medially Leading to loaidng of the Lateral column * Body follows the path of least resistance due to Hallux limitus causing hip to externally rotate * Knee, Hip and Lumbar Flexion occur

Question 53

Explain the determinants of Gait

Answer 53

Pelvic Rotation = Pelvis rotates 4 degrees forward on the swing side and 4 backwards on the stance limb decreasing vertical displacment of center of gravuty Pelvic Tilt = Pelvis drops 5 degrees on the side opposite to that of weight bearing limb during midstance Knee flexion (after heel strike in stance phase) = at heel strike the knee is fully extended and at foot flat the knee is flexed 15-20 degrees; this absorbs shock and helps minimizes the displacement of the center of gravity Foot mechanisms (foot and ankle motion) = at heel strike the foot is dorsiflexed and the center of rotation of the ankle is elevated. At foot flat the foot plantarflexes and the center of rotation on the ankle is lowered. At push off the heel lifts from the floor and the center of rotation of the ankle raises again Knee mechanisms = at heel strike, when the center of rotation of the ankle is high, the knee joint begins to flex. During midstance when the ankle center is low the knee joint flexes a second time. The effects of this relationship between the motions of the foot, ankle, and knee is to smooth the pathway of the center of gravity Lateral displacement of the pelvis – the center of gravity must shift over the stance foot to provide balance, otherwise the person will fall over the unsupported limb.

Question 54

List all the Foot/Ankle pathologies that occur at the Medial ankle

Answer 54

* Flexor Hallucis Longus Tendinopathy - often misdiagnosed as Posterior Tibial Tendon dysfunction * Posterior Tibial Tendon Dysfunction - Inflamed Tendon inner ankle * Flexor Digitorum Longus Tendinopathy * Tarsal Tunnel syndrome - a nerve irritation that can cause inner ankle and foot pain * Deltoid Ligament Sprain - web of ligaments spanning the inner ankle joint * Mueller Weiss syndrome - condition affecting navicular bone * Medial Malleolous Fracture

Question 55

List all the Foot/Ankle pathologies that occur at the Lateral ankle

Answer 55

* Lateral ligament sprain (CFL, ATFL,PTFL) * Sinus Tarsi Syndrome - * Peroneal Tendinopathy - inflammed degerneration of peroneal tendons due to overuse trauma or biomechanical deficit (Peroneus Longus, Brevis, Tertuis) * Lateral Malleoluor fracture - fracture of the lower aspect of the fibula

Question 56

List all the Foot/Ankle pathologies that occur at the Forefoot

Answer 56

* Hallux Rigidus / Limitus / HAV * Plantar Plate Dysfunction/ Rupture - Stabalises MTPJ joints * Metatarsalgia - MTPJ pain * Mortons Neuroma * Hammer Toe/ Mallet Toe / Claw Toe / Turf Toe

Question 57

List all the Foot/Ankle pathologies that occur at the Plantar foot

Answer 57

* Fat pad Contusion * Baxters Neuritus * Plantar Fascitis

Question 58

List all the Foot/Ankle pathologies that occur at the Posterior Heel

Answer 58

* Plantaris Tendinopathy * Achillies Tedinopathy * Retro Calcaneal Bursitus * Sub Cutaneous Bursitus * Haglunds Deformity * Sural Neuropathy

Question 59

List all the Foot/Ankle pathologies that occur at the Midfoot

Answer 59

Inner Midfoot * Navicular Fracture * Midfoot Arthritis - arthritis of the tarsal bones in the midfoot Outer Midfoot * Sinus Tarsi Syndrome * Tarsal Coalition - congenital condition that involves the attachment of two tarsal bones from birth * Cuboid Syndrome - irritation or subluxation of the cuboid bone Top Of Midfoot * Exstensor Tedinopathy * Cuneiform Frcature * Superficial Peronaeal Nerve Entrapment

Question 60

Detail the orthotic prescription appropriate for achillies tedinopathy and how do they work

Answer 60

Heel Raise Heel lift attenuate reduce impact forces at heel strike Heel Raise reduces Plantar flexion of the ankle joint and shortens the muscle-tendon unit, thereby decreasing the load in the Achilles tendon during gait.

Question 61

What is Flexor Stabalization theory

Answer 61

Muscle imbalance Midtarsal unlocked causing unstable forefoot during toe off Midtarsal pronates past midstance As a result Flexors fire for longer to stabalize forfoot overpoweing interosseuos muscles This leads to hammering clawing + adducto Varus 5th

Question 62

What is the Foot Edge test, what does it test for?

Answer 62

Assement of the digits and Reverse Wndlass Mechanism * Standing on the edge of a stool at the MTPJ level and allowing the digits to hang over the edge. * In a positive reverse windlass, the proximal phalanges go into plantarflexion. * If the proximal phalanges are in the same position on the ‘footstool edge test’ as to relaxed stance, this shows a non-functioning reverse windlass mechanism.