chapter 13: lower leg, ankle, and foot ( magee p888)
Resting position of the TALOCRURAL (ANKLE) JOINT
10* of plantar flexion , midway between maximum inversion and maximum eversion. ** talocrural joint has one degree of freedom
Keen sign
Abnormal width of one ankle in relation. To the other
KEEN SIGN
abnormal width of 1 ankle in relation to the other may be caused by swelling, loss of integrity of the syndesmosis, or a malleolar fracture.
LATERAL LONGITUDINAL ARCH
calcaneus, cuboid,4th and 5th metatarsal make up lateral longitudinal arch. This arch is more stable and less adjustable than medial longitudinal arch. It is maintained by: peroneus longus, brevis, tertius, abductor digiti minimi, flexor digitorum brevis, plantar fascia, long plantar ligament.
CLAW TOES
claw toe deformity result in Hyperextension of metatarsophalangeal joint and flexion of the proximal and distal interphalengeal joints.
HAMMER TOE
extension contractures at the metatarsophalangeal joint & flexion contracture at proximal interphalengeal joint maybe flexed, straight or hyperextended.
MALLET TOE
flexion deformity of distal interphalengeal joint It can occur in any of the 4 lateral toes
FICK ANGLE OF THE FOOT
foot assumes a slight toe out position. The fick angle is approximately, 12* to 18* from the sagittal axis of the body. developing from 5* in children
With pes planus, eversion in the non-weight-bearing calcaneus
is greater than 10 degrees Dorsiflexion of the ankle may be limited with severe pes planus . Increased internal rotation may be present with femoral anteversion.
• Pes cavus
is the opposite foot configuration of pes planus. It presents as a high medial arch due to increased twisting or supination of the foot. The calcaneus is inverted. Tibialis anterior, tibialis posterior and the toe flexors are shortened.
TRANSVERSE ARCH
maintained by tibialis posterior, tibialis anterior, peroneus longus mm, plantar fascia. It consist of navicular, cuneiforms, cuboid, metatarsal bones.
closed packed-position of the TALOCRURAL (ANKLE) JOINT
maximum dorsiflexion
FOREFOOT VARUS
midtarsal deviation involves inversion of the forefoot on the hindfoot when subtalar joint is in neutral position. resembles ples planus bec it decrease the medial longitudinal arch.
capsular pattern of restriction of the TALOCRURAL (ANKLE) JOINT
more limited in plantar flexion than dorsiflexion ** joint is most Stable in Dorsiflexed position
METATARSUS ADDUCTUS ( HOOKED FOREFOOT)
most common foot deviation in children It may be seen at birth but often not noticed until child begins to stand. the foot appears adducted and supinated
HAGLUND DISEASE OR DEFORMITY
runner often build up bone and a callus on the heel, producing a pump bump as a result of pressure on the heel.
PLANTAR FLEXED FIRST RAY
structural deformity 1st ray big toe lies lower than the other 4 metatarsal bones so that the forefoot is everted when metatarsal bones are aligned.
FOREFOOT VALGUS
structural midtarsal deviation involves eversion of the forefoot on the hindfoot when subtalar joint is in neutral position because normal valgus tilt (35-45*) of the head and neck of talus to its trochlea has been exceeded.
WEST POINTSPRAIN GRADING SYSTEM
used to determine the severity of the ankle sprains.
COMMON DEFORMITIES, DEBVIATIONS, & INJURIES OF THE FOOT
1. BUNIONETTE (TAILOR'S BUNION) 2. CLAW TOES 3. CLUBFOOT/TALIPES EQUINOVARUS 4. CROSSOVER TOE 5. CURLY TOE 6. EQUINUS DEFORMITY (TALIPES EQUINUS) 7. EXOSTOSIS (BONY SPUR) 8. FOREFOOT VALGUS 9. FOREFOOT VARUS 10. HALLUX RIGIDUS 11. HALLUX VALGUS 12. HAMMER TOE 13. HINDFOOT VALGUS (SUBTALAR OR REARFOOT VALGUS) 14. HINDFOOT VARUS (SUBTALAR OR REARFOOT VARUS) 15. MALLET TOE 16. METATARSAL ADDUCTUS (HOOKED FOREFOOT) 17. MORTON'S (ATAVISTIC OR GRECIAN) FOOT 18. MORTON'S METATARSALGIA (INTERDIGITAL NEUROMA) 19.PES CAVUS (HOLLOW FOOT OR RIGID FOOT) 20. PES PLANUS (FLAT FOOT OR MOBILE FOOT) 21. PLANTAR FLEXED FIRST RAY 22. POLYDACTYL 23. ROCKER-BOTTOM FOOT 24. SPLAY FOOT 25. TURF TOE
HINDFOOT /REARFOOT JOINT
1. Tibiofibular Joint 2. Talocrural (ankle) joint 3. Subtalar (talocalcanean) joint
5 Functions of the Foot
1. acts as support base that provides the necessary stability for upright posture with minimal muscle effort. 2. Provide mechanism for rotation of the tibia and fibula during the stance phase of gait. 3. Provides flexibility to adapt to uneven terrain. 4. Provide flexibility for absorption of shock. 5. acts as a lever during push-off
CLINICAL PREDICTION RULE FOR ANTEROLATERAL ANKLE IMPINGEMENT ** 5 of 6 symptoms must be positive (+)
1. anterolateral ankle joint tenderness 2. anterolateral ankle joint swelling 3. pain on forced dorsiflexion 4. pain on affected side with single leg squat 5. pain with activities 6. absence of ankle instability
3 sections in joint of the foot
1. hindfoot (rear foot) 2. midfoot 3. forefoot
PES PLANUS (FLAT FOOT OR MOBILE FOOT)
2 TYPES 1. rigid or congenital 2. acquired or flexible flat foot
Medial longitudinal arch -maintained by tibialis anterior Tibialis posterior Flexor diditorum longus, flexor hallucis longus, abductor halluces, flexor digitorum Bevis, plantar aponeurosis Plantar calacaneonavicular ligament.
Calcaneal tuberosity, talus, navicular, 3cuneiforms, 1st,2nd and 3rd metatarsal bone.
Fallen metatarsal arch
For non-weight bearing position, callosities are found over metatarsal heads
Genus recurvatum
Hyperextended knee
Exaggerated lateral tibia torsion
In stance with patella facing straight forward The feet pointed outward
peroneus longus, brevis and tertius. (Muscles that evert the foot )
In the pronated foot, these muscles are prone to developing trigger points and taut bands
J sign inverted
Inverted J sign Pathological patellar tracking or patellar instability Sudden movement medially to enter trochlea instead of normal smooth pattern.
Hallux valgus is a valgus orientation of the big toe or hallux, with an accompanying medial deviation of the first metatarsal bone.
It may be caused by, or contribute to, pes planus. The first metatarsophalangeal joint capsule becomes hypermobile; a callus and an inflamed, thickened bursa develop over the joint, which form a bunion. This is often due to poor footwear
Lateral meniscus
Large part small circle O shaped Excursion 10mm
Television or W position
Lead to excessive lateral tibia torsion
Transverse arch -consist of the navicular, cuneiform, Cuboid, metatarsal bone
Maintained by tibialis posterior Tibialis anterior Peroneus longus Plantar fascia
Locking in knee
Mean knee cannot fully extend with flexion normal. Loose bodies cause recurrent locking. Hamstring muscle spasm may also limit extension referred to as Spasm Locking
Pigeon toed deformity
Medial tibia torsion Feet point toward each other
Meniscus
Minimal innervation MinimL or no pain when damaged unless coronary ligament have been damaged as well
LATERAL longitudinal arch
More stable Less adjustable compared to medial longitudinal arch -maintained by Peroneus longs Proteus brevis Proteus tortious Abductor digit Minami Flexor digitorum bravos
Jumper's knee or sending -Larsen-Johansson syndrome
Pain after activity or with overuse characteristic of inflammatory condition Example SYNOVIAL pica irritation or early tendinosis or Para tenonitis
Medial tibia torsion
Position avoided to avoid medial torsion
Quadriceps Lag
Quad muscle are not strong enough to fully extend the knee
TALOCRURAL (ANKLE) JOINT
RESTING POSITION: 10* plantar flexion:, midway between inversion and eversion CLOSED PACKED:maximum dorsiflexion CAPSULAR PATTERN: plantar flexion, dorsiflexion
JOINTS OF THE MIDFOOT (MIDTARSAL JOINTS)
RESTING POSITION: midway between extremes of range of motion CLOSED PACKED POSITION: Supination CAPSULAR PATTERN: Dorsiflexion, plantar flexion, adduction, medial rotation
SUBTALAR
RESTING POSITION: midway between extremes of range of motion CLOSED PACKED: supination CAPSULAR PATTERN: limited range of motion (varus, valgus)
TIBIOFLIBULAR JOINT
RESTING: plantar flexion CLOSED PACKED: maximum dorsiflexion CAPSULAR PATTERN: pain when joint is stressed
Medial meniscus
Small part of large circle C shaped Excursion 2mm
Terrible triad of the knee **** Medial collateral ligament - posteromedial capsule -Medial meniscus -Anterior Cruciate
Valgus force involves 1. Medial collateral ligament - posteromedial capsule -Medial meniscus -Anterior Cruciate 2. Anterior Cruciate injuries 3. Posterior Cruciate LIGAMENTS 4.lateral collateral LIGAMENTS
EXOSTOSIS (BONY SPUR)
abnormal bony outgrowth extending from the surface of the bone. An increase in the bone mass at site of an irritative lesion in response to overuse, trauma or excessive pressure. it is common in dorsal 5th metatarsal bone or calcaneus, often called pump bump or runner's bump)
HELBING SIGN
achilles tendon appears to curve out ; may indicate fallen medial longitudinal arch , resulting in pes planus (flat foot) condition
Gastrocnemius and soleus
are primarily postural muscles and respond to stress by adaptively shortening
EQUINUS DEFORMITY (TALIPES EQUINUS)
deformity with limited dorsiflexion less than 10* at the talocrural joint. usually result of the contracture of the gastrocnemius or soleus or Achilles tendon. This contributes to plantar fasciitis, metatarsalgia, heel spurs and talonavicular pain.
HALLUX RIGIDUS
dorsiflexion or extension of big toe is limited because of OA of the 1st metatarsophalangeal joint
HINDFOOT VALGUS (SUBTALAR OR REARFOOT VALGUS)
eversion of the calcaneus when subtalar joint is in neutral position. The hindfoot is mobile, which may leave to excessive pronation and limited supination may result in genu valgum (knocked knee)
MORTON'S METATARSALGIA (INTERDIGITAL NEUROMA)
formation of digital neuroma in the interdigital nerve between 3rd and 4th toes. to confirm plantar palpation is better because dorsal plapation is more on stress fracture While walking or running mortion's metatarsalgia feel pain in outer border of forefoot. intermittent, cramp, shooting up the side to the tip.
A severe pes planus
has 10 to 15 degrees of hindfoot valgus
A mild pes planus
has four to six degrees of hindfoot valgus when measured in a standing posterior view
A moderate pes planus
has six to 10 degrees of hindfoot valgus
lateral longitudinal arch,
however, is a true architectural arch, with the cuboid bone forming the keystone between the calcaneus and the fourth and fifth metatarsals.
DELTOID OR MEDIAL COLLATERAL LIGAMENT
in the medial side of the joint. consists of the 4 separate ligaments 1. tibionavicular 2. tibiocalcanean 3. posterior tibiotalar ligaments superficially 4. anterior tibiotalar ligament
HINDFOOT VARUS (SUBTALAR OR REARFOOT VARUS)
inversiob of calcaneus when subtalar joint is in neutral position.
CURLY TOE
involves flexion deformity of both proximal and distal interphalengeal joints with the metatarsophalangeal joint in neutral or flexion, often combined with rotation. It is the result of contracture of the flexor digitorum brevis and longus tendon and most commonly seen in the 5th toe in children.
Morton's neuroma
is a swelling of the distal interdigital nerves of the foot, usually between the third and fourth metatarsals. It may be caused by hypermobility of the metatarsals. Pain results on compression or weight bearing, as the nerve is compressed between the bones. Morton's neuroma may be exacerbated by shoes that are too tight
PES CAVUS (HOLLOW FOOT OR RIGID FOOT)
may be congenital, neurological ex spina bifida, poliomyelitis, charcot-marie tooth disease.
HALLUX VALGUS
medial deviation of the head of 1st metatarsal bone in relation to the center of the foot. wearing tight pointed toes, tight stockings, high-heeled shoes.
Pronation of the foot
occurs primarily at the subtalar joint and secondarily at the midtarsal joint
SUPINATION
of the foot involves inversion and outward rotation of the heel, adduction of the forefoot with inward rotation at the tarsometatarsal joints to maintain contact with the ground and outward rotation at the midtarsal joints
CLUBFOOT /TALIPES EQUINOVARUS
on assessment ROM is limited and foot has abnormal form. Congenital deformity
BUNIONETTE (TAILOR'S BUNION)
prominent lateral 5th toe (metatarsal head). Often associated with pronated foot.
CHOPART JOINT
refers collectively to the midtarsal joints between the talus-calcaneus and the navicular-cuboid.
CROSSOVER TOE
result of weakening of the lateral collateral ligament of the metatarsophalangeal joint and insufficiency of the plantar plate along with the pull of extrinsic muscle resulting in medial deviation of the toe, most commonly in 2nd or 3rd toe. Often associated with hallux valgus.
ECCHYMOSIS
swelling or bruising
MORTON'S (ATAVISTIC OR GRECIAN) FOOT
the 2nd toe is longer than the 1st
Tibiofibular Joint
the inferior (distal) tibiofibular joint is a fibrous or syndesmosis type of joint. It is supported by anterior tibiofibular, posterior tibiofibular, and inferior transverse ligaments as well as the interroseous ligament. The movement of this joint are minimal but allow small amount of spread (1-2mm) at the ankle joint during dorsiflexion. Dorsiflexion at the ankle joint causes the fibula to move superiorly putting stress on both inferior tibiofibular joint at the ankle and superior tibiofibular joint at then knee. FIBULA -carries more axial load when it is dorsiflexed. On average fibula carries 17% of the axial loading. The joint is supplied by deep peroneal and tibial nerves.
Treatment Goals Treatment Plan With functional pes planus,
the therapist lengthens the shortened structures and the client strengthens the fatigued muscles.
With structural pes planus,
the therapist maintains tissue health and treats the compensatory structures.
The muscles supporting the arch in the dynamic foot — tibialis anterior and the peroneal muscles — are primarily phasic; that is, they respond to stress by fatiguing
tibialis anterior and the peroneal muscles — are primarily phasic; that is, they respond to stress by fatiguing
1. propulsion 2. support
two principal function of lower leg, ankle and foot For PROPULSION acts like flexible lever For SUPPORT they act like rigid structure that hold entire body.
TALOCRURAL (ANKLE) JOINT
uniaxial, modified hinge , synovial joint located between the TALUS, MEDIAL MALLEOLUS of the tibia, and LATERAL MALLEOLUS of the fibula. The talus is shaped so that in dorsiflexion it is wedged between the malleoli, allowing little or no inversion or eversion of the ankle joint. The talocrural joint is designed for stability, especially in dorsiflexion. In plantar flexion, it is much more mobile. This joint is responsible for dorsiflexion-plantar flexion movement that occurs in ankle foot complex.
A Morton's foot structure,
where the second metatarsal is longer than the first, allows the first metatarsal to become hypermobile. The body's weight is abnormally distributed through the head of the second metatarsal on the toe off phase of the gait cycle. This often results in callus formation and tenderness under the second metatarsal head. A Morton foot structure places stress on tibialis posterior and may occur with pes planus
shortened muscles, such as gastrocnemius, soleus and Achilles tendon,
which reduce the ability of the ankle to dorsiflex. This leads to compensation by the midtarsal joint
PES PLANU S Contraindications • Do not mobilize the hypermobile joints on the medial longitudinal arch.
• Do not passively stretch tibialis anterior and posterior, since this will allow increased pronation of the foot. • Avoid using heat on the plantar surface of the foot in the presence of an inflammatory process such as plantar fasciitis. • Friction techniques are contraindicated if the client is using anti-inflammatory medication