Foot, Toes, Ankle, Leg

Front 1

FIVE FUNCTIONS OF THE FOOT

Back 1

-Load-Bearing (vertical and shear forces)
-Provides mechanical advantage for leg musculature (propulsion)
-Absorbs and dissipates shock forces
-Aids in control of balance (fall prevention)
-Protection as source of sensory information from the environment

Front 2

During locomotion, the foot is in what line of defense for force absorption...

Back 2

The first line of defense

Front 3

What creates a force couple of the foot during gait?

Back 3

The tibialis anterior and posterior by drawing the arch proximally & superiorly (supination of the foot)

Front 4

Categorize the motions of pronation and supination

Back 4

Composite motions since the talocrural, subtalar, midtarsal joints and the distal tibiofibular syndesmosis contribute to these motions

Front 5

Describe the foot when in supination

Back 5

plantarflexion + adduction + inversion

(ankle rolls away from center, heel turns towards center)

Front 6

Describe the foot when in pronation

Back 6

dorsiflexion + abduction + eversion

(heel rotates away from center, ankle rolls towards center)

Front 7

Define Closed Kinetic Change

Back 7

distal segment of
the extremity is met with considerable external resistance

Front 8

Implications of Pronation

Back 8

Pronation of foot & ankle complex

--> Internal rotation of the tibia

--> Internal rotation of the femur

Front 9

Implications of Supination

Back 9

Supination of foot & ankle complex

--> External rotation of the tibia

--> External rotation of the femur

Front 10

What is Morton's Foot (Morton's Toe)?

Back 10

-Shortened 1st MT (giving
the appearance of an
abnormally long 2nd toe)

-Increases weight bearing through the 2nd toe/MT

-10% of the pop

Front 11

Symptoms of Plantar Fasciitis

Back 11

pain at origin of PF

pain/stiffness when waking up

heel pain during/after activity

pain with passive ankle dorsiflexion

pain in DF with passive toe extension

Front 12

Treatment of Plantar Fascitis

Back 12

‐stretching of foot/gastroc‐soleus complex (5 min, 2‐3xday)
‐soft tissue release (massage, Graston, golf ball rolling, etc)
‐longitudinal arch taping
‐ice cup massage with foot on stretch (post exercise)
‐Rx NSAIDS

Front 13

Hallux Rigidus

Back 13

“Stiff great toe”

‐involves progressive
degeneration of first MTP joint’s
articular surfaces
‐often bilateral condition,
genetic disposition
‐may progress to ankylosed joint

Front 14

Hallux Rigidus S/S

Back 14

‐ limited DF of
MTP joint
‐pain and swelling during/after
activity
‐impacts gait (toe‐off)
‐exostosis development possible
on dorsal aspect of MTP joint
‐associations: Morton’s toe

Front 15

Hallux Rigidus Tx

Back 15

‐Passive ROM and joint mobilization techniques
‐Orthotics to unload first MTP joint (decrease hyperextension)
‐turf toe taping (limiting DF)
‐corticosteroid injection
‐surgical intervention (cheilectomy: removal of distal portion of MT and exostosis)

Front 16

Define Hallux Valgus

Back 16

progressive degeneration and
subluxation of the first MTP joint
‐characterized by MTP joint angle >
20deg abduction
‐”valgus deformity”
‐associated with a bunion (exostosis)
on medial aspect of the joint

Front 17

Hallus Valgus TX

Back 17

‐appropriate shoes
‐felt pad between 2nd/3rd phalanges
‐turf toe taping: reinforcing
adduction, preventing abduction
‐NSAIDs
‐surgical intervention: changing
shape of the foot‐

Front 18

Define Turf Toe

Back 18

Sprain of the 1st MTP joint

Front 19

Turf Toe MOI

Back 19

foot is planted and ankle forcibly dorsiflexed,
creating hyperextension of great toe
‐not limited to athletes participating on turf
‐can also involve forced valgus or varus of the 1st MTP joint

Front 20

Turf Toe S/S

Back 20

‐pain during toe‐off (push‐off) during gait or quick
stops
‐pain with palpation
‐limited ROM of MTP joint

Front 21

Turf Toe TX

Back 21

‐rest and NWB‐PWB in acute stages (cam walker)
‐RICE
‐turf toe taping/strap
‐firm (graphite/steel) shoe inserts or fabricated
orthoplast insert
‐NSAIDs

Front 22

Where can stress fractures occur?

Back 22

distal tibia, midshaft of tibia, distal fibula
= Overuse injury

Front 23

Stress Fracture S/S

Back 23

‐focal pain on bone
‐pain during activity and at rest
‐’night pain’
‐positive “bump test” or “squeeze test” (not always sensitive in early stages)

Front 24

Stress Fracture TX

Back 24

‐rest!
‐walking boot (PWB to NWB depending upon severity)
‐modified conditioning to maintain fitness (Swim Ex or UBE, progressing to biking)
‐bone stimulator

Front 25

Lisfranc Injuries

-joint involved?

-type of injuries?

-fracture dislocation?

-

Back 25

tarso-metatarsal joint

Sprain, dislocation, fracture-dislocation

T-MT joint can be dislocated w/o fx

Front 26

Lisfranc MOI

Back 26

high energy axial loading of foot while distal segment is fixed
(e.g. being stepped on back of heel with foot planted)

Front 27

Lisfranc Injury S/S

Back 27

range to from subtle to obvious (pain, swelling, deformity, ecchymosis
on plantar surface) of midfoot
‐acute mid‐foot injury with pain should have f/up to r/o Lisfranc injury
‐Lisfranc fx: 2% of all fx, but often misdiagnosed

Front 28

Lisfranc Injury Tx

Back 28

Conservative:
‐NWB (non‐displaced injury)
Operative:
‐open reduction & internal fixation
‐8 weeks NWB (cast/splint)
‐Arthrodesis (surgical joint fusion) for ligamentous injury‐ worse case
scenario

Front 29

Medial Ankle Spains

prevented by?

ligaments affected?

Back 29

static stabilizers and joint configuration prevent excessive ankle eversion

deltoid ligament sprain = 3-15%

can be associated with syndesmosis injuries or malleolar fractures

Front 30

Medial Ankle Sprains S/S

Back 30

‐TTP medial joint line
‐diffuse ecchymosis and edema/swelling on
medial aspect of ankle
‐pain or laxity w/ Eversion Talar tilt test

Front 31

Medial Ankle Sprains R/O

Back 31

‐medial malleolus fracture (‘knock‐off fx’)
‐bimalleolar fracture (‘Pott’s fx’)

Front 32

Lateral Ankle Sprain MOI (most common)

Back 32

‐typically result of excessive supination (can injure talocrural and subtalar joints)
‐pure inversion: rolling over the lateral surface of the foot, stepping on uneven surface (e.g. first base) with the
ankle dorsiflexed
‐contact with another player (congested playing spaces!)

Front 33

Ligaments involved in lateral ankle sprains

Back 33

Anterior talofibular ligament most often injured (taut during ankle supination)
Calcaneofibular ligament injured with more significant inversion
Posterior talofibular ligament more commonly injured with inversion in dorsiflexed ankle

Front 34

Lateral Ankle Sprain S/S

Back 34

‐popping sound at time of injury?
‐TTP sinus tarsi area and lateral ligament complex
‐diffuse ecchymosis and edema/swelling (increases
with the severity of injury)
‐pain or laxity with Anterior Drawer test, Talar Tilt test

Front 35

Lateral Ankle Sprain R/O

Back 35

‐fracture (fibula, tibia, talus)
‐avulsion fracture (styloid process 5th MT)

Front 36

Mechanical Instability

Back 36

gross laxity of the talocrural or subtalar joints with clinical examination

Front 37

Functional Instability

Back 37

Hx of repeated ankle sprains but normal findings during ligamentous stress tests

Front 38

Maisonneuve Fracture

Back 38

R/o fx of superior portion of fibula with ankle sprains

Front 39

Morton's Neuroma

Back 39

= Intermetatarsal neuroma
‐typically entrapment of the 3rd common digital (plantar) nerve, located
between 3rd and 4th MTs

Front 40

MOI for Morton's Neuroma

Back 40

prolonged pressure of nerve resulting in formation of fibrotic nodules and
edema around the nerve
‐contributors: excessive pronation, improperly fitted shoes (too
tight/pointed, high heels)
‐Women > Men
‐high re‐occurrence rate

Front 41

S/S for Morton's Neuroma

Back 41

‐pain in transverse (metatarsal) arch of foot, radiating to toes
‐numbness into the toes

‐increased pain/numbness when pressure is increased in forefoot (standing
on toes) or with tight shoes
‐positive: increase in symptoms with metatarsal compression, Mulder sign

Front 42

Tx for Morton's Neuroma

Back 42

metatarsal arch pad
low‐dye taping (widens MT arch)
Lidocaine injection (diagnostic)
corticosteroid injection
modification of footwear
surgical excision

Front 43

Achilles Tendinopathy

Back 43

‐AT poor vascularity “distal avascular zone”
tendon twists and inserts slightly medially
on axis of subtalar joint (on calcaneus)
=Common site for achilles pathology:
tendinosis, rupture

Front 44

What is Partenon?

Back 44

highly vascularized layer surrounding AT
‐susceptible to inflammation
‐forms adhesions to underlying tendon
paritendinitis-->tendinosis-->tendon rupture

Front 45

Tendinosis

Back 45

degeneration of tendon midsubstance (often ‘silent’)
‐microscopic tears and necrotic areas
(visible w/ diagnositc ultrasound or MRI)

Front 46

Precipitating Factors for Achilles Tendinopathy

Back 46

‐previous ankle sprain?
‐hyperpronation
‐tibial varum
‐calcaneovalgus
‐achilles tightness
‐hamstring tightness
+ training errors

Front 47

S/S for achilles tendinopathy

Back 47

‐burning pain during activity
‐TTP
‐palpable nodule
‐visible thickening
‐crepitis with active movement
-Visible thickening and limited ROM (DF):

Front 48

Tx for achilles tendinopathy

Back 48

Eccentric training!
Improve limited DF ROM through stretching and tissue and joint mobilization
Taping
Surgery?

Front 49

Define Achilles Rupture

Back 49

Achilles tendinosis or paratendinitis may lead to rupture, but not necessary as precipitating factor
More common in males > 30 yrs old, but any population susceptible

MOI: forceful contraction (landing from a jump, sudden changes in direction)

Front 50

S/S of an Achilles Rupture

Back 50

‐loud pop (gunshot) at time of injury
‐visible defect in tendon
‐absence of palpable in‐tact tendon
‐positive Thompson test
‐can actively plantar flex (why?)
‐may be able to walk but cannot perform a single leg heel raise
‐excessive edema/ecchymosis

Front 51

Achilles Rupture Management

Back 51

Conservative:
Immobilization (cast or night splint) 8 weeks
Surgery:
Outcomes are better with surgical reconstruction compared to conservative management
‐lower incidence of re‐rupture
‐faster return to pre‐injury activity

Front 52

Chronic Onset of Exertional Compartment Syndrome

Back 52

‐S/S during or after exercise
‐Increased fascia thickness inhibits venous outflow but
not arterial inflow
‐anterior, lateral, or posterior compartments
susceptible

Front 53

Acute Onset of Exertional Compartment Syndrome

Back 53

‐same s/s as chronic w/o prior symptoms or history of
traumatic injury

Front 54

Exertional Compartment Syndrome S/S

Back 54

‐pain localized in compartment
‐possible numbness into the toes and/or dorsal and lateral aspect of foot (anterior or lateral CS)
‐decreased strength of muscles associated with the compartment
‐pain with passive ROM (would stretching make them feel better at time of symptoms?)
‐possible visible swelling in compartment
‐reduced or absent pulse (dorsalis pedis) in advanced/extreme cases

Front 55

When is fasciotomy required?

Back 55

Resting pressure > 15mm Hg (compared bilaterally if a unilateral problem)
> 30mm Hg 1 min post exercise
> 20mm Hg 5 minutes post exercise
Pressure = difference between diasolitic BP and intercompartmental pressure

Front 56

Define Traumatic Compartment Syndrome

Back 56

Medical emergency!
MOI: direct blow to anterior or lateral compartments of the leg
‐more common in the anterior compartment
‐may be present with tibia or fibula fracture

S/S: related to the 5 P’s
pain, pallor (reddness), pulselessness,
paresthesia, paralysis

Front 57

S/S for Traumatic Compartment Syndrome

Back 57

‐visibly swollen compartment, skin may appear shiny
‐compartment hard to the touch and TTP
‐may have inability to dorsiflex ankle or extend toes
‐pain with passive ankle ROM (plantar flexion if anterior compartment)
‐extreme pain with walking
‐may present with drop‐foot (why?)
‐check integrity of dorsalis pedis pulse
*do not apply compression wrap with this type of injury