Foot/Ankle

Nerve roots for heel walking versus toe walking

heel walking: L4-S1

toe walking: S1-2

Index plus, index minus, and index plus-minus

index plus: 1st MT >2>3>4>5

index minus: 1

Miserable Malalignment syndrome has what deviations at the hip, tibia, and STJ

hip - femoral anteversion

tibia - external rotation and varus

STJ - pronation

Haglund’s deformity

bony enlargement on posterior calcaneus

Dorsiflexors and inverters of the foot

tib anterior and extensor hallucis longus

dorsiflexors and everters of the foot

fib tertius, extensor digitorum longus

Contents of the gutter of the ankle (4)

EDB tendon, fat pads, sinus tarsi, lateral talar head

Capsular pattern of the talocrural joint

PF > DF

Plantarflexors and inverters of the foot (3)

tib post, flexor digitorum longus, flexor hallucis longus

Plantarflexors and evertors of the foot

fibularis longus

Dermatomes for L2-S2 location

L2 - anterior mid thigh

L3 - medial side of knee

L4 medial lower leg to foot

L5 anterolateral leg to dorsum of foot

S1 - lateral side of foot

S2 posterior popliteal fossa

myotomes of LE

L1-3 hip flexion

L3-4 knee extension

L4-5 ankle DF and inversion

L5 - great toe ext

L5-S1 planatarflexion and eversion

S1-2 plantarflexion standing

Nerve root levels for patellar tendon, medial hamstring, and achillles reflexes

patellar - L3-4

medial hamstring L5-S1

Achilles S1-2

Balance and proprioception tests of LE

star excursion, Y balance test

To increase dorsiflexion, which type of accessory motion should be done at the talocrural joint

AP

To increase plantarflexion, which type of accessory motion should be done at the talocrural joint

PA

To increase great toe extension at the MTP joint, which accessory motion should be done

dorsal glide

Convex and concave of great toe MTP

convex - MTH

concave - phalanx

Lateral ligaments of the ankle

anterior and posterior talofibular ligaments, calcaneofibular ligaments

What ligaments make up the deltoid ligament? What are the deep deltoid ligaments

anterior tibiotalar, tibionavicular, tibiocalcaneal, posterior tibiotalar.

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Deep include A and P tibiotalar ligaments

Acronym for the structures passing through the flexor retinaculum

**T**om: Posterior **T**ib

**D**ick: Flexor **D**igitorum longus

**A**nd: Posterior tibial **A**rtery

**N**ervous: Posterior tibial **N**erve

**H**arry: Flexor **H**allucis longus

Anterior drawer test of the ankle specifically targets which ligament

anterior talofibular

Forced dorsiflexion test looks for

anterior ankle impingement

Medial talar tilt stresses

lateral ligaments

4 tibiofibular syndesmotic tests

Squeeze test, external rotation test, fibular translation test, cotton test

Tests for achilles tendinopathy

arc sign, royal london test

AAOS Clinical Practice guideline diagnosing an Achilles tendon rupture says 2 or more positives with which four tests?

palpable gap, abnormal Thomas squeeze test, decreased PF strength, increased passive DF

Matles test should see

when prone and put into 90 deg KF

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intact achilles = ankle should relax at 20-30 deg PF

not intact = ankle will rest in neutral or DF

Three fracture screening tests of the foot

MT loading test, tap or percussion, vibration

Windlass test two components

test MTP extension in NWB, test MTP extension with WB

Normals for NWB subtalar joint inversion and eversion

inversion: 20 deg

eversion: 10 deg

how to find neutral position of STJ

palpating talar heads feel where there is equal amount felt and then passively DF in NWB

Normal amount of calcaneal inversion that is seen in STJ neutral in NWB

2-4 deg

Commonly seen rearfoot relationship from first to last

rearfoot varus, rearfoot valgus, then neutral

Would expect limited DF of the first ray in a forefoot varus or valgus position

varus

Would expect to see more DF than PF with a forefoot valgus or varus position

valgus

Normal for WB tib-fib varum

12-15 deg

Navicular drop is the difference between what two heights

resting calcaneal stance and subtalar joint neutral position in WB

Rearfoot varus has medial or lateral plantar tubercle off the ground

medial

What is a rearfoot varus

calcanal varus + tibfib varum (normally)

In Non-WB, what are the movements at the subtalar joint in pronation

DF, abduction, and eversion of the calcaneus on the talus (up and out)

In Non-WB, what are the movements at the subtalar joint in supination and what bone moves on what

PF, adduction, and inversion of the calcaneus on talus (down and in)

In WB, what are the movements at the subtalar joint in pronation and what bone moves on what? The calcaneus __

The talus plantarflexes and adducts on the calcaneus, the calcaneus everts

In WB, what are the movements at the subtalar joint in supination and what bone moves on what? The calcaneus ____

The talus dorsiflexes and abducts on the calcaneus; the calcaneus inverts

What is forefoot varus

calcaneus is level but the forefoot medial side more elevated than lateral

Possible cause of forefoot varus

head of talus not completely rotating -- navicular and cuneiform more cephalad -- more elevated medial side of foot

In a forefoot valgus, the plane of the metatarsal heads are in an (inverted/everted) position

everted

Structural foot deformity that may be due to excess rotation of the talar head

forefoot valgus

Two possible forefoot valgus positions

total valgus of all MTHs (true forefoot valgus), or plantarflexed first ray

Forefoot equinus plane of the MTHs relative to the calcaneus

plane of MTH is perpendicular to calcaneus bisection, but not in the same plane as the plantar tubercles of the calcaneus

Difference between forefoot equinus and plantarflexed TCJ

forefoot equinus is the relative plantarflexion of the forefoot on midfoot (TCJ will be in neutral)

Primary sites of compensatory motion for the structural foot deformities

MTJs and STJs

Compensation can be through the ______, _______, and/or ______ of the STJ and MTJ motion

speed, amount, timing

Clinically, we treat the deformities or the compensations of the deformities

compensations

Results of an increase in the amount of compensation will have what results

excessive strain on decelerating muscles and stresses limit of joint excursion (capsular stretch)

Results of a decrease in the amount of compensation will have what results

decreased dissipation of the GRF so more force on the articular surfaces (less shock absorption for example)

An increase in the speed of compensations will have excess strain on the __ unit

excess stress on musculotendinous unit (posterior tib tendinopathy is most common)

Pronation of the STJ encourages knee _______ and _____ of the hip

flexion; MR

Rigid lever for push off of the gait cycle puts the STJ into ________ and should start to occur around ___% of the gait cycle

supination; 35% (start of t-stance)

Supination of the STJ puts the hip into more ______ and the knee into more ______

LR, extension

STJ/MTJ compensations to structural foot deformities are normally in the ___ plane

frontal

To compensate for RF varus, would expect _____ at the STJ and ____ at the calcaneus

pronation; eversion

Weightbearing compensation for rearfoot varus you would expect a ______ in amount and speed of the compensation

increase

If no compensation to rearfoot varus, what might you expect to see during gait? What side of foot would get more pressure?

decreased shock absorption; more stress on lateral foot

What happens to pronation with compensating a forefoot varus

excess and at the wrong time

During loading response, what happens during compensated forefoot valgus

already hits ground so supinates early

This structural foot deformation if compensated can make more susceptible to inversion sprains and why

forefoot valgus - early to return to supination

Compensated forefoot valgus can have what effect on knee and why

more varus stress on knee because of decreased shock absorption

Usual compensation for forefoot equinus

MTJ pronation in mid to late stance

What joint can compensate with forefoot equinus

MTJ

MTJ compensation in mid-stance produces clinical s/s that resemble those of a compensated _____________

Forefoot varus

Keystone of the medial longitudinal arch

talonavicular joint

Primary arch for loadbearing and shock absorption

medial longitudinal

Spring ligament = ____

plantar calcaneonavicular ligament

Plantar fascia attachments

medial calcaneal tubercle to flexor tendon sheaths of digits 1-5 (crosses MTP joint)

During MTP extension in WB, what happens to medial arch, frontal plane motion of foot, more flexible or locked foot

medial arch elevates, move into supination, more locked foot

Should strengthen the foot intrinsics in the position of

terminal stance

What muscle primarily does inversion at the foot during single leg heel raises

tib post

Need a minimum of ____ degrees of plantarflexion for descending stairs

20

Mallet Toe

flexed DIP

Hammer Toe position of DIP, PIP, MTP

flexed PIP, MTP extension, DIP neutral

Hammer toe usually a result of

interosseous muscles unable to maintain proximal phalanx in neutral + tight gastrocs

Claw toe

hyperflexion of PIP and DIP, hyperextension of MTP

Claw toes usually associated with

neuromuscular disorder (charcot tooth) or cavus foot - REFER OUT

Interventions for hammer toe and mallet toe

stretch dorsal extrinsics, strengthen intrinsics

Pathogenesis of hallux limitus/rigidus and what can be due to

degenerative arthritis of first MTP, due to turf toe or gout or surgery

Presentation of hallux limitus/rigidus

stiffness, pain, decreased ROM at first MTP, palpable bone spur on dorsal MTP

Treatment of hallux limitus/rigidus

NSAIDs and orthoses, surgery on bone spur, ROM within range

In hallux abductovalgus, what is the relative position of the metatarsal and the phalanx

abduction of metatarsal, adduction of phalanx

Conservative treatments for bunions (3)

gastroc stretches

bunion pads

shoe wear modification

In hallux abductovalgus, what part of the intrinsic muscles and capsule gets shortened and what part gets lengthened?

adductors of great toe/lateral capsule shortened

abductors of great toe/medial capsule lengthened

Etiology of hallux abductovalgus in terms of men or women get more, and what biomechanical causes are linked to it?

female more than male; tight achilles, pes planus, and hypermobility of 1st MTP

What is the hallus abductus angle

intersection of long axis of 1st MT with proximal phalanx

Metatarsalgia (pain along MTH) is increased by

MTP extension and ambulation

Possible causes of metatarsalgia? Which MET head is most common? Aggravating fx?

structural deformity, overuse/degeneration

2nd met head most common

aggravating = prolonged WB

To reduce the forefoot pressure on the MTHs, where can we transfer the weight and how

to the longitudinal and metatarsal arches with rocker bottoms or met pads PROXIMAL to the MTH

What can be done to the heel of a shoe to decrease metatarsalgia symptom

reduce the heel height

How does extension of the great toe relate to efficient push off when walking? (windlass effect)

stretches plantar fascia which puts intrinsic muscles of the foot in a better position to raise and stabilize the arch, and then 2nd/3rd ray can act as a rigid lever to push off

Age and gender common to see Morton's neuroma

middle-aged women

Common space to see Morton's neuroma

2nd and 3rd interspace