Foot and Ankle Module IV

T/FThe talar tilt test is a special test to rule out a lateral ankle sprain and specifically to assess the calcaneo- fibular ligament

false IN

Approximately 85% of ankle sprains are _______ with the majority resulting in isolated anterior talofibular ligament injury

inversion

T/F The anterior drawer test is a special test to rule in a lateral ankle sprain and specifically to assess the integrity of the anterior talo-fibular ligament

true

The clinical course of ankle sprains is promising with significant improvements in pain and function commonly observed during the first ___ weeks and the majority of individuals expected to return to full participation within __ weeks from the onset of injury

2, 3

The Cumberland Instability Tool is a 9 item questionnaire scored from 0 to 30 with higher scores indicating less severe functional ankle instability. A cutoff score of 27 has been established with scores <= 27 indicative of the presence of _____ _______ instability. The instrument has relatively good ______ and ______ using 0.80 as a cutoff suggesting usefulness in both ruling in and out functional ankle instability

27, functional ankle instability, sensitivity and specificity

Ankle sprains are the most common athletic injury accounting for up to ___% of all athletic injuries

40

Two of the more common and validated questionnaires are the ______ Ankle ______ Tool and the ______ of ______ Ankle Instability

Cumberland Ankle Instability Tool and the Identification of Functional Ankle Instability.

The _____ _____ test is a special test to rule in a high ankle sprain. This test is performed with the patient ______. The therapist passively _______ and ______ rotates the foot. The test is positive if pain is reproduced _______ in the distal tibia- fibula syndesmosis

ER, sitting, dorsiflexes and ER, anteriorly

What makes up the tibiofibular joint

The tibiofibular joint is comprised of the articulation of the concave lateral surface of the tibia and the convex medial surface of the fibula. The anterior tibiofibular ligament, posterior tibiofibular ligament, and tibiofibular syndesmosis provide passive restraint to the region.

____ ___ is a hyperextension injury of the first metatarsal phalangeal joint resulting in a plantar capsular sprain

Turf toe

Cuboid syndrome is defined as

a ""Minor disruption or subluxation of the structural congruity of the calcaneocuboid portion of the midtarsal joint" and may accompany an inversion ankle sprain. The disruption may result in irritation of the surrounding joint capsule and the peroneus longus tendon.

Risk factors for an acute lateral ankle sprain can be categorized as intrinsic meaning related to the patient or extrinsic meaning related to the activity or environment. Furthermore, risk factors can be categorized as modifiable and non- modifiable. Intrinsic, non- modifiable risk factors for acute lateral ankle sprains include

a prior history of a lateral ankle sprain and female sex.

The ______ _____ is the test you are most likely to see and perform yourself clinically

anterior drawer

Grade II ankle sprains will present with _______ deficits and a positive ______ ______ test suggesting _______ _______ ligament involvement. They ___ have point tenderness, limitations in range of motion, and ______ swelling

anterior drawer, anterior talofibular, will, observable

Grade III ankle sprains present with profound functional deficits and positive anterior drawer and talar tilt tests indicating involvement of both the ______ _______ ligament and the _______ ligament. Ankle ROM is _______ by a minimum of __ degrees in comparison to the non- involved side and swelling will be greater than _ cm

anterior drawer, both the anterior talofibular ligament and the calcaneofibular ligament, decreased, 10, 2

The ______ _______ ligament is involved in almost all ______ ankle sprains while the ________ ligament is involved in 50% to 70% and the _______ ________ ligament in less than 10% and typically only with a dislocation of the ankle

anterior talofibular, lateral, calcaneofibular, posterior talofibular

The clinical presentation of a high ankle sprain is with pain in the ______ ankle and pain reproduced with ankle ______

anterior, dorsiflexion

The _________ talar palpation test is a modification of the ______ _____ in which the thumb of the hand on the _____ presses into the lateral ridge of the ______ while grasping the ___ with the other four fingers of the same hand. The opposite hand stabilizes the _______ while the hand on the tibia pushes the leg _______, allowing the thumb to feel, on palpation, the amount of ____ talar movement. A positive test is indicated by excessive _____ compared to the uninvolved side. Improved sensitivity has been observed with this modification of the test

anterolateral talar, anterior drawer, tibia, talus, leg, calcaneus, downwards, anterior talar, laxity

The mechanism of injury of turf toe is ____ loading forces applied to the forefoot while the first MTP joint is in the _______ (____) position. Turf toe can encompass a spectrum of severity from ____ ____ capsular sprains to _____and _____ tears. Untreated, turf toe can lead to _____ _____

axial, equinovarus(tiptoe), low grade capsular, capsular and ligamentous, hallux rigidus

The Weber classification system describe 3 types of fibular fractures. A Weber A fracture is one occurring _____ the ankle joint. A Weber B fracture occurs ___ ___ ___ of the ankle, however, spares the ___- ____ ligaments. A Weber C fracture occurs _____ the ankle joint and results in a _______ ligament tear. The higher up on the bone, the ____ extensive the damage so Weber C fractures often require _____ management while Weber A fractures are often managed ______

below, at the level of, tibia-fibular, above, syndesmotic, more extensive, surgical, conservatively

(Ankle sprains) Despite the rapid return to full function, pain and impairments commonly persist and up to 1/3 of individuals will develop _____ _____ _____ following a lateral ankle sprain defined as continued _____, ______, ______, and/or _______ at one year from their initial injury. Articular changes such as ankle ______, osteophytes, _____changes, and ligamentous _____ may accompany and persist following a lateral ankle sprain. Furthermore, altered ______ strategies during ambulation, balance, and jumping as well as muscle ______ differences are observed throughout the lower extremity and at times on the uninvolved side following a lateral ankle sprain with potential implications for _______and ________ instability

chronic ankle instability, pain, swelling, instability, and/or recurrences, impingement, arthritic, laxity, movement, recruitment, recurrences, chronic ankle

The clinical examination will include special tests assessing the laxity of the ligaments. Acute ankle sprains can be graded based on ______ presentation and the amount of ______

clinical presentation, laxity

Special tests to rule in a high ankle sprain include the _______/_______ ______ test and the _____rotation test

compression/syndesmosis squeeze, external rotation

Chronic ankle instability defined as

continued symptoms or recurrences one year following the initial injury.

The mechanism of injury of a Lisfranc injury is through ____ trauma such as a crush injury to the foot or _____ trauma as can occur in ____ with excessive _____ or ______ of the lisfranc joint on a _______ foot

direct trauma, indirect, sports, pronation or supination, plantarflexed

Excessive _______ may result in gapping of the malleoli with subsequent ____ or _____ of the anterior and posterior tibiofibular ligaments

dorsiflexion, sprain or rupture

The mechanism of injury for eversion ankle injuries is typically due to an ______ or _____ rotation force or landing on an off balanced, ______ foot. The _____ rotation test may be used to assess the _____ ligament with a positive finding being pain _____ rather than anteriorly

eversion, ER, pronated, ER, deltoid, medially

The mechanism of injury of a syndesmotic ankle sprain is most commonly forceful _____ rotation of the ankle, __________, or a combination of the two

external, hyperdorsiflexion

T/F Eversion ankle injuries are less common than lateral ankle sprains accounting for only 20 to 30 % of all ankle sprains

false 5-10% This is due to the bony anatomy of the ankle and the broad and strong deltoid ligament.

T/F a gold standard test does exist for cuboid syndrome?

false A gold standard does not exist for the diagnosis of cuboid syndrome so the diagnosis is based on excluding other possible causes as well as knowledge of the mechanism of injury, a cluster of signs and symptoms, differential diagnosis, and clinical expertise.

T/F Patients presenting with a lateral ankle sprain will be able to describe a specific event and generally will describe an eversion mechanism of injury

false inversion

T/F A syndesmotic ankle sprain or "high" ankle sprain is more common than an inversion ankle sprain and may accompany an inversion ankle sprain

false less common

Finally, in those identified at risk or developing a chronic condition due to higher levels of yellow flags such as _____, kinesiophobia, or low ___ _______may require treatment _______ based on ________ informed physical therapy. The treatment emphasis for patients classified as chronic ankle instability is on improving _______ _______ through treatment focused on _______ and neuromuscular exercises. ______ therapy and dry needling are supported as adjuncts to therapy and modifying treatment based on psychological factors is again encouraged

fear, self efficancy, modifications, psychologically, dynamic, proprioceptive, manual

(Lisfranc injuries) Pain may be provoked by passively ______ the foot at the Lisfranc joint, applying _____ or ______stress forces to the metatarsals, or passive______ and ______ of the forefoot

flexing, lateral or medial, abduction and pronation

Risk factors for chronic ankle instability include

higher body mass index, lower self-reported function at 6 months after the initial injury, the inability to complete jumping and landing within 2 weeks of an initial injury as well as persistent ankle joint laxity beyond 8 weeks following the injury and persistent balance issues.

The Identification of Functional Ankle Instability is a 10 item questionnaire scored from 0 to 37 with (higher or lower?) scores indicating more severe functional ankle instability. A cutoff score of 11 has been established with scores >=11 suggestive of _______ _______ instability

higher scores, 11, functional ankle

Stable and non- displaced Lisfranc injuries are treated with ______ and non-weight bearing for _ weeks. Displaced or unstable Lisfranc injuries require _____

immobilization, 6, surgery

The anterior drawer test typically has high specificity suggesting it is good to rule __ a lateral ankle sprain however, sensitivity values are often low suggesting it is not ideal for ruling __ a lateral ankle sprain

in, out

The compression/ syndesmosis squeeze test is a special test to rule __ a high ankle sprain. This test can be performed with the patient _____ or ______. The therapist grasps the lower leg at the ___ ___ level with both hands and squeezes the ____ and _____ together. This is performed at the __ ____ and moving ______. The test is positive if pain is reproduced ______ in the distal ____- ____ syndesmosis

in, supine or sitting, mid calf, tibia and fibula, mid calf, distally, anteriorly, distal tibia-fibula syndesmosis

The cuboid whip is performed by placing the fingers in an _______ position over the _____ of the foot. The thumbs are placed on the _____ surface of the _____. The knee is then _____ to approximately __°, with the ankle dorsiflexed to approximately __°. The actual manipulation is performed by ______ the knee, ______ _____ the ankle, with slight ______ of the subtalar joint. The thumbs apply a thrust force to the _____ with stabilization of the ____ from the interlocking fingers

interlocking, dorsum, plantar, cuboid, flexed, 70, 0, extending, plantar flexing, supination, cuboid, foot

Component 5 of the clinical practice guidelines involves determining the optimal _________ strategies and these are differentiated based on the established classification of _____ ______ ankle sprain versus ______ _____ instability. In the case of an acute lateral ankle sprain, ______ is recommended with progressive weight bearing. A ________ ________ program addressing impairments but including _______ and functional activities as tolerated. _______ therapy as well as modalities of low level laser and short wave diathermy are supported. Non steroidal anti inflammatory medication is recommended to manage acute symptoms

intervention, acute lateral ankle, chronic ankle, bracing, supervised rehab, balance, manual therapy

Component 3 is consideration of _______, the Maitland term assessing a combination of the ease at which symptoms are provoked, the severity when provoked, and the time it takes for symptoms to return to baseline once provoked. The consideration of _______ is helpful in determining the _________ of your assessment as well as the ____________ of your treatment approach

irritability, irritability, aggressiveness, aggressiveness

Component 2 into the guidelines is to classify the patient. The classification system identifies 1) an acute ______ ankle sprain characterized by a mechanism of injury related to forced _______and positive findings on the ______ _____ or its variations OR 2) _____ ankle instability characterized by at least one prior _______ ankle sprain, episodes of _____ _____, _______ sprains and/or episodes of giving way, decreased performance on _______ or _____ tests, and poor scores on validated questionnaires such as the ________ Ankle Instability Tool or the Identification of ________Ankle Instability tool

lateral ankle, inversion, anterior drawer, chronic ankle, significant ankle, giving way, repeated, balance or hop tests, Cumberland ankle, functional ankle

Grade I sprains are mild resulting in ______ loss of function and no laxity. Clinically individuals with a grade I sprain will present with ____ __ __ point tenderness, near normal range of motion, and _____ __ __ swelling

minimal, little to no, minimal to no

A LIsfranc injury occurs when?

one or more metatarsals become displaced from the tarsus.

Component 4 focuses on determining ______ measures to assess. These are important components of your physical therapy diagnosis and will inform the ______ at which you direct treatment. The guidelines recommend assessing these at _______as well as on several other occasions during the course of care to track progress. These include ______ _______ measures of function such as ___ ___ ___ ___, consideration of _______ factors perhaps necessitating modification of your treatment to include psychologically informed physical therapy approaches, assessment of ___, _____, ____ __ _____, _____ mobility, and, for the appropriate patient, assessment of _____ _____ activities such as ______ and ___ testing. Your assessment of irritability will inform the selected outcomes. For example, you will likely not perform balance activities or hop testing in a patient presenting in the protective phase of rehabilitation or with high irritability. Swelling is a recommended outcome following an acute lateral ankle sprain and hip strength in patients with presentations consistent with chronic ankle instability due to the relationship between hip strength and poor outcomes

outcome, impairments, self report, LEFS, psychological, pain, strength, ROM, joint mobility, higher level, balance and hop testing

Lisfranc injuries are characterized by?

pain, swelling, and tenderness over the Lisfranc joint.

Clinically, cuboid syndrome usually results in pain with ______ of the cuboid and with ______ testing of the _______ joint into ______ and _______. A manual therapy intervention for cuboid syndrome is the "_____ _____"

palpation, mobility, midtarsal, inversion and adduction

Extrinsic risk factors for an acute lateral ankle sprain include

participating in court sports.

Failure to diagnose a Lisfranc injury is problematic and may lead to _______ deformity, instability, and/or post traumatic ______

progressive, arthritis

_______ bracing and _____ exercise programs including balance training may have value in preventing recurrences of ankle sprains following an initial occurrence

prophylactic, supervised

How to preform the anterior drawer test. This test can be performed with the patient either _____ or in _____. The therapist stabilizes the ______ aspect of the leg with one hand while grasping the _____ with the other hand. To isolate the ATFL, the foot should be maintained in __ to __ degrees of ________. The foot is translated _____ while assessing for excessive motion. The anterior drawer test is positive if ____ is noted in ______ to the other side. The diagnostic accuracy of the anterior drawer is best if delayed _ to _ days after injury

seated or in supine., distal, heel, 10-15, plantarflexion, anteriorly, laxity, comparison, 4 to 5

(Talar tilt test) This test can be performed with the patient either _____ or ______. With the ankle maintained at _ degrees of dorsiflexion, the calcaneus is ______. The test is positive if increased ______ is noted in comparison to the opposite side. This test may also be used to assess the ______ ligament by tilting the calcaneus into eversion

seated or supine, 0, inverted, laxity, deltoid

The reverse anterolateral drawer test is a modification of the anterior drawer in which the patient is positioned _____ with the knee ____. Similar to the anterior drawer, the ankle is maintained at 10 to 15 degrees of ______. Additionally, ______ rotation of the foot is allowed to further tension the ATFL. The index and middle finger of the hand stabilizing the foot are placed along the plane of the _____ aspect of the ______ talar dome and the anterior aspect of the ______ malleolus approximately 1 cm proximal to the tip. While this hand stabilized the foot and ankle, the other provides a ________ displacement force to the tibia and parallel to the talus. A positive test is indicated by excessive _____ compared to the uninvolved side

supine, flexed, plantarflexion, IR, lateral, anterior, lateral, posterior, talus, excessive laxity

The Lisfranc joint is comprised of?

the three cuneiforms and the cuboid proximally, and the 5 metatarsals distally.

T/F Syndesmotic ankle sprains take longer to resolve than lateral ankle sprains and may require early immobilization and surgical management if resulting in instability of the joint

true

T/F The talar dome is wider anteriorly than posteriorly resulting in tightening of the interosseous ligament with dorsiflexion

true

What are the red flag questions

unexplained weight loss, history of cancer, fever associated with onset of symptoms, unrelenting night pain. (This is of utmost importance for all patients but possibly a little less of a concern in these patients who will present with a definitive mechanism of injury and point of injury. Specifically, they will not describe an insidious onset but rather onset in response to some sort of trauma.

Intrinsic modifiable risk factors include

weight bearing asymmetries in ankle dorsiflexion range of motion as measured by the weight bearing lunge test; decreased hip musculature strength, decreased performance on functional tests such as balance and hop tests.

The ______ _____ _____ test is a recommended assessment technique. The weight bearing lunge test has been described many ways, however, most consistently, the patient is in tandem stance and performs a ______ lunge with their foot _______ to the wall. The foot is progressively moved ____ from the wall until maximum ankle ________ is reached ______ the heel lifting. The measure is quantified by measuring the distance from the ____ to the ___ ___ OR through the use of an inclinometer commonly placed _______ on the ____ at a location __ cm below the ______ _____. The minimal detectable change for the weight bearing lunge test supporting change beyond measurement error is _ degrees or _ cm depending on the assessment method

weight bearing lunge, tandem, forward, perpendicular, away, dorsiflexion, without, wall to the big toe, anteriorly, tibia, 15cm, tibial tub, 5, 2

(syndesmotic ankle sprain ) External rotation injuries result in _______ of the mortise as the normally stabilized _____ rotates ______ separating the ______ and the _____resulting in tearing of the ______ tibiofibular ligament, the superficial ______ _______ tibiofibular ligament, the ______ tibiofibular ligament, or a combination of these. Excessive forces may result in tears to the_______ ligament and____ fractures

widening, talus, laterally, fibula, tibia, anterior, posterior inferior, transverse, interosseous, fibular