MUSCULOSKELETAL EXAMINATON OF THE ANKLE AND FOOT (P2: Objective)

Often, painful _______________ may be found over abnormal bony prominences due to increased friction or loading

callosities (hyperkeratosis)

The calcaneus moves in the _____________ plane, and the talus moves in the _____________ and _____________planes.

The calcaneus moves in the frontal plane, and the talus moves in the transverse and sagittal planes.

Closed chain supination of subtalar:

• Calcaneus _______

• Talus _______ and _______

• Leg laterally _______

Closed chain supination of subtalar:

• Calcaneus inverts

• Talus abducts and dorsiflexes

• Leg laterally rotates

True or False:

In an open chain, the leg also follows the sagittal plane motion of the talus to some degree. The dorsiflexion motion of the talus on the calcaneus, therefore, tends to impart a slight extension motion to the knee

False:

In an closed chain, the leg also follows the sagittal plane motion of the talus to some degree. The dorsiflexion motion of the talus on the calcaneus, therefore, tends to impart a slight extension motion to the knee

Closed-chain pronation of subtalar:

• Calcaneus ___________

• Talus ___________ and ___________

• Leg medially ___________

Closed-chain pronation of subtalar:

• Calcaneus everts

• Talus adducts and plantarflexes

• Leg medially rotates

True or False:

In weight bearing position, as the talus plantar flexes, the proximal aspect of the tibia moves forward to flex the knee slightly.

True

Open chain subtalar supination:

• calcaneus and foot _______, _______, and _______

• Talus ______________

Open chain subtalar supination:

• calcaneus and foot invert, plantar flex, and adduct

• Talus is stable

Open chain subtalar pronation:

• the calcaneus and foot _______, _______, and _______

• Talus is stable

Open chain subtalar pronation:

• the calcaneus and foot abducts, everts, and dorsiflexes

• Talus is stable

True or False:

When the trunk is rotated to the right, the left foot supinates and the right pronates.

False:

When the trunk is rotated to the right, the right foot supinates and the left pronates.

Note: the supinated foot will have uneven GRF (greater laterally) while the pronated foot will have even GRF

Excessive lateral rotation of the hip or rotation of the trunk away from the opposite hip elevates the ______________ arch of the foot

Excessive lateral rotation of the hip or rotation of the trunk away from the opposite hip elevates the medial longitudinal arch of the foot

True or False:

medial rotation of the hip or trunk rotation toward the opposite hip tends to flatten the arch

True

Medial rotation of the hip can also cause __________, which is a condition more commonly associated with ________ tibial torsion or rotation.

Medial rotation of the hip can also cause pigeon toes, which is a condition more commonly associated with medial tibial torsion or rotation.

True or False:
The medial malleolus usually lies anterior to the lateral malleolus.

True

True or False:

Pigeon toes, or toe-in deformity, result from a medial tibial torsion deformity; it constitutes a foot deformity

False:

Pigeon toes, or toe-in deformity, result from a medial tibial torsion deformity; it does not constitute a foot deformity

Supination of the foot

• Foot __________

• __________rotation of the heel

• __________of the forefoot

• __________rotation at the tarsometatarsal joints

• __________rotation at the midtarsal joints

• __________ at the subtalar joint and midtarsal joints

• medial longitudinal arch is __________

Supination of the foot

• Foot inversion

• outward rotation of the heel

• adduction of the forefoot

• inward rotation at the tarsometatarsal joints

• outward rotation at the midtarsal joints

• plantar flexion at the subtalar joint and midtarsal joints

• medial longitudinal arch is accentuated

True or False:

when there is lateral rotation of the talus, there is medial rotation of the leg in relation to the foot

False:

when there is lateral rotation of the talus, there is lateral rotation of the leg in relation to the foot

Supination of the foot causes the proximal aspect of the tibia to move ____________.

Supination of the foot causes the proximal aspect of the tibia to move posteriorly.

True or False:

supination required during propulsion to give rigidity to the foot and requires more muscle work than pronation

True or False:

supination required during propulsion to give rigidity to the foot and requires less muscle work than pronation

Pronation of the foot

• Foot ____________

• ____________ rotation of the heel

• ____________ of the forefoot

• ____________ rotation at the tarsometatarsal joints

• ____________ rotation at the midtarsal joints

• ____________ rotation of the talus

• ____________ rotation of the leg in relation to the foot

• ____________ of the subtalar and midtarsal joints

• ____________ in the medial longitudinal arch

Pronation of the foot

• Foot eversion

• inward rotation of the heel

• abduction of the forefoot

• outward rotation at the tarsometatarsal joints

• inward rotation at the midtarsal joints

• medial rotation of the talus

• medial rotation of the leg in relation to the foot

• dorsiflexion of the subtalar and midtarsal joints

• decrease in the medial longitudinal arch

True or false

Pronation causes the proximal aspect of the tibia to move anteriorly. The pronated foot has greater subtalar motion than the supinated foot and requires more muscle work to maintain stance stability than the supinated foot.

True

The foot is much more mobile in this ________ position.

The foot is much more mobile in this pronated position.

In the infant, the foot is normally _________ . As the child matures, the foot begins to _________ , accompanied by development of the _________ longitudinal arch.

In the infant, the foot is normally pronated. As the child matures, the foot begins to supinate, accompanied by development of the medial longitudinal arch.

Normally, in standing, how much percent of the weight is taken on the heel?

How much percent is taken by the metatarsal heads?

50% to 60%

40% to 50%

The foot assumes a slight toe-out position. This angle is called?

Fick Angle

The Fick angle is approximately ___________from the sagittal axis of the body, developing from ___________ in children

The Fick angle is approximately 12° to 18° from the sagittal axis of the body, developing from 5° in children

True or False:

Asymmetrical or excessive lateral rotation of the foot may be due to acetabular anteversion, femoral retrotorsion, or femoral head neck abnormalities.

False:

Asymmetrical or excessive lateral rotation of the foot may be due to acetabular retroversion, femoral retrotorsion, or femoral head neck abnormalities.

Foot Loading During Gait

• Walking:__________

• Running: __________

• Jumping (from height of 60 cm [2 feet]):__________

Foot Loading During Gait

• Walking: 1.2 times the body weight

• Running: 2 times the body weight

• Jumping (from height of 60 cm [2 feet]): 5 times the body weight

If a foot If asymmetry is present in normal standing, it is a _________________

If it is still present when the foot is in neutral, it is also an _________________

If a foot If asymmetry is present in normal standing, it is a functional asymmetry

If it is still present when the foot is in neutral, it is also an anatomical or structural asymmetry

What type of forefoot is observed when the first metatarsal (1) is longer than the second (2), with the others (3, 4, and 5) of progressively decreasing lengths, so that 1 > 2 > 3 > 4 > 5.

Index plus type

The first metatarsal is equal in length to the second metatarsal, with the others progressively diminishing in length, so that 1 = 2 > 3 > 4 > 5

Index plus-minus type

The second metatarsal is longer than the first and third metatarsals. The fourth and fifth metatarsals are progressively shorter than the third, so that 1 < 2 > 3 > 4 > 5

Index minus type

index plus type leads to what kind of foot

Egyptian-type foot

index minus type leads to what kind of foot

Morton’s or Greek type foot

Index plus-minus type leads to what kind of foot

squared-type foo

True or False:

Swelling above the medial malleolus may be related to a fibular fracture or disruption of the syndesmosis (“high” ankle sprain).

False:

Swelling above the lateral malleolus may be related to a fibular fracture or disruption of the syndesmosis (“high” ankle sprain).

Swelling posterior to the lateral malleolus may indicate __________________

Swelling posterior to the lateral malleolus may indicate peroneal retinacular injury.

True or False:

Lateral ankle sprains initially swell distal to the lateral malleolus, but swelling may spread into the foot if the capsule has been torn

True

If a tendon appears to curve out, it may indicate a fallen medial longitudinal arch, resulting in a pes planus (flatfoot) condition, this sign is called?

Helbing sign

Runners often build up bone and a callus on the heel, producing a “pump bump” as a result of pressure on the heel, what is this disease or deformity called?

Haglund disease or deformity

True or False:

High-arch feet (i.e., pes cavus) tend to be stiffer while low-arched (i.e., pes planus) feet tend to be more flexible.

True

________ is a normal arch

Pes rectus is a normal arch

Maintained by 3 Mechanisms: 

• Wedging of the interlocking ________

• Tightening of the ligaments on ________ aspect of the foot 

• _________________________ of the foot and their tendons 

Maintained by 3 Mechanisms: 

• Wedging of the interlocking tarsals 

• Tightening of the ligaments on plantar aspect of the foot 

• Intrinsic and extrinsic muscles of the foot and their tendons 

The medial longitudinal arch consists of the:

• calcaneal tuberosity

• talus

• navicular

• three cuneiforms

• first, second, and third metatarsal bones

Bone representing the highest point of the medial arch

Navicular

The medial longhitudinal arch is maintained by the ff:

• tibialis anterior

• tibialis posterior

• flexor digitorum longus

• flexor hallucis longus

• abductor hallucis

• flexor digitorum brevis muscles

• plantar fascia or aponeurosis

• plantar calcaneonavicular ligament

bones that make up the lateral longitudinal arch:

• calcaneus

• cuboid

• fourth and fifth metatarsal bones

The lateral arch is maintained by:

• peroneus longus

• peroneus brevis

• peroneus tertius

• abductor digiti minimi

• flexor digitorum brevis

• he plantar fascia

• the long plantar ligament

• short plantar ligament

Bones that make up the Transverse Arch

• navicular

• cuneiforms

• cuboid

• MT bones

Transverse arch is maintained by

• tibialis posterior and anterior

• peroneus longus

• plantar fascia

A loss of the anterior metatarsal arch results in callus formation under the heads of the metatarsal bones

Especially which metatarsals?

especially the second and third metatarsal heads

Abnormal width of one ankle in relation to the other may be caused by swelling, loss of integrity of the syndesmosis, or a malleolar fracture, this leads to what sign?

Keen sign

This deformity is characterized by prominence of the lateral aspect of the fifth toe metatarsal head.

Bunionette (Tailor’s Bunion)

If Bunionette is associated with hallux valgus, it results in a what?

Splayed foot

True or False

Bunionette is often associated with a supinated foot

False:

It is often associated with a pronated foot.

deformity results in hyperextension of the metatarsophalangeal joints and flexion of the proximal and distal interphalangeal joints

Claw Toes

Claw toes usually result from the defective actions of which muscles?

lumbrical and interosseus

True or False:

Claw toes may be unilateral or bilateral and may be associated with pes planus, fallen metatarsal arch, spina bifida, or other neurological problems.

False:

Claw toes may be unilateral or bilateral and may be associated with pes cavus, fallen metatarsal arch, spina bifida, or other neurological problems.

This congenital deformity is relatively common and can take many forms, Its cause is unknown, but there are probably multifactorial genetic causes modified by environmental factors

Clubfoot

the most common form of clubfoot

talipes equinovarus.

The flexible form of clubfoot is easily treated, but the resistant type often requires __________

surgery

result of weakening of the lateral collateral ligament of the metatarsophalangeal joint and insufficiency of the plantar plate along with the pull of the extrinsic muscles resulting in medial deviation of the toe.

Crossover Toe

Which toes are most commonly medially deviated in crossover toe

Crossover toe is commonly associated with?

second or third toe

Hallux valgus

involves a flexion deformity of both the proximal and distal interphalangeal joints with the metatarsophalangeal joint in neutral or flexion, often combined with rotation.

Curly Toe

Curly toe results due to the contracture of what muscles

flexor digitorum brevis and longus tendons

True or False:

Curly toe is most commonly seen in the fourth toe in children

False:

Curly toe is most commonly seen in the fifth toe in children

This deformity is characterized by limited dorsiflexion (less than 10°) at the talocrural joint, usually as a result of contracture of the gastrocnemius or soleus muscles or Achilles tendon.

Equinus Deformity (Talipes Equinus)

True or False:

Equinus Deformity (Talipes Equinus) can contribute to conditions such as plantar fasciitis, metatarsalgia, heel spurs, and talonavicular pain.

True

an abnormal bony outgrowth extending from the surface of the bone. It is actually an increase in the bone mass at the site of an irritative lesion in response to overuse, trauma, or excessive pressure.

Exostosis (Bony Spur)

Most often these exostoses are the result of poorly fitting footwear that leads to undue pressure on the bone.

This structural midtarsal deviation involves eversion of the forefoot on the hindfoot when the subtalar joint is in the neutral position because the normal valgus tilt (35° to 45°) of the head and neck of the talus to its trochlea has been exceeded.

Forefoot Valgus

True or False:

In forefoot valgus, during the weight-bearing phase of gait, the midtarsal joint is pronated so that the lateral aspect of the foot is brought into contact with the ground.

False:

In forefoot valgus, during the weight-bearing phase of gait, the midtarsal joint is supinated so that the lateral aspect of the foot is brought into contact with the ground.

This structural midtarsal joint deviation involves inversion of the forefoot on the hindfoot when the subtalar joint is in the neutral position. It occurs because the normal valgus tilt (35° to 45°) of the head and neck of the talus to its trochlea has not been achi eved

Forefoot Varus

True or False:

Both forefoot valgus and varus present as pes planus

True

a condition in which dorsiflexion or extension of the big toe is limited because of osteoarthritis of the first metatarsophalangeal joint

Hallux rigidus

a relatively common condition in which there is medial deviation of the head of the first metatarsal bone in relation to the center of the body and lateral deviation of the head in relation to the center of the foot

Hallux valgus

women>men

The angle between the longitudinal axis of the MT bone and the proximal phalan

Metatarsophalangeal Angle

Normal value of the Metatarsophalangeal angle

8-20^o

Types of Hallux Valgus:

• Deformity does not progress and between 20-30 degs valgus

• Jt surfaces are congruent and requires little to no treatment

congruous hallux valgus

Types of Hallux Valgus:

• Progressive deformity increasing from 20-60 degs

• Joint surfaces are not congruent 

• Deviated (if early) and subluxed (if late stages)

pathological hallux valgus

Types of Hallux Valgus:

• 80% of hallux valgus are caused by metatarsus primus varus 

• Abduction deformity of 1st metatarsal; curved medial border

Metatarsus primus varus

Extension contracture at MTP jt and flexion contracture at PIP jt

Hammer toe

This structural position involves eversion of the calcaneus when the subtalar joint is in the neutral position.

Hindfoot Valgus (Subtalar or Rearfoot Valgus)

Normally, individuals have a rearfoot valgus that is about 4°

Hindfoot Valgus:

• hindfoot is (mobile/immobile?)

• lead to excessive ________ and limited __________

• It may result from genu _______

• may contribute to the appearance of a pes _________ foot

• less likely or more likely to cause problems than hindfoot varus?

Hindfoot Valgus:

• hindfoot is mobile

• lead to excessive pronation and limited supination

• It may result from genu valgum

• may contribute to the appearance of a pes planus foot

• less likely

This structural deviation involves inversion of the calcaneus when the subtalar joint is in the neutral position.

Hindfoot Varus (Subtalar or Rearfoot Varus)

characteristics are just opposite to that of hindfoot valgus

A flexion deformity of the distal interphalangeal joint. It can occur on any of the four lateral toes.

Mallet Toe

This deformity is the most common foot deviation in children. It may be seen at birth but often is not noticed until the child begins to stand

Metatarsus Adductus (Hooked Forefoot)

True or False:

In metatarsus adductus, the foot appears to be abducted and supinated (kidney shaped with medial deviation), and the hindfoot may or may not be in valgus.

False:

In metatarsus adductus, the foot appears to be adducted and supinated (kidney shaped with medial deviation), and the hindfoot may or may not be in valgus.

• Longer 2nd toe = more stress on it 

• Often hypertrophy of 2nd metatarsal bone = toe becomes as big as hallux 

• Hard time fitting shoes

Morton’s foot (atavistic or grecian)

• Interdigital neuroma caused by injury of digital nerve 

• 3-4th toe; women

Diff dx is march fx (will be tender and (+) x-ray)

Morton’s metatarsalgia (interdigital neuroma)

• Can be caused by spina bifida, poliomyelitis, or Charcot-Marie-Tooth disease. Talipes equino varus, muscle imbalance 

• May be hereditary 

• High longitudinal arch (medial and lateral if severe)

• Claw toes and degeneration of jts  can occur overtime

• If severe can be associated with neurological disorders

Pes cavus (hollow foot or rigid foot)

• Can be caused by trauma, muscle weakness, ligament laxity, dropping of talar head, paralysis, pronated foot

• Common af

• Rarely rigid or congenital

Pes planus (mobile foot)

In pes planus, rearfoot in ______, talonavicular is _______, talocalcaneal ______, forefoot ________

In pes planus, rearfoot in valgus, talonavicular is everted, talocalcaneal dorsiflexed, forefoot abducted

This structural deformity occurs when the first ray (big toe) lies lower than the other four metatarsal bones so that the forefoot is everted when the metatarsal bones are aligned.

Plantar Flexed First Ray.

This deformity can contribute to the same conditions seen with forefoot valgus.

If plantarflexed first ray is present congenitally, it is indicative of a ________ foot

cavus

In plantarflexed first ray’s acquired form, it occurs as compensation for tibia ________ with limited calcaneal ________

In plantarflexed first ray’s acquired form, it occurs as compensation for tibia varum with limited calcaneal eversion.

This developmental anomaly is characterized by the presence of an extra digit or toe

Polydactyly

a foot deformity where the forefoot is dorsiflexed on the hindfoot . This results in a “broken midfoot,” so that the medial and longitudinal arches are absent and the foot appears to be bent the wrong way.

Rocker-Bottom Foot

This deformity, which is broadening of the forefoot, is often caused by weakness of the intrinsic muscles and associated weakness of the intermetatarsal ligament and dropping of the anterior metatarsal arch

Splay Foot

a hyperextension injury (sprain) combined with compressive loading to the metatarsophalangeal joint of the hallux

Turf Toe

ROM🙂 N o r k i n

• Dorsiflexion = 20

• Plantarflexion = 50

• Inversion = 35

• Eversion = 15

• 1st MTP flexion = 45

• 1st MTP extension = 70

Achilles reflex:

S1-S2